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^Uv(iS{_WS4 ?q'7OnhnG]ك ?Eiw Qn%v{yNYUɑHyŏ礒WEYYLxV2< t7vyVϞ3dSYY־Nܐ\e\^:[v{Yyx׳#d0Y^pTzb cG.dBY6fЦ hǎFd;d|.ˆ-َ=9yPi艢Y{DMve.ؓUœv"5`(YY1RHRNPpg?&.{޲svr_R%/DrI6c=gpfic&gcyZ?Oz_Z@%4a$҃AJY+23;`- q[IĿ 3֞*#&͋++|`m ș=Qhyk@h}+㩨BIkmͫŌ^x5Re^Sz ٧)H"FO .jr.J#{&to+#F#]bۼ1z=Rvf|⁇[qleB^⯊B(XXN*p9Xﱟ.VӅJKskes|ʾ4$hB fP ,/t)sP Bs ǔ>Ej.:,ʎ1&GxTmeFa>fd=; % '򦩬 M|Jv5w~-^W_Y1{)e^Ԣo7P#t~!QFͭPQدj9(=]}Bk 1ķT`mjT  a`|c`xAq2! bP'5R9\`ߨ'w_k$B%m>.}|鳾=5ڣţwƷ9.1) <7i MX j-Wn%m=>Fqr%wi(ɸɚ`<ȝS&su-8C$eڕG H)q9E8 SBq{L ӀRM3~ȜidF+ՄCJOaljJo厠V#pӬUԦ-b[W孫1 M|SnfeffucyZ]zR<.bhȣ9fyC:E, %ƺTntj`pL2U:sQ뒽|&kرq2`<9HF,wyz 9RĐ#CKƑ(ܔFӚms <%|?"?i s1o尿8抰ʺׅ>-`ڰ\sؑɰڻ~'s<e ciO+sF# \wQST/%C&ؓn֝qWB^ X)Eטr6ѓPG<9$eZ"sJ%I&hxN}FCl=:oj:j1[5,ٰIˢ%ѻN1H ʮh/ȟ-z3"iTpn4Q@ՁYa&w1zGcxN ^;2}H /E2ĺcwS̆7VgHl<ӈ =RO0. fxw~[]c])9k>5ZCkTu*NЂ#4vmw^Q$> ޙcS' }:!ma;"s,*`Dwn[g쩛ޟXFa endstream endobj 519 0 obj <>stream xZnmȖe-7Fz eEj_y~ѴY]e_[ﶤl2#eKwTav6kn>*n]+hfNvki[xVMI?̤ Rt&HqUY|:m7҅`m v!D}ɭ2SjNtkI[8۵L[ i>SUEA{v lTǣK;6탟Tu5ںnb9 E7[1XjGZ^7dgQ0eFN0efF0$_9ӯ*z _7eILtIL&dRZ:oԸU2$ʞ歪Y]ީ_Dj#{5XkY\eMɫ=TaS٫TNm嵎j*Akd6l j.6Wu T*Exˈ+r/yRZ٫ Fvj٢`u^]!YQVjv\Wq5 j#qٱ7;re(l-dNjXB]~ ցx"~|O4Y-BxbY:+Λάy!:R&R:Sze/6s-ȔNglRHW8!L \ F~@4, +P|BRUP`o(i#1;/o)kNikpIKt\61bZ 9 )>:A sfY<(sshB@;B8T1lL6,(䍢IHJA nmR }  % Op;Gxm̯q7>}e3Acx[9ggB,.LS㧗 T:H{(U䱥[*:ou|:q"j[ԁZ5XYRwQdL[ D&oc.{=56+.6i]7:Ix|!MZ0RN. _Xhf>g(DtZmwN -E47hĽ;Ejey*/h< Tq~\}؉ g<.G/ȿH_Xnq3E~댫"qֲd٦0ObH`UҔLXWY]t/)gkҒi܂/ ,287+I-LOt"7O]`QAzjO <73iwy{^N\@K)`sݟL4)7Su\2Cϧ+ʟw7NMަ@ 3p5Jz Tk`ʶnnO$aoNosc{ªS\n$'J,y\j2x17v/ o *ci=U⻝~+onaagxPRHol3#v+;45uWWi\Cԛ:mij(emG}U O/jթ"& I?Z$Cqr$n}^1}OK%PK)_`gSv#}e:~BpD{'_Q`\vΘziLwQ&wաtVUӹ8\ @I' ={ k/C!лo[)4 u>Oxq9F8IU璥 _-+CoОN7#N6]0g~lk$ߕ¨[U*+yeOyqxiT4k__n!L,R`k,:"ta[ kh2 ek4hܤ\?(L9+aDdu Gʺт1x:`dW, `^1ȬfUmly>stream xYn7Z zHb AL/o{i%9vb)$MR(6y)I\l4,\0dp9gCj˯oëtwliߔRAa YU7ԺY9x_@w}o\!M] F[)o[[ڮ0+Mkh)n{ShȦl@]m"u! j蕗Vy+گk7+JvrLR/əYѮݮ,eiw;Wt6Vq;B$ѮݶҒxOo;mw8YZNmJ%+B+l+6#>0CPDv2%v}$Gʌ`w׉[*1^*\3 V围L;,?b%ο^4E&w>,)ղ̴Z=q< h_x,No=>ʼnVd'\+~1دxq OmqߟGQDyyaT6$t-1ZC1ϕ LuW?%; ~)810Dn2nrp'>I2=a ͏QjG9-"${fB VhMxrXfC11ŨX(znrW=|T<tS Sg )2x&ރ{ n&~} -K{C+|ɥ.)x+MQ/44B0M:M3ta T<_L.,t}k;_O+Tc / ZOج`o>]$ 2+ 9?}3p⨙_<%zǀsGt?shcYX>+- 缢yE@r W8m^tot)'p K$Ӄ>?۞y~p44ԓ*4䊶ijZ4巂䰿A:8php1_bx.qagP!1fD߂XBۙx !w#8@5R2j(X7*_ !Du+q$kPw-,kcc2~=^gQq̘ s$w>lٲg/ĽxE endstream endobj 521 0 obj <>stream xYKo7-j؎'Mǀkm$JP$ىKQ @ȟOprc۠Xo> : j(ccm-&߆g0qH,rZ}Cu UCWP /4y}{hkج)T_hElhYi[/+{*2wݖs0:&0Ǩ LnAIu+[GO9.;v֞ҌG`2QKeA1c(ʓ4s5b# KCL $}D} tm \w_KZk%{C2lrbIpf"UHQSVj BU(-QFM &}Oz& MM4JSjR֫Ps 'KD4姠M B+-2'L›ܻ%3.$4/ǫ1ٰk²>stream xZn=$@RbǷ(5'0 h\t%mŗ $0#auuL`ܙꪩ{ztǟl~q<~v?3zj+YiK]׳7Bgtɷ0vj}mI6&Я=~C7U4+۳dP7 ZO4sVAoH!R5:!ѭQ.N*ѯ6++Ǝt˶\"[2閝A+Hێ]B1v[ba%eBWD7lW՚e/-t=&-!,Dlm ͂JtöukT[vau͂JtFv<[v 膝^gD Dlou|Nt`7U1+Lzڟ&Mkg<׮ߴӣ%lzQu_퓶t'*6j%}1=I w傃G_~ytq|e_}5_t< 3ׅGuXUK @}CzA䝺 o!;ؾyAŕ{M T& V/I2oāB7wwZ#|P>SbZ" Rmuy_'g*Ρb&axl w0CRfG:0O!WdtF'7_"yɀ3$x)#BLĴ0͍1 X^C j#ߨ,3Wm4JH0eK2|cг2z9<_mM'V3eps?;ľ5Q|"WHz}c$Rs BD[ hJ HCyڃS0K |jfe$>U{ إSFOVS6vC[^&" Aw0܀ZtcDHy= i\]nmM3oF3zߊc>n+/EËMQhI˱QK--Mq=CL;[;\lU%FŽU-EUQMD{m QA+q\IiBkpx7dxw o =6irW; +PZ pcA@-ŵnkBTΟCnTð;wlRðΏоvcӮ?fhǯKksl~e{746,]k]ُ_+Z+|ltncL{G5UGW 'pF$ ·FU!; 'pcnxup#RK@ ={@y77z^OឌPڍj.<:! 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4372 0 obj <> endobj 4373 0 obj <> endobj 4374 0 obj <> endobj 4375 0 obj <> endobj 4376 0 obj <> endobj 4377 0 obj <> endobj 4378 0 obj <> endobj 4379 0 obj <> endobj 4380 0 obj <> endobj 4381 0 obj <> endobj 4382 0 obj <> endobj 4383 0 obj <> endobj 4384 0 obj <> endobj 4385 0 obj <> endobj 4386 0 obj <> endobj 4387 0 obj <> endobj 4388 0 obj <> endobj 4389 0 obj <> endobj 4390 0 obj <> endobj 4391 0 obj <> endobj 4392 0 obj <> endobj 4393 0 obj <> endobj 4394 0 obj <> endobj 4395 0 obj <> endobj 4396 0 obj <> endobj 4397 0 obj <> endobj 4398 0 obj <> endobj 4399 0 obj <> endobj 4400 0 obj <> endobj 4401 0 obj <> endobj 4402 0 obj <> endobj 4403 0 obj <> endobj 4404 0 obj <> endobj 4405 0 obj <> endobj 4406 0 obj <> endobj 4407 0 obj <> endobj 4408 0 obj <> endobj 4409 0 obj <> endobj 4410 0 obj <> endobj 4411 0 obj <> endobj 4412 0 obj <> endobj 4413 0 obj <> endobj 4414 0 obj <> endobj 4415 0 obj <> endobj 4416 0 obj <> endobj 4417 0 obj <> endobj 4418 0 obj <> endobj 4419 0 obj <> endobj 4420 0 obj <> endobj 4421 0 obj <> endobj 4422 0 obj <> endobj 4423 0 obj <> endobj 4424 0 obj <> endobj 4425 0 obj <> endobj 4426 0 obj <> endobj 4427 0 obj <> endobj 4428 0 obj <> endobj 4429 0 obj <> endobj 4430 0 obj <> endobj 4431 0 obj <> endobj 4432 0 obj <> endobj 4433 0 obj <> endobj 4434 0 obj <> endobj 4435 0 obj <> endobj 4436 0 obj <> endobj 4437 0 obj <> endobj 4438 0 obj <> endobj 4439 0 obj <> endobj 4440 0 obj <> endobj 4441 0 obj <> endobj 4442 0 obj <> endobj 4443 0 obj <> endobj 4444 0 obj <> endobj 4445 0 obj <> endobj 4446 0 obj <> endobj 4447 0 obj <> endobj 4448 0 obj <> endobj 4449 0 obj <> endobj 4450 0 obj <> endobj 4451 0 obj <> endobj 4452 0 obj <> endobj 4453 0 obj <> endobj 4454 0 obj <> endobj 4455 0 obj <> endobj 4456 0 obj <> endobj 4457 0 obj <> endobj 4458 0 obj <> endobj 4459 0 obj <> endobj 4460 0 obj <> endobj 4461 0 obj <> endobj 4462 0 obj <> endobj 4463 0 obj <> endobj 4464 0 obj <> endobj 4465 0 obj <> endobj 4466 0 obj <> endobj 4467 0 obj <> endobj 4468 0 obj <> endobj 4469 0 obj <> endobj 4470 0 obj <> endobj 4471 0 obj <> endobj 4472 0 obj <> endobj 4473 0 obj <> endobj 4474 0 obj <> endobj 4475 0 obj <> endobj 4476 0 obj <> endobj 4477 0 obj <> endobj 4478 0 obj <> endobj 4479 0 obj <> endobj 4480 0 obj <> endobj 4481 0 obj <> endobj 4482 0 obj <> endobj 4483 0 obj <> endobj 4484 0 obj <> endobj 4485 0 obj <> endobj 4486 0 obj <> endobj 4487 0 obj <> endobj 4488 0 obj <> endobj 4489 0 obj <> endobj 4490 0 obj <> endobj 4491 0 obj <> endobj 4492 0 obj <> endobj 4493 0 obj <> endobj 4494 0 obj <> endobj 4495 0 obj <> endobj 4496 0 obj <> endobj 4497 0 obj <> endobj 4498 0 obj <> endobj 4499 0 obj <> endobj 4500 0 obj <> endobj 4501 0 obj <> endobj 4502 0 obj <> endobj 4503 0 obj <> endobj 4504 0 obj <> endobj 4505 0 obj <> endobj 4506 0 obj <> endobj 4507 0 obj <> endobj 4508 0 obj <> endobj 4509 0 obj <> endobj 4510 0 obj <> endobj 4511 0 obj <> endobj 4512 0 obj <> endobj 4513 0 obj <>/P 1039 0 R/K[13188 0 R 13189 0 R 13190 0 R]>> endobj 4514 0 obj <>/P 1040 0 R/K[13191 0 R 13192 0 R 13193 0 R]>> endobj 4515 0 obj <>/P 1041 0 R/K[13194 0 R 13195 0 R 13196 0 R]>> endobj 4516 0 obj <>/P 1042 0 R/K[13197 0 R 13198 0 R 13199 0 R]>> endobj 4517 0 obj <>/P 1043 0 R/K[13200 0 R 13201 0 R 13202 0 R]>> endobj 4518 0 obj <>/P 1044 0 R/K[13203 0 R 13204 0 R 13205 0 R]>> endobj 4519 0 obj <>/P 1045 0 R/K[13206 0 R 13207 0 R 13208 0 R]>> endobj 4520 0 obj <>/P 1046 0 R/K[13209 0 R 13210 0 R 13211 0 R]>> endobj 4521 0 obj <>/P 1047 0 R/K[13212 0 R 13213 0 R 13214 0 R]>> endobj 4522 0 obj <>/P 1048 0 R/K[13215 0 R 13216 0 R 13217 0 R]>> endobj 4523 0 obj <>/P 1049 0 R/K[13218 0 R 13219 0 R 13220 0 R]>> endobj 4524 0 obj <>/P 1050 0 R/K[13221 0 R 13222 0 R 13223 0 R]>> endobj 4525 0 obj <>/P 1051 0 R/K[13224 0 R 13225 0 R 13226 0 R]>> endobj 4526 0 obj <>/P 1052 0 R/K[13227 0 R 13228 0 R 13229 0 R]>> endobj 4527 0 obj <>/P 1053 0 R/K[13230 0 R 13231 0 R 13232 0 R]>> endobj 4528 0 obj <>/P 1054 0 R/K[13233 0 R 13234 0 R 13235 0 R]>> endobj 4529 0 obj <>/P 1055 0 R/K[13236 0 R 13237 0 R 13238 0 R]>> endobj 4530 0 obj <>/P 1056 0 R/K[13239 0 R 13240 0 R 13241 0 R]>> endobj 4531 0 obj <>/P 1057 0 R/K[13242 0 R 13243 0 R 13244 0 R]>> endobj 4532 0 obj <>/P 1058 0 R/K[13245 0 R 13246 0 R 13247 0 R]>> endobj 4533 0 obj <>/P 1059 0 R/K[13248 0 R 13249 0 R 13250 0 R]>> endobj 4534 0 obj <>/P 1060 0 R/K[13251 0 R 13252 0 R 13253 0 R]>> endobj 4535 0 obj <>/P 1061 0 R/K[13254 0 R 13255 0 R 13256 0 R]>> endobj 4536 0 obj <>/P 1062 0 R/K[13257 0 R 13258 0 R 13259 0 R]>> endobj 4537 0 obj <>/P 1063 0 R/K[13260 0 R 13261 0 R 13262 0 R]>> endobj 4538 0 obj <>/P 1064 0 R/K[13263 0 R 13264 0 R 13265 0 R]>> endobj 4539 0 obj <>/P 1065 0 R/K[13266 0 R 13267 0 R 13268 0 R]>> endobj 4540 0 obj <>/P 1066 0 R/K[13269 0 R 13270 0 R 13271 0 R]>> endobj 4541 0 obj <>/P 1067 0 R/K[13272 0 R 13273 0 R 13274 0 R]>> endobj 4542 0 obj <>/P 1068 0 R/K[13275 0 R 13276 0 R 13277 0 R]>> endobj 4543 0 obj <>/P 1069 0 R/K[13278 0 R 13279 0 R 13280 0 R]>> endobj 4544 0 obj <>/P 1070 0 R/K[13281 0 R 13282 0 R 13283 0 R]>> endobj 4545 0 obj <>/P 1071 0 R/K[13284 0 R 13285 0 R 13286 0 R]>> endobj 4546 0 obj <>/P 1072 0 R/K[13287 0 R 13288 0 R 13289 0 R]>> endobj 4547 0 obj <>/P 1073 0 R/K[13290 0 R 13291 0 R 13292 0 R]>> endobj 4548 0 obj <>/P 1074 0 R/K[13293 0 R 13294 0 R 13295 0 R]>> endobj 4549 0 obj <>/P 1075 0 R/K[13296 0 R 13297 0 R 13298 0 R]>> endobj 4550 0 obj <>/P 1076 0 R/K[13299 0 R 13300 0 R 13301 0 R]>> endobj 4551 0 obj <>/P 1077 0 R/K[13302 0 R 13303 0 R 13304 0 R]>> endobj 4552 0 obj <>/P 1078 0 R/K[13305 0 R 13306 0 R 13307 0 R]>> endobj 4553 0 obj <>/P 1079 0 R/K[13308 0 R 13309 0 R 13310 0 R]>> endobj 4554 0 obj <>/P 1080 0 R/K[13311 0 R 13312 0 R 13313 0 R]>> endobj 4555 0 obj <>/P 1081 0 R/K[13314 0 R 13315 0 R 13316 0 R]>> endobj 4556 0 obj <>/P 1082 0 R/K[13317 0 R 13318 0 R 13319 0 R]>> endobj 4557 0 obj <>/P 1083 0 R/K[13320 0 R 13321 0 R 13322 0 R]>> endobj 4558 0 obj <>/P 1084 0 R/K[13323 0 R 13324 0 R 13325 0 R]>> endobj 4559 0 obj <>/P 1085 0 R/K[13326 0 R 13327 0 R 13328 0 R]>> endobj 4560 0 obj <>/P 1086 0 R/K[13329 0 R 13330 0 R 13331 0 R]>> endobj 4561 0 obj <>/P 1087 0 R/K[13332 0 R 13333 0 R 13334 0 R]>> endobj 4562 0 obj <>/P 1088 0 R/K[13335 0 R 13336 0 R 13337 0 R]>> endobj 4563 0 obj <>/P 1089 0 R/K[13338 0 R 13339 0 R 13340 0 R]>> endobj 4564 0 obj <>/P 1090 0 R/K[13341 0 R 13342 0 R 13343 0 R]>> endobj 4565 0 obj <>/P 1091 0 R/K[13344 0 R 13345 0 R 13346 0 R]>> endobj 4566 0 obj <>/P 1092 0 R/K[13347 0 R 13348 0 R 13349 0 R]>> endobj 4567 0 obj <>/P 1093 0 R/K[13350 0 R 13351 0 R 13352 0 R]>> endobj 4568 0 obj <>/P 1094 0 R/K[13353 0 R 13354 0 R 13355 0 R]>> endobj 4569 0 obj <>/P 1095 0 R/K[13356 0 R 13357 0 R 13358 0 R]>> endobj 4570 0 obj <>/P 1096 0 R/K[13359 0 R 13360 0 R 13361 0 R]>> endobj 4571 0 obj <>/P 1097 0 R/K[13362 0 R 13363 0 R 13364 0 R]>> endobj 4572 0 obj <>/P 1098 0 R/K[13365 0 R 13366 0 R 13367 0 R]>> endobj 4573 0 obj <>/P 1099 0 R/K[13368 0 R 13369 0 R 13370 0 R]>> endobj 4574 0 obj <>/P 1100 0 R/K[13371 0 R 13372 0 R 13373 0 R]>> endobj 4575 0 obj <> endobj 4576 0 obj <> endobj 4577 0 obj <> endobj 4578 0 obj <> endobj 4579 0 obj <> endobj 4580 0 obj <> endobj 4581 0 obj <> endobj 4582 0 obj <> endobj 4583 0 obj <> endobj 4584 0 obj <> endobj 4585 0 obj <> endobj 4586 0 obj <> endobj 4587 0 obj <> endobj 4588 0 obj <> endobj 4589 0 obj <> endobj 4590 0 obj <> endobj 4591 0 obj <> endobj 4592 0 obj <> endobj 4593 0 obj <> endobj 4594 0 obj <> endobj 4595 0 obj <> endobj 4596 0 obj <> endobj 4597 0 obj <> endobj 4598 0 obj <> endobj 4599 0 obj <> endobj 4600 0 obj <> endobj 4601 0 obj <> endobj 4602 0 obj <> endobj 4603 0 obj <> endobj 4604 0 obj <> endobj 4605 0 obj <> endobj 4606 0 obj <> endobj 4607 0 obj <> endobj 4608 0 obj <> endobj 4609 0 obj <> endobj 4610 0 obj <> endobj 4611 0 obj <> endobj 4612 0 obj <> endobj 4613 0 obj <> endobj 4614 0 obj <> endobj 4615 0 obj <> endobj 4616 0 obj <> endobj 4617 0 obj <> endobj 4618 0 obj <> endobj 4619 0 obj <> endobj 4620 0 obj <> endobj 4621 0 obj <> endobj 4622 0 obj <> endobj 4623 0 obj <> endobj 4624 0 obj <> endobj 4625 0 obj <> endobj 4626 0 obj <> endobj 4627 0 obj <> endobj 4628 0 obj <> endobj 4629 0 obj <> endobj 4630 0 obj <> endobj 4631 0 obj <> endobj 4632 0 obj <> endobj 4633 0 obj <> endobj 4634 0 obj <> endobj 4635 0 obj <> endobj 4636 0 obj <> endobj 4637 0 obj <> endobj 4638 0 obj <> endobj 4639 0 obj <> endobj 4640 0 obj <> endobj 4641 0 obj <> endobj 4642 0 obj <> endobj 4643 0 obj <> endobj 4644 0 obj <> endobj 4645 0 obj <> endobj 4646 0 obj <> endobj 4647 0 obj <> endobj 4648 0 obj <> endobj 4649 0 obj <> endobj 4650 0 obj <> endobj 4651 0 obj <> endobj 4652 0 obj <> endobj 4653 0 obj <> endobj 4654 0 obj <> endobj 4655 0 obj <> endobj 4656 0 obj <> endobj 4657 0 obj <> endobj 4658 0 obj <> endobj 4659 0 obj <> endobj 4660 0 obj <> endobj 4661 0 obj <> endobj 4662 0 obj <> endobj 4663 0 obj <> endobj 4664 0 obj <> endobj 4665 0 obj <> endobj 4666 0 obj <> endobj 4667 0 obj <> endobj 4668 0 obj <> endobj 4669 0 obj <> endobj 4670 0 obj <> endobj 4671 0 obj <> endobj 4672 0 obj <> endobj 4673 0 obj <> endobj 4674 0 obj <> endobj 4675 0 obj <> endobj 4676 0 obj <> endobj 4677 0 obj <> endobj 4678 0 obj <> endobj 4679 0 obj <> endobj 4680 0 obj <> endobj 4681 0 obj <> endobj 4682 0 obj <> endobj 4683 0 obj <> endobj 4684 0 obj <> endobj 4685 0 obj <> endobj 4686 0 obj <> endobj 4687 0 obj <> endobj 4688 0 obj <> endobj 4689 0 obj <> endobj 4690 0 obj <> endobj 4691 0 obj <> endobj 4692 0 obj <> endobj 4693 0 obj <> endobj 4694 0 obj <> endobj 4695 0 obj <> endobj 4696 0 obj <> endobj 4697 0 obj <> endobj 4698 0 obj <> endobj 4699 0 obj <> endobj 4700 0 obj <> endobj 4701 0 obj <> endobj 4702 0 obj <> endobj 4703 0 obj <> endobj 4704 0 obj <> endobj 4705 0 obj <> endobj 4706 0 obj <> endobj 4707 0 obj <> endobj 4708 0 obj <> endobj 4709 0 obj <> endobj 4710 0 obj <> endobj 4711 0 obj <> endobj 4712 0 obj <> endobj 4713 0 obj <> endobj 4714 0 obj <> endobj 4715 0 obj <> endobj 4716 0 obj <> endobj 4717 0 obj <> endobj 4718 0 obj <> endobj 4719 0 obj <> endobj 4720 0 obj <> endobj 4721 0 obj <> endobj 4722 0 obj <> endobj 4723 0 obj <> endobj 4724 0 obj <> endobj 4725 0 obj <> endobj 4726 0 obj <> endobj 4727 0 obj <> endobj 4728 0 obj <> endobj 4729 0 obj <> endobj 4730 0 obj <> endobj 4731 0 obj <> endobj 4732 0 obj <> endobj 4733 0 obj <> endobj 4734 0 obj <> endobj 4735 0 obj <> endobj 4736 0 obj <> endobj 4737 0 obj <> endobj 4738 0 obj <> endobj 4739 0 obj <> endobj 4740 0 obj <> endobj 4741 0 obj <> endobj 4742 0 obj <> endobj 4743 0 obj <> endobj 4744 0 obj <> endobj 4745 0 obj <> endobj 4746 0 obj <> endobj 4747 0 obj <> endobj 4748 0 obj <> endobj 4749 0 obj <> endobj 4750 0 obj <> endobj 4751 0 obj <> endobj 4752 0 obj <> endobj 4753 0 obj <> endobj 4754 0 obj <> endobj 4755 0 obj <> endobj 4756 0 obj <> endobj 4757 0 obj <> endobj 4758 0 obj <> endobj 4759 0 obj <> endobj 4760 0 obj <> endobj 4761 0 obj <> endobj 4762 0 obj <> endobj 4763 0 obj <> endobj 4764 0 obj <> endobj 4765 0 obj <> endobj 4766 0 obj <> endobj 4767 0 obj <> endobj 4768 0 obj <> endobj 4769 0 obj <> endobj 4770 0 obj <> endobj 4771 0 obj <> endobj 4772 0 obj <> endobj 4773 0 obj <> endobj 4774 0 obj <> endobj 4775 0 obj <> endobj 4776 0 obj <> endobj 4777 0 obj <> endobj 4778 0 obj <> endobj 4779 0 obj <> endobj 4780 0 obj <> endobj 4781 0 obj <> endobj 4782 0 obj <> endobj 4783 0 obj <> endobj 4784 0 obj <> endobj 4785 0 obj <> endobj 4786 0 obj <> endobj 4787 0 obj <> endobj 4788 0 obj <> endobj 4789 0 obj <> endobj 4790 0 obj <> endobj 4791 0 obj <> endobj 4792 0 obj <> endobj 4793 0 obj <> endobj 4794 0 obj <> endobj 4795 0 obj <> endobj 4796 0 obj <> endobj 4797 0 obj <> endobj 4798 0 obj <> endobj 4799 0 obj <> endobj 4800 0 obj <> endobj 4801 0 obj <> endobj 4802 0 obj <> endobj 4803 0 obj <> endobj 4804 0 obj <> endobj 4805 0 obj <> endobj 4806 0 obj <> endobj 4807 0 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4855 0 obj <> endobj 4856 0 obj <> endobj 4857 0 obj <> endobj 4858 0 obj <> endobj 4859 0 obj <> endobj 4860 0 obj <> endobj 4861 0 obj <> endobj 4862 0 obj <> endobj 4863 0 obj <> endobj 4864 0 obj <> endobj 4865 0 obj <> endobj 4866 0 obj <> endobj 4867 0 obj <> endobj 4868 0 obj <> endobj 4869 0 obj <> endobj 4870 0 obj <> endobj 4871 0 obj <> endobj 4872 0 obj <> endobj 4873 0 obj <> endobj 4874 0 obj <> endobj 4875 0 obj <> endobj 4876 0 obj <> endobj 4877 0 obj <> endobj 4878 0 obj <> endobj 4879 0 obj <> endobj 4880 0 obj <> endobj 4881 0 obj <> endobj 4882 0 obj <> endobj 4883 0 obj <> endobj 4884 0 obj <> endobj 4885 0 obj <> endobj 4886 0 obj <> endobj 4887 0 obj <> endobj 4888 0 obj <> endobj 4889 0 obj <> endobj 4890 0 obj <> endobj 4891 0 obj <> endobj 4892 0 obj <> endobj 4893 0 obj <> endobj 4894 0 obj <> endobj 4895 0 obj <> endobj 4896 0 obj <> endobj 4897 0 obj <> endobj 4898 0 obj <> endobj 4899 0 obj <> endobj 4900 0 obj <> endobj 4901 0 obj <> endobj 4902 0 obj <> 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0 R/Pg 325 0 R/K[65 66]>> endobj 9810 0 obj <>/P 1138 0 R/Pg 325 0 R/K[67 68]>> endobj 9811 0 obj <>/P 1139 0 R/Pg 325 0 R/K[69 70]>> endobj 9812 0 obj <>/P 1140 0 R/Pg 325 0 R/K[71 72]>> endobj 9813 0 obj <>/P 1141 0 R/Pg 325 0 R/K[73 74]>> endobj 9814 0 obj <>/P 1142 0 R/Pg 325 0 R/K[75 76]>> endobj 9815 0 obj <>/P 1143 0 R/Pg 325 0 R/K[77 78]>> endobj 9816 0 obj <>/P 1144 0 R/Pg 325 0 R/K[79 80]>> endobj 9817 0 obj <>/P 1145 0 R/Pg 325 0 R/K[81 82]>> endobj 9818 0 obj <>/P 1146 0 R/Pg 325 0 R/K[83 84]>> endobj 9819 0 obj <>/P 1147 0 R/Pg 325 0 R/K[85 86]>> endobj 9820 0 obj <>/P 1148 0 R/Pg 325 0 R/K[87 88]>> endobj 9821 0 obj <>/P 1149 0 R/Pg 325 0 R/K[89 90]>> endobj 9822 0 obj <>/P 1150 0 R/Pg 325 0 R/K[91 92]>> endobj 9823 0 obj <>/P 1151 0 R/Pg 325 0 R/K[93 94]>> endobj 9824 0 obj <>/P 1152 0 R/Pg 325 0 R/K[95 96]>> endobj 9825 0 obj <>/P 1153 0 R/Pg 325 0 R/K[97 98]>> endobj 9826 0 obj <>/P 1154 0 R/Pg 325 0 R/K[99 100]>> endobj 9827 0 obj <>/P 1155 0 R/Pg 325 0 R/K[101 102]>> 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0 R/K[8 9]>> endobj 9900 0 obj <>/P 1228 0 R/Pg 326 0 R/K[10 11]>> endobj 9901 0 obj <>/P 1229 0 R/Pg 326 0 R/K[12 13]>> endobj 9902 0 obj <>/P 1230 0 R/Pg 326 0 R/K[14 15]>> endobj 9903 0 obj <>/P 1231 0 R/Pg 326 0 R/K[16 17]>> endobj 9904 0 obj <>/P 1232 0 R/Pg 326 0 R/K[18 19]>> endobj 9905 0 obj <>/P 1233 0 R/Pg 326 0 R/K[20 21]>> endobj 9906 0 obj <>/P 1234 0 R/Pg 326 0 R/K[22 23]>> endobj 9907 0 obj <>/P 1235 0 R/Pg 326 0 R/K[24 25]>> endobj 9908 0 obj <>/P 1236 0 R/Pg 326 0 R/K[26 27]>> endobj 9909 0 obj <>/P 1237 0 R/Pg 326 0 R/K[28 29]>> endobj 9910 0 obj <>/P 1238 0 R/Pg 326 0 R/K[30 31]>> endobj 9911 0 obj <>/P 1239 0 R/Pg 326 0 R/K[32 33]>> endobj 9912 0 obj <>/P 1240 0 R/Pg 326 0 R/K[34 35]>> endobj 9913 0 obj <>/P 1241 0 R/Pg 326 0 R/K[36 37]>> endobj 9914 0 obj <>/P 1242 0 R/Pg 326 0 R/K[38 39]>> endobj 9915 0 obj <>/P 1243 0 R/Pg 326 0 R/K[40 41]>> endobj 9916 0 obj <>/P 1244 0 R/Pg 326 0 R/K[42 43]>> endobj 9917 0 obj <>/P 1245 0 R/Pg 326 0 R/K[44 45]>> endobj 9918 0 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341 0 R/K[152 153]>> endobj 11981 0 obj <>/P 3309 0 R/Pg 341 0 R/K[154 155]>> endobj 11982 0 obj <>/P 3310 0 R/Pg 341 0 R/K[156 157]>> endobj 11983 0 obj <>/P 3311 0 R/Pg 341 0 R/K[158 159]>> endobj 11984 0 obj <>/P 3312 0 R/Pg 341 0 R/K[160 161]>> endobj 11985 0 obj <>/P 3313 0 R/Pg 341 0 R/K[162 163]>> endobj 11986 0 obj <>/P 3314 0 R/Pg 341 0 R/K[164 165]>> endobj 11987 0 obj <>/P 3315 0 R/Pg 341 0 R/K[166 167]>> endobj 11988 0 obj <>/P 3316 0 R/Pg 341 0 R/K[168 169]>> endobj 11989 0 obj <>/P 3317 0 R/Pg 341 0 R/K[170 171]>> endobj 11990 0 obj <>/P 3318 0 R/Pg 341 0 R/K[172 173]>> endobj 11991 0 obj <>/P 3319 0 R/Pg 341 0 R/K[174 175]>> endobj 11992 0 obj <>/P 3320 0 R/Pg 341 0 R/K[176 177]>> endobj 11993 0 obj <>/P 3321 0 R/Pg 341 0 R/K[178 179]>> endobj 11994 0 obj <>/P 3322 0 R/Pg 341 0 R/K[180 181]>> endobj 11995 0 obj <>/P 3323 0 R/Pg 341 0 R/K[182 183]>> endobj 11996 0 obj <>/P 3324 0 R/Pg 341 0 R/K[184 185]>> endobj 11997 0 obj <>/P 3325 0 R/Pg 341 0 R/K[186 187]>> endobj 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95]>> endobj 13171 0 obj <>/P 4499 0 R/Pg 350 0 R/K[96 97]>> endobj 13172 0 obj <>/P 4500 0 R/Pg 350 0 R/K[98 99]>> endobj 13173 0 obj <>/P 4501 0 R/Pg 350 0 R/K[100 101]>> endobj 13174 0 obj <>/P 4502 0 R/Pg 350 0 R/K[102 103]>> endobj 13175 0 obj <>/P 4503 0 R/Pg 350 0 R/K[104 105]>> endobj 13176 0 obj <>/P 4504 0 R/Pg 350 0 R/K[106 107]>> endobj 13177 0 obj <>/P 4505 0 R/Pg 350 0 R/K[108 109]>> endobj 13178 0 obj <>/P 4506 0 R/Pg 350 0 R/K[110 111]>> endobj 13179 0 obj <> endobj 13180 0 obj <> endobj 13181 0 obj <> endobj 13182 0 obj <> endobj 13183 0 obj <> endobj 13184 0 obj <> endobj 13185 0 obj <> endobj 13186 0 obj <> endobj 13187 0 obj <> endobj 13188 0 obj <>/P 4513 0 R/Pg 29 0 R/K 3>> endobj 13189 0 obj <>/P 4513 0 R/Pg 29 0 R/K 4>> endobj 13190 0 obj <>>> endobj 13191 0 obj <>/P 4514 0 R/Pg 29 0 R/K 5>> endobj 13192 0 obj <>/P 4514 0 R/Pg 29 0 R/K 6>> endobj 13193 0 obj <>>> endobj 13194 0 obj <>/P 4515 0 R/Pg 29 0 R/K 7>> endobj 13195 0 obj <>/P 4515 0 R/Pg 29 0 R/K 8>> endobj 13196 0 obj <>>> endobj 13197 0 obj <>/P 4516 0 R/Pg 29 0 R/K 9>> endobj 13198 0 obj <>/P 4516 0 R/Pg 29 0 R/K 10>> endobj 13199 0 obj <>>> endobj 13200 0 obj <>/P 4517 0 R/Pg 29 0 R/K 11>> endobj 13201 0 obj <>/P 4517 0 R/Pg 29 0 R/K 12>> endobj 13202 0 obj <>>> endobj 13203 0 obj <>/P 4518 0 R/Pg 29 0 R/K 13>> endobj 13204 0 obj <>/P 4518 0 R/Pg 29 0 R/K 14>> endobj 13205 0 obj <>>> endobj 13206 0 obj <>/P 4519 0 R/Pg 29 0 R/K 15>> endobj 13207 0 obj <>/P 4519 0 R/Pg 29 0 R/K 16>> endobj 13208 0 obj <>>> endobj 13209 0 obj <>/P 4520 0 R/Pg 29 0 R/K 17>> endobj 13210 0 obj <>/P 4520 0 R/Pg 29 0 R/K 18>> endobj 13211 0 obj <>>> endobj 13212 0 obj <>/P 4521 0 R/Pg 29 0 R/K 19>> endobj 13213 0 obj <>/P 4521 0 R/Pg 29 0 R/K 20>> endobj 13214 0 obj <>>> endobj 13215 0 obj <>/P 4522 0 R/Pg 29 0 R/K 21>> endobj 13216 0 obj <>/P 4522 0 R/Pg 29 0 R/K 22>> endobj 13217 0 obj <>>> endobj 13218 0 obj <>/P 4523 0 R/Pg 29 0 R/K 23>> endobj 13219 0 obj <>/P 4523 0 R/Pg 29 0 R/K 24>> endobj 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13293 0 obj <>/P 4548 0 R/Pg 29 0 R/K 73>> endobj 13294 0 obj <>/P 4548 0 R/Pg 29 0 R/K 74>> endobj 13295 0 obj <>>> endobj 13296 0 obj <>/P 4549 0 R/Pg 29 0 R/K 75>> endobj 13297 0 obj <>/P 4549 0 R/Pg 29 0 R/K 76>> endobj 13298 0 obj <>>> endobj 13299 0 obj <>/P 4550 0 R/Pg 29 0 R/K 77>> endobj 13300 0 obj <>/P 4550 0 R/Pg 29 0 R/K 78>> endobj 13301 0 obj <>>> endobj 13302 0 obj <>/P 4551 0 R/Pg 29 0 R/K 79>> endobj 13303 0 obj <>/P 4551 0 R/Pg 29 0 R/K 80>> endobj 13304 0 obj <>>> endobj 13305 0 obj <>/P 4552 0 R/Pg 29 0 R/K 81>> endobj 13306 0 obj <>/P 4552 0 R/Pg 29 0 R/K 82>> endobj 13307 0 obj <>>> endobj 13308 0 obj <>/P 4553 0 R/Pg 29 0 R/K 83>> endobj 13309 0 obj <>/P 4553 0 R/Pg 29 0 R/K 84>> endobj 13310 0 obj <>>> endobj 13311 0 obj <>/P 4554 0 R/Pg 29 0 R/K 85>> endobj 13312 0 obj <>/P 4554 0 R/Pg 29 0 R/K 86>> endobj 13313 0 obj <>>> endobj 13314 0 obj <>/P 4555 0 R/Pg 29 0 R/K 87>> endobj 13315 0 obj <>/P 4555 0 R/Pg 29 0 R/K 88>> endobj 13316 0 obj <>>> endobj 13317 0 obj <>/P 4556 0 R/Pg 30 0 R/K 0>> endobj 13318 0 obj <>/P 4556 0 R/Pg 30 0 R/K 1>> endobj 13319 0 obj <>>> endobj 13320 0 obj <>/P 4557 0 R/Pg 30 0 R/K 2>> endobj 13321 0 obj <>/P 4557 0 R/Pg 30 0 R/K 3>> endobj 13322 0 obj <>>> endobj 13323 0 obj <>/P 4558 0 R/Pg 30 0 R/K 4>> endobj 13324 0 obj <>/P 4558 0 R/Pg 30 0 R/K 5>> endobj 13325 0 obj <>>> endobj 13326 0 obj <>/P 4559 0 R/Pg 30 0 R/K 6>> endobj 13327 0 obj <>/P 4559 0 R/Pg 30 0 R/K 7>> endobj 13328 0 obj <>>> endobj 13329 0 obj <>/P 4560 0 R/Pg 30 0 R/K 8>> endobj 13330 0 obj <>/P 4560 0 R/Pg 30 0 R/K 9>> endobj 13331 0 obj <>>> endobj 13332 0 obj <>/P 4561 0 R/Pg 30 0 R/K 10>> endobj 13333 0 obj <>/P 4561 0 R/Pg 30 0 R/K 11>> endobj 13334 0 obj <>>> endobj 13335 0 obj <>/P 4562 0 R/Pg 30 0 R/K 12>> endobj 13336 0 obj <>/P 4562 0 R/Pg 30 0 R/K 13>> endobj 13337 0 obj <>>> endobj 13338 0 obj <>/P 4563 0 R/Pg 30 0 R/K 14>> endobj 13339 0 obj <>/P 4563 0 R/Pg 30 0 R/K 15>> endobj 13340 0 obj <>>> endobj 13341 0 obj <>/P 4564 0 R/Pg 30 0 R/K 16>> endobj 13342 0 obj <>/P 4564 0 R/Pg 30 0 R/K 17>> endobj 13343 0 obj <>>> endobj 13344 0 obj <>/P 4565 0 R/Pg 30 0 R/K 18>> endobj 13345 0 obj <>/P 4565 0 R/Pg 30 0 R/K 19>> endobj 13346 0 obj <>>> endobj 13347 0 obj <>/P 4566 0 R/Pg 30 0 R/K 20>> endobj 13348 0 obj <>/P 4566 0 R/Pg 30 0 R/K 21>> endobj 13349 0 obj <>>> endobj 13350 0 obj <>/P 4567 0 R/Pg 30 0 R/K 22>> endobj 13351 0 obj <>/P 4567 0 R/Pg 30 0 R/K 23>> endobj 13352 0 obj <>>> endobj 13353 0 obj <>/P 4568 0 R/Pg 30 0 R/K 24>> endobj 13354 0 obj <>/P 4568 0 R/Pg 30 0 R/K 25>> endobj 13355 0 obj <>>> endobj 13356 0 obj <>/P 4569 0 R/Pg 30 0 R/K 26>> endobj 13357 0 obj <>/P 4569 0 R/Pg 30 0 R/K 27>> endobj 13358 0 obj <>>> endobj 13359 0 obj <>/P 4570 0 R/Pg 30 0 R/K 28>> endobj 13360 0 obj <>/P 4570 0 R/Pg 30 0 R/K 29>> endobj 13361 0 obj <>>> endobj 13362 0 obj <>/P 4571 0 R/Pg 30 0 R/K 30>> endobj 13363 0 obj <>/P 4571 0 R/Pg 30 0 R/K 31>> endobj 13364 0 obj <>>> endobj 13365 0 obj <>/P 4572 0 R/Pg 30 0 R/K 32>> endobj 13366 0 obj <>/P 4572 0 R/Pg 30 0 R/K 33>> endobj 13367 0 obj <>>> endobj 13368 0 obj <>/P 4573 0 R/Pg 30 0 R/K 34>> endobj 13369 0 obj <>/P 4573 0 R/Pg 30 0 R/K 35>> endobj 13370 0 obj <>>> endobj 13371 0 obj <>/P 4574 0 R/Pg 30 0 R/K 36>> endobj 13372 0 obj <>/P 4574 0 R/Pg 30 0 R/K 37>> endobj 13373 0 obj <>>> endobj 13374 0 obj <>/Alt(\(Begin bold\) Drug \(End bold\))/ID(Drug)/P 4575 0 R/K 26902 0 R>> endobj 13375 0 obj <>/Alt(\(Begin bold\) Status \(End bold\))/ID(Status)/P 4575 0 R/K 26903 0 R>> endobj 13376 0 obj <>/Alt(\(Begin bold\) Notes \(End bold\))/ID(Notes)/P 4575 0 R/K 26904 0 R>> endobj 13377 0 obj <>/Alt(\(Begin bold\) Allergy \(End bold\))/P 4576 0 R/K 26905 0 R>> endobj 13378 0 obj <>/Alt(\(Begin bold\) 2Nd Gen Antihistamine & Decongestant Combinations \(End bold\))/P 4577 0 R/K 26906 0 R>> endobj 13379 0 obj <>/Alt(CLARINEX-D 12 HOUR ORAL TABLET, ER MULTIPHASE 12 HR 2.5-120 MG)/P 4578 0 R/K 26907 0 R>> endobj 13380 0 obj <>/Alt(Tier 3)/P 4578 0 R/K 26908 0 R>> endobj 13381 0 obj <>/Alt(ST: Requires prior prescription for Desloratadine or Levocetirizine tablets within the past 120 days; QL \(2 EA per 1 day\))/P 4578 0 R/K 26909 0 R>> endobj 13382 0 obj <>/Alt(\(Begin bold\) Allergenic Extracts, Therapeutics \(End bold\))/P 4579 0 R/K 26910 0 R>> endobj 13383 0 obj <>/Alt(GRASTEK SUBLINGUAL TABLET 2,800 BAU)/P 4580 0 R/K 26911 0 R>> endobj 13384 0 obj <>/Alt(Tier 2)/P 4580 0 R/K 26912 0 R>> endobj 13385 0 obj <>/Alt(PA)/P 4580 0 R/K 26913 0 R>> endobj 13386 0 obj <>/Alt(ODACTRA SUBLINGUAL TABLET 12 SQ-HDM)/P 4581 0 R/K 26914 0 R>> endobj 13387 0 obj <>/Alt(Tier 2)/P 4581 0 R/K 26915 0 R>> endobj 13388 0 obj <>/Alt(PA)/P 4581 0 R/K 26916 0 R>> endobj 13389 0 obj <>/Alt(ORALAIR SUBLINGUAL TABLET 100 INDX REACTIVITY, 300 INDX REACTIVITY)/P 4582 0 R/K 26917 0 R>> endobj 13390 0 obj <>/Alt(Tier 2)/P 4582 0 R/K 26918 0 R>> endobj 13391 0 obj <>/Alt(PA)/P 4582 0 R/K 26919 0 R>> endobj 13392 0 obj <>/Alt(ORALAIR SUBLINGUAL TABLET 100 IR \(3\) /300 IR \(6\))/P 4583 0 R/K 26920 0 R>> endobj 13393 0 obj <>/Alt(Tier 3)/P 4583 0 R/K 26921 0 R>> endobj 13394 0 obj <>/Alt(PA)/P 4583 0 R/K 26922 0 R>> endobj 13395 0 obj <>/Alt(PALFORZIA \(LEVEL 0\) ORAL CAPSULE, SPRINKLE 1 MG)/P 4584 0 R/K 26923 0 R>> endobj 13396 0 obj <>/Alt(Tier 2)/P 4584 0 R/K 26924 0 R>> endobj 13397 0 obj <>/Alt(PA; SP)/P 4584 0 R/K 26925 0 R>> endobj 13398 0 obj <>/Alt(PALFORZIA \(LEVEL 1\) ORAL CAPSULE, SPRINKLE 3 MG \(1 MG X 3\))/P 4585 0 R/K 26926 0 R>> endobj 13399 0 obj <>/Alt(Tier 2)/P 4585 0 R/K 26927 0 R>> endobj 13400 0 obj <>/Alt(PA; SP)/P 4585 0 R/K 26928 0 R>> endobj 13401 0 obj <>/Alt(PALFORZIA \(LEVEL 2\) ORAL CAPSULE, SPRINKLE 6 MG \(1 MG X 6\))/P 4586 0 R/K 26929 0 R>> endobj 13402 0 obj <>/Alt(Tier 2)/P 4586 0 R/K 26930 0 R>> endobj 13403 0 obj <>/Alt(PA; SP)/P 4586 0 R/K 26931 0 R>> endobj 13404 0 obj <>/Alt(PALFORZIA \(LEVEL 3\) ORAL CAPSULE, SPRINKLE 12 MG \(1 MG X 2, 10 MG X 1\))/P 4587 0 R/K 26932 0 R>> endobj 13405 0 obj <>/Alt(Tier 2)/P 4587 0 R/K 26933 0 R>> endobj 13406 0 obj <>/Alt(PA; SP)/P 4587 0 R/K 26934 0 R>> endobj 13407 0 obj <>/Alt(PALFORZIA \(LEVEL 4\) ORAL CAPSULE, SPRINKLE 20 MG)/P 4588 0 R/K 26935 0 R>> endobj 13408 0 obj <>/Alt(Tier 2)/P 4588 0 R/K 26936 0 R>> endobj 13409 0 obj <>/Alt(PA; SP)/P 4588 0 R/K 26937 0 R>> endobj 13410 0 obj <>/Alt(PALFORZIA \(LEVEL 5\) ORAL CAPSULE, SPRINKLE 40 MG \(20 MG X 2\))/P 4589 0 R/K 26938 0 R>> endobj 13411 0 obj <>/Alt(Tier 2)/P 4589 0 R/K 26939 0 R>> endobj 13412 0 obj <>/Alt(PA; SP)/P 4589 0 R/K 26940 0 R>> endobj 13413 0 obj <>/Alt(PALFORZIA \(LEVEL 6\) ORAL CAPSULE, SPRINKLE 80 MG \(20 MG X 4\))/P 4590 0 R/K 26941 0 R>> endobj 13414 0 obj <>/Alt(Tier 2)/P 4590 0 R/K 26942 0 R>> endobj 13415 0 obj <>/Alt(PA; SP)/P 4590 0 R/K 26943 0 R>> endobj 13416 0 obj <>/Alt(PALFORZIA \(LEVEL 7\) ORAL CAPSULE, SPRINKLE 120 MG \(20 MG X 1, 100 MG X 1\))/P 4591 0 R/K 26944 0 R>> endobj 13417 0 obj <>/Alt(Tier 2)/P 4591 0 R/K 26945 0 R>> endobj 13418 0 obj <>/Alt(PA; SP)/P 4591 0 R/K 26946 0 R>> endobj 13419 0 obj <>/Alt(PALFORZIA \(LEVEL 8\) ORAL CAPSULE, SPRINKLE 160 MG \(20 MG X 3, 100 MG X1\))/P 4592 0 R/K 26947 0 R>> endobj 13420 0 obj <>/Alt(Tier 2)/P 4592 0 R/K 26948 0 R>> endobj 13421 0 obj <>/Alt(PA; SP)/P 4592 0 R/K 26949 0 R>> endobj 13422 0 obj <>/Alt(PALFORZIA \(LEVEL 9\) ORAL CAPSULE, SPRINKLE 200 MG \(100 MG X 2\))/P 4593 0 R/K 26950 0 R>> endobj 13423 0 obj <>/Alt(Tier 2)/P 4593 0 R/K 26951 0 R>> endobj 13424 0 obj <>/Alt(PA; SP)/P 4593 0 R/K 26952 0 R>> endobj 13425 0 obj <>/Alt(PALFORZIA \(LEVEL 10\) ORAL CAPSULE, SPRINKLE 240 MG \(20 MG X 2, 100 MG X 2\))/P 4594 0 R/K 26953 0 R>> endobj 13426 0 obj <>/Alt(Tier 2)/P 4594 0 R/K 26954 0 R>> endobj 13427 0 obj <>/Alt(PA; SP)/P 4594 0 R/K 26955 0 R>> endobj 13428 0 obj <>/Alt(PALFORZIA \(LEVEL 11 UP-DOSE\) ORAL POWDER IN PACKET 300 MG)/P 4595 0 R/K 26956 0 R>> endobj 13429 0 obj <>/Alt(Tier 2)/P 4595 0 R/K 26957 0 R>> endobj 13430 0 obj <>/Alt(PA; SP)/P 4595 0 R/K 26958 0 R>> endobj 13431 0 obj <>/Alt(PALFORZIA INITIAL \(1-3 YRS\) ORAL CAPSULE, SPRINKLE 0.5/1/1.5/3 MG)/P 4596 0 R/K 26959 0 R>> endobj 13432 0 obj <>/Alt(Tier 2)/P 4596 0 R/K 26960 0 R>> endobj 13433 0 obj <>/Alt(PA; SP)/P 4596 0 R/K 26961 0 R>> endobj 13434 0 obj <>/Alt(PALFORZIA INITIAL \(4-17 YRS\) ORAL CAPSULE, SPRINKLE 0.5/1/1.5/3/6 MG)/P 4597 0 R/K 26962 0 R>> endobj 13435 0 obj <>/Alt(Tier 2)/P 4597 0 R/K 26963 0 R>> endobj 13436 0 obj <>/Alt(PA; SP)/P 4597 0 R/K 26964 0 R>> endobj 13437 0 obj <>/Alt(PALFORZIA LEVEL 11 MAINTENANCE ORAL POWDER IN PACKET 300 MG)/P 4598 0 R/K 26965 0 R>> endobj 13438 0 obj <>/Alt(Tier 2)/P 4598 0 R/K 26966 0 R>> endobj 13439 0 obj <>/Alt(PA; SP)/P 4598 0 R/K 26967 0 R>> endobj 13440 0 obj <>/Alt(RAGWITEK SUBLINGUAL TABLET 12 AMB A 1 UNIT)/P 4599 0 R/K 26968 0 R>> endobj 13441 0 obj <>/Alt(Tier 2)/P 4599 0 R/K 26969 0 R>> endobj 13442 0 obj <>/Alt(PA)/P 4599 0 R/K 26970 0 R>> endobj 13443 0 obj <>/Alt(\(Begin bold\) Antihistamines - 1St Generation \(End bold\))/P 4600 0 R/K 26971 0 R>> endobj 13444 0 obj <>/Alt(\(Begin italic\) carbinoxamine maleate oral liquid \(End italic\) \(Begin italic\) 4 mg/5 ml \(End italic\))/P 4601 0 R/K 26972 0 R>> endobj 13445 0 obj <>/Alt(Tier 1)/P 4601 0 R/K 26973 0 R>> endobj 13446 0 obj <>/Alt(Age \(Min 2 Years\))/P 4601 0 R/K 26974 0 R>> endobj 13447 0 obj <>/Alt(\(Begin italic\) carbinoxamine maleate oral suspension,extended rel 12 hr \(End italic\) \(Begin italic\) 4 mg/5 ml \(End italic\))/P 4602 0 R/K 26975 0 R>> endobj 13448 0 obj <>/Alt(\(Karbinal ER\))/P 4602 0 R/K 26976 0 R>> endobj 13449 0 obj <>/Alt(Tier 1)/P 4602 0 R/K 26977 0 R>> endobj 13450 0 obj <>/Alt(ST: Requires prior prescription for immediate release Carbinoxamine Maleate oral solution within the past 120 days; QL \(960 ML per 30 days\); Age \(Min 2 Years\))/P 4602 0 R/K 26978 0 R>> endobj 13451 0 obj <>/Alt(\(Begin italic\) carbinoxamine maleate oral tablet \(End italic\) \(Begin italic\) 4 mg \(End italic\))/P 4603 0 R/K 26979 0 R>> endobj 13452 0 obj <>/Alt(Tier 1)/P 4603 0 R/K 26980 0 R>> endobj 13453 0 obj <>/Alt(Age \(Min 2 Years\))/P 4603 0 R/K 26981 0 R>> endobj 13454 0 obj <>/Alt(\(Begin italic\) clemastine oral tablet \(End italic\) \(Begin italic\) 2.68 mg \(End italic\))/P 4604 0 R/K 26982 0 R>> endobj 13455 0 obj <>/Alt(Tier 1)/P 4604 0 R/K 26983 0 R>> endobj 13456 0 obj <>/Alt(\(Begin italic\) cyproheptadine oral syrup \(End italic\) \(Begin italic\) 2 mg/5 ml \(End italic\))/P 4605 0 R/K 26984 0 R>> endobj 13457 0 obj <>/Alt(Tier 1)/P 4605 0 R/K 26985 0 R>> endobj 13458 0 obj <>/Alt(\(Begin italic\) cyproheptadine oral tablet \(End italic\) \(Begin italic\) 4 mg \(End italic\))/P 4606 0 R/K 26986 0 R>> endobj 13459 0 obj <>/Alt(Tier 1)/P 4606 0 R/K 26987 0 R>> endobj 13460 0 obj <>/Alt(DIPHEN ORAL ELIXIR 12.5 MG/5 ML)/P 4607 0 R/K 26988 0 R>> endobj 13461 0 obj <>/Alt(\(diphenhydramine hcl\))/P 4607 0 R/K 26989 0 R>> endobj 13462 0 obj <>/Alt(Tier 1)/P 4607 0 R/K 26990 0 R>> endobj 13463 0 obj <>/Alt(\(Begin italic\) hydroxyzine hcl oral solution \(End italic\) \(Begin italic\) 10 mg/5 ml \(End italic\))/P 4608 0 R/K 26991 0 R>> endobj 13464 0 obj <>/Alt(Tier 1)/P 4608 0 R/K 26992 0 R>> endobj 13465 0 obj <>/Alt(\(Begin italic\) hydroxyzine hcl oral tablet \(End italic\) \(Begin italic\) 10 mg, 25 mg, 50 mg \(End italic\))/P 4609 0 R/K 26993 0 R>> endobj 13466 0 obj <>/Alt(Tier 1)/P 4609 0 R/K 26994 0 R>> endobj 13467 0 obj <>/Alt(\(Begin italic\) hydroxyzine pamoate oral capsule \(End italic\) \(Begin italic\) 100 mg, 25 mg, 50 mg \(End italic\))/P 4610 0 R/K 26995 0 R>> endobj 13468 0 obj <>/Alt(Tier 1)/P 4610 0 R/K 26996 0 R>> endobj 13469 0 obj <>/Alt(KARBINAL ER ORAL SUSPENSION,EXTENDED REL 12 HR 4 MG/5 ML)/P 4611 0 R/K 26997 0 R>> endobj 13470 0 obj <>/Alt(\(carbinoxamine maleate\))/P 4611 0 R/K 26998 0 R>> endobj 13471 0 obj <>/Alt(Tier 3)/P 4611 0 R/K 26999 0 R>> endobj 13472 0 obj <>/Alt(ST: Requires prior prescription for immediate release Carbinoxamine Maleate oral solution within the past 120 days; QL \(960 ML per 30 days\); Age \(Min 2 Years\))/P 4611 0 R/K 27000 0 R>> endobj 13473 0 obj <>/Alt(\(Begin italic\) promethazine injection solution \(End italic\) \(Begin italic\) 25 mg/ml, 50 mg/ml \(End italic\))/P 4612 0 R/K 27001 0 R>> endobj 13474 0 obj <>/Alt(\(Phenergan\))/P 4612 0 R/K 27002 0 R>> endobj 13475 0 obj <>/Alt(Tier 1)/P 4612 0 R/K 27003 0 R>> endobj 13476 0 obj <>/Alt(\(Begin italic\) promethazine oral syrup \(End italic\) \(Begin italic\) 6.25 mg/5 ml \(End italic\))/P 4613 0 R/K 27004 0 R>> endobj 13477 0 obj <>/Alt(Tier 1)/P 4613 0 R/K 27005 0 R>> endobj 13478 0 obj <>/Alt(\(Begin italic\) promethazine oral tablet \(End italic\) \(Begin italic\) 12.5 mg, 25 mg, 50 mg \(End italic\))/P 4614 0 R/K 27006 0 R>> endobj 13479 0 obj <>/Alt(Tier 1)/P 4614 0 R/K 27007 0 R>> endobj 13480 0 obj <>/Alt(\(Begin bold\) Antihistamines - 2Nd Generation \(End bold\))/P 4615 0 R/K 27008 0 R>> endobj 13481 0 obj <>/Alt(\(Begin italic\) cetirizine oral solution \(End italic\) \(Begin italic\) 1 mg/ml \(End italic\))/P 4616 0 R/K 27009 0 R>> endobj 13482 0 obj <>/Alt(\(Allergy Relief \(cetirizine\)\))/P 4616 0 R/K 27010 0 R>> endobj 13483 0 obj <>/Alt(Tier 1)/P 4616 0 R/K 27011 0 R>> endobj 13484 0 obj <>/Alt(\(Begin italic\) desloratadine oral tablet \(End italic\) \(Begin italic\) 5 mg \(End italic\))/P 4617 0 R/K 27012 0 R>> endobj 13485 0 obj <>/Alt(\(Clarinex\))/P 4617 0 R/K 27013 0 R>> endobj 13486 0 obj <>/Alt(Tier 1)/P 4617 0 R/K 27014 0 R>> endobj 13487 0 obj <>/Alt(QL \(1 EA per 1 day\))/P 4617 0 R/K 27015 0 R>> endobj 13488 0 obj <>/Alt(\(Begin italic\) desloratadine oral tablet,disintegrating \(End italic\) \(Begin italic\) 2.5 mg, 5 mg \(End italic\))/P 4618 0 R/K 27016 0 R>> endobj 13489 0 obj <>/Alt(Tier 1)/P 4618 0 R/K 27017 0 R>> endobj 13490 0 obj <>/Alt(ST: Requires prior prescription for Desloratadine or Levocetirizine tablets within the past 120 days; QL \(1 EA per 1 day\))/P 4618 0 R/K 27018 0 R>> endobj 13491 0 obj <>/Alt(\(Begin italic\) levocetirizine oral solution \(End italic\) \(Begin italic\) 2.5 mg/5 ml \(End italic\))/P 4619 0 R/K 27019 0 R>> endobj 13492 0 obj <>/Alt(\(Xyzal\))/P 4619 0 R/K 27020 0 R>> endobj 13493 0 obj <>/Alt(Tier 1)/P 4619 0 R/K 27021 0 R>> endobj 13494 0 obj <>/Alt(ST: Requires prior prescription for Desloratadine or Levocetirizine tablets within the past 120 days; QL \(10 ML per 1 day\))/P 4619 0 R/K 27022 0 R>> endobj 13495 0 obj <>/Alt(\(Begin italic\) levocetirizine oral tablet \(End italic\) \(Begin italic\) 5 mg \(End italic\))/P 4620 0 R/K 27023 0 R>> endobj 13496 0 obj <>/Alt(\(24HR Allergy Relief\))/P 4620 0 R/K 27024 0 R>> endobj 13497 0 obj <>/Alt(Tier 1)/P 4620 0 R/K 27025 0 R>> endobj 13498 0 obj <>/Alt(\(Begin bold\) Nasal Antihistamine \(End bold\))/P 4621 0 R/K 27026 0 R>> endobj 13499 0 obj <>/Alt(\(Begin italic\) azelastine nasal spray,non-aerosol \(End italic\) \(Begin italic\) 137 mcg \(0.1 %\) \(End italic\))/P 4622 0 R/K 27027 0 R>> endobj 13500 0 obj <>/Alt(Tier 1)/P 4622 0 R/K 27028 0 R>> endobj 13501 0 obj <>/Alt(QL \(60 ML per 30 days\))/P 4622 0 R/K 27029 0 R>> endobj 13502 0 obj <>/Alt(\(Begin italic\) azelastine nasal spray,non-aerosol \(End italic\) \(Begin italic\) 205.5 mcg \(0.15 %\) \(End italic\))/P 4623 0 R/K 27030 0 R>> endobj 13503 0 obj <>/Alt(\(Astepro Allergy\))/P 4623 0 R/K 27031 0 R>> endobj 13504 0 obj <>/Alt(Tier 1)/P 4623 0 R/K 27032 0 R>> endobj 13505 0 obj <>/Alt(QL \(60 ML per 30 days\))/P 4623 0 R/K 27033 0 R>> endobj 13506 0 obj <>/Alt(\(Begin italic\) olopatadine nasal spray,non-aerosol \(End italic\) \(Begin italic\) 0.6 % \(End italic\))/P 4624 0 R/K 27034 0 R>> endobj 13507 0 obj <>/Alt(Tier 1)/P 4624 0 R/K 27035 0 R>> endobj 13508 0 obj <>/Alt(QL \(30.5 GM per 30 days\))/P 4624 0 R/K 27036 0 R>> endobj 13509 0 obj <>/Alt(\(Begin bold\) Nasal Antihistamine & Anti-Inflam. Steroid Comb. \(End bold\))/P 4625 0 R/K 27037 0 R>> endobj 13510 0 obj <>/Alt(\(Begin italic\) azelastine-fluticasone nasal spray,non-aerosol \(End italic\) \(Begin italic\) 137-50 mcg/spray \(End italic\))/P 4626 0 R/K 27038 0 R>> endobj 13511 0 obj <>/Alt(\(Dymista\))/P 4626 0 R/K 27039 0 R>> endobj 13512 0 obj <>/Alt(Tier 1)/P 4626 0 R/K 27040 0 R>> endobj 13513 0 obj <>/Alt(ST: Requires prior prescription for Flunisolide \(nasal formulation\) or Fluticasone within the past 120 days; QL \(23 GM per 30 days\))/P 4626 0 R/K 27041 0 R>> endobj 13514 0 obj <>/Alt(\(Begin bold\) Nasal Anti-Inflammatory Steroids \(End bold\))/P 4627 0 R/K 27042 0 R>> endobj 13515 0 obj <>/Alt(\(Begin italic\) flunisolide nasal spray,non-aerosol \(End italic\) \(Begin italic\) 25 mcg \(0.025 %\) \(End italic\))/P 4628 0 R/K 27043 0 R>> endobj 13516 0 obj <>/Alt(Tier 1)/P 4628 0 R/K 27044 0 R>> endobj 13517 0 obj <>/Alt(QL \(25 ML per 30 days\))/P 4628 0 R/K 27045 0 R>> endobj 13518 0 obj <>/Alt(\(Begin italic\) fluticasone propionate nasal spray,suspension \(End italic\) \(Begin italic\) 50 mcg/actuation \(End italic\))/P 4629 0 R/K 27046 0 R>> endobj 13519 0 obj <>/Alt(\(24 Hour Allergy Relief\))/P 4629 0 R/K 27047 0 R>> endobj 13520 0 obj <>/Alt(Tier 1)/P 4629 0 R/K 27048 0 R>> endobj 13521 0 obj <>/Alt(QL \(16 GM per 30 days\))/P 4629 0 R/K 27049 0 R>> endobj 13522 0 obj <>/Alt(\(Begin italic\) mometasone nasal spray,non-aerosol \(End italic\) \(Begin italic\) 50 mcg/actuation \(End italic\))/P 4630 0 R/K 27050 0 R>> endobj 13523 0 obj <>/Alt(\(Allergy Nasal \(mometasone\)\))/P 4630 0 R/K 27051 0 R>> endobj 13524 0 obj <>/Alt(Tier 1)/P 4630 0 R/K 27052 0 R>> endobj 13525 0 obj <>/Alt(QL \(17 GM per 30 days\))/P 4630 0 R/K 27053 0 R>> endobj 13526 0 obj <>/Alt(QNASL NASAL HFA AEROSOL INHALER 40 MCG/ACTUATION)/P 4631 0 R/K 27054 0 R>> endobj 13527 0 obj <>/Alt(Tier 2)/P 4631 0 R/K 27055 0 R>> endobj 13528 0 obj <>/Alt(QL \(6.8 GM per 30 days\))/P 4631 0 R/K 27056 0 R>> endobj 13529 0 obj <>/Alt(QNASL NASAL HFA AEROSOL INHALER 80 MCG/ACTUATION)/P 4632 0 R/K 27057 0 R>> endobj 13530 0 obj <>/Alt(Tier 2)/P 4632 0 R/K 27058 0 R>> endobj 13531 0 obj <>/Alt(QL \(10.6 GM per 30 days\))/P 4632 0 R/K 27059 0 R>> endobj 13532 0 obj <>/Alt(XHANCE NASAL AEROSOL BREATH ACTIVATED 93 MCG/ACTUATION)/P 4633 0 R/K 27060 0 R>> endobj 13533 0 obj <>/Alt(Tier 2)/P 4633 0 R/K 27061 0 R>> endobj 13534 0 obj <>/Alt(ST: Requires prior prescription for one of the following intranasal corticosteroids: Flunisolide, Fluticasone Propionate, or Mometasone within the past 120 days; QL \(32 ML per 30 days\))/P 4633 0 R/K 27062 0 R>> endobj 13535 0 obj <>/Alt(\(Begin bold\) Antiemesis/Antivertigo \(End bold\))/P 4634 0 R/K 27063 0 R>> endobj 13536 0 obj <>/Alt(\(Begin bold\) Antiemetic, Cannibinoid-Type \(End bold\))/P 4635 0 R/K 27064 0 R>> endobj 13537 0 obj <>/Alt(\(Begin italic\) dronabinol oral capsule \(End italic\) \(Begin italic\) 10 mg, 5 mg \(End italic\))/P 4636 0 R/K 27065 0 R>> endobj 13538 0 obj <>/Alt(\(Marinol\))/P 4636 0 R/K 27066 0 R>> endobj 13539 0 obj <>/Alt(Tier 1)/P 4636 0 R/K 27067 0 R>> endobj 13540 0 obj <>/Alt(ST: Requires prior prescription for a 5HT3 antagoist, corticosteroid, Emend, or Megestrol suspension within the past 120 days; QL \(2 EA per 1 day\))/P 4636 0 R/K 27068 0 R>> endobj 13541 0 obj <>/Alt(\(Begin italic\) dronabinol oral capsule \(End italic\) \(Begin italic\) 2.5 mg \(End italic\))/P 4637 0 R/K 27069 0 R>> endobj 13542 0 obj <>/Alt(Tier 1)/P 4637 0 R/K 27070 0 R>> endobj 13543 0 obj <>/Alt(ST: Requires prior prescription for a 5HT3 antagoist, corticosteroid, Emend, or Megestrol suspension within the past 120 days; QL \(2 EA per 1 day\))/P 4637 0 R/K 27071 0 R>> endobj 13544 0 obj <>/Alt(SYNDROS ORAL SOLUTION 5 MG/ML)/P 4638 0 R/K 27072 0 R>> endobj 13545 0 obj <>/Alt(Tier 3)/P 4638 0 R/K 27073 0 R>> endobj 13546 0 obj <>/Alt(ST: Requires prior prescription for generic Dronabinol capsules or Megestrol suspension within the past 120 days; QL \(60 ML per 30 days\))/P 4638 0 R/K 27074 0 R>> endobj 13547 0 obj <>/Alt(\(Begin bold\) Antiemetic/Antivertigo Agents \(End bold\))/P 4639 0 R/K 27075 0 R>> endobj 13548 0 obj <>/Alt(AKYNZEO \(NETUPITANT\) ORAL CAPSULE 300-0.5 MG)/P 4640 0 R/K 27076 0 R>> endobj 13549 0 obj <>/Alt(Tier 2)/P 4640 0 R/K 27077 0 R>> endobj 13550 0 obj <>/Alt(QL \(1 EA per 28 days\))/P 4640 0 R/K 27078 0 R>> endobj 13551 0 obj <>/Alt(\(Begin italic\) aprepitant oral capsule \(End italic\) \(Begin italic\) 125 mg \(End italic\))/P 4641 0 R/K 27079 0 R>> endobj 13552 0 obj <>/Alt(Tier 1)/P 4641 0 R/K 27080 0 R>> endobj 13553 0 obj <>/Alt(QL \(1 EA per 21 days\))/P 4641 0 R/K 27081 0 R>> endobj 13554 0 obj <>/Alt(\(Begin italic\) aprepitant oral capsule \(End italic\) \(Begin italic\) 40 mg \(End italic\))/P 4642 0 R/K 27082 0 R>> endobj 13555 0 obj <>/Alt(Tier 1)/P 4642 0 R/K 27083 0 R>> endobj 13556 0 obj <>/Alt(QL \(1 EA per 28 days\))/P 4642 0 R/K 27084 0 R>> endobj 13557 0 obj <>/Alt(\(Begin italic\) aprepitant oral capsule \(End italic\) \(Begin italic\) 80 mg \(End italic\))/P 4643 0 R/K 27085 0 R>> endobj 13558 0 obj <>/Alt(\(Emend\))/P 4643 0 R/K 27086 0 R>> endobj 13559 0 obj <>/Alt(Tier 1)/P 4643 0 R/K 27087 0 R>> endobj 13560 0 obj <>/Alt(QL \(2 EA per 21 days\))/P 4643 0 R/K 27088 0 R>> endobj 13561 0 obj <>/Alt(\(Begin italic\) aprepitant oral capsule,dose pack \(End italic\) \(Begin italic\) 125 mg \(1\)- 80 mg \(2\) \(End italic\))/P 4644 0 R/K 27089 0 R>> endobj 13562 0 obj <>/Alt(\(Emend\))/P 4644 0 R/K 27090 0 R>> endobj 13563 0 obj <>/Alt(Tier 1)/P 4644 0 R/K 27091 0 R>> endobj 13564 0 obj <>/Alt(QL \(3 EA per 21 days\))/P 4644 0 R/K 27092 0 R>> endobj 13565 0 obj <>/Alt(COMPRO RECTAL SUPPOSITORY 25 MG)/P 4645 0 R/K 27093 0 R>> endobj 13566 0 obj <>/Alt(\(prochlorperazine\))/P 4645 0 R/K 27094 0 R>> endobj 13567 0 obj <>/Alt(Tier 1)/P 4645 0 R/K 27095 0 R>> endobj 13568 0 obj <>/Alt(\(Begin italic\) doxylamine-pyridoxine \(vit b6\) oral tablet,delayed release \(dr/ec\) \(End italic\) \(Begin italic\) 10-10 mg \(End italic\))/P 4646 0 R/K 27096 0 R>> endobj 13569 0 obj <>/Alt(\(Diclegis\))/P 4646 0 R/K 27097 0 R>> endobj 13570 0 obj <>/Alt(Tier 1)/P 4646 0 R/K 27098 0 R>> endobj 13571 0 obj <>/Alt(QL \(120 EA per 30 days\))/P 4646 0 R/K 27099 0 R>> endobj 13572 0 obj <>/Alt(EMEND ORAL SUSPENSION FOR RECONSTITUTION 125 MG \(25 MG/ ML FINAL CONC.\))/P 4647 0 R/K 27100 0 R>> endobj 13573 0 obj <>/Alt(Tier 2)/P 4647 0 R/K 27101 0 R>> endobj 13574 0 obj <>/Alt(QL \(3 EA per 21 days\))/P 4647 0 R/K 27102 0 R>> endobj 13575 0 obj <>/Alt(\(Begin italic\) granisetron hcl oral tablet \(End italic\) \(Begin italic\) 1 mg \(End italic\))/P 4648 0 R/K 27103 0 R>> endobj 13576 0 obj <>/Alt(Tier 1)/P 4648 0 R/K 27104 0 R>> endobj 13577 0 obj <>/Alt(ST: Requires prior prescription for Ondansetron tablets or ODT within the past 120 days; QL \(8 EA per 30 days\))/P 4648 0 R/K 27105 0 R>> endobj 13578 0 obj <>/Alt(\(Begin italic\) meclizine oral tablet \(End italic\) \(Begin italic\) 12.5 mg \(End italic\))/P 4649 0 R/K 27106 0 R>> endobj 13579 0 obj <>/Alt(Tier 1)/P 4649 0 R/K 27107 0 R>> endobj 13580 0 obj <>/Alt(\(Begin italic\) meclizine oral tablet \(End italic\) \(Begin italic\) 25 mg \(End italic\))/P 4650 0 R/K 27108 0 R>> endobj 13581 0 obj <>/Alt(\(Dramamine \(meclizine\)\))/P 4650 0 R/K 27109 0 R>> endobj 13582 0 obj <>/Alt(Tier 1)/P 4650 0 R/K 27110 0 R>> endobj 13583 0 obj <>/Alt(\(Begin italic\) ondansetron hcl oral solution \(End italic\) \(Begin italic\) 4 mg/5 ml \(End italic\))/P 4651 0 R/K 27111 0 R>> endobj 13584 0 obj <>/Alt(Tier 1)/P 4651 0 R/K 27112 0 R>> endobj 13585 0 obj <>/Alt(QL \(50 ML per 15 days\))/P 4651 0 R/K 27113 0 R>> endobj 13586 0 obj <>/Alt(\(Begin italic\) ondansetron hcl oral tablet \(End italic\) \(Begin italic\) 4 mg, 8 mg \(End italic\))/P 4652 0 R/K 27114 0 R>> endobj 13587 0 obj <>/Alt(Tier 1)/P 4652 0 R/K 27115 0 R>> endobj 13588 0 obj <>/Alt(\(Begin italic\) ondansetron oral tablet,disintegrating \(End italic\) \(Begin italic\) 4 mg, 8 mg \(End italic\))/P 4653 0 R/K 27116 0 R>> endobj 13589 0 obj <>/Alt(Tier 1)/P 4653 0 R/K 27117 0 R>> endobj 13590 0 obj <>/Alt(\(Begin italic\) prochlorperazine maleate oral tablet \(End italic\) \(Begin italic\) 10 mg, 5 mg \(End italic\))/P 4654 0 R/K 27118 0 R>> endobj 13591 0 obj <>/Alt(\(Compazine\))/P 4654 0 R/K 27119 0 R>> endobj 13592 0 obj <>/Alt(Tier 1)/P 4654 0 R/K 27120 0 R>> endobj 13593 0 obj <>/Alt(\(Begin italic\) prochlorperazine rectal suppository \(End italic\) \(Begin italic\) 25 mg \(End italic\))/P 4655 0 R/K 27121 0 R>> endobj 13594 0 obj <>/Alt(\(Compro\))/P 4655 0 R/K 27122 0 R>> endobj 13595 0 obj <>/Alt(Tier 1)/P 4655 0 R/K 27123 0 R>> endobj 13596 0 obj <>/Alt(\(Begin italic\) promethazine rectal suppository \(End italic\) \(Begin italic\) 12.5 mg, 25 mg, 50 mg \(End italic\))/P 4656 0 R/K 27124 0 R>> endobj 13597 0 obj <>/Alt(\(Promethegan\))/P 4656 0 R/K 27125 0 R>> endobj 13598 0 obj <>/Alt(Tier 1)/P 4656 0 R/K 27126 0 R>> endobj 13599 0 obj <>/Alt(PROMETHEGAN RECTAL SUPPOSITORY 12.5 MG, 25 MG, 50 MG)/P 4657 0 R/K 27127 0 R>> endobj 13600 0 obj <>/Alt(\(promethazine\))/P 4657 0 R/K 27128 0 R>> endobj 13601 0 obj <>/Alt(Tier 1)/P 4657 0 R/K 27129 0 R>> endobj 13602 0 obj <>/Alt(SANCUSO TRANSDERMAL PATCH WEEKLY 3.1 MG/24 HOUR)/P 4658 0 R/K 27130 0 R>> endobj 13603 0 obj <>/Alt(Tier 3)/P 4658 0 R/K 27131 0 R>> endobj 13604 0 obj <>/Alt(ST: Requires prior prescription for Ondansetron tablets or ODT within the past 120 days; QL \(1 EA per 7 days\))/P 4658 0 R/K 27132 0 R>> endobj 13605 0 obj <>/Alt(\(Begin italic\) scopolamine base transdermal patch 3 day \(End italic\) \(Begin italic\) 1 mg over 3 days \(End italic\))/P 4659 0 R/K 27133 0 R>> endobj 13606 0 obj <>/Alt(\(Transderm-Scop\))/P 4659 0 R/K 27134 0 R>> endobj 13607 0 obj <>/Alt(Tier 1)/P 4659 0 R/K 27135 0 R>> endobj 13608 0 obj <>/Alt(\(Begin italic\) trimethobenzamide oral capsule \(End italic\) \(Begin italic\) 300 mg \(End italic\))/P 4660 0 R/K 27136 0 R>> endobj 13609 0 obj <>/Alt(Tier 1)/P 4660 0 R/K 27137 0 R>> endobj 13610 0 obj <>/Alt(VARUBI ORAL TABLET 90 MG)/P 4661 0 R/K 27138 0 R>> endobj 13611 0 obj <>/Alt(Tier 3)/P 4661 0 R/K 27139 0 R>> endobj 13612 0 obj <>/Alt(QL \(2 EA per 14 days\))/P 4661 0 R/K 27140 0 R>> endobj 13613 0 obj <>/Alt(\(Begin bold\) Asthma And Copd \(End bold\))/P 4662 0 R/K 27141 0 R>> endobj 13614 0 obj <>/Alt(\(Begin bold\) Anticholinergic, Orally Inhaled Short Acting \(End bold\))/P 4663 0 R/K 27142 0 R>> endobj 13615 0 obj <>/Alt(ATROVENT HFA INHALATION HFA AEROSOL INHALER 17 MCG/ACTUATION)/P 4664 0 R/K 27143 0 R>> endobj 13616 0 obj <>/Alt(Tier 2)/P 4664 0 R/K 27144 0 R>> endobj 13617 0 obj <>/Alt(QL \(25.8 GM per 30 days\))/P 4664 0 R/K 27145 0 R>> endobj 13618 0 obj <>/Alt(\(Begin italic\) ipratropium bromide inhalation solution \(End italic\) \(Begin italic\) 0.02 % \(End italic\))/P 4665 0 R/K 27146 0 R>> endobj 13619 0 obj <>/Alt(Tier 1)/P 4665 0 R/K 27147 0 R>> endobj 13620 0 obj <>/Alt(\(Begin bold\) Anticholinergics, Orally Inhaled Long Acting \(End bold\))/P 4666 0 R/K 27148 0 R>> endobj 13621 0 obj <>/Alt(SPIRIVA RESPIMAT INHALATION MIST 1.25 MCG/ACTUATION, 2.5 MCG/ACTUATION)/P 4667 0 R/K 27149 0 R>> endobj 13622 0 obj <>/Alt(Tier 2)/P 4667 0 R/K 27150 0 R>> endobj 13623 0 obj <>/Alt(QL \(4 GM per 30 days\))/P 4667 0 R/K 27151 0 R>> endobj 13624 0 obj <>/Alt(SPIRIVA WITH HANDIHALER INHALATION CAPSULE, W/INHALATION DEVICE 18 MCG)/P 4668 0 R/K 27152 0 R>> endobj 13625 0 obj <>/Alt(\(tiotropium bromide\))/P 4668 0 R/K 27153 0 R>> endobj 13626 0 obj <>/Alt(Tier 1)/P 4668 0 R/K 27154 0 R>> endobj 13627 0 obj <>/Alt(QL \(30 EA per 30 days\))/P 4668 0 R/K 27155 0 R>> endobj 13628 0 obj <>/Alt(\(Begin bold\) Beta-Adrenergic Agents \(End bold\))/P 4669 0 R/K 27156 0 R>> endobj 13629 0 obj <>/Alt(\(Begin italic\) albuterol sulfate oral syrup \(End italic\) \(Begin italic\) 2 mg/5 ml \(End italic\))/P 4670 0 R/K 27157 0 R>> endobj 13630 0 obj <>/Alt(Tier 1)/P 4670 0 R/K 27158 0 R>> endobj 13631 0 obj <>/Alt(\(Begin italic\) albuterol sulfate oral tablet \(End italic\) \(Begin italic\) 2 mg, 4 mg \(End italic\))/P 4671 0 R/K 27159 0 R>> endobj 13632 0 obj <>/Alt(Tier 1)/P 4671 0 R/K 27160 0 R>> endobj 13633 0 obj <>/Alt(\(Begin italic\) albuterol sulfate oral tablet extended release 12 hr \(End italic\) \(Begin italic\) 4 mg, 8 mg \(End italic\))/P 4672 0 R/K 27161 0 R>> endobj 13634 0 obj <>/Alt(Tier 1)/P 4672 0 R/K 27162 0 R>> endobj 13635 0 obj <>/Alt(\(Begin italic\) terbutaline oral tablet \(End italic\) \(Begin italic\) 2.5 mg, 5 mg \(End italic\))/P 4673 0 R/K 27163 0 R>> endobj 13636 0 obj <>/Alt(Tier 1)/P 4673 0 R/K 27164 0 R>> endobj 13637 0 obj <>/Alt(\(Begin bold\) Beta-Adrenergic Agents, Inhaled, Short Acting \(End bold\))/P 4674 0 R/K 27165 0 R>> endobj 13638 0 obj <>/Alt(\(Begin italic\) albuterol sulfate inhalation hfa aerosol inhaler \(End italic\) \(Begin italic\) 90 mcg/actuation \(End italic\))/P 4675 0 R/K 27166 0 R>> endobj 13639 0 obj <>/Alt(\(Ventolin HFA\))/P 4675 0 R/K 27167 0 R>> endobj 13640 0 obj <>/Alt(Tier 1)/P 4675 0 R/K 27168 0 R>> endobj 13641 0 obj <>/Alt(\(Begin italic\) albuterol sulfate inhalation solution for nebulization \(End italic\) \(Begin italic\) 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3 ml \(0.083 %\), 2.5 mg/0.5 ml, 5 mg/ml \(End italic\))/P 4676 0 R/K 27169 0 R>> endobj 13642 0 obj <>/Alt(Tier 1)/P 4676 0 R/K 27170 0 R>> endobj 13643 0 obj <>/Alt(\(Begin italic\) levalbuterol hcl inhalation solution for nebulization \(End italic\) \(Begin italic\) 0.31 mg/3 ml, 0.63 mg/3 ml, 1.25 mg/0.5 ml, 1.25 mg/3 ml \(End italic\))/P 4677 0 R/K 27171 0 R>> endobj 13644 0 obj <>/Alt(Tier 1)/P 4677 0 R/K 27172 0 R>> endobj 13645 0 obj <>/Alt(\(Begin italic\) levalbuterol tartrate inhalation hfa aerosol inhaler \(End italic\) \(Begin italic\) 45 mcg/actuation \(End italic\))/P 4678 0 R/K 27173 0 R>> endobj 13646 0 obj <>/Alt(\(Xopenex HFA\))/P 4678 0 R/K 27174 0 R>> endobj 13647 0 obj <>/Alt(Tier 1)/P 4678 0 R/K 27175 0 R>> endobj 13648 0 obj <>/Alt(\(Begin bold\) Beta-Adrenergic Agents, Inhaled, Ultra-Long Acting \(End bold\))/P 4679 0 R/K 27176 0 R>> endobj 13649 0 obj <>/Alt(STRIVERDI RESPIMAT INHALATION MIST 2.5 MCG/ACTUATION)/P 4680 0 R/K 27177 0 R>> endobj 13650 0 obj <>/Alt(Tier 2)/P 4680 0 R/K 27178 0 R>> endobj 13651 0 obj <>/Alt(QL \(4 GM per 30 days\))/P 4680 0 R/K 27179 0 R>> endobj 13652 0 obj <>/Alt(\(Begin bold\) Beta-Adrenergic Agents, Orally Inhaled,Long Acting \(End bold\))/P 4681 0 R/K 27180 0 R>> endobj 13653 0 obj <>/Alt(\(Begin italic\) arformoterol inhalation solution for nebulization \(End italic\) \(Begin italic\) 15 mcg/2 ml \(End italic\))/P 4682 0 R/K 27181 0 R>> endobj 13654 0 obj <>/Alt(\(Brovana\))/P 4682 0 R/K 27182 0 R>> endobj 13655 0 obj <>/Alt(Tier 1)/P 4682 0 R/K 27183 0 R>> endobj 13656 0 obj <>/Alt(QL \(120 ML per 30 days\))/P 4682 0 R/K 27184 0 R>> endobj 13657 0 obj 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endobj 13796 0 obj <>/Alt(PA)/P 4735 0 R/K 27324 0 R>> endobj 13797 0 obj <>/Alt(\(Begin italic\) roflumilast oral tablet \(End italic\) \(Begin italic\) 250 mcg, 500 mcg \(End italic\))/P 4736 0 R/K 27325 0 R>> endobj 13798 0 obj <>/Alt(\(Daliresp\))/P 4736 0 R/K 27326 0 R>> endobj 13799 0 obj <>/Alt(Tier 1)/P 4736 0 R/K 27327 0 R>> endobj 13800 0 obj <>/Alt(QL \(1 EA per 1 day\))/P 4736 0 R/K 27328 0 R>> endobj 13801 0 obj <>/Alt(\(Begin bold\) Respiratory Aids,Devices,Equipment \(End bold\))/P 4737 0 R/K 27329 0 R>> endobj 13802 0 obj <>/Alt(ACE AEROSOL CLOUD ENHANCER SPACER)/P 4738 0 R/K 27330 0 R>> endobj 13803 0 obj <>/Alt(\(inhalational spacing device\))/P 4738 0 R/K 27331 0 R>> endobj 13804 0 obj <>/Alt(Tier 3)/P 4738 0 R/K 27332 0 R>> endobj 13805 0 obj <>/Alt(AEROBIKA OSCILLATING PEP SYSTM DEVICE)/P 4739 0 R/K 27333 0 R>> endobj 13806 0 obj <>/Alt(Tier 3)/P 4739 0 R/K 27334 0 R>> endobj 13807 0 obj <>/Alt(AEROCHAMBER MECHANICAL VENT SPACER)/P 4740 0 R/K 27335 0 R>> endobj 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0 R>> endobj 14174 0 obj <>/Alt(Tier 3)/P 4880 0 R/K 27702 0 R>> endobj 14175 0 obj <>/Alt(VIXONE NEBULIZER-PEDIATRIC MSK)/P 4881 0 R/K 27703 0 R>> endobj 14176 0 obj <>/Alt(\(nebulizers\))/P 4881 0 R/K 27704 0 R>> endobj 14177 0 obj <>/Alt(Tier 3)/P 4881 0 R/K 27705 0 R>> endobj 14178 0 obj <>/Alt(VORTEX HOLDING CHAMBER SPACER)/P 4882 0 R/K 27706 0 R>> endobj 14179 0 obj <>/Alt(\(inhalational spacing device\))/P 4882 0 R/K 27707 0 R>> endobj 14180 0 obj <>/Alt(Tier 3)/P 4882 0 R/K 27708 0 R>> endobj 14181 0 obj <>/Alt(VORTEX VHC FROG MASK-CHILD SPACER)/P 4883 0 R/K 27709 0 R>> endobj 14182 0 obj <>/Alt(Tier 3)/P 4883 0 R/K 27710 0 R>> endobj 14183 0 obj <>/Alt(VORTEX VHC LADYBUG MASK-TODDLR SPACER)/P 4884 0 R/K 27711 0 R>> endobj 14184 0 obj <>/Alt(Tier 3)/P 4884 0 R/K 27712 0 R>> endobj 14185 0 obj <>/Alt(VORTEX VHC PEDIATRIC MASK SPACER)/P 4885 0 R/K 27713 0 R>> endobj 14186 0 obj <>/Alt(Tier 3)/P 4885 0 R/K 27714 0 R>> endobj 14187 0 obj <>/Alt(WILLIS THE WHALE COMPRESSR NEB 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14210 0 obj <>/Alt(\(Begin italic\) theophylline oral tablet extended release 12 hr \(End italic\) \(Begin italic\) 100 mg, 200 mg, 300 mg, 450 mg \(End italic\))/P 4896 0 R/K 27738 0 R>> endobj 14211 0 obj <>/Alt(Tier 1)/P 4896 0 R/K 27739 0 R>> endobj 14212 0 obj <>/Alt(\(Begin italic\) theophylline oral tablet extended release 24 hr \(End italic\) \(Begin italic\) 400 mg, 600 mg \(End italic\))/P 4897 0 R/K 27740 0 R>> endobj 14213 0 obj <>/Alt(Tier 1)/P 4897 0 R/K 27741 0 R>> endobj 14214 0 obj <>/Alt(\(Begin bold\) Autonomic Nervous System Disorders \(End bold\))/P 4898 0 R/K 27742 0 R>> endobj 14215 0 obj <>/Alt(\(Begin bold\) Alzheimer's Therapy, Nmda Receptor Antagonists \(End bold\))/P 4899 0 R/K 27743 0 R>> endobj 14216 0 obj <>/Alt(\(Begin italic\) memantine oral capsule,sprinkle,er 24hr \(End italic\) \(Begin italic\) 14 mg, 21 mg, 28 mg \(End italic\))/P 4900 0 R/K 27744 0 R>> endobj 14217 0 obj <>/Alt(Tier 1)/P 4900 0 R/K 27745 0 R>> endobj 14218 0 obj <>/Alt(ST: Requires 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4906 0 R/K 27764 0 R>> endobj 14237 0 obj <>/Alt(\(Begin italic\) memantine-donepezil oral capsule,sprinkle,er 24hr \(End italic\) \(Begin italic\) 14-10 mg, 21-10 mg, 28-10 mg \(End italic\))/P 4907 0 R/K 27765 0 R>> endobj 14238 0 obj <>/Alt(\(Namzaric\))/P 4907 0 R/K 27766 0 R>> endobj 14239 0 obj <>/Alt(Tier 1)/P 4907 0 R/K 27767 0 R>> endobj 14240 0 obj <>/Alt(ST: Requires prior prescriptions for Donepezil and Memantine within the past 365 days; QL \(1 EA per 1 day\))/P 4907 0 R/K 27768 0 R>> endobj 14241 0 obj <>/Alt(NAMZARIC ORAL CAPSULE,SPRINKLE,ER 24HR 21-10 MG)/P 4908 0 R/K 27769 0 R>> endobj 14242 0 obj <>/Alt(\(memantine-donepezil\))/P 4908 0 R/K 27770 0 R>> endobj 14243 0 obj <>/Alt(Tier 3)/P 4908 0 R/K 27771 0 R>> endobj 14244 0 obj <>/Alt(ST: Requires prior prescriptions for Donepezil and Memantine within the past 365 days; QL \(1 EA per 1 day\))/P 4908 0 R/K 27772 0 R>> endobj 14245 0 obj <>/Alt(NAMZARIC ORAL CAPSULE,SPRINKLE,ER 24HR 7-10 MG)/P 4909 0 R/K 27773 0 R>> endobj 14246 0 obj <>/Alt(Tier 2)/P 4909 0 R/K 27774 0 R>> endobj 14247 0 obj <>/Alt(ST: Requires prior prescriptions for Donepezil and Memantine within the past 365 days; QL \(1 EA per 1 day\))/P 4909 0 R/K 27775 0 R>> endobj 14248 0 obj <>/Alt(\(Begin bold\) Cholinesterase Inhibitors \(End bold\))/P 4910 0 R/K 27776 0 R>> endobj 14249 0 obj <>/Alt(\(Begin italic\) donepezil oral tablet \(End italic\) \(Begin italic\) 10 mg, 23 mg, 5 mg \(End italic\))/P 4911 0 R/K 27777 0 R>> endobj 14250 0 obj <>/Alt(\(Aricept\))/P 4911 0 R/K 27778 0 R>> endobj 14251 0 obj <>/Alt(Tier 1)/P 4911 0 R/K 27779 0 R>> endobj 14252 0 obj <>/Alt(\(Begin italic\) donepezil oral tablet,disintegrating \(End italic\) \(Begin italic\) 10 mg, 5 mg \(End italic\))/P 4912 0 R/K 27780 0 R>> endobj 14253 0 obj <>/Alt(Tier 1)/P 4912 0 R/K 27781 0 R>> endobj 14254 0 obj <>/Alt(\(Begin italic\) galantamine oral capsule,ext rel. pellets 24 hr \(End italic\) \(Begin italic\) 16 mg, 24 mg, 8 mg \(End italic\))/P 4913 0 R/K 27782 0 R>> endobj 14255 0 obj <>/Alt(Tier 1)/P 4913 0 R/K 27783 0 R>> endobj 14256 0 obj <>/Alt(QL \(30 EA per 30 days\))/P 4913 0 R/K 27784 0 R>> endobj 14257 0 obj <>/Alt(\(Begin italic\) galantamine oral solution \(End italic\) \(Begin italic\) 4 mg/ml \(End italic\))/P 4914 0 R/K 27785 0 R>> endobj 14258 0 obj <>/Alt(Tier 1)/P 4914 0 R/K 27786 0 R>> endobj 14259 0 obj <>/Alt(QL \(200 ML per 30 days\))/P 4914 0 R/K 27787 0 R>> endobj 14260 0 obj <>/Alt(\(Begin italic\) galantamine oral tablet \(End italic\) \(Begin italic\) 12 mg, 4 mg, 8 mg \(End italic\))/P 4915 0 R/K 27788 0 R>> endobj 14261 0 obj <>/Alt(Tier 1)/P 4915 0 R/K 27789 0 R>> endobj 14262 0 obj <>/Alt(QL \(60 EA per 30 days\))/P 4915 0 R/K 27790 0 R>> endobj 14263 0 obj <>/Alt(\(Begin italic\) pyridostigmine bromide oral syrup \(End italic\) \(Begin italic\) 60 mg/5 ml \(End italic\))/P 4916 0 R/K 27791 0 R>> endobj 14264 0 obj <>/Alt(\(Mestinon\))/P 4916 0 R/K 27792 0 R>> endobj 14265 0 obj <>/Alt(Tier 1)/P 4916 0 R/K 27793 0 R>> endobj 14266 0 obj <>/Alt(\(Begin italic\) pyridostigmine bromide oral tablet \(End italic\) \(Begin italic\) 30 mg \(End italic\))/P 4917 0 R/K 27794 0 R>> endobj 14267 0 obj <>/Alt(Tier 1)/P 4917 0 R/K 27795 0 R>> endobj 14268 0 obj <>/Alt(\(Begin italic\) pyridostigmine bromide oral tablet \(End italic\) \(Begin italic\) 60 mg \(End italic\))/P 4918 0 R/K 27796 0 R>> endobj 14269 0 obj <>/Alt(\(Mestinon\))/P 4918 0 R/K 27797 0 R>> endobj 14270 0 obj <>/Alt(Tier 1)/P 4918 0 R/K 27798 0 R>> endobj 14271 0 obj <>/Alt(\(Begin italic\) pyridostigmine bromide oral tablet extended release \(End italic\) \(Begin italic\) 180 mg \(End italic\))/P 4919 0 R/K 27799 0 R>> endobj 14272 0 obj <>/Alt(\(Mestinon Timespan\))/P 4919 0 R/K 27800 0 R>> endobj 14273 0 obj <>/Alt(Tier 1)/P 4919 0 R/K 27801 0 R>> endobj 14274 0 obj <>/Alt(\(Begin italic\) rivastigmine tartrate oral capsule \(End italic\) \(Begin italic\) 1.5 mg, 3 mg, 4.5 mg, 6 mg \(End italic\))/P 4920 0 R/K 27802 0 R>> endobj 14275 0 obj <>/Alt(Tier 1)/P 4920 0 R/K 27803 0 R>> endobj 14276 0 obj <>/Alt(\(Begin italic\) rivastigmine transdermal patch 24 hour \(End italic\) \(Begin italic\) 13.3 mg/24 hour, 4.6 mg/24 hour, 9.5 mg/24 hour \(End italic\))/P 4921 0 R/K 27804 0 R>> endobj 14277 0 obj <>/Alt(\(Exelon Patch\))/P 4921 0 R/K 27805 0 R>> endobj 14278 0 obj <>/Alt(Tier 1)/P 4921 0 R/K 27806 0 R>> endobj 14279 0 obj <>/Alt(QL \(30 EA per 30 days\))/P 4921 0 R/K 27807 0 R>> endobj 14280 0 obj <>/Alt(\(Begin bold\) Behavioral Health - Antidepressants \(End bold\))/P 4922 0 R/K 27808 0 R>> endobj 14281 0 obj <>/Alt(\(Begin bold\) Alpha-2 Receptor Antagonist Antidepressants \(End bold\))/P 4923 0 R/K 27809 0 R>> endobj 14282 0 obj <>/Alt(\(Begin italic\) mirtazapine oral tablet \(End italic\) \(Begin italic\) 15 mg, 30 mg \(End italic\))/P 4924 0 R/K 27810 0 R>> endobj 14283 0 obj <>/Alt(\(Remeron\))/P 4924 0 R/K 27811 0 R>> endobj 14284 0 obj <>/Alt(Tier 1)/P 4924 0 R/K 27812 0 R>> endobj 14285 0 obj <>/Alt(\(Begin italic\) mirtazapine oral tablet \(End italic\) \(Begin italic\) 45 mg, 7.5 mg \(End italic\))/P 4925 0 R/K 27813 0 R>> endobj 14286 0 obj <>/Alt(Tier 1)/P 4925 0 R/K 27814 0 R>> endobj 14287 0 obj <>/Alt(\(Begin italic\) mirtazapine oral tablet,disintegrating \(End italic\) \(Begin italic\) 15 mg, 30 mg, 45 mg \(End italic\))/P 4926 0 R/K 27815 0 R>> endobj 14288 0 obj <>/Alt(\(Remeron SolTab\))/P 4926 0 R/K 27816 0 R>> endobj 14289 0 obj <>/Alt(Tier 1)/P 4926 0 R/K 27817 0 R>> endobj 14290 0 obj <>/Alt(\(Begin bold\) Antidepressant - Nmda Receptor Antagonist \(End bold\))/P 4927 0 R/K 27818 0 R>> endobj 14291 0 obj <>/Alt(SPRAVATO NASAL SPRAY,NON-AEROSOL 28 MG, 56 MG \(28 MG X 2\), 84 MG \(28 MG X 3\))/P 4928 0 R/K 27819 0 R>> endobj 14292 0 obj <>/Alt(Tier 3)/P 4928 0 R/K 27820 0 R>> endobj 14293 0 obj <>/Alt(PA; SP)/P 4928 0 R/K 27821 0 R>> endobj 14294 0 obj <>/Alt(\(Begin bold\) Antidepressant - Postpartum Depression \(Ppd\) \(End bold\))/P 4929 0 R/K 27822 0 R>> endobj 14295 0 obj <>/Alt(ZURZUVAE ORAL CAPSULE 20 MG, 25 MG, 30 MG)/P 4930 0 R/K 27823 0 R>> endobj 14296 0 obj <>/Alt(Tier 2)/P 4930 0 R/K 27824 0 R>> endobj 14297 0 obj <>/Alt(PA; SP)/P 4930 0 R/K 27825 0 R>> endobj 14298 0 obj <>/Alt(\(Begin bold\) Maois - Non-Selective & Irreversible \(End bold\))/P 4931 0 R/K 27826 0 R>> endobj 14299 0 obj <>/Alt(MARPLAN ORAL TABLET 10 MG)/P 4932 0 R/K 27827 0 R>> endobj 14300 0 obj <>/Alt(Tier 3)/P 4932 0 R/K 27828 0 R>> endobj 14301 0 obj <>/Alt(\(Begin italic\) phenelzine oral tablet \(End italic\) \(Begin italic\) 15 mg \(End italic\))/P 4933 0 R/K 27829 0 R>> endobj 14302 0 obj <>/Alt(\(Nardil\))/P 4933 0 R/K 27830 0 R>> endobj 14303 0 obj <>/Alt(Tier 1)/P 4933 0 R/K 27831 0 R>> endobj 14304 0 obj <>/Alt(\(Begin italic\) tranylcypromine oral tablet \(End italic\) \(Begin italic\) 10 mg \(End italic\))/P 4934 0 R/K 27832 0 R>> endobj 14305 0 obj <>/Alt(\(Parnate\))/P 4934 0 R/K 27833 0 R>> endobj 14306 0 obj <>/Alt(Tier 1)/P 4934 0 R/K 27834 0 R>> endobj 14307 0 obj <>/Alt(\(Begin bold\) Monoamine Oxidase\(Mao\) Inhibitors \(End bold\))/P 4935 0 R/K 27835 0 R>> endobj 14308 0 obj <>/Alt(EMSAM TRANSDERMAL PATCH 24 HOUR 12 MG/24 HR, 6 MG/24 HR, 9 MG/24 HR)/P 4936 0 R/K 27836 0 R>> endobj 14309 0 obj <>/Alt(Tier 3)/P 4936 0 R/K 27837 0 R>> endobj 14310 0 obj <>/Alt(QL \(1 EA per 1 day\))/P 4936 0 R/K 27838 0 R>> endobj 14311 0 obj <>/Alt(\(Begin bold\) Ndma Receptor Antagonist And Ndri Comb \(End bold\))/P 4937 0 R/K 27839 0 R>> endobj 14312 0 obj <>/Alt(AUVELITY ORAL TABLET, IR AND ER, BIPHASIC 45-105 MG)/P 4938 0 R/K 27840 0 R>> endobj 14313 0 obj <>/Alt(Tier 3)/P 4938 0 R/K 27841 0 R>> endobj 14314 0 obj <>/Alt(\(Begin bold\) Norepinephrine And Dopamine Reuptake Inhib \(Ndris\) \(End bold\))/P 4939 0 R/K 27842 0 R>> endobj 14315 0 obj <>/Alt(\(Begin italic\) bupropion hcl oral tablet \(End italic\) \(Begin italic\) 100 mg, 75 mg \(End italic\))/P 4940 0 R/K 27843 0 R>> endobj 14316 0 obj <>/Alt(Tier 1)/P 4940 0 R/K 27844 0 R>> endobj 14317 0 obj <>/Alt(\(Begin italic\) bupropion hcl oral tablet extended release 24 hr \(End italic\) \(Begin italic\) 150 mg, 300 mg \(End italic\))/P 4941 0 R/K 27845 0 R>> endobj 14318 0 obj <>/Alt(\(Wellbutrin XL\))/P 4941 0 R/K 27846 0 R>> endobj 14319 0 obj <>/Alt(Tier 1)/P 4941 0 R/K 27847 0 R>> endobj 14320 0 obj <>/Alt(\(Begin italic\) bupropion hcl oral tablet sustained-release 12 hr \(End italic\) \(Begin italic\) 100 mg, 150 mg, 200 mg \(End italic\))/P 4942 0 R/K 27848 0 R>> endobj 14321 0 obj <>/Alt(\(Wellbutrin SR\))/P 4942 0 R/K 27849 0 R>> endobj 14322 0 obj <>/Alt(Tier 1)/P 4942 0 R/K 27850 0 R>> endobj 14323 0 obj <>/Alt(\(Begin bold\) Selective Serotonin Reuptake Inhibitor \(Ssris\) \(End bold\))/P 4943 0 R/K 27851 0 R>> endobj 14324 0 obj <>/Alt(\(Begin italic\) citalopram oral solution \(End italic\) \(Begin italic\) 10 mg/5 ml \(End italic\))/P 4944 0 R/K 27852 0 R>> endobj 14325 0 obj <>/Alt(Tier 1)/P 4944 0 R/K 27853 0 R>> endobj 14326 0 obj <>/Alt(\(Begin italic\) citalopram oral tablet \(End italic\) \(Begin italic\) 10 mg, 20 mg, 40 mg \(End italic\))/P 4945 0 R/K 27854 0 R>> endobj 14327 0 obj <>/Alt(\(Celexa\))/P 4945 0 R/K 27855 0 R>> endobj 14328 0 obj <>/Alt(Tier 1)/P 4945 0 R/K 27856 0 R>> endobj 14329 0 obj <>/Alt(\(Begin italic\) escitalopram oxalate oral solution \(End italic\) \(Begin italic\) 5 mg/5 ml \(End italic\))/P 4946 0 R/K 27857 0 R>> endobj 14330 0 obj <>/Alt(Tier 1)/P 4946 0 R/K 27858 0 R>> endobj 14331 0 obj <>/Alt(\(Begin italic\) escitalopram oxalate oral tablet \(End italic\) \(Begin italic\) 10 mg, 20 mg, 5 mg \(End italic\))/P 4947 0 R/K 27859 0 R>> endobj 14332 0 obj <>/Alt(\(Lexapro\))/P 4947 0 R/K 27860 0 R>> endobj 14333 0 obj <>/Alt(Tier 1)/P 4947 0 R/K 27861 0 R>> endobj 14334 0 obj <>/Alt(\(Begin italic\) fluoxetine oral capsule \(End italic\) \(Begin italic\) 10 mg, 20 mg, 40 mg \(End italic\))/P 4948 0 R/K 27862 0 R>> endobj 14335 0 obj <>/Alt(\(Prozac\))/P 4948 0 R/K 27863 0 R>> endobj 14336 0 obj <>/Alt(Tier 1)/P 4948 0 R/K 27864 0 R>> endobj 14337 0 obj <>/Alt(\(Begin italic\) fluoxetine oral capsule,delayed release\(dr/ec\) \(End italic\) \(Begin italic\) 90 mg \(End italic\))/P 4949 0 R/K 27865 0 R>> endobj 14338 0 obj <>/Alt(Tier 1)/P 4949 0 R/K 27866 0 R>> endobj 14339 0 obj <>/Alt(\(Begin italic\) fluoxetine oral solution \(End italic\) \(Begin italic\) 20 mg/5 ml \(4 mg/ml\) \(End italic\))/P 4950 0 R/K 27867 0 R>> endobj 14340 0 obj <>/Alt(Tier 1)/P 4950 0 R/K 27868 0 R>> endobj 14341 0 obj <>/Alt(\(Begin italic\) fluoxetine oral tablet \(End italic\) \(Begin italic\) 10 mg, 20 mg, 60 mg \(End italic\))/P 4951 0 R/K 27869 0 R>> endobj 14342 0 obj <>/Alt(Tier 1)/P 4951 0 R/K 27870 0 R>> endobj 14343 0 obj <>/Alt(\(Begin italic\) fluvoxamine oral capsule,extended release 24hr \(End italic\) \(Begin italic\) 100 mg, 150 mg \(End italic\))/P 4952 0 R/K 27871 0 R>> endobj 14344 0 obj <>/Alt(Tier 1)/P 4952 0 R/K 27872 0 R>> endobj 14345 0 obj <>/Alt(QL \(2 EA per 1 day\))/P 4952 0 R/K 27873 0 R>> endobj 14346 0 obj <>/Alt(\(Begin italic\) fluvoxamine oral tablet \(End italic\) \(Begin italic\) 100 mg, 25 mg, 50 mg \(End italic\))/P 4953 0 R/K 27874 0 R>> endobj 14347 0 obj <>/Alt(Tier 1)/P 4953 0 R/K 27875 0 R>> endobj 14348 0 obj <>/Alt(\(Begin italic\) paroxetine hcl oral suspension \(End italic\) \(Begin italic\) 10 mg/5 ml \(End italic\))/P 4954 0 R/K 27876 0 R>> endobj 14349 0 obj <>/Alt(\(Paxil\))/P 4954 0 R/K 27877 0 R>> endobj 14350 0 obj <>/Alt(Tier 1)/P 4954 0 R/K 27878 0 R>> endobj 14351 0 obj <>/Alt(\(Begin italic\) paroxetine hcl oral tablet \(End italic\) \(Begin italic\) 10 mg, 20 mg, 30 mg, 40 mg \(End italic\))/P 4955 0 R/K 27879 0 R>> endobj 14352 0 obj <>/Alt(\(Paxil\))/P 4955 0 R/K 27880 0 R>> endobj 14353 0 obj <>/Alt(Tier 1)/P 4955 0 R/K 27881 0 R>> endobj 14354 0 obj <>/Alt(\(Begin italic\) paroxetine hcl oral tablet extended release 24 hr \(End italic\) \(Begin italic\) 12.5 mg, 25 mg, 37.5 mg \(End italic\))/P 4956 0 R/K 27882 0 R>> endobj 14355 0 obj <>/Alt(\(Paxil CR\))/P 4956 0 R/K 27883 0 R>> endobj 14356 0 obj <>/Alt(Tier 1)/P 4956 0 R/K 27884 0 R>> endobj 14357 0 obj <>/Alt(\(Begin italic\) sertraline oral concentrate \(End italic\) \(Begin italic\) 20 mg/ml \(End italic\))/P 4957 0 R/K 27885 0 R>> endobj 14358 0 obj <>/Alt(\(Zoloft\))/P 4957 0 R/K 27886 0 R>> endobj 14359 0 obj <>/Alt(Tier 1)/P 4957 0 R/K 27887 0 R>> endobj 14360 0 obj <>/Alt(\(Begin italic\) sertraline oral tablet \(End italic\) \(Begin italic\) 100 mg, 25 mg, 50 mg \(End italic\))/P 4958 0 R/K 27888 0 R>> endobj 14361 0 obj <>/Alt(\(Zoloft\))/P 4958 0 R/K 27889 0 R>> endobj 14362 0 obj <>/Alt(Tier 1)/P 4958 0 R/K 27890 0 R>> endobj 14363 0 obj <>/Alt(\(Begin bold\) Serotonin-2 Antagonist/Reuptake Inhibitors \(Saris\) \(End bold\))/P 4959 0 R/K 27891 0 R>> endobj 14364 0 obj <>/Alt(\(Begin italic\) nefazodone oral tablet \(End italic\) \(Begin italic\) 100 mg, 150 mg, 200 mg, 250 mg, 50 mg \(End italic\))/P 4960 0 R/K 27892 0 R>> endobj 14365 0 obj <>/Alt(Tier 1)/P 4960 0 R/K 27893 0 R>> endobj 14366 0 obj <>/Alt(\(Begin italic\) trazodone oral tablet \(End italic\) \(Begin italic\) 100 mg, 150 mg, 300 mg, 50 mg \(End italic\))/P 4961 0 R/K 27894 0 R>> endobj 14367 0 obj <>/Alt(Tier 1)/P 4961 0 R/K 27895 0 R>> endobj 14368 0 obj <>/Alt(\(Begin bold\) Serotonin-Norepinephrine Reuptake-Inhib \(Snris\) \(End bold\))/P 4962 0 R/K 27896 0 R>> endobj 14369 0 obj <>/Alt(\(Begin italic\) desvenlafaxine oral tablet extended release 24 hr \(End italic\) \(Begin italic\) 100 mg, 50 mg \(End italic\))/P 4963 0 R/K 27897 0 R>> endobj 14370 0 obj <>/Alt(Tier 1)/P 4963 0 R/K 27898 0 R>> endobj 14371 0 obj <>/Alt(ST: At least 2 prior prescriptions for generic Paroxetine HCL, Bupropion, Citalopram, Escitalopram, Fluoxetine, Mirtazapine, Sertraline, or Venlafaxine ER/IR within the past 365 days; QL \(1 EA per 1 day\))/P 4963 0 R/K 27899 0 R>> endobj 14372 0 obj <>/Alt(\(Begin italic\) desvenlafaxine succinate oral tablet extended release 24 hr \(End italic\) \(Begin italic\) 100 mg, 25 mg, 50 mg \(End italic\))/P 4964 0 R/K 27900 0 R>> endobj 14373 0 obj <>/Alt(\(Pristiq\))/P 4964 0 R/K 27901 0 R>> endobj 14374 0 obj <>/Alt(Tier 1)/P 4964 0 R/K 27902 0 R>> endobj 14375 0 obj <>/Alt(\(Begin italic\) duloxetine oral capsule,delayed release\(dr/ec\) \(End italic\) \(Begin italic\) 20 mg, 30 mg, 60 mg \(End italic\))/P 4965 0 R/K 27903 0 R>> endobj 14376 0 obj <>/Alt(\(Cymbalta\))/P 4965 0 R/K 27904 0 R>> endobj 14377 0 obj <>/Alt(Tier 1)/P 4965 0 R/K 27905 0 R>> endobj 14378 0 obj <>/Alt(FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK 20 MG \(2\)- 40 MG \(26\), 20 MG \(2\)- 40 MG \(5\))/P 4966 0 R/K 27906 0 R>> endobj 14379 0 obj <>/Alt(Tier 2)/P 4966 0 R/K 27907 0 R>> endobj 14380 0 obj <>/Alt(QL \(1 EA per 1 day\))/P 4966 0 R/K 27908 0 R>> endobj 14381 0 obj <>/Alt(FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 120 MG, 20 MG, 40 MG, 80 MG)/P 4967 0 R/K 27909 0 R>> endobj 14382 0 obj <>/Alt(Tier 2)/P 4967 0 R/K 27910 0 R>> endobj 14383 0 obj <>/Alt(QL \(1 EA per 1 day\))/P 4967 0 R/K 27911 0 R>> endobj 14384 0 obj <>/Alt(\(Begin italic\) venlafaxine oral capsule,extended release 24hr \(End italic\) \(Begin italic\) 150 mg, 37.5 mg, 75 mg \(End italic\))/P 4968 0 R/K 27912 0 R>> endobj 14385 0 obj <>/Alt(\(Effexor XR\))/P 4968 0 R/K 27913 0 R>> endobj 14386 0 obj <>/Alt(Tier 1)/P 4968 0 R/K 27914 0 R>> endobj 14387 0 obj <>/Alt(\(Begin italic\) venlafaxine oral tablet \(End italic\) \(Begin italic\) 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg \(End italic\))/P 4969 0 R/K 27915 0 R>> endobj 14388 0 obj <>/Alt(Tier 1)/P 4969 0 R/K 27916 0 R>> endobj 14389 0 obj <>/Alt(\(Begin italic\) venlafaxine oral tablet extended release 24hr \(End italic\) \(Begin italic\) 150 mg, 225 mg, 37.5 mg, 75 mg \(End italic\))/P 4970 0 R/K 27917 0 R>> endobj 14390 0 obj <>/Alt(Tier 1)/P 4970 0 R/K 27918 0 R>> endobj 14391 0 obj <>/Alt(\(Begin bold\) Ssri & 5Ht1a Partial Agonist Antidepressant \(End bold\))/P 4971 0 R/K 27919 0 R>> endobj 14392 0 obj <>/Alt(\(Begin italic\) vilazodone oral tablet \(End italic\) \(Begin italic\) 10 mg, 20 mg, 40 mg \(End italic\))/P 4972 0 R/K 27920 0 R>> endobj 14393 0 obj <>/Alt(\(Viibryd\))/P 4972 0 R/K 27921 0 R>> endobj 14394 0 obj <>/Alt(Tier 1)/P 4972 0 R/K 27922 0 R>> endobj 14395 0 obj <>/Alt(\(Begin bold\) Ssri & Serotonin Receptor Modulator Antidepressant \(End bold\))/P 4973 0 R/K 27923 0 R>> endobj 14396 0 obj <>/Alt(TRINTELLIX ORAL TABLET 10 MG, 20 MG, 5 MG)/P 4974 0 R/K 27924 0 R>> endobj 14397 0 obj <>/Alt(Tier 2)/P 4974 0 R/K 27925 0 R>> endobj 14398 0 obj <>/Alt(QL \(1 EA per 1 day\))/P 4974 0 R/K 27926 0 R>> endobj 14399 0 obj <>/Alt(\(Begin bold\) Tricyclic Antidepressant/Benzodiazepine Combinatns \(End bold\))/P 4975 0 R/K 27927 0 R>> endobj 14400 0 obj <>/Alt(\(Begin italic\) amitriptyline-chlordiazepoxide oral tablet \(End italic\) \(Begin italic\) 12.5-5 mg, 25-10 mg \(End italic\))/P 4976 0 R/K 27928 0 R>> endobj 14401 0 obj <>/Alt(Tier 1)/P 4976 0 R/K 27929 0 R>> endobj 14402 0 obj <>/Alt(\(Begin bold\) Tricyclic Antidepressant/Phenothiazine Combinatns \(End bold\))/P 4977 0 R/K 27930 0 R>> endobj 14403 0 obj <>/Alt(\(Begin italic\) perphenazine-amitriptyline oral tablet \(End italic\) \(Begin italic\) 2-10 mg, 2-25 mg, 4-10 mg, 4-25 mg, 4-50 mg \(End italic\))/P 4978 0 R/K 27931 0 R>> endobj 14404 0 obj <>/Alt(Tier 1)/P 4978 0 R/K 27932 0 R>> endobj 14405 0 obj <>/Alt(\(Begin bold\) Tricyclic Antidepressants & Rel. Non-Sel. Ru-Inhib \(End bold\))/P 4979 0 R/K 27933 0 R>> endobj 14406 0 obj <>/Alt(\(Begin italic\) amitriptyline oral tablet \(End italic\) \(Begin italic\) 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg \(End italic\))/P 4980 0 R/K 27934 0 R>> endobj 14407 0 obj <>/Alt(Tier 1)/P 4980 0 R/K 27935 0 R>> endobj 14408 0 obj <>/Alt(\(Begin italic\) amoxapine oral tablet \(End italic\) \(Begin italic\) 100 mg, 150 mg, 25 mg, 50 mg \(End italic\))/P 4981 0 R/K 27936 0 R>> endobj 14409 0 obj <>/Alt(Tier 1)/P 4981 0 R/K 27937 0 R>> endobj 14410 0 obj <>/Alt(\(Begin italic\) clomipramine oral capsule \(End italic\) \(Begin italic\) 25 mg, 50 mg, 75 mg \(End italic\))/P 4982 0 R/K 27938 0 R>> endobj 14411 0 obj <>/Alt(\(Anafranil\))/P 4982 0 R/K 27939 0 R>> endobj 14412 0 obj <>/Alt(Tier 1)/P 4982 0 R/K 27940 0 R>> endobj 14413 0 obj <>/Alt(\(Begin italic\) desipramine oral tablet \(End italic\) \(Begin italic\) 10 mg, 25 mg \(End italic\))/P 4983 0 R/K 27941 0 R>> endobj 14414 0 obj <>/Alt(\(Norpramin\))/P 4983 0 R/K 27942 0 R>> endobj 14415 0 obj <>/Alt(Tier 1)/P 4983 0 R/K 27943 0 R>> endobj 14416 0 obj <>/Alt(\(Begin italic\) desipramine oral tablet \(End italic\) \(Begin italic\) 100 mg, 150 mg, 50 mg, 75 mg \(End italic\))/P 4984 0 R/K 27944 0 R>> endobj 14417 0 obj <>/Alt(Tier 1)/P 4984 0 R/K 27945 0 R>> endobj 14418 0 obj <>/Alt(\(Begin italic\) doxepin oral capsule \(End italic\) \(Begin italic\) 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg \(End italic\))/P 4985 0 R/K 27946 0 R>> endobj 14419 0 obj <>/Alt(Tier 1)/P 4985 0 R/K 27947 0 R>> endobj 14420 0 obj <>/Alt(\(Begin italic\) doxepin oral concentrate \(End italic\) \(Begin italic\) 10 mg/ml \(End italic\))/P 4986 0 R/K 27948 0 R>> endobj 14421 0 obj <>/Alt(Tier 1)/P 4986 0 R/K 27949 0 R>> endobj 14422 0 obj <>/Alt(\(Begin italic\) imipramine hcl oral tablet \(End italic\) \(Begin italic\) 10 mg, 25 mg, 50 mg \(End italic\))/P 4987 0 R/K 27950 0 R>> endobj 14423 0 obj <>/Alt(Tier 1)/P 4987 0 R/K 27951 0 R>> endobj 14424 0 obj <>/Alt(\(Begin italic\) imipramine pamoate oral capsule \(End italic\) \(Begin italic\) 100 mg, 125 mg, 150 mg, 75 mg \(End italic\))/P 4988 0 R/K 27952 0 R>> endobj 14425 0 obj <>/Alt(Tier 1)/P 4988 0 R/K 27953 0 R>> endobj 14426 0 obj <>/Alt(\(Begin italic\) nortriptyline oral capsule \(End italic\) \(Begin italic\) 10 mg, 25 mg, 50 mg, 75 mg \(End italic\))/P 4989 0 R/K 27954 0 R>> endobj 14427 0 obj <>/Alt(\(Pamelor\))/P 4989 0 R/K 27955 0 R>> endobj 14428 0 obj <>/Alt(Tier 1)/P 4989 0 R/K 27956 0 R>> endobj 14429 0 obj <>/Alt(\(Begin italic\) nortriptyline oral solution \(End italic\) \(Begin italic\) 10 mg/5 ml \(End italic\))/P 4990 0 R/K 27957 0 R>> endobj 14430 0 obj <>/Alt(Tier 1)/P 4990 0 R/K 27958 0 R>> endobj 14431 0 obj <>/Alt(\(Begin italic\) protriptyline oral tablet \(End italic\) \(Begin italic\) 10 mg, 5 mg \(End italic\))/P 4991 0 R/K 27959 0 R>> endobj 14432 0 obj <>/Alt(Tier 1)/P 4991 0 R/K 27960 0 R>> endobj 14433 0 obj <>/Alt(\(Begin italic\) trimipramine oral capsule \(End italic\) \(Begin italic\) 100 mg, 25 mg, 50 mg \(End italic\))/P 4992 0 R/K 27961 0 R>> endobj 14434 0 obj <>/Alt(Tier 1)/P 4992 0 R/K 27962 0 R>> endobj 14435 0 obj <>/Alt(\(Begin bold\) Behavioral Health - Other \(End bold\))/P 4993 0 R/K 27963 0 R>> endobj 14436 0 obj <>/Alt(\(Begin bold\) Adrenergics, Aromatic, Non-Catecholamine \(End bold\))/P 4994 0 R/K 27964 0 R>> endobj 14437 0 obj <>/Alt(\(Begin italic\) amphetamine sulfate oral tablet \(End italic\) \(Begin italic\) 10 mg, 5 mg \(End italic\))/P 4995 0 R/K 27965 0 R>> endobj 14438 0 obj <>/Alt(\(Evekeo\))/P 4995 0 R/K 27966 0 R>> endobj 14439 0 obj <>/Alt(Tier 1)/P 4995 0 R/K 27967 0 R>> endobj 14440 0 obj <>/Alt(PA)/P 4995 0 R/K 27968 0 R>> endobj 14441 0 obj <>/Alt(\(Begin italic\) dextroamphetamine sulfate oral capsule, extended release \(End italic\) \(Begin italic\) 10 mg \(End italic\))/P 4996 0 R/K 27969 0 R>> endobj 14442 0 obj <>/Alt(\(Dexedrine Spansule\))/P 4996 0 R/K 27970 0 R>> endobj 14443 0 obj <>/Alt(Tier 1)/P 4996 0 R/K 27971 0 R>> endobj 14444 0 obj <>/Alt(QL \(60 EA per 30 days\))/P 4996 0 R/K 27972 0 R>> endobj 14445 0 obj <>/Alt(\(Begin italic\) dextroamphetamine sulfate oral capsule, extended release \(End italic\) \(Begin italic\) 15 mg \(End italic\))/P 4997 0 R/K 27973 0 R>> endobj 14446 0 obj <>/Alt(Tier 1)/P 4997 0 R/K 27974 0 R>> endobj 14447 0 obj <>/Alt(QL \(120 EA per 30 days\))/P 4997 0 R/K 27975 0 R>> endobj 14448 0 obj <>/Alt(\(Begin italic\) dextroamphetamine