PLUS Drug Formulary (DMHC)

Plus Drug Formulary January 2020

Blue Shield of California

This formulary corresponds with the following plans: Shield Spectrum PPO℠, Full PPO, Full PPO Savings, Access+ HMO®, Added Advantage POS℠, Local Access+ HMO®, Tandem PPO, Trio HMO

This formulary was last updated on 10/01/2019. This formulary is subject to change and all previous versions of the formulary no longer apply. For the most current information about the Plus Drug Formulary, visit www.blueshieldca.com/pharmacy.

You can find information about specific prescription drug benefits and drug benefit exclusions in the Blue Shield Summary of Benefits and Evidence of Coverage. For plan and coverage documents, visit https://www.blueshieldca.com/bsca/bsc/wcm/connect/employer/employer_contents_en/policies. For additional information about your plan, call the customer service number on your Blue Shield member ID card.

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LAST UPDATED 10/01/2019 Introduction to the formulary drug list

The Blue Shield Plus Drug Formulary is a list of medications that are approved by the Food and Drug Administration (FDA) and are selected based on safety, effectiveness, and cost. This list of generic and brand drugs is covered by your health insurance policy under the prescription drug benefit of the policy.

Definitions The following words and definitions will be used throughout the formulary drug list. Term “Brand name drug” is a drug that is marketed under a proprietary, trademark protected name. The brand name drug shall be listed in all CAPITAL letters. “Coinsurance” is a percentage of the cost of a covered health care benefit that an enrollee pays after the enrollee has paid the deductible, if a deductible applies to the health care benefit, such as the prescription drug benefit. “Copayment” is a fixed dollar amount that an enrollee pays for a covered health care benefit after the enrollee has paid the deductible, if a deductible applies to the health care benefit, such as the prescription drug benefit. “Deductible” is the amount an enrollee pays for covered health care benefits before the enrollee's health plan begins payment for all or part of the cost of the health care benefit under the terms of the policy. “Drug Tier” is a group of prescription drugs that corresponds to a specified cost sharing tier in the health plan's prescription drug coverage. The tier in which a prescription drug is placed determines the enrollee's portion of the cost for the drug. “Enrollee” is a person enrolled in a health plan who is entitled to receive services from the plan. All references to enrollees in this this formulary template shall also include subscriber as defined in this section below. “Exception request” is a request for coverage of a prescription drug. If an enrollee, his or her designee, or prescribing health care provider submits an exception request for coverage of a prescription drug, the health plan must cover the prescription drug when the drug is determined to be medically necessary to treat the enrollee's condition. “Exigent circumstances” are when an enrollee is suffering from a health condition that may seriously jeopardize the enrollee's life, health, or ability to regain maximum function, or when an enrollee is undergoing a current course of treatment using a non-formulary drug. “Formulary” is the complete list of drugs preferred for use and eligible for coverage under a health plan product, and includes all drugs covered under the outpatient prescription drug benefit of the health plan product. Formulary is also known as a prescription drug list. “Generic drug” is the same drug as its brand name equivalent in dosage, safety, strength, how it is taken, quality, performance, and intended use. A generic drug is listed in bold and italicized lowercase letters. “Non-formulary drug” is a prescription drug that is not listed on the health plan's formulary. “Out-of-pocket costs” are copayments, coinsurance, and the applicable deductible, plus all costs for health care services that are not covered by the health plan. “Prescribing provider” is a health care provider authorized to write a prescription to treat a medical condition for a health plan enrollee. “Prescription” is an oral, written, or electronic order by a prescribing provider for a specific enrollee that contains the name of the prescription drug, the quantity of the prescribed drug, the date of issue, the name and contact information of the prescribing provider, the signature of the prescribing provider if the prescription is in writing, and if requested by the enrollee, the medical condition or purpose for which the drug is being prescribed. “Prescription drug” is a drug that is prescribed by the enrollee's prescribing provider and requires a prescription under applicable law.

LAST UPDATED 10/01/2019 Term “Prior authorization” is a health plan's requirement that the enrollee or the enrollee's prescribing provider obtain the health plan's authorization for a prescription drug before the health plan will cover the drug. The health plan shall grant a prior authorization when it is medically necessary for the enrollee to obtain the drug. “Step therapy” is a process specifying the sequence in which different prescription drugs for a given medical condition and medically appropriate for a particular patient are prescribed. The health plan may require the enrollee to try one or more drugs to treat the enrollee's medical condition before the health plan will cover a particular drug for the condition pursuant to a step therapy request. If the enrollee's prescribing provider submits a request for step therapy exception, the health plans shall make exceptions to step therapy when the criteria is met. “Subscriber” means the person who is responsible for payment to a plan or whose employment or other status, except for family dependency, is the basis for eligibility for membership in the plan.

How do I find a drug on this list? The drugs are listed alphabetically under the column titled “Prescription Drug Name” by its brand or generic name under the therapeutic category and class to which it belongs. You can search this list using the brand or generic name of the drug by: • Searching for the category or class to which the drug belongs and search for the name of the drug in alphabetical order or • Searching the Alphabetical Index of Drugs by the name of the drug.

Listing a drug on the formulary does not guarantee that it will be prescribed by your doctor or prescriber.

How do I know if the drug listed is a brand or generic drug? • A generic name for a brand name drug is listed after the brand name of the drug in all lowercase bold italics o If a generic equivalent for a brand name drug is both available and covered, the generic drug will be listed separately from the brand name drug in all lowercase bold italics o When a generic drug is marketed with a brand name, the brand name will be listed after the generic name in parentheses in all CAPITALS. • A brand name drug is listed in all CAPITALS followed by the generic name in parentheses in lowercase bold italics.

Example Drug Type How the drug name will appear in the formulary drug list generic drug atorvastatin calcium generic drug marketed with a brand name oxycodone/acetaminophen (ENDOCET) brand drug LIPITOR (atorvastatin calcium)

What are drug tiers? Drugs are placed into drug tiers based on defined categories. The amount you pay for drugs in different tiers will vary. You can find information about what you pay by drug tier in the Summary of Benefits of your Blue Shield Evidence of Coverage (EOC).

The column titled “Drug Tier” is the cost level you pay for a drug. Drug Description Tier† 1 Most generic drugs or low-cost, preferred brand drugs 2 Non-preferred generic drugs, preferred brand drugs, or drugs recommended by the P&T

LAST UPDATED 10/01/2019 Committee based on drug safety, efficacy, and cost 3 Non-preferred brand drugs; drugs recommended by the P&T Committee based on safety, efficacy, and cost; or drugs that generally have a preferred and often less costly therapeutic alternative at a lower tier 4 Drugs that are biologics; drugs that the FDA or drug manufacturer requires to be distributed by specialty pharmacies; drugs that require training or clinical monitoring for self-administration; or drugs with a plan cost (net of rebates) greater than $600 for a one-month supply

† Affordable Care Act (ACA) drugs are preventive health drugs, including contraceptive drugs and devices. These drugs are covered at $0 when specific criteria are met.

Note about multi-source brand drugs: If you or your doctor choose a brand drug when a generic drug equivalent is available, you will pay the difference in cost, plus the Tier 1 copayment or coinsurance. You or your doctor can ask for an exception to the difference in cost through the Blue Shield prior authorization process. (See “What is the prior authorization/exception request process?” below for more information.)

You can find information about specific prescription drug benefits and drug benefit exclusions in the Blue Shield Evidence of Coverage. For additional information about specific plans, call the customer service number on your Blue Shield member ID card.

Note: Blue Shield drug formularies apply to outpatient prescription drug benefits available through plans underwritten by Blue Shield of California (individually and collectively referred to as Blue Shield throughout this document).

How to read the formulary The column titled “Coverage Requirements and Limits” identifies coverage restrictions or limits for drugs when applicable.

Coverage Requirements and Limits Description AL1 Age Limit Prior authorization may be required if your age does not fall within the FDA, manufacturer, or treatment guideline recommendations. GL Gender Limit Prior authorization may be required if the FDA, manufacturer, or treatment guidelines do not recommend the drug for a gender. OAC Oral Anti-Cancer There is a maximum limit on the copayment/coinsurance amount for orally administered anti-cancer drugs. Please see your Summary of Benefits for more detailed information. PA Prior Authorization Prior authorization is required to determine coverage. PH Preventive Drugs Affordable Care Act (ACA) preventive health drugs, including contraceptive drugs and devices, are covered at $0 when specific criteria are met.* QLC Quantity Limit The prescription quantity covered is limited. Prior authorization is required for amounts greater than the limit. RO Retail Only This prescription can be dispensed at retail pharmacies only. It is not covered through mail service. C Short Cycle Blue Shield’s Short Cycle Specialty Drug Program allows initial prescriptions for select specialty drugs to be filled for a 15-day supply. When this occurs, the copayment or coinsurance will be prorated. SP Specialty Pharmacy These drugs are available exclusively through select specialty pharmacies.

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LAST UPDATED 10/01/2019 ST Step Therapy A specific sequence in which prescription drugs for a particular medical condition must be tried. If a drug is subject to step therapy in this formulary, you may have to try one or more other drugs before your health insurance policy will cover that drug for your medical

* Does not apply to grandfathered plans, planscondition. purchased on or before March 23, 2010.

How often will the formulary change? This formulary is subject to change monthly. Formulary changes that may not have prior notice include the following: • A brand name drug may be moved to a higher tier or removed from the formulary if a new generic drug is added to the formulary, • A drug may be removed from the formulary when is it removed from the market because the Food and Drug Administration (FDA) deems a drug to be unsafe or the drug’s manufacturer removes the drug from the market, or • A drug is added to the formulary, moved to a lower tier, or has a utilization management requirement removed.

Formulary changes that will have at least 30-day prior notice to an affected insured before the change is effective include the following: • Moving a drug or dosage form to a higher tier, • Removal of a drug or dosage form from the formulary, • Adding or changing utilization management requirements or limits for a drug. o When a step therapy utilization management requirement changes, the new requirement will not require you to repeat the step therapy if you are already taking the drug for your condition as long as the drugs is still appropriate, your provider continues to prescribe the drug, and the drug is still considered safe and effective for your condition.

When a drug or dosage form is removed from the formulary and a drug was previously approved for coverage for your medical condition, coverage for the drug will continue if your provider continues to prescribe the drug for your condition and the drug is prescribed appropriately and is safe and effective for your condition.

For the most current information about the Blue Shield Plus Drug Formulary, visit blueshieldca.com/pharmacy.

What is a medical benefit drug versus a drug covered under the Outpatient Prescription Drug Benefit? A medical benefit drug is a drug that is not generally self-administered and administered by a health care professional. The outpatient prescription drug benefit includes FDA-approved drugs that are self- administered, commonly oral or self-injectable drugs, not otherwise excluded from coverage.

For additional information, check your Blue Shield Evidence of Coverage or call the customer service number on your Blue Shield member ID card.

What are preventive health drugs? Preventive health drugs are select drugs required by health reform legislation to be covered at no charge to the insured.* Preventive health drugs are determined based on evidence-based recommendations by the United States Preventive Services Task Force. For more details about preventive health drugs, visit blueshieldca.com/pharmacy.

What is a contraceptive drug or device? Contraceptives are drugs or devices, such as diaphragms or cervical caps, that help prevent pregnancy.

Most generic drug contraceptives and contraceptive devices are covered at no charge to the insured.* Most

LAST UPDATED 10/01/2019 brand drug contraceptives require a copayment, which may be waived based on medical necessity. Physicians or members may provide medical necessity information using the prior authorization process by calling or faxing a form to Blue Shield Pharmacy Services. (See “What is the prior authorization/exception request process?” below.)

What diabetes care drugs and products are covered under the Outpatient Prescription Drug Benefit? FDA-approved drugs for the treatment of diabetes are included in the formulary drug list. Diabetic testing supplies such as blood glucose test strips, urine test strips, lancets, insulin syringes/pens covered under the Outpatient Prescription Drug Benefit are also included in the formulary drug list.

What is step therapy? Step therapy means a specific sequence in which prescription drugs for a particular medical condition must be tried. If a drug is subject to step therapy in this formulary, you may have to try one or more other drugs before your health insurance policy will cover that drug for your medical condition.

Step therapy requirements are based on how the FDA recommends that a drug should be used, nationally recognized treatment guidelines, medical studies, information from the drug manufacturer, and the relative cost of treatment for a condition. Your provider may submit a request for an exception to the step therapy requirement.

To request an exception, please call the customer service number on your Blue Shield member ID card. You, your representative, or your doctor may submit an exception request to Blue Shield.

What is the prior authorization/exception request process? Drug prior authorization involves getting advance approval of coverage for a prescription medication based on medical necessity. Some drugs require review of the patient’s prescription and medical history to determine coverage.

The exception process involves requesting coverage of a non-formulary drug. A formulary exception, which allows coverage of a non-formulary drug is based on medical necessity.

To request prior authorization or a non-formulary coverage exception, please call the customer service number on your Blue Shield member ID card. You, your representative, or your doctor may submit an exception request to Blue Shield.

Once we receive all the needed supporting information, we will approve or deny the exception request based on medical necessity within 72 hours for non-urgent requests, or within 24 hours in urgent or exigent circumstances. If Blue Shield denies a request for prior authorization or an exception request, the member, an authorized representative, or the provider can file an appeal/grievance with Blue Shield, as described in the “Grievance Process” section of the EOC.

Participating retail pharmacies You can fill prescriptions at any participating (network) pharmacy, unless it is a prescription for a specialty drug. Blue Shield contracts with a wide network of retail pharmacies. To find a network pharmacy, visit blueshieldca.com/pharmacy.

What are specialty drugs? Specialty drugs are drugs that may require coordination of care, close monitoring, or extensive patient training for self- administration. These requirements generally cannot be met by a retail pharmacy. Specialty drugs may also require special handling or manufacturing processes (such as biotechnology), restriction to certain physicians or pharmacies, or reporting of certain clinical events to the FDA. Specialty drugs are usually high- cost.

Specialty drugs may require prior authorization for medical necessity by Blue Shield. Most specialty drugs are

LAST UPDATED 10/01/2019 available exclusively from a Network Specialty Pharmacy. If coverage is approved, a Network Specialty Pharmacy can provide specialty drugs by mail or, upon your request, can transfer the specialty drug to an associated retail store for pickup. Call the customer service number on your Blue Shield member ID card or visit blueshieldca.com/pharmacy if you have questions about specialty drugs.

Mail service pharmacy Blue Shield offers an easy-to-use mail service prescription drug program through our contracted mail service pharmacy. You can save time and money using the mail service drug program. It can be a convenient way to fill maintenance medications for up to a 90-day supply. Maintenance medications are drugs that doctors prescribe on an ongoing, regular basis to maintain health. For more information on using the mail service prescription benefit, visit blueshieldca.com/pharmacy.

LAST UPDATED 10/01/2019 Table of Contents ANALGESICS (Drugs for Pain) 1 ANESTHETICS (Drugs for Numbing) 14 ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS (Drugs for Addiction/Substance Abuse) 14 ANTIBACTERIALS (Drugs for Bacterial Infections) 16 ANTICONVULSANTS (Drugs for Seizures) 25 ANTIDEMENTIA AGENTS (Drugs for Alzheimer's Disease and Dementia) 30 ANTIDEPRESSANTS (Drugs for Depression) 31 ANTIEMETICS (Drugs for Nausea and Vomiting) 35 ANTIFUNGALS (Drugs for Fungal Infections) 37 ANTIGOUT AGENTS (Drugs for Gout) 39 ANTIMIGRAINE AGENTS (Drugs for Migraine) 40 ANTIMYASTHENIC AGENTS (Drugs for Myasthenia Gravis) 42 ANTIMYCOBACTERIALS (Drugs for Mycobacterial Infections) 42 ANTINEOPLASTICS (Drugs for Cancer) 43 ANTIPARASITICS (Drugs for Parasitic Infections) 51 ANTIPARKINSON AGENTS (Drugs for Parkinson's Disease) 52 ANTIPSYCHOTICS (Drugs for Mental Health) 55 ANTISPASTICITY AGENTS (Drugs for Muscle Spasm) 57 ANTIVIRALS (Drugs for Viral Infections) 57 ANXIOLYTICS (Drugs for Anxiety) 66 BIPOLAR AGENTS (Drugs for Bipolar Disorder) 67 BLOOD GLUCOSE REGULATORS (Drugs for Diabetes) 68 BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS (Drugs for Blood Disorders) 74 CARDIOVASCULAR AGENTS (Drugs for the Heart and Circulation) 77 CENTRAL NERVOUS SYSTEM AGENTS (Drugs for Nerve Conditions) 94 DENTAL AND ORAL AGENTS (Drugs for the Mouth) 103 DERMATOLOGICAL AGENTS (Drugs for the Skin) 104 ELECTROLYTES/MINERALS/METALS/VITAMINS 112 GASTROINTESTINAL AGENTS (Drugs for the Bowel and Stomach) 122 GENETIC OR ENZYME DISORDER: REPLACEMENT, MODIFIERS, TREATMENT (Drugs for Genetic or Enzyme Disorders) 128 GENITOURINARY AGENTS (Drugs for the Genital, Bladder, and Kidney) 130 HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (ADRENAL) (Drugs for Replacing/Stimulating Adrenal Gland Hormones) 134 HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY) (Drugs for Replacing/Stimulating Pituitary Gland Hormones) 140 HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX HORMONES/MODIFIERS) (Drugs for Replacing/Stimulating Sex Hormones) 141 HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (THYROID) (Drugs for the Thyroid) 155 HORMONAL AGENTS, SUPPRESSANT (PITUITARY) (Drugs for Suppressing Hormones from the Pituitary Gland) 156 HORMONAL AGENTS, SUPPRESSANT (THYROID) (Drugs for the Thyroid) 157

LAST UPDATED 10/01/2019 IMMUNOLOGICAL AGENTS (Drugs for Enhancing or Suppressing the Immune System) 157 INFLAMMATORY BOWEL DISEASE AGENTS (Drugs for Inflammatory Bowel Disease) 160 METABOLIC BONE DISEASE AGENTS (Drugs for the Bone) 161 MISCELLANEOUS THERAPEUTIC AGENTS 163 OPHTHALMIC AGENTS (Drugs for the Eyes) 165 OTIC AGENTS (Drugs for the Ears) 171 RESPIRATORY TRACT/PULMONARY AGENTS (Drugs for the Lungs) 171 SKELETAL MUSCLE RELAXANTS (Drugs for the Muscles) 182 SLEEP DISORDER AGENTS (Drugs for Insomnia) 183

LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS

ANALGESICS (Drugs for Pain) NONSTEROIDAL ANTI-INFLAMMATORY DRUGS (Pain and Arthritis Drugs) ANAPROX (naproxen sodium) TIER 3 ANAPROX DS (naproxen sodium) TIER 3 ARTHROTEC 50 (diclofenac TIER 3 sodium/misoprostol) ARTHROTEC 75 (diclofenac TIER 3 sodium/misoprostol) butalbital/aspirin/caffeine 50-325-40 TIER 1 QLC (6 caps/day) capsule butalbital/aspirin/caffeine 50-325-40 TIER 1 QLC (6 tabs/day) tablet CAMBIA (diclofenac potassium) TIER 3 PA, QLC (9 packs/month) CELEBREX (celecoxib) 400 MG CAPSULE TIER 3 QLC (1 cap/day) CELEBREX (celecoxib) 50 MG CAPSULE, TIER 3 QLC (2 caps/day) 100 MG CAPSULE, 200 MG CAPSULE celecoxib 400 mg capsule TIER 1 QLC (1 cap/day) celecoxib 50 mg capsule, 100 mg TIER 1 QLC (2 caps/day) capsule, 200 mg capsule DAYPRO (oxaprozin) TIER 3 diclofenac epolamine TIER 1 PA, QLC (2 patches/day) diclofenac potassium TIER 1 diclofenac sodium (KLOFENSAID II) TIER 1 PA, QLC (1 bottle/month) diclofenac sodium 1.5 % drops TIER 1 PA, QLC (1 bottle/month) diclofenac sodium 25 mg tablet dr, 50 mg TIER 1 tablet dr, 75 mg tablet dr, 100 mg tab er 24h diclofenac sodium/misoprostol TIER 1 diflunisal TIER 1 DISALCID (salsalate) TIER 3 DUEXIS (ibuprofen/famotidine) TIER 4 PA, QLC (3 tabs/day) EC-NAPROSYN (naproxen) TIER 3

AL1 - Age Limit; GL - Gender Limit; OAC – Oral Anti-Cancer; PA - Prior Authorization; PH - Preventive Health Drugs; QLC - Quantity Limit; RO - Retail Only; C - Short Cycle; SP – Specialty Pharmacy; ST – Step Therapy

1 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS etodolac TIER 1 FELDENE (piroxicam) TIER 3 fenoprofen calcium (FENORTHO) TIER 3 PA, QLC (4 caps/day) fenoprofen calcium (PROFENO) TIER 3 PA, QLC (4 tabs/day) fenoprofen calcium 200 mg capsule TIER 3 PA, QLC (4 caps/day) fenoprofen calcium 400 mg capsule TIER 3 PA, QLC (8 caps/day) fenoprofen calcium 600 mg tablet TIER 3 PA, QLC (4 tabs/day) FENORTHO (fenoprofen calcium) 200 MG TIER 3 PA, QLC (4 caps/day) CAPSULE FENORTHO (fenoprofen calcium) 400 MG TIER 3 PA, QLC (8 caps/day) CAPSULE FIORINAL (butalbital/aspirin/caffeine) TIER 3 QLC (6 caps/day) FLECTOR (diclofenac epolamine) TIER 3 PA, QLC (2 patches/day) flurbiprofen TIER 1 ibuprofen (IBU) TIER 1 ibuprofen 400 mg tablet, 600 mg tablet, TIER 1 800 mg tablet INDOCIN (indomethacin) TIER 3 indomethacin TIER 1 ketoprofen TIER 1 ketorolac tromethamine 10 mg tablet TIER 1 QLC (4 tabs/day, not to exceed 20 tabs/30 days) LODINE (etodolac) TIER 3 meclofenamate sodium TIER 1 mefenamic acid TIER 1 meloxicam TIER 1 MOBIC (meloxicam) TIER 3 nabumetone TIER 1 NALFON (fenoprofen calcium) 400 MG TIER 3 PA, QLC (8 caps/day) CAPSULE NALFON (fenoprofen calcium) 600 MG TIER 3 PA, QLC (4 tabs/day) TABLET NAPRELAN (naproxen sodium) CR 375 MG TIER 4 ST, QLC (1 tab/day) TABLET

2 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS NAPRELAN (naproxen sodium) CR 500 MG TIER 4 ST, QLC (2 tabs/day) TABLET, CR 750 MG TABLET NAPROSYN (naproxen) TIER 3 naproxen TIER 1 naproxen sodium 275 mg tablet, 550 mg TIER 1 tablet naproxen sodium 375 mg tbmp 24hr TIER 4 ST, QLC (1 tab/day) naproxen sodium 500 mg tbmp 24hr TIER 4 ST, QLC (2 tabs/day) oxaprozin TIER 1 PENNSAID (diclofenac sodium) TIER 4 PA, QLC (1 bottle/month) piroxicam TIER 1 PONSTEL (mefenamic acid) TIER 3 QMIIZ ODT (meloxicam) TIER 3 PA, QLC (1 tab/day) salsalate TIER 1 SPRIX (ketorolac tromethamine) TIER 4 PA, QLC (5 bottles/month) sulindac TIER 1 TIVORBEX (indomethacin, submicronized) TIER 3 ST, QLC (3 caps/day) tolmetin sodium TIER 1 VIMOVO (naproxen/esomeprazole TIER 4 PA, QLC (2 tabs/day) magnesium) VIVLODEX (meloxicam, submicronized) TIER 3 PA, QLC (1 cap/day) VOLTAREN-XR (diclofenac sodium) TIER 3 ZIPSOR (diclofenac potassium) TIER 4 ST, QLC (4 caps/day) ZORVOLEX (diclofenac submicronized) TIER 3 ST, QLC (3 caps/day) OPIOID ANALGESICS, LONG-ACTING (Long-acting Narcotic Pain Relievers) ARYMO ER (morphine sulfate) TIER 3 PA, QLC (3 tabs/day) BELBUCA (buprenorphine hcl) TIER 3 PA, QLC (2 films/day) buprenorphine TIER 1 PA, QLC (4 patches/28 days) BUTRANS (buprenorphine) TIER 3 PA, QLC (4 patches/28 days) CONZIP (tramadol hcl) TIER 3 ST, QLC (1 cap/day) DISKETS (methadone hcl) TIER 3 PA, QLC (5 tabs/day)

3 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS DOLOPHINE HCL (methadone hcl) 10 MG TIER 3 PA, QLC (18 tabs/day) TABLET DOLOPHINE HCL (methadone hcl) 5 MG TIER 3 PA, QLC (36 tabs/day) TABLET DURAGESIC (fentanyl) TIER 3 PA, QLC (20 patches/month) EMBEDA (morphine sulfate/naltrexone TIER 3 PA, QLC (4 caps/day) hcl) ER 20-0.8 MG CAPSULE EMBEDA (morphine sulfate/naltrexone TIER 3 PA, QLC (2 caps/day) hcl) ER 30-1.2 MG CAPSULE, ER 50-2 MG CAPSULE, ER 60-2.4 MG CAPSULE EMBEDA (morphine sulfate/naltrexone TIER 3 PA, QLC (1 cap/day) hcl) ER 80-3.2 MG CAPSULE, ER 100-4 MG CAPSULE EXALGO (hydromorphone hcl) ER 12 MG TIER 3 PA, QLC (5 tabs/day) TABLET EXALGO (hydromorphone hcl) ER 16 MG TIER 3 PA, QLC (4 tabs/day) TABLET EXALGO (hydromorphone hcl) ER 32 MG TIER 3 PA, QLC (2 tabs/day) TABLET EXALGO (hydromorphone hcl) ER 8 MG TIER 3 PA, QLC (1 tab/day) TABLET fentanyl 12 mcg/hr patch, 25 mcg/hr TIER 1 PA, QLC (20 patches/month) patch, 50mcg/hr patch, 75mcg/hr patch, 100 mcg/hr patch fentanyl 37.5mcg/hr patch, 62.5mcg/hr TIER 4 PA, QLC (10 patches/month) patch, 87.5mcg/hr patch hydromorphone hcl 12 mg tab er 24h TIER 1 PA, QLC (5 tabs/day) hydromorphone hcl 16 mg tab er 24h TIER 1 PA, QLC (4 tabs/day) hydromorphone hcl 32 mg tab er 24h TIER 1 PA, QLC (2 tabs/day) hydromorphone hcl 8 mg tab er 24h TIER 1 PA, QLC (1 tab/day) HYSINGLA ER (hydrocodone bitartrate) ER TIER 3 PA, QLC (1 cap/day) 20 MG TABLET, ER 30 MG TABLET, ER 40 MG TABLET, ER 60 MG TABLET HYSINGLA ER (hydrocodone bitartrate) ER TIER 4 PA, QLC (1 cap/day) 80 MG TABLET, ER 100 MG TABLET, ER 120 MG TABLET KADIAN (morphine sulfate) ER 10 MG TIER 3 PA, QLC (2 caps/day) CAPSULE, ER 30 MG CAPSULE, ER 40 MG CAPSULE, ER 50 MG CAPSULE, ER 100 MG CAPSULE

4 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS KADIAN (morphine sulfate) ER 20 MG TIER 3 PA, QLC (4 caps/day) CAPSULE KADIAN (morphine sulfate) ER 60 MG TIER 3 PA, QLC (3 caps/day) CAPSULE, ER 80 MG CAPSULE, ER 200 MG CAPSULE levorphanol tartrate 2 mg tablet TIER 4 PA, QLC (9 tabs/day) levorphanol tartrate 3 mg tablet TIER 4 PA, QLC (4 tabs/day) methadone hcl (METHADONE INTENSOL) TIER 2 PA, QLC (18 ml/day) methadone hcl (METHADOSE) TIER 2 PA, QLC (5 tabs/day) methadone hcl 10 mg tablet TIER 2 PA, QLC (18 tabs/day) methadone hcl 10 mg/5 ml solution TIER 2 PA, QLC (90 ml/day) methadone hcl 10 mg/ml oral conc TIER 2 PA, QLC (18 ml/day) methadone hcl 40 mg tablet sol TIER 2 PA, QLC (5 tabs/day) methadone hcl 5 mg tablet TIER 2 PA, QLC (36 tabs/day) methadone hcl 5 mg/5 ml solution TIER 2 PA, QLC (180 ml/day) METHADOSE (methadone hcl) TIER 3 PA, QLC (18 ml/day) MORPHABOND ER (morphine sulfate) TIER 3 PA, QLC (2 tabs/day) morphine sulfate 10 mg cap er, 30 mg TIER 1 PA, QLC (2 caps/day) cap er, 50 mg cap er, 100 mg cap er morphine sulfate 100 mg tablet er, 200 TIER 1 QLC (3 tabs/day) mg tablet er morphine sulfate 120 mg cpmp 24hr TIER 1 PA, QLC (13 caps/day) morphine sulfate 15 mg tablet er, 30 mg TIER 1 QLC (6 tabs/day) tablet er morphine sulfate 20 mg cap er pel TIER 1 PA, QLC (4 caps/day) morphine sulfate 30 mg, 45 mg, 60 mg, 75 TIER 1 PA, QLC (1 cap/day) mg morphine sulfate 40 mg cap er pel TIER 1 PA, QLC (2 caps/day) morphine sulfate 60 mg cap er pel, 80 mg TIER 1 PA, QLC (3 caps/day) cap er pel, 90 mg cpmp 24hr morphine sulfate 60 mg tablet er TIER 1 QLC (5 tabs/day) MS CONTIN (morphine sulfate) ER 100 MG TIER 3 QLC (3 tabs/day) TABLET, ER 200 MG TABLET MS CONTIN (morphine sulfate) ER 15 MG TIER 3 QLC (6 tabs/day) TABLET, ER 30 MG TABLET

5 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS MS CONTIN (morphine sulfate) ER 60 MG TIER 3 QLC (5 tabs/day) TABLET NUCYNTA ER (tapentadol hcl) TIER 3 PA, QLC (2 tabs/day) OPANA ER (oxymorphone hcl) 40 MG TIER 3 PA, QLC (4 tabs/day) TABLET OPANA ER (oxymorphone hcl) ER 5 MG TIER 3 PA, QLC (2 tabs/day) TABLET, ER 7.5 MG TABLET, ER 10 MG TABLET, ER 15 MG TABLET, ER 20 MG TABLET, ER 30 MG TABLET oxycodone hcl 10 mg tab er 12h TIER 1 PA, QLC (9 tabs/day) oxycodone hcl 15 mg tab er, 20 mg tab TIER 1 PA, QLC (6 tabs/day) er, 30 mg tab er oxycodone hcl 40 mg tab er, 80 mg tab TIER 1 PA, QLC (4 tabs/day) er oxycodone hcl 60 mg tab er 12h TIER 1 PA, QLC (2 tabs/day) OXYCONTIN (oxycodone hcl) ER 10 MG TIER 3 PA, QLC (9 tabs/day) TABLET OXYCONTIN (oxycodone hcl) ER 15 MG TIER 3 PA, QLC (6 tabs/day) TABLET, ER 20 MG TABLET, ER 30 MG TABLET OXYCONTIN (oxycodone hcl) ER 40 MG TIER 3 PA, QLC (4 tabs/day) TABLET, ER 80 MG TABLET OXYCONTIN (oxycodone hcl) ER 60 MG TIER 3 PA, QLC (2 tabs/day) TABLET oxymorphone hcl 40 mg tab er 12h TIER 1 PA, QLC (4 tabs/day) oxymorphone hcl 5 mg tab er, 7.5 mg tab TIER 1 PA, QLC (2 tabs/day) er, 10 mg tab er, 15 mg tab er, 20 mg tab er, 30 mg tab er tramadol hcl 100 mg 25-75, 200 mg 25-75, TIER 1 ST, QLC (1 cap/day) 300 mg 17-83 tramadol hcl 100 mg tab er 24h TIER 1 ST, QLC (3 tabs/day) tramadol hcl 100 mg tbmp 24hr, 200 mg TIER 1 ST, QLC (1 tab/day) tbmp 24hr, 200 mg tab er 24h, 300 mg tab er 24h, 300 mg tbmp 24hr tramadol hcl 150 mg cpbp 25-75 TIER 1 ST, QLC (2 caps/day) ULTRAM ER (tramadol hcl) 100 MG TABLET TIER 3 ST, QLC (3 tabs/day) ULTRAM ER (tramadol hcl) ER 200 MG TIER 3 ST, QLC (1 tab/day) TABLET, ER 300 MG TABLET XTAMPZA ER (oxycodone myristate) TIER 3 PA, QLC (2 caps/day)

6 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS ZOHYDRO ER (hydrocodone bitartrate) TIER 3 PA, QLC (2 caps/day) OPIOID ANALGESICS, SHORT-ACTING (Short-acting Narcotic Pain Relievers) ABSTRAL (fentanyl citrate) 100 MCG TAB TIER 3 PA, QLC (56 tabs/month) SUBLINGUAL ABSTRAL (fentanyl citrate) 200 MCG TAB TIER 3 PA, QLC (42 tabs/month) SUBLINGUAL ABSTRAL (fentanyl citrate) 300 MCG TAB, TIER 3 PA, QLC (28 tabs/month) 400 MCG TAB ABSTRAL (fentanyl citrate) 600 MCG TAB, TIER 3 PA, QLC (14 tabs/month) 800 MCG TAB acetaminophen with codeine phosphate TIER 1 QLC (168 tabs/month) -15mg tablet, -30mg tablet acetaminophen with codeine phosphate TIER 1 QLC (840 ml/month) 120-12mg/5, 300mg/12.5 acetaminophen with codeine phosphate TIER 1 QLC (84 tabs/month) 300mg-60mg tablet acetaminophen/caffeine/dihydrocodein TIER 3 PA, QLC (140 tabs/month) e bitartrate (DVORAH) acetaminophen/caffeine/dihydrocodein TIER 1 PA, QLC (140 tabs/month) e bitartrate (PANLOR) acetaminophen/caffeine/dihydrocodein TIER 1 PA, QLC (140 caps/month) e bitartrate acetaminophen/caff/dihydrocod 320.5- 30mg capsule acetaminophen/caffeine/dihydrocodein TIER 1 PA, QLC (140 tabs/month) e bitartrate acetaminophen/caff/dihydrocod 325-30- 16 tablet ACTIQ (fentanyl citrate) TIER 3 PA, QLC (56 lozenges/month) APADAZ (benzhydrocodone TIER 3 PA, QLC (12 tabs/day; not to hcl/acetaminophen) 4.08-325 MG TABLET exceed 168 tabs/30 days) APADAZ (benzhydrocodone TIER 3 PA, QLC (12 tabs/day; not to hcl/acetaminophen) 6.12-325 MG TABLET exceed 168 tabs/30 days) APADAZ (benzhydrocodone TIER 3 PA, QLC (9 tabs/day; not to hcl/acetaminophen) 8.16-325 MG TABLET exceed 126 tabs/30 days) aspirin/caffeine/dihydrocodeine TIER 1 QLC (168 caps/month) bitartrate benzhydrocodone hcl/acetaminophen TIER 3 PA, QLC (12 tabs/day; not to benzhydrocodone/acetaminophen 4.08- exceed 168 tabs/30 days) 325mg tablet

7 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS benzhydrocodone hcl/acetaminophen TIER 3 PA, QLC (12 tabs/day; not to benzhydrocodone/acetaminophen 6.12- exceed 168 tabs/30 days) 325mg tablet benzhydrocodone hcl/acetaminophen TIER 3 PA, QLC (9 tabs/day; not to benzhydrocodone/acetaminophen 8.16- exceed 126 tabs/30 days) 325mg tablet butalbital/acetaminophen/caffeine/cod TIER 1 QLC (84 caps/month) eine phosphate butorphanol tartrate 10 mg/ml spray TIER 1 QLC (4 canisters/month at 2 canisters/fill) CAPITAL W-CODEINE (acetaminophen TIER 3 QLC (2380 ml/month) with codeine phosphate) carisoprodol/aspirin/codeine phosphate TIER 1 AL1 (Up to 65 yrs old), QLC (8 tabs/day) codeine TIER 1 QLC (84 caps/month) phosphate/butalbital/aspirin/caffeine codeine TIER 1 QLC (84 caps/month) phosphate/butalbital/aspirin/caffeine (ASCOMP WITH CODEINE) codeine sulfate 15 mg tablet TIER 1 QLC (336 tabs/month) codeine sulfate 30 mg tablet TIER 1 QLC (168 tabs/month) codeine sulfate 60 mg tablet TIER 1 QLC (84 tabs/month) DEMEROL (meperidine hcl) 100 MG TIER 3 AL1 (Up to 65 yrs old), QLC (126 TABLET tabs/month) DEMEROL (meperidine hcl) 50 MG TABLET TIER 3 AL1 (Up to 65 yrs old), QLC (252 tabs/month) DILAUDID (hydromorphone hcl) 2 MG TIER 3 QLC (154 tabs/month) TABLET DILAUDID (hydromorphone hcl) 4 MG TIER 3 QLC (84 tabs/month) TABLET DILAUDID (hydromorphone hcl) 5 MG/5 TIER 3 QLC (56 ml/month) ML ORAL LIQUID DILAUDID (hydromorphone hcl) 8 MG TIER 3 QLC (42 tabs/month) TABLET fentanyl citrate 100 mcg tablet eff TIER 1 PA, QLC (56 tabs/month) fentanyl citrate 200 mcg tablet eff TIER 1 PA, QLC (42 tabs/month) fentanyl citrate 200 mcg, 400 mcg, 600 TIER 1 PA, QLC (56 lozenges/month) mcg, 800 mcg, 1200 mcg, 1600 mcg fentanyl citrate 400 mcg tablet eff TIER 1 PA, QLC (28 tabs/month)

8 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS fentanyl citrate 600 mcg tablet, 800 mcg TIER 1 PA, QLC (14 tabs/month) tablet FENTORA (fentanyl citrate) 100 MCG TIER 3 PA, QLC (56 tabs/month) BUCCAL TABLET FENTORA (fentanyl citrate) 200 MCG TIER 3 PA, QLC (42 tabs/month) BUCCAL TABLET FENTORA (fentanyl citrate) 400 MCG TIER 3 PA, QLC (28 tabs/month) BUCCAL TABLET FENTORA (fentanyl citrate) 600 MCG TIER 3 PA, QLC (14 tabs/month) TABLET, 800 MCG TABLET FIORICET WITH CODEINE TIER 3 QLC (84 caps/month) (butalbital/acetaminophen/caffeine/cod eine phosphate) FIORINAL WITH CODEINE #3 (codeine TIER 3 QLC (84 caps/month) phosphate/butalbital/aspirin/caffeine) HYCET (hydrocodone TIER 3 QLC (90 ml/day; max 1260 ml/30 bitartrate/acetaminophen) days) hydrocodone bitartrate/acetaminophen TIER 1 QLC (126 tabs/month) (LORCET HD) hydrocodone bitartrate/acetaminophen TIER 1 QLC (168 tabs/month) (LORCET PLUS) hydrocodone bitartrate/acetaminophen TIER 1 QLC (168 tabs/month) (LORCET) hydrocodone bitartrate/acetaminophen TIER 1 QLC (945 ml/month) (LORTAB) hydrocodone/acetaminophen 10-300/15 solution hydrocodone bitartrate/acetaminophen TIER 1 QLC (126 tabs/month) (LORTAB) hydrocodone/acetaminophen 10mg-325mg tablet hydrocodone bitartrate/acetaminophen TIER 1 QLC (168 tabs/month) (LORTAB) hydrocodone/acetaminophen 5 mg-325mg tablet, hydrocodone/acetaminophen 7.5-325 mg tablet hydrocodone bitartrate/acetaminophen TIER 1 QLC (168 tabs/month) (VERDROCET) hydrocodone bitartrate/acetaminophen TIER 1 QLC (168 tabs/month) (VICODIN ES) hydrocodone bitartrate/acetaminophen TIER 1 QLC (126 tabs/month) (VICODIN HP) hydrocodone bitartrate/acetaminophen TIER 1 QLC (168 tabs/month) (VICODIN)

9 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS hydrocodone bitartrate/acetaminophen TIER 1 QLC (126 tabs/month) hydrocodone/acetaminophen -300mg tablet, hydrocodone/acetaminophen - 325mg tablet hydrocodone bitartrate/acetaminophen TIER 1 PA, QLC (868 ml/month) hydrocodone/acetaminophen 10-325/15 solution hydrocodone bitartrate/acetaminophen TIER 1 PA, QLC (90 ml/day; max 1260 hydrocodone/acetaminophen 2.5-108/5, ml/30 days) hydrocodone/acetaminophen 5- 217mg/10 hydrocodone bitartrate/acetaminophen TIER 1 QLC (168 tabs/month) hydrocodone/acetaminophen 2.5-325 mg tablet, hydrocodone/acetaminophen 5 mg- 325mg tablet, hydrocodone/acetaminophen 5 mg- 300mg tablet, hydrocodone/acetaminophen 7.5-325 mg tablet, hydrocodone/acetaminophen 7.5-300 mg tablet hydrocodone bitartrate/acetaminophen TIER 1 QLC (90 ml/day; max 1260 ml/30 hydrocodone/acetaminophen 7.5-325/15 days) solution hydrocodone/ibuprofen (IBUDONE) TIER 1 QLC (112 tabs/month) hydrocodone/ibuprofen (XYLON 10) TIER 1 QLC (70 tabs/month) hydrocodone/ibuprofen 5mg-200mg TIER 1 QLC (112 tabs/month) tablet hydrocodone/ibuprofen 7.5-200 mg TIER 1 QLC (70 tabs/month) tablet, 10mg-200mg tablet hydromorphone hcl 1 mg/ml liquid TIER 1 QLC (56 ml/month) hydromorphone hcl 2 mg tablet TIER 1 QLC (154 tabs/month) hydromorphone hcl 3 mg supp.rect TIER 1 QLC (112 suppositories/month) hydromorphone hcl 4 mg tablet TIER 1 QLC (84 tabs/month) hydromorphone hcl 8 mg tablet TIER 1 QLC (42 tabs/month) IBUDONE (hydrocodone/ibuprofen) TIER 3 QLC (70 tabs/month) ibuprofen/oxycodone hcl TIER 1 QLC (56 tabs/month) LAZANDA (fentanyl citrate) TIER 3 PA, QLC (14 bottles/month) meperidine hcl 100 mg tablet TIER 1 AL1 (Up to 65 yrs old), QLC (126 tabs/month)

10 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS meperidine hcl 50 mg tablet TIER 1 AL1 (Up to 65 yrs old), QLC (252 tabs/month) meperidine hcl 50 mg/5 ml solution TIER 1 AL1 (Up to 65 yrs old), QLC (1260 ml/month) morphine sulfate 10 mg supp.rect TIER 1 QLC (126 suppositories/month) morphine sulfate 10 mg/5 ml solution TIER 1 QLC (630 ml/month) morphine sulfate 100 mg/5ml solution TIER 1 QLC (70 ml/month) morphine sulfate 15 mg tablet TIER 1 QLC (84 tabs/month) morphine sulfate 20 mg supp.rect TIER 1 QLC (70 suppositories/month) morphine sulfate 20 mg/5 ml solution TIER 1 QLC (84 ml/month) morphine sulfate 30 mg supp.rect TIER 1 QLC (42 suppositories/month) morphine sulfate 30 mg tablet TIER 1 QLC (42 tabs/month) morphine sulfate 5 mg supp.rect TIER 1 QLC (168 suppositories/month) NORCO (hydrocodone TIER 3 QLC (126 tabs/month) bitartrate/acetaminophen) 10-325 TABLET NORCO (hydrocodone TIER 3 QLC (168 tabs/month) bitartrate/acetaminophen) 5-325 TABLET, 7.5-325 TABLET NUCYNTA (tapentadol hcl) 50 MG TABLET TIER 3 PA, QLC (70 tabs/month) NUCYNTA (tapentadol hcl) 75 MG TABLET, TIER 3 PA, QLC (56 tabs/month) 100 MG TABLET OPANA (oxymorphone hcl) 10 MG TABLET TIER 3 PA, QLC (56 tabs/month) OPANA (oxymorphone hcl) 5 MG TABLET TIER 3 PA, QLC (84 tabs/month) OXAYDO (oxycodone hcl) 5 MG TABLET TIER 3 PA, QLC (168 tabs/month) OXAYDO (oxycodone hcl) 7.5 MG TABLET TIER 3 PA, QLC (112 tabs/month) oxycodone hcl 10 mg tablet TIER 1 QLC (84 tabs/month) oxycodone hcl 10mg/0.5ml syringe TIER 1 PA, QLC (3 ml/day) oxycodone hcl 15 mg tablet TIER 1 QLC (56 tabs/month) oxycodone hcl 20 mg tablet TIER 1 QLC (42 tabs/month) oxycodone hcl 20 mg/ml oral conc TIER 1 QLC (42 ml/month) oxycodone hcl 30 mg tablet TIER 1 QLC (28 tabs/month) oxycodone hcl 5 mg capsule TIER 1 QLC (168 caps/month) oxycodone hcl 5 mg tablet TIER 1 QLC (168 tabs/month)

11 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS oxycodone hcl 5 mg/5 ml solution TIER 1 QLC (840 ml/month) oxycodone hcl/acetaminophen TIER 1 QLC (84 tabs/month) (ENDOCET) 10mg-325mg tablet oxycodone hcl/acetaminophen TIER 1 QLC (168 tabs/month) (ENDOCET) 2.5-325 mg tablet, 5 mg- 325mg tablet oxycodone hcl/acetaminophen TIER 1 QLC (112 tabs/month) (ENDOCET) 7.5-325 mg tablet oxycodone hcl/acetaminophen TIER 3 PA, QLC (12 tabs/day; not to (NALOCET) exceed 168 tabs/month) oxycodone hcl/acetaminophen TIER 1 QLC (84 tabs/month) (PRIMLEV) 10mg-300mg tablet oxycodone hcl/acetaminophen TIER 1 QLC (168 tabs/month) (PRIMLEV) 5 mg-300mg tablet oxycodone hcl/acetaminophen TIER 1 QLC (112 tabs/month) (PRIMLEV) 7.5-300 mg tablet oxycodone hcl/acetaminophen 10mg- TIER 1 QLC (84 tabs/month) 325mg tablet oxycodone hcl/acetaminophen 2.5-325 TIER 1 QLC (168 tabs/month) mg tablet, 5 mg-325mg tablet oxycodone hcl/acetaminophen 5-325/5 TIER 1 QLC (840 ml/month) ml solution oxycodone hcl/acetaminophen 7.5-325 TIER 1 QLC (112 tabs/month) mg tablet oxycodone hcl/aspirin TIER 1 QLC (168 tabs/month) oxymorphone hcl 10 mg tablet TIER 1 PA, QLC (56 tabs/month) oxymorphone hcl 5 mg tablet TIER 1 PA, QLC (84 tabs/month) pentazocine hcl/naloxone hcl TIER 1 AL1 (Up to 65 yrs old), QLC (18 tabs/day) PERCOCET (oxycodone TIER 3 QLC (84 tabs/month) hcl/acetaminophen) 10-325 MG TABLET PERCOCET (oxycodone TIER 3 QLC (168 tabs/month) hcl/acetaminophen) 2.5-325 MG TABLET, 5-325 MG TABLET PERCOCET (oxycodone TIER 3 QLC (112 tabs/month) hcl/acetaminophen) 7.5-325 MG TABLET ROXICODONE (oxycodone hcl) 15 MG TIER 3 QLC (56 tabs/month) TABLET ROXICODONE (oxycodone hcl) 30 MG TIER 3 QLC (28 tabs/month) TABLET

12 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS ROXICODONE (oxycodone hcl) 5 MG TIER 3 QLC (168 tabs/month) TABLET ROXYBOND (oxycodone hcl) 15 MG TIER 3 PA, QLC (56 tabs/month, not to TABLET exceed 4 tabs/day) ROXYBOND (oxycodone hcl) 30 MG TIER 3 PA, QLC (28 tabs/month, not to TABLET exceed 2 tabs/day) ROXYBOND (oxycodone hcl) 5 MG TABLET TIER 3 PA, QLC (168 tabs/month; not to exceed 12 tabs/day) SKYRIZI (2 SYRINGES) KIT (risankizumab- TIER 4 PA, SP, QLC (1 kit/84 days) rzaa) SUBSYS (fentanyl) 100 MCG SPRAY, 1,200 TIER 3 PA, QLC (56 doses/month) MCG SPRAY, 1,600 MCG SPRAY SUBSYS (fentanyl) 200 MCG SPRAY TIER 3 PA, QLC (42 doses/month) SUBSYS (fentanyl) 400 MCG SPRAY, 600 TIER 3 PA, QLC (14 doses/month) MCG SPRAY, 800 MCG SPRAY SYNALGOS-DC TIER 3 QLC (168 caps/month) (aspirin/caffeine/dihydrocodeine bitartrate) tramadol hcl 50 mg tablet TIER 1 QLC (112 tabs/month) tramadol hcl/acetaminophen TIER 1 QLC (112 tabs/month) TREZIX TIER 3 PA, QLC (140 caps/month) (acetaminophen/caffeine/dihydrocodein e bitartrate) TYLENOL-CODEINE NO.3 (acetaminophen TIER 3 QLC (168 tabs/month) with codeine phosphate) TYLENOL-CODEINE NO.4 (acetaminophen TIER 3 QLC (84 tabs/month) with codeine phosphate) ULTRACET (tramadol hcl/acetaminophen) TIER 3 QLC (112 tabs/month) ULTRAM (tramadol hcl) TIER 3 XARTEMIS XR (oxycodone TIER 3 PA, QLC (4 tabs/day) hcl/acetaminophen) XODOL 10-300 (hydrocodone TIER 3 QLC (126 tabs/month) bitartrate/acetaminophen) XODOL 5-300 (hydrocodone TIER 3 QLC (168 tabs/month) bitartrate/acetaminophen) XODOL 7.5-300 (hydrocodone TIER 3 QLC (168 tabs/month) bitartrate/acetaminophen) ZAMICET (hydrocodone TIER 3 QLC (1890 ml/month) bitartrate/acetaminophen)

13 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS

ANESTHETICS (Drugs for Numbing) LOCAL ANESTHETICS (Skin Numbing Drugs) lidocaine 5 % adh. patch TIER 1 QLC (90 patches/month) lidocaine 5 % oint. (g) TIER 1 QLC (50 gm/month) lidocaine hcl (GLYDO) TIER 1 lidocaine hcl 2 % jelly(ml), 2 % jel/pf app, TIER 1 2 % solution, 40 mg/ml solution lidocaine/prilocaine 2.5 %-2.5% cream (g) TIER 1 QLC (30 gm/month) LIDODERM (lidocaine) TIER 3 QLC (90 patches/month) NAYZILAM (midazolam) TIER 3 QLC (2 sprayers/fill; max 5 fills/30 days) SYNERA (lidocaine/tetracaine) TIER 3 PA, QLC (1 patch/month) XYLOCAINE (lidocaine hcl) 4% SOLUTION TIER 3 ZTLIDO (lidocaine) TIER 3 PA, QLC (3 patches/day)

ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS (Drugs for Addiction/Substance Abuse) ALCOHOL DETERRENTS/ANTI-CRAVING (Drugs for Alcohol Dependence) acamprosate calcium TIER 1 ANTABUSE (disulfiram) TIER 3 disulfiram TIER 1 naltrexone hcl TIER 1 OPIOID DEPENDENCE TREATMENTS (Drugs for Opioid Dependence) BUNAVAIL (buprenorphine hcl/naloxone TIER 3 QLC (1 film/day) hcl) 2.1-0.3 MG FILM BUNAVAIL (buprenorphine hcl/naloxone TIER 3 QLC (2 films/day) hcl) 4.2-0.7 MG FILM, 6.3-1 MG FILM buprenorphine hcl 2 mg tab subl TIER 1 QLC (12 tabs/day; not to exceed 7 days therapy/90 days) buprenorphine hcl 8 mg tab subl TIER 1 QLC (3 tabs/day; not to exceed 7 days supply over 90 days)

14 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS buprenorphine hcl/naloxone hcl TIER 1 QLC (2 films/day) /naloxone 12 mg-3 mg film buprenorphine hcl/naloxone hcl TIER 1 QLC (12 tabs/day) /naloxone 2 mg-0.5mg tab subl buprenorphine hcl/naloxone hcl TIER 1 QLC (5 films/day) /naloxone 2 mg-0.5mg, /naloxone 4mg- 1mg buprenorphine hcl/naloxone hcl TIER 1 QLC (3 films/day) /naloxone 8 mg-2 mg film buprenorphine hcl/naloxone hcl TIER 1 QLC (3 tabs/day) /naloxone 8 mg-2 mg tab subl LUCEMYRA (lofexidine hcl) TIER 3 PA, QLC (16 tabs/day, not to exceed 224 tabs/6 months) SUBOXONE (buprenorphine hcl/naloxone TIER 3 QLC (2 films/day) hcl) 12 MG-3 MG SL FILM SUBOXONE (buprenorphine hcl/naloxone TIER 3 QLC (5 films/day) hcl) 2 MG-0.5 MG FILM, 4 MG-1 MG FILM SUBOXONE (buprenorphine hcl/naloxone TIER 3 QLC (3 films/day) hcl) 8 MG-2 MG SL FILM ZUBSOLV (buprenorphine hcl/naloxone TIER 3 QLC (3 tabs/day) hcl) 0.7-0.18 MG TABLET, 1.4-0.36 MG TABLET, 5.7-1.4 MG TABLET ZUBSOLV (buprenorphine hcl/naloxone TIER 3 QLC (1 tab/day) hcl) 2.9-0.71 MG TABLET, 11.4-2.9 MG TABLET ZUBSOLV (buprenorphine hcl/naloxone TIER 3 QLC (2 tabs/day) hcl) 8.6-2.1 MG TABLET SL OPIOID REVERSAL AGENTS (Drugs for Opioid Overdose) EVZIO (naloxone hcl) TIER 3 PA, QLC (2 injections [1 pack]/6 months) naloxone hcl 0.4 mg/ml vial TIER 1 QLC (two 1 ml vials/month) naloxone hcl 1 mg/ml syringe TIER 1 QLC (2 syringes/month) NARCAN (naloxone hcl) TIER 2 QLC (2 doses/month) SMOKING CESSATION AGENTS (Drugs to Help Quit Smoking) bupropion hcl 150 mg tab er 12h TIER 1 ACA (Preventive Health), QLC (2 tabs/day) CHANTIX (varenicline tartrate) 0.5 MG TIER 2 ACA (Preventive Health), QLC (2 TABLET, 1 MG TABLET, 1 MG CONT MONTH tabs/day) BOX

15 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS CHANTIX (varenicline tartrate) STARTING TIER 2 ACA (Preventive Health), QLC (1 MONTH BOX starting month box/28 days) NICOTROL (nicotine) TIER 2 ACA (Preventive Health), QLC (16 cartridges/day) NICOTROL NS (nicotine) TIER 2 ACA (Preventive Health), QLC (2 ml/day) ZYBAN (bupropion hcl) TIER 3 ACA (Preventive Health), QLC (2 tabs/day)

ANTIBACTERIALS (Drugs for Bacterial Infections) AMINOGLYCOSIDES ARIKAYCE (amikacin sulfate liposomal TIER 4 PA, SP, QLC (1 vial/day) with nebulizer accessories) gentamicin sulfate (GENTAK) TIER 1 gentamicin sulfate 0.1 % oint. (g), 0.1 % TIER 1 cream (g), 0.3 % oint. (g), 0.3 % drops neomycin sulfate TIER 1 paromomycin sulfate TIER 1 tobramycin TIER 1 TOBREX (tobramycin) 0.3% EYE DROP TIER 3 TOBREX (tobramycin) 0.3% EYE OINTMENT TIER 2 ANTIBACTERIALS, OTHER AEMCOLO (rifamycin sodium) TIER 3 PA, QLC (12 tabs/30 days) AKTIPAK (erythromycin base/benzoyl TIER 3 peroxide) ALTABAX (retapamulin) TIER 3 ST bacitracin 500 unit/g oint. (g) TIER 1 BACTROBAN (mupirocin calcium) TIER 3 BACTROBAN (mupirocin) TIER 3 BACTROBAN NASAL (mupirocin calcium) TIER 3 BENZAMYCIN (erythromycin base/benzoyl TIER 3 peroxide) CENTANY (mupirocin) TIER 3 CLEOCIN (clindamycin phosphate) 100 TIER 2 QLC (3 suppositories/fill) MG VAGINAL OVULE

16 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS CLEOCIN (clindamycin phosphate) 2% TIER 3 VAGINAL CREAM CLEOCIN HCL (clindamycin hcl) TIER 3 CLEOCIN PALMITATE (clindamycin TIER 3 palmitate hcl) CLEOCIN T (clindamycin phosphate) TIER 3 CLINDAGEL (clindamycin phosphate) TIER 3 PA, QLC (1 bottle/month) clindamycin hcl TIER 1 clindamycin palmitate hcl TIER 1 clindamycin phosphate (CLINDACIN ETZ) TIER 1 clindamycin phosphate (CLINDACIN P) TIER 1 clindamycin phosphate 1 % foam TIER 1 QLC (1 can/month) clindamycin phosphate 1 % gel (gram), 1 TIER 1 % lotion, 1 % med. swab, 1 % solution, 2 % cream/appl clindamycin phosphate 1 % gel daily TIER 3 PA, QLC (1 bottle/month) CLINDESSE (clindamycin phosphate) TIER 2 erythromycin base/benzoyl peroxide TIER 1 EVOCLIN (clindamycin phosphate) TIER 3 QLC (1 can/month) FIRVANQ (vancomycin hcl) 25 MG/ML TIER 3 PA, QLC (300 ml/month) SOLUTION FIRVANQ (vancomycin hcl) 50 MG/ML TIER 3 PA, QLC (450 ml/30 days) SOLUTION FLAGYL (metronidazole) TIER 3 FURADANTIN (nitrofurantoin) TIER 3 HIPREX (methenamine hippurate) TIER 3 linezolid TIER 1 PA MACROBID (nitrofurantoin TIER 3 monohydrate/macrocrystals) MACRODANTIN (nitrofurantoin TIER 3 macrocrystal) mafenide acetate TIER 1 methenamine hippurate TIER 1 METROGEL-VAGINAL (metronidazole) TIER 3

17 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS metronidazole 0.75 % gel w/appl, 250 mg TIER 1 tablet, 375 mg capsule, 500 mg tablet MONUROL (fosfomycin tromethamine) TIER 3 QLC (1 packet/month) mupirocin TIER 1 mupirocin calcium TIER 1 neomycin sulfate/polymyxin b sulfate TIER 1 PA, QLC (1 ml/day) NEOSPORIN G.U. IRRIGANT (neomycin TIER 3 PA, QLC (1 ml/day) sulfate/polymyxin b sulfate) nitrofurantoin TIER 1 nitrofurantoin macrocrystal TIER 1 nitrofurantoin TIER 1 monohydrate/macrocrystals NUVESSA (metronidazole) TIER 3 QLC (2 tubes/month) PRIMSOL (trimethoprim) TIER 3 SIVEXTRO (tedizolid phosphate) 200 MG TIER 4 PA, QLC (6 tabs/month) TABLET SOLOSEC (secnidazole) TIER 3 PA, QLC (1 pack/month) SULFAMYLON (mafenide acetate) TIER 3 TINDAMAX (tinidazole) TIER 3 QLC (20 tabs/fill) tinidazole 250 mg tablet TIER 1 QLC (40 tabs/fill) tinidazole 500 mg tablet TIER 1 QLC (20 tabs/fill) trimethoprim TIER 1 TRIMPEX (trimethoprim) TIER 3 VANCOCIN HCL (vancomycin hcl) TIER 3 vancomycin hcl 125 mg capsule, 250 mg TIER 1 capsule vancomycin hcl 50 mg/ml soln recon TIER 1 PA, QLC (450 ml/30 days) VANDAZOLE (metronidazole) TIER 3 XIFAXAN (rifaximin) 200 MG TABLET TIER 3 PA, QLC (8 tabs/day) XIFAXAN (rifaximin) 550 MG TABLET TIER 3 PA, QLC (3 tabs/day) ZYVOX (linezolid) TIER 3 PA

18 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS BETA-LACTAM, CEPHALOSPORINS CEDAX (ceftibuten) TIER 3 cefaclor 125 mg/5ml susp recon, 250 TIER 1 mg/5ml susp recon, 250 mg capsule, 375 mg/5ml susp recon, 500 mg capsule cefaclor 500 mg tab er 12h TIER 1 QLC (14 tabs/fill) cefadroxil TIER 1 cefdinir TIER 1 cefditoren pivoxil TIER 1 cefixime TIER 1 cefpodoxime proxetil TIER 1 cefprozil TIER 1 ceftibuten TIER 1 CEFTIN (cefuroxime axetil) TIER 3 cefuroxime axetil TIER 1 cephalexin TIER 1 DAXBIA (cephalexin) TIER 3 PA, QLC (12 caps/day) KEFLEX (cephalexin) TIER 3 SPECTRACEF (cefditoren pivoxil) TIER 3 SUPRAX (cefixime) TIER 3 BETA-LACTAM, PENICILLINS amoxicillin 125 mg/5ml susp recon, 125 TIER 1 mg tab chew, 200 mg/5ml susp recon, 250 mg tab chew, 250 mg/5ml susp recon, 250 mg capsule, 400 mg/5ml susp recon, 500 mg tablet, 500 mg capsule, 875 mg tablet amoxicillin 775 mg tbmp 24hr TIER 1 QLC (10 tabs/fill) amoxicillin/potassium clavulanate 200- TIER 1 28.5/5 susp recon, 200-28.5mg tab chew, 250-62.5/5 susp recon, 250-125 mg tablet, 400-57mg/5 susp recon, 400-57mg tab chew, 500-125 mg tablet, 600-42.9/5 susp recon, 1000-62.5 tab er 12h amoxicillin/potassium clavulanate 875- TIER 1 QLC (2 tabs/day) 125 mg tablet

19 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS ampicillin trihydrate TIER 1 AUGMENTIN (amoxicillin/potassium TIER 2 clavulanate) 125-31.25 MG/5 ML AUGMENTIN (amoxicillin/potassium TIER 3 clavulanate) 250-62.5 MG/5 ML, 500-125 TABLET AUGMENTIN (amoxicillin/potassium TIER 3 QLC (2 tabs/day) clavulanate) 875-125 TABLET AUGMENTIN ES-600 (amoxicillin/potassium TIER 3 clavulanate) AUGMENTIN XR (amoxicillin/potassium TIER 3 clavulanate) dicloxacillin sodium TIER 1 MOXATAG (amoxicillin) TIER 3 QLC (10 tabs/fill) penicillin v potassium TIER 1 MACROLIDES AZASITE (azithromycin) TIER 3 azithromycin 1 g packet, 100 mg/5ml susp TIER 1 recon, 200 mg/5ml susp recon, 250 mg tablet, 500 mg tablet, 600 mg tablet BIAXIN (clarithromycin) 250 MG TABLET, TIER 3 QLC (42 tabs/fill) 500 MG TABLET BIAXIN (clarithromycin) 250 MG/5 ML TIER 3 SUSPENSION clarithromycin 125 mg/5ml, 250 mg/5ml TIER 1 clarithromycin 250 mg tablet, 500 mg TIER 1 QLC (42 tabs/fill) tablet, 500 mg tab er 24h DIFICID (fidaxomicin) TIER 3 PA, QLC (20 tabs/month) E.E.S. 200 (erythromycin ethylsuccinate) TIER 3 E.E.S. 400 (erythromycin ethylsuccinate) TIER 3 ERY-TAB (erythromycin base) TIER 2 ERYGEL (erythromycin base in ethanol) TIER 1 ERYPED 200 (erythromycin ethylsuccinate) TIER 3 ERYPED 400 (erythromycin ethylsuccinate) TIER 3 ERYTHROCIN STEARATE (erythromycin TIER 2 stearate)

20 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS erythromycin base TIER 1 erythromycin base in ethanol TIER 1 erythromycin base in ethanol (ERY) TIER 1 erythromycin ethylsuccinate TIER 1 KETEK (telithromycin) TIER 3 QLC (20 tabs/fill) PCE (erythromycin base) TIER 3 ZITHROMAX (azithromycin) 1 GM POWDER TIER 3 PACKET, 100 MG/5 ML SUSP, 200 MG/5 ML SUSP, 250 MG TABLET, 250 MG Z-PAK TABLET, 500 MG TABLET, 600 MG TABLET ZITHROMAX TRI-PAK (azithromycin) TIER 3 ZMAX (azithromycin) TIER 3 QLC (1 bottle/fill) QUINOLONES AVELOX (moxifloxacin hcl) TIER 3 QLC (10 tabs/fill) AVELOX ABC PACK (moxifloxacin hcl) TIER 3 QLC (10 tabs/fill) BAXDELA (delafloxacin meglumine) 450 TIER 4 PA, QLC (28 tabs/month) MG TABLET BESIVANCE (besifloxacin hcl) TIER 3 QLC (5 ml/month) CETRAXAL (ciprofloxacin hcl) TIER 3 CILOXAN (ciprofloxacin hcl) 0.3% EYE TIER 3 DROPS CILOXAN (ciprofloxacin hcl) 0.3% TIER 2 OINTMENT CIPRO (ciprofloxacin hcl) TIER 3 QLC (2 tabs/day) CIPRO (ciprofloxacin) 10% SUSPENSION TIER 3 QLC (3 bottles/fill) CIPRO (ciprofloxacin) 5% SUSPENSION TIER 3 QLC (2 bottles/fill) CIPRO XR (ciprofloxacin/ciprofloxacin hcl) TIER 3 QLC (14 tabs/fill) 1,000 MG TABLET CIPRO XR (ciprofloxacin/ciprofloxacin hcl) TIER 3 QLC (3 tabs/fill) 500 MG TABLET ciprofloxacin 250 mg/5ml sus mc rec TIER 1 QLC (2 bottles/fill) ciprofloxacin 500 mg/5ml sus mc rec TIER 1 QLC (3 bottles/fill) ciprofloxacin hcl 0.2 % droperette, 0.3 % TIER 1 drops

21 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS ciprofloxacin hcl 100 mg tablet, 250 mg TIER 1 QLC (2 tabs/day) tablet, 500 mg tablet, 750 mg tablet ciprofloxacin/ciprofloxacin hcl 1000 mg TIER 1 QLC (14 tabs/fill) tbmp 24hr ciprofloxacin/ciprofloxacin hcl 500 mg TIER 1 QLC (3 tabs/fill) tbmp 24hr FACTIVE (gemifloxacin mesylate) TIER 3 QLC (1 box/fill) gatifloxacin TIER 1 QLC (one 2.5 ml bottle/month) LEVAQUIN (levofloxacin) TIER 3 QLC (10 tabs/fill) levofloxacin 0.5 % drops TIER 1 levofloxacin 250 mg tablet, 500 mg tablet, TIER 1 QLC (10 tabs/fill) 750 mg tablet levofloxacin 250mg/10ml, 500mg/20ml TIER 1 QLC (300 ml/fill) MOXEZA (moxifloxacin hcl) TIER 2 moxifloxacin hcl 0.5 % drops TIER 1 moxifloxacin hcl 400 mg tablet TIER 1 QLC (10 tabs/fill) OCUFLOX (ofloxacin) TIER 3 ofloxacin TIER 1 VIGAMOX (moxifloxacin hcl) TIER 3 ZYMAXID (gatifloxacin) TIER 3 QLC (one 2.5 ml bottle/month) SULFONAMIDES AVC (sulfanilamide) TIER 2 BACTRIM (sulfamethoxazole/trimethoprim) TIER 3 BACTRIM DS TIER 3 (sulfamethoxazole/trimethoprim) BLEPH-10 (sulfacetamide sodium) TIER 3 KLARON (sulfacetamide sodium) TIER 3 SILVADENE (silver sulfadiazine) TIER 3 silver sulfadiazine TIER 1 SSD (silver sulfadiazine) TIER 3 sulfacetamide sodium 10 % suspension, 10 TIER 1 % oint. (g), 10 % drops sulfadiazine TIER 1

22 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS sulfamethoxazole/trimethoprim 200- TIER 1 40mg/5 oral susp, 400mg-80mg tablet, 800-160 mg tablet sulfamethoxazole/trimethoprim 800- TIER 1 PA 160/20 oral susp SULFATRIM TIER 3 (sulfamethoxazole/trimethoprim) THERMAZENE (silver sulfadiazine) TIER 3 TETRACYCLINES ACTICLATE (doxycycline hyclate) TIER 3 PA, QLC (1 tab/day) ADOXA (doxycycline monohydrate) TIER 3 demeclocycline hcl TIER 1 DORYX (doxycycline hyclate) DR 200 MG TIER 3 PA, QLC (1 tab/day) TABLET DORYX (doxycycline hyclate) DR 50 MG TIER 3 PA, QLC (2 tabs/day) TABLET DORYX MPC (doxycycline hyclate) TIER 3 PA, QLC (2 tabs/day) doxycycline hyclate (MORGIDOX) TIER 1 doxycycline hyclate (SOLOXIDE) TIER 1 PA, QLC (1 tab/day) doxycycline hyclate 20 mg tablet TIER 1 QLC (2 tabs/day) doxycycline hyclate 50 mg capsule, 100 TIER 1 mg capsule, 100 mg tablet doxycycline hyclate 50 mg tablet, 50 mg TIER 1 PA, QLC (2 tabs/day) tablet dr doxycycline hyclate 75 mg tablet dr, 100 TIER 1 PA mg tablet dr doxycycline hyclate 75 mg tablet, 150 mg TIER 1 PA, QLC (1 tab/day) tablet dr, 150 mg tablet, 200 mg tablet dr doxycycline hyclate 80 mg tablet dr TIER 3 PA, QLC (2 tabs/day) doxycycline monohydrate (AVIDOXY) TIER 1 doxycycline monohydrate (MONDOXYNE TIER 1 NL) doxycycline monohydrate (OKEBO) TIER 1

23 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS doxycycline monohydrate 25 mg/5 ml TIER 1 susp recon, 50 mg capsule, 50 mg tablet, 75 mg tablet, 75 mg capsule, 100 mg capsule, 100 mg tablet, 150 mg capsule, 150 mg tablet doxycycline monohydrate 40 mg cap ir TIER 1 PA, QLC (1 cap/day; max 120 caps/5 months) MINOCIN (minocycline hcl) 50 MG CAP, TIER 3 75 MG CAP, 100 MG CAP minocycline hcl (COREMINO) TIER 3 PA, QLC (1 tab/day) minocycline hcl 45 mg tab er, 65 mg tab TIER 3 PA, QLC (1 tab/day) er, 90 mg tab er, 115mg tab er, 135 mg tab er minocycline hcl 50 mg tablet, 50 mg TIER 1 capsule, 75 mg capsule, 75 mg tablet, 100 mg tablet, 100 mg capsule minocycline hcl 55 mg tab er 24h TIER 3 PA, QLC (1 tab/day) minocycline hcl 80 mg tab er, 105 mg tab TIER 3 PA, QLC (1 tab/day) er MINOLIRA ER (minocycline hcl) TIER 3 PA, QLC (1 tab/day) MONODOX (doxycycline monohydrate) TIER 3 NUZYRA (omadacycline tosylate) 150 MG TIER 4 PA, QLC (6 tabs/28 days) TABLET NUZYRA (omadacycline tosylate) 150 MG TIER 4 PA, QLC (28 tabs/28 days) TABLET-7 DAY NUZYRA (omadacycline tosylate) 150 MG- TIER 4 PA, QLC (32 tabs/28 days) 7 DAY WITH LOAD ORACEA (doxycycline monohydrate) TIER 3 PA, QLC (1 cap/day; max 120 caps/5 months) SEYSARA (sarecycline hcl) TIER 4 PA, QLC (1 tab/day) SOLODYN (minocycline hcl) TIER 3 PA, QLC (1 tab/day) TARGADOX (doxycycline hyclate) TIER 3 PA, QLC (2 tabs/day) tetracycline hcl TIER 1 VIBRAMYCIN (doxycycline calcium) TIER 2 VIBRAMYCIN (doxycycline hyclate) TIER 3 VIBRAMYCIN (doxycycline monohydrate) TIER 3 XIMINO (minocycline hcl) TIER 4 PA, QLC (1 cap/day)

24 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS

ANTICONVULSANTS (Drugs for Seizures) ANTICONVULSANTS, OTHER (Other Seizure Control Drugs) BRIVIACT (brivaracetam) 10 MG TABLET, TIER 3 ST, QLC (2 tabs/day) 25 MG TABLET, 50 MG TABLET, 75 MG TABLET, 100 MG TABLET BRIVIACT (brivaracetam) 10 MG/ML ORAL TIER 3 ST, QLC (20 ml/day) SOLN DIACOMIT (stiripentol) 250 MG CAPSULE TIER 4 PA, SP, QLC (3 caps/day) DIACOMIT (stiripentol) 250 MG POWDER TIER 4 PA, SP, QLC (3 packets/day) PACKET DIACOMIT (stiripentol) 500 MG CAPSULE TIER 4 PA, SP, QLC (6 caps/day) DIACOMIT (stiripentol) 500 MG POWDER TIER 4 PA, SP, QLC (6 packets/day) PACKET EPIDIOLEX (cannabidiol (cbd) extract) TIER 4 PA, SP, QLC (4 bottles/28 days) KEPPRA (levetiracetam) 100 MG/ML ORAL TIER 3 SOLN, 250 MG TABLET, 500 MG TABLET, 750 MG TABLET, 1,000 MG TABLET KEPPRA XR (levetiracetam) 500 MG TIER 3 QLC (6 tabs/day) TABLET KEPPRA XR (levetiracetam) 750 MG TIER 3 QLC (4 tabs/day) TABLET levetiracetam (ROWEEPRA XR) 500 mg TIER 1 QLC (6 tabs/day) tab er 24h levetiracetam (ROWEEPRA XR) 750 mg TIER 1 QLC (4 tabs/day) tab er 24h levetiracetam (ROWEEPRA) TIER 1 levetiracetam 100 mg/ml solution, 250 mg TIER 1 tablet, 500 mg tablet, 500 mg/5ml solution, 750 mg tablet, 1000 mg tablet levetiracetam 500 mg tab er 24h TIER 1 QLC (6 tabs/day) levetiracetam 750 mg tab er 24h TIER 1 QLC (4 tabs/day) POTIGA (ezogabine) 200 MG TABLET, 300 TIER 3 QLC (3 tabs/day) MG TABLET, 400 MG TABLET POTIGA (ezogabine) 50 MG TABLET TIER 3 QLC (9 tabs/day) SPRITAM (levetiracetam) 1,000 MG TABLET TIER 3 PA, QLC (3 tabs/day)

25 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS SPRITAM (levetiracetam) 250 MG TABLET, TIER 3 PA, QLC (2 tabs/day) 500 MG TABLET SPRITAM (levetiracetam) 750 MG TABLET TIER 3 PA, QLC (4 tabs/day) CALCIUM CHANNEL MODIFYING AGENTS CELONTIN (methsuximide) TIER 3 ethosuximide TIER 1 ZARONTIN (ethosuximide) TIER 3 ZONEGRAN (zonisamide) TIER 3 zonisamide TIER 1 GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTS clobazam 10 mg tablet, 20 mg tablet TIER 1 ST, QLC (2 tabs/day) clobazam 2.5 mg/ml oral susp TIER 1 ST, QLC (16 ml/day) DEPAKENE (valproic acid (as sodium salt) TIER 3 (valproate sodium)) DEPAKENE (valproic acid) TIER 3 DEPAKOTE (divalproex sodium) TIER 3 DEPAKOTE ER (divalproex sodium) TIER 3 DEPAKOTE SPRINKLE (divalproex sodium) TIER 3 DIASTAT (diazepam) TIER 3 QLC (1 kit [2 doses]/fill) DIASTAT ACUDIAL (diazepam) TIER 3 QLC (1 kit [2 doses]/fill) diazepam 2.5 mg, 5-7.5-10mg, 12.5-15-20 TIER 1 QLC (1 kit [2 doses]/fill) divalproex sodium TIER 1 gabapentin 100 mg capsule, 300 mg TIER 1 capsule, 400 mg capsule, 600 mg tablet, 800 mg tablet gabapentin 250 mg/5ml, 300 mg/6ml TIER 1 PA GABITRIL (tiagabine hcl) TIER 3 GRALISE (gabapentin) 30-DAY STARTER TIER 3 PA, QLC (1 pack/month) PACK GRALISE (gabapentin) ER 300 MG TABLET TIER 3 PA, QLC (1 tab/day) GRALISE (gabapentin) ER 600 MG TABLET TIER 3 PA, QLC (3 tabs/day) MYSOLINE (primidone) TIER 3

