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Health Alliance Individual and Small Group Formulary

Updated September 1, 2021

For the most current list of covered medications or if you have questions, call the Customer Service number on the back of your ID card or log in at HealthAlliance.org.

After logging in, you can also: • Locate a participating retail pharmacy by ZIP code. • Look up possible lower-cost medication alternatives. • Compare medication pricing and options.

HA Midwest IND & SG Understanding your formulary

What is a formulary? A formulary is a list of prescribed medications chosen About this formulary by your plan for their safety, cost and effectiveness. Where differences exist between Medications are listed by categories or classes and this formulary and your benefit plan are placed into cost levels known as tiers. The formulary documents, the benefit plan documents includes both brand-name and generic prescription rule. This may not be a complete list of medications approved by the U.S. Food and Drug medications, and not all medications Administration (FDA). listed may be covered by your plan. Please look at the benefit plan How do I use my formulary? documents provided by your employer You and your doctor can consult the formulary to or plan sponsor for full details. help you select the most cost-effective prescription medications. This guide tells you if a medication is generic or brand name, and if special rules apply. Bring this list with you when you see your doctor. If you have questions on how your medication is covered, call the Customer Service number on the back of your ID card or visit HealthAlliance.org.

What are tiers? Tiers are the different cost levels you pay for a medication. Generally, the higher your medication’s tier, the more you’ll pay out of pocket for it.

When does the formulary change? • Medications may move to a lower tier at any time. • Medications may move to a higher tier when a generic equivalent becomes available. • Medications may move to a higher tier or be excluded from coverage during the year as other formulary alternatives become available. When a medication changes tiers, you may have to pay a different amount for that medication.

Why are some medications excluded from coverage? A medication may be excluded from coverage under your pharmacy benefit when it works the same as or similar to another prescription or over-the-counter (OTC) medication.

What if I don’t agree with a decision about an excluded medication? You (or your authorized representative) and your doctor can ask for a coverage request by calling the Customer Service number on the back of your ID card.

2 Medication tips

What is the difference between brand-name and generic medications? Over-the-counter (OTC) medications Generic medications contain the same active ingredients An OTC medication may be the right (what makes the medication work) as brand-name treatment option for some conditions. medications, but they often cost less. Once the patent for Talk to your doctor about available a brand-name medication ends, the FDA can approve a OTC options. Even though these generic version with the same active ingredients. If you medications may not be covered by choose a brand-name medication after a generic version your pharmacy benefit, they may cost is available, you may pay the brand-name copayment plus less than a prescription medication. the cost difference between the brand-name and generic medication. These medications will have a comment saying “Brand penalty applies” in the notes section.

What if my doctor writes a brand-name prescription? If your doctor gives you a prescription for a brand-name medication, ask if a generic equivalent or lower-cost option is available and could be right for you. Generic medications are usually your lowest-cost option.

3 Reading your formulary

The formulary gives you choices so you and your doctor can determine your best course of treatment. In this formulary, brand-name medications are shown in UPPERCASE (for example, CLOBEX) and generic medications in lowercase (for example, clobetasol).

Tier information Using lower tier or preferred medications can help you pay your lowest out-of-pocket cost. Your plan may have multiple or no tiers. Please note: If you have a high-deductible plan, the tier cost levels will apply once you hit your deductible.

Drug Tier Drug Tier Description Helpful Tips

Brands and generics Preventive No out-of-pocket cost. Deductible does not apply used for preventive care Tier 1 Preferred generics Low out-of-pocket cost Tier 2 Non-preferred generics Most generic drugs Tier 3 Preferred brands Many brands have lower-cost generic options Tier 4 Non-preferred brands Many brands have lower-cost generic options Tier 5 Preferred specialty May be limited to a specialty pharmacy Tier 6 Non-preferred specialty May be limited to a specialty pharmacy General Provided and administered in a doctor’s office or Medical benefit Medical (GM) hospital and not covered by the pharmacy benefit

Drug list Information In this drug list, some medications are noted with letters next to them to help you see which ones may have coverage requirements or limits. Your benefit plan determines how these medications may be covered for you.

AL Age Limit – Based on government or manufacturer guidelines, these medications are only covered for certain age groups. PA Prior Authorization – Your doctor is required to provide additional information to determine coverage. PV Preventive – These medications are covered at $0 under preventive benefit. PV* Preventive* – These medications may be covered as preventive care if you meet the guidelines based on your plan. QL Quantity Limit – Medication may be limited to a certain quantity. ST Step Therapy – Trial of lower-cost medication(s) is required before a higher-cost medication can be covered.

© 2021 Health Alliance. All rights reserved. WF5094812-E9 08192021 4 Health Alliance Medical Plans

Table of Contents Analgesics - Drugs for Pain...... 8 Gastrointestinal Agents - Drugs for Acid Analgesics - Drugs for Pain and Reflux and Ulcer...... 141 Inflammation...... 6 Gastrointestinal Agents - Drugs for Anesthetics...... 15 Bowel, Intestine and Stomach Anti-Addiction / Substance Abuse Conditions Treatment Agents...... 20 ...... 142 Antibacterials...... 21 Genetic or Enzyme Disorder - Drugs for Anticoagulants...... 33 Replacement, Modification, Treatment.. 146 Anticonvulsants - Drugs for Seizures...... 35 Genitourinary Agents - Drugs for Bladder, Antidementia Agents - Drugs for Genital and Kidney Conditions...... 148 Alzheimer's Disease and Dementia...... 40 Genitourinary Agents - Drugs for Prostate Antidepressants...... 40 Conditions...... 151 Antiemetics - Drugs for Nausea and Hormonal Agents - Adrenal...... 152 Vomiting...... 43 Hormonal Agents - Men's Health...... 154 Antifungals...... 45 Hormonal Agents - Osteoporosis...... 155 Antigout Agents...... 48 Hormonal Agents - Pituitary...... 155 Anti-inflammatory Agents...... 48 Hormonal Agents - Prostaglandins...... 159 Antimigraine Agents...... 49 Hormonal Agents - Sex Hormones and Antimyasthenic Agents...... 51 Birth Control...... 159 Antimycobacterials...... 51 Hormonal Agents - Thyroid...... 169 Antineoplastics - Drugs for Cancer...... 52 Immunological Agents - Drugs for Antiparasitics...... 66 Immune System Stimulation or Antiparkinson Agents...... 67 Suppression...... 170 Antiplatelets...... 69 Immunological Agents - Drugs for Antipsychotics - Drugs for Mood ...... 177 Disorders...... 69 Inflammatory Bowel Disease Agents...... 180 Antivirals...... 72 Metabolic Bone Disease Agents - Drugs Anxiolytics - Drugs for Anxiety...... 78 for Osteoporosis...... 182 Bipolar Agents - Drugs for Mood Metabolic Bone Disease Agents - Other.. 183 Disorders...... 80 Miscellaneous Therapeutic Agents...... 183 Blood Products and Modifiers - Drugs for Ophthalmic Agents - Drugs for Eye Blood Disorders...... 80 Allergy, Infection and Inflammation...... 198 Cardiovascular Agents - Drugs for Heart Ophthalmic Agents - Drugs for Glaucoma and Circulation Conditions...... 86 ...... 201 Central Nervous System Agents - Drugs Ophthalmic Agents - Drugs for for Attention Deficit Disorder...... 102 Miscellaneous Eye Conditions...... 203 Central Nervous System Agents - Drugs Otic Agents - Drugs for Conditions... 208 for Multiple Sclerosis...... 105 Respiratory Tract / Pulmonary Agents - Central Nervous System Agents - Drugs for Allergies, Cough, Cold...... 208 Miscellaneous...... 107 Respiratory Tract / Pulmonary Agents - Dental and Oral Agents - Drugs for Mouth Drugs for Asthma and Other Lung and Throat Conditions...... 108 Conditions...... 211 Dermatological Agents - Drugs for Skin Respiratory Tract / Pulmonary Agents - Conditions...... 110 Drugs for Cystic Fibrosis...... 215 - Antidiabetic Agents...... 117 Respiratory Tract / Pulmonary Agents - Diabetes - Glucose Monitoring...... 121 Drugs for Pulmonary Hypertension...... 216 Diabetes - Glycemic Agents...... 122 Skeletal Muscle Relaxants - Drugs for Diabetes - ...... 122 Muscle Pain and Spasm...... 217 Electrolytes / Minerals / Metals / Vitamins126 Sleep Disorder Agents...... 218 Stimulation or Suppression...... 219 Index of Drugs...... 220 5 Drug Drug Drug Name Notes Drug Name Notes Tier Tier Analgesics - Drugs for CELEBREX ORAL Brand Pain and Inflammation 100 MG, 200 4 penalty adult aspirin regimen oral MG, 400 MG, 50 MG applies delayed release 81 PV celecoxib oral capsule mg 100 mg, 200 mg, 400 2 ANJESO mg, 50 mg INTRAVENOUS GM Brand INJECTABLE 30 MG/ML DAYPRO ORAL TABLET 4 penalty ARTHROTEC ORAL 600 MG applies Brand TABLET DELAYED 4 penalty DICLOFENAC PATCH RELEASE 50-0.2 MG, 4 ST applies EXTERNAL PATCH 1.3 75-0.2 MG % aspirin adult low strength diclofenac potassium oral 2 oral tablet delayed PV tablet 50 mg release 81 mg diclofenac sodium er oral 2 aspirin childrens oral PV tablet extended release tablet chewable 81 mg 24 hour 100 mg aspirin ec low dose oral diclofenac sodium 2 tablet delayed release 81 PV external 1 % mg diclofenac sodium oral aspirin ec low strength tablet delayed release 25 2 oral tablet delayed PV mg release 81 mg diclofenac sodium oral 1 aspirin low dose oral PV tablet delayed release 50 tablet chewable 81 mg mg, 75 mg aspirin low dose oral diclofenac-misoprostol tablet delayed release 81 PV oral tablet delayed 2 mg release 50-0.2 mg, 75- 0.2 mg aspirin oral tablet PV delayed release 81 mg DICLOSTREAM BAYER ASPIRIN EC EXTERNAL THERAPY 4 LOW DOSE ORAL PACK 1.5-10 % PV TABLET DELAYED diflunisal oral tablet 500 2 RELEASE 81 MG mg CALDOLOR DIMENTHO EXTERNAL INTRAVENOUS GM THERAPY PACK 1.5 & 4 800 MG/8ML 10 % CAMBIA ORAL PACKET 4 EC-NAPROSYN ORAL Brand 50 MG TABLET DELAYED 4 penalty RELEASE 375 MG, 500 Brand applies CATAFLAM ORAL 4 penalty MG TABLET 50 MG applies

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 6 Drug Drug Drug Name Notes Drug Name Notes Tier Tier ec-naproxen oral tablet INDOCIN RECTAL 3 delayed release 375 mg, 2 50 MG 500 mg indomethacin er oral ENOVARX-IBUPROFEN capsule extended 2 EXTERNAL 10 4 release 75 mg % indomethacin oral 2 etodolac er oral tablet capsule 25 mg, 50 mg extended release 24 hour 2 indomethacin sodium 400 mg, 500 mg, 600 mg intravenous solution GM etodolac oral capsule reconstituted 1 mg 2 200 mg, 300 mg ketoprofen er oral etodolac oral tablet 400 capsule extended 2 2 mg, 500 mg release 24 hour 200 mg

FBL KIT EXTERNAL 4 ketoprofen oral capsule 2 CREAM 15-4-5 % 25 mg, 50 mg, 75 mg FELDENE ORAL Brand ketorolac tromethamine CAPSULE 10 MG, 20 4 penalty solution 15 2 MG applies mg/ml ketorolac tromethamine fenoprofen calcium oral 2 capsule 200 mg, 400 mg intramuscular solution 60 2 fenoprofen calcium oral mg/2ml 2 tablet 600 mg QL (20 EA fenortho oral capsule 200 ketorolac tromethamine 2 per 30 2 mg oral tablet 10 mg days) FLECTOR EXTERNAL KETOROLAC 4 ST PATCH 1.3 % TROMETHAMINE 4 SOLUTION 30 MG/ML flurbiprofen oral tablet 2 INJECTION 30 MG/ML 100 mg, 50 mg ketorolac tromethamine goodsense aspirin low solution 30 mg/ml 2 dose oral tablet delayed PV injection 30 mg/ml release 81 mg KETOROLAC-BUPIV- ibuprofen lysine KETAMINE INJECTION intravenous solution 10 GM SOLUTION PREFILLED GM mg/ml 60-150-60 ibuprofen oral MG/50ML 2 100 mg/5ml KETOROLAC-ROPIV- KETAMINE INJECTION ibuprofen oral tablet 400 2 mg, 600 mg, 800 mg SOLUTION PREFILLED GM INDOCIN ORAL SYRINGE 15-100-30 SUSPENSION 25 4 MG/50ML MG/5ML

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 7 Drug Drug Drug Name Notes Drug Name Notes Tier Tier Brand naproxen sodium er oral LODINE ORAL TABLET 4 penalty tablet extended release 2 400 MG applies 24 hour 375 mg, 500 mg meclofenamate sodium NAPROXEN SODIUM 2 oral capsule 100 mg, 50 ER ORAL TABLET 4 mg EXTENDED RELEASE 24 HOUR 750 MG mefenamic acid oral 2 capsule 250 mg naproxen sodium oral 2 meloxicam oral tablet 15 tablet 275 mg, 550 mg 1 mg, 7.5 mg NEOPROFEN Brand INTRAVENOUS GM MOBIC ORAL TABLET 4 penalty SOLUTION 10 MG/ML applies 15 MG, 7.5 MG oxaprozin oral tablet 600 2 mg nabumetone oral tablet 2 500 mg, 750 mg piroxicam oral capsule 10 2 Brand mg, 20 mg NALFON ORAL 4 penalty RELAFEN ORAL Brand CAPSULE 400 MG applies TABLET 500 MG, 750 4 penalty Brand MG applies NALFON ORAL TABLET 4 penalty salsalate oral tablet 500 2 600 MG applies mg, 750 mg NAPRELAN ORAL ST JOSEPH LOW DOSE Brand TABLET EXTENDED ORAL TABLET 4 penalty PV RELEASE 24 HOUR 375 applies DELAYED RELEASE 81 MG, 500 MG MG

NAPRELAN ORAL sulindac oral tablet 150 2 TABLET EXTENDED 4 mg, 200 mg RELEASE 24 HOUR 750 ZYNRELEF INJECTION MG SOLUTION 200-6 GM NAPROSYN ORAL Brand MG/7ML, 400-12 SUSPENSION 125 4 penalty MG/14ML MG/5ML applies Analgesics - Drugs for Brand Pain NAPROSYN ORAL 4 penalty acetaminophen TABLET 500 MG applies intravenous solution 10 GM mg/ml, 1000 mg/100ml naproxen oral 2 suspension 125 mg/5ml ACETAMINOPHEN INTRAVENOUS naproxen oral tablet 250 2 GM mg, 375 mg, 500 mg SOLUTION PREFILLED naproxen oral tablet SYRINGE 100 MG/10ML 2 acetaminophen-codeine delayed release 375 mg, 2 500 mg #2 oral tablet 300-15 mg

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 8 Drug Drug Drug Name Notes Drug Name Notes Tier Tier acetaminophen-codeine buprenorphine 2 #3 oral tablet 300-30 mg patch weekly 10 mcg/hr, 15 mcg/hr, 20 2 acetaminophen-codeine 2 #4 oral tablet 300-60 mg mcg/hr, 5 mcg/hr, 7.5 mcg/hr acetaminophen-codeine oral solution 120-12 2 butalbital-acetaminophen 2 mg/5ml capsule 50-300 mg oral 50-300 mg acetaminophen-codeine oral tablet 300-15 mg, 2 BUTALBITAL- ACETAMINOPHEN 300-30 mg, 300-60 mg 2 CAPSULE 50-300 MG ACTIQ BUCCAL ORAL 50-300 MG LOZENGE ON A PA; Brand HANDLE 1200 MCG, butalbital-acetaminophen 4 penalty oral tablet 50-300 mg, 2 1600 MCG, 200 MCG, applies 400 MCG, 600 MCG, 800 50-325 mg MCG butalbital-apap-caff-cod 2 alfentanil hcl intravenous oral capsule 50-300-40- solution 1000 mcg/2ml, GM 30 mg, 50-325-40-30 mg 2500 mcg/5ml butalbital-apap-caffeine apap-caff-dihydrocodeine oral capsule 50-300-40 2 oral capsule 320.5-30-16 2 mg, 50-325-40 mg mg butalbital-apap-caffeine 2 ascomp-codeine oral oral tablet 50-325-40 mg capsule 50-325-40-30 2 butalbital-asa-caff- mg codeine oral capsule 50- 2 325-40-30 mg bac oral tablet 50-325-40 2 mg butalbital-aspirin-caffeine 2 BELBUCA BUCCAL oral capsule 50-325-40 FILM 150 MCG, 300 QL (60 EA mg MCG, 450 MCG, 600 4 per 30 butorphanol tartrate MCG, 75 MCG, 750 days) injection solution 1 GM MCG, 900 MCG mg/ml, 2 mg/ml Brand butorphanol tartrate 2 BUPAP ORAL TABLET 4 penalty nasal solution 10 mg/ml 50-300 MG applies BUTRANS BUPRENEX INJECTION GM Brand SOLUTION 0.3 MG/ML WEEKLY 10 MCG/HR, 4 penalty buprenorphine hcl 15 MCG/HR, 20 applies injection solution 0.3 GM MCG/HR, 5 MCG/HR, mg/ml 7.5 MCG/HR carisoprodol-aspirin- codeine oral tablet 200- 2 325-16 mg

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 9 Drug Drug Drug Name Notes Drug Name Notes Tier Tier clonidine hcl (analgesia) fentanyl citrate (pf) Specialty 6 GM epidural solution 100 Medical injection solution mcg/ml, 500 mcg/ml cartridge 100 mcg/2ml codeine sulfate oral fentanyl citrate buccal tablet 15 mg, 30 mg, 60 2 lozenge on a handle mg 1200 mcg, 1600 mcg, 2 PA DEMEROL INJECTION 200 mcg, 400 mcg, 600 SOLUTION 100 mcg, 800 mcg MG/2ML, 100 MG/ML, 25 GM FENTANYL CITRATE MG/ML, 50 MG/ML, 75 BUCCAL TABLET 100 MG/ML MCG, 200 MCG, 400 4 PA DILAUDID INJECTION MCG, 600 MCG, 800 SOLUTION 1 MG/ML, 2 GM MCG MG/ML FENTANYL CITRATE Brand INJECTION SOLUTION GM DILAUDID ORAL 4 penalty 1500 MCG/30ML 1 MG/ML applies FENTANYL CITRATE DILAUDID ORAL Brand INTRAVENOUS SOLUTION 1500 TABLET 2 MG, 4 MG, 8 4 penalty GM MG applies MCG/30ML, 2500 MCG/50ML, 5000 DSUVIA SUBLINGUAL MCG/100ML TABLET SUBLINGUAL 4 30 MCG FENTANYL CITRATE INTRAVENOUS Specialty DURACLON EPIDURAL 6 SOLUTION PREFILLED SOLUTION 100 MCG/ML Medical SYRINGE 100 duramorph injection MCG/10ML, 100 solution 0.5 mg/ml, 1 GM MCG/2ML, 1000 mg/ml MCG/20ML, 1250 GM endocet oral tablet 10- MCG/25ML, 1500 325 mg, 2.5-325 mg, 5- 2 MCG/30ML, 20 325 mg, 7.5-325 mg MCG/2ML, 250 MCG/5ML, 2500 Brand MCG/50ML, 2750 ESGIC ORAL CAPSULE 4 penalty MCG/55ML, 50 50-325-40 MG applies MCG/5ML, 500 Brand MCG/50ML ESGIC ORAL TABLET 4 penalty fentanyl citrate pf 50-325-40 MG applies injection solution prefilled GM fentanyl citrate (pf) syringe 50 mcg/ml injection solution 100 FENTANYL CITRATE- mcg/2ml, 1000 GM NACL INJECTION GM mcg/20ml, 250 mcg/5ml, SOLUTION 10-0.9 2500 mcg/50ml, 500 MCG/ML-% mcg/10ml

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 10 Drug Drug Drug Name Notes Drug Name Notes Tier Tier FENTANYL CITRATE- FENTANYL- NACL INTRAVENOUS BUPIVACAINE-NACL SOLUTION 1-0.9 EPIDURAL SOLUTION GM MG/100ML-%, 1.25-0.9 GM PREFILLED SYRINGE MG/250ML-%, 2-0.9 0.1-0.125-0.9 MG/50ML- MG/100ML-%, 2.5-0.9 % MG/250ML-% FENTANYL- FENTANYL CITRATE- BUPIVACAINE-NACL NACL INTRAVENOUS INJECTION SOLUTION GM SOLUTION PREFILLED 2-0.125-0.9 MCG/ML-%- SYRINGE 10-0.9 % MCG/2ML-%, 10-0.9 GM FENTANYL- MCG/ML-%, 100-0.9 ROPIVACAINE-NACL GM MCG/10ML-%, 1000-0.9 EPIDURAL SOLUTION MCG/50ML-%, 5-0.9 0.2-0.1-0.9 MG/100ML-% MCG/ML-%, 550-0.9 MCG/55ML-% FENTORA BUCCAL TABLET 100 MCG, 200 4 PA FENTANYL CIT- MCG, 400 MCG, 600 ROPIVACAINE-NACL MCG, 800 MCG EPIDURAL SOLUTION FIORICET ORAL Brand 0.3-0.2-0.9 MG/150ML- GM %, 0.4-0.1-0.9 CAPSULE 50-300-40 4 penalty MG/200ML-%, 0.4-0.2- MG applies 0.9 MG/200ML-%, 0.5- FIORICET/CODEINE Brand 0.2-0.9 MG/250ML-% ORAL CAPSULE 50- 4 penalty fentanyl transdermal 300-40-30 MG applies patch 72 hour 100 hydrocodone bitartrate er PA; QL (60 mcg/hr, 12 mcg/hr, 25 2 PA oral capsule extended mcg/hr, 37.5 mcg/hr, 50 release 12 hour 10 mg, 2 EA per 30 mcg/hr, 62.5 mcg/hr, 75 15 mg, 20 mg, 30 mg, 40 days) mcg/hr, 87.5 mcg/hr mg, 50 mg FENTANYL- hydrocodone bitartrate er BUPIVACAINE-NACL oral tablet er 24 hour EPIDURAL SOLUTION abuse-deterrent 100 mg, 2 PA 0.2-0.1-0.9 MG/100ML- 120 mg, 20 mg, 30 mg, %, 0.2-0.125-0.9 40 mg, 60 mg, 80 mg GM MG/100ML-%, 0.5- hydrocodone- 0.0625-0.9 MG/250ML- acetaminophen oral %, 0.5-0.1-0.9 solution 10-325 mg/15ml, 2 MG/250ML-%, 0.5-0.125- 2.5-108 mg/5ml, 5-217 0.9 MG/250ML-%, 0.8- mg/10ml, 7.5-325 0.1667-0.9 MG/200ML-% mg/15ml

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 11 Drug Drug Drug Name Notes Drug Name Notes Tier Tier hydrocodone- HYDROMORPHONE acetaminophen oral HCL-NACL INJECTION 2 tablet 10-300 mg, 10-325 SOLUTION PREFILLED GM mg, 5-300 mg, 5-325 mg, SYRINGE 10-0.9 7.5-300 mg, 7.5-325 mg MG/50ML-%, 30-0.9 hydrocodone-ibuprofen MG/30ML-% oral tablet 10-200 mg, 5- 2 HYDROMORPHONE 200 mg, 7.5-200 mg HCL-NACL hydromorphone hcl er INTRAVENOUS PA; QL (60 GM oral tablet extended SOLUTION 20-0.9 2 EA per 30 MG/100ML-%, 30-0.9 release 24 hour 12 mg, days) 16 mg, 32 mg, 8 mg MG/30ML-% hydromorphone hcl HYDROMORPHONE injection solution 2 GM HCL-NACL mg/ml, 4 mg/ml INTRAVENOUS SOLUTION PREFILLED HYDROMORPHONE SYRINGE 0.2-0.9 HCL INTRAVENOUS GM MG/0.2ML-%, 0.5-0.9 SOLUTION 0.2 MG/ML MG/0.5ML-%, 1-0.9 GM hydromorphone hcl oral MG/5ML-%, 1-0.9 2 liquid 1 mg/ml MG/ML-%, 2-0.9 MG/ML- hydromorphone hcl oral %, 25-0.9 MG/50ML-%, 2 tablet 2 mg, 4 mg, 8 mg 50-0.9 MG/50ML-%, 55- 0.9 MG/55ML-%, 6-0.9 hydromorphone hcl pf MG/30ML-% injection solution 1 mg/ml, 10 mg/ml, 2 GM HYSINGLA ER ORAL TABLET ER 24 HOUR mg/ml, 4 mg/ml, 50 PA; Brand mg/5ml, 500 mg/50ml ABUSE-DETERRENT 4 penalty 100 MG, 120 MG, 20 hydromorphone hcl rectal applies 2 MG, 30 MG, 40 MG, 60 suppository 3 mg MG, 80 MG HYDROMORPHONE INFUMORPH 200 HCL SOLUTION 1 INJECTION SOLUTION GM GM MG/ML INJECTION 1 200 MG/20ML (10 MG/ML MG/ML) hydromorphone hcl INFUMORPH 500 solution 1 mg/ml injection GM INJECTION SOLUTION GM 1 mg/ml 500 MG/20ML (25 HYDROMORPHONE MG/ML) HCL-NACL INJECTION GM LAZANDA NASAL SOLUTION 20-0.9 SOLUTION 100 4 PA MG/100ML-% MCG/ACT, 400 MCG/ACT levorphanol tartrate oral 2 tablet 2 mg, 3 mg

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 12 Drug Drug Drug Name Notes Drug Name Notes Tier Tier LORTAB ORAL morphine sulfate 4 10-300 MG/15ML (concentrate) oral 2 meperidine hcl injection solution 100 mg/5ml, 20 solution 100 mg/ml, 25 GM mg/ml mg/ml, 50 mg/ml morphine sulfate (pf) meperidine hcl oral injection solution 0.5 2 GM solution 50 mg/5ml mg/ml, 1 mg/ml, 10 mg/ml, 2 mg/ml, 4 mg/ml, meperidine hcl oral tablet 2 5 mg/ml, 8 mg/ml 50 mg morphine sulfate (pf) methadone hcl injection GM intravenous solution 10 GM solution 10 mg/ml mg/ml, 2 mg/ml, 4 mg/ml, methadone hcl intensol 8 mg/ml oral concentrate 10 2 morphine sulfate er mg/ml beads oral capsule extended release 24 hour 2 PA methadone hcl oral 2 concentrate 10 mg/ml 120 mg, 30 mg, 45 mg, methadone hcl oral 60 mg, 75 mg, 90 mg solution 10 mg/5ml, 5 2 morphine sulfate er oral mg/5ml capsule extended methadone hcl oral tablet release 24 hour 10 mg, 2 2 PA 10 mg, 5 mg 100 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg, 80 methadone hcl oral tablet 2 mg soluble 40 mg morphine sulfate er oral METHADONE HCL- tablet extended release 2 PA NACL INTRAVENOUS 100 mg, 15 mg, 200 mg, SOLUTION PREFILLED GM 30 mg, 60 mg SYRINGE 1-0.9 MG/ML- % MORPHINE SULFATE INJECTION SOLUTION GM METHADOSE ORAL Brand 1 MG/ML CONCENTRATE 10 4 penalty MG/ML applies morphine sulfate injection solution 2 mg/ml, 4 GM methadose oral tablet 2 mg/ml soluble 40 mg MORPHINE SULFATE METHADOSE SUGAR- Brand INTRAVENOUS GM FREE ORAL 4 penalty SOLUTION 0.5 MG/ML CONCENTRATE 10 applies MG/ML morphine sulfate oral solution 10 mg/5ml, 20 2 mitigo injection solution mg/5ml 200 mg/20ml (10 mg/ml), GM morphine sulfate oral 500 mg/20ml (25 mg/ml) 2 tablet 15 mg, 30 mg

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 13 Drug Drug Drug Name Notes Drug Name Notes Tier Tier morphine sulfate rectal NUCYNTA ORAL suppository 10 mg, 20 2 TABLET 100 MG, 50 4 ST mg, 30 mg, 5 mg MG, 75 MG MORPHINE SULFATE OLINVYK SOLUTION 1 MG/ML GM INTRAVENOUS GM INTRAVENOUS 1 SOLUTION 1 MG/ML, 2 MG/ML MG/2ML, 30 MG/30ML morphine sulfate solution OXAYDO ORAL TABLET 4 1 mg/ml intravenous 1 GM 5 MG mg/ml OXAYDO ORAL TABLET 4 PA MORPHINE SULFATE- 7.5 MG NACL INJECTION OXYCODONE HCL ER SOLUTION PREFILLED GM ORAL TABLET ER 12 SYRINGE 5-0.9 HOUR ABUSE- 4 PA MG/5ML-% DETERRENT 10 MG, 15 MORPHINE SULFATE- MG, 20 MG, 30 MG, 40 NACL INTRAVENOUS MG, 60 MG, 80 MG SOLUTION 100-0.9 GM oxycodone hcl oral 2 MG/100ML-%, 500-0.9 capsule 5 mg MG/100ML-% oxycodone hcl oral 2 MORPHINE SULFATE- concentrate 100 mg/5ml NACL INTRAVENOUS oxycodone hcl oral SOLUTION PREFILLED 2 SYRINGE 1-0.9 MG/ML- solution 5 mg/5ml %, 150-0.9 MG/30ML-%, GM oxycodone hcl oral tablet 2-0.9 MG/ML-%, 30-0.9 10 mg, 15 mg, 20 mg, 30 2 MG/30ML-%, 4-0.9 mg MG/ML-%, 55-0.9 oxycodone hcl oral tablet 2 PA MG/55ML-% 5 mg MS CONTIN ORAL OXYCODONE- PA; Brand TABLET EXTENDED ACETAMINOPHEN 4 penalty RELEASE 100 MG, 15 ORAL TABLET 10-300 4 applies MG, 200 MG, 30 MG, 60 MG, 2.5-300 MG, 5-300 MG MG nalbuphine hcl injection oxycodone- GM solution 10 mg/ml, 20 acetaminophen oral mg/ml tablet 10-325 mg, 2.5- 2 NALOCET ORAL 4 325 mg, 5-325 mg, 7.5- TABLET 2.5-300 MG 325 mg NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HOUR 100 4 PA MG, 150 MG, 200 MG, 250 MG, 50 MG

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 14 Drug Drug Drug Name Notes Drug Name Notes Tier Tier OXYCONTIN ORAL TENCON ORAL TABLET 4 TABLET ER 12 HOUR 50-325 MG ABUSE-DETERRENT 10 4 PA tramadol hcl er (biphasic) MG, 15 MG, 20 MG, 30 oral tablet extended 2 ST MG, 40 MG, 60 MG, 80 release 24 hour 100 mg, MG 200 mg, 300 mg oxymorphone hcl er oral tramadol hcl er oral tablet tablet extended release extended release 24 hour 2 ST 12 hour 10 mg, 15 mg, 2 PA 100 mg, 200 mg, 300 mg 20 mg, 30 mg, 40 mg, 5 tramadol hcl oral tablet mg, 7.5 mg 2 100 mg, 50 mg oxymorphone hcl oral 2 tramadol-acetaminophen tablet 10 mg, 5 mg 2 oral tablet 37.5-325 mg pentazocine-naloxone hcl 2 oral tablet 50-0.5 mg TREZIX ORAL Brand CAPSULE 320.5-30-16 4 penalty PERCOCET ORAL Brand MG applies TABLET 10-325 MG, 2.5- 4 penalty 325 MG, 5-325 MG, 7.5- ULTIVA INTRAVENOUS applies 325 MG SOLUTION GM RECONSTITUTED 1 PRIALT INTRATHECAL MG, 2 MG, 5 MG SOLUTION 100 MCG/ML, 500 GM Brand MCG/20ML, 500 ULTRACET ORAL 4 penalty MCG/5ML TABLET 37.5-325 MG applies PROLATE ORAL Brand TABLET 10-300 MG, 5- 4 ULTRAM ORAL TABLET 4 penalty 300 MG, 7.5-300 MG 50 MG applies remifentanil hcl VTOL LQ ORAL intravenous solution SOLUTION 50-325-40 4 GM reconstituted 1 mg, 2 mg, MG/15ML 5 mg XTAMPZA ER ORAL ROXICODONE ORAL Brand CAPSULE ER 12 HOUR TABLET 15 MG, 30 MG, 4 penalty ABUSE-DETERRENT 4 PA 5 MG applies 13.5 MG, 18 MG, 27 MG, 36 MG, 9 MG SUBSYS SUBLINGUAL LIQUID 100 MCG, 1200 ZEBUTAL ORAL Brand (600 X 2) MCG, 1600 CAPSULE 50-325-40 4 penalty 4 PA (800 X 2) MCG, 200 MG applies MCG, 400 MCG, 600 Anesthetics MCG, 800 MCG 1ST MEDX-PATCH/ sufentanil citrate LIDOCAINE EXTERNAL 4 PATCH 4-0.0375-5-20 % intravenous solution 100 GM mcg/2ml, 250 mcg/5ml, 7T LIDO EXTERNAL 4 50 mcg/ml GEL 2 % Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 15 Drug Drug Drug Name Notes Drug Name Notes Tier Tier AGONEAZE EXTERNAL bupivacaine-epinephrine 4 KIT 2.5-2.5 % injection solution 0.25% - GM ANODYNE LPT 1:200000, 0.5% - EXTERNAL KIT 2.5-2.5 4 1:200000 % CARBOCAINE ARTICADENT DENTAL INJECTION SOLUTION GM 1 % INJECTION SOLUTION GM CARTRIDGE 4 %- CARBOCAINE 1:100000 PRESERVATIVE-FREE GM bupivacaine fisiopharma INJECTION SOLUTION injection solution 2.5 GM 1 %, 1.5 %, 2 % mg/ml, 5 mg/ml CETACAINE EXTERNAL GM bupivacaine hcl (pf) AEROSOL 2-2-14 % injection solution 0.25 %, GM chloroprocaine hcl (pf) 0.5 %, 0.75 % injection solution 2 %, 3 GM BUPIVACAINE HCL % INJECTION SOLUTION GM CLOROTEKAL 0.125 % INTRATHECAL GM bupivacaine hcl injection SOLUTION 50 MG/5ML GM solution 0.25 %, 0.5 % COCAINE HCL NASAL GM BUPIVACAINE HCL SOLUTION 40 MG/ML INJECTION SOLUTION DERMACINRX LIDOGEL GM 4 PREFILLED SYRINGE EXTERNAL GEL 2.8 % 0.125 % (50 ML) ethyl chloride external 2 BUPIVACAINE HCL- aerosol NACL EPIDURAL GM EXPAREL INJECTION GM SOLUTION 0.125-0.9 % SUSPENSION 1.3 % BUPIVACAINE HCL- FLEXIN EXTERNAL NACL EPIDURAL 4 GM PATCH 0.0375-5 % SOLUTION PREFILLED SYRINGE 0.25-0.9 % glydo external prefilled 2 syringe 2 % bupivacaine in dextrose GOPRELTO NASAL intrathecal solution 0.75- GM GM 8.25 % SOLUTION 40 MG/ML bupivacaine spinal LETS KIT 4 intrathecal solution 0.75- GM LEVATIO EXTERNAL 4 8.25 % PATCH 0.03-5 % bupivacaine-epinephrine LIDO BDK EXTERNAL 4 (pf) injection solution GM KIT 2.5-2.5 % 0.25% -1:200000, 0.5% - QL (50 GM 1:200000 lidocaine external 2 per 30 ointment 5 % days)

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 16 Drug Drug Drug Name Notes Drug Name Notes Tier Tier lidocaine external patch 5 LIDOCAINE HCL 2 % INJECTION SOLUTION LIDOCAINE HCL PREFILLED SYRINGE GM (CARDIAC) 10 MG/ML, 100 INTRAVENOUS GM MG/10ML, 200 SOLUTION PREFILLED MG/10ML, 9 MG/ML SYRINGE 100 MG/10ML LIDOCAINE HCL lidocaine hcl (cardiac) INTRADERMAL JET- 4 intravenous solution INJECTOR 0.5 MG GM prefilled syringe 50 lidocaine hcl solution 1 % GM mg/5ml injection 1 % lidocaine hcl (cardiac) pf LIDOCAINE HCL intravenous solution 100 GM SOLUTION 1 % GM mg/5ml INJECTION 1 % lidocaine hcl (cardiac) pf lidocaine hcl solution 2 % GM intravenous solution GM injection 2 % prefilled syringe 100 LIDOCAINE HCL mg/5ml, 50 mg/5ml SOLUTION 2 % GM lidocaine hcl (cardiac) INJECTION 2 % solution prefilled syringe GM lidocaine hcl 100 mg/5ml intravenous urethral/mucosal external 2 100 mg/5ml gel 2 % LIDOCAINE HCL lidocaine hcl (CARDIAC) SOLUTION urethral/mucosal external 2 PREFILLED SYRINGE GM prefilled syringe 2 % 100 MG/5ML INTRAVENOUS 100 lidocaine in d5w MG/5ML intravenous solution 4-5 GM mg/ml-%, 8-5 mg/ml-% lidocaine hcl (pf) injection solution 0.5 %, 1 %, 1.5 GM LIDOCAINE IN %, 2 %, 4 % DEXTROSE SOLUTION GM 5-7.5 % lidocaine hcl external 2 cream 3 % lidocaine-epinephrine injection solution 0.5 %- lidocaine hcl external 2 1:200000, 1 %-1:100000, GM 3 % 1.5 %-1:200000, 2 %- lidocaine hcl external 2 1:100000, 2 %-1:200000, solution 4 % 2 %-1:50000 lidocaine hcl injection GM lidocaine-prilocaine 2 solution 0.5 % external cream 2.5-2.5 % lidocaine-prilocaine 2 external kit 2.5-2.5 %

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 17 Drug Drug Drug Name Notes Drug Name Notes Tier Tier LIDOCAINE- MARCAINE/EPINEPHRI TETRACAINE 4 NE PF INJECTION EXTERNAL CREAM 7-7 SOLUTION 0.25% - GM % 1:200000, 0.5% - 1:200000 LIDOCANNA 4 EXTERNAL PATCH 4 % NAROPIN INJECTION SOLUTION 10 MG/ML, 2 Brand GM LIDODERM EXTERNAL 4 penalty MG/ML, 5 MG/ML, 7.5 PATCH 5 % applies MG/ML NESACAINE INJECTION LIDO-EPINEPHRINE- GM TETRACAINE SOLUTION 1 %, 2 % GM EXTERNAL SOLUTION NESACAINE-MPF 4-0.05-0.5 % INJECTION SOLUTION GM 2 %, 3 % lidopin external cream 3 2 % NUMBRINO NASAL GM SOLUTION 40 MG/ML LIDOPRIL EXTERNAL 4 KIT 2.5-2.5 % ORABLOC INJECTION SOLUTION CARTRIDGE LIDOPRIL XR GM EXTERNAL KIT 2.5-2.5 4 4 %-1:100000, 4 %- % 1:200000 LIDO-PRILO CAINE PAINGO KFT PACK EXTERNAL KIT 4 EXTERNAL KIT 2.5-2.5- GM 2.5-2.5 % 10-30 % PLIAGLIS EXTERNAL LIDO-SORB EXTERNAL 4 4 LOTION 3 % CREAM 7-7 % polocaine injection LIVIXIL PAK EXTERNAL 4 GM KIT 2.5-2.5 % solution 1 %, 2 % MARCAINE INJECTION polocaine-mpf injection GM SOLUTION 0.25 %, 0.5 GM solution 1 %, 1.5 %, 2 % %, 0.75 % QL (50 GM MARCAINE premium lidocaine 2 per 30 PRESERVATIVE FREE external ointment 5 % days) GM INJECTION SOLUTION PRILOLID EXTERNAL 4 0.25 %, 0.5 % KIT 2.5-2.5 %

MARCAINE SPINAL PRILOVIX EXTERNAL 4 INTRATHECAL GM KIT 2.5-2.5 % SOLUTION 0.75-8.25 % PRILOVIX LITE MARCAINE/EPINEPHRI EXTERNAL KIT 2.5-2.5 4 NE INJECTION % GM SOLUTION 0.25% - PRILOVIX LITE PLUS 1:200000, 0.5% - EXTERNAL KIT 2.5-2.5 4 1:200000 %

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 18 Drug Drug Drug Name Notes Drug Name Notes Tier Tier PRILOVIX PLUS ROPIV-CLONIDINE- EXTERNAL KIT 2.5-2.5 4 KETOROLAC % SOLUTION PREFILLED GM PRILOVIX ULTRALITE SYRINGE 123-0.04-15 EXTERNAL KIT 2.5-2.5 4 MG/50ML % SENSORCAINE GM PRILOVIX ULTRALITE INJECTION SOLUTION PLUS EXTERNAL KIT 4 0.25 %, 0.5 % 2.5-2.5 % SENSORCAINE/EPINEP RECK SOLUTION HRINE INJECTION PREFILLED SYRINGE SOLUTION 0.25% - GM GM 123-0.25-0.04- 15 1:200000, 0.5% - MG/50ML 1:200000 RELADOR PAK SENSORCAINE-MPF EXTERNAL KIT 2.5-2.5 4 INJECTION SOLUTION GM % 0.75 % sensorcaine-mpf solution RELADOR PAK PLUS GM EXTERNAL KIT 2.5-2.5 4 0.25 % injection 0.25 % % SENSORCAINE-MPF ROPIVACAINE HCL SOLUTION 0.25 % GM EPIDURAL SOLUTION GM INJECTION 0.25 % 0.2 % sensorcaine-mpf solution GM ropivacaine hcl injection 0.5 % injection 0.5 % solution 10 mg/ml, 5 GM SENSORCAINE-MPF mg/ml, 7.5 mg/ml SOLUTION 0.5 % GM ROPIVACAINE HCL INJECTION 0.5 % INJECTION SOLUTION GM SENSORCAINE- PREFILLED SYRINGE MPF/EPINEPHRINE 0.2 % INJECTION SOLUTION GM ropivacaine hcl solution 2 0.25% -1:200000, 0.5% - GM mg/ml injection 2 mg/ml 1:200000, 0.75-1:200000 % ROPIVACAINE HCL SOLUTION 2 MG/ML GM SYNERA EXTERNAL GM INJECTION 2 MG/ML PATCH 70-70 MG ROPIVACAINE HCL- VEXATROL EXTERNAL 4 NACL EPIDURAL GM KIT 2.5-2.5 % SOLUTION 0.2-0.9 % XARACOLL IMPLANT GM ROPIVACAINE HCL- IMPLANT 3 X 100 MG NACL INJECTION GM XYLOCAINE INJECTION SOLUTION 0.2-0.9 % SOLUTION 0.5 %, 1 %, 2 GM %

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 19 Drug Drug Drug Name Notes Drug Name Notes Tier Tier XYLOCAINE/EPINEPHR buprenorphine hcl- INE INJECTION naloxone hcl sublingual 1 SOLUTION 0.5 %- GM tablet sublingual 2-0.5 1:200000, 1 %-1:100000, mg, 8-2 mg 2 %-1:100000 bupropion hcl er XYLOCAINE-MPF ( det) oral tablet PV INJECTION SOLUTION GM extended release 12 hour 0.5 %, 1 %, 1.5 %, 2 % 150 mg XYLOCAINE- CHANTIX CONTINUING MPF/EPINEPHRINE MONTH PAK ORAL PV INJECTION SOLUTION GM TABLET 1 MG 1 %-1:200000, 1.5 %- CHANTIX ORAL PV 1:200000, 2 %-1:200000 TABLET 0.5 MG, 1 MG ZERUVIA EXTERNAL 4 CHANTIX STARTING PATCH 4-1 % MONTH PAK ORAL PV ZINGO INTRADERMAL 4 TABLET 0.5 MG X 11 & JET-INJECTOR 0.5 MG 1 MG X 42 ZIONODIL 100 disulfiram oral tablet 250 4 1 EXTERNAL LOTION 3 % mg, 500 mg ZIONODIL EXTERNAL goodsense nicotine 4 LOTION 3 % mouth/ 4 PV Anti-Addiction / mg Substance Abuse habitrol transdermal Treatment Agents patch 24 hour 21 PV acamprosate calcium mg/24hr oral tablet delayed 1 KLOXXADO NASAL 3 release 333 mg LIQUID 8 MG/0.1ML APO-VARENICLINE LIFEMS NALOXONE ORAL TABLET 0.5 MG, PV INJECTION PREFILLED 3 1 MG SYRINGE KIT 2 MG/2ML BUNAVAIL BUCCAL QL (224 FILM 2.1-0.3 MG, 4.2-0.7 3 LUCEMYRA ORAL 3 EA per 14 MG, 6.3-1 MG TABLET 0.18 MG days) buprenorphine hcl naloxone hcl injection sublingual tablet 1 solution 0.4 mg/ml, 4 1 sublingual 2 mg, 8 mg mg/10ml buprenorphine hcl- naloxone hcl injection 1 naloxone hcl sublingual 1 solution cartridge 0.4 film 12-3 mg, 2-0.5 mg, mg/ml 4-1 mg, 8-2 mg naloxone hcl injection solution prefilled syringe 1 2 mg/2ml

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 20 Drug Drug Drug Name Notes Drug Name Notes Tier Tier naltrexone hcl oral tablet VIVITROL 1 50 mg INTRAMUSCULAR NALTREXONE SUSPENSION 3 SUBCUTANEOUS 3 RECONSTITUTED 380 IMPLANT 200-6.5 MG MG ZUBSOLV SUBLINGUAL NARCAN NASAL 3 LIQUID 4 MG/0.1ML TABLET SUBLINGUAL 0.7-0.18 MG, 1.4-0.36 3 NICORETTE MG, 11.4-2.9 MG, 2.9- MOUTH/THROAT GUM PV 0.71 MG, 5.7-1.4 MG, 2 MG 8.6-2.1 MG nicotine polacrilex mini Antibacterials mouth/throat lozenge 2 PV QL (12 EA mg AEMCOLO ORAL TABLET DELAYED 4 per 30 nicotine polacrilex RELEASE 194 MG days) mouth/throat gum 2 mg, PV 4 mg ALTABAX EXTERNAL 4 ST OINTMENT 1 % nicotine polacrilex mouth/throat lozenge 2 PV amikacin sulfate injection 2 mg, 4 mg solution 1 gm/4ml, 500 mg/2ml nicotine step 1 amoxicillin oral capsule transdermal patch 24 PV 2 hour 21 mg/24hr 250 mg, 500 mg nicotine step 2 amoxicillin oral transdermal patch 24 PV suspension reconstituted 1 hour 14 mg/24hr 125 mg/5ml, 200 mg/5ml, 250 mg/5ml, 400 mg/5ml nicotine step 3 transdermal patch 24 PV amoxicillin oral tablet 500 2 hour 7 mg/24hr mg amoxicillin oral tablet 875 NICOTROL 1 PV mg 10 MG amoxicillin oral tablet 2 NICOTROL NS NASAL chewable 125 mg, 250 PV SOLUTION 10 MG/ML mg SUBLOCADE amoxicillin-potassium SUBCUTANEOUS clavulanate er oral tablet 2 extended release 12 hour SOLUTION PREFILLED 3 SYRINGE 100 1000-62.5 mg MG/0.5ML, 300 amoxicillin-potassium MG/1.5ML clavulanate oral suspension reconstituted SUBOXONE 2 SUBLINGUAL FILM 12-3 200-28.5 mg/5ml, 250- 3 MG, 2-0.5 MG, 4-1 MG, 62.5 mg/5ml, 400-57 8-2 MG mg/5ml, 600-42.9 mg/5ml

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 21 Drug Drug Drug Name Notes Drug Name Notes Tier Tier amoxicillin-potassium Brand 4 penalty clavulanate oral tablet 2 AUGMENTIN ORAL 250-125 mg, 500-125 TABLET 500-125 MG applies mg, 875-125 mg avidoxy oral tablet 100 2 amoxicillin-potassium mg clavulanate oral tablet 2 AVYCAZ chewable 200-28.5 mg, INTRAVENOUS 400-57 mg SOLUTION GM ampicillin oral capsule RECONSTITUTED 2.5 1 500 mg (2-0.5) GM ampicillin sodium AZACTAM INJECTION injection solution SOLUTION GM reconstituted 1 gm, 125 GM RECONSTITUTED 1 mg, 2 gm, 250 mg, 500 GM, 2 GM mg azithromycin intravenous ampicillin sodium solution reconstituted GM intravenous solution 500 mg GM reconstituted 1 gm, 10 azithromycin oral packet 2 gm, 2 gm 1 gm ampicillin-sulbactam azithromycin oral sodium injection solution GM suspension reconstituted 2 reconstituted 1.5 (1-0.5) 100 mg/5ml, 200 mg/5ml gm, 3 (2-1) gm azithromycin oral tablet 2 ampicillin-sulbactam 250 mg, 500 mg, 600 mg sodium intravenous GM solution reconstituted 15 aztreonam injection (10-5) gm solution reconstituted 1 GM gm, 2 gm ARIKAYCE INHALATION SUSPENSION 590 6 PA bacitracin intramuscular MG/8.4ML solution reconstituted GM 50000 unit AUGMENTIN ES-600 Brand ORAL SUSPENSION Brand 4 penalty BACTRIM DS ORAL 4 penalty RECONSTITUTED 600- applies 42.9 MG/5ML TABLET 800-160 MG applies AUGMENTIN ORAL Brand BACTRIM ORAL 4 penalty SUSPENSION 4 RECONSTITUTED 125- TABLET 400-80 MG applies 31.25 MG/5ML BAXDELA AUGMENTIN ORAL INTRAVENOUS Brand Specialty SUSPENSION SOLUTION 5 4 penalty Medical RECONSTITUTED 250- RECONSTITUTED 300 applies 62.5 MG/5ML MG BAXDELA ORAL 5 TABLET 450 MG

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 22 Drug Drug Drug Name Notes Drug Name Notes Tier Tier benzalkonium chloride CEFAZOLIN SODIUM 2 external solution , 50 % INTRAVENOUS BICILLIN C-R 900/300 SOLUTION PREFILLED GM SYRINGE 1 GM/10ML, 2 INTRAMUSCULAR GM SUSPENSION 900000- GM/20ML 300000 UNIT/2ML cefazolin sodium GM BICILLIN C-R intravenous solution INTRAMUSCULAR reconstituted 1 gm GM SUSPENSION 1200000 cefazolin sodium- UNIT/2ML dextrose intravenous GM BICILLIN L-A solution 1-4 gm/50ml-%, INTRAMUSCULAR 2-4 gm/100ml-% SUSPENSION 1200000 GM CEFAZOLIN SODIUM- UNIT/2ML, 2400000 DEXTROSE UNIT/4ML, 600000 INTRAVENOUS GM UNIT/ML SOLUTION 2-5 cefaclor er oral tablet GM/100ML-% extended release 12 hour 2 cefazolin sodium- 500 mg dextrose intravenous cefaclor oral capsule 250 solution reconstituted 1-4 GM 2 mg, 500 mg gm-%(50ml), 2-3 gm- %(50ml) cefaclor oral suspension cefdinir oral capsule 300 reconstituted 125 2 2 mg/5ml, 250 mg/5ml, 375 mg mg/5ml cefdinir oral suspension reconstituted 125 2 cefadroxil oral capsule 2 500 mg mg/5ml, 250 mg/5ml cefadroxil oral cefepime hcl injection suspension reconstituted 2 solution reconstituted 1 GM 250 mg/5ml, 500 mg/5ml gm, 2 gm cefadroxil oral tablet 1 cefepime hcl intravenous 2 gm solution 1 gm/50ml, 2 GM gm/100ml CEFAZOLIN IN SODIUM CHLORIDE cefepime hcl intravenous solution reconstituted GM INTRAVENOUS GM SOLUTION 2-0.9 100 gm GM/100ML-%, 3-0.9 cefepime-dextrose GM/100ML-% intravenous solution cefazolin sodium reconstituted 1-5 gm- GM injection solution %(50ml), 2-5 gm- reconstituted 1 gm, 10 GM %(50ml) gm, 100 gm, 300 gm, cefixime oral capsule 400 2 500 mg mg

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 23 Drug Drug Drug Name Notes Drug Name Notes Tier Tier cefixime oral suspension ceftazidime and dextrose reconstituted 100 2 intravenous solution mg/5ml, 200 mg/5ml reconstituted 1-5 gm- GM CEFOTAN INJECTION %(50ml), 2-5 gm- %(50ml) SOLUTION GM RECONSTITUTED 1 ceftazidime injection GM, 2 GM solution reconstituted 1 GM cefotaxime sodium gm, 2 gm, 6 gm injection solution GM ceftriaxone sodium in reconstituted 1 gm, 2 gm dextrose intravenous GM cefotetan disodium solution 20 mg/ml, 40 injection solution GM mg/ml reconstituted 1 gm, 2 gm ceftriaxone sodium cefotetan disodium- injection solution dextrose intravenous reconstituted 1 gm, 100 GM solution reconstituted 1- GM gm, 2 gm, 250 mg, 500 3.58 gm-%(50ml), 2-2.08 mg gm-%(50ml) ceftriaxone sodium intravenous solution cefoxitin sodium injection GM solution reconstituted 10 GM reconstituted 1 gm, 10 gm gm, 2 gm cefoxitin sodium ceftriaxone sodium- intravenous solution GM dextrose intravenous reconstituted 1 gm, 2 gm solution reconstituted 1- GM 3.74 gm-%(50ml), 2-2.22 CEFOXITIN SODIUM- gm-%(50ml) DEXTROSE cefuroxime axetil oral INTRAVENOUS 2 SOLUTION GM tablet 250 mg, 500 mg RECONSTITUTED 1-4 cefuroxime sodium GM-%(50ML), 2-2.2 GM- injection solution GM %(50ML) reconstituted 750 mg cefpodoxime proxetil oral cefuroxime sodium suspension reconstituted 2 intravenous solution GM 100 mg/5ml, 50 mg/5ml reconstituted 1.5 gm cefpodoxime proxetil oral 2 CENTANY AT 3 tablet 100 mg, 200 mg EXTERNAL KIT 2 % cefprozil oral suspension cephalexin oral capsule 1 reconstituted 125 2 250 mg, 500 mg mg/5ml, 250 mg/5ml cephalexin oral capsule 2 cefprozil oral tablet 250 750 mg 2 mg, 500 mg cephalexin oral suspension reconstituted 2 125 mg/5ml, 250 mg/5ml

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 24 Drug Drug Drug Name Notes Drug Name Notes Tier Tier cephalexin oral tablet Brand 2 250 mg, 500 mg CLEOCIN VAGINAL 4 penalty chloramphenicol sod CREAM 2 % applies succinate intravenous GM CLEOCIN VAGINAL 3 solution reconstituted 1 SUPPOSITORY 100 MG gm clindamycin hcl oral CIPRO ORAL capsule 150 mg, 300 mg, 2 SUSPENSION 75 mg RECONSTITUTED 250 3 clindamycin palmitate hcl MG/5ML (5%), 500 oral solution 2 MG/5ML (10%) reconstituted 75 mg/5ml Brand clindamycin phosphate in CIPRO ORAL TABLET 4 penalty d5w intravenous solution GM 250 MG, 500 MG applies 300 mg/50ml, 600 ciprofloxacin hcl oral 2 mg/50ml, 900 mg/50ml tablet 100 mg, 750 mg clindamycin phosphate ciprofloxacin hcl oral 1 injection solution 300 tablet 250 mg, 500 mg mg/2ml, 600 mg/4ml, 9 GM ciprofloxacin in d5w gm/60ml, 900 mg/6ml, intravenous solution 200 GM 9000 mg/60ml mg/100ml, 400 mg/200ml clindamycin phosphate 2 clarithromycin er oral vaginal cream 2 % 2 tablet extended release CLINDESSE VAGINAL 4 24 hour 500 mg CREAM 2 % clarithromycin oral colistimethate sodium suspension reconstituted 2 (cba) injection solution GM 125 mg/5ml, 250 mg/5ml reconstituted 150 mg clarithromycin oral tablet 2 COLY-MYCIN M 250 mg, 500 mg INJECTION SOLUTION GM CLEOCIN ORAL Brand RECONSTITUTED 150 CAPSULE 150 MG, 300 4 penalty MG MG, 75 MG applies CUBICIN CLEOCIN ORAL INTRAVENOUS Brand SOLUTION SOLUTION GM 4 penalty RECONSTITUTED 500 RECONSTITUTED 75 applies MG/5ML MG CLEOCIN PHOSPHATE CUBICIN RF INJECTION SOLUTION INTRAVENOUS 300 MG/2ML, 600 GM SOLUTION GM MG/4ML, 9 GM/60ML, RECONSTITUTED 500 900 MG/6ML MG

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 25 Drug Drug Drug Name Notes Drug Name Notes Tier Tier DALVANCE E.E.S. GRANULES Brand INTRAVENOUS Specialty ORAL SUSPENSION 4 penalty 6 SOLUTION Medical RECONSTITUTED 200 applies RECONSTITUTED 500 MG/5ML MG ertapenem sodium daptomycin intravenous injection solution 2 solution reconstituted GM reconstituted 1 gm 350 mg, 500 mg ERYPED 200 ORAL Brand demeclocycline hcl oral SUSPENSION 2 4 penalty tablet 150 mg, 300 mg RECONSTITUTED 200 applies dicloxacillin sodium oral MG/5ML 2 capsule 250 mg, 500 mg ERYPED 400 ORAL Brand DIFICID ORAL SUSPENSION 4 penalty RECONSTITUTED 400 SUSPENSION 5 applies RECONSTITUTED 40 MG/5ML MG/ML ERY-TAB ORAL Brand TABLET DELAYED DIFICID ORAL TABLET 4 penalty 5 RELEASE 250 MG, 333 200 MG applies MG, 500 MG doxy 100 intravenous solution reconstituted GM ERYTHROCIN 100 mg LACTOBIONATE INTRAVENOUS GM doxycycline hyclate SOLUTION intravenous solution GM RECONSTITUTED 500 reconstituted 100 mg MG doxycycline hyclate oral 2 ERYTHROCIN capsule 100 mg, 50 mg STEARATE ORAL 4 TABLET 250 MG doxycycline hyclate oral 2 tablet 100 mg, 20 mg erythromycin base oral doxycycline hyclate oral capsule delayed release 2 tablet delayed release 2 particles 250 mg 100 mg, 150 mg, 75 mg erythromycin base oral 2 doxycycline monohydrate tablet 250 mg, 500 mg oral capsule 100 mg, 150 2 erythromycin base oral mg, 50 mg, 75 mg tablet delayed release 2 doxycycline monohydrate 250 mg, 333 mg, 500 mg oral suspension 2 erythromycin reconstituted 25 mg/5ml ethylsuccinate oral 2 doxycycline monohydrate suspension reconstituted oral tablet 100 mg, 150 2 200 mg/5ml, 400 mg/5ml mg, 50 mg, 75 mg erythromycin E.E.S. 400 ORAL ethylsuccinate oral tablet 2 4 TABLET 400 MG 400 mg

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 26 Drug Drug Drug Name Notes Drug Name Notes Tier Tier erythromycin oral tablet Brand delayed release 250 mg, 2 HUMATIN ORAL 4 penalty 333 mg, 500 mg CAPSULE 250 MG applies

FETROJA hydrogen peroxide 2 Specialty INTRAVENOUS 6 solution 30 % SOLUTION Medical imipenem-cilastatin RECONSTITUTED 1 GM intravenous solution GM FIRVANQ ORAL reconstituted 250 mg, SOLUTION 500 mg 4 RECONSTITUTED 25 INVANZ INJECTION Brand MG/ML, 50 MG/ML SOLUTION 4 penalty Brand RECONSTITUTED 1 GM applies FLAGYL ORAL 4 penalty iodine external 2 CAPSULE 375 MG applies tincture 2 % Brand Brand FLAGYL ORAL TABLET 4 penalty KEFLEX ORAL 4 penalty applies 500 MG CAPSULE 750 MG applies FORTAZ INJECTION KIMYRSA SOLUTION INTRAVENOUS GM Specialty RECONSTITUTED 1 SOLUTION 6 Medical GM, 500 MG RECONSTITUTED 1200 FORTAZ MG INTRAVENOUS GM levofloxacin in d5w SOLUTION intravenous solution 250 GM RECONSTITUTED 2 GM mg/50ml, 500 mg/100ml, fosfomycin tromethamine 2 750 mg/150ml oral packet 3 gm levofloxacin intravenous GM gentamicin in saline solution 25 mg/ml intravenous solution 0.8- levofloxacin oral solution 0.9 mg/ml-%, 1-0.9 2 GM 25 mg/ml mg/ml-%, 1.2-0.9 mg/ml- levofloxacin oral tablet %, 1.6-0.9 mg/ml-%, 2- 2 0.9 mg/ml-% 250 mg, 500 mg, 750 mg LINCOCIN INJECTION gentamicin sulfate 2 GM external cream 0.1 % SOLUTION 300 MG/ML lincomycin hcl injection gentamicin sulfate 2 GM external ointment 0.1 % solution 300 mg/ml gentamicin sulfate linezolid in sodium Specialty injection solution 10 GM chloride intravenous 5 mg/ml, 40 mg/ml solution 600-0.9 Medical mg/300ml-% Brand linezolid intravenous Specialty HIPREX ORAL TABLET 4 penalty 5 1 GM applies solution 600 mg/300ml Medical

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 27 Drug Drug Drug Name Notes Drug Name Notes Tier Tier QL (900 MINOCIN linezolid oral suspension 5 ML per 30 INTRAVENOUS reconstituted 100 mg/5ml days) SOLUTION GM QL (60 EA RECONSTITUTED 100 linezolid oral tablet 600 5 per 30 MG mg days) minocycline hcl oral 2 LUGOLS STRONG capsule 100 mg, 50 mg, IODINE EXTERNAL 4 75 mg SOLUTION 5-10 % minocycline hcl oral Brand tablet 100 mg, 50 mg, 75 2 MACROBID ORAL 4 penalty mg applies CAPSULE 100 MG mondoxyne nl oral 2 MACRODANTIN ORAL Brand capsule 100 mg, 75 mg CAPSULE 100 MG, 25 4 penalty Brand MG, 50 MG applies MONUROL ORAL 4 penalty PACKET 3 GM applies mafenide acetate 2 external packet 5 % morgidox oral capsule 2 meropenem intravenous 100 mg solution reconstituted 1 GM moxifloxacin hcl in nacl gm, 500 mg intravenous solution 400 GM MEROPENEM-SODIUM mg/250ml CHLORIDE MOXIFLOXACIN HCL INTRAVENOUS GM INTRAVENOUS GM SOLUTION SOLUTION 400 RECONSTITUTED 1 MG/250ML GM/50ML, 500 MG/50ML moxifloxacin hcl oral 2 methenamine hippurate 2 tablet 400 mg oral tablet 1 gm mupirocin external 2 methenamine mandelate ointment 2 % 2 oral tablet 0.5 gm, 1 gm NAFCILLIN SODIUM IN metronidazole in nacl DEXTROSE intravenous solution 5- INTRAVENOUS GM 0.79 mg/ml-%, 500-0.74 GM SOLUTION 1 GM/50ML, mg/100ml-%, 500-0.79 2 GM/100ML mg/100ml-% nafcillin sodium injection GM metronidazole oral 2 solution reconstituted 1 capsule 375 mg gm, 2 gm metronidazole oral tablet 2 nafcillin sodium 250 mg, 500 mg intravenous solution GM metronidazole vaginal gel reconstituted 1 gm, 10 2 0.75 % gm, 2 gm neomycin sulfate oral 2 tablet 500 mg

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 28 Drug Drug Drug Name Notes Drug Name Notes Tier Tier neomycin-polymyxin b gu PENICILLIN G POT IN irrigation solution 40- 2 DEXTROSE 200000 INTRAVENOUS nitrofurantoin SOLUTION 20000 GM macrocrystal oral capsule 2 UNIT/ML, 40000 100 mg, 25 mg, 50 mg UNIT/ML, 60000 UNIT/ML nitrofurantoin monohydrate penicillin g potassium 2 injection solution macrocrystals oral GM capsule 100 mg reconstituted 20000000 unit, 5000000 unit nitrofurantoin oral 2 suspension 25 mg/5ml penicillin g procaine intramuscular suspension GM NUTRIDOX ORAL KIT 4 600000 unit/ml 75 MG penicillin g sodium NUZYRA injection solution GM INTRAVENOUS Specialty reconstituted 5000000 6 SOLUTION Medical unit RECONSTITUTED 100 MG penicillin v potassium oral solution 2 QL (30 EA reconstituted 125 NUZYRA ORAL TABLET 6 per 14 mg/5ml, 250 mg/5ml 150 MG days) penicillin v potassium ofloxacin oral tablet 300 2 oral tablet 250 mg, 500 1 mg, 400 mg mg ORBACTIV PFIZERPEN INJECTION INTRAVENOUS Specialty SOLUTION 5 SOLUTION Medical RECONSTITUTED GM RECONSTITUTED 400 20000000 UNIT, MG 5000000 UNIT OXACILLIN SODIUM IN piperacillin sod- DEXTROSE tazobactam so INTRAVENOUS GM intravenous solution SOLUTION 1 GM/50ML, reconstituted 13.5 (12- GM 2 GM/50ML 1.5) gm, 2.25 (2-0.25) oxacillin sodium injection gm, 3.375 (3-0.375) gm, solution reconstituted 1 GM 4.5 (4-0.5) gm, 40.5 (36- gm, 2 gm 4.5) gm oxacillin sodium polymyxin b sulfate intravenous solution GM injection solution GM reconstituted 10 gm reconstituted 500000 unit paromomycin sulfate oral 2 capsule 250 mg

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 29 Drug Drug Drug Name Notes Drug Name Notes Tier Tier PRIMAXIN IV sulfamethoxazole- INTRAVENOUS trimethoprim oral tablet 1 SOLUTION GM 400-80 mg, 800-160 mg RECONSTITUTED 500- SULFAMYLON 500 MG EXTERNAL CREAM 85 4 PRIMSOL ORAL 4 MG/GM SOLUTION 50 MG/5ML SULFAMYLON Brand RECARBRIO EXTERNAL PACKET 5 4 penalty INTRAVENOUS % applies Specialty SOLUTION 6 Medical sulfatrim pediatric oral RECONSTITUTED 1.25 suspension 200-40 2 GM mg/5ml Brand Brand SILVADENE EXTERNAL 4 penalty SUPRAX ORAL 4 penalty CREAM 1 % applies CAPSULE 400 MG applies silver nitrate external SUPRAX ORAL solution 0.5 %, 10 %, 25 2 Brand SUSPENSION 4 penalty %, 50 % RECONSTITUTED 100 applies silver sulfadiazine MG/5ML, 200 MG/5ML 2 external cream 1 % SUPRAX ORAL SIVEXTRO SUSPENSION 4 INTRAVENOUS Specialty RECONSTITUTED 500 6 SOLUTION Medical MG/5ML RECONSTITUTED 200 SUPRAX ORAL TABLET MG CHEWABLE 100 MG, 4 QL (6 EA 200 MG SIVEXTRO ORAL 6 per 30 SYNERCID TABLET 200 MG days) INTRAVENOUS SOLOSEC ORAL SOLUTION GM 4 PACKET 2 GM RECONSTITUTED 150- ssd external cream 1 % 2 350 MG streptomycin sulfate tazicef injection solution intramuscular solution GM reconstituted 1 gm, 2 gm, GM reconstituted 1 gm 6 gm TAZICEF sulfadiazine oral tablet 2 500 mg INTRAVENOUS GM SOLUTION 1 GM/50ML sulfamethoxazole- trimethoprim intravenous GM tazicef intravenous solution 400-80 mg/5ml solution reconstituted 1 GM gm, 2 gm sulfamethoxazole- trimethoprim oral 2 suspension 200-40 mg/5ml

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 30 Drug Drug Drug Name Notes Drug Name Notes Tier Tier TEFLARO Brand INTRAVENOUS VANCOCIN ORAL 4 penalty SOLUTION GM CAPSULE 250 MG applies RECONSTITUTED 400 VANCOMYCIN HCL IN MG, 600 MG DEXTROSE tetracycline hcl oral 2 INTRAVENOUS GM capsule 250 mg, 500 mg SOLUTION 1.25-5 tigecycline intravenous GM/250ML-%, 1.5-5 solution reconstituted 50 GM GM/250ML-% mg vancomycin hcl in tinidazole oral tablet 250 dextrose intravenous 2 mg, 500 mg solution 1-5 gm/200ml-%, GM 500-5 mg/100ml-%, 750- tobramycin sulfate 5 mg/150ml-% injection solution 1.2 GM gm/30ml, 10 mg/ml, 2 vancomycin hcl in nacl intravenous solution 1- gm/50ml, 80 mg/2ml GM 0.9 gm/200ml-%, 500-0.9 tobramycin sulfate mg/100ml-% injection solution GM reconstituted 1.2 gm VANCOMYCIN HCL IN NACL INTRAVENOUS trimethoprim oral tablet 2 SOLUTION 1-0.9 100 mg GM/250ML-%, 1.25-0.9 TYGACIL GM/250ML-%, 1.5-0.9 GM INTRAVENOUS GM/250ML-%, 1.5-0.9 SOLUTION GM GM/500ML-%, 1.75-0.9 RECONSTITUTED 50 GM/250ML-%, 2-0.9 MG GM/500ML-% UNASYN INJECTION VANCOMYCIN HCL IN SOLUTION NACL SOLUTION 750- GM RECONSTITUTED 1.5 0.9 MG/150ML-% GM (1-0.5) GM, 3 (2-1) GM INTRAVENOUS 750-0.9 UNASYN MG/150ML-% INTRAVENOUS vancomycin hcl in nacl GM SOLUTION solution 750-0.9 GM RECONSTITUTED 15 mg/150ml-% intravenous (10-5) GM 750-0.9 mg/150ml-% VABOMERE vancomycin hcl INTRAVENOUS intravenous solution SOLUTION GM 1000 mg/200ml, 1500 GM RECONSTITUTED 2 (1- mg/300ml, 2000 1) GM mg/400ml, 500 mg/100ml Brand vancomycin hcl 4 penalty VANCOCIN HCL ORAL intravenous solution GM PA CAPSULE 125 MG applies 1250 mg/250ml, 1750 mg/350ml, 750 mg/150ml Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 31 Drug Drug Drug Name Notes Drug Name Notes Tier Tier vancomycin hcl ZEMDRI INTRAVENOUS Specialty 6 intravenous solution SOLUTION 500 Medical reconstituted 1 gm, 1.25 GM MG/10ML gm, 1.5 gm, 10 gm, 1000 ZERBAXA mg, 5 gm, 500 mg, 750 INTRAVENOUS mg SOLUTION GM vancomycin hcl oral RECONSTITUTED 1.5 2 capsule 125 mg, 250 mg (1-0.5) GM vancomycin hcl oral ZITHROMAX solution reconstituted 2 INTRAVENOUS 250 mg/5ml SOLUTION GM RECONSTITUTED 500 vandazole vaginal gel 2 0.75 % MG VIBATIV INTRAVENOUS ZITHROMAX ORAL 4 PACKET 1 GM SOLUTION GM RECONSTITUTED 750 ZITHROMAX ORAL Brand MG SUSPENSION 4 penalty RECONSTITUTED 100 Brand applies VIBRAMYCIN ORAL 4 penalty MG/5ML, 200 MG/5ML CAPSULE 100 MG applies ZITHROMAX ORAL Brand VIBRAMYCIN ORAL TABLET 250 MG, 500 4 penalty Brand MG applies SUSPENSION 4 penalty Brand RECONSTITUTED 25 applies MG/5ML ZITHROMAX TRI-PAK 4 penalty ORAL TABLET 500 MG applies VIBRAMYCIN ORAL 3 50 MG/5ML Brand XENLETA ZITHROMAX Z-PAK 4 penalty INTRAVENOUS Specialty ORAL TABLET 250 MG applies 6 SOLUTION 150 Medical ZOSYN INTRAVENOUS MG/15ML SOLUTION 2-0.25 XENLETA ORAL GM/50ML, 3-0.375 GM 6 TABLET 600 MG GM/50ML, 4-0.5 GM/100ML XEPI EXTERNAL 4 ST CREAM 1 % ZYVOX INTRAVENOUS Specialty SOLUTION 200 5 XERAVA MG/100ML, 600 Medical INTRAVENOUS Specialty MG/300ML SOLUTION 5 Medical ZYVOX ORAL RECONSTITUTED 100 QL (900 SUSPENSION MG, 50 MG 5 ML per 30 RECONSTITUTED 100 XIFAXAN ORAL TABLET days) 5 PA MG/5ML 200 MG, 550 MG QL (60 EA ZYVOX ORAL TABLET 5 per 30 600 MG days) Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 32 Drug Drug Drug Name Notes Drug Name Notes Tier Tier Anticoagulants bivalirudin ACD FORMULA A IN trifluoroacetate GM VITRO SOLUTION 0.73- 4 intravenous solution 2.45-2.2 GM/100ML reconstituted 250 mg ACD-A NOCLOT-50 IN BIVALIRUDIN-SODIUM VITRO SOLUTION 0.73- 4 CHLORIDE Specialty INTRAVENOUS 6 2.45-2.2 GM/100ML Medical SOLUTION 500-0.9 ACTIVASE MG/100ML-% INTRAVENOUS SOLUTION GM CATHFLO ACTIVASE RECONSTITUTED 100 INJECTION SOLUTION GM MG, 50 MG RECONSTITUTED 2 MG ANGIOMAX ELIQUIS DVT/PE INTRAVENOUS STARTER PACK ORAL 3 SOLUTION GM TABLET THERAPY RECONSTITUTED 250 PACK 5 MG MG ELIQUIS ORAL TABLET 3 ANTICOAGULANT 2.5 MG, 5 MG SODIUM CITRATE IN 4 enoxaparin sodium VITRO SOLUTION 4 %, injection solution 300 2 4 GM/100ML mg/3ml argatroban in sodium enoxaparin sodium chloride intravenous GM subcutaneous solution solution 50-0.9 mg/50ml- 100 mg/ml, 120 % mg/0.8ml, 150 mg/ml, 30 2 argatroban intravenous mg/0.3ml, 40 mg/0.4ml, solution 250 mg/2.5ml, GM 60 mg/0.6ml, 80 50 mg/50ml mg/0.8ml ARIXTRA fondaparinux sodium SUBCUTANEOUS subcutaneous solution 10 Brand 2 SOLUTION 10 mg/0.8ml, 2.5 mg/0.5ml, 4 penalty 5 mg/0.4ml, 7.5 mg/0.6ml MG/0.8ML, 2.5 applies MG/0.5ML, 5 MG/0.4ML, FRAGMIN 7.5 MG/0.6ML SUBCUTANEOUS BEVYXXA ORAL QL (30 EA SOLUTION 10000 CAPSULE 40 MG, 80 4 per 30 UNIT/ML, 12500 MG days) UNIT/0.5ML, 15000 UNIT/0.6ML, 18000 3 BIVALIRUDIN RTU UNT/0.72ML, 2500 INTRAVENOUS GM UNIT/0.2ML, 5000 SOLUTION 250 UNIT/0.2ML, 7500 MG/50ML UNIT/0.3ML, 95000 UNIT/3.8ML

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 33 Drug Drug Drug Name Notes Drug Name Notes Tier Tier heparin (porcine) in nacl heparin sodium (porcine) intravenous solution pf injection solution 5000 2 1000-0.9 ut/500ml-%, 2 unit/0.5ml 12500-0.45 ut/250ml-%, heparin sodium (porcine) 2000-0.9 unit/l-%, 25000- pf injection solution 5000 GM 0.45 ut/250ml-% unit/ml HEPARIN (PORCINE) IN jantoven oral tablet 1 mg, NACL INTRAVENOUS 10 mg, 2 mg, 2.5 mg, 3 1 SOLUTION 2500-0.9 mg, 4 mg, 5 mg, 6 mg, UT/500ML-%, 500-0.9 GM 7.5 mg UT/500ML-%, 5000-0.9 UNIT/L-%, 5000-0.9 Brand UT/500ML-% LOVENOX INJECTION 4 penalty SOLUTION 300 MG/3ML applies heparin (porcine) in nacl intravenous solution GM LOVENOX 25000-0.45 ut/500ml-% SUBCUTANEOUS SOLUTION 100 MG/ML, Brand HEPARIN (PORCINE) IN 120 MG/0.8ML, 150 4 penalty NACL INTRAVENOUS MG/ML, 30 MG/0.3ML, applies SOLUTION 30000-0.9 4 40 MG/0.4ML, 60 UNIT/L-%, 4000-0.9 MG/0.6ML, 80 MG/0.8ML UNIT/L-% PRADAXA ORAL HEPARIN (PORCINE) IN CAPSULE 110 MG, 150 3 NACL INTRAVENOUS MG, 75 MG SOLUTION PREFILLED 4 SYRINGE 20-0.9 REGIOCIT IN VITRO GM UNT/20ML-% SOLUTION 0.529 % HEPARIN (PORCINE) IN SAVAYSA ORAL NACL INTRAVENOUS TABLET 15 MG, 30 MG, 4 ST SOLUTION PREFILLED GM 60 MG SYRINGE 50-0.9 SODIUM CITRATE IN UNT/50ML-% VITRO SOLUTION GM heparin sod (porcine) in PREFILLED SYRINGE 4 d5w intravenous solution % 100 unit/ml, 25000-5 2 SODIUM CITRATE ut/500ml-%, 40-5 unit/ml- LOCK FLUSH GM % INTRAVENOUS heparin sodium (porcine) SOLUTION 4 % injection solution 1000 SODIUM CITRATE unit/ml, 10000 unit/ml, 2 LOCK FLUSH 20000 unit/ml, 5000 INTRAVENOUS GM unit/ml SOLUTION PREFILLED heparin sodium (porcine) SYRINGE 120 MG/3ML injection solution prefilled GM syringe 5000 unit/0.5ml

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 34 Drug Drug Drug Name Notes Drug Name Notes Tier Tier SODIUM CITRATE- BRIVIACT ORAL GENTAMICIN SULF TABLET 10 MG, 100 4 ST INTRAVENOUS GM MG, 25 MG, 50 MG, 75 SOLUTION 4-320 %- MG MCG/ML carbamazepine er oral THROMBATE III capsule extended 2 INTRAVENOUS release 12 hour 100 mg, SOLUTION GM PA 200 mg, 300 mg RECONSTITUTED 1000 carbamazepine er oral UNIT, 500 UNIT tablet extended release 2 TNKASE 12 hour 100 mg, 200 mg, INTRAVENOUS KIT 50 GM 400 mg MG carbamazepine oral 2 TRICITRASOL IN VITRO 4 suspension 100 mg/5ml CONCENTRATE 46.7 % carbamazepine oral 2 warfarin sodium oral tablet 200 mg tablet 1 mg, 10 mg, 2 mg, 1 carbamazepine oral 2 2.5 mg, 3 mg, 4 mg, 5 tablet chewable 100 mg mg, 6 mg, 7.5 mg CARBATROL ORAL XARELTO ORAL CAPSULE EXTENDED 4 TABLET 10 MG, 15 MG, 3 RELEASE 12 HOUR 100 2.5 MG, 20 MG MG, 200 MG, 300 MG XARELTO STARTER CELONTIN ORAL 4 PACK ORAL TABLET 3 CAPSULE 300 MG THERAPY PACK 15 & 20 MG CEREBYX INJECTION SOLUTION 100 MG Anticonvulsants - GM PE/2ML, 500 MG Drugs for Seizures PE/10ML APTIOM ORAL TABLET clobazam oral 4 ST 2 200 MG, 400 MG, 600 suspension 2.5 mg/ml MG, 800 MG clobazam oral tablet 10 2 BANZEL ORAL mg, 20 mg SUSPENSION 40 4 MG/ML DEPAKOTE ER ORAL TABLET EXTENDED 4 BANZEL ORAL TABLET 4 RELEASE 24 HOUR 250 200 MG, 400 MG MG, 500 MG BRIVIACT DEPAKOTE ORAL INTRAVENOUS GM ST TABLET DELAYED 4 SOLUTION 50 MG/5ML RELEASE 125 MG, 250 BRIVIACT ORAL 4 ST MG, 500 MG SOLUTION 10 MG/ML

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 35 Drug Drug Drug Name Notes Drug Name Notes Tier Tier DEPAKOTE SPRINKLES felbamate oral 2 ORAL CAPSULE 4 suspension 600 mg/5ml DELAYED RELEASE felbamate oral tablet 400 2 SPRINKLE 125 MG mg, 600 mg DIACOMIT ORAL FELBATOL ORAL CAPSULE 250 MG, 500 4 SUSPENSION 600 4 MG MG/5ML DIACOMIT ORAL FELBATOL ORAL PACKET 250 MG, 500 4 TABLET 400 MG, 600 4 MG MG DIASTAT ACUDIAL FINTEPLA ORAL 6 PA RECTAL GEL 10 MG, 20 4 SOLUTION 2.2 MG/ML MG fosphenytoin sodium DIASTAT PEDIATRIC 4 injection solution 100 mg GM RECTAL GEL 2.5 MG pe/2ml, 500 mg pe/10ml diazepam rectal gel 10 2 FYCOMPA ORAL mg, 2.5 mg, 20 mg SUSPENSION 0.5 4 DILANTIN INFATABS MG/ML 4 ORAL TABLET FYCOMPA ORAL CHEWABLE 50 MG TABLET 10 MG, 12 MG, 4 DILANTIN ORAL 2 MG, 4 MG, 6 MG, 8 CAPSULE 100 MG, 30 4 MG MG gabapentin oral capsule 2 DILANTIN ORAL 100 mg, 300 mg, 400 mg SUSPENSION 125 4 gabapentin oral solution 2 MG/5ML 250 mg/5ml, 300 mg/6ml divalproex sodium er oral gabapentin oral tablet 2 tablet extended release 2 600 mg, 800 mg 24 hour 250 mg, 500 mg GABITRIL ORAL divalproex sodium oral TABLET 12 MG, 16 MG, 4 capsule delayed release 2 2 MG, 4 MG sprinkle 125 mg KEPPRA divalproex sodium oral INTRAVENOUS GM tablet delayed release 2 SOLUTION 500 MG/5ML 125 mg, 250 mg, 500 mg KEPPRA ORAL 4 EPIDIOLEX ORAL 6 PA SOLUTION 100 MG/ML SOLUTION 100 MG/ML KEPPRA ORAL TABLET epitol oral tablet 200 mg 2 1000 MG, 250 MG, 500 4 ethosuximide oral 2 MG, 750 MG capsule 250 mg ethosuximide oral 2 solution 250 mg/5ml

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 36 Drug Drug Drug Name Notes Drug Name Notes Tier Tier KEPPRA XR ORAL lamotrigine oral tablet 2 TABLET EXTENDED 4 chewable 25 mg, 5 mg RELEASE 24 HOUR 500 lamotrigine oral tablet MG, 750 MG dispersible 100 mg, 200 2 LAMICTAL ODT ORAL mg, 25 mg, 50 mg KIT 21 X 25 MG & 7 X 50 lamotrigine starter kit- 4 2 MG, 25 & 50 & 100 MG, blue oral kit 35 x 25 mg 42 X 50 MG & 14X100 MG lamotrigine starter kit- green oral kit 84 x 25 mg 2 LAMICTAL ODT ORAL & 14x100 mg TABLET DISPERSIBLE 4 100 MG, 200 MG, 25 lamotrigine starter kit- MG, 50 MG orange oral kit 42 x 25 2 mg & 7 x 100 mg LAMICTAL ORAL TABLET 100 MG, 150 4 levetiracetam er oral MG, 200 MG, 25 MG tablet extended release 2 24 hour 500 mg, 750 mg LAMICTAL ORAL TABLET CHEWABLE 25 4 levetiracetam in nacl MG, 5 MG intravenous solution GM 1000 mg/100ml, 1500 LAMICTAL STARTER mg/100ml, 500 mg/100ml ORAL KIT 35 X 25 MG, 42 X 25 MG & 7 X 100 4 levetiracetam MG, 84 X 25 MG & intravenous solution 500 GM 14X100 MG mg/5ml LAMICTAL XR ORAL levetiracetam oral 2 solution 100 mg/ml KIT 21 X 25 MG & 7 X 50 4 MG, 25 & 50 & 100 MG, levetiracetam oral tablet 50 & 100 & 200 MG 1000 mg, 250 mg, 500 2 LAMICTAL XR ORAL mg, 750 mg TABLET EXTENDED MYSOLINE ORAL 3 RELEASE 24 HOUR 100 4 TABLET 250 MG MG, 200 MG, 25 MG, MYSOLINE ORAL 4 250 MG, 300 MG, 50 MG TABLET 50 MG lamotrigine er oral tablet NAYZILAM NASAL 4 extended release 24 hour 2 SOLUTION 5 MG/0.1ML 100 mg, 200 mg, 25 mg, NEMBUTAL INJECTION 250 mg, 300 mg, 50 mg GM SOLUTION 50 MG/ML lamotrigine oral kit 25 & 2 50 & 100 mg NEURONTIN ORAL CAPSULE 100 MG, 300 4 lamotrigine oral tablet 1 MG, 400 MG 100 mg, 150 mg, 200 mg NEURONTIN ORAL 4 lamotrigine oral tablet 25 2 SOLUTION 250 MG/5ML mg

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 37 Drug Drug Drug Name Notes Drug Name Notes Tier Tier NEURONTIN ORAL phenytoin sodium TABLET 600 MG, 800 4 injection solution 50 GM MG mg/ml