sulfate oral capsule, extended release \(End italic\) \(Begin italic\) 5 mg \(End italic\))/P 4998 0 R/K 27976 0 R>> endobj 14449 0 obj <>/Alt(Tier 1)/P 4998 0 R/K 27977 0 R>> endobj 14450 0 obj <>/Alt(QL \(60 EA per 30 days\))/P 4998 0 R/K 27978 0 R>> endobj 14451 0 obj <>/Alt(\(Begin italic\) dextroamphetamine sulfate oral solution \(End italic\) \(Begin italic\) 5 mg/5 ml \(End italic\))/P 4999 0 R/K 27979 0 R>> endobj 14452 0 obj <>/Alt(\(ProCentra\))/P 4999 0 R/K 27980 0 R>> endobj 14453 0 obj <>/Alt(Tier 1)/P 4999 0 R/K 27981 0 R>> endobj 14454 0 obj <>/Alt(QL \(1800 ML per 30 days\))/P 4999 0 R/K 27982 0 R>> endobj 14455 0 obj <>/Alt(\(Begin italic\) dextroamphetamine sulfate oral tablet \(End italic\) \(Begin italic\) 10 mg \(End italic\))/P 5000 0 R/K 27983 0 R>> endobj 14456 0 obj <>/Alt(\(Zenzedi\))/P 5000 0 R/K 27984 0 R>> endobj 14457 0 obj <>/Alt(Tier 1)/P 5000 0 R/K 27985 0 R>> endobj 14458 0 obj <>/Alt(QL \(180 EA per 30 days\))/P 5000 0 R/K 27986 0 R>> endobj 14459 0 obj <>/Alt(\(Begin italic\) dextroamphetamine sulfate oral tablet \(End italic\) \(Begin italic\) 15 mg \(End italic\))/P 5001 0 R/K 27987 0 R>> endobj 14460 0 obj <>/Alt(\(Zenzedi\))/P 5001 0 R/K 27988 0 R>> endobj 14461 0 obj <>/Alt(Tier 1)/P 5001 0 R/K 27989 0 R>> endobj 14462 0 obj <>/Alt(ST: Requires prior prescription for Dextroamphetamine Sulfate IR 5/10mg tablets or Dextroamphetamine solution within the past 120 days; QL \(3 EA per 1 day\))/P 5001 0 R/K 27990 0 R>> endobj 14463 0 obj <>/Alt(\(Begin italic\) dextroamphetamine sulfate oral tablet \(End italic\) \(Begin italic\) 2.5 mg, 7.5 mg \(End italic\))/P 5002 0 R/K 27991 0 R>> endobj 14464 0 obj <>/Alt(\(Zenzedi\))/P 5002 0 R/K 27992 0 R>> endobj 14465 0 obj <>/Alt(Tier 1)/P 5002 0 R/K 27993 0 R>> endobj 14466 0 obj <>/Alt(ST: Requires prior prescription for Dextroamphetamine Sulfate IR 5/10mg tablets or Dextroamphetamine solution within the past 120 days; QL \(90 EA per 30 days\))/P 5002 0 R/K 27994 0 R>> endobj 14467 0 obj <>/Alt(\(Begin italic\) dextroamphetamine sulfate oral tablet \(End italic\) \(Begin italic\) 20 mg, 30 mg \(End italic\))/P 5003 0 R/K 27995 0 R>> endobj 14468 0 obj <>/Alt(\(Zenzedi\))/P 5003 0 R/K 27996 0 R>> endobj 14469 0 obj <>/Alt(Tier 1)/P 5003 0 R/K 27997 0 R>> endobj 14470 0 obj <>/Alt(ST: Requires prior prescription for Dextroamphetamine Sulfate IR 5/10mg tablets or Dextroamphetamine solution within the past 120 days; QL \(2 EA per 1 day\))/P 5003 0 R/K 27998 0 R>> endobj 14471 0 obj <>/Alt(\(Begin italic\) dextroamphetamine sulfate oral tablet \(End italic\) \(Begin italic\) 5 mg \(End italic\))/P 5004 0 R/K 27999 0 R>> endobj 14472 0 obj <>/Alt(\(Zenzedi\))/P 5004 0 R/K 28000 0 R>> endobj 14473 0 obj <>/Alt(Tier 1)/P 5004 0 R/K 28001 0 R>> endobj 14474 0 obj <>/Alt(QL \(90 EA per 30 days\))/P 5004 0 R/K 28002 0 R>> endobj 14475 0 obj <>/Alt(\(Begin italic\) dextroamphetamine-amphetamine oral capsule, er triphasic 24 hr \(End italic\) \(Begin italic\) 12.5 mg, 25 mg, 37.5 mg, 50 mg \(End italic\))/P 5005 0 R/K 28003 0 R>> endobj 14476 0 obj <>/Alt(\(Mydayis\))/P 5005 0 R/K 28004 0 R>> endobj 14477 0 obj <>/Alt(Tier 1)/P 5005 0 R/K 28005 0 R>> endobj 14478 0 obj <>/Alt(QL \(1 EA per 1 day\))/P 5005 0 R/K 28006 0 R>> endobj 14479 0 obj <>/Alt(\(Begin italic\) dextroamphetamine-amphetamine oral capsule,extended release 24hr \(End italic\) \(Begin italic\) 10 mg, 15 mg, 5 mg \(End italic\))/P 5006 0 R/K 28007 0 R>> endobj 14480 0 obj <>/Alt(\(Adderall XR\))/P 5006 0 R/K 28008 0 R>> endobj 14481 0 obj <>/Alt(Tier 1)/P 5006 0 R/K 28009 0 R>> endobj 14482 0 obj <>/Alt(QL \(1 EA per 1 day\))/P 5006 0 R/K 28010 0 R>> endobj 14483 0 obj <>/Alt(\(Begin italic\) dextroamphetamine-amphetamine oral capsule,extended release 24hr \(End italic\) \(Begin italic\) 20 mg, 25 mg, 30 mg \(End italic\))/P 5007 0 R/K 28011 0 R>> endobj 14484 0 obj <>/Alt(\(Adderall XR\))/P 5007 0 R/K 28012 0 R>> endobj 14485 0 obj <>/Alt(Tier 1)/P 5007 0 R/K 28013 0 R>> endobj 14486 0 obj <>/Alt(QL \(2 EA per 1 day\))/P 5007 0 R/K 28014 0 R>> endobj 14487 0 obj <>/Alt(\(Begin italic\) dextroamphetamine-amphetamine oral tablet \(End italic\) \(Begin italic\) 10 mg, 12.5 mg, 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg \(End italic\))/P 5008 0 R/K 28015 0 R>> endobj 14488 0 obj <>/Alt(\(Adderall\))/P 5008 0 R/K 28016 0 R>> endobj 14489 0 obj <>/Alt(Tier 1)/P 5008 0 R/K 28017 0 R>> endobj 14490 0 obj <>/Alt(QL \(2 EA per 1 day\))/P 5008 0 R/K 28018 0 R>> endobj 14491 0 obj <>/Alt(\(Begin italic\) lisdexamfetamine oral capsule \(End italic\) \(Begin italic\) 10 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg, 70 mg \(End italic\))/P 5009 0 R/K 28019 0 R>> endobj 14492 0 obj <>/Alt(\(Vyvanse\))/P 5009 0 R/K 28020 0 R>> endobj 14493 0 obj <>/Alt(Tier 1)/P 5009 0 R/K 28021 0 R>> endobj 14494 0 obj <>/Alt(QL \(1 EA per 1 day\))/P 5009 0 R/K 28022 0 R>> endobj 14495 0 obj <>/Alt(\(Begin italic\) lisdexamfetamine oral tablet,chewable \(End italic\) \(Begin italic\) 10 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg \(End italic\))/P 5010 0 R/K 28023 0 R>> endobj 14496 0 obj <>/Alt(\(Vyvanse\))/P 5010 0 R/K 28024 0 R>> endobj 14497 0 obj <>/Alt(Tier 1)/P 5010 0 R/K 28025 0 R>> endobj 14498 0 obj <>/Alt(QL \(1 EA per 1 day\))/P 5010 0 R/K 28026 0 R>> endobj 14499 0 obj <>/Alt(\(Begin italic\) methamphetamine oral tablet \(End italic\) \(Begin italic\) 5 mg \(End italic\))/P 5011 0 R/K 28027 0 R>> endobj 14500 0 obj <>/Alt(\(Desoxyn\))/P 5011 0 R/K 28028 0 R>> endobj 14501 0 obj <>/Alt(Tier 1)/P 5011 0 R/K 28029 0 R>> endobj 14502 0 obj <>/Alt(QL \(150 EA per 30 days\))/P 5011 0 R/K 28030 0 R>> endobj 14503 0 obj <>/Alt(ZENZEDI ORAL TABLET 2.5 MG, 7.5 MG)/P 5012 0 R/K 28031 0 R>> endobj 14504 0 obj <>/Alt(\(dextroamphetamine sulfate\))/P 5012 0 R/K 28032 0 R>> endobj 14505 0 obj <>/Alt(Tier 3)/P 5012 0 R/K 28033 0 R>> endobj 14506 0 obj <>/Alt(ST: Requires prior prescription for Dextroamphetamine Sulfate IR 5/10mg tablets or Dextroamphetamine solution within the past 120 days; QL \(90 EA per 30 days\))/P 5012 0 R/K 28034 0 R>> endobj 14507 0 obj <>/Alt(\(Begin bold\) Anti-Alcoholic Preparations \(End bold\))/P 5013 0 R/K 28035 0 R>> endobj 14508 0 obj <>/Alt(\(Begin italic\) acamprosate oral tablet,delayed release \(dr/ec\) \(End italic\) \(Begin italic\) 333 mg \(End italic\))/P 5014 0 R/K 28036 0 R>> endobj 14509 0 obj <>/Alt(Tier 1)/P 5014 0 R/K 28037 0 R>> endobj 14510 0 obj <>/Alt(\(Begin italic\) disulfiram oral tablet \(End italic\) \(Begin italic\) 250 mg, 500 mg \(End italic\))/P 5015 0 R/K 28038 0 R>> endobj 14511 0 obj <>/Alt(Tier 1)/P 5015 0 R/K 28039 0 R>> endobj 14512 0 obj <>/Alt(\(Begin bold\) Anti-Anxiety - Benzodiazepines \(End bold\))/P 5016 0 R/K 28040 0 R>> endobj 14513 0 obj <>/Alt(ALPRAZOLAM INTENSOL ORAL CONCENTRATE 1 MG/ML)/P 5017 0 R/K 28041 0 R>> endobj 14514 0 obj <>/Alt(Tier 2)/P 5017 0 R/K 28042 0 R>> endobj 14515 0 obj <>/Alt(\(Begin italic\) alprazolam oral tablet \(End italic\) \(Begin italic\) 0.25 mg, 0.5 mg, 1 mg, 2 mg \(End italic\))/P 5018 0 R/K 28043 0 R>> endobj 14516 0 obj <>/Alt(\(Xanax\))/P 5018 0 R/K 28044 0 R>> endobj 14517 0 obj <>/Alt(Tier 1)/P 5018 0 R/K 28045 0 R>> endobj 14518 0 obj <>/Alt(\(Begin italic\) alprazolam oral tablet extended release 24 hr \(End italic\) \(Begin italic\) 0.5 mg, 1 mg, 2 mg, 3 mg \(End italic\))/P 5019 0 R/K 28046 0 R>> endobj 14519 0 obj <>/Alt(\(Xanax XR\))/P 5019 0 R/K 28047 0 R>> endobj 14520 0 obj <>/Alt(Tier 1)/P 5019 0 R/K 28048 0 R>> endobj 14521 0 obj <>/Alt(\(Begin italic\) alprazolam oral tablet,disintegrating \(End italic\) \(Begin italic\) 0.25 mg, 0.5 mg, 1 mg, 2 mg \(End italic\))/P 5020 0 R/K 28049 0 R>> endobj 14522 0 obj <>/Alt(Tier 1)/P 5020 0 R/K 28050 0 R>> endobj 14523 0 obj <>/Alt(\(Begin italic\) chlordiazepoxide hcl oral capsule \(End italic\) \(Begin italic\) 10 mg, 25 mg, 5 mg \(End italic\))/P 5021 0 R/K 28051 0 R>> endobj 14524 0 obj <>/Alt(Tier 1)/P 5021 0 R/K 28052 0 R>> endobj 14525 0 obj <>/Alt(\(Begin italic\) clorazepate dipotassium oral tablet \(End italic\) \(Begin italic\) 15 mg, 3.75 mg, 7.5 mg \(End italic\))/P 5022 0 R/K 28053 0 R>> endobj 14526 0 obj <>/Alt(Tier 1)/P 5022 0 R/K 28054 0 R>> endobj 14527 0 obj <>/Alt(DIAZEPAM INTENSOL ORAL CONCENTRATE 5 MG/ML)/P 5023 0 R/K 28055 0 R>> endobj 14528 0 obj <>/Alt(\(diazepam\))/P 5023 0 R/K 28056 0 R>> endobj 14529 0 obj <>/Alt(Tier 1)/P 5023 0 R/K 28057 0 R>> endobj 14530 0 obj <>/Alt(\(Begin italic\) diazepam oral concentrate \(End italic\) \(Begin italic\) 5 mg/ml \(End italic\))/P 5024 0 R/K 28058 0 R>> endobj 14531 0 obj <>/Alt(\(Diazepam Intensol\))/P 5024 0 R/K 28059 0 R>> endobj 14532 0 obj <>/Alt(Tier 1)/P 5024 0 R/K 28060 0 R>> endobj 14533 0 obj <>/Alt(\(Begin italic\) diazepam oral solution \(End italic\) \(Begin italic\) 5 mg/5 ml \(1 mg/ml\), 5 mg/5 ml \(1 mg/ml, 5 ml\) \(End italic\))/P 5025 0 R/K 28061 0 R>> endobj 14534 0 obj <>/Alt(Tier 1)/P 5025 0 R/K 28062 0 R>> endobj 14535 0 obj <>/Alt(\(Begin italic\) diazepam oral tablet \(End italic\) \(Begin italic\) 10 mg, 2 mg, 5 mg \(End italic\))/P 5026 0 R/K 28063 0 R>> endobj 14536 0 obj <>/Alt(\(Valium\))/P 5026 0 R/K 28064 0 R>> endobj 14537 0 obj <>/Alt(Tier 1)/P 5026 0 R/K 28065 0 R>> endobj 14538 0 obj <>/Alt(LORAZEPAM INTENSOL ORAL CONCENTRATE 2 MG/ML)/P 5027 0 R/K 28066 0 R>> endobj 14539 0 obj <>/Alt(\(lorazepam\))/P 5027 0 R/K 28067 0 R>> endobj 14540 0 obj <>/Alt(Tier 1)/P 5027 0 R/K 28068 0 R>> endobj 14541 0 obj <>/Alt(\(Begin italic\) lorazepam oral concentrate \(End italic\) \(Begin italic\) 2 mg/ml \(End italic\))/P 5028 0 R/K 28069 0 R>> endobj 14542 0 obj <>/Alt(\(Lorazepam Intensol\))/P 5028 0 R/K 28070 0 R>> endobj 14543 0 obj <>/Alt(Tier 1)/P 5028 0 R/K 28071 0 R>> endobj 14544 0 obj <>/Alt(\(Begin italic\) lorazepam oral tablet \(End italic\) \(Begin italic\) 0.5 mg, 1 mg, 2 mg \(End italic\))/P 5029 0 R/K 28072 0 R>> endobj 14545 0 obj <>/Alt(\(Ativan\))/P 5029 0 R/K 28073 0 R>> endobj 14546 0 obj <>/Alt(Tier 1)/P 5029 0 R/K 28074 0 R>> endobj 14547 0 obj <>/Alt(\(Begin italic\) oxazepam oral capsule \(End italic\) \(Begin italic\) 10 mg, 15 mg, 30 mg \(End italic\))/P 5030 0 R/K 28075 0 R>> endobj 14548 0 obj <>/Alt(Tier 1)/P 5030 0 R/K 28076 0 R>> endobj 14549 0 obj <>/Alt(\(Begin bold\) Anti-Anxiety Drugs \(End bold\))/P 5031 0 R/K 28077 0 R>> endobj 14550 0 obj <>/Alt(\(Begin italic\) buspirone oral tablet \(End italic\) \(Begin italic\) 10 mg, 15 mg, 30 mg, 5 mg, 7.5 mg \(End italic\))/P 5032 0 R/K 28078 0 R>> endobj 14551 0 obj <>/Alt(Tier 1)/P 5032 0 R/K 28079 0 R>> endobj 14552 0 obj <>/Alt(\(Begin italic\) meprobamate oral tablet \(End italic\) \(Begin italic\) 200 mg, 400 mg \(End italic\))/P 5033 0 R/K 28080 0 R>> endobj 14553 0 obj <>/Alt(Tier 1)/P 5033 0 R/K 28081 0 R>> endobj 14554 0 obj <>/Alt(\(Begin bold\) Anti-Mania Drugs \(End bold\))/P 5034 0 R/K 28082 0 R>> endobj 14555 0 obj <>/Alt(EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 100 MG, 200 MG, 300 MG)/P 5035 0 R/K 28083 0 R>> endobj 14556 0 obj <>/Alt(Tier 3)/P 5035 0 R/K 28084 0 R>> endobj 14557 0 obj <>/Alt(\(Begin italic\) lithium carbonate oral capsule \(End italic\) \(Begin italic\) 150 mg, 300 mg, 600 mg \(End italic\))/P 5036 0 R/K 28085 0 R>> endobj 14558 0 obj <>/Alt(Tier 1)/P 5036 0 R/K 28086 0 R>> endobj 14559 0 obj <>/Alt(\(Begin italic\) lithium carbonate oral tablet \(End italic\) \(Begin italic\) 300 mg \(End italic\))/P 5037 0 R/K 28087 0 R>> endobj 14560 0 obj <>/Alt(Tier 1)/P 5037 0 R/K 28088 0 R>> endobj 14561 0 obj 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0 R>> endobj 14583 0 obj <>/Alt(\(Begin italic\) pimozide oral tablet \(End italic\) \(Begin italic\) 1 mg, 2 mg \(End italic\))/P 5047 0 R/K 28111 0 R>> endobj 14584 0 obj <>/Alt(Tier 1)/P 5047 0 R/K 28112 0 R>> endobj 14585 0 obj <>/Alt(\(Begin bold\) Antipsychotic-Atypical,D3/D2 Partial Ag-5Ht Mixed \(End bold\))/P 5048 0 R/K 28113 0 R>> endobj 14586 0 obj <>/Alt(VRAYLAR ORAL CAPSULE 1.5 MG, 3 MG, 4.5 MG, 6 MG)/P 5049 0 R/K 28114 0 R>> endobj 14587 0 obj <>/Alt(Tier 2)/P 5049 0 R/K 28115 0 R>> endobj 14588 0 obj <>/Alt(QL \(1 EA per 1 day\))/P 5049 0 R/K 28116 0 R>> endobj 14589 0 obj <>/Alt(\(Begin bold\) Antipsychotics, Atyp, D2 Partial Agonist/5Ht Mixed \(End bold\))/P 5050 0 R/K 28117 0 R>> endobj 14590 0 obj <>/Alt(ABILIFY ASIMTUFII INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 720 MG/2.4 ML)/P 5051 0 R/K 28118 0 R>> endobj 14591 0 obj <>/Alt(Tier 2)/P 5051 0 R/K 28119 0 R>> endobj 14592 0 obj <>/Alt(SP; QL \(2.4 ML per 42 days\))/P 5051 0 R/K 28120 0 R>> endobj 14593 0 obj 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endobj 14604 0 obj <>/Alt(\(Begin italic\) aripiprazole oral tablet \(End italic\) \(Begin italic\) 10 mg, 15 mg, 2 mg, 20 mg, 30 mg, 5 mg \(End italic\))/P 5056 0 R/K 28132 0 R>> endobj 14605 0 obj <>/Alt(\(Abilify\))/P 5056 0 R/K 28133 0 R>> endobj 14606 0 obj <>/Alt(Tier 1)/P 5056 0 R/K 28134 0 R>> endobj 14607 0 obj <>/Alt(\(Begin italic\) aripiprazole oral tablet,disintegrating \(End italic\) \(Begin italic\) 10 mg \(End italic\))/P 5057 0 R/K 28135 0 R>> endobj 14608 0 obj <>/Alt(Tier 1)/P 5057 0 R/K 28136 0 R>> endobj 14609 0 obj <>/Alt(QL \(3 EA per 1 day\))/P 5057 0 R/K 28137 0 R>> endobj 14610 0 obj <>/Alt(\(Begin italic\) aripiprazole oral tablet,disintegrating \(End italic\) \(Begin italic\) 15 mg \(End italic\))/P 5058 0 R/K 28138 0 R>> endobj 14611 0 obj <>/Alt(Tier 1)/P 5058 0 R/K 28139 0 R>> endobj 14612 0 obj <>/Alt(QL \(2 EA per 1 day\))/P 5058 0 R/K 28140 0 R>> endobj 14613 0 obj <>/Alt(ARISTADA INITIO INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 675 MG/2.4 ML)/P 5059 0 R/K 28141 0 R>> endobj 14614 0 obj <>/Alt(Tier 3)/P 5059 0 R/K 28142 0 R>> endobj 14615 0 obj <>/Alt(SP)/P 5059 0 R/K 28143 0 R>> endobj 14616 0 obj <>/Alt(ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 1,064 MG/3.9 ML)/P 5060 0 R/K 28144 0 R>> endobj 14617 0 obj <>/Alt(Tier 2)/P 5060 0 R/K 28145 0 R>> endobj 14618 0 obj <>/Alt(SP; QL \(3.9 ML per 14 days\))/P 5060 0 R/K 28146 0 R>> endobj 14619 0 obj <>/Alt(ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 441 MG/1.6 ML)/P 5061 0 R/K 28147 0 R>> endobj 14620 0 obj <>/Alt(Tier 2)/P 5061 0 R/K 28148 0 R>> endobj 14621 0 obj <>/Alt(SP; QL \(1.6 ML per 14 days\))/P 5061 0 R/K 28149 0 R>> endobj 14622 0 obj <>/Alt(ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 662 MG/2.4 ML)/P 5062 0 R/K 28150 0 R>> endobj 14623 0 obj <>/Alt(Tier 2)/P 5062 0 R/K 28151 0 R>> endobj 14624 0 obj <>/Alt(SP; QL \(2.4 ML per 14 days\))/P 5062 0 R/K 28152 0 R>> endobj 14625 0 obj <>/Alt(ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 882 MG/3.2 ML)/P 5063 0 R/K 28153 0 R>> endobj 14626 0 obj <>/Alt(Tier 2)/P 5063 0 R/K 28154 0 R>> endobj 14627 0 obj <>/Alt(SP; QL \(3.2 ML per 14 days\))/P 5063 0 R/K 28155 0 R>> endobj 14628 0 obj <>/Alt(OPIPZA ORAL FILM 10 MG, 2 MG, 5 MG)/P 5064 0 R/K 28156 0 R>> endobj 14629 0 obj <>/Alt(Tier 3)/P 5064 0 R/K 28157 0 R>> endobj 14630 0 obj <>/Alt(ST: Requires prior prescription for generic Aripiprazole tablets within the past 120 days)/P 5064 0 R/K 28158 0 R>> endobj 14631 0 obj <>/Alt(REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG)/P 5065 0 R/K 28159 0 R>> endobj 14632 0 obj <>/Alt(Tier 2)/P 5065 0 R/K 28160 0 R>> endobj 14633 0 obj <>/Alt(QL \(1 EA per 1 day\))/P 5065 0 R/K 28161 0 R>> endobj 14634 0 obj <>/Alt(REXULTI ORAL TABLETS,DOSE PACK 0.5 MG \(7\)- 1 MG \(7\), 1 MG \(4\)- 2 MG \(3\))/P 5066 0 R/K 28162 0 R>> endobj 14635 0 obj <>/Alt(Tier 2)/P 5066 0 R/K 28163 0 R>> endobj 14636 0 obj <>/Alt(QL \(1 EA per 1 day\))/P 5066 0 R/K 28164 0 R>> endobj 14637 0 obj <>/Alt(\(Begin bold\) Antipsychotics, Dopamine & Serotonin Antagonists \(End bold\))/P 5067 0 R/K 28165 0 R>> endobj 14638 0 obj <>/Alt(ADASUVE INHALATION AEROSOL POWDR BREATH ACTIVATED 10 MG)/P 5068 0 R/K 28166 0 R>> endobj 14639 0 obj <>/Alt(Tier 2)/P 5068 0 R/K 28167 0 R>> endobj 14640 0 obj <>/Alt(SP)/P 5068 0 R/K 28168 0 R>> endobj 14641 0 obj <>/Alt(\(Begin italic\) loxapine succinate oral capsule \(End italic\) \(Begin italic\) 10 mg, 25 mg, 5 mg, 50 mg \(End italic\))/P 5069 0 R/K 28169 0 R>> endobj 14642 0 obj <>/Alt(Tier 1)/P 5069 0 R/K 28170 0 R>> endobj 14643 0 obj <>/Alt(\(Begin bold\) Antipsychotics,Atypical,Dopamine,& Serotonin Antag \(End bold\))/P 5070 0 R/K 28171 0 R>> endobj 14644 0 obj <>/Alt(\(Begin italic\) asenapine maleate sublingual tablet \(End italic\) \(Begin italic\) 10 mg, 2.5 mg, 5 mg \(End italic\))/P 5071 0 R/K 28172 0 R>> endobj 14645 0 obj <>/Alt(\(Saphris\))/P 5071 0 R/K 28173 0 R>> endobj 14646 0 obj <>/Alt(Tier 1)/P 5071 0 R/K 28174 0 R>> endobj 14647 0 obj <>/Alt(QL \(2 EA per 1 day\))/P 5071 0 R/K 28175 0 R>> endobj 14648 0 obj <>/Alt(CAPLYTA ORAL CAPSULE 10.5 MG, 21 MG, 42 MG)/P 5072 0 R/K 28176 0 R>> endobj 14649 0 obj <>/Alt(Tier 3)/P 5072 0 R/K 28177 0 R>> endobj 14650 0 obj <>/Alt(ST: Requires prior prescription for Rexulti or Vraylar within the past 120 days; QL \(1 EA per 1 day\))/P 5072 0 R/K 28178 0 R>> endobj 14651 0 obj <>/Alt(\(Begin italic\) clozapine oral tablet \(End italic\) \(Begin italic\) 100 mg, 200 mg, 25 mg, 50 mg \(End italic\))/P 5073 0 R/K 28179 0 R>> endobj 14652 0 obj <>/Alt(\(Clozaril\))/P 5073 0 R/K 28180 0 R>> endobj 14653 0 obj <>/Alt(Tier 1)/P 5073 0 R/K 28181 0 R>> endobj 14654 0 obj <>/Alt(\(Begin italic\) clozapine oral tablet,disintegrating \(End italic\) \(Begin italic\) 100 mg, 12.5 mg, 150 mg, 200 mg, 25 mg \(End italic\))/P 5074 0 R/K 28182 0 R>> endobj 14655 0 obj <>/Alt(Tier 1)/P 5074 0 R/K 28183 0 R>> endobj 14656 0 obj <>/Alt(QL \(3 EA per 1 day\))/P 5074 0 R/K 28184 0 R>> endobj 14657 0 obj <>/Alt(FANAPT ORAL TABLET 1 MG, 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG)/P 5075 0 R/K 28185 0 R>> endobj 14658 0 obj <>/Alt(Tier 3)/P 5075 0 R/K 28186 0 R>> endobj 14659 0 obj <>/Alt(QL \(2 EA per 1 day\))/P 5075 0 R/K 28187 0 R>> endobj 14660 0 obj <>/Alt(FANAPT ORAL TABLETS,DOSE PACK 1MG\(2\)-2MG\(2\)- 4MG\(2\)-6MG\(2\))/P 5076 0 R/K 28188 0 R>> endobj 14661 0 obj <>/Alt(Tier 3)/P 5076 0 R/K 28189 0 R>> endobj 14662 0 obj <>/Alt(QL \(8 EA per 28 days\))/P 5076 0 R/K 28190 0 R>> endobj 14663 0 obj <>/Alt(INVEGA HAFYERA INTRAMUSCULAR SYRINGE 1,092 MG/3.5 ML)/P 5077 0 R/K 28191 0 R>> endobj 14664 0 obj <>/Alt(Tier 2)/P 5077 0 R/K 28192 0 R>> endobj 14665 0 obj <>/Alt(SP; QL \(3.5 ML per 166 days\))/P 5077 0 R/K 28193 0 R>> endobj 14666 0 obj <>/Alt(INVEGA HAFYERA INTRAMUSCULAR SYRINGE 1,560 MG/5 ML)/P 5078 0 R/K 28194 0 R>> endobj 14667 0 obj <>/Alt(Tier 2)/P 5078 0 R/K 28195 0 R>> endobj 14668 0 obj <>/Alt(SP; QL \(5 ML per 166 days\))/P 5078 0 R/K 28196 0 R>> endobj 14669 0 obj <>/Alt(INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 117 MG/0.75 ML)/P 5079 0 R/K 28197 0 R>> endobj 14670 0 obj <>/Alt(Tier 2)/P 5079 0 R/K 28198 0 R>> endobj 14671 0 obj <>/Alt(SP; QL \(0.75 ML per 21 days\))/P 5079 0 R/K 28199 0 R>> endobj 14672 0 obj <>/Alt(INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 156 MG/ML)/P 5080 0 R/K 28200 0 R>> endobj 14673 0 obj <>/Alt(Tier 2)/P 5080 0 R/K 28201 0 R>> endobj 14674 0 obj <>/Alt(SP; QL \(1 ML per 21 days\))/P 5080 0 R/K 28202 0 R>> endobj 14675 0 obj <>/Alt(INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 234 MG/1.5 ML)/P 5081 0 R/K 28203 0 R>> endobj 14676 0 obj <>/Alt(Tier 2)/P 5081 0 R/K 28204 0 R>> endobj 14677 0 obj <>/Alt(SP; QL \(1.5 ML per 21 days\))/P 5081 0 R/K 28205 0 R>> endobj 14678 0 obj <>/Alt(INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 39 MG/0.25 ML)/P 5082 0 R/K 28206 0 R>> endobj 14679 0 obj <>/Alt(Tier 2)/P 5082 0 R/K 28207 0 R>> endobj 14680 0 obj <>/Alt(SP; QL \(0.25 ML per 21 days\))/P 5082 0 R/K 28208 0 R>> endobj 14681 0 obj <>/Alt(INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 78 MG/0.5 ML)/P 5083 0 R/K 28209 0 R>> endobj 14682 0 obj <>/Alt(Tier 2)/P 5083 0 R/K 28210 0 R>> endobj 14683 0 obj <>/Alt(SP; QL \(0.5 ML per 21 days\))/P 5083 0 R/K 28211 0 R>> endobj 14684 0 obj <>/Alt(INVEGA TRINZA INTRAMUSCULAR SYRINGE 273 MG/0.88 ML)/P 5084 0 R/K 28212 0 R>> endobj 14685 0 obj <>/Alt(Tier 2)/P 5084 0 R/K 28213 0 R>> endobj 14686 0 obj <>/Alt(SP; QL \(88 ML per 70 days\))/P 5084 0 R/K 28214 0 R>> endobj 14687 0 obj <>/Alt(INVEGA TRINZA INTRAMUSCULAR SYRINGE 410 MG/1.32 ML)/P 5085 0 R/K 28215 0 R>> endobj 14688 0 obj <>/Alt(Tier 2)/P 5085 0 R/K 28216 0 R>> endobj 14689 0 obj <>/Alt(SP; QL \(1.32 ML per 70 days\))/P 5085 0 R/K 28217 0 R>> endobj 14690 0 obj <>/Alt(INVEGA TRINZA INTRAMUSCULAR SYRINGE 546 MG/1.75 ML)/P 5086 0 R/K 28218 0 R>> endobj 14691 0 obj <>/Alt(Tier 2)/P 5086 0 R/K 28219 0 R>> endobj 14692 0 obj <>/Alt(SP; QL \(1.75 ML per 70 days\))/P 5086 0 R/K 28220 0 R>> endobj 14693 0 obj <>/Alt(INVEGA TRINZA INTRAMUSCULAR SYRINGE 819 MG/2.63 ML)/P 5087 0 R/K 28221 0 R>> endobj 14694 0 obj <>/Alt(Tier 2)/P 5087 0 R/K 28222 0 R>> endobj 14695 0 obj <>/Alt(SP; QL \(2.63 ML per 70 days\))/P 5087 0 R/K 28223 0 R>> endobj 14696 0 obj <>/Alt(\(Begin italic\) lurasidone oral tablet \(End italic\) \(Begin italic\) 120 mg, 20 mg, 40 mg, 60 mg \(End italic\))/P 5088 0 R/K 28224 0 R>> endobj 14697 0 obj <>/Alt(\(Latuda\))/P 5088 0 R/K 28225 0 R>> endobj 14698 0 obj <>/Alt(Tier 1)/P 5088 0 R/K 28226 0 R>> endobj 14699 0 obj <>/Alt(QL \(30 EA per 30 days\))/P 5088 0 R/K 28227 0 R>> endobj 14700 0 obj <>/Alt(\(Begin italic\) lurasidone oral tablet \(End italic\) \(Begin italic\) 80 mg \(End italic\))/P 5089 0 R/K 28228 0 R>> endobj 14701 0 obj <>/Alt(\(Latuda\))/P 5089 0 R/K 28229 0 R>> endobj 14702 0 obj <>/Alt(Tier 1)/P 5089 0 R/K 28230 0 R>> endobj 14703 0 obj <>/Alt(QL \(60 EA per 30 days\))/P 5089 0 R/K 28231 0 R>> endobj 14704 0 obj <>/Alt(\(Begin italic\) olanzapine oral tablet \(End italic\) \(Begin italic\) 10 mg, 15 mg, 2.5 mg, 20 mg, 5 mg, 7.5 mg \(End italic\))/P 5090 0 R/K 28232 0 R>> endobj 14705 0 obj <>/Alt(\(Zyprexa\))/P 5090 0 R/K 28233 0 R>> endobj 14706 0 obj <>/Alt(Tier 1)/P 5090 0 R/K 28234 0 R>> endobj 14707 0 obj <>/Alt(\(Begin italic\) olanzapine oral tablet,disintegrating \(End italic\) \(Begin italic\) 10 mg, 15 mg, 20 mg, 5 mg \(End italic\))/P 5091 0 R/K 28235 0 R>> endobj 14708 0 obj <>/Alt(\(Zyprexa Zydis\))/P 5091 0 R/K 28236 0 R>> endobj 14709 0 obj <>/Alt(Tier 1)/P 5091 0 R/K 28237 0 R>> endobj 14710 0 obj <>/Alt(\(Begin italic\) paliperidone oral tablet extended release 24hr \(End italic\) \(Begin italic\) 1.5 mg \(End italic\))/P 5092 0 R/K 28238 0 R>> endobj 14711 0 obj <>/Alt(Tier 1)/P 5092 0 R/K 28239 0 R>> endobj 14712 0 obj <>/Alt(QL \(1 EA per 1 day\))/P 5092 0 R/K 28240 0 R>> endobj 14713 0 obj <>/Alt(\(Begin italic\) paliperidone oral tablet extended release 24hr \(End italic\) \(Begin italic\) 3 mg, 9 mg \(End italic\))/P 5093 0 R/K 28241 0 R>> endobj 14714 0 obj <>/Alt(\(Invega\))/P 5093 0 R/K 28242 0 R>> endobj 14715 0 obj <>/Alt(Tier 1)/P 5093 0 R/K 28243 0 R>> endobj 14716 0 obj <>/Alt(QL \(1 EA per 1 day\))/P 5093 0 R/K 28244 0 R>> endobj 14717 0 obj <>/Alt(\(Begin italic\) paliperidone oral tablet extended release 24hr \(End italic\) \(Begin italic\) 6 mg \(End italic\))/P 5094 0 R/K 28245 0 R>> endobj 14718 0 obj <>/Alt(\(Invega\))/P 5094 0 R/K 28246 0 R>> endobj 14719 0 obj <>/Alt(Tier 1)/P 5094 0 R/K 28247 0 R>> endobj 14720 0 obj <>/Alt(QL \(2 EA per 1 day\))/P 5094 0 R/K 28248 0 R>> endobj 14721 0 obj <>/Alt(PERSERIS SUBCUTANEOUS SUSPENSION,EXTENDED REL SYRING 120 MG, 90 MG)/P 5095 0 R/K 28249 0 R>> endobj 14722 0 obj <>/Alt(Tier 2)/P 5095 0 R/K 28250 0 R>> endobj 14723 0 obj <>/Alt(SP; QL \(1 EA per 28 days\))/P 5095 0 R/K 28251 0 R>> endobj 14724 0 obj <>/Alt(\(Begin italic\) quetiapine oral tablet \(End italic\) \(Begin italic\) 100 mg, 200 mg, 25 mg, 300 mg, 400 mg, 50 mg \(End italic\))/P 5096 0 R/K 28252 0 R>> endobj 14725 0 obj <>/Alt(\(Seroquel\))/P 5096 0 R/K 28253 0 R>> endobj 14726 0 obj <>/Alt(Tier 1)/P 5096 0 R/K 28254 0 R>> endobj 14727 0 obj <>/Alt(\(Begin italic\) quetiapine oral tablet extended release 24 hr \(End italic\) \(Begin italic\) 150 mg, 200 mg, 300 mg, 400 mg, 50 mg \(End italic\))/P 5097 0 R/K 28255 0 R>> endobj 14728 0 obj <>/Alt(\(Seroquel XR\))/P 5097 0 R/K 28256 0 R>> endobj 14729 0 obj <>/Alt(Tier 1)/P 5097 0 R/K 28257 0 R>> endobj 14730 0 obj <>/Alt(\(Begin italic\) risperidone oral solution \(End italic\) \(Begin italic\) 1 mg/ml \(End italic\))/P 5098 0 R/K 28258 0 R>> endobj 14731 0 obj <>/Alt(\(Risperdal\))/P 5098 0 R/K 28259 0 R>> endobj 14732 0 obj <>/Alt(Tier 1)/P 5098 0 R/K 28260 0 R>> endobj 14733 0 obj <>/Alt(\(Begin italic\) risperidone oral tablet \(End italic\) \(Begin italic\) 0.25 mg \(End italic\))/P 5099 0 R/K 28261 0 R>> endobj 14734 0 obj <>/Alt(Tier 1)/P 5099 0 R/K 28262 0 R>> endobj 14735 0 obj <>/Alt(\(Begin italic\) risperidone oral tablet \(End italic\) \(Begin italic\) 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg \(End italic\))/P 5100 0 R/K 28263 0 R>> endobj 14736 0 obj <>/Alt(\(Risperdal\))/P 5100 0 R/K 28264 0 R>> endobj 14737 0 obj <>/Alt(Tier 1)/P 5100 0 R/K 28265 0 R>> endobj 14738 0 obj <>/Alt(\(Begin italic\) risperidone oral tablet,disintegrating \(End italic\) \(Begin italic\) 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg \(End italic\))/P 5101 0 R/K 28266 0 R>> endobj 14739 0 obj <>/Alt(Tier 1)/P 5101 0 R/K 28267 0 R>> endobj 14740 0 obj <>/Alt(SECUADO TRANSDERMAL PATCH 24 HOUR 3.8 MG/24 HOUR, 5.7 MG/24 HOUR, 7.6 MG/24 HOUR)/P 5102 0 R/K 28268 0 R>> endobj 14741 0 obj <>/Alt(Tier 3)/P 5102 0 R/K 28269 0 R>> endobj 14742 0 obj <>/Alt(QL \(1 EA per 1 day\))/P 5102 0 R/K 28270 0 R>> endobj 14743 0 obj <>/Alt(SEROQUEL XR ORAL TABLET, EXT REL 24HR DOSE PACK 50 MG\(3\)-200 MG \(1\)-300 MG\(11\))/P 5103 0 R/K 28271 0 R>> endobj 14744 0 obj <>/Alt(Tier 3)/P 5103 0 R/K 28272 0 R>> endobj 14745 0 obj <>/Alt(UZEDY SUBCUTANEOUS SUSPENSION,EXTENDED REL SYRING 100 MG/0.28 ML)/P 5104 0 R/K 28273 0 R>> endobj 14746 0 obj <>/Alt(Tier 2)/P 5104 0 R/K 28274 0 R>> endobj 14747 0 obj <>/Alt(SP; QL \(0.28 ML per 28 days\))/P 5104 0 R/K 28275 0 R>> endobj 14748 0 obj <>/Alt(UZEDY SUBCUTANEOUS SUSPENSION,EXTENDED REL SYRING 125 MG/0.35 ML)/P 5105 0 R/K 28276 0 R>> endobj 14749 0 obj <>/Alt(Tier 2)/P 5105 0 R/K 28277 0 R>> endobj 14750 0 obj <>/Alt(SP; QL \(0.35 ML per 28 days\))/P 5105 0 R/K 28278 0 R>> endobj 14751 0 obj <>/Alt(UZEDY SUBCUTANEOUS SUSPENSION,EXTENDED REL SYRING 150 MG/0.42 ML)/P 5106 0 R/K 28279 0 R>> endobj 14752 0 obj <>/Alt(Tier 2)/P 5106 0 R/K 28280 0 R>> endobj 14753 0 obj <>/Alt(SP; QL \(0.42 ML per 56 days\))/P 5106 0 R/K 28281 0 R>> endobj 14754 0 obj <>/Alt(UZEDY SUBCUTANEOUS SUSPENSION,EXTENDED REL SYRING 200 MG/0.56 ML)/P 5107 0 R/K 28282 0 R>> endobj 14755 0 obj <>/Alt(Tier 2)/P 5107 0 R/K 28283 0 R>> endobj 14756 0 obj <>/Alt(SP; QL \(0.56 ML per 56 days\))/P 5107 0 R/K 28284 0 R>> endobj 14757 0 obj <>/Alt(UZEDY SUBCUTANEOUS SUSPENSION,EXTENDED REL SYRING 250 MG/0.7 ML)/P 5108 0 R/K 28285 0 R>> endobj 14758 0 obj <>/Alt(Tier 2)/P 5108 0 R/K 28286 0 R>> endobj 14759 0 obj <>/Alt(SP; QL \(0.7 ML per 56 days\))/P 5108 0 R/K 28287 0 R>> endobj 14760 0 obj <>/Alt(UZEDY SUBCUTANEOUS SUSPENSION,EXTENDED REL SYRING 50 MG/0.14 ML)/P 5109 0 R/K 28288 0 R>> endobj 14761 0 obj <>/Alt(Tier 2)/P 5109 0 R/K 28289 0 R>> endobj 14762 0 obj <>/Alt(SP; QL \(0.14 ML per 28 days\))/P 5109 0 R/K 28290 0 R>> endobj 14763 0 obj <>/Alt(UZEDY SUBCUTANEOUS SUSPENSION,EXTENDED REL SYRING 75 MG/0.21 ML)/P 5110 0 R/K 28291 0 R>> endobj 14764 0 obj <>/Alt(Tier 2)/P 5110 0 R/K 28292 0 R>> endobj 14765 0 obj <>/Alt(SP; QL \(0.21 ML per 28 days\))/P 5110 0 R/K 28293 0 R>> endobj 14766 0 obj <>/Alt(VERSACLOZ ORAL SUSPENSION 50 MG/ML)/P 5111 0 R/K 28294 0 R>> endobj 14767 0 obj <>/Alt(Tier 3)/P 5111 0 R/K 28295 0 R>> endobj 14768 0 obj <>/Alt(QL \(18 ML per 1 day\))/P 5111 0 R/K 28296 0 R>> endobj 14769 0 obj <>/Alt(\(Begin italic\) ziprasidone hcl oral capsule \(End italic\) \(Begin italic\) 20 mg, 40 mg, 60 mg, 80 mg \(End italic\))/P 5112 0 R/K 28297 0 R>> endobj 14770 0 obj <>/Alt(\(Geodon\))/P 5112 0 R/K 28298 0 R>> endobj 14771 0 obj <>/Alt(Tier 1)/P 5112 0 R/K 28299 0 R>> endobj 14772 0 obj <>/Alt(\(Begin bold\) Antipsychotics,Dopamine Antagonists, Thioxanthenes \(End bold\))/P 5113 0 R/K 28300 0 R>> endobj 14773 0 obj <>/Alt(\(Begin italic\) thiothixene oral capsule \(End italic\) \(Begin italic\) 1 mg, 10 mg, 2 mg, 5 mg \(End italic\))/P 5114 0 R/K 28301 0 R>> endobj 14774 0 obj <>/Alt(Tier 1)/P 5114 0 R/K 28302 0 R>> endobj 14775 0 obj <>/Alt(\(Begin bold\) Antipsychotics,Dopamine Antagonists,Butyrophenones \(End bold\))/P 5115 0 R/K 28303 0 R>> endobj 14776 0 obj <>/Alt(\(Begin italic\) haloperidol lactate oral concentrate \(End italic\) \(Begin italic\) 2 mg/ml \(End italic\))/P 5116 0 R/K 28304 0 R>> endobj 14777 0 obj <>/Alt(Tier 1)/P 5116 0 R/K 28305 0 R>> endobj 14778 0 obj <>/Alt(\(Begin italic\) haloperidol oral tablet \(End italic\) \(Begin italic\) 0.5 mg, 1 mg, 10 mg, 2 mg, 20 mg, 5 mg \(End italic\))/P 5117 0 R/K 28306 0 R>> endobj 14779 0 obj <>/Alt(Tier 1)/P 5117 0 R/K 28307 0 R>> endobj 14780 0 obj <>/Alt(\(Begin bold\) Antipsychotics,Dopamine Antagonst,Dihydroindolones \(End bold\))/P 5118 0 R/K 28308 0 R>> endobj 14781 0 obj <>/Alt(\(Begin italic\) molindone oral tablet \(End italic\) \(Begin italic\) 10 mg \(End italic\))/P 5119 0 R/K 28309 0 R>> endobj 14782 0 obj <>/Alt(Tier 1)/P 5119 0 R/K 28310 0 R>> endobj 14783 0 obj <>/Alt(QL \(8 EA per 1 day\))/P 5119 0 R/K 28311 0 R>> endobj 14784 0 obj <>/Alt(\(Begin italic\) molindone oral tablet \(End italic\) \(Begin italic\) 25 mg \(End italic\))/P 5120 0 R/K 28312 0 R>> endobj 14785 0 obj <>/Alt(Tier 1)/P 5120 0 R/K 28313 0 R>> endobj 14786 0 obj <>/Alt(QL \(9 EA per 1 day\))/P 5120 0 R/K 28314 0 R>> endobj 14787 0 obj <>/Alt(\(Begin italic\) molindone oral tablet \(End italic\) \(Begin italic\) 5 mg \(End italic\))/P 5121 0 R/K 28315 0 R>> endobj 14788 0 obj <>/Alt(Tier 1)/P 5121 0 R/K 28316 0 R>> endobj 14789 0 obj <>/Alt(\(Begin bold\) Anti-Psychotics,Phenothiazines \(End bold\))/P 5122 0 R/K 28317 0 R>> endobj 14790 0 obj <>/Alt(\(Begin italic\) chlorpromazine oral concentrate \(End italic\) \(Begin italic\) 100 mg/ml, 30 mg/ml \(End italic\))/P 5123 0 R/K 28318 0 R>> endobj 14791 0 obj <>/Alt(Tier 1)/P 5123 0 R/K 28319 0 R>> endobj 14792 0 obj <>/Alt(\(Begin italic\) chlorpromazine oral tablet \(End italic\) \(Begin italic\) 10 mg, 100 mg, 200 mg, 25 mg, 50 mg \(End italic\))/P 5124 0 R/K 28320 0 R>> endobj 14793 0 obj <>/Alt(Tier 1)/P 5124 0 R/K 28321 0 R>> endobj 14794 0 obj <>/Alt(\(Begin italic\) fluphenazine hcl oral concentrate \(End italic\) \(Begin italic\) 5 mg/ml \(End italic\))/P 5125 0 R/K 28322 0 R>> endobj 14795 0 obj <>/Alt(Tier 1)/P 5125 0 R/K 28323 0 R>> endobj 14796 0 obj <>/Alt(\(Begin italic\) fluphenazine hcl oral elixir \(End italic\) \(Begin italic\) 2.5 mg/5 ml \(End italic\))/P 5126 0 R/K 28324 0 R>> endobj 14797 0 obj <>/Alt(Tier 1)/P 5126 0 R/K 28325 0 R>> endobj 14798 0 obj <>/Alt(\(Begin italic\) fluphenazine hcl oral tablet \(End italic\) \(Begin italic\) 1 mg, 10 mg, 2.5 mg, 5 mg \(End italic\))/P 5127 0 R/K 28326 0 R>> endobj 14799 0 obj <>/Alt(Tier 1)/P 5127 0 R/K 28327 0 R>> endobj 14800 0 obj <>/Alt(\(Begin italic\) perphenazine oral tablet \(End italic\) \(Begin italic\) 16 mg, 2 mg, 4 mg, 8 mg \(End italic\))/P 5128 0 R/K 28328 0 R>> endobj 14801 0 obj <>/Alt(Tier 1)/P 5128 0 R/K 28329 0 R>> endobj 14802 0 obj <>/Alt(\(Begin italic\) thioridazine oral tablet \(End italic\) \(Begin italic\) 10 mg, 100 mg, 25 mg, 50 mg \(End italic\))/P 5129 0 R/K 28330 0 R>> endobj 14803 0 obj <>/Alt(Tier 1)/P 5129 0 R/K 28331 0 R>> endobj 14804 0 obj <>/Alt(\(Begin italic\) trifluoperazine oral tablet \(End italic\) \(Begin italic\) 1 mg, 10 mg, 2 mg, 5 mg \(End italic\))/P 5130 0 R/K 28332 0 R>> endobj 14805 0 obj <>/Alt(Tier 1)/P 5130 0 R/K 28333 0 R>> endobj 14806 0 obj <>/Alt(\(Begin bold\) Barbiturates \(End bold\))/P 5131 0 R/K 28334 0 R>> endobj 14807 0 obj <>/Alt(\(Begin italic\) phenobarbital oral elixir \(End italic\) \(Begin italic\) 20 mg/5 ml \(4 mg/ml\) \(End italic\))/P 5132 0 R/K 28335 0 R>> endobj 14808 0 obj <>/Alt(Tier 1)/P 5132 0 R/K 28336 0 R>> endobj 14809 0 obj <>/Alt(\(Begin italic\) phenobarbital oral tablet \(End italic\) \(Begin italic\) 100 mg, 15 mg, 16.2 mg, 30 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg \(End italic\))/P 5133 0 R/K 28337 0 R>> endobj 14810 0 obj <>/Alt(Tier 1)/P 5133 0 R/K 28338 0 R>> endobj 14811 0 obj <>/Alt(\(Begin bold\) Cholinergic And Anticholinergic Combinations \(End bold\))/P 5134 0 R/K 28339 0 R>> endobj 14812 0 obj <>/Alt(COBENFY ORAL CAPSULE 100-20 MG, 125-30 MG, 50-20 MG)/P 5135 0 R/K 28340 0 R>> endobj 14813 0 obj <>/Alt(Tier 3)/P 5135 0 R/K 28341 0 R>> endobj 14814 0 obj <>/Alt(ST: Requires prior prescription for a generic atypical antipsychotic, Rexulti, or Vraylar within the past 120 days; QL \(2 EA per 1 day\))/P 5135 0 R/K 28342 0 R>> endobj 14815 0 obj <>/Alt(COBENFY STARTER PACK ORAL CAPSULE,DOSE PACK 50 MG-20 MG /100 MG-20 MG)/P 5136 0 R/K 28343 0 R>> endobj 14816 0 obj <>/Alt(Tier 3)/P 5136 0 R/K 28344 0 R>> endobj 14817 0 obj <>/Alt(ST: Requires prior prescription for a generic atypical antipsychotic, Rexulti, or Vraylar within the past 120 days)/P 5136 0 R/K 28345 0 R>> endobj 14818 0 obj <>/Alt(\(Begin bold\) Hsdd Agents-Mixed Serotonin Agonist/Antagonists \(End bold\))/P 5137 0 R/K 28346 0 R>> endobj 14819 0 obj <>/Alt(ADDYI ORAL TABLET 100 MG)/P 5138 0 R/K 28347 0 R>> endobj 14820 0 obj <>/Alt(Tier 3)/P 5138 0 R/K 28348 0 R>> endobj 14821 0 obj <>/Alt(PA)/P 5138 0 R/K 28349 0 R>> endobj 14822 0 obj <>/Alt(VYLEESI SUBCUTANEOUS AUTO-INJECTOR 1.75 MG/0.3 ML)/P 5139 0 R/K 28350 0 R>> endobj 14823 0 obj <>/Alt(Tier 3)/P 5139 0 R/K 28351 0 R>> endobj 14824 0 obj <>/Alt(PA)/P 5139 0 R/K 28352 0 R>> endobj 14825 0 obj <>/Alt(\(Begin bold\) Hypnotics, Melatonin Mt1/Mt2 Receptor Agonists \(End bold\))/P 5140 0 R/K 28353 0 R>> endobj 14826 0 obj <>/Alt(HETLIOZ LQ ORAL SUSPENSION 4 MG/ML)/P 5141 0 R/K 28354 0 R>> endobj 14827 0 obj <>/Alt(Tier 3)/P 5141 0 R/K 28355 0 R>> endobj 14828 0 obj <>/Alt(PA; SP)/P 5141 0 R/K 28356 0 R>> endobj 14829 0 obj <>/Alt(\(Begin italic\) tasimelteon oral capsule \(End italic\) \(Begin italic\) 20 mg \(End italic\))/P 5142 0 R/K 28357 0 R>> endobj 14830 0 obj <>/Alt(\(Hetlioz\))/P 5142 0 R/K 28358 0 R>> endobj 14831 0 obj <>/Alt(Tier 1)/P 5142 0 R/K 28359 0 R>> endobj 14832 0 obj <>/Alt(PA; SP)/P 5142 0 R/K 28360 0 R>> endobj 14833 0 obj <>/Alt(\(Begin bold\) Narcolepsy And Sleep Disorder Therapy Agents \(End bold\))/P 5143 0 R/K 28361 0 R>> endobj 14834 0 obj <>/Alt(\(Begin italic\) armodafinil oral tablet \(End italic\) \(Begin italic\) 150 mg, 200 mg, 250 mg \(End italic\))/P 5144 0 R/K 28362 0 R>> endobj 14835 0 obj <>/Alt(\(Nuvigil\))/P 5144 0 R/K 28363 0 R>> endobj 14836 0 obj <>/Alt(Tier 1)/P 5144 0 R/K 28364 0 R>> endobj 14837 0 obj <>/Alt(QL \(1 EA per 1 day\))/P 5144 0 R/K 28365 0 R>> endobj 14838 0 obj <>/Alt(\(Begin italic\) armodafinil oral tablet \(End italic\) \(Begin italic\) 50 mg \(End italic\))/P 5145 0 R/K 28366 0 R>> endobj 14839 0 obj <>/Alt(\(Nuvigil\))/P 5145 0 R/K 28367 0 R>> endobj 14840 0 obj <>/Alt(Tier 1)/P 5145 0 R/K 28368 0 R>> endobj 14841 0 obj <>/Alt(QL \(3 EA per 1 day\))/P 5145 0 R/K 28369 0 R>> endobj 14842 0 obj <>/Alt(\(Begin italic\) modafinil oral tablet \(End italic\) \(Begin italic\) 100 mg, 200 mg \(End italic\))/P 5146 0 R/K 28370 0 R>> endobj 14843 0 obj <>/Alt(\(Provigil\))/P 5146 0 R/K 28371 0 R>> endobj 14844 0 obj <>/Alt(Tier 1)/P 5146 0 R/K 28372 0 R>> endobj 14845 0 obj <>/Alt(QL \(2 EA per 1 day\))/P 5146 0 R/K 28373 0 R>> endobj 14846 0 obj <>/Alt(SUNOSI ORAL TABLET 150 MG, 75 MG)/P 5147 0 R/K 28374 0 R>> endobj 14847 0 obj <>/Alt(Tier 3)/P 5147 0 R/K 28375 0 R>> endobj 14848 0 obj <>/Alt(PA)/P 5147 0 R/K 28376 0 R>> endobj 14849 0 obj <>/Alt(\(Begin bold\) Narcolepsy Tx-H3-Recept.Antagonist/Inverse Agonist \(End bold\))/P 5148 0 R/K 28377 0 R>> endobj 14850 0 obj <>/Alt(WAKIX ORAL TABLET 17.8 MG, 4.45 MG)/P 5149 0 R/K 28378 0 R>> endobj 14851 0 obj <>/Alt(Tier 3)/P 5149 0 R/K 28379 0 R>> endobj 14852 0 obj <>/Alt(PA; SP)/P 5149 0 R/K 28380 0 R>> endobj 14853 0 obj <>/Alt(\(Begin bold\) Narcotic Antagonists \(End bold\))/P 5150 0 R/K 28381 0 R>> endobj 14854 0 obj <>/Alt(KLOXXADO NASAL SPRAY,NON-AEROSOL 8 MG/ACTUATION)/P 5151 0 R/K 28382 0 R>> endobj 14855 0 obj <>/Alt(Tier 2)/P 5151 0 R/K 28383 0 R>> endobj 14856 0 obj <>/Alt(QL \(4 EA per 30 days\))/P 5151 0 R/K 28384 0 R>> endobj 14857 0 obj <>/Alt(LOTREXONE ORAL CAPSULE 1.5 MG, 4.5 MG)/P 5152 0 R/K 28385 0 R>> endobj 14858 0 obj <>/Alt(Tier 3)/P 5152 0 R/K 28386 0 R>> endobj 14859 0 obj <>/Alt(\(Begin italic\) naloxone injection auto-injector \(End italic\) \(Begin italic\) 10 mg/0.4 ml \(End italic\))/P 5153 0 R/K 28387 0 R>> endobj 14860 0 obj <>/Alt(Tier 1)/P 5153 0 R/K 28388 0 R>> endobj 14861 0 obj <>/Alt(\(Begin italic\) naloxone injection syringe \(End italic\) \(Begin italic\) 0.4 mg/ml, 1 mg/ml \(End italic\))/P 5154 0 R/K 28389 0 R>> endobj 14862 0 obj <>/Alt(Tier 1)/P 5154 0 R/K 28390 0 R>> endobj 14863 0 obj <>/Alt(\(Begin italic\) naloxone nasal spray,non-aerosol \(End italic\) \(Begin italic\) 4 mg/actuation \(End italic\))/P 5155 0 R/K 28391 0 R>> endobj 14864 0 obj <>/Alt(\(Narcan\))/P 5155 0 R/K 28392 0 R>> endobj 14865 0 obj <>/Alt(Tier 1)/P 5155 0 R/K 28393 0 R>> endobj 14866 0 obj <>/Alt(QL \(4 EA per 30 days\))/P 5155 0 R/K 28394 0 R>> endobj 14867 0 obj <>/Alt(NALTREX ORAL CAPSULE 1.5 MG, 4.5 MG)/P 5156 0 R/K 28395 0 R>> endobj 14868 0 obj <>/Alt(Tier 3)/P 5156 0 R/K 28396 0 R>> endobj 14869 0 obj <>/Alt(\(Begin italic\) naltrexone oral tablet \(End italic\) \(Begin italic\) 50 mg \(End italic\))/P 5157 0 R/K 28397 0 R>> endobj 14870 0 obj <>/Alt(Tier 1)/P 5157 0 R/K 28398 0 R>> endobj 14871 0 obj <>/Alt(OPVEE NASAL SPRAY,NON-AEROSOL 2.7 MG/ACTUATION)/P 5158 0 R/K 28399 0 R>> endobj 14872 0 obj <>/Alt(Tier 3)/P 5158 0 R/K 28400 0 R>> endobj 14873 0 obj <>/Alt(QL \(4 EA per 30 days\))/P 5158 0 R/K 28401 0 R>> endobj 14874 0 obj <>/Alt(ZIMHI INJECTION SYRINGE 5 MG/0.5 ML)/P 5159 0 R/K 28402 0 R>> endobj 14875 0 obj <>/Alt(Tier 3)/P 5159 0 R/K 28403 0 R>> endobj 14876 0 obj <>/Alt(QL \(2 ML per 30 days\))/P 5159 0 R/K 28404 0 R>> endobj 14877 0 obj <>/Alt(\(Begin bold\) Sedative-Hypnotics - Benzodiazepines \(End bold\))/P 5160 0 R/K 28405 0 R>> endobj 14878 0 obj <>/Alt(\(Begin italic\) estazolam oral tablet \(End italic\) \(Begin italic\) 1 mg, 2 mg \(End italic\))/P 5161 0 R/K 28406 0 R>> endobj 14879 0 obj <>/Alt(Tier 1)/P 5161 0 R/K 28407 0 R>> endobj 14880 0 obj <>/Alt(\(Begin italic\) flurazepam oral capsule \(End italic\) \(Begin italic\) 15 mg, 30 mg \(End italic\))/P 5162 0 R/K 28408 0 R>> endobj 14881 0 obj <>/Alt(Tier 1)/P 5162 0 R/K 28409 0 R>> endobj 14882 0 obj <>/Alt(\(Begin italic\) midazolam oral syrup \(End italic\) \(Begin italic\) 2 mg/ml \(End italic\))/P 5163 0 R/K 28410 0 R>> endobj 14883 0 obj <>/Alt(Tier 1)/P 5163 0 R/K 28411 0 R>> endobj 14884 0 obj <>/Alt(\(Begin italic\) quazepam oral tablet \(End italic\) \(Begin italic\) 15 mg \(End italic\))/P 5164 0 R/K 28412 0 R>> endobj 14885 0 obj <>/Alt(\(Doral\))/P 5164 0 R/K 28413 0 R>> endobj 14886 0 obj <>/Alt(Tier 1)/P 5164 0 R/K 28414 0 R>> endobj 14887 0 obj <>/Alt(\(Begin italic\) temazepam oral capsule \(End italic\) \(Begin italic\) 15 mg, 22.5 mg, 30 mg, 7.5 mg \(End italic\))/P 5165 0 R/K 28415 0 R>> endobj 14888 0 obj <>/Alt(\(Restoril\))/P 5165 0 R/K 28416 0 R>> endobj 14889 0 obj <>/Alt(Tier 1)/P 5165 0 R/K 28417 0 R>> endobj 14890 0 obj <>/Alt(\(Begin italic\) triazolam oral tablet \(End italic\) \(Begin italic\) 0.125 mg \(End italic\))/P 5166 0 R/K 28418 0 R>> endobj 14891 0 obj <>/Alt(Tier 1)/P 5166 0 R/K 28419 0 R>> endobj 14892 0 obj <>/Alt(\(Begin italic\) triazolam oral tablet \(End italic\) \(Begin italic\) 0.25 mg \(End italic\))/P 5167 0 R/K 28420 0 R>> endobj 14893 0 obj <>/Alt(\(Halcion\))/P 5167 0 R/K 28421 0 R>> endobj 14894 0 obj <>/Alt(Tier 1)/P 5167 0 R/K 28422 0 R>> endobj 14895 0 obj <>/Alt(\(Begin bold\) Sedative-Hypnotics,Non-Barbiturate \(End bold\))/P 5168 0 R/K 28423 0 R>> endobj 14896 0 obj <>/Alt(BELSOMRA ORAL TABLET 10 MG, 15 MG, 20 MG, 5 MG)/P 5169 0 R/K 28424 0 R>> endobj 14897 0 obj <>/Alt(Tier 2)/P 5169 0 R/K 28425 0 R>> endobj 14898 0 obj <>/Alt(QL \(1 EA per 1 day\))/P 5169 0 R/K 28426 0 R>> endobj 14899 0 obj <>/Alt(\(Begin italic\) doxepin oral tablet \(End italic\) \(Begin italic\) 3 mg, 6 mg \(End italic\))/P 5170 0 R/K 28427 0 R>> endobj 14900 0 obj <>/Alt(\(Silenor\))/P 5170 0 R/K 28428 0 R>> endobj 14901 0 obj <>/Alt(Tier 1)/P 5170 0 R/K 28429 0 R>> endobj 14902 0 obj <>/Alt(QL \(1 EA per 1 day\))/P 5170 0 R/K 28430 0 R>> endobj 14903 0 obj <>/Alt(\(Begin italic\) eszopiclone oral tablet \(End italic\) \(Begin italic\) 1 mg, 2 mg, 3 mg \(End italic\))/P 5171 0 R/K 28431 0 R>> endobj 14904 0 obj <>/Alt(\(Lunesta\))/P 5171 0 R/K 28432 0 R>> endobj 14905 0 obj <>/Alt(Tier 1)/P 5171 0 R/K 28433 0 R>> endobj 14906 0 obj <>/Alt(QL \(1 EA per 1 day\))/P 5171 0 R/K 28434 0 R>> endobj 14907 0 obj <>/Alt(\(Begin italic\) zaleplon oral capsule \(End italic\) \(Begin italic\) 10 mg, 5 mg \(End italic\))/P 5172 0 R/K 28435 0 R>> endobj 14908 0 obj <>/Alt(Tier 1)/P 5172 0 R/K 28436 0 R>> endobj 14909 0 obj <>/Alt(QL \(1 EA per 1 day\))/P 5172 0 R/K 28437 0 R>> endobj 14910 0 obj <>/Alt(\(Begin italic\) zolpidem oral tablet \(End italic\) \(Begin italic\) 10 mg, 5 mg \(End italic\))/P 5173 0 R/K 28438 0 R>> endobj 14911 0 obj <>/Alt(\(Ambien\))/P 5173 0 R/K 28439 0 R>> endobj 14912 0 obj <>/Alt(Tier 1)/P 5173 0 R/K 28440 0 R>> endobj 14913 0 obj <>/Alt(QL \(1 EA per 1 day\))/P 5173 0 R/K 28441 0 R>> endobj 14914 0 obj <>/Alt(\(Begin italic\) zolpidem oral tablet,ext release multiphase \(End italic\) \(Begin italic\) 12.5 mg, 6.25 mg \(End italic\))/P 5174 0 R/K 28442 0 R>> endobj 14915 0 obj <>/Alt(\(Ambien CR\))/P 5174 0 R/K 28443 0 R>> endobj 14916 0 obj <>/Alt(Tier 1)/P 5174 0 R/K 28444 0 R>> endobj 14917 0 obj <>/Alt(QL \(1 EA per 1 day\))/P 5174 0 R/K 28445 0 R>> endobj 14918 0 obj <>/Alt(\(Begin italic\) zolpidem sublingual tablet \(End italic\) \(Begin italic\) 1.75 mg, 3.5 mg \(End italic\))/P 5175 0 R/K 28446 0 R>> endobj 14919 0 obj <>/Alt(Tier 1)/P 5175 0 R/K 28447 0 R>> endobj 14920 0 obj <>/Alt(QL \(1 EA per 1 day\))/P 5175 0 R/K 28448 0 R>> endobj 14921 0 obj <>/Alt(\(Begin bold\) Selective Serotonin 5-Ht2a Inverse Agonists \(Ssia\) \(End bold\))/P 5176 0 R/K 28449 0 R>> endobj 14922 0 obj <>/Alt(NUPLAZID ORAL CAPSULE 34 MG)/P 5177 0 R/K 28450 0 R>> endobj 14923 0 obj <>/Alt(Tier 3)/P 5177 0 R/K 28451 0 R>> endobj 14924 0 obj <>/Alt(PA; SP)/P 5177 0 R/K 28452 0 R>> endobj 14925 0 obj <>/Alt(NUPLAZID ORAL TABLET 10 MG)/P 5178 0 R/K 28453 0 R>> endobj 14926 0 obj <>/Alt(Tier 3)/P 5178 0 R/K 28454 0 R>> endobj 14927 0 obj <>/Alt(PA; SP)/P 5178 0 R/K 28455 0 R>> endobj 14928 0 obj <>/Alt(\(Begin bold\) Ssri &Antipsych,Atyp,Dopamine&Serotonin Antag Comb \(End bold\))/P 5179 0 R/K 28456 0 R>> endobj 14929 0 obj <>/Alt(\(Begin italic\) olanzapine-fluoxetine oral capsule \(End italic\) \(Begin italic\) 12-25 mg, 6-50 mg \(End italic\))/P 5180 0 R/K 28457 0 R>> endobj 14930 0 obj <>/Alt(Tier 1)/P 5180 0 R/K 28458 0 R>> endobj 14931 0 obj <>/Alt(QL \(1 EA per 1 day\))/P 5180 0 R/K 28459 0 R>> endobj 14932 0 obj <>/Alt(\(Begin italic\) olanzapine-fluoxetine oral capsule \(End italic\) \(Begin italic\) 12-50 mg, 3-25 mg, 6-25 mg \(End italic\))/P 5181 0 R/K 28460 0 R>> endobj 14933 0 obj <>/Alt(\(Symbyax\))/P 5181 0 R/K 28461 0 R>> endobj 14934 0 obj <>/Alt(Tier 1)/P 5181 0 R/K 28462 0 R>> endobj 14935 0 obj <>/Alt(QL \(1 EA per 1 day\))/P 5181 0 R/K 28463 0 R>> endobj 14936 0 obj <>/Alt(\(Begin bold\) Tx For Adhd - Selective Alpha-2A Receptor Agonist \(End bold\))/P 5182 0 R/K 28464 0 R>> endobj 14937 0 obj <>/Alt(\(Begin italic\) clonidine hcl oral tablet extended release 12 hr \(End italic\) \(Begin italic\) 0.1 mg \(End italic\))/P 5183 0 R/K 28465 0 R>> endobj 14938 0 obj <>/Alt(Tier 1)/P 5183 0 R/K 28466 0 R>> endobj 14939 0 obj <>/Alt(\(Begin italic\) guanfacine oral tablet extended release 24 hr \(End italic\) \(Begin italic\) 1 mg, 2 mg, 3 mg, 4 mg \(End italic\))/P 5184 0 R/K 28467 0 R>> endobj 14940 0 obj <>/Alt(\(Intuniv ER\))/P 5184 0 R/K 28468 0 R>> endobj 14941 0 obj <>/Alt(Tier 1)/P 5184 0 R/K 28469 0 R>> endobj 14942 0 obj <>/Alt(ONYDA XR ORAL SUSPENSION,EXTEND RELEASE 24HR 0.1 MG/ML)/P 5185 0 R/K 28470 0 R>> endobj 14943 0 obj <>/Alt(Tier 3)/P 5185 0 R/K 28471 0 R>> endobj 14944 0 obj <>/Alt(ST: Requires prior prescription for Clonidine 0.1mg ER tablets within the past 120 days; QL \(4 ML per 1 day\); Age \(Min 6 Years\))/P 5185 0 R/K 28472 0 R>> endobj 14945 0 obj <>/Alt(\(Begin bold\) Tx For Attention Deficit-Hyperact\(Adhd\)/Narcolepsy \(End bold\))/P 5186 0 R/K 28473 0 R>> endobj 14946 0 obj <>/Alt(AZSTARYS ORAL CAPSULE 26.1 MG- 5.2 MG, 39.2 MG- 7.8 MG, 52.3 MG- 10.4 MG)/P 5187 0 R/K 28474 0 R>> endobj 14947 0 obj <>/Alt(Tier 2)/P 5187 0 R/K 28475 0 R>> endobj 14948 0 obj <>/Alt(ST: Requires prior prescription for generic Lisdexamfetamine, Methylphenidate ER/LA/CD, or Dextroamphetamine/Amphetamine XR/ER within the past 120 days; QL \(1 EA per 1 day\))/P 5187 0 R/K 28476 0 R>> endobj 14949 0 obj <>/Alt(\(Begin italic\) dexmethylphenidate oral capsule,er biphasic 50-50 \(End italic\) \(Begin italic\) 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 35 mg, 40 mg, 5 mg \(End italic\))/P 5188 0 R/K 28477 0 R>> endobj 14950 0 obj <>/Alt(\(Focalin XR\))/P 5188 0 R/K 28478 0 R>> endobj 14951 0 obj <>/Alt(Tier 1)/P 5188 0 R/K 28479 0 R>> endobj 14952 0 obj <>/Alt(QL \(1 EA per 1 day\))/P 5188 0 R/K 28480 0 R>> endobj 14953 0 obj <>/Alt(\(Begin italic\) dexmethylphenidate oral tablet \(End italic\) \(Begin italic\) 10 mg, 2.5 mg, 5 mg \(End italic\))/P 5189 0 R/K 28481 0 R>> endobj 14954 0 obj <>/Alt(\(Focalin\))/P 5189 0 R/K 28482 0 R>> endobj 14955 0 obj <>/Alt(Tier 1)/P 5189 0 R/K 28483 0 R>> endobj 14956 0 obj <>/Alt(QL \(2 EA per 1 day\))/P 5189 0 R/K 28484 0 R>> endobj 14957 0 obj <>/Alt(JORNAY PM ORAL CAPSULE,DEL REL,EXT REL SPRINK 100 MG, 20 MG, 40 MG, 60 MG, 80 MG)/P 5190 0 R/K 28485 0 R>> endobj 14958 0 obj <>/Alt(Tier 2)/P 5190 0 R/K 28486 0 R>> endobj 14959 0 obj <>/Alt(ST: Requires prior prescription for generic Lisdexamfetamine, Methylphenidate ER/LA/CD, or Dextroamphetamine/Amphetamine XR/ER within the past 120 days; QL \(1 EA per 1 day\))/P 5190 0 R/K 28487 0 R>> endobj 14960 0 obj <>/Alt(\(Begin italic\) methylphenidate hcl oral capsule, er biphasic 30-70 \(End italic\) \(Begin italic\) 10 mg, 20 mg, 40 mg, 50 mg, 60 mg \(End italic\))/P 5191 0 R/K 28488 0 R>> endobj 14961 0 obj <>/Alt(\(Metadate CD\))/P 5191 0 R/K 28489 0 R>> endobj 14962 0 obj <>/Alt(Tier 1)/P 5191 0 R/K 28490 0 R>> endobj 14963 0 obj <>/Alt(QL \(1 EA per 1 day\))/P 5191 0 R/K 28491 0 R>> endobj 14964 0 obj <>/Alt(\(Begin italic\) methylphenidate hcl oral capsule, er biphasic 30-70 \(End italic\) \(Begin italic\) 30 mg \(End italic\))/P 5192 0 R/K 28492 0 R>> endobj 14965 0 obj <>/Alt(\(Metadate CD\))/P 5192 0 R/K 28493 0 R>> endobj 14966 0 obj <>/Alt(Tier 1)/P 5192 0 R/K 28494 0 R>> endobj 14967 0 obj <>/Alt(QL \(2 EA per 1 day\))/P 5192 0 R/K 28495 0 R>> endobj 14968 0 obj <>/Alt(\(Begin italic\) methylphenidate hcl oral capsule,er biphasic 50-50 \(End italic\) \(Begin italic\) 10 mg, 20 mg, 40 mg \(End italic\))/P 5193 0 R/K 28496 0 R>> endobj 14969 0 obj <>/Alt(\(Ritalin LA\))/P 5193 0 R/K 28497 0 R>> endobj 14970 0 obj <>/Alt(Tier 1)/P 5193 0 R/K 28498 0 R>> endobj 14971 0 obj <>/Alt(QL \(1 EA per 1 day\))/P 5193 0 R/K 28499 0 R>> endobj 14972 0 obj <>/Alt(\(Begin italic\) methylphenidate hcl oral capsule,er biphasic 50-50 \(End italic\) \(Begin italic\) 30 mg \(End italic\))/P 5194 0 R/K 28500 0 R>> endobj 14973 0 obj <>/Alt(\(Ritalin LA\))/P 5194 0 R/K 28501 0 R>> endobj 14974 0 obj <>/Alt(Tier 1)/P 5194 0 R/K 28502 0 R>> endobj 14975 0 obj <>/Alt(QL \(2 EA per 1 day\))/P 5194 0 R/K 28503 0 R>> endobj 14976 0 obj <>/Alt(\(Begin italic\) methylphenidate hcl oral capsule,er biphasic 50-50 \(End italic\) \(Begin italic\) 60 mg \(End italic\))/P 5195 0 R/K 28504 0 R>> endobj 14977 0 obj <>/Alt(Tier 1)/P 5195 0 R/K 28505 0 R>> endobj 14978 0 obj <>/Alt(QL \(1 EA per 1 day\))/P 5195 0 R/K 28506 0 R>> endobj 14979 0 obj <>/Alt(\(Begin italic\) methylphenidate hcl oral solution \(End italic\) \(Begin italic\) 10 mg/5 ml, 5 mg/5 ml \(End italic\))/P 5196 0 R/K 28507 0 R>> endobj 14980 0 obj <>/Alt(\(Methylin\))/P 5196 0 R/K 28508 0 R>> endobj 14981 0 obj <>/Alt(Tier 1)/P 5196 0 R/K 28509 0 R>> endobj 14982 0 obj <>/Alt(\(Begin italic\) methylphenidate hcl oral tablet \(End italic\) \(Begin italic\) 10 mg, 20 mg, 5 mg \(End italic\))/P 5197 0 R/K 28510 0 R>> endobj 14983 0 obj <>/Alt(\(Ritalin\))/P 5197 0 R/K 28511 0 R>> endobj 14984 0 obj <>/Alt(Tier 1)/P 5197 0 R/K 28512 0 R>> endobj 14985 0 obj <>/Alt(QL \(90 EA per 30 days\))/P 5197 0 R/K 28513 0 R>> endobj 14986 0 obj <>/Alt(\(Begin italic\) methylphenidate hcl oral tablet extended release \(End italic\) \(Begin italic\) 10 mg \(End italic\))/P 5198 0 R/K 28514 0 R>> endobj 14987 0 obj <>/Alt(Tier 1)/P 5198 0 R/K 28515 0 R>> endobj 14988 0 obj <>/Alt(QL \(3 EA per 1 day\))/P 5198 0 R/K 28516 0 R>> endobj 14989 0 obj <>/Alt(\(Begin italic\) methylphenidate hcl oral tablet extended release \(End italic\) \(Begin italic\) 20 mg \(End italic\))/P 5199 0 R/K 28517 0 R>> endobj 14990 0 obj <>/Alt(\(Metadate ER\))/P 5199 0 R/K 28518 0 R>> endobj 14991 0 obj <>/Alt(Tier 1)/P 5199 0 R/K 28519 0 R>> endobj 14992 0 obj <>/Alt(QL \(90 EA per 30 days\))/P 5199 0 R/K 28520 0 R>> endobj 14993 0 obj <>/Alt(\(Begin italic\) methylphenidate hcl oral tablet extended release 24hr \(End italic\) \(Begin italic\) 18 mg, 27 mg, 54 mg \(End italic\))/P 5200 0 R/K 28521 0 R>> endobj 14994 0 obj <>/Alt(\(Concerta\))/P 5200 0 R/K 28522 0 R>> endobj 14995 0 obj <>/Alt(Tier 1)/P 5200 0 R/K 28523 0 R>> endobj 14996 0 obj <>/Alt(QL \(1 EA per 1 day\))/P 5200 0 R/K 28524 0 R>> endobj 14997 0 obj <>/Alt(\(Begin italic\) methylphenidate hcl oral tablet extended release 24hr \(End italic\) \(Begin italic\) 36 mg \(End italic\))/P 5201 0 R/K 28525 0 R>> endobj 14998 0 obj <>/Alt(\(Concerta\))/P 5201 0 R/K 28526 0 R>> endobj 14999 0 obj <>/Alt(Tier 1)/P 5201 0 R/K 28527 0 R>> endobj 15000 0 obj <>/Alt(QL \(2 EA per 1 day\))/P 5201 0 R/K 28528 0 R>> endobj 15001 0 obj <>/Alt(\(Begin italic\) methylphenidate hcl oral tablet,chewable \(End italic\) \(Begin italic\) 10 mg, 2.5 mg, 5 mg \(End italic\))/P 5202 0 R/K 28529 0 R>> endobj 15002 0 obj <>/Alt(Tier 1)/P 5202 0 R/K 28530 0 R>> endobj 15003 0 obj <>/Alt(QL \(90 EA per 30 days\))/P 5202 0 R/K 28531 0 R>> endobj 15004 0 obj <>/Alt(\(Begin italic\) methylphenidate transdermal patch 24 hour \(End italic\) \(Begin italic\) 10 mg/9 hr, 15 mg/9 hr, 20 mg/9 hr, 30 mg/9 hr \(End italic\))/P 5203 0 R/K 28532 0 R>> endobj 15005 0 obj <>/Alt(\(Daytrana\))/P 5203 0 R/K 28533 0 R>> endobj 15006 0 obj <>/Alt(Tier 1)/P 5203 0 R/K 28534 0 R>> endobj 15007 0 obj <>/Alt(ST: Requires prior prescription for oral Methylphenidate CD/ER/LA formulation or Methylphenidate suspension/solution within the past 120 days; QL \(1 EA per 1 day\))/P 5203 0 R/K 28535 0 R>> endobj 15008 0 obj <>/Alt(QUILLICHEW ER ORAL TABLET,CHEW,IR-ER.BIPHASIC24HR 20 MG, 40 MG)/P 5204 0 R/K 28536 0 R>> endobj 15009 0 obj <>/Alt(Tier 3)/P 5204 0 R/K 28537 0 R>> endobj 15010 0 obj <>/Alt(ST: Requires prior prescription for generic Lisdexamfetamine, Methylphenidate ER/LA/CD, or Dextroamphetamine/Amphetamine XR/ER within the past 120 days; QL \(1 EA per 1 day\))/P 5204 0 R/K 28538 0 R>> endobj 15011 0 obj <>/Alt(QUILLICHEW ER ORAL TABLET,CHEW,IR-ER.BIPHASIC24HR 30 MG)/P 5205 0 R/K 28539 0 R>> endobj 15012 0 obj <>/Alt(Tier 3)/P 5205 0 R/K 28540 0 R>> endobj 15013 0 obj <>/Alt(ST: Requires prior prescription for generic Lisdexamfetamine, Methylphenidate ER/LA/CD, or Dextroamphetamine/Amphetamine XR/ER within the past 120 days; QL \(2 EA per 1 day\))/P 5205 0 R/K 28541 0 R>> endobj 15014 0 obj <>/Alt(QUILLIVANT XR 25 MG/5 ML SUSP 5 MG/ML \(25 MG/5 ML\))/P 5206 0 R/K 28542 0 R>> endobj 15015 0 obj <>/Alt(Tier 3)/P 5206 0 R/K 28543 0 R>> endobj 15016 0 obj <>/Alt(120mL BOTTLE; ST: Requires prior prescription for generic Lisdexamfetamine, Methylphenidate ER/LA/CD, or Dextroamphetamine/Amphetamine XR/ER within the past 120 days; QL \(240 ML per 30 days\))/P 5206 0 R/K 28544 0 R>> endobj 15017 0 obj <>/Alt(QUILLIVANT XR 25 MG/5 ML SUSP 5 MG/ML \(25 MG/5 ML\))/P 5207 0 R/K 28545 0 R>> endobj 15018 0 obj <>/Alt(Tier 3)/P 5207 0 R/K 28546 0 R>> endobj 15019 0 obj <>/Alt(150mL BOTTLE; ST: Requires prior prescription for generic Lisdexamfetamine, Methylphenidate ER/LA/CD, or Dextroamphetamine/Amphetamine XR/ER within the past 120 days; QL \(300 ML per 30 days\))/P 5207 0 R/K 28547 0 R>> endobj 15020 0 obj <>/Alt(QUILLIVANT XR 25 MG/5 ML SUSP 5 MG/ML \(25 MG/5 ML\))/P 5208 0 R/K 28548 0 R>> endobj 15021 0 obj <>/Alt(Tier 3)/P 5208 0 R/K 28549 0 R>> endobj 15022 0 obj <>/Alt(180mL BOTTLE; ST: Requires prior prescription for generic Lisdexamfetamine, Methylphenidate ER/LA/CD, or Dextroamphetamine/Amphetamine XR/ER within the past 120 days; QL \(360 ML per 30 days\))/P 5208 0 R/K 28550 0 R>> endobj 15023 0 obj <>/Alt(QUILLIVANT XR 25 MG/5 ML SUSP 5 MG/ML \(25 MG/5 ML\))/P 5209 0 R/K 28551 0 R>> endobj 15024 0 obj <>/Alt(Tier 3)/P 5209 0 R/K 28552 0 R>> endobj 15025 0 obj <>/Alt(60mL BOTTLE; ST: Requires prior prescription for generic Lisdexamfetamine, Methylphenidate ER/LA/CD, or Dextroamphetamine/Amphetamine XR/ER within the past 120 days; QL \(60 ML per 30 days\))/P 5209 0 R/K 28553 0 R>> endobj 15026 0 obj <>/Alt(\(Begin bold\) Tx For Attention Deficit-Hyperact.\(Adhd\), Nri-Type \(End bold\))/P 5210 0 R/K 28554 0 R>> endobj 15027 0 obj <>/Alt(\(Begin italic\) atomoxetine oral capsule \(End italic\) \(Begin italic\) 10 mg, 100 mg, 18 mg, 25 mg, 40 mg, 60 mg, 80 mg \(End italic\))/P 5211 0 R/K 28555 0 R>> endobj 15028 0 obj <>/Alt(\(Strattera\))/P 5211 0 R/K 28556 0 R>> endobj 15029 0 obj <>/Alt(Tier 1)/P 5211 0 R/K 28557 0 R>> endobj 15030 0 obj <>/Alt(QELBREE ORAL CAPSULE,EXTENDED RELEASE 24HR 100 MG)/P 5212 0 R/K 28558 0 R>> endobj 15031 0 obj <>/Alt(Tier 3)/P 5212 0 R/K 28559 0 R>> endobj 15032 0 obj <>/Alt(ST: Requires prior prescription for Atomoxetine, Clonidine ER \(Kapvay\), Dexmethylphenidate, Dextroamphetamine/Amphetamine, Guanfacine ER \(INTUNIV\), or generic IR Methylphenidate within the past 120 days; QL \(1 EA per 1 day\); Age \(Min 6 Years\))/P 5212 0 R/K 28560 0 R>> endobj 15033 0 obj <>/Alt(QELBREE ORAL CAPSULE,EXTENDED RELEASE 24HR 150 MG)/P 5213 0 R/K 28561 0 R>> endobj 15034 0 obj <>/Alt(Tier 3)/P 5213 0 R/K 28562 0 R>> endobj 15035 0 obj <>/Alt(ST: Requires prior prescription for Atomoxetine, Clonidine ER \(Kapvay\), Dexmethylphenidate, Dextroamphetamine/Amphetamine, Guanfacine ER \(INTUNIV\), or generic IR Methylphenidate within the past 120 days; QL \(2 EA per 1 day\); Age \(Min 6 Years\))/P 5213 0 R/K 28563 0 R>> endobj 15036 0 obj <>/Alt(QELBREE ORAL CAPSULE,EXTENDED RELEASE 24HR 200 MG)/P 5214 0 R/K 28564 0 R>> endobj 15037 0 obj <>/Alt(Tier 3)/P 5214 0 R/K 28565 0 R>> endobj 15038 0 obj <>/Alt(ST: Requires prior prescription for Atomoxetine, Clonidine ER \(Kapvay\), Dexmethylphenidate, Dextroamphetamine/Amphetamine, Guanfacine ER \(INTUNIV\), or generic IR Methylphenidate within the past 120 days; QL \(3 EA per 1 day\); Age \(Min 6 Years\))/P 5214 0 R/K 28566 0 R>> endobj 15039 0 obj <>/Alt(\(Begin bold\) Cardiovascular Disease - Arrhythmia \(End bold\))/P 5215 0 R/K 28567 0 R>> endobj 15040 0 obj <>/Alt(\(Begin bold\) Antiarrhythmics \(End bold\))/P 5216 0 R/K 28568 0 R>> endobj 15041 0 obj <>/Alt(\(Begin italic\) amiodarone oral tablet \(End italic\) \(Begin italic\) 100 mg, 200 mg, 400 mg \(End italic\))/P 5217 0 R/K 28569 0 R>> endobj 15042 0 obj <>/Alt(\(Pacerone\))/P 5217 0 R/K 28570 0 R>> endobj 15043 0 obj <>/Alt(Tier 1)/P 5217 0 R/K 28571 0 R>> endobj 15044 0 obj <>/Alt(\(Begin italic\) disopyramide phosphate oral capsule \(End italic\) \(Begin italic\) 100 mg, 150 mg \(End italic\))/P 5218 0 R/K 28572 0 R>> endobj 15045 0 obj <>/Alt(\(Norpace\))/P 5218 0 R/K 28573 0 R>> endobj 15046 0 obj <>/Alt(Tier 1)/P 5218 0 R/K 28574 0 R>> endobj 15047 0 obj <>/Alt(\(Begin italic\) dofetilide oral capsule \(End italic\) \(Begin italic\) 125 mcg, 250 mcg, 500 mcg \(End italic\))/P 5219 0 R/K 28575 0 R>> endobj 15048 0 obj <>/Alt(\(Tikosyn\))/P 5219 0 R/K 28576 0 R>> endobj 15049 0 obj <>/Alt(Tier 1)/P 5219 0 R/K 28577 0 R>> endobj 15050 0 obj <>/Alt(\(Begin italic\) flecainide oral tablet \(End italic\) \(Begin italic\) 100 mg, 150 mg, 50 mg \(End italic\))/P 5220 0 R/K 28578 0 R>> endobj 15051 0 obj <>/Alt(Tier 1)/P 5220 0 R/K 28579 0 R>> endobj 15052 0 obj <>/Alt(\(Begin italic\) mexiletine oral capsule \(End italic\) \(Begin italic\) 150 mg, 200 mg, 250 mg \(End italic\))/P 5221 0 R/K 28580 0 R>> endobj 15053 0 obj <>/Alt(Tier 1)/P 5221 0 R/K 28581 0 R>> endobj 15054 0 obj <>/Alt(MULTAQ ORAL TABLET 400 MG)/P 5222 0 R/K 28582 0 R>> endobj 15055 0 obj <>/Alt(Tier 2)/P 5222 0 R/K 28583 0 R>> endobj 15056 0 obj <>/Alt(NORPACE CR ORAL CAPSULE, EXTENDED RELEASE 100 MG)/P 5223 0 R/K 28584 0 R>> endobj 15057 0 obj <>/Alt(Tier 2)/P 5223 0 R/K 28585 0 R>> endobj 15058 0 obj <>/Alt(NORPACE CR ORAL CAPSULE, EXTENDED RELEASE 150 MG)/P 5224 0 R/K 28586 0 R>> endobj 15059 0 obj <>/Alt(\(disopyramide phosphate\))/P 5224 0 R/K 28587 0 R>> endobj 15060 0 obj <>/Alt(Tier 2)/P 5224 0 R/K 28588 0 R>> endobj 15061 0 obj <>/Alt(PACERONE ORAL TABLET 100 MG, 200 MG, 400 MG)/P 5225 0 R/K 28589 0 R>> endobj 15062 0 obj <>/Alt(\(amiodarone\))/P 5225 0 R/K 28590 0 R>> endobj 15063 0 obj <>/Alt(Tier 1)/P 5225 0 R/K 28591 0 R>> endobj 15064 0 obj <>/Alt(\(Begin italic\) propafenone oral capsule,extended release 12 hr \(End italic\) \(Begin italic\) 225 mg, 325 mg, 425 mg \(End italic\))/P 5226 0 R/K 28592 0 R>> endobj 15065 0 obj <>/Alt(Tier 1)/P 5226 0 R/K 28593 0 R>> endobj 15066 0 obj <>/Alt(\(Begin italic\) propafenone oral tablet \(End italic\) \(Begin italic\) 150 mg, 225 mg, 300 mg \(End italic\))/P 5227 0 R/K 28594 0 R>> endobj 15067 0 obj <>/Alt(Tier 1)/P 5227 0 R/K 28595 0 R>> endobj 15068 0 obj <>/Alt(\(Begin italic\) quinidine gluconate oral tablet extended release \(End italic\) \(Begin italic\) 324 mg \(End italic\))/P 5228 0 R/K 28596 0 R>> endobj 15069 0 obj <>/Alt(Tier 1)/P 5228 0 R/K 28597 0 R>> endobj 15070 0 obj <>/Alt(\(Begin italic\) quinidine sulfate oral tablet \(End italic\) \(Begin italic\) 200 mg, 300 mg \(End italic\))/P 5229 0 R/K 28598 0 R>> endobj 15071 0 obj <>/Alt(Tier 1)/P 5229 0 R/K 28599 0 R>> endobj 15072 0 obj <>/Alt(\(Begin bold\) Cardiovascular Disease - Cardiac Stimulant \(End bold\))/P 5230 0 R/K 28600 0 R>> endobj 15073 0 obj <>/Alt(\(Begin bold\) Adrenergic Agents,Catecholamines \(End bold\))/P 5231 0 R/K 28601 0 R>> endobj 15074 0 obj <>/Alt(\(Begin italic\) epinephrine injection syringe \(End italic\) \(Begin italic\) 0.1 mg/ml \(End italic\))/P 5232 0 R/K 28602 0 R>> endobj 15075 0 obj <>/Alt(Tier 1)/P 5232 0 R/K 28603 0 R>> endobj 15076 0 obj <>/Alt(\(Begin bold\) Digitalis Glycosides \(End bold\))/P 5233 0 R/K 28604 0 R>> endobj 15077 0 obj <>/Alt(DIGITEK ORAL TABLET 125 MCG \(0.125 MG\), 250 MCG \(0.25 MG\))/P 5234 0 R/K 28605 0 R>> endobj 15078 0 obj <>/Alt(\(digoxin\))/P 5234 0 R/K 28606 0 R>> endobj 15079 0 obj <>/Alt(Tier 1)/P 5234 0 R/K 28607 0 R>> endobj 15080 0 obj <>/Alt(\(Begin italic\) digoxin oral solution \(End italic\) \(Begin italic\) 50 mcg/ml \(0.05 mg/ml\) \(End italic\))/P 5235 0 R/K 28608 0 R>> endobj 15081 0 obj <>/Alt(Tier 2)/P 5235 0 R/K 28609 0 R>> endobj 15082 0 obj <>/Alt(\(Begin italic\) digoxin oral tablet \(End italic\) \(Begin italic\) 125 mcg \(0.125 mg\), 250 mcg \(0.25 mg\) \(End italic\))/P 5236 0 R/K 28610 0 R>> endobj 15083 0 obj <>/Alt(\(Digitek\))/P 5236 0 R/K 28611 0 R>> endobj 15084 0 obj <>/Alt(Tier 1)/P 5236 0 R/K 28612 0 R>> endobj 15085 0 obj <>/Alt(\(Begin italic\) digoxin oral tablet \(End italic\) \(Begin italic\) 62.5 mcg \(0.0625 mg\) \(End italic\))/P 5237 0 R/K 28613 0 R>> endobj 15086 0 obj <>/Alt(\(Lanoxin\))/P 5237 0 R/K 28614 0 R>> endobj 15087 0 obj <>/Alt(Tier 1)/P 5237 0 R/K 28615 0 R>> endobj 15088 0 obj <>/Alt(PA)/P 5237 0 R/K 28616 0 R>> endobj 15089 0 obj <>/Alt(LANOXIN ORAL TABLET 125 MCG \(0.125 MG\), 250 MCG \(0.25 MG\))/P 5238 0 R/K 28617 0 R>> endobj 15090 0 obj <>/Alt(\(digoxin\))/P 5238 0 R/K 28618 0 R>> endobj 15091 0 obj <>/Alt(Tier 3)/P 5238 0 R/K 28619 0 R>> endobj 15092 0 obj <>/Alt(LANOXIN ORAL TABLET 62.5 MCG \(0.0625 MG\))/P 5239 0 R/K 28620 0 R>> endobj 15093 0 obj <>/Alt(\(digoxin\))/P 5239 0 R/K 28621 0 R>> endobj 15094 0 obj <>/Alt(Tier 3)/P 5239 0 R/K 28622 0 R>> endobj 15095 0 obj <>/Alt(PA)/P 5239 0 R/K 28623 0 R>> endobj 15096 0 obj <>/Alt(\(Begin bold\) Cardiovascular Disease - Hypertension \(End bold\))/P 5240 0 R/K 28624 0 R>> endobj 15097 0 obj <>/Alt(\(Begin bold\) Ace Inhibitor/Calcium Channel Blocker Combination \(End bold\))/P 5241 0 R/K 28625 0 R>> endobj 15098 0 obj <>/Alt(\(Begin italic\) amlodipine-benazepril oral capsule \(End italic\) \(Begin italic\) 10-20 mg, 10-40 mg, 5-10 mg, 5-20 mg \(End italic\))/P 5242 0 R/K 28626 0 R>> endobj 15099 0 obj <>/Alt(\(Lotrel\))/P 5242 0 R/K 28627 0 R>> endobj 15100 0 obj <>/Alt(Tier 1)/P 5242 0 R/K 28628 0 R>> endobj 15101 0 obj <>/Alt(\(Begin italic\) amlodipine-benazepril oral capsule \(End italic\) \(Begin italic\) 2.5-10 mg, 5-40 mg \(End italic\))/P 5243 0 R/K 28629 0 R>> endobj 15102 0 obj <>/Alt(Tier 1)/P 5243 0 R/K 28630 0 R>> endobj 15103 0 obj <>/Alt(\(Begin italic\) trandolapril-verapamil oral tablet, ir - er, biphasic 24hr \(End italic\) \(Begin italic\) 1-240 mg, 2-180 mg, 2-240 mg, 4-240 mg \(End italic\))/P 5244 0 R/K 28631 0 R>> endobj 15104 0 obj <>/Alt(Tier 1)/P 5244 0 R/K 28632 0 R>> endobj 15105 0 obj <>/Alt(\(Begin bold\) Ace Inhibitor/Thiazide & Thiazide-Like Diuretic \(End bold\))/P 5245 0 R/K 28633 0 R>> endobj 15106 0 obj <>/Alt(\(Begin italic\) benazepril-hydrochlorothiazide oral tablet \(End italic\) \(Begin italic\) 10-12.5 mg, 20-12.5 mg, 20-25 mg \(End italic\))/P 5246 0 R/K 28634 0 R>> endobj 15107 0 obj <>/Alt(\(Lotensin HCT\))/P 5246 0 R/K 28635 0 R>> endobj 15108 0 obj <>/Alt(Tier 1)/P 5246 0 R/K 28636 0 R>> endobj 15109 0 obj <>/Alt(\(Begin italic\) benazepril-hydrochlorothiazide oral tablet \(End italic\) \(Begin italic\) 5-6.25 mg \(End italic\))/P 5247 0 R/K 28637 0 R>> endobj 15110 0 obj <>/Alt(Tier 1)/P 5247 0 R/K 28638 0 R>> endobj 15111 0 obj <>/Alt(\(Begin italic\) captopril-hydrochlorothiazide oral tablet \(End italic\) \(Begin italic\) 25-15 mg, 25-25 mg, 50-15 mg, 50-25 mg \(End italic\))/P 5248 0 R/K 28639 0 R>> endobj 15112 0 obj <>/Alt(Tier 1)/P 5248 0 R/K 28640 0 R>> endobj 15113 0 obj <>/Alt(\(Begin italic\) enalapril-hydrochlorothiazide oral tablet \(End italic\) \(Begin italic\) 10-25 mg \(End italic\))/P 5249 0 R/K 28641 0 R>> endobj 15114 0 obj <>/Alt(\(Vaseretic\))/P 5249 0 R/K 28642 0 R>> endobj 15115 0 obj <>/Alt(Tier 1)/P 5249 0 R/K 28643 0 R>> endobj 15116 0 obj <>/Alt(\(Begin italic\) enalapril-hydrochlorothiazide oral tablet \(End italic\) \(Begin italic\) 5-12.5 mg \(End italic\))/P 5250 0 R/K 28644 0 R>> endobj 15117 0 obj <>/Alt(Tier 1)/P 5250 0 R/K 28645 0 R>> endobj 15118 0 obj <>/Alt(\(Begin italic\) fosinopril-hydrochlorothiazide oral tablet \(End italic\) \(Begin italic\) 10-12.5 mg, 20-12.5 mg \(End italic\))/P 5251 0 R/K 28646 0 R>> endobj 15119 0 obj <>/Alt(Tier 1)/P 5251 0 R/K 28647 0 R>> endobj 15120 0 obj <>/Alt(\(Begin italic\) lisinopril-hydrochlorothiazide oral tablet \(End italic\) \(Begin italic\) 10-12.5 mg, 20-12.5 mg, 20-25 mg \(End italic\))/P 5252 0 R/K 28648 0 R>> endobj 15121 0 obj <>/Alt(\(Zestoretic\))/P 5252 0 R/K 28649 0 R>> endobj 15122 0 obj <>/Alt(Tier 1)/P 5252 0 R/K 28650 0 R>> endobj 15123 0 obj <>/Alt(\(Begin italic\) quinapril-hydrochlorothiazide oral tablet \(End italic\) \(Begin italic\) 10-12.5 mg, 20-12.5 mg, 20-25 mg \(End italic\))/P 5253 0 R/K 28651 0 R>> endobj 15124 0 obj <>/Alt(\(Accuretic\))/P 5253 0 R/K 28652 0 R>> endobj 15125 0 obj <>/Alt(Tier 1)/P 5253 0 R/K 28653 0 R>> endobj 15126 0 obj <>/Alt(\(Begin bold\) Alpha/Beta-Adrenergic Blocking Agents \(End bold\))/P 5254 0 R/K 28654 0 R>> endobj 15127 0 obj <>/Alt(\(Begin italic\) carvedilol oral tablet \(End italic\) \(Begin italic\) 12.5 mg, 25 mg, 3.125 mg, 6.25 mg \(End italic\))/P 5255 0 R/K 28655 0 R>> endobj 15128 0 obj <>/Alt(\(Coreg\))/P 5255 0 R/K 28656 0 R>> endobj 15129 0 obj <>/Alt(Tier 1)/P 5255 0 R/K 28657 0 R>> endobj 15130 0 obj <>/Alt(\(Begin italic\) carvedilol phosphate oral capsule, er multiphase 24 hr \(End italic\) \(Begin italic\) 10 mg, 20 mg, 40 mg, 80 mg \(End italic\))/P 5256 0 R/K 28658 0 R>> endobj 15131 0 obj <>/Alt(\(Coreg CR\))/P 5256 0 R/K 28659 0 R>> endobj 15132 0 obj <>/Alt(Tier 1)/P 5256 0 R/K 28660 0 R>> endobj 15133 0 obj <>/Alt(QL \(1 EA per 1 day\))/P 5256 0 R/K 28661 0 R>> endobj 15134 0 obj <>/Alt(\(Begin italic\) labetalol oral tablet \(End italic\) \(Begin italic\) 100 mg, 200 mg, 300 mg, 400 mg \(End italic\))/P 5257 0 R/K 28662 0 R>> endobj 15135 0 obj <>/Alt(Tier 1)/P 5257 0 R/K 28663 0 R>> endobj 15136 0 obj <>/Alt(\(Begin bold\) Alpha-Adrenergic Blocking Agents \(End bold\))/P 5258 0 R/K 28664 0 R>> endobj 15137 0 obj <>/Alt(CARDURA XL ORAL TABLET EXTENDED RELEASE 24HR 4 MG, 8 MG)/P 5259 0 R/K 28665 0 R>> endobj 15138 0 obj <>/Alt(Tier 3)/P 5259 0 R/K 28666 0 R>> endobj 15139 0 obj <>/Alt(\(Begin italic\) doxazosin oral tablet \(End italic\) \(Begin italic\) 1 mg, 2 mg, 4 mg, 8 mg \(End italic\))/P 5260 0 R/K 28667 0 R>> endobj 15140 0 obj <>/Alt(\(Cardura\))/P 5260 0 R/K 28668 0 R>> endobj 15141 0 obj <>/Alt(Tier 1)/P 5260 0 R/K 28669 0 R>> endobj 15142 0 obj <>/Alt(\(Begin italic\) phenoxybenzamine oral capsule \(End italic\) \(Begin italic\) 10 mg \(End italic\))/P 5261 0 R/K 28670 0 R>> endobj 15143 0 obj <>/Alt(\(Dibenzyline\))/P 5261 0 R/K 28671 0 R>> endobj 15144 0 obj <>/Alt(Tier 1)/P 5261 0 R/K 28672 0 R>> endobj 15145 0 obj <>/Alt(PA; SP)/P 5261 0 R/K 28673 0 R>> endobj 15146 0 obj <>/Alt(\(Begin italic\) prazosin oral capsule \(End italic\) \(Begin italic\) 1 mg, 2 mg, 5 mg \(End italic\))/P 5262 0 R/K 28674 0 R>> endobj 15147 0 obj <>/Alt(Tier 1)/P 5262 0 R/K 28675 0 R>> endobj 15148 0 obj <>/Alt(\(Begin italic\) terazosin oral capsule \(End italic\) \(Begin italic\) 1 mg, 10 mg, 2 mg, 5 mg \(End italic\))/P 5263 0 R/K 28676 0 R>> endobj 15149 0 obj <>/Alt(Tier 1)/P 5263 0 R/K 28677 0 R>> endobj 15150 0 obj <>/Alt(\(Begin bold\) Angioten.Receptr Antag./Cal.Chanl Blkr/Thiazide Cb \(End bold\))/P 5264 0 R/K 28678 0 R>> endobj 15151 0 obj <>/Alt(\(Begin italic\) amlodipine-valsartan-hcthiazid oral tablet \(End italic\) \(Begin italic\) 10-160-12.5 mg, 10-160-25 mg, 10-320-25 mg, 5-160-12.5 mg, 5-160-25 mg \(End italic\))/P 5265 0 R/K 28679 0 R>> endobj 15152 0 obj <>/Alt(\(Exforge HCT\))/P 5265 0 R/K 28680 0 R>> endobj 15153 0 obj <>/Alt(Tier 1)/P 5265 0 R/K 28681 0 R>> endobj 15154 0 obj <>/Alt(\(Begin italic\) olmesartan-amlodipin-hcthiazid oral tablet \(End italic\) \(Begin italic\) 20-5-12.5 mg, 40-10-12.5 mg, 40-10-25 mg, 40-5-12.5 mg, 40-5-25 mg \(End italic\))/P 5266 0 R/K 28682 0 R>> endobj 15155 0 obj <>/Alt(\(Tribenzor\))/P 5266 0 R/K 28683 0 R>> endobj 15156 0 obj <>/Alt(Tier 1)/P 5266 0 R/K 28684 0 R>> endobj 15157 0 obj <>/Alt(\(Begin bold\) Angiotensin Receptor Antag./Thiazide Diuretic Comb \(End bold\))/P 5267 0 R/K 28685 0 R>> endobj 15158 0 obj <>/Alt(\(Begin italic\) candesartan-hydrochlorothiazid oral tablet \(End italic\) \(Begin italic\) 16-12.5 mg, 32-12.5 mg, 32-25 mg \(End italic\))/P 5268 0 R/K 28686 0 R>> endobj 15159 0 obj <>/Alt(\(Atacand HCT\))/P 5268 0 R/K 28687 0 R>> endobj 15160 0 obj <>/Alt(Tier 1)/P 5268 0 R/K 28688 0 R>> endobj 15161 0 obj <>/Alt(\(Begin italic\) irbesartan-hydrochlorothiazide oral tablet \(End italic\) \(Begin italic\) 150-12.5 mg, 300-12.5 mg \(End italic\))/P 5269 0 R/K 28689 0 R>> endobj 15162 0 obj <>/Alt(\(Avalide\))/P 5269 0 R/K 28690 0 R>> endobj 15163 0 obj <>/Alt(Tier 1)/P 5269 0 R/K 28691 0 R>> endobj 15164 0 obj <>/Alt(\(Begin italic\) losartan-hydrochlorothiazide oral tablet \(End italic\) \(Begin italic\) 100-12.5 mg, 100-25 mg, 50-12.5 mg \(End italic\))/P 5270 0 R/K 28692 0 R>> endobj 15165 0 obj <>/Alt(\(Hyzaar\))/P 5270 0 R/K 28693 0 R>> endobj 15166 0 obj <>/Alt(Tier 1)/P 5270 0 R/K 28694 0 R>> endobj 15167 0 obj <>/Alt(\(Begin italic\) olmesartan-hydrochlorothiazide oral tablet \(End italic\) \(Begin italic\) 20-12.5 mg, 40-12.5 mg, 40-25 mg \(End italic\))/P 5271 0 R/K 28695 0 R>> endobj 15168 0 obj <>/Alt(\(Benicar HCT\))/P 5271 0 R/K 28696 0 R>> endobj 15169 0 obj <>/Alt(Tier 1)/P 5271 0 R/K 28697 0 R>> endobj 15170 0 obj <>/Alt(\(Begin italic\) telmisartan-hydrochlorothiazid oral tablet \(End italic\) \(Begin italic\) 40-12.5 mg, 80-12.5 mg, 80-25 mg \(End italic\))/P 5272 0 R/K 28698 0 R>> endobj 15171 0 obj <>/Alt(\(Micardis HCT\))/P 5272 0 R/K 28699 0 R>> endobj 15172 0 obj <>/Alt(Tier 1)/P 5272 0 R/K 28700 0 R>> endobj 15173 0 obj <>/Alt(\(Begin italic\) valsartan-hydrochlorothiazide oral tablet \(End italic\) \(Begin italic\) 160-12.5 mg, 160-25 mg, 320-12.5 mg, 320-25 mg, 80-12.5 mg \(End italic\))/P 5273 0 R/K 28701 0 R>> endobj 15174 0 obj <>/Alt(\(Diovan HCT\))/P 5273 0 R/K 28702 0 R>> endobj 15175 0 obj <>/Alt(Tier 1)/P 5273 0 R/K 28703 0 R>> endobj 15176 0 obj <>/Alt(\(Begin bold\) Angiotensin Receptor Antgnst & Calc.Channel Blockr \(End bold\))/P 5274 0 R/K 28704 0 R>> endobj 15177 0 obj <>/Alt(\(Begin italic\) amlodipine-olmesartan oral tablet \(End italic\) \(Begin italic\) 10-20 mg, 10-40 mg, 5-20 mg, 5-40 mg \(End italic\))/P 5275 0 R/K 28705 0 R>> endobj 15178 0 obj <>/Alt(\(Azor\))/P 5275 0 R/K 28706 0 R>> endobj 15179 0 obj <>/Alt(Tier 1)/P 5275 0 R/K 28707 0 R>> endobj 15180 0 obj <>/Alt(\(Begin italic\) amlodipine-valsartan oral tablet \(End italic\) \(Begin italic\) 10-160 mg, 10-320 mg, 5-160 mg, 5-320 mg \(End italic\))/P 5276 0 R/K 28708 0 R>> endobj 15181 0 obj <>/Alt(\(Exforge\))/P 5276 0 R/K 28709 0 R>> endobj 15182 0 obj <>/Alt(Tier 1)/P 5276 0 R/K 28710 0 R>> endobj 15183 0 obj <>/Alt(\(Begin italic\) telmisartan-amlodipine oral tablet \(End italic\) \(Begin italic\) 40-10 mg, 40-5 mg, 80-10 mg, 80-5 mg \(End italic\))/P 5277 0 R/K 28711 0 R>> endobj 15184 0 obj <>/Alt(Tier 1)/P 5277 0 R/K 28712 0 R>> endobj 15185 0 obj <>/Alt(\(Begin bold\) Antihypertensives, Ace Inhibitors \(End bold\))/P 5278 0 R/K 28713 0 R>> endobj 15186 0 obj <>/Alt(\(Begin italic\) benazepril oral tablet \(End italic\) \(Begin italic\) 10 mg, 20 mg, 40 mg \(End italic\))/P 5279 0 R/K 28714 0 R>> endobj 15187 0 obj <>/Alt(\(Lotensin\))/P 5279 0 R/K 28715 0 R>> endobj 15188 0 obj <>/Alt(Tier 1)/P 5279 0 R/K 28716 0 R>> endobj 15189 0 obj <>/Alt(\(Begin italic\) benazepril oral tablet \(End italic\) \(Begin italic\) 5 mg \(End italic\))/P 5280 0 R/K 28717 0 R>> endobj 15190 0 obj <>/Alt(Tier 1)/P 5280 0 R/K 28718 0 R>> endobj 15191 0 obj <>/Alt(\(Begin italic\) captopril oral tablet \(End italic\) \(Begin italic\) 100 mg, 12.5 mg, 25 mg, 50 mg \(End italic\))/P 5281 0 R/K 28719 0 R>> endobj 15192 0 obj <>/Alt(Tier 1)/P 5281 0 R/K 28720 0 R>> endobj 15193 0 obj <>/Alt(\(Begin italic\) enalapril maleate oral solution \(End italic\) \(Begin italic\) 1 mg/ml \(End italic\))/P 5282 0 R/K 28721 0 R>> endobj 15194 0 obj <>/Alt(\(Epaned\))/P 5282 0 R/K 28722 0 R>> endobj 15195 0 obj <>/Alt(Tier 1)/P 5282 0 R/K 28723 0 R>> endobj 15196 0 obj <>/Alt(ST: Requires prior prescription for Enalapril tablets if 12 years of age or older within the past 120 days; QL \(1200 ML per 30 days\))/P 5282 0 R/K 28724 0 R>> endobj 15197 0 obj <>/Alt(\(Begin italic\) enalapril maleate oral tablet \(End italic\) \(Begin italic\) 10 mg, 2.5 mg, 20 mg, 5 mg \(End italic\))/P 5283 0 R/K 28725 0 R>> endobj 15198 0 obj <>/Alt(\(Vasotec\))/P 5283 0 R/K 28726 0 R>> endobj 15199 0 obj <>/Alt(Tier 1)/P 5283 0 R/K 28727 0 R>> endobj 15200 0 obj <>/Alt(\(Begin italic\) fosinopril oral tablet \(End italic\) \(Begin italic\) 10 mg, 20 mg, 40 mg \(End italic\))/P 5284 0 R/K 28728 0 R>> endobj 15201 0 obj <>/Alt(Tier 1)/P 5284 0 R/K 28729 0 R>> endobj 15202 0 obj <>/Alt(\(Begin italic\) lisinopril oral tablet \(End italic\) \(Begin italic\) 10 mg, 2.5 mg, 20 mg, 30 mg, 40 mg, 5 mg \(End italic\))/P 5285 0 R/K 28730 0 R>> endobj 15203 0 obj <>/Alt(\(Zestril\))/P 5285 0 R/K 28731 0 R>> endobj 15204 0 obj <>/Alt(Tier 1)/P 5285 0 R/K 28732 0 R>> endobj 15205 0 obj <>/Alt(\(Begin italic\) moexipril oral tablet \(End italic\) \(Begin italic\) 15 mg, 7.5 mg \(End italic\))/P 5286 0 R/K 28733 0 R>> endobj 15206 0 obj <>/Alt(Tier 1)/P 5286 0 R/K 28734 0 R>> endobj 15207 0 obj <>/Alt(\(Begin italic\) perindopril erbumine oral tablet \(End italic\) \(Begin italic\) 2 mg, 4 mg, 8 mg \(End italic\))/P 5287 0 R/K 28735 0 R>> endobj 15208 0 obj <>/Alt(Tier 1)/P 5287 0 R/K 28736 0 R>> endobj 15209 0 obj <>/Alt(QBRELIS ORAL SOLUTION 1 MG/ML)/P 5288 0 R/K 28737 0 R>> endobj 15210 0 obj <>/Alt(Tier 3)/P 5288 0 R/K 28738 0 R>> endobj 15211 0 obj <>/Alt(ST: Requires prior prescription for Lisinopril tablets within the past 120 days if 12 years of age and older; QL \(1200 ML per 30 days\))/P 5288 0 R/K 28739 0 R>> endobj 15212 0 obj <>/Alt(\(Begin italic\) quinapril oral tablet \(End italic\) \(Begin italic\) 10 mg, 20 mg, 40 mg, 5 mg \(End italic\))/P 5289 0 R/K 28740 0 R>> endobj 15213 0 obj <>/Alt(\(Accupril\))/P 5289 0 R/K 28741 0 R>> endobj 15214 0 obj <>/Alt(Tier 1)/P 5289 0 R/K 28742 0 R>> endobj 15215 0 obj <>/Alt(\(Begin italic\) ramipril oral capsule \(End italic\) \(Begin italic\) 1.25 mg, 10 mg, 2.5 mg, 5 mg \(End italic\))/P 5290 0 R/K 28743 0 R>> endobj 15216 0 obj <>/Alt(\(Altace\))/P 5290 0 R/K 28744 0 R>> endobj 15217 0 obj <>/Alt(Tier 1)/P 5290 0 R/K 28745 0 R>> endobj 15218 0 obj <>/Alt(\(Begin italic\) trandolapril oral tablet \(End italic\) \(Begin italic\) 1 mg, 2 mg, 4 mg \(End italic\))/P 5291 0 R/K 28746 0 R>> endobj 15219 0 obj <>/Alt(Tier 1)/P 5291 0 R/K 28747 0 R>> endobj 15220 0 obj <>/Alt(\(Begin bold\) Antihypertensives, Angiotensin Receptor Antagonist \(End bold\))/P 5292 0 R/K 28748 0 R>> endobj 15221 0 obj <>/Alt(\(Begin italic\) candesartan oral tablet \(End italic\) \(Begin italic\) 16 mg, 32 mg, 4 mg, 8 mg \(End italic\))/P 5293 0 R/K 28749 0 R>> endobj 15222 0 obj <>/Alt(\(Atacand\))/P 5293 0 R/K 28750 0 R>> endobj 15223 0 obj <>/Alt(Tier 1)/P 5293 0 R/K 28751 0 R>> endobj 15224 0 obj <>/Alt(\(Begin italic\) eprosartan oral tablet \(End italic\) \(Begin italic\) 600 mg \(End italic\))/P 5294 0 R/K 28752 0 R>> endobj 15225 0 obj <>/Alt(Tier 1)/P 5294 0 R/K 28753 0 R>> endobj 15226 0 obj <>/Alt(\(Begin italic\) irbesartan oral tablet \(End italic\) \(Begin italic\) 150 mg, 300 mg, 75 mg \(End italic\))/P 5295 0 R/K 28754 0 R>> endobj 15227 0 obj <>/Alt(\(Avapro\))/P 5295 0 R/K 28755 0 R>> endobj 15228 0 obj <>/Alt(Tier 1)/P 5295 0 R/K 28756 0 R>> endobj 15229 0 obj <>/Alt(\(Begin italic\) losartan oral tablet \(End italic\) \(Begin italic\) 100 mg, 25 mg, 50 mg \(End italic\))/P 5296 0 R/K 28757 0 R>> endobj 15230 0 obj <>/Alt(\(Cozaar\))/P 5296 0 R/K 28758 0 R>> endobj 15231 0 obj <>/Alt(Tier 1)/P 5296 0 R/K 28759 0 R>> endobj 15232 0 obj <>/Alt(\(Begin italic\) olmesartan oral tablet \(End italic\) \(Begin italic\) 20 mg, 40 mg, 5 mg \(End italic\))/P 5297 0 R/K 28760 0 R>> endobj 15233 0 obj <>/Alt(\(Benicar\))/P 5297 0 R/K 28761 0 R>> endobj 15234 0 obj <>/Alt(Tier 1)/P 5297 0 R/K 28762 0 R>> endobj 15235 0 obj <>/Alt(\(Begin italic\) telmisartan oral tablet \(End italic\) \(Begin italic\) 20 mg, 40 mg, 80 mg \(End italic\))/P 5298 0 R/K 28763 0 R>> endobj 15236 0 obj <>/Alt(\(Micardis\))/P 5298 0 R/K 28764 0 R>> endobj 15237 0 obj <>/Alt(Tier 1)/P 5298 0 R/K 28765 0 R>> endobj 15238 0 obj <>/Alt(\(Begin italic\) valsartan oral tablet \(End italic\) \(Begin italic\) 160 mg, 320 mg, 40 mg, 80 mg \(End italic\))/P 5299 0 R/K 28766 0 R>> endobj 15239 0 obj <>/Alt(\(Diovan\))/P 5299 0 R/K 28767 0 R>> endobj 15240 0 obj <>/Alt(Tier 1)/P 5299 0 R/K 28768 0 R>> endobj 15241 0 obj <>/Alt(\(Begin bold\) Antihypertensives, Miscellaneous \(End bold\))/P 5300 0 R/K 28769 0 R>> endobj 15242 0 obj <>/Alt(\(Begin italic\) metyrosine oral capsule \(End italic\) \(Begin italic\) 250 mg \(End italic\))/P 5301 0 R/K 28770 0 R>> endobj 15243 0 obj <>/Alt(\(Demser\))/P 5301 0 R/K 28771 0 R>> endobj 15244 0 obj <>/Alt(Tier 1)/P 5301 0 R/K 28772 0 R>> endobj 15245 0 obj <>/Alt(SP)/P 5301 0 R/K 28773 0 R>> endobj 15246 0 obj <>/Alt(\(Begin bold\) Antihypertensives, Sympatholytic \(End bold\))/P 5302 0 R/K 28774 0 R>> endobj 15247 0 obj <>/Alt(\(Begin italic\) clonidine hcl oral tablet \(End italic\) \(Begin italic\) 0.1 mg, 0.2 mg, 0.3 mg \(End italic\))/P 5303 0 R/K 28775 0 R>> endobj 15248 0 obj <>/Alt(Tier 1)/P 5303 0 R/K 28776 0 R>> endobj 15249 0 obj <>/Alt(\(Begin italic\) clonidine transdermal patch weekly \(End italic\) \(Begin italic\) 0.1 mg/24 hr \(End italic\))/P 5304 0 R/K 28777 0 R>> endobj 15250 0 obj <>/Alt(\(Catapres-TTS-1\))/P 5304 0 R/K 28778 0 R>> endobj 15251 0 obj <>/Alt(Tier 1)/P 5304 0 R/K 28779 0 R>> endobj 15252 0 obj <>/Alt(\(Begin italic\) clonidine transdermal patch weekly \(End italic\) \(Begin italic\) 0.2 mg/24 hr \(End italic\))/P 5305 0 R/K 28780 0 R>> endobj 15253 0 obj <>/Alt(\(Catapres-TTS-2\))/P 