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2020 Prescription Drug List

Effective December 1, 2020

Ambetter.SuperiorHealthPlan.com Formulary Introduction

SUMMARY OF FORMULARY BENEFITS

The information in this document is designed to help you understand the prescription drug benefits offered under this plan and to compare these benefits to those offered by other plans. Information contained in this summary is designed to help you compare both the value and scope of formulary benefits.

HOW TO FIND INFORMATION ON THE COST OF PRESCRIPTION DRUGS To find the cost of your prescription please visit https://ambetter.superiorhealthplan.com/resources/pharmacy- resources.html. In the Drug Cost Tool please select the plan in which you are participating (planning to participate) and enter medications thatyou are taking. The toolwill provide you an approximate cost ofyour prescriptions, excluding any deductible or maximumoutofpocketrequirements. The tool uses median cost for generic prescriptions andactual allowed costfor branded products. If the total medication cost is less than the co-pay that you would pay for that Tier you will be responsible only for the lesser of amount.

FORMULARY BY HEALTH BENEFIT PLAN

Plan Formulary Summary of Benefits and Coverage Ambetter Essential Care 1 (2020) Standard https://ambetter.superiorhealthplan.com/2020- Formulary brochures.html?plan=EssentialCare Ambetter Essential Care 1 (2020) + Standard https://ambetter.superiorhealthplan.com/2020- Vision Formulary brochures.html?plan=EssentialCare Ambetter Essential Care 1 (2020) + Standard https://ambetter.superiorhealthplan.com/2020- Vision + Dental Formulary brochures.html?plan=EssentialCare Ambetter Essential Care 4 HSA Standard https://ambetter.superiorhealthplan.com/2020- (2020) Formulary brochures.html?plan=EssentialCare Ambetter Essential Care 10 (2020) Standard https://ambetter.superiorhealthplan.com/2020- Formulary brochures.html?plan=EssentialCare Ambetter Essential Care 10 (2020) Standard https://ambetter.superiorhealthplan.com/2020- +Vision Formulary brochures.html?plan=EssentialCare Ambetter Essential Care 10 (2020) Standard https://ambetter.superiorhealthplan.com/2020- + Vision + Dental Formulary brochures.html?plan=EssentialCare Ambetter Balanced Care 1 (2020) Standard https://ambetter.superiorhealthplan.com/2020- Formulary brochures.html?plan=BalancedCare Ambetter Balanced Care 1 (2020) + Standard https://ambetter.superiorhealthplan.com/2020- Vision Formulary brochures.html?plan=BalancedCare Ambetter Balanced Care 1 (2020) + Standard https://ambetter.superiorhealthplan.com/2020- Vision + Dental Formulary brochures.html?plan=BalancedCare Ambetter Balanced Care 3 (2020) Standard https://ambetter.superiorhealthplan.com/2020- Formulary brochures.html?plan=BalancedCare Ambetter Balanced Care 3 (2020) + Standard https://ambetter.superiorhealthplan.com/2020- Vision Formulary brochures.html?plan=BalancedCare Ambetter Balanced Care 3 (2020) + Standard https://ambetter.superiorhealthplan.com/2020- Vision + Dental Formulary brochures.html?plan=BalancedCare Ambetter Balanced Care 4 (2020) Standard https://ambetter.superiorhealthplan.com/2020- Formulary brochures.html?plan=BalancedCare Ambetter Balanced Care 4 (2020) + Standard https://ambetter.superiorhealthplan.com/2020- Vision Formulary brochures.html?plan=BalancedCare Ambetter Balanced Care 4 (2020) + Standard https://ambetter.superiorhealthplan.com/2020- Vision + Dental Formulary brochures.html?plan=BalancedCare Ambetter Balanced Care 5 (2020) Standard https://ambetter.superiorhealthplan.com/2020- Formulary brochures.html?plan=BalancedCare Ambetter Balanced Care 11 (2020) Standard https://ambetter.superiorhealthplan.com/2020- Formulary brochures.html?plan=BalancedCare Ambetter Balanced Care 11 (2020) Standard https://ambetter.superiorhealthplan.com/2020- + Vision Formulary brochures.html?plan=BalancedCare Ambetter Balanced Care 11 (2020) Standard https://ambetter.superiorhealthplan.com/2020- + Vision + Dental Formulary brochures.html?plan=BalancedCare Ambetter Balanced Care 14 (2020) Standard https://ambetter.superiorhealthplan.com/2020- Formulary brochures.html?plan=BalancedCare Ambetter Balanced Care 14 (2020) Standard https://ambetter.superiorhealthplan.com/2020- + Vision Formulary brochures.html?plan=BalancedCare Ambetter Balanced Care 14 (2020) Standard https://ambetter.superiorhealthplan.com/2020- + Vision + Dental Formulary brochures.html?plan=BalancedCare Ambetter Balanced Care 15 (2020) Standard https://ambetter.superiorhealthplan.com/2020- Formulary brochures.html?plan=BalancedCare Ambetter Balanced Care 15 (2020) Standard https://ambetter.superiorhealthplan.com/2020- + Vision Formulary brochures.html?plan=BalancedCare Ambetter Balanced Care 15 (2020) Standard https://ambetter.superiorhealthplan.com/2020- + Vision + Dental Formulary brochures.html?plan=BalancedCare Ambetter Secure Care 5 (2020) Standard https://ambetter.superiorhealthplan.com/2020- Formulary brochures.html?plan=SecureCare Ambetter Secure Care 5 (2020) + Standard https://ambetter.superiorhealthplan.com/2020- Vision Formulary brochures.html?plan=SecureCare Ambetter Secure Care 5 (2020) + Standard https://ambetter.superiorhealthplan.com/2020- Vision + Dental Formulary brochures.html?plan=SecureCare

DRUG BY COST-SHARING TIER

Tier Percent of drugs in each cost-sharing tier: 0 6% 1 84% 2 2% 3 3% 4 5%

HOW PRESCRIPTION DRUGS ARE COVERED UNDER THE PLAN

A) FORMULARY COMPOSITION: a. Ambetter formulary is guided by the principle of offering widest possible access to drugs at the lowest cost. With that in mind, we start with the Affordable Care Act mandated benchmark. We then review the formulary for addition of other clinically necessary and appropriate drugs. Ambetter’s formulary is considered a closed formulary. This means that any drug not found in the formulary requires prior authorization. To make sure that our members always have access to appropriate drugs, we review and update our formulary on a monthly basis.

B) RIGHT TO APPEAL a. If we deny your request for Prior Authorization you have 180 days from being denied coverage for a drug to file an appeal, and your appeal will be resolved within 30 days. In the event that your appeal is successful, non-specialty non-formulary drugs will be covered at your Tier 3 cost-share (co-pay or co- insurance) and specialty non-formulary drugs will be covered at your Tier 4 cost-share (co-pay or co- insurance). Please consult your individual Summary of Benefits and Coverage for additional information on your cost-share. All other provisions of your benefit, such as deductibles and maximum out of pockets, apply to formulary and non-formulary drugs that have been provided through an appeal.

C) CONTINUATION OF COVERAGE a. Ambetter does not make changes to our formulary requiring a continuation of coverage. However, if a formulary change is made requiring a continuation of coverage, you would have the right to continue taking the drug at the coverage level or tier at which the drug was covered at the beginning of the plan year until your plan is renewed.

D) OFF-LABEL DRUG USE a. We provide coverage for off-label drug use. Off-label use indicates medication use that has not been FDA approved for that condition. Coverage of a product under off-label use policy requires that the following must be true: i. Use must be diagnosis specific as defined by ICD-10 code AND ii. Off-label use must be supported by one major multi-site study or three smaller studies published in a reputable medical journal, peer reviewed specialty medical journal, or listed in reputable compendia.

E) COST SHARING a. Cost sharing is your monetary participation in your care. You will need to know few items to determine the cost-share you are responsible for. Knowing the following items will help you estimate the cost you’ll be responsible for at any given time: how much of your deductible you have already paid, how much deductibleremains, what drug you are prescribed, and your maximum out of pocket allowance. All those items, with the exception of the tier, can be obtained from the Summary of Benefits and Coverage (see links above). To obtain the tier for your drug please consult the Formulary. To determine your cost share please follow those steps: i. Determine the tier that the drug/product you are filling is listed under by consulting the Formulary. ii. Once you have determined the tier, utilize the Summary of Benefits and Coverage (SBC) document to determine what cost-share will apply to your selected drug/product. iii. If you have not met your deductible, you will be responsible for the full cost of the drug until you meet your deductible. iv. If you have met your deductible, but not the Maximum Out of Pocket, you will be charged a copay for drugs that are assigned a copay under your SBC and co-insurance for drugs that are assigned a co-insurance under your SBC. Generally, you will pay one (1) co-pay for each 30 day supply of medication. Two co-pays will be charged for 2 month supply and three co-pays for 3 month supply of your medication, respectively. v. To determine the cost for co-insurance drugs/products, please utilize our online drug search tool. Please see section: “HOW TO FIND INFORMATION ON THE COST OF PRESCRIPTION DRUGS” above.

b. Please be aware that pharmacy claims will only process if you present your prescription to an in- network pharmacy. Out-of-network claims will not be covered. To find an in-network-pharmacy close to you please consult our Find a Provider tool available on our website under Pharmacy Resources.

c. Your cost share for maintenance medications obtained through either Mail Order or at retail pharmacies participating in our Extended Day Supply retail network will be calculated based on the day supply that you obtain. For up to 30 day supply you will be charged one (1) copay or co-insurance, 31 to 60 day supply you will be responsible for two (2) copays or co-insurance and for day supply greater than 60 but less than 91 you will be charged three (3) copays or co-insurance.

F) MEDICAL MANAGEMENT REQUIREMENTS a. Prior Authorization (PA) – Drugs that have PA indication on the Formulary require Prior Authorization. You or your provider have to request an authorization from us to use this drug/product prior to be able to fill a prescription for the drug/product. b. Step Therapy (ST) – Drugs that have ST indication on the Formulary require that you try and fail other formulary products before you can obtain the drug/product. When your provider does not feel that trying another product is appropriate your provider or you can submit a regular Prior Authorization request to obtain the Step Therapy drug/product. c. Quantity Limit (QL) – Drugs that have QL indication on the Formulary are limited to the quantity indicated. Those quantity limits are based on the FDA approved maximum doses. If your provider would like to request exception to those limits he/she may submit a Prior Authorization request. All request requested for quantity limit exemptions will be processed under our Off-Label policy. d. Non-Formulary Drugs – Drugs not found on this formulary are considered non-formulary drugs. To obtain non-formulary drugs your provider would have to submit a regular Prior Authorization request. All request for Non-Formulary Drugs will be reviewed under our Non-Formulary Drug Request Policy.

STANDARD FORMULARY

The Ambetter from Superior Health Plan Formulary, or Preferred Drug List, is a guide to available brand and generic drugs that are approved by the Food and Drug Administration (FDA) and covered through your prescription drug benefit. Generic drugs have the same active ingredients as their brand name counterparts and should be considered the first line of treatment. The FDA requires generics to be safe and work the same as brand name drugs. If there is no generic available, there may be more than one brand name drug to treat a condition. Preferred brand name drugs are listed on Tier 2 to help identify brand drugs that are clinically appropriate, safe, and cost-effective treatment options, if a generic medication on the formulary is not suitable for your condition.

Drug List Key: Brand name drugs are listed in CAPS and generic drugs are lower case. Drugs are covered under different copay tiers depending on your benefit:

Tier 0 - No copayment for those drugs that are used for prevention and are mandated by Affordable Care Act. Select oral contraceptives, vitamin D, folic acid for women of child bearing age, over-the-counter (OTC) aspirin, and smoking cessation products may be covered under this tier. Certain age or gender limits apply.

Tier 1 - Lowest copayment for those drugs that offer the greatest value compared to other drugs used to treat similar conditions. Select over-the-counter (OTC), generic or brand name drugs may be covered under this tier.

Tier 2 - Medium copayment covers brand name drugs that are generally more affordable, or may be preferred compared to other drugs to treat the same conditions.

Tier 3 - Highest copayment covers higher cost brand name drugs. This tier may also cover non-specialty drugs that are not on the Preferred Drug List but approval has been granted for coverage.

Tier 4 - Coverage for this tier is for “specialty” drugs used to treat complex, chronic conditions that may require special handling, storage or clinical management. For members who do not have a four Tier plan, these drugs may be covered under Tier 3. Formulary Abbreviations:

Abbreviation Term What it means

AL Age Limit Some drugs are only covered for certain ages.

QL Quantity Limit Some drugs are only covered for a certain amount.

Your doctor must ask for approval from Ambetter before PA Prior Authorization some drugs will be covered. In some cases, you must first try certain drugs before Ambetter covers another drug for your medical condition. ST Step Therapy For example, if Drug A and Drug B both treat your medical condition, Ambetter may not cover Drug B unless you try Drug A first. This product is not covered unless you or your provider NF Non-formulary request an exception. Alternative medications are listed next to non-covered product

These drugs are made in both prescription form and RX/OTC Prescription and OTC Over-the-counter (OTC) form.

Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ADHD/ANTI-NARCOLEPSY/ANTI- amphetamine- QL(2 ea daily) OBESITY/ANOREXIANTS - Drugs to Treat dextroamphetamine cp24 5 ADHD, Sleep and Eating Disorders mg-5 mg-5 mg-5 mg, 6.25 1 mg-6.25 mg-6.25 mg-6.25 Amphetamines mg, 7.5 mg-7.5 mg-7.5 mg- ADDERALL TABS 1.875 QL(3 ea daily) 7.5 mg MG-1.875 MG-1.875 MG- amphetamine- QL(3 ea daily) 1.875 MG, 3.125 MG-3.125 dextroamphetamine tabs MG-3.125 MG-3.125 MG, 1.875 mg-1.875 mg-1.875 3.75 MG-3.75 MG-3.75 mg-1.875 mg, 3.125 mg- MG-3.75 MG, 1.25 MG- NF 3.125 mg-3.125 mg-3.125 1 1.25 MG-1.25 MG-1.25 mg, 3.75 mg-3.75 mg-3.75 MG, 2.5 MG-2.5 MG-2.5 mg-3.75 mg, 1.25 mg-1.25 MG-2.5 MG, 5 MG-5 MG-5 mg-1.25 mg-1.25 mg, 2.5 MG-5 MG (Use mg-2.5 mg-2.5 mg-2.5 mg, amphetamine- 5 mg-5 mg-5 mg-5 mg dextroamphetamine) amphetamine- QL(2 ea daily) ADDERALL TABS 7.5 MG- QL(2 ea daily) dextroamphetamine tabs 1 7.5 MG-7.5 MG-7.5 MG NF 7.5 mg-7.5 mg-7.5 mg-7.5 (Use amphetamine- mg dextroamphetamine) QL(5 ea daily); ADDERALL XR CP24 1.25 QL(1 ea daily) DESOXYN TABS (Use NF methamphetamine hcl) AL(At least 6 MG-1.25 MG-1.25 MG-1.25 yrs old) MG, 2.5 MG-2.5 MG-2.5 NF MG-2.5 MG (Use DEXEDRINE CP24 10 MG, QL(4 ea daily) amphetamine- 15 MG (Use NF dextroamphetamine) dextroamphetamine sulfate) ADDERALL XR CP24 3.75 DEXEDRINE CP24 5 MG MG-3.75 MG-3.75 MG-3.75 NF MG (Use amphetamine- (Use dextroamphetamine NF dextroamphetamine) sulfate) ADDERALL XR CP24 5 QL(2 ea daily) dextroamphetamine sulfate 1 QL(4 ea daily) MG-5 MG-5 MG-5 MG, cp24 10 mg, 15 mg 6.25 MG-6.25 MG-6.25 dextroamphetamine sulfate 1 MG-6.25 MG, 7.5 MG-7.5 NF cp24 5 mg MG-7.5 MG-7.5 MG (Use dextroamphetamine sulfate 1 QL(4 ea daily) amphetamine- tabs 10 mg, 5 mg dextroamphetamine) QL(5 ea daily); ADZENYS ER SUER (Use NF methamphetamine hcl tabs 3 AL(At least 6 amphetamine) yrs old) amphetamine- QL(1 ea daily) VYVANSE CAPS 10 MG, ST; QL(1 ea dextroamphetamine cp24 20 MG, 30 MG, 40 MG, 50 3 daily) 1.25 mg-1.25 mg-1.25 mg- 1 MG, 60 MG, 70 MG 1.25 mg, 2.5 mg-2.5 mg- 2.5 mg-2.5 mg Anorexiants Non-Amphetamine amphetamine- ADIPEX-P CAPS (Use NF PA phentermine hcl) dextroamphetamine cp24 1 3.75 mg-3.75 mg-3.75 mg- phendimetrazine tartrate 1 PA 3.75 mg tabs

Ambetter Formulary Updated December 1, 2020

1 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits phentermine hcl caps 1 PA dexmethylphenidate hcl QL(1 ea daily) cp24 25 mg, 35 mg, 40 mg, 1 Anti-Obesity Agents 10 mg, 15 mg, 20 mg, 30 mg, 5 mg PA BELVIQ TABS 3 QL(2 ea daily); dexmethylphenidate hcl 1 AL(At least 6 PA tabs 10 mg, 2.5 mg, 5 mg CONTRAVE TB12 3 yrs old) Attention-Deficit/Hyperactivity Disorder (ADHD) QL(2 ea daily); FOCALIN TABS (Use NF dexmethylphenidate hcl) AL(At least 6 QL(2 ea daily); yrs old) atomoxetine hcl caps 10 1 AL(At least 6 mg, 18 mg, 25 mg, 40 mg yrs old) FOCALIN XR CP24 (Use NF QL(1 ea daily) dexmethylphenidate hcl) QL(1 ea daily); atomoxetine hcl caps 100 1 AL(At least 6 QL(30 ml mg, 60 mg, 80 mg METHYLIN SOLN (Use NF yrs old) methylphenidate hcl) daily); AL(At least 6 yrs old) clonidine hcl (adhd) tb12 1 methylphenidate hcl cp24 1 AL(At least 6 20 mg, 40 mg yrs old) QL(1 ea daily); guanfacine hcl (adhd) tb24 1 AL(At least 6 QL(3 ea daily); methylphenidate hcl cp24 1 AL(At least 6 yrs old) 30 mg yrs old) QL(1 ea daily); INTUNIV TB24 (Use NF methylphenidate hcl cpcr QL(1 ea daily); guanfacine hcl (adhd)) AL(At least 6 yrs old) 40 mg, 10 mg, 20 mg, 30 1 AL(At least 6 mg, 50 mg, 60 mg yrs old) KAPVAY TB12 (Use NF clonidine hcl (adhd)) QL(30 ml methylphenidate hcl soln 1 daily); AL(At 10 mg/5ml, 5 mg/5ml STRATTERA CAPS 10 QL(2 ea daily); least 6 yrs old) MG, 18 MG, 25 MG, 40 MG NF AL(At least 6 (Use atomoxetine hcl) yrs old) QL(5 ea daily); methylphenidate hcl tabs 1 AL(At least 6 20 mg, 10 mg STRATTERA CAPS 100 QL(1 ea daily); yrs old) MG, 60 MG, 80 MG (Use NF AL(At least 6 atomoxetine hcl) yrs old) QL(6 ea daily); methylphenidate hcl tabs 5 1 AL(At least 6 mg Dopamine and Norepinephrine Reuptake yrs old) SUNOSI TABS 3 PA QL(3 ea daily); methylphenidate hcl tbcr 10 1 AL(At least 6 mg, 20 mg Stimulants - Misc. yrs old) PA; QL(1 ea QL(1 ea daily); methylphenidate hcl tbcr 18 1 AL(At least 6 1 daily); AL(At mg, 27 mg armodafinil tabs least 17 yrs yrs old) old) QL(2 ea daily); methylphenidate hcl tbcr 36 1 AL(At least 6 CONCERTA TBCR 18 MG, QL(1 ea daily); mg, 54 mg 27 MG (Use NF AL(At least 6 yrs old) methylphenidate hcl) yrs old) PA; QL(1 ea daily); AL(At CONCERTA TBCR 36 MG, QL(2 ea daily); modafinil tabs 100 mg 1 54 MG (Use NF AL(At least 6 least 16 yrs methylphenidate hcl) yrs old) old) PA; QL(1 ea DAYTRANA PTCH 3 daily)

Ambetter Formulary Updated December 1, 2020

2 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; QL(2 ea ARIKAYCE SUSP 4 PA daily); AL(At modafinil tabs 200 mg 1 least 16 yrs gentamicin in saline soln old) 0.8 mg/ml-0.9 %, 0.9 %-1 1 PA; QL(1 ea mg/ml, 0.9 %-1.2 mg/ml, 0.9 %-1.6 mg/ml NUVIGIL TABS (Use NF daily); AL(At armodafinil) least 17 yrs gentamicin sulfate soln 40 1 old) mg/ml PA; QL(1 ea KITABIS PAK NEBU (Use NF PA PROVIGIL TABS 100 MG NF daily); AL(At tobramycin) (Use modafinil) least 16 yrs old) neomycin sulfate tabs 1 PA; QL(2 ea paromomycin sulfate caps 1 PROVIGIL TABS 200 MG NF daily); AL(At (Use modafinil) least 16 yrs old) streptomycin sulfate solr 3 RITALIN LA CP24 20 MG, AL(At least 6 TOBI NEBU (Use NF PA 40 MG (Use NF yrs old) tobramycin) methylphenidate hcl) tobramycin nebu 300 4 PA QL(3 ea daily); mg/5ml RITALIN LA CP24 30 MG NF AL(At least 6 (Use methylphenidate hcl) tobramycin sulfate soln 10 yrs old) mg/ml, 40 mg/ml, 80 1 RITALIN TABS 20 MG, 10 QL(5 ea daily); mg/2ml MG (Use methylphenidate NF AL(At least 6 hcl) yrs old) ANALGESICS - ANTI-INFLAMMATORY - Drugs to Treat Pain, Swelling, Muscle and Joint QL(6 ea daily); Conditions RITALIN TABS 5 MG (Use NF methylphenidate hcl) AL(At least 6 yrs old) Anti-TNF-alpha - Monoclonal Antibodies HUMIRA PEDIATRIC PA; QL(0.143 ALLERGENIC EXTRACTS/BIOLOGICALS MISC CROHNS DISEASE 4 ea daily) STARTER PACK PSKT 40 Allergenic Extracts MG/0.8ML PA GRASTEK SUBL 3 PA; 1 rtl pack lmt amt,180 rtl Biologicals Misc HUMIRA PEDIATRIC pack lmt ADAGEN SOLN 4 PA; SP CROHNS DISEASE 4 day(s),1 mail STARTER PACK PSKT 80 pack lmt MG/0.8ML, amt,180 mail AMEBICIDES pack lmt day(s), Amebicides PA; QL(0.143 SOLOSEC PACK 3 PA 4 ea daily,30 ea HUMIRA PEN PNKT per fill retail,30 AMINOGLYCOSIDES - Drugs to Treat Bacterial ea per fill mail) PA; QL(0.143 HUMIRA PEN-CD/UC/HS ea daily,30 ea Aminoglycosides STARTER PNKT 40 4 MG/0.8ML per fill retail,30 amikacin sulfate soln 1 ea per fill mail)

Ambetter Formulary Updated December 1, 2020

3 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; 1 rtl pack RIDAURA CAPS 3 QL(3 ea daily) lmt amt,180 rtl pack lmt Interleukin-1 Blockers HUMIRA PEN-CD/UC/HS day(s),1 mail STARTER PNKT 80 4 PA; QL(0.286 MG/0.8ML pack lmt ARCALYST SOLR 4 amt,180 mail ea daily); SP pack lmt Interleukin-1 Receptor Antagonist (IL-1Ra) day(s), KINERET SOSY 4 PA; SP PA; 1 rtl pack lmt amt,180 rtl Interleukin-1beta Blockers pack lmt PA HUMIRA PEN-PS/UV 4 day(s),1 mail ILARIS SOLN 4 STARTER PNKT pack lmt amt,180 mail Interleukin-6 Receptor Inhibitors pack lmt ACTEMRA SOLN IV 200 PA; SP day(s), MG/10ML, 400 MG/20ML, 4 PA; QL(0.143 80 MG/4ML HUMIRA PEN-PS/UV ea daily,30 ea 4 ACTEMRA SOSY SC 162 4 PA; QL(0.129 STARTER PNKT per fill retail,30 MG/0.9ML ml daily); SP ea per fill mail) KEVZARA SOAJ 4 PA HUMIRA PSKT 4 PA; QL(0.143 ea daily) KEVZARA SOSY 4 PA SIMPONI ARIA SOLN 4 PA Nonsteroidal Anti-inflammatory Agents (NSAIDs) SIMPONI SOAJ 100 4 PA; QL(0.357 MG/ML ml daily); SP ANAPROX DS TABS (Use NF naproxen sodium) SIMPONI SOAJ 50 4 PA; QL(0.0179 MG/0.5ML ml daily); SP ARTHROTEC 50 TBEC (Use diclofenac w/ NF SIMPONI SOSY 100 4 PA; QL(0.357 misoprostol) MG/ML ml daily); SP ARTHROTEC 75 TBEC SIMPONI SOSY 50 4 PA; QL(0.0179 (Use diclofenac w/ NF MG/0.5ML ml daily); SP misoprostol) Antirheumatic - Enzyme Inhibitors CELEBREX CAPS (Use NF PA celecoxib) OLUMIANT TABS 4 PA celecoxib caps 1 PA RINVOQ TB24 4 PA CHILDRENS ADVIL SUSP NF RX/OTC (Use ibuprofen) XELJANZ TABS 10 MG 4 PA; QL(2 ea daily) CHILDRENS MOTRIN NF RX/OTC SUSP (Use ibuprofen) XELJANZ TABS 5 MG 4 PA; QL(2 ea daily); SP DAYPRO TABS (Use NF oxaprozin) XELJANZ XR TB24 4 PA; QL(1 ea daily) diclofenac potassium tabs 1 Antirheumatic Antimetabolites diclofenac sodium tb24 1 METHOTREXATE TABS 4 PA; QL(1.714 ea daily); SP Gold Compounds diclofenac sodium tbec 1

Ambetter Formulary Updated December 1, 2020

4 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits diclofenac w/ misoprostol 1 naproxen sodium tabs 550 1 tbec mg EC-NAPROSYN TBEC 500 NF naproxen susp 125 mg/5ml 1 PA MG (Use naproxen) naproxen tabs 250 mg, 375 etodolac caps 200 mg, 300 1 1 mg mg, 500 mg etodolac tabs 400 mg, 500 1 naproxen tbec 500 mg 1 mg FELDENE CAPS (Use NF oxaprozin tabs 1 piroxicam) piroxicam caps 1 fenoprofen calcium tabs 1 ST; QL(4 ea 600 mg daily) sulindac tabs 1 flurbiprofen tabs 50 mg, 1 100 mg tolmetin sodium caps 1 ibuprofen susp 100 mg/5ml 1 RX/OTC tolmetin sodium tabs 1 ibuprofen tabs 400 mg, 600 1 mg, 800 mg Phosphodiesterase 4 (PDE4) Inhibitors indomethacin caps 25 mg, 1 OTEZLA TABS 4 PA; QL(2 ea 50 mg daily) indomethacin cpcr 75 mg 1 OTEZLA TBPK 4 PA ketoprofen caps 50 mg, 75 1 mg Pyrimidine Synthesis Inhibitors ARAVA TABS (Use QL(1 ea daily) ketorolac tromethamine 1 QL(0.667 ea NF tabs or 10 mg daily) leflunomide) QL(1 ea daily) LODINE TABS (Use NF leflunomide tabs 1 etodolac) Selective Costimulation Modulators meclofenamate sodium 1 caps ORENCIA CLICKJECT 4 PA ST; Must try SOAJ mefenamic acid caps 1 ibuprofen. ORENCIA SOLR IV 250 4 PA; SP ;QL(5 ea daily) MG ORENCIA SOSY SC 125 PA; QL(0.143 meloxicam tabs 1 QL(1 ea daily) 4 MG/ML ml daily); SP MOBIC TABS (Use QL(1 ea daily) NF ORENCIA SOSY SC 50 4 PA; QL(0.143 meloxicam) MG/0.4ML, 87.5 MG/0.7ML ml daily) nabumetone tabs 1 Soluble Tumor Necrosis Factor Receptor Agents ENBREL MINI SOCT 4 PA; NALFON TABS 600 MG NF ST; QL(4 ea (Use fenoprofen calcium) daily) PA; QL(0.286 ENBREL SOLR 25 MG 4 NAPROSYN SUSP 125 NF PA ea daily); SP MG/5ML (Use naproxen) ENBREL SOSY 25 4 PA; QL(0.146 NAPROSYN TABS 500 NF MG/0.5ML ml daily); SP MG (Use naproxen) ENBREL SOSY 50 MG/ML 4 PA; QL(0.28 ml daily); SP

Ambetter Formulary Updated December 1, 2020

5 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ENBREL SURECLICK PA; QL(0.143 New starts 4 CODEINE SULFATE TABS 1 SOAJ ml daily); SP 15 MG, 60 MG limited to 7 day supply ANALGESICS - NonNarcotic - Drugs to Treat Pain, Muscle and Joint Conditions CODEINE SULFATE TABS New starts 30 MG (Use codeine 1 limited to 7 day Analgesic Combinations sulfate) supply butalbital-acetaminophen 1 New starts tabs 325 mg-50 mg codeine sulfate tabs 30 mg, 1 limited to 7 day 60 mg butalbital-acetaminophen- supply caffeine caps 300 mg-40 1 CONZIP CP24 (Use NF mg-50 mg, 325 mg-40 mg- tramadol hcl) 50 mg DEMEROL SOLN 100 butalbital-acetaminophen- MG/ML, 25 MG/ML, 50 NF caffeine tabs 325 mg-40 1 MG/ML (Use meperidine mg-50 mg hcl) butalbital-aspirin-caffeine 1 DILAUDID LIQD OR 1 New starts caps MG/ML (Use NF limited to 7 day BUTALBITAL/ACETAMINO hydromorphone hcl) supply PHEN CAPS (Use NF DILAUDID SOLN IJ 1 butalbital-acetaminophen) MG/ML, 2 MG/ML (Use NF ESGIC TABS (Use hydromorphone hcl) butalbital-acetaminophen- NF New starts caffeine) DILAUDID TABS OR 2 limited to 7 day MG, 4 MG, 8 MG (Use NF FIORICET CAPS (Use hydromorphone hcl) supply;QL(8 ea butalbital-acetaminophen- NF daily) caffeine) DOLOPHINE TABS 10 MG NF QL(10 ea daily) (Use methadone hcl) FIORINAL CAPS (Use NF butalbital-aspirin-caffeine) DOLOPHINE TABS 5 MG NF QL(4 ea daily) Salicylates (Use methadone hcl) AL(At least 45 DURAGESIC PT72 (Use NF QL(0.34 ea aspirin chew 0 yrs old - Up to ) daily) 79 yrs old) PA; QL(2 ea EMBEDA CPCR 3 AL(At least 45 daily) aspirin tabs 0 yrs old - Up to EXALGO TB24 12 MG, 16 PA; QL(2 ea 79 yrs old) MG, 8 MG (Use NF daily) AL(At least 45 hydromorphone hcl) aspirin tbec 0 yrs old - Up to EXALGO TB24 32 MG NF PA; QL(1 ea 79 yrs old) (Use hydromorphone hcl) daily) diflunisal tabs 1 fentanyl citrate lpop bu PA; QL(4 ea 1200 mcg, 1600 mcg, 200 1 daily) salsalate tabs 1 mcg, 400 mcg, 600 mcg, 800 mcg ANALGESICS - OPIOID - Drugs to Treat Pain, fentanyl pt72 100 mcg/hr, QL(0.34 ea Muscle and Joint Conditions 12 mcg/hr, 25 mcg/hr, 50 1 daily) mcg/hr, 75 mcg/hr Opioid Agonists FENTORA TABS (Use NF ACTIQ LPOP (Use fentanyl NF PA; QL(4 ea fentanyl citrate) citrate) daily) Ambetter Formulary Updated December 1, 2020

6 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits hydrocodone bitartrate 1 PA; QL(2 ea methadone hcl soln or 5 1 QL(100 ml cp12 daily) mg/5ml daily) New starts methadone hcl tabs or 10 1 QL(10 ea daily) hydromorphone hcl liqd or 1 limited to 7 day 1 mg/ml mg supply methadone hcl tabs or 5 1 QL(4 ea daily) hydromorphone hcl soln ij mg 10 mg/ml, 50 mg/5ml, 500 1 methadone hcl tbso or 40 1 QL(2 ea daily) mg/50ml mg New starts METHADOSE CONC (Use NF QL(10 ml daily) hydromorphone hcl tabs or 1 limited to 7 day methadone hcl) 2 mg, 4 mg, 8 mg supply;QL(8 ea daily) METHADOSE SUGAR- QL(10 ml daily) FREE CONC (Use NF hydromorphone hcl tb24 or 1 PA; QL(2 ea methadone hcl) 12 mg, 16 mg, 8 mg daily) MORPHABOND ER T12A 3 PA hydromorphone hcl tb24 or 1 PA; QL(1 ea 32 mg daily) morphine sulfate cp24 or PA; QL(2 ea HYDROMORPHONE 100 mg, 20 mg, 30 mg, 50 1 daily) HYDROCHLORIDE SOLN NF mg, 60 mg, 80 mg IJ 10 MG/ML (Use morphine sulfate soln ij 0.5 1 hydromorphone hcl) mg/ml, 1 mg/ml KADIAN CP24 100 MG, 20 PA; QL(2 ea MORPHINE SULFATE MG, 30 MG, 50 MG, 60 NF daily) SOLN IV 10 MG/ML (Use NF MG, 80 MG (Use morphine morphine sulfate) sulfate) New starts New starts morphine sulfate soln or 10 limited to 7 day levorphanol tartrate tabs 2 1 limited to 7 day 1 mg mg/5ml supply;QL(100 supply ml daily) meperidine hcl soln ij 100 1 New starts mg/ml, 25 mg/ml, 50 mg/ml morphine sulfate soln or 20 1 limited to 7 day New starts mg/5ml supply;QL(50 meperidine hcl soln or 50 1 limited to 7 day ml daily) mg/5ml supply;QL(500 morphine sulfate tabs or 15 1 ml per fill retail) mg New starts New starts meperidine hcl tabs or 100 limited to 7 day 1 morphine sulfate tabs or 15 1 limited to 7 day mg, 50 mg supply;QL(6 ea mg, 30 mg supply;QL(6 ea daily) daily) methadone hcl conc or 10 1 QL(10 ml daily) morphine sulfate tbcr or QL(2 ea daily) mg/ml 100 mg, 15 mg, 200 mg, 30 1 methadone hcl soln ij 10 1 mg, 60 mg mg/ml MS CONTIN TBCR (Use NF QL(2 ea daily) METHADONE HCL SOLN morphine sulfate) IJ 10 MG/ML (Use 1 NUCYNTA ER TB12 2 PA; QL(2 ea methadone hcl) daily) methadone hcl soln or 10 QL(50 ml daily) 1 NUCYNTA TABS 2 PA; QL(6 ea mg/5ml daily)

Ambetter Formulary Updated December 1, 2020

7 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits OPANA TABS (Use NF PA; QL(12 ea New starts oxymorphone hcl) daily) acetaminophen w/ codeine 1 limited to 7 day New starts tabs 15 mg-300 mg supply;QL(13 ea daily) OXAYDO TABS 5 MG 2 limited to 7 day supply;QL(12 New starts ea daily) acetaminophen w/ codeine 1 limited to 7 day oxycodone hcl t12a 15 mg, PA; QL(2 ea tabs 30 mg-300 mg supply;QL(12 30 mg, 60 mg, 10 mg, 20 3 daily) ea daily) mg, 80 mg, 40 mg New starts New starts acetaminophen w/ codeine 1 limited to 7 day tabs 300 mg-60 mg supply;QL(6 ea oxycodone hcl tabs 10 mg, 1 limited to 7 day 20 mg, 15 mg, 30 mg, 5 mg supply;QL(12 daily) ea daily) acetaminophen-caff- New starts PA; QL(2 ea dihydrocod caps 16 mg-30 1 limited to 7 day OXYCONTIN T12A 3 daily) mg-320.5 mg supply acetaminophen-caff- PA; New starts oxymorphone hcl tabs 10 1 PA; QL(12 ea mg, 5 mg daily) dihydrocod caps 16 mg-30 3 limited to 7 day mg-320.5 mg supply oxymorphone hcl tb12 10 PA; QL(2 ea mg, 15 mg, 20 mg, 30 mg, 1 daily) butalbital-acetaminophen- New starts 5 mg, 7.5 mg caffeine w/ codeine caps 1 limited to 7 day 30 mg-300 mg-40 mg-50 supply oxymorphone hcl tb12 40 1 PA; QL(4 ea mg mg daily) butalbital-acetaminophen- New starts New starts caffeine w/ codeine caps 1 limited to 7 day ROXICODONE TABS (Use NF limited to 7 day 30 mg-325 mg-40 mg-50 supply;QL(6 ea oxycodone hcl) supply;QL(12 mg daily) ea daily) New starts SUBSYS LIQD 3 PA butalbital-aspirin-caffeine 1 limited to 7 day w/cod caps supply;QL(6 ea New starts daily) 1 limited to 7 day tramadol hcl tabs 50 mg supply;QL(8 ea FIORICET/CODEINE New starts daily) CAPS (Use butalbital- NF limited to 7 day acetaminophen-caffeine w/ supply tramadol hcl tb24 100 mg, 1 QL(1 ea daily) codeine) 200 mg, 300 mg New starts New starts FIORINAL/CODEINE #3 limited to 7 day ULTRAM TABS (Use limited to 7 day CAPS (Use butalbital- NF NF aspirin-caffeine w/cod) supply;QL(6 ea tramadol hcl) supply;QL(8 ea daily) daily) HYDROCODONE New starts XTAMPZA ER C12A 2 PA BITARTRATE/ACETAMIN 1 limited to 7 day OPHEN SOLN supply ZOHYDRO ER CP12 (Use 3 PA; QL(2 ea hydrocodone bitartrate) daily) hydrocodone- New starts acetaminophen soln 108 limited to 7 day Opioid Combinations mg/5ml-2.5 mg/5ml, 217 1 supply;QL(180 New starts mg/10ml-5 mg/10ml, 325 ml daily) acetaminophen w/ codeine mg/15ml-7.5 mg/15ml 1 limited to 7 day soln 12 mg/5ml-120 supply;QL(75 mg/5ml ml daily)

Ambetter Formulary Updated December 1, 2020

8 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits hydrocodone- New starts New starts /CODEINE #4 acetaminophen tabs 10 1 limited to 7 day NF limited to 7 day supply;QL(13 TABS (Use acetaminophen mg-300 mg, 300 mg-5 mg, w/ codeine) supply;QL(6 ea 300 mg-7.5 mg ea daily) daily) hydrocodone- New starts New starts acetaminophen tabs 10 1 limited to 7 day ULTRACET TABS (Use NF limited to 7 day mg-325 mg, 325 mg-5 mg, supply;QL(12 tramadol-acetaminophen) supply;QL(8 ea 325 mg-7.5 mg ea daily) daily) hydrocodone-ibuprofen PA Opioid Partial Agonists tabs 10 mg-200 mg, 200 1 PA mg-5 mg BUNAVAIL FILM 3 New starts BUPRENEX SOLN (Use NF hydrocodone-ibuprofen 1 limited to 7 day buprenorphine hcl) tabs 200 mg-7.5 mg supply;QL(5 ea daily) buprenorphine hcl soln ij 1 0.3 mg/ml New starts LORTAB ELIX 2 limited to 7 day buprenorphine hcl subl sl 2 1 QL(3 ea daily) supply mg, 8 mg buprenorphine hcl- PA; QL(3 ea NORCO TABS ( New starts Use limited to 7 day naloxone hcl dihydrate film 1 daily) hydrocodone- NF 0.5 mg-2 mg, 1 mg-4 mg acetaminophen) supply;QL(12 ea daily) buprenorphine hcl- PA; QL(2 ea oxycodone w/ New starts naloxone hcl dihydrate film 1 daily) 12 mg-3 mg, 2 mg-8 mg acetaminophen tabs 10 1 limited to 7 day mg-325 mg, 325 mg-5 mg, supply;QL(12 buprenorphine hcl- QL(3 ea daily) 325 mg-7.5 mg ea daily) naloxone hcl dihydrate subl 1 New starts 0.5 mg-2 mg, 2 mg-8 mg limited to 7 day buprenorphine ptwk td 10 PA; QL(0.143 oxycodone-ibuprofen tabs 1 supply;QL(1 ea mcg/hr, 15 mcg/hr, 20 1 ea daily) daily) mcg/hr, 5 mcg/hr, 7.5 PERCOCET TABS 10 MG- New starts mcg/hr 325 MG, 325 MG-5 MG, limited to 7 day butorphanol tartrate soln ij 1 325 MG-7.5 MG (Use NF supply;QL(12 1 mg/ml, 2 mg/ml oxycodone w/ ea daily) butorphanol tartrate soln na 1 PA acetaminophen) 10 mg/ml New starts BUTRANS PTWK 10 PA; QL(0.143 ROXICET SOLN 2 limited to 7 day MCG/HR, 15 MCG/HR, 20 NF ea daily) supply MCG/HR, 5 MCG/HR (Use New starts buprenorphine) tramadol-acetaminophen 1 limited to 7 day BUTRANS PTWK 7.5 PA; QL(0.143 tabs supply;QL(8 ea MCG/HR (Use 3 ea daily) daily) buprenorphine) New starts QL(8 ml daily) TYLENOL/CODEINE #3 limited to 7 day nalbuphine hcl soln 1 TABS (Use acetaminophen NF w/ codeine) supply;QL(12 New starts ea daily) pentazocine w/ naloxone 1 limited to 7 day tabs supply

Ambetter Formulary Updated December 1, 2020

9 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SUBOXONE FILM 0.5 MG- PA; QL(3 ea CORTENEMA ENEM (Use NF 2 MG, 1 MG-4 MG (Use NF daily) hydrocortisone (intrarectal)) buprenorphine hcl- hydrocortisone (intrarectal) 1 naloxone hcl dihydrate) enem SUBOXONE FILM 12 MG- PA; QL(2 ea UCERIS FOAM RE 2 4 PA 3 MG, 2 MG-8 MG (Use NF daily) MG/ACT buprenorphine hcl- naloxone hcl dihydrate) Rectal Steroids ANDROGENS-ANABOLIC - Drugs to Regulate ANUSOL-HC CREA (Use NF Hormones hydrocortisone (rectal)) Anabolic Steroids hydrocortisone (rectal) crea 1 ANADROL-50 TABS 3 hydrocortisone acetate 1 (rectal) supp oxandrolone tabs 1 PROCTOCORT CREA (Use hydrocortisone NF Androgens (rectal)) PROCTOCORT SUPP ANDRODERM PT24 2 PA; QL(1 ea daily) (Use hydrocortisone NF ANDROGEL GEL 25 acetate (rectal)) MG/2.5GM, 50 MG/5GM NF Vasodilating Agents (Use testosterone) RECTIV OINT 3 danazol caps 1 ANTHELMINTICS - Drugs to Treat Worm DEPO-TESTOSTERONE Infections SOLN (Use testosterone NF cypionate) Anthelmintics METHITEST TABS 3 albendazole tabs 1 PA ALBENZA TABS (Use PA TESTIM GEL (Use NF NF testosterone) albendazole) TESTOSTERONE BILTRICIDE TABS (Use NF PA CYPIONATE SOLN IJ 200 1 praziquantel) MG/ML QL(2 ea daily,6 ea per fill testosterone cypionate soln 1 ij 200 mg/ml retail,6 ea per fill mail)1 rtl testosterone cypionate soln 1 im 100 mg/ml, 200 mg/ml EMVERM CHEW 2 MAX fill,60 rtl day(s) supply,1 testosterone enanthate 1 mail MAX fill,60 soln im mail day(s) VOGELXO GEL (Use NF supply, testosterone) ivermectin tabs 1 VOGELXO PUMP GEL NF (Use testosterone) praziquantel tabs 1 PA ANORECTAL AND RELATED PRODUCTS - Rectal Drugs to Treat Pain, Swelling and Itching STROMECTOL TABS (Use NF ivermectin) Intrarectal Steroids Ambetter Formulary Updated December 1, 2020

10 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ANTI-INFECTIVE AGENTS - MISC. - Drugs to Carbapenems Treat Bacterial Infections ertapenem sodium solr 1 Anti-infective Agents - Misc. bacitracin solr 3 imipenem-cilastatin solr 1 INVANZ SOLR (Use FLAGYL TABS 500 MG NF NF (Use ) ertapenem sodium) meropenem solr 1 IMPAVIDO CAPS 3 PA; QL(3 ea daily) MERREM SOLR (Use NF metronidazole tabs or 250 1 meropenem) mg, 500 mg PRIMAXIN IV SOLR (Use NF NEBUPENT SOLR (Use 3 imipenem-cilastatin) isethionate) Chloramphenicols PENTAM 300 SOLR (Use 3 pentamidine isethionate) sodium 4 PA; SP succinate solr pentamidine isethionate 1 solr Cyclic Lipopeptides trimethoprim tabs 1 CUBICIN RF SOLR (Use NF daptomycin) vancomycin hcl solr iv 1000 1 CUBICIN SOLR (Use NF mg daptomycin) PA; AL(At least XIFAXAN TABS 3 DAPTOMYCIN SOLR 350 NF 12 yrs old) MG (Use daptomycin) Anti-infective Misc. - Combinations daptomycin solr 500 mg 1 BACTRIM DS TABS (Use sulfamethoxazole- NF Glycopeptides trimethoprim) FIRVANQ SOLR 2 QL(300 ml per BACTRIM TABS (Use fill retail) sulfamethoxazole- NF QL(4 ea trimethoprim) VANCOCIN CAPS (Use NF vancomycin hcl) daily,40 ea per sulfamethoxazole- 1 fill retail) trimethoprim soln QL(4 ea sulfamethoxazole- VANCOCIN HCL CAPS NF daily,40 ea per 1 (Use vancomycin hcl) trimethoprim susp fill retail) sulfamethoxazole- 1 QL(4 ea trimethoprim tabs vancomycin hcl caps or 1 daily,40 ea per 125 mg, 250 mg Antiprotozoal Agents fill retail) vancomycin hcl solr iv 10 ALINIA SUSR 2 gm, 500 mg, 1 gm, 1000 1 mg ALINIA TABS 2 VANCOMYCIN QL(300 ml per HYDROCHLORIDE SOLR 2 fill retail) susp 1 OR 250 MG/5ML MEPRON SUSP (Use NF Leprostatics atovaquone)

Ambetter Formulary Updated December 1, 2020

11 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits tabs or 100 mg, 1 Urinary Anti-infectives 25 mg fosfomycin tromethamine 1 Lincosamides pack CLEOCIN CAPS OR 75 FURADANTIN SUSP (Use NF MG, 150 MG, 300 MG (Use NF nitrofurantoin) hcl) HIPREX TABS (Use NF CLEOCIN PEDIATRIC methenamine hippurate) GRANULES SOLR (Use NF MACROBID CAPS (Use clindamycin palmitate nitrofurantoin monohyd NF hydrochloride) macro) CLEOCIN PHOSPHATE MACRODANTIN CAPS SOLN IJ 300 MG/2ML, 600 100 MG, 50 MG (Use NF MG/4ML, 900 MG/6ML, 9 NF nitrofurantoin macrocrystal) GM/60ML (Use clindamycin phosphate) methenamine hippurate 1 tabs clindamycin hcl caps 1 MONUROL PACK (Use 3 fosfomycin tromethamine) clindamycin palmitate 1 hydrochloride solr nitrofurantoin macrocrystal 1 caps 100 mg, 50 mg clindamycin phosphate 1 soln nitrofurantoin monohyd 1 macro caps LINCOCIN SOLN (Use NF lincomycin hcl) nitrofurantoin susp 1 lincomycin hcl soln 1 ANTIANGINAL AGENTS - Drugs to Treat Chest Pain Monobactams Antianginals-Other AZACTAM SOLR (Use NF aztreonam) RANEXA TB12 1000 MG NF QL(2 ea daily) (Use ranolazine) aztreonam solr 1 RANEXA TB12 500 MG 2 QL(3 ea daily) (Use ranolazine) CAYSTON SOLR 4 PA; QL(3 ml daily) ranolazine tb12 1000 mg 1 QL(2 ea daily) Oxazolidinones ranolazine tb12 500 mg 1 QL(3 ea daily) linezolid susr or 100 1 mg/5ml PA; QL(2 ea Nitrates linezolid tabs or 600 mg 1 daily) ISORDIL TITRADOSE PA TABS 5 MG (Use NF SIVEXTRO TABS OR 3 isosorbide dinitrate) isosorbide dinitrate tabs 30 ZYVOX SUSR OR 100 NF 1 MG/5ML (Use linezolid) mg, 10 mg, 20 mg, 5 mg isosorbide dinitrate tbcr 40 ZYVOX TABS OR 600 MG NF PA; QL(2 ea 1 (Use linezolid) daily) mg Polymyxins isosorbide mononitrate tabs 1 polymyxin b sulfate solr 1 isosorbide mononitrate 1 tb24 Ambetter Formulary Updated December 1, 2020

12 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NITRO-BID OINT 3 ATIVAN TABS OR 1 MG NF QL(4 ea daily) (Use lorazepam) NITRO-DUR PT24 0.1 chlordiazepoxide hcl caps 1 MG/HR, 0.2 MG/HR, 0.4 NF MG/HR, 0.6 MG/HR (Use clorazepate dipotassium 1 nitroglycerin) tabs nitroglycerin cpcr or 2.5 1 QL(4 ea daily) mg, 6.5 mg, 9 mg diazepam conc or 5 mg/ml 1 nitroglycerin pt24 td 0.1 diazepam soln or 5 mg/5ml 1 mg/hr, 0.2 mg/hr, 0.4 1 mg/hr, 0.6 mg/hr diazepam tabs or 10 mg, 2 1 QL(4 ea daily) mg, 5 mg NITROGLYCERIN SOLN 1 IV 5 MG/ML lorazepam conc or 2 mg/ml 1 nitroglycerin subl sl 0.3 mg, 1 0.4 mg, 0.6 mg lorazepam tabs or 0.5 mg, 1 QL(3 ea daily) 2 mg NITROSTAT SUBL (Use NF nitroglycerin) lorazepam tabs or 1 mg 1 QL(4 ea daily) ANTIANXIETY AGENTS - Drugs to Treat Anxiety oxazepam caps 30 mg, 10 1 mg, 15 mg Antianxiety Agents - Misc. TRANXENE T TABS (Use NF buspirone hcl tabs 10 mg, 1 clorazepate dipotassium) 30 mg, 15 mg, 7.5 mg VALIUM TABS (Use NF QL(4 ea daily) buspirone hcl tabs 5 mg 1 QL(6 ea daily) diazepam) XANAX TABS (Use QL(4 ea daily) hydroxyzine hcl soln im 50 1 NF mg/ml alprazolam) XANAX XR TB24 (Use hydroxyzine hcl syrp or 10 1 NF mg/5ml alprazolam) ANTIARRHYTHMICS - Drugs to treat abnormal hydroxyzine hcl tabs or 10 1 mg, 25 mg, 50 mg heart rhythms hydroxyzine pamoate caps 1 Antiarrhythmics Type I-A disopyramide phosphate 1 meprobamate tabs 1 caps NORPACE CAPS (Use VISTARIL CAPS (Use NF NF hydroxyzine pamoate) disopyramide phosphate) procainamide hcl soln 500 1 Benzodiazepines mg/ml alprazolam tabs 0.25 mg, 1 QL(4 ea daily) 0.5 mg, 1 mg, 2 mg quinidine sulfate tabs 1 alprazolam tb24 0.5 mg, 1 1 Antiarrhythmics Type I-B mg, 2 mg, 3 mg mexiletine hcl caps 250 1 alprazolam tbdp 0.25 mg, 1 mg, 150 mg, 200 mg 0.5 mg, 1 mg, 2 mg Antiarrhythmics Type I-C ATIVAN TABS OR 0.5 MG, NF QL(3 ea daily) 2 MG (Use lorazepam) flecainide acetate tabs 1

Ambetter Formulary Updated December 1, 2020

13 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits propafenone hcl cp12 1 SPIRIVA RESPIMAT 2 AERS propafenone hcl tabs 1 Leukotriene Modulators ACCOLATE TABS (Use QL(2 ea daily) RYTHMOL SR CP12 (Use NF NF propafenone hcl) ) montelukast sodium chew 1 QL(1 ea daily) Antiarrhythmics Type III 4 mg, 5 mg hcl soln iv 150 1 montelukast sodium pack 4 1 PA; QL(1 ea mg/3ml, 50 mg/ml mg daily) amiodarone hcl tabs or 100 1 montelukast sodium tabs 1 QL(1 ea daily) mg, 200 mg, 400 mg 10 mg CORDARONE TABS (Use NF SINGULAIR CHEW 4 MG, QL(1 ea daily) amiodarone hcl) 5 MG (Use montelukast NF dofetilide caps 1 sodium) SINGULAIR PACK 4 MG NF PA; QL(1 ea MULTAQ TABS 3 (Use montelukast sodium) daily) SINGULAIR TABS 10 MG NF QL(1 ea daily) TIKOSYN CAPS (Use NF (Use montelukast sodium) dofetilide) QL(2 ea daily) ANTIASTHMATIC AND BRONCHODILATOR zafirlukast tabs 1 AGENTS - Drugs to Treat Lung Conditions zileuton tb12 1 QL(4 ea daily) Anti-Inflammatory Agents ZYFLO CR TB12 (Use QL(4 ea daily) CROMOLYN SODIUM 1 QL(8 ml daily) NF NEBU zileuton) Selective Phosphodiesterase 4 (PDE4) Inhibitors cromolyn sodium nebu 1 QL(8 ml daily) QL(1 ea Antiasthmatic - Monoclonal Antibodies daily)30 rtl PA MAX day(s) FASENRA PEN SOAJ 4 supply,180 rtl DALIRESP TABS 250 3 MCG lmt day(s),30 FASENRA SOSY 4 PA mail MAX day(s) NUCALA SOLR 100 MG 4 PA supply,180 mail lmt day(s), PA; QL(0.214 XOLAIR SOLR 150 MG 4 ea daily); SP DALIRESP TABS 500 3 MCG XOLAIR SOSY 150 4 PA MG/ML, 75 MG/0.5ML Steroid Inhalants Bronchodilators - Anticholinergics ALVESCO AERS 3 PA ATROVENT HFA AERS 3 QL(0.44 gm daily) ARNUITY ELLIPTA AEPB 2 INCRUSE ELLIPTA AEPB 2 ASMANEX HFA AERO 100 2 MCG/ACT, 200 MCG/ACT ipratropium bromide soln 1 QL(15 ml daily) ASMANEX TWISTHALER 120 METERED DOSES 2 SPIRIVA HANDIHALER 2 QL(1 ea daily) AEPB CAPS

Ambetter Formulary Updated December 1, 2020

14 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ASMANEX TWISTHALER Limit 2 Inhalers 14 METERED DOSES 2 per month;1 rtl AEPB albuterol sulfate aers in 108 1 pack lmt per ASMANEX TWISTHALER mcg/act fill,2 rtl MAX 30 METERED DOSES 2 fill,30 rtl day(s) AEPB supply, ASMANEX TWISTHALER albuterol sulfate nebu in QL(15 ml daily) 60 METERED DOSES 2 0.083 %, 0.63 mg/3ml, 1.25 1 AEPB mg/3ml ASMANEX TWISTHALER albuterol sulfate nebu in 0.5 1 7 METERED DOSES 2 %, 2.5 mg/0.5ml AEPB albuterol sulfate syrp or 2 1 mg/5ml budesonide (inhalation) 1 PA; QL(4 ml susp daily) albuterol sulfate tabs or 2 1 mg, 4 mg FLOVENT DISKUS AEPB 2 albuterol sulfate tb12 or 4 1 FLOVENT HFA AERO 2 mg, 8 mg ANORO ELLIPTA AEPB 2 QL(2 ea daily) PULMICORT FLEXHALER 2 AEPB ARCAPTA NEOHALER 2 CAPS PULMICORT SUSP (Use NF PA; QL(4 ml budesonide (inhalation)) daily) BEVESPI AEROSPHERE 2 QL(0.36 gm QVAR REDIHALER AERB 2 AERO daily) BREO ELLIPTA AEPB 2 Sympathomimetics PA; QL(4 ml ADVAIR DISKUS AEPB BROVANA NEBU 3 (Use fluticasone- NF daily) salmeterol) budesonide-formoterol 1 fumarate dihydrate aero ADVAIR HFA AERO 2 epinephrine hcl soln 1 AIRDUO RESPICLICK 113/14 AEPB (Use NF fluticasone-salmeterol aepb fluticasone-salmeterol) 100 mcg/dose-50 AIRDUO RESPICLICK mcg/dose, 250 mcg/dose- 1 232/14 AEPB (Use NF 50 mcg/dose, 50 fluticasone-salmeterol) mcg/dose-500 mcg/dose AIRDUO RESPICLICK ipratropium-albuterol soln 1 QL(18 ml daily) 55/14 AEPB (Use NF fluticasone-salmeterol) levalbuterol hcl nebu 0.31 PA; QL(12 ml 1 2 rtl pack lmt mg/3ml, 0.63 mg/3ml, 1.25 daily) albuterol sulfate aers in 1 amt,30 rtl pack mg/3ml 108 mcg/act lmt day(s), levalbuterol hcl nebu 1.25 1 PA mg/0.5ml Limit 2 inhalers per month;1 rtl PA; Limit 2 inhalers per albuterol sulfate aers in 1 pack lmt per levalbuterol tartrate aero 3 108 mcg/act fill,2 rtl MAX month;QL(1 gm fill,30 rtl day(s) daily) supply, Ambetter Formulary Updated December 1, 2020

15 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits metaproterenol sulfate syrp 1 aminophylline soln 1 metaproterenol sulfate tabs 1 ELIXOPHYLLIN ELIX 1

Limit 2 inhalers theophylline soln 80 1 QL(56 ml daily) per month;1 rtl mg/15ml PROAIR HFA AERS (Use pack lmt per 2 theophylline tb12 100 mg, 1 albuterol sulfate) fill,2 rtl MAX 200 mg, 300 mg, 450 mg fill,30 rtl day(s) supply, theophylline tb24 400 mg, 1 600 mg Limit 2 inhalers per month;1 rtl ANTICOAGULANTS - Blood Thinners PROVENTIL HFA AERS 2 pack lmt per (Use albuterol sulfate) fill,2 rtl MAX Coumarin Anticoagulants fill,30 rtl day(s) COUMADIN TABS (Use 2 supply, warfarin sodium) SEREVENT DISKUS 2 AEPB warfarin sodium tabs 1 STRIVERDI RESPIMAT 2 Direct Factor Xa Inhibitors AERS QL(42 ea per SYMBICORT AERO (Use 3 42 days budesonide-formoterol 2 BEVYXXA CAPS retail,42 ea per fumarate dihydrate) 42 days mail) terbutaline sulfate soln 1 ELIQUIS STARTER PACK 2 QL(2.47 ea TBPK daily) terbutaline sulfate tabs 1 ELIQUIS TABS 2 QL(2.47 ea daily) TRELEGY ELLIPTA AEPB 100 MCG/INH-25 2 1 rtl MAX XARELTO STARTER 2 MCG/INH-62.5 MCG/INH PACK TBPK fill,365 rtl day(s) supply, UTIBRON NEOHALER 3 PA; QL(2 ea CAPS daily) XARELTO TABS 10 MG, 2 QL(1 ea daily) 20 MG Limit 2 inhalers per month;1 rtl XARELTO TABS 15 MG, 2 QL(2 ea daily) 2.5 MG VENTOLIN HFA AERS 2 pack lmt per (Use albuterol sulfate) fill,2 rtl MAX Heparins And Heparinoid-Like Agents fill,30 rtl day(s) QL(7.2 ml per supply, ARIXTRA SOLN 10 180 days XOPENEX PA MG/0.8ML (Use NF retail,7.2 ml per CONCENTRATE NEBU NF fondaparinux sodium) 180 days mail); (Use levalbuterol hcl) SP PA; Limit 2 QL(4.5 ml per XOPENEX HFA AERO 3 inhalers per ARIXTRA SOLN 2.5 180 days (Use levalbuterol tartrate) month;QL(1 gm MG/0.5ML (Use NF retail,4.5 ml per daily) fondaparinux sodium) 180 days mail); SP XOPENEX NEBU (Use NF PA; QL(12 ml levalbuterol hcl) daily) Xanthines

Ambetter Formulary Updated December 1, 2020

16 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(3.6 ml per FRAGMIN SOLN 10000 PA; SP ARIXTRA SOLN 5 180 days UNIT/ML, 12500 MG/0.4ML (Use NF retail,3.6 ml per UNIT/0.5ML, 15000 fondaparinux sodium) 180 days mail); UNIT/0.6ML, 18000 4 SP UNT/0.72ML, 2500 QL(5.4 ml per UNIT/0.2ML, 5000 ARIXTRA SOLN 7.5 180 days UNIT/0.2ML, 7500 MG/0.6ML (Use NF retail,5.4 ml per UNIT/0.3ML fondaparinux sodium) 180 days mail); HEPARIN LOCK FLUSH SP SOLN (Use heparin sodium NF (porcine) lock flush) enoxaparin sodium soln ij 4 QL(6 ml daily) 300 mg/3ml heparin sod (porcine) in 1 d5w soln 40 unit/ml-5 % enoxaparin sodium soln sc 4 QL(2 ml daily) 100 mg/ml, 150 mg/ml heparin sodium (porcine) soln 20000 unit/ml, 10000 1 enoxaparin sodium soln sc 4 QL(1.6 ml 120 mg/0.8ml, 80 mg/0.8ml daily) unit/ml, 5000 unit/ml HEPARIN SODIUM/NACL enoxaparin sodium soln sc 4 QL(0.6 ml 30 mg/0.3ml daily); SP 0.45% SOLN 0.45 %- 1 12500 UNIT/250ML QL(0.8 ml enoxaparin sodium soln sc 4 daily,30 day(s) HEPARIN 40 mg/0.4ml limit); SP SODIUM/SODIUM CHLORIDE 0.9% SOLN IV NF QL(1.2 ml 0.9 %-1000 UNIT/500ML enoxaparin sodium soln sc 4 daily,30 day(s) 60 mg/0.6ml (Use heparin (porcine) in limit); SP sodium chloride) QL(7.2 ml per LOVENOX SOLN IJ 300 QL(6 ml daily) 180 days fondaparinux sodium soln MG/3ML (Use enoxaparin NF 4 retail,7.2 ml per sodium) 10 mg/0.8ml 180 days mail); SP LOVENOX SOLN SC 100 QL(2 ml daily) MG/ML, 150 MG/ML (Use NF QL(4.5 ml per enoxaparin sodium) 180 days fondaparinux sodium soln 4 retail,4.5 ml per LOVENOX SOLN SC 120 QL(1.6 ml 2.5 mg/0.5ml 180 days mail); MG/0.8ML, 80 MG/0.8ML NF daily) SP (Use enoxaparin sodium) QL(3.6 ml per LOVENOX SOLN SC 30 QL(0.6 ml 180 days MG/0.3ML (Use enoxaparin NF daily); SP fondaparinux sodium soln 5 4 retail,3.6 ml per sodium) mg/0.4ml 180 days mail); LOVENOX SOLN SC 40 QL(0.8 ml SP MG/0.4ML (Use enoxaparin NF daily,30 day(s) QL(5.4 ml per sodium) limit); SP 180 days LOVENOX SOLN SC 60 QL(1.2 ml fondaparinux sodium soln 4 retail,5.4 ml per MG/0.6ML (Use enoxaparin NF daily,30 day(s) 7.5 mg/0.6ml 180 days mail); sodium) limit); SP SP Thrombin Inhibitors PRADAXA CAPS 3 QL(2 ea daily)

ANTICONVULSANTS - Drugs to Treat Seizures

Ambetter Formulary Updated December 1, 2020

17 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AMPA Glutamate Receptor Antagonists BRIVIACT TABS OR 10 PA 3 FYCOMPA TABS 10 MG, PA MG, 100 MG, 25 MG, 50 MG, 75 MG 12 MG, 2 MG, 4 MG, 6 MG, 3 8 MG chew 100 1 mg Anticonvulsants - Benzodiazepines carbamazepine cp12 100 PA; QL(16 ml 1 clobazam susp 2.5 mg/ml 1 mg daily) carbamazepine cp12 200 1 QL(6 ea daily) clobazam tabs 10 mg, 20 1 PA; QL(2 ea mg mg daily) carbamazepine cp12 300 1 QL(4 ea daily) clonazepam tabs 0.5 mg, 1 1 mg mg, 2 mg carbamazepine susp 100 1 DIASTAT ACUDIAL GEL mg/5ml (Use diazepam 3 (anticonvulsant)) carbamazepine tabs 200 1 mg DIASTAT PEDIATRIC GEL (Use diazepam 3 carbamazepine tb12 100 1 QL(4 ea daily) (anticonvulsant)) mg, 400 mg carbamazepine tb12 200 QL(6 ea daily) diazepam (anticonvulsant) 3 1 gel mg CARBATROL CP12 100 KLONOPIN TABS (Use NF NF clonazepam) MG (Use carbamazepine) PA; QL(10 ea CARBATROL CP12 200 NF QL(6 ea daily) NAYZILAM SOLN 3 per 30 days MG (Use carbamazepine) retail) CARBATROL CP12 300 NF QL(4 ea daily) ONFI SUSP 2.5 MG/ML PA; QL(16 ml MG (Use carbamazepine) NF PA; QL(12 ea (Use clobazam) daily) DIACOMIT CAPS 250 MG 4 ONFI TABS 10 MG, 20 MG PA; QL(2 ea daily) NF PA; QL(6 ea (Use clobazam) daily) DIACOMIT CAPS 500 MG 4 PA; QL(10 ea daily) PA; QL(12 ea VALTOCO LIQD 4 per 30 days DIACOMIT PACK 250 MG 4 retail) daily) PA; QL(6 ea PA; QL(10 ea DIACOMIT PACK 500 MG 4 VALTOCO LQPK 4 per 30 days daily) retail) EPIDIOLEX SOLN 3 PA Anticonvulsants - Misc. gabapentin caps 100 mg, 1 APTIOM TABS 3 ST; QL(2 ea 300 mg, 400 mg daily) gabapentin soln 250 1 QL(60 ml daily) BANZEL SUSP 40 MG/ML 2 PA; QL(80 ml mg/5ml, 300 mg/6ml (Use rufinamide) daily) gabapentin tabs 600 mg, 1 BANZEL TABS 200 MG 2 PA; QL(2 ea 800 mg daily) KEPPRA SOLN IV 500 QL(30 ml daily) PA; QL(8 ea BANZEL TABS 400 MG 2 MG/5ML (Use NF daily) levetiracetam) BRIVIACT SOLN OR 10 PA 3 KEPPRA SOLN OR 100 NF QL(30 ml daily) MG/ML MG/ML (Use levetiracetam)