ONFI ORAL primidone oral tablet 250 2 SUSPENSION 2.5 4 mg, 50 mg MG/ML QUDEXY XR ORAL ONFI ORAL TABLET 10 4 CAPSULE ER 24 HOUR MG, 20 MG SPRINKLE 100 MG, 150 4 PA oxcarbazepine oral MG, 200 MG, 25 MG, 50 2 suspension 300 mg/5ml MG oxcarbazepine oral tablet roweepra oral tablet 500 2 2 150 mg, 300 mg, 600 mg mg OXTELLAR XR ORAL rufinamide oral 2 suspension 40 mg/ml TABLET EXTENDED 4 RELEASE 24 HOUR 150 rufinamide oral tablet 200 2 MG, 300 MG, 600 MG mg, 400 mg pentobarbital sodium SABRIL ORAL PACKET 6 PA injection solution 50 GM 500 MG mg/ml SABRIL ORAL TABLET 6 PA phenobarbital oral elixir 500 MG 2 20 mg/5ml SPRITAM ORAL phenobarbital oral tablet TABLET 100 mg, 15 mg, 16.2 mg, DISINTEGRATING 4 ST 2 30 mg, 32.4 mg, 60 mg, SOLUBLE 1000 MG, 250 64.8 mg, 97.2 mg MG, 500 MG, 750 MG phenobarbital sodium subvenite oral tablet 100 1 injection solution 130 GM mg, 150 mg, 200 mg mg/ml, 65 mg/ml subvenite oral tablet 25 2 PHENYTEK ORAL mg CAPSULE 200 MG, 300 4 subvenite starter kit-blue 2 MG oral kit 35 x 25 mg phenytoin infatabs oral 2 subvenite starter kit- tablet chewable 50 mg green oral kit 84 x 25 mg 2 phenytoin oral & 14x100 mg suspension 100 mg/4ml, 2 subvenite starter kit- 125 mg/5ml orange oral kit 42 x 25 2 phenytoin oral tablet 2 mg & 7 x 100 mg chewable 50 mg SYMPAZAN ORAL FILM 4 phenytoin sodium 10 MG, 20 MG, 5 MG extended oral capsule 2 TEGRETOL ORAL 100 mg, 200 mg, 300 mg SUSPENSION 100 4 MG/5ML

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 38 Drug Drug Drug Name Notes Drug Name Notes Tier Tier TEGRETOL ORAL VALTOCO NASAL 4 TABLET 200 MG LIQUID 10 MG/0.1ML, 5 4 TEGRETOL-XR ORAL MG/0.1ML TABLET EXTENDED 4 VALTOCO NASAL RELEASE 12 HOUR 100 LIQUID THERAPY PACK 4 MG, 200 MG, 400 MG 10 MG/0.1ML, 7.5 tiagabine hcl oral tablet MG/0.1ML 12 mg, 16 mg, 2 mg, 4 2 vigabatrin oral packet 5 PA mg 500 mg TOPAMAX ORAL vigabatrin oral tablet 500 5 PA TABLET 100 MG, 200 4 mg MG, 25 MG, 50 MG vigadrone oral packet 5 PA TOPAMAX SPRINKLE 500 mg ORAL CAPSULE 4 VIMPAT INTRAVENOUS SPRINKLE 15 MG, 25 SOLUTION 200 GM MG MG/20ML topiramate er oral VIMPAT ORAL capsule er 24 hour 4 2 PA SOLUTION 10 MG/ML sprinkle 100 mg, 150 mg, 200 mg, 25 mg, 50 mg VIMPAT ORAL TABLET 100 MG, 150 MG, 200 4 topiramate oral capsule 2 MG, 50 MG sprinkle 15 mg, 25 mg XCOPRI ORAL TABLET topiramate oral tablet 100 100 MG, 150 MG, 200 4 PA mg, 200 mg, 25 mg, 50 2 MG, 50 MG mg XCOPRI ORAL TABLET TRILEPTAL ORAL THERAPY PACK 100 & SUSPENSION 300 4 150 MG, 14 X 12.5 MG & MG/5ML 14 X 25 MG, 14 X 150 4 PA TRILEPTAL ORAL MG & 14 X200 MG, 14 X TABLET 150 MG, 300 4 50 MG & 14 X100 MG, MG, 600 MG 150 & 200 MG, 50 & 200 TROKENDI XR ORAL MG CAPSULE EXTENDED ZARONTIN ORAL 4 RELEASE 24 HOUR 100 4 PA CAPSULE 250 MG MG, 200 MG, 25 MG, 50 ZARONTIN ORAL 4 MG SOLUTION 250 MG/5ML valproate sodium ZONEGRAN ORAL intravenous solution 100 GM CAPSULE 100 MG, 25 4 mg/ml, 500 mg/5ml MG valproic acid oral capsule zonisamide oral capsule 2 2 250 mg 100 mg, 25 mg, 50 mg valproic acid oral solution 2 250 mg/5ml

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 39 Drug Drug Drug Name Notes Drug Name Notes Tier Tier Antidementia Agents - NAMENDA XR ORAL Drugs for Alzheimer's CAPSULE EXTENDED Brand Disease and Dementia RELEASE 24 HOUR 14 4 penalty ARICEPT ORAL Brand MG, 21 MG, 28 MG, 7 applies TABLET 10 MG, 23 MG, 4 penalty MG 5 MG applies NAMZARIC ORAL CAPSULE ER 24 HOUR donepezil hcl oral tablet 2 4 10 mg, 23 mg, 5 mg THERAPY PACK 7 & 14 & 21 &28 -10 MG donepezil hcl oral tablet 2 dispersible 10 mg, 5 mg NAMZARIC ORAL CAPSULE EXTENDED EXELON RELEASE 24 HOUR 14- 4 Brand TRANSDERMAL PATCH 10 MG, 21-10 MG, 28-10 4 penalty 24 HOUR 13.3 MG, 7-10 MG MG/24HR, 4.6 applies MG/24HR, 9.5 MG/24HR RAZADYNE ER ORAL Brand CAPSULE EXTENDED 4 penalty galantamine RELEASE 24 HOUR 16 applies hydrobromide er oral MG, 24 MG, 8 MG capsule extended 2 release 24 hour 16 mg, rivastigmine tartrate oral 24 mg, 8 mg capsule 1.5 mg, 3 mg, 2 4.5 mg, 6 mg galantamine hydrobromide oral 2 rivastigmine transdermal solution 4 mg/ml patch 24 hour 13.3 2 mg/24hr, 4.6 mg/24hr, galantamine 9.5 mg/24hr hydrobromide oral tablet 2 12 mg, 4 mg, 8 mg Antidepressants memantine hcl er oral amitriptyline hcl oral capsule extended tablet 10 mg, 100 mg, 2 2 release 24 hour 14 mg, 150 mg, 25 mg, 50 mg, 21 mg, 28 mg, 7 mg 75 mg memantine hcl oral amoxapine oral tablet solution 10 mg/5ml, 2 2 100 mg, 150 mg, 25 mg, 2 mg/ml 50 mg memantine hcl oral tablet ANAFRANIL ORAL Brand 10 mg, 28 x 5 mg & 21 x 2 CAPSULE 25 MG, 50 4 penalty 10 mg, 5 mg MG, 75 MG applies NAMENDA TITRATION Brand APLENZIN ORAL ST; QL (30 TABLET EXTENDED PAK ORAL TABLET 28 4 penalty 4 EA per 30 RELEASE 24 HOUR 174 X 5 MG & 21 X 10 MG applies days) MG, 348 MG, 522 MG bupropion hcl er (sr) oral tablet extended release 2 12 hour 100 mg, 150 mg, 200 mg Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 40 Drug Drug Drug Name Notes Drug Name Notes Tier Tier bupropion hcl er (xl) oral duloxetine hcl oral 2 tablet extended release capsule delayed release 2 24 hour 150 mg, 300 mg particles 20 mg, 30 mg, 60 mg bupropion hcl oral tablet 2 100 mg, 75 mg EFFEXOR XR ORAL Brand Brand CAPSULE EXTENDED 4 penalty RELEASE 24 HOUR 150 CELEXA ORAL TABLET 4 penalty applies 10 MG, 20 MG, 40 MG applies MG, 37.5 MG, 75 MG chlordiazepoxide- EMSAM TRANSDERMAL PATCH amitriptyline oral tablet 2 3 10-25 mg, 5-12.5 mg 24 HOUR 12 MG/24HR, 6 MG/24HR, 9 MG/24HR citalopram hydrobromide 2 oral solution 10 mg/5ml escitalopram oxalate oral 2 solution 5 mg/5ml citalopram hydrobromide oral tablet 10 mg, 20 mg, 1 escitalopram oxalate oral 40 mg tablet 10 mg, 20 mg, 5 2 mg clomipramine hcl oral capsule 25 mg, 50 mg, 2 FETZIMA ORAL 75 mg CAPSULE EXTENDED RELEASE 24 HOUR 120 4 PA CYMBALTA ORAL Brand MG, 20 MG, 40 MG, 80 CAPSULE DELAYED 4 penalty MG RELEASE PARTICLES applies 20 MG, 30 MG, 60 MG FETZIMA TITRATION ORAL CAPSULE ER 24 4 desipramine hcl oral HOUR THERAPY PACK tablet 10 mg, 100 mg, 2 20 & 40 MG 150 mg, 25 mg, 50 mg, 75 mg fluoxetine hcl oral capsule 10 mg, 20 mg, 1 DESVENLAFAXINE ER 40 mg ORAL TABLET EXTENDED RELEASE 4 PA fluoxetine hcl oral 24 HOUR 100 MG, 50 capsule delayed release 2 MG 90 mg desvenlafaxine succinate fluoxetine hcl oral 2 solution 20 mg/5ml er oral tablet extended 2 PA release 24 hour 100 mg, fluoxetine hcl oral tablet 2 25 mg, 50 mg 10 mg, 20 mg doxepin hcl oral capsule fluvoxamine maleate er 2 10 mg, 100 mg, 150 mg, oral capsule extended 2 25 mg, 50 mg, 75 mg release 24 hour 100 mg, doxepin hcl oral 150 mg 2 concentrate 10 mg/ml fluvoxamine maleate oral tablet 100 mg, 25 mg, 50 2 mg

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 41 Drug Drug Drug Name Notes Drug Name Notes Tier Tier imipramine hcl oral tablet paroxetine hcl er oral 2 10 mg, 25 mg, 50 mg tablet extended release 2 imipramine pamoate oral 24 hour 12.5 mg, 25 mg, capsule 100 mg, 125 mg, 2 37.5 mg 150 mg, 75 mg paroxetine hcl oral tablet LEXAPRO ORAL Brand 10 mg, 20 mg, 30 mg, 40 2 TABLET 10 MG, 20 MG, 4 penalty mg 5 MG applies PAXIL CR ORAL MARPLAN ORAL TABLET EXTENDED Brand 4 TABLET 10 MG RELEASE 24 HOUR 4 penalty 12.5 MG, 25 MG, 37.5 applies mirtazapine oral tablet 15 MG mg, 30 mg, 45 mg, 7.5 2 mg PAXIL ORAL SUSPENSION 10 3 mirtazapine oral tablet MG/5ML dispersible 15 mg, 30 2 mg, 45 mg PAXIL ORAL TABLET 10 Brand MG, 20 MG, 30 MG, 40 4 penalty Brand MG applies NARDIL ORAL TABLET 4 penalty 15 MG applies perphenazine- amitriptyline oral tablet 2- 2 nefazodone hcl oral 10 mg, 2-25 mg, 4-10 tablet 100 mg, 150 mg, 2 mg, 4-25 mg, 4-50 mg 200 mg, 250 mg, 50 mg phenelzine sulfate oral 2 Brand tablet 15 mg NORPRAMIN ORAL 4 penalty TABLET 10 MG, 25 MG applies PRISTIQ ORAL TABLET PA; Brand EXTENDED RELEASE nortriptyline hcl oral 4 penalty 24 HOUR 100 MG, 25 applies capsule 10 mg, 25 mg, 2 MG, 50 MG 50 mg, 75 mg protriptyline hcl oral 2 nortriptyline hcl oral 2 tablet 10 mg, 5 mg solution 10 mg/5ml PROZAC ORAL Brand olanzapine-fluoxetine hcl CAPSULE 10 MG, 20 4 penalty oral capsule 12-25 mg, 2 PA MG, 40 MG applies 12-50 mg, 3-25 mg, 6-25 mg, 6-50 mg Brand REMERON ORAL 4 penalty PAMELOR ORAL Brand TABLET 15 MG, 30 MG applies CAPSULE 10 MG, 25 4 penalty MG, 50 MG, 75 MG applies REMERON SOLTAB Brand ORAL TABLET 4 penalty Brand DISPERSIBLE 15 MG, applies PARNATE ORAL 4 penalty 30 MG, 45 MG TABLET 10 MG applies sertraline hcl oral 2 concentrate 20 mg/ml

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 42 Drug Drug Drug Name Notes Drug Name Notes Tier Tier sertraline hcl oral tablet WELLBUTRIN XL ORAL 1 Brand 100 mg, 25 mg, 50 mg TABLET EXTENDED 4 penalty SPRAVATO (56 MG RELEASE 24 HOUR 150 applies PA; MG, 300 MG DOSE) NASAL 6 Specialty Brand SOLUTION THERAPY Medical ZOLOFT ORAL PACK 28 MG/DEVICE CONCENTRATE 20 4 penalty MG/ML applies SPRAVATO (84 MG PA; DOSE) NASAL Brand 6 Specialty SOLUTION THERAPY ZOLOFT ORAL TABLET 4 penalty Medical PACK 28 MG/DEVICE 100 MG, 25 MG, 50 MG applies SYMBYAX ORAL PA; Brand Antiemetics - Drugs for CAPSULE 3-25 MG, 6- 4 penalty Nausea and Vomiting 25 MG applies AKYNZEO INTRAVENOUS tranylcypromine sulfate 2 GM oral tablet 10 mg SOLUTION 235-0.25 trazodone hcl oral tablet MG/20ML 100 mg, 150 mg, 300 2 AKYNZEO mg, 50 mg INTRAVENOUS GM trimipramine maleate oral SOLUTION capsule 100 mg, 25 mg, 2 RECONSTITUTED 235- 50 mg 0.25 MG QL (3 EA TRINTELLIX ORAL 4 per 21 TABLET 10 MG, 20 MG, 4 PA AKYNZEO ORAL days) 5 MG CAPSULE 300-0.5 MG venlafaxine hcl er oral ALOXI INTRAVENOUS SOLUTION 0.25 GM capsule extended 2 release 24 hour 150 mg, MG/5ML ANTIVERT ORAL 37.5 mg, 75 mg 3 venlafaxine hcl oral tablet TABLET 50 MG 100 mg, 25 mg, 37.5 mg, 2 QL (6 EA 50 mg, 75 mg aprepitant oral 80 & 125 2 per 30 days) VIIBRYD ORAL TABLET mg 4 PA 10 MG, 20 MG, 40 MG aprepitant oral capsule QL (6 EA 2 per 30 VIIBRYD STARTER 125 mg, 40 mg, 80 & 125 days) PACK ORAL KIT 10 & 20 4 PA mg, 80 mg MG BARHEMSYS WELLBUTRIN SR ORAL INTRAVENOUS GM Brand SOLUTION 10 MG/4ML, TABLET EXTENDED 4 penalty RELEASE 12 HOUR 100 5 MG/2ML applies CINVANTI MG, 150 MG, 200 MG QL (6 ML INTRAVENOUS GM per 30 130 days) MG/18ML

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 43 Drug Drug Drug Name Notes Drug Name Notes Tier Tier compro rectal meclizine hcl oral tablet 2 2 suppository 25 mg 12.5 mg, 25 mg, 50 mg dimenhydrinate injection GM metoclopramide hcl GM solution 50 mg/ml injection solution 5 mg/ml dronabinol oral capsule 2 metoclopramide hcl oral 10 mg, 2.5 mg, 5 mg solution 10 mg/10ml, 5 2 mg/5ml droperidol injection GM solution 2.5 mg/ml metoclopramide hcl oral 2 DROPERIDOL tablet 10 mg, 5 mg INTRAVENOUS metoclopramide hcl oral GM SOLUTION PREFILLED tablet dispersible 10 mg, 2 SYRINGE 0.625 MG/ML 5 mg EMEND INTRAVENOUS ondansetron hcl injection GM SOLUTION GM PA solution 4 mg/2ml, 40 RECONSTITUTED 150 mg/20ml MG ondansetron hcl oral 2 Brand solution 4 mg/5ml penalty ondansetron hcl oral 4 applies; QL 2 tablet 24 mg, 4 mg, 8 mg EMEND ORAL (6 EA per CAPSULE 80 MG 30 days) ondansetron odt oral tablet dispersible 4 mg, 8 2 EMEND ORAL QL (6 EA mg SUSPENSION 3 per 30 palonosetron hcl RECONSTITUTED 125 days) MG/5ML intravenous solution 0.25 GM mg/2ml, 0.25 mg/5ml Brand penalty palonosetron hcl EMEND TRI-PACK 4 applies; QL intravenous solution GM ORAL CAPSULE 80 & (6 EA per prefilled syringe 0.25 125 MG 30 days) mg/5ml fosaprepitant perphenazine oral tablet 2 dimeglumine intravenous 16 mg, 2 mg, 4 mg, 8 mg GM PA solution reconstituted prochlorperazine 150 mg edisylate injection GM granisetron hcl solution 10 mg/2ml, 50 intravenous solution 1 GM mg/10ml mg/ml, 4 mg/4ml prochlorperazine maleate 2 oral tablet 10 mg, 5 mg granisetron hcl oral tablet 2 1 mg prochlorperazine rectal 2 MARINOL ORAL Brand suppository 25 mg CAPSULE 10 MG, 2.5 4 penalty Brand MG, 5 MG applies REGLAN ORAL TABLET 4 penalty 10 MG, 5 MG applies

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 44 Drug Drug Drug Name Notes Drug Name Notes Tier Tier SANCUSO QL (1 EA amphotericin b TRANSDERMAL PATCH 3 per 30 intravenous solution GM 3.1 MG/24HR days) reconstituted 50 mg scopolamine transdermal ANCOBON ORAL Brand patch 72 hour 1 2 CAPSULE 250 MG, 500 4 penalty mg/3days MG applies

SUSTOL QL (2 ML CANCIDAS SUBCUTANEOUS INTRAVENOUS 6 per 30 PREFILLED SYRINGE SOLUTION GM days) 10 MG/0.4ML RECONSTITUTED 50 SYNDROS ORAL MG, 70 MG 4 SOLUTION 5 MG/ML caspofungin acetate TIGAN intravenous solution GM INTRAMUSCULAR GM reconstituted 50 mg, 70 SOLUTION 100 MG/ML mg TRANSDERM SCOP QL (13.2 Brand ciclodan external solution 2 ML per 30 (1.5 MG) 4 penalty TRANSDERMAL PATCH 8 % days) applies 72 HOUR 1 MG/3DAYS ciclopirox external gel 2 TRANSDERM-SCOP 0.77 % Brand (1.5 MG) ciclopirox external 4 penalty 2 TRANSDERMAL PATCH applies 1 % 72 HOUR 1 MG/3DAYS QL (13.2 2 ML per 30 trimethobenzamide hcl 2 ciclopirox external oral capsule 300 mg solution 8 % days)

VARUBI (180 MG DOSE) QL (2 EA ciclopirox olamine 2 ORAL TABLET 4 per 30 external cream 0.77 % THERAPY PACK 2 X 90 days) ciclopirox olamine MG external suspension 0.77 2 Brand % ZOFRAN ORAL TABLET 4 penalty clotrimazole external 2 4 MG applies cream 1 % ZUPLENZ ORAL FILM 4 clotrimazole external 4 2 MG, 8 MG solution 1 % Antifungals clotrimazole mouth/throat 2 ABELCET troche 10 mg GM INTRAVENOUS clotrimazole- SUSPENSION 5 MG/ML betamethasone external 2 AMBISOME cream 1-0.05 % INTRAVENOUS clotrimazole- GM SUSPENSION betamethasone external 2 RECONSTITUTED 50 lotion 1-0.05 % MG

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 45 Drug Drug Drug Name Notes Drug Name Notes Tier Tier CRESEMBA FUNGIMEZ EXTERNAL 4 INTRAVENOUS PA; SOLUTION SOLUTION 6 Specialty griseofulvin microsize RECONSTITUTED 372 Medical oral suspension 125 2 MG mg/5ml CRESEMBA ORAL 6 PA griseofulvin microsize 2 CAPSULE 186 MG oral tablet 500 mg DIFLUCAN ORAL Brand griseofulvin SUSPENSION 4 penalty ultramicrosize oral tablet 2 RECONSTITUTED 10 applies 125 mg, 250 mg MG/ML, 40 MG/ML GYNAZOLE-1 VAGINAL 4 DIFLUCAN ORAL Brand CREAM 2 % TABLET 100 MG, 150 4 penalty itraconazole oral capsule MG, 200 MG, 50 MG applies 2 100 mg econazole nitrate 2 external cream 1 % itraconazole oral solution 2 10 mg/ml ERAXIS INTRAVENOUS SOLUTION JUBLIA EXTERNAL GM 4 PA RECONSTITUTED 100 SOLUTION 10 % MG, 50 MG PA; Brand ERTACZO EXTERNAL KERYDIN EXTERNAL 4 penalty 4 ST CREAM 2 % SOLUTION 5 % applies ketoconazole external EXELDERM EXTERNAL 4 ST 2 CREAM 1 % cream 2 % ketoconazole external EXELDERM EXTERNAL 4 ST 2 SOLUTION 1 % foam 2 % Brand ketoconazole external 2 EXTINA EXTERNAL 4 penalty shampoo 2 % FOAM 2 % applies ketoconazole oral tablet 2 fluconazole in sodium 200 mg chloride intravenous ketodan external foam 2 2 solution 200-0.9 GM % mg/100ml-%, 400-0.9 Brand mg/200ml-% LOPROX EXTERNAL 4 penalty fluconazole oral CREAM 0.77 % applies suspension reconstituted 2 Brand 10 mg/ml, 40 mg/ml LOPROX EXTERNAL 4 penalty fluconazole oral tablet SHAMPOO 1 % applies 100 mg, 150 mg, 200 2 Brand mg, 50 mg LOPROX EXTERNAL 4 penalty flucytosine oral capsule applies 2 SUSPENSION 0.77 % 250 mg, 500 mg LULICONAZOLE 4 ST EXTERNAL CREAM 1 % Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 46 Drug Drug Drug Name Notes Drug Name Notes Tier Tier LUZU EXTERNAL nystatin external 4 ST 2 CREAM 1 % 100000 unit/gm

MENTAX EXTERNAL 4 ST nystatin mouth/throat CREAM 1 % suspension 100000 2 micafungin sodium unit/ml intravenous solution GM nystatin oral tablet 2 reconstituted 100 mg, 50 500000 unit mg nystatin-triamcinolone miconazole 3 vaginal external cream 100000- 2 2 suppository 200 mg 0.1 unit/gm-% MICONAZOLE-ZINC nystatin-triamcinolone OXIDE-PETROLAT external ointment 2 4 EXTERNAL OINTMENT 100000-0.1 unit/gm-% 0.25-15-81.35 % nystop external powder 2 MYCAMINE 100000 unit/gm INTRAVENOUS ORAVIG BUCCAL 4 SOLUTION GM TABLET 50 MG RECONSTITUTED 100 MG, 50 MG oxiconazole nitrate 2 ST external cream 1 % naftifine hcl external 2 ST cream 1 %, 2 % ST; Brand OXISTAT EXTERNAL 4 penalty naftifine hcl external gel 1 2 ST CREAM 1 % applies % OXISTAT EXTERNAL 4 ST ST; Brand LOTION 1 % NAFTIN EXTERNAL 4 penalty posaconazole oral tablet GEL 1 % applies 6 delayed release 100 mg NAFTIN EXTERNAL 4 ST GEL 2 % RECURA EXTERNAL 4 CREAM NOXAFIL INTRAVENOUS Specialty Brand 6 SOLUTION 300 Medical SPORANOX ORAL 4 penalty MG/16.7ML CAPSULE 100 MG applies NOXAFIL ORAL Brand SUSPENSION 40 6 SPORANOX ORAL 4 penalty MG/ML SOLUTION 10 MG/ML applies NOXAFIL ORAL TABLET SPORANOX PULSEPAK Brand DELAYED RELEASE 6 ORAL CAPSULE 100 4 penalty 100 MG MG applies SULCONAZOLE nystatin external cream 2 100000 unit/gm NITRATE EXTERNAL 4 ST CREAM 1 % nystatin external 2 ointment 100000 unit/gm

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 47 Drug Drug Drug Name Notes Drug Name Notes Tier Tier SULCONAZOLE Antigout Agents NITRATE EXTERNAL 4 ST allopurinol oral tablet 100 1 SOLUTION 1 % mg, 300 mg tavaborole external 2 PA allopurinol sodium solution 5 % intravenous solution GM reconstituted 500 mg terbinafine hcl oral tablet 2 250 mg ALOPRIM terconazole vaginal INTRAVENOUS 2 cream 0.4 %, 0.8 % SOLUTION GM terconazole vaginal RECONSTITUTED 500 2 suppository 80 mg MG COLCHICINE ORAL VFEND IV 3 INTRAVENOUS CAPSULE 0.6 MG Specialty 5 colchicine oral tablet 0.6 SOLUTION Medical 2 RECONSTITUTED 200 mg MG colchicine-probenecid 2 VFEND ORAL oral tablet 0.5-500 mg SUSPENSION 6 COLCRYS ORAL 3 RECONSTITUTED 40 TABLET 0.6 MG MG/ML febuxostat oral tablet 40 VFEND ORAL TABLET 2 6 mg, 80 mg 200 MG, 50 MG GLOPERBA ORAL voriconazole intravenous 4 Specialty SOLUTION 0.6 MG/5ML solution reconstituted 5 Medical PA; 200 mg KRYSTEXXA INTRAVENOUS 6 Specialty voriconazole oral SOLUTION 8 MG/ML Medical suspension reconstituted 5 40 mg/ml MITIGARE ORAL 3 CAPSULE 0.6 MG voriconazole oral tablet 5 200 mg, 50 mg probenecid oral tablet 2 500 mg VUSION EXTERNAL Brand OINTMENT 0.25-15- 4 4 penalty 81.35 % ULORIC ORAL TABLET 40 MG, 80 MG applies XOLEGEL COREPAK 4 Brand EXTERNAL KIT 2 & 1 % ZYLOPRIM ORAL TABLET 100 MG, 300 4 penalty XOLEGEL DUO/HEAD & MG applies SHOULDERS 4 Anti-inflammatory EXTERNAL KIT 2 & 1 % Agents XOLEGEL DUO/XOLEX 4 EXTERNAL KIT 2 & 1 % EMFLAZA ORAL SUSPENSION 22.75 6 PA XOLEGEL EXTERNAL 4 MG/ML GEL 2 %

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 48 Drug Drug Drug Name Notes Drug Name Notes Tier Tier EMFLAZA ORAL EMGALITY (300 MG TABLET 18 MG, 30 MG, 6 PA DOSE) PA; QL (3 36 MG, 6 MG SUBCUTANEOUS 4 ML per 28 Antimigraine Agents SOLUTION PREFILLED days) SYRINGE 100 MG/ML AIMOVIG SUBCUTANEOUS PA; QL (1 EMGALITY PA; QL (2 SUBCUTANEOUS SOLUTION AUTO- 4 ML per 28 4 ML per 28 SOLUTION AUTO- INJECTOR 140 MG/ML, days) days) 70 MG/ML INJECTOR 120 MG/ML EMGALITY AJOVY PA; QL (2 SUBCUTANEOUS PA; QL SUBCUTANEOUS 4 ML per 28 SOLUTION AUTO- 4 (1.5 ML per SOLUTION PREFILLED days) INJECTOR 225 28 days) SYRINGE 120 MG/ML MG/1.5ML ERGOMAR AJOVY SUBLINGUAL TABLET 4 SUBCUTANEOUS PA; QL SUBLINGUAL 2 MG SOLUTION PREFILLED 4 (1.5 ML per ergotamine-caffeine oral 2 SYRINGE 225 28 days) tablet 1-100 mg MG/1.5ML Brand QL (9 EA penalty almotriptan malate oral 2 per 30 4 applies; QL tablet 12.5 mg, 6.25 mg days) FROVA ORAL TABLET (9 EA per Brand 2.5 MG 30 days) penalty QL (9 EA 4 applies; QL frovatriptan succinate 2 per 30 AMERGE ORAL (9 EA per oral tablet 2.5 mg days) TABLET 1 MG, 2.5 MG 30 days) Brand Brand penalty CAFERGOT ORAL 4 penalty IMITREX NASAL 4 applies; QL TABLET 1-100 MG applies SOLUTION 20 MG/ACT, (6 EA per D.H.E. 45 INJECTION 5 MG/ACT 30 days) GM SOLUTION 1 MG/ML Brand dihydroergotamine penalty mesylate injection GM 4 applies; QL solution 1 mg/ml IMITREX ORAL TABLET (9 EA per 100 MG, 25 MG, 50 MG 30 days) dihydroergotamine PA; QL (8 IMITREX STATDOSE mesylate nasal solution 4 2 ML per 30 Brand REFILL mg/ml days) penalty SUBCUTANEOUS QL (9 EA 4 applies; QL SOLUTION CARTRIDGE 2 per 30 (2 ML per eletriptan hydrobromide 4 MG/0.5ML, 6 days) 30 days) oral tablet 20 mg, 40 mg MG/0.5ML

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 49 Drug Drug Drug Name Notes Drug Name Notes Tier Tier IMITREX STATDOSE PA; QL (4 Brand 5 EA per 30 SYSTEM penalty REYVOW ORAL days) SUBCUTANEOUS 4 applies; QL TABLET 50 MG SOLUTION AUTO- (2 ML per QL (12 EA INJECTOR 4 MG/0.5ML, 30 days) rizatriptan benzoate oral 2 per 30 6 MG/0.5ML tablet 10 mg, 5 mg days) Brand rizatriptan benzoate oral QL (12 EA penalty tablet dispersible 10 mg, 2 per 30 IMITREX 4 applies; QL 5 mg days) SUBCUTANEOUS (2 ML per SOLUTION 6 MG/0.5ML 30 days) nasal QL (6 EA solution 20 mg/act, 5 2 per 30 Brand mg/act days) penalty 4 applies; QL sumatriptan succinate QL (9 EA MAXALT ORAL TABLET (12 EA per oral tablet 100 mg, 25 2 per 30 10 MG 30 days) mg, 50 mg days) Brand sumatriptan succinate QL (2 ML penalty refill subcutaneous 2 per 30 solution cartridge 4 MAXALT-MLT ORAL 4 applies; QL days) TABLET DISPERSIBLE (12 EA per mg/0.5ml, 6 mg/0.5ml 10 MG 30 days) sumatriptan succinate QL (2 ML MIGERGOT RECTAL subcutaneous solution 6 2 per 30 SUPPOSITORY 2-100 4 mg/0.5ml days) MG sumatriptan succinate QL (2 ML PA; Brand subcutaneous solution 2 per 30 penalty auto-injector 4 mg/0.5ml, days) 4 applies; QL 6 mg/0.5ml MIGRANAL NASAL (8 ML per PA; QL (10 SOLUTION 4 MG/ML 30 days) UBRELVY ORAL 5 EA per 30 QL (9 EA TABLET 100 MG, 50 MG days) naratriptan hcl oral tablet 2 per 30 PA; 1 mg, 2.5 mg days) VYEPTI INTRAVENOUS 5 Specialty PA; QL (8 SOLUTION 100 MG/ML Medical NURTEC ORAL TABLET 5 EA per 30 ZOLMITRIPTAN NASAL QL (6 EA DISPERSIBLE 75 MG days) SOLUTION 2.5 MG, 5 4 per 30 Brand MG days) penalty QL (9 EA 4 applies; QL zolmitriptan oral tablet 2 per 30 RELPAX ORAL TABLET (9 EA per 2.5 mg, 5 mg days) 20 MG, 40 MG 30 days) QL (9 EA PA; QL (8 zolmitriptan oral tablet 2 per 30 REYVOW ORAL 5 EA per 30 dispersible 2.5 mg, 5 mg days) TABLET 100 MG days)

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 50 Drug Drug Drug Name Notes Drug Name Notes Tier Tier ZOMIG NASAL QL (6 EA pyridostigmine bromide SOLUTION 2.5 MG, 5 4 per 30 er oral tablet extended 2 MG days) release 180 mg Brand pyridostigmine bromide 2 penalty oral solution 60 mg/5ml 4 applies; QL pyridostigmine bromide (9 EA per 2 ZOMIG ORAL TABLET oral tablet 30 mg, 60 mg 2.5 MG, 5 MG 30 days) REGONOL Brand INTRAVENOUS GM penalty SOLUTION 10 MG/2ML ZOMIG ZMT ORAL 4 applies; QL Antimycobacterials TABLET DISPERSIBLE (9 EA per 2.5 MG, 5 MG 30 days) CAPASTAT SULFATE Antimyasthenic Agents INJECTION SOLUTION GM RECONSTITUTED 1 GM BLOXIVERZ cycloserine oral capsule INTRAVENOUS GM 2 SOLUTION 10 250 mg MG/10ML, 5 MG/10ML dapsone oral tablet 100 2 Brand mg, 25 mg MESTINON ORAL 4 penalty ethambutol hcl oral tablet 2 SOLUTION 60 MG/5ML applies 100 mg, 400 mg Brand isoniazid injection GM MESTINON ORAL 4 penalty solution 100 mg/ml applies TABLET 60 MG isoniazid oral syrup 50 2 MESTINON ORAL Brand mg/5ml 4 penalty TABLET EXTENDED isoniazid oral tablet 100 applies 2 RELEASE 180 MG mg, 300 mg neostigmine Brand methylsulfate intravenous GM MYAMBUTOL ORAL 4 penalty solution 10 mg/10ml, 5 TABLET 400 MG applies mg/10ml Brand NEOSTIGMINE MYCOBUTIN ORAL 4 penalty METHYLSULFATE CAPSULE 150 MG applies INTRAVENOUS GM PASER ORAL PACKET SOLUTION 3 MG/3ML, 5 4 MG/5ML 4 GM NEOSTIGMINE PA; QL (30 METHYLSULFATE PRETOMANID ORAL 4 EA per 30 INTRAVENOUS TABLET 200 MG days) GM SOLUTION PREFILLED PRIFTIN ORAL TABLET 4 SYRINGE 3 MG/3ML, 4 150 MG MG/4ML pyrazinamide oral tablet 2 500 mg

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 51 Drug Drug Drug Name Notes Drug Name Notes Tier Tier rifabutin oral capsule 150 AFINITOR DISPERZ 2 mg ORAL TABLET 6 PA RIFADIN SOLUBLE 2 MG, 3 MG, INTRAVENOUS 5 MG SOLUTION GM AFINITOR ORAL RECONSTITUTED 600 TABLET 10 MG, 2.5 MG, 6 PA MG 5 MG, 7.5 MG rifampin intravenous ALECENSA ORAL 6 PA solution reconstituted GM CAPSULE 150 MG 600 mg ALIMTA INTRAVENOUS PA; rifampin oral capsule 150 SOLUTION 2 6 Specialty mg, 300 mg RECONSTITUTED 100 Medical MG, 500 MG SIRTURO ORAL 6 PA TABLET 100 MG, 20 MG ALIQOPA INTRAVENOUS PA; TRECATOR ORAL 4 TABLET 250 MG SOLUTION 6 Specialty RECONSTITUTED 60 Medical Antineoplastics - Drugs MG for Cancer ALKERAN PA; ABECMA INTRAVENOUS PA; 6 Specialty INTRAVENOUS SOLUTION 6 Specialty Medical SUSPENSION RECONSTITUTED 50 Medical abiraterone acetate oral 5 PA MG tablet 250 mg PA; Brand abiraterone acetate oral 4 penalty 6 PA ALKERAN ORAL tablet 500 mg TABLET 2 MG applies ABRAXANE ALUNBRIG ORAL INTRAVENOUS PA; TABLET 180 MG, 30 6 PA SUSPENSION 6 Specialty MG, 90 MG Medical RECONSTITUTED 100 ALUNBRIG ORAL MG TABLET THERAPY 6 PA ADCETRIS PACK 90 & 180 MG PA; INTRAVENOUS anastrozole oral tablet 1 6 Specialty 2 SOLUTION mg RECONSTITUTED 50 Medical MG Brand ARIMIDEX ORAL 4 penalty adriamycin intravenous GM PA TABLET 1 MG applies solution 2 mg/ml Brand adriamycin intravenous AROMASIN ORAL 4 penalty GM PA solution reconstituted 10 TABLET 25 MG applies mg, 50 mg ARRANON PA; INTRAVENOUS 6 Specialty SOLUTION 5 MG/ML Medical

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 52 Drug Drug Drug Name Notes Drug Name Notes Tier Tier arsenic trioxide PA; BENDEKA PA; intravenous solution 10 6 Specialty INTRAVENOUS 6 Specialty mg/10ml Medical SOLUTION 100 MG/4ML Medical

ARZERRA PA; BESPONSA PA; INTRAVENOUS 6 Specialty INTRAVENOUS 6 Specialty CONCENTRATE 100 Medical SOLUTION MG/5ML, 1000 MG/50ML RECONSTITUTED 0.9 Medical ASPARLAS MG PA; INTRAVENOUS bexarotene oral capsule 6 Specialty 6 PA SOLUTION 3750 75 mg Medical UNIT/5ML bicalutamide oral tablet 2 AVASTIN PA; 50 mg INTRAVENOUS 6 Specialty BICNU INTRAVENOUS PA; SOLUTION 100 Medical SOLUTION MG/4ML, 400 MG/16ML 6 Specialty RECONSTITUTED 100 Medical AYVAKIT ORAL TABLET MG 6 PA 100 MG, 200 MG, 25 BLENREP MG, 300 MG, 50 MG INTRAVENOUS PA; azacitidine injection PA; SOLUTION 6 Specialty suspension reconstituted 6 Specialty RECONSTITUTED 100 Medical 100 mg Medical MG

AZEDRA DOSIMETRIC bleomycin sulfate PA; GM INTRAVENOUS injection solution 6 Specialty SOLUTION 15 MCI/ML reconstituted 15 unit, 30 Medical AZEDRA unit THERAPEUTIC GM BLINCYTO INTRAVENOUS INTRAVENOUS PA; SOLUTION 15 MCI/ML SOLUTION 6 Specialty BALVERSA ORAL RECONSTITUTED 35 Medical TABLET 3 MG, 4 MG, 5 6 PA MCG MG BORTEZOMIB BAVENCIO INTRAVENOUS PA; PA; INTRAVENOUS SOLUTION 6 Specialty 6 Specialty RECONSTITUTED 3.5 Medical SOLUTION 200 Medical MG/10ML MG BELEODAQ BOSULIF ORAL TABLET PA; QL (30 6 EA per 30 INTRAVENOUS PA; 100 MG, 400 MG, 500 SOLUTION 6 Specialty MG days) RECONSTITUTED 500 Medical BRAFTOVI ORAL 6 PA MG CAPSULE 75 MG BELRAPZO PA; BREYANZI PA; INTRAVENOUS 6 Specialty INTRAVENOUS 6 Specialty SOLUTION 100 MG/4ML Medical SUSPENSION Medical

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 53 Drug Drug Drug Name Notes Drug Name Notes Tier Tier BRUKINSA ORAL CLOLAR PA; 6 PA CAPSULE 80 MG INTRAVENOUS 6 Specialty PA; SOLUTION 1 MG/ML Medical busulfan intravenous 6 Specialty COMETRIQ ORAL KIT solution 6 mg/ml Medical 20 MG, 3 X 20 MG & 80 6 PA BUSULFEX PA; MG, 80 & 20 MG INTRAVENOUS 6 Specialty COPIKTRA ORAL SOLUTION 6 MG/ML Medical CAPSULE 15 MG, 25 6 PA CABOMETYX ORAL MG TABLET 20 MG, 40 MG, 6 PA COSELA 60 MG INTRAVENOUS PA; CALQUENCE ORAL SOLUTION 6 Specialty 6 PA CAPSULE 100 MG RECONSTITUTED 300 Medical MG CAMPTOSAR INTRAVENOUS COSMEGEN SOLUTION 100 GM PA INTRAVENOUS PA; 6 Specialty MG/5ML, 300 MG/15ML, SOLUTION 40 MG/2ML RECONSTITUTED 0.5 Medical MG capecitabine oral tablet 4 PA COTELLIC ORAL 150 mg, 500 mg 6 PA TABLET 20 MG CAPRELSA ORAL TABLET 100 MG, 300 6 PA cyclophosphamide PA; MG injection solution 6 Specialty reconstituted 1 gm, 2 gm, Medical carboplatin intravenous 500 mg solution 150 mg/15ml, GM PA 450 mg/45ml, 50 mg/5ml, CYCLOPHOSPHAMIDE PA; INTRAVENOUS 600 mg/60ml 6 Specialty SOLUTION 1 GM/5ML, Medical carmustine intravenous PA; 500 MG/2.5ML solution reconstituted 6 Specialty cyclophosphamide oral 100 mg Medical 2 PA capsule 25 mg, 50 mg Brand CASODEX ORAL 4 penalty CYCLOPHOSPHAMIDE TABLET 50 MG applies ORAL TABLET 25 MG, 4 50 MG cisplatin intravenous CYRAMZA solution 100 mg/100ml, GM PA PA; 200 mg/200ml, 50 INTRAVENOUS 6 Specialty mg/50ml SOLUTION 100 Medical MG/10ML, 500 MG/50ML PA; cladribine intravenous 6 Specialty cytarabine (pf) injection PA; solution 10 mg/10ml Medical solution 100 mg/ml, 20 6 Specialty mg/ml Medical PA; clofarabine intravenous 6 Specialty solution 1 mg/ml Medical

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 54 Drug Drug Drug Name Notes Drug Name Notes Tier Tier PA; PA; cytarabine injection 6 Specialty DOXIL INTRAVENOUS 6 Specialty solution 20 mg/ml Medical INJECTABLE 2 MG/ML Medical dacarbazine intravenous PA; doxorubicin hcl solution reconstituted 6 Specialty intravenous solution 2 GM PA 100 mg, 200 mg Medical mg/ml DACOGEN doxorubicin hcl INTRAVENOUS PA; intravenous solution GM PA SOLUTION 6 Specialty reconstituted 10 mg RECONSTITUTED 50 Medical doxorubicin hcl liposomal PA; MG intravenous injectable 2 6 Specialty dactinomycin intravenous PA; mg/ml Medical solution reconstituted 0.5 6 Specialty DROXIA ORAL mg Medical CAPSULE 200 MG, 300 4 DANYELZA PA; MG, 400 MG INTRAVENOUS 6 Specialty ELITEK INTRAVENOUS SOLUTION 40 MG/10ML Medical Specialty SOLUTION 6 DARZALEX FASPRO RECONSTITUTED 1.5 Medical PA; SUBCUTANEOUS MG, 7.5 MG 6 Specialty SOLUTION 1800-30000 ELLENCE Medical PA; MG-UT/15ML INTRAVENOUS 6 Specialty DARZALEX PA; SOLUTION 200 Medical INTRAVENOUS 6 Specialty MG/100ML, 50 MG/25ML SOLUTION 100 Medical ELZONRIS MG/5ML, 400 MG/20ML PA; INTRAVENOUS 6 Specialty daunorubicin hcl SOLUTION 1000 Medical intravenous solution 20 GM PA MCG/ML mg/4ml, 50 mg/10ml EMCYT ORAL 3 PA DAURISMO ORAL CAPSULE 140 MG 6 PA TABLET 100 MG, 25 MG EMPLICITI decitabine intravenous PA; INTRAVENOUS PA; solution reconstituted 50 6 Specialty SOLUTION 6 Specialty mg Medical RECONSTITUTED 300 Medical dexrazoxane hcl MG, 400 MG intravenous solution GM ENHERTU reconstituted 250 mg, INTRAVENOUS PA; 500 mg SOLUTION 6 Specialty Medical docetaxel intravenous PA; RECONSTITUTED 100 concentrate 160 mg/8ml, 6 Specialty MG 20 mg/ml, 80 mg/4ml Medical epirubicin hcl intravenous PA; docetaxel intravenous PA; solution 200 mg/100ml, 6 Specialty solution 160 mg/16ml, 20 6 Specialty 50 mg/25ml Medical mg/2ml, 80 mg/8ml Medical

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 55 Drug Drug Drug Name Notes Drug Name Notes Tier Tier ERBITUX Brand INTRAVENOUS PA; FEMARA ORAL TABLET 4 penalty SOLUTION 100 6 Specialty 2.5 MG applies MG/50ML, 200 Medical floxuridine injection PA; MG/100ML solution reconstituted 0.5 6 Specialty Medical ERIVEDGE ORAL 6 PA gm CAPSULE 150 MG fludarabine phosphate PA; ERLEADA ORAL intravenous solution 50 6 Specialty 6 PA TABLET 60 MG mg/2ml Medical erlotinib hcl oral tablet fludarabine phosphate PA; 5 PA 100 mg, 150 mg, 25 mg intravenous solution 6 Specialty ERWINASE INJECTION reconstituted 50 mg Medical PA; SOLUTION 6 Specialty fluorouracil intravenous RECONSTITUTED Medical solution 1 gm/20ml, 2.5 GM PA 10000 UNIT gm/50ml, 5 gm/100ml, ETOPOPHOS 500 mg/10ml PA; INTRAVENOUS flutamide oral capsule 2 PA SOLUTION 6 Specialty 125 mg RECONSTITUTED 100 Medical FOLOTYN PA; MG INTRAVENOUS 6 Specialty etoposide intravenous SOLUTION 20 MG/ML, Medical solution 1 gm/50ml, 100 GM PA 40 MG/2ML mg/5ml, 500 mg/25ml FOTIVDA ORAL 6 PA etoposide oral capsule 2 PA CAPSULE 0.89 MG, 1.34 50 mg MG PA; everolimus oral tablet 2.5 6 PA mg, 5 mg, 7.5 mg fulvestrant intramuscular 6 Specialty Medical EVOMELA solution 250 mg/5ml INTRAVENOUS GAVRETO ORAL 6 PA SOLUTION GM CAPSULE 100 MG RECONSTITUTED 50 GAZYVA PA; MG INTRAVENOUS 6 Specialty exemestane oral tablet SOLUTION 1000 2 Medical 25 mg MG/40ML PA; Brand gemcitabine hcl 4 penalty FARESTON ORAL intravenous solution 1 GM TABLET 60 MG applies gm/10ml, 1.5 gm/15ml, 2 FARYDAK ORAL gm/20ml, 200 mg/2ml CAPSULE 10 MG, 15 6 PA gemcitabine hcl MG, 20 MG intravenous solution 1 GM PA FASLODEX PA; gm/26.3ml, 2 gm/52.6ml, INTRAMUSCULAR 6 Specialty 200 mg/5.26ml SOLUTION 250 MG/5ML Medical

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 56 Drug Drug Drug Name Notes Drug Name Notes Tier Tier gemcitabine hcl Brand 4 penalty intravenous solution GM PA HYDREA ORAL reconstituted 1 gm, 2 gm, CAPSULE 500 MG applies 200 mg hydroxyurea oral capsule 2 GILOTRIF ORAL 500 mg TABLET 20 MG, 30 MG, 6 PA IBRANCE ORAL 40 MG CAPSULE 100 MG, 125 6 PA PA; QL (90 MG, 75 MG GLEEVEC ORAL 6 EA per 30 IBRANCE ORAL TABLET 100 MG days) TABLET 100 MG, 125 6 PA PA; QL (30 MG, 75 MG GLEEVEC ORAL 6 EA per 30 ICLUSIG ORAL TABLET PA; QL (30 TABLET 400 MG days) 10 MG, 15 MG, 30 MG, 6 EA per 30 GLEOSTINE ORAL 45 MG days) CAPSULE 10 MG, 100 6 PA IDAMYCIN PFS MG, 40 MG INTRAVENOUS PA; GLIADEL WAFER SOLUTION 10 6 Specialty IMPLANT WAFER 7.7 GM MG/10ML, 20 MG/20ML, Medical MG 5 MG/5ML HALAVEN PA; idarubicin hcl intravenous PA; INTRAVENOUS 6 Specialty solution 10 mg/10ml, 20 6 Specialty SOLUTION 1 MG/2ML Medical mg/20ml, 5 mg/5ml Medical

HERCEPTIN HYLECTA IDHIFA ORAL TABLET 6 PA SUBCUTANEOUS 6 PA 100 MG, 50 MG SOLUTION 600-10000 IFEX INTRAVENOUS MG-UNT/5ML PA; SOLUTION 6 Specialty HERCEPTIN RECONSTITUTED 1 Medical INTRAVENOUS PA; GM, 3 GM SOLUTION 6 Specialty ifosfamide intravenous PA; RECONSTITUTED 150 Medical solution 1 gm/20ml, 3 6 Specialty MG gm/60ml Medical HERZUMA ifosfamide intravenous PA; INTRAVENOUS PA; solution reconstituted 1 6 Specialty SOLUTION 5 Specialty gm, 3 gm Medical RECONSTITUTED 150 Medical MG, 420 MG PA; QL (90 imatinib mesylate oral 5 EA per 30 HYCAMTIN tablet 100 mg days) INTRAVENOUS GM PA SOLUTION PA; QL (30 RECONSTITUTED 4 MG imatinib mesylate oral 5 EA per 30 tablet 400 mg days) HYCAMTIN ORAL CAPSULE 0.25 MG, 1 4 PA IMBRUVICA ORAL MG CAPSULE 140 MG, 70 6 PA MG

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 57 Drug Drug Drug Name Notes Drug Name Notes Tier Tier IMBRUVICA ORAL JAKAFI ORAL TABLET TABLET 140 MG, 280 6 PA 10 MG, 15 MG, 20 MG, 6 PA MG, 420 MG, 560 MG 25 MG, 5 MG IMLYGIC JELMYTO SOLUTION PA; INTRALESIONAL PA; RECONSTITUTED 80 (2 6 Specialty SUSPENSION 1000000 6 Specialty X 40) MG Medical UNIT/ML, 100000000 Medical JEMPERLI PA; UNIT/ML INTRAVENOUS 6 Specialty INFUGEM SOLUTION 500 Medical INTRAVENOUS MG/10ML SOLUTION 1200-0.9 JEVTANA PA; MG/120ML-%, 1300-0.9 INTRAVENOUS MG/130ML-%, 1400-0.9 6 Specialty SOLUTION 60 Medical MG/140ML-%, 1500-0.9 PA; MG/1.5ML MG/150ML-%, 1600-0.9 6 Specialty MG/160ML-%, 1700-0.9 Medical KADCYLA MG/170ML-%, 1800-0.9 INTRAVENOUS PA; MG/180ML-%, 1900-0.9 SOLUTION 6 Specialty MG/190ML-%, 2000-0.9 RECONSTITUTED 100 Medical MG/200ML-%, 2200-0.9 MG, 160 MG MG/220ML-% KANJINTI INTRAVENOUS PA; INLYTA ORAL TABLET 6 PA 1 MG, 5 MG SOLUTION 5 Specialty RECONSTITUTED 150 Medical INQOVI ORAL TABLET 6 PA MG, 420 MG 35-100 MG KEYTRUDA PA; INREBIC ORAL 6 PA INTRAVENOUS 6 Specialty CAPSULE 100 MG SOLUTION 100 MG/4ML Medical IRESSA ORAL TABLET 6 PA KHAPZORY 250 MG INTRAVENOUS PA; irinotecan hcl intravenous SOLUTION 6 Specialty Medical solution 100 mg/5ml, 300 GM PA RECONSTITUTED 175 mg/15ml, 40 mg/2ml, 500 MG, 300 MG mg/25ml KISQALI ORAL TABLET ISTODAX (OVERFILL) THERAPY PACK 200 6 PA INTRAVENOUS PA; MG 6 SOLUTION Specialty KOSELUGO ORAL RECONSTITUTED 10 Medical CAPSULE 10 MG, 25 6 PA MG MG IXEMPRA KIT KYPROLIS INTRAVENOUS PA; INTRAVENOUS PA; SOLUTION 6 Specialty SOLUTION 6 Specialty RECONSTITUTED 15 Medical RECONSTITUTED 10 Medical MG, 45 MG MG, 30 MG, 60 MG

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 58 Drug Drug Drug Name Notes Drug Name Notes Tier Tier lapatinib ditosylate oral LUMOXITI 6 PA PA; tablet 250 mg INTRAVENOUS 6 Specialty LENVIMA ORAL SOLUTION Medical CAPSULE THERAPY RECONSTITUTED 1 MG PACK 10 & 4 MG, 10 LYNPARZA ORAL MG, 10 MG & 2 X 4 MG, 6 PA TABLET 100 MG, 150 6 PA 2 X 10 MG, 2 X 10 MG & MG 4 MG, 2 X 4 MG, 3 X 4 LYSODREN ORAL 3 PA MG, 4 MG TABLET 500 MG letrozole oral tablet 2.5 MARGENZA 2 PA; mg INTRAVENOUS 6 Specialty leucovorin calcium SOLUTION 250 Medical injection solution 100 GM PA MG/10ML mg/10ml, 500 mg/50ml MARQIBO PA; leucovorin calcium INTRAVENOUS 6 Specialty injection solution SUSPENSION 5 Medical reconstituted 100 mg, GM PA MG/31ML 200 mg, 350 mg, 50 mg, MATULANE ORAL 6 PA 500 mg CAPSULE 50 MG leucovorin calcium oral MEKINIST ORAL 6 PA tablet 10 mg, 15 mg, 25 2 TABLET 0.5 MG, 2 MG mg, 5 mg MEKTOVI ORAL 6 PA LEUKERAN ORAL 3 PA TABLET 15 MG TABLET 2 MG melphalan hcl PA; levoleucovorin calcium PA; intravenous solution 6 Specialty intravenous solution 6 Specialty reconstituted 50 mg Medical reconstituted 50 mg Medical melphalan oral tablet 2 PA; 2 PA levoleucovorin calcium pf mg intravenous solution 175 6 Specialty mg/17.5ml, 250 mg/25ml Medical mercaptopurine oral 2 tablet 50 mg LIBTAYO PA; mesna intravenous Specialty INTRAVENOUS 6 Specialty 6 SOLUTION 350 MG/7ML Medical solution 100 mg/ml Medical MESNEX LONSURF ORAL Specialty INTRAVENOUS 6 TABLET 15-6.14 MG, 20- 6 PA Medical 8.19 MG SOLUTION 100 MG/ML MESNEX ORAL TABLET LORBRENA ORAL 6 PA 3 TABLET 100 MG, 25 MG 400 MG LUMAKRAS ORAL mitomycin intravenous 6 PA TABLET 120 MG solution reconstituted 20 GM PA mg, 40 mg, 5 mg

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 59 Drug Drug Drug Name Notes Drug Name Notes Tier Tier MITOMYCIN NIPENT INTRAVENOUS PA; INTRAVESICAL GM SOLUTION 6 Specialty SOLUTION PREFILLED RECONSTITUTED 10 Medical SYRINGE 20 MG/40ML MG mitoxantrone hcl NUBEQA ORAL TABLET 6 PA Specialty intravenous concentrate 6 300 MG 20 mg/10ml, 25 Medical ODOMZO ORAL 6 PA mg/12.5ml, 30 mg/15ml CAPSULE 200 MG MONJUVI OGIVRI INTRAVENOUS PA; INTRAVENOUS PA; SOLUTION 5 Specialty SOLUTION 6 Specialty RECONSTITUTED 150 Medical RECONSTITUTED 200 Medical MG, 420 MG MG PA; mutamycin intravenous ONCASPAR INJECTION 6 Specialty solution reconstituted 20 GM PA SOLUTION 750 UNIT/ML Medical mg, 40 mg, 5 mg ONIVYDE MVASI INTRAVENOUS PA; PA; INTRAVENOUS 6 Specialty SOLUTION 100 5 Specialty INJECTABLE 43 Medical MG/4ML, 400 MG/16ML Medical MG/10ML MYLERAN ORAL 3 ONTRUZANT TABLET 2 MG INTRAVENOUS PA; MYLOTARG SOLUTION 5 Specialty INTRAVENOUS PA; RECONSTITUTED 150 Medical SOLUTION 6 Specialty MG, 420 MG RECONSTITUTED 4.5 Medical ONUREG ORAL MG TABLET 200 MG, 300 6 PA NAVELBINE PA; MG INTRAVENOUS 6 Specialty OPDIVO SOLUTION 10 MG/ML, Medical INTRAVENOUS PA; 50 MG/5ML SOLUTION 100 6 Specialty NERLYNX ORAL MG/10ML, 240 Medical 6 PA TABLET 40 MG MG/24ML, 40 MG/4ML

NEXAVAR ORAL 6 PA ORGOVYX ORAL 6 PA TABLET 200 MG TABLET 120 MG Brand oxaliplatin intravenous NILANDRON ORAL 4 penalty solution 100 mg/20ml, 50 GM PA TABLET 150 MG applies mg/10ml nilutamide oral tablet 150 2 oxaliplatin intravenous mg solution reconstituted GM PA NINLARO ORAL 100 mg, 50 mg CAPSULE 2.3 MG, 3 6 PA MG, 4 MG

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 60 Drug Drug Drug Name Notes Drug Name Notes Tier Tier paclitaxel intravenous POLIVY INTRAVENOUS PA; PA; concentrate 100 SOLUTION 6 Specialty 6 Specialty mg/16.67ml, 100 RECONSTITUTED 140 Medical mg/16.7ml, 150 mg/25ml, Medical MG, 30 MG 30 mg/5ml, 300 mg/50ml POMALYST ORAL PADCEV CAPSULE 1 MG, 2 MG, 6 PA INTRAVENOUS PA; 3 MG, 4 MG SOLUTION 6 Specialty PORTRAZZA PA; RECONSTITUTED 20 Medical INTRAVENOUS 6 Specialty MG, 30 MG SOLUTION 800 Medical PANRETIN EXTERNAL 4 MG/50ML GEL 0.1 % POTELIGEO PA; paraplatin intravenous INTRAVENOUS 6 Specialty solution 1000 mg/100ml, SOLUTION 20 MG/5ML Medical 150 mg/15ml, 450 GM PA PROLEUKIN mg/45ml, 50 mg/5ml, 600 INTRAVENOUS PA; mg/60ml SOLUTION 6 Specialty PEMAZYRE ORAL RECONSTITUTED Medical TABLET 13.5 MG, 4.5 6 PA 22000000 UNIT MG, 9 MG PURIXAN ORAL PEPAXTO SUSPENSION 2000 4 INTRAVENOUS PA; MG/100ML SOLUTION 6 Specialty QINLOCK ORAL 6 PA RECONSTITUTED 20 Medical TABLET 50 MG MG QUADRAMET PERJETA PA; INTRAVENOUS Specialty INTRAVENOUS 6 6 Specialty SOLUTION 1850 Medical SOLUTION 420 Medical MBQ/ML MG/14ML RETEVMO ORAL PHESGO CAPSULE 40 MG, 80 6 PA SUBCUTANEOUS PA; MG SOLUTION 60-60-2000 6 Specialty MG-MG-U/ML, 80-40- Medical REVLIMID ORAL 2000 MG-MG-U/ML CAPSULE 10 MG, 15 6 PA MG, 2.5 MG, 20 MG, 25 PHOTOFRIN MG, 5 MG INTRAVENOUS PA; SOLUTION 6 Specialty RIABNI INTRAVENOUS PA; RECONSTITUTED 75 Medical SOLUTION 100 5 Specialty MG MG/10ML, 500 MG/50ML Medical PIQRAY ORAL TABLET RITUXAN HYCELA SUBCUTANEOUS PA; THERAPY PACK 2 X 6 PA 150 MG, 200 & 50 MG, SOLUTION 1400-23400 6 Specialty 200 MG MG -UT/11.7ML, 1600- Medical 26800 MG -UT/13.4ML

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 61 Drug Drug Drug Name Notes Drug Name Notes Tier Tier RITUXAN SUTENT ORAL PA; 6 PA INTRAVENOUS 6 Specialty CAPSULE 12.5 MG, 25 SOLUTION 100 Medical MG, 37.5 MG, 50 MG MG/10ML, 500 MG/50ML SYLVANT PA; ROMIDEPSIN PA; INTRAVENOUS 6 Specialty INTRAVENOUS 6 Specialty SOLUTION SOLUTION 27.5 RECONSTITUTED 100 Medical Medical MG/5.5ML MG, 400 MG ROZLYTREK ORAL SYNRIBO CAPSULE 100 MG, 200 6 PA SUBCUTANEOUS MG SOLUTION 6 PA RUBRACA ORAL RECONSTITUTED 3.5 TABLET 200 MG, 250 6 PA MG MG, 300 MG TABLOID ORAL TABLET 3 40 MG RUXIENCE PA; INTRAVENOUS 5 Specialty TABRECTA ORAL SOLUTION 100 TABLET 150 MG, 200 6 PA Medical MG/10ML, 500 MG/50ML MG RYBREVANT PA; TAFINLAR ORAL INTRAVENOUS 6 Specialty CAPSULE 50 MG, 75 6 PA SOLUTION 350 MG/7ML Medical MG

RYDAPT ORAL 6 PA TAGRISSO ORAL 6 PA CAPSULE 25 MG TABLET 40 MG, 80 MG

RYLAZE PA; TALZENNA ORAL 6 PA INTRAMUSCULAR 6 Specialty CAPSULE 0.25 MG, 1 SOLUTION 10 Medical MG MG/0.5ML tamoxifen citrate oral PV SARCLISA tablet 10 mg, 20 mg PA; INTRAVENOUS 6 Specialty TARCEVA ORAL SOLUTION 100 Medical TABLET 100 MG, 150 6 PA MG/5ML, 500 MG/25ML MG, 25 MG SPRYCEL ORAL TARGRETIN EXTERNAL 6 PA TABLET 100 MG, 140 6 PA GEL 1 % MG, 20 MG, 50 MG, 70 MG, 80 MG TARGRETIN ORAL 6 PA CAPSULE 75 MG STIVARGA ORAL 6 PA TABLET 40 MG PA; QL (120 EA TASIGNA ORAL 6 STRONTIUM CAPSULE 150 MG, 200 per 30 CHLORIDE SR-89 GM MG, 50 MG days) INTRAVENOUS TAZVERIK ORAL SOLUTION 1 MCI/ML 6 PA TABLET 200 MG

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 62 Drug Drug Drug Name Notes Drug Name Notes Tier Tier TECARTUS PA; topotecan hcl INTRAVENOUS 6 Specialty intravenous solution GM PA SUSPENSION Medical reconstituted 4 mg

TECENTRIQ PA; toremifene citrate oral 2 PA INTRAVENOUS 6 Specialty tablet 60 mg SOLUTION 1200 Medical TOTECT MG/20ML, 840 MG/14ML INTRAVENOUS TEMODAR SOLUTION GM INTRAVENOUS PA; RECONSTITUTED 500 SOLUTION 6 Specialty MG RECONSTITUTED 100 Medical TRAZIMERA MG INTRAVENOUS PA; TEMODAR ORAL SOLUTION 5 Specialty CAPSULE 100 MG, 140 6 PA RECONSTITUTED 150 Medical MG, 180 MG, 250 MG MG, 420 MG temozolomide oral TREANDA capsule 100 mg, 140 mg, INTRAVENOUS PA; 5 PA 180 mg, 20 mg, 250 mg, SOLUTION 6 Specialty 5 mg RECONSTITUTED 100 Medical PA; MG, 25 MG teniposide intravenous 6 Specialty tretinoin oral capsule 10 2 PA solution 10 mg/ml Medical mg

TEPADINA INJECTION PA; TRODELVY PA; SOLUTION 6 Specialty INTRAVENOUS 6 Specialty RECONSTITUTED 100 Medical SOLUTION MG, 15 MG RECONSTITUTED 180 Medical MG TEPMETKO ORAL 6 PA TABLET 225 MG TRUSELTIQ (100MG DAILY DOSE) ORAL THALOMID ORAL 6 PA CAPSULE 100 MG, 150 6 PA CAPSULE THERAPY MG, 200 MG, 50 MG PACK 100 MG thiotepa injection solution PA; TRUSELTIQ (125MG reconstituted 100 mg, 15 6 Specialty DAILY DOSE) ORAL 6 PA mg Medical CAPSULE THERAPY PACK 100 & 25 MG TIBSOVO ORAL 6 PA TABLET 250 MG TRUSELTIQ (50MG DAILY DOSE) ORAL 6 PA toposar intravenous CAPSULE THERAPY solution 1 gm/50ml, 100 GM PA PACK 25 MG mg/5ml, 500 mg/25ml TRUSELTIQ (75MG topotecan hcl DAILY DOSE) ORAL 6 PA intravenous solution 4 GM PA CAPSULE THERAPY mg/4ml PACK 25 MG

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 63 Drug Drug Drug Name Notes Drug Name Notes Tier Tier TRUXIMA VERZENIO ORAL PA; 6 PA INTRAVENOUS 5 Specialty TABLET 100 MG, 150 SOLUTION 100 Medical MG, 200 MG, 50 MG MG/10ML, 500 MG/50ML VIDAZA INJECTION PA; TUKYSA ORAL TABLET 6 PA SUSPENSION 6 Specialty 150 MG, 50 MG RECONSTITUTED 100 Medical MG TURALIO ORAL 6 PA CAPSULE 200 MG vinblastine sulfate PA; TYKERB ORAL TABLET intravenous solution 1 6 Specialty 6 PA 250 MG mg/ml Medical UKONIQ ORAL TABLET vincristine sulfate 6 PA 200 MG intravenous solution 1 GM PA mg/ml UNITUXIN PA; INTRAVENOUS vinorelbine tartrate PA; 6 Specialty intravenous solution 10 6 Specialty SOLUTION 17.5 Medical MG/5ML mg/ml, 50 mg/5ml Medical UVADEX INJECTION VITRAKVI ORAL GM 6 PA SOLUTION 20 MCG/ML CAPSULE 100 MG, 25 MG VALCHLOR EXTERNAL 6 PA VITRAKVI ORAL GEL 0.016 % 6 PA SOLUTION 20 MG/ML PA; valrubicin intravesical 6 Specialty VIZIMPRO ORAL solution 40 mg/ml Medical TABLET 15 MG, 30 MG, 6 PA 45 MG VALSTAR PA; INTRAVESICAL 6 Specialty VORAXAZE SOLUTION 40 MG/ML Medical INTRAVENOUS SOLUTION GM VECTIBIX PA; RECONSTITUTED 1000 INTRAVENOUS 6 Specialty UNIT SOLUTION 100 Medical VOTRIENT ORAL MG/5ML, 400 MG/20ML 6 PA TABLET 200 MG VELCADE INJECTION PA; SOLUTION VYXEOS 6 Specialty RECONSTITUTED 3.5 INTRAVENOUS PA; Medical MG SUSPENSION 6 Specialty RECONSTITUTED 44- Medical VENCLEXTA ORAL 100 MG TABLET 10 MG, 100 6 PA MG, 50 MG XALKORI ORAL CAPSULE 200 MG, 250 6 PA VENCLEXTA STARTING MG PACK ORAL TABLET 6 PA XELODA ORAL TABLET THERAPY PACK 10 & 6 PA 50 & 100 MG 150 MG, 500 MG

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 64 Drug Drug Drug Name Notes Drug Name Notes Tier Tier XOFIGO PA; YESCARTA PA; INTRAVENOUS 6 Specialty INTRAVENOUS 6 Specialty SOLUTION 30 MCCI/ML Medical SUSPENSION Medical

XOSPATA ORAL 6 PA YONDELIS PA; TABLET 40 MG INTRAVENOUS 6 Specialty XPOVIO (100 MG ONCE SOLUTION Medical RECONSTITUTED 1 MG WEEKLY) ORAL 6 PA TABLET THERAPY YONSA ORAL TABLET 6 PA PACK 50 MG 125 MG XPOVIO (40 MG ONCE ZALTRAP PA; WEEKLY) ORAL INTRAVENOUS 6 PA 6 Specialty TABLET THERAPY SOLUTION 100 Medical PACK 40 MG MG/4ML, 200 MG/8ML

XPOVIO (40 MG TWICE ZANOSAR PA; WEEKLY) ORAL 6 PA INTRAVENOUS 6 Specialty TABLET THERAPY SOLUTION Medical PACK 40 MG RECONSTITUTED 1 GM XPOVIO (60 MG ONCE ZEJULA ORAL 6 PA WEEKLY) ORAL CAPSULE 100 MG 6 PA TABLET THERAPY ZELBORAF ORAL 6 PA PACK 60 MG TABLET 240 MG XPOVIO (60 MG TWICE ZEPZELCA PA; WEEKLY) ORAL 6 PA INTRAVENOUS TABLET THERAPY 6 Specialty SOLUTION Medical PACK 20 MG RECONSTITUTED 4 MG XPOVIO (80 MG ONCE ZEVALIN Y-90 Specialty WEEKLY) ORAL 6 6 PA INTRAVENOUS KIT 3.2 Medical TABLET THERAPY MG/2ML PACK 40 MG ZIRABEV PA; XPOVIO (80 MG TWICE INTRAVENOUS 5 Specialty WEEKLY) ORAL SOLUTION 100 6 PA Medical TABLET THERAPY MG/4ML, 400 MG/16ML PACK 20 MG ZOLINZA ORAL 6 PA XTANDI ORAL 6 PA CAPSULE 100 MG CAPSULE 40 MG ZYDELIG ORAL TABLET 6 PA XTANDI ORAL TABLET 6 PA 100 MG, 150 MG 40 MG, 80 MG ZYKADIA ORAL TABLET 6 PA YERVOY PA; 150 MG INTRAVENOUS 6 Specialty SOLUTION 200 ZYNLONTA Medical MG/40ML, 50 MG/10ML INTRAVENOUS PA; SOLUTION 6 Specialty RECONSTITUTED 10 Medical MG

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 65 Drug Drug Drug Name Notes Drug Name Notes Tier Tier ZYTIGA ORAL TABLET EMVERM ORAL 6 PA 250 MG, 500 MG TABLET CHEWABLE 4 Antiparasitics 100 MG hydroxychloroquine albendazole oral tablet 2 2 200 mg sulfate oral tablet 200 mg Brand IMPAVIDO ORAL 4 ALBENZA ORAL 4 penalty CAPSULE 50 MG TABLET 200 MG applies ivermectin external lotion 2 ALINIA ORAL 0.5 % SUSPENSION ivermectin oral tablet 3 4 2 RECONSTITUTED 100 mg MG/5ML QL (2 EA Brand KRINTAFEL ORAL 3 per 30 ALINIA ORAL TABLET 4 penalty TABLET 150 MG days) 500 MG applies LAMPIT ORAL TABLET 4 ARAKODA ORAL 3 120 MG, 30 MG TABLET 100 MG lindane external 2 ARTESUNATE shampoo 1 % INTRAVENOUS MALARONE ORAL Brand GM SOLUTION TABLET 250-100 MG, 4 penalty RECONSTITUTED 110 62.5-25 MG applies MG malathion external lotion atovaquone oral 2 2 0.5 % suspension 750 mg/5ml mefloquine hcl oral tablet 2 atovaquone-proguanil hcl 250 mg oral tablet 250-100 mg, 2 62.5-25 mg MEPRON ORAL Brand SUSPENSION 750 4 penalty BENZNIDAZOLE ORAL MG/5ML applies TABLET 100 MG, 12.5 4 MG Brand NATROBA EXTERNAL 4 penalty Brand SUSPENSION 0.9 % applies BILTRICIDE ORAL 4 penalty TABLET 600 MG applies NEBUPENT INHALATION Brand chloroquine phosphate SOLUTION 4 penalty 2 oral tablet 250 mg, 500 RECONSTITUTED 300 applies mg MG COARTEM ORAL 3 nitazoxanide oral tablet 2 TABLET 20-120 MG 500 mg crotan external lotion 10 2 PA Brand % OVIDE EXTERNAL 4 penalty applies DARAPRIM ORAL 6 LOTION 0.5 % TABLET 25 MG

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 66 Drug Drug Drug Name Notes Drug Name Notes Tier Tier PENTAM INJECTION Antiparkinson Agents SOLUTION GM amantadine hcl oral 2 RECONSTITUTED 300 capsule 100 mg MG amantadine hcl oral 2 pentamidine isethionate syrup 50 mg/5ml inhalation solution 2 reconstituted 300 mg amantadine hcl oral 2 tablet 100 mg pentamidine isethionate injection solution GM APOKYN SUBCUTANEOUS reconstituted 300 mg 6 PA SOLUTION CARTRIDGE permethrin external 2 30 MG/3ML cream 5 % Brand Brand AZILECT ORAL TABLET 4 penalty PLAQUENIL ORAL 4 penalty 0.5 MG, 1 MG applies TABLET 200 MG applies benztropine mesylate GM praziquantel oral tablet 2 injection solution 1 mg/ml 600 mg benztropine mesylate primaquine phosphate oral tablet 0.5 mg, 1 mg, 1 oral tablet 26.3 (15 base) 2 2 mg mg bromocriptine mesylate pyrimethamine oral tablet 2 6 oral capsule 5 mg 25 mg bromocriptine mesylate 2 PYRIMETHAMINE- oral tablet 2.5 mg LEUCOVORIN ORAL carbidopa oral tablet 25 CAPSULE 12.5-2.5 MG, 4 2 25-10 MG, 25-5 MG, 50- mg 10 MG, 50-20 MG, 50-25 carbidopa-levodopa er MG, 75-25 MG oral tablet extended 2 Brand release 25-100 mg, 50- QUALAQUIN ORAL 4 penalty 200 mg CAPSULE 324 MG applies carbidopa-levodopa oral 2 quinine sulfate oral tablet 10-100 mg, 25-100 2 capsule 324 mg mg, 25-250 mg spinosad external carbidopa-levodopa oral 2 tablet dispersible 10-100 suspension 0.9 % 2 mg, 25-100 mg, 25-250 Brand mg STROMECTOL ORAL 4 penalty TABLET 3 MG applies carbidopa-levodopa- entacapone oral tablet sulfurated lime external 2 12.5-50-200 mg, 18.75- solution 75-200 mg, 25-100-200 2 mg, 31.25-125-200 mg, 37.5-150-200 mg, 50- 200-200 mg Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 67 Drug Drug Drug Name Notes Drug Name Notes Tier Tier COGENTIN INJECTION Brand GM SOLUTION 1 MG/ML PARLODEL ORAL 4 penalty Brand TABLET 2.5 MG applies COMTAN ORAL 4 penalty pramipexole TABLET 200 MG applies dihydrochloride er oral tablet extended release entacapone oral tablet 2 2 200 mg 24 hour 0.375 mg, 0.75 mg, 1.5 mg, 2.25 mg, 3 INBRIJA INHALATION 6 PA mg, 3.75 mg, 4.5 mg CAPSULE 42 MG pramipexole KYNMOBI SUBLINGUAL dihydrochloride oral FILM 10 MG, 15 MG, 20 6 PA tablet 0.125 mg, 0.25 mg, 2 MG, 25 MG, 30 MG 0.5 mg, 0.75 mg, 1 mg, KYNMOBI TITRATION 1.5 mg KIT SUBLINGUAL KIT 6 PA rasagiline mesylate oral 2 10/15/20/25/30 MG tablet 0.5 mg, 1 mg Brand ropinirole hcl er oral LODOSYN ORAL 4 penalty tablet extended release 2 TABLET 25 MG applies 24 hour 12 mg, 2 mg, 4 MIRAPEX ER ORAL mg, 6 mg, 8 mg TABLET EXTENDED Brand ropinirole hcl oral tablet RELEASE 24 HOUR 4 penalty 0.25 mg, 0.5 mg, 1 mg, 2 2 0.375 MG, 0.75 MG, 1.5 applies mg, 3 mg, 4 mg, 5 mg MG, 2.25 MG, 3 MG, 3.75 MG, 4.5 MG RYTARY ORAL CAPSULE EXTENDED MIRAPEX ORAL Brand RELEASE 23.75-95 MG, 4 TABLET 0.125 MG, 0.5 4 penalty 36.25-145 MG, 48.75- MG, 0.75 MG, 1 MG applies 195 MG, 61.25-245 MG NEUPRO selegiline hcl oral 2 TRANSDERMAL PATCH capsule 5 mg 24 HOUR 1 MG/24HR, 2 4 selegiline hcl oral tablet 5 MG/24HR, 3 MG/24HR, 2 4 MG/24HR, 6 mg MG/24HR, 8 MG/24HR SINEMET ORAL Brand TABLET 10-100 MG, 25- 4 penalty NOURIANZ ORAL 6 PA TABLET 20 MG, 40 MG 100 MG applies ONGENTYS ORAL Brand CAPSULE 25 MG, 50 4 PA STALEVO 100 ORAL 4 penalty applies MG TABLET 25-100-200 MG Brand STALEVO 125 ORAL Brand PARLODEL ORAL 4 penalty TABLET 31.25-125-200 4 penalty CAPSULE 5 MG applies MG applies

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 68 Drug Drug Drug Name Notes Drug Name Notes Tier Tier STALEVO 150 ORAL Brand CABLIVI INJECTION KIT 6 PA TABLET 37.5-150-200 4 penalty 11 MG MG applies cilostazol oral tablet 100 2 Brand mg, 50 mg STALEVO 200 ORAL 4 penalty clopidogrel bisulfate oral 2 TABLET 50-200-200 MG applies tablet 300 mg Brand clopidogrel bisulfate oral 1 STALEVO 50 ORAL 4 penalty tablet 75 mg TABLET 12.5-50-200 MG applies DEFITELIO STALEVO 75 ORAL Brand INTRAVENOUS GM TABLET 18.75-75-200 4 penalty SOLUTION 200 MG applies MG/2.5ML Brand dipyridamole oral tablet 2 TASMAR ORAL TABLET 4 penalty 25 mg, 50 mg, 75 mg 100 MG applies Brand tolcapone oral tablet 100 2 EFFIENT ORAL TABLET 4 penalty mg 10 MG, 5 MG applies trihexyphenidyl hcl oral 2 eptifibatide intravenous solution 0.4 mg/ml solution 20 mg/10ml, 200 GM trihexyphenidyl hcl oral mg/100ml, 75 mg/100ml 2 tablet 2 mg, 5 mg KENGREAL XADAGO ORAL TABLET INTRAVENOUS 4 100 MG, 50 MG SOLUTION GM ZELAPAR ORAL RECONSTITUTED 50 TABLET DISPERSIBLE 4 MG 1.25 MG Brand Antiplatelets PLAVIX ORAL TABLET 4 penalty 75 MG applies AGGRASTAT prasugrel hcl oral tablet INTRAVENOUS GM 2 CONCENTRATE 3.75 10 mg, 5 mg MG/15ML ZONTIVITY ORAL 4 AGGRASTAT TABLET 2.08 MG INTRAVENOUS Antipsychotics - Drugs SOLUTION 12.5-0.9 GM for Mood Disorders MG/250ML-%, 5-0.9 ABILIFY MAINTENA MG/100ML-% INTRAMUSCULAR 5 aspirin-dipyridamole er PREFILLED SYRINGE oral capsule extended 2 300 MG, 400 MG release 12 hour 25-200 ABILIFY MAINTENA mg INTRAMUSCULAR BRILINTA ORAL SUSPENSION 5 3 TABLET 60 MG, 90 MG RECONSTITUTED ER 300 MG, 400 MG Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 69 Drug Drug Drug Name Notes Drug Name Notes Tier Tier ABILIFY MYCITE chlorpromazine hcl MAINTENANCE KIT QL (30 EA injection solution 25 GM ORAL TABLET 10 MG, 4 per 30 mg/ml, 50 mg/2ml 15 MG, 2 MG, 20 MG, 30 days) chlorpromazine hcl oral MG, 5 MG concentrate 100 mg/ml, 2 ABILIFY MYCITE 30 mg/ml QL (60 EA STARTER KIT ORAL chlorpromazine hcl oral TABLET 10 MG, 15 MG, 4 per 365 tablet 10 mg, 100 mg, 2 2 MG, 20 MG, 30 MG, 5 days) 200 mg, 25 mg, 50 mg MG clozapine oral tablet 100 Brand mg, 200 mg, 25 mg, 50 2 penalty mg ABILIFY ORAL TABLET 4 applies; QL 10 MG, 15 MG, 2 MG, 20 (30 EA per clozapine oral tablet MG, 30 MG, 5 MG 30 days) dispersible 100 mg, 12.5 2 mg, 150 mg, 200 mg, 25 ADASUVE INHALATION mg AEROSOL POWDER GM BREATH ACTIVATED 10 CLOZARIL ORAL Brand MG TABLET 100 MG, 200 4 penalty MG, 25 MG, 50 MG applies aripiprazole oral solution 2 1 mg/ml FANAPT ORAL TABLET 1 MG, 10 MG, 12 MG, 2 4 PA aripiprazole oral tablet 10 QL (30 EA MG, 4 MG, 6 MG, 8 MG mg, 15 mg, 2 mg, 20 mg, 2 per 30 30 mg, 5 mg days) FANAPT TITRATION PACK ORAL TABLET 1 4 PA QL (30 EA & 2 & 4 & 6 MG aripiprazole oral tablet 2 per 30 dispersible 10 mg, 15 mg days) fluphenazine decanoate injection solution 25 GM ARISTADA INITIO mg/ml INTRAMUSCULAR 5 fluphenazine hcl injection PREFILLED SYRINGE GM 675 MG/2.4ML solution 2.5 mg/ml fluphenazine hcl oral ARISTADA 2 INTRAMUSCULAR concentrate 5 mg/ml PREFILLED SYRINGE fluphenazine hcl oral 2 1064 MG/3.9ML, 441 5 elixir 2.5 mg/5ml MG/1.6ML, 662 fluphenazine hcl oral MG/2.4ML, 882 tablet 1 mg, 10 mg, 2.5 2 MG/3.2ML mg, 5 mg asenapine maleate GEODON sublingual tablet 2 PA INTRAMUSCULAR sublingual 10 mg, 2.5 SOLUTION GM mg, 5 mg RECONSTITUTED 20 CAPLYTA ORAL 4 PA MG CAPSULE 42 MG

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 70 Drug Drug Drug Name Notes Drug Name Notes Tier Tier GEODON ORAL Brand loxapine succinate oral CAPSULE 20 MG, 40 4 penalty capsule 10 mg, 25 mg, 5 2 MG, 60 MG, 80 MG applies mg, 50 mg

HALDOL DECANOATE molindone hcl oral tablet 2 INTRAMUSCULAR GM 10 mg, 25 mg, 5 mg SOLUTION 100 MG/ML, NUPLAZID ORAL 5 PA 50 MG/ML CAPSULE 34 MG HALDOL INJECTION NUPLAZID ORAL GM 5 PA SOLUTION 5 MG/ML TABLET 10 MG haloperidol decanoate olanzapine intramuscular intramuscular solution GM solution reconstituted 10 GM 100 mg/ml, 50 mg/ml mg haloperidol lactate GM olanzapine oral tablet 10 injection solution 5 mg/ml mg, 15 mg, 2.5 mg, 20 2 haloperidol lactate oral 2 mg, 5 mg, 7.5 mg concentrate 2 mg/ml olanzapine oral tablet 2 haloperidol oral tablet 0.5 1 dispersible 10 mg, 15 mg, 1 mg, 2 mg, 5 mg mg, 20 mg, 5 mg haloperidol oral tablet 10 2 paliperidone er oral tablet QL (30 EA mg, 20 mg extended release 24 hour 2 per 30 1.5 mg, 3 mg, 6 mg, 9 Brand days) INVEGA ORAL TABLET penalty mg EXTENDED RELEASE 4 applies; QL PERSERIS (30 EA per 24 HOUR 1.5 MG, 3 MG, SUBCUTANEOUS 5 6 MG, 9 MG 30 days) PREFILLED SYRINGE INVEGA SUSTENNA 120 MG, 90 MG INTRAMUSCULAR pimozide oral tablet 1 2 SUSPENSION mg, 2 mg PREFILLED SYRINGE 5 quetiapine fumarate er 117 MG/0.75ML, 156 oral tablet extended QL (30 EA MG/ML, 234 MG/1.5ML, release 24 hour 150 mg, 2 per 30 39 MG/0.25ML, 78 200 mg, 300 mg, 400 days) MG/0.5ML mg, 50 mg INVEGA TRINZA quetiapine fumarate oral INTRAMUSCULAR tablet 100 mg, 200 mg, 2 SUSPENSION 25 mg, 300 mg, 400 mg, PREFILLED SYRINGE 5 50 mg 273 MG/0.875ML, 410 MG/1.315ML, 546 REXULTI ORAL TABLET MG/1.75ML, 819 0.25 MG, 0.5 MG, 1 MG, 4 PA MG/2.625ML 2 MG, 3 MG, 4 MG LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 4 PA 60 MG, 80 MG Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 71 Drug Drug Drug Name Notes Drug Name Notes Tier Tier RISPERDAL CONSTA trifluoperazine hcl oral INTRAMUSCULAR tablet 1 mg, 10 mg, 2 mg, 2 SUSPENSION 5 5 mg RECONSTITUTED ER VERSACLOZ ORAL 12.5 MG, 25 MG, 37.5 SUSPENSION 50 4 MG, 50 MG MG/ML Brand VRAYLAR ORAL RISPERDAL ORAL 4 penalty CAPSULE 1.5 MG, 3 4 PA SOLUTION 1 MG/ML applies MG, 4.5 MG, 6 MG RISPERDAL ORAL Brand VRAYLAR ORAL TABLET 0.5 MG, 1 MG, 4 penalty CAPSULE THERAPY 4 PA 2 MG, 3 MG, 4 MG applies PACK 1.5 & 3 MG risperidone oral solution 2 ziprasidone hcl oral 1 mg/ml capsule 20 mg, 40 mg, 2 risperidone oral tablet 60 mg, 80 mg 0.25 mg, 0.5 mg, 1 mg, 2 1 ziprasidone mesylate mg, 3 mg, 4 mg intramuscular solution GM risperidone oral tablet reconstituted 20 mg dispersible 0.25 mg, 0.5 2 ZYPREXA mg, 1 mg, 2 mg, 3 mg, 4 INTRAMUSCULAR mg SOLUTION GM SAPHRIS SUBLINGUAL PA; Brand RECONSTITUTED 10 TABLET SUBLINGUAL 4 penalty MG 10 MG, 2.5 MG, 5 MG applies ZYPREXA ORAL Brand SECUADO TABLET 10 MG, 15 MG, 4 penalty TRANSDERMAL PATCH 2.5 MG, 20 MG, 5 MG, applies 24 HOUR 3.8 MG/24HR, 4 PA 7.5 MG 5.7 MG/24HR, 7.6 ZYPREXA RELPREVV MG/24HR INTRAMUSCULAR SEROQUEL ORAL SUSPENSION 5 Brand TABLET 100 MG, 200 RECONSTITUTED 210 4 penalty MG, 25 MG, 300 MG, applies MG, 300 MG, 405 MG 400 MG, 50 MG ZYPREXA ZYDIS ORAL Brand Brand SEROQUEL XR ORAL TABLET DISPERSIBLE 4 penalty penalty TABLET EXTENDED 10 MG, 15 MG, 20 MG, 5 applies RELEASE 24 HOUR 150 4 applies; QL MG MG, 200 MG, 300 MG, (30 EA per Antivirals 400 MG, 50 MG 30 days) abacavir sulfate oral 2 thioridazine hcl oral tablet solution 20 mg/ml 10 mg, 100 mg, 25 mg, 2 abacavir sulfate oral 50 mg 2 tablet 300 mg thiothixene oral capsule 1 2 mg, 10 mg, 2 mg, 5 mg