5305 0 R/K 28781 0 R>> endobj 15254 0 obj <>/Alt(Tier 1)/P 5305 0 R/K 28782 0 R>> endobj 15255 0 obj <>/Alt(\(Begin italic\) clonidine transdermal patch weekly \(End italic\) \(Begin italic\) 0.3 mg/24 hr \(End italic\))/P 5306 0 R/K 28783 0 R>> endobj 15256 0 obj <>/Alt(\(Catapres-TTS-3\))/P 5306 0 R/K 28784 0 R>> endobj 15257 0 obj <>/Alt(Tier 1)/P 5306 0 R/K 28785 0 R>> endobj 15258 0 obj <>/Alt(\(Begin italic\) guanfacine oral tablet \(End italic\) \(Begin italic\) 1 mg, 2 mg \(End italic\))/P 5307 0 R/K 28786 0 R>> endobj 15259 0 obj <>/Alt(Tier 1)/P 5307 0 R/K 28787 0 R>> endobj 15260 0 obj <>/Alt(\(Begin italic\) methyldopa oral tablet \(End italic\) \(Begin italic\) 250 mg, 500 mg \(End italic\))/P 5308 0 R/K 28788 0 R>> endobj 15261 0 obj <>/Alt(Tier 1)/P 5308 0 R/K 28789 0 R>> endobj 15262 0 obj <>/Alt(\(Begin italic\) methyldopa-hydrochlorothiazide oral tablet \(End italic\) \(Begin italic\) 250-15 mg, 250-25 mg \(End italic\))/P 5309 0 R/K 28790 0 R>> endobj 15263 0 obj <>/Alt(Tier 1)/P 5309 0 R/K 28791 0 R>> endobj 15264 0 obj <>/Alt(\(Begin bold\) Antihypertensives, Vasodilators \(End bold\))/P 5310 0 R/K 28792 0 R>> endobj 15265 0 obj <>/Alt(\(Begin italic\) hydralazine oral tablet \(End italic\) \(Begin italic\) 10 mg, 100 mg, 25 mg, 50 mg \(End italic\))/P 5311 0 R/K 28793 0 R>> endobj 15266 0 obj <>/Alt(Tier 1)/P 5311 0 R/K 28794 0 R>> endobj 15267 0 obj <>/Alt(\(Begin italic\) minoxidil oral tablet \(End italic\) \(Begin italic\) 10 mg, 2.5 mg \(End italic\))/P 5312 0 R/K 28795 0 R>> endobj 15268 0 obj <>/Alt(Tier 1)/P 5312 0 R/K 28796 0 R>> endobj 15269 0 obj <>/Alt(\(Begin bold\) Antihypertensives,Endothelin Receptor Antagonists \(End bold\))/P 5313 0 R/K 28797 0 R>> endobj 15270 0 obj <>/Alt(TRYVIO ORAL TABLET 12.5 MG)/P 5314 0 R/K 28798 0 R>> endobj 15271 0 obj <>/Alt(Tier 3)/P 5314 0 R/K 28799 0 R>> endobj 15272 0 obj <>/Alt(PA; SP)/P 5314 0 R/K 28800 0 R>> endobj 15273 0 obj <>/Alt(\(Begin bold\) Beta-Adrenergic Blocking Agents \(End bold\))/P 5315 0 R/K 28801 0 R>> endobj 15274 0 obj <>/Alt(\(Begin italic\) acebutolol oral capsule \(End italic\) \(Begin italic\) 200 mg, 400 mg \(End italic\))/P 5316 0 R/K 28802 0 R>> endobj 15275 0 obj <>/Alt(Tier 1)/P 5316 0 R/K 28803 0 R>> endobj 15276 0 obj <>/Alt(\(Begin italic\) atenolol oral tablet \(End italic\) \(Begin italic\) 100 mg, 25 mg, 50 mg \(End italic\))/P 5317 0 R/K 28804 0 R>> endobj 15277 0 obj <>/Alt(\(Tenormin\))/P 5317 0 R/K 28805 0 R>> endobj 15278 0 obj <>/Alt(Tier 1)/P 5317 0 R/K 28806 0 R>> endobj 15279 0 obj <>/Alt(\(Begin italic\) betaxolol oral tablet \(End italic\) \(Begin italic\) 10 mg, 20 mg \(End italic\))/P 5318 0 R/K 28807 0 R>> endobj 15280 0 obj <>/Alt(Tier 1)/P 5318 0 R/K 28808 0 R>> endobj 15281 0 obj <>/Alt(\(Begin italic\) bisoprolol fumarate oral tablet \(End italic\) \(Begin italic\) 10 mg, 5 mg \(End italic\))/P 5319 0 R/K 28809 0 R>> endobj 15282 0 obj <>/Alt(Tier 1)/P 5319 0 R/K 28810 0 R>> endobj 15283 0 obj <>/Alt(HEMANGEOL ORAL SOLUTION 4.28 MG/ML)/P 5320 0 R/K 28811 0 R>> endobj 15284 0 obj <>/Alt(Tier 3)/P 5320 0 R/K 28812 0 R>> endobj 15285 0 obj <>/Alt(ST: Requires prior prescription for generic Propranolol oral solution within the past 120 days if 1 year of age and older; QL \(360 ML per 30 days\))/P 5320 0 R/K 28813 0 R>> endobj 15286 0 obj <>/Alt(KAPSPARGO SPRINKLE ORAL CAPSULE,SPRINKLE,ER 24HR 100 MG, 200 MG, 25 MG, 50 MG)/P 5321 0 R/K 28814 0 R>> endobj 15287 0 obj <>/Alt(Tier 3)/P 5321 0 R/K 28815 0 R>> endobj 15288 0 obj <>/Alt(\(Begin italic\) metoprolol succinate oral tablet extended release 24 hr \(End italic\) \(Begin italic\) 100 mg, 200 mg, 25 mg, 50 mg \(End italic\))/P 5322 0 R/K 28816 0 R>> endobj 15289 0 obj <>/Alt(\(Toprol XL\))/P 5322 0 R/K 28817 0 R>> endobj 15290 0 obj <>/Alt(Tier 1)/P 5322 0 R/K 28818 0 R>> endobj 15291 0 obj <>/Alt(\(Begin italic\) metoprolol tartrate oral tablet \(End italic\) \(Begin italic\) 100 mg, 50 mg \(End italic\))/P 5323 0 R/K 28819 0 R>> endobj 15292 0 obj <>/Alt(\(Lopressor\))/P 5323 0 R/K 28820 0 R>> endobj 15293 0 obj <>/Alt(Tier 1)/P 5323 0 R/K 28821 0 R>> endobj 15294 0 obj <>/Alt(\(Begin italic\) metoprolol tartrate oral tablet \(End italic\) \(Begin italic\) 25 mg, 37.5 mg, 75 mg \(End italic\))/P 5324 0 R/K 28822 0 R>> endobj 15295 0 obj <>/Alt(Tier 1)/P 5324 0 R/K 28823 0 R>> endobj 15296 0 obj <>/Alt(\(Begin italic\) nadolol oral tablet \(End italic\) \(Begin italic\) 20 mg, 40 mg \(End italic\))/P 5325 0 R/K 28824 0 R>> endobj 15297 0 obj <>/Alt(Tier 1)/P 5325 0 R/K 28825 0 R>> endobj 15298 0 obj <>/Alt(\(Begin italic\) nadolol oral tablet \(End italic\) \(Begin italic\) 80 mg \(End italic\))/P 5326 0 R/K 28826 0 R>> endobj 15299 0 obj <>/Alt(\(Corgard\))/P 5326 0 R/K 28827 0 R>> endobj 15300 0 obj <>/Alt(Tier 1)/P 5326 0 R/K 28828 0 R>> endobj 15301 0 obj <>/Alt(\(Begin italic\) nebivolol oral tablet \(End italic\) \(Begin italic\) 10 mg, 2.5 mg, 20 mg, 5 mg \(End italic\))/P 5327 0 R/K 28829 0 R>> endobj 15302 0 obj <>/Alt(\(Bystolic\))/P 5327 0 R/K 28830 0 R>> endobj 15303 0 obj <>/Alt(Tier 1)/P 5327 0 R/K 28831 0 R>> endobj 15304 0 obj <>/Alt(\(Begin italic\) pindolol oral tablet \(End italic\) \(Begin italic\) 10 mg, 5 mg \(End italic\))/P 5328 0 R/K 28832 0 R>> endobj 15305 0 obj <>/Alt(Tier 1)/P 5328 0 R/K 28833 0 R>> endobj 15306 0 obj <>/Alt(\(Begin italic\) propranolol oral capsule,extended release 24 hr \(End italic\) \(Begin italic\) 120 mg, 160 mg, 60 mg, 80 mg \(End italic\))/P 5329 0 R/K 28834 0 R>> endobj 15307 0 obj <>/Alt(\(Inderal LA\))/P 5329 0 R/K 28835 0 R>> endobj 15308 0 obj <>/Alt(Tier 1)/P 5329 0 R/K 28836 0 R>> endobj 15309 0 obj <>/Alt(\(Begin italic\) propranolol oral solution \(End italic\) \(Begin italic\) 20 mg/5 ml \(4 mg/ml\), 40 mg/5 ml \(8 mg/ml\) \(End italic\))/P 5330 0 R/K 28837 0 R>> endobj 15310 0 obj <>/Alt(Tier 1)/P 5330 0 R/K 28838 0 R>> endobj 15311 0 obj <>/Alt(\(Begin italic\) propranolol oral tablet \(End italic\) \(Begin italic\) 10 mg, 20 mg, 40 mg, 60 mg, 80 mg \(End italic\))/P 5331 0 R/K 28839 0 R>> endobj 15312 0 obj <>/Alt(Tier 1)/P 5331 0 R/K 28840 0 R>> endobj 15313 0 obj <>/Alt(SOTALOL AF ORAL TABLET 120 MG, 160 MG, 80 MG)/P 5332 0 R/K 28841 0 R>> endobj 15314 0 obj <>/Alt(\(sotalol\))/P 5332 0 R/K 28842 0 R>> endobj 15315 0 obj <>/Alt(Tier 1)/P 5332 0 R/K 28843 0 R>> endobj 15316 0 obj <>/Alt(\(Begin italic\) sotalol oral tablet \(End italic\) \(Begin italic\) 120 mg, 160 mg, 80 mg \(End italic\))/P 5333 0 R/K 28844 0 R>> endobj 15317 0 obj <>/Alt(\(Sotalol AF\))/P 5333 0 R/K 28845 0 R>> endobj 15318 0 obj <>/Alt(Tier 1)/P 5333 0 R/K 28846 0 R>> endobj 15319 0 obj <>/Alt(\(Begin italic\) sotalol oral tablet \(End italic\) \(Begin italic\) 240 mg \(End italic\))/P 5334 0 R/K 28847 0 R>> endobj 15320 0 obj <>/Alt(\(Betapace\))/P 5334 0 R/K 28848 0 R>> endobj 15321 0 obj <>/Alt(Tier 1)/P 5334 0 R/K 28849 0 R>> endobj 15322 0 obj <>/Alt(SOTYLIZE ORAL SOLUTION 5 MG/ML)/P 5335 0 R/K 28850 0 R>> endobj 15323 0 obj <>/Alt(Tier 3)/P 5335 0 R/K 28851 0 R>> endobj 15324 0 obj <>/Alt(QL: 8 BOTTLES IN 30 DAYS; ST: Requires prior prescription for Sotalol tablets within the past 120 days)/P 5335 0 R/K 28852 0 R>> endobj 15325 0 obj <>/Alt(\(Begin italic\) timolol maleate oral tablet \(End italic\) \(Begin italic\) 10 mg, 20 mg, 5 mg \(End italic\))/P 5336 0 R/K 28853 0 R>> endobj 15326 0 obj <>/Alt(Tier 1)/P 5336 0 R/K 28854 0 R>> endobj 15327 0 obj <>/Alt(\(Begin bold\) Beta-Adrenergic Blocking Agents/Thiazide & Related \(End bold\))/P 5337 0 R/K 28855 0 R>> endobj 15328 0 obj <>/Alt(\(Begin italic\) atenolol-chlorthalidone oral tablet \(End italic\) \(Begin italic\) 100-25 mg \(End italic\))/P 5338 0 R/K 28856 0 R>> endobj 15329 0 obj <>/Alt(\(Tenoretic 100\))/P 5338 0 R/K 28857 0 R>> endobj 15330 0 obj <>/Alt(Tier 1)/P 5338 0 R/K 28858 0 R>> endobj 15331 0 obj <>/Alt(\(Begin italic\) atenolol-chlorthalidone oral tablet \(End italic\) \(Begin italic\) 50-25 mg \(End italic\))/P 5339 0 R/K 28859 0 R>> endobj 15332 0 obj <>/Alt(\(Tenoretic 50\))/P 5339 0 R/K 28860 0 R>> endobj 15333 0 obj <>/Alt(Tier 1)/P 5339 0 R/K 28861 0 R>> endobj 15334 0 obj <>/Alt(\(Begin italic\) bisoprolol-hydrochlorothiazide oral tablet \(End italic\) \(Begin italic\) 10-6.25 mg, 2.5-6.25 mg, 5-6.25 mg \(End italic\))/P 5340 0 R/K 28862 0 R>> endobj 15335 0 obj <>/Alt(Tier 1)/P 5340 0 R/K 28863 0 R>> endobj 15336 0 obj <>/Alt(\(Begin italic\) metoprolol ta-hydrochlorothiaz oral tablet \(End italic\) \(Begin italic\) 100-25 mg, 100-50 mg, 50-25 mg \(End italic\))/P 5341 0 R/K 28864 0 R>> endobj 15337 0 obj <>/Alt(Tier 1)/P 5341 0 R/K 28865 0 R>> endobj 15338 0 obj <>/Alt(\(Begin italic\) propranolol-hydrochlorothiazid oral tablet \(End italic\) \(Begin italic\) 40-25 mg, 80-25 mg \(End italic\))/P 5342 0 R/K 28866 0 R>> endobj 15339 0 obj <>/Alt(Tier 1)/P 5342 0 R/K 28867 0 R>> endobj 15340 0 obj <>/Alt(\(Begin bold\) Calcium Channel Blocking Agents \(End bold\))/P 5343 0 R/K 28868 0 R>> endobj 15341 0 obj <>/Alt(\(Begin italic\) amlodipine oral tablet \(End italic\) \(Begin italic\) 10 mg, 2.5 mg, 5 mg \(End italic\))/P 5344 0 R/K 28869 0 R>> endobj 15342 0 obj <>/Alt(\(Norvasc\))/P 5344 0 R/K 28870 0 R>> endobj 15343 0 obj <>/Alt(Tier 1)/P 5344 0 R/K 28871 0 R>> endobj 15344 0 obj <>/Alt(CARTIA XT ORAL CAPSULE,EXTENDED RELEASE 24HR 120 MG, 180 MG, 240 MG, 300 MG)/P 5345 0 R/K 28872 0 R>> endobj 15345 0 obj <>/Alt(\(diltiazem hcl\))/P 5345 0 R/K 28873 0 R>> endobj 15346 0 obj <>/Alt(Tier 1)/P 5345 0 R/K 28874 0 R>> endobj 15347 0 obj <>/Alt(CONJUPRI ORAL TABLET 2.5 MG)/P 5346 0 R/K 28875 0 R>> endobj 15348 0 obj <>/Alt(\(levamlodipine\))/P 5346 0 R/K 28876 0 R>> endobj 15349 0 obj <>/Alt(Tier 3)/P 5346 0 R/K 28877 0 R>> endobj 15350 0 obj <>/Alt(PA)/P 5346 0 R/K 28878 0 R>> endobj 15351 0 obj <>/Alt(\(Begin italic\) diltiazem hcl oral capsule,ext.rel 24h degradable \(End italic\) \(Begin italic\) 120 mg, 180 mg, 240 mg \(End italic\))/P 5347 0 R/K 28879 0 R>> endobj 15352 0 obj <>/Alt(\(DILT-XR\))/P 5347 0 R/K 28880 0 R>> endobj 15353 0 obj <>/Alt(Tier 1)/P 5347 0 R/K 28881 0 R>> endobj 15354 0 obj <>/Alt(\(Begin italic\) diltiazem hcl oral capsule,extended release 12 hr \(End italic\) \(Begin italic\) 120 mg, 60 mg, 90 mg \(End italic\))/P 5348 0 R/K 28882 0 R>> endobj 15355 0 obj <>/Alt(Tier 1)/P 5348 0 R/K 28883 0 R>> endobj 15356 0 obj <>/Alt(\(Begin italic\) diltiazem hcl oral capsule,extended release 24 hr \(End italic\) \(Begin italic\) 120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg \(End italic\))/P 5349 0 R/K 28884 0 R>> endobj 15357 0 obj <>/Alt(\(Tiadylt ER\))/P 5349 0 R/K 28885 0 R>> endobj 15358 0 obj <>/Alt(Tier 1)/P 5349 0 R/K 28886 0 R>> endobj 15359 0 obj <>/Alt(\(Begin italic\) diltiazem hcl oral capsule,extended release 24hr \(End italic\) \(Begin italic\) 120 mg, 180 mg, 240 mg, 300 mg \(End italic\))/P 5350 0 R/K 28887 0 R>> endobj 15360 0 obj <>/Alt(\(Cartia XT\))/P 5350 0 R/K 28888 0 R>> endobj 15361 0 obj <>/Alt(Tier 1)/P 5350 0 R/K 28889 0 R>> endobj 15362 0 obj <>/Alt(\(Begin italic\) diltiazem hcl oral capsule,extended release 24hr \(End italic\) \(Begin italic\) 360 mg \(End italic\))/P 5351 0 R/K 28890 0 R>> endobj 15363 0 obj <>/Alt(\(Cardizem CD\))/P 5351 0 R/K 28891 0 R>> endobj 15364 0 obj <>/Alt(Tier 1)/P 5351 0 R/K 28892 0 R>> endobj 15365 0 obj <>/Alt(\(Begin italic\) diltiazem hcl oral tablet \(End italic\) \(Begin italic\) 120 mg, 30 mg, 60 mg \(End italic\))/P 5352 0 R/K 28893 0 R>> endobj 15366 0 obj <>/Alt(\(Cardizem\))/P 5352 0 R/K 28894 0 R>> endobj 15367 0 obj <>/Alt(Tier 1)/P 5352 0 R/K 28895 0 R>> endobj 15368 0 obj <>/Alt(\(Begin italic\) diltiazem hcl oral tablet \(End italic\) \(Begin italic\) 90 mg \(End italic\))/P 5353 0 R/K 28896 0 R>> endobj 15369 0 obj <>/Alt(Tier 1)/P 5353 0 R/K 28897 0 R>> endobj 15370 0 obj <>/Alt(\(Begin italic\) diltiazem hcl oral tablet extended release 24 hr \(End italic\) \(Begin italic\) 120 mg \(End italic\))/P 5354 0 R/K 28898 0 R>> endobj 15371 0 obj <>/Alt(\(Cardizem LA\))/P 5354 0 R/K 28899 0 R>> endobj 15372 0 obj <>/Alt(Tier 1)/P 5354 0 R/K 28900 0 R>> endobj 15373 0 obj <>/Alt(\(Begin italic\) diltiazem hcl oral tablet extended release 24 hr \(End italic\) \(Begin italic\) 180 mg, 240 mg, 300 mg, 360 mg, 420 mg \(End italic\))/P 5355 0 R/K 28901 0 R>> endobj 15374 0 obj <>/Alt(\(Matzim LA\))/P 5355 0 R/K 28902 0 R>> endobj 15375 0 obj <>/Alt(Tier 1)/P 5355 0 R/K 28903 0 R>> endobj 15376 0 obj <>/Alt(DILT-XR ORAL CAPSULE,EXT.REL 24H DEGRADABLE 120 MG, 180 MG, 240 MG)/P 5356 0 R/K 28904 0 R>> endobj 15377 0 obj <>/Alt(\(diltiazem hcl\))/P 5356 0 R/K 28905 0 R>> endobj 15378 0 obj <>/Alt(Tier 1)/P 5356 0 R/K 28906 0 R>> endobj 15379 0 obj <>/Alt(\(Begin italic\) felodipine oral tablet extended release 24 hr \(End italic\) \(Begin italic\) 10 mg, 2.5 mg, 5 mg \(End italic\))/P 5357 0 R/K 28907 0 R>> endobj 15380 0 obj <>/Alt(Tier 1)/P 5357 0 R/K 28908 0 R>> endobj 15381 0 obj <>/Alt(\(Begin italic\) isradipine oral capsule \(End italic\) \(Begin italic\) 2.5 mg, 5 mg \(End italic\))/P 5358 0 R/K 28909 0 R>> endobj 15382 0 obj <>/Alt(Tier 1)/P 5358 0 R/K 28910 0 R>> endobj 15383 0 obj <>/Alt(\(Begin italic\) levamlodipine oral tablet \(End italic\) \(Begin italic\) 2.5 mg, 5 mg \(End italic\))/P 5359 0 R/K 28911 0 R>> endobj 15384 0 obj <>/Alt(\(Conjupri\))/P 5359 0 R/K 28912 0 R>> endobj 15385 0 obj <>/Alt(Tier 1)/P 5359 0 R/K 28913 0 R>> endobj 15386 0 obj <>/Alt(PA)/P 5359 0 R/K 28914 0 R>> endobj 15387 0 obj <>/Alt(MATZIM LA ORAL TABLET EXTENDED RELEASE 24 HR 180 MG, 240 MG, 300 MG, 360 MG, 420 MG)/P 5360 0 R/K 28915 0 R>> endobj 15388 0 obj <>/Alt(\(diltiazem hcl\))/P 5360 0 R/K 28916 0 R>> endobj 15389 0 obj <>/Alt(Tier 1)/P 5360 0 R/K 28917 0 R>> endobj 15390 0 obj <>/Alt(\(Begin italic\) nicardipine oral capsule \(End italic\) \(Begin italic\) 20 mg, 30 mg \(End italic\))/P 5361 0 R/K 28918 0 R>> endobj 15391 0 obj <>/Alt(Tier 1)/P 5361 0 R/K 28919 0 R>> endobj 15392 0 obj <>/Alt(\(Begin italic\) nifedipine oral capsule \(End italic\) \(Begin italic\) 10 mg, 20 mg \(End italic\))/P 5362 0 R/K 28920 0 R>> endobj 15393 0 obj <>/Alt(Tier 1)/P 5362 0 R/K 28921 0 R>> endobj 15394 0 obj <>/Alt(\(Begin italic\) nifedipine oral tablet extended release 24hr \(End italic\) \(Begin italic\) 30 mg, 60 mg, 90 mg \(End italic\))/P 5363 0 R/K 28922 0 R>> endobj 15395 0 obj <>/Alt(\(Procardia XL\))/P 5363 0 R/K 28923 0 R>> endobj 15396 0 obj <>/Alt(Tier 1)/P 5363 0 R/K 28924 0 R>> endobj 15397 0 obj <>/Alt(\(Begin italic\) nifedipine oral tablet extended release \(End italic\) \(Begin italic\) 30 mg, 60 mg, 90 mg \(End italic\))/P 5364 0 R/K 28925 0 R>> endobj 15398 0 obj <>/Alt(Tier 1)/P 5364 0 R/K 28926 0 R>> endobj 15399 0 obj <>/Alt(\(Begin italic\) nimodipine oral capsule \(End italic\) \(Begin italic\) 30 mg \(End italic\))/P 5365 0 R/K 28927 0 R>> endobj 15400 0 obj <>/Alt(Tier 1)/P 5365 0 R/K 28928 0 R>> endobj 15401 0 obj <>/Alt(\(Begin italic\) nimodipine oral solution \(End italic\) \(Begin italic\) 60 mg/20 ml \(End italic\))/P 5366 0 R/K 28929 0 R>> endobj 15402 0 obj <>/Alt(Tier 1)/P 5366 0 R/K 28930 0 R>> endobj 15403 0 obj <>/Alt(PA; SP)/P 5366 0 R/K 28931 0 R>> endobj 15404 0 obj <>/Alt(\(Begin italic\) nisoldipine oral tablet extended release 24 hr \(End italic\) \(Begin italic\) 17 mg, 34 mg, 8.5 mg \(End italic\))/P 5367 0 R/K 28932 0 R>> endobj 15405 0 obj <>/Alt(\(Sular\))/P 5367 0 R/K 28933 0 R>> endobj 15406 0 obj <>/Alt(Tier 1)/P 5367 0 R/K 28934 0 R>> endobj 15407 0 obj <>/Alt(\(Begin italic\) nisoldipine oral tablet extended release 24 hr \(End italic\) \(Begin italic\) 20 mg, 25.5 mg, 30 mg, 40 mg \(End italic\))/P 5368 0 R/K 28935 0 R>> endobj 15408 0 obj <>/Alt(Tier 1)/P 5368 0 R/K 28936 0 R>> endobj 15409 0 obj <>/Alt(NYMALIZE ORAL SOLUTION 60 MG/10 ML)/P 5369 0 R/K 28937 0 R>> endobj 15410 0 obj <>/Alt(Tier 3)/P 5369 0 R/K 28938 0 R>> endobj 15411 0 obj <>/Alt(PA; SP)/P 5369 0 R/K 28939 0 R>> endobj 15412 0 obj <>/Alt(NYMALIZE ORAL SYRINGE 30 MG/5 ML, 60 MG/10 ML)/P 5370 0 R/K 28940 0 R>> endobj 15413 0 obj <>/Alt(Tier 3)/P 5370 0 R/K 28941 0 R>> endobj 15414 0 obj <>/Alt(PA; SP)/P 5370 0 R/K 28942 0 R>> endobj 15415 0 obj <>/Alt(TIADYLT ER ORAL CAPSULE,EXTENDED RELEASE 24 HR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG, 420 MG)/P 5371 0 R/K 28943 0 R>> endobj 15416 0 obj <>/Alt(\(diltiazem hcl\))/P 5371 0 R/K 28944 0 R>> endobj 15417 0 obj <>/Alt(Tier 1)/P 5371 0 R/K 28945 0 R>> endobj 15418 0 obj <>/Alt(\(Begin italic\) verapamil oral capsule, 24 hr er pellet ct \(End italic\) \(Begin italic\) 100 mg, 200 mg, 300 mg \(End italic\))/P 5372 0 R/K 28946 0 R>> endobj 15419 0 obj <>/Alt(\(Verelan PM\))/P 5372 0 R/K 28947 0 R>> endobj 15420 0 obj <>/Alt(Tier 1)/P 5372 0 R/K 28948 0 R>> endobj 15421 0 obj <>/Alt(\(Begin italic\) verapamil oral capsule,ext rel. pellets 24 hr \(End italic\) \(Begin italic\) 120 mg, 180 mg, 240 mg, 360 mg \(End italic\))/P 5373 0 R/K 28949 0 R>> endobj 15422 0 obj <>/Alt(Tier 1)/P 5373 0 R/K 28950 0 R>> endobj 15423 0 obj <>/Alt(\(Begin italic\) verapamil oral tablet \(End italic\) \(Begin italic\) 120 mg, 40 mg, 80 mg \(End italic\))/P 5374 0 R/K 28951 0 R>> endobj 15424 0 obj <>/Alt(Tier 1)/P 5374 0 R/K 28952 0 R>> endobj 15425 0 obj <>/Alt(\(Begin italic\) verapamil oral tablet extended release \(End italic\) \(Begin italic\) 120 mg, 180 mg, 240 mg \(End italic\))/P 5375 0 R/K 28953 0 R>> endobj 15426 0 obj <>/Alt(Tier 1)/P 5375 0 R/K 28954 0 R>> endobj 15427 0 obj <>/Alt(\(Begin bold\) Loop Diuretics \(End bold\))/P 5376 0 R/K 28955 0 R>> endobj 15428 0 obj <>/Alt(\(Begin italic\) bumetanide oral tablet \(End italic\) \(Begin italic\) 0.5 mg, 1 mg, 2 mg \(End italic\))/P 5377 0 R/K 28956 0 R>> endobj 15429 0 obj <>/Alt(Tier 1)/P 5377 0 R/K 28957 0 R>> endobj 15430 0 obj <>/Alt(\(Begin italic\) ethacrynic acid oral tablet \(End italic\) \(Begin italic\) 25 mg \(End italic\))/P 5378 0 R/K 28958 0 R>> endobj 15431 0 obj <>/Alt(\(Edecrin\))/P 5378 0 R/K 28959 0 R>> endobj 15432 0 obj <>/Alt(Tier 1)/P 5378 0 R/K 28960 0 R>> endobj 15433 0 obj <>/Alt(PA)/P 5378 0 R/K 28961 0 R>> endobj 15434 0 obj <>/Alt(FUROSCIX SUBCUTANEOUS KIT 80 MG/10 ML)/P 5379 0 R/K 28962 0 R>> endobj 15435 0 obj <>/Alt(Tier 3)/P 5379 0 R/K 28963 0 R>> endobj 15436 0 obj <>/Alt(SP)/P 5379 0 R/K 28964 0 R>> endobj 15437 0 obj <>/Alt(\(Begin italic\) furosemide oral solution \(End italic\) \(Begin italic\) 10 mg/ml, 40 mg/5 ml \(8 mg/ml\) \(End italic\))/P 5380 0 R/K 28965 0 R>> endobj 15438 0 obj <>/Alt(Tier 1)/P 5380 0 R/K 28966 0 R>> endobj 15439 0 obj <>/Alt(\(Begin italic\) furosemide oral tablet \(End italic\) \(Begin italic\) 20 mg, 40 mg, 80 mg \(End italic\))/P 5381 0 R/K 28967 0 R>> endobj 15440 0 obj <>/Alt(\(Lasix\))/P 5381 0 R/K 28968 0 R>> endobj 15441 0 obj <>/Alt(Tier 1)/P 5381 0 R/K 28969 0 R>> endobj 15442 0 obj <>/Alt(\(Begin italic\) torsemide oral tablet \(End italic\) \(Begin italic\) 10 mg, 100 mg, 20 mg, 5 mg \(End italic\))/P 5382 0 R/K 28970 0 R>> endobj 15443 0 obj <>/Alt(Tier 1)/P 5382 0 R/K 28971 0 R>> endobj 15444 0 obj <>/Alt(\(Begin bold\) Potassium Sparing Diuretics \(End bold\))/P 5383 0 R/K 28972 0 R>> endobj 15445 0 obj <>/Alt(\(Begin italic\) amiloride oral tablet \(End italic\) \(Begin italic\) 5 mg \(End italic\))/P 5384 0 R/K 28973 0 R>> endobj 15446 0 obj <>/Alt(Tier 1)/P 5384 0 R/K 28974 0 R>> endobj 15447 0 obj <>/Alt(\(Begin italic\) eplerenone oral tablet \(End italic\) \(Begin italic\) 25 mg, 50 mg \(End italic\))/P 5385 0 R/K 28975 0 R>> endobj 15448 0 obj <>/Alt(\(Inspra\))/P 5385 0 R/K 28976 0 R>> endobj 15449 0 obj <>/Alt(Tier 1)/P 5385 0 R/K 28977 0 R>> endobj 15450 0 obj <>/Alt(KERENDIA ORAL TABLET 10 MG, 20 MG)/P 5386 0 R/K 28978 0 R>> endobj 15451 0 obj <>/Alt(Tier 3)/P 5386 0 R/K 28979 0 R>> endobj 15452 0 obj <>/Alt(PA)/P 5386 0 R/K 28980 0 R>> endobj 15453 0 obj <>/Alt(\(Begin italic\) spironolactone oral tablet \(End italic\) \(Begin italic\) 100 mg, 25 mg, 50 mg \(End italic\))/P 5387 0 R/K 28981 0 R>> endobj 15454 0 obj <>/Alt(\(Aldactone\))/P 5387 0 R/K 28982 0 R>> endobj 15455 0 obj <>/Alt(Tier 1)/P 5387 0 R/K 28983 0 R>> endobj 15456 0 obj <>/Alt(\(Begin italic\) triamterene oral capsule \(End italic\) \(Begin italic\) 100 mg, 50 mg \(End italic\))/P 5388 0 R/K 28984 0 R>> endobj 15457 0 obj <>/Alt(\(Dyrenium\))/P 5388 0 R/K 28985 0 R>> endobj 15458 0 obj <>/Alt(Tier 1)/P 5388 0 R/K 28986 0 R>> endobj 15459 0 obj <>/Alt(\(Begin bold\) Potassium Sparing Diuretics In Combination \(End bold\))/P 5389 0 R/K 28987 0 R>> endobj 15460 0 obj <>/Alt(\(Begin italic\) amiloride-hydrochlorothiazide oral tablet \(End italic\) \(Begin italic\) 5-50 mg \(End italic\))/P 5390 0 R/K 28988 0 R>> endobj 15461 0 obj <>/Alt(Tier 1)/P 5390 0 R/K 28989 0 R>> endobj 15462 0 obj <>/Alt(\(Begin italic\) spironolacton-hydrochlorothiaz oral tablet \(End italic\) \(Begin italic\) 25-25 mg \(End italic\))/P 5391 0 R/K 28990 0 R>> endobj 15463 0 obj <>/Alt(Tier 1)/P 5391 0 R/K 28991 0 R>> endobj 15464 0 obj <>/Alt(\(Begin italic\) triamterene-hydrochlorothiazid oral capsule \(End italic\) \(Begin italic\) 37.5-25 mg \(End italic\))/P 5392 0 R/K 28992 0 R>> endobj 15465 0 obj <>/Alt(Tier 1)/P 5392 0 R/K 28993 0 R>> endobj 15466 0 obj <>/Alt(\(Begin italic\) triamterene-hydrochlorothiazid oral tablet \(End italic\) \(Begin italic\) 37.5-25 mg, 75-50 mg \(End italic\))/P 5393 0 R/K 28994 0 R>> endobj 15467 0 obj <>/Alt(Tier 1)/P 5393 0 R/K 28995 0 R>> endobj 15468 0 obj <>/Alt(\(Begin bold\) Pulm Anti-Htn,Soluble Guanylate Cyclase Stimulator \(End bold\))/P 5394 0 R/K 28996 0 R>> endobj 15469 0 obj <>/Alt(ADEMPAS ORAL TABLET 0.5 MG, 1 MG, 1.5 MG, 2 MG, 2.5 MG)/P 5395 0 R/K 28997 0 R>> endobj 15470 0 obj <>/Alt(Tier 2)/P 5395 0 R/K 28998 0 R>> endobj 15471 0 obj <>/Alt(PA; SP)/P 5395 0 R/K 28999 0 R>> endobj 15472 0 obj <>/Alt(\(Begin bold\) Pulm.Anti-Htn,Sel.C-Gmp Phosphodiesterase T5 Inhib \(End bold\))/P 5396 0 R/K 29000 0 R>> endobj 15473 0 obj <>/Alt(ALYQ ORAL TABLET 20 MG)/P 5397 0 R/K 29001 0 R>> endobj 15474 0 obj <>/Alt(\(tadalafil \(pulm. hypertension\)\))/P 5397 0 R/K 29002 0 R>> endobj 15475 0 obj <>/Alt(Tier 1)/P 5397 0 R/K 29003 0 R>> endobj 15476 0 obj <>/Alt(PA; SP)/P 5397 0 R/K 29004 0 R>> endobj 15477 0 obj <>/Alt(LIQREV ORAL SUSPENSION 10 MG/ML)/P 5398 0 R/K 29005 0 R>> endobj 15478 0 obj <>/Alt(Tier 3)/P 5398 0 R/K 29006 0 R>> endobj 15479 0 obj <>/Alt(PA; SP)/P 5398 0 R/K 29007 0 R>> endobj 15480 0 obj <>/Alt(\(Begin italic\) sildenafil \(pulm.hypertension\) oral suspension for reconstitution \(End italic\) \(Begin italic\) 10 mg/ml \(End italic\))/P 5399 0 R/K 29008 0 R>> endobj 15481 0 obj <>/Alt(Tier 1)/P 5399 0 R/K 29009 0 R>> endobj 15482 0 obj <>/Alt(PA)/P 5399 0 R/K 29010 0 R>> endobj 15483 0 obj <>/Alt(\(Begin italic\) sildenafil \(pulm.hypertension\) oral tablet \(End italic\) \(Begin italic\) 20 mg \(End italic\))/P 5400 0 R/K 29011 0 R>> endobj 15484 0 obj <>/Alt(\(Revatio\))/P 5400 0 R/K 29012 0 R>> endobj 15485 0 obj <>/Alt(Tier 1)/P 5400 0 R/K 29013 0 R>> endobj 15486 0 obj <>/Alt(PA)/P 5400 0 R/K 29014 0 R>> endobj 15487 0 obj <>/Alt(\(Begin italic\) tadalafil \(pulm. hypertension\) oral tablet \(End italic\) \(Begin italic\) 20 mg \(End italic\))/P 5401 0 R/K 29015 0 R>> endobj 15488 0 obj <>/Alt(\(Alyq\))/P 5401 0 R/K 29016 0 R>> endobj 15489 0 obj <>/Alt(Tier 1)/P 5401 0 R/K 29017 0 R>> endobj 15490 0 obj <>/Alt(PA; SP)/P 5401 0 R/K 29018 0 R>> endobj 15491 0 obj <>/Alt(\(Begin bold\) Pulmonary Anti-Htn, Endothelin Receptor Antagonist \(End bold\))/P 5402 0 R/K 29019 0 R>> endobj 15492 0 obj <>/Alt(\(Begin italic\) ambrisentan oral tablet \(End italic\) \(Begin italic\) 10 mg, 5 mg \(End italic\))/P 5403 0 R/K 29020 0 R>> endobj 15493 0 obj <>/Alt(\(Letairis\))/P 5403 0 R/K 29021 0 R>> endobj 15494 0 obj <>/Alt(Tier 1)/P 5403 0 R/K 29022 0 R>> endobj 15495 0 obj <>/Alt(PA; SP)/P 5403 0 R/K 29023 0 R>> endobj 15496 0 obj <>/Alt(\(Begin italic\) bosentan oral tablet \(End italic\) \(Begin italic\) 125 mg, 62.5 mg \(End italic\))/P 5404 0 R/K 29024 0 R>> endobj 15497 0 obj <>/Alt(\(Tracleer\))/P 5404 0 R/K 29025 0 R>> endobj 15498 0 obj <>/Alt(Tier 1)/P 5404 0 R/K 29026 0 R>> endobj 15499 0 obj <>/Alt(PA; SP)/P 5404 0 R/K 29027 0 R>> endobj 15500 0 obj <>/Alt(OPSUMIT ORAL TABLET 10 MG)/P 5405 0 R/K 29028 0 R>> endobj 15501 0 obj <>/Alt(Tier 2)/P 5405 0 R/K 29029 0 R>> endobj 15502 0 obj <>/Alt(PA; SP)/P 5405 0 R/K 29030 0 R>> endobj 15503 0 obj <>/Alt(TRACLEER ORAL TABLET FOR SUSPENSION 32 MG)/P 5406 0 R/K 29031 0 R>> endobj 15504 0 obj <>/Alt(Tier 2)/P 5406 0 R/K 29032 0 R>> endobj 15505 0 obj <>/Alt(PA; SP)/P 5406 0 R/K 29033 0 R>> endobj 15506 0 obj <>/Alt(\(Begin bold\) Pulmonary Antihyper Agent, Actriia-Fc \(End bold\))/P 5407 0 R/K 29034 0 R>> endobj 15507 0 obj <>/Alt(WINREVAIR SUBCUTANEOUS KIT 45 MG, 60 MG)/P 5408 0 R/K 29035 0 R>> endobj 15508 0 obj <>/Alt(Tier 2)/P 5408 0 R/K 29036 0 R>> endobj 15509 0 obj <>/Alt(PA; SP)/P 5408 0 R/K 29037 0 R>> endobj 15510 0 obj <>/Alt(\(Begin bold\) Pulmonary Antihypertensives, Prostacyclin-Type \(End bold\))/P 5409 0 R/K 29038 0 R>> endobj 15511 0 obj <>/Alt(ORENITRAM MONTH 1 TITRATION KT ORAL TABLET EXTENDED REL,DOSE PACK 0.125 MG \(126\)- 0.25 MG \(42\))/P 5410 0 R/K 29039 0 R>> endobj 15512 0 obj <>/Alt(Tier 2)/P 5410 0 R/K 29040 0 R>> endobj 15513 0 obj <>/Alt(PA; SP)/P 5410 0 R/K 29041 0 R>> endobj 15514 0 obj <>/Alt(ORENITRAM MONTH 2 TITRATION KT ORAL TABLET EXTENDED REL,DOSE PACK 0.125 MG \(126\)- 0.25 MG \(210\))/P 5411 0 R/K 29042 0 R>> endobj 15515 0 obj <>/Alt(Tier 2)/P 5411 0 R/K 29043 0 R>> endobj 15516 0 obj <>/Alt(PA; SP)/P 5411 0 R/K 29044 0 R>> endobj 15517 0 obj <>/Alt(ORENITRAM MONTH 3 TITRATION KT ORAL TABLET EXTENDED REL,DOSE PACK 0.125 MG \(126\)- 0.25 MG\(42\)-1MG)/P 5412 0 R/K 29045 0 R>> endobj 15518 0 obj <>/Alt(Tier 2)/P 5412 0 R/K 29046 0 R>> endobj 15519 0 obj <>/Alt(PA; SP)/P 5412 0 R/K 29047 0 R>> endobj 15520 0 obj <>/Alt(ORENITRAM ORAL TABLET EXTENDED RELEASE 0.125 MG, 0.25 MG, 1 MG, 2.5 MG, 5 MG)/P 5413 0 R/K 29048 0 R>> endobj 15521 0 obj <>/Alt(Tier 2)/P 5413 0 R/K 29049 0 R>> endobj 15522 0 obj <>/Alt(PA; SP)/P 5413 0 R/K 29050 0 R>> endobj 15523 0 obj <>/Alt(REMODULIN INJECTION SOLUTION 1 MG/ML, 10 MG/ML, 2.5 MG/ML, 5 MG/ML)/P 5414 0 R/K 29051 0 R>> endobj 15524 0 obj <>/Alt(\(treprostinil sodium\))/P 5414 0 R/K 29052 0 R>> endobj 15525 0 obj <>/Alt(Tier 3)/P 5414 0 R/K 29053 0 R>> endobj 15526 0 obj <>/Alt(PA; SP)/P 5414 0 R/K 29054 0 R>> endobj 15527 0 obj <>/Alt(\(Begin italic\) treprostinil sodium injection solution \(End italic\) \(Begin italic\) 1 mg/ml, 10 mg/ml, 2.5 mg/ml, 5 mg/ml \(End italic\))/P 5415 0 R/K 29055 0 R>> endobj 15528 0 obj <>/Alt(\(Remodulin\))/P 5415 0 R/K 29056 0 R>> endobj 15529 0 obj <>/Alt(Tier 1)/P 5415 0 R/K 29057 0 R>> endobj 15530 0 obj <>/Alt(PA; SP)/P 5415 0 R/K 29058 0 R>> endobj 15531 0 obj <>/Alt(TYVASO DPI INHALATION CARTRIDGE WITH INHALER 16 MCG, 16\(112\)-32\(112\) -48\(28\) MCG, 32 MCG, 48 MCG, 64 MCG)/P 5416 0 R/K 29059 0 R>> endobj 15532 0 obj <>/Alt(Tier 3)/P 5416 0 R/K 29060 0 R>> endobj 15533 0 obj <>/Alt(PA; SP)/P 5416 0 R/K 29061 0 R>> endobj 15534 0 obj <>/Alt(TYVASO INHALATION SOLUTION FOR NEBULIZATION 1.74 MG/2.9 ML \(0.6 MG/ML\))/P 5417 0 R/K 29062 0 R>> endobj 15535 0 obj <>/Alt(Tier 3)/P 5417 0 R/K 29063 0 R>> endobj 15536 0 obj <>/Alt(PA; SP)/P 5417 0 R/K 29064 0 R>> endobj 15537 0 obj <>/Alt(TYVASO INSTITUTIONAL START KIT INHALATION SOLUTION FOR NEBULIZATION 1.74 MG/2.9 ML)/P 5418 0 R/K 29065 0 R>> endobj 15538 0 obj <>/Alt(Tier 3)/P 5418 0 R/K 29066 0 R>> endobj 15539 0 obj <>/Alt(PA; SP)/P 5418 0 R/K 29067 0 R>> endobj 15540 0 obj <>/Alt(TYVASO REFILL KIT INHALATION SOLUTION FOR NEBULIZATION 1.74 MG/2.9 ML \(0.6 MG/ML\))/P 5419 0 R/K 29068 0 R>> endobj 15541 0 obj <>/Alt(Tier 3)/P 5419 0 R/K 29069 0 R>> endobj 15542 0 obj <>/Alt(PA; SP)/P 5419 0 R/K 29070 0 R>> endobj 15543 0 obj <>/Alt(TYVASO STARTER KIT INHALATION SOLUTION FOR NEBULIZATION 1.74 MG/2.9 ML)/P 5420 0 R/K 29071 0 R>> endobj 15544 0 obj <>/Alt(Tier 3)/P 5420 0 R/K 29072 0 R>> endobj 15545 0 obj <>/Alt(PA; SP)/P 5420 0 R/K 29073 0 R>> endobj 15546 0 obj <>/Alt(UPTRAVI ORAL TABLET 1,000 MCG, 1,200 MCG, 1,400 MCG, 1,600 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG)/P 5421 0 R/K 29074 0 R>> endobj 15547 0 obj <>/Alt(Tier 2)/P 5421 0 R/K 29075 0 R>> endobj 15548 0 obj <>/Alt(PA; SP)/P 5421 0 R/K 29076 0 R>> endobj 15549 0 obj <>/Alt(UPTRAVI ORAL TABLETS,DOSE PACK 200 MCG \(140\)- 800 MCG \(60\))/P 5422 0 R/K 29077 0 R>> endobj 15550 0 obj <>/Alt(Tier 2)/P 5422 0 R/K 29078 0 R>> endobj 15551 0 obj <>/Alt(PA; SP)/P 5422 0 R/K 29079 0 R>> endobj 15552 0 obj <>/Alt(VENTAVIS INHALATION SOLUTION FOR NEBULIZATION 10 MCG/ML, 20 MCG/ML)/P 5423 0 R/K 29080 0 R>> endobj 15553 0 obj <>/Alt(Tier 3)/P 5423 0 R/K 29081 0 R>> endobj 15554 0 obj <>/Alt(PA; SP)/P 5423 0 R/K 29082 0 R>> endobj 15555 0 obj <>/Alt(\(Begin bold\) Renin Inhibitor, Direct \(End bold\))/P 5424 0 R/K 29083 0 R>> endobj 15556 0 obj <>/Alt(\(Begin italic\) aliskiren oral tablet \(End italic\) \(Begin italic\) 150 mg, 300 mg \(End italic\))/P 5425 0 R/K 29084 0 R>> endobj 15557 0 obj <>/Alt(\(Tekturna\))/P 5425 0 R/K 29085 0 R>> endobj 15558 0 obj <>/Alt(Tier 1)/P 5425 0 R/K 29086 0 R>> endobj 15559 0 obj <>/Alt(\(Begin bold\) Thiazide And Related Diuretics \(End bold\))/P 5426 0 R/K 29087 0 R>> endobj 15560 0 obj <>/Alt(\(Begin italic\) chlorthalidone oral tablet \(End italic\) \(Begin italic\) 25 mg, 50 mg \(End italic\))/P 5427 0 R/K 29088 0 R>> endobj 15561 0 obj <>/Alt(Tier 1)/P 5427 0 R/K 29089 0 R>> endobj 15562 0 obj <>/Alt(DIURIL ORAL SUSPENSION 250 MG/5 ML)/P 5428 0 R/K 29090 0 R>> endobj 15563 0 obj <>/Alt(Tier 3)/P 5428 0 R/K 29091 0 R>> endobj 15564 0 obj <>/Alt(\(Begin italic\) hydrochlorothiazide oral capsule \(End italic\) \(Begin italic\) 12.5 mg \(End italic\))/P 5429 0 R/K 29092 0 R>> endobj 15565 0 obj <>/Alt(Tier 1)/P 5429 0 R/K 29093 0 R>> endobj 15566 0 obj <>/Alt(\(Begin italic\) hydrochlorothiazide oral tablet \(End italic\) \(Begin italic\) 12.5 mg, 25 mg, 50 mg \(End italic\))/P 5430 0 R/K 29094 0 R>> endobj 15567 0 obj <>/Alt(Tier 1)/P 5430 0 R/K 29095 0 R>> endobj 15568 0 obj <>/Alt(\(Begin italic\) indapamide oral tablet \(End italic\) \(Begin italic\) 1.25 mg, 2.5 mg \(End italic\))/P 5431 0 R/K 29096 0 R>> endobj 15569 0 obj <>/Alt(Tier 1)/P 5431 0 R/K 29097 0 R>> endobj 15570 0 obj <>/Alt(\(Begin italic\) metolazone oral tablet \(End italic\) \(Begin italic\) 10 mg, 2.5 mg, 5 mg \(End italic\))/P 5432 0 R/K 29098 0 R>> endobj 15571 0 obj <>/Alt(Tier 1)/P 5432 0 R/K 29099 0 R>> endobj 15572 0 obj <>/Alt(\(Begin bold\) Vasodilators, Combination \(End bold\))/P 5433 0 R/K 29100 0 R>> endobj 15573 0 obj <>/Alt(\(Begin italic\) isosorbide-hydralazine oral tablet \(End italic\) \(Begin italic\) 20-37.5 mg \(End italic\))/P 5434 0 R/K 29101 0 R>> endobj 15574 0 obj <>/Alt(\(BiDil\))/P 5434 0 R/K 29102 0 R>> endobj 15575 0 obj <>/Alt(Tier 1)/P 5434 0 R/K 29103 0 R>> endobj 15576 0 obj <>/Alt(\(Begin bold\) Cardiovascular Disease - Lipid Irregularity \(End bold\))/P 5435 0 R/K 29104 0 R>> endobj 15577 0 obj <>/Alt(\(Begin bold\) Antihyperlip.Hmg Coa Reduct Inhib&Cholest.Ab.Inhib \(End bold\))/P 5436 0 R/K 29105 0 R>> endobj 15578 0 obj <>/Alt(\(Begin italic\) ezetimibe-simvastatin oral tablet \(End italic\) \(Begin italic\) 10-10 mg \(End italic\))/P 5437 0 R/K 29106 0 R>> endobj 15579 0 obj <>/Alt(\(Vytorin 10-10\))/P 5437 0 R/K 29107 0 R>> endobj 15580 0 obj <>/Alt(Tier 1)/P 5437 0 R/K 29108 0 R>> endobj 15581 0 obj <>/Alt(QL \(1 EA per 1 day\))/P 5437 0 R/K 29109 0 R>> endobj 15582 0 obj <>/Alt(\(Begin italic\) ezetimibe-simvastatin oral tablet \(End italic\) \(Begin italic\) 10-20 mg \(End italic\))/P 5438 0 R/K 29110 0 R>> endobj 15583 0 obj <>/Alt(\(Vytorin 10-20\))/P 5438 0 R/K 29111 0 R>> endobj 15584 0 obj <>/Alt(Tier 1)/P 5438 0 R/K 29112 0 R>> endobj 15585 0 obj <>/Alt(QL \(1 EA per 1 day\))/P 5438 0 R/K 29113 0 R>> endobj 15586 0 obj <>/Alt(\(Begin italic\) ezetimibe-simvastatin oral tablet \(End italic\) \(Begin italic\) 10-40 mg \(End italic\))/P 5439 0 R/K 29114 0 R>> endobj 15587 0 obj <>/Alt(\(Vytorin 10-40\))/P 5439 0 R/K 29115 0 R>> endobj 15588 0 obj <>/Alt(Tier 1)/P 5439 0 R/K 29116 0 R>> endobj 15589 0 obj <>/Alt(QL \(1 EA per 1 day\))/P 5439 0 R/K 29117 0 R>> endobj 15590 0 obj <>/Alt(\(Begin italic\) ezetimibe-simvastatin oral tablet \(End italic\) \(Begin italic\) 10-80 mg \(End italic\))/P 5440 0 R/K 29118 0 R>> endobj 15591 0 obj <>/Alt(\(Vytorin 10-80\))/P 5440 0 R/K 29119 0 R>> endobj 15592 0 obj <>/Alt(Tier 1)/P 5440 0 R/K 29120 0 R>> endobj 15593 0 obj <>/Alt(PA; QL \(1 EA per 1 day\))/P 5440 0 R/K 29121 0 R>> endobj 15594 0 obj <>/Alt(\(Begin bold\) Antihyperlipidemic - Apo B-100 Synthesis Inhibitor \(End bold\))/P 5441 0 R/K 29122 0 R>> endobj 15595 0 obj <>/Alt(TRYNGOLZA SUBCUTANEOUS AUTO-INJECTOR 80 MG/0.8 ML)/P 5442 0 R/K 29123 0 R>> endobj 15596 0 obj <>/Alt(Tier 3)/P 5442 0 R/K 29124 0 R>> endobj 15597 0 obj <>/Alt(PA; SP)/P 5442 0 R/K 29125 0 R>> endobj 15598 0 obj <>/Alt(\(Begin bold\) Antihyperlipidemic - Atp Citrate Lyase 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YEARS OF AGE, AND NO HISTORY OF CARDIOVASCULAR DISEASE PREVENTION MEDICATIONS IN 120 DAYS; QL \(2 EA per 1 day\))/P 5453 0 R/K 29157 0 R>> endobj 15630 0 obj <>/Alt(\(Begin italic\) fluvastatin oral capsule \(End italic\) \(Begin italic\) 40 mg \(End italic\))/P 5454 0 R/K 29158 0 R>> endobj 15631 0 obj <>/Alt($0)/P 5454 0 R/K 29159 0 R>> endobj 15632 0 obj <>/Alt(ST: At least 2 prior prescriptions for Atorvastatin, Lovastatin, Pravastatin, or Simvastatin within the past 365 days; $0 COPAY IF QUANTITY 2 IN 1 DAY, 40-75 YEARS OF AGE, AND NO HISTORY OF CARDIOVASCULAR DISEASE PREVENTION MEDICATIONS IN 120 DAYS; QL \(2 EA per 1 day\))/P 5454 0 R/K 29160 0 R>> endobj 15633 0 obj <>/Alt(\(Begin italic\) fluvastatin oral tablet extended release 24 hr \(End italic\) \(Begin italic\) 80 mg \(End italic\))/P 5455 0 R/K 29161 0 R>> endobj 15634 0 obj <>/Alt(\(Lescol XL\))/P 5455 0 R/K 29162 0 R>> endobj 15635 0 obj <>/Alt($0)/P 5455 0 R/K 29163 0 R>> endobj 15636 0 obj <>/Alt(ST: At least 2 prior prescriptions for Atorvastatin, Lovastatin, Pravastatin, or Simvastatin within the past 365 days; $0 COPAY IF QUANTITY 1 IN 1 DAY, 40-75 YEARS OF AGE, AND NO HISTORY OF CARDIOVASCULAR DISEASE PREVENTION MEDICATIONS IN 120 DAYS; QL \(1 EA per 1 day\))/P 5455 0 R/K 29164 0 R>> endobj 15637 0 obj <>/Alt(LIVALO ORAL TABLET 1 MG, 2 MG, 4 MG)/P 5456 0 R/K 29165 0 R>> endobj 15638 0 obj <>/Alt(\(pitavastatin calcium\))/P 5456 0 R/K 29166 0 R>> endobj 15639 0 obj <>/Alt($0)/P 5456 0 R/K 29167 0 R>> endobj 15640 0 obj <>/Alt($0 COPAY IF QUANTITY 1 IN 1 DAY, 40-75 YEARS OF AGE, AND NO HISTORY OF CARDIOVASCULAR DISEASE PREVENTION MEDICATIONS IN 120 DAYS; QL \(1 EA per 1 day\))/P 5456 0 R/K 29168 0 R>> endobj 15641 0 obj <>/Alt(\(Begin italic\) lovastatin oral tablet \(End italic\) \(Begin italic\) 10 mg, 20 mg, 40 mg \(End italic\))/P 5457 0 R/K 29169 0 R>> endobj 15642 0 obj <>/Alt($0)/P 5457 0 R/K 29170 0 R>> endobj 15643 0 obj <>/Alt($0 COPAY IF QUANTITY 1 IN 1 DAY, 40-75 YEARS OF AGE, AND NO HISTORY OF CARDIOVASCULAR DISEASE PREVENTION MEDICATIONS IN 120 DAYS; QL \(2 EA per 1 day\))/P 5457 0 R/K 29171 0 R>> endobj 15644 0 obj <>/Alt(\(Begin italic\) pravastatin oral tablet \(End italic\) \(Begin italic\) 10 mg, 20 mg, 40 mg, 80 mg \(End italic\))/P 5458 0 R/K 29172 0 R>> endobj 15645 0 obj <>/Alt($0)/P 5458 0 R/K 29173 0 R>> endobj 15646 0 obj <>/Alt($0 COPAY IF QUANTITY 1 IN 1 DAY, 40-75 YEARS OF AGE, AND NO HISTORY OF CARDIOVASCULAR DISEASE PREVENTION MEDICATIONS IN 120 DAYS; QL \(1 EA per 1 day\))/P 5458 0 R/K 29174 0 R>> endobj 15647 0 obj <>/Alt(\(Begin italic\) rosuvastatin oral tablet \(End italic\) \(Begin italic\) 10 mg, 5 mg \(End italic\))/P 5459 0 R/K 29175 0 R>> endobj 15648 0 obj <>/Alt(\(Crestor\))/P 5459 0 R/K 29176 0 R>> endobj 15649 0 obj <>/Alt($0)/P 5459 0 R/K 29177 0 R>> endobj 15650 0 obj <>/Alt($0 COPAY IF QUANTITY 1 IN 1 DAY, 40-75 YEARS OF AGE, AND NO HISTORY OF CARDIOVASCULAR DISEASE PREVENTION MEDICATIONS IN 120 DAYS; QL \(1 EA per 1 day\))/P 5459 0 R/K 29178 0 R>> endobj 15651 0 obj <>/Alt(\(Begin italic\) rosuvastatin oral tablet \(End italic\) \(Begin italic\) 20 mg, 40 mg \(End italic\))/P 5460 0 R/K 29179 0 R>> endobj 15652 0 obj <>/Alt(\(Crestor\))/P 5460 0 R/K 29180 0 R>> endobj 15653 0 obj <>/Alt(Tier 1)/P 5460 0 R/K 29181 0 R>> endobj 15654 0 obj <>/Alt(QL \(1 EA per 1 day\))/P 5460 0 R/K 29182 0 R>> endobj 15655 0 obj <>/Alt(\(Begin italic\) simvastatin oral tablet \(End italic\) \(Begin italic\) 10 mg, 20 mg, 40 mg \(End italic\))/P 5461 0 R/K 29183 0 R>> endobj 15656 0 obj <>/Alt(\(Zocor\))/P 5461 0 R/K 29184 0 R>> endobj 15657 0 obj <>/Alt($0)/P 5461 0 R/K 29185 0 R>> endobj 15658 0 obj <>/Alt($0 COPAY IF QUANTITY 1 IN 1 DAY, 40-75 YEARS OF AGE, AND NO HISTORY OF CARDIOVASCULAR DISEASE PREVENTION MEDICATIONS IN 120 DAYS; QL \(1 EA per 1 day\))/P 5461 0 R/K 29186 0 R>> endobj 15659 0 obj <>/Alt(\(Begin italic\) simvastatin oral tablet \(End italic\) \(Begin italic\) 5 mg \(End italic\))/P 5462 0 R/K 29187 0 R>> endobj 15660 0 obj <>/Alt($0)/P 5462 0 R/K 29188 0 R>> endobj 15661 0 obj <>/Alt($0 COPAY IF QUANTITY 1 IN 1 DAY, 40-75 YEARS OF AGE, AND NO HISTORY OF CARDIOVASCULAR DISEASE PREVENTION MEDICATIONS IN 120 DAYS; QL \(1 EA per 1 day\))/P 5462 0 R/K 29189 0 R>> endobj 15662 0 obj <>/Alt(\(Begin italic\) simvastatin oral tablet \(End italic\) \(Begin italic\) 80 mg \(End italic\))/P 5463 0 R/K 29190 0 R>> endobj 15663 0 obj <>/Alt(Tier 1)/P 5463 0 R/K 29191 0 R>> endobj 15664 0 obj <>/Alt(PA; QL \(1 EA per 1 day\))/P 5463 0 R/K 29192 0 R>> endobj 15665 0 obj <>/Alt(\(Begin bold\) Antihyperlipidemic - Mtp Inhibitor \(End bold\))/P 5464 0 R/K 29193 0 R>> endobj 15666 0 obj <>/Alt(JUXTAPID ORAL CAPSULE 10 MG, 20 MG, 30 MG, 5 MG)/P 5465 0 R/K 29194 0 R>> endobj 15667 0 obj <>/Alt(Tier 2)/P 5465 0 R/K 29195 0 R>> endobj 15668 0 obj <>/Alt(PA; SP)/P 5465 0 R/K 29196 0 R>> endobj 15669 0 obj <>/Alt(\(Begin bold\) Antihyperlipidemic - Pcsk9 Inhibitors \(End bold\))/P 5466 0 R/K 29197 0 R>> endobj 15670 0 obj <>/Alt(REPATHA PUSHTRONEX SUBCUTANEOUS WEARABLE INJECTOR 420 MG/3.5 ML)/P 5467 0 R/K 29198 0 R>> endobj 15671 0 obj <>/Alt(Tier 2)/P 5467 0 R/K 29199 0 R>> endobj 15672 0 obj <>/Alt(ST: Requires prior prescription for generic statin within the past 120 days)/P 5467 0 R/K 29200 0 R>> endobj 15673 0 obj <>/Alt(REPATHA SURECLICK SUBCUTANEOUS PEN INJECTOR 140 MG/ML)/P 5468 0 R/K 29201 0 R>> endobj 15674 0 obj <>/Alt(Tier 2)/P 5468 0 R/K 29202 0 R>> endobj 15675 0 obj <>/Alt(ST: Requires prior prescription for generic statin within the past 120 days)/P 5468 0 R/K 29203 0 R>> endobj 15676 0 obj <>/Alt(REPATHA SYRINGE SUBCUTANEOUS SYRINGE 140 MG/ML)/P 5469 0 R/K 29204 0 R>> endobj 15677 0 obj <>/Alt(Tier 2)/P 5469 0 R/K 29205 0 R>> endobj 15678 0 obj <>/Alt(ST: Requires prior prescription for generic statin within the past 120 days)/P 5469 0 R/K 29206 0 R>> endobj 15679 0 obj <>/Alt(\(Begin bold\) Antihyperlipidemic-Acly And Choles Absorp Inhib \(End bold\))/P 5470 0 R/K 29207 0 R>> endobj 15680 0 obj <>/Alt(NEXLIZET ORAL TABLET 180-10 MG)/P 5471 0 R/K 29208 0 R>> endobj 15681 0 obj <>/Alt(Tier 2)/P 5471 0 R/K 29209 0 R>> endobj 15682 0 obj <>/Alt(ST: Requires prior prescription for generic statin within the past 120 days)/P 5471 0 R/K 29210 0 R>> endobj 15683 0 obj <>/Alt(\(Begin bold\) Bile Salt Sequestrants \(End bold\))/P 5472 0 R/K 29211 0 R>> endobj 15684 0 obj <>/Alt(\(Begin italic\) cholestyramine \(with sugar\) oral powder \(End italic\) \(Begin italic\) 4 gram \(End italic\))/P 5473 0 R/K 29212 0 R>> endobj 15685 0 obj <>/Alt(\(Questran\))/P 5473 0 R/K 29213 0 R>> endobj 15686 0 obj <>/Alt(Tier 1)/P 5473 0 R/K 29214 0 R>> endobj 15687 0 obj <>/Alt(\(Begin italic\) cholestyramine \(with sugar\) oral powder in packet \(End italic\) \(Begin italic\) 4 gram \(End italic\))/P 5474 0 R/K 29215 0 R>> endobj 15688 0 obj <>/Alt(\(Questran\))/P 5474 0 R/K 29216 0 R>> endobj 15689 0 obj <>/Alt(Tier 1)/P 5474 0 R/K 29217 0 R>> endobj 15690 0 obj <>/Alt(CHOLESTYRAMINE LIGHT ORAL POWDER 4 GRAM)/P 5475 0 R/K 29218 0 R>> endobj 15691 0 obj <>/Alt(\(cholestyramine-aspartame\))/P 5475 0 R/K 29219 0 R>> endobj 15692 0 obj <>/Alt(Tier 1)/P 5475 0 R/K 29220 0 R>> endobj 15693 0 obj <>/Alt(CHOLESTYRAMINE LIGHT ORAL POWDER IN PACKET 4 GRAM)/P 5476 0 R/K 29221 0 R>> endobj 15694 0 obj <>/Alt(\(cholestyramine-aspartame\))/P 5476 0 R/K 29222 0 R>> endobj 15695 0 obj <>/Alt(Tier 1)/P 5476 0 R/K 29223 0 R>> endobj 15696 0 obj <>/Alt(\(Begin italic\) cholestyramine-aspartame oral powder in packet \(End italic\) \(Begin italic\) 4 gram \(End italic\))/P 5477 0 R/K 29224 0 R>> endobj 15697 0 obj <>/Alt(\(Cholestyramine Light\))/P 5477 0 R/K 29225 0 R>> endobj 15698 0 obj <>/Alt(Tier 1)/P 5477 0 R/K 29226 0 R>> endobj 15699 0 obj <>/Alt(\(Begin italic\) colesevelam oral powder in packet \(End italic\) \(Begin italic\) 3.75 gram \(End italic\))/P 5478 0 R/K 29227 0 R>> endobj 15700 0 obj <>/Alt(\(WelChol\))/P 5478 0 R/K 29228 0 R>> endobj 15701 0 obj <>/Alt(Tier 1)/P 5478 0 R/K 29229 0 R>> endobj 15702 0 obj <>/Alt(\(Begin italic\) colesevelam oral tablet \(End italic\) \(Begin italic\) 625 mg \(End italic\))/P 5479 0 R/K 29230 0 R>> endobj 15703 0 obj <>/Alt(\(WelChol\))/P 5479 0 R/K 29231 0 R>> endobj 15704 0 obj <>/Alt(Tier 1)/P 5479 0 R/K 29232 0 R>> endobj 15705 0 obj <>/Alt(\(Begin italic\) colestipol oral granules \(End italic\) \(Begin italic\) 5 gram \(End italic\))/P 5480 0 R/K 29233 0 R>> endobj 15706 0 obj <>/Alt(\(Colestid\))/P 5480 0 R/K 29234 0 R>> endobj 15707 0 obj <>/Alt(Tier 1)/P 5480 0 R/K 29235 0 R>> endobj 15708 0 obj <>/Alt(\(Begin italic\) colestipol oral packet \(End italic\) \(Begin italic\) 5 gram \(End italic\))/P 5481 0 R/K 29236 0 R>> endobj 15709 0 obj <>/Alt(Tier 1)/P 5481 0 R/K 29237 0 R>> endobj 15710 0 obj <>/Alt(\(Begin italic\) colestipol oral tablet \(End italic\) \(Begin italic\) 1 gram \(End italic\))/P 5482 0 R/K 29238 0 R>> endobj 15711 0 obj <>/Alt(\(Colestid\))/P 5482 0 R/K 29239 0 R>> endobj 15712 0 obj <>/Alt(Tier 1)/P 5482 0 R/K 29240 0 R>> endobj 15713 0 obj <>/Alt(PREVALITE ORAL POWDER 4 GRAM)/P 5483 0 R/K 29241 0 R>> endobj 15714 0 obj <>/Alt(\(cholestyramine-aspartame\))/P 5483 0 R/K 29242 0 R>> endobj 15715 0 obj <>/Alt(Tier 1)/P 5483 0 R/K 29243 0 R>> endobj 15716 0 obj <>/Alt(PREVALITE ORAL POWDER IN PACKET 4 GRAM)/P 5484 0 R/K 29244 0 R>> endobj 15717 0 obj <>/Alt(\(cholestyramine-aspartame\))/P 5484 0 R/K 29245 0 R>> endobj 15718 0 obj <>/Alt(Tier 1)/P 5484 0 R/K 29246 0 R>> endobj 15719 0 obj <>/Alt(\(Begin bold\) Lipotropics \(End bold\))/P 5485 0 R/K 29247 0 R>> endobj 15720 0 obj <>/Alt(\(Begin italic\) ezetimibe oral tablet \(End italic\) \(Begin italic\) 10 mg \(End italic\))/P 5486 0 R/K 29248 0 R>> endobj 15721 0 obj <>/Alt(\(Zetia\))/P 5486 0 R/K 29249 0 R>> endobj 15722 0 obj <>/Alt(Tier 1)/P 5486 0 R/K 29250 0 R>> endobj 15723 0 obj <>/Alt(QL \(1 EA per 1 day\))/P 5486 0 R/K 29251 0 R>> endobj 15724 0 obj <>/Alt(\(Begin italic\) fenofibrate micronized oral capsule \(End italic\) \(Begin italic\) 134 mg, 200 mg, 67 mg \(End italic\))/P 5487 0 R/K 29252 0 R>> endobj 15725 0 obj <>/Alt(Tier 1)/P 5487 0 R/K 29253 0 R>> endobj 15726 0 obj <>/Alt(\(Begin italic\) fenofibrate nanocrystallized oral tablet \(End italic\) \(Begin italic\) 145 mg, 48 mg \(End italic\))/P 5488 0 R/K 29254 0 R>> endobj 15727 0 obj <>/Alt(\(Tricor\))/P 5488 0 R/K 29255 0 R>> endobj 15728 0 obj <>/Alt(Tier 1)/P 5488 0 R/K 29256 0 R>> endobj 15729 0 obj <>/Alt(\(Begin italic\) fenofibrate oral capsule \(End italic\) \(Begin italic\) 150 mg, 50 mg \(End italic\))/P 5489 0 R/K 29257 0 R>> endobj 15730 0 obj <>/Alt(\(Lipofen\))/P 5489 0 R/K 29258 0 R>> endobj 15731 0 obj <>/Alt(Tier 1)/P 5489 0 R/K 29259 0 R>> endobj 15732 0 obj <>/Alt(\(Begin italic\) fenofibrate oral tablet \(End italic\) \(Begin italic\) 120 mg, 40 mg \(End italic\))/P 5490 0 R/K 29260 0 R>> endobj 15733 0 obj <>/Alt(\(Fenoglide\))/P 5490 0 R/K 29261 0 R>> endobj 15734 0 obj <>/Alt(Tier 1)/P 5490 0 R/K 29262 0 R>> endobj 15735 0 obj <>/Alt(\(Begin italic\) fenofibrate oral tablet \(End italic\) \(Begin italic\) 160 mg, 54 mg \(End italic\))/P 5491 0 R/K 29263 0 R>> endobj 15736 0 obj <>/Alt(Tier 1)/P 5491 0 R/K 29264 0 R>> endobj 15737 0 obj <>/Alt(\(Begin italic\) fenofibric acid \(choline\) oral capsule,delayed release\(dr/ec\) \(End italic\) \(Begin italic\) 135 mg \(End italic\))/P 5492 0 R/K 29265 0 R>> endobj 15738 0 obj <>/Alt(Tier 1)/P 5492 0 R/K 29266 0 R>> endobj 15739 0 obj <>/Alt(\(Begin italic\) fenofibric acid \(choline\) oral capsule,delayed release\(dr/ec\) \(End italic\) \(Begin italic\) 45 mg \(End italic\))/P 5493 0 R/K 29267 0 R>> endobj 15740 0 obj <>/Alt(\(Trilipix\))/P 5493 0 R/K 29268 0 R>> endobj 15741 0 obj <>/Alt(Tier 1)/P 5493 0 R/K 29269 0 R>> endobj 15742 0 obj <>/Alt(\(Begin italic\) fenofibric acid oral tablet \(End italic\) \(Begin italic\) 105 mg, 35 mg \(End italic\))/P 5494 0 R/K 29270 0 R>> endobj 15743 0 obj <>/Alt(\(Fibricor\))/P 5494 0 R/K 29271 0 R>> endobj 15744 0 obj <>/Alt(Tier 1)/P 5494 0 R/K 29272 0 R>> endobj 15745 0 obj <>/Alt(\(Begin italic\) gemfibrozil oral tablet \(End italic\) \(Begin italic\) 600 mg \(End italic\))/P 5495 0 R/K 29273 0 R>> endobj 15746 0 obj <>/Alt(\(Lopid\))/P 5495 0 R/K 29274 0 R>> endobj 15747 0 obj <>/Alt(Tier 1)/P 5495 0 R/K 29275 0 R>> endobj 15748 0 obj <>/Alt(\(Begin italic\) niacin oral tablet extended release 24 hr \(End italic\) \(Begin italic\) 1,000 mg, 500 mg, 750 mg \(End italic\))/P 5496 0 R/K 29276 0 R>> endobj 15749 0 obj <>/Alt(Tier 1)/P 5496 0 R/K 29277 0 R>> endobj 15750 0 obj <>/Alt(NIACOR ORAL TABLET 500 MG)/P 5497 0 R/K 29278 0 R>> endobj 15751 0 obj <>/Alt(\(niacin\))/P 5497 0 R/K 29279 0 R>> endobj 15752 0 obj <>/Alt(Tier 1)/P 5497 0 R/K 29280 0 R>> endobj 15753 0 obj <>/Alt(\(Begin italic\) omega-3 acid ethyl esters oral capsule \(End italic\) \(Begin italic\) 1 gram \(End italic\))/P 5498 0 R/K 29281 0 R>> endobj 15754 0 obj <>/Alt(\(Lovaza\))/P 5498 0 R/K 29282 0 R>> endobj 15755 0 obj <>/Alt(Tier 1)/P 5498 0 R/K 29283 0 R>> endobj 15756 0 obj <>/Alt(ST: Requires prior prescription for generic Fenofibrate within the past 120 days; QL \(4 EA per 1 day\))/P 5498 0 R/K 29284 0 R>> endobj 15757 0 obj <>/Alt(VASCEPA ORAL CAPSULE 0.5 GRAM)/P 5499 0 R/K 29285 0 R>> endobj 15758 0 obj <>/Alt(\(icosapent ethyl\))/P 5499 0 R/K 29286 0 R>> endobj 15759 0 obj <>/Alt(Tier 1)/P 5499 0 R/K 29287 0 R>> endobj 15760 0 obj <>/Alt(QL \(8 EA per 1 day\))/P 5499 0 R/K 29288 0 R>> endobj 15761 0 obj <>/Alt(VASCEPA ORAL CAPSULE 1 GRAM)/P 5500 0 R/K 29289 0 R>> endobj 15762 0 obj <>/Alt(\(icosapent ethyl\))/P 5500 0 R/K 29290 0 R>> endobj 15763 0 obj <>/Alt(Tier 1)/P 5500 0 R/K 29291 0 R>> endobj 15764 0 obj <>/Alt(QL \(4 EA per 1 day\))/P 5500 0 R/K 29292 0 R>> endobj 15765 0 obj <>/Alt(\(Begin bold\) Niacin Preparations \(End bold\))/P 5501 0 R/K 29293 0 R>> endobj 15766 0 obj <>/Alt(\(Begin italic\) niacin oral tablet \(End italic\) \(Begin italic\) 500 mg \(End italic\))/P 5502 0 R/K 29294 0 R>> endobj 15767 0 obj <>/Alt(\(Niacor\))/P 5502 0 R/K 29295 0 R>> endobj 15768 0 obj <>/Alt(Tier 1)/P 5502 0 R/K 29296 0 R>> endobj 15769 0 obj <>/Alt(\(Begin bold\) Cardiovascular Disease - Miscellaneous Agents \(End bold\))/P 5503 0 R/K 29297 0 R>> endobj 15770 0 obj <>/Alt(\(Begin bold\) Adrenergic Vasopressor Agents \(End bold\))/P 5504 0 R/K 29298 0 R>> endobj 15771 0 obj <>/Alt(\(Begin italic\) droxidopa oral capsule \(End italic\) \(Begin italic\) 100 mg, 200 mg, 300 mg \(End italic\))/P 5505 0 R/K 29299 0 R>> endobj 15772 0 obj <>/Alt(\(Northera\))/P 5505 0 R/K 29300 0 R>> endobj 15773 0 obj <>/Alt(Tier 1)/P 5505 0 R/K 29301 0 R>> endobj 15774 0 obj <>/Alt(PA; SP)/P 5505 0 R/K 29302 0 R>> endobj 15775 0 obj <>/Alt(\(Begin italic\) midodrine oral tablet \(End italic\) \(Begin italic\) 10 mg, 2.5 mg, 5 mg \(End italic\))/P 5506 0 R/K 29303 0 R>> endobj 15776 0 obj <>/Alt(Tier 1)/P 5506 0 R/K 29304 0 R>> endobj 15777 0 obj <>/Alt(\(Begin bold\) Angiotensin Recept-Neprilysin Inhibitor Comb\(Arni\) \(End bold\))/P 5507 0 R/K 29305 0 R>> endobj 15778 0 obj <>/Alt(ENTRESTO ORAL TABLET 24-26 MG)/P 5508 0 R/K 29306 0 R>> endobj 15779 0 obj <>/Alt(\(sacubitril-valsartan\))/P 5508 0 R/K 29307 0 R>> endobj 15780 0 obj <>/Alt(Tier 2)/P 5508 0 R/K 29308 0 R>> endobj 15781 0 obj <>/Alt(QL \(6 EA per 1 day\))/P 5508 0 R/K 29309 0 R>> endobj 15782 0 obj <>/Alt(ENTRESTO ORAL TABLET 49-51 MG, 97-103 MG)/P 5509 0 R/K 29310 0 R>> endobj 15783 0 obj <>/Alt(\(sacubitril-valsartan\))/P 5509 0 R/K 29311 0 R>> endobj 15784 0 obj <>/Alt(Tier 2)/P 5509 0 R/K 29312 0 R>> endobj 15785 0 obj <>/Alt(QL \(2 EA per 1 day\))/P 5509 0 R/K 29313 0 R>> endobj 15786 0 obj <>/Alt(ENTRESTO SPRINKLE ORAL PELLET 15-16 MG, 6-6 MG)/P 5510 0 R/K 29314 0 R>> endobj 15787 0 obj <>/Alt(Tier 2)/P 5510 0 R/K 29315 0 R>> endobj 15788 0 obj <>/Alt(QL \(8 EA per 1 day\))/P 5510 0 R/K 29316 0 R>> endobj 15789 0 obj <>/Alt(\(Begin bold\) Antianginal & Anti-Ischemic 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amlodipine-atorvastatin oral tablet \(End italic\) \(Begin italic\) 2.5-10 mg, 2.5-20 mg, 2.5-40 mg \(End italic\))/P 5519 0 R/K 29337 0 R>> endobj 15810 0 obj <>/Alt(Tier 1)/P 5519 0 R/K 29338 0 R>> endobj 15811 0 obj <>/Alt(QL \(1 EA per 1 day\))/P 5519 0 R/K 29339 0 R>> endobj 15812 0 obj <>/Alt(\(Begin bold\) Cardiac Myosin Inhibitor \(End bold\))/P 5520 0 R/K 29340 0 R>> endobj 15813 0 obj <>/Alt(CAMZYOS ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 5 MG)/P 5521 0 R/K 29341 0 R>> endobj 15814 0 obj <>/Alt(Tier 3)/P 5521 0 R/K 29342 0 R>> endobj 15815 0 obj <>/Alt(PA; SP)/P 5521 0 R/K 29343 0 R>> endobj 15816 0 obj <>/Alt(\(Begin bold\) Protein Stabilizers \(End bold\))/P 5522 0 R/K 29344 0 R>> endobj 15817 0 obj <>/Alt(ATTRUBY ORAL TABLET 356 MG)/P 5523 0 R/K 29345 0 R>> endobj 15818 0 obj <>/Alt(Tier 3)/P 5523 0 R/K 29346 0 R>> endobj 15819 0 obj <>/Alt(PA; SP)/P 5523 0 R/K 29347 0 R>> endobj 15820 0 obj <>/Alt(VYNDAMAX ORAL CAPSULE 61 MG)/P 5524 0 R/K 29348 0 R>> endobj 15821 0 obj 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R>> endobj 15833 0 obj <>/Alt(Tier 1)/P 5530 0 R/K 29361 0 R>> endobj 15834 0 obj <>/Alt(\(Begin italic\) isosorbide dinitrate oral tablet \(End italic\) \(Begin italic\) 10 mg, 20 mg, 30 mg \(End italic\))/P 5531 0 R/K 29362 0 R>> endobj 15835 0 obj <>/Alt(Tier 1)/P 5531 0 R/K 29363 0 R>> endobj 15836 0 obj <>/Alt(\(Begin italic\) isosorbide dinitrate oral tablet \(End italic\) \(Begin italic\) 40 mg \(End italic\))/P 5532 0 R/K 29364 0 R>> endobj 15837 0 obj <>/Alt(\(Isordil\))/P 5532 0 R/K 29365 0 R>> endobj 15838 0 obj <>/Alt(Tier 1)/P 5532 0 R/K 29366 0 R>> endobj 15839 0 obj <>/Alt(\(Begin italic\) isosorbide dinitrate oral tablet \(End italic\) \(Begin italic\) 5 mg \(End italic\))/P 5533 0 R/K 29367 0 R>> endobj 15840 0 obj <>/Alt(\(Isordil Titradose\))/P 5533 0 R/K 29368 0 R>> endobj 15841 0 obj <>/Alt(Tier 1)/P 5533 0 R/K 29369 0 R>> endobj 15842 0 obj <>/Alt(\(Begin italic\) isosorbide mononitrate oral tablet \(End italic\) \(Begin italic\) 10 mg, 20 mg \(End italic\))/P 5534 0 R/K 29370 0 R>> endobj 15843 0 obj <>/Alt(Tier 1)/P 5534 0 R/K 29371 0 R>> endobj 15844 0 obj <>/Alt(\(Begin italic\) isosorbide mononitrate oral tablet extended release 24 hr \(End italic\) \(Begin italic\) 120 mg, 30 mg, 60 mg \(End italic\))/P 5535 0 R/K 29372 0 R>> endobj 15845 0 obj <>/Alt(Tier 1)/P 5535 0 R/K 29373 0 R>> endobj 15846 0 obj <>/Alt(NITRO-BID TRANSDERMAL OINTMENT 2 %)/P 5536 0 R/K 29374 0 R>> endobj 15847 0 obj <>/Alt(\(nitroglycerin\))/P 5536 0 R/K 29375 0 R>> endobj 15848 0 obj <>/Alt(Tier 2)/P 5536 0 R/K 29376 0 R>> endobj 15849 0 obj <>/Alt(NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.3 MG/HR, 0.8 MG/HR)/P 5537 0 R/K 29377 0 R>> endobj 15850 0 obj <>/Alt(Tier 2)/P 5537 0 R/K 29378 0 R>> endobj 15851 0 obj <>/Alt(\(Begin italic\) nitroglycerin sublingual tablet \(End italic\) \(Begin italic\) 0.3 mg, 0.4 mg, 0.6 mg \(End italic\))/P 5538 0 R/K 29379 0 R>> endobj 15852 0 obj <>/Alt(\(Nitrostat\))/P 5538 0 R/K 29380 0 R>> endobj 15853 0 obj <>/Alt(Tier 1)/P 5538 0 R/K 29381 0 R>> endobj 15854 0 obj <>/Alt(\(Begin italic\) nitroglycerin transdermal patch 24 hour \(End italic\) \(Begin italic\) 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr \(End italic\))/P 5539 0 R/K 29382 0 R>> endobj 15855 0 obj <>/Alt(\(Nitro-Dur\))/P 5539 0 R/K 29383 0 R>> endobj 15856 0 obj <>/Alt(Tier 1)/P 5539 0 R/K 29384 0 R>> endobj 15857 0 obj <>/Alt(\(Begin italic\) nitroglycerin translingual spray,non-aerosol \(End italic\) \(Begin italic\) 400 mcg/spray \(End italic\))/P 5540 0 R/K 29385 0 R>> endobj 15858 0 obj <>/Alt(\(Nitrolingual\))/P 5540 0 R/K 29386 0 R>> endobj 15859 0 obj <>/Alt(Tier 1)/P 5540 0 R/K 29387 0 R>> endobj 15860 0 obj <>/Alt(NITROMIST TRANSLINGUAL AEROSOL,SPRAY 400 MCG/SPRAY)/P 5541 0 R/K 29388 0 R>> endobj 15861 0 obj <>/Alt(\(nitroglycerin\))/P 5541 0 R/K 29389 0 R>> endobj 15862 0 obj <>/Alt(Tier 3)/P 5541 0 R/K 29390 0 R>> endobj 15863 0 obj <>/Alt(NITRO-TIME ORAL CAPSULE, EXTENDED RELEASE 2.5 MG, 6.5 MG, 9 MG)/P 5542 0 R/K 29391 0 R>> endobj 15864 0 obj <>/Alt(\(nitroglycerin\))/P 5542 0 R/K 29392 0 R>> endobj 15865 0 obj <>/Alt(Tier 1)/P 5542 0 R/K 29393 0 R>> endobj 15866 0 obj <>/Alt(\(Begin bold\) Vasodilators,Peripheral \(End bold\))/P 5543 0 R/K 29394 0 R>> endobj 15867 0 obj <>/Alt(\(Begin italic\) ergoloid oral tablet \(End italic\) \(Begin italic\) 1 mg \(End italic\))/P 5544 0 R/K 29395 0 R>> endobj 15868 0 obj <>/Alt(Tier 1)/P 5544 0 R/K 29396 0 R>> endobj 15869 0 obj <>/Alt(\(Begin italic\) papaverine injection solution \(End italic\) \(Begin italic\) 30 mg/ml \(End italic\))/P 5545 0 R/K 29397 0 R>> endobj 15870 0 obj <>/Alt(Tier 1)/P 5545 0 R/K 29398 0 R>> endobj 15871 0 obj <>/Alt(\(Begin bold\) Contraception/Oxytocics \(End bold\))/P 5546 0 R/K 29399 0 R>> endobj 15872 0 obj <>/Alt(\(Begin bold\) Contraceptives, Intravaginal, Systemic \(End bold\))/P 5547 0 R/K 29400 0 R>> endobj 15873 0 obj <>/Alt(ANNOVERA VAGINAL RING 0.15-0.013 MG/24 HOUR)/P 5548 0 R/K 29401 0 R>> endobj 15874 0 obj <>/Alt($0)/P 5548 0 R/K 29402 0 R>> endobj 15875 0 obj <>/Alt(ELURYNG VAGINAL RING 0.12-0.015 MG/24 HR)/P 5549 0 R/K 29403 0 R>> endobj 15876 0 obj <>/Alt(\(etonogestrel-ethinyl estradiol\))/P 5549 0 R/K 29404 0 R>> endobj 15877 0 obj <>/Alt($0)/P 5549 0 R/K 29405 0 R>> endobj 15878 0 obj <>/Alt(ENILLORING VAGINAL RING 0.12-0.015 MG/24 HR)/P 5550 0 R/K 29406 0 R>> endobj 15879 0 obj <>/Alt(\(etonogestrel-ethinyl estradiol\))/P 5550 0 R/K 29407 0 R>> endobj 15880 0 obj <>/Alt($0)/P 5550 0 R/K 29408 0 R>> endobj 15881 0 obj <>/Alt(\(Begin italic\) etonogestrel-ethinyl estradiol vaginal ring \(End italic\) \(Begin italic\) 0.12-0.015 mg/24 hr \(End italic\))/P 5551 0 R/K 29409 0 R>> endobj 15882 0 obj <>/Alt(\(EluRyng\))/P 5551 0 R/K 29410 0 R>> endobj 15883 0 obj <>/Alt($0)/P 5551 0 R/K 29411 0 R>> endobj 15884 0 obj <>/Alt(HALOETTE VAGINAL RING 0.12-0.015 MG/24 HR)/P 5552 0 R/K 29412 0 R>> endobj 15885 0 obj <>/Alt(\(etonogestrel-ethinyl estradiol\))/P 5552 0 R/K 29413 0 R>> endobj 15886 0 obj <>/Alt($0)/P 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0 obj <>/Alt($0)/P 5557 0 R/K 29425 0 R>> endobj 15898 0 obj <>/Alt($0 COPAY IF DAY SUPPLY LIMITED TO 90; QL \(1 ML per 84 days\))/P 5557 0 R/K 29426 0 R>> endobj 15899 0 obj <>/Alt(\(Begin italic\) medroxyprogesterone intramuscular syringe \(End italic\) \(Begin italic\) 150 mg/ml \(End italic\))/P 5558 0 R/K 29427 0 R>> endobj 15900 0 obj <>/Alt(\(Depo-Provera\))/P 5558 0 R/K 29428 0 R>> endobj 15901 0 obj <>/Alt($0)/P 5558 0 R/K 29429 0 R>> endobj 15902 0 obj <>/Alt($0 COPAY IF DAY SUPPLY LIMITED TO 90; QL \(1 ML per 84 days\))/P 5558 0 R/K 29430 0 R>> endobj 15903 0 obj <>/Alt(\(Begin bold\) Contraceptives,Intravaginal \(End bold\))/P 5559 0 R/K 29431 0 R>> endobj 15904 0 obj <>/Alt(PHEXXI VAGINAL GEL 1.8-1-0.4 %)/P 5560 0 R/K 29432 0 R>> endobj 15905 0 obj <>/Alt($0)/P 5560 0 R/K 29433 0 R>> endobj 15906 0 obj <>/Alt(VAGINAL CONTRACEPTIVE FILM VAGINAL FILM 28 %)/P 5561 0 R/K 29434 0 R>> endobj 15907 0 obj <>/Alt($0)/P 5561 0 R/K 29435 0 R>> endobj 15908 0 obj <>/Alt(VCF 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endobj 15934 0 obj <>/Alt(AMETHIA ORAL TABLETS,DOSE PACK,3 MONTH 0.15 MG-30 MCG \(84\)/10 MCG \(7\))/P 5571 0 R/K 29462 0 R>> endobj 15935 0 obj <>/Alt(\(l norgest/e.estradiol-e.estrad\))/P 5571 0 R/K 29463 0 R>> endobj 15936 0 obj <>/Alt($0)/P 5571 0 R/K 29464 0 R>> endobj 15937 0 obj <>/Alt($0 COPAY IF QUANTITY 28 IN 28 DAYS; QL \(91 EA per 84 days\))/P 5571 0 R/K 29465 0 R>> endobj 15938 0 obj <>/Alt(AMETHYST \(28\) ORAL TABLET 90-20 MCG \(28\))/P 5572 0 R/K 29466 0 R>> endobj 15939 0 obj <>/Alt(\(levonorgestrel-ethinyl estrad\))/P 5572 0 R/K 29467 0 R>> endobj 15940 0 obj <>/Alt($0)/P 5572 0 R/K 29468 0 R>> endobj 15941 0 obj <>/Alt($0 COPAY IF QUANTITY 28 IN 28 DAYS)/P 5572 0 R/K 29469 0 R>> endobj 15942 0 obj <>/Alt(APRI ORAL TABLET 0.15-0.03 MG)/P 5573 0 R/K 29470 0 R>> endobj 15943 0 obj <>/Alt(\(desogestrel-ethinyl estradiol\))/P 5573 0 R/K 29471 0 R>> endobj 15944 0 obj <>/Alt($0)/P 5573 0 R/K 29472 0 R>> endobj 15945 0 obj <>/Alt($0 COPAY IF QUANTITY 28 IN 28 DAYS)/P 5573 0 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italic\) silver nitrate topical solution \(End italic\) \(Begin italic\) 0.5 %, 25 %, 50 % \(End italic\))/P 5967 0 R/K 30710 0 R>> endobj 17183 0 obj <>/Alt(Tier 1)/P 5967 0 R/K 30711 0 R>> endobj 17184 0 obj <>/Alt(STRONG IODINE TOPICAL SOLUTION 5-10 %)/P 5968 0 R/K 30712 0 R>> endobj 17185 0 obj <>/Alt(\(iodine-potassium iodide\))/P 5968 0 R/K 30713 0 R>> endobj 17186 0 obj <>/Alt(Tier 1)/P 5968 0 R/K 30714 0 R>> endobj 17187 0 obj <>/Alt(\(Begin bold\) Vitamin A Derivatives \(End bold\))/P 5969 0 R/K 30715 0 R>> endobj 17188 0 obj <>/Alt(\(Begin italic\) adapalene topical cream \(End italic\) \(Begin italic\) 0.1 % \(End italic\))/P 5970 0 R/K 30716 0 R>> endobj 17189 0 obj <>/Alt(\(Differin\))/P 5970 0 R/K 30717 0 R>> endobj 17190 0 obj <>/Alt(Tier 1)/P 5970 0 R/K 30718 0 R>> endobj 17191 0 obj <>/Alt(\(Begin italic\) adapalene topical gel \(End italic\) \(Begin italic\) 0.3 % \(End italic\))/P 5971 0 R/K 30719 0 R>> endobj 17192 0 obj <>/Alt(Tier 1)/P 5971 0 R/K 30720 0 R>> endobj 17193 0 obj <>/Alt(\(Begin italic\) adapalene topical gel with pump \(End italic\) \(Begin italic\) 0.3 % \(End italic\))/P 5972 0 R/K 30721 0 R>> endobj 17194 0 obj <>/Alt(\(Differin\))/P 5972 0 R/K 30722 0 R>> endobj 17195 0 obj <>/Alt(Tier 1)/P 5972 0 R/K 30723 0 R>> endobj 17196 0 obj <>/Alt(\(Begin italic\) adapalene topical lotion \(End italic\) \(Begin italic\) 0.1 % \(End italic\))/P 5973 0 R/K 30724 0 R>> endobj 17197 0 obj <>/Alt(\(Differin\))/P 5973 0 R/K 30725 0 R>> endobj 17198 0 obj <>/Alt(Tier 1)/P 5973 0 R/K 30726 0 R>> endobj 17199 0 obj <>/Alt(Age \(Max 39 Years\))/P 5973 0 R/K 30727 0 R>> endobj 17200 0 obj <>/Alt(ALTRENO TOPICAL LOTION 0.05 %)/P 5974 0 R/K 30728 0 R>> endobj 17201 0 obj <>/Alt(Tier 3)/P 5974 0 R/K 30729 0 R>> endobj 17202 0 obj <>/Alt(AVITA TOPICAL CREAM 0.025 %)/P 5975 0 R/K 30730 0 R>> endobj 17203 0 obj <>/Alt(\(tretinoin\))/P 5975 0 R/K 30731 0 R>> endobj 17204 0 obj <>/Alt(Tier 1)/P 5975 0 R/K 30732 0 R>> endobj 17205 0 obj <>/Alt(AVITA 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endobj 17305 0 obj <>/Alt(DELIBON TOPICAL CREAM 2-2.5 %)/P 6012 0 R/K 30833 0 R>> endobj 17306 0 obj <>/Alt(\(ketoconazole-hydrocortisone\))/P 6012 0 R/K 30834 0 R>> endobj 17307 0 obj <>/Alt(Tier 3)/P 6012 0 R/K 30835 0 R>> endobj 17308 0 obj <>/Alt(DIONARIS TOPICAL SHAMPOO 0.77-0.05-3 %)/P 6013 0 R/K 30836 0 R>> endobj 17309 0 obj <>/Alt(\(ciclopirox-clobetasol-salicyl\))/P 6013 0 R/K 30837 0 R>> endobj 17310 0 obj <>/Alt(Tier 3)/P 6013 0 R/K 30838 0 R>> endobj 17311 0 obj <>/Alt(DIVENDO TOPICAL SHAMPOO 0.77-0.05 %)/P 6014 0 R/K 30839 0 R>> endobj 17312 0 obj <>/Alt(\(ciclopirox-clobetasol\))/P 6014 0 R/K 30840 0 R>> endobj 17313 0 obj <>/Alt(Tier 3)/P 6014 0 R/K 30841 0 R>> endobj 17314 0 obj <>/Alt(HAXCHLO TOPICAL SHAMPOO 0.77-0.05 %)/P 6015 0 R/K 30842 0 R>> endobj 17315 0 obj <>/Alt(\(ciclopirox-clobetasol\))/P 6015 0 R/K 30843 0 R>> endobj 17316 0 obj <>/Alt(Tier 3)/P 6015 0 R/K 30844 0 R>> endobj 17317 0 obj <>/Alt(HAXCHLODREX TOPICAL SHAMPOO 0.77-0.05-3 %)/P 6016 0 R/K 30845 0 R>> endobj 17318 0 obj <>/Alt(\(ciclopirox-clobetasol-salicyl\))/P 6016 0 R/K 30846 0 R>> endobj 17319 0 obj <>/Alt(Tier 3)/P 6016 0 R/K 30847 0 R>> endobj 17320 0 obj <>/Alt(PHEYO TOPICAL CREAM 2-2.5 %)/P 6017 0 R/K 30848 0 R>> endobj 17321 0 obj <>/Alt(\(ketoconazole-hydrocortisone\))/P 6017 0 R/K 30849 0 R>> endobj 17322 0 obj <>/Alt(Tier 3)/P 6017 0 R/K 30850 0 R>> endobj 17323 0 obj <>/Alt(\(Begin bold\) Topical Antifungal-Antibiotic-Anti-Inflamm Steroid \(End bold\))/P 6018 0 R/K 30851 0 R>> endobj 17324 0 obj <>/Alt(DAZINIA TOPICAL CREAM 2-1-2.5 %)/P 6019 0 R/K 30852 0 R>> endobj 17325 0 obj <>/Alt(\(ketoconazole-iodoquinol-hc\))/P 6019 0 R/K 30853 0 R>> endobj 17326 0 obj <>/Alt(Tier 3)/P 6019 0 R/K 30854 0 R>> endobj 17327 0 obj <>/Alt(PHEODOYO TOPICAL CREAM 2-1-2.5 %)/P 6020 0 R/K 30855 0 R>> endobj 17328 0 obj <>/Alt(\(ketoconazole-iodoquinol-hc\))/P 6020 0 R/K 30856 0 R>> endobj 17329 0 obj <>/Alt(Tier 3)/P 6020 0 R/K 30857 0 R>> endobj 17330 0 obj <>/Alt(\(Begin bold\) Topical Antifungals \(End bold\))/P 6021 0 R/K 30858 0 R>> endobj 17331 0 obj <>/Alt(CICLODAN KIT TOPICAL COMBO PACK 0.77 %)/P 6022 0 R/K 30859 0 R>> endobj 17332 0 obj <>/Alt(Tier 3)/P 6022 0 R/K 30860 0 R>> endobj 17333 0 obj <>/Alt(\(Begin italic\) ciclopirox topical cream \(End italic\) \(Begin italic\) 0.77 % \(End italic\))/P 6023 0 R/K 30861 0 R>> endobj 17334 0 obj <>/Alt(\(Ciclodan\))/P 6023 0 R/K 30862 0 R>> endobj 17335 0 obj <>/Alt(Tier 1)/P 6023 0 R/K 30863 0 R>> endobj 17336 0 obj <>/Alt(QL \(180 GM per 1 FILL\))/P 6023 0 R/K 30864 0 R>> endobj 17337 0 obj <>/Alt(\(Begin italic\) ciclopirox topical gel \(End italic\) \(Begin italic\) 0.77 % \(End italic\))/P 6024 0 R/K 30865 0 R>> endobj 17338 0 obj <>/Alt(Tier 1)/P 6024 0 R/K 30866 0 R>> endobj 17339 0 obj <>/Alt(\(Begin italic\) ciclopirox topical shampoo \(End italic\) \(Begin italic\) 1 % \(End italic\))/P 6025 0 R/K 30867 0 R>> endobj 17340 0 obj <>/Alt(Tier 1)/P 6025 0 R/K 30868 0 R>> endobj 17341 0 obj <>/Alt(\(Begin italic\) ciclopirox topical solution \(End italic\) \(Begin italic\) 8 % \(End italic\))/P 6026 0 R/K 30869 0 R>> endobj 17342 0 obj <>/Alt(\(Ciclodan\))/P 6026 0 R/K 30870 0 R>> endobj 17343 0 obj <>/Alt(Tier 1)/P 6026 0 R/K 30871 0 R>> endobj 17344 0 obj <>/Alt(QL \(19.8 ML per 1 FILL\))/P 6026 0 R/K 30872 0 R>> endobj 17345 0 obj <>/Alt(\(Begin italic\) ciclopirox topical suspension \(End italic\) \(Begin italic\) 0.77 % \(End italic\))/P 6027 0 R/K 30873 0 R>> endobj 17346 0 obj <>/Alt(\(Loprox \(as olamine\)\))/P 6027 0 R/K 30874 0 R>> endobj 17347 0 obj <>/Alt(Tier 1)/P 6027 0 R/K 30875 0 R>> endobj 17348 0 obj <>/Alt(QL \(180 ML per 1 FILL\))/P 6027 0 R/K 30876 0 R>> endobj 17349 0 obj <>/Alt(\(Begin italic\) ciclopirox-ure-camph-menth-euc topical solution \(End italic\) \(Begin italic\) 8 % \(End italic\))/P 6028 0 R/K 30877 0 R>> endobj 17350 0 obj <>/Alt(\(Ciclodan Kit\))/P 6028 0 R/K 30878 0 R>> endobj 17351 0 obj <>/Alt(Tier 1)/P 6028 0 R/K 30879 0 R>> endobj 17352 0 obj <>/Alt(QL \(19.8 ML per 1 FILL\))/P 6028 0 R/K 30880 0 R>> endobj 17353 0 obj <>/Alt(\(Begin italic\) clotrimazole topical cream \(End italic\) \(Begin italic\) 1 % \(End italic\))/P 6029 0 R/K 30881 0 R>> endobj 17354 0 obj <>/Alt(\(Antifungal \(clotrimazole\)\))/P 6029 0 R/K 30882 0 R>> endobj 17355 0 obj <>/Alt(Tier 1)/P 6029 0 R/K 30883 0 R>> endobj 17356 0 obj <>/Alt(\(Begin italic\) clotrimazole topical solution \(End italic\) \(Begin italic\) 1 % \(End italic\))/P 6030 0 R/K 30884 0 R>> endobj 17357 0 obj <>/Alt(\(Athlete's Foot \(clotrimazole\)\))/P 6030 0 R/K 30885 0 R>> endobj 17358 0 obj <>/Alt(Tier 1)/P 6030 0 R/K 30886 0 R>> endobj 17359 0 obj <>/Alt(DAFILOR TOPICAL SHAMPOO 0.77-2 %)/P 6031 0 R/K 30887 0 R>> endobj 17360 0 obj <>/Alt(\(ciclopirox-salicylic acid\))/P 6031 0 R/K 30888 0 R>> endobj 17361 0 obj <>/Alt(Tier 3)/P 6031 0 R/K 30889 0 R>> endobj 17362 0 obj <>/Alt(DENVITA TOPICAL CREAM 2-4 %)/P 6032 0 R/K 30890 0 R>> endobj 17363 0 obj <>/Alt(\(ketoconazole-niacinamide\))/P 6032 0 R/K 30891 0 R>> endobj 17364 0 obj <>/Alt(Tier 3)/P 6032 0 R/K 30892 0 R>> endobj 17365 0 obj <>/Alt(DIFMETIOXRIME TOPICAL SOLUTION 4-2-1-4 %)/P 6033 0 R/K 30893 0 R>> endobj 17366 0 obj <>/Alt(\(flucona-ibuprof-itracon-terbin\))/P 6033 0 R/K 30894 0 R>> endobj 17367 0 obj <>/Alt(Tier 3)/P 6033 0 R/K 30895 0 R>> endobj 17368 0 obj <>/Alt(\(Begin italic\) econazole nitrate topical cream \(End italic\) \(Begin italic\) 1 % \(End italic\))/P 6034 0 R/K 30896 0 R>> endobj 17369 0 obj <>/Alt(Tier 1)/P 6034 0 R/K 30897 0 R>> endobj 17370 0 obj <>/Alt(QL \(170 GM per 1 FILL\))/P 6034 0 R/K 30898 0 R>> endobj 17371 0 obj <>/Alt(ECOZA TOPICAL FOAM 1 %)/P 6035 0 R/K 30899 0 R>> endobj 17372 0 obj <>/Alt(Tier 3)/P 6035 0 R/K 30900 0 R>> endobj 17373 0 obj <>/Alt(EXELDERM TOPICAL CREAM 1 %)/P 6036 0 R/K 30901 0 R>> endobj 17374 0 obj <>/Alt(\(sulconazole\))/P 6036 0 R/K 30902 0 R>> endobj 17375 0 obj <>/Alt(Tier 2)/P 6036 0 R/K 30903 0 R>> endobj 17376 0 obj <>/Alt(EXELDERM TOPICAL SOLUTION 1 %)/P 6037 0 R/K 30904 0 R>> endobj 17377 0 obj <>/Alt(\(sulconazole\))/P 6037 0 R/K 30905 0 R>> endobj 17378 0 obj <>/Alt(Tier 2)/P 6037 0 R/K 30906 0 R>> endobj 17379 0 obj <>/Alt(EXODERM TOPICAL LOTION 25-1 %)/P 6038 0 R/K 30907 0 R>> endobj 17380 0 obj <>/Alt(Tier 1)/P 6038 0 R/K 30908 0 R>> endobj 17381 0 obj <>/Alt(FENOVIA TOPICAL SOLUTION 4-2-1-4 %)/P 6039 0 R/K 30909 0 R>> endobj 17382 0 obj <>/Alt(\(flucona-ibuprof-itracon-terbin\))/P 6039 0 R/K 30910 0 R>> endobj 17383 0 obj <>/Alt(Tier 3)/P 6039 0 R/K 30911 0 R>> endobj 17384 0 obj <>/Alt(FERVINA TOPICAL LOTION 3-5-20 %)/P 6040 0 R/K 30912 0 R>> endobj 17385 0 obj <>/Alt(Tier 3)/P 6040 0 R/K 30913 0 R>> endobj 17386 0 obj <>/Alt(FIDILA TOPICAL SHAMPOO 2-2 %)/P 6041 0 R/K 30914 0 R>> endobj 17387 0 obj <>/Alt(Tier 3)/P 6041 0 R/K 30915 0 R>> endobj 17388 0 obj <>/Alt(FILOMA TOPICAL SOLUTION 8-1-1 %)/P 6042 0 R/K 30916 0 R>> endobj 17389 0 obj <>/Alt(Tier 3)/P 6042 0 R/K 30917 0 R>> endobj 17390 0 obj <>/Alt(FRIVO TOPICAL CREAM 1-4 %)/P 6043 0 R/K 30918 0 R>> endobj 17391 0 obj <>/Alt(\(econazole-niacinamide\))/P 6043 0 R/K 30919 0 R>> endobj 17392 0 obj <>/Alt(Tier 3)/P 6043 0 R/K 30920 0 R>> endobj 17393 0 obj <>/Alt(HAXDRAX TOPICAL SHAMPOO 0.77-2 %)/P 6044 0 R/K 30921 0 R>> endobj 17394 0 obj <>/Alt(\(ciclopirox-salicylic acid\))/P 6044 0 R/K 30922 0 R>> endobj 17395 0 obj <>/Alt(Tier 3)/P 6044 0 R/K 30923 0 R>> endobj 17396 0 obj <>/Alt(HEXIOUNYL TOPICAL LOTION 3-5-20 %)/P 6045 0 R/K 30924 0 R>> endobj 17397 0 obj <>/Alt(Tier 3)/P 6045 0 R/K 30925 0 R>> endobj 17398 0 obj <>/Alt(HIXDEFRIMA TOPICAL SOLUTION 8-1-1 %)/P 6046 0 R/K 30926 0 R>> endobj 17399 0 obj <>/Alt(Tier 3)/P 6046 0 R/K 30927 0 R>> endobj 17400 0 obj <>/Alt(IMIOXIA TOPICAL CREAM 1-4 %)/P 6047 0 R/K 30928 0 R>> endobj 17401 0 obj <>/Alt(\(econazole-niacinamide\))/P 6047 0 R/K 30929 0 R>> endobj 17402 0 obj <>/Alt(Tier 3)/P 6047 0 R/K 30930 0 R>> endobj 17403 0 obj <>/Alt(\(Begin italic\) 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<>/Alt(Tier 1)/P 6055 0 R/K 30953 0 R>> endobj 17426 0 obj <>/Alt(\(Begin italic\) naftifine topical cream \(End italic\) \(Begin italic\) 2 % \(End italic\))/P 6056 0 R/K 30954 0 R>> endobj 17427 0 obj <>/Alt(Tier 1)/P 6056 0 R/K 30955 0 R>> endobj 17428 0 obj <>/Alt(QL \(180 GM per 1 FILL\))/P 6056 0 R/K 30956 0 R>> endobj 17429 0 obj <>/Alt(\(Begin italic\) naftifine topical gel \(End italic\) \(Begin italic\) 2 % \(End italic\))/P 6057 0 R/K 30957 0 R>> endobj 17430 0 obj <>/Alt(\(Naftin\))/P 6057 0 R/K 30958 0 R>> endobj 17431 0 obj <>/Alt(Tier 1)/P 6057 0 R/K 30959 0 R>> endobj 17432 0 obj <>/Alt(NYAMYC TOPICAL POWDER 100,000 UNIT/GRAM)/P 6058 0 R/K 30960 0 R>> endobj 17433 0 obj <>/Alt(\(nystatin\))/P 6058 0 R/K 30961 0 R>> endobj 17434 0 obj <>/Alt(Tier 1)/P 6058 0 R/K 30962 0 R>> endobj 17435 0 obj <>/Alt(\(Begin italic\) nystatin topical cream \(End italic\) \(Begin italic\) 100,000 unit/gram \(End italic\))/P 6059 0 R/K 30963 0 R>> endobj 17436 0 obj <>/Alt(Tier 1)/P 6059 0 R/K 30964 0 R>> endobj 17437 0 obj <>/Alt(\(Begin italic\) nystatin topical ointment \(End italic\) \(Begin italic\) 100,000 unit/gram \(End italic\))/P 6060 0 R/K 30965 0 R>> endobj 17438 0 obj <>/Alt(Tier 1)/P 6060 0 R/K 30966 0 R>> endobj 17439 0 obj <>/Alt(QL \(90 GM per 1 FILL\))/P 6060 0 R/K 30967 0 R>> endobj 17440 0 obj <>/Alt(\(Begin italic\) nystatin topical powder \(End italic\) \(Begin italic\) 100,000 unit/gram \(End italic\))/P 6061 0 R/K 30968 0 R>> endobj 17441 0 obj <>/Alt(\(Klayesta\))/P 6061 0 R/K 30969 0 R>> endobj 17442 0 obj <>/Alt(Tier 1)/P 6061 0 R/K 30970 0 R>> endobj 17443 0 obj <>/Alt(\(Begin italic\) nystatin-triamcinolone topical cream \(End italic\) \(Begin italic\) 100,000-0.1 unit/g-% \(End italic\))/P 6062 0 R/K 30971 0 R>> endobj 17444 0 obj <>/Alt(Tier 1)/P 6062 0 R/K 30972 0 R>> endobj 17445 0 obj <>/Alt(\(Begin italic\) nystatin-triamcinolone topical ointment \(End italic\) \(Begin italic\) 100,000-0.1 unit/gram-% \(End italic\))/P 6063 0 R/K 30973 0 R>> endobj 17446 0 obj <>/Alt(Tier 1)/P 6063 0 R/K 30974 0 R>> endobj 17447 0 obj <>/Alt(QL \(180 GM per 1 FILL\))/P 6063 0 R/K 30975 0 R>> endobj 17448 0 obj <>/Alt(NYSTOP TOPICAL POWDER 100,000 UNIT/GRAM)/P 6064 0 R/K 30976 0 R>> endobj 17449 0 obj <>/Alt(\(nystatin\))/P 6064 0 R/K 30977 0 R>> endobj 17450 0 obj <>/Alt(Tier 1)/P 6064 0 R/K 30978 0 R>> endobj 17451 0 obj <>/Alt(\(Begin italic\) oxiconazole topical cream \(End italic\) \(Begin italic\) 1 % \(End italic\))/P 6065 0 R/K 30979 0 R>> endobj 17452 0 obj <>/Alt(Tier 1)/P 6065 0 R/K 30980 0 R>> endobj 17453 0 obj <>/Alt(QL \(180 GM per 1 FILL\))/P 6065 0 R/K 30981 0 R>> endobj 17454 0 obj <>/Alt(OXISTAT TOPICAL LOTION 1 %)/P 6066 0 R/K 30982 0 R>> endobj 17455 0 obj <>/Alt(Tier 3)/P 6066 0 R/K 30983 0 R>> endobj 17456 0 obj <>/Alt(PHEDRAX TOPICAL SHAMPOO 2-2 %)/P 6067 0 R/K 30984 0 R>> endobj 17457 0 obj <>/Alt(Tier 3)/P 6067 0 R/K 30985 0 R>> endobj 17458 0 obj <>/Alt(PHEOXIA TOPICAL CREAM 2-4 %)/P 6068 0 R/K 30986 0 R>> endobj 17459 0 obj <>/Alt(\(ketoconazole-niacinamide\))/P 6068 0 R/K 30987 0 R>> endobj 17460 0 obj <>/Alt(Tier 3)/P 6068 0 R/K 30988 0 R>> endobj 17461 0 obj <>/Alt(\(Begin italic\) sulconazole topical cream \(End italic\) \(Begin italic\) 1 % \(End italic\))/P 6069 0 R/K 30989 0 R>> endobj 17462 0 obj <>/Alt(\(Exelderm\))/P 6069 0 R/K 30990 0 R>> endobj 17463 0 obj <>/Alt(Tier 1)/P 6069 0 R/K 30991 0 R>> endobj 17464 0 obj <>/Alt(\(Begin italic\) sulconazole topical solution \(End italic\) \(Begin italic\) 1 % \(End italic\))/P 6070 0 R/K 30992 0 R>> endobj 17465 0 obj <>/Alt(\(Exelderm\))/P 6070 0 R/K 30993 0 R>> endobj 17466 0 obj <>/Alt(Tier 1)/P 6070 0 R/K 30994 0 R>> endobj 17467 0 obj <>/Alt(\(Begin italic\) tavaborole topical solution with applicator \(End italic\) \(Begin italic\) 5 % \(End italic\))/P 6071 0 R/K 30995 0 R>> endobj 17468 0 obj <>/Alt(Tier 1)/P 6071 0 R/K 30996 0 R>> endobj 17469 0 obj <>/Alt(PA)/P 6071 0 R/K 30997 0 R>> endobj 17470 0 obj <>/Alt(\(Begin bold\) Topical Antiparasitics \(End bold\))/P 6072 0 R/K 30998 0 R>> endobj 17471 0 obj <>/Alt(\(Begin italic\) malathion topical lotion \(End italic\) \(Begin italic\) 0.5 % \(End italic\))/P 6073 0 R/K 30999 0 R>> endobj 17472 0 obj <>/Alt(\(Ovide\))/P 6073 0 R/K 31000 0 R>> endobj 17473 0 obj <>/Alt(Tier 1)/P 6073 0 R/K 31001 0 R>> endobj 17474 0 obj <>/Alt(\(Begin italic\) permethrin topical cream \(End italic\) \(Begin italic\) 5 % \(End italic\))/P 6074 0 R/K 31002 0 R>> endobj 17475 0 obj <>/Alt(\(Elimite\))/P 6074 0 R/K 31003 0 R>> endobj 17476 0 obj <>/Alt(Tier 1)/P 6074 0 R/K 31004 0 R>> endobj 17477 0 obj <>/Alt(\(Begin italic\) spinosad topical suspension \(End italic\) \(Begin italic\) 0.9 % \(End italic\))/P 6075 0 R/K 31005 0 R>> endobj 17478 0 obj <>/Alt(\(Natroba\))/P 6075 0 R/K 31006 0 R>> endobj 17479 0 obj <>/Alt(Tier 1)/P 6075 0 R/K 31007 0 R>> endobj 17480 0 obj <>/Alt(ULESFIA TOPICAL LOTION 5 %)/P 6076 0 R/K 31008 0 R>> endobj 17481 0 obj <>/Alt(Tier 3)/P 6076 0 R/K 31009 0 R>> endobj 17482 0 obj <>/Alt(\(Begin bold\) Topical Antivirals \(End bold\))/P 6077 0 R/K 31010 0 R>> endobj 17483 0 obj <>/Alt(\(Begin italic\) acyclovir topical ointment \(End italic\) \(Begin italic\) 5 % \(End italic\))/P 6078 0 R/K 31011 0 R>> endobj 17484 0 obj <>/Alt(\(Zovirax\))/P 6078 0 R/K 31012 0 R>> endobj 17485 0 obj <>/Alt(Tier 1)/P 6078 0 R/K 31013 0 R>> endobj 17486 0 obj <>/Alt(\(Begin bold\) Topical Pleuromutilin Derivatives \(End bold\))/P 6079 0 R/K 31014 0 R>> endobj 17487 0 obj <>/Alt(ALTABAX TOPICAL OINTMENT 1 %)/P 6080 0 R/K 31015 0 R>> endobj 17488 0 obj <>/Alt(Tier 3)/P 6080 0 R/K 31016 0 R>> endobj 17489 0 obj <>/Alt(ST: Requires prior prescription for Mupirocin ointment within the past 120 days)/P 6080 0 R/K 31017 0 R>> endobj 17490 0 obj <>/Alt(\(Begin bold\) Topical Sulfonamides \(End bold\))/P 6081 0 R/K 31018 0 R>> endobj 17491 0 obj <>/Alt(ABENOR HP TOPICAL LOTION 15-4 %)/P 6082 0 R/K 31019 0 R>> endobj 17492 0 obj <>/Alt(Tier 3)/P 6082 0 R/K 31020 0 R>> endobj 17493 0 obj <>/Alt(ABENOR TOPICAL CREAM 10-4 %)/P 6083 0 R/K 31021 0 R>> endobj 17494 0 obj <>/Alt(\(sulfacetamide-niacinamide\))/P 6083 0 R/K 31022 0 R>> endobj 17495 0 obj <>/Alt(Tier 3)/P 6083 0 R/K 31023 0 R>> endobj 17496 0 obj <>/Alt(CLEANSING WASH TOPICAL CLEANSER 10-4-10 %)/P 6084 0 R/K 31024 0 R>> endobj 17497 0 obj <>/Alt(\(sulfacetamide sod-sulfur-urea\))/P 6084 0 R/K 31025 0 R>> endobj 17498 0 obj <>/Alt(Tier 1)/P 6084 0 R/K 31026 0 R>> endobj 17499 0 obj <>/Alt(ECEOXIA TOPICAL CREAM 10-4 %)/P 6085 0 R/K 31027 0 R>> endobj 17500 0 obj <>/Alt(\(sulfacetamide-niacinamide\))/P 6085 0 R/K 31028 0 R>> endobj 17501 0 obj <>/Alt(Tier 3)/P 6085 0 R/K 31029 0 R>> endobj 17502 0 obj <>/Alt(\(Begin italic\) mafenide acetate topical packet \(End italic\) \(Begin italic\) 50 gram \(End italic\))/P 6086 0 R/K 31030 0 R>> endobj 17503 0 obj <>/Alt(\(Sulfamylon\))/P 6086 0 R/K 31031 0 R>> endobj 17504 0 obj <>/Alt(Tier 1)/P 6086 0 R/K 31032 0 R>> endobj 17505 0 obj <>/Alt(OXIAICE TOPICAL LOTION 15-4 %)/P 6087 0 R/K 31033 0 R>> endobj 17506 0 obj <>/Alt(Tier 3)/P 6087 0 R/K 31034 0 R>> endobj 17507 0 obj <>/Alt(ROSULA TOPICAL CLEANSER 10-4.5 %)/P 6088 0 R/K 31035 0 R>> endobj 17508 0 obj <>/Alt(Tier 3)/P 6088 0 R/K 31036 0 R>> endobj 17509 0 obj <>/Alt(\(Begin italic\) silver sulfadiazine topical cream \(End italic\) \(Begin italic\) 1 % \(End italic\))/P 6089 0 R/K 31037 0 R>> endobj 17510 0 obj <>/Alt(\(SSD\))/P 6089 0 R/K 31038 0 R>> endobj 17511 0 obj <>/Alt(Tier 1)/P 6089 0 R/K 31039 0 R>> endobj 17512 0 obj <>/Alt(SSD TOPICAL CREAM 1 %)/P 6090 0 R/K 31040 0 R>> endobj 17513 0 obj <>/Alt(\(silver sulfadiazine\))/P 6090 0 R/K 31041 0 R>> endobj 17514 0 obj <>/Alt(Tier 1)/P 6090 0 R/K 31042 0 R>> endobj 17515 0 obj <>/Alt(\(Begin italic\) sulfacetamide sodium-sulfur topical cleanser \(End italic\) \(Begin italic\) 10-2 % \(End italic\))/P 6091 0 R/K 31043 0 R>> endobj 17516 0 obj <>/Alt(\(Avar LS\))/P 6091 0 R/K 31044 0 R>> endobj 17517 0 obj <>/Alt(Tier 1)/P 6091 0 R/K 31045 0 R>> endobj 17518 0 obj <>/Alt(\(Begin italic\) sulfacetamide sodium-sulfur topical cleanser \(End italic\) \(Begin italic\) 10-5 % \(w/w\) \(End italic\))/P 6092 0 R/K 31046 0 R>> endobj 17519 0 obj <>/Alt(\(Avar\))/P 6092 0 R/K 31047 0 R>> endobj 17520 0 obj <>/Alt(Tier 1)/P 6092 0 R/K 31048 0 R>> endobj 17521 0 obj <>/Alt(QL \(1419 GM per 1 FILL\))/P 6092 0 R/K 31049 0 R>> endobj 17522 0 obj <>/Alt(\(Begin italic\) sulfacetamide sodium-sulfur topical cleanser \(End italic\) \(Begin italic\) 8-4 % \(End italic\))/P 6093 0 R/K 31050 0 R>> endobj 17523 0 obj <>/Alt(Tier 1)/P 6093 0 R/K 31051 0 R>> endobj 17524 0 obj <>/Alt(\(Begin italic\) sulfacetamide sodium-sulfur topical cleanser \(End italic\) \(Begin italic\) 9.8-4.8 % \(End italic\))/P 6094 0 R/K 31052 0 R>> endobj 17525 0 obj <>/Alt(\(Plexion\))/P 6094 0 R/K 31053 0 R>> endobj 17526 0 obj <>/Alt(Tier 1)/P 6094 0 R/K 31054 0 R>> endobj 17527 0 obj <>/Alt(\(Begin italic\) sulfacetamide sodium-sulfur topical cleanser \(End italic\) \(Begin italic\) 9-4 % \(End italic\))/P 6095 0 R/K 31055 0 R>> endobj 17528 0 obj <>/Alt(\(Sumaxin\))/P 6095 0 R/K 31056 0 R>> endobj 17529 0 obj <>/Alt(Tier 1)/P 6095 0 R/K 31057 0 R>> endobj 17530 0 obj <>/Alt(\(Begin italic\) sulfacetamide sodium-sulfur topical cleanser \(End italic\) \(Begin italic\) 9-4.5 % \(End italic\))/P 6096 0 R/K 31058 0 R>> endobj 17531 0 obj <>/Alt(\(Sumadan\))/P 6096 0 R/K 31059 0 R>> endobj 17532 0 obj <>/Alt(Tier 1)/P 6096 0 R/K 31060 0 R>> endobj 17533 0 obj <>/Alt(\(Begin italic\) sulfacetamide sodium-sulfur topical pads, medicated \(End italic\) \(Begin italic\) 9.8-4.8 % \(End italic\))/P 6097 0 R/K 31061 0 R>> endobj 17534 0 obj <>/Alt(\(Plexion Cleansing Cloths\))/P 6097 0 R/K 31062 0 R>> endobj 17535 0 obj <>/Alt(Tier 1)/P 6097 0 R/K 31063 0 R>> endobj 17536 0 obj <>/Alt(\(Begin italic\) sulfacetamide sod-sulfur-urea topical cleanser \(End italic\) \(Begin italic\) 10-5-10 % \(End italic\))/P 6098 0 R/K 31064 0 R>> endobj 17537 0 obj <>/Alt(Tier 1)/P 6098 0 R/K 31065 0 R>> endobj 17538 0 obj <>/Alt(QL \(1419 ML per 1 FILL\))/P 6098 0 R/K 31066 0 R>> endobj 17539 0 obj <>/Alt(SULFAMYLON TOPICAL CREAM 85 MG/G)/P 6099 0 R/K 31067 0 R>> endobj 17540 0 obj <>/Alt(Tier 3)/P 6099 0 R/K 31068 0 R>> endobj 17541 0 obj <>/Alt(SULFAMYLON TOPICAL PACKET 50 GRAM)/P 6100 0 R/K 31069 0 R>> endobj 17542 0 obj <>/Alt(\(mafenide acetate\))/P 6100 0 R/K 31070 0 R>> endobj 17543 0 obj <>/Alt(Tier 3)/P 6100 0 R/K 31071 0 R>> endobj 17544 0 obj <>/Alt(SUMADAN XLT TOPICAL COMBO PACK,CLEANSER AND CREAM 9 %-4.5 % -SPF 25)/P 6101 0 R/K 31072 0 R>> endobj 17545 0 obj <>/Alt(\(sulfact na-sul-avobnz-otn-ocsa\))/P 6101 0 R/K 31073 0 R>> endobj 17546 0 obj <>/Alt(Tier 3)/P 6101 0 R/K 31074 0 R>> endobj 17547 0 obj <>/Alt(\(Begin bold\) Dermatology - Antiinflammatory \(End bold\))/P 6102 0 R/K 31075 0 R>> endobj 17548 0 obj <>/Alt(\(Begin bold\) Interleukin-13 \(Il-13\) Inhibitors, Mab \(End bold\))/P 6103 0 R/K 31076 0 R>> endobj 17549 0 obj <>/Alt(ADBRY SUBCUTANEOUS AUTO-INJECTOR 300 MG/2 ML)/P 6104 0 R/K 31077 0 R>> endobj 17550 0 obj <>/Alt(Tier 2)/P 6104 0 R/K 31078 0 R>> endobj 17551 0 obj <>/Alt(PA; SP)/P 6104 0 R/K 31079 0 R>> endobj 17552 0 obj <>/Alt(ADBRY SUBCUTANEOUS SYRINGE 150 MG/ML)/P 6105 0 R/K 31080 0 R>> endobj 17553 0 obj <>/Alt(Tier 2)/P 6105 0 R/K 31081 0 R>> endobj 17554 0 obj <>/Alt(PA; SP)/P 6105 0 R/K 31082 0 R>> endobj 17555 0 obj <>/Alt(\(Begin bold\) Top. 