montelukast tab peak flow meter roflumilast tab terbutaline sulfate tab theophylline ER tab theophylline soln VENTOLIN HFA INHALER zafirlukast tab CONDITIONS RELATED TO BLOOD CLOTS Tier 1 Tier 2 Tier 3 anagrelide cap BRILINTA TAB AGGRENOX CAP aspirin/dipyridamole cap CABLIVI INJ KIT AGRYLIN CAP cilostazol tab ELIQUIS TAB, ELIQUIS STARTER PACK ARIXTRA INJ clopidogrel tab 75mg XARELTO STARTER PACK COUMADIN TAB dipyridamole tab XARELTO SUSP EFFIENT TAB enoxaparin inj XARELTO TAB FRAGMIN INJ fondaparinux inj LOVENOX INJ prasugrel tab PERSANTINE TAB ticlopidine tab PLAVIX TAB 75mg warfarin tab PLETAL TAB PRADAXA CAP ZONTIVITY TAB DIABETES Tier 1 Tier 2 Tier 3 acarbose tab BAQSIMI NASAL POWDER ACTOS TAB diazoxide susp BYDUREON BCISE AUTO INJ AMARYL TAB glimepiride tab BYDUREON INJ / PEN BYETTA INJ glipizide ER tab FARXIGA TAB CYCLOSET TAB glipizide tab GLUCAGON HYPOKIT INJ DIABETA TAB glipizide/metformin tab GLUCAGON EMR INJ GLUCOPHAGE TAB glucagon (rdna) for inj kit GLUCAGON INJ KIT GLUCOPHAGE XR TAB Page 2 of 10