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 72 Drug Drug Drug Name Notes Drug Name Notes Tier Tier abacavir sulfate- cidofovir intravenous GM lamivudine oral tablet 2 solution 75 mg/ml 600-300 mg CIMDUO ORAL TABLET 6 abacavir-lamivudine- 300-300 MG zidovudine oral tablet 2 Brand 300-150-300 mg COMBIVIR ORAL 4 penalty applies acyclovir external cream 2 TABLET 150-300 MG 5 % COMPLERA ORAL 6 QL (15 GM TABLET 200-25-300 MG acyclovir external 2 per 30 CRIXIVAN ORAL 3 ointment 5 % days) CAPSULE 400 MG acyclovir oral capsule 2 DELSTRIGO ORAL 200 mg TABLET 100-300-300 6 acyclovir oral suspension 2 MG 200 mg/5ml DENAVIR EXTERNAL 4 ST acyclovir oral tablet 400 2 CREAM 1 % mg, 800 mg DESCOVY ORAL 6 PV* acyclovir sodium TABLET 200-25 MG intravenous solution 50 GM DOVATO ORAL TABLET 6 mg/ml 50-300 MG adefovir dipivoxil oral EDURANT ORAL 2 PA 4 tablet 10 mg TABLET 25 MG APTIVUS ORAL efavirenz oral capsule 3 2 CAPSULE 250 MG 200 mg, 50 mg atazanavir sulfate oral efavirenz oral tablet 600 2 capsule 150 mg, 200 mg, 2 mg 300 mg efavirenz-emtricitab- ATRIPLA ORAL TABLET 6 tenofovir oral tablet 600- 5 600-200-300 MG 200-300 mg BARACLUDE ORAL 4 PA efavirenz-lamivudine- SOLUTION 0.05 MG/ML tenofovir oral tablet 400- 6 PA; Brand 300-300 mg, 600-300- BARACLUDE ORAL 4 penalty 300 mg TABLET 0.5 MG, 1 MG applies emtricitabine oral capsule 2 BIKTARVY ORAL 200 mg 6 TABLET 50-200-25 MG emtricitabine-tenofovir df CABENUVA oral tablet 100-150 mg, 5 PV* INTRAMUSCULAR 133-200 mg, 167-250 Specialty SUSPENSION 6 mg, 200-300 mg EXTENDED RELEASE Medical Brand 400 & 600 MG/2ML, 600 EMTRIVA ORAL 3 penalty & 900 MG/3ML CAPSULE 200 MG applies

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 73 Drug Drug Drug Name Notes Drug Name Notes Tier Tier EMTRIVA ORAL GANCICLOVIR 3 SOLUTION 10 MG/ML INTRAVENOUS GM SOLUTION 500 entecavir oral tablet 0.5 2 PA mg, 1 mg MG/250ML EPCLUSA ORAL ganciclovir sodium TABLET 200-50 MG, 5 PA intravenous solution 500 GM 400-100 MG mg/10ml EPIVIR HBV ORAL ganciclovir sodium 4 SOLUTION 5 MG/ML intravenous solution GM reconstituted 500 mg Brand EPIVIR HBV ORAL 4 penalty GENVOYA ORAL TABLET 100 MG applies TABLET 150-150-200-10 6 MG Brand EPIVIR ORAL 4 penalty HARVONI ORAL SOLUTION 10 MG/ML applies PACKET 33.75-150 MG, 5 PA 45-200 MG Brand EPIVIR ORAL TABLET 4 penalty HARVONI ORAL 5 PA 150 MG, 300 MG applies TABLET 45-200 MG, 90- 400 MG Brand EPZICOM ORAL 4 penalty PA; Brand TABLET 600-300 MG applies HEPSERA ORAL 4 penalty TABLET 10 MG applies etravirine oral tablet 100 2 mg, 200 mg INTELENCE ORAL Brand TABLET 100 MG, 200 4 penalty EVOTAZ ORAL TABLET 6 MG applies 300-150 MG INTELENCE ORAL 4 famciclovir oral tablet 125 2 TABLET 25 MG mg, 250 mg, 500 mg INTRON A INJECTION PA; fosamprenavir calcium SOLUTION 10000000 2 6 Specialty oral tablet 700 mg UNIT/ML, 6000000 Medical foscarnet sodium UNIT/ML intravenous solution GM INTRON A INJECTION 6000 mg/250ml SOLUTION PA; FOSCAVIR RECONSTITUTED 6 Specialty INTRAVENOUS 10000000 UNIT, GM Medical SOLUTION 6000 18000000 UNIT, MG/250ML 50000000 UNIT

FUZEON INVIRASE ORAL 3 SUBCUTANEOUS TABLET 500 MG SOLUTION 6 ISENTRESS HD ORAL 3 RECONSTITUTED 90 TABLET 600 MG MG ISENTRESS ORAL 3 PACKET 100 MG

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 74 Drug Drug Drug Name Notes Drug Name Notes Tier Tier ISENTRESS ORAL NORVIR ORAL PACKET 3 4 TABLET 400 MG 100 MG

ISENTRESS ORAL NORVIR ORAL 3 TABLET CHEWABLE 3 SOLUTION 80 MG/ML 100 MG, 25 MG Brand 3 penalty JULUCA ORAL TABLET 6 NORVIR ORAL TABLET 50-25 MG 100 MG applies KALETRA ORAL Brand ODEFSEY ORAL 6 SOLUTION 400-100 4 penalty TABLET 200-25-25 MG MG/5ML applies QL (20 EA KALETRA ORAL Brand oseltamivir phosphate 2 per 180 TABLET 100-25 MG, 3 penalty oral capsule 30 mg days) 200-50 MG applies oseltamivir phosphate QL (10 EA 2 per 180 lamivudine oral solution 2 oral capsule 45 mg, 75 10 mg/ml mg days) QL (120 lamivudine oral tablet 2 oseltamivir phosphate 100 mg, 150 mg, 300 mg oral suspension 2 ML per 180 reconstituted 6 mg/ml days) lamivudine-zidovudine 2 oral tablet 150-300 mg PEGASYS LEDIPASVIR- SUBCUTANEOUS SOFOSBUVIR ORAL 5 PA SOLUTION 180 6 PA TABLET 90-400 MG MCG/0.5ML, 180 MCG/ML LEXIVA ORAL SUSPENSION 50 4 PIFELTRO ORAL 4 MG/ML TABLET 100 MG Brand PREVYMIS PA; LEXIVA ORAL TABLET 4 penalty INTRAVENOUS 6 Specialty 700 MG applies SOLUTION 240 Medical MG/12ML, 480 MG/24ML lopinavir-ritonavir oral 2 solution 400-100 mg/5ml PREVYMIS ORAL TABLET 240 MG, 480 6 PA lopinavir-ritonavir oral MG tablet 100-25 mg, 200-50 2 PREZCOBIX ORAL mg 6 TABLET 800-150 MG MAVYRET ORAL 5 PA TABLET 100-40 MG PREZISTA ORAL SUSPENSION 100 4 nevirapine er oral tablet MG/ML extended release 24 hour 2 100 mg, 400 mg PREZISTA ORAL TABLET 150 MG, 600 4 nevirapine oral 2 MG, 75 MG, 800 MG suspension 50 mg/5ml nevirapine oral tablet 200 2 mg

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 75 Drug Drug Drug Name Notes Drug Name Notes Tier Tier RAPIVAB SOFOSBUVIR- 5 PA INTRAVENOUS GM VELPATASVIR ORAL SOLUTION 200 TABLET 400-100 MG MG/20ML SOVALDI ORAL RELENZA DISKHALER PACKET 150 MG, 200 6 PA INHALATION AEROSOL QL (20 EA MG 4 per 180 POWDER BREATH SOVALDI ORAL ACTIVATED 5 days) TABLET 200 MG, 400 6 PA MG/BLISTER MG RETROVIR stavudine oral capsule 15 INTRAVENOUS GM mg, 20 mg, 30 mg, 40 2 SOLUTION 10 MG/ML mg Brand STRIBILD ORAL RETROVIR ORAL 4 penalty TABLET 150-150-200- 6 CAPSULE 100 MG applies 300 MG Brand SUSTIVA ORAL Brand 4 penalty RETROVIR ORAL CAPSULE 200 MG, 50 4 penalty SYRUP 50 MG/5ML applies MG applies REYATAZ ORAL Brand Brand CAPSULE 150 MG, 200 4 penalty SUSTIVA ORAL TABLET 4 penalty MG, 300 MG applies 600 MG applies REYATAZ ORAL 4 SYMFI LO ORAL PACKET 50 MG TABLET 400-300-300 6 ribavirin inhalation PA; MG solution reconstituted 6 6 Specialty SYMFI ORAL TABLET 6 gm Medical 600-300-300 MG ribavirin oral capsule 200 5 SYMTUZA ORAL mg TABLET 800-150-200-10 6 ribavirin oral tablet 200 MG 5 mg Brand rimantadine hcl oral penalty 2 tablet 100 mg 4 applies; QL ritonavir oral tablet 100 TAMIFLU ORAL (20 EA per 2 mg CAPSULE 30 MG 180 days) RUKOBIA ORAL Brand penalty TABLET EXTENDED 6 RELEASE 12 HOUR 600 TAMIFLU ORAL 4 applies; QL MG CAPSULE 45 MG, 75 (10 EA per MG 180 days) SELZENTRY ORAL 4 SOLUTION 20 MG/ML SELZENTRY ORAL TABLET 150 MG, 25 4 MG, 300 MG, 75 MG Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 76 Drug Drug Drug Name Notes Drug Name Notes Tier Tier Brand valganciclovir hcl oral 5 penalty tablet 450 mg applies; QL TAMIFLU ORAL 4 Brand SUSPENSION (120 ML VALTREX ORAL 4 penalty RECONSTITUTED 6 per 180 TABLET 1 GM, 500 MG applies MG/ML days) VEMLIDY ORAL TEMIXYS ORAL 5 PA 6 TABLET 25 MG TABLET 300-300 MG VIEKIRA PAK ORAL tenofovir disoproxil TABLET THERAPY 6 PA fumarate oral tablet 300 2 PACK 12.5-75-50 mg VIRACEPT ORAL TIVICAY ORAL TABLET 6 TABLET 250 MG, 625 4 10 MG, 25 MG, 50 MG MG TIVICAY PD ORAL VIRAMUNE ORAL Brand TABLET SOLUBLE 5 6 SUSPENSION 50 4 penalty MG MG/5ML applies TRIUMEQ ORAL 6 VIRAMUNE XR ORAL TABLET 600-50-300 MG Brand TABLET EXTENDED 4 penalty Brand RELEASE 24 HOUR 400 applies TRIZIVIR ORAL TABLET 4 penalty MG 300-150-300 MG applies VIRAZOLE INHALATION PA; TROGARZO SOLUTION 6 Specialty Specialty Medical INTRAVENOUS 6 RECONSTITUTED 6 GM SOLUTION 200 Medical VIREAD ORAL 4 MG/1.33ML POWDER 40 MG/GM TRUVADA ORAL VIREAD ORAL TABLET TABLET 100-150 MG, 6 PV* 150 MG, 200 MG, 250 4 133-200 MG, 167-250 MG MG, 200-300 MG Brand TYBOST ORAL TABLET 4 ST VIREAD ORAL TABLET 4 penalty 150 MG 300 MG applies valacyclovir hcl oral VOCABRIA ORAL 2 6 tablet 1 gm, 500 mg TABLET 30 MG VALCYTE ORAL VOSEVI ORAL TABLET 6 PA SOLUTION 6 400-100-100 MG RECONSTITUTED 50 MG/ML XOFLUZA (40 MG QL (2 EA DOSE) ORAL TABLET VALCYTE ORAL 4 per 180 6 THERAPY PACK 1 X 40 days) TABLET 450 MG MG, 2 X 20 MG valganciclovir hcl oral XOFLUZA (80 MG QL (2 EA solution reconstituted 50 5 DOSE) ORAL TABLET 4 per 180 mg/ml THERAPY PACK 1 X 80 days) MG, 2 X 40 MG Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 77 Drug Drug Drug Name Notes Drug Name Notes Tier Tier ZEPATIER ORAL ATIVAN INJECTION 6 PA TABLET 50-100 MG SOLUTION 2 MG/ML, 4 GM Brand MG/ML ZIAGEN ORAL 4 penalty Brand SOLUTION 20 MG/ML applies ATIVAN ORAL TABLET 4 penalty Brand 0.5 MG, 1 MG, 2 MG applies 4 penalty ZIAGEN ORAL TABLET buspirone hcl oral tablet 1 300 MG applies 10 mg, 15 mg, 5 mg zidovudine oral capsule buspirone hcl oral tablet 2 2 100 mg 30 mg, 7.5 mg zidovudine oral syrup 50 BYFAVO 2 mg/5ml INTRAVENOUS zidovudine oral tablet SOLUTION GM 2 300 mg RECONSTITUTED 20 MG Brand ZOVIRAX EXTERNAL 4 penalty chlordiazepoxide hcl oral CREAM 5 % applies capsule 10 mg, 25 mg, 5 2 mg Brand clonazepam oral tablet penalty 2 4 applies; QL 0.5 mg, 1 mg, 2 mg ZOVIRAX EXTERNAL (15 GM per clonazepam oral tablet OINTMENT 5 % 30 days) dispersible 0.125 mg, 2 ZOVIRAX ORAL Brand 0.25 mg, 0.5 mg, 1 mg, 2 SUSPENSION 200 4 penalty mg MG/5ML applies clorazepate dipotassium Anxiolytics - Drugs for oral tablet 15 mg, 3.75 2 Anxiety mg, 7.5 mg alprazolam er oral tablet diazepam intensol oral 2 concentrate 5 mg/ml extended release 24 hour 2 0.5 mg, 1 mg, 2 mg, 3 diazepam oral 2 mg concentrate 5 mg/ml alprazolam intensol oral diazepam oral solution 5 2 2 concentrate 1 mg/ml mg/5ml alprazolam oral tablet diazepam oral tablet 10 2 0.25 mg, 0.5 mg, 1 mg, 2 2 mg, 2 mg, 5 mg mg diazepam solution 5 GM alprazolam oral tablet mg/ml injection 5 mg/ml 2 ST dispersible 0.25 mg, 0.5 DIAZEPAM SOLUTION 5 mg, 1 mg, 2 mg MG/ML INJECTION 5 GM alprazolam xr oral tablet MG/ML extended release 24 hour 2 0.5 mg, 1 mg, 2 mg, 3 mg Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 78 Drug Drug Drug Name Notes Drug Name Notes Tier Tier Brand MIDAZOLAM HCL 4 penalty DORAL ORAL TABLET INTRAVENOUS GM 15 MG applies SOLUTION 150 MG/30ML estazolam oral tablet 1 2 mg, 2 mg MIDAZOLAM HCL- Brand SODIUM CHLORIDE HALCION ORAL 4 penalty INTRAVENOUS TABLET 0.25 MG applies SOLUTION 100-0.8 GM MG/100ML-%, 50-0.8 hydroxyzine hcl MG/50ML-%, 50-0.9 intramuscular solution 25 GM MG/50ML-% mg/ml, 50 mg/ml MIDAZOLAM HCL- hydroxyzine hcl oral 2 SODIUM CHLORIDE syrup 10 mg/5ml INTRAVENOUS hydroxyzine hcl oral SOLUTION PREFILLED GM tablet 10 mg, 25 mg, 50 2 SYRINGE 2-0.9 mg MG/2ML-%, 5-0.9 hydroxyzine pamoate MG/5ML-%, 55-0.9 oral capsule 100 mg, 25 2 MG/55ML-% mg, 50 mg MIDAZOLAM KLONOPIN ORAL INJECTION SOLUTION GM TABLET 0.5 MG, 1 MG, 4 PREFILLED SYRINGE 2 2 MG MG/2ML lorazepam injection MIDAZOLAM INTRAVENOUS solution 2 mg/ml, 4 GM GM mg/ml SOLUTION 100 MG/100ML lorazepam intensol oral 2 concentrate 2 mg/ml MIDAZOLAM INTRAVENOUS lorazepam oral 2 SOLUTION PREFILLED GM concentrate 2 mg/ml SYRINGE 2 MG/2ML, 25 MG/25ML, 30 MG/30ML, lorazepam oral tablet 0.5 2 mg, 1 mg, 2 mg 50 MG/50ML meprobamate oral tablet MIDAZOLAM-SODIUM 2 200 mg, 400 mg CHLORIDE INTRAVENOUS midazolam hcl (pf) GM injection solution 10 SOLUTION 100-0.9 GM mg/2ml, 2 mg/2ml, 5 MG/100ML-%, 50-0.9 mg/5ml, 5 mg/ml MG/50ML-% midazolam hcl injection solution 10 mg/10ml, 10 mg/2ml, 2 mg/2ml, 25 GM mg/5ml, 5 mg/5ml, 5 mg/ml, 50 mg/10ml

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 79 Drug Drug Drug Name Notes Drug Name Notes Tier Tier MIDAZOLAM-SODIUM lithium carbonate oral 2 CHLORIDE tablet 300 mg INTRAVENOUS LITHOBID ORAL SOLUTION PREFILLED TABLET EXTENDED 4 SYRINGE 30-0.9 GM RELEASE 300 MG MG/30ML-%, 50-0.9 Blood Products and MG/50ML-%, 55-0.9 Modifiers - Drugs for MG/55ML-%, 60-0.9 Blood Disorders MG/30ML-% ADVATE oxazepam oral capsule 2 10 mg, 15 mg, 30 mg INTRAVENOUS SOLUTION quazepam oral tablet 15 Specialty 2 RECONSTITUTED 1000 6 mg UNIT, 1500 UNIT, 2000 Medical Brand UNIT, 250 UNIT, 3000 TRANXENE-T ORAL 4 penalty UNIT, 4000 UNIT, 500 TABLET 7.5 MG applies UNIT triazolam oral tablet ADYNOVATE 2 0.125 mg, 0.25 mg INTRAVENOUS Brand SOLUTION RECONSTITUTED 1000 Specialty VALIUM ORAL TABLET 4 penalty 6 Medical 10 MG, 2 MG, 5 MG applies UNIT, 1500 UNIT, 2000 UNIT, 250 UNIT, 3000 VISTARIL ORAL Brand UNIT, 500 UNIT, 750 CAPSULE 25 MG, 50 4 penalty UNIT MG applies AFSTYLA XANAX ORAL TABLET Brand INTRAVENOUS KIT 0.25 MG, 0.5 MG, 1 MG, 4 penalty 1000 UNIT, 1500 UNIT, Specialty 6 2 MG applies 2000 UNIT, 250 UNIT, Medical XANAX XR ORAL 2500 UNIT, 3000 UNIT, Brand TABLET EXTENDED 500 UNIT 4 penalty RELEASE 24 HOUR 0.5 applies Brand MG, 1 MG, 2 MG, 3 MG AGRYLIN ORAL 4 penalty Bipolar Agents - Drugs CAPSULE 0.5 MG applies for Mood Disorders ALPHANATE EQUETRO ORAL INTRAVENOUS SOLUTION CAPSULE EXTENDED 4 Specialty RECONSTITUTED 1000 6 RELEASE 12 HOUR 100 Medical MG, 200 MG, 300 MG UNIT, 1500 UNIT, 2000 lithium carbonate er oral UNIT, 250 UNIT, 500 tablet extended release 2 UNIT 300 mg, 450 mg lithium carbonate oral capsule 150 mg, 300 mg, 1 600 mg

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 80 Drug Drug Drug Name Notes Drug Name Notes Tier Tier ALPHANINE SD ARANESP (ALBUMIN INTRAVENOUS FREE) INJECTION Specialty SOLUTION 6 SOLUTION PREFILLED RECONSTITUTED 1000 Medical SYRINGE 10 UNIT, 1500 UNIT, 500 MCG/0.4ML, 100 UNIT MCG/0.5ML, 150 6 ALPROLIX MCG/0.3ML, 200 INTRAVENOUS MCG/0.4ML, 25 SOLUTION MCG/0.42ML, 300 Specialty 6 MCG/0.6ML, 40 RECONSTITUTED 1000 Medical UNIT, 2000 UNIT, 250 MCG/0.4ML, 500 UNIT, 3000 UNIT, 4000 MCG/ML, 60 MCG/0.3ML UNIT, 500 UNIT ASTRINGYN Brand EXTERNAL SOLUTION 4 AMICAR ORAL 4 penalty 259 MG/GM SOLUTION 0.25 GM/ML applies BENEFIX INTRAVENOUS KIT Brand Specialty 1000 UNIT, 2000 UNIT, 6 AMICAR ORAL TABLET 4 penalty Medical 1000 MG, 500 MG applies 250 UNIT, 3000 UNIT, 500 UNIT aminocaproic acid intravenous solution 250 GM CEPROTIN mg/ml INTRAVENOUS SOLUTION GM aminocaproic acid oral 2 RECONSTITUTED 1000 solution 0.25 gm/ml UNIT, 500 UNIT aminocaproic acid oral 2 COAGADEX tablet 1000 mg, 500 mg INTRAVENOUS Specialty SOLUTION 6 anagrelide hcl oral 2 Medical capsule 0.5 mg, 1 mg RECONSTITUTED 250 ARANESP (ALBUMIN UNIT, 500 UNIT FREE) INJECTION CORIFACT Specialty 6 SOLUTION 100 INTRAVENOUS KIT Medical MCG/ML, 200 MCG/ML, 6 1000-1600 UNIT 25 MCG/ML, 300 CYKLOKAPRON MCG/ML, 40 MCG/ML, INTRAVENOUS GM 60 MCG/ML SOLUTION 1000 MG/10ML DOPTELET ORAL 6 PA TABLET 20 MG

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 81 Drug Drug Drug Name Notes Drug Name Notes Tier Tier ELOCTATE GRANIX INTRAVENOUS SUBCUTANEOUS SOLUTION SOLUTION PREFILLED 5 RECONSTITUTED 1000 Specialty SYRINGE 300 6 UNIT, 1500 UNIT, 2000 Medical MCG/0.5ML, 480 UNIT, 250 UNIT, 3000 MCG/0.8ML UNIT, 4000 UNIT, 500 HEMLIBRA UNIT, 5000 UNIT, 6000 SUBCUTANEOUS UNIT, 750 UNIT SOLUTION 105 GM EMPAVELI MG/0.7ML, 150 MG/ML, SUBCUTANEOUS 6 PA 30 MG/ML, 60 MG/0.4ML SOLUTION 1080 HEMOFIL M MG/20ML INTRAVENOUS Specialty EPOGEN INJECTION SOLUTION 6 SOLUTION 10000 RECONSTITUTED 1000 Medical UNIT/ML, 2000 UNIT/ML, 6 UNIT, 1700 UNIT, 250 20000 UNIT/ML, 3000 UNIT, 500 UNIT UNIT/ML, 4000 UNIT/ML HESPAN ESPEROCT INTRAVENOUS GM INTRAVENOUS SOLUTION 6-0.9 % SOLUTION Specialty hetastarch-nacl 6 RECONSTITUTED 1000 Medical intravenous solution 6- GM UNIT, 1500 UNIT, 2000 0.9 % UNIT, 3000 UNIT, 500 UNIT HEXTEND INTRAVENOUS GM FEIBA INTRAVENOUS SOLUTION 6 % SOLUTION Specialty RECONSTITUTED 1000 6 HUMATE-P Medical UNIT, 2500 UNIT, 500 INTRAVENOUS SOLUTION Specialty UNIT 6 RECONSTITUTED 1000- Medical FIBRYGA 2400 UNIT, 250-600 INTRAVENOUS GM UNIT, 500-1200 UNIT SOLUTION RECONSTITUTED IDELVION INTRAVENOUS FULPHILA SOLUTION Specialty SUBCUTANEOUS RECONSTITUTED 1000 6 5 Medical SOLUTION PREFILLED UNIT, 2000 UNIT, 250 SYRINGE 6 MG/0.6ML UNIT, 3500 UNIT, 500 GRANIX UNIT SUBCUTANEOUS IXINITY INTRAVENOUS SOLUTION 300 5 SOLUTION MCG/ML, 480 Specialty RECONSTITUTED 1000 6 MCG/1.6ML UNIT, 1500 UNIT, 2000 Medical UNIT, 250 UNIT, 3000 UNIT, 500 UNIT Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 82 Drug Drug Drug Name Notes Drug Name Notes Tier Tier JIVI INTRAVENOUS MIRCERA INJECTION SOLUTION Specialty SOLUTION PREFILLED 6 RECONSTITUTED 1000 Medical SYRINGE 100 UNIT, 2000 UNIT, 3000 MCG/0.3ML, 150 UNIT, 500 UNIT MCG/0.3ML, 200 4 KCENTRA MCG/0.3ML, 30 INTRAVENOUS KIT GM MCG/0.3ML, 50 1000 UNIT, 500 UNIT MCG/0.3ML, 75 MCG/0.3ML KOATE INTRAVENOUS SOLUTION MONONINE Specialty RECONSTITUTED 1000 6 INTRAVENOUS Specialty Medical 6 UNIT, 250 UNIT, 500 SOLUTION Medical UNIT RECONSTITUTED 1000 UNIT KOATE-DVI MONSELS FERRIC INTRAVENOUS Specialty SOLUTION 6 SUBSULFATE 4 Medical RECONSTITUTED 1000 EXTERNAL SOLUTION UNIT, 500 UNIT MOZOBIL PA; SUBCUTANEOUS KOGENATE FS 6 Specialty INTRAVENOUS KIT SOLUTION 24 Specialty Medical 6 MG/1.2ML 1000 UNIT, 2000 UNIT, Medical 250 UNIT, 3000 UNIT, MULPLETA ORAL 6 PA 500 UNIT TABLET 3 MG KOVALTRY NEULASTA ONPRO INTRAVENOUS SUBCUTANEOUS 6 SOLUTION PREFILLED SYRINGE Specialty RECONSTITUTED 1000 6 KIT 6 MG/0.6ML Medical UNIT, 2000 UNIT, 250 NEULASTA UNIT, 3000 UNIT, 500 SUBCUTANEOUS 6 UNIT SOLUTION PREFILLED LEUKINE INJECTION SYRINGE 6 MG/0.6ML Specialty SOLUTION 6 NEUPOGEN INJECTION RECONSTITUTED 250 Medical SOLUTION 300 6 MCG MCG/ML, 480 LMD IN D5W MCG/1.6ML INTRAVENOUS GM NEUPOGEN INJECTION SOLUTION 10-5 % SOLUTION PREFILLED LMD IN NACL SYRINGE 300 6 INTRAVENOUS GM MCG/0.5ML, 480 SOLUTION 10-0.9 % MCG/0.8ML Brand NIVESTYM INJECTION 4 penalty LYSTEDA ORAL SOLUTION 300 5 TABLET 650 MG applies MCG/ML, 480 MCG/1.6ML

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 83 Drug Drug Drug Name Notes Drug Name Notes Tier Tier NIVESTYM INJECTION PANHEMATIN SOLUTION PREFILLED INTRAVENOUS SYRINGE 300 5 SOLUTION GM MCG/0.5ML, 480 RECONSTITUTED 350 MCG/0.8ML MG NOVOEIGHT PROCRIT INJECTION INTRAVENOUS SOLUTION 10000 SOLUTION UNIT/ML, 2000 UNIT/ML, Specialty 6 RECONSTITUTED 1000 6 20000 UNIT/ML, 3000 Medical UNIT, 1500 UNIT, 2000 UNIT/ML, 4000 UNIT/ML, UNIT, 250 UNIT, 3000 40000 UNIT/ML UNIT, 500 UNIT PROFILNINE NOVOSEVEN RT INTRAVENOUS Specialty INTRAVENOUS Specialty SOLUTION 6 6 Medical SOLUTION Medical RECONSTITUTED 1000 RECONSTITUTED 1 UNIT, 1500 UNIT, 500 MG, 2 MG, 5 MG, 8 MG UNIT NPLATE PROMACTA ORAL 6 PA SUBCUTANEOUS PACKET 25 MG PA; SOLUTION 6 Specialty PROMACTA ORAL RECONSTITUTED 125 Medical TABLET 12.5 MG, 25 6 PA MCG, 250 MCG, 500 MG, 50 MG, 75 MG MCG protamine sulfate NUWIQ INTRAVENOUS intravenous solution 10 GM KIT 1000 UNIT, 2000 Specialty mg/ml UNIT, 250 UNIT, 2500 6 Medical UNIT, 3000 UNIT, 4000 REBINYN UNIT, 500 UNIT INTRAVENOUS SOLUTION GM NUWIQ INTRAVENOUS RECONSTITUTED 1000 SOLUTION UNIT, 2000 UNIT, 500 RECONSTITUTED 1000 Specialty UNIT 6 UNIT, 2000 UNIT, 250 Medical UNIT, 2500 UNIT, 3000 REBLOZYL UNIT, 4000 UNIT, 500 SUBCUTANEOUS PA; UNIT SOLUTION 6 Specialty RECONSTITUTED 25 Medical NYVEPRIA MG, 75 MG SUBCUTANEOUS 5 PA SOLUTION PREFILLED RECOMBINATE SYRINGE 6 MG/0.6ML INTRAVENOUS SOLUTION OBIZUR INTRAVENOUS RECONSTITUTED 1241- Specialty Specialty 6 SOLUTION 6 1800 UNIT, 1801-2400 Medical RECONSTITUTED 500 Medical UNIT, 220-400 UNIT, UNIT 401-800 UNIT, 801-1240 UNIT

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 84 Drug Drug Drug Name Notes Drug Name Notes Tier Tier RECOTHROM THROMBIN-JMI EXTERNAL SOLUTION 4 EXTERNAL SOLUTION 4 RECONSTITUTED RECONSTITUTED 20000 UNIT, 5000 UNIT 20000 UNIT, 5000 UNIT RECOTHROM SPRAY THROMBOGEN KIT EXTERNAL EXTERNAL KIT 10000 4 SOLUTION 4 UNIT RECONSTITUTED THROMBOGEN 20000 UNIT EXTERNAL SOLUTION 4 RETACRIT INJECTION RECONSTITUTED 1000 SOLUTION 10000 UNIT, 10000 UNIT UNIT/ML, 2000 UNIT/ML, 5 tranexamic acid 20000 UNIT/ML, 3000 intravenous solution GM UNIT/ML, 4000 UNIT/ML, 1000 mg/10ml 40000 UNIT/ML tranexamic acid oral 2 RIASTAP tablet 650 mg INTRAVENOUS GM SOLUTION TRANEXAMIC ACID- NACL INTRAVENOUS RECONSTITUTED GM SOLUTION 1000-0.7 RIXUBIS MG/100ML-% INTRAVENOUS TRETTEN SOLUTION Specialty RECONSTITUTED 1000 6 INTRAVENOUS Specialty Medical 6 UNIT, 2000 UNIT, 250 SOLUTION Medical UNIT, 3000 UNIT, 500 RECONSTITUTED 2000- UNIT 3125 UNIT SEVENFACT UDENYCA INTRAVENOUS SUBCUTANEOUS Specialty 5 SOLUTION 6 SOLUTION PREFILLED Medical RECONSTITUTED 1 SYRINGE 6 MG/0.6ML MG, 5 MG ULTOMIRIS INTRAVENOUS PA; SOLIRIS PA; INTRAVENOUS SOLUTION 1100 6 Specialty 6 Specialty MG/11ML, 300 Medical SOLUTION 300 Medical MG/30ML MG/30ML, 300 MG/3ML TAVALISSE ORAL VONVENDI TABLET 100 MG, 150 6 PA INTRAVENOUS Specialty SOLUTION 6 MG Medical RECONSTITUTED 1300 THROMBIN-JMI UNIT, 650 UNIT EPISTAXIS EXTERNAL 4 WILATE INTRAVENOUS KIT 5000 UNIT Specialty 6 KIT 1000-1000 UNIT, Medical THROMBIN-JMI 500-500 UNIT EXTERNAL KIT 20000 4 UNIT, 5000 UNIT

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 85 Drug Drug Drug Name Notes Drug Name Notes Tier Tier XYNTHA ALDACTONE ORAL Brand Specialty 4 penalty INTRAVENOUS KIT 6 TABLET 100 MG, 25 1000 UNIT, 2000 UNIT, Medical MG, 50 MG applies 250 UNIT, 500 UNIT aliskiren fumarate oral 2 XYNTHA SOLOFUSE tablet 150 mg, 300 mg INTRAVENOUS KIT Specialty alprostadil injection 1000 UNIT, 2000 UNIT, 6 GM Medical solution 500 mcg/ml 250 UNIT, 3000 UNIT, 500 UNIT ALTACE ORAL Brand CAPSULE 1.25 MG, 10 4 penalty ZARXIO INJECTION MG, 2.5 MG, 5 MG applies SOLUTION PREFILLED SYRINGE 300 5 ALTOPREV ORAL TABLET EXTENDED MCG/0.5ML, 480 4 PA MCG/0.8ML RELEASE 24 HOUR 20 MG, 40 MG, 60 MG ZIEXTENZO SUBCUTANEOUS amiloride hcl oral tablet 5 5 2 SOLUTION PREFILLED mg SYRINGE 6 MG/0.6ML amiloride- Cardiovascular Agents hydrochlorothiazide oral 2 - Drugs for Heart and tablet 5-50 mg Circulation Conditions AMIODARONE HCL IN ACCUPRIL ORAL Brand DEXTROSE TABLET 10 MG, 20 MG, 4 penalty INTRAVENOUS GM 40 MG, 5 MG applies SOLUTION 450-5 MG/250ML-% ACCURETIC ORAL Brand TABLET 10-12.5 MG, 20- 4 penalty amiodarone hcl 12.5 MG, 20-25 MG applies intravenous solution 150 GM mg/3ml, 450 mg/9ml, 900 acebutolol hcl oral 2 mg/18ml capsule 200 mg, 400 mg amiodarone hcl oral acetazolamide sodium tablet 100 mg, 200 mg, 2 GM injection solution 400 mg reconstituted 500 mg amlodipine besylate oral adenosine intravenous tablet 10 mg, 2.5 mg, 5 1 GM solution 12 mg/4ml, 6 mg mg/2ml amlodipine besylate- AKOVAZ benazepril hcl oral GM INTRAVENOUS capsule 10-20 mg, 10-40 2 SOLUTION 50 MG/ML mg, 2.5-10 mg, 5-10 mg, Brand 5-20 mg, 5-40 mg 4 penalty ALDACTAZIDE ORAL amlodipine besylate- applies TABLET 25-25 MG valsartan oral tablet 10- 2 ALDACTAZIDE ORAL 3 160 mg, 10-320 mg, 5- TABLET 50-50 MG 160 mg, 5-320 mg

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 86 Drug Drug Drug Name Notes Drug Name Notes Tier Tier amlodipine-atorvastatin AZOR ORAL TABLET Brand oral tablet 10-10 mg, 10- 10-20 MG, 10-40 MG, 5- 3 penalty 20 mg, 10-40 mg, 10-80 20 MG, 5-40 MG applies mg, 2.5-10 mg, 2.5-20 2 benazepril hcl oral tablet mg, 2.5-40 mg, 5-10 mg, 10 mg, 20 mg, 40 mg, 5 1 5-20 mg, 5-40 mg, 5-80 mg mg benazepril- amlodipine-olmesartan hydrochlorothiazide oral oral tablet 10-20 mg, 10- 2 tablet 10-12.5 mg, 20- 2 40 mg, 5-20 mg, 5-40 mg 12.5 mg, 20-25 mg, 5- amlodipine-valsartan- 6.25 mg hctz oral tablet 10-160- BENICAR HCT ORAL Brand 12.5 mg, 10-160-25 mg, 2 TABLET 20-12.5 MG, 40- 4 penalty 10-320-25 mg, 5-160- 12.5 MG, 40-25 MG applies 12.5 mg, 5-160-25 mg BENICAR ORAL Brand ANTARA ORAL TABLET 20 MG, 40 MG, 4 penalty CAPSULE 30 MG, 90 4 5 MG applies MG BETAPACE AF ORAL Brand ASCLERA TABLET 120 MG, 160 4 penalty INTRAVENOUS GM MG, 80 MG applies SOLUTION 0.5 %, 1 % BETAPACE ORAL Brand ATACAND HCT ORAL Brand TABLET 120 MG, 160 4 penalty TABLET 16-12.5 MG, 32- 4 penalty MG, 80 MG applies 12.5 MG, 32-25 MG applies betaxolol hcl oral tablet 2 ATACAND ORAL Brand 10 mg, 20 mg TABLET 16 MG, 32 MG, 4 penalty 4 MG, 8 MG applies BIDIL ORAL TABLET 20- 4 37.5 MG atenolol oral tablet 100 2 mg, 25 mg, 50 mg BIORPHEN INTRAVENOUS GM atenolol-chlorthalidone SOLUTION 0.5 MG/5ML oral tablet 100-25 mg, 2 bisoprolol fumarate oral 50-25 mg 2 tablet 10 mg, 5 mg atorvastatin calcium oral 2 PV* tablet 10 mg, 20 mg bisoprolol- hydrochlorothiazide oral 1 atorvastatin calcium oral 2 tablet 10-6.25 mg, 2.5- tablet 40 mg, 80 mg 6.25 mg, 5-6.25 mg AVALIDE ORAL TABLET Brand BREVIBLOC IN NACL 150-12.5 MG, 300-12.5 4 penalty INTRAVENOUS MG applies SOLUTION 2000 GM Brand MG/100ML, 2500 AVAPRO ORAL TABLET 4 penalty MG/250ML 150 MG, 300 MG, 75 MG applies

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 87 Drug Drug Drug Name Notes Drug Name Notes Tier Tier BREVIBLOC CARDENE IV INTRAVENOUS GM INTRAVENOUS SOLUTION 100 SOLUTION 20-0.86 GM MG/10ML MG/200ML-%, 20-4.8 BREVIBLOC PREMIXED MG/200ML-%, 40-0.83 MG/200ML-% DS INTRAVENOUS GM SOLUTION 2000 CARDIZEM CD ORAL MG/100ML CAPSULE EXTENDED Brand BREVIBLOC PREMIXED RELEASE 24 HOUR 120 4 penalty INTRAVENOUS MG, 180 MG, 240 MG, applies GM SOLUTION 2500 300 MG, 360 MG MG/250ML CARDIZEM LA ORAL TABLET EXTENDED bumetanide injection GM 4 solution 0.25 mg/ml RELEASE 24 HOUR 120 MG bumetanide oral tablet 2 0.5 mg, 1 mg, 2 mg CARDIZEM LA ORAL TABLET EXTENDED Brand Brand RELEASE 24 HOUR 180 4 penalty BUMEX ORAL TABLET 4 penalty MG, 240 MG, 300 MG, applies 0.5 MG applies 360 MG, 420 MG BYSTOLIC ORAL CARDIZEM ORAL Brand TABLET 10 MG, 2.5 MG, 3 TABLET 120 MG, 30 4 penalty 20 MG, 5 MG MG, 60 MG applies CADUET ORAL TABLET CARDURA ORAL Brand 10-10 MG, 10-20 MG, Brand TABLET 1 MG, 2 MG, 4 4 penalty 10-40 MG, 10-80 MG, 5- 4 penalty MG, 8 MG applies 10 MG, 5-20 MG, 5-40 applies MG, 5-80 MG cartia xt oral capsule extended release 24 hour CALAN SR ORAL 2 Brand 120 mg, 180 mg, 240 TABLET EXTENDED 4 penalty mg, 300 mg RELEASE 120 MG, 180 applies MG, 240 MG carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 1 candesartan cilexetil oral 6.25 mg tablet 16 mg, 32 mg, 4 2 mg, 8 mg carvedilol phosphate er oral capsule extended 2 candesartan cilexetil-hctz release 24 hour 10 mg, oral tablet 16-12.5 mg, 2 20 mg, 40 mg, 80 mg 32-12.5 mg, 32-25 mg CATAPRES-TTS-1 Brand captopril oral tablet 100 TRANSDERMAL PATCH 4 penalty mg, 12.5 mg, 25 mg, 50 2 WEEKLY 0.1 MG/24HR applies mg CATAPRES-TTS-2 Brand TRANSDERMAL PATCH 4 penalty WEEKLY 0.2 MG/24HR applies

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 88 Drug Drug Drug Name Notes Drug Name Notes Tier Tier CATAPRES-TTS-3 Brand Brand TRANSDERMAL PATCH 4 penalty COLESTID ORAL 4 penalty WEEKLY 0.3 MG/24HR applies TABLET 1 GM applies chlorothiazide sodium colestipol hcl oral 2 intravenous solution GM granules 5 gm reconstituted 500 mg colestipol hcl oral packet 2 chlorthalidone oral tablet 2 5 gm 25 mg, 50 mg colestipol hcl oral tablet 1 2 cholestyramine light oral gm 2 packet 4 gm COREG CR ORAL cholestyramine light oral CAPSULE EXTENDED Brand 2 powder 4 gm/dose RELEASE 24 HOUR 10 4 penalty cholestyramine oral MG, 20 MG, 40 MG, 80 applies 2 packet 4 gm MG COREG ORAL TABLET Brand cholestyramine oral 2 powder 4 gm/dose 12.5 MG, 25 MG, 3.125 4 penalty MG, 6.25 MG applies CLEVIPREX INTRAVENOUS CORGARD ORAL Brand GM 4 penalty EMULSION 25 TABLET 20 MG, 40 MG, MG/50ML, 50 MG/100ML 80 MG applies clonidine hcl oral tablet CORLANOR ORAL 2 4 PA 0.1 mg, 0.2 mg, 0.3 mg SOLUTION 5 MG/5ML CORLANOR ORAL clonidine transdermal 4 PA patch weekly 0.1 TABLET 5 MG, 7.5 MG 2 mg/24hr, 0.2 mg/24hr, CORLOPAM 0.3 mg/24hr INTRAVENOUS GM SOLUTION 10 MG/ML, colesevelam hcl oral 2 packet 3.75 gm 20 MG/2ML colesevelam hcl oral CORVERT 2 GM tablet 625 mg INTRAVENOUS SOLUTION 1 MG/10ML Brand COLESTID FLAVORED 4 penalty Brand ORAL GRANULES 5 GM applies COZAAR ORAL TABLET 4 penalty 100 MG, 25 MG, 50 MG applies Brand COLESTID FLAVORED 4 penalty CRESTOR ORAL Brand ORAL PACKET 5 GM applies TABLET 10 MG, 20 MG, 4 penalty 40 MG, 5 MG applies Brand COLESTID ORAL 4 penalty DEMSER ORAL 4 GRANULES 5 GM applies CAPSULE 250 MG Brand COLESTID ORAL 4 penalty PACKET 5 GM applies

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 89 Drug Drug Drug Name Notes Drug Name Notes Tier Tier PA; Brand diltiazem hcl intravenous penalty solution 125 mg/25ml, 25 GM 4 applies; QL mg/5ml, 50 mg/10ml DIBENZYLINE ORAL (14 EA per diltiazem hcl intravenous CAPSULE 10 MG 30 days) solution reconstituted GM digitek oral tablet 125 2 100 mg mcg, 250 mcg diltiazem hcl oral tablet digox oral tablet 125 120 mg, 30 mg, 60 mg, 2 2 mcg, 250 mcg 90 mg digoxin injection solution DILTIAZEM HCL- GM 0.25 mg/ml SODIUM CHLORIDE digoxin oral solution 0.05 INTRAVENOUS 2 GM mg/ml SOLUTION 125-0.7 MG/125ML-%, 125-0.9 digoxin oral tablet 125 2 MG/125ML-% mcg, 250 mcg dilt-xr oral capsule DILATRATE-SR ORAL extended release 24 hour 2 CAPSULE EXTENDED 3 120 mg, 180 mg, 240 mg RELEASE 40 MG DIOVAN HCT ORAL diltiazem hcl er beads TABLET 160-12.5 MG, Brand oral capsule extended 160-25 MG, 320-12.5 4 penalty release 24 hour 120 mg, 2 MG, 320-25 MG, 80-12.5 applies 180 mg, 240 mg, 300 MG mg, 360 mg, 420 mg DIOVAN ORAL TABLET Brand diltiazem hcl er coated 160 MG, 320 MG, 40 4 penalty beads oral capsule MG, 80 MG applies extended release 24 hour 2 120 mg, 180 mg, 240 disopyramide phosphate mg, 300 mg, 360 mg oral capsule 100 mg, 150 2 mg diltiazem hcl er coated beads oral tablet DIURIL ORAL extended release 24 hour 2 SUSPENSION 250 4 180 mg, 240 mg, 300 MG/5ML mg, 360 mg, 420 mg dobutamine hcl diltiazem hcl er oral intravenous solution 250 GM mg/20ml capsule extended 2 release 12 hour 120 mg, dobutamine in d5w 60 mg, 90 mg intravenous solution 1-5 GM diltiazem hcl er oral mg/ml-%, 2 mg/ml, 4-5 capsule extended mg/ml-% 2 release 24 hour 120 mg, dofetilide oral capsule 180 mg, 240 mg 125 mcg, 250 mcg, 500 2 mcg

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 90 Drug Drug Drug Name Notes Drug Name Notes Tier Tier dopamine hcl EPANED ORAL 4 intravenous solution 40 GM SOLUTION 1 MG/ML mg/ml EPHEDRINE SULFATE dopamine in d5w (PRESSORS) intravenous solution 0.8- GM INJECTION SOLUTION GM 5 mg/ml-%, 1.6-5 mg/ml- PREFILLED SYRINGE %, 3.2-5 mg/ml-% 25 MG/5ML, 50 doxazosin mesylate oral MG/10ML, 50 MG/5ML tablet 1 mg, 2 mg, 4 mg, 2 ephedrine sulfate 8 mg injection solution 50 GM droxidopa oral capsule mg/ml 6 PA 100 mg, 200 mg, 300 mg ephedrine sulfate DUTOPROL ORAL intravenous solution 50 GM TABLET EXTENDED mg/ml RELEASE 24 HOUR 4 EPHEDRINE SULFATE 100-12.5 MG, 25-12.5 INTRAVENOUS GM MG, 50-12.5 MG SOLUTION PREFILLED DYRENIUM ORAL Brand SYRINGE 25 MG/5ML CAPSULE 100 MG, 50 4 penalty EPINEPHRINE HCL- MG applies DEXTROSE EDARBI ORAL TABLET INTRAVENOUS GM 4 ST 40 MG, 80 MG SOLUTION 4-5 MG/250ML-% EDARBYCLOR ORAL TABLET 40-12.5 MG, 40- 4 ST EPINEPHRINE HCL- 25 MG NACL INTRAVENOUS GM SOLUTION 8-0.9 Brand MG/250ML-% EDECRIN ORAL 4 penalty TABLET 25 MG applies EPINEPHRINE INTRAVENOUS GM EMERPHED SOLUTION 1 MG/10ML INTRAVENOUS GM SOLUTION 5 MG/ML EPINEPHRINE INTRAVENOUS GM enalapril maleate oral SOLUTION PREFILLED tablet 10 mg, 2.5 mg, 20 2 SYRINGE 0.1 MG/10ML mg, 5 mg epinephrine intravenous enalaprilat intravenous GM solution prefilled syringe GM injectable 1.25 mg/ml 1 mg/10ml enalapril- epinephrine pf injection GM hydrochlorothiazide oral 2 solution 1 mg/ml tablet 10-25 mg, 5-12.5 mg epinephrine solution prefilled syringe 1 GM ENTRESTO ORAL mg/10ml injection 1 TABLET 24-26 MG, 49- 3 mg/10ml 51 MG, 97-103 MG

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 91 Drug Drug Drug Name Notes Drug Name Notes Tier Tier EPINEPHRINE EVKEEZA PA; SOLUTION PREFILLED GM INTRAVENOUS 6 Specialty SYRINGE 1 MG/10ML SOLUTION 1200 Medical INJECTION 1 MG/10ML MG/8ML, 345 MG/2.3ML EPINEPHRINE- EXFORGE HCT ORAL DEXTROSE TABLET 10-160-12.5 Brand INTRAVENOUS GM MG, 10-160-25 MG, 10- 4 penalty SOLUTION 2-5 320-25 MG, 5-160-12.5 applies MG/250ML-% MG, 5-160-25 MG EPINEPHRINE- EXFORGE ORAL Brand DEXTROSE TABLET 10-160 MG, 10- 4 penalty INTRAVENOUS GM 320 MG, 5-160 MG, 5- applies SOLUTION PREFILLED 320 MG SYRINGE 100-5 EZALLOR SPRINKLE MCG/10ML-% ORAL CAPSULE 4 PA EPINEPHRINE-NACL SPRINKLE 10 MG, 20 INTRAVENOUS MG, 40 MG, 5 MG GM SOLUTION 2-0.9 ezetimibe oral tablet 10 2 MG/250ML-% mg EPINEPHRINE-NACL ezetimibe-simvastatin INTRAVENOUS oral tablet 10-10 mg, 10- 2 SOLUTION PREFILLED GM 20 mg, 10-40 mg, 10-80 SYRINGE 1-0.9 mg MG/10ML-% felodipine er oral tablet eplerenone oral tablet 25 2 extended release 24 hour 2 mg, 50 mg 10 mg, 2.5 mg, 5 mg esmolol hcl intravenous GM fenofibrate micronized solution 100 mg/10ml oral capsule 130 mg, 134 2 ESMOLOL HCL mg, 200 mg, 43 mg, 67 INTRAVENOUS mg SOLUTION 2000 GM fenofibrate oral capsule MG/100ML, 2500 134 mg, 150 mg, 200 2 MG/250ML mg, 50 mg, 67 mg esmolol hcl-sodium fenofibrate oral tablet 145 chloride intravenous GM mg, 160 mg, 48 mg, 54 2 solution 2000 mg/100ml, mg 2500 mg/250ml fenofibric acid oral ethacrynate sodium capsule delayed release 2 intravenous solution GM 135 mg, 45 mg reconstituted 50 mg fenofibric acid oral tablet ethacrynic acid oral tablet 2 2 105 mg, 35 mg 25 mg FIBRICOR ORAL 4 TABLET 105 MG, 35 MG

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 92 Drug Drug Drug Name Notes Drug Name Notes Tier Tier flecainide acetate oral ibutilide fumarate tablet 100 mg, 150 mg, 2 intravenous solution 1 GM 50 mg mg/10ml fluvastatin sodium er oral icosapent ethyl oral 2 PA tablet extended release 2 PA capsule 1 gm 24 hour 80 mg indapamide oral tablet 2 fluvastatin sodium oral 2 1.25 mg, 2.5 mg capsule 20 mg, 40 mg INDERAL LA ORAL fosinopril sodium oral CAPSULE EXTENDED Brand tablet 10 mg, 20 mg, 40 2 RELEASE 24 HOUR 120 4 penalty mg MG, 160 MG, 60 MG, 80 applies fosinopril sodium-hctz MG oral tablet 10-12.5 mg, 2 INDERAL XL ORAL 20-12.5 mg CAPSULE EXTENDED 4 FUROSEMIDE IN RELEASE 24 HOUR 120 SODIUM CHLORIDE MG, 80 MG INTRAVENOUS GM INNOPRAN XL ORAL SOLUTION 100-0.9 CAPSULE EXTENDED 4 MG/100ML-% RELEASE 24 HOUR 120 furosemide injection MG, 80 MG GM solution 10 mg/ml Brand furosemide oral solution INSPRA ORAL TABLET 4 penalty 2 10 mg/ml, 8 mg/ml 25 MG, 50 MG applies irbesartan oral tablet 150 furosemide oral tablet 20 1 2 mg, 40 mg, 80 mg mg, 300 mg, 75 mg irbesartan- gemfibrozil oral tablet 2 600 mg hydrochlorothiazide oral 2 tablet 150-12.5 mg, 300- guanfacine hcl oral tablet 1 12.5 mg 1 mg, 2 mg ISORDIL TITRADOSE Brand hydralazine hcl injection GM ORAL TABLET 40 MG, 5 4 penalty solution 20 mg/ml MG applies hydralazine hcl oral tablet isosorbide dinitrate oral 10 mg, 100 mg, 25 mg, 2 tablet 10 mg, 20 mg, 30 2 50 mg mg, 40 mg, 5 mg hydrochlorothiazide oral 1 isosorbide mononitrate er capsule 12.5 mg oral tablet extended 2 hydrochlorothiazide oral release 24 hour 120 mg, tablet 12.5 mg, 25 mg, 50 1 30 mg, 60 mg mg isosorbide mononitrate 2 HYZAAR ORAL TABLET Brand oral tablet 10 mg, 20 mg 100-12.5 MG, 100-25 4 penalty isradipine oral capsule 2 MG, 50-12.5 MG applies 2.5 mg, 5 mg

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 93 Drug Drug Drug Name Notes Drug Name Notes Tier Tier JUXTAPID ORAL LEVOPHED CAPSULE 10 MG, 20 6 PA INTRAVENOUS GM MG, 30 MG, 5 MG SOLUTION 1 MG/ML LABETALOL HCL LIPITOR ORAL TABLET Brand 4 penalty INTRAVENOUS GM 10 MG, 20 MG, 40 MG, SOLUTION PREFILLED 80 MG applies SYRINGE 20 MG/4ML LIPOFEN ORAL labetalol hcl oral tablet CAPSULE 150 MG, 50 4 2 100 mg, 200 mg, 300 mg MG LABETALOL HCL lisinopril oral tablet 10 SOLUTION 5 MG/ML mg, 2.5 mg, 20 mg, 30 1 GM INTRAVENOUS 5 mg, 40 mg, 5 mg MG/ML lisinopril- labetalol hcl solution 5 hydrochlorothiazide oral 1 mg/ml intravenous 5 GM tablet 10-12.5 mg, 20- mg/ml 12.5 mg, 20-25 mg

LABETALOL HCL- LIVALO ORAL TABLET 4 PA DEXTROSE 1 MG, 2 MG, 4 MG INTRAVENOUS GM Brand SOLUTION 200-5 LOPID ORAL TABLET 4 penalty MG/200ML-% 600 MG applies LABETALOL HCL- Brand SODIUM CHLORIDE LOPRESSOR ORAL 4 penalty INTRAVENOUS TABLET 100 MG, 50 MG applies SOLUTION 100-0.72 GM MG/100ML-%, 200-0.72 losartan potassium oral MG/200ML-%, 300-0.72 tablet 100 mg, 25 mg, 50 1 MG/300ML-% mg LANOXIN INJECTION losartan potassium-hctz GM SOLUTION 0.25 MG/ML oral tablet 100-12.5 mg, 1 100-25 mg, 50-12.5 mg LANOXIN ORAL TABLET 125 MCG, 250 4 LOTENSIN HCT ORAL Brand MCG, 62.5 MCG TABLET 10-12.5 MG, 20- 4 penalty 12.5 MG, 20-25 MG applies LANOXIN PEDIATRIC INJECTION SOLUTION GM LOTENSIN ORAL Brand 0.1 MG/ML TABLET 10 MG, 20 MG, 4 penalty 40 MG applies Brand LASIX ORAL TABLET 20 4 penalty LOTREL ORAL Brand MG, 40 MG, 80 MG applies CAPSULE 10-20 MG, 4 penalty 10-40 MG, 5-10 MG, 5- LESCOL XL ORAL applies PA; Brand 20 MG TABLET EXTENDED 4 penalty lovastatin oral tablet 10 RELEASE 24 HOUR 80 applies 2 PV* MG mg, 20 mg, 40 mg

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 94 Drug Drug Drug Name Notes Drug Name Notes Tier Tier PA; Brand MICARDIS ORAL Brand LOVAZA ORAL 4 penalty TABLET 20 MG, 40 MG, 4 penalty CAPSULE 1 GM applies 80 MG applies mannitol intravenous GM midodrine hcl oral tablet 2 solution 20 %, 25 % 10 mg, 2.5 mg, 5 mg matzim la oral tablet milrinone lactate in extended release 24 hour 2 dextrose intravenous GM 180 mg, 240 mg, 300 solution 20-5 mg/100ml- mg, 360 mg, 420 mg %, 40-5 mg/200ml-% Brand milrinone lactate MAXZIDE ORAL 4 penalty intravenous solution 10 GM TABLET 75-50 MG applies mg/10ml, 20 mg/20ml, 50 Brand mg/50ml MAXZIDE-25 ORAL 4 penalty MINIPRESS ORAL Brand TABLET 37.5-25 MG applies CAPSULE 1 MG, 2 MG, 4 penalty 5 MG applies methyldopa oral tablet 2 250 mg, 500 mg minitran transdermal patch 24 hour 0.1 mg/hr, metolazone oral tablet 10 2 2 mg, 2.5 mg, 5 mg 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr metoprolol succinate er oral tablet extended minoxidil oral tablet 10 2 2 release 24 hour 100 mg, mg, 2.5 mg 200 mg, 25 mg, 50 mg moexipril hcl oral tablet 2 metoprolol tartrate 15 mg, 7.5 mg GM intravenous solution 5 MULTAQ ORAL TABLET 3 mg/5ml 400 MG metoprolol tartrate oral nadolol oral tablet 20 mg, 2 tablet 100 mg, 25 mg, 50 1 40 mg, 80 mg mg NEXLETOL ORAL 3 PA metoprolol tartrate oral TABLET 180 MG 2 tablet 37.5 mg, 75 mg NEXLIZET ORAL 3 PA metoprolol- TABLET 180-10 MG hydrochlorothiazide oral 2 NEXTERONE tablet 100-25 mg, 100-50 INTRAVENOUS mg, 50-25 mg SOLUTION 150-4.21 GM metyrosine oral capsule 2 MG/100ML-%, 360-4.14 250 mg MG/200ML-% mexiletine hcl oral niacin capsule 150 mg, 200 mg, 2 (antihyperlipidemic) oral 2 250 mg tablet 500 mg MICARDIS HCT ORAL Brand TABLET 40-12.5 MG, 80- 4 penalty 12.5 MG, 80-25 MG applies Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 95 Drug Drug Drug Name Notes Drug Name Notes Tier Tier niacin er NITRO-BID (antihyperlipidemic) oral TRANSDERMAL 3 tablet extended release 2 OINTMENT 2 % 1000 mg, 500 mg, 750 NITRO-DUR mg TRANSDERMAL PATCH 2 niacor oral tablet 500 mg 24 HOUR 0.1 MG/HR, 4 0.2 MG/HR, 0.3 MG/HR, NIASPAN ORAL Brand TABLET EXTENDED 0.4 MG/HR, 0.6 MG/HR, 4 penalty RELEASE 1000 MG, 500 0.8 MG/HR applies MG, 750 MG nitroglycerin in d5w NICARDIPINE HCL IN intravenous solution 100- NACL INTRAVENOUS 5 mcg/ml-%, 200-5 GM SOLUTION 20-0.9 GM mcg/ml-%, 400-5 MG/200ML-%, 40-0.9 mcg/ml-% MG/200ML-% nitroglycerin intravenous GM nicardipine hcl solution 5 mg/ml intravenous solution 2.5 GM nitroglycerin sublingual mg/ml tablet sublingual 0.3 mg, 2 nicardipine hcl oral 0.4 mg, 0.6 mg 2 capsule 20 mg, 30 mg nitroglycerin transdermal patch 24 hour 0.1 mg/hr, nifedipine er oral tablet 2 extended release 24 hour 2 0.2 mg/hr, 0.4 mg/hr, 0.6 30 mg, 60 mg, 90 mg mg/hr nifedipine er osmotic nitroglycerin translingual 2 solution 0.4 mg/spray release oral tablet 2 extended release 24 hour NITROLINGUAL Brand 30 mg, 60 mg, 90 mg TRANSLINGUAL 4 penalty nifedipine oral capsule 10 SOLUTION 0.4 2 applies mg, 20 mg MG/SPRAY nimodipine oral capsule NITROMIST 2 TRANSLINGUAL 30 mg 3 AEROSOL SOLUTION NIPRIDE RTU 400 MCG/SPRAY INTRAVENOUS SOLUTION 20-0.9 GM nitroprusside sodium MG/100ML-%, 50-0.9 intravenous solution 25 GM MG/100ML-% mg/ml nisoldipine er oral tablet NITROSTAT Brand SUBLINGUAL TABLET extended release 24 hour 4 penalty SUBLINGUAL 0.3 MG, 17 mg, 20 mg, 25.5 mg, 2 applies 30 mg, 34 mg, 40 mg, 0.4 MG, 0.6 MG 8.5 mg NITRO-TIME ORAL CAPSULE EXTENDED 4 RELEASE 2.5 MG, 6.5 MG, 9 MG Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 96 Drug Drug Drug Name Notes Drug Name Notes Tier Tier NOREPINEPHRINE olmesartan-amlodipine- (BASE)-DEXTROSE hctz oral tablet 20-5-12.5 2 INTRAVENOUS GM mg, 40-10-12.5 mg, 40- SOLUTION 4-5 10-25 mg, 40-5-12.5 mg, MG/250ML-%, 8-5 40-5-25 mg MG/500ML-% omega-3-acid ethyl 2 PA norepinephrine bitartrate esters oral capsule 1 gm intravenous solution 1 GM OSMITROL mg/ml INTRAVENOUS GM NOREPINEPHRINE- SOLUTION 10 %, 15 %, DEXTROSE 20 % INTRAVENOUS GM PACERONE ORAL Brand SOLUTION 8-5 TABLET 100 MG, 200 4 penalty MG/500ML-% MG, 400 MG applies NOREPINEPHRINE- pentoxifylline er oral SODIUM CHLORIDE tablet extended release 2 INTRAVENOUS GM 400 mg SOLUTION 16-0.9 perindopril erbumine oral MG/250ML-%, 8-0.9 2 MG/500ML-% tablet 2 mg, 4 mg, 8 mg NORPACE CR ORAL PA; QL (14 phenoxybenzamine hcl 2 EA per 30 CAPSULE EXTENDED 3 RELEASE 12 HOUR 100 oral capsule 10 mg days) MG, 150 MG phentolamine mesylate NORPACE ORAL Brand injection solution GM CAPSULE 100 MG, 150 4 penalty reconstituted 5 mg MG applies PHENYLEPHRINE HCL NORTHERA ORAL (PRESSORS) CAPSULE 100 MG, 200 6 PA INTRAVENOUS GM MG, 300 MG SOLUTION 0.4 MG/10ML, 0.8 MG/10ML NORVASC ORAL Brand TABLET 10 MG, 2.5 MG, 4 penalty PHENYLEPHRINE HCL 5 MG applies (PRESSORS) INTRAVENOUS GM olmesartan medoxomil SOLUTION PREFILLED oral tablet 20 mg, 40 mg, 2 SYRINGE 0.5 MG/5ML, 5 mg 1 MG/10ML olmesartan medoxomil- PHENYLEPHRINE HCL hctz oral tablet 20-12.5 2 INTRAVENOUS GM mg, 40-12.5 mg, 40-25 SOLUTION 1 MG/10ML mg phenylephrine hcl intravenous solution 10 GM mg/ml

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 97 Drug Drug Drug Name Notes Drug Name Notes Tier Tier PHENYLEPHRINE HCL Brand INTRAVENOUS PRINIVIL ORAL TABLET 4 penalty applies SOLUTION PREFILLED GM 20 MG SYRINGE 0.4 MG/10ML, procainamide hcl 0.8 MG/10ML, 1 injection solution 100 GM MG/10ML mg/ml, 500 mg/ml PHENYLEPHRINE HCL- PROCARDIA XL ORAL Brand NACL INTRAVENOUS TABLET EXTENDED 4 penalty SOLUTION 10-0.9 RELEASE 24 HOUR 30 applies MG/250ML-%, 100-0.9 MG, 60 MG, 90 MG MG/250ML-%, 20-0.9 GM MG/250ML-%, 25-0.9 propafenone hcl er oral MG/250ML-%, 40-0.9 capsule extended 2 MG/250ML-%, 50-0.9 release 12 hour 225 mg, MG/250ML-%, 80-0.9 325 mg, 425 mg MG/250ML-% propafenone hcl oral PHENYLEPHRINE HCL- tablet 150 mg, 225 mg, 2 NACL INTRAVENOUS 300 mg SOLUTION PREFILLED GM propranolol hcl er oral SYRINGE 0.5-0.9 capsule extended 2 MG/5ML-% release 24 hour 120 mg, 160 mg, 60 mg, 80 mg pindolol oral tablet 10 2 mg, 5 mg propranolol hcl POLIDOCANOL intravenous solution 1 GM INTRAVENOUS GM mg/ml SOLUTION 5 % propranolol hcl oral PRALUENT solution 20 mg/5ml, 40 2 SUBCUTANEOUS mg/5ml SOLUTION AUTO- 3 propranolol hcl oral tablet INJECTOR 150 MG/ML, 10 mg, 20 mg, 40 mg, 60 2 75 MG/ML mg, 80 mg pravastatin sodium oral PROSTIN VR tablet 10 mg, 20 mg, 40 2 PV* INJECTION SOLUTION GM mg, 80 mg 500 MCG/ML prazosin hcl oral capsule 2 QBRELIS ORAL 4 1 mg, 2 mg, 5 mg SOLUTION 1 MG/ML PRESTALIA ORAL QUESTRAN LIGHT Brand TABLET 14-10 MG, 3.5- 4 ORAL POWDER 4 4 penalty 2.5 MG, 7-5 MG GM/DOSE applies prevalite oral packet 4 Brand 2 gm QUESTRAN ORAL 4 penalty PACKET 4 GM applies prevalite oral powder 4 2 gm/dose

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 98 Drug Drug Drug Name Notes Drug Name Notes Tier Tier Brand RYTHMOL SR ORAL Brand 4 penalty QUESTRAN ORAL CAPSULE EXTENDED 4 penalty applies POWDER 4 GM/DOSE RELEASE 12 HOUR 225 applies quinapril hcl oral tablet MG, 325 MG, 425 MG 2 10 mg, 20 mg, 40 mg, 5 simvastatin oral tablet 10 1 PV* mg mg, 20 mg, 40 mg quinapril- simvastatin oral tablet 5 1 hydrochlorothiazide oral mg, 80 mg 2 tablet 10-12.5 mg, 20- SODIUM DIURIL 12.5 mg, 20-25 mg INTRAVENOUS quinidine gluconate er SOLUTION GM oral tablet extended 2 RECONSTITUTED 500 release 324 mg MG quinidine sulfate oral 2 SODIUM EDECRIN tablet 200 mg, 300 mg INTRAVENOUS SOLUTION GM ramipril oral capsule 1.25 2 mg, 10 mg, 2.5 mg, 5 mg RECONSTITUTED 50 MG RANEXA ORAL TABLET Brand EXTENDED RELEASE sodium nitroprusside 4 penalty 12 HOUR 1000 MG, 500 intravenous solution 25 GM applies MG mg/ml ranolazine er oral tablet sodium tetradecyl sulfate GM extended release 12 hour 2 intravenous solution 3 % 1000 mg, 500 mg sorine oral tablet 120 mg, 2 160 mg, 240 mg, 80 mg RECTIV RECTAL 4 OINTMENT 0.4 % sotalol hcl (af) oral tablet 2 REPATHA 120 mg, 160 mg, 80 mg PUSHTRONEX SYSTEM SOTALOL HCL SUBCUTANEOUS 3 INTRAVENOUS GM SOLUTION CARTRIDGE SOLUTION 150 420 MG/3.5ML MG/10ML REPATHA sotalol hcl oral tablet 120 2 SUBCUTANEOUS 3 mg, 160 mg, 240 mg, 80 SOLUTION PREFILLED mg SYRINGE 140 MG/ML SOTRADECOL REPATHA SURECLICK INTRAVENOUS GM SUBCUTANEOUS 3 SOLUTION 1 %, 3 % SOLUTION AUTO- SOTYLIZE ORAL 4 INJECTOR 140 MG/ML SOLUTION 5 MG/ML rosuvastatin calcium oral spironolactone oral tablet 2 tablet 10 mg, 20 mg, 40 2 100 mg, 25 mg, 50 mg mg, 5 mg spironolactone-hctz oral 2 tablet 25-25 mg Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 99 Drug Drug Drug Name Notes Drug Name Notes Tier Tier SULAR ORAL TABLET TIAZAC ORAL Brand EXTENDED RELEASE 4 penalty CAPSULE EXTENDED Brand 24 HOUR 17 MG, 34 applies RELEASE 24 HOUR 120 4 penalty MG, 8.5 MG MG, 180 MG, 240 MG, applies TARKA ORAL TABLET 300 MG, 360 MG, 420 Brand MG EXTENDED RELEASE 4 penalty 2-180 MG, 2-240 MG, 4- TIKOSYN ORAL Brand applies 240 MG CAPSULE 125 MCG, 4 penalty taztia xt oral capsule 250 MCG, 500 MCG applies extended release 24 hour timolol maleate oral 2 120 mg, 180 mg, 240 tablet 10 mg, 20 mg, 5 2 mg, 300 mg, 360 mg mg TEKTURNA HCT ORAL TOPROL XL ORAL Brand TABLET 150-12.5 MG, 3 TABLET EXTENDED 150-25 MG, 300-12.5 RELEASE 24 HOUR 100 4 penalty MG, 300-25 MG MG, 200 MG, 25 MG, 50 applies TEKTURNA ORAL Brand MG TABLET 150 MG, 300 3 penalty torsemide oral tablet 10 MG applies mg, 100 mg, 20 mg, 5 2 telmisartan oral tablet 20 mg 2 mg, 40 mg, 80 mg trandolapril oral tablet 1 2 telmisartan-amlodipine mg, 2 mg, 4 mg oral tablet 40-10 mg, 40- 2 trandolapril-verapamil hcl 5 mg, 80-10 mg, 80-5 mg er oral tablet extended 2 telmisartan-hctz oral release 1-240 mg, 2-180 tablet 40-12.5 mg, 80- 2 mg, 2-240 mg, 4-240 mg 12.5 mg, 80-25 mg triamterene oral capsule 2 Brand 100 mg, 50 mg TENORETIC 100 ORAL 4 penalty triamterene-hctz oral 2 TABLET 100-25 MG applies capsule 37.5-25 mg Brand triamterene-hctz oral TENORETIC 50 ORAL 4 penalty tablet 37.5-25 mg, 75-50 2 TABLET 50-25 MG applies mg TENORMIN ORAL Brand TRIBENZOR ORAL TABLET 100 MG, 25 4 penalty TABLET 20-5-12.5 MG, Brand MG, 50 MG applies 40-10-12.5 MG, 40-10-25 3 penalty tiadylt er oral capsule MG, 40-5-12.5 MG, 40-5- applies extended release 24 hour 25 MG 120 mg, 180 mg, 240 2 Brand mg, 300 mg, 360 mg, TRICOR ORAL TABLET 4 penalty 420 mg 145 MG, 48 MG applies

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 100 Drug Drug Drug Name Notes Drug Name Notes Tier Tier TRILIPIX ORAL verapamil hcl oral tablet Brand 2 CAPSULE DELAYED 4 penalty 120 mg, 40 mg, 80 mg RELEASE 135 MG, 45 applies VERELAN ORAL MG CAPSULE EXTENDED Brand TWYNSTA ORAL Brand RELEASE 24 HOUR 120 4 penalty TABLET 40-10 MG, 40-5 4 penalty MG, 180 MG, 240 MG, applies MG, 80-10 MG, 80-5 MG applies 360 MG valsartan oral tablet 160 VERELAN PM ORAL Brand mg, 320 mg, 40 mg, 80 2 CAPSULE EXTENDED 4 penalty mg RELEASE 24 HOUR 100 applies valsartan- MG, 200 MG, 300 MG hydrochlorothiazide oral VERQUVO ORAL tablet 160-12.5 mg, 160- 2 TABLET 10 MG, 2.5 MG, 4 PA 25 mg, 320-12.5 mg, 5 MG 320-25 mg, 80-12.5 mg VYNDAMAX ORAL 6 PA VARITHENA CAPSULE 61 MG INTRAVENOUS FOAM GM VYNDAQEL ORAL 6 PA 180 MG/18ML CAPSULE 20 MG VASCEPA ORAL VYTORIN ORAL 4 PA Brand CAPSULE 0.5 GM, 1 GM TABLET 10-10 MG, 10- 4 penalty Brand 20 MG, 10-40 MG, 10-80 applies VASERETIC ORAL 4 penalty MG TABLET 10-25 MG applies Brand VASOTEC ORAL Brand WELCHOL ORAL 4 penalty TABLET 10 MG, 2.5 MG, 4 penalty PACKET 3.75 GM applies 20 MG, 5 MG applies Brand VAZCULEP WELCHOL ORAL 4 penalty INTRAVENOUS GM TABLET 625 MG applies SOLUTION 10 MG/ML ZESTORETIC ORAL Brand VECAMYL ORAL TABLET 10-12.5 MG, 20- 4 penalty 4 TABLET 2.5 MG 12.5 MG, 20-25 MG applies verapamil hcl er oral ZESTRIL ORAL TABLET Brand capsule extended 10 MG, 2.5 MG, 20 MG, 4 penalty applies release 24 hour 100 mg, 2 30 MG, 40 MG, 5 MG 120 mg, 180 mg, 200 Brand mg, 240 mg, 300 mg, ZETIA ORAL TABLET 10 4 penalty 360 mg MG applies verapamil hcl er oral ZIAC ORAL TABLET 10- Brand tablet extended release 2 6.25 MG, 2.5-6.25 MG, 4 penalty 120 mg, 180 mg, 240 mg 5-6.25 MG applies verapamil hcl intravenous GM ZOCOR ORAL TABLET Brand solution 2.5 mg/ml 10 MG, 20 MG, 40 MG, 4 penalty 80 MG applies

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 101 Drug Drug Drug Name Notes Drug Name Notes Tier Tier ZYPITAMAG ORAL atomoxetine hcl oral QL (60 EA 4 PA TABLET 2 MG, 4 MG capsule 10 mg, 18 mg, 2 per 30 Central Nervous 25 mg days) System Agents - Drugs atomoxetine hcl oral QL (30 EA for Attention Deficit capsule 100 mg, 40 mg, 2 per 30 Disorder 60 mg, 80 mg days) Brand clonidine hcl er oral tablet ADDERALL ORAL penalty extended release 12 hour 2 TABLET 10 MG, 12.5 4 applies; QL 0.1 mg MG, 15 MG, 20 MG, 30 (90 EA per Brand 30 days) MG, 5 MG, 7.5 MG CONCERTA ORAL penalty Brand TABLET EXTENDED 4 applies; QL ADDERALL XR ORAL penalty RELEASE 18 MG, 27 (30 EA per CAPSULE EXTENDED 4 applies; QL MG, 54 MG 30 days) RELEASE 24 HOUR 10 (30 EA per Brand MG, 15 MG, 5 MG 30 days) penalty Brand CONCERTA ORAL 4 applies; QL ADDERALL XR ORAL penalty TABLET EXTENDED (60 EA per CAPSULE EXTENDED 4 applies; QL RELEASE 36 MG 30 days) (60 EA per RELEASE 24 HOUR 20 DAYTRANA 30 days) MG, 25 MG, 30 MG TRANSDERMAL PATCH QL (30 EA 4 per 30 amphetamine sulfate oral 2 10 MG/9HR, 15 tablet 10 mg, 5 mg MG/9HR, 20 MG/9HR, days) amphetamine- 30 MG/9HR dextroamphetamine er QL (30 EA Brand oral capsule extended 2 per 30 DESOXYN ORAL 4 penalty release 24 hour 10 mg, days) TABLET 5 MG applies 15 mg, 5 mg Brand amphetamine- penalty dextroamphetamine er QL (60 EA DEXEDRINE ORAL applies; QL 4 oral capsule extended 2 per 30 CAPSULE EXTENDED (150 EA release 24 hour 20 mg, days) RELEASE 24 HOUR 10 per 30 25 mg, 30 mg MG, 15 MG, 5 MG days) amphetamine- dexmethylphenidate hcl dextroamphetamine oral QL (90 EA er oral capsule extended QL (30 EA tablet 10 mg, 12.5 mg, 15 2 per 30 release 24 hour 10 mg, 2 per 30 mg, 20 mg, 30 mg, 5 mg, days) 15 mg, 20 mg, 25 mg, 30 days) 7.5 mg mg, 35 mg, 40 mg, 5 mg APTENSIO XR ORAL dexmethylphenidate hcl QL (90 EA CAPSULE EXTENDED 2 per 30 Brand oral tablet 10 mg, 2.5 mg, days) RELEASE 24 HOUR 10 4 penalty 5 mg MG, 15 MG, 20 MG, 30 applies MG, 40 MG, 50 MG, 60 MG

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 102 Drug Drug Drug Name Notes Drug Name Notes Tier Tier dextroamphetamine Brand QL (150 penalty sulfate er oral capsule 2 EA per 30 applies; QL extended release 24 hour days) 4 10 mg, 15 mg, 5 mg METHYLIN ORAL (900 ML dextroamphetamine SOLUTION 10 MG/5ML, per 30 days) sulfate oral solution 5 2 5 MG/5ML mg/5ml methylphenidate hcl er dextroamphetamine QL (180 (cd) oral capsule QL (30 EA sulfate oral tablet 10 mg, 2 EA per 30 extended release 10 mg, 2 per 30 5 mg days) 20 mg, 30 mg, 40 mg, 50 days) mg, 60 mg PA; AL DYANAVEL XR ORAL (Min 6 methylphenidate hcl er SUSPENSION 4 Years and (la) oral capsule QL (30 EA EXTENDED RELEASE Max 12 extended release 24 hour 2 per 30 2.5 MG/ML Years) 10 mg, 20 mg, 30 mg, 40 days) mg, 60 mg Brand penalty methylphenidate hcl er FOCALIN ORAL 4 applies; QL (xr) oral capsule extended release 24 hour TABLET 10 MG, 2.5 MG, (90 EA per 2 5 MG 30 days) 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 FOCALIN XR ORAL Brand mg CAPSULE EXTENDED penalty methylphenidate hcl er RELEASE 24 HOUR 10 4 applies; QL MG, 15 MG, 20 MG, 25 oral tablet extended 2 (30 EA per release 10 mg MG, 30 MG, 35 MG, 40 30 days) MG, 5 MG methylphenidate hcl er QL (30 EA oral tablet extended guanfacine hcl er oral 2 per 30 tablet extended release release 18 mg, 27 mg, 54 2 days) 24 hour 1 mg, 2 mg, 3 mg mg, 4 mg methylphenidate hcl er QL (90 EA INTUNIV ORAL TABLET oral tablet extended 2 per 30 Brand release 20 mg days) EXTENDED RELEASE 4 penalty 24 HOUR 1 MG, 2 MG, 3 applies methylphenidate hcl er MG, 4 MG oral tablet extended 2 KAPVAY ORAL TABLET Brand release 24 hour 18 mg, EXTENDED RELEASE 4 penalty 27 mg, 36 mg, 54 mg 12 HOUR 0.1 MG applies methylphenidate hcl er QL (60 EA methamphetamine hcl oral tablet extended 2 per 30 2 oral tablet 5 mg release 36 mg days) methylphenidate hcl er QL (1 EA 1 oral tablet extended per 1 day) release 72 mg

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 103 Drug Drug Drug Name Notes Drug Name Notes Tier Tier methylphenidate hcl oral QL (900 RITALIN LA ORAL Brand solution 10 mg/5ml, 5 2 ML per 30 CAPSULE EXTENDED penalty mg/5ml days) RELEASE 24 HOUR 10 4 applies; QL QL (180 MG, 20 MG, 30 MG, 40 (30 EA per methylphenidate hcl oral 2 EA per 30 MG 30 days) tablet 10 mg days) Brand penalty methylphenidate hcl oral 2 applies; QL tablet 20 mg 4 (180 EA QL (90 EA RITALIN ORAL TABLET per 30 methylphenidate hcl oral 2 per 30 10 MG days) tablet 5 mg days) Brand methylphenidate hcl oral 2 RITALIN ORAL TABLET 4 penalty tablet chewable 10 mg 20 MG applies methylphenidate hcl oral QL (90 EA Brand tablet chewable 2.5 mg, 2 per 30 penalty 5 mg days) 4 applies; QL Brand RITALIN ORAL TABLET (90 EA per PROCENTRA ORAL 4 penalty 5 MG 30 days) SOLUTION 5 MG/5ML applies Brand QL (30 EA penalty per 30 STRATTERA ORAL 4 applies; QL days); AL CAPSULE 10 MG, 18 (60 EA per QELBREE ORAL 4 (Min 6 MG, 25 MG 30 days) CAPSULE EXTENDED Years and Brand RELEASE 24 HOUR 100 Max 17 penalty MG, 150 MG, 200 MG Years) STRATTERA ORAL 4 applies; QL PA; AL CAPSULE 100 MG, 40 (30 EA per QUILLICHEW ER ORAL (Min 6 MG, 60 MG, 80 MG 30 days) TABLET CHEWABLE 4 Years and VYVANSE ORAL QL (30 EA EXTENDED RELEASE Max 12 CAPSULE 10 MG, 20 20 MG, 30 MG, 40 MG Years) 4 per 30 MG, 30 MG, 40 MG, 50 days) PA; QL MG, 60 MG, 70 MG (180 ML PA; QL (30 per 30 EA per 30 days); AL 4 days); AL QUILLIVANT XR ORAL (Min 6 VYVANSE ORAL 4 (Min 6 SUSPENSION Years and TABLET CHEWABLE 10 Years and RECONSTITUTED ER Max 12 MG, 20 MG, 30 MG, 40 Max 12 25 MG/5ML Years) MG, 50 MG, 60 MG Years) relexxii oral tablet QL (1 EA 1 QL (60 EA extended release 72 mg per 1 day) ZENZEDI ORAL TABLET 4 per 30 15 MG, 20 MG, 30 MG days)

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 104 Drug Drug Drug Name Notes Drug Name Notes Tier Tier Brand AVONEX PREFILLED penalty INTRAMUSCULAR 5 applies; QL 4 PREFILLED SYRINGE (180 EA KIT 30 MCG/0.5ML ZENZEDI TABLET 10 per 30 BAFIERTAM ORAL days) MG ORAL 10 MG CAPSULE DELAYED 5 Brand RELEASE 95 MG penalty BETASERON 4 applies; QL SUBCUTANEOUS KIT 5 ZENZEDI TABLET 10 (2 EA per 1 0.3 MG MG ORAL 10 MG day) dalfampridine er oral ZENZEDI TABLET 2.5 4 tablet extended release 6 PA MG ORAL 2.5 MG 12 hour 10 mg QL (60 EA dimethyl fumarate oral ZENZEDI TABLET 2.5 4 per 30 capsule delayed release 5 MG ORAL 2.5 MG days) 120 mg, 240 mg Brand dimethyl fumarate starter 5 penalty pack oral 120 & 240 mg applies; QL 4 (180 EA EXTAVIA ZENZEDI TABLET 5 MG per 30 SUBCUTANEOUS KIT 6 ORAL 5 MG days) 0.3 MG Brand GILENYA ORAL penalty CAPSULE 0.25 MG, 0.5 6 4 applies; QL MG ZENZEDI TABLET 5 MG (2 EA per 1 glatiramer acetate ORAL 5 MG day) subcutaneous solution 5 ZENZEDI TABLET 7.5 prefilled syringe 20 4 MG ORAL 7.5 MG mg/ml, 40 mg/ml QL (60 EA glatopa subcutaneous ZENZEDI TABLET 7.5 4 per 30 solution prefilled syringe 5 MG ORAL 7.5 MG days) 20 mg/ml, 40 mg/ml Central Nervous KESIMPTA System Agents - Drugs SUBCUTANEOUS 6 for Multiple Sclerosis SOLUTION AUTO- INJECTOR 20 MG/0.4ML AUBAGIO ORAL 6 TABLET 14 MG, 7 MG LEMTRADA PA; INTRAVENOUS 6 Specialty AVONEX PEN SOLUTION 12 INTRAMUSCULAR Medical 5 MG/1.2ML AUTO-INJECTOR KIT 30 MCG/0.5ML MAVENCLAD ORAL TABLET THERAPY 6 PA PACK 10 MG

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 105 Drug Drug Drug Name Notes Drug Name Notes Tier Tier MAYZENT ORAL REBIF REBIDOSE 6 TABLET 0.25 MG, 2 MG SUBCUTANEOUS MAYZENT STARTER SOLUTION AUTO- 6 INJECTOR 22 PACK ORAL TABLET 6 THERAPY PACK 0.25 MCG/0.5ML, 44 MG MCG/0.5ML REBIF REBIDOSE OCREVUS PA; INTRAVENOUS TITRATION PACK 6 Specialty SOLUTION 300 SUBCUTANEOUS Medical 6 MG/10ML SOLUTION AUTO- INJECTOR 6X8.8 & PLEGRIDY 6X22 MCG INTRAMUSCULAR SOLUTION PREFILLED 6 REBIF SYRINGE 125 SUBCUTANEOUS MCG/0.5ML SOLUTION PREFILLED 6 SYRINGE 22 PLEGRIDY STARTER MCG/0.5ML, 44 PACK SUBCUTANEOUS MCG/0.5ML SOLUTION PEN- 6 INJECTOR 63 & 94 REBIF TITRATION MCG/0.5ML PACK SUBCUTANEOUS SOLUTION PREFILLED 6 PLEGRIDY STARTER SYRINGE 6X8.8 & 6X22 PACK SUBCUTANEOUS MCG SOLUTION PREFILLED 6 SYRINGE 63 & 94 TECFIDERA ORAL 120 5 MCG/0.5ML & 240 MG PLEGRIDY TECFIDERA ORAL CAPSULE DELAYED SUBCUTANEOUS 5 SOLUTION PEN- 6 RELEASE 120 MG, 240 INJECTOR 125 MG MCG/0.5ML TYSABRI PA; PLEGRIDY INTRAVENOUS 6 Specialty SUBCUTANEOUS CONCENTRATE 300 Medical SOLUTION PREFILLED 6 MG/15ML SYRINGE 125 VUMERITY ORAL MCG/0.5ML CAPSULE DELAYED 6 PONVORY ORAL RELEASE 231 MG 6 TABLET 20 MG ZEPOSIA 7-DAY PONVORY STARTER STARTER PACK ORAL PACK ORAL TABLET CAPSULE THERAPY 6 6 THERAPY PACK 2-3-4- PACK 4 X 0.23MG & 3 X 5-6-7-8-9 & 10 MG 0.46MG ZEPOSIA ORAL 6 CAPSULE 0.92 MG