26 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS NEURONTIN (gabapentin) TIER 3 ONFI (clobazam) 10 MG TABLET, 20 MG TIER 3 ST, QLC (2 tabs/day) TABLET ONFI (clobazam) 2.5 MG/ML SUSPENSION TIER 3 ST, QLC (16 ml/day) phenobarbital TIER 1 primidone TIER 1 SABRIL (vigabatrin) 500 MG POWDER TIER 4 PA, SP, QLC (6 packs/day) PACKET SABRIL (vigabatrin) 500 MG TABLET TIER 4 PA, SP, QLC (6 tabs/day) SYMPAZAN (clobazam) TIER 3 PA, QLC (2 films/day) tiagabine hcl TIER 1 valproic acid TIER 1 valproic acid (as sodium salt) (valproate TIER 1 sodium) 250 mg/5ml, 500mg/10ml vigabatrin (VIGADRONE) TIER 4 PA, SP, QLC (6 packs/day) vigabatrin 500 mg powd pack TIER 4 PA, SP, QLC (6 packs/day) vigabatrin 500 mg tablet TIER 4 PA, SP, QLC (6 tabs/day) GLUTAMATE REDUCING AGENTS felbamate TIER 1 FELBATOL (felbamate) TIER 3 FYCOMPA (perampanel) 0.5 MG/ML TIER 3 ST, QLC (24 ml/day) ORAL SUSP FYCOMPA (perampanel) 2 MG TABLET TIER 3 ST, QLC (3 tabs/day) FYCOMPA (perampanel) 4 MG TABLET, 6 TIER 3 ST, QLC (1 tab/day) MG TABLET, 8 MG TABLET, 10 MG TABLET, 12 MG TABLET LAMICTAL (BLUE) (lamotrigine) TIER 3 LAMICTAL (GREEN) (lamotrigine) TIER 3 LAMICTAL (lamotrigine) TIER 3 LAMICTAL (ORANGE) (lamotrigine) TIER 3 LAMICTAL ODT (BLUE) (lamotrigine) TIER 3 PA, QLC (1 starter kit/month) LAMICTAL ODT (GREEN) (lamotrigine) TIER 3 PA, QLC (1 starter kit/month) LAMICTAL ODT (lamotrigine) TIER 3 PA

27 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS LAMICTAL ODT (ORANGE) (lamotrigine) TIER 3 PA, QLC (1 starter kit/month) LAMICTAL XR (BLUE) (lamotrigine) TIER 3 ST, QLC (1 kit/month) LAMICTAL XR (GREEN) (lamotrigine) TIER 3 ST, QLC (1 kit/month) LAMICTAL XR (lamotrigine) 200 MG TABLET TIER 3 ST, QLC (3 tabs/day) LAMICTAL XR (lamotrigine) 25 MG TABLET, TIER 3 ST, QLC (1 tab/day) 50 MG TABLET, 100 MG TABLET LAMICTAL XR (lamotrigine) 250 MG TIER 3 ST, QLC (2 tabs/day) TABLET, 300 MG TABLET LAMICTAL XR (ORANGE) (lamotrigine) TIER 3 ST, QLC (1 kit/month) lamotrigine (SUBVENITE (BLUE)) TIER 1 lamotrigine (SUBVENITE (GREEN)) TIER 1 lamotrigine (SUBVENITE (ORANGE)) TIER 1 lamotrigine (SUBVENITE) TIER 1 lamotrigine 200 mg tab er 24 TIER 1 ST, QLC (3 tabs/day) lamotrigine 25 mg tab er 24, 50 mg tab er TIER 1 ST, QLC (1 tab/day) 24, 100 mg tab er 24 lamotrigine 25 mg tab rapdis, 50 mg tab TIER 1 PA rapdis, 100 mg tab rapdis, 200 mg tab rapdis lamotrigine 25-50-100, 25(21)-50, 50(42)- TIER 1 PA, QLC (1 starter pack/month) 100 lamotrigine 250 mg tab er 24, 300 mg tab TIER 1 ST, QLC (2 tabs/day) er 24 lamotrigine 5 mg tb chw dsp, 25(84)-100 TIER 1 tab ds pk, 25 mg tb chw dsp, 25 mg tablet, 25(42)-100 tab ds pk, 25mg (35) tab ds pk, 100 mg tablet, 150 mg tablet, 200 mg tablet QUDEXY XR (topiramate) 150 MG TIER 3 PA, QLC (2 caps/day) CAPSULE, 200 MG CAPSULE QUDEXY XR (topiramate) 25 MG CAPSULE, TIER 3 PA, QLC (1 cap/day) 50 MG CAPSULE, 100 MG CAPSULE TOPAMAX (topiramate) TIER 3 topiramate 15 mg cap sprink, 25 mg TIER 1 tablet, 25 mg cap sprink, 50 mg tablet, 100 mg tablet, 200 mg tablet topiramate 150 mg cap 24, 200 mg cap TIER 1 PA, QLC (2 caps/day) 24

28 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS topiramate 25 mg cap 24, 50 mg cap 24, TIER 1 PA, QLC (1 cap/day) 100 mg cap 24 TROKENDI XR (topiramate) 200 MG TIER 3 PA, QLC (2 caps/day) CAPSULE TROKENDI XR (topiramate) 25 MG TIER 3 PA, QLC (3 caps/day) CAPSULE, 100 MG CAPSULE TROKENDI XR (topiramate) 50 MG TIER 3 PA, QLC (7 caps/day) CAPSULE SODIUM CHANNEL AGENTS APTIOM (eslicarbazepine acetate) 200 TIER 3 ST, QLC (1 tab/day) MG TABLET, 400 MG TABLET APTIOM (eslicarbazepine acetate) 600 TIER 3 ST, QLC (2 tabs/day) MG TABLET, 800 MG TABLET BANZEL (rufinamide) 200 MG TABLET TIER 3 ST, QLC (2 tabs/day) BANZEL (rufinamide) 40 MG/ML TIER 3 ST, QLC (80 ml/day) SUSPENSION BANZEL (rufinamide) 400 MG TABLET TIER 3 ST, QLC (8 tabs/day) carbamazepine TIER 1 carbamazepine (EPITOL) TIER 1 CARBATROL (carbamazepine) TIER 3 DILANTIN (phenytoin sodium extended) TIER 2 DILANTIN (phenytoin) TIER 2 DILANTIN-125 (phenytoin) TIER 2 oxcarbazepine 150 mg tablet, 300 mg TIER 1 QLC (2 tabs/day) tablet oxcarbazepine 300 mg/5ml oral susp TIER 1 QLC (40 ml/day) oxcarbazepine 600 mg tablet TIER 1 QLC (4 tabs/day) OXTELLAR XR (oxcarbazepine) 150 MG TIER 3 ST, QLC (1 tab/day) TABLET, 300 MG TABLET OXTELLAR XR (oxcarbazepine) 600 MG TIER 3 ST, QLC (4 tabs/day) TABLET PEGANONE (ethotoin) TIER 3 PHENYTEK (phenytoin sodium extended) TIER 3 phenytoin TIER 1 phenytoin sodium extended TIER 1

29 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS TEGRETOL (carbamazepine) TIER 3 TEGRETOL XR (carbamazepine) TIER 3 TRILEPTAL (oxcarbazepine) 150 MG TIER 3 QLC (2 tabs/day) TABLET, 300 MG TABLET TRILEPTAL (oxcarbazepine) 300 MG/5 ML TIER 3 QLC (40 ml/day) SUSP TRILEPTAL (oxcarbazepine) 600 MG TABLET TIER 3 QLC (4 tabs/day) VIMPAT (lacosamide) 10 MG/ML TIER 3 ST, QLC (40 ml/day) SOLUTION VIMPAT (lacosamide) 50 MG TABLET, 100 TIER 3 ST, QLC (2 tabs/day) MG TABLET, 150 MG TABLET, 200 MG TABLET

ANTIDEMENTIA AGENTS (Drugs for Alzheimer's Disease and Dementia) ANTIDEMENTIA AGENTS, OTHER ergoloid mesylates TIER 1 CHOLINESTERASE INHIBITORS ARICEPT (donepezil hcl) 23 MG TABLET TIER 3 ST, QLC (1 tab/day) ARICEPT (donepezil hcl) 5 MG TABLET, 10 TIER 3 MG TABLET donepezil hcl 23 mg tablet TIER 1 ST, QLC (1 tab/day) donepezil hcl 5 mg tab rapdis, 5 mg TIER 1 tablet, 10 mg tab rapdis, 10 mg tablet EXELON (rivastigmine tartrate) TIER 3 EXELON (rivastigmine) TIER 3 QLC (1 patch/day) galantamine hbr TIER 1 NAMZARIC (memantine hcl/donepezil TIER 2 QLC (1 cap/day) hcl) 7 MG-10 MG CAPSULE, 14 MG-10 MG CAPSULE, 21 MG-10 MG CAPSULE, 28 MG- 10 MG CAPSULE NAMZARIC (memantine hcl/donepezil TIER 2 QLC (1 dose-pack/6 months) hcl) TITRATION PACK RAZADYNE (galantamine hbr) TIER 3 RAZADYNE ER (galantamine hbr) TIER 3

30 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS rivastigmine TIER 1 QLC (1 patch/day) rivastigmine tartrate TIER 1 N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONIST memantine hcl 2 mg/ml solution, 5 mg-10 TIER 1 mg tab ds pk memantine hcl 5 mg tablet, 10 mg tablet TIER 1 QLC (2 tabs/day) memantine hcl 7 mg cap 24, 14 mg cap TIER 1 QLC (1 cap/day) 24, 21 mg cap 24, 28 mg cap 24 NAMENDA (memantine hcl) 2 MG/ML TIER 3 SOLUTION, 5-10 MG TITRATION PK NAMENDA (memantine hcl) 5 MG TABLET, TIER 3 QLC (2 tabs/day) 10 MG TABLET NAMENDA XR (memantine hcl) 7 MG TIER 3 QLC (1 cap/day) CAPSULE, 14 MG CAPSULE, 21 MG CAPSULE, 28 MG CAPSULE NAMENDA XR (memantine hcl) TITRATION TIER 2 QLC (1 cap/day) PACK

ANTIDEPRESSANTS (Drugs for Depression) ANTIDEPRESSANTS, OTHER amitriptyline hcl/chlordiazepoxide TIER 1 APLENZIN (bupropion hbr) TIER 3 ST, QLC (1 tab/day) bupropion hcl 100 mg tab sr 12h, 100 mg TIER 1 QLC (4 tabs/day) tablet bupropion hcl 150 mg tab sr 12h, 150 mg TIER 1 QLC (3 tabs/day) tab er 24h bupropion hcl 200 mg tab sr 12h TIER 1 QLC (2 tabs/day) bupropion hcl 300 mg tab er 24h TIER 1 QLC (1 tab/day) bupropion hcl 450 mg tab er 24h TIER 1 ST, QLC (1 tab/day) bupropion hcl 75 mg tablet TIER 1 QLC (6 tabs/day) FORFIVO XL (bupropion hcl) TIER 3 ST, QLC (1 tab/day) mirtazapine TIER 1 olanzapine/fluoxetine hcl TIER 1 perphenazine/amitriptyline hcl TIER 1

31 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS REMERON (mirtazapine) TIER 3 SYMBYAX (olanzapine/fluoxetine hcl) TIER 3 WELLBUTRIN (bupropion hcl) 100 MG TIER 3 QLC (4 tabs/day) TABLET WELLBUTRIN (bupropion hcl) 75 MG TABLET TIER 3 QLC (6 tabs/day) WELLBUTRIN SR (bupropion hcl) 100 MG TIER 3 QLC (4 tabs/day) TABLET WELLBUTRIN SR (bupropion hcl) 150 MG TIER 3 QLC (3 tabs/day) TABLET WELLBUTRIN SR (bupropion hcl) 200 MG TIER 3 QLC (2 tabs/day) TABLET WELLBUTRIN XL (bupropion hcl) 150 MG TIER 3 QLC (3 tabs/day) TABLET WELLBUTRIN XL (bupropion hcl) 300 MG TIER 3 QLC (1 tab/day) TABLET MONOAMINE OXIDASE INHIBITORS EMSAM (selegiline) TIER 3 MARPLAN (isocarboxazid) TIER 3 NARDIL (phenelzine sulfate) TIER 3 PARNATE (tranylcypromine sulfate) TIER 3 phenelzine sulfate TIER 1 tranylcypromine sulfate TIER 1 SSRIS/SNRIS (SELECTIVE SEROTONIN REUPTAKE INHIBITOR/SEROTONIN AND NOREPINEPHRINE REUPTAKE INHIBITOR) BRISDELLE (paroxetine mesylate) TIER 3 QLC (1 cap/day) CELEXA (citalopram hydrobromide) 10 TIER 3 QLC (4 tabs/day) MG TABLET CELEXA (citalopram hydrobromide) 20 TIER 3 QLC (2 tabs/day) MG TABLET CELEXA (citalopram hydrobromide) 40 TIER 3 QLC (1 tab/day) MG TABLET CITALOPRAM HBR (citalopram TIER 1 QLC (40 mg/day) hydrobromide) citalopram hydrobromide 10 mg tablet TIER 1 QLC (4 tabs/day) citalopram hydrobromide 10 mg/5 ml TIER 1 QLC (40 mg/day) solution

32 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS citalopram hydrobromide 20 mg tablet TIER 1 QLC (2 tabs/day) citalopram hydrobromide 40 mg tablet TIER 1 QLC (1 tab/day) desvenlafaxine TIER 3 ST, QLC (1 tab/day) desvenlafaxine fumarate TIER 3 ST, QLC (1 tab/day) desvenlafaxine succinate TIER 1 QLC (1 tab/day) EFFEXOR XR (venlafaxine hcl) 37.5 MG TIER 3 QLC (2 caps/day) CAPSULE, 150 MG CAPSULE EFFEXOR XR (venlafaxine hcl) 75 MG TIER 3 QLC (3 caps/day) CAPSULE escitalopram oxalate 10 mg tablet TIER 1 QLC (4 tabs/day) escitalopram oxalate 20 mg tablet TIER 1 QLC (2 tabs/day) escitalopram oxalate 5 mg tablet TIER 1 QLC (8 tabs/day) escitalopram oxalate 5 mg/5 ml solution TIER 1 QLC (24 ml/day) FETZIMA (levomilnacipran hcl) TIER 3 PA, QLC (1 cap/day) fluoxetine hcl 10 mg capsule, 10 mg TIER 1 tablet, 20 mg capsule, 20 mg tablet, 20 mg/5 ml solution, 40 mg capsule fluoxetine hcl 60 mg tablet TIER 3 fluoxetine hcl 90 mg capsule dr TIER 1 QLC (4 caps/month) fluvoxamine maleate 100 mg cap er 24h TIER 1 ST, QLC (3 caps/day) fluvoxamine maleate 150 mg cap er 24h TIER 1 ST, QLC (2 caps/day) fluvoxamine maleate 25 mg tablet, 50 mg TIER 1 tablet, 100 mg tablet KHEDEZLA (desvenlafaxine) TIER 3 ST, QLC (1 tab/day) LEXAPRO (escitalopram oxalate) 10 MG TIER 3 QLC (4 tabs/day) TABLET LEXAPRO (escitalopram oxalate) 20 MG TIER 3 QLC (2 tabs/day) TABLET LEXAPRO (escitalopram oxalate) 5 MG TIER 3 QLC (8 tabs/day) TABLET LEXAPRO (escitalopram oxalate) 5 MG/5 TIER 3 QLC (24 ml/day) ML SOLUTION maprotiline hcl TIER 1 nefazodone hcl TIER 1 paroxetine hcl TIER 1

33 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS paroxetine mesylate TIER 1 QLC (1 cap/day) PAXIL (paroxetine hcl) 10 MG TABLET, 20 TIER 3 MG TABLET, 30 MG TABLET, 40 MG TABLET PAXIL (paroxetine hcl) 10 MG/5 ML TIER 3 QLC (30 ml/day) SUSPENSION PAXIL CR (paroxetine hcl) TIER 3 PEXEVA (paroxetine mesylate) 10 MG TIER 3 PA, QLC (1 tab/day) TABLET, 20 MG TABLET, 40 MG TABLET PEXEVA (paroxetine mesylate) 30 MG TIER 3 PA, QLC (2 tabs/day) TABLET PRISTIQ (desvenlafaxine succinate) TIER 3 QLC (1 tab/day) PROZAC (fluoxetine hcl) TIER 3 PROZAC WEEKLY (fluoxetine hcl) TIER 3 QLC (4 caps/month) SARAFEM (fluoxetine hcl) TIER 3 QLC (1 tab/day) sertraline hcl TIER 1 trazodone hcl TIER 1 TRINTELLIX (vortioxetine hydrobromide) TIER 3 ST, QLC (1 tab/day) venlafaxine hcl 225 mg tab er 24 TIER 3 QLC (1 tab/day) venlafaxine hcl 25 mg tablet, 37.5 mg TIER 1 tablet, 50 mg tablet, 75 mg tablet, 100 mg tablet venlafaxine hcl 37.5 mg cap er, 150 mg TIER 1 QLC (2 caps/day) cap er venlafaxine hcl 37.5 mg tab er 24, 75 mg TIER 1 QLC (1 tab/day) tab er 24, 150 mg tab er 24 venlafaxine hcl 75 mg cap er 24h TIER 1 QLC (3 caps/day) VENLAFAXINE HCL ER (venlafaxine hcl) TIER 3 QLC (1 tab/day) VIIBRYD (vilazodone hcl) 10 MG TABLET, 20 TIER 3 ST, QLC (1 tab/day) MG TABLET, 40 MG TABLET VIIBRYD (vilazodone hcl) 10-20 MG TIER 3 ST, QLC (1 pack/month) STARTER PACK ZOLOFT (sertraline hcl) TIER 3 TRICYCLICS amitriptyline hcl TIER 1 amoxapine TIER 1

34 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS ANAFRANIL (clomipramine hcl) TIER 3 clomipramine hcl TIER 1 desipramine hcl TIER 1 doxepin hcl 10 mg/ml oral conc, 10 mg TIER 1 capsule, 25 mg capsule, 50 mg capsule, 75 mg capsule, 100 mg capsule, 150 mg capsule imipramine hcl TIER 1 imipramine pamoate TIER 1 NORPRAMIN (desipramine hcl) TIER 3 nortriptyline hcl 10 mg capsule, 10 mg/5 TIER 1 ml solution, 25 mg capsule, 50 mg capsule, 75 mg capsule nortriptyline hcl 20 mg/10ml solution TIER 3 PA PAMELOR (nortriptyline hcl) TIER 3 protriptyline hcl TIER 1 SURMONTIL (trimipramine maleate) TIER 3 TOFRANIL (imipramine hcl) TIER 3 trimipramine maleate TIER 1

ANTIEMETICS (Drugs for Nausea and Vomiting) ANTIEMETICS, OTHER (Other Drugs for Nausea and Vomiting) BONJESTA (doxylamine TIER 3 PA, QLC (2 tabs/day) succinate/pyridoxine hcl (b6)) COMPAZINE (prochlorperazine maleate) TIER 3 COMPAZINE (prochlorperazine) TIER 3 DICLEGIS (doxylamine TIER 3 PA, QLC (4 tabs/day) succinate/pyridoxine hcl (b6)) doxylamine succinate/pyridoxine hcl (b6) TIER 1 PA, QLC (4 tabs/day) metoclopramide hcl 5 mg tab rapdis, 10 TIER 1 PA, QLC (4 tabs/day) mg tab rapdis metoclopramide hcl 5 mg tablet, 5 mg/5 TIER 1 ml solution, 10 mg tablet, 10 mg/10ml solution METOZOLV ODT (metoclopramide hcl) TIER 3 PA, QLC (4 tabs/day)

35 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS MOTEGRITY (prucalopride succinate) TIER 3 PA, QLC (1 tab/day) perphenazine TIER 1 PHENERGAN (promethazine hcl) 12.5 MG, TIER 1 25 MG, 50 MG prochlorperazine TIER 1 prochlorperazine (COMPRO) TIER 1 prochlorperazine maleate TIER 1 promethazine hcl (PHENADOZ) TIER 1 promethazine hcl (PROMETHEGAN) TIER 1 promethazine hcl 12.5 mg supp.rect, 25 TIER 1 mg supp.rect, 50 mg tablet, 50 mg supp.rect REGLAN (metoclopramide hcl) TIER 3 scopolamine TIER 1 TIGAN (trimethobenzamide hcl) 300 MG TIER 3 CAPSULE TRANSDERM-SCOP (scopolamine) TIER 3 trimethobenzamide hcl TIER 1 EMETOGENIC THERAPY ADJUNCTS (Drugs for Nausea and Vomiting) AKYNZEO (netupitant/palonosetron hcl) TIER 3 QLC (1 capsule/14 days) ANZEMET (dolasetron mesylate) 50 MG TIER 2 QLC (1 tab/fill) TABLET, 100 MG TABLET aprepitant 125 mg capsule TIER 1 PA, QLC (1 cap/7 days) aprepitant 125mg-80mg cap ds pk TIER 1 QLC (3 caps/7 days) aprepitant 40 mg capsule TIER 1 PA, QLC (1 cap/month) aprepitant 80 mg capsule TIER 1 PA, QLC (2 caps/7 days) CESAMET (nabilone) TIER 3 QLC (6 caps/day) dronabinol TIER 1 QLC (6 caps/day) EMEND (aprepitant) 125 MG CAPSULE TIER 3 PA, QLC (1 cap/7 days) EMEND (aprepitant) 125 MG POWDER TIER 3 PA, QLC (3 packets/7 days) PACKET EMEND (aprepitant) 40 MG CAPSULE TIER 3 PA, QLC (1 cap/month) EMEND (aprepitant) 80 MG CAPSULE TIER 3 PA, QLC (2 caps/7 days)

36 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS EMEND (aprepitant) TRIPACK TIER 3 QLC (3 caps/7 days) granisetron hcl 1 mg tablet TIER 1 QLC (2 tabs/fill) MARINOL (dronabinol) TIER 3 QLC (6 caps/day) ondansetron TIER 1 QLC (3 tabs/day) ondansetron hcl 24 mg tablet TIER 1 QLC (1 tab/fill) ondansetron hcl 4 mg tablet, 8 mg tablet TIER 1 QLC (3 tabs/day) ondansetron hcl 4 mg/5 ml solution TIER 1 QLC (1 bottle/fill) SANCUSO (granisetron) TIER 3 PA, QLC (2 patches/28 days) SYNDROS (dronabinol) TIER 4 PA, QLC (4 bottles/month) VARUBI (rolapitant hcl) 90 MG TABLET TIER 3 SP, QLC (2 tabs/14 days) ZOFRAN (ondansetron hcl) 4 MG TABLET, 8 TIER 3 QLC (3 tabs/day) MG TABLET ZOFRAN (ondansetron hcl) 4 MG/5 ML TIER 3 QLC (1 bottle/fill) ORAL SOLN ZOFRAN ODT (ondansetron) TIER 3 QLC (3 tabs/day) ZUPLENZ (ondansetron) TIER 3 PA, QLC (3 films/day)

ANTIFUNGALS (Drugs for Fungal Infections) ANTIFUNGALS ANCOBON (flucytosine) TIER 3 butoconazole nitrate (GYNAZOLE 1) TIER 1 ciclopirox TIER 1 ciclopirox (CICLODAN) TIER 1 ciclopirox olamine TIER 1 ciclopirox olamine (CICLODAN) TIER 1 clotrimazole 10 mg troche TIER 1 CRESEMBA (isavuconazonium sulfate) 186 TIER 4 PA, QLC (2 caps/day) MG CAPSULE DIFLUCAN (fluconazole) TIER 3 econazole nitrate TIER 1 ECOZA (econazole nitrate) TIER 3 ST, QLC (1 bottle/month) ERTACZO (sertaconazole nitrate) TIER 3 ST, QLC (1 tube/fill)

37 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS EXELDERM (sulconazole nitrate) TIER 3 EXTINA (ketoconazole) TIER 3 ST fluconazole TIER 1 flucytosine TIER 1 GRIS-PEG (griseofulvin ultramicrosize) TIER 3 griseofulvin ultramicrosize TIER 1 griseofulvin, microsize TIER 1 itraconazole TIER 1 PA JUBLIA (efinaconazole) TIER 3 PA, QLC (1 bottle/month) KERYDIN (tavaborole) TIER 3 PA, QLC (1 bottle/month) ketoconazole 2 % cream (g), 2 % TIER 1 shampoo, 200 mg tablet ketoconazole 2 % foam TIER 1 ST LAMISIL (terbinafine hcl) 250 MG TABLET TIER 3 QLC (30 tabs/month) LOPROX (ciclopirox) TIER 3 luliconazole TIER 1 ST, QLC (1 bottle/month) LUZU (luliconazole) TIER 3 ST, QLC (1 bottle/month) miconazole nitrate 200 mg supp.vag TIER 1 miconazole nitrate/zinc TIER 1 ST oxide/petrolatum,white naftifine hcl TIER 1 ST NAFTIN (naftifine hcl) TIER 3 ST NATACYN (natamycin) TIER 3 NIZORAL (ketoconazole) TIER 3 NOXAFIL (posaconazole) 40 MG/ML TIER 3 PA SUSPENSION NOXAFIL (posaconazole) DR 100 MG TIER 2 PA, QLC (3 tabs/day) TABLET nystatin TIER 1 nystatin (NYAMYC) TIER 1 nystatin (NYATA) TIER 1 nystatin (NYSTOP) TIER 1 nystatin/triamcinolone acetonide TIER 1

38 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS ONMEL (itraconazole) TIER 3 PA, QLC (1 tab/day) ORAVIG (miconazole) TIER 3 PA, QLC (14 tabs/month) oxiconazole nitrate TIER 1 ST OXISTAT (oxiconazole nitrate) TIER 3 ST PENLAC (ciclopirox) TIER 3 posaconazole 100 mg tablet dr TIER 1 PA, QLC (3 tabs/day) posaconazole 200 mg/5ml oral susp TIER 1 PA SPORANOX (itraconazole) TIER 3 PA TERAZOL 3 (terconazole) TIER 3 TERAZOL 7 (terconazole) TIER 3 terbinafine hcl 250 mg tablet TIER 1 QLC (30 tabs/month) terconazole TIER 1 TOLSURA (itraconazole) TIER 4 PA, QLC (4 caps/day) VFEND (voriconazole) TIER 3 PA voriconazole 50 mg tablet, 200 mg tablet, TIER 1 PA 200 mg/5ml susp recon VUSION (miconazole nitrate/zinc TIER 3 ST oxide/petrolatum,white) XOLEGEL (ketoconazole) TIER 3 ST

ANTIGOUT AGENTS (Drugs for Gout) ANTIGOUT AGENTS allopurinol TIER 1 colchicine 0.6 mg capsule TIER 1 QLC (2 caps/day) colchicine 0.6 mg tablet TIER 1 QLC (4 tabs/day) COLCRYS (colchicine) TIER 3 QLC (4 tabs/day) DUZALLO (lesinurad/allopurinol) TIER 3 ST, QLC (1 tab/day) febuxostat TIER 1 ST, QLC (1 tab/day) MITIGARE (colchicine) TIER 3 QLC (2 caps/day) probenecid TIER 1 probenecid/colchicine TIER 1

39 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS ULORIC (febuxostat) TIER 2 ST, QLC (1 tab/day) ZURAMPIC (lesinurad) TIER 3 ST, QLC (1 tab/day) ZYLOPRIM (allopurinol) TIER 3

ANTIMIGRAINE AGENTS (Drugs for Migraine) ANTIMIGRAINE AGENTS, OTHER AIMOVIG AUTOINJECTOR (erenumab- TIER 2 PA, QLC (1 injection/28 days) aooe) 140 MG/ML - AIMOVIG AUTOINJECTOR (erenumab- TIER 2 PA, QLC (1 injection/28 days) aooe) 70 MG/ML - AJOVY (fremanezumab-vfrm) TIER 3 PA, QLC (3 syringes/84 days) EMGALITY PEN (galcanezumab-gnlm) TIER 2 PA, QLC (1 pen injector/30 days) EMGALITY SYRINGE (galcanezumab-gnlm) TIER 2 PA, QLC (1 syringe/30 days) 120 MG/ML - ERGOT ALKALOIDS CAFERGOT (ergotamine TIER 3 QLC (10 tabs/week) tartrate/caffeine) D.H.E.45 (dihydroergotamine mesylate) TIER 4 PA, QLC (24 ml/28 days) dihydroergotamine mesylate 0.5mg/spry TIER 3 PA, QLC (8 vials/month) spray/pump dihydroergotamine mesylate 1 mg/ml TIER 3 PA, QLC (24 ml/28 days) ampul, 1 mg/ml vial ERGOMAR (ergotamine tartrate) TIER 3 QLC (20 tabs/28 days) ergotamine tartrate/caffeine TIER 1 QLC (10 tabs/week) ergotamine tartrate/caffeine TIER 1 QLC (5 suppositories/week) (MIGERGOT) MIGRANAL (dihydroergotamine mesylate) TIER 4 PA, QLC (8 vials/month) SEROTONIN (5-HT) 1B/1D RECEPTOR AGONISTS almotriptan malate TIER 1 ST, QLC (24 tabs/month) AMERGE (naratriptan hcl) TIER 3 QLC (18 tabs/month) AXERT (almotriptan malate) TIER 3 ST, QLC (24 tabs/month) eletriptan hydrobromide TIER 1 ST, QLC (18 tabs/month) FROVA (frovatriptan succinate) TIER 3 ST, QLC (27 tabs/month)

40 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS frovatriptan succinate TIER 1 ST, QLC (27 tabs/month) IMITREX (sumatriptan succinate) 25 MG TIER 3 QLC (18 tabs/month) TABLET, 50 MG TABLET, 100 MG TABLET IMITREX (sumatriptan succinate) 4 MG/0.5 TIER 3 QLC (16 injections/month at 4 ML PEN INJECT, 4 MG/0.5 ML CARTRIDGES, injections/fill) 6 MG/0.5 ML PEN INJECT, 6 MG/0.5 ML CARTRIDGES, 6 MG/0.5 ML VIAL IMITREX (sumatriptan) TIER 3 QLC (18 doses/month) MAXALT (rizatriptan benzoate) TIER 3 QLC (24 tabs/month) MAXALT MLT (rizatriptan benzoate) TIER 3 QLC (24 tabs/month) naratriptan hcl TIER 1 QLC (18 tabs/month) ONZETRA XSAIL (sumatriptan succinate) TIER 3 PA, QLC (1 box/month) RELPAX (eletriptan hydrobromide) TIER 3 ST, QLC (18 tabs/month) rizatriptan benzoate TIER 1 QLC (24 tabs/month) sumatriptan TIER 1 QLC (18 nasal sprays/month) sumatriptan succinate 25 mg tablet, 50 TIER 1 QLC (18 tabs/month) mg tablet, 100 mg tablet sumatriptan succinate 4 mg/0.5ml TIER 1 QLC (16 injections/month at 4 cartridge, 4 mg/0.5ml pen injctr, 6 injections/fill) mg/0.5ml cartridge, 6 mg/0.5ml pen injctr, 6 mg/0.5ml vial, 6 mg/0.5ml syringe sumatriptan succinate/naproxen sodium TIER 4 PA, QLC (9 tabs/month) SUMAVEL DOSEPRO (sumatriptan TIER 3 ST, QLC (18 injections/month at 6 succinate) injections/fill) TREXIMET (sumatriptan TIER 4 PA, QLC (9 tabs/month) succinate/naproxen sodium) ZEMBRACE SYMTOUCH (sumatriptan TIER 3 ST, QLC (16 injections/month at 4 succinate) injections/fill) zolmitriptan TIER 1 QLC (18 tabs/month) ZOMIG (zolmitriptan) 2.5 MG SPRAY, 5 MG TIER 3 ST, QLC (18 doses/month) SPRAY ZOMIG (zolmitriptan) 2.5 MG TABLET, 5 MG TIER 3 QLC (18 tabs/month) TABLET ZOMIG ZMT (zolmitriptan) TIER 3 QLC (18 tabs/month)

41 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS

ANTIMYASTHENIC AGENTS (Drugs for Myasthenia Gravis) PARASYMPATHOMIMETICS guanidine hcl TIER 1 MESTINON (pyridostigmine bromide) 180 TIER 3 QLC (6 tabs/day) MG TIMESPAN MESTINON (pyridostigmine bromide) 60 TIER 3 QLC (25 tabs/day) MG TABLET MESTINON (pyridostigmine bromide) 60 TIER 3 QLC (50 ml/day) MG/5 ML SYRUP pyridostigmine bromide 30 mg tablet, 180 TIER 1 QLC (6 tabs/day) mg tablet er pyridostigmine bromide 60 mg tablet TIER 1 QLC (25 tabs/day) pyridostigmine bromide 60 mg/5 ml syrup TIER 1 QLC (50 ml/day)

ANTIMYCOBACTERIALS (Drugs for Mycobacterial Infections) ANTIMYCOBACTERIALS, OTHER (Other Drugs for Mycobacterial Infection) dapsone 25 mg tablet, 100 mg tablet TIER 1 MYCOBUTIN (rifabutin) TIER 3 rifabutin TIER 1 ANTITUBERCULARS (Drugs for Tuberculosis) cycloserine TIER 3 ethambutol hcl TIER 1 isoniazid 50 mg/5 ml solution, 100 mg TIER 1 tablet, 300 mg tablet MYAMBUTOL (ethambutol hcl) TIER 3 PASER (aminosalicylic acid) TIER 3 PRIFTIN (rifapentine) TIER 2 pyrazinamide TIER 1 RIFADIN (rifampin) 150 MG CAPSULE, 300 TIER 3 MG CAPSULE RIFAMATE (rifampin/isoniazid) TIER 3

42 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS rifampin 150 mg capsule, 300 mg capsule TIER 1 RIFATER (rifampin/isoniazid/pyrazinamide) TIER 3 TRECATOR (ethionamide) TIER 3

ANTINEOPLASTICS (Drugs for Cancer) ALKYLATING AGENTS ALKERAN (melphalan) TIER 3 OAC cyclophosphamide 25 mg capsule, 50 TIER 2 OAC mg capsule GLEOSTINE (lomustine) TIER 2 OAC HEXALEN (altretamine) TIER 3 OAC LEUKERAN (chlorambucil) TIER 2 OAC MATULANE (procarbazine hcl) TIER 2 SP, OAC melphalan TIER 1 OAC MYLERAN (busulfan) TIER 2 OAC TEMODAR (temozolomide) 5 MG TIER 4 SP, OAC CAPSULE, 20 MG CAPSULE, 100 MG CAPSULE, 140 MG CAPSULE, 180 MG CAPSULE, 250 MG CAPSULE temozolomide TIER 4 SP, OAC VALCHLOR (mechlorethamine hcl) TIER 4 PA, SP, QLC (1 tube/month) ANTIANDROGENS abiraterone acetate TIER 4 PA, SP, QLC (4 tabs/day), OAC bicalutamide TIER 1 GL (Male), OAC CASODEX (bicalutamide) TIER 3 GL (Male), OAC ERLEADA (apalutamide) TIER 4 PA, SP, QLC (4 tabs/day), OAC flutamide TIER 1 OAC NILANDRON (nilutamide) TIER 4 QLC (1 tab/day), OAC nilutamide TIER 4 QLC (1 tab/day), OAC NUBEQA (darolutamide) TIER 4 PA, SP, QLC (4 tabs/day), OAC XTANDI (enzalutamide) TIER 4 PA, SP, C (Short Cycle), QLC (4 caps/day), OAC

43 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS YONSA (abiraterone acetate, TIER 4 PA, SP, QLC (4 tabs/day), OAC submicronized) ZYTIGA (abiraterone acetate) 250 MG TIER 4 PA, SP, C (Short Cycle), QLC (4 TABLET tabs/day), OAC ZYTIGA (abiraterone acetate) 500 MG TIER 4 PA, SP, C (Short Cycle), QLC (2 TABLET tabs/day), OAC ANTIANGIOGENIC AGENTS POMALYST (pomalidomide) TIER 4 PA, SP, QLC (1 cap/day), OAC REVLIMID (lenalidomide) TIER 4 PA, SP, QLC (1 cap/day), OAC THALOMID (thalidomide) 150 MG TIER 4 PA, SP, QLC (2 caps/day) CAPSULE, 200 MG CAPSULE THALOMID (thalidomide) 50 MG CAPSULE, TIER 4 PA, SP, QLC (1 cap/day) 100 MG CAPSULE ANTIESTROGENS/MODIFIERS EMCYT (estramustine phosphate sodium) TIER 2 OAC FARESTON (toremifene citrate) TIER 3 OAC SOLTAMOX (tamoxifen citrate) TIER 3 ACA (Preventive Health), OAC tamoxifen citrate TIER 1 ACA (Preventive Health), OAC toremifene citrate TIER 1 OAC ANTIMETABOLITES capecitabine TIER 4 SP, OAC DROXIA (hydroxyurea) TIER 2 EFUDEX (fluorouracil) TIER 3 fluorouracil 2 % solution, 5 % cream (g), 5 TIER 1 % solution HYDREA (hydroxyurea) TIER 3 OAC hydroxyurea TIER 1 OAC LONSURF (trifluridine/tipiracil hcl) 15 MG- TIER 4 PA, SP, QLC (100 tabs/28 days), 6.14 MG TABLET OAC LONSURF (trifluridine/tipiracil hcl) 20 MG- TIER 4 PA, SP, QLC (80 tabs/28 days), 8.19 MG TABLET OAC mercaptopurine TIER 1 OAC PURIXAN (mercaptopurine) TIER 4 SP, AL1 (Up to 10 yrs old), QLC (1 bottle/month), OAC

44 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS SIKLOS (hydroxyurea) TIER 3 PA TABLOID (thioguanine) TIER 2 OAC XELODA (capecitabine) TIER 4 SP, OAC ANTINEOPLASTICS, OTHER ALUNBRIG (brigatinib) 30 MG TABLET TIER 4 PA, SP, QLC (2 tabs/day), OAC ALUNBRIG (brigatinib) 90 MG TABLET, 90 TIER 4 PA, SP, QLC (1 tab/day), OAC MG-180 MG TAB PACK, 180 MG TABLET BALVERSA (erdafitinib) 3 MG TABLET TIER 4 PA, SP, QLC (3 tabs/day), OAC BALVERSA (erdafitinib) 4 MG TABLET TIER 4 PA, SP, QLC (2 tabs/day), OAC BALVERSA (erdafitinib) 5 MG TABLET TIER 4 PA, SP, QLC (1 tab/day), OAC COPIKTRA (duvelisib) TIER 4 PA, SP, QLC (56 caps/28 days), OAC HEMANGEOL (propranolol hcl) TIER 3 PA, SP, QLC (2 bottles/month) IDHIFA (enasidenib mesylate) TIER 4 PA, SP, QLC (1 tab/day), OAC INREBIC (fedratinib dihydrochloride) TIER 4 PA, SP, QLC (4 caps/day), OAC leucovorin calcium 5 mg tablet, 10 mg TIER 1 tablet, 15 mg tablet, 25 mg tablet LYSODREN (mitotane) TIER 2 OAC NINLARO (ixazomib citrate) TIER 4 PA, SP, QLC (3 caps/21 days), OAC ROZLYTREK (entrectinib) 100 MG CAPSULE TIER 4 PA, SP, QLC (5 caps/day), OAC ROZLYTREK (entrectinib) 200 MG CAPSULE TIER 4 PA, SP, QLC (3 caps/day), OAC RUBRACA (rucaparib camsylate) 200 MG TIER 4 PA, SP, C (Short Cycle), QLC (4 TABLET, 250 MG TABLET tabs/day), OAC RUBRACA (rucaparib camsylate) 300 MG TIER 4 PA, SP, C (Short Cycle), QLC (1 TABLET tab/month), OAC RYDAPT (midostaurin) TIER 4 PA, SP, QLC (56 caps/21 days [#56 package size] or 224 caps/28 days), OAC SYLATRON (peginterferon alfa-2b) TIER 4 PA, SP SYNRIBO (omacetaxine mepesuccinate) TIER 4 PA, SP, QLC (2 vials/day) TIBSOVO (ivosidenib) TIER 4 PA, SP, QLC (2 tabs/day), OAC TURALIO (pexidartinib hydrochloride) TIER 4 PA, SP, QLC (4 tabs/day), OAC VITRAKVI (larotrectinib sulfate) 100 MG TIER 4 PA, SP, QLC (2 caps/day), OAC CAPSULE

45 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS VITRAKVI (larotrectinib sulfate) 20 MG/ML TIER 4 PA, SP, QLC (10 ml/day), OAC SOLUTION VITRAKVI (larotrectinib sulfate) 25 MG TIER 4 PA, SP, QLC (6 caps/day), OAC CAPSULE VIZIMPRO (dacomitinib) TIER 4 PA, SP, QLC (1 tab/day), OAC XOSPATA (gilteritinib fumarate) TIER 4 PA, SP, QLC (3 tabs/day), OAC XPOVIO (selinexor) 100 MG ONCE WEEKLY TIER 4 PA, SP, QLC (5 tabs/7 days), OAC DOSE XPOVIO (selinexor) 60 MG ONCE WEEKLY TIER 4 PA, SP, QLC (3 tabs/7 days), OAC DOSE XPOVIO (selinexor) 80 MG ONCE WEEKLY TIER 4 PA, SP, QLC (4 tabs/7 days), OAC DOSE XPOVIO (selinexor) 80 MG TWICE WEEKLY TIER 4 PA, SP, QLC (8 tabs/7 days), OAC DOSE ZOLINZA (vorinostat) TIER 4 PA, C (Short Cycle), SP, QLC (4 caps/day), OAC AROMATASE INHIBITORS, 3RD GENERATION anastrozole TIER 1 GL (Female), OAC ARIMIDEX (anastrozole) TIER 3 GL (Female), OAC AROMASIN (exemestane) TIER 3 GL (Female), OAC exemestane TIER 1 GL (Female), OAC FEMARA (letrozole) TIER 3 GL (Female), OAC letrozole TIER 1 GL (Female), OAC ENZYME INHIBITORS etoposide 50 mg capsule TIER 4 OAC HYCAMTIN (topotecan hcl) 0.25 MG TIER 4 RO (Retail Only), SP, OAC CAPSULE, 1 MG CAPSULE LORBRENA (lorlatinib) 100 MG TABLET TIER 4 PA, SP, QLC (1 tab/day), OAC LORBRENA (lorlatinib) 25 MG TABLET TIER 4 PA, SP, QLC (3 tabs/day), OAC PIQRAY (alpelisib) 200 MG DAILY DOSE TIER 4 PA, SP, QLC (1 tab/day), OAC PIQRAY (alpelisib) 250 MG DAILY, 300 MG TIER 4 PA, SP, QLC (2 tabs/day), OAC DAILY

46 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS MOLECULAR TARGET INHIBITORS AFINITOR (everolimus) 2.5 MG TABLET, 5 TIER 4 PA, C (Short Cycle), SP, QLC (1 MG TABLET tab/day), OAC AFINITOR (everolimus) 7.5 MG TABLET, 10 TIER 4 PA, C (Short Cycle), SP, QLC (2 MG TABLET tabs/day), OAC AFINITOR DISPERZ (everolimus) 2 MG TIER 4 PA, C (Short Cycle), SP, QLC (2 TABLET tabs/day), OAC AFINITOR DISPERZ (everolimus) 3 MG TIER 4 PA, C (Short Cycle), SP, QLC (4 TABLET tabs/day), OAC AFINITOR DISPERZ (everolimus) 5 MG TIER 4 PA, C (Short Cycle), SP, QLC (1 TABLET tab/day), OAC ALECENSA (alectinib hcl) TIER 4 PA, SP, QLC (8 caps/day), OAC BOSULIF (bosutinib) 100 MG TABLET TIER 4 PA, C (Short Cycle), SP, QLC (4 tabs/day), OAC BOSULIF (bosutinib) 400 MG TABLET TIER 4 PA, SP, QLC (1 tab/day), OAC BOSULIF (bosutinib) 500 MG TABLET TIER 4 PA, C (Short Cycle), SP, QLC (1 tab/day), OAC BRAFTOVI (encorafenib) 50 MG CAPSULE TIER 4 PA, SP, QLC (4 caps/day), OAC BRAFTOVI (encorafenib) 75 MG CAPSULE TIER 4 PA, SP, QLC (6 caps/day), OAC CABOMETYX (cabozantinib s-malate) TIER 4 PA, SP, QLC (1 tab/day), OAC CALQUENCE (acalabrutinib) TIER 4 PA, SP, QLC (2 caps/day), OAC CAPRELSA (vandetanib) 100 MG TABLET TIER 4 PA, SP, QLC (2 tabs/day), OAC CAPRELSA (vandetanib) 300 MG TABLET TIER 4 PA, SP, QLC (1 tab/day), OAC COMETRIQ (cabozantinib s-malate) 100 TIER 4 PA, C (Short Cycle), SP, QLC (56 MG DAILY-DOSE PK - caps/28 days), OAC COMETRIQ (cabozantinib s-malate) 140 TIER 4 PA, C (Short Cycle), SP, QLC (112 MG DAILY-DOSE PK - caps/28 days), OAC COMETRIQ (cabozantinib s-malate) 60 TIER 4 PA, C (Short Cycle), SP, QLC (84 MG DAILY-DOSE PACK - caps/28 days), OAC COTELLIC (cobimetinib fumarate) TIER 4 PA, SP, QLC (63 tabs/28 days), OAC DAURISMO (glasdegib maleate) 100 MG TIER 4 PA, SP, QLC (1 tab/day), OAC TABLET DAURISMO (glasdegib maleate) 25 MG TIER 4 PA, SP, QLC (2 tabs/day), OAC TABLET ERIVEDGE (vismodegib) TIER 4 PA, SP, C (Short Cycle), QLC (1 cap/day), OAC

47 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS erlotinib hcl 100 mg tablet, 150 mg tablet TIER 4 PA, C (Short Cycle), SP, QLC (1 tab/day), OAC erlotinib hcl 25 mg tablet TIER 4 PA, C (Short Cycle), SP, QLC (3 tabs/day), OAC FARYDAK (panobinostat lactate) TIER 4 PA, SP, QLC (6 caps/12 days, not to exceed 6 caps every 21 days), OAC GILOTRIF (afatinib dimaleate) TIER 4 PA, SP, QLC (1 tab/day), OAC GLEEVEC (imatinib mesylate) 100 MG TIER 4 PA, SP, QLC (8 tabs/day), OAC TABLET GLEEVEC (imatinib mesylate) 400 MG TIER 4 PA, SP, QLC (2 tabs/day), OAC TABLET IBRANCE (palbociclib) TIER 4 PA, SP, QLC (1 cap/day, max 21 caps/28 days), OAC ICLUSIG (ponatinib hcl) 15 MG TABLET TIER 4 PA, SP, QLC (2 tabs/day), OAC ICLUSIG (ponatinib hcl) 45 MG TABLET TIER 4 PA, SP, QLC (1 tab/day), OAC imatinib mesylate 100 mg tablet TIER 4 PA, SP, QLC (8 tabs/day), OAC imatinib mesylate 400 mg tablet TIER 4 PA, SP, QLC (2 tabs/day), OAC IMBRUVICA (ibrutinib) 140 MG CAPSULE TIER 4 PA, SP, C (Short Cycle), QLC (4 caps/day), OAC IMBRUVICA (ibrutinib) 140 MG TABLET TIER 4 PA, SP, C (Short Cycle), QLC (1 tab/day), OAC IMBRUVICA (ibrutinib) 280 MG TABLET, 420 TIER 4 PA, SP, C (Short Cycle), QLC (1 MG TABLET, 560 MG TABLET tab/day), OAC IMBRUVICA (ibrutinib) 70 MG CAPSULE TIER 4 PA, SP, C (Short Cycle), QLC (1 cap/day), OAC INLYTA (axitinib) 1 MG TABLET TIER 4 PA, SP, C (Short Cycle), QLC (6 tabs/day), OAC INLYTA (axitinib) 5 MG TABLET TIER 4 PA, SP, C (Short Cycle), QLC (4 tabs/day), OAC IRESSA (gefitinib) TIER 4 PA, SP, C (Short Cycle), QLC (1 tab/day), OAC JAKAFI (ruxolitinib phosphate) TIER 4 PA, SP, C (Short Cycle), QLC (2 tabs/day), OAC KISQALI (ribociclib succinate) TIER 4 PA, SP, QLC (1 pack/28 days), OAC KISQALI FEMARA CO-PACK (ribociclib TIER 4 PA, SP, QLC (1 pack/28 days), succinate/letrozole) OAC

48 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS LENVIMA (lenvatinib mesylate) 10 MG TIER 4 PA, SP, QLC (30 caps/month), DAILY DOSE OAC LENVIMA (lenvatinib mesylate) 12 MG TIER 4 PA, SP, QLC (3 caps/day), OAC DAILY DOSE LENVIMA (lenvatinib mesylate) 18 MG TIER 4 PA, SP, QLC (90 caps/month), DAILY, 24 MG DAILY OAC LENVIMA (lenvatinib mesylate) 4 MG TIER 4 PA, SP, QLC (1 cap/day), OAC CAPSULE LENVIMA (lenvatinib mesylate) 8 MG TIER 4 PA, SP, QLC (60 caps/month), DAILY, 14 MG DAILY, 20 MG DAILY OAC LYNPARZA (olaparib) 100 MG TABLET, 150 TIER 4 PA, SP, C (Short Cycle), QLC (4 MG TABLET tabs/day), OAC LYNPARZA (olaparib) 50 MG CAPSULE TIER 4 PA, SP, C (Short Cycle), QLC (16 caps/day), OAC MEKINIST (trametinib dimethyl sulfoxide) TIER 4 PA, SP, QLC (3 tabs/day), OAC 0.5 MG TABLET MEKINIST (trametinib dimethyl sulfoxide) 2 TIER 4 PA, SP, QLC (1 tab/day), OAC MG TABLET MEKTOVI (binimetinib) TIER 4 PA, SP, QLC (6 tabs/day), OAC NERLYNX (neratinib maleate) TIER 4 PA, SP, C (Short Cycle), QLC (6 tabs/day), OAC NEXAVAR (sorafenib tosylate) TIER 4 PA, SP, C (Short Cycle), QLC (4 tabs/day), OAC ODOMZO (sonidegib phosphate) TIER 4 PA, SP, QLC (1 cap/day), OAC SPRYCEL (dasatinib) 100 MG TABLET, 140 TIER 4 PA, C (Short Cycle), SP, QLC (1 MG TABLET tab/day), OAC SPRYCEL (dasatinib) 20 MG TABLET, 50 MG TIER 4 PA, C (Short Cycle), SP, QLC (3 TABLET tabs/day), OAC SPRYCEL (dasatinib) 70 MG TABLET, 80 MG TIER 4 PA, C (Short Cycle), SP, QLC (2 TABLET tabs/day), OAC STIVARGA (regorafenib) TIER 4 PA, SP, QLC (4 tabs/day), OAC SUTENT (sunitinib malate) 12.5 MG TIER 4 PA, C (Short Cycle), SP, QLC (3 CAPSULE caps/day), OAC SUTENT (sunitinib malate) 25 MG CAPSULE, TIER 4 PA, C (Short Cycle), SP, QLC (1 37.5 MG CAPSULE, 50 MG CAPSULE cap/day), OAC TAFINLAR (dabrafenib mesylate) TIER 4 PA, SP, QLC (4 caps/day), OAC TAGRISSO (osimertinib mesylate) TIER 4 PA, SP, C (Short Cycle), QLC (1 tab/day), OAC

49 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS TALZENNA (talazoparib tosylate) 0.25 MG TIER 4 PA, SP, QLC (3 caps/day), OAC CAPSULE TALZENNA (talazoparib tosylate) 1 MG TIER 4 PA, SP, QLC (1 cap/day), OAC CAPSULE TARCEVA (erlotinib hcl) 100 MG TABLET, TIER 4 PA, SP, C (Short Cycle), QLC (1 150 MG TABLET tab/day), OAC TARCEVA (erlotinib hcl) 25 MG TABLET TIER 4 PA, SP, C (Short Cycle), QLC (3 tabs/day), OAC TASIGNA (nilotinib hcl) 150 MG CAPSULE, TIER 4 PA, C (Short Cycle), SP, QLC (4 200 MG CAPSULE caps/day), OAC TASIGNA (nilotinib hcl) 50 MG CAPSULE TIER 4 PA, SP, QLC (4 caps/day), OAC TYKERB (lapatinib ditosylate) TIER 4 PA, SP, QLC (22 tabs/day), OAC VENCLEXTA (venetoclax) 10 MG TABLET TIER 4 PA, SP, QLC (2 tabs/day), OAC VENCLEXTA (venetoclax) 100 MG TABLET TIER 4 PA, SP, QLC (6 tabs/day), OAC VENCLEXTA (venetoclax) 50 MG TABLET TIER 4 PA, SP, QLC (1 tab/day), OAC VENCLEXTA STARTING PACK (venetoclax) TIER 4 PA, SP, QLC (1 starter pack/year), OAC VERZENIO (abemaciclib) TIER 4 PA, SP, QLC (2 tabs/day), OAC VOTRIENT (pazopanib hcl) TIER 4 PA, SP, C (Short Cycle), QLC (4 tabs/day), OAC XALKORI (crizotinib) TIER 4 PA, SP, C (Short Cycle), QLC (2 caps/day), OAC ZEJULA (niraparib tosylate) TIER 4 PA, SP, QLC (3 caps/day), OAC ZELBORAF (vemurafenib) TIER 4 PA, SP, QLC (8 tabs/day), OAC ZYDELIG (idelalisib) TIER 4 PA, SP, QLC (2 tabs/day), OAC ZYKADIA (ceritinib) 150 MG CAPSULE TIER 4 PA, SP, C (Short Cycle), QLC (3 caps/day), OAC ZYKADIA (ceritinib) 150 MG TABLET TIER 4 PA, C (Short Cycle), SP, QLC (3 tabs/day), OAC RETINOIDS bexarotene TIER 4 PA, C (Short Cycle), SP, QLC (8 caps/day), OAC PANRETIN (alitretinoin) TIER 3 PA TARGRETIN (bexarotene) 1% GEL TIER 4 PA, SP, QLC (1 tube/month) TARGRETIN (bexarotene) 75 MG CAPSULE TIER 4 PA, C (Short Cycle), SP, QLC (8 caps/day), OAC

50 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS tretinoin 10 mg capsule TIER 1 QLC (9 caps/day), OAC TREATMENT ADJUNCTS (Supportive Treatment Drugs for Cancer) MESNEX (mesna) 400 MG TABLET TIER 2

ANTIPARASITICS (Drugs for Parasitic Infections) ANTIHELMINTHICS (Drugs for Worm Infection) albendazole TIER 1 QLC (4 tabs/day) ALBENZA (albendazole) TIER 3 QLC (4 tabs/day) BILTRICIDE (praziquantel) TIER 3 ivermectin TIER 1 QLC (20 tabs/fill) mebendazole (EMVERM) TIER 3 PA, QLC (2 tabs/month) praziquantel TIER 1 SKLICE (ivermectin) TIER 3 STROMECTOL (ivermectin) TIER 3 QLC (20 tabs/fill) ANTIPROTOZOALS (Drugs for Protozoal Infection) ALINIA (nitazoxanide) 100 MG/5 ML TIER 3 PA, QLC (1 bottle/fill) SUSPENSION ALINIA (nitazoxanide) 500 MG TABLET TIER 3 PA, QLC (6 tabs/fill) ARAKODA (tafenoquine succinate) TIER 3 PA, QLC (12 tabs/28 days) atovaquone TIER 1 PA atovaquone/proguanil hcl 250-100 mg TIER 1 QLC (1 tab/day) tablet atovaquone/proguanil hcl 62.5-25 mg TIER 1 QLC (3 tabs/day) tablet benznidazole 100 mg tablet TIER 3 QLC (4 tabs/day; not to exceed 240 tabs/year) benznidazole 12.5 mg tablet TIER 3 QLC (12 tabs/day; not to exceed 720 tabs/year) chloroquine phosphate TIER 1 COARTEM (artemether/lumefantrine) TIER 2 QLC (24 tabs/fill) DARAPRIM (pyrimethamine) TIER 2 PA hydroxychloroquine sulfate TIER 1

51 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS IMPAVIDO (miltefosine) TIER 4 PA, SP, QLC (84 tabs/28 days) KRINTAFEL (tafenoquine succinate) TIER 3 QLC (2 tabs/28 days) MALARONE (atovaquone/proguanil hcl) TIER 3 QLC (1 tab/day) 250-100 MG TABLET MALARONE (atovaquone/proguanil hcl) TIER 3 QLC (3 tabs/day) 62.5-25 MG PED TAB mefloquine hcl TIER 1 QLC (5 tabs/fill) MEPRON (atovaquone) TIER 3 PA PLAQUENIL (hydroxychloroquine sulfate) TIER 3 primaquine phosphate TIER 1 QUALAQUIN (quinine sulfate) TIER 3 QLC (6 caps/day) quinine sulfate TIER 1 QLC (6 caps/day) PEDICULICIDES/SCABICIDES (Drugs for Scabies and Lice) crotamiton (CROTAN) TIER 1 ELIMITE (permethrin) TIER 3 EURAX (crotamiton) 10% CREAM TIER 2 EURAX (crotamiton) 10% LOTION TIER 3 lindane TIER 1 malathion TIER 1 OVIDE (malathion) TIER 3 permethrin 5 % cream (g) TIER 1

ANTIPARKINSON AGENTS (Drugs for Parkinson's Disease) ANTICHOLINERGICS benztropine mesylate 0.5 mg tablet, 1 mg TIER 1 tablet, 2 mg tablet trihexyphenidyl hcl TIER 1 ANTIPARKINSON AGENTS, OTHER amantadine hcl TIER 1 carbidopa/levodopa/entacapone TIER 1 COMTAN (entacapone) TIER 3 QLC (8 tabs/day)

52 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS entacapone TIER 1 QLC (8 tabs/day) GOCOVRI (amantadine hcl) ER 137 MG TIER 4 PA, QLC (2 caps/day) CAPSULE GOCOVRI (amantadine hcl) ER 68.5 MG TIER 4 PA, QLC (1 cap/day) CAPSULE OSMOLEX ER (amantadine hcl) TIER 3 PA, QLC (1 tab/day) STALEVO 100 TIER 3 (carbidopa/levodopa/entacapone) STALEVO 125 TIER 3 (carbidopa/levodopa/entacapone) STALEVO 150 TIER 3 (carbidopa/levodopa/entacapone) STALEVO 200 TIER 3 (carbidopa/levodopa/entacapone) STALEVO 50 TIER 3 (carbidopa/levodopa/entacapone) STALEVO 75 TIER 3 (carbidopa/levodopa/entacapone) TASMAR (tolcapone) TIER 3 QLC (6 tabs/day) tolcapone TIER 3 ST, QLC (6 tabs/day) DOPAMINE AGONISTS APOKYN (apomorphine hcl) TIER 4 PA, SP bromocriptine mesylate TIER 1 MIRAPEX (pramipexole di-hcl) TIER 3 MIRAPEX ER (pramipexole di-hcl) TIER 3 QLC (1 tab/day) NEUPRO (rotigotine) TIER 3 QLC (1 patch/day) PARLODEL (bromocriptine mesylate) TIER 3 pramipexole di-hcl -0.125 mg tablet, -0.25 TIER 1 mg tablet, -0.5 mg tablet, -0.75 mg tablet, -1 mg tablet, -1.5 mg tablet pramipexole di-hcl -0.375 mg tab er, -0.75 TIER 1 QLC (1 tab/day) mg tab er, -1.5 mg tab er, -2.25 mg tab er, -3 mg tab er, -3.75 mg tab er, -4.5 mg tab er REQUIP (ropinirole hcl) TIER 3 REQUIP XL (ropinirole hcl) 12 MG TABLET TIER 3 QLC (2 tabs/day)

53 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS REQUIP XL (ropinirole hcl) 2 MG TABLET, 4 TIER 3 QLC (1 tab/day) MG TABLET, 6 MG TABLET REQUIP XL (ropinirole hcl) 8 MG TABLET TIER 3 QLC (3 tabs/day) ropinirole hcl 0.25 mg tablet, 0.5 mg TIER 1 tablet, 1 mg tablet, 2 mg tablet, 3 mg tablet, 4 mg tablet, 5 mg tablet ropinirole hcl 12 mg tab er 24h TIER 1 QLC (2 tabs/day) ropinirole hcl 2 mg tab er, 4 mg tab er, 6 TIER 1 QLC (1 tab/day) mg tab er ropinirole hcl 8 mg tab er 24h TIER 1 QLC (3 tabs/day) DOPAMINE PRECURSORS/L-AMINO ACID DECARBOXYLASE INHIBITORS carbidopa TIER 1 carbidopa/levodopa 10mg-100mg tab TIER 1 QLC (8 tabs/day) rapdis, 25mg-100mg tab rapdis, 25mg- 250mg tab rapdis carbidopa/levodopa 10mg-100mg TIER 1 tablet, 25mg-100mg tablet, 25mg-100mg tablet er, 25mg-250mg tablet, 50mg- 200mg tablet er LODOSYN (carbidopa) TIER 3 RYTARY (carbidopa/levodopa) ER 23.75 TIER 3 ST, QLC (25 caps/day) MG-95 MG CAP RYTARY (carbidopa/levodopa) ER 36.25 TIER 3 ST, QLC (16 caps/day) MG-145 MG CAP RYTARY (carbidopa/levodopa) ER 48.75 TIER 3 ST, QLC (12 caps/day) MG-195 MG CAP RYTARY (carbidopa/levodopa) ER 61.25 TIER 3 ST, QLC (10 caps/day) MG-245 MG CAP SINEMET 10-100 (carbidopa/levodopa) TIER 3 SINEMET 25-100 (carbidopa/levodopa) TIER 3 SINEMET 25-250 (carbidopa/levodopa) TIER 3 SINEMET CR (carbidopa/levodopa) TIER 3 MONOAMINE OXIDASE B (MAO-B) INHIBITORS AZILECT (rasagiline mesylate) TIER 3 QLC (1 tab/day) ELDEPRYL (selegiline hcl) TIER 3

54 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS rasagiline mesylate TIER 1 QLC (1 tab/day) selegiline hcl TIER 1 XADAGO (safinamide mesylate) TIER 3 ST, QLC (1 tab/day) ZELAPAR (selegiline hcl) TIER 3

ANTIPSYCHOTICS (Drugs for Mental Health) 1ST GENERATION/TYPICAL chlorpromazine hcl 10 mg tablet, 25 mg TIER 1 tablet, 50 mg tablet, 100 mg tablet, 200 mg tablet fluphenazine hcl 1 mg tablet, 2.5 mg TIER 1 tablet, 2.5 mg/5ml elixir, 5 mg/ml oral conc, 5 mg tablet, 10 mg tablet haloperidol TIER 1 haloperidol lactate 2 mg/ml oral conc TIER 1 loxapine succinate TIER 1 molindone hcl 10 mg tablet TIER 3 QLC (8 tabs/day) molindone hcl 25 mg tablet TIER 3 QLC (9 tabs/day) molindone hcl 5 mg tablet TIER 3 QLC (12 tabs/day) ORAP (pimozide) TIER 3 pimozide TIER 1 thioridazine hcl TIER 1 thiothixene TIER 1 trifluoperazine hcl TIER 1 2ND GENERATION/ATYPICAL ABILIFY (aripiprazole) 10 MG TABLET, 15 TIER 3 QLC (1 tab/day) MG TABLET, 20 MG TABLET, 30 MG TABLET ABILIFY (aripiprazole) 2 MG TABLET TIER 3 QLC (4 tabs/day) ABILIFY (aripiprazole) 5 MG TABLET TIER 3 QLC (2 tabs/day) ABILIFY MYCITE (aripiprazole) 2 MG KIT TIER 4 PA, QLC (4 tabs/day) ABILIFY MYCITE (aripiprazole) 5 MG KIT, 10 TIER 4 PA, QLC (1 tab/day) MG KIT, 15 MG KIT, 20 MG KIT, 30 MG KIT aripiprazole 1 mg/ml solution TIER 1 QLC (25 ml/day)

55 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS aripiprazole 10 mg tablet, 15 mg tablet, TIER 1 QLC (1 tab/day) 20 mg tablet, 30 mg tablet aripiprazole 2 mg tablet TIER 1 QLC (4 tabs/day) aripiprazole 5 mg tablet, 10 mg tab TIER 1 QLC (2 tabs/day) rapdis, 15 mg tab rapdis FANAPT (iloperidone) 1 MG TABLET, 2 MG TIER 3 QLC (2 tabs/day) TABLET, 4 MG TABLET, 6 MG TABLET, 8 MG TABLET, 10 MG TABLET, 12 MG TABLET FANAPT (iloperidone) TITRATION PACK TIER 3 QLC (1 pack/month) GEODON (ziprasidone hcl) TIER 3 INVEGA (paliperidone) ER 1.5 MG TABLET, TIER 3 PA, QLC (1 tab/day) ER 3 MG TABLET, ER 9 MG TABLET INVEGA (paliperidone) ER 6 MG TABLET TIER 3 PA, QLC (2 tabs/day) LATUDA (lurasidone hcl) TIER 3 ST, QLC (1 tab/day) NUPLAZID (pimavanserin tartrate) 10 MG TIER 4 PA, SP, C (Short Cycle), QLC (1 TABLET tab/day) NUPLAZID (pimavanserin tartrate) 17 MG TIER 4 PA, SP, C (Short Cycle), QLC (1 TABLET tab/day) NUPLAZID (pimavanserin tartrate) 34 MG TIER 4 PA, SP, C (Short Cycle), QLC (1 CAPSULE cap/day) olanzapine 2.5 mg tablet, 5 mg tablet, 5 TIER 1 mg tab rapdis, 7.5 mg tablet, 10 mg tab rapdis, 10 mg tablet, 15 mg tab rapdis, 15 mg tablet, 20 mg tablet, 20 mg tab rapdis paliperidone 1.5 mg tab er 24, 3 mg tab TIER 1 PA, QLC (1 tab/day) er 24, 9 mg tab er 24 paliperidone 6 mg tab 24 TIER 1 PA, QLC (2 tabs/day) quetiapine fumarate 25 mg tablet, 50 mg TIER 1 tablet, 100 mg tablet, 200 mg tablet, 300 mg tablet, 400 mg tablet quetiapine fumarate 50 mg tab er, 150 TIER 1 ST mg tab er, 200 mg tab er, 300 mg tab er, 400 mg tab er REXULTI (brexpiprazole) TIER 4 PA, QLC (1 tab/day) RISPERDAL (risperidone) TIER 3 RISPERDAL M-TAB (risperidone) TIER 3 risperidone TIER 1 SAPHRIS (asenapine maleate) TIER 3 QLC (2 tabs/day)

56 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS SEROQUEL (quetiapine fumarate) TIER 3 SEROQUEL XR (quetiapine fumarate) TIER 3 ST VRAYLAR (cariprazine hcl) 1.5 MG TIER 3 PA, QLC (1 cap/day) CAPSULE, 3 MG CAPSULE, 4.5 MG CAPSULE, 6 MG CAPSULE VRAYLAR (cariprazine hcl) 1.5 MG-3 MG TIER 3 PA, QLC (1 pack/month) PACK ziprasidone hcl TIER 1 ZYPREXA (olanzapine) 2.5 MG TABLET, 5 TIER 3 MG TABLET, 7.5 MG TABLET, 10 MG TABLET, 15 MG TABLET, 20 MG TABLET ZYPREXA ZYDIS (olanzapine) TIER 3 TREATMENT-RESISTANT clozapine TIER 1 CLOZARIL (clozapine) TIER 3 FAZACLO (clozapine) TIER 3 VERSACLOZ (clozapine) TIER 3 QLC (18 ml/day)

ANTISPASTICITY AGENTS (Drugs for Muscle Spasm) baclofen 10 mg tablet TIER 1 QLC (8 tabs/day) baclofen 20 mg tablet TIER 1 QLC (4 tabs/day) baclofen 5 mg tablet TIER 1 QLC (3 tabs/day) DANTRIUM (dantrolene sodium) 25 MG TIER 3 CAPSULE, 50 MG CAPSULE dantrolene sodium TIER 1 tizanidine hcl TIER 1 ZANAFLEX (tizanidine hcl) TIER 3

ANTIVIRALS (Drugs for Viral Infections) ANTI-CYTOMEGALOVIRUS (CMV) AGENTS PREVYMIS (letermovir) 240 MG TABLET, 480 TIER 3 PA, QLC (1 tab/day) MG TABLET VALCYTE (valganciclovir hcl) 450 MG TIER 3 QLC (2 tabs/day) TABLET

57 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS VALCYTE (valganciclovir hcl) 50 MG/ML TIER 3 QLC (18 ml/day) SOLUTION valganciclovir hcl 450 mg tablet TIER 1 QLC (2 tabs/day) valganciclovir hcl 50 mg/ml soln recon TIER 1 QLC (18 ml/day) ZIRGAN (ganciclovir) TIER 3 QLC (1 tube/month) ANTI-HEPATITIS B (HBV) AGENTS adefovir dipivoxil TIER 1 QLC (1 tab/day) BARACLUDE (entecavir) 0.05 MG/ML TIER 2 QLC (3 bottles/month) SOLUTION BARACLUDE (entecavir) 0.5 MG TABLET, 1 TIER 3 QLC (1 tab/day) MG TABLET entecavir TIER 1 QLC (1 tab/day) EPIVIR HBV (lamivudine) 100 MG TABLET TIER 3 QLC (1 tab/day) EPIVIR HBV (lamivudine) 25 MG/5 ML TIER 2 QLC (3 bottles/month) SOLN HEPSERA (adefovir dipivoxil) TIER 3 QLC (1 tab/day) lamivudine 100 mg tablet TIER 1 QLC (1 tab/day) VEMLIDY (tenofovir alafenamide) TIER 3 PA, QLC (1 tab/day) ANTI-HEPATITIS C (HCV) AGENTS, DIRECT ACTING AGENTS DAKLINZA (daclatasvir dihydrochloride) TIER 4 PA, SP, QLC (1 tab/day) EPCLUSA (sofosbuvir/velpatasvir) TIER 4 PA, SP, QLC (1 tab/day) HARVONI (ledipasvir/sofosbuvir) TIER 4 PA, SP, QLC (1 tab/day) ledipasvir/sofosbuvir TIER 4 PA, SP, QLC (1 tab/day) MAVYRET (glecaprevir/pibrentasvir) TIER 4 PA, SP, QLC (3 tabs/day) OLYSIO (simeprevir sodium) TIER 4 PA, SP, QLC (1 cap/day) sofosbuvir/velpatasvir TIER 4 PA, SP, QLC (1 tab/day) SOVALDI (sofosbuvir) TIER 4 PA, SP, QLC (1 tab/day) TECHNIVIE TIER 4 PA, SP, QLC (2 tabs/day) (ombitasvir/paritaprevir/ritonavir) VIEKIRA PAK TIER 4 PA, SP, QLC (4 tabs/day) (ombitasvir/paritaprevir/ritonavir/dasabuv ir sodium) VIEKIRA XR TIER 4 PA, SP, QLC (3 tabs/day) (ombitasvir/paritaprevir/ritonavir/dasabuv ir sodium)

58 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS VOSEVI TIER 4 PA, SP, QLC (1 tab/day) (sofosbuvir/velpatasvir/voxilaprevir) ZEPATIER (elbasvir/grazoprevir) TIER 4 PA, SP, QLC (1 tab/day) ANTI-HEPATITIS C (HCV) AGENTS, OTHER COPEGUS (ribavirin) TIER 3 RO (Retail Only) INTRON A (interferon alfa-2b,recomb.) TIER 4 PA, SP PEGASYS (peginterferon alfa-2a) 180 TIER 4 PA, SP, QLC (1 syringe/week) MCG/0.5 ML SYRINGE - PEGASYS (peginterferon alfa-2a) 180 TIER 4 PA, SP, QLC (1 vial/week) MCG/ML VIAL - PEGASYS PROCLICK (peginterferon alfa- TIER 4 PA, SP, QLC (1 pen/week) 2a) PEGINTRON (peginterferon alfa-2b) TIER 4 PA, SP PEGINTRON REDIPEN (peginterferon alfa- TIER 4 PA, SP 2b) REBETOL (ribavirin) 200 MG CAPSULE TIER 3 RO (Retail Only) REBETOL (ribavirin) 40 MG/ML SOLUTION TIER 3 PA, RO (Retail Only) RIBASPHERE RIBAPAK (ribavirin) TIER 3 PA, RO (Retail Only) RIBATAB (ribavirin) TIER 3 PA, RO (Retail Only) ribavirin (MODERIBA) 200 mg tablet TIER 1 RO (Retail Only) ribavirin (MODERIBA) 200-400 mg tab, 400- TIER 3 PA, RO (Retail Only) 400 mg tab, 600-400 mg tab, 600-600 mg tab ribavirin (RIBASPHERE) TIER 1 RO (Retail Only) ribavirin 200 mg capsule, 200 mg tablet TIER 1 RO (Retail Only) ANTI-HIV AGENTS CIMDUO (lamivudine/tenofovir disoproxil TIER 2 QLC (1 tab/day) fumarate) SYMFI (efavirenz/lamivudine/tenofovir TIER 2 QLC (1 tab/day) disoproxil fumarate) ANTI-HIV AGENTS, INTEGRASE INHIBITORS (INSTI) BIKTARVY (bictegravir TIER 2 QLC (1 tab/day) sodium/emtricitabine/tenofovir alafenamide fumar)

59 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS GENVOYA TIER 3 QLC (1 tab/day) (elvitegravir/cobicistat/emtricitabine/ten ofovir alafenamide) ISENTRESS (raltegravir potassium) 100 MG TIER 2 QLC (2 packets/day) POWDER PACKET ISENTRESS (raltegravir potassium) 25 MG TIER 2 QLC (6 tabs/day) TABLET CHEW, 100 MG TABLET CHEW ISENTRESS (raltegravir potassium) 400 MG TIER 2 QLC (4 tabs/day) TABLET ISENTRESS HD (raltegravir potassium) TIER 2 QLC (2 tabs/day) STRIBILD TIER 2 QLC (1 tab/day) (elvitegravir/cobicistat/emtricitabine/ten ofovir disoproxil) TIVICAY (dolutegravir sodium) TIER 2 QLC (2 tabs/day) VITEKTA (elvitegravir) TIER 3 ANTI-HIV AGENTS, NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NNRTI) ATRIPLA TIER 3 PA, QLC (1 tab/day) (efavirenz/emtricitabine/tenofovir disoproxil fumarate) COMPLERA (emtricitabine/rilpivirine TIER 2 QLC (1 tab/day) hcl/tenofovir disoproxil fumarate) DELSTRIGO TIER 3 QLC (1 tab/day) (doravirine/lamivudine/tenofovir disoproxil fumarate) EDURANT (rilpivirine hcl) TIER 2 QLC (2 tabs/day) efavirenz 200 mg capsule TIER 1 QLC (3 caps/day) efavirenz 50 mg capsule TIER 1 QLC (6 caps/day) efavirenz 600 mg tablet TIER 1 QLC (1 tab/day) INTELENCE (etravirine) 100 MG TABLET TIER 2 QLC (4 tabs/day) INTELENCE (etravirine) 200 MG TABLET TIER 2 QLC (2 tabs/day) INTELENCE (etravirine) 25 MG TABLET TIER 2 QLC (12 tabs/day) nevirapine 100 mg tab er 24h TIER 1 QLC (3 tabs/day) nevirapine 200 mg tablet TIER 1 QLC (2 tabs/day) nevirapine 400 mg tab er 24h TIER 1 QLC (1 tab/day) nevirapine 50 mg/5 ml oral susp TIER 1 QLC (40 ml/day)