Ambetter Formulary Updated December 1, 2020

18 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits KEPPRA TABS OR 1000 NF QL(3 ea daily) NEURONTIN CAPS 100 MG (Use levetiracetam) MG, 300 MG, 400 MG (Use NF KEPPRA TABS OR 250 QL(4 ea daily) gabapentin) MG, 750 MG (Use NF NEURONTIN SOLN 250 NF QL(60 ml daily) levetiracetam) MG/5ML (Use gabapentin) KEPPRA TABS OR 500 NF QL(6 ea daily) NEURONTIN TABS 600 MG (Use levetiracetam) MG, 800 MG (Use NF gabapentin) KEPPRA XR TB24 (Use NF QL(4 ea daily) levetiracetam) oxcarbazepine susp 300 1 QL(40 ml daily) LAMICTAL CHEWABLE mg/5ml, 60 mg/ml DISPERSIBLE CHEW (Use NF oxcarbazepine tabs 150 1 QL(3 ea daily) lamotrigine) mg, 300 mg LAMICTAL ODT TBDP 100 QL(1 ea daily) oxcarbazepine tabs 600 mg 1 QL(4 ea daily) MG, 200 MG, 25 MG, 50 NF MG (Use lamotrigine) pregabalin caps 100 mg, PA; QL(3 ea 150 mg, 200 mg, 25 mg, 50 1 daily) LAMICTAL TABS (Use NF lamotrigine) mg, 75 mg pregabalin caps 225 mg, PA; QL(2 ea lamotrigine chew 25 mg, 5 1 1 mg 300 mg daily) PA; QL(30 ml lamotrigine tabs 100 mg, 1 pregabalin soln 20 mg/ml 1 150 mg, 200 mg, 25 mg daily) lamotrigine tbdp 100 mg, 1 QL(1 ea daily) primidone tabs 1 200 mg, 25 mg, 50 mg QUDEXY XR CS24 (Use levetiracetam soln iv 500 1 QL(30 ml daily) NF mg/5ml topiramate) PA; QL(80 ml levetiracetam soln or 100 1 QL(30 ml daily) rufinamide susp 1 mg/ml, 500 mg/5ml daily) TEGRETOL SUSP (Use levetiracetam tabs or 1000 1 QL(3 ea daily) 2 mg carbamazepine) TEGRETOL TABS (Use levetiracetam tabs or 250 1 QL(4 ea daily) 2 mg, 750 mg carbamazepine) TEGRETOL-XR TB12 100 QL(4 ea daily) levetiracetam tabs or 500 1 QL(6 ea daily) mg MG, 400 MG (Use NF carbamazepine) levetiracetam tb24 or 500 1 QL(4 ea daily) mg, 750 mg TEGRETOL-XR TB12 200 NF QL(6 ea daily) MG (Use carbamazepine) LYRICA CAPS 100 MG, PA; QL(3 ea TOPAMAX SPRINKLE QL(6 ea daily) 150 MG, 200 MG, 25 MG, 2 daily) 50 MG, 75 MG (Use CPSP 15 MG (Use NF pregabalin) topiramate) TOPAMAX SPRINKLE QL(8 ea daily) LYRICA CAPS 225 MG, 2 PA; QL(2 ea 300 MG (Use pregabalin) daily) CPSP 25 MG (Use NF topiramate) LYRICA SOLN 20 MG/ML 2 PA; QL(30 ml (Use pregabalin) daily) TOPAMAX TABS 100 MG NF QL(4 ea daily) (Use topiramate) MYSOLINE TABS (Use NF primidone) TOPAMAX TABS 200 MG NF QL(2 ea daily) (Use topiramate)

Ambetter Formulary Updated December 1, 2020

19 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TOPAMAX TABS 25 MG, NF QL(6 ea daily) SABRIL PACK (Use NF PA; QL(6 ea 50 MG (Use topiramate) vigabatrin) daily); SP topiramate cpsp 15 mg 1 QL(6 ea daily) SABRIL TABS (Use 4 PA; QL(6 ea vigabatrin) daily); SP QL(8 ea daily) topiramate cpsp 25 mg 1 tiagabine hcl tabs 2 mg, 4 1 mg QL(4 ea daily) PA; QL(6 ea topiramate tabs 100 mg 1 vigabatrin pack 4 daily); SP QL(2 ea daily) topiramate tabs 200 mg 1 PA; QL(6 ea vigabatrin tabs 4 daily); SP topiramate tabs 25 mg, 50 1 QL(6 ea daily) mg Hydantoins TRILEPTAL SUSP 300 QL(40 ml daily) CEREBYX SOLN (Use NF MG/5ML (Use NF fosphenytoin sodium) oxcarbazepine) DILANTIN CAPS 100 MG TRILEPTAL TABS 150 QL(3 ea daily) (Use sodium 2 MG, 300 MG (Use NF extended) oxcarbazepine) DILANTIN CAPS 30 MG 2 TRILEPTAL TABS 600 MG NF QL(4 ea daily) (Use oxcarbazepine) DILANTIN INFATABS 2 CHEW (Use phenytoin) VIMPAT SOLN IV 200 3 QL(40 ml daily) MG/20ML DILANTIN-125 SUSP (Use 2 phenytoin) VIMPAT SOLN OR 10 3 PA; QL(40 ml MG/ML daily) fosphenytoin sodium soln 1 VIMPAT TABS OR 100 PA; QL(2 ea MG, 150 MG, 200 MG, 50 3 daily) PEGANONE TABS 3 MG PHENYTEK CAPS (Use ZONEGRAN CAPS (Use NF QL(6 ea daily) zonisamide) phenytoin sodium 2 extended) zonisamide caps 1 QL(6 ea daily) phenytoin chew 1 Carbamates phenytoin sodium extended 1 felbamate susp 600 1 QL(30 ml daily) caps mg/5ml phenytoin sodium soln 1 felbamate tabs 400 mg 1 QL(9 ea daily) phenytoin susp 1 felbamate tabs 600 mg 1 QL(6 ea daily) Succinimides FELBATOL SUSP 600 NF QL(30 ml daily) MG/5ML (Use felbamate) CELONTIN CAPS 3 QL(4 ea daily) FELBATOL TABS 400 MG NF QL(9 ea daily) QL(6 ea daily) (Use felbamate) ethosuximide caps 250 mg 1 FELBATOL TABS 600 MG QL(6 ea daily) NF ethosuximide soln 250 1 QL(30 ml daily) (Use felbamate) mg/5ml GABA Modulators ZARONTIN CAPS 250 MG 2 QL(6 ea daily) (Use ethosuximide) GABITRIL TABS 2 MG, 4 NF MG (Use tiagabine hcl) Ambetter Formulary Updated December 1, 2020

20 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ZARONTIN SOLN 250 QL(30 ml daily) REMERON TABS 30 MG NF QL(1.5 ea MG/5ML (Use NF (Use mirtazapine) daily) ethosuximide) Antidepressants - Misc. Valproic Acid bupropion hcl tabs 100 mg, 1 QL(3 ea daily) DEPACON SOLN (Use NF 75 mg sodium) bupropion hcl tb12 100 mg 1 QL(4 ea daily) DEPAKENE CAPS (Use NF valproic acid) bupropion hcl tb12 150 mg 1 QL(3 ea daily) DEPAKENE SOLN (Use NF valproate sodium) bupropion hcl tb12 200 mg 1 QL(2 ea daily) DEPAKOTE ER TB24 (Use NF divalproex sodium) bupropion hcl tb24 150 mg 1 QL(3 ea daily) DEPAKOTE TBEC (Use NF divalproex sodium) bupropion hcl tb24 300 mg 1 QL(1 ea daily) divalproex sodium tb24 250 1 FORFIVO XL TB24 (Use NF mg, 500 mg bupropion hcl) divalproex sodium tbec 125 1 mg, 250 mg, 500 mg maprotiline hcl tabs 1 valproate sodium soln 1 WELLBUTRIN SR TB12 QL(4 ea daily) 100 MG (Use bupropion NF valproic acid caps or 1 hcl) WELLBUTRIN SR TB12 QL(3 ea daily) ANTIDEPRESSANTS - Drugs to Treat 150 MG (Use bupropion NF Depression hcl) Alpha-2 Receptor Antagonists (Tetracyclics) WELLBUTRIN SR TB12 QL(2 ea daily) 200 MG (Use bupropion NF mirtazapine tabs 15 mg 1 QL(3 ea daily) hcl) QL(1.5 ea WELLBUTRIN XL TB24 QL(3 ea daily) mirtazapine tabs 30 mg 1 daily) 150 MG (Use bupropion NF hcl) mirtazapine tabs 7.5 mg, 1 QL(1 ea daily) 45 mg WELLBUTRIN XL TB24 QL(1 ea daily) 300 MG (Use bupropion NF mirtazapine tbdp 15 mg 1 QL(3 ea daily) hcl) QL(1.5 ea Monoamine Oxidase Inhibitors (MAOIs) mirtazapine tbdp 30 mg 1 daily) EMSAM PT24 3 QL(1 ea daily) mirtazapine tbdp 45 mg 1 MARPLAN TABS 2 QL(6 ea daily) REMERON SOLTAB TBDP NF QL(3 ea daily) 15 MG (Use mirtazapine) NARDIL TABS (Use NF phenelzine sulfate) REMERON SOLTAB TBDP NF QL(1.5 ea 30 MG (Use mirtazapine) daily) PARNATE TABS (Use NF tranylcypromine sulfate) REMERON SOLTAB TBDP NF 45 MG (Use mirtazapine) phenelzine sulfate tabs 1 REMERON TABS 15 MG NF QL(3 ea daily) (Use mirtazapine) tranylcypromine sulfate 1 tabs

Ambetter Formulary Updated December 1, 2020

21 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits N-Methyl-D-aspartic acid (NMDA) Receptor FLUOXETINE QL(1 ea daily) HYDROCHLORIDE TABS NF SPRAVATO 56MG DOSE 4 PA (Use fluoxetine hcl) SOPK fluvoxamine maleate tabs QL(3 ea daily) SPRAVATO 84MG DOSE PA 1 4 100 mg SOPK fluvoxamine maleate tabs 1 QL(2 ea daily) Selective Serotonin Reuptake Inhibitors (SSRIs) 25 mg, 50 mg CELEXA TABS 10 MG QL(4 ea daily) LEXAPRO TABS 10 MG NF QL(2 ea daily) (Use citalopram NF (Use escitalopram oxalate) hydrobromide) LEXAPRO TABS 20 MG NF QL(1 ea daily) CELEXA TABS 20 MG QL(2 ea daily) (Use escitalopram oxalate) (Use citalopram NF hydrobromide) LEXAPRO TABS 5 MG NF QL(4 ea daily) (Use escitalopram oxalate) CELEXA TABS 40 MG QL(1 ea daily) (Use citalopram NF paroxetine hcl tabs 10 mg 1 QL(6 ea daily) hydrobromide) paroxetine hcl tabs 20 mg 1 QL(3 ea daily) citalopram hydrobromide 1 QL(20 ml daily) soln 10 mg/5ml paroxetine hcl tabs 30 mg 1 QL(2 ea daily) citalopram hydrobromide 1 QL(4 ea daily) tabs 10 mg paroxetine hcl tabs 40 mg 1 QL(1 ea daily) citalopram hydrobromide 1 QL(2 ea daily) tabs 20 mg paroxetine hcl tb24 12.5 1 QL(1 ea daily) mg citalopram hydrobromide 1 QL(1 ea daily) tabs 40 mg paroxetine hcl tb24 37.5 1 QL(2 ea daily) mg, 25 mg escitalopram oxalate soln 5 1 QL(20 ml daily) mg/5ml PAXIL CR TB24 12.5 MG NF QL(1 ea daily) (Use paroxetine hcl) escitalopram oxalate tabs 1 QL(2 ea daily) 10 mg PAXIL CR TB24 37.5 MG, NF QL(2 ea daily) 25 MG (Use paroxetine hcl) escitalopram oxalate tabs 1 QL(1 ea daily) 20 mg PAXIL SUSP 10 MG/5ML 3 QL(30 ml daily) escitalopram oxalate tabs 5 1 QL(4 ea daily) mg PAXIL TABS 10 MG (Use NF QL(6 ea daily) paroxetine hcl) fluoxetine hcl caps 10 mg 1 QL(1 ea daily) PAXIL TABS 20 MG (Use NF QL(3 ea daily) paroxetine hcl) fluoxetine hcl caps 20 mg 1 QL(3 ea daily) PAXIL TABS 30 MG (Use NF QL(2 ea daily) fluoxetine hcl caps 40 mg 1 QL(2 ea daily) paroxetine hcl) PAXIL TABS 40 MG (Use NF QL(1 ea daily) fluoxetine hcl cpdr 90 mg 1 paroxetine hcl) PROZAC CAPS 10 MG NF QL(1 ea daily) fluoxetine hcl soln 20 1 QL(20 ml daily) (Use fluoxetine hcl) mg/5ml PROZAC CAPS 20 MG NF QL(3 ea daily) fluoxetine hcl tabs 10 mg, 1 QL(1 ea daily) (Use fluoxetine hcl) 60 mg PROZAC CAPS 40 MG NF QL(2 ea daily) fluoxetine hcl tabs 20 mg 1 QL(3 ea daily) (Use fluoxetine hcl) sertraline hcl conc 20 1 QL(10 ml daily) mg/ml Ambetter Formulary Updated December 1, 2020

22 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits sertraline hcl tabs 100 mg 1 QL(2 ea daily) PRISTIQ TB24 100 MG QL(4 ea daily) (Use desvenlafaxine NF succinate) sertraline hcl tabs 25 mg, 1 QL(4 ea daily) 50 mg PRISTIQ TB24 25 MG, 50 QL(1 ea daily) MG (Use desvenlafaxine NF ZOLOFT CONC 20 MG/ML NF QL(10 ml daily) (Use sertraline hcl) succinate) venlafaxine hcl cp24 150 QL(2 ea daily) ZOLOFT TABS 100 MG NF QL(2 ea daily) 1 (Use sertraline hcl) mg venlafaxine hcl cp24 37.5 QL(4 ea daily) ZOLOFT TABS 25 MG, 50 NF QL(4 ea daily) 1 MG (Use sertraline hcl) mg Serotonin Modulators venlafaxine hcl cp24 75 mg 1 QL(5 ea daily) hcl tabs 1 venlafaxine hcl tabs 100 QL(3 ea daily) mg, 25 mg, 37.5 mg, 50 1 trazodone hcl tabs 1 mg, 75 mg PA; QL(1 ea venlafaxine hcl tb24 150 QL(2 ea daily) TRINTELLIX TABS 3 1 daily) mg venlafaxine hcl tb24 225 ST; QL(1 ea VIIBRYD STARTER PACK 3 PA 1 KIT mg daily) venlafaxine hcl tb24 75 mg, QL(1 ea daily) VIIBRYD TABS 3 PA; QL(1 ea 1 daily) 37.5 mg Serotonin-Norepinephrine Reuptake Inhibitors Tricyclic Agents CYMBALTA CPEP (Use NF QL(2 ea daily) amitriptyline hcl tabs 1 duloxetine hcl) amoxapine tabs 3 desvenlafaxine succinate 1 QL(4 ea daily) tb24 100 mg ANAFRANIL CAPS (Use NF desvenlafaxine succinate 1 QL(1 ea daily) clomipramine hcl) tb24 25 mg, 50 mg clomipramine hcl caps 1 duloxetine hcl cpep or 20 1 QL(2 ea daily) mg, 30 mg, 60 mg desipramine hcl tabs 1 duloxetine hcl cpep or 40 1 mg doxepin hcl caps 1 EFFEXOR XR CP24 150 NF QL(2 ea daily) MG (Use venlafaxine hcl) doxepin hcl conc 1 EFFEXOR XR CP24 37.5 NF QL(4 ea daily) MG (Use venlafaxine hcl) imipramine hcl tabs 1 EFFEXOR XR CP24 75 NF QL(5 ea daily) MG (Use venlafaxine hcl) imipramine pamoate caps 1 PA FETZIMA CP24 3 NORPRAMIN TABS (Use NF desipramine hcl) FETZIMA TITRATION 3 PA PACK C4PK nortriptyline hcl caps 1 KHEDEZLA TB24 (Use NF desvenlafaxine) nortriptyline hcl soln 1 PAMELOR CAPS (Use NF nortriptyline hcl) Ambetter Formulary Updated December 1, 2020

23 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits protriptyline hcl tabs 1 JANUMET TABS 2

SURMONTIL CAPS (Use NF JANUMET XR TB24 2 trimipramine maleate) TOFRANIL TABS (Use NF JENTADUETO TABS 2 imipramine hcl) trimipramine maleate caps 1 JENTADUETO XR TB24 2 KAZANO TABS (Use NF ANTIDIABETICS - Drugs to Regulate Blood alogliptin- hcl) Sugar OSENI TABS (Use NF Alpha-Glucosidase Inhibitors alogliptin-pioglitazone) QL(3 ea daily) acarbose tabs 1 pioglitazone hcl-glimepiride 1 QL(1 ea daily) tabs GLYSET TABS (Use NF pioglitazone hcl-metformin 1 QL(2 ea daily) miglitol) hcl tabs miglitol tabs 1 repaglinide-metformin hcl 1 QL(2 ea daily) tabs PRECOSE TABS (Use NF QL(3 ea daily) acarbose) SEGLUROMET TABS 2 QL(2 ea daily)

Antidiabetic - Amylin Analogs SYNJARDY TABS 2 PA; QL(0.36 ml SYMLINPEN 120 SOPN 2 daily) SYNJARDY XR TB24 2 SYMLINPEN 60 SOPN 2 PA; QL(0.2 ml daily) XIGDUO XR TB24 10 MG- PA 1000 MG, 10 MG-500 MG, 3 Antidiabetic Combinations 1000 MG-5 MG, 5 MG-500 ACTOPLUS MET TABS QL(2 ea daily) MG (Use pioglitazone hcl- NF PA metformin hcl) XULTOPHY 100/3.6 SOPN 3 DUETACT TABS (Use QL(1 ea daily) Biguanides pioglitazone hcl- NF glimepiride) GLUCOPHAGE TABS QL(2.5 ea 1000 MG (Use metformin NF daily) glipizide-metformin hcl tabs QL(2 ea daily) hcl) 2.5 mg-250 mg, 2.5 mg- 1 500 mg GLUCOPHAGE TABS 500 NF QL(5 ea daily) MG (Use metformin hcl) glipizide-metformin hcl tabs 1 QL(4 ea daily) 5 mg-500 mg GLUCOPHAGE TABS 850 NF QL(3 ea daily) MG (Use metformin hcl) glyburide-metformin tabs 1 QL(2 ea daily) 1.25 mg-250 mg GLUCOPHAGE XR TB24 NF (Use metformin hcl) glyburide-metformin tabs QL(4 ea daily) 2.5 mg-500 mg, 5 mg-500 1 metformin hcl tabs 1000 1 QL(2.5 ea mg mg daily) QL(5 ea daily) GLYXAMBI TABS 3 PA metformin hcl tabs 500 mg 1 QL(3 ea daily) INVOKAMET TABS 3 PA metformin hcl tabs 850 mg 1

Ambetter Formulary Updated December 1, 2020

24 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits metformin hcl tb24 500 mg, PA; QL(0.3 ml 1 VICTOZA SOPN 2 750 mg daily) Diabetic Other Insulin Sensitizing Agents BAQSIMI ONE PACK 3 QL(0.069 ea ACTOS TABS (Use NF QL(1 ea daily) POWD daily) pioglitazone hcl) BAQSIMI TWO PACK 3 QL(0.069 ea AVANDIA TABS 3 QL(1 ea daily) POWD daily) QL(1 ea daily) diazoxide susp 1 pioglitazone hcl tabs 1

GLUCAGEN HYPOKIT 3 QL(0.035 ea Insulin SOLR daily) BASAGLAR KWIKPEN 2 GLUCAGON 3 QL(0.035 ea SOPN EMERGENCY KIT KIT daily) FIASP FLEXTOUCH 2 GVOKE PFS SOSY 3 QL(0.02 ml SOPN daily) FIASP PENFILL SOCT 2 PROGLYCEM SUSP (Use 3 diazoxide) FIASP SOLN 2 Dipeptidyl Peptidase-4 (DPP-4) Inhibitors HUMULIN R U-500 PA; QL(1 ea 3 alogliptin benzoate tabs 3 (CONCENTRATED) SOLN daily) HUMULIN R U-500 3 JANUVIA TABS 2 QL(1 ea daily) KWIKPEN SOPN LEVEMIR FLEXTOUCH NESINA TABS (Use 3 PA; QL(1 ea 2 alogliptin benzoate) daily) SOPN ONGLYZA TABS 3 PA; QL(1 ea LEVEMIR SOLN 2 daily) NOVOLIN 70/30 FLEXPEN 2 TRADJENTA TABS 2 QL(1 ea daily) RELION SUPN NOVOLIN 70/30 FLEXPEN 2 Dopamine Receptor Agonists - Antidiabetic SUPN QL(6 ea daily) CYCLOSET TABS 3 NOVOLIN 70/30 RELION 2 SUSP Incretin Mimetic Agents (GLP-1 Receptor NOVOLIN 70/30 SUSP 2 BYDUREON BCISE AUIJ 2 PA; QL(0.143 ml daily) NOVOLIN N RELION 2 SUSP BYDUREON PEN PEN 2 PA; QL(0.143 ea daily) NOVOLIN N SUSP 2 PA; QL(0.143 BYDUREON SRER 2 ea daily) NOVOLIN R RELION 2 PA; QL(0.08 ml SOLN BYETTA SOPN 2 daily) NOVOLIN R SOLN 2 TANZEUM PEN 3 PA NOVOLOG FLEXPEN 2 SOPN TRULICITY SOPN 2 PA; QL(0.143 ml daily) NOVOLOG MIX 70/30 PREFILLED FLEXPEN 2 SUPN Ambetter Formulary Updated December 1, 2020

25 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NOVOLOG MIX 70/30 2 glipizide tb24 10 mg, 2.5 1 QL(2 ea daily) SUSP mg, 5 mg NOVOLOG PENFILL 2 GLUCOTROL TABS (Use NF QL(4 ea daily) SOCT glipizide) NOVOLOG SOLN 2 GLUCOTROL XL TB24 NF QL(2 ea daily) (Use glipizide) TRESIBA FLEXTOUCH 3 PA QL(4 ea daily) SOPN glyburide micronized tabs 1 TRESIBA SOLN 3 PA glyburide tabs 1 QL(4 ea daily)

Meglitinide Analogues GLYNASE TABS (Use NF QL(4 ea daily) glyburide micronized) nateglinide tabs 1 QL(3 ea daily) tolazamide tabs 1 QL(4 ea daily) PRANDIN TABS 1 MG NF QL(4 ea daily) (Use repaglinide) tolbutamide tabs 1 QL(6 ea daily) PRANDIN TABS 2 MG NF QL(8 ea daily) (Use repaglinide) ANTIDIARRHEAL/PROBIOTIC AGENTS - Drugs to Treat Diarrhea repaglinide tabs 0.5 mg, 1 1 QL(4 ea daily) mg Antiperistaltic Agents QL(8 ea daily) repaglinide tabs 2 mg 1 diphenoxylate w/ atropine 1 liqd STARLIX TABS (Use QL(3 ea daily) NF diphenoxylate w/ atropine 1 nateglinide) tabs Sodium-Glucose Co-Transporter 2 (SGLT2) IMODIUM A-D CAPS (Use NF RX/OTC loperamide hcl) FARXIGA TABS 3 PA LOMOTIL TABS (Use NF diphenoxylate w/ atropine) INVOKANA TABS 3 PA; QL(1 ea daily) loperamide hcl caps 1 RX/OTC JARDIANCE TABS 2 MOTOFEN TABS 3 STEGLATRO TABS 2 ANTIDOTES AND SPECIFIC ANTAGONISTS Sulfonylureas Antidotes - Chelating Agents AMARYL TABS 1 MG, 2 NF QL(4 ea daily) MG (Use glimepiride) CHEMET CAPS 3 AMARYL TABS 4 MG (Use NF QL(2 ea daily) glimepiride) deferasirox pack 180 mg, 4 PA 360 mg, 90 mg chlorpropamide tabs 100 1 QL(3 ea daily) mg deferasirox tabs 360 mg, 4 PA; SP 90 mg, 180 mg glimepiride tabs 1 mg, 2 1 QL(4 ea daily) mg deferasirox tbso 125 mg, 4 PA; SP 250 mg, 500 mg glimepiride tabs 4 mg 1 QL(2 ea daily) deferiprone tabs 1 glipizide tabs 10 mg, 5 mg 1 QL(4 ea daily) EXJADE TBSO (Use 4 PA; SP deferasirox)

Ambetter Formulary Updated December 1, 2020

26 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FERRIPROX TABS 500 3 ondansetron tbdp 8 mg 1 MG (Use deferiprone) JADENU SPRINKLE PACK 4 PA palonosetron hcl soln 1 (Use deferasirox) ZOFRAN SOLN 4 MG/5ML QL(3.34 ml JADENU TABS (Use 4 PA; SP NF deferasirox) (Use ondansetron hcl) daily) QL(4 ea Antidotes and Specific Antagonists ZOFRAN TABS 4 MG (Use NF daily,60 ea per VISTOGARD PACK 4 PA ondansetron hcl) fill retail,60 ea per fill mail) Opioid Antagonists QL(3 ea ZOFRAN TABS 8 MG (Use daily,45 ea per naloxone hcl soln 0.4 1 NF mg/ml, 4 mg/10ml ondansetron hcl) fill retail,45 ea per fill mail) naltrexone hcl tabs 1 Antiemetics - Anticholinergic QL(2 ea per fill RX/OTC retail)2 rtl MAX hcl tabs 1 NARCAN LIQD 3 fill,30 rtl day(s) QL(0.34 ea scopolamine pt72 1 supply, daily) ANTIEMETICS - Drugs to Treat Nausea and TIGAN CAPS OR 300 MG Vomiting (Use trimethobenzamide NF 5-HT3 Receptor Antagonists hcl) TRANSDERM SCOP PT72 QL(0.34 ea ALOXI SOLN (Use NF 2 palonosetron hcl) (Use scopolamine) daily) TRANSDERM-SCOP PT72 QL(0.34 ea ANZEMET TABS 3 PA; QL(0.167 2 ea daily) (Use scopolamine) daily) trimethobenzamide hcl granisetron hcl soln iv 0.1 1 1 mg/ml, 1 mg/ml caps Antiemetics - Miscellaneous granisetron hcl tabs or 1 1 QL(0.34 ea mg daily) AKYNZEO CAPS OR 0.5 3 PA MG-300 MG ondansetron hcl soln ij 4 1 mg/2ml CESAMET CAPS 3 ondansetron hcl soln or 4 1 QL(3.34 ml mg/5ml daily) PA; QL(4 ea daily)3 rtl MAX ondansetron hcl tabs or 24 1 QL(0.143 ea mg daily) fill,365 rtl DICLEGIS TBEC (Use 3 doxylamine-pyridoxine) day(s) supply,3 QL(4 ea mail MAX ondansetron hcl tabs or 4 1 daily,60 ea per fill,365 mail mg fill retail,60 ea day(s) supply, per fill mail) PA; QL(4 ea QL(3 ea daily)3 rtl MAX ondansetron hcl tabs or 8 1 daily,45 ea per fill,365 rtl mg fill retail,45 ea doxylamine-pyridoxine tbec 1 day(s) supply,3 per fill mail) mail MAX ondansetron tbdp 4 mg 1 QL(1 ea daily) fill,365 mail day(s) supply,

Ambetter Formulary Updated December 1, 2020

27 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits dronabinol caps 1 microsize tabs 1 500 mg MARINOL CAPS (Use NF griseofulvin ultramicrosize 1 dronabinol) tabs Substance P/Neurokinin 1 (NK1) Receptor tabs 1 aprepitant caps 125 mg, 40 1 PA; QL(0.067 mg ea daily) hcl tabs 1 QL(1 ea daily) PA; QL(0.134 aprepitant caps 80 mg 1 ea daily) -Related EMEND CAPS OR 125 PA; QL(0.067 CRESEMBA CAPS OR 3 PA MG, 40 MG (Use NF ea daily) 186 MG aprepitant) DIFLUCAN SUSR (Use NF ) EMEND CAPS OR 80 MG NF PA; QL(0.134 (Use aprepitant) ea daily) DIFLUCAN TABS (Use NF EMEND SOLR IV 150 MG fluconazole) NF (Use fosaprepitant fluconazole susr 1 dimeglumine) VARUBI TBPK 3 PA fluconazole tabs 1 PA; QL(4 ea caps 100 mg 1 ANTIFUNGALS - Drugs to Treat Fungal Infections daily) PA; QL(20 ml - Glucan Synthesis Inhibitors itraconazole soln 10 mg/ml 1 daily) CANCIDAS SOLR (Use NF acetate) tabs 1 caspofungin acetate solr 50 1 mg, 70 mg NOXAFIL SUSP OR 40 3 QL(20 ml daily) MG/ML ERAXIS SOLR 3 SPORANOX CAPS 100 NF PA; QL(4 ea MG (Use itraconazole) daily) sodium solr 100 1 mg, 50 mg SPORANOX PULSEPAK NF PA; QL(4 ea CAPS (Use itraconazole) daily) MYCAMINE SOLR 3 SPORANOX SOLN 10 NF PA; QL(20 ml Antifungals MG/ML (Use itraconazole) daily) PA ABELCET SUSP 3 TOLSURA CAPS 4 VFEND TABS 200 MG, 50 NF QL(4 ea daily) AMBISOME SUSR 3 MG (Use ) voriconazole tabs or 200 1 QL(4 ea daily) solr 3 mg, 50 mg ANCOBON CAPS (Use NF ANTIHISTAMINES - Drugs to Treat Allergies ) flucytosine caps 1 Antihistamines - Alkylamines dexchlorpheniramine 1 griseofulvin microsize susp 1 AL(At least 2 maleate soln 125 mg/5ml yrs old) Antihistamines - Ethanolamines

Ambetter Formulary Updated December 1, 2020

28 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits carbinoxamine maleate 1 CLARITIN REDITABS soln 4 mg/5ml TBDP 10 MG (Use 1 ) carbinoxamine maleate 1 tabs 4 mg CLARITIN REDITABS 1 TBDP 5 MG clemastine fumarate tabs 1 CLARITIN SYRP (Use 1 loratadine) diphenhydramine hcl caps 1 or 50 mg CLARITIN TABS (Use 1 loratadine) diphenhydramine hcl elix or 1 RX/OTC 12.5 mg/5ml desloratadine tabs 5 mg 1 QL(1 ea daily) diphenhydramine hcl soln ij 1 50 mg/ml desloratadine tbdp 2.5 mg 1 QL(1 ea daily) Antihistamines - Non-Sedating fexofenadine hcl susp 30 1 QL(30 ml daily) ALLEGRA ALLERGY QL(30 ml daily) mg/5ml CHILDRENS SUSP 30 1 MG/5ML (Use fexofenadine fexofenadine hcl tabs 180 1 QL(1 ea daily) hcl) mg fexofenadine hcl tabs 60 QL(2 ea daily) ALLEGRA ALLERGY 1 QL(2 ea daily) 1 CHILDRENS TBDP 30 MG mg ALLEGRA ALLERGY QL(1 ea daily) levocetirizine QL(10 ml TABS 180 MG (Use 1 dihydrochloride soln 2.5 1 daily); RX/OTC fexofenadine hcl) mg/5ml ALLEGRA ALLERGY QL(2 ea daily) levocetirizine 1 QL(1 ea daily); TABS 60 MG (Use 1 dihydrochloride tabs 5 mg RX/OTC fexofenadine hcl) loratadine caps 1 cetirizine hcl caps 10 mg 1 QL(1 ea daily) loratadine chew 1 cetirizine hcl chew 5 mg, 1 QL(1 ea daily) 10 mg loratadine soln 1 cetirizine hcl soln 1 mg/ml, 1 QL(10 ml 5 mg/5ml daily); RX/OTC loratadine syrp 1 cetirizine hcl syrp 1 mg/ml, 1 QL(10 ml 5 mg/5ml daily); RX/OTC loratadine tabs 1 cetirizine hcl tabs 5 mg, 10 QL(1 ea daily) 1 loratadine tbdp 1 mg XYZAL ALLERGY 24HR QL(10 ml CLARINEX TABS 5 MG NF QL(1 ea daily) (Use desloratadine) CHILDRENS SOLN (Use NF daily); RX/OTC CLARITIN ALLERGY levocetirizine CHILDRENS SYRP (Use 1 dihydrochloride) loratadine) XYZAL ALLERGY 24HR QL(1 ea daily); TABS (Use levocetirizine NF RX/OTC CLARITIN CAPS (Use 1 loratadine) dihydrochloride) ZYRTEC ALLERGY CAPS QL(1 ea daily) CLARITIN CHEW (Use 1 1 loratadine) (Use cetirizine hcl) ZYRTEC ALLERGY TABS QL(1 ea daily) CLARITIN CHILDRENS 1 1 CHEW (Use loratadine) (Use cetirizine hcl)

Ambetter Formulary Updated December 1, 2020

29 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ZYRTEC CHILDRENS QL(10 ml colesevelam hcl tabs 625 1 QL(7 ea daily) ALLERGY SOLN (Use 1 daily); RX/OTC mg cetirizine hcl) COLESTID FLAVORED QL(6 gm daily) Antihistamines - Phenothiazines GRAN 5 GM (Use NF colestipol hcl) PHENERGAN SOLN (Use NF promethazine hcl) COLESTID FLAVORED QL(6 ea daily) PACK 5 GM/7.5GM (Use NF promethazine hcl soln 1 colestipol hcl) COLESTID GRAN 5 GM NF QL(6 gm daily) promethazine hcl supp 1 (Use colestipol hcl) COLESTID PACK 5 GM NF QL(6 ea daily) promethazine hcl syrp 1 (Use colestipol hcl) promethazine hcl tabs 1 COLESTID TABS 1 GM NF QL(16 ea daily) (Use colestipol hcl) Antihistamines - Piperidines colestipol hcl gran 5 gm 1 QL(6 gm daily) cyproheptadine hcl syrp 1 colestipol hcl pack 5 gm 1 QL(6 ea daily) cyproheptadine hcl tabs 1 colestipol hcl tabs 1 gm 1 QL(16 ea daily) ANTIHYPERLIPIDEMICS - Drugs to Treat High Cholesterol QUESTRAN LIGHT POWD NF QL(24 gm (Use cholestyramine light) daily) Antihyperlipidemics - Combinations QUESTRAN PACK 4 GM NF QL(6 ea daily) ezetimibe- tabs 1 QL(1 ea daily) (Use cholestyramine) QUESTRAN POWD 4 QL(25.2 gm VYTORIN TABS (Use NF QL(1 ea daily) GM/DOSE (Use NF daily) ezetimibe-simvastatin) cholestyramine) Antihyperlipidemics - Misc. WELCHOL PACK 3.75 GM NF PA; QL(1 ea (Use colesevelam hcl) daily) icosapent ethyl caps 1 PA WELCHOL TABS 625 MG NF QL(7 ea daily) (Use colesevelam hcl) LOVAZA CAPS (Use NF QL(4 ea daily) omega-3-acid ethyl esters) Fibric Acid Derivatives omega-3-acid ethyl esters QL(4 ea daily) 1 fenofibrate micronized caps 1 QL(1 ea daily) caps 134 mg, 200 mg, 67 mg VASCEPA CAPS 3 PA fenofibrate tabs 145 mg, 48 1 QL(1 ea daily) mg, 54 mg, 160 mg Sequestrants FIBRICOR TABS 105 MG, NF cholestyramine light pack 4 1 QL(6 ea daily) 35 MG (Use fenofibric acid) gm gemfibrozil tabs 1 QL(2 ea daily) cholestyramine light powd 1 QL(24 gm 4 gm/dose daily) LIPOFEN CAPS (Use NF cholestyramine pack 4 gm 1 QL(6 ea daily) fenofibrate) LOPID TABS (Use NF QL(2 ea daily) cholestyramine powd 4 1 QL(25.2 gm gemfibrozil) gm/dose daily) TRICOR TABS (Use NF QL(1 ea daily) colesevelam hcl pack 3.75 1 PA; QL(1 ea fenofibrate) gm daily) Ambetter Formulary Updated December 1, 2020

30 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits HMG CoA Reductase Inhibitors Nicotinic Acid Derivatives ADVICOR TB24 1000 MG- 3 PA; QL(2 ea niacin (antihyperlipidemic) QL(2 ea daily) 20 MG daily) tbcr 1000 mg, 500 mg, 750 1 mg ADVICOR TB24 1000 MG- 3 PA; QL(1 ea 40 MG daily) NIASPAN TBCR (Use NF QL(2 ea daily) ST; QL(1 ea niacin (antihyperlipidemic)) ALTOPREV TB24 3 daily) Proprotein Convertase Subtilisin/Kexin Type 9 QL(1 ea daily) atorvastatin calcium tabs 1 REPATHA SOSY 4 PA; QL(0.0714 ml daily) CRESTOR TABS (Use QL(1 ea daily) NF REPATHA SURECLICK 4 PA; QL(0.0714 rosuvastatin calcium) SOAJ ml daily) fluvastatin sodium caps 20 1 QL(1 ea daily) mg ANTIHYPERTENSIVES - Drugs to Treat High Blood Pressure fluvastatin sodium caps 40 1 QL(2 ea daily) mg ACE Inhibitors ACCUPRIL TABS (Use LIPITOR TABS (Use NF QL(1 ea daily) NF atorvastatin calcium) quinapril hcl) ALTACE CAPS (Use LIVALO TABS 3 ST; QL(1 ea NF daily) ramipril) $0 copay for benazepril hcl tabs 1 generic only, tabs 10 mg, 20 1 age 40 to captopril tabs 1 mg 76;QL(1 ea daily); PV enalapril maleate tabs 1 $0 copay for generic only, fosinopril sodium tabs 1 lovastatin tabs 40 mg 1 age 40 to 76;QL(2 ea lisinopril tabs 1 daily); PV LOTENSIN TABS (Use PRAVACHOL TABS (Use NF QL(1 ea daily) NF pravastatin sodium) benazepril hcl) pravastatin sodium tabs 1 QL(1 ea daily) moexipril hcl tabs 1 rosuvastatin calcium tabs 1 QL(1 ea daily) perindopril erbumine tabs 1 PRINIVIL TABS (Use SIMCOR TB24 2 PA; QL(1 ea NF daily) lisinopril) simvastatin tabs 80 mg, 10 1 QL(1 ea daily) quinapril hcl tabs 1 mg, 20 mg, 40 mg, 5 mg ramipril caps 1 ZOCOR TABS (Use NF QL(1 ea daily) simvastatin) Intestinal Cholesterol Absorption Inhibitors trandolapril tabs 1 ezetimibe tabs 1 QL(1 ea daily) VASOTEC TABS (Use NF enalapril maleate) ZETIA TABS (Use QL(1 ea daily) NF ZESTRIL TABS (Use NF ezetimibe) lisinopril)

Ambetter Formulary Updated December 1, 2020

31 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Agents for Pheochromocytoma clonidine hcl tabs 1 QL(8 ea daily) DIBENZYLINE CAPS (Use PA NF QL(0.15 ea phenoxybenzamine hcl) clonidine ptwk 3 daily) phenoxybenzamine hcl 3 PA caps doxazosin mesylate tabs 1 Angiotensin II Receptor Antagonists guanfacine hcl tabs 1 ATACAND TABS (Use NF QL(1 ea daily) candesartan cilexetil) methyldopa tabs 1 QL(6 ea daily) AVAPRO TABS (Use NF QL(1 ea daily) irbesartan) MINIPRESS CAPS (Use NF QL(4 ea daily) prazosin hcl) BENICAR TABS (Use NF QL(1 ea daily) olmesartan medoxomil) prazosin hcl caps 1 QL(4 ea daily) candesartan cilexetil tabs 1 QL(1 ea daily) terazosin hcl caps 1 COZAAR TABS (Use NF QL(1 ea daily) losartan potassium) Antihypertensive Combinations ACCURETIC TABS 10 QL(3 ea daily) DIOVAN TABS (Use NF QL(1 ea daily) valsartan) MG-12.5 MG (Use NF quinapril- EDARBI TABS 3 ST; QL(1 ea daily) hydrochlorothiazide) QL(1 ea daily) ACCURETIC TABS 12.5 QL(4 ea daily) eprosartan mesylate tabs 1 MG-20 MG (Use quinapril- NF hydrochlorothiazide) QL(1 ea daily) irbesartan tabs 1 ACCURETIC TABS 20 QL(2 ea daily) MG-25 MG (Use quinapril- NF losartan potassium tabs or 1 QL(1 ea daily) 100 mg, 25 mg, 50 mg hydrochlorothiazide) besylate- MICARDIS TABS (Use NF QL(1 ea daily) 1 ) benazepril hcl caps QL(1 ea daily) amlodipine besylate- 1 ST olmesartan medoxomil tabs 1 olmesartan medoxomil tabs QL(1 ea daily) amlodipine besylate- 1 telmisartan tabs 1 valsartan tabs QL(1 ea daily) valsartan tabs 1 amlodipine-valsartan- 1 hydrochlorothiazide tabs Antiadrenergic Antihypertensives ATACAND HCT TABS (Use candesartan cilexetil- NF CARDURA TABS (Use NF doxazosin mesylate) hydrochlorothiazide) atenolol & chlorthalidone CATAPRES TABS (Use NF QL(8 ea daily) 1 clonidine hcl) tabs AVALIDE TABS (Use CATAPRES-TTS-1 PTWK NF QL(0.15 ea (Use clonidine) daily) irbesartan- NF hydrochlorothiazide) CATAPRES-TTS-2 PTWK NF QL(0.15 ea (Use clonidine) daily) AZOR TABS (Use ST amlodipine besylate- NF CATAPRES-TTS-3 PTWK NF QL(0.15 ea olmesartan medoxomil) (Use clonidine) daily)

Ambetter Formulary Updated December 1, 2020

32 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits benazepril & 1 LOTENSIN HCT TABS hydrochlorothiazide tabs (Use benazepril & NF BENICAR HCT TABS (Use hydrochlorothiazide) olmesartan medoxomil- NF LOTREL CAPS (Use hydrochlorothiazide) amlodipine besylate- NF benazepril hcl) & 1 QL(2 ea daily) hydrochlorothiazide tabs metoprolol & 1 hydrochlorothiazide tabs candesartan cilexetil- 1 hydrochlorothiazide tabs MICARDIS HCT TABS CORZIDE TABS 40 MG-5 (Use telmisartan- NF MG (Use nadolol & NF hydrochlorothiazide) bendroflumethiazide) olmesartan medoxomil- ST DIOVAN HCT TABS (Use amlodipine- 1 valsartan- NF hydrochlorothiazide tabs hydrochlorothiazide) olmesartan medoxomil- 1 hydrochlorothiazide tabs enalapril maleate & 1 hydrochlorothiazide tabs quinapril- QL(3 ea daily) EXFORGE HCT TABS hydrochlorothiazide tabs 10 1 (Use amlodipine-valsartan- NF mg-12.5 mg hydrochlorothiazide) quinapril- QL(4 ea daily) EXFORGE TABS (Use hydrochlorothiazide tabs 1 amlodipine besylate- NF 12.5 mg-20 mg valsartan) quinapril- QL(2 ea daily) hydrochlorothiazide tabs 20 1 fosinopril sodium & 1 hydrochlorothiazide tabs mg-25 mg HYZAAR TABS 100 MG- QL(1 ea daily) TARKA TBCR (Use NF trandolapril-verapamil hcl) 12.5 MG, 100 MG-25 MG NF (Use losartan potassium & telmisartan-amlodipine tabs 1 hydrochlorothiazide) HYZAAR TABS 12.5 MG- QL(2 ea daily) telmisartan- 1 hydrochlorothiazide tabs 50 MG (Use losartan NF potassium & TENORETIC 100 TABS hydrochlorothiazide) (Use atenolol & NF chlorthalidone) irbesartan- 1 hydrochlorothiazide tabs TENORETIC 50 TABS (Use atenolol & NF lisinopril & 1 hydrochlorothiazide tabs chlorthalidone) LOPRESSOR HCT TABS trandolapril-verapamil hcl 1 (Use metoprolol & NF tbcr hydrochlorothiazide) TRIBENZOR TABS (Use ST losartan potassium & QL(1 ea daily) olmesartan medoxomil- NF amlodipine- hydrochlorothiazide tabs 1 100 mg-12.5 mg, 100 mg- hydrochlorothiazide) 25 mg TWYNSTA TABS (Use NF losartan potassium & QL(2 ea daily) telmisartan-amlodipine) hydrochlorothiazide tabs 1 valsartan- 1 12.5 mg-50 mg hydrochlorothiazide tabs

Ambetter Formulary Updated December 1, 2020

33 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VASERETIC TABS (Use Covered for enalapril maleate & NF malaria hydrochlorothiazide) treatment only. ZESTORETIC TABS (Use Limit 1 fill every lisinopril & NF 180 hydrochlorothiazide) days;QL(24 ea per fill retail,24 COARTEM TABS 2 ZIAC TABS (Use bisoprolol NF QL(2 ea daily) ea per fill & hydrochlorothiazide) mail)1 rtl MAX Antihypertensives - Misc. fill,180 rtl PA day(s) supply,1 VECAMYL TABS 3 mail MAX fill,180 mail Direct Renin Inhibitors day(s) supply, aliskiren fumarate tabs 1 QL(1 ea daily) Covered for malaria TEKTURNA TABS (Use 2 QL(1 ea daily) treatment only. aliskiren fumarate) Limit 1 fill every Selective Aldosterone Receptor Antagonists 180 days;QL(12 ea eplerenone tabs 1 MALARONE TABS (Use NF per fill retail,12 atovaquone-proguanil hcl) ea per fill INSPRA TABS (Use NF mail)1 rtl MAX eplerenone) fill,180 rtl Vasodilators day(s) supply,1 mail MAX hydralazine hcl soln 1 fill,180 mail day(s) supply, hydralazine hcl tabs 1 Antimalarials minoxidil tabs 1 chloroquine phosphate tabs 1 ANTIMALARIALS - Drugs to Treat Malaria DARAPRIM TABS 3 PA; QL(3 ea (Parasitic Infections) daily) Antimalarial Combinations hydroxychloroquine sulfate 1 Covered for tabs QL(2 ea per 30 malaria KRINTAFEL TABS 3 treatment only. days retail) Limit 1 fill every Covered for 180 malaria days;QL(12 ea treatment only. atovaquone-proguanil hcl 1 per fill retail,12 Limit 1 fill every tabs ea per fill 180 days;QL(5 mail)1 rtl MAX mefloquine hcl tabs 1 ea daily)1 rtl fill,180 rtl MAX fill,180 rtl day(s) supply,1 day(s) supply,1 mail MAX mail MAX fill,180 mail fill,180 mail day(s) supply, day(s) supply,

Ambetter Formulary Updated December 1, 2020

34 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PLAQUENIL TABS (Use NF Antimycobacterial Agents hydroxychloroquine sulfate) CAPASTAT SULFATE 3 primaquine phosphate tabs 3 SOLR QL(4 ea daily) PRIMAQUINE cycloserine caps 1 PHOSPHATE TABS (Use 3 primaquine phosphate) ethambutol hcl tabs 1 PA; QL(3 ea pyrimethamine tabs 1 daily) isoniazid soln ij 100 mg/ml 1 QUALAQUIN CAPS (Use NF PA; quinine sulfate) isoniazid syrp or 50 mg/5ml 1 quinine sulfate caps 1 PA; ISONIAZID TABS OR 100 1 MG ANTIMYASTHENIC/CHOLINERGIC AGENTS isoniazid tabs or 100 mg, 1 300 mg Antimyasthenic/Cholinergic Agents MYAMBUTOL TABS (Use NF ethambutol hcl) FIRDAPSE TABS 4 PA MYCOBUTIN CAPS (Use NF PA GUANIDINE HCL TABS 2 rifabutin) QL(3 ea daily) MESTINON SOLN 60 PASER PACK 3 MG/5ML (Use 2 pyridostigmine bromide) PRIFTIN TABS 3 MESTINON TABS 60 MG pyrazinamide tabs 1 (Use pyridostigmine NF bromide) rifabutin caps 1 PA MESTINON TIMESPAN TBCR (Use pyridostigmine NF RIFADIN CAPS (Use NF bromide) rifampin) NEOSTIGMINE PA RIFADIN SOLR (Use NF METHYLSULFATE SOSY 3 rifampin) 3 MG/3ML rifampin caps 1 pyridostigmine bromide 1 soln 60 mg/5ml rifampin solr 1 pyridostigmine bromide 1 tabs 60 mg SIRTURO TABS 100 MG 3 PA pyridostigmine bromide 1 tbcr 180 mg TRECATOR TABS 3 QL(4 ea daily) RUZURGI TABS 4 PA; QL(10 ea daily) ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES - Drugs to Treat Cancer ANTIMYCOBACTERIAL AGENTS - Drugs to Treat Tuberculosis (Bacterial Infections) Alkylating Agents ALKERAN SOLR (Use NF Anti TB Combinations melphalan hcl) RIFAMATE CAPS 3 ALKERAN TABS (Use NF melphalan) RIFATER TABS 3 QL(6 ea daily)

Ambetter Formulary Updated December 1, 2020

35 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BICNU SOLR (Use NF PA; SP TEPADINA SOLR 15 MG NF PA; SP carmustine) (Use thiotepa) busulfan soln 4 PA; SP thiotepa solr 15 mg 4 PA; SP

BUSULFEX SOLN (Use NF PA; SP TREANDA SOLR 4 PA; SP busulfan) PA; SP carboplatin soln 50 mg/5ml 4 PA; SP ZANOSAR SOLR 4 carmustine solr 4 PA; SP Antimetabolites ALIMTA SOLR 500 MG 4 PA; SP cisplatin soln 100 4 PA; SP mg/100ml ARRANON SOLN 4 PA; SP caps or 1 PA; SP 25 mg, 50 mg azacitidine susr 4 PA; SP cyclophosphamide solr ij 1 4 PA; SP gm, 2 gm, 500 mg capecitabine tabs 4 PA; SP GLEOSTINE CAPS 10 MG 4 PA; SP clofarabine soln 4 PA; SP GLEOSTINE CAPS 100 4 PA MG, 40 MG CLOLAR SOLN (Use NF PA; SP clofarabine) IFEX SOLR 1 GM (Use NF PA; SP ifosfamide) cytarabine soln 100 mg/ml, 4 PA; SP 20 mg/ml ifosfamide soln 1 gm/20ml 4 PA; SP DACOGEN SOLR (Use NF PA; SP decitabine) ifosfamide solr 1 gm 4 PA; SP decitabine solr 4 PA; SP LEUKERAN TABS 4 PA; SP floxuridine solr 4 PA; SP melphalan hcl solr 1 fludarabine phosphate soln 4 PA; SP melphalan tabs 1 fludarabine phosphate solr 4 PA; SP MUSTARGEN SOLR 4 PA; SP fluorouracil soln 500 4 PA; SP mg/10ml MYLERAN TABS 4 PA; SP FOLOTYN SOLN 20 4 PA; SP oxaliplatin soln 100 4 PA; SP MG/ML mg/20ml, 50 mg/10ml gemcitabine hcl solr 2 gm, 4 PA; SP TEMODAR CAPS OR 100 PA; SP 200 mg MG, 140 MG, 180 MG, 20 NF GEMCITABINE MG, 250 MG, 5 MG (Use HYDROCHLORIDE SOLN temozolomide) 1 GM/10ML, 2 GM/20ML, NF TEMODAR SOLR IV 100 4 PA; SP 200 MG/2ML (Use MG gemcitabine hcl) PA; SP temozolomide caps 4 GEMZAR SOLR 200 MG NF PA; SP (Use gemcitabine hcl) TEPADINA SOLR 100 MG NF (Use thiotepa) mercaptopurine tabs 1

Ambetter Formulary Updated December 1, 2020

36 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits methotrexate sodium soln ij Antineoplastic - Hedgehog Pathway Inhibitors 250 mg/10ml, 50 mg/2ml, 1 PA 50 mg/2ml DAURISMO TABS 4 methotrexate sodium solr ij SP 1 ERIVEDGE CAPS 4 PA; QL(1 ea 1 gm daily); SP methotrexate sodium tabs SP 1 ODOMZO CAPS 4 PA; QL(1 ea or 2.5 mg daily) PA; SP TABLOID TABS 4 Antineoplastic - Hormonal and Related Agents PA; QL(4 ea PA; SP abiraterone acetate tabs 4 TREXALL TABS 4 daily); SP QL(1 ea daily) VIDAZA SUSR (Use NF PA; SP anastrozole tabs 1 azacitidine) ARIMIDEX TABS (Use QL(1 ea daily) XELODA TABS (Use NF PA; SP NF capecitabine) anastrozole) AROMASIN TABS (Use NF QL(1 ea daily); Antineoplastic - Angiogenesis Inhibitors exemestane) SP AVASTIN SOLN 100 4 PA; SP PA; QL(1 ea MG/4ML bicalutamide tabs 4 daily); SP AVASTIN SOLN 400 4 PA CASODEX TABS (Use PA; QL(1 ea MG/16ML NF bicalutamide) daily); SP MVASI SOLN 4 PA ELIGARD KIT 22.5 MG 4 PA; SP ZALTRAP SOLN 100 PA; SP 4 PA; SP MG/4ML ELIGARD KIT 30 MG 4 PA ZIRABEV SOLN 4 ELIGARD KIT 45 MG 4 PA; SP Antineoplastic - Antibodies ELIGARD KIT 7.5 MG 4 PA; QL(0.0089 ea daily); SP ADCETRIS SOLR 4 PA; SP EMCYT CAPS 4 PA; SP ARZERRA CONC 4 PA; SP QL(1 ea daily); exemestane tabs 4 CAMPATH SOLN 4 PA SP FARESTON TABS (Use 2 ERBITUX SOLN 4 PA; SP toremifene citrate) FASLODEX SOLN (Use 4 PA; QL(0.357 HERCEPTIN SOLR 4 PA; SP fulvestrant) ml daily); SP PA; SP FEMARA TABS (Use NF PERJETA SOLN 4 letrozole) PA; SP FIRMAGON SOLR 4 PA; QL(0.143 RITUXAN SOLN 4 ea daily); SP PA; QL(6 ea RUXIENCE SOLN 4 PA flutamide caps 4 daily); SP VECTIBIX SOLN 100 PA; SP PA; QL(0.357 4 fulvestrant soln 4 MG/5ML ml daily); SP PA; SP YERVOY SOLN 4 letrozole tabs 1

Ambetter Formulary Updated December 1, 2020

37 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits leuprolide acetate kit 4 PA; SP XPOVIO 60 MG ONCE 4 PA WEEKLY TBPK LUPRON DEPOT (1- PA; QL(0.0357 4 XPOVIO 80 MG ONCE 4 PA MONTH) KIT ea daily); SP WEEKLY TBPK LUPRON DEPOT (3- PA; SP 4 XPOVIO 80 MG TWICE 4 PA MONTH) KIT WEEKLY TBPK LUPRON DEPOT (4- 4 PA; QL(0.1339 Antineoplastic MONTH) KIT ea daily); SP bleomycin sulfate solr 15 4 PA; SP LUPRON DEPOT (6- 4 PA; QL(0.0089 unit MONTH) KIT ea daily); SP COSMEGEN SOLR (Use NF PA; SP LYSODREN TABS 4 PA; SP dactinomycin) PA; SP megestrol acetate susp 1 dactinomycin solr 4 DAUNORUBICIN megestrol acetate tabs 1 HYDROCHLORIDE SOLN NF 20 MG/4ML (Use NILANDRON TABS (Use NF QL(2 ea daily) nilutamide) daunorubicin hcl) QL(2 ea daily) DOXIL INJ (Use NF PA; SP nilutamide tabs 1 doxorubicin hcl liposomal) PA doxorubicin hcl liposomal 4 PA; SP NUBEQA TABS 4 inj PA; SP tamoxifen citrate tabs 0 doxorubicin hcl soln 4 PA; SP toremifene citrate tabs 1 doxorubicin hcl solr 4 ELLENCE SOLN 50 PA; SP TRELSTAR MIXJECT 4 PA; SP SUSR MG/25ML (Use epirubicin NF PA; QL(4 ea hcl) XTANDI CAPS 4 daily); SP epirubicin hcl soln 50 4 PA; SP mg/25ml YONSA TABS 4 PA IDAMYCIN PFS SOLN 10 PA; SP MG/10ML, 5 MG/5ML (Use NF ZOLADEX IMPL 10.8 MG 4 PA; QL(0.0119 ea daily); SP idarubicin hcl) IDAMYCIN PFS SOLN 20 PA ZOLADEX IMPL 3.6 MG 4 PA; QL(0.0357 ea daily); SP MG/20ML (Use idarubicin NF hcl) ZYTIGA TABS 250 MG NF PA; QL(4 ea (Use abiraterone acetate) daily); SP idarubicin hcl soln 10 4 PA; SP PA; QL(2 ea mg/10ml, 5 mg/5ml ZYTIGA TABS 500 MG 4 daily) idarubicin hcl soln 20 4 PA mg/20ml Antineoplastic - Immunomodulators mitomycin solr iv 20 mg 4 PA; SP POMALYST CAPS 4 PA; QL(1 ea daily) hcl conc 4 PA; SP Antineoplastic - XPO1 Inhibitors PA; SP XPOVIO 100 MG ONCE 4 PA valrubicin soln 4 WEEKLY TBPK

Ambetter Formulary Updated December 1, 2020

38 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Use PA; SP VALSTAR SOLN ( 4 IMBRUVICA CAPS 70 MG 4 PA; QL(1 ea valrubicin) daily) Antineoplastic Enzyme Inhibitors IMBRUVICA TABS 140 PA; QL(1 ea 4 PA; QL(1 ea MG, 280 MG, 420 MG, 560 daily) AFINITOR TABS 10 MG 4 MG daily); SP AFINITOR TABS 2.5 MG, 5 PA; QL(1 ea 4 PA; QL(2 ea INLYTA TABS daily); SP MG, 7.5 MG (Use 4 daily); SP everolimus) INREBIC CAPS 4 PA PA; SL(1 ea AYVAKIT TABS 4 daily) ISTODAX (OVERFILL) 4 PA; SP SOLR BALVERSA TABS 4 PA JAKAFI TABS 10 MG, 20 4 PA; SP MG BORTEZOMIB SOLR 4 PA; JAKAFI TABS 15 MG, 25 4 PA; QL(2 ea MG, 5 MG daily); SP BOSULIF TABS 100 MG, 4 PA; QL(1 ea 500 MG daily); SP KYPROLIS SOLR 4 PA PA; BOSULIF TABS 400 MG 4 PA; QL(6 ea lapatinib ditosylate tabs 4 daily); SP BRAFTOVI CAPS 4 PA; SP LENVIMA 10 MG DAILY 4 PA; QL(1 ea DOSE CPPK daily) BRUKINSA CAPS 4 PA LENVIMA 12MG DAILY 4 PA; QL(3 ea CAPRELSA TABS 4 PA; QL(1 ea DOSE CPPK daily) daily); SP LENVIMA 14 MG DAILY 4 PA; QL(2 ea COMETRIQ KIT 4 PA; QL(2 ea DOSE CPPK daily) daily); SP LENVIMA 18 MG DAILY 4 PA; QL(3 ea COMETRIQ KIT 4 PA; QL(4 ea DOSE CPPK daily) daily); SP LENVIMA 20 MG DAILY 4 PA; QL(2 ea COMETRIQ KIT 4 PA; QL(3 ea DOSE CPPK daily) daily); SP LENVIMA 24 MG DAILY 4 PA; QL(3 ea COPIKTRA CAPS 4 PA DOSE CPPK daily) LENVIMA 4 MG DAILY PA; QL(1 ea PA; QL(1 ea 4 erlotinib hcl tabs 4 DOSE CPPK daily) daily); SP LENVIMA 8 MG DAILY PA; QL(2 ea PA; QL(1 ea 4 everolimus tabs 4 DOSE CPPK daily) daily); SP PA PA; QL(1 ea LORBRENA TABS 4 GILOTRIF TABS 4 daily) PA; QL(16 ea LYNPARZA TABS 4 GLEEVEC TABS (Use NF PA; QL(2 ea daily) imatinib mesylate) daily); SP PA; QL(3 ea MEKINIST TABS 0.5 MG 4 ICLUSIG TABS 15 MG, 45 4 PA daily) MG PA; QL(1 ea PA; QL(2 ea MEKINIST TABS 2 MG 4 imatinib mesylate tabs 4 daily) daily); SP MEKTOVI TABS 4 PA; SP IMBRUVICA CAPS 140 4 PA; QL(3 ea MG daily)

Ambetter Formulary Updated December 1, 2020

39 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; SP NEXAVAR TABS 4 PA; QL(4 ea VELCADE SOLR 4 daily); SP PA NINLARO CAPS 4 PA; QL(0.143 VITRAKVI CAPS 4 ea daily) PA PIQRAY 200MG DAILY 4 PA VITRAKVI SOLN 4 DOSE TBPK VIZIMPRO TABS 4 PA PIQRAY 250MG DAILY 4 PA DOSE TBPK PA; QL(4 ea VOTRIENT TABS 4 PIQRAY 300MG DAILY 4 PA daily); SP DOSE TBPK PA; QL(2 ea XALKORI CAPS 4 RETEVMO CAPS 4 PA daily); SP XOSPATA TABS 4 PA ROMIDEPSIN SOLR 10 4 PA; SP MG ZELBORAF TABS 4 PA; SP ROZLYTREK CAPS 4 PA PA; QL(4 ea ZOLINZA CAPS 4 SPRYCEL TABS 4 PA; QL(1 ea daily); SP daily); SP PA; QL(2 ea ZYDELIG TABS 4 STIVARGA TABS 4 PA; QL(4 ea daily) daily); SP PA; QL(5 ea ZYKADIA CAPS 4 SUTENT CAPS 12.5 MG, 4 PA; QL(1 ea daily) 25 MG, 50 MG daily); SP Antineoplastic Enzymes TABRECTA TABS 4 PA ERWINAZE SOLR 4 PA; SP PA; QL(4 ea TAFINLAR CAPS 4 daily) ONCASPAR SOLN 4 PA; SP PA TALZENNA CAPS 4 Antineoplastics Misc. PA; SP TARCEVA TABS (Use 4 PA; QL(1 ea ACTIMMUNE SOLN 4 erlotinib hcl) daily); SP trioxide soln 10 PA; SP TASIGNA CAPS 150 MG, 4 PA; QL(4 ea 4 200 MG daily); SP mg/10ml PA; SP TASIGNA CAPS 50 MG 4 PA; QL(4 ea bexarotene caps 4 daily) PA; SP TAZVERIK TABS 4 PA dacarbazine solr 200 mg 4 PA; QL(0.143 HYDREA CAPS (Use temsirolimus soln 4 NF ml daily); SP hydroxyurea) TIBSOVO TABS 4 PA hydroxyurea caps 1 PA; SP TORISEL SOLN (Use NF PA; QL(0.143 INTRON A SOLR 18 MU 4 temsirolimus) ml daily); SP MATULANE CAPS 4 PA; SP TURALIO CAPS 4 PA; AC NIPENT SOLR 4 PA; SP TYKERB TABS (Use 4 PA; QL(6 ea lapatinib ditosylate) daily); SP PHOTOFRIN SOLR 4 PA; SP

Ambetter Formulary Updated December 1, 2020

40 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PROLEUKIN SOLR 4 PA; SP conc 150 PA; SP mg/25ml, 100 mg/16.7ml, 6 4 SYLATRON KIT 4 PA; SP mg/ml TAXOTERE CONC 20 NF PA; SP SYNRIBO SOLR 4 PA; SP MG/ML (Use ) TAXOTERE CONC 80 NF TARGRETIN CAPS OR 75 NF PA; SP MG/4ML (Use docetaxel) MG (Use bexarotene) TENIPOSIDE SOLN 4 PA; SP tretinoin (chemotherapy) 1 caps vincristine sulfate soln 4 PA; SP Chemotherapy Adjuncts PA; SP vinorelbine tartrate soln 10 4 PA; SP KEPIVANCE SOLR 4 mg/ml Chemotherapy Rescue/Antidote Agents Topoisomerase I Inhibitors leucovorin calcium solr ij CAMPTOSAR SOLN 40 PA; SP 100 mg, 200 mg, 350 mg, 1 MG/2ML, 100 MG/5ML NF 50 mg, 500 mg (Use irinotecan hcl) HYCAMTIN CAPS OR 0.25 PA; SP leucovorin calcium tabs or 1 4 25 mg, 5 mg, 10 mg, 15 mg MG, 1 MG PA; SP HYCAMTIN SOLR IV 4 MG NF PA; SP VORAXAZE SOLR 4 (Use topotecan hcl) Mitotic Inhibitors irinotecan hcl soln 40 4 PA; SP mg/2ml, 100 mg/5ml ABRAXANE SUSR 4 PA; SP topotecan hcl solr 4 mg 4 PA; SP docetaxel conc 20 mg/ml 4 PA; SP ANTIPARKINSON AND RELATED THERAPY DOCETAXEL SOLN 20 4 PA; SP AGENTS - Drugs to Treat Parkinson's Disease MG/2ML Antiparkinson Adjunctive Therapy docetaxel soln 20 mg/2ml 4 PA; SP carbidopa tabs 1 DOCETAXEL SOLN 20 4 PA; SP MG/2ML (Use docetaxel) LODOSYN TABS (Use NF carbidopa) PA; SP ETOPOPHOS SOLR 4 Antiparkinson Anticholinergics etoposide caps 4 PA; SP benztropine mesylate soln 1 etoposide soln 4 PA; SP benztropine mesylate tabs 1

