California 3 Tier with Specialty Drug List

The 3 Tier with Specialty Drug List (formulary) includes a list of drugs covered by Health Net. The drug list is updated at least monthly and is subject to change. All previous versions are no longer in effect. You can view the most current drug list by going to our website at www.healthnet.com.Refer to Evidence of Coverage or Certificate of Insurance for specific cost share information.

California Small and Large Group members Go to Drug Lists - Use the “3 Tier with Specialty” Formulary.

NOTE: To search the drug list online, open the (pdf) document. Hold down the “Control” (Ctrl) and “F” keys. When the search box appears, type the name of your drug and press the “Enter” key. If you have questions or need more information call us toll free.

Small Group If you have questions about your pharmacy coverage call Customer Service at 1-800-361-3366 Hours of Operation 8:00am – 6:00pm Monday through Friday

Large Group If you have questions about your pharmacy coverage call Customer Service at 1-800-522-0088

Hours of Operation 8:00am – 6:00pm Monday through Friday

Updated June 1, 2020

Health Net of California, Inc. and Health Net Life Insurance Company are subsidiaries of Health Net, LLC and Centene Corporation. Health Net is a registered service mark of Health Net, LLC. Table of Contents

What If I Have Questions Regarding My Pharmacy Benefit? …………………..ii What is the Drug List ?...... ii How do I find a drug on the Drug List? ...... ii How are the drugs listed in the categorical list? ………………………………….ii How much will I pay for my drugs?...... iii Tier description table Are there any limits on my drug coverage? ...... iv Abbreviations table How often does the Drug List change? ...... v How can I get prior authorization or an exception to the rules for drug coverage? v Are all contraceptives covered? ...... vi What blood glucose supplies are covered? ...... vi What drugs are covered under my medical benefit? ...... vii Can I go to any pharmacy? ...... vii Can I use a mail order pharmacy? ...... vii How can I save money on my prescription drugs? ……...... vii Definitions………………………………………………………………………viii Categorical list of prescription drugs...... 1 Alphabetical index of prescription drugs …………………………...... ……Index 1

i Welcome to Health Net

What If I Have Questions Regarding My Pharmacy Benefit? If you have questions about your pharmacy coverage contact Customer Service at the phone number listed on your Health Net ID card or on the cover of this book. Customer Service can help you with questions about your prescription drug benefits, including, but not limited to:  information about drugs covered under the medical benefit  the processes for submitting an exception request, requesting prior authorization and step therapy exceptions  actual dollar amounts of cost sharing for drugs including drugs subject to coinsurance

What is the Drug List? The drug list is a complete list of covered drugs used to treat common diseases or health problems. The drug list is selected by a committee of doctors and pharmacists who meet regularly to decide which drugs should be included. The committee reviews new drugs and new information about existing drugs and chooses drugs based on:  Safety  Effectiveness  Side effects  Value (if two drugs are equally effective, the less costly drug will be preferred)

How do I find a drug in the Drug List? You can search for a drug by using the search tool, alphabetical index or by categorical list. There are three ways to find out if your drug is covered.

Search Tool: Open the List of Drugs (PDF). Hold down the “Control” (Ctrl) and “F” keys. When the search box appears, type the name of your drug. Press the “Enter” key.

Alphabetical Index: The index at the end of the PDF lists the names of generic and brand name drugs from A to Z. Once you find a drug name, go to the page number listed to see if the drug is covered.

Categorical list: The drugs are grouped into categorical or therapeutic categories. If you know what therapeutic category and class your drug is in look through the list to find the category. Then look under the category and class for your drug.

If a generic equivalent for a brand name drug is not available in the market or not covered, the generic drug will not be listed separately. The presence of a drug on the drug list does not guarantee that your doctor will prescribe the drug for a particular medical condition.

How are the drugs listed in the categorical list? A drug is listed alphabetically by its brand and generic names in its therapeutic category and class.

ii Example: Drug Requirements/ Drug Name Tier Limits PA MAVYRET (glecaprevir- 3 pibrentasvir) TABS phentermine hcl caps 1 PA

The generic drug name for a brand drug is included after the brand name in parentheses and all bold italicized lowercase letters.

Brand Drug Example: MAVYRET (glecaprevir-pibrentasvir) TABS

If a generic equivalent for a brand name drug is both available and both the brand name and the generic drug are covered, the generic drug will be listed separately from the brand name drug in all bold and italicized lowercase letters.

Generic Drug Example: terbutaline sulfate tabs If a generic drug is marketed under a proprietary, trademark-protected brand name, the brand name will be listed after the generic name in parentheses and regular typeface in all CAPITAL letters.

Generic Drug Marketed Under A Proprietary Brand Name Example: levothyroxine sodium (LEVOXYL) TABS

How much will I pay for my drugs? To see how much you will pay for a drug, check the abbreviations in the Drug Tier column on the formulary. The copayment or coinsurance for each tier is defined in your Summary of Benefits or other plan documents.

Drug Class/Plan Benefit Phase Maximum Cost Share Days Supply Oral Cancer Drugs Deductible Met $250 30 Days All other (non-oral Deductible Met $250 30 Days cancer) Drugs Bronze Plan Members Deductible Met $500 30 Days

Below is a description for each tier. Refer to Evidence of Coverage or Certificate of Insurance for specific cost share information. Tier Description 1 Drugs in this tier include generic drugs and low-cost preferred brand drugs.

2 Drugs in this tier are higher cost generic drugs and preferred brand drugs

Drugs in this tier are non-preferred brand drugs, brand drugs with generic equivalents on a lower tier, or drugs that have a preferred alternative at a lower 3 tier.

iii Tier 4 Drugs include drugs that are made using biotechnology, drugs that must be distributed through a specialty pharmacy, drugs that require special training for self-administration, or drugs that require regular monitoring of care by a 4 pharmacy, and drugs that cost more than six hundred dollars for a one-month supply.

Includes preventive benefit drugs, including contraceptives, covered at no cost to 5 members under the Affordable Care Act. A deductible does not apply.

Brand is shown for reference only. Generic drugs are preferred. To get a brand 7 drug that has a generic available, your doctor must request prior authorization to show medical necessity. If we approve the request, the drug may be covered at a higher copayment. Refer to your plan.

B Are there any limits on my drug coverage? Some drugs have limitsdocuments on coverage. for coverage The table details. below provides a description of abbreviations that may appear in the Limits column on the drug list:

Abbreviation Definition Description

AL Age Limit These drugs may require prior authorization if your age does not fall within manufacturer, FDA, or clinical recommendations. AC Anti-cancer These oral cancer drugs are subject to a maximum $250 copayment for a one-month supply, after any deductible has been met, per state law (or $750 maximum for a three-month supply through mail order). LA Limited Access Some drugs may be subject to limited access or restricted access. This means that a drug may only be available at select pharmacies. Limited access may be due to the following reasons:  The FDA or the manufacturer has restricted distribution of a drug to certain facilities, pharmacies or prescribers, or  Certain drugs require special handling, coordination of care, or patient education that cannot be provided at a retail pharmacy. If the drug is approved, we will let you know how to get limited access drugs. PA Prior Authorization This drug requires prior authorization. This means that you or your prescriber must get approval from us before you fill your prescription. If you don’t get approval, we may not cover the drug.

iv PV Preventive Drugs Preventive Health Drugs are Affordable Care Act (ACA) preventive health drugs, including contraceptive drugs and devices, covered at no charge. Preventive health drugs are determined based on evidence-based recommendations by the United States Preventive Services Task Force.

QL Quantity Limit These drugs have a limit on the amount that will be covered. Your doctor must request approval for a higher quantity of the drug from Health Net. Health Net covers a 12-month supply when dispensed at one time of all self- administered hormonal contraceptives on the Formulary. RX/OTC Prescription & Certain drugs are available both in a prescription form and Over-the- in an OTC form. Only prescription drugs are covered by Counter (OTC) your plan with the exception of some insulin, insulin supplies and some covered preventive drugs. OTC drugs on the drug list, including OTC preventive drugs and contraceptives, require a prescription to be covered. ST Step Therapy Step therapy is when you are required to use one drug before another, in a stepwise fashion. Unless an exception is made, one or more preferred drugs must be tried first before progressing to a drug that is subject to step therapy. How often does the Drug List change? The formulary will be updated with changes on a monthly basis. The types of changes may include the following:

 Removal of a drug or dosage form of a drug from the formulary;  Any change in tier placement of a drug that results in an increase in cost sharing;  Adding or changing utilization management procedures applicable to a drug.

If these changes occur, you will be notified at least 60 days in advance of the change, unless the drug is removed for safety reasons.

How can I get prior authorization or an exception to the rules for drug coverage? Requests for prior authorization may be submitted electronically, by phone at 1-800-548-5524, or by fax at 1-800-314-6223. Once your doctor’s request is received, we will notify your doctor of our decision within 72 hours. If Health Net fails to respond to a completed prior authorization or step therapy exception request within 72 hours of receiving a non-urgent request and 24 hours of receiving a request based on exigent circumstances, the request is deemed approved and the health insurer may not deny the request thereafter.

If your doctor believes that waiting 72 hours for a standard decision could seriously harm your health, your doctor can ask for a fast (expedited) decision. This applies only to requests for drugs that you have not already received. We must make expedited decisions within 24 hours after we get your doctor’s supporting statement.

If we approve your drug’s exception, the approval continues until the end of the plan year. To keep the exception in place for the plan year, you must remain enrolled in our plan, your doctor must continue to prescribe your drug, and your drug must be safe for treating your condition.

v In some cases, our plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. This is called step therapy. Step therapy is when you are required to use one drug before another, in a stepwise fashion. The required first step drug or preferred drug is a proven, cost-effective medication. Unless an exception is made, one or more preferred drugs must be tried before progressing to a drug that is subject to step therapy. You or your doctor can request an exception if your health may be harmed by waiting. Your doctor must submit a supporting statement to us explaining why you need the drug. You or your doctor may appeal the denial of an exception request. The denial documents provide more information on appeal rights and procedures if there is a medical need to use a second step drug without trying a first step drug, an exception to coverage may be requested by the prescriber. A request for an exception to a step therapy requirement may be submitted in the same manner as a request for prior authorization. The request shall be treated in the same manner, and shall be responded to in the same manner, as a request for prior authorization for prescription drugs. If you have already tried and failed the preferred drug(s), or if you are already taking a drug that is subject to step therapy when you switch to enrolled in a Health Net plan, you will not have to undergo step therapy and the drug will be approved for coverage when medically necessary.

If a drug is not on the drug list, and is not specifically excluded from coverage, your doctor can ask for an exception. To request an exception, your doctor can submit a prior authorization request along with a supporting statement explaining why you need the drug. Requests for prior authorization may be submitted electronically or by telephone or fax. If we approve an exception for a drug that is not on the drug list, the non-preferred brand drug tier (Tier 3) or Tier 4 copayment applies.

Health Net will cover all medically necessary drugs. If Health Net fails to respond to a completed prior authorization or step therapy exception request within 72 hours of receiving a non-urgent request and 24 hours of receiving an expedited request, the request will be approved and Health Net may not deny the request thereafter.

Are all contraceptives covered? Contraceptive benefits include coverage for a variety of U.S. Food and Drug Administration (FDA)- approved prescription contraceptive methods. If your doctor determines that none of the covered methods on the drug list or if a covered therapeutic equivalent of a drug, device, or product is not available, and is medically necessary for you, Health Net will provide coverage. Coverage is subject to limitations and restrictions. Prior authorization or step therapy may be required for some other FDA-approved prescription contraceptive drugs, devices, or products prescribed by your doctor.

What blood glucose supplies are covered? Specific brands of blood glucose monitors, blood glucose testing strips, lancets, ketone testing strips, pen delivery systems for injecting insulin and insulin needles and syringes are covered as shown on the drug list. A prescription from your doctor is required to obtain these from a pharmacy under your pharmacy benefit.

Insulin pumps and all related necessary supplies, podiatric devices to prevent or treat diabetes-related complications and visual aids, excluding eyewear, to assist the visually impaired with proper dosing of insulin are covered under the medical benefit.

What drugs are covered under my medical benefit? Drugs that are not considered self-injectable and are administered by your doctor will be covered under your medical benefit. If your doctor does not have the drug, your doctor will give you instructions on where you can receive the drug. Certain drugs that are self-administered are covered under your

vi pharmacy benefit. Refer to your Evidence of Coverage or Certificate of Insurance for coverage information and exceptions.

Can I go to any pharmacy? Except in emergency and urgent situations, Health Net does not cover drugs dispensed by non-network pharmacies. Health Net contracts with most U.S. chain pharmacies and many independent pharmacies. These pharmacies are called in-network pharmacies. To find an in-network pharmacy near you, visit our website at Find a pharmacy near you or call us at the telephone number on your Health Net ID card or listed on the front cover of this book.

Some injectable and high cost drugs are considered specialty drugs. These drugs must be filled at an in- network specialty pharmacy. Specialty drugs are noted on the drug list in the Requirements/Limits column with the abbreviation “LA” or a statement indicating the drug must be dispensed from a network specialty pharmacy. After your drug has been approved, we will arrange for the specialty pharmacy to contact you to set up delivery.

Can I use a mail order pharmacy? For certain kinds of prescription drugs, you can use the contracted Mail Order Pharmacy. Generally, the drugs available through mail order are drugs that you take on a regular basis for a chronic or long-term medical condition. Tier 4 drugs are not available through mail order.

To use the mail order pharmacy, your doctor must provide a new prescription that allows up to a 90-day supply of each drug. Mail order forms are available on our website at Forms and brochures - Pharmacy or you may call us at the telephone number on your Health Net ID card or on the front cover of this book to request a form.

How can I save money on my prescription drugs? You can save time and money with these simple steps:  Ask your doctor about generic drugs that may work for you.  Fill prescriptions at in-network pharmacies.  Be sure your doctor prescribes drugs on the drug list.  Fill your maintenance drugs through our mail order pharmacy program.

Definitions Brand drug: Is a drug that is marketed under a proprietary, trademark-protected name. A brand drug is listed in this formulary in all CAPITAL letters. Coinsurance: Is a percentage of the cost of a covered health care benefit that you pay after you have paid the deductible, if a deductible applies to the health care benefit. Copayment: Is a fixed dollar amount that you pay for a covered health care benefit after you have paid the deductible, if a deductible applies to the health care benefit. Deductible: Is the amount you pay for covered health care benefits that are subject to the deductible before your health insurer begins to pay. If the plan has a deductible, it may have either one deductible or separate deductibles for medical benefits and prescription drug benefits. After you pay your deductible, you usually pay only a copayment or coinsurance for covered health care benefits. The plan pays the rest.

vii Drug Tier: Is a group of prescription drugs that correspond to a specified cost sharing tier. The drug tier in which a prescription drug is placed determines your 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 formulary template shall also include subscribers as defined in this section below. Exception request: Is a request for coverage of a non-formulary drug. If you, your designee, or your doctor submits a request for coverage of a non-formulary drug, the plan must cover the non-formulary drug when it is medically necessary for you to take the drug. Exigent circumstances: Is when you are suffering from a medical condition that may seriously jeopardize your life, health, or ability to regain maximum function, or when you are undergoing a current course of treatment using a non-formulary drug. Formulary or prescription drug list: Is the list of drugs that is covered by the plan under the prescription drug benefit of the policy. Generic drug: Is a drug that is the same as its brand name drug equivalent in dosage, strength, effect, how it is taken, quality, safety, and intended use. A generic drug is listed in the drug list in bold and italicized lowercase letters. Medically Necessary: Is a health care benefit needed to diagnose, treat, or prevent a medical condition or its symptoms and that meet accepted standards of medicine. Plans usually do not cover health care benefits that are not medically necessary. Non-formulary drug: Is a prescription drug that is not listed on the drug list. Out-of-pocket costs: Are your expenses for health care benefits that aren't reimbursed by the plan. Out- of-pocket costs include deductibles, copayments, and coinsurance for covered health care benefits, plus all costs for health care benefits that are paid by the Member and not covered by the plan. Prescribing provider: This is a health care provider who can write a prescription for a drug to diagnose, treat, or prevent a medical condition. Prescription: Is an oral, written, or electronic order from a prescribing provider authorizing a prescription drug to be provided to a specific individual. Prescription drug: Is a drug that by law requires a prescription. Prior Authorization: Is a decision by the plan that a health care benefit is medically necessary for you. If a prescription drug is subject to prior authorization in the drug list, your doctor must request approval from the plan to cover the drug before you fill your prescription. The plan must grant a prior authorization request when it is medically necessary for you to take the drug. Step therapy: Is a specific sequence in which prescription drugs for a particular medical condition must be tried. If a drug is subject to step therapy in the drug list, you may have to try one or more other drugs before the plan will cover that drug for your medical condition. If your doctor submits a request for an exception to the step therapy requirement, the plan must grant the request when it is medically necessary for you to take the drug.

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

viii Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ADHD/ANTI-NARCOLEPSY/ANTI- DEXEDRINE CP24 OBESITY/ANOREXIANTS - Drugs to Treat (dextroamphetamine 7 ADHD, Sleep and Eating Disorders sulfate) Amphetamines dextroamphetamine (Dextroamphetamine sulfate cp24 5 mg, 10 1 Sulfate) PROCENTRA 3 mg, 15 mg SOLN dextroamphetamine 3 (Dextroamphetamine sulfate soln 5 mg/5ml Sulfate) ZENZEDI TABS 5 1 MG, 10 MG dextroamphetamine ADDERALL TABS sulfate tabs 5 mg, 10 1 (amphetamine- 7 mg ) PA; ST; dextroamphetamine methamphetamine hcl 3 ADDERALL XR CP24 QL(2 ea tabs (amphetamine- 7 daily,90 day(s) VYVANSE CAPS 10 MG, QL(1 ea daily) dextroamphetamine) limit) 20 MG, 30 MG, 40 MG, 50 amphetamine- QL(2 ea MG, 60 MG, 70 MG 2 (lisdexamfetamine dextroamphetamine daily,90 day(s) dimesylate) cp24 5 mg-5 mg-5 mg- limit) VYVANSE CHEW 10 MG, Limited to 1 per 5 mg, 2.5 mg-2.5 mg- 20 MG, 30 MG, 40 MG, 50 day;QL(1 ea 2.5 mg-2.5 mg, 7.5 mg- MG, 60 MG 2 daily) 7.5 mg-7.5 mg-7.5 mg, 1 (lisdexamfetamine 1.25 mg-1.25 mg-1.25 dimesylate) mg-1.25 mg, 3.75 mg- ZENZEDI TABS 15 MG, 20 3.75 mg-3.75 mg-3.75 MG, 30 MG, 2.5 MG, 7.5 mg, 6.25 mg-6.25 mg- MG 3 6.25 mg-6.25 mg (dextroamphetamine amphetamine- sulfate) dextroamphetamine Analeptics tabs 5 mg-5 mg-5 mg-5 mg, 2.5 mg-2.5 mg-2.5 caffeine citrate soln 1 mg-2.5 mg, 7.5 mg-7.5 Attention-Deficit/Hyperactivity Disorder (ADHD) mg-7.5 mg-7.5 mg, QL(2 ea daily) 1 atomoxetine hcl caps 1.25 mg-1.25 mg-1.25 1 mg-1.25 mg, 3.75 mg- 10 mg, 18 mg, 25 mg, 3.75 mg-3.75 mg-3.75 40 mg QL(1 ea daily) mg, 1.875 mg-1.875 atomoxetine hcl caps 1 mg-1.875 mg-1.875 60 mg, 80 mg, 100 mg QL(1 ea daily) mg, 3.125 mg-3.125 guanfacine hcl (adhd) 1 mg-3.125 mg-3.125 mg tb24 DESOXYN TABS PA; ST; INTUNIV TB24 QL(1 ea daily) 7 7 (methamphetamine hcl) (guanfacine hcl (adhd))

1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic Preferred AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

1 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits STRATTERA CAPS 10 QL(2 ea daily) methylphenidate hcl MG, 18 MG, 25 MG, 40 MG 7 cp24 10 mg, 20 mg, 30 3 (atomoxetine hcl) mg, 40 mg STRATTERA CAPS 60 QL(1 ea daily) methylphenidate hcl QL(1 ea MG, 80 MG, 100 MG 7 3 daily,90 ea per (atomoxetine hcl) cp24 60 mg fill retail) Stimulants - Misc. methylphenidate hcl QL(1 ea daily) QL(1 ea cpcr 10 mg, 20 mg, 30 1 (Methylphenidate Hcl) 1 daily,90 day(s) METADATE ER TBCR mg, 40 mg, 50 mg, 60 limit) mg APTENSIO XR CP24 PA; QL(1 ea 3 methylphenidate hcl (methylphenidate hcl) daily) soln 5 mg/5ml, 10 1 armodafinil tabs 1 PA; ST mg/5ml QL(3 ea daily) CONCERTA TBCR 18 MG, QL(1 ea daily) methylphenidate hcl 1 27 MG, 36 MG 7 tabs 20 mg ( ) methylphenidate hcl methylphenidate hcl 1 CONCERTA TBCR 54 MG QL(2 ea daily) tabs 5 mg, 10 mg 7 (methylphenidate hcl) methylphenidate hcl QL(1 ea DAYTRANA PTCH tb24 18 mg, 27 mg, 54 1 daily,90 ea per 3 (methylphenidate) mg fill retail) dexmethylphenidate hcl QL(1 ea daily) methylphenidate hcl QL(2 ea 1 daily,180 ea cp24 5 mg, 10 mg, 15 3 tb24 36 mg mg, 20 mg, 25 mg, 30 per fill retail) mg, 35 mg, 40 mg methylphenidate hcl QL(1 ea 1 daily,90 ea per dexmethylphenidate hcl QL(2 ea daily) tbcr 10 mg fill retail) tabs 5 mg, 10 mg, 2.5 1 methylphenidate hcl QL(1 ea daily) mg tbcr 18 mg, 27 mg, 36 1 FOCALIN TABS QL(2 ea daily) mg (dexmethylphenidate 7 methylphenidate hcl QL(1 ea hcl) 1 daily,90 day(s) FOCALIN XR CP24 QL(1 ea daily) tbcr 20 mg limit) (dexmethylphenidate 7 QL(2 ea daily) methylphenidate hcl 1 hcl) tbcr 54 mg METHYLIN SOLN 7 METHYLPHENIDATE PA; QL(1 ea (methylphenidate hcl) HYDROCHLORIDE ER daily) METHYLPEHNIDATE PA; QL(1 ea CP24 10 MG, 15 MG, 20 3 HYDROCHLORIDE ER daily) MG, 30 MG, 40 MG, 50 MG CP24 (methylphenidate 3 (methylphenidate hcl) hcl) METHYLPHENIDATE QL(1 ea daily) HYDROCHLORIDE ER methylphenidate hcl TBCR 72 MG 3 chew 5 mg, 10 mg, 2.5 3 (methylphenidate hcl) mg

2 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ST; QL(1 ea TOBI PODHALER CAPS PA modafinil tabs 3 4 daily) (tobramycin) NUVIGIL TABS PA; ST 7 4 PA (armodafinil) tobramycin nebu PROVIGIL TABS ST; QL(1 ea TOBRAMYCIN NEBU PA 7 4 (modafinil) daily) (tobramycin) QUILLICHEW ER CHER PA ANALGESICS - ANTI-INFLAMMATORY - Drugs 3 (methylphenidate hcl) to Treat Pain, Swelling, Muscle and Joint QUILLIVANT XR SRER PA; ST;QL(12 Conditions 3 (methylphenidate hcl) ml daily) Anti-TNF-alpha - Monoclonal Antibodies RELEXXII TBCR QL(1 ea daily) HUMIRA PEDIATRIC PA 3 (methylphenidate hcl) CROHNS DISEASE STARTER PACK PSKT 4 RITALIN LA CP24 7 (adalimumab) (methylphenidate hcl) HUMIRA PEDIATRIC PA; ST; Must RITALIN TABS 20 MG QL(3 ea daily) 7 CROHNS DISEASE use AcariaHlth (methylphenidate hcl) STARTER PACK PSKT 40 4 Sp Rx 1-844- RITALIN TABS 5 MG, 10 MG/0.8ML (adalimumab) 538-4661;LA MG (methylphenidate 7 HUMIRA PEDIATRIC PA; ST hcl) CROHNS DISEASE 4 AMINOGLYCOSIDES - Drugs to Treat Bacterial STARTER PACK PSKT 80 Infections MG/0.8ML (adalimumab) PA; ST; Must Aminoglycosides use (Tobramycin) PA HUMIRA PEN PNKT 4 AcariaHealth TOBRAMYCIN 4 (adalimumab) Specialty Rx at INHALATION SOLUTION 1-844-538- PAK NEBU 4661;LA ARIKAYCE SUSP PA PA; ST; Must (amikacin sulfate 4 HUMIRA PEN-CD/UC/HS use liposome) STARTER PNKT 4 AcariaHealth BETHKIS NEBU PA Specialty Rx at 4 (adalimumab) 1-844-538- (tobramycin) 4661;LA KITABIS PAK NEBU PA 4 PA; ST; MUST (tobramycin) HUMIRA PEN-PS/UV USE ACARIA STARTER PNKT neomycin sulfate tabs 1 4 SPECIALTY (adalimumab) RX 844-538- 4661;LA paromomycin sulfate 1 caps PA; ST; Must use PAROMOMYCIN HUMIRA PEN-PS/UV SULFATE CAPS STARTER PNKT 4 AcariaHealth 2 Specialty Rx at (paromomycin sulfate) (adalimumab) 1-844-538- TOBI NEBU (tobramycin) 7 PA 4661;LA

3 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits HUMIRA PSKT 10 PA; ST PA; ST; Must MG/0.1ML, 20 MG/0.2ML, use 4 ACTEMRA SOSY 40 MG/0.4ML 4 AcariaHealth (adalimumab) (tocilizumab) Specialty Rx at HUMIRA PSKT 10 PA; ST; Must 1-844-538- MG/0.2ML, 20 MG/0.4ML, use AcariaHlth 4661 4 KEVZARA SOSY PA; ST;LA 40 MG/0.8ML Sp Rx 1-844- 4 (adalimumab) 538-4661;LA (sarilumab) Antirheumatic - Enzyme Inhibitors Nonsteroidal Anti-inflammatory Agents (NSAIDs) PA; ST; Must (Fenoprofen Calcium) 1 use PROFENO TABS RINVOQ TB24 4 AcariaHealth (Ibuprofen) IBU TABS 1 (upadacitinib) Specialty Rx at 1-844-538- ANAPROX DS TABS 7 4661 (naproxen sodium) XELJANZ TABS 10 MG PA 4 ARTHROTEC 50 TBEC (tofacitinib citrate) (diclofenac w/ 7 XELJANZ TABS 5 MG PA; ST;QL(2 misoprostol) 4 ea daily); LA (tofacitinib citrate) ARTHROTEC 75 TBEC XELJANZ XR TB24 11 MG PA; ST;QL(1 4 (diclofenac w/ 7 (tofacitinib citrate) ea daily); LA misoprostol) Antirheumatic Antimetabolites ST; QL(1 ea CELEBREX CAPS 100 MG METHOTREXATE TABS 7 daily); AL(At (methotrexate sodium 2 (celecoxib) least 60 yrs old) (antirheumatic)) ST; QL(2 ea OTREXUP SOAJ PA; ST CELEBREX CAPS 200 MG 7 daily); AL(At (methotrexate 4 (celecoxib) least 60 yrs (antirheumatic)) old) RASUVO SOAJ PA; ST PA; QL(1 ea CELEBREX CAPS 400 MG (methotrexate 4 7 daily); AL(At (antirheumatic)) (celecoxib) least 60 yrs old) Gold Compounds CELEBREX CAPS 50 MG PA; AL(At least RIDAURA CAPS 7 2 (celecoxib) 60 yrs old) (auranofin) ST; QL(1 ea Interleukin-1 Blockers celecoxib caps 100 mg 1 daily); AL(At ARCALYST SOLR PA least 60 yrs 4 old) (rilonacept) ST; QL(2 ea Interleukin-6 Receptor Inhibitors celecoxib caps 200 mg 1 daily); AL(At PA; ST; MUST least 60 yrs ACTEMRA ACTPEN SOAJ USE ACARIA old) 4 SPECIALTY PA; QL(1 ea (tocilizumab) RX 844-538- 1 daily); AL(At 4661 celecoxib caps 400 mg least 60 yrs old) 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic Preferred AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

4 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; AL(At least INDOMETHACIN CAPS 20 ST; QL(3 ea celecoxib caps 50 mg 1 3 60 yrs old) MG (indomethacin) daily) DAYPRO TABS 7 indomethacin caps 25 1 (oxaprozin) mg, 50 mg diclofenac potassium 3 indomethacin cpcr 75 1 tabs mg diclofenac sodium tb24 KETOPROFEN CAPS 50 3 2 100 mg MG, 75 MG (ketoprofen) diclofenac sodium tbec KETOPROFEN ER CP24 1 3 25 mg, 50 mg, 75 mg (ketoprofen) diclofenac w/ QL(20 ea per 3 ketorolac tromethamine 1 misoprostol tbec tabs fill retail) etodolac caps 200 mg, 1 LODINE TABS (etodolac) 7 300 mg meclofenamate sodium etodolac tabs 400 mg, 1 1 500 mg caps QL(2 ea daily) mefenamic acid caps 3 etodolac tb24 400 mg, 1 500 mg, 600 mg 1 QL(1 ea daily) FELDENE CAPS 10 MG meloxicam tabs 15 mg 7 (piroxicam) meloxicam tabs 7.5 mg 1 QL(2 ea daily) FELDENE CAPS 20 MG QL(1 ea daily) 7 MOBIC TABS 15 MG QL(1 ea daily) (piroxicam) 7 (meloxicam) FENOPROFEN CALCIUM MOBIC TABS 7.5 MG QL(2 ea daily) CAPS 200 MG 2 7 (fenoprofen calcium) (meloxicam) QL(4 ea daily) FENOPROFEN CALCIUM nabumetone tabs 500 1 CAPS 400 MG 3 mg (fenoprofen calcium) QL(3 ea daily) nabumetone tabs 750 1 fenoprofen calcium 1 mg tabs 600 mg NALFON CAPS 400 MG 3 FENORTHO CAPS (fenoprofen calcium) 2 (fenoprofen calcium) NALFON TABS 600 MG 7 (fenoprofen calcium) flurbiprofen tabs 100 3 mg NAPROSYN SUSP 7 flurbiprofen tabs 50 mg 1 (naproxen) NAPROSYN TABS 7 ibuprofen tabs 1 (naproxen) INDOCIN SUPP RE 50 MG naproxen sodium tabs 3 1 (indomethacin) 275 mg, 550 mg INDOCIN SUSP OR 25 1 2 naproxen susp MG/5ML (indomethacin)

5 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 1 PA; ST; Must naproxen tabs ENBREL SOLR 4 use AcariaHlth 1 (etanercept) Sp Rx 1-844- oxaprozin tabs 538-4661;LA piroxicam caps 10 mg 1 PA; ST; Must ENBREL SOSY 4 use AcariaHlth piroxicam caps 20 mg 1 QL(1 ea daily) (etanercept) Sp Rx 1-844- 538-4661;LA sulindac tabs 150 mg 1 QL(2 ea daily) PA; ST; Must ENBREL SURECLICK 4 use AcariaHlth sulindac tabs 200 mg 1 SOAJ (etanercept) Sp Rx 1-844- 538-4661;LA TIVORBEX CAPS 20 MG, ST; QL(3 ea 3 daily) ANALGESICS - NonNarcotic - Drugs to Treat 40 MG (indomethacin) Pain, Muscle and Joint Conditions TOLMETIN SODIUM Analgesic Combinations CAPS 400 MG (tolmetin 2 sodium) (Butalbital-Acetaminophen) 3 BUPAP TABS tolmetin sodium tabs 1 (Butalbital-Acetaminophen- 200 mg, 600 mg Caffeine) ESGIC, 1 VIVLODEX CAPS 10 MG PA ZEBUTAL, PHRENILIN 3 (meloxicam) FORTE CAPS VIVLODEX CAPS 5 MG PA; ST (Butalbital-Acetaminophen- 3 (meloxicam) Caffeine) ESGIC, 3 ZEBUTAL, PHRENILIN Phosphodiesterase 4 (PDE4) Inhibitors FORTE CAPS PA; ST; Must butalbital- OTEZLA TABS use AcariaHlth 4 acetaminophen tabs 3 (apremilast) Sp Rx 1-844- 300 mg-50 mg, 325 538-4661 mg-50 mg PA; ST; Must OTEZLA TBPK butalbital- 4 use AcariaHlth (apremilast) Sp Rx 1-844- acetaminophen- 3 538-4661;LA caffeine caps 300 mg- Pyrimidine Synthesis Inhibitors 50 mg-40 mg ARAVA TABS 10 MG QL(2 ea daily) butalbital- 7 (leflunomide) acetaminophen- 1 ARAVA TABS 20 MG QL(1 ea daily) caffeine caps 325 mg- 7 (leflunomide) 50 mg-40 mg leflunomide tabs 10 mg 1 QL(2 ea daily) butalbital- acetaminophen- 1 leflunomide tabs 20 mg 1 QL(1 ea daily) caffeine tabs 325 mg- 50 mg-40 mg Soluble Tumor Necrosis Factor Receptor Agents butalbital-aspirin- ENBREL MINI SOCT PA; ST 1 4 caffeine caps (etanercept)

6 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ESGIC TABS (butalbital- (Aspirin) ADULT ASPIRIN PV acetaminophen- 7 EC LOW STRENGTH, TGT caffeine) ASPIRIN LOW DOSE, TGT ASPIRIN, ST JOSEPH FIORICET CAPS ASPIRIN, SM ASPIRIN EC (butalbital- LOW STRENGTH, SM acetaminophen- 7 ASPIRIN ADULT LOW caffeine) STRENGTH, SB LOW DOSE ASA EC, SB FIORINAL CAPS ASPIRIN ADULT LOW (butalbital-aspirin- 7 STRENGTH, SB ASPIRIN, caffeine) RA ASPIRIN EC ADULT TENCON TABS LOW STRENGTH, QC (butalbital- 3 ASPIRIN LOW DOSE, MINIPRIN LOW DOSE, KP acetaminophen) ASPIRIN, KLS ASPIRIN Salicylates LOW DOSE, HM ASPIRIN EC LOW DOSE, H-E-B ASPIRIN, GOODSENSE ASPIRIN LOW DOSE, GNP ASPIRIN LOW DOSE, EQL ASPIRIN LOW DOSE, EQ ASPIRIN LOW DOSE, EQ ASPIRIN 7 ADULT LOW DOSE, EQ ADULT ASPIRIN LOW STRENGTH, ECOTRIN LOW STRENGTH, EC-81 ASPIRIN, CVS ASPIRIN LOW STRENGTH, CVS ASPIRIN LOW DOSE, CVS ASPIRIN EC, CVS ASPIRIN ADULT LOW STRENGTH, BAYER LOW DOSE, BAYER ASPIRIN EC LOW DOSE, ASPIRIN REGIMEN LOW DOSE/ADULT, ASPIRIN LOW DOSE, ASPIRIN ENTERIC COATED ADULT LOW STRENGTH, ASPIRIN EC LOW DOSE, ASPIRIN ADULT LOW STRENGTH, ASPIRIN ADULT LOW DOSE, ASPIRIN 81, ASPIR-LOW, ADULT ASPIRIN REGIMEN TBEC

7 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Aspirin) ASPIRIN 81 LOW PV choline & mag 1 DOSE, TGT CHILDRENS salicylate liqd ASPIRIN, TGT ASPIRIN, ST JOSEPH LOW DOSE CHOLINE MAGNESIUM TRISALICYLATE LIQD ASPIRIN, SM CHILDRENS 2 ASPIRIN, SM ASPIRIN (choline & mag LOW DOSE, SM ASPIRIN salicylate) ADULT LOW STRENGTH, SB CHILDRENS ASPIRIN, diflunisal tabs 3 RA CHILDRENS ASPIRIN, RA ASPIRIN CHILDRENS, salsalate tabs 1 RA ASPIRIN ADULT LOW STRENGTH, RA ASPIRIN ANALGESICS - OPIOID - Drugs to Treat Pain, ADULT LOW DOSE, QC Muscle and Joint Conditions CHILDRENS ASPIRIN, QC Opioid Agonists CHEWABLE ASPIRIN (Methadone Hcl) LOW DOSE, QC ASPIRIN METHADONE HCL 1 LOW DOSE, PX ASPIRIN, INTENSOL CONC GOODSENSE ASPIRIN 7 ADULT LOW STRENGTH, (Methadone Hcl) GNP ADULT ASPIRIN METHADOSE TBSO 40 1 LOW STRENGTH, EQL MG ASPIRIN LOW DOSE, EQ ABSTRAL SUBL PA 4 CHILDRENS ASPIRIN, EQ (fentanyl citrate) ASPIRIN LOW DOSE, CVS ACTIQ LPOP 1600 MCG PA; ST;QL(4 ASPIRIN ADULT LOW 7 ea daily) DOSE, CHILDRENS (fentanyl citrate) ASPIRIN LOW ACTIQ LPOP 200 MCG, PA; ST STRENGTH, CHILDRENS 400 MCG, 600 MCG, 800 ASPIRIN, BAYER MCG, 1200 MCG 7 CHEWABLE LOW DOSE, (fentanyl citrate) ASPIRIN LOW ARYMO ER TBEA PA STRENGTH, ASPIRIN 3 LOW DOSE, ASPIRIN (morphine sulfate) CHILDRENS, ASPIRIN codeine sulfate tabs 1 ADULT LOW STRENGTH, ASPIRIN ADULT LOW CONZIP CP24 ( tramadol 3 DOSE CHEW hcl) (Aspirin) GNP ASPIRIN, PV DILAUDID LIQD 7 RA ASPIRIN EC, PX 7 (hydromorphone hcl) ENTERIC ASPIRIN TBEC DILAUDID TABS 81 MG 7 (Aspirin) GOODSENSE PV (hydromorphone hcl) ASPIRIN, HM ASPIRIN 7 DOLOPHINE TABS QL(12 ea daily) 7 CHEW 81 MG (methadone hcl) PV aspirin chew 81 mg 7 DURAGESIC PT72 Limit 15 per 7 month;QL(0.5 (fentanyl) aspirin tbec 81 mg 7 PV ea daily)

8 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EMBEDA CPCR 0.8 MG- PA; ST KADIAN CP24 20 MG, 30 QL(2 ea daily) MG, 40 MG, 50 MG, 60 20 MG (morphine- 3 7 naltrexone) MG, 80 MG, 100 MG EMBEDA CPCR 2 MG-50 PA (morphine sulfate) KADIAN CP24 200 MG MG, 4 MG-100 MG, 1.2 3 MG-30 MG, 2.4 MG-60 3 (morphine sulfate) MG, 3.2 MG-80 MG PA; ST levorphanol tartrate 3 (morphine-naltrexone) tabs 2 mg EXALGO T24A 32 MG QL(2 ea daily) 7 LEVORPHANOL PA; ST (hydromorphone hcl) TARTRATE TABS 3 MG 3 EXALGO T24A 8 MG, 12 QL(4 ea daily) (levorphanol tartrate) MG, 16 MG 7 meperidine hcl soln 50 1 (hydromorphone hcl) mg/5ml PA; ST;QL(4 fentanyl citrate lpop bu 1 ea daily) meperidine hcl tabs 50 1 1600 mcg mg, 100 mg PA; ST fentanyl citrate lpop bu MEPERIDINE HCL TABS 200 mcg, 400 mcg, 600 1 50 MG, 100 MG 2 mcg, 800 mcg, 1200 (meperidine hcl) mcg methadone hcl conc 10 1 fentanyl pt72 12 Limit 15 per mg/ml month;QL(0.5 mcg/hr, 25 mcg/hr, 50 1 ea daily) methadone hcl soln 5 1 mcg/hr, 75 mcg/hr, 100 mg/5ml, 10 mg/5ml mcg/hr QL(12 ea daily) PA; Limit 15 methadone hcl tabs 5 1 fentanyl pt72 37.5 mg, 10 mg 3 patches per mcg/hr, 62.5 mcg/hr, month;QL(0.5 methadone hcl tbso 40 1 87.5 mcg/hr ea daily) mg hydromorphone hcl liqd METHADOSE CONC 10 1 7 1 mg/ml MG/ML (methadone hcl) QL(2 ea daily) METHADOSE SUGAR- hydromorphone hcl 3 t24a 32 mg FREE CONC 7 hydromorphone hcl QL(4 ea daily) (methadone hcl) t24a 8 mg, 12 mg, 16 3 morphine sulfate cp24 1 mg or 10 mg morphine sulfate cp24 QL(2 ea daily) hydromorphone hcl 1 tabs 2 mg, 4 mg, 8 mg or 20 mg, 30 mg, 50 1 HYSINGLA ER T24A PA mg, 60 mg, 80 mg, 100 (hydrocodone 3 mg ) QL(2 ea daily) bitartrate morphine sulfate cp24 3 KADIAN CP24 10 MG or 40 mg 7 (morphine sulfate) MORPHINE SULFATE ER QL(1 ea daily) CP24 (morphine sulfate 2 beads)

9 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits morphine sulfate soln OXYMORPHONE QL(2 ea daily) HYDROCHLORIDE ER or 20 mg/ml, 10 1 2 mg/5ml, 20 mg/5ml, TB12 (oxymorphone 100 mg/5ml hcl) MORPHINE SULFATE OXYMORPHONE QL(2 ea daily) HYDROCHLORIDEER SUPP RE 30 MG 2 2 (morphine sulfate) TB12 (oxymorphone morphine sulfate supp hcl) 1 ROXICODONE TABS 30 QL(4 ea daily) re 5 mg, 10 mg, 20 mg 7 MG (oxycodone hcl) morphine sulfate tabs First fill opioids 1 limited to 7 ROXICODONE TABS 5 or 15 mg, 30 mg days. MG, 15 MG (oxycodone 7 morphine sulfate tbcr or QL(3 ea daily) hcl) 15 mg, 30 mg, 60 mg, 1 SUBSYS LIQD (fentanyl) 4 PA 100 mg, 200 mg TRAMADOL HCL ER CP24 MS CONTIN TBCR QL(3 ea daily) 3 7 (tramadol hcl) (morphine sulfate) QL(8 ea daily) NUCYNTA ER TB12 QL(2 ea daily) tramadol hcl tabs 50 2 1 (tapentadol hcl) mg NUCYNTA TABS QL(6 ea daily) tramadol hcl tb24 100 QL(3 ea daily) 2 3 (tapentadol hcl) mg OPANA TABS 10 MG QL(8 ea daily) tramadol hcl tb24 100 7 3 (oxymorphone hcl) mg, 200 mg, 300 mg OPANA TABS 5 MG tramadol hcl tb24 200 QL(1 ea daily) 7 3 (oxymorphone hcl) mg ULTRAM TABS (tramadol QL(8 ea daily) oxycodone hcl caps 5 1 7 mg hcl) oxycodone hcl conc 1 Opioid Combinations 100 mg/5ml (Butalbital-Aspirin-Caffeine W/Cod) 3 oxycodone hcl soln 5 1 mg/5ml ASCOMP/CODEINE CAPS oxycodone hcl tabs 30 QL(4 ea daily) (Hydrocodone- QL(240 ea per 1 Acetaminophen) LORCET, 1 fill retail) mg LORCET PLUS, LORCET oxycodone hcl tabs 5 HD TABS mg, 10 mg, 15 mg, 20 1 (Hydrocodone-Ibuprofen) mg IBUDONE TABS 200 MG- 1 10 MG QL(8 ea daily) oxymorphone hcl tabs 3 10 mg (Oxycodone W/ QL(4 ea daily) Acetaminophen) 3 ENDOCET TABS 10 MG- oxymorphone hcl tabs 3 5 mg 325 MG, 7.5 MG-325 MG

10 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Oxycodone W/ hydrocodone- Acetaminophen) 3 acetaminophen tabs 5 1 ENDOCET TABS 2.5 MG- mg-300 mg, 10 mg-300 325 MG mg (Oxycodone W/ QL(6 ea daily) Acetaminophen) hydrocodone- QL(240 ea per 1 fill retail) ENDOCET TABS 5 MG- acetaminophen tabs 5 1 325 MG mg-325 mg, 10 mg-325 acetaminophen w/ mg, 7.5 mg-325 mg codeine soln 120 1 hydrocodone- QL(6 ea daily) mg/5ml-12 mg/5ml acetaminophen tabs 1 acetaminophen w/ 7.5 mg-300 mg codeine tabs 300 mg- 1 hydrocodone-ibuprofen Not available 1 through mail 15 mg, 300 mg-30 mg tabs 200 mg-10 mg acetaminophen w/ QL(6 ea daily) order codeine tabs 300 mg- 1 hydrocodone-ibuprofen 60 mg tabs 200 mg-10 mg, 1 ACETAMINOPHEN/CAFFE QL(12 ea daily) 200 mg-7.5 mg INE/DIHYDROCODEINE LORTAB ELIX CAPS (acetaminophen- 3 (hydrocodone- 3 caff-dihydrocod) acetaminophen) butalbital- NORCO TABS QL(240 ea per (hydrocodone- 7 fill retail) acetaminophen- 3 caffeine w/ codeine acetaminophen) caps oxycodone w/ QL(4 ea daily) acetaminophen tabs 10 butalbital-aspirin- 3 3 caffeine w/cod caps mg-325 mg, 7.5 mg- FIORICET/CODEINE 325 mg CAPS (butalbital- oxycodone w/ acetaminophen- 7 acetaminophen tabs 3 caffeine w/ codeine) 2.5 mg-325 mg FIORINAL/CODEINE #3 oxycodone w/ QL(6 ea daily) CAPS (butalbital-aspirin- 7 acetaminophen tabs 5 1 caffeine w/cod) mg-325 mg hydrocodone- OXYCODONE/IBUPROFE QL(4 ea daily) acetaminophen soln N TABS (oxycodone- 3 ibuprofen) 2.5 mg/5ml-108 1 mg/5ml, 5 mg/10ml-217 PERCOCET TABS 10 MG- QL(4 ea daily) 325 MG, 7.5 MG-325 MG mg/10ml, 7.5 mg/15ml- 7 325 mg/15ml (oxycodone w/ acetaminophen) PERCOCET TABS 2.5 MG-325 MG (oxycodone 7 w/ acetaminophen) 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic Preferred AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

11 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PERCOCET TABS 5 MG- QL(6 ea daily) buprenorphine ptwk td QL(4 ea per 28 325 MG (oxycodone w/ 7 days retail) 5 mcg/hr, 10 mcg/hr, 15 3 acetaminophen) mcg/hr, 20 mcg/hr, 7.5 PRIMLEV TABS mcg/hr (oxycodone w/ 3 Limited to 4 acetaminophen) buprenorphine ptwk td patches per PROLATE TABS 5 mcg/hr, 10 mcg/hr, 3 month;QL(4 ea 7.5 mcg/hr per 28 days (oxycodone w/ 3 retail) acetaminophen) Limit 7.5mls tramadol- QL(8 ea daily) 3 butorphanol tartrate 3 per acetaminophen tabs soln month;QL(0.25 TREZIX CAPS QL(12 ea daily) ml daily) (acetaminophen-caff- 3 pentazocine w/ 3 dihydrocod) naloxone tabs TYLENOL/CODEINE #3 ANDROGENS-ANABOLIC - Drugs to Regulate TABS (acetaminophen 7 Hormones w/ codeine) Anabolic Steroids TYLENOL/CODEINE #4 QL(6 ea daily) ANADROL-50 TABS 3 TABS (acetaminophen 7 (oxymetholone) w/ codeine) QL(2 ea daily) oxandrolone tabs 10 1 ULTRACET TABS QL(8 ea daily) mg (tramadol- 7 acetaminophen) oxandrolone tabs 2.5 1 mg Opioid Partial Agonists Androgens buprenorphine hcl subl QL(3 ea daily) 1 ST; QL(60 ea 2 mg ANDRODERM PT24 3 per fill QL(4 ea daily) ( ) retail,120 ea buprenorphine hcl subl 1 testosterone 8 mg per fill mail) ANDROGEL GEL 25 QL(10 gm buprenorphine hcl- QL(3 ea daily) 7 MG/2.5GM (testosterone) daily) naloxone hcl dihydrate 1 subl 8 mg-2 mg, 2 mg- ANDROGEL GEL 40.5 Limited to 300 0.5 mg MG/2.5GM, 20.25 gms per MG/1.25GM 7 month;QL(10 Limit 4 patches (testosterone) gm daily) buprenorphine ptwk td per 28 3 days;QL(4 ea Limited to 300 15 mcg/hr ANDROGEL PUMP GEL per 28 days 7 gms per retail) (testosterone) month;QL(10 Limit 4 patches gm daily) buprenorphine ptwk td 3 per month;QL(4 danazol caps 1 20 mcg/hr ea per 28 days FORTESTA GEL QL(4 gm daily) retail) 7 (testosterone)

12 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits METHITEST TABS CORTIFOAM FOAM 2 (methyltestosterone) (hydrocortisone acetate 2 METHYLTESTOSTERONE (intrarectal)) CAPS 1 QL(60 ml daily) hydrocortisone 1 (methyltestosterone) (intrarectal) enem STRIANT MISC QL(2 ea daily) 3 UCERIS FOAM RE 2 PA; ST (testosterone) MG/ACT (budesonide 3 TESTIM GEL PA; QL(10 gm 3 (intrarectal)) (testosterone) daily) Rectal Combinations 3 QL(10 gm ANALPRAM-HC LOTN testosterone gel 1 % daily) (hydrocortisone acetate 3 Limited to 300 testosterone gel 1 %, w/ pramoxine) 1.62 %, 50 mg/5gm, 25 gms per PROCTOFOAM HC FOAM mg/2.5gm, 40.5 1 month;QL(10 gm daily) (hydrocortisone acetate 2 mg/2.5gm, 20.25 w/ pramoxine) mg/1.25gm Limit 300gms Rectal Steroids (Hydrocortisone (Rectal)) testosterone gel 1 %, 1 per 50 mg/5gm month;QL(10 PROCTO-MED HC, 1 gm daily) PROCTOZONE-HC, testosterone gel 10 QL(4 gm daily) PROCTOSOL HC CREA 1 ANUSOL-HC CREA mg/act 7 ( ) QL(10 gm hydrocortisone (rectal) testosterone gel 50 1 mg/5gm, 25 mg/2.5gm daily) hydrocortisone (rectal) 1 crea TESTOSTERONE PUMP QL(10 gm 2 GEL (testosterone) daily) Vasodilating Agents TESTOSTERONE PUMP PA; QL(10 gm RECTIV OINT 3 GEL (testosterone) daily) (nitroglycerin (intra- 3 VOGELXO GEL PA; QL(10 gm anal)) 3 (testosterone) daily) ANTHELMINTICS - Drugs to Treat Worm VOGELXO PUMP GEL QL(10 gm Infections 2 (testosterone) daily) Anthelmintics ANORECTAL AND RELATED PRODUCTS - albendazole tabs 3 QL(4 ea per fill Rectal Drugs to Treat Pain, Swelling and Itching retail) ALBENZA TABS QL(4 ea per fill Intrarectal Steroids 7 (albendazole) retail) (Hydrocortisone QL(60 ml daily) (Intrarectal)) COLOCORT 1 BENZNIDAZOLE TABS AL(At least 2 ENEM 2 yrs old - Up to (benznidazole) 12 yrs old) CORTENEMA ENEM QL(60 ml daily) BILTRICIDE TABS (hydrocortisone 7 7 (intrarectal)) (praziquantel) ivermectin tabs or 3 mg 3

13 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits praziquantel tabs 1 BACTRIM DS TABS (sulfamethoxazole- 7 STROMECTOL TABS 7 trimethoprim) (ivermectin) BACTRIM TABS ANTI-INFECTIVE AGENTS - MISC. - Drugs to (sulfamethoxazole- 7 Treat Bacterial Infections trimethoprim) Anti-infective Agents - Misc. sulfamethoxazole- 1 FLAGYL CAPS trimethoprim susp 7 (metronidazole) sulfamethoxazole- 1 FLAGYL TABS 7 trimethoprim tabs ( ) metronidazole Antiprotozoal Agents IMPAVIDO CAPS ALINIA SUSR 4 3 (miltefosine) (nitazoxanide) metronidazole caps 1 ALINIA TABS 3 (nitazoxanide) metronidazole tabs 1 atovaquone susp 1 NEBUPENT SOLR MEPRON SUSP (pentamidine 7 7 isethionate) (atovaquone) Glycopeptides pentamidine 1 FIRVANQ SOLR PA isethionate solr 3 PRIMSOL SOLN (vancomycin hcl) 3 VANCOCIN HCL CAPS PA (trimethoprim hcl) 7 TINDAMAX TABS ST (vancomycin hcl) 7 (tinidazole) vancomycin hcl caps 1 PA PA; ST tinidazole tabs 250 mg 3 VANCOMYCIN PA ST HYDROCHLORIDE SOLR tinidazole tabs 500 mg 3 OR 250 MG/5ML 3 (vancomycin hcl) trimethoprim tabs 1 Leprostatics TRIMPEX SOLN 3 QL(4 ea daily) (trimethoprim hcl) dapsone tabs 100 mg 1 XIFAXAN TABS 200 MG PA; Limit 9 per dapsone tabs 25 mg 1 3 month;QL(0.3 (rifaximin) ea daily) Lincosamides XIFAXAN TABS 550 MG PA; QL(2 ea 3 CLEOCIN CAPS OR 75 (rifaximin) daily) MG, 150 MG, 300 MG 7 Anti-infective Misc. - Combinations (clindamycin hcl) (Sulfamethoxazole- CLEOCIN PEDIATRIC GRANULES SOLR Trimethoprim) SULFATRIM 1 7 PEDIATRIC SUSP (clindamycin palmitate hydrochloride)

14 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits clindamycin hcl caps 1 isosorbide mononitrate 1 tb24 clindamycin palmitate NITRO-BID OINT 3 2 hydrochloride solr (nitroglycerin) Oxazolidinones NITRO-DUR PT24 0.1 QL(1 ea daily) QL(210 ml per MG/HR, 0.2 MG/HR, 0.4 linezolid susr 100 1 7 mg/5ml 90 days retail) MG/HR, 0.6 MG/HR (nitroglycerin) 1 QL(20 ea per linezolid tabs 600 mg 90 days retail) NITRO-DUR PT24 0.3 QL(1 ea daily) MG/HR, 0.8 MG/HR SIVEXTRO TABS QL(6 ea per 90 2 2 ( ) (tedizolid phosphate) days retail) nitroglycerin QL(1 ea daily) ZYVOX SUSR 100 QL(210 ml per nitroglycerin pt24 td 0.1 7 MG/5ML (linezolid) 90 days retail) mg/hr, 0.2 mg/hr, 0.4 1 ZYVOX TABS 600 MG QL(20 ea per mg/hr, 0.6 mg/hr 7 (linezolid) 90 days retail) nitroglycerin soln tl 0.4 1 mg/spray ANTIANGINAL AGENTS - Drugs to Treat Chest Pain nitroglycerin subl sl 0.3 1 mg, 0.4 mg, 0.6 mg Antianginals-Other NITROLINGUAL RANEXA TB12 1000 MG 7 PUMPSPRAY SOLN 7 (ranolazine) (nitroglycerin) RANEXA TB12 500 MG QL(4 ea daily) NITROMIST AERS 7 3 (ranolazine) (nitroglycerin) ranolazine tb12 1000 NITROSTAT SUBL 3 7 mg (nitroglycerin) QL(4 ea daily) ranolazine tb12 500 mg 3 ANTIANXIETY AGENTS - Drugs to Treat Anxiety Nitrates Antianxiety Agents - Misc. (Nitroglycerin) MINITRAN 1 QL(1 ea daily) PT24 buspirone hcl tabs 1 DILATRATE SR CPCR 3 hydroxyzine hcl syrp 1 (isosorbide dinitrate) ISORDIL TITRADOSE hydroxyzine hcl tabs 1 TABS (isosorbide 7 dinitrate) hydroxyzine pamoate 1 ISOSORBIDE DINITRATE caps VISTARIL CAPS ER TBCR (isosorbide 2 7 dinitrate) (hydroxyzine pamoate) Benzodiazepines isosorbide dinitrate 1 tabs (Alprazolam) 3 ALPRAZOLAM XR TB24 isosorbide mononitrate 1 tabs (Diazepam) DIAZEPAM 1 INTENSOL CONC

15 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Lorazepam) LORAZEPAM VALIUM TABS 2 MG, 5 1 7 INTENSOL CONC MG (diazepam) ALPRAZOLAM INTENSOL XANAX TABS 3 7 CONC (alprazolam) (alprazolam) alprazolam tabs 0.25 XANAX XR TB24 7 mg, 0.5 mg, 1 mg, 2 1 (alprazolam) mg ANTIARRHYTHMICS - Drugs to treat abnormal alprazolam tb24 0.5 3 heart rhythms mg, 1 mg, 2 mg, 3 mg Antiarrhythmics Type I-A alprazolam tbdp 0.25 disopyramide 1 mg, 0.5 mg, 1 mg, 2 3 phosphate caps mg NORPACE CAPS ATIVAN TABS PA; Use (disopyramide 7 4 generic ) (lorazepam) lorazepam phosphate chlordiazepoxide hcl NORPACE CR CP12 1 (disopyramide 2 caps phosphate) clorazepate 1 dipotassium tabs quinidine gluconate tbcr 1 diazepam conc 5 QUINIDINE SULFATE 1 2 mg/ml TABS (quinidine sulfate) diazepam soln 5 1 Antiarrhythmics Type I-B mg/5ml mexiletine hcl caps 1 diazepam tabs 10 mg 1 QL(4 ea daily) Antiarrhythmics Type I-C diazepam tabs 2 mg, 5 1 mg flecainide acetate tabs 1 lorazepam conc 1 propafenone hcl cp12 225 mg, 325 mg, 425 1 lorazepam tabs 1 mg QL(6 ea daily) propafenone hcl tabs 1 oxazepam caps 10 mg, 1 15 mg 150 mg QL(3 ea daily) OXAZEPAM CAPS 10 MG, propafenone hcl tabs 2 1 15 MG (oxazepam) 225 mg, 300 mg OXAZEPAM CAPS 30 MG QL(2 ea daily) RYTHMOL SR CP12 2 7 (oxazepam) (propafenone hcl) TRANXENE T TABS Antiarrhythmics Type III (clorazepate 7 (Amiodarone Hcl) 1 dipotassium) PACERONE TABS VALIUM TABS 10 MG QL(4 ea daily) 7 amiodarone hcl tabs 1 (diazepam)

16 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CORDARONE TABS SPIRIVA RESPIMAT Limit 1 inhaler 7 (amiodarone hcl) AERS 2.5 MCG/ACT per (tiotropium bromide 2 month;QL(0.14 dofetilide caps 1 monohydrate) gm daily) MULTAQ TABS ST; Limit 1 2 TUDORZA PRESSAIR (dronedarone hcl) AEPB (aclidinium 3 inhaler per TIKOSYN CAPS month;QL(0.04 7 bromide) ea daily) (dofetilide) Leukotriene Modulators ANTIASTHMATIC AND BRONCHODILATOR QL(1 ea daily) AGENTS - Drugs to Treat Lung Conditions montelukast sodium 1 chew Anti-Inflammatory Agents QL(1 ea daily) montelukast sodium 1 cromolyn sodium nebu 1 pack CROMOLYN SODIUM QL(1 ea daily) montelukast sodium 1 NEBU (cromolyn 2 tabs sodium) SINGULAIR CHEW QL(1 ea daily) 7 Antiasthmatic - Monoclonal Antibodies (montelukast sodium) PA; Must use SINGULAIR PACK QL(1 ea daily) XOLAIR SOLR 150 MG 7 4 AcariaHlth Sp (montelukast sodium) (omalizumab) Rx 1-844-538- SINGULAIR TABS QL(1 ea daily) 4661 7 (montelukast sodium) XOLAIR SOSY 150 PA MG/ML, 75 MG/0.5ML 4 zileuton tb12 3 ST ( ) omalizumab ZYFLO CR TB12 ST 7 Bronchodilators - Anticholinergics (zileuton) Limit 2 inhalers ATROVENT HFA AERS ZYFLO TABS (zileuton) 3 ST ( 2 per ipratropium bromide month;QL(0.86 hfa) gm daily) Steroid Inhalants Limit 2 inhalers INCRUSE ELLIPTA AEPB QL(1 ea daily) ALVESCO AERS 2 3 per (umeclidinium bromide) (ciclesonide) month;QL(0.41 gm daily) ipratropium bromide 1 soln ARMONAIR RESPICLICK QL(0.04 ea SEEBRI NEOHALER ST; QL(2 ea 113 AEPB (fluticasone 3 daily) CAPS (glycopyrrolate 3 daily) propionate (inhalation)) (inhalation)) ARMONAIR RESPICLICK QL(0.04 ea SPIRIVA HANDIHALER QL(1 ea daily) 232 AEPB (fluticasone 3 daily) CAPS (tiotropium 2 propionate (inhalation)) bromide monohydrate) ARMONAIR RESPICLICK QL(0.04 ea SPIRIVA RESPIMAT Limit 1 Inhaler 55 AEPB (fluticasone 3 daily) AERS 1.25 MCG/ACT per propionate (inhalation)) (tiotropium bromide 2 month;QL(0.14 monohydrate) 3 gm daily)

17 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ARNUITY ELLIPTA AEPB QL(1 ea daily) FLOVENT DISKUS AEPB QL(40 ea daily) ( 50 MCG/BLIST fluticasone furoate 2 2 (inhalation)) (fluticasone propionate ASMANEX HFA AERO 100 QL(0.44 gm (inhalation)) MCG/ACT, 200 MCG/ACT daily) FLOVENT HFA AERO 110 Limit 2 inhalers ( 2 MCG/ACT, 220 MCG/ACT per mometasone furoate 2 (inhalation)) (fluticasone propionate month;QL(0.8 gm daily) ASMANEX HFA AERO 50 hfa) MCG/ACT (mometasone 2 FLOVENT HFA AERO 44 Limit 1 inhaler furoate (inhalation)) MCG/ACT ( 2 per fluticasone month;QL(0.36 ASMANEX TWISTHALER Limit 1 inhaler propionate hfa) gm daily) 120 METERED DOSES per PULMICORT FLEXHALER Limit 2 inhalers AEPB (mometasone 2 month;QL(0.04 ea daily) AEPB 180 MCG/ACT per furoate (inhalation)) (budesonide 2 month;QL(0.07 ASMANEX TWISTHALER Limit 1 inhaler (inhalation)) ea daily) 14 METERED DOSES per PULMICORT FLEXHALER Limit 2 inhalers AEPB (mometasone 2 month;QL(0.04 ea daily) AEPB 90 MCG/ACT per furoate (inhalation)) (budesonide 2 month;QL(0.27 ASMANEX TWISTHALER Limit 1 inhaler (inhalation)) ea daily) 30 METERED DOSES per PULMICORT SUSP 0.25 QL(8 ml daily) AEPB (mometasone 2 month;QL(0.04 MG/2ML (budesonide 7 furoate (inhalation)) ea daily) (inhalation)) ASMANEX TWISTHALER Limit 1 inhaler 60 METERED DOSES per PULMICORT SUSP 0.5 QL(4 ml daily) AEPB (mometasone 2 month;QL(0.04 MG/2ML (budesonide 7 furoate (inhalation)) ea daily) (inhalation)) ASMANEX TWISTHALER Limit 1 inhaler PULMICORT SUSP 1 QL(2 ml daily) 7 METERED DOSES per MG/2ML (budesonide 7 AEPB (mometasone 2 month;QL(0.04 (inhalation)) furoate (inhalation)) ea daily) QVAR REDIHALER AERB QL(0.72 gm QL(8 ml daily) (beclomethasone 2 daily) budesonide (inhalation) 1 susp 0.25 mg/2ml dipropionate hfa) QL(4 ml daily) Sympathomimetics budesonide (inhalation) 1 susp 0.5 mg/2ml (Fluticasone-Salmeterol) 1 QL(2 ea daily) budesonide (inhalation) QL(2 ml daily) WIXELA INHUB AEPB 1 ADVAIR DISKUS AEPB QL(2 ea daily) susp 1 mg/2ml 7 (fluticasone-salmeterol) FLOVENT DISKUS AEPB QL(20 ea daily) 100 MCG/BLIST Limit 1 inhaler 2 ADVAIR HFA AERO (fluticasone propionate 2 per (fluticasone-salmeterol) month;QL(0.4 (inhalation)) gm daily) FLOVENT DISKUS AEPB QL(8 ea daily) albuterol sulfate aers in QL(1.2 gm 250 MCG/BLIST 1 daily) (fluticasone propionate 2 108 mcg/act (inhalation)) 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic Preferred AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