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solution\) within the past 120 days)/P 6110 0 R/K 31092 0 R>> endobj 17565 0 obj <>/Alt(\(Begin bold\) Topical Anti-Inflammatory Steroidal \(End bold\))/P 6111 0 R/K 31093 0 R>> endobj 17566 0 obj <>/Alt(ACIOXIA TOPICAL GEL 0.1-0.5 %)/P 6112 0 R/K 31094 0 R>> endobj 17567 0 obj <>/Alt(Tier 3)/P 6112 0 R/K 31095 0 R>> endobj 17568 0 obj <>/Alt(ADVANCED ALLERGY COLLECT KIT TOPICAL KIT 2.5 %)/P 6113 0 R/K 31096 0 R>> endobj 17569 0 obj <>/Alt(Tier 1)/P 6113 0 R/K 31097 0 R>> endobj 17570 0 obj <>/Alt(ALA-CORT TOPICAL CREAM 1 %)/P 6114 0 R/K 31098 0 R>> endobj 17571 0 obj <>/Alt(\(hydrocortisone\))/P 6114 0 R/K 31099 0 R>> endobj 17572 0 obj <>/Alt(Tier 1)/P 6114 0 R/K 31100 0 R>> endobj 17573 0 obj <>/Alt(ALA-SCALP TOPICAL LOTION 2 %)/P 6115 0 R/K 31101 0 R>> endobj 17574 0 obj <>/Alt(\(hydrocortisone\))/P 6115 0 R/K 31102 0 R>> endobj 17575 0 obj <>/Alt(Tier 1)/P 6115 0 R/K 31103 0 R>> endobj 17576 0 obj <>/Alt(ST: Requires prior prescription for Hydrocortisone 2.5% lotion within the past 120 days)/P 6115 0 R/K 31104 0 R>> endobj 17577 0 obj <>/Alt(\(Begin italic\) alclometasone topical cream \(End italic\) \(Begin italic\) 0.05 % \(End italic\))/P 6116 0 R/K 31105 0 R>> endobj 17578 0 obj <>/Alt(Tier 1)/P 6116 0 R/K 31106 0 R>> endobj 17579 0 obj <>/Alt(\(Begin italic\) alclometasone topical ointment \(End italic\) \(Begin italic\) 0.05 % \(End italic\))/P 6117 0 R/K 31107 0 R>> endobj 17580 0 obj <>/Alt(Tier 1)/P 6117 0 R/K 31108 0 R>> endobj 17581 0 obj <>/Alt(\(Begin italic\) amcinonide topical cream \(End italic\) \(Begin italic\) 0.1 % \(End italic\))/P 6118 0 R/K 31109 0 R>> endobj 17582 0 obj <>/Alt(Tier 1)/P 6118 0 R/K 31110 0 R>> endobj 17583 0 obj <>/Alt(ST: Requires prior prescription for Betamethasone 0.1% ointment, Fluticasone 0.005% ointment, Mometasone 0.1% ointment, or Triamcinolone 0.5% ointment or cream within the past 120 days)/P 6118 0 R/K 31111 0 R>> endobj 17584 0 obj <>/Alt(\(Begin italic\) betamethasone dipropionate topical cream \(End 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6123 0 R/K 31121 0 R>> endobj 17594 0 obj <>/Alt(Tier 1)/P 6123 0 R/K 31122 0 R>> endobj 17595 0 obj <>/Alt(\(Begin italic\) betamethasone valerate topical lotion \(End italic\) \(Begin italic\) 0.1 % \(End italic\))/P 6124 0 R/K 31123 0 R>> endobj 17596 0 obj <>/Alt(Tier 1)/P 6124 0 R/K 31124 0 R>> endobj 17597 0 obj <>/Alt(\(Begin italic\) betamethasone valerate topical ointment \(End italic\) \(Begin italic\) 0.1 % \(End italic\))/P 6125 0 R/K 31125 0 R>> endobj 17598 0 obj <>/Alt(Tier 1)/P 6125 0 R/K 31126 0 R>> endobj 17599 0 obj <>/Alt(\(Begin italic\) betamethasone, augmented topical cream \(End italic\) \(Begin italic\) 0.05 % \(End italic\))/P 6126 0 R/K 31127 0 R>> endobj 17600 0 obj <>/Alt(Tier 1)/P 6126 0 R/K 31128 0 R>> endobj 17601 0 obj <>/Alt(\(Begin italic\) betamethasone, augmented topical gel \(End italic\) \(Begin italic\) 0.05 % \(End italic\))/P 6127 0 R/K 31129 0 R>> endobj 17602 0 obj <>/Alt(Tier 1)/P 6127 0 R/K 31130 0 R>> endobj 17603 0 obj <>/Alt(\(Begin 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6132 0 R/K 31142 0 R>> endobj 17615 0 obj <>/Alt(Tier 3)/P 6132 0 R/K 31143 0 R>> endobj 17616 0 obj <>/Alt(CHLOOXIA TOPICAL OINTMENT 0.05-4 %)/P 6133 0 R/K 31144 0 R>> endobj 17617 0 obj <>/Alt(\(clobetasol-niacinamide\))/P 6133 0 R/K 31145 0 R>> endobj 17618 0 obj <>/Alt(Tier 3)/P 6133 0 R/K 31146 0 R>> endobj 17619 0 obj <>/Alt(CHLOOXIA TOPICAL SOLUTION 0.05-4 %)/P 6134 0 R/K 31147 0 R>> endobj 17620 0 obj <>/Alt(\(clobetasol-niacinamide\))/P 6134 0 R/K 31148 0 R>> endobj 17621 0 obj <>/Alt(Tier 3)/P 6134 0 R/K 31149 0 R>> endobj 17622 0 obj <>/Alt(\(Begin italic\) clobetasol scalp solution \(End italic\) \(Begin italic\) 0.05 % \(End italic\))/P 6135 0 R/K 31150 0 R>> endobj 17623 0 obj <>/Alt(Tier 1)/P 6135 0 R/K 31151 0 R>> endobj 17624 0 obj <>/Alt(\(Begin italic\) clobetasol topical cream \(End italic\) \(Begin italic\) 0.05 % \(End italic\))/P 6136 0 R/K 31152 0 R>> endobj 17625 0 obj <>/Alt(Tier 1)/P 6136 0 R/K 31153 0 R>> endobj 17626 0 obj <>/Alt(\(Begin italic\) clobetasol 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0.05 % \(End italic\))/P 6141 0 R/K 31164 0 R>> endobj 17637 0 obj <>/Alt(\(Clobex\))/P 6141 0 R/K 31165 0 R>> endobj 17638 0 obj <>/Alt(Tier 1)/P 6141 0 R/K 31166 0 R>> endobj 17639 0 obj <>/Alt(\(Begin italic\) clobetasol topical spray,non-aerosol \(End italic\) \(Begin italic\) 0.05 % \(End italic\))/P 6142 0 R/K 31167 0 R>> endobj 17640 0 obj <>/Alt(\(Clobex\))/P 6142 0 R/K 31168 0 R>> endobj 17641 0 obj <>/Alt(Tier 1)/P 6142 0 R/K 31169 0 R>> endobj 17642 0 obj <>/Alt(\(Begin italic\) clobetasol-emollient topical cream \(End italic\) \(Begin italic\) 0.05 % \(End italic\))/P 6143 0 R/K 31170 0 R>> endobj 17643 0 obj <>/Alt(Tier 1)/P 6143 0 R/K 31171 0 R>> endobj 17644 0 obj <>/Alt(\(Begin italic\) clobetasol-emollient topical foam \(End italic\) \(Begin italic\) 0.05 % \(End italic\))/P 6144 0 R/K 31172 0 R>> endobj 17645 0 obj <>/Alt(\(Olux-E\))/P 6144 0 R/K 31173 0 R>> endobj 17646 0 obj <>/Alt(Tier 1)/P 6144 0 R/K 31174 0 R>> endobj 17647 0 obj <>/Alt(\(Begin italic\) clocortolone pivalate topical cream \(End italic\) \(Begin italic\) 0.1 % \(End italic\))/P 6145 0 R/K 31175 0 R>> endobj 17648 0 obj <>/Alt(Tier 1)/P 6145 0 R/K 31176 0 R>> endobj 17649 0 obj <>/Alt(ST: Requires prior prescription for Mometasone 0.1% cream/solution or Triamcinolone 0.1 % cream/ointment within the past 120 days)/P 6145 0 R/K 31177 0 R>> endobj 17650 0 obj <>/Alt(CLODAN KIT TOPICAL KIT,SHAMPOO AND CLEANSER 0.05 %)/P 6146 0 R/K 31178 0 R>> endobj 17651 0 obj <>/Alt(Tier 3)/P 6146 0 R/K 31179 0 R>> endobj 17652 0 obj <>/Alt(CORDRAN TAPE LARGE ROLL TOPICAL TAPE 4 MCG/CM2)/P 6147 0 R/K 31180 0 R>> endobj 17653 0 obj <>/Alt(Tier 3)/P 6147 0 R/K 31181 0 R>> endobj 17654 0 obj <>/Alt(ST: Requires prior prescription for Betamethasone augmented \(ointment, gel, lotion\), Clobetasol \(spray, lotion, gel, ointment, cream, solution\), Fluocinonide 0.1% cream, Halobetasol 0.05% \(cream, ointment\) within the past 120 days; QL \(2 EA per 30 days\))/P 6147 0 R/K 31182 0 R>> endobj 17655 0 obj <>/Alt(CORDRAN TOPICAL CREAM 0.025 %)/P 6148 0 R/K 31183 0 R>> endobj 17656 0 obj <>/Alt(Tier 3)/P 6148 0 R/K 31184 0 R>> endobj 17657 0 obj <>/Alt(ST: Requires prior prescription for a topical corticosteroid within the past 120 days)/P 6148 0 R/K 31185 0 R>> endobj 17658 0 obj <>/Alt(\(Begin italic\) desonide topical cream \(End italic\) \(Begin italic\) 0.05 % \(End italic\))/P 6149 0 R/K 31186 0 R>> endobj 17659 0 obj <>/Alt(\(DesOwen\))/P 6149 0 R/K 31187 0 R>> endobj 17660 0 obj <>/Alt(Tier 1)/P 6149 0 R/K 31188 0 R>> endobj 17661 0 obj <>/Alt(\(Begin italic\) desonide topical gel \(End italic\) \(Begin italic\) 0.05 % \(End italic\))/P 6150 0 R/K 31189 0 R>> endobj 17662 0 obj <>/Alt(Tier 1)/P 6150 0 R/K 31190 0 R>> endobj 17663 0 obj <>/Alt(ST: Requires prior prescription for Betamethasone \(0.05% lotion, 0.1% cream\), Desonide 0.05% ointment, Fluticasone 0.05% cream, Hydrocortisone 0.2% cream, or Triamcinolone \(0.1% lotion, 0.025% ointment\) within the past 120 days)/P 6150 0 R/K 31191 0 R>> endobj 17664 0 obj <>/Alt(\(Begin italic\) desonide topical lotion \(End italic\) \(Begin italic\) 0.05 % \(End italic\))/P 6151 0 R/K 31192 0 R>> endobj 17665 0 obj <>/Alt(Tier 1)/P 6151 0 R/K 31193 0 R>> endobj 17666 0 obj <>/Alt(\(Begin italic\) desonide topical ointment \(End italic\) \(Begin italic\) 0.05 % \(End italic\))/P 6152 0 R/K 31194 0 R>> endobj 17667 0 obj <>/Alt(Tier 1)/P 6152 0 R/K 31195 0 R>> endobj 17668 0 obj <>/Alt(\(Begin italic\) desoximetasone topical cream \(End italic\) \(Begin italic\) 0.05 %, 0.25 % \(End italic\))/P 6153 0 R/K 31196 0 R>> endobj 17669 0 obj <>/Alt(\(Topicort\))/P 6153 0 R/K 31197 0 R>> endobj 17670 0 obj <>/Alt(Tier 1)/P 6153 0 R/K 31198 0 R>> endobj 17671 0 obj <>/Alt(\(Begin italic\) desoximetasone topical gel \(End italic\) \(Begin italic\) 0.05 % \(End italic\))/P 6154 0 R/K 31199 0 R>> endobj 17672 0 obj <>/Alt(\(Topicort\))/P 6154 0 R/K 31200 0 R>> endobj 17673 0 obj <>/Alt(Tier 1)/P 6154 0 R/K 31201 0 R>> endobj 17674 0 obj <>/Alt(\(Begin italic\) desoximetasone topical ointment \(End italic\) \(Begin italic\) 0.05 %, 0.25 % \(End italic\))/P 6155 0 R/K 31202 0 R>> endobj 17675 0 obj <>/Alt(\(Topicort\))/P 6155 0 R/K 31203 0 R>> endobj 17676 0 obj <>/Alt(Tier 1)/P 6155 0 R/K 31204 0 R>> endobj 17677 0 obj <>/Alt(\(Begin italic\) desoximetasone topical spray,non-aerosol \(End italic\) \(Begin italic\) 0.25 % \(End italic\))/P 6156 0 R/K 31205 0 R>> endobj 17678 0 obj <>/Alt(\(Topicort\))/P 6156 0 R/K 31206 0 R>> endobj 17679 0 obj <>/Alt(Tier 1)/P 6156 0 R/K 31207 0 R>> endobj 17680 0 obj <>/Alt(ST: Requires prior prescription for Betamethasone augmented 0.05% \(cream, gel, lotion, ointment\), Clobetasol \(except foam/shampoo\), Desoximetasone \(cream, gel, ointment\), Fluocinonide \(cream, gel\), or Halobetasol \(cream, ointment\) within the past 120 days)/P 6156 0 R/K 31208 0 R>> endobj 17681 0 obj <>/Alt(DIVINIX TOPICAL CREAM 0.05-4 %)/P 6157 0 R/K 31209 0 R>> endobj 17682 0 obj <>/Alt(\(clobetasol-niacinamide\))/P 6157 0 R/K 31210 0 R>> endobj 17683 0 obj <>/Alt(Tier 3)/P 6157 0 R/K 31211 0 R>> endobj 17684 0 obj <>/Alt(DIVINIX TOPICAL OINTMENT 0.05-4 %)/P 6158 0 R/K 31212 0 R>> endobj 17685 0 obj <>/Alt(\(clobetasol-niacinamide\))/P 6158 0 R/K 31213 0 R>> endobj 17686 0 obj <>/Alt(Tier 3)/P 6158 0 R/K 31214 0 R>> endobj 17687 0 obj <>/Alt(DIVINIX TOPICAL SOLUTION 0.05-4 %)/P 6159 0 R/K 31215 0 R>> endobj 17688 0 obj <>/Alt(\(clobetasol-niacinamide\))/P 6159 0 R/K 31216 0 R>> endobj 17689 0 obj <>/Alt(Tier 3)/P 6159 0 R/K 31217 0 R>> endobj 17690 0 obj <>/Alt(DOMELA TOPICAL CREAM 0.01-4 %)/P 6160 0 R/K 31218 0 R>> endobj 17691 0 obj <>/Alt(\(fluocinolone-niacinamide\))/P 6160 0 R/K 31219 0 R>> endobj 17692 0 obj <>/Alt(Tier 3)/P 6160 0 R/K 31220 0 R>> endobj 17693 0 obj <>/Alt(DYNOMA TOPICAL CREAM 0.05-4 %)/P 6161 0 R/K 31221 0 R>> endobj 17694 0 obj <>/Alt(Tier 3)/P 6161 0 R/K 31222 0 R>> endobj 17695 0 obj <>/Alt(\(Begin italic\) fluocinolone and shower cap 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R>> endobj 17706 0 obj <>/Alt(\(Begin italic\) fluocinolone topical ointment \(End italic\) \(Begin italic\) 0.025 % \(End italic\))/P 6166 0 R/K 31234 0 R>> endobj 17707 0 obj <>/Alt(\(Synalar\))/P 6166 0 R/K 31235 0 R>> endobj 17708 0 obj <>/Alt(Tier 1)/P 6166 0 R/K 31236 0 R>> endobj 17709 0 obj <>/Alt(\(Begin italic\) fluocinolone topical solution \(End italic\) \(Begin italic\) 0.01 % \(End italic\))/P 6167 0 R/K 31237 0 R>> endobj 17710 0 obj <>/Alt(\(Synalar\))/P 6167 0 R/K 31238 0 R>> endobj 17711 0 obj <>/Alt(Tier 1)/P 6167 0 R/K 31239 0 R>> endobj 17712 0 obj <>/Alt(\(Begin italic\) fluocinonide topical cream \(End italic\) \(Begin italic\) 0.05 % \(End italic\))/P 6168 0 R/K 31240 0 R>> endobj 17713 0 obj <>/Alt(Tier 1)/P 6168 0 R/K 31241 0 R>> endobj 17714 0 obj <>/Alt(\(Begin italic\) fluocinonide topical cream \(End italic\) \(Begin italic\) 0.1 % \(End italic\))/P 6169 0 R/K 31242 0 R>> endobj 17715 0 obj <>/Alt(\(Vanos\))/P 6169 0 R/K 31243 0 R>> endobj 17716 0 obj <>/Alt(Tier 1)/P 6169 0 R/K 31244 0 R>> endobj 17717 0 obj <>/Alt(\(Begin italic\) fluocinonide topical gel \(End italic\) \(Begin italic\) 0.05 % \(End italic\))/P 6170 0 R/K 31245 0 R>> endobj 17718 0 obj <>/Alt(Tier 1)/P 6170 0 R/K 31246 0 R>> endobj 17719 0 obj <>/Alt(\(Begin italic\) fluocinonide topical ointment \(End italic\) \(Begin italic\) 0.05 % \(End italic\))/P 6171 0 R/K 31247 0 R>> endobj 17720 0 obj <>/Alt(Tier 1)/P 6171 0 R/K 31248 0 R>> endobj 17721 0 obj <>/Alt(\(Begin italic\) fluocinonide topical solution \(End italic\) \(Begin italic\) 0.05 % \(End italic\))/P 6172 0 R/K 31249 0 R>> endobj 17722 0 obj <>/Alt(Tier 1)/P 6172 0 R/K 31250 0 R>> endobj 17723 0 obj <>/Alt(FLUOCINONIDE-E TOPICAL CREAM 0.05 %)/P 6173 0 R/K 31251 0 R>> endobj 17724 0 obj <>/Alt(\(fluocinonide-emollient\))/P 6173 0 R/K 31252 0 R>> endobj 17725 0 obj <>/Alt(Tier 1)/P 6173 0 R/K 31253 0 R>> endobj 17726 0 obj <>/Alt(\(Begin italic\) fluocinonide-emollient topical cream \(End italic\) \(Begin italic\) 0.05 % \(End italic\))/P 6174 0 R/K 31254 0 R>> endobj 17727 0 obj <>/Alt(\(Fluocinonide-E\))/P 6174 0 R/K 31255 0 R>> endobj 17728 0 obj <>/Alt(Tier 1)/P 6174 0 R/K 31256 0 R>> endobj 17729 0 obj <>/Alt(FLUOXIA TOPICAL CREAM 0.05-4 %)/P 6175 0 R/K 31257 0 R>> endobj 17730 0 obj <>/Alt(Tier 3)/P 6175 0 R/K 31258 0 R>> endobj 17731 0 obj <>/Alt(\(Begin italic\) flurandrenolide topical cream \(End italic\) \(Begin italic\) 0.05 % \(End italic\))/P 6176 0 R/K 31259 0 R>> endobj 17732 0 obj <>/Alt(\(Cordran\))/P 6176 0 R/K 31260 0 R>> endobj 17733 0 obj <>/Alt(Tier 1)/P 6176 0 R/K 31261 0 R>> endobj 17734 0 obj <>/Alt(ST: Requires prior prescription for Betamethasone \(0.05% lotion, 0.1% cream\), Desonide 0.05% ointment, Fluticasone 0.05% cream, Hydrocortisone 0.2% cream, or Triamcinolone \(0.1% lotion, 0.025% ointment\) within the past 120 days)/P 6176 0 R/K 31262 0 R>> endobj 17735 0 obj <>/Alt(\(Begin italic\) flurandrenolide topical lotion \(End italic\) \(Begin italic\) 0.05 % \(End italic\))/P 6177 0 R/K 31263 0 R>> endobj 17736 0 obj <>/Alt(\(Cordran\))/P 6177 0 R/K 31264 0 R>> endobj 17737 0 obj <>/Alt(Tier 1)/P 6177 0 R/K 31265 0 R>> endobj 17738 0 obj <>/Alt(\(Begin italic\) flurandrenolide topical ointment \(End italic\) \(Begin italic\) 0.05 % \(End italic\))/P 6178 0 R/K 31266 0 R>> endobj 17739 0 obj <>/Alt(\(Cordran\))/P 6178 0 R/K 31267 0 R>> endobj 17740 0 obj <>/Alt(Tier 1)/P 6178 0 R/K 31268 0 R>> endobj 17741 0 obj <>/Alt(ST: Requires prior prescription for Mometasone 0.1% cream/solution or Triamcinolone 0.1 % cream/ointment within the past 120 days; QL \(180 GM per 30 days\))/P 6178 0 R/K 31269 0 R>> endobj 17742 0 obj <>/Alt(\(Begin italic\) fluticasone propionate topical cream \(End italic\) \(Begin italic\) 0.05 % \(End italic\))/P 6179 0 R/K 31270 0 R>> endobj 17743 0 obj <>/Alt(Tier 1)/P 6179 0 R/K 31271 0 R>> endobj 17744 0 obj <>/Alt(\(Begin italic\) fluticasone propionate topical lotion \(End italic\) \(Begin italic\) 0.05 % \(End italic\))/P 6180 0 R/K 31272 0 R>> endobj 17745 0 obj <>/Alt(\(Beser\))/P 6180 0 R/K 31273 0 R>> endobj 17746 0 obj <>/Alt(Tier 1)/P 6180 0 R/K 31274 0 R>> endobj 17747 0 obj <>/Alt(\(Begin italic\) fluticasone propionate topical ointment \(End italic\) \(Begin italic\) 0.005 % \(End italic\))/P 6181 0 R/K 31275 0 R>> endobj 17748 0 obj <>/Alt(Tier 1)/P 6181 0 R/K 31276 0 R>> endobj 17749 0 obj <>/Alt(\(Begin italic\) halcinonide topical cream \(End italic\) \(Begin italic\) 0.1 % \(End italic\))/P 6182 0 R/K 31277 0 R>> endobj 17750 0 obj <>/Alt(\(Halog\))/P 6182 0 R/K 31278 0 R>> endobj 17751 0 obj <>/Alt(Tier 1)/P 6182 0 R/K 31279 0 R>> endobj 17752 0 obj <>/Alt(ST: Requires prior prescription for Betamethasone 0.05% \(ointment, augmented cream\), Desoximetasone \(cream, gel, ointment\), Fluocinonide 0.05% \(gel, ointment, solution, cream\) within the past 120 days)/P 6182 0 R/K 31280 0 R>> endobj 17753 0 obj <>/Alt(\(Begin italic\) halcinonide topical solution \(End italic\) 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3)/P 6186 0 R/K 31290 0 R>> endobj 17763 0 obj <>/Alt(ST: Requires prior prescription for Betamethasone 0.05% \(ointment, augmented cream\), Desoximetasone \(cream, gel, ointment\), Fluocinonide 0.05% \(gel, ointment, solution, cream\) within the past 120 days)/P 6186 0 R/K 31291 0 R>> endobj 17764 0 obj <>/Alt(HALOG TOPICAL SOLUTION 0.1 %)/P 6187 0 R/K 31292 0 R>> endobj 17765 0 obj <>/Alt(\(halcinonide\))/P 6187 0 R/K 31293 0 R>> endobj 17766 0 obj <>/Alt(Tier 3)/P 6187 0 R/K 31294 0 R>> endobj 17767 0 obj <>/Alt(ST: Requires prior prescription for Betamethasone 0.05% \(ointment, augmented cream\), Desoximetasone \(cream, gel, ointment\), Fluocinonide 0.05% \(gel, ointment, solution, cream\) within the past 120 days)/P 6187 0 R/K 31295 0 R>> endobj 17768 0 obj <>/Alt(\(Begin italic\) hydrocortisone butyrate topical cream \(End italic\) \(Begin italic\) 0.1 % \(End italic\))/P 6188 0 R/K 31296 0 R>> endobj 17769 0 obj <>/Alt(Tier 1)/P 6188 0 R/K 31297 0 R>> endobj 17770 0 obj <>/Alt(\(Begin italic\) hydrocortisone butyrate topical lotion \(End italic\) \(Begin italic\) 0.1 % \(End italic\))/P 6189 0 R/K 31298 0 R>> endobj 17771 0 obj <>/Alt(\(Locoid\))/P 6189 0 R/K 31299 0 R>> endobj 17772 0 obj <>/Alt(Tier 1)/P 6189 0 R/K 31300 0 R>> endobj 17773 0 obj <>/Alt(ST: Requires prior prescription for Betamethasone \(0.05% lotion, 0.1% cream\), Desonide 0.05% ointment, Fluticasone 0.05% cream, Hydrocortisone 0.2% cream, or Triamcinolone \(0.1% lotion, 0.025% ointment\) within the past 120 days; QL \(236 ML per 30 days\))/P 6189 0 R/K 31301 0 R>> endobj 17774 0 obj <>/Alt(\(Begin italic\) hydrocortisone butyrate topical ointment \(End italic\) \(Begin italic\) 0.1 % \(End italic\))/P 6190 0 R/K 31302 0 R>> endobj 17775 0 obj <>/Alt(Tier 1)/P 6190 0 R/K 31303 0 R>> endobj 17776 0 obj <>/Alt(ST: Requires prior prescription for Betamethasone \(0.05% lotion, 0.1% cream\), Desonide 0.05% ointment, Fluticasone 0.05% cream, Hydrocortisone 0.2% cream, or Triamcinolone 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6194 0 R/K 31313 0 R>> endobj 17786 0 obj <>/Alt(\(Begin italic\) hydrocortisone topical cream with perineal applicator \(End italic\) \(Begin italic\) 2.5 % \(End italic\))/P 6195 0 R/K 31314 0 R>> endobj 17787 0 obj <>/Alt(\(Procto-Med HC\))/P 6195 0 R/K 31315 0 R>> endobj 17788 0 obj <>/Alt(Tier 1)/P 6195 0 R/K 31316 0 R>> endobj 17789 0 obj <>/Alt(\(Begin italic\) hydrocortisone topical lotion \(End italic\) \(Begin italic\) 2 % \(End italic\))/P 6196 0 R/K 31317 0 R>> endobj 17790 0 obj <>/Alt(\(Ala-Scalp\))/P 6196 0 R/K 31318 0 R>> endobj 17791 0 obj <>/Alt(Tier 1)/P 6196 0 R/K 31319 0 R>> endobj 17792 0 obj <>/Alt(ST: Requires prior prescription for Hydrocortisone 2.5% lotion within the past 120 days)/P 6196 0 R/K 31320 0 R>> endobj 17793 0 obj <>/Alt(\(Begin italic\) hydrocortisone topical lotion \(End italic\) \(Begin italic\) 2.5 % \(End italic\))/P 6197 0 R/K 31321 0 R>> endobj 17794 0 obj <>/Alt(Tier 1)/P 6197 0 R/K 31322 0 R>> endobj 17795 0 obj <>/Alt(\(Begin italic\) 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italic\))/P 6201 0 R/K 31332 0 R>> endobj 17805 0 obj <>/Alt(Tier 1)/P 6201 0 R/K 31333 0 R>> endobj 17806 0 obj <>/Alt(\(Begin italic\) hydrocortisone valerate topical ointment \(End italic\) \(Begin italic\) 0.2 % \(End italic\))/P 6202 0 R/K 31334 0 R>> endobj 17807 0 obj <>/Alt(Tier 1)/P 6202 0 R/K 31335 0 R>> endobj 17808 0 obj <>/Alt(ST: Requires prior prescription for Mometasone 0.1% cream/solution or Triamcinolone 0.1 % cream/ointment within the past 120 days)/P 6202 0 R/K 31336 0 R>> endobj 17809 0 obj <>/Alt(ILEXOR TOPICAL SHAMPOO 0.05-2 %)/P 6203 0 R/K 31337 0 R>> endobj 17810 0 obj <>/Alt(\(clobetasol-levocetirizine\))/P 6203 0 R/K 31338 0 R>> endobj 17811 0 obj <>/Alt(Tier 3)/P 6203 0 R/K 31339 0 R>> endobj 17812 0 obj <>/Alt(\(Begin italic\) mometasone topical cream \(End italic\) \(Begin italic\) 0.1 % \(End italic\))/P 6204 0 R/K 31340 0 R>> endobj 17813 0 obj <>/Alt(Tier 1)/P 6204 0 R/K 31341 0 R>> endobj 17814 0 obj <>/Alt(\(Begin italic\) mometasone topical ointment 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0 R/K 31351 0 R>> endobj 17824 0 obj <>/Alt(\(Begin italic\) prednicarbate topical cream \(End italic\) \(Begin italic\) 0.1 % \(End italic\))/P 6209 0 R/K 31352 0 R>> endobj 17825 0 obj <>/Alt(Tier 1)/P 6209 0 R/K 31353 0 R>> endobj 17826 0 obj <>/Alt(\(Begin italic\) prednicarbate topical ointment \(End italic\) \(Begin italic\) 0.1 % \(End italic\))/P 6210 0 R/K 31354 0 R>> endobj 17827 0 obj <>/Alt(Tier 1)/P 6210 0 R/K 31355 0 R>> endobj 17828 0 obj <>/Alt(PROCTO-MED HC TOPICAL CREAM WITH PERINEAL APPLICATOR 2.5 %)/P 6211 0 R/K 31356 0 R>> endobj 17829 0 obj <>/Alt(\(hydrocortisone\))/P 6211 0 R/K 31357 0 R>> endobj 17830 0 obj <>/Alt(Tier 1)/P 6211 0 R/K 31358 0 R>> endobj 17831 0 obj <>/Alt(PROCTOSOL HC TOPICAL CREAM WITH PERINEAL APPLICATOR 2.5 %)/P 6212 0 R/K 31359 0 R>> endobj 17832 0 obj <>/Alt(\(hydrocortisone\))/P 6212 0 R/K 31360 0 R>> endobj 17833 0 obj <>/Alt(Tier 1)/P 6212 0 R/K 31361 0 R>> endobj 17834 0 obj <>/Alt(PROCTOZONE-HC TOPICAL CREAM WITH PERINEAL APPLICATOR 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17846 0 obj <>/Alt(Tier 3)/P 6217 0 R/K 31374 0 R>> endobj 17847 0 obj <>/Alt(QL \(375 GM per 30 days\))/P 6217 0 R/K 31375 0 R>> endobj 17848 0 obj <>/Alt(SYNALAR TS TOPICAL KIT 0.01 %)/P 6218 0 R/K 31376 0 R>> endobj 17849 0 obj <>/Alt(Tier 3)/P 6218 0 R/K 31377 0 R>> endobj 17850 0 obj <>/Alt(TELIORA TOPICAL GEL 0.1-0.5 %)/P 6219 0 R/K 31378 0 R>> endobj 17851 0 obj <>/Alt(Tier 3)/P 6219 0 R/K 31379 0 R>> endobj 17852 0 obj <>/Alt(TETOXIA TOPICAL CREAM 0.01-4 %)/P 6220 0 R/K 31380 0 R>> endobj 17853 0 obj <>/Alt(\(fluocinolone-niacinamide\))/P 6220 0 R/K 31381 0 R>> endobj 17854 0 obj <>/Alt(Tier 3)/P 6220 0 R/K 31382 0 R>> endobj 17855 0 obj <>/Alt(TEXACORT TOPICAL SOLUTION 2.5 %)/P 6221 0 R/K 31383 0 R>> endobj 17856 0 obj <>/Alt(\(hydrocortisone\))/P 6221 0 R/K 31384 0 R>> endobj 17857 0 obj <>/Alt(Tier 3)/P 6221 0 R/K 31385 0 R>> endobj 17858 0 obj <>/Alt(ST: Requires prior prescription for Hydrocortisone 2.5% lotion within the past 120 days)/P 6221 0 R/K 31386 0 R>> endobj 17859 0 obj <>/Alt(\(Begin italic\) triamcinolone acetonide topical aerosol \(End italic\) \(Begin italic\) 0.147 mg/gram \(End italic\))/P 6222 0 R/K 31387 0 R>> endobj 17860 0 obj <>/Alt(\(Kenalog\))/P 6222 0 R/K 31388 0 R>> endobj 17861 0 obj <>/Alt(Tier 1)/P 6222 0 R/K 31389 0 R>> endobj 17862 0 obj <>/Alt(\(Begin italic\) triamcinolone acetonide topical cream \(End italic\) \(Begin italic\) 0.025 %, 0.1 % \(End italic\))/P 6223 0 R/K 31390 0 R>> endobj 17863 0 obj <>/Alt(Tier 1)/P 6223 0 R/K 31391 0 R>> endobj 17864 0 obj <>/Alt(\(Begin italic\) triamcinolone acetonide topical cream \(End italic\) \(Begin italic\) 0.5 % \(End italic\))/P 6224 0 R/K 31392 0 R>> endobj 17865 0 obj <>/Alt(\(Triderm\))/P 6224 0 R/K 31393 0 R>> endobj 17866 0 obj <>/Alt(Tier 1)/P 6224 0 R/K 31394 0 R>> endobj 17867 0 obj <>/Alt(QL \(454 GM per 30 days\))/P 6224 0 R/K 31395 0 R>> endobj 17868 0 obj <>/Alt(\(Begin italic\) triamcinolone acetonide topical lotion \(End italic\) \(Begin italic\) 0.025 %, 0.1 % \(End italic\))/P 6225 0 R/K 31396 0 R>> endobj 17869 0 obj <>/Alt(Tier 1)/P 6225 0 R/K 31397 0 R>> endobj 17870 0 obj <>/Alt(\(Begin italic\) triamcinolone acetonide topical ointment \(End italic\) \(Begin italic\) 0.025 %, 0.1 %, 0.5 % \(End italic\))/P 6226 0 R/K 31398 0 R>> endobj 17871 0 obj <>/Alt(Tier 1)/P 6226 0 R/K 31399 0 R>> endobj 17872 0 obj <>/Alt(TRIDERM TOPICAL CREAM 0.1 %)/P 6227 0 R/K 31400 0 R>> endobj 17873 0 obj <>/Alt(\(triamcinolone acetonide\))/P 6227 0 R/K 31401 0 R>> endobj 17874 0 obj <>/Alt(Tier 1)/P 6227 0 R/K 31402 0 R>> endobj 17875 0 obj <>/Alt(TRIDERM TOPICAL CREAM 0.5 %)/P 6228 0 R/K 31403 0 R>> endobj 17876 0 obj <>/Alt(\(triamcinolone acetonide\))/P 6228 0 R/K 31404 0 R>> endobj 17877 0 obj <>/Alt(Tier 1)/P 6228 0 R/K 31405 0 R>> endobj 17878 0 obj <>/Alt(QL \(454 GM per 30 days\))/P 6228 0 R/K 31406 0 R>> endobj 17879 0 obj <>/Alt(\(Begin bold\) Topical Anti-Inflammatory, Nsaids \(End bold\))/P 6229 0 R/K 31407 0 R>> endobj 17880 0 obj <>/Alt(\(Begin italic\) diclofenac epolamine transdermal patch 12 hour \(End italic\) \(Begin italic\) 1.3 % \(End italic\))/P 6230 0 R/K 31408 0 R>> endobj 17881 0 obj <>/Alt(\(Flector\))/P 6230 0 R/K 31409 0 R>> endobj 17882 0 obj <>/Alt(Tier 1)/P 6230 0 R/K 31410 0 R>> endobj 17883 0 obj <>/Alt(\(Begin italic\) diclofenac sodium topical drops \(End italic\) \(Begin italic\) 1.5 % \(End italic\))/P 6231 0 R/K 31411 0 R>> endobj 17884 0 obj <>/Alt(Tier 1)/P 6231 0 R/K 31412 0 R>> endobj 17885 0 obj <>/Alt(\(Begin italic\) diclofenac sodium topical gel \(End italic\) \(Begin italic\) 1 % \(End italic\))/P 6232 0 R/K 31413 0 R>> endobj 17886 0 obj <>/Alt(\(Arthritis Pain \(diclofenac\)\))/P 6232 0 R/K 31414 0 R>> endobj 17887 0 obj <>/Alt(Tier 1)/P 6232 0 R/K 31415 0 R>> endobj 17888 0 obj <>/Alt(KERAXA TOPICAL GEL 3-2-4 %)/P 6233 0 R/K 31416 0 R>> endobj 17889 0 obj <>/Alt(\(diclofenac-hyaluronate-niacin\))/P 6233 0 R/K 31417 0 R>> endobj 17890 0 obj <>/Alt(Tier 3)/P 6233 0 R/K 31418 0 R>> endobj 17891 0 obj <>/Alt(LICART TRANSDERMAL PATCH 24 HOUR 1.3 %)/P 6234 0 R/K 31419 0 R>> endobj 17892 0 obj <>/Alt(Tier 3)/P 6234 0 R/K 31420 0 R>> endobj 17893 0 obj <>/Alt(ST: Requires prior prescription for generic Flector patch within the past 120 days; QL \(1 EA per 1 day\))/P 6234 0 R/K 31421 0 R>> endobj 17894 0 obj <>/Alt(ROAOXIA TOPICAL GEL 3-2-4 %)/P 6235 0 R/K 31422 0 R>> endobj 17895 0 obj <>/Alt(\(diclofenac-hyaluronate-niacin\))/P 6235 0 R/K 31423 0 R>> endobj 17896 0 obj <>/Alt(Tier 3)/P 6235 0 R/K 31424 0 R>> endobj 17897 0 obj <>/Alt(\(Begin bold\) Topical Janus Kinase \(Jak\) Inhibitors \(End bold\))/P 6236 0 R/K 31425 0 R>> endobj 17898 0 obj <>/Alt(OPZELURA TOPICAL CREAM 1.5 %)/P 6237 0 R/K 31426 0 R>> endobj 17899 0 obj <>/Alt(Tier 2)/P 6237 0 R/K 31427 0 R>> endobj 17900 0 obj <>/Alt(PA)/P 6237 0 R/K 31428 0 R>> endobj 17901 0 obj <>/Alt(\(Begin bold\) Dermatology - Miscellaneous \(End bold\))/P 6238 0 R/K 31429 0 R>> endobj 17902 0 obj <>/Alt(\(Begin bold\) Antiperspirants \(End bold\))/P 6239 0 R/K 31430 0 R>> endobj 17903 0 obj <>/Alt(DRYSOL DAB-O-MATIC TOPICAL SOLUTION 20 %)/P 6240 0 R/K 31431 0 R>> endobj 17904 0 obj <>/Alt(\(aluminum chloride\))/P 6240 0 R/K 31432 0 R>> endobj 17905 0 obj <>/Alt(Tier 2)/P 6240 0 R/K 31433 0 R>> endobj 17906 0 obj <>/Alt(DRYSOL TOPICAL SOLUTION 20 %)/P 6241 0 R/K 31434 0 R>> endobj 17907 0 obj <>/Alt(\(aluminum chloride\))/P 6241 0 R/K 31435 0 R>> endobj 17908 0 obj <>/Alt(Tier 2)/P 6241 0 R/K 31436 0 R>> endobj 17909 0 obj <>/Alt(\(Begin bold\) Antiseborrheic Agents \(End bold\))/P 6242 0 R/K 31437 0 R>> endobj 17910 0 obj <>/Alt(OVACE PLUS SHAMPOO TOPICAL SHAMPOO 10 %)/P 6243 0 R/K 31438 0 R>> endobj 17911 0 obj <>/Alt(\(sulfacetamide sodium\))/P 6243 0 R/K 31439 0 R>> endobj 17912 0 obj <>/Alt(Tier 2)/P 6243 0 R/K 31440 0 R>> endobj 17913 0 obj <>/Alt(OVACE PLUS TOPICAL CREAM 10 %)/P 6244 0 R/K 31441 0 R>> endobj 17914 0 obj <>/Alt(Tier 3)/P 6244 0 R/K 31442 0 R>> endobj 17915 0 obj <>/Alt(OVACE PLUS TOPICAL LOTION 9.8 %)/P 6245 0 R/K 31443 0 R>> endobj 17916 0 obj <>/Alt(Tier 3)/P 6245 0 R/K 31444 0 R>> endobj 17917 0 obj <>/Alt(ST: Requires prior prescription for Ciclopirox\(shampoo/gel\) or Ketoconazole \(shampoo/cream\) within the past 120 days)/P 6245 0 R/K 31445 0 R>> endobj 17918 0 obj <>/Alt(PLEXION NS TOPICAL SHAMPOO 9.8 %)/P 6246 0 R/K 31446 0 R>> endobj 17919 0 obj <>/Alt(\(sulfacetamide sodium\))/P 6246 0 R/K 31447 0 R>> endobj 17920 0 obj <>/Alt(Tier 3)/P 6246 0 R/K 31448 0 R>> endobj 17921 0 obj <>/Alt(\(Begin italic\) selenium sulfide topical lotion \(End italic\) \(Begin italic\) 2.5 % \(End italic\))/P 6247 0 R/K 31449 0 R>> endobj 17922 0 obj <>/Alt(Tier 1)/P 6247 0 R/K 31450 0 R>> endobj 17923 0 obj <>/Alt(\(Begin italic\) selenium sulfide topical shampoo \(End italic\) \(Begin italic\) 2.25 %, 2.3 % \(End italic\))/P 6248 0 R/K 31451 0 R>> endobj 17924 0 obj <>/Alt(Tier 1)/P 6248 0 R/K 31452 0 R>> endobj 17925 0 obj <>/Alt(\(Begin italic\) sulfacetamide sodium topical cleanser \(End italic\) \(Begin italic\) 10 % \(End italic\))/P 6249 0 R/K 31453 0 R>> endobj 17926 0 obj <>/Alt(\(Ovace\))/P 6249 0 R/K 31454 0 R>> endobj 17927 0 obj <>/Alt(Tier 1)/P 6249 0 R/K 31455 0 R>> endobj 17928 0 obj <>/Alt(\(Begin italic\) sulfacetamide sodium topical cleanser, gel \(End italic\) \(Begin italic\) 10 % \(End italic\))/P 6250 0 R/K 31456 0 R>> endobj 17929 0 obj <>/Alt(\(Ovace Plus Wash\))/P 6250 0 R/K 31457 0 R>> endobj 17930 0 obj <>/Alt(Tier 1)/P 6250 0 R/K 31458 0 R>> endobj 17931 0 obj <>/Alt(\(Begin italic\) sulfacetamide sodium topical shampoo \(End italic\) \(Begin italic\) 10 % \(End italic\))/P 6251 0 R/K 31459 0 R>> endobj 17932 0 obj <>/Alt(\(Ovace Plus Shampoo\))/P 6251 0 R/K 31460 0 R>> endobj 17933 0 obj <>/Alt(Tier 1)/P 6251 0 R/K 31461 0 R>> endobj 17934 0 obj <>/Alt(\(Begin italic\) sulfacetamide sodium topical shampoo \(End italic\) \(Begin italic\) 9.8 % \(End italic\))/P 6252 0 R/K 31462 0 R>> endobj 17935 0 obj <>/Alt(\(Plexion NS\))/P 6252 0 R/K 31463 0 R>> endobj 17936 0 obj <>/Alt(Tier 1)/P 6252 0 R/K 31464 0 R>> endobj 17937 0 obj <>/Alt(TERSI FOAM TOPICAL FOAM 2.25 %)/P 6253 0 R/K 31465 0 R>> endobj 17938 0 obj <>/Alt(Tier 3)/P 6253 0 R/K 31466 0 R>> endobj 17939 0 obj <>/Alt(\(Begin bold\) Antiseptics,Miscellaneous \(End bold\))/P 6254 0 R/K 31467 0 R>> endobj 17940 0 obj <>/Alt(\(Begin italic\) guaiacol liquid \(End italic\) \(Begin italic\) \(End italic\))/P 6255 0 R/K 31468 0 R>> endobj 17941 0 obj <>/Alt(Tier 3)/P 6255 0 R/K 31469 0 R>> endobj 17942 0 obj <>/Alt(\(Begin bold\) Emollients \(End bold\))/P 6256 0 R/K 31470 0 R>> endobj 17943 0 obj <>/Alt(\(Begin italic\) ammonium lactate topical cream \(End italic\) \(Begin italic\) 12 % \(End italic\))/P 6257 0 R/K 31471 0 R>> endobj 17944 0 obj <>/Alt(Tier 1)/P 6257 0 R/K 31472 0 R>> endobj 17945 0 obj <>/Alt(\(Begin italic\) ammonium lactate topical lotion \(End italic\) \(Begin italic\) 12 % \(End italic\))/P 6258 0 R/K 31473 0 R>> endobj 17946 0 obj <>/Alt(\(AmLactin\))/P 6258 0 R/K 31474 0 R>> endobj 17947 0 obj <>/Alt(Tier 1)/P 6258 0 R/K 31475 0 R>> endobj 17948 0 obj <>/Alt(ATRAPRO CP TOPICAL COMBO PACK,CREAM AND GEL)/P 6259 0 R/K 31476 0 R>> endobj 17949 0 obj <>/Alt(Tier 3)/P 6259 0 R/K 31477 0 R>> endobj 17950 0 obj <>/Alt(KERASTAT TOPICAL CREAM)/P 6260 0 R/K 31478 0 R>> endobj 17951 0 obj <>/Alt(Tier 3)/P 6260 0 R/K 31479 0 R>> endobj 17952 0 obj <>/Alt(KERASTAT TOPICAL GEL 5 %)/P 6261 0 R/K 31480 0 R>> endobj 17953 0 obj <>/Alt(Tier 3)/P 6261 0 R/K 31481 0 R>> endobj 17954 0 obj <>/Alt(MB HYDROGEL TOPICAL KIT,CREAM AND GEL 96.53-3-0.4 -0.066 %)/P 6262 0 R/K 31482 0 R>> endobj 17955 0 obj <>/Alt(Tier 1)/P 6262 0 R/K 31483 0 R>> endobj 17956 0 obj <>/Alt(PRESERA TOPICAL FOAM)/P 6263 0 R/K 31484 0 R>> endobj 17957 0 obj <>/Alt(Tier 3)/P 6263 0 R/K 31485 0 R>> endobj 17958 0 obj <>/Alt(XCLAIR TOPICAL CREAM)/P 6264 0 R/K 31486 0 R>> endobj 17959 0 obj <>/Alt(Tier 3)/P 6264 0 R/K 31487 0 R>> endobj 17960 0 obj <>/Alt(\(Begin bold\) Iodine Antiseptics \(End bold\))/P 6265 0 R/K 31488 0 R>> endobj 17961 0 obj <>/Alt(BETADINE OPHTHALMIC PREP OPHTHALMIC \(EYE\) SOLUTION 5 %)/P 6266 0 R/K 31489 0 R>> endobj 17962 0 obj <>/Alt(\(povidone-iodine\))/P 6266 0 R/K 31490 0 R>> endobj 17963 0 obj <>/Alt(Tier 3)/P 6266 0 R/K 31491 0 R>> endobj 17964 0 obj <>/Alt(\(Begin italic\) povidone-iodine ophthalmic \(eye\) solution \(End italic\) \(Begin italic\) 5 % \(End italic\))/P 6267 0 R/K 31492 0 R>> endobj 17965 0 obj <>/Alt(\(Betadine Ophthalmic Prep\))/P 6267 0 R/K 31493 0 R>> endobj 17966 0 obj <>/Alt(Tier 1)/P 6267 0 R/K 31494 0 R>> endobj 17967 0 obj <>/Alt(\(Begin bold\) Irrigants \(End bold\))/P 6268 0 R/K 31495 0 R>> endobj 17968 0 obj <>/Alt(\(Begin italic\) acetic acid irrigation solution \(End italic\) \(Begin italic\) 0.25 % \(End italic\))/P 6269 0 R/K 31496 0 R>> endobj 17969 0 obj <>/Alt(Tier 1)/P 6269 0 R/K 31497 0 R>> endobj 17970 0 obj <>/Alt(\(Begin italic\) lactated ringers irrigation solution \(End italic\) \(Begin italic\) \(End italic\))/P 6270 0 R/K 31498 0 R>> endobj 17971 0 obj <>/Alt(Tier 3)/P 6270 0 R/K 31499 0 R>> endobj 17972 0 obj <>/Alt(\(Begin italic\) neomycin-polymyxin b gu irrigation solution \(End italic\) \(Begin italic\) 40 mg-200,000 unit/ml \(End italic\))/P 6271 0 R/K 31500 0 R>> endobj 17973 0 obj <>/Alt(Tier 1)/P 6271 0 R/K 31501 0 R>> endobj 17974 0 obj <>/Alt(PHYSIOLYTE IRRIGATION SOLUTION 140-5-3-98 MEQ/L)/P 6272 0 R/K 31502 0 R>> endobj 17975 0 obj <>/Alt(Tier 3)/P 6272 0 R/K 31503 0 R>> endobj 17976 0 obj <>/Alt(PHYSIOSOL IRRIGATION IRRIGATION SOLUTION 140-5-3-98 MEQ/L)/P 6273 0 R/K 31504 0 R>> endobj 17977 0 obj <>/Alt(Tier 3)/P 6273 0 R/K 31505 0 R>> endobj 17978 0 obj <>/Alt(\(Begin italic\) ringer's irrigation solution \(End italic\) \(Begin italic\) \(End italic\))/P 6274 0 R/K 31506 0 R>> endobj 17979 0 obj <>/Alt(Tier 1)/P 6274 0 R/K 31507 0 R>> endobj 17980 0 obj <>/Alt(\(Begin italic\) sodium chloride irrigation solution \(End italic\) \(Begin italic\) 0.9 % \(End italic\))/P 6275 0 R/K 31508 0 R>> endobj 17981 0 obj <>/Alt(\(Sterile Saline\))/P 6275 0 R/K 31509 0 R>> endobj 17982 0 obj <>/Alt(Tier 1)/P 6275 0 R/K 31510 0 R>> endobj 17983 0 obj <>/Alt(\(Begin italic\) sorbitol irrigation solution \(End italic\) \(Begin italic\) 3 % \(End italic\))/P 6276 0 R/K 31511 0 R>> endobj 17984 0 obj <>/Alt(Tier 1)/P 6276 0 R/K 31512 0 R>> endobj 17985 0 obj <>/Alt(\(Begin italic\) sorbitol-mannitol transurethral solution \(End italic\) \(Begin italic\) 2.7-0.54 gram/100 ml \(End italic\))/P 6277 0 R/K 31513 0 R>> endobj 17986 0 obj <>/Alt(Tier 1)/P 6277 0 R/K 31514 0 R>> endobj 17987 0 obj <>/Alt(TIS-U-SOL PENTALYTE IRRIGATION IRRIGATION SOLUTION 800-40-20-8.75- 6.25 MG/100 ML)/P 6278 0 R/K 31515 0 R>> endobj 17988 0 obj <>/Alt(Tier 3)/P 6278 0 R/K 31516 0 R>> endobj 17989 0 obj <>/Alt(VASHE IRRIGATION IRRIGATION SOLUTION 0.033 %)/P 6279 0 R/K 31517 0 R>> endobj 17990 0 obj <>/Alt(Tier 3)/P 6279 0 R/K 31518 0 R>> endobj 17991 0 obj <>/Alt(\(Begin italic\) water for irrigation, sterile irrigation solution \(End italic\) \(Begin italic\) \(End italic\))/P 6280 0 R/K 31519 0 R>> endobj 17992 0 obj <>/Alt(\(Curity Sterile Water\))/P 6280 0 R/K 31520 0 R>> endobj 17993 0 obj <>/Alt(Tier 1)/P 6280 0 R/K 31521 0 R>> endobj 17994 0 obj <>/Alt(\(Begin bold\) Irritants/Counter-Irritants \(End bold\))/P 6281 0 R/K 31522 0 R>> endobj 17995 0 obj <>/Alt(\(Begin italic\) cantharidin in acetone topical solution \(End italic\) \(Begin italic\) 0.7 % \(End italic\))/P 6282 0 R/K 31523 0 R>> endobj 17996 0 obj <>/Alt(Tier 1)/P 6282 0 R/K 31524 0 R>> endobj 17997 0 obj <>/Alt(\(Begin italic\) methyl salicylate oil \(End italic\) \(Begin italic\) \(End italic\))/P 6283 0 R/K 31525 0 R>> endobj 17998 0 obj <>/Alt(\(Wintergreen Oil\))/P 6283 0 R/K 31526 0 R>> endobj 17999 0 obj <>/Alt(Tier 1)/P 6283 0 R/K 31527 0 R>> endobj 18000 0 obj <>/Alt(\(Begin italic\) methyl salicylate topical liquid \(End italic\) \(Begin italic\) \(End italic\))/P 6284 0 R/K 31528 0 R>> endobj 18001 0 obj <>/Alt(Tier 1)/P 6284 0 R/K 31529 0 R>> endobj 18002 0 obj <>/Alt(QUTENZA TOPICAL KIT 8 %)/P 6285 0 R/K 31530 0 R>> endobj 18003 0 obj <>/Alt(Tier 3)/P 6285 0 R/K 31531 0 R>> endobj 18004 0 obj <>/Alt(PA)/P 6285 0 R/K 31532 0 R>> endobj 18005 0 obj <>/Alt(WINTERGREEN OIL OIL)/P 6286 0 R/K 31533 0 R>> endobj 18006 0 obj <>/Alt(\(methyl salicylate\))/P 6286 0 R/K 31534 0 R>> endobj 18007 0 obj <>/Alt(Tier 1)/P 6286 0 R/K 31535 0 R>> endobj 18008 0 obj <>/Alt(YCANTH TOPICAL SOLUTION WITH APPLICATOR 0.7 %)/P 6287 0 R/K 31536 0 R>> endobj 18009 0 obj <>/Alt(Tier 3)/P 6287 0 R/K 31537 0 R>> endobj 18010 0 obj <>/Alt(PA)/P 6287 0 R/K 31538 0 R>> endobj 18011 0 obj <>/Alt(\(Begin bold\) Keratolytics \(End bold\))/P 6288 0 R/K 31539 0 R>> endobj 18012 0 obj <>/Alt(\(Begin italic\) benzoyl peroxide topical foam \(End italic\) \(Begin italic\) 9.8 % \(End italic\))/P 6289 0 R/K 31540 0 R>> endobj 18013 0 obj <>/Alt(\(BenzePrO\))/P 6289 0 R/K 31541 0 R>> endobj 18014 0 obj <>/Alt(Tier 1)/P 6289 0 R/K 31542 0 R>> endobj 18015 0 obj <>/Alt(BPO TOPICAL GEL 8 %)/P 6290 0 R/K 31543 0 R>> endobj 18016 0 obj <>/Alt(\(benzoyl peroxide\))/P 6290 0 R/K 31544 0 R>> endobj 18017 0 obj <>/Alt(Tier 1)/P 6290 0 R/K 31545 0 R>> endobj 18018 0 obj <>/Alt(CEM-UREA TOPICAL GEL 45 %)/P 6291 0 R/K 31546 0 R>> endobj 18019 0 obj <>/Alt(\(urea\))/P 6291 0 R/K 31547 0 R>> endobj 18020 0 obj <>/Alt(Tier 1)/P 6291 0 R/K 31548 0 R>> endobj 18021 0 obj <>/Alt(HYDRO 35 TOPICAL FOAM 35 %)/P 6292 0 R/K 31549 0 R>> endobj 18022 0 obj <>/Alt(\(urea\))/P 6292 0 R/K 31550 0 R>> endobj 18023 0 obj <>/Alt(Tier 3)/P 6292 0 R/K 31551 0 R>> endobj 18024 0 obj <>/Alt(METDRAY TOPICAL GEL 17-2 %)/P 6293 0 R/K 31552 0 R>> endobj 18025 0 obj <>/Alt(Tier 3)/P 6293 0 R/K 31553 0 R>> endobj 18026 0 obj <>/Alt(NENDRUX TOPICAL GEL 40-5 %)/P 6294 0 R/K 31554 0 R>> endobj 18027 0 obj <>/Alt(Tier 3)/P 6294 0 R/K 31555 0 R>> endobj 18028 0 obj <>/Alt(PACNEX HP TOPICAL PADS, MEDICATED 7 %)/P 6295 0 R/K 31556 0 R>> endobj 18029 0 obj <>/Alt(Tier 3)/P 6295 0 R/K 31557 0 R>> endobj 18030 0 obj <>/Alt(PACNEX LP TOPICAL PADS, MEDICATED 4.25 %)/P 6296 0 R/K 31558 0 R>> endobj 18031 0 obj <>/Alt(Tier 3)/P 6296 0 R/K 31559 0 R>> endobj 18032 0 obj <>/Alt(PODOCON TOPICAL LIQUID 25 %)/P 6297 0 R/K 31560 0 R>> endobj 18033 0 obj <>/Alt(Tier 1)/P 6297 0 R/K 31561 0 R>> endobj 18034 0 obj <>/Alt(\(Begin italic\) podofilox topical gel \(End italic\) \(Begin italic\) 0.5 % \(End italic\))/P 6298 0 R/K 31562 0 R>> endobj 18035 0 obj <>/Alt(\(Condylox\))/P 6298 0 R/K 31563 0 R>> endobj 18036 0 obj <>/Alt(Tier 1)/P 6298 0 R/K 31564 0 R>> endobj 18037 0 obj <>/Alt(ST: Requires prior prescription for Podofilox 0.5% solution within the past 120 days; QL \(0.5 GM per 1 day\))/P 6298 0 R/K 31565 0 R>> endobj 18038 0 obj <>/Alt(\(Begin italic\) podofilox topical solution \(End italic\) \(Begin italic\) 0.5 % \(End italic\))/P 6299 0 R/K 31566 0 R>> endobj 18039 0 obj <>/Alt(Tier 1)/P 6299 0 R/K 31567 0 R>> endobj 18040 0 obj <>/Alt(QL \(0.5 ML per 1 day\))/P 6299 0 R/K 31568 0 R>> endobj 18041 0 obj <>/Alt(PR BENZOYL PEROXIDE TOPICAL CLEANSER 7 %)/P 6300 0 R/K 31569 0 R>> endobj 18042 0 obj <>/Alt(Tier 1)/P 6300 0 R/K 31570 0 R>> endobj 18043 0 obj <>/Alt(PRONAL TOPICAL GEL 10-40 %)/P 6301 0 R/K 31571 0 R>> endobj 18044 0 obj <>/Alt(Tier 3)/P 6301 0 R/K 31572 0 R>> endobj 18045 0 obj <>/Alt(\(Begin italic\) salicylic acid topical cream \(End italic\) \(Begin italic\) 6 % \(End italic\))/P 6302 0 R/K 31573 0 R>> endobj 18046 0 obj <>/Alt(\(Salimez\))/P 6302 0 R/K 31574 0 R>> endobj 18047 0 obj <>/Alt(Tier 1)/P 6302 0 R/K 31575 0 R>> endobj 18048 0 obj <>/Alt(\(Begin italic\) salicylic acid topical cream,extended release \(End italic\) \(Begin italic\) 6 % \(End italic\))/P 6303 0 R/K 31576 0 R>> endobj 18049 0 obj <>/Alt(Tier 1)/P 6303 0 R/K 31577 0 R>> endobj 18050 0 obj <>/Alt(\(Begin italic\) salicylic acid topical film forming liquid w/appl \(End italic\) \(Begin italic\) 27.5 % \(End italic\))/P 6304 0 R/K 31578 0 R>> endobj 18051 0 obj <>/Alt(\(Virasal\))/P 6304 0 R/K 31579 0 R>> endobj 18052 0 obj <>/Alt(Tier 1)/P 6304 0 R/K 31580 0 R>> endobj 18053 0 obj <>/Alt(\(Begin italic\) salicylic acid topical film-forming soln er w/ appl \(End italic\) \(Begin italic\) 28.5 % \(End italic\))/P 6305 0 R/K 31581 0 R>> endobj 18054 0 obj <>/Alt(\(UltraSal-ER\))/P 6305 0 R/K 31582 0 R>> endobj 18055 0 obj <>/Alt(Tier 1)/P 6305 0 R/K 31583 0 R>> endobj 18056 0 obj <>/Alt(\(Begin italic\) salicylic acid topical foam \(End italic\) \(Begin italic\) 6 % \(End italic\))/P 6306 0 R/K 31584 0 R>> endobj 18057 0 obj <>/Alt(\(Salvax\))/P 6306 0 R/K 31585 0 R>> endobj 18058 0 obj <>/Alt(Tier 1)/P 6306 0 R/K 31586 0 R>> endobj 18059 0 obj <>/Alt(\(Begin italic\) salicylic acid topical liquid \(End italic\) \(Begin italic\) 26 % \(End italic\))/P 6307 0 R/K 31587 0 R>> endobj 18060 0 obj <>/Alt(Tier 1)/P 6307 0 R/K 31588 0 R>> endobj 18061 0 obj <>/Alt(\(Begin italic\) salicylic acid topical lotion \(End italic\) \(Begin italic\) 6 % \(End italic\))/P 6308 0 R/K 31589 0 R>> endobj 18062 0 obj <>/Alt(Tier 1)/P 6308 0 R/K 31590 0 R>> endobj 18063 0 obj <>/Alt(\(Begin italic\) salicylic acid topical lotion,extended release \(End italic\) \(Begin italic\) 6 % \(End italic\))/P 6309 0 R/K 31591 0 R>> endobj 18064 0 obj <>/Alt(Tier 1)/P 6309 0 R/K 31592 0 R>> endobj 18065 0 obj <>/Alt(\(Begin italic\) salicylic acid topical ointment \(End italic\) \(Begin italic\) 3 % \(End italic\))/P 6310 0 R/K 31593 0 R>> endobj 18066 0 obj <>/Alt(Tier 1)/P 6310 0 R/K 31594 0 R>> endobj 18067 0 obj <>/Alt(\(Begin italic\) salicylic acid topical shampoo \(End italic\) \(Begin italic\) 6 % \(End italic\))/P 6311 0 R/K 31595 0 R>> endobj 18068 0 obj <>/Alt(\(Keralyt\))/P 6311 0 R/K 31596 0 R>> endobj 18069 0 obj <>/Alt(Tier 1)/P 6311 0 R/K 31597 0 R>> endobj 18070 0 obj <>/Alt(SALIMEZ FORTE TOPICAL CREAM 10 %)/P 6312 0 R/K 31598 0 R>> endobj 18071 0 obj <>/Alt(Tier 3)/P 6312 0 R/K 31599 0 R>> endobj 18072 0 obj <>/Alt(SALVAX DUO PLUS TOPICAL FOAM 6-35 %)/P 6313 0 R/K 31600 0 R>> endobj 18073 0 obj <>/Alt(Tier 3)/P 6313 0 R/K 31601 0 R>> endobj 18074 0 obj <>/Alt(SALVAX TOPICAL FOAM 6 %)/P 6314 0 R/K 31602 0 R>> endobj 18075 0 obj <>/Alt(\(salicylic acid\))/P 6314 0 R/K 31603 0 R>> endobj 18076 0 obj <>/Alt(Tier 1)/P 6314 0 R/K 31604 0 R>> endobj 18077 0 obj <>/Alt(\(Begin italic\) silver nitrate applicators topical stick \(End italic\) \(Begin italic\) 75-25 % \(End italic\))/P 6315 0 R/K 31605 0 R>> endobj 18078 0 obj <>/Alt(Tier 1)/P 6315 0 R/K 31606 0 R>> endobj 18079 0 obj <>/Alt(\(Begin italic\) silver nitrate topical solution \(End italic\) \(Begin italic\) 10 % \(End italic\))/P 6316 0 R/K 31607 0 R>> endobj 18080 0 obj <>/Alt(Tier 1)/P 6316 0 R/K 31608 0 R>> endobj 18081 0 obj <>/Alt(ULTRASAL-ER TOPICAL FILM-FORMING SOLN ER W/ APPL 28.5 %)/P 6317 0 R/K 31609 0 R>> endobj 18082 0 obj <>/Alt(\(salicylic acid\))/P 6317 0 R/K 31610 0 R>> endobj 18083 0 obj <>/Alt(Tier 3)/P 6317 0 R/K 31611 0 R>> endobj 18084 0 obj <>/Alt(URAMAXIN GT TOPICAL KIT,CREAM AND GEL 45 %)/P 6318 0 R/K 31612 0 R>> endobj 18085 0 obj <>/Alt(Tier 3)/P 6318 0 R/K 31613 0 R>> endobj 18086 0 obj <>/Alt(URAMAXIN TOPICAL FOAM 20 %)/P 6319 0 R/K 31614 0 R>> endobj 18087 0 obj <>/Alt(Tier 3)/P 6319 0 R/K 31615 0 R>> endobj 18088 0 obj <>/Alt(URAMAXIN TOPICAL LOTION 45 %)/P 6320 0 R/K 31616 0 R>> endobj 18089 0 obj <>/Alt(\(urea\))/P 6320 0 R/K 31617 0 R>> endobj 18090 0 obj <>/Alt(Tier 3)/P 6320 0 R/K 31618 0 R>> endobj 18091 0 obj <>/Alt(UREA NAIL STICK TOPICAL SOLUTION 50 %)/P 6321 0 R/K 31619 0 R>> endobj 18092 0 obj <>/Alt(\(urea\))/P 6321 0 R/K 31620 0 R>> endobj 18093 0 obj <>/Alt(Tier 1)/P 6321 0 R/K 31621 0 R>> endobj 18094 0 obj <>/Alt(\(Begin italic\) urea topical cream \(End italic\) \(Begin italic\) 39 % \(End italic\))/P 6322 0 R/K 31622 0 R>> endobj 18095 0 obj <>/Alt(\(Uredeb\))/P 6322 0 R/K 31623 0 R>> endobj 18096 0 obj <>/Alt(Tier 1)/P 6322 0 R/K 31624 0 R>> endobj 18097 0 obj <>/Alt(\(Begin italic\) urea topical cream \(End italic\) \(Begin italic\) 40 %, 47 % \(End italic\))/P 6323 0 R/K 31625 0 R>> endobj 18098 0 obj <>/Alt(Tier 1)/P 6323 0 R/K 31626 0 R>> endobj 18099 0 obj <>/Alt(\(Begin italic\) urea topical cream \(End italic\) \(Begin italic\) 45 % \(End italic\))/P 6324 0 R/K 31627 0 R>> endobj 18100 0 obj <>/Alt(\(Uramaxin\))/P 6324 0 R/K 31628 0 R>> endobj 18101 0 obj <>/Alt(Tier 1)/P 6324 0 R/K 31629 0 R>> endobj 18102 0 obj <>/Alt(\(Begin italic\) urea topical cream \(End italic\) \(Begin italic\) 50 % \(End italic\))/P 6325 0 R/K 31630 0 R>> endobj 18103 0 obj <>/Alt(\(Ure-K\))/P 6325 0 R/K 31631 0 R>> endobj 18104 0 obj <>/Alt(Tier 1)/P 6325 0 R/K 31632 0 R>> endobj 18105 0 obj <>/Alt(\(Begin italic\) urea topical foam \(End italic\) \(Begin italic\) 35 % \(End italic\))/P 6326 0 R/K 31633 0 R>> endobj 18106 0 obj <>/Alt(\(Hydro 35\))/P 6326 0 R/K 31634 0 R>> endobj 18107 0 obj <>/Alt(Tier 1)/P 6326 0 R/K 31635 0 R>> endobj 18108 0 obj <>/Alt(\(Begin italic\) urea topical gel \(End italic\) \(Begin italic\) 45 % \(End italic\))/P 6327 0 R/K 31636 0 R>> endobj 18109 0 obj <>/Alt(\(CEM-Urea\))/P 6327 0 R/K 31637 0 R>> endobj 18110 0 obj <>/Alt(Tier 1)/P 6327 0 R/K 31638 0 R>> endobj 18111 0 obj <>/Alt(\(Begin italic\) urea topical lotion \(End italic\) \(Begin italic\) 40 % \(End italic\))/P 6328 0 R/K 31639 0 R>> endobj 18112 0 obj <>/Alt(Tier 1)/P 6328 0 R/K 31640 0 R>> endobj 18113 0 obj <>/Alt(WAYZEN TOPICAL GEL 40-5 %)/P 6329 0 R/K 31641 0 R>> endobj 18114 0 obj <>/Alt(Tier 3)/P 6329 0 R/K 31642 0 R>> endobj 18115 0 obj <>/Alt(WELERIS TOPICAL GEL 17-2 %)/P 6330 0 R/K 31643 0 R>> endobj 18116 0 obj <>/Alt(Tier 3)/P 6330 0 R/K 31644 0 R>> endobj 18117 0 obj <>/Alt(XALIX TOPICAL FILM-FORMING SOLN ER W/ APPL 28 %)/P 6331 0 R/K 31645 0 R>> endobj 18118 0 obj <>/Alt(Tier 3)/P 6331 0 R/K 31646 0 R>> endobj 18119 0 obj <>/Alt(XIRUN TOPICAL GEL 10-40 %)/P 6332 0 R/K 31647 0 R>> endobj 18120 0 obj <>/Alt(Tier 3)/P 6332 0 R/K 31648 0 R>> endobj 18121 0 obj <>/Alt(\(Begin bold\) Oxidizing Agents \(End bold\))/P 6333 0 R/K 31649 0 R>> endobj 18122 0 obj <>/Alt(HYPOCYN ANTIPRURITIC TOPICAL SPRAY GEL 0.012 %)/P 6334 0 R/K 31650 0 R>> endobj 18123 0 obj <>/Alt(Tier 3)/P 6334 0 R/K 31651 0 R>> endobj 18124 0 obj <>/Alt(RENOVAR IRRIGATION IRRIGATION SOLUTION)/P 6335 0 R/K 31652 0 R>> endobj 18125 0 obj <>/Alt(Tier 3)/P 6335 0 R/K 31653 0 R>> endobj 18126 0 obj <>/Alt(RENOVAR TOPICAL SOLUTION)/P 6336 0 R/K 31654 0 R>> endobj 18127 0 obj <>/Alt(Tier 3)/P 6336 0 R/K 31655 0 R>> endobj 18128 0 obj <>/Alt(\(Begin bold\) Protectives \(End bold\))/P 6337 0 R/K 31656 0 R>> endobj 18129 0 obj <>/Alt(GENADUR \(WITH LEXINAL\) KIT 2,500 MCG)/P 6338 0 R/K 31657 0 R>> endobj 18130 0 obj <>/Alt(Tier 3)/P 6338 0 R/K 31658 0 R>> endobj 18131 0 obj <>/Alt(PHARMABASE BARRIER TOPICAL OINTMENT 9.38 %)/P 6339 0 R/K 31659 0 R>> endobj 18132 0 obj <>/Alt(Tier 1)/P 6339 0 R/K 31660 0 R>> endobj 18133 0 obj <>/Alt(PR CREAM TOPICAL CREAM)/P 6340 0 R/K 31661 0 R>> endobj 18134 0 obj <>/Alt(Tier 1)/P 6340 0 R/K 31662 0 R>> endobj 18135 0 obj <>/Alt(RECEDO TOPICAL GEL)/P 6341 0 R/K 31663 0 R>> endobj 18136 0 obj <>/Alt(Tier 3)/P 6341 0 R/K 31664 0 R>> endobj 18137 0 obj <>/Alt(VASELINE WHITE PETROLEUM TOPICAL OINTMENT IN PACKET)/P 6342 0 R/K 31665 0 R>> endobj 18138 0 obj <>/Alt(\(white petrolatum\))/P 6342 0 R/K 31666 0 R>> endobj 18139 0 obj <>/Alt(Tier 1)/P 6342 0 R/K 31667 0 R>> endobj 18140 0 obj <>/Alt(WOUNDGELHA MATRIX TOPICAL GEL 2.5 %)/P 6343 0 R/K 31668 0 R>> endobj 18141 0 obj <>/Alt(Tier 3)/P 6343 0 R/K 31669 0 R>> endobj 18142 0 obj <>/Alt(\(Begin italic\) zinc oxide topical ointment \(End italic\) \(Begin italic\) 20 % \(End italic\))/P 6344 0 R/K 31670 0 R>> endobj 18143 0 obj <>/Alt(\(Endit \(zinc oxide\)\))/P 6344 0 R/K 31671 0 R>> endobj 18144 0 obj <>/Alt(Tier 1)/P 6344 0 R/K 31672 0 R>> endobj 18145 0 obj <>/Alt(\(Begin italic\) zinc oxide topical paste \(End italic\) \(Begin italic\) 25 % \(End italic\))/P 6345 0 R/K 31673 0 R>> endobj 18146 0 obj <>/Alt(Tier 1)/P 6345 0 R/K 31674 0 R>> endobj 18147 0 obj <>/Alt(\(Begin bold\) Topical Anti-Inflammatory Steroid-Local Anesthetic \(End bold\))/P 6346 0 R/K 31675 0 R>> endobj 18148 0 obj <>/Alt(ANALPRAM-HC TOPICAL LOTION 2.5-1 %)/P 6347 0 R/K 31676 0 R>> endobj 18149 0 obj <>/Alt(Tier 2)/P 6347 0 R/K 31677 0 R>> endobj 18150 0 obj <>/Alt(EPIFOAM TOPICAL FOAM 1-1 %)/P 6348 0 R/K 31678 0 R>> endobj 18151 0 obj <>/Alt(Tier 3)/P 6348 0 R/K 31679 0 R>> endobj 18152 0 obj <>/Alt(ST: Requires prior prescription for Hydrocortisone/Pramoxine 2.5%-1% cream within the past 120 days)/P 6348 0 R/K 31680 0 R>> endobj 18153 0 obj <>/Alt(\(Begin italic\) hydrocortisone-pramoxine topical cream \(End italic\) \(Begin italic\) 2.5-1 % \(End italic\))/P 6349 0 R/K 31681 0 R>> endobj 18154 0 obj <>/Alt(Tier 1)/P 6349 0 R/K 31682 0 R>> endobj 18155 0 obj <>/Alt(\(Begin italic\) lidocaine hcl-hydrocortison ac topical cream \(End italic\) \(Begin italic\) 3-0.5 % \(End italic\))/P 6350 0 R/K 31683 0 R>> endobj 18156 0 obj <>/Alt(\(Lidocort\))/P 6350 0 R/K 31684 0 R>> endobj 18157 0 obj <>/Alt(Tier 1)/P 6350 0 R/K 31685 0 R>> endobj 18158 0 obj <>/Alt(PRAMOSONE TOPICAL CREAM 1-1 %)/P 6351 0 R/K 31686 0 R>> endobj 18159 0 obj <>/Alt(\(hydrocortisone-pramoxine\))/P 6351 0 R/K 31687 0 R>> endobj 18160 0 obj <>/Alt(Tier 2)/P 6351 0 R/K 31688 0 R>> endobj 18161 0 obj <>/Alt(ST: Requires prior prescription for Hydrocortisone/Pramoxine 2.5%-1% cream within the past 120 days)/P 6351 0 R/K 31689 0 R>> endobj 18162 0 obj <>/Alt(PRAMOSONE TOPICAL LOTION 1-1 %, 2.5-1 %)/P 6352 0 R/K 31690 0 R>> endobj 18163 0 obj <>/Alt(Tier 2)/P 6352 0 R/K 31691 0 R>> endobj 18164 0 obj <>/Alt(PRAMOSONE TOPICAL OINTMENT 1-1 %)/P 6353 0 R/K 31692 0 R>> endobj 18165 0 obj <>/Alt(Tier 2)/P 6353 0 R/K 31693 0 R>> endobj 18166 0 obj <>/Alt(ST: Requires prior prescription for 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Topical/Mucous Membr./Subcut. 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obj <>/Alt(\(Begin italic\) urea topical cream \(End italic\) \(Begin italic\) 20 % \(End italic\))/P 6446 0 R/K 31923 0 R>> endobj 18396 0 obj <>/Alt(\(Gormel\))/P 6446 0 R/K 31924 0 R>> endobj 18397 0 obj <>/Alt(Tier 1)/P 6446 0 R/K 31925 0 R>> endobj 18398 0 obj <>/Alt(\(Begin bold\) Topical Immunosuppressive Agents \(End bold\))/P 6447 0 R/K 31926 0 R>> endobj 18399 0 obj <>/Alt(ELYZIA TOPICAL CREAM 0.1-1-4 %)/P 6448 0 R/K 31927 0 R>> endobj 18400 0 obj <>/Alt(\(tacrolimus-hyaluronate-niacin\))/P 6448 0 R/K 31928 0 R>> endobj 18401 0 obj <>/Alt(Tier 3)/P 6448 0 R/K 31929 0 R>> endobj 18402 0 obj <>/Alt(ELYZIA TOPICAL OINTMENT 0.1-4 %)/P 6449 0 R/K 31930 0 R>> endobj 18403 0 obj <>/Alt(\(tacrolimus-niacinamide\))/P 6449 0 R/K 31931 0 R>> endobj 18404 0 obj <>/Alt(Tier 3)/P 6449 0 R/K 31932 0 R>> endobj 18405 0 obj <>/Alt(HOVYN TOPICAL SOLUTION 0.1 %)/P 6450 0 R/K 31933 0 R>> endobj 18406 0 obj <>/Alt(Tier 3)/P 6450 0 R/K 31934 0 R>> endobj 18407 0 obj <>/Alt(HYFTOR TOPICAL GEL 0.2 %)/P 6451 0 R/K 31935 0 R>> endobj 18408 0 obj <>/Alt(Tier 3)/P 6451 0 R/K 31936 0 R>> endobj 18409 0 obj <>/Alt(PA; SP)/P 6451 0 R/K 31937 0 R>> endobj 18410 0 obj <>/Alt(NUJO TOPICAL SOLUTION 0.1 %)/P 6452 0 R/K 31938 0 R>> endobj 18411 0 obj <>/Alt(Tier 3)/P 6452 0 R/K 31939 0 R>> endobj 18412 0 obj <>/Alt(NUJU TOPICAL CREAM 0.1 %)/P 6453 0 R/K 31940 0 R>> endobj 18413 0 obj <>/Alt(\(tacrolimus-vehicle base no.238\))/P 6453 0 R/K 31941 0 R>> endobj 18414 0 obj <>/Alt(Tier 3)/P 6453 0 R/K 31942 0 R>> endobj 18415 0 obj <>/Alt(OXIANUJO \(WITH HYALURONATE\) TOPICAL CREAM 0.1-1-4 %)/P 6454 0 R/K 31943 0 R>> endobj 18416 0 obj <>/Alt(\(tacrolimus-hyaluronate-niacin\))/P 6454 0 R/K 31944 0 R>> endobj 18417 0 obj <>/Alt(Tier 3)/P 6454 0 R/K 31945 0 R>> endobj 18418 0 obj <>/Alt(OXIANUJO TOPICAL OINTMENT 0.1-4 %)/P 6455 0 R/K 31946 0 R>> endobj 18419 0 obj <>/Alt(\(tacrolimus-niacinamide\))/P 6455 0 R/K 31947 0 R>> endobj 18420 0 obj <>/Alt(Tier 3)/P 6455 0 R/K 31948 0 R>> endobj 18421 0 obj <>/Alt(\(Begin italic\) pimecrolimus topical cream \(End italic\) \(Begin italic\) 1 % \(End italic\))/P 6456 0 R/K 31949 0 R>> endobj 18422 0 obj <>/Alt(\(Elidel\))/P 6456 0 R/K 31950 0 R>> endobj 18423 0 obj <>/Alt(Tier 1)/P 6456 0 R/K 31951 0 R>> endobj 18424 0 obj <>/Alt(\(Begin italic\) tacrolimus topical ointment \(End italic\) \(Begin italic\) 0.03 %, 0.1 % \(End italic\))/P 6457 0 R/K 31952 0 R>> endobj 18425 0 obj <>/Alt(Tier 1)/P 6457 0 R/K 31953 0 R>> endobj 18426 0 obj <>/Alt(VEVEN TOPICAL CREAM 0.1 %)/P 6458 0 R/K 31954 0 R>> endobj 18427 0 obj <>/Alt(\(tacrolimus-vehicle base no.238\))/P 6458 0 R/K 31955 0 R>> endobj 18428 0 obj <>/Alt(Tier 3)/P 6458 0 R/K 31956 0 R>> endobj 18429 0 obj <>/Alt(\(Begin bold\) Topical Vit D Analog/Antiinflammatory, Steroidal \(End bold\))/P 6459 0 R/K 31957 0 R>> endobj 18430 0 obj <>/Alt(\(Begin italic\) calcipotriene-betamethasone topical ointment \(End italic\) \(Begin italic\) 0.005-0.064 % \(End italic\))/P 6460 0 R/K 31958 0 R>> endobj 18431 0 obj <>/Alt(Tier 1)/P 6460 0 R/K 31959 0 R>> endobj 18432 0 obj <>/Alt(\(Begin italic\) calcipotriene-betamethasone topical suspension \(End italic\) \(Begin italic\) 0.005-0.064 % \(End italic\))/P 6461 0 R/K 31960 0 R>> endobj 18433 0 obj <>/Alt(\(Taclonex\))/P 6461 0 R/K 31961 0 R>> endobj 18434 0 obj <>/Alt(Tier 1)/P 6461 0 R/K 31962 0 R>> endobj 18435 0 obj <>/Alt(DIOCHLOY TOPICAL SOLUTION 0.05-0.005 %)/P 6462 0 R/K 31963 0 R>> endobj 18436 0 obj <>/Alt(\(clobetasol-calcipotriene\))/P 6462 0 R/K 31964 0 R>> endobj 18437 0 obj <>/Alt(Tier 3)/P 6462 0 R/K 31965 0 R>> endobj 18438 0 obj <>/Alt(ENSTILAR TOPICAL FOAM 0.005-0.064 %)/P 6463 0 R/K 31966 0 R>> endobj 18439 0 obj <>/Alt(Tier 3)/P 6463 0 R/K 31967 0 R>> endobj 18440 0 obj <>/Alt(PLENURA TOPICAL SOLUTION 0.05-0.005 %)/P 6464 0 R/K 31968 0 R>> endobj 18441 0 obj <>/Alt(\(clobetasol-calcipotriene\))/P 6464 0 R/K 31969 0 R>> endobj 18442 0 obj <>/Alt(Tier 3)/P 6464 0 R/K 31970 0 R>> endobj 18443 0 obj <>/Alt(WYNZORA TOPICAL CREAM 0.005-0.064 %)/P 6465 0 R/K 31971 0 R>> endobj 18444 0 obj <>/Alt(Tier 3)/P 6465 0 R/K 31972 0 R>> endobj 18445 0 obj <>/Alt(\(Begin bold\) Diabetes \(End bold\))/P 6466 0 R/K 31973 0 R>> endobj 18446 0 obj <>/Alt(\(Begin bold\) Antihypergly, \(Dpp-4\) Inhibitor & Biguanide Comb. \(End bold\))/P 6467 0 R/K 31974 0 R>> endobj 18447 0 obj <>/Alt(JANUMET ORAL TABLET 50-1,000 MG, 50-500 MG)/P 6468 0 R/K 31975 0 R>> endobj 18448 0 obj <>/Alt(Tier 2)/P 6468 0 R/K 31976 0 R>> endobj 18449 0 obj <>/Alt(QL \(2 EA per 1 day\))/P 6468 0 R/K 31977 0 R>> endobj 18450 0 obj <>/Alt(JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 100-1,000 MG)/P 6469 0 R/K 31978 0 R>> endobj 18451 0 obj <>/Alt(Tier 2)/P 6469 0 R/K 31979 0 R>> endobj 18452 0 obj <>/Alt(QL \(1 EA per 1 day\))/P 6469 0 R/K 31980 0 R>> endobj 18453 0 obj <>/Alt(JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 50-1,000 MG, 50-500 MG)/P 6470 0 R/K 31981 0 R>> endobj 18454 0 obj <>/Alt(Tier 2)/P 6470 0 R/K 31982 0 R>> endobj 18455 0 obj <>/Alt(QL \(2 EA per 1 day\))/P 6470 0 R/K 31983 0 R>> endobj 18456 0 obj <>/Alt(\(Begin bold\) Antihypergly,Incretin Mimetic\(Glp-1 Recep.Agonist\) \(End bold\))/P 6471 0 R/K 31984 0 R>> endobj 18457 0 obj <>/Alt(\(Begin italic\) exenatide subcutaneous pen injector \(End italic\) \(Begin italic\) 10 mcg/dose\(250 mcg/ml\) 2.4 ml \(End italic\))/P 6472 0 R/K 31985 0 R>> endobj 18458 0 obj <>/Alt(Tier 1)/P 6472 0 R/K 31986 0 R>> endobj 18459 0 obj <>/Alt(PA; QL \(2.4 ML per 30 days\))/P 6472 0 R/K 31987 0 R>> endobj 18460 0 obj <>/Alt(\(Begin italic\) exenatide subcutaneous pen injector \(End italic\) \(Begin italic\) 5 mcg/dose \(250 mcg/ml\) 1.2 ml \(End italic\))/P 6473 0 R/K 31988 0 R>> endobj 18461 0 obj <>/Alt(Tier 1)/P 6473 0 R/K 31989 0 R>> endobj 18462 0 obj <>/Alt(PA; QL \(1.2 ML per 30 days\))/P 6473 0 R/K 31990 0 R>> endobj 18463 0 obj <>/Alt(\(Begin italic\) liraglutide subcutaneous pen injector \(End italic\) \(Begin italic\) 0.6 mg/0.1 ml \(18 mg/3 ml\) \(End italic\))/P 6474 0 R/K 31991 0 R>> endobj 18464 0 obj <>/Alt(\(Victoza 2-Pak\))/P 6474 0 R/K 31992 0 R>> endobj 18465 0 obj <>/Alt(Tier 3)/P 6474 0 R/K 31993 0 R>> endobj 18466 0 obj <>/Alt(PA; DIAGNOSIS CODE FOR MEDICALLY ACCEPTED INDICATION REQUIRED OR SUBMIT PA REQUEST; QL \(9 ML per 30 days\))/P 6474 0 R/K 31994 0 R>> endobj 18467 0 obj <>/Alt(OZEMPIC SUBCUTANEOUS PEN INJECTOR 0.25 MG OR 0.5 MG \(2 MG/3 ML\), 1 MG/DOSE \(4 MG/3 ML\), 2 MG/DOSE \(8 MG/3 ML\))/P 6475 0 R/K 31995 0 R>> endobj 18468 0 obj <>/Alt(Tier 2)/P 6475 0 R/K 31996 0 R>> endobj 18469 0 obj <>/Alt(PA; DIAGNOSIS CODE FOR MEDICALLY ACCEPTED INDICATION REQUIRED OR SUBMIT PA REQUEST; QL \(3 ML per 28 days\))/P 6475 0 R/K 31997 0 R>> endobj 18470 0 obj <>/Alt(RYBELSUS ORAL TABLET 1.5 MG, 4 MG, 9 MG)/P 6476 0 R/K 31998 0 R>> endobj 18471 0 obj <>/Alt(Tier 2)/P 6476 0 R/K 31999 0 R>> endobj 18472 0 obj <>/Alt(PA; QL \(1 EA per 1 day\))/P 6476 0 R/K 32000 0 R>> endobj 18473 0 obj <>/Alt(RYBELSUS ORAL TABLET 14 MG, 3 MG, 7 MG)/P 6477 0 R/K 32001 0 R>> endobj 18474 0 obj <>/Alt(Tier 2)/P 6477 0 R/K 32002 0 R>> endobj 18475 0 obj <>/Alt(PA; DIAGNOSIS CODE FOR MEDICALLY ACCEPTED INDICATION REQUIRED OR SUBMIT PA REQUEST; QL \(1 EA per 1 day\))/P 6477 0 R/K 32003 0 R>> endobj 18476 0 obj <>/Alt(TRULICITY SUBCUTANEOUS PEN INJECTOR 0.75 MG/0.5 ML, 1.5 MG/0.5 ML, 3 MG/0.5 ML, 4.5 MG/0.5 ML)/P 6478 0 R/K 32004 0 R>> endobj 18477 0 obj <>/Alt(Tier 2)/P 6478 0 R/K 32005 0 R>> endobj 18478 0 obj <>/Alt(PA; DIAGNOSIS CODE FOR MEDICALLY ACCEPTED INDICATION REQUIRED OR SUBMIT PA REQUEST; QL \(2 ML per 28 days\))/P 6478 0 R/K 32006 0 R>> endobj 18479 0 obj <>/Alt(\(Begin bold\) Antihyperglycemc-Sod/Gluc Cotransport2\(Sglt2\)Inhib \(End bold\))/P 6479 0 R/K 32007 0 R>> endobj 18480 0 obj <>/Alt(FARXIGA ORAL TABLET 10 MG, 5 MG)/P 6480 0 R/K 32008 0 R>> endobj 18481 0 obj <>/Alt(\(dapagliflozin propanediol\))/P 6480 0 R/K 32009 0 R>> endobj 18482 0 obj <>/Alt(Tier 2)/P 6480 0 R/K 32010 0 R>> endobj 18483 0 obj <>/Alt(QL \(1 EA per 1 day\))/P 6480 0 R/K 32011 0 R>> endobj 18484 0 obj <>/Alt(JARDIANCE ORAL TABLET 10 MG, 25 MG)/P 6481 0 R/K 32012 0 R>> endobj 18485 0 obj <>/Alt(Tier 2)/P 6481 0 R/K 32013 0 R>> endobj 18486 0 obj <>/Alt(QL \(1 EA per 1 day\))/P 6481 0 R/K 32014 0 R>> endobj 18487 0 obj <>/Alt(\(Begin bold\) Antihyperglycemic - Dopamine Receptor Agonists \(End bold\))/P 6482 0 R/K 32015 0 R>> endobj 18488 0 obj <>/Alt(CYCLOSET ORAL TABLET 0.8 MG)/P 6483 0 R/K 32016 0 R>> endobj 18489 0 obj <>/Alt(Tier 3)/P 6483 0 R/K 32017 0 R>> endobj 18490 0 obj <>/Alt(ST: Requires prior prescription for Metformin \(Glucophage\), Metformin ER, Glyburide/Metformin \(Glucovance\), or Glipizide/Metformin \(Metaglip\) within the past 180 days)/P 6483 0 R/K 32018 0 R>> endobj 18491 0 obj <>/Alt(\(Begin bold\) Antihyperglycemic - Incretin Mimetics Combination \(End bold\))/P 6484 0 R/K 32019 0 R>> endobj 18492 0 obj <>/Alt(MOUNJARO SUBCUTANEOUS PEN INJECTOR 10 MG/0.5 ML, 12.5 MG/0.5 ML, 15 MG/0.5 ML, 2.5 MG/0.5 ML, 5 MG/0.5 ML, 7.5 MG/0.5 ML)/P 6485 0 R/K 32020 0 R>> endobj 18493 0 obj <>/Alt(Tier 2)/P 6485 0 R/K 32021 0 R>> endobj 18494 0 obj <>/Alt(PA; DIAGNOSIS CODE FOR MEDICALLY ACCEPTED INDICATION REQUIRED OR SUBMIT PA REQUEST; QL \(0.5 ML per 7 days\))/P 6485 0 R/K 32022 0 R>> endobj 18495 0 obj <>/Alt(\(Begin bold\) Antihyperglycemic, Alpha-Glucosidase Inhib \(N-S\) \(End bold\))/P 6486 0 R/K 32023 0 R>> endobj 18496 0 obj <>/Alt(\(Begin italic\) acarbose oral tablet \(End italic\) \(Begin italic\) 100 mg, 25 mg, 50 mg \(End italic\))/P 6487 0 R/K 32024 0 R>> endobj 18497 0 obj <>/Alt(\(Precose\))/P 6487 0 R/K 32025 0 R>> endobj 18498 0 obj <>/Alt(Tier 1)/P 6487 0 R/K 32026 0 R>> endobj 18499 0 obj <>/Alt(\(Begin italic\) miglitol oral tablet \(End italic\) \(Begin italic\) 100 mg, 25 mg, 50 mg \(End italic\))/P 6488 0 R/K 32027 0 R>> endobj 18500 0 obj <>/Alt(Tier 1)/P 6488 0 R/K 32028 0 R>> endobj 18501 0 obj <>/Alt(\(Begin bold\) Antihyperglycemic, Dpp-4 Inhibitors \(End bold\))/P 6489 0 R/K 32029 0 R>> endobj 18502 0 obj <>/Alt(JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG)/P 6490 0 R/K 32030 0 R>> endobj 18503 0 obj <>/Alt(Tier 2)/P 6490 0 R/K 32031 0 R>> endobj 18504 0 obj <>/Alt(QL \(1 EA per 1 day\))/P 6490 0 R/K 32032 0 R>> endobj 18505 0 obj <>/Alt(\(Begin bold\) Antihyperglycemic, Insulin-Release Stimulant Type \(End bold\))/P 6491 0 R/K 32033 0 R>> endobj 18506 0 obj <>/Alt(\(Begin italic\) glimepiride oral tablet \(End italic\) \(Begin italic\) 1 mg, 2 mg, 4 mg \(End italic\))/P 6492 0 R/K 32034 0 R>> endobj 18507 0 obj <>/Alt(Tier 1)/P 6492 0 R/K 32035 0 R>> endobj 18508 0 obj <>/Alt(\(Begin italic\) glipizide oral tablet \(End italic\) \(Begin italic\) 10 mg, 5 mg \(End italic\))/P 6493 0 R/K 32036 0 R>> endobj 18509 0 obj <>/Alt(Tier 1)/P 6493 0 R/K 32037 0 R>> endobj 18510 0 obj <>/Alt(\(Begin italic\) glipizide oral tablet \(End italic\) \(Begin italic\) 2.5 mg \(End italic\))/P 6494 0 R/K 32038 0 R>> endobj 18511 0 obj <>/Alt(Tier 1)/P 6494 0 R/K 32039 0 R>> endobj 18512 0 obj <>/Alt(QL \(2 EA per 1 day\))/P 6494 0 R/K 32040 0 R>> endobj 18513 0 obj <>/Alt(\(Begin italic\) glipizide oral tablet extended release 24hr \(End italic\) \(Begin italic\) 10 mg, 2.5 mg, 5 mg \(End italic\))/P 6495 0 R/K 32041 0 R>> endobj 18514 0 obj <>/Alt(\(Glucotrol XL\))/P 6495 0 R/K 32042 0 R>> endobj 18515 0 obj <>/Alt(Tier 1)/P 6495 0 R/K 32043 0 R>> endobj 18516 0 obj <>/Alt(\(Begin italic\) glyburide micronized oral tablet \(End italic\) \(Begin italic\) 1.5 mg, 3 mg, 6 mg \(End italic\))/P 6496 0 R/K 32044 0 R>> endobj 18517 0 obj <>/Alt(Tier 1)/P 6496 0 R/K 32045 0 R>> endobj 18518 0 obj <>/Alt(\(Begin italic\) glyburide oral tablet \(End italic\) \(Begin italic\) 1.25 mg, 2.5 mg, 5 mg \(End italic\))/P 6497 0 R/K 32046 0 R>> endobj 18519 0 obj <>/Alt(Tier 1)/P 6497 0 R/K 32047 0 R>> endobj 18520 0 obj <>/Alt(\(Begin italic\) nateglinide oral tablet \(End italic\) \(Begin italic\) 120 mg, 60 mg \(End italic\))/P 6498 0 R/K 32048 0 R>> endobj 18521 0 obj <>/Alt(Tier 1)/P 6498 0 R/K 32049 0 R>> endobj 18522 0 obj <>/Alt(\(Begin italic\) repaglinide oral tablet \(End italic\) \(Begin italic\) 0.5 mg, 1 mg, 2 mg \(End italic\))/P 6499 0 R/K 32050 0 R>> endobj 18523 0 obj <>/Alt(Tier 1)/P 6499 0 R/K 32051 0 R>> endobj 18524 0 obj <>/Alt(\(Begin bold\) Antihyperglycemic, Insulin-Response Enhancer \(N-S\) \(End bold\))/P 6500 0 R/K 32052 0 R>> endobj 18525 0 obj <>/Alt(\(Begin italic\) pioglitazone oral tablet \(End italic\) \(Begin italic\) 15 mg, 30 mg, 45 mg \(End italic\))/P 6501 0 R/K 32053 0 R>> endobj 18526 0 obj <>/Alt(\(Actos\))/P 6501 0 R/K 32054 0 R>> endobj 18527 0 obj <>/Alt(Tier 1)/P 6501 0 R/K 32055 0 R>> endobj 18528 0 obj <>/Alt(\(Begin bold\) Antihyperglycemic, Sglt-2 & Dpp-4 Inhibitor Comb. \(End bold\))/P 6502 0 R/K 32056 0 R>> endobj 18529 0 obj <>/Alt(GLYXAMBI ORAL TABLET 10-5 MG, 25-5 MG)/P 6503 0 R/K 32057 0 R>> endobj 18530 0 obj <>/Alt(Tier 2)/P 6503 0 R/K 32058 0 R>> endobj 18531 0 obj <>/Alt(QL \(1 EA per 1 day\))/P 6503 0 R/K 32059 0 R>> endobj 18532 0 obj <>/Alt(\(Begin bold\) Antihyperglycemic,Biguanide Type\(Non-Sulfonylurea\) \(End bold\))/P 6504 0 R/K 32060 0 R>> endobj 18533 0 obj <>/Alt(\(Begin italic\) metformin oral solution \(End italic\) \(Begin italic\) 500 mg/5 ml \(End italic\))/P 6505 0 R/K 32061 0 R>> endobj 18534 0 obj <>/Alt(\(Riomet\))/P 6505 0 R/K 32062 0 R>> endobj 18535 0 obj <>/Alt(Tier 1)/P 6505 0 R/K 32063 0 R>> endobj 18536 0 obj <>/Alt(\(Begin italic\) metformin oral tablet \(End italic\) \(Begin italic\) 1,000 mg, 500 mg, 850 mg \(End italic\))/P 6506 0 R/K 32064 0 R>> endobj 18537 0 obj <>/Alt(Tier 1)/P 6506 0 R/K 32065 0 R>> endobj 18538 0 obj <>/Alt(\(Begin italic\) metformin oral tablet extended release 24 hr \(End italic\) \(Begin italic\) 500 mg, 750 mg \(End italic\))/P 6507 0 R/K 32066 0 R>> endobj 18539 0 obj <>/Alt(Tier 1)/P 6507 0 R/K 32067 0 R>> endobj 18540 0 obj <>/Alt(\(Begin bold\) Antihyperglycemic,Insulin & Glp-1 Receptor Agonist \(End bold\))/P 6508 0 R/K 32068 0 R>> endobj 18541 0 obj <>/Alt(SOLIQUA 100/33 SUBCUTANEOUS INSULIN PEN 100 UNIT-33 MCG/ML)/P 6509 0 R/K 32069 0 R>> endobj 18542 0 obj <>/Alt(Tier 2)/P 6509 0 R/K 32070 0 R>> endobj 18543 0 obj <>/Alt(QL \(30 ML per 28 days\))/P 6509 0 R/K 32071 0 R>> endobj 18544 0 obj <>/Alt(XULTOPHY 100/3.6 SUBCUTANEOUS INSULIN PEN 100 UNIT-3.6 MG /ML \(3 ML\))/P 6510 0 R/K 32072 0 R>> endobj 18545 0 obj <>/Alt(Tier 2)/P 6510 0 R/K 32073 0 R>> endobj 18546 0 obj <>/Alt(QL \(15 ML per 28 days\))/P 6510 0 R/K 32074 0 R>> endobj 18547 0 obj <>/Alt(\(Begin bold\) Antihyperglycemic,Insulin-Rel Stim.& Biguanide Cmb \(End bold\))/P 6511 0 R/K 32075 0 R>> endobj 18548 0 obj <>/Alt(\(Begin italic\) glipizide-metformin oral tablet \(End italic\) \(Begin italic\) 2.5-250 mg, 2.5-500 mg, 5-500 mg \(End italic\))/P 6512 0 R/K 32076 0 R>> endobj 18549 0 obj <>/Alt(Tier 1)/P 6512 0 R/K 32077 0 R>> endobj 18550 0 obj <>/Alt(\(Begin italic\) glyburide-metformin oral tablet \(End 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Junior KwikPen U-100\))/P 6685 0 R/K 32524 0 R>> endobj 18997 0 obj <>/Alt(Tier 1)/P 6685 0 R/K 32525 0 R>> endobj 18998 0 obj <>/Alt(QL \(30 ML per 28 days\))/P 6685 0 R/K 32526 0 R>> endobj 18999 0 obj <>/Alt(\(Begin italic\) insulin lispro subcutaneous solution \(End italic\) \(Begin italic\) 100 unit/ml \(End italic\))/P 6686 0 R/K 32527 0 R>> endobj 19000 0 obj <>/Alt(\(Admelog U-100 Insulin lispro\))/P 6686 0 R/K 32528 0 R>> endobj 19001 0 obj <>/Alt(Tier 1)/P 6686 0 R/K 32529 0 R>> endobj 19002 0 obj <>/Alt(QL \(40 ML per 28 days\))/P 6686 0 R/K 32530 0 R>> endobj 19003 0 obj <>/Alt(LYUMJEV KWIKPEN U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML)/P 6687 0 R/K 32531 0 R>> endobj 19004 0 obj <>/Alt(Tier 2)/P 6687 0 R/K 32532 0 R>> endobj 19005 0 obj <>/Alt(QL \(30 ML per 28 days\))/P 6687 0 R/K 32533 0 R>> endobj 19006 0 obj <>/Alt(LYUMJEV KWIKPEN U-200 INSULIN SUBCUTANEOUS INSULIN PEN 200 UNIT/ML \(3 ML\))/P 6688 0 R/K 32534 0 R>> endobj 19007 0 obj <>/Alt(Tier 2)/P 6688 0 R/K 32535 0 R>> endobj 19008 0 obj <>/Alt(QL \(12 ML per 28 days\))/P 6688 0 R/K 32536 0 R>> endobj 19009 0 obj <>/Alt(LYUMJEV U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNIT/ML)/P 6689 0 R/K 32537 0 R>> endobj 19010 0 obj <>/Alt(Tier 2)/P 6689 0 R/K 32538 0 R>> endobj 19011 0 obj <>/Alt(QL \(40 ML per 28 days\))/P 6689 0 R/K 32539 0 R>> endobj 19012 0 obj <>/Alt(SEMGLEE\(INSULIN GLARGINE-YFGN\) SUBCUTANEOUS SOLUTION 100 UNIT/ML)/P 6690 0 R/K 32540 0 R>> endobj 19013 0 obj <>/Alt(\(insulin glargine-yfgn\))/P 6690 0 R/K 32541 0 R>> endobj 19014 0 obj <>/Alt(Tier 2)/P 6690 0 R/K 32542 0 R>> endobj 19015 0 obj <>/Alt(QL \(40 ML per 28 days\))/P 6690 0 R/K 32543 0 R>> endobj 19016 0 obj <>/Alt(SEMGLEE\(INSULIN GLARG-YFGN\)PEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML \(3 ML\))/P 6691 0 R/K 32544 0 R>> endobj 19017 0 obj <>/Alt(\(insulin glargine-yfgn\))/P 6691 0 R/K 32545 0 R>> endobj 19018 0 obj <>/Alt(Tier 2)/P 6691 0 R/K 32546 0 R>> endobj 19019 0 obj <>/Alt(QL \(30 ML per 28 days\))/P 6691 0 R/K 32547 0 R>> endobj 19020 0 obj <>/Alt(TOUJEO MAX U-300 SOLOSTAR SUBCUTANEOUS INSULIN PEN 300 UNIT/ML \(3 ML\))/P 6692 0 R/K 32548 0 R>> endobj 19021 0 obj <>/Alt(\(insulin glargine u-300 conc\))/P 6692 0 R/K 32549 0 R>> endobj 19022 0 obj <>/Alt(Tier 2)/P 6692 0 R/K 32550 0 R>> endobj 19023 0 obj <>/Alt(QL \(18 ML per 28 days\))/P 6692 0 R/K 32551 0 R>> endobj 19024 0 obj <>/Alt(TOUJEO SOLOSTAR U-300 INSULIN SUBCUTANEOUS INSULIN PEN 300 UNIT/ML \(1.5 ML\))/P 6693 0 R/K 32552 0 R>> endobj 19025 0 obj <>/Alt(\(insulin glargine u-300 conc\))/P 6693 0 R/K 32553 0 R>> endobj 19026 0 obj <>/Alt(Tier 2)/P 6693 0 R/K 32554 0 R>> endobj 19027 0 obj <>/Alt(QL \(13.5 ML per 28 days\))/P 6693 0 R/K 32555 0 R>> endobj 19028 0 obj <>/Alt(TRESIBA FLEXTOUCH U-100 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML \(3 ML\))/P 6694 0 R/K 32556 0 R>> endobj 19029 0 obj <>/Alt(\(insulin degludec\))/P 6694 0 R/K 32557 0 R>> endobj 19030 0 obj <>/Alt(Tier 2)/P 6694 0 R/K 32558 0 R>> endobj 19031 0 obj <>/Alt(QL \(30 ML per 28 days\))/P 6694 0 R/K 32559 0 R>> endobj 19032 0 obj <>/Alt(TRESIBA FLEXTOUCH U-200 SUBCUTANEOUS INSULIN PEN 200 UNIT/ML \(3 ML\))/P 6695 0 R/K 32560 0 R>> endobj 19033 0 obj <>/Alt(\(insulin degludec\))/P 6695 0 R/K 32561 0 R>> endobj 19034 0 obj <>/Alt(Tier 2)/P 6695 0 R/K 32562 0 R>> endobj 19035 0 obj <>/Alt(QL \(18 ML per 28 days\))/P 6695 0 R/K 32563 0 R>> endobj 19036 0 obj <>/Alt(TRESIBA U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNIT/ML)/P 6696 0 R/K 32564 0 R>> endobj 19037 0 obj <>/Alt(\(insulin degludec\))/P 6696 0 R/K 32565 0 R>> endobj 19038 0 obj <>/Alt(Tier 2)/P 6696 0 R/K 32566 0 R>> endobj 19039 0 obj <>/Alt(QL \(40 ML per 28 days\))/P 6696 0 R/K 32567 0 R>> endobj 19040 0 obj <>/Alt(\(Begin bold\) Ear - General Disorders \(End bold\))/P 6697 0 R/K 32568 0 R>> endobj 19041 0 obj <>/Alt(\(Begin bold\) Ear Preparations Anti-Inflammatory \(End bold\))/P 6698 0 R/K 32569 0 R>> endobj 19042 0 obj <>/Alt(\(Begin italic\) fluocinolone acetonide oil otic \(ear\) drops 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<>/Alt(Tier 1)/P 6705 0 R/K 32583 0 R>> endobj 19056 0 obj <>/Alt(CORTISPORIN-TC OTIC \(EAR\) DROPS,SUSPENSION 3.3-3-10-0.5 MG/ML)/P 6706 0 R/K 32584 0 R>> endobj 19057 0 obj <>/Alt(Tier 3)/P 6706 0 R/K 32585 0 R>> endobj 19058 0 obj <>/Alt(\(Begin italic\) neomycin-polymyxin-hc otic \(ear\) drops,suspension \(End italic\) \(Begin italic\) 3.5-10,000-1 mg/ml-unit/ml-% \(End italic\))/P 6707 0 R/K 32586 0 R>> endobj 19059 0 obj <>/Alt(Tier 1)/P 6707 0 R/K 32587 0 R>> endobj 19060 0 obj <>/Alt(\(Begin italic\) neomycin-polymyxin-hc otic \(ear\) solution \(End italic\) \(Begin italic\) 3.5-10,000-1 mg/ml-unit/ml-% \(End italic\))/P 6708 0 R/K 32588 0 R>> endobj 19061 0 obj <>/Alt(Tier 1)/P 6708 0 R/K 32589 0 R>> endobj 19062 0 obj <>/Alt(\(Begin italic\) ofloxacin otic \(ear\) drops \(End italic\) \(Begin italic\) 0.3 % \(End italic\))/P 6709 0 R/K 32590 0 R>> endobj 19063 0 obj <>/Alt(Tier 1)/P 6709 0 R/K 32591 0 R>> endobj 19064 0 obj <>/Alt(\(Begin bold\) Otic 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32600 0 R>> endobj 19073 0 obj <>/Alt(\(Samsca\))/P 6715 0 R/K 32601 0 R>> endobj 19074 0 obj <>/Alt(Tier 1)/P 6715 0 R/K 32602 0 R>> endobj 19075 0 obj <>/Alt(SP; QL \(30 EA per 365 days\))/P 6715 0 R/K 32603 0 R>> endobj 19076 0 obj <>/Alt(\(Begin italic\) tolvaptan oral tablet \(End italic\) \(Begin italic\) 30 mg \(End italic\))/P 6716 0 R/K 32604 0 R>> endobj 19077 0 obj <>/Alt(\(Samsca\))/P 6716 0 R/K 32605 0 R>> endobj 19078 0 obj <>/Alt(Tier 1)/P 6716 0 R/K 32606 0 R>> endobj 19079 0 obj <>/Alt(SP; QL \(60 EA per 365 days\))/P 6716 0 R/K 32607 0 R>> endobj 19080 0 obj <>/Alt(\(Begin bold\) Bicarbonate Producing/Containing Agents \(End bold\))/P 6717 0 R/K 32608 0 R>> endobj 19081 0 obj <>/Alt(VAXCHORA BUFFER COMPONENT ORAL SUSPENSION FOR RECONSTITUTION)/P 6718 0 R/K 32609 0 R>> endobj 19082 0 obj <>/Alt(Tier 3)/P 6718 0 R/K 32610 0 R>> endobj 19083 0 obj <>/Alt(\(Begin bold\) Electrolyte Depleters \(End bold\))/P 6719 0 R/K 32611 0 R>> endobj 19084 0 obj <>/Alt(\(Begin italic\) calcium acetate\(phosphat bind\) oral capsule \(End italic\) \(Begin italic\) 667 mg \(End italic\))/P 6720 0 R/K 32612 0 R>> endobj 19085 0 obj <>/Alt(Tier 1)/P 6720 0 R/K 32613 0 R>> endobj 19086 0 obj <>/Alt(\(Begin italic\) calcium acetate\(phosphat bind\) oral tablet \(End italic\) \(Begin italic\) 667 mg \(End italic\))/P 6721 0 R/K 32614 0 R>> endobj 19087 0 obj <>/Alt(Tier 1)/P 6721 0 R/K 32615 0 R>> endobj 19088 0 obj <>/Alt(FOSRENOL ORAL POWDER IN PACKET 1,000 MG, 750 MG)/P 6722 0 R/K 32616 0 R>> endobj 19089 0 obj <>/Alt(Tier 3)/P 6722 0 R/K 32617 0 R>> endobj 19090 0 obj <>/Alt(ST: Requires prior prescriptions for Velphoro and one of the folllowing: generic Sevelamer HCL, Sevelamer Carbonate, Calcium Acetate, or Lanthanum Carbonate within the past 365 days; QL \(3 EA per 1 day\))/P 6722 0 R/K 32618 0 R>> endobj 19091 0 obj <>/Alt(KIONEX \(WITH SORBITOL\) ORAL SUSPENSION 15-20 GRAM/60 ML)/P 6723 0 R/K 32619 0 R>> endobj 19092 0 obj <>/Alt(Tier 1)/P 6723 0 R/K 32620 0 R>> endobj 19093 0 obj <>/Alt(\(Begin italic\) lanthanum oral tablet,chewable \(End italic\) \(Begin italic\) 1,000 mg, 500 mg, 750 mg \(End italic\))/P 6724 0 R/K 32621 0 R>> endobj 19094 0 obj <>/Alt(\(Fosrenol\))/P 6724 0 R/K 32622 0 R>> endobj 19095 0 obj <>/Alt(Tier 1)/P 6724 0 R/K 32623 0 R>> endobj 19096 0 obj <>/Alt(LOKELMA ORAL POWDER IN PACKET 10 GRAM, 5 GRAM)/P 6725 0 R/K 32624 0 R>> endobj 19097 0 obj <>/Alt(Tier 2)/P 6725 0 R/K 32625 0 R>> endobj 19098 0 obj <>/Alt(\(Begin italic\) sevelamer carbonate oral powder in packet \(End italic\) \(Begin italic\) 0.8 gram, 2.4 gram \(End italic\))/P 6726 0 R/K 32626 0 R>> endobj 19099 0 obj <>/Alt(\(Renvela\))/P 6726 0 R/K 32627 0 R>> endobj 19100 0 obj <>/Alt(Tier 1)/P 6726 0 R/K 32628 0 R>> endobj 19101 0 obj <>/Alt(\(Begin italic\) sevelamer carbonate oral tablet \(End italic\) \(Begin italic\) 800 mg \(End italic\))/P 6727 0 R/K 32629 0 R>> endobj 19102 0 obj <>/Alt(\(Renvela\))/P 6727 0 R/K 32630 0 R>> endobj 19103 0 obj <>/Alt(Tier 1)/P 6727 0 R/K 32631 0 R>> endobj 19104 0 obj <>/Alt(\(Begin italic\) sevelamer hcl oral tablet \(End italic\) \(Begin italic\) 400 mg, 800 mg \(End italic\))/P 6728 0 R/K 32632 0 R>> endobj 19105 0 obj <>/Alt(Tier 1)/P 6728 0 R/K 32633 0 R>> endobj 19106 0 obj <>/Alt(\(Begin italic\) sodium polystyrene sulfonate oral powder \(End italic\) \(Begin italic\) \(End italic\))/P 6729 0 R/K 32634 0 R>> endobj 19107 0 obj <>/Alt(Tier 1)/P 6729 0 R/K 32635 0 R>> endobj 19108 0 obj <>/Alt(SPS \(WITH SORBITOL\) ORAL SUSPENSION 15-20 GRAM/60 ML)/P 6730 0 R/K 32636 0 R>> endobj 19109 0 obj <>/Alt(Tier 1)/P 6730 0 R/K 32637 0 R>> endobj 19110 0 obj <>/Alt(SPS \(WITH SORBITOL\) RECTAL ENEMA 30-40 GRAM/120 ML)/P 6731 0 R/K 32638 0 R>> endobj 19111 0 obj <>/Alt(Tier 3)/P 6731 0 R/K 32639 0 R>> endobj 19112 0 obj <>/Alt(VELPHORO ORAL TABLET,CHEWABLE 500 MG)/P 6732 0 R/K 32640 0 R>> endobj 19113 0 obj <>/Alt(Tier 2)/P 6732 0 R/K 32641 0 R>> endobj 19114 0 obj <>/Alt(QL \(6 EA per 1 day\))/P 6732 0 R/K 32642 0 R>> endobj 19115 0 obj <>/Alt(VELTASSA ORAL POWDER IN PACKET 1 GRAM, 16.8 GRAM, 25.2 GRAM, 8.4 GRAM)/P 6733 0 R/K 32643 0 R>> endobj 19116 0 obj <>/Alt(Tier 3)/P 6733 0 R/K 32644 0 R>> endobj 19117 0 obj <>/Alt(PA)/P 6733 0 R/K 32645 0 R>> endobj 19118 0 obj <>/Alt(XPHOZAH ORAL TABLET 20 MG, 30 MG)/P 6734 0 R/K 32646 0 R>> endobj 19119 0 obj <>/Alt(Tier 3)/P 6734 0 R/K 32647 0 R>> endobj 19120 0 obj <>/Alt(ST: Requires prior prescriptions for Velphoro and one of the folllowing: generic Sevelamer HCL, Sevelamer Carbonate, Calcium Acetate, or Lanthanum Carbonate within the past 365 days; QL \(2 EA per 1 day\))/P 6734 0 R/K 32648 0 R>> endobj 19121 0 obj <>/Alt(\(Begin bold\) Potassium Replacement \(End bold\))/P 6735 0 R/K 32649 0 R>> endobj 19122 0 obj <>/Alt(EFFER-K ORAL TABLET, EFFERVESCENT 10 MEQ, 20 MEQ)/P 6736 0 R/K 32650 0 R>> endobj 19123 0 obj <>/Alt(Tier 3)/P 6736 0 R/K 32651 0 R>> endobj 19124 0 obj <>/Alt(EFFER-K ORAL TABLET, EFFERVESCENT 25 MEQ)/P 6737 0 R/K 32652 0 R>> endobj 19125 0 obj <>/Alt(\(potassium bicarb-citric acid\))/P 6737 0 R/K 32653 0 R>> endobj 19126 0 obj <>/Alt(Tier 1)/P 6737 0 R/K 32654 0 R>> endobj 19127 0 obj <>/Alt(KLOR-CON M10 ORAL TABLET,ER PARTICLES/CRYSTALS 10 MEQ)/P 6738 0 R/K 32655 0 R>> endobj 19128 0 obj <>/Alt(\(potassium chloride\))/P 6738 0 R/K 32656 0 R>> endobj 19129 0 obj <>/Alt(Tier 1)/P 6738 0 R/K 32657 0 R>> endobj 19130 0 obj <>/Alt(KLOR-CON M15 ORAL TABLET,ER PARTICLES/CRYSTALS 15 MEQ)/P 6739 0 R/K 32658 0 R>> endobj 19131 0 obj <>/Alt(\(potassium chloride\))/P 6739 0 R/K 32659 0 R>> endobj 19132 0 obj <>/Alt(Tier 1)/P 6739 0 R/K 32660 0 R>> endobj 19133 0 obj <>/Alt(KLOR-CON M20 ORAL TABLET,ER PARTICLES/CRYSTALS 20 MEQ)/P 6740 0 R/K 32661 0 R>> endobj 19134 0 obj <>/Alt(\(potassium chloride\))/P 6740 0 R/K 32662 0 R>> endobj 19135 0 obj <>/Alt(Tier 1)/P 6740 0 R/K 32663 0 R>> endobj 19136 0 obj <>/Alt(\(Begin italic\) potassium chloride oral capsule, extended release \(End italic\) \(Begin italic\) 10 meq, 8 meq \(End italic\))/P 6741 0 R/K 32664 0 R>> endobj 19137 0 obj <>/Alt(Tier 1)/P 6741 0 R/K 32665 0 R>> endobj 19138 0 obj <>/Alt(\(Begin italic\) potassium chloride oral liquid \(End italic\) \(Begin italic\) 20 meq/15 ml, 40 meq/15 ml \(End italic\))/P 6742 0 R/K 32666 0 R>> endobj 19139 0 obj <>/Alt(Tier 1)/P 6742 0 R/K 32667 0 R>> endobj 19140 0 obj <>/Alt(\(Begin italic\) potassium chloride oral packet \(End italic\) \(Begin italic\) 20 meq \(End italic\))/P 6743 0 R/K 32668 0 R>> endobj 19141 0 obj <>/Alt(\(Klor-Con\))/P 6743 0 R/K 32669 0 R>> endobj 19142 0 obj <>/Alt(Tier 1)/P 6743 0 R/K 32670 0 R>> endobj 19143 0 obj <>/Alt(\(Begin italic\) potassium chloride oral tablet extended release \(End italic\) \(Begin italic\) 10 meq \(End italic\))/P 6744 0 R/K 32671 0 R>> endobj 19144 0 obj <>/Alt(\(Klor-Con 10\))/P 6744 0 R/K 32672 0 R>> endobj 19145 0 obj <>/Alt(Tier 1)/P 6744 0 R/K 32673 0 R>> endobj 19146 0 obj <>/Alt(\(Begin italic\) potassium chloride oral 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R/K 32683 0 R>> endobj 19156 0 obj <>/Alt(Tier 1)/P 6748 0 R/K 32684 0 R>> endobj 19157 0 obj <>/Alt(\(Begin italic\) potassium chloride oral tablet,er particles/crystals \(End italic\) \(Begin italic\) 20 meq \(End italic\))/P 6749 0 R/K 32685 0 R>> endobj 19158 0 obj <>/Alt(\(Klor-Con M20\))/P 6749 0 R/K 32686 0 R>> endobj 19159 0 obj <>/Alt(Tier 1)/P 6749 0 R/K 32687 0 R>> endobj 