60 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS ODEFSEY (emtricitabine/rilpivirine TIER 2 QLC (1 tab/day) hcl/tenofovir alafenamide fumarate) PIFELTRO (doravirine) TIER 3 QLC (2 tabs/day) RESCRIPTOR (delavirdine mesylate) 100 TIER 2 QLC (12 tabs/day) MG TABLET RESCRIPTOR (delavirdine mesylate) 200 TIER 2 QLC (6 tabs/day) MG TABLET SUSTIVA (efavirenz) 200 MG CAPSULE TIER 3 QLC (3 caps/day) SUSTIVA (efavirenz) 50 MG CAPSULE TIER 3 QLC (6 caps/day) SUSTIVA (efavirenz) 600 MG TABLET TIER 3 QLC (1 tab/day) SYMFI LO (efavirenz/lamivudine/tenofovir TIER 2 QLC (1 tab/day) disoproxil fumarate) VIRAMUNE (nevirapine) 200 MG TABLET TIER 3 QLC (2 tabs/day) VIRAMUNE (nevirapine) 50 MG/5 ML SUSP TIER 3 QLC (40 ml/day) VIRAMUNE XR (nevirapine) 100 MG TABLET TIER 3 QLC (3 tabs/day) VIRAMUNE XR (nevirapine) 400 MG TABLET TIER 3 QLC (1 tab/day) ANTI-HIV AGENTS, NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS (NRTI) abacavir sulfate 20 mg/ml solution TIER 1 QLC (30 ml/day) abacavir sulfate 300 mg tablet TIER 1 QLC (2 tabs/day) abacavir sulfate/lamivudine TIER 1 QLC (1 tab/day) abacavir sulfate/lamivudine/zidovudine TIER 1 QLC (2 tabs/day) COMBIVIR (lamivudine/zidovudine) TIER 3 QLC (2 tabs/day) didanosine TIER 1 QLC (1 cap/day) EMTRIVA (emtricitabine) 10 MG/ML TIER 2 QLC (24 ml/day) SOLUTION EMTRIVA (emtricitabine) 200 MG CAPSULE TIER 2 QLC (1 cap/day) EPIVIR (lamivudine) 10 MG/ML ORAL SOLN TIER 3 QLC (30 ml/day) EPIVIR (lamivudine) 150 MG TABLET TIER 3 QLC (2 tabs/day) EPIVIR (lamivudine) 300 MG TABLET TIER 3 QLC (1 tab/day) EPZICOM (abacavir sulfate/lamivudine) TIER 3 QLC (1 tab/day) lamivudine 10 mg/ml solution TIER 1 QLC (30 ml/day) lamivudine 150 mg tablet TIER 1 QLC (2 tabs/day)

61 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS lamivudine 300 mg tablet TIER 1 QLC (1 tab/day) lamivudine/zidovudine TIER 1 QLC (2 tabs/day) RETROVIR (zidovudine) 10 MG/ML SYRUP TIER 3 QLC (60 ml/day) RETROVIR (zidovudine) 100 MG CAPSULE TIER 3 QLC (5 caps/day) stavudine 1 mg/ml soln recon TIER 1 QLC (80 ml/day) stavudine 15 mg capsule, 20 mg capsule, TIER 1 QLC (2 caps/day) 30 mg capsule, 40 mg capsule tenofovir disoproxil fumarate TIER 1 QLC (1 tab/day) TRIZIVIR (abacavir TIER 3 QLC (2 tabs/day) sulfate/lamivudine/zidovudine) TRUVADA (emtricitabine/tenofovir TIER 2 QLC (1 tab/day) disoproxil fumarate) VIDEX (didanosine) TIER 2 VIDEX EC (didanosine) TIER 3 QLC (1 cap/day) VIREAD (tenofovir disoproxil fumarate) 150 TIER 2 QLC (1 tab/day) MG TABLET, 200 MG TABLET, 250 MG TABLET VIREAD (tenofovir disoproxil fumarate) 300 TIER 3 QLC (1 tab/day) MG TABLET VIREAD (tenofovir disoproxil fumarate) TIER 2 QLC (3 bottles/month) POWDER ZERIT (stavudine) 1 MG/ML SOLUTION TIER 3 QLC (80 ml/day) ZERIT (stavudine) 15 MG CAPSULE, 20 MG TIER 3 QLC (2 caps/day) CAPSULE, 30 MG CAPSULE, 40 MG CAPSULE ZIAGEN (abacavir sulfate) 20 MG/ML TIER 3 QLC (30 ml/day) SOLUTION ZIAGEN (abacavir sulfate) 300 MG TABLET TIER 3 QLC (2 tabs/day) zidovudine 10 mg/ml syrup TIER 1 QLC (60 ml/day) zidovudine 100 mg capsule TIER 1 QLC (5 caps/day) zidovudine 300 mg tablet TIER 1 QLC (2 tabs/day) ANTI-HIV AGENTS, OTHER DESCOVY (emtricitabine/tenofovir TIER 2 QLC (1 tab/day) alafenamide fumarate) DOVATO (dolutegravir TIER 3 QLC (1 tab/day) sodium/lamivudine)

62 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS FUZEON (enfuvirtide) TIER 4 SP, QLC (1 kit/month) JULUCA (dolutegravir sodium/rilpivirine TIER 3 QLC (1 tab/day) hcl) SELZENTRY (maraviroc) 20 MG/ML ORAL TIER 2 PA, QLC (60 ml/day) SOLN SELZENTRY (maraviroc) 25 MG TABLET TIER 2 PA, QLC (8 tabs/day) SELZENTRY (maraviroc) 300 MG TABLET TIER 2 PA, QLC (4 tabs/day) SELZENTRY (maraviroc) 75 MG TABLET, 150 TIER 2 PA, QLC (2 tabs/day) MG TABLET TRIUMEQ (abacavir sulfate/dolutegravir TIER 3 QLC (1 tab/day) sodium/lamivudine) TYBOST (cobicistat) TIER 3 QLC (1 tab/day) ANTI-HIV AGENTS, PROTEASE INHIBITORS APTIVUS (tipranavir) TIER 2 QLC (4 caps/day) APTIVUS (tipranavir/vitamin e tpgs) TIER 2 QLC (10 ml/day) atazanavir sulfate 150 mg capsule, 200 TIER 1 QLC (2 caps/day) mg capsule atazanavir sulfate 300 mg capsule TIER 1 QLC (1 cap/day) CRIXIVAN (indinavir sulfate) 200 MG TIER 2 QLC (9 caps/day) CAPSULE CRIXIVAN (indinavir sulfate) 400 MG TIER 2 QLC (6 caps/day) CAPSULE EVOTAZ (atazanavir sulfate/cobicistat) TIER 3 QLC (1 tab/day) fosamprenavir calcium TIER 1 QLC (4 tabs/day) INVIRASE (saquinavir mesylate) 200 MG TIER 2 QLC (4 caps/day) CAPSULE INVIRASE (saquinavir mesylate) 500 MG TIER 2 QLC (4 tabs/day) TABLET KALETRA (lopinavir/ritonavir) 100-25 MG TIER 2 QLC (4 tabs/day) TABLET, 200-50 MG TABLET KALETRA (lopinavir/ritonavir) 80 MG-20 TIER 3 QLC (10 ml/day) MG/ML SOLN LEXIVA (fosamprenavir calcium) 50 TIER 2 QLC (56 ml/day) MG/ML SUSPENSION LEXIVA (fosamprenavir calcium) 700 MG TIER 3 QLC (4 tabs/day) TABLET

63 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS lopinavir/ritonavir TIER 1 QLC (10 ml/day) NORVIR (ritonavir) 100 MG POWDER TIER 2 QLC (12 packets/day) PACKET NORVIR (ritonavir) 100 MG SOFTGEL CAP TIER 2 QLC (12 caps/day) NORVIR (ritonavir) 100 MG TABLET TIER 3 QLC (12 tabs/day) NORVIR (ritonavir) 80 MG/ML SOLUTION TIER 2 QLC (15 ml/day) PREZCOBIX (darunavir TIER 2 QLC (1 tab/day) ethanolate/cobicistat) PREZISTA (darunavir ethanolate) 100 TIER 2 QLC (12 ml/day) MG/ML SUSPENSION PREZISTA (darunavir ethanolate) 150 MG TIER 2 QLC (4 tabs/day) TABLET PREZISTA (darunavir ethanolate) 400 MG TIER 2 QLC (2 tabs/day) TABLET PREZISTA (darunavir ethanolate) 75 MG TIER 2 QLC (2 tabs/day) TABLET, 600 MG TABLET PREZISTA (darunavir ethanolate) 800 MG TIER 2 QLC (1 tab/day) TABLET REYATAZ (atazanavir sulfate) 150 MG TIER 3 QLC (2 caps/day) CAPSULE, 200 MG CAPSULE REYATAZ (atazanavir sulfate) 300 MG TIER 3 QLC (1 cap/day) CAPSULE REYATAZ (atazanavir sulfate) 50 MG TIER 2 QLC (5 packs/day) POWDER PACKET ritonavir TIER 1 QLC (12 tabs/day) SYMTUZA (darunavir TIER 3 QLC (1 tab/day) eth/cobicistat/emtricitabine/tenofovir alafenamide) VIRACEPT (nelfinavir mesylate) 250 MG TIER 2 QLC (9 tabs/day) TABLET VIRACEPT (nelfinavir mesylate) 625 MG TIER 2 QLC (4 tabs/day) TABLET ANTI-INFLUENZA AGENTS FLUMADINE (rimantadine hcl) TIER 3 oseltamivir phosphate 30 mg capsule TIER 1 QLC (40 caps/6 months) oseltamivir phosphate 45 mg capsule, 75 TIER 1 QLC (20 caps/6 months) mg capsule

64 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS oseltamivir phosphate 6 mg/ml susp TIER 1 QLC (6 bottles/6 months) recon RELENZA (zanamivir) TIER 2 QLC (2 inhalers/6 months) rimantadine hcl TIER 1 TAMIFLU (oseltamivir phosphate) 30 MG TIER 3 QLC (40 caps/6 months) CAPSULE TAMIFLU (oseltamivir phosphate) 45 MG TIER 3 QLC (20 caps/6 months) CAPSULE, 75 MG CAPSULE TAMIFLU (oseltamivir phosphate) 6 MG/ML TIER 3 QLC (6 bottles/6 months) SUSPENSION XENLETA (lefamulin acetate) 600 MG TIER 4 PA, QLC (10 tabs/month) TABLET ANTIHERPETIC AGENTS acyclovir 200 mg capsule, 200 mg/5ml TIER 1 oral susp, 400 mg tablet, 800 mg tablet acyclovir 5 % cream (g) TIER 1 PA, QLC (1 tube/fill) acyclovir 5 % oint. (g) TIER 1 PA, QLC (1 tube/fill) DENAVIR (penciclovir) TIER 3 PA, QLC (1 tube/month) famciclovir TIER 1 FAMVIR (famciclovir) TIER 3 SITAVIG (acyclovir) TIER 3 PA, QLC (2 tabs/2 months) trifluridine TIER 1 valacyclovir hcl TIER 1 VALTREX (valacyclovir hcl) TIER 3 VIROPTIC (trifluridine) TIER 3 XERESE (acyclovir/hydrocortisone) TIER 3 PA, QLC (5 gm tube/fill) ZOVIRAX (acyclovir) 200 MG CAPSULE, TIER 3 200 MG/5 ML SUSP, 400 MG TABLET, 800 MG TABLET ZOVIRAX (acyclovir) 5% CREAM, 5% TIER 3 PA, QLC (1 tube/fill) OINTMENT

65 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS

ANXIOLYTICS (Drugs for Anxiety) ANXIOLYTICS, OTHER (Other Drugs for Anxiety) buspirone hcl TIER 1 meprobamate TIER 1 AL1 (Up to 65 yrs old) BENZODIAZEPINES alprazolam (ALPRAZOLAM INTENSOL) TIER 1 QLC (4 ml/day) alprazolam 0.25 mg tab rapdis, 0.25 mg TIER 1 QLC (4 tabs/day) tablet, 0.5 mg tablet, 0.5 mg tab rapdis, 1 mg tab rapdis, 1 mg tablet alprazolam 0.5 mg tab er, 1 mg tab er, 3 TIER 1 QLC (1 tab/day) mg tab er alprazolam 2 mg tab er 24h, 2 mg tablet, TIER 1 QLC (2 tabs/day) 2 mg tab rapdis ATIVAN (lorazepam) 0.5 MG TABLET TIER 3 QLC (20 tabs/day) ATIVAN (lorazepam) 1 MG TABLET TIER 3 QLC (10 tabs/day) ATIVAN (lorazepam) 2 MG TABLET TIER 3 QLC (5 tabs/day) chlordiazepoxide hcl 10 mg capsule TIER 1 QLC (30 caps/day) chlordiazepoxide hcl 25 mg capsule TIER 1 QLC (12 caps/day) chlordiazepoxide hcl 5 mg capsule TIER 1 QLC (60 caps/day) clonazepam 0.125 mg tab rapdis, 0.25 TIER 1 mg tab rapdis, 0.5 mg tab rapdis, 1 mg tab rapdis, 2 mg tab rapdis clonazepam 0.5 mg tablet TIER 1 QLC (40 tabs/day) clonazepam 1 mg tablet TIER 1 QLC (20 tabs/day) clonazepam 2 mg tablet TIER 1 QLC (10 tabs/day) clorazepate dipotassium 15 mg tablet TIER 1 QLC (6 tabs/day) clorazepate dipotassium 3.75 mg tablet TIER 1 QLC (24 tabs/day) clorazepate dipotassium 7.5 mg tablet TIER 1 QLC (12 tabs/day) diazepam 10 mg tablet TIER 1 QLC (6 tabs/day) diazepam 2 mg tablet TIER 1 QLC (30 tabs/day) diazepam 5 mg tablet TIER 1 QLC (12 tabs/day) diazepam 5 mg/5 ml solution TIER 1 PA, QLC (60 ml/day)

66 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS diazepam 5 mg/ml oral conc TIER 1 QLC (12 bottles/month) KLONOPIN (clonazepam) 0.5 MG TABLET TIER 3 QLC (40 tabs/day) KLONOPIN (clonazepam) 1 MG TABLET TIER 3 QLC (20 tabs/day) KLONOPIN (clonazepam) 2 MG TABLET TIER 3 QLC (10 tabs/day) lorazepam (LORAZEPAM INTENSOL) TIER 1 QLC (150 ml/month) lorazepam 0.5 mg tablet TIER 1 QLC (20 tabs/day) lorazepam 1 mg tablet TIER 1 QLC (10 tabs/day) lorazepam 2 mg tablet TIER 1 QLC (5 tabs/day) lorazepam 2 mg/ml oral conc TIER 1 QLC (150 ml/month) oxazepam 10 mg capsule TIER 1 QLC (12 caps/day) oxazepam 15 mg capsule TIER 1 QLC (8 caps/day) oxazepam 30 mg capsule TIER 1 QLC (4 caps/day) TRANXENE T-TAB (clorazepate TIER 3 QLC (24 tabs/day) dipotassium) RANXENE -AB 3.75 MG TRANXENE T-TAB (clorazepate TIER 3 QLC (12 tabs/day) dipotassium) RANXENE -AB 7.5 MG VALIUM (diazepam) 10 MG TABLET TIER 3 QLC (6 tabs/day) VALIUM (diazepam) 2 MG TABLET TIER 3 QLC (30 tabs/day) VALIUM (diazepam) 5 MG TABLET TIER 3 QLC (12 tabs/day) XANAX (alprazolam) 0.25 MG TABLET, 0.5 TIER 3 QLC (4 tabs/day) MG TABLET, 1 MG TABLET XANAX (alprazolam) 2 MG TABLET TIER 3 QLC (2 tabs/day) XANAX XR (alprazolam) 0.5 MG TABLET, 1 TIER 3 QLC (1 tab/day) MG TABLET, 3 MG TABLET XANAX XR (alprazolam) 2 MG TABLET TIER 3 QLC (2 tabs/day)

BIPOLAR AGENTS (Drugs for Bipolar Disorder) MOOD STABILIZERS EQUETRO (carbamazepine) TIER 2 lithium carbonate TIER 1 lithium citrate TIER 1 LITHOBID (lithium carbonate) TIER 3

67 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS

BLOOD GLUCOSE REGULATORS (Drugs for Diabetes) ANTIDIABETIC AGENTS (Drugs for High Blood Sugar) acarbose TIER 1 ACTOPLUS MET (pioglitazone TIER 3 ST, QLC (3 tabs/day) hcl/metformin hcl) ACTOPLUS MET XR (pioglitazone TIER 2 ST, QLC (1 tab/day) hcl/metformin hcl) ACTOS (pioglitazone hcl) TIER 3 ADLYXIN (lixisenatide) TIER 3 PA, QLC (1 pack/month) alogliptin benzoate TIER 1 PA, QLC (1 tab/day) alogliptin benzoate/metformin hcl TIER 1 PA, QLC (2 tabs/day) alogliptin benzoate/pioglitazone hcl TIER 1 PA, QLC (1 tab/day) AMARYL (glimepiride) TIER 3 AVANDIA (rosiglitazone maleate) TIER 3 ST BYDUREON (exenatide microspheres) TIER 3 PA, QLC (4 vials/month) BYDUREON BCISE (exenatide TIER 3 PA, QLC (1 injection/week) microspheres) BYDUREON PEN (exenatide microspheres) TIER 3 PA, QLC (4 pens/month) BYETTA (exenatide) TIER 3 PA, QLC (1 pen/month) chlorpropamide TIER 1 CYCLOSET (bromocriptine mesylate) TIER 3 ST, QLC (6 tabs/day) DIABETA (glyburide) TIER 3 DUETACT (pioglitazone hcl/glimepiride) TIER 3 ST, QLC (1 tab/day) FARXIGA (dapagliflozin propanediol) TIER 2 ST, QLC (1 tab/day) FORTAMET (metformin hcl) TIER 3 PA glimepiride TIER 1 glipizide TIER 1 glipizide/metformin hcl TIER 1 GLUCOPHAGE (metformin hcl) TIER 3 GLUCOPHAGE XR (metformin hcl) TIER 3 GLUCOTROL (glipizide) TIER 3

68 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS GLUCOTROL XL (glipizide) TIER 3 GLUCOVANCE (glyburide/metformin hcl) TIER 3 GLUMETZA (metformin hcl) ER 1,000 MG TIER 4 PA, QLC (2 tabs/day) TABLET GLUMETZA (metformin hcl) ER 500 MG TIER 4 PA, QLC (3 tabs/day) TABLET glyburide TIER 1 glyburide,micronized TIER 1 glyburide/metformin hcl TIER 1 GLYNASE (glyburide,micronized) TIER 3 GLYSET (miglitol) TIER 3 QLC (3 tabs/day) GLYXAMBI (empagliflozin/linagliptin) TIER 2 ST, QLC (1 tab/day) INVOKAMET (canagliflozin/metformin hcl) TIER 3 PA, QLC (2 tabs/day) 50-1,000 MG TABLET, 150-1,000 MG TABLET, 150-500 MG TABLET INVOKAMET (canagliflozin/metformin hcl) TIER 3 PA, QLC (4 tabs/day) 50-500 MG TABLET INVOKAMET XR (canagliflozin/metformin TIER 3 PA, QLC (2 tabs/day) hcl) INVOKANA (canagliflozin) TIER 3 PA, QLC (1 tab/day) JANUMET (sitagliptin TIER 2 ST, QLC (2 tabs/day) phosphate/metformin hcl) JANUMET XR (sitagliptin TIER 2 ST, QLC (2 tabs/day) phosphate/metformin hcl) 50-1,000 MG TABLET JANUMET XR (sitagliptin TIER 2 ST, QLC (1 tab/day) phosphate/metformin hcl) 50-500 MG TABLET, 100-1,000 MG TABLET JANUVIA (sitagliptin phosphate) TIER 2 ST, QLC (1 tab/day) JARDIANCE (empagliflozin) TIER 2 ST, QLC (1 tab/day) JENTADUETO (linagliptin/metformin hcl) TIER 3 PA, QLC (2 tabs/day) JENTADUETO XR (linagliptin/metformin hcl) TIER 3 PA, QLC (2 tabs/day) 2.5 MG-1,000 MG JENTADUETO XR (linagliptin/metformin hcl) TIER 3 PA, QLC (1 tab/day) 5 MG-1,000 MG TB KAZANO (alogliptin benzoate/metformin TIER 3 PA, QLC (2 tabs/day) hcl)

69 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS KOMBIGLYZE XR (saxagliptin TIER 3 PA, QLC (2 tabs/day) hcl/metformin hcl) 2.5-1,000 MG TAB KOMBIGLYZE XR (saxagliptin TIER 3 PA, QLC (1 tab/day) hcl/metformin hcl) 5-500 MG TABLET, 5- 1,000 MG TAB metformin hcl 1000 mg tabergr24h TIER 4 PA, QLC (2 tabs/day) metformin hcl 500 mg tab er 24, 1000 mg TIER 3 PA tab er 24 metformin hcl 500 mg tabergr24h TIER 4 PA, QLC (3 tabs/day) metformin hcl 500 mg tablet, 500 mg tab TIER 1 er 24h, 500 mg/5ml solution, 750 mg tab er 24h, 850 mg tablet, 1000 mg tablet miglitol TIER 1 QLC (3 tabs/day) nateglinide TIER 1 NESINA (alogliptin benzoate) TIER 3 PA, QLC (1 tab/day) ONGLYZA (saxagliptin hcl) TIER 3 PA, QLC (1 tab/day) OSENI (alogliptin benzoate/pioglitazone TIER 3 PA, QLC (1 tab/day) hcl) OZEMPIC (semaglutide) 0.25-0.5 MG DOSE TIER 2 ST, QLC (1 pen/28 days) PEN OZEMPIC (semaglutide) 1 MG DOSE PEN TIER 2 ST, QLC (2 pens/28 days) pioglitazone hcl TIER 1 pioglitazone hcl/glimepiride TIER 1 ST, QLC (1 tab/day) pioglitazone hcl/metformin hcl TIER 1 ST, QLC (3 tabs/day) PRANDIN (repaglinide) TIER 3 PRECOSE (acarbose) TIER 3 QTERN (dapagliflozin TIER 3 PA, QLC (1 tab/day) propanediol/saxagliptin hcl) repaglinide TIER 1 repaglinide/metformin hcl TIER 1 PA, QLC (5 tabs/day) RIOMET (metformin hcl) TIER 3 SEGLUROMET (ertugliflozin TIER 3 PA, QLC (2 tabs/day) pidolate/metformin hcl) 2.5-1,000 MG TABLET, 7.5-1,000 MG TABLET, 7.5-500 MG TABLET SEGLUROMET (ertugliflozin TIER 3 PA, QLC (4 tabs/day) pidolate/metformin hcl) 2.5-500 MG TABLET

70 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS STARLIX (nateglinide) TIER 3 STEGLATRO (ertugliflozin pidolate) 15 MG TIER 3 PA, QLC (1 tab/day) TABLET STEGLATRO (ertugliflozin pidolate) 5 MG TIER 3 PA, QLC (2 tabs/day) TABLET STEGLUJAN (ertugliflozin TIER 3 PA, QLC (1 tab/day) pidolate/sitagliptin phosphate) SYMLINPEN 120 (pramlintide acetate) TIER 3 PA SYMLINPEN 60 (pramlintide acetate) TIER 3 PA SYNJARDY (empagliflozin/metformin hcl) TIER 2 ST, QLC (2 tabs/day) SYNJARDY XR (empagliflozin/metformin TIER 2 ST, QLC (1 tab/day) hcl) 25-1,000 MG TABLET SYNJARDY XR (empagliflozin/metformin TIER 2 ST, QLC (2 tabs/day) hcl) 5-MG TABLET, 10-MG TABLET, 12.5-MG TAB TANZEUM (albiglutide) TIER 3 PA, QLC (4 pens/month) tolazamide TIER 1 tolbutamide TIER 1 TRADJENTA (linagliptin) TIER 3 PA, QLC (1 tab/day) TRULICITY (dulaglutide) TIER 2 ST, QLC (1 pen/week) VICTOZA 2-PAK (liraglutide) TIER 2 ST, QLC (3 pens/month) VICTOZA 3-PAK (liraglutide) TIER 2 ST, QLC (3 pens/month) XIGDUO XR (dapagliflozin TIER 2 ST, QLC (2 tabs/day) propanediol/metformin hcl) 2.5 MG-MG TAB, 5 MG-MG TABLET XIGDUO XR (dapagliflozin TIER 2 ST, QLC (1 tab/day) propanediol/metformin hcl) 5 MG-500 MG TABLET, 10 MG-500 MG TABLET, 10 MG-1,000 MG TAB GLYCEMIC AGENTS (Drugs for Low Blood Sugar) BAQSIMI (glucagon) TIER 3 QLC (2 sprayers/30 days) GLUCAGEN (glucagon,human TIER 2 QLC (2 injections/fill) recombinant) 1 MG HYPOKIT GLUCAGON EMERGENCY KIT TIER 2 QLC (2 kits/fill) (glucagon,human recombinant) GVOKE HYPOPEN (glucagon) TIER 3 QLC (2 injectors/30 days)

71 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS GVOKE SYRINGE (glucagon) TIER 3 QLC (2 syringes/30 days) PROGLYCEM (diazoxide) TIER 3 INSULINS ADMELOG (insulin lispro) TIER 3 PA ADMELOG SOLOSTAR (insulin lispro) TIER 3 PA AFREZZA (insulin regular, human) 4 /8 /12, TIER 3 PA, QLC (1 box/month) 90-4 / 90-8, 90-8 / 90-12 AFREZZA (insulin regular, human) 4 TIER 3 PA, QLC (3 boxes/month) CARTRIDGE, 8 CARTRIDGE, 12 CARTRIDGE, 30-4 / 60-8, 60-8 / 30-12, 60-4 / 30-8 APIDRA (insulin glulisine) TIER 3 APIDRA SOLOSTAR (insulin glulisine) TIER 3 BASAGLAR KWIKPEN U-100 (insulin TIER 3 PA, QLC (15 pens/month) glargine,human recombinant analog) FIASP (insulin aspart (niacinamide)) TIER 3 FIASP FLEXTOUCH (insulin aspart TIER 3 (niacinamide)) HUMALOG (insulin lispro) TIER 2 HUMALOG JUNIOR KWIKPEN (insulin lispro) TIER 2 HUMALOG KWIKPEN U-100 (insulin lispro) TIER 2 HUMALOG KWIKPEN U-200 (insulin lispro) TIER 2 HUMALOG MIX 50-50 (insulin lispro TIER 2 protamine and insulin lispro) HUMALOG MIX 50-50 KWIKPEN (insulin TIER 2 lispro protamine and insulin lispro) HUMALOG MIX 75-25 (insulin lispro TIER 2 protamine and insulin lispro) HUMALOG MIX 75-25 KWIKPEN (insulin TIER 2 lispro protamine and insulin lispro) HUMULIN 70-30 (insulin nph human TIER 2 isophane/insulin regular, human) HUMULIN 70/30 KWIKPEN (insulin nph TIER 3 human isophane/insulin regular, human) HUMULIN N (insulin nph human isophane) TIER 2 HUMULIN N KWIKPEN (insulin nph human TIER 3 isophane)

72 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS HUMULIN R (insulin regular, human) TIER 2 HUMULIN R U-500 (insulin regular, human) TIER 2 HUMULIN R U-500 KWIKPEN (insulin regular, TIER 3 human) insulin lispro TIER 3 PA LANTUS (insulin glargine,human TIER 2 QLC (40 ml/month) recombinant analog) LANTUS SOLOSTAR (insulin glargine,human TIER 2 QLC (45 ml/month) recombinant analog) LEVEMIR (insulin detemir) TIER 3 PA, QLC (40 ml/month) LEVEMIR FLEXTOUCH (insulin detemir) TIER 3 PA, QLC (45 ml/month) NOVOLIN 70-30 (insulin nph human TIER 2 isophane/insulin regular, human) NOVOLIN 70-30 FLEXPEN (insulin nph TIER 3 human isophane/insulin regular, human) NOVOLIN N (insulin nph human isophane) TIER 2 NOVOLIN R (insulin regular, human) TIER 2 NOVOLOG (insulin aspart) TIER 2 NOVOLOG FLEXPEN (insulin aspart) TIER 2 NOVOLOG MIX 70-30 (insulin aspart TIER 2 protamine human/insulin aspart) NOVOLOG MIX 70-30 FLEXPEN (insulin TIER 2 aspart protamine human/insulin aspart) SOLIQUA 100-33 (insulin glargine,human TIER 3 PA, QLC (6 pens/month) recombinant analog/lixisenatide) TOUJEO MAX SOLOSTAR (insulin TIER 2 QLC (6 pens/month) glargine,human recombinant analog) TOUJEO SOLOSTAR (insulin TIER 2 QLC (12 pens/month) glargine,human recombinant analog) TRESIBA (insulin degludec) TIER 3 PA, QLC (3 vials/30 days) TRESIBA FLEXTOUCH U-100 (insulin TIER 3 PA, QLC (10 pens/month) degludec) TRESIBA FLEXTOUCH U-200 (insulin TIER 3 PA, QLC (9 pens/month) degludec) XULTOPHY 100-3.6 (insulin TIER 3 PA, QLC (5 pens/month) degludec/liraglutide)

73 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS

BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS (Drugs for Blood Disorders) ANTICOAGULANTS (Blood Thinners) ARIXTRA (fondaparinux sodium) TIER 4 QLC (1 syringe/day) BEVYXXA (betrixaban maleate) TIER 3 PA, QLC (1 cap/day) COUMADIN (warfarin sodium) TIER 3 ELIQUIS (apixaban) 2.5 MG TABLET TIER 2 QLC (2 tabs/day; not to exceed 70 tabs/6 months) ELIQUIS (apixaban) 5 MG STARTER PACK TIER 2 QLC (1 pack/6 months) ELIQUIS (apixaban) 5 MG TABLET TIER 2 QLC (2 tabs/day) enoxaparin sodium 300mg/3ml vial TIER 4 QLC (2 ml/day) enoxaparin sodium 30mg/0.3ml, TIER 4 QLC (2 syringes/day) 40mg/0.4ml, 60mg/0.6ml, 80mg/0.8ml, 100 mg/ml, 120mg/.8ml, 150 mg/ml fondaparinux sodium TIER 4 QLC (1 syringe/day) FRAGMIN (dalteparin sodium,porcine) TIER 4 QLC (1 syringe/day) 10,000 UNITS/ML SYRING, 15,000 UNITS/0.6 ML, 18,000 UNITS/0.72 ML FRAGMIN (dalteparin sodium,porcine) TIER 4 QLC (1 syringe/day) 12,500 UNITS/0.5 ML FRAGMIN (dalteparin sodium,porcine) TIER 4 QLC (2 syringes/day) 2,500 UNITS/0.2 ML SYR, 5,000 UNITS/0.2 ML SYR, 7,500 UNITS/0.3 ML SYR FRAGMIN (dalteparin sodium,porcine) TIER 4 QLC (0.72 ml/day) 95,000 UNITS/3.8 ML VL heparin sodium,porcine 1000/ml vial, TIER 1 5000/ml vial, 10000/ml vial, 20000/ml vial heparin sodium,porcine/pf 5000/0.5ml TIER 1 syringe IPRIVASK (desirudin) TIER 4 QLC (2 vials/day; 24 vials/68 days) LOVENOX (enoxaparin sodium) 30 MG/0.3 TIER 4 QLC (2 syringes/day) ML SYRINGE, 40 MG/0.4 ML SYRINGE, 80 MG/0.8 ML SYRINGE, 100 MG/ML SYRINGE, 120 MG/0.8 ML SYRINGE, 150 MG/ML SYRINGE LOVENOX (enoxaparin sodium) 300 MG/3 TIER 4 QLC (2 ml/day) ML VIAL

74 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS LOVENOX (enoxaparin sodium) 60 MG/0.6 TIER 4 QLC (2 syringes/day) ML SYRINGE PRADAXA (dabigatran etexilate TIER 3 PA, QLC (2 caps/day) mesylate) SAVAYSA (edoxaban tosylate) TIER 3 PA, QLC (1 tab/day) warfarin sodium TIER 1 warfarin sodium (JANTOVEN) TIER 1 XARELTO (rivaroxaban) 10 MG TABLET, 15 TIER 2 QLC (1 tab/day) MG TABLET, 20 MG TABLET XARELTO (rivaroxaban) 2.5 MG TABLET TIER 2 QLC (2 tabs/day) XARELTO (rivaroxaban) STARTER PACK TIER 2 QLC (1 starter pack/6 months) ZONTIVITY (vorapaxar sulfate) TIER 3 PA, QLC (1 tab/day) BLOOD FORMATION MODIFIERS (Blood Formation Drugs) AGRYLIN (anagrelide hcl) TIER 3 anagrelide hcl TIER 1 ARANESP (darbepoetin alfa in TIER 4 PA, SP, QLC (1 syringe or polysorbate 80) vial/week) CABLIVI (caplacizumab-yhdp) TIER 4 PA, SP, QLC (1 kit/day) DOPTELET (avatrombopag maleate) (10 TIER 4 PA, SP, QLC (2 tabs/day, not to TAB PK) 20 MG TAB exceed 10 tabs/4 months) DOPTELET (avatrombopag maleate) (15 TIER 4 PA, SP, QLC (3 tabs/day, not to TAB PK) 20 MG TAB exceed 15 tabs/4 months) DOPTELET (avatrombopag maleate) (30 TIER 4 PA, SP, QLC (2 tabs/day) TAB PK) 20 MG TAB EPOGEN (epoetin alfa) TIER 4 PA, SP FULPHILA (pegfilgrastim-jmdb) TIER 4 PA, SP GRANIX (tbo-filgrastim) TIER 4 PA, SP LEUKINE (sargramostim) TIER 4 PA, SP MIRCERA (methoxy polyethylene glycol- TIER 4 PA, SP, QLC (2 syringes/28 days) epoetin beta) MOZOBIL (plerixafor) TIER 4 PA, SP MULPLETA (lusutrombopag) TIER 4 PA, SP, QLC (1 tab/day, not to exceed 7 tabs/120 days) NEULASTA (pegfilgrastim) 6 MG/0.6 ML TIER 4 PA, SP SYRINGE

75 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS NEUPOGEN (filgrastim) TIER 4 PA, SP NIVESTYM (filgrastim-aafi) TIER 4 PA, SP PROCRIT (epoetin alfa) TIER 4 PA, SP PROMACTA (eltrombopag olamine) 12.5 TIER 4 PA, SP, QLC (1 packet/day) MG SUSPEN PACKET PROMACTA (eltrombopag olamine) 12.5 TIER 4 PA, SP, QLC (1 tab/day) MG TABLET PROMACTA (eltrombopag olamine) 25 TIER 4 PA, SP, QLC (3 tabs/day) MG TABLET, 50 MG TABLET PROMACTA (eltrombopag olamine) 75 TIER 4 PA, SP, QLC (2 tabs/day) MG TABLET RETACRIT (epoetin alfa-epbx) TIER 4 PA, SP TAVALISSE (fostamatinib disodium) TIER 4 PA, SP, QLC (2 tabs/day) UDENYCA (pegfilgrastim-cbqv) TIER 4 PA, SP ZARXIO (filgrastim-sndz) TIER 4 PA, SP HEMOSTASIS AGENTS (Drugs to Stop Bleeding) AMICAR (aminocaproic acid) TIER 3 aminocaproic acid 250 mg/ml solution, TIER 1 500 mg tablet, 1000 mg tablet LYSTEDA (tranexamic acid) TIER 3 QLC (30 tabs/month) MEPHYTON (phytonadione (vit k1)) TIER 3 QLC (5 tabs/week) phytonadione (vit k1) 5 mg tablet TIER 1 QLC (5 tabs/week) tranexamic acid 650 mg tablet TIER 1 QLC (30 tabs/month) PLATELET MODIFYING AGENTS AGGRENOX (aspirin/dipyridamole) TIER 3 aspirin/dipyridamole TIER 1 aspirin/omeprazole TIER 3 PA, QLC (1 tab/day) BRILINTA (ticagrelor) TIER 2 QLC (2 tabs/day) cilostazol TIER 1 clopidogrel bisulfate 75 mg tablet TIER 1 QLC (1 tab/day) dipyridamole 25 mg tablet, 50 mg tablet, TIER 1 75 mg tablet DURLAZA (aspirin) TIER 3 PA, QLC (1 cap/day)

76 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS EFFIENT (prasugrel hcl) TIER 3 QLC (1 tab/day) PERSANTINE (dipyridamole) TIER 3 AL1 (Up to 65 yrs old) PLAVIX (clopidogrel bisulfate) 75 MG TIER 3 QLC (1 tab/day) TABLET PLETAL (cilostazol) TIER 3 prasugrel hcl TIER 1 QLC (1 tab/day) ticlopidine hcl TIER 1 YOSPRALA (aspirin/omeprazole) TIER 3 PA, QLC (1 tab/day)

CARDIOVASCULAR AGENTS (Drugs for the Heart and Circulation) ALPHA-ADRENERGIC AGONISTS CATAPRES (clonidine hcl) TIER 3 CATAPRES-TTS 1 (clonidine) TIER 3 CATAPRES-TTS 2 (clonidine) TIER 3 CATAPRES-TTS 3 (clonidine) TIER 3 clonidine TIER 1 clonidine hcl 0.1 mg tablet, 0.2 mg tablet, TIER 1 0.3 mg tablet guanfacine hcl 1 mg tablet, 2 mg tablet TIER 1 methyldopa TIER 1 midodrine hcl TIER 1 NORTHERA (droxidopa) 100 MG CAPSULE TIER 4 PA, SP, QLC (18 caps/day) NORTHERA (droxidopa) 200 MG CAPSULE TIER 4 PA, SP, QLC (9 caps/day) NORTHERA (droxidopa) 300 MG CAPSULE TIER 4 PA, SP, QLC (6 caps/day) TENEX (guanfacine hcl) TIER 3 ALPHA-ADRENERGIC BLOCKING AGENTS CARDURA (doxazosin mesylate) TIER 3 DIBENZYLINE (phenoxybenzamine hcl) TIER 4 PA doxazosin mesylate TIER 1 MINIPRESS (prazosin hcl) TIER 3 phenoxybenzamine hcl TIER 4 PA

77 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS prazosin hcl TIER 1 terazosin hcl TIER 1 ANGIOTENSIN II RECEPTOR ANTAGONISTS ATACAND (candesartan cilexetil) 16 MG TIER 3 ST, QLC (2 tabs/day) TABLET ATACAND (candesartan cilexetil) 32 MG TIER 3 ST, QLC (1 tab/day) TABLET ATACAND (candesartan cilexetil) 4 MG TIER 3 ST, QLC (8 tabs/day) TABLET ATACAND (candesartan cilexetil) 8 MG TIER 3 ST, QLC (4 tabs/day) TABLET AVAPRO (irbesartan) TIER 3 QLC (1 tab/day) BENICAR (olmesartan medoxomil) 20 MG TIER 3 QLC (1 tab/day) TABLET, 40 MG TABLET BENICAR (olmesartan medoxomil) 5 MG TIER 3 QLC (3 tabs/day) TABLET candesartan cilexetil 16 mg tablet TIER 1 ST, QLC (2 tabs/day) candesartan cilexetil 32 mg tablet TIER 1 ST, QLC (1 tab/day) candesartan cilexetil 4 mg tablet TIER 1 ST, QLC (8 tabs/day) candesartan cilexetil 8 mg tablet TIER 1 ST, QLC (4 tabs/day) COZAAR (losartan potassium) 100 MG TIER 3 QLC (1 tab/day) TABLET COZAAR (losartan potassium) 25 MG TIER 3 QLC (4 tabs/day) TABLET COZAAR (losartan potassium) 50 MG TIER 3 QLC (2 tabs/day) TABLET DIOVAN (valsartan) 320 MG TABLET TIER 3 QLC (1 tab/day) DIOVAN (valsartan) 40 MG TABLET, 80 MG TIER 3 QLC (2 tabs/day) TABLET, 160 MG TABLET EDARBI (azilsartan medoxomil) TIER 3 ST, QLC (1 tab/day) eprosartan mesylate TIER 1 ST, QLC (1 tab/day) irbesartan TIER 1 QLC (1 tab/day) losartan potassium 100 mg tablet TIER 1 QLC (1 tab/day) losartan potassium 25 mg tablet TIER 1 QLC (4 tabs/day) losartan potassium 50 mg tablet TIER 1 QLC (2 tabs/day)

78 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS MICARDIS (telmisartan) 20 MG TABLET, 40 TIER 3 QLC (1 tab/day) MG TABLET MICARDIS (telmisartan) 80 MG TABLET TIER 3 QLC (2 tabs/day) olmesartan medoxomil 20 mg tablet, 40 TIER 1 QLC (1 tab/day) mg tablet olmesartan medoxomil 5 mg tablet TIER 1 QLC (3 tabs/day) telmisartan 20 mg tablet, 40 mg tablet TIER 1 QLC (1 tab/day) telmisartan 80 mg tablet TIER 1 QLC (2 tabs/day) valsartan 320 mg tablet TIER 1 QLC (1 tab/day) valsartan 40 mg tablet, 80 mg tablet, 160 TIER 1 QLC (2 tabs/day) mg tablet ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS ACCUPRIL (quinapril hcl) TIER 3 ACEON (perindopril erbumine) 4 MG TIER 3 QLC (1 tab/day) TABLET ACEON (perindopril erbumine) 8 MG TIER 3 QLC (2 tabs/day) TABLET ALTACE (ramipril) TIER 3 benazepril hcl 40 mg tablet TIER 1 QLC (2 tabs/day) benazepril hcl 5 mg tablet, 10 mg tablet, TIER 1 QLC (1 tab/day) 20 mg tablet captopril TIER 1 enalapril maleate TIER 1 EPANED (enalapril maleate) TIER 3 QLC (40 ml/day) fosinopril sodium 10 mg tablet, 20 mg TIER 1 QLC (1 tab/day) tablet fosinopril sodium 40 mg tablet TIER 1 QLC (2 tabs/day) lisinopril TIER 1 LOTENSIN (benazepril hcl) 10 MG TABLET TIER 3 QLC (1 tab/day) LOTENSIN (benazepril hcl) 20 MG TABLET TIER 3 QLC (1 tab/day) LOTENSIN (benazepril hcl) 40 MG TABLET TIER 3 QLC (2 tabs/day) MAVIK (trandolapril) TIER 3 moexipril hcl TIER 1 perindopril erbumine 2 mg tablet, 4 mg TIER 1 QLC (1 tab/day) tablet

79 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS perindopril erbumine 8 mg tablet TIER 1 QLC (2 tabs/day) PRINIVIL (lisinopril) TIER 3 QBRELIS (lisinopril) TIER 3 PA, QLC (80 ml/day) quinapril hcl TIER 1 ramipril TIER 1 trandolapril TIER 1 VASOTEC (enalapril maleate) TIER 3 ZESTRIL (lisinopril) TIER 3 ANTIARRHYTHMICS (Drugs for Irregular Heart Rhythm) amiodarone hcl (PACERONE) TIER 1 amiodarone hcl 100 mg tablet, 200 mg TIER 1 tablet, 400 mg tablet BETAPACE (sotalol hcl) TIER 3 BETAPACE AF (sotalol hcl) TIER 3 CORDARONE (amiodarone hcl) TIER 3 disopyramide phosphate TIER 1 dofetilide TIER 1 flecainide acetate TIER 1 mexiletine hcl TIER 1 MULTAQ (dronedarone hcl) TIER 2 QLC (2 tabs/day) NORPACE (disopyramide phosphate) TIER 3 NORPACE CR (disopyramide phosphate) TIER 2 QLC (8 caps/day) 100 MG CAPSULE NORPACE CR (disopyramide phosphate) TIER 2 QLC (5 caps/day) 150 MG CAPSULE PACERONE (amiodarone hcl) TIER 3 propafenone hcl TIER 1 quinidine gluconate 324 mg tablet er TIER 1 quinidine sulfate TIER 1 RYTHMOL (propafenone hcl) TIER 3 RYTHMOL SR (propafenone hcl) TIER 3 sotalol hcl (SORINE) TIER 1

80 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS sotalol hcl 80 mg tablet, 120 mg tablet, TIER 1 160 mg tablet, 240 mg tablet SOTYLIZE (sotalol hcl) TIER 3 PA, QLC (64 ml/day) TIKOSYN (dofetilide) TIER 3 BETA-ADRENERGIC BLOCKING AGENTS acebutolol hcl TIER 1 atenolol TIER 1 betaxolol hcl 10 mg tablet, 20 mg tablet TIER 1 bisoprolol fumarate TIER 1 BYSTOLIC (nebivolol hcl) 2.5 MG TABLET, 5 TIER 2 QLC (1 tab/day) MG TABLET, 10 MG TABLET BYSTOLIC (nebivolol hcl) 20 MG TABLET TIER 2 QLC (2 tabs/day) carvedilol TIER 1 carvedilol phosphate TIER 1 ST COREG (carvedilol) TIER 3 COREG CR (carvedilol phosphate) TIER 3 ST CORGARD (nadolol) TIER 3 INDERAL LA (propranolol hcl) TIER 3 INDERAL XL (propranolol hcl) TIER 3 INNOPRAN XL (propranolol hcl) TIER 3 KAPSPARGO SPRINKLE (metoprolol TIER 3 QLC (1 cap/day) succinate) labetalol hcl 100 mg tablet, 200 mg TIER 1 tablet, 300 mg tablet LEVATOL (penbutolol sulfate) TIER 3 LOPRESSOR (metoprolol tartrate) 50 MG TIER 3 TABLET, 100 MG TABLET metoprolol succinate TIER 1 metoprolol tartrate 25 mg tablet, 37.5 mg TIER 1 tablet, 50 mg tablet, 75 mg tablet, 100 mg tablet nadolol TIER 1 pindolol TIER 1

81 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS propranolol hcl 10 mg tablet, 20 mg/5 ml TIER 1 solution, 20 mg tablet, 40 mg tablet, 40mg/5ml solution, 60 mg tablet, 60 mg cap sa 24h, 80 mg tablet, 80 mg cap sa 24h, 120 mg cap sa 24h, 160 mg cap sa 24h SECTRAL (acebutolol hcl) TIER 3 TENORMIN (atenolol) TIER 3 timolol maleate 5 mg tablet, 10 mg TIER 1 tablet, 20 mg tablet TOPROL XL (metoprolol succinate) TIER 3 ZEBETA (bisoprolol fumarate) TIER 3 CALCIUM CHANNEL BLOCKING AGENTS ADALAT CC (nifedipine) TIER 3 amlodipine besylate TIER 1 CALAN (verapamil hcl) TIER 3 CALAN SR (verapamil hcl) TIER 3 CARDIZEM (diltiazem hcl) TIER 3 CARDIZEM CD (diltiazem hcl) TIER 3 CARDIZEM LA (diltiazem hcl) TIER 3 diltiazem hcl (CARTIA XT) TIER 1 diltiazem hcl (DILT-XR) TIER 1 diltiazem hcl (MATZIM LA) TIER 1 diltiazem hcl (TAZTIA XT) TIER 1

82 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS diltiazem hcl 30 mg tablet, 60 mg cap er TIER 1 12h, 60 mg tablet, 90 mg tablet, 90 mg cap er 12h, 120 mg tablet, 120 mg cap er 24h, 120 mg cap er 12h, 120 mg cap sa 24h, 120 mg cap er deg, 180 mg tab er 24h, 180 mg cap er deg, 180 mg cap sa 24h, 180 mg cap er 24h, 240 mg cap er deg, 240 mg tab er 24h, 240 mg cap er 24h, 240 mg cap sa 24h, 300 mg cap er 24h, 300 mg cap sa 24h, 300 mg tab er 24h, 360 mg cap sa 24h, 360 mg tab er 24h, 360 mg cap er 24h, 420 mg tab er 24h, 420 mg cap sa 24h felodipine TIER 1 isradipine TIER 1 KATERZIA (amlodipine benzoate) TIER 3 PA, QLC (10 ml/day) nicardipine hcl 20 mg capsule, 30 mg TIER 1 capsule nifedipine TIER 1 nifedipine (AFEDITAB CR) TIER 1 nifedipine (NIFEDICAL XL) TIER 1 nimodipine TIER 1 nisoldipine TIER 1 NORVASC (amlodipine besylate) TIER 3 NYMALIZE (nimodipine) 30 MG/10 ML TIER 3 PA, QLC (60 ml/day, max of 21 SOLUTION days in 6 months) NYMALIZE (nimodipine) 60 MG/20 ML TIER 3 QLC (120 ml per day, max of 21 SOLUTION days in 6 months) PROCARDIA (nifedipine) TIER 3 PROCARDIA XL (nifedipine) TIER 3 SULAR (nisoldipine) TIER 3 TIAZAC (diltiazem hcl) TIER 3 verapamil hcl 40 mg tablet, 80 mg tablet, TIER 1 100 mg cap24h pct, 120 mg cap24h pel, 120 mg tablet, 120 mg tablet er, 180 mg cap24h pel, 180 mg tablet er, 200 mg cap24h pct, 240 mg tablet er, 240 mg cap24h pel, 300 mg cap24h pct, 360 mg cap24h pel VERELAN (verapamil hcl) TIER 3

83 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS VERELAN PM (verapamil hcl) TIER 3 CARDIOVASCULAR AGENTS, OTHER ACCURETIC (quinapril TIER 3 hcl/hydrochlorothiazide) ALDACTAZIDE TIER 3 (spironolactone/hydrochlorothiazide) aliskiren hemifumarate TIER 1 ST, QLC (1 tab/day) amiloride hcl/hydrochlorothiazide TIER 1 amlodipine besylate/atorvastatin calcium TIER 1 PA, QLC (1 tab/day) amlodipine besylate/benazepril hcl 10 TIER 1 QLC (1 cap/day) mg-20mg capsule, 10 mg-40mg capsule amlodipine besylate/benazepril hcl TIER 1 2.5mg-10mg capsule, 5 mg-20 mg capsule, 5 mg-10 mg capsule amlodipine besylate/benazepril hcl 5 mg- TIER 1 QLC (2 caps/day) 40 mg capsule amlodipine besylate/olmesartan TIER 1 QLC (1 tab/day) medoxomil amlodipine besylate/valsartan TIER 1 QLC (1 tab/day) amlodipine TIER 1 QLC (1 tab/day) besylate/valsartan/hydrochlorothiazide ATACAND HCT (candesartan TIER 3 ST, QLC (2 tabs/day) cilexetil/hydrochlorothiazide) 16-12.5 MG TAB ATACAND HCT (candesartan TIER 3 ST, QLC (1 tab/day) cilexetil/hydrochlorothiazide) 32-12.5 MG TAB, 32-25 MG TABLET atenolol/chlorthalidone TIER 1 AVALIDE (irbesartan/hydrochlorothiazide) TIER 3 QLC (2 tabs/day) 150-12.5 MG TABLET AVALIDE (irbesartan/hydrochlorothiazide) TIER 3 QLC (1 tab/day) 300-12.5 MG TABLET AZOR (amlodipine besylate/olmesartan TIER 3 QLC (1 tab/day) medoxomil) benazepril hcl/hydrochlorothiazide TIER 1 BENICAR HCT (olmesartan TIER 3 QLC (1 tab/day) medoxomil/hydrochlorothiazide)

84 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS BIDIL (isosorbide dinitrate/hydralazine hcl) TIER 3 QLC (6 tabs/day) bisoprolol fumarate/hydrochlorothiazide TIER 1 BYVALSON (nebivolol hcl/valsartan) TIER 3 ST, QLC (1 tab/day) CADUET (amlodipine TIER 3 PA, QLC (1 tab/day) besylate/atorvastatin calcium) candesartan cilexetil/hydrochlorothiazide TIER 1 ST, QLC (2 tabs/day) candesartan/hydrochlorothiazid 16- 12.5mg tablet candesartan cilexetil/hydrochlorothiazide TIER 1 ST, QLC (1 tab/day) candesartan/hydrochlorothiazid 32mg- 25mg tablet, candesartan/hydrochlorothiazid 32- 12.5mg tablet captopril/hydrochlorothiazide TIER 1 CORLANOR (ivabradine hcl) 5 MG TABLET, TIER 3 PA, QLC (2 tabs/day) 7.5 MG TABLET CORLANOR (ivabradine hcl) 5 MG/5 ML TIER 3 PA, QLC (20 ml/day) ORAL SOLN CORZIDE (nadolol/bendroflumethiazide) TIER 3 DEMSER (metyrosine) TIER 3 digoxin (DIGITEK) 125 mcg tablet TIER 1 AL1 (Up to 65 yrs old), QLC (1 tab/day) digoxin (DIGITEK) 250 mcg tablet TIER 1 AL1 (Up to 65 yrs old), QLC (0.5 tab/day) digoxin (DIGOX) 125 mcg tablet TIER 1 AL1 (Up to 65 yrs old), QLC (1 tab/day) digoxin (DIGOX) 250 mcg tablet TIER 1 AL1 (Up to 65 yrs old), QLC (0.5 tab/day) digoxin 125 mcg tablet TIER 1 AL1 (Up to 65 yrs old), QLC (1 tab/day) digoxin 250 mcg tablet TIER 1 AL1 (Up to 65 yrs old), QLC (0.5 tab/day) digoxin 50 mcg/ml solution TIER 1 AL1 (Up to 65 yrs old), QLC (2.5 ml/day) DIOVAN HCT TIER 3 QLC (1 tab/day) (valsartan/hydrochlorothiazide) 320-12.5 MG TAB, 320-25 MG TABLET DIOVAN HCT TIER 3 QLC (2 tabs/day) (valsartan/hydrochlorothiazide) 80-12.5 MG TABLET, 160-25 MG TABLET, 160-12.5 MG TAB

85 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS DUTOPROL (metoprolol TIER 3 PA, QLC (2 tabs/day) succinate/hydrochlorothiazide) 100-12.5 MG TABLET DUTOPROL (metoprolol TIER 3 PA, QLC (1 tab/day) succinate/hydrochlorothiazide) 25-12.5 MG TABLET, 50-12.5 MG TABLET DYAZIDE TIER 3 (triamterene/hydrochlorothiazide) EDARBYCLOR (azilsartan TIER 3 ST, QLC (1 tab/day) medoxomil/chlorthalidone) enalapril maleate/hydrochlorothiazide TIER 1 ENTRESTO (sacubitril/valsartan) TIER 3 PA, QLC (2 tabs/day) EXFORGE (amlodipine besylate/valsartan) TIER 3 QLC (1 tab/day) EXFORGE HCT (amlodipine TIER 3 QLC (1 tab/day) besylate/valsartan/hydrochlorothiazide) fosinopril sodium/hydrochlorothiazide TIER 1 HYZAAR (losartan TIER 3 QLC (1 tab/day) potassium/hydrochlorothiazide) 100-25 TABLET, 100-12.5 TABLET HYZAAR (losartan TIER 3 QLC (2 tabs/day) potassium/hydrochlorothiazide) 50-12.5 TABLET irbesartan/hydrochlorothiazide 150- TIER 1 QLC (2 tabs/day) 12.5mg tablet irbesartan/hydrochlorothiazide 300- TIER 1 QLC (1 tab/day) 12.5mg tablet LANOXIN (digoxin) 125 MCG TABLET, 187.5 TIER 3 AL1 (Up to 65 yrs old), QLC (1 MCG TABLET tab/day) LANOXIN (digoxin) 250 MCG TABLET TIER 3 AL1 (Up to 65 yrs old), QLC (0.5 tab/day) LANOXIN (digoxin) 62.5 MCG TABLET TIER 3 AL1 (Up to 65 yrs old), QLC (2 tabs/day) lisinopril/hydrochlorothiazide TIER 1 LOPRESSOR HCT (metoprolol TIER 3 tartrate/hydrochlorothiazide) losartan potassium/hydrochlorothiazide TIER 1 QLC (1 tab/day) losartan/hydrochlorothiazide 100mg- 25mg tablet, losartan/hydrochlorothiazide 100-12.5mg tablet

86 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS losartan potassium/hydrochlorothiazide TIER 1 QLC (2 tabs/day) losartan/hydrochlorothiazide 50-12.5 mg tablet LOTENSIN HCT (benazepril TIER 3 hcl/hydrochlorothiazide) LOTREL (amlodipine besylate/benazepril TIER 3 QLC (1 cap/day) hcl) 10-20 MG CAPSULE, 10-40 MG CAPSULE LOTREL (amlodipine besylate/benazepril TIER 3 hcl) 5-20 MG CAPSULE, 5-10 MG CAPSULE LOTREL (amlodipine besylate/benazepril TIER 3 QLC (2 caps/day) hcl) 5-40 MG CAPSULE MAXZIDE TIER 3 (triamterene/hydrochlorothiazide) MAXZIDE-25 MG TIER 3 (triamterene/hydrochlorothiazide) mecamylamine hcl (VECAMYL) TIER 1 methyldopa/hydrochlorothiazide TIER 1 metoprolol TIER 3 PA, QLC (2 tabs/day) succinate/hydrochlorothiazide su/hydrochlorothiaz 100-12.5mg tab er 24h metoprolol TIER 3 PA, QLC (1 tab/day) succinate/hydrochlorothiazide su/hydrochlorothiaz 25-12.5 mg tab er, su/hydrochlorothiaz 50-12.5 mg tab er metoprolol tartrate/hydrochlorothiazide TIER 1 MICARDIS HCT TIER 3 ST, QLC (3 tabs/day) (telmisartan/hydrochlorothiazide) 40-12.5 MG TABLET MICARDIS HCT TIER 3 ST, QLC (2 tabs/day) (telmisartan/hydrochlorothiazide) 80-25 MG TABLET, 80-12.5 MG TABLET moexipril hcl/hydrochlorothiazide TIER 1 nadolol/bendroflumethiazide TIER 1 olmesartan medoxomil/amlodipine TIER 1 ST, QLC (1 tab/day) besylate/hydrochlorothiazide olmesartan TIER 1 QLC (1 tab/day) medoxomil/hydrochlorothiazide pentoxifylline TIER 1

87 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS PRESTALIA (perindopril TIER 3 ST, QLC (1 tab/day) arginine/amlodipine besylate) propranolol hcl/hydrochlorothiazide TIER 1 quinapril hcl/hydrochlorothiazide TIER 1 RANEXA (ranolazine) TIER 3 PA, QLC (2 tabs/day) ranolazine TIER 1 PA, QLC (2 tabs/day) reserpine TIER 1 spironolactone/hydrochlorothiazide TIER 1 TARKA (trandolapril/verapamil hcl) TIER 3 TEKTURNA (aliskiren hemifumarate) TIER 3 ST, QLC (1 tab/day) TEKTURNA HCT (aliskiren TIER 3 ST, QLC (1 tab/day) hemifumarate/hydrochlorothiazide) telmisartan/amlodipine besylate TIER 1 ST, QLC (1 tab/day) telmisartan/hydrochlorothiazide 40-12.5 TIER 1 ST, QLC (3 tabs/day) mg tablet telmisartan/hydrochlorothiazide 80 mg- TIER 1 ST, QLC (2 tabs/day) 25mg tablet, 80-12.5mg tablet TENORETIC 100 (atenolol/chlorthalidone) TIER 3 TENORETIC 50 (atenolol/chlorthalidone) TIER 3 trandolapril/verapamil hcl TIER 1 triamterene/hydrochlorothiazide TIER 1 TRIBENZOR (olmesartan TIER 3 ST, QLC (1 tab/day) medoxomil/amlodipine besylate/hydrochlorothiazide) TWYNSTA (telmisartan/amlodipine TIER 3 ST, QLC (1 tab/day) besylate) valsartan/hydrochlorothiazide 320-12.5mg TIER 1 QLC (1 tab/day) tablet, 320mg-25mg tablet valsartan/hydrochlorothiazide 80-12.5mg TIER 1 QLC (2 tabs/day) tablet, 160-12.5mg tablet, 160-25mg tablet VASERETIC (enalapril TIER 3 maleate/hydrochlorothiazide) VYNDAMAX (tafamidis) TIER 4 PA, SP, QLC (1 cap/day) VYNDAQEL (tafamidis meglumine) TIER 4 PA, SP, QLC (4 caps/day) ZESTORETIC (lisinopril/hydrochlorothiazide) TIER 3

88 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS ZIAC (bisoprolol TIER 3 fumarate/hydrochlorothiazide) DIURETICS, CARBONIC ANHYDRASE INHIBITORS acetazolamide TIER 1 DIAMOX SEQUELS (acetazolamide) TIER 3 KEVEYIS (dichlorphenamide) TIER 4 PA, SP, QLC (4 tabs/day) DIURETICS, LOOP bumetanide 0.5 mg tablet, 1 mg tablet, 2 TIER 1 mg tablet DEMADEX (torsemide) TIER 3 EDECRIN (ethacrynic acid) TIER 3 PA ethacrynic acid TIER 1 PA furosemide 10 mg/ml solution, 20 mg TIER 1 tablet, 40mg/5ml solution, 40 mg tablet, 80 mg tablet LASIX (furosemide) TIER 3 torsemide TIER 1 DIURETICS, POTASSIUM-SPARING ALDACTONE (spironolactone) TIER 3 amiloride hcl TIER 1 CAROSPIR (spironolactone) TIER 3 PA, QLC (20 ml/day) DYRENIUM (triamterene) TIER 3 ST eplerenone TIER 1 INSPRA (eplerenone) TIER 3 spironolactone TIER 1 triamterene TIER 1 ST DIURETICS, THIAZIDE chlorothiazide TIER 1 chlorthalidone TIER 1 DIURIL (chlorothiazide) TIER 3 hydrochlorothiazide TIER 1

89 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS indapamide TIER 1 methyclothiazide TIER 1 metolazone TIER 1 MICROZIDE (hydrochlorothiazide) TIER 3 DYSLIPIDEMICS, FIBRIC ACID DERIVATIVES (Drugs for High Cholesterol) ANTARA (fenofibrate,micronized) 30 MG TIER 3 ST, QLC (2 caps/day) CAPSULE ANTARA (fenofibrate,micronized) 90 MG TIER 3 ST, QLC (1 cap/day) CAPSULE fenofibrate (LOFIBRA) 160 mg tablet TIER 1 QLC (1 tab/day) fenofibrate (LOFIBRA) 54 mg tablet TIER 1 QLC (2 tabs/day) fenofibrate 120 mg tablet TIER 1 ST, QLC (1 tab/day) fenofibrate 150 mg capsule TIER 1 ST, QLC (1 cap/day) fenofibrate 160 mg tablet TIER 1 QLC (1 tab/day) fenofibrate 40 mg tablet TIER 1 ST, QLC (2 tabs/day) fenofibrate 50 mg capsule TIER 1 ST, QLC (2 caps/day) fenofibrate 54 mg tablet TIER 1 QLC (2 tabs/day) fenofibrate nanocrystallized 145mg tablet TIER 1 QLC (1 tab/day) fenofibrate nanocrystallized 160 mg TIER 1 ST, QLC (1 tab/day) tablet fenofibrate nanocrystallized 48 mg tablet TIER 1 QLC (2 tabs/day) fenofibrate,micronized (LOFIBRA) 200 mg TIER 1 QLC (1 cap/day) capsule fenofibrate,micronized (LOFIBRA) 67 mg TIER 1 QLC (1 cap/day) capsule, 134 mg capsule fenofibrate,micronized 130 mg capsule TIER 1 ST, QLC (1 cap/day) fenofibrate,micronized 43 mg capsule TIER 1 ST, QLC (2 caps/day) fenofibrate,micronized 67 mg capsule, TIER 1 QLC (1 cap/day) 134 mg capsule, 200 mg capsule fenofibric acid (choline) TIER 1 QLC (1 cap/day) fenofibric acid 105 mg tablet TIER 1 QLC (1 tab/day) fenofibric acid 35 mg tablet TIER 1 QLC (2 tabs/day)

90 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS FENOGLIDE (fenofibrate) 120 MG TABLET TIER 3 ST, QLC (1 tab/day) FENOGLIDE (fenofibrate) 40 MG TABLET TIER 3 ST, QLC (2 tabs/day) FIBRICOR (fenofibric acid) 105 MG TABLET TIER 3 QLC (1 tab/day) FIBRICOR (fenofibric acid) 35 MG TABLET TIER 3 QLC (2 tabs/day) gemfibrozil TIER 1 QLC (2.5 tabs/day) LIPOFEN (fenofibrate) 150 MG CAPSULE TIER 3 ST, QLC (1 cap/day) LIPOFEN (fenofibrate) 50 MG CAPSULE TIER 3 ST, QLC (2 caps/day) LOPID (gemfibrozil) TIER 3 QLC (2.5 tabs/day) TRICOR (fenofibrate nanocrystallized) 145 TIER 3 QLC (1 tab/day) MG TABLET TRICOR (fenofibrate nanocrystallized) 48 TIER 3 QLC (2 tabs/day) MG TABLET TRIGLIDE (fenofibrate nanocrystallized) TIER 3 ST, QLC (1 tab/day) TRILIPIX (fenofibric acid (choline)) TIER 3 QLC (1 cap/day) DYSLIPIDEMICS, HMG COA REDUCTASE INHIBITORS (Drugs for High Cholesterol) ALTOPREV (lovastatin) TIER 3 QLC (1 tab/day) atorvastatin calcium 10 mg tablet, 20 mg TIER 1 ACA (Preventive Health), QLC (1 tablet tab/day) atorvastatin calcium 40 mg tablet, 80 mg TIER 1 QLC (1 tab/day) tablet CRESTOR (rosuvastatin calcium) TIER 3 QLC (1 tab/day) EZALLOR SPRINKLE (rosuvastatin calcium) TIER 3 PA, QLC (1 cap/day) FLOLIPID (simvastatin) 20 MG/5 ML ORAL TIER 3 PA, QLC (5 ml/day) SUSP FLOLIPID (simvastatin) 40 MG/5 ML ORAL TIER 3 PA, QLC (10 ml/day) SUSP fluvastatin sodium 20 mg capsule, 40 mg TIER 1 PA, QLC (1 cap/day) capsule fluvastatin sodium 80 mg tab er 24h TIER 1 PA, QLC (1 tab/day) LESCOL (fluvastatin sodium) TIER 3 PA, QLC (1 cap/day) LESCOL XL (fluvastatin sodium) TIER 3 PA, QLC (1 tab/day) LIPITOR (atorvastatin calcium) TIER 3 QLC (1 tab/day) LIVALO (pitavastatin calcium) TIER 3 ST, QLC (1 tab/day)

91 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS lovastatin 10 mg tablet, 20 mg tablet TIER 1 QLC (1 tab/day) lovastatin 40 mg tablet TIER 1 QLC (2 tabs/day) PRAVACHOL (pravastatin sodium) TIER 3 QLC (1 tab/day) pravastatin sodium TIER 1 QLC (1 tab/day) rosuvastatin calcium TIER 1 QLC (1 tab/day) simvastatin 5 mg tablet, 10 mg tablet, 20 TIER 1 ACA (Preventive Health), QLC (1 mg tablet, 40 mg tablet tab/day) simvastatin 80 mg tablet TIER 1 QLC (1 tab/day) ZOCOR (simvastatin) TIER 3 QLC (1 tab/day) ZYPITAMAG (pitavastatin magnesium) TIER 3 ST, QLC (1 tab/day) DYSLIPIDEMICS, OTHER (Other Drugs for High Cholesterol) cholestyramine (with sugar) TIER 1 cholestyramine/aspartame TIER 1 cholestyramine/aspartame (PREVALITE) TIER 1 colesevelam hcl TIER 1 COLESTID (colestipol hcl) TIER 3 colestipol hcl TIER 1 ezetimibe TIER 1 QLC (1 tab/day) ezetimibe/simvastatin TIER 1 ST, QLC (1 tab/day) JUXTAPID (lomitapide mesylate) TIER 4 PA, SP, QLC (1 cap/day) KYNAMRO (mipomersen sodium) TIER 4 PA, SP, QLC (1 syringe/week) LOVAZA (omega-3 acid ethyl esters) TIER 3 QLC (4 caps/day) niacin (NIACOR) TIER 1 niacin 500 mg tab er 24h TIER 1 QLC (4 tabs/day) niacin 750 mg tab er, 1000 mg tab er TIER 1 QLC (2 tabs/day) NIASPAN (niacin) ER 500 MG TABLET TIER 3 QLC (4 tabs/day) NIASPAN (niacin) ER 750 MG TABLET, ER TIER 3 QLC (2 tabs/day) 1,000 MG TABLET omega-3 acid ethyl esters TIER 1 QLC (4 caps/day) omega-3 acid ethyl esters (TRIKLO) TIER 1 QLC (4 caps/day) PRALUENT PEN (alirocumab) TIER 4 PA, SP, QLC (2 pens/month)

92 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS PRALUENT SYRINGE (alirocumab) TIER 4 PA, SP, QLC (2 syringes/month) QUESTRAN (cholestyramine (with sugar)) TIER 3 QUESTRAN LIGHT TIER 3 (cholestyramine/aspartame) REPATHA PUSHTRONEX (evolocumab) TIER 4 PA, SP, QLC (1 injector/month) REPATHA SURECLICK (evolocumab) TIER 4 PA, SP, QLC (2 pens/month) REPATHA SYRINGE (evolocumab) TIER 4 PA, SP, QLC (2 syringes/month) VASCEPA (icosapent ethyl) 0.5 GM TIER 3 PA, QLC (2 caps/day) CAPSULE VASCEPA (icosapent ethyl) 1 GM TIER 3 PA, QLC (4 caps/day) CAPSULE VYTORIN (ezetimibe/simvastatin) TIER 3 ST, QLC (1 tab/day) WELCHOL (colesevelam hcl) TIER 3 ZETIA (ezetimibe) TIER 3 QLC (1 tab/day) VASODILATORS, DIRECT-ACTING ARTERIAL (Drugs for Relaxing Arteries) hydralazine hcl 10 mg tablet, 25 mg TIER 1 tablet, 50 mg tablet, 100 mg tablet minoxidil 2.5 mg tablet, 10 mg tablet TIER 1 VASODILATORS, DIRECT-ACTING ARTERIAL/VENOUS (Drugs for Relaxing Arteries and Veins) DILATRATE-SR (isosorbide dinitrate) TIER 3 GONITRO (nitroglycerin) TIER 3 PA, QLC (36 packs/month) ISORDIL (isosorbide dinitrate) TIER 3 ISORDIL TITRADOSE (isosorbide dinitrate) TIER 3 isosorbide dinitrate TIER 1 isosorbide dinitrate (ISOCHRON) TIER 1 isosorbide mononitrate TIER 1 NITRO-BID (nitroglycerin) TIER 2 NITRO-DUR (nitroglycerin) -0.1 MG/HR TIER 3 PATCH, -0.2 MG/HR PATCH, -0.4 MG/HR PATCH, -0.6 MG/HR PATCH NITRO-DUR (nitroglycerin) -0.3 MG/HR TIER 2 PATCH, -0.8 MG/HR PATCH

93 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS nitroglycerin (MINITRAN) TIER 1 nitroglycerin (NITRO-TIME) TIER 1 nitroglycerin 0.1mg/hr patch td24, TIER 1 0.2mg/hr patch td24, 0.3 mg tab subl, 0.4mg/hr patch td24, 0.4 mg tab subl, 0.6 mg tab subl, 0.6mg/hr patch td24, 2.5 mg capsule er, 6.5 mg capsule er, 9 mg capsule er, 400mcg/spr spray NITROLINGUAL (nitroglycerin) TIER 3 NITROMIST (nitroglycerin) TIER 3 NITROSTAT (nitroglycerin) TIER 3

CENTRAL NERVOUS SYSTEM AGENTS (Drugs for Nerve Conditions) ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, AMPHETAMINES ADDERALL (dextroamphetamine sulf- TIER 3 AL1 (Up to 18 yrs old), QLC (5 saccharate/amphetamine sulf-aspartate) tabs/day) 12.5 MG TABLET -- ADDERALL (dextroamphetamine sulf- TIER 3 AL1 (Up to 18 yrs old), QLC (3 saccharate/amphetamine sulf-aspartate) tabs/day) 20 MG TABLET -- ADDERALL (dextroamphetamine sulf- TIER 3 AL1 (Up to 18 yrs old), QLC (2 saccharate/amphetamine sulf-aspartate) tabs/day) 30 MG TABLET -- ADDERALL (dextroamphetamine sulf- TIER 3 AL1 (Up to 18 yrs old), QLC (4 saccharate/amphetamine sulf-aspartate) tabs/day) 5 MG TABLET --, 7.5 MG TABLET --, 10 MG TABLET --, 15 MG TABLET -- ADDERALL XR (dextroamphetamine sulf- TIER 3 AL1 (Up to 18 yrs old), QLC (2 saccharate/amphetamine sulf-aspartate) caps/day) ADZENYS ER (amphetamine) TIER 3 PA, QLC (15 ml/day) ADZENYS XR-ODT (amphetamine) TIER 3 PA, QLC (1 tab/day) amphetamine sulfate 10 mg tablet TIER 1 ST, AL1 (Up to 17 yrs old), QLC (6 tabs/day) amphetamine sulfate 5 mg tablet TIER 1 ST, AL1 (Up to 18 yrs old), QLC (8 tabs/day) DESOXYN (methamphetamine hcl) TIER 4 ST, AL1 (Up to 18 yrs old), QLC (8 tabs/day)

94 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS DEXEDRINE (dextroamphetamine sulfate) TIER 3 ST, AL1 (Up to 18 yrs old), QLC (4 10 MG TABLET tabs/day) DEXEDRINE (dextroamphetamine sulfate) TIER 3 ST, AL1 (Up to 18 yrs old), QLC (6 SPANSULE 10 MG caps/day) DEXEDRINE (dextroamphetamine sulfate) TIER 3 ST, AL1 (Up to 18 yrs old), QLC (4 SPANSULE 15 MG caps/day) DEXEDRINE (dextroamphetamine sulfate) TIER 3 ST, AL1 (Up to 18 yrs old), QLC (12 SPANSULE 5 MG caps/day) dextroamphetamine sulf- TIER 1 AL1 (Up to 18 yrs old), QLC (5 saccharate/amphetamine sulf-aspartate tabs/day) dextroamphetamine/amphetamine 12.5 mg tablet dextroamphetamine sulf- TIER 1 AL1 (Up to 18 yrs old), QLC (3 saccharate/amphetamine sulf-aspartate tabs/day) dextroamphetamine/amphetamine 20 mg tablet dextroamphetamine sulf- TIER 1 AL1 (Up to 18 yrs old), QLC (2 saccharate/amphetamine sulf-aspartate tabs/day) dextroamphetamine/amphetamine 30 mg tablet dextroamphetamine sulf- TIER 1 AL1 (Up to 18 yrs old), QLC (2 saccharate/amphetamine sulf-aspartate caps/day) dextroamphetamine/amphetamine 5 mg cap er, dextroamphetamine/amphetamine 10 mg cap er, dextroamphetamine/amphetamine 15 mg cap er, dextroamphetamine/amphetamine 20 mg cap er, dextroamphetamine/amphetamine 25 mg cap er, dextroamphetamine/amphetamine 30 mg cap er dextroamphetamine sulf- TIER 1 AL1 (Up to 18 yrs old), QLC (4 saccharate/amphetamine sulf-aspartate tabs/day) dextroamphetamine/amphetamine 5 mg tablet, dextroamphetamine/amphetamine 7.5 mg tablet, dextroamphetamine/amphetamine 10 mg tablet, dextroamphetamine/amphetamine 15 mg tablet dextroamphetamine sulfate TIER 1 ST, AL1 (Up to 18 yrs old), QLC (40 (PROCENTRA) ml/day)