18 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(0.57 gm albuterol sulfate aers in 1 metaproterenol sulfate 1 108 mcg/act daily) syrp QL(0.47 gm albuterol sulfate aers in 1 metaproterenol sulfate 1 108 mcg/act daily) tabs ALBUTEROL SULFATE QL(2 ea daily) Limit 2 inhalers PROAIR RESPICLICK ER TB12 (albuterol 2 3 per sulfate) AEPB (albuterol sulfate) month;QL(0.07 ea daily) albuterol sulfate nebu SEREVENT DISKUS QL(2 ea daily) in 0.63 mg/3ml, 0.083 1 AEPB (salmeterol 2 %, 0.5 %, 1.25 mg/3ml, xinafoate) 2.5 mg/0.5ml STIOLTO RESPIMAT QL(0.14 gm albuterol sulfate syrp or 1 AERS (tiotropium 2 daily) 2 mg/5ml bromide-olodaterol hcl) albuterol sulfate tabs or 1 Limit 1 inhaler 2 mg, 4 mg STRIVERDI RESPIMAT 2 per ANORO ELLIPTA AEPB QL(2 ea daily) AERS (olodaterol hcl) month;QL(0.14 (umeclidinium- 2 gm daily) vilanterol) SYMBICORT AERO Limit 1 inhaler ( 2 per ARCAPTA NEOHALER QL(1 ea daily) budesonide-formoterol month;QL(0.34 CAPS (indacaterol 3 fumarate dihydrate) gm daily) maleate) 1 BEVESPI AEROSPHERE QL(0.36 gm terbutaline sulfate tabs AERO (glycopyrrolate- 3 daily) TRELEGY ELLIPTA AEPB QL(2 ea daily) formoterol fumarate) (fluticasone- 2 BREO ELLIPTA AEPB QL(2 ea daily) umeclidinium-vilanterol) (fluticasone furoate- 2 UTIBRON NEOHALER QL(2 ea daily) vilanterol) CAPS (indacaterol 3 budesonide-formoterol Limit 1 inhaler maleate-glycopyrrolate) 2 per XOPENEX fumarate dihydrate month;QL(0.34 aero CONCENTRATE NEBU 7 gm daily) (levalbuterol hcl) COMBIVENT RESPIMAT Limit 1 inhaler XOPENEX NEBU 7 AERS ( 3 per ipratropium- month;QL(0.2 (levalbuterol hcl) albuterol) gm daily) Xanthines QL(2 ea daily) ELIXOPHYLLIN ELIX fluticasone-salmeterol 1 3 aepb (theophylline) THEO-24 CP24 ipratropium-albuterol 1 2 soln (theophylline) THEOPHYLLINE ER TB12 QL(1 ea daily) levalbuterol hcl nebu 1 3 300 MG (theophylline) levalbuterol tartrate QL(0.5 gm THEOPHYLLINE ER TB12 QL(1 ea daily) 1 2 aero daily) 450 MG (theophylline)

19 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ARIXTRA SOLN 5 QL(3 ml per 90 theophylline soln 80 3 mg/15ml MG/0.4ML (fondaparinux 7 days retail) sodium) theophylline tb12 100 1 mg, 200 mg enoxaparin sodium QL(42 ml per 7 1 days retail) QL(1 ea daily) soln ij 300 mg/3ml theophylline tb12 300 3 mg enoxaparin sodium QL(14 ml per 7 days retail) QL(1 ea daily) soln sc 100 mg/ml, 150 1 theophylline tb12 450 1 mg mg/ml QL(1 ea daily) enoxaparin sodium QL(4.2 ml per 7 theophylline tb24 400 1 1 days retail) mg, 600 mg soln sc 30 mg/0.3ml QL(5.6 ml per 7 enoxaparin sodium 1 ANTICOAGULANTS - Blood Thinners soln sc 40 mg/0.4ml days retail) Coumarin Anticoagulants QL(8.4 ml per 7 enoxaparin sodium 1 soln sc 60 mg/0.6ml days retail) (Warfarin Sodium) 1 JANTOVEN TABS enoxaparin sodium QL(11.2 ml per COUMADIN TABS 7 days retail) 7 soln sc 80 mg/0.8ml, 1 (warfarin sodium) 120 mg/0.8ml QL(6 ml per 90 warfarin sodium tabs 1 fondaparinux sodium 4 soln 10 mg/0.8ml days retail) Direct Factor Xa Inhibitors fondaparinux sodium QL(4 ml per 90 BEVYXXA CAPS QL(42 ea per 4 days retail) 3 42 days retail) soln 2.5 mg/0.5ml, 7.5 (betrixaban maleate) mg/0.6ml ELIQUIS STARTER PACK 2 fondaparinux sodium QL(3 ml per 90 TABS (apixaban) 4 soln 5 mg/0.4ml days retail) ELIQUIS TABS 2.5 MG QL(2 ea daily) 2 FRAGMIN SOLN 10000 QL(7 ml per 90 (apixaban) UNIT/ML (dalteparin 4 days retail) ELIQUIS TABS 5 MG 2 sodium) (apixaban) FRAGMIN SOLN 12500 QL(4 ml per 90 SAVAYSA TABS 3 UNIT/0.5ML, 15000 days retail) (edoxaban tosylate) UNIT/0.6ML (dalteparin 4 XARELTO TABS 10 MG, sodium) 15 MG, 2.5 MG 2 FRAGMIN SOLN 18000 QL(5 ml per 90 (rivaroxaban) UNT/0.72ML (dalteparin 4 days retail) XARELTO TABS 20 MG QL(1 ea daily) 2 sodium) ( ) rivaroxaban FRAGMIN SOLN 2500 QL(1 ml per 90 Heparins And Heparinoid-Like Agents UNIT/0.2ML, 5000 days retail) 4 ARIXTRA SOLN 10 QL(6 ml per 90 UNIT/0.2ML (dalteparin MG/0.8ML (fondaparinux 7 days retail) sodium) sodium) FRAGMIN SOLN 7500 QL(2 ml per 90 ARIXTRA SOLN 2.5 QL(4 ml per 90 UNIT/0.3ML (dalteparin 4 days retail) MG/0.5ML, 7.5 MG/0.6ML 7 days retail) sodium) (fondaparinux sodium)

20 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FRAGMIN SOLN 95000 PA clonazepam tbdp 0.125 UNIT/3.8ML (dalteparin 4 mg, 0.25 mg, 0.5 mg, 1 3 sodium) mg, 2 mg LOVENOX SOLN IJ 300 QL(42 ml per 7 DIASTAT ACUDIAL GEL Limit 4 per MG/3ML (enoxaparin 7 days retail) (diazepam 3 month;QL(0.14 sodium) (anticonvulsant)) ea daily) LOVENOX SOLN SC 100 QL(14 ml per 7 DIASTAT PEDIATRIC GEL Limit 4 per MG/ML, 150 MG/ML 7 days retail) (diazepam 3 month;QL(0.14 (enoxaparin sodium) (anticonvulsant)) ea daily) LOVENOX SOLN SC 30 QL(4.2 ml per 7 diazepam Limit 4 per MG/0.3ML (enoxaparin 7 days retail) 3 month;QL(0.14 sodium) (anticonvulsant) gel ea daily) LOVENOX SOLN SC 40 QL(5.6 ml per 7 DIAZEPAM RECTAL GEL Limit 4 per MG/0.4ML (enoxaparin 7 days retail) GEL (diazepam 3 month;QL(0.14 sodium) (anticonvulsant)) ea daily) LOVENOX SOLN SC 60 QL(8.4 ml per 7 KLONOPIN TABS 7 MG/0.6ML (enoxaparin 7 days retail) (clonazepam) sodium) NAYZILAM SOLN PA; QL(10 ea LOVENOX SOLN SC 80 QL(11.2 ml per (midazolam 4 per 30 days MG/0.8ML, 120 MG/0.8ML 7 7 days retail) (anticonvulsant)) retail) (enoxaparin sodium) ONFI SUSP 2.5 MG/ML 7 Thrombin Inhibitors (clobazam) IPRIVASK SOLR PA ONFI TABS 10 MG QL(1 ea daily) 4 7 (desirudin) (clobazam) ONFI TABS 20 MG QL(2 ea daily) PRADAXA CAPS 7 (dabigatran etexilate 3 (clobazam) mesylate) Anticonvulsants - Misc. ANTICONVULSANTS - Drugs to Treat Seizures (Carbamazepine) EPITOL 1 TABS AMPA Glutamate Receptor Antagonists (Lamotrigine) SUBVENITE ST FYCOMPA SUSP STARTER KIT/BLUE, 3 (perampanel) SUBVENITE STARTER 1 KIT/ORANGE, FYCOMPA TABS 3 SUBVENITE STARTER (perampanel) KIT/GREEN KIT Anticonvulsants - Benzodiazepines (Lamotrigine) SUBVENITE 1 TABS clobazam susp 2.5 3 mg/ml (Levetiracetam) QL(3 ea daily) ROWEEPRA TABS 1000 1 clobazam tabs 10 mg 3 QL(1 ea daily) MG QL(2 ea daily) (Levetiracetam) QL(6 ea daily) clobazam tabs 20 mg 3 ROWEEPRA TABS 500 1 MG, 750 MG clonazepam tabs 0.5 1 mg, 1 mg, 2 mg 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic Preferred AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

21 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Levetiracetam) QL(4 ea daily) DIACOMIT PACK 250 MG PA; QL(12 ea 1 4 ROWEEPRA XR TB24 (stiripentol) daily) APTIOM TABS PA; QL(1 ea DIACOMIT PACK 500 MG PA; QL(6 ea 4 (eslicarbazepine 3 daily) (stiripentol) daily) acetate) EPIDIOLEX SOLN PA; ST BANZEL SUSP 40 MG/ML 4 2 (cannabidiol) (rufinamide) 1 BANZEL TABS 200 MG gabapentin caps 2 (rufinamide) gabapentin soln 1 BANZEL TABS 400 MG QL(8 ea daily) 2 (rufinamide) gabapentin tabs 1 BRIVIACT SOLN 10 PA KEPPRA SOLN 100 3 7 MG/ML (brivaracetam) MG/ML (levetiracetam) BRIVIACT TABS 10 MG PA; ST KEPPRA TABS 1000 MG QL(3 ea daily) 3 7 (brivaracetam) (levetiracetam) BRIVIACT TABS 100 MG PA; QL(2 ea 3 KEPPRA TABS 250 MG, QL(6 ea daily) (brivaracetam) daily) 500 MG, 750 MG 7 BRIVIACT TABS 25 MG, PA (levetiracetam) 50 MG, 75 MG 3 KEPPRA XR TB24 QL(4 ea daily) 7 (brivaracetam) (levetiracetam) carbamazepine chew 1 LAMICTAL CHEWABLE 100 mg DISPERSIBLE CHEW 7 carbamazepine cp12 (lamotrigine) 1 LAMICTAL ODT KIT PA; ST 100 mg, 200 mg, 300 3 mg (lamotrigine) LAMICTAL ODT TBDP 25 PA carbamazepine susp 1 100 mg/5ml MG, 50 MG, 100 MG, 200 7 MG (lamotrigine) carbamazepine tabs 1 LAMICTAL STARTER/NOT ST 200 mg TAKING 7 carbamazepine tb12 1 CARBAMAZEPINE KIT 100 mg (lamotrigine) QL(8 ea daily) LAMICTAL ST carbamazepine tb12 1 200 mg STARTER/TAKING CARBAMAZEPINE/NOT QL(4 ea daily) 7 carbamazepine tb12 1 TAKING VALPROATE KIT 400 mg (lamotrigine) CARBATROL CP12 7 LAMICTAL ST (carbamazepine) STARTER/TAKING 7 DIACOMIT CAPS 250 MG PA; QL(12 ea VALPROATE KIT 4 (stiripentol) daily) (lamotrigine) DIACOMIT CAPS 500 MG PA; QL(6 ea LAMICTAL TABS 4 7 (stiripentol) daily) (lamotrigine)

22 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LAMICTAL XR KIT PA; ST LYRICA SOLN 20 MG/ML PA; QL(30 ml 3 7 (lamotrigine) (pregabalin) daily) LAMICTAL XR TB24 25 PA; QL(1 ea MYSOLINE TABS 7 MG, 50 MG, 100 MG, 200 7 daily) (primidone) MG (lamotrigine) NEURONTIN CAPS LAMICTAL XR TB24 250 PA 7 7 (gabapentin) MG (lamotrigine) NEURONTIN SOLN LAMICTAL XR TB24 300 PA; QL(2 ea 7 7 (gabapentin) MG (lamotrigine) daily) NEURONTIN TABS 7 lamotrigine chew 5 mg, 1 (gabapentin) 25 mg QL(40 ml daily) oxcarbazepine susp 60 1 lamotrigine kit 3 PA; ST mg/ml, 300 mg/5ml ST oxcarbazepine tabs 1 lamotrigine kit 25 mg, 1 150 mg QL(8 ea daily) lamotrigine tabs 25 mg, oxcarbazepine tabs 1 100 mg, 150 mg, 200 1 300 mg mg QL(4 ea daily) oxcarbazepine tabs 1 lamotrigine tb24 25 mg, PA; QL(1 ea 600 mg 50 mg, 100 mg, 200 3 daily) OXTELLAR XR TB24 150 ST mg MG, 300 MG 3 PA (oxcarbazepine) lamotrigine tb24 250 3 mg OXTELLAR XR TB24 600 ST; QL(4 ea 3 daily) PA; QL(2 ea MG (oxcarbazepine) lamotrigine tb24 300 3 mg daily) pregabalin caps 225 PA; ST;QL(2 3 ea daily) lamotrigine tbdp 25 mg, PA mg, 300 mg 50 mg, 100 mg, 200 3 pregabalin caps 25 mg, PA; ST;QL(3 mg 50 mg, 75 mg, 100 mg, 3 ea daily) 150 mg, 200 mg levetiracetam soln 100 1 mg/ml, 500 mg/5ml pregabalin soln 20 PA; QL(30 ml 3 daily) QL(3 ea daily) mg/ml levetiracetam tabs 1 1000 mg primidone tabs 1 QL(6 ea daily) levetiracetam tabs 250 1 QUDEXY XR CS24 100 PA; ST;QL(1 mg, 500 mg, 750 mg MG, 150 MG, 200 MG 3 ea daily) QL(4 ea daily) (topiramate) levetiracetam tb24 500 1 mg, 750 mg QUDEXY XR CS24 25 MG, PA; ST;QL(2 3 LYRICA CAPS 225 MG, PA; ST;QL(2 50 MG (topiramate) ea daily) 7 300 MG (pregabalin) ea daily) SPRITAM TB3D PA 3 LYRICA CAPS 25 MG, 50 PA; ST;QL(3 (levetiracetam) MG, 75 MG, 100 MG, 150 7 ea daily) TEGRETOL SUSP 7 MG, 200 MG (pregabalin) (carbamazepine)

23 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TEGRETOL TABS TROKENDI XR CP24 200 PA; QL(2 ea 7 3 (carbamazepine) MG (topiramate) daily) TEGRETOL-XR TB12 100 TROKENDI XR CP24 25 PA; ST 7 3 MG (carbamazepine) MG (topiramate) TEGRETOL-XR TB12 200 QL(8 ea daily) TROKENDI XR CP24 50 PA 7 3 MG (carbamazepine) MG, 100 MG (topiramate) TEGRETOL-XR TB12 400 QL(4 ea daily) VIMPAT SOLN 10 MG/ML QL(40 ml daily) 7 2 MG (carbamazepine) (lacosamide) TOPAMAX SPRINKLE VIMPAT TABS 50 MG, 100 7 CPSP (topiramate) MG, 150 MG, 200 MG 2 TOPAMAX TABS 100 MG QL(4 ea daily) (lacosamide) 7 ZONEGRAN CAPS 100 QL(6 ea daily) (topiramate) 7 TOPAMAX TABS 200 MG QL(2 ea daily) MG (zonisamide) 7 ZONEGRAN CAPS 25 MG (topiramate) 7 TOPAMAX TABS 25 MG (zonisamide) 7 QL(6 ea daily) (topiramate) zonisamide caps 100 1 TOPAMAX TABS 50 MG QL(8 ea daily) mg 7 (topiramate) zonisamide caps 25 1 mg, 50 mg topiramate cpsp 15 mg, 1 25 mg Carbamates TOPIRAMATE ER CS24 PA; ST;QL(1 1 100 MG, 150 MG, 200 MG 3 ea daily) felbamate susp (topiramate) felbamate tabs 1 TOPIRAMATE ER CS24 PA; ST;QL(2 FELBATOL SUSP 25 MG, 50 MG 3 ea daily) 7 (topiramate) (felbamate) FELBATOL TABS topiramate tabs 100 mg 1 QL(4 ea daily) 7 (felbamate) topiramate tabs 200 mg 1 QL(2 ea daily) GABA Modulators (Vigabatrin) VIGADRONE 4 QL(6 ea daily) topiramate tabs 25 mg 1 PACK GABITRIL TABS topiramate tabs 50 mg 1 QL(8 ea daily) 7 (tiagabine hcl) TRILEPTAL SUSP 300 QL(40 ml daily) SABRIL PACK QL(6 ea daily) 7 MG/5ML 7 (vigabatrin) (oxcarbazepine) SABRIL TABS TRILEPTAL TABS 150 MG 7 7 (vigabatrin) (oxcarbazepine) TRILEPTAL TABS 300 MG QL(8 ea daily) tiagabine hcl tabs 3 7 (oxcarbazepine) vigabatrin pack 4 QL(6 ea daily) TRILEPTAL TABS 600 MG QL(4 ea daily) 7 (oxcarbazepine) vigabatrin tabs 4

24 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Hydantoins DEPAKOTE SPRINKLES CSDR (divalproex 7 (Phenytoin) PHENYTOIN 1 INFATABS CHEW sodium) DEPAKOTE TBEC DILANTIN CAPS 100 MG 7 (phenytoin sodium 7 (divalproex sodium) extended) divalproex sodium csdr 1 DILANTIN CAPS 30 MG (phenytoin sodium 2 divalproex sodium tb24 1 extended) DILANTIN INFATABS divalproex sodium tbec 1 7 CHEW (phenytoin) valproate sodium soln 1 DILANTIN-125 SUSP 7 (phenytoin) valproic acid caps or 1 PEGANONE TABS 3 (ethotoin) ANTIDEPRESSANTS - Drugs to Treat Depression PHENYTEK CAPS (phenytoin sodium 7 Alpha-2 Receptor Antagonists (Tetracyclics) extended) mirtazapine tabs 1 1 phenytoin chew mirtazapine tbdp 1 phenytoin sodium REMERON SOLTAB TBDP 1 7 extended caps (mirtazapine) phenytoin susp 1 REMERON TABS 7 (mirtazapine) Succinimides CELONTIN CAPS Antidepressants - Misc. 2 (methsuximide) bupropion hcl tabs 75 1 mg, 100 mg ethosuximide caps 1 bupropion hcl tb12 100 1 ethosuximide soln 1 mg, 150 mg, 200 mg bupropion hcl tb24 150 QL(1 ea daily) ZARONTIN CAPS 1 7 mg, 300 mg (ethosuximide) BUPROPION ST; QL(1 ea ZARONTIN SOLN 7 HYDROCHLORIDE ER 3 daily) (ethosuximide) (XL) TB24 (bupropion hcl) Valproic Acid FORFIVO XL TB24 ST; QL(1 ea DEPAKENE CAPS 3 daily) 7 (bupropion hcl) (valproic acid) maprotiline hcl tabs 1 DEPAKENE SOLN 7 WELLBUTRIN SR TB12 (valproate sodium) 7 DEPAKOTE ER TB24 (bupropion hcl) 7 WELLBUTRIN XL TB24 QL(1 ea daily) (divalproex sodium) 7 (bupropion hcl)

25 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(1 ea daily) Monoamine Oxidase Inhibitors (MAOIs) fluoxetine hcl tabs 20 1 EMSAM PT24 QL(1 ea daily) mg 3 (selegiline) QL(1 ea daily) fluoxetine hcl tabs 60 3 MARPLAN TABS mg 3 (isocarboxazid) FLUOXETINE QL(1 ea daily) NARDIL TABS HYDROCHLORIDE TABS 7 7 (phenelzine sulfate) (fluoxetine hcl) QL(3 ea daily) PARNATE TABS fluvoxamine maleate 1 (tranylcypromine 7 cp24 100 mg sulfate) fluvoxamine maleate 1 phenelzine sulfate tabs 1 cp24 150 mg QL(3 ea daily) fluvoxamine maleate 1 tranylcypromine sulfate 1 tabs 100 mg tabs fluvoxamine maleate 1 Selective Serotonin Reuptake Inhibitors (SSRIs) tabs 25 mg, 50 mg CELEXA TABS QL(1 ea daily) LEXAPRO TABS 10 MG, QL(1 ea daily) (citalopram 7 20 MG (escitalopram 7 hydrobromide) oxalate) citalopram QL(20 ml daily) LEXAPRO TABS 5 MG QL(2 ea daily) 7 hydrobromide soln 10 3 (escitalopram oxalate) mg/5ml paroxetine hcl tabs 1 citalopram QL(1 ea daily) hydrobromide tabs 10 1 paroxetine hcl tb24 1 mg, 20 mg, 40 mg PAXIL CR TB24 7 escitalopram oxalate 1 (paroxetine hcl) soln 5 mg/5ml PAXIL SUSP 10 MG/5ML QL(1 ea daily) 2 escitalopram oxalate 1 (paroxetine hcl) tabs 10 mg, 20 mg PAXIL TABS 10 MG, 20 QL(2 ea daily) escitalopram oxalate 1 MG, 30 MG, 40 MG 7 tabs 5 mg (paroxetine hcl) FLUOXETINE DR CPDR PROZAC CAPS 10 MG, 20 3 7 (fluoxetine hcl) MG (fluoxetine hcl) PROZAC CAPS 40 MG QL(1 ea daily) fluoxetine hcl caps 10 1 7 mg, 20 mg (fluoxetine hcl) QL(1 ea daily) sertraline hcl conc 20 fluoxetine hcl caps 40 1 1 mg mg/ml QL(15 ml daily) sertraline hcl tabs 25 QL(2 ea daily) fluoxetine hcl soln 20 1 1 mg/5ml mg, 50 mg, 100 mg ZOLOFT CONC 20 MG/ML fluoxetine hcl tabs 10 1 7 mg (sertraline hcl)

26 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ZOLOFT TABS 25 MG, 50 QL(2 ea daily) FETZIMA TITRATION ST MG, 100 MG (sertraline 7 PACK C4PK 3 hcl) (levomilnacipran hcl) KHEDEZLA TB24 ST; QL(1 ea Serotonin Modulators 3 ( ) daily) NEFAZODONE HCL TABS desvenlafaxine 100 MG, 150 MG 3 PRISTIQ TB24 QL(1 ea daily) (nefazodone hcl) (desvenlafaxine 7 nefazodone hcl tabs 50 succinate) 3 QL(2 ea daily) mg, 250 mg venlafaxine hcl cp24 1 NEFAZODONE 150 mg HYDROCHLORIDE TABS 3 QL(1 ea daily) venlafaxine hcl cp24 75 1 (nefazodone hcl) mg, 37.5 mg trazodone hcl tabs 1 venlafaxine hcl tabs 25 mg, 50 mg, 75 mg, 100 1 TRINTELLIX TABS ST; QL(1 ea 3 mg, 37.5 mg (vortioxetine hbr) daily) venlafaxine hcl tb24 VIIBRYD STARTER PACK PA 1 3 225 mg KIT (vilazodone hcl) QL(1 ea daily) VIIBRYD TABS 10 MG, 40 ST venlafaxine hcl tb24 75 1 3 MG (vilazodone hcl) mg, 150 mg, 37.5 mg VIIBRYD TABS 20 MG ST; QL(2 ea Tricyclic Agents 3 (vilazodone hcl) daily) amitriptyline hcl tabs 1 Serotonin-Norepinephrine Reuptake Inhibitors AMOXAPINE TABS CYMBALTA CPEP QL(2 ea daily) 2 7 (amoxapine) (duloxetine hcl) ANAFRANIL CAPS 7 DESVENLAFAXINE ER ST; QL(1 ea (clomipramine hcl) TB24 50 MG, 100 MG 3 daily) (desvenlafaxine) clomipramine hcl caps 1 desvenlafaxine QL(1 ea daily) 1 desipramine hcl tabs 1 succinate tb24 QL(2 ea daily) doxepin hcl caps 10 duloxetine hcl cpep 20 1 mg, 30 mg, 60 mg mg, 25 mg, 50 mg, 75 1 EFFEXOR XR CP24 150 QL(2 ea daily) mg, 100 mg, 150 mg 7 DOXEPIN HCL CAPS 150 MG (venlafaxine hcl) 2 EFFEXOR XR CP24 75 QL(1 ea daily) MG (doxepin hcl) MG, 37.5 MG 7 doxepin hcl conc 10 1 (venlafaxine hcl) mg/ml FETZIMA CP24 20 MG ST; QL(2 ea 3 imipramine hcl tabs 10 1 (levomilnacipran hcl) daily) mg, 25 mg FETZIMA CP24 40 MG, 80 ST; QL(1 ea QL(4 ea daily) imipramine hcl tabs 50 1 MG, 120 MG 3 daily) mg (levomilnacipran hcl)

27 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DUETACT TABS imipramine pamoate 3 caps (pioglitazone hcl- 7 NORPRAMIN TABS glimepiride) 7 ( ) desipramine hcl glipizide-metformin hcl 1 nortriptyline hcl caps 10 tabs 1 GLUCOVANCE TABS mg, 25 mg, 50 mg, 75 7 mg (glyburide-metformin) glyburide-metformin nortriptyline hcl soln 10 1 1 mg/5ml tabs NORTRIPTYLINE HCL GLYXAMBI TABS SOLN 10 MG/5ML 2 (empagliflozin- 2 (nortriptyline hcl) linagliptin) PAMELOR CAPS INVOKAMET TABS 7 (nortriptyline hcl) (canagliflozin- 2 metformin hcl) protriptyline hcl tabs 3 INVOKAMET XR TB24 SURMONTIL CAPS 7 (canagliflozin- 2 (trimipramine maleate) metformin hcl) TOFRANIL TABS 10 MG, 7 JANUMET TABS 50 MG- 25 MG (imipramine hcl) 1000 MG (sitagliptin- 2 TOFRANIL TABS 50 MG QL(4 ea daily) 7 metformin hcl) (imipramine hcl) JANUMET TABS 50 MG- QL(2 ea daily) trimipramine maleate 3 500 MG (sitagliptin- 2 caps metformin hcl) ANTIDIABETICS - Drugs to Regulate Blood JANUMET XR TB24 100 QL(1 ea daily) Sugar MG-1000 MG (sitagliptin- 2 Alpha-Glucosidase Inhibitors metformin hcl) JANUMET XR TB24 50 QL(2 ea daily) acarbose tabs 1 MG-500 MG, 50 MG-1000 MG (sitagliptin- 2 7 GLYSET TABS (miglitol) metformin hcl) miglitol tabs 3 pioglitazone hcl- 1 glimepiride tabs PRECOSE TABS 7 (acarbose) pioglitazone hcl- 1 metformin hcl tabs Antidiabetic Combinations REPAGLINIDE/METFORM ACTOPLUS MET TABS IN HYDROCHLORIDE (pioglitazone hcl- 7 TABS (repaglinide- 3 metformin hcl) metformin hcl) ACTOPLUS MET XR TB24 SEGLUROMET TABS (pioglitazone hcl- 3 (ertugliflozin-metformin 3 metformin hcl) hcl)

28 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SYNJARDY TABS GLUCAGON PA; QL(1 ea (empagliflozin- 2 EMERGENCY KIT KIT 4 per fill retail,2 metformin hcl) ea per 30 days (glucagon (rdna)) retail) SYNJARDY XR TB24 GVOKE PFS SOSY PA; QL(0..4 ml (empagliflozin- 2 4 per 30 days metformin hcl) (glucagon) retail) XIGDUO XR TB24 10 MG- QL(1 ea daily) PROGLYCEM SUSP 7 500 MG, 10 MG-1000 MG (diazoxide) (dapagliflozin- 3 metformin hcl) Dipeptidyl Peptidase-4 (DPP-4) Inhibitors JANUVIA TABS 25 MG XIGDUO XR TB24 5 MG- QL(2 ea daily) 2 500 MG, 5 MG-1000 MG, (sitagliptin phosphate) 2.5 MG-1000 MG 3 JANUVIA TABS 50 MG, QL(1 ea daily) (dapagliflozin- 100 MG (sitagliptin 2 metformin hcl) phosphate) Biguanides Incretin Mimetic Agents (GLP-1 Receptor GLUCOPHAGE TABS OZEMPIC SOPN PA 7 2 (metformin hcl) (semaglutide) GLUCOPHAGE XR TB24 PA; Not 7 TRULICITY SOPN (metformin hcl) 2 available (dulaglutide) through mail metformin hcl soln 500 3 order mg/5ml PA; Not metformin hcl tabs 500 VICTOZA SOPN 1 2 available mg, 850 mg, 1000 mg (liraglutide) through mail order metformin hcl tb24 500 1 mg, 750 mg Insulin Sensitizing Agents RIOMET SOLN ACTOS TABS 15 MG 7 7 (metformin hcl) (pioglitazone hcl) ACTOS TABS 30 MG, 45 QL(1 ea daily) Diabetic Other 7 PA; QL(2 ea MG (pioglitazone hcl) BAQSIMI ONE PACK AVANDIA TABS 4 per 30 days 2 POWD (glucagon) retail) (rosiglitazone maleate) PA; QL(2 ea BAQSIMI TWO PACK pioglitazone hcl tabs 15 1 4 per 30 days mg POWD (glucagon) retail) QL(1 ea daily) pioglitazone hcl tabs 30 1 diazoxide susp 3 mg, 45 mg Limit 1 per fill, 2 Insulin GLUCAGEN HYPOKIT per HUMALOG JUNIOR Limit 45mls per SOLR (glucagon hcl 4 month;QL(0.07 KWIKPEN SOPN (insulin 2 month;QL(1.5 (rdna)) ea daily,1 ea ml daily) per fill retail) lispro)

29 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits HUMALOG KWIKPEN Limit 45mls per HUMULIN R SOLN Limit 40mls per SOPN 100 UNIT/ML 2 month;QL(1.5 (insulin regular 2 month;QL(1.34 (insulin lispro) ml daily) (human)) ml daily) HUMALOG KWIKPEN Limit 24mls per HUMULIN R U-500 QL(1.34 ml SOPN 200 UNIT/ML 2 month;QL(0.8 daily) (CONCENTRATED) 2 (insulin lispro) ml daily) SOLN (insulin regular HUMALOG MIX 50/50 Limit 45mls per (human)) KWIKPEN SUPN (insulin month;QL(1.5 HUMULIN R U-500 Limit 40mls per 2 lispro protamine & ml daily) KWIKPEN SOPN (insulin 2 month;QL(1.34 lispro) regular (human)) ml daily) HUMALOG MIX 50/50 Limit 45mls per INSULIN LISPRO Limit 45mls per SUSP (insulin lispro 2 month;QL(1.5 PROTAMINE/INSULIN month;QL(1.5 protamine & lispro) ml daily) LISPRO KWIKPEN SUPN 2 ml daily) ( HUMALOG MIX 75/25 Limit 45mls per insulin lispro protamine ) KWIKPEN SUPN (insulin month;QL(1.5 & lispro 2 lispro protamine & ml daily) LANTUS SOLN (insulin Limit 45mls per 2 month;QL(1.5 lispro) glargine) ml daily) HUMALOG MIX 75/25 Limit 40mls per LANTUS SOLOSTAR Limit 45mls per SUSP (insulin lispro 2 month;QL(1.34 2 month;QL(1.5 protamine & lispro) ml daily) SOPN (insulin glargine) ml daily) HUMALOG SOCT Limit 45mls per Limit 45mls per 2 month;QL(1.5 LEVEMIR FLEXTOUCH month;QL(1.5 (insulin lispro) 2 ml daily) SOPN (insulin detemir) ml daily,135 ml per fill mail) HUMALOG SOLN (insulin Limit 45mls per 2 month;QL(1.5 Limit 45mls per lispro) ml daily) LEVEMIR SOLN ( insulin 2 month;QL(1.5 HUMULIN 70/30 KWIKPEN Limit 45mls per detemir) ml daily,135 ml SUPN (insulin nph month;QL(1.5 per fill mail) isophane & reg 2 ml daily) NOVOLIN N FLEXPEN Limit 45mls per (human)) RELION SUPN (insulin 2 month;QL(1.5 ml daily) HUMULIN 70/30 SUSP Limit 40mls per nph (human) (isophane)) (insulin nph isophane & 2 month;QL(1.34 NOVOLIN N FLEXPEN Limit 45mls per reg (human)) ml daily) SUPN (insulin nph 2 month;QL(1.5 ml daily) HUMULIN N KWIKPEN Limit 45mls per (human) (isophane)) SUPN (insulin nph 2 month;QL(1.5 Limit 2 pens TOUJEO MAX SOLOSTAR (human) (isophane)) ml daily) 2 per SOPN (insulin glargine) month;QL(0.2 HUMULIN N SUSP Limit 40mls per ml daily) month;QL(1.34 (insulin nph (human) 2 Limit 3 pens (isophane)) ml daily) TOUJEO SOLOSTAR 2 per HUMULIN R SOLN Limit 45mls per SOPN (insulin glargine) month;QL(0.15 (insulin regular 2 month;QL(1.5 ml daily) (human)) ml daily) TRESIBA FLEXTOUCH Limit 45mls per SOPN 100 UNIT/ML 2 month;QL(1.5 (insulin degludec) ml daily)

30 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limited to 27 GLUCOTROL XL TB24 7 TRESIBA FLEXTOUCH mls /month (glipizide) SOPN 200 UNIT/ML 2 without prior (insulin degludec) authorization;Q glyburide micronized 1 L(0.9 ml daily) tabs TRESIBA SOLN ( insulin 2 glyburide tabs 1 degludec) GLYNASE TABS 7 Meglitinide Analogues (glyburide micronized) TOLAZAMIDE TABS 250 nateglinide tabs 1 2 MG (tolazamide) PRANDIN TABS 7 (repaglinide) tolazamide tabs 500 1 mg repaglinide tabs 1 tolbutamide tabs 1 STARLIX TABS 7 (nateglinide) ANTIDIARRHEAL/PROBIOTIC AGENTS - Drugs to Treat Diarrhea Sodium-Glucose Co-Transporter 2 (SGLT2) FARXIGA TABS Antidiarrheal - Chloride Channel Antagonists (dapagliflozin 3 MYTESI TBEC PA; QL(2 ea 3 daily) propanediol) (crofelemer) INVOKANA TABS 100 MG Antiperistaltic Agents 2 (canagliflozin) (Loperamide Hcl) ANTI- RX/OTC INVOKANA TABS 300 MG QL(1 ea daily) DIARRHEAL, TGT 2 ( ) LOPERAMIDE HCL, SM canagliflozin ANTI-DIARRHEAL, RA JARDIANCE TABS QL(1 ea daily) 2 ANTI-DIARRHEAL, QC (empagliflozin) ANTI-DIARRHEAL, HM 3 STEGLATRO TABS LOPERAMIDE HCL, HM (ertugliflozin l- 3 ANTI-DIARRHEAL, GNP ANTI-DIARRHEAL, EQ pyroglutamic acid) ANTI-DIARRHEAL, CVS Sulfonylureas ANTI-DIARRHEAL CAPS (Glipizide) GLIPIZIDE XL 1 diphenoxylate w/ 1 TB24 atropine liqd AMARYL TABS 7 diphenoxylate w/ 1 (glimepiride) atropine tabs 1 IMODIUM A-D CAPS RX/OTC chlorpropamide tabs 7 (loperamide hcl) glimepiride tabs 1 LOMOTIL TABS (diphenoxylate w/ 7 1 glipizide tabs atropine) glipizide tb24 1 loperamide hcl caps 3 RX/OTC GLUCOTROL TABS 7 3 QL(2.4 ml (glipizide) opium tincture tinc daily)

31 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PAREGORIC TINC PA; ST; Limit 2 3 (paregoric) 3 tablets per granisetron hcl tabs day;QL(2 ea ANTIDOTES AND SPECIFIC ANTAGONISTS daily) ondansetron hcl soln 4 Limit 50mls per Antidotes - Chelating Agents 1 month;QL(1.67 CHEMET CAPS mg/5ml 3 ml daily) (succimer) ondansetron hcl tabs 4 QL(20 ea per PA 1 fill retail) deferasirox tabs 90 mg, 4 mg, 8 mg 180 mg, 360 mg ondansetron tbdp 1 QL(20 ea per FERRIPROX SOLN 100 Not available fill retail) 4 through mail MG/ML (deferiprone) PA; ST;QL(1 order SANCUSO PTCH 3 ea per 21 days FERRIPROX TABS 500 ( ) retail,3 ea per 4 granisetron MG (deferiprone) 90 days mail) JADENU SPRINKLE PACK PA; LA ZOFRAN ODT TBDP QL(20 ea per 4 7 (deferasirox) (ondansetron) fill retail) JADENU TABS PA Limit 50mls per 7 ZOFRAN SOLN 4 MG/5ML (deferasirox) 7 month;QL(1.67 (ondansetron hcl) ml daily) Antidotes and Specific Antagonists ZOFRAN TABS 4 MG, 8 QL(20 ea per 7 ANDEXXA SOLR PA MG (ondansetron hcl) fill retail) (coagulation factor xa recomb inact-zhzo 4 Antiemetics - Anticholinergic (andexanet alfa)) scopolamine pt72 3 CETYLEV TBEF PA TIGAN CAPS (acetylcysteine 4 (trimethobenzamide 7 (antidote)) hcl) VISTOGARD PACK TRANSDERM SCOP PT72 7 (uridine triacetate 4 (scopolamine) ) (emergency treatment) TRANSDERM-SCOP PT72 7 Opioid Antagonists (scopolamine) naloxone hcl sosy 1 trimethobenzamide hcl 1 caps 1 naltrexone hcl tabs Antiemetics - Miscellaneous NARCAN LIQD QL(4 ea per 30 QL(2 ea per 28 2 AKYNZEO CAPS (naloxone hcl) days retail) (netupitant- 3 days retail) ANTIEMETICS - Drugs to Treat Nausea and palonosetron) Vomiting CESAMET CAPS PA; ST;QL(2 3 ea daily) 5-HT3 Receptor Antagonists (nabilone) ANZEMET TABS PA; ST;QL(2 DICLEGIS TBEC QL(4 ea daily) 3 7 (dolasetron mesylate) ea per fill retail) (doxylamine-pyridoxine) QL(4 ea daily) doxylamine-pyridoxine 3 tbec 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic Preferred AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

32 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits dronabinol caps 2.5 mg 3 PA; ST GRIS-PEG TABS (griseofulvin 7 PA dronabinol caps 5 mg, 3 ultramicrosize) 10 mg griseofulvin microsize MARINOL CAPS 2.5 MG PA; ST 1 7 susp (dronabinol) griseofulvin microsize MARINOL CAPS 5 MG, 10 PA 1 7 tabs MG (dronabinol) griseofulvin 1 Substance P/Neurokinin 1 (NK1) Receptor ultramicrosize tabs Limit 3 per aprepitant caps 3 month;QL(0.1 nystatin tabs 1 ea daily) QL(1 ea Limit 2 per terbinafine hcl tabs 1 daily,90 ea per aprepitant caps 40 mg 3 month;QL(0.07 365 days retail) ea daily) Imidazole-Related Antifungals aprepitant caps 80 mg, QL(1 ea per fill 3 retail,1 ea per CRESEMBA CAPS Not available 125 mg 30 days retail) (isavuconazonium 3 through mail sulfate) order EMEND CAPS 40 MG Limit 2 per 7 month;QL(0.07 DIFLUCAN SUSR (aprepitant) 7 ea daily) (fluconazole) QL(1 ea per fill DIFLUCAN TABS EMEND CAPS 80 MG, 125 7 7 retail,1 ea per (fluconazole) MG (aprepitant) 30 days retail) EMEND SUSR 125 MG QL(1 ea per 30 fluconazole susr 1 3 (aprepitant) days retail) fluconazole tabs 1 EMEND TRIPACK CAPS Limit 3 per 7 month;QL(0.1 PA; ST (aprepitant) itraconazole caps 100 1 ea daily) mg VARUBI TBPK QL(4 ea per fill PA 3 retail) itraconazole soln 10 1 (rolapitant hcl) mg/ml ANTIFUNGALS - Drugs to Treat Fungal Infections ketoconazole tabs 1 Antifungals NOXAFIL SUSP 40 MG/ML 3 (Nystatin) BIO-STATIN 3 (posaconazole) POWD NOXAFIL TBEC 100 MG ANCOBON CAPS 7 7 (posaconazole) (flucytosine) BIO-STATIN CAPS 500000 posaconazole tbec 3 UNIT, 1000000 UNIT 3 SPORANOX CAPS 100 PA; ST 7 (nystatin) MG (itraconazole) 3 SPORANOX PULSEPAK PA; ST flucytosine caps 7 CAPS (itraconazole)

33 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SPORANOX SOLN 10 PA CLARINEX TABS 5 MG PA; ST;QL(1 7 7 MG/ML (itraconazole) (desloratadine) ea daily) TOLSURA CAPS PA DESLORATADINE ODT PA; ST 4 (itraconazole) TBDP 2.5 MG 3 VFEND SUSR 40 MG/ML (desloratadine) 7 (voriconazole) DESLORATADINE ODT PA VFEND TABS 50 MG, 200 QL(2 ea daily) TBDP 5 MG 3 7 MG (voriconazole) (desloratadine) desloratadine tabs 3 PA; ST;QL(1 voriconazole susr 40 1 ea daily) mg/ml Antihistamines - Phenothiazines QL(2 ea daily) voriconazole tabs 50 1 (Promethazine Hcl) 1 mg, 200 mg PHENADOZ SUPP ANTIHISTAMINES - Drugs to Treat Allergies (Promethazine Hcl) PROMETHEGAN SUPP 25 1 Antihistamines - Alkylamines MG, 12.5 MG BROMPHENIRAMINE promethazine hcl soln 1 TANNATE CHEW or 6.25 mg/5ml (brompheniramine 3 promethazine hcl supp tannate) 1 re 25 mg, 12.5 mg Antihistamines - Ethanolamines QL(3 ea daily) promethazine hcl supp 1 carbinoxamine maleate 1 re 50 mg soln 4 mg/5ml promethazine hcl syrp 1 CARBINOXAMINE or 6.25 mg/5ml MALEATE SOLN 4 2 MG/5ML (carbinoxamine promethazine hcl tabs 1 maleate) or 12.5 mg promethazine hcl tabs QL(6 ea daily) carbinoxamine maleate 3 1 tabs 4 mg or 25 mg QL(3 ea daily) CARBINOXAMINE promethazine hcl tabs 1 MALEATE TABS 4 MG, 6 or 50 mg 3 MG (carbinoxamine PROMETHEGAN SUPP 50 QL(3 ea daily) 2 maleate) MG (promethazine hcl) CLEMASTINE FUMARATE Antihistamines - Piperidines TABS (clemastine 2 fumarate) cyproheptadine hcl syrp 1 KARBINAL ER SUER cyproheptadine hcl tabs 1 (carbinoxamine 3 maleate) ANTIHYPERLIPIDEMICS - Drugs to Treat High RYVENT TABS Cholesterol (carbinoxamine 3 Antihyperlipidemics - Combinations maleate) QL(1 ea daily) ezetimibe-simvastatin 1 Antihistamines - Non-Sedating tabs

34 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VYTORIN TABS QL(1 ea daily) COLESTID TABS 7 7 (ezetimibe-simvastatin) (colestipol hcl) Antihyperlipidemics - Misc. colestipol hcl gran 5 gm 1 (Omega-3-Acid Ethyl 1 QL(4 ea daily) Esters) TRIKLO CAPS colestipol hcl pack 5 3 KYNAMRO SOSY PA; ST gm 4 (mipomersen sodium) colestipol hcl tabs 1 gm 1 QL(4 ea daily) LOVAZA CAPS (omega- QUESTRAN LIGHT POWD 7 7 3-acid ethyl esters) (cholestyramine light) omega-3-acid ethyl QL(4 ea daily) QUESTRAN PACK 1 7 esters caps (cholestyramine) VASCEPA CAPS 0.5 GM PA; ST QUESTRAN POWD 3 7 (icosapent ethyl) (cholestyramine) VASCEPA CAPS 1 GM PA WELCHOL PACK 3.75 GM QL(1 ea daily) 3 7 (icosapent ethyl) (colesevelam hcl) Bile Acid Sequestrants WELCHOL TABS 625 MG QL(7 ea daily) 7 (colesevelam hcl) (Cholestyramine Light) 3 PREVALITE PACK 4 GM Fibric Acid Derivatives (Cholestyramine Light) ANTARA CAPS PREVALITE POWD 4 1 3 GM/DOSE (fenofibrate micronized) choline fenofibrate cpdr QL(1 ea daily) cholestyramine light 3 1 pack 4 gm 135 mg choline fenofibrate cpdr cholestyramine light 1 1 powd 4 gm/dose 45 mg FENOFIBRATE CAPS 50 cholestyramine pack 4 3 3 gm MG, 150 MG (fenofibrate) fenofibrate micronized QL(1 ea daily) cholestyramine powd 4 1 1 gm/dose caps 130 mg, 200 mg QL(1 ea daily) fenofibrate micronized colesevelam hcl pack 3 3.75 gm caps 43 mg, 67 mg, 1 134 mg colesevelam hcl tabs QL(7 ea daily) 3 QL(1 ea daily) 625 mg fenofibrate tabs 145 1 mg, 160 mg COLESTID FLAVORED 7 FENOFIBRATE TABS 160 QL(1 ea daily) GRAN (colestipol hcl) 2 MG (fenofibrate) COLESTID FLAVORED 7 PACK (colestipol hcl) fenofibrate tabs 48 mg 1 COLESTID GRAN 7 QL(2 ea daily) (colestipol hcl) fenofibrate tabs 54 mg 1 COLESTID PACK FENOFIBRIC ACID TABS 7 3 (colestipol hcl) (fenofibric acid)

35 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FIBRICOR TABS 35 MG, $0 copay for 3 105 MG (fenofibric acid) Generic only, age 40 to gemfibrozil tabs 1 1 75;SL(2 ea lovastatin tabs 40 mg daily); AL(At LIPOFEN CAPS 3 least 40 yrs old (fenofibrate) - Up to 75 yrs LOPID TABS old); PV 7 (gemfibrozil) PRAVACHOL TABS 20 QL(1 ea daily) TRICOR TABS 145 MG QL(1 ea daily) MG, 80 MG (pravastatin 7 7 (fenofibrate) sodium) TRICOR TABS 48 MG PRAVACHOL TABS 40 QL(2 ea daily) 7 (fenofibrate) MG (pravastatin 7 TRIGLIDE TABS QL(1 ea daily) sodium) 2 (fenofibrate) QL(1 ea daily) pravastatin sodium tabs 1 TRILIPIX CPDR 135 MG QL(1 ea daily) 10 mg, 20 mg, 80 mg 7 (choline fenofibrate) QL(2 ea daily) pravastatin sodium tabs 1 TRILIPIX CPDR 45 MG 40 mg 7 (choline fenofibrate) QL(1 ea daily) rosuvastatin calcium 1 HMG CoA Reductase Inhibitors tabs QL(1 ea daily) simvastatin tabs 5 mg, QL(1 ea daily) atorvastatin calcium 1 tabs 10 mg, 20 mg, 40 mg, 1 CRESTOR TABS QL(1 ea daily) 80 mg 7 (rosuvastatin calcium) ZOCOR TABS QL(1 ea daily) 7 (simvastatin) fluvastatin sodium caps 1 QL(1 ea daily) Intestinal Cholesterol Absorption Inhibitors fluvastatin sodium tb24 1 QL(1 ea daily) ezetimibe tabs 1 LESCOL XL TB24 QL(1 ea daily) 7 (fluvastatin sodium) ZETIA TABS (ezetimibe) 7 LIPITOR TABS QL(1 ea daily) 7 Microsomal Triglyceride Transfer Protein (MTP) ) (atorvastatin calcium JUXTAPID CAPS 10 MG, PA $0 copay for 20 MG, 30 MG, 40 MG, 60 Generic only, MG (lomitapide 4 age 40 to lovastatin tabs 10 mg, 75;QL(1 ea mesylate) 1 JUXTAPID CAPS 5 MG PA; ST 20 mg daily); AL(At 4 least 40 yrs old (lomitapide mesylate) - Up to 75 yrs old); PV Nicotinic Acid Derivatives niacin (antihyperlipidemic) 1 tbcr NIACIN TABS ( niacin 3 (antihyperlipidemic))

36 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NIACOR TABS ( niacin 3 quinapril hcl tabs 1 (antihyperlipidemic)) QL(2 ea daily) NIASPAN TBCR ( ramipril caps 1 niacin 7 (antihyperlipidemic)) trandolapril tabs 1 Proprotein Convertase Subtilisin/Kexin Type 9 PRALUENT SOAJ PA VASOTEC TABS QL(2 ea daily) 4 7 (alirocumab) (enalapril maleate) ZESTRIL TABS 40 MG QL(2 ea daily) REPATHA PUSHTRONEX PA; ST 7 SYSTEM SOCT 4 (lisinopril) (evolocumab) ZESTRIL TABS 5 MG, 10 REPATHA SOSY PA; ST MG, 20 MG, 30 MG, 2.5 7 4 (evolocumab) MG (lisinopril) REPATHA SURECLICK PA; ST;LA Agents for Pheochromocytoma 4 DEMSER CAPS SOAJ (evolocumab) 3 ) ANTIHYPERTENSIVES - Drugs to Treat High (metyrosine Blood Pressure DIBENZYLINE CAPS Not available (phenoxybenzamine 7 through mail ACE Inhibitors hcl) ACCUPRIL TABS 7 Not available (quinapril hcl) phenoxybenzamine hcl 1 caps through mail ALTACE CAPS (ramipril) 7 QL(2 ea daily) Angiotensin II Receptor Antagonists ATACAND TABS 32 MG QL(1 ea daily) benazepril hcl tabs 1 7 (candesartan cilexetil) captopril tabs 1 ATACAND TABS 4 MG, 8 QL(2 ea daily) MG, 16 MG (candesartan 7 enalapril maleate tabs 1 cilexetil) AVAPRO TABS fosinopril sodium tabs 1 7 (irbesartan) lisinopril tabs 40 mg 1 QL(2 ea daily) BENICAR TABS 40 MG QL(1 ea daily) lisinopril tabs 5 mg, 10 (olmesartan 7 medoxomil) mg, 20 mg, 30 mg, 2.5 1 mg BENICAR TABS 5 MG, 20 MG (olmesartan 7 LOTENSIN TABS 7 medoxomil) (benazepril hcl) QL(1 ea daily) candesartan cilexetil 1 moexipril hcl tabs 1 tabs 32 mg candesartan cilexetil perindopril erbumine 1 1 tabs tabs 4 mg, 8 mg, 16 mg COZAAR TABS ( PRINIVIL TABS (lisinopril) 7 losartan 7 potassium) QBRELIS SOLN QL(5 ml daily) 3 (lisinopril)

37 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DIOVAN TABS 160 MG QL(2 ea daily) 7 methyldopa tabs 1 (valsartan) DIOVAN TABS 40 MG, 80 MINIPRESS CAPS 7 7 MG, 320 MG (valsartan) (prazosin hcl) EDARBI TABS 40 MG prazosin hcl caps 1 3 (azilsartan medoxomil) terazosin hcl caps 1 EDARBI TABS 80 MG QL(1 ea daily) 1 3 mg, 2 mg, 5 mg (azilsartan medoxomil) terazosin hcl caps 10 QL(2 ea daily) EPROSARTAN 1 MESYLATE TABS 2 mg (eprosartan mesylate) Antihypertensive Combinations 1 ACCURETIC TABS 10 irbesartan tabs MG-12.5 MG, 20 MG-12.5 losartan potassium MG (quinapril- 7 tabs or 25 mg, 50 mg, 1 hydrochlorothiazide) 100 mg ACCURETIC TABS 20 QL(1 ea daily) MICARDIS TABS 20 MG, MG-25 MG (quinapril- 7 7 40 MG (telmisartan) hydrochlorothiazide) MICARDIS TABS 80 MG QL(1 ea daily) amlodipine besylate- 7 (telmisartan) benazepril hcl caps 2.5 1 QL(1 ea daily) mg-10 mg olmesartan medoxomil 1 tabs 40 mg amlodipine besylate- QL(1 ea daily) benazepril hcl caps 5 olmesartan medoxomil 1 tabs 5 mg, 20 mg mg-10 mg, 5 mg-20 1 mg, 5 mg-40 mg, 10 telmisartan tabs 20 mg, 1 40 mg mg-20 mg, 10 mg-40 mg QL(1 ea daily) telmisartan tabs 80 mg 1 amlodipine besylate- QL(1 ea daily) valsartan tabs 160 mg- 1 valsartan tabs 160 mg 1 QL(2 ea daily) 10 mg valsartan tabs 40 mg, 1 amlodipine besylate- 80 mg, 320 mg valsartan tabs 160 mg- 1 Antiadrenergic Antihypertensives 5 mg, 320 mg-5 mg, CARDURA TABS 320 mg-10 mg 7 (doxazosin mesylate) amlodipine-valsartan- CATAPRES TABS hydrochlorothiazide 1 7 (clonidine hcl) tabs clonidine hcl tabs 1 ATACAND HCT TABS (candesartan cilexetil- 7 doxazosin mesylate 1 hydrochlorothiazide) tabs atenolol & 1 guanfacine hcl tabs 1 chlorthalidone tabs

38 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AVALIDE TABS enalapril maleate & (irbesartan- 7 hydrochlorothiazide 1 hydrochlorothiazide) tabs benazepril & EXFORGE HCT TABS hydrochlorothiazide 1 (amlodipine-valsartan- 7 tabs hydrochlorothiazide) BENICAR HCT TABS 20 EXFORGE TABS 160 MG- QL(1 ea daily) MG-12.5 MG (olmesartan 10 MG (amlodipine 7 7 medoxomil- besylate-valsartan) hydrochlorothiazide) EXFORGE TABS 160 MG- BENICAR HCT TABS 40 QL(1 ea daily) 5 MG, 320 MG-5 MG, 320 MG-25 MG, 40 MG-12.5 MG-10 MG (amlodipine 7 MG (olmesartan 7 besylate-valsartan) medoxomil- fosinopril sodium & hydrochlorothiazide) hydrochlorothiazide 1 bisoprolol & tabs hydrochlorothiazide 1 HYZAAR TABS (losartan tabs potassium & 7 BYVALSON TABS QL(1 ea daily) 3 hydrochlorothiazide) (nebivolol-valsartan) irbesartan- candesartan cilexetil- hydrochlorothiazide 1 hydrochlorothiazide 1 tabs tabs lisinopril & captopril & hydrochlorothiazide 1 hydrochlorothiazide 1 tabs 10 mg-12.5 mg, 20 tabs mg-12.5 mg CORZIDE TABS 40 MG-5 lisinopril & QL(2 ea daily) MG (nadolol & 7 hydrochlorothiazide 1 bendroflumethiazide) tabs 20 mg-25 mg CORZIDE TABS 80 MG-5 LOPRESSOR HCT TABS MG (nadolol & 3 (metoprolol & 7 bendroflumethiazide) hydrochlorothiazide) DIOVAN HCT TABS 160 QL(1 ea daily) losartan potassium & MG-25 MG (valsartan- 7 hydrochlorothiazide 1 hydrochlorothiazide) tabs DIOVAN HCT TABS 320 LOTENSIN HCT TABS MG-25 MG, 80 MG-12.5 (benazepril & 7 MG, 160 MG-12.5 MG, 320 7 MG-12.5 MG (valsartan- hydrochlorothiazide) hydrochlorothiazide) LOTREL CAPS QL(1 ea daily) EDARBYCLOR TABS QL(1 ea daily) (amlodipine besylate- 7 (azilsartan medoxomil- 3 benazepril hcl) chlorthalidone)

39 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits methyldopa & TARKA TBCR hydrochlorothiazide 1 (trandolapril-verapamil 7 tabs hcl) metoprolol & TEKTURNA HCT TABS ST hydrochlorothiazide 1 (aliskiren- 3 tabs hydrochlorothiazide) METOPROLOL/HYDROCH telmisartan-amlodipine 1 LOROTHIAZIDE TABS tabs 2 (metoprolol & telmisartan- hydrochlorothiazide) hydrochlorothiazide 1 MICARDIS HCT TABS tabs (telmisartan- 7 TENORETIC 100 TABS hydrochlorothiazide) (atenolol & 7 moexipril- chlorthalidone) hydrochlorothiazide 1 TENORETIC 50 TABS tabs (atenolol & 7 NADOLOL/BENDROFLUM chlorthalidone) ETHIAZIDE TABS 3 trandolapril-verapamil 3 (nadolol & hcl tbcr bendroflumethiazide) TRANDOLAPRIL/VERAPA olmesartan medoxomil- ST MIL HCL ER TBCR 3 amlodipine- 1 (trandolapril-verapamil hydrochlorothiazide hcl) tabs TRIBENZOR TABS ST olmesartan medoxomil- (olmesartan hydrochlorothiazide 1 medoxomil-amlodipine- 7 tabs 20 mg-12.5 mg hydrochlorothiazide) olmesartan medoxomil- QL(1 ea daily) TWYNSTA TABS (telmisartan- 7 hydrochlorothiazide 1 tabs 40 mg-25 mg, 40 amlodipine) mg-12.5 mg valsartan- QL(1 ea daily) propranolol & hydrochlorothiazide 1 hydrochlorothiazide 1 tabs 160 mg-25 mg tabs valsartan- quinapril- hydrochlorothiazide tabs 320 mg-25 mg, 80 hydrochlorothiazide 1 1 tabs 10 mg-12.5 mg, mg-12.5 mg, 160 mg- 20 mg-12.5 mg 12.5 mg, 320 mg-12.5 quinapril- QL(1 ea daily) mg hydrochlorothiazide 1 VASERETIC TABS tabs 20 mg-25 mg (enalapril maleate & 7 hydrochlorothiazide)

40 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ZESTORETIC TABS 10 CHLOROQUINE MG-12.5 MG, 20 MG-12.5 PHOSPHATE TABS 500 MG (lisinopril & 7 MG (chloroquine 2 hydrochlorothiazide) phosphate) ZESTORETIC TABS 20 QL(2 ea daily) hydroxychloroquine 1 MG-25 MG (lisinopril & 7 sulfate tabs hydrochlorothiazide) KRINTAFEL TABS QL(2 ea per 30 2 ZIAC TABS ( ( ) days retail) bisoprolol & 7 tafenoquine succinate hydrochlorothiazide) MEFLOQUINE HCL TABS QL(6 ea per fill 2 Antihypertensives - Misc. (mefloquine hcl) retail) VECAMYL TABS PA PLAQUENIL TABS 4 (mecamylamine hcl) (hydroxychloroquine 7 sulfate) Direct Renin Inhibitors primaquine phosphate 1 aliskiren fumarate tabs 3 tabs Selective Aldosterone Receptor Antagonists PRIMAQUINE PHOSPHATE TABS 7 eplerenone tabs 1 (primaquine phosphate) INSPRA TABS QUALAQUIN CAPS PA; QL(2 ea 7 7 (eplerenone) (quinine sulfate) daily) Vasodilators 3 PA; QL(2 ea quinine sulfate caps daily) hydralazine hcl tabs 1 ANTIMYASTHENIC/CHOLINERGIC AGENTS 1 minoxidil tabs Antimyasthenic/Cholinergic Agents ANTIMALARIALS - Drugs to Treat Malaria FIRDAPSE TABS PA; ST (Parasitic Infections) (amifampridine 4 Antimalarial Combinations phosphate) GUANIDINE HCL TABS atovaquone-proguanil 3 2 hcl tabs (guanidine hcl) COARTEM TABS Limit 24 per MESTINON SOLN 60 PA (artemether- 2 month;QL(0.8 MG/5ML (pyridostigmine 7 lumefantrine) ea daily) bromide) MALARONE TABS MESTINON TABS 60 MG (atovaquone-proguanil 7 (pyridostigmine 7 hcl) bromide) MESTINON TIMESPAN Antimalarials TBCR (pyridostigmine 7 chloroquine phosphate 1 bromide) tabs 250 mg, 500 mg PA pyridostigmine bromide 4 soln 60 mg/5ml pyridostigmine bromide 1 tabs 60 mg 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic Preferred AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

41 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits pyridostigmine bromide 1 cyclophosphamide 1 tbcr 180 mg caps RUZURGI TABS PA; QL(10 ea GLEOSTINE CAPS AC 4 2 (amifampridine) daily) (lomustine) HEXALEN CAPS AC ANTIMYCOBACTERIAL AGENTS - Drugs to 2 Treat Tuberculosis (Bacterial Infections) (altretamine) LEUKERAN TABS AC Anti TB Combinations 2 RIFAMATE CAPS (chlorambucil) 2 (isoniazid & rifampin) melphalan tabs 1 AC RIFATER TABS MYLERAN TABS AC (isoniazid-rifampin w/ 3 2 (busulfan) pyrazinamide) TEMODAR CAPS AC 7 Antimycobacterial Agents (temozolomide) cycloserine caps 3 temozolomide caps 1 AC ethambutol hcl tabs 1 Antimetabolites AC isoniazid syrp 1 capecitabine tabs 4 AC isoniazid tabs 1 mercaptopurine tabs 1 MYAMBUTOL TABS methotrexate sodium 7 (ethambutol hcl) soln ij 25 mg/ml, 1 4 MYCOBUTIN CAPS gm/40ml, 50 mg/2ml, 7 (rifabutin) 250 mg/10ml PASER PACK METHOTREXATE 3 (aminosalicylic acid) SODIUM SOLN IJ 250 MG/10ML (methotrexate 4 PRIFTIN TABS 3 sodium) (rifapentine) AC methotrexate sodium 1 pyrazinamide tabs 1 tabs or 2.5 mg PURIXAN SUSP AC rifabutin caps 1 2 (mercaptopurine) 7 TABLOID TABS AC RIFADIN CAPS (rifampin) 2 (thioguanine) rifampin caps 1 TREXALL TABS AC 3 TRECATOR TABS (methotrexate sodium) 2 (ethionamide) XATMEP SOLN PA; AC 4 ANTINEOPLASTICS AND ADJUNCTIVE (methotrexate) XELODA TABS AC THERAPIES - Drugs to Treat Cancer 7 ) Alkylating Agents (capecitabine ALKERAN TABS AC Antineoplastic - BCL-2 Inhibitors 7 (melphalan) 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic Preferred AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

42 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VENCLEXTA STARTING PA; AC EMCYT CAPS AC PACK TBPK 4 (estramustine 2 (venetoclax) phosphate sodium) VENCLEXTA TABS 10 MG PA; QL(2 ea ERLEADA TABS PA; AC 4 4 (venetoclax) daily); AC (apalutamide) VENCLEXTA TABS 100 PA; QL(4 ea 4 exemestane tabs 1 AC MG (venetoclax) daily); AC VENCLEXTA TABS 50 MG PA; AC FARESTON TABS AC 4 7 (venetoclax) (toremifene citrate) FEMARA TABS AC Antineoplastic - Hedgehog Pathway Inhibitors 7 (letrozole) DAURISMO TABS PA 4 (glasdegib maleate) FENSOLVI KIT PA (leuprolide acetate (6 3 ERIVEDGE CAPS AC 4 month)) (vismodegib) AC ODOMZO CAPS AC flutamide caps 1 4 (sonidegib phosphate) letrozole tabs 1 AC Antineoplastic - Hormonal and Related Agents PA; New leuprolide acetate kit 3 PA commercial LYSODREN TABS AC abiraterone acetate 4 members to be 2 tabs referred to (mitotane) AcariaHealth;L AC A; AC megestrol acetate susp 1 1 QL(1 ea daily); megestrol acetate tabs 1 AC anastrozole tabs AC ARIMIDEX TABS QL(1 ea daily); NILANDRON TABS AC 7 7 (anastrozole) AC (nilutamide) AROMASIN TABS AC AC 7 nilutamide tabs 1 (exemestane) NUBEQA TABS PA 1 QL(1 ea daily); 4 bicalutamide tabs AC (darolutamide) CASODEX TABS QL(1 ea daily); SOLTAMOX SOLN PV; AC 7 5 (bicalutamide) AC (tamoxifen citrate) ELIGARD KIT ( PA tamoxifen citrate tabs 7 PV; AC leuprolide 3 acetate (3 month)) toremifene citrate tabs 1 AC ELIGARD KIT ( PA leuprolide 3 acetate (4 month)) PA; New PA commercial ELIGARD KIT (leuprolide XTANDI CAPS 3 4 members to be acetate (6 month)) (enzalutamide) referred to ELIGARD KIT ( PA AcariaHealth;A leuprolide 3 acetate) C YONSA TABS PA; AC 4 (abiraterone acetate)

43 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; New ALECENSA CAPS PA; AC 4 commercial (alectinib hcl) ZYTIGA TABS 250 MG 7 members to be PA; SP drug (abiraterone acetate) referred to ALUNBRIG TABS 30 MG refer to AcariaHealth;L 4 (brigatinib) Caremark SP A; AC Rx;AC ZYTIGA TABS 500 MG PA; LA; AC ALUNBRIG TABS 90 MG, PA; AC 4 4 (abiraterone acetate) 180 MG (brigatinib) Antineoplastic - Immunomodulators ALUNBRIG TBPK PA; AC POMALYST CAPS AC 4 4 (brigatinib) (pomalidomide) BALVERSA TABS PA; AC 4 Antineoplastic - XPO1 Inhibitors (erdafitinib) XPOVIO 100 MG ONCE PA BOSULIF TABS 100 MG, PA; LA; AC 4 WEEKLY TBPK 4 500 MG (bosutinib) (selinexor) BOSULIF TABS 400 MG PA; AC 4 XPOVIO 60 MG ONCE PA (bosutinib) WEEKLY TBPK 4 BRAFTOVI CAPS 50 MG PA; LA 4 (selinexor) (encorafenib) XPOVIO 80 MG ONCE PA BRAFTOVI CAPS 75 MG PA; LA; AC WEEKLY TBPK 4 4 (encorafenib) (selinexor) BRUKINSA CAPS PA; AC XPOVIO 80 MG TWICE PA 4 ( ) WEEKLY TBPK 4 zanubrutinib CABOMETYX TABS PA; AC (selinexor) 4 (cabozantinib s-malate) Antineoplastic Combinations CALQUENCE CAPS PA; AC KISQALI FEMARA 200 PA; AC 4 (acalabrutinib) DOSE TBPK (ribociclib 4 CAPRELSA TABS AC succinate-letrozole) 4 (vandetanib) KISQALI FEMARA 400 PA; AC COMETRIQ KIT PA; AC DOSE TBPK (ribociclib 4 4 succinate-letrozole) (cabozantinib s-malate) COPIKTRA CAPS PA; AC KISQALI FEMARA 600 PA; AC 4 DOSE TBPK (ribociclib 4 (duvelisib) COTELLIC TABS PA; AC succinate-letrozole) 4 LONSURF TABS PA; AC (cobimetinib fumarate) 4 (trifluridine-tipiracil) PA; New commercial Antineoplastic Enzyme Inhibitors erlotinib hcl tabs 4 members to be AFINITOR DISPERZ TBSO PA; AC referred to 4 (everolimus) AcariaHealth;L A; AC AFINITOR TABS 10 MG PA; AC 4 PA; AC (everolimus) everolimus tabs 4 AFINITOR TABS 5 MG, 2.5 PA; AC FARYDAK CAPS PA; AC 7 4 MG, 7.5 MG (everolimus) (panobinostat lactate) 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic Preferred AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