HALAVEN SOLN 4 PA; SP COGENTIN SOLN (Use NF benztropine mesylate) IXEMPRA KIT SOLR 15 4 PA; SP MG trihexyphenidyl hcl soln 1 JEVTANA SOLN 4 PA; SP trihexyphenidyl hcl tabs 1 NAVELBINE SOLN 10 PA; SP Antiparkinson COMT Inhibitors MG/ML (Use vinorelbine NF COMTAN TABS (Use NF QL(8 ea daily) tartrate) entacapone) Ambetter Formulary Updated December 1, 2020

41 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits entacapone tabs 1 QL(8 ea daily) REQUIP TABS (Use NF ropinirole hydrochloride) TASMAR TABS (Use NF REQUIP XL TB24 12 MG, ST; QL(2 ea tolcapone) 8 MG (Use ropinirole NF daily) tolcapone tabs 1 hydrochloride) REQUIP XL TB24 2 MG, 4 ST; QL(1 ea Antiparkinson Dopaminergics MG, 6 MG (Use ropinirole NF daily) hydrochloride) amantadine hcl caps 1 ropinirole hydrochloride tabs 0.25 mg, 3 mg, 0.5 1 amantadine hcl syrp 1 mg, 1 mg, 2 mg, 4 mg, 5 mg amantadine hcl tabs 1 ropinirole hydrochloride 1 ST; QL(2 ea tb24 12 mg, 8 mg daily) APOKYN SOCT 4 PA; ropinirole hydrochloride 1 ST; QL(1 ea bromocriptine mesylate 1 tb24 2 mg, 4 mg, 6 mg daily) caps SINEMET CR TBCR (Use NF bromocriptine mesylate 1 carbidopa-levodopa) tabs SINEMET TABS (Use NF carbidopa-levodopa tabs 1 carbidopa-levodopa) STALEVO 100 TABS (Use carbidopa-levodopa tbcr 1 carbidopa-levodopa- 1 entacapone) carbidopa-levodopa tbdp 1 STALEVO 100 TABS (Use carbidopa-levodopa- NF carbidopa-levodopa- 1 entacapone) entacapone tabs STALEVO 125 TABS (Use MIRAPEX TABS 0.125 MG QL(4 ea daily) carbidopa-levodopa- 1 (Use pramipexole NF entacapone) dihydrochloride) STALEVO 150 TABS (Use MIRAPEX TABS 0.25 MG, carbidopa-levodopa- 1 0.5 MG, 0.75 MG, 1 MG, NF entacapone) 1.5 MG (Use pramipexole dihydrochloride) STALEVO 200 TABS (Use carbidopa-levodopa- 1 NEUPRO PT24 2 entacapone) STALEVO 50 TABS (Use PARLODEL CAPS (Use NF bromocriptine mesylate) carbidopa-levodopa- 1 entacapone) PARLODEL TABS (Use NF bromocriptine mesylate) STALEVO 75 TABS (Use carbidopa-levodopa- 1 pramipexole QL(4 ea daily) entacapone) dihydrochloride tabs 0.125 1 mg Antiparkinson Monoamine Oxidase Inhibitors pramipexole AZILECT TABS (Use NF PA; QL(1 ea rasagiline mesylate) daily) dihydrochloride tabs 0.25 1 mg, 0.5 mg, 0.75 mg, 1 mg, PA; QL(1 ea rasagiline mesylate tabs 1 1.5 mg daily)

Ambetter Formulary Updated December 1, 2020

42 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits selegiline hcl caps 1 PERSERIS PRSY 2 PA; QL(0.072 ea daily) selegiline hcl tabs 1 RISPERDAL CONSTA 2 PA; QL(0.072 SRER ea daily) ANTIPSYCHOTICS/ANTIMANIC AGENTS - RISPERDAL SOLN 1 NF QL(8 ml daily) Drugs to Treat Mood Disorders MG/ML (Use risperidone) Antimanic Agents RISPERDAL TABS 0.25 QL(4 ea daily) MG, 0.5 MG, 1 MG, 2 MG, NF lithium carbonate caps 1 3 MG, 4 MG (Use risperidone) lithium carbonate tabs 1 risperidone soln 1 mg/ml 1 QL(8 ml daily) lithium carbonate tbcr 1 risperidone tabs 0.25 mg, QL(4 ea daily) 0.5 mg, 1 mg, 2 mg, 3 mg, 1 LITHIUM SOLN 1 4 mg risperidone tbdp 0.25 mg, 3 QL(2 ea daily) LITHOBID TBCR (Use NF lithium carbonate) mg, 4 mg, 0.5 mg, 1 mg, 2 1 mg Antipsychotics - Misc. Butyrophenones EQUETRO CP12 100 MG 3 ST; QL(2 ea daily) HALDOL DECANOATE QL(0.036 ml 100 SOLN (Use haloperidol NF daily) EQUETRO CP12 200 MG 3 ST; QL(8 ea daily) decanoate) ST; QL(4 ea HALDOL DECANOATE 50 QL(0.036 ml EQUETRO CP12 300 MG 3 daily) SOLN (Use haloperidol NF daily) decanoate) GEODON CAPS OR 20 QL(2 ea daily); MG, 40 MG, 60 MG, 80 MG NF AL(At least 18 HALDOL SOLN (Use NF (Use ziprasidone hcl) yrs old) haloperidol lactate) QL(0.036 ml LATUDA TABS 3 PA; QL(1 ea haloperidol decanoate soln 1 daily) daily) QL(2 ea daily); haloperidol lactate conc 1 ziprasidone hcl caps 1 AL(At least 18 yrs old) haloperidol lactate soln 1 Benzisoxazoles haloperidol tabs 1 PA; QL(2 ea FANAPT TABS 2 daily) Dibenzapines FANAPT TITRATION 2 PA PACK TABS clozapine tabs 1 INVEGA TB24 1.5 MG, 3 QL(1 ea daily) MG, 9 MG (Use NF clozapine tbdp 1 paliperidone) CLOZARIL TABS (Use NF clozapine) INVEGA TB24 6 MG (Use NF QL(2 ea daily) paliperidone) FAZACLO TBDP 100 MG, 12.5 MG, 25 MG (Use NF paliperidone tb24 1.5 mg, 3 1 QL(1 ea daily) mg, 9 mg clozapine) paliperidone tb24 6 mg 1 QL(2 ea daily) FAZACLO TBDP 200 MG, 1 150 MG (Use clozapine)

Ambetter Formulary Updated December 1, 2020

43 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits loxapine succinate caps 1 Phenothiazines hcl soln ij QL(0.215 ea 3 olanzapine solr im 10 mg 1 25 mg/ml, 50 mg/2ml daily) chlorpromazine hcl tabs or olanzapine tabs or 10 mg, 1 QL(2 ea daily) 10 mg, 200 mg, 25 mg, 100 1 15 mg, 20 mg, 7.5 mg mg, 50 mg olanzapine tabs or 2.5 mg, QL(4 ea daily) 1 fluphenazine hcl conc or 5 1 5 mg mg/ml olanzapine tbdp or 10 mg, 1 fluphenazine hcl elix or 2.5 1 15 mg, 20 mg, 5 mg mg/5ml quetiapine fumarate tabs QL(4 ea daily); fluphenazine hcl soln ij 2.5 1 100 mg, 200 mg, 25 mg, 50 1 AL(At least 10 mg/ml mg yrs old) fluphenazine hcl tabs or 1 1 QL(2 ea daily); mg, 10 mg, 2.5 mg, 5 mg quetiapine fumarate tabs 1 AL(At least 10 300 mg, 400 mg yrs old) perphenazine tabs 1 PA; QL(1 ea quetiapine fumarate tb24 1 prochlorperazine maleate 150 mg, 200 mg, 50 mg daily) 1 tabs quetiapine fumarate tb24 1 PA; QL(2 ea 300 mg, 400 mg daily) prochlorperazine supp 1 SAPHRIS SUBL 10 MG, 5 2 PA; QL(2 ea MG daily) thioridazine hcl tabs 1 PA SAPHRIS SUBL 2.5 MG 2 trifluoperazine hcl tabs 1 SEROQUEL TABS 100 QL(4 ea daily); Quinolinone Derivatives MG, 200 MG, 25 MG, 50 NF AL(At least 10 MG (Use quetiapine yrs old) QL(1 ea daily); ABILIFY TABS (Use NF fumarate) aripiprazole) AL(At least 6 yrs old) SEROQUEL TABS 300 QL(2 ea daily); MG, 400 MG (Use NF AL(At least 10 QL(30 ml quetiapine fumarate) yrs old) aripiprazole soln 1 mg/ml 3 daily); AL(At least 6 yrs old) SEROQUEL XR TB24 150 PA; QL(1 ea MG, 200 MG, 50 MG (Use NF daily) aripiprazole tabs 10 mg, 15 QL(1 ea daily); quetiapine fumarate) mg, 2 mg, 20 mg, 30 mg, 5 1 AL(At least 6 mg yrs old) SEROQUEL XR TB24 300 PA; QL(2 ea MG, 400 MG (Use NF daily) REXULTI TABS 3 PA quetiapine fumarate) Thioxanthenes ZYPREXA SOLR IM 10 NF QL(0.215 ea MG (Use olanzapine) daily) thiothixene caps 1 ZYPREXA TABS OR 10 QL(2 ea daily) MG, 15 MG, 20 MG, 7.5 NF ANTIVIRALS - Drugs to Treat Viral Infections MG (Use olanzapine) ZYPREXA TABS OR 2.5 QL(4 ea daily) Antiretrovirals MG, 5 MG (Use NF abacavir sulfate soln 20 1 olanzapine) mg/ml ZYPREXA ZYDIS TBDP NF abacavir sulfate tabs 300 1 QL(2 ea daily) (Use olanzapine) mg

Ambetter Formulary Updated December 1, 2020

44 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits abacavir sulfate-lamivudine 1 QL(1 ea daily) -emtricitabine- ST; QL(1 ea tabs tenofovir disoproxil 1 daily) fumarate tabs abacavir sulfate- 1 QL(2 ea daily) lamivudine-zidovudine tabs efavirenz-lamivudine- QL(1 ea daily) QL(4 ea daily) tenofovir disoproxil 1 APTIVUS CAPS 250 MG 2 fumarate tabs QL(1 ea daily) APTIVUS SOLN 100 2 QL(10 ml daily) emtricitabine caps 1 MG/ML atazanavir sulfate caps 150 QL(2 ea daily) QL(1 ea 1 emtricitabine-tenofovir 1 daily,30 day(s) mg, 200 mg disoproxil fumarate tabs limit) atazanavir sulfate caps 300 1 QL(1 ea daily) mg EMTRIVA CAPS 200 MG 2 QL(1 ea daily) (Use emtricitabine) ATRIPLA TABS (Use ST; QL(1 ea EMTRIVA SOLN 10 efavirenz-emtricitabine- 3 daily) 2 tenofovir disoproxil MG/ML fumarate) EPIVIR SOLN 10 MG/ML NF QL(30 ml daily) (Use lamivudine) BIKTARVY TABS 3 QL(1 ea daily) EPIVIR TABS 150 MG NF QL(2 ea daily) CIMDUO TABS 2 QL(1 ea daily) (Use lamivudine) EPIVIR TABS 300 MG NF QL(1 ea daily) COMBIVIR TABS (Use NF QL(2 ea daily) (Use lamivudine) lamivudine-zidovudine) EPZICOM TABS (Use QL(1 ea daily) ST; QL(1 ea COMPLERA TABS 3 abacavir sulfate- NF daily) lamivudine) QL(9 ea daily) CRIXIVAN CAPS 200 MG 2 fosamprenavir calcium tabs 1 QL(4 ea daily) QL(6 ea daily) CRIXIVAN CAPS 400 MG 2 FUZEON SOLR 4 PA; SP ST; QL(1 ea DELSTRIGO TABS 3 3 QL(1 ea daily) daily) GENVOYA TABS DESCOVY TABS 2 QL(1 ea daily) INTELENCE TABS 100 2 QL(4 ea daily) MG QL(2 ea daily) didanosine cpdr 200 mg 1 INTELENCE TABS 200 2 QL(2 ea daily) MG didanosine cpdr 250 mg, 1 QL(1 ea daily) QL(8 ea daily) 400 mg INTELENCE TABS 25 MG 2 DOVATO TABS 2 INVIRASE CAPS 200 MG 2 QL(10 ea daily) QL(1 ea daily) EDURANT TABS 2 INVIRASE TABS 500 MG 2 QL(4 ea daily) QL(2 ea daily) efavirenz caps 200 mg 1 ISENTRESS CHEW 100 2 MG, 25 MG QL(3 ea daily) efavirenz caps 50 mg 1 ISENTRESS HD TABS 2 QL(2 ea daily) QL(1 ea daily) efavirenz tabs 600 mg 1 ISENTRESS TABS 400 2 QL(2 ea daily) MG JULUCA TABS 3 QL(1 ea daily)

Ambetter Formulary Updated December 1, 2020

45 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits KALETRA SOLN 100 QL(12.5 ml RESCRIPTOR TABS 2 QL(6 ea daily) MG/5ML-400 MG/5ML NF daily) (Use lopinavir-) RETROVIR CAPS 100 MG NF QL(6 ea daily) (Use zidovudine) KALETRA TABS 100 MG- 2 QL(4 ea daily) 25 MG, 200 MG-50 MG RETROVIR IV INFUSION 1 SOLN lamivudine soln 10 mg/ml 1 QL(30 ml daily) RETROVIR SYRP 50 NF QL(60 ml daily) lamivudine tabs 150 mg 1 QL(2 ea daily) MG/5ML (Use zidovudine) REYATAZ CAPS 150 MG, QL(2 ea daily) lamivudine tabs 300 mg 1 QL(1 ea daily) 200 MG (Use atazanavir NF sulfate) QL(2 ea daily) lamivudine-zidovudine tabs 1 REYATAZ CAPS 300 MG NF QL(1 ea daily) (Use atazanavir sulfate) LEXIVA SUSP 50 MG/ML 2 QL(56 ml daily) ritonavir tabs 1 QL(12 ea daily) LEXIVA TABS 700 MG QL(4 ea daily) (Use fosamprenavir NF SELZENTRY SOLN 20 2 QL(30 ml daily) calcium) MG/ML QL(12.5 ml SELZENTRY TABS 150 QL(2 ea daily) lopinavir-ritonavir soln 1 2 daily) MG, 25 MG, 75 MG QL(40 ml daily) SELZENTRY TABS 300 2 QL(4 ea daily) susp 50 mg/5ml 1 MG QL(2 ea daily) nevirapine tabs 200 mg 1 QL(2 ea daily) stavudine caps 1 QL(1 ea daily) nevirapine tb24 100 mg 1 QL(3 ea daily) STRIBILD TABS 3 QL(1 ea daily) SUSTIVA CAPS 200 MG NF QL(2 ea daily) nevirapine tb24 400 mg 1 (Use efavirenz) QL(12 ea SUSTIVA CAPS 50 MG NF QL(3 ea daily) (Use efavirenz) 2 daily)30 rtl lmt NORVIR PACK 100 MG day(s),30 mail SUSTIVA TABS 600 MG NF QL(1 ea daily) lmt day(s), (Use efavirenz) NORVIR SOLN 80 MG/ML 2 QL(15 ml daily) SYMFI LO TABS (Use QL(1 ea daily) efavirenz-lamivudine- 2 NORVIR TABS 100 MG NF QL(12 ea daily) tenofovir disoproxil (Use ritonavir) fumarate) ODEFSEY TABS 3 ST; QL(1 ea SYMFI TABS (Use QL(1 ea daily) daily) efavirenz-lamivudine- 2 tenofovir disoproxil PIFELTRO TABS 2 fumarate) QL(1 ea daily) PREZCOBIX TABS 2 SYMTUZA TABS 3 ST; QL(1 ea daily) PREZISTA SUSP 100 2 QL(12 ml daily) QL(1 ea daily) MG/ML TEMIXYS TABS 2 PREZISTA TABS 150 MG, QL(2 ea daily) 2 tenofovir disoproxil 1 600 MG, 75 MG fumarate tabs PREZISTA TABS 800 MG 2 QL(1 ea daily) TIVICAY TABS 3

Ambetter Formulary Updated December 1, 2020

46 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TRIUMEQ TABS 3 QL(1 ea daily) zidovudine caps 100 mg 1 QL(6 ea daily)

TRIZIVIR TABS (Use QL(2 ea daily) zidovudine syrp 50 mg/5ml 1 QL(60 ml daily) abacavir sulfate- NF lamivudine-zidovudine) zidovudine tabs 300 mg 1 QL(2 ea daily) TRUVADA TABS 100 MG- QL(1 ea 150 MG, 133 MG-200 MG, 2 daily,30 day(s) CMV Agents 167 MG-250 MG limit) TRUVADA TABS 200 MG- QL(1 ea cidofovir soln 3 300 MG (Use emtricitabine- daily,30 day(s) 2 CYTOVENE SOLR (Use NF tenofovir disoproxil limit) ganciclovir sodium) fumarate) ganciclovir sodium solr 1 TYBOST TABS 2 QL(1 ea daily) VALCYTE TABS 450 MG NF PA; QL(4 ea VIDEX EC CPDR 125 MG 2 QL(2 ea daily) (Use valganciclovir hcl) daily) valganciclovir hcl tabs 450 1 PA; QL(4 ea VIDEX EC CPDR 200 MG NF QL(2 ea daily) mg daily) (Use didanosine) VIDEX EC CPDR 250 MG, QL(1 ea daily) Hepatitis Agents NF PA; QL(1 ea 400 MG (Use didanosine) adefovir dipivoxil tabs 4 daily); SP VIDEXPEDIATRIC SOLR 2 BARACLUDE SOLN 0.05 4 PA; QL(20 ml MG/ML daily); SP VIRACEPT TABS 250 MG 2 QL(10 ea daily) BARACLUDE TABS 0.5 NF PA; QL(1 ea VIRACEPT TABS 625 MG 2 QL(4 ea daily) MG, 1 MG (Use entecavir) daily); SP DAKLINZA TABS 30 MG, 4 PA; QL(1 ea VIRAMUNE SUSP 50 NF QL(40 ml daily) 60 MG daily) MG/5ML (Use nevirapine) PA; QL(1 ea entecavir tabs 4 VIRAMUNE TABS 200 MG NF QL(2 ea daily) daily); SP (Use nevirapine) EPCLUSA TABS 100 MG- 4 PA; QL(1 ea VIRAMUNE XR TB24 100 NF QL(3 ea daily) 400 MG daily) MG (Use nevirapine) EPIVIR HBV SOLN 5 4 PA; QL(60 ml VIRAMUNE XR TB24 400 NF QL(1 ea daily) MG/ML daily); SP MG (Use nevirapine) EPIVIR HBV TABS 100 NF QL(3 ea daily); VIREAD POWD 40 MG/GM 2 MG (Use lamivudine (hbv)) SP HARVONI TABS 400 MG- 4 PA; QL(1 ea VIREAD TABS 150 MG, 2 QL(1 ea daily) 90 MG daily); SP 200 MG, 250 MG HEPSERA TABS (Use NF PA; QL(1 ea VIREAD TABS 300 MG adefovir dipivoxil) daily); SP (Use tenofovir disoproxil NF QL(3 ea daily); fumarate) lamivudine (hbv) tabs 1 SP ZERIT CAPS (Use NF QL(2 ea daily) stavudine) LEDIPASVIR/SOFOSBUVI 4 PA; QL(1 ea R TABS daily); SP ZIAGEN SOLN 20 MG/ML NF (Use abacavir sulfate) MAVYRET TABS 4 PA; QL(3 ea daily) ZIAGEN TABS 300 MG NF QL(2 ea daily) (Use abacavir sulfate) MODERIBA 1200 DOSE 4 PA PACK TBPK

Ambetter Formulary Updated December 1, 2020

47 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PEGASYS PROCLICK 4 PA; QL(0.0714 valacyclovir hcl tabs 500 1 QL(2 ea daily) SOLN ml daily); SP mg VALTREX TABS 1 GM QL(4 ea daily) PEGASYS SOLN 4 PA; QL(0.0714 NF ml daily); SP (Use valacyclovir hcl) VALTREX TABS 500 MG QL(2 ea daily) PEGINTRON KIT 4 PA; QL(0.143 NF ea daily); SP (Use valacyclovir hcl) REBETOL CAPS 200 MG NF QL(7 ea daily) QL(5 ea (Use ribavirin (hepatitis c)) ZOVIRAX CAPS OR 200 NF daily,50 ea per MG (Use acyclovir) fill retail,50 ea REBETOL SOLN 40 4 PA; QL(35 ml MG/ML daily); SP per fill mail) ZOVIRAX SUSP OR 200 QL(13.34 ml RIBASPHERE RIBAPAK 4 PA NF TBPK 400 MG, 600 MG MG/5ML (Use acyclovir) daily) PA ZOVIRAX TABS OR 400 QL(5 ea daily) RIBASPHERE TABS 4 MG, 800 MG (Use NF acyclovir) ribavirin (hepatitis c) caps 1 QL(7 ea daily) 200 mg Influenza Agents ribavirin (hepatitis c) tabs PA; QL(7 ea 1 FLUMADINE TABS (Use NF QL(2 ea daily) 200 mg daily) rimantadine hydrochloride) ribavirin (hepatitis c) tabs 4 PA Limit 1 fill every 600 mg 90 days.;QL(10 ea per fill SOFOSBUVIR/VELPATAS 4 PA; QL(1 ea VIR TABS daily) retail,10 ea per oseltamivir phosphate caps fill mail)1 rtl SOVALDI TABS 400 MG 4 PA; QL(1 ea 1 daily); SP or 30 mg, 45 mg, 75 mg MAX fill,90 rtl day(s) supply,1 PA; QL(1 ea VEMLIDY TABS 4 mail MAX fill,90 daily); SP mail day(s) VOSEVI TABS 4 PA supply, Limit 1 fill every ZEPATIER TABS 4 PA 90 days.;QL(125 oseltamivir phosphate susr 1 ml per fill Herpes Agents or 6 mg/ml QL(5 ea retail)1 rtl MAX daily,50 ea per fill,90 rtl day(s) acyclovir caps 200 mg 1 fill retail,50 ea supply, per fill mail) RELENZA DISKHALER 2 QL(13.34 ml AEPB acyclovir susp 200 mg/5ml 1 daily) rimantadine hydrochloride 1 QL(2 ea daily) tabs acyclovir tabs 400 mg, 800 1 QL(5 ea daily) mg famciclovir tabs 125 mg, 1 QL(3 ea daily) 250 mg famciclovir tabs 500 mg 1 QL(4 ea daily) valacyclovir hcl tabs 1 gm, 1 QL(4 ea daily) 1000 mg

Ambetter Formulary Updated December 1, 2020

48 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limit 1 fill every metoprolol tartrate tabs or 1 90 days.;QL(10 100 mg, 25 mg, 50 mg ea per fill TENORMIN TABS (Use NF retail,10 ea per atenolol) TAMIFLU CAPS 30 MG, 45 fill mail)1 rtl MG, 75 MG (Use NF TOPROL XL TB24 (Use ) MAX fill,90 rtl NF oseltamivir phosphate day(s) supply,1 metoprolol succinate) mail MAX fill,90 Beta Blockers Non-Selective mail day(s) BETAPACE AF TABS (Use NF supply, sotalol hcl (afib/afl)) Limit 1 fill every BETAPACE TABS (Use NF QL(2 ea daily) 90 sotalol hcl) TAMIFLU SUSR 6 MG/ML days.;QL(125 (Use oseltamivir NF ml per fill CORGARD TABS (Use NF phosphate) retail)1 rtl MAX nadolol) PA; QL(75 ml fill,90 rtl day(s) HEMANGEOL SOLN 4 supply, daily) BETA BLOCKERS - Drugs to Treat High Blood INDERAL LA CP24 (Use NF Pressure propranolol hcl) Alpha-Beta Blockers nadolol tabs 1 tabs 1 pindolol tabs 1 COREG TABS (Use NF carvedilol) propranolol hcl cp24 1 labetalol hcl soln 1 propranolol hcl soln 1 labetalol hcl tabs 1 propranolol hcl tabs 1

Beta Blockers Cardio-Selective sotalol hcl (afib/afl) tabs 1 acebutolol hcl caps 1 sotalol hcl tabs 120 mg, 1 QL(2 ea daily) 160 mg, 80 mg atenolol tabs 1 sotalol hcl tabs 240 mg 1 betaxolol hcl tabs 1 timolol maleate tabs 1 bisoprolol fumarate tabs 1 CALCIUM CHANNEL BLOCKERS - Drugs to Treat High Blood Pressure BYSTOLIC TABS 10 MG, 2 PA; QL(1 ea 2.5 MG, 5 MG daily) Calcium Channel Blockers PA; QL(2 ea BYSTOLIC TABS 20 MG 2 ADALAT CC TB24 (Use NF daily) ) LOPRESSOR TABS (Use NF metoprolol tartrate) amlodipine besylate tabs 1 metoprolol succinate tb24 1 CALAN SR TBCR (Use NF verapamil hcl) metoprolol tartrate soln iv 5 1 CALAN TABS (Use NF mg/5ml verapamil hcl)

Ambetter Formulary Updated December 1, 2020

49 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CARDIZEM CD CP24 (Use NF PROCARDIA XL TB24 NF diltiazem hcl coated beads) (Use nifedipine) CARDIZEM LA TB24 420 SULAR TB24 (Use NF MG, 180 MG, 240 MG, 300 NF ) MG, 360 MG (Use TIAZAC CP24 120 MG, diltiazem hcl coated beads) 180 MG, 240 MG, 300 MG, NF CARDIZEM TABS (Use NF 360 MG (Use diltiazem hcl diltiazem hcl) extended release beads) diltiazem hcl coated beads 1 verapamil hcl cp24 1 cp24 diltiazem hcl coated beads 1 verapamil hcl soln 1 tb24 diltiazem hcl cp12 or 120 1 verapamil hcl tabs 1 mg, 60 mg, 90 mg verapamil hcl tbcr 1 diltiazem hcl cp24 or 120 1 mg, 180 mg, 240 mg VERELAN CP24 120 MG, diltiazem hcl extended 180 MG, 240 MG (Use NF release beads cp24 120 1 verapamil hcl) mg, 180 mg, 240 mg, 300 mg, 360 mg VERELAN CP24 360 MG 1 (Use verapamil hcl) diltiazem hcl soln iv 50 1 mg/10ml VERELAN PM CP24 100 MG, 200 MG (Use NF DILTIAZEM HCL SOLR IV 1 verapamil hcl) 100 MG VERELAN PM CP24 300 1 diltiazem hcl tabs or 120 1 MG (Use verapamil hcl) mg, 60 mg, 30 mg, 90 mg CARDIOTONICS - Drugs to Treat Heart Failure tb24 1 and Abnormal Heart Rhythm isradipine caps 1 Cardiac Glycosides digoxin soln 1 hcl caps 1 digoxin tabs 1 nicardipine hcl soln 1 LANOXIN SOLN IJ 0.25 2 nifedipine caps 1 MG/ML (Use digoxin) LANOXIN TABS OR 250 nifedipine tb24 1 MCG, 125 MCG (Use 2 digoxin) nimodipine caps 1 LANOXIN TABS OR 62.5 2 MCG nisoldipine tb24 17 mg, 20 mg, 30 mg, 34 mg, 40 mg, 1 CARDIOVASCULAR AGENTS - MISC. - Drugs to 8.5 mg Treat Heart and Circulation Conditions NORVASC TABS (Use NF Cardioplegic Solutions amlodipine besylate) PLEGISOL SOLN (Use NF PROCARDIA CAPS (Use NF cardioplegic soln) nifedipine) Cardiovascular Agents Misc. - Combinations

Ambetter Formulary Updated December 1, 2020

50 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits amlodipine besylate- QL(1 ea daily) 1 OPSUMIT TABS 4 PA; QL(1 ea atorvastatin calcium tabs daily) BIDIL TABS 2 TRACLEER TABS 125 MG 4 PA; QL(2 ea (Use ) daily); SP CADUET TABS (Use QL(1 ea daily) TRACLEER TABS 62.5 4 PA; QL(2 ea amlodipine besylate- NF MG (Use bosentan) daily) atorvastatin calcium) PA; QL(2 ea TRACLEER TBSO 32 MG 4 ENTRESTO TABS 3 PA daily); SP Pulmonary Hypertension - Phosphodiesterase Impotence Agents ADCIRCA TABS (Use PA; QL(2 ea PA; BPH tadalafil (pulmonary NF daily); SP CIALIS TABS 5 MG (Use NF tadalafil) Only;QL(1 ea hypertension)) daily) REVATIO SOLN IV 10 PA; QL(37.5 ml PA; QL(0.1334 sildenafil citrate tabs 1 MG/12.5ML (Use sildenafil NF daily); SP ea daily) citrate (pulmonary QL(0.134 ea STENDRA TABS 3 hypertension)) daily) REVATIO SUSR OR 10 PA; QL(6 ml PA; BPH MG/ML (Use sildenafil NF daily) tadalafil tabs 5 mg 1 Only;QL(1 ea citrate (pulmonary daily) hypertension)) VIAGRA TABS (Use NF PA; QL(0.1334 REVATIO TABS OR 20 PA; QL(3 ea sildenafil citrate) ea daily) MG (Use sildenafil citrate NF daily); SP Prostaglandin Vasodilators (pulmonary hypertension)) PA sildenafil citrate (pulmonary PA; QL(37.5 ml epoprostenol sodium solr 4 hypertension) soln iv 10 4 daily); SP mg/12.5ml FLOLAN SOLR (Use NF PA epoprostenol sodium) sildenafil citrate (pulmonary PA; QL(6 ml ORENITRAM TBCR 0.125 PA hypertension) susr or 10 4 daily) MG, 0.25 MG, 1 MG, 2.5 3 mg/ml MG sildenafil citrate (pulmonary PA; QL(3 ea PA; SP hypertension) tabs or 20 4 daily); SP REMODULIN SOLN 4 mg PA; SP tadalafil (pulmonary 4 PA; QL(2 ea treprostinil soln 4 hypertension) tabs daily); SP VENTAVIS SOLN 4 PA; SP Pulmonary Hypertension - Sol Guanylate Cyclase ADEMPAS TABS 0.5 MG, 4 PA; QL(3 ea Pulmonary Hypertension - Endothelin Receptor 1.5 MG, 2 MG, 2.5 MG daily) PA; QL(1 ea tabs 4 Sinus Node Inhibitors daily); SP CORLANOR SOLN 5 PA; QL(15 ml PA; QL(2 ea 3 bosentan tabs 125 mg 4 MG/5ML daily) daily); SP CORLANOR TABS 5 MG, PA; QL(2 ea PA; QL(2 ea 3 bosentan tabs 62.5 mg 4 7.5 MG daily) daily) Transthyretin Stabilizers LETAIRIS TABS (Use 4 PA; QL(1 ea ambrisentan) daily); SP VYNDAMAX CAPS 4 PA; QL(1 ea daily)

Ambetter Formulary Updated December 1, 2020

51 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VYNDAQEL CAPS 4 PA; QL(4 ea cefdinir susr 1 daily) CEPHALOSPORINS - Drugs to Treat Bacterial cefditoren pivoxil tabs 200 3 Infections mg cefditoren pivoxil tabs 400 1 Cephalosporins - 1st Generation mg cefadroxil caps 1 cefixime susr 100 mg/5ml, 1 ST 200 mg/5ml cefadroxil susr 1 cefotaxime sodium solr 1 1 gm, 2 gm cefadroxil tabs 1 cefpodoxime proxetil susr 1 cefazolin sodium solr ij 20 1 gm, 500 mg, 1 gm, 10 gm cefpodoxime proxetil tabs 1 cephalexin caps 1 ceftazidime solr ij 2 gm, 1 1 gm, 6 gm cephalexin susr 1 ceftriaxone sodium solr ij 1 1 gm, 2 gm, 250 mg, 500 mg cephalexin tabs 1 CLAFORAN SOLR (Use NF cefotaxime sodium) KEFLEX CAPS (Use NF cephalexin) FORTAZ SOLR IJ 1 GM NF Cephalosporins - 2nd Generation (Use ceftazidime) SUPRAX SUSR 100 ST cefaclor caps 1 MG/5ML, 200 MG/5ML NF (Use cefixime) cefaclor susr 1 Cephalosporins - 4th Generation CEFOTAN SOLR (Use NF cefotetan disodium) cefepime hcl solr 1 cefotetan disodium solr 1 1 MAXIPIME SOLR IJ 1 GM, NF gm, 2 gm 2 GM (Use cefepime hcl) cefotetan disodium solr 10 3 Cephalosporins - 5th Generation gm TEFLARO SOLR 3 cefoxitin sodium solr ij 10 1 gm CONTRACEPTIVES - Drugs to Prevent cefoxitin sodium solr iv 1 1 Pregnancy gm, 2 gm Combination Contraceptives - Oral cefprozil susr 1 BALCOLTRA TABS 0 cefprozil tabs 1 BEYAZ TABS (Use drospirenone-ethinyl 0 cefuroxime axetil tabs 1 estradiol-levomefolate calcium) cefuroxime sodium solr ij 1 7.5 gm, 750 mg desogestrel & ethinyl 0 estradiol tabs Cephalosporins - 3rd Generation desogestrel-ethinyl 0 cefdinir caps 1 estradiol (biphasic) tabs

Ambetter Formulary Updated December 1, 2020

52 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits desogestrel-ethinyl 0 norethindrone & eth 0 estradiol (triphasic) tabs estradiol tabs drospirenone-ethinyl 0 norethindrone & ethinyl 0 estradiol tabs estradiol-fe chew drospirenone-ethinyl norethindrone acet & eth 0 estradiol-levomefolate 0 estra tabs calcium tabs norethindrone acetate- 0 ESTROSTEP FE TABS ethinyl estradiol-fe tabs (Use norethindrone 0 norethindrone-eth estradiol 0 acetate-ethinyl estradiol-fe) (triphasic) tabs ethynodiol diacet & eth 0 norgestimate-ethinyl 0 estrad tabs estradiol (triphasic) tabs FALESSA KIT 0 norgestimate-ethinyl 0 estradiol tabs GENERESS FE CHEW norgestrel & ethinyl 0 (Use norethindrone & 0 estradiol tabs ethinyl estradiol-fe) ORTHO TRI-CYCLEN LO levonorgestrel & eth 0 TABS (Use norgestimate- 0 estradiol tabs ethinyl estradiol (triphasic)) levonorgestrel-eth estradiol 0 ORTHO TRI-CYCLEN (triphasic) tabs TABS (Use norgestimate- 0 levonorgestrel-ethinyl 0 ethinyl estradiol (triphasic)) estradiol (91-day) tabs ORTHO-CYCLEN TABS levonorgestrel-ethinyl 0 (Use norgestimate-ethinyl 0 estradiol (continuous) tabs estradiol) LO LOESTRIN FE TABS 0 ORTHO-NOVUM 1/35 TABS (Use norethindrone 0 LOSEASONIQUE TABS & eth estradiol) (Use levonorgestrel-ethinyl 0 ORTHO-NOVUM 7/7/7 estradiol (91-day)) TABS (Use norethindrone- 0 MINASTRIN 24 FE CHEW 0 eth estradiol (triphasic)) QUARTETTE TABS (Use MINASTRIN 24 FE CHEW levonorgestrel-ethinyl 0 (Use norethin acet & 0 estradiol (91-day)) estrad-fe) SAFYRAL TABS (Use MIRCETTE TABS (Use drospirenone-ethinyl 0 desogestrel-ethinyl 0 estradiol-levomefolate estradiol (biphasic)) calcium) NATAZIA TABS 0 SEASONIQUE TABS (Use levonorgestrel-ethinyl 0 norethin acet & estrad-fe 0 estradiol (91-day)) caps TAYTULLA CAPS (Use 0 norethin acet & estrad-fe 0 norethin acet & estrad-fe) chew TRI-NORINYL 28 TABS norethin acet & estrad-fe 0 (Use norethindrone-eth 0 tabs estradiol (triphasic))

Ambetter Formulary Updated December 1, 2020

53 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TYBLUME TABS 0 DEPO-PROVERA QL(1 ml per 90 CONTRACEPTIVE SUSP 0 days retail) YASMIN 28 TABS (Use (Use medroxyprogesterone drospirenone-ethinyl 0 acetate (contraceptive)) estradiol) DEPO-PROVERA QL(90 day(s) YAZ TABS (Use CONTRACEPTIVE SUSY 0 limit,1 ml per drospirenone-ethinyl 0 (Use medroxyprogesterone 90 days retail) estradiol) acetate (contraceptive)) Combination Contraceptives - Transdermal DEPO-SUBQ PROVERA 0 104 SUSY -ethinyl 0 estradiol ptwk medroxyprogesterone QL(1 ml per 90 acetate (contraceptive) 0 days retail) Combination Contraceptives - Vaginal susp ANNOVERA RING 0 PA medroxyprogesterone QL(90 day(s) acetate (contraceptive) 0 limit,1 ml per etonogestrel-ethinyl 0 susy 90 days retail) estradiol ring Progestin Contraceptives - Oral NUVARING RING (Use etonogestrel-ethinyl 0 norethindrone 0 estradiol) (contraceptive) tabs ORTHO MICRONOR Copper Contraceptives - IUD TABS (Use norethindrone 0 PARAGARD (contraceptive)) INTRAUTERINE COPPER 0 QL(1 ea daily) CONTRACEPTIVE T380A SLYND TABS 0 IUD CORTICOSTEROIDS - Steroid Hormone Drugs to Emergency Contraceptives Treat Systemic Swelling Conditions ELLA TABS 0 Glucocorticosteroids PA levonorgestrel (emergency 0 budesonide cpep 3 mg 1 oc) tabs CELESTONE-SOLUSPAN PLAN B ONE-STEP TABS SUSP (Use betamethasone NF (Use levonorgestrel 0 sod phosphate & acetate) (emergency oc)) CORTEF TABS (Use NF Progestin Contraceptives - IUD hydrocortisone) KYLEENA IUD 0 cortisone acetate tabs 1

LILETTA IUD 0 DEPO-MEDROL SUSP 20 3 MG/ML MIRENA IUD 0 DEPO-MEDROL SUSP 80 MG/ML, 40 MG/ML (Use NF SKYLA IUD 0 acetate) Progestin Contraceptives - Implants elix 0.5 1 NEXPLANON IMPL 0 mg/5ml DEXAMETHASONE 1 Progestin Contraceptives - Injectable INTENSOL CONC

Ambetter Formulary Updated December 1, 2020

54 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits dexamethasone sodium sodium phosphate soln ij 120 1 phosphate soln or 10 mg/30ml, 20 mg/5ml, 4 mg/5ml, 15 mg/5ml, 20 1 mg/ml mg/5ml, 25 mg/5ml, 5 mg/5ml dexamethasone soln 0.5 1 mg/5ml prednisolone sodium dexamethasone tabs 1 mg, phosphate tbdp or 10 mg, 3 1.5 mg, 2 mg, 0.5 mg, 0.75 1 15 mg, 30 mg mg, 4 mg, 6 mg prednisolone soln 1 EMFLAZA SUSP 4 PA prednisone soln 1 EMFLAZA TABS 4 PA prednisone tabs 1 ENTOCORT EC CPEP NF PA (Use budesonide) prednisone tbpk 1 hydrocortisone tabs 1 2 rtl MAX fill,30 SOLU-CORTEF SOLR 100 3 rtl day(s) KENALOG-40 SUSP (Use NF MG, 1000 MG, 500 MG triamcinolone acetonide) supply, SOLU-CORTEF SOLR 250 MEDROL DOSEPAK TBPK NF 3 (Use methylprednisolone) MG MEDROL TABS 16 MG, 32 SOLU-MEDROL SOLR 125 MG, 8 MG, 4 MG (Use NF MG, 40 MG, 1000 MG (Use NF methylprednisolone) methylprednisolone sod succ) MEDROL TABS 2 MG 3 SOLU-MEDROL SOLR 2 3 GM methylprednisolone acetate 1 susp 80 mg/ml, 40 mg/ml SOLU-MEDROL SOLR 500 MG (Use 1 methylprednisolone sod 1 methylprednisolone sod succ solr succ) methylprednisolone tabs 1 triamcinolone acetonide 1 susp 40 mg/ml methylprednisolone tbpk 1 VERIPRED 20 SOLN (Use prednisolone sodium NF MILLIPRED DP TBPK 3 phosphate) MILLIPRED SOLN 10 Mineralocorticoids MG/5ML (Use prednisolone NF sodium phosphate) fludrocortisone acetate tabs 1 MILLIPRED TABS 5 MG 3 COUGH/COLD/ALLERGY - Drugs to Treat Cough, Cold and Allergy Symptoms ORAPRED ODT TBDP (Use prednisolone sodium NF Antitussives phosphate) benzonatate caps 100 mg 1 QL(6 ea daily) PEDIAPRED SOLN (Use prednisolone sodium NF benzonatate caps 150 mg 1 QL(4 ea daily) phosphate)

Ambetter Formulary Updated December 1, 2020

55 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits benzonatate caps 200 mg 1 QL(3 ea daily) HYPERSAL NEBU 3.5 % 1

TESSALON PERLES NF QL(6 ea daily) HYPERSAL NEBU 7 % CAPS (Use benzonatate) (Use sodium chloride NF (inhalant)) Cough/Cold/Allergy Combinations ALLEGRA-D 12 HOUR QL(2 ea daily) NEBUSAL NEBU 1 ALLERGY & CONGESTION TB12 (Use NF sodium chloride (inhalant) 1 fexofenadine- nebu 7 % pseudoephedrine) Mucolytics ALLEGRA-D 24 HOUR QL(1 ea daily) acetylcysteine soln 1 ALLERGY & CONGESTION TB24 (Use NF DERMATOLOGICALS - Drugs to Treat Skin fexofenadine- Conditions pseudoephedrine) cetirizine-pseudoephedrine QL(2 ea daily) Acne Products 1 PA; AL(At least tb12 adapalene crea 0.1 % 1 CLARITIN-D 12 HOUR QL(2 ea daily) 12 yrs old) TB12 (Use loratadine & 1 PA; AL(At least pseudoephedrine) adapalene gel 0.1 % 1 12 yrs old); CLARITIN-D 24 HOUR QL(1 ea daily) RX/OTC ST; AL(At least TB24 (Use loratadine & 1 adapalene gel 0.3 % 1 pseudoephedrine) 12 yrs old) ST; AL(At least fexofenadine- QL(2 ea daily) adapalene lotn 0.1 % 1 pseudoephedrine tb12 120 1 12 yrs old) mg-60 mg adapalene-benzoyl 1 ST; AL(At least fexofenadine- QL(1 ea daily) peroxide gel 12 yrs old) pseudoephedrine tb24 180 1 AZELEX CREA 3 ST; AL(At least mg-240 mg 12 yrs old) HYDROCODONE BENZACLIN GEL (Use PA; AL(At least BITARTRATE/GUAIFENES 2 clindamycin phosphate- NF 12 yrs old) IN SOLN benzoyl peroxide) loratadine & QL(2 ea daily) BENZACLIN WITH PUMP PA; AL(At least pseudoephedrine tb12 120 1 GEL (Use clindamycin NF 12 yrs old) mg-5 mg phosphate-benzoyl loratadine & QL(1 ea daily) peroxide) pseudoephedrine tb24 10 1 BENZAMYCIN GEL (Use PA; AL(At least mg-10 mg-240 mg-240 mg, benzoyl peroxide- NF 12 yrs old) 10 mg-240 mg ) ZYRTEC-D QL(2 ea daily) AL(At least 12 ALLERGY/CONGESTION BENZEFOAM FOAM (Use NF 1 benzoyl peroxide) yrs old); TB12 (Use cetirizine- RX/OTC pseudoephedrine) BENZEFOAM ULTRA AL(At least 12 Misc. Respiratory Inhalants FOAM (Use benzoyl NF yrs old) peroxide) HYPER-SAL NEBU (Use NF sodium chloride (inhalant)) BENZOYL PEROXIDE 2 AL(At least 12 CLEANSER LIQD yrs old)

Ambetter Formulary Updated December 1, 2020

56 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AL(At least 12 PA; AL(At least benzoyl peroxide foam 5.3 1 yrs old); DIFFERIN GEL 0.1 % (Use NF % adapalene) 12 yrs old); RX/OTC RX/OTC benzoyl peroxide foam 9.8 1 AL(At least 12 DIFFERIN GEL 0.3 % (Use NF ST; AL(At least % yrs old) adapalene) 12 yrs old) benzoyl peroxide gel 5 %, AL(At least 12 1 DIFFERIN LOTN 0.1 % 1 ST; AL(At least 10 % yrs old) 12 yrs old) benzoyl peroxide liqd 4 %, 1 AL(At least 12 DUAC GEL (Use PA; AL(At least 7 %, 10 % yrs old) clindamycin phosphate- NF 12 yrs old) benzoyl peroxide benzoyl peroxide- 1 PA; AL(At least erythromycin gel 12 yrs old) (refrigerate)) CLEOCIN-T GEL (Use AL(At least 12 EPIDUO GEL (Use ST; AL(At least clindamycin phosphate NF yrs old) adapalene-benzoyl NF 12 yrs old) (topical)) peroxide) CLEOCIN-T LOTN (Use AL(At least 12 erythromycin (acne aid) 1 AL(At least 12 clindamycin phosphate NF yrs old) pads yrs old) (topical)) erythromycin (acne aid) 1 AL(At least 12 CLEOCIN-T SOLN (Use AL(At least 12 soln yrs old) clindamycin phosphate NF yrs old) EVOCLIN FOAM (Use PA; AL(At least (topical)) clindamycin phosphate NF 12 yrs old) CLEOCIN-T SWAB (Use AL(At least 12 (topical)) NF PA; AL(At least clindamycin phosphate yrs old) isotretinoin caps 3 (topical)) 12 yrs old) CLINDAGEL GEL (Use AL(At least 12 KLARON LOTN (Use AL(At least 12 clindamycin phosphate NF yrs old) sulfacetamide sodium NF yrs old) (topical)) (acne)) clindamycin phosphate 1 PA; AL(At least PANOXYL-4 CREAMY AL(At least 12 (topical) foam 12 yrs old) WASH LIQD (Use benzoyl NF yrs old) peroxide) clindamycin phosphate 1 AL(At least 12 (topical) gel yrs old) AL(At least 12 RETIN-A CREA (Use NF yrs old - Up to clindamycin phosphate 1 AL(At least 12 tretinoin) (topical) lotn yrs old) 30 yrs old) clindamycin phosphate AL(At least 12 AL(At least 12 1 RETIN-A GEL (Use NF (topical) soln yrs old) tretinoin) yrs old - Up to 30 yrs old) clindamycin phosphate 1 AL(At least 12 (topical) swab yrs old) RETIN-A MICRO GEL 0.1 PA; AL(At least % (Use tretinoin NF 12 yrs old - Up clindamycin phosphate- PA; AL(At least microsphere) to 30 yrs old) benzoyl peroxide 1 12 yrs old) (refrigerate) gel RETIN-A MICRO PUMP PA; AL(At least GEL 0.1 % (Use tretinoin NF 12 yrs old - Up clindamycin phosphate- PA; AL(At least microsphere) to 30 yrs old) benzoyl peroxide gel 1 %-5 1 12 yrs old) % sulfacetamide sodium 1 AL(At least 12 (acne) lotn yrs old) clindamycin phosphate- 1 ST; AL(At least tretinoin gel 12 yrs old) sulfacetamide sodium w/ 1 AL(At least 12 sulfur crea 10 %-5 % yrs old) DIFFERIN CREA 0.1 % NF PA; AL(At least (Use adapalene) 12 yrs old) sulfacetamide sodium w/ 1 AL(At least 12 sulfur emul 10 %-5 % yrs old)

Ambetter Formulary Updated December 1, 2020

57 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits sulfacetamide sodium w/ 1 ST; AL(At least mupirocin oint 1 sulfur liqd 4.5 %-9 % 12 yrs old) PA sulfacetamide sodium- 1 AL(At least 12 NEO-SYNALAR CREA 3 sulfur in urea vehicle emul yrs old) SUMADAN WASH LIQD ST; AL(At least Antifungals - Topical (Use sulfacetamide sodium NF 12 yrs old) RX/OTC w/ sulfur) hcl crea 1 AL(At least 12 CICLODAN SOLUTION NF tretinoin crea 0.05 %, 0.1 1 yrs old - Up to KIT KIT (Use ) %, 0.025 % 30 yrs old) ciclopirox gel ex 0.77 % 1 AL(At least 12 tretinoin gel 0.01 %, 0.025 1 yrs old - Up to % QL(90 gm per 30 yrs old) fill retail)1 rtl ciclopirox olamine crea 1 PA; AL(At least MAX fill,30 rtl tretinoin microsphere gel 1 12 yrs old - Up day(s) supply, 0.1 % to 30 yrs old) ciclopirox olamine susp 1 ZIANA GEL (Use ST; AL(At least clindamycin phosphate- NF 12 yrs old) ciclopirox sham ex 1 % 1 tretinoin) Agents for External Genital and Perianal Warts ciclopirox soln ex 8 % 1 VEREGEN OINT 3 (topical) crea 1 RX/OTC

Anti-inflammatory Agents - Topical clotrimazole (topical) soln 1 RX/OTC PA; QL(2 ea diclofenac epolamine ptch 1 daily) clotrimazole w/ 1 PA; QL(2 ea betamethasone crea diclofenac epolamine ptch 3 daily) clotrimazole w/ 1 betamethasone lotn diclofenac sodium (topical) 1 QL(3.34 gm gel 1 % daily); RX/OTC nitrate crea 1 PA; QL(2 ea FLECTOR PTCH 3 daily) ERTACZO CREA 3 FLECTOR PTCH (Use PA; QL(2 ea 3 EXELDERM CREA (Use 3 diclofenac epolamine) daily) nitrate) VOLTAREN GEL (Use NF QL(3.34 gm diclofenac sodium (topical)) daily); RX/OTC EXELDERM SOLN 3 Antibiotics - Topical JUBLIA SOLN 3 PA ALTABAX OINT 2 KERYDIN SOLN (Use 3 PA ) CORTISPORIN CREA 2 ketoconazole (topical) crea 1 CORTISPORIN OINT 2 2 % ketoconazole (topical) 1 gentamicin sulfate (topical) 1 QL(1 gm daily) sham 2 % crea gentamicin sulfate (topical) 1 oint

Ambetter Formulary Updated December 1, 2020

58 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(90 gm per QL(2 gm LOPROX CREA (Use NF fill retail)1 rtl daily)1 rtl MAX ciclopirox olamine) MAX fill,30 rtl fill,180 rtl NAFTIN CREA 2 % (Use NF day(s) supply, hcl) day(s) supply,1 mail MAX LOPROX SHAMPOO NF SHAM (Use ciclopirox) fill,180 mail day(s) supply, LOPROX SUSP (Use NF ciclopirox olamine) QL(3 gm daily)1 rtl MAX LOTRIMIN AF CREA (Use NF RX/OTC fill,180 rtl clotrimazole (topical)) NAFTIN GEL 1 % (Use 3 naftifine hcl) day(s) supply,1 LOTRIMIN AF JOCK RX/OTC mail MAX CREA (Use clotrimazole NF fill,180 mail (topical)) day(s) supply, LOTRIMIN ULTRA CREA RX/OTC 1 NIZORAL SHAM (Use NF (Use butenafine hcl) ketoconazole (topical)) LOTRISONE CREA (Use clotrimazole w/ NF nystatin (topical) crea 1 betamethasone) nystatin (topical) oint 1 crea 1 PA nystatin (topical) powd 1 LUZU CREA (Use 3 PA luliconazole) nystatin-triamcinolone crea 1 QL(3 gm daily)1 rtl MAX nystatin-triamcinolone oint 1 fill,180 rtl naftifine hcl crea 1 % 1 day(s) supply,1 Limit 1 Fill per mail MAX 180 days;QL(3 fill,180 mail gm daily)1 rtl MAX fill,180 rtl day(s) supply, nitrate crea 1 QL(2 gm day(s) supply,1 daily)1 rtl MAX mail MAX fill,180 rtl fill,180 mail naftifine hcl crea 2 % 1 day(s) supply,1 day(s) supply, mail MAX Limit 1 Fill per fill,180 mail 180 days;QL(3 day(s) supply, gm daily)1 rtl QL(3 gm OXISTAT CREA (Use NF MAX fill,180 rtl daily)1 rtl MAX oxiconazole nitrate) day(s) supply,1 fill,180 rtl mail MAX naftifine hcl gel 1 % 1 day(s) supply,1 fill,180 mail mail MAX day(s) supply, fill,180 mail Limit 1 Fill per day(s) supply, 180 days;QL(2 ml daily)1 rtl 2 MAX fill,180 rtl OXISTAT LOTN day(s) supply,1 mail MAX fill,180 mail day(s) supply,

Ambetter Formulary Updated December 1, 2020

59 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PENLAC NAIL LACQUER NF PA; Limit 1 fill SOLN (Use ciclopirox) every 180 days;QL(45 gm sulconazole nitrate crea 1 per fill retail,45 gm per fill sulconazole nitrate soln 1 doxepin hcl (antipruritic) 3 mail)1 rtl MAX crea PA fill,180 rtl tavaborole soln 1 day(s) supply,1 mail MAX VUSION OINT (Use fill,180 mail -zinc oxide- NF day(s) supply, white petrolatum) PA; Limit 1 fill Antineoplastic or Premalignant Lesion Agents - every 180 days;QL(45 gm CARAC CREA (Use NF fluorouracil (topical)) per fill retail,45 diclofenac sodium (actinic PA; QL(3.34 gm per fill 1 PRUDOXIN CREA (Use 3 keratoses) gel gm daily) doxepin hcl (antipruritic)) mail)1 rtl MAX fill,180 rtl EFUDEX CREA (Use NF day(s) supply,1 fluorouracil (topical)) mail MAX fluorouracil (topical) crea 5 1 fill,180 mail % day(s) supply, fluorouracil (topical) soln 2 1 PA; Limit 1 fill %, 5 % every 180 days;QL(45 gm PANRETIN GEL 3 per fill retail,45 QL(3 ea per fill gm per fill ZONALON CREA (Use 3 retail,3 ea per doxepin hcl (antipruritic)) mail)1 rtl MAX fill mail)1 rtl fill,180 rtl day(s) supply,1 2 MAX fill,60 rtl PICATO GEL 0.015 % day(s) supply,1 mail MAX mail MAX fill,60 fill,180 mail mail day(s) day(s) supply, supply, Antipsoriatics QL(2 ea per fill acitretin caps 10 mg, 17.5 1 QL(1 ea daily) retail,2 ea per mg fill mail)1 rtl acitretin caps 25 mg 1 QL(2 ea daily) 2 MAX fill,60 rtl PICATO GEL 0.05 % day(s) supply,1 PA; QL(4 gm mail MAX fill,60 calcipotriene crea 1 mail day(s) daily) PA; QL(4 gm supply, calcipotriene oint 1 daily) TARGRETIN GEL EX 1 % 4 PA; SP PA; QL(4 ml calcipotriene soln 1 Antipruritics - Topical daily) calcitriol (topical) oint 1

COSENTYX 4 PA SENSOREADY PEN SOAJ

Ambetter Formulary Updated December 1, 2020

60 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits COSENTYX SOSY 4 PA acyclovir topical oint 1

DOVONEX CREA (Use NF PA; QL(4 gm DENAVIR CREA 3 calcipotriene) daily) PA ZOVIRAX CREA EX 5 % 3 ILUMYA SOSY 4 (Use acyclovir topical) methoxsalen rapid caps 1 QL(4 ea daily) ZOVIRAX OINT EX 5 % NF (Use acyclovir topical) OXSORALEN ULTRA QL(4 ea daily) Burn Products CAPS (Use methoxsalen NF rapid) mafenide acetate pack 3 SILIQ SOSY 4 PA SILVADENE CREA (Use NF silver sulfadiazine) SKYRIZI PSKT 4 PA silver sulfadiazine crea 1 SORIATANE CAPS 10 MG NF QL(1 ea daily) (Use acitretin) SULFAMYLON CREA 85 3 MG/GM SORIATANE CAPS 25 MG NF QL(2 ea daily) (Use acitretin) SULFAMYLON PACK 5 % NF (Use mafenide acetate) STELARA SOLN SC 45 4 PA MG/0.5ML Corticosteroids - Topical alclometasone dipropionate STELARA SOSY SC 45 4 PA; SP 1 MG/0.5ML, 90 MG/ML crea TALTZ SOAJ 4 PA alclometasone dipropionate 1 oint TALTZ SOSY 4 PA QL(60 gm per fill retail,60 gm tazarotene crea 1 per fill mail)1 rtl MAX fill,30 rtl amcinonide crea 1 TAZORAC CREA 0.05 % 2 day(s) supply,1 mail MAX fill,30 mail day(s) TAZORAC CREA 0.1 % NF (Use tazarotene) supply, TAZORAC GEL 0.05 %, 2 amcinonide lotn 3 0.1 % TREMFYA SOPN 4 PA AMCINONIDE OINT 3 PA betamethasone 1 TREMFYA SOSY 4 dipropionate (topical) crea betamethasone VECTICAL OINT (Use 1 1 calcitriol (topical)) dipropionate (topical) lotn Antiseborrheic Products betamethasone 1 dipropionate (topical) oint selenium sulfide lotn 1 betamethasone dipropionate augmented 1 Antivirals - Topical crea acyclovir topical crea 1

Ambetter Formulary Updated December 1, 2020

61 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits betamethasone CUTIVATE LOTN (Use NF dipropionate augmented 1 fluticasone propionate) lotn DERMA-SMOOTHE/FS QL(118.28 ml betamethasone per fill retail)1 1 BODY OIL (Use NF dipropionate augmented fluocinolone acetonide) rtl MAX fill,30 rtl oint day(s) supply, betamethasone valerate 1 DERMA-SMOOTHE/FS crea SCALP OIL (Use NF fluocinolone acetonide) betamethasone valerate 1 foam desonide crea 1 QL(4 gm daily) betamethasone valerate 1 lotn desonide lotn 1 QL(4 ml daily) betamethasone valerate 1 oint desonide oint 1 QL(3 gm daily) calcipotriene- ST DESOWEN CREA (Use NF QL(4 gm daily) betamethasone 1 desonide) dipropionate oint DESOWEN LOTN (Use NF QL(4 ml daily) calcipotriene- ST desonide) betamethasone 1 dipropionate susp desoximetasone crea 0.25 1 % PA; QL(3 gm clobetasol propionate crea 1 daily) desoximetasone gel 0.05 % 1 clobetasol propionate 1 PA; QL(1 gm emollient base crea daily) desoximetasone oint 0.25 1 % ST; QL(3 gm clobetasol propionate foam 1 daily) diflorasone diacetate crea 1 PA ST; QL(2 gm clobetasol propionate gel 1 PA daily) diflorasone diacetate oint 1 PA; QL(1 gm clobetasol propionate oint 1 DIPROLENE AF CREA daily) (Use betamethasone NF PA; QL(3.34 ml dipropionate augmented) clobetasol propionate soln 1 daily) DIPROLENE OINT (Use betamethasone NF clocortolone pivalate crea 3 dipropionate augmented) CLODERM CREA 3 ELOCON CREA (Use NF mometasone furoate) CLODERM CREA (Use 3 ELOCON OINT (Use NF clocortolone pivalate) mometasone furoate) CLODERM PUMP CREA 3 fluocinolone acetonide crea 1 0.01 %, 0.025 % CORDRAN CREA 0.05 % NF QL(118.28 ml (Use flurandrenolide) fluocinolone acetonide oil 1 per fill retail)1 CORDRAN LOTN 0.05 % NF 0.01 % rtl MAX fill,30 rtl (Use flurandrenolide) day(s) supply, CORDRAN TAPE 4 3 fluocinolone acetonide oil 1 MCG/SQCM 0.01 %

Ambetter Formulary Updated December 1, 2020

62 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits fluocinolone acetonide oint 1 HYDROCORTISONE 0.025 % ACETATE/LIDOCAINE HYDROCHLORIDE CREA NF fluocinolone acetonide soln 1 0.01 % (Use lidocaine- hydrocortisone acetate) fluocinonide crea 0.05 % 1 QL(4 gm daily) hydrocortisone butyrate 1 crea fluocinonide emulsified 1 base crea hydrocortisone butyrate 1 oint fluocinonide gel 0.05 % 1 hydrocortisone butyrate 1 soln fluocinonide oint 0.05 % 1 hydrocortisone valerate 1 fluocinonide soln 0.05 % 1 crea hydrocortisone valerate oint 1 flurandrenolide crea 2 QL(2 gm daily) LOCOID CREA (Use NF flurandrenolide lotn 2 QL(2 ml daily) hydrocortisone butyrate) LOCOID SOLN (Use NF fluticasone propionate crea 1 hydrocortisone butyrate) LUXIQ FOAM (Use NF fluticasone propionate lotn 1 betamethasone valerate) fluticasone propionate oint 1 mometasone furoate crea 1 halcinonide crea 1 PA mometasone furoate oint 1 halobetasol propionate 1 mometasone furoate soln 1 crea MONISTAT SOOTHING RX/OTC halobetasol propionate oint 1 CARE ITCH RELIEF CREA NF (Use hydrocortisone HALOG CREA (Use 3 PA halcinonide) (topical)) OLUX FOAM (Use ST; QL(3 gm PA NF HALOG OINT 3 clobetasol propionate) daily) hydrocortisone (topical) 1 RX/OTC prednicarbate crea 1 crea 1 % prednicarbate oint 1 hydrocortisone (topical) 1 crea 2.5 % PSORCON CREA 2 PA hydrocortisone (topical) 1 lotn 2.5 % SYNALAR CREA (Use NF hydrocortisone (topical) 1 RX/OTC fluocinolone acetonide) oint 1 % SYNALAR OINT (Use NF hydrocortisone (topical) 1 fluocinolone acetonide) oint 2.5 % SYNALAR SOLN (Use NF fluocinolone acetonide)

Ambetter Formulary Updated December 1, 2020

63 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TACLONEX OINT (Use ST LAC-HYDRIN TWELVE RX/OTC calcipotriene- NF LOTN (Use NF betamethasone (ammonium lactate)) dipropionate) lactic acid (ammonium 1 RX/OTC TACLONEX SUSP (Use ST lactate) crea 12 % calcipotriene- 3 lactic acid (ammonium 1 RX/OTC betamethasone lactate) lotn 12 % dipropionate) Enzymes - Topical TEMOVATE CREA (Use NF PA; QL(3 gm clobetasol propionate) daily) SANTYL OINT 3 PA TEMOVATE OINT (Use NF PA; QL(1 gm clobetasol propionate) daily) Immunomodulating Agents - Topical TOPICORT CREA 0.25 % QL(12 ea per NF ALDARA CREA (Use NF (Use desoximetasone) imiquimod) fill retail,12 ea per fill mail) TOPICORT GEL 0.05 % NF (Use desoximetasone) QL(12 ea per imiquimod crea 5 % 1 fill retail,12 ea TOPICORT OINT 0.25 % NF (Use desoximetasone) per fill mail) triamcinolone acetonide ZYCLARA CREA (Use NF (topical) crea 0.025 %, 0.5 1 imiquimod) %, 0.1 % ZYCLARA PUMP CREA NF triamcinolone acetonide 3.75 % (Use imiquimod) (topical) lotn 0.025 %, 0.1 1 Immunosuppressive Agents - Topical % ELIDEL CREA (Use NF PA; AL(At least triamcinolone acetonide pimecrolimus) 2 yrs old) (topical) oint 0.025 %, 0.1 1 PA; AL(At least pimecrolimus crea 1 %, 0.5 % 2 yrs old) triamcinolone acetonide- PA 1 PROTOPIC OINT (Use NF AL(At least 2 dimethicone-silicone kit (topical)) yrs old) TRIDESILON CREA (Use QL(4 gm daily) AL(At least 2 NF tacrolimus (topical) oint 1 desonide) yrs old) ULTRAVATE CREA (Use NF halobetasol propionate) Keratolytic/Antimitotic Agents podofilox soln 1 ULTRAVATE OINT (Use NF halobetasol propionate) Local Anesthetics - Topical Eczema Agents lidocaine hcl gel ex 2 % 1 QL(4 ml daily) DUPIXENT SOSY 200 4 PA MG/1.14ML, 300 MG/2ML QL(4 ml daily); lidocaine hcl gel ex 2 % 1 Emollient/Keratolytic Agents RX/OTC QL(4 ml daily) HYDRO 35 FOAM (Use NF lidocaine hcl prsy ex 2 % 1 urea in lactic acid vehicle) Emollients lidocaine hcl soln ex 4 % 1 LAC-HYDRIN CREA (Use RX/OTC PA lactic acid (ammonium NF lidocaine ptch 5 % 1 lactate)) lidocaine-prilocaine crea 1 QL(1 gm daily)

Ambetter Formulary Updated December 1, 2020

64 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LIDODERM PTCH (Use NF PA lindane sham 1 lidocaine) QL(10 ea per malathion lotn 1 fill retail,10 ea per fill mail)1 rtl NATROBA SUSP (Use 1 PA spinosad) SYNERA PTCH 3 MAX fill,30 rtl day(s) supply,1 NIX CREME RINSE LIQD NF mail MAX fill,30 (Use ) mail day(s) OVIDE LOTN (Use NF supply, malathion) Phosphodiesterase 4 (PDE4) Inhibitors - Topical permethrin crea 1 PA; QL(2 gm EUCRISA OINT 3 daily) permethrin liqd 1 Rosacea Agents SKLICE LOTN 3 PA azelaic acid gel 1 PA spinosad susp 1 PA FINACEA GEL (Use NF PA azelaic acid) METROCREAM CREA ULESFIA LOTN 3 (Use metronidazole NF Wound Care Products (topical)) REGRANEX GEL 3 METROGEL GEL (Use NF metronidazole (topical)) METROLOTION LOTN DIAGNOSTIC PRODUCTS (Use metronidazole NF (topical)) Diagnostic Drugs GLUCAGEN DIAGNOSTIC QL(0.035 ea metronidazole (topical) 1 3 crea SOLR daily) Diagnostic Tests metronidazole (topical) gel 1 CHEMSTRIP-K STRP 1 metronidazole (topical) lotn 1 FORA GTEL BLOOD KETONE TEST STRIPS 1 MIRVASO GEL 3 PA; QL(1 gm daily) STRP ORACEA CPDR (Use NF GOJJI BLOOD KETONE 1 doxycycline (rosacea)) TEST STRIPS STRP SOOLANTRA CREA (Use NF KETONE STRP 1 ivermectin (rosacea)) Scabicides & Pediculicides KETONE TEST STRIPS 1 STRP crotamiton lotn 1 PA KETOSTIX STRP 1 ELIMITE CREA (Use NF permethrin) NOVA MAX PLUS KETONE TESTSTRIPS 1 EURAX CREA 3 STRP PRECISION XTRA STRP 1 EURAX LOTN (Use NF PA VI crotamiton) Ambetter Formulary Updated December 1, 2020