19160 0 obj <>/Alt(\(Begin bold\) Sodium/Saline Preparations \(End bold\))/P 6750 0 R/K 32688 0 R>> endobj 19161 0 obj <>/Alt(BD POSIFLUSH NORMAL SALINE 0.9 INJECTION SYRINGE)/P 6751 0 R/K 32689 0 R>> endobj 19162 0 obj <>/Alt(\(sodium chloride 0.9 % \(flush\)\))/P 6751 0 R/K 32690 0 R>> endobj 19163 0 obj <>/Alt(Tier 1)/P 6751 0 R/K 32691 0 R>> endobj 19164 0 obj <>/Alt(CLEARSHIELD SODIUM CHLOR FLUSH INJECTION SYRINGE)/P 6752 0 R/K 32692 0 R>> endobj 19165 0 obj <>/Alt(\(sodium chloride 0.9 % \(flush\)\))/P 6752 0 R/K 32693 0 R>> endobj 19166 0 obj <>/Alt(Tier 1)/P 6752 0 R/K 32694 0 R>> endobj 19167 0 obj <>/Alt(NORMAL SALINE FLUSH INJECTION SYRINGE)/P 6753 0 R/K 32695 0 R>> endobj 19168 0 obj <>/Alt(\(sodium chloride 0.9 % \(flush\)\))/P 6753 0 R/K 32696 0 R>> endobj 19169 0 obj <>/Alt(Tier 1)/P 6753 0 R/K 32697 0 R>> endobj 19170 0 obj <>/Alt(\(Begin italic\) sodium chlor 0.9% bacteriostat injection solution \(End italic\) \(Begin italic\) 0.9 % \(End italic\))/P 6754 0 R/K 32698 0 R>> endobj 19171 0 obj <>/Alt(Tier 1)/P 6754 0 R/K 32699 0 R>> endobj 19172 0 obj <>/Alt(\(Begin italic\) sodium chloride 0.45 % intravenous parenteral solution \(End italic\) \(Begin italic\) 0.45 % \(End italic\))/P 6755 0 R/K 32700 0 R>> endobj 19173 0 obj <>/Alt(Tier 1)/P 6755 0 R/K 32701 0 R>> endobj 19174 0 obj <>/Alt(\(Begin italic\) sodium chloride 0.9 % \(flush\) injection syringe \(End italic\) \(Begin italic\) \(End italic\))/P 6756 0 R/K 32702 0 R>> endobj 19175 0 obj <>/Alt(\(BD PosiFlush Normal Saline 0.9\))/P 6756 0 R/K 32703 0 R>> endobj 19176 0 obj <>/Alt(Tier 1)/P 6756 0 R/K 32704 0 R>> endobj 19177 0 obj <>/Alt(\(Begin italic\) sodium chloride 0.9 % injection solution \(End italic\) \(Begin italic\) \(End italic\))/P 6757 0 R/K 32705 0 R>> endobj 19178 0 obj <>/Alt(Tier 1)/P 6757 0 R/K 32706 0 R>> endobj 19179 0 obj <>/Alt(\(Begin italic\) sodium chloride 0.9 % intravenous parenteral solution \(End italic\) \(Begin italic\) \(End italic\))/P 6758 0 R/K 32707 0 R>> endobj 19180 0 obj <>/Alt(Tier 1)/P 6758 0 R/K 32708 0 R>> endobj 19181 0 obj <>/Alt(\(Begin italic\) sodium chloride 0.9 % intravenous piggyback \(End italic\) \(Begin italic\) \(End italic\))/P 6759 0 R/K 32709 0 R>> endobj 19182 0 obj <>/Alt(Tier 1)/P 6759 0 R/K 32710 0 R>> endobj 19183 0 obj <>/Alt(\(Begin italic\) sodium chloride injection syringe \(End italic\) \(Begin italic\) 0.9 % \(End italic\))/P 6760 0 R/K 32711 0 R>> endobj 19184 0 obj <>/Alt(Tier 1)/P 6760 0 R/K 32712 0 R>> endobj 19185 0 obj <>/Alt(\(Begin bold\) Endocrine Disorder - Fertility \(End bold\))/P 6761 0 R/K 32713 0 R>> endobj 19186 0 obj <>/Alt(\(Begin bold\) Drugs To Treat Impotency \(End bold\))/P 6762 0 R/K 32714 0 R>> endobj 19187 0 obj <>/Alt(\(Begin italic\) avanafil oral tablet \(End italic\) \(Begin italic\) 100 mg, 200 mg, 50 mg \(End italic\))/P 6763 0 R/K 32715 0 R>> endobj 19188 0 obj <>/Alt(\(Stendra\))/P 6763 0 R/K 32716 0 R>> endobj 19189 0 obj <>/Alt(Tier 1)/P 6763 0 R/K 32717 0 R>> endobj 19190 0 obj <>/Alt(ST: Requires prior prescription for Viagra within the past 120 days; QL \(1 EA per 5 days\))/P 6763 0 R/K 32718 0 R>> endobj 19191 0 obj <>/Alt(CAVERJECT IMPULSE INTRACAVERNOSAL KIT 10 MCG, 20 MCG)/P 6764 0 R/K 32719 0 R>> endobj 19192 0 obj <>/Alt(Tier 3)/P 6764 0 R/K 32720 0 R>> endobj 19193 0 obj <>/Alt(QL \(1 EA per 5 days\))/P 6764 0 R/K 32721 0 R>> endobj 19194 0 obj <>/Alt(CAVERJECT INTRACAVERNOSAL RECON SOLN 20 MCG, 40 MCG)/P 6765 0 R/K 32722 0 R>> endobj 19195 0 obj <>/Alt(Tier 3)/P 6765 0 R/K 32723 0 R>> endobj 19196 0 obj <>/Alt(QL \(1 EA per 5 days\))/P 6765 0 R/K 32724 0 R>> 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0 R>> endobj 19209 0 obj <>/Alt(QL \(1 EA per 5 days\))/P 6769 0 R/K 32737 0 R>> endobj 19210 0 obj <>/Alt(\(Begin italic\) tadalafil oral tablet \(End italic\) \(Begin italic\) 10 mg, 20 mg \(End italic\))/P 6770 0 R/K 32738 0 R>> endobj 19211 0 obj <>/Alt(\(Cialis\))/P 6770 0 R/K 32739 0 R>> endobj 19212 0 obj <>/Alt(Tier 1)/P 6770 0 R/K 32740 0 R>> endobj 19213 0 obj <>/Alt(QL \(1 EA per 5 days\))/P 6770 0 R/K 32741 0 R>> endobj 19214 0 obj <>/Alt(\(Begin italic\) tadalafil oral tablet \(End italic\) \(Begin italic\) 2.5 mg \(End italic\))/P 6771 0 R/K 32742 0 R>> endobj 19215 0 obj <>/Alt(Tier 1)/P 6771 0 R/K 32743 0 R>> endobj 19216 0 obj <>/Alt(PA)/P 6771 0 R/K 32744 0 R>> endobj 19217 0 obj <>/Alt(\(Begin italic\) tadalafil oral tablet \(End italic\) \(Begin italic\) 5 mg \(End italic\))/P 6772 0 R/K 32745 0 R>> endobj 19218 0 obj <>/Alt(\(Cialis\))/P 6772 0 R/K 32746 0 R>> endobj 19219 0 obj <>/Alt(Tier 1)/P 6772 0 R/K 32747 0 R>> endobj 19220 0 obj <>/Alt(PA)/P 6772 0 R/K 32748 0 R>> endobj 19221 0 obj <>/Alt(TRI-MIX \(PAPAVRN-PHNTLMN-PGE1\) INTRACAVERNOSAL RECON SOLN 150 MG-5 MG- 50 MCG)/P 6773 0 R/K 32749 0 R>> endobj 19222 0 obj <>/Alt(Tier 3)/P 6773 0 R/K 32750 0 R>> endobj 19223 0 obj <>/Alt(\(Begin bold\) Fertility Stimulating Preparations,Non-Fsh \(End bold\))/P 6774 0 R/K 32751 0 R>> endobj 19224 0 obj <>/Alt(CLOMID ORAL TABLET 50 MG)/P 6775 0 R/K 32752 0 R>> endobj 19225 0 obj <>/Alt(\(clomiphene citrate\))/P 6775 0 R/K 32753 0 R>> endobj 19226 0 obj <>/Alt(Tier 3)/P 6775 0 R/K 32754 0 R>> endobj 19227 0 obj <>/Alt(\(Begin italic\) clomiphene citrate oral tablet \(End italic\) \(Begin italic\) 50 mg \(End italic\))/P 6776 0 R/K 32755 0 R>> endobj 19228 0 obj <>/Alt(\(Clomid\))/P 6776 0 R/K 32756 0 R>> endobj 19229 0 obj <>/Alt(Tier 1)/P 6776 0 R/K 32757 0 R>> endobj 19230 0 obj <>/Alt(\(Begin bold\) Follicle Stim./Luteinizing Hormones \(End bold\))/P 6777 0 R/K 32758 0 R>> endobj 19231 0 obj <>/Alt(MENOPUR SUBCUTANEOUS RECON SOLN 75 UNIT)/P 6778 0 R/K 32759 0 R>> endobj 19232 0 obj <>/Alt(Tier 2)/P 6778 0 R/K 32760 0 R>> endobj 19233 0 obj <>/Alt(SP)/P 6778 0 R/K 32761 0 R>> endobj 19234 0 obj <>/Alt(\(Begin bold\) Follicle-Stimulating Hormone \(Fsh\) \(End bold\))/P 6779 0 R/K 32762 0 R>> endobj 19235 0 obj <>/Alt(FOLLISTIM AQ SUBCUTANEOUS CARTRIDGE 300 UNIT/0.36 ML, 600 UNIT/0.72 ML, 900 UNIT/1.08 ML)/P 6780 0 R/K 32763 0 R>> endobj 19236 0 obj <>/Alt(Tier 3)/P 6780 0 R/K 32764 0 R>> endobj 19237 0 obj <>/Alt(SP; ST: Requires prior prescription for Gonal-F or Gonal-F-RFF within the past 120 days)/P 6780 0 R/K 32765 0 R>> endobj 19238 0 obj <>/Alt(GONAL-F RFF REDI-JECT SUBCUTANEOUS PEN INJECTOR 300/0.5 UNIT/ML, 450/0.75 UNIT/ML, 900/1.5 UNIT/ML)/P 6781 0 R/K 32766 0 R>> endobj 19239 0 obj <>/Alt(Tier 2)/P 6781 0 R/K 32767 0 R>> endobj 19240 0 obj <>/Alt(SP)/P 6781 0 R/K 32768 0 R>> endobj 19241 0 obj <>/Alt(GONAL-F RFF SUBCUTANEOUS RECON SOLN 75 UNIT)/P 6782 0 R/K 32769 0 R>> endobj 19242 0 obj <>/Alt(Tier 2)/P 6782 0 R/K 32770 0 R>> endobj 19243 0 obj <>/Alt(SP)/P 6782 0 R/K 32771 0 R>> endobj 19244 0 obj <>/Alt(GONAL-F SUBCUTANEOUS RECON SOLN 1,050 UNIT, 450 UNIT)/P 6783 0 R/K 32772 0 R>> endobj 19245 0 obj <>/Alt(Tier 2)/P 6783 0 R/K 32773 0 R>> endobj 19246 0 obj <>/Alt(SP)/P 6783 0 R/K 32774 0 R>> endobj 19247 0 obj <>/Alt(\(Begin bold\) Human Chorionic Gonadotropin \(Hcg\) \(End bold\))/P 6784 0 R/K 32775 0 R>> endobj 19248 0 obj <>/Alt(\(Begin italic\) chorionic gonadotropin, human intramuscular recon soln \(End italic\) \(Begin italic\) 10,000 unit \(End italic\))/P 6785 0 R/K 32776 0 R>> endobj 19249 0 obj <>/Alt(\(Pregnyl\))/P 6785 0 R/K 32777 0 R>> endobj 19250 0 obj <>/Alt(Tier 3)/P 6785 0 R/K 32778 0 R>> endobj 19251 0 obj <>/Alt(ST: Requires prior prescription for Novarel or Ovidrel within the past 120 days)/P 6785 0 R/K 32779 0 R>> endobj 19252 0 obj <>/Alt(NOVAREL INTRAMUSCULAR RECON SOLN 5,000 UNIT)/P 6786 0 R/K 32780 0 R>> endobj 19253 0 obj <>/Alt(Tier 2)/P 6786 0 R/K 32781 0 R>> endobj 19254 0 obj <>/Alt(OVIDREL SUBCUTANEOUS SYRINGE 250 MCG/0.5 ML)/P 6787 0 R/K 32782 0 R>> endobj 19255 0 obj <>/Alt(Tier 2)/P 6787 0 R/K 32783 0 R>> endobj 19256 0 obj <>/Alt(PREGNYL INTRAMUSCULAR RECON SOLN 10,000 UNIT)/P 6788 0 R/K 32784 0 R>> endobj 19257 0 obj <>/Alt(\(chorionic gonadotropin, human\))/P 6788 0 R/K 32785 0 R>> endobj 19258 0 obj <>/Alt(Tier 3)/P 6788 0 R/K 32786 0 R>> endobj 19259 0 obj <>/Alt(ST: Requires prior prescription for Novarel or Ovidrel within the past 120 days)/P 6788 0 R/K 32787 0 R>> endobj 19260 0 obj <>/Alt(\(Begin bold\) Pregnancy Facilitating/Maintaining Agent,Hormonal \(End bold\))/P 6789 0 R/K 32788 0 R>> endobj 19261 0 obj <>/Alt(CRINONE VAGINAL GEL 8 %)/P 6790 0 R/K 32789 0 R>> endobj 19262 0 obj <>/Alt(Tier 2)/P 6790 0 R/K 32790 0 R>> endobj 19263 0 obj <>/Alt(ENDOMETRIN VAGINAL INSERT 100 MG)/P 6791 0 R/K 32791 0 R>> endobj 19264 0 obj <>/Alt(Tier 2)/P 6791 0 R/K 32792 0 R>> endobj 19265 0 obj <>/Alt(\(Begin bold\) Endocrine Disorder - Other \(End bold\))/P 6792 0 R/K 32793 0 R>> endobj 19266 0 obj <>/Alt(\(Begin bold\) Adrenal Steroid Inhibitors \(End bold\))/P 6793 0 R/K 32794 0 R>> endobj 19267 0 obj <>/Alt(ISTURISA ORAL TABLET 1 MG, 5 MG)/P 6794 0 R/K 32795 0 R>> endobj 19268 0 obj <>/Alt(Tier 3)/P 6794 0 R/K 32796 0 R>> endobj 19269 0 obj <>/Alt(PA; SP)/P 6794 0 R/K 32797 0 R>> endobj 19270 0 obj <>/Alt(RECORLEV ORAL TABLET 150 MG)/P 6795 0 R/K 32798 0 R>> endobj 19271 0 obj <>/Alt(Tier 3)/P 6795 0 R/K 32799 0 R>> endobj 19272 0 obj <>/Alt(PA; SP)/P 6795 0 R/K 32800 0 R>> endobj 19273 0 obj <>/Alt(\(Begin bold\) Adrenocorticotrophic Hormones \(End bold\))/P 6796 0 R/K 32801 0 R>> endobj 19274 0 obj <>/Alt(ACTHAR INJECTION GEL 80 UNIT/ML)/P 6797 0 R/K 32802 0 R>> endobj 19275 0 obj <>/Alt(Tier 3)/P 6797 0 R/K 32803 0 R>> endobj 19276 0 obj <>/Alt(PA; SP)/P 6797 0 R/K 32804 0 R>> endobj 19277 0 obj <>/Alt(ACTHAR SELFJECT SUBCUTANEOUS PEN INJECTOR 40 UNIT/0.5 ML, 80 UNIT/ML)/P 6798 0 R/K 32805 0 R>> endobj 19278 0 obj <>/Alt(Tier 3)/P 6798 0 R/K 32806 0 R>> endobj 19279 0 obj <>/Alt(PA; SP)/P 6798 0 R/K 32807 0 R>> endobj 19280 0 obj <>/Alt(CORTROPHIN GEL INJECTION GEL 80 UNIT/ML)/P 6799 0 R/K 32808 0 R>> endobj 19281 0 obj <>/Alt(Tier 3)/P 6799 0 R/K 32809 0 R>> endobj 19282 0 obj <>/Alt(PA; SP)/P 6799 0 R/K 32810 0 R>> endobj 19283 0 obj <>/Alt(\(Begin bold\) Antidiuretic And Vasopressor Hormones \(End bold\))/P 6800 0 R/K 32811 0 R>> endobj 19284 0 obj <>/Alt(\(Begin italic\) desmopressin injection solution \(End italic\) \(Begin italic\) 4 mcg/ml \(End italic\))/P 6801 0 R/K 32812 0 R>> endobj 19285 0 obj <>/Alt(\(DDAVP\))/P 6801 0 R/K 32813 0 R>> endobj 19286 0 obj <>/Alt(Tier 1)/P 6801 0 R/K 32814 0 R>> endobj 19287 0 obj <>/Alt(\(Begin italic\) desmopressin nasal spray with pump \(End italic\) \(Begin italic\) 10 mcg/spray \(0.1 ml\) \(End italic\))/P 6802 0 R/K 32815 0 R>> endobj 19288 0 obj <>/Alt(Tier 1)/P 6802 0 R/K 32816 0 R>> endobj 19289 0 obj <>/Alt(\(Begin italic\) desmopressin nasal spray,non-aerosol \(End italic\) \(Begin italic\) 10 mcg/spray \(0.1 ml\), 150 mcg/spray \(0.1 ml\) \(End italic\))/P 6803 0 R/K 32817 0 R>> endobj 19290 0 obj <>/Alt(Tier 1)/P 6803 0 R/K 32818 0 R>> endobj 19291 0 obj <>/Alt(\(Begin italic\) desmopressin oral tablet \(End italic\) \(Begin italic\) 0.1 mg, 0.2 mg \(End italic\))/P 6804 0 R/K 32819 0 R>> endobj 19292 0 obj <>/Alt(\(DDAVP\))/P 6804 0 R/K 32820 0 R>> endobj 19293 0 obj <>/Alt(Tier 1)/P 6804 0 R/K 32821 0 R>> endobj 19294 0 obj <>/Alt(NOCDURNA \(MEN\) SUBLINGUAL TABLET,DISINTEGRATING 55.3 MCG)/P 6805 0 R/K 32822 0 R>> endobj 19295 0 obj <>/Alt(Tier 3)/P 6805 0 R/K 32823 0 R>> endobj 19296 0 obj <>/Alt(QL \(1 EA per 1 day\))/P 6805 0 R/K 32824 0 R>> endobj 19297 0 obj <>/Alt(NOCDURNA \(WOMEN\) SUBLINGUAL TABLET,DISINTEGRATING 27.7 MCG)/P 6806 0 R/K 32825 0 R>> endobj 19298 0 obj <>/Alt(Tier 3)/P 6806 0 R/K 32826 0 R>> endobj 19299 0 obj <>/Alt(QL \(1 EA per 1 day\))/P 6806 0 R/K 32827 0 R>> endobj 19300 0 obj <>/Alt(NOCTIVA NASAL SPRAY,NON-AEROSOL 0.83 MCG/SPRAY \(0.1 ML\), 1.66 MCG/SPRAY \(0.1 ML\))/P 6807 0 R/K 32828 0 R>> endobj 19301 0 obj <>/Alt(Tier 3)/P 6807 0 R/K 32829 0 R>> endobj 19302 0 obj <>/Alt(QL \(3.8 GM per 30 days\))/P 6807 0 R/K 32830 0 R>> endobj 19303 0 obj <>/Alt(\(Begin bold\) Antineoplastic Lhrh\(Gnrh\) Agonist,Pituitary Suppr. \(End bold\))/P 6808 0 R/K 32831 0 R>> endobj 19304 0 obj <>/Alt(ELIGARD \(3 MONTH\) SUBCUTANEOUS SYRINGE 22.5 MG)/P 6809 0 R/K 32832 0 R>> endobj 19305 0 obj <>/Alt(Tier 2)/P 6809 0 R/K 32833 0 R>> endobj 19306 0 obj <>/Alt(PA; SP)/P 6809 0 R/K 32834 0 R>> endobj 19307 0 obj <>/Alt(ELIGARD \(4 MONTH\) SUBCUTANEOUS SYRINGE 30 MG)/P 6810 0 R/K 32835 0 R>> endobj 19308 0 obj <>/Alt(Tier 2)/P 6810 0 R/K 32836 0 R>> endobj 19309 0 obj <>/Alt(PA; SP)/P 6810 0 R/K 32837 0 R>> endobj 19310 0 obj <>/Alt(ELIGARD \(6 MONTH\) SUBCUTANEOUS SYRINGE 45 MG)/P 6811 0 R/K 32838 0 R>> endobj 19311 0 obj <>/Alt(Tier 2)/P 6811 0 R/K 32839 0 R>> endobj 19312 0 obj <>/Alt(PA; SP)/P 6811 0 R/K 32840 0 R>> endobj 19313 0 obj <>/Alt(ELIGARD SUBCUTANEOUS SYRINGE 7.5 MG \(1 MONTH\))/P 6812 0 R/K 32841 0 R>> endobj 19314 0 obj <>/Alt(Tier 2)/P 6812 0 R/K 32842 0 R>> endobj 19315 0 obj <>/Alt(PA; SP)/P 6812 0 R/K 32843 0 R>> endobj 19316 0 obj <>/Alt(\(Begin italic\) leuprolide subcutaneous kit \(End italic\) \(Begin italic\) 1 mg/0.2 ml \(End italic\))/P 6813 0 R/K 32844 0 R>> endobj 19317 0 obj <>/Alt(Tier 1)/P 6813 0 R/K 32845 0 R>> endobj 19318 0 obj <>/Alt(PA; SP)/P 6813 0 R/K 32846 0 R>> endobj 19319 0 obj <>/Alt(\(Begin bold\) Bone Formation Stim. Agents - Parathyroid Hormone \(End bold\))/P 6814 0 R/K 32847 0 R>> endobj 19320 0 obj <>/Alt(\(Begin italic\) teriparatide subcutaneous pen injector \(End italic\) \(Begin italic\) 20 mcg/dose \(600mcg/2.4ml\) \(End italic\))/P 6815 0 R/K 32848 0 R>> endobj 19321 0 obj <>/Alt(\(Forteo\))/P 6815 0 R/K 32849 0 R>> endobj 19322 0 obj <>/Alt(Tier 1)/P 6815 0 R/K 32850 0 R>> endobj 19323 0 obj <>/Alt(PA; SP)/P 6815 0 R/K 32851 0 R>> endobj 19324 0 obj <>/Alt(\(Begin italic\) teriparatide subcutaneous pen injector \(End italic\) \(Begin italic\) 20 mcg/dose \(620mcg/2.48ml\) \(End italic\))/P 6816 0 R/K 32852 0 R>> endobj 19325 0 obj <>/Alt(Tier 1)/P 6816 0 R/K 32853 0 R>> endobj 19326 0 obj <>/Alt(PA; SP)/P 6816 0 R/K 32854 0 R>> endobj 19327 0 obj <>/Alt(\(Begin bold\) Bone Formation Stimulating Agts - Pth Rel Peptides \(End bold\))/P 6817 0 R/K 32855 0 R>> endobj 19328 0 obj <>/Alt(TYMLOS SUBCUTANEOUS PEN INJECTOR 80 MCG \(3,120 MCG/1.56 ML\))/P 6818 0 R/K 32856 0 R>> endobj 19329 0 obj <>/Alt(Tier 2)/P 6818 0 R/K 32857 0 R>> endobj 19330 0 obj <>/Alt(PA; SP)/P 6818 0 R/K 32858 0 R>> endobj 19331 0 obj <>/Alt(\(Begin bold\) Bone Resorption Inhibitor & Vitamin D Combinations \(End bold\))/P 6819 0 R/K 32859 0 R>> endobj 19332 0 obj <>/Alt(FOSAMAX PLUS D ORAL TABLET 70 MG- 2,800 UNIT, 70 MG- 5,600 UNIT)/P 6820 0 R/K 32860 0 R>> endobj 19333 0 obj <>/Alt(Tier 2)/P 6820 0 R/K 32861 0 R>> endobj 19334 0 obj <>/Alt(\(Begin bold\) Bone Resorption Inhibitors \(End bold\))/P 6821 0 R/K 32862 0 R>> endobj 19335 0 obj <>/Alt(\(Begin italic\) alendronate oral solution \(End italic\) \(Begin italic\) 70 mg/75 ml \(End italic\))/P 6822 0 R/K 32863 0 R>> endobj 19336 0 obj <>/Alt(Tier 1)/P 6822 0 R/K 32864 0 R>> endobj 19337 0 obj <>/Alt(QL \(75 ML per 7 days\))/P 6822 0 R/K 32865 0 R>> endobj 19338 0 obj <>/Alt(\(Begin italic\) alendronate oral tablet \(End italic\) \(Begin italic\) 10 mg, 35 mg, 5 mg \(End italic\))/P 6823 0 R/K 32866 0 R>> endobj 19339 0 obj <>/Alt(Tier 1)/P 6823 0 R/K 32867 0 R>> endobj 19340 0 obj <>/Alt(\(Begin italic\) alendronate oral tablet \(End italic\) \(Begin italic\) 70 mg \(End italic\))/P 6824 0 R/K 32868 0 R>> endobj 19341 0 obj <>/Alt(\(Fosamax\))/P 6824 0 R/K 32869 0 R>> endobj 19342 0 obj <>/Alt(Tier 1)/P 6824 0 R/K 32870 0 R>> endobj 19343 0 obj <>/Alt(\(Begin italic\) calcitonin \(salmon\) injection solution \(End italic\) \(Begin italic\) 200 unit/ml \(End italic\))/P 6825 0 R/K 32871 0 R>> endobj 19344 0 obj <>/Alt(\(Miacalcin\))/P 6825 0 R/K 32872 0 R>> endobj 19345 0 obj <>/Alt(Tier 1)/P 6825 0 R/K 32873 0 R>> endobj 19346 0 obj <>/Alt(\(Begin italic\) calcitonin \(salmon\) nasal spray,non-aerosol \(End italic\) \(Begin italic\) 200 unit/actuation \(End italic\))/P 6826 0 R/K 32874 0 R>> endobj 19347 0 obj <>/Alt(Tier 1)/P 6826 0 R/K 32875 0 R>> endobj 19348 0 obj <>/Alt(\(Begin italic\) ibandronate oral tablet \(End italic\) \(Begin italic\) 150 mg \(End italic\))/P 6827 0 R/K 32876 0 R>> endobj 19349 0 obj <>/Alt(Tier 1)/P 6827 0 R/K 32877 0 R>> endobj 19350 0 obj <>/Alt(\(Begin italic\) raloxifene oral tablet \(End italic\) \(Begin italic\) 60 mg \(End italic\))/P 6828 0 R/K 32878 0 R>> endobj 19351 0 obj <>/Alt(\(Evista\))/P 6828 0 R/K 32879 0 R>> endobj 19352 0 obj <>/Alt($0)/P 6828 0 R/K 32880 0 R>> endobj 19353 0 obj <>/Alt($0 COPAY IF QUANTITY 1 IN 1 DAY AND 35 YEARS OF AGE OR OLDER; 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QL \(1 EA per 7 days\))/P 6831 0 R/K 32892 0 R>> endobj 19365 0 obj <>/Alt(\(Begin italic\) risedronate oral tablet,delayed release \(dr/ec\) \(End italic\) \(Begin italic\) 35 mg \(End italic\))/P 6832 0 R/K 32893 0 R>> endobj 19366 0 obj <>/Alt(\(Atelvia\))/P 6832 0 R/K 32894 0 R>> endobj 19367 0 obj <>/Alt(Tier 1)/P 6832 0 R/K 32895 0 R>> endobj 19368 0 obj <>/Alt(ST: Requires prior prescriptions for generic Alendronate and Ibandronate within the past 365 days; QL \(1 EA per 7 days\))/P 6832 0 R/K 32896 0 R>> endobj 19369 0 obj <>/Alt(\(Begin bold\) Calcimimetic,Parathyroid Calcium Enhancer \(End bold\))/P 6833 0 R/K 32897 0 R>> endobj 19370 0 obj <>/Alt(\(Begin italic\) cinacalcet oral tablet \(End italic\) \(Begin italic\) 30 mg, 60 mg \(End italic\))/P 6834 0 R/K 32898 0 R>> endobj 19371 0 obj <>/Alt(\(Sensipar\))/P 6834 0 R/K 32899 0 R>> endobj 19372 0 obj <>/Alt(Tier 1)/P 6834 0 R/K 32900 0 R>> endobj 19373 0 obj <>/Alt(SP; QL \(2 EA per 1 day\))/P 6834 0 R/K 32901 0 R>> endobj 19374 0 obj <>/Alt(\(Begin italic\) cinacalcet oral tablet \(End italic\) \(Begin italic\) 90 mg \(End italic\))/P 6835 0 R/K 32902 0 R>> endobj 19375 0 obj <>/Alt(\(Sensipar\))/P 6835 0 R/K 32903 0 R>> endobj 19376 0 obj <>/Alt(Tier 1)/P 6835 0 R/K 32904 0 R>> endobj 19377 0 obj <>/Alt(SP; 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SP)/P 6875 0 R/K 33001 0 R>> endobj 19474 0 obj <>/Alt(\(Begin italic\) danazol oral capsule \(End italic\) \(Begin italic\) 100 mg, 200 mg, 50 mg \(End italic\))/P 6876 0 R/K 33002 0 R>> endobj 19475 0 obj <>/Alt(Tier 1)/P 6876 0 R/K 33003 0 R>> endobj 19476 0 obj <>/Alt(\(Begin bold\) Endocrine Disorder - Thyroid \(End bold\))/P 6877 0 R/K 33004 0 R>> endobj 19477 0 obj <>/Alt(\(Begin bold\) Antithyroid Preparations \(End bold\))/P 6878 0 R/K 33005 0 R>> endobj 19478 0 obj <>/Alt(\(Begin italic\) methimazole oral tablet \(End italic\) \(Begin italic\) 10 mg, 5 mg \(End italic\))/P 6879 0 R/K 33006 0 R>> endobj 19479 0 obj <>/Alt(Tier 1)/P 6879 0 R/K 33007 0 R>> endobj 19480 0 obj <>/Alt(\(Begin italic\) propylthiouracil oral tablet \(End italic\) \(Begin italic\) 50 mg \(End italic\))/P 6880 0 R/K 33008 0 R>> endobj 19481 0 obj <>/Alt(Tier 1)/P 6880 0 R/K 33009 0 R>> endobj 19482 0 obj <>/Alt(\(Begin bold\) Iodine Containing Agents \(End bold\))/P 6881 0 R/K 33010 0 R>> endobj 19483 0 obj <>/Alt(LUGOLS ORAL SOLUTION 5 %)/P 6882 0 R/K 33011 0 R>> endobj 19484 0 obj <>/Alt(Tier 3)/P 6882 0 R/K 33012 0 R>> endobj 19485 0 obj <>/Alt(\(Begin italic\) potassium iodide oral solution \(End italic\) \(Begin italic\) 1 gram/ml \(End italic\))/P 6883 0 R/K 33013 0 R>> endobj 19486 0 obj <>/Alt(\(SSKI\))/P 6883 0 R/K 33014 0 R>> endobj 19487 0 obj <>/Alt(Tier 1)/P 6883 0 R/K 33015 0 R>> endobj 19488 0 obj <>/Alt(SSKI ORAL SOLUTION 1 GRAM/ML)/P 6884 0 R/K 33016 0 R>> endobj 19489 0 obj <>/Alt(\(potassium iodide\))/P 6884 0 R/K 33017 0 R>> endobj 19490 0 obj <>/Alt(Tier 1)/P 6884 0 R/K 33018 0 R>> endobj 19491 0 obj <>/Alt(STRONG IODINE ORAL SOLUTION 5 %)/P 6885 0 R/K 33019 0 R>> endobj 19492 0 obj <>/Alt(Tier 1)/P 6885 0 R/K 33020 0 R>> endobj 19493 0 obj <>/Alt(\(Begin bold\) Thyroid Hormones \(End bold\))/P 6886 0 R/K 33021 0 R>> endobj 19494 0 obj <>/Alt(ADTHYZA ORAL TABLET 130 MG, 16.25 MG, 32.5 MG, 65 MG, 97.5 MG)/P 6887 0 R/K 33022 0 R>> endobj 19495 0 obj <>/Alt(Tier 3)/P 6887 0 R/K 33023 0 R>> endobj 19496 0 obj <>/Alt(ERMEZA ORAL SOLUTION 30 MCG/ML)/P 6888 0 R/K 33024 0 R>> endobj 19497 0 obj <>/Alt(Tier 1)/P 6888 0 R/K 33025 0 R>> endobj 19498 0 obj <>/Alt(PA)/P 6888 0 R/K 33026 0 R>> endobj 19499 0 obj <>/Alt(EUTHYROX ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG)/P 6889 0 R/K 33027 0 R>> endobj 19500 0 obj <>/Alt(\(levothyroxine\))/P 6889 0 R/K 33028 0 R>> endobj 19501 0 obj <>/Alt(Tier 1)/P 6889 0 R/K 33029 0 R>> endobj 19502 0 obj <>/Alt(QL \(2 EA per 1 day\))/P 6889 0 R/K 33030 0 R>> endobj 19503 0 obj <>/Alt(\(Begin italic\) levothyroxine oral capsule \(End italic\) \(Begin italic\) 100 mcg, 112 mcg, 125 mcg, 13 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg \(End italic\))/P 6890 0 R/K 33031 0 R>> endobj 19504 0 obj <>/Alt(\(Tirosint\))/P 6890 0 R/K 33032 0 R>> endobj 19505 0 obj <>/Alt(Tier 1)/P 6890 0 R/K 33033 0 R>> endobj 19506 0 obj <>/Alt(PA)/P 6890 0 R/K 33034 0 R>> endobj 19507 0 obj <>/Alt(\(Begin italic\) levothyroxine oral tablet \(End italic\) \(Begin italic\) 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg \(End italic\))/P 6891 0 R/K 33035 0 R>> endobj 19508 0 obj <>/Alt(\(Euthyrox\))/P 6891 0 R/K 33036 0 R>> endobj 19509 0 obj <>/Alt(Tier 1)/P 6891 0 R/K 33037 0 R>> endobj 19510 0 obj <>/Alt(QL \(2 EA per 1 day\))/P 6891 0 R/K 33038 0 R>> endobj 19511 0 obj <>/Alt(\(Begin italic\) levothyroxine oral tablet \(End italic\) \(Begin italic\) 300 mcg \(End italic\))/P 6892 0 R/K 33039 0 R>> endobj 19512 0 obj <>/Alt(\(Levo-T\))/P 6892 0 R/K 33040 0 R>> endobj 19513 0 obj <>/Alt(Tier 1)/P 6892 0 R/K 33041 0 R>> endobj 19514 0 obj <>/Alt(QL \(2 EA per 1 day\))/P 6892 0 R/K 33042 0 R>> endobj 19515 0 obj <>/Alt(\(Begin italic\) liothyronine oral tablet \(End italic\) \(Begin italic\) 25 mcg, 5 mcg, 50 mcg \(End italic\))/P 6893 0 R/K 33043 0 R>> endobj 19516 0 obj <>/Alt(\(Cytomel\))/P 6893 0 R/K 33044 0 R>> endobj 19517 0 obj <>/Alt(Tier 1)/P 6893 0 R/K 33045 0 R>> endobj 19518 0 obj <>/Alt(NP THYROID ORAL TABLET 120 MG, 15 MG, 30 MG, 60 MG, 90 MG)/P 6894 0 R/K 33046 0 R>> endobj 19519 0 obj <>/Alt(\(thyroid \(pork\)\))/P 6894 0 R/K 33047 0 R>> endobj 19520 0 obj <>/Alt(Tier 1)/P 6894 0 R/K 33048 0 R>> endobj 19521 0 obj <>/Alt(THYQUIDITY ORAL SOLUTION 20 MCG/ML)/P 6895 0 R/K 33049 0 R>> endobj 19522 0 obj <>/Alt(Tier 3)/P 6895 0 R/K 33050 0 R>> endobj 19523 0 obj <>/Alt(ST: Requires prior prescription for generic Levothyroxine tablets within the past 120 days; QL \(20 ML per 1 day\))/P 6895 0 R/K 33051 0 R>> endobj 19524 0 obj <>/Alt(\(Begin italic\) thyroid \(pork\) oral tablet \(End italic\) \(Begin italic\) 120 mg, 15 mg, 30 mg, 60 mg, 90 mg \(End italic\))/P 6896 0 R/K 33052 0 R>> endobj 19525 0 obj <>/Alt(\(NP Thyroid\))/P 6896 0 R/K 33053 0 R>> endobj 19526 0 obj <>/Alt(Tier 1)/P 6896 0 R/K 33054 0 R>> endobj 19527 0 obj <>/Alt(TIROSINT ORAL CAPSULE 37.5 MCG, 44 MCG, 62.5 MCG)/P 6897 0 R/K 33055 0 R>> endobj 19528 0 obj <>/Alt(Tier 3)/P 6897 0 R/K 33056 0 R>> endobj 19529 0 obj <>/Alt(PA)/P 6897 0 R/K 33057 0 R>> endobj 19530 0 obj <>/Alt(TIROSINT-SOL ORAL SOLUTION 100 MCG/ML, 112 MCG/ML, 125 MCG/ML, 13 MCG/ML, 137 MCG/ML, 150 MCG/ML, 175 MCG/ML, 200 MCG/ML, 25 MCG/ML, 37.5 MCG/ML, 44 MCG/ML, 50 MCG/ML, 62.5 MCG/ML, 75 MCG/ML, 88 MCG/ML)/P 6898 0 R/K 33058 0 R>> endobj 19531 0 obj <>/Alt(Tier 3)/P 6898 0 R/K 33059 0 R>> endobj 19532 0 obj <>/Alt(PA)/P 6898 0 R/K 33060 0 R>> endobj 19533 0 obj <>/Alt(\(Begin bold\) Eye - General Disorders \(End bold\))/P 6899 0 R/K 33061 0 R>> endobj 19534 0 obj <>/Alt(\(Begin bold\) Eye Antibiotic, Glucocorticoid And Nsaid Comb. \(End bold\))/P 6900 0 R/K 33062 0 R>> endobj 19535 0 obj <>/Alt(\(Begin italic\) prednisolon-moxiflox-bromf\(pf\) ophthalmic \(eye\) drops \(End italic\) \(Begin italic\) 1-0.5-0.09 % \(End italic\))/P 6901 0 R/K 33063 0 R>> endobj 19536 0 obj <>/Alt(Tier 1)/P 6901 0 R/K 33064 0 R>> endobj 19537 0 obj <>/Alt(\(Begin bold\) Eye Antibiotic-Corticoid Combinations \(End bold\))/P 6902 0 R/K 33065 0 R>> endobj 19538 0 obj <>/Alt(\(Begin italic\) neomycin-bacitracin-poly-hc ophthalmic \(eye\) ointment \(End italic\) \(Begin italic\) 3.5-400-10,000 mg-unit/g-1% \(End italic\))/P 6903 0 R/K 33066 0 R>> endobj 19539 0 obj <>/Alt(\(Neo-Polycin HC\))/P 6903 0 R/K 33067 0 R>> endobj 19540 0 obj <>/Alt(Tier 1)/P 6903 0 R/K 33068 0 R>> endobj 19541 0 obj <>/Alt(\(Begin italic\) neomycin-polymyxin b-dexameth ophthalmic \(eye\) drops,suspension \(End italic\) \(Begin italic\) 3.5mg/ml-10,000 unit/ml-0.1 % \(End italic\))/P 6904 0 R/K 33069 0 R>> endobj 19542 0 obj <>/Alt(\(Maxitrol\))/P 6904 0 R/K 33070 0 R>> endobj 19543 0 obj <>/Alt(Tier 1)/P 6904 0 R/K 33071 0 R>> endobj 19544 0 obj <>/Alt(\(Begin italic\) neomycin-polymyxin b-dexameth ophthalmic \(eye\) ointment \(End italic\) \(Begin italic\) 3.5 mg/g-10,000 unit/g-0.1 % \(End italic\))/P 6905 0 R/K 33072 0 R>> endobj 19545 0 obj <>/Alt(\(Maxitrol\))/P 6905 0 R/K 33073 0 R>> endobj 19546 0 obj <>/Alt(Tier 1)/P 6905 0 R/K 33074 0 R>> endobj 19547 0 obj <>/Alt(\(Begin italic\) neomycin-polymyxin-hc ophthalmic \(eye\) drops,suspension \(End italic\) \(Begin italic\) 3.5-10,000-10 mg-unit-mg/ml \(End italic\))/P 6906 0 R/K 33075 0 R>> endobj 19548 0 obj <>/Alt(Tier 1)/P 6906 0 R/K 33076 0 R>> endobj 19549 0 obj <>/Alt(NEO-POLYCIN HC OPHTHALMIC \(EYE\) OINTMENT 3.5-400-10,000 MG-UNIT/G-1%)/P 6907 0 R/K 33077 0 R>> endobj 19550 0 obj <>/Alt(\(neomycin-bacitracin-poly-hc\))/P 6907 0 R/K 33078 0 R>> endobj 19551 0 obj <>/Alt(Tier 1)/P 6907 0 R/K 33079 0 R>> endobj 19552 0 obj <>/Alt(PRED-G S.O.P. OPHTHALMIC \(EYE\) OINTMENT 0.3-0.6 %)/P 6908 0 R/K 33080 0 R>> endobj 19553 0 obj <>/Alt(Tier 3)/P 6908 0 R/K 33081 0 R>> endobj 19554 0 obj <>/Alt(TOBRADEX OPHTHALMIC \(EYE\) OINTMENT 0.3-0.1 %)/P 6909 0 R/K 33082 0 R>> endobj 19555 0 obj <>/Alt(Tier 2)/P 6909 0 R/K 33083 0 R>> endobj 19556 0 obj <>/Alt(\(Begin italic\) tobramycin-dexamethasone ophthalmic \(eye\) drops,suspension \(End italic\) \(Begin italic\) 0.3-0.1 % \(End italic\))/P 6910 0 R/K 33084 0 R>> endobj 19557 0 obj <>/Alt(Tier 1)/P 6910 0 R/K 33085 0 R>> endobj 19558 0 obj <>/Alt(\(Begin bold\) Eye Antihistamines \(End bold\))/P 6911 0 R/K 33086 0 R>> endobj 19559 0 obj <>/Alt(\(Begin italic\) azelastine ophthalmic \(eye\) drops \(End italic\) \(Begin italic\) 0.05 % \(End italic\))/P 6912 0 R/K 33087 0 R>> endobj 19560 0 obj <>/Alt(Tier 1)/P 6912 0 R/K 33088 0 R>> endobj 19561 0 obj <>/Alt(QL \(12 ML per 30 days\))/P 6912 0 R/K 33089 0 R>> endobj 19562 0 obj <>/Alt(\(Begin italic\) epinastine ophthalmic \(eye\) drops \(End italic\) \(Begin italic\) 0.05 % \(End italic\))/P 6913 0 R/K 33090 0 R>> endobj 19563 0 obj <>/Alt(Tier 1)/P 6913 0 R/K 33091 0 R>> endobj 19564 0 obj <>/Alt(QL \(10 ML per 30 days\))/P 6913 0 R/K 33092 0 R>> endobj 19565 0 obj <>/Alt(\(Begin italic\) olopatadine ophthalmic \(eye\) drops \(End italic\) \(Begin italic\) 0.1 % \(End italic\))/P 6914 0 R/K 33093 0 R>> endobj 19566 0 obj <>/Alt(\(Eye Allergy Itch-Redness Rlf\))/P 6914 0 R/K 33094 0 R>> endobj 19567 0 obj <>/Alt(Tier 1)/P 6914 0 R/K 33095 0 R>> endobj 19568 0 obj <>/Alt(\(Begin italic\) olopatadine ophthalmic \(eye\) drops \(End italic\) \(Begin italic\) 0.2 % \(End italic\))/P 6915 0 R/K 33096 0 R>> endobj 19569 0 obj <>/Alt(\(Eye Allergy Itch Relief\))/P 6915 0 R/K 33097 0 R>> endobj 19570 0 obj <>/Alt(Tier 1)/P 6915 0 R/K 33098 0 R>> endobj 19571 0 obj <>/Alt(QL \(3 ML per 30 days\))/P 6915 0 R/K 33099 0 R>> endobj 19572 0 obj <>/Alt(\(Begin bold\) Eye Antiinflammatory Agents \(End bold\))/P 6916 0 R/K 33100 0 R>> endobj 19573 0 obj <>/Alt(ACUVAIL \(PF\) OPHTHALMIC \(EYE\) DROPPERETTE 0.45 %)/P 6917 0 R/K 33101 0 R>> endobj 19574 0 obj <>/Alt(Tier 3)/P 6917 0 R/K 33102 0 R>> endobj 19575 0 obj <>/Alt(QL \(60 EA per 15 days\))/P 6917 0 R/K 33103 0 R>> endobj 19576 0 obj <>/Alt(\(Begin italic\) bromfenac ophthalmic \(eye\) drops \(End italic\) \(Begin italic\) 0.07 % \(End italic\))/P 6918 0 R/K 33104 0 R>> endobj 19577 0 obj <>/Alt(\(Prolensa\))/P 6918 0 R/K 33105 0 R>> endobj 19578 0 obj <>/Alt(Tier 1)/P 6918 0 R/K 33106 0 R>> endobj 19579 0 obj <>/Alt(QL \(3 ML per 16 days\))/P 6918 0 R/K 33107 0 R>> endobj 19580 0 obj <>/Alt(\(Begin italic\) bromfenac ophthalmic \(eye\) drops \(End italic\) \(Begin italic\) 0.075 % \(End italic\))/P 6919 0 R/K 33108 0 R>> endobj 19581 0 obj <>/Alt(\(BromSite\))/P 6919 0 R/K 33109 0 R>> endobj 19582 0 obj <>/Alt(Tier 1)/P 6919 0 R/K 33110 0 R>> endobj 19583 0 obj <>/Alt(QL \(5 ML per 16 days\))/P 6919 0 R/K 33111 0 R>> endobj 19584 0 obj <>/Alt(\(Begin italic\) bromfenac ophthalmic \(eye\) drops \(End italic\) \(Begin italic\) 0.09 % \(End italic\))/P 6920 0 R/K 33112 0 R>> endobj 19585 0 obj <>/Alt(Tier 1)/P 6920 0 R/K 33113 0 R>> endobj 19586 0 obj <>/Alt(QL \(3.4 ML per 16 days\))/P 6920 0 R/K 33114 0 R>> endobj 19587 0 obj <>/Alt(\(Begin italic\) clobetasol ophthalmic \(eye\) drops,suspension \(End italic\) \(Begin italic\) 0.05 % \(End italic\))/P 6921 0 R/K 33115 0 R>> endobj 19588 0 obj <>/Alt(Tier 1)/P 6921 0 R/K 33116 0 R>> endobj 19589 0 obj <>/Alt(ST: Requires prior prescription for generic ophthalmic Fluorometholone 0.1%, Dexamethasone 0.1%, or Prednisolone 1% within the past 120 days; QL \(3.5 ML per 14 days\))/P 6921 0 R/K 33117 0 R>> endobj 19590 0 obj <>/Alt(\(Begin italic\) dexamethasone sodium phosphate ophthalmic \(eye\) drops \(End italic\) \(Begin italic\) 0.1 % \(End italic\))/P 6922 0 R/K 33118 0 R>> endobj 19591 0 obj <>/Alt(Tier 1)/P 6922 0 R/K 33119 0 R>> endobj 19592 0 obj <>/Alt(QL \(15 ML per 14 days\))/P 6922 0 R/K 33120 0 R>> endobj 19593 0 obj <>/Alt(DEXTENZA INTRACANALICULAR INSERT 0.4 MG)/P 6923 0 R/K 33121 0 R>> endobj 19594 0 obj <>/Alt(Tier 3)/P 6923 0 R/K 33122 0 R>> endobj 19595 0 obj <>/Alt(\(Begin italic\) diclofenac sodium ophthalmic \(eye\) drops \(End italic\) \(Begin italic\) 0.1 % \(End italic\))/P 6924 0 R/K 33123 0 R>> endobj 19596 0 obj <>/Alt(Tier 1)/P 6924 0 R/K 33124 0 R>> endobj 19597 0 obj <>/Alt(QL \(10 ML per 14 days\))/P 6924 0 R/K 33125 0 R>> endobj 19598 0 obj <>/Alt(\(Begin italic\) difluprednate ophthalmic \(eye\) drops \(End italic\) \(Begin italic\) 0.05 % \(End italic\))/P 6925 0 R/K 33126 0 R>> endobj 19599 0 obj <>/Alt(\(Durezol\))/P 6925 0 R/K 33127 0 R>> endobj 19600 0 obj <>/Alt(Tier 1)/P 6925 0 R/K 33128 0 R>> endobj 19601 0 obj <>/Alt(QL \(10 ML per 14 days\))/P 6925 0 R/K 33129 0 R>> endobj 19602 0 obj <>/Alt(\(Begin italic\) fluorometholone ophthalmic \(eye\) drops,suspension \(End italic\) \(Begin italic\) 0.1 % \(End italic\))/P 6926 0 R/K 33130 0 R>> endobj 19603 0 obj <>/Alt(\(FML Liquifilm\))/P 6926 0 R/K 33131 0 R>> endobj 19604 0 obj <>/Alt(Tier 1)/P 6926 0 R/K 33132 0 R>> endobj 19605 0 obj <>/Alt(QL \(10 ML per 14 days\))/P 6926 0 R/K 33133 0 R>> endobj 19606 0 obj <>/Alt(\(Begin italic\) flurbiprofen sodium ophthalmic \(eye\) drops \(End italic\) \(Begin italic\) 0.03 % \(End italic\))/P 6927 0 R/K 33134 0 R>> endobj 19607 0 obj <>/Alt(Tier 1)/P 6927 0 R/K 33135 0 R>> endobj 19608 0 obj <>/Alt(ILEVRO OPHTHALMIC \(EYE\) DROPS,SUSPENSION 0.3 %)/P 6928 0 R/K 33136 0 R>> endobj 19609 0 obj <>/Alt(Tier 2)/P 6928 0 R/K 33137 0 R>> endobj 19610 0 obj <>/Alt(QL \(3.4 ML per 16 days\))/P 6928 0 R/K 33138 0 R>> endobj 19611 0 obj <>/Alt(\(Begin italic\) ketorolac ophthalmic \(eye\) drops \(End italic\) \(Begin italic\) 0.4 % \(End italic\))/P 6929 0 R/K 33139 0 R>> endobj 19612 0 obj <>/Alt(\(Acular LS\))/P 6929 0 R/K 33140 0 R>> endobj 19613 0 obj <>/Alt(Tier 1)/P 6929 0 R/K 33141 0 R>> endobj 19614 0 obj <>/Alt(\(Begin italic\) ketorolac ophthalmic \(eye\) drops \(End italic\) \(Begin italic\) 0.5 % \(End italic\))/P 6930 0 R/K 33142 0 R>> endobj 19615 0 obj <>/Alt(\(Acular\))/P 6930 0 R/K 33143 0 R>> endobj 19616 0 obj <>/Alt(Tier 1)/P 6930 0 R/K 33144 0 R>> endobj 19617 0 obj <>/Alt(QL \(20 ML per 30 days\))/P 6930 0 R/K 33145 0 R>> endobj 19618 0 obj <>/Alt(LOTEMAX OPHTHALMIC \(EYE\) OINTMENT 0.5 %)/P 6931 0 R/K 33146 0 R>> endobj 19619 0 obj <>/Alt(Tier 2)/P 6931 0 R/K 33147 0 R>> endobj 19620 0 obj <>/Alt(QL \(7 GM per 14 days\))/P 6931 0 R/K 33148 0 R>> endobj 19621 0 obj <>/Alt(LOTEMAX SM OPHTHALMIC \(EYE\) DROPS,GEL 0.38 %)/P 6932 0 R/K 33149 0 R>> endobj 19622 0 obj <>/Alt(Tier 2)/P 6932 0 R/K 33150 0 R>> endobj 19623 0 obj <>/Alt(QL \(10 GM per 14 days\))/P 6932 0 R/K 33151 0 R>> endobj 19624 0 obj <>/Alt(\(Begin italic\) loteprednol etabonate ophthalmic \(eye\) drops,gel \(End italic\) \(Begin italic\) 0.5 % \(End italic\))/P 6933 0 R/K 33152 0 R>> endobj 19625 0 obj <>/Alt(\(Lotemax\))/P 6933 0 R/K 33153 0 R>> endobj 19626 0 obj <>/Alt(Tier 1)/P 6933 0 R/K 33154 0 R>> endobj 19627 0 obj <>/Alt(QL \(10 GM per 14 days\))/P 6933 0 R/K 33155 0 R>> endobj 19628 0 obj <>/Alt(\(Begin italic\) loteprednol etabonate ophthalmic \(eye\) drops,suspension \(End italic\) \(Begin italic\) 0.2 % \(End italic\))/P 6934 0 R/K 33156 0 R>> endobj 19629 0 obj <>/Alt(\(Alrex\))/P 6934 0 R/K 33157 0 R>> endobj 19630 0 obj <>/Alt(Tier 1)/P 6934 0 R/K 33158 0 R>> endobj 19631 0 obj <>/Alt(ST: Requires prior prescription for generic ophthalmic Fluorometholone 0.1%, Dexamethasone 0.1%, or Prednisolone 1% within the past 120 days; QL \(10 ML per 14 days\))/P 6934 0 R/K 33159 0 R>> endobj 19632 0 obj <>/Alt(\(Begin italic\) loteprednol etabonate ophthalmic \(eye\) drops,suspension \(End italic\) \(Begin italic\) 0.5 % \(End italic\))/P 6935 0 R/K 33160 0 R>> endobj 19633 0 obj <>/Alt(\(Lotemax\))/P 6935 0 R/K 33161 0 R>> endobj 19634 0 obj <>/Alt(Tier 1)/P 6935 0 R/K 33162 0 R>> endobj 19635 0 obj <>/Alt(QL \(20 ML per 14 days\))/P 6935 0 R/K 33163 0 R>> endobj 19636 0 obj <>/Alt(MAXIDEX OPHTHALMIC \(EYE\) DROPS,SUSPENSION 0.1 %)/P 6936 0 R/K 33164 0 R>> endobj 19637 0 obj <>/Alt(Tier 3)/P 6936 0 R/K 33165 0 R>> endobj 19638 0 obj <>/Alt(ST: Requires prior prescription for generic ophthalmic Fluorometholone 0.1%, Dexamethasone 0.1%, or Prednisolone 1% within the past 120 days; QL \(25 ML per 14 days\))/P 6936 0 R/K 33166 0 R>> endobj 19639 0 obj <>/Alt(\(Begin italic\) prednisolone acetate ophthalmic \(eye\) drops,suspension \(End italic\) \(Begin italic\) 1 % \(End italic\))/P 6937 0 R/K 33167 0 R>> endobj 19640 0 obj <>/Alt(\(Pred Forte\))/P 6937 0 R/K 33168 0 R>> endobj 19641 0 obj <>/Alt(Tier 1)/P 6937 0 R/K 33169 0 R>> endobj 19642 0 obj <>/Alt(QL \(20 ML per 14 days\))/P 6937 0 R/K 33170 0 R>> endobj 19643 0 obj <>/Alt(\(Begin italic\) prednisolone sod ph-bromf \(pf\) ophthalmic \(eye\) drops \(End italic\) \(Begin italic\) 1-0.09 % \(End italic\))/P 6938 0 R/K 33171 0 R>> endobj 19644 0 obj <>/Alt(Tier 1)/P 6938 0 R/K 33172 0 R>> endobj 19645 0 obj <>/Alt(\(Begin italic\) prednisolone sod ph-bromfenac ophthalmic \(eye\) drops \(End italic\) \(Begin italic\) 1-0.075 % \(End italic\))/P 6939 0 R/K 33173 0 R>> endobj 19646 0 obj <>/Alt(Tier 1)/P 6939 0 R/K 33174 0 R>> endobj 19647 0 obj <>/Alt(\(Begin italic\) prednisolone sodium phosphate ophthalmic \(eye\) drops \(End italic\) \(Begin italic\) 1 % \(End italic\))/P 6940 0 R/K 33175 0 R>> endobj 19648 0 obj <>/Alt(Tier 1)/P 6940 0 R/K 33176 0 R>> endobj 19649 0 obj <>/Alt(QL \(20 ML per 14 days\))/P 6940 0 R/K 33177 0 R>> endobj 19650 0 obj <>/Alt(\(Begin bold\) Eye Antivirals \(End bold\))/P 6941 0 R/K 33178 0 R>> endobj 19651 0 obj <>/Alt(\(Begin italic\) trifluridine ophthalmic \(eye\) drops \(End italic\) \(Begin italic\) 1 % \(End italic\))/P 6942 0 R/K 33179 0 R>> endobj 19652 0 obj <>/Alt(Tier 1)/P 6942 0 R/K 33180 0 R>> endobj 19653 0 obj <>/Alt(\(Begin bold\) Eye Local Anesthetics \(End bold\))/P 6943 0 R/K 33181 0 R>> endobj 19654 0 obj <>/Alt(AKTEN \(PF\) OPHTHALMIC \(EYE\) GEL 3.5 %)/P 6944 0 R/K 33182 0 R>> endobj 19655 0 obj <>/Alt(Tier 3)/P 6944 0 R/K 33183 0 R>> endobj 19656 0 obj <>/Alt(ALCAINE OPHTHALMIC \(EYE\) DROPS 0.5 %)/P 6945 0 R/K 33184 0 R>> endobj 19657 0 obj <>/Alt(\(proparacaine\))/P 6945 0 R/K 33185 0 R>> endobj 19658 0 obj <>/Alt(Tier 1)/P 6945 0 R/K 33186 0 R>> endobj 19659 0 obj <>/Alt(ALTACAINE OPHTHALMIC \(EYE\) DROPS 0.5 %)/P 6946 0 R/K 33187 0 R>> endobj 19660 0 obj <>/Alt(\(tetracaine hcl\))/P 6946 0 R/K 33188 0 R>> endobj 19661 0 obj <>/Alt(Tier 1)/P 6946 0 R/K 33189 0 R>> endobj 19662 0 obj <>/Alt(ALTAFLUOR BENOX OPHTHALMIC \(EYE\) DROPS 0.25-0.4 %)/P 6947 0 R/K 33190 0 R>> endobj 19663 0 obj <>/Alt(\(fluorescein-benoxinate\))/P 6947 0 R/K 33191 0 R>> endobj 19664 0 obj <>/Alt(Tier 1)/P 6947 0 R/K 33192 0 R>> endobj 19665 0 obj <>/Alt(\(Begin italic\) fluorescein-benoxinate ophthalmic \(eye\) drops \(End italic\) \(Begin italic\) 0.3-0.4 % \(End italic\))/P 6948 0 R/K 33193 0 R>> endobj 19666 0 obj <>/Alt(Tier 1)/P 6948 0 R/K 33194 0 R>> endobj 19667 0 obj <>/Alt(\(Begin italic\) fluorescein-proparacaine ophthalmic \(eye\) drops \(End italic\) \(Begin italic\) 0.25-0.5 % \(End italic\))/P 6949 0 R/K 33195 0 R>> endobj 19668 0 obj <>/Alt(Tier 1)/P 6949 0 R/K 33196 0 R>> endobj 19669 0 obj <>/Alt(IHEEZO \(PF\) OPHTHALMIC \(EYE\) DROPPERETTE,GEL 3 %)/P 6950 0 R/K 33197 0 R>> endobj 19670 0 obj <>/Alt(Tier 3)/P 6950 0 R/K 33198 0 R>> endobj 19671 0 obj <>/Alt(\(Begin italic\) proparacaine ophthalmic \(eye\) drops \(End italic\) \(Begin italic\) 0.5 % \(End italic\))/P 6951 0 R/K 33199 0 R>> endobj 19672 0 obj <>/Alt(\(Alcaine\))/P 6951 0 R/K 33200 0 R>> endobj 19673 0 obj <>/Alt(Tier 1)/P 6951 0 R/K 33201 0 R>> endobj 19674 0 obj <>/Alt(\(Begin italic\) tetracaine hcl \(pf\) ophthalmic \(eye\) drops \(End italic\) \(Begin italic\) 0.5 % \(End italic\))/P 6952 0 R/K 33202 0 R>> endobj 19675 0 obj <>/Alt(Tier 1)/P 6952 0 R/K 33203 0 R>> endobj 19676 0 obj <>/Alt(\(Begin italic\) tetracaine hcl ophthalmic \(eye\) drops \(End italic\) \(Begin italic\) 0.5 % \(End italic\))/P 6953 0 R/K 33204 0 R>> endobj 19677 0 obj <>/Alt(\(Altacaine\))/P 6953 0 R/K 33205 0 R>> endobj 19678 0 obj <>/Alt(Tier 1)/P 6953 0 R/K 33206 0 R>> endobj 19679 0 obj <>/Alt(\(Begin bold\) Eye Sulfonamides \(End bold\))/P 6954 0 R/K 33207 0 R>> endobj 19680 0 obj <>/Alt(BLEPHAMIDE S.O.P. OPHTHALMIC \(EYE\) OINTMENT 10-0.2 %)/P 6955 0 R/K 33208 0 R>> endobj 19681 0 obj <>/Alt(Tier 2)/P 6955 0 R/K 33209 0 R>> endobj 19682 0 obj <>/Alt(\(Begin italic\) sulfacetamide sodium ophthalmic \(eye\) drops \(End italic\) \(Begin italic\) 10 % \(End italic\))/P 6956 0 R/K 33210 0 R>> endobj 19683 0 obj <>/Alt(Tier 1)/P 6956 0 R/K 33211 0 R>> endobj 19684 0 obj <>/Alt(\(Begin italic\) sulfacetamide sodium ophthalmic \(eye\) ointment \(End italic\) \(Begin italic\) 10 % \(End italic\))/P 6957 0 R/K 33212 0 R>> endobj 19685 0 obj <>/Alt(Tier 1)/P 6957 0 R/K 33213 0 R>> endobj 19686 0 obj <>/Alt(\(Begin italic\) sulfacetamide-prednisolone ophthalmic \(eye\) drops \(End italic\) \(Begin italic\) 10 %-0.23 % \(0.25 %\) \(End italic\))/P 6958 0 R/K 33214 0 R>> endobj 19687 0 obj <>/Alt(Tier 1)/P 6958 0 R/K 33215 0 R>> endobj 19688 0 obj <>/Alt(\(Begin bold\) Eye Vasoconstrictors \(Rx Only\) \(End bold\))/P 6959 0 R/K 33216 0 R>> endobj 19689 0 obj <>/Alt(\(Begin italic\) phenylephrine hcl ophthalmic \(eye\) drops \(End italic\) \(Begin italic\) 10 %, 2.5 % \(End italic\))/P 6960 0 R/K 33217 0 R>> endobj 19690 0 obj <>/Alt(Tier 1)/P 6960 0 R/K 33218 0 R>> endobj 19691 0 obj <>/Alt(UPNEEQ \(PF\) OPHTHALMIC \(EYE\) DROPPERETTE 0.1 %)/P 6961 0 R/K 33219 0 R>> endobj 19692 0 obj <>/Alt(Tier 3)/P 6961 0 R/K 33220 0 R>> endobj 19693 0 obj <>/Alt(PA)/P 6961 0 R/K 33221 0 R>> endobj 19694 0 obj <>/Alt(\(Begin bold\) Nicotinic Recept.Partial Agonist, Alpha4beta2 Spec \(End bold\))/P 6962 0 R/K 33222 0 R>> endobj 19695 0 obj <>/Alt(TYRVAYA NASAL SPRAY, METERED, NON-AEROSOL 0.03 MG/SPRAY)/P 6963 0 R/K 33223 0 R>> endobj 19696 0 obj <>/Alt(Tier 2)/P 6963 0 R/K 33224 0 R>> endobj 19697 0 obj <>/Alt(PA)/P 6963 0 R/K 33225 0 R>> endobj 19698 0 obj <>/Alt(\(Begin bold\) Ophthalmic \(Eye\) Antiparasitics \(End bold\))/P 6964 0 R/K 33226 0 R>> endobj 19699 0 obj <>/Alt(XDEMVY OPHTHALMIC \(EYE\) DROPS 0.25 %)/P 6965 0 R/K 33227 0 R>> endobj 19700 0 obj <>/Alt(Tier 3)/P 6965 0 R/K 33228 0 R>> endobj 19701 0 obj <>/Alt(PA; SP)/P 6965 0 R/K 33229 0 R>> endobj 19702 0 obj <>/Alt(\(Begin bold\) Ophthalmic Antibiotics \(End bold\))/P 6966 0 R/K 33230 0 R>> endobj 19703 0 obj <>/Alt(\(Begin italic\) bacitracin ophthalmic \(eye\) ointment \(End italic\) \(Begin italic\) 500 unit/gram \(End italic\))/P 6967 0 R/K 33231 0 R>> endobj 19704 0 obj <>/Alt(Tier 1)/P 6967 0 R/K 33232 0 R>> endobj 19705 0 obj <>/Alt(\(Begin italic\) bacitracin-polymyxin b ophthalmic \(eye\) ointment \(End italic\) \(Begin italic\) 500-10,000 unit/gram \(End italic\))/P 6968 0 R/K 33233 0 R>> endobj 19706 0 obj <>/Alt(\(Polycin\))/P 6968 0 R/K 33234 0 R>> endobj 19707 0 obj <>/Alt(Tier 1)/P 6968 0 R/K 33235 0 R>> endobj 19708 0 obj <>/Alt(BESIVANCE OPHTHALMIC \(EYE\) DROPS,SUSPENSION 0.6 %)/P 6969 0 R/K 33236 0 R>> endobj 19709 0 obj <>/Alt(Tier 2)/P 6969 0 R/K 33237 0 R>> endobj 19710 0 obj <>/Alt(CILOXAN OPHTHALMIC \(EYE\) OINTMENT 0.3 %)/P 6970 0 R/K 33238 0 R>> endobj 19711 0 obj <>/Alt(Tier 2)/P 6970 0 R/K 33239 0 R>> endobj 19712 0 obj <>/Alt(\(Begin italic\) ciprofloxacin hcl ophthalmic \(eye\) drops \(End italic\) \(Begin italic\) 0.3 % \(End italic\))/P 6971 0 R/K 33240 0 R>> endobj 19713 0 obj <>/Alt(Tier 1)/P 6971 0 R/K 33241 0 R>> endobj 19714 0 obj <>/Alt(\(Begin italic\) erythromycin ophthalmic \(eye\) ointment \(End italic\) \(Begin italic\) 5 mg/gram \(0.5 %\) \(End italic\))/P 6972 0 R/K 33242 0 R>> endobj 19715 0 obj <>/Alt(Tier 1)/P 6972 0 R/K 33243 0 R>> endobj 19716 0 obj <>/Alt(\(Begin italic\) gatifloxacin ophthalmic \(eye\) drops \(End italic\) \(Begin italic\) 0.5 % \(End italic\))/P 6973 0 R/K 33244 0 R>> endobj 19717 0 obj <>/Alt(Tier 1)/P 6973 0 R/K 33245 0 R>> endobj 19718 0 obj <>/Alt(\(Begin italic\) gentamicin ophthalmic \(eye\) drops \(End italic\) \(Begin italic\) 0.3 % \(End italic\))/P 6974 0 R/K 33246 0 R>> endobj 19719 0 obj <>/Alt(Tier 1)/P 6974 0 R/K 33247 0 R>> endobj 19720 0 obj <>/Alt(\(Begin italic\) levofloxacin ophthalmic \(eye\) drops \(End italic\) \(Begin italic\) 1.5 % \(End italic\))/P 6975 0 R/K 33248 0 R>> endobj 19721 0 obj <>/Alt(Tier 1)/P 6975 0 R/K 33249 0 R>> endobj 19722 0 obj <>/Alt(\(Begin italic\) moxifloxacin ophthalmic \(eye\) drops \(End italic\) \(Begin italic\) 0.5 % \(End italic\))/P 6976 0 R/K 33250 0 R>> endobj 19723 0 obj <>/Alt(\(Vigamox\))/P 6976 0 R/K 33251 0 R>> endobj 19724 0 obj <>/Alt(Tier 1)/P 6976 0 R/K 33252 0 R>> endobj 19725 0 obj <>/Alt(\(Begin italic\) moxifloxacin ophthalmic \(eye\) drops, viscous \(End italic\) \(Begin italic\) 0.5 % \(End italic\))/P 6977 0 R/K 33253 0 R>> endobj 19726 0 obj <>/Alt(Tier 1)/P 6977 0 R/K 33254 0 R>> endobj 19727 0 obj <>/Alt(\(Begin italic\) neomycin-bacitracin-polymyxin ophthalmic \(eye\) ointment \(End italic\) \(Begin italic\) 3.5-400-10,000 mg-unit-unit/g \(End italic\))/P 6978 0 R/K 33255 0 R>> endobj 19728 0 obj <>/Alt(\(Neo-Polycin\))/P 6978 0 R/K 33256 0 R>> endobj 19729 0 obj <>/Alt(Tier 1)/P 6978 0 R/K 33257 0 R>> endobj 19730 0 obj <>/Alt(\(Begin italic\) neomycin-polymyxin-gramicidin ophthalmic \(eye\) drops \(End italic\) \(Begin italic\) 1.75 mg-10,000 unit-0.025mg/ml \(End italic\))/P 6979 0 R/K 33258 0 R>> endobj 19731 0 obj <>/Alt(Tier 1)/P 6979 0 R/K 33259 0 R>> endobj 19732 0 obj <>/Alt(NEO-POLYCIN OPHTHALMIC \(EYE\) OINTMENT 3.5-400-10,000 MG-UNIT-UNIT/G)/P 6980 0 R/K 33260 0 R>> endobj 19733 0 obj <>/Alt(\(neomycin-bacitracin-polymyxin\))/P 6980 0 R/K 33261 0 R>> endobj 19734 0 obj <>/Alt(Tier 1)/P 6980 0 R/K 33262 0 R>> endobj 19735 0 obj <>/Alt(\(Begin italic\) ofloxacin ophthalmic \(eye\) drops \(End italic\) \(Begin italic\) 0.3 % \(End italic\))/P 6981 0 R/K 33263 0 R>> endobj 19736 0 obj <>/Alt(\(Ocuflox\))/P 6981 0 R/K 33264 0 R>> endobj 19737 0 obj <>/Alt(Tier 1)/P 6981 0 R/K 33265 0 R>> endobj 19738 0 obj <>/Alt(POLYCIN OPHTHALMIC \(EYE\) OINTMENT 500-10,000 UNIT/GRAM)/P 6982 0 R/K 33266 0 R>> endobj 19739 0 obj <>/Alt(\(bacitracin-polymyxin b\))/P 6982 0 R/K 33267 0 R>> endobj 19740 0 obj <>/Alt(Tier 1)/P 6982 0 R/K 33268 0 R>> endobj 19741 0 obj <>/Alt(\(Begin italic\) polymyxin b sulf-trimethoprim ophthalmic \(eye\) drops \(End italic\) \(Begin italic\) 10,000 unit- 1 mg/ml \(End italic\))/P 6983 0 R/K 33269 0 R>> endobj 19742 0 obj <>/Alt(Tier 1)/P 6983 0 R/K 33270 0 R>> endobj 19743 0 obj <>/Alt(\(Begin italic\) tobramycin ophthalmic \(eye\) drops \(End italic\) \(Begin italic\) 0.3 % \(End italic\))/P 6984 0 R/K 33271 0 R>> endobj 19744 0 obj <>/Alt(Tier 1)/P 6984 0 R/K 33272 0 R>> endobj 19745 0 obj <>/Alt(TOBREX OPHTHALMIC \(EYE\) OINTMENT 0.3 %)/P 6985 0 R/K 33273 0 R>> endobj 19746 0 obj <>/Alt(Tier 2)/P 6985 0 R/K 33274 0 R>> endobj 19747 0 obj <>/Alt(\(Begin italic\) vancomycin in 0.9 % sodium chl ophthalmic \(eye\) drops \(End italic\) \(Begin italic\) 10 mg/ml \(End italic\))/P 6986 0 R/K 33275 0 R>> endobj 19748 0 obj <>/Alt(Tier 1)/P 6986 0 R/K 33276 0 R>> endobj 19749 0 obj <>/Alt(\(Begin bold\) Ophthalmic Antifungal Agents \(End bold\))/P 6987 0 R/K 33277 0 R>> endobj 19750 0 obj <>/Alt(NATACYN OPHTHALMIC \(EYE\) DROPS,SUSPENSION 5 %)/P 6988 0 R/K 33278 0 R>> endobj 19751 0 obj <>/Alt(Tier 3)/P 6988 0 R/K 33279 0 R>> endobj 19752 0 obj <>/Alt(\(Begin bold\) Ophthalmic Anti-Inflammatory Immunomodulator-Type \(End bold\))/P 6989 0 R/K 33280 0 R>> endobj 19753 0 obj <>/Alt(\(Begin italic\) cyclosporine ophthalmic \(eye\) dropperette \(End italic\) \(Begin italic\) 0.05 % \(End italic\))/P 6990 0 R/K 33281 0 R>> endobj 19754 0 obj <>/Alt(\(Restasis\))/P 6990 0 R/K 33282 0 R>> endobj 19755 0 obj <>/Alt(Tier 1)/P 6990 0 R/K 33283 0 R>> endobj 19756 0 obj <>/Alt(QL \(60 EA per 30 days\))/P 6990 0 R/K 33284 0 R>> endobj 19757 0 obj <>/Alt(RESTASIS MULTIDOSE OPHTHALMIC \(EYE\) DROPS 0.05 %)/P 6991 0 R/K 33285 0 R>> endobj 19758 0 obj <>/Alt(Tier 2)/P 6991 0 R/K 33286 0 R>> endobj 19759 0 obj <>/Alt(QL \(5.5 ML per 30 days\))/P 6991 0 R/K 33287 0 R>> endobj 19760 0 obj <>/Alt(RESTASIS OPHTHALMIC \(EYE\) DROPPERETTE 0.05 %)/P 6992 0 R/K 33288 0 R>> endobj 19761 0 obj <>/Alt(\(cyclosporine\))/P 6992 0 R/K 33289 0 R>> endobj 19762 0 obj <>/Alt(Tier 1)/P 6992 0 R/K 33290 0 R>> endobj 19763 0 obj <>/Alt(QL \(60 EA per 30 days\))/P 6992 0 R/K 33291 0 R>> endobj 19764 0 obj <>/Alt(VERKAZIA OPHTHALMIC \(EYE\) DROPPERETTE 0.1 %)/P 6993 0 R/K 33292 0 R>> endobj 19765 0 obj <>/Alt(Tier 3)/P 6993 0 R/K 33293 0 R>> endobj 19766 0 obj <>/Alt(PA; SP)/P 6993 0 R/K 33294 0 R>> endobj 19767 0 obj <>/Alt(XIIDRA OPHTHALMIC \(EYE\) DROPPERETTE 5 %)/P 6994 0 R/K 33295 0 R>> endobj 19768 0 obj <>/Alt(Tier 2)/P 6994 0 R/K 33296 0 R>> endobj 19769 0 obj <>/Alt(QL \(60 EA per 30 days\))/P 6994 0 R/K 33297 0 R>> endobj 19770 0 obj <>/Alt(\(Begin bold\) Ophthalmic Human Nerve Growth Factor \(Hngf\) \(End bold\))/P 6995 0 R/K 33298 0 R>> endobj 19771 0 obj <>/Alt(OXERVATE OPHTHALMIC \(EYE\) DROPS 0.002 %)/P 6996 0 R/K 33299 0 R>> endobj 19772 0 obj <>/Alt(Tier 3)/P 6996 0 R/K 33300 0 R>> endobj 19773 0 obj <>/Alt(PA; SP)/P 6996 0 R/K 33301 0 R>> endobj 19774 0 obj <>/Alt(\(Begin bold\) Ophthalmic Mast Cell Stabilizers \(End bold\))/P 6997 0 R/K 33302 0 R>> endobj 19775 0 obj <>/Alt(ALOMIDE OPHTHALMIC \(EYE\) DROPS 0.1 %)/P 6998 0 R/K 33303 0 R>> endobj 19776 0 obj <>/Alt(Tier 2)/P 6998 0 R/K 33304 0 R>> endobj 19777 0 obj <>/Alt(ST: Requires prior prescription for Cromolyn 4% ophthalmic drops within the past 120 days; QL \(40 ML per 30 days\))/P 6998 0 R/K 33305 0 R>> endobj 19778 0 obj <>/Alt(\(Begin italic\) cromolyn ophthalmic \(eye\) drops \(End italic\) \(Begin italic\) 4 % \(End italic\))/P 6999 0 R/K 33306 0 R>> endobj 19779 0 obj <>/Alt(Tier 1)/P 6999 0 R/K 33307 0 R>> endobj 19780 0 obj <>/Alt(QL \(50 ML per 30 days\))/P 6999 0 R/K 33308 0 R>> endobj 19781 0 obj <>/Alt(\(Begin bold\) Ophthalmic Preparations, Miscellaneous \(End bold\))/P 7000 0 R/K 33309 0 R>> endobj 19782 0 obj <>/Alt(RYZUMVI OPHTHALMIC \(EYE\) DROPPERETTE 0.75 %)/P 7001 0 R/K 33310 0 R>> endobj 19783 0 obj <>/Alt(Tier 3)/P 7001 0 R/K 33311 0 R>> endobj 19784 0 obj <>/Alt(\(Begin bold\) Eye - Glaucoma \(End bold\))/P 7002 0 R/K 33312 0 R>> endobj 19785 0 obj <>/Alt(\(Begin bold\) Carbonic Anhydrase Inhibitors \(End bold\))/P 7003 0 R/K 33313 0 R>> endobj 19786 0 obj <>/Alt(\(Begin italic\) acetazolamide oral capsule, extended release \(End italic\) \(Begin italic\) 500 mg \(End italic\))/P 7004 0 R/K 33314 0 R>> endobj 19787 0 obj <>/Alt(Tier 1)/P 7004 0 R/K 33315 0 R>> endobj 19788 0 obj <>/Alt(\(Begin italic\) acetazolamide oral tablet \(End italic\) \(Begin italic\) 125 mg, 250 mg \(End italic\))/P 7005 0 R/K 33316 0 R>> endobj 19789 0 obj <>/Alt(Tier 1)/P 7005 0 R/K 33317 0 R>> endobj 19790 0 obj <>/Alt(\(Begin italic\) methazolamide oral tablet \(End italic\) \(Begin italic\) 25 mg, 50 mg \(End italic\))/P 7006 0 R/K 33318 0 R>> endobj 19791 0 obj <>/Alt(Tier 1)/P 7006 0 R/K 33319 0 R>> endobj 19792 0 obj <>/Alt(\(Begin bold\) Miotics/Other Intraoc. Pressure Reducers \(End bold\))/P 7007 0 R/K 33320 0 R>> endobj 19793 0 obj <>/Alt(\(Begin italic\) apraclonidine ophthalmic \(eye\) drops \(End italic\) \(Begin italic\) 0.5 % \(End italic\))/P 7008 0 R/K 33321 0 R>> endobj 19794 0 obj <>/Alt(Tier 1)/P 7008 0 R/K 33322 0 R>> endobj 19795 0 obj <>/Alt(\(Begin italic\) betaxolol ophthalmic \(eye\) drops \(End italic\) \(Begin italic\) 0.5 % \(End italic\))/P 7009 0 R/K 33323 0 R>> endobj 19796 0 obj <>/Alt(Tier 1)/P 7009 0 R/K 33324 0 R>> endobj 19797 0 obj <>/Alt(BETIMOL OPHTHALMIC \(EYE\) DROPS 0.5 %)/P 7010 0 R/K 33325 0 R>> endobj 19798 0 obj <>/Alt(\(timolol\))/P 7010 0 R/K 33326 0 R>> endobj 19799 0 obj <>/Alt(Tier 3)/P 7010 0 R/K 33327 0 R>> endobj 19800 0 obj <>/Alt(BETOPTIC S OPHTHALMIC \(EYE\) DROPS,SUSPENSION 0.25 %)/P 7011 0 R/K 33328 0 R>> endobj 19801 0 obj <>/Alt(Tier 3)/P 7011 0 R/K 33329 0 R>> endobj 19802 0 obj <>/Alt(\(Begin italic\) bimatoprost ophthalmic \(eye\) drops \(End italic\) \(Begin italic\) 0.03 % \(End italic\))/P 7012 0 R/K 33330 0 R>> endobj 19803 0 obj <>/Alt(Tier 1)/P 7012 0 R/K 33331 0 R>> endobj 19804 0 obj <>/Alt(QL \(1 ML per 12 days\))/P 7012 0 R/K 33332 0 R>> endobj 19805 0 obj <>/Alt(\(Begin italic\) brimonidine ophthalmic \(eye\) drops \(End italic\) \(Begin italic\) 0.1 %, 0.15 % \(End italic\))/P 7013 0 R/K 33333 0 R>> endobj 19806 0 obj <>/Alt(\(Alphagan P\))/P 7013 0 R/K 33334 0 R>> endobj 19807 0 obj <>/Alt(Tier 1)/P 7013 0 R/K 33335 0 R>> endobj 19808 0 obj <>/Alt(\(Begin italic\) brimonidine ophthalmic \(eye\) drops \(End italic\) \(Begin italic\) 0.2 % \(End italic\))/P 7014 0 R/K 33336 0 R>> endobj 19809 0 obj <>/Alt(Tier 1)/P 7014 0 R/K 33337 0 R>> endobj 19810 0 obj <>/Alt(\(Begin italic\) brimonidine-dorzolamide ophthalmic \(eye\) drops \(End italic\) \(Begin italic\) 0.1-2 % \(End italic\))/P 7015 0 R/K 33338 0 R>> endobj 19811 0 obj <>/Alt(Tier 1)/P 7015 0 R/K 33339 0 R>> endobj 19812 0 obj <>/Alt(\(Begin italic\) brimonidine-timolol ophthalmic \(eye\) drops \(End italic\) \(Begin italic\) 0.2-0.5 % \(End italic\))/P 7016 0 R/K 33340 0 R>> endobj 19813 0 obj <>/Alt(\(Combigan\))/P 7016 0 R/K 33341 0 R>> endobj 19814 0 obj <>/Alt(Tier 1)/P 7016 0 R/K 33342 0 R>> endobj 19815 0 obj <>/Alt(\(Begin italic\) brinzolamide ophthalmic \(eye\) drops,suspension \(End italic\) \(Begin italic\) 1 % \(End italic\))/P 7017 0 R/K 33343 0 R>> endobj 19816 0 obj <>/Alt(\(Azopt\))/P 7017 0 R/K 33344 0 R>> endobj 19817 0 obj <>/Alt(Tier 1)/P 7017 0 R/K 33345 0 R>> endobj 19818 0 obj <>/Alt(\(Begin italic\) carteolol ophthalmic \(eye\) drops \(End italic\) \(Begin italic\) 1 % \(End italic\))/P 7018 0 R/K 33346 0 R>> endobj 19819 0 obj <>/Alt(Tier 1)/P 7018 0 R/K 33347 0 R>> endobj 19820 0 obj <>/Alt(\(Begin italic\) dorzolamide ophthalmic \(eye\) drops \(End italic\) \(Begin italic\) 2 % \(End italic\))/P 7019 0 R/K 33348 0 R>> endobj 19821 0 obj <>/Alt(Tier 1)/P 7019 0 R/K 33349 0 R>> endobj 19822 0 obj <>/Alt(\(Begin italic\) dorzolamide-timolol \(pf\) ophthalmic \(eye\) dropperette \(End italic\) \(Begin italic\) 2-0.5 % \(End italic\))/P 7020 0 R/K 33350 0 R>> endobj 19823 0 obj <>/Alt(\(Cosopt \(PF\)\))/P 7020 0 R/K 33351 0 R>> endobj 19824 0 obj <>/Alt(Tier 1)/P 7020 0 R/K 33352 0 R>> endobj 19825 0 obj <>/Alt(QL \(2 EA per 1 day\))/P 7020 0 R/K 33353 0 R>> endobj 19826 0 obj <>/Alt(\(Begin italic\) dorzolamide-timolol ophthalmic \(eye\) drops \(End italic\) \(Begin italic\) 22.3-6.8 mg/ml \(End italic\))/P 7021 0 R/K 33354 0 R>> endobj 19827 0 obj <>/Alt(\(Cosopt\))/P 7021 0 R/K 33355 0 R>> endobj 19828 0 obj <>/Alt(Tier 1)/P 7021 0 R/K 33356 0 R>> endobj 19829 0 obj <>/Alt(IOPIDINE OPHTHALMIC \(EYE\) DROPPERETTE 1 %)/P 7022 0 R/K 33357 0 R>> endobj 19830 0 obj <>/Alt(Tier 3)/P 7022 0 R/K 33358 0 R>> endobj 19831 0 obj <>/Alt(\(Begin italic\) latanoprost ophthalmic \(eye\) drops \(End italic\) \(Begin italic\) 0.005 % \(End italic\))/P 7023 0 R/K 33359 0 R>> endobj 19832 0 obj <>/Alt(\(Xalatan\))/P 7023 0 R/K 33360 0 R>> endobj 19833 0 obj <>/Alt(Tier 1)/P 7023 0 R/K 33361 0 R>> endobj 19834 0 obj <>/Alt(\(Begin italic\) levobunolol ophthalmic \(eye\) drops \(End italic\) \(Begin italic\) 0.5 % \(End italic\))/P 7024 0 R/K 33362 0 R>> endobj 19835 0 obj <>/Alt(Tier 1)/P 7024 0 R/K 33363 0 R>> endobj 19836 0 obj <>/Alt(LUMIGAN OPHTHALMIC \(EYE\) DROPS 0.01 %)/P 7025 0 R/K 33364 0 R>> endobj 19837 0 obj <>/Alt(Tier 2)/P 7025 0 R/K 33365 0 R>> endobj 19838 0 obj <>/Alt(QL \(2.5 ML per 25 days\))/P 7025 0 R/K 33366 0 R>> endobj 19839 0 obj <>/Alt(PHOSPHOLINE IODIDE OPHTHALMIC \(EYE\) DROPS 0.125 %)/P 7026 0 R/K 33367 0 R>> endobj 19840 0 obj <>/Alt(Tier 3)/P 7026 0 R/K 33368 0 R>> endobj 19841 0 obj <>/Alt(SP)/P 7026 0 R/K 33369 0 R>> endobj 19842 0 obj <>/Alt(\(Begin italic\) pilocarpine hcl ophthalmic \(eye\) drops \(End italic\) \(Begin italic\) 1 %, 2 %, 4 % \(End italic\))/P 7027 0 R/K 33370 0 R>> endobj 19843 0 obj <>/Alt(Tier 1)/P 7027 0 R/K 33371 0 R>> endobj 19844 0 obj <>/Alt(QLOSI OPHTHALMIC \(EYE\) DROPPERETTE 0.4 %)/P 7028 0 R/K 33372 0 R>> endobj 19845 0 obj <>/Alt(Tier 3)/P 7028 0 R/K 33373 0 R>> endobj 19846 0 obj <>/Alt(PA)/P 7028 0 R/K 33374 0 R>> endobj 19847 0 obj <>/Alt(RHOPRESSA OPHTHALMIC \(EYE\) DROPS 0.02 %)/P 7029 0 R/K 33375 0 R>> endobj 19848 0 obj <>/Alt(Tier 3)/P 7029 0 R/K 33376 0 R>> endobj 19849 0 obj <>/Alt(ST: Requires prior prescriptions for Latanoprost and one of the following: Alphagan P 0.1%, Azopt, Combigan, Lumigan 0.01%, Travatan Z, or Simbrinza within the past 365 days; QL \(2.5 ML per 30 days\))/P 7029 0 R/K 33377 0 R>> endobj 19850 0 obj <>/Alt(ROCKLATAN OPHTHALMIC \(EYE\) DROPS 0.02-0.005 %)/P 7030 0 R/K 33378 0 R>> endobj 19851 0 obj <>/Alt(Tier 3)/P 7030 0 R/K 33379 0 R>> endobj 19852 0 obj <>/Alt(ST: Requires prior prescriptions for Latanoprost and one of the following: Alphagan P 0.1%, Azopt, Brimonidine 0.2%, Combigan, Lumigan 0.01%, Simbrinza, or Travatan Z within the past 365 days; QL \(2.5 ML per 25 days\))/P 7030 0 R/K 33380 0 R>> endobj 19853 0 obj <>/Alt(SIMBRINZA OPHTHALMIC \(EYE\) DROPS,SUSPENSION 1-0.2 %)/P 7031 0 R/K 33381 0 R>> endobj 19854 0 obj <>/Alt(Tier 2)/P 7031 0 R/K 33382 0 R>> endobj 19855 0 obj <>/Alt(\(Begin italic\) tafluprost \(pf\) ophthalmic \(eye\) dropperette \(End italic\) \(Begin italic\) 0.0015 % \(End italic\))/P 7032 0 R/K 33383 0 R>> endobj 19856 0 obj <>/Alt(\(Zioptan \(PF\)\))/P 7032 0 R/K 33384 0 R>> endobj 19857 0 obj <>/Alt(Tier 1)/P 7032 0 R/K 33385 0 R>> endobj 19858 0 obj <>/Alt(QL \(1 EA per 1 day\))/P 7032 0 R/K 33386 0 R>> endobj 19859 0 obj <>/Alt(\(Begin italic\) timolol maleate \(pf\) ophthalmic \(eye\) dropperette \(End italic\) \(Begin italic\) 0.25 %, 0.5 % \(End italic\))/P 7033 0 R/K 33387 0 R>> endobj 19860 0 obj <>/Alt(\(Timoptic Ocudose \(PF\)\))/P 7033 0 R/K 33388 0 R>> endobj 19861 0 obj <>/Alt(Tier 1)/P 7033 0 R/K 33389 0 R>> endobj 19862 0 obj <>/Alt(QL \(2 EA per 1 day\))/P 7033 0 R/K 33390 0 R>> endobj 19863 0 obj <>/Alt(\(Begin italic\) timolol maleate ophthalmic \(eye\) drops \(End italic\) \(Begin italic\) 0.25 %, 0.5 % \(End italic\))/P 7034 0 R/K 33391 0 R>> endobj 19864 0 obj <>/Alt(Tier 1)/P 7034 0 R/K 33392 0 R>> endobj 19865 0 obj <>/Alt(\(Begin italic\) timolol maleate ophthalmic \(eye\) drops, once daily \(End italic\) \(Begin italic\) 0.5 % \(End italic\))/P 7035 0 R/K 33393 0 R>> endobj 19866 0 obj <>/Alt(\(Istalol\))/P 7035 0 R/K 33394 0 R>> endobj 19867 0 obj <>/Alt(Tier 1)/P 7035 0 R/K 33395 0 R>> endobj 19868 0 obj <>/Alt(\(Begin italic\) timolol maleate ophthalmic \(eye\) gel forming solution \(End italic\) \(Begin italic\) 0.25 %, 0.5 % \(End italic\))/P 7036 0 R/K 33396 0 R>> endobj 19869 0 obj <>/Alt(Tier 1)/P 7036 0 R/K 33397 0 R>> endobj 19870 0 obj <>/Alt(\(Begin italic\) timolol ophthalmic \(eye\) drops \(End italic\) \(Begin italic\) 0.5 % \(End italic\))/P 7037 0 R/K 33398 0 R>> endobj 19871 0 obj <>/Alt(\(Betimol\))/P 7037 0 R/K 33399 0 R>> endobj 19872 0 obj <>/Alt(Tier 1)/P 7037 0 R/K 33400 0 R>> endobj 19873 0 obj <>/Alt(\(Begin italic\) travoprost ophthalmic \(eye\) drops \(End italic\) \(Begin italic\) 0.004 % \(End italic\))/P 7038 0 R/K 33401 0 R>> endobj 19874 0 obj <>/Alt(\(Travatan Z\))/P 7038 0 R/K 33402 0 R>> endobj 19875 0 obj <>/Alt(Tier 1)/P 7038 0 R/K 33403 0 R>> endobj 19876 0 obj <>/Alt(QL \(2.5 ML per 25 days\))/P 7038 0 R/K 33404 0 R>> endobj 19877 0 obj <>/Alt(VUITY OPHTHALMIC \(EYE\) DROPS 1.25 %)/P 7039 0 R/K 33405 0 R>> endobj 19878 0 obj <>/Alt(Tier 3)/P 7039 0 R/K 33406 0 R>> endobj 19879 0 obj <>/Alt(PA)/P 7039 0 R/K 33407 0 R>> endobj 19880 0 obj <>/Alt(VYZULTA OPHTHALMIC \(EYE\) DROPS 0.024 %)/P 7040 0 R/K 33408 0 R>> endobj 19881 0 obj <>/Alt(Tier 3)/P 7040 0 R/K 33409 0 R>> endobj 19882 0 obj <>/Alt(ST: Requires prior prescriptions for a generic prostaglandin analog and Lumigan within the past 365 days; QL \(2.5 ML per 30 days\))/P 7040 0 R/K 33410 0 R>> endobj 19883 0 obj <>/Alt(XELPROS OPHTHALMIC \(EYE\) DROPS, EMULSION 0.005 %)/P 7041 0 R/K 33411 0 R>> endobj 19884 0 obj <>/Alt(Tier 3)/P 7041 0 R/K 33412 0 R>> endobj 19885 0 obj <>/Alt(ST: Requires prior prescriptions for a generic prostaglandin analog and Lumigan within the past 365 days; QL \(2.5 ML per 25 days\))/P 7041 0 R/K 33413 0 R>> endobj 19886 0 obj <>/Alt(\(Begin bold\) Mydriatics \(End bold\))/P 7042 0 R/K 33414 0 R>> endobj 19887 0 obj <>/Alt(\(Begin italic\) atropine ophthalmic \(eye\) drops \(End italic\) \(Begin italic\) 1 % \(End italic\))/P 7043 0 R/K 33415 0 R>> endobj 19888 0 obj <>/Alt(\(Isopto Atropine\))/P 7043 0 R/K 33416 0 R>> endobj 19889 0 obj <>/Alt(Tier 1)/P 7043 0 R/K 33417 0 R>> endobj 19890 0 obj <>/Alt(\(Begin italic\) atropine ophthalmic \(eye\) ointment \(End italic\) \(Begin italic\) 1 % \(End italic\))/P 7044 0 R/K 33418 0 R>> endobj 19891 0 obj <>/Alt(Tier 1)/P 7044 0 R/K 33419 0 R>> endobj 19892 0 obj <>/Alt(\(Begin italic\) atropine sulfate \(pf\) ophthalmic \(eye\) dropperette \(End italic\) \(Begin italic\) 1 % \(End italic\))/P 7045 0 R/K 33420 0 R>> endobj 19893 0 obj <>/Alt(Tier 1)/P 7045 0 R/K 33421 0 R>> endobj 19894 0 obj <>/Alt(CYCLOMYDRIL OPHTHALMIC \(EYE\) DROPS 0.2-1 %)/P 7046 0 R/K 33422 0 R>> endobj 19895 0 obj <>/Alt(Tier 3)/P 7046 0 R/K 33423 0 R>> endobj 19896 0 obj <>/Alt(\(Begin italic\) cyclopentolate ophthalmic \(eye\) drops \(End italic\) \(Begin italic\) 1 % \(End italic\))/P 7047 0 R/K 33424 0 R>> endobj 19897 0 obj <>/Alt(\(Cyclogyl\))/P 7047 0 R/K 33425 0 R>> endobj 19898 0 obj <>/Alt(Tier 1)/P 7047 0 R/K 33426 0 R>> endobj 19899 0 obj <>/Alt(\(Begin italic\) cyclopen-tropic-phenyleph-watr ophthalmic \(eye\) drops \(End italic\) \(Begin italic\) 1-1-2.5 % \(End italic\))/P 7048 0 R/K 33427 0 R>> endobj 19900 0 obj <>/Alt(Tier 1)/P 7048 0 R/K 33428 0 R>> endobj 19901 0 obj <>/Alt(\(Begin italic\) cyclopent-tropic-phen-ketr-wat ophthalmic \(eye\) drops \(End italic\) \(Begin italic\) 1 %-1 %-10 %- 0.5 %, 1 %-1 %-2.5 %- 0.5 % \(End italic\))/P 7049 0 R/K 33429 0 R>> endobj 19902 0 obj <>/Alt(Tier 1)/P 7049 0 R/K 33430 0 R>> endobj 19903 0 obj <>/Alt(\(Begin italic\) cyclop-trop-propa-phen-ket-wat ophthalmic \(eye\) drops \(End italic\) \(Begin italic\) 1 %-1 %-0.1 %- 2.5 %-0.4 % \(End italic\))/P 7050 0 R/K 33431 0 R>> endobj 19904 0 obj <>/Alt(Tier 1)/P 7050 0 R/K 33432 0 R>> endobj 19905 0 obj <>/Alt(HOMATROPAIRE OPHTHALMIC \(EYE\) DROPS 5 %)/P 7051 0 R/K 33433 0 R>> endobj 19906 0 obj <>/Alt(\(homatropine hbr\))/P 7051 0 R/K 33434 0 R>> endobj 19907 0 obj <>/Alt(Tier 1)/P 7051 0 R/K 33435 0 R>> endobj 19908 0 obj <>/Alt(MYDCOMBI OPHTHALMIC \(EYE\) CARTRIDGE 2.5-1 %)/P 7052 0 R/K 33436 0 R>> endobj 19909 0 obj <>/Alt(Tier 3)/P 7052 0 R/K 33437 0 R>> endobj 19910 0 obj <>/Alt(\(Begin italic\) phenyleph-tropicamide in water ophthalmic \(eye\) drops \(End italic\) \(Begin italic\) 2.5-1 % \(End italic\))/P 7053 0 R/K 33438 0 R>> endobj 19911 0 obj <>/Alt(Tier 1)/P 7053 0 R/K 33439 0 R>> endobj 19912 0 obj <>/Alt(\(Begin italic\) tropicamide ophthalmic \(eye\) drops \(End italic\) \(Begin italic\) 0.5 % \(End italic\))/P 7054 0 R/K 33440 0 R>> endobj 19913 0 obj <>/Alt(Tier 1)/P 7054 0 R/K 33441 0 R>> endobj 19914 0 obj <>/Alt(\(Begin italic\) tropicamide ophthalmic \(eye\) drops \(End italic\) \(Begin italic\) 1 % \(End italic\))/P 7055 0 R/K 33442 0 R>> endobj 19915 0 obj <>/Alt(\(Mydriacyl\))/P 7055 0 R/K 33443 0 R>> endobj 19916 0 obj <>/Alt(Tier 1)/P 7055 0 R/K 33444 0 R>> endobj 19917 0 obj <>/Alt(\(Begin bold\) Ophthalmic Antifibrotic Agents \(End bold\))/P 7056 0 R/K 33445 0 R>> endobj 19918 0 obj <>/Alt(\(Begin italic\) mitomycin \(pf\) in water ophthalmic \(eye\) syringe \(End italic\) \(Begin italic\) 0.2 mg/ml, 0.4 mg/ml \(End italic\))/P 7057 0 R/K 33446 0 R>> endobj 19919 0 obj <>/Alt(Tier 1)/P 7057 0 R/K 33447 0 R>> endobj 19920 0 obj <>/Alt(SP)/P 7057 0 R/K 33448 0 R>> endobj 19921 0 obj <>/Alt(MITOSOL OPHTHALMIC \(EYE\) KIT 0.2 MG)/P 7058 0 R/K 33449 0 R>> endobj 19922 0 obj <>/Alt(Tier 3)/P 7058 0 R/K 33450 0 R>> endobj 19923 0 obj <>/Alt(\(Begin bold\) Eye - Miscellaneous \(End bold\))/P 7059 0 R/K 33451 0 R>> endobj 19924 0 obj <>/Alt(\(Begin bold\) Agents For Corneal Collagen Cross-Linking \(End bold\))/P 7060 0 R/K 33452 0 R>> endobj 19925 0 obj <>/Alt(PHOTREXA CROSS-LINKING KIT OPHTHALMIC \(EYE\) COMBO, DROPS AND DROPS VISCOUS 0.146 % -0.146 %)/P 7061 0 R/K 33453 0 R>> endobj 19926 0 obj <>/Alt(Tier 3)/P 7061 0 R/K 33454 0 R>> endobj 19927 0 obj <>/Alt(SP)/P 7061 0 R/K 33455 0 R>> endobj 19928 0 obj <>/Alt(PHOTREXA OPHTHALMIC \(EYE\) DROPS 0.146 %)/P 7062 0 R/K 33456 0 R>> endobj 19929 0 obj <>/Alt(Tier 3)/P 7062 0 R/K 33457 0 R>> endobj 19930 0 obj <>/Alt(SP)/P 7062 0 R/K 33458 0 R>> endobj 19931 0 obj <>/Alt(PHOTREXA VISCOUS OPHTHALMIC \(EYE\) DROPS, VISCOUS 0.146 %)/P 7063 0 R/K 33459 0 R>> endobj 19932 0 obj <>/Alt(Tier 3)/P 7063 0 R/K 33460 0 R>> endobj 19933 0 obj <>/Alt(SP)/P 7063 0 R/K 33461 0 R>> endobj 19934 0 obj <>/Alt(\(Begin bold\) Artificial Tears \(End bold\))/P 7064 0 R/K 33462 0 R>> endobj 19935 0 obj <>/Alt(MIEBO \(PF\) OPHTHALMIC \(EYE\) DROPS 100 %)/P 7065 0 R/K 33463 0 R>> endobj 19936 0 obj <>/Alt(Tier 2)/P 7065 0 R/K 33464 0 R>> endobj 19937 0 obj <>/Alt(\(Begin bold\) Eye Preparations, Miscellaneous \(Otc\) \(End bold\))/P 7066 0 R/K 33465 0 R>> endobj 19938 0 obj <>/Alt(GELFILM OPHTHALMIC \(EYE\) FILM)/P 7067 0 R/K 33466 0 R>> endobj 19939 0 obj <>/Alt(Tier 3)/P 7067 0 R/K 33467 0 R>> endobj 19940 0 obj <>/Alt(\(Begin bold\) Ophthalmic Cystine Depleting Agents \(End bold\))/P 7068 0 R/K 33468 0 R>> endobj 19941 0 obj <>/Alt(CYSTADROPS OPHTHALMIC \(EYE\) DROPS 0.37 %)/P 7069 0 R/K 33469 0 R>> endobj 19942 0 obj <>/Alt(Tier 2)/P 7069 0 R/K 33470 0 R>> endobj 19943 0 obj <>/Alt(PA; SP)/P 7069 0 R/K 33471 0 R>> endobj 19944 0 obj <>/Alt(CYSTARAN OPHTHALMIC \(EYE\) DROPS 0.44 %)/P 7070 0 R/K 33472 0 R>> endobj 19945 0 obj <>/Alt(Tier 2)/P 7070 0 R/K 33473 0 R>> endobj 19946 0 obj <>/Alt(PA; SP)/P 7070 0 R/K 33474 0 R>> endobj 19947 0 obj <>/Alt(\(Begin bold\) Fluid Replacement \(End bold\))/P 7071 0 R/K 33475 0 R>> endobj 19948 0 obj <>/Alt(\(Begin bold\) Nucleic Acid/Nucleotide Supplements \(End bold\))/P 7072 0 R/K 33476 0 R>> endobj 19949 0 obj <>/Alt(XURIDEN ORAL GRANULES IN PACKET 2 GRAM)/P 7073 0 R/K 33477 0 R>> endobj 19950 0 obj <>/Alt(Tier 2)/P 7073 0 R/K 33478 0 R>> endobj 19951 0 obj <>/Alt(PA; SP)/P 7073 0 R/K 33479 0 R>> endobj 19952 0 obj <>/Alt(\(Begin bold\) Gout And Related Diseases \(End bold\))/P 7074 0 R/K 33480 0 R>> endobj 19953 0 obj <>/Alt(\(Begin bold\) Colchicine \(End bold\))/P 7075 0 R/K 33481 0 R>> endobj 19954 0 obj <>/Alt(\(Begin italic\) colchicine oral capsule \(End italic\) \(Begin italic\) 0.6 mg \(End italic\))/P 7076 0 R/K 33482 0 R>> endobj 19955 0 obj <>/Alt(\(Mitigare\))/P 7076 0 R/K 33483 0 R>> endobj 19956 0 obj <>/Alt(Tier 1)/P 7076 0 R/K 33484 0 R>> endobj 19957 0 obj <>/Alt(QL \(2 EA per 1 day\))/P 7076 0 R/K 33485 0 R>> endobj 19958 0 obj <>/Alt(\(Begin italic\) colchicine oral tablet \(End italic\) 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obj <>/Alt(PRADAXA ORAL PELLETS IN PACKET 110 MG, 150 MG, 20 MG, 30 MG, 40 MG, 50 MG)/P 7252 0 R/K 33933 0 R>> endobj 20406 0 obj <>/Alt(Tier 3)/P 7252 0 R/K 33934 0 R>> endobj 20407 0 obj <>/Alt(PA)/P 7252 0 R/K 33935 0 R>> endobj 20408 0 obj <>/Alt(\(Begin bold\) Thrombopoietin Receptor Agonists \(End bold\))/P 7253 0 R/K 33936 0 R>> endobj 20409 0 obj <>/Alt(ALVAIZ ORAL TABLET 18 MG, 36 MG, 54 MG, 9 MG)/P 7254 0 R/K 33937 0 R>> endobj 20410 0 obj <>/Alt(Tier 3)/P 7254 0 R/K 33938 0 R>> endobj 20411 0 obj <>/Alt(PA; SP)/P 7254 0 R/K 33939 0 R>> endobj 20412 0 obj <>/Alt(DOPTELET \(10 TAB PACK\) ORAL TABLET 20 MG)/P 7255 0 R/K 33940 0 R>> endobj 20413 0 obj <>/Alt(Tier 2)/P 7255 0 R/K 33941 0 R>> endobj 20414 0 obj <>/Alt(PA; SP)/P 7255 0 R/K 33942 0 R>> endobj 20415 0 obj <>/Alt(DOPTELET \(15 TAB PACK\) ORAL TABLET 20 MG)/P 7256 0 R/K 33943 0 R>> endobj 20416 0 obj <>/Alt(Tier 2)/P 7256 0 R/K 33944 0 R>> endobj 20417 0 obj <>/Alt(PA; SP)/P 7256 0 R/K 33945 0 R>> endobj 20418 0 obj 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endobj 20469 0 obj <>/Alt(THROMBIN-JMI TOPICAL SPRAY SYRINGE 20,000 UNIT, 5,000 UNIT)/P 7281 0 R/K 33997 0 R>> endobj 20470 0 obj <>/Alt(Tier 1)/P 7281 0 R/K 33998 0 R>> endobj 20471 0 obj <>/Alt(THROMBIN-JMI TOPICAL SPRAY,NON-AEROSOL 20,000 UNIT)/P 7282 0 R/K 33999 0 R>> endobj 20472 0 obj <>/Alt(Tier 1)/P 7282 0 R/K 34000 0 R>> endobj 20473 0 obj <>/Alt(THROMBI-PAD TOPICAL PADS, MEDICATED 3 X 3 ")/P 7283 0 R/K 34001 0 R>> endobj 20474 0 obj <>/Alt(Tier 1)/P 7283 0 R/K 34002 0 R>> endobj 20475 0 obj <>/Alt(ULTRAFOAM TOPICAL SPONGE 2 X 6.25 X 7 CM-CM-MM, 8 X 12.5 X 1 CM, 8 X 12.5 X 3 CM-CM-MM, 8 X 6.25 X 1 CM)/P 7284 0 R/K 34003 0 R>> endobj 20476 0 obj <>/Alt(Tier 3)/P 7284 0 R/K 34004 0 R>> endobj 20477 0 obj <>/Alt(VISTASEAL-FIBRIN SEALANT TOPICAL SYRINGE 500 UNIT-80 MG /ML \(10 ML\), 500 UNIT-80 MG /ML \(2 ML\), 500 UNIT-80 MG /ML \(4 ML\))/P 7285 0 R/K 34005 0 R>> endobj 20478 0 obj <>/Alt(Tier 3)/P 7285 0 R/K 34006 0 R>> endobj 20479 0 obj <>/Alt(\(Begin bold\) Vitamin K 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methyltestosterone oral capsule \(End italic\) \(Begin italic\) 10 mg \(End italic\))/P 7296 0 R/K 34030 0 R>> endobj 20503 0 obj <>/Alt(Tier 1)/P 7296 0 R/K 34031 0 R>> endobj 20504 0 obj <>/Alt(PA)/P 7296 0 R/K 34032 0 R>> endobj 20505 0 obj <>/Alt(\(Begin italic\) testosterone cypionate intramuscular oil \(End italic\) \(Begin italic\) 100 mg/ml, 200 mg/ml \(End italic\))/P 7297 0 R/K 34033 0 R>> endobj 20506 0 obj <>/Alt(\(Depo-Testosterone\))/P 7297 0 R/K 34034 0 R>> endobj 20507 0 obj <>/Alt(Tier 1)/P 7297 0 R/K 34035 0 R>> endobj 20508 0 obj <>/Alt(PA)/P 7297 0 R/K 34036 0 R>> endobj 20509 0 obj <>/Alt(\(Begin italic\) testosterone enanthate intramuscular oil \(End italic\) \(Begin italic\) 200 mg/ml \(End italic\))/P 7298 0 R/K 34037 0 R>> endobj 20510 0 obj <>/Alt(Tier 1)/P 7298 0 R/K 34038 0 R>> endobj 20511 0 obj <>/Alt(PA)/P 7298 0 R/K 34039 0 R>> endobj 20512 0 obj <>/Alt(\(Begin italic\) testosterone transdermal gel \(End italic\) \(Begin italic\) 50 mg/5 gram \(1 %\) 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italic\))/P 7509 0 R/K 34605 0 R>> endobj 21078 0 obj <>/Alt(Tier 1)/P 7509 0 R/K 34606 0 R>> endobj 21079 0 obj <>/Alt(\(Begin italic\) cefuroxime axetil oral tablet \(End italic\) \(Begin italic\) 250 mg, 500 mg \(End italic\))/P 7510 0 R/K 34607 0 R>> endobj 21080 0 obj <>/Alt(Tier 1)/P 7510 0 R/K 34608 0 R>> endobj 21081 0 obj <>/Alt(\(Begin bold\) Cephalosporins - 3Rd Generation \(End bold\))/P 7511 0 R/K 34609 0 R>> endobj 21082 0 obj <>/Alt(\(Begin italic\) cefdinir oral capsule \(End italic\) \(Begin italic\) 300 mg \(End italic\))/P 7512 0 R/K 34610 0 R>> endobj 21083 0 obj <>/Alt(Tier 1)/P 7512 0 R/K 34611 0 R>> endobj 21084 0 obj <>/Alt(\(Begin italic\) cefdinir oral suspension for reconstitution \(End italic\) \(Begin italic\) 125 mg/5 ml, 250 mg/5 ml \(End italic\))/P 7513 0 R/K 34612 0 R>> endobj 21085 0 obj <>/Alt(Tier 1)/P 7513 0 R/K 34613 0 R>> endobj 21086 0 obj <>/Alt(\(Begin italic\) cefixime oral capsule \(End italic\) \(Begin italic\) 400 mg \(End italic\))/P 7514 0 R/K 34614 0 R>> endobj 21087 0 obj <>/Alt(Tier 1)/P 7514 0 R/K 34615 0 R>> endobj 21088 0 obj <>/Alt(\(Begin italic\) cefixime oral suspension for reconstitution \(End italic\) \(Begin italic\) 100 mg/5 ml, 200 mg/5 ml \(End italic\))/P 7515 0 R/K 34616 0 R>> endobj 21089 0 obj <>/Alt(Tier 1)/P 7515 0 R/K 34617 0 R>> endobj 21090 0 obj <>/Alt(\(Begin italic\) cefpodoxime oral suspension for reconstitution \(End italic\) \(Begin italic\) 100 mg/5 ml, 50 mg/5 ml \(End italic\))/P 7516 0 R/K 34618 0 R>> endobj 21091 0 obj <>/Alt(Tier 1)/P 7516 0 R/K 34619 0 R>> endobj 21092 0 obj <>/Alt(\(Begin italic\) cefpodoxime oral tablet \(End italic\) \(Begin italic\) 100 mg, 200 mg \(End italic\))/P 7517 0 R/K 34620 0 R>> endobj 21093 0 obj <>/Alt(Tier 1)/P 7517 0 R/K 34621 0 R>> endobj 21094 0 obj <>/Alt(SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 500 MG/5 ML)/P 7518 0 R/K 34622 0 R>> endobj 21095 0 obj <>/Alt(Tier 2)/P 7518 0 R/K 34623 0 R>> endobj 21096 0 obj <>/Alt(SUPRAX ORAL TABLET,CHEWABLE 100 MG, 200 MG)/P 7519 0 R/K 34624 0 R>> endobj 21097 0 obj <>/Alt(Tier 2)/P 7519 0 R/K 34625 0 R>> endobj 21098 0 obj <>/Alt(\(Begin bold\) Chemotherapeutics, Antibacterial, Misc. \(End bold\))/P 7520 0 R/K 34626 0 R>> endobj 21099 0 obj <>/Alt(\(Begin italic\) fosfomycin tromethamine oral packet \(End italic\) \(Begin italic\) 3 gram \(End italic\))/P 7521 0 R/K 34627 0 R>> endobj 21100 0 obj <>/Alt(Tier 1)/P 7521 0 R/K 34628 0 R>> endobj 21101 0 obj <>/Alt(\(Begin italic\) methenamine hippurate oral tablet \(End italic\) \(Begin italic\) 1 gram \(End italic\))/P 7522 0 R/K 34629 0 R>> endobj 21102 0 obj <>/Alt(Tier 1)/P 7522 0 R/K 34630 0 R>> endobj 21103 0 obj <>/Alt(\(Begin italic\) methenamine mandelate oral tablet \(End italic\) \(Begin italic\) 0.5 gram, 1 gram \(End italic\))/P 7523 0 R/K 34631 0 R>> endobj 21104 0 obj <>/Alt(Tier 1)/P 7523 0 R/K 34632 0 R>> endobj 21105 0 obj <>/Alt(\(Begin italic\) methen-sod phos-meth blue-hyos oral tablet \(End italic\) \(Begin italic\) 81.6-40.8-0.12 mg \(End italic\))/P 7524 0 R/K 34633 0 R>> endobj 21106 0 obj <>/Alt(\(Urogesic-Blue\))/P 7524 0 R/K 34634 0 R>> endobj 21107 0 obj <>/Alt(Tier 1)/P 7524 0 R/K 34635 0 R>> endobj 21108 0 obj <>/Alt(PRIMSOL ORAL SOLUTION 50 MG/5 ML)/P 7525 0 R/K 34636 0 R>> endobj 21109 0 obj <>/Alt(Tier 2)/P 7525 0 R/K 34637 0 R>> endobj 21110 0 obj <>/Alt(\(Begin italic\) trimethoprim oral tablet \(End italic\) \(Begin italic\) 100 mg \(End italic\))/P 7526 0 R/K 34638 0 R>> endobj 21111 0 obj <>/Alt(Tier 1)/P 7526 0 R/K 34639 0 R>> endobj 21112 0 obj <>/Alt(URETRON D-S ORAL TABLET 81.6-10.8-40.8 MG)/P 7527 0 R/K 34640 0 R>> endobj 21113 0 obj <>/Alt(Tier 2)/P 7527 0 R/K 34641 0 R>> endobj 21114 0 obj <>/Alt(URIBEL TABS ORAL TABLET 81.6-0.12-10.8 MG)/P 7528 0 R/K 34642 0 R>> endobj 21115 0 obj <>/Alt(Tier 3)/P 7528 0 R/K 34643 0 R>> endobj 21116 0 obj <>/Alt(URIMAR-T ORAL TABLET 120-10.8-0.12 MG)/P 7529 0 R/K 34644 0 R>> endobj 21117 0 obj <>/Alt(Tier 3)/P 7529 0 R/K 34645 0 R>> endobj 21118 0 obj <>/Alt(URO-458 ORAL TABLET 81-10.8-40.8 MG)/P 7530 0 R/K 34646 0 R>> endobj 21119 0 obj <>/Alt(Tier 1)/P 7530 0 R/K 34647 0 R>> endobj 21120 0 obj <>/Alt(UROGESIC-BLUE ORAL TABLET 81.6-40.8-0.12 MG)/P 7531 0 R/K 34648 0 R>> endobj 21121 0 obj <>/Alt(\(methen-sod phos-meth blue-hyos\))/P 7531 0 R/K 34649 0 R>> endobj 21122 0 obj <>/Alt(Tier 1)/P 7531 0 R/K 34650 0 R>> endobj 21123 0 obj <>/Alt(URO-MP ORAL CAPSULE 118-10-40.8-36 MG)/P 7532 0 R/K 34651 0 R>> endobj 21124 0 obj <>/Alt(Tier 1)/P 7532 0 R/K 34652 0 R>> endobj 21125 0 obj <>/Alt(\(Begin bold\) Fecal Microbiota Transplantation \(Fmt\) \(End bold\))/P 7533 0 R/K 34653 0 R>> endobj 21126 0 obj <>/Alt(REBYOTA RECTAL ENEMA 150 ML)/P 7534 0 R/K 34654 0 R>> endobj 21127 0 obj <>/Alt(Tier 3)/P 7534 0 R/K 34655 0 R>> endobj 21128 0 obj <>/Alt(PA; SP)/P 7534 0 R/K 34656 0 R>> endobj 21129 0 obj <>/Alt(VOWST ORAL CAPSULE)/P 7535 0 R/K 34657 0 R>> endobj 21130 0 obj <>/Alt(Tier 2)/P 7535 0 R/K 34658 0 R>> endobj 21131 0 obj <>/Alt(PA; SP)/P 7535 0 R/K 34659 0 R>> endobj 21132 0 obj <>/Alt(\(Begin bold\) Macrolides \(End bold\))/P 7536 0 R/K 34660 0 R>> endobj 21133 0 obj <>/Alt(\(Begin italic\) azithromycin oral packet \(End italic\) \(Begin italic\) 1 gram \(End italic\))/P 7537 0 R/K 34661 0 R>> endobj 21134 0 obj <>/Alt(\(Zithromax\))/P 7537 0 R/K 34662 0 R>> endobj 21135 0 obj <>/Alt(Tier 1)/P 7537 0 R/K 34663 0 R>> endobj 21136 0 obj <>/Alt(\(Begin italic\) azithromycin oral suspension for reconstitution \(End italic\) \(Begin italic\) 100 mg/5 ml, 200 mg/5 ml \(End italic\))/P 7538 0 R/K 34664 0 R>> endobj 21137 0 obj <>/Alt(\(Zithromax\))/P 7538 0 R/K 34665 0 R>> endobj 21138 0 obj <>/Alt(Tier 1)/P 7538 0 R/K 34666 0 R>> endobj 21139 0 obj <>/Alt(\(Begin italic\) azithromycin oral tablet \(End italic\) \(Begin italic\) 250 mg, 500 mg \(End italic\))/P 7539 0 R/K 34667 0 R>> endobj 21140 0 obj <>/Alt(\(Zithromax\))/P 7539 0 R/K 34668 0 R>> endobj 21141 0 obj <>/Alt(Tier 1)/P 7539 0 R/K 34669 0 R>> endobj 21142 0 obj <>/Alt(\(Begin italic\) azithromycin oral tablet \(End italic\) \(Begin italic\) 600 mg \(End italic\))/P 7540 0 R/K 34670 0 R>> endobj 21143 0 obj <>/Alt(Tier 1)/P 7540 0 R/K 34671 0 R>> endobj 21144 0 obj <>/Alt(\(Begin italic\) clarithromycin oral suspension for reconstitution \(End italic\) \(Begin italic\) 125 mg/5 ml, 250 mg/5 ml \(End italic\))/P 7541 0 R/K 34672 0 R>> endobj 21145 0 obj <>/Alt(Tier 1)/P 7541 0 R/K 34673 0 R>> endobj 21146 0 obj <>/Alt(\(Begin italic\) clarithromycin oral tablet \(End italic\) \(Begin italic\) 250 mg, 500 mg \(End italic\))/P 7542 0 R/K 34674 0 R>> endobj 21147 0 obj <>/Alt(Tier 1)/P 7542 0 R/K 34675 0 R>> endobj 21148 0 obj <>/Alt(\(Begin italic\) clarithromycin oral tablet extended release 24 hr \(End italic\) \(Begin italic\) 500 mg \(End italic\))/P 7543 0 R/K 34676 0 R>> endobj 21149 0 obj <>/Alt(Tier 1)/P 7543 0 R/K 34677 0 R>> endobj 21150 0 obj <>/Alt(DIFICID ORAL SUSPENSION FOR RECONSTITUTION 40 MG/ML)/P 7544 0 R/K 34678 0 R>> endobj 21151 0 obj <>/Alt(Tier 2)/P 7544 0 R/K 34679 0 R>> endobj 21152 0 obj <>/Alt(QL \(10 ML per 1 day\))/P 7544 0 R/K 34680 0 R>> endobj 21153 0 obj <>/Alt(DIFICID ORAL TABLET 200 MG)/P 7545 0 R/K 34681 0 R>> endobj 21154 0 obj <>/Alt(Tier 2)/P 7545 0 R/K 34682 0 R>> endobj 21155 0 obj <>/Alt(QL \(20 EA per 10 days\))/P 7545 0 R/K 34683 0 R>> endobj 21156 0 obj <>/Alt(E.E.S. 400 ORAL TABLET 400 MG)/P 7546 0 R/K 34684 0 R>> endobj 21157 0 obj <>/Alt(\(erythromycin ethylsuccinate\))/P 7546 0 R/K 34685 0 R>> endobj 21158 0 obj <>/Alt(Tier 1)/P 7546 0 R/K 34686 0 R>> endobj 21159 0 obj <>/Alt(ERY-TAB ORAL TABLET,DELAYED RELEASE \(DR/EC\) 250 MG, 500 MG)/P 7547 0 R/K 34687 0 R>> endobj 21160 0 obj <>/Alt(\(erythromycin\))/P 7547 0 R/K 34688 0 R>> endobj 21161 0 obj <>/Alt(Tier 1)/P 7547 0 R/K 34689 0 R>> endobj 21162 0 obj <>/Alt(ERYTHROCIN \(AS STEARATE\) ORAL TABLET 250 MG)/P 7548 0 R/K 34690 0 R>> endobj 21163 0 obj <>/Alt(\(erythromycin stearate\))/P 7548 0 R/K 34691 0 R>> endobj 21164 0 obj <>/Alt(Tier 1)/P 7548 0 R/K 34692 0 R>> endobj 21165 0 obj <>/Alt(\(Begin italic\) erythromycin ethylsuccinate oral suspension for reconstitution \(End italic\) \(Begin italic\) 200 mg/5 ml \(End italic\))/P 7549 0 R/K 34693 0 R>> endobj 21166 0 obj <>/Alt(\(E.E.S. Granules\))/P 7549 0 R/K 34694 0 R>> endobj 21167 0 obj <>/Alt(Tier 1)/P 7549 0 R/K 34695 0 R>> endobj 21168 0 obj <>/Alt(\(Begin italic\) erythromycin ethylsuccinate oral suspension for reconstitution \(End italic\) \(Begin italic\) 400 mg/5 ml \(End italic\))/P 7550 0 R/K 34696 0 R>> endobj 21169 0 obj <>/Alt(\(EryPed 400\))/P 7550 0 R/K 34697 0 R>> endobj 21170 0 obj <>/Alt(Tier 1)/P 7550 0 R/K 34698 0 R>> endobj 21171 0 obj <>/Alt(\(Begin italic\) erythromycin ethylsuccinate oral tablet \(End italic\) \(Begin italic\) 400 mg \(End italic\))/P 7551 0 R/K 34699 0 R>> endobj 21172 0 obj <>/Alt(\(E.E.S. 400\))/P 7551 0 R/K 34700 0 R>> endobj 21173 0 obj <>/Alt(Tier 1)/P 7551 0 R/K 34701 0 R>> endobj 21174 0 obj <>/Alt(\(Begin italic\) erythromycin oral capsule,delayed release\(dr/ec\) \(End italic\) \(Begin italic\) 250 mg \(End italic\))/P 7552 0 R/K 34702 0 R>> endobj 21175 0 obj <>/Alt(Tier 1)/P 7552 0 R/K 34703 0 R>> endobj 21176 0 obj <>/Alt(\(Begin italic\) erythromycin oral tablet \(End italic\) \(Begin italic\) 250 mg, 500 mg \(End italic\))/P 7553 0 R/K 34704 0 R>> endobj 21177 0 obj <>/Alt(Tier 1)/P 7553 0 R/K 34705 0 