44 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GILOTRIF TABS ( PA; AC LENVIMA 24 MG DAILY PA; AC afatinib 4 dimaleate) DOSE CPPK (lenvatinib 4 GLEEVEC TABS ( AC mesylate) imatinib 7 mesylate) LENVIMA 8 MG DAILY PA; AC PA; Must use DOSE CPPK (lenvatinib 4 IBRANCE CAPS 75 MG, mesylate) 100 MG, 125 MG 4 AcariaHlth Sp Rx 1-844-538- LORBRENA TABS 100 MG PA; AC (palbociclib) 4 4661;LA; AC (lorlatinib) IBRANCE TABS 75 MG, PA LORBRENA TABS 25 MG PA 4 100 MG, 125 MG 4 (lorlatinib) (palbociclib) LYNPARZA CAPS 50 MG PA; AC ICLUSIG TABS PA; AC 4 4 (olaparib) (ponatinib hcl) PA; Refer to IDHIFA TABS PA; LA; AC LYNPARZA TABS 100 MG, 4 4 Accredo SP (enasidenib mesylate) 150 MG (olaparib) Rx;AC imatinib mesylate tabs 4 AC MEKINIST TABS PA; AC (trametinib dimethyl 4 IMBRUVICA CAPS 70 MG, PA; AC 4 sulfoxide) 140 MG (ibrutinib) MEKTOVI TABS PA; LA; AC 4 IMBRUVICA TABS 140 PA; QL(1 ea (binimetinib) MG, 280 MG, 420 MG, 560 4 daily); AC NERLYNX TABS PA; LA; AC MG (ibrutinib) 4 (neratinib maleate) PA; AC INLYTA TABS (axitinib) 4 PA; Must use NEXAVAR TABS INREBIC CAPS PA; AC 4 AcariaHlth Sp 4 (sorafenib tosylate) Rx 1-844-538- (fedratinib hcl) 4661;LA; AC IRESSA TABS (gefitinib) 4 AC PA; Limited to NINLARO CAPS 3 capsules per JAKAFI TABS ( AC 4 ruxolitinib 4 (ixazomib citrate) month;;QL(0.1 phosphate) ea daily); AC KISQALI TBPK ( PA; AC PIQRAY 200MG DAILY PA; AC ribociclib 4 4 succinate) DOSE TBPK (alpelisib) PIQRAY 250MG DAILY PA; AC LENVIMA 10 MG DAILY PA; AC 4 DOSE CPPK (lenvatinib 4 DOSE TBPK (alpelisib) mesylate) PIQRAY 300MG DAILY PA; AC 4 LENVIMA 14 MG DAILY PA; AC DOSE TBPK (alpelisib) DOSE CPPK (lenvatinib 4 ROZLYTREK CAPS PA; AC 4 mesylate) (entrectinib) LENVIMA 18 MG DAILY PA; AC RUBRACA TABS PA; AC 4 DOSE CPPK (lenvatinib 4 (rucaparib camsylate) mesylate) RYDAPT CAPS PA; AC 4 LENVIMA 20 MG DAILY PA; AC (midostaurin) DOSE CPPK (lenvatinib 4 SPRYCEL TABS 20 MG, PA; AC 4 mesylate) 50 MG, 70 MG (dasatinib) 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic Preferred AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

45 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; Must use XALKORI CAPS PA; AC 4 SPRYCEL TABS 80 MG, AcariaHealth (crizotinib) 100 MG, 140 MG 4 Specialty Rx at XOSPATA TABS PA; AC (dasatinib) 1-844-538- 4 4661;AC (gilteritinib fumarate) STIVARGA TABS PA; SP; AC ZEJULA CAPS (niraparib PA; AC 4 4 (regorafenib) tosylate) ZELBORAF TABS PA; AC PA; Must use 4 SUTENT CAPS ( ( ) sunitinib 4 AcariaHlth Sp vemurafenib malate) Rx 1-844-538- ZOLINZA CAPS PA; AC 4 4661;LA; AC (vorinostat) TAFINLAR CAPS PA; AC ZYDELIG TABS PA; AC 4 3 (dabrafenib mesylate) (idelalisib) TAGRISSO TABS PA; AC ZYKADIA CAPS PA; AC 4 4 (osimertinib mesylate) (ceritinib) TALZENNA CAPS PA; AC ZYKADIA TABS PA; AC 4 4 (talazoparib tosylate) (ceritinib) PA; New commercial Antineoplastics Misc. TARCEVA TABS members to be ACTIMMUNE SOLN PA 7 4 (erlotinib hcl) referred to (interferon gamma-1b) AcariaHealth;L ALFERON N SOLN PA A; AC 4 (interferon alfa-n3) TASIGNA CAPS ( PA; AC nilotinib 4 AC hcl) bexarotene caps 4 TIBSOVO TABS PA; AC HYDREA CAPS AC 4 7 (ivosidenib) (hydroxyurea) TURALIO CAPS PA; AC 4 hydroxyurea caps 1 AC (pexidartinib hcl) TYKERB TABS ( PA; AC INTRON A SOLN PA lapatinib 4 4 ditosylate) (interferon alfa-2b) VERZENIO TABS PA; AC INTRON A SOLR PA 4 4 (abemaciclib) (interferon alfa-2b) VITRAKVI CAPS 100 MG PA; AC MATULANE CAPS AC 4 4 (larotrectinib sulfate) (procarbazine hcl) VITRAKVI CAPS 25 MG PA SYLATRON KIT PA; Must use 4 ( 4 AcariaHlth Sp (larotrectinib sulfate) peginterferon alfa-2b Rx 1-844-538- VITRAKVI SOLN 20 PA (antineoplastic)) 4661;LA MG/ML (larotrectinib 4 TARGRETIN CAPS OR 75 AC 7 sulfate) MG (bexarotene) VIZIMPRO TABS PA; AC AC 4 tretinoin 1 (dacomitinib) (chemotherapy) caps VOTRIENT TABS PA; AC 4 Chemotherapy Rescue/Antidote Agents (pazopanib hcl)

46 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AC leucovorin calcium tabs 1 bromocriptine mesylate 1 tabs AC MESNEX TABS (mesna) 3 carbidopa-levodopa tabs 10 mg-100 mg, 25 Mitotic Inhibitors 1 mg-100 mg, 25 mg-250 ETOPOSIDE CAPS PA; AC 4 mg (etoposide) QL(8 ea daily) carbidopa-levodopa 1 Topoisomerase I Inhibitors tbcr 25 mg-100 mg HYCAMTIN CAPS AC 4 carbidopa-levodopa (topotecan hcl) 1 tbcr 50 mg-200 mg ANTIPARKINSON AND RELATED THERAPY carbidopa-levodopa AGENTS - Drugs to Treat Parkinson's Disease tbdp 10 mg-100 mg, 25 3 Antiparkinson Adjunctive Therapy mg-100 mg, 25 mg-250 carbidopa tabs 3 mg LODOSYN TABS carbidopa-levodopa- 1 7 (carbidopa) entacapone tabs MIRAPEX ER TB24 0.375 Antiparkinson Anticholinergics MG, 0.75 MG, 1.5 MG, 4.5 MG, 2.25 MG, 3.75 MG benztropine mesylate 1 7 tabs (pramipexole dihydrochloride) trihexyphenidyl hcl soln 1 MIRAPEX ER TB24 3 MG QL(1 ea daily) trihexyphenidyl hcl tabs 1 (pramipexole 7 dihydrochloride) Antiparkinson COMT Inhibitors MIRAPEX TABS 0.125 COMTAN TABS MG, 0.25 MG, 0.75 MG, 7 (entacapone) 0.5 MG (pramipexole 7 entacapone tabs 3 dihydrochloride) MIRAPEX TABS 1 MG QL(4 ea daily) TASMAR TABS 7 (pramipexole 7 (tolcapone) dihydrochloride) tolcapone tabs 3 MIRAPEX TABS 1.5 MG QL(3 ea daily) (pramipexole 7 Antiparkinson Dopaminergics dihydrochloride) amantadine hcl caps NEUPRO PT24 1 3 100 mg (rotigotine) amantadine hcl syrp 50 1 PARLODEL CAPS mg/5ml (bromocriptine 7 mesylate) amantadine hcl tabs 3 100 mg PARLODEL TABS (bromocriptine 7 bromocriptine mesylate 1 caps mesylate)

47 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits pramipexole RYTARY CPCR 36.25 MG- PA; QL(10 ea 145 MG, 48.75 MG-195 daily) dihydrochloride tabs 1 3 0.125 mg, 0.25 mg, MG, 61.25 MG-245 MG 0.75 mg, 0.5 mg (carbidopa-levodopa) pramipexole QL(4 ea daily) SINEMET CR TBCR 25 QL(8 ea daily) MG-100 MG (carbidopa- 7 dihydrochloride tabs 1 1 levodopa) mg SINEMET CR TBCR 50 QL(3 ea daily) pramipexole MG-200 MG (carbidopa- 7 1 dihydrochloride tabs levodopa) 1.5 mg SINEMET TABS 7 pramipexole (carbidopa-levodopa) dihydrochloride tb24 STALEVO 100 TABS 3 0.375 mg, 0.75 mg, 1.5 (carbidopa-levodopa- 2 mg, 4.5 mg, 2.25 mg, entacapone) 3.75 mg STALEVO 125 TABS pramipexole QL(1 ea daily) (carbidopa-levodopa- 2 dihydrochloride tb24 3 3 entacapone) mg STALEVO 150 TABS REQUIP TABS ( ropinirole 7 (carbidopa-levodopa- 2 hydrochloride) entacapone) REQUIP XL TB24 12 MG QL(2 ea daily) STALEVO 50 TABS (ropinirole 7 (carbidopa-levodopa- 2 hydrochloride) entacapone) REQUIP XL TB24 2 MG, 4 STALEVO 75 TABS MG, 6 MG, 8 MG 7 (carbidopa-levodopa- 2 (ropinirole entacapone) hydrochloride) ropinirole hydrochloride Antiparkinson Monoamine Oxidase Inhibitors AZILECT TABS tabs 0.25 mg, 0.5 mg, 1 1 7 mg, 2 mg, 3 mg, 4 mg, (rasagiline mesylate) ELDEPRYL CAPS QL(2 ea daily) 5 mg 7 (selegiline hcl) QL(2 ea daily) ropinirole hydrochloride 3 tb24 12 mg rasagiline mesylate 1 tabs ropinirole hydrochloride tb24 2 mg, 4 mg, 6 mg, 3 selegiline hcl caps 1 QL(2 ea daily) 8 mg 1 QL(2 ea daily) RYTARY CPCR 23.75 MG- PA; ST;QL(10 selegiline hcl tabs 95 MG (carbidopa- 3 ea daily) SELEGILINE HCL TABS QL(2 ea daily) 2 levodopa) (selegiline hcl) ZELAPAR TBDP 3 (selegiline hcl)

48 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ANTIPSYCHOTICS/ANTIMANIC AGENTS - (Risperidone) Drugs to Treat Mood Disorders RISPERIDONE M-TAB 1 TBDP Antimanic Agents INVEGA TB24 7 lithium carbonate caps 1 (paliperidone) 150 mg, 600 mg QL(6 ea daily) paliperidone tb24 3 lithium carbonate caps 1 RISPERDAL M-TAB TBDP 300 mg 7 lithium carbonate tabs (risperidone) 1 RISPERDAL SOLN 1 300 mg 7 MG/ML (risperidone) lithium carbonate tbcr 1 300 mg, 450 mg RISPERDAL TABS 0.25 MG, 0.5 MG, 1 MG, 2 MG, 7 LITHIUM SOLN (lithium) 2 4 MG (risperidone) LITHOBID TBCR ( RISPERDAL TABS 3 MG QL(2 ea daily) lithium 7 7 carbonate) (risperidone) RISPERIDONE ODT TBDP Antipsychotics - Misc. 3 (risperidone) EQUETRO CP12 (carbamazepine 3 risperidone soln 1 1 (antipsychotic)) mg/ml GEODON CAPS 20 MG, risperidone tabs 0.25 7 40 MG (ziprasidone hcl) mg, 0.5 mg, 1 mg, 2 1 GEODON CAPS 60 MG, QL(2 ea daily) mg, 4 mg 7 80 MG (ziprasidone hcl) risperidone tabs 3 mg 1 QL(2 ea daily) LATUDA TABS ST 3 risperidone tbdp 0.5 (lurasidone hcl) mg, 1 mg, 2 mg, 3 mg, 1 NUPLAZID CAPS 34 MG PA; QL(1 ea 4 4 mg (pimavanserin tartrate) daily) NUPLAZID TABS 10 MG PA; QL(1 ea Butyrophenones 4 (pimavanserin tartrate) daily) haloperidol lactate conc 1 NUPLAZID TABS 17 MG PA 4 (pimavanserin tartrate) haloperidol tabs 1 VRAYLAR CAPS QL(1 ea daily) 4 Dibenzapines (cariprazine hcl) CLOZAPINE ODT TBDP VRAYLAR CPPK QL(1 ea daily) 3 4 (clozapine) (cariprazine hcl) clozapine tabs 25 mg, 1 ziprasidone hcl caps 20 1 50 mg, 100 mg, 200 mg mg, 40 mg clozapine tbdp 25 mg, QL(2 ea daily) 3 ziprasidone hcl caps 60 1 100 mg mg, 80 mg CLOZARIL TABS 7 Benzisoxazoles (clozapine)

49 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FAZACLO TBDP 150 MG, VERSACLOZ SUSP QL(18 ml daily) 3 3 200 MG (clozapine) (clozapine) FAZACLO TBDP 25 MG, ZYPREXA TABS 15 MG, QL(1 ea daily) 7 100 MG, 12.5 MG 7 20 MG (olanzapine) (clozapine) ZYPREXA TABS 5 MG, 10 MG, 2.5 MG, 7.5 MG 7 loxapine succinate 1 caps (olanzapine) QL(1 ea daily) ZYPREXA ZYDIS TBDP olanzapine tabs 15 mg, 1 7 20 mg (olanzapine) Phenothiazines olanzapine tabs 5 mg, 1 10 mg, 2.5 mg, 7.5 mg (Prochlorperazine) 1 QL(2 ea daily) COMPRO SUPP olanzapine tbdp 5 mg, 3 10 mg, 15 mg, 20 mg chlorpromazine hcl tabs 1 QL(4 ea daily) quetiapine fumarate 1 FLUPHENAZINE HCL tabs 200 mg CONC 5 MG/ML 3 quetiapine fumarate (fluphenazine hcl) tabs 25 mg, 50 mg, 100 1 fluphenazine hcl elix 1 mg 2.5 mg/5ml QL(2 ea daily) quetiapine fumarate 1 fluphenazine hcl tabs 1 tabs 300 mg, 400 mg mg, 5 mg, 10 mg, 2.5 1 quetiapine fumarate PA mg tb24 150 mg, 200 mg, 3 FLUPHENAZINE HCL TABS 1 MG, 5 MG, 10 MG, 300 mg, 400 mg 2 PA; ST 2.5 MG (fluphenazine quetiapine fumarate 3 tb24 50 mg hcl) SAPHRIS SUBL perphenazine tabs 1 3 (asenapine maleate) prochlorperazine SEROQUEL TABS 200 MG QL(4 ea daily) 1 7 maleate tabs (quetiapine fumarate) QL(2 ea daily) SEROQUEL TABS 25 MG, prochlorperazine supp 1 50 MG, 100 MG 7 thioridazine hcl tabs 10 1 (quetiapine fumarate) mg, 25 mg, 100 mg SEROQUEL TABS 300 QL(2 ea daily) thioridazine hcl tabs 50 QL(4 ea daily) MG, 400 MG (quetiapine 7 1 mg fumarate) SEROQUEL XR TB24 150 PA trifluoperazine hcl tabs 1 MG, 200 MG, 300 MG, 400 MG (quetiapine 7 Quinolinone Derivatives ABILIFY TABS 15 MG QL(2 ea daily) fumarate) 7 SEROQUEL XR TB24 50 PA; ST (aripiprazole) MG (quetiapine 7 fumarate)

50 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ABILIFY TABS 2 MG, 5 BIKTARVY TABS MG, 10 MG, 30 MG 7 (bictegravir- (aripiprazole) emtricitabine-tenofovir 2 ABILIFY TABS 20 MG QL(1 ea daily) alafenamide fumarate) 7 (aripiprazole) CIMDUO TABS (lamivudine-tenofovir 2 aripiprazole soln 1 1 mg/ml disoproxil fumarate) QL(2 ea daily) COMBIVIR TABS aripiprazole tabs 15 mg 1 7 (lamivudine-zidovudine) aripiprazole tabs 2 mg, 1 COMPLERA TABS 5 mg, 10 mg, 30 mg (emtricitabine- 2 aripiprazole tabs 20 mg 1 QL(1 ea daily) rilpivirine-tenofovir disoproxil fumarate) aripiprazole tbdp 10 PA CRIXIVAN CAPS 3 2 mg, 15 mg (indinavir sulfate) REXULTI TABS 3 DELSTRIGO TABS (brexpiprazole) (doravirine-lamivudine- 2 Thioxanthenes tenofovir disoproxil fumarate) thiothixene caps 1 DESCOVY TABS ANTIVIRALS - Drugs to Treat Viral Infections (emtricitabine-tenofovir 2 alafenamide fumarate) Antiretrovirals DIDANOSINE CPDR 2 abacavir sulfate soln 1 (didanosine) DOVATO TABS abacavir sulfate tabs 1 (dolutegravir sodium- 2 abacavir sulfate- lamivudine) 1 EDURANT TABS lamivudine tabs 2 abacavir sulfate- (rilpivirine hcl) lamivudine-zidovudine 1 efavirenz caps 1 tabs APTIVUS CAPS efavirenz tabs 1 2 (tipranavir) EMTRIVA CAPS 2 APTIVUS SOLN (emtricitabine) 2 (tipranavir) EMTRIVA SOLN 2 atazanavir sulfate caps 1 (emtricitabine) EPIVIR SOLN 7 ATRIPLA TABS QL(1 ea daily) (lamivudine) (efavirenz- 2 EPIVIR TABS emtricitabine-tenofovir 7 (lamivudine) disoproxil fumarate)

51 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EPZICOM TABS LEXIVA SUSP 50 MG/ML (abacavir sulfate- 7 (fosamprenavir 2 lamivudine) calcium) EVOTAZ TABS LEXIVA TABS 700 MG (atazanavir sulfate- 2 (fosamprenavir 7 cobicistat) calcium) fosamprenavir calcium 1 lopinavir-ritonavir soln 1 tabs NEVIRAPINE ER TB24 FUZEON SOLR PA; ST 2 4 ( ) (enfuvirtide) nevirapine GENVOYA TABS nevirapine susp 1 (elvitegravir-cobicistat- emtricitabine-tenofovir 2 nevirapine tabs 1 alafenamide) nevirapine tb24 1 INTELENCE TABS 2 NORVIR CAPS 100 MG (etravirine) 2 INVIRASE CAPS (ritonavir) 2 NORVIR PACK 100 MG (saquinavir mesylate) 2 INVIRASE TABS (ritonavir) 2 NORVIR SOLN 80 MG/ML (saquinavir mesylate) 2 ISENTRESS CHEW (ritonavir) 2 NORVIR TABS 100 MG (raltegravir potassium) 7 ISENTRESS HD TABS (ritonavir) 2 PIFELTRO TABS (raltegravir potassium) 2 ISENTRESS TABS (doravirine) 2 PREZCOBIX TABS QL(1 ea daily) (raltegravir potassium) 2 JULUCA TABS (darunavir-cobicistat) (dolutegravir sodium- 2 PREZISTA SUSP 100 rilpivirine hcl) MG/ML (darunavir 3 KALETRA SOLN 400 ethanolate) MG/5ML-100 MG/5ML 7 PREZISTA TABS 75 MG, (lopinavir-ritonavir) 150 MG, 600 MG, 800 MG 2 KALETRA TABS 100 MG- (darunavir ethanolate) 25 MG, 200 MG-50 MG RESCRIPTOR TABS 2 2 (lopinavir-ritonavir) (delavirdine mesylate) RETROVIR CAPS lamivudine soln 1 7 (zidovudine) 1 RETROVIR SYRP lamivudine tabs 7 (zidovudine) lamivudine-zidovudine 1 REYATAZ CAPS 150 MG, tabs 200 MG, 300 MG 7 (atazanavir sulfate)

52 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits REYATAZ PACK 50 MG VIDEX EC CPDR 200 MG, 2 (atazanavir sulfate) 250 MG, 400 MG 7 (didanosine) ritonavir tabs 1 VIDEXPEDIATRIC SOLR 2 SELZENTRY SOLN ( ) 2 didanosine (maraviroc) VIRACEPT TABS 2 SELZENTRY TABS ( ) 2 nelfinavir mesylate (maraviroc) VIRAMUNE SUSP 7 stavudine caps 1 (nevirapine) VIRAMUNE TABS 7 STRIBILD TABS (nevirapine) (elvitegravir-cobicistat- 2 VIRAMUNE XR TB24 emtricitabine-tenofovir 7 (nevirapine) df) VIREAD POWD 40 MG/GM SUSTIVA CAPS 7 (tenofovir disoproxil 2 (efavirenz) fumarate) SUSTIVA TABS 7 VIREAD TABS 150 MG, (efavirenz) 200 MG, 250 MG SYMTUZA TABS QL(1 ea daily) (tenofovir disoproxil 2 (darunavir-cobicistat- 2 fumarate) emtricitabine-tenofovir VIREAD TABS 300 MG alafenamide) (tenofovir disoproxil 7 TEMIXYS TABS fumarate) (lamivudine-tenofovir 2 ZERIT CAPS 15 MG, 20 disoproxil fumarate) MG, 30 MG, 40 MG 7 ( ) tenofovir disoproxil 1 stavudine fumarate tabs ZERIT SOLR 1 MG/ML 2 TIVICAY TABS (stavudine) 2 (dolutegravir sodium) ZIAGEN SOLN ( abacavir 7 TRIUMEQ TABS sulfate) (abacavir-dolutegravir- 2 ZIAGEN TABS ( abacavir 7 lamivudine) sulfate) TRIZIVIR TABS (abacavir sulfate-lamivudine- 7 zidovudine caps 1 zidovudine) zidovudine syrp 1 TRUVADA TABS (emtricitabine-tenofovir 2 zidovudine tabs 1 disoproxil fumarate) CMV Agents TYBOST TABS 2 (cobicistat) VALCYTE SOLR 50 QL(21 ml daily) MG/ML (valganciclovir 7 VIDEX EC CPDR 125 MG 2 hcl) (didanosine)

53 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VALCYTE TABS 450 MG PA; Must use 7 (valganciclovir hcl) MAVYRET TABS AcariaHealth (glecaprevir- 3 Specialty Rx at valganciclovir hcl solr QL(21 ml daily) 1 pibrentasvir) 1-844-538- 50 mg/ml 4661;;LA valganciclovir hcl tabs 1 MODERIBA 1200 DOSE PA 450 mg PACK TBPK (ribavirin 2 Hepatitis Agents (hepatitis c)) PEGASYS PROCLICK PA (Ribavirin (Hepatitis C)) 1 PA MODERIBA TABS SOLN (peginterferon 4 (Ribavirin (Hepatitis C)) PA alfa-2a) RIBASPHERE TABS 200 1 PEGASYS SOLN PA 4 MG (peginterferon alfa-2a) 1 PEGINTRON KIT PA adefovir dipivoxil tabs 4 (peginterferon alfa-2b) BARACLUDE SOLN 0.05 PA 4 MG/ML (entecavir) RIBASPHERE RIBAPAK PA TBPK (ribavirin 2 BARACLUDE TABS 0.5 7 (hepatitis c)) MG, 1 MG (entecavir) PA ribavirin (hepatitis c) 1 entecavir tabs 1 tabs EPCLUSA TABS PA; LA SOFOSBUVIR/VELPATAS PA; LA 4 (sofosbuvir-velpatasvir) VIR TABS (sofosbuvir- 4 EPIVIR HBV SOLN 5 velpatasvir) MG/ML ( SOVALDI TABS 400 MG PA; LA lamivudine 3 4 (hbv)) (sofosbuvir) EPIVIR HBV TABS 100 VEMLIDY TABS ST; LA 7 MG (lamivudine (hbv)) (tenofovir alafenamide 4 PA; Must use fumarate) HARVONI TABS 200 MG- AcariaHealth VIEKIRA PAK TBPK PA; LA 45 MG, 400 MG-90 MG 3 Specialty Rx at (ombitasvir-paritaprevir- 4 (ledipasvir-sofosbuvir) 1-844-538- ritonavir-dasabuvir) 4661 PA; Must use HEPSERA TABS 7 VOSEVI TABS AcariaHealth (adefovir dipivoxil) (sofosbuvir-velpatasvir- 4 Specialty Rx at 3 voxilaprevir) 1-844-538- lamivudine (hbv) tabs 4661;LA PA; Must use ZEPATIER TABS PA; LA LEDIPASVIR/SOFOSBUVI 4 AcariaHealth (elbasvir-grazoprevir) R TABS (ledipasvir- 3 Specialty Rx at sofosbuvir) 1-844-538- Herpes Agents 4661 acyclovir caps 200 mg 1

acyclovir susp 200 1 mg/5ml

54 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits acyclovir tabs 400 mg 1 TAMIFLU CAPS 30 MG, 45 QL(10 ea per MG (oseltamivir 7 fill retail); AL(At acyclovir tabs 800 mg 1 QL(5 ea daily) phosphate) least 1 yrs old) TAMIFLU CAPS 75 MG 7 famciclovir tabs 1 (oseltamivir phosphate) SITAVIG TABS PA QL(75 ml 3 TAMIFLU SUSR 6 MG/ML (acyclovir) 7 daily,5 day(s) (oseltamivir phosphate) limit); AL(At QL(4 ea daily) valacyclovir hcl tabs 1 1 least 1 yrs old) gm, 1000 mg BETA BLOCKERS - Drugs to Treat High Blood QL(8 ea daily) valacyclovir hcl tabs 1 Pressure 500 mg Alpha-Beta Blockers VALTREX TABS 1 GM QL(4 ea daily) 7 carvedilol phosphate (valacyclovir hcl) 3 cp24 VALTREX TABS 500 MG QL(8 ea daily) 7 (valacyclovir hcl) carvedilol tabs 25 mg, 1 12.5 mg, 6.25 mg ZOVIRAX CAPS OR 200 7 QL(2 ea daily) MG (acyclovir) carvedilol tabs 3.125 1 ZOVIRAX SUSP OR 200 mg 7 COREG CR CP24 MG/5ML (acyclovir) 7 ZOVIRAX TABS OR 400 (carvedilol phosphate) 7 MG (acyclovir) COREG TABS 25 MG, 12.5 MG, 6.25 MG 7 ZOVIRAX TABS OR 800 QL(5 ea daily) 7 (carvedilol) MG (acyclovir) COREG TABS 3.125 MG QL(2 ea daily) 7 Influenza Agents (carvedilol) FLUMADINE TABS (rimantadine 7 labetalol hcl tabs 1 hydrochloride) Beta Blockers Cardio-Selective oseltamivir phosphate QL(10 ea per 1 fill retail); AL(At acebutolol hcl caps 1 caps or 30 mg, 45 mg least 1 yrs old) atenolol tabs 1 oseltamivir phosphate 1 caps or 75 mg betaxolol hcl tabs 1 QL(75 ml bisoprolol fumarate QL(1 ea daily) oseltamivir phosphate 1 daily,5 day(s) 1 susr or 6 mg/ml limit); AL(At tabs least 1 yrs old) BYSTOLIC TABS RELENZA DISKHALER QL(20 ea per 3 3 (nebivolol hcl) AEPB (zanamivir) fill retail) LOPRESSOR TABS 7 RIMANTADINE (metoprolol tartrate) HYDROCHLORIDE TABS metoprolol succinate (rimantadine 3 1 tb24 hydrochloride)

55 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits metoprolol tartrate tabs 1 CALCIUM CHANNEL BLOCKERS - Drugs to Treat High Blood Pressure TENORMIN TABS 7 (atenolol) Calcium Channel Blockers (Diltiazem Hcl Coated QL(1 ea daily) TOPROL XL TB24 7 Beads) CARTIA XT, 1 (metoprolol succinate) DILTIAZEM CD CP24 Beta Blockers Non-Selective (Diltiazem Hcl Coated 1 Beads) MATZIM LA TB24 (Sotalol Hcl) SORINE 1 TABS (Diltiazem Hcl Extended BETAPACE AF TABS Release Beads) TAZTIA 1 7 (sotalol hcl (afib/afl)) XT, TIADYLT ER CP24 (Nifedipine) AFEDITAB CR BETAPACE TABS ( 1 sotalol 7 TB24 hcl) ADALAT CC TB24 30 MG, CORGARD TABS 7 7 60 MG (nifedipine) (nadolol) ADALAT CC TB24 90 MG QL(1 ea daily) INDERAL LA CP24 7 7 (nifedipine) (propranolol hcl) QL(2 ea daily) amlodipine besylate 1 INDERAL XL CP24 80 MG, tabs 2.5 mg 120 MG (propranolol hcl 3 QL(1 ea daily) sustained-release amlodipine besylate 1 beads) tabs 5 mg, 10 mg CALAN SR TBCR 120 MG INNOPRAN XL CP24 80 7 MG, 120 MG (propranolol (verapamil hcl) 3 CALAN SR TBCR 180 MG, QL(2 ea daily) hcl sustained-release 7 beads) 240 MG (verapamil hcl) CALAN TABS (verapamil nadolol tabs 1 7 hcl) pindolol tabs 1 CARDIZEM CD CP24 QL(1 ea daily) (diltiazem hcl coated 7 propranolol hcl cp24 1 beads) CARDIZEM LA TB24 120 1 propranolol hcl soln MG (diltiazem hcl 2 propranolol hcl tabs 1 coated beads) CARDIZEM LA TB24 180 sotalol hcl (afib/afl) tabs 1 MG, 240 MG, 300 MG, 360 MG, 420 MG (diltiazem 7 sotalol hcl tabs 1 hcl coated beads) QL(6 ea daily) CARDIZEM TABS timolol maleate tabs 10 1 7 mg (diltiazem hcl) QL(2 ea daily) DILT-XR CP24 (diltiazem timolol maleate tabs 5 1 2 mg, 20 mg hcl)

56 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(1 ea daily) PROCARDIA CAPS diltiazem hcl coated 7 (nifedipine) beads cp24 120 mg, 1 180 mg, 240 mg, 300 PROCARDIA XL TB24 QL(1 ea daily) 7 mg, 360 mg (nifedipine) SULAR TB24 diltiazem hcl coated 7 (nisoldipine) beads tb24 180 mg, 1 240 mg, 300 mg, 360 TIAZAC CP24 (diltiazem mg, 420 mg hcl extended release 7 diltiazem hcl cp12 1 beads) verapamil hcl cp24 100 diltiazem hcl cp24 1 mg, 120 mg, 200 mg, 1 diltiazem hcl extended 240 mg, 300 mg 1 QL(2 ea daily) release beads cp24 verapamil hcl cp24 180 1 mg 1 diltiazem hcl tabs VERAPAMIL HCL ER 2 felodipine tb24 10 mg 1 QL(1 ea daily) CP24 (verapamil hcl) VERAPAMIL HCL SR QL(1 ea daily) 2 felodipine tb24 5 mg, 1 CP24 (verapamil hcl) 2.5 mg verapamil hcl tabs 40 1 isradipine caps 3 mg, 80 mg, 120 mg verapamil hcl tbcr 120 1 nicardipine hcl caps 3 mg nifedipine caps 10 mg, QL(2 ea daily) 1 verapamil hcl tbcr 180 1 20 mg mg, 240 mg VERAPAMIL nifedipine tb24 30 mg, 1 60 mg HYDROCHLORIDE ER 2 nifedipine tb24 30 mg, QL(1 ea daily) CP24 (verapamil hcl) 1 VERELAN CP24 120 MG, 60 mg, 90 mg 7 240 MG (verapamil hcl) nimodipine caps 1 VERELAN CP24 180 MG QL(2 ea daily) 7 NISOLDIPINE ER TB24 (verapamil hcl) 2 (nisoldipine) VERELAN CP24 360 MG QL(1 ea daily) 2 nisoldipine tb24 1 (verapamil hcl) VERELAN PM CP24 NORVASC TABS 2.5 MG QL(2 ea daily) 2 7 (verapamil hcl) (amlodipine besylate) CARDIOTONICS - Drugs to Treat Heart Failure NORVASC TABS 5 MG, 10 QL(1 ea daily) and Abnormal Heart Rhythm MG (amlodipine 7 besylate) Cardiac Glycosides NYMALIZE SOLN 30 (Digoxin) DIGITEK, DIGOX 1 TABS MG/10ML, 60 MG/20ML 3 (nimodipine) digoxin soln 0.05 mg/ml 1

57 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits digoxin tabs 0.125 mg, 1 Prostaglandin Vasodilators 125 mcg, 250 mcg ORENITRAM TBCR PA 4 LANOXIN TABS 125 MCG, ( ) 7 treprostinil diolamine 250 MCG (digoxin) TYVASO REFILL SOLN PA 4 LANOXIN TABS 62.5 (treprostinil) MCG, 187.5 MCG 2 TYVASO SOLN PA 4 (digoxin) (treprostinil) CARDIOVASCULAR AGENTS - MISC. - Drugs to TYVASO STARTER SOLN PA 4 Treat Heart and Circulation Conditions (treprostinil) Cardiovascular Agents Misc. - Combinations VENTAVIS SOLN PA 4 amlodipine besylate- PA (iloprost) atorvastatin calcium 3 Pulmonary Hypertension - Endothelin Receptor tabs PA; ST; Must BIDIL TABS (isosorbide use dinitrate-hydralazine 3 ambrisentan tabs 4 AcariaHealth hcl) Specialty Rx at 1-844-538- CADUET TABS PA 4661 (amlodipine besylate- 7 PA; ST atorvastatin calcium) bosentan tabs 125 mg 4 ENTRESTO TABS 24 MG- PA; QL(2 ea PA; ST; Must 26 MG (sacubitril- 3 daily) use valsartan) 4 AcariaHealth bosentan tabs 62.5 mg Specialty Rx at ENTRESTO TABS 49 MG- PA 1-844-538- 51 MG, 97 MG-103 MG 3 4661 (sacubitril-valsartan) PA; ST; Must Impotence Agents use LETAIRIS TABS PA; Sildenafil is 7 AcariaHealth preferred ED (ambrisentan) Specialty Rx at drug;QL(8 ea 1-844-538- 4661 4 per fill retail,8 sildenafil citrate tabs ea per 30 days OPSUMIT TABS PA; ST 4 retail); AL(At (macitentan) least 21 yrs TRACLEER TABS 125 MG PA; ST old) 7 (bosentan) PA; Sildenafil is preferred ED PA; ST; Must drug;QL(8 ea use TRACLEER TABS 62.5 VIAGRA TABS (sildenafil per fill retail,8 7 AcariaHealth 7 Specialty Rx at citrate) ea per 30 days MG (bosentan) retail); AL(At 1-844-538- least 21 yrs 4661 TRACLEER TBSO 32 MG PA; ST;LA old) 4 Peripheral Vasodilators (bosentan) Pulmonary Hypertension - Phosphodiesterase isoxsuprine hcl tabs 3 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic Preferred AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

58 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; New ADEMPAS TABS 0.5 MG PA; ST 4 (Tadalafil (Pulmonary commercial (riociguat) Hypertension)) ALYQ 4 members to be ADEMPAS TABS 1 MG, 2 PA TABS referred to MG, 1.5 MG, 2.5 MG AcariaHealth;Q 4 L(2 ea daily) (riociguat) PA; New Sinus Node Inhibitors commercial CORLANOR SOLN 5 ST; QL(15 ml ADCIRCA TABS (tadalafil 3 7 members to be MG/5ML (ivabradine hcl) daily) (pulmonary referred to ) CORLANOR TABS 5 MG, ST; QL(2 ea hypertension) AcariaHealth;Q 3 L(2 ea daily) 7.5 MG (ivabradine hcl) daily) REVATIO SUSR 10 PA Transthyretin Stabilizers MG/ML (sildenafil citrate VYNDAMAX CAPS PA; QL(1 ea 7 4 (pulmonary (tafamidis) daily) hypertension)) VYNDAQEL CAPS PA; QL(4 ea REVATIO TABS 20 MG PA; QL(3 ea (tafamidis meglumine 4 daily) (sildenafil citrate daily) (cardiac)) (pulmonary 7 CEPHALOSPORINS - Drugs to Treat Bacterial hypertension)) Infections PA sildenafil citrate Cephalosporins - 1st Generation (pulmonary 4 hypertension) susr 10 cefadroxil caps 1 mg/ml cefadroxil susr 1 sildenafil citrate PA; QL(3 ea daily) (pulmonary 1 cefadroxil tabs 1 hypertension) tabs 20 mg cephalexin caps 250 1 PA; New mg, 500 mg commercial cephalexin caps 750 3 tadalafil (pulmonary 4 members to be mg hypertension) tabs referred to AcariaHealth;Q cephalexin susr 125 1 L(2 ea daily) mg/5ml, 250 mg/5ml CEPHALEXIN TABS 250 Pulmonary Hypertension - Prostacyclin Receptor 3 MG, 500 MG (cephalexin) UPTRAVI TABS 200 MCG PA; ST 4 KEFLEX CAPS (selexipag) 7 (cephalexin) UPTRAVI TABS 400 MCG, PA 600 MCG, 800 MCG, 1000 Cephalosporins - 2nd Generation MCG, 1200 MCG, 1400 4 cefaclor caps 250 mg, 1 MCG, 1600 MCG 500 mg (selexipag) CEFACLOR ER TB12 UPTRAVI TBPK PA; ST 3 4 (cefaclor monohydrate) (selexipag) Pulmonary Hypertension - Sol Guanylate Cyclase

59 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CEFACLOR SUSR 125 Combination Contraceptives - Oral MG/5ML, 250 MG/5ML, 2 (Desogestrel & Ethinyl PV 375 MG/5ML (cefaclor) Estradiol) APRI, cefprozil susr 1 RECLIPSEN, KALLIGA, 7 JULEBER, ISIBLOOM, 1 ENSKYCE, EMOQUETTE, cefprozil tabs CYRED EQ, CYRED TABS cefuroxime axetil tabs 1 (Desogestrel-Ethinyl PV Estradiol (Biphasic)) Cephalosporins - 3rd Generation KIMIDESS, KARIVA, 7 BEKYREE, AZURETTE, cefdinir caps 1 VOLNEA, VIORELE, SIMLIYA, PIMTREA TABS cefdinir susr 1 (Desogestrel-Ethinyl PV CEFDITOREN PIVOXIL Estradiol (Triphasic)) 7 TABS 200 MG, 400 MG 3 CAZIANT, VELIVET TABS (cefditoren pivoxil) (Drospirenone-Ethinyl QL(1 ea daily); Estradiol) GIANVI, PV cefixime caps 400 mg 3 ZUMANDIMINE, ZARAH, SYEDA, OCELLA, NIKKI, 7 cefixime susr 100 1 LORYNA, LO- mg/5ml, 200 mg/5ml ZUMANDIMINE, JASMIEL TABS cefpodoxime proxetil 1 susr (Drospirenone-Ethinyl QL(1 ea daily); Estradiol-Levomefolate 7 PV cefpodoxime proxetil 1 Calcium) RAJANI, tabs TYDEMY TABS SPECTRACEF TABS 3 (Ethynodiol Diacet & Eth PV (cefditoren pivoxil) Estrad) KELNOR 1/35, 7 SUPRAX CAPS 400 MG ZOVIA 1/35E, KELNOR 7 1/50 TABS (cefixime) (Levonorgestrel & Eth PV SUPRAX CHEW 100 MG, 3 Estradiol) AFIRMELLE, 200 MG (cefixime) VIENVA, SRONYX, SUPRAX SUSR 100 PORTIA-28, ORSYTHIA, MG/5ML, 200 MG/5ML 7 MARLISSA, LUTERA, (cefixime) LILLOW, LEVORA 0.15/30- 7 SUPRAX SUSR 500 28, LESSINA, LARISSIA, 3 KURVELO, FALMINA, MG/5ML (cefixime) DELYLA, CHATEAL EQ, CHATEAL, AYUNA, CHEMICALS AVIANE, AUBRA EQ, Bulk Chemicals - E's AUBRA, ALTAVERA TABS ESTRADIOL (Levonorgestrel-Eth PV CONCENTRATE CREA 3 Estradiol (Triphasic)) (estradiol (bulk)) ENPRESSE-28, TRIVORA- 7 28, MYZILRA, LEVONEST CONTRACEPTIVES - Drugs to Prevent TABS Pregnancy

60 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Levonorgestrel-Ethinyl QL(1 ea (Norethindrone Acet & Eth PV Estradiol (91-Day)) daily,91 day(s) Estra) AUROVELA 1.5/30, AMETHIA, SIMPESSE, limit); PV MICROGESTIN 1/20, SETLAKIN, RIVELSA, MICROGESTIN 1.5/30, 7 QUASENSE, LOJAIMIESS, 7 LARIN 1/20, LARIN 1.5/30, JOLESSA, JAIMIESS, JUNEL 1/20, JUNEL INTROVALE, FAYOSIM, 1.5/30, HAILEY 1.5/30, DAYSEE, CAMRESE LO, AUROVELA 1/20 TABS CAMRESE, ASHLYNA, (Norethindrone Acetate- PV AMETHIA LO TABS Ethinyl Estradiol-Fe) TILIA 7 (Levonorgestrel-Ethinyl PV FE, TRI-LEGEST FE TABS Estradiol (Continuous)) 7 (Norethindrone-Eth QL(1 ea daily); AMETHYST TABS Estradiol (Triphasic)) PV (Norethin Acet & Estrad- QL(365 ea per ALYACEN 7/7/7, 7 Fe) MELODETTA 24 FE, fill retail); PV PIRMELLA 7/7/7, 7 MIBELAS 24 FE CHEW NORTREL 7/7/7, NECON (Norethin Acet & Estrad- PV 7/7/7, LEENA, DASETTA Fe) TARINA FE 1/20, 7/7/7, CYCLAFEM 7/7/7, MICROGESTIN FE 1.5/30, ARANELLE TABS MICROGESTIN FE, LARIN (Norethindrone-Eth PV FE 1/20, LARIN FE 1.5/30, Estradiol (Triphasic)) JUNEL FE 1/20, JUNEL FE 7 ALYACEN 7/7/7, 1.5/30, BLISOVI FE 1/20, PIRMELLA 7/7/7, 7 BLISOVI FE 1.5/30, NORTREL 7/7/7, NECON AUROVELA FE 1/20, 7/7/7, LEENA, DASETTA AUROVELA FE 1.5/30, 7/7/7, CYCLAFEM 7/7/7, TARINA FE 1/20 EQ TABS ARANELLE TABS (Norethindrone & Eth PV (Norgestimate-Ethinyl QL(1 ea daily); Estradiol) ALYACEN 1/35, Estradiol (Triphasic)) TRI PV ZENCHENT, WERA, FEMYNOR, TRINESSA VYFEMLA, PIRMELLA LO, TRINESSA, TRI- 1/35, PHILITH, NORTREL VYLIBRA LO, TRI- 7 1/35, NORTREL 0.5/35 VYLIBRA, TRI-SPRINTEC, 7 (28), NECON 0.5/35-28, TRI-PREVIFEM, TRI-MILI, DASETTA 1/35, TRI-LO-SPRINTEC, TRI- CYCLAFEM 1/35, LO-MILI, TRI-LO-MARZIA, BRIELLYN, BALZIVA TRI-LO-ESTARYLLA, TRI- TABS LINYAH, TRI-ESTARYLLA (Norethindrone & Ethinyl QL(1 ea daily); TABS Estradiol-Fe) KAITLIB FE, 7 PV WYMZYA FE, LAYOLIS FE CHEW (Norethindrone & Ethinyl PV Estradiol-Fe) KAITLIB FE, 7 WYMZYA FE, LAYOLIS FE CHEW

61 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Norgestimate-Ethinyl PV GENERESS FE CHEW QL(1 ea daily); Estradiol (Triphasic)) TRI (norethindrone & 5 PV FEMYNOR, TRINESSA ethinyl estradiol-fe) LO, TRINESSA, TRI- PV VYLIBRA LO, TRI- levonorgestrel & eth 7 estradiol tabs VYLIBRA, TRI-SPRINTEC, 7 TRI-PREVIFEM, TRI-MILI, levonorgestrel-eth PV TRI-LO-SPRINTEC, TRI- 7 LO-MILI, TRI-LO-MARZIA, estradiol (triphasic) TRI-LO-ESTARYLLA, TRI- tabs LINYAH, TRI-ESTARYLLA levonorgestrel-ethinyl QL(1 ea 7 daily,91 day(s) TABS estradiol (91-day) tabs (Norgestimate-Ethinyl QL(1 ea daily); limit); PV Estradiol) ESTARYLLA, PV levonorgestrel-ethinyl PV VYLIBRA, SPRINTEC 28, estradiol (continuous) 7 PREVIFEM, 7 tabs MONONESSA, MONO- LINYAH, MILI, FEMYNOR LO LOESTRIN FE TABS QL(1 ea daily); TABS (norethindrone acetate- PV 5 (Norgestrel & Ethinyl PV ethinyl estradiol-fe fum ) Estradiol) CRYSELLE-28, 7 (biphasic) LOW-OGESTREL, LOESTRIN 1.5/30-21 PV ELINEST TABS TABS (norethindrone 5 BEYAZ TABS QL(1 ea daily); acet & eth estra) (drospirenone-ethinyl PV 5 LOESTRIN 1/20-21 TABS PV estradiol-levomefolate (norethindrone acet & 5 calcium) eth estra) DESOGEN TABS PV LOESTRIN FE 1.5/30 PV ( desogestrel & ethinyl 5 TABS (norethin acet & 5 estradiol) estrad-fe) PV desogestrel & ethinyl 7 LOESTRIN FE 1/20 TABS PV estradiol tabs (norethin acet & estrad- 5 desogestrel-ethinyl PV fe) estradiol (biphasic) 7 LOSEASONIQUE TABS QL(1 ea tabs (levonorgestrel-ethinyl 5 daily,91 day(s) QL(1 ea daily); estradiol (91-day)) limit); PV drospirenone-ethinyl 7 estradiol tabs PV MINASTRIN 24 FE CHEW QL(365 ea per drospirenone-ethinyl QL(1 ea daily); (norethin acet & estrad- 5 fill retail); PV estradiol-levomefolate 7 PV fe) calcium tabs MINASTRIN 24 FE CHEW QL(365 ea per ESTROSTEP FE TABS PV (norethin acet & estrad- 5 fill retail); PV (norethindrone acetate- 5 fe) ethinyl estradiol-fe) MIRCETTE TABS PV PV (desogestrel-ethinyl 5 ethynodiol diacet & eth 7 estrad tabs estradiol (biphasic))

62 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NATAZIA TABS QL(1 ea daily); ORTHO-NOVUM 1/35 PV (estradiol valerate- 5 PV TABS (norethindrone & 5 dienogest) eth estradiol) norethin acet & estrad- QL(365 ea per ORTHO-NOVUM 7/7/7 QL(1 ea daily); fe chew 75 mg-20 mcg- 7 fill retail); PV TABS (norethindrone- 5 PV 1 mg eth estradiol (triphasic)) norethin acet & estrad- PV QUARTETTE TABS QL(1 ea (levonorgestrel-ethinyl 5 daily,91 day(s) fe tabs 75 mg-20 mcg- 7 1 mg, 75 mg-30 mcg- estradiol (91-day)) limit); PV 1.5 mg SAFYRAL TABS QL(1 ea daily); (drospirenone-ethinyl PV norethindrone & ethinyl PV 5 estradiol-fe chew 0.4 7 estradiol-levomefolate mg-35 mcg calcium) norethindrone & ethinyl QL(1 ea daily); SEASONIQUE TABS QL(1 ea PV (levonorgestrel-ethinyl 5 daily,91 day(s) estradiol-fe chew 75 7 limit); PV mg-0.8 mg-25 mcg estradiol (91-day)) norethindrone acet & PV TAYTULLA CAPS PA; PV 7 (norethin acet & estrad- 5 eth estra tabs fe) PV norgestimate-ethinyl TRI-NORINYL 28 TABS PV estradiol (triphasic) 7 (norethindrone-eth 5 tabs estradiol (triphasic)) norgestimate-ethinyl QL(1 ea daily); YASMIN 28 TABS QL(1 ea daily); PV estradiol (triphasic) 7 (drospirenone-ethinyl 5 PV tabs estradiol) QL(1 ea daily); norgestimate-ethinyl 7 YAZ TABS QL(1 ea daily); estradiol tabs PV (drospirenone-ethinyl 5 PV OGESTREL TABS PV estradiol) (norgestrel & ethinyl 5 Combination Contraceptives - Transdermal estradiol) XULANE PTWK PV ORTHO TRI-CYCLEN LO PV (norelgestromin-ethinyl 5 TABS (norgestimate- estradiol) ethinyl estradiol 5 (triphasic)) Combination Contraceptives - Vaginal ORTHO TRI-CYCLEN QL(1 ea daily); (Etonogestrel-Ethinyl 1 PV Estradiol) ELURYNG RING TABS (norgestimate- PV 5 PV ethinyl estradiol etonogestrel-ethinyl 1 (triphasic)) estradiol ring ORTHO-CYCLEN TABS QL(1 ea daily); NUVARING RING PV (norgestimate-ethinyl 5 PV (etonogestrel-ethinyl 7 estradiol) estradiol) Emergency Contraceptives

63 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Levonorgestrel AL(Up to 17 yrs cortisone acetate tabs 1 (Emergency Oc)) AFTERA, old ); PV TAKE ACTION, REACT, dexamethasone elix 0.5 1 PREVENTEZA, OPTION 2, mg/5ml OPCICON ONE-STEP, 7 NEW DAY, MY WAY, MY DEXAMETHASONE CHOICE, ECONTRA ONE- INTENSOL CONC 2 STEP, ECONTRA EZ (dexamethasone) TABS dexamethasone soln 1 ELLA TABS ( PV ulipristal 5 0.5 mg/5ml acetate) dexamethasone tabs levonorgestrel AL(Up to 17 yrs 7 0.75 mg, 0.5 mg, 1 mg, 1 (emergency oc) tabs old ); PV 2 mg, 4 mg, 6 mg, 1.5 PLAN B ONE-STEP TABS AL(Up to 17 yrs mg (levonorgestrel 5 old ); PV EMFLAZA SUSP PA; LA 4 (emergency oc)) (deflazacort) EMFLAZA TABS PA; LA Progestin Contraceptives - Oral 4 (Norethindrone QL(1 ea daily); (deflazacort) (Contraceptive)) CAMILA, PV ENTOCORT EC CPEP QL(3 ea daily) 7 TULANA, SHAROBEL, (budesonide) NORLYROC, NORLYDA, 7 NORA-BE, LYZA, hydrocortisone tabs 1 JOLIVETTE, JENCYCLA, MEDROL DOSEPAK TBPK INCASSIA, HEATHER, 7 ERRIN, DEBLITANE TABS (methylprednisolone) QL(1 ea daily); MEDROL TABS 2 MG norethindrone 7 2 (contraceptive) tabs PV (methylprednisolone) ORTHO MICRONOR QL(1 ea daily); MEDROL TABS 4 MG, 8 MG, 16 MG, 32 MG TABS (norethindrone 5 PV 7 ( ) (contraceptive)) methylprednisolone SLYND TABS QL(1 ea daily); methylprednisolone 5 1 (drospirenone) PV tabs CORTICOSTEROIDS - Steroid Hormone Drugs to methylprednisolone 1 Treat Systemic Swelling Conditions tbpk ORAPRED ODT TBDP Glucocorticosteroids (prednisolone sodium 7 (Dexamethasone) 1 DECADRON ELIX phosphate) PREDNISOLONE SODIUM (Dexamethasone) 1 DECADRON TABS PHOSPHATE SOLN OR 25 MG/5ML 3 budesonide cpep 3 mg 1 QL(3 ea daily) (prednisolone sodium PA phosphate) budesonide tb24 9 mg 3 prednisolone sodium CORTEF TABS phosphate soln or 5 1 7 (hydrocortisone) mg/5ml, 15 mg/5ml

64 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits prednisolone sodium (Guaifenesin-Codeine) G phosphate tbdp or 10 3 TUSSIN AC, VIRTUSSIN 1 mg, 15 mg, 30 mg A/C, ROBAFEN AC SOLN (Guaifenesin-Codeine) prednisolone soln 1 TRYMINE CG, VIRTUSSIN 3 AC/ALC LIQD PREDNISONE INTENSOL 2 CONC (prednisone) (Guaifenesin-Codeine) TRYMINE CG, VIRTUSSIN 1 prednisone soln 5 1 AC/ALC LIQD mg/5ml (Phenylephrine- prednisone tabs 1 mg, Brompheniramine-Dm) BIO 5 mg, 10 mg, 20 mg, 1 T PRES-B, TUSSI-PRES 3 B, PRESGEN B, 50 mg, 2.5 mg GLENMAX PEB DM prednisone tbpk 10 mg 1 FORTE LIQD (Phenylephrine-Chlorphen- prednisone tbpk 5 mg 3 Dm) ED A-HIST DM, 3 NOHIST-DM LIQD UCERIS TB24 OR 9 MG PA 7 (Promethazine & QL(30 ml daily) (budesonide) Phenylephrine) 1 Mineralocorticoids PROMETHAZINE VC PLAIN SOLN fludrocortisone acetate 1 tabs (Promethazine- Phenylephrine-Codeine) 1 COUGH/COLD/ALLERGY - Drugs to Treat PROMETHAZINE Cough, Cold and Allergy Symptoms VC/CODEINE SYRP Antitussives (Pseudoephed-Bromphen- 3 Dm) BROMFED DM SYRP (Hydrocodone W/ Homatropine) HYDROMET 1 (Pseudoephedrine W/ SYRP Codeine-Gg) 1 GUAIFENESIN DAC, benzonatate caps 100 1 VIRTUSSIN DAC SOLN mg, 200 mg (Pseudoephedrine- Dexchlorpheniramine- benzonatate caps 150 3 mg Chlophedianol) AMBI 3 12.5CPD/1DCPM/30PSE hydrocodone w/ LIQD homatropine syrp 5 1 (Pseudoephedrine- mg/5ml-1.5 mg/5ml Guaifenesin) AMBI 3 TESSALON PERLES 40PSE/400GFN TABS 7 CAPS (benzonatate) Cough/Cold/Allergy Combinations (Guaifenesin-Codeine) CHERATUSSIN AC, 1 GUAIFENESIN AC, GUAIATUSSIN AC SYRP

65 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Pseudoephedrine- BIO-DTUSS DMX LIQD Guaifenesin) CVS MUCUS (pseudoephed- 3 D EXTENDED RELEASE, bromphen-dm) SM MUCUS RELIEF D, RA MUCUS RELIEF D BIONEL PEDIATRIC LIQD MAXIMUMSTRENGTH, RA (pseudoephedrine w/ 3 ) MUCUS RELIEF D, 1 dm-gg MUCUS-D, MUCUS D BRONKIDS LIQD MAXIMUM STRENGTH, (phenylephrine- 3 MUCUS D, HM MUCUS RELIEF D, GNP MUCUS D chlorphen-dm) 12 HR, CVS MUCUS D CAPCOF SYRP MAXIMUM STRENGTH ER (phenylephrine- TB12 chlorpheniramine w/ 3 (Pseudoephedrine- codeine) Guaifenesin) CVS MUCUS CARBAPHEN 12 LIQD D EXTENDED RELEASE, (phenylephrine- SM MUCUS RELIEF D, RA 3 MUCUS RELIEF D chlorpheniramine- MAXIMUMSTRENGTH, RA carbetapentane) MUCUS RELIEF D, 3 CARBAPHEN 12 PED MUCUS-D, MUCUS D SUSP (phenylephrine- MAXIMUM STRENGTH, 3 MUCUS D, HM MUCUS chlorpheniramine- RELIEF D, GNP MUCUS D carbetapentane) 12 HR, CVS MUCUS D CODITUSSIN AC LIQD 3 MAXIMUM STRENGTH ER (guaifenesin-codeine) TB12 DECON-G LIQD (Pseudoephedrine- (phenylephrine- Guaifenesin) MUCUS 3 3 RELIEF D TABS 40 MG- brompheniramine- 400 MG guaifenesin) (Pseudoephedrine- ED BRON GP LIQD ( 3 Guaifenesin) MUCUS 1 phenylephrine- RELIEF D TB12 60 MG- guaifenesin) 600 MG EXACTUSS TR TABS RX/OTC ACTINEL PEDIATRIC (phenylephrine w/ dm- 3 LIQD (pseudoephedrine 3 gg) w/ dm-gg) EXAPHEX TR TABS RX/OTC AMBI (phenylephrine- 3 12.5CPD/100GFN/30PSE ) LIQD guaifenesin (pseudoephedrine- 3 GILPHEX TR TABS RX/OTC chlophedianol- (phenylephrine- 3 guaifenesin) guaifenesin) AP-HIST DM LIQD GILTUSS COUGH & COLD RX/OTC (phenylephrine- 3 TABS (phenylephrine w/ 3 brompheniramine-dm) dm-gg)

66 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GILTUSS SINUS & RX/OTC MUCINEX D TB12 CONGESTION TABS ( 3 pseudoephedrine- 7 (phenylephrine- guaifenesin) guaifenesin) NEOTUSS PLUS LIQD GILTUSS TR TABS RX/OTC (phenylephrine- 3 (phenylephrine w/ dm- 3 chlorphen-dm) gg) NINJACOF-XG LIQD 3 GLENMAX PEB LIQD (guaifenesin-codeine) (brompheniramine & 3 PRO-RED AC SYRP phenyleph) (phenylephrine- 3 guaifenesin-codeine 1 dexchlorpheniramine- soln codeine) HYDROCODONE QL(30 ml daily) promethazine & 1 BITARTRATE/CHLORPHE phenylephrine syrp NIRAMINE MALEATE/PSE 3 QL(30 ml daily) SOLN (pseudoephed- promethazine 1 cpm w/ hydrocod) w/codeine soln QL(30 ml daily) hydrocodone polistirex- promethazine 1 chlorpheniramine 1 w/codeine syrp polistirex lqcr promethazine-dm syrp 1 QL(30 ml daily) hydrocodone polistirex- promethazine- 1 chlorpheniramine phenylephrine-codeine 1 polistirex suer syrp LOHIST-DM SYRP PROMETHAZINE/DEXTR QL(30 ml daily) (phenylephrine- 3 OMETHORPHAN SOLN 2 brompheniramine-dm) (promethazine-dm) M-CLEAR WC SOLN 3 PROMETHAZINE/PHENYL QL(30 ml daily) (guaifenesin-codeine) EPHRINE SYRP M-END PE LIQD (promethazine & 1 (phenylephrine- phenylephrine) 3 brompheniramine w/ PROMETHAZINE/PHENYL codeine) EPHRINE/CODEINE SYRP 2 MAR-COF BP LIQD (promethazine- (pseudoephedrine- phenylephrine-codeine) brompheniramine- 3 pseudoephed- 3 codeine) bromphen-dm syrp MAR-COF CG pseudoephedrine- EXPECTORANT LIQD 7 guaifenesin tb12 120 3 (guaifenesin-codeine) mg-1200 mg MUCINEX D MAXIMUM STRENGTH TB12 pseudoephedrine- 1 (pseudoephedrine- 7 guaifenesin tb12 60 guaifenesin) mg-600 mg

67 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits RYDEX LIQD (Guaifenesin) BIDEX, (pseudoephedrine- XPECT, SM CHEST brompheniramine- 3 CONGESTION RELIEF, ) SB MUCUS RELIEF, codeine REFENESEN 400, RA SORBUTUSS NR LIQD MUCUS RELIEF CHEST, (dextromethorphan-gg- 3 RA MUCUS RELIEF, QC potassium citrate) MEDIFIN 400, TUSNEL C SYRP PHARBINEX, MUCUS RELIEF CHEST (pseudoephedrine w/ 3 CONGESTION, MUCUS codeine-gg) RELIEF, MUCOSA, TUSNEL PEDIATRIC LIQD LIQUIBID, KLS MUCUS 3 (pseudoephedrine w/ 3 RELIEF CHEST, HM dm-gg) CHEST CONGESTION RELIEF, GOODSENSE TUSNEL TABS MUCUS RELIEF, GNP (pseudoephedrine w/ 3 TAB TUSSIN, GNP dm-gg) MUCUS RELIEF, G-FEN TUSSICAPS CP12 EX, FENESIN IR, CVS CHEST CONGESTION (hydrocodone RELIEF, CHEST polistirex- 3 CONGESTION RELIEF chlorpheniramine EXPECTORANT, CHEST polistirex) CONGESTION RELIEF TUSSIONEX TABS PENNKINETIC guaifenesin tabs 3 EXTENDED RELEASE SUER (hydrocodone 7 Misc. Respiratory Inhalants polistirex- (Sodium Chloride chlorpheniramine (Inhalant)) PULMOSAL 3 polistirex) NEBU VANACOF LIQD HYPER-SAL NEBU (pseudoephedrine- (sodium chloride 7 dexchlorpheniramine- 7 (inhalant)) chlophedianol) HYPERSAL NEBU 3.5 % Expectorants (sodium chloride 3 (inhalant)) HYPERSAL NEBU 7 % (sodium chloride 7 (inhalant)) NEBUSAL NEBU (sodium chloride 3 (inhalant)) sodium chloride 1 (inhalant) nebu 0.9 %

68 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(45 gm per sodium chloride 3 (inhalant) nebu 7 % adapalene gel 0.1 % 1 fill retail); RX/OTC Mucolytics QL(45 gm per acetylcysteine soln 1 adapalene gel 0.3 % 1 fill retail,135 gm per fill mail) DERMATOLOGICALS - Drugs to Treat Skin ADAPALENE LOTN 0.1 % Limit 59mls per Conditions 3 month;QL(1.97 (adapalene) Acne Products ml daily) (Clindamycin Phosphate Limit 45gms adapalene-benzoyl per (Topical)) CLINDACIN ETZ 3 3 PLEDGETS, CLINDACIN-P peroxide gel month;QL(1.5 SWAB gm daily) (Clindamycin Phosphate- Limit 45gms per Benzoyl Peroxide 1 ATRALIN GEL (tretinoin) 7 (Refrigerate)) NEUAC GEL month;QL(1.5 gm daily) (Isotretinoin) QL(2 ea daily) AZELEX CREA ( AMNESTEEM, MYORISAN 1 azelaic 3 CAPS 40 MG acid (acne)) (Isotretinoin) QL(4 ea daily) BENZACLIN GEL AMNESTEEM, 1 (clindamycin ZENATANE, MYORISAN, phosphate-benzoyl 7 CLARAVIS CAPS 10 MG peroxide) (Isotretinoin) QL(5 ea daily) BENZACLIN WITH PUMP AMNESTEEM, 1 GEL (clindamycin ZENATANE, MYORISAN, 7 CLARAVIS CAPS 20 MG phosphate-benzoyl (Isotretinoin) CLARAVIS, QL(2 ea daily) peroxide) ZENATANE CAPS 30 MG, 1 BENZAMYCIN GEL QL(2 gm daily) 40 MG (benzoyl peroxide- 7 (Isotretinoin) MYORISAN 1 erythromycin) CAPS 30 MG QL(2 gm daily) benzoyl peroxide- 1 (Sulfacetamide Sodium W/ erythromycin gel Sulfur) BP 10-1, 3 SULFAMEZ WASH EMUL BP CLEANSING WASH EMUL (sulfacetamide (Tretinoin) AVITA CREA 1 sodium-sulfur in urea 2 vehicle) (Tretinoin) AVITA GEL 1 CLEOCIN-T GEL ACZONE GEL 5 % PA; ST 7 (clindamycin phosphate 2 (dapsone (topical)) (topical)) ACZONE GEL 7.5 % PA; ST;QL(2 7 CLEOCIN-T LOTN (dapsone (topical)) gm daily) (clindamycin phosphate 7 1 QL(45 gm per (topical)) adapalene crea 0.1 % fill retail)