65 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PTS PANELS KETONE 1 DYAZIDE CAPS (Use TEST STRP triamterene & NF hydrochlorothiazide) RELION KETONE STRP 1 MAXZIDE TABS (Use triamterene & NF RELION KETONE TEST 1 STRIPS STRP hydrochlorothiazide) Limit 100 per MAXZIDE-25 TABS (Use TRUE METRIX BLOOD month;QL(3.34 triamterene & NF GLUCOSETEST STRIPS 1 hydrochlorothiazide) STRP ea daily); RX/OTC & 1 Limit 100 per hydrochlorothiazide tabs month;QL(3.34 TRUETRACK TEST STRP 1 triamterene & 1 ea daily); hydrochlorothiazide caps RX/OTC triamterene & 1 DIGESTIVE AIDS - Drugs to Treat Low Digestive hydrochlorothiazide tabs Enzymes Loop Diuretics Digestive Enzymes bumetanide soln ij 0.25 1 CREON CPEP 2 mg/ml bumetanide tabs or 0.5 mg, 1 QL(5 ea daily) SUCRAID SOLN 3 1 mg, 2 mg BUMEX TABS (Use NF QL(5 ea daily) ZENPEP CPEP 2 bumetanide) DEMADEX TABS (Use NF DIURETICS - Drugs to Treat Heart, Circulation torsemide) Conditions and Blood Pressure EDECRIN TABS (Use NF QL(16 ea daily) Carbonic Anhydrase Inhibitors ethacrynic acid) acetazolamide cp12 500 1 QL(2 ea daily) ethacrynic acid tabs 1 QL(16 ea daily) mg acetazolamide sodium solr 1 furosemide soln 1 acetazolamide tabs 125 mg 1 QL(8 ea daily) furosemide tabs 1

QL(4 ea daily) LASIX TABS (Use NF acetazolamide tabs 250 mg 1 furosemide) PA; QL(4 ea KEVEYIS TABS 4 torsemide tabs 1 daily) methazolamide tabs 1 QL(6 ea daily) Potassium Sparing Diuretics ALDACTONE TABS (Use NF Diuretic Combinations spironolactone) ALDACTAZIDE TABS 25 amiloride hcl tabs 1 MG-25 MG (Use NF spironolactone & DYRENIUM CAPS (Use 3 QL(3 ea daily) hydrochlorothiazide) triamterene) amiloride & 1 hydrochlorothiazide tabs spironolactone tabs 1 triamterene caps 1 QL(3 ea daily)

Ambetter Formulary Updated December 1, 2020

66 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Thiazides and Thiazide-Like Diuretics FORTEO SOPN 4 PA; QL(0.09 ml daily); SP chlorothiazide tabs 1 FOSAMAX PLUS D TABS 3 PA; QL(0.143 ea daily) chlorthalidone tabs 1 FOSAMAX TABS (Use NF QL(0.143 ea alendronate sodium) daily) DIURIL SUSP 2 QL(20 ml daily) ibandronate sodium soln iv 4 PA; SP hydrochlorothiazide caps 1 QL(2 ea daily) 3 mg/3ml ibandronate sodium tabs or 1 QL(0.036 ea hydrochlorothiazide tabs 1 QL(2 ea daily) 150 mg daily) pamidronate disodium soln 4 PA; SP indapamide tabs 1.25 mg 1 QL(1 ea daily) 30 mg/10ml, 90 mg/10ml QL(2 ea daily) PAMIDRONATE PA; SP indapamide tabs 2.5 mg 1 DISODIUM SOLN 6 4 MG/ML methyclothiazide tabs 1 pamidronate disodium solr 4 PA; SP 30 mg, 90 mg metolazone tabs 1 QL(2 ea daily) PA; 1 rtl MAX fill,180 rtl MICROZIDE CAPS (Use NF QL(2 ea daily) PROLIA SOSY 4 hydrochlorothiazide) day(s) supply,; SP ENDOCRINE AND METABOLIC AGENTS - MISC. - Drugs to Treat Bone Disease and RECLAST SOLN (Use NF PA; SP Regulate Hormones zoledronic acid) risedronate sodium tabs 1 PA; QL(0.036 Bone Density Regulators 150 mg ea daily) ACTONEL TABS 150 MG PA; QL(0.036 NF risedronate sodium tabs 30 1 PA; QL(1 ea (Use risedronate sodium) ea daily) mg, 5 mg daily) ACTONEL TABS 35 MG PA; QL(0.143 NF risedronate sodium tabs 35 1 PA; QL(0.143 (Use risedronate sodium) ea daily) mg ea daily) ACTONEL TABS 5 MG PA; QL(1 ea NF risedronate sodium tbec 35 1 PA (Use risedronate sodium) daily) mg alendronate sodium tabs 1 QL(0.143 ea PA; 35 mg, 70 mg daily) TYMLOS SOPN 4 alendronate sodium tabs 1 QL(1 ea daily) PA; SP 40 mg, 10 mg, 5 mg XGEVA SOLN 4 ATELVIA TBEC (Use PA NF zoledronic acid conc 4 4 PA; SP risedronate sodium) mg/5ml BONIVA SOLN IV 3 PA; SP ZOLEDRONIC ACID SOLN 4 PA; SP MG/3ML (Use ibandronate NF 4 MG/100ML sodium) zoledronic acid soln 4 4 PA; SP BONIVA TABS OR 150 MG NF QL(0.036 ea mg/100ml, 5 mg/100ml (Use ibandronate sodium) daily) ZOLEDRONIC ACID SOLR 4 PA; SP calcitonin (salmon) soln 1 4 MG ZOMETA CONC 4 PA; SP etidronate disodium tabs 1 MG/5ML (Use zoledronic NF acid)

Ambetter Formulary Updated December 1, 2020

67 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ZOMETA SOLN 4 4 PA; SP OMNITROPE SOCT 10 4 PA; SP MG/100ML MG/1.5ML, 5 MG/1.5ML Corticotropin SOLR 4 PA; SP PA ACTHAR GEL 4 SAIZENPREP PA; SP RECONSTITUTIONKIT 4 Fertility Regulators SOLR CHORIONIC 4 PA; SP PA; SP GONADOTROPIN SOLR SEROSTIM SOLR 4 NOVAREL SOLR 10000 4 PA; SP ZOMACTON SOLR 4 PA; SP UNIT PREGNYL W/DILUENT PA; SP ZORBTIVE SOLR 4 PA; SP BENZYLALCOHOL/NACL 4 SOLR Hormone Receptor Modulators GnRH/LHRH Antagonists EVISTA TABS (Use NF QL(1 ea daily) raloxifene hcl) CETROTIDE KIT 4 PA OSPHENA TABS 3 PA ganirelix acetate sosy 4 PA raloxifene hcl tabs 0 QL(1 ea daily) GANIRELIX ACETATE PA SOSY (Use ganirelix 4 Insulin-Like Growth Factors (Somatomedins) acetate) INCRELEX SOLN 4 PA; SP Receptor Antagonists SOMAVERT SOLR 10 MG, 4 PA; SP LHRH/GnRH Agonist Analog Pituitary 15 MG, 20 MG FENSOLVI KIT 4 PA; SP Growth Hormone Releasing Hormones (GHRH) PA EGRIFTA SOLR 4 PA LUPANETA PACK KIT 4 PA LUPRON DEPOT-PED (1- 4 PA; SP EGRIFTA SV SOLR 4 MONTH) KIT Growth Hormones LUPRON DEPOT-PED (3- 4 PA; SP MONTH) KIT 30 MG GENOTROPIN MINIQUICK 4 PA; SP SOLR 0.2 MG SYNAREL SOLN 4 PA; SP GENOTROPIN SOLR 5 4 PA; SP MG Metabolic Modifiers PA; SP HUMATROPE COMBO 4 PA; SP ALDURAZYME SOLN 4 PACK SOLR BUPHENYL POWD (Use NF PA HUMATROPE SOLR 4 PA; SP sodium phenylbutyrate) NORDITROPIN FLEXPRO PA; SP BUPHENYL TABS (Use NF PA SOPN 10 MG/1.5ML, 15 4 sodium phenylbutyrate) MG/1.5ML, 5 MG/1.5ML calcitriol caps 1 NORDITROPIN FLEXPRO 4 PA SOPN 30 MG/3ML calcitriol soln 1 NUTROPIN AQ NUSPIN PA; SP 4 PA; SP 10 SOPN CARBAGLU TABS 4

Ambetter Formulary Updated December 1, 2020

68 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; QL(4 ea cinacalcet hcl tabs 4 SENSIPAR TABS (Use NF PA; QL(4 ea daily); SP cinacalcet hcl) daily); SP CYSTADANE POWD 4 PA; SP sodium phenylbutyrate 1 PA powd doxercalciferol caps 1 sodium phenylbutyrate tabs 1 PA doxercalciferol soln 1 ZEMPLAR CAPS (Use NF paricalcitol) PA; SP ELAPRASE SOLN 4 ZEMPLAR SOLN (Use NF paricalcitol) FABRAZYME SOLR 35 4 PA; SP MG Posterior Pituitary Hormones DDAVP SOLN IJ 4 PA GALAFOLD CAPS 4 PA; QL(0.5 ea daily) MCG/ML (Use NF HECTOROL SOLN 4 desmopressin acetate) MCG/2ML (Use NF DDAVP SOLN NA 0.01 % doxercalciferol) (Use desmopressin acetate NF KUVAN PACK 100 MG, PA spray) 500 MG (Use sapropterin 4 DDAVP TABS OR 0.1 MG QL(6 ea daily) dihydrochloride) (Use desmopressin NF KUVAN TBSO 100 MG PA; SP acetate) (Use sapropterin 4 DDAVP TABS OR 0.2 MG QL(8 ea daily) dihydrochloride) (Use desmopressin NF acetate) LUMIZYME SOLR 4 PA; SP desmopressin acetate soln 1 PA ij 4 mcg/ml MYALEPT SOLR 4 PA desmopressin acetate 1 spray refrigerated soln NAGLAZYME SOLN 4 PA; SP desmopressin acetate 1 nitisinone caps 4 PA; SP spray soln desmopressin acetate tabs 1 QL(6 ea daily) ORFADIN CAPS 10 MG, 2 4 PA; SP or 0.1 mg MG, 5 MG (Use nitisinone) desmopressin acetate tabs 1 QL(8 ea daily) PALYNZIQ SOSY 4 PA or 0.2 mg STIMATE SOLN 4 PA; SP paricalcitol caps 1 Prolactin Inhibitors paricalcitol soln 1 cabergoline tabs 1 ROCALTROL CAPS (Use NF calcitriol) Somatostatic Agents ROCALTROL SOLN (Use NF PA; SP calcitriol) octreotide acetate soln 4 sapropterin dihydrochloride 4 PA SANDOSTATIN SOLN NF PA; SP pack 100 mg, 500 mg (Use octreotide acetate) sapropterin dihydrochloride 4 PA; SP SIGNIFOR SOLN 4 PA tbso 100 mg

Ambetter Formulary Updated December 1, 2020

69 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SOMATULINE DEPOT 4 PA; QL(0.0179 ESTRACE TABS (Use NF SOLN 120 MG/0.5ML ml daily); SP estradiol) SOMATULINE DEPOT 4 PA; QL(0.0075 estradiol pttw td 0.025 QL(0.286 ea SOLN 60 MG/0.2ML ml daily); SP mg/24hr, 0.0375 mg/24hr, 1 daily) 0.05 mg/24hr, 0.075 SOMATULINE DEPOT 4 PA; QL(0.011 SOLN 90 MG/0.3ML ml daily); SP mg/24hr, 0.1 mg/24hr estradiol ptwk td 0.05 Vasopressin Receptor Antagonists mg/24hr, 0.06 mg/24hr, JYNARQUE TABS 15 MG, 4 PA; QL(2 ea 0.075 mg/24hr, 0.1 1 30 MG daily); SP mg/24hr, 37.5 mcg/24hr, JYNARQUE TBPK 4 PA; SP 0.025 mg/24hr estradiol tabs or 0.5 mg, 1 1 SAMSCA TABS (Use 4 PA; QL(2 ea mg, 2 mg tolvaptan) daily); SP PA; QL(2 ea estradiol valerate oil 1 tolvaptan tabs 4 daily); SP ESTROGEL GEL 3 ESTROGENS - Hormone Replacement/Modifying Drugs EVAMIST SOLN 3 Estrogen Combinations MENEST TABS 3 CLIMARA PRO PTWK 3 MENOSTAR PTWK 3 DUAVEE TABS 3 PA MINIVELLE PTTW (Use NF QL(0.286 ea FEMHRT LOW DOSE estradiol) daily) TABS (Use norethindrone NF acetate-ethinyl estradiol) PREMARIN SOLR 2 norethindrone acetate- 1 ethinyl estradiol tabs PREMARIN TABS 2 PREMPHASE TABS 2 VIVELLE-DOT PTTW (Use NF QL(0.286 ea estradiol) daily) PREMPRO TABS 2 FLUOROQUINOLONES - Drugs to Treat Bacterial Infections Estrogens Fluoroquinolones CLIMARA PTWK (Use NF estradiol) AVELOX SOLN IV 0.8 %- 1 400 MG/250ML DELESTROGEN OIL 10 1 MG/ML AVELOX TABS OR 400 NF MG (Use moxifloxacin hcl) DELESTROGEN OIL 20 MG/ML, 40 MG/ML (Use NF BAXDELA SOLR 3 PA estradiol valerate) BAXDELA TABS 3 PA DEPO-ESTRADIOL OIL 3 2 rtl MAX fill,30 DIVIGEL GEL 0.25 CIPRO SUSR 5 2 GM/100ML, 500 MG/5ML rtl day(s) MG/0.25GM, 0.5 3 supply, MG/0.5GM, 1 MG/GM CIPRO TABS 250 MG, 500 NF ELESTRIN GEL 3 MG (Use ciprofloxacin hcl)

Ambetter Formulary Updated December 1, 2020

70 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ciprofloxacin hcl tabs 1 metoclopramide hcl soln ij 1 5 mg/ml ciprofloxacin in d5w soln 3 metoclopramide hcl soln or 1 QL(60 ml daily) 200 mg/100ml-5 % 10 mg/10ml, 5 mg/5ml 2 rtl MAX fill,30 metoclopramide hcl tabs or 1 QL(6 ea daily) ciprofloxacin susr 1 rtl day(s) 5 mg, 10 mg supply, REGLAN TABS (Use NF QL(6 ea daily) ciprofloxacin-ciprofloxacin 1 metoclopramide hcl) hcl tb24 Inflammatory Bowel Agents LEVAQUIN TABS (Use NF levofloxacin) APRISO CP24 (Use 2 mesalamine) levofloxacin in d5w soln 5 1 %-500 mg/100ml ASACOL HD TBEC (Use NF QL(6 ea daily) mesalamine) levofloxacin soln 1 AZULFIDINE EN-TABS NF TBEC (Use sulfasalazine) levofloxacin tabs 1 AZULFIDINE TABS (Use NF MOXIFLOXACIN sulfasalazine) HYDROCHLORIDE/SODIU 1 balsalazide disodium caps 1 M HYDROCHLORIDE SOLN CANASA SUPP (Use NF mesalamine) moxifloxacin hcl tabs 1 PA; QL(0.0714 CIMZIA KIT 4 ofloxacin tabs 1 ea daily); SP CIMZIA STARTER KIT KIT 4 PA; QL(0.214 GASTROINTESTINAL AGENTS - MISC. - ea daily); SP Miscellaneous Gastrointestinal Drugs COLAZAL CAPS (Use NF Bile Acid Synthesis Disorder Agents balsalazide disodium) PA; SP DELZICOL CPDR (Use NF CHOLBAM CAPS 4 mesalamine) Gallstone Solubilizing Agents DIPENTUM CAPS 2 ACTIGALL CAPS (Use NF ursodiol) ENTYVIO SOLR 4 PA URSO 250 TABS (Use NF PA; 30 rtl lmt ursodiol) INFLECTRA SOLR 4 day(s),30 mail URSO FORTE TABS (Use NF lmt day(s), ursodiol) LIALDA TBEC (Use NF ursodiol caps 1 mesalamine) mesalamine cp24 or 0.375 1 ursodiol tabs 1 gm mesalamine cpdr or 400 1 Gastrointestinal Chloride Channel Activators mg AMITIZA CAPS 2 PA; QL(2 ea daily) mesalamine enem re 4 gm 1 Gastrointestinal Stimulants mesalamine supp re 1000 1 mg

Ambetter Formulary Updated December 1, 2020

71 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits mesalamine tbec or 1.2 gm 1 RENVELA TABS (Use NF sevelamer carbonate) mesalamine tbec or 800 1 QL(6 ea daily) mg sevelamer carbonate pack 1 REMICADE SOLR 4 PA; SP sevelamer carbonate tabs 1

PA; 30 rtl lmt VELPHORO CHEW 3 PA RENFLEXIS SOLR 4 day(s),30 mail lmt day(s), GENITOURINARY AGENTS - MISCELLANEOUS STELARA SOLN IV 130 4 PA - Miscellaneous Drugs to Treat Reproductive MG/26ML Organs and Urinary System sulfasalazine tabs 1 Alkalinizers potassium citrate 1 sulfasalazine tbec 1 (alkalinizer) tbcr 1080 mg sodium citrate & citric acid 1 RX/OTC Intestinal Acidifiers soln lactulose (encephalopathy) 1 UROCIT-K 10 TBCR (Use soln potassium citrate NF Irritable Bowel Syndrome (IBS) Agents (alkalinizer)) alosetron hcl tabs 1 QL(2 ea daily) Cystinosis Agents CYSTAGON CAPS 3 PA LINZESS CAPS 145 MCG, 3 PA 290 MCG Genitourinary Irrigants PA; QL(1 ea LINZESS CAPS 72 MCG 3 daily) soln 1 LOTRONEX TABS (Use NF QL(2 ea daily) alosetron hcl) glycine (gu irrigant) soln 1 Peripheral Opioid Receptor Antagonists RESECTISOL SOLN 1 ENTEREG CAPS 3 sodium chloride (gu 1 irrigant) soln RELISTOR SOLN SC 12 3 PA MG/0.6ML, 8 MG/0.4ML SORBITOL SOLN 1 Phosphate Binder Agents SORBITOL-MANNITOL 1 calcium acetate (phosphate 1 SOLN binder) caps SORBITOL/MANNITOL 1 calcium acetate (phosphate 1 RX/OTC IRRIGATION SOLN binder) tabs FOSRENOL CHEW 1000 Interstitial Cystitis Agents MG, 500 MG, 750 MG (Use NF ELMIRON CAPS 2 lanthanum carbonate) lanthanum carbonate chew 1 Prostatic Hypertrophy Agents alfuzosin hcl tb24 1 QL(1 ea daily) PHOSLYRA SOLN 2 AVODART CAPS (Use NF QL(1 ea daily) RENVELA PACK (Use NF dutasteride) sevelamer carbonate)

Ambetter Formulary Updated December 1, 2020

72 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits dutasteride caps 1 QL(1 ea daily) ZURAMPIC TABS 3 PA finasteride tabs 1 5 mg only ZYLOPRIM TABS (Use NF allopurinol) FLOMAX CAPS (Use NF Uricosurics tamsulosin hcl) probenecid tabs 1 PROSCAR TABS (Use NF 5 mg only finasteride) HEMATOLOGICAL AGENTS - MISC. - Drugs to RAPAFLO CAPS (Use NF Treat Blood Disorders silodosin) Bradykinin B2 Receptor Antagonists silodosin caps 8 mg, 4 mg 1 FIRAZYR SOLN (Use 4 PA; QL(9 ml icatibant acetate) daily) tamsulosin hcl caps 1 PA; QL(9 ml icatibant acetate soln 4 UROXATRAL TB24 (Use NF QL(1 ea daily) daily) alfuzosin hcl) Complement Inhibitors Urinary Analgesics CINRYZE SOLR 4 PA phenazopyridine hcl tabs 1 HAEGARDA SOLR 4 PA PYRIDIUM TABS (Use NF phenazopyridine hcl) PA; QL(0.143 RUCONEST SOLR 4 ea daily) GOUT AGENTS - Drugs to Treat Gout SOLIRIS SOLN 4 PA Gout Agent Combinations Hematorheologic Agents colchicine w/ probenecid 1 tabs pentoxifylline tbcr 1 QL(3 ea daily) DUZALLO TABS 3 PA Plasma Kallikrein Inhibitors Gout Agents TAKHZYRO SOLN 4 PA; allopurinol tabs 1 Platelet Aggregation Inhibitors QL(1 ea daily) colchicine tabs 1 AGGRENOX CP12 (Use NF PA; QL(2 ea aspirin-dipyridamole) daily) colchicine tabs 1 AGRYLIN CAPS (Use NF ) QL(6 ea per fill anagrelide hcl COLCRYS TABS (Use 2 colchicine) retail,6 ea per anagrelide hcl caps 1 fill mail) PA; QL(1 ea PA; QL(2 ea febuxostat tabs 1 aspirin-dipyridamole cp12 1 daily) daily) KRYSTEXXA SOLN 4 PA BRILINTA TABS 2 CABLIVI KIT 4 PA MITIGARE CAPS (Use NF colchicine) cilostazol tabs 1 ULORIC TABS (Use 3 PA; QL(1 ea febuxostat) daily)

Ambetter Formulary Updated December 1, 2020

73 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits clopidogrel bisulfate tabs 1 Hematopoietic Growth Factors 300 mg ARANESP ALBUMIN PA; SP clopidogrel bisulfate tabs 1 QL(1 ea daily) FREE SOLN 100 MCG/ML, 4 75 mg 40 MCG/ML, 60 MCG/ML dipyridamole tabs 1 ARANESP ALBUMIN 4 SP FREE SOLN 25 MCG/ML EFFIENT TABS (Use NF QL(1 ea daily) ARANESP ALBUMIN PA; SP prasugrel hcl) FREE SOSY 150 PLAVIX TABS 300 MG NF MCG/0.3ML, 200 4 (Use clopidogrel bisulfate) MCG/0.4ML, 300 MCG/0.6ML, 500 MCG/ML PLAVIX TABS 75 MG (Use NF QL(1 ea daily) clopidogrel bisulfate) DOPTELET TABS 4 PA prasugrel hcl tabs 1 QL(1 ea daily) EPOGEN SOLN 3 PA; SP REOPRO SOLN 3 FULPHILA SOSY 4 PA; ZONTIVITY TABS 3 PA LEUKINE SOLR 4 PA; SP HEMATOPOIETIC AGENTS - Drugs to Treat Blood Disorders MIRCERA SOSY 4 PA Agents for Gaucher Disease MULPLETA TABS 4 PA CERDELGA CAPS 4 PA; QL(2 ea daily) NEULASTA ONPRO KIT 4 PA; SP PSKT CEREZYME SOLR 4 PA; SP NEULASTA SOSY 4 PA; SP ELELYSO SOLR 4 PA; SP NEUPOGEN SOLN 4 PA; SP PA; QL(3 ea miglustat caps 4 daily); SP NEUPOGEN SOSY 4 PA; SP VPRIV SOLR 4 PA; SP NIVESTYM SOSY 300 PA MCG/0.5ML, 480 4 ZAVESCA CAPS (Use NF PA; QL(3 ea miglustat) daily); SP MCG/0.8ML Agents for Sickle Cell Disease NPLATE SOLR 250 MCG, 4 PA; SP 500 MCG DROXIA CAPS 3 PROCRIT SOLN 10000 PA; SP PA UNIT/ML, 2000 UNIT/ML, 3 OXBRYTA TABS 4 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML Cobalamins PROCRIT SOLN 40000 4 PA; SP cyanocobalamin soln ij 1 QL(1 ml daily) UNIT/ML 1000 mcg/ml PROMACTA PACK 12.5 4 PA; QL(1 ea Folic Acid/Folates MG daily) folic acid tabs or 1 mg 0 RX/OTC PROMACTA TABS 12.5 4 PA; SP MG, 25 MG, 50 MG, 75 MG folic acid tabs or 400 mcg 0

Ambetter Formulary Updated December 1, 2020

74 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits RETACRIT SOLN 10000 PA elix 20 1 UNIT/ML, 2000 UNIT/ML, mg/5ml 20000 UNIT/2ML, 3000 4 phenobarbital soln 20 1 UNIT/ML, 4000 UNIT/ML, mg/5ml 40000 UNIT/ML phenobarbital tabs 100 mg, UDENYCA SOSY 4 PA 15 mg, 30 mg, 64.8 mg, 1 97.2 mg, 16.2 mg, 32.4 mg PA; 30 rtl lmt ZARXIO SOSY 4 day(s),30 mail Hypnotics - Tricyclic Agents PA; QL(1 ea lmt day(s), doxepin hcl (sleep) tabs 1 daily) Hematopoietic Mixtures SILENOR TABS (Use 3 PA; QL(1 ea ferrous fumarate-folic acid 1 QL(1 ea daily) doxepin hcl (sleep)) daily) tabs Non-Barbiturate Hypnotics Iron ST; Must try FER-IN-SOL SOLN (Use 0 AL(Up to 1 yrs immediate ferrous sulfate) old ) AMBIEN CR TBCR (Use NF zolpidem tartrate) release ferrous sulfate soln or 15 0 AL(Up to 1 yrs zolpidem.;QL(1 mg/ml old ) ea daily) ferrous sulfate tabs or 325 0 QL(1 ea daily); mg, 65 mg AMBIEN TABS (Use NF zolpidem tartrate) AL(At least 18 yrs old) ferrous sulfate tbec or 325 0 mg DORAL TABS (Use NF Stem Cell Mobilizers quazepam) MOZOBIL SOLN 4 PA; SP estazolam tabs 1 ST; QL(1 ea HEMOSTATICS - Drugs to Stop Bleeding/Treat 1 daily); AL(At Blood Disorders eszopiclone tabs least 18 yrs Hemostatics - Systemic old) AMICAR TABS 1000 MG, PA HALCION TABS (Use NF 500 MG (Use aminocaproic NF triazolam) acid) ST; QL(1 ea LUNESTA TABS (Use daily); AL(At aminocaproic acid tabs or 1 PA NF 1000 mg, 500 mg eszopiclone) least 18 yrs old) CYKLOKAPRON SOLN NF (Use tranexamic acid) RESTORIL CAPS (Use NF QL(1 ea daily) temazepam) LYSTEDA TABS (Use NF tranexamic acid) temazepam caps 1 QL(1 ea daily) tranexamic acid soln 1 triazolam tabs 1 tranexamic acid tabs 1 QL(2 ea daily); zaleplon caps 10 mg 1 AL(At least 18 HYPNOTICS/SEDATIVES/SLEEP DISORDER yrs old) AGENTS QL(1 ea daily); Barbiturate Hypnotics zaleplon caps 5 mg 1 AL(At least 18 yrs old)

Ambetter Formulary Updated December 1, 2020

75 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(1 ea daily); peg 3350-kcl-nacl-na PA zolpidem tartrate tabs or 10 1 AL(At least 18 1 mg, 5 mg sulfate-na ascorbate- yrs old) ascorbic acid solr ST; Must try peg 3350-kcl-sod bicarb- immediate sod chloride-sod sulfate 0 zolpidem tartrate tbcr or 1 release 12.5 mg, 6.25 mg solr 2.97 gm-22.74 gm-236 zolpidem.;QL(1 gm-5.86 gm-6.74 gm ea daily) PREPOPIK PACK 3 PA Orexin Receptor Antagonists PA SUPREP BOWEL PREP 0 BELSOMRA TABS 3 KIT SOLN Selective Melatonin Receptor Agonists Laxatives - Miscellaneous lactulose soln 10 gm/15ml, HETLIOZ CAPS 3 PA; QL(1 ea 1 daily) 20 gm/30ml ST; QL(1 ea Saline Laxatives 1 daily); AL(At PA ramelteon tabs least 18 yrs OSMOPREP TABS 3 old) Stimulant Laxatives ST; QL(1 ea bisacodyl tbec 1 ROZEREM TABS (Use 3 daily); AL(At ramelteon) least 18 yrs old) DULCOLAX TBEC (Use NF bisacodyl) LAXATIVES - Bowel Treatment Drugs Surfactant Laxatives Bulk Laxatives COLACE CAPS (Use NF sodium) calcium polycarbophil tabs 1 docusate calcium caps 1 FIBERCON TABS (Use NF calcium polycarbophil) docusate sodium caps 1 Laxative Combinations LOCAL ANESTHETICS-Parenteral - Drugs for CLENPIQ SOLN 3 PA Numbing COLYTE-FLAVOR PACKS Local Anesthetics - Amides SOLR (Use peg 3350-kcl- NF lidocaine hcl (local anesth.) 1 sod bicarb-sod chloride- soln 0.5 %, 1 %, 2 % sod sulfate) MARCAINE SOLN 0.5 % NF GOLYTELY SOLR 2.97 (Use bupivacaine hcl) GM-22.74 GM-236 GM- NAROPIN SOLN 5 MG/ML, 5.86 GM-6.74 GM (Use 0 2 MG/ML (Use ropivacaine NF peg 3350-kcl-sod bicarb- hcl) sod chloride-sod sulfate) XYLOCAINE SOLN 0.5 %, MOVIPREP SOLR (Use PA 1 % (Use lidocaine hcl NF peg 3350-kcl-nacl-na 2 (local anesth.)) sulfate-na ascorbate- ascorbic acid) XYLOCAINE-MPF SOLN 0.5 %, 1 %, 2 % (Use NF lidocaine hcl (local anesth.)) Ambetter Formulary Updated December 1, 2020

76 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MACROLIDES - Drugs to Treat Bacterial E.E.S. GRANULES SUSR Infections (Use erythromycin NF ethylsuccinate) Azithromycin ERYPED 200 SUSR (Use azithromycin pack or 1 gm 1 erythromycin NF ethylsuccinate) azithromycin solr iv 500 mg 1 ERYPED 400 SUSR (Use erythromycin 3 azithromycin susr or 100 1 ethylsuccinate) mg/5ml, 200 mg/5ml erythromycin base cpep 3 QL(6 ea per fill 250 mg azithromycin tabs or 250 1 retail,6 ea per mg fill mail) erythromycin base tabs 250 3 mg, 500 mg QL(4 ea per fill azithromycin tabs or 500 1 retail,4 ea per erythromycin base tbec 250 mg 1 fill mail) mg, 333 mg, 500 mg erythromycin azithromycin tabs or 600 1 QL(0.286 ea mg daily) ethylsuccinate susr 200 1 mg/5ml, 400 mg/5ml ZITHROMAX PACK OR 1 NF GM (Use azithromycin) erythromycin 3 ethylsuccinate tabs 400 mg ZITHROMAX SOLR IV 500 NF MG (Use azithromycin) Fidaxomicin ZITHROMAX SUSR OR DIFICID TABS 2 100 MG/5ML, 200 MG/5ML NF (Use azithromycin) MEDICAL DEVICES AND SUPPLIES QL(6 ea per fill ZITHROMAX TABS OR NF Contraceptives 250 MG (Use azithromycin) retail,6 ea per fill mail) AIMSCO LUBRICATED 0 QL(2 ea daily) QL(4 ea per fill MISC ZITHROMAX TABS OR NF retail,4 ea per 500 MG (Use azithromycin) fill mail) CAYA DPRH 0 ZITHROMAX TABS OR QL(0.286 ea NF DUREX EXTRA 0 QL(2 ea daily) 600 MG (Use azithromycin) daily) SENSITIVE DEVI QL(4 ea per fill FANTASY LUBRICATED QL(2 ea daily) ZITHROMAX TRI-PAK NF retail,4 ea per 0 TABS (Use azithromycin) MISC fill mail) FANTASY QL(2 ea daily) QL(6 ea per fill LUBRICATED/SPERMICID 0 ZITHROMAX Z-PAK TABS NF retail,6 ea per (Use azithromycin) E MISC fill mail) FC FEMALE 0 QL(1 ea daily) Clarithromycin MISC clarithromycin susr 1 FEMCAP DEVI 0 K-Y ME & YOU EXTRA 0 QL(2 ea daily) clarithromycin tabs 1 LUBRICATED DEVI clarithromycin tb24 1 K-Y ME & YOU INTENSE 0 QL(2 ea daily) DEVI

Ambetter Formulary Updated December 1, 2020

77 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits KAMELEON LUBRICATED 0 QL(2 ea daily) TRUSTEX LUBRICATED 0 QL(2 ea daily) MISC EXTRASTRENGTH MISC KIMONO COLORS DEVI 0 QL(2 ea daily) TRUSTEX LUBRICATED 0 QL(2 ea daily) MISC KIMONO LUBRICATED 0 QL(2 ea daily) TRUSTEX QL(2 ea daily) MISC LUBRICATED/RIBBED/ST 0 KIMONO MICRO THIN QL(2 ea daily) UDDED MISC PLUS SPERMICIDE 0 TRUSTEX QL(2 ea daily) LUBRICATED MISC LUBRICATED/SPERMICID 0 KIMONO PLUS QL(2 ea daily) E EXTRA LARGE MISC SPERMICIDE 0 TRUSTEX QL(2 ea daily) LUBRICATED MISC LUBRICATED/SPERMICID 0 KIMONO PLUS QL(2 ea daily) E EXTRA STRENGTH SPERMICIDE/LUBRICATE 0 MISC D MISC TRUSTEX QL(2 ea daily) LUBRICATED/SPERMICID 0 KIMONO PS LUBRICATED 0 QL(2 ea daily) MISC E MISC KIMONO PS PLUS QL(2 ea daily) TRUSTEX NATURAL QL(2 ea daily) SPERMICIDE/LUBRICATE 0 0 D MISC +LUBE/LUBRICATED MISC KIMONO SENSATION 0 QL(2 ea daily) LUBRICATED MISC TRUSTEX WITH QL(2 ea daily) KIMONO SENSATION QL(2 ea daily) NONOXYNOL- 0 PLUS SPERMICIDE 0 9/RIBBED/STUDDED LUBRICATED MISC MISC QL(2 ea daily) TRUSTEX/RIA 0 QL(2 ea daily) KIMONO SPECIAL DEVI 0 LUBRICATED MISC QL(2 ea daily) TRUSTEX/RIA QL(2 ea daily) MAXX LUBRICATED MISC 0 LUBRICATED 0 SPERMICIDE MISC MAXX PLUS SPERMICIDE 0 QL(2 ea daily) LUBRICATED MISC TRUSTEX/RIA QL(2 ea daily) LUBRICATED/SPERMICID 0 OMNIFLEX DIAPHRAGM 0 DPRH E MISC WIDE-SEAL SILICONE PREMIUM CONDOMS 0 QL(2 ea daily) LUBRICATED MISC DIAPHRAGM KIT 60 0 DPRH REALITY LATEX QL(2 ea daily) CONDOMS/LUBRICATED 0 WIDE-SEAL SILICONE MISC DIAPHRAGM KIT 65 0 DPRH REALITY LATEX/ULTRA 0 QL(2 ea daily) TEXTURED DEVI WIDE-SEAL SILICONE DIAPHRAGM KIT 70 0 REALITY LATEX/ULTRA 0 QL(2 ea daily) DPRH THIN DEVI WIDE-SEAL SILICONE TRUSTEX COLOR 0 QL(2 ea daily) DIAPHRAGM KIT 75 0 CONDOMS + LUBE MISC DPRH TRUSTEX LUBRICATED 0 QL(2 ea daily) WIDE-SEAL SILICONE EXTRALARGE MISC DIAPHRAGM KIT 80 0 DPRH Ambetter Formulary Updated December 1, 2020

78 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits WIDE-SEAL SILICONE ADVOCATE LANCETS 1 QL(6.6667 ea DIAPHRAGM KIT 85 0 MISC daily) DPRH ADVOCATE LANCING 1 WIDE-SEAL SILICONE DEVICE MISC DIAPHRAGM KIT 90 0 ADVOCATE RAPID-SAFE 1 DPRH LANCING DEVICE MISC WIDE-SEAL SILICONE ADVOCATE SAFETY 1 QL(6.6667 ea DIAPHRAGM KIT 95 0 LANCETS 26G MISC daily) DPRH ADVOCATE SAFETY 1 QL(6.6667 ea Diabetic Supplies LANCETS MISC daily) 1ST TIER UNILET QL(6.6667 ea AGAMATRIX ULTRA-THIN 1 QL(6.6667 ea COMFORTOUCH 1 daily) LANCETS 33G MISC daily) LANCETS 28G MISC AIMSCO TWIST LANCETS 1 QL(6.6667 ea 1ST TIER UNILET QL(6.6667 ea 32G MISC daily) COMFORTOUCH 1 daily) AIMSCO TWIST LANCETS 1 QL(6.6667 ea LANCETS 30G MISC 33G MISC daily) ACCU-CHEK FASTCLIX QL(6.6667 ea 1 ALTERNATE SITE 1 LANCETS MISC daily) LANCING DEVICE MISC ACCU-CHEK MULTICLIX 1 QL(6.6667 ea AQUA LANCE LANCETS MISC daily) ADJUSTABLE LANCING 1 ACCU-CHEK SAFE-T-PRO 1 QL(6.6667 ea DEVICE DEVI LANCETS MISC daily) AQUALANCE LANCETS 1 QL(6.6667 ea ACCU-CHEK SAFE-T-PRO 1 QL(6.6667 ea ULTRA THIN 30G MISC daily) PLUSLANCETS MISC daily) ASSURE COMFORT QL(6.6667 ea ACCU-CHEK SOFTCLIX 1 QL(6.6667 ea LANCETS ULTRA THIN 1 daily) LANCETS MISC daily) 28G MISC ACTI-LANCE LANCETS 1 QL(6.6667 ea ASSURE HAEMOLANCE QL(6.6667 ea 28G MISC daily) PLUS HIGH FLOW 18G 1 daily) ACTI-LANCE LITE QL(6.6667 ea MISC SAFETY LANCETS 28G 1 daily) ASSURE HAEMOLANCE QL(6.6667 ea MISC PLUS LOW FLOW 25G 1 daily) ACTI-LANCE SPECIAL QL(6.6667 ea MISC SAFETY LANCETS 17G 1 daily) ASSURE HAEMOLANCE QL(6.6667 ea MISC PLUS MICRO FLOW 28G 1 daily) ACTI-LANCE SPECIAL QL(6.6667 ea MISC SAFETYLANCETS 17G 1 daily) ASSURE HAEMOLANCE QL(6.6667 ea MISC PLUS NORMAL FLOW 1 daily) ACTI-LANCE UNIVERSAL QL(6.6667 ea 21G MISC SAFETY LANCETS 23G 1 daily) ASSURE HAEMOLANCE QL(6.6667 ea MISC PLUS PEDIATRIC BLADE 1 daily) MISC ADJUSTABLE LANCING 1 DEVICE MISC ASSURE LANCE 1 QL(6.6667 ea LANCETS 21G MISC daily) ADVANCED MOBILE 1 QL(6.6667 ea LANCET 30G MISC daily) ASSURE LANCE 1 QL(6.6667 ea LANCETS MISC daily) ADVOCATE LANCETS 1 QL(6.6667 ea 30G MISC daily)

Ambetter Formulary Updated December 1, 2020

79 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ASSURE LANCE PLUS QL(6.6667 ea CARETOUCH LANCING SAFETYLANCETS 25G 1 daily) DEVICEWITH EJECTOR 1 MISC MISC ASSURE LANCE PLUS QL(6.6667 ea CARETOUCH SAFETY 1 QL(6.6667 ea SAFETYLANCETS 30G 1 daily) LANCETS/26G MISC daily) MISC CARETOUCH SAFETY 1 QL(6.6667 ea ASSURE LANCE SAFETY 1 QL(6.6667 ea LANCETS/28G MISC daily) LANCET 28G MISC daily) CARETOUCH SAFETY 1 QL(6.6667 ea LANCETS/30G MISC daily) ASSURE LANCETS MISC 1 QL(6.6667 ea daily) CARETOUCH TWIST 1 QL(6.6667 ea AURORA LANCET SUPER 1 QL(6.6667 ea LANCETS 28G MISC daily) THIN30G MISC daily) CARETOUCH TWIST 1 QL(6.6667 ea AURORA LANCET THIN 1 QL(6.6667 ea LANCETS 30G MISC daily) 23G MISC daily) CARETOUCH TWIST 1 QL(6.6667 ea AUTO-LANCET MINI MISC 1 LANCETS 33G MISC daily) CLEANLET LANCETS 28G 1 QL(6.6667 ea AUTO-LANCET MISC 1 MISC daily) CLEVER CHEK LANCETS 1 QL(6.6667 ea AUTOLET IMPRESSION 1 ULTRATHIN 30G MISC daily) LANCING DEVICE MISC CLEVER CHEK LANCETS 1 QL(6.6667 ea AUTOLET LANCING 1 ULTRATHIN MISC daily) DEVICE MISC CLEVER CHOICE QL(6.6667 ea AUTOLET MINI MISC 1 COMFORT EZLANCETS 1 daily) 21G MISC AUTOLET PLUS MISC 1 CLEVER CHOICE QL(6.6667 ea COMFORT EZLANCETS 1 daily) BD LANCET ULTRAFINE 1 QL(6.6667 ea 23G MISC 30G MISC daily) CLEVER CHOICE QL(6.6667 ea BD LANCET ULTRAFINE 1 QL(6.6667 ea COMFORT EZLANCETS 1 daily) 33G MISC daily) 28G MISC BD MICROTAINER QL(6.6667 ea 1 COAGUCHEK LANCETS 1 QL(6.6667 ea LANCETS MISC daily) MISC daily) BULLSEYE MINI SAFETY 1 QL(6.6667 ea COMFORT ASSURED QL(6.6667 ea LANCETS MISC daily) LANCETS MICRO THIN 1 daily) BULLSEYE SAFETY 1 QL(6.6667 ea 33G MISC LANCETS MISC daily) COMFORT ASSURED QL(6.6667 ea CARDIOCOM LANCING 1 LANCETS SUPER THIN 1 daily) DEVICE MISC 28G MISC CAREONE ADVANCED 1 COMFORT LANCETS 1 QL(6.6667 ea LANCINGDEVICE MISC MISC daily) CAREONE LANCET THIN QL(6.6667 ea 1 CVS LANCETS 21G MISC 1 QL(6.6667 ea MISC daily) daily) CAREONE LANCET QL(6.6667 ea 1 CVS LANCETS MICRO 1 QL(6.6667 ea ULTRA THIN MISC daily) THIN 33G MISC daily) CARESENS LANCETS QL(6.6667 ea 1 CVS LANCETS MICRO- 1 QL(6.6667 ea MISC daily) THIN 33G MISC daily)

Ambetter Formulary Updated December 1, 2020

80 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CVS LANCETS ORIGINAL QL(6.6667 ea 1 E-Z JECT LANCETS MISC 1 QL(6.6667 ea MISC daily) daily) CVS LANCETS THIN 26G 1 QL(6.6667 ea E-Z JECT LANCETS 1 QL(6.6667 ea MISC daily) SUPER THIN 30G MISC daily) CVS LANCETS ULTRA 1 QL(6.6667 ea E-Z JECT LANCETS THIN 1 QL(6.6667 ea THIN 30G MISC daily) 26G MISC daily) CVS LANCETS ULTRA- 1 QL(6.6667 ea E-ZJECT LANCETS 1 QL(6.6667 ea THIN 30G MISC daily) MICRO-THIN 33G MISC daily) CVS LANCING DEVICE 1 EASY COMFORT QL(6.6667 ea MISC LANCETS 30G/PULL TOP 1 daily) MISC CVS ULTRA THIN 1 QL(6.6667 ea LANCETS MISC daily) EASY COMFORT QL(6.6667 ea LANCETS 30G/THIN TOP 1 daily) DIATHRIVE LANCETS 1 QL(6.6667 ea MISC daily) MISC EASY COMFORT QL(6.6667 ea DIATHRIVE LANCETS 1 QL(6.6667 ea 1 ULTRA THIN 30G MISC daily) LANCETS MISC daily) EASY COMFORT QL(6.6667 ea DIATHRIVE LANCING 1 DEVICE MISC LANCETS TWIST TOP 1 daily) MISC DROPLET LANCETS 1 QL(6.6667 ea ULTRA THIN 30G MISC daily) EASY MINI EJECT 1 LANCING DEVICE MISC DROPLET LANCING 1 DEVICE MISC EASY MINI LANCING 1 DEVICE MISC DROPLET PERSONAL 1 QL(6.6667 ea LANCETS30G MISC daily) EASY TOUCH LANCETS QL(6.6667 ea 21G/PRESSURE 1 daily) DRUG MART ACTIVATED MISC ADJUSTABLE LANCING 1 DEVICE MISC EASY TOUCH LANCETS QL(6.6667 ea 23G/PRESSURE 1 daily) DRUG MART LANCETS 1 QL(6.6667 ea ACTIVATED MISC THIN MISC daily) EASY TOUCH LANCETS QL(6.6667 ea DRUG MART ON-THE-GO QL(6.6667 ea 26G/PRESSURE 1 daily) LANCETS GENTLE 30G 1 daily) ACTIVATED MISC MISC EASY TOUCH LANCETS 1 QL(6.6667 ea DRUG MART UNILET QL(6.6667 ea 26G/PULL-TOP MISC daily) LANCETSSUPER THIN 1 daily) 30G MISC EASY TOUCH LANCETS QL(6.6667 ea 28G/PRESSURE 1 daily) DRUG MART UNILET QL(6.6667 ea ACTIVATED MISC LANCETSULTRA THIN 1 daily) 28G MISC EASY TOUCH LANCETS 1 QL(6.6667 ea 28G/PULL-TOP MISC daily) DRUG MART UNILET QL(6.6667 ea MICRO THIN LANCETS 1 daily) EASY TOUCH LANCETS 1 QL(6.6667 ea 33G MISC 28G/TWIST MISC daily) EASY TOUCH LANCETS QL(6.6667 ea E-Z JECT LANCETS 21G 1 QL(6.6667 ea MISC daily) 30G/BUTTON-ACTIVATED 1 daily) MISC E-Z JECT LANCETS 1 QL(6.6667 ea COLOR MISC daily) EASY TOUCH LANCETS QL(6.6667 ea 30G/PRESSURE 1 daily) ACTIVATED MISC Ambetter Formulary Updated December 1, 2020

81 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EASY TOUCH LANCETS 1 QL(6.6667 ea EQL THIN LANCETS 26G 1 QL(6.6667 ea 30G/PULL-TOP MISC daily) MISC daily) EASY TOUCH LANCETS 1 QL(6.6667 ea EZ SMART BLOOD QL(6.6667 ea 30G/TWIST MISC daily) GLUCOSE LANCETS 1 daily) EASY TOUCH LANCETS QL(6.6667 ea MISC 1 32G/PRESSURE daily) EZ-LETS LANCETS 21G 1 QL(6.6667 ea ACTIVATED MISC MISC daily) EASY TOUCH LANCETS 1 QL(6.6667 ea EZ-LETS LANCETS 26G 1 QL(6.6667 ea 32G/PULL-TOP MISC daily) SUPER-SOFT MISC daily) EASY TOUCH LANCETS 1 QL(6.6667 ea EZ-LETS LANCETS 28G 1 QL(6.6667 ea 32G/TWIST MISC daily) ULTRA-SOFT MISC daily) EASY TOUCH LANCETS 1 QL(6.6667 ea EZ-LETS LANCETS 30G 1 QL(6.6667 ea 33G/TWIST MISC daily) MISC daily) EASY TOUCH LANCING 1 FIFTY50 SAFETY SEAL 1 QL(6.6667 ea DEVICE/EJECTOR MISC LANCETS 30G MISC daily) EASY TOUCH SAFETY QL(6.6667 ea FIFTY50 SAFETY SEAL 1 QL(6.6667 ea LANCETS21G/PRESSURE 1 daily) LANCETS 32G MISC daily) ACTIVATED MISC FIFTY50 UNILET 1 QL(6.6667 ea EASY TOUCH SAFETY QL(6.6667 ea LANCETS 33G MISC daily) LANCETS23G/PRESSURE 1 daily) FINE 30 MISC 1 QL(6.6667 ea ACTIVATED MISC daily) EASY TOUCH SAFETY QL(6.6667 ea FINGERSTIX LANCETS 1 QL(6.6667 ea LANCETS26G/BUTTON 1 daily) MISC daily) ACTIVATED MISC FORA LANCETS MISC 1 QL(6.6667 ea EASY TOUCH SAFETY QL(6.6667 ea daily) LANCETS26G/PRESSURE 1 daily) ACTIVATED MISC FORA LANCING DEVICE 1 MISC EASY TOUCH SAFETY QL(6.6667 ea LANCETS28G/BUTTON 1 daily) FORA LANCING 1 ACTIVATED MISC DEVICE/CLEARCAP MISC EASY TOUCH SAFETY QL(6.6667 ea FREDS PHARMACY LANCETS28G/PRESSURE 1 daily) AUTOLET LANCING 1 ACTIVATED MISC DEVICE MISC FREDS PHARMACY QL(6.6667 ea EASY TWIST & CAP 1 QL(6.6667 ea LANCETS MISC daily) UNILET LANCETS SUPER 1 daily) THIN 30G MISC EMBRACE LANCETS 1 QL(6.6667 ea ULTRA THIN 30G MISC daily) FREDS PHARMACY QL(6.6667 ea UNILET LANCETS ULTRA 1 daily) EMBRACE LANCING THIN 28G MISC DEVICE WITH EJECTOR 1 MISC FREESTYLE LANCETS 1 QL(6.6667 ea MISC daily) EQL COLOR LANCETS 1 QL(6.6667 ea 21G MISC daily) FREESTYLE UNISTICK II 1 QL(6.6667 ea LANCETS MISC daily) EQL COLOR LANCETS 1 QL(6.6667 ea MICRO THIN 33G MISC daily) GENTEEL BUTTERFLY 1 QL(6.6667 ea TOUCH LANCETS MISC daily) EQL SUPER THIN 1 QL(6.6667 ea LANCETS 30G MISC daily)

Ambetter Formulary Updated December 1, 2020

82 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GENTEEL LANCING GLUCOCOM LANCETS 1 QL(6.6667 ea DEVICE/BUFF BLACK 1 30G MISC daily) MISC GLUCOCOM LANCETS 1 QL(6.6667 ea GENTEEL LANCING 33G MISC daily) DEVICE/BUTTERFLY 1 GNP LANCETS 21G MISC 1 QL(6.6667 ea BLUE MISC daily) GENTEEL LANCING GNP LANCETS MICRO 1 QL(6.6667 ea DEVICE/GLORIOUS 1 THIN 33G MISC daily) GOLD MISC QL(6.6667 ea GNP LANCETS MISC 1 GENTEEL LANCING daily) DEVICE/PLAYFUL 1 PURPLE MISC GNP LANCETS SUPER 1 QL(6.6667 ea THIN 30G MISC daily) GENTEEL LANCING DEVICE/PRECIOUS 1 GNP LANCETS THIN 26G 1 QL(6.6667 ea PLATINUM MISC MISC daily) GENTEEL LANCING GNP LANCETS THIN 1 QL(6.6667 ea DEVICE/PRINCESS PINK 1 MISC daily) MISC GNP MICRO THIN 1 QL(6.6667 ea GENTEEL LANCING LANCETS 33G MISC daily) DEVICE/STATELY SILVER 1 GNP SUPER THIN 1 QL(6.6667 ea MISC LANCETS/30G MISC daily) GENTEEL LANCING GOJJI LANCING DEVICE/WILLOWY WHITE 1 DEVICE/CLEAR CAP 1 MISC MISC GOJJI STERILE LANCETS QL(6.6667 ea GENTLE-LET GP 1 QL(6.6667 ea 1 LANCETS MISC daily) 30G MISC daily) GENTLE-LET LANCETS QL(6.6667 ea GOODSENSE COLOR QL(6.6667 ea GENERAL PURPOSE 1 daily) LANCETS MICRO-THIN 1 daily) STYLE/FINE POINT MISC 33G UNIVERSAL MISC GENTLE-LET LANCETS QL(6.6667 ea GOODSENSE LANCETS 1 QL(6.6667 ea MICRO-THIN 33G MISC daily) GENERAL PURPOSE 1 daily) STYLE/MEDIUM POINT GOODSENSE LANCETS QL(6.6667 ea MISC MICRO-THIN 33G 1 daily) GENTLE-LET LANCETS QL(6.6667 ea UNIVERSAL MISC SAFETY STYLE/FINE 1 daily) GOODSENSE LANCETS QL(6.6667 ea POINT MISC ULTRA-THIN 26G 1 daily) GENTLE-LET LANCETS QL(6.6667 ea UNIVERSAL MISC SAFETY STYLE/MEDIUM 1 daily) GOODSENSE LANCETS 1 QL(6.6667 ea POINT MISC ULTRA-THIN 30G MISC daily) GLOBAL INJECT EASE 1 QL(6.6667 ea GOODSENSE LANCETS QL(6.6667 ea LANCETS 28G MISC daily) ULTRA-THIN 30G 1 daily) UNIVERSAL MISC GLOBAL INJECT EASE 1 QL(6.6667 ea LANCETS 30G MISC daily) GOODSENSE LANCING 1 DEVICE MISC GLOBAL LANCING 1 DEVICE MISC H-E-B INCONTROL ADVANCEDLANCING 1 GLUCOCOM LANCETS 1 QL(6.6667 ea 28G MISC daily) DEVICE MISC

Ambetter Formulary Updated December 1, 2020

83 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits H-E-B INCONTROL QL(6.6667 ea KROGER HEALTHPRO QL(6.6667 ea LANCETS MICRO THIN 1 daily) TWIST LANCETS/26G 1 daily) 33G MISC MISC H-E-B INCONTROL QL(6.6667 ea KROGER LANCETS 21G 1 QL(6.6667 ea LANCETS SUPER THIN 1 daily) MISC daily) 30G MISC KROGER LANCETS 1 QL(6.6667 ea H-E-B INCONTROL QL(6.6667 ea MICRO THIN33G MISC daily) LANCETS ULTRA THIN 1 daily) KROGER LANCETS MISC 1 QL(6.6667 ea 28G MISC daily) HAEMOLANCE LOW QL(6.6667 ea 1 KROGER LANCETS 1 QL(6.6667 ea FLOW LANCETS MISC daily) SUPER THIN MISC daily) QL(6.6667 ea HAEMOLANCE MISC 1 KROGER LANCETS THIN 1 QL(6.6667 ea daily) 26G MISC daily) HAEMOLANCE PLUS QL(6.6667 ea 1 KROGER LANCETS THIN 1 QL(6.6667 ea HIGH FLOW MISC daily) MISC daily) HAEMOLANCE PLUS QL(6.6667 ea 1 KROGER LANCETS 1 QL(6.6667 ea LOW FLOW MISC daily) ULTRATHIN30G MISC daily) HAEMOLANCE PLUS QL(6.6667 ea 1 KROGER LANCING 1 MAX FLOW MISC daily) DEVICE MISC HAEMOLANCE PLUS QL(6.6667 ea 1 LANCET DEVICE 1 MISC daily) ADJUSTABLE MISC HAEMOLANCE PLUS QL(6.6667 ea 1 LANCET DEVICE WITH 1 PEDIATRIC FLOW MISC daily) EJECTOR MISC HEALTH CARE LANCING 1 LANCETS 26G TWIST 1 QL(6.6667 ea DEVICE MISC TOP MISC daily) HEALTHY ACCENTS LANCETS 28G MISC 1 QL(6.6667 ea AUTOLET IMPRESSION 1 daily) LANCING DEVICE MISC LANCETS 30G MISC 1 QL(6.6667 ea HEALTHY ACCENTS QL(6.6667 ea daily) UNILET LANCETS SUPER 1 daily) THIN 30G MISC LANCETS 30G TWIST 1 QL(6.6667 ea TOP MISC daily) QL(6.6667 ea HY-VEE LANCETS MISC 1 daily) LANCETS 30G/TWIST 1 QL(6.6667 ea TOP MISC daily) HY-VEE THIN LANCETS 1 QL(6.6667 ea MISC daily) LANCETS 31G TWIST 1 QL(6.6667 ea TOP MISC daily) IN TOUCH LANCING 1 DEVICE MISC LANCETS 33G QL(6.6667 ea UNIVERSAL DESIGN 1 daily) IN TOUCH STERILE 1 QL(6.6667 ea MISC LANCETS30G MISC daily) LANCETS MICRO THIN 1 QL(6.6667 ea KINNEY LANCETS MISC 1 QL(6.6667 ea 33G MISC daily) daily) QL(6.6667 ea LANCETS MISC 1 KINNEY THIN LANCETS 1 QL(6.6667 ea daily) MISC daily) LANCETS SAFETY SEAL 1 QL(6.6667 ea KROGER AUTOLET 1 21G MISC daily) LANCING DEVICE MISC LANCETS SAFETY SEAL 1 QL(6.6667 ea 26G MISC daily)

Ambetter Formulary Updated December 1, 2020

84 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LANCETS SAFETY SEAL 1 QL(6.6667 ea LIVE BETTER LANCET 1 QL(6.6667 ea 28G MISC daily) ULTRATHIN 28G MISC daily) LANCETS SAFETY SEAL 1 QL(6.6667 ea LONGS LANCETS 1 QL(6.6667 ea 30G MISC daily) STANDARD MISC daily) LANCETS SUPER THIN 1 QL(6.6667 ea LONGS LANCETS THIN 1 QL(6.6667 ea 28G MISC daily) MISC daily) QL(6.6667 ea LONGS LANCETS ULTRA QL(6.6667 ea LANCETS THIN MISC 1 1 daily) THIN MISC daily) LANCETS TWIST TOP 1 QL(6.6667 ea MEDICHOICE PRE-SET QL(6.6667 ea MISC daily) SAFETY LANCET DUAL 1 daily) USE MISC LANCETS ULTRA FINE 1 QL(6.6667 ea MISC daily) MEDICHOICE PRE-SET QL(6.6667 ea SAFETY LANCET LOW 1 daily) LANCETS ULTRA THIN 1 QL(6.6667 ea 30G MISC daily) FLOW MISC MEDICHOICE PRE-SET QL(6.6667 ea LANCETS ULTRA THIN 1 QL(6.6667 ea MISC daily) SAFETY LANCET 1 daily) MEDIUM FLOW MISC LANCETSBULLSEYE 1 QL(6.6667 ea SAFETY MISC daily) MEDICHOICE PRE-SET QL(6.6667 ea SAFETY LANCET 1 daily) LANCING DEVICE 1 MODERATE FLOW MISC ADJUSTABLE MISC MEDICHOICE SAFETY 1 QL(6.6667 ea LANCING DEVICE MISC 1 LANCETEXTRA MISC daily) MEDICHOICE SAFETY 1 QL(6.6667 ea LANZO MISC 1 LANCETNORMAL MISC daily) MEDISENSE THIN QL(6.6667 ea LEADER ADVANCED 1 1 LANCING DEVICE MISC LANCETS MISC daily) MEDLANCE PLUS EXTRA QL(6.6667 ea LIBERTY MEDICAL 1 QL(6.6667 ea 1 LANCETS 30G MISC daily) LANCETS 21G MISC daily) MEDLANCE PLUS QL(6.6667 ea LIBERTY MINI LANCING 1 1 DEVICE MISC LANCETS LITE 25G MISC daily) LIFESCAN UNISTIK 2 QL(6.6667 ea MEDLANCE PLUS 1 QL(6.6667 ea DEEP PENETRATION 1 daily) LANCETS MISC daily) MISC MEDLANCE PLUS LITE 1 QL(6.6667 ea LANCETS 25G MISC daily) LIFESCAN UNISTIK II 1 QL(6.6667 ea LANCETS MISC daily) MEDLANCE PLUS QL(6.6667 ea SPECIAL LANCETS 1 daily) LITE TOUCH LANCETS 1 QL(6.6667 ea MISC daily) 0.8MM MISC MEDLANCE PLUS QL(6.6667 ea LITE TOUCH LANCING 1 1 PEN MISC SUPERLITE 30G MISC daily) MEDLANCE PLUS QL(6.6667 ea LITETOUCH LANCETS 1 QL(6.6667 ea MICRO THIN 33G MISC daily) SUPERLITE 1 daily) 30G/COMFORT MAX LIVE BETTER ADVANCED 1 LANCING DEVICE MISC MISC MEDLANCE PLUS QL(6.6667 ea LIVE BETTER LANCET 1 QL(6.6667 ea SUPERTHIN 30G MISC daily) UNIVERSAL LANCETS 1 daily) 21G MISC

Ambetter Formulary Updated December 1, 2020

85 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MEDLANCE PLUS/LITE 1 QL(6.6667 ea MPD SAFETY LANCET 1 QL(6.6667 ea 25G MISC daily) 28G/1.8MM MISC daily) QL(6.6667 ea MPD SAFETY LANCET QL(6.6667 ea MEDLANCE/EXTRA MISC 1 1 daily) 30G/1.8MM MISC daily) QL(6.6667 ea MPD SAFETY LANCETS QL(6.6667 ea MEDLANCE/LITE MISC 1 1 daily) 23G/1.8MM MISC daily) MEDLANCE/UNIVERSAL 1 QL(6.6667 ea MULTI-LANCET DEVICE 1 MISC daily) MISC MEIJER COLOR QL(6.6667 ea MYGLUCOHEALTH MGH QL(6.6667 ea LANCETS UNIVERSAL 1 daily) SOFTLANCE LANCETS 1 daily) 33G MISC 30G MISC NOVA SAFETY LANCETS QL(6.6667 ea MEIJER LANCETS MISC 1 QL(6.6667 ea 1 daily) 23G MISC daily) MEIJER LANCETS THIN 1 QL(6.6667 ea NOVA SAFETY LANCETS 1 QL(6.6667 ea MISC daily) 28G MISC daily) MEIJER LANCETS 1 QL(6.6667 ea NOVA SUREFLEX 1 QL(6.6667 ea UNIVERSAL21G MISC daily) LANCETS MISC daily) MEIJER LANCETS 1 QL(6.6667 ea NOVA SUREFLEX 1 UNIVERSAL30G MISC daily) LANCING DEVICE MISC MEIJER LANCETS QL(6.6667 ea QL(6.6667 ea 1 ON CALL LANCETS MISC 1 UNIVERSAL33G MISC daily) daily) MEIJER SUPER THIN 1 QL(6.6667 ea ON CALL LANCING 1 LANCETS MISC daily) DEVICE MISC MICROLET LANCETS 1 QL(6.6667 ea ON CALL PLUS LANCETS 1 QL(6.6667 ea MISC daily) MISC daily) MICROLET NEXT MISC 1 ON CALL PLUS LANCING 1 DEVICE MISC MICROTAINER SAFETY QL(6.6667 ea ONETOUCH CLUB QL(6.6667 ea FLOW 1 daily) LANCETS FINE POINT 1 daily) LANCET/STERILE/SINGL MISC E-USE MISC ONETOUCH DELICA QL(6.6667 ea MINI LANCING DEVICE 1 LANCETS EXTRA FINE 1 daily) MISC 33G MISC MM LANCING DEVICE 1 ONETOUCH DELICA 1 QL(6.6667 ea MISC LANCETS FINE 30G MISC daily) MM TWIST LANCETS QL(6.6667 ea 1 ONETOUCH DELICA 1 MISC daily) LANCING DEVICE MISC MONOLET LANCETS 1 QL(6.6667 ea ONETOUCH DELICA QL(6.6667 ea MISC daily) PLUS LANCETS EXTRA 1 daily) FINE 33G MISC MONOLET OPD LANCETS 1 QL(6.6667 ea MISC daily) ONETOUCH DELICA QL(6.6667 ea PLUS LANCETS FINE 30G 1 daily) MONOLETTOR SAFETY 1 QL(6.6667 ea LANCETS MISC daily) MISC ONETOUCH DELICA MPD SAFETY LANCET 1 QL(6.6667 ea 21G/1.8MM MISC daily) PLUS LANCING DEVICE 1 MISC

Ambetter Formulary Updated December 1, 2020

86 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ONETOUCH FINEPOINT QL(6.6667 ea 1 PRO COMFORT 1 QL(6.6667 ea LANCETS MISC daily) LANCETS 31G MISC daily) ONETOUCH ULTRASOFT QL(6.6667 ea 1 PRODIGY LANCING 1 LANCETS MISC daily) DEVICE MISC PC LANCETS SUPER 1 QL(6.6667 ea PRODIGY PRESSURE QL(6.6667 ea THIN 30G MISC daily) ACTIVATED SAFETY 1 daily) LANCETS MISC PERFECT LANCETS 30G 1 QL(6.6667 ea MISC daily) PRODIGY SAFETY 1 QL(6.6667 ea PERFECT PRESSURE QL(6.6667 ea LANCETS MISC daily) ACTIVATED SAFETY 1 daily) PRODIGY TWIST TOP 1 QL(6.6667 ea LANCETS 28G MISC LANCETS MISC daily) PHARMACIST CHOICE QL(6.6667 ea PSS SELECT GP 1 QL(6.6667 ea ULTRA THIN LANCETS 1 daily) LANCETS MISC daily) 28G MISC PSS SELECT SAFETY 1 QL(6.6667 ea PHARMACIST CHOICE QL(6.6667 ea LANCETS MISC daily) ULTRA THIN LANCETS 1 daily) PUSH BUTTON SAFETY 1 QL(6.6667 ea 30G MISC LANCETS 21G MISC daily) PHARMACIST CHOICE QL(6.6667 ea PUSH BUTTON SAFETY 1 QL(6.6667 ea ULTRA THIN LANCETS 1 daily) LANCETS 28G MISC daily) 31G MISC PX ADVANCED LANCING 1 PHARMACIST CHOICE QL(6.6667 ea DEVICE MISC ULTRA THIN LANCETS 1 daily) 33G MISC PX LANCET AUTO 1 INJECTOR MISC PHARMACIST CHOICE QL(6.6667 ea ULTRA THIN LANCETS 1 daily) PX LANCETS ULTRA 1 QL(6.6667 ea MISC THIN 28G MISC daily) PX LANCETS ULTRA QL(6.6667 ea PHARMACY COUNTER 1 QL(6.6667 ea 1 LANCETS MISC daily) THIN MISC daily) QC ADVANCED LANCING PIP LANCETS/28G MISC 1 QL(6.6667 ea 1 daily) DEVICE MISC QC LANCETS SUPER QL(6.6667 ea PIP LANCETS/30G MISC 1 QL(6.6667 ea 1 daily) THIN MISC daily) QC LANCETS ULTRA QL(6.6667 ea PRECISION THINS GP 1 QL(6.6667 ea 1 LANCET MISC daily) THIN MISC daily) PREFERRED PLUS QL(6.6667 ea QC UNILET LANCETS 1 QL(6.6667 ea LANCETS COLORED 21G 1 daily) 28G/ULTRA THIN MISC daily) MISC QC UNILET LANCETS 1 QL(6.6667 ea PREFERRED PLUS QL(6.6667 ea 33G/MICRO THIN MISC daily) LANCETS SUPER THIN 1 daily) RA E-ZJECT COLOR QL(6.6667 ea 30G MISC LANCETSMICRO-THIN 1 daily) 33G MISC PREFERRED PLUS 1 QL(6.6667 ea LANCETS THIN 26G MISC daily) RA E-ZJECT LANCETS 1 QL(6.6667 ea PRESSURE ACTIVATED QL(6.6667 ea 28G MISC daily) SAFETYLANCET 21G 1 daily) RA E-ZJECT LANCETS 1 QL(6.6667 ea MISC THIN 26G MISC daily) RA E-ZJECT LANCETS QL(6.6667 ea PRO COMFORT 1 QL(6.6667 ea 1 LANCETS 30G MISC daily) THIN 28G MISC daily) Ambetter Formulary Updated December 1, 2020