R>> endobj 21178 0 obj <>/Alt(\(Begin italic\) erythromycin oral tablet,delayed release \(dr/ec\) \(End italic\) \(Begin italic\) 250 mg, 333 mg, 500 mg \(End italic\))/P 7554 0 R/K 34706 0 R>> endobj 21179 0 obj <>/Alt(\(Ery-Tab\))/P 7554 0 R/K 34707 0 R>> endobj 21180 0 obj <>/Alt(Tier 1)/P 7554 0 R/K 34708 0 R>> endobj 21181 0 obj <>/Alt(\(Begin bold\) Nitrofuran Derivatives \(End bold\))/P 7555 0 R/K 34709 0 R>> endobj 21182 0 obj <>/Alt(\(Begin italic\) nitrofurantoin macrocrystal oral capsule \(End italic\) \(Begin italic\) 100 mg, 50 mg \(End italic\))/P 7556 0 R/K 34710 0 R>> endobj 21183 0 obj <>/Alt(Tier 1)/P 7556 0 R/K 34711 0 R>> endobj 21184 0 obj <>/Alt(\(Begin italic\) nitrofurantoin macrocrystal oral capsule \(End italic\) \(Begin italic\) 25 mg \(End italic\))/P 7557 0 R/K 34712 0 R>> endobj 21185 0 obj <>/Alt(Tier 1)/P 7557 0 R/K 34713 0 R>> endobj 21186 0 obj <>/Alt(QL \(4 EA per 1 day\))/P 7557 0 R/K 34714 0 R>> endobj 21187 0 obj <>/Alt(\(Begin italic\) nitrofurantoin monohyd/m-cryst oral capsule \(End italic\) \(Begin italic\) 100 mg \(End italic\))/P 7558 0 R/K 34715 0 R>> endobj 21188 0 obj <>/Alt(\(Macrobid\))/P 7558 0 R/K 34716 0 R>> endobj 21189 0 obj <>/Alt(Tier 1)/P 7558 0 R/K 34717 0 R>> endobj 21190 0 obj <>/Alt(\(Begin italic\) nitrofurantoin oral suspension \(End italic\) \(Begin italic\) 25 mg/5 ml \(End italic\))/P 7559 0 R/K 34718 0 R>> endobj 21191 0 obj <>/Alt(\(Furadantin\))/P 7559 0 R/K 34719 0 R>> endobj 21192 0 obj <>/Alt(Tier 1)/P 7559 0 R/K 34720 0 R>> endobj 21193 0 obj <>/Alt(PA)/P 7559 0 R/K 34721 0 R>> endobj 21194 0 obj <>/Alt(\(Begin bold\) Oxazolidinones \(End bold\))/P 7560 0 R/K 34722 0 R>> endobj 21195 0 obj <>/Alt(\(Begin italic\) linezolid oral suspension for reconstitution \(End italic\) \(Begin italic\) 100 mg/5 ml \(End italic\))/P 7561 0 R/K 34723 0 R>> endobj 21196 0 obj <>/Alt(\(Zyvox\))/P 7561 0 R/K 34724 0 R>> endobj 21197 0 obj <>/Alt(Tier 1)/P 7561 0 R/K 34725 0 R>> endobj 21198 0 obj <>/Alt(\(Begin italic\) linezolid oral tablet \(End italic\) \(Begin italic\) 600 mg \(End italic\))/P 7562 0 R/K 34726 0 R>> endobj 21199 0 obj <>/Alt(\(Zyvox\))/P 7562 0 R/K 34727 0 R>> endobj 21200 0 obj <>/Alt(Tier 1)/P 7562 0 R/K 34728 0 R>> endobj 21201 0 obj <>/Alt(SIVEXTRO ORAL TABLET 200 MG)/P 7563 0 R/K 34729 0 R>> endobj 21202 0 obj <>/Alt(Tier 2)/P 7563 0 R/K 34730 0 R>> endobj 21203 0 obj <>/Alt(PA)/P 7563 0 R/K 34731 0 R>> endobj 21204 0 obj <>/Alt(\(Begin bold\) Penicillins \(End bold\))/P 7564 0 R/K 34732 0 R>> endobj 21205 0 obj <>/Alt(\(Begin italic\) amoxicillin oral capsule \(End italic\) \(Begin italic\) 250 mg, 500 mg \(End italic\))/P 7565 0 R/K 34733 0 R>> endobj 21206 0 obj <>/Alt(Tier 1)/P 7565 0 R/K 34734 0 R>> endobj 21207 0 obj <>/Alt(\(Begin italic\) amoxicillin oral suspension for reconstitution \(End italic\) \(Begin italic\) 125 mg/5 ml, 200 mg/5 ml, 250 mg/5 ml, 400 mg/5 ml \(End italic\))/P 7566 0 R/K 34735 0 R>> endobj 21208 0 obj <>/Alt(Tier 1)/P 7566 0 R/K 34736 0 R>> endobj 21209 0 obj <>/Alt(\(Begin italic\) amoxicillin oral tablet \(End italic\) \(Begin italic\) 500 mg, 875 mg \(End italic\))/P 7567 0 R/K 34737 0 R>> endobj 21210 0 obj <>/Alt(Tier 1)/P 7567 0 R/K 34738 0 R>> endobj 21211 0 obj <>/Alt(\(Begin italic\) amoxicillin oral tablet,chewable \(End italic\) \(Begin italic\) 125 mg, 250 mg \(End italic\))/P 7568 0 R/K 34739 0 R>> endobj 21212 0 obj <>/Alt(Tier 1)/P 7568 0 R/K 34740 0 R>> endobj 21213 0 obj <>/Alt(\(Begin italic\) amoxicillin-pot clavulanate oral suspension for reconstitution \(End italic\) \(Begin italic\) 200-28.5 mg/5 ml, 400-57 mg/5 ml \(End italic\))/P 7569 0 R/K 34741 0 R>> endobj 21214 0 obj <>/Alt(Tier 1)/P 7569 0 R/K 34742 0 R>> endobj 21215 0 obj <>/Alt(\(Begin italic\) amoxicillin-pot clavulanate oral suspension for reconstitution \(End italic\) \(Begin italic\) 250-62.5 mg/5 ml \(End italic\))/P 7570 0 R/K 34743 0 R>> endobj 21216 0 obj <>/Alt(\(Augmentin\))/P 7570 0 R/K 34744 0 R>> endobj 21217 0 obj <>/Alt(Tier 1)/P 7570 0 R/K 34745 0 R>> endobj 21218 0 obj <>/Alt(\(Begin italic\) amoxicillin-pot clavulanate oral suspension for reconstitution \(End italic\) \(Begin italic\) 600-42.9 mg/5 ml \(End italic\))/P 7571 0 R/K 34746 0 R>> endobj 21219 0 obj <>/Alt(\(Augmentin ES-600\))/P 7571 0 R/K 34747 0 R>> endobj 21220 0 obj <>/Alt(Tier 1)/P 7571 0 R/K 34748 0 R>> endobj 21221 0 obj <>/Alt(\(Begin italic\) amoxicillin-pot clavulanate oral tablet \(End italic\) \(Begin italic\) 250-125 mg, 875-125 mg \(End italic\))/P 7572 0 R/K 34749 0 R>> endobj 21222 0 obj <>/Alt(Tier 1)/P 7572 0 R/K 34750 0 R>> endobj 21223 0 obj <>/Alt(\(Begin italic\) amoxicillin-pot clavulanate oral tablet \(End italic\) \(Begin italic\) 500-125 mg \(End italic\))/P 7573 0 R/K 34751 0 R>> endobj 21224 0 obj <>/Alt(\(Augmentin\))/P 7573 0 R/K 34752 0 R>> endobj 21225 0 obj <>/Alt(Tier 1)/P 7573 0 R/K 34753 0 R>> endobj 21226 0 obj <>/Alt(\(Begin italic\) amoxicillin-pot clavulanate oral tablet extended release 12 hr \(End italic\) \(Begin italic\) 1,000-62.5 mg \(End italic\))/P 7574 0 R/K 34754 0 R>> endobj 21227 0 obj <>/Alt(\(Augmentin XR\))/P 7574 0 R/K 34755 0 R>> endobj 21228 0 obj <>/Alt(Tier 1)/P 7574 0 R/K 34756 0 R>> endobj 21229 0 obj <>/Alt(\(Begin italic\) amoxicillin-pot clavulanate oral tablet,chewable \(End italic\) \(Begin italic\) 200-28.5 mg, 400-57 mg \(End italic\))/P 7575 0 R/K 34757 0 R>> endobj 21230 0 obj <>/Alt(Tier 1)/P 7575 0 R/K 34758 0 R>> endobj 21231 0 obj <>/Alt(\(Begin italic\) ampicillin oral capsule \(End italic\) \(Begin italic\) 500 mg \(End italic\))/P 7576 0 R/K 34759 0 R>> endobj 21232 0 obj <>/Alt(Tier 1)/P 7576 0 R/K 34760 0 R>> endobj 21233 0 obj <>/Alt(\(Begin italic\) dicloxacillin oral capsule \(End italic\) \(Begin italic\) 250 mg, 500 mg \(End italic\))/P 7577 0 R/K 34761 0 R>> endobj 21234 0 obj <>/Alt(Tier 1)/P 7577 0 R/K 34762 0 R>> endobj 21235 0 obj <>/Alt(MOXATAG ORAL TABLET, ER MULTIPHASE 24 HR 775 MG)/P 7578 0 R/K 34763 0 R>> endobj 21236 0 obj <>/Alt(\(amoxicillin\))/P 7578 0 R/K 34764 0 R>> endobj 21237 0 obj <>/Alt(Tier 3)/P 7578 0 R/K 34765 0 R>> endobj 21238 0 obj <>/Alt(\(Begin italic\) penicillin v potassium oral recon soln \(End italic\) \(Begin italic\) 125 mg/5 ml, 250 mg/5 ml \(End italic\))/P 7579 0 R/K 34766 0 R>> endobj 21239 0 obj <>/Alt(Tier 1)/P 7579 0 R/K 34767 0 R>> endobj 21240 0 obj <>/Alt(\(Begin italic\) penicillin v potassium oral tablet \(End italic\) \(Begin italic\) 250 mg, 500 mg \(End italic\))/P 7580 0 R/K 34768 0 R>> endobj 21241 0 obj <>/Alt(Tier 1)/P 7580 0 R/K 34769 0 R>> endobj 21242 0 obj <>/Alt(PIVYA ORAL TABLET 185 MG)/P 7581 0 R/K 34770 0 R>> endobj 21243 0 obj <>/Alt(Tier 3)/P 7581 0 R/K 34771 0 R>> endobj 21244 0 obj <>/Alt(PA)/P 7581 0 R/K 34772 0 R>> endobj 21245 0 obj <>/Alt(\(Begin bold\) Pleuromutilin Derivatives \(End bold\))/P 7582 0 R/K 34773 0 R>> endobj 21246 0 obj <>/Alt(XENLETA ORAL TABLET 600 MG)/P 7583 0 R/K 34774 0 R>> endobj 21247 0 obj <>/Alt(Tier 3)/P 7583 0 R/K 34775 0 R>> endobj 21248 0 obj <>/Alt(PA)/P 7583 0 R/K 34776 0 R>> endobj 21249 0 obj <>/Alt(\(Begin bold\) Quinolones \(End bold\))/P 7584 0 R/K 34777 0 R>> endobj 21250 0 obj <>/Alt(BAXDELA ORAL TABLET 450 MG)/P 7585 0 R/K 34778 0 R>> endobj 21251 0 obj <>/Alt(Tier 3)/P 7585 0 R/K 34779 0 R>> endobj 21252 0 obj <>/Alt(PA)/P 7585 0 R/K 34780 0 R>> endobj 21253 0 obj <>/Alt(CIPRO ORAL SUSPENSION,MICROCAPSULE RECON 250 MG/5 ML, 500 MG/5 ML)/P 7586 0 R/K 34781 0 R>> endobj 21254 0 obj <>/Alt(\(ciprofloxacin\))/P 7586 0 R/K 34782 0 R>> endobj 21255 0 obj <>/Alt(Tier 2)/P 7586 0 R/K 34783 0 R>> endobj 21256 0 obj <>/Alt(\(Begin italic\) ciprofloxacin hcl oral tablet \(End italic\) \(Begin italic\) 100 mg, 750 mg \(End italic\))/P 7587 0 R/K 34784 0 R>> endobj 21257 0 obj <>/Alt(Tier 1)/P 7587 0 R/K 34785 0 R>> endobj 21258 0 obj <>/Alt(\(Begin italic\) ciprofloxacin hcl oral tablet \(End italic\) \(Begin italic\) 250 mg, 500 mg \(End italic\))/P 7588 0 R/K 34786 0 R>> endobj 21259 0 obj <>/Alt(\(Cipro\))/P 7588 0 R/K 34787 0 R>> endobj 21260 0 obj <>/Alt(Tier 1)/P 7588 0 R/K 34788 0 R>> endobj 21261 0 obj <>/Alt(\(Begin italic\) ciprofloxacin oral suspension,microcapsule recon \(End italic\) \(Begin italic\) 250 mg/5 ml, 500 mg/5 ml \(End italic\))/P 7589 0 R/K 34789 0 R>> endobj 21262 0 obj <>/Alt(\(Cipro\))/P 7589 0 R/K 34790 0 R>> endobj 21263 0 obj <>/Alt(Tier 1)/P 7589 0 R/K 34791 0 R>> endobj 21264 0 obj <>/Alt(\(Begin italic\) levofloxacin oral solution \(End italic\) \(Begin italic\) 250 mg/10 ml \(End italic\))/P 7590 0 R/K 34792 0 R>> endobj 21265 0 obj <>/Alt(Tier 1)/P 7590 0 R/K 34793 0 R>> endobj 21266 0 obj <>/Alt(\(Begin italic\) levofloxacin oral tablet \(End italic\) \(Begin italic\) 250 mg, 500 mg, 750 mg \(End italic\))/P 7591 0 R/K 34794 0 R>> endobj 21267 0 obj <>/Alt(Tier 1)/P 7591 0 R/K 34795 0 R>> endobj 21268 0 obj <>/Alt(\(Begin italic\) moxifloxacin oral tablet \(End italic\) \(Begin italic\) 400 mg \(End italic\))/P 7592 0 R/K 34796 0 R>> endobj 21269 0 obj <>/Alt(Tier 1)/P 7592 0 R/K 34797 0 R>> endobj 21270 0 obj <>/Alt(\(Begin italic\) ofloxacin oral tablet \(End italic\) \(Begin italic\) 300 mg, 400 mg \(End italic\))/P 7593 0 R/K 34798 0 R>> endobj 21271 0 obj <>/Alt(Tier 1)/P 7593 0 R/K 34799 0 R>> endobj 21272 0 obj <>/Alt(\(Begin bold\) Tetracyclines \(End bold\))/P 7594 0 R/K 34800 0 R>> endobj 21273 0 obj <>/Alt(\(Begin italic\) demeclocycline oral tablet \(End italic\) \(Begin italic\) 150 mg, 300 mg \(End italic\))/P 7595 0 R/K 34801 0 R>> endobj 21274 0 obj <>/Alt(Tier 1)/P 7595 0 R/K 34802 0 R>> endobj 21275 0 obj <>/Alt(\(Begin italic\) doxycycline hyclate oral capsule \(End italic\) \(Begin italic\) 100 mg \(End italic\))/P 7596 0 R/K 34803 0 R>> endobj 21276 0 obj <>/Alt(Tier 1)/P 7596 0 R/K 34804 0 R>> endobj 21277 0 obj <>/Alt(QL \(2 EA per 1 day\))/P 7596 0 R/K 34805 0 R>> endobj 21278 0 obj <>/Alt(\(Begin italic\) doxycycline hyclate oral capsule \(End italic\) \(Begin italic\) 50 mg \(End italic\))/P 7597 0 R/K 34806 0 R>> endobj 21279 0 obj <>/Alt(\(Morgidox\))/P 7597 0 R/K 34807 0 R>> endobj 21280 0 obj <>/Alt(Tier 1)/P 7597 0 R/K 34808 0 R>> endobj 21281 0 obj <>/Alt(QL \(2 EA per 1 day\))/P 7597 0 R/K 34809 0 R>> endobj 21282 0 obj <>/Alt(\(Begin italic\) doxycycline hyclate oral tablet \(End italic\) \(Begin italic\) 100 mg \(End italic\))/P 7598 0 R/K 34810 0 R>> endobj 21283 0 obj <>/Alt(Tier 1)/P 7598 0 R/K 34811 0 R>> endobj 21284 0 obj <>/Alt(\(Begin italic\) doxycycline hyclate oral tablet \(End italic\) \(Begin italic\) 150 mg \(End italic\))/P 7599 0 R/K 34812 0 R>> endobj 21285 0 obj <>/Alt(\(Acticlate\))/P 7599 0 R/K 34813 0 R>> endobj 21286 0 obj <>/Alt(Tier 1)/P 7599 0 R/K 34814 0 R>> endobj 21287 0 obj <>/Alt(ST: Requires prior prescription for generic Doxycycline Monohydrate 150mg tablets within the past 120 days; QL \(2 EA per 1 day\))/P 7599 0 R/K 34815 0 R>> endobj 21288 0 obj <>/Alt(\(Begin italic\) doxycycline hyclate oral tablet \(End italic\) \(Begin italic\) 50 mg \(End italic\))/P 7600 0 R/K 34816 0 R>> endobj 21289 0 obj <>/Alt(\(Targadox\))/P 7600 0 R/K 34817 0 R>> endobj 21290 0 obj <>/Alt(Tier 1)/P 7600 0 R/K 34818 0 R>> endobj 21291 0 obj <>/Alt(ST: Requires prior prescription for Doxycycline Hyclate 50mg capsules or Doxycycline Monohydrate 50mg capsules or tablets within the past 120 days; QL \(4 EA per 1 day\))/P 7600 0 R/K 34819 0 R>> endobj 21292 0 obj <>/Alt(\(Begin italic\) doxycycline hyclate oral tablet \(End italic\) \(Begin italic\) 75 mg \(End italic\))/P 7601 0 R/K 34820 0 R>> endobj 21293 0 obj <>/Alt(\(Acticlate\))/P 7601 0 R/K 34821 0 R>> endobj 21294 0 obj <>/Alt(Tier 1)/P 7601 0 R/K 34822 0 R>> endobj 21295 0 obj <>/Alt(ST: Requires prior prescription for generic Doxycycline Monohydrate 75mg tablets within the past 120 days; QL \(2 EA per 1 day\))/P 7601 0 R/K 34823 0 R>> endobj 21296 0 obj <>/Alt(\(Begin italic\) doxycycline monohydrate oral capsule \(End italic\) \(Begin italic\) 100 mg \(End italic\))/P 7602 0 R/K 34824 0 R>> endobj 21297 0 obj <>/Alt(\(Mondoxyne NL\))/P 7602 0 R/K 34825 0 R>> endobj 21298 0 obj <>/Alt(Tier 1)/P 7602 0 R/K 34826 0 R>> endobj 21299 0 obj <>/Alt(\(Begin italic\) doxycycline monohydrate oral capsule \(End italic\) \(Begin italic\) 150 mg \(End italic\))/P 7603 0 R/K 34827 0 R>> endobj 21300 0 obj <>/Alt(Tier 1)/P 7603 0 R/K 34828 0 R>> endobj 21301 0 obj <>/Alt(QL \(2 EA per 1 day\))/P 7603 0 R/K 34829 0 R>> endobj 21302 0 obj <>/Alt(\(Begin italic\) doxycycline monohydrate oral capsule \(End italic\) \(Begin italic\) 50 mg \(End italic\))/P 7604 0 R/K 34830 0 R>> endobj 21303 0 obj <>/Alt(\(Monodox\))/P 7604 0 R/K 34831 0 R>> endobj 21304 0 obj <>/Alt(Tier 1)/P 7604 0 R/K 34832 0 R>> endobj 21305 0 obj <>/Alt(\(Begin italic\) doxycycline monohydrate oral capsule \(End italic\) \(Begin italic\) 75 mg \(End italic\))/P 7605 0 R/K 34833 0 R>> endobj 21306 0 obj <>/Alt(\(Mondoxyne NL\))/P 7605 0 R/K 34834 0 R>> endobj 21307 0 obj <>/Alt(Tier 1)/P 7605 0 R/K 34835 0 R>> endobj 21308 0 obj <>/Alt(ST: Requires prior prescription for generic Doxycycline Monohydrate 75mg tablets within the past 120 days; QL \(2 EA per 1 day\))/P 7605 0 R/K 34836 0 R>> endobj 21309 0 obj <>/Alt(\(Begin italic\) doxycycline monohydrate oral capsule,ir - delay rel,biphase \(End italic\) \(Begin italic\) 40 mg \(End italic\))/P 7606 0 R/K 34837 0 R>> endobj 21310 0 obj <>/Alt(\(Oracea\))/P 7606 0 R/K 34838 0 R>> endobj 21311 0 obj <>/Alt(Tier 1)/P 7606 0 R/K 34839 0 R>> endobj 21312 0 obj <>/Alt(PA)/P 7606 0 R/K 34840 0 R>> endobj 21313 0 obj <>/Alt(\(Begin italic\) doxycycline monohydrate oral suspension for reconstitution \(End italic\) \(Begin italic\) 25 mg/5 ml \(End italic\))/P 7607 0 R/K 34841 0 R>> endobj 21314 0 obj <>/Alt(Tier 1)/P 7607 0 R/K 34842 0 R>> endobj 21315 0 obj <>/Alt(\(Begin italic\) doxycycline monohydrate oral tablet \(End italic\) \(Begin italic\) 100 mg \(End italic\))/P 7608 0 R/K 34843 0 R>> endobj 21316 0 obj <>/Alt(\(Avidoxy\))/P 7608 0 R/K 34844 0 R>> endobj 21317 0 obj <>/Alt(Tier 1)/P 7608 0 R/K 34845 0 R>> endobj 21318 0 obj <>/Alt(QL \(2 EA per 1 day\))/P 7608 0 R/K 34846 0 R>> endobj 21319 0 obj <>/Alt(\(Begin italic\) doxycycline monohydrate oral tablet \(End italic\) \(Begin italic\) 150 mg \(End italic\))/P 7609 0 R/K 34847 0 R>> endobj 21320 0 obj <>/Alt(Tier 1)/P 7609 0 R/K 34848 0 R>> endobj 21321 0 obj <>/Alt(QL \(2 EA per 1 day\))/P 7609 0 R/K 34849 0 R>> endobj 21322 0 obj <>/Alt(\(Begin italic\) doxycycline monohydrate oral tablet \(End italic\) \(Begin italic\) 50 mg, 75 mg \(End italic\))/P 7610 0 R/K 34850 0 R>> endobj 21323 0 obj <>/Alt(Tier 1)/P 7610 0 R/K 34851 0 R>> endobj 21324 0 obj <>/Alt(EMROSI ORAL CAPSULE,IR -EXTEND REL,BIPHASE 40 MG)/P 7611 0 R/K 34852 0 R>> endobj 21325 0 obj <>/Alt(Tier 3)/P 7611 0 R/K 34853 0 R>> endobj 21326 0 obj <>/Alt(PA)/P 7611 0 R/K 34854 0 R>> endobj 21327 0 obj <>/Alt(\(Begin italic\) minocycline oral capsule \(End italic\) \(Begin italic\) 100 mg, 50 mg, 75 mg \(End italic\))/P 7612 0 R/K 34855 0 R>> endobj 21328 0 obj <>/Alt(Tier 1)/P 7612 0 R/K 34856 0 R>> endobj 21329 0 obj <>/Alt(\(Begin italic\) minocycline oral tablet \(End italic\) \(Begin italic\) 100 mg, 50 mg, 75 mg \(End italic\))/P 7613 0 R/K 34857 0 R>> endobj 21330 0 obj <>/Alt(Tier 1)/P 7613 0 R/K 34858 0 R>> endobj 21331 0 obj <>/Alt(MONDOXYNE NL ORAL CAPSULE 100 MG)/P 7614 0 R/K 34859 0 R>> endobj 21332 0 obj <>/Alt(\(doxycycline monohydrate\))/P 7614 0 R/K 34860 0 R>> endobj 21333 0 obj <>/Alt(Tier 1)/P 7614 0 R/K 34861 0 R>> endobj 21334 0 obj <>/Alt(MONDOXYNE NL ORAL CAPSULE 75 MG)/P 7615 0 R/K 34862 0 R>> endobj 21335 0 obj <>/Alt(\(doxycycline monohydrate\))/P 7615 0 R/K 34863 0 R>> endobj 21336 0 obj <>/Alt(Tier 1)/P 7615 0 R/K 34864 0 R>> endobj 21337 0 obj <>/Alt(ST: Requires prior prescription for generic Doxycycline Monohydrate 75mg tablets within the past 120 days; QL \(2 EA per 1 day\))/P 7615 0 R/K 34865 0 R>> endobj 21338 0 obj <>/Alt(NUZYRA ORAL TABLET 150 MG)/P 7616 0 R/K 34866 0 R>> endobj 21339 0 obj <>/Alt(Tier 3)/P 7616 0 R/K 34867 0 R>> endobj 21340 0 obj <>/Alt(PA)/P 7616 0 R/K 34868 0 R>> endobj 21341 0 obj <>/Alt(\(Begin italic\) tetracycline oral capsule \(End italic\) \(Begin italic\) 250 mg, 500 mg \(End italic\))/P 7617 0 R/K 34869 0 R>> endobj 21342 0 obj <>/Alt(Tier 1)/P 7617 0 R/K 34870 0 R>> endobj 21343 0 obj <>/Alt(\(Begin bold\) Infectious Disease - Fungal \(End bold\))/P 7618 0 R/K 34871 0 R>> endobj 21344 0 obj <>/Alt(\(Begin bold\) Antifungal Agents \(End bold\))/P 7619 0 R/K 34872 0 R>> endobj 21345 0 obj <>/Alt(\(Begin italic\) clotrimazole mucous membrane troche \(End italic\) \(Begin italic\) 10 mg \(End italic\))/P 7620 0 R/K 34873 0 R>> endobj 21346 0 obj <>/Alt(Tier 1)/P 7620 0 R/K 34874 0 R>> endobj 21347 0 obj <>/Alt(CRESEMBA ORAL CAPSULE 186 MG, 74.5 MG)/P 7621 0 R/K 34875 0 R>> endobj 21348 0 obj <>/Alt(Tier 3)/P 7621 0 R/K 34876 0 R>> endobj 21349 0 obj <>/Alt(PA)/P 7621 0 R/K 34877 0 R>> endobj 21350 0 obj <>/Alt(\(Begin italic\) fluconazole oral suspension for reconstitution \(End italic\) \(Begin italic\) 10 mg/ml \(End italic\))/P 7622 0 R/K 34878 0 R>> endobj 21351 0 obj <>/Alt(Tier 1)/P 7622 0 R/K 34879 0 R>> endobj 21352 0 obj <>/Alt(\(Begin italic\) fluconazole oral suspension for reconstitution \(End italic\) \(Begin italic\) 40 mg/ml \(End italic\))/P 7623 0 R/K 34880 0 R>> endobj 21353 0 obj <>/Alt(\(Diflucan\))/P 7623 0 R/K 34881 0 R>> endobj 21354 0 obj <>/Alt(Tier 1)/P 7623 0 R/K 34882 0 R>> endobj 21355 0 obj <>/Alt(\(Begin italic\) fluconazole oral tablet \(End italic\) \(Begin italic\) 100 mg, 200 mg \(End italic\))/P 7624 0 R/K 34883 0 R>> endobj 21356 0 obj <>/Alt(\(Diflucan\))/P 7624 0 R/K 34884 0 R>> endobj 21357 0 obj <>/Alt(Tier 1)/P 7624 0 R/K 34885 0 R>> endobj 21358 0 obj <>/Alt(\(Begin italic\) fluconazole oral tablet \(End italic\) \(Begin italic\) 150 mg, 50 mg \(End italic\))/P 7625 0 R/K 34886 0 R>> endobj 21359 0 obj <>/Alt(Tier 1)/P 7625 0 R/K 34887 0 R>> endobj 21360 0 obj <>/Alt(\(Begin italic\) flucytosine oral capsule \(End italic\) \(Begin italic\) 250 mg, 500 mg \(End italic\))/P 7626 0 R/K 34888 0 R>> endobj 21361 0 obj <>/Alt(\(Ancobon\))/P 7626 0 R/K 34889 0 R>> endobj 21362 0 obj <>/Alt(Tier 1)/P 7626 0 R/K 34890 0 R>> endobj 21363 0 obj <>/Alt(\(Begin italic\) itraconazole oral capsule \(End italic\) \(Begin italic\) 100 mg \(End italic\))/P 7627 0 R/K 34891 0 R>> endobj 21364 0 obj <>/Alt(\(Sporanox\))/P 7627 0 R/K 34892 0 R>> endobj 21365 0 obj <>/Alt(Tier 1)/P 7627 0 R/K 34893 0 R>> endobj 21366 0 obj <>/Alt(\(Begin italic\) itraconazole oral solution \(End italic\) \(Begin italic\) 10 mg/ml \(End italic\))/P 7628 0 R/K 34894 0 R>> endobj 21367 0 obj <>/Alt(\(Sporanox\))/P 7628 0 R/K 34895 0 R>> endobj 21368 0 obj <>/Alt(Tier 1)/P 7628 0 R/K 34896 0 R>> endobj 21369 0 obj <>/Alt(\(Begin italic\) ketoconazole oral tablet \(End italic\) \(Begin italic\) 200 mg \(End italic\))/P 7629 0 R/K 34897 0 R>> endobj 21370 0 obj <>/Alt(Tier 1)/P 7629 0 R/K 34898 0 R>> endobj 21371 0 obj <>/Alt(NOXAFIL ORAL SUSP,DELAYED RELEASE FOR RECON 300 MG)/P 7630 0 R/K 34899 0 R>> endobj 21372 0 obj <>/Alt(Tier 3)/P 7630 0 R/K 34900 0 R>> endobj 21373 0 obj <>/Alt(PA)/P 7630 0 R/K 34901 0 R>> endobj 21374 0 obj <>/Alt(ORAVIG BUCCAL MUCO-ADHESIVE BUCCAL TABLET 50 MG)/P 7631 0 R/K 34902 0 R>> endobj 21375 0 obj <>/Alt(Tier 3)/P 7631 0 R/K 34903 0 R>> endobj 21376 0 obj <>/Alt(\(Begin italic\) posaconazole oral suspension \(End italic\) \(Begin italic\) 200 mg/5 ml \(40 mg/ml\) \(End italic\))/P 7632 0 R/K 34904 0 R>> endobj 21377 0 obj <>/Alt(\(Noxafil\))/P 7632 0 R/K 34905 0 R>> endobj 21378 0 obj <>/Alt(Tier 1)/P 7632 0 R/K 34906 0 R>> endobj 21379 0 obj <>/Alt(PA)/P 7632 0 R/K 34907 0 R>> endobj 21380 0 obj <>/Alt(\(Begin italic\) posaconazole oral tablet,delayed release \(dr/ec\) \(End italic\) \(Begin italic\) 100 mg \(End italic\))/P 7633 0 R/K 34908 0 R>> endobj 21381 0 obj <>/Alt(\(Noxafil\))/P 7633 0 R/K 34909 0 R>> endobj 21382 0 obj <>/Alt(Tier 1)/P 7633 0 R/K 34910 0 R>> endobj 21383 0 obj <>/Alt(PA)/P 7633 0 R/K 34911 0 R>> endobj 21384 0 obj <>/Alt(\(Begin italic\) terbinafine hcl oral tablet \(End italic\) \(Begin italic\) 250 mg \(End italic\))/P 7634 0 R/K 34912 0 R>> endobj 21385 0 obj <>/Alt(Tier 1)/P 7634 0 R/K 34913 0 R>> endobj 21386 0 obj <>/Alt(VIVJOA ORAL CAPSULE 150 MG)/P 7635 0 R/K 34914 0 R>> endobj 21387 0 obj <>/Alt(Tier 3)/P 7635 0 R/K 34915 0 R>> endobj 21388 0 obj <>/Alt(PA)/P 7635 0 R/K 34916 0 R>> endobj 21389 0 obj <>/Alt(\(Begin italic\) voriconazole oral suspension for reconstitution \(End italic\) \(Begin italic\) 200 mg/5 ml \(40 mg/ml\) \(End italic\))/P 7636 0 R/K 34917 0 R>> endobj 21390 0 obj <>/Alt(\(Vfend\))/P 7636 0 R/K 34918 0 R>> endobj 21391 0 obj <>/Alt(Tier 1)/P 7636 0 R/K 34919 0 R>> endobj 21392 0 obj <>/Alt(\(Begin italic\) voriconazole oral tablet \(End italic\) \(Begin italic\) 200 mg \(End italic\))/P 7637 0 R/K 34920 0 R>> endobj 21393 0 obj <>/Alt(Tier 1)/P 7637 0 R/K 34921 0 R>> endobj 21394 0 obj <>/Alt(\(Begin italic\) voriconazole oral tablet \(End italic\) \(Begin italic\) 50 mg \(End italic\))/P 7638 0 R/K 34922 0 R>> endobj 21395 0 obj <>/Alt(\(Vfend\))/P 7638 0 R/K 34923 0 R>> endobj 21396 0 obj <>/Alt(Tier 1)/P 7638 0 R/K 34924 0 R>> endobj 21397 0 obj <>/Alt(\(Begin bold\) Antifungal Antibiotics \(End bold\))/P 7639 0 R/K 34925 0 R>> endobj 21398 0 obj <>/Alt(BREXAFEMME ORAL TABLET 150 MG)/P 7640 0 R/K 34926 0 R>> endobj 21399 0 obj <>/Alt(Tier 3)/P 7640 0 R/K 34927 0 R>> endobj 21400 0 obj <>/Alt(PA)/P 7640 0 R/K 34928 0 R>> endobj 21401 0 obj <>/Alt(\(Begin italic\) griseofulvin microsize oral suspension \(End italic\) \(Begin italic\) 125 mg/5 ml \(End italic\))/P 7641 0 R/K 34929 0 R>> endobj 21402 0 obj <>/Alt(Tier 1)/P 7641 0 R/K 34930 0 R>> endobj 21403 0 obj <>/Alt(\(Begin italic\) griseofulvin microsize oral tablet \(End italic\) \(Begin italic\) 500 mg \(End italic\))/P 7642 0 R/K 34931 0 R>> endobj 21404 0 obj <>/Alt(Tier 1)/P 7642 0 R/K 34932 0 R>> endobj 21405 0 obj <>/Alt(\(Begin italic\) griseofulvin ultramicrosize oral tablet \(End italic\) \(Begin italic\) 125 mg, 250 mg \(End italic\))/P 7643 0 R/K 34933 0 R>> endobj 21406 0 obj <>/Alt(Tier 1)/P 7643 0 R/K 34934 0 R>> endobj 21407 0 obj <>/Alt(\(Begin italic\) nystatin oral suspension \(End italic\) \(Begin italic\) 100,000 unit/ml \(End italic\))/P 7644 0 R/K 34935 0 R>> endobj 21408 0 obj <>/Alt(Tier 1)/P 7644 0 R/K 34936 0 R>> endobj 21409 0 obj <>/Alt(\(Begin italic\) nystatin oral tablet \(End italic\) \(Begin italic\) 500,000 unit \(End italic\))/P 7645 0 R/K 34937 0 R>> endobj 21410 0 obj <>/Alt(Tier 1)/P 7645 0 R/K 34938 0 R>> endobj 21411 0 obj <>/Alt(\(Begin bold\) Infectious Disease - Miscellaneous \(End bold\))/P 7646 0 R/K 34939 0 R>> endobj 21412 0 obj <>/Alt(\(Begin bold\) Aminoglycosides \(End bold\))/P 7647 0 R/K 34940 0 R>> endobj 21413 0 obj <>/Alt(ARIKAYCE INHALATION SUSPENSION FOR NEBULIZATION 590 MG/8.4 ML)/P 7648 0 R/K 34941 0 R>> endobj 21414 0 obj <>/Alt(Tier 3)/P 7648 0 R/K 34942 0 R>> endobj 21415 0 obj <>/Alt(PA; SP)/P 7648 0 R/K 34943 0 R>> endobj 21416 0 obj <>/Alt(\(Begin italic\) neomycin oral tablet \(End italic\) \(Begin italic\) 500 mg \(End italic\))/P 7649 0 R/K 34944 0 R>> endobj 21417 0 obj <>/Alt(Tier 1)/P 7649 0 R/K 34945 0 R>> endobj 21418 0 obj <>/Alt(TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE 28 MG)/P 7650 0 R/K 34946 0 R>> endobj 21419 0 obj <>/Alt(Tier 2)/P 7650 0 R/K 34947 0 R>> endobj 21420 0 obj <>/Alt(PA; SP)/P 7650 0 R/K 34948 0 R>> endobj 21421 0 obj <>/Alt(\(Begin italic\) tobramycin in 0.225 % nacl inhalation solution for nebulization \(End italic\) \(Begin italic\) 300 mg/5 ml \(End italic\))/P 7651 0 R/K 34949 0 R>> endobj 21422 0 obj <>/Alt(\(Tobi\))/P 7651 0 R/K 34950 0 R>> endobj 21423 0 obj <>/Alt(Tier 1)/P 7651 0 R/K 34951 0 R>> endobj 21424 0 obj <>/Alt(PA; SP)/P 7651 0 R/K 34952 0 R>> endobj 21425 0 obj <>/Alt(\(Begin italic\) tobramycin inhalation solution for nebulization \(End italic\) \(Begin italic\) 300 mg/4 ml \(End italic\))/P 7652 0 R/K 34953 0 R>> endobj 21426 0 obj <>/Alt(\(Bethkis\))/P 7652 0 R/K 34954 0 R>> endobj 21427 0 obj <>/Alt(Tier 1)/P 7652 0 R/K 34955 0 R>> endobj 21428 0 obj <>/Alt(PA; SP)/P 7652 0 R/K 34956 0 R>> endobj 21429 0 obj <>/Alt(\(Begin italic\) tobramycin with nebulizer inhalation solution for nebulization \(End italic\) \(Begin italic\) 300 mg/5 ml \(End italic\))/P 7653 0 R/K 34957 0 R>> endobj 21430 0 obj <>/Alt(\(Kitabis Pak\))/P 7653 0 R/K 34958 0 R>> endobj 21431 0 obj <>/Alt(Tier 1)/P 7653 0 R/K 34959 0 R>> endobj 21432 0 obj <>/Alt(PA; SP)/P 7653 0 R/K 34960 0 R>> endobj 21433 0 obj <>/Alt(\(Begin bold\) Antibacterial Agents,Miscellaneous \(End bold\))/P 7654 0 R/K 34961 0 R>> endobj 21434 0 obj <>/Alt(\(Begin italic\) glycine urologic solution irrigation solution \(End italic\) \(Begin italic\) 1.5 % \(End italic\))/P 7655 0 R/K 34962 0 R>> endobj 21435 0 obj <>/Alt(\(Glycine Urologic\))/P 7655 0 R/K 34963 0 R>> endobj 21436 0 obj <>/Alt(Tier 1)/P 7655 0 R/K 34964 0 R>> endobj 21437 0 obj <>/Alt(\(Begin bold\) Antileprotics \(End bold\))/P 7656 0 R/K 34965 0 R>> endobj 21438 0 obj <>/Alt(\(Begin italic\) dapsone oral tablet \(End italic\) \(Begin italic\) 100 mg, 25 mg \(End italic\))/P 7657 0 R/K 34966 0 R>> endobj 21439 0 obj <>/Alt(Tier 1)/P 7657 0 R/K 34967 0 R>> endobj 21440 0 obj <>/Alt(THALOMID ORAL CAPSULE 100 MG, 50 MG)/P 7658 0 R/K 34968 0 R>> endobj 21441 0 obj <>/Alt(Tier 2)/P 7658 0 R/K 34969 0 R>> endobj 21442 0 obj <>/Alt(PA; SP)/P 7658 0 R/K 34970 0 R>> endobj 21443 0 obj <>/Alt(\(Begin bold\) Anti-Mycobacterium Agents \(End bold\))/P 7659 0 R/K 34971 0 R>> endobj 21444 0 obj <>/Alt(\(Begin italic\) ethambutol oral tablet \(End italic\) \(Begin italic\) 100 mg, 400 mg \(End italic\))/P 7660 0 R/K 34972 0 R>> endobj 21445 0 obj <>/Alt(Tier 1)/P 7660 0 R/K 34973 0 R>> endobj 21446 0 obj <>/Alt(\(Begin italic\) isoniazid oral solution \(End italic\) \(Begin italic\) 50 mg/5 ml \(End italic\))/P 7661 0 R/K 34974 0 R>> endobj 21447 0 obj <>/Alt(Tier 1)/P 7661 0 R/K 34975 0 R>> endobj 21448 0 obj <>/Alt(\(Begin italic\) isoniazid oral tablet \(End italic\) \(Begin italic\) 100 mg, 300 mg \(End italic\))/P 7662 0 R/K 34976 0 R>> endobj 21449 0 obj <>/Alt(Tier 1)/P 7662 0 R/K 34977 0 R>> endobj 21450 0 obj <>/Alt(PASER ORAL GRANULES DR FOR SUSP IN PACKET 4 GRAM)/P 7663 0 R/K 34978 0 R>> endobj 21451 0 obj <>/Alt(Tier 3)/P 7663 0 R/K 34979 0 R>> endobj 21452 0 obj <>/Alt(\(Begin italic\) pyrazinamide oral tablet \(End italic\) \(Begin italic\) 500 mg \(End italic\))/P 7664 0 R/K 34980 0 R>> endobj 21453 0 obj <>/Alt(Tier 1)/P 7664 0 R/K 34981 0 R>> endobj 21454 0 obj <>/Alt(\(Begin italic\) rifabutin oral capsule \(End italic\) \(Begin italic\) 150 mg \(End italic\))/P 7665 0 R/K 34982 0 R>> endobj 21455 0 obj <>/Alt(Tier 1)/P 7665 0 R/K 34983 0 R>> endobj 21456 0 obj <>/Alt(TRECATOR ORAL TABLET 250 MG)/P 7666 0 R/K 34984 0 R>> endobj 21457 0 obj <>/Alt(Tier 3)/P 7666 0 R/K 34985 0 R>> endobj 21458 0 obj <>/Alt(\(Begin bold\) Antitubercular Antibiotics \(End bold\))/P 7667 0 R/K 34986 0 R>> endobj 21459 0 obj <>/Alt(\(Begin italic\) cycloserine oral capsule \(End italic\) \(Begin italic\) 250 mg \(End italic\))/P 7668 0 R/K 34987 0 R>> endobj 21460 0 obj <>/Alt(Tier 1)/P 7668 0 R/K 34988 0 R>> endobj 21461 0 obj <>/Alt(\(Begin italic\) pretomanid oral tablet \(End italic\) \(Begin italic\) 200 mg \(End italic\))/P 7669 0 R/K 34989 0 R>> endobj 21462 0 obj <>/Alt(Tier 3)/P 7669 0 R/K 34990 0 R>> endobj 21463 0 obj <>/Alt(QL \(1 EA per 1 day\))/P 7669 0 R/K 34991 0 R>> endobj 21464 0 obj <>/Alt(PRIFTIN ORAL TABLET 150 MG)/P 7670 0 R/K 34992 0 R>> endobj 21465 0 obj <>/Alt(Tier 3)/P 7670 0 R/K 34993 0 R>> endobj 21466 0 obj <>/Alt(\(Begin italic\) rifampin oral capsule \(End italic\) \(Begin italic\) 150 mg, 300 mg \(End italic\))/P 7671 0 R/K 34994 0 R>> endobj 21467 0 obj <>/Alt(Tier 1)/P 7671 0 R/K 34995 0 R>> endobj 21468 0 obj <>/Alt(SIRTURO ORAL TABLET 100 MG, 20 MG)/P 7672 0 R/K 34996 0 R>> endobj 21469 0 obj <>/Alt(Tier 3)/P 7672 0 R/K 34997 0 R>> endobj 21470 0 obj <>/Alt(PA; SP)/P 7672 0 R/K 34998 0 R>> endobj 21471 0 obj <>/Alt(\(Begin bold\) Lincosamides \(End bold\))/P 7673 0 R/K 34999 0 R>> endobj 21472 0 obj <>/Alt(\(Begin italic\) clindamycin hcl oral capsule \(End italic\) \(Begin italic\) 150 mg, 300 mg, 75 mg \(End italic\))/P 7674 0 R/K 35000 0 R>> endobj 21473 0 obj <>/Alt(\(Cleocin HCl\))/P 7674 0 R/K 35001 0 R>> endobj 21474 0 obj <>/Alt(Tier 1)/P 7674 0 R/K 35002 0 R>> endobj 21475 0 obj <>/Alt(\(Begin italic\) clindamycin palmitate hcl oral recon soln \(End italic\) \(Begin italic\) 75 mg/5 ml \(End italic\))/P 7675 0 R/K 35003 0 R>> endobj 21476 0 obj <>/Alt(\(Clindamycin Pediatric\))/P 7675 0 R/K 35004 0 R>> endobj 21477 0 obj <>/Alt(Tier 1)/P 7675 0 R/K 35005 0 R>> endobj 21478 0 obj <>/Alt(CLINDAMYCIN PEDIATRIC ORAL RECON SOLN 75 MG/5 ML)/P 7676 0 R/K 35006 0 R>> endobj 21479 0 obj <>/Alt(\(clindamycin palmitate hcl\))/P 7676 0 R/K 35007 0 R>> endobj 21480 0 obj <>/Alt(Tier 1)/P 7676 0 R/K 35008 0 R>> endobj 21481 0 obj <>/Alt(\(Begin bold\) Rifamycins And Related Derivative Antibiotics \(End bold\))/P 7677 0 R/K 35009 0 R>> endobj 21482 0 obj <>/Alt(AEMCOLO ORAL TABLET,DELAYED RELEASE \(DR/EC\) 194 MG)/P 7678 0 R/K 35010 0 R>> endobj 21483 0 obj <>/Alt(Tier 3)/P 7678 0 R/K 35011 0 R>> endobj 21484 0 obj <>/Alt(ST: Requires prior prescription for generic oral Ciprofloxacin, Azithromycin, Levofloxacin, or Ofloxacin within the past 120 days; QL \(12 EA per 1 FILL\))/P 7678 0 R/K 35012 0 R>> endobj 21485 0 obj <>/Alt(XIFAXAN ORAL TABLET 200 MG)/P 7679 0 R/K 35013 0 R>> endobj 21486 0 obj <>/Alt(Tier 3)/P 7679 0 R/K 35014 0 R>> endobj 21487 0 obj <>/Alt(PA)/P 7679 0 R/K 35015 0 R>> endobj 21488 0 obj <>/Alt(XIFAXAN ORAL TABLET 550 MG)/P 7680 0 R/K 35016 0 R>> endobj 21489 0 obj <>/Alt(Tier 2)/P 7680 0 R/K 35017 0 R>> endobj 21490 0 obj <>/Alt(PA)/P 7680 0 R/K 35018 0 R>> endobj 21491 0 obj <>/Alt(\(Begin bold\) Vancomycin And Derivatives \(End bold\))/P 7681 0 R/K 35019 0 R>> endobj 21492 0 obj <>/Alt(\(Begin italic\) vancomycin oral capsule \(End italic\) \(Begin italic\) 125 mg \(End italic\))/P 7682 0 R/K 35020 0 R>> endobj 21493 0 obj <>/Alt(\(Vancocin\))/P 7682 0 R/K 35021 0 R>> endobj 21494 0 obj <>/Alt(Tier 1)/P 7682 0 R/K 35022 0 R>> endobj 21495 0 obj <>/Alt(QL \(56 EA per 1 FILL\))/P 7682 0 R/K 35023 0 R>> endobj 21496 0 obj <>/Alt(\(Begin italic\) vancomycin oral capsule \(End italic\) \(Begin italic\) 250 mg \(End italic\))/P 7683 0 R/K 35024 0 R>> endobj 21497 0 obj <>/Alt(\(Vancocin\))/P 7683 0 R/K 35025 0 R>> endobj 21498 0 obj <>/Alt(Tier 1)/P 7683 0 R/K 35026 0 R>> endobj 21499 0 obj <>/Alt(QL \(112 EA per 1 FILL\))/P 7683 0 R/K 35027 0 R>> endobj 21500 0 obj <>/Alt(\(Begin italic\) vancomycin oral recon soln \(End italic\) \(Begin italic\) 25 mg/ml \(End italic\))/P 7684 0 R/K 35028 0 R>> endobj 21501 0 obj <>/Alt(\(Firvanq\))/P 7684 0 R/K 35029 0 R>> endobj 21502 0 obj <>/Alt(Tier 1)/P 7684 0 R/K 35030 0 R>> endobj 21503 0 obj <>/Alt(QL \(300 ML per 1 FILL\))/P 7684 0 R/K 35031 0 R>> endobj 21504 0 obj <>/Alt(\(Begin italic\) vancomycin oral recon soln \(End italic\) \(Begin italic\) 50 mg/ml \(End italic\))/P 7685 0 R/K 35032 0 R>> endobj 21505 0 obj <>/Alt(\(Firvanq\))/P 7685 0 R/K 35033 0 R>> endobj 21506 0 obj <>/Alt(Tier 1)/P 7685 0 R/K 35034 0 R>> endobj 21507 0 obj <>/Alt(QL \(600 ML per 1 FILL\))/P 7685 0 R/K 35035 0 R>> endobj 21508 0 obj <>/Alt(\(Begin bold\) Infectious Disease - Parasitic \(End bold\))/P 7686 0 R/K 35036 0 R>> endobj 21509 0 obj <>/Alt(\(Begin bold\) 2Nd Gen. Anaerobic Antiprotozoal-Antibacterial \(End bold\))/P 7687 0 R/K 35037 0 R>> endobj 21510 0 obj <>/Alt(SOLOSEC ORAL GRANULES DEL RELEASE IN PACKET 2 GRAM)/P 7688 0 R/K 35038 0 R>> endobj 21511 0 obj <>/Alt(Tier 3)/P 7688 0 R/K 35039 0 R>> endobj 21512 0 obj <>/Alt(ST: At least 2 prior prescriptions for Clindamycin, vaginal Clindamycin cream, oral Metronidazole, vaginal Metronidazole gel, or Tinidazole within the past 365 days; QL \(1 EA per 30 days\))/P 7688 0 R/K 35040 0 R>> endobj 21513 0 obj <>/Alt(\(Begin italic\) tinidazole oral tablet \(End italic\) \(Begin italic\) 250 mg, 500 mg \(End italic\))/P 7689 0 R/K 35041 0 R>> endobj 21514 0 obj <>/Alt(Tier 1)/P 7689 0 R/K 35042 0 R>> endobj 21515 0 obj <>/Alt(\(Begin bold\) Amebacides \(End bold\))/P 7690 0 R/K 35043 0 R>> endobj 21516 0 obj <>/Alt(\(Begin italic\) paromomycin oral capsule \(End italic\) \(Begin italic\) 250 mg \(End italic\))/P 7691 0 R/K 35044 0 R>> endobj 21517 0 obj <>/Alt(\(Humatin\))/P 7691 0 R/K 35045 0 R>> endobj 21518 0 obj <>/Alt(Tier 1)/P 7691 0 R/K 35046 0 R>> endobj 21519 0 obj <>/Alt(\(Begin bold\) Anaerobic Antiprotozoal-Antibacterial Agents \(End bold\))/P 7692 0 R/K 35047 0 R>> endobj 21520 0 obj <>/Alt(LIKMEZ ORAL SUSPENSION 500 MG/5 ML)/P 7693 0 R/K 35048 0 R>> endobj 21521 0 obj <>/Alt(Tier 3)/P 7693 0 R/K 35049 0 R>> endobj 21522 0 obj <>/Alt(PA)/P 7693 0 R/K 35050 0 R>> endobj 21523 0 obj <>/Alt(\(Begin italic\) metronidazole oral capsule \(End italic\) \(Begin italic\) 375 mg \(End italic\))/P 7694 0 R/K 35051 0 R>> endobj 21524 0 obj <>/Alt(\(Flagyl\))/P 7694 0 R/K 35052 0 R>> endobj 21525 0 obj <>/Alt(Tier 1)/P 7694 0 R/K 35053 0 R>> endobj 21526 0 obj <>/Alt(\(Begin italic\) metronidazole oral tablet \(End italic\) \(Begin italic\) 250 mg, 500 mg \(End italic\))/P 7695 0 R/K 35054 0 R>> endobj 21527 0 obj <>/Alt(Tier 1)/P 7695 0 R/K 35055 0 R>> endobj 21528 0 obj <>/Alt(\(Begin bold\) Anthelmintics \(End bold\))/P 7696 0 R/K 35056 0 R>> endobj 21529 0 obj <>/Alt(\(Begin italic\) albendazole oral tablet \(End italic\) \(Begin italic\) 200 mg \(End italic\))/P 7697 0 R/K 35057 0 R>> endobj 21530 0 obj <>/Alt(Tier 1)/P 7697 0 R/K 35058 0 R>> endobj 21531 0 obj <>/Alt(EGATEN ORAL TABLET 250 MG)/P 7698 0 R/K 35059 0 R>> endobj 21532 0 obj <>/Alt(Tier 3)/P 7698 0 R/K 35060 0 R>> endobj 21533 0 obj <>/Alt(EMVERM ORAL TABLET,CHEWABLE 100 MG)/P 7699 0 R/K 35061 0 R>> endobj 21534 0 obj <>/Alt(\(mebendazole\))/P 7699 0 R/K 35062 0 R>> endobj 21535 0 obj <>/Alt(Tier 2)/P 7699 0 R/K 35063 0 R>> endobj 21536 0 obj <>/Alt(PA)/P 7699 0 R/K 35064 0 R>> endobj 21537 0 obj <>/Alt(\(Begin italic\) ivermectin oral tablet \(End italic\) \(Begin italic\) 3 mg \(End italic\))/P 7700 0 R/K 35065 0 R>> endobj 21538 0 obj <>/Alt(\(Stromectol\))/P 7700 0 R/K 35066 0 R>> endobj 21539 0 obj <>/Alt(Tier 1)/P 7700 0 R/K 35067 0 R>> endobj 21540 0 obj <>/Alt(\(Begin italic\) praziquantel oral tablet \(End italic\) \(Begin italic\) 600 mg \(End italic\))/P 7701 0 R/K 35068 0 R>> endobj 21541 0 obj <>/Alt(\(Biltricide\))/P 7701 0 R/K 35069 0 R>> endobj 21542 0 obj <>/Alt(Tier 1)/P 7701 0 R/K 35070 0 R>> endobj 21543 0 obj <>/Alt(\(Begin bold\) Antimalarial Drugs \(End bold\))/P 7702 0 R/K 35071 0 R>> endobj 21544 0 obj <>/Alt(ARAKODA ORAL TABLET 100 MG)/P 7703 0 R/K 35072 0 R>> endobj 21545 0 obj <>/Alt(Tier 3)/P 7703 0 R/K 35073 0 R>> endobj 21546 0 obj <>/Alt(\(Begin italic\) atovaquone-proguanil oral tablet \(End italic\) \(Begin italic\) 250-100 mg \(End italic\))/P 7704 0 R/K 35074 0 R>> endobj 21547 0 obj <>/Alt(\(Malarone\))/P 7704 0 R/K 35075 0 R>> endobj 21548 0 obj <>/Alt(Tier 1)/P 7704 0 R/K 35076 0 R>> endobj 21549 0 obj <>/Alt(\(Begin italic\) atovaquone-proguanil oral tablet \(End italic\) \(Begin italic\) 62.5-25 mg \(End italic\))/P 7705 0 R/K 35077 0 R>> endobj 21550 0 obj <>/Alt(\(Malarone Pediatric\))/P 7705 0 R/K 35078 0 R>> endobj 21551 0 obj <>/Alt(Tier 1)/P 7705 0 R/K 35079 0 R>> endobj 21552 0 obj <>/Alt(\(Begin italic\) chloroquine phosphate oral tablet \(End italic\) \(Begin italic\) 250 mg \(End italic\))/P 7706 0 R/K 35080 0 R>> endobj 21553 0 obj <>/Alt(Tier 1)/P 7706 0 R/K 35081 0 R>> endobj 21554 0 obj <>/Alt(QL \(36 EA per 16 days\))/P 7706 0 R/K 35082 0 R>> endobj 21555 0 obj <>/Alt(\(Begin italic\) chloroquine phosphate oral tablet \(End italic\) \(Begin italic\) 500 mg \(End italic\))/P 7707 0 R/K 35083 0 R>> endobj 21556 0 obj <>/Alt(Tier 1)/P 7707 0 R/K 35084 0 R>> endobj 21557 0 obj <>/Alt(QL \(18 EA per 16 days\))/P 7707 0 R/K 35085 0 R>> endobj 21558 0 obj <>/Alt(COARTEM ORAL TABLET 20-120 MG)/P 7708 0 R/K 35086 0 R>> endobj 21559 0 obj <>/Alt(Tier 3)/P 7708 0 R/K 35087 0 R>> endobj 21560 0 obj <>/Alt(\(Begin italic\) hydroxychloroquine oral tablet \(End italic\) \(Begin italic\) 100 mg \(End italic\))/P 7709 0 R/K 35088 0 R>> endobj 21561 0 obj <>/Alt(Tier 1)/P 7709 0 R/K 35089 0 R>> endobj 21562 0 obj <>/Alt(QL \(180 EA per 30 days\))/P 7709 0 R/K 35090 0 R>> endobj 21563 0 obj <>/Alt(\(Begin italic\) hydroxychloroquine oral tablet \(End italic\) \(Begin italic\) 200 mg \(End italic\))/P 7710 0 R/K 35091 0 R>> endobj 21564 0 obj <>/Alt(\(Sovuna\))/P 7710 0 R/K 35092 0 R>> endobj 21565 0 obj <>/Alt(Tier 1)/P 7710 0 R/K 35093 0 R>> endobj 21566 0 obj <>/Alt(QL \(100 EA per 30 days\))/P 7710 0 R/K 35094 0 R>> endobj 21567 0 obj <>/Alt(\(Begin italic\) hydroxychloroquine oral tablet \(End italic\) \(Begin italic\) 300 mg \(End italic\))/P 7711 0 R/K 35095 0 R>> endobj 21568 0 obj <>/Alt(\(Sovuna\))/P 7711 0 R/K 35096 0 R>> endobj 21569 0 obj <>/Alt(Tier 1)/P 7711 0 R/K 35097 0 R>> endobj 21570 0 obj <>/Alt(QL \(60 EA per 30 days\))/P 7711 0 R/K 35098 0 R>> endobj 21571 0 obj <>/Alt(\(Begin italic\) hydroxychloroquine oral tablet \(End italic\) \(Begin italic\) 400 mg \(End italic\))/P 7712 0 R/K 35099 0 R>> endobj 21572 0 obj <>/Alt(Tier 1)/P 7712 0 R/K 35100 0 R>> endobj 21573 0 obj <>/Alt(QL \(60 EA per 30 days\))/P 7712 0 R/K 35101 0 R>> endobj 21574 0 obj <>/Alt(KRINTAFEL ORAL TABLET 150 MG)/P 7713 0 R/K 35102 0 R>> endobj 21575 0 obj <>/Alt(Tier 2)/P 7713 0 R/K 35103 0 R>> endobj 21576 0 obj <>/Alt(QL \(2 EA per 1 FILL\))/P 7713 0 R/K 35104 0 R>> endobj 21577 0 obj <>/Alt(\(Begin italic\) mefloquine oral tablet \(End italic\) \(Begin italic\) 250 mg \(End italic\))/P 7714 0 R/K 35105 0 R>> endobj 21578 0 obj <>/Alt(Tier 1)/P 7714 0 R/K 35106 0 R>> endobj 21579 0 obj <>/Alt(\(Begin italic\) primaquine oral tablet \(End italic\) \(Begin italic\) 26.3 mg \(15 mg base\) \(End italic\))/P 7715 0 R/K 35107 0 R>> endobj 21580 0 obj <>/Alt(Tier 2)/P 7715 0 R/K 35108 0 R>> endobj 21581 0 obj <>/Alt(\(Begin italic\) pyrimethamine oral tablet \(End italic\) \(Begin italic\) 25 mg \(End italic\))/P 7716 0 R/K 35109 0 R>> endobj 21582 0 obj <>/Alt(\(Daraprim\))/P 7716 0 R/K 35110 0 R>> endobj 21583 0 obj <>/Alt(Tier 1)/P 7716 0 R/K 35111 0 R>> endobj 21584 0 obj <>/Alt(PA; SP)/P 7716 0 R/K 35112 0 R>> endobj 21585 0 obj <>/Alt(\(Begin italic\) quinine sulfate oral capsule \(End italic\) \(Begin italic\) 324 mg \(End italic\))/P 7717 0 R/K 35113 0 R>> endobj 21586 0 obj <>/Alt(\(Qualaquin\))/P 7717 0 R/K 35114 0 R>> endobj 21587 0 obj <>/Alt(Tier 1)/P 7717 0 R/K 35115 0 R>> endobj 21588 0 obj <>/Alt(SOVUNA ORAL TABLET 200 MG)/P 7718 0 R/K 35116 0 R>> endobj 21589 0 obj <>/Alt(\(hydroxychloroquine\))/P 7718 0 R/K 35117 0 R>> endobj 21590 0 obj <>/Alt(Tier 2)/P 7718 0 R/K 35118 0 R>> endobj 21591 0 obj <>/Alt(QL \(100 EA per 30 days\))/P 7718 0 R/K 35119 0 R>> endobj 21592 0 obj <>/Alt(SOVUNA ORAL TABLET 300 MG)/P 7719 0 R/K 35120 0 R>> endobj 21593 0 obj <>/Alt(\(hydroxychloroquine\))/P 7719 0 R/K 35121 0 R>> endobj 21594 0 obj <>/Alt(Tier 3)/P 7719 0 R/K 35122 0 R>> endobj 21595 0 obj <>/Alt(QL \(60 EA per 30 days\))/P 7719 0 R/K 35123 0 R>> endobj 21596 0 obj <>/Alt(\(Begin bold\) Antiparasitics \(End bold\))/P 7720 0 R/K 35124 0 R>> endobj 21597 0 obj <>/Alt(ALINIA ORAL SUSPENSION FOR RECONSTITUTION 100 MG/5 ML)/P 7721 0 R/K 35125 0 R>> endobj 21598 0 obj <>/Alt(Tier 3)/P 7721 0 R/K 35126 0 R>> endobj 21599 0 obj <>/Alt(QL \(50 ML per 1 day\))/P 7721 0 R/K 35127 0 R>> endobj 21600 0 obj <>/Alt(\(Begin italic\) nitazoxanide oral tablet \(End italic\) \(Begin italic\) 500 mg \(End italic\))/P 7722 0 R/K 35128 0 R>> endobj 21601 0 obj <>/Alt(\(Alinia\))/P 7722 0 R/K 35129 0 R>> endobj 21602 0 obj <>/Alt(Tier 1)/P 7722 0 R/K 35130 0 R>> endobj 21603 0 obj <>/Alt(QL \(2 EA per 1 day\))/P 7722 0 R/K 35131 0 R>> endobj 21604 0 obj <>/Alt(\(Begin bold\) Antiprotozoal Drugs,Miscellaneous \(End bold\))/P 7723 0 R/K 35132 0 R>> endobj 21605 0 obj <>/Alt(\(Begin italic\) atovaquone oral suspension \(End italic\) \(Begin italic\) 750 mg/5 ml \(End italic\))/P 7724 0 R/K 35133 0 R>> endobj 21606 0 obj <>/Alt(\(Mepron\))/P 7724 0 R/K 35134 0 R>> endobj 21607 0 obj <>/Alt(Tier 1)/P 7724 0 R/K 35135 0 R>> endobj 21608 0 obj <>/Alt(\(Begin italic\) benznidazole oral tablet \(End italic\) \(Begin italic\) 100 mg, 12.5 mg \(End italic\))/P 7725 0 R/K 35136 0 R>> endobj 21609 0 obj <>/Alt(Tier 1)/P 7725 0 R/K 35137 0 R>> endobj 21610 0 obj <>/Alt(IMPAVIDO ORAL CAPSULE 50 MG)/P 7726 0 R/K 35138 0 R>> endobj 21611 0 obj <>/Alt(Tier 2)/P 7726 0 R/K 35139 0 R>> endobj 21612 0 obj <>/Alt(PA)/P 7726 0 R/K 35140 0 R>> endobj 21613 0 obj <>/Alt(LAMPIT ORAL TABLET 120 MG, 30 MG)/P 7727 0 R/K 35141 0 R>> endobj 21614 0 obj <>/Alt(Tier 3)/P 7727 0 R/K 35142 0 R>> endobj 21615 0 obj <>/Alt(\(Begin italic\) pentamidine inhalation recon soln \(End italic\) \(Begin italic\) 300 mg \(End italic\))/P 7728 0 R/K 35143 0 R>> endobj 21616 0 obj <>/Alt(\(Nebupent\))/P 7728 0 R/K 35144 0 R>> endobj 21617 0 obj <>/Alt(Tier 1)/P 7728 0 R/K 35145 0 R>> endobj 21618 0 obj <>/Alt(\(Begin bold\) Infectious Disease - Viral \(End bold\))/P 7729 0 R/K 35146 0 R>> endobj 21619 0 obj <>/Alt(\(Begin bold\) Antiretroviral - Capsid Inhibitors \(End bold\))/P 7730 0 R/K 35147 0 R>> endobj 21620 0 obj <>/Alt(SUNLENCA ORAL TABLET 300 MG)/P 7731 0 R/K 35148 0 R>> endobj 21621 0 obj <>/Alt(Tier 2)/P 7731 0 R/K 35149 0 R>> endobj 21622 0 obj <>/Alt(PA; SP)/P 7731 0 R/K 35150 0 R>> endobj 21623 0 obj <>/Alt(\(Begin bold\) Antiretroviral-Integrase Inhibitor And Nnrti Comb. \(End bold\))/P 7732 0 R/K 35151 0 R>> endobj 21624 0 obj <>/Alt(JULUCA ORAL TABLET 50-25 MG)/P 7733 0 R/K 35152 0 R>> endobj 21625 0 obj <>/Alt(Tier 2)/P 7733 0 R/K 35153 0 R>> endobj 21626 0 obj <>/Alt(SP; QL \(1 EA per 1 day\))/P 7733 0 R/K 35154 0 R>> endobj 21627 0 obj <>/Alt(\(Begin bold\) Antiretroviral-Integrase Inhibitor And Nrti Comb. \(End bold\))/P 7734 0 R/K 35155 0 R>> endobj 21628 0 obj <>/Alt(DOVATO ORAL TABLET 50-300 MG)/P 7735 0 R/K 35156 0 R>> endobj 21629 0 obj <>/Alt(Tier 2)/P 7735 0 R/K 35157 0 R>> endobj 21630 0 obj <>/Alt(SP; QL \(1 EA per 1 day\))/P 7735 0 R/K 35158 0 R>> endobj 21631 0 obj <>/Alt(\(Begin bold\) Antiretroviral-Nucleoside,Nucleotide,Protease Inh. \(End bold\))/P 7736 0 R/K 35159 0 R>> endobj 21632 0 obj <>/Alt(SYMTUZA ORAL TABLET 800-150-200-10 MG)/P 7737 0 R/K 35160 0 R>> endobj 21633 0 obj <>/Alt(Tier 2)/P 7737 0 R/K 35161 0 R>> endobj 21634 0 obj <>/Alt(SP; QL \(1 EA per 1 day\))/P 7737 0 R/K 35162 0 R>> endobj 21635 0 obj <>/Alt(\(Begin bold\) Antiviral - Main Protease \(Mpro\) Inhibitor \(End bold\))/P 7738 0 R/K 35163 0 R>> endobj 21636 0 obj <>/Alt(PAXLOVID ORAL TABLETS,DOSE PACK 150-100 MG)/P 7739 0 R/K 35164 0 R>> endobj 21637 0 obj <>/Alt(Tier 2)/P 7739 0 R/K 35165 0 R>> endobj 21638 0 obj <>/Alt(QL \(20 EA per 28 days\); Age \(Min 12 Years\))/P 7739 0 R/K 35166 0 R>> endobj 21639 0 obj <>/Alt(PAXLOVID ORAL TABLETS,DOSE PACK 300 MG \(150 MG X 2\)-100 MG)/P 7740 0 R/K 35167 0 R>> endobj 21640 0 obj <>/Alt(Tier 2)/P 7740 0 R/K 35168 0 R>> endobj 21641 0 obj <>/Alt(QL \(30 EA per 28 days\); Age \(Min 12 Years\))/P 7740 0 R/K 35169 0 R>> endobj 21642 0 obj <>/Alt(\(Begin bold\) Antiviral Monoclonal Antibodies \(End bold\))/P 7741 0 R/K 35170 0 R>> endobj 21643 0 obj <>/Alt(BEYFORTUS INTRAMUSCULAR SYRINGE 100 MG/ML)/P 7742 0 R/K 35171 0 R>> endobj 21644 0 obj <>/Alt($0)/P 7742 0 R/K 35172 0 R>> endobj 21645 0 obj <>/Alt(PA; $0 COPAY IF QUANTITY LIMITED TO 2, FILL OF 2 IN 120 DAYS, AND 19 MONTHS OF AGE OR YOUNGER)/P 7742 0 R/K 35173 0 R>> endobj 21646 0 obj <>/Alt(BEYFORTUS INTRAMUSCULAR SYRINGE 50 MG/0.5 ML)/P 7743 0 R/K 35174 0 R>> endobj 21647 0 obj <>/Alt($0)/P 7743 0 R/K 35175 0 R>> endobj 21648 0 obj <>/Alt(PA; $0 COPAY IF QUANTITY LIMITED TO 0.5, FILL OF 2 IN 120 DAYS, AND 19 MONTHS OF AGE OR YOUNGER)/P 7743 0 R/K 35176 0 R>> endobj 21649 0 obj <>/Alt(\(Begin bold\) Antiviral Nucleotide Analogs \(End bold\))/P 7744 0 R/K 35177 0 R>> endobj 21650 0 obj <>/Alt(LAGEVRIO \(EUA\) ORAL CAPSULE 200 MG)/P 7745 0 R/K 35178 0 R>> endobj 21651 0 obj <>/Alt(Tier 1)/P 7745 0 R/K 35179 0 R>> endobj 21652 0 obj <>/Alt(QL \(40 EA per 29 days\); Age \(Min 18 Years\))/P 7745 0 R/K 35180 0 R>> endobj 21653 0 obj <>/Alt(\(Begin bold\) Antivirals, General \(End bold\))/P 7746 0 R/K 35181 0 R>> endobj 21654 0 obj <>/Alt(\(Begin italic\) acyclovir oral capsule \(End italic\) \(Begin italic\) 200 mg \(End italic\))/P 7747 0 R/K 35182 0 R>> endobj 21655 0 obj <>/Alt(Tier 1)/P 7747 0 R/K 35183 0 R>> endobj 21656 0 obj <>/Alt(\(Begin italic\) acyclovir oral suspension \(End italic\) \(Begin italic\) 200 mg/5 ml \(End italic\))/P 7748 0 R/K 35184 0 R>> endobj 21657 0 obj <>/Alt(\(Zovirax\))/P 7748 0 R/K 35185 0 R>> endobj 21658 0 obj <>/Alt(Tier 1)/P 7748 0 R/K 35186 0 R>> endobj 21659 0 obj <>/Alt(\(Begin italic\) acyclovir oral tablet \(End italic\) \(Begin italic\) 400 mg, 800 mg \(End italic\))/P 7749 0 R/K 35187 0 R>> endobj 21660 0 obj <>/Alt(Tier 1)/P 7749 0 R/K 35188 0 R>> endobj 21661 0 obj <>/Alt(\(Begin italic\) famciclovir oral tablet \(End italic\) \(Begin italic\) 125 mg, 250 mg, 500 mg \(End italic\))/P 7750 0 R/K 35189 0 R>> endobj 21662 0 obj <>/Alt(Tier 1)/P 7750 0 R/K 35190 0 R>> endobj 21663 0 obj <>/Alt(LIVTENCITY ORAL TABLET 200 MG)/P 7751 0 R/K 35191 0 R>> endobj 21664 0 obj <>/Alt(Tier 2)/P 7751 0 R/K 35192 0 R>> endobj 21665 0 obj <>/Alt(PA; SP)/P 7751 0 R/K 35193 0 R>> endobj 21666 0 obj <>/Alt(\(Begin italic\) oseltamivir oral capsule \(End italic\) \(Begin italic\) 30 mg \(End italic\))/P 7752 0 R/K 35194 0 R>> endobj 21667 0 obj <>/Alt(\(Tamiflu\))/P 7752 0 R/K 35195 0 R>> endobj 21668 0 obj <>/Alt(Tier 1)/P 7752 0 R/K 35196 0 R>> endobj 21669 0 obj <>/Alt(QL \(40 EA per 180 days\))/P 7752 0 R/K 35197 0 R>> endobj 21670 0 obj <>/Alt(\(Begin italic\) oseltamivir oral capsule \(End italic\) \(Begin italic\) 45 mg, 75 mg \(End italic\))/P 7753 0 R/K 35198 0 R>> endobj 21671 0 obj <>/Alt(\(Tamiflu\))/P 7753 0 R/K 35199 0 R>> endobj 21672 0 obj <>/Alt(Tier 1)/P 7753 0 R/K 35200 0 R>> endobj 21673 0 obj <>/Alt(QL \(20 EA per 180 days\))/P 7753 0 R/K 35201 0 R>> endobj 21674 0 obj <>/Alt(\(Begin italic\) oseltamivir oral suspension for reconstitution \(End italic\) \(Begin italic\) 6 mg/ml \(End italic\))/P 7754 0 R/K 35202 0 R>> endobj 21675 0 obj <>/Alt(\(Tamiflu\))/P 7754 0 R/K 35203 0 R>> endobj 21676 0 obj <>/Alt(Tier 1)/P 7754 0 R/K 35204 0 R>> endobj 21677 0 obj <>/Alt(QL \(360 ML per 180 days\))/P 7754 0 R/K 35205 0 R>> endobj 21678 0 obj <>/Alt(PREVYMIS ORAL PELLETS IN PACKET 120 MG, 20 MG)/P 7755 0 R/K 35206 0 R>> endobj 21679 0 obj <>/Alt(Tier 3)/P 7755 0 R/K 35207 0 R>> endobj 21680 0 obj <>/Alt(PA)/P 7755 0 R/K 35208 0 R>> endobj 21681 0 obj <>/Alt(PREVYMIS ORAL TABLET 240 MG, 480 MG)/P 7756 0 R/K 35209 0 R>> endobj 21682 0 obj <>/Alt(Tier 3)/P 7756 0 R/K 35210 0 R>> endobj 21683 0 obj <>/Alt(PA)/P 7756 0 R/K 35211 0 R>> endobj 21684 0 obj <>/Alt(RELENZA DISKHALER INHALATION BLISTER WITH DEVICE 5 MG/ACTUATION)/P 7757 0 R/K 35212 0 R>> endobj 21685 0 obj <>/Alt(Tier 3)/P 7757 0 R/K 35213 0 R>> endobj 21686 0 obj <>/Alt(QL \(40 EA per 180 days\))/P 7757 0 R/K 35214 0 R>> endobj 21687 0 obj <>/Alt(\(Begin italic\) ribavirin inhalation recon soln \(End italic\) \(Begin italic\) 6 gram \(End italic\))/P 7758 0 R/K 35215 0 R>> endobj 21688 0 obj <>/Alt(\(Virazole\))/P 7758 0 R/K 35216 0 R>> endobj 21689 0 obj <>/Alt(Tier 1)/P 7758 0 R/K 35217 0 R>> endobj 21690 0 obj <>/Alt(\(Begin italic\) rimantadine oral tablet \(End italic\) \(Begin italic\) 100 mg \(End italic\))/P 7759 0 R/K 35218 0 R>> endobj 21691 0 obj <>/Alt(\(Flumadine\))/P 7759 0 R/K 35219 0 R>> endobj 21692 0 obj <>/Alt(Tier 1)/P 7759 0 R/K 35220 0 R>> endobj 21693 0 obj <>/Alt(TEMBEXA ORAL SUSPENSION 10 MG/ML)/P 7760 0 R/K 35221 0 R>> endobj 21694 0 obj <>/Alt(Tier 2)/P 7760 0 R/K 35222 0 R>> endobj 21695 0 obj <>/Alt(TEMBEXA ORAL TABLET 100 MG)/P 7761 0 R/K 35223 0 R>> endobj 21696 0 obj <>/Alt(Tier 2)/P 7761 0 R/K 35224 0 R>> endobj 21697 0 obj <>/Alt(TPOXX \(NATIONAL STOCKPILE\) ORAL CAPSULE 200 MG)/P 7762 0 R/K 35225 0 R>> endobj 21698 0 obj <>/Alt(Tier 2)/P 7762 0 R/K 35226 0 R>> endobj 21699 0 obj <>/Alt(\(Begin italic\) valacyclovir oral tablet \(End italic\) \(Begin italic\) 1 gram, 500 mg \(End italic\))/P 7763 0 R/K 35227 0 R>> endobj 21700 0 obj <>/Alt(\(Valtrex\))/P 7763 0 R/K 35228 0 R>> endobj 21701 0 obj <>/Alt(Tier 1)/P 7763 0 R/K 35229 0 R>> endobj 21702 0 obj <>/Alt(\(Begin italic\) valganciclovir oral recon soln \(End italic\) \(Begin italic\) 50 mg/ml \(End italic\))/P 7764 0 R/K 35230 0 R>> endobj 21703 0 obj <>/Alt(\(Valcyte\))/P 7764 0 R/K 35231 0 R>> endobj 21704 0 obj <>/Alt(Tier 1)/P 7764 0 R/K 35232 0 R>> endobj 21705 0 obj <>/Alt(\(Begin italic\) valganciclovir oral tablet \(End italic\) \(Begin italic\) 450 mg \(End italic\))/P 7765 0 R/K 35233 0 R>> endobj 21706 0 obj <>/Alt(\(Valcyte\))/P 7765 0 R/K 35234 0 R>> endobj 21707 0 obj <>/Alt(Tier 1)/P 7765 0 R/K 35235 0 R>> endobj 21708 0 obj <>/Alt(XOFLUZA ORAL TABLET 20 MG, 40 MG)/P 7766 0 R/K 35236 0 R>> endobj 21709 0 obj <>/Alt(Tier 2)/P 7766 0 R/K 35237 0 R>> endobj 21710 0 obj <>/Alt(QL \(4 EA per 180 days\))/P 7766 0 R/K 35238 0 R>> endobj 21711 0 obj <>/Alt(XOFLUZA ORAL TABLET 80 MG)/P 7767 0 R/K 35239 0 R>> endobj 21712 0 obj <>/Alt(Tier 2)/P 7767 0 R/K 35240 0 R>> endobj 21713 0 obj <>/Alt(QL \(2 EA per 180 days\))/P 7767 0 R/K 35241 0 R>> endobj 21714 0 obj <>/Alt(\(Begin bold\) Antivirals, Hiv-Spec, Non-Peptidic Protease Inhib \(End bold\))/P 7768 0 R/K 35242 0 R>> endobj 21715 0 obj <>/Alt(APTIVUS ORAL CAPSULE 250 MG)/P 7769 0 R/K 35243 0 R>> endobj 21716 0 obj <>/Alt(Tier 2)/P 7769 0 R/K 35244 0 R>> endobj 21717 0 obj <>/Alt(SP; QL \(4 EA per 1 day\))/P 7769 0 R/K 35245 0 R>> endobj 21718 0 obj <>/Alt(\(Begin italic\) darunavir oral tablet \(End italic\) \(Begin italic\) 600 mg \(End italic\))/P 7770 0 R/K 35246 0 R>> endobj 21719 0 obj <>/Alt(\(Prezista\))/P 7770 0 R/K 35247 0 R>> endobj 21720 0 obj <>/Alt(Tier 1)/P 7770 0 R/K 35248 0 R>> endobj 21721 0 obj <>/Alt(SP; QL \(2 EA per 1 day\))/P 7770 0 R/K 35249 0 R>> endobj 21722 0 obj <>/Alt(\(Begin italic\) darunavir oral tablet \(End italic\) \(Begin italic\) 800 mg \(End italic\))/P 7771 0 R/K 35250 0 R>> endobj 21723 0 obj <>/Alt(\(Prezista\))/P 7771 0 R/K 35251 0 R>> endobj 21724 0 obj <>/Alt(Tier 1)/P 7771 0 R/K 35252 0 R>> endobj 21725 0 obj <>/Alt(SP; QL \(1 EA per 1 day\))/P 7771 0 R/K 35253 0 R>> endobj 21726 0 obj <>/Alt(PREZISTA ORAL SUSPENSION 100 MG/ML)/P 7772 0 R/K 35254 0 R>> endobj 21727 0 obj <>/Alt(Tier 2)/P 7772 0 R/K 35255 0 R>> endobj 21728 0 obj <>/Alt(SP; QL \(400 ML per 30 days\))/P 7772 0 R/K 35256 0 R>> endobj 21729 0 obj <>/Alt(PREZISTA ORAL TABLET 150 MG)/P 7773 0 R/K 35257 0 R>> endobj 21730 0 obj <>/Alt(Tier 2)/P 7773 0 R/K 35258 0 R>> endobj 21731 0 obj <>/Alt(SP; QL \(8 EA per 1 day\))/P 7773 0 R/K 35259 0 R>> endobj 21732 0 obj <>/Alt(PREZISTA ORAL TABLET 75 MG)/P 7774 0 R/K 35260 0 R>> endobj 21733 0 obj <>/Alt(Tier 2)/P 7774 0 R/K 35261 0 R>> endobj 21734 0 obj <>/Alt(SP; QL \(16 EA per 1 day\))/P 7774 0 R/K 35262 0 R>> endobj 21735 0 obj <>/Alt(\(Begin bold\) Antivirals, Hiv-Spec, Nucleoside-Nucleotide Analog \(End bold\))/P 7775 0 R/K 35263 0 R>> endobj 21736 0 obj <>/Alt(CIMDUO ORAL TABLET 300-300 MG)/P 7776 0 R/K 35264 0 R>> endobj 21737 0 obj <>/Alt(Tier 2)/P 7776 0 R/K 35265 0 R>> endobj 21738 0 obj <>/Alt(SP; QL \(1 EA per 1 day\))/P 7776 0 R/K 35266 0 R>> endobj 21739 0 obj <>/Alt(DESCOVY ORAL TABLET 120-15 MG)/P 7777 0 R/K 35267 0 R>> endobj 21740 0 obj <>/Alt(Tier 2)/P 7777 0 R/K 35268 0 R>> endobj 21741 0 obj <>/Alt(SP; QL \(1 EA per 1 day\))/P 7777 0 R/K 35269 0 R>> endobj 21742 0 obj <>/Alt(DESCOVY ORAL TABLET 200-25 MG)/P 7778 0 R/K 35270 0 R>> endobj 21743 0 obj <>/Alt($0)/P 7778 0 R/K 35271 0 R>> endobj 21744 0 obj <>/Alt($0 COPAY IF QUANTITY 1 IN 1 DAY AND AND NO HISTORY OF ANTIRETROVIRAL MEDICATION IN 120 DAYS; QL \(1 EA per 1 day\))/P 7778 0 R/K 35272 0 R>> endobj 21745 0 obj <>/Alt(\(Begin italic\) emtricitabine-tenofovir \(tdf\) oral tablet \(End italic\) \(Begin italic\) 100-150 mg, 133-200 mg, 167-250 mg \(End italic\))/P 7779 0 R/K 35273 0 R>> endobj 21746 0 obj <>/Alt(\(Truvada\))/P 7779 0 R/K 35274 0 R>> endobj 21747 0 obj <>/Alt(Tier 1)/P 7779 0 R/K 35275 0 R>> endobj 21748 0 obj <>/Alt(SP; QL \(1 EA per 1 day\))/P 7779 0 R/K 35276 0 R>> endobj 21749 0 obj <>/Alt(\(Begin italic\) emtricitabine-tenofovir \(tdf\) oral tablet \(End italic\) \(Begin italic\) 200-300 mg \(End italic\))/P 7780 0 R/K 35277 0 R>> endobj 21750 0 obj <>/Alt(\(Truvada\))/P 7780 0 R/K 35278 0 R>> endobj 21751 0 obj <>/Alt($0)/P 7780 0 R/K 35279 0 R>> endobj 21752 0 obj <>/Alt($0 COPAY IF QUANTITY 1 IN 1 DAY AND AND NO HISTORY OF ANTIRETROVIRAL MEDICATION IN 120 DAYS; QL \(1 EA per 1 day\))/P 7780 0 R/K 35280 0 R>> endobj 21753 0 obj <>/Alt(\(Begin bold\) Antivirals, Hiv-Spec., Nucleoside Analog, Rti Comb \(End bold\))/P 7781 0 R/K 35281 0 R>> endobj 21754 0 obj <>/Alt(\(Begin italic\) abacavir-lamivudine oral tablet \(End italic\) \(Begin italic\) 600-300 mg \(End italic\))/P 7782 0 R/K 35282 0 R>> endobj 21755 0 obj <>/Alt(Tier 1)/P 7782 0 R/K 35283 0 R>> endobj 21756 0 obj <>/Alt(SP; QL \(1 EA per 1 day\))/P 7782 0 R/K 35284 0 R>> endobj 21757 0 obj <>/Alt(\(Begin italic\) lamivudine-zidovudine oral tablet \(End italic\) \(Begin italic\) 150-300 mg \(End italic\))/P 7783 0 R/K 35285 0 R>> endobj 21758 0 obj <>/Alt(Tier 1)/P 7783 0 R/K 35286 0 R>> endobj 21759 0 obj <>/Alt(SP; QL \(2 EA per 1 day\))/P 7783 0 R/K 35287 0 R>> endobj 21760 0 obj <>/Alt(\(Begin bold\) Antivirals, Hiv-Specific, Ccr5 Co-Receptor Antag. \(End bold\))/P 7784 0 R/K 35288 0 R>> endobj 21761 0 obj <>/Alt(\(Begin italic\) maraviroc oral tablet \(End italic\) \(Begin italic\) 150 mg \(End italic\))/P 7785 0 R/K 35289 0 R>> endobj 21762 0 obj <>/Alt(\(Selzentry\))/P 7785 0 R/K 35290 0 R>> endobj 21763 0 obj <>/Alt(Tier 1)/P 7785 0 R/K 35291 0 R>> endobj 21764 0 obj <>/Alt(SP; QL \(2 EA per 1 day\))/P 7785 0 R/K 35292 0 R>> endobj 21765 0 obj <>/Alt(\(Begin italic\) maraviroc oral tablet \(End italic\) \(Begin italic\) 300 mg \(End italic\))/P 7786 0 R/K 35293 0 R>> endobj 21766 0 obj <>/Alt(\(Selzentry\))/P 7786 0 R/K 35294 0 R>> endobj 21767 0 obj <>/Alt(Tier 1)/P 7786 0 R/K 35295 0 R>> endobj 21768 0 obj <>/Alt(SP; QL \(4 EA per 1 day\))/P 7786 0 R/K 35296 0 R>> endobj 21769 0 obj <>/Alt(SELZENTRY ORAL SOLUTION 20 MG/ML)/P 7787 0 R/K 35297 0 R>> endobj 21770 0 obj <>/Alt(Tier 2)/P 7787 0 R/K 35298 0 R>> endobj 21771 0 obj <>/Alt(SP; QL \(31 ML per 1 day\))/P 7787 0 R/K 35299 0 R>> endobj 21772 0 obj <>/Alt(\(Begin bold\) Antivirals, Hiv-Specific, Cd4 Attachment Inhibitor \(End bold\))/P 7788 0 R/K 35300 0 R>> endobj 21773 0 obj <>/Alt(RUKOBIA ORAL TABLET EXTENDED RELEASE 12 HR 600 MG)/P 7789 0 R/K 35301 0 R>> endobj 21774 0 obj <>/Alt(Tier 2)/P 7789 0 R/K 35302 0 R>> endobj 21775 0 obj <>/Alt(PA; SP)/P 7789 0 R/K 35303 0 R>> endobj 21776 0 obj <>/Alt(\(Begin bold\) Antivirals, Hiv-Specific, Fusion Inhibitors \(End bold\))/P 7790 0 R/K 35304 0 R>> endobj 21777 0 obj <>/Alt(FUZEON SUBCUTANEOUS RECON SOLN 90 MG)/P 7791 0 R/K 35305 0 R>> endobj 21778 0 obj <>/Alt(Tier 2)/P 7791 0 R/K 35306 0 R>> endobj 21779 0 obj <>/Alt(SP; QL \(2 EA per 1 day\))/P 7791 0 R/K 35307 0 R>> endobj 21780 0 obj <>/Alt(\(Begin bold\) Antivirals, Hiv-Specific, Non-Nucleoside, Rti \(End bold\))/P 7792 0 R/K 35308 0 R>> endobj 21781 0 obj <>/Alt(EDURANT ORAL TABLET 25 MG)/P 7793 0 R/K 35309 0 R>> endobj 21782 0 obj <>/Alt(Tier 2)/P 7793 0 R/K 35310 0 R>> endobj 21783 0 obj <>/Alt(SP; QL \(1 EA per 1 day\))/P 7793 0 R/K 35311 0 R>> endobj 21784 0 obj <>/Alt(\(Begin italic\) efavirenz oral capsule \(End italic\) \(Begin italic\) 200 mg, 50 mg \(End italic\))/P 7794 0 R/K 35312 0 R>> endobj 21785 0 obj <>/Alt(Tier 1)/P 7794 0 R/K 35313 0 R>> endobj 21786 0 obj <>/Alt(SP)/P 7794 0 R/K 35314 0 R>> endobj 21787 0 obj <>/Alt(\(Begin italic\) efavirenz oral tablet \(End italic\) \(Begin italic\) 600 mg \(End italic\))/P 7795 0 R/K 35315 0 R>> endobj 21788 0 obj <>/Alt(Tier 1)/P 7795 0 R/K 35316 0 R>> endobj 21789 0 obj <>/Alt(SP)/P 7795 0 R/K 35317 0 R>> endobj 21790 0 obj <>/Alt(\(Begin italic\) etravirine oral tablet \(End italic\) \(Begin italic\) 100 mg \(End italic\))/P 7796 0 R/K 35318 0 R>> endobj 21791 0 obj <>/Alt(\(Intelence\))/P 7796 0 R/K 35319 0 R>> endobj 21792 0 obj <>/Alt(Tier 1)/P 7796 0 R/K 35320 0 R>> endobj 21793 0 obj <>/Alt(SP; QL \(4 EA per 1 day\))/P 7796 0 R/K 35321 0 R>> endobj 21794 0 obj <>/Alt(\(Begin italic\) etravirine oral tablet \(End italic\) \(Begin italic\) 200 mg \(End italic\))/P 7797 0 R/K 35322 0 R>> endobj 21795 0 obj <>/Alt(\(Intelence\))/P 7797 0 R/K 35323 0 R>> endobj 21796 0 obj <>/Alt(Tier 1)/P 7797 0 R/K 35324 0 R>> endobj 21797 0 obj <>/Alt(SP; QL \(2 EA per 1 day\))/P 7797 0 R/K 35325 0 R>> endobj 21798 0 obj <>/Alt(INTELENCE ORAL TABLET 25 MG)/P 7798 0 R/K 35326 0 R>> endobj 21799 0 obj <>/Alt(Tier 2)/P 7798 0 R/K 35327 0 R>> endobj 21800 0 obj <>/Alt(SP; QL \(4 EA per 1 day\))/P 7798 0 R/K 35328 0 R>> endobj 21801 0 obj <>/Alt(\(Begin italic\) nevirapine oral suspension \(End italic\) \(Begin italic\) 50 mg/5 ml \(End italic\))/P 7799 0 R/K 35329 0 R>> endobj 21802 0 obj <>/Alt(Tier 1)/P 7799 0 R/K 35330 0 R>> endobj 21803 0 obj <>/Alt(SP; QL \(1200 ML per 30 days\))/P 7799 0 R/K 35331 0 R>> endobj 21804 0 obj <>/Alt(\(Begin italic\) nevirapine oral tablet \(End italic\) \(Begin italic\) 200 mg \(End italic\))/P 7800 0 R/K 35332 0 R>> endobj 21805 0 obj <>/Alt(Tier 1)/P 7800 0 R/K 35333 0 R>> endobj 21806 0 obj <>/Alt(SP; QL \(2 EA per 1 day\))/P 7800 0 R/K 35334 0 R>> endobj 21807 0 obj <>/Alt(\(Begin italic\) nevirapine oral tablet extended release 24 hr \(End italic\) \(Begin italic\) 100 mg \(End italic\))/P 7801 0 R/K 35335 0 R>> endobj 21808 0 obj <>/Alt(Tier 1)/P 7801 0 R/K 35336 0 R>> endobj 21809 0 obj <>/Alt(SP; QL \(3 EA per 1 day\))/P 7801 0 R/K 35337 0 R>> endobj 21810 0 obj <>/Alt(\(Begin italic\) nevirapine oral tablet extended release 24 hr \(End italic\) \(Begin italic\) 400 mg \(End italic\))/P 7802 0 R/K 35338 0 R>> endobj 21811 0 obj <>/Alt(Tier 1)/P 7802 0 R/K 35339 0 R>> endobj 21812 0 obj <>/Alt(SP; QL \(1 EA per 1 day\))/P 7802 0 R/K 35340 0 R>> endobj 21813 0 obj <>/Alt(\(Begin bold\) Antivirals, Hiv-Specific, Nucleoside Analog, Rti \(End bold\))/P 7803 0 R/K 35341 0 R>> endobj 21814 0 obj <>/Alt(\(Begin italic\) abacavir oral solution \(End italic\) \(Begin italic\) 20 mg/ml \(End italic\))/P 7804 0 R/K 35342 0 R>> endobj 21815 0 obj <>/Alt(\(Ziagen\))/P 7804 0 R/K 35343 0 R>> endobj 21816 0 obj <>/Alt(Tier 1)/P 7804 0 R/K 35344 0 R>> endobj 21817 0 obj <>/Alt(SP; QL \(960 ML per 30 days\))/P 7804 0 R/K 35345 0 R>> endobj 21818 0 obj <>/Alt(\(Begin italic\) abacavir oral tablet \(End italic\) \(Begin italic\) 300 mg \(End italic\))/P 7805 0 R/K 35346 0 R>> endobj 21819 0 obj <>/Alt(Tier 1)/P 7805 0 R/K 35347 0 R>> endobj 21820 0 obj <>/Alt(SP; QL \(2 EA per 1 day\))/P 7805 0 R/K 35348 0 R>> endobj 21821 0 obj <>/Alt(\(Begin italic\) emtricitabine oral capsule \(End italic\) \(Begin italic\) 200 mg \(End italic\))/P 7806 0 R/K 35349 0 R>> endobj 21822 0 obj <>/Alt(\(Emtriva\))/P 7806 0 R/K 35350 0 R>> endobj 21823 0 obj <>/Alt($0)/P 7806 0 R/K 35351 0 R>> endobj 21824 0 obj <>/Alt($0 COPAY IF QUANTITY 1 IN 1 DAY AND AND NO HISTORY OF ANTIRETROVIRAL MEDICATION IN 120 DAYS; QL \(1 EA per 1 day\))/P 7806 0 R/K 35352 0 R>> endobj 21825 0 obj <>/Alt(EMTRIVA ORAL SOLUTION 10 MG/ML)/P 7807 0 R/K 35353 0 R>> endobj 21826 0 obj <>/Alt(Tier 2)/P 7807 0 R/K 35354 0 R>> endobj 21827 0 obj <>/Alt(SP; QL \(850 ML per 30 days\))/P 7807 0 R/K 35355 0 R>> endobj 21828 0 obj <>/Alt(\(Begin italic\) lamivudine oral solution \(End italic\) \(Begin italic\) 10 mg/ml \(End italic\))/P 7808 0 R/K 35356 0 R>> endobj 21829 0 obj <>/Alt(\(Epivir\))/P 7808 0 R/K 35357 0 R>> endobj 21830 0 obj <>/Alt(Tier 1)/P 7808 0 R/K 35358 0 R>> endobj 21831 0 obj <>/Alt(SP; QL \(960 ML per 30 days\))/P 7808 0 R/K 35359 0 R>> endobj 21832 0 obj <>/Alt(\(Begin italic\) lamivudine oral tablet \(End italic\) \(Begin italic\) 150 mg \(End italic\))/P 7809 0 R/K 35360 0 R>> endobj 21833 0 obj <>/Alt(\(Epivir\))/P 7809 0 R/K 35361 0 R>> endobj 21834 0 obj <>/Alt(Tier 1)/P 7809 0 R/K 35362 0 R>> endobj 21835 0 obj <>/Alt(SP; QL \(2 EA per 1 day\))/P 7809 0 R/K 35363 0 R>> endobj 21836 0 obj <>/Alt(\(Begin italic\) lamivudine oral tablet \(End italic\) \(Begin italic\) 300 mg \(End italic\))/P 7810 0 R/K 35364 0 R>> endobj 21837 0 obj <>/Alt(\(Epivir\))/P 7810 0 R/K 35365 0 R>> endobj 21838 0 obj <>/Alt(Tier 1)/P 7810 0 R/K 35366 0 R>> endobj 21839 0 obj <>/Alt(SP; QL \(1 EA per 1 day\))/P 7810 0 R/K 35367 0 R>> endobj 21840 0 obj <>/Alt(\(Begin italic\) stavudine oral capsule \(End italic\) \(Begin italic\) 15 mg, 20 mg \(End italic\))/P 7811 0 R/K 35368 0 R>> endobj 21841 0 obj <>/Alt(Tier 1)/P 7811 0 R/K 35369 0 R>> endobj 21842 0 obj <>/Alt(SP; QL \(2 EA per 1 day\))/P 7811 0 R/K 35370 0 R>> endobj 21843 0 obj <>/Alt(\(Begin italic\) zidovudine oral capsule \(End italic\) \(Begin italic\) 100 mg \(End italic\))/P 7812 0 R/K 35371 0 R>> endobj 21844 0 obj <>/Alt(\(Retrovir\))/P 7812 0 R/K 35372 0 R>> endobj 21845 0 obj <>/Alt(Tier 1)/P 7812 0 R/K 35373 0 R>> endobj 21846 0 obj <>/Alt(SP; QL \(6 EA per 1 day\))/P 7812 0 R/K 35374 0 R>> endobj 21847 0 obj <>/Alt(\(Begin italic\) zidovudine oral syrup \(End italic\) \(Begin italic\) 10 mg/ml \(End italic\))/P 7813 0 R/K 35375 0 R>> endobj 21848 0 obj <>/Alt(\(Retrovir\))/P 7813 0 R/K 35376 0 R>> endobj 21849 0 obj <>/Alt(Tier 1)/P 7813 0 R/K 35377 0 R>> endobj 21850 0 obj <>/Alt(SP; QL \(1920 ML per 30 days\))/P 7813 0 R/K 35378 0 R>> endobj 21851 0 obj <>/Alt(\(Begin italic\) zidovudine oral tablet \(End italic\) \(Begin italic\) 300 mg \(End italic\))/P 7814 0 R/K 35379 0 R>> endobj 21852 0 obj <>/Alt(Tier 1)/P 7814 0 R/K 35380 0 R>> endobj 21853 0 obj <>/Alt(SP; QL \(2 EA per 1 day\))/P 7814 0 R/K 35381 0 R>> endobj 21854 0 obj <>/Alt(\(Begin bold\) Antivirals, Hiv-Specific, Nucleotide Analog, Rti \(End bold\))/P 7815 0 R/K 35382 0 R>> endobj 21855 0 obj <>/Alt(\(Begin italic\) tenofovir disoproxil fumarate oral tablet \(End italic\) \(Begin italic\) 300 mg \(End italic\))/P 7816 0 R/K 35383 0 R>> endobj 21856 0 obj <>/Alt(\(Viread\))/P 7816 0 R/K 35384 0 R>> endobj 21857 0 obj <>/Alt($0)/P 7816 0 R/K 35385 0 R>> endobj 21858 0 obj <>/Alt($0 COPAY IF QUANTITY 1 IN 1 DAY AND AND NO HISTORY OF ANTIRETROVIRAL MEDICATION IN 120 DAYS; QL \(1 EA per 1 day\))/P 7816 0 R/K 35386 0 R>> endobj 21859 0 obj <>/Alt(VIREAD ORAL POWDER 40 MG/SCOOP \(40 MG/GRAM\))/P 7817 0 R/K 35387 0 R>> endobj 21860 0 obj <>/Alt(Tier 2)/P 7817 0 R/K 35388 0 R>> endobj 21861 0 obj <>/Alt(SP; QL \(240 GM per 30 days\))/P 7817 0 R/K 35389 0 R>> endobj 21862 0 obj <>/Alt(VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG)/P 7818 0 R/K 35390 0 R>> endobj 21863 0 obj <>/Alt(Tier 2)/P 7818 0 R/K 35391 0 R>> endobj 21864 0 obj <>/Alt(SP; QL \(1 EA per 1 day\))/P 7818 0 R/K 35392 0 R>> endobj 21865 0 obj <>/Alt(\(Begin bold\) Antivirals, Hiv-Specific, Protease Inhibitor Comb \(End bold\))/P 7819 0 R/K 35393 0 R>> endobj 21866 0 obj <>/Alt(\(Begin italic\) lopinavir-ritonavir oral solution \(End italic\) \(Begin italic\) 400-100 mg/5 ml \(End italic\))/P 7820 0 R/K 35394 0 R>> endobj 21867 0 obj <>/Alt(\(Kaletra\))/P 7820 0 R/K 35395 0 R>> endobj 21868 0 obj <>/Alt(Tier 1)/P 7820 0 R/K 35396 0 R>> endobj 21869 0 obj <>/Alt(SP; QL \(480 ML per 30 days\))/P 7820 0 R/K 35397 0 R>> endobj 21870 0 obj <>/Alt(\(Begin italic\) lopinavir-ritonavir oral tablet \(End italic\) \(Begin italic\) 100-25 mg \(End italic\))/P 7821 0 R/K 35398 0 R>> endobj 21871 0 obj <>/Alt(\(Kaletra\))/P 7821 0 R/K 35399 0 R>> endobj 21872 0 obj <>/Alt(Tier 1)/P 7821 0 R/K 35400 0 R>> endobj 21873 0 obj <>/Alt(SP; QL \(10 EA per 1 day\))/P 7821 0 R/K 35401 0 R>> endobj 21874 0 obj <>/Alt(\(Begin italic\) lopinavir-ritonavir oral tablet \(End italic\) \(Begin italic\) 200-50 mg \(End italic\))/P 7822 0 R/K 35402 0 R>> endobj 21875 0 obj <>/Alt(\(Kaletra\))/P 7822 0 R/K 35403 0 R>> endobj 21876 0 obj <>/Alt(Tier 1)/P 7822 0 R/K 35404 0 R>> endobj 21877 0 obj <>/Alt(SP; QL \(4 EA per 1 day\))/P 7822 0 R/K 35405 0 R>> endobj 21878 0 obj <>/Alt(\(Begin bold\) Antivirals, Hiv-Specific, Protease Inhibitors \(End bold\))/P 7823 0 R/K 35406 0 R>> endobj 21879 0 obj <>/Alt(\(Begin italic\) atazanavir oral capsule \(End italic\) \(Begin italic\) 150 mg \(End italic\))/P 7824 0 R/K 35407 0 R>> endobj 21880 0 obj <>/Alt(Tier 1)/P 7824 0 R/K 35408 0 R>> endobj 21881 0 obj <>/Alt(SP; QL \(2 EA per 1 day\))/P 7824 0 R/K 35409 0 R>> endobj 21882 0 obj <>/Alt(\(Begin italic\) atazanavir oral capsule \(End italic\) \(Begin italic\) 200 mg \(End italic\))/P 7825 0 R/K 35410 0 R>> endobj 21883 0 obj <>/Alt(\(Reyataz\))/P 7825 0 R/K 35411 0 R>> endobj 21884 0 obj <>/Alt(Tier 1)/P 7825 0 R/K 35412 0 R>> endobj 21885 0 obj <>/Alt(SP; QL \(2 EA per 1 day\))/P 7825 0 R/K 35413 0 R>> endobj 21886 0 obj <>/Alt(\(Begin italic\) atazanavir oral capsule \(End italic\) \(Begin italic\) 300 mg \(End italic\))/P 7826 0 R/K 35414 0 R>> endobj 21887 0 obj <>/Alt(\(Reyataz\))/P 7826 0 R/K 35415 0 R>> endobj 21888 0 obj <>/Alt(Tier 1)/P 7826 0 R/K 35416 0 R>> endobj 21889 0 obj <>/Alt(SP; QL \(1 EA per 1 day\))/P 7826 0 R/K 35417 0 R>> endobj 21890 0 obj <>/Alt(EVOTAZ ORAL TABLET 300-150 MG)/P 7827 0 R/K 35418 0 R>> endobj 21891 0 obj <>/Alt(Tier 2)/P 7827 0 R/K 35419 0 R>> endobj 21892 0 obj <>/Alt(SP; QL \(1 EA per 1 day\))/P 7827 0 R/K 35420 0 R>> endobj 21893 0 obj <>/Alt(\(Begin italic\) fosamprenavir oral tablet \(End italic\) \(Begin italic\) 700 mg \(End italic\))/P 7828 0 R/K 35421 0 R>> endobj 21894 0 obj <>/Alt(Tier 1)/P 7828 0 R/K 35422 0 R>> endobj 21895 0 obj <>/Alt(SP; QL \(4 EA per 1 day\))/P 7828 0 R/K 35423 0 R>> endobj 21896 0 obj <>/Alt(NORVIR ORAL CAPSULE 100 MG)/P 7829 0 R/K 35424 0 R>> endobj 21897 0 obj <>/Alt(Tier 2)/P 7829 0 R/K 35425 0 R>> endobj 21898 0 obj <>/Alt(SP; QL \(12 EA per 1 day\))/P 7829 0 R/K 35426 0 R>> endobj 21899 0 obj <>/Alt(NORVIR ORAL POWDER IN PACKET 100 MG)/P 7830 0 R/K 35427 0 R>> endobj 21900 0 obj <>/Alt(Tier 2)/P 7830 0 R/K 35428 0 R>> endobj 21901 0 obj <>/Alt(SP; QL \(12 EA per 1 day\))/P 7830 0 R/K 35429 0 R>> endobj 21902 0 obj <>/Alt(REYATAZ ORAL POWDER IN PACKET 50 MG)/P 7831 0 R/K 35430 0 R>> endobj 21903 0 obj <>/Alt(Tier 2)/P 7831 0 R/K 35431 0 R>> endobj 21904 0 obj <>/Alt(SP; QL \(5 EA per 1 day\))/P 7831 0 R/K 35432 0 R>> endobj 21905 0 obj <>/Alt(\(Begin italic\) ritonavir oral tablet \(End italic\) \(Begin italic\) 100 mg \(End italic\))/P 7832 0 R/K 35433 0 R>> endobj 21906 0 obj <>/Alt(\(Norvir\))/P 7832 0 R/K 35434 0 R>> endobj 21907 0 obj <>/Alt(Tier 1)/P 7832 0 R/K 35435 0 R>> endobj 21908 0 obj <>/Alt(SP; QL \(12 EA per 1 day\))/P 7832 0 R/K 35436 0 R>> endobj 21909 0 obj <>/Alt(VIRACEPT ORAL TABLET 250 MG, 625 MG)/P 7833 0 R/K 35437 0 R>> endobj 21910 0 obj <>/Alt(Tier 2)/P 7833 0 R/K 35438 0 R>> endobj 21911 0 obj <>/Alt(SP)/P 7833 0 R/K 35439 0 R>> endobj 21912 0 obj <>/Alt(\(Begin bold\) Antivirals,Hiv-1 Integrase Strand Transfer Inhibtr \(End bold\))/P 7834 0 R/K 35440 0 R>> endobj 21913 0 obj <>/Alt(APRETUDE INTRAMUSCULAR SUSPENSION,EXTENDED RELEASE 600 MG/3 ML \(200 MG/ML\))/P 7835 0 R/K 35441 0 R>> endobj 21914 0 obj <>/Alt(\(cabotegravir\))/P 7835 0 R/K 35442 0 R>> endobj 21915 0 obj <>/Alt($0)/P 7835 0 R/K 35443 0 R>> endobj 21916 0 obj <>/Alt($0 COPAY IF QUANTITY 0.15 IN 1 DAY, FILL OF 7 IN 365 DAYS, AND NO HISTORY OF ANTIRETROVIRAL MEDICATION IN 120 DAYS; QL \(21 ML per 365 days\); Age \(Min 12 Years\))/P 7835 0 R/K 35444 0 R>> endobj 21917 0 obj <>/Alt(\(Begin italic\) cabotegravir intramuscular suspension,extended release \(End italic\) \(Begin italic\) 600 mg/3 ml \(200 mg/ml\) \(End italic\))/P 7836 0 R/K 35445 0 R>> endobj 21918 0 obj <>/Alt(\(Apretude\))/P 7836 0 R/K 35446 0 R>> endobj 21919 0 obj <>/Alt($0)/P 7836 0 R/K 35447 0 R>> endobj 21920 0 obj <>/Alt($0 COPAY IF QUANTITY 0.15 IN 1 DAY, FILL OF 7 IN 365 DAYS, AND NO HISTORY OF ANTIRETROVIRAL MEDICATION IN 120 DAYS; QL \(21 ML per 365 days\); Age \(Min 12 Years\))/P 7836 0 R/K 35448 0 R>> endobj 21921 0 obj <>/Alt(ISENTRESS HD ORAL TABLET 600 MG)/P 7837 0 R/K 35449 0 R>> endobj 21922 0 obj <>/Alt(Tier 2)/P 7837 0 R/K 35450 0 R>> endobj 21923 0 obj <>/Alt(SP; QL \(2 EA per 1 day\))/P 7837 0 R/K 35451 0 R>> endobj 21924 0 obj <>/Alt(ISENTRESS ORAL POWDER IN PACKET 100 MG)/P 7838 0 R/K 35452 0 R>> endobj 21925 0 obj <>/Alt(Tier 2)/P 7838 0 R/K 35453 0 R>> endobj 21926 0 obj <>/Alt(SP; QL \(2 EA per 1 day\))/P 7838 0 R/K 35454 0 R>> endobj 21927 0 obj <>/Alt(ISENTRESS ORAL TABLET 400 MG)/P 7839 0 R/K 35455 0 R>> endobj 21928 0 obj <>/Alt(Tier 2)/P 7839 0 R/K 35456 0 R>> endobj 21929 0 obj <>/Alt(SP; QL \(2 EA per 1 day\))/P 7839 0 R/K 35457 0 R>> endobj 21930 0 obj <>/Alt(ISENTRESS ORAL TABLET,CHEWABLE 100 MG, 25 MG)/P 7840 0 R/K 35458 0 R>> endobj 21931 0 obj <>/Alt(Tier 2)/P 7840 0 R/K 35459 0 R>> endobj 21932 0 obj <>/Alt(SP; QL \(6 EA per 1 day\))/P 7840 0 R/K 35460 0 R>> endobj 21933 0 obj <>/Alt(TIVICAY ORAL TABLET 50 MG)/P 7841 0 R/K 35461 0 R>> endobj 21934 0 obj <>/Alt(Tier 2)/P 7841 0 R/K 35462 0 R>> endobj 21935 0 obj <>/Alt(SP; QL \(2 EA per 1 day\))/P 7841 0 R/K 35463 0 R>> endobj 21936 0 obj <>/Alt(TIVICAY PD ORAL TABLET FOR SUSPENSION 5 MG)/P 7842 0 R/K 35464 0 R>> endobj 21937 0 obj <>/Alt(Tier 2)/P 7842 0 R/K 35465 0 R>> endobj 21938 0 obj <>/Alt(SP; QL \(6 EA per 1 day\))/P 7842 0 R/K 35466 0 R>> endobj 21939 0 obj <>/Alt(VOCABRIA ORAL TABLET 30 MG)/P 7843 0 R/K 35467 0 R>> endobj 21940 0 obj <>/Alt(Tier 2)/P 7843 0 R/K 35468 0 R>> endobj 21941 0 obj <>/Alt(SP; QL \(1 EA per 1 day\); Age \(Min 12 Years\))/P 7843 0 R/K 35469 0 R>> endobj 21942 0 obj <>/Alt(\(Begin bold\) Artv Cmb Nucleoside,Nucleotide,&Non-Nucleoside Rti \(End bold\))/P 7844 0 R/K 35470 0 R>> endobj 21943 0 obj <>/Alt(\(Begin italic\) efavirenz-emtricitabin-tenofov oral tablet \(End italic\) \(Begin italic\) 600-200-300 mg \(End italic\))/P 7845 0 R/K 35471 0 R>> endobj 21944 0 obj <>/Alt(Tier 1)/P 7845 0 R/K 35472 0 R>> endobj 21945 0 obj <>/Alt(SP; QL \(1 EA per 1 day\))/P 7845 0 R/K 35473 0 R>> endobj 21946 0 obj <>/Alt(\(Begin italic\) efavirenz-lamivu-tenofov disop oral tablet \(End italic\) \(Begin italic\) 400-300-300 mg \(End italic\))/P 7846 0 R/K 35474 0 R>> endobj 21947 0 obj <>/Alt(\(Symfi Lo\))/P 7846 0 R/K 35475 0 R>> endobj 21948 0 obj <>/Alt(Tier 1)/P 7846 0 R/K 35476 0 R>> endobj 21949 0 obj <>/Alt(SP; QL \(1 EA per 1 day\))/P 7846 0 R/K 35477 0 R>> endobj 21950 0 obj <>/Alt(\(Begin italic\) efavirenz-lamivu-tenofov disop oral tablet \(End italic\) \(Begin italic\) 600-300-300 mg \(End italic\))/P 7847 0 R/K 35478 0 R>> endobj 21951 0 obj <>/Alt(\(Symfi\))/P 7847 0 R/K 35479 0 R>> endobj 21952 0 obj <>/Alt(Tier 1)/P 7847 0 R/K 35480 0 R>> endobj 21953 0 obj <>/Alt(SP; QL \(1 EA per 1 day\))/P 7847 0 R/K 35481 0 R>> endobj 21954 0 obj <>/Alt(ODEFSEY ORAL TABLET 200-25-25 MG)/P 7848 0 R/K 35482 0 R>> endobj 21955 0 obj <>/Alt(Tier 2)/P 7848 0 R/K 35483 0 R>> endobj 21956 0 obj <>/Alt(SP; QL \(1 EA per 1 day\))/P 7848 0 R/K 35484 0 R>> endobj 21957 0 obj <>/Alt(\(Begin bold\) Arv Cmb-Nrti,N\(T\)Rti, Integrase Inhibitor \(End bold\))/P 7849 0 R/K 35485 0 R>> endobj 21958 0 obj <>/Alt(BIKTARVY ORAL TABLET 30-120-15 MG, 50-200-25 MG)/P 7850 0 R/K 35486 0 R>> endobj 21959 0 obj <>/Alt(Tier 2)/P 7850 0 R/K 35487 0 R>> endobj 21960 0 obj <>/Alt(SP; QL \(1 EA per 1 day\))/P 7850 0 R/K 35488 0 R>> endobj 21961 0 obj <>/Alt(GENVOYA ORAL TABLET 150-150-200-10 MG)/P 7851 0 R/K 35489 0 R>> endobj 21962 0 obj <>/Alt(Tier 2)/P 7851 0 R/K 35490 0 R>> endobj 21963 0 obj <>/Alt(SP; QL \(1 EA per 1 day\))/P 7851 0 R/K 35491 0 R>> endobj 21964 0 obj <>/Alt(STRIBILD ORAL TABLET 150-150-200-300 MG)/P 7852 0 R/K 35492 0 R>> endobj 21965 0 obj <>/Alt(Tier 2)/P 7852 0 R/K 35493 0 R>> endobj 21966 0 obj <>/Alt(SP; QL \(1 EA per 1 day\))/P 7852 0 R/K 35494 0 R>> endobj 21967 0 obj <>/Alt(\(Begin bold\) Arv Comb-Nrtis & Integrase Inhibitor \(End bold\))/P 7853 0 R/K 35495 0 R>> endobj 21968 0 obj <>/Alt(TRIUMEQ ORAL TABLET 600-50-300 MG)/P 7854 0 R/K 35496 0 R>> endobj 21969 0 obj <>/Alt(Tier 2)/P 7854 0 R/K 35497 0 R>> endobj 21970 0 obj <>/Alt(SP; QL \(1 EA per 1 day\))/P 7854 0 R/K 35498 0 R>> endobj 21971 0 obj <>/Alt(TRIUMEQ PD ORAL TABLET FOR SUSPENSION 60-5-30 MG)/P 7855 0 R/K 35499 0 R>> endobj 21972 0 obj <>/Alt(Tier 2)/P 7855 0 R/K 35500 0 R>> endobj 21973 0 obj <>/Alt(SP; QL \(6 EA per 1 day\))/P 7855 0 R/K 35501 0 R>> endobj 21974 0 obj <>/Alt(\(Begin bold\) Cytochrome P450 Inhibitors \(End bold\))/P 7856 0 R/K 35502 0 R>> endobj 21975 0 obj <>/Alt(TYBOST ORAL TABLET 150 MG)/P 7857 0 R/K 35503 0 R>> endobj 21976 0 obj <>/Alt(Tier 2)/P 7857 0 R/K 35504 0 R>> endobj 21977 0 obj <>/Alt(QL \(1 EA per 1 day\))/P 7857 0 R/K 35505 0 R>> endobj 21978 0 obj <>/Alt(\(Begin bold\) Hep C - Ns5a, Ns3/4A, Nucleotide Ns5b Inhib Combo \(End bold\))/P 7858 0 R/K 35506 0 R>> endobj 21979 0 obj <>/Alt(VOSEVI ORAL TABLET 400-100-100 MG)/P 7859 0 R/K 35507 0 R>> endobj 21980 0 obj <>/Alt(Tier 2)/P 7859 0 R/K 35508 0 R>> endobj 21981 0 obj <>/Alt(PA; SP)/P 7859 0 R/K 35509 0 R>> endobj 21982 0 obj <>/Alt(\(Begin bold\) Hep C Virus - Ns5a & Ns5b Polymerase Inhib. Combo. \(End bold\))/P 7860 0 R/K 35510 0 R>> endobj 21983 0 obj <>/Alt(EPCLUSA ORAL PELLETS IN PACKET 150-37.5 MG, 200-50 MG)/P 7861 0 R/K 35511 0 R>> endobj 21984 0 obj <>/Alt(Tier 2)/P 7861 0 R/K 35512 0 R>> endobj 21985 0 obj <>/Alt(PA; SP)/P 7861 0 R/K 35513 0 R>> endobj 21986 0 obj <>/Alt(EPCLUSA ORAL TABLET 200-50 MG)/P 7862 0 R/K 35514 0 R>> endobj 21987 0 obj <>/Alt(Tier 2)/P 7862 0 R/K 35515 0 R>> endobj 21988 0 obj <>/Alt(PA; SP)/P 7862 0 R/K 35516 0 R>> endobj 21989 0 obj <>/Alt(EPCLUSA ORAL TABLET 400-100 MG)/P 7863 0 R/K 35517 0 R>> endobj 21990 0 obj <>/Alt(\(sofosbuvir-velpatasvir\))/P 7863 0 R/K 35518 0 R>> endobj 21991 0 obj <>/Alt(Tier 2)/P 7863 0 R/K 35519 0 R>> endobj 21992 0 obj <>/Alt(PA; SP)/P 7863 0 R/K 35520 0 R>> endobj 21993 0 obj <>/Alt(HARVONI ORAL PELLETS IN PACKET 33.75-150 MG, 45-200 MG)/P 7864 0 R/K 35521 0 R>> endobj 21994 0 obj <>/Alt(Tier 2)/P 7864 0 R/K 35522 0 R>> endobj 21995 0 obj <>/Alt(PA; SP)/P 7864 0 R/K 35523 0 R>> endobj 21996 0 obj <>/Alt(HARVONI ORAL TABLET 45-200 MG)/P 7865 0 R/K 35524 0 R>> endobj 21997 0 obj <>/Alt(Tier 2)/P 7865 0 R/K 35525 0 R>> endobj 21998 0 obj <>/Alt(PA; SP)/P 7865 0 R/K 35526 0 R>> endobj 21999 0 obj <>/Alt(HARVONI ORAL TABLET 90-400 MG)/P 7866 0 R/K 35527 0 R>> endobj 22000 0 obj <>/Alt(\(ledipasvir-sofosbuvir\))/P 7866 0 R/K 35528 0 R>> endobj 22001 0 obj <>/Alt(Tier 2)/P 7866 0 R/K 35529 0 R>> endobj 22002 0 obj <>/Alt(PA; SP)/P 7866 0 R/K 35530 0 R>> endobj 22003 0 obj <>/Alt(\(Begin bold\) Hep C Virus,Nucleotide Analog Ns5b Polymerase Inh \(End bold\))/P 7867 0 R/K 35531 0 R>> endobj 22004 0 obj <>/Alt(SOVALDI ORAL PELLETS IN PACKET 150 MG, 200 MG)/P 7868 0 R/K 35532 0 R>> endobj 22005 0 obj <>/Alt(Tier 3)/P 7868 0 R/K 35533 0 R>> endobj 22006 0 obj <>/Alt(PA; SP)/P 7868 0 R/K 35534 0 R>> endobj 22007 0 obj <>/Alt(SOVALDI ORAL TABLET 200 MG, 400 MG)/P 7869 0 R/K 35535 0 R>> endobj 22008 0 obj <>/Alt(Tier 3)/P 7869 0 R/K 35536 0 R>> endobj 22009 0 obj <>/Alt(PA; SP)/P 7869 0 R/K 35537 0 R>> endobj 22010 0 obj <>/Alt(\(Begin bold\) Hepatitis B Treatment Agents \(End bold\))/P 7870 0 R/K 35538 0 R>> endobj 22011 0 obj <>/Alt(\(Begin italic\) adefovir oral tablet \(End italic\) \(Begin italic\) 10 mg \(End italic\))/P 7871 0 R/K 35539 0 R>> endobj 22012 0 obj <>/Alt(\(Hepsera\))/P 7871 0 R/K 35540 0 R>> endobj 22013 0 obj <>/Alt(Tier 1)/P 7871 0 R/K 35541 0 R>> endobj 22014 0 obj <>/Alt(SP; QL \(1 EA per 1 day\))/P 7871 0 R/K 35542 0 R>> endobj 22015 0 obj <>/Alt(BARACLUDE ORAL SOLUTION 0.05 MG/ML)/P 7872 0 R/K 35543 0 R>> endobj 22016 0 obj <>/Alt(Tier 2)/P 7872 0 R/K 35544 0 R>> endobj 22017 0 obj <>/Alt(SP; QL \(630 ML per 30 days\))/P 7872 0 R/K 35545 0 R>> endobj 22018 0 obj <>/Alt(\(Begin italic\) entecavir oral tablet \(End italic\) \(Begin italic\) 0.5 mg, 1 mg \(End italic\))/P 7873 0 R/K 35546 0 R>> endobj 22019 0 obj <>/Alt(\(Baraclude\))/P 7873 0 R/K 35547 0 R>> endobj 22020 0 obj <>/Alt(Tier 1)/P 7873 0 R/K 35548 0 R>> endobj 22021 0 obj <>/Alt(SP; QL \(1 EA per 1 day\))/P 7873 0 R/K 35549 0 R>> endobj 22022 0 obj <>/Alt(\(Begin italic\) lamivudine oral tablet \(End italic\) \(Begin italic\) 100 mg \(End italic\))/P 7874 0 R/K 35550 0 R>> endobj 22023 0 obj <>/Alt(Tier 1)/P 7874 0 R/K 35551 0 R>> endobj 22024 0 obj <>/Alt(QL \(1 EA per 1 day\))/P 7874 0 R/K 35552 0 R>> endobj 22025 0 obj <>/Alt(VEMLIDY ORAL TABLET 25 MG)/P 7875 0 R/K 35553 0 R>> endobj 22026 0 obj <>/Alt(Tier 2)/P 7875 0 R/K 35554 0 R>> endobj 22027 0 obj <>/Alt(SP; QL \(1 EA per 1 day\))/P 7875 0 R/K 35555 0 R>> endobj 22028 0 obj <>/Alt(\(Begin bold\) Hepatitis C Treatment Agents \(End bold\))/P 7876 0 R/K 35556 0 R>> endobj 22029 0 obj <>/Alt(PEGASYS SUBCUTANEOUS SOLUTION 180 MCG/ML)/P 7877 0 R/K 35557 0 R>> endobj 22030 0 obj <>/Alt(Tier 2)/P 7877 0 