69 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CLEOCIN-T SOLN DIFFERIN LOTN 0.1 % Limit 59mls per 3 month;QL(1.97 (clindamycin phosphate 7 (adapalene) (topical)) ml daily) CLEOCIN-T SWAB DUAC GEL (clindamycin (clindamycin phosphate 7 phosphate-benzoyl 7 (topical)) peroxide (refrigerate)) EPIDUO FORTE GEL PA; ST; Limited clindamycin phosphate 3 ( 3 45gms per (topical) foam adapalene-benzoyl month;QL(1.5 peroxide) clindamycin phosphate 1 gm daily) (topical) gel EPIDUO GEL Limit 45gms per clindamycin phosphate 1 (adapalene-benzoyl 7 (topical) lotn month;QL(1.5 peroxide) gm daily) clindamycin phosphate 1 ERY PADS (topical) soln (erythromycin (acne 3 clindamycin phosphate 3 aid)) (topical) swab ERYGEL GEL CLINDAMYCIN (erythromycin (acne 7 PHOSPHATE GEL aid)) (clindamycin phosphate 2 erythromycin (acne aid) 1 (topical)) gel clindamycin phosphate- erythromycin (acne aid) 3 benzoyl peroxide 1 pads (refrigerate) gel erythromycin (acne aid) 1 clindamycin phosphate- soln benzoyl peroxide gel 1 3 %-5 % EVOCLIN FOAM (clindamycin phosphate 7 QL(1 gm daily) clindamycin phosphate- 3 (topical)) tretinoin gel Limit 50gms dapsone (topical) gel 5 PA; ST FABIOR FOAM 3 3 per % (tazarotene (acne)) month;QL(1.67 PA; ST;QL(2 gm daily) dapsone (topical) gel 3 7.5 % gm daily) isotretinoin caps 10 mg 1 QL(4 ea daily) DIFFERIN CREA 0.1 % QL(45 gm per 7 QL(5 ea daily) (adapalene) fill retail) isotretinoin caps 20 mg 1 QL(45 gm per QL(2 ea daily) DIFFERIN GEL 0.1 % isotretinoin caps 30 mg, 1 7 fill retail); 40 mg (adapalene) RX/OTC KLARON LOTN DIFFERIN GEL 0.3 % QL(45 gm per 7 fill retail,135 gm (sulfacetamide sodium 7 (adapalene) per fill mail) (acne))

70 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PLEXION CLEANSER sulfacetamide sodium LIQD (sulfacetamide 7 w/ sulfur lotn 4.8 %-9.8 3 sodium w/ sulfur) % PLEXION CREA tretinoin crea 0.025 %, 1 (sulfacetamide sodium 7 0.05 %, 0.1 % w/ sulfur) tretinoin gel 0.025 %, 1 PLEXION LOTN 0.01 % ( 7 sulfacetamide sodium Limit 45gms w/ sulfur) tretinoin gel 0.05 % 3 per RETIN-A CREA (tretinoin) 7 month;QL(1.5 gm daily) RETIN-A GEL (tretinoin) 7 Limit 20gms tretinoin microsphere 1 per RETIN-A MICRO GEL 0.04 Limit 20gms gel month;QL(0.67 %, 0.1 % (tretinoin 7 per gm daily) month;QL(0.67 VELTIN GEL QL(1 gm daily) microsphere) gm daily) (clindamycin 3 RETIN-A MICRO PUMP Limit 20gms ) per phosphate-tretinoin GEL 0.04 %, 0.1 % 7 ZIANA GEL ( QL(1 gm daily) month;QL(0.67 clindamycin 7 (tretinoin microsphere) gm daily) phosphate-tretinoin) RETIN-A MICRO PUMP PA; ST Agents for External Genital and Perianal Warts GEL 0.08 % (tretinoin 3 VEREGEN OINT QL(30 gm per 3 microsphere) (sinecatechins) fill retail) SODIUM SULFACETAMIDE/SULFU Anti-inflammatory Agents - Topical R CLEANSER IN UREA (Diclofenac Sodium QL(5 ml daily) EMUL (sulfacetamide 3 (Topical)) KLOFENSAID II 1 sodium-sulfur in urea SOLN vehicle) DICLOFENAC QL(2 ea daily) EPOLAMINE PTCH 3 SODIUM QL(30 gm per SULFACETAMIDE/SULFU fill retail) (diclofenac epolamine) 2 RX/OTC R LOTN (sulfacetamide diclofenac sodium 1 sodium w/ sulfur) (topical) gel 1 % QL(5 ml daily) SSS 10-5 FOAM diclofenac sodium 1 (sulfacetamide sodium 2 (topical) soln 1.5 % w/ sulfur) FLECTOR PTCH QL(2 ea daily) 3 (diclofenac epolamine) sulfacetamide sodium 1 (acne) lotn REXAPHENAC CREA sulfacetamide sodium (diclofenac sodium 3 w/ sulfur crea 4.8 %-9.8 3 (topical)) % VOLTAREN GEL RX/OTC sulfacetamide sodium (diclofenac sodium 7 w/ sulfur liqd 4.8 %-9.8 3 (topical)) % Antibiotics - Topical 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic Preferred AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

71 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ALTABAX OINT 3 econazole nitrate crea 1 (retapamulin) CENTANY OINT Limit 70gms 2 ECOZA FOAM per ( ) 3 mupirocin (econazole nitrate) month;QL(2.34 CORTISPORIN CREA gm daily) (neomycin-polymyxin- 3 ERTACZO CREA PA 4 hc) (sertaconazole nitrate) CORTISPORIN OINT EXELDERM CREA 3 (bacitracin-polymyxin- 3 (sulconazole nitrate) neomycin hc) EXELDERM SOLN 2 gentamicin sulfate 1 (sulconazole nitrate) (topical) crea EXODERM LOTN (sodium thiosulfate- 3 gentamicin sulfate 1 (topical) oint salicylic acid) EXTINA FOAM mupirocin oint 1 7 (ketoconazole (topical)) Antifungals - Topical iodoquinol- (Ciclopirox Olamine) 1 hydrocortisone in aloe 3 CICLODAN CREA 0.77 % vehicle crea (Ciclopirox) CICLODAN 3 JUBLIA SOLN PA; ST SOLN 8 % 3 (efinaconazole) (Iodoquinol-Hydrocortisone QL(2 gm daily) In Aloe Vehicle) 3 ketoconazole (topical) 1 IODOQUIMEZ-HC CREA crea (Ketoconazole (Topical)) 3 ketoconazole (topical) 3 KETODAN FOAM foam (Nystatin (Topical)) ketoconazole (topical) NYAMYC, NYSTOP 1 1 POWD sham LOPROX CREA 7 ciclopirox gel 0.77 % 1 (ciclopirox olamine) LOPROX SHAMPOO ciclopirox olamine crea 1 7 SHAM (ciclopirox) 1 LOPROX SUSP ciclopirox olamine susp 7 (ciclopirox olamine) ciclopirox sham 1 % 3 LOTRISONE CREA Limit 45gms ( 7 per ciclopirox soln 8 % 3 clotrimazole w/ month;QL(1.5 betamethasone) Limit 45gms gm daily) LULICONAZOLE CREA PA clotrimazole w/ 1 per 3 betamethasone crea month;QL(1.5 (luliconazole) gm daily) LUZU CREA PA QL(2 ml daily) 3 clotrimazole w/ 1 (luliconazole) betamethasone lotn

72 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NAFTIFINE HCL CREA 1 PA 3 diclofenac sodium 3 % (naftifine hcl) (actinic keratoses) gel naftifine hcl crea 1 %, 2 EFUDEX CREA 3 7 % (fluorouracil (topical)) NAFTIN CREA 2 % FLUOROPLEX CREA 7 2 (naftifine hcl) (fluorouracil (topical)) NAFTIN GEL 2 % 3 fluorouracil (topical) 1 (naftifine hcl) crea NIZORAL SHAM 7 FLUOROURACIL CREA QL(1 gm daily) (ketoconazole (topical)) 0.5 % (fluorouracil 2 nystatin (topical) crea 1 (topical)) FLUOROURACIL SOLN 2 nystatin (topical) oint 1 %, 5 % (fluorouracil 2 (topical)) nystatin (topical) powd 1 PANRETIN GEL PA 3 (alitretinoin) nystatin-triamcinolone 1 PICATO GEL ( crea ingenol 3 mebutate) nystatin-triamcinolone 1 TARGRETIN GEL EX 1 % oint 2 (bexarotene (topical)) oxiconazole nitrate 3 crea VALCHLOR GEL PA; ST OXISTAT CREA (mechlorethamine hcl 4 7 (oxiconazole nitrate) (topical)) OXISTAT LOTN Antipsoriatics 3 (oxiconazole nitrate) (Calcipotriene) 1 QL(5 gm daily) PENLAC NAIL LACQUER CALCITRENE OINT 7 SOLN (ciclopirox) acitretin caps 10 mg 3 QL(1 ea daily) SULCONAZOLE NITRATE CREA (sulconazole 3 acitretin caps 17.5 mg 3 nitrate) acitretin caps 25 mg 3 QL(2 ea daily) SULCONAZOLE NITRATE SOLN (sulconazole 2 calcipotriene crea 1 QL(5 gm daily) nitrate) CALCIPOTRIENE FOAM QL(4 gm daily) VYTONE CREA 3 (calcipotriene) (iodoquinol- 7 hydrocortisone in aloe calcipotriene oint 1 QL(5 gm daily) vehicle) calcipotriene soln 1 Antineoplastic or Premalignant Lesion Agents - CARAC CREA QL(1 gm daily) Limit 100gms 2 (fluorouracil (topical)) 1 per calcitriol (topical) oint month;QL(3.34 gm daily)

73 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits COSENTYX PA; ST OVACE PLUS WASH LIQD 7 SENSOREADY PEN SOAJ 4 (sulfacetamide sodium) (secukinumab) OVACE WASH LIQD COSENTYX SOSY PA; ST 7 4 (sulfacetamide sodium) (secukinumab) selenium sulfide lotn 1 DOVONEX CREA QL(5 gm daily) 7 (calcipotriene) SODIUM ILUMYA SOSY PA; ST SULFACETAMIDE WASH 4 LIQD 0.5 %-10 % (tildrakizumab-asmn) 3 (sulfacetamide sodium methoxsalen rapid 1 in bakuchiol vehicle) caps sulfacetamide sodium 1 OXSORALEN ULTRA liqd CAPS (methoxsalen 7 rapid) Antivirals - Topical SKYRIZI PSKT PA PA; Limit 5gms 4 3 per (risankizumab-rzaa) acyclovir topical crea month;QL(0.17 SORIATANE CAPS 10 MG QL(1 ea daily) 7 gm daily) (acitretin) acyclovir topical oint 1 QL(1 gm daily) SORIATANE CAPS 17.5 7 MG (acitretin) PA; Limit 5gms ZOVIRAX CREA EX 5 % SORIATANE CAPS 25 MG QL(2 ea daily) 7 per 7 (acyclovir topical) month;QL(0.17 (acitretin) gm daily) SORILUX FOAM QL(4 gm daily) ZOVIRAX OINT EX 5 % QL(1 gm daily) 3 7 (calcipotriene) (acyclovir topical) QL(1 gm daily) tazarotene crea 1 Burn Products TAZORAC CREA 0.05 % QL(1 gm daily) (Silver Sulfadiazine) SSD 2 1 (tazarotene) CREA TAZORAC CREA 0.1 % QL(1 gm daily) mafenide acetate pack 3 7 (tazarotene) SILVADENE CREA (silver TAZORAC GEL 0.05 %, QL(1 gm daily) 7 2 sulfadiazine) 0.1 % (tazarotene) Limit 100gms silver sulfadiazine crea 1 VECTICAL OINT 2 per SULFAMYLON CREA 85 (calcitriol (topical)) month;QL(3.34 gm daily) MG/GM (mafenide 3 acetate) Antiseborrheic Products SULFAMYLON PACK 5 % 7 (Sulfacetamide Sodium) 1 (mafenide acetate) SEB-PREV WASH LIQD (Sulfacetamide Sodium) Corticosteroids - Topical SODIUM 1 SULFACETAMIDE WASH LIQD 10 %

74 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Clobetasol Propionate betamethasone Emollient Base) dipropionate (topical) 1 CLOBETASOL crea PROPIONATE E, 1 CLOBETASOL betamethasone PROPIONATE dipropionate (topical) 1 EMOLLIENT CREA lotn (Clobetasol Propionate 3 betamethasone Emulsion) TOVET FOAM dipropionate (topical) 1 (Clobetasol Propionate) 1 oint CLODAN SHAM betamethasone (Diflorasone Diacetate) 1 PSORCON CREA dipropionate 1 augmented crea (Flurandrenolide) NOLIX 3 CREA betamethasone 1 (Flurandrenolide) NOLIX 3 PA dipropionate LOTN augmented gel (Fluticasone Propionate) 3 betamethasone BESER LOTN dipropionate 1 (Hydrocortisone (Topical)) 1 augmented lotn ALA-CORT CREA betamethasone (Triamcinolone Acetonide 1 (Topical)) TRIDERM CREA dipropionate 1 ALA SCALP LOTN augmented oint (hydrocortisone 3 betamethasone 1 (topical)) valerate crea 0.1 % betamethasone alclometasone 1 3 dipropionate crea valerate foam 0.12 % betamethasone alclometasone 1 1 dipropionate oint valerate lotn 0.1 % AMCINONIDE CREA betamethasone 3 1 (amcinonide) valerate oint 0.1 % AMCINONIDE LOTN ST; QL(2 gm 3 calcipotriene- (amcinonide) betamethasone 3 daily) AMCINONIDE OINT dipropionate oint 3 (amcinonide) calcipotriene- ST; QL(2 gm APEXICON E CREA betamethasone 3 daily) (diflorasone diacetate 2 dipropionate susp emollient base) CAPEX SHAM 2 AUGMENTED (fluocinolone acetonide) BETAMETHASONE DIPROPIONATE GEL clobetasol propionate 1 (betamethasone 2 crea dipropionate clobetasol propionate 1 augmented) emollient base crea 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic Preferred AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

75 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CUTIVATE LOTN clobetasol propionate 3 7 emulsion foam (fluticasone propionate) DERMA-SMOOTHE/FS clobetasol propionate 3 foam BODY OIL (fluocinolone 7 acetonide) clobetasol propionate 1 gel DERMA-SMOOTHE/FS SCALP OIL (fluocinolone 7 clobetasol propionate 3 acetonide) liqd DESONATE GEL 3 clobetasol propionate 3 (desonide) lotn desonide crea 1 clobetasol propionate 1 oint desonide lotn 1 clobetasol propionate 1 sham desonide oint 1 clobetasol propionate DESOWEN CREA 1 7 soln (desonide) CLOBEX LIQD DESOWEN LOTN 7 7 (clobetasol propionate) (desonide) CLOBEX LOTN 7 DESOXIMETASONE (clobetasol propionate) CREA 0.05 % 2 CLOBEX SHAM (desoximetasone) 7 (clobetasol propionate) desoximetasone crea 1 CLOCORTOLONE 0.05 %, 0.25 % PIVALATE CREA 3 desoximetasone gel 1 (clocortolone pivalate) 0.05 % CLOCORTOLONE desoximetasone liqd ST PIVALATE PUMP CREA 3 3 (clocortolone pivalate) 0.25 % CLODERM CREA desoximetasone oint 3 3 (clocortolone pivalate) 0.05 % CLODERM PUMP CREA desoximetasone oint 3 1 (clocortolone pivalate) 0.25 % CORDRAN CREA 0.05 % diflorasone diacetate 7 1 (flurandrenolide) crea CORDRAN LOTN 0.05 % PA diflorasone diacetate 7 1 (flurandrenolide) oint CORDRAN OINT 0.05 % PA DIPROLENE AF CREA 7 (flurandrenolide) (betamethasone 7 CORDRAN TAPE 4 dipropionate MCG/SQCM 3 augmented) (flurandrenolide)

76 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DIPROLENE OINT halobetasol propionate 1 (betamethasone oint dipropionate 7 hydrocortisone (topical) 1 augmented) crea ELOCON CREA 7 hydrocortisone (topical) 1 (mometasone furoate) lotn ELOCON OINT 7 hydrocortisone (topical) (mometasone furoate) 1 oint EPIFOAM FOAM 3 (pramoxine-hc) hydrocortisone butyrate 1 crea fluocinolone acetonide 1 crea hydrocortisone butyrate hydrophilic lipo base 3 fluocinolone acetonide 1 crea oil PA hydrocortisone butyrate 3 fluocinolone acetonide 1 lotn oint hydrocortisone butyrate 1 fluocinolone acetonide 1 oint soln hydrocortisone butyrate 3 fluocinonide crea 1 soln hydrocortisone valerate fluocinonide emulsified 1 3 base crea crea hydrocortisone valerate fluocinonide gel 1 3 oint fluocinonide oint 1 KENALOG AERS (triamcinolone 7 fluocinonide soln 1 acetonide (topical)) LOCOID CREA flurandrenolide crea 3 (hydrocortisone 7 flurandrenolide lotn 3 PA butyrate) LOCOID LIPOCREAM flurandrenolide oint 3 PA CREA (hydrocortisone 7 fluticasone propionate butyrate hydrophilic lipo 1 base) crea 0.05 % LOCOID LOTN PA fluticasone propionate 3 (hydrocortisone 7 lotn 0.05 % butyrate) fluticasone propionate 1 LOCOID OINT oint 0.005 % (hydrocortisone 7 halobetasol propionate 1 butyrate) crea

77 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LOCOID SOLN TACLONEX SUSP ST; QL(2 gm (hydrocortisone 7 (calcipotriene- daily) 7 butyrate) betamethasone LUXIQ FOAM dipropionate) (betamethasone 7 TEMOVATE CREA 7 valerate) (clobetasol propionate) TEMOVATE OINT mometasone furoate 1 7 crea (clobetasol propionate) TEXACORT SOLN mometasone furoate 1 oint (hydrocortisone 3 (topical)) mometasone furoate 1 soln TOPICORT CREA 0.05 %, 0.25 % 7 OLUX FOAM ( clobetasol 7 (desoximetasone) ) propionate TOPICORT GEL 0.05 % 7 OLUX-E FOAM (desoximetasone) ( 7 clobetasol propionate TOPICORT LIQD 0.25 % ST ) 7 emulsion (desoximetasone) PRAMOSONE E CREA TOPICORT OINT 0.05 %, (pramoxine-hc 3 0.25 % 7 emollient base) (desoximetasone) PRAMOSONE LOTN 3 triamcinolone acetonide (pramoxine-hc) (topical) aers 0.147 1 PRAMOSONE OINT 3 mg/gm (pramoxine-hc) triamcinolone acetonide PREDNICARBATE CREA 2 (topical) crea 0.025 %, 1 (prednicarbate) 0.1 %, 0.5 % PREDNICARBATE OINT 3 triamcinolone acetonide (prednicarbate) (topical) lotn 0.025 %, 1 SYNALAR CREA 0.1 % (fluocinolone 7 acetonide) triamcinolone acetonide (topical) oint 0.025 %, 1 SYNALAR OINT 0.1 %, 0.5 % (fluocinolone 7 TRIDESILON CREA acetonide) 7 (desonide) SYNALAR SOLN (fluocinolone 7 ULTRAVATE CREA acetonide) (halobetasol 7 propionate) TACLONEX OINT ST; QL(2 gm (calcipotriene- daily) ULTRAVATE LOTN PA; ST betamethasone 7 (halobetasol 3 dipropionate) propionate)

78 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ULTRAVATE OINT BENSAL HP OINT (halobetasol 7 (salicylic acid & benzoic 3 propionate) acid) VANOS CREA CONDYLOX GEL 7 2 (fluocinonide) (podofilox) Eczema Agents PODOCON 25 IN BENZOIN TINCTURE DUPIXENT SOSY 200 PA 4 3 MG/1.14ML (dupilumab) SOLN (podophyllum resin) PA; Must use DUPIXENT SOSY 300 AcariaHealth podofilox soln 1 4 Specialty Rx at MG/2ML (dupilumab) SALEX SHAM ( 1-844-538- salicylic 7 4661;;LA acid) Enzymes - Topical salicylic acid crea 6 % 3 SANTYL OINT 3 (collagenase) salicylic acid sham 6 % 1 Immunomodulating Agents - Topical SALICYLIC ACID SOLN 26 3 ALDARA CREA % (salicylic acid) 7 (imiquimod) PA salicylic acid soln 28.5 3 imiquimod crea 1 % ULTRASAL-ER SOLN PA 7 Immunosuppressive Agents - Topical (salicylic acid) ELIDEL CREA QL(60 gm per 7 Local Anesthetics - Topical (pimecrolimus) fill retail) lidocaine ptch 3 QL(3 ea daily) 3 QL(60 gm per pimecrolimus crea fill retail) lidocaine-prilocaine 3 PROTOPIC OINT 0.03 % QL(2 gm daily); crea 7 AL(At least 2 (tacrolimus (topical)) LIDODERM PTCH QL(3 ea daily) yrs old) 7 (lidocaine) PROTOPIC OINT 0.1 % QL(2 gm daily); 7 AL(At least 15 (tacrolimus (topical)) Misc. Topical yrs old) DRYSOL SOLN 2 tacrolimus (topical) oint QL(2 gm daily); (aluminum chloride) 1 AL(At least 2 0.03 % yrs old) XERAC AC SOLN (aluminum chloride in 3 tacrolimus (topical) oint QL(2 gm daily); 1 AL(At least 15 alcohol) 0.1 % yrs old) Phosphodiesterase 4 (PDE4) Inhibitors - Topical Keratolytic/Antimitotic Agents PA; ST; Limited EUCRISA OINT to 60 gm per (Salicylic Acid) SALIMEZ 3 3 CREA (crisaborole) month;QL(2 gm daily) (Salicylic Acid) SALISOL 3 FORTE SOLN Rosacea Agents

79 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Metronidazole (Topical)) SOOLANTRA CREA PA; ST;QL(1.5 1 3 ROSADAN CREA (ivermectin (rosacea)) gm daily) (Metronidazole (Topical)) 1 QL(45 gm per Scabicides & Pediculicides ROSADAN GEL fill retail) ELIMITE CREA QL(60 gm per 7 azelaic acid gel 1 (permethrin) fill retail) DOXYCYCLINE CPDR PA; ST;QL(1 3 malathion lotn 3 (doxycycline (rosacea)) ea daily) NATROBA SUSP AL(At least 4 FINACEA FOAM ( 3 azelaic 3 (spinosad) yrs old) acid) FINACEA GEL ( OVIDE LOTN (malathion) 7 azelaic 7 acid) permethrin crea 1 QL(60 gm per PA; ST;QL(1.5 fill retail) ivermectin (rosacea) 3 crea gm daily) SKLICE LOTN IVERMECTIN CREA EX 1 PA; ST;QL(1.5 (ivermectin 3 % (ivermectin 3 gm daily) (pediculicide)) (rosacea)) SPINOSAD SUSP AL(At least 4 3 yrs old) METROCREAM CREA (spinosad) (metronidazole 7 Wound Care Products (topical)) REGRANEX GEL QL(15 gm per 3 METROGEL GEL (becaplermin) fill retail) (metronidazole 7 DIAGNOSTIC PRODUCTS (topical)) METROLOTION LOTN QL(60 ml per Diagnostic Drugs (metronidazole 7 fill retail) METOPIRONE CAPS 3 (topical)) (metyrapone) metronidazole (topical) 1 Diagnostic Tests crea 0.75 % FREESTYLE INSULINX Limit 200 per QL(45 gm per month without metronidazole (topical) 1 BLOODGLUCOSE TEST gel 0.75 % fill retail) STRIPS STRP ( 2 authorization;Q glucose L(6.7 ea daily); blood) metronidazole (topical) 1 RX/OTC gel 1 % Limit 200 per QL(60 ml per FREESTYLE INSULINX month without metronidazole (topical) 1 lotn 0.75 % fill retail) BLOODGLUCOSE TEST 2 authorization;Q STRP (glucose blood) L(6.7 ea daily); MIRVASO GEL PA; ST RX/OTC (brimonidine tartrate 3 Limit 200 per (topical)) FREESTYLE LITE TEST month without ORACEA CPDR PA; ST;QL(1 STRIPS STRP ( 2 authorization;Q 3 glucose (doxycycline (rosacea)) ea daily) blood) L(6.7 ea daily); RHOFADE CREA PA; ST RX/OTC (oxymetazoline hcl 3 (topical))

80 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limit 200 per VIOKACE TABS FREESTYLE TEST month without (pancrelipase (lipase- 3 STRIPS STRP (glucose 2 authorization;Q protease-amylase)) blood) L(6.7 ea daily); RX/OTC ZENPEP CPEP (pancrelipase (lipase- 2 KETONE STRP (acetone QL(50 ea per 2 protease-amylase)) (urine) test) fill retail) KETOSTIX STRP QL(50 ea per DIURETICS - Drugs to Treat Heart, Circulation 2 Conditions and Blood Pressure (acetone (urine) test) fill retail) Limit 200 per Carbonic Anhydrase Inhibitors month without QL(2 ea daily) ONETOUCH ULTRA STRP acetazolamide cp12 1 2 authorization;Q 500 mg (glucose blood) L(6.7 ea daily); RX/OTC acetazolamide tabs 125 1 Limit 200 per mg ONETOUCH VERIO TEST month without QL(4 ea daily) acetazolamide tabs 250 1 STRIPS STRP (glucose 2 authorization;Q mg blood) L(6.7 ea daily); RX/OTC methazolamide tabs 1 Limit 200 per NEPTAZANE TABS PRECISION XTRA BLOOD 7 month without (methazolamide) GLUCOSE TEST STRIPS 2 authorization;Q STRP (glucose blood) L(6.7 ea daily); Diuretic Combinations RX/OTC ALDACTAZIDE TABS 25 Limit 200 per MG-25 MG PRECISION XTRA STRP 7 2 month without (spironolactone & VI (ketone blood test) authorization;Q hydrochlorothiazide) L(6.7 ea daily) ALDACTAZIDE TABS 50 RELION KETONE STRP QL(50 ea per MG-50 MG 2 fill retail) (acetone (urine) test) (spironolactone & 2 DIGESTIVE AIDS - Drugs to Treat Low Digestive hydrochlorothiazide) Enzymes amiloride & Digestive Enzymes hydrochlorothiazide 1 CREON CPEP tabs (pancrelipase (lipase- 2 DYAZIDE CAPS protease-amylase)) (triamterene & 7 PANCREAZE CPEP hydrochlorothiazide) (pancrelipase (lipase- 3 MAXZIDE TABS QL(1 ea daily) protease-amylase)) (triamterene & 7 PERTZYE CPEP hydrochlorothiazide) (pancrelipase (lipase- 3 MAXZIDE-25 TABS QL(2 ea daily) protease-amylase)) (triamterene & 7 SUCRAID SOLN PA hydrochlorothiazide) 4 (sacrosidase)

81 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits spironolactone & amiloride hcl tabs 1 hydrochlorothiazide 1 DYRENIUM CAPS tabs 7 (triamterene) triamterene & hydrochlorothiazide 1 spironolactone tabs 1 caps 37.5 mg-25 mg triamterene & QL(2 ea daily) triamterene caps 3 hydrochlorothiazide 1 Thiazides and Thiazide-Like Diuretics tabs 37.5 mg-25 mg CHLOROTHIAZIDE TABS triamterene & QL(1 ea daily) 250 MG, 500 MG 3 hydrochlorothiazide 1 (chlorothiazide) tabs 75 mg-50 mg chlorothiazide tabs 500 3 Loop Diuretics mg 1 bumetanide tabs 0.5 1 chlorthalidone tabs mg, 1 mg DIURIL SUSP 3 bumetanide tabs 2 mg 1 QL(5 ea daily) (chlorothiazide) BUMEX TABS 0.5 MG, 1 hydrochlorothiazide 7 1 MG (bumetanide) caps 12.5 mg BUMEX TABS 2 MG QL(5 ea daily) hydrochlorothiazide 7 3 (bumetanide) tabs 12.5 mg DEMADEX TABS hydrochlorothiazide 7 1 (torsemide) tabs 25 mg, 50 mg EDECRIN TABS ST 7 indapamide tabs 1 (ethacrynic acid) ethacrynic acid tabs 3 ST metolazone tabs 1 MICROZIDE CAPS furosemide soln 10 1 7 mg/ml (hydrochlorothiazide) FUROSEMIDE SOLN 8 ENDOCRINE AND METABOLIC AGENTS - 3 MG/ML (furosemide) MISC. - Drugs to Treat Bone Disease and Regulate Hormones furosemide tabs 20 mg, 1 40 mg, 80 mg Bone Density Regulators Limit 1 per LASIX TABS ACTONEL TABS 150 MG 7 7 month;QL(0.04 (furosemide) (risedronate sodium) ea daily) QL(2 ea daily) torsemide tabs 100 mg 1 ACTONEL TABS 35 MG Limit 4 for 28 7 days;QL(0.15 (risedronate sodium) ea daily) torsemide tabs 5 mg, 1 10 mg, 20 mg ACTONEL TABS 5 MG, 30 QL(1 ea daily) Potassium Sparing Diuretics MG (risedronate 7 ALDACTONE TABS sodium) 7 (spironolactone)

82 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ALENDRONATE SODIUM TYMLOS SOPN PA 4 SOLN 70 MG/75ML 3 (abaloparatide) (alendronate sodium) Fertility Regulators alendronate sodium Limit 4 per 28 1 days;QL(0.15 Check plan tabs 35 mg, 70 mg documents for ea daily) coverage;QL(1 ALENDRONATE SODIUM 1 5 ea per fill TABS 40 MG 2 clomiphene citrate tabs retail,00 ea per (alendronate sodium) fill mail,15 ea ALENDRONATE SODIUM QL(1 ea daily) per 30 days TABS 5 MG (alendronate 2 retail) sodium) Growth Hormone Receptor Antagonists QL(1 ea daily) SOMAVERT SOLR PA alendronate sodium 1 4 tabs 5 mg, 10 mg (pegvisomant) BONIVA TABS Limit 1 per Growth Hormone Releasing Hormones (GHRH) 7 month;QL(0.04 EGRIFTA SOLR 1 MG PA (ibandronate sodium) 4 ea daily) (tesamorelin acetate) calcitonin (salmon) soln 1 EGRIFTA SOLR 2 MG PA; LA 4 ETIDRONATE DISODIUM (tesamorelin acetate) EGRIFTA SV SOLR PA; LA TABS (etidronate 3 4 disodium) (tesamorelin acetate) FORTEO SOPN PA Growth Hormones (teriparatide 4 HUMATROPE COMBO PA (recombinant)) PACK SOLR 4 (somatropin) FOSAMAX TABS Limit 4 per 28 7 days;QL(0.15 HUMATROPE SOLR PA (alendronate sodium) 4 ea daily) (somatropin) Limit 1 per NORDITROPIN FLEXPRO PA ibandronate sodium 4 1 month;QL(0.04 SOLN (somatropin) tabs ea daily) SEROSTIM SOLR PA MIACALCIN SOLN PA 4 (somatropin (non- 4 (calcitonin (salmon)) refrigerated)) NATPARA CART PA ZORBTIVE SOLR PA (parathyroid hormone 4 (somatropin (non- 4 (recombinant)) refrigerated)) risedronate sodium Limit 1 per 3 month;QL(0.04 Hormone Receptor Modulators tabs 150 mg ea daily) EVISTA TABS ( PV raloxifene 5 risedronate sodium Limit 4 for 28 hcl) 3 days;QL(0.15 OSPHENA TABS tabs 35 mg ea daily) 3 (ospemifene) QL(1 ea daily) risedronate sodium 3 PV tabs 5 mg, 30 mg raloxifene hcl tabs 7

83 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Insulin-Like Growth Factors (Somatomedins) KUVAN PACK Specialty Drug refer to INCRELEX SOLN PA (sapropterin 4 4 Caremark SP (mecasermin) dihydrochloride) RX LHRH/GnRH Agonist Analog Pituitary KUVAN TBSO Specialty Drug SYNAREL SOLN refer to 2 (sapropterin 4 (nafarelin acetate) Caremark SP dihydrochloride) RX Metabolic Modifiers levocarnitine (metabolic (Levocarnitine (Metabolic RX/OTC modifiers) soln 1 3 Modifiers)) MCCARNITINE 3 TABS gm/10ml RX/OTC BUPHENYL POWD PA levocarnitine (metabolic 3 (sodium 7 modifiers) tabs 330 mg MYALEPT SOLR PA phenylbutyrate) 4 BUPHENYL TABS PA (metreleptin) (sodium 7 nitisinone caps 4 PA phenylbutyrate) ORFADIN CAPS 2 MG, 5 PA 7 calcitriol caps 0.25 mcg 1 MG, 10 MG (nitisinone) ORFADIN CAPS 20 MG PA calcitriol caps 0.5 mcg 1 QL(4 ea daily) 4 (nitisinone) ORFADIN SUSP 4 MG/ML PA calcitriol soln 1 mcg/ml 1 4 (nitisinone) CARBAGLU TABS 4 PALYNZIQ SOSY PA (carglumic acid) 4 (pegvaliase-pqpz) CARNITOR SF SOLN (levocarnitine 7 paricalcitol caps 3 ) (metabolic modifiers) RAVICTI LIQD ( PA glycerol 4 CARNITOR SOLN 1 phenylbutyrate) GM/10ML ( levocarnitine 7 ROCALTROL CAPS 0.25 ) 7 (metabolic modifiers) MCG (calcitriol) CARNITOR TABS 330 MG RX/OTC ROCALTROL CAPS 0.5 QL(4 ea daily) 7 (levocarnitine 7 MCG (calcitriol) (metabolic modifiers)) ROCALTROL SOLN 1 PA 7 cinacalcet hcl tabs 3 MCG/ML (calcitriol) CYSTADANE POWD PA SENSIPAR TABS PA 4 7 (betaine) (cinacalcet hcl) PA sodium phenylbutyrate 4 doxercalciferol caps 3 powd GALAFOLD CAPS PA; QL(0.5 ea PA 4 sodium phenylbutyrate 4 (migalastat hcl) daily) tabs STRENSIQ SOLN PA 4 (asfotase alfa)

84 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ZEMPLAR CAPS 7 Vasopressin Receptor Antagonists (paricalcitol) JYNARQUE TBPK PA; LA 4 Posterior Pituitary Hormones (tolvaptan) DDAVP SOLN NA 0.01 % ESTROGENS - Hormone Replacement/Modifying (desmopressin acetate 2 Drugs refrigerated) Estrogen Combinations DDAVP SOLN NA 0.01 % (Estradiol & Norethindrone (desmopressin acetate 7 Acetate) AMABELZ, 1 spray) MIMVEY LO, MIMVEY, DDAVP TABS OR 0.1 MG LOPREEZA TABS 7 (desmopressin acetate) (Norethindrone Acetate- DDAVP TABS OR 0.2 MG QL(6 ea daily) Ethinyl Estradiol) 1 7 FYAVOLV, JINTELI, (desmopressin acetate) JEVANTIQUE LO TABS desmopressin acetate 1 ACTIVELLA TABS spray refrigerated soln (estradiol & 7 norethindrone acetate) desmopressin acetate 1 spray soln ANGELIQ TABS 3 (drospirenone-estradiol) desmopressin acetate 1 tabs 0.1 mg CLIMARA PRO PTWK Limit 4 per 28 QL(6 ea daily) (estradiol- 2 days;QL(0.15 desmopressin acetate 1 tabs 0.2 mg levonorgestrel) ea daily) STIMATE SOLN COMBIPATCH PTTW 3 (desmopressin acetate) (estradiol & 3 norethindrone acetate) Prolactin Inhibitors DUAVEE TABS cabergoline tabs 1 (conjugated estrogens- 3 bazedoxifene) Somatostatic Agents OCTREOTIDE ACETATE PA estradiol & SOLN 200 MCG/ML, 1000 norethindrone acetate 1 MCG/ML (octreotide 7 tabs acetate) FEMHRT LOW DOSE TABS (norethindrone octreotide acetate soln PA 7 50 mcg/ml, 100 acetate-ethinyl mcg/ml, 200 mcg/ml, 4 estradiol) 500 mcg/ml, 1000 norethindrone acetate- 1 mcg/ml, 1000 mcg/5ml ethinyl estradiol tabs SANDOSTATIN SOLN PA PREFEST TABS 7 3 (octreotide acetate) (estradiol-norgestimate) SIGNIFOR SOLN PA PREMPHASE TABS (conjugated estrogens- (pasireotide 4 2 diaspartate) medroxyprogesterone acetate)

85 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PREMPRO TABS 0.3 MG- QL(1 ea daily) Limit 50gms ESTROGEL GEL 1.5 MG (conjugated 3 per estrogens- 2 (estradiol) month;QL(1.67 medroxyprogesterone gm daily) ESTROPIPATE TABS 0.75 acetate) 2 MG (estropipate) PREMPRO TABS 0.625 ESTROPIPATE TABS 1.5 PV MG-2.5 MG, 0.45 MG-1.5 2 MG, 0.625 MG-5 MG MG (estropipate) (conjugated estrogens- 2 EVAMIST SOLN 3 medroxyprogesterone (estradiol) acetate) MENEST TABS 2 Estrogens (esterified estrogens) Limit 8 patches MENOSTAR PTWK Limit 4 per 28 3 days;QL(0.15 1 per (estradiol) (Estradiol) DOTTI PTTW month;QL(0.29 ea daily) ea daily) Limit 8 patches MINIVELLE PTTW Limit 8 patches 7 per (estradiol) month;QL(0.29 2 per ALORA PTTW (estradiol) month;QL(0.29 ea daily) ea daily) PREMARIN TABS OR QL(1 ea daily) 0.625 MG, 0.45 MG, 0.3 CLIMARA PTWK Limit 4 per 28 7 days;QL(0.15 MG, 1.25 MG ( 2 (estradiol) estrogens, ea daily) conjugated) DIVIGEL GEL 0.25 PREMARIN TABS OR 0.9 MG/0.25GM, 0.5 MG (estrogens, 2 MG/0.5GM, 1 MG/GM, 1.25 3 conjugated) MG/1.25GM (estradiol) Limit 8 patches ELESTRIN GEL VIVELLE-DOT PTTW 3 7 per (estradiol) (estradiol) month;QL(0.29 ESTRACE TABS ea daily) 7 (estradiol) FLUOROQUINOLONES - Drugs to Treat Bacterial estradiol pttw td 0.0375 Limit 8 patches Infections mg/24hr, 0.025 per month;QL(0.29 Fluoroquinolones mg/24hr, 0.075 1 AVELOX TABS ea daily) 7 mg/24hr, 0.05 mg/24hr, (moxifloxacin hcl) 0.1 mg/24hr CIPRO SUSR 5 estradiol ptwk td 0.025 Limit 4 per 28 GM/100ML, 500 MG/5ML 2 mg/24hr, 0.075 days;QL(0.15 (ciprofloxacin) ea daily) mg/24hr, 0.05 mg/24hr, CIPRO TABS 250 MG, 500 1 7 0.06 mg/24hr, 0.1 MG (ciprofloxacin hcl) mg/24hr, 37.5 CIPROFLOXACIN ER QL(14 ea per mcg/24hr TB24 1000 MG fill retail) (ciprofloxacin- 2 estradiol tabs or 0.5 1 mg, 1 mg, 2 mg ciprofloxacin hcl)

86 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CIPROFLOXACIN ER QL(3 ea per fill URSO FORTE TABS 7 TB24 500 MG retail) (ursodiol) (ciprofloxacin- 2 ciprofloxacin hcl) ursodiol caps 1 CIPROFLOXACIN HCL ursodiol tabs 1 TABS 100 MG 2 (ciprofloxacin hcl) Gastrointestinal Chloride Channel Activators AMITIZA CAPS ciprofloxacin hcl tabs 2 250 mg, 500 mg, 750 1 (lubiprostone) mg Gastrointestinal Stimulants ciprofloxacin susr 1 metoclopramide hcl soln 5 mg/5ml, 10 3 LEVAQUIN TABS QL(14 ea per 7 mg/10ml (levofloxacin) fill retail) metoclopramide hcl 1 levofloxacin soln 25 1 mg/ml tabs 5 mg, 10 mg METOCLOPRAMIDE ODT levofloxacin tabs 250 QL(14 ea per 1 fill retail) TBDP (metoclopramide 3 mg, 500 mg, 750 mg hcl) moxifloxacin hcl tabs 1 REGLAN TABS 7 OFLOXACIN TABS 300 (metoclopramide hcl) 2 MG (ofloxacin) Inflammatory Bowel Agents QL(28 ea per APRISO CP24 QL(4 ea daily) ofloxacin tabs 400 mg 3 7 90 days retail) (mesalamine) ASACOL HD TBEC GASTROINTESTINAL AGENTS - MISC. - 7 Miscellaneous Gastrointestinal Drugs (mesalamine) AZULFIDINE EN-TABS QL(8 ea daily) Agents for Chronic Idiopathic Constipation (CIC) 7 TRULANCE TABS PA; ST TBEC (sulfasalazine) 3 AZULFIDINE TABS QL(8 ea daily) (plecanatide) 7 ( ) Farnesoid X Receptor (FXR) Agonists sulfasalazine OCALIVA TABS 10 MG PA balsalazide disodium QL(9 ea 4 1 daily,280 ea (obeticholic acid) caps per fill retail) OCALIVA TABS 5 MG PA; ST CANASA SUPP QL(1 ea daily) 4 7 (obeticholic acid) (mesalamine) Gallstone Solubilizing Agents COLAZAL CAPS QL(9 ea ACTIGALL CAPS 7 daily,280 ea 7 (balsalazide disodium) (ursodiol) per fill retail) CHENODAL TABS PA DELZICOL CPDR QL(6 ea daily) 4 7 (chenodiol) (mesalamine) URSO 250 TABS DIPENTUM CAPS 7 3 (ursodiol) (olsalazine sodium) GIAZO TABS ST; QL(6 ea 3 (balsalazide disodium) daily) 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic Preferred AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

87 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LIALDA TBEC QL(4 ea daily) 7 Peripheral Opioid Receptor Antagonists (mesalamine) ENTEREG CAPS QL(4 ea daily) 3 mesalamine cp24 or 1 (alvimopan) 0.375 gm MOVANTIK TABS 12.5 MG 3 QL(6 ea daily) (naloxegol oxalate) mesalamine cpdr or 1 400 mg MOVANTIK TABS 25 MG QL(1 ea daily) 3 QL(60 ml daily) (naloxegol oxalate) mesalamine enem re 4 1 gm RELISTOR SOLN SC 8 PA QL(1 ea daily) MG/0.4ML, 12 MG/0.6ML mesalamine supp re 1 4 1000 mg (methylnaltrexone bromide) QL(4 ea daily) mesalamine tbec or 1.2 1 gm RELISTOR TABS OR 150 PA; ST MG (methylnaltrexone 4 mesalamine tbec or 1 bromide) 800 mg Phosphate Binder Agents PENTASA CPCR 250 MG PA 3 (Calcium Acetate RX/OTC (mesalamine) (Phosphate Binder)) 1 PENTASA CPCR 500 MG PA; QL(8 ea CALPHRON TABS 3 daily) (mesalamine) AURYXIA TABS (ferric PA; ST SFROWASA ENEM 3 2 citrate) (mesalamine) calcium acetate sulfasalazine tabs 1 QL(8 ea daily) (phosphate binder) 1 QL(8 ea daily) caps sulfasalazine tbec 1 RX/OTC calcium acetate 1 Intestinal Acidifiers (phosphate binder) tabs (Lactulose FOSRENOL CHEW 1000 QL(3 ea daily) MG ( 7 (Encephalopathy)) 1 lanthanum ENULOSE, GENERLAC carbonate) SOLN FOSRENOL CHEW 500 lactulose 1 MG (lanthanum 7 (encephalopathy) soln carbonate) Irritable Bowel Syndrome (IBS) Agents FOSRENOL CHEW 750 QL(4 ea daily) MG (lanthanum 7 alosetron hcl tabs 3 carbonate) LINZESS CAPS 2 FOSRENOL PACK 750 (linaclotide) MG, 1000 MG 3 LOTRONEX TABS (lanthanum carbonate) 7 (alosetron hcl) QL(3 ea daily) lanthanum carbonate 1 VIBERZI TABS 100 MG PA 3 chew 1000 mg (eluxadoline) lanthanum carbonate VIBERZI TABS 75 MG PA; ST 1 3 chew 500 mg (eluxadoline)

88 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(4 ea daily) (Potassium Citrate-Citric lanthanum carbonate 1 chew 750 mg Acid) CYTRA K 1 CRYSTALS, TARON- PHOSLYRA SOLN CRYSTALS PACK (calcium acetate 3 (Potassium Citrate-Citric 1 RX/OTC (phosphate binder)) Acid) CYTRA-K SOLN RENAGEL TABS PA; ST;QL(16 ORACIT SOLN (sodium 7 ea daily) 3 (sevelamer hcl) citrate & citric acid) RENVELA PACK 0.8 GM 7 pot & sod citrates 3 (sevelamer carbonate) w/citric ac soln RENVELA PACK 2.4 GM QL(5 ea daily) 7 (sevelamer carbonate) potassium citrate 1 (alkalinizer) tbcr RENVELA TABS 800 MG 7 RX/OTC (sevelamer carbonate) potassium citrate-citric 1 acid soln sevelamer carbonate 1 pack 0.8 gm UROCIT-K 10 TBCR (potassium citrate 7 QL(5 ea daily) sevelamer carbonate 1 (alkalinizer)) pack 2.4 gm UROCIT-K 15 TBCR sevelamer carbonate 1 (potassium citrate 7 tabs 800 mg (alkalinizer)) sevelamer hcl tabs 3 PA; ST;QL(16 UROCIT-K 5 TBCR ea daily) (potassium citrate 7 SEVELAMER PA; ST (alkalinizer)) HYDROCHLORIDE TABS 3 (sevelamer hcl) Cystinosis Agents CYSTAGON CAPS PA Short Bowel Syndrome (SBS) Agents 4 (cysteamine bitartrate) GATTEX KIT PA; ST 4 PROCYSBI CPDR PA (teduglutide (rdna)) 4 (cysteamine bitartrate) Tryptophan Hydroxylase Inhibitors PROCYSBI PACK PA 4 XERMELO TABS PA; ST; Not (cysteamine bitartrate) 4 available (telotristat etiprate) through mail Interstitial Cystitis Agents GENITOURINARY AGENTS - MISCELLANEOUS ELMIRON CAPS QL(3 ea daily) - Miscellaneous Drugs to Treat Reproductive (pentosan polysulfate 3 Organs and Urinary System sodium) Acidifiers Prostatic Hypertrophy Agents K-PHOS NO 2 TABS alfuzosin hcl tb24 1 QL(1 ea daily) (potassium & sodium 2 AVODART CAPS AL(At least 40 acid phosphates) 7 (dutasteride) yrs old) Alkalinizers CARDURA XL TB24 (Pot & Sod Citrates W/Citric Ac) CYTRA-3 1 (doxazosin mesylate 3 SYRP (bph))

89 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 1 AL(At least 40 colchicine tabs 1 dutasteride caps yrs old) COLCRYS TABS dutasteride-tamsulosin 1 7 hcl caps (colchicine) QL(1 ea daily); febuxostat tabs 40 mg 1 QL(2 ea daily) finasteride tabs 1 AL(At least 40 yrs old) febuxostat tabs 80 mg 1 QL(1 ea daily) FLOMAX CAPS QL(2 ea daily) 7 MITIGARE CAPS (tamsulosin hcl) 3 (colchicine) JALYN CAPS ULORIC TABS 40 MG QL(2 ea daily) (dutasteride-tamsulosin 7 7 (febuxostat) hcl) ULORIC TABS 80 MG QL(1 ea daily) PROSCAR TABS QL(1 ea daily); 7 7 AL(At least 40 (febuxostat) (finasteride) ZYLOPRIM TABS 100 MG QL(3 ea daily) yrs old) 7 RAPAFLO CAPS 8 MG QL(1 ea daily) (allopurinol) 7 ( ) ZYLOPRIM TABS 300 MG QL(2 ea daily) silodosin 7 (allopurinol) silodosin caps 4 mg 1 Uricosurics 3 QL(1 ea daily) silodosin caps 8 mg probenecid tabs 1 QL(2 ea daily) tamsulosin hcl caps 1 HEMATOLOGICAL AGENTS - MISC. - Drugs to UROXATRAL TB24 QL(1 ea daily) Treat Blood Disorders 7 (alfuzosin hcl) Antihemophilic Products Urinary Stone Agents ADVATE SOLR PA LITHOSTAT TABS (antihemophilic factor 4 3 (acetohydroxamic acid) rahf-pfm) THIOLA EC TBEC ADYNOVATE SOLR 250 PA 3 UNIT, 500 UNIT, 1000 (tiopronin) UNIT, 2000 UNIT 4 THIOLA TABS (tiopronin) 3 (antihemophilic factor (recombinant) pegylated) GOUT AGENTS - Drugs to Treat Gout ADYNOVATE SOLR 3000 PA; LA Gout Agent Combinations UNIT (antihemophilic 4 factor (recombinant) colchicine w/ 1 pegylated) probenecid tabs ADYNOVATE SOLR 750 PA; Must use Gout Agents UNIT, 1500 UNIT AcariaHlth Sp (antihemophilic factor 4 Rx 1-844-538- allopurinol tabs 100 mg 1 QL(3 ea daily) (recombinant) pegylated) 4661 allopurinol tabs 300 mg 1 QL(2 ea daily) AFSTYLA KIT PA; LA (antihemophilic factor COLCHICINE CAPS 4 3 (recombinant) single (colchicine) chain)

90 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ALPHANATE/VON PA FIBRYGA SOLR PA WILLEBRANDFACTOR (fibrinogen concentrate 4 COMPLEX/HUMAN SOLR (human)) (antihemophilic 4 HELIXATE FS KIT PA factor/von willebrand (antihemophilic factor 4 factor complex (recombinant)) (human)) HEMOFIL M SOLR 1700 PA ALPHANINE SD SOLR PA 4 UNIT, 1501 -2000 UNIT (coagulation factor ix) (antihemophilic factor 4 ALPROLIX SOLR 250 PA (human)) UNIT, 500 UNIT, 1000 HEMOFIL M SOLR 250 PA; LA UNIT, 2000 UNIT, 3000 4 UNIT, 500 UNIT, 1000 UNIT (coagulation factor UNIT (antihemophilic 3 ix (recomb) fc fusion ) protein (rfixfc)) factor (human) ALPROLIX SOLR 4000 PA; Must use HUMATE-P SOLR PA AcariaHlth Sp (antihemophilic UNIT (coagulation factor 4 ix (recomb) fc fusion Rx 1-844-538- factor/von willebrand 4 protein (rfixfc)) 4661;LA factor complex (human)) BEBULIN SOLR ( PA factor ix 4 complex) IDELVION SOLR 250 PA; SP UNIT, 500 UNIT, 1000 BENEFIX KIT PA UNIT, 2000 UNIT (coagulation factor ix 4 (coagulation factor ix 4 (recombinant)) recomb albumin fusion COAGADEX SOLR PA protein (rix-fp)) (coagulation factor x 4 IDELVION SOLR 3500 PA (human)) UNIT (coagulation factor 4 CORIFACT KIT (factor PA ix recomb albumin xiii concentrate 4 fusion protein (rix-fp)) (human)) IXINITY SOLR 1500 UNIT PA; LA ELOCTATE SOLR 250 PA; LA (coagulation factor ix 4 UNIT, 500 UNIT, 750 UNIT, (recombinant)) 1000 UNIT, 1500 UNIT, IXINITY SOLR 250 UNIT, PA 2000 UNIT, 3000 UNIT 4 500 UNIT, 1000 UNIT, ( antihemophilic factor 2000 UNIT, 3000 UNIT 4 (rcmb) fc fusion (coagulation factor ix protein(bdd-rfviiifc)) (recombinant)) ELOCTATE SOLR 4000 PA; Must use UNIT, 5000 UNIT, 6000 AcariaHlth Sp JIVI SOLR PA UNIT (antihemophilic 4 Rx 1-844-538- (antihemophilic factor 4 factor (rcmb) fc fusion 4661;SP (recombinant) pegylated- protein(bdd-rfviiifc)) aucl) FEIBA SOLR PA KCENTRA KIT PA (antiinhibitor coagulant 4 (prothrombin complex 4 complex) concentrate human) 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic Preferred AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

91 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits KOATE SOLR PA; LA PROFILNINE SOLR PA 4 (antihemophilic factor 3 (factor ix complex) (human)) RECOMBINATE SOLR PA KOATE-DVI SOLR PA; LA (antihemophilic factor 4 (antihemophilic factor 3 (recombinant)) (human)) RIASTAP SOLR PA KOGENATE FS BIO-SET PA (fibrinogen concentrate 4 KIT (antihemophilic 4 (human)) factor (recombinant)) RIXUBIS SOLR PA KOGENATE FS KIT PA (coagulation factor ix 4 (antihemophilic factor 4 (recombinant)) (recombinant)) TRETTEN SOLR PA KOVALTRY SOLR PA (coagulation factor xiii 4 (antihemophilic factor 4 a-subunit rahf-pfm) (recombinant)) MONOCLATE-P KIT PA VONVENDI SOLR (von PA (antihemophilic factor 4 willebrand factor 4 (human)) (recombinant)) MONONINE SOLR PA 4 WILATE KIT PA; SP (coagulation factor ix) (antihemophilic NOVOEIGHT SOLR PA factor/von willebrand 4 (antihemophilic factor 4 factor complex (rcmb) bd truncated (bd (human)) trunc-rfviii)) XYNTHA KIT PA NOVOSEVEN RT SOLR PA (antihemophilic factor 4 (coagulation factor viia 4 (recombinant) (recombinant)) plasma/albumin free) NUWIQ KIT 2500 UNIT, PA; Refer to XYNTHA SOLOFUSE KIT PA 3000 UNIT, 4000 UNIT Accredo SP 250 UNIT, 500 UNIT, 1000 Rx;LA UNIT, 2000 UNIT (antihemophilic factor 4 4 (rcmb) simoctocog (antihemophilic factor alfa(bdd-rfviii,sim)) (recombinant) NUWIQ SOLR 2500 UNIT, PA; SP- Acaria plasma/albumin free) 3000 UNIT, 4000 UNIT Health;LA XYNTHA SOLOFUSE KIT PA; SP (antihemophilic factor 4 3000 UNIT (rcmb) simoctocog (antihemophilic factor 4 alfa(bdd-rfviii,sim)) (recombinant) OBIZUR SOLR PA plasma/albumin free) (antihemophilic factor 4 Bradykinin B2 Receptor Antagonists (recombinant porcine) PA; Must use (rpfviii)) AcariaHealth PROFILNINE SD SOLR PA icatibant acetate soln 4 Specialty Rx at 4 (factor ix complex) 1-844-538- 4661;LA

92 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Hemataologic - Tyrosine Kinase Inhibitors miglustat caps 4 PA; ST TAVALISSE TABS 100 MG PA; ST;LA 4 ZAVESCA CAPS PA; ST (fostamatinib disodium) 7 (miglustat) TAVALISSE TABS 150 MG PA; LA 4 (fostamatinib disodium) Agents for Sickle Cell Disease DROXIA CAPS Hematorheologic Agents (hydroxyurea (sickle 2 pentoxifylline tbcr 1 QL(3 ea daily) cell anemia)) SIKLOS TABS 100 MG PA; ST;AC Human Protein C (hydroxyurea (sickle 4 CEPROTIN SOLR PA cell anemia)) (protein c concentrate 4 SIKLOS TABS 1000 MG PA; AC (human)) (hydroxyurea (sickle 4 Platelet Aggregation Inhibitors cell anemia)) AGGRENOX CP12 7 Folic Acid/Folates (aspirin-dipyridamole) (Folic Acid) CVS FOLIC PV AGRYLIN CAPS 7 ACID, YL FOLIC ACID, SM (anagrelide hcl) FOLIC ACID, RA FOLIC ACID, QC FOLIC ACID, PX 7 anagrelide hcl caps 1 FOLIC ACID, HM FOLIC ACID, GNP FOLIC ACID, aspirin-dipyridamole 3 cp12 FOLATE, FA-8 TABS (Folic Acid) KP FOLIC RX/OTC BRILINTA TABS 60 MG QL(2 ea daily) 1 2 ACID TABS 1 MG (ticagrelor) (Folic Acid) KP FOLIC PV BRILINTA TABS 90 MG 7 2 ACID TABS 800 MCG (ticagrelor) folic acid tabs 1 mg 1 RX/OTC cilostazol tabs 1 QL(2 ea daily) folic acid tabs 400 mcg, PV QL(2 ea daily) 7 clopidogrel bisulfate 1 800 mcg tabs Hematopoietic Growth Factors dipyridamole tabs 1 FULPHILA SOSY PA 4 EFFIENT TABS (pegfilgrastim-jmdb) 7 GRANIX SOLN ( PA (prasugrel hcl) tbo- 4 PLAVIX TABS QL(2 ea daily) filgrastim) 7 LEUKINE SOLR PA (clopidogrel bisulfate) 4 (sargramostim) prasugrel hcl tabs 1 MULPLETA TABS PA 4 HEMATOPOIETIC AGENTS - Drugs to Treat (lusutrombopag) Blood Disorders NIVESTYM SOLN 300 PA; ST 4 Agents for Gaucher Disease MCG/ML (filgrastim-aafi) CERDELGA CAPS PA 4 (eliglustat tartrate)

93 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NIVESTYM SOLN 480 PA HYPNOTICS/SEDATIVES/SLEEP DISORDER MCG/1.6ML (filgrastim- 4 AGENTS aafi) Barbiturate Hypnotics NIVESTYM SOSY 300 PA BUTISOL SODIUM TABS MCG/0.5ML, 480 3 (butabarbital sodium) MCG/0.8ML (filgrastim- 4 aafi) phenobarbital elix 1 PROMACTA PACK 12.5 PA; QL(1 ea MG (eltrombopag 4 daily) phenobarbital soln 1 olamine) phenobarbital tabs 1 PROMACTA PACK 25 MG 2 (eltrombopag olamine) Non-Barbiturate Hypnotics AMBIEN CR TBCR QL(1 ea daily) PROMACTA TABS 25 MG, PA; QL(1 ea 7 50 MG, 75 MG, 12.5 MG 4 daily) (zolpidem tartrate) (eltrombopag olamine) AMBIEN TABS ( QL(1 ea daily) zolpidem 7 RETACRIT SOLN 2000 PA tartrate) UNIT/ML, 3000 UNIT/ML, DORAL TABS 4000 UNIT/ML, 10000 4 3 UNIT/ML, 40000 UNIT/ML (quazepam) (epoetin alfa-epbx) estazolam tabs 1 PA; ST; Must use eszopiclone tabs 3 QL(1 ea daily) UDENYCA SOSY AcariaHealth 4 QL(2 ea daily) (pegfilgrastim-cbqv) Specialty Rx at flurazepam hcl caps 15 1 1-844-538- mg 4661 flurazepam hcl caps 30 QL(1 ea daily) ZARXIO SOSY PA; LA 1 3 mg (filgrastim-sndz) HALCION TABS QL(1 ea daily) ZIEXTENZO SOSY PA; ST 7 4 (triazolam) (pegfilgrastim-bmez) LUNESTA TABS QL(1 ea daily) 7 HEMOSTATICS - Drugs to Stop Bleeding/Treat (eszopiclone) Blood Disorders midazolam hcl syrp 3 Hemostatics - Systemic AMICAR SOLN QUAZEPAM TABS 7 3 (aminocaproic acid) (quazepam) AMICAR TABS RESTORIL CAPS 15 MG QL(2 ea daily) 7 7 (aminocaproic acid) (temazepam) RESTORIL CAPS 30 MG, QL(1 ea daily) 7 aminocaproic acid soln 3 22.5 MG (temazepam) RESTORIL CAPS 7.5 MG aminocaproic acid tabs 3 7 (temazepam) LYSTEDA TABS QL(6 ea daily,5 SONATA CAPS QL(1 ea daily) 7 day(s) limit) 7 (tranexamic acid) (zaleplon) 1 QL(6 ea daily,5 tranexamic acid tabs day(s) limit) 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic Preferred AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

94 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(2 ea daily) COLYTE-FLAVOR PACKS QL(4000 ml per temazepam caps 15 1 SOLR (peg 3350-kcl-sod fill retail); PV mg 5 QL(1 ea daily) bicarb-sod chloride-sod temazepam caps 22.5 3 mg sulfate) QL(1 ea daily) GAVILYTE-C SOLR (peg QL(4000 ml per temazepam caps 30 1 fill retail); PV mg 3350-kcl-sod bicarb- 5 sod chloride-sod temazepam caps 7.5 1 sulfate) mg GOLYTELY SOLR 227.1 PA; QL(4000 triazolam tabs 0.125 1 GM-21.5 GM-5.53 GM-2.82 ea per fill mg GM-6.36 GM (peg 3350- 5 retail); PV triazolam tabs 0.25 mg 1 QL(1 ea daily) kcl-sod bicarb-sod chloride-sod sulfate) zaleplon caps 1 QL(1 ea daily) GOLYTELY SOLR 236 QL(4000 ml per GM-22.74 GM-5.86 GM- fill retail); PV QL(1 ea daily) zolpidem tartrate tabs 1 2.97 GM-6.74 GM (peg or 5 mg, 10 mg 3350-kcl-sod bicarb- 5 QL(1 ea daily) zolpidem tartrate tbcr 3 sod chloride-sod or 12.5 mg, 6.25 mg sulfate) Orexin Receptor Antagonists MOVIPREP SOLR (peg PA; PV BELSOMRA TABS ST; QL(1 ea 3350-kcl-nacl-na 2 5 (suvorexant) daily) sulfate-na ascorbate- Selective Melatonin Receptor Agonists ascorbic acid) HETLIOZ CAPS PA; ST NULYTELY/FLAVOR PV 4 (tasimelteon) PACKS SOLR (peg 3350- potassium chloride-sod 5 3 ST; QL(1 ea ramelteon tabs daily) bicarbonate-sod ROZEREM TABS ST; QL(1 ea chloride) 7 (ramelteon) daily) peg 3350-kcl-sod QL(4000 ml per bicarb-sod chloride-sod 7 fill retail); PV LAXATIVES - Bowel Treatment Drugs sulfate solr Laxative Combinations peg 3350-potassium PV (Bisacodyl-Peg 3350-Pot QL(1 ea per fill chloride-sod 7 Chloride-Sod Bicarb-Sod 7 retail); PV bicarbonate-sod Chloride) GAVILYTE-H, chloride solr PEG-PREP KIT PLENVU SOLR (peg PA; PV (Peg 3350-Kcl-Sod Bicarb- QL(4000 ml per Sod Chloride-Sod Sulfate) 7 fill retail); PV 3350-kcl-nacl-na 5 GAVILYTE-G SOLR sulfate-na ascorbate- (Peg 3350-Potassium PV ascorbic acid) Chloride-Sod Bicarbonate- PREPOPIK PACK PA; PV Sod Chloride) GAVILYTE- 7 (sodium picosulfate- N/FLAVOR PACK, magnesium oxide- 5 TRILYTE SOLR anhydrous citric acid)

95 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SUPREP BOWEL PREP PV Available for KIT SOLN (sodium members in sulfate-potassium 5 non- ORAL SALINE LAXATIVE grandfathered sulfate-magnesium SOLN (sodium 2 plans ages 50- sulfate) phosphates) 74;AL(At least Laxatives - Miscellaneous 50 yrs old - Up to 74 yrs old); (Lactulose) CONSTULOSE 1 SOLN PV (Polyethylene Glycol 3350) Limited to 510 OSMOPREP TABS PA (sodium phosphate CLEARLAX, TGT Gm per 5 POWDERLAX, SMOOTH month;QL(17.6 monobasic-sodium LAX, SM CLEARLAX, SB gm daily); phosphate dibasic) POLYETHYLENE GLYCOL RX/OTC 3350, QC NATURA-LAX, Stimulant Laxatives PEGYLAX, KLS LAXACLEAR, HM 1 CLEARLAX, GOODSENSE CLEARLAX, GNP CLEARLAX, GLYCOLAX, GENTLELAX, GAVILAX, EQL CLEARLAX, EQ CLEARLAX, CVS PURELAX POWD Limited to 510 (Polyethylene Glycol 3350) Gm per RA LAXATIVE POWD 17 1 month;QL(17.6 GM/SCOOP gm daily); RX/OTC lactulose soln 10 1 gm/15ml, 20 gm/30ml Limited to 510 MIRALAX POWD Gm per (polyethylene glycol 7 month;QL(17.6 3350) gm daily); RX/OTC Limited to 510 polyethylene glycol Gm per 1 month;QL(17.6 3350 powd gm daily); RX/OTC Saline Laxatives

96 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Bisacodyl) ALOPHEN, Available for (Bisacodyl) BISACODYL Available for WOMENS LAXATIVE, members in LAXATIVE, THE MAGIC members in WOMANS LAXATIVE, non- BULLET, SM LAXATIVE, non- VERACOLATE, TGT grandfathered SB LAXATIVE, RA grandfathered WOMENS LAXATIVE, TGT plans ages 50- STIMULANT LAXATIVE, plans ages 50- GENTLE LAXATIVE, 74;AL(At least RA FAST RELIEF 74;AL(At least STIMULANT LAXATIVE, 50 yrs old - Up LAXATIVE, QC GENTLE 50 yrs old - Up SM WOMANS LAXATIVE, to 74 yrs old); LAXATIVE, LAXATIVE, HM 1 to 74 yrs old); SM GENTLE LAXATIVE, PV LAXATIVE, GNP PV SB GENTLE LAXATIVE LAXATIVE, GNP GENTLE WOMENS, SB GENTLE LAXATIVE, GENTLE LAX-WOMEN, SB LAXATIVE, CVS GENTLE BISACODYL LAXATIVE LAXATIVE, CVS EC, RA WOMENS BISACODYL, BISCOLAX LAXATIVE, QC GENTLE SUPP LAXATIVE, PX LAXATIVE, Available for LAXATIVE, KP members in BISACODYL, HM non- LAXATIVE, GOODSENSE grandfathered WOMENS LAXATIVE, (Bisacodyl) RA LAXATIVE 1 plans ages 50- GOODSENSE TBEC 5 MG 74;AL(At least BISACODYL EC, GNP 50 yrs old - Up WOMENS LAXATIVE, 1 to 74 yrs old); GNP WOMENS GENTLE PV LAXATIVE, GNP LAXATIVE, GNP GENTLE Available for LAXATIVE, GNP BISA- members in LAX, GENTLE LAXATIVE non- OVERNIGHTRELIEF, grandfathered GENTLE LAXATIVE FOR bisacodyl supp 1 plans ages 50- WOMEN, GENTLE 74;AL(At least LAXATIVE, FEENAMINT, 50 yrs old - Up EX-LAX ULTRA, EQL to 74 yrs old); WOMANS LAXATIVE, EQL PV LAXATIVE, EQL GENTLE Available for LAXATIVE, EQ WOMENS members in LAXATIVE, EQ WOMANS non- LAXATIVE, EQ GENTLE DULCOLAX SUPP grandfathered 7 plans ages 50- LAXATIVE, DUCODYL, (bisacodyl) CVS GENTLE LAXATIVE 74;AL(At least WOMENS, CVS GENTLE 50 yrs old - Up LAXATIVE, CVS C-LAX to 74 yrs old); LAXATIVE, CVS PV BISACODYL, Available for CORRECTOL, CORRECT, members in BISACODYL EC TBEC non- DULCOLAX TBEC grandfathered 7 plans ages 50- (bisacodyl) 74;AL(At least 50 yrs old - Up to 74 yrs old); PV 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic Preferred AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