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 106 Drug Drug Drug Name Notes Drug Name Notes Tier Tier ZEPOSIA STARTER KIT INGREZZA ORAL ORAL CAPSULE CAPSULE THERAPY 6 PA THERAPY PACK 6 PACK 40 & 80 MG 0.23MG & 0.46MG & LYRICA CR ORAL 0.92MG Brand TABLET EXTENDED 4 penalty Central Nervous RELEASE 24 HOUR 165 applies System Agents - MG, 330 MG, 82.5 MG Miscellaneous LYRICA ORAL ANECTINE INJECTION Brand GM CAPSULE 100 MG, 150 SOLUTION 20 MG/ML MG, 200 MG, 225 MG, 4 penalty atracurium besylate 25 MG, 300 MG, 50 MG, applies intravenous solution 100 GM 75 MG mg/10ml, 50 mg/5ml LYRICA ORAL 4 AUSTEDO ORAL SOLUTION 20 MG/ML TABLET 12 MG, 6 MG, 9 6 PA NIMBEX INTRAVENOUS MG SOLUTION 10 MG/5ML, GM 20 MG/10ML, 200 CAFCIT INTRAVENOUS GM SOLUTION 60 MG/3ML MG/20ML NUEDEXTA ORAL caffeine citrate 4 PA intravenous solution 60 GM CAPSULE 20-10 MG mg/3ml ONPATTRO PA; caffeine citrate oral INTRAVENOUS 6 Specialty solution 20 mg/ml, 60 2 SOLUTION 10 MG/5ML Medical mg/3ml pancuronium bromide cisatracurium besylate intravenous solution 1 GM (pf) intravenous solution GM mg/ml 10 mg/5ml, 200 mg/20ml pregabalin er oral tablet extended release 24 hour cisatracurium besylate 2 intravenous solution 20 GM 165 mg, 330 mg, 82.5 mg/10ml mg DOPRAM pregabalin oral capsule 100 mg, 150 mg, 200 INTRAVENOUS GM 2 SOLUTION 20 MG/ML mg, 225 mg, 25 mg, 300 mg, 50 mg, 75 mg GRALISE ORAL TABLET 300 MG, 600 4 ST pregabalin oral solution 2 MG 20 mg/ml HORIZANT ORAL QUELICIN INJECTION GM SOLUTION 20 MG/ML TABLET EXTENDED 4 ST RELEASE 300 MG, 600 RADICAVA PA; MG INTRAVENOUS 6 Specialty SOLUTION 30 INGREZZA ORAL Medical CAPSULE 40 MG, 60 6 PA MG/100ML MG, 80 MG

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 107 Drug Drug Drug Name Notes Drug Name Notes Tier Tier RILUTEK ORAL TABLET vecuronium bromide 6 50 MG intravenous solution GM riluzole oral tablet 50 mg 6 reconstituted 10 mg, 20 mg rocuronium bromide intravenous solution 100 GM XENAZINE ORAL mg/10ml, 50 mg/5ml TABLET 12.5 MG, 25 6 PA MG ROCURONIUM Dental and Oral Agents BROMIDE - Drugs for Mouth and INTRAVENOUS GM Throat Conditions SOLUTION PREFILLED SYRINGE 100 ARESTIN DENTAL 1 MG GM MG/10ML, 75 MG/7.5ML BOCASAL SAVELLA ORAL MOUTH/THROAT 4 TABLET 100 MG, 12.5 4 PA PACKET MG, 25 MG, 50 MG cavarest dental gel 1.1 % 2 SAVELLA TITRATION cevimeline hcl oral 2 PACK ORAL 12.5 & 25 & 4 PA capsule 30 mg 50 MG chlorhexidine gluconate SUCCINYLCHOLINE mouth/throat solution 2 CHLORIDE INJECTION 0.12 % SOLUTION PREFILLED GM CLINPRO 5000 DENTAL SYRINGE 100 MG/5ML, 4 140 MG/7ML, 200 1.1 % MG/10ML DEBACTEROL 4 succinylcholine chloride MOUTH/THROAT solution 20 mg/ml GM SOLUTION 30-50 % injection 20 mg/ml DENTA 5000 PLUS 4 SUCCINYLCHOLINE DENTAL CREAM 1.1 % CHLORIDE SOLUTION DENTAGEL DENTAL GM 4 20 MG/ML INJECTION GEL 1.1 % 20 MG/ML easygel dental gel 0.4 % 2 TEGSEDI Brand SUBCUTANEOUS EVOXAC ORAL 4 penalty SOLUTION PREFILLED 6 PA CAPSULE 30 MG applies SYRINGE 284 MG/1.5ML FIRST- BLM MOUTH/THROAT 4 tetrabenazine oral tablet 5 PA SUSPENSION 12.5 mg, 25 mg fluoridex daily renewal TIGLUTIK ORAL mouth/throat concentrate 2 SUSPENSION 50 6 0.63 % MG/10ML FLUORIDEX DENTAL 4 PASTE 1.1 %

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 108 Drug Drug Drug Name Notes Drug Name Notes Tier Tier FLUORIDEX oralone mouth/throat 2 ENHANCED 4 paste 0.1 % WHITENING DENTAL PERIDEX Brand PASTE 1.1 % MOUTH/THROAT 4 penalty FLUORIDEX SOLUTION 0.12 % applies SENSITIVITY RELIEF 4 periogard mouth/throat 2 DENTAL PASTE 1.1-5 % solution 0.12 % KEPIVANCE pilocarpine hcl oral tablet 2 INTRAVENOUS PA; 5 mg, 7.5 mg SOLUTION 6 Specialty RECONSTITUTED 6.25 Medical PREVIDENT 5000 MG BOOSTER PLUS 4 DENTAL PASTE 1.1 % lidocaine viscous hcl 2 mouth/throat solution 2 % PREVIDENT 5000 DRY MOUTH DENTAL GEL 4 MI PASTE DENTAL 4 1.1 % PASTE PREVIDENT 5000 MI PASTE PLUS 4 ENAMEL PROTECT 4 DENTAL PASTE DENTAL PASTE 1.1-5 % MUCOSITISRX PREVIDENT 5000 MOUTH/THROAT 4 ORTHO DEFENSE 4 PACKET DENTAL PASTE 1.1 % NAFRINSE DAILY PREVIDENT 5000 PLUS 4 ACIDULATED DENTAL CREAM 1.1 % MOUTH/THROAT 4 SOLUTION PREVIDENT 5000 RECONSTITUTED 1 SENSITIVE DENTAL 4 MG/5ML PASTE 1.1-5 % NAFRINSE PREVIDENT DENTAL 4 DAILY/NEUTRAL GEL 1.1 % MOUTH/THROAT 4 prevident mouth/throat 2 SOLUTION solution 0.2 % RECONSTITUTED 0.05 REMESENSE DENTAL 3 4 % % NAFRINSE WEEKLY Brand MOUTH/THROAT 4 SALAGEN ORAL 4 penalty SOLUTION TABLET 5 MG, 7.5 MG applies RECONSTITUTED 0.2 % SALIVAMAX NEUTRASAL MOUTH/THROAT 4 4 MOUTH/THROAT PACKET PACKET sf 5000 plus dental 2 NUMOISYN cream 1.1 % MOUTH/THROAT 4 LOZENGE sf dental gel 1.1 % 2

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 109 Drug Drug Drug Name Notes Drug Name Notes Tier Tier sodium fluoride 5000 Brand enamel dental paste 1.1- 2 ACZONE EXTERNAL 4 penalty 5 % GEL 5 % applies sodium fluoride 5000 2 adapalene external 2 plus dental cream 1.1 % cream 0.1 % sodium fluoride 5000 2 adapalene external gel 2 ppm dental cream 1.1 % 0.1 %, 0.3 % sodium fluoride 5000 ala-cort external cream 1 2 2 ppm dental paste 1.1 % %, 2.5 % sodium fluoride 5000 alclometasone sensitive dental paste 2 dipropionate external 2 1.1-5 % cream 0.05 % sodium fluoride dental alclometasone 2 cream 1.1 % dipropionate external 2 ointment 0.05 % sodium fluoride dental 2 gel 1.1 % amcinonide external 2 sodium fluoride cream 0.1 % 2 mouth/throat solution 0.2 amcinonide external 2 % lotion 0.1 % triamcinolone acetonide amcinonide external 2 2 mouth/throat paste 0.1 % ointment 0.1 % XEROSTOMIA RELIEF ammonium lactate 2 SPRAY external cream 12 % 4 MOUTH/THROAT ammonium lactate 2 SOLUTION external lotion 12 % Dermatological Agents amnesteem oral capsule QL (2 EA - Drugs for Skin 2 10 mg, 20 mg, 40 mg per 1 day) Conditions ANACAINE EXTERNAL 4 ABSORICA LD ORAL OINTMENT 10 % CAPSULE 16 MG, 24 4 PA MG, 32 MG, 8 MG AQUACEL AG BURN 4 EXTERNAL PAD 4"X5" ABSORICA ORAL PA; Brand CAPSULE 10 MG, 20 ARZOL SILVER NIT 4 penalty MG, 25 MG, 30 MG, 35 APPLICATORS 4 applies MG, 40 MG EXTERNAL 75-25 % QL (2 EA azelaic acid external gel accutane oral capsule 20 2 2 PA mg, 30 mg, 40 mg per 1 day) 15 % AZELEX EXTERNAL acitretin oral capsule 10 2 4 PA mg, 17.5 mg, 25 mg CREAM 20 % balsam peru-castor oil ACNESIC EXTERNAL 4 2 GEL 0.5 % external ointment

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 110 Drug Drug Drug Name Notes Drug Name Notes Tier Tier BENSAL HP EXTERNAL calcipotriene external 4 2 OINTMENT 3 % cream 0.005 % benzoin compound 2 calcipotriene external 2 external tincture ointment 0.005 % 2 benzoin external tincture calcipotriene external 2 solution 0.005 % beser external lotion 0.05 2 % calcipotriene-betameth betamethasone diprop external ointment 2 ST dipropionate aug external 2 0.005-0.064 % cream 0.05 % calcitriol external 2 ST betamethasone ointment 3 mcg/gm dipropionate aug external 2 cerovel external lotion 40 2 gel 0.05 % % betamethasone claravis oral capsule 10 QL (2 EA 2 2 dipropionate aug external mg, 20 mg, 30 mg, 40 per 1 day) lotion 0.05 % mg betamethasone clindacin etz external 2 dipropionate aug external 2 swab 1 % ointment 0.05 % clindacin-p external swab 2 betamethasone 1 % dipropionate external 2 clindamycin phosphate 2 cream 0.05 % external foam 1 % betamethasone clindamycin phosphate 2 dipropionate external 2 external gel 1 % lotion 0.05 % clindamycin phosphate 2 betamethasone external lotion 1 % dipropionate external 2 ointment 0.05 % clindamycin phosphate 2 external solution 1 % betamethasone valerate 2 external cream 0.1 % clindamycin phosphate 2 external swab 1 % betamethasone valerate 2 external lotion 0.1 % clobetasol prop emollient base external cream 0.05 2 betamethasone valerate 2 % external ointment 0.1 % clobetasol propionate e bp 10-1 external 2 2 external cream 0.05 % emulsion 10-1 % clobetasol propionate BP CLEANSING WASH emulsion external foam 2 EXTERNAL EMULSION 4 0.05 % 10-4 % clobetasol propionate 2 BPCO EXTERNAL 4 external cream 0.05 % OINTMENT

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 111 Drug Drug Drug Name Notes Drug Name Notes Tier Tier clobetasol propionate desonide external 2 2 external foam 0.05 % ointment 0.05 % clobetasol propionate 2 desoximetasone external 2 external gel 0.05 % cream 0.05 %, 0.25 % clobetasol propionate 2 desoximetasone external 2 external lotion 0.05 % gel 0.05 % clobetasol propionate 2 desoximetasone external 2 external ointment 0.05 % liquid 0.25 % clobetasol propionate desoximetasone external 2 2 external shampoo 0.05 % ointment 0.05 %, 0.25 % clobetasol propionate desrx external gel 0.05 % 2 2 external solution 0.05 % diclofenac sodium 2 clocortolone pivalate external gel 3 % 2 external cream 0.1 % diflorasone diacetate 2 clodan external shampoo 2 external cream 0.05 % 0.05 % diflorasone diacetate 2 Brand external ointment 0.05 % CLODERM EXTERNAL 4 penalty doxepin hcl external 2 CREAM 0.1 % applies cream 5 % coal tar external solution 2 DRITHO-CREME HP 3 20 % EXTERNAL CREAM 1 % CONDYLOX EXTERNAL 3 DRYSOL EXTERNAL 3 GEL 0.5 % SOLUTION 20 % CORDRAN EXTERNAL 4 DUPIXENT CREAM 0.025 % SUBCUTANEOUS Brand SOLUTION PEN- 5 PA CORDRAN EXTERNAL 4 penalty INJECTOR 200 CREAM 0.05 % applies MG/1.14ML, 300 Brand MG/2ML CORDRAN EXTERNAL 4 penalty DUPIXENT LOTION 0.05 % applies SUBCUTANEOUS SOLUTION PREFILLED CORDRAN EXTERNAL 4 5 PA TAPE 4 MCG/SQCM SYRINGE 200 MG/1.14ML, 300 dapsone external gel 5 % 2 MG/2ML desonide external cream 2 Brand 0.05 % ELIDEL EXTERNAL 4 penalty desonide external gel CREAM 1 % applies 2 0.05 % EPIFOAM EXTERNAL 4 desonide external lotion FOAM 1-1 % 2 0.05 % ery external pad 2 % 2

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 112 Drug Drug Drug Name Notes Drug Name Notes Tier Tier erythromycin external gel flurandrenolide external 2 2 2 % lotion 0.05 % erythromycin external 2 flurandrenolide external 2 solution 2 % ointment 0.05 %

EUCRISA EXTERNAL 4 PA fluticasone propionate 2 OINTMENT 2 % external cream 0.05 %

FINACEA EXTERNAL 4 PA fluticasone propionate 2 FOAM 15 % external lotion 0.05 % PA; Brand fluticasone propionate FINACEA EXTERNAL 4 penalty external ointment 0.005 2 GEL 15 % applies % fluocinolone acetonide glycolic acid solution 70 2 2 body external oil 0.01 % % fluocinolone acetonide GORDOFILM external cream 0.01 %, 2 EXTERNAL SOLUTION 4 0.025 % 16.7-16.7 % fluocinolone acetonide GUANENDRUX external ointment 0.025 2 EXTERNAL GEL 10-5-40 4 % % fluocinolone acetonide halcinonide external 2 2 external solution 0.01 % cream 0.1 % fluocinolone acetonide halobetasol propionate 2 2 scalp external oil 0.01 % external cream 0.05 % fluocinonide emulsified halobetasol propionate 2 base external cream 0.05 2 external ointment 0.05 % % Brand 4 penalty fluocinonide external 2 HALOG EXTERNAL cream 0.05 % CREAM 0.1 % applies fluocinonide external gel 2 HALOG EXTERNAL 4 0.05 % OINTMENT 0.1 % fluocinonide external 2 hydrocortisone butyr lipo ointment 0.05 % base external cream 0.1 2 fluocinonide external % 2 solution 0.05 % hydrocortisone butyrate 2 fluorouracil external external cream 0.1 % 2 cream 5 % hydrocortisone butyrate 2 fluorouracil external external lotion 0.1 % 2 solution 2 %, 5 % hydrocortisone butyrate 2 external ointment 0.1 % flurandrenolide external 2 cream 0.05 % hydrocortisone butyrate 2 external solution 0.1 %

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 113 Drug Drug Drug Name Notes Drug Name Notes Tier Tier hydrocortisone cream 1 LEVULAN KERASTICK 2 % external (rx) 1 % EXTERNAL SOLUTION GM RECONSTITUTED 20 % hydrocortisone external 2 cream 2.5 % LOYON EXTERNAL 4 SOLUTION hydrocortisone external 2 lotion 2.5 % methoxsalen rapid oral 2 capsule 10 mg hydrocortisone external 2 ointment 2.5 % methyl salicylate external 2 hydrocortisone ointment liquid 2 1 % external (rx) 1 % metronidazole external 2 hydrocortisone valerate cream 0.75 % 2 external cream 0.2 % metronidazole external 2 hydrocortisone valerate gel 0.75 %, 1 % 2 external ointment 0.2 % metronidazole external 2 lotion 0.75 % imiquimod external 2 cream 5 % MICROCYN EXTERNAL 4 LIQUID 0.023 % isotretinoin oral capsule QL (2 EA 2 10 mg, 20 mg, 30 mg, 40 per 1 day) MIRVASO EXTERNAL 4 PA mg GEL 0.33 % isotretinoin oral capsule 2 PA mometasone furoate 2 25 mg, 35 mg external cream 0.1 % ivermectin external mometasone furoate 2 PA 2 cream 1 % external ointment 0.1 % KERALYT EXTERNAL mometasone furoate 4 2 GEL 6 % external solution 0.1 % KERALYT EXTERNAL myorisan oral capsule 10 4 QL (2 EA 2 SHAMPOO 6 % mg, 20 mg, 30 mg, 40 per 1 day) mg KERALYT SCALP 4 EXTERNAL KIT 6 % NEO-SYNALAR KERAMATRIX EXTERNAL CREAM 0.5- 4 REPLICINE 5CMX5CM 4 0.025 % EXTERNAL SHEET nolix external cream 0.05 2 % KLISYRI EXTERNAL 4 PA OINTMENT 1 % nolix external lotion 0.05 2 lactic acid e external % cream 10-3500 %- 2 NUVAIL EXTERNAL 4 unt/30gm SOLUTION lactic acid external lotion OVACE PLUS 2 10 % EXTERNAL CREAM 10 4 %

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 114 Drug Drug Drug Name Notes Drug Name Notes Tier Tier OVACE PLUS REGRANEX EXTERNAL 4 PA EXTERNAL SHAMPOO 4 GEL 0.01 % 10 % RESORCINOL-SULFUR OVACE PLUS WASH EXTERNAL LOTION 2-5 4 EXTERNAL LIQUID 10 4 % % Brand OVACE WASH RETIN-A MICRO 4 penalty EXTERNAL LIQUID 10 4 EXTERNAL GEL 0.1 % applies % Brand pimecrolimus external RETIN-A MICRO PUMP 4 penalty 2 cream 1 % EXTERNAL GEL 0.1 % applies podocon external RHOFADE EXTERNAL 2 4 PA solution 25 % CREAM 1 % podofilox external 2 rosadan external cream 2 solution 0.5 % 0.75 % 2 pramox external gel 1 % rosadan external gel 0.75 2 PRE & POST SX % POUCH EXTERNAL 4 SALEX EXTERNAL 4 THERAPY PACK 4 & 2 & SHAMPOO 6 % 5 % salicylic acid external 2 prednicarbate external foam 6 % 2 ointment 0.1 % salicylic acid external gel 2 PROSILK EXTERNAL 6 % 4 GEL salicylic acid external 2 Brand shampoo 6 % PRUDOXIN EXTERNAL 4 penalty salicylic acid external 2 CREAM 5 % applies solution 26 % PSORCON EXTERNAL 4 salicylic acid wart CREAM 0.05 % remover external liquid 2 PURAPLY EXTERNAL GM 27.5 % SHEET 6X9CM salicylic acid-cleanser 2 PYROGALLIC ACID external kit 6 % (cream) EXTERNAL OINTMENT 4 salimez external cream 6 2 25-2 % % QBREXZA EXTERNAL 4 PA SALIMEZ FORTE PAD 2.4 % EXTERNAL CREAM 10 4 Specialty QUTENZA (2 PATCH) 6 % EXTERNAL KIT 8 % Medical SALVAX DUO PLUS Specialty 4 QUTENZA (4 PATCH) 6 EXTERNAL KIT 6 & 35 EXTERNAL KIT 8 % Medical % Specialty QUTENZA EXTERNAL 6 SALVAX EXTERNAL 4 KIT 8 % Medical FOAM 6 % Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 115 Drug Drug Drug Name Notes Drug Name Notes Tier Tier SANTYL EXTERNAL sulfacetamide sodium- OINTMENT 250 6 sulfur external lotion 10-5 2 UNIT/GM %, 9.8-4.8 % SCALACORT DK sulfacetamide sodium- EXTERNAL KIT 2 & 2-2 4 sulfur external pad 10-4 2 % %, 9.8-4.8 % SCENESSE PA; sulfacetamide sodium- SUBCUTANEOUS 6 Specialty sulfur external 2 IMPLANT 16 MG Medical suspension 10-5 %, 8-4 selenium sulfide external % 2 lotion 2.5 % sulfacetamide-sulfur in selenium sulfide external urea external emulsion 2 2 shampoo 2.25 %, 2.3 % 10-5 % sulfamez wash external SELRX EXTERNAL 4 2 SHAMPOO 2.3 % emulsion 10-1 % tacrolimus external sodium sulfacetamide 2 2 external shampoo 10 % ointment 0.03 %, 0.1 % tazarotene external sodium sulfacetamide 2 2 PA wash external liquid 10 % cream 0.1 % TAZORAC EXTERNAL SODIUM 4 PA SULFACETAMIDE- CREAM 0.05 % 4 BAKUCHIOL EXTERNAL PA; Brand LIQUID 10 % TAZORAC EXTERNAL 4 penalty PA; Brand CREAM 0.1 % applies 4 penalty SOOLANTRA TAZORAC EXTERNAL 4 PA EXTERNAL CREAM 1 % applies GEL 0.05 %, 0.1 % SORIATANE ORAL Brand Brand CAPSULE 10 MG, 25 4 penalty TOPICORT EXTERNAL 4 penalty MG applies OINTMENT 0.25 % applies sss 10-5 external cream 2 tovet external foam 0.05 2 10-5 % % sulfacetamide sodium tretinoin external cream 2 (acne) external lotion 10 2 0.025 %, 0.05 %, 0.1 % % tretinoin external gel 0.01 2 sulfacetamide sodium %, 0.025 % 2 external liquid 10 % tretinoin microsphere sulfacetamide sodium- external gel 0.04 %, 0.1 2 sulfur external cream 10- 2 % 2 %, 10-5 % tretinoin microsphere sulfacetamide sodium- pump external gel 0.04 2 sulfur external emulsion 2 %, 0.1 % 10-5 %

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 116 Drug Drug Drug Name Notes Drug Name Notes Tier Tier triamcinolone acetonide XEROFORM OIL external aerosol solution 2 EMULSION 2"X2" 4 0.147 mg/gm EXTERNAL PAD triamcinolone acetonide XEROFORM OIL external cream 0.025 %, 2 EMULSION GAUZE 4 0.1 %, 0.5 % EXTERNAL PAD triamcinolone acetonide XEROFORM OIL external lotion 0.025 %, 2 EMULSION STRIP 4 0.1 % EXTERNAL triamcinolone acetonide XEROFORM OIL ROLL 4 external ointment 0.025 2 4"X9' EXTERNAL 3 % %, 0.05 %, 0.1 %, 0.5 % XEROFORM PETROLAT 4 TRI-CHLOR EXTERNAL 4 GAUZE 1"X8" LIQUID 80 % EXTERNAL triderm external cream 2 XEROFORM PETROLAT 0.1 %, 0.5 % GAUZE 5"X9" 4 EXTERNAL tritocin external ointment 2 0.05 % XEROFORM PETROLAT turpentine external spirit 2 PATCH 2"X2" 4 EXTERNAL PAD urea external cream 39 2 %, 40 %, 41 %, 45 % XEROFORM PETROLAT PATCH 4"X4" 4 urea external lotion 40 % 2 EXTERNAL PAD urea hydrating external 2 XEROFORM foam 35 % PETROLATUM ROLL 4 urea nail external gel 45 4"X9' EXTERNAL 2 % xurea external cream 39 2 % uredeb external cream 2 39 % zenatane oral capsule 10 QL (2 EA ST; Brand mg, 20 mg, 30 mg, 40 2 per 1 day) VECTICAL EXTERNAL 4 penalty mg OINTMENT 3 MCG/GM applies ZITHRANOL EXTERNAL 4 SHAMPOO 1 % VENELEX EXTERNAL 4 OINTMENT Brand VEREGEN EXTERNAL ZONALON EXTERNAL 4 penalty 4 OINTMENT 15 % CREAM 5 % applies VIRASAL EXTERNAL Diabetes - Antidiabetic 4 LIQUID 27.5 % Agents WINLEVI EXTERNAL acarbose oral tablet 100 4 PA 2 CREAM 1 % mg, 25 mg, 50 mg

XERAC AC EXTERNAL 4 SOLUTION 6.25 %

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 117 Drug Drug Drug Name Notes Drug Name Notes Tier Tier ACTOPLUS MET ORAL Brand BYETTA 5 MCG PEN TABLET 15-500 MG, 15- 4 penalty SUBCUTANEOUS ST; QL 850 MG applies SOLUTION PEN- 3 (1.2 ML per Brand INJECTOR 5 30 days) ACTOS ORAL TABLET 4 penalty MCG/0.02ML applies 15 MG, 30 MG, 45 MG CYCLOSET ORAL 4 ADLYXIN STARTER TABLET 0.8 MG PACK SUBCUTANEOUS DUETACT ORAL Brand 4 ST PEN-INJECTOR KIT 10 TABLET 30-2 MG, 30-4 4 penalty & 20 MCG/0.2ML MG applies ADLYXIN PA; QL (30 SUBCUTANEOUS FARXIGA ORAL 4 EA per 30 SOLUTION PEN- 4 ST TABLET 10 MG, 5 MG days) INJECTOR 20 glimepiride oral tablet 1 1 MCG/0.2ML mg, 2 mg, 4 mg ALOGLIPTIN PA; QL (30 glipizide er oral tablet BENZOATE ORAL 4 EA per 30 extended release 24 hour 2 TABLET 12.5 MG, 25 days) 10 mg, 2.5 mg, 5 mg MG, 6.25 MG glipizide oral tablet 10 ALOGLIPTIN- 1 PA; QL (60 mg, 5 mg METFORMIN HCL ORAL 4 EA per 30 glipizide xl oral tablet TABLET 12.5-1000 MG, days) 12.5-500 MG extended release 24 hour 2 10 mg, 2.5 mg, 5 mg ALOGLIPTIN- PIOGLITAZONE ORAL glipizide-metformin hcl PA; QL (30 oral tablet 2.5-250 mg, 2 TABLET 12.5-15 MG, 4 EA per 30 12.5-30 MG, 12.5-45 2.5-500 mg, 5-500 mg days) MG, 25-15 MG, 25-30 GLUCOTROL XL ORAL Brand MG, 25-45 MG TABLET EXTENDED 4 penalty RELEASE 24 HOUR 10 Brand applies AMARYL ORAL TABLET 4 penalty MG, 2.5 MG, 5 MG 1 MG, 2 MG, 4 MG applies glyburide micronized oral 2 BYDUREON BCISE tablet 1.5 mg, 3 mg, 6 mg ST; QL glyburide oral tablet 1.25 2 SUBCUTANEOUS 3 (3.4 ML per mg, 2.5 mg, 5 mg 28 days) AUTO-INJECTOR 2 glyburide-metformin oral MG/0.85ML tablet 1.25-250 mg, 2.5- 2 BYETTA 10 MCG PEN 500 mg, 5-500 mg ST; QL SUBCUTANEOUS GLYNASE ORAL Brand 3 (2.4 ML per SOLUTION PEN- TABLET 1.5 MG, 3 MG, 4 penalty 30 days) INJECTOR 10 6 MG applies MCG/0.04ML GLYXAMBI ORAL PA; QL (30 TABLET 10-5 MG, 25-5 4 EA per 30 MG days) Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 118 Drug Drug Drug Name Notes Drug Name Notes Tier Tier INVOKAMET ORAL KAZANO ORAL TABLET PA; QL (60 ST; QL (60 4 EA per 30 TABLET 150-1000 MG, 3 EA per 30 12.5-1000 MG, 12.5-500 days) 150-500 MG, 50-1000 days) MG MG, 50-500 MG KOMBIGLYZE XR ORAL PA; QL (60 INVOKAMET XR ORAL TABLET EXTENDED 4 EA per 30 TABLET EXTENDED ST; QL (60 RELEASE 24 HOUR 2.5- days) RELEASE 24 HOUR 1000 MG 3 EA per 30 150-1000 MG, 150-500 KOMBIGLYZE XR ORAL days) PA; QL (30 MG, 50-1000 MG, 50- TABLET EXTENDED 4 EA per 30 500 MG RELEASE 24 HOUR 5- days) INVOKANA ORAL ST; QL (30 1000 MG, 5-500 MG TABLET 100 MG, 300 3 EA per 30 metformin hcl er oral MG days) tablet extended release 1 JANUMET ORAL ST; QL (60 24 hour 500 mg, 750 mg TABLET 50-1000 MG, 3 EA per 30 metformin hcl oral 2 50-500 MG days) solution 500 mg/5ml JANUMET XR ORAL metformin hcl oral tablet TABLET EXTENDED ST; QL (30 1000 mg, 500 mg, 850 1 RELEASE 24 HOUR 3 EA per 30 mg 100-1000 MG, 50-500 days) miglitol oral tablet 100 MG 2 mg, 25 mg, 50 mg JANUMET XR ORAL ST; QL (60 nateglinide oral tablet TABLET EXTENDED 2 3 EA per 30 120 mg, 60 mg RELEASE 24 HOUR 50- days) 1000 MG NESINA ORAL TABLET PA; QL (30 ST; QL (30 12.5 MG, 25 MG, 6.25 4 EA per 30 JANUVIA ORAL TABLET 3 EA per 30 MG days) 100 MG, 25 MG, 50 MG days) PA; QL (30 ST; QL (30 ONGLYZA ORAL 4 EA per 30 JARDIANCE ORAL 3 EA per 30 TABLET 2.5 MG, 5 MG days) TABLET 10 MG, 25 MG days) OSENI ORAL TABLET JENTADUETO ORAL ST; QL (60 12.5-15 MG, 12.5-30 PA; QL (30 TABLET 2.5-1000 MG, 3 EA per 30 MG, 12.5-45 MG, 25-15 4 EA per 30 2.5-500 MG, 2.5-850 MG days) MG, 25-30 MG, 25-45 days) MG JENTADUETO XR ORAL ST; QL (60 OZEMPIC TABLET EXTENDED 3 EA per 30 ST; QL RELEASE 24 HOUR 2.5- SUBCUTANEOUS days) 3 (1.5 ML per 1000 MG SOLUTION PEN- 28 days) INJECTOR 2 MG/1.5ML JENTADUETO XR ORAL ST; QL (30 TABLET EXTENDED OZEMPIC 3 EA per 30 SUBCUTANEOUS ST; QL (3 RELEASE 24 HOUR 5- days) 1000 MG SOLUTION PEN- 3 ML per 28 INJECTOR 2 MG/1.5ML, days) 4 MG/3ML

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 119 Drug Drug Drug Name Notes Drug Name Notes Tier Tier pioglitazone hcl oral SYMLINPEN 120 tablet 15 mg, 30 mg, 45 2 SUBCUTANEOUS mg SOLUTION PEN- 4 ST pioglitazone hcl- INJECTOR 2700 glimepiride oral tablet 30- 2 MCG/2.7ML 2 mg, 30-4 mg SYMLINPEN 60 pioglitazone hcl- SUBCUTANEOUS metformin hcl oral tablet 2 SOLUTION PEN- 4 ST 15-500 mg, 15-850 mg INJECTOR 1500 MCG/1.5ML PRECOSE ORAL Brand TABLET 100 MG, 25 4 penalty SYNJARDY ORAL ST; QL (60 MG, 50 MG applies TABLET 12.5-1000 MG, 3 EA per 30 12.5-500 MG, 5-1000 days) PA; QL (30 MG, 5-500 MG QTERN ORAL TABLET 4 EA per 30 10-5 MG days) SYNJARDY XR ORAL TABLET EXTENDED ST; QL (60 PA; QL (1 RELEASE 24 HOUR 10- 3 EA per 30 QTERN ORAL TABLET 4 EA per 1 1000 MG, 12.5-1000 MG, days) 5-5 MG day) 25-1000 MG, 5-1000 MG repaglinide oral tablet 0.5 tolbutamide oral tablet 2 2 mg, 1 mg, 2 mg 500 mg Brand ST; QL (30 RIOMET ORAL 4 penalty TRADJENTA ORAL 3 EA per 30 SOLUTION 500 MG/5ML applies TABLET 5 MG days) RYBELSUS ORAL ST; QL (30 TRIJARDY XR ORAL TABLET 14 MG, 3 MG, 7 3 EA per 30 TABLET EXTENDED PA; QL (30 MG days) RELEASE 24 HOUR 10- 4 EA per 30 5-1000 MG, 25-5-1000 days) SEGLUROMET ORAL PA; QL (60 MG TABLET 2.5-1000 MG, 4 EA per 30 2.5-500 MG, 7.5-1000 days) TRIJARDY XR ORAL MG, 7.5-500 MG TABLET EXTENDED PA; QL (60 SOLIQUA RELEASE 24 HOUR 4 EA per 30 SUBCUTANEOUS PA; QL (18 12.5-2.5-1000 MG, 5-2.5- days) SOLUTION PEN- 4 ML per 30 1000 MG INJECTOR 100-33 UNT- days) TRULICITY MCG/ML SUBCUTANEOUS PA; QL (30 SOLUTION PEN- ST; QL (4 STEGLATRO ORAL 4 EA per 30 INJECTOR 0.75 3 ML per 28 TABLET 15 MG, 5 MG days) MG/0.5ML, 1.5 days) STEGLUJAN ORAL PA; QL (30 MG/0.5ML, 3 MG/0.5ML, TABLET 15-100 MG, 5- 4 EA per 30 4.5 MG/0.5ML 100 MG days)

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 120 Drug Drug Drug Name Notes Drug Name Notes Tier Tier VICTOZA SOLUTION DEXCOM G4 / G5 / G6 PEN-INJECTOR 18 ST; QL (6 RECEIVER, 3 ML per 30 MG/3ML TRANSMITTER, 4 SUBCUTANEOUS 18 days) SENSOR (INCLUDING MG/3ML PLATINUM, PLATINUM VICTOZA SOLUTION PEDIATRIC) DEVICE PEN-INJECTOR 18 ST; QL (9 FREESTYLE FREEDOM 3 MG/3ML 3 ML per 30 LITE KIT W/DEVICE SUBCUTANEOUS 18 days) FREESTYLE INSULINX 3 MG/3ML SYSTEM KIT W/DEVICE XIGDUO XR ORAL QL (150 TABLET EXTENDED PA; QL (30 FREESTYLE INSULINX 3 EA per 30 RELEASE 24 HOUR 10- 4 EA per 30 TEST IN VITRO STRIP days) 1000 MG, 10-500 MG, 5- days) 500 MG FREESTYLE LIBRE 14 3 DAY READER DEVICE XIGDUO XR ORAL TABLET EXTENDED FREESTYLE LIBRE 14 4 PA 3 RELEASE 24 HOUR 2.5- DAY SENSOR 1000 MG FREESTYLE LIBRE 2 3 XIGDUO XR ORAL READER DEVICE PA; QL (60 TABLET EXTENDED FREESTYLE LIBRE 2 4 EA per 30 3 RELEASE 24 HOUR 5- days) SENSOR 1000 MG FREESTYLE LIBRE 3 XULTOPHY READER DEVICE PA; QL (15 SUBCUTANEOUS FREESTYLE LIBRE 4 ML per 30 3 SOLUTION PEN- SENSOR SYSTEM INJECTOR 100-3.6 days) UNIT-MG/ML QL (150 FREESTYLE LITE TEST 3 EA per 30 Diabetes - Glucose IN VITRO STRIP days) Monitoring FREESTYLE QL (150 ACCU-CHEK FASTCLIX 1 PRECISION NEO TEST 3 EA per 30 LANCET KIT KIT IN VITRO STRIP days) ACCU-CHEK SOFTCLIX QL (150 1 LANCET DEVICE KIT FREESTYLE TEST IN 3 EA per 30 KIT VITRO STRIP days) AUTOLET II CLINISAFE GENTEEL LANCING KIT 1 1 KIT (BLUE) KIT DEXCOM G4 / G5 / G6 LANCETS 1 RECEIVER, TRANSMITTER, QL (150 4 SENSOR (INCLUDING PRECISION PCX PLUS 3 EA per 30 PLATINUM, PLATINUM TEST IN VITRO STRIP days) PEDIATRIC)

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 121 Drug Drug Drug Name Notes Drug Name Notes Tier Tier QL (150 Diabetes - Insulins PRECISION QID TEST 3 EA per 30 ADMELOG SOLOSTAR IN VITRO STRIP days) ST; QL (60 SUBCUTANEOUS 4 ML per 30 QL (150 SOLUTION PEN- days) PRECISION SOF-TACT 3 EA per 30 INJECTOR 100 UNIT/ML TEST IN VITRO STRIP days) ADMELOG ST; QL (60 PRECISION XTRA QL (150 SUBCUTANEOUS 4 ML per 30 BLOOD GLUCOSE IN 3 EA per 30 SOLUTION 100 UNIT/ML days) VITRO STRIP days) QL (270 PRECISION XTRA AFREZZA INHALATION 4 EA per 30 3 DEVICE POWDER 12 UNIT days) Diabetes - Glycemic AFREZZA INHALATION QL (360 Agents POWDER 4 & 8 & 12 4 EA per 30 BAQSIMI ONE PACK UNIT, 8 UNIT, 90 X 8 days) NASAL POWDER 3 4 UNIT & 90X12 UNIT MG/DOSE AFREZZA INHALATION QL (540 BAQSIMI TWO PACK POWDER 4 UNIT, 90 X 4 EA per 30 days) NASAL POWDER 3 4 4 UNIT & 90X8 UNIT MG/DOSE APIDRA SOLOSTAR ST; QL (60 SUBCUTANEOUS diazoxide oral 4 ML per 30 2 SOLUTION PEN- suspension 50 mg/ml days) INJECTOR 100 UNIT/ML GLUCAGEN HYPOKIT INJECTION SOLUTION 3 APIDRA VIAL ST; QL (60 RECONSTITUTED 1 MG INJECTION SOLUTION 4 ML per 30 100 UNIT/ML days) glucagon emergency kit 2 1 mg injection 1 mg BD AUTOSHIELD DUO PEN NEEDLES 30G X 5 3 GLUCAGON Brand MM EMERGENCY KIT 1 MG 3 penalty INJECTION 1 MG applies BD ULTRA-FINE GLUCAGON 27G X 1/2" 1 ML, 29G X EMERGENCY KIT 1/2" 0.3 ML, 29G X 1/2" INJECTION SOLUTION GM 0.5 ML, 29G X 1/2" 1 ML, RECONSTITUTED 1 30G X 1/2" 0.3 ML, 30G MG/ML X 1/2" 0.5 ML, 30G X 3 GVOKE PFS 1/2" 1 ML, 31G X 15/64" SUBCUTANEOUS 0.3 ML, 31G X 15/64" 0.5 SOLUTION PREFILLED 4 ML, 31G X 15/64" 1 ML, SYRINGE 0.5 31G X 5/16" 0.3 ML, 31G MG/0.1ML, 1 MG/0.2ML X 5/16" 0.5 ML, 31G X PROGLYCEM ORAL Brand 5/16" 1 ML, 31G X 6MM SUSPENSION 50 4 penalty 0.5 ML MG/ML applies

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 122 Drug Drug Drug Name Notes Drug Name Notes Tier Tier BD ULTRA-FINE PEN HUMALOG MIX 75/25 QL (60 ML NEEDLES 29G X VIAL SUBCUTANEOUS 3 per 30 3 12.7MM , 31G X 5 MM , SUSPENSION (75-25) days) 31G X 8 MM , 32G X 4 100 UNIT/ML MM , 32G X 6 MM HUMALOG QL (60 ML BD VEO INSULIN SYR SUBCUTANEOUS 3 per 30 U/F 1/2UNIT 31G X 3 SOLUTION 100 UNIT/ML days) 15/64" 0.3 ML HUMALOG QL (60 ML DROPLET MICRON 34G SUBCUTANEOUS 3 3 per 30 X 3.5 MM SOLUTION CARTRIDGE days) FIASP FLEXTOUCH 100 UNIT/ML ST; QL (60 SUBCUTANEOUS 4 ML per 30 HUMALOG U-100 QL (60 ML SOLUTION PEN- days) JUNIOR KWIKPEN INJECTOR 100 UNIT/ML SUBCUTANEOUS 3 per 30 FIASP PENFILL SOLUTION PEN- days) ST; QL (60 INJECTOR 100 UNIT/ML SUBCUTANEOUS 4 ML per 30 SOLUTION CARTRIDGE HUMULIN 70/30 days) 100 UNIT/ML KWIKPEN QL (60 ML SUBCUTANEOUS FIASP ST; QL (60 3 per 30 SUSPENSION PEN- SUBCUTANEOUS 4 ML per 30 days) SOLUTION 100 UNIT/ML days) INJECTOR (70-30) 100 UNIT/ML HUMALOG KWIKPEN SUBCUTANEOUS QL (60 ML HUMULIN 70/30 VIAL QL (60 ML SOLUTION PEN- 3 per 30 SUBCUTANEOUS 3 per 30 INJECTOR 100 days) SUSPENSION (70-30) days) UNIT/ML, 200 UNIT/ML 100 UNIT/ML HUMULIN N KWIKPEN HUMALOG MIX 50/50 QL (60 ML KWIKPEN SUBCUTANEOUS QL (60 ML 3 per 30 SUBCUTANEOUS SUSPENSION PEN- 3 per 30 days) SUSPENSION PEN- INJECTOR 100 UNIT/ML days) INJECTOR (50-50) 100 HUMULIN N VIAL QL (60 ML UNIT/ML SUBCUTANEOUS 3 per 30 HUMALOG MIX 50/50 SUSPENSION 100 days) QL (60 ML UNIT/ML VIAL SUBCUTANEOUS 3 per 30 SUSPENSION (50-50) days) HUMULIN R U-500 100 UNIT/ML KWIKPEN QL (60 ML HUMALOG MIX 75/25 SUBCUTANEOUS 3 per 30 KWIKPEN SOLUTION PEN- days) QL (60 ML SUBCUTANEOUS INJECTOR 500 UNIT/ML 3 per 30 SUSPENSION PEN- HUMULIN R U-500 VIAL QL (60 ML days) INJECTOR (75-25) 100 SUBCUTANEOUS 3 per 30 UNIT/ML SOLUTION 500 UNIT/ML days)

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 123 Drug Drug Drug Name Notes Drug Name Notes Tier Tier HUMULIN R VIAL QL (60 ML INSULIN SYRINGES INJECTION SOLUTION 3 per 30 27G X 1/2" 0.5 ML, 27G 100 UNIT/ML days) X 1/2" 1 ML, 28G X 1/2" INSULIN ASP PROT & 0.5 ML, 28G X 1/2" 1 ML, ASP FLEXPEN 29G X 1/2" 0.3 ML, 29G ST; QL (60 X 1/2" 0.5 ML, 29G X SUBCUTANEOUS 4 ML per 30 SUSPENSION PEN- 1/2" 1 ML, 30G X 1/2" 0.3 days) INJECTOR (70-30) 100 ML, 30G X 1/2" 0.5 ML, UNIT/ML 30G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 3 INSULIN ASPART 5/16" 0.5 ML, 30G X FLEXPEN ST; QL (60 5/16" 1 ML, 31G X 15/64" SUBCUTANEOUS 4 ML per 30 0.3 ML, 31G X 15/64" 0.5 SOLUTION PEN- days) ML, 31G X 15/64" 1 ML, INJECTOR 100 UNIT/ML 31G X 5/16" 0.3 ML, 31G INSULIN ASPART X 5/16" 0.5 ML, 31G X PENFILL ST; QL (60 5/16" 1 ML, 32G X 5/16" SUBCUTANEOUS 4 ML per 30 0.5 ML, 32G X 5/16" 1 SOLUTION CARTRIDGE days) ML 100 UNIT/ML LANTUS SOLOSTAR QL (60 ML INSULIN ASPART PROT SUBCUTANEOUS 3 per 30 ST; QL (60 & ASPART SOLUTION PEN- days) SUBCUTANEOUS 4 ML per 30 INJECTOR 100 UNIT/ML SUSPENSION (70-30) days) LANTUS U-100 VIAL QL (60 ML 100 UNIT/ML SUBCUTANEOUS 3 per 30 INSULIN ASPART ST; QL (60 SOLUTION 100 UNIT/ML days) SUBCUTANEOUS 4 ML per 30 LEVEMIR U-100 SOLUTION 100 UNIT/ML days) FLEXTOUCH QL (60 ML INSULIN PEN NEEDLES SUBCUTANEOUS 3 per 30 29G X 12.7MM , 29G X SOLUTION PEN- days) 12MM , 29G X 5MM , INJECTOR 100 UNIT/ML 29G X 8MM , 30G X 5 LEVEMIR U-100 VIAL QL (60 ML MM , 30G X 6 MM , 30G SUBCUTANEOUS 3 per 30 X 8 MM , 31G X 4 MM , 3 SOLUTION 100 UNIT/ML days) 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G MYXREDLIN INTRAVENOUS X 4 MM , 32G X 5 MM , GM 32G X 6 MM , 32G X 8 SOLUTION 100-0.9 MM , 33G X 4 MM , 33G UT/100ML-% X 5 MM , 33G X 6 MM NOVOFINE AUTOCOVER PEN 3 NEEDLE 30G X 8 MM

NOVOFINE PEN 3 NEEDLE 32G X 6 MM NOVOFINE PLUS PEN 3 NEEDLE 32G X 4 MM Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 124 Drug Drug Drug Name Notes Drug Name Notes Tier Tier NOVOLIN 70/30 NOVOLOG FLEXPEN ST; QL (60 FLEXPEN RELION ST; QL (60 RELION 4 ML per 30 SUBCUTANEOUS 4 ML per 30 SUBCUTANEOUS days) SUSPENSION PEN- days) SOLUTION PEN- INJECTOR (70-30) 100 INJECTOR 100 UNIT/ML UNIT/ML NOVOLOG FLEXPEN ST; QL (60 NOVOLIN 70/30 SUBCUTANEOUS 4 ML per 30 FLEXPEN SOLUTION PEN- ST; QL (60 days) SUBCUTANEOUS INJECTOR 100 UNIT/ML 4 ML per 30 SUSPENSION PEN- days) NOVOLOG MIX 70/30 INJECTOR (70-30) 100 FLEXPEN UNIT/ML ST; QL (60 SUBCUTANEOUS 4 ML per 30 NOVOLIN 70/30 RELION ST; QL (60 SUSPENSION PEN- days) SUBCUTANEOUS 4 ML per 30 INJECTOR (70-30) 100 SUSPENSION (70-30) days) UNIT/ML 100 UNIT/ML NOVOLOG MIX 70/30 NOVOLIN 70/30 VIAL RELION ST; QL (60 ST; QL (60 SUBCUTANEOUS SUBCUTANEOUS 4 ML per 30 4 ML per 30 SUSPENSION (70-30) SUSPENSION (70-30) days) days) 100 UNIT/ML 100 UNIT/ML

NOVOLIN N RELION ST; QL (60 NOVOLOG MIX 70/30 ST; QL (60 SUBCUTANEOUS 4 ML per 30 VIAL SUBCUTANEOUS 4 ML per 30 SUSPENSION 100 days) SUSPENSION (70-30) days) UNIT/ML 100 UNIT/ML

NOVOLIN N VIAL ST; QL (60 NOVOLOG PENFILL ST; QL (60 SUBCUTANEOUS SUBCUTANEOUS 4 ML per 30 4 ML per 30 SUSPENSION 100 SOLUTION CARTRIDGE days) days) UNIT/ML 100 UNIT/ML NOVOLIN R RELION ST; QL (60 NOVOLOG RELION ST; QL (60 INJECTION SOLUTION 4 ML per 30 SUBCUTANEOUS 4 ML per 30 100 UNIT/ML days) SOLUTION 100 UNIT/ML days) NOVOLIN R VIAL ST; QL (60 NOVOLOG U-100 VIAL ST; QL (60 INJECTION SOLUTION 4 ML per 30 SUBCUTANEOUS 4 ML per 30 100 UNIT/ML days) SOLUTION 100 UNIT/ML days)

NOVOLOG 70/30 NOVOTWIST PEN 3 FLEXPEN RELION NEEDLE 32G X 5 MM ST; QL (60 SUBCUTANEOUS 4 ML per 30 TOUJEO MAX SUSPENSION PEN- days) SOLOSTAR QL (60 ML INJECTOR (70-30) 100 SUBCUTANEOUS 3 per 30 UNIT/ML SOLUTION PEN- days) INJECTOR 300 UNIT/ML

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 125 Drug Drug Drug Name Notes Drug Name Notes Tier Tier TOUJEO SOLOSTAR AMINOSYN II QL (60 ML GM SUBCUTANEOUS 3 per 30 INTRAVENOUS SOLUTION PEN- days) SOLUTION 10 %, 15 % INJECTOR 300 UNIT/ML AMINOSYN-PF TRESIBA FLEXTOUCH INTRAVENOUS GM SUBCUTANEOUS QL (60 ML SOLUTION 10 %, 7 % SOLUTION PEN- 3 per 30 ANIMI-3 ORAL 4 INJECTOR 100 days) CAPSULE 1 MG UNIT/ML, 200 UNIT/ML ANIMI-3/VITAMIN D 4 TRESIBA QL (60 ML ORAL CAPSULE 1 MG SUBCUTANEOUS 3 per 30 SOLUTION 100 UNIT/ML days) AQUASOL A INTRAMUSCULAR GM ULTIGUARD SOLUTION 50000 SAFEPACK UNIT/ML SYR/NEEDLE 30G X 1/2" 0.3 ML, 30G X 1/2" ARGININE HCL 3 0.5 ML, 30G X 1/2" 1 ML, INJECTION SOLUTION GM 31G X 5/16" 0.3 ML, 31G 6 GM/30ML X 5/16" 0.5 ML, 31G X argyle sterile saline 2 5/16" 1 ML irrigation solution 0.9 % Electrolytes / Minerals / argyle sterile water 2 Metals / Vitamins irrigation solution ABANEU-SL ASCOR INTRAVENOUS GM SUBLINGUAL TABLET 4 SOLUTION 25000 SUBLINGUAL 600-600 MG/50ML MCG ASCORBIC ACID ACTIVE FE ORAL 4 INTRAVENOUS GM TABLET 75-1.25 MG SOLUTION 15000 ACTIVITE ORAL MG/30ML 4 TABLET 1 MG ATABEX OB ORAL 4 adc/f (0.5mg/ml) oral TABLET 29-1 MG 2 solution 0.5 mg/ml b-6 folic acid oral capsule 2 ADENOCAINE 8.333-100-1 mg 4 INTRAVENOUS GM BACMIN ORAL TABLET SOLUTION PREFILLED biocel oral tablet 2 SYRINGE BIOPAR DELTA-FORTE 4 ADRENAL C FORMULA 4 ORAL CAPSULE ORAL TABLET bp vit 3 oral capsule 1 aminoamrms oral 2 2 mg capsule b-plex oral tablet 2 aminoreliefrms oral 2 capsule b-plex plus oral tablet 2

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 126 Drug Drug Drug Name Notes Drug Name Notes Tier Tier CALCIFOL ORAL CARDIOPLEGIA MAIN 4 WAFER 1342-1.6 MG PLASMA-TROME GM PERFUSION SOLUTION calcium chloride solution GM 10 % intravenous 10 % CARDIOPLEGIA CALCIUM CHLORIDE MAINTENANCE GM SOLUTION 10 % GM PERFUSION SOLUTION INTRAVENOUS 10 % CARDIOPLEGIA CALCIUM GLUCONATE- REPERFUSATE 4:1 GM NACL INTRAVENOUS PERFUSION SOLUTION SOLUTION 1-0.675 GM CARDIOPLEGIC GM GM/50ML-%, 2-0.675 SOLUTION PERFUSION GM/100ML-% cardioplegic solution GM CALCIUM-FOLIC ACID perfusion PLUS D ORAL WAFER 4 CARNITOR 1342-1 MG INTRAVENOUS GM CARBAGLU ORAL 6 PA SOLUTION 200 MG/ML TABLET 200 MG Brand CARDIOPLEGIA DEL CARNITOR ORAL 4 penalty NIDO FORMULA GM SOLUTION 1 GM/10ML applies PERFUSION SOLUTION Brand CARDIOPLEGIA IND CARNITOR ORAL 4 penalty PLASMA HIGH K GM TABLET 330 MG applies PERFUSION SOLUTION Brand CARDIOPLEGIA IND CARNITOR SF ORAL 4 penalty PLASMA-TROMET GM SOLUTION 1 GM/10ML applies PERFUSION SOLUTION CENTRATEX ORAL 4 CARDIOPLEGIA CAPSULE 106-1 MG INDUCTION HIGH K GM CHEMET ORAL 4 PERFUSION SOLUTION CAPSULE 100 MG CARDIOPLEGIA CHROMAGEN ORAL 4 INDUCTION LOW DEX GM CAPSULE PERFUSION SOLUTION chromic chloride CARDIOPLEGIA intravenous solution 40 GM INDUCTION NON-ENR GM mcg/10ml PERFUSION SOLUTION CITRANATAL MEDLEY CARDIOPLEGIA MAIN ORAL CAPSULE 27-1- 4 LOW DEXTROSE GM 200 MG PERFUSION SOLUTION CLINIMIX E/DEXTROSE CARDIOPLEGIA MAIN (2.75/5) INTRAVENOUS GM GM LOW TROMETHA SOLUTION 2.75 % PERFUSION SOLUTION

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 127 Drug Drug Drug Name Notes Drug Name Notes Tier Tier CLINIMIX E/DEXTROSE CLINISOL SF GM (4.25/10) GM INTRAVENOUS INTRAVENOUS SOLUTION 15 % SOLUTION 4.25 % CLINOLIPID CLINIMIX E/DEXTROSE INTRAVENOUS GM (4.25/5) INTRAVENOUS GM EMULSION 20 % SOLUTION 4.25 % clovique oral capsule 250 6 PA CLINIMIX E/DEXTROSE mg (5/15) INTRAVENOUS GM cod liver oil oral oil 2 SOLUTION 5 % corvita 150 oral tablet 2 CLINIMIX E/DEXTROSE 150-1.25 mg (5/20) INTRAVENOUS GM CORVITA ORAL SOLUTION 5 % 4 TABLET 1.25 MG CLINIMIX E/DEXTROSE (8/10) INTRAVENOUS GM CORVITE 150 ORAL 4 SOLUTION 8 % TABLET , 150-1.25 MG CLINIMIX E/DEXTROSE CORVITE FE ORAL 4 (8/14) INTRAVENOUS GM TABLET SOLUTION 8 % CUPRIC CHLORIDE CLINIMIX/DEXTROSE INTRAVENOUS GM (4.25/10) SOLUTION 0.4 MG/ML GM INTRAVENOUS curity sterile saline 2 SOLUTION 4.25 % irrigation solution 0.9 % CLINIMIX/DEXTROSE cyanocobalamin injection 2 (4.25/5) INTRAVENOUS GM solution 1000 mcg/ml SOLUTION 4.25 % CYANOCOBALAMIN CLINIMIX/DEXTROSE INJECTION SOLUTION GM (5/15) INTRAVENOUS GM 2000 MCG/ML SOLUTION 5 % cytra k crystals oral 2 CLINIMIX/DEXTROSE packet 3300-1002 mg (5/20) INTRAVENOUS GM DAYAVITE ORAL 4 SOLUTION 5 % TABLET CLINIMIX/DEXTROSE DECARA ORAL GM (6/5) INTRAVENOUS CAPSULE 1.25 MG 2 SOLUTION 6 % (50000 UT) CLINIMIX/DEXTROSE deferasirox granules oral GM (8/10) INTRAVENOUS packet 180 mg, 360 mg, 6 PA SOLUTION 8 % 90 mg CLINIMIX/DEXTROSE deferasirox oral packet GM 6 PA (8/14) INTRAVENOUS 180 mg, 360 mg, 90 mg SOLUTION 8 % deferasirox oral tablet 5 PA 180 mg, 360 mg, 90 mg

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 128 Drug Drug Drug Name Notes Drug Name Notes Tier Tier deferasirox oral tablet dextrose intravenous soluble 125 mg, 250 mg, 5 PA solution 10 %, 20 %, 40 GM 500 mg %, 5 %, 70 % deferiprone oral tablet 6 PA DEXTROSE SOLUTION 500 mg 250 MG/ML GM DELFLEX-LC/1.5% INTRAVENOUS 250 MG/ML DEXTROSE 4 INTRAPERITONEAL dextrose solution 250 SOLUTION 344 MOSM/L mg/ml intravenous 250 GM DELFLEX-LC/2.5% mg/ml DEXTROSE DEXTROSE SOLUTION 4 INTRAPERITONEAL 50 % INTRAVENOUS 50 GM SOLUTION 394 MOSM/L %

DELFLEX-LC/4.25% dextrose solution 50 % GM DEXTROSE 4 intravenous 50 % INTRAPERITONEAL dextrose-nacl SOLUTION 483 MOSM/L intravenous solution 10- DELFLEX-SM/1.5% 0.2 %, 10-0.45 %, 2.5- GM DEXTROSE 0.45 %, 5-0.2 %, 5-0.33 4 INTRAPERITONEAL %, 5-0.45 %, 5-0.9 % SOLUTION 347 MOSM/L dextrose-sodium chloride DELFLEX-SM/2.5% intravenous solution 2.5- GM DEXTROSE 4 0.45 %, 5-0.225 %, 5-0.3 INTRAPERITONEAL %, 5-0.45 %, 5-0.9 % SOLUTION 398 MOSM/L DIALYVITE 3000 ORAL 4 DERMACINRX TABLET 3 MG PRETRATE ORAL 4 DIALYVITE 5000 ORAL 4 TABLET 1 MG TABLET 5 MG DERMACINRX DIALYVITE ORAL 4 RIBOTIN-E ORAL 4 TABLET TABLET DIALYVITE SUPREME D 4 DERMACINRX ORAL TABLET 3 MG ZINTREXYL-C ORAL 4 DIALYVITE/ZINC ORAL TABLET 4 TABLET DEXIFOL ORAL TABLET 4 5 MG DIANEAL LOW CALCIUM/1.5% DEX 4 DEXTROSE INTRAPERITONEAL 5%/ELECTROLYTE #48 GM SOLUTION 344 MOSM/L INTRAVENOUS SOLUTION DIANEAL LOW CALCIUM/2.5% DEX 4 dextrose in lactated INTRAPERITONEAL ringers intravenous GM SOLUTION 395 MOSM/L solution 5 %

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 129 Drug Drug Drug Name Notes Drug Name Notes Tier Tier DIANEAL LOW EXTRANEAL 4 CALCIUM/4.25% DEX 4 INTRAPERITONEAL INTRAPERITONEAL SOLUTION 7.5 % SOLUTION 483 MOSM/L fabb oral tablet 2.2-25-1 2 DIANEAL PD-2/1.5% mg DEXTROSE 4 fa-vitamin b-6-vitamin b- INTRAPERITONEAL 12 oral tablet 2.2-25-0.5 2 SOLUTION 346 MOSM/L mg DIANEAL PD-2/2.5% FERAHEME DEXTROSE INTRAVENOUS 4 GM INTRAPERITONEAL SOLUTION 510 SOLUTION 396 MOSM/L MG/17ML DIANEAL PD-2/4.25% FERIVAFA ORAL 4 DEXTROSE 4 CAPSULE 110-1 MG INTRAPERITONEAL SOLUTION 485 MOSM/L ferocon oral capsule 2 DILUENT FOR ferotrinsic oral capsule 2 LEFAMULIN GM FERRALET 90 ORAL 4 INTRAVENOUS TABLET 90-1 MG SOLUTION 0.9 % FERRAPLUS 90 ORAL 4 DRISDOL ORAL Brand TABLET 90-1 MG 4 penalty CAPSULE 1.25 MG FERRIPROX ORAL applies 6 PA (50000 UT) SOLUTION 100 MG/ML EFFER-K ORAL TABLET FERRIPROX ORAL 4 EFFERVESCENT 10 TABLET 1000 MG, 500 6 PA MEQ, 20 MEQ MG effer-k oral tablet 2 FERRIPROX TWICE-A- effervescent 25 meq DAY ORAL TABLET 6 PA ELITE-OB ORAL 4 1000 MG TABLET 50-1.25 MG FERRLECIT ELLIOTTS B INTRAVENOUS GM INTRATHECAL GM SOLUTION 12.5 MG/ML SOLUTION FERRO-PLEX 4 ENBRACE HR ORAL 4 HEMATINIC ORAL CAPSULE TABLET 115-1 MG ergocalciferol oral ferumoxytol intravenous GM capsule 1.25 mg (50000 2 solution 510 mg/17ml ut) FLORIVA PLUS ORAL 4 EXJADE ORAL TABLET SOLUTION 0.25 MG/ML SOLUBLE 125 MG, 250 6 PA fluoritab oral solution PV MG, 500 MG 0.275 (0.125 f) mg/drop folate oral tablet 400 mcg PV

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 130 Drug Drug Drug Name Notes Drug Name Notes Tier Tier folbee plus oral tablet 2 HEMATOGEN FA ORAL CAPSULE 200-250-0.01- 4 FOLGARD OS ORAL 4 TABLET 500-1.1 MG 1 MG HEMATRON-AF ORAL FOLGARD RX ORAL 4 4 TABLET 2.2-25-1 MG TABLET 150-1 MG HEMOCYTE PLUS folic acid injection GM solution 5 mg/ml ORAL CAPSULE 106-1 4 MG folic acid oral tablet 1 mg 2 hemocyte-f oral tablet 2 folic acid oral tablet 400 PV 324-1 mg mcg, 800 mcg hydroxocobalamin FOLITIN-Z ORAL 4 acetate intramuscular GM TABLET solution 1000 mcg/ml FOLIVANE-F ORAL 4 HYLAVITE ORAL 4 CAPSULE 125-1 MG TABLET FOLIVANE-PLUS ORAL 4 HYLAZINC ORAL 4 CAPSULE TABLET folplex 2.2 oral tablet 2.2- 2 HYPERLYTE-CR 25-0.5 mg INTRAVENOUS GM CONCENTRATE FOLTRATE ORAL 4 TABLET 500-1 MCG-MG ICAR-C PLUS ORAL foltrin oral capsule 2 TABLET 100-250-0.025- 4 FREAMINE III 1 MG INTRAVENOUS GM iferex 150 forte oral SOLUTION 10 % capsule 150-25-1 mg- 2 FUSION PLUS ORAL mcg-mg 4 CAPSULE INFED INJECTION GM GALZIN ORAL SOLUTION 50 MG/ML CAPSULE 25 MG, 50 3 INFUVITE ADULT MG INTRAVENOUS GM INJECTABLE GENICIN VITA-S ORAL 4 TABLET 1 MG INFUVITE PEDIATRIC GM GLUTATHIONE INTRAVENOUS INJECTION SOLUTION GM SOLUTION 200 MG/ML, 6 GM/30ML INJECTAFER GLUTATHIONE INTRAVENOUS GM INTRAVENOUS GM SOLUTION 750 SOLUTION 6 GM/30ML MG/15ML GLYCINE INJECTION INTEGRA F ORAL GM 4 SOLUTION 50 MG/ML CAPSULE 125-1 MG hematinic/folic acid oral INTEGRA PLUS ORAL 2 4 tablet 324-1 mg CAPSULE

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 131 Drug Drug Drug Name Notes Drug Name Notes Tier Tier INTRALIPID kcl in dextrose-nacl INTRAVENOUS GM intravenous solution 10- EMULSION 20 %, 30 % 5-0.45 meq/l-%-%, 20-5- 0.2 meq/l-%-%, 20-5- iodine strong oral 2 solution 5 % 0.225 meq/l-%-%, 20-5- GM 0.45 meq/l-%-%, 20-5- IONOSOL-MB IN D5W 0.9 meq/l-%-%, 30-5- INTRAVENOUS GM 0.45 meq/l-%-%, 40-5- SOLUTION 0.45 meq/l-%-%, 40-5- IROSPAN 24/6 ORAL 4 0.9 meq/l-%-% ISOLYTE-P IN D5W kcl-lactated ringers-d5w INTRAVENOUS GM intravenous solution 20 GM SOLUTION meq/l ISOLYTE-S KCL-LIDOCAINE-NACL GM INTRAVENOUS INTRAVENOUS GM SOLUTION SOLUTION 10-10 MEQ- ISOLYTE-S PH 7.4 MG /100ML GM klor-con 10 oral tablet INTRAVENOUS 2 SOLUTION extended release 10 meq JADENU ORAL TABLET klor-con m10 oral tablet 6 PA 2 180 MG, 360 MG, 90 MG extended release 10 meq

JADENU SPRINKLE klor-con m15 oral tablet 2 ORAL PACKET 180 MG, 6 PA extended release 15 meq 360 MG, 90 MG klor-con m20 oral tablet 2 JENLIVA extended release 20 meq PRENATAL/POSTNATA 4 klor-con oral packet 20 2 L ORAL CAPSULE 1 MG meq JYNARQUE ORAL klor-con oral tablet 6 PA 2 TABLET 15 MG, 30 MG extended release 8 meq JYNARQUE ORAL klor-con/ef oral tablet 2 TABLET THERAPY effervescent 25 meq PACK 15 MG, 30 & 15 6 PA K-PHOS NO 2 ORAL MG, 45 & 15 MG, 60 & 4 30 MG, 90 & 30 MG TABLET 305-700 MG K-PHOS ORAL TABLET KABIVEN 4 500 MG INTRAVENOUS GM EMULSION 3.3-9.8-3.9- K-PHOS-NEUTRAL 0.7 % ORAL TABLET 155-852- 4 KCL (IN NACL 0.9%) 130 MG INTRAVENOUS GM k-prime oral tablet 2 SOLUTION 40 effervescent 25 meq MEQ/500ML

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 132 Drug Drug Drug Name Notes Drug Name Notes Tier Tier K-TAB ORAL TABLET magnesium sulfate in Brand GM EXTENDED RELEASE 4 penalty d5w intravenous solution 10 MEQ, 20 MEQ, 8 applies 1-5 gm/100ml-% MEQ magnesium sulfate 2 k-tan plus oral capsule 2 injection solution 50 % 162-115.2-1 mg magnesium sulfate lactated ringers GM intravenous solution 2 intravenous solution gm/50ml, 20 gm/500ml, 4 GM lactated ringers irrigation gm/100ml, 4 gm/50ml, 40 2 solution gm/1000ml LEVOCARNITINE MAGNESIUM SULFATE- INJECTION SOLUTION GM NACL INTRAVENOUS GM 500 MG/ML SOLUTION 2-0.9 GM/50ML-% levocarnitine oral solution 2 1 gm/10ml MANGANESE CHLORIDE GM levocarnitine oral tablet 2 INTRAVENOUS 330 mg SOLUTION 0.1 MG/ML levocarnitine sf oral 2 Brand solution 1 gm/10ml MEPHYTON ORAL 4 penalty LIPO INTRAMUSCULAR TABLET 5 MG applies SOLUTION 50-50-25 GM METHYLCOBALAMIN MG/ML INJECTION SOLUTION GM LIPO-C 150 MG/30ML, 30 INTRAMUSCULAR GM MG/30ML, 300 MG/30ML SOLUTION METHYLCOBALAMIN INJECTION SOLUTION LOKELMA ORAL 6 PA GM PACKET 10 GM, 5 GM RECONSTITUTED 10000 MCG, 50000 MCG LORID ORAL TABLET 1 4 MG MIC-L-CARNITINE GM LYSINE HCL INJECTION SOLUTION INJECTION SOLUTION GM 25-50-50-50 MG/ML 100 MG/ML MICROPLEGIA MSA- GM lysiplex plus oral tablet 2 MSG PERFUSION SOLUTION M.V.I. ADULT Brand INTRAVENOUS GM 4 penalty INJECTABLE MIFEPREX ORAL TABLET 200 MG applies M.V.I. PEDIATRIC mifepristone oral tablet INTRAVENOUS GM 2 SOLUTION 200 mg M-NATAL PLUS ORAL QL (1 EA RECONSTITUTED 4 TABLET 27-1 MG per 1 day)

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 133 Drug Drug Drug Name Notes Drug Name Notes Tier Tier MONOFERRIC nafrinse oral tablet PV INTRAVENOUS GM chewable 2.2 (1 f) mg SOLUTION 1000 NASCOBAL NASAL MG/10ML SOLUTION 500 3 monoject flush syringe MCG/0.1ML intravenous solution 0.9 2 QL (1 EA NEONATAL COMPLETE 4 % ORAL TABLET 27-1 MG per 1 day) monoject sodium chloride NEONATAL COMPLETE 4 flush intravenous solution 2 ORAL TABLET 29-1 MG 0.9 % NEONATAL PLUS ORAL QL (1 EA 4 MULTIGEN FOLIC TABLET 27-1 MG per 1 day) ORAL TABLET 70-150- 4 NEOVITE ORAL 2-1 MG 4 TABLET MULTIGEN ORAL 4 TABLET 70 MG NEPHPLEX RX ORAL 4 TABLET MULTIGEN PLUS ORAL 4 TABLET 50-101-1 MG NEPHRON FA ORAL 4 TABLET MULTIPRO ORAL 4 CAPSULE nephronex oral tablet 2 multi-vitamin/fluoride oral NEPHRO-VITE RX 4 solution 0.25 mg/ml, 0.5 2 ORAL TABLET 1 MG mg/ml NESTABS ORAL 4 multivitamin/fluoride oral TABLET 32-1 MG tablet chewable 0.25 mg, 2 NEURIN-SL 1 mg SUBLINGUAL TABLET 4 multi-vitamin/fluoride/iron SUBLINGUAL 600-600 oral solution 0.25-10 2 MCG mg/ml NICADAN ORAL 4 myferon 150 forte oral TABLET capsule 150-25-1 mg- 2 NICAZEL FORTE ORAL 4 mcg-mg TABLET mynephrocaps oral 4 2 NICAZEL ORAL TABLET capsule 1 mg NICOMIDE ORAL MYNEPHRON ORAL 4 4 TABLET 750-27-2-0.5 CAPSULE 1 MG MG na ferric gluc cplx in nicotinamide oral tablet 2 sucrose intravenous GM 750-27-2-0.5 mg solution 12.5 mg/ml NIFEREX ORAL 4 nafrinse drops oral TABLET PV solution 0.275 (0.125 f) normal saline flush mg/drop intravenous solution 0.9 2 %

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 134 Drug Drug Drug Name Notes Drug Name Notes Tier Tier NORMOSOL-M IN D5W phospho-trin 250 neutral INTRAVENOUS GM oral tablet 155-852-130 2 SOLUTION mg NORMOSOL-R IN D5W PHOXILLUM BK4/2.5 GM INTRAVENOUS INTRAVENOUS GM SOLUTION SOLUTION 32-4-2.5-1 NORMOSOL-R MEQ-MMOL/L INTRAVENOUS GM PHYSIOLYTE 4 SOLUTION IRRIGATION SOLUTION NORMOSOL-R PH 7.4 PHYSIOSOL INTRAVENOUS GM IRRIGATION 4 SOLUTION IRRIGATION SOLUTION NUFERA ORAL TABLET 4 phytonadione injection solution 1 mg/0.5ml, 10 GM NUTRICAP ORAL 4 TABLET mg/ml nutrifac zx oral tablet 2 phytonadione oral tablet 2 5 mg nutrilipid intravenous GM emulsion 20 % PLASMA-LYTE 148 INTRAVENOUS GM NUTRIVIT ORAL LIQUID 4 SOLUTION OMEGAVEN PA; PLASMA-LYTE A INTRAVENOUS 6 Specialty INTRAVENOUS GM EMULSION 10 Medical SOLUTION GM/100ML, 5 GM/50ML PLEGISOL PERFUSION ONE VITE WOMENS GM QL (1 EA SOLUTION 4 PLUS ORAL TABLET per 1 day) 27-1 MG PLENAMINE INTRAVENOUS GM ONEVITE ORAL 4 SOLUTION 15 % TABLET 1 MG poly-iron 150 forte oral ORACIT ORAL capsule 150-25-1 mg- 2 SOLUTION 490-640 3 mcg-mg MG/5ML polysaccharide iron forte PERIKABIVEN oral capsule 150-25-1 2 INTRAVENOUS GM mg-mcg-mg EMULSION 2.4-6.8-3.5- 0.5 % POLY-VI-FLOR ORAL SUSPENSION 0.25 4 PHOSPHA 250 MG/ML NEUTRAL ORAL 4 TABLET 155-852-130 POLY-VI-FLOR ORAL MG TABLET CHEWABLE 4 0.25 MG, 0.5 MG, 1 MG phosphorous oral tablet 2 155-852-130 mg POLY-VI-FLOR/IRON ORAL SUSPENSION 4 0.25-7 MG/ML Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 135 Drug Drug Drug Name Notes Drug Name Notes Tier Tier POLY-VI-FLOR/IRON potassium 4 ORAL TABLET phosphates(71 meq k) GM CHEWABLE 0.5-10 MG intravenous solution 45 potassium acetate mmole/15ml intravenous solution 2 GM PREMASOL meq/ml INTRAVENOUS GM potassium chloride crys SOLUTION 10 % er oral tablet extended PREMESISRX ORAL 2 4 release 10 meq, 15 meq, TABLET 1 MG 20 meq PRENAISSANCE ORAL potassium chloride er CAPSULE 29-1.25-325 4 oral capsule extended 2 MG release 10 meq, 8 meq QL (1 EA prenatal oral tablet 27-1 2 potassium chloride er mg per 1 day) oral tablet extended 2 prenatal plus iron oral 2 release 10 meq, 20 meq, tablet 29-1 mg 8 meq QL (1 EA prenatal vitamin plus low 2 potassium chloride in iron oral tablet 27-1 mg per 1 day) dextrose intravenous GM solution 20-5 meq/l-% PRENATE DHA ORAL CAPSULE 18-0.6-0.4- 4 potassium chloride in 300 MG nacl intravenous solution GM PRENATE ELITE ORAL 20-0.45 meq/l-%, 20-0.9 4 meq/l-%, 40-0.9 meq/l-% TABLET 20-0.6-0.4 MG potassium chloride PRENATE ENHANCE intravenous solution 10 ORAL CAPSULE 28-0.6- 4 meq/100ml, 10 0.4-400 MG GM meq/50ml, 2 meq/ml, 20 PRENATE ESSENTIAL meq/100ml, 20 ORAL CAPSULE 18-0.6- 4 meq/50ml, 40 meq/100ml 0.4-300 MG potassium chloride oral 2 PRENATE MINI ORAL packet 20 meq CAPSULE 18-0.6-0.4- 4 potassium chloride oral 350 MG solution 10 %, 20 2 PRENATE ORAL meq/15ml (10%), 40 TABLET CHEWABLE 4 meq/15ml (20%) 0.6-0.4 MG potassium citrate er oral PRENATE PIXIE ORAL tablet extended release CAPSULE 10-0.6-0.4- 4 10 meq (1080 mg), 15 2 200 MG meq (1620 mg), 5 meq PRENATE RESTORE (540 mg) ORAL CAPSULE 27-0.6- 4 potassium citrate-citric 0.4-400 MG acid oral solution 1100- 2 334 mg/5ml Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 136 Drug Drug Drug Name Notes Drug Name Notes Tier Tier PRENATRIX ORAL QL (1 EA PRO HIS RX ORAL 4 4 TABLET 27-1 MG per 1 day) CAPSULE QL (1 EA PRENATRYL ORAL 4 PRO PCOS RX ORAL 4 TABLET 27-1 MG per 1 day) CAPSULE PRENATVITE PROCALAMINE COMPLETE ORAL 4 INTRAVENOUS GM TABLET 1 MG SOLUTION 3 % PRENATVITE PLUS PROSOL 4 ORAL TABLET 1 MG INTRAVENOUS GM PRENATVITE RX ORAL SOLUTION 20 % 4 TABLET 0.8 MG purevit dualfe plus oral 2 preplus oral tablet 27-1 QL (1 EA capsule 162-115.2-1 mg 2 mg per 1 day) PYRIDOXAL-5 PHOSPHATE PRETAB ORAL TABLET 4 GM 29-1 MG INJECTION SOLUTION 100 MG/ML PRISMASOL B22GK 4/0 INTRAVENOUS GM pyridoxine hcl solution SOLUTION 22-4 MEQ/L 100 mg/ml injection 100 GM mg/ml PRISMASOL BGK 0/2.5 INTRAVENOUS PYRIDOXINE HCL GM SOLUTION 32-2.5 SOLUTION 100 MG/ML GM MEQ/L INJECTION 100 MG/ML PRISMASOL BGK 2/0 QUFLORA PEDIATRIC INTRAVENOUS GM ORAL SOLUTION 0.25 4 SOLUTION 32-2 MEQ/L MG/ML, 0.5 MG/ML PRISMASOL BGK 2/3.5 QUFLORA PEDIATRIC ORAL TABLET INTRAVENOUS GM 4 SOLUTION 32-2-3.5 CHEWABLE 0.25 MG, 1 MEQ/L MG RELNATE DHA ORAL PRISMASOL BGK 4 4/0/1.2 INTRAVENOUS CAPSULE 28-1-200 MG GM SOLUTION 32-4-1.2 RENAL ORAL CAPSULE 4 MEQ/L 1 MG PRISMASOL BGK 4/2.5 RENATABS ORAL 4 INTRAVENOUS GM TABLET 1 MG SOLUTION 32-4-2.5 RENATABS WITH IRON 4 MEQ/L ORAL 1 & 100 MG PRISMASOL BK 0/0/1.2 REQ 49+ ORAL TABLET 4 INTRAVENOUS GM SOLUTION 32-1.2 ringers intravenous GM MEQ/L solution PRO HERS RX ORAL ringers irrigation irrigation 4 2 CAPSULE solution Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 137 Drug Drug Drug Name Notes Drug Name Notes Tier Tier saline bacteriostatic sodium chloride flush GM injection solution 0.9 % intravenous solution 0.9 2 SALINE-PHENOL % GM INJECTION SOLUTION sodium chloride injection GM 0.4-0.9 % solution 2.5 meq/ml

SAMSCA ORAL TABLET 6 PA sodium chloride 15 MG, 30 MG intravenous solution 0.45 GM SELECT-OB ORAL %, 3 %, 5 % TABLET CHEWABLE 4 sodium chloride 29-1 MG intravenous solution 0.9 2 SELENIOUS ACID % INTRAVENOUS GM sodium chloride irrigation 2 SOLUTION 60 MCG/ML solution 0.9 % se-tan plus oral capsule 2 sodium fluoride oral 162-115.2-1 mg solution 0.5 mg/ml, 1.1 PV SMOFLIPID (0.5 f) mg/ml INTRAVENOUS GM sodium fluoride oral EMULSION 20 % tablet 1.1 (0.5 f) mg, 2.2 PV (1 f) mg sod citrate-citric acid oral 2 solution 500-334 mg/5ml sodium fluoride oral tablet chewable 0.55 sodium acetate PV intravenous solution 2 GM (0.25 f) mg, 1.1 (0.5 f) meq/ml mg, 2.2 (1 f) mg sodium bicarbonate sodium polystyrene 2 solution 8.4 % GM sulfonate oral powder intravenous 8.4 % sps oral suspension 15 2 SODIUM gm/60ml BICARBONATE GM sterile water for irrigation 2 SOLUTION 8.4 % irrigation solution INTRAVENOUS 8.4 % STROVITE FORTE 4 SODIUM ORAL SYRUP BICARBONATE- STROVITE FORTE DEXTROSE 4 GM ORAL TABLET INTRAVENOUS STROVITE ONE ORAL SOLUTION 150-5 4 MEQ/L-% TABLET SUPERVITE ORAL sodium chloride (pf) GM 4 injection solution 0.9 % LIQUID sodium chloride SYPRINE ORAL 6 PA bacteriostatic injection GM CAPSULE 250 MG solution 0.9 % TALIVA ORAL 4 CAPSULE 1 MG

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 138 Drug Drug Drug Name Notes Drug Name Notes Tier Tier TARON FORTE ORAL triphrocaps oral capsule 4 2 CAPSULE 1 mg

TAURINE INJECTION GM TRISTART DHA ORAL SOLUTION 50 MG/ML CAPSULE 31-0.6-0.4- 4 THAM INTRAVENOUS 200 MG SOLUTION 30 GM TRI-VI-FLOR ORAL MEQ/100ML SUSPENSION 0.25 4 thiamine hcl injection MG/ML, 0.5 MG/ML GM solution 100 mg/ml TRI-VI-FLORO ORAL tis-u-sol irrigation solution 2 SUSPENSION 0.25 4 MG/ML, 0.5 MG/ML tl-hem 150 oral tablet 2 150-1 mg tri-vite/fluoride oral solution 0.25 mg/ml, 0.5 2 TOLVAPTAN ORAL 6 PA mg/ml TABLET 15 MG TRONVITE ORAL 4 tolvaptan oral tablet 30 6 PA TABLET 1 MG mg TROPHAMINE TPN ELECTROLYTES INTRAVENOUS GM INTRAVENOUS GM SOLUTION 10 % CONCENTRATE UDAMIN SP ORAL 4 TRALEMENT TABLET 1 MG INTRAVENOUS GM SOLUTION 300-55-60- ULTRABAG/DIANEAL PD-2/1.5% DEX 3000 MCG/ML 4 INTRAPERITONEAL TRAVASOL SOLUTION 346 MOSM/L INTRAVENOUS GM SOLUTION 10 % ULTRABAG/DIANEAL PD-2/2.5% DEX 4 TRICARE PRENATAL INTRAPERITONEAL DHA ONE ORAL 4 SOLUTION 396 MOSM/L CAPSULE 27-1-500 MG ULTRABAG/DIANEAL tricitrates oral solution PD-2/4.25%DEX 2 4 550-500-334 mg/5ml INTRAPERITONEAL TRICON ORAL SOLUTION 485 MOSM/L 4 CAPSULE ULTRABAG/DIANEAL/1. trientine hcl oral capsule 5% DEXTROSE 6 PA 4 250 mg INTRAPERITONEAL TRIFERIC SOLUTION 344 MOSM/L ULTRABAG/DIANEAL/2. HEMODIALYSIS GM 5% DEXTROSE SOLUTION 27.2 4 MG/5ML INTRAPERITONEAL SOLUTION 395 MOSM/L trigels-f forte oral capsule 2 460-60-0.01-1 mg TRINATE ORAL TABLET 4 Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 139 Drug Drug Drug Name Notes Drug Name Notes Tier Tier ULTRABAG/DIANEAL/4. vitacel oral tablet 2 25% DEX 4 VITAFOL ORAL TABLET 4 INTRAPERITONEAL SOLUTION 483 MOSM/L VITAFOL-NANO ORAL 4 TABLET 18-0.6-0.4 MG UROCIT-K 10 ORAL Brand VITAFOL-OB+DHA TABLET EXTENDED 4 penalty 4 RELEASE 10 MEQ ORAL 65-1 & 250 MG applies (1080 MG) VITAL-D RX ORAL 4 UROCIT-K 15 ORAL TABLET 1 MG Brand TABLET EXTENDED 4 penalty VITAMEZ ORAL 4 RELEASE 15 MEQ applies CAPSULE 1 MG (1620 MG) vitamin d (ergocalciferol) 2 UROCIT-K 5 ORAL Brand oral capsule 1.25 mg TABLET EXTENDED 4 penalty (50000 ut) RELEASE 5 MEQ (540 applies vitamin k1 injection MG) solution 1 mg/0.5ml, 10 GM urosex oral tablet 2 mg/ml v-c forte oral capsule 2 vitamins acd-fluoride oral 2 VELTASSA ORAL solution 0.25 mg/ml PACKET 16.8 GM, 25.2 4 PA VITAROCA PLUS ORAL 4 GM, 8.4 GM TABLET VENEXA FE ORAL 4 VITA-RX DIABETIC TABLET VITAMIN ORAL 4 VENEXA ORAL TABLET 4 CAPSULE VITASURE ORAL VENOFER 4 INTRAVENOUS GM TABLET 1 MG SOLUTION 20 MG/ML VITATHELY WITH QL (1 EA GINGER ORAL TABLET 4 VENTRIXYL ORAL 4 per 1 day) TABLET 1 MG 27-1 MG vic-forte oral capsule 2 VITRANOL FE ORAL 4 TABLET VINATE ONE ORAL 4 TABLET 60-1 MG VITREXATE FE ORAL 4 TABLET virt-caps oral capsule 1 2 mg VITREXATE ORAL 4 TABLET VIRT-FEFA PLUS ORAL 4 VITREXYL + IRON CAPSULE 4 ORAL TABLET virt-gard oral tablet 2.2- 2 VITREXYL ORAL 25-1 mg 4 TABLET virt-phos 250 neutral oral 2 vp-pnv-dha oral capsule tablet 155-852-130 mg 2 28-1-215.8 mg vita s forte oral tablet 2 vp-vite rx oral tablet 1 mg 2