95 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS dextroamphetamine sulfate (ZENZEDI) 10 TIER 3 ST, AL1 (Up to 18 yrs old), QLC (4 mg tablet tabs/day) dextroamphetamine sulfate (ZENZEDI) 5 TIER 3 ST, AL1 (Up to 18 yrs old), QLC (8 mg tablet tabs/day) dextroamphetamine sulfate 10 mg TIER 1 ST, AL1 (Up to 18 yrs old), QLC (6 capsule er caps/day) dextroamphetamine sulfate 10 mg tablet TIER 1 ST, AL1 (Up to 18 yrs old), QLC (4 tabs/day) dextroamphetamine sulfate 15 mg TIER 1 ST, AL1 (Up to 18 yrs old), QLC (4 capsule er caps/day) dextroamphetamine sulfate 5 mg TIER 1 ST, AL1 (Up to 18 yrs old), QLC (12 capsule er caps/day) dextroamphetamine sulfate 5 mg tablet TIER 1 ST, AL1 (Up to 18 yrs old), QLC (8 tabs/day) dextroamphetamine sulfate 5 mg/5 ml TIER 1 ST, AL1 (Up to 18 yrs old), QLC (40 solution ml/day) DYANAVEL XR (amphetamine) TIER 3 ST, AL1 (Up to 18 yrs old), QLC (8 ml/day) EVEKEO (amphetamine sulfate) 10 MG TIER 3 ST, AL1 (Up to 17 yrs old), QLC (6 TABLET tabs/day) EVEKEO (amphetamine sulfate) 5 MG TIER 3 ST, AL1 (Up to 17 yrs old), QLC (8 TABLET tabs/day) EVEKEO ODT (amphetamine sulfate) TIER 3 ST, AL1 (Up to 17 yrs old), QLC (2 tabs/day) methamphetamine hcl TIER 4 ST, AL1 (Up to 18 yrs old), QLC (8 tabs/day) MYDAYIS (dextroamphetamine sulf- TIER 3 PA, QLC (1 cap/day) saccharate/amphetamine sulf-aspartate) VYVANSE (lisdexamfetamine dimesylate) TIER 2 AL1 (Up to 18 yrs old), QLC (1 10 MG CAPSULE, 20 MG CAPSULE, 30 MG cap/day) CAPSULE, 40 MG CAPSULE, 50 MG CAPSULE, 60 MG CAPSULE, 70 MG CAPSULE VYVANSE (lisdexamfetamine dimesylate) TIER 2 AL1 (Up to 18 yrs old), QLC (1 10 MG TABLET, 20 MG TABLET, 30 MG tab/day) TABLET, 40 MG TABLET, 50 MG TABLET, 60 MG TABLET ZENZEDI (dextroamphetamine sulfate) 15 TIER 3 ST, AL1 (Up to 18 yrs old), QLC (3 MG TABLET, 20 MG TABLET tabs/day) ZENZEDI (dextroamphetamine sulfate) 2.5 TIER 3 ST, AL1 (Up to 18 yrs old), QLC (2 MG TABLET, 30 MG TABLET tabs/day)

96 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS ZENZEDI (dextroamphetamine sulfate) 7.5 TIER 3 ST, AL1 (Up to 18 yrs old), QLC (4 MG TABLET tabs/day) ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, NON- AMPHETAMINES ADHANSIA XR (methylphenidate hcl) TIER 3 PA, AL1 (Up to 18 yrs old), QLC (1 cap/day) APTENSIO XR (methylphenidate hcl) TIER 3 ST, AL1 (Up to 18 yrs old), QLC (1 cap/day) atomoxetine hcl 10 mg capsule, 18 mg TIER 1 AL1 (Up to 18 yrs old), QLC (4 capsule, 25 mg capsule caps/day) atomoxetine hcl 40 mg capsule TIER 1 AL1 (Up to 18 yrs old), QLC (2 caps/day) atomoxetine hcl 60 mg capsule, 80 mg TIER 1 AL1 (Up to 18 yrs old), QLC (1 capsule, 100 mg capsule cap/day) clonidine hcl 0.1 mg tab er 12h TIER 1 PA, AL1 (Up to 18 yrs old), QLC (4 tabs/day) CONCERTA (methylphenidate hcl) TIER 3 AL1 (Up to 18 yrs old), QLC (2 CONCTA 36 MG TABLET tabs/day) CONCERTA (methylphenidate hcl) ER 18 TIER 3 AL1 (Up to 18 yrs old), QLC (1 MG TABLET, ER 27 MG TABLET, ER 54 MG tab/day) TABLET COTEMPLA XR-ODT (methylphenidate) - TIER 3 PA, AL1 (Up to 18 yrs old), QLC (2 17.3 MG TABLET tabs/day) COTEMPLA XR-ODT (methylphenidate) - TIER 3 PA, AL1 (Up to 18 yrs old) 25.9 MG TABLET COTEMPLA XR-ODT (methylphenidate) - TIER 3 PA, AL1 (Up to 18 yrs old), QLC (5 8.6 MG TABLET tabs/day) DAYTRANA (methylphenidate) 10 MG/9 TIER 3 ST, AL1 (Up to 18 yrs old), QLC (1 HR PATCH, 15 MG/9 HR PATCH, 20 MG/9 patch/day) HOUR PATCH, 30 MG/9 HOUR PATCH dexmethylphenidate hcl 2.5 mg tablet, 5 TIER 1 AL1 (Up to 18 yrs old), QLC (2 mg tablet, 10 mg tablet tabs/day) dexmethylphenidate hcl 5 mg 50-50, 10 TIER 1 ST, AL1 (Up to 18 yrs old), QLC (1 mg 50-50, 15 mg 50-50, 20 mg 50-50, 25 cap/day) mg 50-50, 30 mg 50-50, 35 mg 50-50, 40 mg 50-50 FOCALIN (dexmethylphenidate hcl) TIER 3 AL1 (Up to 18 yrs old), QLC (2 tabs/day) FOCALIN XR (dexmethylphenidate hcl) TIER 3 ST, AL1 (Up to 18 yrs old), QLC (1 cap/day)

97 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS guanfacine hcl 1 mg tab er, 2 mg tab er, TIER 1 AL1 (Up to 18 yrs old), QLC (1 3 mg tab er, 4 mg tab er tab/day) INTUNIV (guanfacine hcl) TIER 3 AL1 (Up to 18 yrs old), QLC (1 tab/day) JORNAY PM (methylphenidate hcl) TIER 3 PA, AL1 (Up to 18 yrs old), QLC (1 cap/day) KAPVAY (clonidine hcl) TIER 3 PA, AL1 (Up to 18 yrs old), QLC (4 tabs/day) METADATE CD (methylphenidate hcl) 10 TIER 3 ST, AL1 (Up to 18 yrs old), QLC (2 MG CAPSULE, 20 MG CAPSULE, 30 MG caps/day) CAPSULE METADATE CD (methylphenidate hcl) 40 TIER 3 ST, AL1 (Up to 18 yrs old), QLC (1 MG CAPSULE, 50 MG CAPSULE, 60 MG cap/day) CAPSULE METHYLIN (methylphenidate hcl) 10 MG/5 TIER 3 ST, AL1 (Up to 18 yrs old), QLC (30 ML SOLUTION ml/day) METHYLIN (methylphenidate hcl) 2.5 MG TIER 3 AL1 (Up to 18 yrs old), QLC (6 TAB, 5 MG TABLET, 10 MG TABLET tabs/day) METHYLIN (methylphenidate hcl) 5 MG/5 TIER 3 ST, AL1 (Up to 18 yrs old), QLC (60 ML SOLUTION ml/day) methylphenidate hcl (METADATE ER) TIER 1 ST, AL1 (Up to 18 yrs old), QLC (3 tabs/day) methylphenidate hcl (RELEXXII) TIER 1 PA, AL1 (Up to 18 yrs old), QLC (1 tab/day) methylphenidate hcl 10 mg 30-70, 20 mg TIER 1 ST, AL1 (Up to 18 yrs old), QLC (2 30-70, 30 mg 30-70 caps/day) methylphenidate hcl 10 mg 50-50, 20 mg TIER 1 AL1 (Up to 18 yrs old), QLC (2 50-50 caps/day) methylphenidate hcl 10 mg tablet er TIER 1 ST, AL1 (Up to 18 yrs old), QLC (6 tabs/day) methylphenidate hcl 10 mg/5 ml solution TIER 1 ST, AL1 (Up to 18 yrs old), QLC (30 ml/day) methylphenidate hcl 18 mg tab er 24, 27 TIER 1 AL1 (Up to 18 yrs old), QLC (1 mg tab er 24, 54 mg tab er 24 tab/day) methylphenidate hcl 2.5 mg tab chew, 5 TIER 1 AL1 (Up to 18 yrs old), QLC (6 mg tab chew, 10 mg tab chew, 10 mg tabs/day) tablet methylphenidate hcl 20 mg tablet TIER 1 AL1 (Up to 18 yrs old), QLC (3 tabs/day) methylphenidate hcl 20 mg tablet er TIER 1 ST, AL1 (Up to 18 yrs old), QLC (3 tabs/day)

98 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS methylphenidate hcl 30 mg cpbp 50-50 TIER 1 AL1 (Up to 17 yrs old), QLC (2 caps/day) methylphenidate hcl 36 mg tab er 24 TIER 1 AL1 (Up to 18 yrs old), QLC (2 tabs/day) methylphenidate hcl 40 mg 30-70, 50 mg TIER 1 ST, AL1 (Up to 18 yrs old), QLC (1 30-70, 60 mg 30-70 cap/day) methylphenidate hcl 40 mg 50-50, 60 mg TIER 1 AL1 (Up to 18 yrs old), QLC (1 50-50 cap/day) methylphenidate hcl 5 mg tablet TIER 1 AL1 (Up to 18 yrs old), QLC (12 tabs/day) methylphenidate hcl 5 mg/5 ml solution TIER 1 ST, AL1 (Up to 18 yrs old), QLC (60 ml/day) methylphenidate hcl 72 mg tab er 24 TIER 1 PA, AL1 (Up to 18 yrs old), QLC (1 tab/day) QUILLICHEW ER (methylphenidate hcl) 30 TIER 3 PA, AL1 (Up to 18 yrs old), QLC (2 MG TAB tabs/day) QUILLICHEW ER (methylphenidate hcl) ER TIER 3 PA, AL1 (Up to 18 yrs old), QLC (1 20 MG CHEW TAB, ER 40 MG CHEW TAB tab/day) QUILLIVANT XR (methylphenidate hcl) TIER 3 PA, QLC (12 ml/day) RITALIN (methylphenidate hcl) 10 MG TIER 3 AL1 (Up to 18 yrs old), QLC (6 TABLET tabs/day) RITALIN (methylphenidate hcl) 20 MG TIER 3 AL1 (Up to 18 yrs old), QLC (3 TABLET tabs/day) RITALIN (methylphenidate hcl) 5 MG TIER 3 AL1 (Up to 18 yrs old), QLC (12 TABLET tabs/day) RITALIN LA (methylphenidate hcl) 10 MG TIER 3 AL1 (Up to 18 yrs old), QLC (2 CAPSULE, 20 MG CAPSULE, 30 MG caps/day) CAPSULE RITALIN LA (methylphenidate hcl) 40 MG TIER 3 AL1 (Up to 18 yrs old), QLC (1 CAPSULE cap/day) RITALIN LA (methylphenidate hcl) 60 MG TIER 3 AL1 (Up to 18 yrs old), QLC (1 CAPSULE cap/day) STRATTERA (atomoxetine hcl) 10 MG TIER 3 AL1 (Up to 18 yrs old), QLC (4 CAPSULE, 18 MG CAPSULE, 25 MG caps/day) CAPSULE STRATTERA (atomoxetine hcl) 40 MG TIER 3 AL1 (Up to 18 yrs old), QLC (2 CAPSULE caps/day) STRATTERA (atomoxetine hcl) 60 MG TIER 3 AL1 (Up to 18 yrs old), QLC (1 CAPSULE, 80 MG CAPSULE, 100 MG cap/day) CAPSULE

99 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS CENTRAL NERVOUS SYSTEM, OTHER ADIPEX-P (phentermine hcl) TIER 3 PA ALLZITAL (butalbital/acetaminophen) TIER 3 ST, QLC (12 tabs/day) AUSTEDO (deutetrabenazine) TIER 4 PA, SP, QLC (4 tabs/day) BELVIQ (lorcaserin hcl) TIER 3 PA, QLC (2 tabs/day) BELVIQ XR (lorcaserin hcl) TIER 3 PA, QLC (1 tab/day) benzphetamine hcl 25 mg tablet TIER 1 PA, QLC (3 tabs/day) benzphetamine hcl 50 mg tablet TIER 1 PA butalbital/acetaminophen (BUPAP) TIER 1 QLC (6 tabs/day) butalbital/acetaminophen (TENCON) TIER 1 QLC (6 tabs/day) butalbital/acetaminophen -300mg tablet, TIER 1 QLC (6 tabs/day) -325mg tablet butalbital/acetaminophen 50mg-300mg TIER 3 PA, QLC (6 caps/day) capsule butalbital/acetaminophen/caffeine TIER 1 QLC (6 caps/day) (FIORICET) butalbital/acetaminophen/caffeine TIER 1 QLC (6 caps/day) (PHRENILIN FORTE) butalbital/acetaminophen/caffeine TIER 4 PA, QLC (90 ml/day) (VANATOL LQ) butalbital/acetaminophen/caffeine TIER 4 PA, QLC (90 ml/day) (VANATOL S) butalbital/acetaminophen/caffeine TIER 1 QLC (6 caps/day) butalb/acetaminophen/caffeine 50-300- 40 capsule, butalb/acetaminophen/caffeine 50-325- 40 capsule butalbital/acetaminophen/caffeine TIER 1 QLC (6 tabs/day) butalb/acetaminophen/caffeine 50-325- 40 tablet CONTRAVE (naltrexone hcl/bupropion TIER 3 PA, QLC (4 tabs/day) hcl) diethylpropion hcl TIER 1 PA ESGIC TIER 3 QLC (6 tabs/day) (butalbital/acetaminophen/caffeine) 50- 325-40 MG TABLET ESGIC TIER 3 QLC (6 caps/day) (butalbital/acetaminophen/caffeine) CAPSULE

100 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS HORIZANT (gabapentin enacarbil) TIER 3 PA, QLC (2 tabs/day) INGREZZA (valbenazine tosylate) TIER 4 PA, SP, QLC (1 cap/day) INGREZZA INITIATION PACK (valbenazine TIER 4 PA, SP, QLC (1 packet/6 months) tosylate) MARTEN-TAB (butalbital/acetaminophen) TIER 3 QLC (6 tabs/day) NUEDEXTA (dextromethorphan TIER 2 PA, QLC (2 caps/day) hbr/quinidine sulfate) phendimetrazine tartrate TIER 1 PA phentermine hcl TIER 1 PA phentermine hcl (ADIPEX-P) TIER 1 PA phentermine hcl (LOMAIRA) TIER 1 PA QSYMIA (phentermine hcl/topiramate) TIER 3 PA, QLC (1 cap/day) REGIMEX (benzphetamine hcl) TIER 3 PA, QLC (3 tabs/day) RILUTEK (riluzole) TIER 3 riluzole TIER 1 SUPRENZA ODT (phentermine hcl) TIER 3 PA TEGSEDI (inotersen sodium) TIER 4 PA, SP, QLC (1 syringe/week) tetrabenazine 12.5 mg tablet TIER 4 PA, SP, QLC (8 tabs/day) tetrabenazine 25 mg tablet TIER 4 PA, SP, QLC (4 tabs/day) TIGLUTIK (riluzole) TIER 4 PA, SP, QLC (20 ml/day) XENAZINE (tetrabenazine) 12.5 MG TABLET TIER 4 PA, SP, QLC (8 tabs/day) XENAZINE (tetrabenazine) 25 MG TABLET TIER 4 PA, SP, QLC (4 tabs/day) ZEBUTAL TIER 3 QLC (6 caps/day) (butalbital/acetaminophen/caffeine) FIBROMYALGIA AGENTS CYMBALTA (duloxetine hcl) 20 MG TIER 3 QLC (3 caps/day) CAPSULE, 30 MG CAPSULE CYMBALTA (duloxetine hcl) 60 MG TIER 3 QLC (2 caps/day) CAPSULE duloxetine hcl 20 mg capsule dr, 30 mg TIER 1 QLC (3 caps/day) capsule dr duloxetine hcl 40 mg capsule dr, 60 mg TIER 1 QLC (2 caps/day) capsule dr IRENKA (duloxetine hcl) TIER 3 QLC (2 caps/day)

101 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS LYRICA (pregabalin) 20 MG/ML ORAL TIER 3 QLC (30 ml/day) SOLUTION LYRICA (pregabalin) 225 MG CAPSULE, TIER 3 QLC (2 caps/day) 300 MG CAPSULE LYRICA (pregabalin) 25 MG CAPSULE, 50 TIER 3 QLC (3 caps/day) MG CAPSULE, 75 MG CAPSULE, 100 MG CAPSULE, 150 MG CAPSULE, 200 MG CAPSULE LYRICA CR (pregabalin) 330 MG TABLET TIER 3 PA, QLC (2 tabs/day) LYRICA CR (pregabalin) CR 82.5 MG TIER 3 PA, QLC (3 tabs/day) TABLET, CR 165 MG TABLET pregabalin 20 mg/ml solution TIER 1 QLC (30 ml/day) pregabalin 225 mg capsule, 300 mg TIER 1 QLC (2 caps/day) capsule pregabalin 25 mg capsule, 50 mg TIER 1 QLC (3 caps/day) capsule, 75 mg capsule, 100 mg capsule, 150 mg capsule, 200 mg capsule SAVELLA (milnacipran hcl) 12.5 MG TIER 3 ST, QLC (2 tabs/day) TABLET, 25 MG TABLET, 50 MG TABLET, 100 MG TABLET SAVELLA (milnacipran hcl) TITRATION TIER 3 ST, QLC (1 pack/28 days) PACK MULTIPLE SCLEROSIS AGENTS AMPYRA (dalfampridine) TIER 4 PA, SP, QLC (2 tabs/day) AUBAGIO (teriflunomide) TIER 4 PA, SP, QLC (1 tab/day) AVONEX (interferon beta-1a) TIER 4 PA, SP, QLC (4 injections/month) AVONEX (interferon beta-1a/albumin TIER 4 PA, SP, QLC (4 injections/month) human) AVONEX PEN (interferon beta-1a) TIER 4 PA, SP, QLC (4 injections/month) BETASERON (interferon beta-1b) TIER 4 PA, SP, QLC (15 injections/month) COPAXONE (glatiramer acetate) 20 TIER 4 SP, QLC (1 syringe/day) MG/ML SYRINGE COPAXONE (glatiramer acetate) 40 TIER 4 SP, QLC (12 syringes/month) MG/ML SYRINGE dalfampridine TIER 4 PA, SP, QLC (2 tabs/day) EXTAVIA (interferon beta-1b) TIER 3 SP, QLC (1 kit/month) FIRDAPSE (amifampridine phosphate) TIER 4 PA, SP, QLC (8 tabs/day)

102 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS GILENYA (fingolimod hcl) TIER 3 SP, QLC (1 cap/day) glatiramer acetate (GLATOPA) 20 mg/ml TIER 2 SP, QLC (1 syringe/day) syringe glatiramer acetate (GLATOPA) 40 mg/ml TIER 2 SP, QLC (12 syringes/month) syringe glatiramer acetate 20 mg/ml syringe TIER 2 SP, QLC (1 syringe/day) glatiramer acetate 40 mg/ml syringe TIER 2 SP, QLC (12 syringes/month) MAVENCLAD (cladribine) TIER 4 PA, SP, QLC (20 tabs/year) MAYZENT (siponimod) 0.25 MG TABLET TIER 4 PA, SP, QLC (4 tabs/day) MAYZENT (siponimod) 2 MG TABLET TIER 4 PA, SP, QLC (1 tab/day) PLEGRIDY (peginterferon beta-1a) 125 TIER 4 PA, SP, QLC (2 syringes/28 days) MCG/0.5 ML SYRING - PLEGRIDY (peginterferon beta-1a) TIER 4 PA, SP, QLC (1 starter pack/12 SYRINGE STARTER PACK - months) PLEGRIDY PEN (peginterferon beta-1a) TIER 4 PA, SP, QLC (2 pens/28 days) 125 MCG/0.5 ML - PLEGRIDY PEN (peginterferon beta-1a) INJ TIER 4 PA, SP, QLC (1 starter pack/12 STARTER PACK - months) REBIF (interferon beta-1a/albumin human) TIER 4 PA, SP, QLC (12 injections/month) 22 MCG/0.5 ML SYRINGE -, 44 MCG/0.5 ML SYRINGE - REBIF (interferon beta-1a/albumin human) TIER 4 PA, SP, QLC (1 pack/month) TITRATION PACK - REBIF REBIDOSE (interferon beta- TIER 4 PA, SP, QLC (12 injections/month) 1a/albumin human) TECFIDERA (dimethyl fumarate) DR 120 TIER 3 SP, QLC (2 caps/day) MG CAPSULE, DR 240 MG CAPSULE TECFIDERA (dimethyl fumarate) STARTER TIER 3 SP, QLC (1 pack/month) PACK

DENTAL AND ORAL AGENTS (Drugs for the Mouth) DENTAL AND ORAL AGENTS cevimeline hcl TIER 1 EVOXAC (cevimeline hcl) TIER 3 pilocarpine hcl 5 mg tablet, 7.5 mg tablet TIER 1 SALAGEN (pilocarpine hcl) TIER 3

103 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS triamcinolone acetonide (ORALONE) TIER 1 triamcinolone acetonide 0.1 % paste (g) TIER 1

DERMATOLOGICAL AGENTS (Drugs for the Skin) 8-MOP (methoxsalen) TIER 3 ABSORICA (isotretinoin) TIER 4 PA ACANYA (clindamycin TIER 3 ST phosphate/benzoyl peroxide) acitretin TIER 1 ACZONE (dapsone) TIER 3 PA, QLC (90 gm/month) adapalene (PLIXDA) TIER 3 PA adapalene 0.1 % cream (g), 0.1 % lotion, TIER 1 AL1 (Up to 40 yrs old) 0.3 % gel w/pump, 0.3 % gel (gram) adapalene 0.1 % solution, 0.1 % med. TIER 3 PA swab adapalene/benzoyl peroxide TIER 1 ST, AL1 (Up to 40 yrs old) ALDARA (imiquimod) TIER 3 QLC (24 packs/month, max of 48 packs/6 months) ALTRENO (tretinoin) TIER 3 PA ANALPRAM HC (hydrocortisone TIER 3 acetate/pramoxine hcl) 1% CREAM ANALPRAM HC (hydrocortisone TIER 2 acetate/pramoxine hcl) 2.5%-1% LOTION ATRALIN (tretinoin) TIER 3 AL1 (Up to 40 yrs old) AVAR (sulfacetamide sodium/sulfur) 9.5- TIER 3 PA 5% CLEANSING PADS AVAR LS (sulfacetamide sodium/sulfur) 10- TIER 3 PA 2% CLEANSING PADS AVAR LS (sulfacetamide sodium/sulfur) TIER 3 CLEANSER AVAR-E LS (sulfacetamide sodium/sulfur) TIER 3 AVITA (tretinoin) TIER 3 AL1 (Up to 40 yrs old) azelaic acid TIER 1 QLC (1 tube/month) AZELEX (azelaic acid) TIER 3 BENZACLIN (clindamycin TIER 3 phosphate/benzoyl peroxide) GEL

104 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS BENZACLIN (clindamycin TIER 3 ST phosphate/benzoyl peroxide) GEL 35G PUMP, GEL 50G PUMP calcipotriene TIER 1 calcipotriene (CALCITRENE) TIER 1 calcipotriene/betamethasone TIER 1 PA, QLC (400 gm/month) dipropionate calcitriol 3 mcg/g oint. (g) TIER 1 CARAC (fluorouracil) TIER 4 PA, QLC (1 tube/month) clindamycin phosphate/benzoyl peroxide TIER 3 (NEUAC) clindamycin phosphate/benzoyl peroxide TIER 1 phos/benzoyl 1 %-5 % gel (gram), phos/benzoyl 1.2(1)%-5% gel (gram) clindamycin phosphate/benzoyl peroxide TIER 1 ST phos/benzoyl 1 %-5 % gel w/pump, phos/benzoyl 1.2%-2.5% gel w/pump clindamycin phosphate/tretinoin TIER 1 ST, AL1 (Up to 40 yrs old) clotrimazole/betamethasone TIER 1 dipropionate CONDYLOX (podofilox) 0.5% GEL TIER 2 CONDYLOX (podofilox) 0.5% TOPICAL TIER 3 SOLN CORTISPORIN (neomycin TIER 3 sulfate/polymyxin b sulfate/hydrocortisone) CORTISPORIN TIER 3 (neomycin/bacitracin/polymyxin b/hydrocortisone) COSENTYX (2 SYRINGES) (secukinumab) TIER 4 PA, SP, QLC (2 syringes/28 days) COSENTYX PEN (2 PENS) (secukinumab) TIER 4 PA, SP, QLC (2 pens/28 days) COSENTYX PEN (secukinumab) TIER 4 PA, SP, QLC (1 pen/28 days) COSENTYX SYRINGE (secukinumab) TIER 4 PA, SP, QLC (1 syringe/28 days) dapsone 5 % gel (gram) TIER 1 PA, QLC (90 gm/month) diclofenac sodium 1 % gel (gram) TIER 1 QLC (5 tubes/month) diclofenac sodium 3 % gel (gram) TIER 4 PA, QLC (1 tube/month; max 3 tubes/year)

105 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS DIFFERIN (adapalene) 0.1% CREAM, 0.1% TIER 3 AL1 (Up to 40 yrs old) LOTION, 0.3% GEL, 0.3% GEL PUMP DOVONEX (calcipotriene) TIER 3 doxepin hcl 5 % cream (g) TIER 3 DUAC (clindamycin phosphate/benzoyl TIER 3 peroxide) DUOBRII (halobetasol TIER 4 PA, QLC (200 gm/28 days) propionate/tazarotene) DUPIXENT (dupilumab) 200 MG/1.14 ML TIER 4 PA, SP, QLC (2 syringes/28 days) SYRING DUPIXENT (dupilumab) 300 MG/2 ML TIER 4 PA, SP, QLC (2 syringes/28 days) SYRINGE ELIDEL (pimecrolimus) TIER 3 ST, AL1 (Up to 12 yrs old), QLC (1 tube/fill) ENSTILAR (calcipotriene/betamethasone TIER 3 PA, QLC (7 bottles/month) dipropionate) EPIDUO (adapalene/benzoyl peroxide) TIER 3 ST, AL1 (Up to 40 yrs old) EPIDUO FORTE (adapalene/benzoyl TIER 2 ST, AL1 (Up to 40 yrs old) peroxide) EPIFOAM (hydrocortisone TIER 2 acetate/pramoxine hcl) EUCRISA (crisaborole) TIER 3 PA, QLC (1 tube/month) FABIOR (tazarotene) TIER 3 AL1 (Up to 40 yrs old), QLC (100 gm/month) FINACEA (azelaic acid) 15% FOAM TIER 3 QLC (1 bottle/month) FINACEA (azelaic acid) 15% GEL TIER 3 QLC (1 tube/month) FLUOROPLEX (fluorouracil) TIER 3 PA, QLC (1 tube/month) fluorouracil 0.5 % cream (g) TIER 4 PA, QLC (1 tube/month) GORDON'S UREA (urea) TIER 3 HYDRO 35 (urea) TIER 3 ST HYDRO 40 (urea) TIER 3 ST hydrocortisone acetate (MICORT-HC) TIER 1 hydrocortisone acetate/pramoxine hcl TIER 1 hydrocortisone/pramoxine 1 %-1 % cream/appl imiquimod 3.75 % crm md pmp TIER 3 ST, QLC (1 bottle/month, max of 2 bottles/6 months)

106 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS imiquimod 5 % cream pack TIER 1 QLC (24 packs/month, max of 48 packs/6 months) isotretinoin TIER 1 isotretinoin (AMNESTEEM) TIER 1 isotretinoin (CLARAVIS) TIER 1 isotretinoin (MYORISAN) TIER 1 isotretinoin (ZENATANE) TIER 1 KERAFOAM (urea) TIER 3 ST KERALAC (urea) TIER 3 ST, QLC (1 tube/month) KERALYT (salicylic acid) 6% GEL TIER 3 LOTRISONE (clotrimazole/betamethasone TIER 3 dipropionate) methoxsalen TIER 1 METROCREAM (metronidazole) TIER 3 METROGEL (metronidazole) TIER 3 METROLOTION (metronidazole) TIER 3 metronidazole (ROSADAN) TIER 1 metronidazole 0.75 % lotion, 0.75 % cream TIER 1 (g), 0.75 % gel (gram), 1 % gel w/pump, 1 % gel (gram) MIRVASO (brimonidine tartrate) TIER 3 QLC (1 tube/month) NATROBA (spinosad) TIER 3 QLC (1 bottle/fill) NEO-SYNALAR (neomycin TIER 3 PA, QLC (1 tube/month) sulfate/fluocinolone acetonide) NORITATE (metronidazole) TIER 4 PA ONEXTON (clindamycin TIER 3 ST, QLC (1 bottle/month) phosphate/benzoyl peroxide) OVACE (sulfacetamide sodium) TIER 3 OVACE PLUS (sulfacetamide sodium) 10% TIER 3 WASH, 10% SHAMPOO, 10% CREAM OVACE PLUS (sulfacetamide sodium) 9.8% TIER 3 QLC (1 bottle/month) LOTION OVACE PLUS WASH (sulfacetamide TIER 3 PA, QLC (1 bottle/month) sodium) OXSORALEN-ULTRA (methoxsalen) TIER 3

107 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS PICATO (ingenol mebutate) 0.015% GEL TIER 2 QLC (3 doses/month) PICATO (ingenol mebutate) 0.05% GEL TIER 2 QLC (2 doses/month) pimecrolimus TIER 1 ST, AL1 (Up to 12 yrs old), QLC (1 tube/fill) PLEXION (sulfacetamide sodium/sulfur) TIER 3 PA, QLC (1 bottle/month) 9.8-4.8% CLEANSER, 9.8-4.8% LOTION, 9.8- 4.8% CREAM PLEXION (sulfacetamide sodium/sulfur) TIER 3 PA, QLC (1 box/month) 9.8-4.8% CLNSING CLOTH podofilox TIER 1 PRAMOSONE (hydrocortisone TIER 2 acetate/pramoxine hcl) 1% LOTION, 2.5%- 1% LOTION PRAMOSONE (hydrocortisone TIER 3 acetate/pramoxine hcl) 1%-1% CREAM PROCTOFOAM-HC (hydrocortisone TIER 2 acetate/pramoxine hcl) PROTOPIC (tacrolimus) 0.03% OINTMENT TIER 3 ST, AL1 (Up to 13 yrs old), QLC (1 tube/fill) PROTOPIC (tacrolimus) 0.1% OINTMENT TIER 3 ST, AL1 (At least 15 yrs old), QLC (1 tube/fill) PRUDOXIN (doxepin hcl) TIER 3 QBREXZA (glycopyrronium tosylate) TIER 3 PA, QLC (1 towelette/day) RECTIV (nitroglycerin) TIER 3 PA REGRANEX (becaplermin) TIER 4 PA, QLC (15 gm/30 days) RETIN-A (tretinoin) TIER 3 AL1 (Up to 40 yrs old) RETIN-A MICRO (tretinoin microspheres) TIER 3 ST, AL1 (Up to 40 yrs old) RETIN-A MICRO PUMP (tretinoin TIER 3 ST, AL1 (Up to 40 yrs old) microspheres) -PUMP 0.04% GEL, -PUMP 0.1% GEL RETIN-A MICRO PUMP (tretinoin TIER 3 ST, AL1 (Up to 40 yrs old), QLC (1 microspheres) -PUMP 0.06% GEL, -PUMP bottle/month) 0.08% GEL RHOFADE (oxymetazoline hcl) TIER 3 PA, QLC (one 30 gm tube/month) ROSULA (sulfacetamide sodium/sulfur) TIER 3 PA, QLC (1 bottle/month) SALEX (salicylic acid) TIER 3 salicylic acid (SALIMEZ) TIER 1

108 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS salicylic acid 6 % lotion er TIER 1 QLC (400 gm/month) salicylic acid 6 % lotion, 6 % crm er (g), 6 TIER 1 % gel (gram), 6 % foam, 6 % cream (g), 6 % shampoo, 26 % liquid, 27.5 % liq-film SALVAX (salicylic acid) TIER 3 SANTYL (collagenase clostridium TIER 2 QLC (180 grams/month) histolyticum) selenium sulfide 2.5 % lotion TIER 1 QLC (1 bottle/month) SILIQ (brodalumab) TIER 4 PA, SP, QLC (2 syringes/28 days) SOLARAZE (diclofenac sodium) TIER 4 PA, QLC (1 tube/month; max 3 tubes/year) SOOLANTRA (ivermectin) TIER 3 QLC (1 tube/month) SORIATANE (acitretin) TIER 3 SORILUX (calcipotriene) TIER 3 PA spinosad TIER 1 QLC (1 bottle/fill) STELARA (ustekinumab) 45 MG/0.5 ML TIER 4 PA, SP, QLC (1 syringe/84 days) SYRINGE, 90 MG/ML SYRINGE sulfacetamide sodium (SEB-PREV) TIER 1 sulfacetamide sodium 10 % clnsr gel TIER 1 PA, QLC (1 bottle/month) sulfacetamide sodium 10 % shampoo, 10 TIER 1 % cleanser sulfacetamide sodium/sulfur (AVAR) TIER 1 sulfacetamide sodium/sulfur (AVAR-E TIER 1 GREEN) sulfacetamide sodium/sulfur (AVAR-E) TIER 1 sulfacetamide sodium/sulfur (BP 10-1) TIER 1 sulfacetamide sodium/sulfur (ROSANIL) TIER 1 sulfacetamide sodium/sulfur (ROSULA) TIER 3 QLC (60 pads/month) sulfacetamide sodium/sulfur (SSS 10-5) TIER 1 sulfacetamide sodium/sulfur TIER 1 PA (SULFACLEANSE 8-4) sulfacetamide sodium/sulfur 8 %-4 % TIER 1 PA suspension

109 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS sulfacetamide sodium/sulfur 9 %-4 % TIER 1 cleanser, 10 %-2 % cream (g), 10-5%(w/v) lotion, 10 %-2 % cleanser, 10-5%(w/w) cream (g), 10-5%(w/w) lotion, 10-5%(w/w) cleanser, 10 %-4 % med. pad, 10-5%(w/w) suspension sulfacetamide sodium/sulfur 9.8%-4.8% TIER 1 PA, QLC (1 bottle/month) cleanser, 9.8%-4.8% lotion, 9.8%-4.8% cream (g) SUMAXIN (sulfacetamide sodium/sulfur) TIER 3 SUMAXIN TS (sulfacetamide sodium/sulfur) TIER 3 PA TACLONEX TIER 3 PA (calcipotriene/betamethasone dipropionate) 0.005%-0.064% SUSPENS TACLONEX TIER 3 PA, QLC (400 gm/28 days) (calcipotriene/betamethasone dipropionate) OINTMENT tacrolimus 0.03 % oint. (g) TIER 1 ST, AL1 (Up to 13 yrs old), QLC (1 tube/fill) tacrolimus 0.1 % oint. (g) TIER 1 ST, AL1 (At least 15 yrs old), QLC (1 tube/fill) TALTZ AUTOINJECTOR (2 PACK) TIER 4 PA, SP, QLC (1 pen/28 days) (ixekizumab) TALTZ AUTOINJECTOR (3 PACK) TIER 4 PA, SP, QLC (1 pen/28 days) (ixekizumab) TALTZ AUTOINJECTOR (ixekizumab) TIER 4 PA, SP, QLC (1 pen/28 days) TALTZ SYRINGE (2 PACK) (ixekizumab) TIER 4 PA, SP, QLC (1 syringe/28 days) TALTZ SYRINGE (3 PACK) (ixekizumab) TIER 4 PA, SP, QLC (1 syringe/28 days) TALTZ SYRINGE (ixekizumab) TIER 4 PA, SP, QLC (1 syringe/28 days) tazarotene TIER 1 AL1 (Up to 40 yrs old) TAZORAC (tazarotene) TIER 3 AL1 (Up to 40 yrs old) TOLAK (fluorouracil) TIER 2 QLC (1 tube/month) TREMFYA (guselkumab) 100 MG/ML TIER 4 PA, SP, QLC (1 injection/8 weeks) INJECTOR TREMFYA (guselkumab) 100 MG/ML TIER 4 PA, SP, QLC (1 syringe/8 weeks) SYRINGE TRETIN-X (tretinoin) -0.075% CREAM TIER 3 ST, AL1 (Up to 40 yrs old)

110 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS tretinoin 0.01 % gel (gram), 0.025 % gel TIER 1 AL1 (Up to 40 yrs old) (gram), 0.025 % cream (g), 0.05 % cream (g), 0.05 % gel (gram), 0.1 % cream (g) tretinoin microspheres TIER 1 ST, AL1 (Up to 40 yrs old) ULESFIA (benzyl alcohol) TIER 3 URAMAXIN (urea) 20% FOAM, 45% UREA TIER 3 CREAM URAMAXIN (urea) 45% NAIL GEL, 45% TIER 3 ST LOTION URAMAXIN GT (urea) TIER 3 ST urea (CEM-UREA) TIER 1 ST urea (METOPIC) TIER 1 ST, QLC (2 bottles/month) urea (UMECTA) TIER 1 ST urea (URE-K) TIER 4 PA urea (UREDEB) TIER 1 ST urea 35 % foam, 39 % cream (g), 45 % gel TIER 1 ST (ml), 45 % lotion urea 40 % cream (g), 40 % lotion, 45 % TIER 1 cream (g), 50 % sol/pf app, 50 % cream (g) urea 41 % cream (g) TIER 1 ST, QLC (2 bottles/month) urea 47 % cream (g) TIER 1 ST, QLC (1 bottle/month) UTOPIC (urea) TIER 3 ST, QLC (2 bottles/month) VECTICAL (calcitriol) TIER 3 VELTIN (clindamycin phosphate/tretinoin) TIER 3 ST, AL1 (Up to 40 yrs old) VEREGEN (sinecatechins) TIER 3 ST, QLC (1 tube/month, not to exceed 4 tubes/6 months) VIRASAL (salicylic acid) TIER 3 VOLTAREN (diclofenac sodium) TIER 3 QLC (5 tubes/month) XEPI (ozenoxacin) TIER 3 ST, QLC (1 tube/60 days) ZIANA (clindamycin phosphate/tretinoin) TIER 3 ST, AL1 (Up to 40 yrs old) ZONALON (doxepin hcl) TIER 3 ZYCLARA (imiquimod) 2.5% CREAM PUMP, TIER 3 ST, QLC (1 bottle/month, max of 2 3.75% CREAM PUMP bottles/6 months) ZYCLARA (imiquimod) 3.75% CREAM TIER 3 ST, QLC (28 packets/month, max of 56 packets/6 months)

111 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS

ELECTROLYTES/MINERALS/METALS/VITAMINS ELECTROLYTE/MINERAL/METAL MODIFIERS FERRIPROX (deferiprone) 1,000 MG TABLET TIER 4 PA, SP, QLC (9 tabs/day) JADENU SPRINKLE (deferasirox) TIER 4 SP JYNARQUE (tolvaptan) 45 MG-15 MG TIER 4 PA, SP, QLC (2 tabs/day) TABLET, 60 MG-30 MG TABLET, 90 MG-30 MG TABLET ATABEX EC (prenatal vits with calcium TIER 3 43/iron/folic acid/docusate sod.) AZESCO (prenatal vitamins no.147/ferrous TIER 3 PA, QLC (2 tabs/day) gluconate/folic acid) CADEAU DHA (prenatal vitamins TIER 3 no.83/iron fumarate/folate combo no.6/dha) CARNITOR (levocarnitine (with sugar)) TIER 3 CARNITOR (levocarnitine) 330 MG TABLET TIER 3 CARNITOR SF (levocarnitine) TIER 3 CHEMET (succimer) TIER 2 CITRANATAL HARMONY (prenatal vitamin TIER 3 no.59/iron carb,fum/folic acid/docusate/dha) CITRANATAL RX (prenatal vits no.81/iron TIER 3 carbonyl,gluc/folic acid/docusate) CONCEPT DHA (prenatal vit no.16/iron TIER 3 fum,ps complex/folic acid/omega-3) CONCEPT OB (prenatal vitamin no.15/iron TIER 3 fumarate,polysac comp/folic acid) cyanocobalamin (vitamin b-12) TIER 1 cyanocoalamin -1000mcg/ml vial deferasirox TIER 4 SP EFFER-K (potassium bicarbonate/citric TIER 3 acid) ENBRACE HR (prenatal vits no.92/iron TIER 3 cysteine gly/folate no.8/phosph-dha) ENDARI (glutamine) TIER 4 PA, QLC (6 packets/day)

112 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS ESCAVITE (pediatric multivitamin TIER 3 ACA (Preventive Health) no.47/ferrous fumarate/sod fluoride) ESCAVITE D (pediatric multivitamin no.78 TIER 3 with iron and sodium fluoride) ESCAVITE LQ (pediatric multivitamin no.86 TIER 3 with iron and sodium fluoride) EXJADE (deferasirox) TIER 4 SP, C (Short Cycle) FERRIPROX (deferiprone) 100 MG/ML TIER 4 PA, SP, QLC (90 ml/day) SOLUTION FERRIPROX (deferiprone) 500 MG TABLET TIER 4 PA, SP, QLC (18 tabs/day) FLORIVA (pediatric multivitamin no.85 with TIER 3 ACA (Preventive Health) sodium fluoride) FLORIVA PLUS (pediatric multivitamin TIER 3 ACA (Preventive Health) no.130/sodium fluoride) fluoride/iron/vitamins a,c,and d TIER 1 ACA (Preventive Health) FOLET ONE (prenatal vit no.80/iron TIER 3 carb,bisgl/methylfolate/docusate/dha) folic acid 1 mg tablet TIER 1 GALZIN (zinc acetate) TIER 3 JADENU (deferasirox) TIER 4 SP, C (Short Cycle) JYNARQUE (tolvaptan) 15 MG TABLET TIER 4 PA, SP, QLC (2 tabs/day) JYNARQUE (tolvaptan) 30 MG TABLET TIER 4 PA, SP, QLC (1 tab/day) K-TAB ER (potassium chloride) TIER 3 KAYEXALATE (sodium polystyrene TIER 3 sulfonate) KLOR-CON (potassium chloride) TIER 3 KLOR-CON 10 (potassium chloride) TIER 3 KLOR-CON 8 (potassium chloride) TIER 3 KLOR-CON M15 (potassium chloride) TIER 3 KOSHER PRENATAL PLUS IRON (prenatal TIER 3 vitamins no.108/iron,carbonyl/folic acid) levocarnitine (with sugar) TIER 1 levocarnitine 330 mg tablet TIER 1 MARNATAL-F (prenatal vits with calcium TIER 3 no.65/iron polysacchar/folic acid)

113 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS MVC-FLUORIDE (pediatric multivitamin TIER 3 ACA (Preventive Health) no.12 with sodium fluoride) MYNATAL (prenatal vitamins with TIER 3 calcium/ferrous fumarate/folic acid) NASCOBAL (cyanocobalamin (vitamin b- TIER 3 QLC (1 bottle/week) 12)) NATACHEW (prenatal vitamin no.55/iron TIER 3 fumarate,bisglycinate/folic acid) NATELLE ONE (prenatal vit, calcium TIER 3 no.70/ferrous fumarate/folic acid/dha) NEEVODHA (prenatal vit no.64/iron/l- TIER 3 mefolate ca/algal oil/soy lecithin) NESTABS (prenatal vitamin no.86/iron bis- TIER 3 glycinate/folic acid) NESTABS ONE (pnv no.111/iron TIER 3 carbonyl,bis-glyc/methyltetra-folate/dha) NEXA PLUS (prenatal vits no.53/iron TIER 3 fum/folic acid/docusate calcium/dha) O-CAL PRENATAL (prenatal vit with TIER 3 calcium no.127/ferrous fumarate/folic acid) OB COMPLETE (prenatal vitamins TIER 3 no.123/iron,carbonyl/folic acid) OB COMPLETE ONE (prenatal vit TIER 3 no.85/iron carb,asp.gly/folic acid/dha/fish oil) OB COMPLETE PETITE (prenatal no56/iron TIER 3 carbonyl,asparto glycinate/folic acid/dha) OB COMPLETE PREMIER (prenatal vits TIER 3 no.83/iron,carbonyl,iron aspart.gly/folic acid) OB COMPLETE WITH DHA (prenatal vit TIER 3 no.30/iron carbonyl,asp glyc/folic acid/omega-3) OBSTETRIX EC (prenatal vitamins TIER 3 no.127/iron,carbonyl/folic acid/docusate) pediatric multivit with a,c,d3 TIER 1 ACA (Preventive Health) no.21/sodium fluoride pediatric multivit with a,c,d3 TIER 1 ACA (Preventive Health) no.21/sodium fluoride (TRI-VITE WITH FLUORIDE)

114 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS pediatric multivitamin no.16/sodium TIER 1 ACA (Preventive Health) fluoride pediatric multivitamin no.2/sodium TIER 1 ACA (Preventive Health) fluoride pediatric multivitamin no.45/sodium TIER 1 ACA (Preventive Health) fluoride/ferrous sulfate pediatric multivitamin no.75/sodium TIER 1 ACA (Preventive Health) fluoride/ferrous sulfate pediatric multivitamin no.82 with sodium TIER 1 ACA (Preventive Health) fluoride pediatric multivitamins no.17 with sodium TIER 1 ACA (Preventive Health) fluoride POLY-VI-FLOR (pediatric multivitamin TIER 3 ACA (Preventive Health) no.33 with sodium fluoride) POLY-VI-FLOR (pediatric multivitamin TIER 3 ACA (Preventive Health) no.37 with sodium fluoride) POLY-VI-FLOR WITH IRON (pediatric TIER 3 ACA (Preventive Health) multivit no.37/sodium fluoride/iron bisglycin.hcl) POLY-VI-FLOR WITH IRON (pediatric TIER 3 ACA (Preventive Health) multivitamin no.33/sodium fluoride/iron carbonyl) potassium bicarbonate/citric acid TIER 1 potassium bicarbonate/citric acid (EFFER- TIER 1 K) potassium bicarbonate/citric acid (K TIER 1 EFFERVESCENT) potassium bicarbonate/citric acid (KLOR- TIER 1 CON-EF) potassium chloride (KLOR-CON M10) TIER 1 potassium chloride (KLOR-CON M20) TIER 1 potassium chloride (KLOR-CON SPRINKLE) TIER 1 potassium chloride (KLOR-CON) TIER 1

115 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS potassium chloride 8 meq capsule er, 8 TIER 1 meq tablet er, 10 meq tablet er, 10 meq capsule er, 10 meq tab er prt, 20 meq tablet er, 20 meq packet, 20 meq tab er prt, 20meq/15ml liquid, 40meq/15ml liquid potassium chloride/potassium TIER 1 bicarbonate/citric acid PREFERA OB (prenatal vit no.21/iron TIER 3 polysacch,heme polypep/folic acid) PREFERA-OB ONE (prenatal vitamin TIER 3 no.19/iron polysac,iron heme/folic acid/dha) PRENA1 CHEW (prenatal vitamins TIER 3 combination no.42/folic acid) PRENATA (prenatal vitamins no.37/ferrous TIER 3 fumarate/folic acid) PRENATABS FA (prenatal vits with calcium TIER 3 no.78/ferrous fumarate/folic acid) PRENATABS RX (prenatal vitamin with TIER 3 calcium no.76/iron,carbonyl/folic acid) prenatal vit no.16/iron fum,ps TIER 1 complex/folic acid/omega-3 (DOTHELLE DHA) prenatal vit no.16/iron fum,ps TIER 1 complex/folic acid/omega-3 (TARON-C DHA) prenatal vit no.16/iron fum,ps TIER 1 complex/folic acid/omega-3 (VIRT-C DHA) prenatal vit no.21/iron polysacch,heme TIER 1 polypep/folic acid (HEMENATAL OB) prenatal vit no.21/iron polysacch,heme TIER 1 polypep/folic acid (VP-HEME OB) prenatal vit no.71/iron fum-sodium TIER 1 feredetate/folic acid/dha (PRENA1 PEARL) prenatal vit no.80/iron TIER 1 carb,bisgl/methylfolate/docusate/dha (OBSTETRIX ONE) prenatal vit with calcium 15/iron/folic TIER 1 acid/docusate sodium (MYNATAL ADVANCE)

116 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS prenatal vit with calcium TIER 1 no.37/iron,aspg/folic acid/omega-3 (ULTIMATECARE ONE) prenatal vit with calcium no.40/iron TIER 1 fumarate/folate no.1 (PNV-SELECT) prenatal vit with calcium no.40/iron TIER 1 fumarate/folate no.1 (VIRT-PN) prenatal vit with calcium no.68/iron TIER 1 fum/folic acid no.1/dha (PNV-OMEGA) prenatal vit with calcium no.68/iron TIER 1 fum/folic acid no.1/dha (VIRT-PN PLUS) prenatal vit with calcium no.68/iron TIER 1 fum/folic acid no.1/dha (ZATEAN-PN PLUS) prenatal vit with calcium no.69/iron/folic TIER 1 acid/docusate/dha (PRENAISSANCE PLUS) prenatal vit,calcium no.35/iron/folic TIER 1 acid/docusate/omega-3 (ULTIMATECARE ONE NF) prenatal vit/folic acid/b6/calcium TIER 1 phosph di,tribasic/ginger (VP-GGR-B6) prenatal vit/folic acid/b6/calcium TIER 1 phosph di,tribasic/ginger (ZINGIBER) prenatal vitamin 27 with calcium/ferrous TIER 1 fumarate/folic acid (TRINATAL RX 1) prenatal vitamin 27 with calcium/ferrous TIER 1 fumarate/folic acid (VINATE ONE) prenatal vitamin no.15/iron TIER 1 fumarate,polysac comp/folic acid (FOLIVANE-OB) prenatal vitamin no.19/iron polysac,iron TIER 1 heme/folic acid/dha (VP-HEME ONE) prenatal vitamin no.86/iron bis- TIER 1 glycinate/folic acid (NEWGEN) prenatal vitamin with calcium TIER 1 no.76/iron,carbonyl/folic acid (PNV 29-1) prenatal vitamin with calcium TIER 1 no.76/iron,carbonyl/folic acid (THRIVITE RX) prenatal vitamins no.11/ferrous TIER 1 fumarate/folic acid/omega-3 (C-NATE DHA)

117 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS prenatal vitamins no.11/ferrous TIER 1 fumarate/folic acid/omega-3 (VIRT-NATE DHA) prenatal vitamins TIER 1 no.123/iron,carbonyl/folic acid (ELITE-OB) prenatal vitamins no.14/ferrous TIER 1 fumarate/folic acid (COMPLETENATE) prenatal vitamins no.5/ferrous TIER 1 fumarate/folic acid prenatal vitamins no.5/ferrous TIER 1 fumarate/folic acid (PNV-VP-U) prenatal vitamins TIER 3 no.66/iron,carbonyl/folic acid/dha (R- NATAL OB) prenatal vitamins no.79/iron fum/folic TIER 1 acid/levomefolate/dha prenatal vitamins with calcium/ferrous TIER 1 fum/docusate/folic ac (MYNATE 90 PLUS) prenatal vitamins with calcium/ferrous TIER 1 fumarate/folic acid (MYNATAL PLUS) prenatal vitamins with calcium/ferrous TIER 1 fumarate/folic acid (MYNATAL-Z) prenatal vitamins with TIER 1 calcium/iron,carb/docusate/folic acid (MYNATAL) prenatal vits no.115/iron fumarate/folic TIER 1 acid/docusate sod. prenatal vits no.119/iron fumarate/folic TIER 1 acid/docusate sod. prenatal vits no.34/iron,carb/folic TIER 1 acid/docusate sodium/dha (VP-CH-PNV) prenatal vits with calcium 118/ferrous TIER 1 fumarate/folic acid prenatal vits with calcium 136/ferrous TIER 1 fumarate/folic acid (VINATE-M) prenatal vits with calcium no.115/iron TIER 1 fumarate/folic acid prenatal vits with calcium no.47/ferrous TIER 1 fum/folate no.1/dha (PNV-DHA) prenatal vits with calcium no.47/ferrous TIER 1 fum/folate no.1/dha (VIRT-PN DHA)

118 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS prenatal vits with calcium no.47/ferrous TIER 1 fum/folate no.1/dha (ZATEAN-PN DHA) prenatal vits with calcium no.72/ferrous TIER 1 fumarate/folic acid prenatal vits with calcium no.72/ferrous TIER 1 fumarate/folic acid (M-NATAL PLUS) prenatal vits with calcium no.72/ferrous TIER 1 fumarate/folic acid (PREPLUS) prenatal vits with calcium TIER 1 no.72/iron,carbonyl/folic acid prenatal vits with calcium no.73/ferrous TIER 1 fumarate/folic acid (VIRT-NATE) prenatal vits with calcium no.74/ferrous TIER 1 fumarate/folic acid prenatal vits with calcium no.78/ferrous TIER 1 fumarate/folic acid (PRETAB) prenatal vits with calcium no.80/iron TIER 1 fum/folic acid/dss/dha (PRENAISSANCE) prenatal vits,calcium no.39/iron fum/folic TIER 1 acid/docusate/dha (TARON-PREX PRENATAL) prenatal vits,calcium no.66/iron fum/folic TIER 1 acid/docusate/dha (PNV-DHA + DOCUSATE) prenatal vits,calcium no.66/iron fum/folic TIER 1 acid/docusate/dha (VEMAVITE-PRX 2) PRENATE AM (prenatal vit TIER 3 114/methyltetrahydfolate gluc,folic acid/ginger) PRENATE CHEWABLE (prenatal vits TIER 3 no.112/methyltetrahydrofolate gluc,folic acid) PRENATE DHA (prenatal vitamins TIER 3 no.38/iron fumarate/folate comb no.6/dha) PRENATE DHA (prenatal vitamins TIER 3 no.78/iron asparto glycin/folate no.1/dha) PRENATE ELITE (prenatal vitamins TIER 3 no.36/ferrous fumarate/folate comb. no.6)

119 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS PRENATE ELITE (prenatal vits no.114/ferrous TIER 3 aspart glycinate/folate no.1) PRENATE ENHANCE (prenatal vitamins TIER 3 no.68/iron fumarate/folate no.6/dha) PRENATE ESSENTIAL (prenatal vitamin TIER 3 no.35/iron fumarate/folate comb. no.6/dha) PRENATE ESSENTIAL (prenatal vitamins TIER 3 no.84/iron asparto glycin/folate no.1/dha) PRENATE MINI (prenatal vits no.87/iron TIER 3 carb-asp.glycinate/folate no.1/dha) PRENATE PIXIE (prenatal vitamins TIER 3 no.85/iron asparto glycin/folate no.1/dha) PRENATE RESTORE (prenatal vitamins TIER 3 no.69/iron fumarate/folate comb no.6/dha) PRENATE STAR (prenatal vitamins TIER 3 no.77/ferrous asparto glycinate/folic acid) PRIMACARE (prenatal vits no.118/iron TIER 3 asparto glycinate/folate no.6/dha) PROVIDA DHA (prenatal vitamins TIER 3 no.90/iron fum,polysac comp/folic acid/dha) PROVIDA OB (prenatal vits no.65/iron TIER 3 fumarate,polysac complex/folic acid) PUREFE OB PLUS (prenatal vits no.4/iron TIER 3 fumarate,polysacc complex/folic acid) QUFLORA (pediatric multivitamin no.63 TIER 3 ACA (Preventive Health), QLC (1 with sodium fluoride) tab/day) QUFLORA (pediatric multivitamin no.83 TIER 3 ACA (Preventive Health) with sodium fluoride) QUFLORA (pediatric multivitamin no.84 TIER 3 ACA (Preventive Health) with sodium fluoride) QUFLORA FE (pediatric multivitamin TIER 3 ACA (Preventive Health), QLC (1 no.142/iron,carbonyl/sodium fluoride) tab/day) RADIOGARDASE (prussian blue TIER 3 (insoluble)) SAMSCA (tolvaptan) 15 MG TABLET TIER 4 PA, SP, QLC (1 tab/day)

120 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS SAMSCA (tolvaptan) 30 MG TABLET TIER 4 PA, SP, QLC (2 tabs/day) SELECT-OB (prenatal vit no.128/iron TIER 3 polysaccharide complex/folic acid) SELECT-OB (prenatal vitamin no.13/iron TIER 3 polysaccharides/folate comb no.1) sodium polystyrene sulfonate TIER 1 sodium polystyrene sulfonate (KIONEX) TIER 1 sodium polystyrene sulfonate/sorbitol TIER 1 solution (KIONEX) SPS (sodium polystyrene sulfonate/sorbitol TIER 3 solution) SYPRINE (trientine hcl) TIER 4 PA, QLC (8 caps/day) TRI-VI-FLOR (pediatric multivitamin TIER 3 ACA (Preventive Health) a,c,and d3 no.38 with sodium fluoride) TRICARE (prenatal vits with calcium TIER 3 103/ferrous fumarate/folic acid) TRICARE PRENATAL (prenatal vitamins TIER 3 no.113/iron pyrophosphate/levomefolate) TRICARE PRENATAL DHA ONE (prenatal vit TIER 3 no.20/iron/folic acid/docusate/fish oil/dha/epa) trientine hcl TIER 4 PA, QLC (8 caps/day) TRINATE (prenatal vits with calcium TIER 3 no.73/ferrous fumarate/folic acid) TRISTART DHA (prenatal vitamins TIER 3 no.93/iron carbonyl/folate comb no.9/dha) VELTASSA (patiromer calcium sorbitex) TIER 4 PA, SP, QLC (1 packet/day) VINATE CARE (prenatal vits with calcium TIER 1 109/ferrous fumarate/folic acid) VINATE DHA RF (prenatal vit no.64/iron/l- TIER 3 mefolate ca/algal oil/soy lecithin) VITAFOL GUMMIES (prenatal vit TIER 3 no.112/iron phosph/folic acid/omega- 3s/dha/epa) VITAFOL NANO (prenatal vitamins TIER 3 no.75/ferrous fumarate/folate comb. no.1)

121 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS VITAFOL ULTRA (prenatal vit no.67/iron TIER 3 polysaccharides/folate comb.no.1/dha) VITAFOL-OB (prenatal vits with calcium TIER 3 no.10/ferrous fumarate/folic acid) VITAFOL-ONE (prenatal vits no.26/iron TIER 3 polysaccharide cplex/folic acid/dha) VITAMEDMD ONE RX (prenatal vits TIER 3 no.25/ferrous fumarate/folate comb. no.6/dha) VITAMEDMD REDICHEW RX (prenatal TIER 3 vitamins combination no.42/folic acid) VITAPEARL (prenatal vit no.71/iron fum- TIER 3 sodium feredetate/folic acid/dha) VP-PNV-DHA (prenatal vitamins TIER 3 no.52/ferrous fumarate/folic acid/dha) XURIDEN (uridine triacetate) TIER 4 PA, SP, QLC (4 packets/day) VITAMINS QUFLORA FE (pediatric multivitamin TIER 3 ACA (Preventive Health) no.151/ferrous sulfate/sod fluoride)

GASTROINTESTINAL AGENTS (Drugs for the Bowel and Stomach) ANTISPASMODICS, GASTROINTESTINAL (Drugs to Prevent Bowel and Stomach Spasam) ANASPAZ (hyoscyamine sulfate) TIER 3 BENTYL (dicyclomine hcl) 10 MG CAPSULE, TIER 3 20 MG TABLET chlordiazepoxide/clidinium bromide TIER 3 CUVPOSA (glycopyrrolate) TIER 3 PA, QLC (45 ml/day) dicyclomine hcl 10 mg/5 ml solution, 10 TIER 1 mg capsule, 20 mg tablet DONNATAL (phenobarbital/hyoscyamine TIER 3 PA, QLC (40 ml/day) sulf/atropine sulf/scopolamine hb) ELIXIR DONNATAL (phenobarbital/hyoscyamine TIER 3 sulf/atropine sulf/scopolamine hb) TABLET GLYCATE (glycopyrrolate) TIER 3 PA, QLC (3 tabs/day) glycopyrrolate 1 mg tablet, 2 mg tablet TIER 1

122 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS glycopyrrolate 1.5 mg tablet TIER 4 PA, QLC (3 tabs/day) hyoscyamine sulfate TIER 1 hyoscyamine sulfate (ED-SPAZ) TIER 1 hyoscyamine sulfate (HYOSYNE) TIER 1 hyoscyamine sulfate (NULEV) TIER 1 hyoscyamine sulfate (OSCIMIN SL) TIER 1 hyoscyamine sulfate (OSCIMIN SR) TIER 1 hyoscyamine sulfate (OSCIMIN) TIER 1 hyoscyamine sulfate (SYMAX) TIER 1 hyoscyamine sulfate (SYMAX-SL) TIER 1 hyoscyamine sulfate (SYMAX-SR) TIER 1 LEVBID (hyoscyamine sulfate) TIER 3 LEVSIN (hyoscyamine sulfate) 0.125 MG TIER 3 TABLET LEVSIN-SL (hyoscyamine sulfate) TIER 3 LIBRAX (chlordiazepoxide/clidinium TIER 3 bromide) methscopolamine bromide TIER 1 phenobarbital/hyoscyamine sulf/atropine TIER 1 sulf/scopolamine hb (PHENOHYTRO) phenobarb/hyoscy/atropine/scop 16.2 mg tablet phenobarbital/hyoscyamine sulf/atropine TIER 1 QLC (40 ml/day) sulf/scopolamine hb (PHENOHYTRO) phenobarb/hyoscy/atropine/scop 16.2mg/5ml elixir phenobarbital/hyoscyamine sulf/atropine TIER 1 sulf/scopolamine hb phenobarb/hyoscy/atropine/scop 16.2 mg tablet phenobarbital/hyoscyamine sulf/atropine TIER 1 PA, QLC (40 ml/day) sulf/scopolamine hb phenobarb/hyoscy/atropine/scop 16.2mg/5ml elixir propantheline bromide TIER 1 ROBINUL (glycopyrrolate) 1 MG TABLET TIER 3 ROBINUL FORTE (glycopyrrolate) TIER 3

123 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS SYMAX DUOTAB (hyoscyamine sulfate) TIER 3 GASTROINTESTINAL AGENTS, OTHER (Other Drugs for the Bowel and Stomach) ACTIGALL (ursodiol) TIER 3 CHENODAL (chenodiol) TIER 4 PA, SP, QLC (6 tabs/day) CHOLBAM (cholic acid) 250 MG CAPSULE TIER 4 PA, SP, QLC (5 caps/day) CHOLBAM (cholic acid) 50 MG CAPSULE TIER 4 PA, SP, QLC (4 caps/day) cromolyn sodium 20 mg/ml oral conc TIER 1 diphenoxylate hcl/atropine sulfate TIER 1 GASTROCROM (cromolyn sodium) TIER 3 lansoprazole/amoxicillin TIER 1 QLC (one 14-day course/month) trihydrate/clarithromycin LOMOTIL (diphenoxylate hcl/atropine TIER 3 sulfate) MOTOFEN (difenoxin hcl/atropine sulfate) TIER 3 MOVANTIK (naloxegol oxalate) TIER 3 QLC (1 tab/day) MYALEPT (metreleptin) TIER 4 PA, SP, QLC (1 vial/day) MYTESI (crofelemer) TIER 3 PA, QLC (2 tabs/day) OCALIVA (obeticholic acid) TIER 4 PA, SP, C (Short Cycle), QLC (1 tab/day) OMECLAMOX-PAK TIER 3 QLC (1 pack/month) (omeprazole/clarithromycin/amoxicillin trihydrate) PREVPAC (lansoprazole/amoxicillin TIER 3 QLC (one 14-day course/month) trihydrate/clarithromycin) PYLERA (colloidal bismuth TIER 3 QLC (120 caps/month) subcitrate/metronidazole/tetracycline hcl) RELISTOR (methylnaltrexone bromide) 150 TIER 4 PA, QLC (3 tabs/day) MG TABLET RELISTOR (methylnaltrexone bromide) 8 TIER 4 PA MG/0.4 ML SYRINGE, 12 MG/0.6 ML SYRINGE, 12 MG/0.6 ML VIAL SYMPROIC (naldemedine tosylate) TIER 3 PA, QLC (1 tab/day) URSO (ursodiol) TIER 3

124 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS URSO FORTE (ursodiol) TIER 3 ursodiol TIER 1 XENICAL (orlistat) TIER 3 PA XERMELO (telotristat etiprate) TIER 4 PA, SP, QLC (3 tabs/day) HISTAMINE2 (H2) RECEPTOR ANTAGONISTS cimetidine 300 mg tablet, 400 mg tablet, TIER 1 800 mg tablet cimetidine hcl TIER 1 famotidine (PEPCID) 40 mg tablet TIER 1 famotidine 40mg/5ml oral susp, 40 mg TIER 1 tablet nizatidine TIER 1 PEPCID (famotidine) 40 MG TABLET TIER 1 PEPCID (famotidine) 40 MG/5 ML ORAL TIER 3 SUSP ranitidine hcl 15 mg/ml syrup, 150 mg TIER 1 capsule, 300 mg tablet, 300 mg capsule ZANTAC (ranitidine hcl) 300 MG TABLET TIER 3 IRRITABLE BOWEL SYNDROME AGENTS alosetron hcl TIER 1 PA AMITIZA (lubiprostone) 24 MCG CAPSULES TIER 3 PA, AL1 (At least 18 yrs old), QLC (2 caps/day) AMITIZA (lubiprostone) 8 MCG CAPSULE TIER 3 PA, ST, AL1 (At least 18 yrs old), QLC (2 caps/day) LINZESS (linaclotide) TIER 2 QLC (1 cap/day) LOTRONEX (alosetron hcl) TIER 3 PA TRULANCE (plecanatide) TIER 3 PA, QLC (1 tab/day) VIBERZI (eluxadoline) TIER 4 PA, QLC (2 tabs/day) ZELNORM (tegaserod hydrogen maleate) TIER 3 PA, QLC (2 tabs/day) LAXATIVES (Drugs for Bowel Cleansing and Constipation) bisacodyl/sodium chlor/sodium TIER 1 ACA (Preventive Health) bicarb/potassium chl/peg 3350 (PEG- PREP)

125 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS CLENPIQ (sodium picosulfate/magnesium TIER 3 PA oxide/citric acid) COLYTE WITH FLAVOR PACKETS (peg TIER 3 PA, ACA (Preventive Health) 3350/sod sulf/sod bicarb/sod chloride/potassium chloride) GOLYTELY (peg 3350/sod sulf/sod TIER 3 PA, ACA (Preventive Health) bicarb/sod chloride/potassium chloride) KRISTALOSE (lactulose) 10 GM PACKET TIER 3 PA, QLC (1 pack/day) KRISTALOSE (lactulose) 20 GM PACKET TIER 3 PA, QLC (2 packs/day) lactulose (CONSTULOSE) TIER 1 lactulose (ENULOSE) TIER 1 lactulose (GENERLAC) TIER 1 lactulose 10 g packet TIER 4 PA, QLC (1 pack/day) lactulose 10 g/15 ml, 20 g/30 ml TIER 1 MOVIPREP (peg 3350/sodium sulfate/sod TIER 3 PA, ACA (Preventive Health) chloride/kcl/ascorbate sod/vit c) NULYTELY WITH FLAVOR PACKS (sodium TIER 3 ACA (Preventive Health) chloride/sodium bicarbonate/potassium chloride/peg) OSMOPREP (sodium TIER 3 PA, ACA (Preventive Health) phosphate,monobasic/sodium phosphate,dibasic) peg 3350/sod sulf/sod bicarb/sod TIER 1 ACA (Preventive Health) chloride/potassium chloride peg 3350/sod sulf/sod bicarb/sod TIER 1 ACA (Preventive Health) chloride/potassium chloride (GAVILYTE-C) peg 3350/sod sulf/sod bicarb/sod TIER 1 ACA (Preventive Health) chloride/potassium chloride (GAVILYTE-G) PLENVU (peg 3350/sodium sulfate/sod TIER 3 PA chloride/kcl/ascorbate sod/vit c) PREPOPIK (sodium TIER 3 PA, ACA (Preventive Health) picosulfate/magnesium oxide/citric acid) sodium chloride/sodium TIER 1 ACA (Preventive Health) bicarbonate/potassium chloride/peg sodium chloride/sodium TIER 1 ACA (Preventive Health) bicarbonate/potassium chloride/peg (GAVILYTE-N) sodium chloride/sodium TIER 1 ACA (Preventive Health) bicarbonate/potassium chloride/peg (TRILYTE WITH FLAVOR PACKETS)

126 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS SUPREP (sodium sulfate/potassium TIER 2 ACA (Preventive Health) sulfate/magnesium sulfate) PROTECTANTS CARAFATE (sucralfate) 1 GM TABLET TIER 3 CARAFATE (sucralfate) 1 GM/10 ML SUSP TIER 2 CYTOTEC (misoprostol) TIER 3 misoprostol TIER 1 sucralfate TIER 1 PROTON PUMP INHIBITORS ACIPHEX (rabeprazole sodium) TIER 3 ACIPHEX SPRINKLE (rabeprazole sodium) TIER 3 ST, QLC (1 cap/day) DEXILANT (dexlansoprazole) TIER 2 ST, QLC (1 cap/day) esomeprazole magnesium 40 mg capsule TIER 1 PA dr esomeprazole strontium 24.65 mg capsule TIER 3 ST, QLC (1 cap/day) dr esomeprazole strontium 49.3 mg capsule TIER 3 ST, QLC (6 caps/day) dr lansoprazole 15 mg tab dr, 30 mg tab dr TIER 1 ST lansoprazole 30 mg capsule dr TIER 1 NEXIUM (esomeprazole magnesium) DR TIER 3 ST, QLC (1 packet/day) 10 MG PACKET, DR 20 MG PACKET, DR 40 MG PACKET NEXIUM (esomeprazole magnesium) DR TIER 3 PA, QLC (1 packet/day) 2.5 MG PACKET, DR 5 MG PACKET NEXIUM (esomeprazole magnesium) DR TIER 3 PA 40 MG CAPSULE omeprazole 10 mg capsule dr, 20 mg TIER 1 capsule dr, 40 mg capsule dr omeprazole/sodium bicarbonate TIER 4 PA (OMEPPI) 40mg-1.1g capsule omeprazole/sodium bicarbonate 20- TIER 4 PA, QLC (2 packs/day) 1680mg packet omeprazole/sodium bicarbonate 40- TIER 4 PA, QLC (1 pack/day) 1680mg packet

127 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS omeprazole/sodium bicarbonate 40mg- TIER 4 PA, QLC (1 cap/day) 1.1g capsule pantoprazole sodium 20 mg tablet dr, 40 TIER 1 mg tablet dr PREVACID (lansoprazole) 15 MG, 30 MG TIER 3 ST PREVACID (lansoprazole) DR 30 MG TIER 3 CAPSULE PRILOSEC (omeprazole magnesium) DR TIER 3 QLC (2 packs/day) 10 MG SUSPENSION PRILOSEC (omeprazole magnesium) DR TIER 3 QLC (3 packs/day) 2.5 MG SUSPENSION PROTONIX (pantoprazole sodium) 40 MG TIER 2 SUSPENSION PROTONIX (pantoprazole sodium) DR 20 TIER 3 MG TABLET, DR 40 MG TABLET rabeprazole sodium 10 mg cap dr spr TIER 3 ST, QLC (1 cap/day) rabeprazole sodium 20 mg tablet dr TIER 1 ZEGERID (omeprazole/sodium TIER 4 PA, QLC (2 packs/day) bicarbonate) 20 MG PACKET ZEGERID (omeprazole/sodium TIER 4 PA, QLC (1 cap/day) bicarbonate) 40 MG CAPSULE ZEGERID (omeprazole/sodium TIER 4 PA, QLC (1 pack/day) bicarbonate) 40 MG PACKET

GENETIC OR ENZYME DISORDER: REPLACEMENT, MODIFIERS, TREATMENT (Drugs for Genetic or Enzyme Disorders) GENETIC OR ENZYME DISORDER: REPLACEMENT, MODIFIERS, TREATMENT BUPHENYL (sodium phenylbutyrate) 500 TIER 4 PA, SP, QLC (40 tabs/day) MG TABLET BUPHENYL (sodium phenylbutyrate) TIER 4 PA, SP, QLC (20 gm/day) POWDER CARBAGLU (carglumic acid) TIER 4 PA, SP, QLC (35 tabs/day) CERDELGA (eliglustat tartrate) TIER 4 PA, SP, QLC (2 caps/day) CREON (lipase/protease/amylase) TIER 2 CYSTADANE (betaine) TIER 3 SP

128 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS GALAFOLD (migalastat hcl) TIER 4 PA, SP, QLC (14 caps/28 days) KUVAN (sapropterin dihydrochloride) 100 TIER 4 PA, SP, QLC (14 packs/day) MG POWDER PACKET KUVAN (sapropterin dihydrochloride) 100 TIER 4 PA, SP, QLC (14 tabs/day) MG TABLET KUVAN (sapropterin dihydrochloride) 500 TIER 4 PA, SP, QLC (3 packets/day) MG POWDER PACKET miglustat TIER 4 PA, SP, QLC (3 caps/day) NITYR (nitisinone) 10 MG TABLET TIER 4 PA, SP, QLC (14 tabs/day) NITYR (nitisinone) 2 MG TABLET TIER 4 PA, SP, QLC (70 tabs/day) NITYR (nitisinone) 5 MG TABLET TIER 4 PA, SP, QLC (28 tabs/day) ORFADIN (nitisinone) 10 MG CAPSULE TIER 4 PA, SP, QLC (14 caps/day) ORFADIN (nitisinone) 2 MG CAPSULE TIER 4 PA, SP, QLC (10 caps/day) ORFADIN (nitisinone) 20 MG CAPSULE TIER 4 PA, SP, QLC (8 caps/day) ORFADIN (nitisinone) 4 MG/ML TIER 4 PA, SP, QLC (35 ml/day) SUSPENSION ORFADIN (nitisinone) 5 MG CAPSULE TIER 4 PA, SP, QLC (2 caps/day) PALYNZIQ (pegvaliase-pqpz) 10 MG/0.5 TIER 4 PA, SP, QLC (1 syringe/day) ML SYRINGE - PALYNZIQ (pegvaliase-pqpz) 2.5 MG/0.5 TIER 4 PA, SP, QLC (4 syringes/28 days) ML SYRINGE - PALYNZIQ (pegvaliase-pqpz) 20 MG/ML TIER 4 PA, SP, QLC (2 syringes/day) SYRINGE - PANCREAZE (lipase/protease/amylase) TIER 3 PERTZYE (lipase/protease/amylase) TIER 3 PROCYSBI (cysteamine bitartrate) DR 25 TIER 4 PA, SP, QLC (4 caps/day) MG CAPSULE PROCYSBI (cysteamine bitartrate) DR 75 TIER 4 PA, SP, QLC (26 caps/day) MG CAPSULE RAVICTI (glycerol phenylbutyrate) TIER 4 PA, SP, QLC (17.5 ml/day) sodium phenylbutyrate 0.94 g/g powder TIER 4 PA, SP, QLC (20 gm/day) sodium phenylbutyrate 500 mg tablet TIER 4 PA, SP, QLC (40 tabs/day) STRENSIQ (asfotase alfa) TIER 4 PA, SP, QLC (24 vials/28 days) SUCRAID (sacrosidase) TIER 4 PA, SP, QLC (12 ml/day) VIOKACE (lipase/protease/amylase) TIER 3

129 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS ZAVESCA (miglustat) TIER 4 PA, SP, QLC (3 caps/day) ZENPEP (lipase/protease/amylase) TIER 2