97 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MACROLIDES - Drugs to Treat Bacterial (Erythromycin Stearate) Infections ERYTHROCIN STEARATE 1 TABS Azithromycin E.E.S. GRANULES SUSR AZITHROMYCIN PACK 1 2 (erythromycin 7 GM (azithromycin) ethylsuccinate) azithromycin susr 100 1 ERYPED 200 SUSR mg/5ml, 200 mg/5ml (erythromycin 7 QL(6 ea per fill ) azithromycin tabs 250 1 ethylsuccinate mg retail) ERYPED 400 SUSR QL(3 ea daily) (erythromycin 7 azithromycin tabs 500 1 mg ethylsuccinate) QL(10 ea per erythromycin base azithromycin tabs 600 1 1 mg fill retail) cpep ZITHROMAX PACK 1 GM 2 erythromycin base tabs 1 (azithromycin) ZITHROMAX SUSR 100 erythromycin base tbec 1 MG/5ML, 200 MG/5ML 7 ERYTHROMYCIN CPEP (azithromycin) 2 (erythromycin base) ZITHROMAX TABS 250 QL(6 ea per fill 7 MG (azithromycin) retail) erythromycin 1 ethylsuccinate susr ZITHROMAX TABS 500 QL(3 ea daily) 7 MG (azithromycin) erythromycin 1 ZITHROMAX TABS 600 QL(10 ea per ethylsuccinate tabs 7 MG (azithromycin) fill retail) Fidaxomicin ZITHROMAX TRI-PAK QL(3 ea daily) DIFICID TABS 7 3 TABS (azithromycin) (fidaxomicin) ZITHROMAX Z-PAK TABS QL(6 ea per fill 7 MEDICAL DEVICES AND SUPPLIES (azithromycin) retail) Contraceptives Clarithromycin CAYA DPRH (diaphragm QL(1 ea per CLARITHROMYCIN SUSR 5 365 days 125 MG/5ML, 250 MG/5ML 2 arc-spring) retail); PV (clarithromycin) FC FEMALE CONDOM PV clarithromycin tabs 250 1 MISC (condoms - 5 mg, 500 mg female) clarithromycin tb24 500 QL(14 ea per FC2 FEMALE CONDOM PV 1 fill retail) mg MISC (condoms - 5 Erythromycins female) (Erythromycin Base) ERY- FEMCAP DEVI ( PV 1 cervical 5 TAB TBEC caps) (Erythromycin OMNIFLEX DIAPHRAGM PV 5 Ethylsuccinate) E.E.S. 400 1 DPRH (diaphragms) TABS 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic Preferred AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

98 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits WIDE-SEAL SILICONE PV 1ST TIER UNIFINE Limit 200 per DIAPHRAGM KIT 60 month without 5 PENTIPS/MINI/31GX5MM DPRH (diaphragm wide MISC (insulin pen 2 authorization;Q seal) L(6.67 ea needle) daily); RX/OTC WIDE-SEAL SILICONE PV DIAPHRAGM KIT 65 1ST TIER UNIFINE RX/OTC PENTIPS29GX12MM DPRH (diaphragm wide 5 MISC (insulin pen 2 seal) needle) WIDE-SEAL SILICONE PV DIAPHRAGM KIT 70 1ST TIER UNIFINE RX/OTC PENTIPS31GX6MM MISC DPRH (diaphragm wide 5 2 (insulin pen needle) seal) Limited to 200 WIDE-SEAL SILICONE PV 1ST TIER UNIFINE without prior DIAPHRAGM KIT 75 5 PENTIPS31GX8MM MISC 2 auth;QL(6.67 DPRH (diaphragm wide (insulin pen needle) ea daily); seal) RX/OTC WIDE-SEAL SILICONE PV 1ST TIER UNIFINE DIAPHRAGM KIT 80 PENTIPS32GX6MM MISC 5 2 DPRH (diaphragm wide (insulin pen needle) seal) 1ST TIER UNIFINE WIDE-SEAL SILICONE PV PENTIPS33GX4MM MISC 2 DIAPHRAGM KIT 85 (insulin pen needle) DPRH (diaphragm wide 5 1ST TIER UNIFINE Limited to 200 seal) PENTIPSPLUS 31GX8MM without prior WIDE-SEAL SILICONE PV MISC ( 2 auth;QL(6.67 insulin pen ea daily); DIAPHRAGM KIT 90 needle) DPRH (diaphragm wide 5 RX/OTC seal) 1ST TIER UNIFINE PENTIPSPLUS 33GX4MM WIDE-SEAL SILICONE PV 2 DIAPHRAGM KIT 95 MISC (insulin pen DPRH (diaphragm wide 5 needle) seal) 1ST TIER UNIFINE Limit 200 per PENTIPSPLUS/MINI/31GX month without Diabetic Supplies 5MM MISC (insulin pen 2 authorization;Q ONETOUCH ULTRA 2 KIT QL(1 ea per L(6.67 ea needle) (blood glucose 2 365 days daily); RX/OTC monitoring supplies) retail); RX/OTC 1ST TIER UNIFINE RX/OTC PENTIPSPLUS/ORIGINAL/ ONETOUCH VERIO FLEX QL(1 ea per 2 BLOOD GLUCOSE 365 days 29GX12MM MISC (insulin MONITORING SYSTEM 2 retail); RX/OTC pen needle) KIT (blood glucose 1ST TIER UNIFINE RX/OTC monitoring supplies) PENTIPSPLUS/ULTRA SHORT/31GX6MM MISC 2 Parenteral Therapy Supplies (insulin pen needle)

99 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ABOUTTIME PEN RX/OTC Limited to 200 NEEDLES 30GX 5/16" AURORA PEN NEEDLES without prior MISC (insulin pen 2 31G X8MM MISC (insulin 2 auth;QL(6.67 needle) pen needle) ea daily); RX/OTC Limit 200 per ABOUTTIME PEN Limit 200 per NEEDLES 31G X 3/16" month without AURORA UNIFINE PENTIPS/MINI/31GX3/16" month without MISC (insulin pen 2 authorization;Q L(6.67 ea MISC (insulin pen 2 authorization;Q needle) daily); RX/OTC L(6.67 ea needle) daily); RX/OTC ABOUTTIME PEN Limited to 200 without prior BD ECLIPSE NEEDLE NEEDLES 31G X 5/16" 30G X1/2" MISC (needle 2 MISC ( 2 auth;QL(6.67 insulin pen ea daily); (disp) 30 g) needle) RX/OTC BD NEEDLE/30G X 1/2" ADVOCATE INSULIN PEN RX/OTC MISC (needle (disp) 30 2 NEEDLES 29GX12.7MM g) 2 MISC (insulin pen BD PEN needle) NEEDLE/MICRO/ULTRA- FINE/32G X 6MM MISC 2 ADVOCATE INSULIN PEN Limit 200 per NEEDLES 31GX5MM month without (insulin pen needle) 2 authorization;Q MISC (insulin pen BD PEN Limit 200 per L(6.67 ea month without needle) daily); RX/OTC NEEDLE/MINI/ULTRA- FINE/31G X 5MM MISC 2 authorization;Q Limited to 200 L(6.67 ea ADVOCATE INSULIN PEN (insulin pen needle) NEEDLES 31GX8MM without prior daily); RX/OTC MISC ( 2 auth;QL(6.67 BD PEN RX/OTC insulin pen ea daily); needle) NEEDLE/ORIGINAL/ULTR RX/OTC A-FINE/29G X 12.7MM 2 ADVOCATE INSULIN PEN MISC (insulin pen NEEDLES MISC (insulin 2 needle) pen needle) BD PEN Limited to 200 ASSURE ID SAFETY PEN RX/OTC NEEDLE/SHORT/ULTRA- without prior NEEDLES 30G X 5/16" FINE/31G X 8MM MISC 2 auth;QL(6.67 2 ea daily); MISC (insulin pen (insulin pen needle) needle) RX/OTC BD SAFETYGLIDE RX/OTC ASSURE ID SAFETY PEN Limit 200 per month without INSULIN NEEDLES 31G X 3/16" SYRINGE/0.3ML/31G X 2 MISC ( 2 authorization;Q insulin pen L(6.67 ea 15/64" MISC (insulin needle) daily); RX/OTC syringe/needle u-100) AURORA PEN NEEDLES RX/OTC BD SAFETYGLIDE Limit 200 per 29GX12MM MISC 2 INSULIN month;QL(6.67 (insulin pen needle) SYRINGE/1ML/31G X 2 ea daily) AURORA PEN NEEDLES RX/OTC 15/64" MISC (insulin 31G X6MM MISC (insulin 2 syringe/needle u-100) pen needle)

100 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BD VEO INSULIN RX/OTC CAREONE UNIFINE RX/OTC SYRINGE ULTRA- PENTIPS 29GX12MM AFINE/0.3ML/31G X 6MM 2 MISC (insulin pen 2 MISC (insulin needle) syringe/needle u-100) Limit 200 per BD VEO INSULIN RX/OTC CAREONE UNIFINE month without SYRINGE ULTRA- PENTIPS 31GX5MM MISC 2 authorization;Q FINE/0.3ML/31G X 6MM 2 (insulin pen needle) L(6.67 ea MISC (insulin daily); RX/OTC syringe/needle u-100) CAREONE UNIFINE RX/OTC BD VEO INSULIN RX/OTC PENTIPS 31GX6MM MISC 2 SYRINGE ULTRA- (insulin pen needle) FINE/1/2 UNIT/0.3ML/31G 2 Limited to 200 X 6MM MISC (insulin CAREONE UNIFINE without prior syringe/needle u-100) PENTIPS 31GX8MM MISC 2 auth;QL(6.67 (insulin pen needle) ea daily); BD VEO INSULIN Limit 200 per RX/OTC SYRINGE ULTRA- month;QL(6.67 FINE/1ML/31G X 6MM 2 ea daily) CAREONE UNIFINE RX/OTC MISC (insulin PENTIPS PLUS PEN NEEDLES 29GX12MM syringe/needle u-100) 2 MISC (insulin pen CAREFINE PEN RX/OTC needle) NEEDLES 29GX1/2" MISC 2 (insulin pen needle) CAREONE UNIFINE Limit 200 per PENTIPS PLUS PEN month without CAREFINE PEN RX/OTC NEEDLES 31GX5MM 2 authorization;Q NEEDLES 30GX5/16" 2 MISC (insulin pen L(6.67 ea MISC (insulin pen needle) daily); RX/OTC needle) CAREONE UNIFINE RX/OTC CAREFINE PEN RX/OTC PENTIPS PLUS PEN NEEDLES 31GX6MM 2 NEEDLES 31GX6MM 2 MISC (insulin pen MISC (insulin pen needle) needle) CAREFINE PEN Limited to 200 CAREONE UNIFINE Limited to 200 NEEDLES 31GX8MM without prior PENTIPS PLUS PEN without prior MISC (insulin pen 2 auth;QL(6.67 NEEDLES 31GX8MM 2 auth;QL(6.67 ea daily); MISC (insulin pen ea daily); needle) RX/OTC needle) RX/OTC CAREFINE PEN RX/OTC NEEDLES 32GX5MM CARETOUCH PEN RX/OTC NEEDLES 31G X 6 MM MISC (insulin pen 2 MISC (insulin pen 2 needle) needle) CAREFINE PEN NEEDLES 32GX6MM CARETOUCH PEN Limit 200 per month without MISC (insulin pen 2 NEEDLES 31GX 5MM MISC ( 2 authorization;Q needle) insulin pen L(6.67 ea needle) daily); RX/OTC

101 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CARETOUCH PEN Limited to 200 CLEVER CHOICE NEEDLES 31GX 8MM without prior COMFORT EZPEN MISC ( 2 auth;QL(6.67 NEEDLES 32GX6MM 2 insulin pen ea daily); needle) MISC (insulin pen RX/OTC needle) CARETOUCH PEN RX/OTC CLEVER CHOICE NEEDLES 32GX 5MM 2 COMFORT EZPEN MISC (insulin pen NEEDLES 32GX8MM 2 needle) MISC (insulin pen CLEVER CHOICE Limited to 200 needle) COMFORT EZINSULIN without prior CLEVER CHOICE PEN NEEDLES 31GX8MM 2 auth;QL(6.67 COMFORT EZPEN MISC (insulin pen ea daily); NEEDLES 33GX4MM RX/OTC 2 needle) MISC (insulin pen CLEVER CHOICE needle) COMFORT EZINSULIN CLICKFINE PEN NEEDLE RX/OTC PEN NEEDLES 33GX4MM 2 UNIVERSAL/31GX1/4" MISC (insulin pen MISC (insulin pen 2 needle) needle) CLEVER CHOICE RX/OTC CLICKFINE PEN NEEDLE Limited to 200 COMFORT EZPEN without prior NEEDLES 29GX12MM 2 UNIVERSAL/31GX5/16" MISC ( 2 auth;QL(6.67 MISC (insulin pen insulin pen ea daily); needle) needle) RX/OTC CLEVER CHOICE Limit 200 per CLICKFINE PEN RX/OTC COMFORT EZPEN month without NEEDLES 31G X 1/4" NEEDLES 31GX5MM 2 authorization;Q MISC (insulin pen 2 MISC (insulin pen L(6.67 ea needle) needle) daily); RX/OTC CLICKFINE PEN Limit 200 per CLEVER CHOICE RX/OTC NEEDLES 31G X 3/16" month without COMFORT EZPEN MISC ( 2 authorization;Q NEEDLES 31GX6MM insulin pen L(6.67 ea 2 ) MISC (insulin pen needle daily); RX/OTC needle) CLICKFINE PEN Limited to 200 CLEVER CHOICE Limited to 200 NEEDLES 31G X 5/16" without prior COMFORT EZPEN without prior MISC (insulin pen 2 auth;QL(6.67 NEEDLES 31GX8MM auth;QL(6.67 ea daily); 2 needle) RX/OTC MISC (insulin pen ea daily); needle) RX/OTC CLICKFINE PEN Limited to 200 without prior CLEVER CHOICE RX/OTC NEEDLES 31G X 8MM MISC ( 2 auth;QL(6.67 COMFORT EZPEN insulin pen ea daily); NEEDLES 32GX5MM 2 needle) RX/OTC MISC (insulin pen CLICKFINE PEN RX/OTC needle) NEEDLES/31GX1/4" MISC 2 (insulin pen needle)

102 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CLICKFINE UNIVERSAL Limited to 200 DROPLET PEN NEEDLES RX/OTC PEN NEEDLES 31GX5/16" without prior 31GX6MM MISC (insulin 2 MISC ( 2 auth;QL(6.67 pen needle) insulin pen ea daily); needle) RX/OTC Limited to 200 DROPLET PEN NEEDLES without prior Limited to 200 31GX8MM MISC (insulin 2 auth;QL(6.67 COMFORT EZ without prior pen needle) ea daily); SHORT/31G X 8MM MISC 2 auth;QL(6.67 RX/OTC (insulin pen needle) ea daily); RX/OTC DROPLET PEN NEEDLES Limit 200 per 32G X 1/4" MISC (insulin 2 COMFORT EZ/31G X 5MM month without pen needle) MISC (insulin pen 2 authorization;Q DROPLET PEN NEEDLES RX/OTC needle) L(6.67 ea 32G X 3/16" MISC 2 daily); RX/OTC (insulin pen needle) COMFORT EZ/31G X 6MM RX/OTC DROPLET PEN NEEDLES MISC (insulin pen 2 32G X 5/16" MISC 2 needle) (insulin pen needle) DROPLET INSULIN RX/OTC DROPLET PEN NEEDLES RX/OTC SYRINGE U- 32GX5MM MISC (insulin 2 100/0.3ML/31G X 15/64" 2 pen needle) MISC ( insulin DROPLET PEN NEEDLES syringe/needle u-100) 32GX6MM MISC (insulin 2 DROPLET INSULIN Limit 200 per pen needle) SYRINGE U-100/1ML/31G month;QL(6.67 X 15/64" MISC (insulin 2 ea daily) DROPLET PEN NEEDLES syringe/needle u-100) 32GX8MM MISC (insulin 2 pen needle) DROPLET INSULIN RX/OTC SYRINGE/U- DROPSAFE SAFETY PEN Limited to 200 100/0.3ML/31G X 15/64" 2 NEEDLES/31G X 5/16" without prior MISC ( MISC ( 2 auth;QL(6.67 insulin insulin pen ea daily); syringe/needle u-100) needle) RX/OTC DROPLET INSULIN Limit 200 per DROPSAFE SAFTEY PEN RX/OTC SYRINGE/U-100/1ML/31G month;QL(6.67 2 NEEDLES/31G X 1/4" X 15/64" MISC (insulin ea daily) MISC (insulin pen 2 syringe/needle u-100) needle) DROPLET PEN NEEDLES RX/OTC Limit 200 per 29GX12MM MISC 2 DRUG MART UNIFINE month without (insulin pen needle) PENTIPS 31GX5MM MISC 2 authorization;Q DROPLET PEN NEEDLES RX/OTC (insulin pen needle) L(6.67 ea 30G X 5/16" MISC 2 daily); RX/OTC (insulin pen needle) DRUG MART UNIFINE RX/OTC PENTIPS29G X 12MM Limit 200 per 2 DROPLET PEN NEEDLES month without MISC (insulin pen 31GX5MM MISC (insulin 2 authorization;Q needle) pen needle) L(6.67 ea daily); RX/OTC 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic Preferred AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

103 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DRUG MART UNIFINE RX/OTC EASY TOUCH PEN RX/OTC PENTIPS31GX6MM MISC 2 NEEDLES 29GX1/2" MISC 2 (insulin pen needle) (insulin pen needle) Limited to 200 EASY TOUCH PEN RX/OTC DRUG MART UNIFINE without prior NEEDLES 31GX1/4" MISC 2 PENTIPS31GX8MM MISC 2 auth;QL(6.67 (insulin pen needle) (insulin pen needle) ea daily); EASY TOUCH PEN Limited to 200 RX/OTC without prior EASY COMFORT PEN RX/OTC NEEDLES 31GX5/16" MISC ( 2 auth;QL(6.67 NEEDLES31GX1/4" MISC 2 insulin pen ea daily); (insulin pen needle) needle) RX/OTC EASY COMFORT PEN Limit 200 per EASY TOUCH PEN NEEDLES31GX3/16" month without NEEDLES 32GX1/4" MISC 2 MISC ( 2 authorization;Q (insulin pen needle) insulin pen L(6.67 ea needle) EASY TOUCH PEN RX/OTC daily); RX/OTC NEEDLES 32GX3/16" EASY COMFORT PEN Limited to 200 MISC (insulin pen 2 without prior NEEDLES31GX5/16" needle) MISC ( 2 auth;QL(6.67 insulin pen ea daily); Limit 200 per ) EASY TOUCH PEN needle RX/OTC NEEDLES/31G X 3/16" month without EASY COMFORT PEN MISC (insulin pen 2 authorization;Q NEEDLES33G X 4MM L(6.67 ea needle) daily); RX/OTC MISC (insulin pen 2 ) EASY TOUCH SAFETY RX/OTC needle PEN NEEDLES/30G X EASY GLIDE PEN 5/16" MISC (insulin pen 2 NEEDLES 33G X 5/32" needle) MISC (insulin pen 2 ) EXEL COMFORT POINT RX/OTC needle INSULIN PEN NEEDLES EASY TOUCH 32GX5MM RX/OTC 29G X 12MM MISC 2 MISC (insulin pen 2 (insulin pen needle) needle) EXEL COMFORT POINT RX/OTC EASY TOUCH 32GX6MM INSULIN PEN NEEDLES MISC (insulin pen 2 31G X 6MM MISC (insulin 2 needle) pen needle) EASY TOUCH FLIPLOCK EXEL COMFORT POINT Limited to 200 NEEDLES 30GX1/2" MISC 2 INSULIN PEN NEEDLES without prior (needle (disp) 30 g) 31G X 8MM MISC ( 2 auth;QL(6.67 insulin ea daily); EASY TOUCH pen needle) HYPODERMIC NEEDLES RX/OTC 30GX1/2" MISC (needle 2 Limit 200 per FIFTY50 PEN NEEDLES (disp) 30 g) month without 31G X3/16" (5MM) MISC 2 authorization;Q EASY TOUCH PEN RX/OTC (insulin pen needle) L(6.67 ea NEEDLE 30G X 5/16" daily); RX/OTC MISC (insulin pen 2 needle)

104 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limited to 200 GLOBAL EASY GLIDE Limit 200 per FIFTY50 PEN NEEDLES without prior INSULIN month;QL(6.67 31G X5/16" (8MM) MISC 2 auth;QL(6.67 SYRINGE/1ML/31G X 2 ea daily) (insulin pen needle) ea daily); 15/64" MISC (insulin RX/OTC syringe/needle u-100) Limit 200 per FIFTY50 PEN NEEDLES GNP CLICKFINE PEN Limited to 200 month without without prior 31GX5MM MISC (insulin 2 authorization;Q NEEDLEUNIVERSAL/31G X5/16" MISC ( 2 auth;QL(6.67 pen needle) L(6.67 ea insulin pen ea daily); daily); RX/OTC needle) RX/OTC FIFTY50 PEN Limited to 200 GNP CLICKFINE RX/OTC NEEDLES/31GX8MM without prior UNIVERSAL PEN 2 MISC ( 2 auth;QL(6.67 NEEDLES 31GX1/4" MISC insulin pen ea daily); needle) RX/OTC (insulin pen needle) FIFTY50 PEN GNP CLICKFINE Limited to 200 NEEDLES/32GX6MM UNIVERSAL PEN without prior NEEDLES 31GX5/16" auth;QL(6.67 MISC (insulin pen 2 2 MISC (insulin pen ea daily); needle) needle) RX/OTC FREDS PHARMACY Limit 200 per month without GOODSENSE CLICKFINE Limit 200 per UNIFINE PENTIPS PLUS SAFETY PEN month without 31GX5MM MISC ( 2 authorization;Q insulin L(6.67 ea NEEDLE/31G X 3/16" 2 authorization;Q pen needle) daily); RX/OTC MISC (insulin pen L(6.67 ea needle) daily); RX/OTC FREDS PHARMACY Limited to 200 UNIFINE PENTIPS PLUS without prior GOODSENSE PEN Limit 200 per NEEDLE/PENFINE month without 31GX8MM MISC (insulin 2 auth;QL(6.67 ea daily); CLASSIC/31G X 3/16" 2 authorization;Q pen needle) RX/OTC MISC (insulin pen L(6.67 ea GLOBAL EASE INJECT RX/OTC needle) daily); RX/OTC PEN NEEDLES 2 GOODSENSE PEN Limited to 200 29GX12MM MISC NEEDLE/PENFINE without prior (insulin pen needle) CLASSIC/31G X 5/16" 2 auth;QL(6.67 GLOBAL EASE INJECT Limited to 200 MISC (insulin pen ea daily); PEN NEEDLES 31GX8MM without prior needle) RX/OTC MISC ( 2 auth;QL(6.67 GOODSENSE PEN insulin pen ea daily); needle) NEEDLE/PENFINE RX/OTC CLASSIC/32G X 1/4" MISC 2 GLOBAL EASE INJECT Limit 200 per (insulin pen needle) month without PEN NEEEDLES Limit 200 per 31GX5MM MISC ( 2 authorization;Q H-E-B IN CONTROL PEN insulin L(6.67 ea NEEDLES 31GX5MM month without ) pen needle daily); RX/OTC MISC ( 2 authorization;Q insulin pen L(6.67 ea GLOBAL EASY GLIDE RX/OTC needle) daily); RX/OTC INSULIN H-E-B IN CONTROL PEN RX/OTC SYRINGE/0.3ML/31G X 2 NEEDLES 31GX6MM 15/64" MISC (insulin 2 syringe/needle u-100) MISC (insulin pen needle) 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic Preferred AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

105 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits H-E-B IN CONTROL PEN Limited to 200 HEALTHY ACCENTS RX/OTC NEEDLES 31GX8MM without prior UNIFINE PENTIPS PEN MISC ( 2 auth;QL(6.67 NEEDLES 31GX6MM 2 insulin pen ea daily); needle) MISC (insulin pen RX/OTC needle) H-E-B IN CONTROL Limit 200 per HEALTHY ACCENTS Limited to 200 UNIFINEPENTIPS PLUS month without UNIFINE PENTIPS PEN without prior 2 authorization;Q 31GX5MM MISC (insulin NEEDLES 31GX8MM 2 auth;QL(6.67 L(6.67 ea ea daily); pen needle) daily); RX/OTC MISC (insulin pen needle) RX/OTC H-E-B INCONTROL PEN RX/OTC NEEDLES 29GX12MM HM ULTICARE SHORT Limited to 200 MISC (insulin pen 2 PEN NEEDLES 31GX8MM without prior MISC ( 2 auth;QL(6.67 needle) insulin pen ea daily); HEALTHWISE MINI PEN RX/OTC needle) RX/OTC NEEDLES 31GX6MM 2 HYPODERMIC NEEDLE MISC (insulin pen 30GX1/2" MISC (needle 2 needle) (disp) 30 g) HEALTHWISE PEN RX/OTC INSULIN SYRINGES AND NEEDLES 29GX12MM 2 2 PEN NEEDLES MISC (insulin pen INSUPEN 29G X 12MM RX/OTC needle) MISC (insulin pen 2 HEALTHWISE SHORT Limited to 200 needle) without prior PEN NEEDLES 31GX8MM Limit 200 per MISC ( 2 auth;QL(6.67 INSUPEN 31G X 5MM insulin pen ea daily); month without needle) RX/OTC MISC (insulin pen 2 authorization;Q needle) L(6.67 ea HEALTHWISE SHORT Limit 200 per daily); RX/OTC month without PEN NEEDLES/31G X Limited to 200 3/16" MISC ( 2 authorization;Q INSUPEN 31G X 8MM insulin pen L(6.67 ea without prior needle) daily); RX/OTC MISC (insulin pen 2 auth;QL(6.67 needle) ea daily); HEALTHWISE SHORT Limited to 200 RX/OTC without prior PEN NEEDLES/31G X INSUPEN 33GX4MM MISC 5/16" MISC ( 2 auth;QL(6.67 2 insulin pen ea daily); (insulin pen needle) needle) RX/OTC INSUPEN SENSITIVE HEALTHY ACCENTS RX/OTC 32GX6MM MISC (insulin 2 UNIFINE PENTIPS PEN pen needle) NEEDLES 29GX12MM 2 INSUPEN SENSITIVE MISC (insulin pen 32GX8MM MISC (insulin 2 needle) pen needle) HEALTHY ACCENTS Limit 200 per INSUPEN ULTRAFIN RX/OTC UNIFINE PENTIPS PEN month without 29GX12MM MISC ( 2 NEEDLES 31GX5MM 2 authorization;Q insulin MISC (insulin pen L(6.67 ea pen needle) needle) daily); RX/OTC

106 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits INSUPEN ULTRAFIN RX/OTC LEADER UNIFINE Limited to 200 30GX8MM MISC (insulin 2 PENTIPS without prior pen needle) PLUS/SHORT/31GX5/16" 2 auth;QL(6.67 MISC (insulin pen ea daily); INSUPEN ULTRAFIN RX/OTC RX/OTC 31GX6MM MISC (insulin 2 needle) pen needle) LEADER UNIFINE Limit 200 per month without Limited to 200 PENTIPS/MINI/31GX3/16" INSUPEN ULTRAFIN MISC ( 2 authorization;Q without prior insulin pen L(6.67 ea 31GX8MM MISC (insulin 2 auth;QL(6.67 needle) daily); RX/OTC pen needle) ea daily); RX/OTC LITETOUCH PEN RX/OTC NEEDLES 29GX12.7MM KROGER PEN NEEDLES RX/OTC MISC (insulin pen 2 29G X12MM MISC 2 (insulin pen needle) needle) Limited to 200 LITETOUCH PEN RX/OTC NEEDLES 31G X 6MM KROGER PEN NEEDLES without prior 2 31G X8MM MISC (insulin 2 auth;QL(6.67 MISC (insulin pen pen needle) ea daily); needle) RX/OTC LITETOUCH PEN RX/OTC KROGER PEN NEEDLES RX/OTC NEEDLES 31G X 31GX1/4" MISC (insulin 2 6MM/ULTRA SHORT 2 pen needle) MISC (insulin pen KROGER PEN RX/OTC needle) NEEDLES/31G X1/4" Limited to 200 2 LITETOUCH PEN MISC (insulin pen NEEDLES 31GX8MM without prior needle) SHORT MISC ( 2 auth;QL(6.67 insulin ea daily); KROGER PEN Limit 200 per pen needle) RX/OTC NEEDLES/31G X3/16" month without LITETOUCH PEN Limit 200 per MISC ( 2 authorization;Q insulin pen L(6.67 ea NEEDLES/31G X 3/16" month without needle) daily); RX/OTC MISC ( 2 authorization;Q insulin pen L(6.67 ea KROGER PEN Limited to 200 needle) daily); RX/OTC NEEDLES/31G X5/16" without prior LITETOUCH PEN Limit 200 per MISC ( 2 auth;QL(6.67 insulin pen ea daily); NEEDLES/31G X month without needle) RX/OTC 5MM/MINI MISC ( 2 authorization;Q insulin L(6.67 ea KROGER PEN pen needle) daily); RX/OTC NEEDLES/33G X5/32" 2 LITETOUCH PEN Limited to 200 MISC (insulin pen without prior needle) NEEDLES/31G X 8MM/SHORT MISC 2 auth;QL(6.67 ea daily); LEADER UNIFINE Limit 200 per (insulin pen needle) PENTIPS month without RX/OTC PLUS/MINI/31GX3/16" 2 authorization;Q MARATHON MEDICAL RX/OTC MISC (insulin pen L(6.67 ea PENTIPS29GX12MM needle) daily); RX/OTC MISC (insulin pen 2 needle)

107 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limit 200 per MM PEN NEEDLES 31G X RX/OTC MARATHON MEDICAL month without 1/4" MISC (insulin pen 2 PENTIPS31GX5MM MISC 2 authorization;Q needle) (insulin pen needle) L(6.67 ea daily); RX/OTC Limit 200 per MM PEN NEEDLES 31G X month without Limited to 200 3/16" MISC (insulin pen 2 authorization;Q MARATHON MEDICAL without prior needle) L(6.67 ea PENTIPS31GX8MM MISC 2 auth;QL(6.67 daily); RX/OTC (insulin pen needle) ea daily); RX/OTC Limited to 200 MM PEN NEEDLES 31G X without prior MAXICOMFORT II PEN RX/OTC 5/16" MISC (insulin pen 2 auth;QL(6.67 NEEDLES/31G X 1/4" 2 needle) ea daily); MISC (insulin pen RX/OTC needle) NOVOFINE 32GX6MM MEDICINE SHOPPE PEN RX/OTC MISC (insulin pen 2 NEEDLES 29G X 12MM 2 needle) MISC (insulin pen NOVOFINE AUTOCOVER RX/OTC needle) 30GX8MM MISC (insulin 2 MEDICINE SHOPPE PEN RX/OTC pen needle) NEEDLES 31G X 6MM NOVOTWIST 32GX5MM RX/OTC MISC (insulin pen 2 MISC (insulin pen 2 needle) needle) Limited to 200 MEDICINE SHOPPE PEN PC UNIFINE PENTIPS RX/OTC NEEDLES 31G X 8MM without prior 29G X1/2" MISC (insulin 2 MISC ( 2 auth;QL(6.67 insulin pen ea daily); pen needle) needle) RX/OTC Limit 200 per MEIJER PEN NEEDLES RX/OTC PC UNIFINE PENTIPS month without 29G X12MM MISC 2 31G X5MM MINI MISC 2 authorization;Q (insulin pen needle) (insulin pen needle) L(6.67 ea MEIJER PEN NEEDLES RX/OTC daily); RX/OTC 31G X6MM MISC (insulin 2 PC UNIFINE PENTIPS RX/OTC 31G X6MM ULTRA pen needle) SHORT MISC (insulin 2 Limited to 200 ) MEIJER PEN NEEDLES without prior pen needle 31G X8MM MISC (insulin 2 auth;QL(6.67 Limited to 200 pen needle) ea daily); PC UNIFINE PENTIPS without prior RX/OTC 31G X8MM SHORT MISC 2 auth;QL(6.67 MICRODOT PEN RX/OTC (insulin pen needle) ea daily); NEEDLE/31G X 6 MM RX/OTC MISC (insulin pen 2 PEN NEEDLES 29G X RX/OTC needle) 12MM MISC (insulin pen 2 ) MICRODOT PEN needle NEEDLE/33G X 4 MM PEN NEEDLES 29GX1/2" RX/OTC MISC (insulin pen 2 MISC (insulin pen 2 needle) needle)

108 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PEN NEEDLES 30GX5/16" RX/OTC PEN NEEDLES 32G X RX/OTC MISC (insulin pen 2 5MM MISC (insulin pen 2 needle) needle) PEN NEEDLES 30GX8MM RX/OTC PEN NEEDLES 32G X MISC (insulin pen 2 6MM MISC (insulin pen 2 needle) needle) PEN NEEDLES 31G X 1/4" RX/OTC PEN NEEDLES 33G X SHORT MISC (insulin 2 5/32" MISC (insulin pen 2 pen needle) needle) Limit 200 per PEN NEEDLES/29G X 1/2" RX/OTC PEN NEEDLES 31G X month without MISC (insulin pen 2 3/16" MISC (insulin pen 2 authorization;Q needle) needle) L(6.67 ea daily); RX/OTC PEN NEEDLES/31G X 1/4" RX/OTC Limit 200 per MISC (insulin pen 2 PEN NEEDLES 31G X month without needle) 5MM MISC (insulin pen 2 authorization;Q Limit 200 per needle) L(6.67 ea PEN NEEDLES/31G X month without daily); RX/OTC 3/16" MISC (insulin pen 2 authorization;Q PEN NEEDLES 31G X RX/OTC needle) L(6.67 ea 6MM MISC (insulin pen 2 daily); RX/OTC needle) Limited to 200 PEN NEEDLES/31G X without prior Limited to 200 5/16" MISC (insulin pen 2 auth;QL(6.67 PEN NEEDLES 31G X without prior needle) ea daily); 8MM MISC (insulin pen 2 auth;QL(6.67 RX/OTC needle) ea daily); RX/OTC PENTIPS 29G X 12MM RX/OTC Limited to 200 MISC (insulin pen 2 PEN NEEDLES 31GX5/16" without prior needle) MISC (insulin pen 2 auth;QL(6.67 PENTIPS 29GX12MM RX/OTC needle) ea daily); MISC (insulin pen 2 RX/OTC needle) PEN NEEDLES 31GX6MM RX/OTC Limit 200 per (1/4") MISC (insulin pen 2 PENTIPS 31G X 5MM month without needle) MISC (insulin pen 2 authorization;Q Limited to 200 needle) L(6.67 ea PEN NEEDLES 31GX8MM without prior daily); RX/OTC (5/16") MISC (insulin pen 2 auth;QL(6.67 Limited to 200 needle) ea daily); PENTIPS 31G X 8MM without prior RX/OTC MISC (insulin pen 2 auth;QL(6.67 Limited to 200 needle) ea daily); PEN NEEDLES 31GX8MM without prior RX/OTC MISC (insulin pen 2 auth;QL(6.67 Limit 200 per ea daily); needle) PENTIPS 31GX5MM MISC month without RX/OTC 2 authorization;Q (insulin pen needle) L(6.67 ea daily); RX/OTC

109 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PENTIPS 31GX6MM MISC RX/OTC PRO COMFORT PEN 2 ( ) NEEDLES/32G X 6MM insulin pen needle 2 Limited to 200 MISC (insulin pen needle) PENTIPS 31GX8MM MISC without prior 2 auth;QL(6.67 (insulin pen needle) PURE COMFORT PEN ea daily); NEEDLE 32G X6MM MISC 2 RX/OTC (insulin pen needle) POLY HUB NEEDLE/30G PURE COMFORT PEN X 1/2" MISC (needle 2 NEEDLE 32G X8MM MISC 2 (disp) 30 g) (insulin pen needle) PREFERRED PLUS RX/OTC PURE COMFORT PEN RX/OTC UNIFINE PENTIPS 29G X 2 NEEDLE/32G X 5MM 12MM MISC (insulin pen MISC (insulin pen 2 needle) needle) PREFERRED PLUS RX/OTC PX EXTRA SHORT PEN RX/OTC UNIFINE PENTIPS 31G X NEEDLES 31GX6MM 6MM ULTRA SHORT 2 MISC (insulin pen 2 MISC (insulin pen needle) ) needle Limit 200 per PREFERRED PLUS Limited to 200 PX MINI PEN NEEDLES month without UNIFINE PENTIPS 31G X without prior 31GX5MM MISC (insulin 2 authorization;Q 8MM SHORT MISC 2 auth;QL(6.67 pen needle) L(6.67 ea ea daily); (insulin pen needle) daily); RX/OTC RX/OTC PX PEN NEEDLE RX/OTC PREFERRED PLUS Limit 200 per 29GX12MM MISC (insulin 2 UNIFINE month without pen needle) PENTIPS/MINI/31GX5MM 2 authorization;Q L(6.67 ea Limited to 200 MISC (insulin pen PX PEN NEEDLE ) daily); RX/OTC without prior needle 31GX8MM MISC (insulin 2 auth;QL(6.67 PREVENT SAFETY PEN RX/OTC pen needle) ea daily); NEEDLES 31GX1/4" MISC 2 RX/OTC (insulin pen needle) PX SHORTLENGTH PEN Limited to 200 PREVENT SAFETY PEN Limited to 200 NEEDLES/31GX8MM without prior NEEDLES 31GX5/16" without prior MISC (insulin pen 2 auth;QL(6.67 MISC ( 2 auth;QL(6.67 ea daily); insulin pen ea daily); needle) RX/OTC needle) RX/OTC QC PEN NEEDLES 29G X RX/OTC PRO COMFORT PEN Limited to 200 12MM MISC (insulin pen 2 NEEDLES/31G X 8MM without prior needle) MISC ( 2 auth;QL(6.67 insulin pen ea daily); QC PEN NEEDLES 31G X RX/OTC needle) RX/OTC 6MM MISC (insulin pen 2 PRO COMFORT PEN RX/OTC needle) NEEDLES/32G X 5MM MISC (insulin pen 2 needle)

110 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limited to 200 RELION PEN RX/OTC QC PEN NEEDLES 31G X without prior NEEDLES/31G X1/4" MISC 2 8MM MISC (insulin pen 2 auth;QL(6.67 (insulin pen needle) needle) ea daily); Limited to 200 RX/OTC RELION SHORT PEN without prior Limit 200 per NEEDLES31GX8MM MISC 2 auth;QL(6.67 RA PEN NEEDLES 31G X month without (insulin pen needle) ea daily); 5MM3/16" MISC (insulin 2 authorization;Q RX/OTC pen needle) L(6.67 ea SHOPKO UNIFINE Limit 200 per daily); RX/OTC PENTIPS PEN month without Limited to 200 NEEDLES/MINI/31GX5MM authorization;Q RA PEN NEEDLES 31G X 2 without prior MISC (insulin pen L(6.67 ea 8MM5/16" MISC (insulin 2 auth;QL(6.67 needle) daily); RX/OTC pen needle) ea daily); RX/OTC SHOPKO UNIFINE RX/OTC RELION INSULIN Limit 200 per PENTIPS PEN SYRINGE month;QL(6.67 NEEDLES/ORIGINAL/29G 2 1ML/31GX15/64" MISC 2 ea daily) X12MM MISC (insulin (insulin syringe/needle pen needle) u-100) SHOPKO UNIFINE Limited to 200 RELION INSULIN RX/OTC PENTIPS PEN without prior SYRINGE/U- NEEDLES/SHORT/31GX8 2 auth;QL(6.67 100/0.3ML/31G X 15/64" MM MISC (insulin pen ea daily); 2 RX/OTC MISC (insulin needle) syringe/needle u-100) SHOPKO UNIFINE Limit 200 per RELION INSULIN Limit 200 per PENTIPS PLUS PEN month without SYRINGE/U-100/1ML/31G month;QL(6.67 NEEDLES/MINI/REMOVE 2 authorization;Q R/31GX5MM MISC L(6.67 ea X 15/64" MISC (insulin 2 ea daily) (insulin pen needle) daily); RX/OTC syringe/needle u-100) SHOPKO UNIFINE RX/OTC RELION MINI PEN RX/OTC PENTIPS PLUS PEN NEEDLES 31GX6MM 2 NEEDLES/REMOVER/29G 2 MISC (insulin pen X12MM MISC (insulin needle) pen needle) RELION PEN NEEDLES RX/OTC SHOPKO UNIFINE Limited to 200 29GX12MM MISC 2 PENTIPS PLUS PEN without prior (insulin pen needle) NEEDLES/SHORT/REMO 2 auth;QL(6.67 RELION PEN NEEDLES RX/OTC VR/31GX8MM MISC ea daily); 31GX6MM MISC (insulin 2 (insulin pen needle) RX/OTC pen needle) SURE COMFORT PEN RX/OTC NEEDLES29GX1/2" Limited to 200 2 RELION PEN NEEDLES without prior 12.7MM MISC (insulin 31GX8MM MISC (insulin 2 auth;QL(6.67 pen needle) pen needle) ea daily); SURE COMFORT PEN RX/OTC RX/OTC NEEDLES30GX5/16" SHORT MISC (insulin 2 pen needle)

111 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SURE COMFORT PEN Limit 200 per TECHLITE PEN Limit 200 per NEEDLES31GX3/16" month without NEEDLES/31GX 5MM month without 2 authorization;Q MISC ( 2 authorization;Q (5MM) MISC (insulin pen L(6.67 ea insulin pen L(6.67 ea needle) daily); RX/OTC needle) daily); RX/OTC SURE COMFORT PEN Limited to 200 TECHLITE PEN RX/OTC NEEDLES31GX5/16" without prior NEEDLES/31GX 6 MM 2 auth;QL(6.67 2 (8MM) MISC (insulin pen MISC (insulin pen ea daily); needle) needle) RX/OTC TECHLITE PEN Limited to 200 SURE COMFORT PEN without prior NEEDLES32GX6MM MISC 2 NEEDLES/31GX 8MM MISC ( 2 auth;QL(6.67 (insulin pen needle) insulin pen ea daily); SURE-FINE PEN RX/OTC needle) RX/OTC NEEDLES 29GX1/2" TECHLITE PEN 12.7MM MISC (insulin 2 NEEDLES/32GX 6MM pen needle) MISC (insulin pen 2 SURE-FINE PEN Limit 200 per needle) NEEDLES 31GX3/16" month without TECHLITE PEN 5MM MISC ( 2 authorization;Q NEEDLES/32GX 8MM insulin pen L(6.67 ea 2 needle) MISC (insulin pen daily); RX/OTC needle) SURE-FINE PEN Limited to 200 without prior TODAYS HEALTH MINI RX/OTC NEEDLES 31GX5/16" PEN NEEDLES 31G X 1/4" 8MM MISC ( 2 auth;QL(6.67 2 insulin pen ea daily); MISC (insulin pen needle) RX/OTC needle) TECHLITE INSULIN RX/OTC TODAYS HEALTH RX/OTC SYRINGEU- ORIGINAL PEN NEEDLES 2 100/0.3ML/31G X 15/64" 2 29G X 1/2" MISC (insulin MISC (insulin pen needle) ) syringe/needle u-100 TODAYS HEALTH SHORT Limited to 200 TECHLITE INSULIN Limit 200 per PEN NEEDLES 31G X without prior SYRINGEU-100/1ML/31G month;QL(6.67 5/16" MISC (insulin pen 2 auth;QL(6.67 2 ea daily) ea daily); X 15/64" MISC (insulin needle) syringe/needle u-100) RX/OTC TECHLITE PEN NEEDLES RX/OTC TOPCARE CLICKFINE RX/OTC UNIVERSAL PEN EEDLES 29GX 12 MM MISC 2 2 (insulin pen needle) 31GX1/4" MISC (insulin pen needle) Limit 200 per TECHLITE PEN NEEDLES month without TOPCARE CLICKFINE Limited to 200 31GX 5MM MISC (insulin 2 authorization;Q UNIVERSAL PEN EEDLES without prior pen needle) L(6.67 ea 31GX5/16" MISC (insulin 2 auth;QL(6.67 daily); RX/OTC ea daily); pen needle) RX/OTC

112 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TRUE COMFORT PEN Limit 200 per ULTICARE MICRO PEN Limited to 200 NEEDLES31G X 5MM month without NEEDLES 31G X 8MM without prior MISC ( 2 authorization;Q MISC ( 2 auth;QL(6.67 insulin pen L(6.67 ea insulin pen ea daily); needle) daily); RX/OTC needle) RX/OTC TRUE COMFORT PEN RX/OTC ULTICARE MICRO PEN RX/OTC NEEDLES31G X 6MM NEEDLES/31G X 1/4" MISC (insulin pen 2 MISC (insulin pen 2 needle) needle) TRUEPLUS 5-BEVEL PEN RX/OTC ULTICARE MICRO PEN Limited to 200 NEEDLES 29GX12.7MM without prior 2 NEEDLES/31G X 5/16" MISC (insulin pen MISC (insulin pen 2 auth;QL(6.67 needle) ea daily); needle) RX/OTC TRUEPLUS 5-BEVEL PEN Limit 200 per month without ULTICARE MINI PEN RX/OTC NEEDLES 31GX5MM NEEDLES 31GX6MM MISC ( 2 authorization;Q 2 insulin pen L(6.67 ea MISC (insulin pen needle) daily); RX/OTC needle) TRUEPLUS 5-BEVEL PEN RX/OTC ULTICARE MINI PEN RX/OTC NEEDLES 31GX6MM NEEDLES ULTI-FINE IV MISC (insulin pen 2 MISC (insulin pen 2 needle) needle) TRUEPLUS 5-BEVEL PEN Limited to 200 ULTICARE MINI PEN RX/OTC without prior NEEDLES/31G X 6MM NEEDLES 31GX8MM 2 MISC (insulin pen 2 auth;QL(6.67 MISC (insulin pen ea daily); needle) needle) RX/OTC ULTICARE MINI PEN TRUEPLUS PEN RX/OTC NEEDLES/32G X 1/4" NEEDLES 29GX12MM MISC (insulin pen 2 MISC (insulin pen 2 needle) needle) ULTICARE MINI PEN RX/OTC TRUEPLUS PEN Limit 200 per NEEDLES31GX6MM MISC 2 month without NEEDLES 31GX5MM (insulin pen needle) MISC ( 2 authorization;Q insulin pen L(6.67 ea ULTICARE ORIGINAL RX/OTC needle) daily); RX/OTC PEN NEEDLES ULTI-FINE 2 TRUEPLUS PEN RX/OTC MISC (insulin pen NEEDLES 31GX6MM needle) 2 MISC (insulin pen Limit 200 per needle) ULTICARE PEN NEEDLES month without 31GX 5MM MISC (insulin 2 authorization;Q TRUEPLUS PEN Limited to 200 without prior pen needle) L(6.67 ea NEEDLES 31GX8MM daily); RX/OTC MISC ( 2 auth;QL(6.67 insulin pen ea daily); Limit 200 per needle) RX/OTC ULTICARE PEN NEEDLES month without 31GX 5MM/MINI MISC 2 authorization;Q (insulin pen needle) L(6.67 ea daily); RX/OTC 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic Preferred AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

113 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ULTICARE PEN RX/OTC ULTILET PEN NEEDLE RX/OTC NEEDLES/29GX 12.7MM 29GX12.7MM MISC 2 MISC (insulin pen 2 (insulin pen needle) needle) Limit 200 per ULTILET PEN NEEDLE ULTICARE SHORT PEN Limited to 200 month without 31GX5MM MISC ( NEEDLES 31GX8MM without prior insulin 2 authorization;Q ) L(6.67 ea MISC ( 2 auth;QL(6.67 pen needle insulin pen ea daily); daily); RX/OTC needle) RX/OTC Limited to 200 ULTILET PEN NEEDLE ULTICARE SHORT PEN Limited to 200 without prior 31GX8MM MISC ( NEEDLES ULTI-FINE IV without prior insulin 2 auth;QL(6.67 ) ea daily); MISC ( 2 auth;QL(6.67 pen needle insulin pen ea daily); RX/OTC needle) RX/OTC ULTILET SHORT PEN Limited to 200 ULTICARE SHORT PEN Limited to 200 NEEDLES 31GX5/16" without prior NEEDLES/31G X 8MM without prior MISC ( 2 auth;QL(6.67 insulin pen ea daily); MISC ( 2 auth;QL(6.67 ) insulin pen ea daily); needle RX/OTC needle) RX/OTC Limit 200 per ULTIGUARD RX/OTC ULTILET SHORT PEN month without SAFEPACK/MINI PEN NEEDLES31GX3/16" MISC 2 authorization;Q NEEDLE/31G X (insulin pen needle) L(6.67 ea 1/4"/SHARPS CONTAIN 2 daily); RX/OTC MISC (insulin pen ULTRA FLO INSULIN PEN RX/OTC needle) NEEDLES MISC (insulin 2 ULTIGUARD Limit 200 per pen needle) SAFEPACK/MINI PEN month without ULTRA-THIN II MINI PEN Limit 200 per NEEDLE/31G X authorization;Q NEEEDLES/31GX3/16" month without 3/16"/SHARPS CONTAI 2 L(6.67 ea MISC (insulin pen 2 authorization;Q MISC (insulin pen daily); RX/OTC L(6.67 ea needle) needle) daily); RX/OTC ULTIGUARD ULTRA-THIN II PEN RX/OTC SAFEPACK/MINI PEN NEEDLES 29GX1/2" MISC 2 NEEDLE/32G X (insulin pen needle) 1/4"/SHARPS CONTAIN 2 ULTRA-THIN II PEN Limited to 200 MISC (insulin pen NEEDLES/SHORT/31GX5/ without prior needle) 16" MISC ( 2 auth;QL(6.67 insulin pen ea daily); ULTIGUARD Limited to 200 needle) SAFEPACK/SHORTPEN without prior RX/OTC NEEDLE/31G X auth;QL(6.67 ULTRACARE PEN RX/OTC 5/16"/SHARPS CONTA 2 ea daily); NEEDLES/31G X 1/4" 2 MISC (insulin pen RX/OTC MISC (insulin pen needle) needle) ULTILET INSULIN RX/OTC ULTRACARE PEN Limit 200 per SYRINGE 31X6MM MISC NEEDLES/31G X 3/16" month without 2 (insulin syringe/needle MISC (insulin pen 2 authorization;Q ) L(6.67 ea u-100 needle) daily); RX/OTC 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic Preferred AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

114 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ULTRACARE PEN Limited to 200 UNIFINE PENTIPS PLUS RX/OTC NEEDLES/31G X 5/16" without prior 29GX12MM MISC (insulin 2 MISC ( 2 auth;QL(6.67 pen needle) insulin pen ea daily); needle) RX/OTC Limit 200 per UNIFINE PENTIPS PLUS month without ULTRACARE PEN 31GX5MM MISC (insulin 2 authorization;Q NEEDLES/32G X 1/14" 2 pen needle) L(6.67 ea MISC (insulin pen daily); RX/OTC needle) UNIFINE PENTIPS PLUS RX/OTC ULTRACARE PEN RX/OTC 31GX6MM MISC (insulin 2 NEEDLES/32G X 3/16" 2 pen needle) MISC (insulin pen Limited to 200 needle) UNIFINE PENTIPS PLUS without prior ULTRACARE PEN 31GX8MM MISC (insulin 2 auth;QL(6.67 NEEDLES/33G X 5/32" pen needle) ea daily); MISC (insulin pen 2 RX/OTC needle) UNIFINE PENTIPS PLUS UNIFINE PENTIPS RX/OTC 33GX 5/32" MISC (insulin 2 29GX12MM MISC 2 pen needle) (insulin pen needle) UNIFINE PENTIPS PLUS Limit 200 per 33GX4MM MISC (insulin 2 UNIFINE PENTIPS 31G X month without pen needle) 3/16" MISC (insulin pen 2 authorization;Q UNIFINE SAFECONTROL RX/OTC needle) L(6.67 ea PEN NEEDLE/30G X 5/16" daily); RX/OTC MISC (insulin pen 2 Limit 200 per ) UNIFINE PENTIPS month without needle 31GX5MM MISC (insulin 2 authorization;Q VALUMARK PEN RX/OTC NEEDLES 29GX12MM pen needle) L(6.67 ea 2 daily); RX/OTC MISC (insulin pen UNIFINE PENTIPS RX/OTC needle) 31GX6MM MISC (insulin 2 VALUMARK PEN RX/OTC ) NEEDLES 31GX 6MM pen needle 2 Limited to 200 MISC (insulin pen UNIFINE PENTIPS without prior needle) 31GX8MM MISC ( 2 insulin auth;QL(6.67 VALUMARK PEN Limited to 200 pen needle) ea daily); NEEDLES 31GX 8MM without prior RX/OTC MISC (insulin pen 2 auth;QL(6.67 UNIFINE PENTIPS ea daily); needle) 32GX6MM MISC (insulin 2 RX/OTC pen needle) VIDA MIA UNIFINE RX/OTC PENTIPSMINI 31GX6MM UNIFINE PENTIPS 2 33GX4MM MISC (insulin 2 MISC (insulin pen pen needle) needle)

115 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VIDA MIA UNIFINE RX/OTC AEROCHAMBER PLUS RX/OTC PENTIPSORIGINAL FLOW-VU/MASK MISC 2 29GX12MM MISC (spacer/aerosol-holding 2 (insulin pen needle) chambers) VIDA MIA UNIPFINE Limited to 200 AEROCHAMBER PLUS RX/OTC PENTIPSSHORT without prior FLOW-VU/MEDIUM MASK 2 31GX8MM MISC (insulin 2 auth;QL(6.67 MISC (spacer/aerosol- ea daily); ) pen needle) RX/OTC holding chambers WEGMANS UNIFINE Limit 200 per AEROCHAMBER PLUS RX/OTC FLOW-VU/SMALL MASK PENTIPS month without 2 PLUS/MINI/31GX5MM 2 authorization;Q MISC (spacer/aerosol- MISC (insulin pen L(6.67 ea holding chambers) needle) daily); RX/OTC AEROCHAMBER Z-STAT RX/OTC WEGMANS UNIFINE Limited to 200 PLUS VALVED HOLDING PENTIPS without prior CHAMBER W/FLOW VU 2 PLUS/SHORT/31GX8MM 2 auth;QL(6.67 MISC (spacer/aerosol- MISC (insulin pen ea daily); holding chambers) needle) RX/OTC AEROCHAMBER Z-STAT RX/OTC PLUS/FLOWSIGNAL MISC WEGMANS UNIFINE RX/OTC 2 PENTIPS PLUS/ULTRA (spacer/aerosol-holding SHORT/31GX6MM MISC 2 chambers) (insulin pen needle) AEROCHAMBER Z-STAT RX/OTC PLUS/LARGE MASK MISC Respiratory Therapy Supplies (spacer/aerosol-holding 2 AEROCHAMBER MINI RX/OTC AEROSOLCHAMBER chambers) DEVI (spacer/aerosol- 2 AEROCHAMBER Z-STAT RX/OTC holding chambers) PLUS/MEDIUM MASK MISC (spacer/aerosol- 2 AEROCHAMBER MV RX/OTC holding chambers) MISC (spacer/aerosol- 2 ) AEROCHAMBER Z-STAT RX/OTC holding chambers PLUS/SMALL MASK MISC AEROCHAMBER PLUS RX/OTC (spacer/aerosol-holding 2 FLOW VU MISC chambers) (spacer/aerosol-holding 2 ) AEROCHAMBER/FLOWSI RX/OTC chambers GNAL MISC AEROCHAMBER PLUS RX/OTC (spacer/aerosol-holding 2 FLOW-VU MISC chambers) (spacer/aerosol-holding 2 ) AEROVENT PLUS RX/OTC chambers HOLDING AEROCHAMBER PLUS RX/OTC CHAMBER/COLLAPSIBLE 2 FLOW-VU/LARGE MASK 2 DEVI (spacer/aerosol- MISC (spacer/aerosol- holding chambers) ) holding chambers ARIAL CHAMBER DEVI RX/OTC (spacer/aerosol-holding 2 chambers)

116 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BREATHE EASE/LARGE RX/OTC BREATHERITE W/LARGE RX/OTC MASK DEVI MASK MISC (spacer/aerosol-holding 2 (spacer/aerosol-holding 2 chambers) chambers) BREATHE EASE/MEDIUM RX/OTC BREATHERITE RX/OTC MASK DEVI W/MEDIUM MASK MISC (spacer/aerosol-holding 2 (spacer/aerosol-holding 2 chambers) chambers) BREATHE EASE/SMALL RX/OTC BREATHERITE W/SMALL RX/OTC MASK DEVI MASK MISC (spacer/aerosol-holding 2 (spacer/aerosol-holding 2 chambers) chambers) BREATHERITE RX/OTC CLEVER CHOICE ANTI- RX/OTC COLLAPSIBLEADULT STATICVALVED SPACER W/MASK MISC 2 HOLDING (spacer/aerosol-holding CHAMBER/ADULT LARGE 2 chambers) DEVI (spacer/aerosol- BREATHERITE RX/OTC holding chambers) COLLAPSIBLECHILD CLEVER CHOICE ANTI- RX/OTC SPACER W/MASK MISC 2 STATICVALVED ( HOLDING spacer/aerosol-holding 2 chambers) CHAMBER/MEDIUM DEVI BREATHERITE RX/OTC (spacer/aerosol-holding COLLAPSIBLEINFANT chambers) SPACER W/MASK MISC 2 CLEVER CHOICE ANTI- RX/OTC (spacer/aerosol-holding STATICVALVED chambers) HOLDING CHAMBER/MEDIUM/3 2 BREATHERITE RX/OTC YEA DEVI COLLAPSIBLESMALL (spacer/aerosol-holding CHILD SPACER W/MASK 2 MISC (spacer/aerosol- chambers) holding chambers) CLEVER CHOICE ANTI- RX/OTC STATICVALVED BREATHERITE RX/OTC HOLDING COLLAPSIBLESPACER CHAMBER/SMALL DEVI 2 W/ NEONATE MASK MISC 2 (spacer/aerosol-holding (spacer/aerosol-holding chambers) chambers) CLEVER CHOICE ANTI- RX/OTC BREATHERITE MISC RX/OTC STATICVALVED (spacer/aerosol-holding 2 HOLDING chambers) CHAMBER/SMALL 2 BREATHERITE RIGID RX/OTC INFANT DEVI SPACERW/MASK MISC (spacer/aerosol-holding (spacer/aerosol-holding 2 chambers) chambers)

117 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits COMPACT SPACE RX/OTC INSPIRACHAMBER/SOOT RX/OTC CHAMBER/ANTI-STATIC HERMASK/INSPIRAMASK DEVI (spacer/aerosol- 2 /MEDIUM DEVI 2 holding chambers) (spacer/aerosol-holding COMPACT SPACE RX/OTC chambers) CHAMBER/ANTI- INSPIRACHAMBER/SOOT RX/OTC STATIC/LARGE MASK 2 HERMASK/INSPIRAMASK DEVI (spacer/aerosol- /SMALL DEVI 2 holding chambers) (spacer/aerosol-holding COMPACT SPACE RX/OTC chambers) CHAMBER/ANTI- INSPIREASE DRUG RX/OTC STATIC/MEDIUM MASK 2 DELIVERYSYSTEM MISC DEVI (spacer/aerosol- (spacer/aerosol-holding 2 holding chambers) chambers) COMPACT SPACE RX/OTC LITEAIRE DEVI RX/OTC CHAMBER/ANTI- (spacer/aerosol-holding 2 STATIC/SMALL MASK 2 chambers) DEVI (spacer/aerosol- MICROCHAMBER DEVI RX/OTC holding chambers) (spacer/aerosol-holding 2 EASIVENT MISC RX/OTC chambers) (spacer/aerosol-holding 2 MICROCHAMBER MISC RX/OTC chambers) (spacer/aerosol-holding 2 EASIVENT/MASK-LARGE RX/OTC chambers) MISC (spacer/aerosol- 2 MICROSPACER MISC RX/OTC holding chambers) (spacer/aerosol-holding 2 EASIVENT/MASK- RX/OTC chambers) MEDIUM MISC 2 OPTICHAMBER RX/OTC (spacer/aerosol-holding ADVANTAGE/LARGE chambers) MASK MISC 2 EASIVENT/MASK-SMALL RX/OTC (spacer/aerosol-holding MISC (spacer/aerosol- 2 chambers) holding chambers) OPTICHAMBER RX/OTC FLEXICHAMBER DEVI RX/OTC ADVANTAGE/MEDIUM (spacer/aerosol-holding 2 FACE MASK MISC 2 chambers) (spacer/aerosol-holding INSPIRACHAMBER/ANTI- RX/OTC chambers) STATIC OPTICHAMBER RX/OTC VALVED/MOUTHPIECE 2 ADVANTAGE/SMALL DEVI (spacer/aerosol- FACE MASK MISC 2 holding chambers) (spacer/aerosol-holding INSPIRACHAMBER/LARG RX/OTC chambers) E DEVI (spacer/aerosol- 2 OPTICHAMBER RX/OTC holding chambers) DIAMOND MISC (spacer/aerosol-holding 2 chambers)

118 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits OPTICHAMBER RX/OTC PRO COMFORT INHALER RX/OTC DIAMOND/LARGEFACE SPACER CHAMBER MASK DEVI 2 CHILD MISC 2 (spacer/aerosol-holding (spacer/aerosol-holding chambers) chambers) OPTICHAMBER RX/OTC PRO COMFORT INHALER RX/OTC DIAMOND/MEDIUM FACE SPACER CHAMBER MASK MISC 2 INFANT DEVI 2 (spacer/aerosol-holding (spacer/aerosol-holding chambers) chambers) OPTICHAMBER RX/OTC PROCARE SPACER RX/OTC DIAMOND/SMALLFACE CHAMBER W/ADULT MASK MISC 2 MASK DEVI 2 (spacer/aerosol-holding (spacer/aerosol-holding chambers) chambers) OPTICHAMBER FACE RX/OTC PROCARE SPACER RX/OTC MASK/LARGE MISC CHAMBER W/CHILD (spacer/aerosol-holding 2 MASK DEVI 2 chambers) (spacer/aerosol-holding OPTICHAMBER FACE RX/OTC chambers) MASK/MEDIUM MISC RITEFLO DEVI RX/OTC (spacer/aerosol-holding 2 (spacer/aerosol-holding 2 chambers) chambers) OPTICHAMBER FACE RX/OTC VALVED HOLDING RX/OTC MASK/SMALL MISC CHAMBER DEVI (spacer/aerosol-holding 2 (spacer/aerosol-holding 2 chambers) chambers) OPTIHALER MDI DRUG RX/OTC VORTEX VALVED RX/OTC DELIVERY SYSTEM DEVI HOLDING CHAMBER (spacer/aerosol-holding 2 DEVI (spacer/aerosol- 2 chambers) holding chambers) OPTIHALER MISC RX/OTC WATCHHALER DEVI RX/OTC (spacer/aerosol-holding 2 (spacer/aerosol-holding 2 chambers) chambers) POCKET CHAMBER DEVI RX/OTC MIGRAINE PRODUCTS - Drugs to Treat Migraine (spacer/aerosol-holding 2 Headaches chambers) Calcitonin Gene-Related Peptide (CGRP) POCKET SPACER DEVI RX/OTC AIMOVIG SOAJ 140 PA; ST (spacer/aerosol-holding 2 MG/ML (erenumab- 2 chambers) aooe) PRO COMFORT INHALER RX/OTC AIMOVIG SOAJ 70 MG/ML PA; ST;LA SPACER CHAMBER 2 (erenumab-aooe) ADULT MISC 2 AJOVY SOAJ PA (spacer/aerosol-holding 2 chambers) (fremanezumab-vfrm)

119 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AJOVY SOSY PA; ST Limit 9 per 2 frovatriptan succinate (fremanezumab-vfrm) 3 month;QL(0.3 tabs ea daily) Migraine Combinations Limit 6 CAFERGOT TABS IMITREX SOLN NA 20 7 sprayers per (ergotamine w/ 7 MG/ACT (sumatriptan) month;QL(2 ea caffeine) daily) Limit 6 per ergotamine w/ caffeine 1 IMITREX SOLN NA 5 tabs 7 month;QL(0.2 MG/ACT (sumatriptan) ea daily) MIGERGOT SUPP IMITREX SOLN SC 6 PA; ST;QL(2 ml (ergotamine w/ 2 MG/0.5ML (sumatriptan 7 per 30 days caffeine) succinate) retail) Migraine Products IMITREX STATDOSE PA; ST D.H.E. 45 SOLN PA REFILL SOCT 4 MG/0.5ML 7 (dihydroergotamine 7 (sumatriptan succinate) mesylate) IMITREX STATDOSE PA dihydroergotamine PA REFILL SOCT 6 MG/0.5ML 7 mesylate soln ij 1 4 (sumatriptan succinate) mg/ml IMITREX STATDOSE PA SYSTEM SOAJ 4 dihydroergotamine QL(0.27 ml 7 mesylate soln na 4 3 daily) MG/0.5ML (sumatriptan mg/ml succinate) ERGOMAR SUBL IMITREX STATDOSE PA; Limit 2 per 2 fill, 4 per (ergotamine tartrate) SYSTEM SOAJ 6 MG/0.5ML ( 7 month;QL(0.14 MIGRANAL SOLN QL(0.27 ml sumatriptan ml daily,2 ml (dihydroergotamine 7 daily) succinate) per fill retail) mesylate) IMITREX TABS OR 25 MG, Limit 9 per 50 MG, 100 MG month;QL(2 ea Serotonin Agonists 7 (sumatriptan succinate) daily) Limit 6 per 1 month;QL(0.2 Limit 18 tabs almotriptan malate tabs MAXALT TABS ea daily) 7 per (rizatriptan benzoate) month;QL(0.6 AMERGE TABS Limit 9 per ea daily) 7 month;QL(0.3 ( ) naratriptan hcl ea daily) MAXALT-MLT TBDP Limit 12 per 7 month;QL(0.4 AXERT TABS Limit 6 per (rizatriptan benzoate) ea daily) 7 month;QL(0.2 (almotriptan malate) ea daily) Limit 9 per naratriptan hcl tabs 1 month;QL(0.3 eletriptan hydrobromide Limit 6 per ea daily) 3 month;QL(0.2 tabs ea daily) RELPAX TABS (eletriptan Limit 6 per 7 month;QL(0.2 FROVA TABS Limit 9 per hydrobromide) ea daily) 7 month;QL(0.3 (frovatriptan succinate) ea daily)