R/K 35558 0 R>> endobj 22031 0 obj <>/Alt(PA; SP)/P 7877 0 R/K 35559 0 R>> endobj 22032 0 obj <>/Alt(PEGASYS SUBCUTANEOUS SYRINGE 180 MCG/0.5 ML)/P 7878 0 R/K 35560 0 R>> endobj 22033 0 obj <>/Alt(Tier 2)/P 7878 0 R/K 35561 0 R>> endobj 22034 0 obj <>/Alt(PA; SP)/P 7878 0 R/K 35562 0 R>> endobj 22035 0 obj <>/Alt(\(Begin italic\) ribavirin oral capsule \(End italic\) \(Begin italic\) 200 mg \(End italic\))/P 7879 0 R/K 35563 0 R>> endobj 22036 0 obj <>/Alt(Tier 1)/P 7879 0 R/K 35564 0 R>> endobj 22037 0 obj <>/Alt(\(Begin italic\) ribavirin oral tablet \(End italic\) \(Begin italic\) 200 mg \(End italic\))/P 7880 0 R/K 35565 0 R>> endobj 22038 0 obj <>/Alt(Tier 1)/P 7880 0 R/K 35566 0 R>> endobj 22039 0 obj <>/Alt(\(Begin bold\) Hepatitis C Virus- Ns5a And Ns3/4A Inhibitor Comb \(End bold\))/P 7881 0 R/K 35567 0 R>> endobj 22040 0 obj <>/Alt(MAVYRET ORAL PELLETS IN PACKET 50-20 MG)/P 7882 0 R/K 35568 0 R>> endobj 22041 0 obj <>/Alt(Tier 3)/P 7882 0 R/K 35569 0 R>> endobj 22042 0 obj <>/Alt(PA; SP)/P 7882 0 R/K 35570 0 R>> endobj 22043 0 obj <>/Alt(MAVYRET ORAL TABLET 100-40 MG)/P 7883 0 R/K 35571 0 R>> endobj 22044 0 obj <>/Alt(Tier 3)/P 7883 0 R/K 35572 0 R>> endobj 22045 0 obj <>/Alt(PA; SP)/P 7883 0 R/K 35573 0 R>> endobj 22046 0 obj <>/Alt(\(Begin bold\) Inflammatory Disease \(End bold\))/P 7884 0 R/K 35574 0 R>> endobj 22047 0 obj <>/Alt(\(Begin bold\) Anti-Arthritic And Chelating Agents \(End bold\))/P 7885 0 R/K 35575 0 R>> endobj 22048 0 obj <>/Alt(CUPRIMINE ORAL CAPSULE 250 MG)/P 7886 0 R/K 35576 0 R>> endobj 22049 0 obj <>/Alt(\(penicillamine\))/P 7886 0 R/K 35577 0 R>> endobj 22050 0 obj <>/Alt(Tier 3)/P 7886 0 R/K 35578 0 R>> endobj 22051 0 obj <>/Alt(PA; SP)/P 7886 0 R/K 35579 0 R>> endobj 22052 0 obj <>/Alt(D-PENAMINE ORAL TABLET 125 MG)/P 7887 0 R/K 35580 0 R>> endobj 22053 0 obj <>/Alt(Tier 1)/P 7887 0 R/K 35581 0 R>> endobj 22054 0 obj <>/Alt(PA; SP)/P 7887 0 R/K 35582 0 R>> endobj 22055 0 obj <>/Alt(\(Begin italic\) penicillamine oral capsule \(End italic\) \(Begin italic\) 250 mg \(End italic\))/P 7888 0 R/K 35583 0 R>> endobj 22056 0 obj <>/Alt(\(Cuprimine\))/P 7888 0 R/K 35584 0 R>> endobj 22057 0 obj <>/Alt(Tier 1)/P 7888 0 R/K 35585 0 R>> endobj 22058 0 obj <>/Alt(PA; SP)/P 7888 0 R/K 35586 0 R>> endobj 22059 0 obj <>/Alt(\(Begin italic\) penicillamine oral tablet \(End italic\) \(Begin italic\) 250 mg \(End italic\))/P 7889 0 R/K 35587 0 R>> endobj 22060 0 obj <>/Alt(\(Depen Titratabs\))/P 7889 0 R/K 35588 0 R>> endobj 22061 0 obj <>/Alt(Tier 1)/P 7889 0 R/K 35589 0 R>> endobj 22062 0 obj <>/Alt(PA; SP)/P 7889 0 R/K 35590 0 R>> endobj 22063 0 obj <>/Alt(\(Begin bold\) Anti-Arthritic, Folate Antagonist Agents \(End bold\))/P 7890 0 R/K 35591 0 R>> endobj 22064 0 obj <>/Alt(OTREXUP \(PF\) SUBCUTANEOUS AUTO-INJECTOR 10 MG/0.4 ML, 12.5 MG/0.4 ML, 15 MG/0.4 ML, 17.5 MG/0.4 ML, 20 MG/0.4 ML, 22.5 MG/0.4 ML, 25 MG/0.4 ML)/P 7891 0 R/K 35592 0 R>> endobj 22065 0 obj <>/Alt(Tier 2)/P 7891 0 R/K 35593 0 R>> endobj 22066 0 obj <>/Alt(QL \(1.6 ML per 28 days\))/P 7891 0 R/K 35594 0 R>> endobj 22067 0 obj <>/Alt(\(Begin bold\) Anti-Flam. Interleukin-1 Receptor Antagonist \(End bold\))/P 7892 0 R/K 35595 0 R>> endobj 22068 0 obj <>/Alt(ARCALYST SUBCUTANEOUS RECON SOLN 220 MG)/P 7893 0 R/K 35596 0 R>> endobj 22069 0 obj <>/Alt(Tier 3)/P 7893 0 R/K 35597 0 R>> endobj 22070 0 obj <>/Alt(PA; SP)/P 7893 0 R/K 35598 0 R>> endobj 22071 0 obj <>/Alt(KINERET SUBCUTANEOUS SYRINGE 100 MG/0.67 ML)/P 7894 0 R/K 35599 0 R>> endobj 22072 0 obj <>/Alt(Tier 3)/P 7894 0 R/K 35600 0 R>> endobj 22073 0 obj <>/Alt(PA; SP)/P 7894 0 R/K 35601 0 R>> endobj 22074 0 obj <>/Alt(\(Begin bold\) Anti-Inflammatory Tumor Necrosis Factor Inhibitor \(End bold\))/P 7895 0 R/K 35602 0 R>> endobj 22075 0 obj <>/Alt(\(Begin italic\) adalimumab-adaz subcutaneous pen injector \(End italic\) \(Begin italic\) 40 mg/0.4 ml \(End italic\))/P 7896 0 R/K 35603 0 R>> endobj 22076 0 obj <>/Alt(\(Hyrimoz\(CF\) Pen\))/P 7896 0 R/K 35604 0 R>> endobj 22077 0 obj <>/Alt(Tier 2)/P 7896 0 R/K 35605 0 R>> endobj 22078 0 obj <>/Alt(PA; SP)/P 7896 0 R/K 35606 0 R>> endobj 22079 0 obj <>/Alt(\(Begin italic\) adalimumab-adaz subcutaneous pen injector \(End italic\) \(Begin italic\) 80 mg/0.8 ml \(End italic\))/P 7897 0 R/K 35607 0 R>> endobj 22080 0 obj <>/Alt(\(Hyrimoz Pen Crohn's-UC Starter\))/P 7897 0 R/K 35608 0 R>> endobj 22081 0 obj <>/Alt(Tier 2)/P 7897 0 R/K 35609 0 R>> endobj 22082 0 obj <>/Alt(PA; SP)/P 7897 0 R/K 35610 0 R>> endobj 22083 0 obj <>/Alt(\(Begin italic\) adalimumab-adaz subcutaneous syringe \(End italic\) \(Begin italic\) 20 mg/0.2 ml, 40 mg/0.4 ml \(End italic\))/P 7898 0 R/K 35611 0 R>> endobj 22084 0 obj <>/Alt(\(Hyrimoz\(CF\)\))/P 7898 0 R/K 35612 0 R>> endobj 22085 0 obj <>/Alt(Tier 2)/P 7898 0 R/K 35613 0 R>> endobj 22086 0 obj <>/Alt(PA; SP)/P 7898 0 R/K 35614 0 R>> endobj 22087 0 obj <>/Alt(CIMZIA POWDER FOR RECONST SUBCUTANEOUS KIT 400 MG \(200 MG X 2 VIALS\))/P 7899 0 R/K 35615 0 R>> endobj 22088 0 obj <>/Alt(Tier 3)/P 7899 0 R/K 35616 0 R>> endobj 22089 0 obj <>/Alt(PA; SP)/P 7899 0 R/K 35617 0 R>> endobj 22090 0 obj <>/Alt(CIMZIA STARTER KIT SUBCUTANEOUS SYRINGE KIT 400 MG/2 ML \(200 MG/ML X 2\))/P 7900 0 R/K 35618 0 R>> endobj 22091 0 obj <>/Alt(Tier 3)/P 7900 0 R/K 35619 0 R>> endobj 22092 0 obj <>/Alt(PA; SP)/P 7900 0 R/K 35620 0 R>> endobj 22093 0 obj <>/Alt(CIMZIA SUBCUTANEOUS SYRINGE KIT 200 MG/ML, 400 MG/2 ML \(200 MG/ML X 2\))/P 7901 0 R/K 35621 0 R>> endobj 22094 0 obj <>/Alt(Tier 3)/P 7901 0 R/K 35622 0 R>> endobj 22095 0 obj <>/Alt(PA; 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0 R>> endobj 22332 0 obj <>/Alt(XELJANZ ORAL TABLET 10 MG, 5 MG)/P 7993 0 R/K 35860 0 R>> endobj 22333 0 obj <>/Alt(Tier 2)/P 7993 0 R/K 35861 0 R>> endobj 22334 0 obj <>/Alt(PA; SP)/P 7993 0 R/K 35862 0 R>> endobj 22335 0 obj <>/Alt(XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HR 11 MG, 22 MG)/P 7994 0 R/K 35863 0 R>> endobj 22336 0 obj <>/Alt(Tier 2)/P 7994 0 R/K 35864 0 R>> endobj 22337 0 obj <>/Alt(PA; SP)/P 7994 0 R/K 35865 0 R>> endobj 22338 0 obj <>/Alt(\(Begin bold\) Mineralocorticoids \(End bold\))/P 7995 0 R/K 35866 0 R>> endobj 22339 0 obj <>/Alt(\(Begin italic\) fludrocortisone oral tablet \(End italic\) \(Begin italic\) 0.1 mg \(End italic\))/P 7996 0 R/K 35867 0 R>> endobj 22340 0 obj <>/Alt(Tier 1)/P 7996 0 R/K 35868 0 R>> endobj 22341 0 obj <>/Alt(\(Begin bold\) Monoclonal Antibody-Human Interleukin 12/23 Inhib \(End bold\))/P 7997 0 R/K 35869 0 R>> endobj 22342 0 obj <>/Alt(SELARSDI SUBCUTANEOUS SYRINGE 45 MG/0.5 ML, 90 MG/ML)/P 7998 0 R/K 35870 0 R>> endobj 22343 0 obj 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obj <>/Alt(EC-NAPROXEN ORAL TABLET,DELAYED RELEASE \(DR/EC\) 375 MG, 500 MG)/P 8012 0 R/K 35903 0 R>> endobj 22376 0 obj <>/Alt(\(naproxen\))/P 8012 0 R/K 35904 0 R>> endobj 22377 0 obj <>/Alt(Tier 1)/P 8012 0 R/K 35905 0 R>> endobj 22378 0 obj <>/Alt(\(Begin italic\) etodolac oral capsule \(End italic\) \(Begin italic\) 200 mg, 300 mg \(End italic\))/P 8013 0 R/K 35906 0 R>> endobj 22379 0 obj <>/Alt(Tier 1)/P 8013 0 R/K 35907 0 R>> endobj 22380 0 obj <>/Alt(\(Begin italic\) etodolac oral tablet \(End italic\) \(Begin italic\) 400 mg \(End italic\))/P 8014 0 R/K 35908 0 R>> endobj 22381 0 obj <>/Alt(\(Lodine\))/P 8014 0 R/K 35909 0 R>> endobj 22382 0 obj <>/Alt(Tier 1)/P 8014 0 R/K 35910 0 R>> endobj 22383 0 obj <>/Alt(\(Begin italic\) etodolac oral tablet \(End italic\) \(Begin italic\) 500 mg \(End italic\))/P 8015 0 R/K 35911 0 R>> endobj 22384 0 obj <>/Alt(Tier 1)/P 8015 0 R/K 35912 0 R>> endobj 22385 0 obj <>/Alt(\(Begin italic\) etodolac oral tablet extended release 24 hr \(End 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0 R/K 35923 0 R>> endobj 22396 0 obj <>/Alt(\(IBU\))/P 8020 0 R/K 35924 0 R>> endobj 22397 0 obj <>/Alt(Tier 1)/P 8020 0 R/K 35925 0 R>> endobj 22398 0 obj <>/Alt(\(Begin italic\) indomethacin oral capsule \(End italic\) \(Begin italic\) 25 mg, 50 mg \(End italic\))/P 8021 0 R/K 35926 0 R>> endobj 22399 0 obj <>/Alt(Tier 1)/P 8021 0 R/K 35927 0 R>> endobj 22400 0 obj <>/Alt(\(Begin italic\) indomethacin oral capsule, extended release \(End italic\) \(Begin italic\) 75 mg \(End italic\))/P 8022 0 R/K 35928 0 R>> endobj 22401 0 obj <>/Alt(Tier 1)/P 8022 0 R/K 35929 0 R>> endobj 22402 0 obj <>/Alt(\(Begin italic\) indomethacin rectal suppository \(End italic\) \(Begin italic\) 100 mg \(End italic\))/P 8023 0 R/K 35930 0 R>> endobj 22403 0 obj <>/Alt(Tier 1)/P 8023 0 R/K 35931 0 R>> endobj 22404 0 obj <>/Alt(\(Begin italic\) ketoprofen oral capsule \(End italic\) \(Begin italic\) 25 mg \(End italic\))/P 8024 0 R/K 35932 0 R>> endobj 22405 0 obj <>/Alt(\(Kiprofen\))/P 8024 0 R/K 35933 0 R>> endobj 22406 0 obj <>/Alt(Tier 1)/P 8024 0 R/K 35934 0 R>> endobj 22407 0 obj <>/Alt(\(Begin italic\) ketoprofen oral capsule \(End italic\) \(Begin italic\) 50 mg, 75 mg \(End italic\))/P 8025 0 R/K 35935 0 R>> endobj 22408 0 obj <>/Alt(Tier 1)/P 8025 0 R/K 35936 0 R>> endobj 22409 0 obj <>/Alt(\(Begin italic\) ketoprofen oral capsule,ext rel. pellets 24 hr \(End italic\) \(Begin italic\) 200 mg \(End italic\))/P 8026 0 R/K 35937 0 R>> endobj 22410 0 obj <>/Alt(Tier 1)/P 8026 0 R/K 35938 0 R>> endobj 22411 0 obj <>/Alt(\(Begin italic\) ketorolac injection solution \(End italic\) \(Begin italic\) 15 mg/ml, 30 mg/ml, 30 mg/ml \(1 ml\) \(End italic\))/P 8027 0 R/K 35939 0 R>> endobj 22412 0 obj <>/Alt(Tier 1)/P 8027 0 R/K 35940 0 R>> endobj 22413 0 obj <>/Alt(\(Begin italic\) ketorolac injection syringe \(End italic\) \(Begin italic\) 15 mg/ml, 30 mg/ml \(End italic\))/P 8028 0 R/K 35941 0 R>> endobj 22414 0 obj <>/Alt(Tier 1)/P 8028 0 R/K 35942 0 R>> endobj 22415 0 obj <>/Alt(\(Begin italic\) ketorolac intramuscular solution \(End italic\) \(Begin italic\) 60 mg/2 ml \(End italic\))/P 8029 0 R/K 35943 0 R>> endobj 22416 0 obj <>/Alt(Tier 1)/P 8029 0 R/K 35944 0 R>> endobj 22417 0 obj <>/Alt(\(Begin italic\) ketorolac intramuscular syringe \(End italic\) \(Begin italic\) 60 mg/2 ml \(End italic\))/P 8030 0 R/K 35945 0 R>> endobj 22418 0 obj <>/Alt(Tier 1)/P 8030 0 R/K 35946 0 R>> endobj 22419 0 obj <>/Alt(\(Begin italic\) ketorolac oral tablet \(End italic\) \(Begin italic\) 10 mg \(End italic\))/P 8031 0 R/K 35947 0 R>> endobj 22420 0 obj <>/Alt(Tier 1)/P 8031 0 R/K 35948 0 R>> endobj 22421 0 obj <>/Alt(QL \(20 EA per 5 days\))/P 8031 0 R/K 35949 0 R>> endobj 22422 0 obj <>/Alt(KIPROFEN ORAL CAPSULE 25 MG)/P 8032 0 R/K 35950 0 R>> endobj 22423 0 obj <>/Alt(\(ketoprofen\))/P 8032 0 R/K 35951 0 R>> endobj 22424 0 obj <>/Alt(Tier 1)/P 8032 0 R/K 35952 0 R>> endobj 22425 0 obj <>/Alt(\(Begin italic\) meclofenamate oral capsule \(End italic\) \(Begin italic\) 100 mg, 50 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naproxen oral tablet \(End italic\) \(Begin italic\) 250 mg, 375 mg \(End italic\))/P 8038 0 R/K 35963 0 R>> endobj 22436 0 obj <>/Alt(Tier 1)/P 8038 0 R/K 35964 0 R>> endobj 22437 0 obj <>/Alt(\(Begin italic\) naproxen oral tablet \(End italic\) \(Begin italic\) 500 mg \(End italic\))/P 8039 0 R/K 35965 0 R>> endobj 22438 0 obj <>/Alt(\(Naprosyn\))/P 8039 0 R/K 35966 0 R>> endobj 22439 0 obj <>/Alt(Tier 1)/P 8039 0 R/K 35967 0 R>> endobj 22440 0 obj <>/Alt(\(Begin italic\) naproxen oral tablet,delayed release \(dr/ec\) \(End italic\) \(Begin italic\) 375 mg, 500 mg \(End italic\))/P 8040 0 R/K 35968 0 R>> endobj 22441 0 obj <>/Alt(\(EC-Naproxen\))/P 8040 0 R/K 35969 0 R>> endobj 22442 0 obj <>/Alt(Tier 1)/P 8040 0 R/K 35970 0 R>> endobj 22443 0 obj <>/Alt(\(Begin italic\) naproxen sodium oral tablet \(End italic\) \(Begin italic\) 275 mg \(End italic\))/P 8041 0 R/K 35971 0 R>> endobj 22444 0 obj <>/Alt(Tier 1)/P 8041 0 R/K 35972 0 R>> endobj 22445 0 obj <>/Alt(\(Begin italic\) naproxen sodium oral tablet \(End italic\) \(Begin italic\) 550 mg \(End italic\))/P 8042 0 R/K 35973 0 R>> endobj 22446 0 obj <>/Alt(\(Anaprox DS\))/P 8042 0 R/K 35974 0 R>> endobj 22447 0 obj <>/Alt(Tier 1)/P 8042 0 R/K 35975 0 R>> endobj 22448 0 obj <>/Alt(\(Begin italic\) oxaprozin oral tablet \(End italic\) \(Begin italic\) 600 mg \(End italic\))/P 8043 0 R/K 35976 0 R>> endobj 22449 0 obj <>/Alt(\(Daypro\))/P 8043 0 R/K 35977 0 R>> endobj 22450 0 obj <>/Alt(Tier 1)/P 8043 0 R/K 35978 0 R>> endobj 22451 0 obj <>/Alt(\(Begin italic\) piroxicam oral capsule \(End italic\) \(Begin italic\) 10 mg \(End italic\))/P 8044 0 R/K 35979 0 R>> endobj 22452 0 obj <>/Alt(Tier 1)/P 8044 0 R/K 35980 0 R>> endobj 22453 0 obj <>/Alt(\(Begin italic\) piroxicam oral capsule \(End italic\) \(Begin italic\) 20 mg \(End italic\))/P 8045 0 R/K 35981 0 R>> endobj 22454 0 obj <>/Alt(\(Feldene\))/P 8045 0 R/K 35982 0 R>> endobj 22455 0 obj <>/Alt(Tier 1)/P 8045 0 R/K 35983 0 R>> endobj 22456 0 obj 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8061 0 R/K 36018 0 R>> endobj 22491 0 obj <>/Alt(Tier 1)/P 8061 0 R/K 36019 0 R>> endobj 22492 0 obj <>/Alt(MARVONA SUIK \(PF\) KIT 0.5 % \(5 MG/ML\))/P 8062 0 R/K 36020 0 R>> endobj 22493 0 obj <>/Alt(Tier 3)/P 8062 0 R/K 36021 0 R>> endobj 22494 0 obj <>/Alt(\(Begin bold\) Periodontal Anesthetics \(End bold\))/P 8063 0 R/K 36022 0 R>> endobj 22495 0 obj <>/Alt(ORAQIX DENTAL CARTRIDGE 2.5-2.5 %)/P 8064 0 R/K 36023 0 R>> endobj 22496 0 obj <>/Alt(Tier 3)/P 8064 0 R/K 36024 0 R>> endobj 22497 0 obj <>/Alt(\(Begin bold\) Lower Gastrointestinal Disorders - Bowel Inflammat \(End bold\))/P 8065 0 R/K 36025 0 R>> endobj 22498 0 obj <>/Alt(\(Begin bold\) Chronic Inflam. 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<>/Alt(\(Azulfidine\))/P 8078 0 R/K 36057 0 R>> endobj 22530 0 obj <>/Alt(Tier 1)/P 8078 0 R/K 36058 0 R>> endobj 22531 0 obj <>/Alt(\(Begin italic\) sulfasalazine oral tablet,delayed release \(dr/ec\) \(End italic\) \(Begin italic\) 500 mg \(End italic\))/P 8079 0 R/K 36059 0 R>> endobj 22532 0 obj <>/Alt(\(Azulfidine EN-tabs\))/P 8079 0 R/K 36060 0 R>> endobj 22533 0 obj <>/Alt(Tier 1)/P 8079 0 R/K 36061 0 R>> endobj 22534 0 obj <>/Alt(\(Begin bold\) Hemorrhoidal Prep, Anti-Infam Steroid/Local Anesth \(End bold\))/P 8080 0 R/K 36062 0 R>> endobj 22535 0 obj <>/Alt(ANA-LEX KIT RECTAL KIT 2-2 %)/P 8081 0 R/K 36063 0 R>> endobj 22536 0 obj <>/Alt(Tier 1)/P 8081 0 R/K 36064 0 R>> endobj 22537 0 obj <>/Alt(\(Begin italic\) hydrocortisone-pramoxine rectal cream \(End italic\) \(Begin italic\) 1-1 %, 2.5-1 % \(End italic\))/P 8082 0 R/K 36065 0 R>> endobj 22538 0 obj <>/Alt(\(Analpram-HC\))/P 8082 0 R/K 36066 0 R>> endobj 22539 0 obj <>/Alt(Tier 1)/P 8082 0 R/K 36067 0 R>> endobj 22540 0 obj <>/Alt(\(Begin italic\) hydrocortisone-pramoxine rectal cream \(End italic\) \(Begin italic\) 2.5-1 % \(4g\) \(End italic\))/P 8083 0 R/K 36068 0 R>> endobj 22541 0 obj <>/Alt(Tier 1)/P 8083 0 R/K 36069 0 R>> endobj 22542 0 obj <>/Alt(\(Begin italic\) lidocaine hcl-hydrocortison ac rectal cream \(End italic\) \(Begin italic\) 3-0.5 % \(End italic\))/P 8084 0 R/K 36070 0 R>> endobj 22543 0 obj <>/Alt(Tier 1)/P 8084 0 R/K 36071 0 R>> endobj 22544 0 obj <>/Alt(\(Begin italic\) lidocaine hcl-hydrocortison ac rectal gel \(End italic\) \(Begin italic\) 3 %-2.5 % \(7 gram\) \(End italic\))/P 8085 0 R/K 36072 0 R>> endobj 22545 0 obj <>/Alt(Tier 1)/P 8085 0 R/K 36073 0 R>> endobj 22546 0 obj <>/Alt(\(Begin italic\) lidocaine hcl-hydrocortison ac rectal kit \(End italic\) \(Begin italic\) 2 %-2 % \(7 gram\), 3-0.5 %, 3-1 % \(7 gram\), 3-2.5 % \(7 gram\) \(End italic\))/P 8086 0 R/K 36074 0 R>> endobj 22547 0 obj <>/Alt(Tier 1)/P 8086 0 R/K 36075 0 R>> endobj 22548 0 obj <>/Alt(\(Begin italic\) lidocaine-hydrocortisone-aloe rectal gel \(End italic\) \(Begin italic\) 2.8-0.55 % \(End italic\))/P 8087 0 R/K 36076 0 R>> endobj 22549 0 obj <>/Alt(Tier 1)/P 8087 0 R/K 36077 0 R>> endobj 22550 0 obj <>/Alt(\(Begin italic\) lidocaine-hydrocortisone-aloe rectal kit \(End italic\) \(Begin italic\) 3-2.5 % \(7 gram\) \(End italic\))/P 8088 0 R/K 36078 0 R>> endobj 22551 0 obj <>/Alt(Tier 1)/P 8088 0 R/K 36079 0 R>> endobj 22552 0 obj <>/Alt(PROCORT RECTAL CREAM 1.85-1.15 %)/P 8089 0 R/K 36080 0 R>> endobj 22553 0 obj <>/Alt(Tier 3)/P 8089 0 R/K 36081 0 R>> endobj 22554 0 obj <>/Alt(PROCTOFOAM HC RECTAL FOAM 1-1 %)/P 8090 0 R/K 36082 0 R>> endobj 22555 0 obj <>/Alt(Tier 2)/P 8090 0 R/K 36083 0 R>> endobj 22556 0 obj <>/Alt(ZYPRAM RECTAL KIT,CREAM AND TOWELETTE 2.35-1 %)/P 8091 0 R/K 36084 0 R>> endobj 22557 0 obj <>/Alt(Tier 3)/P 8091 0 R/K 36085 0 R>> endobj 22558 0 obj <>/Alt(\(Begin bold\) Ibs Agents,Mixed Opioid Recep Agonists/Antagonists \(End bold\))/P 8092 0 R/K 36086 0 R>> endobj 22559 0 obj <>/Alt(VIBERZI ORAL TABLET 100 MG, 75 MG)/P 8093 0 R/K 36087 0 R>> endobj 22560 0 obj <>/Alt(Tier 2)/P 8093 0 R/K 36088 0 R>> endobj 22561 0 obj <>/Alt(\(Begin bold\) Integrin Receptor Antagonist, Monoclonal Antibody \(End bold\))/P 8094 0 R/K 36089 0 R>> endobj 22562 0 obj <>/Alt(ENTYVIO PEN SUBCUTANEOUS PEN INJECTOR 108 MG/0.68 ML)/P 8095 0 R/K 36090 0 R>> endobj 22563 0 obj <>/Alt(Tier 3)/P 8095 0 R/K 36091 0 R>> endobj 22564 0 obj <>/Alt(PA; SP)/P 8095 0 R/K 36092 0 R>> endobj 22565 0 obj <>/Alt(\(Begin bold\) Irritable Bowel Agents,Guanylate Cylase-C Agonist \(End bold\))/P 8096 0 R/K 36093 0 R>> endobj 22566 0 obj <>/Alt(LINZESS ORAL CAPSULE 145 MCG, 290 MCG, 72 MCG)/P 8097 0 R/K 36094 0 R>> endobj 22567 0 obj <>/Alt(Tier 2)/P 8097 0 R/K 36095 0 R>> endobj 22568 0 obj <>/Alt(QL \(1 EA per 1 day\))/P 8097 0 R/K 36096 0 R>> endobj 22569 0 obj <>/Alt(TRULANCE ORAL TABLET 3 MG)/P 8098 0 R/K 36097 0 R>> endobj 22570 0 obj <>/Alt(Tier 2)/P 8098 0 R/K 36098 0 R>> endobj 22571 0 obj <>/Alt(QL \(1 EA per 1 day\))/P 8098 0 R/K 36099 0 R>> endobj 22572 0 obj <>/Alt(\(Begin bold\) Local Anorectal Nitrate Preparations \(End bold\))/P 8099 0 R/K 36100 0 R>> endobj 22573 0 obj <>/Alt(\(Begin italic\) nitroglycerin rectal ointment \(End italic\) \(Begin italic\) 0.4 % \(w/w\) \(End italic\))/P 8100 0 R/K 36101 0 R>> endobj 22574 0 obj <>/Alt(\(Rectiv\))/P 8100 0 R/K 36102 0 R>> endobj 22575 0 obj <>/Alt(Tier 1)/P 8100 0 R/K 36103 0 R>> endobj 22576 0 obj <>/Alt(\(Begin bold\) Rectal Preparations \(End bold\))/P 8101 0 R/K 36104 0 R>> endobj 22577 0 obj <>/Alt(ANUCORT-HC RECTAL SUPPOSITORY 25 MG)/P 8102 0 R/K 36105 0 R>> endobj 22578 0 obj <>/Alt(\(hydrocortisone acetate\))/P 8102 0 R/K 36106 0 R>> endobj 22579 0 obj <>/Alt(Tier 1)/P 8102 0 R/K 36107 0 R>> endobj 22580 0 obj <>/Alt(\(Begin italic\) hydrocortisone acetate rectal suppository \(End italic\) \(Begin italic\) 25 mg \(End italic\))/P 8103 0 R/K 36108 0 R>> endobj 22581 0 obj <>/Alt(\(Anucort-HC\))/P 8103 0 R/K 36109 0 R>> endobj 22582 0 obj <>/Alt(Tier 1)/P 8103 0 R/K 36110 0 R>> endobj 22583 0 obj <>/Alt(\(Begin italic\) hydrocortisone acetate rectal suppository \(End italic\) \(Begin italic\) 30 mg \(End italic\))/P 8104 0 R/K 36111 0 R>> endobj 22584 0 obj <>/Alt(\(Hemmorex-HC\))/P 8104 0 R/K 36112 0 R>> endobj 22585 0 obj <>/Alt(Tier 1)/P 8104 0 R/K 36113 0 R>> endobj 22586 0 obj <>/Alt(\(Begin bold\) Rectal/Lower Bowel Prep.,Glucocort. \(Non-Hemorr\) \(End bold\))/P 8105 0 R/K 36114 0 R>> endobj 22587 0 obj <>/Alt(\(Begin italic\) budesonide rectal foam \(End italic\) \(Begin italic\) 2 mg/actuation \(End italic\))/P 8106 0 R/K 36115 0 R>> endobj 22588 0 obj <>/Alt(\(Uceris\))/P 8106 0 R/K 36116 0 R>> endobj 22589 0 obj <>/Alt(Tier 1)/P 8106 0 R/K 36117 0 R>> endobj 22590 0 obj <>/Alt(CORTIFOAM RECTAL FOAM 10 % \(80 MG\))/P 8107 0 R/K 36118 0 R>> endobj 22591 0 obj <>/Alt(Tier 3)/P 8107 0 R/K 36119 0 R>> endobj 22592 0 obj <>/Alt(\(Begin italic\) hydrocortisone rectal enema \(End italic\) \(Begin italic\) 100 mg/60 ml \(End italic\))/P 8108 0 R/K 36120 0 R>> endobj 22593 0 obj <>/Alt(\(Cortenema\))/P 8108 0 R/K 36121 0 R>> endobj 22594 0 obj <>/Alt(Tier 1)/P 8108 0 R/K 36122 0 R>> endobj 22595 0 obj <>/Alt(\(Begin bold\) Lower Gastrointestinal Disorders - Other \(End bold\))/P 8109 0 R/K 36123 0 R>> endobj 22596 0 obj <>/Alt(\(Begin bold\) Ammonia Inhibitors \(End bold\))/P 8110 0 R/K 36124 0 R>> endobj 22597 0 obj <>/Alt(CARBAGLU ORAL TABLET, DISPERSIBLE 200 MG)/P 8111 0 R/K 36125 0 R>> endobj 22598 0 obj <>/Alt(\(carglumic acid\))/P 8111 0 R/K 36126 0 R>> endobj 22599 0 obj <>/Alt(Tier 3)/P 8111 0 R/K 36127 0 R>> endobj 22600 0 obj <>/Alt(PA; SP)/P 8111 0 R/K 36128 0 R>> endobj 22601 0 obj <>/Alt(\(Begin italic\) carglumic acid oral tablet, dispersible \(End italic\) \(Begin italic\) 200 mg \(End italic\))/P 8112 0 R/K 36129 0 R>> endobj 22602 0 obj <>/Alt(\(Carbaglu\))/P 8112 0 R/K 36130 0 R>> endobj 22603 0 obj <>/Alt(Tier 1)/P 8112 0 R/K 36131 0 R>> endobj 22604 0 obj <>/Alt(PA; SP)/P 8112 0 R/K 36132 0 R>> endobj 22605 0 obj <>/Alt(ENULOSE ORAL SOLUTION 10 GRAM/15 ML)/P 8113 0 R/K 36133 0 R>> endobj 22606 0 obj <>/Alt(\(lactulose\))/P 8113 0 R/K 36134 0 R>> endobj 22607 0 obj <>/Alt(Tier 1)/P 8113 0 R/K 36135 0 R>> endobj 22608 0 obj <>/Alt(GENERLAC ORAL SOLUTION 10 GRAM/15 ML)/P 8114 0 R/K 36136 0 R>> endobj 22609 0 obj <>/Alt(\(lactulose\))/P 8114 0 R/K 36137 0 R>> endobj 22610 0 obj <>/Alt(Tier 1)/P 8114 0 R/K 36138 0 R>> endobj 22611 0 obj <>/Alt(LITHOSTAT ORAL TABLET 250 MG)/P 8115 0 R/K 36139 0 R>> endobj 22612 0 obj <>/Alt(Tier 3)/P 8115 0 R/K 36140 0 R>> endobj 22613 0 obj <>/Alt(OLPRUVA ORAL PELLETS IN PACKET 2 GRAM, 3 GRAM, 4 GRAM, 5 GRAM, 6 GRAM, 6.67 GRAM)/P 8116 0 R/K 36141 0 R>> endobj 22614 0 obj <>/Alt(Tier 3)/P 8116 0 R/K 36142 0 R>> endobj 22615 0 obj <>/Alt(PA; SP)/P 8116 0 R/K 36143 0 R>> endobj 22616 0 obj <>/Alt(PHEBURANE ORAL GRANULES 483 MG/GRAM)/P 8117 0 R/K 36144 0 R>> endobj 22617 0 obj <>/Alt(Tier 3)/P 8117 0 R/K 36145 0 R>> endobj 22618 0 obj <>/Alt(PA; SP)/P 8117 0 R/K 36146 0 R>> endobj 22619 0 obj <>/Alt(RAVICTI ORAL LIQUID 1.1 GRAM/ML)/P 8118 0 R/K 36147 0 R>> endobj 22620 0 obj <>/Alt(Tier 3)/P 8118 0 R/K 36148 0 R>> endobj 22621 0 obj <>/Alt(PA; SP)/P 8118 0 R/K 36149 0 R>> endobj 22622 0 obj <>/Alt(\(Begin italic\) sodium phenylbutyrate oral powder \(End italic\) \(Begin italic\) 0.94 gram/gram \(End italic\))/P 8119 0 R/K 36150 0 R>> endobj 22623 0 obj <>/Alt(\(Buphenyl\))/P 8119 0 R/K 36151 0 R>> endobj 22624 0 obj <>/Alt(Tier 1)/P 8119 0 R/K 36152 0 R>> endobj 22625 0 obj <>/Alt(PA; SP)/P 8119 0 R/K 36153 0 R>> endobj 22626 0 obj <>/Alt(\(Begin italic\) sodium phenylbutyrate oral tablet \(End italic\) \(Begin italic\) 500 mg \(End italic\))/P 8120 0 R/K 36154 0 R>> endobj 22627 0 obj <>/Alt(\(Buphenyl\))/P 8120 0 R/K 36155 0 R>> endobj 22628 0 obj <>/Alt(Tier 1)/P 8120 0 R/K 36156 0 R>> endobj 22629 0 obj <>/Alt(PA; SP)/P 8120 0 R/K 36157 0 R>> endobj 22630 0 obj <>/Alt(\(Begin bold\) Antidiarrheal - G.I. 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endobj 23711 0 obj <>/Alt(\(Hydrea\))/P 8554 0 R/K 37239 0 R>> endobj 23712 0 obj <>/Alt(Tier 1)/P 8554 0 R/K 37240 0 R>> endobj 23713 0 obj <>/Alt(LEUKERAN ORAL TABLET 2 MG)/P 8555 0 R/K 37241 0 R>> endobj 23714 0 obj <>/Alt(Tier 2)/P 8555 0 R/K 37242 0 R>> endobj 23715 0 obj <>/Alt(SP)/P 8555 0 R/K 37243 0 R>> endobj 23716 0 obj <>/Alt(MYLERAN ORAL TABLET 2 MG)/P 8556 0 R/K 37244 0 R>> endobj 23717 0 obj <>/Alt(Tier 2)/P 8556 0 R/K 37245 0 R>> endobj 23718 0 obj <>/Alt(SP)/P 8556 0 R/K 37246 0 R>> endobj 23719 0 obj <>/Alt(\(Begin italic\) temozolomide oral capsule \(End italic\) \(Begin italic\) 100 mg, 140 mg, 180 mg, 20 mg, 250 mg, 5 mg \(End italic\))/P 8557 0 R/K 37247 0 R>> endobj 23720 0 obj <>/Alt(Tier 1)/P 8557 0 R/K 37248 0 R>> endobj 23721 0 obj <>/Alt(PA; SP)/P 8557 0 R/K 37249 0 R>> endobj 23722 0 obj <>/Alt(\(Begin bold\) Antiandrogenic Agents \(End bold\))/P 8558 0 R/K 37250 0 R>> endobj 23723 0 obj <>/Alt(\(Begin italic\) abiraterone oral tablet \(End italic\) \(Begin italic\) 250 mg \(End italic\))/P 8559 0 R/K 37251 0 R>> endobj 23724 0 obj <>/Alt(\(Abirtega\))/P 8559 0 R/K 37252 0 R>> endobj 23725 0 obj <>/Alt(Tier 1)/P 8559 0 R/K 37253 0 R>> endobj 23726 0 obj <>/Alt(PA; SP)/P 8559 0 R/K 37254 0 R>> endobj 23727 0 obj <>/Alt(\(Begin italic\) abiraterone oral tablet \(End italic\) \(Begin italic\) 500 mg \(End italic\))/P 8560 0 R/K 37255 0 R>> endobj 23728 0 obj <>/Alt(\(Zytiga\))/P 8560 0 R/K 37256 0 R>> endobj 23729 0 obj <>/Alt(Tier 1)/P 8560 0 R/K 37257 0 R>> endobj 23730 0 obj <>/Alt(PA; SP)/P 8560 0 R/K 37258 0 R>> endobj 23731 0 obj <>/Alt(\(Begin italic\) bicalutamide oral tablet \(End italic\) \(Begin italic\) 50 mg \(End italic\))/P 8561 0 R/K 37259 0 R>> endobj 23732 0 obj <>/Alt(\(Casodex\))/P 8561 0 R/K 37260 0 R>> endobj 23733 0 obj <>/Alt(Tier 1)/P 8561 0 R/K 37261 0 R>> endobj 23734 0 obj <>/Alt(ERLEADA ORAL TABLET 240 MG, 60 MG)/P 8562 0 R/K 37262 0 R>> endobj 23735 0 obj <>/Alt(Tier 2)/P 8562 0 R/K 37263 0 R>> endobj 23736 0 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0 obj <>/Alt(YONSA ORAL TABLET 125 MG)/P 8567 0 R/K 37278 0 R>> endobj 23751 0 obj <>/Alt(Tier 3)/P 8567 0 R/K 37279 0 R>> endobj 23752 0 obj <>/Alt(PA; SP)/P 8567 0 R/K 37280 0 R>> endobj 23753 0 obj <>/Alt(\(Begin bold\) Antibiotic Antineoplastics \(End bold\))/P 8568 0 R/K 37281 0 R>> endobj 23754 0 obj <>/Alt(JELMYTO INTRA-PYELOCALYCEAL KIT 40 MG X 2)/P 8569 0 R/K 37282 0 R>> endobj 23755 0 obj <>/Alt(Tier 3)/P 8569 0 R/K 37283 0 R>> endobj 23756 0 obj <>/Alt(PA; SP)/P 8569 0 R/K 37284 0 R>> endobj 23757 0 obj <>/Alt(\(Begin bold\) Antimetabolites \(End bold\))/P 8570 0 R/K 37285 0 R>> endobj 23758 0 obj <>/Alt(\(Begin italic\) capecitabine oral tablet \(End italic\) \(Begin italic\) 150 mg, 500 mg \(End italic\))/P 8571 0 R/K 37286 0 R>> endobj 23759 0 obj <>/Alt(\(Xeloda\))/P 8571 0 R/K 37287 0 R>> endobj 23760 0 obj <>/Alt(Tier 1)/P 8571 0 R/K 37288 0 R>> endobj 23761 0 obj <>/Alt(PA; SP)/P 8571 0 R/K 37289 0 R>> endobj 23762 0 obj <>/Alt(INQOVI ORAL TABLET 35-100 MG)/P 8572 0 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R>> endobj 23807 0 obj <>/Alt(\(Femara\))/P 8588 0 R/K 37335 0 R>> endobj 23808 0 obj <>/Alt(Tier 1)/P 8588 0 R/K 37336 0 R>> endobj 23809 0 obj <>/Alt(\(Begin bold\) Antineoplastic - Braf Kinase Inhibitors \(End bold\))/P 8589 0 R/K 37337 0 R>> endobj 23810 0 obj <>/Alt(BRAFTOVI ORAL CAPSULE 75 MG)/P 8590 0 R/K 37338 0 R>> endobj 23811 0 obj <>/Alt(Tier 2)/P 8590 0 R/K 37339 0 R>> endobj 23812 0 obj <>/Alt(PA; SP)/P 8590 0 R/K 37340 0 R>> endobj 23813 0 obj <>/Alt(OJEMDA ORAL SUSPENSION FOR RECONSTITUTION 25 MG/ML)/P 8591 0 R/K 37341 0 R>> endobj 23814 0 obj <>/Alt(Tier 3)/P 8591 0 R/K 37342 0 R>> endobj 23815 0 obj <>/Alt(PA; SP)/P 8591 0 R/K 37343 0 R>> endobj 23816 0 obj <>/Alt(OJEMDA ORAL TABLET 400 MG/WEEK \(100 MG X 4\), 500 MG/WEEK \(100 MG X 5\), 600 MG/WEEK \(100 MG X 6\))/P 8592 0 R/K 37344 0 R>> endobj 23817 0 obj <>/Alt(Tier 3)/P 8592 0 R/K 37345 0 R>> endobj 23818 0 obj <>/Alt(PA; SP)/P 8592 0 R/K 37346 0 R>> endobj 23819 0 obj <>/Alt(TAFINLAR ORAL CAPSULE 50 MG, 75 MG)/P 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0 obj <>/Alt(Tier 2)/P 8609 0 R/K 37388 0 R>> endobj 23861 0 obj <>/Alt(PA; SP)/P 8609 0 R/K 37389 0 R>> endobj 23862 0 obj <>/Alt(MEKINIST ORAL RECON SOLN 0.05 MG/ML)/P 8610 0 R/K 37390 0 R>> endobj 23863 0 obj <>/Alt(Tier 2)/P 8610 0 R/K 37391 0 R>> endobj 23864 0 obj <>/Alt(PA; SP)/P 8610 0 R/K 37392 0 R>> endobj 23865 0 obj <>/Alt(MEKINIST ORAL TABLET 0.5 MG, 2 MG)/P 8611 0 R/K 37393 0 R>> endobj 23866 0 obj <>/Alt(Tier 2)/P 8611 0 R/K 37394 0 R>> endobj 23867 0 obj <>/Alt(PA; SP)/P 8611 0 R/K 37395 0 R>> endobj 23868 0 obj <>/Alt(MEKTOVI ORAL TABLET 15 MG)/P 8612 0 R/K 37396 0 R>> endobj 23869 0 obj <>/Alt(Tier 2)/P 8612 0 R/K 37397 0 R>> endobj 23870 0 obj <>/Alt(PA; SP)/P 8612 0 R/K 37398 0 R>> endobj 23871 0 obj <>/Alt(\(Begin bold\) Antineoplastic - Mtor Kinase Inhibitors \(End bold\))/P 8613 0 R/K 37399 0 R>> endobj 23872 0 obj <>/Alt(\(Begin italic\) everolimus \(antineoplastic\) oral tablet \(End italic\) \(Begin italic\) 10 mg, 2.5 mg, 5 mg, 7.5 mg \(End italic\))/P 8614 0 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R/K 37412 0 R>> endobj 23885 0 obj <>/Alt(TAZVERIK ORAL TABLET 200 MG)/P 8618 0 R/K 37413 0 R>> endobj 23886 0 obj <>/Alt(Tier 2)/P 8618 0 R/K 37414 0 R>> endobj 23887 0 obj <>/Alt(PA; SP)/P 8618 0 R/K 37415 0 R>> endobj 23888 0 obj <>/Alt(\(Begin bold\) Antineoplastic - Topoisomerase I Inhibitors \(End bold\))/P 8619 0 R/K 37416 0 R>> endobj 23889 0 obj <>/Alt(HYCAMTIN ORAL CAPSULE 0.25 MG, 1 MG)/P 8620 0 R/K 37417 0 R>> endobj 23890 0 obj <>/Alt(Tier 2)/P 8620 0 R/K 37418 0 R>> endobj 23891 0 obj <>/Alt(SP)/P 8620 0 R/K 37419 0 R>> endobj 23892 0 obj <>/Alt(\(Begin bold\) Antineoplastic Immunomodulator Agents \(End bold\))/P 8621 0 R/K 37420 0 R>> endobj 23893 0 obj <>/Alt(\(Begin italic\) lenalidomide oral capsule \(End italic\) \(Begin italic\) 10 mg, 15 mg, 2.5 mg, 20 mg, 25 mg, 5 mg \(End italic\))/P 8622 0 R/K 37421 0 R>> endobj 23894 0 obj <>/Alt(\(Revlimid\))/P 8622 0 R/K 37422 0 R>> endobj 23895 0 obj <>/Alt(Tier 1)/P 8622 0 R/K 37423 0 R>> endobj 23896 0 obj <>/Alt(PA; SP)/P 8622 0 R/K 37424 0 R>> endobj 23897 0 obj <>/Alt(POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG)/P 8623 0 R/K 37425 0 R>> endobj 23898 0 obj <>/Alt(Tier 2)/P 8623 0 R/K 37426 0 R>> endobj 23899 0 obj <>/Alt(PA; SP)/P 8623 0 R/K 37427 0 R>> endobj 23900 0 obj <>/Alt(REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 20 MG, 25 MG, 5 MG)/P 8624 0 R/K 37428 0 R>> endobj 23901 0 obj <>/Alt(\(lenalidomide\))/P 8624 0 R/K 37429 0 R>> endobj 23902 0 obj <>/Alt(Tier 2)/P 8624 0 R/K 37430 0 R>> endobj 23903 0 obj <>/Alt(PA; SP)/P 8624 0 R/K 37431 0 R>> endobj 23904 0 obj <>/Alt(\(Begin bold\) Antineoplastic Lhrh\(Gnrh\) Antagonist,Pituit.Supprs \(End bold\))/P 8625 0 R/K 37432 0 R>> endobj 23905 0 obj <>/Alt(FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 120 MG)/P 8626 0 R/K 37433 0 R>> endobj 23906 0 obj <>/Alt(Tier 3)/P 8626 0 R/K 37434 0 R>> endobj 23907 0 obj <>/Alt(QL \(2 EA per 365 days\))/P 8626 0 R/K 37435 0 R>> endobj 23908 0 obj <>/Alt(FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON 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37449 0 R>> endobj 23922 0 obj <>/Alt(Tier 3)/P 8632 0 R/K 37450 0 R>> endobj 23923 0 obj <>/Alt(PA; SP)/P 8632 0 R/K 37451 0 R>> endobj 23924 0 obj <>/Alt(ALUNBRIG ORAL TABLETS,DOSE PACK 90 MG \(7\)- 180 MG \(23\))/P 8633 0 R/K 37452 0 R>> endobj 23925 0 obj <>/Alt(Tier 3)/P 8633 0 R/K 37453 0 R>> endobj 23926 0 obj <>/Alt(PA; SP)/P 8633 0 R/K 37454 0 R>> endobj 23927 0 obj <>/Alt(AUGTYRO ORAL CAPSULE 160 MG, 40 MG)/P 8634 0 R/K 37455 0 R>> endobj 23928 0 obj <>/Alt(Tier 2)/P 8634 0 R/K 37456 0 R>> endobj 23929 0 obj <>/Alt(PA; SP)/P 8634 0 R/K 37457 0 R>> endobj 23930 0 obj <>/Alt(AYVAKIT ORAL TABLET 100 MG, 200 MG, 25 MG, 300 MG, 50 MG)/P 8635 0 R/K 37458 0 R>> endobj 23931 0 obj <>/Alt(Tier 2)/P 8635 0 R/K 37459 0 R>> endobj 23932 0 obj <>/Alt(PA; SP)/P 8635 0 R/K 37460 0 R>> endobj 23933 0 obj <>/Alt(BALVERSA ORAL TABLET 3 MG, 4 MG, 5 MG)/P 8636 0 R/K 37461 0 R>> endobj 23934 0 obj <>/Alt(Tier 2)/P 8636 0 R/K 37462 0 R>> endobj 23935 0 obj <>/Alt(PA; SP)/P 8636 0 R/K 37463 0 R>> 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8645 0 R/K 37491 0 R>> endobj 23964 0 obj <>/Alt(\(Begin italic\) dasatinib oral tablet \(End italic\) \(Begin italic\) 100 mg, 140 mg, 20 mg, 50 mg, 70 mg, 80 mg \(End italic\))/P 8646 0 R/K 37492 0 R>> endobj 23965 0 obj <>/Alt(\(Sprycel\))/P 8646 0 R/K 37493 0 R>> endobj 23966 0 obj <>/Alt(Tier 1)/P 8646 0 R/K 37494 0 R>> endobj 23967 0 obj <>/Alt(PA; SP)/P 8646 0 R/K 37495 0 R>> endobj 23968 0 obj <>/Alt(\(Begin italic\) erlotinib oral tablet \(End italic\) \(Begin italic\) 100 mg \(End italic\))/P 8647 0 R/K 37496 0 R>> endobj 23969 0 obj <>/Alt(\(Tarceva\))/P 8647 0 R/K 37497 0 R>> endobj 23970 0 obj <>/Alt(Tier 1)/P 8647 0 R/K 37498 0 R>> endobj 23971 0 obj <>/Alt(PA; SP)/P 8647 0 R/K 37499 0 R>> endobj 23972 0 obj <>/Alt(\(Begin italic\) erlotinib oral tablet \(End italic\) \(Begin italic\) 150 mg, 25 mg \(End italic\))/P 8648 0 R/K 37500 0 R>> endobj 23973 0 obj <>/Alt(Tier 1)/P 8648 0 R/K 37501 0 R>> endobj 23974 0 obj <>/Alt(PA; SP)/P 8648 0 R/K 37502 0 R>> endobj 23975 0 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37516 0 R>> endobj 23989 0 obj <>/Alt(Tier 2)/P 8653 0 R/K 37517 0 R>> endobj 23990 0 obj <>/Alt(PA; SP)/P 8653 0 R/K 37518 0 R>> endobj 23991 0 obj <>/Alt(IBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG)/P 8654 0 R/K 37519 0 R>> endobj 23992 0 obj <>/Alt(Tier 3)/P 8654 0 R/K 37520 0 R>> endobj 23993 0 obj <>/Alt(PA; SP)/P 8654 0 R/K 37521 0 R>> endobj 23994 0 obj <>/Alt(IBRANCE ORAL TABLET 100 MG, 125 MG, 75 MG)/P 8655 0 R/K 37522 0 R>> endobj 23995 0 obj <>/Alt(Tier 3)/P 8655 0 R/K 37523 0 R>> endobj 23996 0 obj <>/Alt(PA; SP)/P 8655 0 R/K 37524 0 R>> endobj 23997 0 obj <>/Alt(ICLUSIG ORAL TABLET 10 MG, 15 MG, 30 MG, 45 MG)/P 8656 0 R/K 37525 0 R>> endobj 23998 0 obj <>/Alt(Tier 2)/P 8656 0 R/K 37526 0 R>> endobj 23999 0 obj <>/Alt(PA; SP)/P 8656 0 R/K 37527 0 R>> endobj 24000 0 obj <>/Alt(\(Begin italic\) imatinib oral tablet \(End italic\) \(Begin italic\) 100 mg, 400 mg \(End italic\))/P 8657 0 R/K 37528 0 R>> endobj 24001 0 obj <>/Alt(\(Gleevec\))/P 8657 0 R/K 37529 0 R>> endobj 24002 0 obj <>/Alt(Tier 1)/P 8657 0 R/K 37530 0 R>> endobj 24003 0 obj <>/Alt(PA; SP)/P 8657 0 R/K 37531 0 R>> endobj 24004 0 obj <>/Alt(IMBRUVICA ORAL CAPSULE 140 MG, 70 MG)/P 8658 0 R/K 37532 0 R>> endobj 24005 0 obj <>/Alt(Tier 2)/P 8658 0 R/K 37533 0 R>> endobj 24006 0 obj <>/Alt(PA; SP)/P 8658 0 R/K 37534 0 R>> endobj 24007 0 obj <>/Alt(IMBRUVICA ORAL SUSPENSION 70 MG/ML)/P 8659 0 R/K 37535 0 R>> endobj 24008 0 obj <>/Alt(Tier 2)/P 8659 0 R/K 37536 0 R>> endobj 24009 0 obj <>/Alt(PA; SP)/P 8659 0 R/K 37537 0 R>> endobj 24010 0 obj <>/Alt(IMBRUVICA ORAL TABLET 140 MG, 280 MG, 420 MG)/P 8660 0 R/K 37538 0 R>> endobj 24011 0 obj <>/Alt(Tier 2)/P 8660 0 R/K 37539 0 R>> endobj 24012 0 obj <>/Alt(PA; SP)/P 8660 0 R/K 37540 0 R>> endobj 24013 0 obj <>/Alt(IMKELDI ORAL SOLUTION 80 MG/ML)/P 8661 0 R/K 37541 0 R>> endobj 24014 0 obj <>/Alt(Tier 3)/P 8661 0 R/K 37542 0 R>> endobj 24015 0 obj <>/Alt(PA; SP)/P 8661 0 R/K 37543 0 R>> endobj 24016 0 obj <>/Alt(INLYTA ORAL TABLET 1 MG, 5 MG)/P 8662 0 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X 1\), 400 MG/DAY \(200 MG X 2\), 600 MG/DAY \(200 MG X 3\))/P 8667 0 R/K 37559 0 R>> endobj 24032 0 obj <>/Alt(Tier 2)/P 8667 0 R/K 37560 0 R>> endobj 24033 0 obj <>/Alt(PA; SP)/P 8667 0 R/K 37561 0 R>> endobj 24034 0 obj <>/Alt(\(Begin italic\) lapatinib oral tablet \(End italic\) \(Begin italic\) 250 mg \(End italic\))/P 8668 0 R/K 37562 0 R>> endobj 24035 0 obj <>/Alt(\(Tykerb\))/P 8668 0 R/K 37563 0 R>> endobj 24036 0 obj <>/Alt(Tier 1)/P 8668 0 R/K 37564 0 R>> endobj 24037 0 obj <>/Alt(PA; SP)/P 8668 0 R/K 37565 0 R>> endobj 24038 0 obj <>/Alt(LAZCLUZE ORAL TABLET 240 MG, 80 MG)/P 8669 0 R/K 37566 0 R>> endobj 24039 0 obj <>/Alt(Tier 3)/P 8669 0 R/K 37567 0 R>> endobj 24040 0 obj <>/Alt(PA; SP)/P 8669 0 R/K 37568 0 R>> endobj 24041 0 obj <>/Alt(LENVIMA ORAL CAPSULE 10 MG/DAY \(10 MG X 1\), 12 MG/DAY \(4 MG X 3\), 14 MG/DAY\(10 MG X 1-4 MG X 1\), 18 MG/DAY \(10 MG X 1-4 MG X2\), 20 MG/DAY \(10 MG X 2\), 24 MG/DAY\(10 MG X 2-4 MG X 1\), 4 MG, 8 MG/DAY \(4 MG X 2\))/P 8670 0 R/K 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endobj 24056 0 obj <>/Alt(NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 MG)/P 8675 0 R/K 37584 0 R>> endobj 24057 0 obj <>/Alt(Tier 2)/P 8675 0 R/K 37585 0 R>> endobj 24058 0 obj <>/Alt(PA; SP)/P 8675 0 R/K 37586 0 R>> endobj 24059 0 obj <>/Alt(OGSIVEO ORAL TABLET 100 MG, 150 MG, 50 MG)/P 8676 0 R/K 37587 0 R>> endobj 24060 0 obj <>/Alt(Tier 3)/P 8676 0 R/K 37588 0 R>> endobj 24061 0 obj <>/Alt(PA; SP)/P 8676 0 R/K 37589 0 R>> endobj 24062 0 obj <>/Alt(OJJAARA ORAL TABLET 100 MG, 150 MG, 200 MG)/P 8677 0 R/K 37590 0 R>> endobj 24063 0 obj <>/Alt(Tier 2)/P 8677 0 R/K 37591 0 R>> endobj 24064 0 obj <>/Alt(PA; SP)/P 8677 0 R/K 37592 0 R>> endobj 24065 0 obj <>/Alt(\(Begin italic\) pazopanib oral tablet \(End italic\) \(Begin italic\) 200 mg \(End italic\))/P 8678 0 R/K 37593 0 R>> endobj 24066 0 obj <>/Alt(\(Votrient\))/P 8678 0 R/K 37594 0 R>> endobj 24067 0 obj <>/Alt(Tier 1)/P 8678 0 R/K 37595 0 R>> endobj 24068 0 obj <>/Alt(PA; SP)/P 8678 0 R/K 37596 0 R>> endobj 24069 0 obj <>/Alt(PEMAZYRE 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R>> endobj 24097 0 obj <>/Alt(Tier 3)/P 8688 0 R/K 37625 0 R>> endobj 24098 0 obj <>/Alt(PA; SP)/P 8688 0 R/K 37626 0 R>> endobj 24099 0 obj <>/Alt(RYDAPT ORAL CAPSULE 25 MG)/P 8689 0 R/K 37627 0 R>> endobj 24100 0 obj <>/Alt(Tier 2)/P 8689 0 R/K 37628 0 R>> endobj 24101 0 obj <>/Alt(PA; SP)/P 8689 0 R/K 37629 0 R>> endobj 24102 0 obj <>/Alt(SCEMBLIX ORAL TABLET 100 MG, 20 MG, 40 MG)/P 8690 0 R/K 37630 0 R>> endobj 24103 0 obj <>/Alt(Tier 2)/P 8690 0 R/K 37631 0 R>> endobj 24104 0 obj <>/Alt(PA; SP)/P 8690 0 R/K 37632 0 R>> endobj 24105 0 obj <>/Alt(\(Begin italic\) sorafenib oral tablet \(End italic\) \(Begin italic\) 200 mg \(End italic\))/P 8691 0 R/K 37633 0 R>> endobj 24106 0 obj <>/Alt(\(Nexavar\))/P 8691 0 R/K 37634 0 R>> endobj 24107 0 obj <>/Alt(Tier 1)/P 8691 0 R/K 37635 0 R>> endobj 24108 0 obj <>/Alt(PA; SP)/P 8691 0 R/K 37636 0 R>> endobj 24109 0 obj <>/Alt(STIVARGA ORAL TABLET 40 MG)/P 8692 0 R/K 37637 0 R>> endobj 24110 0 obj <>/Alt(Tier 2)/P 8692 0 R/K 37638 0 R>> endobj 24111 0 obj <>/Alt(PA; SP)/P 8692 0 R/K 37639 0 R>> endobj 24112 0 obj <>/Alt(\(Begin italic\) sunitinib malate oral capsule \(End italic\) \(Begin italic\) 12.5 mg, 25 mg, 37.5 mg, 50 mg \(End italic\))/P 8693 0 R/K 37640 0 R>> endobj 24113 0 obj <>/Alt(\(Sutent\))/P 8693 0 R/K 37641 0 R>> endobj 24114 0 obj <>/Alt(Tier 1)/P 8693 0 R/K 37642 0 R>> endobj 24115 0 obj <>/Alt(PA; SP)/P 8693 0 R/K 37643 0 R>> endobj 24116 0 obj <>/Alt(TABRECTA ORAL TABLET 150 MG, 200 MG)/P 8694 0 R/K 37644 0 R>> endobj 24117 0 obj <>/Alt(Tier 2)/P 8694 0 R/K 37645 0 R>> endobj 24118 0 obj <>/Alt(PA; SP)/P 8694 0 R/K 37646 0 R>> endobj 24119 0 obj <>/Alt(TAGRISSO ORAL TABLET 40 MG, 80 MG)/P 8695 0 R/K 37647 0 R>> endobj 24120 0 obj <>/Alt(Tier 2)/P 8695 0 R/K 37648 0 R>> endobj 24121 0 obj <>/Alt(PA; SP)/P 8695 0 R/K 37649 0 R>> endobj 24122 0 obj <>/Alt(TALZENNA ORAL CAPSULE 0.1 MG, 0.25 MG, 0.35 MG, 0.5 MG, 0.75 MG, 1 MG)/P 8696 0 R/K 37650 0 R>> endobj 24123 0 obj <>/Alt(Tier 2)/P 8696 0 R/K 37651 0 R>> endobj 24124 0 obj <>/Alt(PA; SP)/P 8696 0 R/K 37652 0 R>> endobj 24125 0 obj <>/Alt(TASIGNA ORAL CAPSULE 150 MG, 200 MG, 50 MG)/P 8697 0 R/K 37653 0 R>> endobj 24126 0 obj <>/Alt(Tier 2)/P 8697 0 R/K 37654 0 R>> endobj 24127 0 obj <>/Alt(PA; SP)/P 8697 0 R/K 37655 0 R>> endobj 24128 0 obj <>/Alt(TEPMETKO ORAL TABLET 225 MG)/P 8698 0 R/K 37656 0 R>> endobj 24129 0 obj <>/Alt(Tier 2)/P 8698 0 R/K 37657 0 R>> endobj 24130 0 obj <>/Alt(PA; SP)/P 8698 0 R/K 37658 0 R>> endobj 24131 0 obj <>/Alt(TRUQAP ORAL TABLET 160 MG, 200 MG)/P 8699 0 R/K 37659 0 R>> endobj 24132 0 obj <>/Alt(Tier 2)/P 8699 0 R/K 37660 0 R>> endobj 24133 0 obj <>/Alt(PA; SP)/P 8699 0 R/K 37661 0 R>> endobj 24134 0 obj <>/Alt(TUKYSA ORAL TABLET 150 MG, 50 MG)/P 8700 0 R/K 37662 0 R>> endobj 24135 0 obj <>/Alt(Tier 2)/P 8700 0 R/K 37663 0 R>> endobj 24136 0 obj <>/Alt(PA; SP)/P 8700 0 R/K 37664 0 R>> endobj 24137 0 obj <>/Alt(TURALIO ORAL CAPSULE 125 MG)/P 8701 0 R/K 37665 0 R>> endobj 24138 0 obj <>/Alt(Tier 2)/P 8701 0 R/K 37666 0 R>> endobj 24139 0 obj <>/Alt(PA; SP)/P 8701 0 R/K 37667 0 R>> endobj 24140 0 obj <>/Alt(VANFLYTA ORAL TABLET 17.7 MG, 26.5 MG)/P 8702 0 R/K 37668 0 R>> endobj 24141 0 obj <>/Alt(Tier 2)/P 8702 0 R/K 37669 0 R>> endobj 24142 0 obj <>/Alt(PA; SP)/P 8702 0 R/K 37670 0 R>> endobj 24143 0 obj <>/Alt(VERZENIO ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG)/P 8703 0 R/K 37671 0 R>> endobj 24144 0 obj <>/Alt(Tier 2)/P 8703 0 R/K 37672 0 R>> endobj 24145 0 obj <>/Alt(PA; SP)/P 8703 0 R/K 37673 0 R>> endobj 24146 0 obj <>/Alt(VITRAKVI ORAL CAPSULE 100 MG, 25 MG)/P 8704 0 R/K 37674 0 R>> endobj 24147 0 obj <>/Alt(Tier 2)/P 8704 0 R/K 37675 0 R>> endobj 24148 0 obj <>/Alt(PA; SP)/P 8704 0 R/K 37676 0 R>> endobj 24149 0 obj <>/Alt(VITRAKVI ORAL SOLUTION 20 MG/ML)/P 8705 0 R/K 37677 0 R>> endobj 24150 0 obj <>/Alt(Tier 2)/P 8705 0 R/K 37678 0 R>> endobj 24151 0 obj <>/Alt(PA; SP)/P 8705 0 R/K 37679 0 R>> endobj 24152 0 obj <>/Alt(VIZIMPRO ORAL TABLET 15 MG, 30 MG, 45 MG)/P 8706 0 R/K 37680 0 R>> endobj 24153 0 obj <>/Alt(Tier 2)/P 8706 0 R/K 37681 0 R>> endobj 24154 0 obj <>/Alt(PA; SP)/P 8706 0 R/K 37682 0 R>> endobj 24155 0 obj <>/Alt(VONJO ORAL CAPSULE 100 MG)/P 8707 0 R/K 37683 0 R>> endobj 24156 0 obj <>/Alt(Tier 2)/P 8707 0 R/K 37684 0 R>> endobj 24157 0 obj <>/Alt(PA; SP)/P 8707 0 R/K 37685 0 R>> endobj 24158 0 obj <>/Alt(XALKORI ORAL CAPSULE 200 MG, 250 MG)/P 8708 0 R/K 37686 0 R>> endobj 24159 0 obj <>/Alt(Tier 2)/P 8708 0 R/K 37687 0 R>> endobj 24160 0 obj <>/Alt(PA; SP)/P 8708 0 R/K 37688 0 R>> endobj 24161 0 obj <>/Alt(XALKORI ORAL PELLET 150 MG, 20 MG, 50 MG)/P 8709 0 R/K 37689 0 R>> endobj 24162 0 obj <>/Alt(Tier 2)/P 8709 0 R/K 37690 0 R>> endobj 24163 0 obj <>/Alt(PA; SP)/P 8709 0 R/K 37691 0 R>> endobj 24164 0 obj <>/Alt(XOSPATA ORAL TABLET 40 MG)/P 8710 0 R/K 37692 0 R>> endobj 24165 0 obj <>/Alt(Tier 2)/P 8710 0 R/K 37693 0 R>> endobj 24166 0 obj <>/Alt(PA; SP)/P 8710 0 R/K 37694 0 R>> endobj 24167 0 obj <>/Alt(ZEJULA ORAL TABLET 100 MG, 200 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obj <>/Alt(\(Begin italic\) tretinoin \(antineoplastic\) oral capsule \(End italic\) \(Begin italic\) 10 mg \(End italic\))/P 8733 0 R/K 37748 0 R>> endobj 24221 0 obj <>/Alt(Tier 1)/P 8733 0 R/K 37749 0 R>> endobj 24222 0 obj <>/Alt(SP)/P 8733 0 R/K 37750 0 R>> endobj 24223 0 obj <>/Alt(\(Begin bold\) Antineoplastic-Select Inhib Of Nuclear Exp \(Sine\) \(End bold\))/P 8734 0 R/K 37751 0 R>> endobj 24224 0 obj <>/Alt(XPOVIO ORAL TABLET 100 MG/WEEK \(50 MG X 2\), 40 MG/WEEK \(40 MG X 1\), 40MG TWICE WEEK \(40 MG X 2\), 60 MG/WEEK \(60 MG X 1\), 60MG TWICE WEEK \(120 MG/WEEK\), 80 MG/WEEK \(40 MG X 2\), 80MG TWICE WEEK \(160 MG/WEEK\))/P 8735 0 R/K 37752 0 R>> endobj 24225 0 obj <>/Alt(Tier 2)/P 8735 0 R/K 37753 0 R>> endobj 24226 0 obj <>/Alt(PA; SP)/P 8735 0 R/K 37754 0 R>> endobj 24227 0 obj <>/Alt(\(Begin bold\) Chemotherapy Rescue/Antidote Agents \(End bold\))/P 8736 0 R/K 37755 0 R>> endobj 24228 0 obj <>/Alt(\(Begin italic\) leucovorin calcium oral tablet \(End italic\) \(Begin italic\) 10 mg, 15 mg, 25 mg, 5 mg \(End italic\))/P 8737 0 R/K 37756 0 R>> endobj 24229 0 obj <>/Alt(Tier 1)/P 8737 0 R/K 37757 0 R>> endobj 24230 0 obj <>/Alt(\(Begin italic\) mesna oral tablet \(End italic\) \(Begin italic\) 400 mg \(End italic\))/P 8738 0 R/K 37758 0 R>> endobj 24231 0 obj <>/Alt(\(Mesnex\))/P 8738 0 R/K 37759 0 R>> endobj 24232 0 obj <>/Alt(Tier 1)/P 8738 0 R/K 37760 0 R>> endobj 24233 0 obj <>/Alt(VISTOGARD ORAL GRANULES IN PACKET 10 GRAM)/P 8739 0 R/K 37761 0 R>> endobj 24234 0 obj <>/Alt(Tier 2)/P 8739 0 R/K 37762 0 R>> endobj 24235 0 obj <>/Alt(SP; QL \(24 EA per 14 days\))/P 8739 0 R/K 37763 0 R>> endobj 24236 0 obj <>/Alt(\(Begin bold\) Intrapleural Sclerosing Agents, Antineoplast. 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8861 0 R/K 38056 0 R>> endobj 24529 0 obj <>/Alt(CARDIOPLEGIA IND 4:1 PLASMALYT PERFUSION SOLUTION 30 MEQ/542 ML \(POTASSIUM\))/P 8862 0 R/K 38057 0 R>> endobj 24530 0 obj <>/Alt(Tier 1)/P 8862 0 R/K 38058 0 R>> endobj 24531 0 obj <>/Alt(CARDIOPLEGIA IND 4:1 RINGER PERFUSION SOLUTION 48 MEQ/522.8 ML \(POTASSIUM\))/P 8863 0 R/K 38059 0 R>> endobj 24532 0 obj <>/Alt(Tier 1)/P 8863 0 R/K 38060 0 R>> endobj 24533 0 obj <>/Alt(CARDIOPLEGIA IND 8:1 NON-ENRCH PERFUSION SOLUTION 70 MEQ/300 ML \(POTASSIUM\))/P 8864 0 R/K 38061 0 R>> endobj 24534 0 obj <>/Alt(Tier 1)/P 8864 0 R/K 38062 0 R>> endobj 24535 0 obj <>/Alt(CARDIOPLEGIA INDUCTION 4:1 PERFUSION SOLUTION 30 MEQ/415 ML \(POTASSIUM\), 36 MEQ/500 ML \(POTASSIUM\), 60 MEQ/830 ML \(POTASSIUM\))/P 8865 0 R/K 38063 0 R>> endobj 24536 0 obj <>/Alt(Tier 1)/P 8865 0 R/K 38064 0 R>> endobj 24537 0 obj <>/Alt(CARDIOPLEGIA INDUCTION 8:1 PERFUSION SOLUTION 100 MEQ/500 ML \(POTASSIUM\))/P 8866 0 R/K 38065 0 R>> endobj 24538 0 obj <>/Alt(Tier 1)/P 8866 0 R/K 38066 0 R>> endobj 24539 0 obj <>/Alt(CARDIOPLEGIA MAIN 8:1 NO-ENRCH PERFUSION SOLUTION 24 MEQ/300 ML \(POTASSIUM\))/P 8867 0 R/K 38067 0 R>> endobj 24540 0 obj <>/Alt(Tier 1)/P 8867 0 R/K 38068 0 R>> endobj 24541 0 obj <>/Alt(CARDIOPLEGIA MAINT 4:1 PLASMA PERFUSION SOLUTION 30 MEQ/1,047 ML \(POTASSIUM\))/P 8868 0 R/K 38069 0 R>> endobj 24542 0 obj <>/Alt(Tier 3)/P 8868 0 R/K 38070 0 R>> endobj 24543 0 obj <>/Alt(CARDIOPLEGIA MAINT 4:1 RINGER PERFUSION SOLUTION 12 MEQ/504.8 ML \(POTASSIUM\))/P 8869 0 R/K 38071 0 R>> endobj 24544 0 obj <>/Alt(Tier 1)/P 8869 0 R/K 38072 0 R>> endobj 24545 0 obj <>/Alt(CARDIOPLEGIA MAINTENANCE 4:1 PERFUSION SOLUTION 20 MEQ/810 ML \(POTASSIUM\), 36 MEQ/L \(POTASSIUM\))/P 8870 0 R/K 38073 0 R>> endobj 24546 0 obj <>/Alt(Tier 1)/P 8870 0 R/K 38074 0 R>> endobj 24547 0 obj <>/Alt(CARDIOPLEGIA MAINTENANCE 8:1 PERFUSION SOLUTION 36 MEQ/500 ML \(POTASSIUM\))/P 8871 0 R/K 38075 0 R>> endobj 24548 0 obj <>/Alt(Tier 1)/P 8871 0 R/K 38076 0 R>> endobj 24549 0 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italic\))/P 8876 0 R/K 38085 0 R>> endobj 24558 0 obj <>/Alt(Tier 1)/P 8876 0 R/K 38086 0 R>> endobj 24559 0 obj <>/Alt(\(Begin italic\) cardioplegic soln perfusion solution \(End italic\) \(Begin italic\) 16 meq/l \(= k+\) \(End italic\))/P 8877 0 R/K 38087 0 R>> endobj 24560 0 obj <>/Alt(\(Plegisol\))/P 8877 0 R/K 38088 0 R>> endobj 24561 0 obj <>/Alt(Tier 1)/P 8877 0 R/K 38089 0 R>> endobj 24562 0 obj <>/Alt(\(Begin italic\) cardioplegic solution no.25 perfusion solution \(End italic\) \(Begin italic\) 29 mmol/l \(potassium\) \(End italic\))/P 8878 0 R/K 38090 0 R>> endobj 24563 0 obj <>/Alt(Tier 1)/P 8878 0 R/K 38091 0 R>> endobj 24564 0 obj <>/Alt(CUSTODIOL HTK PERFUSION SOLUTION 9 MMOL-198 MMOL -2 MMOL/L)/P 8879 0 R/K 38092 0 R>> endobj 24565 0 obj <>/Alt(Tier 3)/P 8879 0 R/K 38093 0 R>> endobj 24566 0 obj <>/Alt(\(Begin italic\) microplegic solution no.1 perfusion solution \(End italic\) \(Begin italic\) 7.84 %-8.56 % \(0.92 molar\) \(End italic\))/P 8880 0 R/K 38094 0 R>> 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38454 0 R>> endobj 24927 0 obj <>/Alt(Tier 3)/P 9037 0 R/K 38455 0 R>> endobj 24928 0 obj <>/Alt(\(Begin italic\) isopropyl alcohol solution \(End italic\) \(Begin italic\) 91 %, 99 % \(End italic\))/P 9038 0 R/K 38456 0 R>> endobj 24929 0 obj <>/Alt(Tier 3)/P 9038 0 R/K 38457 0 R>> endobj 24930 0 obj <>/Alt(MURI-LUBE OIL)/P 9039 0 R/K 38458 0 R>> endobj 24931 0 obj <>/Alt(Tier 3)/P 9039 0 R/K 38459 0 R>> endobj 24932 0 obj <>/Alt(\(Begin bold\) Somatostatic Agents \(End bold\))/P 9040 0 R/K 38460 0 R>> endobj 24933 0 obj <>/Alt(MYCAPSSA ORAL CAPSULE,DELAYED RELEASE\(DR/EC\) 20 MG)/P 9041 0 R/K 38461 0 R>> endobj 24934 0 obj <>/Alt(Tier 3)/P 9041 0 R/K 38462 0 R>> endobj 24935 0 obj <>/Alt(PA; SP)/P 9041 0 R/K 38463 0 R>> endobj 24936 0 obj <>/Alt(\(Begin italic\) octreotide acetate injection solution \(End italic\) \(Begin italic\) 1,000 mcg/ml, 200 mcg/ml \(End italic\))/P 9042 0 R/K 38464 0 R>> endobj 24937 0 obj <>/Alt(Tier 1)/P 9042 0 R/K 38465 0 R>> endobj 24938 0 obj 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<>/Alt(\(Begin bold\) Other Respiratory Disorders \(End bold\))/P 9062 0 R/K 38505 0 R>> endobj 24978 0 obj <>/Alt(\(Begin bold\) Antifibrotic Therapy - Pyridone Analogs \(End bold\))/P 9063 0 R/K 38506 0 R>> endobj 24979 0 obj <>/Alt(\(Begin italic\) pirfenidone oral capsule \(End italic\) \(Begin italic\) 267 mg \(End italic\))/P 9064 0 R/K 38507 0 R>> endobj 24980 0 obj <>/Alt(\(Esbriet\))/P 9064 0 R/K 38508 0 R>> endobj 24981 0 obj <>/Alt(Tier 1)/P 9064 0 R/K 38509 0 R>> endobj 24982 0 obj <>/Alt(PA; SP)/P 9064 0 R/K 38510 0 R>> endobj 24983 0 obj <>/Alt(\(Begin italic\) pirfenidone oral tablet \(End italic\) \(Begin italic\) 267 mg, 801 mg \(End italic\))/P 9065 0 R/K 38511 0 R>> endobj 24984 0 obj <>/Alt(\(Esbriet\))/P 9065 0 R/K 38512 0 R>> endobj 24985 0 obj <>/Alt(Tier 1)/P 9065 0 R/K 38513 0 R>> endobj 24986 0 obj <>/Alt(PA; SP)/P 9065 0 R/K 38514 0 R>> endobj 24987 0 obj <>/Alt(\(Begin italic\) pirfenidone oral tablet \(End italic\) \(Begin italic\) 534 mg \(End italic\))/P 9066 0 R/K 38515 0 R>> endobj 24988 0 obj <>/Alt(Tier 1)/P 9066 0 R/K 38516 0 R>> endobj 24989 0 obj <>/Alt(PA; SP)/P 9066 0 R/K 38517 0 R>> endobj 24990 0 obj <>/Alt(\(Begin bold\) Cystic Fib.Transmemb Conduct.Reg.\(Cftr\)Potentiator \(End bold\))/P 9067 0 R/K 38518 0 R>> endobj 24991 0 obj <>/Alt(KALYDECO ORAL GRANULES IN PACKET 13.4 MG, 25 MG, 5.8 MG, 50 MG, 75 MG)/P 9068 0 R/K 38519 0 R>> endobj 24992 0 obj <>/Alt(Tier 2)/P 9068 0 R/K 38520 0 R>> endobj 24993 0 obj <>/Alt(PA; SP)/P 9068 0 R/K 38521 0 R>> endobj 24994 0 obj <>/Alt(KALYDECO ORAL TABLET 150 MG)/P 9069 0 R/K 38522 0 R>> endobj 24995 0 obj <>/Alt(Tier 2)/P 9069 0 R/K 38523 0 R>> endobj 24996 0 obj <>/Alt(PA; SP)/P 9069 0 R/K 38524 0 R>> endobj 24997 0 obj <>/Alt(\(Begin bold\) Cystic Fibrosis-Cftr Potentiator & Corrector Comb. \(End bold\))/P 9070 0 R/K 38525 0 R>> endobj 24998 0 obj <>/Alt(ALYFTREK ORAL TABLET 10-50-125 MG, 4-20-50 MG)/P 9071 0 R/K 38526 0 R>> endobj 24999 0 obj <>/Alt(Tier 2)/P 9071 0 R/K 38527 0 R>> endobj 25000 0 obj <>/Alt(PA; SP)/P 9071 0 R/K 38528 0 R>> endobj 25001 0 obj <>/Alt(ORKAMBI ORAL GRANULES IN PACKET 100-125 MG, 150-188 MG, 75-94 MG)/P 9072 0 R/K 38529 0 R>> endobj 25002 0 obj <>/Alt(Tier 2)/P 9072 0 R/K 38530 0 R>> endobj 25003 0 obj <>/Alt(PA; SP)/P 9072 0 R/K 38531 0 R>> endobj 25004 0 obj <>/Alt(ORKAMBI ORAL TABLET 100-125 MG, 200-125 MG)/P 9073 0 R/K 38532 0 R>> endobj 25005 0 obj <>/Alt(Tier 2)/P 9073 0 R/K 38533 0 R>> endobj 25006 0 obj <>/Alt(PA; SP)/P 9073 0 R/K 38534 0 R>> endobj 25007 0 obj <>/Alt(SYMDEKO ORAL TABLETS, SEQUENTIAL 100-150 MG \(D\)/ 150 MG \(N\), 50-75 MG \(D\)/ 75 MG \(N\))/P 9074 0 R/K 38535 0 R>> endobj 25008 0 obj <>/Alt(Tier 2)/P 9074 0 R/K 38536 0 R>> endobj 25009 0 obj <>/Alt(PA; SP)/P 9074 0 R/K 38537 0 R>> endobj 25010 0 obj <>/Alt(TRIKAFTA ORAL GRANULES IN PACKET, SEQUENTIAL 100-50-75MG \(D\) /75 MG \(N\), 80-40-60 MG \(D\) /59.5 MG \(N\))/P 9075 0 R/K 38538 0 R>> endobj 25011 0 obj <>/Alt(Tier 2)/P 9075 0 R/K 38539 0 R>> endobj 25012 0 obj <>/Alt(PA; SP)/P 9075 0 R/K 38540 0 R>> endobj 25013 0 obj <>/Alt(TRIKAFTA ORAL TABLETS, SEQUENTIAL 100-50-75 MG\(D\) /150 MG \(N\), 50-25-37.5 MG \(D\)/75 MG \(N\))/P 9076 0 R/K 38541 0 R>> endobj 25014 0 obj <>/Alt(Tier 2)/P 9076 0 R/K 38542 0 R>> endobj 25015 0 obj <>/Alt(PA; SP)/P 9076 0 R/K 38543 0 R>> endobj 25016 0 obj <>/Alt(\(Begin bold\) Lung Surfactants \(End bold\))/P 9077 0 R/K 38544 0 R>> endobj 25017 0 obj <>/Alt(CUROSURF INTRATRACHEAL SUSPENSION 120 MG/1.5 ML, 240 MG/3 ML)/P 9078 0 R/K 38545 0 R>> endobj 25018 0 obj <>/Alt(Tier 3)/P 9078 0 R/K 38546 0 R>> endobj 25019 0 obj <>/Alt(INFASURF INTRATRACHEAL SUSPENSION 35 MG/ML)/P 9079 0 R/K 38547 0 R>> endobj 25020 0 obj <>/Alt(Tier 3)/P 9079 0 R/K 38548 0 R>> endobj 25021 0 obj <>/Alt(SURVANTA INTRATRACHEAL SUSPENSION 25 MG/ML)/P 9080 0 R/K 38549 0 R>> endobj 25022 0 obj <>/Alt(Tier 3)/P 9080 0 R/K 38550 0 R>> endobj 25023 0 obj <>/Alt(\(Begin bold\) Mucolytics \(End bold\))/P 9081 0 R/K 38551 0 R>> endobj 25024 0 obj <>/Alt(\(Begin italic\) acetylcysteine solution \(End italic\) \(Begin italic\) 100 mg/ml \(10 %\), 200 mg/ml \(20 %\) \(End italic\))/P 9082 0 R/K 38552 0 R>> endobj 25025 0 obj <>/Alt(Tier 1)/P 9082 0 R/K 38553 0 R>> endobj 25026 0 obj <>/Alt(PULMOZYME INHALATION SOLUTION 1 MG/ML)/P 9083 0 R/K 38554 0 R>> endobj 25027 0 obj <>/Alt(Tier 2)/P 9083 0 R/K 38555 0 R>> endobj 25028 0 obj <>/Alt(PA; SP)/P 9083 0 R/K 38556 0 R>> endobj 25029 0 obj <>/Alt(\(Begin bold\) Pulmonary Fibrosis - Systemic Enzyme Inhibitors \(End bold\))/P 9084 0 R/K 38557 0 R>> endobj 25030 0 obj <>/Alt(OFEV ORAL CAPSULE 100 MG, 150 MG)/P 9085 0 R/K 38558 0 R>> endobj 25031 0 obj <>/Alt(Tier 2)/P 9085 0 R/K 38559 0 R>> endobj 25032 0 obj <>/Alt(PA; SP)/P 9085 0 R/K 38560 0 R>> endobj 25033 0 obj <>/Alt(\(Begin bold\) Pain Management - Analgesics \(End bold\))/P 9086 0 R/K 38561 0 R>> endobj 25034 0 obj <>/Alt(\(Begin bold\) Analgesic, Non-Salicylate & Barbiturate Comb. \(End bold\))/P 9087 0 R/K 38562 0 R>> endobj 25035 0 obj <>/Alt(\(Begin italic\) butalbital-acetaminophen oral tablet \(End italic\) \(Begin italic\) 50-300 mg \(End italic\))/P 9088 0 R/K 38563 0 R>> endobj 25036 0 obj <>/Alt(Tier 1)/P 9088 0 R/K 38564 0 R>> endobj 25037 0 obj <>/Alt(ST: Requires prior prescription for generic Butalbital/acetaminophen 50mg-325mg combination product within the past 120 days; QL \(6 EA per 1 day\))/P 9088 0 R/K 38565 0 R>> endobj 25038 0 obj <>/Alt(\(Begin italic\) butalbital-acetaminophen oral tablet \(End italic\) \(Begin italic\) 50-325 mg \(End italic\))/P 9089 0 R/K 38566 0 R>> endobj 25039 0 obj <>/Alt(\(Tencon\))/P 9089 0 R/K 38567 0 R>> endobj 25040 0 obj <>/Alt(Tier 1)/P 9089 0 R/K 38568 0 R>> endobj 25041 0 obj <>/Alt(TENCON ORAL TABLET 50-325 MG)/P 9090 0 R/K 38569 0 R>> endobj 25042 0 obj <>/Alt(\(butalbital-acetaminophen\))/P 9090 0 R/K 38570 0 R>> endobj 25043 0 obj <>/Alt(Tier 1)/P 9090 0 R/K 38571 0 R>> endobj 25044 0 obj <>/Alt(\(Begin bold\) Analgesic, Salicylate, Barbiturate,& Xanthine Cmb \(End bold\))/P 9091 0 R/K 38572 0 R>> endobj 25045 0 obj <>/Alt(\(Begin italic\) butalbital-aspirin-caffeine oral capsule \(End italic\) \(Begin italic\) 50-325-40 mg \(End italic\))/P 9092 0 R/K 38573 0 R>> endobj 25046 0 obj <>/Alt(Tier 1)/P 9092 0 R/K 38574 0 R>> endobj 25047 0 obj <>/Alt(\(Begin italic\) butalbital-aspirin-caffeine oral tablet \(End italic\) \(Begin italic\) 50-325-40 mg \(End italic\))/P 9093 0 R/K 38575 0 R>> endobj 25048 0 obj <>/Alt(Tier 1)/P 9093 0 R/K 38576 0 R>> endobj 25049 0 obj <>/Alt(\(Begin bold\) Analgesic,Non-Salicylate,Barbiturate,&Xanthine Cmb \(End bold\))/P 9094 0 R/K 38577 0 R>> endobj 25050 0 obj <>/Alt(\(Begin italic\) butalbital-acetaminophen-caff oral capsule \(End italic\) \(Begin italic\) 50-300-40 mg \(End italic\))/P 9095 0 R/K 38578 0 R>> endobj 25051 0 obj <>/Alt(\(Fioricet\))/P 9095 0 R/K 38579 0 R>> endobj 25052 0 obj <>/Alt(Tier 1)/P 9095 0 R/K 38580 0 R>> endobj 25053 0 obj <>/Alt(\(Begin italic\) butalbital-acetaminophen-caff oral capsule \(End italic\) \(Begin italic\) 50-325-40 mg \(End italic\))/P 9096 0 R/K 38581 0 R>> endobj 25054 0 obj <>/Alt(Tier 1)/P 9096 0 R/K 38582 0 R>> endobj 25055 0 obj <>/Alt(\(Begin italic\) butalbital-acetaminophen-caff oral tablet \(End italic\) \(Begin italic\) 50-325-40 mg \(End italic\))/P 9097 0 R/K 38583 0 R>> endobj 25056 0 obj <>/Alt(\(Esgic\))/P 9097 0 R/K 38584 0 R>> endobj 25057 0 obj <>/Alt(Tier 1)/P 9097 0 R/K 38585 0 R>> endobj 25058 0 obj <>/Alt(FIORICET ORAL CAPSULE 50-300-40 MG)/P 9098 0 R/K 38586 0 R>> endobj 25059 0 obj <>/Alt(\(butalbital-acetaminophen-caff\))/P 9098 0 R/K 38587 0 R>> endobj 25060 0 obj <>/Alt(Tier 1)/P 9098 0 R/K 38588 0 R>> endobj 25061 0 obj <>/Alt(\(Begin bold\) Analgesic/Antipyretics, Salicylates \(End bold\))/P 9099 0 R/K 38589 0 R>> endobj 25062 0 obj <>/Alt(\(Begin italic\) aspirin oral tablet \(End italic\) \(Begin italic\) 325 mg \(End italic\))/P 9100 0 R/K 38590 0 R>> endobj 25063 0 obj <>/Alt(\(Bayer Aspirin\))/P 9100 0 R/K 38591 0 R>> endobj 25064 0 obj <>/Alt($0)/P 9100 0 R/K 38592 0 R>> endobj 25065 0 obj <>/Alt(\(Begin italic\) aspirin oral tablet,delayed release \(dr/ec\) \(End italic\) \(Begin italic\) 325 mg \(End italic\))/P 9101 0 R/K 38593 0 R>> endobj 25066 0 obj <>/Alt(\(Bayer Aspirin\))/P 9101 0 R/K 38594 0 R>> endobj 25067 0 obj <>/Alt($0)/P 9101 0 R/K 38595 0 R>> endobj 25068 0 obj <>/Alt(BAYER ASPIRIN ORAL TABLET 325 MG)/P 9102 0 R/K 38596 0 R>> endobj 25069 0 obj <>/Alt(\(aspirin\))/P 9102 0 R/K 38597 0 R>> endobj 25070 0 obj <>/Alt($0)/P 9102 0 R/K 38598 0 R>> endobj 25071 0 obj <>/Alt(BAYER ASPIRIN ORAL TABLET,DELAYED RELEASE \(DR/EC\) 325 MG)/P 9103 0 R/K 38599 0 R>> endobj 25072 0 obj <>/Alt(\(aspirin\))/P 9103 0 R/K 38600 0 R>> endobj 25073 0 obj <>/Alt($0)/P 9103 0 R/K 38601 0 R>> endobj 25074 0 obj <>/Alt(\(Begin italic\) choline,magnesium salicylate oral liquid \(End italic\) \(Begin italic\) 500 mg/5 ml \(End italic\))/P 9104 0 R/K 38602 0 R>> endobj 25075 0 obj <>/Alt(Tier 1)/P 9104 0 R/K 38603 0 R>> endobj 25076 0 obj <>/Alt(\(Begin italic\) diflunisal oral tablet \(End italic\) \(Begin italic\) 500 mg \(End italic\))/P 9105 0 R/K 38604 0 R>> endobj 25077 0 obj <>/Alt(Tier 1)/P 9105 0 R/K 38605 0 R>> endobj 25078 0 obj <>/Alt(ECOTRIN ORAL TABLET,DELAYED RELEASE \(DR/EC\) 325 MG)/P 9106 0 R/K 38606 0 R>> endobj 25079 0 obj <>/Alt(\(aspirin\))/P 9106 0 R/K 38607 0 R>> endobj 25080 0 obj <>/Alt($0)/P 9106 0 R/K 38608 0 R>> endobj 25081 0 obj <>/Alt(\(Begin italic\) salsalate oral tablet \(End italic\) \(Begin italic\) 500 mg, 750 mg \(End italic\))/P 9107 0 R/K 38609 0 R>> endobj 25082 0 obj <>/Alt(\(Disalcid\))/P 9107 0 R/K 38610 0 R>> endobj 25083 0 obj <>/Alt(Tier 1)/P 9107 0 R/K 38611 0 R>> endobj 25084 0 obj <>/Alt(\(Begin bold\) Analgesics, Narcotic Agonist And Nsaid Combination \(End bold\))/P 9108 0 R/K 38612 0 R>> endobj 25085 0 obj <>/Alt(\(Begin italic\) hydrocodone-ibuprofen oral tablet \(End italic\) \(Begin italic\) 10-200 mg, 5-200 mg, 7.5-200 mg \(End italic\))/P 9109 0 R/K 38613 0 R>> endobj 25086 0 obj <>/Alt(Tier 1)/P 9109 0 R/K 38614 0 R>> endobj 25087 0 obj <>/Alt(\(Begin bold\) Analgesics, Non-Narcotics \(End bold\))/P 9110 0 R/K 38615 0 R>> endobj 25088 0 obj <>/Alt(JOURNAVX ORAL TABLET 50 MG)/P 9111 0 R/K 38616 0 R>> endobj 25089 0 obj <>/Alt(Tier 3)/P 9111 0 R/K 38617 0 R>> endobj 25090 0 obj <>/Alt(PA)/P 9111 0 R/K 38618 0 R>> endobj 25091 0 obj <>/Alt(\(Begin bold\) Analgesics,Narcotics \(End bold\))/P 9112 0 R/K 38619 0 R>> endobj 25092 0 obj <>/Alt(BELBUCA BUCCAL FILM 150 MCG, 300 MCG, 450 MCG, 600 MCG, 75 MCG, 750 MCG, 900 MCG)/P 9113 0 R/K 38620 0 R>> endobj 25093 0 obj <>/Alt(\(buprenorphine hcl\))/P 9113 0 R/K 38621 0 R>> endobj 25094 0 obj <>/Alt(Tier 3)/P 9113 0 R/K 38622 0 R>> endobj 25095 0 obj <>/Alt(ST: Requires 7 consecutive days therapy of current short-acting opioid prescription; QL \(2 EA per 1 day\))/P 9113 0 R/K 38623 0 R>> endobj 25096 0 obj <>/Alt(\(Begin italic\) belladonna alkaloids-opium rectal suppository \(End italic\) \(Begin italic\) 16.2-30 mg, 16.2-60 mg \(End italic\))/P 9114 0 R/K 38624 0 R>> endobj 25097 0 obj <>/Alt(Tier 1)/P 9114 0 R/K 38625 0 R>> endobj 25098 0 obj <>/Alt(\(Begin italic\) buprenorphine hcl injection solution \(End italic\) \(Begin italic\) 0.3 mg/ml \(End italic\))/P 9115 0 R/K 38626 0 R>> endobj 25099 0 obj <>/Alt(Tier 1)/P 9115 0 R/K 38627 0 R>> endobj 25100 0 obj <>/Alt(ST: Requires 7 consecutive days therapy of current short-acting opioid prescription)/P 9115 0 R/K 38628 0 R>> endobj 25101 0 obj <>/Alt(\(Begin italic\) buprenorphine hcl injection syringe \(End italic\) \(Begin italic\) 0.3 mg/ml \(End italic\))/P 9116 0 R/K 38629 0 R>> endobj 25102 0 obj <>/Alt(Tier 1)/P 9116 0 R/K 38630 0 R>> endobj 25103 0 obj <>/Alt(ST: Requires 7 consecutive days therapy of current short-acting opioid prescription)/P 9116 0 R/K 38631 0 R>> endobj 25104 0 obj <>/Alt(\(Begin italic\) buprenorphine transdermal patch weekly \(End italic\) \(Begin italic\) 10 mcg/hour, 15 mcg/hour, 20 mcg/hour, 5 mcg/hour, 7.5 mcg/hour \(End italic\))/P 9117 0 R/K 38632 0 R>> endobj 25105 0 obj <>/Alt(\(Butrans\))/P 9117 0 R/K 38633 0 R>> endobj 25106 0 obj <>/Alt(Tier 1)/P 9117 0 R/K 38634 0 R>> endobj 25107 0 obj <>/Alt(ST: Requires 7 consecutive days therapy of current short-acting opioid prescription; QL \(4 EA per 28 days\))/P 9117 0 R/K 38635 0 R>> endobj 25108 0 obj <>/Alt(\(Begin italic\) butorphanol injection solution \(End italic\) \(Begin italic\) 1 mg/ml, 2 mg/ml \(End italic\))/P 9118 0 R/K 38636 0 R>> endobj 25109 0 obj <>/Alt(Tier 1)/P 9118 0 R/K 38637 0 R>> endobj 25110 0 obj <>/Alt(\(Begin italic\) butorphanol nasal spray,non-aerosol \(End italic\) \(Begin italic\) 10 mg/ml \(End italic\))/P 9119 0 R/K 38638 0 R>> endobj 25111 0 obj <>/Alt(Tier 1)/P 9119 0 R/K 38639 0 R>> endobj 25112 0 obj <>/Alt(\(Begin italic\) codeine sulfate oral tablet \(End italic\) \(Begin italic\) 15 mg, 30 mg \(End italic\))/P 9120 0 R/K 38640 0 R>> endobj 25113 0 obj <>/Alt(Tier 1)/P 9120 0 R/K 38641 0 R>> endobj 25114 0 obj <>/Alt(QL \(12 EA per 1 day\); Age \(Min 12 Years\))/P 9120 0 R/K 38642 0 R>> endobj 25115 0 obj <>/Alt(\(Begin italic\) codeine sulfate oral tablet \(End italic\) \(Begin italic\) 60 mg \(End italic\))/P 9121 0 R/K 38643 0 R>> endobj 25116 0 obj <>/Alt(Tier 1)/P 9121 0 R/K 38644 0 R>> endobj 25117 0 obj <>/Alt(QL \(6 EA per 1 day\); Age \(Min 12 Years\))/P 9121 0 R/K 38645 0 R>> endobj 25118 0 obj <>/Alt(DEMEROL \(PF\) INJECTION SYRINGE 100 MG/ML, 25 MG/ML, 50 MG/ML, 75 MG/ML)/P 9122 0 R/K 38646 0 R>> endobj 25119 0 obj <>/Alt(Tier 3)/P 9122 0 R/K 38647 0 R>> endobj 25120 0 obj <>/Alt(DILAUDID \(PF\) INJECTION SYRINGE 0.5 MG/0.5 ML, 1 MG/ML, 2 MG/ML, 4 MG/ML)/P 9123 0 R/K 38648 0 R>> endobj 25121 0 obj <>/Alt(\(hydromorphone \(pf\)\))/P 9123 0 R/K 38649 0 R>> endobj 25122 0 obj <>/Alt(Tier 3)/P 9123 0 R/K 38650 0 R>> endobj 25123 0 obj <>/Alt(\(Begin italic\) fentanyl citrate \(pf\) intravenous patient control.analgesia soln \(End italic\) \(Begin italic\) 1,500 mcg/30 ml \(50 mcg/ml\) \(End italic\))/P 9124 0 R/K 38651 0 R>> endobj 25124 0 obj <>/Alt(Tier 1)/P 9124 0 R/K 38652 0 R>> endobj 25125 0 obj <>/Alt(\(Begin italic\) fentanyl citrate \(pf\)-0.9%nacl intravenous pt controlled analgesia syring \(End italic\) \(Begin italic\) 1,000 mcg/50 ml \(20 mcg/ml\), 500 mcg/50 ml \(10 mcg/ml\) \(End italic\))/P 9125 0 R/K 38653 0 R>> endobj 25126 0 obj <>/Alt(Tier 1)/P 9125 0 R/K 38654 0 R>> endobj 25127 0 obj <>/Alt(\(Begin italic\) fentanyl citrate buccal lozenge on a handle \(End italic\) \(Begin italic\) 1,200 mcg, 1,600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg \(End italic\))/P 9126 0 R/K 38655 0 R>> endobj 25128 0 obj <>/Alt(Tier 1)/P 9126 0 R/K 38656 0 R>> endobj 25129 0 obj <>/Alt(PA)/P 9126 0 R/K 38657 0 R>> endobj 25130 0 obj <>/Alt(\(Begin italic\) fentanyl transdermal patch 72 hour \(End italic\) \(Begin italic\) 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 37.5 mcg/hour, 50 mcg/hr, 62.5 mcg/hour, 75 mcg/hr, 87.5 mcg/hour \(End italic\))/P 9127 0 R/K 38658 0 R>> endobj 25131 0 obj <>/Alt(Tier 1)/P 9127 0 R/K 38659 0 R>> endobj 25132 0 obj <>/Alt(PA; ST: Requires 7 consecutive days therapy of current short-acting opioid prescription)/P 9127 0 R/K 38660 0 R>> endobj 25133 0 obj <>/Alt(\(Begin italic\) hydrocodone bitartrate oral capsule, oral only, er 12hr \(End italic\) \(Begin italic\) 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 50 mg \(End italic\))/P 9128 0 R/K 38661 0 R>> endobj 25134 0 obj <>/Alt(Tier 1)/P 9128 0 R/K 38662 0 R>> endobj 25135 0 obj <>/Alt(ST: Requires 7 consecutive days therapy of current short-acting opioid prescription; QL \(2 EA per 1 day\))/P 9128 0 R/K 38663 0 R>> endobj 25136 0 obj <>/Alt(\(Begin italic\) hydrocodone bitartrate oral tablet,oral only,ext.rel.24 hr \(End italic\) \(Begin italic\) 100 mg, 120 mg, 20 mg, 30 mg, 40 mg, 60 mg, 80 mg \(End italic\))/P 9129 0 R/K 38664 0 R>> endobj 25137 0 obj <>/Alt(\(Hysingla ER\))/P 9129 0 R/K 38665 0 R>> endobj 25138 0 obj <>/Alt(Tier 1)/P 9129 0 R/K 38666 0 R>> endobj 25139 0 obj <>/Alt(ST: Requires 7 consecutive days therapy of current short-acting opioid prescription; QL \(1 EA per 1 day\))/P 9129 0 R/K 38667 0 R>> endobj 25140 0 obj <>/Alt(\(Begin italic\) hydromorphone \(pf\) injection syringe \(End italic\) \(Begin italic\) 0.5 mg/0.5 ml, 1 mg/ml, 2 mg/ml \(End italic\))/P 9130 0 R/K 38668 0 R>> endobj 25141 0 obj <>/Alt(\(Dilaudid \(PF\)\))/P 9130 0 R/K 38669 0 R>> endobj 25142 0 obj <>/Alt(Tier 1)/P 9130 0 R/K 38670 0 R>> endobj 25143 0 obj <>/Alt(\(Begin italic\) hydromorphone \(pf\)-0.9 % nacl intravenous pt controlled analgesia syring \(End italic\) \(Begin italic\) 30 mg/30 ml \(1 mg/ml\) \(End italic\))/P 9131 0 R/K 38671 0 R>> endobj 25144 0 obj <>/Alt(Tier 1)/P 9131 0 R/K 38672 0 R>> endobj 25145 0 obj <>/Alt(\(Begin italic\) hydromorphone oral liquid \(End italic\) \(Begin italic\) 1 mg/ml \(End italic\))/P 9132 0 R/K 38673 0 R>> endobj 25146 0 obj <>/Alt(\(Dilaudid\))/P 9132 0 R/K 38674 0 R>> endobj 25147 0 obj <>/Alt(Tier 1)/P 9132 0 R/K 38675 0 R>> endobj 25148 0 obj <>/Alt(\(Begin italic\) hydromorphone oral tablet \(End italic\) \(Begin italic\) 2 mg, 4 mg, 8 mg \(End italic\))/P 9133 0 R/K 38676 0 R>> endobj 25149 0 obj <>/Alt(\(Dilaudid\))/P 9133 0 R/K 38677 0 R>> endobj 25150 0 obj <>/Alt(Tier 1)/P 9133 0 R/K 38678 0 R>> endobj 25151 0 obj <>/Alt(\(Begin italic\) hydromorphone oral tablet extended release 24 hr \(End italic\) \(Begin italic\) 12 mg, 16 mg, 32 mg, 8 mg \(End italic\))/P 9134 0 R/K 38679 0 R>> endobj 25152 0 obj <>/Alt(Tier 1)/P 9134 0 R/K 38680 0 R>> endobj 25153 0 obj <>/Alt(PA; ST: Requires 7 consecutive days therapy of current short-acting opioid prescription)/P 9134 0 R/K 38681 0 R>> endobj 25154 0 obj <>/Alt(\(Begin italic\) hydromorphone rectal suppository \(End italic\) \(Begin italic\) 3 mg \(End italic\))/P 9135 0 R/K 38682 0 R>> endobj 25155 0 obj <>/Alt(Tier 1)/P 9135 0 R/K 38683 0 R>> endobj 25156 0 obj <>/Alt(\(Begin italic\) levorphanol tartrate oral tablet \(End italic\) \(Begin italic\) 2 mg \(End italic\))/P 9136 0 R/K 38684 0 R>> endobj 25157 0 obj <>/Alt(Tier 1)/P 9136 0 R/K 38685 0 R>> endobj 25158 0 obj <>/Alt(ST: Requires 7 consecutive days therapy of current short-acting opioid prescription)/P 9136 0 R/K 38686 0 R>> endobj 25159 0 obj <>/Alt(\(Begin italic\) meperidine \(pf\) injection solution \(End italic\) \(Begin italic\) 100 mg/ml, 25 mg/ml, 50 mg/ml \(End italic\))/P 9137 0 R/K 38687 0 R>> endobj 25160 0 obj <>/Alt(Tier 1)/P 9137 0 R/K 38688 0 R>> endobj 25161 0 obj <>/Alt(\(Begin italic\) meperidine oral solution \(End italic\) \(Begin italic\) 50 mg/5 ml \(End italic\))/P 9138 0 R/K 38689 0 R>> endobj 25162 0 obj <>/Alt(Tier 1)/P 9138 0 R/K 38690 0 R>> endobj 25163 0 obj <>/Alt(QL \(30 ML per 1 day\))/P 9138 0 R/K 38691 0 R>> endobj 25164 0 obj <>/Alt(\(Begin italic\) meperidine oral tablet \(End italic\) \(Begin italic\) 50 mg \(End italic\))/P 9139 0 R/K 38692 0 R>> endobj 25165 0 obj <>/Alt(Tier 1)/P 9139 0 R/K 38693 0 R>> endobj 25166 0 obj <>/Alt(QL \(6 EA per 1 day\))/P 9139 0 R/K 38694 0 R>> endobj 25167 0 obj <>/Alt(\(Begin italic\) methadone injection solution \(End italic\) \(Begin italic\) 10 mg/ml \(End italic\))/P 9140 0 R/K 38695 0 R>> endobj 25168 0 obj <>/Alt(Tier 1)/P 9140 0 R/K 38696 0 R>> endobj 25169 0 obj <>/Alt(QL \(4 ML per 1 day\))/P 9140 0 R/K 38697 0 R>> endobj 25170 0 obj <>/Alt(METHADONE INTENSOL ORAL CONCENTRATE 10 MG/ML)/P 9141 0 R/K 38698 0 R>> endobj 25171 0 obj <>/Alt(\(methadone\))/P 9141 0 R/K 38699 0 R>> endobj 25172 0 obj <>/Alt(Tier 1)/P 9141 0 R/K 38700 0 R>> endobj 25173 0 obj <>/Alt(QL \(4 ML per 1 day\))/P 9141 0 R/K 38701 0 R>> endobj 25174 0 obj <>/Alt(\(Begin italic\) methadone oral concentrate \(End italic\) \(Begin italic\) 10 mg/ml \(End italic\))/P 9142 0 R/K 38702 0 R>> endobj 25175 0 obj <>/Alt(\(Methadone Intensol\))/P 9142 0 R/K 38703 0 R>> endobj 25176 0 obj <>/Alt(Tier 1)/P 9142 0 R/K 38704 0 R>> endobj 25177 0 obj <>/Alt(QL \(4 ML per 1 day\))/P 9142 0 R/K 38705 0 R>> endobj 25178 0 obj <>/Alt(\(Begin italic\) methadone oral solution \(End italic\) \(Begin italic\) 10 mg/5 ml \(End italic\))/P 9143 0 R/K 38706 0 R>> endobj 25179 0 obj <>/Alt(Tier 1)/P 9143 0 R/K 38707 0 R>> endobj 25180 0 obj <>/Alt(QL \(20 ML per 1 day\))/P 9143 0 R/K 38708 0 R>> endobj 25181 0 obj <>/Alt(\(Begin italic\) methadone oral solution \(End italic\) \(Begin italic\) 5 mg/5 ml \(End italic\))/P 9144 0 R/K 38709 0 R>> endobj 25182 0 obj <>/Alt(Tier 1)/P 9144 0 R/K 38710 0 R>> endobj 25183 0 obj <>/Alt(QL \(40 ML per 1 day\))/P 9144 0 R/K 38711 0 R>> endobj 25184 0 obj <>/Alt(\(Begin italic\) methadone oral tablet \(End italic\) \(Begin italic\) 10 mg \(End italic\))/P 9145 0 R/K 38712 0 R>> endobj 25185 0 obj <>/Alt(Tier 1)/P 9145 0 R/K 38713 0 R>> endobj 25186 0 obj <>/Alt(QL \(4 EA per 1 day\))/P 9145 0 R/K 38714 0 R>> endobj 25187 0 obj <>/Alt(\(Begin italic\) methadone oral tablet \(End italic\) \(Begin italic\) 5 mg \(End italic\))/P 9146 0 R/K 38715 0 R>> endobj 25188 0 obj <>/Alt(Tier 1)/P 9146 0 R/K 38716 0 R>> endobj 25189 0 obj <>/Alt(QL \(8 EA per 1 day\))/P 9146 0 R/K 38717 0 R>> endobj 25190 0 obj <>/Alt(\(Begin italic\) methadone oral tablet,soluble \(End italic\) \(Begin italic\) 40 mg \(End italic\))/P 9147 0 R/K 38718 0 R>> endobj 25191 0 obj <>/Alt(\(Methadose\))/P 9147 0 R/K 38719 0 R>> endobj 25192 0 obj <>/Alt(Tier 1)/P 9147 0 R/K 38720 0 R>> endobj 25193 0 obj <>/Alt(QL \(1 EA per 1 day\))/P 9147 0 R/K 38721 0 R>> endobj 25194 0 obj <>/Alt(METHADOSE ORAL TABLET,SOLUBLE 40 MG)/P 9148 0 R/K 38722 0 R>> endobj 25195 0 obj <>/Alt(\(methadone\))/P 9148 0 R/K 38723 0 R>> endobj 25196 0 obj <>/Alt(Tier 1)/P 9148 0 R/K 38724 0 R>> endobj 25197 0 obj <>/Alt(QL \(1 EA per 1 day\))/P 9148 0 R/K 38725 0 R>> endobj 25198 0 obj <>/Alt(\(Begin italic\) morphine \(pf\) intravenous syringe \(End italic\) \(Begin italic\) 1 mg/2 ml \(End italic\))/P 9149 0 R/K 38726 0 R>> endobj 25199 0 obj <>/Alt(Tier 1)/P 9149 0 R/K 38727 0 R>> endobj 25200 0 obj <>/Alt(\(Begin italic\) morphine concentrate oral solution \(End italic\) \(Begin italic\) 100 mg/5 ml \(20 mg/ml\) \(End italic\))/P 9150 0 R/K 38728 0 R>> endobj 25201 0 obj <>/Alt(Tier 1)/P 9150 0 R/K 38729 0 R>> endobj 25202 0 obj <>/Alt(PA)/P 9150 0 R/K 38730 0 R>> endobj 25203 0 obj <>/Alt(\(Begin italic\) morphine in 0.9 % sodium chlor intravenous pt controlled analgesia syring \(End italic\) \(Begin italic\) 275 mg/55 ml \(5 mg/ml\) \(End italic\))/P 9151 0 R/K 38731 0 R>> endobj 25204 0 obj <>/Alt(Tier 1)/P 9151 0 R/K 38732 0 R>> endobj 25205 0 obj <>/Alt(\(Begin italic\) morphine in 0.9 % sodium chlor intravenous solution \(End italic\) \(Begin italic\) 1 mg/ml, 5 mg/ml \(End italic\))/P 9152 0 R/K 38733 0 R>> endobj 25206 0 obj <>/Alt(Tier 1)/P 9152 0 R/K 38734 0 R>> endobj 25207 0 obj <>/Alt(\(Begin italic\) morphine intramuscular pen injector \(End italic\) \(Begin italic\) 10 mg/0.7 ml \(End italic\))/P 9153 0 R/K 38735 0 R>> endobj 25208 0 obj <>/Alt(Tier 1)/P 9153 0 R/K 38736 0 R>> endobj 25209 0 obj <>/Alt(\(Begin italic\) morphine oral capsule, er multiphase 24 hr \(End italic\) \(Begin italic\) 120 mg \(End italic\))/P 9154 0 R/K 38737 0 R>> endobj 25210 0 obj <>/Alt(Tier 1)/P 9154 0 R/K 38738 0 R>> endobj 25211 0 obj <>/Alt(ST: Requires 7 consecutive days therapy of current short-acting opioid prescription; QL \(2 EA per 1 day\))/P 9154 0 R/K 38739 0 R>> endobj 25212 0 obj <>/Alt(\(Begin italic\) morphine oral capsule, er multiphase 24 hr \(End italic\) \(Begin italic\) 30 mg, 45 mg, 60 mg, 75 mg, 90 mg \(End italic\))/P 9155 0 R/K 38740 0 R>> endobj 25213 0 obj <>/Alt(Tier 1)/P 9155 0 R/K 38741 0 R>> endobj 25214 0 obj <>/Alt(ST: Requires 7 consecutive days therapy of current short-acting opioid prescription; QL \(1 EA per 1 day\))/P 9155 0 R/K 38742 0 R>> endobj 25215 0 obj <>/Alt(\(Begin italic\) morphine oral solution \(End italic\) \(Begin italic\) 10 mg/5 ml, 20 mg/5 ml \(4 mg/ml\) \(End italic\))/P 9156 0 R/K 38743 0 R>> endobj 25216 0 obj <>/Alt(Tier 1)/P 9156 0 R/K 38744 0 R>> endobj 25217 0 obj <>/Alt(\(Begin italic\) morphine oral tablet \(End italic\) \(Begin italic\) 15 mg \(End italic\))/P 9157 0 R/K 38745 0 R>> endobj 25218 0 obj <>/Alt(Tier 1)/P 9157 0 R/K 38746 0 R>> endobj 25219 0 obj <>/Alt(\(Begin italic\) morphine oral tablet \(End italic\) \(Begin italic\) 30 mg \(End italic\))/P 9158 0 R/K 38747 0 R>> endobj 25220 0 obj <>/Alt(Tier 2)/P 9158 0 R/K 38748 0 R>> endobj 25221 0 obj <>/Alt(\(Begin italic\) morphine oral tablet extended release \(End italic\) \(Begin italic\) 100 mg, 15 mg, 200 mg, 30 mg, 60 mg \(End italic\))/P 9159 0 R/K 38749 0 R>> endobj 25222 0 obj <>/Alt(\(MS Contin\))/P 9159 0 R/K 38750 0 R>> endobj 25223 0 obj <>/Alt(Tier 1)/P 9159 0 R/K 38751 0 R>> endobj 25224 0 obj <>/Alt(ST: Requires 7 consecutive days therapy of current short-acting opioid prescription; QL \(3 EA per 1 day\))/P 9159 0 R/K 38752 0 R>> endobj 25225 0 obj <>/Alt(\(Begin italic\) morphine rectal suppository \(End italic\) \(Begin italic\) 10 mg, 20 mg, 30 mg, 5 mg \(End italic\))/P 9160 0 R/K 38753 0 R>> endobj 25226 0 obj <>/Alt(Tier 1)/P 9160 0 R/K 38754 0 R>> endobj 25227 0 obj <>/Alt(\(Begin italic\) nalbuphine injection solution \(End italic\) \(Begin italic\) 10 mg/ml, 20 mg/ml \(End italic\))/P 9161 0 R/K 38755 0 R>> endobj 25228 0 obj <>/Alt(Tier 1)/P 9161 0 R/K 38756 0 R>> endobj 25229 0 obj <>/Alt(NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HR 100 MG, 150 MG, 200 MG, 250 MG, 50 MG)/P 9162 0 R/K 38757 0 R>> endobj 25230 0 obj <>/Alt(Tier 3)/P 9162 0 R/K 38758 0 R>> endobj 25231 0 obj <>/Alt(ST: Requires 7 consecutive days therapy of current short-acting opioid prescription; QL \(2 EA per 1 day\))/P 9162 0 R/K 38759 0 R>> endobj 25232 0 obj <>/Alt(NUCYNTA ORAL TABLET 100 MG, 50 MG, 75 MG)/P 9163 0 R/K 38760 0 R>> endobj 25233 0 obj <>/Alt(Tier 3)/P 9163 0 R/K 38761 0 R>> endobj 25234 0 obj <>/Alt(QL \(6 EA per 1 day\))/P 9163 0 R/K 38762 0 R>> endobj 25235 0 obj <>/Alt(\(Begin italic\) oxycodone oral capsule \(End italic\) \(Begin italic\) 5 mg \(End italic\))/P 9164 0 R/K 38763 0 R>> endobj 25236 0 obj <>/Alt(Tier 1)/P 9164 0 R/K 38764 0 R>> endobj 25237 0 obj <>/Alt(\(Begin italic\) oxycodone oral concentrate \(End italic\) \(Begin italic\) 20 mg/ml \(End italic\))/P 9165 0 R/K 38765 0 R>> endobj 25238 0 obj <>/Alt(Tier 1)/P 9165 0 R/K 38766 0 R>> endobj 25239 0 obj <>/Alt(PA)/P 9165 0 R/K 38767 0 R>> endobj 25240 0 obj <>/Alt(\(Begin italic\) oxycodone oral solution \(End italic\) \(Begin italic\) 5 mg/5 ml \(End italic\))/P 9166 0 R/K 38768 0 R>> endobj 25241 0 obj <>/Alt(Tier 1)/P 9166 0 R/K 38769 0 R>> endobj 25242 0 obj <>/Alt(\(Begin italic\) oxycodone oral tablet \(End italic\) \(Begin italic\) 10 mg, 20 mg, 5 mg \(End italic\))/P 9167 0 R/K 38770 0 R>> endobj 25243 0 obj <>/Alt(Tier 1)/P 9167 0 R/K 38771 0 R>> endobj 25244 0 obj <>/Alt(\(Begin italic\) oxycodone oral tablet \(End italic\) \(Begin italic\) 15 mg, 30 mg \(End italic\))/P 9168 0 R/K 38772 0 R>> endobj 25245 0 obj <>/Alt(\(Roxicodone\))/P 9168 0 R/K 38773 0 R>> endobj 25246 0 obj <>/Alt(Tier 1)/P 9168 0 R/K 38774 0 R>> endobj 25247 0 obj <>/Alt(\(Begin italic\) oxycodone oral tablet, oral only \(End italic\) \(Begin italic\) 10 mg, 15 mg, 30 mg, 5 mg \(End italic\))/P 9169 0 R/K 38775 0 R>> endobj 25248 0 obj <>/Alt(\(RoxyBond\))/P 9169 0 R/K 38776 0 R>> endobj 25249 0 obj <>/Alt(Tier 1)/P 9169 0 R/K 38777 0 R>> endobj 25250 0 obj <>/Alt(\(Begin italic\) oxycodone oral tablet,oral only,ext.rel.12 hr \(End italic\) \(Begin italic\) 10 mg, 20 mg, 40 mg \(End italic\))/P 9170 0 R/K 38778 0 R>> endobj 25251 0 obj <>/Alt(\(OxyContin\))/P 9170 0 R/K 38779 0 R>> endobj 25252 0 obj <>/Alt(Tier 1)/P 9170 0 R/K 38780 0 R>> endobj 25253 0 obj <>/Alt(ST: Requires 7 consecutive days therapy of current short-acting opioid prescription; QL \(2 EA per 1 day\))/P 9170 0 R/K 38781 0 R>> endobj 25254 0 obj <>/Alt(\(Begin italic\) oxycodone oral tablet,oral only,ext.rel.12 hr \(End italic\) \(Begin italic\) 80 mg \(End italic\))/P 9171 0 R/K 38782 0 R>> endobj 25255 0 obj <>/Alt(\(OxyContin\))/P 9171 0 R/K 38783 0 R>> endobj 25256 0 obj <>/Alt(Tier 1)/P 9171 0 R/K 38784 0 R>> endobj 25257 0 obj <>/Alt(ST: Requires 7 consecutive days therapy of current short-acting opioid prescription; QL \(4 EA per 1 day\))/P 9171 0 R/K 38785 0 R>> endobj 25258 0 obj <>/Alt(OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60 MG)/P 9172 0 R/K 38786 0 R>> endobj 25259 0 obj <>/Alt(\(oxycodone\))/P 9172 0 R/K 38787 0 R>> endobj 25260 0 obj <>/Alt(Tier 2)/P 9172 0 R/K 38788 0 R>> endobj 25261 0 obj <>/Alt(ST: Requires 7 consecutive days therapy of current short-acting opioid prescription; QL \(2 EA per 1 day\))/P 9172 0 R/K 38789 0 R>> endobj 25262 0 obj <>/Alt(OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 80 MG)/P 9173 0 R/K 38790 0 R>> endobj 25263 0 obj <>/Alt(\(oxycodone\))/P 9173 0 R/K 38791 0 R>> endobj 25264 0 obj <>/Alt(Tier 2)/P 9173 0 R/K 38792 0 R>> endobj 25265 0 obj <>/Alt(ST: Requires 7 consecutive days therapy of current short-acting opioid prescription; QL \(4 EA per 1 day\))/P 9173 0 R/K 38793 0 R>> endobj 25266 0 obj <>/Alt(\(Begin italic\) oxymorphone oral tablet \(End italic\) \(Begin italic\) 10 mg, 5 mg \(End italic\))/P 9174 0 R/K 38794 0 R>> endobj 25267 0 obj <>/Alt(Tier 1)/P 9174 0 R/K 38795 0 R>> endobj 25268 0 obj <>/Alt(\(Begin italic\) oxymorphone oral tablet extended release 12 hr \(End italic\) \(Begin italic\) 10 mg, 15 mg, 20 mg, 5 mg, 7.5 mg \(End italic\))/P 9175 0 R/K 38796 0 R>> endobj 25269 0 obj <>/Alt(Tier 1)/P 9175 0 R/K 38797 0 R>> endobj 25270 0 obj <>/Alt(ST: Requires 7 consecutive days therapy of current short-acting opioid prescription; QL \(2 EA per 1 day\))/P 9175 0 R/K 38798 0 R>> endobj 25271 0 obj <>/Alt(\(Begin italic\) oxymorphone oral tablet extended release 12 hr \(End italic\) \(Begin italic\) 30 mg, 40 mg \(End italic\))/P 9176 0 R/K 38799 0 R>> endobj 25272 0 obj <>/Alt(Tier 1)/P 9176 0 R/K 38800 0 R>> endobj 25273 0 obj <>/Alt(ST: Requires 7 consecutive days therapy of current short-acting opioid prescription; QL \(4 EA per 1 day\))/P 9176 0 R/K 38801 0 R>> endobj 25274 0 obj <>/Alt(\(Begin italic\) pentazocine-naloxone oral tablet \(End italic\) \(Begin