GENITOURINARY AGENTS (Drugs for the Genital, Bladder, and Kidney) ANTISPASMODICS, URINARY (Drugs for Bladder Spasms) darifenacin hydrobromide 15 mg tab er TIER 1 ST, QLC (1 tab/day) 24h darifenacin hydrobromide 7.5 mg tab er TIER 1 ST, QLC (2 tabs/day) 24h DETROL (tolterodine tartrate) TIER 3 ST, QLC (2 tabs/day) DETROL LA (tolterodine tartrate) TIER 3 ST, QLC (1 tab/day) DITROPAN XL (oxybutynin chloride) 10 MG TIER 3 QLC (3 tabs/day) TABLET DITROPAN XL (oxybutynin chloride) 15 MG TIER 3 QLC (2 tabs/day) TABLET DITROPAN XL (oxybutynin chloride) 5 MG TIER 3 QLC (1 tab/day) TABLET ENABLEX (darifenacin hydrobromide) 15 TIER 3 ST, QLC (1 tab/day) MG TABLET ENABLEX (darifenacin hydrobromide) 7.5 TIER 3 ST, QLC (2 tabs/day) MG TABLET flavoxate hcl TIER 1 GELNIQUE (oxybutynin chloride) 10% GEL TIER 3 ST, QLC (1 pack/day) SACHET, 10% GEL SACHETS GELNIQUE (oxybutynin chloride) 10% TIER 3 ST, QLC (one 30 gm gel PUMP pump/month) MYRBETRIQ (mirabegron) TIER 2 ST, QLC (1 tab/day) oxybutynin chloride 10 mg tab er 24 TIER 1 QLC (3 tabs/day) oxybutynin chloride 15 mg tab er 24 TIER 1 QLC (2 tabs/day) oxybutynin chloride 5 mg tab er 24 TIER 1 QLC (1 tab/day) oxybutynin chloride 5 mg/5 ml syrup, 5 mg TIER 1 tablet OXYTROL (oxybutynin) TIER 3 ST, QLC (8 patches/month) solifenacin succinate TIER 1 ST, QLC (1 tab/day)

130 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS tolterodine tartrate 1 mg tablet, 2 mg TIER 1 ST, QLC (2 tabs/day) tablet tolterodine tartrate 2 mg cap er, 4 mg TIER 1 ST, QLC (1 tab/day) cap er TOVIAZ (fesoterodine fumarate) TIER 3 ST, QLC (1 tab/day) trospium chloride 20 mg tablet TIER 1 QLC (2 tabs/day) trospium chloride 60 mg cap er 24h TIER 1 QLC (1 cap/day) VESICARE (solifenacin succinate) TIER 3 ST, QLC (1 tab/day) BENIGN PROSTATIC HYPERTROPHY AGENTS alfuzosin hcl TIER 1 AVODART (dutasteride) TIER 3 QLC (1 cap/day) CARDURA XL (doxazosin mesylate) TIER 3 ST, QLC (1 tab/day) CIALIS (tadalafil) 2.5 MG TABLET, 5 MG TIER 3 PA, GL (Male), RO (Retail Only), TABLET QLC (6 tabs/month) dutasteride TIER 1 QLC (1 cap/day) dutasteride/tamsulosin hcl TIER 1 PA, QLC (1 cap/day) finasteride 5 mg tablet TIER 1 FLOMAX (tamsulosin hcl) TIER 3 JALYN (dutasteride/tamsulosin hcl) TIER 3 PA, QLC (1 cap/day) PROSCAR (finasteride) TIER 3 RAPAFLO (silodosin) TIER 3 ST, QLC (1 cap/day) silodosin TIER 1 ST, QLC (1 cap/day) tadalafil 2.5 mg tablet, 5 mg tablet TIER 1 PA, GL (Male), RO (Retail Only), QLC (6 tabs/month) tamsulosin hcl TIER 1 UROXATRAL (alfuzosin hcl) TIER 3 GENITOURINARY AGENTS, OTHER (Other Drugs for the Genital, Bladder, and Kidney) ADDYI (flibanserin) TIER 3 PA, GL (Female), QLC (1 tab/day) bethanechol chloride TIER 1 CAVERJECT (alprostadil) IMPULSE 10 MCG TIER 3 PA, GL (Male), QLC (6 KIT, 20 MCG VIAL, IMPULSE 20 MCG KIT, 40 injections/month) MCG VIAL

131 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS CIALIS (tadalafil) 10 MG TABLET, 20 MG TIER 3 PA, GL (Male), RO (Retail Only), TABLET QLC (6 tabs/month) citric acid/sodium citrate TIER 1 citric acid/sodium citrate (CYTRA-2) TIER 1 citric acid/sodium citrate (VIRTRATE-2) TIER 1 CUPRIMINE (penicillamine) TIER 4 PA, QLC (16 caps/day) CYSTAGON (cysteamine bitartrate) 150 TIER 4 PA, SP, QLC (26 caps/day) MG CAPSULE CYSTAGON (cysteamine bitartrate) 50 TIER 4 PA, SP, QLC (4 caps/day) MG CAPSULE D-PENAMINE (penicillamine) TIER 4 PA, QLC (32 tabs/day) DEPEN (penicillamine) TIER 4 PA, QLC (16 tabs/day) EDEX (alprostadil) TIER 3 PA, GL (Male), QLC (6 injections/month) ELMIRON (pentosan polysulfate sodium) TIER 2 K-PHOS NEUTRAL (sodium TIER 3 phosphate,dibasic/pot phos,monob/sod phosphate mono) K-PHOS NO.2 (sodium TIER 3 phosphate,monobasic/potassium phosphate,monobasic) K-PHOS ORIGINAL (potassium TIER 3 phosphate,monobasic) LEVITRA (vardenafil hcl) TIER 3 PA, GL (Male), RO (Retail Only), QLC (6 tabs/month) LITHOSTAT (acetohydroxamic acid) TIER 3 MUSE (alprostadil) TIER 2 PA, GL (Male), QLC (6 suppositories/month) ORACIT (citric acid/sodium citrate) TIER 3 penicillamine TIER 4 PA, QLC (16 caps/day) phenazopyridine hcl TIER 1 potassium citrate TIER 1 potassium citrate/citric acid TIER 1 potassium citrate/citric acid (CYTRA-K) TIER 1 potassium citrate/citric acid (VIRTRATE-K) TIER 1 PYRIDIUM (phenazopyridine hcl) TIER 3

132 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS RENACIDIN (citric TIER 3 PA, QLC (180 ml/day) acid/gluconolactone/magnesium carbonate) sildenafil citrate 25 mg tablet, 50 mg TIER 1 PA, GL (Male), RO (Retail Only), tablet, 100 mg tablet QLC (6 tabs/month) sodium phosphate,dibasic/pot TIER 1 phos,monob/sod phosphate mono (PHOSPHA 250 NEUTRAL) sodium phosphate,dibasic/pot TIER 1 phos,monob/sod phosphate mono (VIRT- PHOS 250 NEUTRAL) sodium/potassium/potassium TIER 1 citrate/sodium citrate/cit ac sodium/potassium/potassium TIER 1 citrate/sodium citrate/cit ac (CYTRA-3) sodium/potassium/potassium TIER 1 citrate/sodium citrate/cit ac (TRICITRATES) sodium/potassium/potassium TIER 1 citrate/sodium citrate/cit ac (VIRTRATE-3) STAXYN (vardenafil hcl) TIER 3 PA, GL (Male), RO (Retail Only), QLC (6 tabs/month) STENDRA (avanafil) TIER 3 PA, GL (Male), RO (Retail Only), QLC (6 tabs/month) tadalafil 10 mg tablet TIER 1 PA, GL (Male), RO (Retail Only), QLC (6 tabs/month) tadalafil 20 mg tablet TIER 1 PA, GL (Male), RO (Retail Only), SP, QLC (2 tabs/day) THIOLA (tiopronin) TIER 4 PA, SP THIOLA EC (tiopronin) TIER 4 PA, SP URECHOLINE (bethanechol chloride) TIER 3 UROCIT-K (potassium citrate) TIER 3 UROQID-ACID NO.2 (methenamine TIER 3 mandelate/sodium phosphate,monobasic) vardenafil hcl TIER 1 PA, GL (Male), RO (Retail Only), QLC (6 tabs/month) VIAGRA (sildenafil citrate) TIER 3 PA, GL (Male), RO (Retail Only), QLC (6 tabs/month) VYLEESI (bremelanotide acetate) TIER 4 PA, SP, GL (Female), QLC (8 doses/30 days)

133 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS PHOSPHATE BINDERS (Drugs to Lower Phosphate) AURYXIA (ferric citrate) TIER 3 calcium acetate 667 mg capsule TIER 1 FOSRENOL (lanthanum carbonate) TIER 3 lanthanum carbonate TIER 1 PHOSLYRA (calcium acetate) TIER 3 RENAGEL (sevelamer hcl) TIER 3 RENVELA (sevelamer carbonate) TIER 3 sevelamer carbonate TIER 1 sevelamer hcl TIER 1 VELPHORO (sucroferric oxyhydroxide) TIER 3

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (ADRENAL) (Drugs for Replacing/Stimulating Adrenal Gland Hormones) HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (ADRENAL) (Glucocorticoids) ALA-SCALP (hydrocortisone) TIER 3 ST alclometasone dipropionate TIER 1 amcinonide TIER 3 ST betamethasone dipropionate TIER 1 betamethasone dipropionate/propylene TIER 1 glycol betamethasone valerate 0.1 % lotion, 0.1 TIER 1 % cream (g), 0.1 % oint. (g) betamethasone valerate 0.12 % foam TIER 3 ST BRYHALI (halobetasol propionate) TIER 3 PA, QLC (200 gm/28 days) CAPEX SHAMPOO (fluocinolone TIER 3 PA acetonide) clobetasol propionate (CLODAN) TIER 1 ST clobetasol propionate (CORMAX) TIER 1 clobetasol propionate 0.05 % foam TIER 1 PA

134 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS clobetasol propionate 0.05 % gel (gram), TIER 1 0.05 % solution, 0.05 % cream (g), 0.05 % oint. (g) clobetasol propionate 0.05 % shampoo, TIER 1 ST 0.05 % lotion clobetasol propionate 0.05 % spray TIER 3 ST, QLC (125 ml/month) clobetasol propionate/emollient base TIER 1 0.05 % cream (g) clobetasol propionate/emollient base TIER 1 PA 0.05 % foam CLOBEX (clobetasol propionate) 0.05% TIER 3 ST SHAMPOO, 0.05% TOPICAL LOTION CLOBEX (clobetasol propionate) 0.05% TIER 3 ST, QLC (125 ml/month) SPRAY clocortolone pivalate TIER 3 ST CLODERM (clocortolone pivalate) TIER 3 ST CORDRAN (flurandrenolide) TIER 3 PA CORTEF (hydrocortisone) TIER 3 cortisone acetate TIER 1 CUTIVATE (fluticasone propionate) 0.05% TIER 3 CREAM CUTIVATE (fluticasone propionate) 0.05% TIER 3 ST LOTION DELTASONE (prednisone) TIER 3 DERMA-SMOOTHE-FS (fluocinolone TIER 3 acetonide) DERMA-SMOOTHE-FS (fluocinolone TIER 3 acetonide/shower cap) DERMATOP (prednicarbate) TIER 3 DESONATE (desonide) TIER 3 PA desonide 0.05 % lotion TIER 1 ST desonide 0.05 % oint. (g), 0.05 % cream TIER 1 (g) DESOWEN (desonide) 0.05% CREAM TIER 3 DESOWEN (desonide) 0.05% LOTION TIER 3 ST

135 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS desoximetasone 0.05 % oint. (g), 0.05 % TIER 1 ST gel (gram), 0.05 % cream (g), 0.25 % cream (g), 0.25 % oint. (g) desoximetasone 0.25 % spray TIER 1 ST, QLC (1 bottle/month) dexamethasone (21) tab, (35) tab, (51) TIER 3 PA tab dexamethasone (DECADRON) TIER 1 dexamethasone (DEXAMETHASONE TIER 1 INTENSOL) dexamethasone (HIDEX) TIER 3 PA dexamethasone (LOCORT) 1.5mg (27) TIER 1 PA tab ds pk dexamethasone (LOCORT) 1.5mg (41) TIER 1 PA, QLC (1 pack/month) tab ds pk dexamethasone (TAPERDEX) (21) tab, (27) TIER 3 PA tab dexamethasone (TAPERDEX) 1.5 mg(49) TIER 1 PA tab ds pk dexamethasone (ZODEX) TIER 3 PA dexamethasone 0.5 mg/5ml solution, 0.5 TIER 1 mg tablet, 0.5 mg/5ml elixir, 0.75 mg tablet, 1 mg tablet, 1.5 mg tablet, 2 mg tablet, 4 mg tablet, 6 mg tablet DEXPAK (dexamethasone) TIER 3 PA diflorasone diacetate TIER 3 ST diflorasone diacetate (PSORCON) TIER 3 ST diflorasone diacetate/emollient base TIER 3 ST (APEXICON E) DIPROLENE (betamethasone TIER 3 dipropionate/propylene glycol) DIPROLENE AF (betamethasone TIER 3 dipropionate/propylene glycol) DXEVO (dexamethasone) TIER 3 PA ELOCON (mometasone furoate) TIER 3 EMFLAZA (deflazacort) 18 MG TABLET TIER 4 PA, SP, QLC (1 tab/day) EMFLAZA (deflazacort) 22.75 MG/ML TIER 4 PA, SP, QLC (6 bottles/month) ORAL SUSP

136 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS EMFLAZA (deflazacort) 6 MG TABLET, 30 TIER 4 PA, SP, QLC (2 tabs/day) MG TABLET, 36 MG TABLET fludrocortisone acetate TIER 1 fluocinolone acetonide TIER 1 fluocinolone acetonide/shower cap TIER 1 fluocinonide 0.05 % cream (g), 0.05 % oint. TIER 1 (g), 0.05 % gel (gram), 0.05 % solution fluocinonide 0.1 % cream (g) TIER 1 PA fluocinonide/emollient base TIER 1 flurandrenolide (NOLIX) 0.05 % cream (g) TIER 3 PA flurandrenolide (NOLIX) 0.05 % lotion TIER 1 PA flurandrenolide 0.05 % cream (g) TIER 3 PA flurandrenolide 0.05 % oint. (g), 0.05 % TIER 1 PA lotion fluticasone propionate (BESER) TIER 3 ST fluticasone propionate 0.005 % oint. (g), TIER 1 0.05 % cream (g) fluticasone propionate 0.05 % lotion TIER 3 ST halcinonide TIER 2 PA halobetasol propionate 0.05 % cream (g), TIER 1 0.05 % oint. (g) halobetasol propionate 0.05 % foam TIER 3 PA, QLC (50 grams/week) HALOG (halcinonide) 0.1% CREAM TIER 3 PA HALOG (halcinonide) 0.1% OINTMENT TIER 3 hydrocortisone (ALA-CORT) TIER 1 hydrocortisone (ANUSOL-HC) TIER 1 hydrocortisone (PROCTO-MED HC) TIER 1 hydrocortisone (PROCTO-PAK) TIER 1 hydrocortisone (PROCTOSOL-HC) TIER 1 hydrocortisone (PROCTOZONE-HC) TIER 1 hydrocortisone (SCALACORT) TIER 1 ST

137 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS hydrocortisone 1 % crm/pe app, 2.5 % TIER 1 cream (g), 2.5 % crm/pe app, 2.5 % oint. (g), 2.5 % lotion, 5 mg tablet, 10 mg tablet, 20 mg tablet hydrocortisone acetate (ANUCORT-HC) TIER 1 hydrocortisone acetate (ANUSOL-HC) TIER 1 hydrocortisone acetate (HEMMOREX-HC) TIER 1 25 mg supp.rect - hydrocortisone acetate 25 mg supp.rect TIER 1 hydrocortisone acetate/urea (U-CORT) TIER 1 hydrocortisone butyrate 0.1 % cream (g), TIER 1 0.1 % solution, 0.1 % oint. (g) hydrocortisone butyrate 0.1 % lotion TIER 3 ST hydrocortisone butyrate/emollient base TIER 3 ST hydrocortisone valerate TIER 1 hydrocortisone/mineral TIER 4 PA, QLC (110 gm/month) oil/petrolatum,white IMPOYZ (clobetasol propionate) TIER 3 PA, QLC (1 tube/month) KENALOG (triamcinolone acetonide) TIER 3 ST KORLYM (mifepristone) TIER 4 PA, SP, QLC (4 tabs/day) LEXETTE (halobetasol propionate) TIER 3 PA, QLC (200 gm/28 days) LOCOID (hydrocortisone butyrate) 0.1% TIER 3 ST LOTION LOCOID (hydrocortisone butyrate) 0.1% TIER 3 SOLUTION, 0.1% OINTMENT, 0.1% CREAM LOCOID LIPOCREAM (hydrocortisone TIER 3 ST butyrate/emollient base) LUXIQ (betamethasone valerate) TIER 3 ST MEDROL (methylprednisolone) 2 MG TIER 2 TABLET MEDROL (methylprednisolone) 4 MG TIER 3 TABLET, 4 MG DOSEPAK, 8 MG TABLET, 16 MG TABLET, 32 MG TABLET methylprednisolone TIER 1 MICORT-HC (hydrocortisone acetate) TIER 3 PA, QLC (56 tubes/month) MILLIPRED (prednisolone sodium TIER 3 phosphate)

138 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS mometasone furoate 0.1 % cream (g), 0.1 TIER 1 % oint. (g), 0.1 % solution OLUX (clobetasol propionate) TIER 3 PA OLUX-E (clobetasol propionate/emollient TIER 3 PA base) ORAPRED ODT (prednisolone sodium TIER 3 phosphate) PANDEL (hydrocortisone probutate) TIER 3 PA prednicarbate TIER 1 prednisolone TIER 1 prednisolone (MILLIPRED DP) TIER 1 prednisolone (MILLIPRED) TIER 1 prednisolone sodium phosphate TIER 3 (PEDIAPRED) prednisolone sodium phosphate 5 mg/5 TIER 1 ml solution, 10 mg/5 ml solution, 10 mg tab rapdis, 15 mg/5 ml solution, 15 mg tab rapdis, 20 mg/5 ml solution, 25 mg/5 ml solution, 30 mg tab rapdis prednisone TIER 1 prednisone (PREDNISONE INTENSOL) TIER 1 RAYOS (prednisone) DR 1 MG TABLET TIER 3 PA, QLC (3 tabs/day) RAYOS (prednisone) DR 2 MG TABLET TIER 3 PA, QLC (2 tabs/day) RAYOS (prednisone) DR 5 MG TABLET TIER 3 PA, QLC (12 tabs/day) SERNIVO (betamethasone dipropionate) TIER 3 PA, QLC (1 bottle/month) SYNALAR (fluocinolone acetonide) TIER 3 TEMOVATE (clobetasol propionate) TIER 3 TEXACORT (hydrocortisone) TIER 3 TOPICORT (desoximetasone) 0.05% GEL, TIER 3 ST 0.05% OINTMENT, 0.05% CREAM, 0.25% CREAM, 0.25% OINTMENT TOPICORT (desoximetasone) 0.25% SPRAY TIER 3 ST, QLC (1 bottle/month) triamcinolone acetonide (TRIANEX) TIER 3 ST triamcinolone acetonide (TRIDERM) TIER 1

139 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS triamcinolone acetonide 0.025 % oint. (g), TIER 1 0.025 % cream (g), 0.025 % lotion, 0.1 % cream (g), 0.1 % lotion, 0.1 % oint. (g), 0.5 % cream (g), 0.5 % oint. (g) triamcinolone acetonide 0.147mg/g TIER 1 ST aerosol ULTRAVATE (halobetasol propionate) TIER 3 0.05% CREAM, 0.05% OINTMENT ULTRAVATE (halobetasol propionate) TIER 3 ST, QLC (1 bottle/month) 0.05% LOTION VANOS (fluocinonide) TIER 3 PA VERDESO (desonide) TIER 3 PA VERIPRED 20 (prednisolone sodium TIER 3 phosphate) ZONACORT (dexamethasone) 11 DAY 1.5 TIER 3 PA, QLC (1 pack/month) MG TABLET ZONACORT (dexamethasone) 7 DAY 1.5 TIER 3 PA MG TABLET

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY) (Drugs for Replacing/Stimulating Pituitary Gland Hormones) HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY) (Drugs to Replace/Stimulate Pituitary Gland Hormones) ACTHAR (corticotropin) TIER 4 PA, SP DDAVP (desmopressin acetate (non- TIER 3 refrigerated)) DDAVP (desmopressin acetate) 0.1 MG TIER 3 TABLET, 0.2 MG TABLET, 10 MCG/0.1 ML SOLUTION desmopressin acetate (non-refrigerated) TIER 1 desmopressin acetate 0.1 mg/ml solution, TIER 1 0.1 mg tablet, 0.2 mg tablet, 10/spray spray/pump GENOTROPIN (somatropin) TIER 4 PA, SP HUMATROPE (somatropin) TIER 4 PA, SP INCRELEX (mecasermin) TIER 4 PA, SP

140 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS NOCDURNA (desmopressin acetate) 27.7 TIER 3 PA, QLC (1 tab/day) MCG TABLET SL NOCDURNA (desmopressin acetate) 55.3 TIER 3 PA, QLC (1 tab/day) MCG TABLET SL NOCTIVA (desmopressin acetate) TIER 3 PA, QLC (1 bottle/month) NORDITROPIN FLEXPRO (somatropin) TIER 4 PA, SP NUTROPIN AQ NUSPIN (somatropin) TIER 4 PA, SP OMNITROPE (somatropin) TIER 4 PA, SP SAIZEN (somatropin) TIER 4 PA, SP SAIZEN-SAIZENPREP (somatropin) TIER 4 PA, SP SEROSTIM (somatropin) TIER 4 PA, SP STIMATE (desmopressin acetate) TIER 4 SP, QLC (2.5 ml/month) ZOMACTON (somatropin) TIER 4 PA, SP ZORBTIVE (somatropin) TIER 4 PA, SP

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX HORMONES/MODIFIERS) (Drugs for Replacing/Stimulating Sex Hormones) ANABOLIC STEROIDS ANADROL-50 (oxymetholone) TIER 3 PA OXANDRIN (oxandrolone) TIER 3 PA oxandrolone TIER 1 PA ANDROGENS ANDRODERM (testosterone) TIER 3 PA, QLC (1 patch/day) ANDROGEL (testosterone) 1% PUMP TIER 3 PA, QLC (300 grams/month) ANDROGEL (testosterone) 1%(5G) GEL TIER 3 PA, QLC (300 grams/month) PACKET, 1%(2.5G) GEL PACKET ANDROGEL (testosterone) 1.62% PUMP TIER 3 PA, QLC (2 bottles/month) ANDROGEL (testosterone) 1.62%(1.25G) TIER 3 PA, QLC (1 packet/day) PCKT ANDROGEL (testosterone) 1.62%(2.5G) TIER 3 PA, QLC (2 packets/day) PCKT ANDROID (methyltestosterone) TIER 2 PA

141 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS AXIRON (testosterone) TIER 3 PA, QLC (2 bottles/month) danazol TIER 1 DEPO-TESTOSTERONE (testosterone TIER 3 QLC (10 ml/month) cypionate) fluoxymesterone (ANDROXY) TIER 1 PA, QLC (4 tabs/day) FORTESTA (testosterone) TIER 3 PA, QLC (2 bottles/month) METHITEST (methyltestosterone) TIER 2 PA methyltestosterone TIER 1 PA NATESTO (testosterone) TIER 3 PA, QLC (3 bottles/month) STRIANT (testosterone) TIER 3 PA, QLC (2 tabs/day) TESTIM (testosterone) TIER 3 PA, QLC (10 grams/day) testosterone 1.25g-1.62 gel packet TIER 1 PA, QLC (1 packet/day) testosterone 10 mg (2%) gel, 30mg/1.5ml TIER 1 PA, QLC (2 bottles/month) sol testosterone 12.5/1.25g gel md pmp, TIER 1 PA, QLC (300 grams/month) 25mg(1%) gel packet, 50 mg (1%) gel packet testosterone 2.5g-1.62% gel packet TIER 1 PA, QLC (2 packets/day) testosterone 20.25/1.25 gel md pmp TIER 1 PA, QLC (2 bottles/month) testosterone 50 mg (1%) gel (gram) TIER 1 PA, QLC (10 grams/day) testosterone cypionate TIER 1 QLC (10 ml/month) testosterone enanthate TIER 1 QLC (5 ml/month) TESTRED (methyltestosterone) TIER 3 PA VOGELXO (testosterone) 12.5 MG/1.25 TIER 3 PA, QLC (300 grams/month) PUMP, 50 MG/5 GEL PACKT VOGELXO (testosterone) 50 MG/5 GRAM TIER 3 PA, QLC (10 grams/day) XYOSTED (testosterone enanthate) TIER 3 PA, QLC (1 injection/week) ESTROGENS (Contraceptives and Drugs for Menopause) ACTIVELLA (estradiol/norethindrone TIER 3 QLC (1 tab/day) acetate) ALORA (estradiol) TIER 3 QLC (16 patches/28 days) ANGELIQ (drospirenone/estradiol) TIER 3 QLC (1 tab/day) ANNOVERA (segesterone acetate/ethinyl TIER 3 PA, QLC (1 ring/364 days) estradiol)

142 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS BALCOLTRA (levonorgestrel/ethinyl TIER 3 PA estradiol/ferrous bisglycinate) BEYAZ (drospirenone/ethinyl TIER 3 estradiol/levomefolate calcium) BIJUVA (estradiol/progesterone) TIER 3 QLC (1 cap/day) BREVICON (norethindrone-ethinyl TIER 3 estradiol) CLIMARA (estradiol) TIER 3 QLC (8 patches/28 days) CLIMARA PRO (estradiol/levonorgestrel) TIER 2 QLC (4 patches/month) COMBIPATCH (estradiol/norethindrone TIER 3 QLC (8 patches/month) acetate) CYCLESSA (desogestrel-ethinyl estradiol) TIER 3 DELESTROGEN (estradiol valerate) TIER 3 DEPO-ESTRADIOL (estradiol cypionate) TIER 3 desogestrel-ethinyl estradiol TIER 1 ACA (Preventive Health) desogestrel-ethinyl estradiol (APRI) TIER 1 ACA (Preventive Health) desogestrel-ethinyl estradiol (CAZIANT) TIER 1 ACA (Preventive Health) desogestrel-ethinyl estradiol (CYRED EQ) TIER 1 ACA (Preventive Health) desogestrel-ethinyl estradiol (CYRED) TIER 1 ACA (Preventive Health) desogestrel-ethinyl estradiol (EMOQUETTE) TIER 1 ACA (Preventive Health) desogestrel-ethinyl estradiol (ENSKYCE) TIER 1 ACA (Preventive Health) desogestrel-ethinyl estradiol (ISIBLOOM) TIER 1 ACA (Preventive Health) desogestrel-ethinyl estradiol (JULEBER) TIER 1 ACA (Preventive Health) desogestrel-ethinyl estradiol (KALLIGA) TIER 1 ACA (Preventive Health) desogestrel-ethinyl estradiol (RECLIPSEN) TIER 1 ACA (Preventive Health) desogestrel-ethinyl estradiol (VELIVET) TIER 1 ACA (Preventive Health) desogestrel-ethinyl estradiol/ethinyl TIER 1 ACA (Preventive Health) estradiol desogestrel-ethinyl estradiol/ethinyl TIER 1 ACA (Preventive Health) estradiol (AZURETTE) desogestrel-ethinyl estradiol/ethinyl TIER 1 ACA (Preventive Health) estradiol (BEKYREE) desogestrel-ethinyl estradiol/ethinyl TIER 1 ACA (Preventive Health) estradiol (KARIVA)

143 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS desogestrel-ethinyl estradiol/ethinyl TIER 1 ACA (Preventive Health) estradiol (KIMIDESS) desogestrel-ethinyl estradiol/ethinyl TIER 1 ACA (Preventive Health) estradiol (PIMTREA) desogestrel-ethinyl estradiol/ethinyl TIER 1 ACA (Preventive Health) estradiol (SIMLIYA) desogestrel-ethinyl estradiol/ethinyl TIER 1 ACA (Preventive Health) estradiol (VIORELE) DIVIGEL (estradiol) 0.25 MG GEL PACKET, TIER 3 QLC (1 pack/day) 0.5 MG GEL PACKET, 1 MG GEL PACKET DIVIGEL (estradiol) 0.75 MG PACKET TIER 3 QLC (1 pack/day) drospirenone/ethinyl TIER 1 ACA (Preventive Health) estradiol/levomefolate calcium drospirenone/ethinyl TIER 1 ACA (Preventive Health) estradiol/levomefolate calcium (RAJANI) drospirenone/ethinyl TIER 1 ACA (Preventive Health) estradiol/levomefolate calcium (TYDEMY) DUAVEE (estrogens, TIER 2 QLC (1 tab/day) conjugated/bazedoxifene acetate) ELESTRIN (estradiol) TIER 3 QLC (1 bottle/month) ESTRACE (estradiol) TIER 3 estradiol (DOTTI) TIER 1 QLC (16 patches/28 days) estradiol (YUVAFEM) TIER 1 estradiol .025mg/24h patch, .0375mg/24 TIER 1 QLC (16 patches/28 days) patch, 0.05mg/24h patch, .075mg/24h patch, 0.1mg/24hr patch estradiol .025mg/24h patch, .0375mg/24 TIER 1 QLC (8 patches/28 days) patch, 0.05mg/24h patch, 0.06mg/24h patch, .075mg/24h patch, 0.1mg/24hr patch estradiol 0.01 % cream/appl, 0.5 mg TIER 1 tablet, 1 mg tablet, 2 mg tablet, 10 mcg tablet estradiol valerate TIER 1 estradiol/norethindrone acetate TIER 1 QLC (1 tab/day) estradiol/norethindrone acetate TIER 1 QLC (1 tab/day) (AMABELZ) estradiol/norethindrone acetate TIER 1 QLC (1 tab/day) (LOPREEZA)

144 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS estradiol/norethindrone acetate (MIMVEY TIER 1 QLC (1 tab/day) LO) estradiol/norethindrone acetate TIER 1 QLC (1 tab/day) (MIMVEY) ESTRING (estradiol) TIER 2 ESTROGEL (estradiol) TIER 3 QLC (1 bottle/month) estrogens,esterified/methyltestosterone TIER 1 estrogens,esterified/methyltestosterone TIER 1 (COVARYX H.S.) estrogens,esterified/methyltestosterone TIER 1 (COVARYX) estrogens,esterified/methyltestosterone TIER 1 (EEMT H.S.) estrogens,esterified/methyltestosterone TIER 1 (EEMT) estropipate TIER 1 ESTROSTEP FE (norethindrone acetate- TIER 3 ethinyl estradiol/ferrous fumarate) ethinyl estradiol/drospirenone TIER 1 ACA (Preventive Health) ethinyl estradiol/drospirenone (GIANVI) TIER 1 ACA (Preventive Health) ethinyl estradiol/drospirenone (JASMIEL) TIER 1 ACA (Preventive Health) ethinyl estradiol/drospirenone (LO- TIER 1 ACA (Preventive Health) ZUMANDIMINE) ethinyl estradiol/drospirenone (LORYNA) TIER 1 ACA (Preventive Health) ethinyl estradiol/drospirenone (NIKKI) TIER 1 ACA (Preventive Health) ethinyl estradiol/drospirenone (OCELLA) TIER 1 ACA (Preventive Health) ethinyl estradiol/drospirenone (SYEDA) TIER 1 ACA (Preventive Health) ethinyl estradiol/drospirenone (VESTURA) TIER 1 ACA (Preventive Health) ethinyl estradiol/drospirenone (ZARAH) TIER 1 ACA (Preventive Health) ethinyl estradiol/drospirenone TIER 1 ACA (Preventive Health) (ZUMANDIMINE) ethynodiol diacetate-ethinyl estradiol TIER 1 ACA (Preventive Health) ethynodiol diacetate-ethinyl estradiol TIER 1 ACA (Preventive Health) (KELNOR 1-35) ethynodiol diacetate-ethinyl estradiol TIER 1 ACA (Preventive Health) (KELNOR 1-50)

145 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS ethynodiol diacetate-ethinyl estradiol TIER 1 ACA (Preventive Health) (ZOVIA 1-35E) ethynodiol diacetate-ethinyl estradiol TIER 1 ACA (Preventive Health) (ZOVIA 1-50E) EVAMIST (estradiol) TIER 3 QLC (2 bottles/month) FEMHRT (norethindrone acetate-ethinyl TIER 3 QLC (1 tab/day) estradiol) FEMRING (estradiol acetate) TIER 3 QLC (1 ring/3 months) GENERESS FE (norethindrone-ethinyl TIER 3 estradiol/ferrous fumarate) IMVEXXY (estradiol) 4 MCG PACK, 10 TIER 3 PA, QLC (18 inserts/28 days) MCG PACK IMVEXXY (estradiol) 4 MCG PACK, 10 TIER 3 PA, QLC (8 inserts/28 days) MCG PAK LAYOLIS FE (norethindrone-ethinyl TIER 3 estradiol/ferrous fumarate) levonorgestrel-ethinyl estradiol TIER 1 ACA (Preventive Health) (AFIRMELLE) levonorgestrel-ethinyl estradiol TIER 1 ACA (Preventive Health) (ALTAVERA) levonorgestrel-ethinyl estradiol TIER 1 ACA (Preventive Health), QLC (1 (AMETHYST) pack/month) levonorgestrel-ethinyl estradiol (AUBRA TIER 1 ACA (Preventive Health) EQ) levonorgestrel-ethinyl estradiol (AUBRA) TIER 1 ACA (Preventive Health) levonorgestrel-ethinyl estradiol (AVIANE) TIER 1 ACA (Preventive Health) levonorgestrel-ethinyl estradiol (AYUNA) TIER 1 ACA (Preventive Health) levonorgestrel-ethinyl estradiol (CHATEAL TIER 1 ACA (Preventive Health) EQ) levonorgestrel-ethinyl estradiol (CHATEAL) TIER 1 ACA (Preventive Health) levonorgestrel-ethinyl estradiol (DELYLA) TIER 1 ACA (Preventive Health) levonorgestrel-ethinyl estradiol (ENPRESSE) TIER 1 ACA (Preventive Health) levonorgestrel-ethinyl estradiol (FALMINA) TIER 1 ACA (Preventive Health) levonorgestrel-ethinyl estradiol TIER 1 ACA (Preventive Health) (INTROVALE) levonorgestrel-ethinyl estradiol (JOLESSA) TIER 1 ACA (Preventive Health)

146 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS levonorgestrel-ethinyl estradiol (KURVELO) TIER 1 ACA (Preventive Health) levonorgestrel-ethinyl estradiol (LARISSIA) TIER 1 ACA (Preventive Health) levonorgestrel-ethinyl estradiol (LESSINA) TIER 1 ACA (Preventive Health) levonorgestrel-ethinyl estradiol TIER 1 ACA (Preventive Health) (LEVONEST) levonorgestrel-ethinyl estradiol (LEVORA- TIER 1 ACA (Preventive Health) 28) levonorgestrel-ethinyl estradiol (LILLOW) TIER 1 ACA (Preventive Health) levonorgestrel-ethinyl estradiol (LUTERA) TIER 1 ACA (Preventive Health) levonorgestrel-ethinyl estradiol (MARLISSA) TIER 1 ACA (Preventive Health) levonorgestrel-ethinyl estradiol (MYZILRA) TIER 1 ACA (Preventive Health) levonorgestrel-ethinyl estradiol (ORSYTHIA) TIER 1 ACA (Preventive Health) levonorgestrel-ethinyl estradiol (PORTIA) TIER 1 ACA (Preventive Health) levonorgestrel-ethinyl estradiol TIER 1 ACA (Preventive Health) (QUASENSE) levonorgestrel-ethinyl estradiol (SETLAKIN) TIER 1 ACA (Preventive Health) levonorgestrel-ethinyl estradiol (SRONYX) TIER 1 ACA (Preventive Health) levonorgestrel-ethinyl estradiol (TRIVORA- TIER 1 ACA (Preventive Health) 28) levonorgestrel-ethinyl estradiol (VIENVA) TIER 1 ACA (Preventive Health) levonorgestrel-ethinyl estradiol -0.1- TIER 1 ACA (Preventive Health) 0.02mg tablet, -0.15-0.03 tbdspk 3mo, - 0.15-0.03 tablet, -6-5-10 tablet levonorgestrel-ethinyl estradiol -90-20 mcg TIER 1 ACA (Preventive Health), QLC (1 tablet pack/month) levonorgestrel/ethinyl estradiol and TIER 1 ACA (Preventive Health) ethinyl estradiol levonorgestrel/ethinyl estradiol and TIER 1 ACA (Preventive Health) ethinyl estradiol (AMETHIA LO) levonorgestrel/ethinyl estradiol and TIER 1 ACA (Preventive Health) ethinyl estradiol (AMETHIA) levonorgestrel/ethinyl estradiol and TIER 1 ACA (Preventive Health) ethinyl estradiol (ASHLYNA) levonorgestrel/ethinyl estradiol and TIER 1 ACA (Preventive Health) ethinyl estradiol (CAMRESE LO) levonorgestrel/ethinyl estradiol and TIER 1 ACA (Preventive Health) ethinyl estradiol (CAMRESE)

147 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS levonorgestrel/ethinyl estradiol and TIER 1 ACA (Preventive Health) ethinyl estradiol (DAYSEE) levonorgestrel/ethinyl estradiol and TIER 1 ACA (Preventive Health) ethinyl estradiol (FAYOSIM) levonorgestrel/ethinyl estradiol and TIER 1 ACA (Preventive Health) ethinyl estradiol (RIVELSA) levonorgestrel/ethinyl estradiol and TIER 1 ACA (Preventive Health) ethinyl estradiol (SIMPESSE) LO LOESTRIN FE (norethindrone acetate- TIER 3 ethinyl estradiol/ferrous fumarate) LO MINASTRIN FE (norethindrone acetate- TIER 3 ethinyl estradiol/ferrous fumarate) LOESTRIN (norethindrone acetate-ethinyl TIER 3 estradiol) LOESTRIN FE (norethindrone acetate- TIER 3 ethinyl estradiol/ferrous fumarate) LOSEASONIQUE (levonorgestrel/ethinyl TIER 3 estradiol and ethinyl estradiol) MENEST (estrogens,esterified) TIER 3 MENOSTAR (estradiol) TIER 3 MICROGESTIN 24 FE (norethindrone TIER 3 acetate-ethinyl estradiol/ferrous fumarate) MINASTRIN 24 FE (norethindrone acetate- TIER 3 ethinyl estradiol/ferrous fumarate) MINIVELLE (estradiol) TIER 3 QLC (16 patches/28 days) MIRCETTE (desogestrel-ethinyl TIER 3 estradiol/ethinyl estradiol) NATAZIA (estradiol valerate/dienogest) TIER 3 norelgestromin/ethinyl estradiol (XULANE) TIER 1 ACA (Preventive Health), QLC (3 patches/month) norethindrone acetate-ethinyl estradiol TIER 1 ACA (Preventive Health) (AUROVELA) norethindrone acetate-ethinyl estradiol TIER 1 QLC (1 tab/day) (FYAVOLV) norethindrone acetate-ethinyl estradiol TIER 1 ACA (Preventive Health) (GILDESS) norethindrone acetate-ethinyl estradiol TIER 1 ACA (Preventive Health) (HAILEY)

148 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS norethindrone acetate-ethinyl estradiol TIER 1 QLC (1 tab/day) (JEVANTIQUE LO) norethindrone acetate-ethinyl estradiol TIER 1 QLC (1 tab/day) (JINTELI) norethindrone acetate-ethinyl estradiol TIER 1 ACA (Preventive Health) (JUNEL) norethindrone acetate-ethinyl estradiol TIER 1 ACA (Preventive Health) (LARIN) norethindrone acetate-ethinyl estradiol TIER 1 ACA (Preventive Health) (MICROGESTIN) norethindrone acetate-ethinyl estradiol - TIER 1 QLC (1 tab/day) 0.5mg-2.5 tablet, -1mg-5mcg tablet norethindrone acetate-ethinyl estradiol - TIER 1 ACA (Preventive Health) 1mg-20mcg tablet norethindrone acetate-ethinyl TIER 1 ACA (Preventive Health) estradiol/ferrous fumarate norethindrone acetate-ethinyl TIER 1 ACA (Preventive Health) estradiol/ferrous fumarate (AUROVELA 24 FE) norethindrone acetate-ethinyl TIER 1 ACA (Preventive Health) estradiol/ferrous fumarate (AUROVELA FE) norethindrone acetate-ethinyl TIER 1 ACA (Preventive Health) estradiol/ferrous fumarate (BLISOVI 24 FE) norethindrone acetate-ethinyl TIER 1 ACA (Preventive Health) estradiol/ferrous fumarate (BLISOVI FE) norethindrone acetate-ethinyl TIER 1 ACA (Preventive Health) estradiol/ferrous fumarate (GILDESS 24 FE) norethindrone acetate-ethinyl TIER 1 ACA (Preventive Health) estradiol/ferrous fumarate (HAILEY 24 FE) norethindrone acetate-ethinyl TIER 1 ACA (Preventive Health) estradiol/ferrous fumarate (JUNEL FE 24) norethindrone acetate-ethinyl TIER 1 ACA (Preventive Health) estradiol/ferrous fumarate (JUNEL FE) norethindrone acetate-ethinyl TIER 1 ACA (Preventive Health) estradiol/ferrous fumarate (LARIN 24 FE) norethindrone acetate-ethinyl TIER 1 ACA (Preventive Health) estradiol/ferrous fumarate (LARIN FE) norethindrone acetate-ethinyl TIER 1 ACA (Preventive Health) estradiol/ferrous fumarate (LOMEDIA 24 FE)

149 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS norethindrone acetate-ethinyl TIER 1 ACA (Preventive Health) estradiol/ferrous fumarate (MELODETTA 24 FE) norethindrone acetate-ethinyl TIER 1 ACA (Preventive Health) estradiol/ferrous fumarate (MIBELAS 24 FE) norethindrone acetate-ethinyl TIER 1 ACA (Preventive Health) estradiol/ferrous fumarate (MICROGESTIN FE) norethindrone acetate-ethinyl TIER 1 ACA (Preventive Health) estradiol/ferrous fumarate (TARINA 24 FE) norethindrone acetate-ethinyl TIER 1 ACA (Preventive Health) estradiol/ferrous fumarate (TARINA FE 1-20 EQ) norethindrone acetate-ethinyl TIER 1 ACA (Preventive Health) estradiol/ferrous fumarate (TARINA FE) norethindrone acetate-ethinyl TIER 1 ACA (Preventive Health) estradiol/ferrous fumarate (TILIA FE) norethindrone acetate-ethinyl TIER 1 ACA (Preventive Health) estradiol/ferrous fumarate (TRI-LEGEST FE) norethindrone-ethinyl estradiol (ALYACEN) TIER 1 ACA (Preventive Health) norethindrone-ethinyl estradiol TIER 1 ACA (Preventive Health) (ARANELLE) norethindrone-ethinyl estradiol (BALZIVA) TIER 1 ACA (Preventive Health) norethindrone-ethinyl estradiol (BRIELLYN) TIER 1 ACA (Preventive Health) norethindrone-ethinyl estradiol TIER 1 ACA (Preventive Health) (CYCLAFEM) norethindrone-ethinyl estradiol (DASETTA) TIER 1 ACA (Preventive Health) norethindrone-ethinyl estradiol TIER 1 ACA (Preventive Health) (GILDAGIA) norethindrone-ethinyl estradiol (LEENA) TIER 1 ACA (Preventive Health) norethindrone-ethinyl estradiol (NECON) TIER 1 ACA (Preventive Health) norethindrone-ethinyl estradiol (NORTREL) TIER 1 ACA (Preventive Health) norethindrone-ethinyl estradiol (PHILITH) TIER 1 ACA (Preventive Health) norethindrone-ethinyl estradiol (PIRMELLA) TIER 1 ACA (Preventive Health) norethindrone-ethinyl estradiol (VYFEMLA) TIER 1 ACA (Preventive Health) norethindrone-ethinyl estradiol (WERA) TIER 1 ACA (Preventive Health) norethindrone-ethinyl estradiol TIER 1 ACA (Preventive Health) (ZENCHENT)

150 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS norethindrone-ethinyl estradiol/ferrous TIER 1 ACA (Preventive Health) fumarate norethindrone-ethinyl estradiol/ferrous TIER 1 ACA (Preventive Health) fumarate (KAITLIB FE) norethindrone-ethinyl estradiol/ferrous TIER 1 ACA (Preventive Health) fumarate (WYMZYA FE) norethindrone-mestranol (NECON) TIER 1 ACA (Preventive Health) norgestimate-ethinyl estradiol TIER 1 ACA (Preventive Health) norgestimate-ethinyl estradiol (ESTARYLLA) TIER 1 ACA (Preventive Health) norgestimate-ethinyl estradiol (FEMYNOR) TIER 1 ACA (Preventive Health) norgestimate-ethinyl estradiol (MILI) TIER 1 ACA (Preventive Health) norgestimate-ethinyl estradiol (MONO- TIER 1 ACA (Preventive Health) LINYAH) norgestimate-ethinyl estradiol TIER 1 ACA (Preventive Health) (MONONESSA) norgestimate-ethinyl estradiol (PREVIFEM) TIER 1 ACA (Preventive Health) norgestimate-ethinyl estradiol (SPRINTEC) TIER 1 ACA (Preventive Health) norgestimate-ethinyl estradiol (TRI TIER 1 ACA (Preventive Health) FEMYNOR) norgestimate-ethinyl estradiol (TRI- TIER 1 ACA (Preventive Health) ESTARYLLA) norgestimate-ethinyl estradiol (TRI-LINYAH) TIER 1 ACA (Preventive Health) norgestimate-ethinyl estradiol (TRI-LO- TIER 1 ACA (Preventive Health) ESTARYLLA) norgestimate-ethinyl estradiol (TRI-LO- TIER 1 ACA (Preventive Health) MARZIA) norgestimate-ethinyl estradiol (TRI-LO-MILI) TIER 1 ACA (Preventive Health) norgestimate-ethinyl estradiol (TRI-LO- TIER 1 ACA (Preventive Health) SPRINTEC) norgestimate-ethinyl estradiol (TRI-MILI) TIER 1 ACA (Preventive Health) norgestimate-ethinyl estradiol (TRI- TIER 1 ACA (Preventive Health) PREVIFEM) norgestimate-ethinyl estradiol (TRI- TIER 1 ACA (Preventive Health) SPRINTEC) norgestimate-ethinyl estradiol (TRI- TIER 1 ACA (Preventive Health) VYLIBRA LO)

151 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS norgestimate-ethinyl estradiol (TRI- TIER 1 ACA (Preventive Health) VYLIBRA) norgestimate-ethinyl estradiol (TRINESSA TIER 1 ACA (Preventive Health) LO) norgestimate-ethinyl estradiol (TRINESSA) TIER 1 ACA (Preventive Health) norgestimate-ethinyl estradiol (VYLIBRA) TIER 1 ACA (Preventive Health) norgestrel-ethinyl estradiol (CRYSELLE) TIER 1 ACA (Preventive Health) norgestrel-ethinyl estradiol (ELINEST) TIER 1 ACA (Preventive Health) norgestrel-ethinyl estradiol (LOW- TIER 1 ACA (Preventive Health) OGESTREL) norgestrel-ethinyl estradiol (OGESTREL) TIER 1 ACA (Preventive Health) NUVARING (etonogestrel/ethinyl estradiol) TIER 2 ACA (Preventive Health), QLC (1 ring/month) ORTHO TRI-CYCLEN (norgestimate-ethinyl TIER 3 estradiol) ORTHO TRI-CYCLEN LO (norgestimate- TIER 3 ethinyl estradiol) ORTHO-CYCLEN (norgestimate-ethinyl TIER 3 estradiol) ORTHO-NOVUM (norethindrone-ethinyl TIER 3 estradiol) PREFEST (estradiol/norgestimate) TIER 3 QLC (1 tab/day) PREMARIN (estrogens, conjugated) 0.3 TIER 3 MG TABLET, 0.45 MG TABLET, 0.625 MG TABLET, 0.9 MG TABLET, 1.25 MG TABLET PREMARIN (estrogens, conjugated) TIER 2 VAGINAL CREAM-APPL PREMPHASE (estrogens, TIER 2 QLC (28 tabs/month) conjugated/medroxyprogesterone acetate) PREMPRO (estrogens, TIER 2 QLC (28 tabs/month) conjugated/medroxyprogesterone acetate) QUARTETTE (levonorgestrel/ethinyl TIER 3 estradiol and ethinyl estradiol) SAFYRAL (drospirenone/ethinyl TIER 3 estradiol/levomefolate calcium) SEASONIQUE (levonorgestrel/ethinyl TIER 3 estradiol and ethinyl estradiol)

152 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS TAYTULLA (norethindrone acetate-ethinyl TIER 3 estradiol/ferrous fumarate) TRI-NORINYL (norethindrone-ethinyl TIER 3 estradiol) VAGIFEM (estradiol) TIER 3 VIVELLE-DOT (estradiol) TIER 3 QLC (16 patches/28 days) YASMIN 28 (ethinyl TIER 3 estradiol/drospirenone) YAZ (ethinyl estradiol/drospirenone) TIER 3 PROGESTERONE AGONISTS/ANTAGONISTS ELLA (ulipristal acetate) TIER 3 ACA (Preventive Health), QLC (1 tab/fill) PROGESTINS AYGESTIN (norethindrone acetate) TIER 3 CRINONE (progesterone, micronized) TIER 2 PA ENDOMETRIN (progesterone, micronized) TIER 3 PA hydroxyprogesterone caproate TIER 4 PA, SP, QLC (5 ml/month) hydroxyprogesterone caproate/pf TIER 4 PA, SP, QLC (1 vial/week) levonorgestrel TIER 1 ACA (Preventive Health), QLC (1 tab/fill) levonorgestrel (AFTERA) TIER 1 ACA (Preventive Health), QLC (1 tab/fill) levonorgestrel (ECONTRA EZ) TIER 1 ACA (Preventive Health), QLC (1 tab/fill) levonorgestrel (ECONTRA ONE-STEP) TIER 1 ACA (Preventive Health), QLC (1 tab/fill) levonorgestrel (FALLBACK SOLO) TIER 1 ACA (Preventive Health), QLC (1 tab/fill) levonorgestrel (MY CHOICE) TIER 1 ACA (Preventive Health), QLC (1 tab/fill) levonorgestrel (MY WAY) TIER 1 ACA (Preventive Health), QLC (1 tab/fill) levonorgestrel (NEW DAY) TIER 1 ACA (Preventive Health), QLC (1 tab/faill) levonorgestrel (NEXT CHOICE ONE DOSE) TIER 1 ACA (Preventive Health), QLC (1 tab/fill)

153 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS levonorgestrel (OPCICON ONE-STEP) TIER 1 ACA (Preventive Health), QLC (1 tab/fill) levonorgestrel (OPTION 2) TIER 1 ACA (Preventive Health), QLC (1 tab/fill) levonorgestrel (TAKE ACTION) TIER 3 QLC (1 tab/fill) MAKENA (hydroxyprogesterone TIER 4 PA, SP, QLC (5 ml/month) caproate) MAKENA (hydroxyprogesterone TIER 4 PA, SP, QLC (1 vial/week) caproate/pf) 250 MG/ML VIAL MAKENA (hydroxyprogesterone TIER 4 PA, SP, QLC (1 injection/week) caproate/pf) 275 MG/1.1 ML AUTOINJCT medroxyprogesterone acetate 2.5 mg TIER 1 tablet, 5 mg tablet, 10 mg tablet MEGACE (megestrol acetate) TIER 3 MEGACE ES (megestrol acetate) TIER 3 megestrol acetate 20 mg tablet, 40 mg TIER 1 OAC tablet megestrol acetate 400mg/10ml oral susp TIER 1 PA megestrol acetate 625mg/5ml oral susp TIER 1 NOR-Q-D (norethindrone) TIER 3 norethindrone TIER 1 ACA (Preventive Health) norethindrone (CAMILA) TIER 1 ACA (Preventive Health) norethindrone (DEBLITANE) TIER 1 ACA (Preventive Health) norethindrone (ERRIN) TIER 1 ACA (Preventive Health) norethindrone (HEATHER) TIER 1 ACA (Preventive Health) norethindrone (INCASSIA) TIER 1 ACA (Preventive Health) norethindrone (JENCYCLA) TIER 1 ACA (Preventive Health) norethindrone (JOLIVETTE) TIER 1 ACA (Preventive Health) norethindrone (LYZA) TIER 1 ACA (Preventive Health) norethindrone (NORA-BE) TIER 1 ACA (Preventive Health) norethindrone (NORLYDA) TIER 1 ACA (Preventive Health) norethindrone (NORLYROC) TIER 1 ACA (Preventive Health) norethindrone (SHAROBEL) TIER 1 ACA (Preventive Health) norethindrone (TULANA) TIER 1 ACA (Preventive Health)

154 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS norethindrone acetate TIER 1 ORTHO MICRONOR (norethindrone) TIER 3 PLAN B ONE-STEP (levonorgestrel) TIER 3 QLC (1 tab/fill) progesterone TIER 1 progesterone, micronized TIER 1 PROMETRIUM (progesterone, micronized) TIER 3 PROVERA (medroxyprogesterone TIER 3 acetate) SLYND (drospirenone) TIER 3 ST TAKE ACTION (levonorgestrel) TIER 3 QLC (1 tab/fill) SELECTIVE ESTROGEN RECEPTOR MODIFYING AGENTS clomiphene citrate TIER 1 PA, GL (Female) EVISTA (raloxifene hcl) TIER 3 ACA (Preventive Health), QLC (1 tab/day) OSPHENA (ospemifene) TIER 3 PA, QLC (1 tab/day) raloxifene hcl TIER 1 GL (Female), ACA (Preventive Health), QLC (1 tab/day) SEROPHENE (clomiphene citrate) TIER 1 PA, GL (Female)

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (THYROID) (Drugs for the Thyroid) HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (THYROID) (Drugs to Replace Thyroid Hormone) ARMOUR THYROID (thyroid,pork) TIER 2 CYTOMEL (liothyronine sodium) TIER 3 EUTHYROX (levothyroxine sodium) TIER 3 LEVO-T (levothyroxine sodium) TIER 3 levothyroxine sodium 25 mcg tablet, 50 TIER 1 mcg tablet, 75 mcg tablet, 88 mcg tablet, 100 mcg tablet, 112 mcg tablet, 125 mcg tablet, 137 mcg tablet, 150 mcg tablet, 175 mcg tablet, 200 mcg tablet, 300 mcg tablet LEVOXYL (levothyroxine sodium) TIER 3

155 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS liothyronine sodium 5 mcg tablet, 25 mcg TIER 1 tablet, 50 mcg tablet NATURE-THROID (thyroid,pork) TIER 3 SYNTHROID (levothyroxine sodium) TIER 2 thyroid,pork TIER 2 thyroid,pork (NP THYROID) TIER 2 thyroid,pork (THYROID) TIER 2 THYROLAR-1 (liotrix) TIER 2 THYROLAR-1/2 (liotrix) TIER 2 THYROLAR-1/4 (liotrix) TIER 2 THYROLAR-2 (liotrix) TIER 2 THYROLAR-3 (liotrix) TIER 2 TIROSINT (levothyroxine sodium) TIER 3 TIROSINT-SOL (levothyroxine sodium) TIER 3 UNITHROID (levothyroxine sodium) TIER 3 WESTHROID (thyroid,pork) TIER 3 WP THYROID (thyroid,pork) TIER 3

HORMONAL AGENTS, SUPPRESSANT (PITUITARY) (Drugs for Suppressing Hormones from the Pituitary Gland) HORMONAL AGENTS, SUPPRESSANT (PITUITARY) (Drugs to Suppress Pituitary Hormones) cabergoline TIER 1 QLC (16 tabs/month) EGRIFTA (tesamorelin acetate) 1 MG VIAL TIER 4 PA, SP, QLC (2 vials/day) EGRIFTA (tesamorelin acetate) 2 MG VIAL TIER 4 PA, SP, QLC (1 vial/day) leuprolide acetate TIER 4 PA, SP octreotide acetate TIER 4 PA, SP ORILISSA (elagolix sodium) 150 MG TABLET TIER 3 PA, QLC (1 tab/day) ORILISSA (elagolix sodium) 200 MG TABLET TIER 3 PA, QLC (2 tabs/day) SANDOSTATIN (octreotide acetate) TIER 4 PA, SP SIGNIFOR (pasireotide diaspartate) TIER 4 PA, SP, QLC (2 ampules/day)

156 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS SOMAVERT (pegvisomant) TIER 4 PA, SP, QLC (1 vial/day) SYNAREL (nafarelin acetate) TIER 4

HORMONAL AGENTS, SUPPRESSANT (THYROID) (Drugs for the Thyroid) ANTITHYROID AGENTS (Drugs to Suppress Thyroid Hormone) methimazole TIER 1 potassium iodide (SSKI) TIER 1 propylthiouracil TIER 1 TAPAZOLE (methimazole) TIER 3

IMMUNOLOGICAL AGENTS (Drugs for Enhancing or Suppressing the Immune System) ANGIOEDEMA AGENTS FIRAZYR (icatibant acetate) TIER 4 PA, SP, QLC (2 syringes per fill; not to exceed 12 syringes/2 months) HAEGARDA (c1 esterase inhibitor) TIER 4 PA, SP icatibant acetate TIER 4 PA, SP, QLC (2 syringes/fill; max 12 syringes/2 months) TAKHZYRO (lanadelumab-flyo) TIER 4 PA, SP, QLC (1 vial/14 days) IMMUNE SUPPRESSANTS (Drugs to Suppress the Immune System) ASTAGRAF XL (tacrolimus) TIER 3 AZASAN (azathioprine) TIER 3 azathioprine TIER 1 CELLCEPT (mycophenolate mofetil) TIER 3 CIMZIA (certolizumab pegol) 200 MG/ML TIER 4 PA, SP, QLC (3 kits/180 days per STARTER KIT year) CIMZIA (certolizumab pegol) 200 MG/ML TIER 4 PA, SP, QLC (1 kit/28 days) SYRINGE KIT cyclosporine 25 mg capsule, 100 mg TIER 1 capsule cyclosporine, modified TIER 1

157 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS cyclosporine, modified (GENGRAF) TIER 1 ENBREL (etanercept) 25 MG KIT TIER 4 PA, SP, QLC (8 vials/28 days) ENBREL (etanercept) 25 MG/0.5 ML TIER 4 PA, SP, QLC (4 ml/28 days) SYRINGE, 50 MG/ML SYRINGE ENBREL MINI (etanercept) TIER 4 PA, SP, QLC (4 ml/ 28 days) ENBREL SURECLICK (etanercept) TIER 4 PA, SP, QLC (4 ml/28 days) ENVARSUS XR (tacrolimus) 0.75 MG TABLET TIER 3 ST, QLC (11 tabs/day) ENVARSUS XR (tacrolimus) 1 MG TABLET TIER 3 ST, QLC (8 tabs/day) ENVARSUS XR (tacrolimus) 4 MG TABLET TIER 3 ST, QLC (2 tabs/day) HUMIRA (adalimumab) TIER 4 PA, SP, QLC (2 syringes/28 days) HUMIRA PEDIATRIC CROHN'S TIER 4 PA, SP, QLC (3 or 6 syringes/year (adalimumab) depending upon package size) HUMIRA PEN (adalimumab) TIER 4 PA, SP, QLC (2 syringes/28 days) HUMIRA PEN CROHN'S-UC-HS TIER 4 PA, SP, QLC (6 syringes/year) (adalimumab) HUMIRA PEN PSOR-UVEITS-ADOL HS TIER 4 PA, SP, QLC (4 syringes/year) (adalimumab) HUMIRA(CF) (adalimumab) TIER 4 PA, SP, QLC (2 syringes [1 kit]/28 days) HUMIRA(CF) PEDIATRIC CROHN'S TIER 4 PA, SP, QLC (2 syr [1 kit]/year) (adalimumab) 80-40 MG HUMIRA(CF) PEDIATRIC CROHN'S TIER 4 PA, SP, QLC (3 syr [1 kit]/year) (adalimumab) 80MG/0.8 HUMIRA(CF) PEN (adalimumab) TIER 4 PA, SP, QLC (2 pens [1 kit]/28 days) HUMIRA(CF) PEN CROHN'S-UC-HS TIER 4 PA, SP, QLC (1 carton/year) (adalimumab) HUMIRA(CF) PEN PSOR-UV-ADOL HS TIER 4 PA, SP, QLC (1 carton/year) (adalimumab) IMURAN (azathioprine) TIER 3 KINERET (anakinra) TIER 4 PA, SP, QLC (1 syringe/day) methotrexate sodium 2.5 mg tablet TIER 1 OAC methotrexate sodium 25 mg/ml vial TIER 1 QLC (8 ml/month) methotrexate sodium/pf 25 mg/ml vial TIER 1 QLC (8 ml/month) mycophenolate mofetil TIER 1

158 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS mycophenolate sodium TIER 1 MYFORTIC (mycophenolate sodium) TIER 3 NEORAL (cyclosporine, modified) TIER 3 OLUMIANT (baricitinib) TIER 4 PA, SP, QLC (1 tab/day) ORENCIA (abatacept) TIER 4 PA, SP, QLC (1 syringe/week) ORENCIA CLICKJECT (abatacept) TIER 4 PA, SP, QLC (1 syringe/week) OTREXUP (methotrexate/pf) 10 MG/0.4 ML TIER 4 PA, SP, QLC (1 syringe/week) AUTO-INJ, 12.5 MG/0.4 ML AUTOINJ, 15 MG/0.4 ML AUTO-INJ, 17.5 MG/0.4 ML AUTOINJ, 20 MG/0.4 ML AUTO-INJ, 22.5 MG/0.4 ML AUTOINJ, 25 MG/0.4 ML AUTO- INJ PROGRAF (tacrolimus) 0.2 MG GRANULE TIER 3 PA PACKET, 1 MG GRANULE PACKET PROGRAF (tacrolimus) 0.5 MG CAPSULE, 1 TIER 3 MG CAPSULE, 5 MG CAPSULE RAPAMUNE (sirolimus) TIER 3 RASUVO (methotrexate/pf) TIER 4 PA, SP, QLC (1 syringe/week) RHEUMATREX (methotrexate sodium) TIER 3 RINVOQ ER (upadacitinib) TIER 4 PA, SP, QLC (1 tab/day) SANDIMMUNE (cyclosporine) 100 MG/ML TIER 2 SOLN SANDIMMUNE (cyclosporine) 25 MG TIER 3 CAPSULE, 100 MG CAPSULE SIMPONI (golimumab) TIER 4 PA, SP, QLC (1 syringe/4 weeks) sirolimus TIER 1 tacrolimus 0.5 mg capsule, 1 mg capsule, TIER 1 5 mg capsule TREXALL (methotrexate sodium) TIER 3 OAC XATMEP (methotrexate) TIER 4 AL1 (Up to 8 yrs old), QLC (1 bottle/month), OAC XELJANZ (tofacitinib citrate) TIER 4 PA, SP, QLC (2 tabs/day) XELJANZ XR (tofacitinib citrate) TIER 4 PA, SP, QLC (1 tab/day) ZORTRESS (everolimus) 0.25 MG TABLET, TIER 2 QLC (2 tabs/day) 0.75 MG TABLET ZORTRESS (everolimus) 0.5 MG TABLET TIER 2 QLC (4 tabs/day)

159 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS ZORTRESS (everolimus) 1 MG TABLET TIER 2 QLC (2 tabs/day) IMMUNOMODULATORS (Drugs that Changes the Immune System) ACTEMRA (tocilizumab) 162 MG/0.9 ML TIER 4 PA, SP, QLC (1 syringe/week) SYRINGE ACTEMRA ACTPEN (tocilizumab) TIER 4 PA, SP, QLC (1 pen injector/week) ACTIMMUNE (interferon gamma- TIER 4 PA, SP 1b,recomb.) ARAVA (leflunomide) TIER 3 ARCALYST (rilonacept) TIER 4 PA, SP BENLYSTA (belimumab) 200 MG/ML TIER 4 PA, SP, QLC (1 syringe/week) AUTOINJECT, 200 MG/ML SYRINGE KEVZARA (sarilumab) 150 MG/1.14 ML PEN TIER 4 PA, SP, QLC (1 pen/14 days) INJ, 200 MG/1.14 ML PEN INJ KEVZARA (sarilumab) 150 MG/1.14 ML TIER 4 PA, SP, QLC (2 syringes/28 days) SYRINGE, 200 MG/1.14 ML SYRINGE leflunomide TIER 1 OTEZLA (apremilast) 28 DAY PACK, PACK TIER 4 PA, SP, QLC (1 pack/month) OTEZLA (apremilast) 30 MG TABLET TIER 4 PA, SP, QLC (2 tabs/day) RIDAURA (auranofin) TIER 2 VACCINES XOFLUZA (baloxavir marboxil) 20 MG TAB TIER 3 QLC (2 tabs/day, max 2 courses (40 MG DOSE) (4 tabs)/180 days) XOFLUZA (baloxavir marboxil) 40 MG TAB TIER 3 QLC (2 tabs/day, max 2 courses (80 MG DOSE) (4 tabs)/180 days)

INFLAMMATORY BOWEL DISEASE AGENTS (Drugs for Inflammatory Bowel Disease) AMINOSALICYLATES APRISO (mesalamine) TIER 2 QLC (4 caps/day) ASACOL HD (mesalamine) TIER 3 ST, QLC (6 tabs/day) balsalazide disodium TIER 1 QLC (9 caps/day) CANASA (mesalamine) TIER 3 COLAZAL (balsalazide disodium) TIER 3 QLC (9 caps/day)

160 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS DELZICOL (mesalamine) TIER 3 ST, QLC (12 caps/day) DIPENTUM (olsalazine sodium) TIER 3 ST, QLC (12 caps/day) GIAZO (balsalazide disodium) TIER 3 ST, QLC (6 tabs/day) LIALDA (mesalamine) TIER 3 QLC (4 tabs/day) mesalamine 1.2 g tablet dr TIER 1 QLC (4 tabs/day) mesalamine 4 g/60 ml enema, 1000 mg TIER 1 supp.rect mesalamine 400 mg cap(drtab) TIER 1 ST, QLC (12 caps/day) mesalamine 800 mg tablet dr TIER 1 ST, QLC (6 tabs/day) PENTASA (mesalamine) 250 MG CAPSULE TIER 3 ST, QLC (4 caps/day) PENTASA (mesalamine) 500 MG CAPSULE TIER 3 ST, QLC (8 caps/day) SFROWASA (mesalamine) TIER 3 GLUCOCORTICOIDS budesonide 3 mg capdr - er TIER 1 PA, QLC (3 caps/day) budesonide 9 mg tabdr - er TIER 3 PA, QLC (1 tab/day) CORTENEMA (hydrocortisone) TIER 3 CORTIFOAM (hydrocortisone acetate) TIER 2 ENTOCORT EC (budesonide) TIER 3 PA, QLC (3 caps/day) hydrocortisone (COLOCORT) TIER 1 hydrocortisone 100mg/60ml enema TIER 1 UCERIS (budesonide) 2 MG RECTAL FOAM TIER 3 QLC (4 cans/6 weeks; not to exceed 6 weeks therapy/6 months) UCERIS (budesonide) 9 MG TABLET TIER 3 PA, QLC (1 tab/day) SULFONAMIDES AZULFIDINE (sulfasalazine) TIER 3 sulfasalazine TIER 1

METABOLIC BONE DISEASE AGENTS (Drugs for the Bone) METABOLIC BONE DISEASE AGENTS ACTONEL (risedronate sodium) 150 MG TIER 3 ST, QLC (1 tab/month) TABLET

161 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS ACTONEL (risedronate sodium) 30 MG TIER 3 PA TABLET ACTONEL (risedronate sodium) 35 MG TIER 3 ST, QLC (4 tabs/month) TABLET ACTONEL (risedronate sodium) 5 MG TIER 3 ST, QLC (1 tab/day) TABLET alendronate sodium 35 mg tablet, 70 mg TIER 1 QLC (4 tabs/month) tablet alendronate sodium 40 mg tablet TIER 1 QLC (1 tab/day) alendronate sodium 5 mg tablet, 10 mg TIER 1 tablet alendronate sodium 70 mg/75ml solution TIER 1 QLC (4 bottles/month) ATELVIA (risedronate sodium) TIER 3 ST, QLC (4 tabs/month) BINOSTO (alendronate sodium) TIER 3 ST, QLC (4 tabs/month) BONIVA (ibandronate sodium) 150 MG TIER 3 ST, QLC (1 tab/month) TABLET calcitonin,salmon,synthetic TIER 1 QLC (1 bottle/month) calcitriol 0.25 mcg capsule, 0.5 mcg TIER 1 capsule, 1 mcg/ml solution cinacalcet hcl TIER 1 PA doxercalciferol 0.5 mcg capsule, 1 mcg TIER 1 capsule, 2.5 mcg capsule DRISDOL (ergocalciferol (vitamin d2)) TIER 3 ergocalciferol (vitamin d2) 50000 unit TIER 1 capsule etidronate disodium TIER 1 FORTEO (teriparatide) TIER 4 PA, SP, QLC (1 pen/month) FORTICAL (calcitonin,salmon,synthetic) TIER 3 QLC (1 bottle/month) FOSAMAX (alendronate sodium) TIER 3 QLC (4 tabs/month) FOSAMAX PLUS D (alendronate TIER 2 QLC (4 tabs/month) sodium/cholecalciferol (vitamin d3)) 70 MG-2,800 IU FOSAMAX PLUS D (alendronate TIER 3 QLC (4 tabs/month) sodium/cholecalciferol (vitamin d3)) 70 MG-5,600 IU HECTOROL (doxercalciferol) 0.5 MCG TIER 3 CAPSULE, 1 MCG CAPSULE, 2.5 MCG CAPSULE

162 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS ibandronate sodium 150 mg tablet TIER 1 ST, QLC (1 tab/month) MIACALCIN (calcitonin,salmon,synthetic) TIER 3 QLC (1 bottle/month) 200 UNIT NASAL SPRAY MIACALCIN (calcitonin,salmon,synthetic) TIER 4 400 UNIT/2 ML VIAL NATPARA (parathyroid hormone) TIER 4 PA, SP, QLC (2 cartridges/month) paricalcitol 1 mcg capsule, 2 mcg TIER 1 capsule, 4 mcg capsule RAYALDEE (calcifediol) TIER 3 PA risedronate sodium 150 mg tablet TIER 1 ST, QLC (1 tab/month) risedronate sodium 30 mg tablet TIER 1 PA risedronate sodium 35 mg tablet, 35 mg TIER 1 ST, QLC (4 tabs/month) tablet dr risedronate sodium 5 mg tablet TIER 1 ST, QLC (1 tab/day) ROCALTROL (calcitriol) TIER 3 SENSIPAR (cinacalcet hcl) TIER 3 PA TYMLOS (abaloparatide) TIER 4 PA, SP, QLC (1 pen/month) XGEVA (denosumab) TIER 4 PA, SP, QLC (1 vial/month) ZEMPLAR (paricalcitol) 1 MCG CAPSULE, 2 TIER 3 MCG CAPSULE

MISCELLANEOUS THERAPEUTIC AGENTS accu-chek blood glucose test strips TIER 2 QLC (200 strips/month) all non accu-chek blood glucose test TIER 3 PA, QLC (200 strips/month) strips blood ketone test, strips TIER 2 cervical cap TIER 2 ACA (Preventive Health) diaphragms, contoured TIER 2 ACA (Preventive Health) diaphragms, wide seal TIER 2 ACA (Preventive Health) INBRIJA (levodopa) TIER 4 PA, SP, QLC (10 caps/day) inhaler, assist devices TIER 2 inhaler, assist devices, accessories TIER 2 inhaler,assist device with large mask TIER 2

163 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS inhaler,assist device with medium mask TIER 2 inhaler,assist device with small mask TIER 2 insulin admin. supplies TIER 2 PA, QLC (1 pen/year) insulin pump cartridge TIER 3 PA, QLC (1 pod/2 days) insulin syringe-needle,safety,disposal TIER 2 unit,0.5 ml INTRAROSA (prasterone (dhea)) TIER 3 PA, QLC (1 insert/day) lancets TIER 2 QLC (200 lancets/month) LOKELMA (sodium zirconium cyclosilicate) TIER 4 PA, QLC (1 pack/day) 10 GRAM POWDER PACKET LOKELMA (sodium zirconium cyclosilicate) TIER 4 PA, QLC (3 packs/day) 5 GRAM POWDER PACKET methylergonovine maleate (METHERGINE) TIER 1 methylergonovine maleate 0.2 mg tablet TIER 1 nebulizer and compressor TIER 2 needles, safety 25gx1 1/2" dis TIER 2 ODACTRA (allergenic extract, mite- TIER 3 PA, QLC (1 tab/day) d.farinae-d.pteronyssinus,standard) pen needle, diabetic TIER 2 pen needle, diabetic disposable, safety TIER 2 pen needle, diabetic, safety TIER 2 RUZURGI (amifampridine) TIER 4 PA, SP, QLC (10 tabs/day) SAXENDA (liraglutide) TIER 4 PA, QLC (5 pens/month) sub-q insulin delivery device, 20 TIER 3 PA, QLC (1 device/day) unit,disposable sub-q insulin delivery device, 30 unit, TIER 3 PA, QLC (1 device/day) disposable sub-q insulin delivery device, 40 unit, TIER 3 PA, QLC (1 device/day) disposable syringe w-needle 0.3 ml,insulin,safety w- TIER 2 self-cont.dis.unit syringe with needle 1 ml,insulin,safety w- TIER 2 self-con.disp.unit syringe with needle, insulin, safety, 0.3 ml TIER 2 syringe with needle, insulin, safety, 0.5 ml TIER 2

164 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS syringe with needle, insulin, safety, 1 ml TIER 2 syringe with needle,disposable,insulin 1 ml TIER 2 syringe with needle,insulin 0.3 ml (half unit TIER 2 mark) syringe with needle,insulin 0.5 ml (half unit TIER 2 mark) syringe with needle,insulin disposable TIER 2 syringe with needle,insulin,0.3 ml TIER 2 syringe with needle,insulin,0.5 ml TIER 2 syringe without needle,insulin disposible, 1 TIER 2 ml syringe, insulin u-500 with needle, TIER 2 disposable, 0.5 ml urine acetone test,strips TIER 2 urine glucose-acet test strip TIER 2 VISTOGARD (uridine triacetate) TIER 4 SP, QLC (20 packets/month)

OPHTHALMIC AGENTS (Drugs for the Eyes) OPHTHALMIC AGENTS, OTHER (Other Drugs for the Eyes) ALCAINE (proparacaine hcl) TIER 3 atropine sulfate 1 % oint. (g), 1 % drops TIER 1 bacitracin/polymyxin b sulfate (AK-POLY- TIER 1 BAC) bacitracin/polymyxin b sulfate (POLYCIN) TIER 1 bacitracin/polymyxin b sulfate 500-10k/g TIER 1 oint. (g) BLEPHAMIDE (sulfacetamide TIER 2 sodium/prednisolone acetate) BLEPHAMIDE S.O.P. (sulfacetamide TIER 2 sodium/prednisolone acetate) CEQUA (cyclosporine) TIER 3 PA, QLC (60 droperettes/30 days) CYCLOGYL (cyclopentolate hcl) TIER 3 CYCLOMYDRIL (cyclopentolate TIER 3 hcl/phenylephrine hcl)

165 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS cyclopentolate hcl TIER 1 CYSTARAN (cysteamine hcl) TIER 4 PA, SP, QLC (4 bottles/28 days) homatropine hbr TIER 1 homatropine hbr (HOMATROPAIRE) TIER 1 ISOPTO ATROPINE (atropine sulfate) TIER 3 LACRISERT (hydroxypropyl cellulose) TIER 3 MAXITROL (neomycin/polymyxin b TIER 3 sulfate/dexamethasone) MYDRIACYL (tropicamide) TIER 3 naphazoline hcl TIER 1 neomycin sulfate/bacitracin TIER 1 zinc/polymyxin b/hydrocortisone neomycin sulfate/bacitracin TIER 1 zinc/polymyxin b/hydrocortisone (NEO- POLYCIN HC) neomycin sulfate/bacitracin/polymyxin b TIER 1 neomycin sulfate/bacitracin/polymyxin b TIER 1 (NEO-POLYCIN) neomycin sulfate/polymyxin b TIER 1 sulfate/gramicidin d neomycin sulfate/polymyxin b TIER 1 sulfate/hydrocortisone neomycin/polymyxin b/hydrocort 3.5-10k- 10 drops susp neomycin/polymyxin b TIER 1 sulfate/dexamethasone OXERVATE (cenegermin-bkbj) TIER 4 PA, SP, QLC (28 ml/28 days) phenylephrine hcl 2.5 % drops, 10 % drops TIER 1 polymyxin b sulfate/trimethoprim TIER 1 POLYTRIM (polymyxin b TIER 3 sulfate/trimethoprim) PRED-G (gentamicin sulfate/prednisolone TIER 3 acetate) proparacaine hcl TIER 1 RESTASIS (cyclosporine) TIER 2 QLC (2 droperettes/day) RESTASIS MULTIDOSE (cyclosporine) TIER 2 QLC (1 bottle/month)