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 140 Drug Drug Drug Name Notes Drug Name Notes Tier Tier water for irrigation, sterile cimetidine hcl oral 2 irrigation solution solution 300 mg/5ml, 400 2 mg/6.67ml weekly-d oral capsule 2 1.25 mg (50000 ut) cimetidine oral tablet 200 mg, 300 mg, 400 mg, 2 westab mini oral tablet 2 2.2-25-1 mg 800 mg QL (1 EA CYTOTEC ORAL Brand WESTAB PLUS ORAL 4 TABLET 27-1 MG per 1 day) TABLET 100 MCG, 200 4 penalty MCG applies WESTGEL DHA ORAL CAPSULE 31-0.6-0.4- 4 DEXILANT ORAL CAPSULE DELAYED 200 MG 4 PA RELEASE 30 MG, 60 wheat germ oil oral oil 2 MG WILZIN ORAL CAPSULE 3 esomeprazole QL (60 EA 25 MG magnesium oral capsule 2 per 30 delayed release 20 mg days) XVITE ORAL TABLET 1 4 MG esomeprazole QL (60 EA magnesium oral capsule 2 per 30 yl folic acid oral tablet PV 400 mcg delayed release 40 mg days) ZINC CHLORIDE esomeprazole sodium INTRAVENOUS GM intravenous solution GM SOLUTION 1 MG/ML reconstituted 40 mg ZINC SULFATE famotidine intravenous INTRAVENOUS GM solution 20 mg/2ml, 200 GM SOLUTION 3 MG/ML mg/20ml, 40 mg/4ml ZYVANA ORAL famotidine oral 4 CAPSULE suspension reconstituted 2 Gastrointestinal Agents 40 mg/5ml - Drugs for Acid Reflux famotidine oral tablet 20 2 and Ulcer mg, 40 mg ACIPHEX ORAL Brand famotidine premixed TABLET DELAYED 4 penalty intravenous solution 20- GM RELEASE 20 MG applies 0.9 mg/50ml-% ACIPHEX SPRINKLE FIRST-LANSOPRAZOLE ORAL CAPSULE 4 ORAL SUSPENSION 3 4 SPRINKLE 10 MG, 5 MG MG/ML CARAFATE ORAL FIRST-OMEPRAZOLE SUSPENSION 1 3 ORAL SUSPENSION 2 2 GM/10ML MG/ML

CARAFATE ORAL 4 lansoprazole oral capsule TABLET 1 GM delayed release 15 mg, 2 30 mg

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 141 Drug Drug Drug Name Notes Drug Name Notes Tier Tier lansoprazole oral tablet PREVACID SOLUTAB delayed release 2 ORAL TABLET Brand dispersible 15 mg, 30 mg DELAYED RELEASE 4 penalty DISPERSIBLE 15 MG, applies misoprostol oral tablet 2 100 mcg, 200 mcg 30 MG NEXIUM 24HR ORAL QL (120 PRILOSEC ORAL 4 CAPSULE DELAYED 2 EA per 30 PACKET 10 MG, 2.5 MG RELEASE 20 MG days) PROTONIX NEXIUM 24HR ORAL QL (120 INTRAVENOUS TABLET DELAYED 2 EA per 30 SOLUTION GM RELEASE 20 MG days) RECONSTITUTED 40 MG NEXIUM I.V. INTRAVENOUS Brand SOLUTION GM PROTONIX ORAL 4 penalty RECONSTITUTED 40 PACKET 40 MG applies MG PROTONIX ORAL Brand TABLET DELAYED nizatidine oral capsule 4 penalty 2 RELEASE 20 MG, 40 150 mg, 300 mg applies MG nizatidine oral solution 15 2 mg/ml RABEPRAZOLE SODIUM ORAL 4 omeprazole oral capsule CAPSULE SPRINKLE 10 delayed release 10 mg, 2 MG 20 mg, 40 mg rabeprazole sodium oral OMEPRAZOLE+SYRSP tablet delayed release 20 2 END SF ALKA ORAL 2 mg SUSPENSION 2 MG/ML sucralfate oral 2 pantoprazole sodium suspension 1 gm/10ml intravenous solution GM sucralfate oral tablet 1 reconstituted 40 mg 2 gm pantoprazole sodium oral 2 Gastrointestinal Agents packet 40 mg - Drugs for Bowel, pantoprazole sodium oral Intestine and Stomach tablet delayed release 20 2 Conditions mg, 40 mg alosetron hcl oral tablet 2 Brand 0.5 mg, 1 mg PEPCID ORAL TABLET 4 penalty 20 MG, 40 MG applies alvimopan oral capsule GM 12 mg PREVACID ORAL Brand QL (60 EA CAPSULE DELAYED 4 penalty AMITIZA ORAL 3 per 30 RELEASE 30 MG applies CAPSULE 24 MCG, 8 MCG days) amoxicill-clarithro- 2 lansopraz oral

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 142 Drug Drug Drug Name Notes Drug Name Notes Tier Tier ANASPAZ ORAL diphenoxylate-atropine TABLET DISPERSIBLE 4 oral liquid 2.5-0.025 2 0.125 MG mg/5ml atropine sulfate diphenoxylate-atropine 2 intravenous solution 0.4 GM oral tablet 2.5-0.025 mg mg/ml, 1 mg/ml ED-SPAZ ORAL ATROPINE SULFATE TABLET DISPERSIBLE 4 INTRAVENOUS 0.125 MG GM SOLUTION PREFILLED ENTEREG ORAL GM SYRINGE 1.2 MG/3ML CAPSULE 12 MG belladonna alkaloids- enulose oral solution 10 2 opium rectal suppository 2 gm/15ml 16.2-30 mg, 16.2-60 mg GASTROCROM ORAL Brand BENTYL CONCENTRATE 100 4 penalty INTRAMUSCULAR GM MG/5ML applies SOLUTION 10 MG/ML GATTEX CHENODAL ORAL 6 SUBCUTANEOUS KIT 5 6 PA TABLET 250 MG MG chlordiazepoxide- PV*; QL (1 clidinium oral capsule 5- 2 gavilax oral powder 17 2 fill per 365 2.5 mg gm/scoop days) PV*; QL (1 PV*; QL (1 clearlax oral powder 17 2 fill per 365 gavilyte-c oral solution 2 fill per 365 gm/scoop days) reconstituted 240 gm days) CLENPIQ ORAL PV*; QL (1 SOLUTION 10-3.5-12 4 gavilyte-g oral solution 2 fill per 365 MG-GM -GM/160ML reconstituted 236 gm days) constulose oral solution 2 gavilyte-n with flavor PV*; QL (1 10 gm/15ml pack oral solution 2 fill per 365 cromolyn sodium oral reconstituted 420 gm days) 2 concentrate 100 mg/5ml generlac oral solution 10 2 CUVPOSA ORAL gm/15ml 4 SOLUTION 1 MG/5ML PV*; QL (1 dicyclomine hcl glycolax oral powder 17 2 fill per 365 intramuscular solution 10 GM gm/scoop days) mg/ml glycopyrrolate injection dicyclomine hcl oral 1 solution 0.2 mg/ml, 0.4 GM capsule 10 mg mg/2ml, 1 mg/5ml, 4 mg/20ml dicyclomine hcl oral 2 solution 10 mg/5ml GLYCOPYRROLATE INJECTION SOLUTION dicyclomine hcl oral 1 GM tablet 20 mg PREFILLED SYRINGE 0.6 MG/3ML, 1 MG/5ML Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 143 Drug Drug Drug Name Notes Drug Name Notes Tier Tier glycopyrrolate oral tablet hyosyne oral solution 2 2 1 mg, 2 mg 0.125 mg/ml glycopyrrolate pf injection KRISTALOSE ORAL 4 solution prefilled syringe GM PACKET 10 GM, 20 GM 0.2 mg/ml, 0.4 mg/2ml lactulose encephalopathy 2 GLYRX-PF INJECTION oral solution 10 gm/15ml SOLUTION 0.2 MG/ML, GM lactulose oral packet 10 2 0.4 MG/2ML gm GLYRX-PF INJECTION lactulose oral solution 10 SOLUTION PREFILLED 2 GM gm/15ml, 20 gm/30ml SYRINGE 0.6 MG/3ML, 1 MG/5ML LEVBID ORAL TABLET EXTENDED RELEASE 4 Brand 12 HOUR 0.375 MG GOLYTELY ORAL penalty SOLUTION 4 applies; QL LEVSIN ORAL TABLET 4 RECONSTITUTED 236 (1 fill per 0.125 MG GM 365 days) LEVSIN/SL PV*; QL (1 SUBLINGUAL TABLET 4 healthylax oral packet 17 2 fill per 365 SUBLINGUAL 0.125 MG gm days) Brand HELIDAC THERAPY LIBRAX ORAL 4 penalty 4 ORAL CAPSULE 5-2.5 MG applies hyoscyamine sulfate er LINZESS ORAL QL (30 EA CAPSULE 145 MCG, 3 per 30 oral tablet extended 2 release 12 hour 0.375 290 MCG, 72 MCG days) mg Brand LOMOTIL ORAL 4 penalty hyoscyamine sulfate oral 2 elixir 0.125 mg/5ml TABLET 2.5-0.025 MG applies hyoscyamine sulfate oral loperamide hcl oral 2 2 solution 0.125 mg/ml capsule 2 mg hyoscyamine sulfate oral Brand 2 tablet 0.125 mg LOTRONEX ORAL 4 penalty TABLET 0.5 MG, 1 MG applies hyoscyamine sulfate oral tablet dispersible 0.125 2 LUBIPROSTONE ORAL QL (60 EA mg CAPSULE 24 MCG, 8 3 per 30 MCG days) hyoscyamine sulfate sl sublingual tablet 2 methscopolamine sublingual 0.125 mg bromide oral tablet 2.5 2 mg, 5 mg hyoscyamine sulfate sublingual tablet 2 mineral oil heavy oral oil 2 sublingual 0.125 mg PV*; QL (1 hyosyne oral elixir 0.125 MIRALAX MIX-IN PAX 4 fill per 365 2 mg/5ml ORAL PACKET 17 GM days) Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 144 Drug Drug Drug Name Notes Drug Name Notes Tier Tier PV*; QL (1 peg 3350-kcl-na bicarb- PV*; QL (1 mm clearlax oral powder 2 fill per 365 nacl oral solution 2 fill per 365 17 gm/scoop days) reconstituted 420 gm days) QL (30 EA peg-3350/electrolytes PV*; QL (1 MOTEGRITY ORAL 4 per 30 oral solution 2 fill per 365 TABLET 1 MG, 2 MG days) reconstituted 236 gm days)

MOTOFEN ORAL 4 peg- TABLET 1-0.025 MG 3350/electrolytes/ascorb 2 MOVANTIK ORAL QL (30 EA at oral solution TABLET 12.5 MG, 25 4 per 30 reconstituted 100 gm MG days) peg-kcl-nacl-nasulf-na MOVIPREP ORAL asc-c oral solution 2 Brand reconstituted 100 gm SOLUTION 4 penalty RECONSTITUTED 100 applies peg-prep oral kit 5-210 2 GM mg-gm MYTESI ORAL TABLET PV*; QL (1 DELAYED RELEASE 4 PA polyethylene glycol 3350 2 fill per 365 125 MG oral packet 17 gm days) NULEV ORAL TABLET PV*; QL (1 4 DISPERSIBLE 0.125 MG polyethylene glycol 3350 2 fill per 365 Brand oral powder 17 gm/scoop days) NULYTELY LEMON- penalty PYLERA ORAL LIME ORAL SOLUTION 4 applies; QL CAPSULE 140-125-125 4 RECONSTITUTED 420 (1 fill per MG GM 365 days) RELISTOR ORAL 3 PA OMECLAMOX-PAK 4 TABLET 150 MG ORAL 500-500-20 MG RELISTOR opium oral tincture 10 2 SUBCUTANEOUS 3 PA mg/ml (1%) SOLUTION 12 oscimin oral tablet 0.125 MG/0.6ML, 8 MG/0.4ML 2 mg SEROSTIM oscimin sr oral tablet SUBCUTANEOUS extended release 12 hour 2 SOLUTION 6 PA 0.375 mg RECONSTITUTED 4 MG, 5 MG, 6 MG oscimin sublingual tablet 2 sublingual 0.125 mg sodium bicarbonate oral 2 powder OSMOPREP ORAL 4 TABLET 1.102-0.398 GM SUPREP BOWEL PREP KIT ORAL SOLUTION 4 PV*; QL (1 17.5-3.13-1.6 GM/177ML peg 3350 oral packet 17 2 fill per 365 SUTAB ORAL TABLET gm days) 4 1479-225-188 MG

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 145 Drug Drug Drug Name Notes Drug Name Notes Tier Tier SYMAX DUOTAB ORAL AMMONUL TABLET EXTENDED 4 INTRAVENOUS GM RELEASE 0.375 MG SOLUTION 10-10 % SYMAX-SL AMONDYS 45 PA; SUBLINGUAL TABLET 4 INTRAVENOUS 6 Specialty SUBLINGUAL 0.125 MG SOLUTION 100 MG/2ML Medical SYMAX-SR ORAL PA; TABLET EXTENDED BRINEURA KIT 2 X 150 6 Specialty 4 RELEASE 12 HOUR MG/5ML Medical 0.375 MG Brand QL (30 EA BUPHENYL ORAL 4 penalty SYMPROIC ORAL 4 per 30 POWDER 3 GM/TSP applies TABLET 0.2 MG days) Brand QL (30 EA BUPHENYL ORAL 4 penalty TRULANCE ORAL 4 per 30 TABLET 500 MG applies TABLET 3 MG days) CERDELGA ORAL 6 PA Brand CAPSULE 84 MG 4 penalty URSO 250 ORAL CEREZYME TABLET 250 MG applies INTRAVENOUS PA; Brand SOLUTION 6 Specialty URSO FORTE ORAL 4 penalty RECONSTITUTED 400 Medical TABLET 500 MG applies UNIT ursodiol oral capsule 300 2 CHOLBAM ORAL mg CAPSULE 250 MG, 50 6 PA MG ursodiol oral tablet 250 2 mg, 500 mg CREON ORAL CAPSULE DELAYED VIBERZI ORAL TABLET 5 PA 100 MG, 75 MG RELEASE PARTICLES 12000-38000 UNIT, 3 XERMELO ORAL 6 PA 24000-76000 UNIT, TABLET 250 MG 3000-9500 UNIT, 36000- ZORBTIVE 114000 UNIT, 6000- SUBCUTANEOUS 19000 UNIT SOLUTION 6 PA CRYSVITA PA; RECONSTITUTED 8.8 SUBCUTANEOUS MG 6 Specialty SOLUTION 10 MG/ML, Medical Genetic or Enzyme 20 MG/ML, 30 MG/ML Disorder - Drugs for CYSTADANE ORAL Replacement, 4 POWDER Modification, Treatment CYSTAGON ORAL PA; ALDURAZYME CAPSULE 150 MG, 50 4 6 Specialty INTRAVENOUS MG SOLUTION 2.9 MG/5ML Medical

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 146 Drug Drug Drug Name Notes Drug Name Notes Tier Tier ELAPRASE PA; NAGLAZYME PA; INTRAVENOUS 6 Specialty INTRAVENOUS 6 Specialty SOLUTION 6 MG/3ML Medical SOLUTION 1 MG/ML Medical

ELELYSO nitisinone oral capsule 10 6 PA INTRAVENOUS PA; mg, 2 mg, 5 mg SOLUTION 6 Specialty NITYR ORAL TABLET Medical 6 PA RECONSTITUTED 200 10 MG, 2 MG, 5 MG UNIT NULIBRY ENZADYNE ORAL 4 INTRAVENOUS PA; CAPSULE SOLUTION 6 Specialty EVRYSDI ORAL RECONSTITUTED 9.5 Medical SOLUTION 6 PA MG RECONSTITUTED 0.75 OCALIVA ORAL 6 PA MG/ML TABLET 10 MG, 5 MG FABRAZYME ORFADIN ORAL INTRAVENOUS PA; CAPSULE 10 MG, 2 MG, 6 PA 6 Specialty SOLUTION 20 MG, 5 MG RECONSTITUTED 35 Medical MG, 5 MG ORFADIN ORAL 6 PA SUSPENSION 4 MG/ML GALAFOLD ORAL 6 PA CAPSULE 123 MG PALYNZIQ SUBCUTANEOUS KANUMA PA; SOLUTION PREFILLED 6 PA INTRAVENOUS 6 Specialty SYRINGE 10 MG/0.5ML, SOLUTION 20 MG/10ML Medical 2.5 MG/0.5ML, 20 KUVAN ORAL PACKET 6 PA MG/ML 100 MG, 500 MG PANCREAZE ORAL KUVAN ORAL TABLET 6 PA CAPSULE DELAYED 100 MG RELEASE PARTICLES LUMIZYME 10500-35500 UNIT, INTRAVENOUS PA; 16800-56800 UNIT, 4 SOLUTION 6 Specialty 21000-54700 UNIT, RECONSTITUTED 50 Medical 2600-8800 UNIT, 37000- MG 97300 UNIT, 4200-14200 UNIT MEPSEVII PA; INTRAVENOUS 6 Specialty PERTZYE ORAL SOLUTION 10 MG/5ML Medical CAPSULE DELAYED RELEASE PARTICLES miglustat oral capsule 6 PA 16000-57500 UNIT, 4 100 mg 24000-86250 UNIT, MYALEPT 4000-14375 UNIT, 8000- SUBCUTANEOUS 28750 UNIT SOLUTION 6 PA RAVICTI ORAL LIQUID 6 PA RECONSTITUTED 11.3 1.1 GM/ML MG

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 147 Drug Drug Drug Name Notes Drug Name Notes Tier Tier REVCOVI ZENPEP ORAL PA; INTRAMUSCULAR 6 Specialty CAPSULE DELAYED SOLUTION 2.4 Medical RELEASE PARTICLES MG/1.5ML 10000-32000 UNIT, sapropterin 15000-47000 UNIT, 3 dihydrochloride oral 6 PA 20000-63000 UNIT, packet 100 mg, 500 mg 25000-79000 UNIT, 3000-10000 UNIT, sapropterin 40000-126000 UNIT, dihydrochloride oral 6 PA 5000-24000 UNIT tablet 100 mg ZOLGENSMA sod benz-sod phenylacet INTRAVENOUS KIT intravenous solution 10- GM 1X5.5ML & 2X8.3ML, 10 % 1X5.5ML & 3X8.3ML, 1X5.5ML & 4X8.3ML, sodium phenylbutyrate 2 oral powder 3 gm/tsp 1X5.5ML & 5X8.3ML, 1X5.5ML & 6X8.3ML, sodium phenylbutyrate 2 oral tablet 500 mg 1X5.5ML & 7X8.3ML, 1X5.5ML & 8X8.3ML, PA; STRENSIQ 2X5.5ML & 1X8.3ML, SUBCUTANEOUS 6 Specialty PA; 2X5.5ML & 2X8.3ML, SOLUTION 18 Medical 6 Specialty 2X5.5ML & 3X8.3ML, MG/0.45ML, 28 Medical 2X5.5ML & 4X8.3ML, MG/0.7ML, 40 MG/ML, 2X5.5ML & 5X8.3ML, 80 MG/0.8ML 2X5.5ML & 6X8.3ML, SUCRAID ORAL 2X5.5ML & 7X8.3ML, SOLUTION 8500 6 PA 2X8.3 ML, 3X8.3 ML, UNIT/ML 4X8.3 ML, 5X8.3 ML, PA; 6X8.3 ML, 7X8.3 ML, VIMIZIM INTRAVENOUS 6 Specialty 8X8.3 ML, 9X8.3 ML SOLUTION 5 MG/5ML Medical Genitourinary Agents - Drugs for Bladder, VIOKACE ORAL Genital and Kidney TABLET 10440-39150 4 Conditions UNIT, 20880-78300 acetic acid irrigation UNIT 2 solution 0.25 % VPRIV INTRAVENOUS PA; AURYXIA ORAL SOLUTION 6 Specialty TABLET 1 GM 210 4 RECONSTITUTED 400 Medical UNIT MG(FE) bethanechol chloride oral XURIDEN ORAL 6 PA PACKET 2 GM tablet 10 mg, 25 mg, 5 2 ZAVESCA ORAL mg, 50 mg 6 PA CAPSULE 100 MG

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 148 Drug Drug Drug Name Notes Drug Name Notes Tier Tier BI-MIX DITROPAN XL ORAL Brand INTRACAVERNOSAL TABLET EXTENDED 4 penalty GM SOLUTION RELEASE 24 HOUR 10 applies RECONSTITUTED 150-5 MG, 5 MG MG ELMIRON ORAL 4 calcium acetate (phos CAPSULE 100 MG binder) oral capsule 667 2 flavoxate hcl oral tablet 2 mg 100 mg calcium acetate (phos FOSRENOL ORAL Brand binder) oral tablet 667 2 TABLET CHEWABLE 4 penalty mg 1000 MG, 500 MG, 750 applies calcium acetate oral 2 MG tablet 667 mg GELNIQUE 4 CERVIDIL VAGINAL 4 TRANSDERMAL GEL 10 INSERT 10 MG % PA; Brand glycine irrigation solution 2 penalty 1.5 % applies; QL glycine urologic irrigation 2 4 (4 EA per solution 1.5 % 30 days); HYOPHEN ORAL CIALIS ORAL TABLET AL (Min 18 4 10 MG, 20 MG Years) TABLET 81.6 MG INTRAROSA VAGINAL PA; Brand 4 penalty INSERT 6.5 MG applies; QL lanthanum carbonate oral 4 (30 EA per tablet chewable 1000 2 30 days); mg, 500 mg, 750 mg AL (Min 18 CIALIS ORAL TABLET LITHOSTAT ORAL Years) 4 2.5 MG, 5 MG TABLET 250 MG darifenacin hydrobromide me/naphos/mb/hyo1 oral 2 er oral tablet extended 2 tablet 81.6 mg release 24 hour 15 mg, 7.5 mg MYRBETRIQ ORAL SUSPENSION 4 DEPEN TITRATABS 5 RECONSTITUTED ER 8 ORAL TABLET 250 MG MG/ML DETROL LA ORAL Brand MYRBETRIQ ORAL CAPSULE EXTENDED 4 penalty TABLET EXTENDED RELEASE 24 HOUR 2 3 applies RELEASE 24 HOUR 25 MG, 4 MG MG, 50 MG Brand OXLUMO 4 penalty PA; DETROL ORAL TABLET SUBCUTANEOUS applies 6 Specialty 1 MG, 2 MG SOLUTION 94.5 Medical MG/0.5ML

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 149 Drug Drug Drug Name Notes Drug Name Notes Tier Tier oxybutynin chloride er Brand 4 penalty oral tablet extended 2 RENVELA ORAL release 24 hour 10 mg, TABLET 800 MG applies 15 mg, 5 mg RIMSO-50 GM oxybutynin chloride oral 2 INTRAVESICAL syrup 5 mg/5ml SOLUTION 50 % oxybutynin chloride oral 2 sevelamer carbonate oral 2 tablet 5 mg packet 0.8 gm, 2.4 gm penicillamine oral tablet sevelamer carbonate oral 5 2 250 mg tablet 800 mg phenazo oral tablet 200 sevelamer hcl oral tablet 2 2 mg 400 mg, 800 mg phenazopyridine hcl oral sildenafil citrate oral PA; QL (4 2 tablet 100 mg, 200 mg tablet 100 mg, 25 mg, 50 2 EA per 30 PHENYLEPHRINE HCL mg days) GM INTRACAVERNOSAL solifenacin succinate oral 2 SOLUTION 2 MG/2ML tablet 10 mg, 5 mg

PHOSLYRA ORAL 4 SUPER BI-MIX SOLUTION 667 MG/5ML INTRACAVERNOSAL PHOSPHASAL ORAL SOLUTION GM 4 TABLET 81.6 MG RECONSTITUTED 150- 10 MG PREPIDIL VAGINAL 4 GEL 0.5 MG/3GM SUPER QUAD-MIX INTRACAVERNOSAL PROSTIN E2 VAGINAL 4 SOLUTION GM SUPPOSITORY 20 MG RECONSTITUTED 150- PYRIDIUM ORAL 20-0.2-2 MG TABLET 100 MG, 200 4 SUPER TRI-MIX MG INTRACAVERNOSAL QUAD-MIX SOLUTION GM INTRACAVERNOSAL RECONSTITUTED 150- SOLUTION GM 10-100 MG-MG-MCG RECONSTITUTED 150- PA; QL (4 10-0.1-1 MG EA per 30 RENACIDIN 2 days); AL 4 IRRIGATION SOLUTION tadalafil oral tablet 10 (Min 18 Brand mg, 20 mg Years) RENAGEL ORAL 4 penalty PA; QL (30 TABLET 800 MG applies EA per 30 2 days); AL RENVELA ORAL Brand (Min 18 PACKET 0.8 GM, 2.4 4 penalty tadalafil oral tablet 2.5 Years) GM applies mg, 5 mg

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 150 Drug Drug Drug Name Notes Drug Name Notes Tier Tier THIOLA EC ORAL Brand 4 penalty TABLET DELAYED 4 PA VESICARE ORAL RELEASE 100 MG, 300 TABLET 10 MG, 5 MG applies MG PA; Brand PA; Brand penalty THIOLA ORAL TABLET 4 penalty 4 applies; QL 100 MG applies VIAGRA ORAL TABLET (4 EA per tiopronin oral tablet 100 100 MG, 25 MG, 50 MG 30 days) 2 PA mg VILAMIT MB ORAL 4 tolterodine tartrate er oral CAPSULE 118 MG capsule extended VILEVEV MB ORAL 2 4 release 24 hour 2 mg, 4 TABLET 81 MG mg Genitourinary Agents - Drugs for Prostate tolterodine tartrate oral 2 tablet 1 mg, 2 mg Conditions TOVIAZ ORAL TABLET alfuzosin hcl er oral tablet EXTENDED RELEASE 4 extended release 24 hour 2 24 HOUR 4 MG, 8 MG 10 mg trospium chloride er oral Brand capsule extended 2 AVODART ORAL 4 penalty release 24 hour 60 mg CAPSULE 0.5 MG applies trospium chloride oral CARDURA XL ORAL 2 tablet 20 mg TABLET EXTENDED 3 RELEASE 24 HOUR 4 URIBEL ORAL 4 CAPSULE 118 MG MG, 8 MG dutasteride oral capsule URIMAR-T ORAL 4 2 TABLET 120 MG 0.5 mg urin ds oral tablet 81.6 dutasteride-tamsulosin 2 2 mg hcl oral capsule 0.5-0.4 mg URO-458 ORAL TABLET 4 finasteride oral tablet 5 81 MG 2 mg UROGESIC-BLUE ORAL 4 Brand TABLET 81.6 MG FLOMAX ORAL 4 penalty uro-mp oral capsule 118 2 CAPSULE 0.4 MG applies mg Brand USTELL ORAL 4 JALYN ORAL CAPSULE 4 penalty CAPSULE 120 MG 0.5-0.4 MG applies UTIRA-C ORAL TABLET 4 Brand 81.6 MG PROSCAR ORAL 4 penalty VELPHORO ORAL TABLET 5 MG applies TABLET CHEWABLE 6 500 MG

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 151 Drug Drug Drug Name Notes Drug Name Notes Tier Tier Brand DEPO-MEDROL RAPAFLO ORAL 4 penalty INJECTION CAPSULE 4 MG, 8 MG applies SUSPENSION 20 GM MG/ML, 40 MG/ML, 80 silodosin oral capsule 4 2 mg, 8 mg MG/ML DEXAMETH SOD tamsulosin hcl oral 2 capsule 0.4 mg PHOS-BUPIV-EPIN INJECTION SOLUTION GM terazosin hcl oral capsule 1 PREFILLED SYRINGE 1 mg, 10 mg, 2 mg, 5 mg 0.01-0.375 %-1:200000 UROXATRAL ORAL Brand dexamethasone intensol TABLET EXTENDED 2 4 penalty oral concentrate 1 mg/ml RELEASE 24 HOUR 10 applies MG dexamethasone oral 2 elixir 0.5 mg/5ml Hormonal Agents - Adrenal dexamethasone oral 2 solution 0.5 mg/5ml BETAMETHASONE COMBO INJECTION dexamethasone oral GM tablet 0.5 mg, 0.75 mg, 1 SUSPENSION 6 (3-3) 1 MG/ML mg, 1.5 mg, 2 mg, 4 mg, 6 mg betamethasone sod phos & acet suspension 6 (3- dexamethasone oral GM 3) mg/ml injection 6 (3-3) tablet therapy pack 1.5 2 mg/ml mg (21), 1.5 mg (35), 1.5 mg (51) BETAMETHASONE SOD PHOS & ACET DEXAMETHASONE SUSPENSION 6 (3-3) GM SOD PHOS-NACL MG/ML INJECTION 6 (3- INTRAVENOUS GM 3) MG/ML SOLUTION 6-0.9 MG/25ML-% BETAMETHASONE SODIUM PHOSPHATE dexamethasone sod GM INJECTION SOLUTION phosphate pf injection GM 12 MG/2ML, 6 MG/ML solution 10 mg/ml CELESTONE dexamethasone sod phosphate pf injection SOLUSPAN INJECTION GM GM SUSPENSION 6 (3-3) solution prefilled syringe MG/ML 10 mg/ml Brand dexamethasone sodium phosphate injection CORTEF ORAL TABLET 4 penalty GM 10 MG, 20 MG, 5 MG applies solution 100 mg/10ml, 120 mg/30ml, 20 mg/5ml DECADRON ORAL TABLET 0.5 MG, 0.75 4 dexamethasone sodium MG, 4 MG, 6 MG phosphate solution 10 GM mg/ml injection 10 mg/ml

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 152 Drug Drug Drug Name Notes Drug Name Notes Tier Tier DEXAMETHASONE methylprednisolone GM SODIUM PHOSPHATE GM acetate suspension 40 SOLUTION 10 MG/ML mg/ml injection 40 mg/ml INJECTION 10 MG/ML METHYLPREDNISOLON DEXAMETHASONE E ACETATE GM SODIUM PHOSPHATE GM SUSPENSION 40 SOLUTION 4 MG/ML MG/ML INJECTION 40 INJECTION 4 MG/ML MG/ML dexamethasone sodium methylprednisolone phosphate solution 4 GM acetate suspension 80 GM mg/ml injection 4 mg/ml mg/ml injection 80 mg/ml DEXONTO 0.4% METHYLPREDNISOLON IONTOPHORESIS GM E ACETATE SOLUTION 20 MG/5ML SUSPENSION 80 GM MG/ML INJECTION 80 fludrocortisone acetate 2 oral tablet 0.1 mg MG/ML HIDEX 6-DAY ORAL methylprednisolone oral TABLET THERAPY 4 tablet 16 mg, 32 mg, 4 2 PACK 1.5 MG (21) mg, 8 mg hydrocortisone oral tablet methylprednisolone oral 2 2 10 mg, 20 mg, 5 mg tablet therapy pack 4 mg KENALOG INJECTION methylprednisolone SUSPENSION 10 GM sodium succ injection MG/ML, 40 MG/ML solution reconstituted GM 1000 mg, 125 mg, 40 KENALOG-80 mg, 500 mg INJECTION GM SUSPENSION 80 METHYLPREDNISOLON MG/ML E-BUPIVACAINE INJECTION GM LIDOCIDEX I SUSPENSION 40-5 INJECTION SOLUTION GM MG/ML, 80-5 MG/ML 5-10 MG/1.5ML MILLIPRED ORAL 3 MEDROL ORAL TABLET Brand TABLET 5 MG 16 MG, 32 MG, 4 MG, 8 4 penalty MG applies ORAPRED ODT ORAL Brand TABLET DISPERSIBLE 4 penalty MEDROL ORAL TABLET 4 10 MG, 15 MG, 30 MG applies 2 MG PEDIAPRED ORAL Brand Brand SOLUTION 6.7 (5 BASE) 4 penalty MEDROL ORAL TABLET 4 penalty MG/5ML applies THERAPY PACK 4 MG applies prednisolone oral 2 METHYLPREDNISOLON solution 15 mg/5ml E ACETATE INJECTION GM SUSPENSION 50 MG/ML

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 153 Drug Drug Drug Name Notes Drug Name Notes Tier Tier prednisolone sodium TRIAMCINOLONE- phosphate oral solution BUPIVACAINE 10 mg/5ml, 15 mg/5ml, 2 INJECTION GM 20 mg/5ml, 25 mg/5ml, SUSPENSION 40-5 6.7 (5 base) mg/5ml MG/ML prednisolone sodium ZILRETTA INTRA- phosphate oral tablet ARTICULAR 2 dispersible 10 mg, 15 SUSPENSION GM mg, 30 mg RECONSTITUTED ER prednisone intensol oral 32 MG 2 concentrate 5 mg/ml Hormonal Agents - Men's Health prednisone oral solution 2 5 mg/5ml ANDRODERM prednisone oral tablet 1 TRANSDERMAL PATCH 4 PA mg, 10 mg, 2.5 mg, 20 1 24 HOUR 2 MG/24HR, 4 mg, 5 mg, 50 mg MG/24HR PA; Brand prednisone oral tablet ANDROGEL PUMP 4 penalty therapy pack 10 mg (21), TRANSDERMAL GEL 2 applies 10 mg (48), 5 mg (21), 5 20.25 MG/ACT (1.62%) mg (48) ANDROGEL TRANSDERMAL GEL SOLU-CORTEF PA; Brand INJECTION SOLUTION 20.25 MG/1.25GM 4 penalty RECONSTITUTED 100 GM (1.62%), 40.5 MG/2.5GM applies MG, 1000 MG, 250 MG, (1.62%), 50 MG/5GM 500 MG (1%) PA; Brand SOLU-MEDROL ANDROGEL 3 penalty INJECTION SOLUTION TRANSDERMAL GEL 25 applies RECONSTITUTED 1000 GM MG/2.5GM (1%) danazol oral capsule 100 MG, 125 MG, 2 GM, 40 2 MG, 500 MG mg, 200 mg, 50 mg DEPO-TESTOSTERONE TAPERDEX 6-DAY Brand INTRAMUSCULAR ORAL TABLET 4 4 penalty THERAPY PACK 1.5 SOLUTION 100 MG/ML, applies MG, 1.5 MG (21) 200 MG/ML TRIAMCINOLONE FORTESTA PA; Brand ACETONIDE TRANSDERMAL GEL 10 4 penalty SUSPENSION 40 GM MG/ACT (2%) applies MG/ML INJECTION 40 JATENZO ORAL MG/ML CAPSULE 158 MG, 198 4 PA triamcinolone acetonide MG, 237 MG suspension 40 mg/ml GM METHITEST ORAL 4 injection 40 mg/ml TABLET 10 MG

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 154 Drug Drug Drug Name Notes Drug Name Notes Tier Tier methyltestosterone oral OSPHENA ORAL 2 4 capsule 10 mg TABLET 60 MG oxandrolone oral tablet 2 raloxifene hcl oral tablet PV 10 mg, 2.5 mg 60 mg TESTIM PA; Brand Hormonal Agents - TRANSDERMAL GEL 50 4 penalty Pituitary MG/5GM (1%) applies ACTHAR INJECTION 6 PA TESTONE CIK GEL 80 UNIT/ML INTRAMUSCULAR KIT 4 cabergoline oral tablet 2 200 MG/ML 0.5 mg TESTOPEL IMPLANT GM PA carboprost tromethamine PELLET 75 MG intramuscular solution GM TESTOSTERONE 250 mcg/ml CYPIONATE INJECTION 4 CETROTIDE SOLUTION 200 MG/ML SUBCUTANEOUS KIT 6 PA testosterone cypionate 0.25 MG intramuscular solution 2 chorionic gonadotropin 100 mg/ml, 200 mg/ml intramuscular solution 6 PA testosterone enanthate reconstituted 10000 unit intramuscular solution 2 clomiphene citrate oral 2 PA 200 mg/ml tablet 50 mg testosterone transdermal DDAVP INJECTION GM gel 1.62 %, 10 mg/act SOLUTION 4 MCG/ML (2%), 12.5 mg/act (1%), Brand 20.25 mg/1.25gm 4 penalty (1.62%), 20.25 mg/act 2 PA DDAVP ORAL TABLET applies (1.62%), 25 mg/2.5gm 0.1 MG, 0.2 MG (1%), 40.5 mg/2.5gm DDAVP PF INJECTION GM (1.62%), 50 mg/5gm SOLUTION 4 MCG/ML (1%) desmopressin ace spray testosterone transdermal refrig nasal solution 0.01 2 2 PA solution 30 mg/act % VOGELXO PUMP PA; Brand desmopressin acetate TRANSDERMAL GEL 4 penalty injection solution 4 GM 12.5 MG/ACT (1%) applies mcg/ml VOGELXO PA; Brand DESMOPRESSIN TRANSDERMAL GEL 50 4 penalty ACETATE NASAL 3 MG/5GM (1%) applies SOLUTION 1.5 MG/ML Hormonal Agents - desmopressin acetate 2 Osteoporosis oral tablet 0.1 mg, 0.2 mg Brand desmopressin acetate pf EVISTA ORAL TABLET 4 penalty injection solution 4 GM 60 MG applies mcg/ml

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 155 Drug Drug Drug Name Notes Drug Name Notes Tier Tier desmopressin acetate GENOTROPIN spray nasal solution 0.01 2 SUBCUTANEOUS % SOLUTION 6 PA EGRIFTA SV RECONSTITUTED 12 MG, 5 MG SUBCUTANEOUS 6 PA SOLUTION GONAL-F INJECTION RECONSTITUTED 2 MG SOLUTION 6 PA ELIGARD RECONSTITUTED 1050 PA; SUBCUTANEOUS KIT UNIT, 450 UNIT 6 Specialty 22.5 MG, 30 MG, 45 MG, GONAL-F RFF Medical 7.5 MG REDIJECT FENSOLVI (6 MONTH) PA; SUBCUTANEOUS SUBCUTANEOUS KIT 6 Specialty SOLUTION 300 6 PA 45 MG (PED) Medical UNIT/0.5ML, 450 UNT/0.75ML, 900 FIRMAGON (240 MG UNIT/1.5ML DOSE) PA; SUBCUTANEOUS GONAL-F RFF 6 Specialty SOLUTION SUBCUTANEOUS Medical RECONSTITUTED 120 SOLUTION 6 PA MG/VIAL RECONSTITUTED 75 UNIT FIRMAGON SUBCUTANEOUS PA; HEMABATE SOLUTION 6 Specialty INTRAMUSCULAR GM RECONSTITUTED 80 Medical SOLUTION 250 MCG/ML MG HUMATROPE INJECTION SOLUTION FOLLISTIM AQ 6 PA SUBCUTANEOUS RECONSTITUTED 12 SOLUTION 300 MG, 24 MG, 5 MG, 6 MG 5 PA UNT/0.36ML, 600 INCRELEX UNT/0.72ML, 900 SUBCUTANEOUS 6 PA UNT/1.08ML SOLUTION 40 MG/4ML ganirelix acetate ISTURISA ORAL 6 PA subcutaneous solution 6 PA TABLET 1 MG, 10 MG, 5 prefilled syringe 250 MG mcg/0.5ml leuprolide acetate 6 PA GENOTROPIN injection kit 1 mg/0.2ml MINIQUICK LEUPROLIDE SUBCUTANEOUS ACETATE- SOLUTION BUPIVACAINE GM RECONSTITUTED 0.2 6 PA INTRAMUSCULAR MG, 0.4 MG, 0.6 MG, 0.8 SOLUTION 25-5 MG/ML MG, 1 MG, 1.2 MG, 1.4 MG, 1.6 MG, 1.8 MG, 2 MG

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 156 Drug Drug Drug Name Notes Drug Name Notes Tier Tier LUPANETA PACK NORDITROPIN PA; COMBINATION KIT 6 Specialty FLEXPRO 11.25 & 5 MG, 3.75 & 5 Medical SUBCUTANEOUS MG SOLUTION PEN- 6 PA LUPRON DEPOT (1- INJECTOR 10 PA; MG/1.5ML, 15 MONTH) 6 Specialty INTRAMUSCULAR KIT MG/1.5ML, 30 MG/3ML, Medical 3.75 MG, 7.5 MG 5 MG/1.5ML LUPRON DEPOT (3- novarel intramuscular PA; MONTH) solution reconstituted 6 PA 6 Specialty 10000 unit INTRAMUSCULAR KIT Medical 11.25 MG, 22.5 MG NOVAREL LUPRON DEPOT (4- INTRAMUSCULAR MONTH) SOLUTION 6 PA PA; RECONSTITUTED 5000 INTRAMUSCULAR KIT 6 Specialty 30MG UNIT Medical INTRAMUSCULAR KIT NUTROPIN AQ NUSPIN 30 MG 10 SUBCUTANEOUS 6 PA LUPRON DEPOT (6- SOLUTION PEN- MONTH) INJECTOR 10 MG/2ML PA; INTRAMUSCULAR KIT 6 Specialty NUTROPIN AQ NUSPIN 45MG Medical 20 SUBCUTANEOUS 6 PA INTRAMUSCULAR KIT SOLUTION PEN- 45 MG INJECTOR 20 MG/2ML LUPRON DEPOT-PED NUTROPIN AQ NUSPIN (1-MONTH) PA; 5 SUBCUTANEOUS 6 PA INTRAMUSCULAR KIT 6 Specialty SOLUTION PEN- 11.25 MG, 15 MG, 7.5 Medical INJECTOR 5 MG/2ML MG octreotide acetate LUPRON DEPOT-PED solution 100 mcg/ml 5 PA (3-MONTH) PA; injection 100 mcg/ml INTRAMUSCULAR KIT 6 Specialty octreotide acetate 11.25 MG (PED), 30 MG Medical solution 100 mcg/ml 6 PA (PED) injection 100 mcg/ml MENOPUR octreotide acetate SUBCUTANEOUS solution 1000 mcg/ml 5 PA SOLUTION 6 PA injection 1000 mcg/ml RECONSTITUTED 75 UNIT octreotide acetate solution 1000 mcg/ml 6 PA injection 1000 mcg/ml octreotide acetate solution 200 mcg/ml 5 PA injection 200 mcg/ml

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 157 Drug Drug Drug Name Notes Drug Name Notes Tier Tier octreotide acetate PITOCIN INJECTION GM solution 200 mcg/ml 6 PA SOLUTION 10 UNIT/ML injection 200 mcg/ml pregnyl intramuscular octreotide acetate solution reconstituted 6 PA solution 50 mcg/ml 5 PA 10000 unit injection 50 mcg/ml SAIZEN INJECTION octreotide acetate SOLUTION 6 PA solution 50 mcg/ml 6 PA RECONSTITUTED 5 injection 50 mcg/ml MG, 8.8 MG octreotide acetate SAIZENPREP solution 500 mcg/ml 5 PA INJECTION SOLUTION 6 PA injection 500 mcg/ml RECONSTITUTED 8.8 octreotide acetate MG solution 500 mcg/ml 6 PA SANDOSTATIN injection 500 mcg/ml INJECTION SOLUTION 6 PA OMNITROPE 100 MCG/ML, 50 SUBCUTANEOUS MCG/ML, 500 MCG/ML SOLUTION CARTRIDGE 5 PA SANDOSTATIN LAR PA; 10 MG/1.5ML, 5 DEPOT 6 Specialty MG/1.5ML INTRAMUSCULAR KIT Medical OMNITROPE 10 MG, 20 MG, 30 MG SUBCUTANEOUS SIGNIFOR LAR SOLUTION 5 PA INTRAMUSCULAR PA; RECONSTITUTED 5.8 SUSPENSION 6 Specialty MG RECONSTITUTED ER Medical ORILISSA ORAL 10 MG, 30 MG TABLET 150 MG, 200 4 PA SIGNIFOR MG SUBCUTANEOUS 6 PA OVIDREL SOLUTION 0.3 MG/ML, SUBCUTANEOUS 0.6 MG/ML, 0.9 MG/ML 6 PA INJECTABLE 250 SOMATULINE DEPOT MCG/0.5ML SUBCUTANEOUS PA; SOLUTION 120 6 Specialty oxytocin injection solution GM 10 unit/ml MG/0.5ML, 60 Medical MG/0.2ML, 90 MG/0.3ML OXYTOCIN-LACTATED SOMAVERT RINGERS GM INTRAVENOUS SUBCUTANEOUS SOLUTION SOLUTION 20 UNIT/L 6 PA RECONSTITUTED 10 OXYTOCIN-SODIUM MG, 15 MG, 20 MG, 25 CHLORIDE MG, 30 MG INTRAVENOUS GM SOLUTION 15-0.9 STIMATE NASAL 3 UT/250ML-%, 30-0.9 SOLUTION 1.5 MG/ML UT/500ML-% Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 158 Drug Drug Drug Name Notes Drug Name Notes Tier Tier SUPPRELIN LA PA; ZOMACTON SUBCUTANEOUS KIT 6 Specialty SUBCUTANEOUS 50 MG Medical SOLUTION 6 PA RECONSTITUTED 10 SYNAREL NASAL 6 PA SOLUTION 2 MG/ML MG, 5 MG Hormonal Agents - TEPEZZA Prostaglandins INTRAVENOUS PA; 6 Specialty KORLYM ORAL TABLET SOLUTION 6 PA RECONSTITUTED 500 Medical 300 MG MG Hormonal Agents - Sex TRELSTAR MIXJECT Hormones and Birth INTRAMUSCULAR PA; Control SUSPENSION 6 Specialty Brand RECONSTITUTED 11.25 Medical ACTIVELLA ORAL 4 penalty MG, 22.5 MG, 3.75 MG TABLET 1-0.5 MG applies TRIPTODUR afirmelle oral tablet 0.1- PV INTRAMUSCULAR PA; 20 mg-mcg SUSPENSION 6 Specialty RECONSTITUTED ER Medical AFTERPILL ORAL PV 22.5 MG TABLET 1.5 MG VANTAS PA; ALORA TRANSDERMAL SUBCUTANEOUS KIT 6 Specialty PATCH TWICE WEEKLY 4 50 MG Medical 0.025 MG/24HR, 0.05 MG/24HR, 0.075 VAPRISOL MG/24HR, 0.1 MG/24HR INTRAVENOUS GM SOLUTION 20-5 altavera oral tablet 0.15- PV MG/100ML-% 30 mg-mcg VASOSTRICT alyacen 1/35 oral tablet PV INTRAVENOUS GM 1-35 mg-mcg SOLUTION 20 UNIT/ML alyacen 7/7/7 oral tablet PV ZOLADEX 0.5/0.75/1-35 mg-mcg PA; amabelz oral tablet 0.5- SUBCUTANEOUS 6 Specialty 2 0.1 mg, 1-0.5 mg IMPLANT 10.8 MG, 3.6 Medical MG amethia oral tablet 0.15- PV ZOMACTON (FOR 0.03 &0.01 mg ZOMA-JET 10) amethyst oral tablet 90- SUBCUTANEOUS PV 6 PA 20 mcg SOLUTION RECONSTITUTED 10 ANGELIQ ORAL 4 MG TABLET 0.25-0.5 MG, 0.5-1 MG ANNOVERA VAGINAL RING 0.013-0.15 4 MG/24HR

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 159 Drug Drug Drug Name Notes Drug Name Notes Tier Tier apri oral tablet 0.15-30 blisovi fe 1/20 oral tablet PV PV mg-mcg 1-20 mg-mcg aranelle oral tablet PV briellyn oral tablet 0.4-35 PV 0.5/1/0.5-35 mg-mcg mg-mcg ashlyna oral tablet 0.15- PV camila oral tablet 0.35 PV 0.03 &0.01 mg mg aubra eq oral tablet 0.1- PV camrese lo oral tablet PV 20 mg-mcg 0.1-0.02 & 0.01 mg aubra oral tablet 0.1-20 camrese oral tablet 0.15- PV PV mg-mcg 0.03 &0.01 mg aurovela 1.5/30 oral caziant oral tablet PV PV tablet 1.5-30 mg-mcg 0.1/0.125/0.15 -0.025 mg aurovela 1/20 oral tablet charlotte 24 fe oral tablet PV 1-20 mg-mcg chewable 1-20 mg- PV mcg(24) aurovela 24 fe oral tablet PV 1-20 mg-mcg(24) chateal eq oral tablet PV 0.15-30 mg-mcg aurovela fe 1.5/30 oral PV tablet 1.5-30 mg-mcg chateal oral tablet 0.15- PV 30 mg-mcg aurovela fe 1/20 oral PV tablet 1-20 mg-mcg CLIMARA PRO TRANSDERMAL PATCH aviane oral tablet 0.1-20 PV 4 mg-mcg WEEKLY 0.045-0.015 MG/DAY Brand AYGESTIN ORAL 4 penalty CLIMARA TABLET 5 MG applies TRANSDERMAL PATCH WEEKLY 0.025 ayuna oral tablet 0.15-30 Brand PV MG/24HR, 0.0375 mg-mcg 4 penalty MG/24HR, 0.05 applies MG/24HR, 0.06 azurette oral tablet 0.15- PV 0.02/0.01 mg (21/5) MG/24HR, 0.075 BALCOLTRA ORAL MG/24HR, 0.1 MG/24HR TABLET 0.1-20 MG- 4 COMBIPATCH MCG(21) TRANSDERMAL PATCH TWICE WEEKLY 0.05- 4 balziva oral tablet 0.4-35 PV mg-mcg 0.14 MG/DAY, 0.05-0.25 MG/DAY Brand BEYAZ ORAL TABLET 4 penalty CRINONE VAGINAL 4 3-0.02-0.451 MG applies GEL 4 %, 8 % blisovi 24 fe oral tablet 1- cryselle-28 oral tablet PV PV 20 mg-mcg(24) 0.3-30 mg-mcg cyclafem 1/35 oral tablet blisovi fe 1.5/30 oral PV PV tablet 1.5-30 mg-mcg 1-35 mg-mcg

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 160 Drug Drug Drug Name Notes Drug Name Notes Tier Tier cyclafem 7/7/7 oral tablet DIVIGEL PV 0.5/0.75/1-35 mg-mcg TRANSDERMAL GEL 0.25 MG/0.25GM, 0.5 cyred eq oral tablet 0.15- PV 4 30 mg-mcg MG/0.5GM, 0.75 MG/0.75GM, 1 MG/GM, cyred oral tablet 0.15-30 PV 1.25 MG/1.25GM mg-mcg dolishale oral tablet 90- PV dasetta 1/35 oral tablet 1- PV 20 mcg 35 mg-mcg dotti transdermal patch dasetta 7/7/7 oral tablet PV twice weekly 0.025 0.5/0.75/1-35 mg-mcg mg/24hr, 0.0375 2 daysee oral tablet 0.15- mg/24hr, 0.05 mg/24hr, PV 0.03 &0.01 mg 0.075 mg/24hr, 0.1 deblitane oral tablet 0.35 mg/24hr PV mg drospiren-eth estrad- levomefol oral tablet 3- DELESTROGEN PV INTRAMUSCULAR OIL 4 0.02-0.451 mg, 3-0.03- 10 MG/ML 0.451 mg DELESTROGEN Brand drospirenone-ethinyl PV INTRAMUSCULAR OIL 4 penalty estradiol oral tablet 3- 20 MG/ML, 40 MG/ML applies 0.02 mg, 3-0.03 mg delyla oral tablet 0.1-20 DUAVEE ORAL TABLET PV 4 mg-mcg 0.45-20 MG DEPO-ESTRADIOL EC-RX INTRAMUSCULAR OIL 5 GM PROGESTERONE 4 MG/ML TRANSDERMAL CREAM 10 % DEPO-PROVERA Brand INTRAMUSCULAR ELESTRIN 4 penalty TRANSDERMAL GEL SUSPENSION 150 applies 4 MG/ML 0.52 MG/0.87 GM (0.06%) DEPO-PROVERA INTRAMUSCULAR Brand elinest oral tablet 0.3-30 PV SUSPENSION 4 penalty mg-mcg applies PREFILLED SYRINGE ELLA ORAL TABLET 30 PV 150 MG/ML MG

DEPO-SUBQ PROVERA eluryng vaginal ring 0.12- PV 104 SUBCUTANEOUS 0.015 mg/24hr SUSPENSION 4 emoquette oral tablet PV PREFILLED SYRINGE 0.15-30 mg-mcg 104 MG/0.65ML ENDOMETRIN VAGINAL 3 desogestrel-ethinyl INSERT 100 MG estradiol oral tablet 0.15- PV enpresse-28 oral tablet 0.02/0.01 mg (21/5), PV 0.15-30 mg-mcg 50-30/75-40/ 125-30 mcg Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 161 Drug Drug Drug Name Notes Drug Name Notes Tier Tier enskyce oral tablet 0.15- ESTRING VAGINAL PV 3 30 mg-mcg RING 2 MG errin oral tablet 0.35 mg PV ESTROGEL TRANSDERMAL GEL est estrogens-methyltest 2 4 ds oral tablet 1.25-2.5 mg 0.75 MG/1.25 GM (0.06%) est estrogens-methyltest hs oral tablet 0.625-1.25 2 ESTROSTEP FE ORAL Brand mg TABLET 1-20/1-30/1-35 4 penalty MG-MCG applies est estrogens-methyltest oral tablet 0.625-1.25 2 ethynodiol diac-eth mg, 1.25-2.5 mg estradiol oral tablet 1-35 PV mg-mcg, 1-50 mg-mcg estarylla oral tablet 0.25- PV 35 mg-mcg etonogestrel-ethinyl estradiol vaginal ring PV ESTRACE ORAL Brand 0.12-0.015 mg/24hr TABLET 0.5 MG, 1 MG, 4 penalty 2 MG applies EVAMIST TRANSDERMAL 4 Brand SOLUTION 1.53 ESTRACE VAGINAL 4 penalty MG/SPRAY CREAM 0.1 MG/GM applies FALESSA ORAL KIT 20- estradiol oral tablet 0.5 4 1 1-0.1 MCG-MG mg, 1 mg, 2 mg falmina oral tablet 0.1-20 PV estradiol transdermal mg-mcg patch twice weekly 0.025 mg/24hr, 0.0375 fayosim oral tablet 42-21- 2 PV mg/24hr, 0.05 mg/24hr, 21-7 days 0.075 mg/24hr, 0.1 Brand mg/24hr FEMHRT ORAL TABLET 4 penalty estradiol transdermal 0.5-2.5 MG-MCG applies patch weekly 0.025 FEMRING VAGINAL mg/24hr, 0.0375 RING 0.05 MG/24HR, 4 2 mg/24hr, 0.05 mg/24hr, 0.1 MG/24HR 0.06 mg/24hr, 0.075 femynor oral tablet 0.25- PV mg/24hr, 0.1 mg/24hr 35 mg-mcg estradiol vaginal cream 2 FIRST- 0.1 mg/gm PROGESTERONE VGS 4 estradiol vaginal tablet 10 2 VAGINAL mcg SUPPOSITORY 100 MG, estradiol valerate 200 MG 2 intramuscular oil 20 fyavolv oral tablet 0.5-2.5 2 mg/ml, 40 mg/ml mg-mcg, 1-5 mg-mcg estradiol-norethindrone gemmily oral capsule 1- 2 acet oral tablet 0.5-0.1 2 20 mg-mcg(24) mg, 1-0.5 mg Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 162 Drug Drug Drug Name Notes Drug Name Notes Tier Tier GENERESS FE ORAL Brand junel 1.5/30 oral tablet PV TABLET CHEWABLE 4 penalty 1.5-30 mg-mcg 0.8-25 MG-MCG applies junel 1/20 oral tablet 1-20 PV gianvi oral tablet 3-0.02 PV mg-mcg mg junel fe 1.5/30 oral tablet PV hailey 1.5/30 oral tablet PV 1.5-30 mg-mcg 1.5-30 mg-mcg junel fe 1/20 oral tablet 1- PV hailey 24 fe oral tablet 1- 20 mg-mcg PV 20 mg-mcg(24) junel fe 24 oral tablet 1- PV hailey fe 1.5/30 oral 20 mg-mcg(24) PV tablet 1.5-30 mg-mcg kaitlib fe oral tablet PV hailey fe 1/20 oral tablet chewable 0.8-25 mg-mcg PV 1-20 mg-mcg kalliga oral tablet 0.15-30 PV heather oral tablet 0.35 PV mg-mcg mg kariva oral tablet 0.15- PV hydroxyprogesterone PA; 0.02/0.01 mg (21/5) caproate intramuscular 6 Specialty kelnor 1/35 oral tablet 1- PV oil 250 mg/ml Medical 35 mg-mcg hydroxyprogesterone kelnor 1/50 oral tablet 1- 5 PA PV caproate intramuscular 50 mg-mcg solution 1.25 gm/5ml kurvelo oral tablet 0.15- iclevia oral tablet 0.15- PV PV 30 mg-mcg 0.03 mg KYLEENA incassia oral tablet 0.35 INTRAUTERINE PV GM PV mg INTRAUTERINE introvale oral tablet 0.15- PV DEVICE 19.5 MG 0.03 mg larin 1.5/30 oral tablet PV isibloom oral tablet 0.15- PV 1.5-30 mg-mcg 30 mg-mcg larin 1/20 oral tablet 1-20 PV jaimiess oral tablet 0.15- PV mg-mcg 0.03 &0.01 mg larin 24 fe oral tablet 1-20 PV jasmiel oral tablet 3-0.02 PV mg-mcg(24) mg larin fe 1.5/30 oral tablet PV jencycla oral tablet 0.35 1.5-30 mg-mcg PV mg larin fe 1/20 oral tablet 1- PV jinteli oral tablet 1-5 mg- 20 mg-mcg 2 mcg larissia oral tablet 0.1-20 PV jolessa oral tablet 0.15- mg-mcg PV 0.03 mg layolis fe oral tablet PV juleber oral tablet 0.15-30 PV chewable 0.8-25 mg-mcg mg-mcg

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 163 Drug Drug Drug Name Notes Drug Name Notes Tier Tier leena oral tablet LOESTRIN FE 1/20 Brand PV 0.5/1/0.5-35 mg-mcg ORAL TABLET 1-20 MG- 4 penalty MCG applies lessina oral tablet 0.1-20 PV mg-mcg lojaimiess oral tablet 0.1- PV 0.02 & 0.01 mg levonest oral tablet 50- PV 30/75-40/ 125-30 mcg loryna oral tablet 3-0.02 PV levonorgest-eth est & eth mg est oral tablet 42-21-21-7 PV LOSEASONIQUE ORAL Brand days TABLET 0.1-0.02 & 0.01 4 penalty levonorgest-eth estrad MG applies 91-day oral tablet 0.1- low-ogestrel oral tablet PV 0.02 & 0.01 mg, 0.15- PV 0.3-30 mg-mcg 0.03 &0.01 mg, 0.15-0.03 lo-zumandimine oral PV mg tablet 3-0.02 mg levonorgestrel oral tablet PV lutera oral tablet 0.1-20 PV 1.5 mg mg-mcg levonorgestrel-ethinyl lyleq oral tablet 0.35 mg PV estrad oral tablet 0.1-20 PV mg-mcg, 0.15-30 mg- lyllana transdermal patch mcg, 90-20 mcg twice weekly 0.025 mg/24hr, 0.0375 2 levonorg-eth estrad mg/24hr, 0.05 mg/24hr, triphasic oral tablet 50- PV 0.075 mg/24hr, 0.1 30/75-40/ 125-30 mcg mg/24hr levora 0.15/30 (28) oral PV lyza oral tablet 0.35 mg PV tablet 0.15-30 mg-mcg MAKENA PA; LILETTA (52 MG) INTRAMUSCULAR OIL 6 Specialty INTRAUTERINE GM PV 250 MG/ML Medical 19.5 MCG/DAY MAKENA SUBCUTANEOUS lillow oral tablet 0.15-30 PV SOLUTION AUTO- 6 PA mg-mcg INJECTOR 275 LO LOESTRIN FE ORAL MG/1.1ML TABLET 1 MG-10 MCG / 4 marlissa oral tablet 0.15- PV 10 MCG 30 mg-mcg LOESTRIN 1.5/30 (21) Brand medroxyprogesterone ORAL TABLET 1.5-30 4 penalty acetate intramuscular PV MG-MCG applies suspension 150 mg/ml LOESTRIN 1/20 (21) Brand medroxyprogesterone ORAL TABLET 1-20 MG- 4 penalty acetate intramuscular applies PV MCG suspension prefilled LOESTRIN FE 1.5/30 Brand syringe 150 mg/ml ORAL TABLET 1.5-30 4 penalty MG-MCG applies Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 164 Drug Drug Drug Name Notes Drug Name Notes Tier Tier medroxyprogesterone MINIVELLE acetate oral tablet 10 mg, 1 TRANSDERMAL PATCH 2.5 mg, 5 mg TWICE WEEKLY 0.025 megestrol acetate oral MG/24HR, 0.0375 3 MG/24HR, 0.05 suspension 40 mg/ml, 2 400 mg/10ml, 625 MG/24HR, 0.075 mg/5ml MG/24HR, 0.1 MG/24HR megestrol acetate oral MIRCETTE ORAL Brand 2 tablet 20 mg, 40 mg TABLET 0.15-0.02/0.01 4 penalty MG (21/5) applies MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 3 MIRENA (52 MG) MG INTRAUTERINE GM PV INTRAUTERINE MENOSTAR DEVICE 20 MCG/24HR TRANSDERMAL PATCH 3 WEEKLY 14 MCG/24HR mono-linyah oral tablet PV 0.25-35 mg-mcg merzee oral capsule 1-20 2 NATAZIA ORAL TABLET mg-mcg(24) PV 3/2-2/2-3/1 MG mibelas 24 fe oral tablet necon 0.5/35 (28) oral chewable 1-20 mg- PV PV mcg(24) tablet 0.5-35 mg-mcg microgestin 1.5/30 oral NEXPLANON PV tablet 1.5-30 mg-mcg SUBCUTANEOUS GM PV IMPLANT 68 MG microgestin 1/20 oral PV tablet 1-20 mg-mcg NEXTSTELLIS ORAL 4 TABLET 3-14.2 MG microgestin 24 fe oral PV tablet 1-20 mg-mcg nikki oral tablet 3-0.02 PV mg microgestin fe 1.5/30 oral PV tablet 1.5-30 mg-mcg nora-be oral tablet 0.35 PV mg microgestin fe 1/20 oral PV tablet 1-20 mg-mcg norethin ace-eth estrad- fe oral capsule 1-20 mg- 2 mili oral tablet 0.25-35 PV mcg(24) mg-mcg norethin ace-eth estrad- mimvey oral tablet 1-0.5 2 fe oral tablet 1-20 mg- PV mg mcg, 1.5-30 mg-mcg MINASTRIN 24 FE Brand norethin ace-eth estrad- ORAL TABLET 4 penalty fe oral tablet chewable 1- PV CHEWABLE 1-20 MG- applies 20 mg-mcg(24) MCG(24) norethindrone acetate 2 oral tablet 5 mg

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 165 Drug Drug Drug Name Notes Drug Name Notes Tier Tier norethindrone acet- ocella oral tablet 3-0.03 PV ethinyl est oral tablet 1- PV mg 20 mg-mcg, 1.5-30 mg- ORIAHNN ORAL mcg CAPSULE THERAPY 4 PA norethindrone oral tablet PV PACK 300-1-0.5 & 300 0.35 mg MG norethindrone-eth orsythia oral tablet 0.1-20 PV estradiol oral tablet 0.5- 2 mg-mcg 2.5 mg-mcg, 1-5 mg-mcg PARAGARD norethin-eth estradiol-fe INTRAUTERINE oral tablet chewable 0.4- COPPER PV GM PV 35 mg-mcg, 0.8-25 mg- INTRAUTERINE mcg INTRAUTERINE norgestimate-eth DEVICE PV estradiol oral tablet 0.25- philith oral tablet 0.4-35 PV 35 mg-mcg mg-mcg norgestimate-ethinyl pimtrea oral tablet 0.15- PV estradiol triphasic oral 0.02/0.01 mg (21/5) tablet 0.18/0.215/0.25 pirmella 1/35 oral tablet PV PV mg-25 mcg, 1-35 mg-mcg 0.18/0.215/0.25 mg-35 pirmella 7/7/7 oral tablet mcg PV 0.5/0.75/1-35 mg-mcg norlyda oral tablet 0.35 PV PLAN B ONE-STEP mg PV ORAL TABLET 1.5 MG norlyroc oral tablet 0.35 PV mg portia-28 oral tablet 0.15- PV 30 mg-mcg nortrel 0.5/35 (28) oral PV tablet 0.5-35 mg-mcg PREFEST ORAL TABLET 1/1-0.09 MG 4 nortrel 1/35 (21) oral PV (15/15) tablet 1-35 mg-mcg PREMARIN INJECTION nortrel 1/35 (28) oral SOLUTION PV GM tablet 1-35 mg-mcg RECONSTITUTED 25 nortrel 7/7/7 oral tablet MG PV 0.5/0.75/1-35 mg-mcg PREMARIN ORAL Brand NUVARING VAGINAL TABLET 0.3 MG, 0.45 4 RING 0.12-0.015 4 penalty MG, 0.625 MG, 0.9 MG, MG/24HR applies 1.25 MG nylia 7/7/7 oral tablet PV PREMARIN VAGINAL 4 0.5/0.75/1-35 mg-mcg CREAM 0.625 MG/GM nymyo oral tablet 0.25-35 PV PREMPHASE ORAL 4 mg-mcg TABLET 0.625-5 MG

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 166 Drug Drug Drug Name Notes Drug Name Notes Tier Tier PREMPRO ORAL SKYLA INTRAUTERINE GM PV TABLET 0.3-1.5 MG, 4 INTRAUTERINE 0.45-1.5 MG, 0.625-2.5 DEVICE 13.5 MG MG, 0.625-5 MG SLYND ORAL TABLET 4 PV preventeza oral tablet 1.5 PV MG mg sprintec 28 oral tablet PV previfem oral tablet 0.25- PV 0.25-35 mg-mcg 35 mg-mcg sronyx oral tablet 0.1-20 PV progesterone mg-mcg intramuscular oil 50 2 syeda oral tablet 3-0.03 PV mg/ml mg progesterone micronized tarina 24 fe oral tablet 1- 2 PV transdermal cream 10 % 20 mg-mcg(24) progesterone oral 2 tarina fe 1/20 eq oral PV capsule 100 mg, 200 mg tablet 1-20 mg-mcg PROMETRIUM ORAL Brand tarina fe 1/20 oral tablet PV CAPSULE 100 MG, 200 4 penalty 1-20 mg-mcg MG applies TAYTULLA ORAL Brand PROVERA ORAL Brand CAPSULE 1-20 MG- 4 penalty TABLET 10 MG, 2.5 MG, 4 penalty MCG(24) applies 5 MG applies tilia fe oral tablet 1-20/1- PV QUARTETTE ORAL Brand 30/1-35 mg-mcg TABLET 42-21-21-7 4 penalty DAYS applies tri femynor oral tablet 0.18/0.215/0.25 mg-35 PV reclipsen oral tablet 0.15- PV mcg 30 mg-mcg tri-estarylla oral tablet rivelsa oral tablet 42-21- PV 0.18/0.215/0.25 mg-35 PV 21-7 days mcg SAFYRAL ORAL Brand tri-legest fe oral tablet 1- PV TABLET 3-0.03-0.451 4 penalty 20/1-30/1-35 mg-mcg MG applies tri-linyah oral tablet SEASONIQUE ORAL Brand 0.18/0.215/0.25 mg-35 PV TABLET 0.15-0.03 &0.01 4 penalty mcg MG applies tri-lo-estarylla oral tablet setlakin oral tablet 0.15- PV 0.18/0.215/0.25 mg-25 PV 0.03 mg mcg sharobel oral tablet 0.35 PV tri-lo-marzia oral tablet mg 0.18/0.215/0.25 mg-25 PV simliya oral tablet 0.15- PV mcg 0.02/0.01 mg (21/5) tri-lo-mili oral tablet PV simpesse oral tablet PV 0.18/0.215/0.25 mg-25 0.15-0.03 &0.01 mg mcg

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 167 Drug Drug Drug Name Notes Drug Name Notes Tier Tier tri-lo-sprintec oral tablet viorele oral tablet 0.15- PV 0.18/0.215/0.25 mg-25 PV 0.02/0.01 mg (21/5) mcg VIVELLE-DOT tri-mili oral tablet TRANSDERMAL PATCH 0.18/0.215/0.25 mg-35 PV TWICE WEEKLY 0.025 Brand mcg MG/24HR, 0.0375 4 penalty applies tri-nymyo oral tablet MG/24HR, 0.05 0.18/0.215/0.25 mg-35 PV MG/24HR, 0.075 mcg MG/24HR, 0.1 MG/24HR volnea oral tablet 0.15- tri-previfem oral tablet PV 0.18/0.215/0.25 mg-35 PV 0.02/0.01 mg (21/5) mcg vyfemla oral tablet 0.4-35 PV tri-sprintec oral tablet mg-mcg PV 0.18/0.215/0.25 mg-35 vylibra oral tablet 0.25-35 PV mcg mg-mcg trivora (28) oral tablet 50- PV wera oral tablet 0.5-35 PV 30/75-40/ 125-30 mcg mg-mcg tri-vylibra lo oral tablet wymzya fe oral tablet PV 0.18/0.215/0.25 mg-25 PV chewable 0.4-35 mg-mcg mcg xulane transdermal patch PV tri-vylibra oral tablet weekly 150-35 mcg/24hr 0.18/0.215/0.25 mg-35 PV Brand mcg YASMIN 28 ORAL 4 penalty tulana oral tablet 0.35 mg PV TABLET 3-0.03 MG applies TWIRLA Brand 4 penalty TRANSDERMAL PATCH 4 YAZ ORAL TABLET 3- WEEKLY 120-30 0.02 MG applies MCG/24HR yuvafem vaginal tablet 10 2 tyblume oral tablet PV mcg chewable 0.1-20 mg-mcg zafemy transdermal tydemy oral tablet 3-0.03- patch weekly 150-35 PV PV 0.451 mg mcg/24hr Brand zarah oral tablet 3-0.03 PV VAGIFEM VAGINAL 4 penalty mg TABLET 10 MCG applies zovia 1/35 (28) oral tablet PV velivet oral tablet PV 1-35 mg-mcg 0.1/0.125/0.15 -0.025 mg zovia 1/35e (28) oral PV vestura oral tablet 3-0.02 PV tablet 1-35 mg-mcg mg zumandimine oral tablet PV vienva oral tablet 0.1-20 PV 3-0.03 mg mg-mcg

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 168 Drug Drug Drug Name Notes Drug Name Notes Tier Tier Hormonal Agents - levoxyl oral tablet 100 Thyroid mcg, 112 mcg, 125 mcg, ARMOUR THYROID 137 mcg, 150 mcg, 175 2 ORAL TABLET 120 MG, mcg, 200 mcg, 25 mcg, 15 MG, 180 MG, 240 3 50 mcg, 75 mcg, 88 mcg MG, 30 MG, 300 MG, 60 liothyronine sodium MG, 90 MG intravenous solution 10 GM CYTOMEL ORAL Brand mcg/ml TABLET 25 MCG, 5 4 penalty liothyronine sodium oral MCG, 50 MCG applies tablet 25 mcg, 5 mcg, 50 2 euthyrox oral tablet 100 mcg mcg, 112 mcg, 125 mcg, methimazole oral tablet 2 137 mcg, 150 mcg, 175 2 10 mg, 5 mg mcg, 200 mcg, 25 mcg, NATURE-THROID ORAL 50 mcg, 75 mcg, 88 mcg TABLET 113.75 MG, 130 levo-t oral tablet 100 MG, 146.25 MG, 16.25 mcg, 112 mcg, 125 mcg, MG, 162.5 MG, 195 MG, 4 137 mcg, 150 mcg, 175 2 260 MG, 32.5 MG, 325 mcg, 200 mcg, 25 mcg, MG, 48.75 MG, 65 MG, 300 mcg, 50 mcg, 75 81.25 MG, 97.5 MG mcg, 88 mcg np thyroid oral tablet 120 levothyroxine sodium mg, 15 mg, 30 mg, 60 2 intravenous solution 100 GM mg, 90 mg mcg/5ml, 200 mcg/5ml, propylthiouracil oral 2 500 mcg/5ml tablet 50 mg levothyroxine sodium SODIUM IODIDE I-131 intravenous solution GM ORAL SOLUTION 1000 GM reconstituted 100 mcg, MCI/ML 200 mcg, 500 mcg SYNTHROID ORAL LEVOTHYROXINE TABLET 100 MCG, 112 SODIUM ORAL MCG, 125 MCG, 137 CAPSULE 100 MCG, MCG, 150 MCG, 175 3 4 112 MCG, 125 MCG, 13 MCG, 200 MCG, 25 MCG, 137 MCG, 150 MCG, 300 MCG, 50 MCG, 25 MCG, 50 MCG, MCG, 75 MCG, 88 MCG 75 MCG, 88 MCG Brand levothyroxine sodium oral TAPAZOLE ORAL 4 penalty tablet 100 mcg, 112 mcg, TABLET 10 MG, 5 MG applies 125 mcg, 137 mcg, 150 2 mcg, 175 mcg, 200 mcg, TIROSINT ORAL 25 mcg, 300 mcg, 50 CAPSULE 100 MCG, mcg, 75 mcg, 88 mcg 112 MCG, 125 MCG, 13 4 MCG, 137 MCG, 150 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 169 Drug Drug Drug Name Notes Drug Name Notes Tier Tier TRIOSTAT Brand INTRAVENOUS GM ARAVA ORAL TABLET 4 penalty SOLUTION 10 MCG/ML 10 MG, 20 MG applies unithroid oral tablet 100 ARCALYST mcg, 112 mcg, 125 mcg, SUBCUTANEOUS 6 PA 137 mcg, 150 mcg, 175 2 SOLUTION mcg, 200 mcg, 25 mcg, RECONSTITUTED 220 300 mcg, 50 mcg, 75 MG mcg, 88 mcg ASCENIV PA; WESTHROID ORAL INTRAVENOUS 6 Specialty Medical TABLET 130 MG, 195 4 SOLUTION 5 GM/50ML MG, 32.5 MG, 65 MG, ASTAGRAF XL ORAL 97.5 MG CAPSULE EXTENDED 4 WP THYROID ORAL RELEASE 24 HOUR 0.5 TABLET 113.75 MG, 130 MG, 1 MG, 5 MG MG, 16.25 MG, 32.5 MG, 4 PA; 48.75 MG, 65 MG, 81.25 ATGAM INTRAVENOUS 6 Specialty MG, 97.5 MG INJECTABLE 50 MG/ML Medical Immunological Agents - AVSOLA Drugs for Immune INTRAVENOUS PA; System Stimulation or SOLUTION 5 Specialty Suppression RECONSTITUTED 100 Medical ACTEMRA ACTPEN MG SUBCUTANEOUS AZASAN ORAL TABLET 6 PA 4 SOLUTION AUTO- 100 MG, 75 MG INJECTOR 162 MG/0.9ML azathioprine oral tablet 2 50 mg ACTEMRA INTRAVENOUS PA; azathioprine sodium SOLUTION 200 6 Specialty injection solution GM MG/10ML, 400 Medical reconstituted 100 mg MG/20ML, 80 MG/4ML BENLYSTA ACTEMRA INTRAVENOUS PA; SUBCUTANEOUS SOLUTION 6 Specialty SOLUTION PREFILLED 6 PA RECONSTITUTED 120 Medical SYRINGE 162 MG, 400 MG MG/0.9ML BENLYSTA ACTIMMUNE SUBCUTANEOUS 6 PA SUBCUTANEOUS SOLUTION AUTO- 6 PA SOLUTION 2000000 INJECTOR 200 MG/ML UNIT/0.5ML BENLYSTA SUBCUTANEOUS ALFERON N INJECTION PA; 6 PA SOLUTION 5000000 6 Specialty SOLUTION PREFILLED UNIT/ML Medical SYRINGE 200 MG/ML

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 170 Drug Drug Drug Name Notes Drug Name Notes Tier Tier BERINERT PA; COSENTYX INTRAVENOUS KIT 500 6 Specialty SENSOREADY (300 UNIT Medical MG) SUBCUTANEOUS 6 PA BIVIGAM PA; SOLUTION AUTO- INTRAVENOUS 6 Specialty INJECTOR 150 MG/ML SOLUTION 5 GM/50ML Medical COSENTYX CELLCEPT SENSOREADY PEN INTRAVENOUS SUBCUTANEOUS 6 PA INTRAVENOUS SOLUTION AUTO- GM SOLUTION INJECTOR 150 MG/ML RECONSTITUTED 500 CUTAQUIG MG SUBCUTANEOUS SOLUTION 1 GM/6ML, CELLCEPT ORAL 4 6 PA CAPSULE 250 MG 1.65 GM/10ML, 2 GM/12ML, 3.3 GM/20ML, CELLCEPT ORAL 4 GM/24ML, 8 GM/48ML SUSPENSION 4 RECONSTITUTED 200 CUVITRU MG/ML SUBCUTANEOUS SOLUTION 1 GM/5ML, CELLCEPT ORAL 6 PA 4 10 GM/50ML, 2 TABLET 500 MG GM/10ML, 4 GM/20ML, 8 CIMZIA PREFILLED KIT GM/40ML SUBCUTANEOUS KIT 2 5 PA cyclosporine intravenous GM X 200 MG/ML solution 50 mg/ml CIMZIA STARTER KIT cyclosporine modified SUBCUTANEOUS KIT 6 5 PA oral capsule 100 mg, 25 2 X 200 MG/ML mg, 50 mg CIMZIA PA; cyclosporine modified 2 SUBCUTANEOUS KIT 2 5 Specialty oral solution 100 mg/ml X 200 MG Medical cyclosporine oral capsule 2 CINRYZE 100 mg, 25 mg INTRAVENOUS PA; SOLUTION 6 Specialty CYTOGAM Specialty 6 RECONSTITUTED 500 Medical INTRAVENOUS Medical UNIT INJECTABLE 50 MG/ML COSENTYX (300 MG ENBREL MINI DOSE) SUBCUTANEOUS 6 PA SUBCUTANEOUS 6 PA SOLUTION CARTRIDGE SOLUTION PREFILLED 50 MG/ML SYRINGE 150 MG/ML ENBREL SUBCUTANEOUS COSENTYX 150 MG/ML 6 PA SUBCUTANEOUS SOLUTION 25 SOLUTION PREFILLED 6 PA MG/0.5ML SYRINGE 150 MG/ML, 75 MG/0.5ML Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 171 Drug Drug Drug Name Notes Drug Name Notes Tier Tier ENBREL GAMASTAN PA; SUBCUTANEOUS INTRAMUSCULAR 6 Specialty SOLUTION PREFILLED 6 PA INJECTABLE Medical SYRINGE 25 MG/0.5ML, GAMIFANT 50 MG/ML INTRAVENOUS PA; ENBREL SOLUTION 10 MG/2ML, 6 Specialty SUBCUTANEOUS 100 MG/20ML, 50 Medical SOLUTION 6 PA MG/10ML RECONSTITUTED 25 GAMMAGARD MG INJECTION SOLUTION ENBREL SURECLICK 1 GM/10ML, 10 PA; 6 Specialty SUBCUTANEOUS 6 PA GM/100ML, 2.5 SOLUTION AUTO- GM/25ML, 20 Medical INJECTOR 50 MG/ML GM/200ML, 30 ENSPRYNG GM/300ML, 5 GM/50ML SUBCUTANEOUS GAMMAGARD S/D 6 PA SOLUTION PREFILLED LESS IGA PA; SYRINGE 120 MG/ML INTRAVENOUS 6 Specialty SOLUTION ENTYVIO Medical INTRAVENOUS PA; RECONSTITUTED 10 SOLUTION 6 Specialty GM, 5 GM RECONSTITUTED 300 Medical GAMMAKED MG INJECTION SOLUTION PA; ENVARSUS XR ORAL 1 GM/10ML, 10 6 Specialty GM/100ML, 20 Medical TABLET EXTENDED 4 RELEASE 24 HOUR GM/200ML, 5 GM/50ML 0.75 MG, 1 MG, 4 MG GAMMAPLEX everolimus oral tablet INTRAVENOUS SOLUTION 10 0.25 mg, 0.5 mg, 0.75 6 PA; mg GM/100ML, 10 6 Specialty GM/200ML, 20 Medical FIRAZYR PA; QL (18 GM/200ML, 20 SUBCUTANEOUS 6 ML per 30 GM/400ML, 5 SOLUTION 30 MG/3ML days) GM/100ML, 5 GM/50ML FLEBOGAMMA DIF GAMUNEX-C INTRAVENOUS INJECTION SOLUTION SOLUTION 0.5 1 GM/10ML, 10 PA; GM/10ML, 10 PA; GM/100ML, 2.5 6 Specialty GM/100ML, 10 6 Specialty GM/25ML, 20 Medical GM/200ML, 2.5 Medical GM/200ML, 40 GM/50ML, 20 GM/400ML, 5 GM/50ML GM/200ML, 20 GM/400ML, 5 gengraf oral capsule 100 2 GM/100ML, 5 GM/50ML mg, 25 mg gengraf oral solution 100 2 mg/ml Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 172 Drug Drug Drug Name Notes Drug Name Notes Tier Tier HAEGARDA HUMIRA PEN- SUBCUTANEOUS PSOR/UVEIT STARTER 6 PA SOLUTION SUBCUTANEOUS PEN- 5 PA RECONSTITUTED 2000 INJECTOR KIT 80 UNIT, 3000 UNIT MG/0.8ML & 40MG/0.4ML HEPAGAM B GM INJECTION SOLUTION HUMIRA HIZENTRA SUBCUTANEOUS SUBCUTANEOUS PREFILLED SYRINGE KIT 10 MG/0.1ML, 10 SOLUTION 1 GM/5ML, 6 PA 5 PA 10 GM/50ML, 2 MG/0.2ML, 20 GM/10ML, 4 GM/20ML MG/0.2ML, 20 MG/0.4ML, 40 HIZENTRA MG/0.4ML, 40 MG/0.8ML SUBCUTANEOUS SOLUTION PREFILLED 6 PA HYPERHEP B SYRINGE 1 GM/5ML, 2 INTRAMUSCULAR GM GM/10ML, 4 GM/20ML SOLUTION HUMIRA PEDIATRIC HYPERRAB INJECTION SOLUTION 1500 CROHNS START GM SUBCUTANEOUS UNIT/5ML, 300 UNIT/ML, PREFILLED SYRINGE 5 PA 900 UNIT/3ML KIT 80 MG/0.8ML, 80 HYPERRHO S/D MG/0.8ML & INTRAMUSCULAR Specialty 6 40MG/0.4ML SOLUTION PREFILLED Medical HUMIRA PEN SYRINGE 1500 UNIT, SUBCUTANEOUS PEN- 250 UNIT INJECTOR KIT 40 5 PA HYPERTET S/D MG/0.4ML, 40 INTRAMUSCULAR GM MG/0.8ML, 80 MG/0.8ML INJECTABLE 250 HUMIRA PEN- UNIT/ML CD/UC/HS STARTER HYQVIA SUBCUTANEOUS PEN- 5 PA SUBCUTANEOUS KIT INJECTOR KIT 40 10 GM/100ML, 2.5 6 PA MG/0.8ML, 80 MG/0.8ML GM/25ML, 20 HUMIRA PEN- GM/200ML, 30 PEDIATRIC UC START GM/300ML, 5 GM/50ML SUBCUTANEOUS PEN- 5 PA icatibant acetate PA; QL (18 INJECTOR KIT 80 subcutaneous solution 30 6 ML per 30 MG/0.8ML mg/3ml days) HUMIRA PEN- ILARIS PS/UV/ADOL HS START SUBCUTANEOUS 6 PA SUBCUTANEOUS PEN- 5 PA SOLUTION 150 MG/ML INJECTOR KIT 40 MG/0.8ML

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 173 Drug Drug Drug Name Notes Drug Name Notes Tier Tier ILUMYA LUPKYNIS ORAL 6 PA SUBCUTANEOUS 6 PA CAPSULE 7.9 MG SOLUTION PREFILLED methotrexate oral tablet 2 SYRINGE 100 MG/ML 2.5 mg IMOGAM RABIES-HT methotrexate sodium (pf) INJECTION SOLUTION GM injection solution 1 2 300 UNIT/2ML gm/40ml, 250 mg/10ml, Brand 50 mg/2ml IMURAN ORAL TABLET 4 penalty methotrexate sodium 50 MG applies injection solution 250 2 INFLECTRA mg/10ml, 50 mg/2ml INTRAVENOUS PA; methotrexate sodium Specialty SOLUTION 5 Specialty 6 injection solution Medical RECONSTITUTED 100 Medical reconstituted 1 gm MG methotrexate sodium oral 2 KALBITOR PA; tablet 2.5 mg SUBCUTANEOUS 6 Specialty SOLUTION 10 MG/ML Medical MICRHOGAM ULTRA- FILTERED PLUS Specialty KEDRAB INJECTION INTRAMUSCULAR 6 SOLUTION 1500 Medical GM SOLUTION PREFILLED UNIT/10ML, 300 SYRINGE 250 UNIT UNIT/2ML mycophenolate mofetil KEVZARA hcl intravenous solution GM SUBCUTANEOUS reconstituted 500 mg SOLUTION AUTO- 6 PA INJECTOR 150 mycophenolate mofetil MG/1.14ML, 200 intravenous solution GM MG/1.14ML reconstituted 500 mg KEVZARA mycophenolate mofetil 2 SUBCUTANEOUS oral capsule 250 mg SOLUTION PREFILLED 6 PA mycophenolate mofetil SYRINGE 150 oral suspension 2 MG/1.14ML, 200 reconstituted 200 mg/ml MG/1.14ML mycophenolate mofetil 2 KINERET oral tablet 500 mg SUBCUTANEOUS mycophenolate sodium 6 PA SOLUTION PREFILLED oral tablet delayed 2 SYRINGE 100 release 180 mg, 360 mg MG/0.67ML MYFORTIC ORAL PA; KYMRIAH TABLET DELAYED 6 Specialty 4 INTRAVENOUS RELEASE 180 MG, 360 Medical SUSPENSION MG leflunomide oral tablet 10 2 mg, 20 mg