87 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits RA E-ZJECT LANCETS 1 QL(6.6667 ea RELION ULTRA THIN QL(6.6667 ea ULTRATHIN 30G MISC daily) PLUS LANCETS 33G 1 daily) MISC RA LANCING DEVICE 1 MISC REXALL LANCETS ULTRA 1 QL(6.6667 ea READYLANCE SAFETY QL(6.6667 ea THIN MISC daily) 1 LANCETS/21G/2.2MM daily) RIGHTEST GD500 1 MISC LANCING DEVICE MISC READYLANCE SAFETY QL(6.6667 ea RIGHTEST GL300 1 QL(6.6667 ea LANCETS/23G/1.8MM 1 daily) LANCETS MISC daily) MISC SAFE-T-LANCE LOW 1 QL(6.6667 ea READYLANCE SAFETY QL(6.6667 ea FLOW 25G MISC daily) LANCETS/26G/1.8MM 1 daily) SAFE-T-LANCE NORMAL 1 QL(6.6667 ea MISC FLOW21G MISC daily) READYLANCE SAFETY QL(6.6667 ea SAFE-T-LANCE PLUS QL(6.6667 ea LANCETS/28G/1.8MM 1 daily) SAFETYLANCET HIGH 1 daily) MISC FLOW MISC READYLANCE SAFETY QL(6.6667 ea SAFE-T-LANCE PLUS QL(6.6667 ea LANCETS/30G/1.6MM 1 daily) SAFETYLANCET LOW 1 daily) MISC FLOW MISC QL(6.6667 ea REALITY LANCETS MISC 1 SAFE-T-LANCE PLUS QL(6.6667 ea daily) SAFETYLANCET 1 daily) REALITY TRIGGER 1 QL(6.6667 ea NORMAL FLOW MISC LANCETS MISC daily) SAFETY LANCET QL(6.6667 ea 1 RELION 2-IN-1 LANCET 1 21G/PRESSURE daily) DEVICES 30G MISC ACTIVATED MISC RELION 2-IN-1 LANCING 1 SAFETY LANCET QL(6.6667 ea DEVICE 25G MISC 23G/PRESSURE 1 daily) ACTIVATED MISC RELION 2-IN-1 LANCING 1 DEVICE 30G MISC SAFETY LANCET QL(6.6667 ea 28G/PRESSURE 1 daily) RELION LANCETS 1 QL(6.6667 ea MICRO-THIN33G MISC daily) ACTIVATED MISC SAFETY LANCET QL(6.6667 ea RELION LANCETS 1 QL(6.6667 ea STANDARD 21G MISC daily) 30G/PRESSURE 1 daily) ACTIVATED MISC RELION LANCETS THIN 1 QL(6.6667 ea 26G MISC daily) SAFETY LANCETS 21G 1 QL(6.6667 ea MISC daily) RELION LANCETS 1 QL(6.6667 ea ULTRA-THIN30G MISC daily) SAFETY LANCETS 28G 1 QL(6.6667 ea MISC daily) RELION LANCING 1 DEVICE MISC SAFETY LANCETS MISC 1 QL(6.6667 ea daily) RELION ULTRA THIN 1 QL(6.6667 ea LANCETS/30G MISC daily) SAFETY LET LANCETS 1 QL(6.6667 ea MISC daily) RELION ULTRA THIN 1 QL(6.6667 ea LANCETS30G MISC daily) SAFETY SEAL LANCETS 1 QL(6.6667 ea 28G MISC daily) RELION ULTRA THIN QL(6.6667 ea PLUS LANCETS 32G 1 daily) SAFETY SEAL LANCETS 1 QL(6.6667 ea MISC 30G MISC daily)

Ambetter Formulary Updated December 1, 2020

88 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SAPS HEALTH CARE QL(6.6667 ea SMART SENSE THIN QL(6.6667 ea TWIST TOP LANCETS 1 daily) LANCETSUNIVERSAL 1 daily) MISC 26G MISC SAPS HEALTH TWIST 1 QL(6.6667 ea SMARTEST LANCETS 1 QL(6.6667 ea TOP LANCETS 30G MISC daily) 28G MISC daily) SAPSCARE TWIST TOP 1 QL(6.6667 ea SOLUS V2 LANCING 1 LANCETS 30G MISC daily) DEVICE MISC SOLUS V2 PRESSURE QL(6.6667 ea SB LANCETS THIN MISC 1 QL(6.6667 ea daily) ACTIVATED SAFETY 1 daily) LANCETS 28G MISC SB LANCETS ULTRA 1 QL(6.6667 ea THIN MISC daily) SOLUS V2 TWIST 1 QL(6.6667 ea LANCETS 30G MISC daily) SELECT-LITE LANCING 1 DEVICE MISC STERILANCE TL MISC 1 QL(6.6667 ea daily) SHOPKO AUTOLET 1 LANCING DEVICE MISC SUPER THIN LANCETS 1 QL(6.6667 ea SHOPKO ON-THE-GO QL(6.6667 ea MISC daily) 1 COMFORTLANCETS 30G daily) SURE COMFORT 1 QL(6.6667 ea MISC LANCETS 18G MISC daily) SHOPKO UNILET QL(6.6667 ea SURE COMFORT 1 QL(6.6667 ea LANCETS SUPER THIN 1 daily) LANCETS 21G MISC daily) 30G MISC SURE COMFORT 1 QL(6.6667 ea SHOPKO UNILET QL(6.6667 ea LANCETS 23G MISC daily) LANCETS ULTRA THIN 1 daily) SURE COMFORT 1 QL(6.6667 ea 28G MISC LANCETS 28G MISC daily) SIDE BUTTON SAFETY QL(6.6667 ea 1 SURE COMFORT 1 QL(6.6667 ea LANCET21G MISC daily) LANCETS 30G MISC daily) SIMPLE DIAGNOSTICS 1 SURE COMFORT 1 LANCING DEVICE MISC LANCING PEN MISC QL(6.6667 ea SINGLE-LET MISC 1 SURE-LANCE FLAT 1 QL(6.6667 ea daily) LANCETS MISC daily) SM MICRO THIN QL(6.6667 ea 1 SURE-LANCE LANCETS 1 QL(6.6667 ea LANCETS 33G MISC daily) 26G MISC daily) SM TRUEDRAW LANCING 1 SURE-LANCE THIN 1 QL(6.6667 ea DEVICE MISC LANCETS 28G MISC daily) SMART DIABETES SURE-LANCE ULTRA 1 QL(6.6667 ea VANTAGE LANCING 1 THIN LANCETS MISC daily) DEVICE MISC SMART SENSE COLOR QL(6.6667 ea SURE-PEN MISC 1 LANCETS UNIVERSAL 1 daily) SURE-TOUCH LANCETS 1 QL(6.6667 ea 33G MISC UNIVERSAL MISC daily) SMART SENSE QL(6.6667 ea SURELITE LANCETS 1 QL(6.6667 ea STANDARD LANCETS 1 daily) MISC daily) UNIVERSAL 21G MISC TECHLITE AST LANCETS 1 QL(6.6667 ea SMART SENSE SUPER QL(6.6667 ea MISC daily) THIN LANCETS 1 daily) UNIVERSAL 30G MISC TECHLITE LANCETS 30G 1 QL(6.6667 ea MISC daily)

Ambetter Formulary Updated December 1, 2020

89 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TECHLITE LANCETS 1 QL(6.6667 ea TRUEPLUS SAFETY 1 QL(6.6667 ea MISC daily) LANCETS 28G MISC daily) TGT LANCET MICRO 1 QL(6.6667 ea ULTI-LANCE AUTOMATIC/ 1 THIN 33G MISC daily) CLEAR TIP MISC TGT LANCET THIN 26G 1 QL(6.6667 ea ULTILET CLASSIC 1 QL(6.6667 ea MISC daily) LANCETS MISC daily) TGT LANCET ULTRA 1 QL(6.6667 ea ULTILET LANCETS 33G 1 QL(6.6667 ea THIN 30G MISC daily) MISC daily) TGT LANCING DEVICE QL(6.6667 ea 1 ULTILET LANCETS MISC 1 MISC daily) THINLETS GP LANCETS 1 QL(6.6667 ea ULTILET SAFETY QL(6.6667 ea MISC daily) LANCETS 21G X 2.2MM 1 daily) TODAYS HEALTH MISC ADVANCED LANCING 1 ULTILET SAFETY 1 QL(6.6667 ea DEVICE MISC LANCETS 23G MISC daily) TODAYS HEALTH SUPER 1 QL(6.6667 ea ULTRA THIN LANCETS 1 QL(6.6667 ea THINLANCETS 30G MISC daily) 31G MISC daily) TODAYS HEALTH ULTRA 1 QL(6.6667 ea ULTRA-CARE LANCETS 1 QL(6.6667 ea THINLANCETS 28G MISC daily) 30G MISC daily) TOPCARE LANCETS 1 QL(6.6667 ea ULTRA-THIN II AUTO 1 QL(6.6667 ea MICRO-THIN 33G MISC daily) LANCET MISC daily) TRAVEL LANCETS 30G 1 QL(6.6667 ea ULTRA-THIN II LANCETS 1 QL(6.6667 ea MISC daily) 28G MISC daily) TRAVEL LANCETS 1 QL(6.6667 ea ULTRA-THIN II LANCETS 1 QL(6.6667 ea ADVANCED 28G MISC daily) 30G MISC daily) TRUE COMFORT TWIST 1 QL(6.6667 ea UNILET COMFORTOUCH 1 QL(6.6667 ea TOP LANCETS 30G MISC daily) LANCET MISC daily) TRUE METRIX CONTROL QL(6.6667 ea UNILET EXCELITE II MISC 1 SOLUTION LEVEL 3 1 daily) SOLN QL(6.6667 ea UNILET EXCELITE MISC 1 TRUEDRAW LANCING 1 daily) DEVICE MISC UNILET G.P. LANCET 1 QL(6.6667 ea TRUEPLUS LANCETS 1 QL(6.6667 ea MISC daily) 26G MISC daily) UNILET G.P. SUPERLITE 1 QL(6.6667 ea TRUEPLUS LANCETS 1 QL(6.6667 ea LANCET MISC daily) 28G MISC daily) UNILET GP 28 ULTRA 1 QL(6.6667 ea TRUEPLUS LANCETS 1 QL(6.6667 ea THIN MISC daily) 28G SUPER THIN MISC daily) QL(6.6667 ea UNILET LANCET MISC 1 TRUEPLUS LANCETS 1 QL(6.6667 ea daily) 30G MISC daily) UNILET LANCETS 1 QL(6.6667 ea TRUEPLUS LANCETS 1 QL(6.6667 ea MICRO-THIN33G MISC daily) 30G ULTRA THIN MISC daily) UNILET LANCETS 1 QL(6.6667 ea TRUEPLUS LANCETS 1 QL(6.6667 ea SUPER-THIN30G MISC daily) 33G MICRO THIN MISC daily) UNILET LANCETS 1 QL(6.6667 ea TRUEPLUS LANCETS 1 QL(6.6667 ea ULTRA-THIN 28G MISC daily) 33G MISC daily)

Ambetter Formulary Updated December 1, 2020

90 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits UNILET SUPERLITE 1 QL(6.6667 ea VIDA MIA UNILET QL(6.6667 ea LANCET MISC daily) LANCETS ULTRA THIN 1 daily) QL(6.6667 ea 28G MISC UNISTIK 3 GENTLE MISC 1 daily) VITALET PRO LANCETS 1 QL(6.6667 ea MISC daily) UNISTIK PRO SAFETY 1 QL(6.6667 ea LANCET 21G MISC daily) VITALET PRO PLUS 1 QL(6.6667 ea LANCETS MISC daily) UNISTIK PRO SAFETY 1 QL(6.6667 ea LANCET 25G MISC daily) VIVAGUARD LANCETS 1 QL(6.6667 ea MISC daily) UNISTIK PRO SAFETY 1 QL(6.6667 ea LANCET 28G MISC daily) VIVAGUARD LANCING 1 DEVICE MISC UNISTIK SAFETY 1 QL(6.6667 ea LANCETS 28G MISC daily) WALGREENS ADVANCED QL(6.6667 ea TRAVELLANCETS 28G 1 daily) UNISTIK SAFETY 1 QL(6.6667 ea LANCETS 30G MISC daily) MISC WALGREENS COMFORT QL(6.6667 ea UNISTIK TOUCH SAFETY 1 QL(6.6667 ea LANCETS 21G MISC daily) ASSUREDLANCETS 1 daily) MICRO THIN/33G MISC UNISTIK TOUCH SAFETY 1 QL(6.6667 ea LANCETS 23G MISC daily) WALGREENS COMFORT QL(6.6667 ea ASSUREDLANCETS 1 daily) UNISTIK TOUCH SAFETY 1 QL(6.6667 ea SUPER THIN/28G MISC LANCETS 28G MISC daily) WALGREENS LANCETS 1 QL(6.6667 ea UNISTIK TOUCH SAFETY 1 QL(6.6667 ea MISC daily) LANCETS 30G MISC daily) WALGREENS THIN 1 QL(6.6667 ea UNIVERSAL 1 LANCETS 1 QL(6.6667 ea LANCETS MISC daily) THIN26G MISC daily) WALGREENS ULTRA 1 QL(6.6667 ea UNIVERSAL 1 LANCETS 1 QL(6.6667 ea THIN LANCETS MISC daily) ULTRA THIN 30G MISC daily) UNIVERSAL 1 QL(6.6667 ea Parenteral Therapy Supplies LANCETS/33G/MICRO- 1 daily) 1ST TIER UNIFINE QL(5 ea daily); THIN MISC PENTIPS/MINI/31GX5MM 1 RX/OTC MISC VALUE PLUS LANCETS 1 QL(6.6667 ea STANDARD 21G MISC daily) 1ST TIER UNIFINE QL(5 ea daily); PENTIPS29GX12MM 1 RX/OTC VALUE PLUS LANCETS 1 QL(6.6667 ea SUPERTHIN 30G MISC daily) MISC 1ST TIER UNIFINE QL(5 ea daily) VALUE PLUS LANCETS 1 QL(6.6667 ea 1 THIN 26G MISC daily) PENTIPS31GX6MM MISC 1ST TIER UNIFINE QL(5 ea daily); VALUE PLUS LANCING 1 1 DEVICE MISC PENTIPS31GX8MM MISC RX/OTC 1ST TIER UNIFINE QL(5 ea daily); VALUMARK LANCET 1 QL(6.6667 ea 1 SUPER THIN 30G MISC daily) PENTIPS32GX4MM MISC RX/OTC 1ST TIER UNIFINE QL(5 ea daily) VALUMARK LANCET 1 QL(6.6667 ea 1 ULTRA THIN 28G MISC daily) PENTIPS32GX6MM MISC 1ST TIER UNIFINE QL(5 ea daily); VIDA MIA AUTOLET 1 LANCINGDEVICE MISC PENTIPSPLUS 31GX8MM 1 RX/OTC MISC VIDA MIA UNILET QL(6.6667 ea LANCETS SUPER THIN 1 daily) 30G MISC

Ambetter Formulary Updated December 1, 2020

91 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 1ST TIER UNIFINE QL(5 ea daily); ADVOCATE INSULIN QL(5 ea daily); 1 PENTIPSPLUS 32GX4MM RX/OTC SYRINGE/U- 1 RX/OTC MISC 100/0.5ML/30GX5/16" 1ST TIER UNIFINE QL(5 ea daily); MISC PENTIPSPLUS/MINI/31GX 1 RX/OTC ADVOCATE INSULIN QL(5 ea daily) 5MM MISC SYRINGE/U- 1 1ST TIER UNIFINE QL(5 ea daily); 100/0.5ML/31GX5/16" PENTIPSPLUS/ORIGINAL/ 1 RX/OTC MISC 29GX12MM MISC ADVOCATE INSULIN QL(5 ea daily); 1ST TIER UNIFINE QL(5 ea daily) SYRINGE/U- 1 RX/OTC PENTIPSPLUS/ULTRA 1 100/1ML/29GX1/2" MISC SHORT/31GX6MM MISC ADVOCATE INSULIN QL(5 ea daily); SYRINGE/U- 1 RX/OTC ABOUTTIME PEN 1 QL(5 ea daily); NEEDLE 32GX 5/32" MISC RX/OTC 100/1ML/30GX5/16" MISC ABOUTTIME PEN QL(5 ea daily); ADVOCATE INSULIN QL(5 ea daily) NEEDLES 30GX 5/16" 1 RX/OTC SYRINGE/U- 1 MISC 100/1ML/31GX5/16" MISC ABOUTTIME PEN QL(5 ea daily); ASSURE ID INSULIN QL(5 ea daily); NEEDLES 31G X 3/16" 1 RX/OTC SAFETYSYRINGE/U- 1 RX/OTC MISC 100/0.5ML/29G X 1/2" MISC ABOUTTIME PEN QL(5 ea daily); NEEDLES 31G X 5/16" 1 RX/OTC ASSURE ID INSULIN QL(5 ea daily); MISC SAFETYSYRINGE/U- 1 RX/OTC 100/1ML/29G X 1/2" MISC ADVOCATE INSULIN PEN QL(5 ea daily) NEEDLES 29GX12.7MM 1 ASSURE ID SAFETY PEN QL(5 ea daily); MISC NEEDLES 30G X 5/16" 1 RX/OTC MISC ADVOCATE INSULIN PEN QL(5 ea daily); NEEDLES 31GX5MM 1 RX/OTC ASSURE ID SAFETY PEN QL(5 ea daily); MISC NEEDLES 31G X 3/16" 1 RX/OTC MISC ADVOCATE INSULIN PEN QL(5 ea daily); NEEDLES 31GX8MM 1 RX/OTC AURORA PEN NEEDLES 1 QL(5 ea daily); MISC 29GX12MM MISC RX/OTC ADVOCATE INSULIN QL(5 ea daily); AURORA PEN NEEDLES 1 QL(5 ea daily) SYRINGE/U- 1 RX/OTC 31G X6MM MISC 100/0.3ML/29GX1/2" MISC AURORA PEN NEEDLES 1 QL(5 ea daily); ADVOCATE INSULIN QL(5 ea daily); 31G X8MM MISC RX/OTC SYRINGE/U- 1 RX/OTC AURORA UNIFINE 1 QL(5 ea daily); 100/0.3ML/30GX5/16" PENTIPS/32GX5/32" MISC RX/OTC MISC AURORA UNIFINE QL(5 ea daily); ADVOCATE INSULIN QL(5 ea daily) PENTIPS/MINI/31GX3/16" 1 RX/OTC SYRINGE/U- 1 MISC 100/0.3ML/31GX5/16" B-D INSULIN SYRINGE QL(5 ea daily) MISC ULTRAFINE II/0.3ML/31G 1 ADVOCATE INSULIN QL(5 ea daily); X 5/16" MISC SYRINGE/U- 1 RX/OTC B-D INSULIN SYRINGE QL(5 ea daily) 100/0.5ML/29GX1/2" MISC ULTRAFINE II/0.5ML/31G 1 X 5/16" MISC

Ambetter Formulary Updated December 1, 2020

92 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits B-D INSULIN SYRINGE QL(5 ea daily) BD INSULIN SYRINGE QL(5 ea daily) ULTRAFINE II/1ML/31G X 1 ULTRA-FINE/0.5ML/30G X 1 5/16" MISC 12.7MM MISC B-D INSULIN SYRINGE QL(5 ea daily) BD INSULIN SYRINGE QL(5 ea daily) ULTRAFINE/0.3ML/30G X 1 ULTRA-FINE/0.5ML/31G X 1 1/2" MISC 8MM MISC B-D INSULIN SYRINGE QL(5 ea daily) BD INSULIN SYRINGE QL(5 ea daily) ULTRAFINE/0.5ML/30G X 1 ULTRA-FINE/1/2 1 1/2" MISC UNIT/0.3ML/31G X 8MM BD LO-DOSE INSULIN QL(5 ea daily); MISC SYRINGE MICROFINE 1 RX/OTC BD INSULIN SYRINGE QL(5 ea daily) IV/0.5ML/28G X 1/2" MISC ULTRA-FINE/1ML/30G X 1 12.7MM MISC BD AUTOSHIELD 29G X 1 QL(5 ea daily) 5/16" MISC BD INSULIN SYRINGE QL(5 ea daily) BD INSULIN SYRINGE QL(5 ea daily); ULTRA-FINE/1ML/31G X 1 LUER-LOK/U-100/1ML 1 RX/OTC 8MM MISC MISC BD INSULIN SYRINGE QL(5 ea daily) BD INSULIN SYRINGE QL(5 ea daily); ULTRAFINE HALF- 1 UNIT/0.3ML/31G X 5/16" MICROFINE IV/U- 1 RX/OTC 100/0.5ML/28G X 1/2" MISC MISC BD INSULIN SYRINGE QL(5 ea daily) BD INSULIN SYRINGE QL(5 ea daily) ULTRAFINE/0.3ML/30G X 1 MICROFINE IV/U- 1 1/2" MISC 100/1ML/27G X 5/8" MISC BD INSULIN SYRINGE QL(5 ea daily) BD INSULIN SYRINGE QL(5 ea daily); ULTRAFINE/0.3ML/31G X 1 MICROFINE IV/U- 1 RX/OTC 5/16" MISC 100/1ML/28G X 1/2" MISC BD INSULIN SYRINGE QL(5 ea daily) BD INSULIN SYRINGE QL(5 ea daily); ULTRAFINE/0.5ML/30G X 1 1/2" MISC MICROFINE/U- 1 RX/OTC 100/0.5ML/28G X 1/2" BD INSULIN SYRINGE QL(5 ea daily) MISC ULTRAFINE/0.5ML/31G X 1 BD INSULIN SYRINGE QL(5 ea daily) 5/16" MISC MICROFINE/U- 1 BD INSULIN SYRINGE QL(5 ea daily) 100/1ML/27G X 5/8" MISC ULTRAFINE/1ML/30G X 1 BD INSULIN SYRINGE QL(5 ea daily); 1/2" MISC MICROFINE/U- 1 RX/OTC BD INSULIN SYRINGE QL(5 ea daily); 100/1ML/28G X 1/2" MISC ULTRAFINE/U- 1 RX/OTC BD INSULIN SYRINGE QL(5 ea daily); 100/0.3ML/29G X 1/2" SAFETYGLIDE/1ML/29G X 1 RX/OTC MISC 1/2" MISC BD INSULIN SYRINGE QL(5 ea daily); ULTRAFINE/U- RX/OTC BD INSULIN SYRINGE 1 QL(5 ea daily); 1 SLIP TIP/U-100/1ML MISC RX/OTC 100/0.5ML/29G X 1/2" MISC BD INSULIN SYRINGE QL(5 ea daily) ULTRA-FINE/0.3ML/30G X 1 BD INSULIN SYRINGE QL(5 ea daily); 12.7MM MISC ULTRAFINE/U- 1 RX/OTC 100/1ML/29G X 1/2" MISC BD INSULIN SYRINGE QL(5 ea daily) ULTRA-FINE/0.3ML/31G X 1 8MM MISC Ambetter Formulary Updated December 1, 2020

93 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BD INSULIN SYRINGE QL(5 ea daily) BD SAFETY-GLIDE QL(5 ea daily); ULTRAFINE/U- 1 INSULIN 1 RX/OTC 100/1ML/30G X 1/2" MISC SYRINGE/0.5ML/29G X BD INSULIN QL(5 ea daily); 1/2" MISC SYRINGE/0.3ML/29G X 1 RX/OTC BD SAFETY-LOK INSULIN QL(5 ea daily); 12.7MM MISC SYRINGE/PERM 1 RX/OTC BD INSULIN QL(5 ea daily); NEEDLE/UF/1ML/29G X SYRINGE/0.5ML/29G X 1 RX/OTC 1/2" MISC 12.7MM MISC BD SAFETYGLIDE QL(5 ea daily); BD INSULIN QL(5 ea daily); INSULIN 1 RX/OTC SYRINGE/1ML/27G X 1 RX/OTC SYRINGE/0.3ML/29G X 12.7MM MISC 1/2" MISC BD INSULIN QL(5 ea daily); BD SAFETYGLIDE QL(5 ea daily) SYRINGE/1ML/29G X 1 RX/OTC INSULIN 1 12.7MM MISC SYRINGE/0.3ML/31G X 5/16" MISC BD INSULIN QL(5 ea daily) BD SAFETYGLIDE QL(5 ea daily) SYRINGE/DETACHABLE 1 NEEDLE/U-100/1ML/25G INSULIN 1 X 1" MISC SYRINGE/1ML/31G X 15/64" MISC BD INSULIN QL(5 ea daily) BD SAFETYGLIDE QL(5 ea daily); SYRINGE/DETACHABLE 1 NEEDLE/U-100/1ML/25G INSULIN 1 RX/OTC X 5/8" MISC SYSYRINGE/0.5ML/30G X 5/16" MISC BD INSULIN QL(5 ea daily) BD VEO INSULIN QL(5 ea daily) SYRINGE/DETACHABLE 1 NEEDLE/U-100/1ML/26G SYRINGE ULTRA- 1 X 1/2" MISC FINE/1ML/31G X 6MM MISC BD INSULIN SYRINGE/U- 1 QL(5 ea daily); 100/1ML/27G X 1/2" MISC RX/OTC BD VEO INSULIN QL(5 ea daily) SYRINGE ULTRA-FINE/U- 1 BD PEN QL(5 ea daily) 100/1ML/31G X 15/64" NEEDLE/MICRO/ULTRA- 1 MISC FINE/32G X 6MM MISC CAREFINE PEN NEEDLE 1 QL(5 ea daily); BD PEN QL(5 ea daily); 32GX4MM MISC RX/OTC NEEDLE/MINI/ULTRA- 1 RX/OTC FINE/31G X 5MM MISC CAREFINE PEN 1 QL(5 ea daily); NEEDLES 29GX1/2" MISC RX/OTC BD PEN NEEDLE/NANO QL(5 ea daily); 2ND GEN/32G X 5/32" 1 RX/OTC CAREFINE PEN QL(5 ea daily); MISC NEEDLES 30GX5/16" 1 RX/OTC MISC BD PEN QL(5 ea daily); NEEDLE/NANO/ULTRA- 1 RX/OTC CAREFINE PEN QL(5 ea daily) FINE/32G X 4MM MISC NEEDLES 31GX6MM 1 MISC BD PEN QL(5 ea daily) CAREFINE PEN QL(5 ea daily); NEEDLE/ORIGINAL/ULTR 1 A-FINE/29G X 12.7MM NEEDLES 31GX8MM 1 RX/OTC MISC MISC BD PEN QL(5 ea daily); CAREFINE PEN QL(5 ea daily); NEEDLE/SHORT/ULTRA- 1 RX/OTC NEEDLES 32GX5MM 1 RX/OTC FINE/31G X 8MM MISC MISC

Ambetter Formulary Updated December 1, 2020

94 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CAREFINE PEN QL(5 ea daily) CAREONE UNIFINE QL(5 ea daily); NEEDLES 32GX6MM 1 PENTIPS PLUS PEN 1 RX/OTC MISC NEEDLES 31GX8MM CAREONE INSULIN QL(5 ea daily) MISC SYRINGES/0.3ML/30G X 1 CAREONE UNIFINE QL(5 ea daily); 1/2" MISC PENTIPS PLUS PEN 1 RX/OTC CAREONE INSULIN QL(5 ea daily) NEEDLES 32GX4MM SYRINGES/0.3ML/31G X 1 MISC 5/16" MISC CARETOUCH PEN QL(5 ea daily) CAREONE INSULIN QL(5 ea daily) NEEDLES 31G X 6 MM 1 SYRINGES/0.5ML/30G X 1 MISC 1/2" MISC CARETOUCH PEN QL(5 ea daily); CAREONE INSULIN QL(5 ea daily) NEEDLES 31GX 5MM 1 RX/OTC SYRINGES/0.5ML/31G X 1 MISC 5/16" MISC CARETOUCH PEN QL(5 ea daily); CAREONE INSULIN QL(5 ea daily) NEEDLES 31GX 8MM 1 RX/OTC SYRINGES/1ML/30G X 1 MISC 1/2" MISC CARETOUCH PEN QL(5 ea daily); CAREONE INSULIN QL(5 ea daily) NEEDLES 32GX 4MM 1 RX/OTC SYRINGES/1ML/31GX5/16 1 MISC " MISC CARETOUCH PEN QL(5 ea daily); CAREONE UNIFINE QL(5 ea daily); NEEDLES 32GX 5MM 1 RX/OTC PENTIPS 29GX12MM 1 RX/OTC MISC MISC CLEVER CHOICE QL(5 ea daily); COMFORT EZINSULIN RX/OTC CAREONE UNIFINE 1 QL(5 ea daily); 1 PENTIPS 31GX5MM MISC RX/OTC PEN NEEDLES 31GX8MM MISC CAREONE UNIFINE 1 QL(5 ea daily) PENTIPS 31GX6MM MISC CLEVER CHOICE QL(5 ea daily); COMFORT EZINSULIN 1 RX/OTC CAREONE UNIFINE 1 QL(5 ea daily); SYRINGE/0.3ML/29G X PENTIPS 31GX8MM MISC RX/OTC 1/2" MISC CAREONE UNIFINE QL(5 ea daily); CLEVER CHOICE QL(5 ea daily) PENTIPS PEN NEEDLES 1 RX/OTC COMFORT EZINSULIN 1 32GX4MM MISC SYRINGE/0.3ML/30G X CAREONE UNIFINE QL(5 ea daily); 1/2" MISC PENTIPS PLUS PEN 1 RX/OTC CLEVER CHOICE QL(5 ea daily); NEEDLES 29GX12MM COMFORT EZINSULIN 1 RX/OTC MISC SYRINGE/0.3ML/30G X CAREONE UNIFINE QL(5 ea daily); 5/16" MISC PENTIPS PLUS PEN 1 RX/OTC CLEVER CHOICE QL(5 ea daily) NEEDLES 31GX5MM COMFORT EZINSULIN 1 MISC SYRINGE/0.3ML/31G X CAREONE UNIFINE QL(5 ea daily) 5/16" MISC PENTIPS PLUS PEN 1 CLEVER CHOICE QL(5 ea daily); NEEDLES 31GX6MM COMFORT EZINSULIN 1 RX/OTC MISC SYRINGE/0.5ML/28G X 1/2" MISC

Ambetter Formulary Updated December 1, 2020

95 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CLEVER CHOICE QL(5 ea daily); CLEVER CHOICE QL(5 ea daily); COMFORT EZINSULIN 1 RX/OTC COMFORT EZPEN 1 RX/OTC SYRINGE/0.5ML/29G X NEEDLES 31GX8MM 1/2" MISC MISC CLEVER CHOICE QL(5 ea daily) CLEVER CHOICE QL(5 ea daily); COMFORT EZINSULIN 1 COMFORT EZPEN 1 RX/OTC SYRINGE/0.5ML/30G X NEEDLES 32GX4MM 1/2" MISC MISC CLEVER CHOICE QL(5 ea daily); CLEVER CHOICE QL(5 ea daily); COMFORT EZINSULIN 1 RX/OTC COMFORT EZPEN 1 RX/OTC SYRINGE/0.5ML/30G X NEEDLES 32GX5MM 5/16" MISC MISC CLEVER CHOICE QL(5 ea daily) CLEVER CHOICE QL(5 ea daily) COMFORT EZINSULIN 1 COMFORT EZPEN 1 SYRINGE/0.5ML/31G X NEEDLES 32GX6MM 5/16" MISC MISC CLEVER CHOICE QL(5 ea daily) CLICKFINE PEN NEEDLE 1 QL(5 ea daily); COMFORT EZINSULIN 1 32GX5/32" MISC RX/OTC SYRINGE/1.0ML/30G X CLICKFINE PEN NEEDLE QL(5 ea daily) 1/2" MISC UNIVERSAL/31GX1/4" 1 CLEVER CHOICE QL(5 ea daily); MISC COMFORT EZINSULIN 1 RX/OTC CLICKFINE PEN NEEDLE QL(5 ea daily); SYRINGE/1ML/28G X 1/2" UNIVERSAL/31GX5/16" 1 RX/OTC MISC MISC CLEVER CHOICE QL(5 ea daily); CLICKFINE PEN QL(5 ea daily) COMFORT EZINSULIN 1 RX/OTC NEEDLES 31G X 1/4" 1 SYRINGE/1ML/29G X 1/2" MISC MISC CLICKFINE PEN QL(5 ea daily); CLEVER CHOICE QL(5 ea daily); NEEDLES 31G X 3/16" 1 RX/OTC COMFORT EZINSULIN 1 RX/OTC MISC SYRINGE/1ML/30G X 5/16" MISC CLICKFINE PEN QL(5 ea daily); NEEDLES 31G X 5/16" 1 RX/OTC CLEVER CHOICE QL(5 ea daily) MISC COMFORT EZINSULIN 1 SYRINGE/U- CLICKFINE PEN QL(5 ea daily); 100/1ML/31GX5/16" MISC NEEDLES 31G X 8MM 1 RX/OTC MISC CLEVER CHOICE QL(5 ea daily); CLICKFINE PEN QL(5 ea daily); COMFORT EZPEN 1 RX/OTC NEEDLES 29GX12MM NEEDLES 32G X 5/32" 1 RX/OTC MISC MISC CLEVER CHOICE QL(5 ea daily); CLICKFINE PEN 1 QL(5 ea daily) NEEDLES/31GX1/4" MISC COMFORT EZPEN 1 RX/OTC NEEDLES 31GX5MM CLICKFINE UNIVERSAL QL(5 ea daily); MISC PEN NEEDLES 31GX5/16" 1 RX/OTC CLEVER CHOICE QL(5 ea daily) MISC COMFORT ASSIST QL(5 ea daily); COMFORT EZPEN 1 NEEDLES 31GX6MM INSULIN SYRINGE 1 RX/OTC MISC 0.3ML/29G X 1/2" MISC

Ambetter Formulary Updated December 1, 2020

96 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits COMFORT ASSIST QL(5 ea daily); DIATHRIVE PEN QL(5 ea daily) INSULIN 1 RX/OTC NEEDLE/31 G X 6MM 1 SYRINGE/0.3ML/30G X MISC 5/16" MISC DIATHRIVE PEN QL(5 ea daily); COMFORT ASSIST QL(5 ea daily) NEEDLE/31 GX 8MM 1 RX/OTC INSULIN 1 MISC SYRINGE/0.3ML/31G X DIATHRIVE PEN 1 QL(5 ea daily); 5/16" MISC NEEDLE/31GX 5MM MISC RX/OTC COMFORT ASSIST QL(5 ea daily); DIATHRIVE PEN 1 QL(5 ea daily); INSULIN 1 RX/OTC NEEDLE/32GX 4MM MISC RX/OTC SYRINGE/0.5ML/29G X 1/2" MISC DROPLET INSULIN QL(5 ea daily); SYRINGE 0.3ML/29G X 1 RX/OTC COMFORT ASSIST QL(5 ea daily); 1/2" MISC INSULIN 1 RX/OTC SYRINGE/0.5ML/30G X DROPLET INSULIN QL(5 ea daily); 5/16" MISC SYRINGE 0.5ML/29G X 1 RX/OTC 1/2" MISC COMFORT ASSIST QL(5 ea daily) DROPLET INSULIN QL(5 ea daily); INSULIN 1 SYRINGE/0.5ML/31G X SYRINGE 1ML/29G X 1/2" 1 RX/OTC 5/16" MISC MISC COMFORT ASSIST QL(5 ea daily); DROPLET INSULIN QL(5 ea daily) SYRINGE U-100/0.3/31G X 1 INSULIN 1 RX/OTC SYRINGE/1ML/29G X 1/2" 5/16" MISC MISC DROPLET INSULIN QL(5 ea daily) COMFORT ASSIST QL(5 ea daily); SYRINGE U- 1 100/0.3ML/30G X 1/2" INSULIN 1 RX/OTC SYRINGE/1ML/30G X MISC 5/16" MISC DROPLET INSULIN QL(5 ea daily); COMFORT ASSIST QL(5 ea daily) SYRINGE U- 1 RX/OTC 100/0.3ML/30G X 5/16" INSULIN 1 SYRINGE/1ML/31G X MISC 5/16" MISC DROPLET INSULIN QL(5 ea daily) COMFORT EZ INSULIN QL(5 ea daily) SYRINGE U- 1 100/0.5ML/30G X 1/2" SYRINGE/U- 1 100/0.5ML/31G X 5/16" MISC MISC DROPLET INSULIN QL(5 ea daily); COMFORT EZ INSULIN QL(5 ea daily) SYRINGE U- 1 RX/OTC SYRINGE/U-100/1ML/31G 1 100/0.5ML/30G X 5/16" X 5/16" MISC MISC DROPLET INSULIN QL(5 ea daily) COMFORT EZ 1 QL(5 ea daily); MICRO/32G X 4MM MISC RX/OTC SYRINGE U- 1 100/0.5ML/31G X 5/16" COMFORT EZ 1 QL(5 ea daily); MISC SHORT/31G X 8MM MISC RX/OTC DROPLET INSULIN QL(5 ea daily) COMFORT EZ/31G X 5MM 1 QL(5 ea daily); SYRINGE U-100/1ML/30G 1 MISC RX/OTC X 1/2" MISC COMFORT EZ/31G X 6MM 1 QL(5 ea daily) DROPLET INSULIN QL(5 ea daily); MISC SYRINGE U-100/1ML/30G 1 RX/OTC X 5/16" MISC

Ambetter Formulary Updated December 1, 2020

97 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DROPLET INSULIN QL(5 ea daily) DROPLET PEN NEEDLES 1 QL(5 ea daily) SYRINGE U-100/1ML/31G 1 32GX6MM MISC X 15/64" MISC DROPSAFE SAFETY PEN QL(5 ea daily); DROPLET INSULIN QL(5 ea daily) NEEDLES/31G X 5/16" 1 RX/OTC SYRINGE U-100/1ML/31G 1 MISC X 5/16" MISC DROPSAFE SAFTEY PEN QL(5 ea daily) DROPLET INSULIN QL(5 ea daily) NEEDLES/31G X 1/4" 1 SYRINGE/U- 1 MISC 100/0.3ML/31G X 5/16" DRUG MART UNIFINE 1 QL(5 ea daily); MISC PENTIPS 31GX5MM MISC RX/OTC DROPLET INSULIN QL(5 ea daily) DRUG MART UNIFINE QL(5 ea daily); SYRINGE/U- 1 PENTIPS29G X 12MM 1 RX/OTC 100/0.5ML/30G X 1/2" MISC MISC DRUG MART UNIFINE 1 QL(5 ea daily) DROPLET INSULIN QL(5 ea daily) PENTIPS31GX6MM MISC SYRINGE/U- 1 100/0.5ML/31G X 5/16" DRUG MART UNIFINE 1 QL(5 ea daily); MISC PENTIPS31GX8MM MISC RX/OTC DROPLET INSULIN QL(5 ea daily) DRUG MART UNIFINE 1 QL(5 ea daily); SYRINGE/U-100/1ML/30G 1 PENTIPS32GX4MM MISC RX/OTC X 1/2" MISC DRUG MART UNIFINE QL(5 ea daily); DROPLET INSULIN QL(5 ea daily) PENTIPSPLUS 32GX4MM 1 RX/OTC SYRINGE/U-100/1ML/31G 1 MISC X 15/64" MISC EASY COMFORT INSULIN QL(5 ea daily); DROPLET INSULIN QL(5 ea daily) SYRINGE/0.5ML/30G X 1 RX/OTC SYRINGE/U-100/1ML/31G 1 5/16" MISC X 5/16" MISC EASY COMFORT INSULIN QL(5 ea daily) SYRINGE/0.5ML/31G X 1 DROPLET PEN NEEDLES 1 QL(5 ea daily); 29GX12MM MISC RX/OTC 5/16" MISC EASY COMFORT INSULIN QL(5 ea daily); DROPLET PEN NEEDLES 1 QL(5 ea daily); 30G X 5/16" MISC RX/OTC SYRINGE/1ML/30G X 1 RX/OTC 5/16" MISC DROPLET PEN NEEDLES 1 QL(5 ea daily); 31GX5MM MISC RX/OTC EASY COMFORT INSULIN QL(5 ea daily) SYRINGE/1ML/31G X 1 DROPLET PEN NEEDLES 1 QL(5 ea daily) 5/16" MISC 31GX6MM MISC EASY COMFORT INSULIN QL(5 ea daily) DROPLET PEN NEEDLES QL(5 ea daily); 1 SYRINGE/U- 1 31GX8MM MISC RX/OTC 100/0.5ML/30G X 1/2" DROPLET PEN NEEDLES 1 QL(5 ea daily) MISC 32G X 1/4" MISC EASY COMFORT INSULIN QL(5 ea daily) DROPLET PEN NEEDLES 1 QL(5 ea daily); SYRINGE/U-100/1ML/30G 1 32G X 3/16" MISC RX/OTC X 1/2" MISC DROPLET PEN NEEDLES QL(5 ea daily); 1 EASY COMFORT PEN 1 QL(5 ea daily) 32G X 5/32" MISC RX/OTC NEEDLES31GX1/4" MISC DROPLET PEN NEEDLES QL(5 ea daily); 1 EASY COMFORT PEN 1 QL(5 ea daily); 32GX4MM MISC RX/OTC NEEDLES31GX3/16" MISC RX/OTC DROPLET PEN NEEDLES QL(5 ea daily); 1 EASY COMFORT PEN 1 QL(5 ea daily); 32GX5MM MISC RX/OTC NEEDLES31GX5/16" MISC RX/OTC

Ambetter Formulary Updated December 1, 2020

98 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EASY COMFORT PEN QL(5 ea daily); EASY TOUCH INSULIN QL(5 ea daily); NEEDLES32GX5/32" 1 RX/OTC SYRINGE/SAFETY/U- 1 RX/OTC MISC 100/1ML/29G X 1/2" MISC EASY TOUCH 32GX5MM 1 QL(5 ea daily); EASY TOUCH INSULIN QL(5 ea daily) MISC RX/OTC SYRINGE/SAFETY/U- 1 100/1ML/30G X 1/2" MISC EASY TOUCH 32GX6MM 1 QL(5 ea daily) MISC EASY TOUCH INSULIN QL(5 ea daily) EASY TOUCH FLIPLOCK QL(5 ea daily); SYRINGE/U- 1 100/0.3ML/30G X 1/2" SAFETY INSULIN 1 RX/OTC SYRINGE 1ML/29GX1/2" MISC MISC EASY TOUCH INSULIN QL(5 ea daily) EASY TOUCH FLIPLOCK QL(5 ea daily) SYRINGE/U- 1 100/0.5ML/27G X 1/2" SAFETY INSULIN 1 SYRINGE 1ML/30GX1/2" MISC MISC EASY TOUCH INSULIN QL(5 ea daily); EASY TOUCH FLIPLOCK QL(5 ea daily); SYRINGE/U- 1 RX/OTC 100/0.5ML/28G X 1/2" SAFETY INSULIN 1 RX/OTC SYRINGE 1ML/30GX5/16" MISC MISC EASY TOUCH INSULIN QL(5 ea daily) EASY TOUCH FLIPLOCK QL(5 ea daily) SYRINGE/U- 1 100/0.5ML/30G X 1/2" SAFETY INSULIN 1 SYRINGE 1ML/31GX5/16" MISC MISC EASY TOUCH INSULIN QL(5 ea daily) EASY TOUCH INSULIN QL(5 ea daily); SYRINGE/U- 1 SYRINGE/0.3ML/30G X 1 RX/OTC 100/0.5ML/31G X 5/16" 5/16" MISC MISC EASY TOUCH INSULIN QL(5 ea daily) EASY TOUCH INSULIN QL(5 ea daily); SYRINGE/0.3ML/31G X 1 SYRINGE/U-100/1ML/27G 1 RX/OTC 5/16" MISC X 1/2" MISC EASY TOUCH INSULIN QL(5 ea daily); EASY TOUCH INSULIN QL(5 ea daily); SYRINGE/0.5ML/29G X 1 RX/OTC SYRINGE/U-100/1ML/28G 1 RX/OTC 1/2" MISC X 1/2" MISC EASY TOUCH INSULIN QL(5 ea daily); EASY TOUCH INSULIN QL(5 ea daily); SYRINGE/0.5ML/30G X 1 RX/OTC SYRINGE/U-100/1ML/29G 1 RX/OTC 5/16" MISC X 1/2" MISC EASY TOUCH INSULIN QL(5 ea daily); EASY TOUCH INSULIN QL(5 ea daily) SYRINGE/1ML/30G X 1 RX/OTC SYRINGE/U-100/1ML/30G 1 5/16" MISC X 1/2" MISC EASY TOUCH INSULIN QL(5 ea daily); EASY TOUCH INSULIN QL(5 ea daily) SYRINGE/U-100/1ML/31G 1 SYRINGE/SAFETY/U- 1 RX/OTC 100/0.5ML/29G X 1/2" X 5/16" MISC MISC EASY TOUCH PEN QL(5 ea daily); EASY TOUCH INSULIN QL(5 ea daily); NEEDLE 30G X 5/16" 1 RX/OTC MISC SYRINGE/SAFETY/U- 1 RX/OTC 100/0.5ML/30G X 5/16" EASY TOUCH PEN 1 QL(5 ea daily); MISC NEEDLES 29GX1/2" MISC RX/OTC EASY TOUCH PEN 1 QL(5 ea daily) NEEDLES 31GX1/4" MISC

Ambetter Formulary Updated December 1, 2020

99 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EASY TOUCH PEN QL(5 ea daily); ELITE-THIN INSULIN QL(5 ea daily); 1 NEEDLES 31GX5/16" RX/OTC SYRINGE/U- 1 RX/OTC MISC 100/0.5ML/28G X 1/2" MISC EASY TOUCH PEN 1 QL(5 ea daily) NEEDLES 32GX1/4" MISC ELITE-THIN INSULIN QL(5 ea daily) EASY TOUCH PEN QL(5 ea daily); SYRINGE/U- 1 NEEDLES 32GX3/16" 1 RX/OTC 100/0.5ML/31G X 5/16" MISC MISC EASY TOUCH PEN QL(5 ea daily); ELITE-THIN INSULIN QL(5 ea daily); NEEDLES 32GX5/32" 1 RX/OTC SYRINGE/U-100/1ML/28G 1 RX/OTC MISC X 1/2" MISC EASY TOUCH PEN QL(5 ea daily); ELITE-THIN INSULIN QL(5 ea daily); NEEDLES/31G X 3/16" 1 RX/OTC SYRINGE/U-100/1ML/29G 1 RX/OTC MISC X 1/2" MISC EASY TOUCH SAFETY QL(5 ea daily) ELITE-THIN INSULIN QL(5 ea daily) PEN NEEDLES/29G X 1 SYRINGE/U-100/1ML/31G 1 8MM MISC X 5/16" MISC EASY TOUCH SAFETY QL(5 ea daily); EQL INSULIN QL(5 ea daily); PEN NEEDLES/30G X 1 RX/OTC SYRINGE/0.3ML/29G X 1 RX/OTC 5/16" MISC 1/2" MISC EASY TOUCH QL(5 ea daily); EQL INSULIN QL(5 ea daily); SYRINGE/0.3ML/30G X 1 RX/OTC SHEATHLOCK SAFETY 1 RX/OTC INSULIN SYRINGE 5/16" MISC 1ML/29GX1/2" MISC EQL INSULIN QL(5 ea daily) EASY TOUCH QL(5 ea daily); SYRINGE/0.3ML/31G X 1 5/16" MISC SHEATHLOCK SAFETY 1 RX/OTC INSULIN SYRINGE EQL INSULIN QL(5 ea daily); 1ML/30GX5/16" MISC SYRINGE/0.5ML/29G X 1 RX/OTC EASY TOUCH QL(5 ea daily) 1/2" MISC SHEATHLOCK SAFETY 1 EQL INSULIN QL(5 ea daily); INSULIN SYRINGE SYRINGE/0.5ML/30G X 1 RX/OTC 1ML/31GX5/16" MISC 5/16" MISC EASY TOUCH QL(5 ea daily) EQL INSULIN QL(5 ea daily) SHEATHLOCK SAFETY 1 SYRINGE/0.5ML/31G X 1 SYRINGE 1ML/30GX1/2" 5/16" MISC MISC EQL INSULIN QL(5 ea daily); ELITE-THIN INSULIN QL(5 ea daily) SYRINGE/1ML/29G X 1/2" 1 RX/OTC SYRINGE/0.3ML/31G X 1 MISC 5/16" MISC EQL INSULIN QL(5 ea daily); ELITE-THIN INSULIN QL(5 ea daily); SYRINGE/1ML/30G X 1 RX/OTC SYRINGE/0.5ML/29G X 1 RX/OTC 5/16" MISC 1/2" MISC EQL INSULIN QL(5 ea daily) ELITE-THIN INSULIN QL(5 ea daily); SYRINGE/1ML/31G X 1 SYRINGE/0.5ML/30G X 1 RX/OTC 5/16" MISC 5/16" MISC EXEL COMFORT POINT QL(5 ea daily); ELITE-THIN INSULIN QL(5 ea daily); INSULIN PEN NEEDLES 1 RX/OTC SYRINGE/1ML/30G X 1 RX/OTC 29G X 12MM MISC 5/16" MISC

Ambetter Formulary Updated December 1, 2020

100 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EXEL COMFORT POINT QL(5 ea daily) FIFTY50 PEN QL(5 ea daily); INSULIN PEN NEEDLES 1 NEEDLES/32GX4MM 1 RX/OTC 31G X 6MM MISC MISC EXEL COMFORT POINT QL(5 ea daily); FIFTY50 PEN QL(5 ea daily) INSULIN PEN NEEDLES 1 RX/OTC NEEDLES/32GX6MM 1 31G X 8MM MISC MISC EXEL COMFORT POINT QL(5 ea daily); FIFTY50 SUPERIOR QL(5 ea daily) INSULIN 1 RX/OTC COMFORTINSULIN 1 SYRINGE/0.3ML/29G X SYRINGE/0.3ML/31G X 1/2" MISC 5/16" MISC EXEL COMFORT POINT QL(5 ea daily); FIFTY50 SUPERIOR QL(5 ea daily) INSULIN 1 RX/OTC COMFORTINSULIN 1 SYRINGE/0.3ML/30G X SYRINGE/0.5ML/31G X 5/16" MISC 5/16" MISC EXEL COMFORT POINT QL(5 ea daily); FIFTY50 SUPERIOR QL(5 ea daily) INSULIN 1 RX/OTC COMFORTINSULIN 1 SYRINGE/0.5ML/28G X SYRINGE/1ML/31G X 1/2" MISC 5/16" MISC EXEL COMFORT POINT QL(5 ea daily); FREDS PHARMACY QL(5 ea daily); INSULIN 1 RX/OTC UNIFINE PENTIPS PEN 1 RX/OTC SYRINGE/0.5ML/29G X NEEDLES 32GX4MM 1/2" MISC MISC EXEL COMFORT POINT QL(5 ea daily); FREDS PHARMACY QL(5 ea daily); 1 INSULIN 1 RX/OTC UNIFINE PENTIPS PLUS RX/OTC SYRINGE/0.5ML/30G X 31GX5MM MISC 5/16" MISC FREDS PHARMACY QL(5 ea daily); EXEL COMFORT POINT QL(5 ea daily); UNIFINE PENTIPS PLUS 1 RX/OTC INSULIN 1 RX/OTC 31GX8MM MISC SYRINGE/1ML/28G X 1/2" FREESTYLE PRECISION QL(5 ea daily); MISC INSULIN SYRINGE/U- 1 RX/OTC EXEL COMFORT POINT QL(5 ea daily); 100/0.5ML/30G X 5/16" INSULIN 1 RX/OTC MISC SYRINGE/1ML/29G X 1/2" FREESTYLE PRECISION QL(5 ea daily) MISC INSULIN SYRINGE/U- 1 EXEL COMFORT POINT QL(5 ea daily); 100/0.5ML/31G X 5/16" INSULIN 1 RX/OTC MISC SYRINGE/1ML/30G X FREESTYLE PRECISION QL(5 ea daily) 5/16" MISC INSULIN SYRINGE/U- 1 FIFTY50 PEN NEEDLES 1 QL(5 ea daily); 100/1ML/31G X 5/16" 31G X3/16" (5MM) MISC RX/OTC MISC FIFTY50 PEN NEEDLES 1 QL(5 ea daily); FREESTYLE PRECISION QL(5 ea daily); ) MISC 31G X5/16" (8MM RX/OTC INSULIN SYRINGES/U- 1 RX/OTC 100/1ML/30G X 5/16" FIFTY50 PEN NEEDLES 1 QL(5 ea daily); 31GX5MM MISC RX/OTC MISC FIFTY50 PEN QL(5 ea daily); GLOBAL EASE INJECT QL(5 ea daily); NEEDLES/31GX8MM 1 RX/OTC PEN NEEDLES 1 RX/OTC MISC 29GX12MM MISC

Ambetter Formulary Updated December 1, 2020

101 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GLOBAL EASE INJECT QL(5 ea daily); GLOBAL INJECT EASE QL(5 ea daily); 1 PEN NEEDLES 31GX8MM RX/OTC INSULIN SYRINGE/U- 1 RX/OTC MISC 100/0.5ML/30G X 5/16" GLOBAL EASE INJECT QL(5 ea daily); MISC PEN NEEDLES 32GX4MM 1 RX/OTC GLOBAL INJECT EASE QL(5 ea daily) MISC INSULIN SYRINGE/U- 1 GLOBAL EASE INJECT QL(5 ea daily); 100/0.5ML/31G X 5/16" PEN NEEEDLES 1 RX/OTC MISC 31GX5MM MISC GLOBAL INJECT EASE QL(5 ea daily); GLOBAL EASY GLIDE QL(5 ea daily) INSULIN SYRINGE/U- 1 RX/OTC 100/1ML/28G X 1/2" MISC INSULIN 1 SYRINGE/1ML/31G X GLOBAL INJECT EASE QL(5 ea daily); 15/64" MISC INSULIN SYRINGE/U- 1 RX/OTC GLOBAL EASY GLIDE QL(5 ea daily) 100/1ML/29G X 1/2" MISC INSULINSYRINGE/U- 1 GLOBAL INJECT EASE QL(5 ea daily) 100/0.3ML/31G X 5/16" INSULIN SYRINGE/U- 1 MISC 100/1ML/30G X 1/2" MISC GLOBAL EASY GLIDE QL(5 ea daily); GLOBAL INJECT EASE QL(5 ea daily); 1 PEN NEEDLES 32GX4MM RX/OTC INSULIN SYRINGE/U- 1 RX/OTC MISC 100/1ML/30G X 5/16" GLOBAL INJECT EASE QL(5 ea daily); MISC INSULIN SYRINGE/U- 1 RX/OTC GLOBAL INJECT EASE QL(5 ea daily) 100/0.3ML/29G X 1/2" INSULIN SYRINGE/U- 1 MISC 100/1ML/31G X 5/16" GLOBAL INJECT EASE QL(5 ea daily) MISC INSULIN SYRINGE/U- 1 GLOBAL INSULIN QL(5 ea daily) 100/0.3ML/30G X 1/2" SYRINGE/U- 1 MISC 100/0.3ML/30G X 1/2" GLOBAL INJECT EASE QL(5 ea daily); MISC INSULIN SYRINGE/U- 1 RX/OTC GLOBAL INSULIN QL(5 ea daily); 100/0.3ML/30G X 5/16" SYRINGES/U- 1 RX/OTC MISC 100/0.3ML/30GX5/16" GLOBAL INJECT EASE QL(5 ea daily) MISC INSULIN SYRINGE/U- 1 GLUCOPRO INSULIN QL(5 ea daily) 100/0.3ML/31G X 5/16" SYRINGE/U- 1 MISC 100/0.3ML/30G X 1/2" GLOBAL INJECT EASE QL(5 ea daily); MISC INSULIN SYRINGE/U- 1 RX/OTC GLUCOPRO INSULIN QL(5 ea daily); 100/0.5ML/28G X 1/2" SYRINGE/U- 1 RX/OTC MISC 100/0.3ML/30G X 5/16" GLOBAL INJECT EASE QL(5 ea daily); MISC INSULIN SYRINGE/U- 1 RX/OTC GLUCOPRO INSULIN QL(5 ea daily) 100/0.5ML/29G X 1/2" SYRINGE/U- 1 MISC 100/0.3ML/31G X 5/16" GLOBAL INJECT EASE QL(5 ea daily) MISC INSULIN SYRINGE/U- 1 100/0.5ML/30G X 1/2" MISC

Ambetter Formulary Updated December 1, 2020

102 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GLUCOPRO INSULIN QL(5 ea daily) GNP INSULIN QL(5 ea daily); SYRINGE/U- 1 SYRINGE/0.5ML/30G X 1 RX/OTC 100/0.5ML/30G X 1/2" 5/16" MISC MISC GNP INSULIN QL(5 ea daily) GLUCOPRO INSULIN QL(5 ea daily); SYRINGE/0.5ML/31G X 1 SYRINGE/U- 1 RX/OTC 5/16" MISC 100/0.5ML/30G X 5/16" GNP INSULIN QL(5 ea daily); MISC SYRINGE/1ML/28G X 1/2" 1 RX/OTC GLUCOPRO INSULIN QL(5 ea daily) MISC SYRINGE/U- 1 GNP INSULIN QL(5 ea daily); 100/0.5ML/31G X 5/16" SYRINGE/1ML/29G X 1/2" 1 RX/OTC MISC MISC GLUCOPRO INSULIN QL(5 ea daily) GNP INSULIN QL(5 ea daily); SYRINGE/U-100/1ML/30G 1 SYRINGE/1ML/30G X 1 RX/OTC X 1/2" MISC 5/16" MISC GLUCOPRO INSULIN QL(5 ea daily); GNP INSULIN QL(5 ea daily) SYRINGE/U-100/1ML/30G 1 RX/OTC SYRINGE/1ML/31G X 1 X 5/16" MISC 5/16" MISC GLUCOPRO INSULIN QL(5 ea daily) GNP ULTICARE PEN QL(5 ea daily); SYRINGE/U-100/1ML/31G 1 NEEDLES/31GX5/16" 1 RX/OTC X 5/16" MISC MISC GNP CLICKFINE PEN QL(5 ea daily); GNP ULTICARE PEN QL(5 ea daily); NEEDLEUNIVERSAL/31G 1 RX/OTC NEEDLES/32GX 5/32" 1 RX/OTC X5/16" MISC MISC GNP CLICKFINE QL(5 ea daily) GNP ULTICARE PEN 1 QL(5 ea daily) UNIVERSAL PEN 1 NEEDLES/32GX1/4" MISC NEEDLES 31GX1/4" MISC GNP ULTRA COMFORT QL(5 ea daily); GNP CLICKFINE QL(5 ea daily); INSULIN 1 RX/OTC UNIVERSAL PEN 1 RX/OTC SYRINGE/0.3ML/29G X NEEDLES 31GX5/16" 1/2" MISC MISC GNP ULTRA COMFORT QL(5 ea daily); GNP INSULIN QL(5 ea daily); INSULIN 1 RX/OTC SYRINGE/0.3ML/29G X 1 RX/OTC SYRINGE/0.3ML/30G X 1/2" MISC 5/16" SHORT MISC GNP INSULIN QL(5 ea daily); GNP ULTRA COMFORT QL(5 ea daily) SYRINGE/0.3ML/30G X 1 RX/OTC INSULIN 1 5/16" MISC SYRINGE/0.3ML/31G X GNP INSULIN QL(5 ea daily) 5/16" SHORT MISC SYRINGE/0.3ML/31G X 1 GNP ULTRA COMFORT QL(5 ea daily); 5/16" MISC INSULIN 1 RX/OTC GNP INSULIN QL(5 ea daily); SYRINGE/0.5ML/28G X SYRINGE/0.5ML/28G X 1 RX/OTC 1/2" MISC 1/2" MISC GNP ULTRA COMFORT QL(5 ea daily); GNP INSULIN QL(5 ea daily); INSULIN 1 RX/OTC SYRINGE/0.5ML/29G X 1 RX/OTC SYRINGE/0.5ML/29G X 1/2" MISC 1/2" MISC

Ambetter Formulary Updated December 1, 2020

103 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GNP ULTRA COMFORT QL(5 ea daily); H-E-B IN CONTROL PEN QL(5 ea daily) INSULIN 1 RX/OTC NEEDLES 31GX6MM 1 SYRINGE/0.5ML/30G X MISC 5/16" SHORT MISC H-E-B IN CONTROL PEN QL(5 ea daily); GNP ULTRA COMFORT QL(5 ea daily) NEEDLES 31GX8MM 1 RX/OTC INSULIN 1 MISC SYRINGE/0.5ML/31G X H-E-B IN CONTROL PEN QL(5 ea daily); 5/16" SHORT MISC NEEDLES/NANO/32GX4M 1 RX/OTC GNP ULTRA COMFORT QL(5 ea daily); M MISC INSULIN 1 RX/OTC H-E-B IN CONTROL QL(5 ea daily); SYRINGE/1ML/28G X 1/2" UNIFINEPENTIPS PLUS 1 RX/OTC MISC 31GX5MM MISC GNP ULTRA COMFORT QL(5 ea daily); H-E-B IN CONTROL QL(5 ea daily); INSULIN 1 RX/OTC UNIFINEPENTIPS PLUS 1 RX/OTC SYRINGE/1ML/29G X 1/2" 32GX4MM MISC MISC H-E-B INCONTROL PEN QL(5 ea daily); GNP ULTRA COMFORT QL(5 ea daily); NEEDLES 29GX12MM 1 RX/OTC INSULIN 1 RX/OTC MISC SYRINGE/1ML/30G X 5/16" SHORT MISC HEALTHWISE INSULIN QL(5 ea daily); SYRINGE/U- 1 RX/OTC GNP ULTRA COMFORT QL(5 ea daily) 100/0.3ML/30G X 5/16" INSULIN 1 MISC SYRINGE/1ML/31G X 5/16" SHORT MISC HEALTHWISE INSULIN QL(5 ea daily) SYRINGE/U- 1 GOODSENSE CLICKFINE QL(5 ea daily); 100/0.3ML/31G X 5/16" SAFETY PEN 1 RX/OTC MISC NEEDLE/31G X 3/16" MISC HEALTHWISE INSULIN QL(5 ea daily); SYRINGE/U- 1 RX/OTC GOODSENSE PEN QL(5 ea daily); 100/0.5ML/30G X 5/16" NEEDLE/PENFINE 1 RX/OTC MISC CLASSIC/31G X 3/16" MISC HEALTHWISE INSULIN QL(5 ea daily) SYRINGE/U- 1 GOODSENSE PEN QL(5 ea daily); 100/0.5ML/31G X 5/16" NEEDLE/PENFINE 1 RX/OTC MISC CLASSIC/31G X 5/16" MISC HEALTHWISE INSULIN QL(5 ea daily); SYRINGE/U-100/1ML/30G 1 RX/OTC GOODSENSE PEN QL(5 ea daily) X 5/16" MISC NEEDLE/PENFINE 1 CLASSIC/32G X 1/4" MISC HEALTHWISE INSULIN QL(5 ea daily) SYRINGE/U-100/1ML/31G 1 GOODSENSE PEN QL(5 ea daily); X 5/16" MISC NEEDLE/PENFINE 1 RX/OTC CLASSIC/32G X 5/32" HEALTHWISE MICRON QL(5 ea daily); MISC PEN NEEDLES/32G X 1 RX/OTC 5/32" MISC H-E-B IN CONTROL PEN QL(5 ea daily); NEEDLES 31GX5MM 1 RX/OTC HEALTHWISE MINI PEN QL(5 ea daily) MISC NEEDLES 31GX6MM 1 MISC