166 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS sulfacetamide sodium/prednisolone TIER 1 sodium phosphate TOBRADEX (tobramycin/dexamethasone) TIER 3 EYE DROPS TOBRADEX (tobramycin/dexamethasone) TIER 2 EYE OINTMENT TOBRADEX ST TIER 3 QLC (1 bottle/fill) (tobramycin/dexamethasone) tobramycin/dexamethasone TIER 1 tropicamide TIER 1 XIIDRA (lifitegrast) TIER 2 QLC (2 droperettes/day) ZYLET (tobramycin/loteprednol TIER 2 etabonate) OPHTHALMIC ANTI-ALLERGY AGENTS (Drugs for Eye Allergies) ALOCRIL (nedocromil sodium) TIER 3 ALOMIDE (lodoxamide tromethamine) TIER 2 azelastine hcl 0.05 % drops TIER 1 BEPREVE (bepotastine besilate) TIER 3 QLC (5 ml/month) cromolyn sodium 4 % drops TIER 1 ELESTAT (epinastine hcl) TIER 3 EMADINE (emedastine difumarate) TIER 3 ST epinastine hcl TIER 1 LASTACAFT (alcaftadine) TIER 2 QLC (1 bottle/month) olopatadine hcl 0.1 % drops TIER 1 QLC (10 ml/month) olopatadine hcl 0.2 % drops TIER 1 QLC (1 bottle/month) PATADAY (olopatadine hcl) TIER 3 QLC (1 bottle/month) PATANOL (olopatadine hcl) TIER 3 QLC (10 ml/month) PAZEO (olopatadine hcl) TIER 2 QLC (1 bottle/month) OPHTHALMIC ANTI-INFLAMMATORIES (Drugs to Reduce Eye Swelling) ACULAR (ketorolac tromethamine) TIER 3 ACULAR LS (ketorolac tromethamine) TIER 3

167 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS ACUVAIL (ketorolac tromethamine/pf) TIER 2 ALREX (loteprednol etabonate) TIER 3 bromfenac sodium TIER 1 BROMSITE (bromfenac sodium) TIER 3 PA, QLC (1 bottle/month) dexamethasone sodium phosphate 0.1 % TIER 1 drops diclofenac sodium 0.1 % drops TIER 1 DUREZOL (difluprednate) TIER 3 FLAREX (fluorometholone acetate) TIER 3 fluorometholone TIER 1 flurbiprofen sodium TIER 1 FML (fluorometholone) TIER 3 FML FORTE (fluorometholone) TIER 2 FML S.O.P. (fluorometholone) TIER 2 ILEVRO (nepafenac) TIER 3 QLC (1 bottle/month) INVELTYS (loteprednol etabonate) TIER 3 PA ketorolac tromethamine 0.4 % drops, 0.5 TIER 1 % drops LOTEMAX (loteprednol etabonate) 0.5% TIER 3 EYE DROPS LOTEMAX (loteprednol etabonate) 0.5% TIER 3 QLC (1 tube/month) EYE OINTMENT LOTEMAX (loteprednol etabonate) 0.5% TIER 2 OPHTHALMIC GEL LOTEMAX SM (loteprednol etabonate) TIER 3 loteprednol etabonate TIER 1 MAXIDEX (dexamethasone) TIER 3 NEVANAC (nepafenac) TIER 3 OCUFEN (flurbiprofen sodium) TIER 3 OMNIPRED (prednisolone acetate) TIER 3 PRED FORTE (prednisolone acetate) TIER 3 PRED MILD (prednisolone acetate) TIER 2 prednisolone acetate TIER 1

168 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS prednisolone sodium phosphate 1 % TIER 1 drops PROLENSA (bromfenac sodium) TIER 3 QLC (1 bottle/month) VEXOL (rimexolone) TIER 3 OPHTHALMIC ANTIGLAUCOMA AGENTS (Drugs for Glaucoma) ALPHAGAN P (brimonidine tartrate) TIER 2 ALHAGAN 0.1% DROS ALPHAGAN P (brimonidine tartrate) TIER 3 ALHAGAN 0.15% EYE DROS apraclonidine hcl TIER 1 AZOPT (brinzolamide) TIER 2 BETAGAN (levobunolol hcl) TIER 3 betaxolol hcl 0.5 % drops TIER 1 BETIMOL (timolol) TIER 2 BETOPTIC S (betaxolol hcl) TIER 2 brimonidine tartrate TIER 1 carteolol hcl TIER 1 COMBIGAN (brimonidine tartrate/timolol TIER 2 maleate) COSOPT (dorzolamide hcl/timolol TIER 3 maleate) COSOPT PF (dorzolamide hcl/timolol TIER 3 QLC (2 droperettes/day) maleate/pf) dorzolamide hcl TIER 1 dorzolamide hcl/timolol maleate TIER 1 dorzolamide hcl/timolol maleate/pf TIER 1 QLC (2 droperettes/day) dorzolamide/timolol/pf 2 %-0.5 % droperette IOPIDINE (apraclonidine hcl) 0.5% EYE TIER 3 DROPS IOPIDINE (apraclonidine hcl) 1% EYE TIER 2 DROPS ISOPTO CARPINE (pilocarpine hcl) TIER 3 ISTALOL (timolol maleate) TIER 3 levobunolol hcl TIER 1

169 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS methazolamide TIER 1 metipranolol TIER 1 NEPTAZANE (methazolamide) TIER 3 PHOSPHOLINE IODIDE (echothiophate TIER 3 iodide) pilocarpine hcl 1 % drops, 2 % drops, 4 % TIER 1 drops RHOPRESSA (netarsudil mesylate) TIER 3 PA, QLC (1 bottle/month) ROCKLATAN (netarsudil TIER 3 PA, QLC (2.5 ml/25 days) mesylate/latanoprost) SIMBRINZA (brinzolamide/brimonidine TIER 2 tartrate) timolol maleate 0.25 % sol-gel, 0.25 % TIER 1 drops, 0.5 % drops, 0.5 % drop daily, 0.5 % sol-gel TIMOPTIC (timolol maleate) TIER 3 TIMOPTIC OCUDOSE (timolol maleate/pf) TIER 3 0.25% DROP TIMOPTIC OCUDOSE (timolol maleate/pf) TIER 2 0.5% DROP TIMOPTIC-XE (timolol maleate) TIER 3 TRUSOPT (dorzolamide hcl) TIER 3 VYZULTA (latanoprostene bunod) TIER 3 PA, QLC (1 bottle/month) OPHTHALMIC PROSTAGLANDIN AND PROSTAMIDE ANALOGS (Drugs for Glaucoma) bimatoprost 0.03 % drops TIER 1 ST, QLC (5 ml/month) latanoprost TIER 1 QLC (5 ml/month) LUMIGAN (bimatoprost) TIER 2 ST, QLC (5 ml/month) TRAVATAN Z (travoprost) TIER 2 ST, QLC (5 ml/month) travoprost (benzalkonium) TIER 1 ST, QLC (1 bottle/month) XALATAN (latanoprost) TIER 3 QLC (5 ml/month) XELPROS (latanoprost) TIER 3 ST, QLC (1 bottle/month) ZIOPTAN (tafluprost/pf) TIER 3 PA, QLC (1 droperette/day)

170 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS

OTIC AGENTS (Drugs for the Ears) OTIC AGENTS (Drugs for Ear Infection) acetic acid 2 % solution TIER 1 acetic acid/aluminum acetate TIER 1 CIPRO HC (ciprofloxacin TIER 3 hcl/hydrocortisone) CIPRODEX (ciprofloxacin TIER 3 hcl/dexamethasone) COLY-MYCIN S (neomycin sulf/colistin TIER 3 sul/hydrocortisone ac/thonzonium brom) CORTISPORIN-TC (neomycin sulf/colistin TIER 3 sul/hydrocortisone ac/thonzonium brom) DERMOTIC (fluocinolone acetonide oil) TIER 2 fluocinolone acetonide oil TIER 3 PA fluocinolone acetonide oil (FLAC OTIC TIER 3 PA OIL) hydrocortisone/acetic acid TIER 1 hydrocortisone/acetic acid (ACETASOL TIER 1 HC) neomycin sulfate/polymyxin b TIER 1 sulfate/hydrocortisone neomycin/polymyxin b/hydrocort 3.5--1 solution, neomycin/polymyxin b/hydrocort 3.5--1 drops susp OTOVEL (ciprofloxacin hcl/fluocinolone TIER 3 QLC (14 vials/7 days) acetonide)

RESPIRATORY TRACT/PULMONARY AGENTS (Drugs for the Lungs) ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS (Inhaled Drugs to Prevent Swelling of the Airways) AEROSPAN (flunisolide) TIER 3 ST, QLC (2 inhalers/month) ALVESCO (ciclesonide) 160 MCG INHALER TIER 3 ST, QLC (2 inhalers/month) ALVESCO (ciclesonide) 80 MCG INHALER TIER 3 ST, QLC (1 inhaler/month) ARMONAIR RESPICLICK (fluticasone TIER 3 PA, QLC (1 inhaler/month) propionate)

171 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS ARNUITY ELLIPTA (fluticasone furoate) TIER 2 QLC (1 inhaler/month) ASMANEX (mometasone furoate) TIER 3 ST, QLC (1 inhaler/month) TWISTHALER 110 MCG #30, TWISTHALER 220 MCG #30, TWISTHALER 220 MCG #14, TWISTHALER 220 MCG #60, TWISTHALR 220 MCG #120 ASMANEX HFA (mometasone furoate) TIER 3 ST, QLC (1 inhaler/month) BECONASE AQ (beclomethasone TIER 3 ST, QLC (1 bottle/month) dipropionate) budesonide 0.25mg/2ml -, 0.5 mg/2ml - TIER 1 QLC (4 ml/day) budesonide 1 mg/2 ml ampul-neb TIER 1 QLC (2 ml/day) FLOVENT DISKUS (fluticasone propionate) TIER 2 QLC (4 inhalers/month) 250 MCG FLOVENT DISKUS (fluticasone propionate) TIER 2 QLC (1 inhaler/month) 50 MCG, 100 MCG FLOVENT HFA (fluticasone propionate) TIER 2 QLC (2 inhalers/month) flunisolide TIER 1 QLC (2 bottles/month) fluticasone propionate 50 mcg spray susp TIER 1 QLC (1 bottle/month) mometasone furoate 50 mcg TIER 1 ST, QLC (1 bottle/month) spray/pump NASONEX (mometasone furoate) TIER 3 ST, QLC (1 bottle/month) OMNARIS (ciclesonide) TIER 3 ST, QLC (1 bottle/month) PULMICORT (budesonide) 0.25 MG/2 ML TIER 3 QLC (4 doses/day) RESPUL, 0.5 MG/2 ML RESPULE PULMICORT (budesonide) 1 MG/2 ML TIER 3 QLC (2 ml/day) RESPULE PULMICORT FLEXHALER (budesonide) TIER 2 QLC (2 inhalers/month) QNASL (beclomethasone dipropionate) TIER 3 ST, QLC (1 bottle/month) QNASL CHILDREN (beclomethasone TIER 3 ST, QLC (1 bottle/month) dipropionate) QVAR (beclomethasone dipropionate) 40 TIER 2 QLC (4 inhalers/month) MCG ORAL INHALER QVAR (beclomethasone dipropionate) 80 TIER 2 QLC (2 inhalers/month) MCG ORAL INHALER QVAR REDIHALER (beclomethasone TIER 2 QLC (2 inhalers/month) dipropionate) XHANCE (fluticasone propionate) TIER 3 PA, QLC (2 bottles/month)

172 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS ZETONNA (ciclesonide) TIER 3 ST, QLC (1 bottle/month) ANTIHISTAMINES ASTEPRO (azelastine hcl) TIER 3 QLC (1 bottle/month) azelastine hcl 137 mcg spray/pump TIER 1 QLC (1 bottle/25 days) azelastine hcl 205.5 mcg spray/pump TIER 1 QLC (1 bottle/25 days) carbinoxamine maleate (ARBINOXA) TIER 1 carbinoxamine maleate 4 mg/5 ml liquid, TIER 1 4 mg tablet carbinoxamine maleate 6 mg tablet TIER 4 PA, QLC (4 tabs/day) CLARINEX (desloratadine) TIER 3 ST clemastine fumarate TIER 1 cyproheptadine hcl 2 mg/5 ml syrup, 4 TIER 1 mg tablet cyproheptadine hcl 4 mg/10 ml syrup TIER 3 PA desloratadine TIER 1 ST dexchlorpheniramine maleate TIER 4 PA, AL1 (Up to 65 yrs old), QLC (30 ml/day) hydroxyzine hcl 10 mg tablet, 10 mg/5 ml TIER 1 solution, 25 mg tablet, 50 mg tablet, 50 mg/25ml solution hydroxyzine pamoate TIER 1 KARBINAL ER (carbinoxamine maleate) TIER 3 PA, QLC (40 ml/day) olopatadine hcl 0.6 % spray/pump TIER 1 ST, QLC (1 bottle/month) PATANASE (olopatadine hcl) TIER 3 ST, QLC (1 bottle/month) promethazine hcl 6.25mg/5ml syrup, 12.5 TIER 1 mg tablet, 25 mg tablet RYCLORA (dexchlorpheniramine TIER 4 PA, AL1 (Up to 65 yrs old), QLC (30 maleate) ml/day) RYVENT (carbinoxamine maleate) TIER 3 PA, QLC (4 tabs/day) VISTARIL (hydroxyzine pamoate) TIER 3 ANTILEUKOTRIENES ACCOLATE (zafirlukast) TIER 3 montelukast sodium 4 mg gran pack TIER 1 QLC (1 pack/day)

173 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS montelukast sodium 4 mg tab chew, 5 mg TIER 1 QLC (1 tab/day) tab chew, 10 mg tablet SINGULAIR (montelukast sodium) 4 MG TIER 3 QLC (1 pack/day) GRANULES SINGULAIR (montelukast sodium) 4 MG TIER 3 QLC (1 tab/day) TABLET CHEW, 5 MG TABLET CHEW, 10 MG TABLET zafirlukast TIER 1 zileuton TIER 4 PA ZYFLO (zileuton) TIER 4 PA ZYFLO CR (zileuton) TIER 4 PA BRONCHODILATORS (Drugs to Open the Airway) AUVI-Q (epinephrine) -0.1 MG AUTO- TIER 4 PA, QLC (4 injections/fill; max 6 fills INJECTOR per year) BRONCHODILATORS, ANTICHOLINERGIC (Anticholinergic Drugs to Open the Airway) ATROVENT (ipratropium bromide) 0.03% TIER 3 QLC (1 bottle/month) SPRAY ATROVENT (ipratropium bromide) 0.06% TIER 3 QLC (3 bottles/month) SPRAY ATROVENT HFA (ipratropium bromide) TIER 2 QLC (2 inhalers/month) INCRUSE ELLIPTA (umeclidinium bromide) TIER 2 QLC (1 inhaler/month) ipratropium bromide 0.2 mg/ml solution TIER 1 QLC (120 doses/month) ipratropium bromide 21 mcg spray TIER 1 QLC (1 bottle/month) ipratropium bromide 42 mcg spray TIER 1 QLC (3 bottles/month) LONHALA MAGNAIR REFILL TIER 4 PA, QLC (2 vials/day) (glycopyrrolate/nebulizer accessories) LONHALA MAGNAIR STARTER TIER 4 PA, QLC (2 vials/day) (glycopyrrolate/nebulizer and accessories) SEEBRI NEOHALER (glycopyrrolate) TIER 3 ST, QLC (1 inhaler[60 caps]/month) SPIRIVA (tiotropium bromide) TIER 2 QLC (30 caps/month) SPIRIVA RESPIMAT (tiotropium bromide) TIER 2 QLC (1 inhaler/month) TUDORZA PRESSAIR (aclidinium bromide) TIER 3 ST, QLC (1 inhaler/month)

174 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS YUPELRI (revefenacin) TIER 4 PA, QLC (3 ml/day) BRONCHODILATORS, SYMPATHOMIMETIC (Sympathomimetic Drugs to Open the Airway) albuterol hfa (generic proair hfa) TIER 1 QLC (2 inhalers/month) albuterol hfa (generic proventil hfa) TIER 1 QLC (2 inhalers/month) albuterol hfa (generic ventolin hfa) TIER 3 PA, QLC (2 inhalers/month) albuterol sulfate 0.63mg/3ml vial-, TIER 1 QLC (5 boxes/month) 1.25mg/3ml vial-, 2.5 mg/0.5 vial- albuterol sulfate 2 mg tablet, 2 mg/5 ml TIER 1 syrup, 4 mg tab er 12h, 4 mg tablet, 8 mg tab er 12h albuterol sulfate 2.5 mg/3ml vial-neb TIER 1 QLC (375 ml/month) albuterol sulfate 5 mg/ml solution TIER 1 QLC (4 bottles/month) ARCAPTA NEOHALER (indacaterol TIER 3 ST, QLC (1 cap/day) maleate) AUVI-Q (epinephrine) -0.15 MG AUTO-, - TIER 4 PA, QLC (4 injections/fill; max 6 fills 0.3 MG AUTO- per year) BROVANA (arformoterol tartrate) TIER 3 QLC (120 ml/month) epinephrine 0.15mg/0.3, 0.15/0.15, TIER 1 QLC (4 injections/fill; max 6 fills per 0.3mg/0.3 year) EPIPEN 2-PAK (epinephrine) TIER 2 QLC (4 injections/fill; max 6 fills per year) EPIPEN JR 2-PAK (epinephrine) TIER 2 QLC (4 injections/fill; max 6 fills per year) FORADIL (formoterol fumarate) TIER 3 PA levalbuterol hcl 0.31mg/3ml vial-, TIER 1 QLC (90 nebs/month) 0.63mg/3ml vial-, 1.25mg/3ml vial- levalbuterol hcl 1.25mg/0.5 vial-neb TIER 1 QLC (90 vials/month) levalbuterol tartrate TIER 1 QLC (2 inhalers/month at retail, 5 inhalers/3 months at mail order) metaproterenol sulfate TIER 1 PERFOROMIST (formoterol fumarate) TIER 3 QLC (1 box/month) PROAIR HFA (albuterol sulfate) TIER 3 QLC (2 inhalers/month) PROAIR RESPICLICK (albuterol sulfate) TIER 3 ST, QLC (2 inhalers/month) PROVENTIL HFA (albuterol sulfate) TIER 3 QLC (2 inhalers/month)

175 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS SEREVENT DISKUS (salmeterol xinafoate) TIER 2 QLC (1 inhaler/month) STRIVERDI RESPIMAT (olodaterol hcl) TIER 2 QLC (1 inhaler/month) SYMJEPI (epinephrine) TIER 3 PA, QLC (4 injections/fill; max 6 fills/year) terbutaline sulfate 2.5 mg tablet, 5 mg TIER 1 tablet VENTOLIN HFA (albuterol sulfate) TIER 2 QLC (2 inhalers/month) XOPENEX (levalbuterol hcl) TIER 3 QLC (90 nebs/month) XOPENEX CONCENTRATE (levalbuterol TIER 3 QLC (90 vials/month) hcl) XOPENEX HFA (levalbuterol tartrate) TIER 3 QLC (2 inhalers/month at retail, 5 inhalers/3 months at mail order) CYSTIC FIBROSIS AGENTS BETHKIS (tobramycin) TIER 4 PA, SP, QLC (1 box/2 months) CAYSTON (aztreonam lysine) TIER 4 PA, SP, QLC (1 box/2 months) KALYDECO (ivacaftor) 150 MG TABLET TIER 4 PA, SP, QLC (2 tabs/day) KALYDECO (ivacaftor) 25 MG GRANULES TIER 4 PA, SP, QLC (2 packets/day) PACKET KALYDECO (ivacaftor) 50 MG GRANULES TIER 4 PA, SP, QLC (2 packs/day) PACKET, 75 MG GRANULES PACKET KITABIS PAK (tobramycin/nebulizer) TIER 4 PA, SP, QLC (1 pack/56 days) ORKAMBI (lumacaftor/ivacaftor) 100 MG- TIER 4 PA, SP, QLC (4 tabs/day) 125 MG TABLET, 200 MG-125 MG TABLET ORKAMBI (lumacaftor/ivacaftor) 100-125 TIER 4 PA, SP, QLC (2 packs/day) MG GRANULE PKT, 150-188 MG GRANULE PKT SYMDEKO (tezacaftor/ivacaftor) TIER 4 PA, SP, QLC (2 tabs/day) TOBI PODHALER (tobramycin) TIER 4 PA, SP, QLC (224 caps/2 months) tobramycin in 0.225 % sodium chloride TIER 4 PA, SP, QLC (1 box/2 months) tobramycin/nebulizer TIER 4 PA, SP, QLC (1 pack/56 days) MAST CELL STABILIZERS (Drugs to Block Mast Cells) cromolyn sodium 20 mg/2 ml ampul-neb TIER 1 QLC (2 boxes/month)

176 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS PHOSPHODIESTERASE INHIBITORS, AIRWAYS DISEASE (Drugs that Block Phosphodiesterase) caffeine citrate 60 mg/3 ml solution TIER 1 DALIRESP (roflumilast) 250 MCG TABLET TIER 3 PA, QLC (1 tab/day, not to exceed 28 days therapy/6 months) DALIRESP (roflumilast) 500 MCG TABLET TIER 3 PA, QLC (1 tab/day) ELIXOPHYLLIN (theophylline anhydrous) TIER 3 THEO-24 (theophylline anhydrous) TIER 2 theophylline anhydrous TIER 1 theophylline anhydrous (THEOCHRON) TIER 1 PULMONARY ANTIHYPERTENSIVES (Drugs for Pulmonary Hypertension) ADCIRCA (tadalafil) TIER 4 PA, SP, QLC (2 tabs/day) ADEMPAS (riociguat) TIER 4 PA, SP, QLC (3 tabs/day) ambrisentan TIER 4 PA, SP, QLC (1 tab/day) bosentan TIER 4 PA, SP, QLC (2 tabs/day) LETAIRIS (ambrisentan) TIER 4 PA, SP, QLC (1 tab/day) OPSUMIT (macitentan) TIER 4 PA, SP, QLC (1 tab/day) ORENITRAM ER (treprostinil diolamine) 1 TIER 4 PA, SP, QLC (42 tabs/day) MG TABLET ORENITRAM ER (treprostinil diolamine) 2.5 TIER 4 PA, SP, QLC (16 tabs/day) MG TABLET ORENITRAM ER (treprostinil diolamine) 5 TIER 4 PA, SP, QLC (8 tabs/day) MG TABLET ORENITRAM ER (treprostinil diolamine) ER TIER 4 PA, SP, QLC (9 tabs/day) 0.125 MG TABLET, ER 0.25 MG TABLET REVATIO (sildenafil citrate) 10 MG/ML TIER 4 PA, SP, QLC (6 ml/day) ORAL SUSP REVATIO (sildenafil citrate) 20 MG TABLET TIER 4 PA, SP, QLC (3 tabs/day) sildenafil citrate 10 mg/ml susp recon TIER 4 PA, SP, QLC (6 ml/day) sildenafil citrate 20 mg tablet TIER 4 PA, SP, QLC (3 tabs/day) tadalafil (ALYQ) TIER 4 PA, SP, QLC (2 tabs/day)

177 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS TRACLEER (bosentan) 32 MG TABLET FOR TIER 4 PA, SP, QLC (4 tabs/day) SUSP TRACLEER (bosentan) 62.5 MG TABLET, 125 TIER 4 PA, SP, QLC (2 tabs/day) MG TABLET UPTRAVI (selexipag) 200 MCG TABLET, 400 TIER 4 PA, SP, QLC (2 tabs/day) MCG TABLET, 600 MCG TABLET, 800 MCG TABLET, 1,000 MCG TABLET, 1,200 MCG TABLET, 1,400 MCG TABLET, 1,600 MCG TABLET UPTRAVI (selexipag) 200-800 TITRATION TIER 4 PA, SP, QLC (200 tabs/6 months) PACK RESPIRATORY TRACT AGENTS, OTHER (Other Drugs for Breathing Conditions) acetylcysteine 100 mg/ml vial, 200 mg/ml TIER 1 vial ADVAIR DISKUS (fluticasone TIER 3 QLC (1 inhaler/month) propionate/salmeterol xinafoate) ADVAIR HFA (fluticasone TIER 2 QLC (1 inhaler/month) propionate/salmeterol xinafoate) AIRDUO RESPICLICK (fluticasone TIER 3 QLC (1 inhaler/month) propionate/salmeterol xinafoate) ANORO ELLIPTA (umeclidinium TIER 2 QLC (1 inhaler/month) bromide/vilanterol trifenatate) benzonatate TIER 1 BEVESPI AEROSPHERE TIER 3 ST, QLC (1 inhaler/month) (glycopyrrolate/formoterol fumarate) BREO ELLIPTA (fluticasone TIER 2 QLC (1 inhaler/month) furoate/vilanterol trifenatate) brompheniramine TIER 1 maleate/pseudoephedrine hcl/dextromethorphan brompheniramine TIER 1 maleate/pseudoephedrine hcl/dextromethorphan (BROMFED DM) CLARINEX-D 12 HOUR TIER 3 ST (desloratadine/pseudoephedrine sulfate) codeine phosphate/guaifenesin TIER 1 AL1 (At least 18 yrs old), QLC (60 ml/day; max 7 days therapy/month) codeine phosphate/guaifenesin TIER 1 AL1 (At least 18 yrs old), QLC (60 (CHERATUSSIN AC) ml/day; max 7 days therapy/month)

178 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS codeine phosphate/guaifenesin (G TIER 1 AL1 (At least 18 yrs old), QLC (60 TUSSIN AC) ml/day; max 7 days therapy/month) codeine phosphate/guaifenesin TIER 1 AL1 (At least 18 yrs old), QLC (60 (GUAIATUSSIN AC) ml/day; max 7 days therapy/month) codeine phosphate/guaifenesin TIER 1 AL1 (At least 18 yrs old), QLC (60 (GUAIFENESIN AC) ml/day; max 7 days therapy/month) codeine phosphate/guaifenesin TIER 1 AL1 (At least 18 yrs old), QLC (60 (ROBAFEN AC) ml/day; max 7 days therapy/month) codeine phosphate/guaifenesin TIER 1 AL1 (At least 18 yrs old), QLC (60 (VIRTUSSIN AC) ml/day; max 7 days therapy/month) COMBIVENT RESPIMAT (ipratropium TIER 2 QLC (1 inhaler/month) bromide/albuterol sulfate) DULERA (mometasone furoate/formoterol TIER 3 PA, QLC (1 inhaler/month) fumarate) DYMISTA (azelastine hcl/fluticasone TIER 3 ST, QLC (1 bottle/month) propionate) ESBRIET (pirfenidone) 267 MG CAPSULE TIER 4 PA, SP, QLC (9 caps/day) ESBRIET (pirfenidone) 267 MG TABLET TIER 4 PA, SP, QLC (9 tabs/day) ESBRIET (pirfenidone) 801 MG TABLET TIER 4 PA, SP, QLC (3 tabs/day) FLOWTUSS (guaifenesin/hydrocodone TIER 3 PA, AL1 (At least 18 yrs old), QLC bitartrate) (60 ml/day, max 7 days therapy/month) fluticasone propionate/salmeterol TIER 1 QLC (1 inhaler/month) xinafoate (WIXELA INHUB) fluticasone propionate/salmeterol TIER 1 QLC (1 inhaler/month) xinafoate propion/salmeterol 250-50 mcg w/dev, propion/salmeterol 500-50 mcg w/dev fluticasone propionate/salmeterol TIER 1 QLC (1 inhaler/month) xinafoate propion/salmeterol 55-14 mcg aer pow ba, propion/salmeterol 100-50 mcg blst w/dev, propion/salmeterol 113- 14 mcg aer pow ba, propion/salmeterol 232-14 mcg aer pow ba GRASTEK (allergenic extract,grass pollen- TIER 3 PA, QLC (1 tab/day) timothy,standard)

179 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS guaifenesin/hydrocodone bitartrate TIER 4 PA, AL1 (At least 18 yrs old), QLC (60 ml/day, max 7 days therapy/month) HYCOFENIX (hydrocodone TIER 3 AL1 (At least 18 yrs old), QLC (40 bitartrate/pseudoephedrine ml/day; max 7 days hcl/guaifenesin) therapy/month) hydrocodone bitart/chlorpheniramine TIER 1 AL1 (At least 18 yrs old), QLC (20 maleate/pseudoephedrine ml/day; max 7 days therapy/month) hydrocodone bitartrate/homatropine TIER 1 AL1 (At least 18 yrs old), QLC (30 methylbromide (HYDROMET) ml/day; max 7 days therapy/month) hydrocodone bitartrate/homatropine TIER 1 AL1 (At least 18 yrs old), QLC (6 methylbromide (TUSSIGON) tabs/day; max 7 days therapy/month) hydrocodone bitartrate/homatropine TIER 1 AL1 (At least 18 yrs old), QLC (6 methylbromide bit/homatrop -5 mg- tabs/day; max 7 days 1.5mg tablet therapy/month) hydrocodone bitartrate/homatropine TIER 1 AL1 (At least 18 yrs old), QLC (30 methylbromide bit/homatrop -5-1.5 mg/5 ml/day; max 7 days syrup therapy/month) hydrocodone polistirex/chlorpheniramine TIER 1 AL1 (At least 18 yrs old), QLC (10 polistirex ml/day; max 7 days therapy/month) HYPER-SAL (sodium chloride for inhalation) TIER 3 ipratropium bromide/albuterol sulfate TIER 1 QLC (6 boxes [30 doses/box]/month) NEBUSAL (sodium chloride for inhalation) TIER 3 NUCALA (mepolizumab) 100 MG/ML TIER 4 PA, SP, QLC (3 auto-injectors/28 AUTO-INJECTOR days) NUCALA (mepolizumab) 100 MG/ML TIER 4 PA, SP, QLC (3 syringes/28 days) SYRINGE OBREDON (guaifenesin/hydrocodone TIER 3 PA, AL1 (At least 18 yrs old), QLC bitartrate) (60 ml/day, max 7 days therapy/month) OFEV (nintedanib esylate) TIER 4 PA, SP, QLC (2 caps/day) ORALAIR (grass pollen-orchard/sweet TIER 3 PA, SP, RO (Retail Only), QLC (1 vernal/rye/kentucky/timothy, std.) tab/day) phenylephrine hcl/promethazine hcl TIER 1 promethazine hcl/codeine TIER 1 AL1 (At least 18 yrs old), QLC (30 ml/day; max 7 days therapy/month)

180 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS promethazine hcl/dextromethorphan hbr TIER 1 promethazine/phenylephrine TIER 1 AL1 (At least 18 yrs old), QLC (30 hcl/codeine ml/day; max 7 days therapy/month) PULMOZYME (dornase alfa) TIER 4 SP, QLC (5 ml/day) RAGWITEK (allergenic extract-weed TIER 3 PA, QLC (1 tab/day) pollen-short ragweed) REZIRA (pseudoephedrine TIER 3 QLC (max 7 days therapy/month) hcl/hydrocodone bitartrate) sodium chloride for inhalation TIER 1 sodium chloride for inhalation (NEBUSAL) TIER 1 sodium chloride for inhalation TIER 1 (PULMOSAL) STIOLTO RESPIMAT (tiotropium TIER 3 ST, QLC (1 inhaler/month) bromide/olodaterol hcl) SYMBICORT (budesonide/formoterol TIER 2 QLC (1 inhaler/month) fumarate) TESSALON PERLE (benzonatate) TIER 3 TOBI (tobramycin in 0.225 % sodium TIER 4 PA, SP, QLC (1 box/2 months) chloride) TRELEGY ELLIPTA (fluticasone TIER 2 QLC (1 inhaler/month) furoate/umeclidinium bromide/vilanterol trifenat) TUSSICAPS (hydrocodone TIER 3 PA, AL1 (At least 18 yrs old), QLC polistirex/chlorpheniramine polistirex) (2 caps/day; max 7 days therapy/month) TUSSIONEX (hydrocodone TIER 3 AL1 (At least 18 yrs old), QLC (10 polistirex/chlorpheniramine polistirex) ml/day; max 7 days therapy/month) TUXARIN ER (chlorpheniramine TIER 3 AL1 (At least 18 yrs old), QLC (2 maleate/codeine phosphate) tabs/day; max 14 tabs/30 days) TUZISTRA XR (codeine TIER 3 AL1 (At least 18 yrs old), QLC (20 polistirex/chlorpheniramine polistirex) ml/day; max 7 days therapy/month) UTIBRON NEOHALER (indacaterol TIER 3 ST, QLC (1 inhaler[60 maleate/glycopyrrolate) caps]/month) VITUZ (hydrocodone TIER 3 AL1 (At least 18 yrs old), QLC (20 bitartrate/chlorpheniramine maleate) ml/day; max 7 days therapy/month)

181 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS ZUTRIPRO (hydrocodone TIER 3 AL1 (At least 18 yrs old), QLC (20 bitart/chlorpheniramine ml/day; max 7 days maleate/pseudoephedrine) therapy/month)

SKELETAL MUSCLE RELAXANTS (Drugs for the Muscles) SKELETAL MUSCLE RELAXANTS (Drugs to Relax the Muscles) AMRIX (cyclobenzaprine hcl) TIER 3 ST, AL1 (Up to 65 yrs old), QLC (1 cap/day) carisoprodol TIER 1 AL1 (Up to 65 yrs old), QLC (4 tabs/day) carisoprodol/aspirin TIER 1 AL1 (Up to 65 yrs old), QLC (8 tabs/day) chlorzoxazone 250 mg tablet, 500 mg TIER 1 AL1 (Up to 65 yrs old), QLC (4 tablet tabs/day) chlorzoxazone 375 mg tablet, 750 mg TIER 1 QLC (4 tabs/day) tablet cyclobenzaprine hcl 15 mg cap er 24h TIER 1 ST, AL1 (Up to 65 yrs old), QLC (1 cap/day) cyclobenzaprine hcl 30 mg cap er 24h TIER 1 ST, AL1 (Up to 65 yrs old), QLC (1 CAP/DAY) cyclobenzaprine hcl 5 mg tablet, 10 mg TIER 1 AL1 (Up to 65 yrs old) tablet cyclobenzaprine hcl 7.5 mg tablet TIER 1 ST, AL1 (Up to 65 yrs old), QLC (3 tabs/day) FEXMID (cyclobenzaprine hcl) TIER 3 ST, AL1 (Up to 65 yrs old), QLC (3 tabs/day) LORZONE (chlorzoxazone) TIER 3 QLC (4 tabs/day) metaxalone TIER 1 AL1 (Up to 65 yrs old), QLC (4 tabs/day) metaxalone (METAXALL) TIER 1 AL1 (Up to 65 yrs old), QLC (4 tabs/day) methocarbamol 500 mg tablet, 750 mg TIER 1 AL1 (Up to 65 yrs old) tablet NORGESIC FORTE (orphenadrine TIER 3 QLC (4 tabs/day) citrate/aspirin/caffeine) orphenadrine citrate 100 mg tablet er TIER 1 AL1 (Up to 65 yrs old) orphenadrine citrate/aspirin/caffeine TIER 3 QLC (4 tabs/day)

182 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS orphenadrine citrate/aspirin/caffeine TIER 3 QLC (4 tabs/day) (ORPHENGESIC FORTE) PARAFON FORTE DSC (chlorzoxazone) TIER 3 AL1 (Up to 65 yrs old), QLC (4 tabs/day) ROBAXIN (methocarbamol) 500 MG TIER 3 AL1 (Up to 65 yrs old) TABLET ROBAXIN-750 (methocarbamol) TIER 3 AL1 (Up to 65 yrs old) SKELAXIN (metaxalone) TIER 3 AL1 (Up to 65 yrs old), QLC (4 tabs/day) SOMA (carisoprodol) TIER 3 AL1 (Up to 65 yrs old), QLC (4 tabs/day)

SLEEP DISORDER AGENTS (Drugs for Insomnia) GABA RECEPTOR MODULATORS AMBIEN (zolpidem tartrate) 10 MG TABLET TIER 3 AL1 (Up to 65 yrs old), QLC (1 tab/day) AMBIEN (zolpidem tartrate) 5 MG TABLET TIER 3 AL1 (Up to 65 yrs old), QLC (2 tabs/day) AMBIEN CR (zolpidem tartrate) 12.5 MG TIER 3 AL1 (Up to 65 yrs old), QLC (1 TABLET tab/day) AMBIEN CR (zolpidem tartrate) 6.25 MG TIER 3 AL1 (Up to 65 yrs old), QLC (2 TABLET tabs/day) DORAL (quazepam) TIER 3 AL1 (Up to 65 yrs old), QLC (1 tab/day) EDLUAR (zolpidem tartrate) TIER 3 PA, AL1 (Up to 65 yrs old), QLC (1 tab/day) estazolam 1 mg tablet TIER 1 QLC (2 tabs/day) estazolam 2 mg tablet TIER 1 QLC (1 tab/day) eszopiclone TIER 1 AL1 (Up to 65 yrs old), QLC (1 tab/day) flurazepam hcl 15 mg capsule TIER 1 AL1 (Up to 65 yrs old), QLC (2 caps/day) flurazepam hcl 30 mg capsule TIER 1 AL1 (Up to 65 yrs old), QLC (1 cap/day) HALCION (triazolam) TIER 3 QLC (2 tabs/day) INTERMEZZO (zolpidem tartrate) TIER 3 PA, AL1 (Up to 65 yrs old), QLC (1 tab/day)

183 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS LUNESTA (eszopiclone) TIER 3 AL1 (Up to 65 yrs old), QLC (1 tab/day) quazepam TIER 1 AL1 (Up to 65 yrs old), QLC (1 tab/day) RESTORIL (temazepam) 15 MG CAPSULE TIER 3 QLC (2 caps/day) RESTORIL (temazepam) 22.5 MG CAPSULE, TIER 3 QLC (1 cap/day) 30 MG CAPSULE RESTORIL (temazepam) 7.5 MG CAPSULE TIER 3 QLC (4 caps/day) SONATA (zaleplon) 10 MG CAPSULE TIER 3 AL1 (Up to 65 yrs old), QLC (2 caps/day) SONATA (zaleplon) 5 MG CAPSULE TIER 3 AL1 (Up to 65 yrs old), QLC (4 caps/day) temazepam 15 mg capsule TIER 1 QLC (2 caps/day) temazepam 22.5 mg capsule, 30 mg TIER 1 QLC (1 cap/day) capsule temazepam 7.5 mg capsule TIER 1 QLC (4 caps/day) triazolam 0.125 mg tablet TIER 1 QLC (4 tabs/day) triazolam 0.25 mg tablet TIER 1 QLC (2 tabs/day) zaleplon 10 mg capsule TIER 1 AL1 (Up to 65 yrs old), QLC (2 caps/day) zaleplon 5 mg capsule TIER 1 AL1 (Up to 65 yrs old), QLC (4 caps/day) zolpidem tartrate 1.75 mg tab, 3.5 mg tab TIER 1 PA, AL1 (Up to 65 yrs old), QLC (1 tab/day) zolpidem tartrate 10 mg tablet, 12.5 mg TIER 1 AL1 (Up to 65 yrs old), QLC (1 tab mphase tab/day) zolpidem tartrate 5 mg tablet, 6.25 mg TIER 1 AL1 (Up to 65 yrs old), QLC (2 tab mphase tabs/day) ZOLPIMIST (zolpidem tartrate) TIER 3 PA, AL1 (Up to 65 yrs old), QLC (1 bottle/month) SLEEP DISORDERS, OTHER armodafinil 150 mg tablet, 200 mg tablet, TIER 3 PA, QLC (1 tab/day) 250 mg tablet armodafinil 50 mg tablet TIER 3 PA, QLC (2 tabs/day) BELSOMRA (suvorexant) TIER 3 ST, QLC (1 tab/day) BUTISOL SODIUM (butabarbital sodium) TIER 3

184 LAST UPDATED 10/01/2019 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS HETLIOZ (tasimelteon) TIER 4 PA, SP, QLC (1 cap/day) modafinil 100 mg tablet TIER 1 PA, QLC (3 tabs/day) modafinil 200 mg tablet TIER 1 PA, QLC (2 tabs/day) NUVIGIL (armodafinil) 150 MG TABLET, 200 TIER 3 PA, QLC (1 tab/day) MG TABLET, 250 MG TABLET NUVIGIL (armodafinil) 50 MG TABLET TIER 3 PA, QLC (2 tabs/day) PROVIGIL (modafinil) 100 MG TABLET TIER 3 PA, QLC (3 tabs/day) PROVIGIL (modafinil) 200 MG TABLET TIER 3 PA, QLC (2 tabs/day) ramelteon TIER 1 ST, AL1 (At least 65 yrs old), QLC (1 tab/day) ROZEREM (ramelteon) TIER 3 ST, AL1 (At least 65 yrs old), QLC (1 tab/day) SECONAL SODIUM (secobarbital sodium) TIER 3 QLC (1 cap/day, not to exceed 14 caps/30 days) SILENOR (doxepin hcl) TIER 3 QLC (1 tab/day) SUNOSI (solriamfetol hcl) TIER 3 PA, QLC (1 tab/day) XYREM (sodium oxybate) TIER 4 PA, SP, QLC (3 bottles/month)

185 LAST UPDATED 10/01/2019 Alphabetical Index of Prescription Drugs ACTICLATE (doxycycline hyclate) 23 8 ACTIGALL (ursodiol) 124 8-MOP (methoxsalen) 104 ACTIMMUNE (interferon gamma- 1b,recomb.) 160 A ACTIQ (fentanyl citrate) 7 abacavir sulfate 61 ACTIVELLA (estradiol/norethindrone abacavir sulfate/lamivudine 61 acetate) 142 abacavir sulfate/lamivudine/zidovudine 61 ACTONEL (risedronate sodium) 161,162 ABILIFY (aripiprazole) 55 ACTOPLUS MET (pioglitazone hcl/metformin ABILIFY MYCITE (aripiprazole) 55 hcl) 68 abiraterone acetate 43 ACTOPLUS MET XR (pioglitazone ABSORICA (isotretinoin) 104 hcl/metformin hcl) 68 ABSTRAL (fentanyl citrate) 7 ACTOS (pioglitazone hcl) 68 acamprosate calcium 14 ACULAR (ketorolac tromethamine) 167 ACANYA (clindamycin phosphate/benzoyl ACULAR LS (ketorolac tromethamine) 167 peroxide) 104 ACUVAIL (ketorolac tromethamine/pf) 168 acarbose 68 acyclovir 65 ACCOLATE (zafirlukast) 173 ACZONE (dapsone) 104 accu-chek blood glucose test strips 163 ADALAT CC (nifedipine) 82 ACCUPRIL (quinapril hcl) 79 adapalene 104 ACCURETIC (quinapril adapalene (PLIXDA) 104 hcl/hydrochlorothiazide) 84 adapalene/benzoyl peroxide 104 acebutolol hcl 81 ADCIRCA (tadalafil) 177 ACEON (perindopril erbumine) 79 ADDERALL (dextroamphetamine sulf- acetaminophen with codeine phosphate 7 saccharate/amphetamine sulf-aspartate) 94 acetaminophen/caffeine/dihydrocodeine ADDERALL XR (dextroamphetamine sulf- bitartrate 7 saccharate/amphetamine sulf-aspartate) 94 acetaminophen/caffeine/dihydrocodeine ADDYI (flibanserin) 131 bitartrate (DVORAH) 7 adefovir dipivoxil 58 acetaminophen/caffeine/dihydrocodeine ADEMPAS (riociguat) 177 bitartrate (PANLOR) 7 ADHANSIA XR (methylphenidate hcl) 97 acetazolamide 89 ADIPEX-P (phentermine hcl) 100 acetic acid 171 ADLYXIN (lixisenatide) 68 acetic acid/aluminum acetate 171 ADMELOG (insulin lispro) 72 acetylcysteine 178 ADMELOG SOLOSTAR (insulin lispro) 72 ACIPHEX (rabeprazole sodium) 127 ADOXA (doxycycline monohydrate) 23 ACIPHEX SPRINKLE (rabeprazole sodium) 127 ADVAIR DISKUS (fluticasone acitretin 104 propionate/salmeterol xinafoate) 178 ACTEMRA (tocilizumab) 160 ADVAIR HFA (fluticasone ACTEMRA ACTPEN (tocilizumab) 160 propionate/salmeterol xinafoate) 178 ACTHAR (corticotropin) 140 ADZENYS ER (amphetamine) 94

186 LAST UPDATED 10/01/2019 ADZENYS XR-ODT (amphetamine) 94 alogliptin benzoate 68 AEMCOLO (rifamycin sodium) 16 alogliptin benzoate/metformin hcl 68 AEROSPAN (flunisolide) 171 alogliptin benzoate/pioglitazone hcl 68 AFINITOR (everolimus) 47 ALOMIDE (lodoxamide tromethamine) 167 AFINITOR DISPERZ (everolimus) 47 ALORA (estradiol) 142 AFREZZA (insulin regular, human) 72 alosetron hcl 125 AGGRENOX (aspirin/dipyridamole) 76 ALPHAGAN P (brimonidine tartrate) 169 AGRYLIN (anagrelide hcl) 75 alprazolam 66 AIMOVIG AUTOINJECTOR (erenumab- alprazolam (ALPRAZOLAM INTENSOL) 66 aooe) 40 ALREX (loteprednol etabonate) 168 AIRDUO RESPICLICK (fluticasone ALTABAX (retapamulin) 16 propionate/salmeterol xinafoate) 178 ALTACE (ramipril) 79 AJOVY (fremanezumab-vfrm) 40 ALTOPREV (lovastatin) 91 AKTIPAK (erythromycin base/benzoyl ALTRENO (tretinoin) 104 peroxide) 16 ALUNBRIG (brigatinib) 45 AKYNZEO (netupitant/palonosetron hcl) 36 ALVESCO (ciclesonide) 171 ALA-SCALP (hydrocortisone) 134 amantadine hcl 52 albendazole 51 AMARYL (glimepiride) 68 ALBENZA (albendazole) 51 AMBIEN (zolpidem tartrate) 183 albuterol hfa (generic proair hfa) 175 AMBIEN CR (zolpidem tartrate) 183 albuterol hfa (generic proventil hfa) 175 ambrisentan 177 albuterol hfa (generic ventolin hfa) 175 amcinonide 134 albuterol sulfate 175 AMERGE (naratriptan hcl) 40 ALCAINE (proparacaine hcl) 165 AMICAR (aminocaproic acid) 76 alclometasone dipropionate 134 amiloride hcl 89 ALDACTAZIDE amiloride hcl/hydrochlorothiazide 84 (spironolactone/hydrochlorothiazide) 84 aminocaproic acid 76 ALDACTONE (spironolactone) 89 amiodarone hcl 80 ALDARA (imiquimod) 104 amiodarone hcl (PACERONE) 80 ALECENSA (alectinib hcl) 47 AMITIZA (lubiprostone) 125 alendronate sodium 162 amitriptyline hcl 34 alfuzosin hcl 131 amitriptyline hcl/chlordiazepoxide 31 ALINIA (nitazoxanide) 51 amlodipine besylate 82 aliskiren hemifumarate 84 amlodipine besylate/atorvastatin calcium 84 ALKERAN (melphalan) 43 amlodipine besylate/benazepril hcl 84 all non accu-chek blood glucose test amlodipine besylate/olmesartan strips 163 medoxomil 84 allopurinol 39 amlodipine besylate/valsartan 84 ALLZITAL (butalbital/acetaminophen) 100 amlodipine almotriptan malate 40 besylate/valsartan/hydrochlorothiazide 84 ALOCRIL (nedocromil sodium) 167 amoxapine 34

187 LAST UPDATED 10/01/2019 amoxicillin 19 ARANESP (darbepoetin alfa in polysorbate amoxicillin/potassium clavulanate 19 80) 75 amphetamine sulfate 94 ARAVA (leflunomide) 160 ampicillin trihydrate 20 ARCALYST (rilonacept) 160 AMPYRA (dalfampridine) 102 ARCAPTA NEOHALER (indacaterol AMRIX (cyclobenzaprine hcl) 182 maleate) 175 ANADROL-50 (oxymetholone) 141 ARICEPT (donepezil hcl) 30 ANAFRANIL (clomipramine hcl) 35 ARIKAYCE (amikacin sulfate liposomal with anagrelide hcl 75 nebulizer accessories) 16 ANALPRAM HC (hydrocortisone ARIMIDEX (anastrozole) 46 acetate/pramoxine hcl) 104 aripiprazole 55,56 ANAPROX (naproxen sodium) 1 ARIXTRA (fondaparinux sodium) 74 ANAPROX DS (naproxen sodium) 1 armodafinil 184 ANASPAZ (hyoscyamine sulfate) 122 ARMONAIR RESPICLICK (fluticasone anastrozole 46 propionate) 171 ANCOBON (flucytosine) 37 ARMOUR THYROID (thyroid,pork) 155 ANDRODERM (testosterone) 141 ARNUITY ELLIPTA (fluticasone furoate) 172 ANDROGEL (testosterone) 141 AROMASIN (exemestane) 46 ANDROID (methyltestosterone) 141 ARTHROTEC 50 (diclofenac ANGELIQ (drospirenone/estradiol) 142 sodium/misoprostol) 1 ANNOVERA (segesterone acetate/ethinyl ARTHROTEC 75 (diclofenac estradiol) 142 sodium/misoprostol) 1 ANORO ELLIPTA (umeclidinium ARYMO ER (morphine sulfate) 3 bromide/vilanterol trifenatate) 178 ASACOL HD (mesalamine) 160 ANTABUSE (disulfiram) 14 ASMANEX (mometasone furoate) 172 ANTARA (fenofibrate,micronized) 90 ASMANEX HFA (mometasone furoate) 172 ANZEMET (dolasetron mesylate) 36 aspirin/caffeine/dihydrocodeine bitartrate 7 APADAZ (benzhydrocodone aspirin/dipyridamole 76 hcl/acetaminophen) 7 aspirin/omeprazole 76 APIDRA (insulin glulisine) 72 ASTAGRAF XL (tacrolimus) 157 APIDRA SOLOSTAR (insulin glulisine) 72 ASTEPRO (azelastine hcl) 173 APLENZIN (bupropion hbr) 31 ATABEX EC (prenatal vits with calcium APOKYN (apomorphine hcl) 53 43/iron/folic acid/docusate sod.) 112 apraclonidine hcl 169 ATACAND (candesartan cilexetil) 78 aprepitant 36 ATACAND HCT (candesartan APRISO (mesalamine) 160 cilexetil/hydrochlorothiazide) 84 APTENSIO XR (methylphenidate hcl) 97 atazanavir sulfate 63 APTIOM (eslicarbazepine acetate) 29 ATELVIA (risedronate sodium) 162 APTIVUS (tipranavir) 63 atenolol 81 APTIVUS (tipranavir/vitamin e tpgs) 63 atenolol/chlorthalidone 84 ARAKODA (tafenoquine succinate) 51 ATIVAN (lorazepam) 66

188 LAST UPDATED 10/01/2019 atomoxetine hcl 97 azelaic acid 104 atorvastatin calcium 91 azelastine hcl 167,173 atovaquone 51 AZELEX (azelaic acid) 104 atovaquone/proguanil hcl 51 AZESCO (prenatal vitamins no.147/ferrous ATRALIN (tretinoin) 104 gluconate/folic acid) 112 ATRIPLA (efavirenz/emtricitabine/tenofovir AZILECT (rasagiline mesylate) 54 disoproxil fumarate) 60 azithromycin 20 atropine sulfate 165 AZOPT (brinzolamide) 169 ATROVENT (ipratropium bromide) 174 AZOR (amlodipine besylate/olmesartan ATROVENT HFA (ipratropium bromide) 174 medoxomil) 84 AUBAGIO (teriflunomide) 102 AZULFIDINE (sulfasalazine) 161 AUGMENTIN (amoxicillin/potassium clavulanate) 20 B AUGMENTIN ES-600 (amoxicillin/potassium bacitracin 16 clavulanate) 20 bacitracin/polymyxin b sulfate 165 AUGMENTIN XR (amoxicillin/potassium bacitracin/polymyxin b sulfate (AK-POLY- clavulanate) 20 BAC) 165 AURYXIA (ferric citrate) 134 bacitracin/polymyxin b sulfate (POLYCIN) 165 AUSTEDO (deutetrabenazine) 100 baclofen 57 AUVI-Q (epinephrine) 174,175 BACTRIM (sulfamethoxazole/trimethoprim) 22 AVALIDE (irbesartan/hydrochlorothiazide) 84 BACTRIM DS AVANDIA (rosiglitazone maleate) 68 (sulfamethoxazole/trimethoprim) 22 AVAPRO (irbesartan) 78 BACTROBAN (mupirocin calcium) 16 AVAR (sulfacetamide sodium/sulfur) 104 BACTROBAN (mupirocin) 16 AVAR LS (sulfacetamide sodium/sulfur) 104 BACTROBAN NASAL (mupirocin calcium) 16 AVAR-E LS (sulfacetamide sodium/sulfur) 104 BALCOLTRA (levonorgestrel/ethinyl AVC (sulfanilamide) 22 estradiol/ferrous bisglycinate) 143 AVELOX (moxifloxacin hcl) 21 balsalazide disodium 160 AVELOX ABC PACK (moxifloxacin hcl) 21 BALVERSA (erdafitinib) 45 AVITA (tretinoin) 104 BANZEL (rufinamide) 29 AVODART (dutasteride) 131 BAQSIMI (glucagon) 71 AVONEX (interferon beta-1a) 102 BARACLUDE (entecavir) 58 AVONEX (interferon beta-1a/albumin BASAGLAR KWIKPEN U-100 (insulin human) 102 glargine,human recombinant analog) 72 AVONEX PEN (interferon beta-1a) 102 BAXDELA (delafloxacin meglumine) 21 AXERT (almotriptan malate) 40 BECONASE AQ (beclomethasone AXIRON (testosterone) 142 dipropionate) 172 AYGESTIN (norethindrone acetate) 153 BELBUCA (buprenorphine hcl) 3 AZASAN (azathioprine) 157 BELSOMRA (suvorexant) 184 AZASITE (azithromycin) 20 BELVIQ (lorcaserin hcl) 100 azathioprine 157 BELVIQ XR (lorcaserin hcl) 100

189 LAST UPDATED 10/01/2019 benazepril hcl 79 BIKTARVY (bictegravir benazepril hcl/hydrochlorothiazide 84 sodium/emtricitabine/tenofovir alafenamide BENICAR (olmesartan medoxomil) 78 fumar) 59 BENICAR HCT (olmesartan BILTRICIDE (praziquantel) 51 medoxomil/hydrochlorothiazide) 84 bimatoprost 170 BENLYSTA (belimumab) 160 BINOSTO (alendronate sodium) 162 BENTYL (dicyclomine hcl) 122 bisacodyl/sodium chlor/sodium BENZACLIN (clindamycin phosphate/benzoyl bicarb/potassium chl/peg 3350 (PEG- peroxide) 104,105 PREP) 125 BENZAMYCIN (erythromycin base/benzoyl bisoprolol fumarate 81 peroxide) 16 bisoprolol fumarate/hydrochlorothiazide 85 benzhydrocodone hcl/acetaminophen 7,8 BLEPH-10 (sulfacetamide sodium) 22 benznidazole 51 BLEPHAMIDE (sulfacetamide benzonatate 178 sodium/prednisolone acetate) 165 benzphetamine hcl 100 BLEPHAMIDE S.O.P. (sulfacetamide benztropine mesylate 52 sodium/prednisolone acetate) 165 BEPREVE (bepotastine besilate) 167 blood ketone test, strips 163 BESIVANCE (besifloxacin hcl) 21 BONIVA (ibandronate sodium) 162 BETAGAN (levobunolol hcl) 169 BONJESTA (doxylamine succinate/pyridoxine betamethasone dipropionate 134 hcl (b6)) 35 betamethasone dipropionate/propylene bosentan 177 glycol 134 BOSULIF (bosutinib) 47 betamethasone valerate 134 BRAFTOVI (encorafenib) 47 BETAPACE (sotalol hcl) 80 BREO ELLIPTA (fluticasone furoate/vilanterol BETAPACE AF (sotalol hcl) 80 trifenatate) 178 BETASERON (interferon beta-1b) 102 BREVICON (norethindrone-ethinyl betaxolol hcl 81,169 estradiol) 143 bethanechol chloride 131 BRILINTA (ticagrelor) 76 BETHKIS (tobramycin) 176 brimonidine tartrate 169 BETIMOL (timolol) 169 BRISDELLE (paroxetine mesylate) 32 BETOPTIC S (betaxolol hcl) 169 BRIVIACT (brivaracetam) 25 BEVESPI AEROSPHERE bromfenac sodium 168 (glycopyrrolate/formoterol fumarate) 178 bromocriptine mesylate 53 BEVYXXA (betrixaban maleate) 74 brompheniramine maleate/pseudoephedrine bexarotene 50 hcl/dextromethorphan 178 BEYAZ (drospirenone/ethinyl brompheniramine maleate/pseudoephedrine estradiol/levomefolate calcium) 143 hcl/dextromethorphan (BROMFED DM) 178 BIAXIN (clarithromycin) 20 BROMSITE (bromfenac sodium) 168 bicalutamide 43 BROVANA (arformoterol tartrate) 175 BIDIL (isosorbide dinitrate/hydralazine hcl) 85 BRYHALI (halobetasol propionate) 134 BIJUVA (estradiol/progesterone) 143 budesonide 161,172

190 LAST UPDATED 10/01/2019 bumetanide 89 CADUET (amlodipine besylate/atorvastatin BUNAVAIL (buprenorphine hcl/naloxone calcium) 85 hcl) 14 CAFERGOT (ergotamine tartrate/caffeine) 40 BUPHENYL (sodium phenylbutyrate) 128 caffeine citrate 177 buprenorphine 3 CALAN (verapamil hcl) 82 buprenorphine hcl 14 CALAN SR (verapamil hcl) 82 buprenorphine hcl/naloxone hcl 15 calcipotriene 105 bupropion hcl 15,31 calcipotriene (CALCITRENE) 105 buspirone hcl 66 calcipotriene/betamethasone butalbital/acetaminophen 100 dipropionate 105 butalbital/acetaminophen (BUPAP) 100 calcitonin,salmon,synthetic 162 butalbital/acetaminophen (TENCON) 100 calcitriol 105,162 butalbital/acetaminophen/caffeine 100 calcium acetate 134 butalbital/acetaminophen/caffeine CALQUENCE (acalabrutinib) 47 (FIORICET) 100 CAMBIA (diclofenac potassium) 1 butalbital/acetaminophen/caffeine CANASA (mesalamine) 160 (PHRENILIN FORTE) 100 candesartan cilexetil 78 butalbital/acetaminophen/caffeine candesartan cilexetil/hydrochlorothiazide 85 (VANATOL LQ) 100 capecitabine 44 butalbital/acetaminophen/caffeine CAPEX SHAMPOO (fluocinolone (VANATOL S) 100 acetonide) 134 butalbital/acetaminophen/caffeine/codeine CAPITAL W-CODEINE (acetaminophen with phosphate 8 codeine phosphate) 8 butalbital/aspirin/caffeine 1 CAPRELSA (vandetanib) 47 BUTISOL SODIUM (butabarbital sodium) 184 captopril 79 butoconazole nitrate (GYNAZOLE 1) 37 captopril/hydrochlorothiazide 85 butorphanol tartrate 8 CARAC (fluorouracil) 105 BUTRANS (buprenorphine) 3 CARAFATE (sucralfate) 127 BYDUREON (exenatide microspheres) 68 CARBAGLU (carglumic acid) 128 BYDUREON BCISE (exenatide microspheres) 68 carbamazepine 29 BYDUREON PEN (exenatide microspheres) 68 carbamazepine (EPITOL) 29 BYETTA (exenatide) 68 CARBATROL (carbamazepine) 29 BYSTOLIC (nebivolol hcl) 81 carbidopa 54 BYVALSON (nebivolol hcl/valsartan) 85 carbidopa/levodopa 54 carbidopa/levodopa/entacapone 52 C carbinoxamine maleate 173 cabergoline 156 carbinoxamine maleate (ARBINOXA) 173 CABLIVI (caplacizumab-yhdp) 75 CARDIZEM (diltiazem hcl) 82 CABOMETYX (cabozantinib s-malate) 47 CARDIZEM CD (diltiazem hcl) 82 CADEAU DHA (prenatal vitamins no.83/iron CARDIZEM LA (diltiazem hcl) 82 fumarate/folate combo no.6/dha) 112 CARDURA (doxazosin mesylate) 77

191 LAST UPDATED 10/01/2019 CARDURA XL (doxazosin mesylate) 131 cevimeline hcl 103 carisoprodol 182 CHANTIX (varenicline tartrate) 15,16 carisoprodol/aspirin 182 CHEMET (succimer) 112 carisoprodol/aspirin/codeine phosphate 8 CHENODAL (chenodiol) 124 CARNITOR (levocarnitine (with sugar)) 112 chlordiazepoxide hcl 66 CARNITOR (levocarnitine) 112 chlordiazepoxide/clidinium bromide 122 CARNITOR SF (levocarnitine) 112 chloroquine phosphate 51 CAROSPIR (spironolactone) 89 chlorothiazide 89 carteolol hcl 169 chlorpromazine hcl 55 carvedilol 81 chlorpropamide 68 carvedilol phosphate 81 chlorthalidone 89 CASODEX (bicalutamide) 43 chlorzoxazone 182 CATAPRES (clonidine hcl) 77 CHOLBAM (cholic acid) 124 CATAPRES-TTS 1 (clonidine) 77 cholestyramine (with sugar) 92 CATAPRES-TTS 2 (clonidine) 77 cholestyramine/aspartame 92 CATAPRES-TTS 3 (clonidine) 77 cholestyramine/aspartame (PREVALITE) 92 CAVERJECT (alprostadil) 131 CIALIS (tadalafil) 131,132 CAYSTON (aztreonam lysine) 176 ciclopirox 37 CEDAX (ceftibuten) 19 ciclopirox (CICLODAN) 37 cefaclor 19 ciclopirox olamine 37 cefadroxil 19 ciclopirox olamine (CICLODAN) 37 cefdinir 19 cilostazol 76 cefditoren pivoxil 19 CILOXAN (ciprofloxacin hcl) 21 cefixime 19 CIMDUO (lamivudine/tenofovir disoproxil cefpodoxime proxetil 19 fumarate) 59 cefprozil 19 cimetidine 125 ceftibuten 19 cimetidine hcl 125 CEFTIN (cefuroxime axetil) 19 CIMZIA (certolizumab pegol) 157 cefuroxime axetil 19 cinacalcet hcl 162 CELEBREX (celecoxib) 1 CIPRO (ciprofloxacin hcl) 21 celecoxib 1 CIPRO (ciprofloxacin) 21 CELEXA (citalopram hydrobromide) 32 CIPRO HC (ciprofloxacin CELLCEPT (mycophenolate mofetil) 157 hcl/hydrocortisone) 171 CELONTIN (methsuximide) 26 CIPRO XR (ciprofloxacin/ciprofloxacin hcl) 21 CENTANY (mupirocin) 16 CIPRODEX (ciprofloxacin cephalexin 19 hcl/dexamethasone) 171 CEQUA (cyclosporine) 165 ciprofloxacin 21 CERDELGA (eliglustat tartrate) 128 ciprofloxacin hcl 21,22 cervical cap 163 ciprofloxacin/ciprofloxacin hcl 22 CESAMET (nabilone) 36 CITALOPRAM HBR (citalopram CETRAXAL (ciprofloxacin hcl) 21 hydrobromide) 32

192 LAST UPDATED 10/01/2019 citalopram hydrobromide 32,33 CLODERM (clocortolone pivalate) 135 CITRANATAL HARMONY (prenatal vitamin clomiphene citrate 155 no.59/iron carb,fum/folic clomipramine hcl 35 acid/docusate/dha) 112 clonazepam 66 CITRANATAL RX (prenatal vits no.81/iron clonidine 77 carbonyl,gluc/folic acid/docusate) 112 clonidine hcl 77,97 citric acid/sodium citrate 132 clopidogrel bisulfate 76 citric acid/sodium citrate (CYTRA-2) 132 clorazepate dipotassium 66 citric acid/sodium citrate (VIRTRATE-2) 132 clotrimazole 37 CLARINEX (desloratadine) 173 clotrimazole/betamethasone CLARINEX-D 12 HOUR dipropionate 105 (desloratadine/pseudoephedrine sulfate) 178 clozapine 57 clarithromycin 20 CLOZARIL (clozapine) 57 clemastine fumarate 173 COARTEM (artemether/lumefantrine) 51 CLENPIQ (sodium picosulfate/magnesium codeine oxide/citric acid) 126 phosphate/butalbital/aspirin/caffeine 8 CLEOCIN (clindamycin phosphate) 16,17 codeine CLEOCIN HCL (clindamycin hcl) 17 phosphate/butalbital/aspirin/caffeine CLEOCIN PALMITATE (clindamycin palmitate (ASCOMP WITH CODEINE) 8 hcl) 17 codeine phosphate/guaifenesin 178 CLEOCIN T (clindamycin phosphate) 17 codeine phosphate/guaifenesin CLIMARA (estradiol) 143 (CHERATUSSIN AC) 178 CLIMARA PRO (estradiol/levonorgestrel) 143 codeine phosphate/guaifenesin (G TUSSIN CLINDAGEL (clindamycin phosphate) 17 AC) 179 clindamycin hcl 17 codeine phosphate/guaifenesin clindamycin palmitate hcl 17 (GUAIATUSSIN AC) 179 clindamycin phosphate 17 codeine phosphate/guaifenesin clindamycin phosphate (CLINDACIN ETZ) 17 (GUAIFENESIN AC) 179 clindamycin phosphate (CLINDACIN P) 17 codeine phosphate/guaifenesin (ROBAFEN clindamycin phosphate/benzoyl peroxide 105 AC) 179 clindamycin phosphate/benzoyl peroxide codeine phosphate/guaifenesin (VIRTUSSIN (NEUAC) 105 AC) 179 clindamycin phosphate/tretinoin 105 codeine sulfate 8 CLINDESSE (clindamycin phosphate) 17 COLAZAL (balsalazide disodium) 160 clobazam 26 colchicine 39 clobetasol propionate 134,135 COLCRYS (colchicine) 39 clobetasol propionate (CLODAN) 134 colesevelam hcl 92 clobetasol propionate (CORMAX) 134 COLESTID (colestipol hcl) 92 clobetasol propionate/emollient base 135 colestipol hcl 92 CLOBEX (clobetasol propionate) 135 COLY-MYCIN S (neomycin sulf/colistin clocortolone pivalate 135 sul/hydrocortisone ac/thonzonium brom) 171

193 LAST UPDATED 10/01/2019 COLYTE WITH FLAVOR PACKETS (peg 3350/sod CORTISPORIN sulf/sod bicarb/sod chloride/potassium (neomycin/bacitracin/polymyxin chloride) 126 b/hydrocortisone) 105 COMBIGAN (brimonidine tartrate/timolol CORTISPORIN-TC (neomycin sulf/colistin maleate) 169 sul/hydrocortisone ac/thonzonium brom) 171 COMBIPATCH (estradiol/norethindrone CORZIDE (nadolol/bendroflumethiazide) 85 acetate) 143 COSENTYX (2 SYRINGES) (secukinumab) 105 COMBIVENT RESPIMAT (ipratropium COSENTYX PEN (2 PENS) (secukinumab) 105 bromide/albuterol sulfate) 179 COSENTYX PEN (secukinumab) 105 COMBIVIR (lamivudine/zidovudine) 61 COSENTYX SYRINGE (secukinumab) 105 COMETRIQ (cabozantinib s-malate) 47 COSOPT (dorzolamide hcl/timolol COMPAZINE (prochlorperazine maleate) 35 maleate) 169 COMPAZINE (prochlorperazine) 35 COSOPT PF (dorzolamide hcl/timolol COMPLERA (emtricitabine/rilpivirine maleate/pf) 169 hcl/tenofovir disoproxil fumarate) 60 COTELLIC (cobimetinib fumarate) 47 COMTAN (entacapone) 52 COTEMPLA XR-ODT (methylphenidate) 97 CONCEPT DHA (prenatal vit no.16/iron fum,ps COUMADIN (warfarin sodium) 74 complex/folic acid/omega-3) 112 COZAAR (losartan potassium) 78 CONCEPT OB (prenatal vitamin no.15/iron CREON (lipase/protease/amylase) 128 fumarate,polysac comp/folic acid) 112 CRESEMBA (isavuconazonium sulfate) 37 CONCERTA (methylphenidate hcl) 97 CRESTOR (rosuvastatin calcium) 91 CONDYLOX (podofilox) 105 CRINONE (progesterone, micronized) 153 CONTRAVE (naltrexone hcl/bupropion hcl)100 CRIXIVAN (indinavir sulfate) 63 CONZIP (tramadol hcl) 3 cromolyn sodium 124,167,176 COPAXONE (glatiramer acetate) 102 crotamiton (CROTAN) 52 COPEGUS (ribavirin) 59 CUPRIMINE (penicillamine) 132 COPIKTRA (duvelisib) 45 CUTIVATE (fluticasone propionate) 135 CORDARONE (amiodarone hcl) 80 CUVPOSA (glycopyrrolate) 122 CORDRAN (flurandrenolide) 135 cyanocobalamin (vitamin b-12) 112 COREG (carvedilol) 81 CYCLESSA (desogestrel-ethinyl estradiol) 143 COREG CR (carvedilol phosphate) 81 cyclobenzaprine hcl 182 CORGARD (nadolol) 81 CYCLOGYL (cyclopentolate hcl) 165 CORLANOR (ivabradine hcl) 85 CYCLOMYDRIL (cyclopentolate CORTEF (hydrocortisone) 135 hcl/phenylephrine hcl) 165 CORTENEMA (hydrocortisone) 161 cyclopentolate hcl 166 CORTIFOAM (hydrocortisone acetate) 161 cyclophosphamide 43 cortisone acetate 135 cycloserine 42 CORTISPORIN (neomycin sulfate/polymyxin b CYCLOSET (bromocriptine mesylate) 68 sulfate/hydrocortisone) 105 cyclosporine 157 cyclosporine, modified 157 cyclosporine, modified (GENGRAF) 158

194 LAST UPDATED 10/01/2019 CYMBALTA (duloxetine hcl) 101 DEPAKOTE (divalproex sodium) 26 cyproheptadine hcl 173 DEPAKOTE ER (divalproex sodium) 26 CYSTADANE (betaine) 128 DEPAKOTE SPRINKLE (divalproex sodium) 26 CYSTAGON (cysteamine bitartrate) 132 DEPEN (penicillamine) 132 CYSTARAN (cysteamine hcl) 166 DEPO-ESTRADIOL (estradiol cypionate) 143 CYTOMEL (liothyronine sodium) 155 DEPO-TESTOSTERONE (testosterone CYTOTEC (misoprostol) 127 cypionate) 142 DERMA-SMOOTHE-FS (fluocinolone D acetonide) 135 D-PENAMINE (penicillamine) 132 DERMA-SMOOTHE-FS (fluocinolone D.H.E.45 (dihydroergotamine mesylate) 40 acetonide/shower cap) 135 DAKLINZA (daclatasvir dihydrochloride) 58 DERMATOP (prednicarbate) 135 dalfampridine 102 DERMOTIC (fluocinolone acetonide oil) 171 DALIRESP (roflumilast) 177 DESCOVY (emtricitabine/tenofovir danazol 142 alafenamide fumarate) 62 DANTRIUM (dantrolene sodium) 57 desipramine hcl 35 dantrolene sodium 57 desloratadine 173 dapsone 42,105 desmopressin acetate 140 DARAPRIM (pyrimethamine) 51 desmopressin acetate (non-refrigerated) 140 darifenacin hydrobromide 130 desogestrel-ethinyl estradiol 143 DAURISMO (glasdegib maleate) 47 desogestrel-ethinyl estradiol (APRI) 143 DAXBIA (cephalexin) 19 desogestrel-ethinyl estradiol (CAZIANT) 143 DAYPRO (oxaprozin) 1 desogestrel-ethinyl estradiol (CYRED EQ) 143 DAYTRANA (methylphenidate) 97 desogestrel-ethinyl estradiol (CYRED) 143 DDAVP (desmopressin acetate (non- desogestrel-ethinyl estradiol (EMOQUETTE) 143 refrigerated)) 140 desogestrel-ethinyl estradiol (ENSKYCE) 143 DDAVP (desmopressin acetate) 140 desogestrel-ethinyl estradiol (ISIBLOOM) 143 deferasirox 112 desogestrel-ethinyl estradiol (JULEBER) 143 DELESTROGEN (estradiol valerate) 143 desogestrel-ethinyl estradiol (KALLIGA) 143 DELSTRIGO (doravirine/lamivudine/tenofovir desogestrel-ethinyl estradiol (RECLIPSEN) 143 disoproxil fumarate) 60 desogestrel-ethinyl estradiol (VELIVET) 143 DELTASONE (prednisone) 135 desogestrel-ethinyl estradiol/ethinyl DELZICOL (mesalamine) 161 estradiol 143 DEMADEX (torsemide) 89 desogestrel-ethinyl estradiol/ethinyl estradiol demeclocycline hcl 23 (AZURETTE) 143 DEMEROL (meperidine hcl) 8 desogestrel-ethinyl estradiol/ethinyl estradiol DEMSER (metyrosine) 85 (BEKYREE) 143 DENAVIR (penciclovir) 65 desogestrel-ethinyl estradiol/ethinyl estradiol DEPAKENE (valproic acid (as sodium salt) (KARIVA) 143 (valproate sodium)) 26 desogestrel-ethinyl estradiol/ethinyl estradiol DEPAKENE (valproic acid) 26 (KIMIDESS) 144

195 LAST UPDATED 10/01/2019 desogestrel-ethinyl estradiol/ethinyl estradiol DIASTAT ACUDIAL (diazepam) 26 (PIMTREA) 144 diazepam 26,66,67 desogestrel-ethinyl estradiol/ethinyl estradiol DIBENZYLINE (phenoxybenzamine hcl) 77 (SIMLIYA) 144 DICLEGIS (doxylamine succinate/pyridoxine desogestrel-ethinyl estradiol/ethinyl estradiol hcl (b6)) 35 (VIORELE) 144 diclofenac epolamine 1 DESONATE (desonide) 135 diclofenac potassium 1 desonide 135 diclofenac sodium 1,105,168 DESOWEN (desonide) 135 diclofenac sodium (KLOFENSAID II) 1 desoximetasone 136 diclofenac sodium/misoprostol 1 DESOXYN (methamphetamine hcl) 94 dicloxacillin sodium 20 desvenlafaxine 33 dicyclomine hcl 122 desvenlafaxine fumarate 33 didanosine 61 desvenlafaxine succinate 33 diethylpropion hcl 100 DETROL (tolterodine tartrate) 130 DIFFERIN (adapalene) 106 DETROL LA (tolterodine tartrate) 130 DIFICID (fidaxomicin) 20 dexamethasone 136 diflorasone diacetate 136 dexamethasone (DECADRON) 136 diflorasone diacetate (PSORCON) 136 dexamethasone (DEXAMETHASONE diflorasone diacetate/emollient base INTENSOL) 136 (APEXICON E) 136 dexamethasone (HIDEX) 136 DIFLUCAN (fluconazole) 37 dexamethasone (LOCORT) 136 diflunisal 1 dexamethasone (TAPERDEX) 136 digoxin 85 dexamethasone (ZODEX) 136 digoxin (DIGITEK) 85 dexamethasone sodium phosphate 168 digoxin (DIGOX) 85 dexchlorpheniramine maleate 173 dihydroergotamine mesylate 40 DEXEDRINE (dextroamphetamine sulfate) 95 DILANTIN (phenytoin sodium extended) 29 DEXILANT (dexlansoprazole) 127 DILANTIN (phenytoin) 29 dexmethylphenidate hcl 97 DILANTIN-125 (phenytoin) 29 DEXPAK (dexamethasone) 136 DILATRATE-SR (isosorbide dinitrate) 93 dextroamphetamine sulf- DILAUDID (hydromorphone hcl) 8 saccharate/amphetamine sulf-aspartate 95 diltiazem hcl 83 dextroamphetamine sulfate 96 diltiazem hcl (CARTIA XT) 82 dextroamphetamine sulfate (PROCENTRA) 95 diltiazem hcl (DILT-XR) 82 dextroamphetamine sulfate (ZENZEDI) 96 diltiazem hcl (MATZIM LA) 82 DIABETA (glyburide) 68 diltiazem hcl (TAZTIA XT) 82 DIACOMIT (stiripentol) 25 DIOVAN (valsartan) 78 DIAMOX SEQUELS (acetazolamide) 89 DIOVAN HCT diaphragms, contoured 163 (valsartan/hydrochlorothiazide) 85 diaphragms, wide seal 163 DIPENTUM (olsalazine sodium) 161 DIASTAT (diazepam) 26 diphenoxylate hcl/atropine sulfate 124