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 174 Drug Drug Drug Name Notes Drug Name Notes Tier Tier NABI-HB OTEZLA ORAL TABLET INTRAMUSCULAR GM THERAPY PACK 10 & 5 PA SOLUTION 20 & 30 MG NEORAL ORAL PANZYGA CAPSULE 100 MG, 25 3 INTRAVENOUS MG SOLUTION 1 GM/10ML, PA; 10 GM/100ML, 2.5 6 Specialty NEORAL ORAL 3 SOLUTION 100 MG/ML GM/25ML, 20 Medical GM/200ML, 30 NULOJIX GM/300ML, 5 GM/50ML INTRAVENOUS SOLUTION GM PRIVIGEN RECONSTITUTED 250 INTRAVENOUS PA; MG SOLUTION 10 6 Specialty GM/100ML, 20 Medical OCTAGAM GM/200ML, 40 INTRAVENOUS GM/400ML, 5 GM/50ML SOLUTION 1 GM/20ML, 10 GM/100ML, 10 PA; PROGRAF GM/200ML, 2 GM/20ML, 6 Specialty INTRAVENOUS GM 2.5 GM/50ML, 20 Medical SOLUTION 5 MG/ML GM/200ML, 25 PROGRAF ORAL GM/500ML, 5 CAPSULE 0.5 MG, 1 3 GM/100ML, 5 GM/50ML MG, 5 MG PA; OLUMIANT ORAL 6 PA PROVENGE TABLET 1 MG, 2 MG INTRAVENOUS 6 Specialty ORENCIA CLICKJECT SUSPENSION Medical SUBCUTANEOUS 6 PA RAPAMUNE ORAL 3 SOLUTION AUTO- SOLUTION 1 MG/ML INJECTOR 125 MG/ML RAPAMUNE ORAL ORENCIA TABLET 0.5 MG, 1 MG, 3 INTRAVENOUS PA; 2 MG SOLUTION 6 Specialty REMICADE RECONSTITUTED 250 Medical INTRAVENOUS PA; MG SOLUTION 6 Specialty ORENCIA RECONSTITUTED 100 Medical SUBCUTANEOUS MG SOLUTION PREFILLED 6 PA RENFLEXIS SYRINGE 125 MG/ML, INTRAVENOUS PA; 50 MG/0.4ML, 87.5 SOLUTION 5 Specialty MG/0.7ML RECONSTITUTED 100 Medical ORLADEYO ORAL MG CAPSULE 110 MG, 150 6 PA REZUROCK ORAL 4 MG TABLET 200 MG OTEZLA ORAL TABLET 5 PA 30 MG

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 175 Drug Drug Drug Name Notes Drug Name Notes Tier Tier RHOGAM ULTRA- SIMULECT FILTERED PLUS Specialty INTRAVENOUS 6 GM INTRAMUSCULAR Medical SOLUTION SOLUTION PREFILLED RECONSTITUTED 10 SYRINGE 1500 UNIT MG, 20 MG

RHOPHYLAC sirolimus oral solution 1 2 INJECTION SOLUTION Specialty mg/ml 6 PREFILLED SYRINGE Medical sirolimus oral tablet 0.5 2 1500 UNIT/2ML mg, 1 mg, 2 mg RIDAURA ORAL 3 SKYRIZI (150 MG CAPSULE 3 MG DOSE) RINVOQ ORAL TABLET SUBCUTANEOUS 5 PA EXTENDED RELEASE 5 PA PREFILLED SYRINGE 24 HOUR 15 MG KIT 75 MG/0.83ML

RUCONEST STELARA PA; PA; INTRAVENOUS INTRAVENOUS 5 Specialty SOLUTION 6 Specialty SOLUTION 130 Medical RECONSTITUTED 2100 Medical MG/26ML UNIT STELARA SANDIMMUNE SUBCUTANEOUS 5 PA INTRAVENOUS GM SOLUTION 45 SOLUTION 50 MG/ML MG/0.5ML SANDIMMUNE ORAL STELARA CAPSULE 100 MG, 25 3 SUBCUTANEOUS MG SOLUTION PREFILLED 5 PA SYRINGE 45 MG/0.5ML, SANDIMMUNE ORAL 3 SOLUTION 100 MG/ML 90 MG/ML SYNAGIS SILIQ SUBCUTANEOUS PA; INTRAMUSCULAR SOLUTION PREFILLED 6 Specialty 6 PA SOLUTION 100 MG/ML, SYRINGE 210 Medical MG/1.5ML 50 MG/0.5ML SIMPONI ARIA PA; tacrolimus oral capsule 2 INTRAVENOUS 5 Specialty 0.5 mg, 1 mg, 5 mg SOLUTION 50 MG/4ML Medical TALTZ SIMPONI SUBCUTANEOUS 6 PA SUBCUTANEOUS SOLUTION AUTO- SOLUTION AUTO- 5 PA INJECTOR 80 MG/ML INJECTOR 100 MG/ML, TALTZ 50 MG/0.5ML SUBCUTANEOUS 6 PA SIMPONI SOLUTION PREFILLED SUBCUTANEOUS SYRINGE 80 MG/ML SOLUTION PREFILLED 5 PA PA; SYRINGE 100 MG/ML, temsirolimus intravenous 6 Specialty 50 MG/0.5ML solution 25 mg/ml Medical Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 176 Drug Drug Drug Name Notes Drug Name Notes Tier Tier THYMOGLOBULIN XEMBIFY INTRAVENOUS SUBCUTANEOUS SOLUTION GM SOLUTION 1 GM/5ML, 6 PA RECONSTITUTED 25 10 GM/50ML, 2 MG GM/10ML, 4 GM/20ML TICE BCG ZINPLAVA INTRAVESICAL INTRAVENOUS GM SUSPENSION GM PA SOLUTION 1000 RECONSTITUTED 50 MG/40ML MG ZORTRESS ORAL TORISEL PA; TABLET 0.25 MG, 0.5 6 INTRAVENOUS 6 Specialty MG, 0.75 MG, 1 MG SOLUTION 25 MG/ML Medical Immunological Agents - TREMFYA Drugs for Vaccination SUBCUTANEOUS 5 PA ACTHIB SOLUTION PEN- AL (Max 6 INTRAMUSCULAR PV INJECTOR 100 MG/ML SOLUTION Years) TREMFYA RECONSTITUTED SUBCUTANEOUS 5 PA ADACEL SOLUTION PREFILLED INTRAMUSCULAR PV SYRINGE 100 MG/ML SUSPENSION 5-2-15.5 TREXALL ORAL LF-MCG/0.5 TABLET 10 MG, 15 MG, 3 AFLURIA 5 MG, 7.5 MG QUADRIVALENT PV INTRAMUSCULAR UPLIZNA PA; SUSPENSION INTRAVENOUS 6 Specialty SOLUTION 100 Medical AFLURIA MG/10ML QUADRIVALENT INTRAMUSCULAR WINRHO SDF PV INJECTION SOLUTION SUSPENSION Specialty PREFILLED SYRINGE 1500 UNIT/1.3ML, 15000 6 UNIT/13ML, 2500 Medical 0.25 ML, 0.5 ML UNIT/2.2ML, 5000 BCG VACCINE UNIT/4.4ML INJECTION GM INJECTABLE XELJANZ ORAL 5 PA SOLUTION 1 MG/ML BEXSERO XELJANZ ORAL INTRAMUSCULAR 5 PA PV TABLET 10 MG, 5 MG SUSPENSION XELJANZ XR ORAL PREFILLED SYRINGE TABLET EXTENDED BIOTHRAX 5 PA RELEASE 24 HOUR 11 INTRAMUSCULAR GM MG, 22 MG SUSPENSION

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 177 Drug Drug Drug Name Notes Drug Name Notes Tier Tier BOOSTRIX FLULAVAL INTRAMUSCULAR PV QUADRIVALENT SUSPENSION 5-2.5- INTRAMUSCULAR PV 18.5 LF-MCG/0.5 SUSPENSION DAPTACEL PREFILLED SYRINGE INTRAMUSCULAR PV 0.5 ML SUSPENSION 23-15-5 AL (Min 2 FLUMIST Years and DIPHTHERIA-TETANUS PV TOXOIDS DT QUADRIVALENT NASAL Max 49 INTRAMUSCULAR PV SUSPENSION Years) SUSPENSION 25-5 FLUZONE HIGH-DOSE LFU/0.5ML QUADRIVALENT AL (Min 65 ENGERIX-B INJECTION INTRAMUSCULAR PV SUSPENSION 10 PV SUSPENSION Years) MCG/0.5ML, 20 MCG/ML PREFILLED SYRINGE 0.7 ML FLUAD QUADRIVALENT INTRAMUSCULAR AL (Min 65 FLUZONE PV QUADRIVALENT PREFILLED SYRINGE Years) PV 0.5 ML INTRAMUSCULAR SUSPENSION , 0.5 ML FLUARIX QUADRIVALENT FLUZONE QUADRIVALENT INTRAMUSCULAR PV SUSPENSION INTRAMUSCULAR PV PREFILLED SYRINGE SUSPENSION 0.5 ML PREFILLED SYRINGE 0.5 ML FLUBLOK QUADRIVALENT AL (Min 9 GARDASIL 9 Years and INTRAMUSCULAR PV PV SOLUTION PREFILLED INTRAMUSCULAR Max 27 SYRINGE 0.5 ML SUSPENSION Years) FLUCELVAX GARDASIL 9 AL (Min 9 INTRAMUSCULAR Years and QUADRIVALENT PV PV INTRAMUSCULAR SUSPENSION Max 27 SUSPENSION PREFILLED SYRINGE Years) FLUCELVAX HAVRIX INTRAMUSCULAR QUADRIVALENT PV INTRAMUSCULAR SUSPENSION 1440 EL PV SUSPENSION U/ML, 720 EL U/0.5ML PREFILLED SYRINGE HEPLISAV-B 0.5 ML INTRAMUSCULAR AL (Min 18 PV SOLUTION PREFILLED Years) SYRINGE 20 MCG/0.5ML

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 178 Drug Drug Drug Name Notes Drug Name Notes Tier Tier HIBERIX INJECTION NOVAVAX COVID-19 AL (Max 6 SOLUTION PV VACCINE RECONSTITUTED 10 Years) INTRAMUSCULAR PV MCG SUSPENSION 5 IMOVAX RABIES MCG/0.5ML INTRAMUSCULAR GM PEDIARIX INJECTABLE 2.5 INTRAMUSCULAR PV UNIT/ML SUSPENSION INFANRIX PEDVAX HIB INTRAMUSCULAR PV INTRAMUSCULAR AL (Max 6 PV SUSPENSION 25-58-10 SUSPENSION 7.5 Years) AL (Max 17 MCG/0.5ML IPOL INJECTION PV INJECTABLE Years) PENTACEL IXIARO INTRAMUSCULAR PV INTRAMUSCULAR GM SUSPENSION SUSPENSION RECONSTITUTED QL (1 ML JANSSEN COVID-19 PFIZER-BIONTECH VACCINE COVID-19 VACC per 21 PV INTRAMUSCULAR INTRAMUSCULAR PV days); AL SUSPENSION 0.5 ML SUSPENSION 30 (Min 12 MCG/0.3ML Years) KINRIX INTRAMUSCULAR PV PNEUMOVAX 23 SUSPENSION INJECTION PV INJECTABLE 25 MENACTRA MCG/0.5ML INTRAMUSCULAR PV INJECTABLE PREVNAR 13 INTRAMUSCULAR PV MENQUADFI SUSPENSION INTRAMUSCULAR PV INJECTABLE PROQUAD SUBCUTANEOUS PV MENVEO SUSPENSION INTRAMUSCULAR PV RECONSTITUTED SOLUTION RECONSTITUTED QUADRACEL INTRAMUSCULAR PV M-M-R II INJECTION SUSPENSION SOLUTION PV RECONSTITUTED RABAVERT INTRAMUSCULAR GM MODERNA COVID-19 QL (1 ML SUSPENSION VACCINE per 28 RECONSTITUTED INTRAMUSCULAR PV days); AL SUSPENSION 100 (Min 18 RECOMBIVAX HB MCG/0.5ML Years) INJECTION SUSPENSION 10 PV MCG/ML, 40 MCG/ML, 5 MCG/0.5ML

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 179 Drug Drug Drug Name Notes Drug Name Notes Tier Tier ROTARIX ORAL VARIVAX AL (Max 8 PV SUSPENSION Months) SUBCUTANEOUS PV RECONSTITUTED INJECTABLE 1350 AL (Max 8 PFU/0.5ML ROTATEQ ORAL PV SOLUTION Months) VAXELIS SHINGRIX QL (2 fill INTRAMUSCULAR PV INTRAMUSCULAR per 1 SUSPENSION SUSPENSION PV lifetime); VAXELIS RECONSTITUTED 50 AL (Min 50 INTRAMUSCULAR PV MCG/0.5ML Years) SUSPENSION STAMARIL INJECTION PREFILLED SYRINGE SUSPENSION GM YF-VAX RECONSTITUTED SUBCUTANEOUS GM TDVAX INJECTABLE Inflammatory Bowel INTRAMUSCULAR PV SUSPENSION 2-2 Disease Agents LF/0.5ML ana-lex rectal kit 2-2 % 2 TENIVAC ANALPRAM HC INTRAMUSCULAR PV EXTERNAL CREAM 2.5- 4 INJECTABLE 5-2 LFU 1 % TETANUS-DIPHTHERIA ANALPRAM HC TOXOIDS TD SINGLES EXTERNAL 4 INTRAMUSCULAR PV CREAM 2.5-1 % SUSPENSION 2-2 LF/0.5ML ANALPRAM-HC EXTERNAL CREAM 1-1 4 TRUMENBA % INTRAMUSCULAR PV SUSPENSION ANALPRAM-HC 4 PREFILLED SYRINGE EXTERNAL LOTION 2.5- 1 % TWINRIX Brand INTRAMUSCULAR ANUSOL-HC 4 penalty SUSPENSION PV EXTERNAL CREAM 2.5 applies PREFILLED SYRINGE % APRISO ORAL 720-20 ELU-MCG/ML Brand TYPHIM VI CAPSULE EXTENDED 4 penalty RELEASE 24 HOUR INTRAMUSCULAR GM applies SOLUTION 25 0.375 GM MCG/0.5ML ASACOL HD ORAL Brand 4 penalty VAQTA TABLET DELAYED applies INTRAMUSCULAR RELEASE 800 MG PV AZULFIDINE EN-TABS SUSPENSION 25 Brand ORAL TABLET UNIT/0.5ML, 50 UNIT/ML 4 penalty DELAYED RELEASE applies 500 MG

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 180 Drug Drug Drug Name Notes Drug Name Notes Tier Tier Brand LIALDA ORAL TABLET Brand AZULFIDINE ORAL 4 penalty DELAYED RELEASE 1.2 4 penalty TABLET 500 MG applies GM applies balsalazide disodium oral 2 lidocaine-hydrocort capsule 750 mg (perianal) external cream 2 budesonide er oral tablet 3-0.5 % extended release 24 hour 5 PA LIDOCAINE- 9 mg HYDROCORTISONE 4 budesonide oral capsule ACE RECTAL GEL 2.8- delayed release particles 5 0.55 % 3 mg lidocaine-hydrocortisone CANASA RECTAL Brand ace rectal kit 2-2 %, 3-0.5 2 SUPPOSITORY 1000 4 penalty %, 3-1 %, 3-2.5 % applies MG LIDOCORT EXTERNAL 4 Brand CREAM 3-0.5 % COLAZAL ORAL 4 penalty mesalamine er oral applies CAPSULE 750 MG capsule extended 2 Brand release 24 hour 0.375 CORTENEMA RECTAL 4 penalty gm 100 MG/60ML applies mesalamine oral capsule 2 CORTIFOAM delayed release 400 mg 3 EXTERNAL FOAM 10 % mesalamine oral tablet DELZICOL ORAL Brand delayed release 1.2 gm, 2 CAPSULE DELAYED 4 penalty 800 mg applies RELEASE 400 MG mesalamine rectal 2 enema 4 gm DIPENTUM ORAL 3 CAPSULE 250 MG mesalamine rectal 2 ENTOCORT EC ORAL suppository 1000 mg CAPSULE DELAYED 6 mesalamine-cleanser 2 RELEASE PARTICLES 3 rectal kit 4 gm MG PENTASA ORAL hydrocortisone (perianal) CAPSULE EXTENDED 4 external cream 1 %, 2.5 2 RELEASE 250 MG, 500 % MG hydrocortisone ace- Brand pramoxine external 2 PROCTOCORT 4 penalty cream 1-1 % EXTERNAL CREAM 1 % applies hydrocortisone rectal 2 PROCTOFOAM HC 4 enema 100 mg/60ml EXTERNAL FOAM 1-1 % hydrocort-pramoxine procto-med hc external 2 (perianal) external cream 2 cream 2.5 % 2.5-1 %

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 181 Drug Drug Drug Name Notes Drug Name Notes Tier Tier procto-pak external calcitonin (salmon) 2 cream 1 % injection solution 200 2 unit/ml proctozone-hc external 2 cream 2.5 % calcitonin (salmon) nasal 2 Brand solution 200 unit/act ROWASA RECTAL KIT 4 4 penalty EVENITY GM applies SUBCUTANEOUS PA; SFROWASA RECTAL SOLUTION PREFILLED 6 Specialty 4 ENEMA 4 GM/60ML SYRINGE 105 Medical MG/1.17ML sulfasalazine oral tablet 2 500 mg FORTEO SUBCUTANEOUS sulfasalazine oral tablet 2 SOLUTION PEN- 6 PA delayed release 500 mg INJECTOR 620 UCERIS ORAL TABLET MCG/2.48ML EXTENDED RELEASE 6 PA Brand 24 HOUR 9 MG penalty 4 applies; QL UCERIS RECTAL FOAM 4 2 MG/ACT FOSAMAX ORAL (4 EA per Metabolic Bone TABLET 70 MG 28 days) Disease Agents - Drugs FOSAMAX PLUS D for Osteoporosis ORAL TABLET 70-2800 4 ST; Brand MG-UNIT, 70-5600 MG- ACTONEL ORAL 4 penalty UNIT TABLET 150 MG, 35 MG applies ibandronate sodium alendronate sodium oral intravenous solution 3 GM 2 solution 70 mg/75ml mg/3ml ibandronate sodium oral alendronate sodium oral 1 2 tablet 10 mg tablet 150 mg QL (4 EA Brand alendronate sodium oral 1 per 28 MIACALCIN INJECTION 3 penalty tablet 35 mg, 70 mg days) SOLUTION 200 UNIT/ML applies alendronate sodium oral pamidronate disodium 2 Specialty tablet 5 mg intravenous solution 30 5 mg/10ml, 6 mg/ml, 90 Medical ST; Brand ATELVIA ORAL TABLET mg/10ml DELAYED RELEASE 35 4 penalty MG applies PROLIA SUBCUTANEOUS Specialty 6 BINOSTO ORAL SOLUTION PREFILLED Medical 4 ST TABLET SYRINGE 60 MG/ML EFFERVESCENT 70 MG RAYALDEE ORAL Brand CAPSULE EXTENDED 6 PA 4 penalty BONIVA ORAL TABLET RELEASE 30 MCG 150 MG applies

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 182 Drug Drug Drug Name Notes Drug Name Notes Tier Tier RECLAST doxercalciferol oral Specialty 6 2 PA INTRAVENOUS Medical capsule 0.5 mcg, 1 mcg, SOLUTION 5 MG/100ML 2.5 mcg risedronate sodium oral HECTOROL tablet 150 mg, 30 mg, 35 2 ST INTRAVENOUS GM mg, 5 mg SOLUTION 4 MCG/2ML risedronate sodium oral NATPARA tablet delayed release 35 2 ST SUBCUTANEOUS PA; mg CARTRIDGE 100 MCG, 6 Specialty TERIPARATIDE 25 MCG, 50 MCG, 75 Medical (RECOMBINANT) MCG SUBCUTANEOUS 6 PA paricalcitol intravenous SOLUTION PEN- solution 2 mcg/ml, 5 GM INJECTOR 620 mcg/ml MCG/2.48ML paricalcitol oral capsule 1 2 ST TYMLOS mcg, 2 mcg, 4 mcg SUBCUTANEOUS PARSABIV SOLUTION PEN- 6 PA INTRAVENOUS Specialty 6 INJECTOR 3120 SOLUTION 10 MG/2ML, Medical MCG/1.56ML 2.5 MG/0.5ML, 5 MG/ML XGEVA ROCALTROL ORAL Brand Specialty SUBCUTANEOUS 6 CAPSULE 0.25 MCG, 4 penalty SOLUTION 120 Medical 0.5 MCG applies MG/1.7ML Brand zoledronic acid Specialty ROCALTROL ORAL 4 penalty 5 intravenous concentrate Medical SOLUTION 1 MCG/ML applies 4 mg/5ml SENSIPAR ORAL zoledronic acid Specialty TABLET 30 MG, 60 MG, 6 PA intravenous solution 4 5 Medical 90 MG mg/100ml, 5 mg/100ml ZEMPLAR Metabolic Bone INTRAVENOUS Disease Agents - Other GM SOLUTION 2 MCG/ML, 5 calcitriol intravenous GM MCG/ML solution 1 mcg/ml ZEMPLAR ORAL ST; Brand 4 penalty calcitriol oral capsule 2 CAPSULE 1 MCG, 2 0.25 mcg, 0.5 mcg MCG applies Miscellaneous calcitriol oral solution 1 2 mcg/ml Therapeutic Agents cinacalcet hcl oral tablet ACACIA 5 PA 30 mg, 60 mg, 90 mg SUBCUTANEOUS GM doxercalciferol SOLUTION 1:20 intravenous solution 4 GM mcg/2ml

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 183 Drug Drug Drug Name Notes Drug Name Notes Tier Tier ACETADOTE alburx intravenous GM INTRAVENOUS GM solution 5 % SOLUTION 200 MG/ML ALBUTEIN acetylcysteine INTRAVENOUS GM intravenous solution 200 GM SOLUTION 25 %, 5 % mg/ml ALDER ACREMONIUM SUBCUTANEOUS GM SUBCUTANEOUS SOLUTION 1:20 GM SOLUTION 20000 ALPHA-LIPOIC ACID PNU/ML INJECTION SOLUTION GM ADAKVEO 25 MG/ML PA; INTRAVENOUS 6 Specialty ALTERNARIA SOLUTION 100 Medical SUBCUTANEOUS GM MG/10ML SOLUTION 20000 adenosine (diagnostic) PNU/ML intravenous solution 3 GM AMD FOAM DRESSING mg/ml PAD 3-1/2"X3" , 4"X4" , 4 adenosine intravenous 6"X6" GM solution 3 mg/ml AMD FOAM DRESSING 4 AEROCHAMBER MINI TOPSHEET PAD 4"X4" 2 CHAMBER DEVICE AMERICAN BEECH AEROCHAMBER MV 2 SUBCUTANEOUS GM AEROCHAMBER PLUS SOLUTION 1:20 2 FLO-VU AMERICAN COCKROACH AEROCHAMBER PLUS 2 GM FLOW VU SUBCUTANEOUS SOLUTION 1:20 AEROCHAMBER 2 W/FLOWSIGNAL AMERICAN ELM SUBCUTANEOUS GM ALBUKED 25 SOLUTION 1:20 INTRAVENOUS GM SOLUTION 25 % AMIDATE INTRAVENOUS GM ALBUKED 5 SOLUTION 2 MG/ML INTRAVENOUS GM SOLUTION 5 % AMPHADASE INJECTION SOLUTION GM albumin human 150 UNIT/ML intravenous solution 25 GM %, 5 % ANASCORP INTRAVENOUS GM ALBUMINEX SOLUTION INTRAVENOUS GM RECONSTITUTED SOLUTION 25 %, 5 % ANAVIP INTRAVENOUS Specialty albumin-zlb intravenous SOLUTION 6 GM Medical solution 25 %, 5 % RECONSTITUTED

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 184 Drug Drug Drug Name Notes Drug Name Notes Tier Tier ANDEXXA BACTERIOSTATIC GM INTRAVENOUS Specialty WATER(BENZ ALC) 6 SOLUTION Medical INJECTION SOLUTION RECONSTITUTED 200 BAHIA MG SUBCUTANEOUS GM ANESTHESIA S/I-40A SOLUTION 1:20 INTRAVENOUS KIT 200 GM bal in oil intramuscular GM MG/20ML solution 100 mg/ml ANESTHESIA S/I-40H BALD CYPRESS INTRAVENOUS KIT 200 GM SUBCUTANEOUS GM MG/20ML SOLUTION 1:20 ANESTHESIA S/I-40S BAYBERRY (WAX INTRAVENOUS KIT 200 GM MYRTLE) GM MG/20ML SUBCUTANEOUS ANTIVENIN MICRURUS SOLUTION 1:20 FULVIUS BERMUDA GRASS GM INTRAVENOUS INJECTION SOLUTION GM SOLUTION 10000 BAU/ML RECONSTITUTED BERMUDA GRASS APP SLIM RMS ORAL SUBCUTANEOUS 4 GM CAPSULE SOLUTION 10000 ARIZONA CYPRESS BAU/ML SUBCUTANEOUS GM BIOFREQUENCY 4 SOLUTION 1:20 INSOLES arnica flower tincture 2 BIOGUARD GAUZE 4 ARTISS EXTERNAL 4 SPONGES PAD 4"X4" SOLUTION BIOGUARD ISLAND ASPERGILLUS DRESSINGS PAD 4 FUMIGATUS 4"X10" , 4"X14" , 4"X5" GM INJECTION SOLUTION BIOGUARD NON- 1:10 , 1:20 ADHERENT DRESSING 4 AUREOBASIDIUM PAD 3"X4" , 3"X8" PULLULANS GM BLACK WILLOW INJECTION SOLUTION SUBCUTANEOUS GM 1:20 SOLUTION 1:20 AUREOBASIDIUM BOTOX INJECTION SUBCUTANEOUS GM SOLUTION GM PA SOLUTION 10000 RECONSTITUTED 100 PNU/ML, 20000 PNU/ML UNIT, 200 UNIT AUSTRALIAN PINE BOTRYTIS INJECTION SUBCUTANEOUS GM SOLUTION 1:20 , 43000 GM SOLUTION 1:20 PNU/ML

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 185 Drug Drug Drug Name Notes Drug Name Notes Tier Tier BOTRYTIS CAT HAIR EXTRACT SUBCUTANEOUS GM INJECTION SOLUTION GM SOLUTION 20000 10000 BAU/ML, 5000 PNU/ML BAU/ML

BREATHE EASE LARGE 2 CAT HAIR EXTRACT DEVICE SUBCUTANEOUS GM SOLUTION 10000 BREATHE EASE 2 MEDIUM DEVICE BAU/ML BREATHE EASE SMALL CATTLE EPITHELIUM 2 DEVICE SUBCUTANEOUS GM SOLUTION 1:20 BREVITAL SODIUM INJECTION SOLUTION CAYA VAGINAL GM PV RECONSTITUTED 500 DIAPHRAGM MG CEDAR ELM BRIDION SUBCUTANEOUS GM SOLUTION 1:20 INTRAVENOUS GM SOLUTION 200 CHIRHOSTIM MG/2ML, 500 MG/5ML INTRAVENOUS BROME SOLUTION GM SUBCUTANEOUS GM RECONSTITUTED 16 SOLUTION 1:20 MCG BYLVAY (PELLETS) CHLORHEXIDINE GLUCONATE 4 ORAL CAPSULE 4 SPRINKLE 200 MCG, SOLUTION 20 % 600 MCG CLADOSPORIUM BYLVAY ORAL CLADOSPORIOIDES GM CAPSULE 1200 MCG, 4 INJECTION SOLUTION 400 MCG 1:20 , 64000 PNU/ML CALCIUM DISODIUM CLADOSPORIUM VERSENATE CLADOSPORIOIDES GM GM INJECTION SOLUTION INTRADERMAL 1 GM/5ML SOLUTION 1:20 CALIFORNIA PEPPER CLADOSPORIUM TREE SUBCUTANEOUS GM CLADOSPORIOIDES SOLUTION 1:20 SUBCUTANEOUS GM SOLUTION 10000 CANDIDA ALBICANS PNU/ML, 20000 PNU/ML EXTRACT INJECTION GM SOLUTION 100 MG/ML CLADOSPORIUM SPHAEROSPERMUM CANDIDA ALBICANS SUBCUTANEOUS GM EXTRACT SOLUTION 20000 SUBCUTANEOUS GM PNU/ML SOLUTION 10000 PNU/ML

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 186 Drug Drug Drug Name Notes Drug Name Notes Tier Tier CLEVER CHOICE CURVULARIA 2 HOLDING CHAMBER SUBCUTANEOUS GM DEVICE SOLUTION 20000 COCKLEBUR PNU/ML SUBCUTANEOUS GM CYANOKIT SOLUTION 1:20 INTRAVENOUS GM COENZYME Q-10 SOLUTION INJECTION SOLUTION GM RECONSTITUTED 5 GM 20 MG/ML CYSVIEW COMPACT SPACE INTRAVESICAL 2 CHAMBER DEVICE SOLUTION GM RECONSTITUTED 100 COMPACT SPACE MG CHAMBER/LG MASK 2 DEVICE DANDELION SUBCUTANEOUS GM COMPACT SPACE SOLUTION 1:20 CHAMBER/MED MASK 2 DEVICE deferoxamine mesylate injection solution GM COMPACT SPACE reconstituted 2 gm, 500 CHAMBER/SM MASK 2 mg DEVICE DEFLUX INJECTION CORN POLLEN PREFILLED SYRINGE GM SUBCUTANEOUS GM 50-15 MG/ML SOLUTION 1:20 DEFLUX METAL GM CORTROSYN NEEDLE 23G X 350MM INJECTION SOLUTION GM RECONSTITUTED 0.25 DESFERAL INJECTION MG SOLUTION GM RECONSTITUTED 500 cosyntropin injection MG solution reconstituted GM 0.25 mg dexmedetomidine hcl in nacl intravenous solution CROFAB 200 mcg/50ml, 200-0.9 GM INTRAVENOUS GM mcg/50ml-%, 400 SOLUTION mcg/100ml, 80 mcg/20ml RECONSTITUTED DEXMEDETOMIDINE CURITY AMD HCL IN NACL ANTIMICROBIAL 4 INTRAVENOUS GM SPNGE PAD 4"X4" SOLUTION PREFILLED SYRINGE 20-0.9 CURITY AMD 4 ANTIMICROBIAL STRIP MCG/5ML-% CURITY IODOFORM 4 PACKING STRIP

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 187 Drug Drug Drug Name Notes Drug Name Notes Tier Tier DEXMEDETOMIDINE DUODOTE HCL INTRAVENOUS INTRAMUSCULAR GM SOLUTION 1000 GM SOLUTION AUTO- MCG/10ML, 400 INJECTOR 2.1-600 MG MCG/4ML DUROLANE INTRA- dexmedetomidine hcl ARTICULAR GM intravenous solution 200 GM PREFILLED SYRINGE mcg/2ml 60 MG/3ML DEXMEDETOMIDINE DUST MITE MIXED HCL-DEXTROSE ALLERGEN EXT GM INTRAVENOUS GM INJECTION SOLUTION SOLUTION 10000 AU/ML, 15000- 200MCG/50ML -5%, 15000 AU/ML 400MCG/100ML -5% DUST MITE MIXED DIGIFAB ALLERGEN EXT INTRAVENOUS SUBCUTANEOUS GM SOLUTION GM SOLUTION 10000 RECONSTITUTED 40 AU/ML MG DYSPORT diluent for treprostinil INTRAMUSCULAR GM intravenous solution SOLUTION GM PA DIMERCAPTOPROPAN RECONSTITUTED 300 UNIT, 500 UNIT E-SULFONATE GM INJECTION SOLUTION EASIVENT 2 250 MG/5ML EASTERN DIPRIVAN COTTONWOOD GM INTRAVENOUS SUBCUTANEOUS EMULSION 100 SOLUTION 1:20 GM MG/10ML, 1000 ENCARE VAGINAL PV MG/100ML, 200 SUPPOSITORY 100 MG MG/20ML, 500 MG/50ML ENDARI ORAL PACKET 6 dipyridamole intravenous GM 5 GM solution 5 mg/ml EPICOCCUM NIGRUM DOG EPITHELIUM INJECTION SOLUTION GM SUBCUTANEOUS GM 1:10 SOLUTION 1:10 , 1:20 EPICOCCUM DOG FENNEL SUBCUTANEOUS GM SUBCUTANEOUS GM SOLUTION 10000 SOLUTION 1:20 PNU/ML, 20000 PNU/ML DRECHSLERA ergoloid mesylates oral SUBCUTANEOUS 2 GM tablet 1 mg SOLUTION 10000 etomidate intravenous PNU/ML, 20000 PNU/ML GM solution 2 mg/ml

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 188 Drug Drug Drug Name Notes Drug Name Notes Tier Tier EUFLEXXA INTRA- FRESENIUS ARTICULAR SOLUTION GM PROPOVEN PREFILLED SYRINGE INTRAVENOUS GM 20 MG/2ML EMULSION 2000 MG/100ML EXCILON AMD DRAIN 4 SPONGES PAD 4"X4" FUSARIUM SUBCUTANEOUS QL (36 EA GM PV per 365 SOLUTION 10000 FC FEMALE CONDOM days) PNU/ML, 20000 PNU/ML QL (36 EA GELFOAM-JMI PV per 365 SPONGE EXTERNAL 4 FC2 FEMALE CONDOM days) KIT FEMCAP VAGINAL GEL-ONE INTRA- DEVICE 22 MM, 26 MM, PV ARTICULAR GM 30 MM PREFILLED SYRINGE 30 MG/3ML FIRE ANT SUBCUTANEOUS GM GELSYN-3 INTRA- ARTICULAR SOLUTION SOLUTION 1:10 , 1:20 GM PREFILLED SYRINGE FLEXBUMIN 16.8 MG/2ML INTRAVENOUS GM SOLUTION 25 %, 5 % GENVISC 850 INTRA- ARTICULAR SOLUTION FLEXICHAMBER ADULT GM 2 PREFILLED SYRINGE MASK/SMALL 25 MG/2.5ML FLEXICHAMBER CHILD 2 GERMAN COCKROACH MASK/LARGE SUBCUTANEOUS GM SOLUTION 1:20 FLEXICHAMBER CHILD 2 MASK/SMALL GIVLAARI PA; SUBCUTANEOUS 6 Specialty FLEXICHAMBER 2 DEVICE SOLUTION 189 MG/ML Medical flumazenil intravenous GLEOLAN ORAL GM solution 0.5 mg/5ml, 1 SOLUTION GM mg/10ml RECONSTITUTED 1.5 fomepizole intravenous GM GM solution 1.5 gm/1.5ml GLUCAGEN formaldehyde external DIAGNOSTIC 2 GM solution 10 %, 37 % INJECTION SOLUTION RECONSTITUTED 1 MG fresenius propoven intravenous emulsion GLUCAGON HCL GM (DIAGNOSTIC) 1000 mg/100ml, 200 GM mg/20ml, 500 mg/50ml INJECTION SOLUTION RECONSTITUTED 1 MG

glutaraldehyde external 2 solution 25 % Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 189 Drug Drug Drug Name Notes Drug Name Notes Tier Tier GOLDENROD HYALGAN INTRA- SUBCUTANEOUS GM ARTICULAR SOLUTION GM SOLUTION 1:20 20 MG/2ML GRASS POLLEN(K-O-R- HYALGAN INTRA- T-SWT VERN) GM ARTICULAR SOLUTION GM INJECTION SOLUTION PREFILLED SYRINGE 100000 BAU/ML 20 MG/2ML GRASTEK HYLENEX INJECTION GM SUBLINGUAL TABLET 3 SOLUTION 150 UNIT/ML SUBLINGUAL 2800 BAU HYMOVIS INTRA- HACKBERRY ARTICULAR SOLUTION GM SUBCUTANEOUS GM PREFILLED SYRINGE SOLUTION 1:20 24 MG/3ML heparin lock flush IC GREEN intravenous solution 1 2 INTRAVENOUS unit/ml, 10 unit/ml SOLUTION GM heparin sodium lock flush RECONSTITUTED 25 intravenous solution 100 2 MG unit/ml ID NOW INFLUENZA A HEPMED & B 2 CONTR IN VITRO GM COMBINATION KIT 4 KIT 100&0.9&2.5-2.5 UT/ML ID NOW INFLUENZA A GM & B 2 IN VITRO KIT HISTATROL INJECTION GM SOLUTION 2.75 MG/ML indocyanine green HONEY BEE VENOM intravenous solution GM PROTEIN INJECTION reconstituted 25 mg GM SOLUTION INSPIREASE 2 RECONSTITUTED 550 RESERVOIR BAGS MCG isosulfan blue HONEY BEE VENOM subcutaneous solution 1 GM SUBCUTANEOUS % SOLUTION GM IV STABILIZER FOR RECONSTITUTED 1100 LUMOXITI MCG, 120 MCG INTRAVENOUS GM HORSE EPITHELIUM SOLUTION 0.7-6.5-6.4 SUBCUTANEOUS GM MG/ML SOLUTION 1:10 , 1:20 JOHNSON GRASS HUMAN ALBUMIN SUBCUTANEOUS GM GRIFOLS SOLUTION 1:20 GM INTRAVENOUS SOLUTION 25 %

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 190 Drug Drug Drug Name Notes Drug Name Notes Tier Tier JUNE GRASS POLLEN KETAMINE HCL- STANDARDIZED SODIUM CHLORIDE SUBCUTANEOUS GM INJECTION SOLUTION GM SOLUTION 100000 PREFILLED SYRINGE BAU/ML 50-0.9 MG/5ML-% KAPOK KETAMINE HCL- SUBCUTANEOUS GM SODIUM CHLORIDE SOLUTION 1:20 INTRAVENOUS kedbumin intravenous SOLUTION PREFILLED GM GM solution 25 % SYRINGE 10-0.9 MG/ML-%, 20-0.9 KERLIX AMD 4 MG/2ML-% ANTIMICROBIAL KINEVAC INJECTION KERLIX AMD SUPER SOLUTION GM SPONGES PAD 6"X6- 4 RECONSTITUTED 5 3/4" MCG KETALAR INJECTION KOCHIA SOLUTION 10 MG/ML, GM SUBCUTANEOUS GM 100 MG/ML, 50 MG/ML SOLUTION 1:20 KETAMINE HCL LENSCALE INJECTION SOLUTION GM SUBCUTANEOUS GM 0.6 MG/ML, 1 MG/ML SOLUTION 1:20 ketamine hcl injection LEXISCAN solution 100 mg/ml, 50 GM INTRAVENOUS GM mg/ml SOLUTION 0.4 MG/5ML KETAMINE HCL MACI INTRA- GM INJECTION SOLUTION ARTICULAR SHEET PREFILLED SYRINGE GM MACRILEN ORAL 20 MG/2ML, 30 MG/3ML, 6 50 MG/5ML, 50 MG/ML PACKET 60 MG KETAMINE HCL MEADOW FESCUE INTRAVENOUS GRASS POLLEN GM PA SOLUTION 100 SUBCUTANEOUS GM MG/100ML SOLUTION 100000 BAU/ML KETAMINE HCL INTRAVENOUS MELALEUCA SOLUTION PREFILLED GM SUBCUTANEOUS GM SYRINGE 30 MG/3ML, SOLUTION 1:20 50 MG/5ML MESQUITE KETAMINE HCL SUBCUTANEOUS GM SOLUTION 10 MG/ML GM SOLUTION 1:20 INJECTION 10 MG/ML methergine oral tablet 0.2 2 ketamine hcl solution 10 mg GM mg/ml injection 10 mg/ml

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 191 Drug Drug Drug Name Notes Drug Name Notes Tier Tier methylergonovine mixed vespid venom GM maleate injection solution protein subcutaneous GM 0.2 mg/ml solution reconstituted methylergonovine 1100-1100-1100 mcg maleate oral tablet 0.2 2 MIXED VESPID VENOM mg PROTEIN SUBCUTANEOUS MICROCHAMBER 2 GM DEVICE SOLUTION RECONSTITUTED 120- MITE (D. FARINAE) 120-120 MCG INJECTION SOLUTION GM 10000 AU/ML, 30000 MONOVISC INTRA- AU/ML, 5000 AU/ML ARTICULAR SOLUTION GM PREFILLED SYRINGE MITE (D. FARINAE) 88 MG/4ML SUBCUTANEOUS GM SOLUTION 10000 MOUNTAIN CEDAR AU/ML SUBCUTANEOUS GM SOLUTION 1:20 MITE (D. PTERONYSSINUS) MOUSE EPITHELIUM INJECTION SOLUTION GM SUBCUTANEOUS GM 10000 AU/ML, 30000 SOLUTION 1:20 AU/ML, 5000 AU/ML MUCOR INJECTION GM MITE (D. SOLUTION 1:20 PTERONYSSINUS) MUCOR INTRADERMAL GM SUBCUTANEOUS GM SOLUTION 1:20 SOLUTION 10000 MUCOR AU/ML SUBCUTANEOUS GM MIXED ASPERGILLUS SOLUTION 10000 SUBCUTANEOUS PNU/ML, 20000 PNU/ML GM SOLUTION 20000 MUGWORT PNU/ML SUBCUTANEOUS GM MIXED FEATHERS SOLUTION 1:20 SUBCUTANEOUS GM MYOBLOC SOLUTION 1:20 INTRAMUSCULAR MIXED RAGWEED SOLUTION 10000 GM PA SUBCUTANEOUS GM UNIT/2ML, 2500 SOLUTION 1:20 UNIT/0.5ML, 5000 MIXED VESPID VENOM UNIT/ML PROTEIN INJECTION NEURACEQ SOLUTION GM INTRAVENOUS GM RECONSTITUTED 550- SOLUTION 1.4-135 550-550 MCG MCI/ML

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 192 Drug Drug Drug Name Notes Drug Name Notes Tier Tier NITHIODOTE ORALAIR ADULT INTRAVENOUS KIT GM STARTER PACK 4 300MG/10ML&12.5 SUBLINGUAL TABLET GM/50ML SUBLINGUAL 300 IR OCTAPLAS BLOOD ORALAIR CHILDRENS GROUP A GM STARTER PACK 4 INTRAVENOUS SUBLINGUAL TABLET SOLUTION SUBLINGUAL 100 IR OCTAPLAS BLOOD ORALAIR SUBLINGUAL GROUP AB TABLET SUBLINGUAL 4 GM INTRAVENOUS 300 IR SOLUTION ORCHARD GRASS OCTAPLAS BLOOD POLLEN GM GROUP B GM SUBCUTANEOUS INTRAVENOUS SOLUTION 100000 SOLUTION BAU/ML OCTAPLAS BLOOD ORTHOVISC INTRA- GROUP O ARTICULAR SOLUTION GM GM INTRAVENOUS PREFILLED SYRINGE SOLUTION 30 MG/2ML ODACTRA OXBRYTA ORAL 6 PA SUBLINGUAL TABLET 4 TABLET 500 MG SUBLINGUAL 12 SQ- PALFORZIA ORAL 0.5 & HDM 1 & 1.5 & 3 & 6 MG, 2 X OLIVE TREE 1 MG & 10 MG, 2 X 100 SUBCUTANEOUS GM MG, 2 X 20 MG, 2 X 20 SOLUTION 1:20 MG & 2 X 100 MG, 20 5 PA OMNIPOD DASH 5 MG, 20 MG & 100 MG, 3 4 PA PACK PODS X 1 MG, 3 X 20 MG & 100 MG, 4 X 20 MG, 6 X OPTICHAMBER 2 1 MG DIAMOND PALFORZIA ORAL 5 PA OPTICHAMBER PACKET 300 MG DIAMOND-LG MASK 2 DEVICE PANDA MASK LARGE 2 PANDA MASK MEDIUM 2 OPTICHAMBER 2 DIAMOND-MD MASK PANDA MASK SMALL 2

OPTICHAMBER 2 PEDIATRIC PANDA 2 DIAMOND-SM MASK MASK ORAFATE PENICILLIUM MOUTH/THROAT 4 NOTATUM INJECTION GM PASTE 10 % SOLUTION 1:10 , 1:20

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 193 Drug Drug Drug Name Notes Drug Name Notes Tier Tier PENICILLIUM PRIVET NOTATUM SUBCUTANEOUS GM SUBCUTANEOUS GM SOLUTION 1:20 SOLUTION 10000 PRO COMFORT 2 PNU/ML, 20000 PNU/ML SPACER ADULT PERENNIAL RYE PRO COMFORT GRASS POLLEN 2 GM SPACER CHILD INJECTION SOLUTION 100000 BAU/ML PRO COMFORT SPACER INFANT 2 PHENOL INJECTION GM DEVICE SOLUTION 6 % PROCARE PHEXXI VAGINAL GEL 4 SPACER/ADULT MASK 2 1.8-1-0.4 % DEVICE PHOMA EXIGUA PROCARE SUBCUTANEOUS GM SPACER/CHILD MASK 2 SOLUTION 20000 DEVICE PNU/ML propofol intravenous PHOTREXA VISCOUS emulsion 1000 OPHTHALMIC GM 6 PA mg/100ml, 200 mg/20ml, SOLUTION PREFILLED 500 mg/50ml SYRINGE 0.146-20 % propofol-lipuro PLASBUMIN-25 intravenous emulsion GM INTRAVENOUS GM 1000 mg/100ml SOLUTION 25 % PROTHELIAL PLASBUMIN-5 MOUTH/THROAT 4 INTRAVENOUS GM PASTE 10 % SOLUTION 5 % PROTOPAM CHLORIDE PLASMANATE INTRAVENOUS GM INTRAVENOUS GM SOLUTION SOLUTION 5 % RECONSTITUTED 1 GM POCKET SPACER 2 PROVAYBLUE DEVICE INTRAVENOUS GM PRAXBIND SOLUTION 50 MG/10ML INTRAVENOUS GM PYLARIFY SOLUTION 2.5 INTRAVENOUS GM GM/50ML SOLUTION PREFILLED PRECEDEX SYRINGE 9 MCI INTRAVENOUS QUEEN PALM SOLUTION 1000 SUBCUTANEOUS GM MCG/250ML, 200 GM SOLUTION 1:20 MCG/2ML, 200 QUICKVUE + STREP A MCG/50ML, 400 GM MCG/100ML, 80 TEST IN VITRO KIT MCG/20ML Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 194 Drug Drug Drug Name Notes Drug Name Notes Tier Tier QUICKVUE DIPSTICK SACCHAROMYCES GM STREP A TEST IN CEREVISIAE GM VITRO KIT INJECTION SOLUTION 1:20 QUICKVUE INFLUENZA GM A+B TEST IN VITRO KIT SACCHAROMYCES QUICKVUE IN-LINE CEREVISIAE GM STREP A TEST IN GM SUBCUTANEOUS VITRO KIT SOLUTION 20000 PNU/ML RABBIT EPITHELIUM SUBCUTANEOUS GM SHAGBARK HICKORY SOLUTION 1:10 , 1:20 SUBCUTANEOUS GM SOLUTION 1:20 RADIOGARDASE ORAL 6 CAPSULE 0.5 GM SHEEP SORREL SUBCUTANEOUS GM RAGWITEK SOLUTION 1:20 SUBLINGUAL TABLET 3 SUBLINGUAL 12 AMB A SHORT RAGWEED POLLEN EXT 1-U GM SUBCUTANEOUS RED MAPLE SOLUTION 1:20 SUBCUTANEOUS GM SOLUTION 1:20 sodium nitrite intravenous solution 30 GM RED MULBERRY mg/ml SUBCUTANEOUS GM SOLUTION 1:20 sodium saccharin powder 2 RED TOP GRASS SODIUM THIOSULFATE POLLEN SOLUTION 25 % GM SUBCUTANEOUS GM INTRAVENOUS 25 % SOLUTION 100000 sodium thiosulfate BAU/ML solution 25 % GM R-GENE 10 intravenous 25 % INTRAVENOUS GM SOFIA INFLUENZA A+B GM SOLUTION 10 % FIA IN VITRO KIT RHIZOPUS SOFIA STREP A FIA IN GM SUBCUTANEOUS GM VITRO KIT SOLUTION 20000 SOFIA STREP A+ FIA IN GM PNU/ML VITRO KIT ROUGH MARSH ELDER SOLESTA INJECTION GM SUBCUTANEOUS GM GEL 50-15 MG/ML SOLUTION 1:20 SORBITOL IRRIGATION 4 RUSSIAN THISTLE SOLUTION 3 % SUBCUTANEOUS GM SOLUTION 1:20 sorbitol-mannitol irrigation solution 2.7- 2 RUZURGI ORAL 6 PA 0.54 gm/100ml TABLET 10 MG

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 195 Drug Drug Drug Name Notes Drug Name Notes Tier Tier SORREL/DOCK MIX SYNVISC ONE INTRA- GM SUBCUTANEOUS ARTICULAR SOLUTION GM SOLUTION 1:20 PREFILLED SYRINGE SPINRAZA PA; 48 MG/6ML INTRATHECAL 6 Specialty TACHOSIL EXTERNAL SOLUTION 12 MG/5ML Medical PATCH 4.8 X 4.8 CM, 4 SPINY PIGWEED 9.5 X 4.8 CM SUBCUTANEOUS GM TALL RAGWEED SOLUTION 1:20 SUBCUTANEOUS GM STEMPHYLIUM SOLUTION 1:20 SUBCUTANEOUS TELFA AMD ISLAND GM SOLUTION 20000 DRESSING PAD 4"X5" , 4 PNU/ML 4"X8"

STERILE DILUENT TELFA AMD NON- 4 FLOLAN PH 12 GM ADHERENT PAD 3"X8" INTRAVENOUS THYROGEN SOLUTION INTRAMUSCULAR sterile SOLUTION GM diluent/epoprostenol GM RECONSTITUTED 1.1 intravenous solution MG sterile water for injection TIMOTHY GRASS GM injection solution POLLEN ALLERGEN INJECTION SOLUTION GM sterile water for injection 2 intravenous solution 10000 BAU/ML, 100000 BAU/ML SUPARTZ FX INTRA- TIMOTHY GRASS ARTICULAR SOLUTION GM PREFILLED SYRINGE POLLEN ALLERGEN SUBCUTANEOUS 25 MG/2.5ML GM SOLUTION 10000 SWEET GUM BAU/ML, 100000 SUBCUTANEOUS GM BAU/ML SOLUTION 1:20 TISSEEL EXTERNAL 4 SWEET VERNAL KIT 10 ML, 2 ML, 4 ML GRASS POLLEN SUBCUTANEOUS GM TISSEEL EXTERNAL 4 SOLUTION 100000 SOLUTION BAU/ML TODAY SPONGE PV SYNVISC INTRA- VAGINAL 1000 MG ARTICULAR SOLUTION GM TRICHOPHYTON PREFILLED SYRINGE MENTAGROPHYTES GM 16 MG/2ML SUBCUTANEOUS SOLUTION 1:20

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 196 Drug Drug Drug Name Notes Drug Name Notes Tier Tier TRICHOPHYTON WESTERN JUNIPER GM SUBCUTANEOUS GM SUBCUTANEOUS SOLUTION 20000 SOLUTION 1:20 PNU/ML WHITE BIRCH TRILURON INTRA- SUBCUTANEOUS GM ARTICULAR SOLUTION GM SOLUTION 1:20 PREFILLED SYRINGE WHITE FACED 20 MG/2ML HORNET VENOM TRIVISC INTRA- SUBCUTANEOUS GM ARTICULAR SOLUTION SOLUTION GM PREFILLED SYRINGE RECONSTITUTED 1100 25 MG/2.5ML MCG, 120 MCG VCF VAGINAL WHITE MULBERRY CONTRACEPTIVE PV SUBCUTANEOUS GM VAGINAL FILM 28 % SOLUTION 1:20 vcf vaginal contraceptive PV WHITE OAK vaginal gel 4 % SUBCUTANEOUS GM VENOMIL MIXED SOLUTION 1:20 VESPID VENOM WHITE PINE INJECTION SOLUTION GM SUBCUTANEOUS GM RECONSTITUTED 550- SOLUTION 1:20 550-550 MCG WHITE-FACED VISCO-3 INTRA- HORNET VENOM GM ARTICULAR SOLUTION GM INJECTION SOLUTION PREFILLED SYRINGE RECONSTITUTED 550 25 MG/2.5ML MCG WIDE-SEAL VISTOGARD ORAL 6 PACKET 10 GM DIAPHRAGM 60 PV VITRASE INJECTION VAGINAL DIAPHRAGM GM SOLUTION 200 UNIT/ML 2 % VORTEX VALVED WIDE-SEAL HOLDING CHAMBER 2 DIAPHRAGM 65 PV DEVICE VAGINAL DIAPHRAGM 2 % WASP VENOM PROTEIN INJECTION WIDE-SEAL SOLUTION GM DIAPHRAGM 70 PV RECONSTITUTED 550 VAGINAL DIAPHRAGM MCG 2 % WASP VENOM WIDE-SEAL DIAPHRAGM 75 PROTEIN PV SUBCUTANEOUS VAGINAL DIAPHRAGM GM SOLUTION 2 % RECONSTITUTED 1100 MCG, 120 MCG Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 197 Drug Drug Drug Name Notes Drug Name Notes Tier Tier WIDE-SEAL YELLOW JACKET DIAPHRAGM 80 PV VENOM PROTEIN VAGINAL DIAPHRAGM INJECTION SOLUTION GM 2 % RECONSTITUTED 550 WIDE-SEAL MCG DIAPHRAGM 85 PV YELLOW JACKET VAGINAL DIAPHRAGM VENOM PROTEIN 2 % SUBCUTANEOUS GM WIDE-SEAL SOLUTION DIAPHRAGM 90 RECONSTITUTED 120 PV VAGINAL DIAPHRAGM MCG 2 % ZOKINVY ORAL WIDE-SEAL CAPSULE 50 MG, 75 6 PA MG DIAPHRAGM 95 PV VAGINAL DIAPHRAGM Ophthalmic Agents - 2 % Drugs for Eye Allergy, Infection and XEOMIN Inflammation INTRAMUSCULAR SOLUTION ACULAR LS Brand GM PA RECONSTITUTED 100 OPHTHALMIC 4 penalty UNIT, 200 UNIT, 50 SOLUTION 0.4 % applies UNIT Brand ACULAR OPHTHALMIC 4 penalty XIAFLEX INJECTION PA; SOLUTION 0.5 % applies SOLUTION 6 Specialty RECONSTITUTED 0.9 Medical ACUVAIL OPHTHALMIC 4 MG SOLUTION 0.45 % YELLOW DOCK ALOCRIL OPHTHALMIC 4 SUBCUTANEOUS GM SOLUTION 2 % SOLUTION 1:20 ALOMIDE OPHTHALMIC 3 YELLOW HORNET SOLUTION 0.1 % VENOM PROTEIN ALREX OPHTHALMIC INJECTION SOLUTION GM 4 RECONSTITUTED 550 SUSPENSION 0.2 % AZASITE OPHTHALMIC MCG 4 YELLOW HORNET SOLUTION 1 % VENOM PROTEIN azelastine hcl ophthalmic 2 SUBCUTANEOUS solution 0.05 % GM SOLUTION bacitracin ophthalmic 2 RECONSTITUTED 1100 ointment 500 unit/gm MCG, 120 MCG bepotastine besilate ophthalmic solution 1.5 2 %

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 198 Drug Drug Drug Name Notes Drug Name Notes Tier Tier BEPREVE Brand erythromycin ophthalmic 2 OPHTHALMIC 4 penalty ointment 5 mg/gm SOLUTION 1.5 % applies FLAREX OPHTHALMIC 3 BESIVANCE SUSPENSION 0.1 % OPHTHALMIC 4 fluorometholone SUSPENSION 0.6 % ophthalmic suspension 2 BETADINE 0.1 % OPHTHALMIC PREP 4 flurbiprofen sodium OPHTHALMIC ophthalmic solution 0.03 2 SOLUTION 5 % % BLEPH-10 Brand FML FORTE OPHTHALMIC 4 penalty OPHTHALMIC 3 SOLUTION 10 % applies SUSPENSION 0.25 % bromfenac sodium (once- FML LIQUIFILM Brand daily) ophthalmic solution 2 OPHTHALMIC 4 penalty 0.09 % SUSPENSION 0.1 % applies BROMSITE FML OPHTHALMIC 4 3 OPHTHALMIC OINTMENT 0.1 % SOLUTION 0.075 % gatifloxacin ophthalmic CILOXAN OPHTHALMIC 2 4 solution 0.5 % OINTMENT 0.3 % gentak ophthalmic 2 Brand ointment 0.3 % CILOXAN OPHTHALMIC 4 penalty SOLUTION 0.3 % applies gentamicin sulfate ophthalmic solution 0.3 2 ciprofloxacin hcl % ophthalmic solution 0.3 2 % ILEVRO OPHTHALMIC 4 SUSPENSION 0.3 % cromolyn sodium 1 ophthalmic solution 4 % ILUVIEN INTRAVITREAL GM IMPLANT 0.19 MG dexamethasone sodium phosphate ophthalmic 2 INVELTYS solution 0.1 % OPHTHALMIC 4 SUSPENSION 1 % DEXYCU Specialty 5 ketorolac tromethamine INTRAOCULAR Medical SUSPENSION 9 % ophthalmic solution 0.4 2 %, 0.5 % diclofenac sodium ophthalmic solution 0.1 2 KLARITY-A % OPHTHALMIC 4 SOLUTION 1 % DUREZOL OPHTHALMIC 4 levofloxacin ophthalmic 2 EMULSION 0.05 % solution 0.5 % epinastine hcl ophthalmic 2 solution 0.05 % Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 199 Drug Drug Drug Name Notes Drug Name Notes Tier Tier LOTEMAX Brand moxifloxacin hcl OPHTHALMIC GEL 0.5 4 penalty ophthalmic solution 0.5 2 % applies % LOTEMAX MOXIFLOXACIN HCL 4 OPHTHALMIC OPHTHALMIC GM OINTMENT 0.5 % SOLUTION PREFILLED LOTEMAX Brand SYRINGE 0.5 % OPHTHALMIC 4 penalty NATACYN SUSPENSION 0.5 % applies OPHTHALMIC 4 LOTEMAX SM SUSPENSION 5 % OPHTHALMIC GEL 0.38 4 NEVANAC % OPHTHALMIC 4 SUSPENSION 0.1 % loteprednol etabonate 2 ophthalmic gel 0.5 % OCUFLOX Brand loteprednol etabonate OPHTHALMIC 4 penalty ophthalmic suspension 2 SOLUTION 0.3 % applies 0.5 % ofloxacin ophthalmic 2 solution 0.3 % MAXIDEX OPHTHALMIC 4 SUSPENSION 0.1 % olopatadine hcl MITOMYCIN ophthalmic solution 0.1 2 INTRAOCULAR %, 0.2 % SOLUTION PREFILLED GM OZURDEX Specialty 6 SYRINGE 0.02 %, 0.03 INTRAVITREAL Medical %, 0.04 % IMPLANT 0.7 MG

MITOSOL OPHTHALMIC GM POVIDONE-IODINE KIT 0.2 MG OPHTHALMIC 4 Brand SOLUTION 5 % MOXEZA OPHTHALMIC 4 penalty PRED FORTE Brand SOLUTION 0.5 % applies OPHTHALMIC 4 penalty moxifloxacin hcl (2x day) SUSPENSION 1 % applies ophthalmic solution 0.5 2 PRED MILD % OPHTHALMIC 3 MOXIFLOXACIN HCL SUSPENSION 0.12 % INTRAOCULAR GM PREDNISOL ACE- SOLUTION 1 MG/ML, 5 MOXIFLOX-BROMFEN MG/ML OPHTHALMIC 4 MOXIFLOXACIN HCL SUSPENSION 1-0.5- INTRAOCULAR 0.075 % SOLUTION PREFILLED GM prednisolone acetate SYRINGE 0.16 %, 0.3 ophthalmic suspension 1 2 MG/0.3ML %

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 200 Drug Drug Drug Name Notes Drug Name Notes Tier Tier prednisolone acetate p-f VIGAMOX Brand ophthalmic suspension 1 2 OPHTHALMIC 4 penalty % SOLUTION 0.5 % applies prednisolone sodium ZERVIATE phosphate ophthalmic 2 OPHTHALMIC 4 solution 1 % SOLUTION 0.24 %

PROLENSA ZIRGAN OPHTHALMIC 4 OPHTHALMIC 4 GEL 0.15 % SOLUTION 0.07 % Brand sulfacetamide sodium ZYMAXID OPHTHALMIC 4 penalty ophthalmic ointment 10 2 SOLUTION 0.5 % applies % Ophthalmic Agents - Drugs for Glaucoma sulfacetamide sodium 2 ophthalmic solution 10 % acetazolamide er oral capsule extended 2 tobramycin ophthalmic 1 solution 0.3 % release 12 hour 500 mg acetazolamide oral tablet TOBREX OPHTHALMIC 3 2 OINTMENT 0.3 % 125 mg, 250 mg Brand ALPHAGAN P TOBREX OPHTHALMIC 4 penalty OPHTHALMIC 4 SOLUTION 0.3 % applies SOLUTION 0.1 % TRIESENCE ALPHAGAN P Brand INTRAOCULAR OPHTHALMIC 4 penalty 4 SUSPENSION 40 SOLUTION 0.15 % applies MG/ML apraclonidine hcl ophthalmic solution 0.5 2 trifluridine ophthalmic 2 solution 1 % % TRIPLE PMB Brand OPHTHALMIC AZOPT OPHTHALMIC 4 penalty SOLUTION 4 SUSPENSION 1 % applies RECONSTITUTED 1- betaxolol hcl ophthalmic 2 0.5-0.09 % solution 0.5 % TRIPLE PMK BETIMOL OPHTHALMIC OPHTHALMIC SOLUTION 0.25 %, 0.5 4 SOLUTION 4 % RECONSTITUTED 1- 0.5-0.5 % BETOPTIC-S OPHTHALMIC 3 UPNEEQ OPHTHALMIC 4 SUSPENSION 0.25 % SOLUTION 0.1 % bimatoprost ophthalmic 2 VANCOMYCIN HCL solution 0.03 % OPHTHALMIC GM SOLUTION PREFILLED SYRINGE 10 MG/ML

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 201 Drug Drug Drug Name Notes Drug Name Notes Tier Tier brimonidine tartrate ISOPTO CARPINE Brand 2 ophthalmic solution 0.15 OPHTHALMIC 4 penalty % SOLUTION 1 %, 2 %, 4 applies brimonidine tartrate % ophthalmic solution 0.2 1 Brand % ISTALOL OPHTHALMIC 4 penalty applies BRIMONIDINE- SOLUTION 0.5 % DORZOLAMIDE KEVEYIS ORAL TABLET 4 6 PA OPHTHALMIC 50 MG SOLUTION 0.15-2 % latanoprost ophthalmic 2 brinzolamide ophthalmic solution 0.005 % 2 suspension 1 % LATANOPROST- carteolol hcl ophthalmic 2 TIMOLOL MALEATE 4 solution 1 % OPHTHALMIC COMBIGAN SOLUTION 0.005-0.5 % OPHTHALMIC 4 levobunolol hcl SOLUTION 0.2-0.5 % ophthalmic solution 0.5 2 COSOPT OPHTHALMIC Brand % SOLUTION 22.3-6.8 4 penalty LUMIGAN MG/ML applies OPHTHALMIC 3 COSOPT PF Brand SOLUTION 0.01 % OPHTHALMIC 4 penalty methazolamide oral 2 SOLUTION 2-0.5 % applies tablet 25 mg, 50 mg DORZOLAMIDE HCL pilocarpine hcl SOLUTION 2 % 4 ophthalmic solution 1 %, 2 OPHTHALMIC 2 % 2 %, 4 % dorzolamide hcl solution 2 RHOPRESSA 2 % ophthalmic 2 % OPHTHALMIC 4 dorzolamide hcl-timolol SOLUTION 0.02 % mal ophthalmic solution 2 ROCKLATAN 22.3-6.8 mg/ml OPHTHALMIC 4 dorzolamide hcl-timolol SOLUTION 0.02-0.005 % mal pf ophthalmic 2 SIMBRINZA solution 2-0.5 % OPHTHALMIC 4 DURYSTA PA; SUSPENSION 1-0.2 % INTRAOCULAR 6 Specialty timolol maleate ocudose IMPLANT 10 MCG Medical ophthalmic solution 0.5 2 EPINEPHRINE HCL % INTRAOCULAR GM timolol maleate SOLUTION PREFILLED ophthalmic gel forming 2 SYRINGE 1 MG/ML solution 0.25 %, 0.5 % IOPIDINE OPHTHALMIC 4 SOLUTION 1 % Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 202 Drug Drug Drug Name Notes Drug Name Notes Tier Tier timolol maleate travoprost (bak free) ophthalmic solution 0.25 1 ophthalmic solution 0.004 2 %, 0.5 % % timolol maleate TRUSOPT Brand ophthalmic solution 0.5 2 OPHTHALMIC 4 penalty % (daily) SOLUTION 2 % applies timolol maleate pf VYZULTA OPHTHALMIC 4 ophthalmic solution 0.5 2 SOLUTION 0.024 % % XALATAN Brand TIMOLOL-BRIMON- OPHTHALMIC 4 penalty DORZOL-LATANOPR SOLUTION 0.005 % applies OPHTHALMIC 4 ZIOPTAN OPHTHALMIC 4 SOLUTION 0.5-0.15-2 - SOLUTION 0.0015 % 0.005% Ophthalmic Agents - TIMOLOL- Drugs for BRIMONIDINE- Miscellaneous Eye DORZOLAMID 4 Conditions OPHTHALMIC SOLUTION 0.5-0.15-2 % ak-fluor intravenous GM solution 10 %, 25 % TIMOLOL- DORZOLAMID- ak-poly-bac ophthalmic ointment 500-10000 2 LATANOPROST 4 OPHTHALMIC unit/gm AKTEN OPHTHALMIC SOLUTION 0.5-0.15- 4 0.005 % GEL 3.5 % TIMOPTIC OCUDOSE Brand OPHTHALMIC 4 ALCAINE OPHTHALMIC 4 penalty SOLUTION 0.25 % SOLUTION 0.5 % applies TIMOPTIC OCUDOSE Brand ALTACAINE OPHTHALMIC 4 penalty OPHTHALMIC 4 SOLUTION 0.5 % applies SOLUTION 0.5 % altafrin ophthalmic TIMOPTIC Brand 2 solution 10 %, 2.5 % OPHTHALMIC 4 penalty SOLUTION 0.25 %, 0.5 AMVISC INTRAOCULAR applies 4 % SOLUTION 12 MG/ML TIMOPTIC-XE Brand AMVISC PLUS OPHTHALMIC GEL 4 penalty INTRAOCULAR 4 FORMING SOLUTION applies SOLUTION 16 MG/ML 0.25 %, 0.5 % atropine sulfate 2 TRAVATAN Z Brand ophthalmic ointment 1 % OPHTHALMIC 4 penalty SOLUTION 0.004 % applies ATROPINE SULFATE OPHTHALMIC 4 SOLUTION 0.01 %

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 203 Drug Drug Drug Name Notes Drug Name Notes Tier Tier atropine sulfate CYCLOMYDRIL 2 ophthalmic solution 1 % OPHTHALMIC 3 bacitracin-polymyxin b SOLUTION 0.2-1 % ophthalmic ointment 500- 2 cyclopentolate hcl 10000 unit/gm ophthalmic solution 0.5 2 bacitra-neomycin- % polymyxin-hc ophthalmic 2 cyclopentolate hcl ointment 1 % ophthalmic solution 1 %, 1 balanced salt intraocular 2 % 2 solution CYCLOSPORINE IN BEOVU INTRAVITREAL KLARITY OPHTHALMIC 4 Specialty SOLUTION 6 6 EMULSION 0.1 % Medical MG/0.05ML CYSTADROPS BEVACIZUMAB OPHTHALMIC 4 SOLUTION 0.37 % INTRAOCULAR PA; SOLUTION PREFILLED 6 Specialty DEXAMETHASONE- SYRINGE 2.75 Medical MOXIFLOXACIN GM MG/0.11ML, 3.75 INTRAOCULAR MG/0.15ML SOLUTION 1-5 MG/ML BEVACIZUMAB DEXAMETH- INTRAVITREAL MOXIFLOX- SOLUTION PREFILLED PA; KETOROLAC GM SYRINGE 2.5 6 Specialty INTRAOCULAR MG/0.1ML, 3 Medical SOLUTION 1-0.5-0.4 MG/0.12ML, 3.25 MG/ML MG/0.13ML, 3.75 DUOVISC MG/0.15ML INTRAOCULAR KIT GM BLEPHAMIDE 0.85-0.5 ML OPHTHALMIC 3 EYLEA INTRAVITREAL Specialty SUSPENSION 10-0.2 % SOLUTION 2 6 Medical BLEPHAMIDE S.O.P. MG/0.05ML OPHTHALMIC 3 EYLEA INTRAVITREAL Specialty OINTMENT 10-0.2 % 6 SOLUTION PREFILLED Medical BSS INTRAOCULAR 4 SYRINGE 2 MG/0.05ML SOLUTION FLUORESCEIN bss plus solution 2 SODIUM/BENOXINATE GM intraocular OPHTHALMIC SOLUTION 0.3-0.4 % BSS PLUS SOLUTION 4 INTRAOCULAR FLUORESCITE CYCLOGYL INTRAVENOUS GM Brand OPHTHALMIC SOLUTION 10 % 4 penalty SOLUTION 0.5 %, 1 %, 2 GELFILM OPHTHALMIC applies 4 % FILM

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 204 Drug Drug Drug Name Notes Drug Name Notes Tier Tier GLOSTRIPS LIDOCAINE- OPHTHALMIC STRIP GM EPINEPHRINE 1.3 MG INTRAOCULAR GM HEALON DUET PRO SOLUTION 7.5-0.25 MG/ML INTRAOCULAR 4 SOLUTION PREFILLED LIDOCAINE- SYRINGE 1 & 3 % PHENYLEPHRINE GM HEALON GV INTRAOCULAR INTRAOCULAR 4 SOLUTION 1-1.5 % SOLUTION 14 MG/ML LIDOCAINE- HEALON GV PRO PHENYLEPHRINE-BSS INTRAOCULAR 4 INTRAOCULAR GM SOLUTION 18 MG/ML SOLUTION PREFILLED SYRINGE 1-1.5 % (1ML) HEALON INTRAOCULAR 4 LUCENTIS INTRAVITREAL SOLUTION 10 MG/ML Specialty SOLUTION 0.3 6 Medical HEALON PRO MG/0.05ML, 0.5 INTRAOCULAR 4 MG/0.05ML SOLUTION 10 MG/ML LUCENTIS HEALON5 INTRAVITREAL INTRAOCULAR 4 SOLUTION PREFILLED 4 SOLUTION 23 MG/ML SYRINGE 0.3 HEALON5 PRO MG/0.05ML INTRAOCULAR 4 LUCENTIS SOLUTION 23 MG/ML INTRAVITREAL Specialty SOLUTION PREFILLED 6 homatropaire ophthalmic 2 Medical solution 5 % SYRINGE 0.5 HYALURONIDASE MG/0.05ML (INTRAOCULAR) LUXTURNA GM PA; INTRAOCULAR INTRAOCULAR 6 Specialty SOLUTION 175 UNIT/ML SUSPENSION Medical ISOPTO ATROPINE 5000000000000 VG/ML 4 OPHTHALMIC MAXITROL Brand OPHTHALMIC SOLUTION 1 % 4 penalty OINTMENT 3.5-10000- LACRISERT applies OPHTHALMIC INSERT 5 4 0.1 MAXITROL MG Brand OPHTHALMIC LASTACAFT 4 penalty OPHTHALMIC 4 SUSPENSION 3.5- applies SOLUTION 0.25 % 10000-0.1 MEMBRANEBLUE OPHTHALMIC GM SOLUTION 0.15 %

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 205 Drug Drug Drug Name Notes Drug Name Notes Tier Tier MIOCHOL-E phenylephrine hcl INTRAOCULAR ophthalmic solution 10 2 SOLUTION 4 %, 2.5 % RECONSTITUTED 20 polycin ophthalmic MG ointment 500-10000 2 MIOSTAT unit/gm 4 INTRAOCULAR polymyxin b-trimethoprim SOLUTION 0.01 % ophthalmic solution 2 MOXIFLOXACIN HCL- 10000-0.1 unit/ml-% BSS INTRAVITREAL GM POLYTRIM Brand SOLUTION 1 MG/ML OPHTHALMIC 4 penalty neomycin-bacitracin zn- SOLUTION 10000-0.1 applies polymyx ophthalmic 2 UNIT/ML-% ointment 3.5-400-10000 , PRED-G OPHTHALMIC 3 5-400-10000 SUSPENSION 0.3-1 % neomycin-polymyxin- PRED-G S.O.P. 2 dexameth ophthalmic OPHTHALMIC 3 ointment 3.5-10000-0.1 OINTMENT 0.3-0.6 % neomycin-polymyxin- PREDNISOLONE- dexameth ophthalmic BROMFENAC 2 4 suspension 3.5-10000- OPHTHALMIC 0.1 SOLUTION 1-0.075 % neomycin-polymyxin- PREDNISOLONE- gramicidin ophthalmic 2 BROMFENAC solution 1.75-10000-.025 OPHTHALMIC GM neomycin-polymyxin-hc SUSPENSION 1-0.075 ophthalmic suspension 2 % 3.5-10000-1 PREDNISOLONE- neo-polycin hc GATIFLOXACIN 2 4 ophthalmic ointment 1 % OPHTHALMIC neo-polycin ophthalmic SUSPENSION 1-0.5 % 2 ointment 3.5-400-10000 PREDNISOLON- OMIDRIA GATIFLOX- INTRAOCULAR GM BROMFENAC 4 SOLUTION 1-0.3 % OPHTHALMIC SOLUTION 1-0.5-0.075 OXERVATE PA; QL (28 % OPHTHALMIC 6 ML per 28 SOLUTION 0.002 % days) PREDNISOLON- GATIFLOX- PHENYLEPHRINE HCL BROMFENAC INTRAOCULAR 4 GM OPHTHALMIC SOLUTION PREFILLED SUSPENSION 1-0.5- SYRINGE 1.5 % 0.075 %

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 206 Drug Drug Drug Name Notes Drug Name Notes Tier Tier PREDNISOLON- TRIAMCINOLONE- MOXIFLOX- MOXIFLOXACIN GM BROMFENAC 4 INTRAOCULAR OPHTHALMIC SUSPENSION 15-1 SOLUTION 1-0.5-0.075 MG/ML % TROPICAMIDE- proparacaine hcl CYCLOPENTOLATE-PE 4 ophthalmic solution 0.5 2 OPHTHALMIC % SOLUTION 1-1-2.5 % PROVISC TROPICAMIDE- 4 INTRAOCULAR PHENYLEPHRINE 4 SOLUTION 10 MG/ML OPHTHALMIC RESTASIS MULTIDOSE SOLUTION 1-2.5 % OPHTHALMIC 3 TROPIC-CYCLOPENT- EMULSION 0.05 % PE-KETOROLAC RESTASIS OPHTHALMIC 4 OPHTHALMIC 3 SOLUTION 1-1-10-0.5 EMULSION 0.05 % %, 1-1-2.5-0.5 % sulfacetamide- TROPIC-CYCLOPENT- prednisolone ophthalmic 2 PE-KETOROLAC solution 10-0.23 % OPHTHALMIC 4 SOLUTION PREFILLED tetracaine hcl ophthalmic 2 SYRINGE 1-1-10-0.5 %, solution 0.5 % 1-1-2.5-0.5 % TISSUEBLUE TROPIC-CYCLOP-PE- INTRAOCULAR GM KETO-PROPAR SOLUTION PREFILLED OPHTHALMIC 4 SYRINGE 0.025 % SOLUTION PREFILLED TOBRADEX SYRINGE OPHTHALMIC 3 TROPIC-PROPARACA- OINTMENT 0.3-0.1 % PE-KETOROLAC TOBRADEX Brand OPHTHALMIC 4 OPHTHALMIC 4 penalty SOLUTION 1-0.5-2.5-0.5 SUSPENSION 0.3-0.1 % applies % TOBRADEX ST VISIONBLUE OPHTHALMIC GM OPHTHALMIC 3 SUSPENSION 0.3-0.05 SOLUTION 0.06 % % VISUDYNE INTRAVENOUS tobramycin- Specialty dexamethasone SOLUTION 6 2 Medical ophthalmic suspension RECONSTITUTED 15 0.3-0.1 % MG

XIIDRA OPHTHALMIC 3 SOLUTION 5 %

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 207 Drug Drug Drug Name Notes Drug Name Notes Tier Tier ZYLET OPHTHALMIC OTIPRIO 4 SUSPENSION 0.5-0.3 % INTRATYMPANIC 4 Otic Agents - Drugs for SUSPENSION 6 % Ear Conditions OTOVEL OTIC 4 SOLUTION 0.3-0.025 % acetic acid otic solution 2 2 % PRAMOTIC OTIC 4 Brand LIQUID 1-0.1 % CETRAXAL OTIC 4 penalty Respiratory Tract / SOLUTION 0.2 % applies Pulmonary Agents - CIPRO HC OTIC Drugs for Allergies, 4 SUSPENSION 0.2-1 % Cough, Cold ADRENALIN NASAL Brand 4 CIPRODEX OTIC 4 penalty SOLUTION 0.1 % SUSPENSION 0.3-0.1 % applies azelastine hcl nasal solution 0.1 %, 0.15 %, 2 ciprofloxacin hcl otic 2 solution 0.2 % 137 mcg/spray ciprofloxacin- BECONASE AQ NASAL dexamethasone otic 2 SUSPENSION 42 4 suspension 0.3-0.1 % MCG/SPRAY benzonatate oral capsule CIPROFLOXACIN- 2 FLUOCINOLONE PF 100 mg, 150 mg, 200 mg 4 OTIC SOLUTION 0.3- budesonide nasal 2 0.025 % suspension 32 mcg/act CORTISPORIN-TC OTIC carbinoxamine maleate 2 SUSPENSION 3.3-3-10- 4 oral solution 4 mg/5ml 0.5 MG/ML carbinoxamine maleate 2 DERMOTIC OTIC OIL 4 oral tablet 4 mg 0.01 % CINQAIR PA; 2 flac otic oil 0.01 % INTRAVENOUS 6 Specialty SOLUTION 100 fluocinolone acetonide 2 Medical otic oil 0.01 % MG/10ML hydrocortisone-acetic clemastine fumarate oral 2 2 acid otic solution 1-2 % syrup 0.67 mg/5ml clemastine fumarate oral neomycin-polymyxin-hc 2 otic solution 1 %, 3.5- 2 tablet 2.68 mg 10000-1 CUROSURF neomycin-polymyxin-hc INTRATRACHEAL 4 otic suspension 3.5- 2 SUSPENSION 120 10000-1 MG/1.5ML, 240 MG/3ML cyproheptadine hcl oral ofloxacin otic solution 0.3 2 2 % syrup 2 mg/5ml

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 208 Drug Drug Drug Name Notes Drug Name Notes Tier Tier cyproheptadine hcl oral hydrocodone- 2 tablet 4 mg homatropine oral syrup 2 5-1.5 mg/5ml desloratadine oral tablet 2 5 mg hydrocodone- homatropine oral tablet 2 desloratadine oral tablet 2 dispersible 2.5 mg, 5 mg 5-1.5 mg dexchlorpheniramine hydromet oral syrup 5- 2 maleate oral solution 2 2 1.5 mg/5ml mg/5ml HYPERSAL diphen oral elixir 12.5 INHALATION 2 4 mg/5ml NEBULIZATION SOLUTION 3.5 %, 7 % di-phen oral elixir 12.5 2 mg/5ml INFASURF INTRATRACHEAL 4 diphenhydramine hcl SUSPENSION 35-0.9 injection solution 50 2 MG/ML-% mg/ml ipratropium bromide diphenhydramine hcl oral 2 nasal solution 0.03 %, 2 elixir 12.5 mg/5ml 0.06 % FASENRA PEN KARBINAL ER ORAL SUBCUTANEOUS SUSPENSION 6 PA 4 SOLUTION AUTO- EXTENDED RELEASE 4 INJECTOR 30 MG/ML MG/5ML FASENRA PA; levocetirizine SUBCUTANEOUS 6 Specialty dihydrochloride oral 2 SOLUTION PREFILLED Medical solution 2.5 mg/5ml SYRINGE 30 MG/ML levocetirizine flunisolide nasal solution 2 dihydrochloride oral 2 25 mcg/act (0.025%) tablet 5 mg fluticasone propionate mometasone furoate nasal suspension 50 2 nasal suspension 50 2 mcg/act mcg/act GILPHEX TR ORAL 4 NASONEX NASAL Brand TABLET 10-388 MG SUSPENSION 50 4 penalty Brand MCG/ACT applies HYCODAN ORAL 4 penalty NUCALA SYRUP 5-1.5 MG/5ML applies SUBCUTANEOUS 6 PA hydrocodone polst- SOLUTION AUTO- chlorphen polst er susp INJECTOR 100 MG/ML oral suspension 2 NUCALA extended release 10-8 SUBCUTANEOUS 6 PA mg/5ml SOLUTION PREFILLED SYRINGE 100 MG/ML

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 209 Drug Drug Drug Name Notes Drug Name Notes Tier Tier NUCALA promethazine-phenyleph- SUBCUTANEOUS PA; codeine oral syrup 6.25- 2 SOLUTION 6 Specialty 5-10 mg/5ml RECONSTITUTED 100 Medical promethazine- MG phenylephrine oral syrup 2 olopatadine hcl nasal 2 6.25-5 mg/5ml solution 0.6 % promethegan rectal OMNARIS NASAL suppository 12.5 mg, 25 2 SUSPENSION 50 4 mg, 50 mg MCG/ACT pseudoephedrine- Brand bromphen-dm oral syrup 2 PATANASE NASAL 4 penalty 30-2-10 mg/5ml SOLUTION 0.6 % applies QNASL CHILDRENS Brand PHENERGAN NASAL AEROSOL 4 INJECTION SOLUTION 4 penalty SOLUTION 40 25 MG/ML, 50 MG/ML applies MCG/ACT promethazine hcl QNASL NASAL injection solution 25 2 AEROSOL SOLUTION 4 mg/ml, 50 mg/ml 80 MCG/ACT promethazine hcl oral QUZYTTIR 2 solution 6.25 mg/5ml INTRAVENOUS GM promethazine hcl oral SOLUTION 10 MG/ML 2 syrup 6.25 mg/5ml Brand promethazine hcl oral RYCLORA ORAL 4 penalty tablet 12.5 mg, 25 mg, 50 2 SOLUTION 2 MG/5ML applies Specialty mg SINUVA NASAL 5 promethazine hcl rectal IMPLANT 1350 MCG Medical suppository 12.5 mg, 25 2 sodium chloride mg inhalation nebulization 2 promethazine vc oral solution 0.9 %, 10 %, 3 2 syrup 6.25-5 mg/5ml %, 7 % SSKI ORAL SOLUTION promethazine vc/codeine 4 oral syrup 6.25-5-10 2 1 GM/ML mg/5ml SURVANTA promethazine-codeine INTRATRACHEAL 4 oral solution 6.25-10 2 SUSPENSION 25-0.9 mg/5ml MG/ML-% promethazine-codeine TESSALON PERLES Brand 4 penalty oral syrup 6.25-10 2 ORAL CAPSULE 100 mg/5ml MG applies promethazine-dm oral 2 syrup 6.25-15 mg/5ml

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 210 Drug Drug Drug Name Notes Drug Name Notes Tier Tier TUSSICAPS ORAL ADVAIR DISKUS CAPSULE EXTENDED 4 INHALATION AEROSOL RELEASE 12 HOUR 10- POWDER BREATH PA; Brand 8 MG ACTIVATED 100-50 4 penalty TUXARIN ER ORAL MCG/DOSE, 250-50 applies MCG/DOSE, 500-50 TABLET EXTENDED 4 RELEASE 12 HOUR MCG/DOSE 54.3-8 MG ADVAIR HFA TUZISTRA XR ORAL INHALATION AEROSOL SUSPENSION 115-21 MCG/ACT, 230- 4 PA 4 EXTENDED RELEASE 21 MCG/ACT, 45-21 14.7-2.8 MG/5ML MCG/ACT XHANCE NASAL albuterol sulfate hfa QL (3 GM inhalation aerosol EXHALER 4 2 per 30 SUSPENSION 93 solution 108 (90 base) days) MCG/ACT mcg/act XOLAIR albuterol sulfate SUBCUTANEOUS inhalation nebulization solution (2.5 mg/3ml) SOLUTION PREFILLED 6 PA 2 SYRINGE 150 MG/ML, 0.083%, 0.63 mg/3ml, 75 MG/0.5ML 1.25 mg/3ml, 2.5 mg/0.5ml XOLAIR SUBCUTANEOUS PA; ALBUTEROL SULFATE SOLUTION 6 Specialty NEBULIZATION 4 RECONSTITUTED 150 Medical SOLUTION (5 MG/ML) MG 0.5% INHALATION (5 MG/ML) 0.5% ZETONNA NASAL AEROSOL SOLUTION 4 albuterol sulfate nebulization solution (5 37 MCG/ACT 2 mg/ml) 0.5% inhalation (5 Respiratory Tract / mg/ml) 0.5% Pulmonary Agents - Drugs for Asthma and albuterol sulfate oral 2 Other Lung Conditions syrup 2 mg/5ml Brand albuterol sulfate oral 2 ACCOLATE ORAL 4 penalty tablet 2 mg TABLET 10 MG, 20 MG applies albuterol sulfate oral 1 acetylcysteine inhalation tablet 4 mg 2 solution 10 %, 20 % ALVESCO INHALATION AEROSOL SOLUTION ADRENALIN INJECTION QL (4 ML 4 SOLUTION 1 MG/ML, 30 GM per 30 160 MCG/ACT, 80 MG/30ML days) MCG/ACT aminophylline intravenous solution 25 2 mg/ml