120 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limit 18 tabs ZOMIG TABS OR 5 MG, Limit 6 per rizatriptan benzoate 1 per 7 month;QL(0.2 tabs 5 mg, 10 mg month;QL(0.6 2.5 MG (zolmitriptan) ea daily) ea daily) ZOMIG ZMT TBDP Limit 6 per rizatriptan benzoate Limit 12 per 7 month;QL(0.2 1 month;QL(0.4 (zolmitriptan) ea daily) tbdp 5 mg, 10 mg ea daily) Limit 6 MINERALS & ELECTROLYTES sumatriptan soln 20 1 sprayers per Calcium mg/act month;QL(2 ea daily) CALCIFOL WAFR (calcium carbonate-folic sumatriptan soln 5 Limit 6 per 3 1 month;QL(0.2 acid-vit d-b6-b12- mg/act ea daily) boron-magnesium) PA CALCIUM-FOLIC ACID sumatriptan succinate 4 soaj sc 4 mg/0.5ml PLUS D WAFR (calcium PA; Limit 2 per carbonate-folic acid-vit 3 d-b6-b12-boron- sumatriptan succinate fill, 4 per 4 month;QL(0.14 magnesium) soaj sc 6 mg/0.5ml ml daily,2 ml Fluoride per fill retail) (Sodium Fluoride) AL(Up to 6 yrs PA; ST sumatriptan succinate 4 FLUORITAB, NAFRINSE 1 old ); PV soct sc 4 mg/0.5ml DROPS SOLN PA (Sodium Fluoride) AL(Up to 6 yrs sumatriptan succinate 4 soct sc 6 mg/0.5ml FLUORITAB, NAFRINSE, 1 old ); PV PA; ST;QL(2 ml LUDENT CHEW sumatriptan succinate FLORIVA LIQD ( 4 per 30 days sodium 3 soln sc 6 mg/0.5ml retail) fluoride-vitamin d) SUMATRIPTAN PA FLUORABON SOLN AL(Up to 6 yrs SUCCINATE SOSY SC 6 2 old ); PV 4 (sodium fluoride) MG/0.5ML (sumatriptan FLURA-DROPS SOLN AL(Up to 6 yrs 2 succinate) (sodium fluoride) old ); PV sumatriptan succinate Limit 9 per 1 AL(Up to 6 yrs tabs or 25 mg, 50 mg, 1 month;QL(2 ea sodium fluoride chew old ); PV 100 mg daily) 1 AL(Up to 6 yrs Limit 6 per sodium fluoride soln old ); PV zolmitriptan tabs 3 month;QL(0.2 1 AL(Up to 6 yrs ea daily) sodium fluoride tabs old ); PV Limit 6 per Iodine Products zolmitriptan tbdp 3 month;QL(0.2 IODINE STRONG SOLN ea daily) 3 (iodine strong (lugol's)) ZOMIG SOLN NA 5 MG, Limit 6 per 3 month;QL(0.2 2.5 MG (zolmitriptan) Magnesium ea daily) MAGNEBIND 400 TABS (magnesium-calcium- 3 folic acid) 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic Preferred AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

121 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Phosphate (Potassium Chloride) 1 (Pot Phosphate Monobasic KLOR-CON SPRINKLE W/ Sod Phosphate Dibasic CPCR & Monobasic) AV-PHOS EFFER-K TBEF 1 GM-0.84 GM, 2 GM-1.68 GM 250 NEUTRAL, VIRT- 1 3 PHOS 250 NEUTRAL, (potassium PHOSPHO-TRIN 250 bicarbonate-citric acid) NEUTRAL, PHOSPHA 250 EFFERVESCENT NEUTRAL TABS POTASSIUM/CHLORIDE K-PHOS NEUTRAL TABS TBEF (potassium bicarb 2 (pot phosphate & chloride) monobasic w/ sod 7 K-TAB TBCR 10 MEQ, 20 phosphate dibasic & MEQ (potassium 7 monobasic) chloride) K-PHOS TABS K-TAB TBCR 8 MEQ 2 (potassium phosphate 2 (potassium chloride) monobasic) KLOR-CON M15 TBCR pot phosphate (potassium chloride 2 monobasic w/ sod 1 microencapsulated phosphate dibasic & crystals er) monobasic tabs potassium bicarbonate 1 Potassium tbef (Potassium Bicarb & potassium chloride cpcr 1 Chloride) 1 EFFERVESCENT POT or 8 meq, 10 meq CHLORIDE TBEF POTASSIUM CHLORIDE ER TBCR (potassium 2 (Potassium Bicarbonate) 1 EFFER-K TBEF 25 MEQ chloride) (Potassium Bicarbonate) K- potassium chloride EFFERVESCENT, KLOR- 1 microencapsulated 1 CON/EF, K-VESCENT, K- crystals er tbcr PRIME TBEF (Potassium Chloride potassium chloride 1 Microencapsulated pack or 20 meq Crystals Er) KLOR-CON 1 potassium chloride soln 1 M10, KLOR-CON M20 or 10 %, 20 % TBCR potassium chloride tbcr (Potassium Chloride) K- 1 3 SOL SOLN or 20 meq (Potassium Chloride) potassium chloride tbcr 1 KLOR-CON 10, KLOR- 1 or 8 meq, 10 meq CON 8 TBCR Zinc (Potassium Chloride) 1 GALZIN CAPS ( KLOR-CON PACK zinc 3 acetate (oral))

122 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CELLCEPT TABS MISCELLANEOUS THERAPEUTIC CLASSES (mycophenolate 7 Chelating Agents mofetil) (Trientine Hcl) CLOVIQUE 4 PA 1 CAPS cyclosporine caps CUPRIMINE CAPS PA cyclosporine modified 7 (penicillamine) (for microemulsion) 1 D-PENAMINE TABS caps 2 (penicillamine) cyclosporine modified DEPEN TITRATABS TABS (for microemulsion) 1 7 (penicillamine) soln penicillamine caps 4 PA everolimus (immunosuppressant) 1 penicillamine tabs 1 tabs IMURAN TABS SYPRINE CAPS (trientine PA 7 7 (azathioprine) hcl) PA mycophenolate mofetil 1 trientine hcl caps 4 caps Immunomodulators mycophenolate mofetil 1 REVLIMID CAPS PA; AC susr 4 (lenalidomide) mycophenolate mofetil 1 THALOMID CAPS AC tabs 3 (thalidomide) mycophenolate sodium 3 Immunosuppressive Agents tbec (Cyclosporine Modified MYFORTIC TBEC (For Microemulsion)) 1 (mycophenolate 7 GENGRAF CAPS sodium) (Cyclosporine Modified NEORAL CAPS (For Microemulsion)) 1 (cyclosporine modified 7 GENGRAF SOLN (for microemulsion)) ASTAGRAF XL CP24 PA 3 NEORAL SOLN (tacrolimus) (cyclosporine modified 7 AZASAN TABS 3 (for microemulsion)) (azathioprine) PROGRAF CAPS 0.5 MG, 7 azathioprine tabs 1 1 MG, 5 MG (tacrolimus) PROGRAF PACK 0.2 MG, PA CELLCEPT CAPS 4 (mycophenolate 7 1 MG (tacrolimus) RAPAMUNE SOLN mofetil) 7 CELLCEPT SUSR (sirolimus) RAPAMUNE TABS (mycophenolate 7 7 mofetil) (sirolimus)

123 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SANDIMMUNE CAPS 25 PA; Must use MG, 100 MG 7 BENLYSTA SOSY AcariaHealth 4 Specialty Rx at (cyclosporine) (belimumab) SANDIMMUNE SOLN 100 1-844-538- 2 4661;;LA MG/ML (cyclosporine) MOUTH/THROAT/DENTAL AGENTS sirolimus soln 3 Anesthetics Topical Oral sirolimus tabs 3 FIRST-MOUTHWASH BLM SUSP 1 tacrolimus caps (diphenhydramine- 3 ZORTRESS TABS 0.25 lidocaine-alum MG, 0.75 MG, 0.5 MG 7 hydroxide-mg (everolimus hydroxide-simeth) (immunosuppressant)) lidocaine hcl (mouth- 1 ZORTRESS TABS 1 MG throat) soln (everolimus 2 (immunosuppressant)) Anti-infectives - Throat Potassium Removing Agents clotrimazole lozg 1 (Sodium Polystyrene 1 1 Sulfonate) KIONEX POWD clotrimazole troc (Sodium Polystyrene nystatin (mouth-throat) 1 Sulfonate) KIONEX, SPS 1 susp SUSP ORAVIG TABS LOKELMA PACK ST (miconazole (mouth- 3 (sodium zirconium 3 throat)) cyclosilicate) Dental Products sodium polystyrene 1 (Sodium Fluoride (Dental)) sulfonate powd or NEUTRAL SODIUM 3 sodium polystyrene FLUORIDE SOLN sulfonate susp or 15 1 PREVIDENT RINSE SOLN gm/60ml (sodium fluoride 7 sodium polystyrene (dental)) sulfonate susp re 30 3 Steroids - Mouth/Throat/Dental gm/120ml, 50 (Triamcinolone Acetonide gm/200ml (Mouth)) ORALONE 1 Systemic Lupus Erythematosus Agents DENTAL PASTE PSTE PA; Must use triamcinolone acetonide 1 (mouth) pste BENLYSTA SOAJ AcariaHealth 4 Specialty Rx at Throat Products - Misc. (belimumab) 1-844-538- 4661;;LA cevimeline hcl caps 3 QL(3 ea daily) EVOXAC CAPS QL(3 ea daily) 7 (cevimeline hcl) 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic Preferred AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

124 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MUCOTROL WAFR ( (Pediatric Multivitamins AL(Up to 6 yrs oral 3 wound care products) W/Fl) old ) MULTIVITAMIN/FLUORID QL(6 ea daily) pilocarpine hcl (oral) 1 E CHEW 15 UNIT-1 MG- tabs 5 mg 2500 UNIT-13.5 MG-1.2 pilocarpine hcl (oral) QL(4 ea daily) MG-4.5 MCG-400 UNIT- 1 1.05 MG-0.3 MG-1.05 MG- tabs 7.5 mg 60 MG, 15 UNIT-0.5 MG- SALAGEN TABS 5 MG QL(6 ea daily) 1 7 2500 UNIT-13.5 MG-1.2 (pilocarpine hcl (oral)) MG-4.5 MCG-400 UNIT- SALAGEN TABS 7.5 MG QL(4 ea daily) 1.05 MG-0.3 MG-1.05 MG- 7 (pilocarpine hcl (oral)) 60 MG, 15 UNIT-0.25 MG- 2500 UNIT-13.5 MG-1.2 MULTIVITAMINS MG-4.5 MCG-400 UNIT- 1.05 MG-0.3 MG-1.05 MG- Multiple Vitamins w/ Minerals 60 MG ONEVITE TABS (multiple (Pediatric Multivitamins AL(Up to 6 yrs vitamins w/ minerals & 3 W/Fl) old ) ) MULTIVITAMIN/FLUORID folic acid E SOLN 0.25 MG/ML-5 THRIVITE 19 TABS UNIT/ML-0.6 MG/ML-8 (multiple vitamins w/ 3 MG/ML-1500 UNIT/ML-2 minerals & folic acid) MCG/ML-400 UNIT/ML-0.5 1 UDAMIN SP TABS MG/ML-0.4 MG/ML-35 MG/ML, 0.5 MG/ML-5 (multiple vitamins w/ 3 UNIT/ML-0.6 MG/ML-8 minerals & folic acid) MG/ML-1500 UNIT/ML-2 Ped MV w/ Fluoride MCG/ML-400 UNIT/ML-0.5 MG/ML-0.4 MG/ML-35 (Pediatric Multivitamins AL(Up to 6 yrs MG/ML W/Fl) MULTI- old ) VIT/FLUORIDE, (Pediatric Vitamins Acd W/ AL(Up to 6 yrs MULTIVITAMIN WITH 1 Fluoride) TRI- old ) FLUORIDE, MULTI- VIT/FLUORIDE, VITAMINS VITAMIN/FLUORIDE A/C/D/FLUORIDE, TRI- 1 DROPS SOLN VITE/FLUORIDE, TRI- VITAMIN/FLUORIDE (Pediatric Multivitamins AL(Up to 6 yrs SOLN W/Fl) MULTIVITAMIN old ) FLORIVA PLUS SOLN AL(Up to 6 yrs WITH FLUORIDE, MVC- 1 FLUORIDE, (pediatric multivitamins 2 old ) MULTIVITAMINS/FLUORI w/fl) DE CHEW

125 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MULTIVITAMIN/FLUORID AL(Up to 6 yrs TRI-VI-FLOR SUSP E CHEW 0.25 MG-2500 old ) (pediatric vitamins acd UNIT-13.5 MG-1.2 MG-4.5 & l-methylfolate w/ 3 MCG-400 UNIT-1.05 MG- ) 0.3 MG-15 UNIT-1.05 MG- fluoride 60 MG, 0.5 MG-2500 TRI-VI-FLORO SUSP UNIT-13.5 MG-1.2 MG-4.5 (pediatric vitamins acd MCG-400 UNIT-1.05 MG- & l-methylfolate w/ 3 0.3 MG-15 UNIT-1.05 MG- fluoride) 60 MG, 1 MG-2500 UNIT- 13.5 MG-1.2 MG-4.5 MCG- Ped Multi Vitamins w/Fl & FE 400 UNIT-1.05 MG-0.3 (Ped Multivitamins W/Fl & MG-15 UNIT-1.05 MG-60 Iron) MULTI- MG, 2500 UNIT-1 MG-15 2 VIT/IRON/FLUORIDE, UNIT-400 UNIT-1.2 MG- MULTIVITAMIN/FLUORID 1 4.5 MCG-1.05 MG-13.5 E/IRON, MULTI- MG-1.05 MG-300 MCG-60 VITAMIN/FLUORIDE/IRON MG, 2500 UNIT-0.5 MG-15 SOLN UNIT-400 UNIT-1.2 MG- (Pediatric Vitamins Acd AL(Up to 6 yrs 4.5 MCG-1.05 MG-13.5 Fluoride & Iron) TRI- 1 old ) MG-1.05 MG-300 MCG-60 VIT/FLUORIDE/IRON MG, 2500 UNIT-0.25 MG- SOLN 15 UNIT-400 UNIT-1.2 MG-4.5 MCG-1.05 MG- ESCAVITE D CHEW (ped 13.5 MG-1.05 MG-300 multivitamins w/fl & 3 MCG-60 MG (pediatric iron) multivitamins w/fl) POLY-VI-FLOR/IRON AL(Up to 6 yrs AL(Up to 6 yrs CHEW 200 MCG-0.5 MG- old ) pediatric vitamins acd 1 w/ fluoride soln old ) 10 MG-15 UNIT-400 UNIT 3 (ped multivitamins w/fl POLY-VI-FLOR CHEW 200 AL(Up to 6 yrs MCG-1 MG-15 UNIT-400 old ) & iron) UNIT, 200 MCG-0.5 MG-15 POLY-VI-FLOR/IRON UNIT-400 UNIT, 200 MCG- 3 SUSP 200 MCG/ML-7 0.25 MG-15 UNIT-400 MG/ML-0.25 MG/ML (ped 3 UNIT (pediatric multivitamins w/fl & multivitamins w/fl) iron) POLY-VI-FLOR SUSP 200 QUFLORA FE PEDIATRIC AL(Up to 6 yrs MCG/ML-0.25 MG/ML LIQD ( 2 old ) 3 ped multivitamins (pediatric multivitamins w/fl & iron) w/fl) Pediatric Multiple Vitamins & Minerals w/ Fluoride QUFLORA PEDIATRIC AL(Up to 6 yrs FLORIVA CHEW old ) CHEW (pediatric 2 (pediatric multiple multivitamins w/fl) vitamins & minerals w/ 3 QUFLORA PEDIATRIC AL(Up to 6 yrs fluoride) SOLN (pediatric 2 old ) multivitamins w/fl) Prenatal Vitamins

126 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Prenatal Vit W/ Docusate- COMPLETENATE CHEW Iron Carbonyl-Folic Acid) 1 (prenatal vit w/ ferrous 2 INATAL GT TABS fumarate-folic acid) ATABEX EC TBEC CONCEPT DHA CAPS (prenatal vit w/ 2 (prenatal vit w/ fe fum- docusate-iron carbonyl- iron polysacch complex 2 folic acid) -fa-omega 3) C-NATE DHA CAPS CONCEPT OB CAPS (prenatal vit w/ ferrous 3 (prenatal without a vit fumarate-fa-omega 3 w/ fe fum-iron 2 fatty acids) polysacch complex -fa) CITRANATAL 90 DHA CVS WOMENS MISC (prenatal w/o vit a 2 PRENATAL+DHA MISC w/ fe carbonyl-fe (prenatal mv & min w/fe 3 gluconate-dss-fa-dha) fumarate-fa-dha) CITRANATAL ASSURE DOTHELLE DHA CAPS MISC (prenatal w/o vit a 2 (prenatal vit w/ fe fum- w/ fe carbonyl-fe iron polysacch complex 2 gluconate-dss-fa-dha) -fa-omega 3) CITRANATAL B-CALM DUET DHA 400 MISC MISC (prenatal w/o vit a 3 (prenatal w/fe w/ fe carbonyl-fe polysacch cmplx-sod 3 gluconate-fa & vit b6) feredetate-fa-omega 3) CITRANATAL BLOOM DUET DHA BALANCED DHA MISC (prenatal w/o 2 MISC (prenatal w/fe vit a w/ fe carbonyl-fe polysacch cmplx-sod 3 gluconate-dss-fa-dha) feredetate-fa-omega 3) CITRANATAL BLOOM ENBRACE HR CAPS TABS (prenatal vit w/ 3 (prenatal vit w/ fe docusate-fe carbonyl-fe glycine cysteinate-fa- 3 gluconate-folic acid) omega 3 fatty acids) CITRANATAL HARMONY FOLET DHA THPK CAPS (prenatal w/o vit 3 (prenatal vit w/fe a w/ fe fumarate-fe carbonyl-fe bisglyc- 3 carbonyl-dss-fa-dha) methylfol-dss & dha) CITRANATAL MEDLEY FOLIVANE-OB CAPS CAPS (prenatal w/o vit 3 (prenatal without a vit a w/ fe fumarate-fe w/ fe fum-iron 2 carbonyl-fa-dha) polysacch complex -fa) CITRANATAL RX TABS HEMENATAL OB + DHA (prenatal without vit a 2 MISC (prenatal vit w/ fe w/ fe carbonyl-fe gluc- poly cmplx-fe heme 2 docusate-fa) polypept-fa & omega 3)

127 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits HEMENATAL OB TABS NESTABS DHA MISC (prenatal vit w/ fe (prenatal vit without vit polysacch complex-fe 3 a w/ fe bisglycinate-fa- 2 heme polypeptide-fa) omeg 3) INFANATE BALANCE NESTABS ONE CAPS CAPS (prenatal w/o vit (prenatal w/o a w/fe a w/ fe carbonyl-dss-fa- 3 carbonyl-fe bisglyc-l 3 dha) methylfol-dha) MARNATAL-F CAPS NESTABS TABS (prenatal without vit a (prenatal vit without vit w/ iron polysaccharide 2 a w/ fe bisglycinate-folic 3 complex-fa) acid) MYNATAL ADVANCE NEXA PLUS CAPS TABS (prenatal vit w/ (prenatal w/o vit a w/fe docusate-iron carbonyl- 2 fumarate-docusate ca- 3 folic acid) folic acid-dha) MYNATAL ULTRACAPLET OB COMPLETE ONE TABS (prenatal vit w/ CAPS (prenatal w/o vit docusate-iron carbonyl- 2 a w/ fe carbonyl-fe 3 folic acid) aspart glyc-fa-fish oil) MYNATE 90 PLUS TBCR OB COMPLETE PETITE (prenatal vit w/ CAPS (prenatal w/o vit docusate-fe fumarate- 2 a w/ fe carbonyl-fe 3 folic acid) aspart glyc-fa-omega 3) NATACHEW CHEW OB COMPLETE PREMIER (prenatal vit w/ fe fum- TABS (prenatal vit w/ fe bisglycinate chelate- 3 iron carbonyl-fe aspart 3 folic acid) glycinate-fa) NATELLE ONE CAPS OB COMPLETE/DHA (prenatal without vit a CAPS (prenat vit w/ iron w/ fe fum-fa-omega 3 carbonyl-fe asp glyc-fa- 3 fatty acids) omega fatty acid) NEEVO DHA CAPS OBSTETRIX DHA MISC RX/OTC (prenatal without vit a (prenatal w/fe carbonyl- w/ fe fumarate-l 3 fa-dss-omega 3 fatty 2 methylfolate-omegas) acids) NESTABS ABC MISC OBTREX DHA MISC RX/OTC (prenatal mv & min w/o (prenatal w/fe carbonyl- vit a w/fe polysac 3 fa-dss-omega 3 fatty 2 cmplx-fa-ca-omega 3) acids) PNV TABS 29-1 TABS (prenatal vit w/ iron 2 carbonyl-folic acid)

128 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PNV-DHA CAPS PRENAISSANCE CAPS (prenatal without a w/ (prenatal w/o vit a w/ fe 3 3 fe fumarate-l fumarate-dss-fa-dha) methylfolate-fa-dha) PRENAISSANCE PLUS PNV-DHA+DOCUSATE CAPS (prenatal w/o vit 3 CAPS (prenatal w/o vit a w/ fe carbonyl-dss-fa- 3 a w/ fe fumarate-dss- dha) fa-dha) PRENATA CHEW PNV-OMEGA CAPS (prenatal without a vit 2 (prenatal without a w/ w/ fe fumarate-folic fe fumarate-l 3 acid) methylfolate-fa-omega PRENATABS RX TABS 3) (prenatal vit w/ iron 2 PNV-SELECT TABS carbonyl-folic acid) (prenatal vit w/ ferrous 3 PRENATAL + DHA THPK fumarate-l methylfolate- (prenatal w/o vit a w/ folic acid) ferrous fumarate-folic 3 PR NATAL 400 EC MISC acid-dha) (prenatal mv & min w/fe 2 PRENATAL 19 CHEW 30 bisglyc-fe prot succ-fa- UNIT-1000 UNIT-20 MG-3 ca-omega 3) MG-200 MG-29 MG-7 MG- PR NATAL 430 EC MISC 15 MG-3 MG-12 MCG-400 UNIT-1 MG-20 MG-100 (prenatal mv & min w/fe 2 MG, 1000 UNIT-400 UNIT- bisglyc-fe prot succ-fa- 20 MG-25 MG-3 MG-200 2 ca-omega 3) MG-29 MG-7 MG-6 MG-3 PR NATAL 430 MISC MG-12 MCG-1 MG-30 (prenatal mv & min w/fe UNIT-20 MG-100 MG bisglyc-fe prot succ-fa- 2 (prenatal vit w/ ferrous ca-omega 3) fumarate-folic acid) PREMESISRX TABS PRENATAL 19 TABS 1000 UNIT-30 UNIT-20 MG-25 (prenatal w/ calcium-vit 3 MG-3 MG-200 MG-29 MG- b6-vit b12-folic acid- 15 MG-3 MG-7 MG-12 ginger) MCG-400 UNIT-20 MG-1 PRENA 1 TRUE MISC MG-100 MG, 30 UNIT- (prenatal without a w/ 1000 UNIT-20 MG-25 MG- 3 2 3 MG-200 MG-29 MG-7 fe amino acid chelate- MG-15 MG-3 MG-12 MCG- fa-dha) 400 UNIT-1 MG-20 MG- PRENA1 PEARL CPCR 100 MG (prenatal vit w/ (prenatal without a w/ 3 docusate-fe fumarate- fe fumarate-sod folic acid) feredetate-fa-dha)

129 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PRENATAL PRENATE RESTORE MULTIVITAMIN PLUS CAPS (prenatal without DHA MISC (prenatal mv 3 a w/ fe fumarate-l 3 & min w/fe fumarate-fa- methylfolate-fa-dha) dha) PROVIDA OB CAPS PRENATAL PLUS IRON (prenatal without a vit TABS (prenatal vit w/ 2 w/ fe fum-iron 2 iron carbonyl-folic acid) polysacch complex -fa) PRENATAL+DHA MISC R-NATAL OB CAPS (prenatal mv & min w/fe 3 (prenatal w/o vit a w/ fe 3 fumarate-fa-dha) carbonyl-folic acid-dha) PRENATAL-U CAPS RELNATE DHA CAPS (prenatal without a vit 2 (prenatal vit w/ ferrous w/ fe fumarate-folic fumarate-fa-omega 3 3 acid) fatty acids) PRENATE AM TABS SE-NATAL 19 CHEW 30 (prenatal w/ calcium-vit UNIT-1000 UNIT-100 MG- b6-vit b12-folic acid- 3 20 MG-3 MG-200 MG-29 ginger) MG-7 MG-15 MG-3 MG-12 MCG-400 UNIT-1 MG-20 2 PRENATE CHEW MG (prenatal vit w/ (prenatal multivitamins ferrous fumarate-folic & minerals w/ l- 3 acid) methylfolate-fa) SE-NATAL 19 TABS 30 PRENATE DHA CAPS UNIT-1000 UNIT-20 MG-25 (prenatal w/o a w/ fe 3 MG-200 MG-29 MG-7 MG- asparto glyc-l 15 MG-3 MG-12 MCG-400 methylfolate-fa-dha) UNIT-3 MG-20 MG-1 MG- 3 PRENATE ENHANCE 100 MG (prenatal vit w/ CAPS (prenatal without docusate-fe fumarate- a w/ fe fumarate-l 3 folic acid) methylfolate-fa-dha) SELECT-OB CHEW 0.6 PRENATE ESSENTIAL MG-29 MG-30 UNIT-15 MG-25 MG-1700 UNIT-15 CAPS (prenatal w/o a 3 MG-1.8 MG-5 MCG-400 w/ fe asparto glyc-l UNIT-1.6 MG-0.4 MG-2.5 2 methylfolate-fa-dha) MG-60 MG (prenatal vit PRENATE MINI CAPS w/ iron polysaccharide (prenatal w/o vit a w/ fe cmplx-l methylfolate-fa) carbonyl-fe asp glyc- 3 methfol-fa-dha) PRENATE PIXIE CAPS (prenatal w/o a w/ fe asparto glyc-l 3 methylfolate-fa-dha)

130 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SELECT-OB CHEW 1700 TRISTART ONE CAPS UNIT-29 MG-30 UNIT-15 (prenatal without a w/ MG-25 MG-1.6 MG-15 MG- fe carbonyl-l 3 1.8 MG-5 MCG-400 UNIT- ) 1 MG-2.5 MG-60 MG 3 methylfolate-fa-dha (prenatal vit w/ iron VIL-RX TABS (prenatal polysaccharide vit w/ iron carbonyl-folic 2 complex-folic acid) acid) SELECT-OB+DHA MISC VINATE DHA RF CAPS (prenatal without vit a (prenatal mv & min w/fe 3 polysaccharide 3 w/ fe fumarate-l complex-fa-dha) methylfolate-omegas) TARON-C DHA CAPS VINATE ONE TABS (prenatal vit w/ fe fum- (prenatal vit w/ ferrous 2 iron polysacch complex 2 fumarate-folic acid) -fa-omega 3) VIRT-C DHA CAPS (prenatal vit w/ fe fum- TARON-PREX CAPS 2 (prenatal w/o vit a w/ fe 3 iron polysacch complex fumarate-dss-fa-dha) -fa-omega 3) THRIVITE RX TABS VIRT-NATE DHA CAPS (prenatal vit w/ ferrous (prenatal vit w/ iron 2 3 carbonyl-folic acid) fumarate-fa-omega 3 TL-CARE DHA CAPS fatty acids) (prenatal w/fe 3 VIRT-PN DHA CAPS (prenatal without a w/ fumarate-fa-dss-fish oil) 3 TL-SELECT CAPS fe fumarate-l (prenatal w/o vit a w/ fe 3 methylfolate-fa-dha) fumarate-dss-fa-dha) VIRT-PN PLUS CAPS TRI-TABS DHA MISC (prenatal without a w/ (prenatal vit without vit fe fumarate-l 3 a w/ fe bisglycinate-fa- 2 methylfolate-fa-omega omeg 3) 3) TRICARE PRENATAL VIRT-PN TABS (prenatal DHA ONE CAPS vit w/ ferrous fumarate-l 3 (prenatal w/fe 3 methylfolate-folic acid) fumarate-fa-dss-fish oil) TRINATAL RX 1 TABS (prenatal vit w/ ferrous 2 fumarate-folic acid) TRISTART DHA CAPS (prenatal without a w/ fe carbonyl-l 3 methylfolate-fa-dha)

131 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VITAFOL FE+ CPPK 415 VP-HEME OB + DHA MISC MG-0.6 MG-90 MG-20 (prenatal vit w/ fe poly UNIT-150 MCG-1100 cmplx-fe heme 2 UNIT-200 MG-2 MG-25 ) MG-20 MG-50 MG-15 MG- polypept-fa & omega 3 VP-HEME OB TABS 1.8 MG-25 MCG-1000 3 UNIT-1.6 MG-0.4 MG-2.5 (prenatal vit w/ fe 3 MG-60 MG (prenatal vit polysacch complex-fe w/ fe polysacch heme polypeptide-fa) complex-l methylfol-fa- VP-PNV-DHA CAPS dha-dss) (prenatal vit w/ ferrous 3 VITAFOL GUMMIES fumarate-fa-omega 3 CHEW (prenatal vit w/ fatty acids) 3 ferric phosphate-fa- WEGMANS COMPLETE omega 3 fatty acids) PRENATAL+DHA MISC 3 VITAFOL-NANO TABS (prenatal mv & min w/fe (prenatal w/o a vit w/ fe fumarate-fa-dha) 3 fumarate-l methylfolate- ZATEAN-PN DHA CAPS folic acid) (prenatal without a w/ 3 VITAFOL-ONE CAPS fe fumarate-l (prenatal mv & min w/fe methylfolate-fa-dha) 3 polysaccharide ZATEAN-PN PLUS CAPS complex-fa-dha) (prenatal without a w/ VITAMEDMD ONE fe fumarate-l 3 RX/QUATREFOLIC CAPS methylfolate-fa-omega (prenatal without a w/ 3 3) fe fumarate-l MUSCULOSKELETAL THERAPY AGENTS - methylfolate-fa-dha) Drugs to Treat Spasms VITAPEARL CPCR Central Muscle Relaxants (prenatal without a w/ 3 (Metaxalone) METAXALL 3 QL(4 ea daily) fe fumarate-sod TABS feredetate-fa-dha) QL(6 ea daily) VITATRUE MISC baclofen tabs 10 mg 1 (prenatal without a w/ baclofen tabs 20 mg 1 QL(4 ea daily) fe amino acid chelate- 2 BACLOFEN TABS 5 MG fa-dha) 2 VIVA DHA CAPS (baclofen) (prenatal vit w/ ferrous carisoprodol tabs 250 3 fumarate-fa-omega 3 3 mg fatty acids) carisoprodol tabs 350 1 VOL-TAB RX TABS mg (prenatal vit w/ iron 2 chlorzoxazone tabs 3 carbonyl-folic acid) 500 mg

132 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits cyclobenzaprine hcl CARISOPRODOL/ASPIRI 1 N/CODEINE TABS tabs 5 mg, 10 mg 3 QL(4 ea daily) (carisoprodol w/ aspirin metaxalone tabs 3 & codeine) methocarbamol tabs 1 orphenadrine w/ aspirin 1 & caff tabs orphenadrine citrate 1 NASAL AGENTS - SYSTEMIC AND TOPICAL - tb12 Drugs to treat the Nose or Sinus ROBAXIN TABS 7 Nasal Agent Combinations (methocarbamol) Limit 1 bottle ROBAXIN-750 TABS azelastine hcl- 7 3 per (methocarbamol) fluticasone propionate month;QL(0.77 SKELAXIN TABS QL(4 ea daily) susp gm daily) 7 (metaxalone) DYMISTA SUSP Limit 1 bottle SOMA TABS per 7 (azelastine hcl- 7 (carisoprodol) month;QL(0.77 fluticasone propionate) gm daily) tizanidine hcl caps 2 3 mg, 4 mg, 6 mg Nasal Anti-infectives BACTROBAN NASAL tizanidine hcl tabs 2 mg 1 OINT (mupirocin 2 calcium) tizanidine hcl tabs 4 mg 1 QL(9 ea daily) Nasal Antiallergy ZANAFLEX CAPS 2 MG, 4 Limit 1 bottle MG, 6 MG (tizanidine 7 ASTEPRO SOLN 7 per hcl) (azelastine hcl) month;QL(1.2 ZANAFLEX TABS 4 MG QL(9 ea daily) ml daily) 7 (tizanidine hcl) Limit 1 inhaler azelastine hcl soln 0.1 1 per Direct Muscle Relaxants %, 137 mcg/spray month;QL(1.2 DANTRIUM CAPS ml daily) 7 (dantrolene sodium) Limit 1 bottle azelastine hcl soln 0.15 per dantrolene sodium 1 1 caps % month;QL(1.2 ml daily) Muscle Relaxant Combinations olopatadine hcl (nasal) 3 carisoprodol w/ aspirin 3 soln & codeine tabs PATANASE SOLN carisoprodol w/ aspirin 1 (olopatadine hcl 7 tabs (nasal)) CARISOPRODOL/ASPIRI Nasal Anticholinergics N TABS (carisoprodol 2 ipratropium bromide 1 w/ aspirin) (nasal) soln Nasal Steroids

133 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limit 2 inhalers FLONASE ALLERGY Limit 2 inhalers (Fluticasone Propionate per (Nasal)) ALLERGY NASAL per RELIEF CHILDRENS 1 month;QL(1.07 SUSP ( 7 month;QL(1.07 SPRAY 24 HOUR SUSP fluticasone ml daily); 50 MCG/ACT ml daily); RX/OTC propionate (nasal)) RX/OTC (Fluticasone Propionate Limit 2 inhalers FLONASE ALLERGY Limit 2 inhalers (Nasal)) ALLERGY per RELIEF SUSP per RELIEF, SM ALLERGY month;QL(1.07 ( 7 month;QL(1.07 RELIEF NASAL SPRAY, ml daily); fluticasone propionate ml daily); QC FLUTICASONE RX/OTC (nasal)) RX/OTC PROPIONATE, QC Limit 2 inhalers ALLERGY RELIEF, KP fluticasone propionate per FLUTICASONE 1 month;QL(1.07 PROPIONATE, KLS (nasal) susp ml daily); ALLER-FLO, HM RX/OTC ALLERGY RELIEF NASAL SPRAY 24HR, GNP Limit 2 inhalers FLUTICASONE mometasone furoate 1 per PROPIONATE 1 (nasal) susp month;QL(1.22 CHILDRENS, GNP gm daily) FLUTICASONE NASACORT ALLERGY Limit 1 sprayer PROPIONATE, EQL 24HR AERO per FLUTICASONE ( 2 month;QL(1.2 triamcinolone ml daily); PROPIONATE acetonide (nasal)) CHILDRENS, EQL RX/OTC FLUTICASONE NASACORT ALLERGY Limit 1 sprayer PROPIONATE, EQ 24HR AERO per ALLERGY RELIEF, CVS ( 7 month;QL(1.2 FLUTICASONE triamcinolone ml daily); PROPRIONATE NASAL acetonide (nasal)) RX/OTC SPRAY, CLARISPRAY Limit 1 sprayer SUSP NASACORT ALLERGY 24HR CHILDRENS AERO per Limit 1 sprayer (Triamcinolone Acetonide ( 7 month;QL(1.2 per triamcinolone ml daily); (Nasal)) ALLERGY NASAL 1 month;QL(1.2 acetonide (nasal)) SPRAY 24 HOUR AERO RX/OTC 55 MCG/ACT ml daily); Limit 2 inhalers RX/OTC NASONEX SUSP ( 7 per (Triamcinolone Acetonide Limit 1 sprayer mometasone furoate month;QL(1.22 (Nasal)) CVS NASAL per (nasal)) gm daily) ALLERGY SPRAY, RA month;QL(1.2 Limit 1 sprayer NASAL ALLERGY SPRAY, ml daily); triamcinolone acetonide per NASAL ALLERGY 24 RX/OTC 1 month;QL(1.2 HOUR MULTI-SYMPTOM, (nasal) aero ml daily); NASAL ALLERGY 24 1 RX/OTC HOUR, KLS ALLER-CORT, GOODSENSE NASAL NEUROMUSCULAR AGENTS - Drugs to ALLERGY SPRAY, GNP Relax/Paralyze Muscles 24 HOUR NASAL ALS Agents ALLERGY SPRAY, EQ NASAL ALLERGY SPRAY RILUTEK TABS (riluzole) 7 AERO

134 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LEVOBUNOLOL HCL riluzole tabs 3 2 SOLN (levobunolol hcl) METIPRANOLOL SOLN OPHTHALMIC AGENTS - Drugs to Treat the Eye 3 (metipranolol) Artificial Tears and Lubricants timolol maleate (ophth) LACRISERT INST 1 3 soln (artificial tear insert) TIMOLOL MALEATE Beta-blockers - Ophthalmic OPHTHALMIC GEL BETAGAN SOLN FORMING SOLG ( 2 7 timolol (levobunolol hcl) maleate (ophth)) TIMOPTIC OCUDOSE betaxolol hcl (ophth) 1 soln SOLN (timolol maleate 3 (ophth)) BETIMOL SOLN (timolol) 2 TIMOPTIC SOLN (timolol BETOPTIC-S SUSP 7 2 maleate (ophth)) (betaxolol hcl (ophth)) TIMOPTIC-XE SOLG CARTEOLOL HCL SOLN 3 (timolol maleate 2 (carteolol hcl (ophth)) (ophth)) COMBIGAN SOLN Cycloplegic Mydriatics (brimonidine tartrate- 3 (Phenylephrine Hcl timolol maleate) (Mydriatic)) ALTAFRIN 3 COSOPT PF SOLN SOLN 10 % (dorzolamide hcl-timolol 7 (Phenylephrine Hcl maleate) (Mydriatic)) ALTAFRIN 1 COSOPT SOLN SOLN 2.5 % (dorzolamide hcl-timolol 7 ATROPINE SULFATE maleate) OINT OP 1 % (atropine 2 dorzolamide hcl-timolol sulfate (ophthalmic)) maleate soln 2 %-0.5 3 ATROPINE SULFATE % SOLN OP 1 % (atropine 2 dorzolamide hcl-timolol sulfate (ophthalmic)) CYCLOGYL SOLN maleate soln 20 mg/ml- 1 7 5 mg/ml, 22.3 mg/ml- (cyclopentolate hcl) 6.8 mg/ml CYCLOMYDRIL SOLN DORZOLAMIDE (cyclopentolate w/ 3 HCL/TIMOLOL MALEATE phenylephrine) 2 SOLN (dorzolamide hcl- cyclopentolate hcl soln 1 timolol maleate) HOMATROPAIRE SOLN ISTALOL SOLN (timolol 2 7 (homatropine hbr) maleate (ophth)) 1 levobunolol hcl soln 1 homatropine hbr soln

135 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ISOPTO ATROPINE SOLN (Neomycin-Bacitracin Zn- (atropine sulfate 2 Polymyxin) NEO-POLYCIN 1 (ophthalmic)) OINT MYDRIACYL SOLN AZASITE SOLN Limit 5mls per 7 3 month;QL(0.17 (tropicamide) (azithromycin (ophth)) ml daily) phenylephrine hcl 3 bacitracin (ophthalmic) 1 (mydriatic) soln 10 % oint phenylephrine hcl 1 bacitracin-polymyxin b 1 (mydriatic) soln 2.5 % (ophth) oint tropicamide soln 3 BESIVANCE SUSP 3 (besifloxacin hcl) Miotics BETADINE OPHTHALMIC ISOPTO CARPINE SOLN QL(0.5 ml PREP SOLN ( 3 7 daily) povidone- (pilocarpine hcl) iodine (ophth)) PHOSPHOLINE IODIDE BLEPH-10 SOLN SOLR (echothiophate 2 (sulfacetamide sodium 7 iodide) (ophth)) 1 QL(0.5 ml CILOXAN OINT pilocarpine hcl soln daily) (ciprofloxacin hcl 2 Ophthalmic Adrenergic Agents (ophth)) ALPHAGAN P SOLN 0.1 % 2 CILOXAN SOLN (brimonidine tartrate) (ciprofloxacin hcl 7 ALPHAGAN P SOLN 0.15 7 (ophth)) % (brimonidine tartrate) ciprofloxacin hcl (ophth) 1 apraclonidine hcl soln 3 soln erythromycin (ophth) brimonidine tartrate 1 1 soln oint IOPIDINE SOLN 0.5 % gatifloxacin (ophth) soln 3 7 (apraclonidine hcl) GENTAK OINT IOPIDINE SOLN 1 % 3 (gentamicin sulfate 2 (apraclonidine hcl) (ophth)) SIMBRINZA SUSP gentamicin sulfate 1 (brinzolamide- 3 (ophth) soln brimonidine tartrate) KLARITY-A SOLN Limit 5mls per Ophthalmic Anti-infectives 3 month;QL(0.17 (azithromycin (ophth)) (Bacitracin-Polymyxin B ml daily) (Ophth)) POLYCIN, AK- 1 levofloxacin (ophth) 3 POLY-BAC OINT soln (Erythromycin (Ophth)) 1 MOXEZA SOLN ILOTYCIN OINT (moxifloxacin hcl 7 (ophth))

136 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(3 ml per fill VIROPTIC SOLN moxifloxacin hcl (ophth) 1 7 soln retail) (trifluridine) ZIRGAN GEL moxifloxacin hcl (ophth) 1 3 soln (ganciclovir ophthalmic) NATACYN SUSP ZYMAXID SOLN 2 7 (natamycin) (gatifloxacin (ophth)) Ophthalmic Immunomodulators neomycin-bacitracin 1 zn-polymyxin oint RESTASIS EMUL QL(2 ml 2 daily,64 ml per NEOMYCIN/POLYMYXIN/ (cyclosporine (ophth)) GRAMICIDIN SOLN fill retail) (neomycin-polymyxin- 2 RESTASIS MULTIDOSE QL(2 ml gramicidin) EMUL (cyclosporine 2 daily,64 ml per fill retail) NEOSPORIN SOLN (ophth)) (neomycin-polymyxin- 7 Ophthalmic Integrin Antagonists gramicidin) XIIDRA SOLN (lifitegrast) 3 PA; ST OCUFLOX SOLN QL(5 ml per fill 7 (ofloxacin (ophth)) retail) Ophthalmic Local Anesthetics (Tetracaine Hcl (Ophth)) ofloxacin (ophth) soln 1 QL(5 ml per fill retail) ALTACAINE, TETRAVISC 3 FORTE, TETRAVISC, polymyxin b- 1 TETCAINE SOLN trimethoprim soln AKTEN GEL (lidocaine POLYTRIM SOLN 3 hcl (ophth)) (polymyxin b- 7 ALCAINE SOLN trimethoprim) 7 (proparacaine hcl) POVIDONE IODINE SOLN (povidone-iodine 3 proparacaine hcl soln 3 (ophth)) tetracaine hcl (ophth) 3 sulfacetamide sodium 1 soln (ophth) oint Ophthalmic Nerve Growth Factors sulfacetamide sodium 1 OXERVATE SOLN PA (ophth) soln 4 (cenegermin-bkbj) tobramycin (ophth) soln 1 Ophthalmic Steroids TOBREX OINT (Bacitracin-Poly-Neomycin- QL(4 gm per fill 2 (tobramycin (ophth)) Hc) NEO-POLYCIN HC 1 retail) OINT TOBREX SOLN 7 (tobramycin (ophth)) (Prednisolone Acetate (Ophth)) PREDNISOLONE 1 TRIFLURIDINE SOLN 2 ACETATE P-F SUSP (trifluridine) ALREX SUSP 3 VIGAMOX SOLN QL(3 ml per fill (loteprednol etabonate) retail) (moxifloxacin hcl 7 QL(4 gm per fill bacitracin-poly- 1 (ophth)) neomycin-hc oint retail)

137 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BLEPHAMIDE S.O.P. MAXITROL SUSP OINT (sulfacetamide 2 (neomycin-polymy- 7 sod-prednisolone) dexameth) BLEPHAMIDE SUSP neomycin-polymy- 1 (sulfacetamide sod- 2 dexameth oint prednisolone) neomycin-polymy- 1 DEXAMETHASONE dexameth susp SODIUM PHOSPHATE neomycin-polymyxin-hc SOLN (dexamethasone 2 1 sodium phosphate (ophth) susp (ophth)) PRED FORTE SUSP ( DUREZOL EMUL prednisolone acetate 2 3 (difluprednate) (ophth)) PRED MILD SUSP FLAREX SUSP ( (fluorometholone 2 prednisolone acetate 2 acetate) (ophth)) fluorometholone PRED-G S.O.P. OINT 1 (gentamicin- 3 (ophth) susp prednisolone acetate) FML FORTE SUSP PRED-G SUSP (fluorometholone 2 (gentamicin- 3 (ophth)) prednisolone acetate) FML LIQUIFILM SUSP prednisolone acetate (fluorometholone 7 1 (ophth)) (ophth) susp PREDNISOLONE SODIUM FML OINT PHOSPHATE SOLN OP 1 ( fluorometholone 2 % (prednisolone sodium 2 ) (ophth) phosphate (ophth)) LOTEMAX GEL 3 PREDNISOLONE SODIUM (loteprednol etabonate) PHOSPHATE/MOXIFLOXA LOTEMAX OINT CIN SOLN 3 3 (loteprednol etabonate) (prednisolone- ) LOTEMAX SUSP Limit 6 per moxifloxacin 7 month;QL(0.2 (loteprednol etabonate) sulfacetamide sod- 1 ml daily) prednisolone soln loteprednol etabonate Limit 6 per 3 month;QL(0.2 SULFACETAMIDE susp ml daily) SODIUM/PREDNISOLONE SODIUM PHOSPHATE 2 MAXIDEX SUSP SOLN (sulfacetamide (dexamethasone 2 sod-prednisolone) (ophth)) TOBRADEX OINT MAXITROL OINT (tobramycin- 3 (neomycin-polymy- 7 dexamethasone) dexameth)

138 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TOBRADEX ST SUSP BROMSITE SOLN (tobramycin- 3 (bromfenac sodium 3 dexamethasone) (ophth)) TOBRADEX SUSP QL(5 ml per fill cromolyn sodium 1 (tobramycin- 7 retail) (ophth) soln dexamethasone) PA; Limit 4 QL(5 ml per fill CYSTARAN SOLN bottles per tobramycin- 1 4 dexamethasone susp retail) (cysteamine hcl) month;QL(2.15 ml daily) ZYLET SUSP QL(5 ml per fill (loteprednol etabonate- 3 retail) diclofenac sodium 1 tobramycin) (ophth) soln Ophthalmic Surgical Aids dorzolamide hcl soln 1 GELFILM OP FILM DORZOLAMIDE HCL 2 (gelatin adsorbable 3 SOLN (dorzolamide hcl) (ophth)) ELESTAT SOLN 7 Ophthalmics - Misc. (epinastine hcl (ophth)) ACULAR LS SOLN EMADINE SOLN (ketorolac 7 (emedastine 3 tromethamine (ophth)) difumarate) ACULAR SOLN epinastine hcl (ophth) 1 (ketorolac 7 soln tromethamine (ophth)) flurbiprofen sodium 1 ACUVAIL SOLN soln (ketorolac 3 FLURBIPROFEN SODIUM tromethamine (ophth)) SOLN (flurbiprofen 2 ALOCRIL SOLN sodium) (nedocromil sodium 3 ILEVRO SUSP 3 (ophth)) (nepafenac) ALOMIDE SOLN ketorolac tromethamine 1 (lodoxamide 2 (ophth) soln tromethamine) LASTACAFT SOLN ST 3 azelastine hcl (ophth) 1 (alcaftadine) soln NEVANAC SUSP 3 AZOPT SUSP Limit 10mls per (nepafenac) 2 month;QL(0.34 (brinzolamide) ml daily) Limit 10mls per olopatadine hcl soln 0.1 month;QL(0.34 BEPREVE SOLN ST; QL(0.34 ml 1 3 % ml daily); (bepotastine besilate) daily) RX/OTC bromfenac sodium 1 Limit 2.5mls (ophth) soln olopatadine hcl soln 0.2 per 1 month;QL(0.08 % 4 ml daily); RX/OTC 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic Preferred AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

139 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PAREMYD SOLN Limit 2.5mls (hydroxyamphetamine- 3 travoprost soln 1 per tropicamide) month;QL(0.08 4 ml daily) Limit 10mls per PATADAY SOLN 0.1 % month;QL(0.34 Limit 2.5mls 7 XALATAN SOLN (olopatadine hcl) ml daily); 7 per RX/OTC (latanoprost) month;QL(0.08 4 ml daily) Limit 2.5mls ZIOPTAN SOLN QL(1 ea daily) PATADAY SOLN 0.2 % per 3 7 month;QL(0.08 (tafluprost) (olopatadine hcl) 4 ml daily); RX/OTC OTIC AGENTS - Drugs to Treat the Ear Limit 10mls per Otic Agents - Miscellaneous PATANOL SOLN 7 month;QL(0.34 (olopatadine hcl) ml daily); acetic acid (otic) soln 1 RX/OTC Otic Anti-infectives ST; Limit 1 PAZEO SOLN CETRAXAL SOLN 3 bottle per 2 (olopatadine hcl) month;QL(0.08 (ciprofloxacin hcl (otic)) 4 ml daily) ciprofloxacin hcl (otic) 1 PROLENSA SOLN soln (bromfenac sodium 3 FLOXIN OTIC SOLN 7 (ophth)) (ofloxacin (otic)) TRUSOPT SOLN 7 (dorzolamide hcl) ofloxacin (otic) soln 1 Prostaglandins - Ophthalmic Otic Combinations Limit 2.5mls (Pramoxine-Hc- Chloroxylenol) CORTIC- 1 1 per bimatoprost soln month;QL(0.08 ND, EXOTIC-HC SOLN 4 ml daily) CIPRO HC SUSP Limit 2.5mls (ciprofloxacin- 3 1 per hydrocortisone) latanoprost soln op month;QL(0.08 4 ml daily) CIPRODEX SUSP QL(8 ml per fill ( retail) Limit 2.5mls ciprofloxacin- 2 LATANOPROST SOLN OP dexamethasone) 2 per (latanoprost) month;QL(0.08 CIPROFLOXACIN/FLUOCI Limit 15mls per 4 ml daily) NOLONE ACETONIDE PF month;QL(0.5 3 Limit 2.5mls SOLN (ciprofloxacin- ea daily) LUMIGAN SOLN 2 per fluocinolone acetonide) (bimatoprost) month;QL(0.08 COLY-MYCIN S SUSP 4 ml daily) (neomycin-colistin-hc- 3 Limit 2.5mls ) TRAVATAN Z SOLN thonzonium 7 per (travoprost) month;QL(0.08 CORTANE-B-OTIC SOLN 4 ml daily) (pramoxine-hc- 7 chloroxylenol)

140 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CORTISPORIN-TC SUSP Aminopenicillins (neomycin-colistin-hc- 3 thonzonium) amoxicillin caps 1 neomycin-polymyxin-hc 1 amoxicillin chew 1 (otic) soln amoxicillin susr 1 neomycin-polymyxin-hc 1 (otic) susp amoxicillin tabs 1 OTICIN HC NR SOLN (pramoxine-hc- 7 ampicillin caps 1 chloroxylenol) MOXATAG TB24 PA; QL(1 ea OTOVEL SOLN Limit 15mls per 3 daily,10 ea per (ciprofloxacin- 3 month;QL(0.5 (amoxicillin) fill retail) fluocinolone acetonide) ea daily) Natural Penicillins Otic Steroids PENICILLIN V (Fluocinolone Acetonide 3 POTASSIUM SOLR 125 (Otic)) FLAC OIL MG/5ML, 250 MG/5ML 2 (Hydrocortisone W/Acetic QL(10 ml per (penicillin v potassium) Acid) ACETASOL HC 3 fill retail,30 ml penicillin v potassium 1 SOLN per fill mail) tabs 250 mg, 500 mg DERMOTIC OIL (fluocinolone acetonide 7 Penicillin Combinations (otic)) amoxicillin & pot 1 clavulanate susr fluocinolone acetonide 3 (otic) oil amoxicillin & pot 1 clavulanate tabs hydrocortisone w/acetic QL(10 ml per 3 fill retail,30 ml acid soln amoxicillin & pot 1 per fill mail) clavulanate tb12 OXYTOCICS - Drugs to Prevent/Control Uterine AMOXICILLIN/CLAVULAN Bleeding ATE POTASSIUM CHEW 2 Abortifacients/Agents for Cervical Ripening (amoxicillin & pot CERVIDIL INST clavulanate) 3 (dinoprostone) AMOXICILLIN/CLAVULAN PREPIDIL GEL ATE POTASSIUM ER 3 2 (dinoprostone) TB12 (amoxicillin & pot clavulanate) Oxytocics AUGMENTIN ES-600 (Methylergonovine SUSR (amoxicillin & pot 7 Maleate) METHERGINE 1 TABS clavulanate) AUGMENTIN SUSR 125 methylergonovine 1 MG/5ML-31.25 MG/5ML maleate tabs (amoxicillin & pot 2 PENICILLINS - Drugs to Treat Bacterial Infections clavulanate)

141 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AUGMENTIN SUSR 250 PROMETRIUM CAPS QL(1 ea daily) MG/5ML-62.5 MG/5ML ( 7 progesterone 7 (amoxicillin & pot micronized) clavulanate) PROVERA TABS 10 MG QL(1 ea daily) AUGMENTIN TABS 500 (medroxyprogesterone 7 MG-125 MG, 875 MG-125 7 acetate) MG (amoxicillin & pot PROVERA TABS 5 MG, clavulanate) 2.5 MG AUGMENTIN XR TB12 (medroxyprogesterone 7 (amoxicillin & pot 7 acetate) clavulanate) PSYCHOTHERAPEUTIC AND NEUROLOGICAL Penicillinase-Resistant Penicillins AGENTS - MISC. - Drugs to Treat Mental and Emotional Conditions dicloxacillin sodium 1 caps Agents for Chemical Dependency PHARMACEUTICAL ADJUVANTS acamprosate calcium 1 tbec Liquid Vehicles ANTABUSE TABS 7 BASE GELATIN GUMMY (disulfiram) TROCHE GEL (gummy 3 1 gel base) disulfiram tabs GUM BASE GELATIN GEL 3 Anti-Cataplectic Agents (gummy gel base) XYREM SOLN ( PA; ST sodium 4 PROGESTINS - Hormone Replacement/Modifying oxybate) Drugs Antidementia Agents Progestins ARICEPT TABS QL(1 ea daily) AYGESTIN TABS 7 (donepezil 7 (norethindrone acetate) hydrochloride) medroxyprogesterone QL(1 ea daily) QL(1 ea daily) 1 donepezil 1 acetate tabs 10 mg hydrochloride tabs medroxyprogesterone QL(1 ea daily) donepezil 1 acetate tabs 5 mg, 2.5 1 hydrochloride tbdp mg EXELON PT24 7 MEGACE ES SUSP AC (rivastigmine) (megestrol acetate 7 galantamine QL(1 ea daily) (appetite)) hydrobromide cp24 8 1 AC megestrol acetate 3 mg, 16 mg, 24 mg (appetite) susp GALANTAMINE HYDROBROMIDE SOLN 4 norethindrone acetate 1 2 tabs MG/ML (galantamine QL(1 ea daily) hydrobromide) progesterone 3 micronized caps

142 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits galantamine RAZADYNE ER CP24 QL(1 ea daily) hydrobromide tabs 4 1 (galantamine 7 mg, 8 mg, 12 mg hydrobromide) PA RAZADYNE TABS memantine hcl cp24 14 3 mg, 21 mg, 28 mg (galantamine 7 PA; ST hydrobromide) memantine hcl cp24 7 3 mg rivastigmine pt24 1 memantine hcl soln 2 1 rivastigmine tartrate 1 mg/ml, 10 mg/5ml caps memantine hcl tabs 1 Combination Psychotherapeutics QL(2 ea daily) CHLORDIAZEPOXIDE/AMI memantine hcl tabs 10 1 mg TRIPTYLINE TABS (chlordiazepoxide- 3 QL(4 ea daily) memantine hcl tabs 5 1 amitriptyline) mg olanzapine-fluoxetine NAMENDA TABS 10 MG QL(2 ea daily) 3 7 hcl caps (memantine hcl) PERPHENAZINE/AMITRIP NAMENDA TABS 5 MG QL(4 ea daily) 7 TYLINE TABS (memantine hcl) (perphenazine- 3 NAMENDA TITRATION amitriptyline) PAK TABS (memantine 7 SYMBYAX CAPS hcl) (olanzapine-fluoxetine 7 NAMENDA XR CP24 14 PA hcl) MG, 21 MG, 28 MG 7 (memantine hcl) Fibromyalgia Agents NAMENDA XR CP24 7 MG PA; ST SAVELLA TABS 12.5 MG PA; ST;QL(2 7 3 ea daily) (memantine hcl) (milnacipran hcl) NAMENDA XR TITRATION PA; ST SAVELLA TABS 25 MG, 50 PA; QL(2 ea daily) PACK CP24 (memantine 3 MG, 100 MG (milnacipran 3 hcl) hcl) NAMZARIC C4PK 10 MG PA SAVELLA TITRATION PA; QL(2 ea PACK MISC daily) (memantine hcl- 3 3 (milnacipran hcl) donepezil hcl) NAMZARIC CP24 10 MG- PA Movement Disorder Drug Therapy 14 MG, 10 MG-21 MG, 10 AUSTEDO TABS 6 MG PA; ST 4 MG-28 MG (memantine 3 (deutetrabenazine) hcl-donepezil hcl) AUSTEDO TABS 9 MG, 12 PA 4 NAMZARIC CP24 10 MG-7 PA; ST MG (deutetrabenazine) MG (memantine hcl- 3 PA; Specialty INGREZZA CAPS donepezil hcl) 4 drug-Health (valbenazine tosylate) Net will refer to SP Pharmacy

143 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits INGREZZA CPPK PA MAYZENT TABS PA 4 3 (valbenazine tosylate) (siponimod fumarate) tetrabenazine tabs 4 PA; Must use PLEGRIDY SOPN AcariaHealth XENAZINE TABS 4 Specialty Rx at 7 (peginterferon beta-1a) (tetrabenazine) 1-844-538- 4661;LA Multiple Sclerosis Agents PA; Must use (Glatiramer Acetate) PA PLEGRIDY SOSY 1 4 AcariaHlth Sp GLATOPA SOSY (peginterferon beta-1a) Rx 1-844-538- AMPYRA TB12 PA 4661;LA 7 (dalfampridine) PA; Must use AUBAGIO TABS PA PLEGRIDY STARTER AcariaHealth 3 PACK SOPN (teriflunomide) 4 Specialty Rx at (peginterferon beta-1a) 1-844-538- PA; Must use 4661;LA AVONEX KIT (interferon AcariaHlth Sp 4 PA; Must use beta-1a) Rx 1-844-538- PLEGRIDY STARTER 4661;LA PACK SOSY 4 AcariaHlth Sp Rx 1-844-538- PA; Must use (peginterferon beta-1a) 4661;LA AVONEX PEN AJKT AcariaHlth Sp 4 PA; Must use (interferon beta-1a) Rx 1-844-538- REBIF REBIDOSE SOAJ 4661;LA 4 AcariaHlth Sp (interferon beta-1a) Rx 1-844-538- PA; Must use 4661;LA AVONEX PSKT AcariaHlth Sp 4 PA; Must use (interferon beta-1a) Rx 1-844-538- REBIF REBIDOSE 4661;LA TITRATIONPACK SOAJ 4 AcariaHlth Sp Rx 1-844-538- BETASERON KIT PA (interferon beta-1a) 4 4661;LA (interferon beta-1b) PA; Must use COPAXONE SOSY PA REBIF SOSY (interferon AcariaHlth Sp 7 4 (glatiramer acetate) beta-1a) Rx 1-844-538- 4661;LA dalfampridine tb12 1 PA REBIF TITRATION PACK PA; Must use EXTAVIA KIT (interferon PA SOSY ( 4 AcariaHlth Sp 4 interferon beta- Rx 1-844-538- ) beta-1b 1a) 4661;LA GILENYA CAPS PA; LA 3 PA; MUST (fingolimod hcl) TECFIDERA CPDR USE ACARIA 1 PA 3 SPECIALTY glatiramer acetate sosy (dimethyl fumarate) RX 844-538- MAVENCLAD TBPK PA 4661;LA (cladribine (multiple 4 PA; MUST sclerosis)) TECFIDERA STARTER USE ACARIA MAYZENT STARTER PA PACK MISC (dimethyl 3 SPECIALTY fumarate) RX 844-538- PACK TBPK (siponimod 3 4661;LA fumarate) Postherpetic Neuralgia (PHN)/Neuropathic Pain

144 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GRALISE STARTER MISC PA; ST (Nicotine Polacrilex) SR PV (gabapentin (once- 3 NICOTINE GUM, SM daily)) NICOTINE POLACRILEX, SM NICOTINE, RA GRALISE TABS 300 MG PA; ST NICOTINE POLACRILEX, (gabapentin (once- 3 RA NICOTINE GUM, RA daily)) NICOTINE, PX STOP GRALISE TABS 600 MG PA; ST;QL(3 SMOKING AID, (gabapentin (once- 3 ea daily) NICORELIEF, KLS QUIT4, KLS QUIT2, HM NICOTINE daily)) POLACRILEX, Premenstrual Dysphoric Disorder (PMDD) Agents GOODSENSE NICOTINE FLUOXETINE CAPS 10 GUM, GNP NICOTINE POLACRILEX, GNP MG (fluoxetine hcl 2 NICOTINE GUM, EQL (pmdd)) NICOTINE POLACRILEX 7 FLUOXETINE CAPS 20 QL(1 ea daily) STARTER, EQL NICOTINE MG (fluoxetine hcl 2 POLACRILEX REFILL, (pmdd)) EQL NICOTINE POLACRILEX, EQ fluoxetine hcl (pmdd) 3 NICOTINE POLACRILEX, tabs EQ NICOTINE GUM SARAFEM TABS STARTER, EQ NICOTINE 7 (fluoxetine hcl (pmdd)) GUM REFILL, CVS NICOTINE POLACRILEX Pseudobulbar Affect (PBA) Agents STARTER, CVS NUEDEXTA CAPS PA NICOTINE POLACRILEX, (dextromethorphan hbr- 4 CVS NICOTINE, THRIVE, TGT NICOTINE quinidine sulfate) POLACRILEX, TGT Psychotherapeutic and Neurological Agents - NICOTINE GUM GUM ERGOLOID MESYLATES TABS (ergoloid 3 mesylates) ORAP TABS (pimozide) 7 PIMOZIDE TABS 3 (pimozide) Restless Leg Syndrome (RLS) Agents HORIZANT TBCR 300 MG QL(1 ea daily) 3 (gabapentin enacarbil) HORIZANT TBCR 600 MG QL(2 ea daily) 3 (gabapentin enacarbil) Smoking Deterrents

145 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Nicotine Polacrilex) TGT PV (Nicotine) CVS NICOTINE PV NICOTINE POLACRILEX, TRANSDERMALSYSTEM, SM NICOTINE TGT NICOTINE STEP POLACRILEX, SM TWO, TGT NICOTINE NICOTINE, RA NICOTINE STEP THREE, TGT POLACRILEX, RA MINI NICOTINE STEP ONE, SM NICOTINE, PX STOP NICOTINE SMOKING AID, NICOTINE TRANSDERMAL MINI LOZENGE, KLS SYSTEM/STEP 3/CLEAR, QUIT4, KLS QUIT2, HM SM NICOTINE NICOTINE POLACRILEX, TRANSDERMAL GOODSENSE NICOTINE SYSTEM/STEP 2/CLEAR, POLACRILEX, SM NICOTINE GOODSENSE NICOTINE, 7 TRANSDERMAL GNP NICOTINE SYSTEM/STEP 1/CLEAR, POLACRILEX MINI, GNP SM NICOTINE NICOTINE POLACRILEX, TRANSDERMAL SYSTEM, GNP NICOTINE MINI RA NICOTINE LOZENGE, EQL TRANSDERMAL SYSTEM NICOTINE POLACRILEX, STEP 3, RA NICOTINE EQ NICOTINE TRANSDERMAL SYSTEM, POLACRILEX, EQ RA NICOTINE, NICOTINE NICOTINE LOZENGES, TRANSDERMAL SYSTEM EQ NICOTINE, CVS STEP 3, NICOTINE NICOTINE POLACRILEX, TRANSDERMAL SYSTEM CVS NICOTINE LOZENGE STEP 2, NICOTINE 7 LOZG TRANSDERMAL SYSTEM STEP 1, NICOTINE STEP 3, NICOTINE STEP 2, NICOTINE STEP 1, HM NICOTINE TRANSDERMALSYSTEM, HM NICOTINE TRANSDERMAL SYSTEM STEP 3, HM NICOTINE TRANSDERMAL SYSTEM STEP 2, HM NICOTINE TRANSDERMAL SYSTEM STEP 1, HM NICOTINE TRANSDERMAL SYSTEM, GNP NICOTINE TRANSDERMALSYSTEM STEP 2, GNP NICOTINE TRANSDERMALSYSTEM, EQ NICOTINE STEP 3, EQ NICOTINE, CVS NICOTINE TRANSDERMALSYSTEM/ STEP 3, CVS NICOTINE TRANSDERMALSYSTEM STEP 2, CVS NICOTINE TRANSDERMALSYSTEM 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic Preferred AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