196 LAST UPDATED 10/01/2019 DIPROLENE (betamethasone drospirenone/ethinyl estradiol/levomefolate dipropionate/propylene glycol) 136 calcium 144 DIPROLENE AF (betamethasone drospirenone/ethinyl estradiol/levomefolate dipropionate/propylene glycol) 136 calcium (RAJANI) 144 dipyridamole 76 drospirenone/ethinyl estradiol/levomefolate DISALCID (salsalate) 1 calcium (TYDEMY) 144 DISKETS (methadone hcl) 3 DROXIA (hydroxyurea) 44 disopyramide phosphate 80 DUAC (clindamycin phosphate/benzoyl disulfiram 14 peroxide) 106 DITROPAN XL (oxybutynin chloride) 130 DUAVEE (estrogens, DIURIL (chlorothiazide) 89 conjugated/bazedoxifene acetate) 144 divalproex sodium 26 DUETACT (pioglitazone hcl/glimepiride) 68 DIVIGEL (estradiol) 144 DUEXIS (ibuprofen/famotidine) 1 dofetilide 80 DULERA (mometasone furoate/formoterol DOLOPHINE HCL (methadone hcl) 4 fumarate) 179 donepezil hcl 30 duloxetine hcl 101 DONNATAL (phenobarbital/hyoscyamine DUOBRII (halobetasol sulf/atropine sulf/scopolamine hb) 122 propionate/tazarotene) 106 DOPTELET (avatrombopag maleate) 75 DUPIXENT (dupilumab) 106 DORAL (quazepam) 183 DURAGESIC (fentanyl) 4 DORYX (doxycycline hyclate) 23 DUREZOL (difluprednate) 168 DORYX MPC (doxycycline hyclate) 23 DURLAZA (aspirin) 76 dorzolamide hcl 169 dutasteride 131 dorzolamide hcl/timolol maleate 169 dutasteride/tamsulosin hcl 131 dorzolamide hcl/timolol maleate/pf 169 DUTOPROL (metoprolol DOVATO (dolutegravir sodium/lamivudine) 62 succinate/hydrochlorothiazide) 86 DOVONEX (calcipotriene) 106 DUZALLO (lesinurad/allopurinol) 39 doxazosin mesylate 77 DXEVO (dexamethasone) 136 doxepin hcl 35,106 DYANAVEL XR (amphetamine) 96 doxercalciferol 162 DYAZIDE (triamterene/hydrochlorothiazide) 86 doxycycline hyclate 23 DYMISTA (azelastine hcl/fluticasone doxycycline hyclate (MORGIDOX) 23 propionate) 179 doxycycline hyclate (SOLOXIDE) 23 DYRENIUM (triamterene) 89 doxycycline monohydrate 24 doxycycline monohydrate (AVIDOXY) 23 E doxycycline monohydrate (MONDOXYNE E.E.S. 200 (erythromycin ethylsuccinate) 20 NL) 23 E.E.S. 400 (erythromycin ethylsuccinate) 20 doxycycline monohydrate (OKEBO) 23 EC-NAPROSYN (naproxen) 1 doxylamine succinate/pyridoxine hcl (b6) 35 econazole nitrate 37 DRISDOL (ergocalciferol (vitamin d2)) 162 ECOZA (econazole nitrate) 37 dronabinol 36 EDARBI (azilsartan medoxomil) 78

197 LAST UPDATED 10/01/2019 EDARBYCLOR (azilsartan ENDARI (glutamine) 112 medoxomil/chlorthalidone) 86 ENDOMETRIN (progesterone, micronized) 153 EDECRIN (ethacrynic acid) 89 enoxaparin sodium 74 EDEX (alprostadil) 132 ENSTILAR (calcipotriene/betamethasone EDLUAR (zolpidem tartrate) 183 dipropionate) 106 EDURANT (rilpivirine hcl) 60 entacapone 53 efavirenz 60 entecavir 58 EFFER-K (potassium bicarbonate/citric ENTOCORT EC (budesonide) 161 acid) 112 ENTRESTO (sacubitril/valsartan) 86 EFFEXOR XR (venlafaxine hcl) 33 ENVARSUS XR (tacrolimus) 158 EFFIENT (prasugrel hcl) 77 EPANED (enalapril maleate) 79 EFUDEX (fluorouracil) 44 EPCLUSA (sofosbuvir/velpatasvir) 58 EGRIFTA (tesamorelin acetate) 156 EPIDIOLEX (cannabidiol (cbd) extract) 25 ELDEPRYL (selegiline hcl) 54 EPIDUO (adapalene/benzoyl peroxide) 106 ELESTAT (epinastine hcl) 167 EPIDUO FORTE (adapalene/benzoyl ELESTRIN (estradiol) 144 peroxide) 106 eletriptan hydrobromide 40 EPIFOAM (hydrocortisone acetate/pramoxine ELIDEL (pimecrolimus) 106 hcl) 106 ELIMITE (permethrin) 52 epinastine hcl 167 ELIQUIS (apixaban) 74 epinephrine 175 ELIXOPHYLLIN (theophylline anhydrous) 177 EPIPEN 2-PAK (epinephrine) 175 ELLA (ulipristal acetate) 153 EPIPEN JR 2-PAK (epinephrine) 175 ELMIRON (pentosan polysulfate sodium) 132 EPIVIR (lamivudine) 61 ELOCON (mometasone furoate) 136 EPIVIR HBV (lamivudine) 58 EMADINE (emedastine difumarate) 167 eplerenone 89 EMBEDA (morphine sulfate/naltrexone hcl) 4 EPOGEN (epoetin alfa) 75 EMCYT (estramustine phosphate sodium) 44 eprosartan mesylate 78 EMEND (aprepitant) 36,37 EPZICOM (abacavir sulfate/lamivudine) 61 EMFLAZA (deflazacort) 136,137 EQUETRO (carbamazepine) 67 EMGALITY PEN (galcanezumab-gnlm) 40 ergocalciferol (vitamin d2) 162 EMGALITY SYRINGE (galcanezumab-gnlm) 40 ergoloid mesylates 30 EMSAM (selegiline) 32 ERGOMAR (ergotamine tartrate) 40 EMTRIVA (emtricitabine) 61 ergotamine tartrate/caffeine 40 ENABLEX (darifenacin hydrobromide) 130 ergotamine tartrate/caffeine (MIGERGOT) 40 enalapril maleate 79 ERIVEDGE (vismodegib) 47 enalapril maleate/hydrochlorothiazide 86 ERLEADA (apalutamide) 43 ENBRACE HR (prenatal vits no.92/iron cysteine erlotinib hcl 48 gly/folate no.8/phosph-dha) 112 ERTACZO (sertaconazole nitrate) 37 ENBREL (etanercept) 158 ERY-TAB (erythromycin base) 20 ENBREL MINI (etanercept) 158 ERYGEL (erythromycin base in ethanol) 20 ENBREL SURECLICK (etanercept) 158 ERYPED 200 (erythromycin ethylsuccinate) 20

198 LAST UPDATED 10/01/2019 ERYPED 400 (erythromycin ethylsuccinate) 20 estrogens,esterified/methyltestosterone (EEMT ERYTHROCIN STEARATE (erythromycin H.S.) 145 stearate) 20 estrogens,esterified/methyltestosterone erythromycin base 21 (EEMT) 145 erythromycin base in ethanol 21 estropipate 145 erythromycin base in ethanol (ERY) 21 ESTROSTEP FE (norethindrone acetate-ethinyl erythromycin base/benzoyl peroxide 17 estradiol/ferrous fumarate) 145 erythromycin ethylsuccinate 21 eszopiclone 183 ESBRIET (pirfenidone) 179 ethacrynic acid 89 ESCAVITE (pediatric multivitamin no.47/ferrous ethambutol hcl 42 fumarate/sod fluoride) 113 ethinyl estradiol/drospirenone 145 ESCAVITE D (pediatric multivitamin no.78 with ethinyl estradiol/drospirenone (GIANVI) 145 iron and sodium fluoride) 113 ethinyl estradiol/drospirenone (JASMIEL) 145 ESCAVITE LQ (pediatric multivitamin no.86 ethinyl estradiol/drospirenone (LO- with iron and sodium fluoride) 113 ZUMANDIMINE) 145 escitalopram oxalate 33 ethinyl estradiol/drospirenone (LORYNA) 145 ESGIC ethinyl estradiol/drospirenone (NIKKI) 145 (butalbital/acetaminophen/caffeine) 100 ethinyl estradiol/drospirenone (OCELLA) 145 esomeprazole magnesium 127 ethinyl estradiol/drospirenone (SYEDA) 145 esomeprazole strontium 127 ethinyl estradiol/drospirenone (VESTURA) 145 estazolam 183 ethinyl estradiol/drospirenone (ZARAH) 145 ESTRACE (estradiol) 144 ethinyl estradiol/drospirenone estradiol 144 (ZUMANDIMINE) 145 estradiol (DOTTI) 144 ethosuximide 26 estradiol (YUVAFEM) 144 ethynodiol diacetate-ethinyl estradiol 145 estradiol valerate 144 ethynodiol diacetate-ethinyl estradiol estradiol/norethindrone acetate 144 (KELNOR 1-35) 145 estradiol/norethindrone acetate ethynodiol diacetate-ethinyl estradiol (AMABELZ) 144 (KELNOR 1-50) 145 estradiol/norethindrone acetate ethynodiol diacetate-ethinyl estradiol (ZOVIA (LOPREEZA) 144 1-35E) 146 estradiol/norethindrone acetate (MIMVEY ethynodiol diacetate-ethinyl estradiol (ZOVIA LO) 145 1-50E) 146 estradiol/norethindrone acetate (MIMVEY)145 etidronate disodium 162 ESTRING (estradiol) 145 etodolac 2 ESTROGEL (estradiol) 145 etoposide 46 estrogens,esterified/methyltestosterone 145 EUCRISA (crisaborole) 106 estrogens,esterified/methyltestosterone EURAX (crotamiton) 52 (COVARYX H.S.) 145 EUTHYROX (levothyroxine sodium) 155 estrogens,esterified/methyltestosterone EVAMIST (estradiol) 146 (COVARYX) 145 EVEKEO (amphetamine sulfate) 96

199 LAST UPDATED 10/01/2019 EVEKEO ODT (amphetamine sulfate) 96 FEMRING (estradiol acetate) 146 EVISTA (raloxifene hcl) 155 fenofibrate 90 EVOCLIN (clindamycin phosphate) 17 fenofibrate (LOFIBRA) 90 EVOTAZ (atazanavir sulfate/cobicistat) 63 fenofibrate nanocrystallized 90 EVOXAC (cevimeline hcl) 103 fenofibrate,micronized 90 EVZIO (naloxone hcl) 15 fenofibrate,micronized (LOFIBRA) 90 EXALGO (hydromorphone hcl) 4 fenofibric acid 90 EXELDERM (sulconazole nitrate) 38 fenofibric acid (choline) 90 EXELON (rivastigmine tartrate) 30 FENOGLIDE (fenofibrate) 91 EXELON (rivastigmine) 30 fenoprofen calcium 2 exemestane 46 fenoprofen calcium (FENORTHO) 2 EXFORGE (amlodipine besylate/valsartan) 86 fenoprofen calcium (PROFENO) 2 EXFORGE HCT (amlodipine FENORTHO (fenoprofen calcium) 2 besylate/valsartan/hydrochlorothiazide) 86 fentanyl 4 EXJADE (deferasirox) 113 fentanyl citrate 8,9 EXTAVIA (interferon beta-1b) 102 FENTORA (fentanyl citrate) 9 EXTINA (ketoconazole) 38 FERRIPROX (deferiprone) 112,113 EZALLOR SPRINKLE (rosuvastatin calcium) 91 FETZIMA (levomilnacipran hcl) 33 ezetimibe 92 FEXMID (cyclobenzaprine hcl) 182 ezetimibe/simvastatin 92 FIASP (insulin aspart (niacinamide)) 72 FIASP FLEXTOUCH (insulin aspart F (niacinamide)) 72 FABIOR (tazarotene) 106 FIBRICOR (fenofibric acid) 91 FACTIVE (gemifloxacin mesylate) 22 FINACEA (azelaic acid) 106 famciclovir 65 finasteride 131 famotidine 125 FIORICET WITH CODEINE famotidine (PEPCID) 125 (butalbital/acetaminophen/caffeine/codein FAMVIR (famciclovir) 65 e phosphate) 9 FANAPT (iloperidone) 56 FIORINAL (butalbital/aspirin/caffeine) 2 FARESTON (toremifene citrate) 44 FIORINAL WITH CODEINE #3 (codeine FARXIGA (dapagliflozin propanediol) 68 phosphate/butalbital/aspirin/caffeine) 9 FARYDAK (panobinostat lactate) 48 FIRAZYR (icatibant acetate) 157 FAZACLO (clozapine) 57 FIRDAPSE (amifampridine phosphate) 102 febuxostat 39 FIRVANQ (vancomycin hcl) 17 felbamate 27 FLAGYL (metronidazole) 17 FELBATOL (felbamate) 27 FLAREX (fluorometholone acetate) 168 FELDENE (piroxicam) 2 flavoxate hcl 130 felodipine 83 flecainide acetate 80 FEMARA (letrozole) 46 FLECTOR (diclofenac epolamine) 2 FEMHRT (norethindrone acetate-ethinyl FLOLIPID (simvastatin) 91 estradiol) 146 FLOMAX (tamsulosin hcl) 131

200 LAST UPDATED 10/01/2019 FLORIVA (pediatric multivitamin no.85 with FML (fluorometholone) 168 sodium fluoride) 113 FML FORTE (fluorometholone) 168 FLORIVA PLUS (pediatric multivitamin FML S.O.P. (fluorometholone) 168 no.130/sodium fluoride) 113 FOCALIN (dexmethylphenidate hcl) 97 FLOVENT DISKUS (fluticasone propionate) 172 FOCALIN XR (dexmethylphenidate hcl) 97 FLOVENT HFA (fluticasone propionate) 172 FOLET ONE (prenatal vit no.80/iron FLOWTUSS (guaifenesin/hydrocodone carb,bisgl/methylfolate/docusate/dha) 113 bitartrate) 179 folic acid 113 fluconazole 38 fondaparinux sodium 74 flucytosine 38 FORADIL (formoterol fumarate) 175 fludrocortisone acetate 137 FORFIVO XL (bupropion hcl) 31 FLUMADINE (rimantadine hcl) 64 FORTAMET (metformin hcl) 68 flunisolide 172 FORTEO (teriparatide) 162 fluocinolone acetonide 137 FORTESTA (testosterone) 142 fluocinolone acetonide oil 171 FORTICAL (calcitonin,salmon,synthetic) 162 fluocinolone acetonide oil (FLAC OTIC FOSAMAX (alendronate sodium) 162 OIL) 171 FOSAMAX PLUS D (alendronate fluocinolone acetonide/shower cap 137 sodium/cholecalciferol (vitamin d3)) 162 fluocinonide 137 fosamprenavir calcium 63 fluocinonide/emollient base 137 fosinopril sodium 79 fluoride/iron/vitamins a,c,and d 113 fosinopril sodium/hydrochlorothiazide 86 fluorometholone 168 FOSRENOL (lanthanum carbonate) 134 FLUOROPLEX (fluorouracil) 106 FRAGMIN (dalteparin sodium,porcine) 74 fluorouracil 44,106 FROVA (frovatriptan succinate) 40 fluoxetine hcl 33 frovatriptan succinate 41 fluoxymesterone (ANDROXY) 142 FULPHILA (pegfilgrastim-jmdb) 75 fluphenazine hcl 55 FURADANTIN (nitrofurantoin) 17 flurandrenolide 137 furosemide 89 flurandrenolide (NOLIX) 137 FUZEON (enfuvirtide) 63 flurazepam hcl 183 FYCOMPA (perampanel) 27 flurbiprofen 2 flurbiprofen sodium 168 G flutamide 43 gabapentin 26 fluticasone propionate 137,172 GABITRIL (tiagabine hcl) 26 fluticasone propionate (BESER) 137 GALAFOLD (migalastat hcl) 129 fluticasone propionate/salmeterol galantamine hbr 30 xinafoate 179 GALZIN (zinc acetate) 113 fluticasone propionate/salmeterol xinafoate GASTROCROM (cromolyn sodium) 124 (WIXELA INHUB) 179 gatifloxacin 22 fluvastatin sodium 91 GELNIQUE (oxybutynin chloride) 130 fluvoxamine maleate 33 gemfibrozil 91

201 LAST UPDATED 10/01/2019 GENERESS FE (norethindrone-ethinyl GORDON'S UREA (urea) 106 estradiol/ferrous fumarate) 146 GRALISE (gabapentin) 26 GENOTROPIN (somatropin) 140 granisetron hcl 37 gentamicin sulfate 16 GRANIX (tbo-filgrastim) 75 gentamicin sulfate (GENTAK) 16 GRASTEK (allergenic extract,grass pollen- GENVOYA timothy,standard) 179 (elvitegravir/cobicistat/emtricitabine/tenofovi GRIS-PEG (griseofulvin ultramicrosize) 38 r alafenamide) 60 griseofulvin ultramicrosize 38 GEODON (ziprasidone hcl) 56 griseofulvin, microsize 38 GIAZO (balsalazide disodium) 161 guaifenesin/hydrocodone bitartrate 180 GILENYA (fingolimod hcl) 103 guanfacine hcl 77,98 GILOTRIF (afatinib dimaleate) 48 guanidine hcl 42 glatiramer acetate 103 GVOKE HYPOPEN (glucagon) 71 glatiramer acetate (GLATOPA) 103 GVOKE SYRINGE (glucagon) 72 GLEEVEC (imatinib mesylate) 48 GLEOSTINE (lomustine) 43 H glimepiride 68 HAEGARDA (c1 esterase inhibitor) 157 glipizide 68 halcinonide 137 glipizide/metformin hcl 68 HALCION (triazolam) 183 GLUCAGEN (glucagon,human halobetasol propionate 137 recombinant) 71 HALOG (halcinonide) 137 GLUCAGON EMERGENCY KIT haloperidol 55 (glucagon,human recombinant) 71 haloperidol lactate 55 GLUCOPHAGE (metformin hcl) 68 HARVONI (ledipasvir/sofosbuvir) 58 GLUCOPHAGE XR (metformin hcl) 68 HECTOROL (doxercalciferol) 162 GLUCOTROL (glipizide) 68 HEMANGEOL (propranolol hcl) 45 GLUCOTROL XL (glipizide) 69 heparin sodium,porcine 74 GLUCOVANCE (glyburide/metformin hcl) 69 heparin sodium,porcine/pf 74 GLUMETZA (metformin hcl) 69 HEPSERA (adefovir dipivoxil) 58 glyburide 69 HETLIOZ (tasimelteon) 185 glyburide,micronized 69 HEXALEN (altretamine) 43 glyburide/metformin hcl 69 HIPREX (methenamine hippurate) 17 GLYCATE (glycopyrrolate) 122 homatropine hbr 166 glycopyrrolate 122,123 homatropine hbr (HOMATROPAIRE) 166 GLYNASE (glyburide,micronized) 69 HORIZANT (gabapentin enacarbil) 101 GLYSET (miglitol) 69 HUMALOG (insulin lispro) 72 GLYXAMBI (empagliflozin/linagliptin) 69 HUMALOG JUNIOR KWIKPEN (insulin lispro) 72 GOCOVRI (amantadine hcl) 53 HUMALOG KWIKPEN U-100 (insulin lispro) 72 GOLYTELY (peg 3350/sod sulf/sod bicarb/sod HUMALOG KWIKPEN U-200 (insulin lispro) 72 chloride/potassium chloride) 126 HUMALOG MIX 50-50 (insulin lispro protamine GONITRO (nitroglycerin) 93 and insulin lispro) 72

202 LAST UPDATED 10/01/2019 HUMALOG MIX 50-50 KWIKPEN (insulin lispro HYDREA (hydroxyurea) 44 protamine and insulin lispro) 72 HYDRO 35 (urea) 106 HUMALOG MIX 75-25 (insulin lispro protamine HYDRO 40 (urea) 106 and insulin lispro) 72 hydrochlorothiazide 89 HUMALOG MIX 75-25 KWIKPEN (insulin lispro hydrocodone bitart/chlorpheniramine protamine and insulin lispro) 72 maleate/pseudoephedrine 180 HUMATROPE (somatropin) 140 hydrocodone bitartrate/acetaminophen 10 HUMIRA (adalimumab) 158 hydrocodone bitartrate/acetaminophen HUMIRA PEDIATRIC CROHN'S (LORCET HD) 9 (adalimumab) 158 hydrocodone bitartrate/acetaminophen HUMIRA PEN (adalimumab) 158 (LORCET PLUS) 9 HUMIRA PEN CROHN'S-UC-HS hydrocodone bitartrate/acetaminophen (adalimumab) 158 (LORCET) 9 HUMIRA PEN PSOR-UVEITS-ADOL HS hydrocodone bitartrate/acetaminophen (adalimumab) 158 (LORTAB) 9 HUMIRA(CF) (adalimumab) 158 hydrocodone bitartrate/acetaminophen HUMIRA(CF) PEDIATRIC CROHN'S (VERDROCET) 9 (adalimumab) 158 hydrocodone bitartrate/acetaminophen HUMIRA(CF) PEN (adalimumab) 158 (VICODIN ES) 9 HUMIRA(CF) PEN CROHN'S-UC-HS hydrocodone bitartrate/acetaminophen (adalimumab) 158 (VICODIN HP) 9 HUMIRA(CF) PEN PSOR-UV-ADOL HS hydrocodone bitartrate/acetaminophen (adalimumab) 158 (VICODIN) 9 HUMULIN 70-30 (insulin nph human hydrocodone bitartrate/homatropine isophane/insulin regular, human) 72 methylbromide 180 HUMULIN 70/30 KWIKPEN (insulin nph human hydrocodone bitartrate/homatropine isophane/insulin regular, human) 72 methylbromide (HYDROMET) 180 HUMULIN N (insulin nph human isophane) 72 hydrocodone bitartrate/homatropine HUMULIN N KWIKPEN (insulin nph human methylbromide (TUSSIGON) 180 isophane) 72 hydrocodone polistirex/chlorpheniramine HUMULIN R (insulin regular, human) 73 polistirex 180 HUMULIN R U-500 (insulin regular, human) 73 hydrocodone/ibuprofen 10 HUMULIN R U-500 KWIKPEN (insulin regular, hydrocodone/ibuprofen (IBUDONE) 10 human) 73 hydrocodone/ibuprofen (XYLON 10) 10 HYCAMTIN (topotecan hcl) 46 hydrocortisone 138,161 HYCET (hydrocodone hydrocortisone (ALA-CORT) 137 bitartrate/acetaminophen) 9 hydrocortisone (ANUSOL-HC) 137 HYCOFENIX (hydrocodone hydrocortisone (COLOCORT) 161 bitartrate/pseudoephedrine hydrocortisone (PROCTO-MED HC) 137 hcl/guaifenesin) 180 hydrocortisone (PROCTO-PAK) 137 hydralazine hcl 93 hydrocortisone (PROCTOSOL-HC) 137

203 LAST UPDATED 10/01/2019 hydrocortisone (PROCTOZONE-HC) 137 IBRANCE (palbociclib) 48 hydrocortisone (SCALACORT) 137 IBUDONE (hydrocodone/ibuprofen) 10 hydrocortisone acetate 138 ibuprofen 2 hydrocortisone acetate (ANUCORT-HC) 138 ibuprofen (IBU) 2 hydrocortisone acetate (ANUSOL-HC) 138 ibuprofen/oxycodone hcl 10 hydrocortisone acetate (HEMMOREX-HC) 138 icatibant acetate 157 hydrocortisone acetate (MICORT-HC) 106 ICLUSIG (ponatinib hcl) 48 hydrocortisone acetate/pramoxine hcl 106 IDHIFA (enasidenib mesylate) 45 hydrocortisone acetate/urea (U-CORT) 138 ILEVRO (nepafenac) 168 hydrocortisone butyrate 138 imatinib mesylate 48 hydrocortisone butyrate/emollient base 138 IMBRUVICA (ibrutinib) 48 hydrocortisone valerate 138 imipramine hcl 35 hydrocortisone/acetic acid 171 imipramine pamoate 35 hydrocortisone/acetic acid (ACETASOL imiquimod 106,107 HC) 171 IMITREX (sumatriptan succinate) 41 hydrocortisone/mineral IMITREX (sumatriptan) 41 oil/petrolatum,white 138 IMPAVIDO (miltefosine) 52 hydromorphone hcl 4,10 IMPOYZ (clobetasol propionate) 138 hydroxychloroquine sulfate 51 IMURAN (azathioprine) 158 hydroxyprogesterone caproate 153 IMVEXXY (estradiol) 146 hydroxyprogesterone caproate/pf 153 INBRIJA (levodopa) 163 hydroxyurea 44 INCRELEX (mecasermin) 140 hydroxyzine hcl 173 INCRUSE ELLIPTA (umeclidinium bromide) 174 hydroxyzine pamoate 173 indapamide 90 hyoscyamine sulfate 123 INDERAL LA (propranolol hcl) 81 hyoscyamine sulfate (ED-SPAZ) 123 INDERAL XL (propranolol hcl) 81 hyoscyamine sulfate (HYOSYNE) 123 INDOCIN (indomethacin) 2 hyoscyamine sulfate (NULEV) 123 indomethacin 2 hyoscyamine sulfate (OSCIMIN SL) 123 INGREZZA (valbenazine tosylate) 101 hyoscyamine sulfate (OSCIMIN SR) 123 INGREZZA INITIATION PACK (valbenazine hyoscyamine sulfate (OSCIMIN) 123 tosylate) 101 hyoscyamine sulfate (SYMAX) 123 inhaler, assist devices 163 hyoscyamine sulfate (SYMAX-SL) 123 inhaler, assist devices, accessories 163 hyoscyamine sulfate (SYMAX-SR) 123 inhaler,assist device with large mask 163 HYPER-SAL (sodium chloride for inhalation) 180 inhaler,assist device with medium mask 164 HYSINGLA ER (hydrocodone bitartrate) 4 inhaler,assist device with small mask 164 HYZAAR (losartan INLYTA (axitinib) 48 potassium/hydrochlorothiazide) 86 INNOPRAN XL (propranolol hcl) 81 INREBIC (fedratinib dihydrochloride) 45 I INSPRA (eplerenone) 89 ibandronate sodium 163 insulin admin. supplies 164

204 LAST UPDATED 10/01/2019 insulin lispro 73 itraconazole 38 insulin pump cartridge 164 ivermectin 51 insulin syringe-needle,safety,disposal unit,0.5 ml 164 J INTELENCE (etravirine) 60 JADENU (deferasirox) 113 INTERMEZZO (zolpidem tartrate) 183 JADENU SPRINKLE (deferasirox) 112 INTRAROSA (prasterone (dhea)) 164 JAKAFI (ruxolitinib phosphate) 48 INTRON A (interferon alfa-2b,recomb.) 59 JALYN (dutasteride/tamsulosin hcl) 131 INTUNIV (guanfacine hcl) 98 JANUMET (sitagliptin phosphate/metformin INVEGA (paliperidone) 56 hcl) 69 INVELTYS (loteprednol etabonate) 168 JANUMET XR (sitagliptin phosphate/metformin INVIRASE (saquinavir mesylate) 63 hcl) 69 INVOKAMET (canagliflozin/metformin hcl) 69 JANUVIA (sitagliptin phosphate) 69 INVOKAMET XR (canagliflozin/metformin JARDIANCE (empagliflozin) 69 hcl) 69 JENTADUETO (linagliptin/metformin hcl) 69 INVOKANA (canagliflozin) 69 JENTADUETO XR (linagliptin/metformin hcl) 69 IOPIDINE (apraclonidine hcl) 169 JORNAY PM (methylphenidate hcl) 98 ipratropium bromide 174 JUBLIA (efinaconazole) 38 ipratropium bromide/albuterol sulfate 180 JULUCA (dolutegravir sodium/rilpivirine hcl) 63 IPRIVASK (desirudin) 74 JUXTAPID (lomitapide mesylate) 92 irbesartan 78 JYNARQUE (tolvaptan) 112,113 irbesartan/hydrochlorothiazide 86 IRENKA (duloxetine hcl) 101 K IRESSA (gefitinib) 48 K-PHOS NEUTRAL (sodium ISENTRESS (raltegravir potassium) 60 phosphate,dibasic/pot phos,monob/sod ISENTRESS HD (raltegravir potassium) 60 phosphate mono) 132 isoniazid 42 K-PHOS NO.2 (sodium ISOPTO ATROPINE (atropine sulfate) 166 phosphate,monobasic/potassium ISOPTO CARPINE (pilocarpine hcl) 169 phosphate,monobasic) 132 ISORDIL (isosorbide dinitrate) 93 K-PHOS ORIGINAL (potassium ISORDIL TITRADOSE (isosorbide dinitrate) 93 phosphate,monobasic) 132 isosorbide dinitrate 93 K-TAB ER (potassium chloride) 113 isosorbide dinitrate (ISOCHRON) 93 KADIAN (morphine sulfate) 4,5 isosorbide mononitrate 93 KALETRA (lopinavir/ritonavir) 63 isotretinoin 107 KALYDECO (ivacaftor) 176 isotretinoin (AMNESTEEM) 107 KAPSPARGO SPRINKLE (metoprolol isotretinoin (CLARAVIS) 107 succinate) 81 isotretinoin (MYORISAN) 107 KAPVAY (clonidine hcl) 98 isotretinoin (ZENATANE) 107 KARBINAL ER (carbinoxamine maleate) 173 isradipine 83 KATERZIA (amlodipine benzoate) 83 ISTALOL (timolol maleate) 169

205 LAST UPDATED 10/01/2019 KAYEXALATE (sodium polystyrene sulfonate) 113 L KAZANO (alogliptin benzoate/metformin labetalol hcl 81 hcl) 69 LACRISERT (hydroxypropyl cellulose) 166 KEFLEX (cephalexin) 19 lactulose 126 KENALOG (triamcinolone acetonide) 138 lactulose (CONSTULOSE) 126 KEPPRA (levetiracetam) 25 lactulose (ENULOSE) 126 KEPPRA XR (levetiracetam) 25 lactulose (GENERLAC) 126 KERAFOAM (urea) 107 LAMICTAL (BLUE) (lamotrigine) 27 KERALAC (urea) 107 LAMICTAL (GREEN) (lamotrigine) 27 KERALYT (salicylic acid) 107 LAMICTAL (lamotrigine) 27 KERYDIN (tavaborole) 38 LAMICTAL (ORANGE) (lamotrigine) 27 KETEK (telithromycin) 21 LAMICTAL ODT (BLUE) (lamotrigine) 27 ketoconazole 38 LAMICTAL ODT (GREEN) (lamotrigine) 27 ketoprofen 2 LAMICTAL ODT (lamotrigine) 27 ketorolac tromethamine 2,168 LAMICTAL ODT (ORANGE) (lamotrigine) 28 KEVEYIS (dichlorphenamide) 89 LAMICTAL XR (BLUE) (lamotrigine) 28 KEVZARA (sarilumab) 160 LAMICTAL XR (GREEN) (lamotrigine) 28 KHEDEZLA (desvenlafaxine) 33 LAMICTAL XR (lamotrigine) 28 KINERET (anakinra) 158 LAMICTAL XR (ORANGE) (lamotrigine) 28 KISQALI (ribociclib succinate) 48 LAMISIL (terbinafine hcl) 38 KISQALI FEMARA CO-PACK (ribociclib lamivudine 58,61,62 succinate/letrozole) 48 lamivudine/zidovudine 62 KITABIS PAK (tobramycin/nebulizer) 176 lamotrigine 28 KLARON (sulfacetamide sodium) 22 lamotrigine (SUBVENITE (BLUE)) 28 KLONOPIN (clonazepam) 67 lamotrigine (SUBVENITE (GREEN)) 28 KLOR-CON (potassium chloride) 113 lamotrigine (SUBVENITE (ORANGE)) 28 KLOR-CON 10 (potassium chloride) 113 lamotrigine (SUBVENITE) 28 KLOR-CON 8 (potassium chloride) 113 lancets 164 KLOR-CON M15 (potassium chloride) 113 LANOXIN (digoxin) 86 KOMBIGLYZE XR (saxagliptin hcl/metformin lansoprazole 127 hcl) 70 lansoprazole/amoxicillin KORLYM (mifepristone) 138 trihydrate/clarithromycin 124 KOSHER PRENATAL PLUS IRON (prenatal lanthanum carbonate 134 vitamins no.108/iron,carbonyl/folic acid) 113 LANTUS (insulin glargine,human recombinant KRINTAFEL (tafenoquine succinate) 52 analog) 73 KRISTALOSE (lactulose) 126 LANTUS SOLOSTAR (insulin glargine,human KUVAN (sapropterin dihydrochloride) 129 recombinant analog) 73 KYNAMRO (mipomersen sodium) 92 LASIX (furosemide) 89 LASTACAFT (alcaftadine) 167 latanoprost 170

206 LAST UPDATED 10/01/2019 LATUDA (lurasidone hcl) 56 levonorgestrel (OPTION 2) 154 LAYOLIS FE (norethindrone-ethinyl levonorgestrel (TAKE ACTION) 154 estradiol/ferrous fumarate) 146 levonorgestrel-ethinyl estradiol 147 LAZANDA (fentanyl citrate) 10 levonorgestrel-ethinyl estradiol ledipasvir/sofosbuvir 58 (AFIRMELLE) 146 leflunomide 160 levonorgestrel-ethinyl estradiol LENVIMA (lenvatinib mesylate) 49 (ALTAVERA) 146 LESCOL (fluvastatin sodium) 91 levonorgestrel-ethinyl estradiol (AMETHYST)146 LESCOL XL (fluvastatin sodium) 91 levonorgestrel-ethinyl estradiol (AUBRA LETAIRIS (ambrisentan) 177 EQ) 146 letrozole 46 levonorgestrel-ethinyl estradiol (AUBRA) 146 leucovorin calcium 45 levonorgestrel-ethinyl estradiol (AVIANE) 146 LEUKERAN (chlorambucil) 43 levonorgestrel-ethinyl estradiol (AYUNA) 146 LEUKINE (sargramostim) 75 levonorgestrel-ethinyl estradiol (CHATEAL leuprolide acetate 156 EQ) 146 levalbuterol hcl 175 levonorgestrel-ethinyl estradiol (CHATEAL) 146 levalbuterol tartrate 175 levonorgestrel-ethinyl estradiol (DELYLA) 146 LEVAQUIN (levofloxacin) 22 levonorgestrel-ethinyl estradiol (ENPRESSE) 146 LEVATOL (penbutolol sulfate) 81 levonorgestrel-ethinyl estradiol (FALMINA) 146 LEVBID (hyoscyamine sulfate) 123 levonorgestrel-ethinyl estradiol LEVEMIR (insulin detemir) 73 (INTROVALE) 146 LEVEMIR FLEXTOUCH (insulin detemir) 73 levonorgestrel-ethinyl estradiol (JOLESSA) 146 levetiracetam 25 levonorgestrel-ethinyl estradiol (KURVELO) 147 levetiracetam (ROWEEPRA XR) 25 levonorgestrel-ethinyl estradiol (LARISSIA) 147 levetiracetam (ROWEEPRA) 25 levonorgestrel-ethinyl estradiol (LESSINA) 147 LEVITRA (vardenafil hcl) 132 levonorgestrel-ethinyl estradiol (LEVONEST) 147 LEVO-T (levothyroxine sodium) 155 levonorgestrel-ethinyl estradiol (LEVORA- levobunolol hcl 169 28) 147 levocarnitine 113 levonorgestrel-ethinyl estradiol (LILLOW) 147 levocarnitine (with sugar) 113 levonorgestrel-ethinyl estradiol (LUTERA) 147 levofloxacin 22 levonorgestrel-ethinyl estradiol (MARLISSA) 147 levonorgestrel 153 levonorgestrel-ethinyl estradiol (MYZILRA) 147 levonorgestrel (AFTERA) 153 levonorgestrel-ethinyl estradiol (ORSYTHIA) 147 levonorgestrel (ECONTRA EZ) 153 levonorgestrel-ethinyl estradiol (PORTIA) 147 levonorgestrel (ECONTRA ONE-STEP) 153 levonorgestrel-ethinyl estradiol levonorgestrel (FALLBACK SOLO) 153 (QUASENSE) 147 levonorgestrel (MY CHOICE) 153 levonorgestrel-ethinyl estradiol (SETLAKIN) 147 levonorgestrel (MY WAY) 153 levonorgestrel-ethinyl estradiol (SRONYX) 147 levonorgestrel (NEW DAY) 153 levonorgestrel-ethinyl estradiol (TRIVORA- levonorgestrel (NEXT CHOICE ONE DOSE) 153 28) 147 levonorgestrel (OPCICON ONE-STEP) 154 levonorgestrel-ethinyl estradiol (VIENVA) 147

207 LAST UPDATED 10/01/2019 levonorgestrel/ethinyl estradiol and ethinyl LIPOFEN (fenofibrate) 91 estradiol 147 lisinopril 79 levonorgestrel/ethinyl estradiol and ethinyl lisinopril/hydrochlorothiazide 86 estradiol (AMETHIA LO) 147 lithium carbonate 67 levonorgestrel/ethinyl estradiol and ethinyl lithium citrate 67 estradiol (AMETHIA) 147 LITHOBID (lithium carbonate) 67 levonorgestrel/ethinyl estradiol and ethinyl LITHOSTAT (acetohydroxamic acid) 132 estradiol (ASHLYNA) 147 LIVALO (pitavastatin calcium) 91 levonorgestrel/ethinyl estradiol and ethinyl LO LOESTRIN FE (norethindrone acetate- estradiol (CAMRESE LO) 147 ethinyl estradiol/ferrous fumarate) 148 levonorgestrel/ethinyl estradiol and ethinyl LO MINASTRIN FE (norethindrone acetate- estradiol (CAMRESE) 147 ethinyl estradiol/ferrous fumarate) 148 levonorgestrel/ethinyl estradiol and ethinyl LOCOID (hydrocortisone butyrate) 138 estradiol (DAYSEE) 148 LOCOID LIPOCREAM (hydrocortisone levonorgestrel/ethinyl estradiol and ethinyl butyrate/emollient base) 138 estradiol (FAYOSIM) 148 LODINE (etodolac) 2 levonorgestrel/ethinyl estradiol and ethinyl LODOSYN (carbidopa) 54 estradiol (RIVELSA) 148 LOESTRIN (norethindrone acetate-ethinyl levonorgestrel/ethinyl estradiol and ethinyl estradiol) 148 estradiol (SIMPESSE) 148 LOESTRIN FE (norethindrone acetate-ethinyl levorphanol tartrate 5 estradiol/ferrous fumarate) 148 levothyroxine sodium 155 LOKELMA (sodium zirconium cyclosilicate) 164 LEVOXYL (levothyroxine sodium) 155 LOMOTIL (diphenoxylate hcl/atropine LEVSIN (hyoscyamine sulfate) 123 sulfate) 124 LEVSIN-SL (hyoscyamine sulfate) 123 LONHALA MAGNAIR REFILL LEXAPRO (escitalopram oxalate) 33 (glycopyrrolate/nebulizer accessories) 174 LEXETTE (halobetasol propionate) 138 LONHALA MAGNAIR STARTER LEXIVA (fosamprenavir calcium) 63 (glycopyrrolate/nebulizer and LIALDA (mesalamine) 161 accessories) 174 LIBRAX (chlordiazepoxide/clidinium LONSURF (trifluridine/tipiracil hcl) 44 bromide) 123 LOPID (gemfibrozil) 91 lidocaine 14 lopinavir/ritonavir 64 lidocaine hcl 14 LOPRESSOR (metoprolol tartrate) 81 lidocaine hcl (GLYDO) 14 LOPRESSOR HCT (metoprolol lidocaine/prilocaine 14 tartrate/hydrochlorothiazide) 86 LIDODERM (lidocaine) 14 LOPROX (ciclopirox) 38 lindane 52 lorazepam 67 linezolid 17 lorazepam (LORAZEPAM INTENSOL) 67 LINZESS (linaclotide) 125 LORBRENA (lorlatinib) 46 liothyronine sodium 156 LORZONE (chlorzoxazone) 182 LIPITOR (atorvastatin calcium) 91 losartan potassium 78

208 LAST UPDATED 10/01/2019 losartan potassium/hydrochlorothiazide 86,87 maprotiline hcl 33 LOSEASONIQUE (levonorgestrel/ethinyl MARINOL (dronabinol) 37 estradiol and ethinyl estradiol) 148 MARNATAL-F (prenatal vits with calcium LOTEMAX (loteprednol etabonate) 168 no.65/iron polysacchar/folic acid) 113 LOTEMAX SM (loteprednol etabonate) 168 MARPLAN (isocarboxazid) 32 LOTENSIN (benazepril hcl) 79 MARTEN-TAB (butalbital/acetaminophen) 101 LOTENSIN HCT (benazepril MATULANE (procarbazine hcl) 43 hcl/hydrochlorothiazide) 87 MAVENCLAD (cladribine) 103 loteprednol etabonate 168 MAVIK (trandolapril) 79 LOTREL (amlodipine besylate/benazepril MAVYRET (glecaprevir/pibrentasvir) 58 hcl) 87 MAXALT (rizatriptan benzoate) 41 LOTRISONE (clotrimazole/betamethasone MAXALT MLT (rizatriptan benzoate) 41 dipropionate) 107 MAXIDEX (dexamethasone) 168 LOTRONEX (alosetron hcl) 125 MAXITROL (neomycin/polymyxin b lovastatin 92 sulfate/dexamethasone) 166 LOVAZA (omega-3 acid ethyl esters) 92 MAXZIDE (triamterene/hydrochlorothiazide) 87 LOVENOX (enoxaparin sodium) 74,75 MAXZIDE-25 MG loxapine succinate 55 (triamterene/hydrochlorothiazide) 87 LUCEMYRA (lofexidine hcl) 15 MAYZENT (siponimod) 103 luliconazole 38 mebendazole (EMVERM) 51 LUMIGAN (bimatoprost) 170 mecamylamine hcl (VECAMYL) 87 LUNESTA (eszopiclone) 184 meclofenamate sodium 2 LUXIQ (betamethasone valerate) 138 MEDROL (methylprednisolone) 138 LUZU (luliconazole) 38 medroxyprogesterone acetate 154 LYNPARZA (olaparib) 49 mefenamic acid 2 LYRICA (pregabalin) 102 mefloquine hcl 52 LYRICA CR (pregabalin) 102 MEGACE (megestrol acetate) 154 LYSODREN (mitotane) 45 MEGACE ES (megestrol acetate) 154 LYSTEDA (tranexamic acid) 76 megestrol acetate 154 MEKINIST (trametinib dimethyl sulfoxide) 49 M MEKTOVI (binimetinib) 49 MACROBID (nitrofurantoin meloxicam 2 monohydrate/macrocrystals) 17 melphalan 43 MACRODANTIN (nitrofurantoin memantine hcl 31 macrocrystal) 17 MENEST (estrogens,esterified) 148 mafenide acetate 17 MENOSTAR (estradiol) 148 MAKENA (hydroxyprogesterone caproate)154 meperidine hcl 10,11 MAKENA (hydroxyprogesterone MEPHYTON (phytonadione (vit k1)) 76 caproate/pf) 154 meprobamate 66 MALARONE (atovaquone/proguanil hcl) 52 MEPRON (atovaquone) 52 malathion 52 mercaptopurine 44

209 LAST UPDATED 10/01/2019 mesalamine 161 METROCREAM (metronidazole) 107 MESNEX (mesna) 51 METROGEL (metronidazole) 107 MESTINON (pyridostigmine bromide) 42 METROGEL-VAGINAL (metronidazole) 17 METADATE CD (methylphenidate hcl) 98 METROLOTION (metronidazole) 107 metaproterenol sulfate 175 metronidazole 18,107 metaxalone 182 metronidazole (ROSADAN) 107 metaxalone (METAXALL) 182 mexiletine hcl 80 metformin hcl 70 MIACALCIN (calcitonin,salmon,synthetic) 163 methadone hcl 5 MICARDIS (telmisartan) 79 methadone hcl (METHADONE INTENSOL) 5 MICARDIS HCT methadone hcl (METHADOSE) 5 (telmisartan/hydrochlorothiazide) 87 METHADOSE (methadone hcl) 5 miconazole nitrate 38 methamphetamine hcl 96 miconazole nitrate/zinc methazolamide 170 oxide/petrolatum,white 38 methenamine hippurate 17 MICORT-HC (hydrocortisone acetate) 138 methimazole 157 MICROGESTIN 24 FE (norethindrone acetate- METHITEST (methyltestosterone) 142 ethinyl estradiol/ferrous fumarate) 148 methocarbamol 182 MICROZIDE (hydrochlorothiazide) 90 methotrexate sodium 158 midodrine hcl 77 methotrexate sodium/pf 158 miglitol 70 methoxsalen 107 miglustat 129 methscopolamine bromide 123 MIGRANAL (dihydroergotamine mesylate) 40 methyclothiazide 90 MILLIPRED (prednisolone sodium methyldopa 77 phosphate) 138 methyldopa/hydrochlorothiazide 87 MINASTRIN 24 FE (norethindrone acetate- methylergonovine maleate 164 ethinyl estradiol/ferrous fumarate) 148 methylergonovine maleate (METHERGINE) 164 MINIPRESS (prazosin hcl) 77 METHYLIN (methylphenidate hcl) 98 MINIVELLE (estradiol) 148 methylphenidate hcl 98,99 MINOCIN (minocycline hcl) 24 methylphenidate hcl (METADATE ER) 98 minocycline hcl 24 methylphenidate hcl (RELEXXII) 98 minocycline hcl (COREMINO) 24 methylprednisolone 138 MINOLIRA ER (minocycline hcl) 24 methyltestosterone 142 minoxidil 93 metipranolol 170 MIRAPEX (pramipexole di-hcl) 53 metoclopramide hcl 35 MIRAPEX ER (pramipexole di-hcl) 53 metolazone 90 MIRCERA (methoxy polyethylene glycol- metoprolol succinate 81 epoetin beta) 75 metoprolol succinate/hydrochlorothiazide 87 MIRCETTE (desogestrel-ethinyl estradiol/ethinyl metoprolol tartrate 81 estradiol) 148 metoprolol tartrate/hydrochlorothiazide 87 mirtazapine 31 METOZOLV ODT (metoclopramide hcl) 35 MIRVASO (brimonidine tartrate) 107

210 LAST UPDATED 10/01/2019 misoprostol 127 MYNATAL (prenatal vitamins with MITIGARE (colchicine) 39 calcium/ferrous fumarate/folic acid) 114 MOBIC (meloxicam) 2 MYRBETRIQ (mirabegron) 130 modafinil 185 MYSOLINE (primidone) 26 moexipril hcl 79 MYTESI (crofelemer) 124 moexipril hcl/hydrochlorothiazide 87 molindone hcl 55 N mometasone furoate 139,172 nabumetone 2 MONODOX (doxycycline monohydrate) 24 nadolol 81 montelukast sodium 173,174 nadolol/bendroflumethiazide 87 MONUROL (fosfomycin tromethamine) 18 naftifine hcl 38 MORPHABOND ER (morphine sulfate) 5 NAFTIN (naftifine hcl) 38 morphine sulfate 5,11 NALFON (fenoprofen calcium) 2 MOTEGRITY (prucalopride succinate) 36 naloxone hcl 15 MOTOFEN (difenoxin hcl/atropine sulfate) 124 naltrexone hcl 14 MOVANTIK (naloxegol oxalate) 124 NAMENDA (memantine hcl) 31 MOVIPREP (peg 3350/sodium sulfate/sod NAMENDA XR (memantine hcl) 31 chloride/kcl/ascorbate sod/vit c) 126 NAMZARIC (memantine hcl/donepezil hcl) 30 MOXATAG (amoxicillin) 20 naphazoline hcl 166 MOXEZA (moxifloxacin hcl) 22 NAPRELAN (naproxen sodium) 2,3 moxifloxacin hcl 22 NAPROSYN (naproxen) 3 MOZOBIL (plerixafor) 75 naproxen 3 MS CONTIN (morphine sulfate) 5,6 naproxen sodium 3 MULPLETA (lusutrombopag) 75 naratriptan hcl 41 MULTAQ (dronedarone hcl) 80 NARCAN (naloxone hcl) 15 mupirocin 18 NARDIL (phenelzine sulfate) 32 mupirocin calcium 18 NASCOBAL (cyanocobalamin (vitamin b- MUSE (alprostadil) 132 12)) 114 MVC-FLUORIDE (pediatric multivitamin no.12 NASONEX (mometasone furoate) 172 with sodium fluoride) 114 NATACHEW (prenatal vitamin no.55/iron MYALEPT (metreleptin) 124 fumarate,bisglycinate/folic acid) 114 MYAMBUTOL (ethambutol hcl) 42 NATACYN (natamycin) 38 MYCOBUTIN (rifabutin) 42 NATAZIA (estradiol valerate/dienogest) 148 mycophenolate mofetil 158 nateglinide 70 mycophenolate sodium 159 NATELLE ONE (prenatal vit, calcium MYDAYIS (dextroamphetamine sulf- no.70/ferrous fumarate/folic acid/dha) 114 saccharate/amphetamine sulf-aspartate) 96 NATESTO (testosterone) 142 MYDRIACYL (tropicamide) 166 NATPARA (parathyroid hormone) 163 MYFORTIC (mycophenolate sodium) 159 NATROBA (spinosad) 107 MYLERAN (busulfan) 43 NATURE-THROID (thyroid,pork) 156 NAYZILAM (midazolam) 14

211 LAST UPDATED 10/01/2019 nebulizer and compressor 164 NEXAVAR (sorafenib tosylate) 49 NEBUSAL (sodium chloride for inhalation) 180 NEXIUM (esomeprazole magnesium) 127 needles, safety 164 niacin 92 NEEVODHA (prenatal vit no.64/iron/l-mefolate niacin (NIACOR) 92 ca/algal oil/soy lecithin) 114 NIASPAN (niacin) 92 nefazodone hcl 33 nicardipine hcl 83 NEO-SYNALAR (neomycin sulfate/fluocinolone NICOTROL (nicotine) 16 acetonide) 107 NICOTROL NS (nicotine) 16 neomycin sulfate 16 nifedipine 83 neomycin sulfate/bacitracin zinc/polymyxin nifedipine (AFEDITAB CR) 83 b/hydrocortisone 166 nifedipine (NIFEDICAL XL) 83 neomycin sulfate/bacitracin zinc/polymyxin NILANDRON (nilutamide) 43 b/hydrocortisone (NEO-POLYCIN HC) 166 nilutamide 43 neomycin sulfate/bacitracin/polymyxin b 166 nimodipine 83 neomycin sulfate/bacitracin/polymyxin b NINLARO (ixazomib citrate) 45 (NEO-POLYCIN) 166 nisoldipine 83 neomycin sulfate/polymyxin b sulfate 18 NITRO-BID (nitroglycerin) 93 neomycin sulfate/polymyxin b NITRO-DUR (nitroglycerin) 93 sulfate/gramicidin d 166 nitrofurantoin 18 neomycin sulfate/polymyxin b nitrofurantoin macrocrystal 18 sulfate/hydrocortisone 166,171 nitrofurantoin monohydrate/macrocrystals 18 neomycin/polymyxin b nitroglycerin 94 sulfate/dexamethasone 166 nitroglycerin (MINITRAN) 94 NEORAL (cyclosporine, modified) 159 nitroglycerin (NITRO-TIME) 94 NEOSPORIN G.U. IRRIGANT (neomycin NITROLINGUAL (nitroglycerin) 94 sulfate/polymyxin b sulfate) 18 NITROMIST (nitroglycerin) 94 NEPTAZANE (methazolamide) 170 NITROSTAT (nitroglycerin) 94 NERLYNX (neratinib maleate) 49 NITYR (nitisinone) 129 NESINA (alogliptin benzoate) 70 NIVESTYM (filgrastim-aafi) 76 NESTABS (prenatal vitamin no.86/iron bis- nizatidine 125 glycinate/folic acid) 114 NIZORAL (ketoconazole) 38 NESTABS ONE (pnv no.111/iron carbonyl,bis- NOCDURNA (desmopressin acetate) 141 glyc/methyltetra-folate/dha) 114 NOCTIVA (desmopressin acetate) 141 NEULASTA (pegfilgrastim) 75 NOR-Q-D (norethindrone) 154 NEUPOGEN (filgrastim) 76 NORCO (hydrocodone NEUPRO (rotigotine) 53 bitartrate/acetaminophen) 11 NEURONTIN (gabapentin) 27 NORDITROPIN FLEXPRO (somatropin) 141 NEVANAC (nepafenac) 168 norelgestromin/ethinyl estradiol (XULANE) 148 nevirapine 60 norethindrone 154 NEXA PLUS (prenatal vits no.53/iron fum/folic norethindrone (CAMILA) 154 acid/docusate calcium/dha) 114 norethindrone (DEBLITANE) 154

212 LAST UPDATED 10/01/2019 norethindrone (ERRIN) 154 norethindrone acetate-ethinyl norethindrone (HEATHER) 154 estradiol/ferrous fumarate (BLISOVI FE) 149 norethindrone (INCASSIA) 154 norethindrone acetate-ethinyl norethindrone (JENCYCLA) 154 estradiol/ferrous fumarate (GILDESS 24 FE) 149 norethindrone (JOLIVETTE) 154 norethindrone acetate-ethinyl norethindrone (LYZA) 154 estradiol/ferrous fumarate (HAILEY 24 FE) 149 norethindrone (NORA-BE) 154 norethindrone acetate-ethinyl norethindrone (NORLYDA) 154 estradiol/ferrous fumarate (JUNEL FE 24) 149 norethindrone (NORLYROC) 154 norethindrone acetate-ethinyl norethindrone (SHAROBEL) 154 estradiol/ferrous fumarate (JUNEL FE) 149 norethindrone (TULANA) 154 norethindrone acetate-ethinyl norethindrone acetate 155 estradiol/ferrous fumarate (LARIN 24 FE) 149 norethindrone acetate-ethinyl estradiol 149 norethindrone acetate-ethinyl norethindrone acetate-ethinyl estradiol estradiol/ferrous fumarate (LARIN FE) 149 (AUROVELA) 148 norethindrone acetate-ethinyl norethindrone acetate-ethinyl estradiol estradiol/ferrous fumarate (LOMEDIA 24 (FYAVOLV) 148 FE) 149 norethindrone acetate-ethinyl estradiol norethindrone acetate-ethinyl (GILDESS) 148 estradiol/ferrous fumarate (MELODETTA 24 norethindrone acetate-ethinyl estradiol FE) 150 (HAILEY) 148 norethindrone acetate-ethinyl norethindrone acetate-ethinyl estradiol estradiol/ferrous fumarate (MIBELAS 24 FE) 150 (JEVANTIQUE LO) 149 norethindrone acetate-ethinyl norethindrone acetate-ethinyl estradiol estradiol/ferrous fumarate (MICROGESTIN (JINTELI) 149 FE) 150 norethindrone acetate-ethinyl estradiol norethindrone acetate-ethinyl (JUNEL) 149 estradiol/ferrous fumarate (TARINA 24 FE) 150 norethindrone acetate-ethinyl estradiol norethindrone acetate-ethinyl (LARIN) 149 estradiol/ferrous fumarate (TARINA FE 1-20 norethindrone acetate-ethinyl estradiol EQ) 150 (MICROGESTIN) 149 norethindrone acetate-ethinyl norethindrone acetate-ethinyl estradiol/ferrous fumarate (TARINA FE) 150 estradiol/ferrous fumarate 149 norethindrone acetate-ethinyl norethindrone acetate-ethinyl estradiol/ferrous fumarate (TILIA FE) 150 estradiol/ferrous fumarate (AUROVELA 24 norethindrone acetate-ethinyl FE) 149 estradiol/ferrous fumarate (TRI-LEGEST FE) 150 norethindrone acetate-ethinyl norethindrone-ethinyl estradiol (ALYACEN) 150 estradiol/ferrous fumarate (AUROVELA FE) 149 norethindrone-ethinyl estradiol (ARANELLE)150 norethindrone acetate-ethinyl norethindrone-ethinyl estradiol (BALZIVA) 150 estradiol/ferrous fumarate (BLISOVI 24 FE) 149 norethindrone-ethinyl estradiol (BRIELLYN) 150

213 LAST UPDATED 10/01/2019 norethindrone-ethinyl estradiol norgestimate-ethinyl estradiol (TRI-LO-MILI) 151 (CYCLAFEM) 150 norgestimate-ethinyl estradiol (TRI-LO- norethindrone-ethinyl estradiol (DASETTA) 150 SPRINTEC) 151 norethindrone-ethinyl estradiol (GILDAGIA)150 norgestimate-ethinyl estradiol (TRI-MILI) 151 norethindrone-ethinyl estradiol (LEENA) 150 norgestimate-ethinyl estradiol (TRI- norethindrone-ethinyl estradiol (NECON) 150 PREVIFEM) 151 norethindrone-ethinyl estradiol (NORTREL) 150 norgestimate-ethinyl estradiol (TRI- norethindrone-ethinyl estradiol (PHILITH) 150 SPRINTEC) 151 norethindrone-ethinyl estradiol (PIRMELLA) 150 norgestimate-ethinyl estradiol (TRI-VYLIBRA norethindrone-ethinyl estradiol (VYFEMLA) 150 LO) 151 norethindrone-ethinyl estradiol (WERA) 150 norgestimate-ethinyl estradiol (TRI- norethindrone-ethinyl estradiol VYLIBRA) 152 (ZENCHENT) 150 norgestimate-ethinyl estradiol (TRINESSA norethindrone-ethinyl estradiol/ferrous LO) 152 fumarate 151 norgestimate-ethinyl estradiol (TRINESSA) 152 norethindrone-ethinyl estradiol/ferrous norgestimate-ethinyl estradiol (VYLIBRA) 152 fumarate (KAITLIB FE) 151 norgestrel-ethinyl estradiol (CRYSELLE) 152 norethindrone-ethinyl estradiol/ferrous norgestrel-ethinyl estradiol (ELINEST) 152 fumarate (WYMZYA FE) 151 norgestrel-ethinyl estradiol (LOW- norethindrone-mestranol (NECON) 151 OGESTREL) 152 NORGESIC FORTE (orphenadrine norgestrel-ethinyl estradiol (OGESTREL) 152 citrate/aspirin/caffeine) 182 NORITATE (metronidazole) 107 norgestimate-ethinyl estradiol 151 NORPACE (disopyramide phosphate) 80 norgestimate-ethinyl estradiol (ESTARYLLA) 151 NORPACE CR (disopyramide phosphate) 80 norgestimate-ethinyl estradiol (FEMYNOR) 151 NORPRAMIN (desipramine hcl) 35 norgestimate-ethinyl estradiol (MILI) 151 NORTHERA (droxidopa) 77 norgestimate-ethinyl estradiol (MONO- nortriptyline hcl 35 LINYAH) 151 NORVASC (amlodipine besylate) 83 norgestimate-ethinyl estradiol NORVIR (ritonavir) 64 (MONONESSA) 151 NOVOLIN 70-30 (insulin nph human norgestimate-ethinyl estradiol (PREVIFEM) 151 isophane/insulin regular, human) 73 norgestimate-ethinyl estradiol (SPRINTEC) 151 NOVOLIN 70-30 FLEXPEN (insulin nph human norgestimate-ethinyl estradiol (TRI isophane/insulin regular, human) 73 FEMYNOR) 151 NOVOLIN N (insulin nph human isophane) 73 norgestimate-ethinyl estradiol (TRI- NOVOLIN R (insulin regular, human) 73 ESTARYLLA) 151 NOVOLOG (insulin aspart) 73 norgestimate-ethinyl estradiol (TRI-LINYAH) 151 NOVOLOG FLEXPEN (insulin aspart) 73 norgestimate-ethinyl estradiol (TRI-LO- NOVOLOG MIX 70-30 (insulin aspart ESTARYLLA) 151 protamine human/insulin aspart) 73 norgestimate-ethinyl estradiol (TRI-LO- NOVOLOG MIX 70-30 FLEXPEN (insulin aspart MARZIA) 151 protamine human/insulin aspart) 73

214 LAST UPDATED 10/01/2019 NOXAFIL (posaconazole) 38 OBSTETRIX EC (prenatal vitamins NUBEQA (darolutamide) 43 no.127/iron,carbonyl/folic acid/docusate) 114 NUCALA (mepolizumab) 180 OCALIVA (obeticholic acid) 124 NUCYNTA (tapentadol hcl) 11 octreotide acetate 156 NUCYNTA ER (tapentadol hcl) 6 OCUFEN (flurbiprofen sodium) 168 NUEDEXTA (dextromethorphan hbr/quinidine OCUFLOX (ofloxacin) 22 sulfate) 101 ODACTRA (allergenic extract, mite-d.farinae- NULYTELY WITH FLAVOR PACKS (sodium d.pteronyssinus,standard) 164 chloride/sodium bicarbonate/potassium ODEFSEY (emtricitabine/rilpivirine chloride/peg) 126 hcl/tenofovir alafenamide fumarate) 61 NUPLAZID (pimavanserin tartrate) 56 ODOMZO (sonidegib phosphate) 49 NUTROPIN AQ NUSPIN (somatropin) 141 OFEV (nintedanib esylate) 180 NUVARING (etonogestrel/ethinyl estradiol) 152 ofloxacin 22 NUVESSA (metronidazole) 18 olanzapine 56 NUVIGIL (armodafinil) 185 olanzapine/fluoxetine hcl 31 NUZYRA (omadacycline tosylate) 24 olmesartan medoxomil 79 NYMALIZE (nimodipine) 83 olmesartan medoxomil/amlodipine nystatin 38 besylate/hydrochlorothiazide 87 nystatin (NYAMYC) 38 olmesartan nystatin (NYATA) 38 medoxomil/hydrochlorothiazide 87 nystatin (NYSTOP) 38 olopatadine hcl 167,173 nystatin/triamcinolone acetonide 38 OLUMIANT (baricitinib) 159 OLUX (clobetasol propionate) 139 O OLUX-E (clobetasol propionate/emollient O-CAL PRENATAL (prenatal vit with calcium base) 139 no.127/ferrous fumarate/folic acid) 114 OLYSIO (simeprevir sodium) 58 OB COMPLETE (prenatal vitamins OMECLAMOX-PAK no.123/iron,carbonyl/folic acid) 114 (omeprazole/clarithromycin/amoxicillin OB COMPLETE ONE (prenatal vit no.85/iron trihydrate) 124 carb,asp.gly/folic acid/dha/fish oil) 114 omega-3 acid ethyl esters 92 OB COMPLETE PETITE (prenatal no56/iron omega-3 acid ethyl esters (TRIKLO) 92 carbonyl,asparto glycinate/folic omeprazole 127 acid/dha) 114 omeprazole/sodium bicarbonate 127,128 OB COMPLETE PREMIER (prenatal vits omeprazole/sodium bicarbonate no.83/iron,carbonyl,iron aspart.gly/folic (OMEPPI) 127 acid) 114 OMNARIS (ciclesonide) 172 OB COMPLETE WITH DHA (prenatal vit OMNIPRED (prednisolone acetate) 168 no.30/iron carbonyl,asp glyc/folic OMNITROPE (somatropin) 141 acid/omega-3) 114 ondansetron 37 OBREDON (guaifenesin/hydrocodone ondansetron hcl 37 bitartrate) 180

215 LAST UPDATED 10/01/2019 ONEXTON (clindamycin phosphate/benzoyl OSMOPREP (sodium peroxide) 107 phosphate,monobasic/sodium ONFI (clobazam) 27 phosphate,dibasic) 126 ONGLYZA (saxagliptin hcl) 70 OSPHENA (ospemifene) 155 ONMEL (itraconazole) 39 OTEZLA (apremilast) 160 ONZETRA XSAIL (sumatriptan succinate) 41 OTOVEL (ciprofloxacin hcl/fluocinolone OPANA (oxymorphone hcl) 11 acetonide) 171 OPANA ER (oxymorphone hcl) 6 OTREXUP (methotrexate/pf) 159 OPSUMIT (macitentan) 177 OVACE (sulfacetamide sodium) 107 ORACEA (doxycycline monohydrate) 24 OVACE PLUS (sulfacetamide sodium) 107 ORACIT (citric acid/sodium citrate) 132 OVACE PLUS WASH (sulfacetamide ORALAIR (grass pollen-orchard/sweet sodium) 107 vernal/rye/kentucky/timothy, std.) 180 OVIDE (malathion) 52 ORAP (pimozide) 55 OXANDRIN (oxandrolone) 141 ORAPRED ODT (prednisolone sodium oxandrolone 141 phosphate) 139 oxaprozin 3 ORAVIG (miconazole) 39 OXAYDO (oxycodone hcl) 11 ORENCIA (abatacept) 159 oxazepam 67 ORENCIA CLICKJECT (abatacept) 159 oxcarbazepine 29 ORENITRAM ER (treprostinil diolamine) 177 OXERVATE (cenegermin-bkbj) 166 ORFADIN (nitisinone) 129 oxiconazole nitrate 39 ORILISSA (elagolix sodium) 156 OXISTAT (oxiconazole nitrate) 39 ORKAMBI (lumacaftor/ivacaftor) 176 OXSORALEN-ULTRA (methoxsalen) 107 orphenadrine citrate 182 OXTELLAR XR (oxcarbazepine) 29 orphenadrine citrate/aspirin/caffeine 182 oxybutynin chloride 130 orphenadrine citrate/aspirin/caffeine oxycodone hcl 6,11,12 (ORPHENGESIC FORTE) 183 oxycodone hcl/acetaminophen 12 ORTHO MICRONOR (norethindrone) 155 oxycodone hcl/acetaminophen ORTHO TRI-CYCLEN (norgestimate-ethinyl (ENDOCET) 12 estradiol) 152 oxycodone hcl/acetaminophen ORTHO TRI-CYCLEN LO (norgestimate-ethinyl (NALOCET) 12 estradiol) 152 oxycodone hcl/acetaminophen (PRIMLEV) 12 ORTHO-CYCLEN (norgestimate-ethinyl oxycodone hcl/aspirin 12 estradiol) 152 OXYCONTIN (oxycodone hcl) 6 ORTHO-NOVUM (norethindrone-ethinyl oxymorphone hcl 6,12 estradiol) 152 OXYTROL (oxybutynin) 130 oseltamivir phosphate 64,65 OZEMPIC (semaglutide) 70 OSENI (alogliptin benzoate/pioglitazone hcl) 70 P OSMOLEX ER (amantadine hcl) 53 PACERONE (amiodarone hcl) 80 paliperidone 56

216 LAST UPDATED 10/01/2019 PALYNZIQ (pegvaliase-pqpz) 129 peg 3350/sod sulf/sod bicarb/sod PAMELOR (nortriptyline hcl) 35 chloride/potassium chloride (GAVILYTE-G) 126 PANCREAZE (lipase/protease/amylase) 129 PEGANONE (ethotoin) 29 PANDEL (hydrocortisone probutate) 139 PEGASYS (peginterferon alfa-2a) 59 PANRETIN (alitretinoin) 50 PEGASYS PROCLICK (peginterferon alfa-2a) 59 pantoprazole sodium 128 PEGINTRON (peginterferon alfa-2b) 59 PARAFON FORTE DSC (chlorzoxazone) 183 PEGINTRON REDIPEN (peginterferon alfa- paricalcitol 163 2b) 59 PARLODEL (bromocriptine mesylate) 53 pen needle, diabetic 164 PARNATE (tranylcypromine sulfate) 32 pen needle, diabetic disposable, safety 164 paromomycin sulfate 16 pen needle, diabetic, safety 164 paroxetine hcl 33 penicillamine 132 paroxetine mesylate 34 penicillin v potassium 20 PASER (aminosalicylic acid) 42 PENLAC (ciclopirox) 39 PATADAY (olopatadine hcl) 167 PENNSAID (diclofenac sodium) 3 PATANASE (olopatadine hcl) 173 PENTASA (mesalamine) 161 PATANOL (olopatadine hcl) 167 pentazocine hcl/naloxone hcl 12 PAXIL (paroxetine hcl) 34 pentoxifylline 87 PAXIL CR (paroxetine hcl) 34 PEPCID (famotidine) 125 PAZEO (olopatadine hcl) 167 PERCOCET (oxycodone PCE (erythromycin base) 21 hcl/acetaminophen) 12 pediatric multivit with a,c,d3 no.21/sodium PERFOROMIST (formoterol fumarate) 175 fluoride 114 perindopril erbumine 79,80 pediatric multivit with a,c,d3 no.21/sodium permethrin 52 fluoride (TRI-VITE WITH FLUORIDE) 114 perphenazine 36 pediatric multivitamin no.16/sodium perphenazine/amitriptyline hcl 31 fluoride 115 PERSANTINE (dipyridamole) 77 pediatric multivitamin no.2/sodium PERTZYE (lipase/protease/amylase) 129 fluoride 115 PEXEVA (paroxetine mesylate) 34 pediatric multivitamin no.45/sodium phenazopyridine hcl 132 fluoride/ferrous sulfate 115 phendimetrazine tartrate 101 pediatric multivitamin no.75/sodium phenelzine sulfate 32 fluoride/ferrous sulfate 115 PHENERGAN (promethazine hcl) 36 pediatric multivitamin no.82 with sodium phenobarbital 27 fluoride 115 phenobarbital/hyoscyamine sulf/atropine pediatric multivitamins no.17 with sodium sulf/scopolamine hb 123 fluoride 115 phenobarbital/hyoscyamine sulf/atropine peg 3350/sod sulf/sod bicarb/sod sulf/scopolamine hb (PHENOHYTRO) 123 chloride/potassium chloride 126 phenoxybenzamine hcl 77 peg 3350/sod sulf/sod bicarb/sod phentermine hcl 101 chloride/potassium chloride (GAVILYTE-C) 126 phentermine hcl (ADIPEX-P) 101

217 LAST UPDATED 10/01/2019 phentermine hcl (LOMAIRA) 101 POLYTRIM (polymyxin b phenylephrine hcl 166 sulfate/trimethoprim) 166 phenylephrine hcl/promethazine hcl 180 POMALYST (pomalidomide) 44 PHENYTEK (phenytoin sodium extended) 29 PONSTEL (mefenamic acid) 3 phenytoin 29 posaconazole 39 phenytoin sodium extended 29 potassium bicarbonate/citric acid 115 PHOSLYRA (calcium acetate) 134 potassium bicarbonate/citric acid (EFFER- PHOSPHOLINE IODIDE (echothiophate K) 115 iodide) 170 potassium bicarbonate/citric acid (K phytonadione (vit k1) 76 EFFERVESCENT) 115 PICATO (ingenol mebutate) 108 potassium bicarbonate/citric acid (KLOR- PIFELTRO (doravirine) 61 CON-EF) 115 pilocarpine hcl 103,170 potassium chloride 116 pimecrolimus 108 potassium chloride (KLOR-CON M10) 115 pimozide 55 potassium chloride (KLOR-CON M20) 115 pindolol 81 potassium chloride (KLOR-CON SPRINKLE) 115 pioglitazone hcl 70 potassium chloride (KLOR-CON) 115 pioglitazone hcl/glimepiride 70 potassium chloride/potassium pioglitazone hcl/metformin hcl 70 bicarbonate/citric acid 116 PIQRAY (alpelisib) 46 potassium citrate 132 piroxicam 3 potassium citrate/citric acid 132 PLAN B ONE-STEP (levonorgestrel) 155 potassium citrate/citric acid (CYTRA-K) 132 PLAQUENIL (hydroxychloroquine sulfate) 52 potassium citrate/citric acid (VIRTRATE-K) 132 PLAVIX (clopidogrel bisulfate) 77 potassium iodide (SSKI) 157 PLEGRIDY (peginterferon beta-1a) 103 POTIGA (ezogabine) 25 PLEGRIDY PEN (peginterferon beta-1a) 103 PRADAXA (dabigatran etexilate mesylate) 75 PLENVU (peg 3350/sodium sulfate/sod PRALUENT PEN (alirocumab) 92 chloride/kcl/ascorbate sod/vit c) 126 PRALUENT SYRINGE (alirocumab) 93 PLETAL (cilostazol) 77 pramipexole di-hcl 53 PLEXION (sulfacetamide sodium/sulfur) 108 PRAMOSONE (hydrocortisone podofilox 108 acetate/pramoxine hcl) 108 POLY-VI-FLOR (pediatric multivitamin no.33 PRANDIN (repaglinide) 70 with sodium fluoride) 115 prasugrel hcl 77 POLY-VI-FLOR (pediatric multivitamin no.37 PRAVACHOL (pravastatin sodium) 92 with sodium fluoride) 115 pravastatin sodium 92 POLY-VI-FLOR WITH IRON (pediatric multivit praziquantel 51 no.37/sodium fluoride/iron bisglycin.hcl) 115 prazosin hcl 78 POLY-VI-FLOR WITH IRON (pediatric PRECOSE (acarbose) 70 multivitamin no.33/sodium fluoride/iron PRED FORTE (prednisolone acetate) 168 carbonyl) 115 PRED MILD (prednisolone acetate) 168 polymyxin b sulfate/trimethoprim 166