Ambetter Formulary Updated December 1, 2020

104 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits HEALTHWISE PEN QL(5 ea daily); INSULIN QL(5 ea daily); NEEDLES 29GX12MM 1 RX/OTC SYRINGE/0.3ML/29G X 1 RX/OTC MISC 1/2" MISC HEALTHWISE SHORT QL(5 ea daily); INSULIN QL(5 ea daily); PEN NEEDLES 31GX8MM 1 RX/OTC SYRINGE/0.3ML/30G X 1 RX/OTC MISC 5/16" MISC HEALTHWISE SHORT QL(5 ea daily); INSULIN QL(5 ea daily) PEN NEEDLES/31G X 1 RX/OTC SYRINGE/0.3ML/31G X 1 3/16" MISC 5/16" MISC HEALTHWISE SHORT QL(5 ea daily); INSULIN QL(5 ea daily) PEN NEEDLES/31G X 1 RX/OTC SYRINGE/0.5ML/27G X 1 5/16" MISC 1/2" MISC HEALTHWISE UNIFINE QL(5 ea daily); INSULIN QL(5 ea daily); PENTIPS PEN NEEDLES 1 RX/OTC SYRINGE/0.5ML/28G X 1 RX/OTC 32GX4MM MISC 1/2" MISC HEALTHY ACCENTS QL(5 ea daily); INSULIN QL(5 ea daily) UNIFINE PENTIPS PEN 1 RX/OTC SYRINGE/0.5ML/30G X 1 NEEDLES 29GX12MM 1/2" MISC MISC INSULIN QL(5 ea daily); HEALTHY ACCENTS QL(5 ea daily); SYRINGE/0.5ML/30G X 1 RX/OTC UNIFINE PENTIPS PEN 1 RX/OTC 5/16" MISC NEEDLES 31GX5MM INSULIN QL(5 ea daily) MISC SYRINGE/0.5ML/31G X 1 HEALTHY ACCENTS QL(5 ea daily) 5/16" MISC UNIFINE PENTIPS PEN 1 INSULIN QL(5 ea daily); NEEDLES 31GX6MM SYRINGE/1ML/28G X 1/2" 1 RX/OTC MISC MISC HEALTHY ACCENTS QL(5 ea daily); INSULIN QL(5 ea daily); UNIFINE PENTIPS PEN 1 RX/OTC SYRINGE/1ML/29G X 1/2" 1 RX/OTC NEEDLES 31GX8MM MISC MISC INSULIN QL(5 ea daily); HEALTHY ACCENTS QL(5 ea daily); SYRINGE/1ML/30G X 1 RX/OTC UNIFINE PENTIPS PEN 1 RX/OTC 5/16" MISC NEEDLES 32GX4MM MISC INSULIN QL(5 ea daily); SYRINGE/NEEDLE 1 RX/OTC HM ULTICARE INSULIN QL(5 ea daily) 0.3ML/30G X 5/16" MISC SYRINGE/1ML/30G X 1/2" 1 MISC INSULIN QL(5 ea daily) SYRINGE/NEEDLE 1 HM ULTICARE INSULIN QL(5 ea daily) 0.3ML/31G X 5/16" MISC SYRINGE/U- 1 100/0.3ML/31G X 5/16" INSULIN QL(5 ea daily); MISC SYRINGE/NEEDLE 1 RX/OTC 0.5ML/29G X 1/2" MISC HM ULTICARE SHORT QL(5 ea daily); PEN NEEDLES 31GX8MM 1 RX/OTC INSULIN QL(5 ea daily); MISC SYRINGE/NEEDLE 1 RX/OTC 0.5ML/30G X 5/16" MISC INSULIN QL(5 ea daily) SYRINGE/0.3ML/29G X 1" 1 INSULIN QL(5 ea daily) MISC SYRINGE/NEEDLE 1 0.5ML/31G X 5/16" MISC Ambetter Formulary Updated December 1, 2020

105 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits INSULIN QL(5 ea daily); INSULIN QL(5 ea daily); SYRINGE/NEEDLE 1 RX/OTC SYRINGES/1ML/27GX1/2" 1 RX/OTC 1ML/29G X 1/2" MISC MISC INSULIN QL(5 ea daily); INSULIN QL(5 ea daily); SYRINGE/NEEDLE 1 RX/OTC SYRINGES/1ML/28GX1/2" 1 RX/OTC 1ML/30G X 5/16" MISC MISC INSULIN QL(5 ea daily) INSULIN QL(5 ea daily); SYRINGE/NEEDLE 1 SYRINGES/1ML/29GX1/2" 1 RX/OTC 1ML/31G X 5/16" MISC MISC INSULIN SYRINGE/U- QL(5 ea daily); INSULIN QL(5 ea daily) 100/0.3ML/29G X 1/2" 1 RX/OTC SYRINGES/1ML/30GX1/2" 1 MISC MISC INSULIN SYRINGE/U- QL(5 ea daily); INSULIN QL(5 ea daily) 100/0.5ML/29G X 1/2" 1 RX/OTC SYRINGES/1ML/31GX5/16 1 MISC " MISC INSULIN SYRINGE/U- QL(5 ea daily); 1 INSUPEN 29G X 12MM 1 QL(5 ea daily); 100/1ML/29G X 1/2" MISC RX/OTC MISC RX/OTC INSULIN SYRINGE/U- QL(5 ea daily) INSUPEN 31G X 5MM 1 QL(5 ea daily); 100/1ML/30G X 5/16" 1 MISC RX/OTC MISC INSUPEN 31G X 8MM 1 QL(5 ea daily); INSULIN SYRINGE/U- QL(5 ea daily); MISC RX/OTC 100/1ML/30G X 5/16" 1 RX/OTC INSUPEN 32G X 4MM 1 QL(5 ea daily); MISC MISC RX/OTC INSULIN SYRINGE/U- QL(5 ea daily) INSUPEN PEN NEEDLES 1 QL(5 ea daily); 100/1ML/31G X 5/16" 1 32G X4MM MISC RX/OTC MISC INSUPEN SENSITIVE 1 QL(5 ea daily) INSULIN QL(5 ea daily) 32GX6MM MISC SYRINGES/0.5ML/27GX1/ 1 2" MISC INSUPEN ULTRAFIN 1 QL(5 ea daily); 29GX12MM MISC RX/OTC INSULIN QL(5 ea daily); SYRINGES/0.5ML/28GX1/ 1 RX/OTC INSUPEN ULTRAFIN 1 QL(5 ea daily); 2" MISC 30GX8MM MISC RX/OTC INSULIN QL(5 ea daily); INSUPEN ULTRAFIN 1 QL(5 ea daily) SYRINGES/0.5ML/29GX1/ 1 RX/OTC 31GX6MM MISC 2" MISC INSUPEN ULTRAFIN 1 QL(5 ea daily); INSULIN QL(5 ea daily); 31GX8MM MISC RX/OTC SYRINGES/0.5ML/30GX5/ 1 RX/OTC KINRAY INSULIN QL(5 ea daily) 16" MISC SYRINGE PREFERRED 1 INSULIN QL(5 ea daily) PLUS/0.3ML/31G X 5/16" SYRINGES/0.5ML/31GX 1 MISC 5/16" MISC KINRAY INSULIN QL(5 ea daily) INSULIN QL(5 ea daily) SYRINGE PREFERRED 1 SYRINGES/0.5ML/31GX5/ 1 PLUS/0.5ML/31G X 5/16" 16" MISC MISC INSULIN QL(5 ea daily); KINRAY INSULIN QL(5 ea daily) SYRINGES/1ML/27GX/1/2" 1 RX/OTC SYRINGE PREFERRED 1 MISC PLUS/1ML/31G X 5/16" MISC

Ambetter Formulary Updated December 1, 2020

106 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits KINRAY INSULIN QL(5 ea daily); KROGER PEN QL(5 ea daily); SYRINGE/0.5ML/29G X 1 RX/OTC NEEDLES/31G X3/16" 1 RX/OTC 1/2" MISC MISC KMART VALU PLUS QL(5 ea daily); KROGER PEN QL(5 ea daily); INSULIN 1 RX/OTC NEEDLES/31G X5/16" 1 RX/OTC SYRINGE/1ML/29G MISC MISC KMART VALU PLUS QL(5 ea daily); KROGER PEN QL(5 ea daily); INSULIN 1 RX/OTC NEEDLES/32G X5/32" 1 RX/OTC SYRINGE/1ML/30G MISC MISC KROGER INSULIN QL(5 ea daily); LEADER INSULIN QL(5 ea daily); SYRINGE/0.3ML/29G X 1 RX/OTC SYRINGE/0.3ML/29G X 1 RX/OTC 1/2" MISC 1/2" MISC KROGER INSULIN QL(5 ea daily); LEADER INSULIN QL(5 ea daily); SYRINGE/0.3ML/30G X 1 RX/OTC SYRINGE/0.3ML/30G X 1 RX/OTC 5/16" MISC 5/16" MISC KROGER INSULIN QL(5 ea daily) LEADER INSULIN QL(5 ea daily) SYRINGE/0.3ML/31G X 1 SYRINGE/0.3ML/31G X 1 5/16" MISC 5/16" MISC KROGER INSULIN QL(5 ea daily); LEADER INSULIN QL(5 ea daily); SYRINGE/0.5ML/29G X 1 RX/OTC SYRINGE/0.5ML/28G X 1 RX/OTC 1/2" MISC 1/2" MISC KROGER INSULIN QL(5 ea daily); LEADER INSULIN QL(5 ea daily); SYRINGE/0.5ML/30G X 1 RX/OTC SYRINGE/0.5ML/29G X 1 RX/OTC 5/16" MISC 1/2" MISC KROGER INSULIN QL(5 ea daily) LEADER INSULIN QL(5 ea daily); SYRINGE/0.5ML/31G X 1 SYRINGE/0.5ML/30G X 1 RX/OTC 5/16" MISC 5/16" MISC KROGER INSULIN QL(5 ea daily); LEADER INSULIN QL(5 ea daily) SYRINGE/1ML/29G X 1/2" 1 RX/OTC SYRINGE/0.5ML/31G X 1 MISC 5/16" MISC KROGER INSULIN QL(5 ea daily); LEADER INSULIN QL(5 ea daily); SYRINGE/1ML/30G X 1 RX/OTC SYRINGE/1ML/28G X 1/2" 1 RX/OTC 5/16" MISC MISC KROGER INSULIN QL(5 ea daily) LEADER INSULIN QL(5 ea daily); SYRINGE/1ML/31G X 1 SYRINGE/1ML/29G X 1/2" 1 RX/OTC 5/16" MISC MISC KROGER PEN NEEDLES 1 QL(5 ea daily); LEADER INSULIN QL(5 ea daily); 29G X12MM MISC RX/OTC SYRINGE/1ML/30G X 1 RX/OTC 5/16" MISC KROGER PEN NEEDLES 1 QL(5 ea daily); 31G X8MM MISC RX/OTC LEADER INSULIN QL(5 ea daily) SYRINGE/1ML/31G X 1 KROGER PEN NEEDLES 1 QL(5 ea daily) 31GX1/4" MISC 5/16" MISC KROGER PEN QL(5 ea daily) LEADER UNIFINE QL(5 ea daily); NEEDLES/31G X1/4" 1 PENTIPS 1 RX/OTC MISC PLUS/MINI/31GX3/16" MISC

Ambetter Formulary Updated December 1, 2020

107 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LEADER UNIFINE QL(5 ea daily); LITETOUCH INSULIN QL(5 ea daily); PENTIPS 1 RX/OTC SYRINGE/U- 1 RX/OTC PLUS/SHORT/31GX5/16" 100/0.5ML/29G X 1/2" MISC MISC LEADER UNIFINE QL(5 ea daily); LITETOUCH INSULIN QL(5 ea daily); 1 PENTIPS/MINI/31GX3/16" RX/OTC SYRINGE/U- 1 RX/OTC MISC 100/0.5ML/30G X 5/16" LEADER UNIFINE QL(5 ea daily); MISC PENTIPS/NANO/32GX5/32 1 RX/OTC LITETOUCH INSULIN QL(5 ea daily) " MISC SYRINGE/U- 1 LEADER UNIFINE QL(5 ea daily); 100/0.5ML/31G X 5/16" PENTIPS/PLUS/32GX5/32 1 RX/OTC MISC " MISC LITETOUCH INSULIN QL(5 ea daily); LITETOUCH INSULIN PEN QL(5 ea daily); SYRINGE/U-100/1ML/28G 1 RX/OTC NEEDLES/32G X 1 RX/OTC X 1/2" MISC 4MM/MINI MISC LITETOUCH INSULIN QL(5 ea daily); LITETOUCH INSULIN QL(5 ea daily); SYRINGE/U-100/1ML/29G 1 RX/OTC SYRINGE/0.3ML/29G X 1 RX/OTC X 1/2" MISC 1/2" MISC LITETOUCH INSULIN QL(5 ea daily); LITETOUCH INSULIN QL(5 ea daily); SYRINGE/U-100/1ML/30G 1 RX/OTC SYRINGE/0.3ML/30G X 1 RX/OTC X 5/16" MISC 5/16" MISC LITETOUCH INSULIN QL(5 ea daily) LITETOUCH INSULIN QL(5 ea daily) SYRINGE/U-100/1ML/31G 1 SYRINGE/0.3ML/31G X 1 X 5/16" MISC 5/16" MISC LITETOUCH PEN QL(5 ea daily) LITETOUCH INSULIN QL(5 ea daily); NEEDLES 29GX12.7MM 1 SYRINGE/0.5ML/30G X 1 RX/OTC MISC 5/16" MISC LITETOUCH PEN QL(5 ea daily) LITETOUCH INSULIN QL(5 ea daily) NEEDLES 31G X 6MM 1 SYRINGE/0.5ML/31G X 1 MISC 5/16" MISC LITETOUCH PEN QL(5 ea daily) LITETOUCH INSULIN QL(5 ea daily); NEEDLES 31G X 1 SYRINGE/1ML/30G X 1 RX/OTC 6MM/ULTRA SHORT 5/16" MISC MISC LITETOUCH INSULIN QL(5 ea daily); LITETOUCH PEN QL(5 ea daily); NEEDLES 31GX8MM 1 RX/OTC SYRINGE/U- 1 RX/OTC 100/0.3ML/30G X 5/16" SHORT MISC MISC LITETOUCH PEN QL(5 ea daily); LITETOUCH INSULIN QL(5 ea daily) NEEDLES/31G X 3/16" 1 RX/OTC MISC SYRINGE/U- 1 100/0.3ML/31G X 5/16" LITETOUCH PEN QL(5 ea daily); MISC NEEDLES/31G X 1 RX/OTC LITETOUCH INSULIN QL(5 ea daily); 5MM/MINI MISC SYRINGE/U- 1 RX/OTC LITETOUCH PEN QL(5 ea daily); 100/0.5ML/28G X 1/2" NEEDLES/31G X 1 RX/OTC MISC 8MM/SHORT MISC

Ambetter Formulary Updated December 1, 2020

108 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LONGS INSULIN QL(5 ea daily) MAXICOMFORT INSULIN QL(5 ea daily) SYRINGE/0.5ML/31G X 1 SYRINGES 27G X 1/2" 1 5/16" MISC MISC MAGELLAN INSULIN QL(5 ea daily); MAXICOMFORT INSULIN QL(5 ea daily); SAFETY SYRINGE/U- 1 RX/OTC SYRINGES 27G X 1/2" 1 RX/OTC 100/0.3ML/29G X 1/2" MISC MISC MEDIC INSULIN QL(5 ea daily); MAGELLAN INSULIN QL(5 ea daily); SYRINGE/0.3ML/30G X 1 RX/OTC SAFETY SYRINGE/U- 1 RX/OTC 5/16" MISC 100/0.3ML/30G X 5/16" MEDIC INSULIN QL(5 ea daily); MISC SYRINGE/0.5ML/30G X 1 RX/OTC MAGELLAN INSULIN QL(5 ea daily); 5/16" MISC SAFETY SYRINGE/U- 1 RX/OTC MEDICINE SHOPPE PEN QL(5 ea daily); 100/0.5ML/29G X 1/2" NEEDLES 29G X 12MM 1 RX/OTC MISC MISC MAGELLAN INSULIN QL(5 ea daily); MEDICINE SHOPPE PEN QL(5 ea daily) SAFETY SYRINGE/U- 1 RX/OTC NEEDLES 31G X 6MM 1 100/0.5ML/30G X 5/16" MISC MISC MEDICINE SHOPPE PEN QL(5 ea daily); MAGELLAN INSULIN QL(5 ea daily); NEEDLES 31G X 8MM 1 RX/OTC SAFETY SYRINGE/U- 1 RX/OTC MISC 100/1ML/29G X 1/2" MISC MEIJER PEN NEEDLES 1 QL(5 ea daily); MAGELLAN INSULIN QL(5 ea daily); 29G X12MM MISC RX/OTC SAFETY SYRINGE/U- 1 RX/OTC 100/1ML/30G X 5/16" MEIJER PEN NEEDLES 1 QL(5 ea daily) MISC 31G X6MM MISC MARATHON MEDICAL QL(5 ea daily); MEIJER PEN NEEDLES 1 QL(5 ea daily); PENTIPS29GX12MM 1 RX/OTC 31G X8MM MISC RX/OTC MISC MICRODOT PEN QL(5 ea daily) NEEDLE/31G X 6 MM 1 MARATHON MEDICAL 1 QL(5 ea daily); PENTIPS31GX5MM MISC RX/OTC MISC MICRODOT PEN QL(5 ea daily); MARATHON MEDICAL 1 QL(5 ea daily); PENTIPS31GX8MM MISC RX/OTC NEEDLE/32G X 4 MM 1 RX/OTC MISC MARATHON MEDICAL 1 QL(5 ea daily); PENTIPS32GX4MM MISC RX/OTC MM INSULIN SYRINGE/U- QL(5 ea daily); 100/0.3ML/30G X 5/16" 1 RX/OTC MAXI-COMFORT INSULIN QL(5 ea daily); MISC SYRINGE/U- 1 RX/OTC 100/0.5ML/28GX1/2" MISC MM INSULIN SYRINGE/U- QL(5 ea daily) 100/0.3ML/31G X 5/16" 1 MAXI-COMFORT INSULIN QL(5 ea daily); MISC SYRINGE/U- 1 RX/OTC 100/1ML/28GX1/2" MISC MM INSULIN SYRINGE/U- QL(5 ea daily); 100/1/2ML/30G X 5/16" 1 RX/OTC MAXI-COMFORT SAFETY QL(5 ea daily) MISC PEN NEEDLE/29G X 5/16" 1 MISC MM INSULIN SYRINGE/U- QL(5 ea daily) 100/1/2ML/31G X 5/16" 1 MAXICOMFORT II PEN QL(5 ea daily) MISC NEEDLES/31G X 1/4" 1 MISC

Ambetter Formulary Updated December 1, 2020

109 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MM INSULIN SYRINGE/U- QL(5 ea daily); MONOJECT INSULIN QL(5 ea daily); 1 100/1ML/30G X 5/16" RX/OTC SYRINGE/SAFETY/PERM 1 RX/OTC MISC NEEDLE/1ML/29G X 1/2" MM INSULIN SYRINGE/U- QL(5 ea daily) MISC 100/1ML/31G X 5/16" 1 MONOJECT INSULIN QL(5 ea daily); MISC SYRINGE/SOFTPACK/1M 1 RX/OTC L/27G X 1/2" MISC MM PEN NEEDLES 31G X 1 QL(5 ea daily) 1/4" MISC MONOJECT INSULIN QL(5 ea daily); SYRINGE/SOFTPACK/U- RX/OTC MM PEN NEEDLES 31G X 1 QL(5 ea daily); 1 3/16" MISC RX/OTC 100/0.5ML/28G X 1/2" MISC MM PEN NEEDLES 31G X 1 QL(5 ea daily); 5/16" MISC RX/OTC MONOJECT INSULIN QL(5 ea daily); SYRINGE/U- 1 RX/OTC MM PEN NEEDLES 32G X 1 QL(5 ea daily); 100/0.3ML/30G X 5/16" 5/32" MISC RX/OTC MISC MONOJECT INSULIN 1 QL(5 ea daily); MONOJECT INSULIN QL(5 ea daily); SYRINGE/1ML MISC RX/OTC SYRINGE/U- 1 RX/OTC MONOJECT INSULIN QL(5 ea daily) 100/0.5ML/30G X 5/16" SYRINGE/1ML/31G X 1 MISC 5/16" MISC MONOJECT INSULIN QL(5 ea daily); MONOJECT INSULIN QL(5 ea daily) SYRINGE/U-100/1ML/28G 1 RX/OTC SYRINGE/DETACH 1 X 1/2" MISC NEEDLE/1ML/25G X 5/8" MONOJECT INSULIN QL(5 ea daily); MISC SYRINGE/U-100/1ML/30G 1 RX/OTC MONOJECT INSULIN QL(5 ea daily); X 5/16" MISC SYRINGE/DETACH 1 RX/OTC MONOJECT INSULIN QL(5 ea daily); NEEDLE/1ML/27G X 1/2" SYRINGEREGULAR LUER 1 RX/OTC MISC TIP/SOFTPACK/1ML MISC MONOJECT INSULIN QL(5 ea daily); MONOJECT ULTRA QL(5 ea daily); SYRINGE/PERM RX/OTC 1 COMFORT INSULIN 1 RX/OTC NEEDLE/1ML/28G X 1/2" SYRINGE/0.3ML/29G X MISC 1/2" MISC MONOJECT INSULIN QL(5 ea daily); MONOJECT ULTRA QL(5 ea daily); SYRINGE/PERM RX/OTC 1 COMFORT INSULIN 1 RX/OTC NEEDLE/U-100/0.5ML/28G SYRINGE/0.3ML/30G X X 1/2" MISC 5/16" MISC MONOJECT INSULIN QL(5 ea daily); MONOJECT ULTRA QL(5 ea daily) SYRINGE/SAFETY/PERM RX/OTC 1 COMFORT INSULIN 1 NEEDLE/0.3ML/29G X 1/2" SYRINGE/0.3ML/31G X MISC 5/16" MISC MONOJECT INSULIN QL(5 ea daily); MONOJECT ULTRA QL(5 ea daily); SYRINGE/SAFETY/PERM RX/OTC 1 COMFORT INSULIN 1 RX/OTC NEEDLE/0.3ML/29GX1/2" SYRINGE/0.5ML/28G X MISC 1/2" MISC MONOJECT INSULIN QL(5 ea daily); MONOJECT ULTRA QL(5 ea daily); SYRINGE/SAFETY/PERM RX/OTC 1 COMFORT INSULIN 1 RX/OTC NEEDLE/0.5ML/29G X 1/2" SYRINGE/0.5ML/29G X MISC 1/2" MISC

Ambetter Formulary Updated December 1, 2020

110 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MONOJECT ULTRA QL(5 ea daily); PEN NEEDLES 1 QL(5 ea daily); COMFORT INSULIN 1 RX/OTC 29GX12MM MISC RX/OTC SYRINGE/0.5ML/30G X PEN NEEDLES 30GX5/16" 1 QL(5 ea daily); 5/16" MISC MISC RX/OTC MONOJECT ULTRA QL(5 ea daily) PEN NEEDLES 30GX8MM 1 QL(5 ea daily); COMFORT INSULIN 1 MISC RX/OTC SYRINGE/0.5ML/31G X 5/16" MISC PEN NEEDLES 31G X 1/4" 1 QL(5 ea daily) SHORT MISC MONOJECT ULTRA QL(5 ea daily); PEN NEEDLES 31G X QL(5 ea daily); COMFORT INSULIN 1 RX/OTC 1 SYRINGE/1ML/28G X 1/2" 3/16" MISC RX/OTC MISC PEN NEEDLES 31G X 1 QL(5 ea daily); MONOJECT ULTRA QL(5 ea daily); 5MM MISC RX/OTC PEN NEEDLES 31G X QL(5 ea daily) COMFORT INSULIN 1 RX/OTC 1 SYRINGE/1ML/29G X 1/2" 6MM MISC MISC PEN NEEDLES 31G X 1 QL(5 ea daily); MS INSULIN QL(5 ea daily) 8MM MISC RX/OTC SYRINGE/0.3ML/31G X 1 PEN NEEDLES 31GX5/16" 1 QL(5 ea daily); 5/16" MISC MISC RX/OTC MS INSULIN QL(5 ea daily) PEN NEEDLES 31GX6MM 1 QL(5 ea daily) SYRINGE/0.5ML/31G X 1 (1/4") MISC 5/16" MISC PEN NEEDLES 31GX8MM 1 QL(5 ea daily); MS INSULIN QL(5 ea daily) (5/16") MISC RX/OTC SYRINGE/1ML/31G X 1 PEN NEEDLES 31GX8MM 1 QL(5 ea daily); 5/16" MISC MISC RX/OTC NOVOFINE 32GX6MM QL(5 ea daily) 1 PEN NEEDLES 32G X 1 QL(5 ea daily); MISC 4MM MISC RX/OTC NOVOFINE AUTOCOVER QL(5 ea daily); 1 PEN NEEDLES 32G X 1 QL(5 ea daily); 30GX8MM MISC RX/OTC 5MM MISC RX/OTC NOVOFINE PLUS QL(5 ea daily); 1 PEN NEEDLES 32G X 1 QL(5 ea daily) 32GX4MM MISC RX/OTC 6MM MISC NOVOTWIST 32GX5MM QL(5 ea daily); 1 PEN NEEDLES 32GX4MM 1 QL(5 ea daily); MISC RX/OTC MISC RX/OTC PC UNIFINE PENTIPS QL(5 ea daily); 1 PEN NEEDLES/29G X 1/2" 1 QL(5 ea daily); 29G X1/2" MISC RX/OTC MISC RX/OTC PC UNIFINE PENTIPS QL(5 ea daily); 1 PEN NEEDLES/31G X 1/4" 1 QL(5 ea daily) 31G X5MM MINI MISC RX/OTC MISC PC UNIFINE PENTIPS QL(5 ea daily) PEN NEEDLES/31G X 1 QL(5 ea daily); 31G X6MM ULTRA 1 3/16" MISC RX/OTC SHORT MISC PEN NEEDLES/31G X 1 QL(5 ea daily); PC UNIFINE PENTIPS 1 QL(5 ea daily); 5/16" MISC RX/OTC 31G X8MM SHORT MISC RX/OTC PEN NEEDLES/31G X 1 QL(5 ea daily) PEN NEEDLES 29G X 1 QL(5 ea daily); 6MM MISC 12MM MISC RX/OTC PEN NEEDLES/32G X 1 QL(5 ea daily); PEN NEEDLES 29GX1/2" 1 QL(5 ea daily); 5/32" MISC RX/OTC MISC RX/OTC PENTIPS 29G X 12MM 1 QL(5 ea daily); MISC RX/OTC Ambetter Formulary Updated December 1, 2020

111 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PENTIPS 29GX12MM 1 QL(5 ea daily); PREFERRED PLUS QL(5 ea daily); MISC RX/OTC INSULIN SYRINGE/U- 1 RX/OTC 100/0.3ML/30G X 5/16" PENTIPS 31G X 5MM 1 QL(5 ea daily); MISC RX/OTC MISC PREFERRED PLUS QL(5 ea daily); PENTIPS 31G X 8MM 1 QL(5 ea daily); MISC RX/OTC INSULIN SYRINGE/U- 1 RX/OTC 100/0.5ML/28G X 1/2" PENTIPS 31GX5MM MISC 1 QL(5 ea daily); MISC RX/OTC PREFERRED PLUS QL(5 ea daily); PENTIPS 31GX6MM MISC 1 QL(5 ea daily) INSULIN SYRINGE/U- 1 RX/OTC 100/0.5ML/29G X 1/2" QL(5 ea daily); PENTIPS 31GX8MM MISC 1 MISC RX/OTC PREFERRED PLUS QL(5 ea daily); PENTIPS 32G X 4MM QL(5 ea daily); 1 INSULIN SYRINGE/U- 1 RX/OTC MISC RX/OTC 100/0.5ML/30G X 5/16" QL(5 ea daily); PENTIPS 32GX4MM MISC 1 MISC RX/OTC PREFERRED PLUS QL(5 ea daily); PRECISION SURE-DOSE QL(5 ea daily); INSULIN SYRINGE/U- 1 RX/OTC INSULIN 1 RX/OTC 100/1ML/28G X 1/2" MISC SYRINGE/0.3ML/30G X PREFERRED PLUS QL(5 ea daily); 5/16" MISC INSULIN SYRINGE/U- 1 RX/OTC PRECISION SURE-DOSE QL(5 ea daily); 100/1ML/29G X 1/2" MISC INSULIN 1 RX/OTC PREFERRED PLUS QL(5 ea daily); SYRINGE/0.5ML/28G X INSULIN SYRINGE/U- 1 RX/OTC 1/2" MISC 100/1ML/30G X 5/16" PRECISION SURE-DOSE QL(5 ea daily); MISC INSULIN 1 RX/OTC PREFERRED PLUS QL(5 ea daily); SYRINGE/0.5ML/29G X UNIFINE PENTIPS 29G X 1 RX/OTC 1/2" MISC 12MM MISC PRECISION SURE-DOSE QL(5 ea daily) PREFERRED PLUS QL(5 ea daily) INSULIN 1 UNIFINE PENTIPS 31G X 1 SYRINGE/0.5ML/30G X 6MM ULTRA SHORT 3/8" MISC MISC PRECISION SURE-DOSE QL(5 ea daily); PREFERRED PLUS QL(5 ea daily); INSULIN 1 RX/OTC UNIFINE PENTIPS 31G X 1 RX/OTC SYRINGE/1ML/28G X 1/2" 8MM SHORT MISC MISC PREFERRED PLUS QL(5 ea daily); PRECISION SURE-DOSE QL(5 ea daily); UNIFINE PENTIPS 1 RX/OTC PLUSINSULIN 1 RX/OTC 32GX4MM MISC SYRINGE/0.3ML/29G X 1/2" MISC PREFERRED PLUS QL(5 ea daily); UNIFINE 1 RX/OTC PRECISION SURE-DOSE QL(5 ea daily); PENTIPS/MINI/31GX5MM PLUSINSULIN 1 RX/OTC MISC SYRINGE/1ML/29G X 1/2" MISC PREVENT SAFETY PEN 1 QL(5 ea daily) NEEDLES 31GX1/4" MISC PREFERRED PLUS QL(5 ea daily); PREVENT SAFETY PEN QL(5 ea daily); INSULIN SYRINGE/U- 1 RX/OTC 100/0.3ML/29G X 1/2" NEEDLES 31GX5/16" 1 RX/OTC MISC MISC Ambetter Formulary Updated December 1, 2020

112 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PRO COMFORT INSULIN QL(5 ea daily) PX EXTRA SHORT PEN QL(5 ea daily) SYRINGES/0.5ML/30G X 1 NEEDLES 31GX6MM 1 1/2" MISC MISC PRO COMFORT INSULIN QL(5 ea daily); PX INSULIN SYRINGE/U- QL(5 ea daily) SYRINGES/0.5ML/30G X 1 RX/OTC 100/0.5ML/30G X 1/2" 1 5/16" MISC MISC PRO COMFORT INSULIN QL(5 ea daily) PX MINI PEN NEEDLES 1 QL(5 ea daily); SYRINGES/0.5ML/31G X 1 31GX5MM MISC RX/OTC 5/16" MISC PX PEN NEEDLE 1 QL(5 ea daily); PRO COMFORT INSULIN QL(5 ea daily) 29GX12MM MISC RX/OTC SYRINGES/1ML/30G X 1 PX PEN NEEDLE 1 QL(5 ea daily); 1/2" MISC 31GX8MM MISC RX/OTC PRO COMFORT INSULIN QL(5 ea daily); PX SHORTLENGTH PEN QL(5 ea daily); SYRINGES/1ML/30G X 1 RX/OTC NEEDLES/31GX8MM 1 RX/OTC 5/16" MISC MISC PRO COMFORT INSULIN QL(5 ea daily) QC PEN NEEDLES 29G X 1 QL(5 ea daily); SYRINGES/1ML/31G X 1 12MM MISC RX/OTC 5/16" MISC QC PEN NEEDLES 31G X 1 QL(5 ea daily) PRO COMFORT PEN QL(5 ea daily); 6MM MISC NEEDLES/31G X 8MM 1 RX/OTC MISC QC PEN NEEDLES 31G X 1 QL(5 ea daily); 8MM MISC RX/OTC PRO COMFORT PEN QL(5 ea daily); NEEDLES/32G X 4MM 1 RX/OTC QC UNIFINE PENTIPS 1 QL(5 ea daily); MISC 32GX4MM MISC RX/OTC PRO COMFORT PEN QL(5 ea daily); RA INSULIN QL(5 ea daily); NEEDLES/32G X 5MM 1 RX/OTC SYRINGE/0.5ML/29G X 1 RX/OTC MISC 1/2" MISC PRO COMFORT PEN QL(5 ea daily) RA INSULIN QL(5 ea daily); NEEDLES/32G X 6MM 1 SYRINGE/1ML/29G X 1/2" 1 RX/OTC MISC MISC PRODIGY INSULIN QL(5 ea daily) RA INSULIN SYRINGE/U- QL(5 ea daily); SYRING/U-100/0.3ML/31G 1 100/0.5ML/30G X 5/16" 1 RX/OTC X 5/16" MISC MISC PRODIGY INSULIN QL(5 ea daily) RA INSULIN SYRINGE/U- QL(5 ea daily); SYRINGE/1/2ML/31G X 1 100/1 ML/30G X 5/16" 1 RX/OTC 5/16" MISC MISC PRODIGY INSULIN QL(5 ea daily); RA PEN NEEDLES 31G X 1 QL(5 ea daily); SYRINGE/1ML/28G X 1/2" 1 RX/OTC 5MM3/16" MISC RX/OTC MISC RA PEN NEEDLES 31G X 1 QL(5 ea daily); 8MM5/16" MISC RX/OTC PURE COMFORT PEN 1 QL(5 ea daily) NEEDLE 32G X6MM MISC REALITY INSULIN QL(5 ea daily); PURE COMFORT PEN QL(5 ea daily); SYRINGE/U- 1 RX/OTC NEEDLE/32G X 5MM 1 RX/OTC 100/0.5ML/28G X 1/2" MISC MISC REALITY INSULIN QL(5 ea daily); PURE COMFORT PEN 1 QL(5 ea daily); NEEDLE/32G X4MM MISC RX/OTC SYRINGE/U- 1 RX/OTC 100/0.5ML/29G X 1/2" MISC

Ambetter Formulary Updated December 1, 2020

113 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits REALITY INSULIN QL(5 ea daily); RELION PEN NEEDLES 1 QL(5 ea daily); SYRINGE/U-100/1ML/28G 1 RX/OTC 29GX12MM MISC RX/OTC X 1/2" MISC RELION PEN NEEDLES 1 QL(5 ea daily); REALITY INSULIN QL(5 ea daily); 31GX5/16" MISC RX/OTC SYRINGE/U-100/1ML/29G 1 RX/OTC RELION PEN NEEDLES 1 QL(5 ea daily) X 1/2" MISC 31GX6MM MISC RELION INSULIN QL(5 ea daily) RELION PEN NEEDLES 1 QL(5 ea daily); SYRINGE 1 31GX8MM MISC RX/OTC 1ML/31GX15/64" MISC RELION PEN NEEDLES 1 QL(5 ea daily); RELION INSULIN QL(5 ea daily); 32G X5/32" MISC RX/OTC SYRINGE/U-00/1ML/29G 1 RX/OTC X 1/2" MISC RELION PEN NEEDLES 1 QL(5 ea daily); 32GX4MM MISC RX/OTC RELION INSULIN QL(5 ea daily); RELION PEN QL(5 ea daily) SYRINGE/U- 1 RX/OTC 1 100/0.3ML/29G X 1/2" NEEDLES/31G X1/4" MISC MISC RELION SHORT PEN 1 QL(5 ea daily); RELION INSULIN QL(5 ea daily); NEEDLES31GX8MM MISC RX/OTC SAFESNAP INSULIN QL(5 ea daily); SYRINGE/U- 1 RX/OTC 100/0.3ML/30G X 5/16" SYRINGE/0.3ML/30G X 1 RX/OTC MISC 5/16" MISC RELION INSULIN QL(5 ea daily) SAFESNAP INSULIN QL(5 ea daily); SYRINGE/0.5ML/29G X 1 RX/OTC SYRINGE/U- 1 100/0.3ML/31G X 5/16" 1/2" MISC MISC SAFESNAP INSULIN QL(5 ea daily); RELION INSULIN QL(5 ea daily); SYRINGE/0.5ML/30G X 1 RX/OTC 5/16" MISC SYRINGE/U- 1 RX/OTC 100/0.5ML/29G X 1/2" SAFESNAP INSULIN QL(5 ea daily); MISC SYRINGE/1ML/28G X 1/2" 1 RX/OTC RELION INSULIN QL(5 ea daily); MISC SYRINGE/U- 1 RX/OTC SAFESNAP INSULIN QL(5 ea daily); 100/0.5ML/30G X 5/16" SYRINGE/1ML/29G X 1/2" 1 RX/OTC MISC MISC RELION INSULIN QL(5 ea daily) SAFETY INSULIN QL(5 ea daily); SYRINGE/U- 1 SYRINGES 1 RX/OTC 100/0.5ML/31G X 5/16" 0.5ML/29GX1/2" MISC MISC SAFETY INSULIN QL(5 ea daily); RELION INSULIN QL(5 ea daily); SYRINGES 1 RX/OTC SYRINGE/U-100/1ML/30G 1 RX/OTC 0.5ML/30GX5/16" MISC X 5/16" MISC SAFETY INSULIN QL(5 ea daily); RELION INSULIN QL(5 ea daily) SYRINGES 1ML/27GX1/2" 1 RX/OTC SYRINGE/U-100/1ML/31G 1 MISC X 15/64" MISC SAFETY INSULIN QL(5 ea daily); RELION INSULIN QL(5 ea daily) SYRINGES 1ML/29GX1/2" 1 RX/OTC SYRINGE/U-100/1ML/31G 1 MISC X 5/16" MISC SAFETY INSULIN QL(5 ea daily) RELION MINI PEN QL(5 ea daily) SYRINGES 1ML/30GX1/2" 1 NEEDLES 31GX6MM 1 MISC MISC

Ambetter Formulary Updated December 1, 2020

114 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SB INSULIN SYRINGE/U- QL(5 ea daily); SHOPKO UNIFINE QL(5 ea daily); 1 100/0.5ML/29G X 1/2" RX/OTC PENTIPS PLUS PEN 1 RX/OTC MISC NEEDLES/SHORT/REMO SB INSULIN SYRINGE/U- QL(5 ea daily); VR/31GX8MM MISC 100/0.5ML/30G X 5/16" 1 RX/OTC SURE COMFORT QL(5 ea daily); MISC INSULIN SYRINGE/U- 1 RX/OTC 100/0.3ML/29G X 1/2" SB INSULIN SYRINGE/U- 1 QL(5 ea daily); 100/1ML/29G X 1/2" MISC RX/OTC MISC SB INSULIN SYRINGE/U- QL(5 ea daily); SURE COMFORT QL(5 ea daily) 100/1ML/30G X 5/16" 1 RX/OTC INSULIN SYRINGE/U- 1 MISC 100/0.3ML/30G X 1/2" MISC SB INSULIN SYRINGE/U- QL(5 ea daily) 100/1ML/31G X 5/16" 1 SURE COMFORT QL(5 ea daily); MISC INSULIN SYRINGE/U- 1 RX/OTC 100/0.3ML/30G X 5/16" SECURESAFE SAFETY QL(5 ea daily); MISC INSULIN SYRINGES/U- 1 RX/OTC 100/0.5ML/29GX1/2" MISC SURE COMFORT QL(5 ea daily) INSULIN SYRINGE/U- 1 SECURESAFE SAFETY QL(5 ea daily); 100/0.3ML/31G X 5/16 INSULIN SYRINGES/U- 1 RX/OTC MISC 100/1ML/29GX1/2" MISC SURE COMFORT QL(5 ea daily) SHOPKO UNIFINE QL(5 ea daily); INSULIN SYRINGE/U- 1 PENTIPS PEN 1 RX/OTC 100/0.3ML/31G X 5/16" NEEDLES/MICRO/32GX4 MISC MM MISC SURE COMFORT QL(5 ea daily); SHOPKO UNIFINE QL(5 ea daily); INSULIN SYRINGE/U- 1 RX/OTC PENTIPS PEN 1 RX/OTC 100/0.5ML/28G X 1/2" NEEDLES/MINI/31GX5MM MISC MISC SURE COMFORT QL(5 ea daily); SHOPKO UNIFINE QL(5 ea daily); INSULIN SYRINGE/U- 1 RX/OTC PENTIPS PEN 1 RX/OTC 100/0.5ML/29G X 1/2" NEEDLES/ORIGINAL/29G MISC X12MM MISC SURE COMFORT QL(5 ea daily) SHOPKO UNIFINE QL(5 ea daily); INSULIN SYRINGE/U- 1 PENTIPS PEN 1 RX/OTC 100/0.5ML/30G X 1/2" NEEDLES/SHORT/31GX8 MISC MM MISC SURE COMFORT QL(5 ea daily); SHOPKO UNIFINE QL(5 ea daily); INSULIN SYRINGE/U- 1 RX/OTC PENTIPS PLUS PEN 1 RX/OTC 100/0.5ML/30G X 5/16" NEEDLES/MICRO/REMOV MISC R/32GX4MM MISC SURE COMFORT QL(5 ea daily) SHOPKO UNIFINE QL(5 ea daily); INSULIN SYRINGE/U- 1 PENTIPS PLUS PEN 1 RX/OTC 100/0.5ML/31G X 5/16 NEEDLES/MINI/REMOVE MISC R/31GX5MM MISC SURE COMFORT QL(5 ea daily); SHOPKO UNIFINE QL(5 ea daily); INSULIN SYRINGE/U- 1 RX/OTC PENTIPS PLUS PEN 1 RX/OTC 100/1ML/28G X 1/2" MISC NEEDLES/REMOVER/29G X12MM MISC

Ambetter Formulary Updated December 1, 2020

115 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SURE COMFORT QL(5 ea daily); SURE-JECT INSULIN QL(5 ea daily) 1 INSULIN SYRINGE/U- RX/OTC SYRINGE/U- 1 100/1ML/29G X 1/2" MISC 100/0.3ML/31G X 5/16" SURE COMFORT QL(5 ea daily) MISC INSULIN SYRINGE/U- 1 SURE-JECT INSULIN QL(5 ea daily); 100/1ML/30G X 1/2" MISC SYRINGE/U- 1 RX/OTC SURE COMFORT QL(5 ea daily); 100/0.5ML/28G X 1/2" MISC INSULIN SYRINGE/U- 1 RX/OTC 100/1ML/30G X 5/16" SURE-JECT INSULIN QL(5 ea daily); MISC SYRINGE/U- 1 RX/OTC SURE COMFORT QL(5 ea daily) 100/0.5ML/29G X 1/2" MISC INSULIN SYRINGE/U- 1 100/1ML/31G X 5/16" SURE-JECT INSULIN QL(5 ea daily); MISC SYRINGE/U- 1 RX/OTC SURE COMFORT PEN QL(5 ea daily) 100/0.5ML/30G X 5/16" NEEDLES29GX1/2" 1 MISC 12.7MM MISC SURE-JECT INSULIN QL(5 ea daily) SURE COMFORT PEN QL(5 ea daily); SYRINGE/U- 1 NEEDLES30GX5/16" 1 RX/OTC 100/0.5ML/31G X 5/16" SHORT MISC MISC SURE COMFORT PEN QL(5 ea daily); SURE-JECT INSULIN QL(5 ea daily); NEEDLES31GX3/16" 1 RX/OTC SYRINGE/U-100/1ML/28G 1 RX/OTC (5MM) MISC X 1/2" MISC SURE COMFORT PEN QL(5 ea daily); SURE-JECT INSULIN QL(5 ea daily); NEEDLES31GX5/16" 1 RX/OTC SYRINGE/U-100/1ML/29G 1 RX/OTC (8MM) MISC X 1/2" MISC SURE COMFORT PEN QL(5 ea daily); SURE-JECT INSULIN QL(5 ea daily); NEEDLES32GX5/32" 1 RX/OTC SYRINGE/U-100/1ML/30G 1 RX/OTC MISC X 5/16" MISC SURE-JECT INSULIN QL(5 ea daily) SURE COMFORT PEN 1 QL(5 ea daily) NEEDLES32GX6MM MISC SYRINGE/U-100/1ML/31G 1 X 5/16" MISC SURE-FINE PEN QL(5 ea daily) NEEDLES 29GX1/2" 1 TECHLITE INSULIN QL(5 ea daily); 12.7MM MISC SYRINGEU- 1 RX/OTC 100/0.3ML/29G X 1/2" SURE-FINE PEN QL(5 ea daily); MISC NEEDLES 31GX3/16" 1 RX/OTC 5MM MISC TECHLITE INSULIN QL(5 ea daily) SYRINGEU- 1 SURE-FINE PEN QL(5 ea daily); 100/0.3ML/30G X 1/2" NEEDLES 31GX5/16" 1 RX/OTC MISC 8MM MISC TECHLITE INSULIN QL(5 ea daily); SURE-JECT INSULIN QL(5 ea daily); SYRINGEU- 1 RX/OTC SYRINGE/U- 1 RX/OTC 100/0.3ML/30G X 5/16" 100/0.3ML/29G X 1/2" MISC MISC TECHLITE INSULIN QL(5 ea daily) SURE-JECT INSULIN QL(5 ea daily); SYRINGEU- 1 SYRINGE/U- 1 RX/OTC 100/0.3ML/31G X 5/16" 100/0.3ML/30G X 5/16" MISC MISC

Ambetter Formulary Updated December 1, 2020

116 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TECHLITE INSULIN QL(5 ea daily); TECHLITE PEN QL(5 ea daily) SYRINGEU- 1 RX/OTC NEEDLES/32GX 6MM 1 100/0.5ML/29G X 1/2" MISC MISC TODAYS HEALTH MINI QL(5 ea daily) TECHLITE INSULIN QL(5 ea daily) PEN NEEDLES 31G X 1/4" 1 SYRINGEU- 1 MISC 100/0.5ML/30G X 1/2" TODAYS HEALTH QL(5 ea daily); MISC ORIGINAL PEN NEEDLES 1 RX/OTC TECHLITE INSULIN QL(5 ea daily); 29G X 1/2" MISC SYRINGEU- 1 RX/OTC TODAYS HEALTH SHORT QL(5 ea daily); 100/0.5ML/30G X 5/16" PEN NEEDLES 31G X 1 RX/OTC MISC 5/16" MISC TECHLITE INSULIN QL(5 ea daily) TOPCARE CLICKFINE QL(5 ea daily) SYRINGEU- 1 UNIVERSAL PEN EEDLES 1 100/0.5ML/31G X 5/16" 31GX1/4" MISC MISC TOPCARE CLICKFINE QL(5 ea daily); TECHLITE INSULIN QL(5 ea daily); UNIVERSAL PEN EEDLES 1 RX/OTC SYRINGEU-100/1ML/29G 1 RX/OTC 31GX5/16" MISC X 1/2" MISC TOPCARE ULTRA QL(5 ea daily); TECHLITE INSULIN QL(5 ea daily) COMFORT INSULIN 1 RX/OTC SYRINGEU-100/1ML/30G 1 SYRINGE/0.3ML/30G X X 1/2" MISC 5/16" MISC TECHLITE INSULIN QL(5 ea daily); TOPCARE ULTRA QL(5 ea daily) SYRINGEU-100/1ML/30G 1 RX/OTC COMFORT INSULIN 1 X 5/16" MISC SYRINGE/0.3ML/31G X TECHLITE INSULIN QL(5 ea daily) 5/16" MISC SYRINGEU-100/1ML/31G 1 TOPCARE ULTRA QL(5 ea daily); X 15/64" MISC COMFORT INSULIN 1 RX/OTC TECHLITE INSULIN QL(5 ea daily) SYRINGE/0.5ML/30G X SYRINGEU-100/1ML/31G 1 5/16" MISC X 5/16" MISC TOPCARE ULTRA QL(5 ea daily) TECHLITE PEN NEEDLES 1 QL(5 ea daily); COMFORT INSULIN 1 29GX 12 MM MISC RX/OTC SYRINGE/0.5ML/31G X 5/16" MISC TECHLITE PEN NEEDLES 1 QL(5 ea daily); 31GX 5MM MISC RX/OTC TOPCARE ULTRA QL(5 ea daily); TECHLITE PEN QL(5 ea daily); COMFORT INSULIN 1 RX/OTC NEEDLES/31GX 5MM 1 RX/OTC SYRINGE/1ML/30G X MISC 5/16" MISC TECHLITE PEN QL(5 ea daily) TOPCARE ULTRA QL(5 ea daily) NEEDLES/31GX 6 MM 1 COMFORT INSULIN 1 MISC SYRINGE/1ML/31G X 5/16" MISC TECHLITE PEN QL(5 ea daily); NEEDLES/31GX 8MM 1 RX/OTC TOPCARE ULTRA QL(5 ea daily); MISC COMFORT INSULIN RX/OTC SYRINGE/U- 1 TECHLITE PEN QL(5 ea daily); 100/0.3ML/29G X 1/2" NEEDLES/32GX 4MM 1 RX/OTC MISC MISC

Ambetter Formulary Updated December 1, 2020

117 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TOPCARE ULTRA QL(5 ea daily); TRUEPLUS INSULIN QL(5 ea daily) COMFORT INSULIN RX/OTC SYRINGE/U- 1 SYRINGE/U- 1 100/0.3ML/31G X 5/16" 100/0.5ML/29G X 1/2" MISC MISC TRUEPLUS INSULIN QL(5 ea daily); TOPCARE ULTRA QL(5 ea daily); SYRINGE/U- 1 RX/OTC COMFORT INSULIN 1 RX/OTC 100/0.5ML/28G X 1/2" SYRINGE/U-100/1ML/29G MISC X 1/2" MISC TRUEPLUS INSULIN QL(5 ea daily); TRUE COMFORT INSULIN QL(5 ea daily) SYRINGE/U- 1 RX/OTC SYRINGE/0.5ML/31G X 1 100/0.5ML/29G X 1/2" 5/16" MISC MISC TRUE COMFORT INSULIN QL(5 ea daily) TRUEPLUS INSULIN QL(5 ea daily); 1 SYRINGE/1ML/31G X SYRINGE/U- 1 RX/OTC 5/16" MISC 100/0.5ML/30G X 5/16" TRUE COMFORT PEN QL(5 ea daily); MISC NEEDLES31G X 5MM 1 RX/OTC TRUEPLUS INSULIN QL(5 ea daily) MISC SYRINGE/U- 1 TRUE COMFORT PEN QL(5 ea daily) 100/0.5ML/31G X 5/16" NEEDLES31G X 6MM 1 MISC MISC TRUEPLUS INSULIN QL(5 ea daily); TRUE COMFORT PEN QL(5 ea daily); SYRINGE/U-100/1ML/28G 1 RX/OTC NEEDLES32G X 4MM 1 RX/OTC X 1/2" MISC MISC TRUEPLUS INSULIN QL(5 ea daily); TRUEPLUS 5-BEVEL PEN QL(5 ea daily) SYRINGE/U-100/1ML/29G 1 RX/OTC NEEDLES 29GX12.7MM 1 X 1/2" MISC MISC TRUEPLUS INSULIN QL(5 ea daily); TRUEPLUS 5-BEVEL PEN QL(5 ea daily); SYRINGE/U-100/1ML/30G 1 RX/OTC NEEDLES 31GX5MM 1 RX/OTC X 5/16" MISC MISC TRUEPLUS INSULIN QL(5 ea daily) TRUEPLUS 5-BEVEL PEN QL(5 ea daily) SYRINGE/U-100/1ML/31G 1 NEEDLES 31GX6MM 1 X 5/16" MISC MISC TRUEPLUS PEN QL(5 ea daily); TRUEPLUS 5-BEVEL PEN QL(5 ea daily); NEEDLES 29GX12MM 1 RX/OTC NEEDLES 31GX8MM 1 RX/OTC MISC MISC TRUEPLUS PEN QL(5 ea daily); TRUEPLUS 5-BEVEL PEN QL(5 ea daily); NEEDLES 31GX5MM 1 RX/OTC NEEDLES 32GX4MM 1 RX/OTC MISC MISC TRUEPLUS PEN QL(5 ea daily) TRUEPLUS INSULIN QL(5 ea daily); NEEDLES 31GX6MM 1 MISC SYRINGE/U- 1 RX/OTC 100/0.3ML/29G X 1/2" TRUEPLUS PEN QL(5 ea daily); MISC NEEDLES 31GX8MM 1 RX/OTC TRUEPLUS INSULIN QL(5 ea daily); MISC SYRINGE/U- 1 RX/OTC TRUEPLUS PEN QL(5 ea daily); 100/0.3ML/30G X 5/16" NEEDLES 32GX4MM 1 RX/OTC MISC MISC

Ambetter Formulary Updated December 1, 2020

118 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ULTICARE INSULIN QL(5 ea daily); ULTICARE INSULIN QL(5 ea daily); SAFETY 1 RX/OTC SYRINGE/SHORT/0.5ML/3 1 RX/OTC SYRINGE/0.5ML/29G X 0G X 5/16" MISC 1/2" MISC ULTICARE INSULIN QL(5 ea daily) ULTICARE INSULIN QL(5 ea daily); SYRINGE/SHORT/0.5ML/3 1 SAFETY 1 RX/OTC 1G X 5/16" MISC SYRINGE/1ML/29G X 1/2" ULTICARE INSULIN QL(5 ea daily); MISC SYRINGE/SHORT/1ML/30 1 RX/OTC ULTICARE INSULIN QL(5 ea daily); G X 5/16" MISC SYRINGE/0.3ML/29G X 1 RX/OTC ULTICARE INSULIN QL(5 ea daily) 1/2" MISC SYRINGE/SHORT/1ML/31 1 ULTICARE INSULIN QL(5 ea daily) G X 5/16" MISC SYRINGE/0.3ML/30G X 1 ULTICARE INSULIN QL(5 ea daily) 1/2" MISC SYRINGE/U- 1 ULTICARE INSULIN QL(5 ea daily); 100/0.3ML/30G X 1/2" SYRINGE/0.3ML/30G X 1 RX/OTC MISC 5/16" MISC ULTICARE INSULIN QL(5 ea daily) ULTICARE INSULIN QL(5 ea daily); SYRINGE/U- 1 SYRINGE/0.5ML/28G X 1 RX/OTC 100/0.3ML/31G X 5/16" 1/2" MISC MISC ULTICARE INSULIN QL(5 ea daily); ULTICARE INSULIN QL(5 ea daily) 1 SYRINGE/0.5ML/29G X RX/OTC SYRINGE/U- 1 1/2" MISC 100/0.5ML/30G X 1/2" ULTICARE INSULIN QL(5 ea daily) MISC SYRINGE/0.5ML/30G X 1 ULTICARE INSULIN QL(5 ea daily) 1/2" MISC SYRINGE/U- 1 ULTICARE INSULIN QL(5 ea daily); 100/0.5ML/31G X 5/16" SYRINGE/0.5ML/30G X 1 RX/OTC MISC 5/16" MISC ULTICARE INSULIN QL(5 ea daily) ULTICARE INSULIN QL(5 ea daily); SYRINGE/U-100/1ML/30G 1 SYRINGE/1ML/28G X 1/2" 1 RX/OTC X 1/2" MISC MISC ULTICARE INSULIN QL(5 ea daily) ULTICARE INSULIN QL(5 ea daily); SYRINGE/U-100/1ML/31G 1 SYRINGE/1ML/29G X 1/2" 1 RX/OTC X 5/16" MISC MISC ULTICARE INSULIN QL(5 ea daily) ULTICARE INSULIN QL(5 ea daily) SYRINGEULTRAFINE U- 1 SYRINGE/1ML/30G X 1/2" 1 100/0.3ML/31G X 5/16" MISC MISC ULTICARE INSULIN QL(5 ea daily); ULTICARE INSULIN QL(5 ea daily) SYRINGE/1ML/30G X 1 RX/OTC SYRINGEULTRAFINE U- 1 5/16" MISC 100/0.5ML/31G X 5/16" MISC ULTICARE INSULIN QL(5 ea daily); SYRINGE/SHORT/0.3ML/3 1 RX/OTC ULTICARE INSULIN QL(5 ea daily) 0G X 5/16" MISC SYRINGEULTRAFINE U- 1 100/1ML/31G X 5/16" ULTICARE INSULIN QL(5 ea daily) MISC SYRINGE/SHORT/0.3ML/3 1 1G X 5/16" MISC

Ambetter Formulary Updated December 1, 2020

119 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ULTICARE MICRO PEN QL(5 ea daily); ULTICARE SHORT PEN QL(5 ea daily); NEEDLES 31G X 8MM 1 RX/OTC NEEDLES ULTI-FINE IV 1 RX/OTC MISC MISC ULTICARE MICRO PEN QL(5 ea daily); ULTICARE SHORT PEN QL(5 ea daily); NEEDLES 32G X 4MM 1 RX/OTC NEEDLES/31G X 8MM 1 RX/OTC MISC MISC ULTICARE MICRO PEN QL(5 ea daily) ULTIGUARD QL(5 ea daily); NEEDLES/31G X 1/4" 1 SAFEPACK/MICROPEN RX/OTC MISC NEEDLE/32G X 1 ULTICARE MICRO PEN QL(5 ea daily); 5/32"/SHARPS CONTA NEEDLES/31G X 5/16" 1 RX/OTC MISC MISC ULTIGUARD QL(5 ea daily) ULTICARE MICRO PEN QL(5 ea daily); SAFEPACK/MINI PEN NEEDLES/32G X 4MM 1 RX/OTC NEEDLE/31G X 1 MISC 1/4"/SHARPS CONTAIN MISC ULTICARE MICRO PEN QL(5 ea daily); NEEDLES/32G X 5/32" 1 RX/OTC ULTIGUARD QL(5 ea daily); MISC SAFEPACK/MINI PEN RX/OTC NEEDLE/31G X 1 ULTICARE MINI PEN QL(5 ea daily) 3/16"/SHARPS CONTAI NEEDLES 31GX6MM 1 MISC MISC ULTIGUARD QL(5 ea daily) ULTICARE MINI PEN QL(5 ea daily) SAFEPACK/MINI PEN NEEDLES ULTI-FINE IV 1 NEEDLE/32G X 1 MISC 1/4"/SHARPS CONTAIN ULTICARE MINI PEN QL(5 ea daily) MISC NEEDLES/31G X 6MM 1 ULTIGUARD QL(5 ea daily); MISC SAFEPACK/SHORTPEN RX/OTC ULTICARE MINI PEN QL(5 ea daily) NEEDLE/31G X 1 NEEDLES/32G X 1/4" 1 5/16"/SHARPS CONTA MISC MISC ULTICARE MINI PEN 1 QL(5 ea daily) ULTILET INSULIN QL(5 ea daily); NEEDLES31GX6MM MISC SYRINGE/0.3ML/30G X 1 RX/OTC ULTICARE ORIGINAL QL(5 ea daily) 8MM MISC PEN NEEDLES ULTI-FINE 1 ULTILET INSULIN QL(5 ea daily) MISC SYRINGE/0.3ML/31G X 1 8MM MISC ULTICARE PEN NEEDLES 1 QL(5 ea daily); 31GX 5MM MISC RX/OTC ULTILET INSULIN QL(5 ea daily); SYRINGE/0.5ML/30G X 1 RX/OTC ULTICARE PEN NEEDLES 1 QL(5 ea daily); 31GX 5MM/MINI MISC RX/OTC 8MM MISC ULTICARE PEN QL(5 ea daily) ULTILET INSULIN QL(5 ea daily); NEEDLES/29GX 12.7MM 1 SYRINGE/1ML/30G X 1 RX/OTC MISC 8MM MISC ULTICARE SHORT PEN QL(5 ea daily); ULTILET INSULIN QL(5 ea daily) NEEDLES 31GX8MM 1 RX/OTC SYRINGE/1ML/31G X 1 MISC 8MM MISC

Ambetter Formulary Updated December 1, 2020

120 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ULTILET INSULIN QL(5 ea daily) ULTRA COMFORT QL(5 ea daily); SYRINGE/SHORT/0.3ML/3 1 INSULIN SYRINGE/U- 1 RX/OTC 0G X 12.7MM MISC 100/0.3ML/30G X 5/16" ULTILET INSULIN QL(5 ea daily); MISC SYRINGE/SHORT/0.3ML/3 1 RX/OTC ULTRA FLO INSULIN PEN 1 QL(5 ea daily); 0G X 5/16" MISC NEEDLES MISC RX/OTC ULTILET INSULIN QL(5 ea daily) ULTRA FLO INSULIN QL(5 ea daily); SYRINGE/SHORT/0.3ML/3 1 SYRINGE 0.3ML/29G X 1 RX/OTC 1G X 5/16" MISC 1/2" MISC ULTILET INSULIN QL(5 ea daily); ULTRA THIN PEN QL(5 ea daily); SYRINGE/SHORT/0.5ML/3 1 RX/OTC NEEDLES 32G X 4MM 1 RX/OTC 0G X 5/16" MISC MISC ULTILET INSULIN QL(5 ea daily) ULTRA-COMFORT QL(5 ea daily); SYRINGE/SHORT/0.5ML/3 1 INSULIN SYRINGE/U- 1 RX/OTC 1G X 5/16" MISC 100/0.3ML/29G X 1/2" ULTILET INSULIN QL(5 ea daily); MISC SYRINGE/SHORT/1ML/30 1 RX/OTC ULTRA-COMFORT QL(5 ea daily); G X 5/16" MISC INSULIN SYRINGE/U- 1 RX/OTC ULTILET INSULIN QL(5 ea daily) 100/0.3ML/30G X 5/16" SYRINGE/SHORT/1ML/31 1 MISC G X 5/16" MISC ULTRA-COMFORT QL(5 ea daily) ULTILET INSULIN QL(5 ea daily) INSULIN SYRINGE/U- 1 100/0.3ML/31G X 5/16" SYRINGE/U- 1 100/0.5ML/30G X 1/2" MISC MISC ULTRA-COMFORT QL(5 ea daily); ULTILET INSULIN QL(5 ea daily) INSULIN SYRINGE/U- 1 RX/OTC SYRINGE/U-100/1ML/30G 1 100/0.5ML/28G X 1/2" X 1/2" MISC MISC ULTRA-COMFORT QL(5 ea daily); ULTILET PEN NEEDLE 1 QL(5 ea daily) 29GX12.7MM MISC INSULIN SYRINGE/U- 1 RX/OTC 100/0.5ML/29G X 1/2" ULTILET PEN NEEDLE 1 QL(5 ea daily); MISC 31GX5MM MISC RX/OTC ULTRA-COMFORT QL(5 ea daily); ULTILET PEN NEEDLE QL(5 ea daily); 1 INSULIN SYRINGE/U- 1 RX/OTC 31GX8MM MISC RX/OTC 100/0.5ML/30G X 5/16" ULTILET PEN NEEDLE 1 QL(5 ea daily); MISC 32GX4MM MISC RX/OTC ULTRA-COMFORT QL(5 ea daily) ULTILET PEN NEEDLE QL(5 ea daily); 1 INSULIN SYRINGE/U- 1 32GX4MM/SHORT MISC RX/OTC 100/0.5ML/31G X 5/16" ULTILET SHORT PEN QL(5 ea daily); MISC NEEDLES 31GX5/16" 1 RX/OTC ULTRA-COMFORT QL(5 ea daily); MISC INSULIN SYRINGE/U- 1 RX/OTC ULTILET SHORT PEN QL(5 ea daily); 100/1ML/28G X 1/2" MISC NEEDLES31GX3/16" 1 RX/OTC ULTRA-COMFORT QL(5 ea daily); MISC INSULIN SYRINGE/U- 1 RX/OTC 100/1ML/29G X 1/2" MISC

Ambetter Formulary Updated December 1, 2020

121 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ULTRA-COMFORT QL(5 ea daily); ULTRACARE INSULIN QL(5 ea daily) INSULIN SYRINGE/U- 1 RX/OTC SYRINGE/U- 1 100/1ML/30G X 5/16" 100/0.3ML/31G X 5/16" MISC MISC ULTRA-COMFORT QL(5 ea daily) ULTRACARE INSULIN QL(5 ea daily) INSULIN SYRINGE/U- 1 SYRINGE/U- 1 100/1ML/31G X 5/16" 100/0.5ML/30G X 1/2" MISC MISC ULTRA-THIN II INSULIN QL(5 ea daily); ULTRACARE INSULIN QL(5 ea daily); SYRINGE SHORT/U- 1 RX/OTC SYRINGE/U- 1 RX/OTC 100/0.3ML/30GX5/16" 100/0.5ML/30G X 5/16" MISC MISC ULTRA-THIN II INSULIN QL(5 ea daily) ULTRACARE INSULIN QL(5 ea daily) SYRINGE SHORT/U- 1 SYRINGE/U- 1 100/0.3ML/31GX5/16" 100/0.5ML/31G X 5/16" MISC MISC ULTRA-THIN II INSULIN QL(5 ea daily); ULTRACARE INSULIN QL(5 ea daily) SYRINGE SHORT/U- 1 RX/OTC SYRINGE/U-100/1ML/30G 1 100/0.5ML/30GX5/16" X 1/2" MISC MISC ULTRACARE INSULIN QL(5 ea daily); ULTRA-THIN II INSULIN QL(5 ea daily) SYRINGE/U-100/1ML/30G 1 RX/OTC SYRINGE SHORT/U- 1 X 5/16" MISC 100/0.5ML/31GX5/16" ULTRACARE INSULIN QL(5 ea daily) MISC SYRINGE/U-100/1ML/31G 1 ULTRA-THIN II INSULIN QL(5 ea daily); X 5/16" MISC SYRINGE SHORT/U- 1 RX/OTC ULTRACARE PEN QL(5 ea daily) 100/1ML/30GX5/16" MISC NEEDLES/31G X 1/4" 1 ULTRA-THIN II INSULIN QL(5 ea daily) MISC SYRINGE SHORT/U- 1 ULTRACARE PEN QL(5 ea daily); 100/1ML/31GX5/16" MISC NEEDLES/31G X 3/16" 1 RX/OTC ULTRA-THIN II INSULIN QL(5 ea daily); MISC SYRINGE/U- 1 RX/OTC ULTRACARE PEN QL(5 ea daily); 100/0.5ML/29GX1/2" MISC NEEDLES/31G X 5/16" 1 RX/OTC ULTRA-THIN II INSULIN QL(5 ea daily); MISC SYRINGE/U- 1 RX/OTC ULTRACARE PEN QL(5 ea daily) 100/1ML/29GX1/2" MISC NEEDLES/32G X 1/14" 1 ULTRA-THIN II MINI PEN QL(5 ea daily); MISC NEEEDLES/31GX3/16" 1 RX/OTC ULTRACARE PEN QL(5 ea daily); MISC NEEDLES/32G X 3/16" 1 RX/OTC ULTRA-THIN II PEN 1 QL(5 ea daily) MISC NEEDLES 29GX1/2" MISC ULTRACARE PEN QL(5 ea daily); ULTRA-THIN II PEN QL(5 ea daily); NEEDLES/32G X 5/32" 1 RX/OTC NEEDLES/SHORT/31GX5/ 1 RX/OTC MISC 16" MISC UNIFINE PENTIPS 1 QL(5 ea daily); ULTRACARE INSULIN QL(5 ea daily); 29GX12MM MISC RX/OTC SYRINGE/U- RX/OTC 1 UNIFINE PENTIPS 31G X 1 QL(5 ea daily); 100/0.3ML/30G X 5/16" 3/16" MISC RX/OTC MISC