146 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits STEP 1 PT24 RESPIRATORY AGENTS - MISC. - Drugs to Treat Lung Conditions PV bupropion hcl (smoking 7 deterrent) tb12 Cystic Fibrosis Agents KALYDECO PACK 25 MG PA CHANTIX CONTINUING QL(2 ea daily); 4 (ivacaftor) MONTHPAK TABS 5 PV (varenicline tartrate) KALYDECO PACK 50 MG, PA; Must use 4 Accredo SP CHANTIX STARTING PV 75 MG (ivacaftor) pharmacy;LA MONTH PAK TABS 5 KALYDECO TABS 150 MG PA; Must use (varenicline tartrate) 4 Accredo SP CHANTIX TABS 0.5 MG PV (ivacaftor) 5 pharmacy;LA (varenicline tartrate) ORKAMBI PACK 100 MG- PA CHANTIX TABS 1 MG QL(2 ea daily); 125 MG, 150 MG-188 MG 4 5 (varenicline tartrate) PV (lumacaftor-ivacaftor) NICODERM CQ PT24 PV PA; Must use 5 (nicotine) ORKAMBI TABS 100 MG- AcariaHealth Specialty Rx at NICORETTE GUM PV 125 MG, 200 MG-125 MG 4 5 1-844-538- (nicotine polacrilex) (lumacaftor-ivacaftor) 4661;QL(4 ea NICORETTE LOZG PV daily); LA 5 (nicotine polacrilex) PULMOZYME SOLN PA; QL(5 ml 4 NICORETTE MINI LOZG PV (dornase alfa) daily) 5 (nicotine polacrilex) SYMDEKO TBPK PA; LA 4 NICORETTE STARTER PV (tezacaftor-ivacaftor) KIT GUM (nicotine 5 TRIKAFTA TBPK PA; QL(3 ea polacrilex) (elexacaftor-tezacaftor- 4 daily) nicotine polacrilex gum 7 PV ivacaftor) Pulmonary Fibrosis Agents PV nicotine polacrilex lozg 7 ESBRIET CAPS PA 4 (pirfenidone) nicotine pt24 7 PV ESBRIET TABS PA 4 NICOTINE PV (pirfenidone) TRANSDERMAL SYSTEM 5 OFEV CAPS (nintedanib PA; QL(1 ea KIT (nicotine) 4 esylate) daily) NICOTROL INHALER PV 5 INHA (nicotine) SULFONAMIDES - Drugs to Treat Bacterial Infections NICOTROL NS SOLN PV 5 (nicotine) Sulfonamides ZYBAN TB12 ( PV SULFADIAZINE TABS bupropion 5 3 hcl (smoking deterrent)) (sulfadiazine) Transthyretin Amyloidosis Agents TETRACYCLINES - Drugs to Treat Bacterial Infections TEGSEDI SOSY PA 4 (inotersen sodium) Tetracyclines

147 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Doxycycline PA minocycline hcl tabs 50 1 (Monohydrate)) AVIDOXY 3 mg, 75 mg, 100 mg TABS (Doxycycline tetracycline hcl caps 1 (Monohydrate)) 1 VIBRAMYCIN CAPS 100 MONDOXYNE NL, OKEBO CAPS MG (doxycycline 7 ) (Doxycycline Hyclate) hyclate MORGIDOX 1X100MG, VIBRAMYCIN SUSR 25 MORGIDOX 2X100MG, 1 MG/5ML (doxycycline 7 MORGIDOX 1X50MG (monohydrate)) CAPS VIBRAMYCIN SYRP 50 ACTICLATE TABS 7 MG/5ML (doxycycline 2 (doxycycline hyclate) calcium) demeclocycline hcl 1 THYROID AGENTS - Drugs to Regulate Thyroid tabs Hormones doxycycline ST Antithyroid Agents (monohydrate) caps 3 150 mg methimazole tabs 1 doxycycline propylthiouracil tabs 1 QL(3 ea daily) (monohydrate) caps 50 1 TAPAZOLE TABS mg, 75 mg, 100 mg 7 doxycycline (methimazole) (monohydrate) susr 25 1 Thyroid Hormones mg/5ml (Levothyroxine Sodium) ST EUTHYROX, LEVOXYL doxycycline TABS 25 MCG, 50 MCG, 1 (monohydrate) tabs 3 75 MCG, 88 MCG, 100 150 mg MCG, 137 MCG, 150 MCG doxycycline (Levothyroxine Sodium) QL(1 ea daily) (monohydrate) tabs 50 3 EUTHYROX, UNITHROID, mg, 75 mg, 100 mg LEVOXYL, LEVO-T TABS 1 112 MCG, 125 MCG, 175 doxycycline hyclate 1 MCG, 200 MCG caps 50 mg, 100 mg (Levothyroxine Sodium) LEVO-T, UNITHROID doxycycline hyclate 1 tabs 100 mg TABS 25 MCG, 50 MCG, 1 75 MCG, 88 MCG, 100 doxycycline hyclate MCG, 137 MCG, 150 MCG, tabs 20 mg, 75 mg, 150 3 300 MCG mg (Thyroid) NP THYROID 15, MINOCIN CAPS NP THYROID 90, NP 7 1 (minocycline hcl) THYROID 60, NP THYROID 30 TABS minocycline hcl caps 1 ARMOUR THYROID TABS 50 mg, 75 mg, 100 mg 2 (thyroid)

148 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CYTOMEL TABS 25 MCG, QL(2 ea daily) THYROLAR-1/4 TABS 3 50 MCG (liothyronine 7 (liotrix (t3-t4)) sodium) THYROLAR-2 TABS 3 CYTOMEL TABS 5 MCG (liotrix (t3-t4)) 7 (liothyronine sodium) THYROLAR-3 TABS 3 levothyroxine sodium QL(1 ea daily) (liotrix (t3-t4)) tabs or 112 mcg, 125 WESTHROID TABS 1 2 mcg, 175 mcg, 200 (thyroid) mcg WP THYROID TABS 48.75 3 levothyroxine sodium MG (thyroid) tabs or 25 mcg, 50 WP THYROID TABS 65 1 MG, 130 MG, 32.5 MG, mcg, 75 mcg, 88 mcg, 2 100 mcg, 137 mcg, 150 97.5 MG, 16.25 MG, 81.25 mcg, 300 mcg MG, 113.75 MG (thyroid) QL(2 ea daily) ULCER DRUGS - Drugs to Treat Bowel, Intestine liothyronine sodium 1 tabs 25 mcg, 50 mcg and Stomach Conditions Antispasmodics liothyronine sodium 1 tabs 5 mcg (Hyoscyamine Sulfate) ED- NATURE-THROID NT-2.5 SPAZ, OSCIMIN, NULEV 1 3 TBDP TABS (thyroid) (Hyoscyamine Sulfate) NATURE-THROID TABS 3 OSCIMIN SR, SYMAX-SR 1 48.75 MG (thyroid) TB12 NATURE-THROID TABS (Hyoscyamine Sulfate) 1 65 MG, 130 MG, 195 MG, OSCIMIN TABS 260 MG, 325 MG, 32.5 ANASPAZ TBDP MG, 97.5 MG, 16.25 MG, 2 7 81.25 MG, 113.75 MG, (hyoscyamine sulfate) 146.25 MG (thyroid) BELLADONNA/OPIUM SYNTHROID TABS 112 QL(1 ea daily) SUPP (belladonna 3 MCG, 125 MCG, 175 alkaloids & opium) MCG, 200 MCG 7 BENTYL CAPS 7 (levothyroxine sodium) (dicyclomine hcl) SYNTHROID TABS 25 PA chlordiazepoxide hcl- 1 MCG, 50 MCG, 75 MCG, clidinium bromide caps 88 MCG, 100 MCG, 137 7 CUVPOSA SOLN MCG, 150 MCG, 300 MCG 2 (levothyroxine sodium) (glycopyrrolate) thyroid tabs 1 dicyclomine hcl caps 1 THYROLAR-1 TABS 1 3 dicyclomine hcl soln (liotrix (t3-t4)) THYROLAR-1/2 TABS dicyclomine hcl tabs 1 3 (liotrix (t3-t4)) GLYCATE TABS 3 (glycopyrrolate)

149 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Ranitidine Hcl) ACID QL(4 ea daily); glycopyrrolate tabs or 1 1 mg, 2 mg REDUCER, WAL-ZAN 150 RX/OTC MAXIMUM STRENGTH, GLYCOPYRROLATE SB ACID REDUCER, TABS OR 1.5 MG 3 RANITIDINE 150 (glycopyrrolate) MAXIMUM STRENGTH, KLS ACID REDUCER hyoscyamine sulfate 1 tabs MAXIMUMSTRENGTH, HM ACID REDUCER hyoscyamine sulfate 1 MAXIMUM STRENGTH, tb12 HM ACID REDUCER, hyoscyamine sulfate HEARTBURN RELIEF 150 1 MAXIMUM STRENGTH, 1 tbdp GOODSENSE ACID LEVBID TB12 7 REDUCER, GNP ACID (hyoscyamine sulfate) CONTROL 150 MAXIMUM LEVSIN TABS STRENGTH, EQL 7 ( ) HEARTBURN RELIEF hyoscyamine sulfate MAXIMUM STRENGTH, LIBRAX CAPS PA EQL ACID REDUCER (chlordiazepoxide hcl- 7 MAXIMUMSTRENGTH, clidinium bromide) EQ ACID REDUCER, CVS ACID REDUCER methscopolamine 1 MAXIMUMSTRENGTH bromide tabs TABS propantheline bromide CIMETIDINE HCL SOLN 1 2 tabs (cimetidine hcl) ROBINUL FORTE TABS 7 cimetidine tabs 300 mg, 1 (glycopyrrolate) 800 mg ROBINUL TABS 7 1 QL(4 ea daily) (glycopyrrolate) cimetidine tabs 400 mg H-2 Antagonists famotidine susr 40 3 (Ranitidine Hcl) ACID QL(4 ea daily); mg/5ml CONTROL MAXIMUM RX/OTC famotidine tabs 40 mg 1 QL(2 ea daily) STRENGTH, SM ACID REDUCER MAXIMUM NIZATIDINE CAPS 150 2 STRENGTH, RA ACID MG (nizatidine) REDUCER MAXIMUM 1 STRENGTH, PX ACID nizatidine caps 150 mg, 1 REDUCER MAXIMUM 300 mg STRENGTH, ACID NIZATIDINE SOLN 15 2 REDUCER MAXIMUM MG/ML (nizatidine) STRENGTH TABS 150 MG PEPCID SUSR 40 MG/5ML 7 (famotidine) PEPCID TABS 40 MG QL(2 ea daily) 7 (famotidine) ranitidine hcl caps 150 3 mg, 300 mg 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic Preferred AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

150 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(1 ea daily); ranitidine hcl syrp 15 lansoprazole cpdr 15 1 mg/ml, 75 mg/5ml, 150 1 mg RX/OTC mg/10ml QL(1 ea daily) lansoprazole cpdr 30 1 QL(4 ea daily); ranitidine hcl tabs 150 1 mg mg RX/OTC lansoprazole tbdd 15 QL(2 ea daily); QL(2 ea daily) 3 AL(Up to 12 yrs ranitidine hcl tabs 300 1 mg mg old ); RX/OTC ZANTAC 150 MAXIMUM QL(4 ea daily); QL(1 ea daily); lansoprazole tbdd 30 3 STRENGTH TABS RX/OTC AL(Up to 12 yrs 7 mg old ) (ranitidine hcl) QL(1 ea daily); ZANTAC TABS ( QL(2 ea daily) omeprazole cpdr 20 mg 1 ranitidine 7 RX/OTC hcl) omeprazole cpdr 40 mg 1 QL(1 ea daily) Misc. Anti-Ulcer CARAFATE SUSP 1 pantoprazole sodium QL(1 ea daily) 7 1 GM/10ML (sucralfate) tbec CARAFATE TABS 1 GM QL(4 ea daily) PREVACID 24HR CPDR QL(1 ea daily); 7 7 (sucralfate) (lansoprazole) RX/OTC PREVACID CPDR 15 MG QL(1 ea daily); sucralfate susp 1 1 7 gm/10ml (lansoprazole) RX/OTC PREVACID CPDR 30 MG QL(1 ea daily) QL(4 ea daily) 7 sucralfate tabs 1 gm 1 (lansoprazole) Proton Pump Inhibitors PREVACID SOLUTAB QL(2 ea daily); TBDD 15 MG 7 AL(Up to 12 yrs (Lansoprazole) CVS QL(1 ea daily); old ); RX/OTC LANSOPRAZOLE, SM RX/OTC (lansoprazole) LANSOPRAZOLE, RA PREVACID SOLUTAB QL(1 ea daily); LANSOPRAZOLE, QC TBDD 30 MG 7 AL(Up to 12 yrs LANSOPRAZOLE, KLS (lansoprazole) old ) LANSOPRAZOLE, HM PRILOSEC PACK PA LANSOPRAZOLE, 1 HEARTBURN (omeprazole 3 TREATMENT 24 HOUR, magnesium) GOODSENSE PROTONIX PACK 40 MG QL(1 ea daily) 3 LANSOPRAZOLE, GNP (pantoprazole sodium) LANSOPRAZOLE, EQ LANSOPRAZOLE CPDR PROTONIX TBEC 20 MG, QL(1 ea daily) 40 MG (pantoprazole 7 ACIPHEX SPRINKLE PA ) CPSP 10 MG 3 sodium (rabeprazole sodium) RABEPRAZOLE SODIUM PA DR SPRINKLE CPSP ACIPHEX SPRINKLE PA; ST 3 (rabeprazole sodium) CPSP 5 MG (rabeprazole 3 sodium) rabeprazole sodium PA; ST;QL(1 3 ea daily) ACIPHEX TBEC PA; ST;QL(1 tbec 7 (rabeprazole sodium) ea daily) Ulcer Drugs - Prostaglandins

151 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CYTOTEC TABS 7 Urinary Antispasmodic - Antimuscarinics (misoprostol) darifenacin 3 misoprostol tabs 1 hydrobromide tb24 DETROL LA CP24 QL(1 ea daily) 7 Ulcer Therapy Combinations (tolterodine tartrate) OMECLAMOX-PAK MISC DETROL TABS QL(2 ea daily) ( 7 amoxicillin- (tolterodine tartrate) clarithromycin w/ 3 DITROPAN XL TB24 omeprazole) 7 (oxybutynin chloride) PYLERA CAPS ( PA bismuth ENABLEX TB24 subcitrate potassium- 2 (darifenacin 7 metronidazole- hydrobromide) tetracycline) QL(15 ml daily) oxybutynin chloride 1 URINARY ANTI-INFECTIVES - Drugs to Treat syrp 5 mg/5ml Bladder/Kidney Infections QL(4 ea daily) oxybutynin chloride 1 Urinary Anti-infectives tabs 5 mg FURADANTIN SUSP 7 (nitrofurantoin) oxybutynin chloride tb24 5 mg, 10 mg, 15 1 HIPREX TABS mg (methenamine 7 QL(1 ea daily) hippurate) solifenacin succinate 3 tabs 10 mg MACROBID CAPS (nitrofurantoin monohyd 7 solifenacin succinate 3 macro) tabs 5 mg QL(1 ea daily) MACRODANTIN CAPS tolterodine tartrate cp24 1 (nitrofurantoin 7 2 mg, 4 mg macrocrystal) QL(2 ea daily) tolterodine tartrate tabs 1 1 mg, 2 mg methenamine hippurate 3 tabs TOVIAZ TB24 QL(1 ea daily) 2 (fesoterodine fumarate) methenamine 1 mandelate tabs trospium chloride cp24 1 MONUROL PACK 60 mg (fosfomycin 3 QL(2 ea daily) trospium chloride tabs 1 tromethamine) 20 mg nitrofurantoin VESICARE TABS 10 MG QL(1 ea daily) 1 7 macrocrystal caps (solifenacin succinate) VESICARE TABS 5 MG nitrofurantoin monohyd 1 7 macro caps (solifenacin succinate) nitrofurantoin susp 1 Urinary Antispasmodics - Beta-3 Adrenergic MYRBETRIQ TB24 QL(1 ea daily) 3 URINARY ANTISPASMODICS - Drugs to Treat (mirabegron) Miscellaneous Bladder Spasms

152 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Urinary Antispasmodics - Cholinergic Agonists Vaginal Anti-infectives (Metronidazole Vaginal) bethanechol chloride 1 1 tabs VANDAZOLE GEL URECHOLINE TABS AVC CREA 7 3 (bethanechol chloride) (sulfanilamide vaginal) CLEOCIN CREA VA 2 % Urinary Antispasmodics - Direct Muscle Relaxants (clindamycin phosphate 7 flavoxate hcl tabs 1 vaginal) CLEOCIN SUPP VA 100 VACCINES MG (clindamycin 3 Viral Vaccines phosphate vaginal) FLUMIST clindamycin phosphate 1 QUADRIVALENT SUSP vaginal crea 3 (influenza virus vaccine CLINDESSE CREA live quadrivalent) (clindamycin phosphate 3 VAGINAL AND RELATED PRODUCTS (one dose)) GYNAZOLE-1 CREA Miscellaneous Vaginal Products (butoconazole nitrate 3 FEM PH GEL (acetic (one dose)) acid-oxyquinoline 3 METROGEL-VAGINAL vaginal) GEL (metronidazole 7 Spermicides vaginal) (Nonoxynol-9) VCF PV metronidazole vaginal 1 VAGINAL 7 gel CONTRACEPTIVEGEL MICONAZOLE 3 SUPP GEL (miconazole nitrate 3 ENCARE SUPP PV 5 vaginal) (nonoxynol-9) NUVESSA GEL PA 3 OPTIONS CONCEPTROL PV ( ) VAGINAL metronidazole vaginal 5 TERAZOL 7 CREA CONTRACEPTIVE GEL 7 (nonoxynol-9) (terconazole vaginal) TERCONAZOLE CREA OPTIONS GYNOL II PV 2 VAGINALCONTRACEPTIV 5 (terconazole vaginal) E GEL (nonoxynol-9) terconazole vaginal 1 TODAY SPONGE MISC PV 5 crea 0.4 % (nonoxynol-9) terconazole vaginal 3 VCF VAGINAL PV supp 80 mg CONTRACEPTIVE FILM 5 FILM (nonoxynol-9) Vaginal Estrogens VCF VAGINAL PV (Estradiol Vaginal) 1 YUVAFEM TABS CONTRACEPTIVE FOAM 5 ESTRACE CREA FOAM (nonoxynol-9) 7 (estradiol vaginal) 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic Preferred AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

153 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits estradiol vaginal crea 1 EPINEPHRINE SOAJ 0.3 QL(2 ea per fill MG/0.3ML (epinephrine 3 retail,4 ea per estradiol vaginal tabs 1 (anaphylaxis)) 30 days retail) SYMJEPI SOSY 0.15 PA; QL(2 ea ESTRING RING 3 MG/0.3ML (epinephrine 3 per fill retail) (estradiol vaginal) (anaphylaxis)) FEMRING RING Limit 1 per PA; QL(2 ea (estradiol acetate 3 month;QL(0.04 SYMJEPI SOSY 0.3 ea daily) MG/0.3ML ( 3 per fill retail,4 vaginal) epinephrine ea per 30 days PREMARIN CREA VA QL(2 gm daily) (anaphylaxis)) retail) 0.625 MG/GM Neurogenic Orthostatic Hypotension (NOH) - (estrogens, conjugated 2 NORTHERA CAPS PA vaginal) 4 (droxidopa) VAGIFEM TABS 7 (estradiol vaginal) Vasopressors Vaginal Progestins midodrine hcl tabs 3 CRINONE GEL PA (progesterone 3 VITAMINS (vaginal)) Oil Soluble Vitamins ENDOMETRIN INST PA; ST DRISDOL CAPS PV 7 (progesterone 3 (ergocalciferol) (vaginal)) ergocalciferol caps 1 PV VASOPRESSORS - Drugs to Treat Heart and MEPHYTON TABS Circulation Conditions 7 (phytonadione) Anaphylaxis Therapy Agents Not available phytonadione tabs 1 through epinephrine Water Soluble Vitamins (anaphylaxis) soaj 0.15 4 mail;QL(2 ea per fill retail,4 AMINOBENZOATE mg/0.15ml ea per 30 days POTASSIUM PACK retail) (potassium 3 epinephrine QL(2 ea per fill aminobenzoate) (anaphylaxis) soaj 0.15 4 retail,4 ea per POTABA CAPS 30 days retail) mg/0.3ml (potassium 3 Limited to 2 aminobenzoate) pens per fill; 4 epinephrine pens per (anaphylaxis) soaj 0.3 3 month;QL(2 ea mg/0.3ml per fill retail,4 ea per 30 days retail) epinephrine QL(2 ea per fill (anaphylaxis) soaj 0.3 3 retail,4 ea per mg/0.3ml 30 days retail)

154 Index 1ST TIER UNIFINE ACIPHEX SPRINKLE 151 AEROCHAMBER PLUS FLOW- PENTIPS/MINI/31GX5MM 99 acitretin 73 VU/LARGE MASK 116 1ST TIER UNIFINE AEROCHAMBER PLUS FLOW- PENTIPS29GX12MM 99 ACTEMRA 4 VU/MASK 116 1ST TIER UNIFINE ACTEMRA ACTPEN 4 AEROCHAMBER PLUS FLOW- PENTIPS31GX6MM 99 ACTICLATE 148 VU/MEDIUM MASK 116 1ST TIER UNIFINE AEROCHAMBER PLUS FLOW- PENTIPS31GX8MM 99 ACTIGALL 87 VU/SMALL MASK 116 1ST TIER UNIFINE ACTIMMUNE 46 AEROCHAMBER Z-STAT PLUS PENTIPS32GX6MM 99 ACTINEL PEDIATRIC 66 VALVED HOLDING CHAMBER 1ST TIER UNIFINE ACTIQ 8 W/FLOW VU 116 PENTIPS33GX4MM 99 AEROCHAMBER Z-STAT 1ST TIER UNIFINE ACTIVELLA 85 PLUS/FLOWSIGNAL 116 PENTIPSPLUS 31GX8MM 99 ACTONEL 82 AEROCHAMBER Z-STAT 1ST TIER UNIFINE ACTOPLUS MET 28 PLUS/LARGE MASK 116 PENTIPSPLUS 33GX4MM 99 AEROCHAMBER Z-STAT 1ST TIER UNIFINE ACTOPLUS MET XR 28 PLUS/MEDIUM MASK 116 PENTIPSPLUS/MINI/31GX5MM ACTOS 29 AEROCHAMBER Z-STAT 99 ACULAR 139 PLUS/SMALL MASK 116 1ST TIER UNIFINE ACULAR LS 139 AEROCHAMBER/FLOWSIGNAL PENTIPSPLUS/ORIGINAL/29GX 116 12MM 99 ACUVAIL 139 AEROVENT PLUS HOLDING 1ST TIER UNIFINE acyclovir 54,55 CHAMBER/COLLAPSIBLE 116 PENTIPSPLUS/ULTRA acyclovir topical 74 afeditab cr 56 SHORT/31GX6MM 99 ACZONE 69 AFINITOR 44 abacavir sulfate 51 ADALAT CC 56 AFINITOR DISPERZ 44 abacavir sulfate-lamivudine 51 afirmelle 60 abacavir sulfate-lamivudine- adapalene 69 zidovudine 51 ADAPALENE 69 AFSTYLA 90 ABILIFY 50,51 adapalene-benzoyl aftera 64 abiraterone acetate 43 peroxide 69 AGGRENOX 93 ABOUTTIME PEN NEEDLES ADCIRCA 59 AGRYLIN 93 30GX 5/16" 100 ADDERALL 1 AIMOVIG 119 ABOUTTIME PEN NEEDLES ADDERALL XR 1 AJOVY 119 31G X 3/16" 100 adefovir dipivoxil 54 ABOUTTIME PEN NEEDLES AKTEN 137 31G X 5/16" 100 ADEMPAS 59 AKYNZEO 32 ABSTRAL 8 adult aspirin ec low strength 7 ALA SCALP 75 acamprosate calcium 142 ADVAIR DISKUS 18 ala-cort 75 acarbose 28 ADVAIR HFA 18 albendazole 13 ACCUPRIL 37 ADVATE 90 ALBENZA 13 ACCURETIC 38 ADVOCATE INSULIN PEN NEEDLES 100 albuterol sulfate 18,19 acebutolol hcl 55 ADVOCATE INSULIN PEN ALBUTEROL SULFATE ER 19 acetaminophen w/ codeine 11 NEEDLES 29GX12.7MM 100 ALCAINE 137 ACETAMINOPHEN/CAFFEINE/D ADVOCATE INSULIN PEN alclometasone dipropionate 75 IHYDROCODEINE 11 NEEDLES 31GX5MM 100 acetasol hc 141 ADVOCATE INSULIN PEN ALDACTAZIDE 81 acetazolamide 81 NEEDLES 31GX8MM 100 ALDACTONE 82 ADYNOVATE 90 acetic acid (otic) 140 ALDARA 79 AEROCHAMBER MINI ALECENSA 44 acetylcysteine 69 AEROSOLCHAMBER 116 ALENDRONATE SODIUM 83 acid control maximum AEROCHAMBER MV 116 strength 150 AEROCHAMBER PLUS FLOW alendronate sodium 83 acid reducer 150 VU 116 ALENDRONATE SODIUM 83 ACIPHEX 151 AEROCHAMBER PLUS alendronate sodium 83 FLOW-VU 116

Index 1 ALFERON N 46 AMICAR 94 ANZEMET 32 alfuzosin hcl 89 amiloride & AP-HIST DM 66 ALINIA 14 hydrochlorothiazide 81 APEXICON E 75 amiloride hcl 82 aliskiren fumarate 41 apraclonidine hcl 136 AMINOBENZOATE ALKERAN 42 POTASSIUM 154 aprepitant 33 allergy nasal spray 24 hour 134 aminocaproic acid 94 apri 60 allergy relief 134 amiodarone hcl 16 APRISO 87 allopurinol 90 AMITIZA 87 APTENSIO XR 2 almotriptan malate 120 amitriptyline hcl 27 APTIOM 22 ALOCRIL 139 amlodipine besylate 56 APTIVUS 51 ALOMIDE 139 amlodipine besylate- aranelle 61 alophen 97 atorvastatin calcium 58 ARAVA 6 amlodipine besylate-benazepril ALORA 86 hcl 38 ARCALYST 4 alosetron hcl 88 amlodipine besylate- ARCAPTA NEOHALER 19 ALPHAGAN P 136 valsartan 38 ARIAL CHAMBER 116 ALPHANATE/VON amlodipine-valsartan- ARICEPT 142 hydrochlorothiazide 38 WILLEBRANDFACTOR ARIKAYCE 3 COMPLEX/HUMAN 91 amnesteem 69 ALPHANINE SD 91 AMOXAPINE 27 ARIMIDEX 43 alprazolam 16 amoxicillin 141 aripiprazole 51 ALPRAZOLAM INTENSOL 16 amoxicillin & pot ARIXTRA 20 alprazolam xr 15 clavulanate 141 armodafinil 2 AMOXICILLIN/CLAVULANATE ARMONAIR RESPICLICK ALPROLIX 91 POTASSIUM 141 113 17 ALREX 137 AMOXICILLIN/CLAVULANATE ARMONAIR RESPICLICK ALTABAX 72 POTASSIUM ER 141 232 17 amphetamine- altacaine 137 ARMONAIR RESPICLICK dextroamphetamine 1 55 17 ALTACE 37 ampicillin 141 ARMOUR THYROID 148 altafrin 135 AMPYRA 144 ARNUITY ELLIPTA 18 ALUNBRIG 44 ANADROL-50 12 AROMASIN 43 ALVESCO 17 ANAFRANIL 27 ARTHROTEC 50 4 alyacen 1/35 61 anagrelide hcl 93 ARTHROTEC 75 4 alyacen 7/7/7 61 ANALPRAM-HC 13 ARYMO ER 8 alyq 59 ANAPROX DS 4 ASACOL HD 87 amabelz 85 ANASPAZ 149 ascomp/codeine 10 amantadine hcl 47 anastrozole 43 ASMANEX HFA 18 AMARYL 31 ANCOBON 33 ASMANEX TWISTHALER 120 AMBI 12.5CPD/100GFN/30PSE ANDEXXA 32 METERED DOSES 18 66 ASMANEX TWISTHALER 14 12 ambi 12.5cpd/1dcpm/30pse 65 ANDRODERM METERED DOSES 18 12 ambi 40pse/400gfn 65 ANDROGEL ASMANEX TWISTHALER 30 12 METERED DOSES 18 AMBIEN 94 ANDROGEL PUMP ANGELIQ 85 ASMANEX TWISTHALER 60 AMBIEN CR 94 METERED DOSES 18 19 ambrisentan 58 ANORO ELLIPTA ASMANEX TWISTHALER 7 142 AMCINONIDE 75 ANTABUSE METERED DOSES 18 35 aspirin 8 AMERGE 120 ANTARA 31 aspirin 81 low dose 8 amethia 61 anti-diarrheal 13 aspirin-dipyridamole 93 amethyst 61 ANUSOL-HC

Index 2 ASSURE ID SAFETY PEN AVONEX PEN 144 BD SAFETYGLIDE INSULIN NEEDLES 30G X 5/16" 100 AXERT 120 SYRINGE/0.3ML/31G X ASSURE ID SAFETY PEN 15/64" 100 NEEDLES 31G X 3/16" 100 AYGESTIN 142 BD SAFETYGLIDE INSULIN ASTAGRAF XL 123 AZASAN 123 SYRINGE/1ML/31G X ASTEPRO 133 AZASITE 136 15/64" 100 BD VEO INSULIN SYRINGE ATABEX EC 127 azathioprine 123 ULTRA-AFINE/0.3ML/31G X ATACAND 37 azelaic acid 80 6MM 101 ATACAND HCT 38 azelastine hcl 133 BD VEO INSULIN SYRINGE atazanavir sulfate 51 azelastine hcl (ophth) 139 ULTRA-FINE/0.3ML/31G X azelastine hcl-fluticasone 6MM 101 atenolol 55 BD VEO INSULIN SYRINGE propionate 133 atenolol & chlorthalidone 38 ULTRA-FINE/1/2 AZELEX 69 ATIVAN 16 UNIT/0.3ML/31G X 6MM 101 AZILECT 48 BD VEO INSULIN SYRINGE atomoxetine hcl 1 AZITHROMYCIN 98 ULTRA-FINE/1ML/31G X atorvastatin calcium 36 azithromycin 98 6MM 101 atovaquone 14 BEBULIN 91 AZOPT 139 atovaquone-proguanil hcl 41 BELLADONNA/OPIUM 149 AZULFIDINE 87 ATRALIN 69 BELSOMRA 95 AZULFIDINE EN-TABS 87 ATRIPLA 51 benazepril & bacitracin (ophthalmic) 136 ATROPINE SULFATE 135 hydrochlorothiazide 39 bacitracin-poly-neomycin-hc benazepril hcl 37 ATROVENT HFA 17 137 BENEFIX 91 AUBAGIO 144 bacitracin-polymyxin b AUGMENTED (ophth) 136 BENICAR 37 BETAMETHASONE baclofen 132 BENICAR HCT 39 DIPROPIONATE 75 BACLOFEN 132 BENLYSTA 124 AUGMENTIN 141,142 BACTRIM 14 BENSAL HP 79 AUGMENTIN ES-600 141 BACTRIM DS 14 BENTYL 149 AUGMENTIN XR 142 BACTROBAN NASAL 133 BENZACLIN 69 AURORA PEN NEEDLES balsalazide disodium 87 BENZACLIN WITH PUMP 69 29GX12MM 100 AURORA PEN NEEDLES 31G BALVERSA 44 BENZAMYCIN 69 X6MM 100 BANZEL 22 BENZNIDAZOLE 13 AURORA PEN NEEDLES 31G BAQSIMI ONE PACK 29 benzonatate 65 X8MM 100 BAQSIMI TWO PACK 29 benzoyl peroxide- AURORA UNIFINE erythromycin 69 PENTIPS/MINI/31GX3/16" 100 BARACLUDE 54 benztropine mesylate 47 aurovela 1.5/30 61 BASE GELATIN GUMMY BEPREVE 139 AURYXIA 88 TROCHE 142 BD ECLIPSE NEEDLE 30G beser 75 AUSTEDO 143 X1/2" 100 BESIVANCE 136 av-phos 250 neutral 122 BD NEEDLE/30G X 1/2" 100 BETADINE OPHTHALMIC AVALIDE 39 BD PEN PREP 136 AVANDIA 29 NEEDLE/MICRO/ULTRA- BETAGAN 135 FINE/32G X 6MM 100 AVAPRO 37 BD PEN betamethasone dipropionate AVC 153 NEEDLE/MINI/ULTRA- (topical) 75 betamethasone dipropionate FINE/31G X 5MM 100 AVELOX 86 augmented 75 avidoxy 148 BD PEN NEEDLE/ORIGINAL/ULTRA- betamethasone valerate 75 avita 69 FINE/29G X 12.7MM 100 BETAPACE 56 AVODART 89 BD PEN BETAPACE AF 56 AVONEX 144 NEEDLE/SHORT/ULTRA- BETASERON 144 FINE/31G X 8MM 100

Index 3 betaxolol hcl 55 BREATHERITE butalbital-aspirin-caffeine 6 betaxolol hcl (ophth) 135 COLLAPSIBLEINFANT butalbital-aspirin-caffeine SPACER W/MASK 117 bethanechol chloride 153 w/cod 11 BREATHERITE BUTISOL SODIUM 94 BETHKIS 3 COLLAPSIBLESMALL CHILD butorphanol tartrate 12 BETIMOL 135 SPACER W/MASK 117 BREATHERITE BYSTOLIC 55 BETOPTIC-S 135 COLLAPSIBLESPACER W/ BYVALSON 39 BEVESPI AEROSPHERE 19 NEONATE MASK 117 C-NATE DHA 127 BEVYXXA 20 BREATHERITE RIGID cabergoline 85 bexarotene 46 SPACERW/MASK 117 BREATHERITE W/LARGE CABOMETYX 44 BEYAZ 62 MASK 117 CADUET 58 bicalutamide 43 BREATHERITE W/MEDIUM CAFERGOT 120 bidex 68 MASK 117 BREATHERITE W/SMALL caffeine citrate 1 BIDIL 58 MASK 117 CALAN 56 BIKTARVY 51 BREO ELLIPTA 19 CALAN SR 56 BILTRICIDE 13 BRILINTA 93 CALCIFOL 121 bimatoprost 140 brimonidine tartrate 136 calcipotriene 73 bio t pres-b 65 BRIVIACT 22 CALCIPOTRIENE 73 BIO-DTUSS DMX 66 bromfed dm 65 calcipotriene-betamethasone bio-statin 33 bromfenac sodium dipropionate 75 BIO-STATIN 33 (ophth) 139 calcitonin (salmon) 83 BIONEL PEDIATRIC 66 bromocriptine mesylate 47 calcitrene 73 bisacodyl 97 BROMPHENIRAMINE TANNATE 34 calcitriol 84 bisacodyl laxative 97 BROMSITE 139 calcitriol (topical) 73 bisoprolol & BRONKIDS 66 calcium acetate (phosphate hydrochlorothiazide 39 binder) 88 bisoprolol fumarate 55 BRUKINSA 44 CALCIUM-FOLIC ACID PLUS BLEPH-10 136 budesonide 64 D 121 BLEPHAMIDE 138 budesonide (inhalation) 18 calphron 88 BLEPHAMIDE S.O.P. 138 budesonide-formoterol CALQUENCE 44 fumarate dihydrate 19 BONIVA 83 camila 64 bumetanide 82 CANASA 87 bosentan 58 BUMEX 82 BOSULIF 44 candesartan cilexetil 37 bupap 6 candesartan cilexetil- bp 10-1 69 BUPHENYL 84 hydrochlorothiazide 39 BP CLEANSING WASH 69 buprenorphine 12 CAPCOF 66 BRAFTOVI 44 buprenorphine hcl 12 capecitabine 42 BREATHE EASE/LARGE buprenorphine hcl-naloxone hcl CAPEX 75 MASK 117 BREATHE EASE/MEDIUM dihydrate 12 CAPRELSA 44 MASK 117 bupropion hcl 25 captopril 37 BREATHE EASE/SMALL bupropion hcl (smoking captopril & MASK 117 deterrent) 147 hydrochlorothiazide 39 BUPROPION BREATHERITE 117 CARAC 73 BREATHERITE HYDROCHLORIDE ER (XL) 25 CARAFATE 151 COLLAPSIBLEADULT SPACER W/MASK 117 buspirone hcl 15 CARBAGLU 84 BREATHERITE butalbital-acetaminophen 6 carbamazepine 22 COLLAPSIBLECHILD SPACER butalbital-acetaminophen- CARBAPHEN 12 66 W/MASK 117 caffeine 6 CARBAPHEN 12 PED 66 butalbital-acetaminophen- caffeine w/ codeine 11 CARBATROL 22

Index 4 carbidopa 47 carisoprodol w/ aspirin 133 CHENODAL 87 carbidopa-levodopa 47 carisoprodol w/ aspirin & cheratussin ac 65 carbidopa-levodopa-entacapone codeine 133 chlordiazepoxide hcl 16 CARISOPRODOL/ASPIRIN 47 chlordiazepoxide hcl-clidinium carbinoxamine maleate 34 133 CARISOPRODOL/ASPIRIN/CO bromide 149 CARBINOXAMINE DEINE 133 CHLORDIAZEPOXIDE/AMITRIP MALEATE 34 TYLINE 143 CARNITOR 84 carbinoxamine maleate 34 chloroquine phosphate 41 CARBINOXAMINE CARNITOR SF 84 CHLOROQUINE MALEATE 34 CARTEOLOL HCL 135 PHOSPHATE 41 CARDIZEM 56 cartia xt 56 CHLOROTHIAZIDE 82 CARDIZEM CD 56 carvedilol 55 chlorothiazide 82 CARDIZEM LA 56 carvedilol phosphate 55 chlorpromazine hcl 50 CARDURA 38 CASODEX 43 chlorpropamide 31 CARDURA XL 89 CATAPRES 38 chlorthalidone 82 CAREFINE PEN NEEDLES CAYA 98 chlorzoxazone 132 29GX1/2" 101 caziant 60 cholestyramine 35 CAREFINE PEN NEEDLES 30GX5/16" 101 cefaclor 59 cholestyramine light 35 CAREFINE PEN NEEDLES CEFACLOR 60 choline & mag salicylate 8 31GX6MM 101 CEFACLOR ER 59 choline fenofibrate 35 CAREFINE PEN NEEDLES cefadroxil 59 CHOLINE MAGNESIUM 31GX8MM 101 TRISALICYLATE 8 CAREFINE PEN NEEDLES cefdinir 60 ciclodan 72 32GX5MM 101 CEFDITOREN PIVOXIL 60 ciclopirox 72 CAREFINE PEN NEEDLES cefixime 60 32GX6MM 101 ciclopirox olamine 72 cefpodoxime proxetil 60 CAREONE UNIFINE PENTIPS cilostazol 93 29GX12MM 101 cefprozil 60 CILOXAN 136 CAREONE UNIFINE PENTIPS cefuroxime axetil 60 31GX5MM 101 CIMDUO 51 CELEBREX 4 CAREONE UNIFINE PENTIPS cimetidine 150 31GX6MM 101 celecoxib 4,5 CIMETIDINE HCL 150 CAREONE UNIFINE PENTIPS CELEXA 26 cinacalcet hcl 84 31GX8MM 101 CELLCEPT 123 CAREONE UNIFINE PENTIPS CIPRO 86 CELONTIN 25 PLUS PEN NEEDLES CIPRO HC 140 29GX12MM 101 CENTANY 72 CIPRODEX 140 CAREONE UNIFINE PENTIPS cephalexin 59 PLUS PEN NEEDLES ciprofloxacin 87 CEPHALEXIN 59 31GX5MM 101 CIPROFLOXACIN ER 86,87 CAREONE UNIFINE PENTIPS CEPROTIN 93 CIPROFLOXACIN HCL 87 PLUS PEN NEEDLES CERDELGA 93 ciprofloxacin hcl 87 31GX6MM 101 CERVIDIL 141 CAREONE UNIFINE PENTIPS ciprofloxacin hcl (ophth) 136 CESAMET 32 PLUS PEN NEEDLES ciprofloxacin hcl (otic) 140 CETRAXAL 140 31GX8MM 101 CIPROFLOXACIN/FLUOCINOLO CARETOUCH PEN NEEDLES CETYLEV 32 31G X 6 MM 101 NE ACETONIDE PF 140 CARETOUCH PEN NEEDLES cevimeline hcl 124 citalopram hydrobromide 26 31GX 5MM 101 CHANTIX 147 CITRANATAL 90 DHA 127 CARETOUCH PEN NEEDLES CHANTIX CONTINUING CITRANATAL ASSURE 127 31GX 8MM 102 MONTHPAK 147 CARETOUCH PEN NEEDLES CHANTIX STARTING MONTH CITRANATAL B-CALM 127 32GX 5MM 102 PAK 147 CITRANATAL BLOOM 127 carisoprodol 132 CHEMET 32 CITRANATAL BLOOM DHA 127

Index 5 CITRANATAL HARMONY 127 CLEVER CHOICE COMFORT clomiphene citrate 83 CITRANATAL MEDLEY 127 EZPEN NEEDLES clomipramine hcl 27 32GX8MM 102 CITRANATAL RX 127 CLEVER CHOICE COMFORT clonazepam 21 claravis 69 EZPEN NEEDLES clonidine hcl 38 CLARINEX 34 33GX4MM 102 clopidogrel bisulfate 93 CLICKFINE PEN NEEDLE CLARITHROMYCIN 98 UNIVERSAL/31GX1/4" 102 clorazepate dipotassium 16 clarithromycin 98 CLICKFINE PEN NEEDLE clotrimazole 124 clearlax 96 UNIVERSAL/31GX5/16" 102 clotrimazole w/ CLEMASTINE FUMARATE 34 CLICKFINE PEN NEEDLES betamethasone 72 31G X 1/4" 102 clovique 123 CLEOCIN 14,153 CLICKFINE PEN NEEDLES clozapine 49 CLEOCIN PEDIATRIC 31G X 3/16" 102 GRANULES 14 CLICKFINE PEN NEEDLES CLOZAPINE ODT 49 CLEOCIN-T 69 31G X 5/16" 102 CLOZARIL 49 CLEVER CHOICE ANTI- CLICKFINE PEN NEEDLES COAGADEX 91 31G X 8MM 102 STATICVALVED HOLDING COARTEM 41 CHAMBER/ADULT LARGE 117 CLICKFINE PEN CLEVER CHOICE ANTI- NEEDLES/31GX1/4" 102 codeine sulfate 8 STATICVALVED HOLDING CLICKFINE UNIVERSAL PEN CODITUSSIN AC 66 CHAMBER/MEDIUM 117 NEEDLES 31GX5/16" 103 COLAZAL 87 CLEVER CHOICE ANTI- CLIMARA 86 COLCHICINE 90 STATICVALVED HOLDING CLIMARA PRO 85 colchicine 90 CHAMBER/MEDIUM/3 clindacin etz pledgets 69 YEA 117 colchicine w/ probenecid 90 clindamycin hcl 15 CLEVER CHOICE ANTI- COLCRYS 90 STATICVALVED HOLDING clindamycin palmitate CHAMBER/SMALL 117 hydrochloride 15 colesevelam hcl 35 CLEVER CHOICE ANTI- CLINDAMYCIN COLESTID 35 STATICVALVED HOLDING PHOSPHATE 70 COLESTID FLAVORED 35 clindamycin phosphate CHAMBER/SMALL colestipol hcl 35 INFANT 117 (topical) 70 CLEVER CHOICE COMFORT clindamycin phosphate colocort 13 EZINSULIN PEN NEEDLES vaginal 153 COLY-MYCIN S 140 31GX8MM 102 clindamycin phosphate-benzoyl COLYTE-FLAVOR PACKS 95 CLEVER CHOICE COMFORT peroxide 70 EZINSULIN PEN NEEDLES clindamycin phosphate-benzoyl COMBIGAN 135 33GX4MM 102 peroxide (refrigerate) 70 COMBIPATCH 85 CLEVER CHOICE COMFORT clindamycin phosphate- COMBIVENT RESPIMAT 19 tretinoin 70 EZPEN NEEDLES COMBIVIR 51 29GX12MM 102 CLINDESSE 153 COMETRIQ 44 CLEVER CHOICE COMFORT clobazam 21 COMFORT EZ SHORT/31G X EZPEN NEEDLES clobetasol propionate 75 31GX5MM 102 8MM 103 CLEVER CHOICE COMFORT clobetasol propionate e 75 COMFORT EZ/31G X 5MM 103 EZPEN NEEDLES clobetasol propionate emollient COMFORT EZ/31G X 6MM 103 31GX6MM 102 base 75 COMPACT SPACE CLEVER CHOICE COMFORT clobetasol propionate CHAMBER/ANTI-STATIC 118 EZPEN NEEDLES emulsion 76 COMPACT SPACE 31GX8MM 102 CLOBEX 76 CHAMBER/ANTI- CLEVER CHOICE COMFORT CLOCORTOLONE STATIC/LARGE MASK 118 EZPEN NEEDLES PIVALATE 76 COMPACT SPACE 32GX5MM 102 CLOCORTOLONE PIVALATE CHAMBER/ANTI- CLEVER CHOICE COMFORT PUMP 76 STATIC/MEDIUM MASK 118 EZPEN NEEDLES clodan 75 COMPACT SPACE 32GX6MM 102 CLODERM 76 CHAMBER/ANTI-STATIC/SMALL CLODERM PUMP 76 MASK 118

Index 6 COMPLERA 51 CUTIVATE 76 DELSTRIGO 51 COMPLETENATE 127 CUVPOSA 149 DELZICOL 87 compro 50 cvs folic acid 93 DEMADEX 82 COMTAN 47 cvs lansoprazole 151 demeclocycline hcl 148 CONCEPT DHA 127 cvs mucus d extended DEMSER 37 CONCEPT OB 127 release 66 DEPAKENE 25 cvs mucus d maximum strength CONCERTA 2 er 66 DEPAKOTE 25 CONDYLOX 79 cvs nasal allergy spray 134 DEPAKOTE ER 25 constulose 96 cvs nicotine DEPAKOTE SPRINKLES 25 CONZIP 8 transdermalsystem 146 DEPEN TITRATABS 123 CVS WOMENS DERMA-SMOOTHE/FS COPAXONE 144 PRENATAL+DHA 127 COPIKTRA 44 BODY 76 cyclobenzaprine hcl 133 DERMA-SMOOTHE/FS CORDARONE 17 CYCLOGYL 135 SCALP 76 CORDRAN 76 CYCLOMYDRIL 135 DERMOTIC 141 COREG 55 cyclopentolate hcl 135 DESCOVY 51 COREG CR 55 cyclophosphamide 42 desipramine hcl 27 CORGARD 56 cycloserine 42 desloratadine 34 CORIFACT 91 cyclosporine 123 DESLORATADINE ODT 34 CORLANOR 59 cyclosporine modified (for desmopressin acetate 85 CORTANE-B-OTIC 140 microemulsion) 123 desmopressin acetate spray 85 CORTEF 64 CYMBALTA 27 desmopressin acetate spray CORTENEMA 13 cyproheptadine hcl 34 refrigerated 85 cortic-nd 140 CYSTADANE 84 DESOGEN 62 CYSTAGON 89 desogestrel & ethinyl CORTIFOAM 13 estradiol 62 cortisone acetate 64 CYSTARAN 139 desogestrel-ethinyl estradiol CORTISPORIN 72 CYTOMEL 149 (biphasic) 62 CORTISPORIN-TC 141 CYTOTEC 152 DESONATE 76 CORZIDE 39 cytra k crystals 89 desonide 76 COSENTYX 74 cytra-3 89 DESOWEN 76 COSENTYX SENSOREADY cytra-k 89 DESOXIMETASONE 76 PEN 74 D-PENAMINE 123 desoximetasone 76 COSOPT 135 D.H.E. 45 120 DESOXYN 1 COSOPT PF 135 dalfampridine 144 DESVENLAFAXINE ER 27 COTELLIC 44 danazol 12 desvenlafaxine succinate 27 COUMADIN 20 DANTRIUM 133 DETROL 152 COZAAR 37 dantrolene sodium 133 DETROL LA 152 CREON 81 dapsone 14 dexamethasone 64 CRESEMBA 33 dapsone (topical) 70 DEXAMETHASONE CRESTOR 36 darifenacin hydrobromide 152 INTENSOL 64 CRINONE 154 DEXAMETHASONE SODIUM DAURISMO 43 PHOSPHATE 138 CRIXIVAN 51 DAYPRO 5 DEXEDRINE 1 cromolyn sodium 17 DAYTRANA 2 dexmethylphenidate hcl 2 CROMOLYN SODIUM 17 DDAVP 85 dextroamphetamine sulfate 1 cromolyn sodium (ophth) 139 decadron 64 DIACOMIT 22 cryselle-28 62 DECON-G 66 DIASTAT ACUDIAL 21 CUPRIMINE 123 deferasirox 32 DIASTAT PEDIATRIC 21

Index 7 diazepam 16 DIURIL 82 DROPLET PEN NEEDLES 32G diazepam (anticonvulsant) 21 divalproex sodium 25 X 3/16" 103 DROPLET PEN NEEDLES 32G diazepam intensol 15 DIVIGEL 86 X 5/16" 103 DIAZEPAM RECTAL GEL 21 dofetilide 17 DROPLET PEN NEEDLES diazoxide 29 DOLOPHINE 8 32GX5MM 103 DROPLET PEN NEEDLES DIBENZYLINE 37 donepezil hydrochloride 142 32GX6MM 103 DICLEGIS 32 DORAL 94 DROPLET PEN NEEDLES DICLOFENAC EPOLAMINE 71 dorzolamide hcl 139 32GX8MM 103 diclofenac potassium 5 DORZOLAMIDE HCL 139 DROPSAFE SAFETY PEN NEEDLES/31G X 5/16" 103 diclofenac sodium 5 dorzolamide hcl-timolol DROPSAFE SAFTEY PEN diclofenac sodium (actinic maleate 135 NEEDLES/31G X 1/4" 103 keratoses) 73 DORZOLAMIDE drospirenone-ethinyl diclofenac sodium (ophth) 139 HCL/TIMOLOL estradiol 62 MALEATE 135 diclofenac sodium (topical) 71 drospirenone-ethinyl estradiol- DOTHELLE DHA 127 levomefolate calcium 62 diclofenac w/ misoprostol 5 dotti 86 DROXIA 93 dicloxacillin sodium 142 DOVATO 51 DRUG MART UNIFINE PENTIPS dicyclomine hcl 149 DOVONEX 74 31GX5MM 103 DIDANOSINE 51 DRUG MART UNIFINE doxazosin mesylate 38 PENTIPS29G X 12MM 103 DIFFERIN 70 doxepin hcl 27 DRUG MART UNIFINE DIFICID 98 DOXEPIN HCL 27 PENTIPS31GX6MM 104 DRUG MART UNIFINE diflorasone diacetate 76 doxepin hcl 27 DIFLUCAN 33 PENTIPS31GX8MM 104 doxercalciferol 84 DRYSOL 79 diflunisal 8 DOXYCYCLINE 80 digitek 57 DUAC 70 doxycycline DUAVEE 85 digoxin 57,58 (monohydrate) 148 dihydroergotamine doxycycline hyclate 148 DUET DHA 400 127 mesylate 120 doxylamine-pyridoxine 32 DUET DHA BALANCED 127 DILANTIN 25 DRISDOL 154 DUETACT 28 DILANTIN INFATABS 25 dronabinol 33 DULCOLAX 97 DILANTIN-125 25 DROPLET INSULIN SYRINGE duloxetine hcl 27 DILATRATE SR 15 U-100/0.3ML/31G X DUPIXENT 79 DILAUDID 8 15/64" 103 DURAGESIC 8 DROPLET INSULIN SYRINGE DILT-XR 56 U-100/1ML/31G X 15/64" 103 DUREZOL 138 diltiazem hcl 57 DROPLET INSULIN dutasteride 90 diltiazem hcl coated beads 57 SYRINGE/U-100/0.3ML/31G X dutasteride-tamsulosin hcl 90 diltiazem hcl extended release 15/64" 103 DYAZIDE 81 DROPLET INSULIN beads 57 DYMISTA 133 DIOVAN 38 SYRINGE/U-100/1ML/31G X 15/64" 103 DYRENIUM 82 DIOVAN HCT 39 DROPLET PEN NEEDLES e.e.s. 400 98 DIPENTUM 87 29GX12MM 103 E.E.S. GRANULES 98 diphenoxylate w/ atropine 31 DROPLET PEN NEEDLES 30G EASIVENT 118 DIPROLENE 77 X 5/16" 103 DROPLET PEN NEEDLES EASIVENT/MASK-LARGE 118 DIPROLENE AF 76 31GX5MM 103 EASIVENT/MASK-MEDIUM dipyridamole 93 DROPLET PEN NEEDLES 118 disopyramide phosphate 16 31GX6MM 103 EASIVENT/MASK-SMALL 118 DROPLET PEN NEEDLES disulfiram 142 31GX8MM 103 EASY COMFORT PEN DITROPAN XL 152 DROPLET PEN NEEDLES 32G NEEDLES31GX1/4" 104 X 1/4" 103

Index 8 EASY COMFORT PEN eletriptan hydrobromide 120 epinephrine (anaphylaxis) 154 NEEDLES31GX3/16" 104 ELIDEL 79 epitol 21 EASY COMFORT PEN NEEDLES31GX5/16" 104 ELIGARD 43 EPIVIR 51 EASY COMFORT PEN ELIMITE 80 EPIVIR HBV 54 NEEDLES33G X 4MM 104 ELIQUIS 20 eplerenone 41 EASY GLIDE PEN NEEDLES 33G X 5/32" 104 ELIQUIS STARTER PACK 20 EPROSARTAN MESYLATE 38 EASY TOUCH 32GX5MM 104 ELIXOPHYLLIN 19 EPZICOM 52 EASY TOUCH 32GX6MM 104 ELLA 64 EQUETRO 49 EASY TOUCH FLIPLOCK ELMIRON 89 ergocalciferol 154 NEEDLES 30GX1/2" 104 ELOCON 77 ERGOLOID MESYLATES 145 EASY TOUCH HYPODERMIC ELOCTATE 91 ERGOMAR 120 NEEDLES 30GX1/2" 104 EASY TOUCH PEN NEEDLE eluryng 63 ergotamine w/ caffeine 120 30G X 5/16" 104 EMADINE 139 ERIVEDGE 43 EASY TOUCH PEN NEEDLES EMBEDA 9 ERLEADA 43 29GX1/2" 104 EASY TOUCH PEN NEEDLES EMCYT 43 erlotinib hcl 44 31GX1/4" 104 EMEND 33 ERTACZO 72 EASY TOUCH PEN NEEDLES EMEND TRIPACK 33 ERY 70 31GX5/16" 104 EASY TOUCH PEN NEEDLES EMFLAZA 64 ery-tab 98 32GX1/4" 104 EMSAM 26 ERYGEL 70 EASY TOUCH PEN NEEDLES EMTRIVA 51 ERYPED 200 98 32GX3/16" 104 ENABLEX 152 ERYPED 400 98 EASY TOUCH PEN NEEDLES/31G X 3/16" 104 enalapril maleate 37 erythrocin stearate 98 EASY TOUCH SAFETY PEN enalapril maleate & ERYTHROMYCIN 98 NEEDLES/30G X 5/16" 104 hydrochlorothiazide 39 erythromycin (acne aid) 70 ENBRACE HR 127 econazole nitrate 72 erythromycin (ophth) 136 ENBREL 6 ECOZA 72 erythromycin base 98 ENBREL MINI 6 ed a-hist dm 65 erythromycin ethylsuccinate 98 ENBREL SURECLICK 6 ED BRON GP 66 ESBRIET 147 ENCARE 153 ed-spaz 149 ESCAVITE D 126 endocet 10,11 EDARBI 38 escitalopram oxalate 26 ENDOMETRIN 154 EDARBYCLOR 39 esgic 6 enoxaparin sodium 20 EDECRIN 82 ESGIC 7 enpresse-28 60 EDURANT 51 estarylla 62 entacapone 47 efavirenz 51 estazolam 94 entecavir 54 effer-k 122 ESTRACE 86 ENTEREG 88 EFFER-K 122 estradiol 86 effervescent pot chloride 122 ENTOCORT EC 64 estradiol & norethindrone EFFERVESCENT ENTRESTO 58 acetate 85 POTASSIUM/CHLORIDE 122 enulose 88 ESTRADIOL EFFEXOR XR 27 EPCLUSA 54 CONCENTRATE 60 estradiol vaginal 154 EFFIENT 93 EPIDIOLEX 22 ESTRING 154 EFUDEX 73 EPIDUO 70 ESTROGEL 86 EGRIFTA 83 EPIDUO FORTE 70 ESTROPIPATE 86 EGRIFTA SV 83 EPIFOAM 77 ESTROSTEP FE 62 ELDEPRYL 48 epinastine hcl (ophth) 139 eszopiclone 94 ELESTAT 139 EPINEPHRINE 154 ELESTRIN 86 ethacrynic acid 82

Index 9 ethambutol hcl 42 febuxostat 90 flac 141 ethosuximide 25 FEIBA 91 FLAGYL 14 ethynodiol diacet & eth felbamate 24 FLAREX 138 estrad 62 FELBATOL 24 flavoxate hcl 153 ETIDRONATE DISODIUM 83 FELDENE 5 flecainide acetate 16 etodolac 5 felodipine 57 FLECTOR 71 etonogestrel-ethinyl estradiol63 FEM PH 153 FLEXICHAMBER 118 ETOPOSIDE 47 FEMARA 43 FLOMAX 90 EUCRISA 79 FEMCAP 98 FLONASE ALLERGY euthyrox 148 FEMHRT LOW DOSE 85 RELIEF 134 EVAMIST 86 FLONASE ALLERGY RELIEF FEMRING 154 everolimus 44 CHILDRENS 134 FENOFIBRATE 35 everolimus FLORIVA 121 (immunosuppressant) 123 fenofibrate 35 FLORIVA PLUS 125 EVISTA 83 FENOFIBRATE 35 FLOVENT DISKUS 18 EVOCLIN 70 fenofibrate 35 FLOVENT HFA 18 EVOTAZ 52 fenofibrate micronized 35 FLOXIN OTIC 140 EVOXAC 124 FENOFIBRIC ACID 35 fluconazole 33 EXACTUSS TR 66 FENOPROFEN CALCIUM 5 flucytosine 33 EXALGO 9 fenoprofen calcium 5 fludrocortisone acetate 65 EXAPHEX TR 66 FENORTHO 5 FLUMADINE 55 EXEL COMFORT POINT FENSOLVI 43 FLUMIST QUADRIVALENT153 INSULIN PEN NEEDLES 29G X fentanyl 9 fluocinolone acetonide 77 12MM 104 EXEL COMFORT POINT fentanyl citrate 9 fluocinolone acetonide INSULIN PEN NEEDLES 31G X FERRIPROX 32 (otic) 141 6MM 104 FETZIMA 27 fluocinonide 77 EXEL COMFORT POINT FETZIMA TITRATION fluocinonide emulsified base 77 INSULIN PEN NEEDLES 31G X PACK 27 FLUORABON 121 8MM 104 FIBRICOR 36 fluoritab 121 EXELDERM 72 FIBRYGA 91 fluorometholone (ophth) 138 EXELON 142 FIFTY50 PEN NEEDLES 31G FLUOROPLEX 73 exemestane 43 X3/16" (5MM) 104 FLUOROURACIL 73 EXFORGE 39 FIFTY50 PEN NEEDLES 31G fluorouracil (topical) 73 EXFORGE HCT 39 X5/16" (8MM) 105 FIFTY50 PEN NEEDLES FLUOXETINE 145 EXODERM 72 31GX5MM 105 FLUOXETINE DR 26 EXTAVIA 144 FIFTY50 PEN fluoxetine hcl 26 EXTINA 72 NEEDLES/31GX8MM 105 FIFTY50 PEN fluoxetine hcl (pmdd) 145 ezetimibe 36 NEEDLES/32GX6MM 105 FLUOXETINE ezetimibe-simvastatin 34 FINACEA 80 HYDROCHLORIDE 26 FABIOR 70 finasteride 90 FLUPHENAZINE HCL 50 famciclovir 55 FIORICET 7 fluphenazine hcl 50 famotidine 150 FIORICET/CODEINE 11 FLUPHENAZINE HCL 50 FARESTON 43 FIORINAL 7 FLURA-DROPS 121 FARXIGA 31 FIORINAL/CODEINE #3 11 flurandrenolide 77 FARYDAK 44 FIRDAPSE 41 flurazepam hcl 94 FAZACLO 50 FIRST-MOUTHWASH flurbiprofen 5 FC FEMALE CONDOM 98 BLM 124 flurbiprofen sodium 139 FC2 FEMALE CONDOM 98 FIRVANQ 14 FLURBIPROFEN SODIUM 139

Index 10 flutamide 43 gabapentin 22 GLOBAL EASE INJECT PEN fluticasone propionate 77 GABITRIL 24 NEEEDLES 31GX5MM 105 GLOBAL EASY GLIDE INSULIN fluticasone propionate GALAFOLD 84 SYRINGE/0.3ML/31G X (nasal) 134 galantamine 15/64" 105 fluticasone-salmeterol 19 hydrobromide 142 GLOBAL EASY GLIDE INSULIN fluvastatin sodium 36 GALANTAMINE SYRINGE/1ML/31G X fluvoxamine maleate 26 HYDROBROMIDE 142 15/64" 105 galantamine FML 138 GLUCAGEN HYPOKIT 29 hydrobromide 143 GLUCAGON EMERGENCY FML FORTE 138 GALZIN 122 KIT 29 FML LIQUIFILM 138 gatifloxacin (ophth) 136 GLUCOPHAGE 29 FOCALIN 2 GATTEX 89 GLUCOPHAGE XR 29 FOCALIN XR 2 GAVILYTE-C 95 GLUCOTROL 31 FOLET DHA 127 gavilyte-g 95 GLUCOTROL XL 31 folic acid 93 gavilyte-h 95 GLUCOVANCE 28 FOLIVANE-OB 127 gavilyte-n/flavor pack 95 glyburide 31 fondaparinux sodium 20 GELFILM OP 139 glyburide micronized 31 FORFIVO XL 25 gemfibrozil 36 glyburide-metformin 28 FORTEO 83 GENERESS FE 62 GLYCATE 149 FORTESTA 12 gengraf 123 glycopyrrolate 150 FOSAMAX 83 GENTAK 136 GLYCOPYRROLATE 150 fosamprenavir calcium 52 gentamicin sulfate GLYNASE 31 (ophth) 136 fosinopril sodium 37 GLYSET 28 gentamicin sulfate (topical) 72 fosinopril sodium & GLYXAMBI 28 hydrochlorothiazide 39 GENVOYA 52 gnp aspirin 8 FOSRENOL 88 GEODON 49 GNP CLICKFINE PEN FRAGMIN 20,21 gianvi 60 NEEDLEUNIVERSAL/31GX5/16" FREDS PHARMACY UNIFINE GIAZO 87 105 PENTIPS PLUS 31GX5MM 105 GILENYA 144 GNP CLICKFINE UNIVERSAL FREDS PHARMACY UNIFINE PEN NEEDLES 31GX1/4" 105 PENTIPS PLUS 31GX8MM 105 GILOTRIF 45 GNP CLICKFINE UNIVERSAL FREESTYLE INSULINX GILPHEX TR 66 PEN NEEDLES 31GX5/16" 105 BLOODGLUCOSE TEST 80 GILTUSS COUGH & GOLYTELY 95 FREESTYLE INSULINX COLD 66 BLOODGLUCOSE TEST GILTUSS SINUS & goodsense aspirin 8 STRIPS 80 CONGESTION 67 GOODSENSE CLICKFINE FREESTYLE LITE TEST GILTUSS TR 67 SAFETY PEN NEEDLE/31G X STRIPS 80 3/16" 105 FREESTYLE TEST STRIPS 81 glatiramer acetate 144 GOODSENSE PEN FROVA 120 glatopa 144 NEEDLE/PENFINE GLEEVEC 45 CLASSIC/31G X 3/16" 105 frovatriptan succinate 120 GOODSENSE PEN FULPHILA 93 GLENMAX PEB 67 NEEDLE/PENFINE FURADANTIN 152 GLEOSTINE 42 CLASSIC/31G X 5/16" 105 GOODSENSE PEN furosemide 82 glimepiride 31 glipizide 31 NEEDLE/PENFINE FUROSEMIDE 82 CLASSIC/32G X 1/4" 105 furosemide 82 glipizide xl 31 GRALISE 145 FUZEON 52 glipizide-metformin hcl 28 GRALISE STARTER 145 GLOBAL EASE INJECT PEN fyavolv 85 NEEDLES 29GX12MM 105 granisetron hcl 32 FYCOMPA 21 GLOBAL EASE INJECT PEN GRANIX 93 g tussin ac 65 NEEDLES 31GX8MM 105 GRIS-PEG 33