italic\) 50-0.5 mg \(End italic\))/P 9177 0 R/K 38802 0 R>> endobj 25275 0 obj <>/Alt(Tier 1)/P 9177 0 R/K 38803 0 R>> endobj 25276 0 obj <>/Alt(ROXYBOND ORAL TABLET, ORAL ONLY 10 MG, 15 MG, 30 MG, 5 MG)/P 9178 0 R/K 38804 0 R>> endobj 25277 0 obj <>/Alt(\(oxycodone\))/P 9178 0 R/K 38805 0 R>> endobj 25278 0 obj <>/Alt(Tier 3)/P 9178 0 R/K 38806 0 R>> endobj 25279 0 obj <>/Alt(\(Begin italic\) tramadol oral solution \(End italic\) \(Begin italic\) 5 mg/ml \(End italic\))/P 9179 0 R/K 38807 0 R>> endobj 25280 0 obj <>/Alt(\(Qdolo\))/P 9179 0 R/K 38808 0 R>> endobj 25281 0 obj <>/Alt(Tier 1)/P 9179 0 R/K 38809 0 R>> endobj 25282 0 obj <>/Alt(PA)/P 9179 0 R/K 38810 0 R>> endobj 25283 0 obj <>/Alt(\(Begin italic\) tramadol oral tablet \(End italic\) \(Begin italic\) 50 mg \(End italic\))/P 9180 0 R/K 38811 0 R>> endobj 25284 0 obj <>/Alt(Tier 1)/P 9180 0 R/K 38812 0 R>> endobj 25285 0 obj <>/Alt(QL \(8 EA per 1 day\); Age \(Min 12 Years\))/P 9180 0 R/K 38813 0 R>> endobj 25286 0 obj <>/Alt(\(Begin italic\) tramadol oral tablet extended release 24 hr \(End italic\) \(Begin italic\) 100 mg \(End italic\))/P 9181 0 R/K 38814 0 R>> endobj 25287 0 obj <>/Alt(Tier 1)/P 9181 0 R/K 38815 0 R>> endobj 25288 0 obj <>/Alt(ST: Requires 7 consecutive days therapy of current short-acting opioid prescription; QL \(3 EA per 1 day\); Age \(Min 12 Years\))/P 9181 0 R/K 38816 0 R>> endobj 25289 0 obj <>/Alt(\(Begin italic\) tramadol oral tablet extended release 24 hr \(End italic\) \(Begin italic\) 200 mg, 300 mg \(End italic\))/P 9182 0 R/K 38817 0 R>> endobj 25290 0 obj <>/Alt(Tier 1)/P 9182 0 R/K 38818 0 R>> endobj 25291 0 obj <>/Alt(ST: Requires 7 consecutive days therapy of current short-acting opioid prescription; QL \(1 EA per 1 day\); Age \(Min 12 Years\))/P 9182 0 R/K 38819 0 R>> endobj 25292 0 obj <>/Alt(\(Begin italic\) tramadol oral tablet, er multiphase 24 hr \(End italic\) \(Begin italic\) 100 mg \(End italic\))/P 9183 0 R/K 38820 0 R>> endobj 25293 0 obj <>/Alt(Tier 1)/P 9183 0 R/K 38821 0 R>> endobj 25294 0 obj <>/Alt(ST: Requires 7 consecutive days therapy of current short-acting opioid prescription; QL \(3 EA per 1 day\); Age \(Min 12 Years\))/P 9183 0 R/K 38822 0 R>> endobj 25295 0 obj <>/Alt(\(Begin italic\) tramadol oral tablet, er multiphase 24 hr \(End italic\) \(Begin italic\) 200 mg, 300 mg \(End italic\))/P 9184 0 R/K 38823 0 R>> endobj 25296 0 obj <>/Alt(Tier 1)/P 9184 0 R/K 38824 0 R>> endobj 25297 0 obj <>/Alt(ST: Requires 7 consecutive days therapy of current short-acting opioid prescription; QL \(1 EA per 1 day\); Age \(Min 12 Years\))/P 9184 0 R/K 38825 0 R>> endobj 25298 0 obj <>/Alt(XTAMPZA ER ORAL CAP,SPRINKL,ER12HR\(DONT CRUSH\) 13.5 MG, 18 MG, 9 MG)/P 9185 0 R/K 38826 0 R>> endobj 25299 0 obj <>/Alt(Tier 3)/P 9185 0 R/K 38827 0 R>> endobj 25300 0 obj <>/Alt(ST: Requires 7 consecutive days therapy of current short-acting opioid prescription; QL \(2 EA per 1 day\))/P 9185 0 R/K 38828 0 R>> endobj 25301 0 obj <>/Alt(XTAMPZA ER ORAL CAP,SPRINKL,ER12HR\(DONT CRUSH\) 27 MG)/P 9186 0 R/K 38829 0 R>> endobj 25302 0 obj <>/Alt(Tier 3)/P 9186 0 R/K 38830 0 R>> endobj 25303 0 obj <>/Alt(ST: Requires 7 consecutive days therapy of current short-acting opioid prescription; QL \(4 EA per 1 day\))/P 9186 0 R/K 38831 0 R>> endobj 25304 0 obj <>/Alt(XTAMPZA ER ORAL CAP,SPRINKL,ER12HR\(DONT CRUSH\) 36 MG)/P 9187 0 R/K 38832 0 R>> endobj 25305 0 obj <>/Alt(Tier 3)/P 9187 0 R/K 38833 0 R>> endobj 25306 0 obj <>/Alt(ST: Requires 7 consecutive days therapy of current short-acting opioid prescription; QL \(8 EA per 1 day\))/P 9187 0 R/K 38834 0 R>> endobj 25307 0 obj <>/Alt(\(Begin bold\) Antimigraine Preparations \(End bold\))/P 9188 0 R/K 38835 0 R>> endobj 25308 0 obj <>/Alt(AIMOVIG AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR 140 MG/ML, 70 MG/ML)/P 9189 0 R/K 38836 0 R>> endobj 25309 0 obj <>/Alt(Tier 2)/P 9189 0 R/K 38837 0 R>> endobj 25310 0 obj <>/Alt(PA)/P 9189 0 R/K 38838 0 R>> endobj 25311 0 obj <>/Alt(AJOVY AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR 225 MG/1.5 ML)/P 9190 0 R/K 38839 0 R>> endobj 25312 0 obj <>/Alt(Tier 2)/P 9190 0 R/K 38840 0 R>> endobj 25313 0 obj <>/Alt(PA)/P 9190 0 R/K 38841 0 R>> endobj 25314 0 obj <>/Alt(AJOVY SYRINGE SUBCUTANEOUS SYRINGE 225 MG/1.5 ML)/P 9191 0 R/K 38842 0 R>> endobj 25315 0 obj <>/Alt(Tier 2)/P 9191 0 R/K 38843 0 R>> endobj 25316 0 obj <>/Alt(PA)/P 9191 0 R/K 38844 0 R>> endobj 25317 0 obj <>/Alt(\(Begin italic\) almotriptan malate oral tablet \(End italic\) \(Begin italic\) 12.5 mg, 6.25 mg \(End italic\))/P 9192 0 R/K 38845 0 R>> endobj 25318 0 obj <>/Alt(Tier 1)/P 9192 0 R/K 38846 0 R>> endobj 25319 0 obj <>/Alt(ST: Requires prior prescription for oral Sumatriptan or Rizatriptan within the past 180 days; QL \(18 EA per 30 days\))/P 9192 0 R/K 38847 0 R>> endobj 25320 0 obj <>/Alt(\(Begin italic\) dihydroergotamine injection solution \(End italic\) \(Begin italic\) 1 mg/ml \(End italic\))/P 9193 0 R/K 38848 0 R>> endobj 25321 0 obj <>/Alt(Tier 1)/P 9193 0 R/K 38849 0 R>> endobj 25322 0 obj <>/Alt(QL \(15 ML per 14 days\))/P 9193 0 R/K 38850 0 R>> endobj 25323 0 obj <>/Alt(\(Begin italic\) dihydroergotamine nasal spray,non-aerosol \(End italic\) \(Begin italic\) 0.5 mg/pump act. \(4 mg/ml\) \(End italic\))/P 9194 0 R/K 38851 0 R>> endobj 25324 0 obj <>/Alt(\(Migranal\))/P 9194 0 R/K 38852 0 R>> endobj 25325 0 obj <>/Alt(Tier 1)/P 9194 0 R/K 38853 0 R>> endobj 25326 0 obj <>/Alt(ST: Requires prior prescription for oral Sumatriptan or Rizatriptan within the past 180 days; QL \(8 ML per 28 days\))/P 9194 0 R/K 38854 0 R>> endobj 25327 0 obj <>/Alt(\(Begin italic\) eletriptan oral tablet \(End italic\) \(Begin italic\) 20 mg, 40 mg \(End italic\))/P 9195 0 R/K 38855 0 R>> endobj 25328 0 obj <>/Alt(\(Relpax\))/P 9195 0 R/K 38856 0 R>> endobj 25329 0 obj <>/Alt(Tier 1)/P 9195 0 R/K 38857 0 R>> endobj 25330 0 obj <>/Alt(ST: Requires prior prescription for oral Sumatriptan or Rizatriptan within the past 180 days; QL \(18 EA per 30 days\))/P 9195 0 R/K 38858 0 R>> endobj 25331 0 obj <>/Alt(ELYXYB ORAL SOLUTION 120 MG/4.8 ML \(25 MG/ML\))/P 9196 0 R/K 38859 0 R>> endobj 25332 0 obj <>/Alt(Tier 3)/P 9196 0 R/K 38860 0 R>> endobj 25333 0 obj <>/Alt(PA)/P 9196 0 R/K 38861 0 R>> endobj 25334 0 obj <>/Alt(EMGALITY PEN SUBCUTANEOUS PEN INJECTOR 120 MG/ML)/P 9197 0 R/K 38862 0 R>> endobj 25335 0 obj <>/Alt(Tier 2)/P 9197 0 R/K 38863 0 R>> endobj 25336 0 obj <>/Alt(PA)/P 9197 0 R/K 38864 0 R>> endobj 25337 0 obj <>/Alt(EMGALITY SYRINGE SUBCUTANEOUS SYRINGE 120 MG/ML)/P 9198 0 R/K 38865 0 R>> endobj 25338 0 obj <>/Alt(Tier 2)/P 9198 0 R/K 38866 0 R>> endobj 25339 0 obj <>/Alt(PA)/P 9198 0 R/K 38867 0 R>> endobj 25340 0 obj <>/Alt(ERGOMAR SUBLINGUAL TABLET 2 MG)/P 9199 0 R/K 38868 0 R>> endobj 25341 0 obj <>/Alt(Tier 3)/P 9199 0 R/K 38869 0 R>> endobj 25342 0 obj <>/Alt(QL \(10 EA per 7 days\))/P 9199 0 R/K 38870 0 R>> endobj 25343 0 obj <>/Alt(\(Begin italic\) ergotamine-caffeine oral tablet \(End italic\) \(Begin italic\) 1-100 mg \(End italic\))/P 9200 0 R/K 38871 0 R>> endobj 25344 0 obj <>/Alt(Tier 1)/P 9200 0 R/K 38872 0 R>> endobj 25345 0 obj <>/Alt(QL \(10 EA per 7 days\))/P 9200 0 R/K 38873 0 R>> endobj 25346 0 obj <>/Alt(\(Begin italic\) frovatriptan oral tablet \(End italic\) \(Begin italic\) 2.5 mg \(End italic\))/P 9201 0 R/K 38874 0 R>> endobj 25347 0 obj <>/Alt(\(Frova\))/P 9201 0 R/K 38875 0 R>> endobj 25348 0 obj <>/Alt(Tier 1)/P 9201 0 R/K 38876 0 R>> endobj 25349 0 obj <>/Alt(ST: Requires prior prescription for oral Sumatriptan or Rizatriptan within the past 180 days; QL \(18 EA per 30 days\))/P 9201 0 R/K 38877 0 R>> endobj 25350 0 obj <>/Alt(\(Begin italic\) naratriptan oral tablet \(End italic\) \(Begin italic\) 1 mg, 2.5 mg \(End italic\))/P 9202 0 R/K 38878 0 R>> endobj 25351 0 obj <>/Alt(Tier 1)/P 9202 0 R/K 38879 0 R>> endobj 25352 0 obj <>/Alt(QL \(18 EA per 30 days\))/P 9202 0 R/K 38880 0 R>> endobj 25353 0 obj <>/Alt(NURTEC ODT ORAL TABLET,DISINTEGRATING 75 MG)/P 9203 0 R/K 38881 0 R>> endobj 25354 0 obj <>/Alt(Tier 2)/P 9203 0 R/K 38882 0 R>> endobj 25355 0 obj <>/Alt(PA)/P 9203 0 R/K 38883 0 R>> endobj 25356 0 obj <>/Alt(QULIPTA ORAL TABLET 10 MG, 30 MG, 60 MG)/P 9204 0 R/K 38884 0 R>> endobj 25357 0 obj <>/Alt(Tier 2)/P 9204 0 R/K 38885 0 R>> endobj 25358 0 obj <>/Alt(PA)/P 9204 0 R/K 38886 0 R>> endobj 25359 0 obj <>/Alt(REYVOW ORAL TABLET 100 MG, 50 MG)/P 9205 0 R/K 38887 0 R>> endobj 25360 0 obj <>/Alt(Tier 2)/P 9205 0 R/K 38888 0 R>> endobj 25361 0 obj <>/Alt(PA)/P 9205 0 R/K 38889 0 R>> endobj 25362 0 obj <>/Alt(\(Begin italic\) rizatriptan oral tablet \(End italic\) \(Begin italic\) 10 mg \(End italic\))/P 9206 0 R/K 38890 0 R>> endobj 25363 0 obj <>/Alt(\(Maxalt\))/P 9206 0 R/K 38891 0 R>> endobj 25364 0 obj <>/Alt(Tier 1)/P 9206 0 R/K 38892 0 R>> endobj 25365 0 obj <>/Alt(QL \(27 EA per 30 days\))/P 9206 0 R/K 38893 0 R>> endobj 25366 0 obj <>/Alt(\(Begin italic\) rizatriptan oral tablet \(End italic\) \(Begin italic\) 5 mg \(End italic\))/P 9207 0 R/K 38894 0 R>> endobj 25367 0 obj <>/Alt(Tier 1)/P 9207 0 R/K 38895 0 R>> endobj 25368 0 obj <>/Alt(QL \(27 EA per 30 days\))/P 9207 0 R/K 38896 0 R>> endobj 25369 0 obj <>/Alt(\(Begin italic\) rizatriptan oral tablet,disintegrating \(End italic\) \(Begin italic\) 10 mg \(End italic\))/P 9208 0 R/K 38897 0 R>> endobj 25370 0 obj <>/Alt(\(Maxalt-MLT\))/P 9208 0 R/K 38898 0 R>> endobj 25371 0 obj <>/Alt(Tier 1)/P 9208 0 R/K 38899 0 R>> endobj 25372 0 obj <>/Alt(QL \(27 EA per 30 days\))/P 9208 0 R/K 38900 0 R>> endobj 25373 0 obj <>/Alt(\(Begin italic\) rizatriptan oral tablet,disintegrating \(End italic\) \(Begin italic\) 5 mg \(End italic\))/P 9209 0 R/K 38901 0 R>> endobj 25374 0 obj <>/Alt(Tier 1)/P 9209 0 R/K 38902 0 R>> endobj 25375 0 obj <>/Alt(QL \(27 EA per 30 days\))/P 9209 0 R/K 38903 0 R>> endobj 25376 0 obj <>/Alt(\(Begin italic\) sumatriptan nasal spray,non-aerosol \(End italic\) \(Begin italic\) 20 mg/actuation \(End italic\))/P 9210 0 R/K 38904 0 R>> endobj 25377 0 obj <>/Alt(Tier 1)/P 9210 0 R/K 38905 0 R>> endobj 25378 0 obj <>/Alt(QL \(18 EA per 30 days\))/P 9210 0 R/K 38906 0 R>> endobj 25379 0 obj <>/Alt(\(Begin italic\) sumatriptan nasal spray,non-aerosol \(End italic\) \(Begin italic\) 5 mg/actuation \(End italic\))/P 9211 0 R/K 38907 0 R>> endobj 25380 0 obj <>/Alt(Tier 1)/P 9211 0 R/K 38908 0 R>> endobj 25381 0 obj <>/Alt(QL \(36 EA per 30 days\))/P 9211 0 R/K 38909 0 R>> endobj 25382 0 obj <>/Alt(\(Begin italic\) sumatriptan succinate oral tablet \(End italic\) \(Begin italic\) 100 mg, 25 mg, 50 mg \(End italic\))/P 9212 0 R/K 38910 0 R>> endobj 25383 0 obj <>/Alt(\(Imitrex\))/P 9212 0 R/K 38911 0 R>> endobj 25384 0 obj <>/Alt(Tier 1)/P 9212 0 R/K 38912 0 R>> endobj 25385 0 obj <>/Alt(QL \(18 EA per 30 days\))/P 9212 0 R/K 38913 0 R>> endobj 25386 0 obj <>/Alt(\(Begin italic\) sumatriptan succinate subcutaneous cartridge \(End italic\) \(Begin italic\) 4 mg/0.5 ml, 6 mg/0.5 ml \(End italic\))/P 9213 0 R/K 38914 0 R>> endobj 25387 0 obj <>/Alt(\(Imitrex STATdose Refill\))/P 9213 0 R/K 38915 0 R>> endobj 25388 0 obj <>/Alt(Tier 1)/P 9213 0 R/K 38916 0 R>> endobj 25389 0 obj <>/Alt(QL \(18 ML per 30 days\))/P 9213 0 R/K 38917 0 R>> endobj 25390 0 obj <>/Alt(\(Begin italic\) sumatriptan succinate subcutaneous pen injector \(End italic\) \(Begin italic\) 4 mg/0.5 ml, 6 mg/0.5 ml \(End italic\))/P 9214 0 R/K 38918 0 R>> endobj 25391 0 obj <>/Alt(\(Imitrex STATdose Pen\))/P 9214 0 R/K 38919 0 R>> endobj 25392 0 obj <>/Alt(Tier 1)/P 9214 0 R/K 38920 0 R>> endobj 25393 0 obj <>/Alt(QL \(18 ML per 30 days\))/P 9214 0 R/K 38921 0 R>> endobj 25394 0 obj <>/Alt(\(Begin italic\) sumatriptan succinate subcutaneous solution \(End italic\) \(Begin italic\) 6 mg/0.5 ml \(End italic\))/P 9215 0 R/K 38922 0 R>> endobj 25395 0 obj <>/Alt(\(Imitrex\))/P 9215 0 R/K 38923 0 R>> endobj 25396 0 obj <>/Alt(Tier 1)/P 9215 0 R/K 38924 0 R>> endobj 25397 0 obj <>/Alt(QL \(18 ML per 30 days\))/P 9215 0 R/K 38925 0 R>> endobj 25398 0 obj <>/Alt(\(Begin italic\) sumatriptan succinate subcutaneous syringe \(End italic\) \(Begin italic\) 6 mg/0.5 ml \(End italic\))/P 9216 0 R/K 38926 0 R>> endobj 25399 0 obj <>/Alt(Tier 1)/P 9216 0 R/K 38927 0 R>> endobj 25400 0 obj <>/Alt(QL \(18 ML per 30 days\))/P 9216 0 R/K 38928 0 R>> endobj 25401 0 obj <>/Alt(TRUDHESA NASAL SPRAY,NON-AEROSOL 0.725 MG/PUMP ACT. \(4 MG/ML\))/P 9217 0 R/K 38929 0 R>> endobj 25402 0 obj <>/Alt(Tier 3)/P 9217 0 R/K 38930 0 R>> endobj 25403 0 obj <>/Alt(ST: Requires prior prescription for oral Sumatriptan or Rizatriptan within the past 180 days; QL \(12 ML per 28 days\); Age \(Min 18 Years\))/P 9217 0 R/K 38931 0 R>> endobj 25404 0 obj <>/Alt(UBRELVY ORAL TABLET 100 MG, 50 MG)/P 9218 0 R/K 38932 0 R>> endobj 25405 0 obj <>/Alt(Tier 2)/P 9218 0 R/K 38933 0 R>> endobj 25406 0 obj <>/Alt(PA)/P 9218 0 R/K 38934 0 R>> endobj 25407 0 obj <>/Alt(ZAVZPRET NASAL SPRAY,NON-AEROSOL 10 MG/ACTUATION)/P 9219 0 R/K 38935 0 R>> endobj 25408 0 obj <>/Alt(Tier 3)/P 9219 0 R/K 38936 0 R>> endobj 25409 0 obj <>/Alt(PA)/P 9219 0 R/K 38937 0 R>> endobj 25410 0 obj <>/Alt(\(Begin italic\) zolmitriptan nasal spray,non-aerosol \(End italic\) \(Begin italic\) 2.5 mg, 5 mg \(End italic\))/P 9220 0 R/K 38938 0 R>> endobj 25411 0 obj <>/Alt(\(Zomig\))/P 9220 0 R/K 38939 0 R>> endobj 25412 0 obj <>/Alt(Tier 1)/P 9220 0 R/K 38940 0 R>> endobj 25413 0 obj <>/Alt(ST: Requires prior prescription for oral Sumatriptan or Rizatriptan within the past 180 days; QL \(18 EA per 30 days\))/P 9220 0 R/K 38941 0 R>> endobj 25414 0 obj <>/Alt(\(Begin italic\) zolmitriptan oral tablet \(End italic\) \(Begin italic\) 2.5 mg, 5 mg \(End italic\))/P 9221 0 R/K 38942 0 R>> endobj 25415 0 obj <>/Alt(\(Zomig\))/P 9221 0 R/K 38943 0 R>> endobj 25416 0 obj <>/Alt(Tier 1)/P 9221 0 R/K 38944 0 R>> endobj 25417 0 obj <>/Alt(ST: Requires prior prescription for oral Sumatriptan or Rizatriptan within the past 180 days; QL \(18 EA per 30 days\))/P 9221 0 R/K 38945 0 R>> endobj 25418 0 obj <>/Alt(\(Begin italic\) zolmitriptan oral tablet,disintegrating \(End italic\) \(Begin italic\) 2.5 mg, 5 mg \(End italic\))/P 9222 0 R/K 38946 0 R>> endobj 25419 0 obj <>/Alt(Tier 1)/P 9222 0 R/K 38947 0 R>> endobj 25420 0 obj <>/Alt(ST: Requires prior prescription for oral Sumatriptan or Rizatriptan within the past 180 days; QL \(18 EA per 30 days\))/P 9222 0 R/K 38948 0 R>> endobj 25421 0 obj <>/Alt(ZOMIG ORAL TABLET 2.5 MG, 5 MG)/P 9223 0 R/K 38949 0 R>> endobj 25422 0 obj <>/Alt(\(zolmitriptan\))/P 9223 0 R/K 38950 0 R>> endobj 25423 0 obj <>/Alt(Tier 1)/P 9223 0 R/K 38951 0 R>> endobj 25424 0 obj <>/Alt(ST: Requires prior prescription for oral Sumatriptan or Rizatriptan within the past 180 days; QL \(18 EA per 30 days\))/P 9223 0 R/K 38952 0 R>> endobj 25425 0 obj <>/Alt(\(Begin bold\) Calcitonin Gene-Related Peptide \(Cgrp\) Inhibitors \(End bold\))/P 9224 0 R/K 38953 0 R>> endobj 25426 0 obj <>/Alt(EMGALITY SYRINGE SUBCUTANEOUS SYRINGE 300 MG/3 ML \(100 MG/ML X 3\))/P 9225 0 R/K 38954 0 R>> endobj 25427 0 obj <>/Alt(Tier 2)/P 9225 0 R/K 38955 0 R>> endobj 25428 0 obj <>/Alt(PA)/P 9225 0 R/K 38956 0 R>> endobj 25429 0 obj <>/Alt(\(Begin bold\) Narc.& Non-Sal.Analgesic,Barbiturate &Xanthine Cmb \(End bold\))/P 9226 0 R/K 38957 0 R>> endobj 25430 0 obj <>/Alt(\(Begin italic\) butalbital-acetaminop-caf-cod oral capsule \(End italic\) \(Begin italic\) 50-300-40-30 mg \(End italic\))/P 9227 0 R/K 38958 0 R>> endobj 25431 0 obj <>/Alt(\(Fioricet with Codeine\))/P 9227 0 R/K 38959 0 R>> endobj 25432 0 obj <>/Alt(Tier 1)/P 9227 0 R/K 38960 0 R>> endobj 25433 0 obj <>/Alt(QL \(6 EA per 1 day\); Age \(Min 12 Years\))/P 9227 0 R/K 38961 0 R>> endobj 25434 0 obj <>/Alt(\(Begin italic\) butalbital-acetaminop-caf-cod oral capsule \(End italic\) \(Begin italic\) 50-325-40-30 mg \(End italic\))/P 9228 0 R/K 38962 0 R>> endobj 25435 0 obj <>/Alt(Tier 1)/P 9228 0 R/K 38963 0 R>> endobj 25436 0 obj <>/Alt(QL \(6 EA per 1 day\); Age \(Min 12 Years\))/P 9228 0 R/K 38964 0 R>> endobj 25437 0 obj <>/Alt(\(Begin bold\) Narcotic & Salicylate Analgesics, Barb.& Xanthine \(End bold\))/P 9229 0 R/K 38965 0 R>> endobj 25438 0 obj <>/Alt(ASCOMP WITH CODEINE ORAL CAPSULE 30-50-325-40 MG)/P 9230 0 R/K 38966 0 R>> endobj 25439 0 obj <>/Alt(\(codeine-butalbital-asa-caff\))/P 9230 0 R/K 38967 0 R>> endobj 25440 0 obj <>/Alt(Tier 1)/P 9230 0 R/K 38968 0 R>> endobj 25441 0 obj <>/Alt(QL \(6 EA per 1 day\); Age \(Min 12 Years\))/P 9230 0 R/K 38969 0 R>> endobj 25442 0 obj <>/Alt(\(Begin italic\) codeine-butalbital-asa-caff oral capsule \(End italic\) \(Begin italic\) 30-50-325-40 mg \(End italic\))/P 9231 0 R/K 38970 0 R>> endobj 25443 0 obj <>/Alt(\(Ascomp with Codeine\))/P 9231 0 R/K 38971 0 R>> endobj 25444 0 obj <>/Alt(Tier 1)/P 9231 0 R/K 38972 0 R>> endobj 25445 0 obj <>/Alt(QL \(6 EA per 1 day\); Age \(Min 12 Years\))/P 9231 0 R/K 38973 0 R>> endobj 25446 0 obj <>/Alt(\(Begin bold\) Narcotic Analgesic & Non-Salicylate Analgesic Comb \(End bold\))/P 9232 0 R/K 38974 0 R>> endobj 25447 0 obj <>/Alt(\(Begin italic\) acetaminophen-codeine oral solution \(End italic\) \(Begin italic\) 120 mg-12 mg /5 ml \(5 ml\), 120-12 mg/5 ml \(End italic\))/P 9233 0 R/K 38975 0 R>> endobj 25448 0 obj <>/Alt(Tier 1)/P 9233 0 R/K 38976 0 R>> endobj 25449 0 obj <>/Alt(QL \(150 ML per 1 day\); Age \(Min 12 Years\))/P 9233 0 R/K 38977 0 R>> endobj 25450 0 obj <>/Alt(\(Begin italic\) acetaminophen-codeine oral solution \(End italic\) \(Begin italic\) 300 mg-30 mg /12.5 ml \(End italic\))/P 9234 0 R/K 38978 0 R>> endobj 25451 0 obj <>/Alt(Tier 1)/P 9234 0 R/K 38979 0 R>> endobj 25452 0 obj <>/Alt(Age \(Min 12 Years\))/P 9234 0 R/K 38980 0 R>> endobj 25453 0 obj <>/Alt(\(Begin italic\) acetaminophen-codeine oral tablet \(End italic\) \(Begin italic\) 300-15 mg, 300-30 mg \(End italic\))/P 9235 0 R/K 38981 0 R>> endobj 25454 0 obj <>/Alt(Tier 1)/P 9235 0 R/K 38982 0 R>> endobj 25455 0 obj <>/Alt(QL \(12 EA per 1 day\); Age \(Min 12 Years\))/P 9235 0 R/K 38983 0 R>> endobj 25456 0 obj <>/Alt(\(Begin italic\) acetaminophen-codeine oral tablet \(End italic\) \(Begin italic\) 300-60 mg \(End italic\))/P 9236 0 R/K 38984 0 R>> endobj 25457 0 obj <>/Alt(Tier 1)/P 9236 0 R/K 38985 0 R>> endobj 25458 0 obj <>/Alt(QL \(6 EA per 1 day\); Age \(Min 12 Years\))/P 9236 0 R/K 38986 0 R>> endobj 25459 0 obj <>/Alt(APADAZ ORAL TABLET 4.08-325 MG, 6.12-325 MG, 8.16-325 MG)/P 9237 0 R/K 38987 0 R>> endobj 25460 0 obj <>/Alt(\(benzhydrocodone-acetaminophen\))/P 9237 0 R/K 38988 0 R>> endobj 25461 0 obj <>/Alt(Tier 3)/P 9237 0 R/K 38989 0 R>> endobj 25462 0 obj <>/Alt(ST: Requires prior prescription for generic Norco \(Hydrocodone/Acetaminophen\) tablets within the past 120 days; QL \(12 EA per 1 day\))/P 9237 0 R/K 38990 0 R>> endobj 25463 0 obj <>/Alt(\(Begin italic\) benzhydrocodone-acetaminophen oral tablet \(End italic\) \(Begin italic\) 4.08-325 mg, 6.12-325 mg, 8.16-325 mg \(End italic\))/P 9238 0 R/K 38991 0 R>> endobj 25464 0 obj <>/Alt(\(Apadaz\))/P 9238 0 R/K 38992 0 R>> endobj 25465 0 obj <>/Alt(Tier 1)/P 9238 0 R/K 38993 0 R>> endobj 25466 0 obj <>/Alt(ST: Requires prior prescription for generic Norco \(Hydrocodone/Acetaminophen\) tablets within the past 120 days; QL \(12 EA per 1 day\))/P 9238 0 R/K 38994 0 R>> endobj 25467 0 obj <>/Alt(ENDOCET ORAL TABLET 10-325 MG, 2.5-325 MG, 5-325 MG, 7.5-325 MG)/P 9239 0 R/K 38995 0 R>> endobj 25468 0 obj <>/Alt(\(oxycodone-acetaminophen\))/P 9239 0 R/K 38996 0 R>> endobj 25469 0 obj <>/Alt(Tier 1)/P 9239 0 R/K 38997 0 R>> endobj 25470 0 obj <>/Alt(QL \(12 EA per 1 day\))/P 9239 0 R/K 38998 0 R>> endobj 25471 0 obj <>/Alt(\(Begin italic\) hydrocodone-acetaminophen oral solution \(End italic\) \(Begin italic\) 7.5-325 mg/15 ml \(End italic\))/P 9240 0 R/K 38999 0 R>> endobj 25472 0 obj <>/Alt(Tier 1)/P 9240 0 R/K 39000 0 R>> endobj 25473 0 obj <>/Alt(QL \(184 ML per 1 day\))/P 9240 0 R/K 39001 0 R>> endobj 25474 0 obj <>/Alt(\(Begin italic\) hydrocodone-acetaminophen oral tablet \(End italic\) \(Begin italic\) 10-300 mg, 5-300 mg, 7.5-300 mg \(End italic\))/P 9241 0 R/K 39002 0 R>> endobj 25475 0 obj <>/Alt(Tier 1)/P 9241 0 R/K 39003 0 R>> endobj 25476 0 obj <>/Alt(QL \(13 EA per 1 day\))/P 9241 0 R/K 39004 0 R>> endobj 25477 0 obj <>/Alt(\(Begin italic\) hydrocodone-acetaminophen oral tablet \(End italic\) \(Begin italic\) 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg \(End italic\))/P 9242 0 R/K 39005 0 R>> endobj 25478 0 obj <>/Alt(Tier 1)/P 9242 0 R/K 39006 0 R>> endobj 25479 0 obj <>/Alt(QL \(12 EA per 1 day\))/P 9242 0 R/K 39007 0 R>> endobj 25480 0 obj <>/Alt(\(Begin italic\) oxycodone-acetaminophen oral solution \(End italic\) \(Begin italic\) 5-325 mg/5 ml \(End italic\))/P 9243 0 R/K 39008 0 R>> endobj 25481 0 obj <>/Alt(Tier 1)/P 9243 0 R/K 39009 0 R>> endobj 25482 0 obj <>/Alt(QL \(61 ML per 1 day\))/P 9243 0 R/K 39010 0 R>> endobj 25483 0 obj <>/Alt(\(Begin italic\) oxycodone-acetaminophen oral tablet \(End italic\) \(Begin italic\) 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg \(End italic\))/P 9244 0 R/K 39011 0 R>> endobj 25484 0 obj <>/Alt(\(Endocet\))/P 9244 0 R/K 39012 0 R>> endobj 25485 0 obj <>/Alt(Tier 1)/P 9244 0 R/K 39013 0 R>> endobj 25486 0 obj <>/Alt(QL \(12 EA per 1 day\))/P 9244 0 R/K 39014 0 R>> endobj 25487 0 obj <>/Alt(PERCOCET ORAL TABLET 10-325 MG, 2.5-325 MG, 5-325 MG, 7.5-325 MG)/P 9245 0 R/K 39015 0 R>> endobj 25488 0 obj <>/Alt(\(oxycodone-acetaminophen\))/P 9245 0 R/K 39016 0 R>> endobj 25489 0 obj <>/Alt(Tier 1)/P 9245 0 R/K 39017 0 R>> endobj 25490 0 obj <>/Alt(QL \(12 EA per 1 day\))/P 9245 0 R/K 39018 0 R>> endobj 25491 0 obj <>/Alt(\(Begin italic\) tramadol-acetaminophen oral tablet \(End italic\) \(Begin italic\) 37.5-325 mg \(End italic\))/P 9246 0 R/K 39019 0 R>> endobj 25492 0 obj <>/Alt(Tier 1)/P 9246 0 R/K 39020 0 R>> endobj 25493 0 obj <>/Alt(QL \(10 EA per 1 day\); Age \(Min 12 Years\))/P 9246 0 R/K 39021 0 R>> endobj 25494 0 obj <>/Alt(\(Begin bold\) Narcotic Withdrawal Therapy Agents \(End bold\))/P 9247 0 R/K 39022 0 R>> endobj 25495 0 obj <>/Alt(\(Begin italic\) buprenorphine hcl sublingual tablet \(End italic\) \(Begin italic\) 2 mg, 8 mg \(End italic\))/P 9248 0 R/K 39023 0 R>> endobj 25496 0 obj <>/Alt(Tier 1)/P 9248 0 R/K 39024 0 R>> endobj 25497 0 obj <>/Alt(QL \(3 EA per 1 day\))/P 9248 0 R/K 39025 0 R>> endobj 25498 0 obj <>/Alt(\(Begin italic\) buprenorphine-naloxone sublingual film \(End italic\) \(Begin italic\) 12-3 mg, 2-0.5 mg, 4-1 mg, 8-2 mg \(End italic\))/P 9249 0 R/K 39026 0 R>> endobj 25499 0 obj <>/Alt(\(Suboxone\))/P 9249 0 R/K 39027 0 R>> endobj 25500 0 obj <>/Alt(Tier 1)/P 9249 0 R/K 39028 0 R>> endobj 25501 0 obj <>/Alt(\(Begin italic\) buprenorphine-naloxone sublingual tablet \(End italic\) \(Begin italic\) 2-0.5 mg, 8-2 mg \(End italic\))/P 9250 0 R/K 39029 0 R>> endobj 25502 0 obj <>/Alt(Tier 1)/P 9250 0 R/K 39030 0 R>> endobj 25503 0 obj <>/Alt(QL \(3 EA per 1 day\))/P 9250 0 R/K 39031 0 R>> endobj 25504 0 obj <>/Alt(ZUBSOLV SUBLINGUAL TABLET 0.7-0.18 MG, 1.4-0.36 MG, 11.4-2.9 MG, 2.9-0.71 MG, 5.7-1.4 MG)/P 9251 0 R/K 39032 0 R>> endobj 25505 0 obj <>/Alt(Tier 2)/P 9251 0 R/K 39033 0 R>> endobj 25506 0 obj <>/Alt(QL \(1 EA per 1 day\))/P 9251 0 R/K 39034 0 R>> endobj 25507 0 obj <>/Alt(ZUBSOLV SUBLINGUAL TABLET 8.6-2.1 MG)/P 9252 0 R/K 39035 0 R>> endobj 25508 0 obj <>/Alt(Tier 2)/P 9252 0 R/K 39036 0 R>> endobj 25509 0 obj <>/Alt(QL \(2 EA per 1 day\))/P 9252 0 R/K 39037 0 R>> endobj 25510 0 obj <>/Alt(\(Begin bold\) Opioid Withdrawal Ther, Alpha-2 Adrenergic Agonist \(End bold\))/P 9253 0 R/K 39038 0 R>> endobj 25511 0 obj <>/Alt(\(Begin italic\) lofexidine oral tablet \(End italic\) \(Begin italic\) 0.18 mg \(End italic\))/P 9254 0 R/K 39039 0 R>> endobj 25512 0 obj <>/Alt(\(Lucemyra\))/P 9254 0 R/K 39040 0 R>> endobj 25513 0 obj <>/Alt(Tier 1)/P 9254 0 R/K 39041 0 R>> endobj 25514 0 obj <>/Alt(PA)/P 9254 0 R/K 39042 0 R>> endobj 25515 0 obj <>/Alt(\(Begin bold\) Skeletal Muscle Relaxant,Salicylate,Narc Analgesic \(End bold\))/P 9255 0 R/K 39043 0 R>> endobj 25516 0 obj <>/Alt(\(Begin italic\) carisoprodol-aspirin-codeine oral tablet \(End italic\) \(Begin italic\) 200-325-16 mg \(End italic\))/P 9256 0 R/K 39044 0 R>> endobj 25517 0 obj <>/Alt(Tier 1)/P 9256 0 R/K 39045 0 R>> endobj 25518 0 obj <>/Alt(QL \(8 EA per 1 day\); Age \(Min 12 Years\))/P 9256 0 R/K 39046 0 R>> endobj 25519 0 obj <>/Alt(\(Begin bold\) Parkinsons Disease \(End bold\))/P 9257 0 R/K 39047 0 R>> endobj 25520 0 obj <>/Alt(\(Begin bold\) Antiparkinsonism Drugs,Anticholinergic \(End bold\))/P 9258 0 R/K 39048 0 R>> endobj 25521 0 obj <>/Alt(\(Begin italic\) benztropine oral tablet \(End italic\) \(Begin italic\) 0.5 mg, 1 mg, 2 mg \(End italic\))/P 9259 0 R/K 39049 0 R>> endobj 25522 0 obj <>/Alt(Tier 1)/P 9259 0 R/K 39050 0 R>> endobj 25523 0 obj <>/Alt(\(Begin italic\) trihexyphenidyl oral elixir \(End italic\) \(Begin italic\) 0.4 mg/ml \(End italic\))/P 9260 0 R/K 39051 0 R>> endobj 25524 0 obj <>/Alt(Tier 1)/P 9260 0 R/K 39052 0 R>> endobj 25525 0 obj <>/Alt(\(Begin italic\) trihexyphenidyl oral tablet \(End italic\) \(Begin italic\) 2 mg, 5 mg \(End italic\))/P 9261 0 R/K 39053 0 R>> endobj 25526 0 obj <>/Alt(Tier 1)/P 9261 0 R/K 39054 0 R>> endobj 25527 0 obj <>/Alt(\(Begin bold\) Antiparkinsonism Drugs,Other \(End bold\))/P 9262 0 R/K 39055 0 R>> endobj 25528 0 obj <>/Alt(\(Begin italic\) amantadine hcl oral capsule \(End italic\) \(Begin italic\) 100 mg \(End italic\))/P 9263 0 R/K 39056 0 R>> endobj 25529 0 obj <>/Alt(Tier 1)/P 9263 0 R/K 39057 0 R>> endobj 25530 0 obj <>/Alt(\(Begin italic\) amantadine hcl oral solution \(End italic\) \(Begin italic\) 50 mg/5 ml \(End italic\))/P 9264 0 R/K 39058 0 R>> endobj 25531 0 obj <>/Alt(Tier 1)/P 9264 0 R/K 39059 0 R>> endobj 25532 0 obj <>/Alt(\(Begin italic\) amantadine hcl oral tablet \(End italic\) \(Begin italic\) 100 mg \(End italic\))/P 9265 0 R/K 39060 0 R>> endobj 25533 0 obj <>/Alt(Tier 1)/P 9265 0 R/K 39061 0 R>> endobj 25534 0 obj <>/Alt(\(Begin italic\) apomorphine subcutaneous cartridge \(End italic\) \(Begin italic\) 10 mg/ml \(End italic\))/P 9266 0 R/K 39062 0 R>> endobj 25535 0 obj <>/Alt(\(APOKYN\))/P 9266 0 R/K 39063 0 R>> endobj 25536 0 obj <>/Alt(Tier 1)/P 9266 0 R/K 39064 0 R>> endobj 25537 0 obj <>/Alt(PA; SP)/P 9266 0 R/K 39065 0 R>> endobj 25538 0 obj <>/Alt(\(Begin italic\) bromocriptine oral capsule \(End italic\) \(Begin italic\) 5 mg \(End italic\))/P 9267 0 R/K 39066 0 R>> endobj 25539 0 obj <>/Alt(Tier 1)/P 9267 0 R/K 39067 0 R>> endobj 25540 0 obj <>/Alt(\(Begin italic\) bromocriptine oral tablet \(End italic\) \(Begin italic\) 2.5 mg \(End italic\))/P 9268 0 R/K 39068 0 R>> endobj 25541 0 obj <>/Alt(Tier 1)/P 9268 0 R/K 39069 0 R>> endobj 25542 0 obj <>/Alt(\(Begin italic\) carbidopa-levodopa oral tablet \(End italic\) \(Begin italic\) 10-100 mg \(End italic\))/P 9269 0 R/K 39070 0 R>> endobj 25543 0 obj <>/Alt(\(Sinemet\))/P 9269 0 R/K 39071 0 R>> endobj 25544 0 obj <>/Alt(Tier 1)/P 9269 0 R/K 39072 0 R>> endobj 25545 0 obj <>/Alt(\(Begin italic\) carbidopa-levodopa oral tablet \(End italic\) \(Begin italic\) 25-100 mg \(End italic\))/P 9270 0 R/K 39073 0 R>> endobj 25546 0 obj <>/Alt(\(Dhivy\))/P 9270 0 R/K 39074 0 R>> endobj 25547 0 obj <>/Alt(Tier 1)/P 9270 0 R/K 39075 0 R>> endobj 25548 0 obj <>/Alt(\(Begin italic\) carbidopa-levodopa oral tablet \(End italic\) \(Begin italic\) 25-250 mg \(End italic\))/P 9271 0 R/K 39076 0 R>> endobj 25549 0 obj <>/Alt(Tier 1)/P 9271 0 R/K 39077 0 R>> endobj 25550 0 obj <>/Alt(\(Begin italic\) carbidopa-levodopa oral tablet extended release \(End italic\) \(Begin italic\) 25-100 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italic\) 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg, 5 mg \(End italic\))/P 9286 0 R/K 39117 0 R>> endobj 25590 0 obj <>/Alt(Tier 1)/P 9286 0 R/K 39118 0 R>> endobj 25591 0 obj <>/Alt(\(Begin italic\) ropinirole oral tablet extended release 24 hr \(End italic\) \(Begin italic\) 12 mg, 2 mg, 4 mg, 6 mg, 8 mg \(End italic\))/P 9287 0 R/K 39119 0 R>> endobj 25592 0 obj <>/Alt(Tier 1)/P 9287 0 R/K 39120 0 R>> endobj 25593 0 obj <>/Alt(ST: Requires prior prescription for immediate-release Pramipexole or immediate-release Ropinirole within the past 120 days; QL \(1 EA per 1 day\))/P 9287 0 R/K 39121 0 R>> endobj 25594 0 obj <>/Alt(RYTARY ORAL CAPSULE, EXTENDED RELEASE 23.75-95 MG, 36.25-145 MG, 48.75-195 MG, 61.25-245 MG)/P 9288 0 R/K 39122 0 R>> endobj 25595 0 obj <>/Alt(Tier 3)/P 9288 0 R/K 39123 0 R>> endobj 25596 0 obj <>/Alt(ST: Requires prior prescription for generic Carbidopa/Levodopa ER within the past 120 days; QL \(10 EA per 1 day\))/P 9288 0 R/K 39124 0 R>> endobj 25597 0 obj 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R>> endobj 25647 0 obj <>/Alt(SP; ST: Requires trial of or contraindication to 2 of the following generic anticonsulvants: Clobazam, Lamotrigine, Levetiracetam, Topiramate, or Valproic Acid witihn the past 365 days)/P 9308 0 R/K 39175 0 R>> endobj 25648 0 obj <>/Alt(\(Begin bold\) Anticonvulsants \(End bold\))/P 9309 0 R/K 39176 0 R>> endobj 25649 0 obj <>/Alt(APTIOM ORAL TABLET 200 MG, 400 MG)/P 9310 0 R/K 39177 0 R>> endobj 25650 0 obj <>/Alt(Tier 3)/P 9310 0 R/K 39178 0 R>> endobj 25651 0 obj <>/Alt(QL \(1 EA per 1 day\))/P 9310 0 R/K 39179 0 R>> endobj 25652 0 obj <>/Alt(APTIOM ORAL TABLET 600 MG, 800 MG)/P 9311 0 R/K 39180 0 R>> endobj 25653 0 obj <>/Alt(Tier 3)/P 9311 0 R/K 39181 0 R>> endobj 25654 0 obj <>/Alt(QL \(2 EA per 1 day\))/P 9311 0 R/K 39182 0 R>> endobj 25655 0 obj <>/Alt(BRIVIACT ORAL SOLUTION 10 MG/ML)/P 9312 0 R/K 39183 0 R>> endobj 25656 0 obj <>/Alt(Tier 2)/P 9312 0 R/K 39184 0 R>> endobj 25657 0 obj <>/Alt(QL \(600 ML per 30 days\))/P 9312 0 R/K 39185 0 R>> endobj 25658 0 obj <>/Alt(BRIVIACT ORAL TABLET 10 MG, 100 MG, 25 MG, 50 MG, 75 MG)/P 9313 0 R/K 39186 0 R>> endobj 25659 0 obj <>/Alt(Tier 2)/P 9313 0 R/K 39187 0 R>> endobj 25660 0 obj <>/Alt(QL \(2 EA per 1 day\))/P 9313 0 R/K 39188 0 R>> endobj 25661 0 obj <>/Alt(\(Begin italic\) carbamazepine oral capsule, er multiphase 12 hr \(End italic\) \(Begin italic\) 100 mg, 200 mg, 300 mg \(End italic\))/P 9314 0 R/K 39189 0 R>> endobj 25662 0 obj <>/Alt(\(Carbatrol\))/P 9314 0 R/K 39190 0 R>> endobj 25663 0 obj <>/Alt(Tier 1)/P 9314 0 R/K 39191 0 R>> endobj 25664 0 obj <>/Alt(\(Begin italic\) carbamazepine oral suspension \(End italic\) \(Begin italic\) 100 mg/5 ml \(End italic\))/P 9315 0 R/K 39192 0 R>> endobj 25665 0 obj <>/Alt(\(Tegretol\))/P 9315 0 R/K 39193 0 R>> endobj 25666 0 obj <>/Alt(Tier 1)/P 9315 0 R/K 39194 0 R>> endobj 25667 0 obj <>/Alt(\(Begin italic\) carbamazepine oral tablet \(End italic\) \(Begin italic\) 200 mg \(End italic\))/P 9316 0 R/K 39195 0 R>> endobj 25668 0 obj <>/Alt(\(Epitol\))/P 9316 0 R/K 39196 0 R>> endobj 25669 0 obj <>/Alt(Tier 1)/P 9316 0 R/K 39197 0 R>> endobj 25670 0 obj <>/Alt(\(Begin italic\) carbamazepine oral tablet extended release 12 hr \(End italic\) \(Begin italic\) 100 mg, 200 mg, 400 mg \(End italic\))/P 9317 0 R/K 39198 0 R>> endobj 25671 0 obj <>/Alt(\(Tegretol XR\))/P 9317 0 R/K 39199 0 R>> endobj 25672 0 obj <>/Alt(Tier 1)/P 9317 0 R/K 39200 0 R>> endobj 25673 0 obj <>/Alt(\(Begin italic\) carbamazepine oral tablet,chewable \(End italic\) \(Begin italic\) 100 mg, 200 mg \(End italic\))/P 9318 0 R/K 39201 0 R>> endobj 25674 0 obj <>/Alt(Tier 1)/P 9318 0 R/K 39202 0 R>> endobj 25675 0 obj <>/Alt(CARBATROL ORAL CAPSULE, ER MULTIPHASE 12 HR 100 MG, 200 MG, 300 MG)/P 9319 0 R/K 39203 0 R>> endobj 25676 0 obj <>/Alt(\(carbamazepine\))/P 9319 0 R/K 39204 0 R>> endobj 25677 0 obj <>/Alt(Tier 3)/P 9319 0 R/K 39205 0 R>> endobj 25678 0 obj <>/Alt(DEPAKOTE ER ORAL TABLET EXTENDED RELEASE 24 HR 250 MG, 500 MG)/P 9320 0 R/K 39206 0 R>> endobj 25679 0 obj <>/Alt(\(divalproex\))/P 9320 0 R/K 39207 0 R>> endobj 25680 0 obj <>/Alt(Tier 3)/P 9320 0 R/K 39208 0 R>> endobj 25681 0 obj <>/Alt(DEPAKOTE ORAL TABLET,DELAYED RELEASE \(DR/EC\) 125 MG, 250 MG, 500 MG)/P 9321 0 R/K 39209 0 R>> endobj 25682 0 obj <>/Alt(\(divalproex\))/P 9321 0 R/K 39210 0 R>> endobj 25683 0 obj <>/Alt(Tier 3)/P 9321 0 R/K 39211 0 R>> endobj 25684 0 obj <>/Alt(DEPAKOTE SPRINKLES ORAL CAPSULE, DELAYED REL SPRINKLE 125 MG)/P 9322 0 R/K 39212 0 R>> endobj 25685 0 obj <>/Alt(\(divalproex\))/P 9322 0 R/K 39213 0 R>> endobj 25686 0 obj <>/Alt(Tier 3)/P 9322 0 R/K 39214 0 R>> endobj 25687 0 obj <>/Alt(DIACOMIT ORAL CAPSULE 250 MG, 500 MG)/P 9323 0 R/K 39215 0 R>> endobj 25688 0 obj <>/Alt(Tier 3)/P 9323 0 R/K 39216 0 R>> endobj 25689 0 obj <>/Alt(PA; SP)/P 9323 0 R/K 39217 0 R>> endobj 25690 0 obj <>/Alt(DIACOMIT ORAL POWDER IN PACKET 250 MG, 500 MG)/P 9324 0 R/K 39218 0 R>> endobj 25691 0 obj <>/Alt(Tier 3)/P 9324 0 R/K 39219 0 R>> endobj 25692 0 obj <>/Alt(PA; SP)/P 9324 0 R/K 39220 0 R>> endobj 25693 0 obj <>/Alt(DILANTIN EXTENDED ORAL CAPSULE 100 MG)/P 9325 0 R/K 39221 0 R>> endobj 25694 0 obj <>/Alt(\(phenytoin sodium extended\))/P 9325 0 R/K 39222 0 R>> endobj 25695 0 obj <>/Alt(Tier 3)/P 9325 0 R/K 39223 0 R>> endobj 25696 0 obj <>/Alt(DILANTIN INFATABS ORAL TABLET,CHEWABLE 50 MG)/P 9326 0 R/K 39224 0 R>> endobj 25697 0 obj <>/Alt(\(phenytoin\))/P 9326 0 R/K 39225 0 R>> endobj 25698 0 obj <>/Alt(Tier 3)/P 9326 0 R/K 39226 0 R>> endobj 25699 0 obj <>/Alt(DILANTIN ORAL CAPSULE 30 MG)/P 9327 0 R/K 39227 0 R>> endobj 25700 0 obj <>/Alt(Tier 3)/P 9327 0 R/K 39228 0 R>> endobj 25701 0 obj <>/Alt(DILANTIN-125 ORAL SUSPENSION 125 MG/5 ML)/P 9328 0 R/K 39229 0 R>> endobj 25702 0 obj <>/Alt(\(phenytoin\))/P 9328 0 R/K 39230 0 R>> endobj 25703 0 obj <>/Alt(Tier 3)/P 9328 0 R/K 39231 0 R>> endobj 25704 0 obj <>/Alt(\(Begin italic\) divalproex oral capsule, delayed rel sprinkle \(End italic\) \(Begin italic\) 125 mg \(End italic\))/P 9329 0 R/K 39232 0 R>> endobj 25705 0 obj <>/Alt(\(Depakote Sprinkles\))/P 9329 0 R/K 39233 0 R>> endobj 25706 0 obj <>/Alt(Tier 1)/P 9329 0 R/K 39234 0 R>> endobj 25707 0 obj <>/Alt(\(Begin italic\) divalproex oral tablet extended release 24 hr \(End italic\) \(Begin italic\) 250 mg, 500 mg \(End italic\))/P 9330 0 R/K 39235 0 R>> endobj 25708 0 obj <>/Alt(\(Depakote ER\))/P 9330 0 R/K 39236 0 R>> endobj 25709 0 obj <>/Alt(Tier 1)/P 9330 0 R/K 39237 0 R>> endobj 25710 0 obj <>/Alt(\(Begin italic\) divalproex oral tablet,delayed release \(dr/ec\) \(End italic\) \(Begin italic\) 125 mg, 250 mg, 500 mg \(End italic\))/P 9331 0 R/K 39238 0 R>> endobj 25711 0 obj <>/Alt(\(Depakote\))/P 9331 0 R/K 39239 0 R>> endobj 25712 0 obj <>/Alt(Tier 1)/P 9331 0 R/K 39240 0 R>> endobj 25713 0 obj <>/Alt(EPITOL ORAL TABLET 200 MG)/P 9332 0 R/K 39241 0 R>> endobj 25714 0 obj <>/Alt(\(carbamazepine\))/P 9332 0 R/K 39242 0 R>> endobj 25715 0 obj <>/Alt(Tier 1)/P 9332 0 R/K 39243 0 R>> endobj 25716 0 obj <>/Alt(EPRONTIA ORAL SOLUTION 25 MG/ML)/P 9333 0 R/K 39244 0 R>> endobj 25717 0 obj <>/Alt(Tier 3)/P 9333 0 R/K 39245 0 R>> endobj 25718 0 obj <>/Alt(PA)/P 9333 0 R/K 39246 0 R>> endobj 25719 0 obj <>/Alt(\(Begin italic\) ethosuximide oral capsule \(End italic\) \(Begin italic\) 250 mg \(End italic\))/P 9334 0 R/K 39247 0 R>> endobj 25720 0 obj <>/Alt(\(Zarontin\))/P 9334 0 R/K 39248 0 R>> endobj 25721 0 obj <>/Alt(Tier 1)/P 9334 0 R/K 39249 0 R>> endobj 25722 0 obj <>/Alt(\(Begin italic\) ethosuximide oral solution \(End italic\) \(Begin italic\) 250 mg/5 ml \(End italic\))/P 9335 0 R/K 39250 0 R>> endobj 25723 0 obj <>/Alt(\(Zarontin\))/P 9335 0 R/K 39251 0 R>> endobj 25724 0 obj <>/Alt(Tier 1)/P 9335 0 R/K 39252 0 R>> endobj 25725 0 obj <>/Alt(\(Begin italic\) felbamate oral suspension \(End italic\) \(Begin italic\) 600 mg/5 ml \(End italic\))/P 9336 0 R/K 39253 0 R>> endobj 25726 0 obj <>/Alt(Tier 1)/P 9336 0 R/K 39254 0 R>> endobj 25727 0 obj <>/Alt(QL \(30 ML per 1 day\))/P 9336 0 R/K 39255 0 R>> endobj 25728 0 obj <>/Alt(\(Begin italic\) felbamate oral tablet \(End italic\) \(Begin italic\) 400 mg \(End italic\))/P 9337 0 R/K 39256 0 R>> endobj 25729 0 obj <>/Alt(\(Felbatol\))/P 9337 0 R/K 39257 0 R>> endobj 25730 0 obj <>/Alt(Tier 1)/P 9337 0 R/K 39258 0 R>> endobj 25731 0 obj <>/Alt(QL \(9 EA per 1 day\))/P 9337 0 R/K 39259 0 R>> endobj 25732 0 obj <>/Alt(\(Begin italic\) felbamate oral tablet \(End italic\) \(Begin italic\) 600 mg \(End italic\))/P 9338 0 R/K 39260 0 R>> endobj 25733 0 obj <>/Alt(\(Felbatol\))/P 9338 0 R/K 39261 0 R>> endobj 25734 0 obj <>/Alt(Tier 1)/P 9338 0 R/K 39262 0 R>> endobj 25735 0 obj <>/Alt(QL \(6 EA per 1 day\))/P 9338 0 R/K 39263 0 R>> endobj 25736 0 obj <>/Alt(FINTEPLA ORAL SOLUTION 2.2 MG/ML)/P 9339 0 R/K 39264 0 R>> endobj 25737 0 obj <>/Alt(Tier 3)/P 9339 0 R/K 39265 0 R>> endobj 25738 0 obj <>/Alt(PA; SP)/P 9339 0 R/K 39266 0 R>> endobj 25739 0 obj <>/Alt(FYCOMPA ORAL SUSPENSION 0.5 MG/ML)/P 9340 0 R/K 39267 0 R>> endobj 25740 0 obj <>/Alt(Tier 2)/P 9340 0 R/K 39268 0 R>> endobj 25741 0 obj <>/Alt(QL \(680 ML per 28 days\))/P 9340 0 R/K 39269 0 R>> endobj 25742 0 obj <>/Alt(FYCOMPA ORAL TABLET 10 MG, 12 MG, 8 MG)/P 9341 0 R/K 39270 0 R>> endobj 25743 0 obj <>/Alt(Tier 2)/P 9341 0 R/K 39271 0 R>> endobj 25744 0 obj <>/Alt(QL \(30 EA per 30 days\))/P 9341 0 R/K 39272 0 R>> endobj 25745 0 obj <>/Alt(FYCOMPA ORAL TABLET 2 MG)/P 9342 0 R/K 39273 0 R>> endobj 25746 0 obj <>/Alt(Tier 2)/P 9342 0 R/K 39274 0 R>> endobj 25747 0 obj <>/Alt(QL \(120 EA per 30 days\))/P 9342 0 R/K 39275 0 R>> endobj 25748 0 obj <>/Alt(FYCOMPA ORAL TABLET 4 MG, 6 MG)/P 9343 0 R/K 39276 0 R>> endobj 25749 0 obj <>/Alt(Tier 2)/P 9343 0 R/K 39277 0 R>> endobj 25750 0 obj <>/Alt(QL \(60 EA per 30 days\))/P 9343 0 R/K 39278 0 R>> endobj 25751 0 obj <>/Alt(\(Begin italic\) gabapentin oral capsule \(End italic\) \(Begin italic\) 100 mg, 300 mg, 400 mg \(End italic\))/P 9344 0 R/K 39279 0 R>> endobj 25752 0 obj <>/Alt(\(Neurontin\))/P 9344 0 R/K 39280 0 R>> endobj 25753 0 obj <>/Alt(Tier 1)/P 9344 0 R/K 39281 0 R>> endobj 25754 0 obj <>/Alt(\(Begin italic\) gabapentin oral solution \(End italic\) \(Begin italic\) 250 mg/5 ml \(End italic\))/P 9345 0 R/K 39282 0 R>> endobj 25755 0 obj <>/Alt(\(Neurontin\))/P 9345 0 R/K 39283 0 R>> endobj 25756 0 obj <>/Alt(Tier 1)/P 9345 0 R/K 39284 0 R>> endobj 25757 0 obj <>/Alt(\(Begin italic\) gabapentin oral solution \(End italic\) \(Begin italic\) 300 mg/6 ml \(6 ml\) \(End italic\))/P 9346 0 R/K 39285 0 R>> endobj 25758 0 obj <>/Alt(Tier 1)/P 9346 0 R/K 39286 0 R>> endobj 25759 0 obj <>/Alt(\(Begin italic\) gabapentin oral tablet \(End italic\) \(Begin italic\) 600 mg, 800 mg \(End italic\))/P 9347 0 R/K 39287 0 R>> endobj 25760 0 obj <>/Alt(\(Neurontin\))/P 9347 0 R/K 39288 0 R>> endobj 25761 0 obj <>/Alt(Tier 1)/P 9347 0 R/K 39289 0 R>> endobj 25762 0 obj <>/Alt(\(Begin italic\) lacosamide oral solution \(End italic\) \(Begin italic\) 10 mg/ml \(End italic\))/P 9348 0 R/K 39290 0 R>> endobj 25763 0 obj <>/Alt(\(Vimpat\))/P 9348 0 R/K 39291 0 R>> endobj 25764 0 obj <>/Alt(Tier 1)/P 9348 0 R/K 39292 0 R>> endobj 25765 0 obj <>/Alt(QL \(1200 ML per 30 days\))/P 9348 0 R/K 39293 0 R>> endobj 25766 0 obj <>/Alt(\(Begin italic\) lacosamide oral tablet \(End italic\) \(Begin italic\) 100 mg, 150 mg, 200 mg, 50 mg \(End italic\))/P 9349 0 R/K 39294 0 R>> endobj 25767 0 obj <>/Alt(\(Vimpat\))/P 9349 0 R/K 39295 0 R>> endobj 25768 0 obj <>/Alt(Tier 1)/P 9349 0 R/K 39296 0 R>> endobj 25769 0 obj <>/Alt(QL \(2 EA per 1 day\))/P 9349 0 R/K 39297 0 R>> endobj 25770 0 obj <>/Alt(LAMICTAL XR STARTER \(BLUE\) ORAL TABLET EXTENDED REL,DOSE PACK 25 MG \(21\) -50 MG \(7\))/P 9350 0 R/K 39298 0 R>> endobj 25771 0 obj <>/Alt(Tier 3)/P 9350 0 R/K 39299 0 R>> endobj 25772 0 obj <>/Alt(LAMICTAL XR STARTER \(GREEN\) ORAL TABLET EXTENDED REL,DOSE PACK 50 MG\(14\)-100MG \(14\)-200 MG \(7\))/P 9351 0 R/K 39300 0 R>> endobj 25773 0 obj <>/Alt(Tier 3)/P 9351 0 R/K 39301 0 R>> endobj 25774 0 obj <>/Alt(LAMICTAL XR STARTER \(ORANGE\) ORAL TABLET EXTENDED REL,DOSE PACK 25MG \(14\)-50 MG \(14\)-100MG \(7\))/P 9352 0 R/K 39302 0 R>> endobj 25775 0 obj <>/Alt(Tier 3)/P 9352 0 R/K 39303 0 R>> endobj 25776 0 obj <>/Alt(\(Begin italic\) lamotrigine oral tablet \(End italic\) \(Begin italic\) 100 mg, 150 mg, 200 mg, 25 mg \(End italic\))/P 9353 0 R/K 39304 0 R>> endobj 25777 0 obj <>/Alt(\(Lamictal\))/P 9353 0 R/K 39305 0 R>> endobj 25778 0 obj <>/Alt(Tier 1)/P 9353 0 R/K 39306 0 R>> endobj 25779 0 obj <>/Alt(\(Begin italic\) lamotrigine oral tablet disintegrating, dose pk \(End italic\) \(Begin italic\) 25 mg \(21\) -50 mg \(7\) \(End italic\))/P 9354 0 R/K 39307 0 R>> endobj 25780 0 obj <>/Alt(\(Lamictal ODT Starter \(Blue\)\))/P 9354 0 R/K 39308 0 R>> endobj 25781 0 obj <>/Alt(Tier 1)/P 9354 0 R/K 39309 0 R>> endobj 25782 0 obj <>/Alt(\(Begin italic\) lamotrigine oral tablet disintegrating, dose pk \(End italic\) \(Begin italic\) 25 mg\(14\)-50 mg \(14\)-100 mg \(7\) \(End italic\))/P 9355 0 R/K 39310 0 R>> endobj 25783 0 obj <>/Alt(\(Lamictal ODT Starter \(Orange\)\))/P 9355 0 R/K 39311 0 R>> endobj 25784 0 obj <>/Alt(Tier 1)/P 9355 0 R/K 39312 0 R>> endobj 25785 0 obj <>/Alt(\(Begin italic\) lamotrigine oral tablet disintegrating, dose pk \(End italic\) \(Begin italic\) 50 mg \(42\) -100 mg \(14\) \(End italic\))/P 9356 0 R/K 39313 0 R>> endobj 25786 0 obj <>/Alt(\(Lamictal ODT Starter \(Green\)\))/P 9356 0 R/K 39314 0 R>> endobj 25787 0 obj <>/Alt(Tier 1)/P 9356 0 R/K 39315 0 R>> endobj 25788 0 obj <>/Alt(\(Begin italic\) lamotrigine oral tablet extended release 24hr \(End italic\) \(Begin italic\) 100 mg \(End italic\))/P 9357 0 R/K 39316 0 R>> endobj 25789 0 obj <>/Alt(\(Lamictal XR\))/P 9357 0 R/K 39317 0 R>> endobj 25790 0 obj <>/Alt(Tier 1)/P 9357 0 R/K 39318 0 R>> endobj 25791 0 obj <>/Alt(QL \(3 EA per 1 day\))/P 9357 0 R/K 39319 0 R>> endobj 25792 0 obj <>/Alt(\(Begin italic\) lamotrigine oral tablet extended release 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<>/Alt(\(Begin italic\) lamotrigine oral tablet,disintegrating \(End italic\) \(Begin italic\) 100 mg \(End italic\))/P 9361 0 R/K 39331 0 R>> endobj 25804 0 obj <>/Alt(\(Lamictal ODT\))/P 9361 0 R/K 39332 0 R>> endobj 25805 0 obj <>/Alt(Tier 1)/P 9361 0 R/K 39333 0 R>> endobj 25806 0 obj <>/Alt(QL \(3 EA per 1 day\))/P 9361 0 R/K 39334 0 R>> endobj 25807 0 obj <>/Alt(\(Begin italic\) lamotrigine oral tablet,disintegrating \(End italic\) \(Begin italic\) 200 mg \(End italic\))/P 9362 0 R/K 39335 0 R>> endobj 25808 0 obj <>/Alt(\(Lamictal ODT\))/P 9362 0 R/K 39336 0 R>> endobj 25809 0 obj <>/Alt(Tier 1)/P 9362 0 R/K 39337 0 R>> endobj 25810 0 obj <>/Alt(QL \(2 EA per 1 day\))/P 9362 0 R/K 39338 0 R>> endobj 25811 0 obj <>/Alt(\(Begin italic\) lamotrigine oral tablet,disintegrating \(End italic\) \(Begin italic\) 25 mg, 50 mg \(End italic\))/P 9363 0 R/K 39339 0 R>> endobj 25812 0 obj <>/Alt(\(Lamictal ODT\))/P 9363 0 R/K 39340 0 R>> endobj 25813 0 obj <>/Alt(Tier 1)/P 9363 0 R/K 39341 0 R>> endobj 25814 0 obj <>/Alt(QL \(6 EA per 1 day\))/P 9363 0 R/K 39342 0 R>> endobj 25815 0 obj <>/Alt(\(Begin italic\) lamotrigine oral tablets,dose pack \(End italic\) \(Begin italic\) 25 mg \(35\) \(End italic\))/P 9364 0 R/K 39343 0 R>> endobj 25816 0 obj <>/Alt(\(Lamictal Starter \(Blue\) Kit\))/P 9364 0 R/K 39344 0 R>> endobj 25817 0 obj <>/Alt(Tier 1)/P 9364 0 R/K 39345 0 R>> endobj 25818 0 obj <>/Alt(\(Begin italic\) lamotrigine oral tablets,dose pack \(End italic\) \(Begin italic\) 25 mg \(42\) -100 mg \(7\) \(End italic\))/P 9365 0 R/K 39346 0 R>> endobj 25819 0 obj <>/Alt(\(Lamictal Starter \(Orange\) Kit\))/P 9365 0 R/K 39347 0 R>> endobj 25820 0 obj <>/Alt(Tier 1)/P 9365 0 R/K 39348 0 R>> endobj 25821 0 obj <>/Alt(\(Begin italic\) lamotrigine oral tablets,dose pack \(End italic\) \(Begin italic\) 25 mg \(84\) -100 mg \(14\) \(End italic\))/P 9366 0 R/K 39349 0 R>> endobj 25822 0 obj <>/Alt(\(Lamictal Starter \(Green\) Kit\))/P 9366 0 R/K 39350 0 R>> endobj 25823 0 obj <>/Alt(Tier 1)/P 9366 0 R/K 39351 0 R>> endobj 25824 0 obj <>/Alt(\(Begin italic\) levetiracetam oral solution \(End italic\) \(Begin italic\) 100 mg/ml \(End italic\))/P 9367 0 R/K 39352 0 R>> endobj 25825 0 obj <>/Alt(\(Keppra\))/P 9367 0 R/K 39353 0 R>> endobj 25826 0 obj <>/Alt(Tier 1)/P 9367 0 R/K 39354 0 R>> endobj 25827 0 obj <>/Alt(\(Begin italic\) levetiracetam oral tablet \(End italic\) \(Begin italic\) 1,000 mg, 250 mg, 500 mg, 750 mg \(End italic\))/P 9368 0 R/K 39355 0 R>> endobj 25828 0 obj <>/Alt(\(Keppra\))/P 9368 0 R/K 39356 0 R>> endobj 25829 0 obj <>/Alt(Tier 1)/P 9368 0 R/K 39357 0 R>> endobj 25830 0 obj <>/Alt(\(Begin italic\) levetiracetam oral tablet extended release 24 hr \(End italic\) \(Begin italic\) 500 mg, 750 mg \(End italic\))/P 9369 0 R/K 39358 0 R>> endobj 25831 0 obj <>/Alt(\(Keppra XR\))/P 9369 0 R/K 39359 0 R>> endobj 25832 0 obj <>/Alt(Tier 1)/P 9369 0 R/K 39360 0 R>> endobj 25833 0 obj <>/Alt(\(Begin italic\) methsuximide oral capsule \(End italic\) \(Begin italic\) 300 mg \(End italic\))/P 9370 0 R/K 39361 0 R>> endobj 25834 0 obj <>/Alt(\(Celontin\))/P 9370 0 R/K 39362 0 R>> endobj 25835 0 obj <>/Alt(Tier 1)/P 9370 0 R/K 39363 0 R>> endobj 25836 0 obj <>/Alt(\(Begin italic\) oxcarbazepine oral suspension \(End italic\) \(Begin italic\) 300 mg/5 ml \(60 mg/ml\) \(End italic\))/P 9371 0 R/K 39364 0 R>> endobj 25837 0 obj <>/Alt(\(Trileptal\))/P 9371 0 R/K 39365 0 R>> endobj 25838 0 obj <>/Alt(Tier 1)/P 9371 0 R/K 39366 0 R>> endobj 25839 0 obj <>/Alt(\(Begin italic\) oxcarbazepine oral tablet \(End italic\) \(Begin italic\) 150 mg, 300 mg, 600 mg \(End italic\))/P 9372 0 R/K 39367 0 R>> endobj 25840 0 obj <>/Alt(\(Trileptal\))/P 9372 0 R/K 39368 0 R>> endobj 25841 0 obj <>/Alt(Tier 1)/P 9372 0 R/K 39369 0 R>> endobj 25842 0 obj <>/Alt(\(Begin italic\) oxcarbazepine oral tablet extended release 24 hr \(End italic\) \(Begin italic\) 150 mg, 300 mg \(End italic\))/P 9373 0 R/K 39370 0 R>> endobj 25843 0 obj <>/Alt(\(Oxtellar XR\))/P 9373 0 R/K 39371 0 R>> endobj 25844 0 obj <>/Alt(Tier 1)/P 9373 0 R/K 39372 0 R>> endobj 25845 0 obj <>/Alt(QL \(1 EA per 1 day\))/P 9373 0 R/K 39373 0 R>> endobj 25846 0 obj <>/Alt(\(Begin italic\) oxcarbazepine oral tablet extended release 24 hr \(End italic\) \(Begin italic\) 600 mg \(End italic\))/P 9374 0 R/K 39374 0 R>> endobj 25847 0 obj <>/Alt(\(Oxtellar XR\))/P 9374 0 R/K 39375 0 R>> endobj 25848 0 obj <>/Alt(Tier 1)/P 9374 0 R/K 39376 0 R>> endobj 25849 0 obj <>/Alt(QL \(4 EA per 1 day\))/P 9374 0 R/K 39377 0 R>> endobj 25850 0 obj <>/Alt(PHENYTEK ORAL CAPSULE 200 MG, 300 MG)/P 9375 0 R/K 39378 0 R>> endobj 25851 0 obj <>/Alt(\(phenytoin sodium extended\))/P 9375 0 R/K 39379 0 R>> endobj 25852 0 obj <>/Alt(Tier 3)/P 9375 0 R/K 39380 0 R>> endobj 25853 0 obj <>/Alt(\(Begin italic\) phenytoin oral suspension \(End italic\) \(Begin italic\) 125 mg/5 ml \(End italic\))/P 9376 0 R/K 39381 0 R>> endobj 25854 0 obj <>/Alt(\(Dilantin-125\))/P 9376 0 R/K 39382 0 R>> endobj 25855 0 obj <>/Alt(Tier 1)/P 9376 0 R/K 39383 0 R>> endobj 25856 0 obj <>/Alt(\(Begin italic\) phenytoin oral tablet,chewable \(End italic\) \(Begin italic\) 50 mg \(End italic\))/P 9377 0 R/K 39384 0 R>> endobj 25857 0 obj <>/Alt(\(Dilantin Infatabs\))/P 9377 0 R/K 39385 0 R>> endobj 25858 0 obj <>/Alt(Tier 1)/P 9377 0 R/K 39386 0 R>> endobj 25859 0 obj <>/Alt(\(Begin italic\) phenytoin sodium extended oral capsule \(End italic\) \(Begin italic\) 100 mg \(End italic\))/P 9378 0 R/K 39387 0 R>> endobj 25860 0 obj <>/Alt(\(Dilantin Extended\))/P 9378 0 R/K 39388 0 R>> endobj 25861 0 obj <>/Alt(Tier 1)/P 9378 0 R/K 39389 0 R>> endobj 25862 0 obj <>/Alt(\(Begin italic\) phenytoin sodium extended oral capsule \(End italic\) \(Begin italic\) 200 mg, 300 mg \(End italic\))/P 9379 0 R/K 39390 0 R>> endobj 25863 0 obj <>/Alt(\(Phenytek\))/P 9379 0 R/K 39391 0 R>> endobj 25864 0 obj <>/Alt(Tier 1)/P 9379 0 R/K 39392 0 R>> endobj 25865 0 obj <>/Alt(\(Begin italic\) pregabalin oral capsule \(End italic\) \(Begin italic\) 100 mg, 150 mg, 200 mg, 225 mg, 25 mg, 300 mg, 50 mg, 75 mg \(End italic\))/P 9380 0 R/K 39393 0 R>> endobj 25866 0 obj <>/Alt(\(Lyrica\))/P 9380 0 R/K 39394 0 R>> endobj 25867 0 obj <>/Alt(Tier 1)/P 9380 0 R/K 39395 0 R>> endobj 25868 0 obj <>/Alt(\(Begin italic\) pregabalin oral solution \(End italic\) \(Begin italic\) 20 mg/ml \(End italic\))/P 9381 0 R/K 39396 0 R>> endobj 25869 0 obj <>/Alt(\(Lyrica\))/P 9381 0 R/K 39397 0 R>> endobj 25870 0 obj <>/Alt(Tier 1)/P 9381 0 R/K 39398 0 R>> endobj 25871 0 obj <>/Alt(\(Begin italic\) primidone oral tablet \(End italic\) \(Begin italic\) 125 mg \(End italic\))/P 9382 0 R/K 39399 0 R>> endobj 25872 0 obj <>/Alt(Tier 1)/P 9382 0 R/K 39400 0 R>> endobj 25873 0 obj <>/Alt(\(Begin italic\) primidone oral tablet \(End italic\) \(Begin italic\) 250 mg, 50 mg \(End italic\))/P 9383 0 R/K 39401 0 R>> endobj 25874 0 obj <>/Alt(\(Mysoline\))/P 9383 0 R/K 39402 0 R>> endobj 25875 0 obj <>/Alt(Tier 1)/P 9383 0 R/K 39403 0 R>> endobj 25876 0 obj <>/Alt(\(Begin italic\) rufinamide oral suspension \(End italic\) \(Begin italic\) 40 mg/ml \(End italic\))/P 9384 0 R/K 39404 0 R>> endobj 25877 0 obj <>/Alt(\(Banzel\))/P 9384 0 R/K 39405 0 R>> endobj 25878 0 obj <>/Alt(Tier 1)/P 9384 0 R/K 39406 0 R>> endobj 25879 0 obj <>/Alt(QL \(80 ML per 1 day\))/P 9384 0 R/K 39407 0 R>> endobj 25880 0 obj <>/Alt(\(Begin italic\) rufinamide oral tablet \(End italic\) \(Begin italic\) 200 mg \(End italic\))/P 9385 0 R/K 39408 0 R>> endobj 25881 0 obj <>/Alt(\(Banzel\))/P 9385 0 R/K 39409 0 R>> endobj 25882 0 obj <>/Alt(Tier 1)/P 9385 0 R/K 39410 0 R>> endobj 25883 0 obj <>/Alt(QL \(16 EA per 1 day\))/P 9385 0 R/K 39411 0 R>> endobj 25884 0 obj <>/Alt(\(Begin italic\) rufinamide oral tablet \(End italic\) \(Begin italic\) 400 mg \(End italic\))/P 9386 0 R/K 39412 0 R>> endobj 25885 0 obj <>/Alt(\(Banzel\))/P 9386 0 R/K 39413 0 R>> endobj 25886 0 obj <>/Alt(Tier 1)/P 9386 0 R/K 39414 0 R>> endobj 25887 0 obj <>/Alt(QL \(8 EA per 1 day\))/P 9386 0 R/K 39415 0 R>> endobj 25888 0 obj <>/Alt(SABRIL ORAL TABLET 500 MG)/P 9387 0 R/K 39416 0 R>> endobj 25889 0 obj <>/Alt(\(vigabatrin\))/P 9387 0 R/K 39417 0 R>> endobj 25890 0 obj <>/Alt(Tier 3)/P 9387 0 R/K 39418 0 R>> endobj 25891 0 obj <>/Alt(PA; SP)/P 9387 0 R/K 39419 0 R>> endobj 25892 0 obj <>/Alt(TEGRETOL ORAL SUSPENSION 100 MG/5 ML)/P 9388 0 R/K 39420 0 R>> endobj 25893 0 obj <>/Alt(\(carbamazepine\))/P 9388 0 R/K 39421 0 R>> endobj 25894 0 obj <>/Alt(Tier 3)/P 9388 0 R/K 39422 0 R>> endobj 25895 0 obj <>/Alt(TEGRETOL ORAL TABLET 200 MG)/P 9389 0 R/K 39423 0 R>> endobj 25896 0 obj <>/Alt(\(carbamazepine\))/P 9389 0 R/K 39424 0 R>> endobj 25897 0 obj <>/Alt(Tier 3)/P 9389 0 R/K 39425 0 R>> endobj 25898 0 obj <>/Alt(TEGRETOL XR ORAL TABLET EXTENDED RELEASE 12 HR 100 MG, 200 MG, 400 MG)/P 9390 0 R/K 39426 0 R>> endobj 25899 0 obj <>/Alt(\(carbamazepine\))/P 9390 0 R/K 39427 0 R>> endobj 25900 0 obj <>/Alt(Tier 3)/P 9390 0 R/K 39428 0 R>> endobj 25901 0 obj <>/Alt(\(Begin italic\) tiagabine oral tablet \(End italic\) \(Begin italic\) 12 mg, 2 mg, 4 mg \(End italic\))/P 9391 0 R/K 39429 0 R>> endobj 25902 0 obj <>/Alt(Tier 1)/P 9391 0 R/K 39430 0 R>> endobj 25903 0 obj <>/Alt(QL \(4 EA per 1 day\))/P 9391 0 R/K 39431 0 R>> endobj 25904 0 obj <>/Alt(\(Begin italic\) tiagabine oral tablet \(End italic\) \(Begin italic\) 16 mg \(End italic\))/P 9392 0 R/K 39432 0 R>> endobj 25905 0 obj <>/Alt(Tier 1)/P 9392 0 R/K 39433 0 R>> endobj 25906 0 obj <>/Alt(QL \(3 EA per 1 day\))/P 9392 0 R/K 39434 0 R>> endobj 25907 0 obj <>/Alt(\(Begin italic\) topiramate oral capsule, sprinkle \(End italic\) \(Begin italic\) 15 mg, 25 mg \(End italic\))/P 9393 0 R/K 39435 0 R>> endobj 25908 0 obj <>/Alt(\(Topamax\))/P 9393 0 R/K 39436 0 R>> endobj 25909 0 obj <>/Alt(Tier 1)/P 9393 0 R/K 39437 0 R>> endobj 25910 0 obj <>/Alt(\(Begin italic\) topiramate oral capsule, sprinkle \(End italic\) \(Begin italic\) 50 mg \(End italic\))/P 9394 0 R/K 39438 0 R>> endobj 25911 0 obj <>/Alt(Tier 1)/P 9394 0 R/K 39439 0 R>> endobj 25912 0 obj <>/Alt(\(Begin italic\) topiramate oral capsule,extended release 24hr \(End italic\) \(Begin italic\) 100 mg, 200 mg \(End italic\))/P 9395 0 R/K 39440 0 R>> endobj 25913 0 obj <>/Alt(\(Trokendi XR\))/P 9395 0 R/K 39441 0 R>> endobj 25914 0 obj <>/Alt(Tier 1)/P 9395 0 R/K 39442 0 R>> endobj 25915 0 obj <>/Alt(QL \(2 EA per 1 day\))/P 9395 0 R/K 39443 0 R>> endobj 25916 0 obj <>/Alt(\(Begin italic\) topiramate oral capsule,extended release 24hr \(End italic\) \(Begin italic\) 25 mg \(End italic\))/P 9396 0 R/K 39444 0 R>> endobj 25917 0 obj <>/Alt(\(Trokendi XR\))/P 9396 0 R/K 39445 0 R>> endobj 25918 0 obj <>/Alt(Tier 1)/P 9396 0 R/K 39446 0 R>> endobj 25919 0 obj <>/Alt(QL \(8 EA per 1 day\))/P 9396 0 R/K 39447 0 R>> endobj 25920 0 obj <>/Alt(\(Begin italic\) topiramate oral capsule,extended release 24hr \(End italic\) \(Begin italic\) 50 mg \(End italic\))/P 9397 0 R/K 39448 0 R>> endobj 25921 0 obj <>/Alt(\(Trokendi XR\))/P 9397 0 R/K 39449 0 R>> endobj 25922 0 obj <>/Alt(Tier 1)/P 9397 0 R/K 39450 0 R>> endobj 25923 0 obj <>/Alt(QL \(4 EA per 1 day\))/P 9397 0 R/K 39451 0 R>> endobj 25924 0 obj <>/Alt(\(Begin italic\) topiramate oral capsule,sprinkle,er 24hr \(End italic\) \(Begin italic\) 100 mg, 25 mg, 50 mg \(End italic\))/P 9398 0 R/K 39452 0 R>> endobj 25925 0 obj <>/Alt(\(Qudexy XR\))/P 9398 0 R/K 39453 0 R>> endobj 25926 0 obj <>/Alt(Tier 1)/P 9398 0 R/K 39454 0 R>> endobj 25927 0 obj <>/Alt(QL \(1 EA per 1 day\))/P 9398 0 R/K 39455 0 R>> endobj 25928 0 obj <>/Alt(\(Begin italic\) topiramate oral capsule,sprinkle,er 24hr \(End italic\) \(Begin italic\) 150 mg, 200 mg \(End italic\))/P 9399 0 R/K 39456 0 R>> endobj 25929 0 obj <>/Alt(\(Qudexy XR\))/P 9399 0 R/K 39457 0 R>> endobj 25930 0 obj <>/Alt(Tier 1)/P 9399 0 R/K 39458 0 R>> endobj 25931 0 obj <>/Alt(QL \(2 EA per 1 day\))/P 9399 0 R/K 39459 0 R>> endobj 25932 0 obj <>/Alt(\(Begin italic\) topiramate oral tablet 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0 R>> endobj 25981 0 obj <>/Alt(Tier 1)/P 9415 0 R/K 39509 0 R>> endobj 25982 0 obj <>/Alt(\(Begin italic\) zonisamide oral capsule \(End italic\) \(Begin italic\) 50 mg \(End italic\))/P 9416 0 R/K 39510 0 R>> endobj 25983 0 obj <>/Alt(Tier 1)/P 9416 0 R/K 39511 0 R>> endobj 25984 0 obj <>/Alt(\(Begin bold\) Neuroactive Steroid Gaba-A Receptor Modulator \(End bold\))/P 9417 0 R/K 39512 0 R>> endobj 25985 0 obj <>/Alt(ZTALMY ORAL SUSPENSION 50 MG/ML)/P 9418 0 R/K 39513 0 R>> endobj 25986 0 obj <>/Alt(Tier 3)/P 9418 0 R/K 39514 0 R>> endobj 25987 0 obj <>/Alt(PA; SP)/P 9418 0 R/K 39515 0 R>> endobj 25988 0 obj <>/Alt(\(Begin bold\) Skeletal Muscle Disorder \(End bold\))/P 9419 0 R/K 39516 0 R>> endobj 25989 0 obj <>/Alt(\(Begin bold\) Agents To Tx Periodic Paralysis - Carbon Anhyd Inh \(End bold\))/P 9420 0 R/K 39517 0 R>> endobj 25990 0 obj <>/Alt(\(Begin italic\) dichlorphenamide oral tablet \(End italic\) \(Begin italic\) 50 mg \(End italic\))/P 9421 0 R/K 39518 0 R>> endobj 25991 0 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26005 0 obj <>/Alt(PA; SP)/P 9425 0 R/K 39533 0 R>> endobj 26006 0 obj <>/Alt(\(Begin bold\) Skeletal Muscle Relaxants \(End bold\))/P 9426 0 R/K 39534 0 R>> endobj 26007 0 obj <>/Alt(\(Begin italic\) baclofen oral solution \(End italic\) \(Begin italic\) 10 mg/5 ml \(2 mg/ml\) \(End italic\))/P 9427 0 R/K 39535 0 R>> endobj 26008 0 obj <>/Alt(\(Ozobax DS\))/P 9427 0 R/K 39536 0 R>> endobj 26009 0 obj <>/Alt(Tier 1)/P 9427 0 R/K 39537 0 R>> endobj 26010 0 obj <>/Alt(PA)/P 9427 0 R/K 39538 0 R>> endobj 26011 0 obj <>/Alt(\(Begin italic\) baclofen oral solution \(End italic\) \(Begin italic\) 5 mg/5 ml \(End italic\))/P 9428 0 R/K 39539 0 R>> endobj 26012 0 obj <>/Alt(\(Ozobax\))/P 9428 0 R/K 39540 0 R>> endobj 26013 0 obj <>/Alt(Tier 1)/P 9428 0 R/K 39541 0 R>> endobj 26014 0 obj <>/Alt(PA)/P 9428 0 R/K 39542 0 R>> endobj 26015 0 obj <>/Alt(\(Begin italic\) baclofen oral suspension \(End italic\) \(Begin italic\) 25 mg/5 ml \(5 mg/ml\) \(End italic\))/P 9429 0 R/K 39543 0 R>> endobj 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endobj 26028 0 obj <>/Alt(\(Begin italic\) carisoprodol oral tablet \(End italic\) \(Begin italic\) 250 mg, 350 mg \(End italic\))/P 9433 0 R/K 39556 0 R>> endobj 26029 0 obj <>/Alt(\(Soma\))/P 9433 0 R/K 39557 0 R>> endobj 26030 0 obj <>/Alt(Tier 1)/P 9433 0 R/K 39558 0 R>> endobj 26031 0 obj <>/Alt(QL \(4 EA per 1 day\))/P 9433 0 R/K 39559 0 R>> endobj 26032 0 obj <>/Alt(\(Begin italic\) carisoprodol-aspirin oral tablet \(End italic\) \(Begin italic\) 200-325 mg \(End italic\))/P 9434 0 R/K 39560 0 R>> endobj 26033 0 obj <>/Alt(Tier 1)/P 9434 0 R/K 39561 0 R>> endobj 26034 0 obj <>/Alt(\(Begin italic\) chlorzoxazone oral tablet \(End italic\) \(Begin italic\) 500 mg \(End italic\))/P 9435 0 R/K 39562 0 R>> endobj 26035 0 obj <>/Alt(Tier 1)/P 9435 0 R/K 39563 0 R>> endobj 26036 0 obj <>/Alt(QL \(4 EA per 1 day\))/P 9435 0 R/K 39564 0 R>> endobj 26037 0 obj <>/Alt(\(Begin italic\) cyclobenzaprine oral tablet \(End italic\) \(Begin italic\) 10 mg, 5 mg \(End italic\))/P 9436 0 R/K 39565 0 R>> endobj 26038 0 obj <>/Alt(Tier 1)/P 9436 0 R/K 39566 0 R>> endobj 26039 0 obj <>/Alt(QL \(3 EA per 1 day\))/P 9436 0 R/K 39567 0 R>> endobj 26040 0 obj <>/Alt(\(Begin italic\) dantrolene oral capsule \(End italic\) \(Begin italic\) 100 mg \(End italic\))/P 9437 0 R/K 39568 0 R>> endobj 26041 0 obj <>/Alt(Tier 1)/P 9437 0 R/K 39569 0 R>> endobj 26042 0 obj <>/Alt(QL \(4 EA per 1 day\))/P 9437 0 R/K 39570 0 R>> endobj 26043 0 obj <>/Alt(\(Begin italic\) dantrolene oral capsule \(End italic\) \(Begin italic\) 25 mg \(End italic\))/P 9438 0 R/K 39571 0 R>> endobj 26044 0 obj <>/Alt(\(Dantrium\))/P 9438 0 R/K 39572 0 R>> endobj 26045 0 obj <>/Alt(Tier 1)/P 9438 0 R/K 39573 0 R>> endobj 26046 0 obj <>/Alt(QL \(3 EA per 1 day\))/P 9438 0 R/K 39574 0 R>> endobj 26047 0 obj <>/Alt(\(Begin italic\) dantrolene oral capsule \(End italic\) \(Begin italic\) 50 mg \(End italic\))/P 9439 0 R/K 39575 0 R>> endobj 26048 0 obj <>/Alt(Tier 1)/P 9439 0 R/K 39576 0 R>> endobj 26049 0 obj <>/Alt(QL \(3 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endobj 26093 0 obj <>/Alt($0 COPAY IF QUANTITY 24 IN 1 DAY, LIMITED TO 180 IN 365 DAYS, AND 18 YEARS OF AGE OR OLDER)/P 9453 0 R/K 39621 0 R>> endobj 26094 0 obj <>/Alt(\(Begin italic\) nicotine \(polacrilex\) buccal gum \(End italic\) \(Begin italic\) 4 mg \(End italic\))/P 9454 0 R/K 39622 0 R>> endobj 26095 0 obj <>/Alt(\(Quit 4\))/P 9454 0 R/K 39623 0 R>> endobj 26096 0 obj <>/Alt($0)/P 9454 0 R/K 39624 0 R>> endobj 26097 0 obj <>/Alt($0 COPAY IF QUANTITY 24 IN 1 DAY, LIMITED TO 180 IN 365 DAYS, AND 18 YEARS OF AGE OR OLDER)/P 9454 0 R/K 39625 0 R>> endobj 26098 0 obj <>/Alt(\(Begin italic\) nicotine \(polacrilex\) buccal lozenge \(End italic\) \(Begin italic\) 2 mg \(End italic\))/P 9455 0 R/K 39626 0 R>> endobj 26099 0 obj <>/Alt(\(Quit 2\))/P 9455 0 R/K 39627 0 R>> endobj 26100 0 obj <>/Alt($0)/P 9455 0 R/K 39628 0 R>> endobj 26101 0 obj <>/Alt($0 COPAY IF QUANTITY 20 IN 1 DAY, LIMITED TO 180 IN 365 DAYS, AND 18 YEARS OF AGE OR OLDER)/P 9455 0 R/K 39629 0 R>> endobj 26102 0 obj 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0 R>> endobj 26150 0 obj <>/Alt(\(Begin italic\) bupropion hcl \(smoking deter\) oral tablet extended release 12 hr \(End italic\) \(Begin italic\) 150 mg \(End italic\))/P 9470 0 R/K 39678 0 R>> endobj 26151 0 obj <>/Alt($0)/P 9470 0 R/K 39679 0 R>> endobj 26152 0 obj <>/Alt($0 COPAY IF QUANTITY 2 IN 1 DAY, LIMITED TO 180 IN 365 DAYS AND 18 YEARS OF AGE OR OLDER)/P 9470 0 R/K 39680 0 R>> endobj 26153 0 obj <>/Alt(\(Begin bold\) Upper Gastrointestinal Disorders - Digestive \(End bold\))/P 9471 0 R/K 39681 0 R>> endobj 26154 0 obj <>/Alt(\(Begin bold\) Gastric Enzymes \(End bold\))/P 9472 0 R/K 39682 0 R>> endobj 26155 0 obj <>/Alt(SUCRAID ORAL SOLUTION 8,500 UNIT/ML)/P 9473 0 R/K 39683 0 R>> endobj 26156 0 obj <>/Alt(Tier 3)/P 9473 0 R/K 39684 0 R>> endobj 26157 0 obj <>/Alt(PA; SP)/P 9473 0 R/K 39685 0 R>> endobj 26158 0 obj <>/Alt(\(Begin bold\) Pancreatic Enzymes \(End bold\))/P 9474 0 R/K 39686 0 R>> endobj 26159 0 obj <>/Alt(CREON ORAL CAPSULE,DELAYED RELEASE\(DR/EC\) 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endobj 26230 0 obj <>/Alt(\(Robinul Forte\))/P 9504 0 R/K 39758 0 R>> endobj 26231 0 obj <>/Alt(Tier 1)/P 9504 0 R/K 39759 0 R>> endobj 26232 0 obj <>/Alt(GLYRX-PF INJECTION SYRINGE 0.6 MG/3 ML \(0.2 MG/ML\))/P 9505 0 R/K 39760 0 R>> endobj 26233 0 obj <>/Alt(\(glycopyrrolate \(pf\)\))/P 9505 0 R/K 39761 0 R>> endobj 26234 0 obj <>/Alt(Tier 3)/P 9505 0 R/K 39762 0 R>> endobj 26235 0 obj <>/Alt(\(Begin bold\) Anti-Ulcer Preparations \(End bold\))/P 9506 0 R/K 39763 0 R>> endobj 26236 0 obj <>/Alt(\(Begin italic\) misoprostol oral tablet \(End italic\) \(Begin italic\) 100 mcg, 200 mcg \(End italic\))/P 9507 0 R/K 39764 0 R>> endobj 26237 0 obj <>/Alt(\(Cytotec\))/P 9507 0 R/K 39765 0 R>> endobj 26238 0 obj <>/Alt(Tier 1)/P 9507 0 R/K 39766 0 R>> endobj 26239 0 obj <>/Alt(\(Begin italic\) sucralfate oral suspension \(End italic\) \(Begin italic\) 100 mg/ml \(End italic\))/P 9508 0 R/K 39767 0 R>> endobj 26240 0 obj <>/Alt(\(Carafate\))/P 9508 0 R/K 39768 0 R>> endobj 26241 0 obj 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9517 0 R/K 39791 0 R>> endobj 26264 0 obj <>/Alt(\(Begin italic\) cimetidine hcl oral solution \(End italic\) \(Begin italic\) 300 mg/5 ml \(End italic\))/P 9518 0 R/K 39792 0 R>> endobj 26265 0 obj <>/Alt(Tier 1)/P 9518 0 R/K 39793 0 R>> endobj 26266 0 obj <>/Alt(\(Begin italic\) cimetidine oral tablet \(End italic\) \(Begin italic\) 200 mg \(End italic\))/P 9519 0 R/K 39794 0 R>> endobj 26267 0 obj <>/Alt(\(Acid Reducer \(cimetidine\)\))/P 9519 0 R/K 39795 0 R>> endobj 26268 0 obj <>/Alt(Tier 1)/P 9519 0 R/K 39796 0 R>> endobj 26269 0 obj <>/Alt(\(Begin italic\) cimetidine oral tablet \(End italic\) \(Begin italic\) 300 mg, 400 mg, 800 mg \(End italic\))/P 9520 0 R/K 39797 0 R>> endobj 26270 0 obj <>/Alt(Tier 1)/P 9520 0 R/K 39798 0 R>> endobj 26271 0 obj <>/Alt(\(Begin italic\) famotidine oral suspension for reconstitution \(End italic\) \(Begin italic\) 40 mg/5 ml \(8 mg/ml\) \(End italic\))/P 9521 0 R/K 39799 0 R>> endobj 26272 0 obj <>/Alt(Tier 1)/P 9521 0 R/K 39800 0 R>> endobj 26273 0 obj <>/Alt(\(Begin italic\) famotidine oral tablet \(End italic\) \(Begin italic\) 20 mg \(End italic\))/P 9522 0 R/K 39801 0 R>> endobj 26274 0 obj <>/Alt(\(Acid Controller\))/P 9522 0 R/K 39802 0 R>> endobj 26275 0 obj <>/Alt(Tier 1)/P 9522 0 R/K 39803 0 R>> endobj 26276 0 obj <>/Alt(\(Begin italic\) famotidine oral tablet \(End italic\) \(Begin italic\) 40 mg \(End italic\))/P 9523 0 R/K 39804 0 R>> endobj 26277 0 obj <>/Alt(\(Pepcid\))/P 9523 0 R/K 39805 0 R>> endobj 26278 0 obj <>/Alt(Tier 1)/P 9523 0 R/K 39806 0 R>> endobj 26279 0 obj <>/Alt(\(Begin italic\) nizatidine oral capsule \(End italic\) \(Begin italic\) 150 mg, 300 mg \(End italic\))/P 9524 0 R/K 39807 0 R>> endobj 26280 0 obj <>/Alt(Tier 1)/P 9524 0 R/K 39808 0 R>> endobj 26281 0 obj <>/Alt(\(Begin bold\) Intestinal Motility Stimulants \(End bold\))/P 9525 0 R/K 39809 0 R>> endobj 26282 0 obj <>/Alt(GIMOTI NASAL SPRAY WITH PUMP 15 MG/SPRAY)/P 9526 0 R/K 39810 0 R>> endobj 26283 0 obj <>/Alt(Tier 3)/P 9526 0 R/K 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9545 0 R/K 39870 0 R>> endobj 26343 0 obj <>/Alt(\(Zegerid OTC\))/P 9545 0 R/K 39871 0 R>> endobj 26344 0 obj <>/Alt(Tier 1)/P 9545 0 R/K 39872 0 R>> endobj 26345 0 obj <>/Alt(ST: Requires prior prescription for Lansoprazole, Omeprazole, or Pantoprazole within the past 120 days; QL \(1 EA per 1 day\))/P 9545 0 R/K 39873 0 R>> endobj 26346 0 obj <>/Alt(\(Begin italic\) omeprazole-sodium bicarbonate oral capsule \(End italic\) \(Begin italic\) 40-1.1 mg-gram \(End italic\))/P 9546 0 R/K 39874 0 R>> endobj 26347 0 obj <>/Alt(Tier 1)/P 9546 0 R/K 39875 0 R>> endobj 26348 0 obj <>/Alt(ST: Requires prior prescription for Lansoprazole, Omeprazole, or Pantoprazole within the past 120 days; QL \(1 EA per 1 day\))/P 9546 0 R/K 39876 0 R>> endobj 26349 0 obj <>/Alt(\(Begin italic\) pantoprazole oral granules dr for susp in packet \(End italic\) \(Begin italic\) 40 mg \(End italic\))/P 9547 0 R/K 39877 0 R>> endobj 26350 0 obj <>/Alt(\(Protonix\))/P 9547 0 R/K 39878 0 R>> endobj 26351 0 obj <>/Alt(Tier 1)/P 9547 0 R/K 39879 0 R>> endobj 26352 0 obj <>/Alt(ST: Requires prior prescription for Omeprazole Magnesium, Omeprazole, Pantoprazole Sodium, Prilosec OTC, or Prilosec within the past 120 days)/P 9547 0 R/K 39880 0 R>> endobj 26353 0 obj <>/Alt(\(Begin italic\) pantoprazole oral tablet,delayed release \(dr/ec\) \(End italic\) \(Begin italic\) 20 mg, 40 mg \(End italic\))/P 9548 0 R/K 39881 0 R>> endobj 26354 0 obj <>/Alt(\(Protonix\))/P 9548 0 R/K 39882 0 R>> endobj 26355 0 obj <>/Alt(Tier 1)/P 9548 0 R/K 39883 0 R>> endobj 26356 0 obj <>/Alt(\(Begin italic\) rabeprazole oral capsule, delayed rel sprinkle \(End italic\) \(Begin italic\) 10 mg \(End italic\))/P 9549 0 R/K 39884 0 R>> endobj 26357 0 obj <>/Alt(\(AcipHex Sprinkle\))/P 9549 0 R/K 39885 0 R>> endobj 26358 0 obj <>/Alt(Tier 1)/P 9549 0 R/K 39886 0 R>> endobj 26359 0 obj <>/Alt(ST: At least 2 prior prescriptions for Lansoprazole, Omeprazole, or Pantoprazole within the past 365 days; QL \(1 EA per 1 day\))/P 9549 0 R/K 39887 0 R>> endobj 26360 0 obj <>/Alt(\(Begin italic\) rabeprazole oral tablet,delayed release \(dr/ec\) \(End italic\) \(Begin italic\) 20 mg \(End italic\))/P 9550 0 R/K 39888 0 R>> endobj 26361 0 obj <>/Alt(\(AcipHex\))/P 9550 0 R/K 39889 0 R>> endobj 26362 0 obj <>/Alt(Tier 1)/P 9550 0 R/K 39890 0 R>> endobj 26363 0 obj <>/Alt(QL \(1 EA per 1 day\))/P 9550 0 R/K 39891 0 R>> endobj 26364 0 obj <>/Alt(\(Begin bold\) Urinary Tract - Functional Disorders \(End bold\))/P 9551 0 R/K 39892 0 R>> endobj 26365 0 obj <>/Alt(\(Begin bold\) Benign Prostatic Hypertrophy/Micturition Agents \(End bold\))/P 9552 0 R/K 39893 0 R>> endobj 26366 0 obj <>/Alt(\(Begin italic\) alfuzosin oral tablet extended release 24 hr \(End italic\) \(Begin italic\) 10 mg \(End italic\))/P 9553 0 R/K 39894 0 R>> endobj 26367 0 obj <>/Alt(\(Uroxatral\))/P 9553 0 R/K 39895 0 R>> endobj 26368 0 obj <>/Alt(Tier 1)/P 9553 0 R/K 39896 0 R>> endobj 26369 0 obj <>/Alt(\(Begin italic\) dutasteride oral capsule 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39908 0 R>> endobj 26381 0 obj <>/Alt(\(Begin bold\) Bph Agents,5-Alpha-Red Inh & Alpha-1-Adr Antg Cmb \(End bold\))/P 9558 0 R/K 39909 0 R>> endobj 26382 0 obj <>/Alt(\(Begin italic\) dutasteride-tamsulosin oral capsule, er multiphase 24 hr \(End italic\) \(Begin italic\) 0.5-0.4 mg \(End italic\))/P 9559 0 R/K 39910 0 R>> endobj 26383 0 obj <>/Alt(\(Jalyn\))/P 9559 0 R/K 39911 0 R>> endobj 26384 0 obj <>/Alt(Tier 1)/P 9559 0 R/K 39912 0 R>> endobj 26385 0 obj <>/Alt(ST: Requires prior prescription for Alfuzosin, Doxazosin, Finasteride 5mg, Prazosin, Silodosin, Tamsulosin, or Terazosin within the past 120 days)/P 9559 0 R/K 39913 0 R>> endobj 26386 0 obj <>/Alt(\(Begin bold\) Cystine-Depleting Agents, Nephropathic Cystinosis \(End bold\))/P 9560 0 R/K 39914 0 R>> endobj 26387 0 obj <>/Alt(CYSTAGON ORAL CAPSULE 150 MG, 50 MG)/P 9561 0 R/K 39915 0 R>> endobj 26388 0 obj <>/Alt(Tier 3)/P 9561 0 R/K 39916 0 R>> endobj 26389 0 obj <>/Alt(SP)/P 9561 0 R/K 39917 0 R>> endobj 26390 0 obj <>/Alt(PROCYSBI ORAL CAPSULE, DELAYED REL SPRINKLE 25 MG, 75 MG)/P 9562 0 R/K 39918 0 R>> endobj 26391 0 obj <>/Alt(Tier 2)/P 9562 0 R/K 39919 0 R>> endobj 26392 0 obj <>/Alt(PA; SP)/P 9562 0 R/K 39920 0 R>> endobj 26393 0 obj <>/Alt(PROCYSBI ORAL GRANULES DEL RELEASE IN PACKET 300 MG, 75 MG)/P 9563 0 R/K 39921 0 R>> endobj 26394 0 obj <>/Alt(Tier 2)/P 9563 0 R/K 39922 0 R>> endobj 26395 0 obj <>/Alt(PA; SP)/P 9563 0 R/K 39923 0 R>> endobj 26396 0 obj <>/Alt(\(Begin bold\) Endothelin-Angiotensin Receptor Antagonist \(End bold\))/P 9564 0 R/K 39924 0 R>> endobj 26397 0 obj <>/Alt(FILSPARI ORAL TABLET 200 MG, 400 MG)/P 9565 0 R/K 39925 0 R>> endobj 26398 0 obj <>/Alt(Tier 3)/P 9565 0 R/K 39926 0 R>> endobj 26399 0 obj <>/Alt(PA; SP)/P 9565 0 R/K 39927 0 R>> endobj 26400 0 obj <>/Alt(\(Begin bold\) Kidney Stone Agents \(End bold\))/P 9566 0 R/K 39928 0 R>> endobj 26401 0 obj <>/Alt(THIOLA EC ORAL TABLET,DELAYED RELEASE \(DR/EC\) 100 MG, 300 MG)/P 9567 0 R/K 39929 0 R>> endobj 26402 0 obj <>/Alt(\(tiopronin\))/P 9567 0 R/K 39930 0 R>> endobj 26403 0 obj <>/Alt(Tier 2)/P 9567 0 R/K 39931 0 R>> endobj 26404 0 obj <>/Alt(SP)/P 9567 0 R/K 39932 0 R>> endobj 26405 0 obj <>/Alt(\(Begin italic\) tiopronin oral tablet \(End italic\) \(Begin italic\) 100 mg \(End italic\))/P 9568 0 R/K 39933 0 R>> endobj 26406 0 obj <>/Alt(\(Thiola\))/P 9568 0 R/K 39934 0 R>> endobj 26407 0 obj <>/Alt(Tier 1)/P 9568 0 R/K 39935 0 R>> endobj 26408 0 obj <>/Alt(SP)/P 9568 0 R/K 39936 0 R>> endobj 26409 0 obj <>/Alt(\(Begin italic\) tiopronin oral tablet,delayed release \(dr/ec\) \(End italic\) \(Begin italic\) 100 mg, 300 mg \(End italic\))/P 9569 0 R/K 39937 0 R>> endobj 26410 0 obj <>/Alt(\(Venxxiva\))/P 9569 0 R/K 39938 0 R>> endobj 26411 0 obj <>/Alt(Tier 1)/P 9569 0 R/K 39939 0 R>> endobj 26412 0 obj <>/Alt(SP)/P 9569 0 R/K 39940 0 R>> endobj 26413 0 obj <>/Alt(VENXXIVA ORAL TABLET,DELAYED RELEASE \(DR/EC\) 100 MG, 300 MG)/P 9570 0 R/K 39941 0 R>> endobj 26414 0 obj <>/Alt(\(tiopronin\))/P 9570 0 R/K 39942 0 R>> endobj 26415 0 obj <>/Alt(Tier 1)/P 9570 0 R/K 39943 0 R>> endobj 26416 0 obj <>/Alt(SP)/P 9570 0 R/K 39944 0 R>> endobj 26417 0 obj <>/Alt(\(Begin bold\) Overactive Bladder Agents, Beta-3 Adrenergic Recep \(End bold\))/P 9571 0 R/K 39945 0 R>> endobj 26418 0 obj <>/Alt(MYRBETRIQ ORAL SUSPENSION,EXTENDED REL RECON 8 MG/ML)/P 9572 0 R/K 39946 0 R>> endobj 26419 0 obj <>/Alt(Tier 2)/P 9572 0 R/K 39947 0 R>> endobj 26420 0 obj <>/Alt(MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR 25 MG, 50 MG)/P 9573 0 R/K 39948 0 R>> endobj 26421 0 obj <>/Alt(\(mirabegron\))/P 9573 0 R/K 39949 0 R>> endobj 26422 0 obj <>/Alt(Tier 1)/P 9573 0 R/K 39950 0 R>> endobj 26423 0 obj <>/Alt(QL \(1 EA per 1 day\))/P 9573 0 R/K 39951 0 R>> endobj 26424 0 obj <>/Alt(\(Begin bold\) Oxalosis Agent - Oxalate Inhibitor, Sirna Based \(End bold\))/P 9574 0 R/K 39952 0 R>> endobj 26425 0 obj <>/Alt(RIVFLOZA SUBCUTANEOUS SOLUTION 80 MG/0.5 ML \(160 MG/ML\))/P 9575 0 R/K 39953 0 R>> endobj 26426 0 obj 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Antag \(End bold\))/P 9577 0 R/K 39959 0 R>> endobj 26432 0 obj <>/Alt(JYNARQUE ORAL TABLET 15 MG, 30 MG)/P 9578 0 R/K 39960 0 R>> endobj 26433 0 obj <>/Alt(Tier 2)/P 9578 0 R/K 39961 0 R>> endobj 26434 0 obj <>/Alt(PA; SP)/P 9578 0 R/K 39962 0 R>> endobj 26435 0 obj <>/Alt(JYNARQUE ORAL TABLETS, SEQUENTIAL 15 MG \(AM\)/ 15 MG \(PM\), 30 MG \(AM\)/ 15 MG \(PM\), 45 MG \(AM\)/ 15 MG \(PM\), 60 MG \(AM\)/ 30 MG \(PM\), 90 MG \(AM\)/ 30 MG \(PM\))/P 9579 0 R/K 39963 0 R>> endobj 26436 0 obj <>/Alt(Tier 2)/P 9579 0 R/K 39964 0 R>> endobj 26437 0 obj <>/Alt(PA; SP)/P 9579 0 R/K 39965 0 R>> endobj 26438 0 obj <>/Alt(\(Begin bold\) Urinary Ph Modifiers \(End bold\))/P 9580 0 R/K 39966 0 R>> endobj 26439 0 obj <>/Alt(K-PHOS NO 2 ORAL TABLET 305-700 MG)/P 9581 0 R/K 39967 0 R>> endobj 26440 0 obj <>/Alt(Tier 3)/P 9581 0 R/K 39968 0 R>> endobj 26441 0 obj <>/Alt(K-PHOS ORIGINAL ORAL TABLET,SOLUBLE 500 MG)/P 9582 0 R/K 39969 0 R>> endobj 26442 0 obj <>/Alt(Tier 3)/P 9582 0 R/K 39970 0 R>> endobj 26443 0 obj <>/Alt(ORACIT ORAL SOLUTION 490-640 MG/5 ML)/P 9583 0 R/K 39971 0 R>> endobj 26444 0 obj <>/Alt(\(sodium citrate-citric acid\))/P 9583 0 R/K 39972 0 R>> endobj 26445 0 obj <>/Alt(Tier 3)/P 9583 0 R/K 39973 0 R>> endobj 26446 0 obj <>/Alt(\(Begin italic\) potassium citrate oral tablet extended release \(End italic\) \(Begin italic\) 10 meq \(1,080 mg\) \(End italic\))/P 9584 0 R/K 39974 0 R>> endobj 26447 0 obj <>/Alt(\(Urocit-K 10\))/P 9584 0 R/K 39975 0 R>> endobj 26448 0 obj <>/Alt(Tier 1)/P 9584 0 R/K 39976 0 R>> endobj 26449 0 obj <>/Alt(\(Begin italic\) potassium citrate oral tablet extended release \(End italic\) \(Begin italic\) 15 meq \(End italic\))/P 9585 0 R/K 39977 0 R>> endobj 26450 0 obj <>/Alt(\(Urocit-K 15\))/P 9585 0 R/K 39978 0 R>> endobj 26451 0 obj <>/Alt(Tier 1)/P 9585 0 R/K 39979 0 R>> endobj 26452 0 obj <>/Alt(\(Begin italic\) potassium citrate oral tablet extended release \(End italic\) \(Begin italic\) 5 meq \(540 mg\) \(End italic\))/P 9586 0 R/K 39980 0 R>> endobj 26453 0 obj <>/Alt(Tier 1)/P 9586 0 R/K 39981 0 R>> endobj 26454 0 obj <>/Alt(RENACIDIN IRRIGATION SOLUTION 1980.6 MG-59.4 MG-980.4MG/30ML)/P 9587 0 R/K 39982 0 R>> endobj 26455 0 obj <>/Alt(Tier 3)/P 9587 0 R/K 39983 0 R>> endobj 26456 0 obj <>/Alt(\(Begin italic\) sodium citrate-citric acid oral solution \(End italic\) \(Begin italic\) 490-640 mg/5 ml \(End italic\))/P 9588 0 R/K 39984 0 R>> endobj 26457 0 obj <>/Alt(\(Oracit\))/P 9588 0 R/K 39985 0 R>> endobj 26458 0 obj <>/Alt(Tier 1)/P 9588 0 R/K 39986 0 R>> endobj 26459 0 obj <>/Alt(UROQID-ACID NO.2 ORAL TABLET 500-500 MG)/P 9589 0 R/K 39987 0 R>> endobj 26460 0 obj <>/Alt(Tier 3)/P 9589 0 R/K 39988 0 R>> endobj 26461 0 obj <>/Alt(\(Begin bold\) Urinary Tract Analgesic Agents \(End bold\))/P 9590 0 R/K 39989 0 R>> endobj 26462 0 obj <>/Alt(ELMIRON ORAL CAPSULE 100 MG)/P 9591 0 R/K 39990 0 R>> endobj 26463 0 obj <>/Alt(Tier 2)/P 9591 0 R/K 39991 0 R>> endobj 26464 0 obj <>/Alt(PA)/P 9591 0 R/K 39992 0 R>> endobj 26465 0 obj <>/Alt(\(Begin bold\) Urinary Tract Anesthetic/Analgesic Agnt \(Azo-Dye\) \(End bold\))/P 9592 0 R/K 39993 0 R>> endobj 26466 0 obj <>/Alt(\(Begin italic\) phenazopyridine oral tablet \(End italic\) \(Begin italic\) 100 mg, 200 mg \(End italic\))/P 9593 0 R/K 39994 0 R>> endobj 26467 0 obj <>/Alt(\(Pyridium\))/P 9593 0 R/K 39995 0 R>> endobj 26468 0 obj <>/Alt(Tier 1)/P 9593 0 R/K 39996 0 R>> endobj 26469 0 obj <>/Alt(\(Begin bold\) Urinary Tract Antispasmodic, M\(3\) Selective Antag. \(End bold\))/P 9594 0 R/K 39997 0 R>> endobj 26470 0 obj <>/Alt(\(Begin italic\) darifenacin oral tablet extended release 24 hr \(End italic\) \(Begin italic\) 15 mg, 7.5 mg \(End italic\))/P 9595 0 R/K 39998 0 R>> endobj 26471 0 obj <>/Alt(Tier 1)/P 9595 0 R/K 39999 0 R>> endobj 26472 0 obj <>/Alt(\(Begin italic\) solifenacin oral tablet \(End italic\) \(Begin italic\) 10 mg, 5 mg \(End italic\))/P 9596 0 R/K 40000 0 R>> endobj 26473 0 obj <>/Alt(\(Vesicare\))/P 9596 0 R/K 40001 0 R>> endobj 26474 0 obj <>/Alt(Tier 1)/P 9596 0 R/K 40002 0 R>> endobj 26475 0 obj <>/Alt(\(Begin bold\) Urinary Tract Antispasmodic/Antiincontinence Agent \(End bold\))/P 9597 0 R/K 40003 0 R>> endobj 26476 0 obj <>/Alt(\(Begin italic\) fesoterodine oral tablet extended release 24 hr \(End italic\) \(Begin italic\) 4 mg, 8 mg \(End italic\))/P 9598 0 R/K 40004 0 R>> endobj 26477 0 obj <>/Alt(\(Toviaz\))/P 9598 0 R/K 40005 0 R>> endobj 26478 0 obj <>/Alt(Tier 1)/P 9598 0 R/K 40006 0 R>> endobj 26479 0 obj <>/Alt(QL \(1 EA per 1 day\))/P 9598 0 R/K 40007 0 R>> endobj 26480 0 obj <>/Alt(\(Begin italic\) flavoxate oral tablet \(End italic\) \(Begin italic\) 100 mg \(End italic\))/P 9599 0 R/K 40008 0 R>> endobj 26481 0 obj <>/Alt(Tier 1)/P 9599 0 R/K 40009 0 R>> endobj 26482 0 obj <>/Alt(\(Begin italic\) oxybutynin chloride oral syrup \(End italic\) \(Begin italic\) 5 mg/5 ml \(End italic\))/P 9600 0 R/K 40010 0 R>> endobj 26483 0 obj <>/Alt(Tier 1)/P 9600 0 R/K 40011 0 R>> endobj 26484 0 obj 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0 obj <>/Alt(\(Begin italic\) tolterodine oral tablet \(End italic\) \(Begin italic\) 1 mg, 2 mg \(End italic\))/P 9605 0 R/K 40021 0 R>> endobj 26494 0 obj <>/Alt(Tier 1)/P 9605 0 R/K 40022 0 R>> endobj 26495 0 obj <>/Alt(\(Begin italic\) trospium oral capsule,extended release 24hr \(End italic\) \(Begin italic\) 60 mg \(End italic\))/P 9606 0 R/K 40023 0 R>> endobj 26496 0 obj <>/Alt(Tier 1)/P 9606 0 R/K 40024 0 R>> endobj 26497 0 obj <>/Alt(\(Begin italic\) trospium oral tablet \(End italic\) \(Begin italic\) 20 mg \(End italic\))/P 9607 0 R/K 40025 0 R>> endobj 26498 0 obj <>/Alt(Tier 1)/P 9607 0 R/K 40026 0 R>> endobj 26499 0 obj <>/Alt(\(Begin bold\) Vaginal Disorders \(End bold\))/P 9608 0 R/K 40027 0 R>> endobj 26500 0 obj <>/Alt(\(Begin bold\) Vaginal Antibiotics \(End bold\))/P 9609 0 R/K 40028 0 R>> endobj 26501 0 obj <>/Alt(CLEOCIN VAGINAL SUPPOSITORY 100 MG)/P 9610 0 R/K 40029 0 R>> endobj 26502 0 obj <>/Alt(Tier 3)/P 9610 0 R/K 40030 0 R>> endobj 26503 0 obj <>/Alt(ST: At 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endobj 26614 0 obj <>/Alt(Tier 3)/P 9654 0 R/K 40142 0 R>> endobj 26615 0 obj <>/Alt(PHOS-FLUR DENTAL SOLUTION 0.02 % \(0.044 % SOD. 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26629 0 obj <>/Alt(\(Begin italic\) sodium fluoride-pot nitrate dental paste \(End italic\) \(Begin italic\) 1.1-5 % \(End italic\))/P 9660 0 R/K 40157 0 R>> endobj 26630 0 obj <>/Alt(\(Denta 5000 Plus Sensitive\))/P 9660 0 R/K 40158 0 R>> endobj 26631 0 obj <>/Alt(Tier 1)/P 9660 0 R/K 40159 0 R>> endobj 26632 0 obj <>/Alt(\(Begin bold\) Folic Acid Preparations \(End bold\))/P 9661 0 R/K 40160 0 R>> endobj 26633 0 obj <>/Alt(\(Begin italic\) folic acid injection solution \(End italic\) \(Begin italic\) 5 mg/ml \(End italic\))/P 9662 0 R/K 40161 0 R>> endobj 26634 0 obj <>/Alt(Tier 1)/P 9662 0 R/K 40162 0 R>> endobj 26635 0 obj <>/Alt(\(Begin italic\) folic acid oral tablet \(End italic\) \(Begin italic\) 1 mg \(End italic\))/P 9663 0 R/K 40163 0 R>> endobj 26636 0 obj <>/Alt(Tier 1)/P 9663 0 R/K 40164 0 R>> endobj 26637 0 obj <>/Alt(\(Begin italic\) folic acid oral tablet \(End italic\) \(Begin italic\) 400 mcg, 800 mcg \(End italic\))/P 9664 0 R/K 40165 0 R>> endobj 26638 0 obj 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