Ambetter Formulary Updated December 1, 2020

122 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits UNIFINE PENTIPS 1 QL(5 ea daily); VANISHPOINT INSULIN QL(5 ea daily); 31GX5MM MISC RX/OTC SYRINGE/1ML/29G X 1/2" 1 RX/OTC MISC UNIFINE PENTIPS 1 QL(5 ea daily) 31GX6MM MISC VANISHPOINT INSULIN QL(5 ea daily); SYRINGE/1ML/30G X 1 RX/OTC UNIFINE PENTIPS 1 QL(5 ea daily); 31GX8MM MISC RX/OTC 5/16" MISC VIDA MIA UNIFINE QL(5 ea daily); UNIFINE PENTIPS 1 QL(5 ea daily); 1 32GX4MM MISC RX/OTC PENTIPS32GX4MM MISC RX/OTC VIDA MIA UNIFINE QL(5 ea daily) UNIFINE PENTIPS 1 QL(5 ea daily) 32GX6MM MISC PENTIPSMINI 31GX6MM 1 MISC UNIFINE PENTIPS PLUS 1 QL(5 ea daily); 29GX12MM MISC RX/OTC VIDA MIA UNIFINE QL(5 ea daily); PENTIPSORIGINAL 1 RX/OTC UNIFINE PENTIPS PLUS 1 QL(5 ea daily); 29GX12MM MISC 31GX5MM MISC RX/OTC VIDA MIA UNIPFINE QL(5 ea daily); UNIFINE PENTIPS PLUS 1 QL(5 ea daily) PENTIPSSHORT 1 RX/OTC 31GX6MM MISC 31GX8MM MISC UNIFINE PENTIPS PLUS 1 QL(5 ea daily); VP INSULIN SYRINGE/U- QL(5 ea daily); 31GX8MM MISC RX/OTC 100/0.3ML/29G X 1/2" 1 RX/OTC UNIFINE PENTIPS PLUS 1 QL(5 ea daily); MISC 32GX4MM MISC RX/OTC WEGMANS UNIFINE QL(5 ea daily); UNIFINE SAFECONTROL QL(5 ea daily); PENTIPS PLUS 32GX4MM 1 RX/OTC PEN NEEDLE/30G X 5/16" 1 RX/OTC MISC MISC WEGMANS UNIFINE QL(5 ea daily); VALUE HEALTH INSULIN QL(5 ea daily); PENTIPS 1 RX/OTC SYRINGE/U- 1 RX/OTC PLUS/MINI/31GX5MM 100/0.5ML/29G X 1/2" MISC MISC WEGMANS UNIFINE QL(5 ea daily); VALUE HEALTH INSULIN QL(5 ea daily); PENTIPS 1 RX/OTC SYRINGE/U-100/1ML/29G 1 RX/OTC PLUS/SHORT/31GX8MM X 1/2" MISC MISC VALUMARK PEN QL(5 ea daily); WEGMANS UNIFINE QL(5 ea daily) NEEDLES 29GX12MM 1 RX/OTC PENTIPS PLUS/ULTRA 1 MISC SHORT/31GX6MM MISC VALUMARK PEN QL(5 ea daily) MIGRAINE PRODUCTS - Drugs to Treat Migraine NEEDLES 31GX 6MM 1 MISC VALUMARK PEN QL(5 ea daily); Calcitonin Gene-Related Peptide (CGRP) PA; QL(0.04 ml NEEDLES 31GX 8MM 1 RX/OTC AIMOVIG SOAJ 3 MISC daily) PA; QL(0.06 ml VANISHPOINT INSULIN QL(5 ea daily) AJOVY SOSY 3 SYRINGE/0.5ML/30G X 1 daily) 1/2" MISC EMGALITY SOAJ 120 3 PA VANISHPOINT INSULIN QL(5 ea daily); MG/ML SYRINGE/0.5ML/30G X 1 RX/OTC EMGALITY SOSY 120 3 PA 5/16" MISC MG/ML Migraine Combinations

Ambetter Formulary Updated December 1, 2020

123 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CAFERGOT TABS (Use QL(0.2 ea NF IMITREX SOLN NA 20 ergotamine w/ caffeine) NF daily); AL(At MG/ACT, 5 MG/ACT (Use least 18 yrs ergotamine w/ caffeine tabs 1 sumatriptan) or 1 mg-100 mg old) QL(0.134 ml Migraine Products IMITREX SOLN SC 6 daily); AL(At D.H.E. 45 SOLN (Use MG/0.5ML (Use NF sumatriptan succinate) least 18 yrs dihydroergotamine NF old) ) mesylate QL(0.134 ml IMITREX STATDOSE dihydroergotamine 1 daily); AL(At mesylate soln ij 1 mg/ml REFILL SOCT (Use NF sumatriptan succinate) least 18 yrs old) dihydroergotamine 1 PA; QL(0.267 mesylate soln na 4 mg/ml ml daily) QL(0.134 ml IMITREX STATDOSE daily); AL(At dihydroergotamine 1 QL(0.267 ml SYSTEM SOAJ (Use NF mesylate soln na 4 mg/ml daily) sumatriptan succinate) least 18 yrs QL(0.667 ea old) ERGOMAR SUBL 3 QL(0.3 ea daily) IMITREX TABS OR 100 MIGRANAL SOLN (Use ST; QL(0.267 NF daily); AL(At MG, 25 MG, 50 MG (Use least 18 yrs dihydroergotamine NF ml daily) sumatriptan succinate) mesylate) old) QL(0.6 ea Serotonin Agonists MAXALT TABS (Use NF rizatriptan benzoate) daily); AL(At ST; QL(0.4 ea least 6 yrs old) almotriptan malate tabs 1 daily); AL(At MAXALT-MLT TBDP 10 QL(0.6 ea 12.5 mg least 12 yrs MG (Use rizatriptan NF daily); AL(At old) benzoate) least 6 yrs old) ST; QL(0.3 ea QL(0.4 ea almotriptan malate tabs daily); AL(At MAXALT-MLT TBDP 5 MG NF daily); AL(At 1 (Use rizatriptan benzoate) 6.25 mg least 12 yrs least 6 yrs old) old) QL(0.3 ea QL(0.3 ea daily); AL(At naratriptan hcl tabs 1 AMERGE TABS (Use NF daily); AL(At least 18 yrs naratriptan hcl) least 18 yrs old) old) ST; QL(0.2 ea ST; QL(0.2 ea RELPAX TABS (Use NF daily); AL(At eletriptan hydrobromide 1 daily); AL(At eletriptan hydrobromide) least 18 yrs tabs least 18 yrs old) old) QL(0.6 ea ST; QL(0.4 ea rizatriptan benzoate tabs 1 daily); AL(At 10 mg FROVA TABS (Use NF daily); AL(At least 6 yrs old) frovatriptan succinate) least 18 yrs old) QL(0.4 ea rizatriptan benzoate tabs 5 1 daily); AL(At mg ST; QL(0.4 ea least 6 yrs old) 1 daily); AL(At frovatriptan succinate tabs least 18 yrs QL(0.6 ea rizatriptan benzoate tbdp 1 daily); AL(At old) 10 mg least 6 yrs old)

Ambetter Formulary Updated December 1, 2020

124 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(0.4 ea Bicarbonates rizatriptan benzoate tbdp 5 1 daily); AL(At mg SODIUM ACETATE SOLN least 6 yrs old) 1 2 MEQ/ML QL(0.2 ea sodium acetate soln 4 1 daily); AL(At 1 sumatriptan soln least 18 yrs meq/ml old) Calcium QL(0.134 ml calcium chloride (dihydrate) 1 sumatriptan succinate soaj 1 daily); AL(At soln sc 4 mg/0.5ml, 6 mg/0.5ml least 18 yrs CALCIUM GLUCONATE 1 old) SOLN QL(0.134 ml calcium gluconate soln 1 sumatriptan succinate soct 1 daily); AL(At sc 4 mg/0.5ml, 6 mg/0.5ml least 18 yrs old) Electrolyte Mixtures QL(0.134 ml dextrose in lactated ringers 1 soln sumatriptan succinate soln 1 daily); AL(At sc 6 mg/0.5ml least 18 yrs IONOSOL-MB/DEXTROSE old) 5% SOLN 20 MEQ/L-22 QL(0.134 ml MEQ/L-23 MEQ/L-25 MEQ/L-3 MEQ/L-3 MEQ/L- 1 sumatriptan succinate sosy 1 daily); AL(At sc 6 mg/0.5ml least 18 yrs 5 %, 20 MEQ/L-22 MEQ/L- old) 23 MEQ/L-25 MEQ/L-3 MEQ/L-3 MMOLE/L-5 % QL(0.3 ea ISOLYTE-P/DEXTROSE sumatriptan succinate tabs 1 daily); AL(At 1 or 100 mg, 25 mg, 50 mg least 18 yrs 5% SOLN old) ISOLYTE-S SOLN 1 ST; QL(0.3 ea KCL 0.3%/D5W/NACL 1 daily); AL(At 1 zolmitriptan tabs least 12 yrs 0.9% SOLN old) lactated ringer's soln 109 ST; QL(0.3 ea meq/l-130 meq/l-28 meq/l-3 meq/l-4 meq/l, 20 1 daily); AL(At 1 zolmitriptan tbdp least 12 yrs mg/100ml-30 mg/100ml- old) 310 mg/100ml-600 mg/100ml ST; QL(0.2 ea NORMOSOL-M IN D5W ZOMIG SOLN NA 2.5 MG, 3 daily); AL(At 1 5 MG least 12 yrs SOLN old) NORMOSOL-R SOLN 1 ST; QL(0.3 ea ZOMIG TABS OR 2.5 MG, NF daily); AL(At parenteral electrolytes conc 1 5 MG (Use zolmitriptan) least 12 yrs old) PLASMA-LYTE A SOLN 1 ST; QL(0.3 ea ZOMIG ZMT TBDP (Use NF daily); AL(At PLASMA-LYTE-148 SOLN 1 zolmitriptan) least 12 yrs old) potassium chloride in dextrose & sodium chloride 1 MINERALS & ELECTROLYTES soln

Ambetter Formulary Updated December 1, 2020

125 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits potassium chloride in 1 potassium chloride tbcr or 1 dextrose soln 10 meq, 8 meq potassium chloride in nacl 1 Sodium soln sodium chloride soln ij 2.5 1 POTASSIUM meq/ml CHLORIDE/DEXTROSE/L sodium chloride soln iv 3 ACTATED RINGERS 1 SOLN 129 MEQ/L-130 %, 5 %, 23.4 %, 4 meq/ml, MEQ/L-2.7 MEQ/L-24 1 0.45 %, 0.9 % MEQ/L-28 MEQ/L-5 %, 130 MISCELLANEOUS THERAPEUTIC CLASSES MEQ/L-149 MEQ/L-24 MEQ/L-28 MEQ/L-3 Chelating Agents MEQ/L-5 % CUPRIMINE CAPS (Use 3 PA ringer's soln 1 penicillamine) DEPEN TITRATABS TABS 3 QL(8 ea daily) Magnesium (Use penicillamine) magnesium sulfate soln ij 1 penicillamine caps 1 PA 50 % Phosphate penicillamine tabs 1 QL(8 ea daily) potassium phosphates soln 1 SYPRINE CAPS (Use NF PA; QL(8 ea 224 mg/ml-236 mg/ml trientine hcl) daily); SP Potassium PA; QL(8 ea trientine hcl caps 4 daily); SP K-TAB TBCR 10 MEQ (Use NF potassium chloride) Immunomodulators K-TAB TBCR 8 MEQ (Use 1 REVLIMID CAPS 10 MG, PA; QL(1 ea potassium chloride) 15 MG, 2.5 MG, 25 MG, 5 4 daily); SP potassium acetate soln 1 MG REVLIMID CAPS 20 MG 4 potassium bicarb & 1 chloride tbef PA; QL(3 ea THALOMID CAPS 4 potassium bicarbonate tbef 1 daily); SP Immunosuppressive Agents potassium chloride cpcr or 1 10 meq, 8 meq ATGAM INJ 4 PA; SP potassium chloride microencapsulated crystals 1 AZASAN TABS 3 er tbcr AZATHIOPRINE SOLR IJ 1 potassium chloride pack or 1 PA 100 MG 20 meq POTASSIUM CHLORIDE azathioprine tabs or 50 mg 1 SOLN IV 10 MEQ/100ML, 1 10 MEQ/50ML CELLCEPT CAPS 250 MG (Use mycophenolate NF potassium chloride soln iv 1 mofetil) 2 meq/ml CELLCEPT TABS 500 MG potassium chloride soln or 1 (Use mycophenolate NF 10 % mofetil)

Ambetter Formulary Updated December 1, 2020

126 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits cyclosporine caps 1 tabs 0.5 mg, 1 1 mg, 2 mg cyclosporine modified (for 1 microemulsion) caps tacrolimus caps 1 cyclosporine modified (for 1 THYMOGLOBULIN SOLR 4 PA; SP microemulsion) soln ZORTRESS TABS 0.25 PA; QL(20 ea cyclosporine soln 1 MG, 0.5 MG, 0.75 MG (Use 4 daily); SP everolimus everolimus 4 PA; QL(20 ea (immunosuppressant) tabs daily); SP (immunosuppressant)) Irrigation Solutions IMURAN TABS (Use NF azathioprine) irrigation solutions, 1 physiological soln mycophenolate mofetil 1 caps 250 mg lactated ringer's (irrigation) 1 soln mycophenolate mofetil tabs 1 500 mg ringer's irrigation soln 1 mycophenolate sodium 1 tbec water for irrigation, sterile 1 soln MYFORTIC TBEC (Use NF mycophenolate sodium) Potassium Removing Agents NEORAL CAPS (Use sodium polystyrene 1 cyclosporine modified (for NF sulfonate powd or microemulsion)) sodium polystyrene NEORAL SOLN (Use sulfonate susp or 15 1 cyclosporine modified (for NF gm/60ml microemulsion)) MOUTH/THROAT/DENTAL AGENTS NULOJIX SOLR 4 PA; SP PROGRAF CAPS OR 0.5 Anesthetics Topical Oral MG, 1 MG, 5 MG (Use NF lidocaine hcl (mouth-throat) 1 QL(4 ml daily) tacrolimus) soln 2 % lidocaine hcl (mouth-throat) PROGRAF PACK OR 0.2 2 PA 1 MG, 1 MG soln 4 % PROGRAF SOLN IV 5 2 Anti-infectives - Throat MG/ML clotrimazole troc 1 RAPAMUNE TABS 0.5 MG, 1 MG, 2 MG (Use NF nystatin (mouth-throat) 1 sirolimus) susp SANDIMMUNE CAPS OR - Mouth/Throat 100 MG, 25 MG (Use NF cyclosporine) chlorhexidine gluconate 1 (mouth-throat) soln SANDIMMUNE SOLN IV 50 MG/ML (Use NF DEBACTEROL SOLN 2 cyclosporine) PERIDEX SOLN (Use SIMULECT SOLR 3 chlorhexidine gluconate NF (mouth-throat))

Ambetter Formulary Updated December 1, 2020

127 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Dental Products NEONATAL VITAMIN 2 QL(1 ea daily) TABS stannous fluoride conc 0 RX/OTC NIVA-PLUS TABS 2 QL(1 ea daily); RX/OTC Steroids - Mouth/Throat/Dental QL(1 ea daily); O-CAL FA TABS 2 triamcinolone acetonide 1 RX/OTC (mouth) pste ONE VITE WOMENS QL(1 ea daily); Throat Products - Misc. PRENATALVITAMIN PLUS 2 RX/OTC cevimeline hcl caps 1 TABS ONE VITE WOMENS 2 QL(1 ea daily) EVOXAC CAPS (Use NF PRENATALVITAMIN TABS cevimeline hcl) PRENATAL LOW IRON 2 QL(1 ea daily) pilocarpine hcl (oral) tabs 1 TABS PRENATAL 2 QL(1 ea daily) SALAGEN TABS (Use NF MULTIVITAMIN TABS pilocarpine hcl (oral)) PRENATAL ONE DAILY 2 QL(1 ea daily) MULTIVITAMINS TABS PRENATAL PLUS TABS 2 QL(1 ea daily); Prenatal Vitamins RX/OTC CLASSIC PRENATAL 2 QL(1 ea daily) PRENATAL TABS 0.8 MG- QL(1 ea daily) TABS 1.5 MG-1.7 MG-100 MG-11 CVS PRENATAL TABS 2 QL(1 ea daily) UNIT-18 MG-2.6 MG-25 MG-263 MG-27 MG-4 MCG-400 UNIT-4000 EQL PRENATAL 2 QL(1 ea daily) FORMULA TABS UNIT, 0.8 MG-1.7 MG-1.8 QL(1 ea daily) MG-120 MG-2.6 MG-20 GNP PRENATAL TABS 2 MG-200 MG-25 MG-28 MG-30 UNIT-400 UNIT- GOODSENSE PRENATAL 2 QL(1 ea daily) VITAMINS TABS 4000 UNIT-8 MCG, 1.7 2 MG-1.8 MG-120 MG-2.6 HM PRENATAL TABS 2 QL(1 ea daily) MG-20 MG-200 MG-25 MG-28 MG-30 UNIT-400 KP PRENATAL 2 QL(1 ea daily) UNIT-4000 UNIT-8 MCG- MULTIVITAMINS TABS 800 MCG, 1.7 MG-1.84 MG-100 MG-11 UNIT-160 M-NATAL PLUS TABS 2 QL(1 ea daily); RX/OTC MG-18 MG-2.6 MG-200 QL(1 ea daily) MG-25 MG-27 MG-4 MCG- MULTI PRENATAL TABS 2 400 UNIT-4000 UNIT-800 NEONATAL COMPLETE QL(1 ea daily); MCG TABS 0.2 MG-1.84 MG-10 RX/OTC PRENATAL TABS 1 MG- QL(1 ea daily); MCG-10 MG-1000 MCG- 1.84 MG-10 MG-12 MCG- RX/OTC 12 MCG-120 MG-1200 2 120 MG-2 MG-20 MG-200 2 MCG-2 MG-2 MG-20 MG- MG-22 MG-25 MG-27 MG- 200 MG-25 MG-27 MG-3 3 MG-400 UNIT-4000 UNIT MG-5 MG-9.2 MG PRENATAL VITAMIN & 2 QL(1 ea daily) MINERAL TABS NEONATAL PLUS TABS 2 QL(1 ea daily); RX/OTC PRENATAL VITAMIN 2 QL(1 ea daily) TABS

Ambetter Formulary Updated December 1, 2020

128 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PRENATAL 2 QL(1 ea daily) methocarbamol tabs or 500 1 VITAMIN/IRON TABS mg, 750 mg PRENATAL VITAMINS 2 QL(1 ea daily); orphenadrine citrate tb12 or 1 QL(2 ea daily) PLUS LOW IRON TABS RX/OTC 100 mg PRENATAL VITAMINS 2 QL(1 ea daily) ROBAXIN TABS OR 500 NF TABS MG (Use methocarbamol) ROBAXIN-750 TABS (Use PRENATRIX TABS 2 QL(1 ea daily); NF RX/OTC methocarbamol) QL(1 ea daily); SKELAXIN TABS (Use QL(4 ea daily) PREPLUS TABS 2 NF RX/OTC metaxalone) PX PRENATAL 2 QL(1 ea daily) SOMA TABS (Use NF MULTIVITAMINS TABS carisoprodol) QC PRENATAL TABS 2 QL(1 ea daily) tizanidine hcl caps 1

RA PRENATAL QL(1 ea daily) tizanidine hcl tabs 1 FORMULA/FOLICACID 2 TABS ZANAFLEX CAPS (Use NF tizanidine hcl) RA PRENATAL TABS 2 QL(1 ea daily) ZANAFLEX TABS (Use NF RIGHT STEP PRENATAL 2 QL(1 ea daily) tizanidine hcl) TABS Direct Muscle Relaxants SM PRENATAL VITAMINS QL(1 ea daily) 2 DANTRIUM CAPS (Use NF QL(4 ea daily) TABS dantrolene sodium) THERANATAL CORE 2 QL(1 ea daily); dantrolene sodium caps or QL(4 ea daily) NUTRITION TABS RX/OTC 1 100 mg, 50 mg, 25 mg TRICARE TABS 2 QL(1 ea daily); RX/OTC NASAL AGENTS - SYSTEMIC AND TOPICAL - Drugs to treat the Nose or Sinus VITATHELY/GINGER 2 QL(1 ea daily); TABS RX/OTC Nasal Antiallergy VOL-PLUS TABS 2 QL(1 ea daily); azelastine hcl soln 1 RX/OTC WESTAB PLUS TABS 2 QL(1 ea daily); olopatadine hcl (nasal) soln 1 RX/OTC PATANASE SOLN (Use NF MUSCULOSKELETAL THERAPY AGENTS - olopatadine hcl (nasal)) Drugs to Treat Spasms Nasal Anticholinergics Central Muscle Relaxants ipratropium bromide (nasal) 1 QL(1 ml daily) baclofen tabs or 10 mg, 20 1 soln 0.03 % mg ipratropium bromide (nasal) 1 carisoprodol tabs 1 soln 0.06 % Nasal Steroids chlorzoxazone tabs 500 mg 1 QL(6 ea daily) budesonide (nasal) susp 1 cyclobenzaprine hcl tabs 1 QL(3 ea daily) 10 mg, 5 mg metaxalone tabs 800 mg 1 QL(4 ea daily)

Ambetter Formulary Updated December 1, 2020

129 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limit 2 inhalers FLONASE ALLERGY per NUTRIENTS RELIEF CHILDRENS NF month;QL(32 SUSP (Use fluticasone Proteins propionate (nasal)) ml per 30 days retail); RX/OTC CLINIMIX 4.25%/DEXTROSE 10% 3 Limit 2 inhalers SOLN FLONASE ALLERGY per RELIEF SUSP (Use NF month;QL(32 CLINIMIX fluticasone propionate 4.25%/DEXTROSE 25% 3 (nasal)) ml per 30 days retail); RX/OTC SOLN 1 rtl pack lmt CLINIMIX flunisolide (nasal) soln 1 per fill, 4.25%/DEXTROSE 5% 3 SOLN Limit 2 inhalers per CLINIMIX 5%/DEXTROSE 3 fluticasone propionate 1 month;QL(32 25% SOLN (nasal) susp ml per 30 days CLINIMIX E retail); RX/OTC 5%/DEXTROSE 20% 3 SOLN mometasone furoate 1 PA; QL(1.14 (nasal) susp gm daily) OPHTHALMIC AGENTS - Drugs to Treat the Eye NASACORT ALLERGY Artificial Tears and Lubricants 24HR AERO (Use NF triamcinolone acetonide (nasal)) LACRISERT INST 3 NASACORT ALLERGY Beta-blockers - Ophthalmic 24HR CHILDRENS AERO NF BETAGAN SOLN (Use NF (Use triamcinolone levobunolol hcl) acetonide (nasal)) NASONEX SUSP (Use PA; QL(1.14 betaxolol hcl (ophth) soln 1 mometasone furoate NF gm daily) (nasal)) carteolol hcl (ophth) soln 1 triamcinolone acetonide 1 (nasal) aero COMBIGAN SOLN 2 NEUROMUSCULAR AGENTS - Drugs to COSOPT SOLN (Use Relax/Paralyze Muscles dorzolamide hcl-timolol NF maleate) ALS Agents dorzolamide hcl-timolol RILUTEK TABS (Use NF maleate soln 0.5 %-2 %, 20 1 riluzole) mg/ml-5 mg/ml, 22.3 riluzole tabs 3 mg/ml-6.8 mg/ml levobunolol hcl soln 1 Neuromuscular Blocking Agent - Neurotoxins BOTOX SOLR 3 PA metipranolol soln 1

DYSPORT SOLR 3 PA timolol maleate (ophth) solg 1 0.25 %, 0.5 % PA XEOMIN SOLR 3 timolol maleate (ophth) soln 1 0.25 %, 0.5 %

Ambetter Formulary Updated December 1, 2020

130 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TIMOPTIC SOLN (Use NF gentamicin sulfate (ophth) 1 timolol maleate (ophth)) oint TIMOPTIC-XE SOLG (Use NF gentamicin sulfate (ophth) 1 timolol maleate (ophth)) soln Cycloplegic Mydriatics KLARITY-A SOLN 3 MYDRIACYL SOLN (Use NF tropicamide) levofloxacin (ophth) soln 1 tropicamide soln 1 moxifloxacin hcl (ophth) 1 soln Miotics NATACYN SUSP 2 ISOPTO CARPINE SOLN NF (Use pilocarpine hcl) neomycin-bacitracin zn- 1 polymyxin oint PHOSPHOLINE IODIDE 3 SOLR NEOSPORIN SOLN (Use neomycin-polymyxin- NF pilocarpine hcl soln 1 gramicidin) Ophthalmic Adrenergic Agents OCUFLOX SOLN (Use NF ALPHAGAN P SOLN 0.15 ofloxacin (ophth)) % (Use brimonidine NF ofloxacin (ophth) soln 1 tartrate) polymyxin b-trimethoprim 1 apraclonidine hcl soln 1 soln POLYTRIM SOLN (Use NF brimonidine tartrate soln 1 polymyxin b-trimethoprim) IOPIDINE SOLN 0.5 % NF sulfacetamide sodium 1 (Use apraclonidine hcl) (ophth) soln IOPIDINE SOLN 1 % 3 tobramycin (ophth) soln 1 PA SIMBRINZA SUSP 3 TOBREX SOLN (Use NF tobramycin (ophth)) Ophthalmic Anti-infectives trifluridine soln 1 AZASITE SOLN 3 VIGAMOX SOLN (Use NF moxifloxacin hcl (ophth)) bacitracin (ophthalmic) oint 3 VIROPTIC SOLN (Use NF BLEPH-10 SOLN (Use trifluridine) sulfacetamide sodium NF (ophth)) ZIRGAN GEL 2 CILOXAN SOLN (Use NF ZYMAXID SOLN (Use NF ciprofloxacin hcl (ophth)) gatifloxacin (ophth)) ciprofloxacin hcl (ophth) 1 Ophthalmic Immunomodulators soln RESTASIS EMUL 2 PA erythromycin (ophth) oint 1 RESTASIS MULTIDOSE 2 PA gatifloxacin (ophth) soln 1 EMUL Ophthalmic Local Anesthetics Ambetter Formulary Updated December 1, 2020

131 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ALCAINE SOLN (Use NF OMNIPRED SUSP (Use proparacaine hcl) prednisolone acetate NF (ophth)) proparacaine hcl soln 1 PRED FORTE SUSP (Use Ophthalmic Nerve Growth Factors prednisolone acetate NF (ophth)) OXERVATE SOLN 4 PA PRED MILD SUSP 3 PA Ophthalmic Steroids prednisolone acetate 1 ALREX SUSP 3 PA (ophth) susp PREDNISOLONE 1 dexamethasone sodium 1 ACETATE P-F SUSP phosphate (ophth) soln PREDNISOLONE SODIUM DUREZOL EMUL 3 PA PHOSPHATE SOLN OP 1 3 % (ophth) 1 susp TOBRADEX SUSP (Use tobramycin- NF FML FORTE SUSP 3 PA dexamethasone) tobramycin- 1 FML LIQUIFILM SUSP dexamethasone susp (Use fluorometholone NF (ophth)) Ophthalmics - Misc. FML OINT 3 PA ACULAR LS SOLN (Use ketorolac tromethamine NF (ophth)) LOTEMAX GEL 3 PA ACULAR SOLN (Use LOTEMAX OINT 3 PA ketorolac tromethamine NF (ophth)) LOTEMAX SUSP (Use 3 PA PA loteprednol etabonate) ALOCRIL SOLN 3 loteprednol etabonate susp 1 PA ALOMIDE SOLN 3 PA PA MAXIDEX SUSP 3 azelastine hcl (ophth) soln 1 MAXITROL OINT ( Use BEPREVE SOLN 3 PA neomycin-polymy- NF dexameth) bromfenac sodium (ophth) 1 MAXITROL SUSP (Use soln neomycin-polymy- NF cromolyn sodium (ophth) 1 dexameth) soln neomycin-polymy- 1 CYSTARAN SOLN 2 PA; QL(2.143 dexameth oint ml daily) neomycin-polymy- 1 diclofenac sodium (ophth) 1 dexameth susp soln neomycin-polymyxin-hc 1 (ophth) susp dorzolamide hcl soln 1 ELESTAT SOLN (Use NF epinastine hcl (ophth))

Ambetter Formulary Updated December 1, 2020

132 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EMADINE SOLN 3 acetic acid (otic) soln 1 epinastine hcl (ophth) soln 1 Otic Anti-infectives CETRAXAL SOLN (Use 1 flurbiprofen sodium soln 1 ciprofloxacin hcl (otic))

ILEVRO SUSP 3 ST; QL(0.2 ml ciprofloxacin hcl (otic) soln 1 daily) FLOXIN OTIC SOLN (Use NF ketorolac tromethamine 1 ofloxacin (otic)) (ophth) soln ofloxacin (otic) soln 1 ketotifen fumarate (ophth) 1 soln Otic Combinations LASTACAFT SOLN 3 PA CIPRO HC SUSP 3 NEVANAC SUSP 3 ST; QL(0.2 ml daily) CIPRODEX SUSP (Use PA ciprofloxacin- 2 olopatadine hcl soln 1 RX/OTC dexamethasone) ciprofloxacin- PA PATADAY SOLN (Use NF RX/OTC 1 olopatadine hcl) dexamethasone susp ciprofloxacin-fluocinolone PA; QL(0.5 ea PATANOL SOLN (Use NF RX/OTC 1 olopatadine hcl) acetonide soln daily) TRUSOPT SOLN (Use NF COLY-MYCIN S SUSP 3 dorzolamide hcl) CORTISPORIN-TC SUSP 3 ZADITOR SOLN (Use 1 ketotifen fumarate (ophth)) neomycin-polymyxin-hc 1 ZERVIATE SOLN 3 PA (otic) soln neomycin-polymyxin-hc 1 Prostaglandins - Ophthalmic (otic) susp bimatoprost soln 3 OTOVEL SOLN (Use PA; QL(0.5 ea ciprofloxacin-fluocinolone 3 daily) latanoprost soln 1 acetonide) ST Otic Steroids LUMIGAN SOLN 3 DERMOTIC OIL (Use fluocinolone acetonide NF TRAVATAN Z SOLN (Use 2 travoprost) (otic)) fluocinolone acetonide 1 travoprost soln 1 (otic) oil hydrocortisone w/acetic XALATAN SOLN (Use NF 1 latanoprost) acid soln ZIOPTAN SOLN 2 PASSIVE IMMUNIZING AND TREATMENT AGENTS - Antibody Drugs to Treat Low Immune OTIC AGENTS - Drugs to Treat the Ear System Immune Serums Otic Agents - Miscellaneous

Ambetter Formulary Updated December 1, 2020

133 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CUVITRU SOLN 1 PA; SP PENICILLIN G PROCAINE 3 GM/5ML, 10 GM/50ML, 2 4 SUSP GM/10ML, 4 GM/20ML penicillin g sodium solr 3 GAMMAGARD LIQUID PA; SP SOLN 1 GM/10ML, 10 4 penicillin v potassium solr 1 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 5 GM/50ML penicillin v potassium tabs 1 GAMMAGARD LIQUID 4 PA SOLN 30 GM/300ML Penicillin Combinations GAMMAGARD S/D IGA PA; SP amoxicillin & pot 1 LESS THAN 1MCG/ML 4 clavulanate chew SOLR amoxicillin & pot 1 GAMMAKED SOLN 4 PA; SP clavulanate susr amoxicillin & pot 1 GAMUNEX-C SOLN 4 PA; SP clavulanate tabs HIZENTRA SOLN 1 PA; SP amoxicillin & pot 1 GM/5ML, 10 GM/50ML, 2 4 clavulanate tb12 GM/10ML, 4 GM/20ML ampicillin & sulbactam sodium solr ij 0.5 gm-1 gm, 1 Passive Immunizing Agents - Combinations 1 gm-2 gm PA HYQVIA KIT 4 ampicillin & sulbactam 1 sodium solr iv 10 gm-5 gm PENICILLINS - Drugs to Treat Bacterial Infections AUGMENTIN ES-600 SUSR (Use amoxicillin & NF Aminopenicillins pot clavulanate) amoxicillin caps 1 AUGMENTIN SUSR 250 MG/5ML-62.5 MG/5ML NF amoxicillin chew 1 (Use amoxicillin & pot clavulanate) amoxicillin susr 1 AUGMENTIN TABS 125 MG-875 MG, 125 MG-500 NF amoxicillin tabs 1 MG (Use amoxicillin & pot clavulanate) ampicillin caps 1 AUGMENTIN XR TB12 (Use amoxicillin & pot NF ampicillin sodium solr ij 1 1 clavulanate) gm piperacillin sodium- 1 ampicillin sodium solr iv 10 1 tazobactam sodium solr gm UNASYN BULK PACK Natural Penicillins SOLR (Use ampicillin & NF PENICILLIN G sulbactam sodium) POTASSIUM IN ISO- UNASYN SOLR (Use OSMOTIC DEXTROSE 1 ampicillin & sulbactam NF SOLN 40000 UNIT/ML, sodium) 60000 UNIT/ML penicillin g potassium solr 1 5000000 unit

Ambetter Formulary Updated December 1, 2020

134 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ZOSYN SOLR 0.25 GM-2 PA; QL(224 ea GM, 0.375 GM-3 GM, 0.5 LUCEMYRA TABS 3 per 14 days GM-4 GM, 36 GM-4.5 GM NF retail) (Use piperacillin sodium- tazobactam sodium) Anti-Cataplectic Agents XYREM SOLN 4 PA; QL(18 ml Penicillinase-Resistant Penicillins daily); SP sodium caps 1 Antidementia Agents ARICEPT TABS 10 MG QL(2 ea daily) sodium solr ij 1 gm 1 (Use donepezil NF hydrochloride) oxacillin sodium solr ij 1 gm 1 ARICEPT TABS 5 MG QL(1 ea daily) (Use donepezil NF oxacillin sodium solr iv 10 1 gm hydrochloride) PROGESTINS - Hormone Replacement/Modifying donepezil hydrochloride 1 QL(2 ea daily) Drugs tabs 10 mg donepezil hydrochloride 1 QL(1 ea daily) Progestins tabs 5 mg AYGESTIN TABS (Use 0 donepezil hydrochloride 1 QL(2 ea daily) norethindrone acetate) tbdp 10 mg medroxyprogesterone 1 donepezil hydrochloride 1 QL(1 ea daily) acetate tabs tbdp 5 mg MEGACE ES SUSP (Use PA galantamine hydrobromide 1 QL(1 ea daily) megestrol acetate NF cp24 16 mg, 24 mg, 8 mg (appetite)) galantamine hydrobromide 1 QL(6 ml daily) megestrol acetate 1 PA soln 4 mg/ml (appetite) susp galantamine hydrobromide 1 QL(2 ea daily) norethindrone acetate tabs 0 tabs 12 mg, 4 mg, 8 mg memantine hcl tabs 1 micronized 1 caps memantine hcl tabs 10 mg 1 QL(2 ea daily) PROMETRIUM CAPS (Use NF progesterone micronized) QL(1 ea daily) PROVERA TABS (Use memantine hcl tabs 5 mg 1 medroxyprogesterone NF NAMENDA TABS 10 MG NF QL(2 ea daily) acetate) (Use memantine hcl) PSYCHOTHERAPEUTIC AND NEUROLOGICAL NAMENDA TABS 5 MG NF QL(1 ea daily) AGENTS - MISC. - Drugs to Treat Mental and (Use memantine hcl) Emotional Conditions NAMENDA TITRATION Agents for Chemical Dependency PAK TABS (Use NF memantine hcl) acamprosate calcium tbec 1 RAZADYNE ER CP24 (Use NF QL(1 ea daily) galantamine hydrobromide) ANTABUSE TABS (Use NF disulfiram) RAZADYNE TABS (Use NF QL(2 ea daily) galantamine hydrobromide) disulfiram tabs 1 rivastigmine tartrate caps 1

Ambetter Formulary Updated December 1, 2020

135 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Combination Psychotherapeutics glatiramer acetate sosy 20 3 PA; QL(1 ml mg/ml daily); SP perphenazine-amitriptyline 1 QL(4 ea daily) tabs glatiramer acetate sosy 40 3 PA; QL(0.429 mg/ml ml daily); SP Fibromyalgia Agents MAVENCLAD TBPK 4 PA SAVELLA TABS 2 PA; QL(2 ea daily) MAYZENT STARTER 4 PA SAVELLA TITRATION 2 PA PACK TBPK PACK MISC MAYZENT TABS 4 PA Movement Disorder Drug Therapy PA AUSTEDO TABS 4 PA; QL(4 ea OCREVUS SOLN 4 daily) PA; QL(0.0357 PA; QL(3 ea PLEGRIDY SOPN 4 tetrabenazine tabs 4 ml daily) daily); SP PLEGRIDY SOSY 4 PA XENAZINE TABS (Use NF PA; QL(3 ea tetrabenazine) daily); SP PLEGRIDY STARTER 4 PA Multiple Sclerosis Agents PACK SOPN AMPYRA TB12 (Use PA; QL(2 ea NF PLEGRIDY STARTER 4 PA; QL(0.0357 dalfampridine) daily); SP PACK SOSY ml daily) PA AUBAGIO TABS 4 REBIF REBIDOSE SOAJ 4 PA; QL(0.214 ml daily); SP PA; QL(0.0714 AVONEX PEN AJKT 4 REBIF REBIDOSE 4 PA; SP ea daily); SP TITRATIONPACK SOAJ PA; QL(0.0714 AVONEX PSKT 4 REBIF SOSY 4 PA; QL(0.214 ml daily); SP ml daily); SP PA; QL(0.5 ea BETASERON KIT 4 REBIF TITRATION PACK 4 PA; SP daily); SP SOSY COPAXONE SOSY 20 PA; QL(1 ml TECFIDERA CPDR (Use 4 PA MG/ML (Use glatiramer NF daily); SP dimethyl fumarate) acetate) TECFIDERA STARTER PA COPAXONE SOSY 40 PA; QL(0.429 PACK MISC (Use dimethyl 4 MG/ML (Use glatiramer NF ml daily); SP fumarate) acetate) PA; QL(0.536 PA; QL(2 ea TYSABRI CONC 4 dalfampridine tb12 4 ml daily); SP daily); SP Postherpetic Neuralgia (PHN)/Neuropathic Pain dimethyl fumarate cpdr 4 PA LYRICA CR TB24 165 MG, 3 PA; QL(1 ea 82.5 MG daily) dimethyl fumarate misc 4 PA PA; QL(2 ea LYRICA CR TB24 330 MG 3 PA; QL(0.5 ea daily) EXTAVIA KIT 4 daily); SP Premenstrual Dysphoric Disorder (PMDD) Agents PA; 30 rtl lmt fluoxetine hcl (pmdd) caps 1 QL(1 ea daily) GILENYA CAPS 0.25 MG 4 day(s),30 mail 10 mg lmt day(s), fluoxetine hcl (pmdd) caps 1 QL(3 ea daily) GILENYA CAPS 0.5 MG 4 PA; SP 20 mg Pseudobulbar Affect (PBA) Agents Ambetter Formulary Updated December 1, 2020

136 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NUEDEXTA CAPS 3 PA ZYBAN TB12 (Use QL(2 ea daily) bupropion hcl (smoking 0 Psychotherapeutic and Neurological Agents - deterrent)) ergoloid mesylates tabs 1 Transthyretin Amyloidosis Agents TEGSEDI SOSY 4 PA ORAP TABS (Use NF pimozide) RESPIRATORY AGENTS - MISC. - Drugs to pimozide tabs 1 Treat Lung Conditions Alpha-Proteinase Inhibitor (Human) Restless Leg Syndrome (RLS) Agents ARALAST NP SOLR 1000 4 PA; SP HORIZANT TBCR 3 PA; QL(2 ea MG, 400 MG daily) ARALAST NP SOLR 500 4 PA Smoking Deterrents MG bupropion hcl (smoking QL(2 ea daily) 0 PROLASTIN-C SOLN 1000 4 PA; deterrent) tb12 MG/20ML CHANTIX CONTINUING QL(2 ea daily) 0 PROLASTIN-C SOLR 1000 4 PA; SP MONTHPAK TABS MG CHANTIX STARTING 0 PA; SP MONTH PAK TABS ZEMAIRA SOLR 4 CHANTIX TABS 0 QL(2 ea daily) Cystic Fibrosis Agents PA; QL(2 ea KALYDECO TABS 150 MG 4 NICODERM CQ PT24 (Use 0 QL(1 ea daily) daily); SP ) ORKAMBI PACK 100 MG- 4 PA; QL(2 ea GUM (Use 0 125 MG, 150 MG-188 MG daily) nicotine polacrilex) ORKAMBI TABS 100 MG- 4 PA; QL(4 ea NICORETTE LOZG (Use 0 125 MG, 125 MG-200 MG daily) nicotine polacrilex) PA; QL(2.5 ml PULMOZYME SOLN 4 NICORETTE MINI LOZG 0 daily); SP (Use nicotine polacrilex) TRIKAFTA TBPK 4 PA; QL(3 ea NICORETTE STARTER daily) KIT GUM (Use nicotine 0 polacrilex) Pulmonary Fibrosis Agents OFEV CAPS 4 PA; QL(2 ea nicotine polacrilex gum 0 daily) nicotine polacrilex lozg 0 SULFONAMIDES - Drugs to Treat Bacterial Infections QL(1 ea daily) nicotine pt24 0 Sulfonamides NICOTINE SULFADIAZINE TABS 1 TRANSDERMAL SYSTEM 0 KIT - Drugs to Treat Bacterial Infections NICOTROL INHALER 0 INHA Glycylcyclines NICOTROL NS SOLN 0 tigecycline solr 1

Ambetter Formulary Updated December 1, 2020

137 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TIGECYCLINE SOLR 3 Thyroid Hormones ARMOUR THYROID TABS QL(1 ea daily) TYGACIL SOLR (Use 3 120 MG, 15 MG, 30 MG, 2 tigecycline) 60 MG, 90 MG (Use Tetracyclines thyroid) demeclocycline hcl tabs 1 ARMOUR THYROID TABS 2 QL(1 ea daily) 180 MG, 240 MG, 300 MG doxycycline (monohydrate) QL(2 ea daily) 1 CYTOMEL TABS (Use NF caps 100 mg, 50 mg liothyronine sodium) doxycycline (monohydrate) 1 sodium tabs caps 75 mg or 300 mcg, 100 mcg, 112 mcg, 125 mcg, 137 mcg, doxycycline (monohydrate) 1 QL(2 ea daily) 1 tabs 100 mg 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 doxycycline (monohydrate) 1 tabs 50 mg mcg, 88 mcg liothyronine sodium soln 1 doxycycline hyclate caps or 1 QL(2 ea daily) 50 mg, 100 mg liothyronine sodium tabs 1 doxycycline hyclate solr iv 1 100 mg NATURE-THROID NT-2.5 2 doxycycline hyclate tabs or 1 QL(2 ea daily) TABS 100 mg, 20 mg NATURE-THROID TABS 2 MINOCIN CAPS OR 50 NF QL(3 ea daily) MG (Use minocycline hcl) SYNTHROID TABS (Use 2 minocycline hcl caps 50 1 QL(3 ea daily) levothyroxine sodium) mg, 75 mg, 100 mg thyroid tabs 1 QL(1 ea daily) minocycline hcl tabs 100 1 QL(3 ea daily) mg, 50 mg, 75 mg TRIOSTAT SOLN (Use NF liothyronine sodium) TARGADOX TABS (Use NF doxycycline hyclate) WESTHROID TABS 2 hcl caps 1 QL(8 ea daily) WP THYROID TABS 2 VIBRAMYCIN CAPS 100 QL(2 ea daily) MG (Use doxycycline NF TOXOIDS hyclate) XIMINO CP24 135 MG, 45 Toxoid Combinations MG, 90 MG (Use NF minocycline hcl) ADACEL SUSP 0 THYROID AGENTS - Drugs to Regulate Thyroid BOOSTRIX SUSP 0 Hormones Antithyroid Agents DAPTACEL SUSP 0 methimazole tabs 1 DIPHTHERIA/TETANUS TOXOIDS ADSORBED 0 propylthiouracil tabs 1 PEDIATRIC SUSP INFANRIX SUSP 0 TAPAZOLE TABS (Use NF methimazole)

Ambetter Formulary Updated December 1, 2020

138 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits KINRIX SUSP 0 famotidine in nacl soln 1

PEDIARIX SUSP 0 famotidine soln iv 20 mg/2ml, 200 mg/20ml, 40 1 PENTACEL SUSR 0 mg/4ml famotidine susr or 40 1 QL(10 ml daily) QUADRACEL SUSP 0 mg/5ml famotidine tabs or 20 mg 1 RX/OTC TDVAX SUSP 0 famotidine tabs or 40 mg 1 TENIVAC INJ 0 NIZATIDINE CAPS 150 1 TETANUS/DIPHTHERIA MG TOXOIDS-ADSORBED 0 ADULT SUSP nizatidine caps 150 mg, 1 300 mg ULCER DRUGS - Drugs to Treat Bowel, Intestine QL(20 ml daily) and Stomach Conditions nizatidine soln 15 mg/ml 1 Antispasmodics PEPCID AC MAXIMUM RX/OTC STRENGTH TABS (Use NF atropine sulfate soln ij 0.1 1 mg/ml, 0.4 mg/ml, 1 mg/ml famotidine) PEPCID SUSR 40 MG/5ML QL(10 ml daily) atropine sulfate sosy ij 0.25 1 NF mg/5ml (Use famotidine) PEPCID TABS 20 MG (Use RX/OTC chlordiazepoxide hcl- 1 NF clidinium bromide caps famotidine) PEPCID TABS 40 MG (Use dicyclomine hcl caps or 10 1 NF mg famotidine) ranitidine hcl caps or 150 dicyclomine hcl soln or 10 1 1 mg/5ml mg, 300 mg ranitidine hcl soln ij 150 dicyclomine hcl tabs or 20 1 1 mg mg/6ml ranitidine hcl syrp or 15 QL(40 ml daily) glycopyrrolate soln ij 4 1 mg/20ml mg/ml, 150 mg/10ml, 75 1 mg/5ml glycopyrrolate tabs or 1 1 mg, 2 mg ranitidine hcl tabs or 150 1 RX/OTC mg LIBRAX CAPS (Use chlordiazepoxide hcl- NF ranitidine hcl tabs or 300 1 clidinium bromide) mg TAGAMET HB TABS (Use RX/OTC methscopolamine bromide 1 NF tabs cimetidine) ZANTAC 150 MAXIMUM RX/OTC H-2 Antagonists STRENGTH TABS (Use NF cimetidine hcl soln 1 QL(20 ml daily) ranitidine hcl) ZANTAC SOLN 25 MG/ML, cimetidine tabs 200 mg 1 RX/OTC 25 MG/ML (Use ranitidine NF hcl) cimetidine tabs 300 mg, 1 400 mg, 800 mg Misc. Anti-Ulcer

Ambetter Formulary Updated December 1, 2020

139 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CARAFATE SUSP 1 2 QL(40 ml daily) PREVACID CPDR 15 MG NF QL(2 ea daily); GM/10ML (Use sucralfate) (Use lansoprazole) RX/OTC CARAFATE TABS 1 GM NF QL(4 ea daily) PREVACID CPDR 30 MG NF (Use sucralfate) (Use lansoprazole) sucralfate susp 1 gm/10ml 1 QL(40 ml daily) PRILOSEC OTC TBEC QL(4 ea daily) (Use 1 sucralfate tabs 1 gm 1 QL(4 ea daily) magnesium) PROTONIX TBEC OR 20 QL(1 ea daily) Proton Pump Inhibitors MG (Use pantoprazole NF sodium) ACIPHEX TBEC (Use NF QL(1 ea daily) rabeprazole sodium) PROTONIX TBEC OR 40 MG (Use pantoprazole NF DEXILANT CPDR 3 PA; QL(1 ea daily) sodium) QL(1 ea daily) esomeprazole magnesium 1 QL(2 ea daily); rabeprazole sodium tbec 1 cpdr 20 mg RX/OTC Ulcer Drugs - Prostaglandins esomeprazole magnesium 3 QL(1 ea daily) cpdr 40 mg CYTOTEC TABS (Use NF QL(4 ea daily) QL(2 ea daily); misoprostol) lansoprazole cpdr 15 mg 1 RX/OTC misoprostol tabs 1 QL(4 ea daily) lansoprazole cpdr 30 mg 1 Ulcer Therapy Combinations NEXIUM 24HR TBEC 1 QL(2 ea daily) omeprazole-sodium QL(1 ea daily); bicarbonate caps 1100 mg- 1 RX/OTC NEXIUM CPDR 20 MG QL(2 ea daily); 20 mg (Use esomeprazole NF RX/OTC ZEGERID CAPS 1100 MG- RX/OTC magnesium) 20 MG (Use omeprazole- NF NEXIUM CPDR 40 MG QL(1 ea daily) sodium bicarbonate) (Use esomeprazole NF magnesium) URINARY ANTI-INFECTIVES - Drugs to Treat Bladder/Kidney Infections omeprazole cpdr 10 mg, 40 1 QL(2 ea daily) mg Urinary Anti-infectives QL(2 ea daily); nitrofurantoin monohyd omeprazole cpdr 20 mg 1 1 RX/OTC macro caps omeprazole magnesium 1 QL(4 ea daily) URINARY ANTISPASMODICS - Drugs to Treat cpdr Miscellaneous Bladder Spasms omeprazole magnesium 1 QL(4 ea daily) Urinary Antispasmodic - Antimuscarinics tbec darifenacin hydrobromide 1 QL(1 ea daily) omeprazole tbec 20 mg 1 QL(2 ea daily) tb24 DETROL LA CP24 (Use NF QL(1 ea daily) pantoprazole sodium tbec 1 QL(1 ea daily) tolterodine tartrate) or 20 mg DETROL TABS (Use NF pantoprazole sodium tbec 1 tolterodine tartrate) or 40 mg DITROPAN XL TB24 (Use NF PREVACID 24HR CPDR NF QL(2 ea daily); oxybutynin chloride) (Use lansoprazole) RX/OTC ENABLEX TB24 (Use NF QL(1 ea daily) darifenacin hydrobromide)

Ambetter Formulary Updated December 1, 2020

140 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits oxybutynin chloride syrp 1 MENACTRA INJ 0 oxybutynin chloride tabs 1 MENQUADFI INJ 0 oxybutynin chloride tb24 1 MENVEO SOLR 0 PA; QL(1 ea solifenacin succinate tabs 1 PEDVAX HIB SUSP 0 daily) tolterodine tartrate cp24 2 1 QL(1 ea daily) PNEUMOVAX 23 INJ 0 mg, 4 mg PNEUMOVAX 23/1 DOSE tolterodine tartrate tabs 1 1 0 mg, 2 mg INJ TOVIAZ TB24 3 PA; QL(1 ea PREVNAR 13 SUSP 0 daily) TRUMENBA SUSY 0 trospium chloride cp24 60 1 QL(1 ea daily) mg Viral Vaccines trospium chloride tabs 20 1 mg Limit 1 dose per season;1 rtl AFLURIA 2018-2019 SUSP 0 VESICARE TABS (Use 3 PA; QL(1 ea MAX fill,180 rtl solifenacin succinate) daily) day(s) supply, Urinary Antispasmodics - Beta-3 Adrenergic Limit 1 dose MYRBETRIQ TB24 3 PA AFLURIA PF 2018-2019 0 per season;1 rtl SUSY MAX fill,180 rtl Urinary Antispasmodics - Cholinergic Agonists day(s) supply, Limit 1 dose bethanechol chloride tabs 1 QL(4 ea daily) 10 mg, 5 mg, 50 mg AFLURIA QUADRIVALENT 0 per season;1 rtl 2018-2019 SUSP MAX fill,180 rtl bethanechol chloride tabs 1 day(s) supply, 25 mg Limit 1 dose URECHOLINE TABS 10 QL(4 ea daily) AFLURIA QUADRIVALENT 0 per season;1 rtl MG, 5 MG, 50 MG (Use NF 2018-2019 SUSY MAX fill,180 rtl bethanechol chloride) day(s) supply, URECHOLINE TABS 25 Limit 1 dose MG (Use bethanechol NF AFLURIA QUADRIVALENT 0 per season;1 rtl chloride) 2019-2020 SUSP MAX fill,180 rtl Urinary Antispasmodics - Direct Muscle Relaxants day(s) supply, Limit 1 dose flavoxate hcl tabs 1 AFLURIA QUADRIVALENT 0 per season;1 rtl 2019-2020 SUSY MAX fill,180 rtl VACCINES day(s) supply, Bacterial Vaccines Limit 1 dose AFLURIA QUADRIVALENT 0 per season;1 rtl ACTHIB SOLR 0 2020-2021 SUSP MAX fill,180 rtl day(s) supply, BEXSERO SUSY 0

HIBERIX SOLR 0

Ambetter Formulary Updated December 1, 2020

141 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limit 1 dose Limit 1 dose FLUCELVAX AFLURIA QUADRIVALENT 0 per season;1 rtl 0 per season;1 rtl 2020-2021 SUSY MAX fill,180 rtl QUADRIVALENT 2018- 2019 SUSP MAX fill,180 rtl day(s) supply, day(s) supply, Limit 1 dose ENGERIX-B INJ 0 FLUCELVAX QUADRIVALENT 2018- 0 per season;1 rtl ENGERIX-B SUSP 0 2019 SUSY MAX fill,180 rtl day(s) supply, Limit 1 dose Limit 1 dose FLUCELVAX FLUAD 2018-2019 SUSY 0 per season;1 rtl per season;1 rtl MAX fill,180 rtl QUADRIVALENT 2019- 0 2020 SUSP MAX fill,180 rtl day(s) supply, day(s) supply, Limit 1 dose Limit 1 dose FLUCELVAX FLUAD 2019-2020 SUSY 0 per season;1 rtl per season;1 rtl MAX fill,180 rtl QUADRIVALENT 2019- 0 2020 SUSY MAX fill,180 rtl day(s) supply, day(s) supply, Limit 1 dose Limit 1 dose FLUCELVAX FLUAD 2020-2021 SUSY 0 per season;1 rtl per season;1 rtl MAX fill,180 rtl QUADRIVALENT 2020- 0 2021 SUSP MAX fill,180 rtl day(s) supply, day(s) supply, FLUAD QUADRIVALENT 1 rtl MAX Limit 1 dose INFLUENZA VACCINE 0 fill,180 rtl FLUCELVAX 0 per season;1 rtl FOR ADULTS PRSY day(s) supply, QUADRIVALENT 2020- MAX fill,180 rtl 2021 SUSY Limit 1 dose day(s) supply, FLUARIX QUADRIVALENT 0 per season;1 rtl Limit 1 dose 2018-2019 SUSY MAX fill,180 rtl FLULAVAL 0 per season;1 rtl day(s) supply, QUADRIVALENT 2018- MAX fill,180 rtl 2019 SUSP Limit 1 dose day(s) supply, FLUARIX QUADRIVALENT 0 per season;1 rtl Limit 1 dose 2019-2020 SUSY MAX fill,180 rtl FLULAVAL 0 per season;1 rtl day(s) supply, QUADRIVALENT 2018- MAX fill,180 rtl 2019 SUSY Limit 1 dose day(s) supply, FLUARIX QUADRIVALENT 0 per season;1 rtl Limit 1 dose 2020-2021 SUSY MAX fill,180 rtl FLULAVAL 0 per season;1 rtl day(s) supply, QUADRIVALENT 2019- MAX fill,180 rtl 2020 SUSP Limit 1 dose day(s) supply, FLUBLOK per season;1 rtl QUADRIVALENT 2018- 0 Limit 1 dose MAX fill,180 rtl FLULAVAL 2019 SOSY 0 per season;1 rtl day(s) supply, QUADRIVALENT 2019- MAX fill,180 rtl 2020 SUSY Limit 1 dose day(s) supply, FLUBLOK QUADRIVALENT 2019- 0 per season;1 rtl Limit 1 dose MAX fill,180 rtl FLULAVAL 2020 SOSY 0 per season;1 rtl day(s) supply, QUADRIVALENT 2020- MAX fill,180 rtl 2021 SUSY Limit 1 dose day(s) supply, FLUBLOK QUADRIVALENT 2020- 0 per season;1 rtl Limit 1 dose MAX fill,180 rtl 2021 SOSY FLUMIST 0 per season;1 rtl day(s) supply, QUADRIVALENT SUSP MAX fill,180 rtl day(s) supply,

Ambetter Formulary Updated December 1, 2020

142 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limit 1 dose 1 rtl MAX FLUZONE HIGH-DOSE PF 0 per season;1 rtl M-M-R II SOLR 0 fill,365 rtl 2018-2019 SUSY MAX fill,180 rtl day(s) supply, day(s) supply, RECOMBIVAX HB SUSP 0 Limit 1 dose FLUZONE HIGH-DOSE PF 0 per season;1 rtl ROTARIX SUSR 0 2019-2020 SUSY MAX fill,180 rtl day(s) supply, ROTATEQ SOLN 0 1 rtl MAX FLUZONE HIGH-DOSE PF 0 AL(At least 50 2020-2021 SUSY fill,180 rtl SHINGRIX SUSR 0 day(s) supply, yrs old) Limit 1 dose FLUZONE TWINRIX SUSP 0 QUADRIVALENT 2018- 0 per season;1 rtl 2019 SUSP MAX fill,180 rtl TWINRIX SUSY 0 day(s) supply, Limit 1 dose VAQTA SUSP 0 FLUZONE per season;1 rtl QUADRIVALENT 2018- 0 1 rtl MAX 2019 SUSY MAX fill,180 rtl day(s) supply, VARIVAX INJ 0 fill,365 rtl Limit 1 dose day(s) supply, FLUZONE per season;1 rtl ZOSTAVAX SUSR 0 AL(At least 50 QUADRIVALENT 2019- 0 yrs old) 2020 SUSP MAX fill,180 rtl day(s) supply, VAGINAL AND RELATED PRODUCTS Limit 1 dose FLUZONE QUADRIVALENT 2019- 0 per season;1 rtl Miscellaneous Vaginal Products 2020 SUSY MAX fill,180 rtl day(s) supply, INTRAROSA INST 3 PA Limit 1 dose FLUZONE Spermicides QUADRIVALENT 2020- 0 per season;1 rtl 2021 SUSP MAX fill,180 rtl SHUR-SEAL GEL 0 day(s) supply, Limit 1 dose FLUZONE TODAY SPONGE MISC 0 QUADRIVALENT 2020- 0 per season;1 rtl MAX fill,180 rtl Vaginal Anti-infectives 2021 SUSY day(s) supply, CLEOCIN CREA VA 2 % GARDASIL 9 SUSP 0 (Use clindamycin NF phosphate vaginal) GARDASIL 9 SUSY 0 clindamycin phosphate 1 vaginal crea HAVRIX SUSP 0 clotrimazole vaginal crea 1

HEPLISAV-B SOLN 0 GYNAZOLE-1 CREA 3

HEPLISAV-B SOSY 0 GYNE-LOTRIMIN CREA NF (Use clotrimazole vaginal) IPOL INACTIVATED IPV 0 INJ METROGEL-VAGINAL GEL (Use metronidazole NF vaginal)

Ambetter Formulary Updated December 1, 2020

143 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits metronidazole vaginal gel 1 QL(2 ea per fill retail,2 ea per miconazole nitrate vaginal fill mail)2 rtl 1 EPIPEN-JR 2-PAK SOAJ MAX fill,365 rtl supp (Use epinephrine 2 (anaphylaxis)) day(s) supply,2 terconazole vaginal crea 1 mail MAX fill,365 mail terconazole vaginal supp 1 day(s) supply, Vaginal Estrogens Vasopressors ESTRACE CREA (Use NF midodrine hcl tabs 1 estradiol vaginal) estradiol vaginal crea 1 VITAMINS Oil Soluble Vitamins estradiol vaginal tabs 1 cholecalciferol caps 1.25 1 FEMRING RING 3 mg, 50000 unit cholecalciferol tabs 400 0 PREMARIN CREA 2 unit DRISDOL CAPS (Use 0 VAGIFEM TABS (Use NF ergocalciferol) estradiol vaginal) ergocalciferol caps or 1.25 0 VASOPRESSORS - Drugs to Treat Heart and mg, 50000 unit Circulation Conditions ergocalciferol soln or 8000 1 Anaphylaxis Therapy Agents unit/ml AL(At least 65 QL(2 ea per fill VITAMIN D2 TABS 0 retail,2 ea per yrs old) fill mail)2 rtl Water Soluble Vitamins epinephrine (anaphylaxis) 1 MAX fill,365 rtl soaj 0.15 mg/0.3ml day(s) supply,2 niacin cpcr or 500 mg, 250 1 mail MAX mg fill,365 mail niacin tabs or 50 mg, 250 1 day(s) supply, mg, 100 mg, 500 mg QL(2 ea per fill niacin tbcr or 750 mg, 250 1 mg, 500 mg epinephrine (anaphylaxis) 2 retail)2 rtl MAX soaj 0.3 mg/0.3ml fill,365 rtl day(s) supply, NIACIN TR TBCR 1 QL(2 ea per fill niacinamide tabs or 100 1 retail,2 ea per mg, 500 mg fill mail)2 rtl SLO-NIACIN TBCR (Use 1 epinephrine (anaphylaxis) 2 MAX fill,365 rtl niacin) soaj 0.3 mg/0.3ml day(s) supply,2 mail MAX fill,365 mail day(s) supply, EPIPEN 2-PAK SOAJ (Use NF epinephrine (anaphylaxis))

Ambetter Formulary Updated December 1, 2020

144 Index 1ST TIER UNIFINE ACCU-CHEK SAFE-T-PRO adefovir dipivoxil 47 PENTIPS/MINI/31GX5MM 91 PLUSLANCETS 79 ADEMPAS 51 1ST TIER UNIFINE ACCU-CHEK SOFTCLIX PENTIPS29GX12MM 91 LANCETS 79 ADIPEX-P 1 1ST TIER UNIFINE ACCUPRIL 31 ADJUSTABLE LANCING DEVICE 79 PENTIPS31GX6MM 91 ACCURETIC 32 1ST TIER UNIFINE ADVAIR DISKUS 15 acebutolol hcl 49 PENTIPS31GX8MM 91 ADVAIR HFA 15 1ST TIER UNIFINE acetaminophen w/ codeine 8 ADVANCED MOBILE LANCET PENTIPS32GX4MM 91 acetaminophen-caff- 30G 79 1ST TIER UNIFINE dihydrocod 8 ADVICOR 31 PENTIPS32GX6MM 91 acetazolamide 66 1ST TIER UNIFINE ADVOCATE INSULIN PEN PENTIPSPLUS 31GX8MM 91 acetazolamide sodium 66 NEEDLES 29GX12.7MM 92 1ST TIER UNIFINE acetic acid 72 ADVOCATE INSULIN PEN PENTIPSPLUS 32GX4MM 92 acetic acid (otic) 133 NEEDLES 31GX5MM 92 ADVOCATE INSULIN PEN 1ST TIER UNIFINE acetylcysteine 56 PENTIPSPLUS/MINI/31GX5MM NEEDLES 31GX8MM 92 92 ACIPHEX 140 ADVOCATE INSULIN 1ST TIER UNIFINE acitretin 60 SYRINGE/U- 100/0.3ML/29GX1/2" 92 PENTIPSPLUS/ORIGINAL/29GX ACTEMRA 4 12MM 92 ADVOCATE INSULIN 1ST TIER UNIFINE ACTHAR 68 SYRINGE/U- PENTIPSPLUS/ULTRA ACTHIB 141 100/0.3ML/30GX5/16" 92 SHORT/31GX6MM 92 ACTI-LANCE LANCETS ADVOCATE INSULIN 1ST TIER UNILET 28G 79 SYRINGE/U- COMFORTOUCH LANCETS ACTI-LANCE LITE SAFETY 100/0.3ML/31GX5/16" 92 28G 79 LANCETS 28G 79 ADVOCATE INSULIN 1ST TIER UNILET ACTI-LANCE SPECIAL SYRINGE/U- COMFORTOUCH LANCETS SAFETY LANCETS 17G 79 100/0.5ML/29GX1/2" 92 30G 79 ACTI-LANCE SPECIAL ADVOCATE INSULIN abacavir sulfate 44 SAFETYLANCETS 17G 79 SYRINGE/U- ACTI-LANCE UNIVERSAL 100/0.5ML/30GX5/16" 92 abacavir sulfate-lamivudine 45 SAFETY LANCETS 23G 79 ADVOCATE INSULIN abacavir sulfate-lamivudine- ACTIGALL 71 SYRINGE/U- zidovudine 45 100/0.5ML/31GX5/16" 92 ABELCET 28 ACTIMMUNE 40 ADVOCATE INSULIN ABILIFY 44 ACTIQ 6 SYRINGE/U-100/1ML/29GX1/2" abiraterone acetate 37 ACTONEL 67 92 ACTOPLUS MET 24 ADVOCATE INSULIN ABOUTTIME PEN NEEDLE SYRINGE/U-100/1ML/30GX5/16" 32GX 5/32" 92 ACTOS 25 92 ABOUTTIME PEN NEEDLES ACULAR 132 ADVOCATE INSULIN 30GX 5/16" 92 ACULAR LS 132 SYRINGE/U-100/1ML/31GX5/16" ABOUTTIME PEN NEEDLES 92 31G X 3/16" 92 acyclovir 48 ADVOCATE LANCETS 79 ABOUTTIME PEN NEEDLES acyclovir topical 61 ADVOCATE LANCETS 30G 79 31G X 5/16" 92 ADACEL 138 ABRAXANE 41 ADVOCATE LANCING ADAGEN 3 acamprosate calcium 135 DEVICE 79 ADALAT CC 49 ADVOCATE RAPID-SAFE acarbose 24 adapalene 56 LANCING DEVICE 79 ACCOLATE 14 adapalene-benzoyl ADVOCATE SAFETY LANCETS 79 ACCU-CHEK FASTCLIX peroxide 56 LANCETS 79 ADVOCATE SAFETY LANCETS ACCU-CHEK MULTICLIX ADCETRIS 37 26G 79 LANCETS 79 ADCIRCA 51 ADZENYS ER 1 ACCU-CHEK SAFE-T-PRO ADDERALL 1 AFINITOR 39 LANCETS 79 ADDERALL XR 1 AFLURIA 2018-2019 141