Index 11 griseofulvin microsize 33 HEPSERA 54 hydrocodone- griseofulvin ultramicrosize 33 HETLIOZ 95 acetaminophen 11 hydrocodone-ibuprofen 11 guaifenesin 68 HEXALEN 42 hydrocortisone 64 guaifenesin dac 65 HIPREX 152 hydrocortisone (intrarectal) 13 guaifenesin-codeine 67 HM ULTICARE SHORT PEN hydrocortisone (rectal) 13 guanfacine hcl 38 NEEDLES 31GX8MM 106 HOMATROPAIRE 135 hydrocortisone (topical) 77 guanfacine hcl (adhd) 1 homatropine hbr 135 hydrocortisone butyrate 77 GUANIDINE HCL 41 HORIZANT 145 hydrocortisone butyrate GUM BASE GELATIN 142 HUMALOG 30 hydrophilic lipo base 77 GVOKE PFS 29 HUMALOG JUNIOR hydrocortisone valerate 77 GYNAZOLE-1 153 KWIKPEN 29 hydrocortisone w/acetic H-E-B IN CONTROL PEN HUMALOG KWIKPEN 30 acid 141 NEEDLES 31GX5MM 105 hydromet 65 HUMALOG MIX 50/50 30 H-E-B IN CONTROL PEN hydromorphone hcl 9 NEEDLES 31GX6MM 105 HUMALOG MIX 50/50 H-E-B IN CONTROL PEN KWIKPEN 30 hydroxychloroquine sulfate 41 NEEDLES 31GX8MM 106 HUMALOG MIX 75/25 30 hydroxyurea 46 H-E-B IN CONTROL HUMALOG MIX 75/25 hydroxyzine hcl 15 UNIFINEPENTIPS PLUS KWIKPEN 30 hydroxyzine pamoate 15 31GX5MM 106 HUMATE-P 91 hyoscyamine sulfate 150 H-E-B INCONTROL PEN HUMATROPE 83 106 HYPER-SAL 68 NEEDLES 29GX12MM HUMATROPE COMBO HALCION 94 PACK 83 HYPERSAL 68 halobetasol propionate 77 HUMIRA 4 HYPODERMIC NEEDLE haloperidol 49 HUMIRA PEDIATRIC CROHNS 30GX1/2" 106 haloperidol lactate 49 DISEASE STARTER PACK 3 HYSINGLA ER 9 HARVONI 54 HUMIRA PEN 3 HYZAAR 39 HEALTHWISE MINI PEN HUMIRA PEN-CD/UC/HS ibandronate sodium 83 NEEDLES 31GX6MM 106 STARTER 3 IBRANCE 45 HUMIRA PEN-PS/UV HEALTHWISE PEN NEEDLES ibu 4 29GX12MM 106 STARTER 3 HEALTHWISE SHORT PEN HUMULIN 70/30 30 ibudone 10 NEEDLES 31GX8MM 106 HUMULIN 70/30 ibuprofen 5 HEALTHWISE SHORT PEN KWIKPEN 30 icatibant acetate 92 NEEDLES/31G X 3/16" 106 HUMULIN N 30 ICLUSIG 45 HEALTHWISE SHORT PEN HUMULIN N KWIKPEN 30 NEEDLES/31G X 5/16" 106 IDELVION 91 HEALTHY ACCENTS UNIFINE HUMULIN R 30 IDHIFA 45 PENTIPS PEN NEEDLES HUMULIN R U-500 ILEVRO 139 29GX12MM 106 (CONCENTRATED) 30 HEALTHY ACCENTS UNIFINE HUMULIN R U-500 ilotycin 136 PENTIPS PEN NEEDLES KWIKPEN 30 ILUMYA 74 31GX5MM 106 HYCAMTIN 47 imatinib mesylate 45 HEALTHY ACCENTS UNIFINE hydralazine hcl 41 IMBRUVICA 45 PENTIPS PEN NEEDLES HYDREA 46 31GX6MM 106 imipramine hcl 27 HEALTHY ACCENTS UNIFINE hydrochlorothiazide 82 imipramine pamoate 28 PENTIPS PEN NEEDLES HYDROCODONE imiquimod 79 BITARTRATE/CHLORPHENIR 31GX8MM 106 IMITREX 120 HELIXATE FS 91 AMINE MALEATE/PSE 67 hydrocodone polistirex- IMITREX STATDOSE HEMENATAL OB 128 chlorpheniramine polistirex 67 REFILL 120 HEMENATAL OB + DHA 127 hydrocodone w/ IMITREX STATDOSE HEMOFIL M 91 homatropine 65 SYSTEM 120 IMODIUM A-D 31

Index 12 IMPAVIDO 14 INTUNIV 1 JIVI 91 IMURAN 123 INVEGA 49 JUBLIA 72 inatal gt 127 INVIRASE 52 JULUCA 52 INCRELEX 84 INVOKAMET 28 JUXTAPID 36 INCRUSE ELLIPTA 17 INVOKAMET XR 28 JYNARQUE 85 indapamide 82 INVOKANA 31 k-effervescent 122 INDERAL LA 56 IODINE STRONG 121 K-PHOS 122 INDERAL XL 56 iodoquimez-hc 72 K-PHOS NEUTRAL 122 INDOCIN 5 iodoquinol-hydrocortisone in K-PHOS NO 2 89 INDOMETHACIN 5 aloe vehicle 72 k-sol 122 IOPIDINE 136 indomethacin 5 K-TAB 122 ipratropium bromide 17 INFANATE BALANCE 128 KADIAN 9 ipratropium bromide INGREZZA 143 (nasal) 133 kaitlib fe 61 INLYTA 45 ipratropium-albuterol 19 KALETRA 52 INNOPRAN XL 56 IPRIVASK 21 KALYDECO 147 INREBIC 45 irbesartan 38 KARBINAL ER 34 INSPIRACHAMBER/ANTI- irbesartan-hydrochlorothiazide KCENTRA 91 STATIC 39 KEFLEX 59 VALVED/MOUTHPIECE 118 IRESSA 45 INSPIRACHAMBER/LARGE kelnor 1/35 60 118 ISENTRESS 52 KENALOG 77 INSPIRACHAMBER/SOOTHER ISENTRESS HD 52 KEPPRA 22 MASK/INSPIRAMASK/MEDIUM isoniazid 42 KEPPRA XR 22 118 ISOPTO ATROPINE 136 INSPIRACHAMBER/SOOTHER ketoconazole 33 MASK/INSPIRAMASK/SMALL ISOPTO CARPINE 136 ketoconazole (topical) 72 118 ISORDIL TITRADOSE 15 ketodan 72 INSPIREASE DRUG isosorbide dinitrate 15 KETONE 81 DELIVERYSYSTEM 118 ISOSORBIDE DINITRATE INSPRA 41 ER 15 KETOPROFEN 5 INSULIN LISPRO isosorbide mononitrate 15 KETOPROFEN ER 5 PROTAMINE/INSULIN LISPRO isotretinoin 70 ketorolac tromethamine 5 KWIKPEN 30 isoxsuprine hcl 58 ketorolac tromethamine INSULIN SYRINGES AND PEN (ophth) 139 NEEDLES 106 isradipine 57 KETOSTIX 81 INSUPEN 29G X 12MM 106 ISTALOL 135 KEVZARA 4 INSUPEN 31G X 5MM 106 itraconazole 33 KHEDEZLA 27 INSUPEN 31G X 8MM 106 ivermectin 13 kimidess 60 INSUPEN 33GX4MM 106 IVERMECTIN 80 kionex 124 INSUPEN SENSITIVE ivermectin (rosacea) 80 32GX6MM 106 KISQALI 45 INSUPEN SENSITIVE IXINITY 91 KISQALI FEMARA 200 32GX8MM 106 JADENU 32 DOSE 44 INSUPEN ULTRAFIN JADENU SPRINKLE 32 KISQALI FEMARA 400 29GX12MM 106 DOSE 44 INSUPEN ULTRAFIN JAKAFI 45 KISQALI FEMARA 600 30GX8MM 107 JALYN 90 DOSE 44 INSUPEN ULTRAFIN jantoven 20 KITABIS PAK 3 31GX6MM 107 JANUMET 28 KLARITY-A 136 INSUPEN ULTRAFIN 31GX8MM 107 JANUMET XR 28 KLARON 70 INTELENCE 52 JANUVIA 29 klofensaid ii 71 INTRON A 46 JARDIANCE 31 KLONOPIN 21

Index 13 klor-con 122 LANTUS 30 levonorgestrel & eth klor-con 10 122 LANTUS SOLOSTAR 30 estradiol 62 levonorgestrel (emergency klor-con m10 122 LASIX 82 oc) 64 KLOR-CON M15 122 LASTACAFT 139 levonorgestrel-eth estradiol klor-con sprinkle 122 latanoprost 140 (triphasic) 62 levonorgestrel-ethinyl estradiol KOATE 92 LATANOPROST 140 (91-day) 62 KOATE-DVI 92 LATUDA 49 levonorgestrel-ethinyl estradiol KOGENATE FS 92 LEADER UNIFINE PENTIPS (continuous) 62 KOGENATE FS BIO-SET 92 PLUS/MINI/31GX3/16" 107 levorphanol tartrate 9 LEADER UNIFINE PENTIPS LEVORPHANOL TARTRATE 9 KOVALTRY 92 PLUS/SHORT/31GX5/16" kp folic acid 93 107 levothyroxine sodium 149 KRINTAFEL 41 LEADER UNIFINE LEVSIN 150 KROGER PEN NEEDLES 29G PENTIPS/MINI/31GX3/16" LEXAPRO 26 X12MM 107 107 LEDIPASVIR/SOFOSBUVIR LEXIVA 52 KROGER PEN NEEDLES 31G LIALDA 88 X8MM 107 54 KROGER PEN NEEDLES leflunomide 6 LIBRAX 150 31GX1/4" 107 LENVIMA 10 MG DAILY lidocaine 79 KROGER PEN NEEDLES/31G DOSE 45 lidocaine hcl (mouth-throat) 124 X1/4" 107 LENVIMA 14 MG DAILY KROGER PEN NEEDLES/31G DOSE 45 lidocaine-prilocaine 79 X3/16" 107 LENVIMA 18 MG DAILY LIDODERM 79 KROGER PEN NEEDLES/31G DOSE 45 linezolid 15 LENVIMA 20 MG DAILY X5/16" 107 LINZESS 88 KROGER PEN NEEDLES/33G DOSE 45 X5/32" 107 LENVIMA 24 MG DAILY liothyronine sodium 149 KUVAN 84 DOSE 45 LIPITOR 36 LENVIMA 8 MG DAILY LIPOFEN 36 KYNAMRO 35 DOSE 45 labetalol hcl 55 LESCOL XL 36 lisinopril 37 LACRISERT 135 lisinopril & LETAIRIS 58 hydrochlorothiazide 39 lactulose 96 letrozole 43 LITEAIRE 118 lactulose (encephalopathy) 88 leucovorin calcium 47 LITETOUCH PEN NEEDLES LAMICTAL 22 LEUKERAN 42 29GX12.7MM 107 LAMICTAL CHEWABLE LEUKINE 93 LITETOUCH PEN NEEDLES DISPERSIBLE 22 31G X 6MM 107 LAMICTAL ODT 22 leuprolide acetate 43 LITETOUCH PEN NEEDLES LAMICTAL STARTER/NOT levalbuterol hcl 19 31G X 6MM/ULTRA TAKING CARBAMAZEPINE 22 levalbuterol tartrate 19 SHORT 107 LITETOUCH PEN NEEDLES LAMICTAL STARTER/TAKING LEVAQUIN 87 CARBAMAZEPINE/NOT TAKING 31GX8MM SHORT 107 VALPROATE 22 LEVBID 150 LITETOUCH PEN LAMICTAL STARTER/TAKING LEVEMIR 30 NEEDLES/31G X 3/16" 107 VALPROATE 22 LEVEMIR FLEXTOUCH 30 LITETOUCH PEN LAMICTAL XR 23 NEEDLES/31G X levetiracetam 23 5MM/MINI 107 lamivudine 52 levo-t 148 LITETOUCH PEN lamivudine (hbv) 54 levobunolol hcl 135 NEEDLES/31G X 8MM/SHORT 107 lamivudine-zidovudine 52 LEVOBUNOLOL HCL 135 LITHIUM 49 lamotrigine 23 levocarnitine (metabolic LANOXIN 58 modifiers) 84 lithium carbonate 49 lansoprazole 151 levofloxacin 87 LITHOBID 49 lanthanum carbonate 88,89 levofloxacin (ophth) 136 LITHOSTAT 90

Index 14 LO LOESTRIN FE 62 LYRICA 23 medroxyprogesterone LOCOID 77 LYSODREN 43 acetate 142 mefenamic acid 5 LOCOID LIPOCREAM 77 LYSTEDA 94 MEFLOQUINE HCL 41 LODINE 5 M-CLEAR WC 67 MEGACE ES 142 LODOSYN 47 M-END PE 67 megestrol acetate 43 LOESTRIN 1.5/30-21 62 MACROBID 152 megestrol acetate LOESTRIN 1/20-21 62 MACRODANTIN 152 (appetite) 142 LOESTRIN FE 1.5/30 62 mafenide acetate 74 MEIJER PEN NEEDLES 29G LOESTRIN FE 1/20 62 MAGNEBIND 400 121 X12MM 108 MEIJER PEN NEEDLES 31G LOHIST-DM 67 MALARONE 41 X6MM 108 LOKELMA 124 malathion 80 MEIJER PEN NEEDLES 31G LOMOTIL 31 maprotiline hcl 25 X8MM 108 LONSURF 44 MAR-COF BP 67 MEKINIST 45 loperamide hcl 31 MAR-COF CG MEKTOVI 45 LOPID 36 EXPECTORANT 67 melodetta 24 fe 61 MARATHON MEDICAL meloxicam 5 lopinavir-ritonavir 52 PENTIPS29GX12MM 107 LOPRESSOR 55 MARATHON MEDICAL melphalan 42 LOPRESSOR HCT 39 PENTIPS31GX5MM 108 memantine hcl 143 MARATHON MEDICAL MENEST 86 LOPROX 72 PENTIPS31GX8MM 108 MENOSTAR 86 LOPROX SHAMPOO 72 MARINOL 33 meperidine hcl 9 lorazepam 16 MARNATAL-F 128 MEPERIDINE HCL 9 lorazepam intensol 16 MARPLAN 26 MEPHYTON 154 LORBRENA 45 MATULANE 46 MEPRON 14 lorcet 10 matzim la 56 mercaptopurine 42 LORTAB 11 MAVENCLAD 144 mesalamine 88 losartan potassium 38 MAVYRET 54 MESNEX 47 losartan potassium & MAXALT 120 hydrochlorothiazide 39 MESTINON 41 LOSEASONIQUE 62 MAXALT-MLT 120 MAXICOMFORT II PEN MESTINON TIMESPAN 41 LOTEMAX 138 NEEDLES/31G X 1/4" 108 metadate er 2 LOTENSIN 37 MAXIDEX 138 metaproterenol sulfate 19 LOTENSIN HCT 39 MAXITROL 138 metaxall 132 loteprednol etabonate 138 MAXZIDE 81 metaxalone 133 LOTREL 39 MAXZIDE-25 81 metformin hcl 29 LOTRISONE 72 MAYZENT 144 methadone hcl 9 LOTRONEX 88 MAYZENT STARTER methadone hcl intensol 8 lovastatin 36 PACK 144 methadose 8 mccarnitine 84 LOVAZA 35 METHADOSE 9 meclofenamate sodium 5 LOVENOX 21 METHADOSE SUGAR-FREE 9 loxapine succinate 50 MEDICINE SHOPPE PEN NEEDLES 29G X 12MM 108 methamphetamine hcl 1 LULICONAZOLE 72 MEDICINE SHOPPE PEN methazolamide 81 LUMIGAN 140 NEEDLES 31G X 6MM 108 methenamine hippurate 152 LUNESTA 94 MEDICINE SHOPPE PEN NEEDLES 31G X 8MM 108 methenamine mandelate 152 LUXIQ 78 MEDROL 64 methergine 141 LUZU 72 MEDROL DOSEPAK 64 methimazole 148 LYNPARZA 45 METHITEST 13

Index 15 methocarbamol 133 midazolam hcl 94 MOVIPREP 95 METHOTREXATE 4 midodrine hcl 154 MOXATAG 141 methotrexate sodium 42 MIGERGOT 120 MOXEZA 136 METHOTREXATE SODIUM 42 miglitol 28 moxifloxacin hcl 87 methotrexate sodium 42 miglustat 93 moxifloxacin hcl (ophth) 137 methoxsalen rapid 74 MIGRANAL 120 MS CONTIN 10 methscopolamine bromide 150 MINASTRIN 24 FE 62 MUCINEX D 67 methyldopa 38 MINIPRESS 38 MUCINEX D MAXIMUM methyldopa & minitran 15 STRENGTH 67 MUCOTROL 125 hydrochlorothiazide 40 MINIVELLE 86 methylergonovine maleate 141 mucus relief d 66 MINOCIN 148 METHYLIN 2 MULPLETA 93 minocycline hcl 148 METHYLPEHNIDATE MULTAQ 17 minoxidil 41 HYDROCHLORIDE ER 2 multi-vit/fluoride 125 methylphenidate hcl 2 MIRALAX 96 multi-vit/iron/fluoride 126 METHYLPHENIDATE MIRAPEX 47 multivitamin with fluoride 125 HYDROCHLORIDE ER 2 MIRAPEX ER 47 multivitamin/fluoride 125 methylprednisolone 64 MIRCETTE 62 METHYLTESTOSTERONE 13 MULTIVITAMIN/FLUORIDE mirtazapine 25 126 METIPRANOLOL 135 MIRVASO 80 mupirocin 72 metoclopramide hcl 87 misoprostol 152 MYALEPT 84 METOCLOPRAMIDE ODT 87 MITIGARE 90 MYAMBUTOL 42 metolazone 82 MM PEN NEEDLES 31G X MYCOBUTIN 42 METOPIRONE 80 1/4" 108 mycophenolate mofetil 123 metoprolol & MM PEN NEEDLES 31G X hydrochlorothiazide 40 3/16" 108 mycophenolate sodium 123 metoprolol succinate 55 MM PEN NEEDLES 31G X MYDRIACYL 136 5/16" 108 metoprolol tartrate 56 MYFORTIC 123 MOBIC 5 METOPROLOL/HYDROCHLOR MYLERAN 42 modafinil 3 OTHIAZIDE 40 MYNATAL ADVANCE 128 moderiba 54 METROCREAM 80 MYNATAL ULTRACAPLET 128 METROGEL 80 MODERIBA 1200 DOSE PACK 54 MYNATE 90 PLUS 128 METROGEL-VAGINAL 153 moexipril hcl 37 myorisan 69 METROLOTION 80 moexipril-hydrochlorothiazide MYRBETRIQ 152 metronidazole 14 40 MYSOLINE 23 metronidazole (topical) 80 mometasone furoate 78 MYTESI 31 mometasone furoate metronidazole vaginal 153 nabumetone 5 mexiletine hcl 16 (nasal) 134 mondoxyne nl 148 nadolol 56 MIACALCIN 83 MONOCLATE-P 92 NADOLOL/BENDROFLUMETHIA MICARDIS 38 ZIDE 40 MONONINE 92 MICARDIS HCT 40 NAFTIFINE HCL 73 montelukast sodium 17 MICONAZOLE 3 153 naftifine hcl 73 MONUROL 152 MICROCHAMBER 118 NAFTIN 73 MICRODOT PEN NEEDLE/31G morgidox 1x100mg 148 NALFON 5 X 6 MM 108 morphine sulfate 9,10 naloxone hcl 32 MICRODOT PEN NEEDLE/33G MORPHINE SULFATE 10 naltrexone hcl 32 X 4 MM 108 morphine sulfate 10 MICROSPACER 118 NAMENDA 143 MORPHINE SULFATE ER 9 MICROZIDE 82 NAMENDA TITRATION MOVANTIK 88 PAK 143

Index 16 NAMENDA XR 143 NESTABS 128 NITROMIST 15 NAMENDA XR TITRATION NESTABS ABC 128 NITROSTAT 15 PACK 143 NESTABS DHA 128 NIVESTYM 93,94 NAMZARIC 143 NESTABS ONE 128 NIZATIDINE 150 NAPROSYN 5 neuac 69 nizatidine 150 naproxen 5 NEUPRO 47 NIZATIDINE 150 naproxen sodium 5 NEURONTIN 23 NIZORAL 73 naratriptan hcl 120 neutral sodium fluoride 124 nolix 75 NARCAN 32 NEVANAC 139 NORCO 11 NARDIL 26 nevirapine 52 NORDITROPIN FLEXPRO 83 NASACORT ALLERGY 24HR 134 NEVIRAPINE ER 52 norethin acet & estrad-fe 63 NASACORT ALLERGY 24HR NEXA PLUS 128 norethindrone & ethinyl estradiol- CHILDRENS 134 NEXAVAR 45 fe 63 NASONEX 134 norethindrone NIACIN 36 (contraceptive) 64 NATACHEW 128 niacin (antihyperlipidemic) 36 norethindrone acet & eth NATACYN 137 NIACOR 37 estra 63 NATAZIA 63 NIASPAN 37 norethindrone acetate 142 norethindrone acetate-ethinyl nateglinide 31 nicardipine hcl 57 NATELLE ONE 128 estradiol 85 NICODERM CQ 147 norgestimate-ethinyl NATPARA 83 NICORETTE 147 estradiol 63 NATROBA 80 NICORETTE MINI 147 norgestimate-ethinyl estradiol (triphasic) 63 NATURE-THROID 149 NICORETTE STARTER NATURE-THROID NT-2.5 149 KIT 147 NORPACE 16 NAYZILAM 21 nicotine 147 NORPACE CR 16 NEBUPENT 14 nicotine polacrilex 147 NORPRAMIN 28 NEBUSAL 68 NICOTINE TRANSDERMAL NORTHERA 154 SYSTEM 147 NEEVO DHA 128 nortriptyline hcl 28 NICOTROL INHALER 147 NEFAZODONE HCL 27 NORTRIPTYLINE HCL 28 NICOTROL NS 147 nefazodone hcl 27 NORVASC 57 nifedipine 57 NEFAZODONE NORVIR 52 HYDROCHLORIDE 27 NILANDRON 43 NOVOEIGHT 92 neo-polycin 136 nilutamide 43 NOVOFINE 32GX6MM 108 neo-polycin hc 137 nimodipine 57 NOVOFINE AUTOCOVER neomycin sulfate 3 NINJACOF-XG 67 30GX8MM 108 neomycin-bacitracin zn- NINLARO 45 NOVOLIN N FLEXPEN 30 polymyxin 137 nisoldipine 57 NOVOLIN N FLEXPEN neomycin-polymy- RELION 30 dexameth 138 NISOLDIPINE ER 57 NOVOSEVEN RT 92 neomycin-polymyxin-hc nitisinone 84 NOVOTWIST 32GX5MM 108 (ophth) 138 NITRO-BID 15 NOXAFIL 33 neomycin-polymyxin-hc NITRO-DUR 15 (otic) 141 np thyroid 15 148 NEOMYCIN/POLYMYXIN/GRAM nitrofurantoin 152 NUBEQA 43 nitrofurantoin ICIDIN 137 NUCYNTA 10 NEORAL 123 macrocrystal 152 nitrofurantoin monohyd NUCYNTA ER 10 NEOSPORIN 137 macro 152 NUEDEXTA 145 NEOTUSS PLUS 67 nitroglycerin 15 NULYTELY/FLAVOR NEPTAZANE 81 NITROLINGUAL PACKS 95 NERLYNX 45 PUMPSPRAY 15 NUPLAZID 49

Index 17 NUVARING 63 ONETOUCH ULTRA 2 99 ORKAMBI 147 NUVESSA 153 ONETOUCH VERIO FLEX orphenadrine citrate 133 NUVIGIL 3 BLOOD GLUCOSE orphenadrine w/ aspirin & MONITORING SYSTEM 99 NUWIQ 92 caff 133 ONETOUCH VERIO TEST ORTHO MICRONOR 64 nyamyc 72 STRIPS 81 ORTHO TRI-CYCLEN 63 NYMALIZE 57 ONEVITE 125 ORTHO TRI-CYCLEN LO 63 nystatin 33 ONFI 21 ORTHO-CYCLEN 63 nystatin (mouth-throat) 124 OPANA 10 ORTHO-NOVUM 1/35 63 nystatin (topical) 73 opium tincture 31 ORTHO-NOVUM 7/7/7 63 nystatin-triamcinolone 73 OPSUMIT 58 oscimin 149 OB COMPLETE ONE 128 OPTICHAMBER ADVANTAGE/LARGE oscimin sr 149 OB COMPLETE PETITE 128 MASK 118 oseltamivir phosphate 55 OB COMPLETE PREMIER 128 OPTICHAMBER OSMOPREP 96 OB COMPLETE/DHA 128 ADVANTAGE/MEDIUM FACE OSPHENA 83 OBIZUR 92 MASK 118 OPTICHAMBER OTEZLA 6 OBSTETRIX DHA 128 ADVANTAGE/SMALL FACE OTICIN HC NR 141 OBTREX DHA 128 MASK 118 OTOVEL 141 OCALIVA 87 OPTICHAMBER OTREXUP 4 OCTREOTIDE ACETATE 85 DIAMOND 118 OPTICHAMBER OVACE PLUS WASH 74 octreotide acetate 85 DIAMOND/LARGEFACE OVACE WASH 74 OCUFLOX 137 MASK 119 OVIDE 80 ODOMZO 43 OPTICHAMBER DIAMOND/MEDIUM FACE oxandrolone 12 OFEV 147 MASK 119 oxaprozin 6 OFLOXACIN 87 OPTICHAMBER oxazepam 16 ofloxacin 87 DIAMOND/SMALLFACE OXAZEPAM 16 ofloxacin (ophth) 137 MASK 119 OPTICHAMBER FACE oxcarbazepine 23 ofloxacin (otic) 140 MASK/LARGE 119 OXERVATE 137 OGESTREL 63 OPTICHAMBER FACE oxiconazole nitrate 73 olanzapine 50 MASK/MEDIUM 119 OPTICHAMBER FACE OXISTAT 73 olanzapine-fluoxetine hcl 143 MASK/SMALL 119 OXSORALEN ULTRA 74 olmesartan medoxomil 38 OPTIHALER 119 OXTELLAR XR 23 olmesartan medoxomil- OPTIHALER MDI DRUG amlodipine-hydrochlorothiazide DELIVERY SYSTEM 119 oxybutynin chloride 152 40 OPTIONS CONCEPTROL oxycodone hcl 10 olmesartan medoxomil- VAGINAL oxycodone w/ hydrochlorothiazide 40 CONTRACEPTIVE 153 acetaminophen 11 olopatadine hcl 139 OPTIONS GYNOL II OXYCODONE/IBUPROFEN 11 olopatadine hcl (nasal) 133 VAGINALCONTRACEPTIVE oxymorphone hcl 10 OLUX 78 153 OXYMORPHONE ORACEA 80 OLUX-E 78 HYDROCHLORIDE ER 10 ORACIT 89 OMECLAMOX-PAK 152 OXYMORPHONE ORAL SALINE LAXATIVE 96 HYDROCHLORIDEER 10 omega-3-acid ethyl esters 35 oralone dental paste 124 OZEMPIC 29 omeprazole 151 ORAP 145 pacerone 16 OMNIFLEX DIAPHRAGM 98 ORAPRED ODT 64 paliperidone 49 ondansetron 32 ORAVIG 124 PALYNZIQ 84 ondansetron hcl 32 ORENITRAM 58 PAMELOR 28 ONETOUCH ULTRA 81 ORFADIN 84 PANCREAZE 81

Index 18 PANRETIN 73 PEN NEEDLES 31GX6MM phenytoin infatabs 25 pantoprazole sodium 151 (1/4") 109 phenytoin sodium extended 25 PEN NEEDLES PAREGORIC 32 31GX8MM 109 PHOSLYRA 89 PAREMYD 140 PEN NEEDLES 31GX8MM PHOSPHOLINE IODIDE 136 paricalcitol 84 (5/16") 109 phrenilin forte 6 PEN NEEDLES 32G X PARLODEL 47 5MM 109 phytonadione 154 PARNATE 26 PEN NEEDLES 32G X PICATO 73 paromomycin sulfate 3 6MM 109 PIFELTRO 52 PAROMOMYCIN SULFATE 3 PEN NEEDLES 33G X pilocarpine hcl 136 5/32" 109 paroxetine hcl 26 PEN NEEDLES/29G X pilocarpine hcl (oral) 125 PASER 42 1/2" 109 pimecrolimus 79 PATADAY 140 PEN NEEDLES/31G X PIMOZIDE 145 1/4" 109 PATANASE 133 PEN NEEDLES/31G X pindolol 56 PATANOL 140 3/16" 109 pioglitazone hcl 29 PAXIL 26 PEN NEEDLES/31G X pioglitazone hcl-glimepiride 28 PAXIL CR 26 5/16" 109 pioglitazone hcl-metformin penicillamine 123 PAZEO 140 hcl 28 PENICILLIN V PIQRAY 200MG DAILY PC UNIFINE PENTIPS 29G POTASSIUM 141 DOSE 45 X1/2" 108 PIQRAY 250MG DAILY PC UNIFINE PENTIPS 31G penicillin v potassium 141 PENLAC NAIL LACQUER 73 DOSE 45 X5MM MINI 108 PIQRAY 300MG DAILY PC UNIFINE PENTIPS 31G pentamidine isethionate 14 DOSE 45 X6MM ULTRA SHORT 108 PENTASA 88 PC UNIFINE PENTIPS 31G piroxicam 6 X8MM SHORT 108 pentazocine w/ naloxone 12 PLAN B ONE-STEP 64 pediatric vitamins acd w/ PENTIPS 29G X 12MM 109 PLAQUENIL 41 fluoride 126 PENTIPS 29GX12MM 109 PLAVIX 93 peg 3350-kcl-sod bicarb-sod chloride-sod sulfate 95 PENTIPS 31G X 5MM 109 PLEGRIDY 144 peg 3350-potassium chloride-sod PENTIPS 31G X 8MM 109 PLEGRIDY STARTER bicarbonate-sod chloride 95 PENTIPS 31GX5MM 109 PACK 144 PEGANONE 25 PENTIPS 31GX6MM 110 PLENVU 95 PEGASYS 54 PENTIPS 31GX8MM 110 PLEXION 71 PEGASYS PROCLICK 54 pentoxifylline 93 PLEXION CLEANSER 71 PEGINTRON 54 PEPCID 150 PNV TABS 29-1 128 PEN NEEDLES 29G X PERCOCET 11,12 PNV-DHA 129 12MM 108 perindopril erbumine 37 PNV-DHA+DOCUSATE 129 PEN NEEDLES 29GX1/2" 108 PNV-OMEGA 129 PEN NEEDLES 30GX5/16" 109 permethrin 80 perphenazine 50 PNV-SELECT 129 PEN NEEDLES 30GX8MM 109 POCKET CHAMBER 119 PEN NEEDLES 31G X 1/4" PERPHENAZINE/AMITRIPTYL SHORT 109 INE 143 POCKET SPACER 119 PEN NEEDLES 31G X PERTZYE 81 PODOCON 25 IN BENZOIN 3/16" 109 phenadoz 34 TINCTURE 79 PEN NEEDLES 31G X phenelzine sulfate 26 podofilox 79 5MM 109 POLY HUB NEEDLE/30G X PEN NEEDLES 31G X phenobarbital 94 1/2" 110 6MM 109 phenoxybenzamine hcl 37 POLY-VI-FLOR 126 PEN NEEDLES 31G X phenylephrine hcl POLY-VI-FLOR/IRON 126 8MM 109 (mydriatic) 136 PEN NEEDLES 31GX5/16" 109 PHENYTEK 25 polycin 136 phenytoin 25 polyethylene glycol 3350 96

Index 19 polymyxin b-trimethoprim 137 prednisolone sodium PREVACID 24HR 151 POLYTRIM 137 phosphate 64,65 PREVACID SOLUTAB 151 PREDNISOLONE SODIUM POMALYST 44 PHOSPHATE 138 prevalite 35 posaconazole 33 PREDNISOLONE SODIUM PREVENT SAFETY PEN pot & sod citrates w/citric ac 89 PHOSPHATE/MOXIFLOXACIN NEEDLES 31GX1/4" 110 138 PREVENT SAFETY PEN pot phosphate monobasic w/ sod NEEDLES 31GX5/16" 110 phosphate dibasic & prednisone 65 monobasic 122 PREDNISONE INTENSOL 65 PREVIDENT RINSE 124 POTABA 154 PREFERRED PLUS UNIFINE PREZCOBIX 52 potassium bicarbonate 122 PENTIPS 29G X 12MM 110 PREZISTA 52 PREFERRED PLUS UNIFINE PRIFTIN 42 potassium chloride 122 PENTIPS 31G X 6MM ULTRA POTASSIUM CHLORIDE SHORT 110 PRILOSEC 151 ER 122 PREFERRED PLUS UNIFINE primaquine phosphate 41 potassium chloride PENTIPS 31G X 8MM PRIMAQUINE PHOSPHATE 41 microencapsulated crystals SHORT 110 primidone 23 er 122 PREFERRED PLUS UNIFINE potassium citrate PENTIPS/MINI/31GX5MM PRIMLEV 12 (alkalinizer) 89 110 PRIMSOL 14 potassium citrate-citric acid 89 PREFEST 85 PRINIVIL 37 POVIDONE IODINE 137 pregabalin 23 PRISTIQ 27 PR NATAL 400 EC 129 PREMARIN 86,154 PRO COMFORT INHALER PR NATAL 430 129 PREMESISRX 129 SPACER CHAMBER PR NATAL 430 EC 129 ADULT 119 PREMPHASE 85 PRO COMFORT INHALER PRADAXA 21 PREMPRO 86 SPACER CHAMBER PRALUENT 37 PRENA 1 TRUE 129 CHILD 119 pramipexole dihydrochloride 48 PRENA1 PEARL 129 PRO COMFORT INHALER PRAMOSONE 78 SPACER CHAMBER PRENAISSANCE 129 INFANT 119 PRAMOSONE E 78 PRENAISSANCE PLUS 129 PRO COMFORT PEN PRANDIN 31 PRENATA 129 NEEDLES/31G X 8MM 110 prasugrel hcl 93 PRO COMFORT PEN PRENATABS RX 129 NEEDLES/32G X 5MM 110 PRAVACHOL 36 PRENATAL + DHA 129 PRO COMFORT PEN pravastatin sodium 36 PRENATAL 19 129 NEEDLES/32G X 6MM 110 praziquantel 14 PRENATAL MULTIVITAMIN PRO-RED AC 67 prazosin hcl 38 PLUS DHA 130 PROAIR RESPICLICK 19 PRECISION XTRA 81 PRENATAL PLUS IRON 130 probenecid 90 PRECISION XTRA BLOOD PRENATAL+DHA 130 PROCARDIA 57 GLUCOSE TEST STRIPS 81 PRENATAL-U 130 PROCARDIA XL 57 PRECOSE 28 PRENATE 130 PROCARE SPACER CHAMBER PRED FORTE 138 PRENATE AM 130 W/ADULT MASK 119 PRED MILD 138 PRENATE DHA 130 PROCARE SPACER CHAMBER PRED-G 138 W/CHILD MASK 119 PRENATE ENHANCE 130 procentra 1 PRED-G S.O.P. 138 PRENATE ESSENTIAL 130 prochlorperazine 50 PREDNICARBATE 78 PRENATE MINI 130 prochlorperazine maleate 50 prednisolone 65 PRENATE PIXIE 130 procto-med hc 13 prednisolone acetate PRENATE RESTORE 130 (ophth) 138 PROCTOFOAM HC 13 prednisolone acetate p-f 137 PREPIDIL 141 PROCYSBI 89 PREDNISOLONE SODIUM PREPOPIK 95 profeno 4 PHOSPHATE 64 PREVACID 151 PROFILNINE 92

Index 20 PROFILNINE SD 92 PURE COMFORT PEN rajani 60 progesterone micronized 142 NEEDLE 32G X8MM 110 raloxifene hcl 83 PURE COMFORT PEN PROGLYCEM 29 NEEDLE/32G X 5MM 110 ramelteon 95 PROGRAF 123 PURIXAN 42 ramipril 37 PROLATE 12 PX EXTRA SHORT PEN RANEXA 15 PROLENSA 140 NEEDLES 31GX6MM 110 ranitidine hcl 150,151 PX MINI PEN NEEDLES PROMACTA 94 31GX5MM 110 ranolazine 15 promethazine & PX PEN NEEDLE RAPAFLO 90 phenylephrine 67 29GX12MM 110 RAPAMUNE 123 promethazine hcl 34 PX PEN NEEDLE rasagiline mesylate 48 promethazine vc plain 65 31GX8MM 110 RASUVO 4 promethazine vc/codeine 65 PX SHORTLENGTH PEN NEEDLES/31GX8MM 110 RAVICTI 84 promethazine w/codeine 67 PYLERA 152 RAZADYNE 143 promethazine-dm 67 pyrazinamide 42 RAZADYNE ER 143 promethazine-phenylephrine- codeine 67 pyridostigmine bromide 41,42 REBIF 144 PROMETHAZINE/DEXTROMET QBRELIS 37 REBIF REBIDOSE 144 HORPHAN 67 QC PEN NEEDLES 29G X REBIF REBIDOSE PROMETHAZINE/PHENYLEPHR 12MM 110 TITRATIONPACK 144 INE 67 QC PEN NEEDLES 31G X REBIF TITRATION PACK 144 PROMETHAZINE/PHENYLEPHR 6MM 110 INE/CODEINE 67 QC PEN NEEDLES 31G X RECOMBINATE 92 promethegan 34 8MM 111 RECTIV 13 PROMETHEGAN 34 QUALAQUIN 41 REGLAN 87 PROMETRIUM 142 QUARTETTE 63 REGRANEX 80 propafenone hcl 16 QUAZEPAM 94 RELENZA DISKHALER 55 propantheline bromide 150 QUDEXY XR 23 RELEXXII 3 proparacaine hcl 137 QUESTRAN 35 RELION INSULIN SYRINGE QUESTRAN LIGHT 35 1ML/31GX15/64" 111 propranolol & RELION INSULIN SYRINGE/U- hydrochlorothiazide 40 quetiapine fumarate 50 100/0.3ML/31G X 15/64" 111 propranolol hcl 56 QUFLORA FE RELION INSULIN SYRINGE/U- propylthiouracil 148 PEDIATRIC 126 100/1ML/31G X 15/64" 111 PROSCAR 90 QUFLORA PEDIATRIC 126 RELION KETONE 81 PROTONIX 151 QUILLICHEW ER 3 RELION MINI PEN NEEDLES QUILLIVANT XR 3 31GX6MM 111 PROTOPIC 79 RELION PEN NEEDLES protriptyline hcl 28 quinapril hcl 37 29GX12MM 111 PROVERA 142 quinapril-hydrochlorothiazide RELION PEN NEEDLES 40 PROVIDA OB 130 31GX6MM 111 quinidine gluconate 16 RELION PEN NEEDLES PROVIGIL 3 QUINIDINE SULFATE 16 31GX8MM 111 PROZAC 26 quinine sulfate 41 RELION PEN NEEDLES/31G X1/4" 111 pseudoephed-bromphen-dm 67 QVAR REDIHALER 18 pseudoephedrine-guaifenesin RELION SHORT PEN 67 R-NATAL OB 130 NEEDLES31GX8MM 111 psorcon 75 ra laxative 96,97 RELISTOR 88 PULMICORT 18 RA PEN NEEDLES 31G X RELNATE DHA 130 5MM3/16" 111 RELPAX 120 PULMICORT FLEXHALER 18 RA PEN NEEDLES 31G X pulmosal 68 8MM5/16" 111 REMERON 25 PULMOZYME 147 rabeprazole sodium 151 REMERON SOLTAB 25 PURE COMFORT PEN NEEDLE RABEPRAZOLE SODIUM DR RENAGEL 89 32G X6MM 110 SPRINKLE 151

Index 21 RENVELA 89 RITALIN 3 SAVELLA TITRATION repaglinide 31 RITALIN LA 3 PACK 143 scopolamine 32 REPAGLINIDE/METFORMIN RITEFLO 119 SE-NATAL 19 130 HYDROCHLORIDE 28 ritonavir 53 REPATHA 37 SEASONIQUE 63 rivastigmine 143 REPATHA PUSHTRONEX seb-prev wash 74 rivastigmine tartrate 143 SYSTEM 37 SEEBRI NEOHALER 17 REPATHA SURECLICK 37 RIXUBIS 92 SEGLUROMET 28 REQUIP 48 rizatriptan benzoate 121 SELECT-OB 130,131 REQUIP XL 48 ROBAXIN 133 SELECT-OB+DHA 131 RESCRIPTOR 52 ROBAXIN-750 133 selegiline hcl 48 RESTASIS 137 ROBINUL 150 SELEGILINE HCL 48 RESTASIS MULTIDOSE 137 ROBINUL FORTE 150 selenium sulfide 74 RESTORIL 94 ROCALTROL 84 SELZENTRY 53 RETACRIT 94 ropinirole hydrochloride 48 SENSIPAR 84 RETIN-A 71 rosadan 80 SEREVENT DISKUS 19 RETIN-A MICRO 71 rosuvastatin calcium 36 SEROQUEL 50 RETIN-A MICRO PUMP 71 roweepra 21 SEROQUEL XR 50 RETROVIR 52 roweepra xr 22 SEROSTIM 83 REVATIO 59 ROXICODONE 10 sertraline hcl 26 REVLIMID 123 ROZEREM 95 sevelamer carbonate 89 REXAPHENAC 71 ROZLYTREK 45 sevelamer hcl 89 RUBRACA 45 REXULTI 51 SEVELAMER REYATAZ 52,53 RUZURGI 42 HYDROCHLORIDE 89 RHOFADE 80 RYDAPT 45 SFROWASA 88 RIASTAP 92 RYDEX 68 SHOPKO UNIFINE PENTIPS ribasphere 54 RYTARY 48 PEN NEEDLES/MINI/31GX5MM 111 RIBASPHERE RIBAPAK 54 RYTHMOL SR 16 SHOPKO UNIFINE PENTIPS ribavirin (hepatitis c) 54 RYVENT 34 PEN RIDAURA 4 SABRIL 24 NEEDLES/ORIGINAL/29GX12M SAFYRAL 63 M 111 rifabutin 42 SHOPKO UNIFINE PENTIPS RIFADIN 42 SALAGEN 125 PEN RIFAMATE 42 SALEX 79 NEEDLES/SHORT/31GX8MM rifampin 42 salicylic acid 79 111 SALICYLIC ACID 79 SHOPKO UNIFINE PENTIPS RIFATER 42 PLUS PEN RILUTEK 134 salicylic acid 79 NEEDLES/MINI/REMOVER/31G riluzole 135 salimez 79 X5MM 111 RIMANTADINE salisol forte 79 SHOPKO UNIFINE PENTIPS PLUS PEN HYDROCHLORIDE 55 salsalate 8 RINVOQ 4 NEEDLES/REMOVER/29GX12M SANCUSO 32 M 111 RIOMET 29 SANDIMMUNE 124 SHOPKO UNIFINE PENTIPS risedronate sodium 83 SANDOSTATIN 85 PLUS PEN NEEDLES/SHORT/REMOVR/31 RISPERDAL 49 SANTYL 79 RISPERDAL M-TAB 49 GX8MM 111 SAPHRIS 50 SIGNIFOR 85 risperidone 49 SARAFEM 145 SIKLOS 93 risperidone m-tab 49 SAVAYSA 20 sildenafil citrate 58 RISPERIDONE ODT 49 SAVELLA 143

Index 22 sildenafil citrate (pulmonary SPIRIVA RESPIMAT 17 sulfamethoxazole-trimethoprim hypertension) 59 spironolactone 82 14 silodosin 90 spironolactone & SULFAMYLON 74 SILVADENE 74 hydrochlorothiazide 82 sulfasalazine 88 silver sulfadiazine 74 SPORANOX 33,34 sulfatrim pediatric 14 SIMBRINZA 136 SPORANOX PULSEPAK 33 sulindac 6 simvastatin 36 SPRITAM 23 sumatriptan 121 SINEMET 48 SPRYCEL 45,46 sumatriptan succinate 121 SINEMET CR 48 sr nicotine gum 145 SUMATRIPTAN SINGULAIR 17 ssd 74 SUCCINATE 121 sumatriptan succinate 121 sirolimus 124 SSS 10-5 71 SUPRAX 60 SITAVIG 55 STALEVO 100 48 SUPREP BOWEL PREP KIT96 SIVEXTRO 15 STALEVO 125 48 SURE COMFORT PEN SKELAXIN 133 STALEVO 150 48 NEEDLES29GX1/2" SKLICE 80 STALEVO 50 48 12.7MM 111 SKYRIZI 74 STALEVO 75 48 SURE COMFORT PEN NEEDLES30GX5/16" SLYND 64 STARLIX 31 SHORT 111 sodium chloride (inhalant)68,69 stavudine 53 SURE COMFORT PEN sodium fluoride 121 STEGLATRO 31 NEEDLES31GX3/16" sodium phenylbutyrate 84 STIMATE 85 (5MM) 112 sodium polystyrene SURE COMFORT PEN STIOLTO RESPIMAT 19 NEEDLES31GX5/16" sulfonate 124 STIVARGA 46 (8MM) 112 sodium sulfacetamide wash 74 STRATTERA 2 SURE COMFORT PEN SODIUM SULFACETAMIDE NEEDLES32GX6MM 112 WASH 74 STRENSIQ 84 SURE-FINE PEN NEEDLES SODIUM STRIANT 13 29GX1/2" 12.7MM 112 SULFACETAMIDE/SULFUR STRIBILD 53 SURE-FINE PEN NEEDLES 71 STRIVERDI RESPIMAT 19 31GX3/16" 5MM 112 SODIUM SURE-FINE PEN NEEDLES SULFACETAMIDE/SULFUR STROMECTOL 14 31GX5/16" 8MM 112 CLEANSER IN UREA 71 SUBSYS 10 SURMONTIL 28 SOFOSBUVIR/VELPATASVIR subvenite 21 54 SUSTIVA 53 solifenacin succinate 152 subvenite starter kit/blue 21 SUTENT 46 SOLTAMOX 43 SUCRAID 81 SYLATRON 46 SOMA 133 sucralfate 151 SYMBICORT 19 SOMAVERT 83 SULAR 57 SYMBYAX 143 SONATA 94 SULCONAZOLE NITRATE73 SYMDEKO 147 sulfacetamide sod- SYMJEPI 154 SOOLANTRA 80 prednisolone 138 53 SORBUTUSS NR 68 sulfacetamide sodium 74 SYMTUZA SORIATANE 74 sulfacetamide sodium SYNALAR 78 SORILUX 74 (acne) 71 SYNAREL 84 sorine 56 sulfacetamide sodium SYNJARDY 29 (ophth) 137 sotalol hcl 56 sulfacetamide sodium w/ SYNJARDY XR 29 sotalol hcl (afib/afl) 56 sulfur 71 SYNTHROID 149 SOVALDI 54 SULFACETAMIDE SYPRINE 123 SODIUM/PREDNISOLONE TABLOID 42 SPECTRACEF 60 SODIUM PHOSPHATE 138 TACLONEX 78 SPINOSAD 80 SULFADIAZINE 147 SPIRIVA HANDIHALER 17 tacrolimus 124

Index 23 tacrolimus (topical) 79 telmisartan-hydrochlorothiazide TIGAN 32 tadalafil (pulmonary 40 TIKOSYN 17 temazepam 95 hypertension) 59 tilia fe 61 TAFINLAR 46 TEMIXYS 53 timolol maleate 56 TAGRISSO 46 TEMODAR 42 timolol maleate (ophth) 135 TALZENNA 46 TEMOVATE 78 TIMOLOL MALEATE TAMIFLU 55 temozolomide 42 OPHTHALMIC GEL tamoxifen citrate 43 TENCON 7 FORMING 135 tamsulosin hcl 90 tenofovir disoproxil TIMOPTIC 135 TAPAZOLE 148 fumarate 53 TIMOPTIC OCUDOSE 135 TENORETIC 100 40 TARCEVA 46 TIMOPTIC-XE 135 TENORETIC 50 40 TARGRETIN 46,73 TINDAMAX 14 TENORMIN 56 tarina fe 1/20 61 tinidazole 14 TERAZOL 7 153 TARKA 40 TIVICAY 53 terazosin hcl 38 TARON-C DHA 131 TIVORBEX 6 terbinafine hcl 33 TARON-PREX 131 tizanidine hcl 133 terbutaline sulfate 19 TASIGNA 46 TL-CARE DHA 131 TERCONAZOLE 153 TASMAR 47 TL-SELECT 131 terconazole vaginal 153 TAVALISSE 93 TOBI 3 TESSALON PERLES 65 TAYTULLA 63 TOBI PODHALER 3 TESTIM 13 tazarotene 74 TOBRADEX 138 testosterone 13 TAZORAC 74 TOBRADEX ST 139 TESTOSTERONE PUMP 13 taztia xt 56 tobramycin 3 tetrabenazine 144 TECFIDERA 144 TOBRAMYCIN 3 TECFIDERA STARTER tetracaine hcl (ophth) 137 tobramycin (ophth) 137 PACK 144 tetracycline hcl 148 tobramycin inhalation solution TECHLITE INSULIN SYRINGEU- TEXACORT 78 pak 3 100/0.3ML/31G X 15/64" 112 tgt nicotine polacrilex 146 tobramycin- TECHLITE INSULIN SYRINGEU- dexamethasone 139 100/1ML/31G X 15/64" 112 THALOMID 123 TOBREX 137 TECHLITE PEN NEEDLES 29GX THEO-24 19 TODAY SPONGE 153 12 MM 112 theophylline 20 TECHLITE PEN NEEDLES 31GX TODAYS HEALTH MINI PEN 5MM 112 THEOPHYLLINE ER 19 NEEDLES 31G X 1/4" 112 TECHLITE PEN NEEDLES/31GX THIOLA 90 TODAYS HEALTH ORIGINAL 5MM 112 PEN NEEDLES 29G X 1/2" 112 THIOLA EC 90 TODAYS HEALTH SHORT PEN TECHLITE PEN NEEDLES/31GX thioridazine hcl 50 6 MM 112 NEEDLES 31G X 5/16" 112 TECHLITE PEN NEEDLES/31GX thiothixene 51 TOFRANIL 28 8MM 112 THRIVITE 19 125 TOLAZAMIDE 31 TECHLITE PEN NEEDLES/32GX THRIVITE RX 131 tolazamide 31 6MM 112 TECHLITE PEN NEEDLES/32GX thyroid 149 tolbutamide 31 8MM 112 THYROLAR-1 149 tolcapone 47 TEGRETOL 23 THYROLAR-1/2 149 TOLMETIN SODIUM 6 TEGRETOL-XR 24 THYROLAR-1/4 149 tolmetin sodium 6 TEGSEDI 147 THYROLAR-2 149 TOLSURA 34 TEKTURNA HCT 40 THYROLAR-3 149 tolterodine tartrate 152 telmisartan 38 tiagabine hcl 24 TOPAMAX 24 telmisartan-amlodipine 40 TIAZAC 57 TOPAMAX SPRINKLE 24 TIBSOVO 46

Index 24 TOPCARE CLICKFINE tri-vit/fluoride 125 TRUEPLUS 5-BEVEL PEN UNIVERSAL PEN EEDLES tri-vit/fluoride/iron 126 NEEDLES 31GX8MM 113 31GX1/4" 112 TRUEPLUS PEN NEEDLES TOPCARE CLICKFINE triamcinolone acetonide 29GX12MM 113 UNIVERSAL PEN EEDLES (mouth) 124 TRUEPLUS PEN NEEDLES 31GX5/16" 112 triamcinolone acetonide 31GX5MM 113 (nasal) 134 TOPICORT 78 TRUEPLUS PEN NEEDLES triamcinolone acetonide 31GX6MM 113 topiramate 24 (topical) 78 TRUEPLUS PEN NEEDLES TOPIRAMATE ER 24 triamterene 82 31GX8MM 113 TOPROL XL 56 triamterene & TRULANCE 87 hydrochlorothiazide 82 toremifene citrate 43 TRULICITY 29 triazolam 95 torsemide 82 TRUSOPT 140 TRIBENZOR 40 TOUJEO MAX SOLOSTAR 30 TRICARE PRENATAL DHA TRUVADA 53 TOUJEO SOLOSTAR 30 ONE 131 trymine cg 65 tovet 75 TRICOR 36 TUDORZA PRESSAIR 17 TOVIAZ 152 triderm 75 TURALIO 46 TRACLEER 58 TRIDESILON 78 TUSNEL 68 tramadol hcl 10 trientine hcl 123 TUSNEL C 68 TRAMADOL HCL ER 10 trifluoperazine hcl 50 TUSNEL PEDIATRIC 68 tramadol-acetaminophen 12 TRIFLURIDINE 137 TUSSICAPS 68 trandolapril 37 TRIGLIDE 36 TUSSIONEX PENNKINETIC trandolapril-verapamil hcl 40 trihexyphenidyl hcl 47 EXTENDED RELEASE 68 TWYNSTA 40 TRANDOLAPRIL/VERAPAMIL TRIKAFTA 147 TYBOST 53 HCL ER 40 triklo 35 tranexamic acid 94 TYKERB 46 TRILEPTAL 24 TRANSDERM SCOP 32 TYLENOL/CODEINE #3 12 TRILIPIX 36 TRANSDERM-SCOP 32 TYLENOL/CODEINE #4 12 trimethobenzamide hcl 32 TRANXENE T 16 TYMLOS 83 trimethoprim 14 tranylcypromine sulfate 26 TYVASO 58 trimipramine maleate 28 TRAVATAN Z 140 TYVASO REFILL 58 TRIMPEX 14 travoprost 140 TYVASO STARTER 58 TRINATAL RX 1 131 trazodone hcl 27 UCERIS 13,65 TRINTELLIX 27 TRECATOR 42 UDAMIN SP 125 TRISTART DHA 131 TRELEGY ELLIPTA 19 UDENYCA 94 TRISTART ONE 131 TRESIBA 31 ULORIC 90 TRIUMEQ 53 TRESIBA FLEXTOUCH 30,31 ULTICARE MICRO PEN TRIZIVIR 53 tretinoin 71 NEEDLES 31G X 8MM 113 TROKENDI XR 24 ULTICARE MICRO PEN tretinoin (chemotherapy) 46 tropicamide 136 NEEDLES/31G X 1/4" 113 tretinoin microsphere 71 ULTICARE MICRO PEN trospium chloride 152 TRETTEN 92 NEEDLES/31G X 5/16" 113 TRUE COMFORT PEN ULTICARE MINI PEN NEEDLES TREXALL 42 NEEDLES31G X 5MM 113 31GX6MM 113 TREZIX 12 TRUE COMFORT PEN ULTICARE MINI PEN NEEDLES tri femynor 61 NEEDLES31G X 6MM 113 ULTI-FINE IV 113 TRUEPLUS 5-BEVEL PEN tri-lo-estarylla 62 ULTICARE MINI PEN NEEDLES 29GX12.7MM 113 NEEDLES/31G X 6MM 113 TRI-NORINYL 28 63 TRUEPLUS 5-BEVEL PEN ULTICARE MINI PEN TRI-TABS DHA 131 NEEDLES 31GX5MM 113 NEEDLES/32G X 1/4" 113 TRUEPLUS 5-BEVEL PEN TRI-VI-FLOR 126 ULTICARE MINI PEN NEEDLES 31GX6MM 113 NEEDLES31GX6MM 113 TRI-VI-FLORO 126

Index 25 ULTICARE ORIGINAL PEN ULTRACARE PEN valsartan-hydrochlorothiazide NEEDLES ULTI-FINE 113 NEEDLES/33G X 5/32" 115 40 ULTICARE PEN NEEDLES ULTRACET 12 VALTREX 55 31GX 5MM 113 ULTRAM 10 VALUMARK PEN NEEDLES ULTICARE PEN NEEDLES ULTRASAL-ER 79 29GX12MM 115 31GX 5MM/MINI 113 VALUMARK PEN NEEDLES ULTICARE PEN ULTRAVATE 78 31GX 6MM 115 NEEDLES/29GX 12.7MM 114 UNIFINE PENTIPS VALUMARK PEN NEEDLES ULTICARE SHORT PEN 29GX12MM 115 31GX 8MM 115 NEEDLES 31GX8MM 114 UNIFINE PENTIPS 31G X VALVED HOLDING ULTICARE SHORT PEN 3/16" 115 CHAMBER 119 NEEDLES ULTI-FINE IV 114 UNIFINE PENTIPS VANACOF 68 ULTICARE SHORT PEN 31GX5MM 115 NEEDLES/31G X 8MM 114 UNIFINE PENTIPS VANCOCIN HCL 14 ULTIGUARD SAFEPACK/MINI 31GX6MM 115 vancomycin hcl 14 PEN NEEDLE/31G X UNIFINE PENTIPS VANCOMYCIN 1/4"/SHARPS CONTAIN 114 31GX8MM 115 HYDROCHLORIDE 14 ULTIGUARD SAFEPACK/MINI UNIFINE PENTIPS vandazole 153 PEN NEEDLE/31G X 32GX6MM 115 VANOS 79 3/16"/SHARPS CONTAI 114 UNIFINE PENTIPS ULTIGUARD SAFEPACK/MINI 33GX4MM 115 VARUBI 33 PEN NEEDLE/32G X UNIFINE PENTIPS PLUS VASCEPA 35 1/4"/SHARPS CONTAIN 114 29GX12MM 115 VASERETIC 40 ULTIGUARD UNIFINE PENTIPS PLUS SAFEPACK/SHORTPEN 31GX5MM 115 VASOTEC 37 NEEDLE/31G X 5/16"/SHARPS UNIFINE PENTIPS PLUS VCF VAGINAL CONTA 114 31GX6MM 115 CONTRACEPTIVE FILM 153 ULTILET INSULIN SYRINGE UNIFINE PENTIPS PLUS VCF VAGINAL 31X6MM 114 31GX8MM 115 CONTRACEPTIVE FOAM 153 ULTILET PEN NEEDLE UNIFINE PENTIPS PLUS vcf vaginal contraceptivegel153 29GX12.7MM 114 33GX 5/32" 115 VECAMYL 41 ULTILET PEN NEEDLE UNIFINE PENTIPS PLUS VECTICAL 74 31GX5MM 114 33GX4MM 115 ULTILET PEN NEEDLE UNIFINE SAFECONTROL PEN VELTIN 71 31GX8MM 114 NEEDLE/30G X 5/16" 115 VEMLIDY 54 ULTILET SHORT PEN UPTRAVI 59 VENCLEXTA 43 NEEDLES 31GX5/16" 114 URECHOLINE 153 VENCLEXTA STARTING ULTILET SHORT PEN PACK 43 NEEDLES31GX3/16" 114 UROCIT-K 10 89 ULTRA FLO INSULIN PEN UROCIT-K 15 89 venlafaxine hcl 27 NEEDLES 114 UROCIT-K 5 89 VENTAVIS 58 ULTRA-THIN II MINI PEN verapamil hcl 57 NEEEDLES/31GX3/16" 114 UROXATRAL 90 ULTRA-THIN II PEN NEEDLES URSO 250 87 VERAPAMIL HCL ER 57 29GX1/2" 114 URSO FORTE 87 VERAPAMIL HCL SR 57 VERAPAMIL HYDROCHLORIDE ULTRA-THIN II PEN ursodiol 87 NEEDLES/SHORT/31GX5/16" ER 57 114 UTIBRON NEOHALER 19 VEREGEN 71 ULTRACARE PEN VAGIFEM 154 VERELAN 57 NEEDLES/31G X 1/4" 114 valacyclovir hcl 55 ULTRACARE PEN VERELAN PM 57 NEEDLES/31G X 3/16" 114 VALCHLOR 73 VERSACLOZ 50 ULTRACARE PEN VALCYTE 53,54 VERZENIO 46 NEEDLES/31G X 5/16" 115 valganciclovir hcl 54 VESICARE 152 ULTRACARE PEN VALIUM 16 NEEDLES/32G X 1/14" 115 VFEND 34 ULTRACARE PEN valproate sodium 25 VIAGRA 58 NEEDLES/32G X 3/16" 115 valproic acid 25 VIBERZI 88 valsartan 38

Index 26 VIBRAMYCIN 148 VIZIMPRO 46 wixela inhub 18 VICTOZA 29 VOGELXO 13 WP THYROID 149 VIDA MIA UNIFINE VOGELXO PUMP 13 wymzya fe 61 PENTIPSMINI 31GX6MM 115 VOL-TAB RX 132 XALATAN 140 VIDA MIA UNIFINE PENTIPSORIGINAL VOLTAREN 71 XALKORI 46 29GX12MM 116 VONVENDI 92 XANAX 16 VIDA MIA UNIPFINE voriconazole 34 XANAX XR 16 PENTIPSSHORT VORTEX VALVED HOLDING 31GX8MM 116 XARELTO 20 CHAMBER 119 XATMEP 42 VIDEX EC 53 VOSEVI 54 XELJANZ 4 VIDEXPEDIATRIC 53 VOTRIENT 46 XELJANZ XR 4 VIEKIRA PAK 54 VP-HEME OB 132 XELODA 42 vigabatrin 24 VP-HEME OB + DHA 132 XENAZINE 144 vigadrone 24 VP-PNV-DHA 132 XERAC AC 79 VIGAMOX 137 VRAYLAR 49 XERMELO 89 VIIBRYD 27 VYNDAMAX 59 XIFAXAN 14 VIIBRYD STARTER PACK 27 VYNDAQEL 59 XIGDUO XR 29 VIL-RX 131 VYTONE 73 XIIDRA 137 VIMPAT 24 VYTORIN 35 XOLAIR 17 VINATE DHA RF 131 VYVANSE 1 XOPENEX 19 VINATE ONE 131 warfarin sodium 20 XOPENEX CONCENTRATE 19 VIOKACE 81 WATCHHALER 119 XOSPATA 46 VIRACEPT 53 WEGMANS COMPLETE VIRAMUNE 53 PRENATAL+DHA 132 XPOVIO 100 MG ONCE WEEKLY 44 VIRAMUNE XR 53 WEGMANS UNIFINE PENTIPS PLUS/MINI/31GX5MM 116 XPOVIO 60 MG ONCE VIREAD 53 WEGMANS UNIFINE PENTIPS WEEKLY 44 VIROPTIC 137 PLUS/SHORT/31GX8MM116 XPOVIO 80 MG ONCE WEGMANS UNIFINE PENTIPS WEEKLY 44 VIRT-C DHA 131 XPOVIO 80 MG TWICE VIRT-NATE DHA 131 PLUS/ULTRA SHORT/31GX6MM 116 WEEKLY 44 VIRT-PN 131 WELCHOL 35 XTANDI 43 VIRT-PN DHA 131 WELLBUTRIN SR 25 XULANE 63 VIRT-PN PLUS 131 WELLBUTRIN XL 25 XYNTHA 92 virtussin ac/alc 65 WESTHROID 149 XYNTHA SOLOFUSE 92 VISTARIL 15 WIDE-SEAL SILICONE XYREM 142 VISTOGARD 32 DIAPHRAGM KIT 60 99 YASMIN 28 63 VITAFOL FE+ 132 WIDE-SEAL SILICONE YAZ 63 DIAPHRAGM KIT 65 99 VITAFOL GUMMIES 132 WIDE-SEAL SILICONE YONSA 43 VITAFOL-NANO 132 DIAPHRAGM KIT 70 99 yuvafem 153 VITAFOL-ONE 132 WIDE-SEAL SILICONE zaleplon 95 VITAMEDMD ONE DIAPHRAGM KIT 75 99 ZANAFLEX 133 RX/QUATREFOLIC 132 WIDE-SEAL SILICONE DIAPHRAGM KIT 80 99 ZANTAC 151 VITAPEARL 132 WIDE-SEAL SILICONE ZANTAC 150 MAXIMUM VITATRUE 132 DIAPHRAGM KIT 85 99 STRENGTH 151 VITRAKVI 46 WIDE-SEAL SILICONE ZARONTIN 25 VIVA DHA 132 DIAPHRAGM KIT 90 99 ZARXIO 94 WIDE-SEAL SILICONE VIVELLE-DOT 86 DIAPHRAGM KIT 95 99 ZATEAN-PN DHA 132 VIVLODEX 6 WILATE 92 ZATEAN-PN PLUS 132

Index 27 ZAVESCA 93 ZYMAXID 137 ZEJULA 46 ZYPREXA 50 ZELAPAR 48 ZYPREXA ZYDIS 50 ZELBORAF 46 ZYTIGA 44 ZEMPLAR 85 ZYVOX 15 ZENPEP 81 zenzedi 1 ZENZEDI 1 ZEPATIER 54 ZERIT 53 ZESTORETIC 41 ZESTRIL 37 ZETIA 36 ZIAC 41 ZIAGEN 53 ZIANA 71 zidovudine 53 ZIEXTENZO 94 zileuton 17 ZIOPTAN 140 ziprasidone hcl 49 ZIRGAN 137 ZITHROMAX 98 ZITHROMAX TRI-PAK 98 ZITHROMAX Z-PAK 98 ZOCOR 36 ZOFRAN 32 ZOFRAN ODT 32 ZOLINZA 46 zolmitriptan 121 ZOLOFT 26,27 zolpidem tartrate 95 ZOMIG 121 ZOMIG ZMT 121 ZONEGRAN 24 zonisamide 24 ZORBTIVE 83 ZORTRESS 124 ZOVIRAX 55,74 ZYBAN 147 ZYDELIG 46 ZYFLO 17 ZYFLO CR 17 ZYKADIA 46 ZYLET 139 ZYLOPRIM 90

Index 28