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 211 Drug Drug Drug Name Notes Drug Name Notes Tier Tier ANORO ELLIPTA ASMANEX (7 METERED INHALATION AEROSOL DOSES) INHALATION QL (1 EA POWDER BREATH 3 AEROSOL POWDER 3 per 30 ACTIVATED 62.5-25 BREATH ACTIVATED days) MCG/INH 110 MCG/INH ARALAST NP ASMANEX HFA INTRAVENOUS PA; INHALATION AEROSOL 3 SOLUTION 6 Specialty 100 MCG/ACT, 200 RECONSTITUTED 1000 Medical MCG/ACT, 50 MCG/ACT MG, 500 MG ATROVENT HFA arformoterol tartrate INHALATION AEROSOL 3 inhalation nebulization 2 SOLUTION 17 solution 15 mcg/2ml MCG/ACT ARNUITY ELLIPTA BREO ELLIPTA INHALATION AEROSOL INHALATION AEROSOL POWDER BREATH POWDER BREATH 4 PA 4 PA ACTIVATED 100 ACTIVATED 100-25 MCG/ACT, 200 MCG/INH, 200-25 MCG/ACT, 50 MCG/ACT MCG/INH ASMANEX (120 BREZTRI METERED DOSES) QL (1 EA AEROSPHERE 3 INHALATION AEROSOL 3 per 30 INHALATION AEROSOL POWDER BREATH days) 160-9-4.8 MCG/ACT ACTIVATED 220 BROVANA INHALATION Brand MCG/INH NEBULIZATION 4 penalty ASMANEX (14 SOLUTION 15 MCG/2ML applies METERED DOSES) QL (1 EA budesonide inhalation INHALATION AEROSOL 3 per 30 suspension 0.25 mg/2ml, 2 POWDER BREATH days) 0.5 mg/2ml, 1 mg/2ml ACTIVATED 220 MCG/INH COMBIVENT INHALATION AEROSOL 3 ASMANEX (30 SOLUTION 20-100 METERED DOSES) QL (1 EA MCG/ACT INHALATION AEROSOL 3 per 30 POWDER BREATH cromolyn sodium days) ACTIVATED 110 inhalation nebulization 2 MCG/INH, 220 MCG/INH solution 20 mg/2ml ASMANEX (60 DALIRESP ORAL METERED DOSES) TABLET 250 MCG, 500 4 PA QL (1 EA MCG INHALATION AEROSOL 3 per 30 POWDER BREATH days) DULERA INHALATION ACTIVATED 220 AEROSOL 100-5 MCG/INH MCG/ACT, 200-5 3 MCG/ACT, 50-5 MCG/ACT

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 212 Drug Drug Drug Name Notes Drug Name Notes Tier Tier ELIXOPHYLLIN ORAL FLUTICASONE- 4 ELIXIR 80 MG/15ML SALMETEROL epinephrine QL (4 ML INHALATION AEROSOL (anaphylaxis) injection GM per 30 POWDER BREATH 2 solution 30 mg/30ml days) ACTIVATED 113-14 MCG/ACT, 232-14 epinephrine injection QL (4 EA MCG/ACT, 55-14 solution auto-injector 2 per 30 MCG/ACT 0.15 mg/0.15ml, 0.15 days) mg/0.3ml, 0.3 mg/0.3ml formoterol fumarate inhalation nebulization 2 Brand solution 20 mcg/2ml EPIPEN 2-PAK penalty INJECTION SOLUTION 4 applies; QL GLASSIA PA; AUTO-INJECTOR 0.3 (4 EA per INTRAVENOUS 6 Specialty MG/0.3ML 30 days) SOLUTION 1000 Medical MG/50ML Brand EPIPEN JR 2-PAK penalty INCRUSE ELLIPTA INJECTION SOLUTION 4 applies; QL INHALATION AEROSOL AUTO-INJECTOR 0.15 (4 EA per POWDER BREATH 3 MG/0.3ML 30 days) ACTIVATED 62.5 MCG/INH ESBRIET ORAL 6 PA CAPSULE 267 MG ipratropium bromide inhalation solution 0.02 2 ESBRIET ORAL TABLET 6 PA % 267 MG, 801 MG ipratropium-albuterol FLOVENT DISKUS inhalation solution 0.5- 2 INHALATION AEROSOL 2.5 (3) mg/3ml POWDER BREATH isoproterenol hcl injection ACTIVATED 100 4 GM MCG/BLIST, 250 solution 0.2 mg/ml MCG/BLIST, 50 ISOPROTERENOL- MCG/BLIST SODIUM CHLORIDE FLOVENT HFA INTRAVENOUS GM QL (24 GM INHALATION AEROSOL SOLUTION 200-0.9 4 per 30 MCG/50ML-% 110 MCG/ACT, 220 days) MCG/ACT, 44 MCG/ACT ISUPREL INJECTION GM fluticasone-salmeterol SOLUTION 0.2 MG/ML inhalation aerosol levalbuterol hcl inhalation powder breath activated nebulization solution 0.31 2 100-50 mcg/dose, 250- mg/3ml, 0.63 mg/3ml, 2 50 mcg/dose, 500-50 1.25 mg/0.5ml, 1.25 mcg/dose mg/3ml LONHALA MAGNAIR REFILL KIT 6 PA INHALATION SOLUTION 25 MCG/ML

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 213 Drug Drug Drug Name Notes Drug Name Notes Tier Tier LONHALA MAGNAIR PULMICORT STARTER KIT 6 PA SUSPENSION Brand INHALATION INHALATION 4 penalty SOLUTION 25 MCG/ML SUSPENSION 0.25 applies MG/2ML, 0.5 MG/2ML, 1 montelukast sodium oral 2 packet 4 mg MG/2ML montelukast sodium oral QVAR REDIHALER 2 INHALATION AEROSOL tablet 10 mg 3 BREATH ACTIVATED 40 montelukast sodium oral MCG/ACT, 80 MCG/ACT tablet chewable 4 mg, 5 2 mg SCLEROSOL INTRAPLEURAL OFEV ORAL CAPSULE 6 PA INTRAPLEURAL 4 100 MG, 150 MG AEROSOL POWDER 4 GM PERFOROMIST Brand INHALATION 4 penalty SEREVENT DISKUS NEBULIZATION applies INHALATION AEROSOL SOLUTION 20 MCG/2ML POWDER BREATH 3 ACTIVATED 50 PROAIR HFA QL (3 GM INHALATION AEROSOL MCG/DOSE 2 per 30 SOLUTION 108 (90 days) Brand BASE) MCG/ACT SINGULAIR ORAL 4 penalty PROAIR RESPICLICK PACKET 4 MG applies INHALATION AEROSOL QL (3 EA Brand POWDER BREATH 2 per 30 SINGULAIR ORAL 4 penalty ACTIVATED 108 (90 days) TABLET 10 MG applies BASE) MCG/ACT SINGULAIR ORAL Brand PROLASTIN-C PA; TABLET CHEWABLE 4 4 penalty INTRAVENOUS 6 Specialty MG, 5 MG applies SOLUTION 1000 Medical MG/20ML SPIRIVA HANDIHALER INHALATION CAPSULE 3 PROLASTIN-C 18 MCG INTRAVENOUS PA; SOLUTION 6 Specialty SPIRIVA RESPIMAT RECONSTITUTED 1000 Medical INHALATION AEROSOL MG SOLUTION 1.25 3 MCG/ACT, 2.5 PULMICORT MCG/ACT FLEXHALER INHALATION AEROSOL STERILE TALC 3 POWDER BREATH POWDER ACTIVATED 180 INTRAPLEURAL 4 MCG/ACT, 90 MCG/ACT SUSPENSION RECONSTITUTED 5 GM

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 214 Drug Drug Drug Name Notes Drug Name Notes Tier Tier STIOLTO RESPIMAT wixela inhub inhalation INHALATION AEROSOL 3 aerosol powder breath SOLUTION 2.5-2.5 activated 100-50 2 MCG/ACT mcg/dose, 250-50 STRIVERDI RESPIMAT mcg/dose, 500-50 mcg/dose INHALATION AEROSOL 3 SOLUTION 2.5 XOPENEX MCG/ACT CONCENTRATE Brand INHALATION SYMBICORT 4 penalty INHALATION AEROSOL NEBULIZATION 3 applies 160-4.5 MCG/ACT, 80- SOLUTION 1.25 4.5 MCG/ACT MG/0.5ML XOPENEX INHALATION terbutaline sulfate GM injection solution 1 mg/ml NEBULIZATION Brand SOLUTION 0.31 4 penalty terbutaline sulfate oral 2 MG/3ML, 0.63 MG/3ML, applies tablet 2.5 mg, 5 mg 1.25 MG/3ML THEO-24 ORAL YUPELRI INHALATION CAPSULE EXTENDED SOLUTION 175 6 PA RELEASE 24 HOUR 100 4 MCG/3ML MG, 200 MG, 300 MG, 400 MG zafirlukast oral tablet 10 2 mg, 20 mg theophylline er oral tablet extended release 12 hour 2 ZEMAIRA 300 mg, 450 mg INTRAVENOUS PA; SOLUTION 6 Specialty theophylline er oral tablet RECONSTITUTED 1000 Medical extended release 24 hour 2 MG 400 mg, 600 mg zileuton er oral tablet theophylline oral solution 2 extended release 12 hour 5 80 mg/15ml 600 mg TRELEGY ELLIPTA ZYFLO ORAL TABLET 5 INHALATION AEROSOL 600 MG POWDER BREATH 3 Respiratory Tract / ACTIVATED 100-62.5-25 Pulmonary Agents - MCG/INH, 200-62.5-25 Drugs for Cystic MCG/INH Fibrosis VENTOLIN HFA QL (3 GM INHALATION AEROSOL BETHKIS INHALATION 2 per 30 6 PA SOLUTION 108 (90 NEBULIZATION days) BASE) MCG/ACT SOLUTION 300 MG/4ML BRONCHITOL INHALATION CAPSULE 6 PA 40 MG

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 215 Drug Drug Drug Name Notes Drug Name Notes Tier Tier BRONCHITOL TOBRAMYCIN TOLERANCE TEST 6 PA NEBULIZATION INHALATION CAPSULE SOLUTION 300 MG/5ML 6 PA 40 MG INHALATION 300 CAYSTON INHALATION MG/5ML SOLUTION 6 PA TRIKAFTA ORAL RECONSTITUTED 75 TABLET THERAPY 6 PA MG PACK 100-50-75 & 150 KALYDECO ORAL MG, 50-25-37.5 & 75 MG PACKET 25 MG, 50 MG, 6 PA Respiratory Tract / 75 MG Pulmonary Agents - Drugs for Pulmonary KALYDECO ORAL 6 PA Hypertension TABLET 150 MG KITABIS PAK ADCIRCA ORAL 6 PA TABLET 20 MG INHALATION 6 PA NEBULIZATION ADEMPAS ORAL SOLUTION 300 MG/5ML TABLET 0.5 MG, 1 MG, 6 PA ORKAMBI ORAL 1.5 MG, 2 MG, 2.5 MG PACKET 100-125 MG, 6 PA alyq oral tablet 20 mg 5 PA 150-188 MG ambrisentan oral tablet 5 PA ORKAMBI ORAL 10 mg, 5 mg TABLET 100-125 MG, 6 PA bosentan oral tablet 125 5 PA 200-125 MG mg, 62.5 mg PULMOZYME epoprostenol sodium PA; INHALATION 6 PA intravenous solution SOLUTION 1 MG/ML 5 Specialty reconstituted 0.5 mg, 1.5 Medical SYMDEKO ORAL mg TABLET THERAPY 6 PA FLOLAN PACK 100-150 & 150 INTRAVENOUS PA; MG, 50-75 & 75 MG SOLUTION 6 Specialty TOBI RECONSTITUTED 0.5 Medical INHALATION MG, 1.5 MG 6 PA NEBULIZATION LETAIRIS ORAL 6 PA SOLUTION 300 MG/5ML TABLET 10 MG, 5 MG TOBI PODHALER OPSUMIT ORAL 6 PA INHALATION CAPSULE 6 PA TABLET 10 MG 28 MG ORENITRAM ORAL tobramycin inhalation TABLET EXTENDED nebulization solution 300 6 PA RELEASE 0.125 MG, 6 PA mg/4ml 0.25 MG, 1 MG, 2.5 MG, tobramycin nebulization 5 MG solution 300 mg/5ml 5 PA inhalation 300 mg/5ml

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 216 Drug Drug Drug Name Notes Drug Name Notes Tier Tier REMODULIN UPTRAVI ORAL INJECTION SOLUTION PA; TABLET 1000 MCG, 6 Specialty 100 MG/20ML, 20 1200 MCG, 1400 MCG, 6 PA MG/20ML, 200 Medical 1600 MCG, 200 MCG, MG/20ML, 50 MG/20ML 400 MCG, 600 MCG, 800 MCG REVATIO PA; INTRAVENOUS UPTRAVI ORAL 6 Specialty SOLUTION 10 TABLET THERAPY 4 Medical MG/12.5ML PACK 200 & 800 MCG REVATIO ORAL VELETRI PA; SUSPENSION 6 PA INTRAVENOUS RECONSTITUTED 10 SOLUTION 6 Specialty MG/ML RECONSTITUTED 0.5 Medical MG, 1.5 MG REVATIO ORAL 6 PA TABLET 20 MG VENTAVIS INHALATION sildenafil citrate PA; SOLUTION 10 MCG/ML, 6 PA intravenous solution 10 5 Specialty 20 MCG/ML mg/12.5ml Medical Skeletal Muscle Relaxants - Drugs for sildenafil citrate oral Muscle Pain and suspension reconstituted 6 PA Spasm 10 mg/ml sildenafil citrate oral baclofen intrathecal 5 PA GM tablet 20 mg solution 10 mg/20ml, 40 mg/20ml tadalafil (pah) oral tablet 5 PA 20 mg baclofen oral tablet 10 2 mg, 20 mg, 5 mg TRACLEER ORAL TABLET 125 MG, 62.5 6 PA carisoprodol oral tablet 2 MG 250 mg, 350 mg TRACLEER ORAL chlorzoxazone oral tablet 2 TABLET SOLUBLE 32 6 PA 250 mg, 375 mg, 500 MG mg, 750 mg treprostinil injection cyclobenzaprine hcl oral PA; 2 solution 100 mg/20ml, 20 tablet 10 mg, 5 mg, 7.5 6 Specialty mg mg/20ml, 200 mg/20ml, Medical 50 mg/20ml DANTRIUM TYVASO INHALATION INTRAVENOUS 6 PA GM SOLUTION 0.6 MG/ML SOLUTION RECONSTITUTED 20 TYVASO REFILL MG INHALATION 6 PA Brand SOLUTION 0.6 MG/ML DANTRIUM ORAL CAPSULE 25 MG, 50 4 penalty TYVASO STARTER MG applies INHALATION 6 PA SOLUTION 0.6 MG/ML

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 217 Drug Drug Drug Name Notes Drug Name Notes Tier Tier dantrolene sodium ORPHENGESIC FORTE intravenous solution GM ORAL TABLET 50-770- 4 reconstituted 20 mg 60 MG dantrolene sodium oral revonto intravenous capsule 100 mg, 25 mg, 2 solution reconstituted 20 GM 50 mg mg Brand ROBAXIN INJECTION FEXMID ORAL TABLET 4 penalty SOLUTION 1000 GM 7.5 MG applies MG/10ML FIRST-BACLOFEN RYANODEX ORAL SUSPENSION 1 2 INTRAVENOUS MG/ML, 5 MG/ML SUSPENSION GM GABLOFEN RECONSTITUTED 250 INTRATHECAL MG SOLUTION 10000 GM Brand MCG/20ML, 40000 SKELAXIN ORAL 4 penalty MCG/20ML TABLET 800 MG applies LIORESAL Brand INTRATHECAL SOMA ORAL TABLET 4 penalty SOLUTION 0.05 MG/ML, GM 250 MG, 350 MG applies 10 MG/20ML, 10 tizanidine hcl oral MG/5ML, 40 MG/20ML capsule 2 mg, 4 mg, 6 2 LORZONE ORAL Brand mg TABLET 375 MG, 750 4 penalty tizanidine hcl oral tablet 2 2 MG applies mg, 4 mg metaxalone oral tablet 2 Brand 400 mg, 800 mg VANADOM ORAL 4 penalty methocarbamol injection TABLET 350 MG applies GM solution 1000 mg/10ml ZANAFLEX ORAL Brand methocarbamol oral CAPSULE 2 MG, 4 MG, 4 penalty 2 tablet 500 mg, 750 mg 6 MG applies NORGESIC FORTE Brand ORAL TABLET 50-770- 4 ZANAFLEX ORAL 4 penalty 60 MG TABLET 4 MG applies orphenadrine citrate er Sleep Disorder Agents oral tablet extended 2 AMBIEN CR ORAL release 12 hour 100 mg Brand TABLET EXTENDED 4 penalty orphenadrine citrate RELEASE 12.5 MG, 6.25 applies injection solution 30 GM MG mg/ml Brand orphenadrine-asa- AMBIEN ORAL TABLET 4 penalty caffeine oral tablet 50- 2 10 MG, 5 MG applies 770-60 mg

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 218 Drug Drug Drug Name Notes Drug Name Notes Tier Tier armodafinil oral tablet Brand 150 mg, 200 mg, 250 2 SILENOR ORAL 4 penalty mg, 50 mg TABLET 3 MG, 6 MG applies PA; QL (30 AZSTARYS ORAL QL (30 EA 4 EA per 30 CAPSULE 26.1-5.2 MG, 4 per 30 SUNOSI ORAL TABLET days) 39.2-7.8 MG, 52.3-10.4 days) 150 MG, 75 MG MG temazepam oral capsule BELSOMRA ORAL 15 mg, 22.5 mg, 30 mg, 2 TABLET 10 MG, 15 MG, 4 7.5 mg 20 MG, 5 MG WAKIX ORAL TABLET 6 PA DAYVIGO ORAL 17.8 MG, 4.45 MG 4 TABLET 10 MG, 5 MG XYREM ORAL 6 PA doxepin hcl oral tablet 3 2 SOLUTION 500 MG/ML mg, 6 mg zaleplon oral capsule 10 2 eszopiclone oral tablet 1 2 mg, 5 mg mg, 2 mg, 3 mg zolpidem tartrate er oral 2 flurazepam hcl oral 2 tablet extended release capsule 15 mg, 30 mg 12.5 mg, 6.25 mg

HETLIOZ LQ ORAL 6 PA zolpidem tartrate oral 2 SUSPENSION 4 MG/ML tablet 10 mg, 5 mg HETLIOZ ORAL Stimulation or 6 PA CAPSULE 20 MG Suppression LUNESTA ORAL Brand TAKHZYRO PA; QL (4 TABLET 1 MG, 2 MG, 3 4 penalty SUBCUTANEOUS 6 ML per 28 MG applies SOLUTION 300 MG/2ML days) modafinil oral tablet 100 2 mg, 200 mg NUVIGIL ORAL TABLET Brand 150 MG, 200 MG, 250 4 penalty MG, 50 MG applies PROVIGIL ORAL Brand TABLET 100 MG, 200 4 penalty MG applies ramelteon oral tablet 8 2 mg RESTORIL ORAL Brand CAPSULE 15 MG, 22.5 4 penalty MG, 30 MG, 7.5 MG applies Brand ROZEREM ORAL 4 penalty TABLET 8 MG applies

Updated September 1, 2021 PA=Prior Auth Required; ST = Step Therapy; QL = Quantity Limits; AL = Age Limit; PV = Preventive; PV* = Preventive if member meets criteria 219 Index of Drugs 1ST MEDX-PATCH/ ACTHAR...... 155 AEROCHAMBER LIDOCAINE...... 15 ACTHIB...... 177 W/FLOWSIGNAL...... 184 7T LIDO...... 15 ACTIMMUNE...... 170 AFINITOR...... 52 abacavir sulfate...... 72 ACTIQ...... 9 AFINITOR DISPERZ...... 52 abacavir sulfate-lamivudine 73 ACTIVASE...... 33 afirmelle...... 159 abacavir-lamivudine- ACTIVE FE...... 126 AFLURIA zidovudine...... 73 ACTIVELLA...... 159 QUADRIVALENT...... 177 ABANEU-SL...... 126 ACTIVITE...... 126 AFREZZA...... 122 ABECMA...... 52 ACTONEL...... 182 AFSTYLA...... 80 ABELCET...... 45 ACTOPLUS MET...... 118 AFTERPILL...... 159 ABILIFY...... 70 ACTOS...... 118 AGGRASTAT...... 69 ABILIFY MAINTENA...... 69 ACULAR...... 198 AGONEAZE...... 16 ABILIFY MYCITE ACULAR LS...... 198 AGRYLIN...... 80 MAINTENANCE KIT...... 70 ACUVAIL...... 198 AIMOVIG...... 49 ABILIFY MYCITE acyclovir...... 73 AJOVY...... 49 STARTER KIT...... 70 acyclovir sodium...... 73 ak-fluor...... 203 abiraterone acetate...... 52 ACZONE...... 110 AKOVAZ...... 86 ABRAXANE...... 52 ADACEL...... 177 ak-poly-bac...... 203 ABSORICA...... 110 ADAKVEO...... 184 AKTEN...... 203 ABSORICA LD...... 110 adapalene...... 110 AKYNZEO...... 43 ACACIA...... 183 ADASUVE...... 70 ala-cort...... 110 acamprosate calcium...... 20 adc/f (0.5mg/ml)...... 126 albendazole...... 66 acarbose...... 117 ADCETRIS...... 52 ALBENZA...... 66 ACCOLATE...... 211 ADCIRCA...... 216 ALBUKED 25...... 184 ACCU-CHEK FASTCLIX ADDERALL...... 102 ALBUKED 5...... 184 LANCET KIT...... 121 ADDERALL XR...... 102 albumin human...... 184 ACCU-CHEK SOFTCLIX adefovir dipivoxil...... 73 ALBUMINEX...... 184 LANCET DEVICE KIT...... 121 ADEMPAS...... 216 albumin-zlb...... 184 ACCUPRIL...... 86 ADENOCAINE...... 126 alburx...... 184 ACCURETIC...... 86 adenosine...... 86, 184 ALBUTEIN...... 184 accutane...... 110 adenosine (diagnostic)...... 184 albuterol sulfate...... 211 ACD FORMULA A...... 33 ADLYXIN...... 118 ALBUTEROL SULFATE... 211 ACD-A NOCLOT-50...... 33 ADLYXIN STARTER albuterol sulfate hfa...... 211 acebutolol hcl...... 86 PACK...... 118 ALCAINE...... 203 ACETADOTE...... 184 ADMELOG...... 122 alclometasone acetaminophen...... 8 ADMELOG SOLOSTAR... 122 dipropionate...... 110 ACETAMINOPHEN...... 8 ADRENAL C FORMULA...126 ALDACTAZIDE...... 86 acetaminophen-codeine...... 9 ADRENALIN...... 208, 211 ALDACTONE...... 86 acetaminophen-codeine #2.. 8 adriamycin...... 52 ALDER...... 184 acetaminophen-codeine #3.. 9 adult aspirin regimen...... 6 ALDURAZYME...... 146 acetaminophen-codeine #4.. 9 ADVAIR DISKUS...... 211 ALECENSA...... 52 acetazolamide...... 201 ADVAIR HFA...... 211 alendronate sodium...... 182 acetazolamide er...... 201 ADVATE...... 80 alfentanil hcl...... 9 acetazolamide sodium...... 86 ADYNOVATE...... 80 ALFERON N...... 170 acetic acid...... 148, 208 AEMCOLO...... 21 alfuzosin hcl er...... 151 acetylcysteine...... 184, 211 AEROCHAMBER MINI ALIMTA...... 52 ACIPHEX...... 141 CHAMBER...... 184 ALINIA...... 66 ACIPHEX SPRINKLE...... 141 AEROCHAMBER MV...... 184 ALIQOPA...... 52 acitretin...... 110 AEROCHAMBER PLUS aliskiren fumarate...... 86 ACNESIC...... 110 FLO-VU...... 184 ALKERAN...... 52 ACREMONIUM...... 184 AEROCHAMBER PLUS allopurinol...... 48 ACTEMRA...... 170 FLOW VU...... 184 allopurinol sodium...... 48 ACTEMRA ACTPEN...... 170 almotriptan malate...... 49 220 ALOCRIL...... 198 AMICAR...... 81 ana-lex...... 180 ALOGLIPTIN BENZOATE 118 AMIDATE...... 184 ANALPRAM HC...... 180 ALOGLIPTIN- amikacin sulfate...... 21 ANALPRAM HC SINGLES180 METFORMIN HCL...... 118 amiloride hcl...... 86 ANALPRAM-HC...... 180 ALOGLIPTIN- amiloride- ANASCORP...... 184 PIOGLITAZONE...... 118 hydrochlorothiazide...... 86 ANASPAZ...... 143 ALOMIDE...... 198 aminoamrms...... 126 anastrozole...... 52 ALOPRIM...... 48 aminocaproic acid...... 81 ANAVIP...... 184 ALORA...... 159 aminophylline...... 211 ANCOBON...... 45 alosetron hcl...... 142 aminoreliefrms...... 126 ANDEXXA...... 185 ALOXI...... 43 AMINOSYN II...... 126 ANDRODERM...... 154 ALPHAGAN P...... 201 AMINOSYN-PF...... 126 ANDROGEL...... 154 ALPHA-LIPOIC ACID...... 184 amiodarone hcl...... 86 ANDROGEL PUMP...... 154 ALPHANATE...... 80 AMIODARONE HCL IN ANECTINE...... 107 ALPHANINE SD...... 81 DEXTROSE...... 86 ANESTHESIA S/I-40A...... 185 alprazolam...... 78 AMITIZA...... 142 ANESTHESIA S/I-40H...... 185 alprazolam er...... 78 amitriptyline hcl...... 40 ANESTHESIA S/I-40S...... 185 alprazolam intensol...... 78 amlodipine besylate...... 86 ANGELIQ...... 159 alprazolam xr...... 78 amlodipine besylate- ANGIOMAX...... 33 ALPROLIX...... 81 benazepril hcl...... 86 ANIMI-3...... 126 alprostadil...... 86 amlodipine besylate- ANIMI-3/VITAMIN D...... 126 ALREX...... 198 valsartan...... 86 ANJESO...... 6 ALTABAX...... 21 amlodipine-atorvastatin...... 87 ANNOVERA...... 159 ALTACAINE...... 203 amlodipine-olmesartan...... 87 ANODYNE LPT...... 16 ALTACE...... 86 amlodipine-valsartan-hctz...87 ANORO ELLIPTA...... 212 altafrin...... 203 ammonium lactate...... 110 ANTARA...... 87 altavera...... 159 AMMONUL...... 146 ANTICOAGULANT ALTERNARIA...... 184 amnesteem...... 110 SODIUM CITRATE...... 33 ALTOPREV...... 86 AMONDYS 45...... 146 ANTIVENIN MICRURUS ALUNBRIG...... 52 amoxapine...... 40 FULVIUS...... 185 ALVESCO...... 211 amoxicill-clarithro- ANTIVERT...... 43 alvimopan...... 142 lansopraz...... 142 ANUSOL-HC...... 180 alyacen 1/35...... 159 amoxicillin...... 21 apap-caff-dihydrocodeine..... 9 alyacen 7/7/7...... 159 amoxicillin-potassium APIDRA SOLOSTAR...... 122 alyq...... 216 clavulanate...... 21, 22 APIDRA VIAL...... 122 amabelz...... 159 amoxicillin-potassium APLENZIN...... 40 amantadine hcl...... 67 clavulanate er...... 21 APOKYN...... 67 AMARYL...... 118 AMPHADASE...... 184 APO-VARENICLINE...... 20 AMBIEN...... 218 amphetamine sulfate...... 102 APP SLIM RMS...... 185 AMBIEN CR...... 218 amphetamine- apraclonidine hcl...... 201 AMBISOME...... 45 dextroamphetamine...... 102 aprepitant...... 43 ambrisentan...... 216 amphetamine- apri...... 160 amcinonide...... 110 dextroamphetamine er...... 102 APRISO...... 180 AMD FOAM DRESSING...184 amphotericin b...... 45 APTENSIO XR...... 102 AMD FOAM DRESSING ampicillin...... 22 APTIOM...... 35 TOPSHEET...... 184 ampicillin sodium...... 22 APTIVUS...... 73 AMERGE...... 49 ampicillin-sulbactam AQUACEL AG BURN...... 110 AMERICAN BEECH...... 184 sodium...... 22 AQUASOL A...... 126 AMERICAN COCKROACH AMVISC...... 203 ARAKODA...... 66 ...... 184 AMVISC PLUS...... 203 ARALAST NP...... 212 AMERICAN ELM...... 184 ANACAINE...... 110 aranelle...... 160 amethia...... 159 ANAFRANIL...... 40 ARANESP (ALBUMIN amethyst...... 159 anagrelide hcl...... 81 FREE)...... 81

221 ARAVA...... 170 ASPERGILLUS AVONEX PEN...... 105 ARCALYST...... 170 FUMIGATUS...... 185 AVONEX PREFILLED...... 105 ARESTIN...... 108 aspirin...... 6 AVSOLA...... 170 arformoterol tartrate...... 212 aspirin adult low strength...... 6 AVYCAZ...... 22 argatroban...... 33 aspirin childrens...... 6 AYGESTIN...... 160 argatroban in sodium aspirin ec low dose...... 6 ayuna...... 160 chloride...... 33 aspirin ec low strength...... 6 AYVAKIT...... 53 ARGININE HCL...... 126 aspirin low dose...... 6 azacitidine...... 53 argyle sterile saline...... 126 aspirin-dipyridamole er...... 69 AZACTAM...... 22 argyle sterile water...... 126 ASTAGRAF XL...... 170 AZASAN...... 170 ARICEPT...... 40 ASTRINGYN...... 81 AZASITE...... 198 ARIKAYCE...... 22 ATABEX OB...... 126 azathioprine...... 170 ARIMIDEX...... 52 ATACAND...... 87 azathioprine sodium...... 170 aripiprazole...... 70 ATACAND HCT...... 87 AZEDRA DOSIMETRIC...... 53 ARISTADA...... 70 atazanavir sulfate...... 73 AZEDRA THERAPEUTIC...53 ARISTADA INITIO...... 70 ATELVIA...... 182 azelaic acid...... 110 ARIXTRA...... 33 atenolol...... 87 azelastine hcl...... 198, 208 ARIZONA CYPRESS...... 185 atenolol-chlorthalidone...... 87 AZELEX...... 110 armodafinil...... 219 ATGAM...... 170 AZILECT...... 67 ARMOUR THYROID...... 169 ATIVAN...... 78 azithromycin...... 22 arnica flower...... 185 atomoxetine hcl...... 102 AZOPT...... 201 ARNUITY ELLIPTA...... 212 atorvastatin calcium...... 87 AZOR...... 87 AROMASIN...... 52 atovaquone...... 66 AZSTARYS...... 219 ARRANON...... 52 atovaquone-proguanil hcl... 66 aztreonam...... 22 arsenic trioxide...... 53 atracurium besylate...... 107 AZULFIDINE...... 181 ARTESUNATE...... 66 ATRIPLA...... 73 AZULFIDINE EN-TABS.... 180 ARTHROTEC...... 6 atropine sulfate. 143, 203, 204 azurette...... 160 ARTICADENT DENTAL...... 16 ATROPINE SULFATE b-6 folic acid...... 126 ARTISS...... 185 ...... 143, 203 bac...... 9 ARZERRA...... 53 ATROVENT HFA...... 212 bacitracin...... 22, 198 ARZOL SILVER NIT AUBAGIO...... 105 bacitracin-polymyxin b...... 204 APPLICATORS...... 110 aubra...... 160 bacitra-neomycin- ASACOL HD...... 180 aubra eq...... 160 polymyxin-hc...... 204 ASCENIV...... 170 AUGMENTIN...... 22 baclofen...... 217 ASCLERA...... 87 AUGMENTIN ES-600...... 22 BACMIN...... 126 ascomp-codeine...... 9 AUREOBASIDIUM...... 185 BACTERIOSTATIC ASCOR...... 126 AUREOBASIDIUM WATER(BENZ ALC)...... 185 ASCORBIC ACID...... 126 PULLULANS...... 185 BACTRIM...... 22 asenapine maleate...... 70 aurovela 1.5/30...... 160 BACTRIM DS...... 22 ashlyna...... 160 aurovela 1/20...... 160 BAFIERTAM...... 105 ASMANEX (120 aurovela 24 fe...... 160 BAHIA...... 185 METERED DOSES)...... 212 aurovela fe 1.5/30...... 160 bal in oil...... 185 ASMANEX (14 METERED aurovela fe 1/20...... 160 balanced salt...... 204 DOSES)...... 212 AURYXIA...... 148 BALCOLTRA...... 160 ASMANEX (30 METERED AUSTEDO...... 107 BALD CYPRESS...... 185 DOSES)...... 212 AUSTRALIAN PINE...... 185 balsalazide disodium...... 181 ASMANEX (60 METERED AUTOLET II CLINISAFE...121 balsam peru-castor oil...... 110 DOSES)...... 212 AVALIDE...... 87 BALVERSA...... 53 ASMANEX (7 METERED AVAPRO...... 87 balziva...... 160 DOSES)...... 212 AVASTIN...... 53 BANZEL...... 35 ASMANEX HFA...... 212 aviane...... 160 BAQSIMI ONE PACK...... 122 ASPARLAS...... 53 avidoxy...... 22 BAQSIMI TWO PACK...... 122 AVODART...... 151 BARACLUDE...... 73

222 BARHEMSYS...... 43 betamethasone BLACK WILLOW...... 185 BAVENCIO...... 53 dipropionate aug...... 111 BLENREP...... 53 BAXDELA...... 22 betamethasone sod phos bleomycin sulfate...... 53 BAYBERRY (WAX & acet...... 152 BLEPH-10...... 199 MYRTLE)...... 185 BETAMETHASONE SOD BLEPHAMIDE...... 204 BAYER ASPIRIN EC LOW PHOS & ACET...... 152 BLEPHAMIDE S.O.P...... 204 DOSE...... 6 BETAMETHASONE BLINCYTO...... 53 BCG VACCINE...... 177 SODIUM PHOSPHATE.... 152 blisovi 24 fe...... 160 BD AUTOSHIELD DUO betamethasone valerate... 111 blisovi fe 1.5/30...... 160 PEN NEEDLES...... 122 BETAPACE...... 87 blisovi fe 1/20...... 160 BD ULTRA-FINE INSULIN BETAPACE AF...... 87 BLOXIVERZ...... 51 SYRINGES...... 122 BETASERON...... 105 BOCASAL...... 108 BD ULTRA-FINE PEN betaxolol hcl...... 87, 201 BONIVA...... 182 NEEDLES...... 123 bethanechol chloride...... 148 BOOSTRIX...... 178 BD VEO INSULIN SYR BETHKIS...... 215 BORTEZOMIB...... 53 U/F 1/2UNIT...... 123 BETIMOL...... 201 bosentan...... 216 BECONASE AQ...... 208 BETOPTIC-S...... 201 BOSULIF...... 53 BELBUCA...... 9 BEVACIZUMAB...... 204 BOTOX...... 185 BELEODAQ...... 53 BEVYXXA...... 33 BOTRYTIS...... 185, 186 belladonna alkaloids-opium bexarotene...... 53 bp 10-1...... 111 ...... 143 BEXSERO...... 177 BP CLEANSING WASH... 111 BELRAPZO...... 53 BEYAZ...... 160 bp vit 3...... 126 BELSOMRA...... 219 bicalutamide...... 53 BPCO...... 111 benazepril hcl...... 87 BICILLIN C-R...... 23 b-plex...... 126 benazepril- BICILLIN C-R 900/300...... 23 b-plex plus...... 126 hydrochlorothiazide...... 87 BICILLIN L-A...... 23 BRAFTOVI...... 53 BENDEKA...... 53 BICNU...... 53 BREATHE EASE LARGE. 186 BENEFIX...... 81 BIDIL...... 87 BREATHE EASE MEDIUM BENICAR...... 87 BIKTARVY...... 73 ...... 186 BENICAR HCT...... 87 BILTRICIDE...... 66 BREATHE EASE SMALL. 186 BENLYSTA...... 170 bimatoprost...... 201 BREO ELLIPTA...... 212 BENSAL HP...... 111 BI-MIX...... 149 BREVIBLOC...... 88 BENTYL...... 143 BINOSTO...... 182 BREVIBLOC IN NACL...... 87 benzalkonium chloride...... 23 biocel...... 126 BREVIBLOC PREMIXED... 88 BENZNIDAZOLE...... 66 BIOFREQUENCY BREVIBLOC PREMIXED benzoin...... 111 INSOLES...... 185 DS...... 88 benzoin compound...... 111 BIOGUARD GAUZE BREVITAL SODIUM...... 186 benzonatate...... 208 SPONGES...... 185 BREYANZI...... 53 benztropine mesylate...... 67 BIOGUARD ISLAND BREZTRI AEROSPHERE 212 BEOVU...... 204 DRESSINGS...... 185 BRIDION...... 186 bepotastine besilate...... 198 BIOGUARD NON- briellyn...... 160 BEPREVE...... 199 ADHERENT DRESSING.. 185 BRILINTA...... 69 BERINERT...... 171 BIOPAR DELTA-FORTE.. 126 brimonidine tartrate...... 202 BERMUDA GRASS...... 185 BIORPHEN...... 87 BRIMONIDINE- beser...... 111 BIOTHRAX...... 177 DORZOLAMIDE...... 202 BESIVANCE...... 199 bisoprolol fumarate...... 87 BRINEURA...... 146 BESPONSA...... 53 bisoprolol- brinzolamide...... 202 BETADINE OPHTHALMIC hydrochlorothiazide...... 87 BRIVIACT...... 35 PREP...... 199 BIVALIRUDIN RTU...... 33 BROME...... 186 BETAMETHASONE bivalirudin trifluoroacetate...33 bromfenac sodium (once- COMBO...... 152 BIVALIRUDIN-SODIUM daily)...... 199 betamethasone CHLORIDE...... 33 bromocriptine mesylate...... 67 dipropionate...... 111 BIVIGAM...... 171 BROMSITE...... 199

223 BRONCHITOL...... 215 BYLVAY (PELLETS)...... 186 carbidopa...... 67 BRONCHITOL BYSTOLIC...... 88 carbidopa-levodopa...... 67 TOLERANCE TEST...... 216 CABENUVA...... 73 carbidopa-levodopa er...... 67 BROVANA...... 212 cabergoline...... 155 carbidopa-levodopa- BRUKINSA...... 54 CABLIVI...... 69 entacapone...... 67 BSS...... 204 CABOMETYX...... 54 carbinoxamine maleate.....208 bss plus...... 204 CADUET...... 88 CARBOCAINE...... 16 BSS PLUS...... 204 CAFCIT...... 107 CARBOCAINE budesonide...... 181, 208, 212 CAFERGOT...... 49 PRESERVATIVE-FREE..... 16 budesonide er...... 181 caffeine citrate...... 107 carboplatin...... 54 bumetanide...... 88 CALAN SR...... 88 carboprost tromethamine..155 BUMEX...... 88 CALCIFOL...... 127 CARDENE IV...... 88 BUNAVAIL...... 20 calcipotriene...... 111 CARDIOPLEGIA DEL BUPAP...... 9 calcipotriene-betameth NIDO FORMULA...... 127 BUPHENYL...... 146 diprop...... 111 CARDIOPLEGIA IND bupivacaine fisiopharma..... 16 calcitonin (salmon)...... 182 PLASMA HIGH K...... 127 BUPIVACAINE HCL...... 16 calcitriol...... 111, 183 CARDIOPLEGIA IND bupivacaine hcl...... 16 calcium acetate...... 149 PLASMA-TROMET...... 127 bupivacaine hcl (pf)...... 16 calcium acetate (phos CARDIOPLEGIA BUPIVACAINE HCL-NACL.16 binder)...... 149 INDUCTION HIGH K...... 127 bupivacaine in dextrose...... 16 calcium chloride...... 127 CARDIOPLEGIA bupivacaine spinal...... 16 CALCIUM CHLORIDE...... 127 INDUCTION LOW DEX.... 127 bupivacaine-epinephrine.....16 CALCIUM DISODIUM CARDIOPLEGIA bupivacaine-epinephrine VERSENATE...... 186 INDUCTION NON-ENR.... 127 (pf)...... 16 CALCIUM GLUCONATE- CARDIOPLEGIA MAIN BUPRENEX...... 9 NACL...... 127 LOW DEXTROSE...... 127 buprenorphine...... 9 CALCIUM-FOLIC ACID CARDIOPLEGIA MAIN buprenorphine hcl...... 9, 20 PLUS D...... 127 LOW TROMETHA...... 127 buprenorphine hcl- CALDOLOR...... 6 CARDIOPLEGIA MAIN naloxone hcl...... 20 CALIFORNIA PEPPER PLASMA-TROME...... 127 bupropion hcl...... 41 TREE...... 186 CARDIOPLEGIA bupropion hcl er (smoking CALQUENCE...... 54 MAINTENANCE...... 127 det)...... 20 CAMBIA...... 6 CARDIOPLEGIA bupropion hcl er (sr)...... 40 camila...... 160 REPERFUSATE 4:1...... 127 bupropion hcl er (xl)...... 41 CAMPTOSAR...... 54 CARDIOPLEGIC...... 127 buspirone hcl...... 78 camrese...... 160 cardioplegic...... 127 busulfan...... 54 camrese lo...... 160 CARDIZEM...... 88 BUSULFEX...... 54 CANASA...... 181 CARDIZEM CD...... 88 butalbital-acetaminophen...... 9 CANCIDAS...... 45 CARDIZEM LA...... 88 BUTALBITAL- candesartan cilexetil...... 88 CARDURA...... 88 ACETAMINOPHEN...... 9 candesartan cilexetil-hctz... 88 CARDURA XL...... 151 butalbital-apap-caff-cod...... 9 CANDIDA ALBICANS carisoprodol...... 217 butalbital-apap-caffeine...... 9 EXTRACT...... 186 carisoprodol-aspirin- butalbital-asa-caff-codeine....9 CAPASTAT SULFATE...... 51 codeine...... 9 butalbital-aspirin-caffeine...... 9 capecitabine...... 54 carmustine...... 54 butorphanol tartrate...... 9 CAPLYTA...... 70 CARNITOR...... 127 BUTRANS...... 9 CAPRELSA...... 54 CARNITOR SF...... 127 BYDUREON BCISE captopril...... 88 carteolol hcl...... 202 AUTOINJECTOR...... 118 CARAFATE...... 141 cartia xt...... 88 BYETTA 10 MCG PEN..... 118 CARBAGLU...... 127 carvedilol...... 88 BYETTA 5 MCG PEN...... 118 carbamazepine...... 35 carvedilol phosphate er...... 88 BYFAVO...... 78 carbamazepine er...... 35 CASODEX...... 54 BYLVAY...... 186 CARBATROL...... 35 caspofungin acetate...... 45

224 CAT HAIR EXTRACT...... 186 CENTANY AT...... 24 cimetidine...... 141 CATAFLAM...... 6 CENTRATEX...... 127 cimetidine hcl...... 141 CATAPRES-TTS-1...... 88 cephalexin...... 24, 25 CIMZIA...... 171 CATAPRES-TTS-2...... 88 CEPROTIN...... 81 CIMZIA PREFILLED KIT.. 171 CATAPRES-TTS-3...... 89 CERDELGA...... 146 CIMZIA STARTER KIT..... 171 CATHFLO ACTIVASE...... 33 CEREBYX...... 35 cinacalcet hcl...... 183 CATTLE EPITHELIUM..... 186 CEREZYME...... 146 CINQAIR...... 208 cavarest...... 108 cerovel...... 111 CINRYZE...... 171 CAYA...... 186 CERVIDIL...... 149 CINVANTI...... 43 CAYSTON...... 216 CETACAINE...... 16 CIPRO...... 25 caziant...... 160 CETRAXAL...... 208 CIPRO HC...... 208 CEDAR ELM...... 186 CETROTIDE...... 155 CIPRODEX...... 208 cefaclor...... 23 cevimeline hcl...... 108 ciprofloxacin hcl.. 25, 199, 208 cefaclor er...... 23 CHANTIX...... 20 ciprofloxacin in d5w...... 25 cefadroxil...... 23 CHANTIX CONTINUING ciprofloxacin- CEFAZOLIN IN SODIUM MONTH PAK...... 20 dexamethasone...... 208 CHLORIDE...... 23 CHANTIX STARTING CIPROFLOXACIN- cefazolin sodium...... 23 MONTH PAK...... 20 FLUOCINOLONE PF...... 208 CEFAZOLIN SODIUM...... 23 charlotte 24 fe...... 160 cisatracurium besylate...... 107 cefazolin sodium-dextrose.. 23 chateal...... 160 cisatracurium besylate (pf)107 CEFAZOLIN SODIUM- chateal eq...... 160 cisplatin...... 54 DEXTROSE...... 23 CHEMET...... 127 citalopram hydrobromide.... 41 cefdinir...... 23 CHENODAL...... 143 CITRANATAL MEDLEY....127 cefepime hcl...... 23 CHIRHOSTIM...... 186 CLADOSPORIUM cefepime-dextrose...... 23 chloramphenicol sod CLADOSPORIOIDES...... 186 cefixime...... 23, 24 succinate...... 25 CLADOSPORIUM CEFOTAN...... 24 chlordiazepoxide hcl...... 78 SPHAEROSPERMUM...... 186 cefotaxime sodium...... 24 chlordiazepoxide- cladribine...... 54 cefotetan disodium...... 24 amitriptyline...... 41 claravis...... 111 cefotetan disodium- chlordiazepoxide-clidinium143 clarithromycin...... 25 dextrose...... 24 chlorhexidine gluconate.... 108 clarithromycin er...... 25 cefoxitin sodium...... 24 CHLORHEXIDINE clearlax...... 143 CEFOXITIN SODIUM- GLUCONATE...... 186 clemastine fumarate...... 208 DEXTROSE...... 24 chloroprocaine hcl (pf)...... 16 CLENPIQ...... 143 cefpodoxime proxetil...... 24 chloroquine phosphate...... 66 CLEOCIN...... 25 cefprozil...... 24 chlorothiazide sodium...... 89 CLEOCIN PHOSPHATE.....25 ceftazidime...... 24 chlorpromazine hcl...... 70 CLEVER CHOICE ceftazidime and dextrose....24 chlorthalidone...... 89 HOLDING CHAMBER...... 187 ceftriaxone sodium...... 24 chlorzoxazone...... 217 CLEVIPREX...... 89 ceftriaxone sodium in CHOLBAM...... 146 CLIMARA...... 160 dextrose...... 24 cholestyramine...... 89 CLIMARA PRO...... 160 ceftriaxone sodium- cholestyramine light...... 89 clindacin etz...... 111 dextrose...... 24 chorionic gonadotropin..... 155 clindacin-p...... 111 cefuroxime axetil...... 24 CHROMAGEN...... 127 clindamycin hcl...... 25 cefuroxime sodium...... 24 chromic chloride...... 127 clindamycin palmitate hcl....25 CELEBREX...... 6 CIALIS...... 149 clindamycin phosphate25, 111 celecoxib...... 6 ciclodan...... 45 clindamycin phosphate in CELESTONE SOLUSPAN152 ciclopirox...... 45 d5w...... 25 CELEXA...... 41 ciclopirox olamine...... 45 CLINDESSE...... 25 CELLCEPT...... 171 cidofovir...... 73 CLINIMIX E/DEXTROSE CELLCEPT cilostazol...... 69 (2.75/5)...... 127 INTRAVENOUS...... 171 CILOXAN...... 199 CLINIMIX E/DEXTROSE CELONTIN...... 35 CIMDUO...... 73 (4.25/10)...... 128

225 CLINIMIX E/DEXTROSE clozapine...... 70 CORTIFOAM...... 181 (4.25/5)...... 128 CLOZARIL...... 70 CORTISPORIN-TC...... 208 CLINIMIX E/DEXTROSE COAGADEX...... 81 CORTROSYN...... 187 (5/15)...... 128 coal tar...... 112 CORVERT...... 89 CLINIMIX E/DEXTROSE COARTEM...... 66 CORVITA...... 128 (5/20)...... 128 COCAINE HCL...... 16 corvita 150...... 128 CLINIMIX E/DEXTROSE COCKLEBUR...... 187 CORVITE 150...... 128 (8/10)...... 128 cod liver oil...... 128 CORVITE FE...... 128 CLINIMIX E/DEXTROSE codeine sulfate...... 10 COSELA...... 54 (8/14)...... 128 COENZYME Q-10...... 187 COSENTYX (300 MG CLINIMIX/DEXTROSE COGENTIN...... 68 DOSE)...... 171 (4.25/10)...... 128 COLAZAL...... 181 COSENTYX 150 MG/ML.. 171 CLINIMIX/DEXTROSE COLCHICINE...... 48 COSENTYX (4.25/5)...... 128 colchicine...... 48 SENSOREADY (300 MG).171 CLINIMIX/DEXTROSE colchicine-probenecid...... 48 COSENTYX (5/15)...... 128 COLCRYS...... 48 SENSOREADY PEN...... 171 CLINIMIX/DEXTROSE colesevelam hcl...... 89 COSMEGEN...... 54 (5/20)...... 128 COLESTID...... 89 COSOPT...... 202 CLINIMIX/DEXTROSE COLESTID FLAVORED..... 89 COSOPT PF...... 202 (6/5)...... 128 colestipol hcl...... 89 cosyntropin...... 187 CLINIMIX/DEXTROSE colistimethate sodium COTELLIC...... 54 (8/10)...... 128 (cba)...... 25 COZAAR...... 89 CLINIMIX/DEXTROSE COLY-MYCIN M...... 25 CREON...... 146 (8/14)...... 128 COMBIGAN...... 202 CRESEMBA...... 46 CLINISOL SF...... 128 COMBIPATCH...... 160 CRESTOR...... 89 CLINOLIPID...... 128 COMBIVENT RESPIMAT. 212 CRINONE...... 160 CLINPRO 5000...... 108 COMBIVIR...... 73 CRIXIVAN...... 73 clobazam...... 35 COMETRIQ...... 54 CROFAB...... 187 clobetasol prop emollient COMPACT SPACE cromolyn sodium base...... 111 CHAMBER...... 187 ...... 143, 199, 212 clobetasol propionate111, 112 COMPACT SPACE crotan...... 66 clobetasol propionate e.....111 CHAMBER/LG MASK...... 187 cryselle-28...... 160 clobetasol propionate COMPACT SPACE CRYSVITA...... 146 emulsion...... 111 CHAMBER/MED MASK....187 CUBICIN...... 25 clocortolone pivalate...... 112 COMPACT SPACE CUBICIN RF...... 25 clodan...... 112 CHAMBER/SM MASK...... 187 CUPRIC CHLORIDE...... 128 CLODERM...... 112 COMPLERA...... 73 CURITY AMD clofarabine...... 54 compro...... 44 ANTIMICROBIAL SPNGE 187 CLOLAR...... 54 COMTAN...... 68 CURITY AMD clomiphene citrate...... 155 CONCERTA...... 102 ANTIMICROBIAL STRIP.. 187 clomipramine hcl...... 41 CONDYLOX...... 112 CURITY IODOFORM clonazepam...... 78 constulose...... 143 PACKING STRIP...... 187 clonidine...... 89 COPIKTRA...... 54 curity sterile saline...... 128 clonidine hcl...... 89 CORDRAN...... 112 CUROSURF...... 208 clonidine hcl (analgesia)..... 10 COREG...... 89 CURVULARIA...... 187 clonidine hcl er...... 102 COREG CR...... 89 CUTAQUIG...... 171 clopidogrel bisulfate...... 69 CORGARD...... 89 CUVITRU...... 171 clorazepate dipotassium..... 78 CORIFACT...... 81 CUVPOSA...... 143 CLOROTEKAL...... 16 CORLANOR...... 89 cyanocobalamin...... 128 clotrimazole...... 45 CORLOPAM...... 89 CYANOCOBALAMIN...... 128 clotrimazole- CORN POLLEN...... 187 CYANOKIT...... 187 betamethasone...... 45 CORTEF...... 152 cyclafem 1/35...... 160 clovique...... 128 CORTENEMA...... 181 cyclafem 7/7/7...... 161

226 cyclobenzaprine hcl...... 217 DAYPRO...... 6 DERMACINRX RIBOTIN-E CYCLOGYL...... 204 daysee...... 161 ...... 129 CYCLOMYDRIL...... 204 DAYTRANA...... 102 DERMACINRX cyclopentolate hcl...... 204 DAYVIGO...... 219 ZINTREXYL-C...... 129 cyclophosphamide...... 54 DDAVP...... 155 DERMOTIC...... 208 CYCLOPHOSPHAMIDE.....54 DDAVP PF...... 155 DESCOVY...... 73 cycloserine...... 51 DEBACTEROL...... 108 DESFERAL...... 187 CYCLOSET...... 118 deblitane...... 161 desipramine hcl...... 41 cyclosporine...... 171 DECADRON...... 152 desloratadine...... 209 CYCLOSPORINE IN DECARA...... 128 desmopressin ace spray KLARITY...... 204 decitabine...... 55 refrig...... 155 cyclosporine modified...... 171 deferasirox...... 128, 129 desmopressin acetate...... 155 CYKLOKAPRON...... 81 deferasirox granules...... 128 DESMOPRESSIN CYMBALTA...... 41 deferiprone...... 129 ACETATE...... 155 cyproheptadine hcl....208, 209 deferoxamine mesylate.....187 desmopressin acetate pf...155 CYRAMZA...... 54 DEFITELIO...... 69 desmopressin acetate cyred...... 161 DEFLUX...... 187 spray...... 156 cyred eq...... 161 DEFLUX METAL NEEDLE187 desogestrel-ethinyl CYSTADANE...... 146 DELESTROGEN...... 161 estradiol...... 161 CYSTADROPS...... 204 DELFLEX-LC/1.5% desonide...... 112 CYSTAGON...... 146 DEXTROSE...... 129 desoximetasone...... 112 CYSVIEW...... 187 DELFLEX-LC/2.5% DESOXYN...... 102 cytarabine...... 55 DEXTROSE...... 129 desrx...... 112 cytarabine (pf)...... 54 DELFLEX-LC/4.25% DESVENLAFAXINE ER...... 41 CYTOGAM...... 171 DEXTROSE...... 129 desvenlafaxine succinate CYTOMEL...... 169 DELFLEX-SM/1.5% er...... 41 CYTOTEC...... 141 DEXTROSE...... 129 DETROL...... 149 cytra k crystals...... 128 DELFLEX-SM/2.5% DETROL LA...... 149 D.H.E. 45...... 49 DEXTROSE...... 129 DEXAMETH SOD PHOS- dacarbazine...... 55 DELSTRIGO...... 73 BUPIV-EPIN...... 152 DACOGEN...... 55 delyla...... 161 dexamethasone...... 152 dactinomycin...... 55 DELZICOL...... 181 dexamethasone intensol...152 dalfampridine er...... 105 demeclocycline hcl...... 26 DEXAMETHASONE SOD DALIRESP...... 212 DEMEROL...... 10 PHOS-NACL...... 152 DALVANCE...... 26 DEMSER...... 89 dexamethasone sod danazol...... 154 DENAVIR...... 73 phosphate pf...... 152 DANDELION...... 187 DENTA 5000 PLUS...... 108 dexamethasone sodium DANTRIUM...... 217 DENTAGEL...... 108 phosphate...... 152, 153, 199 dantrolene sodium...... 218 DEPAKOTE...... 35 DEXAMETHASONE DANYELZA...... 55 DEPAKOTE ER...... 35 SODIUM PHOSPHATE.... 153 dapsone...... 51, 112 DEPAKOTE SPRINKLES... 36 DEXAMETHASONE- DAPTACEL...... 178 DEPEN TITRATABS...... 149 MOXIFLOXACIN...... 204 daptomycin...... 26 DEPO-ESTRADIOL...... 161 DEXAMETH-MOXIFLOX- DARAPRIM...... 66 DEPO-MEDROL...... 152 KETOROLAC...... 204 darifenacin hydrobromide DEPO-PROVERA...... 161 dexchlorpheniramine er...... 149 DEPO-SUBQ PROVERA maleate...... 209 DARZALEX...... 55 104...... 161 DEXCOM G4 / G5 / G6 DARZALEX FASPRO...... 55 DEPO-TESTOSTERONE. 154 RECEIVER, dasetta 1/35...... 161 DERMACINRX LIDOGEL... 16 TRANSMITTER, SENSOR dasetta 7/7/7...... 161 DERMACINRX (INCLUDING PLATINUM, daunorubicin hcl...... 55 PRETRATE...... 129 PLATINUM PEDIATRIC).. 121 DAURISMO...... 55 DEXEDRINE...... 102 DAYAVITE...... 128 DEXIFOL...... 129

227 DEXILANT...... 141 diclofenac potassium...... 6 DIURIL...... 90 DEXMEDETOMIDINE HCL diclofenac sodium. 6, 112, 199 divalproex sodium...... 36 ...... 188 diclofenac sodium er...... 6 divalproex sodium er...... 36 dexmedetomidine hcl...... 188 diclofenac-misoprostol...... 6 DIVIGEL...... 161 dexmedetomidine hcl in DICLOSTREAM...... 6 dobutamine hcl...... 90 nacl...... 187 dicloxacillin sodium...... 26 dobutamine in d5w...... 90 DEXMEDETOMIDINE HCL dicyclomine hcl...... 143 docetaxel...... 55 IN NACL...... 187 DIFICID...... 26 dofetilide...... 90 DEXMEDETOMIDINE diflorasone diacetate...... 112 DOG EPITHELIUM...... 188 HCL-DEXTROSE...... 188 DIFLUCAN...... 46 DOG FENNEL...... 188 dexmethylphenidate hcl.... 102 diflunisal...... 6 dolishale...... 161 dexmethylphenidate hcl er 102 DIGIFAB...... 188 donepezil hcl...... 40 DEXONTO 0.4%...... 153 digitek...... 90 dopamine hcl...... 91 dexrazoxane hcl...... 55 digox...... 90 dopamine in d5w...... 91 dextroamphetamine sulfate digoxin...... 90 DOPRAM...... 107 ...... 103 dihydroergotamine DOPTELET...... 81 dextroamphetamine sulfate mesylate...... 49 DORAL...... 79 er...... 103 DILANTIN...... 36 DORZOLAMIDE HCL...... 202 dextrose...... 129 DILANTIN INFATABS...... 36 dorzolamide hcl...... 202 DEXTROSE...... 129 DILATRATE-SR...... 90 dorzolamide hcl-timolol mal DEXTROSE DILAUDID...... 10 ...... 202 5%/ELECTROLYTE #48...129 diltiazem hcl...... 90 dorzolamide hcl-timolol mal dextrose in lactated ringers diltiazem hcl er...... 90 pf...... 202 ...... 129 diltiazem hcl er beads...... 90 dotti...... 161 dextrose-nacl...... 129 diltiazem hcl er coated DOVATO...... 73 dextrose-sodium chloride..129 beads...... 90 doxazosin mesylate...... 91 DEXYCU...... 199 DILTIAZEM HCL-SODIUM doxepin hcl...... 41, 112, 219 DIACOMIT...... 36 CHLORIDE...... 90 doxercalciferol...... 183 DIALYVITE...... 129 dilt-xr...... 90 DOXIL...... 55 DIALYVITE 3000...... 129 DILUENT FOR doxorubicin hcl...... 55 DIALYVITE 5000...... 129 LEFAMULIN...... 130 doxorubicin hcl liposomal....55 DIALYVITE SUPREME D. 129 diluent for treprostinil...... 188 doxy 100...... 26 DIALYVITE/ZINC...... 129 dimenhydrinate...... 44 doxycycline hyclate...... 26 DIANEAL LOW DIMENTHO...... 6 doxycycline monohydrate... 26 CALCIUM/1.5% DEX...... 129 DIMERCAPTOPROPANE- DRECHSLERA...... 188 DIANEAL LOW SULFONATE...... 188 DRISDOL...... 130 CALCIUM/2.5% DEX...... 129 dimethyl fumarate...... 105 DRITHO-CREME HP...... 112 DIANEAL LOW dimethyl fumarate starter dronabinol...... 44 CALCIUM/4.25% DEX...... 130 pack...... 105 droperidol...... 44 DIANEAL PD-2/1.5% DIOVAN...... 90 DROPERIDOL...... 44 DEXTROSE...... 130 DIOVAN HCT...... 90 DROPLET MICRON...... 123 DIANEAL PD-2/2.5% DIPENTUM...... 181 drospiren-eth estrad- DEXTROSE...... 130 diphen...... 209 levomefol...... 161 DIANEAL PD-2/4.25% di-phen...... 209 drospirenone-ethinyl DEXTROSE...... 130 diphenhydramine hcl...... 209 estradiol...... 161 DIASTAT ACUDIAL...... 36 diphenoxylate-atropine..... 143 DROXIA...... 55 DIASTAT PEDIATRIC...... 36 DIPHTHERIA-TETANUS droxidopa...... 91 diazepam...... 36, 78 TOXOIDS DT...... 178 DRYSOL...... 112 DIAZEPAM...... 78 DIPRIVAN...... 188 DSUVIA...... 10 diazepam intensol...... 78 dipyridamole...... 69, 188 DUAVEE...... 161 diazoxide...... 122 disopyramide phosphate.....90 DUETACT...... 118 DIBENZYLINE...... 90 disulfiram...... 20 DULERA...... 212 DICLOFENAC PATCH...... 6 DITROPAN XL...... 149 duloxetine hcl...... 41

228 DUODOTE...... 188 ELIXOPHYLLIN...... 213 EPCLUSA...... 74 DUOVISC...... 204 ELLA...... 161 ephedrine sulfate...... 91 DUPIXENT...... 112 ELLENCE...... 55 EPHEDRINE SULFATE...... 91 DURACLON...... 10 ELLIOTTS B...... 130 EPHEDRINE SULFATE duramorph...... 10 ELMIRON...... 149 (PRESSORS)...... 91 DUREZOL...... 199 ELOCTATE...... 82 EPICOCCUM...... 188 DUROLANE...... 188 eluryng...... 161 EPICOCCUM NIGRUM.... 188 DURYSTA...... 202 ELZONRIS...... 55 EPIDIOLEX...... 36 DUST MITE MIXED EMCYT...... 55 EPIFOAM...... 112 ALLERGEN EXT...... 188 EMEND...... 44 epinastine hcl...... 199 dutasteride...... 151 EMEND TRI-PACK...... 44 EPINEPHRINE...... 91, 92 dutasteride-tamsulosin hcl 151 EMERPHED...... 91 epinephrine...... 91, 213 DUTOPROL...... 91 EMFLAZA...... 48, 49 epinephrine (anaphylaxis).213 DYANAVEL XR...... 103 EMGALITY...... 49 EPINEPHRINE HCL...... 202 DYRENIUM...... 91 EMGALITY (300 MG EPINEPHRINE HCL- DYSPORT...... 188 DOSE)...... 49 DEXTROSE...... 91 E.E.S. 400...... 26 emoquette...... 161 EPINEPHRINE HCL-NACL 91 E.E.S. GRANULES...... 26 EMPAVELI...... 82 epinephrine pf...... 91 EASIVENT...... 188 EMPLICITI...... 55 EPINEPHRINE- EASTERN EMSAM...... 41 DEXTROSE...... 92 COTTONWOOD...... 188 emtricitabine...... 73 EPINEPHRINE-NACL...... 92 easygel...... 108 emtricitabine-tenofovir df.... 73 EPIPEN 2-PAK...... 213 EC-NAPROSYN...... 6 EMTRIVA...... 73, 74 EPIPEN JR 2-PAK...... 213 ec-naproxen...... 7 EMVERM...... 66 epirubicin hcl...... 55 econazole nitrate...... 46 enalapril maleate...... 91 epitol...... 36 EC-RX PROGESTERONE161 enalaprilat...... 91 EPIVIR...... 74 EDARBI...... 91 enalapril- EPIVIR HBV...... 74 EDARBYCLOR...... 91 hydrochlorothiazide...... 91 eplerenone...... 92 EDECRIN...... 91 ENBRACE HR...... 130 EPOGEN...... 82 ED-SPAZ...... 143 ENBREL...... 171, 172 epoprostenol sodium...... 216 EDURANT...... 73 ENBREL MINI...... 171 eptifibatide...... 69 efavirenz...... 73 ENBREL SURECLICK...... 172 EPZICOM...... 74 efavirenz-emtricitab- ENCARE...... 188 EQUETRO...... 80 tenofovir...... 73 ENDARI...... 188 ERAXIS...... 46 efavirenz-lamivudine- endocet...... 10 ERBITUX...... 56 tenofovir...... 73 ENDOMETRIN...... 161 ergocalciferol...... 130 EFFER-K...... 130 ENGERIX-B...... 178 ergoloid mesylates...... 188 effer-k...... 130 ENHERTU...... 55 ERGOMAR...... 49 EFFEXOR XR...... 41 ENOVARX-IBUPROFEN...... 7 ergotamine-caffeine...... 49 EFFIENT...... 69 enoxaparin sodium...... 33 ERIVEDGE...... 56 EGRIFTA SV...... 156 enpresse-28...... 161 ERLEADA...... 56 ELAPRASE...... 147 enskyce...... 162 erlotinib hcl...... 56 ELELYSO...... 147 ENSPRYNG...... 172 errin...... 162 ELESTRIN...... 161 entacapone...... 68 ERTACZO...... 46 eletriptan hydrobromide...... 49 entecavir...... 74 ertapenem sodium...... 26 ELIDEL...... 112 ENTEREG...... 143 ERWINASE...... 56 ELIGARD...... 156 ENTOCORT EC...... 181 ery...... 112 elinest...... 161 ENTRESTO...... 91 ERYPED 200...... 26 ELIQUIS...... 33 ENTYVIO...... 172 ERYPED 400...... 26 ELIQUIS DVT/PE enulose...... 143 ERY-TAB...... 26 STARTER PACK...... 33 ENVARSUS XR...... 172 ERYTHROCIN ELITEK...... 55 ENZADYNE...... 147 LACTOBIONATE...... 26 ELITE-OB...... 130 EPANED...... 91

229 ERYTHROCIN EVISTA...... 155 femynor...... 162 STEARATE...... 26 EVKEEZA...... 92 fenofibrate...... 92 erythromycin...... 27, 113, 199 EVOMELA...... 56 fenofibrate micronized...... 92 erythromycin base...... 26 EVOTAZ...... 74 fenofibric acid...... 92 erythromycin EVOXAC...... 108 fenoprofen calcium...... 7 ethylsuccinate...... 26 EVRYSDI...... 147 fenortho...... 7 ESBRIET...... 213 EXCILON AMD DRAIN FENSOLVI (6 MONTH).... 156 escitalopram oxalate...... 41 SPONGES...... 189 fentanyl...... 11 ESGIC...... 10 EXELDERM...... 46 fentanyl citrate...... 10 esmolol hcl...... 92 EXELON...... 40 FENTANYL CITRATE...... 10 ESMOLOL HCL...... 92 exemestane...... 56 fentanyl citrate (pf)...... 10 esmolol hcl-sodium EXFORGE...... 92 fentanyl citrate pf...... 10 chloride...... 92 EXFORGE HCT...... 92 FENTANYL CITRATE- esomeprazole magnesium141 EXJADE...... 130 NACL...... 10, 11 esomeprazole sodium...... 141 EXPAREL...... 16 FENTANYL CIT- ESPEROCT...... 82 EXTAVIA...... 105 ROPIVACAINE-NACL...... 11 est estrogens-methyltest...162 EXTINA...... 46 FENTANYL- est estrogens-methyltest EXTRANEAL...... 130 BUPIVACAINE-NACL...... 11 ds...... 162 EYLEA...... 204 FENTANYL- est estrogens-methyltest EZALLOR SPRINKLE...... 92 ROPIVACAINE-NACL...... 11 hs...... 162 ezetimibe...... 92 FENTORA...... 11 estarylla...... 162 ezetimibe-simvastatin...... 92 FERAHEME...... 130 estazolam...... 79 fabb...... 130 FERIVAFA...... 130 ESTRACE...... 162 FABRAZYME...... 147 ferocon...... 130 estradiol...... 162 FALESSA...... 162 ferotrinsic...... 130 estradiol valerate...... 162 falmina...... 162 FERRALET 90...... 130 estradiol-norethindrone famciclovir...... 74 FERRAPLUS 90...... 130 acet...... 162 famotidine...... 141 FERRIPROX...... 130 ESTRING...... 162 famotidine premixed...... 141 FERRIPROX TWICE-A- ESTROGEL...... 162 FANAPT...... 70 DAY...... 130 ESTROSTEP FE...... 162 FANAPT TITRATION FERRLECIT...... 130 eszopiclone...... 219 PACK...... 70 FERRO-PLEX ethacrynate sodium...... 92 FARESTON...... 56 HEMATINIC...... 130 ethacrynic acid...... 92 FARXIGA...... 118 ferumoxytol...... 130 ethambutol hcl...... 51 FARYDAK...... 56 FETROJA...... 27 ethosuximide...... 36 FASENRA...... 209 FETZIMA...... 41 ethyl chloride...... 16 FASENRA PEN...... 209 FETZIMA TITRATION...... 41 ethynodiol diac-eth FASLODEX...... 56 FEXMID...... 218 estradiol...... 162 fa-vitamin b-6-vitamin b-12130 FIASP...... 123 etodolac...... 7 fayosim...... 162 FIASP FLEXTOUCH...... 123 etodolac er...... 7 FBL KIT...... 7 FIASP PENFILL...... 123 etomidate...... 188 FC FEMALE CONDOM.... 189 FIBRICOR...... 92 etonogestrel-ethinyl FC2 FEMALE CONDOM.. 189 FIBRYGA...... 82 estradiol...... 162 febuxostat...... 48 FINACEA...... 113 ETOPOPHOS...... 56 FEIBA...... 82 finasteride...... 151 etoposide...... 56 felbamate...... 36 FINTEPLA...... 36 etravirine...... 74 FELBATOL...... 36 FIORICET...... 11 EUCRISA...... 113 FELDENE...... 7 FIORICET/CODEINE...... 11 EUFLEXXA...... 189 felodipine er...... 92 FIRAZYR...... 172 euthyrox...... 169 FEMARA...... 56 FIRE ANT...... 189 EVAMIST...... 162 FEMCAP...... 189 FIRMAGON...... 156 EVENITY...... 182 FEMHRT...... 162 FIRMAGON (240 MG everolimus...... 56, 172 FEMRING...... 162 DOSE)...... 156

230 FIRST-BACLOFEN...... 218 fluocinolone acetonide folplex 2.2...... 131 FIRST-LANSOPRAZOLE. 141 scalp...... 113 FOLTRATE...... 131 FIRST-MOUTHWASH fluocinonide...... 113 foltrin...... 131 BLM...... 108 fluocinonide emulsified fomepizole...... 189 FIRST-OMEPRAZOLE..... 141 base...... 113 fondaparinux sodium...... 33 FIRST-PROGESTERONE FLUORESCEIN formaldehyde...... 189 VGS...... 162 SODIUM/BENOXINATE... 204 formoterol fumarate...... 213 FIRVANQ...... 27 FLUORESCITE...... 204 FORTAZ...... 27 flac...... 208 FLUORIDEX...... 108 FORTEO...... 182 FLAGYL...... 27 fluoridex daily renewal...... 108 FORTESTA...... 154 FLAREX...... 199 FLUORIDEX ENHANCED FOSAMAX...... 182 flavoxate hcl...... 149 WHITENING...... 109 FOSAMAX PLUS D...... 182 FLEBOGAMMA DIF...... 172 FLUORIDEX SENSITIVITY fosamprenavir calcium...... 74 flecainide acetate...... 93 RELIEF...... 109 fosaprepitant dimeglumine..44 FLECTOR...... 7 fluoritab...... 130 foscarnet sodium...... 74 FLEXBUMIN...... 189 fluorometholone...... 199 FOSCAVIR...... 74 FLEXICHAMBER...... 189 fluorouracil...... 56, 113 fosfomycin tromethamine....27 FLEXICHAMBER ADULT fluoxetine hcl...... 41 fosinopril sodium...... 93 MASK/SMALL...... 189 fluphenazine decanoate...... 70 fosinopril sodium-hctz...... 93 FLEXICHAMBER CHILD fluphenazine hcl...... 70 fosphenytoin sodium...... 36 MASK/LARGE...... 189 flurandrenolide...... 113 FOSRENOL...... 149 FLEXICHAMBER CHILD flurazepam hcl...... 219 FOTIVDA...... 56 MASK/SMALL...... 189 flurbiprofen...... 7 FRAGMIN...... 33 FLEXIN...... 16 flurbiprofen sodium...... 199 FREAMINE III...... 131 FLOLAN...... 216 flutamide...... 56 FREESTYLE FREEDOM FLOMAX...... 151 fluticasone propionate LITE...... 121 FLORIVA PLUS...... 130 ...... 113, 209 FREESTYLE INSULINX FLOVENT DISKUS...... 213 fluticasone-salmeterol...... 213 SYSTEM...... 121 FLOVENT HFA...... 213 FLUTICASONE- FREESTYLE INSULINX floxuridine...... 56 SALMETEROL...... 213 TEST...... 121 FLUAD QUADRIVALENT. 178 fluvastatin sodium...... 93 FREESTYLE LIBRE 14 FLUARIX fluvastatin sodium er...... 93 DAY READER...... 121 QUADRIVALENT...... 178 fluvoxamine maleate...... 41 FREESTYLE LIBRE 14 FLUBLOK fluvoxamine maleate er...... 41 DAY SENSOR...... 121 QUADRIVALENT...... 178 FLUZONE HIGH-DOSE FREESTYLE LIBRE 2 FLUCELVAX QUADRIVALENT...... 178 READER...... 121 QUADRIVALENT...... 178 FLUZONE FREESTYLE LIBRE 2 fluconazole...... 46 QUADRIVALENT...... 178 SENSOR...... 121 fluconazole in sodium FML...... 199 FREESTYLE LIBRE chloride...... 46 FML FORTE...... 199 READER...... 121 flucytosine...... 46 FML LIQUIFILM...... 199 FREESTYLE LIBRE fludarabine phosphate...... 56 FOCALIN...... 103 SENSOR SYSTEM...... 121 fludrocortisone acetate..... 153 FOCALIN XR...... 103 FREESTYLE LITE TEST.. 121 FLULAVAL folate...... 130 FREESTYLE PRECISION QUADRIVALENT...... 178 folbee plus...... 131 NEO TEST...... 121 flumazenil...... 189 FOLGARD OS...... 131 FREESTYLE TEST...... 121 FLUMIST FOLGARD RX...... 131 fresenius propoven...... 189 QUADRIVALENT...... 178 folic acid...... 131 FRESENIUS PROPOVEN 189 flunisolide...... 209 FOLITIN-Z...... 131 FROVA...... 49 fluocinolone acetonide FOLIVANE-F...... 131 frovatriptan succinate...... 49 ...... 113, 208 FOLIVANE-PLUS...... 131 FULPHILA...... 82 fluocinolone acetonide FOLLISTIM AQ...... 156 fulvestrant...... 56 body...... 113 FOLOTYN...... 56 FUNGIMEZ...... 46

231 furosemide...... 93 gentamicin in saline...... 27 GOLDENROD...... 190 FUROSEMIDE IN gentamicin sulfate...... 27, 199 GOLYTELY...... 144 SODIUM CHLORIDE...... 93 GENTEEL LANCING KIT GONAL-F...... 156 FUSARIUM...... 189 (BLUE)...... 121 GONAL-F RFF...... 156 FUSION PLUS...... 131 GENVISC 850...... 189 GONAL-F RFF REDIJECT156 FUZEON...... 74 GENVOYA...... 74 goodsense aspirin low fyavolv...... 162 GEODON...... 70, 71 dose...... 7 FYCOMPA...... 36 GERMAN COCKROACH..189 goodsense nicotine...... 20 gabapentin...... 36 gianvi...... 163 GOPRELTO...... 16 GABITRIL...... 36 GILENYA...... 105 GORDOFILM...... 113 GABLOFEN...... 218 GILOTRIF...... 57 GRALISE...... 107 GALAFOLD...... 147 GILPHEX TR...... 209 granisetron hcl...... 44 galantamine hydrobromide. 40 GIVLAARI...... 189 GRANIX...... 82 galantamine hydrobromide GLASSIA...... 213 GRASS POLLEN(K-O-R- er...... 40 glatiramer acetate...... 105 T-SWT VERN)...... 190 GALZIN...... 131 glatopa...... 105 GRASTEK...... 190 GAMASTAN...... 172 GLEEVEC...... 57 griseofulvin microsize...... 46 GAMIFANT...... 172 GLEOLAN...... 189 griseofulvin ultramicrosize.. 46 GAMMAGARD...... 172 GLEOSTINE...... 57 GUANENDRUX...... 113 GAMMAGARD S/D LESS GLIADEL WAFER...... 57 guanfacine hcl...... 93 IGA...... 172 glimepiride...... 118 guanfacine hcl er...... 103 GAMMAKED...... 172 glipizide...... 118 GVOKE PFS...... 122 GAMMAPLEX...... 172 glipizide er...... 118 GYNAZOLE-1...... 46 GAMUNEX-C...... 172 glipizide xl...... 118 habitrol...... 20 GANCICLOVIR...... 74 glipizide-metformin hcl...... 118 HACKBERRY...... 190 ganciclovir sodium...... 74 GLOPERBA...... 48 HAEGARDA...... 173 ganirelix acetate...... 156 GLOSTRIPS...... 205 hailey 1.5/30...... 163 GARDASIL 9...... 178 GLUCAGEN DIAGNOSTIC hailey 24 fe...... 163 GASTROCROM...... 143 ...... 189 hailey fe 1.5/30...... 163 gatifloxacin...... 199 GLUCAGEN HYPOKIT.....122 hailey fe 1/20...... 163 GATTEX...... 143 glucagon emergency kit....122 HALAVEN...... 57 gavilax...... 143 GLUCAGON halcinonide...... 113 gavilyte-c...... 143 EMERGENCY KIT...... 122 HALCION...... 79 gavilyte-g...... 143 GLUCAGON HCL HALDOL...... 71 gavilyte-n with flavor pack.143 (DIAGNOSTIC)...... 189 HALDOL DECANOATE...... 71 GAVRETO...... 56 GLUCOTROL XL...... 118 halobetasol propionate..... 113 GAZYVA...... 56 glutaraldehyde...... 189 HALOG...... 113 GELFILM...... 204 GLUTATHIONE...... 131 haloperidol...... 71 GELFOAM-JMI SPONGE.189 glyburide...... 118 haloperidol decanoate...... 71 GELNIQUE...... 149 glyburide micronized...... 118 haloperidol lactate...... 71 GEL-ONE...... 189 glyburide-metformin...... 118 HARVONI...... 74 GELSYN-3...... 189 GLYCINE...... 131 HAVRIX...... 178 gemcitabine hcl...... 56, 57 glycine...... 149 HEALON...... 205 gemfibrozil...... 93 glycine urologic...... 149 HEALON DUET PRO...... 205 gemmily...... 162 glycolax...... 143 HEALON GV...... 205 GENERESS FE...... 163 glycolic acid...... 113 HEALON GV PRO...... 205 generlac...... 143 glycopyrrolate...... 143, 144 HEALON PRO...... 205 gengraf...... 172 GLYCOPYRROLATE...... 143 HEALON5...... 205 GENICIN VITA-S...... 131 glycopyrrolate pf...... 144 HEALON5 PRO...... 205 GENOTROPIN...... 156 glydo...... 16 healthylax...... 144 GENOTROPIN GLYNASE...... 118 heather...... 163 MINIQUICK...... 156 GLYRX-PF...... 144 HECTOROL...... 183 gentak...... 199 GLYXAMBI...... 118 HELIDAC THERAPY...... 144

232 HEMABATE...... 156 HUMAN ALBUMIN hydromet...... 209 hematinic/folic acid...... 131 GRIFOLS...... 190 hydromorphone hcl...... 12 HEMATOGEN FA...... 131 HUMATE-P...... 82 HYDROMORPHONE HCL. 12 HEMATRON-AF...... 131 HUMATIN...... 27 hydromorphone hcl er...... 12 HEMLIBRA...... 82 HUMATROPE...... 156 hydromorphone hcl pf...... 12 HEMOCYTE PLUS...... 131 HUMIRA...... 173 HYDROMORPHONE HCL- hemocyte-f...... 131 HUMIRA PEDIATRIC NACL...... 12 HEMOFIL M...... 82 CROHNS START...... 173 hydroxocobalamin acetate 131 HEPAGAM B...... 173 HUMIRA PEN...... 173 hydroxychloroquine sulfate. 66 heparin (porcine) in nacl..... 34 HUMIRA PEN-CD/UC/HS hydroxyprogesterone HEPARIN (PORCINE) IN STARTER...... 173 caproate...... 163 NACL...... 34 HUMIRA PEN-PEDIATRIC hydroxyurea...... 57 heparin lock flush...... 190 UC START...... 173 hydroxyzine hcl...... 79 heparin sod (porcine) in HUMIRA PEN- hydroxyzine pamoate...... 79 d5w...... 34 PS/UV/ADOL HS START. 173 HYLAVITE...... 131 heparin sodium (porcine).... 34 HUMIRA PEN- HYLAZINC...... 131 heparin sodium (porcine) PSOR/UVEIT STARTER.. 173 HYLENEX...... 190 pf...... 34 HUMULIN 70/30 HYMOVIS...... 190 heparin sodium lock flush. 190 KWIKPEN...... 123 HYOPHEN...... 149 HEPLISAV-B...... 178 HUMULIN 70/30 VIAL...... 123 hyoscyamine sulfate...... 144 HEPMED...... 190 HUMULIN N KWIKPEN.... 123 hyoscyamine sulfate er..... 144 HEPSERA...... 74 HUMULIN N VIAL...... 123 hyoscyamine sulfate sl...... 144 HERCEPTIN...... 57 HUMULIN R U-500 hyosyne...... 144 HERCEPTIN HYLECTA..... 57 KWIKPEN...... 123 HYPERHEP B...... 173 HERZUMA...... 57 HUMULIN R U-500 VIAL.. 123 HYPERLYTE-CR...... 131 HESPAN...... 82 HUMULIN R VIAL...... 124 HYPERRAB...... 173 hetastarch-nacl...... 82 HYALGAN...... 190 HYPERRHO S/D...... 173 HETLIOZ...... 219 HYALURONIDASE HYPERSAL...... 209 HETLIOZ LQ...... 219 (INTRAOCULAR)...... 205 HYPERTET S/D...... 173 HEXTEND...... 82 HYCAMTIN...... 57 HYQVIA...... 173 HIBERIX...... 179 HYCODAN...... 209 HYSINGLA ER...... 12 HIDEX 6-DAY...... 153 hydralazine hcl...... 93 HYZAAR...... 93 HIPREX...... 27 HYDREA...... 57 ibandronate sodium...... 182 HISTATROL...... 190 hydrochlorothiazide...... 93 IBRANCE...... 57 HIZENTRA...... 173 hydrocodone bitartrate er....11 ibuprofen...... 7 homatropaire...... 205 hydrocodone polst- ibuprofen lysine...... 7 HONEY BEE VENOM...... 190 chlorphen polst er susp.....209 ibutilide fumarate...... 93 HONEY BEE VENOM hydrocodone- IC GREEN...... 190 PROTEIN...... 190 acetaminophen...... 11, 12 ICAR-C PLUS...... 131 HORIZANT...... 107 hydrocodone-homatropine 209 icatibant acetate...... 173 HORSE EPITHELIUM...... 190 hydrocodone-ibuprofen...... 12 iclevia...... 163 HUMALOG...... 123 hydrocortisone.. 114, 153, 181 ICLUSIG...... 57 HUMALOG KWIKPEN...... 123 hydrocortisone (perianal).. 181 icosapent ethyl...... 93 HUMALOG MIX 50/50 hydrocortisone ace- ID NOW INFLUENZA A & KWIKPEN...... 123 pramoxine...... 181 B 2...... 190 HUMALOG MIX 50/50 hydrocortisone butyr lipo ID NOW INFLUENZA A & VIAL...... 123 base...... 113 B 2 CONTR...... 190 HUMALOG MIX 75/25 hydrocortisone butyrate.... 113 IDAMYCIN PFS...... 57 KWIKPEN...... 123 hydrocortisone valerate.... 114 idarubicin hcl...... 57 HUMALOG MIX 75/25 hydrocortisone-acetic acid 208 IDELVION...... 82 VIAL...... 123 hydrocort-pramoxine IDHIFA...... 57 HUMALOG U-100 JUNIOR (perianal)...... 181 iferex 150 forte...... 131 KWIKPEN...... 123 hydrogen peroxide...... 27 IFEX...... 57