218 LAST UPDATED 10/01/2019 PRED-G (gentamicin sulfate/prednisolone prenatal vit no.21/iron polysacch,heme acetate) 166 polypep/folic acid (VP-HEME OB) 116 prednicarbate 139 prenatal vit no.71/iron fum-sodium prednisolone 139 feredetate/folic acid/dha (PRENA1 PEARL)116 prednisolone (MILLIPRED DP) 139 prenatal vit no.80/iron prednisolone (MILLIPRED) 139 carb,bisgl/methylfolate/docusate/dha prednisolone acetate 168 (OBSTETRIX ONE) 116 prednisolone sodium phosphate 139,169 prenatal vit with calcium 15/iron/folic prednisolone sodium phosphate acid/docusate sodium (MYNATAL (PEDIAPRED) 139 ADVANCE) 116 prednisone 139 prenatal vit with calcium no.37/iron,aspg/folic prednisone (PREDNISONE INTENSOL) 139 acid/omega-3 (ULTIMATECARE ONE) 117 PREFERA OB (prenatal vit no.21/iron prenatal vit with calcium no.40/iron polysacch,heme polypep/folic acid) 116 fumarate/folate no.1 (PNV-SELECT) 117 PREFERA-OB ONE (prenatal vitamin no.19/iron prenatal vit with calcium no.40/iron polysac,iron heme/folic acid/dha) 116 fumarate/folate no.1 (VIRT-PN) 117 PREFEST (estradiol/norgestimate) 152 prenatal vit with calcium no.68/iron fum/folic pregabalin 102 acid no.1/dha (PNV-OMEGA) 117 PREMARIN (estrogens, conjugated) 152 prenatal vit with calcium no.68/iron fum/folic PREMPHASE (estrogens, acid no.1/dha (VIRT-PN PLUS) 117 conjugated/medroxyprogesterone prenatal vit with calcium no.68/iron fum/folic acetate) 152 acid no.1/dha (ZATEAN-PN PLUS) 117 PREMPRO (estrogens, prenatal vit with calcium no.69/iron/folic conjugated/medroxyprogesterone acid/docusate/dha (PRENAISSANCE PLUS) 117 acetate) 152 prenatal vit,calcium no.35/iron/folic PRENA1 CHEW (prenatal vitamins acid/docusate/omega-3 (ULTIMATECARE combination no.42/folic acid) 116 ONE NF) 117 PRENATA (prenatal vitamins no.37/ferrous prenatal vit/folic acid/b6/calcium phosph fumarate/folic acid) 116 di,tribasic/ginger (VP-GGR-B6) 117 PRENATABS FA (prenatal vits with calcium prenatal vit/folic acid/b6/calcium phosph no.78/ferrous fumarate/folic acid) 116 di,tribasic/ginger (ZINGIBER) 117 PRENATABS RX (prenatal vitamin with calcium prenatal vitamin 27 with calcium/ferrous no.76/iron,carbonyl/folic acid) 116 fumarate/folic acid (TRINATAL RX 1) 117 prenatal vit no.16/iron fum,ps complex/folic prenatal vitamin 27 with calcium/ferrous acid/omega-3 (DOTHELLE DHA) 116 fumarate/folic acid (VINATE ONE) 117 prenatal vit no.16/iron fum,ps complex/folic prenatal vitamin no.15/iron fumarate,polysac acid/omega-3 (TARON-C DHA) 116 comp/folic acid (FOLIVANE-OB) 117 prenatal vit no.16/iron fum,ps complex/folic prenatal vitamin no.19/iron polysac,iron acid/omega-3 (VIRT-C DHA) 116 heme/folic acid/dha (VP-HEME ONE) 117 prenatal vit no.21/iron polysacch,heme prenatal vitamin no.86/iron bis-glycinate/folic polypep/folic acid (HEMENATAL OB) 116 acid (NEWGEN) 117

219 LAST UPDATED 10/01/2019 prenatal vitamin with calcium prenatal vits with calcium no.115/iron no.76/iron,carbonyl/folic acid (PNV 29-1) 117 fumarate/folic acid 118 prenatal vitamin with calcium prenatal vits with calcium no.47/ferrous no.76/iron,carbonyl/folic acid (THRIVITE fum/folate no.1/dha (PNV-DHA) 118 RX) 117 prenatal vits with calcium no.47/ferrous prenatal vitamins no.11/ferrous fumarate/folic fum/folate no.1/dha (VIRT-PN DHA) 118 acid/omega-3 (C-NATE DHA) 117 prenatal vits with calcium no.47/ferrous prenatal vitamins no.11/ferrous fumarate/folic fum/folate no.1/dha (ZATEAN-PN DHA) 119 acid/omega-3 (VIRT-NATE DHA) 118 prenatal vits with calcium no.72/ferrous prenatal vitamins no.123/iron,carbonyl/folic fumarate/folic acid 119 acid (ELITE-OB) 118 prenatal vits with calcium no.72/ferrous prenatal vitamins no.14/ferrous fumarate/folic fumarate/folic acid (M-NATAL PLUS) 119 acid (COMPLETENATE) 118 prenatal vits with calcium no.72/ferrous prenatal vitamins no.5/ferrous fumarate/folic fumarate/folic acid (PREPLUS) 119 acid 118 prenatal vits with calcium prenatal vitamins no.5/ferrous fumarate/folic no.72/iron,carbonyl/folic acid 119 acid (PNV-VP-U) 118 prenatal vits with calcium no.73/ferrous prenatal vitamins no.66/iron,carbonyl/folic fumarate/folic acid (VIRT-NATE) 119 acid/dha (R-NATAL OB) 118 prenatal vits with calcium no.74/ferrous prenatal vitamins no.79/iron fum/folic fumarate/folic acid 119 acid/levomefolate/dha 118 prenatal vits with calcium no.78/ferrous prenatal vitamins with calcium/ferrous fumarate/folic acid (PRETAB) 119 fum/docusate/folic ac (MYNATE 90 PLUS) 118 prenatal vits with calcium no.80/iron fum/folic prenatal vitamins with calcium/ferrous acid/dss/dha (PRENAISSANCE) 119 fumarate/folic acid (MYNATAL PLUS) 118 prenatal vits,calcium no.39/iron fum/folic prenatal vitamins with calcium/ferrous acid/docusate/dha (TARON-PREX fumarate/folic acid (MYNATAL-Z) 118 PRENATAL) 119 prenatal vitamins with prenatal vits,calcium no.66/iron fum/folic calcium/iron,carb/docusate/folic acid acid/docusate/dha (PNV-DHA + (MYNATAL) 118 DOCUSATE) 119 prenatal vits no.115/iron fumarate/folic prenatal vits,calcium no.66/iron fum/folic acid/docusate sod. 118 acid/docusate/dha (VEMAVITE-PRX 2) 119 prenatal vits no.119/iron fumarate/folic PRENATE AM (prenatal vit acid/docusate sod. 118 114/methyltetrahydfolate gluc,folic prenatal vits no.34/iron,carb/folic acid/ginger) 119 acid/docusate sodium/dha (VP-CH-PNV) 118 PRENATE CHEWABLE (prenatal vits prenatal vits with calcium 118/ferrous no.112/methyltetrahydrofolate gluc,folic fumarate/folic acid 118 acid) 119 prenatal vits with calcium 136/ferrous PRENATE DHA (prenatal vitamins no.38/iron fumarate/folic acid (VINATE-M) 118 fumarate/folate comb no.6/dha) 119

220 LAST UPDATED 10/01/2019 PRENATE DHA (prenatal vitamins no.78/iron PRISTIQ (desvenlafaxine succinate) 34 asparto glycin/folate no.1/dha) 119 PROAIR HFA (albuterol sulfate) 175 PRENATE ELITE (prenatal vitamins no.36/ferrous PROAIR RESPICLICK (albuterol sulfate) 175 fumarate/folate comb. no.6) 119 probenecid 39 PRENATE ELITE (prenatal vits no.114/ferrous probenecid/colchicine 39 aspart glycinate/folate no.1) 120 PROCARDIA (nifedipine) 83 PRENATE ENHANCE (prenatal vitamins PROCARDIA XL (nifedipine) 83 no.68/iron fumarate/folate no.6/dha) 120 prochlorperazine 36 PRENATE ESSENTIAL (prenatal vitamin prochlorperazine (COMPRO) 36 no.35/iron fumarate/folate comb. prochlorperazine maleate 36 no.6/dha) 120 PROCRIT (epoetin alfa) 76 PRENATE ESSENTIAL (prenatal vitamins PROCTOFOAM-HC (hydrocortisone no.84/iron asparto glycin/folate no.1/dha) 120 acetate/pramoxine hcl) 108 PRENATE MINI (prenatal vits no.87/iron carb- PROCYSBI (cysteamine bitartrate) 129 asp.glycinate/folate no.1/dha) 120 progesterone 155 PRENATE PIXIE (prenatal vitamins no.85/iron progesterone, micronized 155 asparto glycin/folate no.1/dha) 120 PROGLYCEM (diazoxide) 72 PRENATE RESTORE (prenatal vitamins PROGRAF (tacrolimus) 159 no.69/iron fumarate/folate comb PROLENSA (bromfenac sodium) 169 no.6/dha) 120 PROMACTA (eltrombopag olamine) 76 PRENATE STAR (prenatal vitamins no.77/ferrous promethazine hcl 36,173 asparto glycinate/folic acid) 120 promethazine hcl (PHENADOZ) 36 PREPOPIK (sodium picosulfate/magnesium promethazine hcl (PROMETHEGAN) 36 oxide/citric acid) 126 promethazine hcl/codeine 180 PRESTALIA (perindopril arginine/amlodipine promethazine hcl/dextromethorphan hbr 181 besylate) 88 promethazine/phenylephrine hcl/codeine 181 PREVACID (lansoprazole) 128 PROMETRIUM (progesterone, micronized) 155 PREVPAC (lansoprazole/amoxicillin propafenone hcl 80 trihydrate/clarithromycin) 124 propantheline bromide 123 PREVYMIS (letermovir) 57 proparacaine hcl 166 PREZCOBIX (darunavir propranolol hcl 82 ethanolate/cobicistat) 64 propranolol hcl/hydrochlorothiazide 88 PREZISTA (darunavir ethanolate) 64 propylthiouracil 157 PRIFTIN (rifapentine) 42 PROSCAR (finasteride) 131 PRILOSEC (omeprazole magnesium) 128 PROTONIX (pantoprazole sodium) 128 PRIMACARE (prenatal vits no.118/iron asparto PROTOPIC (tacrolimus) 108 glycinate/folate no.6/dha) 120 protriptyline hcl 35 primaquine phosphate 52 PROVENTIL HFA (albuterol sulfate) 175 primidone 27 PROVERA (medroxyprogesterone PRIMSOL (trimethoprim) 18 acetate) 155 PRINIVIL (lisinopril) 80

221 LAST UPDATED 10/01/2019 PROVIDA DHA (prenatal vitamins no.90/iron QUFLORA (pediatric multivitamin no.83 with fum,polysac comp/folic acid/dha) 120 sodium fluoride) 120 PROVIDA OB (prenatal vits no.65/iron QUFLORA (pediatric multivitamin no.84 with fumarate,polysac complex/folic acid) 120 sodium fluoride) 120 PROVIGIL (modafinil) 185 QUFLORA FE (pediatric multivitamin PROZAC (fluoxetine hcl) 34 no.142/iron,carbonyl/sodium fluoride) 120 PROZAC WEEKLY (fluoxetine hcl) 34 QUFLORA FE (pediatric multivitamin PRUDOXIN (doxepin hcl) 108 no.151/ferrous sulfate/sod fluoride) 122 PULMICORT (budesonide) 172 QUILLICHEW ER (methylphenidate hcl) 99 PULMICORT FLEXHALER (budesonide) 172 QUILLIVANT XR (methylphenidate hcl) 99 PULMOZYME (dornase alfa) 181 quinapril hcl 80 PUREFE OB PLUS (prenatal vits no.4/iron quinapril hcl/hydrochlorothiazide 88 fumarate,polysacc complex/folic acid) 120 quinidine gluconate 80 PURIXAN (mercaptopurine) 44 quinidine sulfate 80 PYLERA (colloidal bismuth quinine sulfate 52 subcitrate/metronidazole/tetracycline hcl)124 QVAR (beclomethasone dipropionate) 172 pyrazinamide 42 QVAR REDIHALER (beclomethasone PYRIDIUM (phenazopyridine hcl) 132 dipropionate) 172 pyridostigmine bromide 42 R Q rabeprazole sodium 128 QBRELIS (lisinopril) 80 RADIOGARDASE (prussian blue (insoluble)) 120 QBREXZA (glycopyrronium tosylate) 108 RAGWITEK (allergenic extract-weed pollen- QMIIZ ODT (meloxicam) 3 short ragweed) 181 QNASL (beclomethasone dipropionate) 172 raloxifene hcl 155 QNASL CHILDREN (beclomethasone ramelteon 185 dipropionate) 172 ramipril 80 QSYMIA (phentermine hcl/topiramate) 101 RANEXA (ranolazine) 88 QTERN (dapagliflozin propanediol/saxagliptin ranitidine hcl 125 hcl) 70 ranolazine 88 QUALAQUIN (quinine sulfate) 52 RAPAFLO (silodosin) 131 QUARTETTE (levonorgestrel/ethinyl estradiol RAPAMUNE (sirolimus) 159 and ethinyl estradiol) 152 rasagiline mesylate 55 quazepam 184 RASUVO (methotrexate/pf) 159 QUDEXY XR (topiramate) 28 RAVICTI (glycerol phenylbutyrate) 129 QUESTRAN (cholestyramine (with sugar)) 93 RAYALDEE (calcifediol) 163 QUESTRAN LIGHT RAYOS (prednisone) 139 (cholestyramine/aspartame) 93 RAZADYNE (galantamine hbr) 30 quetiapine fumarate 56 RAZADYNE ER (galantamine hbr) 30 QUFLORA (pediatric multivitamin no.63 with REBETOL (ribavirin) 59 sodium fluoride) 120 REBIF (interferon beta-1a/albumin human) 103

222 LAST UPDATED 10/01/2019 REBIF REBIDOSE (interferon beta-1a/albumin RHOPRESSA (netarsudil mesylate) 170 human) 103 RIBASPHERE RIBAPAK (ribavirin) 59 RECTIV (nitroglycerin) 108 RIBATAB (ribavirin) 59 REGIMEX (benzphetamine hcl) 101 ribavirin 59 REGLAN (metoclopramide hcl) 36 ribavirin (MODERIBA) 59 REGRANEX (becaplermin) 108 ribavirin (RIBASPHERE) 59 RELENZA (zanamivir) 65 RIDAURA (auranofin) 160 RELISTOR (methylnaltrexone bromide) 124 rifabutin 42 RELPAX (eletriptan hydrobromide) 41 RIFADIN (rifampin) 42 REMERON (mirtazapine) 32 RIFAMATE (rifampin/isoniazid) 42 RENACIDIN (citric rifampin 43 acid/gluconolactone/magnesium RIFATER (rifampin/isoniazid/pyrazinamide) 43 carbonate) 133 RILUTEK (riluzole) 101 RENAGEL (sevelamer hcl) 134 riluzole 101 RENVELA (sevelamer carbonate) 134 rimantadine hcl 65 repaglinide 70 RINVOQ ER (upadacitinib) 159 repaglinide/metformin hcl 70 RIOMET (metformin hcl) 70 REPATHA PUSHTRONEX (evolocumab) 93 risedronate sodium 163 REPATHA SURECLICK (evolocumab) 93 RISPERDAL (risperidone) 56 REPATHA SYRINGE (evolocumab) 93 RISPERDAL M-TAB (risperidone) 56 REQUIP (ropinirole hcl) 53 risperidone 56 REQUIP XL (ropinirole hcl) 53,54 RITALIN (methylphenidate hcl) 99 RESCRIPTOR (delavirdine mesylate) 61 RITALIN LA (methylphenidate hcl) 99 reserpine 88 ritonavir 64 RESTASIS (cyclosporine) 166 rivastigmine 31 RESTASIS MULTIDOSE (cyclosporine) 166 rivastigmine tartrate 31 RESTORIL (temazepam) 184 rizatriptan benzoate 41 RETACRIT (epoetin alfa-epbx) 76 ROBAXIN (methocarbamol) 183 RETIN-A (tretinoin) 108 ROBAXIN-750 (methocarbamol) 183 RETIN-A MICRO (tretinoin microspheres) 108 ROBINUL (glycopyrrolate) 123 RETIN-A MICRO PUMP (tretinoin ROBINUL FORTE (glycopyrrolate) 123 microspheres) 108 ROCALTROL (calcitriol) 163 RETROVIR (zidovudine) 62 ROCKLATAN (netarsudil REVATIO (sildenafil citrate) 177 mesylate/latanoprost) 170 REVLIMID (lenalidomide) 44 ropinirole hcl 54 REXULTI (brexpiprazole) 56 ROSULA (sulfacetamide sodium/sulfur) 108 REYATAZ (atazanavir sulfate) 64 rosuvastatin calcium 92 REZIRA (pseudoephedrine hcl/hydrocodone ROXICODONE (oxycodone hcl) 12,13 bitartrate) 181 ROXYBOND (oxycodone hcl) 13 RHEUMATREX (methotrexate sodium) 159 ROZEREM (ramelteon) 185 RHOFADE (oxymetazoline hcl) 108 ROZLYTREK (entrectinib) 45

223 LAST UPDATED 10/01/2019 RUBRACA (rucaparib camsylate) 45 SELECT-OB (prenatal vit no.128/iron RUZURGI (amifampridine) 164 polysaccharide complex/folic acid) 121 RYCLORA (dexchlorpheniramine maleate) 173 SELECT-OB (prenatal vitamin no.13/iron RYDAPT (midostaurin) 45 polysaccharides/folate comb no.1) 121 RYTARY (carbidopa/levodopa) 54 selegiline hcl 55 RYTHMOL (propafenone hcl) 80 selenium sulfide 109 RYTHMOL SR (propafenone hcl) 80 SELZENTRY (maraviroc) 63 RYVENT (carbinoxamine maleate) 173 SENSIPAR (cinacalcet hcl) 163 SEREVENT DISKUS (salmeterol xinafoate) 176 S SERNIVO (betamethasone dipropionate) 139 SABRIL (vigabatrin) 27 SEROPHENE (clomiphene citrate) 155 SAFYRAL (drospirenone/ethinyl SEROQUEL (quetiapine fumarate) 57 estradiol/levomefolate calcium) 152 SEROQUEL XR (quetiapine fumarate) 57 SAIZEN (somatropin) 141 SEROSTIM (somatropin) 141 SAIZEN-SAIZENPREP (somatropin) 141 sertraline hcl 34 SALAGEN (pilocarpine hcl) 103 sevelamer carbonate 134 SALEX (salicylic acid) 108 sevelamer hcl 134 salicylic acid 109 SEYSARA (sarecycline hcl) 24 salicylic acid (SALIMEZ) 108 SFROWASA (mesalamine) 161 salsalate 3 SIGNIFOR (pasireotide diaspartate) 156 SALVAX (salicylic acid) 109 SIKLOS (hydroxyurea) 45 SAMSCA (tolvaptan) 120,121 sildenafil citrate 133,177 SANCUSO (granisetron) 37 SILENOR (doxepin hcl) 185 SANDIMMUNE (cyclosporine) 159 SILIQ (brodalumab) 109 SANDOSTATIN (octreotide acetate) 156 silodosin 131 SANTYL (collagenase clostridium SILVADENE (silver sulfadiazine) 22 histolyticum) 109 silver sulfadiazine 22 SAPHRIS (asenapine maleate) 56 SIMBRINZA (brinzolamide/brimonidine SARAFEM (fluoxetine hcl) 34 tartrate) 170 SAVAYSA (edoxaban tosylate) 75 SIMPONI (golimumab) 159 SAVELLA (milnacipran hcl) 102 simvastatin 92 SAXENDA (liraglutide) 164 SINEMET 10-100 (carbidopa/levodopa) 54 scopolamine 36 SINEMET 25-100 (carbidopa/levodopa) 54 SEASONIQUE (levonorgestrel/ethinyl estradiol SINEMET 25-250 (carbidopa/levodopa) 54 and ethinyl estradiol) 152 SINEMET CR (carbidopa/levodopa) 54 SECONAL SODIUM (secobarbital sodium) 185 SINGULAIR (montelukast sodium) 174 SECTRAL (acebutolol hcl) 82 sirolimus 159 SEEBRI NEOHALER (glycopyrrolate) 174 SITAVIG (acyclovir) 65 SEGLUROMET (ertugliflozin pidolate/metformin SIVEXTRO (tedizolid phosphate) 18 hcl) 70 SKELAXIN (metaxalone) 183 SKLICE (ivermectin) 51

224 LAST UPDATED 10/01/2019 SKYRIZI (2 SYRINGES) KIT (risankizumab-rzaa) 13 SOMAVERT (pegvisomant) 157 SLYND (drospirenone) 155 SONATA (zaleplon) 184 sodium chloride for inhalation 181 SOOLANTRA (ivermectin) 109 sodium chloride for inhalation (NEBUSAL) 181 SORIATANE (acitretin) 109 sodium chloride for inhalation (PULMOSAL)181 SORILUX (calcipotriene) 109 sodium chloride/sodium sotalol hcl 81 bicarbonate/potassium chloride/peg 126 sotalol hcl (SORINE) 80 sodium chloride/sodium SOTYLIZE (sotalol hcl) 81 bicarbonate/potassium chloride/peg SOVALDI (sofosbuvir) 58 (GAVILYTE-N) 126 SPECTRACEF (cefditoren pivoxil) 19 sodium chloride/sodium spinosad 109 bicarbonate/potassium chloride/peg (TRILYTE SPIRIVA (tiotropium bromide) 174 WITH FLAVOR PACKETS) 126 SPIRIVA RESPIMAT (tiotropium bromide) 174 sodium phenylbutyrate 129 spironolactone 89 sodium phosphate,dibasic/pot spironolactone/hydrochlorothiazide 88 phos,monob/sod phosphate mono SPORANOX (itraconazole) 39 (PHOSPHA 250 NEUTRAL) 133 SPRITAM (levetiracetam) 25,26 sodium phosphate,dibasic/pot SPRIX (ketorolac tromethamine) 3 phos,monob/sod phosphate mono (VIRT- SPRYCEL (dasatinib) 49 PHOS 250 NEUTRAL) 133 SPS (sodium polystyrene sulfonate/sorbitol sodium polystyrene sulfonate 121 solution) 121 sodium polystyrene sulfonate (KIONEX) 121 SSD (silver sulfadiazine) 22 sodium polystyrene sulfonate/sorbitol solution STALEVO 100 (KIONEX) 121 (carbidopa/levodopa/entacapone) 53 sodium/potassium/potassium citrate/sodium STALEVO 125 citrate/cit ac 133 (carbidopa/levodopa/entacapone) 53 sodium/potassium/potassium citrate/sodium STALEVO 150 citrate/cit ac (CYTRA-3) 133 (carbidopa/levodopa/entacapone) 53 sodium/potassium/potassium citrate/sodium STALEVO 200 citrate/cit ac (TRICITRATES) 133 (carbidopa/levodopa/entacapone) 53 sodium/potassium/potassium citrate/sodium STALEVO 50 citrate/cit ac (VIRTRATE-3) 133 (carbidopa/levodopa/entacapone) 53 sofosbuvir/velpatasvir 58 STALEVO 75 SOLARAZE (diclofenac sodium) 109 (carbidopa/levodopa/entacapone) 53 solifenacin succinate 130 STARLIX (nateglinide) 71 SOLIQUA 100-33 (insulin glargine,human stavudine 62 recombinant analog/lixisenatide) 73 STAXYN (vardenafil hcl) 133 SOLODYN (minocycline hcl) 24 STEGLATRO (ertugliflozin pidolate) 71 SOLOSEC (secnidazole) 18 STEGLUJAN (ertugliflozin pidolate/sitagliptin SOLTAMOX (tamoxifen citrate) 44 phosphate) 71 SOMA (carisoprodol) 183 STELARA (ustekinumab) 109

225 LAST UPDATED 10/01/2019 STENDRA (avanafil) 133 sulfamethoxazole/trimethoprim 23 STIMATE (desmopressin acetate) 141 SULFAMYLON (mafenide acetate) 18 STIOLTO RESPIMAT (tiotropium sulfasalazine 161 bromide/olodaterol hcl) 181 SULFATRIM (sulfamethoxazole/trimethoprim)23 STIVARGA (regorafenib) 49 sulindac 3 STRATTERA (atomoxetine hcl) 99 sumatriptan 41 STRENSIQ (asfotase alfa) 129 sumatriptan succinate 41 STRIANT (testosterone) 142 sumatriptan succinate/naproxen sodium 41 STRIBILD SUMAVEL DOSEPRO (sumatriptan (elvitegravir/cobicistat/emtricitabine/tenofovi succinate) 41 r disoproxil) 60 SUMAXIN (sulfacetamide sodium/sulfur) 110 STRIVERDI RESPIMAT (olodaterol hcl) 176 SUMAXIN TS (sulfacetamide sodium/sulfur) 110 STROMECTOL (ivermectin) 51 SUNOSI (solriamfetol hcl) 185 sub-q insulin delivery device, 20 SUPRAX (cefixime) 19 unit,disposable 164 SUPRENZA ODT (phentermine hcl) 101 sub-q insulin delivery device, 30 unit, SUPREP (sodium sulfate/potassium disposable 164 sulfate/magnesium sulfate) 127 sub-q insulin delivery device, 40 unit, SURMONTIL (trimipramine maleate) 35 disposable 164 SUSTIVA (efavirenz) 61 SUBOXONE (buprenorphine hcl/naloxone SUTENT (sunitinib malate) 49 hcl) 15 SYLATRON (peginterferon alfa-2b) 45 SUBSYS (fentanyl) 13 SYMAX DUOTAB (hyoscyamine sulfate) 124 SUCRAID (sacrosidase) 129 SYMBICORT (budesonide/formoterol sucralfate 127 fumarate) 181 SULAR (nisoldipine) 83 SYMBYAX (olanzapine/fluoxetine hcl) 32 sulfacetamide sodium 22,109 SYMDEKO (tezacaftor/ivacaftor) 176 sulfacetamide sodium (SEB-PREV) 109 SYMFI (efavirenz/lamivudine/tenofovir sulfacetamide sodium/prednisolone sodium disoproxil fumarate) 59 phosphate 167 SYMFI LO (efavirenz/lamivudine/tenofovir sulfacetamide sodium/sulfur 109,110 disoproxil fumarate) 61 sulfacetamide sodium/sulfur (AVAR) 109 SYMJEPI (epinephrine) 176 sulfacetamide sodium/sulfur (AVAR-E SYMLINPEN 120 (pramlintide acetate) 71 GREEN) 109 SYMLINPEN 60 (pramlintide acetate) 71 sulfacetamide sodium/sulfur (AVAR-E) 109 SYMPAZAN (clobazam) 27 sulfacetamide sodium/sulfur (BP 10-1) 109 SYMPROIC (naldemedine tosylate) 124 sulfacetamide sodium/sulfur (ROSANIL) 109 SYMTUZA (darunavir sulfacetamide sodium/sulfur (ROSULA) 109 eth/cobicistat/emtricitabine/tenofovir sulfacetamide sodium/sulfur (SSS 10-5) 109 alafenamide) 64 sulfacetamide sodium/sulfur (SULFACLEANSE SYNALAR (fluocinolone acetonide) 139 8-4) 109 sulfadiazine 22

226 LAST UPDATED 10/01/2019 SYNALGOS-DC TAKHZYRO (lanadelumab-flyo) 157 (aspirin/caffeine/dihydrocodeine TALTZ AUTOINJECTOR (2 PACK) bitartrate) 13 (ixekizumab) 110 SYNAREL (nafarelin acetate) 157 TALTZ AUTOINJECTOR (3 PACK) SYNDROS (dronabinol) 37 (ixekizumab) 110 SYNERA (lidocaine/tetracaine) 14 TALTZ AUTOINJECTOR (ixekizumab) 110 SYNJARDY (empagliflozin/metformin hcl) 71 TALTZ SYRINGE (2 PACK) (ixekizumab) 110 SYNJARDY XR (empagliflozin/metformin hcl) 71 TALTZ SYRINGE (3 PACK) (ixekizumab) 110 SYNRIBO (omacetaxine mepesuccinate) 45 TALTZ SYRINGE (ixekizumab) 110 SYNTHROID (levothyroxine sodium) 156 TALZENNA (talazoparib tosylate) 50 SYPRINE (trientine hcl) 121 TAMIFLU (oseltamivir phosphate) 65 syringe w-needle 0.3 ml,insulin,safety w-self- tamoxifen citrate 44 cont.dis.unit 164 tamsulosin hcl 131 syringe with needle 1 ml,insulin,safety w-self- TANZEUM (albiglutide) 71 con.disp.unit 164 TAPAZOLE (methimazole) 157 syringe with needle, insulin, safety, 0.3 ml 164 TARCEVA (erlotinib hcl) 50 syringe with needle, insulin, safety, 0.5 ml 164 TARGADOX (doxycycline hyclate) 24 syringe with needle, insulin, safety, 1 ml 165 TARGRETIN (bexarotene) 50 syringe with needle,disposable,insulin 1 ml 165 TARKA (trandolapril/verapamil hcl) 88 syringe with needle,insulin 0.3 ml (half unit TASIGNA (nilotinib hcl) 50 mark) 165 TASMAR (tolcapone) 53 syringe with needle,insulin 0.5 ml (half unit TAVALISSE (fostamatinib disodium) 76 mark) 165 TAYTULLA (norethindrone acetate-ethinyl syringe with needle,insulin disposable 165 estradiol/ferrous fumarate) 153 syringe with needle,insulin,0.3 ml 165 tazarotene 110 syringe with needle,insulin,0.5 ml 165 TAZORAC (tazarotene) 110 syringe without needle,insulin disposible, 1 TECFIDERA (dimethyl fumarate) 103 ml 165 TECHNIVIE (ombitasvir/paritaprevir/ritonavir)58 syringe, insulin u-500 with needle, disposable, TEGRETOL (carbamazepine) 30 0.5 ml 165 TEGRETOL XR (carbamazepine) 30 TEGSEDI (inotersen sodium) 101 T TEKTURNA (aliskiren hemifumarate) 88 TABLOID (thioguanine) 45 TEKTURNA HCT (aliskiren TACLONEX (calcipotriene/betamethasone hemifumarate/hydrochlorothiazide) 88 dipropionate) 110 telmisartan 79 tacrolimus 110,159 telmisartan/amlodipine besylate 88 tadalafil 131,133 telmisartan/hydrochlorothiazide 88 tadalafil (ALYQ) 177 temazepam 184 TAFINLAR (dabrafenib mesylate) 49 TEMODAR (temozolomide) 43 TAGRISSO (osimertinib mesylate) 49 TEMOVATE (clobetasol propionate) 139 TAKE ACTION (levonorgestrel) 155 temozolomide 43

227 LAST UPDATED 10/01/2019 TENEX (guanfacine hcl) 77 TIGAN (trimethobenzamide hcl) 36 tenofovir disoproxil fumarate 62 TIGLUTIK (riluzole) 101 TENORETIC 100 (atenolol/chlorthalidone) 88 TIKOSYN (dofetilide) 81 TENORETIC 50 (atenolol/chlorthalidone) 88 timolol maleate 82,170 TENORMIN (atenolol) 82 TIMOPTIC (timolol maleate) 170 TERAZOL 3 (terconazole) 39 TIMOPTIC OCUDOSE (timolol maleate/pf) 170 TERAZOL 7 (terconazole) 39 TIMOPTIC-XE (timolol maleate) 170 terazosin hcl 78 TINDAMAX (tinidazole) 18 terbinafine hcl 39 tinidazole 18 terbutaline sulfate 176 TIROSINT (levothyroxine sodium) 156 terconazole 39 TIROSINT-SOL (levothyroxine sodium) 156 TESSALON PERLE (benzonatate) 181 TIVICAY (dolutegravir sodium) 60 TESTIM (testosterone) 142 TIVORBEX (indomethacin, submicronized) 3 testosterone 142 tizanidine hcl 57 testosterone cypionate 142 TOBI (tobramycin in 0.225 % sodium testosterone enanthate 142 chloride) 181 TESTRED (methyltestosterone) 142 TOBI PODHALER (tobramycin) 176 tetrabenazine 101 TOBRADEX (tobramycin/dexamethasone) 167 tetracycline hcl 24 TOBRADEX ST TEXACORT (hydrocortisone) 139 (tobramycin/dexamethasone) 167 THALOMID (thalidomide) 44 tobramycin 16 THEO-24 (theophylline anhydrous) 177 tobramycin in 0.225 % sodium chloride 176 theophylline anhydrous 177 tobramycin/dexamethasone 167 theophylline anhydrous (THEOCHRON) 177 tobramycin/nebulizer 176 THERMAZENE (silver sulfadiazine) 23 TOBREX (tobramycin) 16 THIOLA (tiopronin) 133 TOFRANIL (imipramine hcl) 35 THIOLA EC (tiopronin) 133 TOLAK (fluorouracil) 110 thioridazine hcl 55 tolazamide 71 thiothixene 55 tolbutamide 71 thyroid,pork 156 tolcapone 53 thyroid,pork (NP THYROID) 156 tolmetin sodium 3 thyroid,pork (THYROID) 156 TOLSURA (itraconazole) 39 THYROLAR-1 (liotrix) 156 tolterodine tartrate 131 THYROLAR-1/2 (liotrix) 156 TOPAMAX (topiramate) 28 THYROLAR-1/4 (liotrix) 156 TOPICORT (desoximetasone) 139 THYROLAR-2 (liotrix) 156 topiramate 28,29 THYROLAR-3 (liotrix) 156 TOPROL XL (metoprolol succinate) 82 tiagabine hcl 27 toremifene citrate 44 TIAZAC (diltiazem hcl) 83 torsemide 89 TIBSOVO (ivosidenib) 45 TOUJEO MAX SOLOSTAR (insulin ticlopidine hcl 77 glargine,human recombinant analog) 73

228 LAST UPDATED 10/01/2019 TOUJEO SOLOSTAR (insulin glargine,human triamcinolone acetonide (TRIANEX) 139 recombinant analog) 73 triamcinolone acetonide (TRIDERM) 139 TOVIAZ (fesoterodine fumarate) 131 triamterene 89 TRACLEER (bosentan) 178 triamterene/hydrochlorothiazide 88 TRADJENTA (linagliptin) 71 triazolam 184 tramadol hcl 6,13 TRIBENZOR (olmesartan tramadol hcl/acetaminophen 13 medoxomil/amlodipine trandolapril 80 besylate/hydrochlorothiazide) 88 trandolapril/verapamil hcl 88 TRICARE (prenatal vits with calcium tranexamic acid 76 103/ferrous fumarate/folic acid) 121 TRANSDERM-SCOP (scopolamine) 36 TRICARE PRENATAL (prenatal vitamins TRANXENE T-TAB (clorazepate dipotassium) 67 no.113/iron pyrophosphate/levomefolate) 121 tranylcypromine sulfate 32 TRICARE PRENATAL DHA ONE (prenatal vit TRAVATAN Z (travoprost) 170 no.20/iron/folic acid/docusate/fish travoprost (benzalkonium) 170 oil/dha/epa) 121 trazodone hcl 34 TRICOR (fenofibrate nanocrystallized) 91 TRECATOR (ethionamide) 43 trientine hcl 121 TRELEGY ELLIPTA (fluticasone trifluoperazine hcl 55 furoate/umeclidinium bromide/vilanterol trifluridine 65 trifenat) 181 TRIGLIDE (fenofibrate nanocrystallized) 91 TREMFYA (guselkumab) 110 trihexyphenidyl hcl 52 TRESIBA (insulin degludec) 73 TRILEPTAL (oxcarbazepine) 30 TRESIBA FLEXTOUCH U-100 (insulin TRILIPIX (fenofibric acid (choline)) 91 degludec) 73 trimethobenzamide hcl 36 TRESIBA FLEXTOUCH U-200 (insulin trimethoprim 18 degludec) 73 trimipramine maleate 35 TRETIN-X (tretinoin) 110 TRIMPEX (trimethoprim) 18 tretinoin 51,111 TRINATE (prenatal vits with calcium tretinoin microspheres 111 no.73/ferrous fumarate/folic acid) 121 TREXALL (methotrexate sodium) 159 TRINTELLIX (vortioxetine hydrobromide) 34 TREXIMET (sumatriptan succinate/naproxen TRISTART DHA (prenatal vitamins no.93/iron sodium) 41 carbonyl/folate comb no.9/dha) 121 TREZIX TRIUMEQ (abacavir sulfate/dolutegravir (acetaminophen/caffeine/dihydrocodeine sodium/lamivudine) 63 bitartrate) 13 TRIZIVIR (abacavir TRI-NORINYL (norethindrone-ethinyl sulfate/lamivudine/zidovudine) 62 estradiol) 153 TROKENDI XR (topiramate) 29 TRI-VI-FLOR (pediatric multivitamin a,c,and d3 tropicamide 167 no.38 with sodium fluoride) 121 trospium chloride 131 triamcinolone acetonide 104,140 TRULANCE (plecanatide) 125 triamcinolone acetonide (ORALONE) 104 TRULICITY (dulaglutide) 71

229 LAST UPDATED 10/01/2019 TRUSOPT (dorzolamide hcl) 170 URECHOLINE (bethanechol chloride) 133 TRUVADA (emtricitabine/tenofovir disoproxil urine acetone test,strips 165 fumarate) 62 urine glucose-acet test strip 165 TUDORZA PRESSAIR (aclidinium bromide) 174 UROCIT-K (potassium citrate) 133 TURALIO (pexidartinib hydrochloride) 45 UROQID-ACID NO.2 (methenamine TUSSICAPS (hydrocodone mandelate/sodium polistirex/chlorpheniramine polistirex) 181 phosphate,monobasic) 133 TUSSIONEX (hydrocodone UROXATRAL (alfuzosin hcl) 131 polistirex/chlorpheniramine polistirex) 181 URSO (ursodiol) 124 TUXARIN ER (chlorpheniramine URSO FORTE (ursodiol) 125 maleate/codeine phosphate) 181 ursodiol 125 TUZISTRA XR (codeine UTIBRON NEOHALER (indacaterol polistirex/chlorpheniramine polistirex) 181 maleate/glycopyrrolate) 181 TWYNSTA (telmisartan/amlodipine besylate)88 UTOPIC (urea) 111 TYBOST (cobicistat) 63 TYKERB (lapatinib ditosylate) 50 V TYLENOL-CODEINE NO.3 (acetaminophen VAGIFEM (estradiol) 153 with codeine phosphate) 13 valacyclovir hcl 65 TYLENOL-CODEINE NO.4 (acetaminophen VALCHLOR (mechlorethamine hcl) 43 with codeine phosphate) 13 VALCYTE (valganciclovir hcl) 57,58 TYMLOS (abaloparatide) 163 valganciclovir hcl 58 VALIUM (diazepam) 67 U valproic acid 27 UCERIS (budesonide) 161 valproic acid (as sodium salt) (valproate UDENYCA (pegfilgrastim-cbqv) 76 sodium) 27 ULESFIA (benzyl alcohol) 111 valsartan 79 ULORIC (febuxostat) 40 valsartan/hydrochlorothiazide 88 ULTRACET (tramadol hcl/acetaminophen) 13 VALTREX (valacyclovir hcl) 65 ULTRAM (tramadol hcl) 13 VANCOCIN HCL (vancomycin hcl) 18 ULTRAM ER (tramadol hcl) 6 vancomycin hcl 18 ULTRAVATE (halobetasol propionate) 140 VANDAZOLE (metronidazole) 18 UNITHROID (levothyroxine sodium) 156 VANOS (fluocinonide) 140 UPTRAVI (selexipag) 178 vardenafil hcl 133 URAMAXIN (urea) 111 VARUBI (rolapitant hcl) 37 URAMAXIN GT (urea) 111 VASCEPA (icosapent ethyl) 93 urea 111 VASERETIC (enalapril urea (CEM-UREA) 111 maleate/hydrochlorothiazide) 88 urea (METOPIC) 111 VASOTEC (enalapril maleate) 80 urea (UMECTA) 111 VECTICAL (calcitriol) 111 urea (URE-K) 111 VELPHORO (sucroferric oxyhydroxide) 134 urea (UREDEB) 111 VELTASSA (patiromer calcium sorbitex) 121

230 LAST UPDATED 10/01/2019 VELTIN (clindamycin phosphate/tretinoin) 111 VINATE CARE (prenatal vits with calcium VEMLIDY (tenofovir alafenamide) 58 109/ferrous fumarate/folic acid) 121 VENCLEXTA (venetoclax) 50 VINATE DHA RF (prenatal vit no.64/iron/l- VENCLEXTA STARTING PACK (venetoclax) 50 mefolate ca/algal oil/soy lecithin) 121 venlafaxine hcl 34 VIOKACE (lipase/protease/amylase) 129 VENLAFAXINE HCL ER (venlafaxine hcl) 34 VIRACEPT (nelfinavir mesylate) 64 VENTOLIN HFA (albuterol sulfate) 176 VIRAMUNE (nevirapine) 61 verapamil hcl 83 VIRAMUNE XR (nevirapine) 61 VERDESO (desonide) 140 VIRASAL (salicylic acid) 111 VEREGEN (sinecatechins) 111 VIREAD (tenofovir disoproxil fumarate) 62 VERELAN (verapamil hcl) 83 VIROPTIC (trifluridine) 65 VERELAN PM (verapamil hcl) 84 VISTARIL (hydroxyzine pamoate) 173 VERIPRED 20 (prednisolone sodium VISTOGARD (uridine triacetate) 165 phosphate) 140 VITAFOL GUMMIES (prenatal vit no.112/iron VERSACLOZ (clozapine) 57 phosph/folic acid/omega-3s/dha/epa) 121 VERZENIO (abemaciclib) 50 VITAFOL NANO (prenatal vitamins VESICARE (solifenacin succinate) 131 no.75/ferrous fumarate/folate comb. no.1)121 VEXOL (rimexolone) 169 VITAFOL ULTRA (prenatal vit no.67/iron VFEND (voriconazole) 39 polysaccharides/folate comb.no.1/dha) 122 VIAGRA (sildenafil citrate) 133 VITAFOL-OB (prenatal vits with calcium VIBERZI (eluxadoline) 125 no.10/ferrous fumarate/folic acid) 122 VIBRAMYCIN (doxycycline calcium) 24 VITAFOL-ONE (prenatal vits no.26/iron VIBRAMYCIN (doxycycline hyclate) 24 polysaccharide cplex/folic acid/dha) 122 VIBRAMYCIN (doxycycline monohydrate) 24 VITAMEDMD ONE RX (prenatal vits VICTOZA 2-PAK (liraglutide) 71 no.25/ferrous fumarate/folate comb. VICTOZA 3-PAK (liraglutide) 71 no.6/dha) 122 VIDEX (didanosine) 62 VITAMEDMD REDICHEW RX (prenatal vitamins VIDEX EC (didanosine) 62 combination no.42/folic acid) 122 VIEKIRA PAK VITAPEARL (prenatal vit no.71/iron fum-sodium (ombitasvir/paritaprevir/ritonavir/dasabuvir feredetate/folic acid/dha) 122 sodium) 58 VITEKTA (elvitegravir) 60 VIEKIRA XR VITRAKVI (larotrectinib sulfate) 45,46 (ombitasvir/paritaprevir/ritonavir/dasabuvir VITUZ (hydrocodone sodium) 58 bitartrate/chlorpheniramine maleate) 181 vigabatrin 27 VIVELLE-DOT (estradiol) 153 vigabatrin (VIGADRONE) 27 VIVLODEX (meloxicam, submicronized) 3 VIGAMOX (moxifloxacin hcl) 22 VIZIMPRO (dacomitinib) 46 VIIBRYD (vilazodone hcl) 34 VOGELXO (testosterone) 142 VIMOVO (naproxen/esomeprazole VOLTAREN (diclofenac sodium) 111 magnesium) 3 VOLTAREN-XR (diclofenac sodium) 3 VIMPAT (lacosamide) 30 voriconazole 39

231 LAST UPDATED 10/01/2019 VOSEVI (sofosbuvir/velpatasvir/voxilaprevir) 59 XEPI (ozenoxacin) 111 VOTRIENT (pazopanib hcl) 50 XERESE (acyclovir/hydrocortisone) 65 VP-PNV-DHA (prenatal vitamins no.52/ferrous XERMELO (telotristat etiprate) 125 fumarate/folic acid/dha) 122 XGEVA (denosumab) 163 VRAYLAR (cariprazine hcl) 57 XHANCE (fluticasone propionate) 172 VUSION (miconazole nitrate/zinc XIFAXAN (rifaximin) 18 oxide/petrolatum,white) 39 XIGDUO XR (dapagliflozin VYLEESI (bremelanotide acetate) 133 propanediol/metformin hcl) 71 VYNDAMAX (tafamidis) 88 XIIDRA (lifitegrast) 167 VYNDAQEL (tafamidis meglumine) 88 XIMINO (minocycline hcl) 24 VYTORIN (ezetimibe/simvastatin) 93 XODOL 10-300 (hydrocodone VYVANSE (lisdexamfetamine dimesylate) 96 bitartrate/acetaminophen) 13 VYZULTA (latanoprostene bunod) 170 XODOL 5-300 (hydrocodone bitartrate/acetaminophen) 13 W XODOL 7.5-300 (hydrocodone warfarin sodium 75 bitartrate/acetaminophen) 13 warfarin sodium (JANTOVEN) 75 XOFLUZA (baloxavir marboxil) 160 WELCHOL (colesevelam hcl) 93 XOLEGEL (ketoconazole) 39 WELLBUTRIN (bupropion hcl) 32 XOPENEX (levalbuterol hcl) 176 WELLBUTRIN SR (bupropion hcl) 32 XOPENEX CONCENTRATE (levalbuterol hcl) 176 WELLBUTRIN XL (bupropion hcl) 32 XOPENEX HFA (levalbuterol tartrate) 176 WESTHROID (thyroid,pork) 156 XOSPATA (gilteritinib fumarate) 46 WP THYROID (thyroid,pork) 156 XPOVIO (selinexor) 46 XTAMPZA ER (oxycodone myristate) 6 X XTANDI (enzalutamide) 43 XADAGO (safinamide mesylate) 55 XULTOPHY 100-3.6 (insulin XALATAN (latanoprost) 170 degludec/liraglutide) 73 XALKORI (crizotinib) 50 XURIDEN (uridine triacetate) 122 XANAX (alprazolam) 67 XYLOCAINE (lidocaine hcl) 14 XANAX XR (alprazolam) 67 XYOSTED (testosterone enanthate) 142 XARELTO (rivaroxaban) 75 XYREM (sodium oxybate) 185 XARTEMIS XR (oxycodone hcl/acetaminophen) 13 Y XATMEP (methotrexate) 159 YASMIN 28 (ethinyl estradiol/drospirenone) 153 XELJANZ (tofacitinib citrate) 159 YAZ (ethinyl estradiol/drospirenone) 153 XELJANZ XR (tofacitinib citrate) 159 YONSA (abiraterone acetate, XELODA (capecitabine) 45 submicronized) 44 XELPROS (latanoprost) 170 YOSPRALA (aspirin/omeprazole) 77 XENAZINE (tetrabenazine) 101 YUPELRI (revefenacin) 175 XENICAL (orlistat) 125 XENLETA (lefamulin acetate) 65

232 LAST UPDATED 10/01/2019 ZITHROMAX (azithromycin) 21 Z ZITHROMAX TRI-PAK (azithromycin) 21 zafirlukast 174 ZMAX (azithromycin) 21 zaleplon 184 ZOCOR (simvastatin) 92 ZAMICET (hydrocodone ZOFRAN (ondansetron hcl) 37 bitartrate/acetaminophen) 13 ZOFRAN ODT (ondansetron) 37 ZANAFLEX (tizanidine hcl) 57 ZOHYDRO ER (hydrocodone bitartrate) 7 ZANTAC (ranitidine hcl) 125 ZOLINZA (vorinostat) 46 ZARONTIN (ethosuximide) 26 zolmitriptan 41 ZARXIO (filgrastim-sndz) 76 ZOLOFT (sertraline hcl) 34 ZAVESCA (miglustat) 130 zolpidem tartrate 184 ZEBETA (bisoprolol fumarate) 82 ZOLPIMIST (zolpidem tartrate) 184 ZEBUTAL ZOMACTON (somatropin) 141 (butalbital/acetaminophen/caffeine) 101 ZOMIG (zolmitriptan) 41 ZEGERID (omeprazole/sodium ZOMIG ZMT (zolmitriptan) 41 bicarbonate) 128 ZONACORT (dexamethasone) 140 ZEJULA (niraparib tosylate) 50 ZONALON (doxepin hcl) 111 ZELAPAR (selegiline hcl) 55 ZONEGRAN (zonisamide) 26 ZELBORAF (vemurafenib) 50 zonisamide 26 ZELNORM (tegaserod hydrogen maleate) 125 ZONTIVITY (vorapaxar sulfate) 75 ZEMBRACE SYMTOUCH (sumatriptan ZORBTIVE (somatropin) 141 succinate) 41 ZORTRESS (everolimus) 159,160 ZEMPLAR (paricalcitol) 163 ZORVOLEX (diclofenac submicronized) 3 ZENPEP (lipase/protease/amylase) 130 ZOVIRAX (acyclovir) 65 ZENZEDI (dextroamphetamine sulfate) 96,97 ZTLIDO (lidocaine) 14 ZEPATIER (elbasvir/grazoprevir) 59 ZUBSOLV (buprenorphine hcl/naloxone hcl) 15 ZERIT (stavudine) 62 ZUPLENZ (ondansetron) 37 ZESTORETIC (lisinopril/hydrochlorothiazide) 88 ZURAMPIC (lesinurad) 40 ZESTRIL (lisinopril) 80 ZUTRIPRO (hydrocodone ZETIA (ezetimibe) 93 bitart/chlorpheniramine ZETONNA (ciclesonide) 173 maleate/pseudoephedrine) 182 ZIAC (bisoprolol ZYBAN (bupropion hcl) 16 fumarate/hydrochlorothiazide) 89 ZYCLARA (imiquimod) 111 ZIAGEN (abacavir sulfate) 62 ZYDELIG (idelalisib) 50 ZIANA (clindamycin phosphate/tretinoin) 111 ZYFLO (zileuton) 174 zidovudine 62 ZYFLO CR (zileuton) 174 zileuton 174 ZYKADIA (ceritinib) 50 ZIOPTAN (tafluprost/pf) 170 ZYLET (tobramycin/loteprednol ziprasidone hcl 57 etabonate) 167 ZIPSOR (diclofenac potassium) 3 ZYLOPRIM (allopurinol) 40 ZIRGAN (ganciclovir) 58 ZYMAXID (gatifloxacin) 22

233 LAST UPDATED 10/01/2019 ZYPITAMAG (pitavastatin magnesium) 92 ZYPREXA (olanzapine) 57 ZYPREXA ZYDIS (olanzapine) 57 ZYTIGA (abiraterone acetate) 44 ZYVOX (linezolid) 18

234 LAST UPDATED 10/01/2019

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Blue Shield of California Notice Informing Individuals about Nondiscrimination and Accessibility Requirements

Discrimination is against the law Blue Shield of California complies with applicable state laws and federal civil rights laws, and does not discriminate on the basis of race, color, national origin, ancestry, religion, sex, marital status, gender, gender identity, sexual orientation, age or disability. Blue Shield of California does not exclude people or treat them differently because of race, color, national origin, ancestry, religion, sex, marital status, gender, gender identity, sexual orientation, age or disability.

Blue Shield of California: • Provides aids and services at no cost to people with disabilities to communicate effectively with us such as: - Qualified sign language interpreters

- Written information in other formats (including large print, audio, accessible electronic formats and other formats) • Provides language services at no cost to people whose primary language is not English such as:

- Qualified interpreters A20275(3/18) - Information written in other languages

If you need these services, contact the Blue Shield of California Civil Rights Coordinator. If you believe that Blue Shield of California has failed to provide these services or discriminated in another way on the basis of race, color, national origin, ancestry, religion, sex, marital status, gender, gender identity, sexual orientation, age or disability, you can file a grievance with:

Blue Shield of California Civil Rights Coordinator P.O. Box 629007 El Dorado Hills, CA 95762-9007 Phone: (844) 831-4133 (TTY: 711) Fax: (844) 696-6070 Email: [email protected]

You can file a grievance in person or by mail, fax or email. If you need help filing a grievance, our Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services 200 Independence Avenue SW.

Room 509F, HHH Building BlueShield of California is an independent memberof theBlue Shield Association Washington, DC 20201 (800) 368-1019; TTY: (800) 537-7697

Complaint forms are available at www.hhs.gov/ocr/office/file/index.html.

Blue Shield of California 50 Beale Street, San Francisco, CA 94105 Notice of the Availability of Language Assistance Services Blue Shield of California

IMPORTANT: Can you read this letter? If not, we can have somebody help you read it. You may also be able to get this letter written in your language. For help at no cost, please call right away at the Member/Customer Service telephone number on the back of your Blue Shield ID card, or (866) 346-7198.

IMPORTANTE: ¿Puede leer esta carta? Si no, podemos hacer que alguien le ayude a leerla. También puede recibir esta carta en su idioma. Para ayuda sin cargo, por favor llame inmediatamente al teléfono de Servicios al miembro/cliente que se encuentra al reverso de su tarjeta de identificación de Blue Shield o al (866) 346-7198. (Spanish)

重要通知：您能讀懂這封信嗎？如果不能，我們可以請人幫您閱讀。這封信也可以用您所講的語言書寫。如需免费幫助，請立即撥打登列在您的Blue Shield ID卡背面上的會員/客戶服務部的電話，或者撥打電話 (866) 346-7198。(Chinese)

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MAHALAGA: Nababasa mo ba ang sulat na ito? Kung hindi, maari kaming kumuha ng isang tao upang matulungan ka upang mabasa ito. Maari ka ring makakuha ng sulat na ito na nakasulat sa iyong wika. Para sa libreng tulong, mangyaring tumawag kaagad sa numerong telepono ng Miyembro/Customer Service sa likod ng iyong Blue Shield ID kard, o (866) 346-7198. (Tagalog) Baa’ ákohwiindzindoo7g7: D77 naaltsoos7sh y77ni ta’go b77n7ghah? Doo b77n7ghahgóó é7, naaltsoos nich’8’ yiid0o[tah7g77 a’ nihee hól=. D77 naaltsoos a[d0’ t’11 Din4 k’ehj7 1dooln77[ n7n7zingo b7ighah. Doo b22h 7l7n7g0 sh7k1’ adoowo[ n7n7zing0 nihich’8’ b44sh bee hod7ilnihł d00 n1mboo 47 d77 Blue Shield bee n47ho’d7lzin7g7 bine’d44’ bik11’ł 47 doodag0 47 (866) 346-7198 j8’ hod77lnih. (Navajo)

중요: 이 서신을 읽을 수 있으세요? 읽으실 수 경우, 도움을 드릴 수 있는 사람이 있습니다. 또한 다른 언어로 작성된 이 서신을 받으실 수도 있습니다. 무료로 도움을 받으시려면 Blue Shield ID 카드 뒷면의 회원/고객 서비스 전화번호 또는 (866) 346-7198로 지금 전환하세요. (Korean)

ԿԱՐԵՎՈՐ Է․ Կարողանում ե՞ք կարդալ այս նամակը։ Եթե ոչ, ապա մենք կօգնենք ձեզ։ Դուք պետք է նաև կարողանաք ստանալ այս նամակը ձեր լեզվով։ Ծառայությունն անվճար է։ Խնդրում ենք անմիջապես զանգահարել Հաճախորդների սպասարկման բաժնի հեռախոսահամարով, որը նշված է ձեր Blue Shield ID քարտի ետևի մասում, կամ (866) 346-7198 համարով։ (Armenian)

ВАЖНО: Не можете прочесть данное письмо? Мы поможем вам, если необходимо. Вы также можете получить это письмо написанное на вашем родном языке. Позвоните в Службу клиентской/членской поддержки прямо сейчас по телефону, указанному сзади идентификационной карты Blue Shield, или по телефону (866) 346-7198, и вам помогут совершенно бесплатно. (Russian)

重要：お客様は、この手紙を読むことができますか？もし読むことができない場合、弊社が、お客様をサポートする人物を手配いたします。また、お客様の母国語で書かれた手紙をお送りすることも可能です。無料のサポートを希望される場合は、Blue Shield IDカードの裏面に記載されている会員/お客様サービスの電話番号、または、(866) 346-7198にお電話をおかけください。 (Japanese) blueshieldca.com ﻣﮭﻢ: آﯾﺎ ﻣﯽﺗﻮاﻧﯿﺪ اﯾﻦ ﻧﺎﻣﮫ را ﺑﺨﻮاﻧﯿﺪ؟ اﮔﺮ ﭘﺎﺳﺨﺘﺎن ﻣﻨﻔﯽ اﺳﺖ، ﻣﯽﺗﻮاﻧﯿﻢ ﮐﺴﯽ را ﺑﺮای ﮐﻤﮏ ﺑﮫ ﺷﻤﺎ در اﺧﺘﯿﺎرﺗﺎن ﻗﺮار دھﯿﻢ. ﺣﺘﯽ ﻣﯽﺗﻮاﻧﯿﺪ ﻧﺴﺨﮫ ﻣﮑﺘﻮب اﯾﻦ ﻧﺎﻣﮫ را ﺑﮫ زﺑﺎن ﺧﻮدﺗﺎن درﯾﺎﻓﺖ ﮐﻨﯿﺪ. ﺑﺮای درﯾﺎﻓﺖ ﮐﻤﮏ راﯾﮕﺎن، ﻟﻄﻔﺎً ﺑﺪون ﻓﻮت وﻗﺖ از طﺮﯾﻖ ﺷﻤﺎره ﺗﻠﻔﻨﯽ ﮐﮫ در ﭘﺸﺖ ﮐﺎرت ﺷﻨﺎﺳﯽ Blue Shield ﺗﺎن درج ﺷﺪه اﺳﺖ و ﯾﺎ از طﺮﯾﻖ ﺷﻤﺎره ﺗﻠﻔﻦ 7198-346 (866) ﺑﺎ ﺧﺪﻣﺎت اﻋﻀﺎ/ﻣﺸﺘﺮی ﺗﻤﺎس ﺑﮕﯿﺮﯾﺪ. (Persian)

ਮ ਹੱ ਤ ਵ ਪ ਰੂ ਨ : ਕੀ ਤੁਸ� ਇਸ ਪੱ ਤ ਰ ਨ ੂੰ ਪੜ� ਸਕਦੇ ਹੋ? ਜੇ ਨਹ� ਤ� ਇਸ ਨ ੂੰ ਪੜ�ਨ ਿਵਚ ਮਦਦ ਲਈ ਅਸ� ਿਕਸੇ ਿਵਅਕਤੀ ਦਾ ਪ ਬੰ� ਧ ਕਰ ਸਕਦੇ ਹ�। ਤੁਸ� ਇਹ ਪੱ ਤ ਰ ਆਪਣੀ ਭਾਸ਼ਾ ਿਵਚ ਿਲਿਖਆ ਹੋਇਆ ਵੀ ਪ�ਾਪਤ ਕਰ ਸਕਦੇ ਹੋ। ਮੁਫ਼ਤ ਿਵਚ ਮਦਦ ਪ�ਾਪਤ ਕਰਨ ਲਈ ਤੁਹਾਡੇ Blue Shield ID ਕਾਰਡ ਦੇ ਿ ਪੱ ਛ ੇ ਿ ਦੱ ਤ ੇ ਮ�ਬਰ/ਕਸਟਮਰ ਸਰਿਵਸ ਟੈਲੀਫ਼ੋਨ ਨੰ ਬ ਰ ਤੇ, ਜ� (866) 346-7198 ਤੇ ਕਾੱਲ ਕਰੋ। (Punjabi)

䮚ប�រសំ�ន់៖ េតើអ�ក�ចលិខិតេនះ �នែដរឬេទ? េបើមិន�ចេទ េយើង�ចឲ䮙េគជួយអ�កក��ង�រ�នលិ ខិតេនះ។ អ�កក៏�ចទទួល�នលិខិតេនះ��របស់អ�កផងែដរ។ ស䮚�ប់ជំនួយេ�យឥតគិតៃថ� សូមេ�ទូរស័ព��មៗេ��ន់េលខទូរស័ព�េស�ស�ជិក/អតិថិជនែដល�នេ�េលើខ�ងប័ណ�ស��ល់ Blue Shield របស់អ� ក ឬ�មរយៈេលខ (866) 346-7198។ (Khmer)

اﻟﻤﮭﻢ :ھﻞ ﺗﺴﺘﻄﯿﻊ ﻗﺮاءة ھﺬا اﻟﺨﻄﺎب؟ أن ﻟﻢ ﺗﺴﺘﻄﻊ ﻗﺮاءﺗﮫ، ﯾﻤﻜﻨﻨﺎ إﺣﻀﺎر ﺷﺨﺺ ﻣﺎ ﻟﯿﺴﺎﻋﺪك ﻓﻲ ﻗﺮاءﺗﮫ. ﻗﺪ ﺗﺤﺘﺎج أﯾﻀﺎً إﻟﻰ اﻟﺤﺼﻮل ﻋﻠﻰ ھﺬا اﻟﺨﻄﺎب ﻣﻜﺘﻮﺑﺎً ﺑﻠﻐﺘﻚ. ﻟﻠﺤﺼﻮل ﻋﻠﻰ اﻟﻤﺴﺎﻋﺪة ﺑﺪون ﺗﻜﻠﻔﺔ، ﯾﺮﺟﻰ اﻻﺗﺼﺎل اﻵن ﻋﻠﻰ رﻗﻢ ھﺎﺗﻒ ﺧﺪﻣﺔ اﻟﻌﻤﻼء/أﺣﺪ اﻷﻋﻀﺎء اﻟﻤﺪون ﻋﻠﻰ اﻟﺠﺎﻧﺐ اﻟﺨﻠﻔﻲ ﻣﻦ ﺑﻄﺎﻗﺔ اﻟﮭﻮﯾﺔ Blue Shield أو ﻋﻠﻰ اﻟﺮﻗﻢ Arabic).(866) 346-7198)

TSEEM CEEB: Koj pos tuaj yeem nyeem tau tsab ntawv no? Yog hais tias nyeem tsis tau, peb tuaj yeem nrhiav ib tug neeg los pab nyeem nws rau koj. Tej zaum koj kuj yuav tau txais muab tsab ntawv no sau ua koj hom lus. Rau kev pab txhais dawb, thov hu kiag rau tus xov tooj Kev Pab Cuam Tub Koom Xeeb/Tub Lag Luam uas nyob rau sab nraum nrob qaum ntawm koj daim npav Blue Shield ID, los yog hu rau tus xov tooj (866) 346-7198. (Hmong)

สําคัญ: คุณอ่านจดหมายฉบับนีได้หรือไม่้ หากไม่ได้ โปรดขอคงามช่วยจากผู้อ่านได้ คุณอาจได้รับจดหมายฉบับนีเป็นภาษาของคุณ้ หากต้องการความช่วยเหลือโดยไม่มีค่าใช ้จ่าย โปรดติดต่อฝ่ายบริการลูกค้า/สมาชิกทางเบอร ์โทรศัพท ์ในบัตรประจําตัว Blue Shield ของคุณ หรือโทร (866) 346-7198 (Thai)

मह配वपण셍ू : 啍या आप इस पत्र को पढ़ सकते ह�? य�द नह�ं, तो हम इसे पढ़ने म� आपक� मदद के �लए �कसी 핍यि啍त का प्रबंध कर सकते ह�। आप इस पत्र को अपनी भाषा म� भी प्राꥍत कर सकते ह�। �न:श쥍कु मदद प्राꥍत करने के �लए अपने Blue Shield ID काड셍 के पीछे �दए गये म�बर/कटमर स�व셍स टेल�फोन नंबर, या (866) 346-7198 पर कॉल कर� । (Hindi)

ິ່ສງໍສາຄັ ນ: ທ່ ານສາມາດອ່ ານຈົ ດໝາຍນີ ້ ໄດ້ ໍບ? ຖ້ າອ່ ານບໍ່ ໄດ້ , ພວກເຮົ າສາມາດໃຫ້ ບາງຄົ ນຊ່ ວຍອ່ ານໃຫ້ ທ່ ານຟັ ງໄດ້ . ທ່ ານຍັ ງສາມາດໍຂໃຫ້ ແປຈົ ດໝາຍນີ ້ ເປັ ນພາສາຂອງທ່ ານໄດ້ .ໍສາລັ ບຄວາມຊ່ ວຍເຫືຼ ອແບບໍ່ບເສຍຄ່ າ, ກະລຸ ນາ ໂທຫາເບີ ໂທຂອງຝ່ າຍໍບິລການສະມາິຊກ/ລູ ກຄ້ າໃນທັ ນທີ ເບີ ໂທລະສັ ບຢູ່ ດ້ ານຫຼັ ງບັ ດສະມາິຊກ Blue Shield ຂອງທ່ ານ, ືຫຼ ໂທໄປຫາເບີ (866) 346-7198. (Laotian)

blueshieldca.com Notice of the Availability of Language Assistance Services Blue Shield of California Life & Health Insurance Company

No Cost Language Services. You can get an interpreter. You can get documents read to you and some sent to you in your language. For help, call us at the number listed on your ID card or 1-866-346-7198. For more help call the CA Dept. of Insurance at 1-800-927-4357. English

Servicios de idiomas sin costo. Puede obtener un intérprete. Le pueden leer documentos y que le envíen algunos en español. Para obtener ayuda, llámenos al número que figura en su tarjeta de identificación o al 1-866-346-7198. Para obtener más ayuda, llame al Departamento de Seguros de CA al 1-800-927-4357. Spanish 免費語言服務。您可獲得口譯員服務。可以用中文把文件唸給您聽，有些文件有中文的版本，也可以把這些文件寄給您。欲取得協助，請致電您的保險卡所列的電話號碼，或撥打 1-866-346-7198 與我們聯絡。欲取得其他協助，請致電 1-800-927-4357 與加州保險部聯絡。Chinese Các Dịch Vụ Trợ Giúp Ngôn Ngữ Miễn Phí. Quý vị có thể được nhận dịch vụ thông dịch. Quý vị có thể được người khác đọc giúp các tài liệu và nhận một số tài liệu bằng tiếng Việt. Để được giúp đỡ, hãy gọi cho chúng tôi tại số điện thoại ghi trên thẻ hội viên của quý vị hoặc 1-866-346-7198. Để được trợ giúp thêm, xin gọi Sở Bảo Hiểm California tại số 1-800-927-4357. Vietnamese

무료 통역 서비스. 귀하는 한국어 통역 서비스를 받으실 수 있으며 한국어로 서류를 낭독해주는 서비스를 받으실 수 있습니다. 도움이 필요하신 분은 귀하의 ID 카드에 나와있는 안내 전화: 1-866-346-7198번으로 문의해 주십시오. 보다 자세한 사항을 문의하실 분은 캘리포니아 주 보험국, 안내 전화 1-800-927-4357번으로 연락해 주십시오. Korean

Walang Gastos na mga Serbisyo sa Wika. Makakakuha ka ng interpreter o tagasalin at maipababasa mo sa Tagalog ang mga dokumento. Para makakuha ng tulong, tawagan kami sa numerong nakalista sa iyong ID card o sa 1-866-346-7198. Para sa karagdagang tulong, tawagan ang CA Dept. of Insurance sa 1-800-927-4357 Tagalog

Անվճար Լեզվական Ծառայություններ։ Դուք կարող եք թարգման ձեռք բերել և փաստաթղթերը ընթերցել տալ ձեզ համար հայերեն լեզվով։ Օգնության համար մեզ զանգահարեք ձեր ինքնության (ID) տոմսի վրա նշված կամ 1-866-346-7198 համարով։ Լրացուցիչ օգնության համար 1-800-927-4357 համարով զանգահարեք Կալիֆորնիայի Ապահովագրության Բաժանմունք։ Armenian Беслпатные услуги перевода. Вы можете воспользоваться услугами переводчика, и ваши документы прочтут для вас на русском языке. Если вам требуется помощь, звоните нам по номеру, указанному на вашей идентификационной карте, или 1-866-346-7198. Если вам требуется дополнительная помощь, звоните в Департамент страхования штата Калифорния (Department of Insurance), по телефону 1-800-927-4357. Russian 無料の言語サービス日本語で通訳をご提供し、書類をお読みします。サービスをご希望の方は、ＩＤカード記載の番号または1-866-346-7198までお問い合わせください。更なるお問い合わせは、カリフォルニア州保険庁、1-800-927-4357までご連絡ください。Japanese ﻣﺠﺎﻧﺧﺪﻣﺎت ﯽ ﻣﺮﺑﻮط ﺑﮫ زﺑﺎن . ﻣﯿﺘﻮاﻧﯿﺪ از ﺧﺪﻣﺎت ﯾﮏ ﻣﺘﺮﺟﻢ ﺷﻔﺎھﯽ اﺳﺘﻔﺎده ﮐﻨﯿﺪ و ﺑﮕﻮﺋﯿﺪ ﻣﺪارک ﺑﮫ زﺑﺎن ﻓﺎرﺳﯽ ﺑﺮاﯾﺘﺎن ﺧﻮاﻧﺪه ﺷﻮﻧﺪ.ﺑﺮای درﯾﺎﻓﺖ ﮐﻤﮏ،ﺑﺎ ﻣﺎ از طﺮﯾﻖ ﺷﻤﺎره ﺗﻠﻔﻨﯽ ﮐﮫ روی ﮐﺎرت ﺷﻨﺎﺳﺎﺋﯽ ﺷﻤﺎ ﻗﯿﺪ ﺷﺪه اﺳﺖ و ﯾﺎ اﯾﻦ ﺷﻤﺎره 7198-346-866-1 ﺗﻤﺎس ﺑﮕﯿﺮﯾﺪ.ﺑﺮای درﯾﺎﻓﺖ ﮐﻤﮏ ﺑﯿﺸﺘﺮ، ﺑﮫ CA Dept. of Insurance(اداره ﺑﯿﻤﮫ ﮐﺎﻟﯿﻔﺮﻧﯿﺎ) ﺑﮫ ﺷﻤﺎره 4357-927-800-1 ﺗﻠﻔﻦ ﮐﻨﯿﺪ.Persian

blueshieldca.com ਮੁਫ਼ਤ ਭਾਸ਼ਾ ਸੇਵਾਵਾਂ: ਤੁਸੀ ਂ ਦੁਭਾਸ਼ੀਏ ਦੀਆਂ ਸੇਵਾਵਾਂ ਹਾਸਲ ਕਰ ਸਕਦੇ ਹੋ ਅਤੇ ਦਸਤਾਵੇਜ਼ਾਂ ਨ ੂੰ ਪੰਜਾਬੀ ਿਵੱਚ ਸੁਣ ਸਕਦੇ ਹੋ। ਕੁਝ ਦਸਤਾਵੇਜ਼ ਤ ੁਹ ਾ ਨ ੂੰ ਪੰਜਾਬੀ ਿਵੱਚ ਭੇਜੇ ਜਾ ਸਕਦੇ ਹਨ। ਮਦਦ ਲਈ ਤੁਹਾਡੇ ਆਈਡੀ (ID) ਕਾਰਡ 'ਤੇ ਿਦੱਤੇ ਨੰ ਬ ਰ 'ਤੇ ਜਾਂ 1-866-346-7198 'ਤੇ ' ਸ ਾ ਨੂੰ ਫ਼ੋਨ ਕਰੋ। ਵਧੇਰੇ ਮਦਦ ਲਈ ਕੈਲੀਫ਼ੋਰਨੀਆ ਿਡਪਾਰਟਮ�ਟ ਆਫ਼ ਇਨਸ਼ੋਰ�ਸ ਨੂੰ 1-800-927-4357 'ਤੇ ਫ਼ੋਨ ਕਰੋ। Punjabi

េស�កម��ឥតគិតៃថ�។ អ�ក�ចទទួល�នអ�កបកែ䮚ប�� និង�នឯក�រជូនអ�ក� ��ែខ� រ ។ ស䮚�ប់ជំនួយ សូមទូរស័ព�មកេយើងខ��ំ�មេលខែដល�នប��ញេលើប័ណ�សំ�ល់ខ� �នរបស់អ�ក ឬេលខ 1-866-346-7198 ។ ស䮚�ប់ជំនួយបែន�មេទៀត សូមទូរស័ព�េ�䮚កសួង��ប់រងរដ��លីហ��រ�៉ �មេលខ 1-800-927-4357 Khmer ﺧﺪﻣﺎت ﺗﺮﺟﻤﺔ ﺑﺪون ﺗﻜﻠﻘﺔ. ﯾﻤﻜﻨﻚ اﻟﺤﺼﻮل ﻋﻠﻲ ﻣﺘﺮﺟﻢ و ﻗﺮاءة اﻟﻮﺛﺎﺋﻖ ﻟﻚ ﺑﺎﻟﻠﻐﺔ اﻟﻌﺮﺑﯿﺔ. ﻟﻠﺤﺼﻮل ﻋﻠﻲ اﻟﻤﺴﺎﻋﺪة، اﺗﺼﻞ ﺑﻨﺎ ﻋﻠﻲ اﻟﺮﻗﻢ اﻟﻤﺒﯿﻦ ﻋﻠﻲ ﺑﻄﺎﻗﺔ ﻋﻀﻮﯾﺘﻚ أو ﻋﻠﻲ اﻟﺮﻗﻢ 7198-346-866-1. ﻟﻠﺤﺼﻮل ﻋﻠﻲ اﻟﻤﺰﯾﺪ ﻣﻦ اﻟﻤﻌﻠﻮﻣﺎت، اﺗﺼﻞ ﺑﺈدارة اﻟﺘﺄﻣﯿﻦ ﻟﻮﻻﯾﺔ ﻛﺎﻟﯿﻔﻮرﻧﯿﺎ ﻋﻠﻲ اﻟﺮﻗﻢ Arabic .1-800-927-4357

Cov Kev Pab Txhais Lus Tsis Them Nqi. Koj yuav thov tau kom muaj neeg los txhais lus rau koj thiab kom neeg nyeem cov ntawv ua lus Hmoob. Yog xav tau kev pab, hu rau peb ntawm tus xov tooj nyob hauv koj daim yuaj ID los sis 1-866-346-7198. Yog xav tau kev pab ntxiv hu rau CA lub Caj Meem Fai Muab Kev Tuav Pov Hwm ntawm 1-800-927-4357 Hmong

บริการทางภาษาอย่างไม่เสียค่าใช ้จ่าย คุณสามารถรับบริการจากล่าม รวมถึงให้เจ ้าหน้าทีอ่านเอกสารให้คุณฟัง่ หรือส่งเอกสารบางส่วนในภาษาของคุณไปหาคุณได้ หากต้องการความช่วยเหลือ กรุณาโทรศัพท ์ตามหมายเลขทีระบุอยู่ด้านหลังบัตรประจําตัวของคุณ่ หร ือ ทีหมายเลข่ 1-866-346-7198 หากต้องการความช่วยเหลือเพิมเติม่ โปรดโทรมาที ่ กรมการประกันภัยแห่งมลรัฐแคลิฟอร ์เนียทีหมายเลข่ 1-800-927-4357 Thai

िनःशु� भाषा स ेव ा एँ । आप एक दुभािषया की सेवा प्रा� कर सकते ह�। आप द�ावेजों को पढ़वा के सुन सकते ह� और कु छ को अपनी भाषा म� �यं को िभजवा सकते ह�। सहायता के िलए, अपने ID काड� पर िदए गए नंबर पर, या 1-866-346-7198 पर हम� फ़ोन कर� । अिधक सहायता के िलए कैलीफोिन�या बीमा िवभाग (CA Dept. of Insurance) को 1-800-927-4357 पर फ़ोन कर� । Hindi Doo b11h 7l7n7g0 saad bee y1t’i’ bee an1’1wo’. D77 sh1 ata’halne’doo7g7 h0l=-doo n7n7zingo 47 b7ighah. Naaltsoos naanin1h1jeeh7g7 shich’8’ y7idooltah 47 doodag0 [a’ shich’8’ 1dooln77[ n7n7zingo b7ighah. Sh7k1 a’doowo[ n7n7zingo nihich’8’ b44sh bee hod7ilnih d00 n1mboo 47 d77 ninaaltsoos doot[‘7zh7g7 bee n47ho’d7lzin7g7 bine’d44’ bik11’ 47 doodag0 47 (866)346-7198j8’ hod77lnih. H0zh= sh7k1 an11’doowo[ n7n7zingo 47 d77 b4eso 1ch’22h naa’nil bi[ haz’32j8’ 1-800-927-4357j8’ hod77lnih. Navajo

ໍບິລການແປພາສາໂດຍໍ່ບເສຍຄ່ າ. ທ່ ານສາມາດໍຂເອົ າຜູ້ ແປພາສາໄດ້ . ທ່ ານສາມາດໍຂໃຫ້ ອ່ ານເອກະສານໃຫ້ ທ່ ານຟັ ງ ແລະ ສົ່ ງເອກະສານບາງຢ່ າງີ່ທເປັ ນພາສາຂອງທ່ ານ. ໍສາລັ ບຄວາມຊ່ ວຍເຫືຼ ອ, ໃຫ້ ໂທຫາພວກເຮົ າຕາມເບີ ໂທລະສັ ບີ່ທີ ມ ໃນບັ ດປະໍຈາຕົ ວຂອງທ່ ານ ືຫຼ ໂທຫາເບີ 1-866-346-7198. ໍສາລັ ບຄວາມຊ່ ວຍເຫືຼ ອເພີ່ ມເ ຕີ ມ ໂທຫາ ພະແນກ ປະກັ ນໄພຂອງ ລັ ດຄາີລຟໍ ເນຍໄດ້ ີ່ທເບີ 1-800-927-4357. Laotian

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