233 ifosfamide...... 57 INSULIN ASPART...... 124 isosorbide mononitrate...... 93 ILARIS...... 173 INSULIN ASPART isosorbide mononitrate er... 93 ILEVRO...... 199 FLEXPEN...... 124 isosulfan blue...... 190 ILUMYA...... 174 INSULIN ASPART isotretinoin...... 114 ILUVIEN...... 199 PENFILL...... 124 isradipine...... 93 imatinib mesylate...... 57 INSULIN ASPART PROT ISTALOL...... 202 IMBRUVICA...... 57, 58 & ASPART...... 124 ISTODAX (OVERFILL)...... 58 imipenem-cilastatin...... 27 INSULIN PEN NEEDLES. 124 ISTURISA...... 156 imipramine hcl...... 42 INSULIN SYRINGES...... 124 ISUPREL...... 213 imipramine pamoate...... 42 INTEGRA F...... 131 itraconazole...... 46 imiquimod...... 114 INTEGRA PLUS...... 131 IV STABILIZER FOR IMITREX...... 49, 50 INTELENCE...... 74 LUMOXITI...... 190 IMITREX STATDOSE INTRALIPID...... 132 ivermectin...... 66, 114 REFILL...... 49 INTRAROSA...... 149 IXEMPRA KIT...... 58 IMITREX STATDOSE INTRON A...... 74 IXIARO...... 179 SYSTEM...... 50 introvale...... 163 IXINITY...... 82 IMLYGIC...... 58 INTUNIV...... 103 JADENU...... 132 IMOGAM RABIES-HT...... 174 INVANZ...... 27 JADENU SPRINKLE...... 132 IMOVAX RABIES...... 179 INVEGA...... 71 jaimiess...... 163 IMPAVIDO...... 66 INVEGA SUSTENNA...... 71 JAKAFI...... 58 IMURAN...... 174 INVEGA TRINZA...... 71 JALYN...... 151 INBRIJA...... 68 INVELTYS...... 199 JANSSEN COVID-19 incassia...... 163 INVIRASE...... 74 VACCINE...... 179 INCRELEX...... 156 INVOKAMET...... 119 jantoven...... 34 INCRUSE ELLIPTA...... 213 INVOKAMET XR...... 119 JANUMET...... 119 indapamide...... 93 INVOKANA...... 119 JANUMET XR...... 119 INDERAL LA...... 93 iodine strong...... 132 JANUVIA...... 119 INDERAL XL...... 93 iodine tincture...... 27 JARDIANCE...... 119 INDOCIN...... 7 IONOSOL-MB IN D5W..... 132 jasmiel...... 163 indocyanine green...... 190 IOPIDINE...... 202 JATENZO...... 154 indomethacin...... 7 IPOL...... 179 JELMYTO...... 58 indomethacin er...... 7 ipratropium bromide..209, 213 JEMPERLI...... 58 indomethacin sodium...... 7 ipratropium-albuterol...... 213 jencycla...... 163 INFANRIX...... 179 irbesartan...... 93 JENLIVA INFASURF...... 209 irbesartan- PRENATAL/POSTNATAL 132 INFED...... 131 hydrochlorothiazide...... 93 JENTADUETO...... 119 INFLECTRA...... 174 IRESSA...... 58 JENTADUETO XR...... 119 INFUGEM...... 58 irinotecan hcl...... 58 JEVTANA...... 58 INFUMORPH 200...... 12 IROSPAN 24/6...... 132 jinteli...... 163 INFUMORPH 500...... 12 ISENTRESS...... 74, 75 JIVI...... 83 INFUVITE ADULT...... 131 ISENTRESS HD...... 74 JOHNSON GRASS...... 190 INFUVITE PEDIATRIC..... 131 isibloom...... 163 jolessa...... 163 INGREZZA...... 107 ISOLYTE-P IN D5W...... 132 JUBLIA...... 46 INJECTAFER...... 131 ISOLYTE-S...... 132 juleber...... 163 INLYTA...... 58 ISOLYTE-S PH 7.4...... 132 JULUCA...... 75 INNOPRAN XL...... 93 isoniazid...... 51 JUNE GRASS POLLEN INQOVI...... 58 isoproterenol hcl...... 213 STANDARDIZED...... 191 INREBIC...... 58 ISOPROTERENOL- junel 1.5/30...... 163 INSPIREASE SODIUM CHLORIDE...... 213 junel 1/20...... 163 RESERVOIR BAGS...... 190 ISOPTO ATROPINE...... 205 junel fe 1.5/30...... 163 INSPRA...... 93 ISOPTO CARPINE...... 202 junel fe 1/20...... 163 INSULIN ASP PROT & ISORDIL TITRADOSE...... 93 junel fe 24...... 163 ASP FLEXPEN...... 124 isosorbide dinitrate...... 93 JUXTAPID...... 94

234 JYNARQUE...... 132 KETOROLAC-BUPIV- LABETALOL HCL- KABIVEN...... 132 KETAMINE...... 7 SODIUM CHLORIDE...... 94 KADCYLA...... 58 KETOROLAC-ROPIV- LACRISERT...... 205 kaitlib fe...... 163 KETAMINE...... 7 lactated ringers...... 133 KALBITOR...... 174 KEVEYIS...... 202 lactic acid...... 114 KALETRA...... 75 KEVZARA...... 174 lactic acid e...... 114 kalliga...... 163 KEYTRUDA...... 58 lactulose...... 144 KALYDECO...... 216 KHAPZORY...... 58 lactulose encephalopathy. 144 KANJINTI...... 58 KIMYRSA...... 27 LAMICTAL...... 37 KANUMA...... 147 KINERET...... 174 LAMICTAL ODT...... 37 KAPOK...... 191 KINEVAC...... 191 LAMICTAL STARTER...... 37 KAPVAY...... 103 KINRIX...... 179 LAMICTAL XR...... 37 KARBINAL ER...... 209 KISQALI...... 58 lamivudine...... 75 kariva...... 163 KITABIS PAK...... 216 lamivudine-zidovudine...... 75 KAZANO...... 119 KLARITY-A...... 199 lamotrigine...... 37 KCENTRA...... 83 KLISYRI...... 114 lamotrigine er...... 37 KCL (IN NACL 0.9%)...... 132 KLONOPIN...... 79 lamotrigine starter kit-blue.. 37 kcl in dextrose-nacl...... 132 klor-con...... 132 lamotrigine starter kit- kcl-lactated ringers-d5w....132 klor-con 10...... 132 green...... 37 KCL-LIDOCAINE-NACL... 132 klor-con m10...... 132 lamotrigine starter kit- kedbumin...... 191 klor-con m15...... 132 orange...... 37 KEDRAB...... 174 klor-con m20...... 132 LAMPIT...... 66 KEFLEX...... 27 klor-con/ef...... 132 LANCETS...... 121 kelnor 1/35...... 163 KLOXXADO...... 20 LANOXIN...... 94 kelnor 1/50...... 163 KOATE...... 83 LANOXIN PEDIATRIC...... 94 KENALOG...... 153 KOATE-DVI...... 83 lansoprazole...... 141, 142 KENALOG-80...... 153 KOCHIA...... 191 lanthanum carbonate...... 149 KENGREAL...... 69 KOGENATE FS...... 83 LANTUS SOLOSTAR...... 124 KEPIVANCE...... 109 KOMBIGLYZE XR...... 119 LANTUS U-100 VIAL...... 124 KEPPRA...... 36 KORLYM...... 159 lapatinib ditosylate...... 59 KEPPRA XR...... 37 KOSELUGO...... 58 larin 1.5/30...... 163 KERALYT...... 114 KOVALTRY...... 83 larin 1/20...... 163 KERALYT SCALP...... 114 K-PHOS...... 132 larin 24 fe...... 163 KERAMATRIX REPLICINE K-PHOS NO 2...... 132 larin fe 1.5/30...... 163 5CMX5CM...... 114 K-PHOS-NEUTRAL...... 132 larin fe 1/20...... 163 KERLIX AMD k-prime...... 132 larissia...... 163 ANTIMICROBIAL...... 191 KRINTAFEL...... 66 LASIX...... 94 KERLIX AMD SUPER KRISTALOSE...... 144 LASTACAFT...... 205 SPONGES...... 191 KRYSTEXXA...... 48 latanoprost...... 202 KERYDIN...... 46 K-TAB...... 133 LATANOPROST- KESIMPTA...... 105 k-tan plus...... 133 TIMOLOL MALEATE...... 202 KETALAR...... 191 kurvelo...... 163 LATUDA...... 71 KETAMINE HCL...... 191 KUVAN...... 147 layolis fe...... 163 ketamine hcl...... 191 KYLEENA...... 163 LAZANDA...... 12 KETAMINE HCL-SODIUM KYMRIAH...... 174 LEDIPASVIR- CHLORIDE...... 191 KYNMOBI...... 68 SOFOSBUVIR...... 75 ketoconazole...... 46 KYNMOBI TITRATION KIT.68 leena...... 164 ketodan...... 46 KYPROLIS...... 58 leflunomide...... 174 ketoprofen...... 7 LABETALOL HCL...... 94 LEMTRADA...... 105 ketoprofen er...... 7 labetalol hcl...... 94 LENSCALE...... 191 ketorolac tromethamine 7, 199 LABETALOL HCL- LENVIMA...... 59 KETOROLAC DEXTROSE...... 94 LESCOL XL...... 94 TROMETHAMINE...... 7 lessina...... 164

235 LETAIRIS...... 216 LIBRAX...... 144 LIORESAL...... 218 letrozole...... 59 LIBTAYO...... 59 liothyronine sodium...... 169 LETS...... 16 LIDO BDK...... 16 LIPITOR...... 94 leucovorin calcium...... 59 lidocaine...... 16, 17 LIPO...... 133 LEUKERAN...... 59 lidocaine hcl...... 17 LIPO-C...... 133 LEUKINE...... 83 LIDOCAINE HCL...... 17 LIPOFEN...... 94 leuprolide acetate...... 156 LIDOCAINE HCL lisinopril...... 94 LEUPROLIDE ACETATE- (CARDIAC)...... 17 lisinopril- BUPIVACAINE...... 156 lidocaine hcl (cardiac)...... 17 hydrochlorothiazide...... 94 levalbuterol hcl...... 213 lidocaine hcl (cardiac) pf..... 17 lithium carbonate...... 80 LEVATIO...... 16 lidocaine hcl (pf)...... 17 lithium carbonate er...... 80 LEVBID...... 144 lidocaine hcl LITHOBID...... 80 LEVEMIR U-100 urethral/mucosal...... 17 LITHOSTAT...... 149 FLEXTOUCH...... 124 lidocaine in d5w...... 17 LIVALO...... 94 LEVEMIR U-100 VIAL...... 124 LIDOCAINE IN LIVIXIL PAK...... 18 levetiracetam...... 37 DEXTROSE...... 17 LMD IN D5W...... 83 levetiracetam er...... 37 lidocaine viscous hcl...... 109 LMD IN NACL...... 83 levetiracetam in nacl...... 37 lidocaine-epinephrine...... 17 LO LOESTRIN FE...... 164 levobunolol hcl...... 202 LIDOCAINE- LODINE...... 8 LEVOCARNITINE...... 133 EPINEPHRINE...... 205 LODOSYN...... 68 levocarnitine...... 133 lidocaine-hydrocort LOESTRIN 1.5/30 (21)..... 164 levocarnitine sf...... 133 (perianal)...... 181 LOESTRIN 1/20 (21)...... 164 levocetirizine LIDOCAINE- LOESTRIN FE 1.5/30...... 164 dihydrochloride...... 209 HYDROCORTISONE ACE LOESTRIN FE 1/20...... 164 levofloxacin...... 27, 199 ...... 181 lojaimiess...... 164 levofloxacin in d5w...... 27 lidocaine-hydrocortisone LOKELMA...... 133 levoleucovorin calcium...... 59 ace...... 181 LOMOTIL...... 144 levoleucovorin calcium pf....59 LIDOCAINE- LONHALA MAGNAIR levonest...... 164 PHENYLEPHRINE...... 205 REFILL KIT...... 213 levonorgest-eth est & eth LIDOCAINE- LONHALA MAGNAIR est...... 164 PHENYLEPHRINE-BSS... 205 STARTER KIT...... 214 levonorgest-eth estrad 91- lidocaine-prilocaine...... 17 LONSURF...... 59 day...... 164 LIDOCAINE-TETRACAINE 18 loperamide hcl...... 144 levonorgestrel...... 164 LIDOCANNA...... 18 LOPID...... 94 levonorgestrel-ethinyl LIDOCIDEX I...... 153 lopinavir-ritonavir...... 75 estrad...... 164 LIDOCORT...... 181 LOPRESSOR...... 94 levonorg-eth estrad LIDODERM...... 18 LOPROX...... 46 triphasic...... 164 LIDO-EPINEPHRINE- lorazepam...... 79 LEVOPHED...... 94 TETRACAINE...... 18 lorazepam intensol...... 79 levora 0.15/30 (28)...... 164 lidopin...... 18 LORBRENA...... 59 levorphanol tartrate...... 12 LIDOPRIL...... 18 LORID...... 133 levo-t...... 169 LIDOPRIL XR...... 18 LORTAB...... 13 levothyroxine sodium...... 169 LIDO-PRILO CAINE PACK.18 loryna...... 164 LEVOTHYROXINE LIDO-SORB...... 18 LORZONE...... 218 SODIUM...... 169 LIFEMS NALOXONE...... 20 losartan potassium...... 94 levoxyl...... 169 LILETTA (52 MG)...... 164 losartan potassium-hctz...... 94 LEVSIN...... 144 lillow...... 164 LOSEASONIQUE...... 164 LEVSIN/SL...... 144 LINCOCIN...... 27 LOTEMAX...... 200 LEVULAN KERASTICK.... 114 lincomycin hcl...... 27 LOTEMAX SM...... 200 LEXAPRO...... 42 lindane...... 66 LOTENSIN...... 94 LEXISCAN...... 191 linezolid...... 27, 28 LOTENSIN HCT...... 94 LEXIVA...... 75 linezolid in sodium chloride.27 loteprednol etabonate...... 200 LIALDA...... 181 LINZESS...... 144 LOTREL...... 94

236 LOTRONEX...... 144 MACRILEN...... 191 meloxicam...... 8 lovastatin...... 94 MACROBID...... 28 melphalan...... 59 LOVAZA...... 95 MACRODANTIN...... 28 melphalan hcl...... 59 LOVENOX...... 34 mafenide acetate...... 28 memantine hcl...... 40 low-ogestrel...... 164 magnesium sulfate...... 133 memantine hcl er...... 40 loxapine succinate...... 71 magnesium sulfate in d5w 133 MEMBRANEBLUE...... 205 LOYON...... 114 MAGNESIUM SULFATE- MENACTRA...... 179 lo-zumandimine...... 164 NACL...... 133 MENEST...... 165 LUBIPROSTONE...... 144 MAKENA...... 164 MENOPUR...... 157 LUCEMYRA...... 20 MALARONE...... 66 MENOSTAR...... 165 LUCENTIS...... 205 malathion...... 66 MENQUADFI...... 179 LUGOLS STRONG MANGANESE CHLORIDE133 MENTAX...... 47 IODINE...... 28 mannitol...... 95 MENVEO...... 179 LULICONAZOLE...... 46 MARCAINE...... 18 meperidine hcl...... 13 LUMAKRAS...... 59 MARCAINE MEPHYTON...... 133 LUMIGAN...... 202 PRESERVATIVE FREE...... 18 meprobamate...... 79 LUMIZYME...... 147 MARCAINE SPINAL...... 18 MEPRON...... 66 LUMOXITI...... 59 MARCAINE/EPINEPHRIN MEPSEVII...... 147 LUNESTA...... 219 E...... 18 mercaptopurine...... 59 LUPANETA PACK...... 157 MARCAINE/EPINEPHRIN meropenem...... 28 LUPKYNIS...... 174 E PF...... 18 MEROPENEM-SODIUM LUPRON DEPOT (1- MARGENZA...... 59 CHLORIDE...... 28 MONTH)...... 157 MARINOL...... 44 merzee...... 165 LUPRON DEPOT (3- marlissa...... 164 mesalamine...... 181 MONTH)...... 157 MARPLAN...... 42 mesalamine er...... 181 LUPRON DEPOT (4- MARQIBO...... 59 mesalamine-cleanser...... 181 MONTH) MATULANE...... 59 mesna...... 59 INTRAMUSCULAR KIT matzim la...... 95 MESNEX...... 59 30MG...... 157 MAVENCLAD...... 105 MESQUITE...... 191 LUPRON DEPOT (6- MAVYRET...... 75 MESTINON...... 51 MONTH) MAXALT...... 50 metaxalone...... 218 INTRAMUSCULAR KIT MAXALT-MLT...... 50 metformin hcl...... 119 45MG...... 157 MAXIDEX...... 200 metformin hcl er...... 119 LUPRON DEPOT-PED (1- MAXITROL...... 205 methadone hcl...... 13 MONTH)...... 157 MAXZIDE...... 95 methadone hcl intensol...... 13 LUPRON DEPOT-PED (3- MAXZIDE-25...... 95 METHADONE HCL-NACL..13 MONTH)...... 157 MAYZENT...... 106 METHADOSE...... 13 lutera...... 164 MAYZENT STARTER methadose...... 13 LUXTURNA...... 205 PACK...... 106 METHADOSE SUGAR- LUZU...... 47 me/naphos/mb/hyo1...... 149 FREE...... 13 lyleq...... 164 MEADOW FESCUE methamphetamine hcl...... 103 lyllana...... 164 GRASS POLLEN...... 191 methazolamide...... 202 LYNPARZA...... 59 meclizine hcl...... 44 methenamine hippurate...... 28 LYRICA...... 107 meclofenamate sodium...... 8 methenamine mandelate.... 28 LYRICA CR...... 107 MEDROL...... 153 methergine...... 191 LYSINE HCL...... 133 medroxyprogesterone methimazole...... 169 lysiplex plus...... 133 acetate...... 164, 165 METHITEST...... 154 LYSODREN...... 59 mefenamic acid...... 8 methocarbamol...... 218 LYSTEDA...... 83 mefloquine hcl...... 66 methotrexate...... 174 lyza...... 164 megestrol acetate...... 165 methotrexate sodium...... 174 M.V.I. ADULT...... 133 MEKINIST...... 59 methotrexate sodium (pf)..174 M.V.I. PEDIATRIC...... 133 MEKTOVI...... 59 methoxsalen rapid...... 114 MACI...... 191 MELALEUCA...... 191 methscopolamine bromide144

237 methyl salicylate...... 114 MICROPLEGIA MSA-MSG MIXED RAGWEED...... 192 METHYLCOBALAMIN...... 133 ...... 133 MIXED VESPID VENOM methyldopa...... 95 MIDAZOLAM...... 79 PROTEIN...... 192 methylergonovine maleate192 midazolam hcl...... 79 mixed vespid venom METHYLIN...... 103 MIDAZOLAM HCL...... 79 protein...... 192 methylphenidate hcl...... 104 midazolam hcl (pf)...... 79 mm clearlax...... 145 methylphenidate hcl er...... 103 MIDAZOLAM HCL- M-M-R II...... 179 methylphenidate hcl er (cd) SODIUM CHLORIDE...... 79 M-NATAL PLUS...... 133 ...... 103 MIDAZOLAM-SODIUM MOBIC...... 8 methylphenidate hcl er (la)103 CHLORIDE...... 79, 80 modafinil...... 219 methylphenidate hcl er (xr)103 midodrine hcl...... 95 MODERNA COVID-19 methylprednisolone...... 153 MIFEPREX...... 133 VACCINE...... 179 METHYLPREDNISOLONE mifepristone...... 133 moexipril hcl...... 95 ACETATE...... 153 MIGERGOT...... 50 molindone hcl...... 71 methylprednisolone miglitol...... 119 mometasone furoate.114, 209 acetate...... 153 miglustat...... 147 mondoxyne nl...... 28 methylprednisolone MIGRANAL...... 50 MONJUVI...... 60 sodium succ...... 153 mili...... 165 MONOFERRIC...... 134 METHYLPREDNISOLONE MILLIPRED...... 153 monoject flush syringe...... 134 -BUPIVACAINE...... 153 milrinone lactate...... 95 monoject sodium chloride methyltestosterone...... 155 milrinone lactate in flush...... 134 metoclopramide hcl...... 44 dextrose...... 95 mono-linyah...... 165 metolazone...... 95 mimvey...... 165 MONONINE...... 83 metoprolol succinate er...... 95 MINASTRIN 24 FE...... 165 MONOVISC...... 192 metoprolol tartrate...... 95 mineral oil heavy...... 144 MONSELS FERRIC metoprolol- MINIPRESS...... 95 SUBSULFATE...... 83 hydrochlorothiazide...... 95 minitran...... 95 montelukast sodium...... 214 metronidazole...... 28, 114 MINIVELLE...... 165 MONUROL...... 28 metronidazole in nacl...... 28 MINOCIN...... 28 morgidox...... 28 metyrosine...... 95 minocycline hcl...... 28 MORPHINE SULFATE. 13, 14 mexiletine hcl...... 95 minoxidil...... 95 morphine sulfate...... 13, 14 MI PASTE...... 109 MIOCHOL-E...... 206 morphine sulfate MI PASTE PLUS...... 109 MIOSTAT...... 206 (concentrate)...... 13 MIACALCIN...... 182 MIRALAX MIX-IN PAX...... 144 morphine sulfate (pf)...... 13 mibelas 24 fe...... 165 MIRAPEX...... 68 morphine sulfate er...... 13 micafungin sodium...... 47 MIRAPEX ER...... 68 morphine sulfate er beads.. 13 MICARDIS...... 95 MIRCERA...... 83 MORPHINE SULFATE- MICARDIS HCT...... 95 MIRCETTE...... 165 NACL...... 14 MIC-L-CARNITINE...... 133 MIRENA (52 MG)...... 165 MOTEGRITY...... 145 miconazole 3...... 47 mirtazapine...... 42 MOTOFEN...... 145 MICONAZOLE-ZINC MIRVASO...... 114 MOUNTAIN CEDAR...... 192 OXIDE-PETROLAT...... 47 misoprostol...... 142 MOUSE EPITHELIUM...... 192 MICRHOGAM ULTRA- MITE (D. FARINAE)...... 192 MOVANTIK...... 145 FILTERED PLUS...... 174 MITE (D. MOVIPREP...... 145 MICROCHAMBER...... 192 PTERONYSSINUS)...... 192 MOXEZA...... 200 MICROCYN...... 114 MITIGARE...... 48 MOXIFLOXACIN HCL 28, 200 microgestin 1.5/30...... 165 mitigo...... 13 moxifloxacin hcl...... 28, 200 microgestin 1/20...... 165 mitomycin...... 59 moxifloxacin hcl (2x day).. 200 microgestin 24 fe...... 165 MITOMYCIN...... 60, 200 moxifloxacin hcl in nacl...... 28 microgestin fe 1.5/30...... 165 MITOSOL...... 200 MOXIFLOXACIN HCL- microgestin fe 1/20...... 165 mitoxantrone hcl...... 60 BSS...... 206 MIXED ASPERGILLUS.... 192 MOZOBIL...... 83 MIXED FEATHERS...... 192 MS CONTIN...... 14

238 MUCOR...... 192 NALFON...... 8 NEOVITE...... 134 MUCOSITISRX...... 109 NALOCET...... 14 NEPHPLEX RX...... 134 MUGWORT...... 192 naloxone hcl...... 20 NEPHRON FA...... 134 MULPLETA...... 83 NALTREXONE...... 21 nephronex...... 134 MULTAQ...... 95 naltrexone hcl...... 21 NEPHRO-VITE RX...... 134 MULTIGEN...... 134 NAMENDA TITRATION NERLYNX...... 60 MULTIGEN FOLIC...... 134 PAK...... 40 NESACAINE...... 18 MULTIGEN PLUS...... 134 NAMENDA XR...... 40 NESACAINE-MPF...... 18 MULTIPRO...... 134 NAMZARIC...... 40 NESINA...... 119 multivitamin/fluoride...... 134 NAPRELAN...... 8 NESTABS...... 134 multi-vitamin/fluoride...... 134 NAPROSYN...... 8 NEULASTA...... 83 multi-vitamin/fluoride/iron..134 naproxen...... 8 NEULASTA ONPRO...... 83 mupirocin...... 28 naproxen sodium...... 8 NEUPOGEN...... 83 mutamycin...... 60 naproxen sodium er...... 8 NEUPRO...... 68 MVASI...... 60 NAPROXEN SODIUM ER.... 8 NEURACEQ...... 192 MYALEPT...... 147 naratriptan hcl...... 50 NEURIN-SL...... 134 MYAMBUTOL...... 51 NARCAN...... 21 NEURONTIN...... 37, 38 MYCAMINE...... 47 NARDIL...... 42 NEUTRASAL...... 109 MYCOBUTIN...... 51 NAROPIN...... 18 NEVANAC...... 200 mycophenolate mofetil...... 174 NASCOBAL...... 134 nevirapine...... 75 mycophenolate mofetil hcl 174 NASONEX...... 209 nevirapine er...... 75 mycophenolate sodium.....174 NATACYN...... 200 NEXAVAR...... 60 myferon 150 forte...... 134 NATAZIA...... 165 NEXIUM 24HR...... 142 MYFORTIC...... 174 nateglinide...... 119 NEXIUM I.V...... 142 MYLERAN...... 60 NATPARA...... 183 NEXLETOL...... 95 MYLOTARG...... 60 NATROBA...... 66 NEXLIZET...... 95 mynephrocaps...... 134 NATURE-THROID...... 169 NEXPLANON...... 165 MYNEPHRON...... 134 NAVELBINE...... 60 NEXTERONE...... 95 MYOBLOC...... 192 NAYZILAM...... 37 NEXTSTELLIS...... 165 myorisan...... 114 NEBUPENT...... 66 niacin (antihyperlipidemic).. 95 MYRBETRIQ...... 149 necon 0.5/35 (28)...... 165 niacin er MYSOLINE...... 37 nefazodone hcl...... 42 (antihyperlipidemic)...... 96 MYTESI...... 145 NEMBUTAL...... 37 niacor...... 96 MYXREDLIN...... 124 neomycin sulfate...... 28 NIASPAN...... 96 na ferric gluc cplx in neomycin-bacitracin zn- NICADAN...... 134 sucrose...... 134 polymyx...... 206 nicardipine hcl...... 96 NABI-HB...... 175 neomycin-polymyxin b gu... 29 NICARDIPINE HCL IN nabumetone...... 8 neomycin-polymyxin- NACL...... 96 nadolol...... 95 dexameth...... 206 NICAZEL...... 134 nafcillin sodium...... 28 neomycin-polymyxin- NICAZEL FORTE...... 134 NAFCILLIN SODIUM IN gramicidin...... 206 NICOMIDE...... 134 DEXTROSE...... 28 neomycin-polymyxin-hc NICORETTE...... 21 nafrinse...... 134 ...... 206, 208 nicotinamide...... 134 NAFRINSE DAILY NEONATAL COMPLETE..134 nicotine polacrilex...... 21 ACIDULATED...... 109 NEONATAL PLUS...... 134 nicotine polacrilex mini...... 21 NAFRINSE neo-polycin...... 206 nicotine step 1...... 21 DAILY/NEUTRAL...... 109 neo-polycin hc...... 206 nicotine step 2...... 21 nafrinse drops...... 134 NEOPROFEN...... 8 nicotine step 3...... 21 NAFRINSE WEEKLY...... 109 NEORAL...... 175 NICOTROL...... 21 naftifine hcl...... 47 neostigmine methylsulfate.. 51 NICOTROL NS...... 21 NAFTIN...... 47 NEOSTIGMINE nifedipine...... 96 NAGLAZYME...... 147 METHYLSULFATE...... 51 nifedipine er...... 96 nalbuphine hcl...... 14 NEO-SYNALAR...... 114

239 nifedipine er osmotic norgestimate-ethinyl NOVOLOG RELION...... 125 release...... 96 estradiol triphasic...... 166 NOVOLOG U-100 VIAL.... 125 NIFEREX...... 134 norlyda...... 166 NOVOSEVEN RT...... 84 nikki...... 165 norlyroc...... 166 NOVOTWIST PEN NILANDRON...... 60 normal saline flush...... 134 NEEDLE...... 125 nilutamide...... 60 NORMOSOL-M IN D5W... 135 NOXAFIL...... 47 NIMBEX...... 107 NORMOSOL-R...... 135 np thyroid...... 169 nimodipine...... 96 NORMOSOL-R IN D5W... 135 NPLATE...... 84 NINLARO...... 60 NORMOSOL-R PH 7.4..... 135 NUBEQA...... 60 NIPENT...... 60 NORPACE...... 97 NUCALA...... 209, 210 NIPRIDE RTU...... 96 NORPACE CR...... 97 NUCYNTA...... 14 nisoldipine er...... 96 NORPRAMIN...... 42 NUCYNTA ER...... 14 nitazoxanide...... 66 NORTHERA...... 97 NUEDEXTA...... 107 NITHIODOTE...... 193 nortrel 0.5/35 (28)...... 166 NUFERA...... 135 nitisinone...... 147 nortrel 1/35 (21)...... 166 NULEV...... 145 NITRO-BID...... 96 nortrel 1/35 (28)...... 166 NULIBRY...... 147 NITRO-DUR...... 96 nortrel 7/7/7...... 166 NULOJIX...... 175 nitrofurantoin...... 29 nortriptyline hcl...... 42 NULYTELY LEMON-LIME 145 nitrofurantoin macrocrystal. 29 NORVASC...... 97 NUMBRINO...... 18 nitrofurantoin monohydrate NORVIR...... 75 NUMOISYN...... 109 macrocrystals...... 29 NOURIANZ...... 68 NUPLAZID...... 71 nitroglycerin...... 96 novarel...... 157 NURTEC...... 50 nitroglycerin in d5w...... 96 NOVAREL...... 157 NUTRICAP...... 135 NITROLINGUAL...... 96 NOVAVAX COVID-19 NUTRIDOX...... 29 NITROMIST...... 96 VACCINE...... 179 nutrifac zx...... 135 nitroprusside sodium...... 96 NOVOEIGHT...... 84 nutrilipid...... 135 NITROSTAT...... 96 NOVOFINE AUTOCOVER NUTRIVIT...... 135 NITRO-TIME...... 96 PEN NEEDLE...... 124 NUTROPIN AQ NUSPIN NITYR...... 147 NOVOFINE PEN NEEDLE124 10...... 157 NIVESTYM...... 83, 84 NOVOFINE PLUS PEN NUTROPIN AQ NUSPIN nizatidine...... 142 NEEDLE...... 124 20...... 157 nolix...... 114 NOVOLIN 70/30 FLEXPEN NUTROPIN AQ NUSPIN 5157 nora-be...... 165 ...... 125 NUVAIL...... 114 NORDITROPIN FLEXPRO NOVOLIN 70/30 FLEXPEN NUVARING...... 166 ...... 157 RELION...... 125 NUVIGIL...... 219 NOREPINEPHRINE NOVOLIN 70/30 RELION. 125 NUWIQ...... 84 (BASE)-DEXTROSE...... 97 NOVOLIN 70/30 VIAL...... 125 NUZYRA...... 29 norepinephrine bitartrate.....97 NOVOLIN N RELION...... 125 nylia 7/7/7...... 166 NOREPINEPHRINE- NOVOLIN N VIAL...... 125 nymyo...... 166 DEXTROSE...... 97 NOVOLIN R RELION...... 125 nystatin...... 47 NOREPINEPHRINE- NOVOLIN R VIAL...... 125 nystatin-triamcinolone...... 47 SODIUM CHLORIDE...... 97 NOVOLOG 70/30 nystop...... 47 norethin ace-eth estrad-fe.165 FLEXPEN RELION...... 125 NYVEPRIA...... 84 norethindrone...... 166 NOVOLOG FLEXPEN...... 125 OBIZUR...... 84 norethindrone acetate...... 165 NOVOLOG FLEXPEN OCALIVA...... 147 norethindrone acet-ethinyl RELION...... 125 ocella...... 166 est...... 166 NOVOLOG MIX 70/30 OCREVUS...... 106 norethindrone-eth estradiol FLEXPEN...... 125 OCTAGAM...... 175 ...... 166 NOVOLOG MIX 70/30 OCTAPLAS BLOOD norethin-eth estradiol-fe....166 RELION...... 125 GROUP A...... 193 NORGESIC FORTE...... 218 NOVOLOG MIX 70/30 OCTAPLAS BLOOD norgestimate-eth estradiol 166 VIAL...... 125 GROUP AB...... 193 NOVOLOG PENFILL...... 125

240 OCTAPLAS BLOOD OPTICHAMBER oxaliplatin...... 60 GROUP B...... 193 DIAMOND-LG MASK...... 193 oxandrolone...... 155 OCTAPLAS BLOOD OPTICHAMBER oxaprozin...... 8 GROUP O...... 193 DIAMOND-MD MASK...... 193 OXAYDO...... 14 octreotide acetate..... 157, 158 OPTICHAMBER oxazepam...... 80 OCUFLOX...... 200 DIAMOND-SM MASK...... 193 OXBRYTA...... 193 ODACTRA...... 193 ORABLOC...... 18 oxcarbazepine...... 38 ODEFSEY...... 75 ORACIT...... 135 OXERVATE...... 206 ODOMZO...... 60 ORAFATE...... 193 oxiconazole nitrate...... 47 OFEV...... 214 ORALAIR...... 193 OXISTAT...... 47 ofloxacin...... 29, 200, 208 ORALAIR ADULT OXLUMO...... 149 OGIVRI...... 60 STARTER PACK...... 193 OXTELLAR XR...... 38 olanzapine...... 71 ORALAIR CHILDRENS oxybutynin chloride...... 150 olanzapine-fluoxetine hcl.... 42 STARTER PACK...... 193 oxybutynin chloride er...... 150 OLINVYK...... 14 oralone...... 109 oxycodone hcl...... 14 OLIVE TREE...... 193 ORAPRED ODT...... 153 OXYCODONE HCL ER...... 14 olmesartan medoxomil...... 97 ORAVIG...... 47 OXYCODONE- olmesartan medoxomil- ORBACTIV...... 29 ACETAMINOPHEN...... 14 hctz...... 97 ORCHARD GRASS oxycodone-acetaminophen.14 olmesartan-amlodipine- POLLEN...... 193 OXYCONTIN...... 15 hctz...... 97 ORENCIA...... 175 oxymorphone hcl...... 15 olopatadine hcl...... 200, 210 ORENCIA CLICKJECT.....175 oxymorphone hcl er...... 15 OLUMIANT...... 175 ORENITRAM...... 216 oxytocin...... 158 OMECLAMOX-PAK...... 145 ORFADIN...... 147 OXYTOCIN-LACTATED omega-3-acid ethyl esters.. 97 ORGOVYX...... 60 RINGERS...... 158 OMEGAVEN...... 135 ORIAHNN...... 166 OXYTOCIN-SODIUM omeprazole...... 142 ORILISSA...... 158 CHLORIDE...... 158 OMEPRAZOLE+SYRSPE ORKAMBI...... 216 OZEMPIC...... 119 ND SF ALKA...... 142 ORLADEYO...... 175 OZURDEX...... 200 OMIDRIA...... 206 orphenadrine citrate...... 218 PACERONE...... 97 OMNARIS...... 210 orphenadrine citrate er...... 218 paclitaxel...... 61 OMNIPOD DASH 5 PACK orphenadrine-asa-caffeine 218 PADCEV...... 61 PODS...... 193 ORPHENGESIC FORTE.. 218 PAINGO KFT...... 18 OMNITROPE...... 158 orsythia...... 166 PALFORZIA...... 193 ONCASPAR...... 60 ORTHOVISC...... 193 paliperidone er...... 71 ondansetron hcl...... 44 oscimin...... 145 palonosetron hcl...... 44 ondansetron odt...... 44 oscimin sr...... 145 PALYNZIQ...... 147 ONE VITE WOMENS oseltamivir phosphate...... 75 PAMELOR...... 42 PLUS...... 135 OSENI...... 119 pamidronate disodium...... 182 ONEVITE...... 135 OSMITROL...... 97 PANCREAZE...... 147 ONFI...... 38 OSMOPREP...... 145 pancuronium bromide...... 107 ONGENTYS...... 68 OSPHENA...... 155 PANDA MASK LARGE..... 193 ONGLYZA...... 119 OTEZLA...... 175 PANDA MASK MEDIUM...193 ONIVYDE...... 60 OTIPRIO...... 208 PANDA MASK SMALL..... 193 ONPATTRO...... 107 OTOVEL...... 208 PANHEMATIN...... 84 ONTRUZANT...... 60 OVACE PLUS...... 114, 115 PANRETIN...... 61 ONUREG...... 60 OVACE PLUS WASH...... 115 pantoprazole sodium...... 142 OPDIVO...... 60 OVACE WASH...... 115 PANZYGA...... 175 opium...... 145 OVIDE...... 66 PARAGARD OPSUMIT...... 216 OVIDREL...... 158 INTRAUTERINE COPPER OPTICHAMBER oxacillin sodium...... 29 ...... 166 DIAMOND...... 193 OXACILLIN SODIUM IN paraplatin...... 61 DEXTROSE...... 29 paricalcitol...... 183

241 PARLODEL...... 68 permethrin...... 67 pioglitazone hcl-glimepiride PARNATE...... 42 perphenazine...... 44 ...... 120 paromomycin sulfate...... 29 perphenazine-amitriptyline..42 pioglitazone hcl-metformin paroxetine hcl...... 42 PERSERIS...... 71 hcl...... 120 paroxetine hcl er...... 42 PERTZYE...... 147 piperacillin sod-tazobactam PARSABIV...... 183 PFIZER-BIONTECH so...... 29 PASER...... 51 COVID-19 VACC...... 179 PIQRAY...... 61 PATANASE...... 210 PFIZERPEN...... 29 pirmella 1/35...... 166 PAXIL...... 42 phenazo...... 150 pirmella 7/7/7...... 166 PAXIL CR...... 42 phenazopyridine hcl...... 150 piroxicam...... 8 PEDIAPRED...... 153 phenelzine sulfate...... 42 PITOCIN...... 158 PEDIARIX...... 179 PHENERGAN...... 210 PLAN B ONE-STEP...... 166 PEDIATRIC PANDA phenobarbital...... 38 PLAQUENIL...... 67 MASK...... 193 phenobarbital sodium...... 38 PLASBUMIN-25...... 194 PEDVAX HIB...... 179 PHENOL...... 194 PLASBUMIN-5...... 194 peg 3350...... 145 phenoxybenzamine hcl...... 97 PLASMA-LYTE 148...... 135 peg 3350-kcl-na bicarb- phentolamine mesylate...... 97 PLASMA-LYTE A...... 135 nacl...... 145 PHENYLEPHRINE HCL PLASMANATE...... 194 peg-3350/electrolytes...... 145 ...... 97, 98, 150, 206 PLAVIX...... 69 peg- phenylephrine hcl...... 97, 206 PLEGISOL...... 135 3350/electrolytes/ascorbat 145 PHENYLEPHRINE HCL PLEGRIDY...... 106 PEGASYS...... 75 (PRESSORS)...... 97 PLEGRIDY STARTER peg-kcl-nacl-nasulf-na asc- PHENYLEPHRINE HCL- PACK...... 106 c...... 145 NACL...... 98 PLENAMINE...... 135 peg-prep...... 145 PHENYTEK...... 38 PLIAGLIS...... 18 PEMAZYRE...... 61 phenytoin...... 38 PNEUMOVAX 23...... 179 penicillamine...... 150 phenytoin infatabs...... 38 POCKET SPACER...... 194 PENICILLIN G POT IN phenytoin sodium...... 38 podocon...... 115 DEXTROSE...... 29 phenytoin sodium podofilox...... 115 penicillin g potassium...... 29 extended...... 38 POLIDOCANOL...... 98 penicillin g procaine...... 29 PHESGO...... 61 POLIVY...... 61 penicillin g sodium...... 29 PHEXXI...... 194 polocaine...... 18 penicillin v potassium...... 29 philith...... 166 polocaine-mpf...... 18 PENICILLIUM NOTATUM PHOMA EXIGUA...... 194 polycin...... 206 ...... 193, 194 PHOSLYRA...... 150 polyethylene glycol 3350.. 145 PENTACEL...... 179 PHOSPHA 250 NEUTRAL135 poly-iron 150 forte...... 135 PENTAM...... 67 PHOSPHASAL...... 150 polymyxin b sulfate...... 29 pentamidine isethionate...... 67 phosphorous...... 135 polymyxin b-trimethoprim..206 PENTASA...... 181 phospho-trin 250 neutral...135 polysaccharide iron forte...135 pentazocine-naloxone hcl... 15 PHOTOFRIN...... 61 POLYTRIM...... 206 pentobarbital sodium...... 38 PHOTREXA VISCOUS.....194 POLY-VI-FLOR...... 135 pentoxifylline er...... 97 PHOXILLUM BK4/2.5...... 135 POLY-VI-FLOR/IRON PEPAXTO...... 61 PHYSIOLYTE...... 135 ...... 135, 136 PEPCID...... 142 PHYSIOSOL IRRIGATION POMALYST...... 61 PERCOCET...... 15 ...... 135 PONVORY...... 106 PERENNIAL RYE GRASS phytonadione...... 135 PONVORY STARTER POLLEN...... 194 PIFELTRO...... 75 PACK...... 106 PERFOROMIST...... 214 pilocarpine hcl...... 109, 202 portia-28...... 166 PERIDEX...... 109 pimecrolimus...... 115 PORTRAZZA...... 61 PERIKABIVEN...... 135 pimozide...... 71 posaconazole...... 47 perindopril erbumine...... 97 pimtrea...... 166 potassium acetate...... 136 periogard...... 109 pindolol...... 98 potassium chloride...... 136 PERJETA...... 61 pioglitazone hcl...... 120 potassium chloride crys er 136

242 potassium chloride er...... 136 PREDNISOLON- PREVIDENT 5000 PLUS..109 potassium chloride in MOXIFLOX-BROMFENAC PREVIDENT 5000 dextrose...... 136 ...... 207 SENSITIVE...... 109 potassium chloride in nacl 136 prednisone...... 154 previfem...... 167 potassium citrate er...... 136 prednisone intensol...... 154 PREVNAR 13...... 179 potassium citrate-citric acid PREFEST...... 166 PREVYMIS...... 75 ...... 136 pregabalin...... 107 PREZCOBIX...... 75 potassium phosphates(71 pregabalin er...... 107 PREZISTA...... 75 meq k)...... 136 pregnyl...... 158 PRIALT...... 15 POTELIGEO...... 61 PREMARIN...... 166 PRIFTIN...... 51 POVIDONE-IODINE...... 200 PREMASOL...... 136 PRILOLID...... 18 PRADAXA...... 34 PREMESISRX...... 136 PRILOSEC...... 142 PRALUENT...... 98 premium lidocaine...... 18 PRILOVIX...... 18 pramipexole PREMPHASE...... 166 PRILOVIX LITE...... 18 dihydrochloride...... 68 PREMPRO...... 167 PRILOVIX LITE PLUS...... 18 pramipexole PRENAISSANCE...... 136 PRILOVIX PLUS...... 19 dihydrochloride er...... 68 prenatal...... 136 PRILOVIX ULTRALITE...... 19 PRAMOTIC...... 208 prenatal plus iron...... 136 PRILOVIX ULTRALITE pramox...... 115 prenatal vitamin plus low PLUS...... 19 prasugrel hcl...... 69 iron...... 136 primaquine phosphate...... 67 pravastatin sodium...... 98 PRENATE...... 136 PRIMAXIN IV...... 30 PRAXBIND...... 194 PRENATE DHA...... 136 primidone...... 38 praziquantel...... 67 PRENATE ELITE...... 136 PRIMSOL...... 30 prazosin hcl...... 98 PRENATE ENHANCE...... 136 PRINIVIL...... 98 PRE & POST SX POUCH 115 PRENATE ESSENTIAL.... 136 PRISMASOL B22GK 4/0.. 137 PRECEDEX...... 194 PRENATE MINI...... 136 PRISMASOL BGK 0/2.5... 137 PRECISION PCX PLUS PRENATE PIXIE...... 136 PRISMASOL BGK 2/0...... 137 TEST...... 121 PRENATE RESTORE...... 136 PRISMASOL BGK 2/3.5... 137 PRECISION QID TEST.... 122 PRENATRIX...... 137 PRISMASOL BGK 4/0/1.2 137 PRECISION SOF-TACT PRENATRYL...... 137 PRISMASOL BGK 4/2.5... 137 TEST...... 122 PRENATVITE COMPLETE PRISMASOL BK 0/0/1.2... 137 PRECISION XTRA...... 122 ...... 137 PRISTIQ...... 42 PRECISION XTRA PRENATVITE PLUS...... 137 PRIVET...... 194 BLOOD GLUCOSE...... 122 PRENATVITE RX...... 137 PRIVIGEN...... 175 PRECOSE...... 120 PREPIDIL...... 150 PRO COMFORT SPACER PRED FORTE...... 200 preplus...... 137 ADULT...... 194 PRED MILD...... 200 PRESTALIA...... 98 PRO COMFORT SPACER PRED-G...... 206 PRETAB...... 137 CHILD...... 194 PRED-G S.O.P...... 206 PRETOMANID...... 51 PRO COMFORT SPACER prednicarbate...... 115 PREVACID...... 142 INFANT...... 194 PREDNISOL ACE- PREVACID SOLUTAB...... 142 PRO HERS RX...... 137 MOXIFLOX-BROMFEN.... 200 prevalite...... 98 PRO HIS RX...... 137 prednisolone...... 153 preventeza...... 167 PRO PCOS RX...... 137 prednisolone acetate...... 200 PREVIDENT...... 109 PROAIR HFA...... 214 prednisolone acetate p-f... 201 prevident...... 109 PROAIR RESPICLICK...... 214 prednisolone sodium PREVIDENT 5000 probenecid...... 48 phosphate...... 154, 201 BOOSTER PLUS...... 109 procainamide hcl...... 98 PREDNISOLONE- PREVIDENT 5000 DRY PROCALAMINE...... 137 BROMFENAC...... 206 MOUTH...... 109 PROCARDIA XL...... 98 PREDNISOLONE- PREVIDENT 5000 PROCARE GATIFLOXACIN...... 206 ENAMEL PROTECT...... 109 SPACER/ADULT MASK... 194 PREDNISOLON- PREVIDENT 5000 ORTHO PROCARE GATIFLOX-BROMFENAC 206 DEFENSE...... 109 SPACER/CHILD MASK.... 194

243 PROCENTRA...... 104 PROVERA...... 167 QUICKVUE DIPSTICK prochlorperazine...... 44 PROVIGIL...... 219 STREP A TEST...... 195 prochlorperazine edisylate..44 PROVISC...... 207 QUICKVUE INFLUENZA prochlorperazine maleate... 44 PROZAC...... 42 A+B TEST...... 195 PROCRIT...... 84 PRUDOXIN...... 115 QUICKVUE IN-LINE PROCTOCORT...... 181 pseudoephedrine- STREP A TEST...... 195 PROCTOFOAM HC...... 181 bromphen-dm...... 210 QUILLICHEW ER...... 104 procto-med hc...... 181 PSORCON...... 115 QUILLIVANT XR...... 104 procto-pak...... 182 PULMICORT FLEXHALER quinapril hcl...... 99 proctozone-hc...... 182 ...... 214 quinapril- PROFILNINE...... 84 PULMICORT hydrochlorothiazide...... 99 progesterone...... 167 SUSPENSION...... 214 quinidine gluconate er...... 99 progesterone micronized.. 167 PULMOZYME...... 216 quinidine sulfate...... 99 PROGLYCEM...... 122 PURAPLY...... 115 quinine sulfate...... 67 PROGRAF...... 175 purevit dualfe plus...... 137 QUTENZA...... 115 PROLASTIN-C...... 214 PURIXAN...... 61 QUTENZA (2 PATCH)...... 115 PROLATE...... 15 PYLARIFY...... 194 QUTENZA (4 PATCH)...... 115 PROLENSA...... 201 PYLERA...... 145 QUZYTTIR...... 210 PROLEUKIN...... 61 pyrazinamide...... 51 QVAR REDIHALER...... 214 PROLIA...... 182 PYRIDIUM...... 150 RABAVERT...... 179 PROMACTA...... 84 pyridostigmine bromide...... 51 RABBIT EPITHELIUM...... 195 promethazine hcl...... 210 pyridostigmine bromide er.. 51 RABEPRAZOLE SODIUM 142 promethazine vc...... 210 PYRIDOXAL-5 rabeprazole sodium...... 142 promethazine vc/codeine..210 PHOSPHATE...... 137 RADICAVA...... 107 promethazine-codeine...... 210 pyridoxine hcl...... 137 RADIOGARDASE...... 195 promethazine-dm...... 210 PYRIDOXINE HCL...... 137 RAGWITEK...... 195 promethazine-phenyleph- pyrimethamine...... 67 raloxifene hcl...... 155 codeine...... 210 PYRIMETHAMINE- ramelteon...... 219 promethazine- LEUCOVORIN...... 67 ramipril...... 99 phenylephrine...... 210 PYROGALLIC ACID...... 115 RANEXA...... 99 promethegan...... 210 QBRELIS...... 98 ranolazine er...... 99 PROMETRIUM...... 167 QBREXZA...... 115 RAPAFLO...... 152 propafenone hcl...... 98 QELBREE...... 104 RAPAMUNE...... 175 propafenone hcl er...... 98 QINLOCK...... 61 RAPIVAB...... 76 proparacaine hcl...... 207 QNASL...... 210 rasagiline mesylate...... 68 propofol...... 194 QNASL CHILDRENS...... 210 RAVICTI...... 147 propofol-lipuro...... 194 QTERN...... 120 RAYALDEE...... 182 propranolol hcl...... 98 QUAD-MIX...... 150 RAZADYNE ER...... 40 propranolol hcl er...... 98 QUADRACEL...... 179 REBIF...... 106 propylthiouracil...... 169 QUADRAMET...... 61 REBIF REBIDOSE...... 106 PROQUAD...... 179 QUALAQUIN...... 67 REBIF REBIDOSE PROSCAR...... 151 QUARTETTE...... 167 TITRATION PACK...... 106 PROSILK...... 115 quazepam...... 80 REBIF TITRATION PACK 106 PROSOL...... 137 QUDEXY XR...... 38 REBINYN...... 84 PROSTIN E2...... 150 QUEEN PALM...... 194 REBLOZYL...... 84 PROSTIN VR...... 98 QUELICIN...... 107 RECARBRIO...... 30 protamine sulfate...... 84 QUESTRAN...... 98, 99 RECK...... 19 PROTHELIAL...... 194 QUESTRAN LIGHT...... 98 RECLAST...... 183 PROTONIX...... 142 quetiapine fumarate...... 71 reclipsen...... 167 PROTOPAM CHLORIDE..194 quetiapine fumarate er...... 71 RECOMBINATE...... 84 protriptyline hcl...... 42 QUFLORA PEDIATRIC.... 137 RECOMBIVAX HB...... 179 PROVAYBLUE...... 194 QUICKVUE + STREP A RECOTHROM...... 85 PROVENGE...... 175 TEST...... 194 RECOTHROM SPRAY KIT 85

244 RECTIV...... 99 REZUROCK...... 175 ROTARIX...... 180 RECURA...... 47 R-GENE 10...... 195 ROTATEQ...... 180 RED MAPLE...... 195 RHIZOPUS...... 195 ROUGH MARSH ELDER. 195 RED MULBERRY...... 195 RHOFADE...... 115 ROWASA...... 182 RED TOP GRASS RHOGAM ULTRA- roweepra...... 38 POLLEN...... 195 FILTERED PLUS...... 176 ROXICODONE...... 15 REGIOCIT...... 34 RHOPHYLAC...... 176 ROZEREM...... 219 REGLAN...... 44 RHOPRESSA...... 202 ROZLYTREK...... 62 REGONOL...... 51 RIABNI...... 61 RUBRACA...... 62 REGRANEX...... 115 RIASTAP...... 85 RUCONEST...... 176 RELADOR PAK...... 19 ribavirin...... 76 rufinamide...... 38 RELADOR PAK PLUS...... 19 RIDAURA...... 176 RUKOBIA...... 76 RELAFEN...... 8 rifabutin...... 52 RUSSIAN THISTLE...... 195 RELENZA DISKHALER...... 76 RIFADIN...... 52 RUXIENCE...... 62 relexxii...... 104 rifampin...... 52 RUZURGI...... 195 RELISTOR...... 145 RILUTEK...... 108 RYANODEX...... 218 RELNATE DHA...... 137 riluzole...... 108 RYBELSUS...... 120 RELPAX...... 50 rimantadine hcl...... 76 RYBREVANT...... 62 REMERON...... 42 RIMSO-50...... 150 RYCLORA...... 210 REMERON SOLTAB...... 42 ringers...... 137 RYDAPT...... 62 REMESENSE...... 109 ringers irrigation...... 137 RYLAZE...... 62 REMICADE...... 175 RINVOQ...... 176 RYTARY...... 68 remifentanil hcl...... 15 RIOMET...... 120 RYTHMOL SR...... 99 REMODULIN...... 217 risedronate sodium...... 183 SABRIL...... 38 RENACIDIN...... 150 RISPERDAL...... 72 SACCHAROMYCES RENAGEL...... 150 RISPERDAL CONSTA...... 72 CEREVISIAE...... 195 RENAL...... 137 risperidone...... 72 SAFYRAL...... 167 RENATABS...... 137 RITALIN...... 104 SAIZEN...... 158 RENATABS WITH IRON.. 137 RITALIN LA...... 104 SAIZENPREP...... 158 RENFLEXIS...... 175 ritonavir...... 76 SALAGEN...... 109 RENVELA...... 150 RITUXAN...... 62 SALEX...... 115 repaglinide...... 120 RITUXAN HYCELA...... 61 salicylic acid...... 115 REPATHA...... 99 rivastigmine...... 40 salicylic acid wart remover 115 REPATHA PUSHTRONEX rivastigmine tartrate...... 40 salicylic acid-cleanser...... 115 SYSTEM...... 99 rivelsa...... 167 salimez...... 115 REPATHA SURECLICK..... 99 RIXUBIS...... 85 SALIMEZ FORTE...... 115 REQ 49+...... 137 rizatriptan benzoate...... 50 saline bacteriostatic...... 138 RESORCINOL-SULFUR.. 115 ROBAXIN...... 218 SALINE-PHENOL...... 138 RESTASIS...... 207 ROCALTROL...... 183 SALIVAMAX...... 109 RESTASIS MULTIDOSE.. 207 ROCKLATAN...... 202 salsalate...... 8 RESTORIL...... 219 rocuronium bromide...... 108 SALVAX...... 115 RETACRIT...... 85 ROCURONIUM BROMIDE SALVAX DUO PLUS...... 115 RETEVMO...... 61 ...... 108 SAMSCA...... 138 RETIN-A MICRO...... 115 ROMIDEPSIN...... 62 SANCUSO...... 45 RETIN-A MICRO PUMP... 115 ropinirole hcl...... 68 SANDIMMUNE...... 176 RETROVIR...... 76 ropinirole hcl er...... 68 SANDOSTATIN...... 158 REVATIO...... 217 ROPIVACAINE HCL...... 19 SANDOSTATIN LAR REVCOVI...... 148 ropivacaine hcl...... 19 DEPOT...... 158 REVLIMID...... 61 ROPIVACAINE HCL-NACL 19 SANTYL...... 116 revonto...... 218 ROPIV-CLONIDINE- SAPHRIS...... 72 REXULTI...... 71 KETOROLAC...... 19 sapropterin dihydrochloride REYATAZ...... 76 rosadan...... 115 ...... 148 REYVOW...... 50 rosuvastatin calcium...... 99 SARCLISA...... 62

245 SAVAYSA...... 34 silver sulfadiazine...... 30 sodium sulfacetamide SAVELLA...... 108 SIMBRINZA...... 202 wash...... 116 SAVELLA TITRATION simliya...... 167 SODIUM PACK...... 108 simpesse...... 167 SULFACETAMIDE- SCALACORT DK...... 116 SIMPONI...... 176 BAKUCHIOL...... 116 SCENESSE...... 116 SIMPONI ARIA...... 176 sodium tetradecyl sulfate.... 99 SCLEROSOL SIMULECT...... 176 SODIUM THIOSULFATE..195 INTRAPLEURAL...... 214 simvastatin...... 99 sodium thiosulfate...... 195 scopolamine...... 45 SINEMET...... 68 SOFIA INFLUENZA A+B SEASONIQUE...... 167 SINGULAIR...... 214 FIA...... 195 SECUADO...... 72 SINUVA...... 210 SOFIA STREP A FIA...... 195 SEGLUROMET...... 120 sirolimus...... 176 SOFIA STREP A+ FIA...... 195 SELECT-OB...... 138 SIRTURO...... 52 SOFOSBUVIR- selegiline hcl...... 68 SIVEXTRO...... 30 VELPATASVIR...... 76 SELENIOUS ACID...... 138 SKELAXIN...... 218 SOLESTA...... 195 selenium sulfide...... 116 SKYLA...... 167 solifenacin succinate...... 150 SELRX...... 116 SKYRIZI (150 MG DOSE) 176 SOLIQUA...... 120 SELZENTRY...... 76 SLYND...... 167 SOLIRIS...... 85 SENSIPAR...... 183 SMOFLIPID...... 138 SOLOSEC...... 30 SENSORCAINE...... 19 sod benz-sod phenylacet..148 SOLU-CORTEF...... 154 SENSORCAINE/EPINEPH sod citrate-citric acid...... 138 SOLU-MEDROL...... 154 RINE...... 19 sodium acetate...... 138 SOMA...... 218 SENSORCAINE-MPF...... 19 sodium bicarbonate.. 138, 145 SOMATULINE DEPOT..... 158 sensorcaine-mpf...... 19 SODIUM BICARBONATE.138 SOMAVERT...... 158 SENSORCAINE- SODIUM BICARBONATE- SOOLANTRA...... 116 MPF/EPINEPHRINE...... 19 DEXTROSE...... 138 SORBITOL...... 195 SEREVENT DISKUS...... 214 sodium chloride...... 138, 210 sorbitol-mannitol...... 195 SEROQUEL...... 72 sodium chloride (pf)...... 138 SORIATANE...... 116 SEROQUEL XR...... 72 sodium chloride sorine...... 99 SEROSTIM...... 145 bacteriostatic...... 138 SORREL/DOCK MIX...... 196 sertraline hcl...... 42, 43 sodium chloride flush...... 138 SOTALOL HCL...... 99 se-tan plus...... 138 SODIUM CITRATE...... 34 sotalol hcl...... 99 setlakin...... 167 SODIUM CITRATE LOCK sotalol hcl (af)...... 99 sevelamer carbonate...... 150 FLUSH...... 34 SOTRADECOL...... 99 sevelamer hcl...... 150 SODIUM CITRATE- SOTYLIZE...... 99 SEVENFACT...... 85 GENTAMICIN SULF...... 35 SOVALDI...... 76 sf...... 109 SODIUM DIURIL...... 99 spinosad...... 67 sf 5000 plus...... 109 SODIUM EDECRIN...... 99 SPINRAZA...... 196 SFROWASA...... 182 sodium fluoride...... 110, 138 SPINY PIGWEED...... 196 SHAGBARK HICKORY.... 195 sodium fluoride 5000 SPIRIVA HANDIHALER... 214 sharobel...... 167 enamel...... 110 SPIRIVA RESPIMAT...... 214 SHEEP SORREL...... 195 sodium fluoride 5000 plus.110 spironolactone...... 99 SHINGRIX...... 180 sodium fluoride 5000 ppm 110 spironolactone-hctz...... 99 SHORT RAGWEED sodium fluoride 5000 SPORANOX...... 47 POLLEN EXT...... 195 sensitive...... 110 SPORANOX PULSEPAK... 47 SIGNIFOR...... 158 SODIUM IODIDE I-131.....169 SPRAVATO (56 MG SIGNIFOR LAR...... 158 sodium nitrite...... 195 DOSE)...... 43 sildenafil citrate...... 150, 217 sodium nitroprusside...... 99 SPRAVATO (84 MG SILENOR...... 219 sodium phenylbutyrate...... 148 DOSE)...... 43 SILIQ...... 176 sodium polystyrene sprintec 28...... 167 silodosin...... 152 sulfonate...... 138 SPRITAM...... 38 SILVADENE...... 30 sodium saccharin...... 195 SPRYCEL...... 62 silver nitrate...... 30 sodium sulfacetamide...... 116 sps...... 138

246 sronyx...... 167 SULCONAZOLE NITRATE SYMLINPEN 60...... 120 ssd...... 30 ...... 47, 48 SYMPAZAN...... 38 SSKI...... 210 sulfacetamide sodium SYMPROIC...... 146 sss 10-5...... 116 ...... 116, 201 SYMTUZA...... 76 ST JOSEPH LOW DOSE..... 8 sulfacetamide sodium SYNAGIS...... 176 STALEVO 100...... 68 (acne)...... 116 SYNAREL...... 159 STALEVO 125...... 68 sulfacetamide sodium- SYNDROS...... 45 STALEVO 150...... 69 sulfur...... 116 SYNERA...... 19 STALEVO 200...... 69 sulfacetamide- SYNERCID...... 30 STALEVO 50...... 69 prednisolone...... 207 SYNJARDY...... 120 STALEVO 75...... 69 sulfacetamide-sulfur in SYNJARDY XR...... 120 STAMARIL...... 180 urea...... 116 SYNRIBO...... 62 stavudine...... 76 sulfadiazine...... 30 SYNTHROID...... 169 STEGLATRO...... 120 sulfamethoxazole- SYNVISC...... 196 STEGLUJAN...... 120 trimethoprim...... 30 SYNVISC ONE...... 196 STELARA...... 176 sulfamez wash...... 116 SYPRINE...... 138 STEMPHYLIUM...... 196 SULFAMYLON...... 30 TABLOID...... 62 STERILE DILUENT sulfasalazine...... 182 TABRECTA...... 62 FLOLAN PH 12...... 196 sulfatrim pediatric...... 30 TACHOSIL...... 196 sterile diluent/epoprostenol sulfurated lime...... 67 tacrolimus...... 116, 176 ...... 196 sulindac...... 8 tadalafil...... 150 STERILE TALC POWDER214 sumatriptan...... 50 tadalafil (pah)...... 217 sterile water for injection... 196 sumatriptan succinate...... 50 TAFINLAR...... 62 sterile water for irrigation.. 138 sumatriptan succinate refill. 50 TAGRISSO...... 62 STIMATE...... 158 SUNOSI...... 219 TAKHZYRO...... 219 STIOLTO RESPIMAT...... 215 SUPARTZ FX...... 196 TALIVA...... 138 STIVARGA...... 62 SUPER BI-MIX...... 150 TALL RAGWEED...... 196 STRATTERA...... 104 SUPER QUAD-MIX...... 150 TALTZ...... 176 STRENSIQ...... 148 SUPER TRI-MIX...... 150 TALZENNA...... 62 streptomycin sulfate...... 30 SUPERVITE...... 138 TAMIFLU...... 76, 77 STRIBILD...... 76 SUPPRELIN LA...... 159 tamoxifen citrate...... 62 STRIVERDI RESPIMAT... 215 SUPRAX...... 30 tamsulosin hcl...... 152 STROMECTOL...... 67 SUPREP BOWEL PREP TAPAZOLE...... 169 STRONTIUM CHLORIDE KIT...... 145 TAPERDEX 6-DAY...... 154 SR-89...... 62 SURVANTA...... 210 TARCEVA...... 62 STROVITE FORTE...... 138 SUSTIVA...... 76 TARGRETIN...... 62 STROVITE ONE...... 138 SUSTOL...... 45 tarina 24 fe...... 167 SUBLOCADE...... 21 SUTAB...... 145 tarina fe 1/20...... 167 SUBOXONE...... 21 SUTENT...... 62 tarina fe 1/20 eq...... 167 SUBSYS...... 15 SWEET GUM...... 196 TARKA...... 100 subvenite...... 38 SWEET VERNAL GRASS TARON FORTE...... 139 subvenite starter kit-blue.....38 POLLEN...... 196 TASIGNA...... 62 subvenite starter kit-green.. 38 syeda...... 167 TASMAR...... 69 subvenite starter kit-orange 38 SYLVANT...... 62 TAURINE...... 139 SUCCINYLCHOLINE SYMAX DUOTAB...... 146 tavaborole...... 48 CHLORIDE...... 108 SYMAX-SL...... 146 TAVALISSE...... 85 succinylcholine chloride.... 108 SYMAX-SR...... 146 TAYTULLA...... 167 SUCRAID...... 148 SYMBICORT...... 215 tazarotene...... 116 sucralfate...... 142 SYMBYAX...... 43 tazicef...... 30 sufentanil citrate...... 15 SYMDEKO...... 216 TAZICEF...... 30 SULAR...... 100 SYMFI...... 76 TAZORAC...... 116 SYMFI LO...... 76 taztia xt...... 100 SYMLINPEN 120...... 120 TAZVERIK...... 62

247 TDVAX...... 180 THALOMID...... 63 TOBI NEBULIZER...... 216 TECARTUS...... 63 THAM...... 139 TOBI PODHALER...... 216 TECENTRIQ...... 63 THEO-24...... 215 TOBRADEX...... 207 TECFIDERA...... 106 theophylline...... 215 TOBRADEX ST...... 207 TEFLARO...... 31 theophylline er...... 215 tobramycin...... 201, 216 TEGRETOL...... 38, 39 thiamine hcl...... 139 TOBRAMYCIN...... 216 TEGRETOL-XR...... 39 THIOLA...... 151 tobramycin sulfate...... 31 TEGSEDI...... 108 THIOLA EC...... 151 tobramycin- TEKTURNA...... 100 thioridazine hcl...... 72 dexamethasone...... 207 TEKTURNA HCT...... 100 thiotepa...... 63 TOBREX...... 201 TELFA AMD ISLAND thiothixene...... 72 TODAY SPONGE...... 196 DRESSING...... 196 THROMBATE III...... 35 tolbutamide...... 120 TELFA AMD NON- THROMBIN-JMI...... 85 tolcapone...... 69 ADHERENT...... 196 THROMBIN-JMI tolterodine tartrate...... 151 telmisartan...... 100 EPISTAXIS...... 85 tolterodine tartrate er...... 151 telmisartan-amlodipine...... 100 THROMBOGEN...... 85 TOLVAPTAN...... 139 telmisartan-hctz...... 100 THYMOGLOBULIN...... 177 tolvaptan...... 139 temazepam...... 219 THYROGEN...... 196 TOPAMAX...... 39 TEMIXYS...... 77 tiadylt er...... 100 TOPAMAX SPRINKLE...... 39 TEMODAR...... 63 tiagabine hcl...... 39 TOPICORT...... 116 temozolomide...... 63 TIAZAC...... 100 topiramate...... 39 temsirolimus...... 176 TIBSOVO...... 63 topiramate er...... 39 TENCON...... 15 TICE BCG...... 177 toposar...... 63 teniposide...... 63 TIGAN...... 45 topotecan hcl...... 63 TENIVAC...... 180 tigecycline...... 31 TOPROL XL...... 100 tenofovir disoproxil TIGLUTIK...... 108 toremifene citrate...... 63 fumarate...... 77 TIKOSYN...... 100 TORISEL...... 177 TENORETIC 100...... 100 tilia fe...... 167 torsemide...... 100 TENORETIC 50...... 100 timolol maleate..100, 202, 203 TOTECT...... 63 TENORMIN...... 100 timolol maleate ocudose... 202 TOUJEO MAX TEPADINA...... 63 timolol maleate pf...... 203 SOLOSTAR...... 125 TEPEZZA...... 159 TIMOLOL-BRIMON- TOUJEO SOLOSTAR...... 126 TEPMETKO...... 63 DORZOL-LATANOPR...... 203 tovet...... 116 terazosin hcl...... 152 TIMOLOL-BRIMONIDINE- TOVIAZ...... 151 terbinafine hcl...... 48 DORZOLAMID...... 203 TPN ELECTROLYTES..... 139 terbutaline sulfate...... 215 TIMOLOL-DORZOLAMID- TRACLEER...... 217 terconazole...... 48 LATANOPROST...... 203 TRADJENTA...... 120 TERIPARATIDE TIMOPTIC...... 203 TRALEMENT...... 139 (RECOMBINANT)...... 183 TIMOPTIC OCUDOSE..... 203 tramadol hcl...... 15 TESSALON PERLES...... 210 TIMOPTIC-XE...... 203 tramadol hcl er...... 15 TESTIM...... 155 TIMOTHY GRASS tramadol hcl er (biphasic)... 15 TESTONE CIK...... 155 POLLEN ALLERGEN...... 196 tramadol-acetaminophen.... 15 TESTOPEL...... 155 tinidazole...... 31 trandolapril...... 100 testosterone...... 155 tiopronin...... 151 trandolapril-verapamil hcl TESTOSTERONE TIROSINT...... 169 er...... 100 CYPIONATE...... 155 TISSEEL...... 196 tranexamic acid...... 85 testosterone cypionate...... 155 TISSUEBLUE...... 207 TRANEXAMIC ACID- testosterone enanthate..... 155 tis-u-sol...... 139 NACL...... 85 TETANUS-DIPHTHERIA TIVICAY...... 77 TRANSDERM SCOP (1.5 TOXOIDS TD...... 180 TIVICAY PD...... 77 MG)...... 45 tetrabenazine...... 108 tizanidine hcl...... 218 TRANSDERM-SCOP (1.5 tetracaine hcl...... 207 tl-hem 150...... 139 MG)...... 45 tetracycline hcl...... 31 TNKASE...... 35 TRANXENE-T...... 80

248 tranylcypromine sulfate...... 43 TRIJARDY XR...... 120 TRULANCE...... 146 TRAVASOL...... 139 TRIKAFTA...... 216 TRULICITY...... 120 TRAVATAN Z...... 203 tri-legest fe...... 167 TRUMENBA...... 180 travoprost (bak free)...... 203 TRILEPTAL...... 39 TRUSELTIQ (100MG TRAZIMERA...... 63 tri-linyah...... 167 DAILY DOSE)...... 63 trazodone hcl...... 43 TRILIPIX...... 101 TRUSELTIQ (125MG TREANDA...... 63 tri-lo-estarylla...... 167 DAILY DOSE)...... 63 TRECATOR...... 52 tri-lo-marzia...... 167 TRUSELTIQ (50MG DAILY TRELEGY ELLIPTA...... 215 tri-lo-mili...... 167 DOSE)...... 63 TRELSTAR MIXJECT...... 159 tri-lo-sprintec...... 168 TRUSELTIQ (75MG DAILY TREMFYA...... 177 TRILURON...... 197 DOSE)...... 63 treprostinil...... 217 trimethobenzamide hcl...... 45 TRUSOPT...... 203 TRESIBA...... 126 trimethoprim...... 31 TRUVADA...... 77 TRESIBA FLEXTOUCH....126 tri-mili...... 168 TRUXIMA...... 64 tretinoin...... 63, 116 trimipramine maleate...... 43 TUKYSA...... 64 tretinoin microsphere...... 116 TRINATE...... 139 tulana...... 168 tretinoin microsphere pump TRINTELLIX...... 43 TURALIO...... 64 ...... 116 tri-nymyo...... 168 turpentine...... 117 TRETTEN...... 85 TRIOSTAT...... 170 TUSSICAPS...... 211 TREXALL...... 177 triphrocaps...... 139 TUXARIN ER...... 211 TREZIX...... 15 TRIPLE PMB...... 201 TUZISTRA XR...... 211 tri femynor...... 167 TRIPLE PMK...... 201 TWINRIX...... 180 triamcinolone acetonide tri-previfem...... 168 TWIRLA...... 168 ...... 110, 117, 154 TRIPTODUR...... 159 TWYNSTA...... 101 TRIAMCINOLONE tri-sprintec...... 168 tyblume...... 168 ACETONIDE...... 154 TRISTART DHA...... 139 TYBOST...... 77 TRIAMCINOLONE- tritocin...... 117 tydemy...... 168 BUPIVACAINE...... 154 TRIUMEQ...... 77 TYGACIL...... 31 TRIAMCINOLONE- TRI-VI-FLOR...... 139 TYKERB...... 64 MOXIFLOXACIN...... 207 TRI-VI-FLORO...... 139 TYMLOS...... 183 triamterene...... 100 TRIVISC...... 197 TYPHIM VI...... 180 triamterene-hctz...... 100 tri-vite/fluoride...... 139 TYSABRI...... 106 triazolam...... 80 trivora (28)...... 168 TYVASO...... 217 TRIBENZOR...... 100 tri-vylibra...... 168 TYVASO REFILL...... 217 TRICARE PRENATAL tri-vylibra lo...... 168 TYVASO STARTER...... 217 DHA ONE...... 139 TRIZIVIR...... 77 UBRELVY...... 50 TRI-CHLOR...... 117 TRODELVY...... 63 UCERIS...... 182 TRICHOPHYTON...... 197 TROGARZO...... 77 UDAMIN SP...... 139 TRICHOPHYTON TROKENDI XR...... 39 UDENYCA...... 85 MENTAGROPHYTES...... 196 TRONVITE...... 139 UKONIQ...... 64 TRICITRASOL...... 35 TROPHAMINE...... 139 ULORIC...... 48 tricitrates...... 139 TROPICAMIDE- ULTIGUARD SAFEPACK TRICON...... 139 CYCLOPENTOLATE-PE.. 207 SYR/NEEDLE...... 126 TRICOR...... 100 TROPICAMIDE- ULTIVA...... 15 triderm...... 117 PHENYLEPHRINE...... 207 ULTOMIRIS...... 85 trientine hcl...... 139 TROPIC-CYCLOPENT- ULTRABAG/DIANEAL PD- TRIESENCE...... 201 PE-KETOROLAC...... 207 2/1.5% DEX...... 139 tri-estarylla...... 167 TROPIC-CYCLOP-PE- ULTRABAG/DIANEAL PD- TRIFERIC...... 139 KETO-PROPAR...... 207 2/2.5% DEX...... 139 trifluoperazine hcl...... 72 TROPIC-PROPARACA- ULTRABAG/DIANEAL PD- trifluridine...... 201 PE-KETOROLAC...... 207 2/4.25%DEX...... 139 trigels-f forte...... 139 trospium chloride...... 151 ULTRABAG/DIANEAL/1.5 trihexyphenidyl hcl...... 69 trospium chloride er...... 151 % DEXTROSE...... 139

249 ULTRABAG/DIANEAL/2.5 VANCOMYCIN HCL...... 201 VERQUVO...... 101 % DEXTROSE...... 139 VANCOMYCIN HCL IN VERSACLOZ...... 72 ULTRABAG/DIANEAL/4.2 DEXTROSE...... 31 VERZENIO...... 64 5% DEX...... 140 vancomycin hcl in dextrose.31 VESICARE...... 151 ULTRACET...... 15 vancomycin hcl in nacl...... 31 vestura...... 168 ULTRAM...... 15 VANCOMYCIN HCL IN VEXATROL...... 19 UNASYN...... 31 NACL...... 31 VFEND...... 48 unithroid...... 170 vandazole...... 32 VFEND IV...... 48 UNITUXIN...... 64 VANTAS...... 159 VIAGRA...... 151 UPLIZNA...... 177 VAPRISOL...... 159 VIBATIV...... 32 UPNEEQ...... 201 VAQTA...... 180 VIBERZI...... 146 UPTRAVI...... 217 VARITHENA...... 101 VIBRAMYCIN...... 32 urea...... 117 VARIVAX...... 180 vic-forte...... 140 urea hydrating...... 117 VARUBI (180 MG DOSE)... 45 VICTOZA...... 121 urea nail...... 117 VASCEPA...... 101 VIDAZA...... 64 uredeb...... 117 VASERETIC...... 101 VIEKIRA PAK...... 77 URIBEL...... 151 VASOSTRICT...... 159 vienva...... 168 URIMAR-T...... 151 VASOTEC...... 101 vigabatrin...... 39 urin ds...... 151 VAXELIS...... 180 vigadrone...... 39 URO-458...... 151 VAZCULEP...... 101 VIGAMOX...... 201 UROCIT-K 10...... 140 v-c forte...... 140 VIIBRYD...... 43 UROCIT-K 15...... 140 VCF VAGINAL VIIBRYD STARTER PACK.43 UROCIT-K 5...... 140 CONTRACEPTIVE...... 197 VILAMIT MB...... 151 UROGESIC-BLUE...... 151 vcf vaginal contraceptive.. 197 VILEVEV MB...... 151 uro-mp...... 151 VECAMYL...... 101 VIMIZIM...... 148 urosex...... 140 VECTIBIX...... 64 VIMPAT...... 39 UROXATRAL...... 152 VECTICAL...... 117 VINATE ONE...... 140 URSO 250...... 146 vecuronium bromide...... 108 vinblastine sulfate...... 64 URSO FORTE...... 146 VELCADE...... 64 vincristine sulfate...... 64 ursodiol...... 146 VELETRI...... 217 vinorelbine tartrate...... 64 USTELL...... 151 velivet...... 168 VIOKACE...... 148 UTIRA-C...... 151 VELPHORO...... 151 viorele...... 168 UVADEX...... 64 VELTASSA...... 140 VIRACEPT...... 77 VABOMERE...... 31 VEMLIDY...... 77 VIRAMUNE...... 77 VAGIFEM...... 168 VENCLEXTA...... 64 VIRAMUNE XR...... 77 valacyclovir hcl...... 77 VENCLEXTA STARTING VIRASAL...... 117 VALCHLOR...... 64 PACK...... 64 VIRAZOLE...... 77 VALCYTE...... 77 VENELEX...... 117 VIREAD...... 77 valganciclovir hcl...... 77 VENEXA...... 140 virt-caps...... 140 VALIUM...... 80 VENEXA FE...... 140 VIRT-FEFA PLUS...... 140 valproate sodium...... 39 venlafaxine hcl...... 43 virt-gard...... 140 valproic acid...... 39 venlafaxine hcl er...... 43 virt-phos 250 neutral...... 140 valrubicin...... 64 VENOFER...... 140 VISCO-3...... 197 valsartan...... 101 VENOMIL MIXED VESPID VISIONBLUE...... 207 valsartan- VENOM...... 197 VISTARIL...... 80 hydrochlorothiazide...... 101 VENTAVIS...... 217 VISTOGARD...... 197 VALSTAR...... 64 VENTOLIN HFA...... 215 VISUDYNE...... 207 VALTOCO...... 39 VENTRIXYL...... 140 vita s forte...... 140 VALTREX...... 77 verapamil hcl...... 101 vitacel...... 140 VANADOM...... 218 verapamil hcl er...... 101 VITAFOL...... 140 VANCOCIN...... 31 VEREGEN...... 117 VITAFOL-NANO...... 140 VANCOCIN HCL...... 31 VERELAN...... 101 VITAFOL-OB+DHA...... 140 vancomycin hcl...... 31, 32 VERELAN PM...... 101 VITAL-D RX...... 140

250 VITAMEZ...... 140 WELLBUTRIN SR...... 43 XEMBIFY...... 177 vitamin d (ergocalciferol)...140 WELLBUTRIN XL...... 43 XENAZINE...... 108 vitamin k1...... 140 wera...... 168 XENLETA...... 32 vitamins acd-fluoride...... 140 westab mini...... 141 XEOMIN...... 198 VITAROCA PLUS...... 140 WESTAB PLUS...... 141 XEPI...... 32 VITA-RX DIABETIC WESTERN JUNIPER...... 197 XERAC AC...... 117 VITAMIN...... 140 WESTGEL DHA...... 141 XERAVA...... 32 VITASURE...... 140 WESTHROID...... 170 XERMELO...... 146 VITATHELY WITH wheat germ oil...... 141 XEROFORM OIL GINGER...... 140 WHITE BIRCH...... 197 EMULSION 2"X2"...... 117 VITRAKVI...... 64 WHITE FACED HORNET XEROFORM OIL VITRANOL FE...... 140 VENOM...... 197 EMULSION GAUZE...... 117 VITRASE...... 197 WHITE MULBERRY...... 197 XEROFORM OIL VITREXATE...... 140 WHITE OAK...... 197 EMULSION STRIP...... 117 VITREXATE FE...... 140 WHITE PINE...... 197 XEROFORM OIL ROLL VITREXYL...... 140 WHITE-FACED HORNET 4"X9'...... 117 VITREXYL + IRON...... 140 VENOM...... 197 XEROFORM PETROLAT VIVELLE-DOT...... 168 WIDE-SEAL DIAPHRAGM GAUZE 1"X8"...... 117 VIVITROL...... 21 60...... 197 XEROFORM PETROLAT VIZIMPRO...... 64 WIDE-SEAL DIAPHRAGM GAUZE 5"X9"...... 117 VOCABRIA...... 77 65...... 197 XEROFORM PETROLAT VOGELXO...... 155 WIDE-SEAL DIAPHRAGM PATCH 2"X2"...... 117 VOGELXO PUMP...... 155 70...... 197 XEROFORM PETROLAT volnea...... 168 WIDE-SEAL DIAPHRAGM PATCH 4"X4"...... 117 VONVENDI...... 85 75...... 197 XEROFORM VORAXAZE...... 64 WIDE-SEAL DIAPHRAGM PETROLATUM ROLL voriconazole...... 48 80...... 198 4"X9'...... 117 VORTEX VALVED WIDE-SEAL DIAPHRAGM XEROSTOMIA RELIEF HOLDING CHAMBER...... 197 85...... 198 SPRAY...... 110 VOSEVI...... 77 WIDE-SEAL DIAPHRAGM XGEVA...... 183 VOTRIENT...... 64 90...... 198 XHANCE...... 211 vp-pnv-dha...... 140 WIDE-SEAL DIAPHRAGM XIAFLEX...... 198 VPRIV...... 148 95...... 198 XIFAXAN...... 32 vp-vite rx...... 140 WILATE...... 85 XIGDUO XR...... 121 VRAYLAR...... 72 WILZIN...... 141 XIIDRA...... 207 VTOL LQ...... 15 WINLEVI...... 117 XOFIGO...... 65 VUMERITY...... 106 WINRHO SDF...... 177 XOFLUZA (40 MG DOSE)..77 VUSION...... 48 wixela inhub...... 215 XOFLUZA (80 MG DOSE)..77 VYEPTI...... 50 WP THYROID...... 170 XOLAIR...... 211 vyfemla...... 168 wymzya fe...... 168 XOLEGEL...... 48 vylibra...... 168 XADAGO...... 69 XOLEGEL COREPAK...... 48 VYNDAMAX...... 101 XALATAN...... 203 XOLEGEL DUO/HEAD & VYNDAQEL...... 101 XALKORI...... 64 SHOULDERS...... 48 VYTORIN...... 101 XANAX...... 80 XOLEGEL DUO/XOLEX..... 48 VYVANSE...... 104 XANAX XR...... 80 XOPENEX...... 215 VYXEOS...... 64 XARACOLL...... 19 XOPENEX VYZULTA...... 203 XARELTO...... 35 CONCENTRATE...... 215 WAKIX...... 219 XARELTO STARTER XOSPATA...... 65 warfarin sodium...... 35 PACK...... 35 XPOVIO (100 MG ONCE WASP VENOM PROTEIN 197 XCOPRI...... 39 WEEKLY)...... 65 water for irrigation, sterile. 141 XELJANZ...... 177 XPOVIO (40 MG ONCE weekly-d...... 141 XELJANZ XR...... 177 WEEKLY)...... 65 WELCHOL...... 101 XELODA...... 64

251 XPOVIO (40 MG TWICE ZELAPAR...... 69 zolpidem tartrate...... 219 WEEKLY)...... 65 ZELBORAF...... 65 zolpidem tartrate er...... 219 XPOVIO (60 MG ONCE ZEMAIRA...... 215 ZOMACTON...... 159 WEEKLY)...... 65 ZEMDRI...... 32 ZOMACTON (FOR ZOMA- XPOVIO (60 MG TWICE ZEMPLAR...... 183 JET 10)...... 159 WEEKLY)...... 65 zenatane...... 117 ZOMIG...... 51 XPOVIO (80 MG ONCE ZENPEP...... 148 ZOMIG ZMT...... 51 WEEKLY)...... 65 ZENZEDI...... 104, 105 ZONALON...... 117 XPOVIO (80 MG TWICE ZEPATIER...... 78 ZONEGRAN...... 39 WEEKLY)...... 65 ZEPOSIA...... 106 zonisamide...... 39 XTAMPZA ER...... 15 ZEPOSIA 7-DAY ZONTIVITY...... 69 XTANDI...... 65 STARTER PACK...... 106 ZORBTIVE...... 146 xulane...... 168 ZEPOSIA STARTER KIT..107 ZORTRESS...... 177 XULTOPHY...... 121 ZEPZELCA...... 65 ZOSYN...... 32 xurea...... 117 ZERBAXA...... 32 zovia 1/35 (28)...... 168 XURIDEN...... 148 ZERUVIA...... 20 zovia 1/35e (28)...... 168 XVITE...... 141 ZERVIATE...... 201 ZOVIRAX...... 78 XYLOCAINE...... 19 ZESTORETIC...... 101 ZUBSOLV...... 21 XYLOCAINE/EPINEPHRIN ZESTRIL...... 101 zumandimine...... 168 E...... 20 ZETIA...... 101 ZUPLENZ...... 45 XYLOCAINE-MPF...... 20 ZETONNA...... 211 ZYDELIG...... 65 XYLOCAINE- ZEVALIN Y-90...... 65 ZYFLO...... 215 MPF/EPINEPHRINE...... 20 ZIAC...... 101 ZYKADIA...... 65 XYNTHA...... 86 ZIAGEN...... 78 ZYLET...... 208 XYNTHA SOLOFUSE...... 86 zidovudine...... 78 ZYLOPRIM...... 48 XYREM...... 219 ZIEXTENZO...... 86 ZYMAXID...... 201 YASMIN 28...... 168 zileuton er...... 215 ZYNLONTA...... 65 YAZ...... 168 ZILRETTA...... 154 ZYNRELEF...... 8 YELLOW DOCK...... 198 ZINC CHLORIDE...... 141 ZYPITAMAG...... 102 YELLOW HORNET ZINC SULFATE...... 141 ZYPREXA...... 72 VENOM PROTEIN...... 198 ZINGO...... 20 ZYPREXA RELPREVV...... 72 YELLOW JACKET ZINPLAVA...... 177 ZYPREXA ZYDIS...... 72 VENOM PROTEIN...... 198 ZIONODIL...... 20 ZYTIGA...... 66 YERVOY...... 65 ZIONODIL 100...... 20 ZYVANA...... 141 YESCARTA...... 65 ZIOPTAN...... 203 ZYVOX...... 32 YF-VAX...... 180 ziprasidone hcl...... 72 yl folic acid...... 141 ziprasidone mesylate...... 72 YONDELIS...... 65 ZIRABEV...... 65 YONSA...... 65 ZIRGAN...... 201 YUPELRI...... 215 ZITHRANOL...... 117 yuvafem...... 168 ZITHROMAX...... 32 zafemy...... 168 ZITHROMAX TRI-PAK...... 32 zafirlukast...... 215 ZITHROMAX Z-PAK...... 32 zaleplon...... 219 ZOCOR...... 101 ZALTRAP...... 65 ZOFRAN...... 45 ZANAFLEX...... 218 ZOKINVY...... 198 ZANOSAR...... 65 ZOLADEX...... 159 zarah...... 168 zoledronic acid...... 183 ZARONTIN...... 39 ZOLGENSMA...... 148 ZARXIO...... 86 ZOLINZA...... 65 ZAVESCA...... 148 ZOLMITRIPTAN...... 50 ZEBUTAL...... 15 zolmitriptan...... 50 ZEJULA...... 65 ZOLOFT...... 43

252