Index 1 AFLURIA PF 2018-2019 141 alosetron hcl 72 ampicillin & sulbactam AFLURIA QUADRIVALENT ALOXI 27 sodium 134 ampicillin sodium 134 2018-2019 141 ALPHAGAN P 131 AFLURIA QUADRIVALENT AMPYRA 136 alprazolam 13 2019-2020 141 ANADROL-50 10 AFLURIA QUADRIVALENT ALREX 132 ANAFRANIL 23 2020-2021 141 ALTABAX 58 AGAMATRIX ULTRA-THIN anagrelide hcl 73 ALTACE 31 LANCETS 33G 79 ANAPROX DS 4 AGGRENOX 73 ALTERNATE SITE LANCING DEVICE 79 anastrozole 37 AGRYLIN 73 ALTOPREV 31 ANCOBON 28 AIMOVIG 123 ALVESCO 14 ANDRODERM 10 AIMSCO LUBRICATED 77 amantadine hcl 42 ANDROGEL 10 AIMSCO TWIST LANCETS 32G 79 AMARYL 26 ANNOVERA 54 AIMSCO TWIST LANCETS AMBIEN 75 ANORO ELLIPTA 15 33G 79 AMBIEN CR 75 ANTABUSE 135 AIRDUO RESPICLICK AMBISOME 28 ANUSOL-HC 10 113/14 15 AIRDUO RESPICLICK ambrisentan 51 ANZEMET 27 232/14 15 amcinonide 61 APOKYN 42 AIRDUO RESPICLICK 55/1415 AMCINONIDE 61 apraclonidine hcl 131 AJOVY 123 AMERGE 124 aprepitant 28 AKYNZEO 27 AMICAR 75 APRISO 71 albendazole 10 amikacin sulfate 3 APTIOM 18 ALBENZA 10 amiloride & APTIVUS 45 albuterol sulfate 15 hydrochlorothiazide 66 AQUA LANCE ADJUSTABLE ALCAINE 132 amiloride hcl 66 LANCING DEVICE 79 AQUALANCE LANCETS ULTRA alclometasone dipropionate 61 aminocaproic acid 75 aminophylline 16 THIN 30G 79 ALDACTAZIDE 66 ARALAST NP 137 amiodarone hcl 14 ALDACTONE 66 ARANESP ALBUMIN FREE 74 AMITIZA 71 ALDARA 64 ARAVA 5 amitriptyline hcl 23 ALDURAZYME 68 ARCALYST 4 alendronate sodium 67 amlodipine besylate 49 amlodipine besylate- ARCAPTA NEOHALER 15 alfuzosin hcl 72 atorvastatin calcium 51 ARICEPT 135 ALIMTA 36 amlodipine besylate-benazepril ARIKAYCE 3 ALINIA 11 hcl 32 ARIMIDEX 37 aliskiren fumarate 34 amlodipine besylate-olmesartan medoxomil 32 aripiprazole 44 ALKERAN 35 amlodipine besylate- ARIXTRA 16,17 ALLEGRA ALLERGY 29 valsartan 32 armodafinil 2 amlodipine-valsartan- ALLEGRA ALLERGY ARMOUR THYROID 138 CHILDRENS 29 hydrochlorothiazide 32 ALLEGRA-D 12 HOUR amoxapine 23 ARNUITY ELLIPTA 14 ALLERGY & CONGESTION 56 amoxicillin 134 AROMASIN 37 ALLEGRA-D 24 HOUR amoxicillin & pot ARRANON 36 ALLERGY & CONGESTION 56 clavulanate 134 arsenic trioxide 40 allopurinol 73 amphetamine- ARTHROTEC 50 4 almotriptan malate 124 dextroamphetamine 1 ARTHROTEC 75 4 ALOCRIL 132 amphotericin b 28 ARZERRA 37 alogliptin benzoate 25 ampicillin 134 ASACOL HD 71 ALOMIDE 132

Index 2 ASMANEX HFA 14 atovaquone 11 azelastine hcl 129 ASMANEX TWISTHALER 120 atovaquone-proguanil hcl 34 azelastine hcl (ophth) 132 METERED DOSES 14 ATRIPLA 45 AZELEX 56 ASMANEX TWISTHALER 14 METERED DOSES 15 atropine sulfate 139 AZILECT 42 ASMANEX TWISTHALER 30 ATROVENT HFA 14 azithromycin 77 METERED DOSES 15 AUBAGIO 136 AZOR 32 ASMANEX TWISTHALER 60 METERED DOSES 15 AUGMENTIN 134 aztreonam 12 ASMANEX TWISTHALER 7 AUGMENTIN ES-600 134 AZULFIDINE 71 METERED DOSES 15 AUGMENTIN XR 134 AZULFIDINE EN-TABS 71 aspirin 6 AURORA LANCET SUPER B-D INSULIN SYRINGE aspirin-dipyridamole 73 THIN30G 80 ULTRAFINE II/0.3ML/31G X ASSURE COMFORT LANCETS AURORA LANCET THIN 5/16" 92 ULTRA THIN 28G 79 23G 80 B-D INSULIN SYRINGE ASSURE HAEMOLANCE PLUS AURORA PEN NEEDLES ULTRAFINE II/0.5ML/31G X HIGH FLOW 18G 79 29GX12MM 92 5/16" 92 ASSURE HAEMOLANCE PLUS AURORA PEN NEEDLES 31G B-D INSULIN SYRINGE LOW FLOW 25G 79 X6MM 92 ULTRAFINE II/1ML/31G X ASSURE HAEMOLANCE PLUS AURORA PEN NEEDLES 31G 5/16" 93 MICRO FLOW 28G 79 X8MM 92 B-D INSULIN SYRINGE ASSURE HAEMOLANCE PLUS AURORA UNIFINE ULTRAFINE/0.3ML/30G X NORMAL FLOW 21G 79 PENTIPS/32GX5/32" 92 1/2" 93 ASSURE HAEMOLANCE PLUS AURORA UNIFINE B-D INSULIN SYRINGE PEDIATRIC BLADE 79 PENTIPS/MINI/31GX3/16" ULTRAFINE/0.5ML/30G X ASSURE ID INSULIN 92 1/2" 93 SAFETYSYRINGE/U- AUSTEDO 136 bacitracin 11 100/0.5ML/29G X 1/2" 92 AUTO-LANCET 80 bacitracin (ophthalmic) 131 ASSURE ID INSULIN AUTO-LANCET MINI 80 SAFETYSYRINGE/U- baclofen 129 100/1ML/29G X 1/2" 92 AUTOLET IMPRESSION BACTRIM 11 ASSURE ID SAFETY PEN LANCING DEVICE 80 AUTOLET LANCING BACTRIM DS 11 NEEDLES 30G X 5/16" 92 BALCOLTRA 52 ASSURE ID SAFETY PEN DEVICE 80 NEEDLES 31G X 3/16" 92 AUTOLET MINI 80 balsalazide disodium 71 ASSURE LANCE LANCETS 79 AUTOLET PLUS 80 BALVERSA 39 ASSURE LANCE LANCETS AVALIDE 32 BANZEL 18 21G 79 AVANDIA 25 BAQSIMI ONE PACK 25 ASSURE LANCE PLUS SAFETYLANCETS 25G 80 AVAPRO 32 BAQSIMI TWO PACK 25 ASSURE LANCE PLUS AVASTIN 37 BARACLUDE 47 SAFETYLANCETS 30G 80 AVELOX 70 BASAGLAR KWIKPEN 25 ASSURE LANCE SAFETY AVODART 72 BAXDELA 70 LANCET 28G 80 BD LO-DOSE INSULIN ASSURE LANCETS 80 AVONEX 136 AVONEX PEN 136 SYRINGE MICROFINE ATACAND 32 IV/0.5ML/28G X 1/2" 93 ATACAND HCT 32 AYGESTIN 135 BD AUTOSHIELD 29G X atazanavir sulfate 45 AYVAKIT 39 5/16" 93 azacitidine 36 BD INSULIN SYRINGE LUER- ATELVIA 67 LOK/U-100/1ML 93 atenolol 49 AZACTAM 12 BD INSULIN SYRINGE atenolol & chlorthalidone 32 AZASAN 126 MICROFINE IV/U- ATGAM 126 AZASITE 131 100/0.5ML/28G X 1/2" 93 AZATHIOPRINE 126 BD INSULIN SYRINGE ATIVAN 13 MICROFINE IV/U-100/1ML/27G atomoxetine hcl 2 azathioprine 126 X 5/8" 93 atorvastatin calcium 31 azelaic acid 65

Index 3 BD INSULIN SYRINGE BD INSULIN SYRINGE BD SAFETYGLIDE INSULIN MICROFINE IV/U-100/1ML/28G ULTRAFINE/U-100/1ML/30G X SYRINGE/0.3ML/29G X 1/2" 94 X 1/2" 93 1/2" 94 BD SAFETYGLIDE INSULIN BD INSULIN SYRINGE BD INSULIN SYRINGE/0.3ML/31G X MICROFINE/U-100/0.5ML/28G X SYRINGE/0.3ML/29G X 5/16" 94 1/2" 93 12.7MM 94 BD SAFETYGLIDE INSULIN BD INSULIN SYRINGE BD INSULIN SYRINGE/1ML/31G X MICROFINE/U-100/1ML/27G X SYRINGE/0.5ML/29G X 15/64" 94 5/8" 93 12.7MM 94 BD SAFETYGLIDE INSULIN BD INSULIN SYRINGE BD INSULIN SYSYRINGE/0.5ML/30G X MICROFINE/U-100/1ML/28G X SYRINGE/1ML/27G X 5/16" 94 1/2" 93 12.7MM 94 BD VEO INSULIN SYRINGE BD INSULIN SYRINGE BD INSULIN ULTRA-FINE/1ML/31G X SAFETYGLIDE/1ML/29G X SYRINGE/1ML/29G X 6MM 94 1/2" 93 12.7MM 94 BD VEO INSULIN SYRINGE BD INSULIN SYRINGE SLIP BD INSULIN ULTRA-FINE/U-100/1ML/31G X TIP/U-100/1ML 93 SYRINGE/DETACHABLE 15/64" 94 BD INSULIN SYRINGE ULTRA- NEEDLE/U-100/1ML/25G X BELSOMRA 76 FINE/0.3ML/30G X 12.7MM 93 1" 94 BELVIQ 2 BD INSULIN SYRINGE ULTRA- BD INSULIN FINE/0.3ML/31G X 8MM 93 benazepril & SYRINGE/DETACHABLE hydrochlorothiazide 33 BD INSULIN SYRINGE ULTRA- NEEDLE/U-100/1ML/25G X FINE/0.5ML/30G X 12.7MM 93 5/8" 94 benazepril hcl 31 BD INSULIN SYRINGE ULTRA- BD INSULIN BENICAR 32 FINE/0.5ML/31G X 8MM 93 SYRINGE/DETACHABLE BENICAR HCT 33 BD INSULIN SYRINGE ULTRA- NEEDLE/U-100/1ML/26G X BENZACLIN 56 FINE/1/2 UNIT/0.3ML/31G X 1/2" 94 8MM 93 BD INSULIN SYRINGE/U- BENZACLIN WITH PUMP 56 BD INSULIN SYRINGE ULTRA- 100/1ML/27G X 1/2" 94 BENZAMYCIN 56 FINE/1ML/30G X 12.7MM 93 BD LANCET ULTRAFINE BENZEFOAM 56 BD INSULIN SYRINGE ULTRA- 30G 80 FINE/1ML/31G X 8MM 93 BD LANCET ULTRAFINE BENZEFOAM ULTRA 56 BD INSULIN SYRINGE 33G 80 benzonatate 55,56 ULTRAFINE HALF- BD MICROTAINER benzoyl peroxide 57 UNIT/0.3ML/31G X 5/16" 93 LANCETS 80 BENZOYL PEROXIDE BD INSULIN SYRINGE BD PEN CLEANSER 56 ULTRAFINE/0.3ML/30G X NEEDLE/MICRO/ULTRA- benzoyl peroxide- 1/2" 93 FINE/32G X 6MM 94 erythromycin 57 BD INSULIN SYRINGE BD PEN benztropine mesylate 41 ULTRAFINE/0.3ML/31G X NEEDLE/MINI/ULTRA- 5/16" 93 FINE/31G X 5MM 94 BEPREVE 132 BD INSULIN SYRINGE BD PEN NEEDLE/NANO 2ND BETAGAN 130 ULTRAFINE/0.5ML/30G X GEN/32G X 5/32" 94 betamethasone dipropionate 1/2" 93 BD PEN (topical) 61 BD INSULIN SYRINGE NEEDLE/NANO/ULTRA- betamethasone dipropionate ULTRAFINE/0.5ML/31G X FINE/32G X 4MM 94 augmented 61 5/16" 93 BD PEN betamethasone valerate 62 BD INSULIN SYRINGE NEEDLE/ORIGINAL/ULTRA- BETAPACE 49 ULTRAFINE/1ML/30G X FINE/29G X 12.7MM 94 1/2" 93 BD PEN BETAPACE AF 49 BD INSULIN SYRINGE NEEDLE/SHORT/ULTRA- BETASERON 136 ULTRAFINE/U-100/0.3ML/29G X FINE/31G X 8MM 94 betaxolol hcl 49 1/2" 93 BD SAFETY-GLIDE INSULIN BD INSULIN SYRINGE SYRINGE/0.5ML/29G X betaxolol hcl (ophth) 130 ULTRAFINE/U-100/0.5ML/29G X 1/2" 94 bethanechol chloride 141 1/2" 93 BD SAFETY-LOK INSULIN BEVESPI AEROSPHERE 15 BD INSULIN SYRINGE SYRINGE/PERM BEVYXXA 16 ULTRAFINE/U-100/1ML/29G X NEEDLE/UF/1ML/29G X 1/2" 93 1/2" 94 bexarotene 40

Index 4 BEXSERO 141 bupropion hcl (smoking capecitabine 36 BEYAZ 52 deterrent) 137 CAPRELSA 39 buspirone hcl 13 bicalutamide 37 captopril 31 busulfan 36 BICNU 36 CARAC 60 BUSULFEX 36 BIDIL 51 CARAFATE 140 butalbital-acetaminophen 6 BIKTARVY 45 CARBAGLU 68 butalbital-acetaminophen- BILTRICIDE 10 caffeine 6 carbamazepine 18 bimatoprost 133 butalbital-acetaminophen- CARBATROL 18 bisacodyl 76 caffeine w/ codeine 8 carbidopa 41 bisoprolol & butalbital-aspirin-caffeine 6 carbidopa-levodopa 42 hydrochlorothiazide 33 butalbital-aspirin-caffeine carbidopa-levodopa-entacapone bisoprolol fumarate 49 w/cod 8 42 BUTALBITAL/ACETAMINOPH bleomycin sulfate 38 EN 6 carbinoxamine maleate 29 BLEPH-10 131 butenafine hcl 58 carboplatin 36 BONIVA 67 butorphanol tartrate 9 CARDIOCOM LANCING BOOSTRIX 138 DEVICE 80 BUTRANS 9 CARDIZEM 50 BORTEZOMIB 39 BYDUREON 25 CARDIZEM CD 50 bosentan 51 BYDUREON BCISE 25 CARDIZEM LA 50 BOSULIF 39 BYDUREON PEN 25 CARDURA 32 BOTOX 130 BYETTA 25 CAREFINE PEN NEEDLE BRAFTOVI 39 BYSTOLIC 49 32GX4MM 94 BREO ELLIPTA 15 cabergoline 69 CAREFINE PEN NEEDLES BRILINTA 73 29GX1/2" 94 CABLIVI 73 CAREFINE PEN NEEDLES brimonidine tartrate 131 CADUET 51 30GX5/16" 94 BRIVIACT 18 CAFERGOT 124 CAREFINE PEN NEEDLES bromfenac sodium (ophth) 132 CALAN 49 31GX6MM 94 bromocriptine mesylate 42 CAREFINE PEN NEEDLES CALAN SR 49 31GX8MM 94 BROVANA 15 calcipotriene 60 CAREFINE PEN NEEDLES BRUKINSA 39 calcipotriene-betamethasone 32GX5MM 94 budesonide 54 dipropionate 62 CAREFINE PEN NEEDLES calcitonin (salmon) 67 32GX6MM 95 budesonide (inhalation) 15 CAREONE ADVANCED budesonide (nasal) 129 calcitriol 68 LANCINGDEVICE 80 budesonide-formoterol fumarate calcitriol (topical) 60 CAREONE INSULIN dihydrate 15 calcium acetate (phosphate SYRINGES/0.3ML/30G X BULLSEYE MINI SAFETY binder) 72 1/2" 95 LANCETS 80 calcium chloride CAREONE INSULIN BULLSEYE SAFETY (dihydrate) 125 SYRINGES/0.3ML/31G X LANCETS 80 CALCIUM GLUCONATE 125 5/16" 95 bumetanide 66 calcium gluconate 125 CAREONE INSULIN BUMEX 66 SYRINGES/0.5ML/30G X calcium polycarbophil 76 1/2" 95 BUNAVAIL 9 CAMPATH 37 CAREONE INSULIN BUPHENYL 68 CAMPTOSAR 41 SYRINGES/0.5ML/31G X BUPRENEX 9 5/16" 95 CANASA 71 CAREONE INSULIN buprenorphine 9 CANCIDAS 28 SYRINGES/1ML/30G X 1/2" 95 buprenorphine hcl 9 candesartan cilexetil 32 CAREONE INSULIN buprenorphine hcl-naloxone hcl candesartan cilexetil- SYRINGES/1ML/31GX5/16" 95 dihydrate 9 hydrochlorothiazide 33 CAREONE LANCET THIN 80 bupropion hcl 21 CAPASTAT SULFATE 35

Index 5 CAREONE LANCET ULTRA caspofungin acetate 28 CHEMSTRIP-K 65 THIN 80 CATAPRES 32 CHILDRENS ADVIL 4 CAREONE UNIFINE PENTIPS 29GX12MM 95 CATAPRES-TTS-1 32 CHILDRENS MOTRIN 4 CAREONE UNIFINE PENTIPS CATAPRES-TTS-2 32 chloramphenicol sodium 31GX5MM 95 CATAPRES-TTS-3 32 succinate 11 CAREONE UNIFINE PENTIPS chlordiazepoxide hcl 13 CAYA 77 31GX6MM 95 chlordiazepoxide hcl-clidinium CAREONE UNIFINE PENTIPS CAYSTON 12 bromide 139 31GX8MM 95 cefaclor 52 chlorhexidine gluconate (mouth- CAREONE UNIFINE PENTIPS cefadroxil 52 throat) 127 PEN NEEDLES 32GX4MM 95 chloroquine phosphate 34 CAREONE UNIFINE PENTIPS cefazolin sodium 52 PLUS PEN NEEDLES cefdinir 52 chlorothiazide 67 29GX12MM 95 cefditoren pivoxil 52 chlorpromazine hcl 44 CAREONE UNIFINE PENTIPS cefepime hcl 52 chlorpropamide 26 PLUS PEN NEEDLES chlorthalidone 67 31GX5MM 95 cefixime 52 CAREONE UNIFINE PENTIPS CEFOTAN 52 chlorzoxazone 129 PLUS PEN NEEDLES cefotaxime sodium 52 CHOLBAM 71 31GX6MM 95 cholecalciferol 144 CAREONE UNIFINE PENTIPS cefotetan disodium 52 PLUS PEN NEEDLES cefoxitin sodium 52 cholestyramine 30 31GX8MM 95 cefpodoxime proxetil 52 cholestyramine light 30 CAREONE UNIFINE PENTIPS CHORIONIC PLUS PEN NEEDLES cefprozil 52 GONADOTROPIN 68 32GX4MM 95 ceftazidime 52 CIALIS 51 CARESENS LANCETS 80 ceftriaxone sodium 52 CICLODAN SOLUTION KIT 58 CARETOUCH LANCING cefuroxime axetil 52 ciclopirox 58 DEVICEWITH EJECTOR 80 cefuroxime sodium 52 CARETOUCH PEN NEEDLES ciclopirox olamine 58 31G X 6 MM 95 CELEBREX 4 cidofovir 47 CARETOUCH PEN NEEDLES celecoxib 4 cilostazol 73 31GX 5MM 95 CELESTONE-SOLUSPAN 54 CARETOUCH PEN NEEDLES CILOXAN 131 31GX 8MM 95 CELEXA 22 CIMDUO 45 CARETOUCH PEN NEEDLES CELLCEPT 126 cimetidine 139 32GX 4MM 95 CELONTIN 20 cimetidine hcl 139 CARETOUCH PEN NEEDLES cephalexin 52 32GX 5MM 95 CIMZIA 71 CARETOUCH SAFETY CERDELGA 74 CIMZIA STARTER KIT 71 LANCETS/26G 80 CEREBYX 20 cinacalcet hcl 69 CARETOUCH SAFETY CEREZYME 74 LANCETS/28G 80 CINRYZE 73 CARETOUCH SAFETY CESAMET 27 CIPRO 70 LANCETS/30G 80 cetirizine hcl 29 CIPRO HC 133 CARETOUCH TWIST LANCETS cetirizine-pseudoephedrine CIPRODEX 133 28G 80 56 CARETOUCH TWIST LANCETS CETRAXAL 133 ciprofloxacin 71 30G 80 CETROTIDE 68 ciprofloxacin hcl 71 CARETOUCH TWIST LANCETS ciprofloxacin hcl (ophth) 131 33G 80 cevimeline hcl 128 ciprofloxacin hcl (otic) 133 carisoprodol 129 CHANTIX 137 ciprofloxacin in d5w 71 carmustine 36 CHANTIX CONTINUING MONTHPAK 137 ciprofloxacin-ciprofloxacin carteolol hcl (ophth) 130 CHANTIX STARTING MONTH hcl 71 carvedilol 49 PAK 137 ciprofloxacin-dexamethasone CASODEX 37 CHEMET 26 133

Index 6 ciprofloxacin-fluocinolone CLEVER CHOICE COMFORT CLICKFINE PEN NEEDLES 31G acetonide 133 EZINSULIN X 1/4" 96 cisplatin 36 SYRINGE/0.5ML/30G X CLICKFINE PEN NEEDLES 31G citalopram hydrobromide 22 5/16" 96 X 3/16" 96 CLEVER CHOICE COMFORT CLICKFINE PEN NEEDLES 31G CLAFORAN 52 EZINSULIN X 5/16" 96 CLARINEX 29 SYRINGE/0.5ML/31G X CLICKFINE PEN NEEDLES 31G clarithromycin 77 5/16" 96 X 8MM 96 CLICKFINE PEN NEEDLES 32G CLARITIN 29 CLEVER CHOICE COMFORT EZINSULIN X 5/32" 96 CLARITIN ALLERGY SYRINGE/1.0ML/30G X CLICKFINE PEN CHILDRENS 29 1/2" 96 NEEDLES/31GX1/4" 96 CLARITIN CHILDRENS 29 CLEVER CHOICE COMFORT CLICKFINE UNIVERSAL PEN CLARITIN REDITABS 29 EZINSULIN NEEDLES 31GX5/16" 96 CLARITIN-D 12 HOUR 56 SYRINGE/1ML/28G X 1/2" 96 CLIMARA 70 CLEVER CHOICE COMFORT CLARITIN-D 24 HOUR 56 CLIMARA PRO 70 EZINSULIN CLINDAGEL 57 CLASSIC PRENATAL 128 SYRINGE/1ML/29G X 1/2" 96 CLEANLET LANCETS 28G 80 CLEVER CHOICE COMFORT clindamycin hcl 12 clemastine fumarate 29 EZINSULIN clindamycin palmitate SYRINGE/1ML/30G X hydrochloride 12 CLENPIQ 76 5/16" 96 clindamycin phosphate 12 CLEOCIN 12,143 CLEVER CHOICE COMFORT clindamycin phosphate CLEOCIN PEDIATRIC EZINSULIN SYRINGE/U- (topical) 57 GRANULES 12 100/1ML/31GX5/16" 96 clindamycin phosphate CLEOCIN PHOSPHATE 12 CLEVER CHOICE COMFORT vaginal 143 CLEOCIN-T 57 EZLANCETS 21G 80 clindamycin phosphate-benzoyl CLEVER CHOICE COMFORT peroxide 57 CLEVER CHEK LANCETS EZLANCETS 23G 80 clindamycin phosphate-benzoyl ULTRATHIN 80 CLEVER CHOICE COMFORT peroxide (refrigerate) 57 CLEVER CHEK LANCETS EZLANCETS 28G 80 clindamycin phosphate- ULTRATHIN 30G 80 CLEVER CHOICE COMFORT tretinoin 57 CLEVER CHOICE COMFORT EZPEN NEEDLES CLINIMIX 4.25%/DEXTROSE EZINSULIN PEN NEEDLES 29GX12MM 96 10% 130 31GX8MM 95 CLEVER CHOICE COMFORT CLINIMIX 4.25%/DEXTROSE CLEVER CHOICE COMFORT EZPEN NEEDLES 25% 130 EZINSULIN 31GX5MM 96 CLINIMIX 4.25%/DEXTROSE SYRINGE/0.3ML/29G X 1/2" 95 CLEVER CHOICE COMFORT 5% 130 CLEVER CHOICE COMFORT EZPEN NEEDLES CLINIMIX 5%/DEXTROSE EZINSULIN 31GX6MM 96 25% 130 SYRINGE/0.3ML/30G X 1/2" 95 CLEVER CHOICE COMFORT CLINIMIX E 5%/DEXTROSE CLEVER CHOICE COMFORT EZPEN NEEDLES 20% 130 EZINSULIN 31GX8MM 96 clobazam 18 SYRINGE/0.3ML/30G X CLEVER CHOICE COMFORT 5/16" 95 clobetasol propionate 62 EZPEN NEEDLES clobetasol propionate emollient CLEVER CHOICE COMFORT 32GX4MM 96 EZINSULIN CLEVER CHOICE COMFORT base 62 SYRINGE/0.3ML/31G X EZPEN NEEDLES clocortolone pivalate 62 5/16" 95 32GX5MM 96 CLODERM 62 CLEVER CHOICE COMFORT CLEVER CHOICE COMFORT EZINSULIN CLODERM PUMP 62 EZPEN NEEDLES clofarabine 36 SYRINGE/0.5ML/28G X 1/2" 95 32GX6MM 96 CLEVER CHOICE COMFORT CLICKFINE PEN NEEDLE CLOLAR 36 EZINSULIN 32GX5/32" 96 clomipramine hcl 23 SYRINGE/0.5ML/29G X 1/2" 96 CLICKFINE PEN NEEDLE clonazepam 18 CLEVER CHOICE COMFORT UNIVERSAL/31GX1/4" 96 EZINSULIN CLICKFINE PEN NEEDLE clonidine 32 SYRINGE/0.5ML/30G X 1/2" 96 UNIVERSAL/31GX5/16" 96 clonidine hcl 32 clonidine hcl (adhd) 2

Index 7 clopidogrel bisulfate 74 COMFORT ASSURED cromolyn sodium 14 clorazepate dipotassium 13 LANCETS MICRO THIN cromolyn sodium (ophth) 132 33G 80 clotrimazole 127 COMFORT ASSURED crotamiton 65 clotrimazole (topical) 58 LANCETS SUPER THIN CUBICIN 11 clotrimazole vaginal 143 28G 80 CUBICIN RF 11 clotrimazole w/ COMFORT EZ INSULIN SYRINGE/U-100/0.5ML/31G X CUPRIMINE 126 betamethasone 58 CUTIVATE 62 clozapine 43 5/16" 97 COMFORT EZ INSULIN CUVITRU 134 CLOZARIL 43 SYRINGE/U-100/1ML/31G X CVS LANCETS 21G 80 COAGUCHEK LANCETS 80 5/16" 97 CVS LANCETS MICRO THIN COMFORT EZ MICRO/32G X COARTEM 34 33G 80 4MM 97 CVS LANCETS MICRO-THIN CODEINE SULFATE 6 COMFORT EZ SHORT/31G X 33G 80 codeine sulfate 6 8MM 97 CVS LANCETS ORIGINAL 81 COGENTIN 41 COMFORT EZ/31G X CVS LANCETS THIN 26G 81 COLACE 76 5MM 97 COMFORT EZ/31G X CVS LANCETS ULTRA THIN COLAZAL 71 6MM 97 30G 81 colchicine 73 COMFORT LANCETS 80 CVS LANCETS ULTRA-THIN colchicine w/ probenecid 73 COMPLERA 45 30G 81 CVS LANCING DEVICE 81 COLCRYS 73 COMTAN 41 CVS PRENATAL 128 colesevelam hcl 30 CONCERTA 2 CVS ULTRA THIN COLESTID 30 CONTRAVE 2 LANCETS 81 COLESTID FLAVORED 30 CONZIP 6 cyanocobalamin 74 colestipol hcl 30 COPAXONE 136 cyclobenzaprine hcl 129 COLY-MYCIN S 133 COPIKTRA 39 cyclophosphamide 36 COLYTE-FLAVOR PACKS 76 CORDARONE 14 cycloserine 35 COMBIGAN 130 CORDRAN 62 CYCLOSET 25 COMBIVIR 45 COREG 49 cyclosporine 127 COMETRIQ 39 CORGARD 49 cyclosporine modified (for COMFORT ASSIST INSULIN CORLANOR 51 microemulsion) 127 SYRINGE 0.3ML/29G X 1/2" 96 CORTEF 54 CYKLOKAPRON 75 COMFORT ASSIST INSULIN CYMBALTA 23 SYRINGE/0.3ML/30G X CORTENEMA 10 5/16" 97 cortisone acetate 54 cyproheptadine hcl 30 COMFORT ASSIST INSULIN CORTISPORIN 58 CYSTADANE 69 SYRINGE/0.3ML/31G X CYSTAGON 72 5/16" 97 CORTISPORIN-TC 133 COMFORT ASSIST INSULIN CORZIDE 33 CYSTARAN 132 SYRINGE/0.5ML/29G X 1/2" 97 COSENTYX 61 cytarabine 36 COMFORT ASSIST INSULIN COSENTYX SENSOREADY CYTOMEL 138 SYRINGE/0.5ML/30G X PEN 60 CYTOTEC 140 5/16" 97 COSMEGEN 38 COMFORT ASSIST INSULIN CYTOVENE 47 SYRINGE/0.5ML/31G X COSOPT 130 D.H.E. 45 124 5/16" 97 COUMADIN 16 dacarbazine 40 COMFORT ASSIST INSULIN COZAAR 32 DACOGEN 36 SYRINGE/1ML/29G X 1/2" 97 COMFORT ASSIST INSULIN CREON 66 dactinomycin 38 SYRINGE/1ML/30G X 5/16" 97 CRESEMBA 28 DAKLINZA 47 COMFORT ASSIST INSULIN CRESTOR 31 dalfampridine 136 SYRINGE/1ML/31G X 5/16" 97 CRIXIVAN 45 DALIRESP 14 CROMOLYN SODIUM 14 danazol 10

Index 8 DANTRIUM 129 desogestrel & ethinyl diclofenac sodium (actinic dantrolene sodium 129 estradiol 52 keratoses) 60 desogestrel-ethinyl estradiol diclofenac sodium (ophth) 132 dapsone 12 (biphasic) 52 diclofenac sodium (topical) 58 DAPTACEL 138 desogestrel-ethinyl estradiol diclofenac w/ misoprostol 5 DAPTOMYCIN 11 (triphasic) 53 dicloxacillin sodium 135 daptomycin 11 desonide 62 dicyclomine hcl 139 DARAPRIM 34 DESOWEN 62 didanosine 45 darifenacin hydrobromide 140 desoximetasone 62 DAUNORUBICIN DESOXYN 1 DIFFERIN 57 HYDROCHLORIDE 38 desvenlafaxine succinate 23 DIFICID 77 DAURISMO 37 DETROL 140 diflorasone diacetate 62 DAYPRO 4 DETROL LA 140 DIFLUCAN 28 DAYTRANA 2 dexamethasone 54,55 diflunisal 6 DDAVP 69 DEXAMETHASONE digoxin 50 DEBACTEROL 127 INTENSOL 54 dihydroergotamine dexamethasone sodium decitabine 36 mesylate 124 phosphate 55 DILANTIN 20 deferasirox 26 dexamethasone sodium DILANTIN INFATABS 20 deferiprone 26 phosphate (ophth) 132 DILANTIN-125 20 DELESTROGEN 70 dexchlorpheniramine maleate 28 DILAUDID 6 DELSTRIGO 45 DEXEDRINE 1 diltiazem hcl 50 DELZICOL 71 DEXILANT 140 DILTIAZEM HCL 50 DEMADEX 66 dexmethylphenidate hcl 2 diltiazem hcl 50 demeclocycline hcl 138 dextroamphetamine sulfate 1 diltiazem hcl coated beads 50 DEMEROL 6 dextrose in lactated diltiazem hcl extended release DENAVIR 61 ringers 125 beads 50 DEPACON 21 DIACOMIT 18 dimethyl fumarate 136 DEPAKENE 21 DIASTAT ACUDIAL 18 DIOVAN 32 DEPAKOTE 21 DIASTAT PEDIATRIC 18 DIOVAN HCT 33 DEPAKOTE ER 21 DIATHRIVE LANCETS 81 DIPENTUM 71 DEPEN TITRATABS 126 DIATHRIVE LANCETS ULTRA diphenhydramine hcl 29 THIN 30G 81 DEPO-ESTRADIOL 70 DIATHRIVE LANCING diphenoxylate w/ atropine 26 DEPO-MEDROL 54 DEVICE 81 DIPHTHERIA/TETANUS DEPO-PROVERA DIATHRIVE PEN NEEDLE/31 TOXOIDS ADSORBED CONTRACEPTIVE 54 G X 6MM 97 PEDIATRIC 138 DEPO-SUBQ PROVERA DIATHRIVE PEN NEEDLE/31 DIPROLENE 62 104 54 GX 8MM 97 DIPROLENE AF 62 DIATHRIVE PEN DEPO-TESTOSTERONE 10 dipyridamole 74 DERMA-SMOOTHE/FS NEEDLE/31GX 5MM 97 BODY 62 DIATHRIVE PEN disopyramide phosphate 13 DERMA-SMOOTHE/FS NEEDLE/32GX 4MM 97 disulfiram 135 SCALP 62 diazepam 13 DITROPAN XL 140 DERMOTIC 133 diazepam (anticonvulsant) 18 DIURIL 67 DESCOVY 45 diazoxide 25 divalproex sodium 21 desipramine hcl 23 DIBENZYLINE 32 DIVIGEL 70 desloratadine 29 DICLEGIS 27 docetaxel 41 desmopressin acetate 69 diclofenac epolamine 58 DOCETAXEL 41 desmopressin acetate spray 69 diclofenac potassium 4 docetaxel 41 desmopressin acetate spray diclofenac sodium 4 docusate calcium 76 refrigerated 69

Index 9 docusate sodium 76 DROPLET INSULIN DRUG MART UNIFINE PENTIPS dofetilide 14 SYRINGE/U-100/0.5ML/30G X 31GX5MM 98 1/2" 98 DRUG MART UNIFINE DOLOPHINE 6 DROPLET INSULIN PENTIPS29G X 12MM 98 donepezil hydrochloride 135 SYRINGE/U-100/0.5ML/31G X DRUG MART UNIFINE DOPTELET 74 5/16" 98 PENTIPS31GX6MM 98 DROPLET INSULIN DRUG MART UNIFINE DORAL 75 SYRINGE/U-100/1ML/30G X PENTIPS31GX8MM 98 dorzolamide hcl 132 1/2" 98 DRUG MART UNIFINE dorzolamide hcl-timolol DROPLET INSULIN PENTIPS32GX4MM 98 maleate 130 SYRINGE/U-100/1ML/31G X DRUG MART UNIFINE DOVATO 45 15/64" 98 PENTIPSPLUS 32GX4MM 98 DOVONEX 61 DROPLET INSULIN DRUG MART UNILET SYRINGE/U-100/1ML/31G X LANCETSSUPER THIN 30G81 doxazosin mesylate 32 5/16" 98 DRUG MART UNILET doxepin hcl 23 DROPLET LANCETS ULTRA LANCETSULTRA THIN 28G 81 doxepin hcl (antipruritic) 60 THIN 30G 81 DRUG MART UNILET MICRO THIN LANCETS 33G 81 doxepin hcl (sleep) 75 DROPLET LANCING DEVICE 81 DUAC 57 doxercalciferol 69 DROPLET PEN NEEDLES DUAVEE 70 DOXIL 38 29GX12MM 98 DUETACT 24 doxorubicin hcl 38 DROPLET PEN NEEDLES 30G X 5/16" 98 DULCOLAX 76 doxorubicin hcl liposomal 38 DROPLET PEN NEEDLES duloxetine hcl 23 doxycycline (monohydrate) 138 31GX5MM 98 DUPIXENT 64 doxycycline hyclate 138 DROPLET PEN NEEDLES DURAGESIC 6 doxylamine-pyridoxine 27 31GX6MM 98 DROPLET PEN NEEDLES DUREX EXTRA SENSITIVE 77 DRISDOL 144 31GX8MM 98 DUREZOL 132 dronabinol 28 DROPLET PEN NEEDLES 32G dutasteride 73 DROPLET INSULIN SYRINGE X 1/4" 98 0.3ML/29G X 1/2" 97 DROPLET PEN NEEDLES 32G DUZALLO 73 DROPLET INSULIN SYRINGE X 3/16" 98 DYAZIDE 66 0.5ML/29G X 1/2" 97 DROPLET PEN NEEDLES 32G DYRENIUM 66 DROPLET INSULIN SYRINGE X 5/32" 98 1ML/29G X 1/2" 97 DROPLET PEN NEEDLES DYSPORT 130 DROPLET INSULIN SYRINGE 32GX4MM 98 E-Z JECT LANCETS 81 U-100/0.3/31G X 5/16" 97 DROPLET PEN NEEDLES E-Z JECT LANCETS 21G 81 DROPLET INSULIN SYRINGE 32GX5MM 98 E-Z JECT LANCETS U-100/0.3ML/30G X 1/2" 97 DROPLET PEN NEEDLES COLOR 81 DROPLET INSULIN SYRINGE 32GX6MM 98 E-Z JECT LANCETS SUPER U-100/0.3ML/30G X 5/16" 97 DROPLET PERSONAL THIN 30G 81 DROPLET INSULIN SYRINGE LANCETS30G 81 E-Z JECT LANCETS THIN U-100/0.5ML/30G X 1/2" 97 DROPSAFE SAFETY PEN 26G 81 DROPLET INSULIN SYRINGE NEEDLES/31G X 5/16" 98 E-ZJECT LANCETS MICRO- U-100/0.5ML/30G X 5/16" 97 DROPSAFE SAFTEY PEN THIN 33G 81 NEEDLES/31G X 1/4" 98 DROPLET INSULIN SYRINGE E.E.S. GRANULES 77 U-100/0.5ML/31G X 5/16" 97 drospirenone-ethinyl DROPLET INSULIN SYRINGE estradiol 53 EASY COMFORT INSULIN U-100/1ML/30G X 1/2" 97 drospirenone-ethinyl estradiol- SYRINGE/0.5ML/30G X DROPLET INSULIN SYRINGE levomefolate calcium 53 5/16" 98 U-100/1ML/30G X 5/16" 97 DROXIA 74 EASY COMFORT INSULIN DROPLET INSULIN SYRINGE DRUG MART ADJUSTABLE SYRINGE/0.5ML/31G X U-100/1ML/31G X 15/64" 98 LANCING DEVICE 81 5/16" 98 DROPLET INSULIN SYRINGE DRUG MART LANCETS EASY COMFORT INSULIN U-100/1ML/31G X 5/16" 98 THIN 81 SYRINGE/1ML/30G X 5/16" 98 DROPLET INSULIN DRUG MART ON-THE-GO EASY COMFORT INSULIN SYRINGE/U-100/0.3ML/31G X LANCETS GENTLE 30G 81 SYRINGE/1ML/31G X 5/16" 98 5/16" 98

Index 10 EASY COMFORT INSULIN EASY TOUCH INSULIN EASY TOUCH LANCETS SYRINGE/U-100/0.5ML/30G X SYRINGE/SAFETY/U- 30G/PRESSURE 1/2" 98 100/1ML/29G X 1/2" 99 ACTIVATED 81 EASY COMFORT INSULIN EASY TOUCH INSULIN EASY TOUCH LANCETS SYRINGE/U-100/1ML/30G X SYRINGE/SAFETY/U- 30G/PULL-TOP 82 1/2" 98 100/1ML/30G X 1/2" 99 EASY TOUCH LANCETS EASY COMFORT LANCETS81 EASY TOUCH INSULIN 30G/TWIST 82 EASY COMFORT LANCETS SYRINGE/U-100/0.3ML/30G X EASY TOUCH LANCETS 30G/PULL TOP 81 1/2" 99 32G/PRESSURE EASY COMFORT LANCETS EASY TOUCH INSULIN ACTIVATED 82 30G/THIN TOP 81 SYRINGE/U-100/0.5ML/27G X EASY TOUCH LANCETS EASY COMFORT LANCETS 1/2" 99 32G/PULL-TOP 82 TWIST TOP 81 EASY TOUCH INSULIN EASY TOUCH LANCETS EASY COMFORT PEN SYRINGE/U-100/0.5ML/28G X 32G/TWIST 82 NEEDLES31GX1/4" 98 1/2" 99 EASY TOUCH LANCETS EASY COMFORT PEN EASY TOUCH INSULIN 33G/TWIST 82 NEEDLES31GX3/16" 98 SYRINGE/U-100/0.5ML/30G X EASY TOUCH LANCING EASY COMFORT PEN 1/2" 99 DEVICE/EJECTOR 82 NEEDLES31GX5/16" 98 EASY TOUCH INSULIN EASY TOUCH PEN NEEDLE EASY COMFORT PEN SYRINGE/U-100/0.5ML/31G X 30G X 5/16" 99 NEEDLES32GX5/32" 99 5/16" 99 EASY TOUCH PEN NEEDLES EASY MINI EJECT LANCING EASY TOUCH INSULIN 29GX1/2" 99 DEVICE 81 SYRINGE/U-100/1ML/27G X EASY TOUCH PEN NEEDLES EASY MINI LANCING 1/2" 99 31GX1/4" 99 DEVICE 81 EASY TOUCH INSULIN EASY TOUCH PEN NEEDLES EASY TOUCH 32GX5MM 99 SYRINGE/U-100/1ML/28G X 31GX5/16" 100 1/2" 99 EASY TOUCH PEN NEEDLES EASY TOUCH 32GX6MM 99 EASY TOUCH INSULIN 32GX1/4" 100 EASY TOUCH FLIPLOCK SYRINGE/U-100/1ML/29G X EASY TOUCH PEN NEEDLES SAFETY INSULIN SYRINGE 1/2" 99 32GX3/16" 100 1ML/29GX1/2" 99 EASY TOUCH INSULIN EASY TOUCH PEN NEEDLES EASY TOUCH FLIPLOCK SYRINGE/U-100/1ML/30G X 32GX5/32" 100 SAFETY INSULIN SYRINGE 1/2" 99 EASY TOUCH PEN 1ML/30GX1/2" 99 EASY TOUCH INSULIN NEEDLES/31G X 3/16" 100 EASY TOUCH FLIPLOCK SYRINGE/U-100/1ML/31G X EASY TOUCH SAFETY SAFETY INSULIN SYRINGE 5/16" 99 LANCETS21G/PRESSURE 1ML/30GX5/16" 99 EASY TOUCH LANCETS ACTIVATED 82 EASY TOUCH FLIPLOCK 21G/PRESSURE EASY TOUCH SAFETY SAFETY INSULIN SYRINGE ACTIVATED 81 LANCETS23G/PRESSURE 1ML/31GX5/16" 99 EASY TOUCH LANCETS ACTIVATED 82 EASY TOUCH INSULIN 23G/PRESSURE EASY TOUCH SAFETY SYRINGE/0.3ML/30G X ACTIVATED 81 LANCETS26G/BUTTON 5/16" 99 EASY TOUCH LANCETS ACTIVATED 82 EASY TOUCH INSULIN 26G/PRESSURE EASY TOUCH SAFETY SYRINGE/0.3ML/31G X ACTIVATED 81 LANCETS26G/PRESSURE 5/16" 99 EASY TOUCH LANCETS ACTIVATED 82 EASY TOUCH INSULIN 26G/PULL-TOP 81 EASY TOUCH SAFETY SYRINGE/0.5ML/29G X 1/2" 99 EASY TOUCH LANCETS LANCETS28G/BUTTON EASY TOUCH INSULIN 28G/PRESSURE ACTIVATED 82 SYRINGE/0.5ML/30G X ACTIVATED 81 EASY TOUCH SAFETY 5/16" 99 EASY TOUCH LANCETS LANCETS28G/PRESSURE EASY TOUCH INSULIN 28G/PULL-TOP 81 ACTIVATED 82 SYRINGE/1ML/30G X 5/16" 99 EASY TOUCH LANCETS EASY TOUCH SAFETY PEN EASY TOUCH INSULIN 28G/TWIST 81 NEEDLES/29G X 8MM 100 SYRINGE/SAFETY/U- EASY TOUCH LANCETS EASY TOUCH SAFETY PEN 100/0.5ML/29G X 1/2" 99 30G/BUTTON-ACTIVATED NEEDLES/30G X 5/16" 100 EASY TOUCH INSULIN 81 EASY TOUCH SHEATHLOCK SYRINGE/SAFETY/U- SAFETY INSULIN SYRINGE 100/0.5ML/30G X 5/16" 99 1ML/29GX1/2" 100

Index 11 EASY TOUCH SHEATHLOCK ELITE-THIN INSULIN EPIDUO 57 SAFETY INSULIN SYRINGE SYRINGE/U-100/0.5ML/31G X epinastine hcl (ophth) 133 1ML/30GX5/16" 100 5/16" 100 EASY TOUCH SHEATHLOCK ELITE-THIN INSULIN epinephrine (anaphylaxis) 144 SAFETY INSULIN SYRINGE SYRINGE/U-100/1ML/28G X epinephrine hcl 15 1ML/31GX5/16" 100 1/2" 100 EPIPEN 2-PAK 144 EASY TOUCH SHEATHLOCK ELITE-THIN INSULIN SAFETY SYRINGE SYRINGE/U-100/1ML/29G X EPIPEN-JR 2-PAK 144 1ML/30GX1/2" 100 1/2" 100 epirubicin hcl 38 EASY TWIST & CAP ELITE-THIN INSULIN EPIVIR 45 LANCETS 82 SYRINGE/U-100/1ML/31G X EPIVIR HBV 47 EC-NAPROSYN 5 5/16" 100 eplerenone 34 econazole nitrate 58 ELIXOPHYLLIN 16 EPOGEN 74 EDARBI 32 ELLA 54 epoprostenol sodium 51 EDECRIN 66 ELLENCE 38 eprosartan mesylate 32 EDURANT 45 ELMIRON 72 EPZICOM 45 ELOCON 62 efavirenz 45 EQL COLOR LANCETS 21G82 efavirenz-emtricitabine-tenofovir EMADINE 133 EQL COLOR LANCETS MICRO disoproxil fumarate 45 EMBEDA 6 efavirenz-lamivudine-tenofovir THIN 33G 82 EMBRACE LANCETS ULTRA EQL INSULIN disoproxil fumarate 45 THIN 30G 82 SYRINGE/0.3ML/29G X EFFEXOR XR 23 EMBRACE LANCING DEVICE 1/2" 100 EFFIENT 74 WITH EJECTOR 82 EQL INSULIN EFUDEX 60 EMCYT 37 SYRINGE/0.3ML/30G X EGRIFTA 68 EMEND 28 5/16" 100 EMFLAZA 55 EQL INSULIN EGRIFTA SV 68 SYRINGE/0.3ML/31G X ELAPRASE 69 EMGALITY 123 5/16" 100 ELELYSO 74 EMSAM 21 EQL INSULIN emtricitabine 45 SYRINGE/0.5ML/29G X ELESTAT 132 1/2" 100 ELESTRIN 70 emtricitabine-tenofovir disoproxil fumarate 45 EQL INSULIN SYRINGE/0.5ML/30G X eletriptan hydrobromide 124 EMTRIVA 45 ELIDEL 64 5/16" 100 EMVERM 10 EQL INSULIN ELIGARD 37 ENABLEX 140 SYRINGE/0.5ML/31G X ELIMITE 65 enalapril maleate 31 5/16" 100 ELIQUIS 16 enalapril maleate & EQL INSULIN SYRINGE/1ML/29G X 1/2" 100 ELIQUIS STARTER PACK 16 hydrochlorothiazide 33 EQL INSULIN ELITE-THIN INSULIN ENBREL 5 SYRINGE/1ML/30G X SYRINGE/0.3ML/31G X ENBREL MINI 5 5/16" 100 5/16" 100 EQL INSULIN ELITE-THIN INSULIN ENBREL SURECLICK 6 ENGERIX-B 142 SYRINGE/1ML/31G X SYRINGE/0.5ML/29G X 5/16" 100 1/2" 100 enoxaparin sodium 17 EQL PRENATAL ELITE-THIN INSULIN entacapone 42 FORMULA 128 SYRINGE/0.5ML/30G X entecavir 47 EQL SUPER THIN LANCETS 5/16" 100 30G 82 ENTEREG 72 ELITE-THIN INSULIN EQL THIN LANCETS 26G 82 SYRINGE/1ML/30G X ENTOCORT EC 55 EQUETRO 43 5/16" 100 ENTRESTO 51 ELITE-THIN INSULIN ERAXIS 28 ENTYVIO 71 SYRINGE/U-100/0.5ML/28G X ERBITUX 37 1/2" 100 EPCLUSA 47 ergocalciferol 144 EPIDIOLEX 18 ergoloid mesylates 137

Index 12 ERGOMAR 124 EXEL COMFORT POINT FANTASY LUBRICATED 77 ergotamine w/ caffeine 124 INSULIN PEN NEEDLES 31G FANTASY X 6MM 101 ERIVEDGE 37 LUBRICATED/SPERMICIDE EXEL COMFORT POINT 77 erlotinib hcl 39 INSULIN PEN NEEDLES 31G FARESTON 37 ERTACZO 58 X 8MM 101 EXEL COMFORT POINT FARXIGA 26 ertapenem sodium 11 INSULIN SYRINGE/0.3ML/29G FASENRA 14 ERWINAZE 40 X 1/2" 101 FASENRA PEN 14 EXEL COMFORT POINT ERYPED 200 77 FASLODEX 37 ERYPED 400 77 INSULIN SYRINGE/0.3ML/30G X 5/16" 101 FAZACLO 43 erythromycin (acne aid) 57 EXEL COMFORT POINT FC FEMALE CONDOM 77 erythromycin (ophth) 131 INSULIN SYRINGE/0.5ML/28G febuxostat 73 X 1/2" 101 erythromycin base 77 felbamate 20 erythromycin ethylsuccinate 77 EXEL COMFORT POINT INSULIN SYRINGE/0.5ML/29G FELBATOL 20 escitalopram oxalate 22 X 1/2" 101 FELDENE 5 ESGIC 6 EXEL COMFORT POINT felodipine 50 esomeprazole magnesium 140 INSULIN SYRINGE/0.5ML/30G X 5/16" 101 FEMARA 37 estazolam 75 EXEL COMFORT POINT FEMCAP 77 ESTRACE 70 INSULIN SYRINGE/1ML/28G X FEMHRT LOW DOSE 70 1/2" 101 estradiol 70 FEMRING 144 estradiol vaginal 144 EXEL COMFORT POINT INSULIN SYRINGE/1ML/29G X fenofibrate 30 estradiol valerate 70 1/2" 101 fenofibrate micronized 30 ESTROGEL 70 EXEL COMFORT POINT fenoprofen calcium 5 INSULIN SYRINGE/1ML/30G X ESTROSTEP FE 53 FENSOLVI 68 eszopiclone 75 5/16" 101 EXELDERM 58 fentanyl 6 ethacrynic acid 66 exemestane 37 fentanyl citrate 6 ethambutol hcl 35 EXFORGE 33 FENTORA 6 ethosuximide 20 FER-IN-SOL 75 ethynodiol diacet & eth EXFORGE HCT 33 estrad 53 EXJADE 26 FERRIPROX 27 etidronate disodium 67 EXTAVIA 136 ferrous fumarate-folic acid 75 etodolac 5 EZ SMART BLOOD GLUCOSE ferrous sulfate 75 etonogestrel-ethinyl estradiol54 LANCETS 82 FETZIMA 23 EZ-LETS LANCETS 21G 82 FETZIMA TITRATION PACK23 ETOPOPHOS 41 EZ-LETS LANCETS 26G etoposide 41 SUPER-SOFT 82 fexofenadine hcl 29 EUCRISA 65 EZ-LETS LANCETS 28G fexofenadine-pseudoephedrine ULTRA-SOFT 82 56 EURAX 65 FIASP 25 EVAMIST 70 EZ-LETS LANCETS 30G 82 ezetimibe 31 FIASP FLEXTOUCH 25 everolimus 39 FIASP PENFILL 25 everolimus ezetimibe-simvastatin 30 (immunosuppressant) 127 FABRAZYME 69 FIBERCON 76 EVISTA 68 FALESSA 53 FIBRICOR 30 EVOCLIN 57 famciclovir 48 FIFTY50 PEN NEEDLES 31G X3/16" (5MM) 101 EVOXAC 128 famotidine 139 FIFTY50 PEN NEEDLES 31G EXALGO 6 famotidine in nacl 139 X5/16" (8MM) 101 EXEL COMFORT POINT FANAPT 43 FIFTY50 PEN NEEDLES INSULIN PEN NEEDLES 29G X 31GX5MM 101 FANAPT TITRATION FIFTY50 PEN 12MM 100 43 PACK NEEDLES/31GX8MM 101

Index 13 FIFTY50 PEN FLUAD QUADRIVALENT fluticasone propionate NEEDLES/32GX4MM 101 INFLUENZA VACCINE FOR (nasal) 130 FIFTY50 PEN ADULTS 142 fluticasone-salmeterol 15 NEEDLES/32GX6MM 101 FLUARIX QUADRIVALENT fluvastatin sodium 31 FIFTY50 SAFETY SEAL 2018-2019 142 LANCETS 30G 82 FLUARIX QUADRIVALENT fluvoxamine maleate 22 FIFTY50 SAFETY SEAL 2019-2020 142 FLUZONE HIGH-DOSE PF 2018- LANCETS 32G 82 FLUARIX QUADRIVALENT 2019 143 FIFTY50 SUPERIOR 2020-2021 142 FLUZONE HIGH-DOSE PF 2019- COMFORTINSULIN FLUBLOK QUADRIVALENT 2020 143 SYRINGE/0.3ML/31G X 2018-2019 142 FLUZONE HIGH-DOSE PF 2020- 5/16" 101 FLUBLOK QUADRIVALENT 2021 143 FIFTY50 SUPERIOR 2019-2020 142 FLUZONE QUADRIVALENT COMFORTINSULIN FLUBLOK QUADRIVALENT 2018-2019 143 SYRINGE/0.5ML/31G X 2020-2021 142 FLUZONE QUADRIVALENT 5/16" 101 FLUCELVAX QUADRIVALENT 2019-2020 143 FIFTY50 SUPERIOR 2018-2019 142 FLUZONE QUADRIVALENT COMFORTINSULIN FLUCELVAX QUADRIVALENT 2020-2021 143 SYRINGE/1ML/31G X 2019-2020 142 FML 132 5/16" 101 FLUCELVAX QUADRIVALENT FML FORTE 132 2020-2021 142 FIFTY50 UNILET LANCETS FML LIQUIFILM 132 33G 82 fluconazole 28 FOCALIN 2 FINACEA 65 flucytosine 28 FOCALIN XR 2 finasteride 73 fludarabine phosphate 36 folic acid 74 FINE 30 82 fludrocortisone acetate 55 FINGERSTIX LANCETS 82 FLULAVAL QUADRIVALENT FOLOTYN 36 FIORICET 6 2018-2019 142 fondaparinux sodium 17 FLULAVAL QUADRIVALENT FORA GTEL BLOOD KETONE FIORICET/CODEINE 8 2019-2020 142 TEST STRIPS 65 FIORINAL 6 FLULAVAL QUADRIVALENT FORA LANCETS 82 FIORINAL/CODEINE #3 8 2020-2021 142 FORA LANCING DEVICE 82 FIRAZYR 73 FLUMADINE 48 FORA LANCING FIRDAPSE 35 FLUMIST DEVICE/CLEARCAP 82 QUADRIVALENT 142 FORFIVO XL 21 FIRMAGON 37 flunisolide (nasal) 130 FORTAZ 52 FIRVANQ 11 fluocinolone acetonide 62,63 FORTEO 67 FLAGYL 11 fluocinolone acetonide flavoxate hcl 141 (otic) 133 FOSAMAX 67 flecainide acetate 13 fluocinonide 63 FOSAMAX PLUS D 67 FLECTOR 58 fluocinonide emulsified fosamprenavir calcium 45 base 63 FLOLAN 51 fosfomycin tromethamine 12 fluorometholone (ophth) 132 FLOMAX 73 fosinopril sodium 31 fluorouracil 36 FLONASE ALLERGY fosinopril sodium & RELIEF 130 fluorouracil (topical) 60 hydrochlorothiazide 33 FLONASE ALLERGY RELIEF fluoxetine hcl 22 fosphenytoin sodium 20 CHILDRENS 130 fluoxetine hcl (pmdd) 136 FOSRENOL 72 FLOVENT DISKUS 15 FLUOXETINE FRAGMIN 17 FLOVENT HFA 15 HYDROCHLORIDE 22 FREDS PHARMACY AUTOLET FLOXIN OTIC 133 fluphenazine hcl 44 LANCING DEVICE 82 floxuridine 36 flurandrenolide 63 FREDS PHARMACY UNIFINE PENTIPS PEN NEEDLES FLUAD 2018-2019 142 flurbiprofen 5 32GX4MM 101 FLUAD 2019-2020 142 flurbiprofen sodium 133 FREDS PHARMACY UNIFINE FLUAD 2020-2021 142 flutamide 37 PENTIPS PLUS 31GX5MM 101 fluticasone propionate 63

Index 14 FREDS PHARMACY UNIFINE GENOTROPIN GLOBAL EASE INJECT PEN PENTIPS PLUS 31GX8MM 101 MINIQUICK 68 NEEDLES 29GX12MM 101 FREDS PHARMACY UNILET gentamicin in saline 3 GLOBAL EASE INJECT PEN LANCETS SUPER THIN gentamicin sulfate 3 NEEDLES 31GX8MM 102 30G 82 GLOBAL EASE INJECT PEN FREDS PHARMACY UNILET gentamicin sulfate NEEDLES 32GX4MM 102 LANCETS ULTRA THIN (ophth) 131 GLOBAL EASE INJECT PEN 28G 82 gentamicin sulfate (topical) 58 NEEEDLES 31GX5MM 102 FREESTYLE LANCETS 82 GENTEEL BUTTERFLY GLOBAL EASY GLIDE INSULIN TOUCH LANCETS 82 SYRINGE/1ML/31G X FREESTYLE PRECISION GENTEEL LANCING INSULIN SYRINGE/U- 15/64" 102 DEVICE/BUFF BLACK 83 100/0.5ML/30G X 5/16" 101 GLOBAL EASY GLIDE GENTEEL LANCING INSULINSYRINGE/U- FREESTYLE PRECISION DEVICE/BUTTERFLY INSULIN SYRINGE/U- 100/0.3ML/31G X 5/16" 102 BLUE 83 100/0.5ML/31G X 5/16" 101 GLOBAL EASY GLIDE PEN GENTEEL LANCING NEEDLES 32GX4MM 102 FREESTYLE PRECISION DEVICE/GLORIOUS INSULIN SYRINGE/U- GLOBAL INJECT EASE INSULIN GOLD 83 100/1ML/31G X 5/16" 101 SYRINGE/U-100/0.3ML/29G X GENTEEL LANCING 1/2" 102 FREESTYLE PRECISION DEVICE/PLAYFUL INSULIN SYRINGES/U- GLOBAL INJECT EASE INSULIN PURPLE 83 100/1ML/30G X 5/16" 101 SYRINGE/U-100/0.3ML/30G X GENTEEL LANCING 1/2" 102 FREESTYLE UNISTICK II DEVICE/PRECIOUS LANCETS 82 GLOBAL INJECT EASE INSULIN PLATINUM 83 FROVA 124 SYRINGE/U-100/0.3ML/30G X GENTEEL LANCING 5/16" 102 frovatriptan succinate 124 DEVICE/PRINCESS PINK 83 GLOBAL INJECT EASE INSULIN FULPHILA 74 GENTEEL LANCING SYRINGE/U-100/0.3ML/31G X fulvestrant 37 DEVICE/STATELY 5/16" 102 SILVER 83 GLOBAL INJECT EASE INSULIN FURADANTIN 12 GENTEEL LANCING SYRINGE/U-100/0.5ML/28G X furosemide 66 DEVICE/WILLOWY 1/2" 102 FUZEON 45 WHITE 83 GLOBAL INJECT EASE INSULIN GENTLE-LET GP FYCOMPA 18 SYRINGE/U-100/0.5ML/29G X LANCETS 83 1/2" 102 gabapentin 18 GENTLE-LET LANCETS GLOBAL INJECT EASE INSULIN GABITRIL 20 GENERAL PURPOSE SYRINGE/U-100/0.5ML/30G X GALAFOLD 69 STYLE/FINE POINT 83 1/2" 102 GENTLE-LET LANCETS GLOBAL INJECT EASE INSULIN galantamine hydrobromide 135 GENERAL PURPOSE SYRINGE/U-100/0.5ML/30G X GAMMAGARD LIQUID 134 STYLE/MEDIUM POINT 83 5/16" 102 GAMMAGARD S/D IGA LESS GENTLE-LET LANCETS GLOBAL INJECT EASE INSULIN THAN 1MCG/ML 134 SAFETY STYLE/FINE SYRINGE/U-100/0.5ML/31G X GAMMAKED 134 POINT 83 5/16" 102 GENTLE-LET LANCETS GAMUNEX-C 134 GLOBAL INJECT EASE INSULIN SAFETY STYLE/MEDIUM SYRINGE/U-100/1ML/28G X ganciclovir sodium 47 POINT 83 1/2" 102 ganirelix acetate 68 GENVOYA 45 GLOBAL INJECT EASE INSULIN GANIRELIX ACETATE 68 GEODON 43 SYRINGE/U-100/1ML/29G X GARDASIL 9 143 1/2" 102 GILENYA 136 GLOBAL INJECT EASE INSULIN gatifloxacin (ophth) 131 GILOTRIF 39 SYRINGE/U-100/1ML/30G X gemcitabine hcl 36 glatiramer acetate 136 1/2" 102 GEMCITABINE GLEEVEC 39 GLOBAL INJECT EASE INSULIN SYRINGE/U-100/1ML/30G X HYDROCHLORIDE 36 GLEOSTINE 36 gemfibrozil 30 5/16" 102 glimepiride 26 GLOBAL INJECT EASE INSULIN GEMZAR 36 glipizide 26 SYRINGE/U-100/1ML/31G X GENERESS FE 53 glipizide-metformin hcl 24 5/16" 102 GENOTROPIN 68

Index 15 GLOBAL INJECT EASE GLYNASE 26 GNP SUPER THIN LANCETS 28G 83 GLYSET 24 LANCETS/30G 83 GLOBAL INJECT EASE GNP ULTICARE PEN LANCETS 30G 83 GLYXAMBI 24 NEEDLES/31GX5/16" 103 GLOBAL INSULIN SYRINGE/U- GNP CLICKFINE PEN GNP ULTICARE PEN 100/0.3ML/30G X 1/2" 102 NEEDLEUNIVERSAL/31GX5/1 NEEDLES/32GX 5/32" 103 GLOBAL INSULIN SYRINGES/U- 6" 103 GNP ULTICARE PEN 100/0.3ML/30GX5/16" 102 GNP CLICKFINE UNIVERSAL NEEDLES/32GX1/4" 103 GLOBAL LANCING DEVICE 83 PEN NEEDLES GNP ULTRA COMFORT GLUCAGEN DIAGNOSTIC 65 31GX1/4" 103 INSULIN SYRINGE/0.3ML/29G X GNP CLICKFINE UNIVERSAL 1/2" 103 GLUCAGEN HYPOKIT 25 PEN NEEDLES GNP ULTRA COMFORT GLUCAGON EMERGENCY 31GX5/16" 103 INSULIN SYRINGE/0.3ML/30G X KIT 25 GNP INSULIN 5/16" SHORT 103 GLUCOCOM LANCETS SYRINGE/0.3ML/29G X GNP ULTRA COMFORT 28G 83 1/2" 103 INSULIN SYRINGE/0.3ML/31G X GLUCOCOM LANCETS GNP INSULIN 5/16" SHORT 103 30G 83 SYRINGE/0.3ML/30G X GNP ULTRA COMFORT GLUCOCOM LANCETS 5/16" 103 INSULIN SYRINGE/0.5ML/28G X 33G 83 GNP INSULIN 1/2" 103 GLUCOPHAGE 24 SYRINGE/0.3ML/31G X GNP ULTRA COMFORT GLUCOPHAGE XR 24 5/16" 103 INSULIN SYRINGE/0.5ML/29G X GLUCOPRO INSULIN GNP INSULIN 1/2" 103 SYRINGE/U-100/0.3ML/30G X SYRINGE/0.5ML/28G X GNP ULTRA COMFORT 1/2" 102 1/2" 103 INSULIN SYRINGE/0.5ML/30G X GLUCOPRO INSULIN GNP INSULIN 5/16" SHORT 104 SYRINGE/U-100/0.3ML/30G X SYRINGE/0.5ML/29G X GNP ULTRA COMFORT 5/16" 102 1/2" 103 INSULIN SYRINGE/0.5ML/31G X GLUCOPRO INSULIN GNP INSULIN 5/16" SHORT 104 SYRINGE/U-100/0.3ML/31G X SYRINGE/0.5ML/30G X GNP ULTRA COMFORT 5/16" 102 5/16" 103 INSULIN SYRINGE/1ML/28G X GLUCOPRO INSULIN GNP INSULIN 1/2" 104 SYRINGE/U-100/0.5ML/30G X SYRINGE/0.5ML/31G X GNP ULTRA COMFORT 1/2" 103 5/16" 103 INSULIN SYRINGE/1ML/29G X GLUCOPRO INSULIN GNP INSULIN 1/2" 104 SYRINGE/U-100/0.5ML/30G X SYRINGE/1ML/28G X GNP ULTRA COMFORT 5/16" 103 1/2" 103 INSULIN SYRINGE/1ML/30G X GLUCOPRO INSULIN GNP INSULIN 5/16" SHORT 104 SYRINGE/U-100/0.5ML/31G X SYRINGE/1ML/29G X GNP ULTRA COMFORT 5/16" 103 1/2" 103 INSULIN SYRINGE/1ML/31G X GLUCOPRO INSULIN GNP INSULIN 5/16" SHORT 104 SYRINGE/U-100/1ML/30G X SYRINGE/1ML/30G X GOJJI BLOOD KETONE TEST 1/2" 103 5/16" 103 STRIPS 65 GLUCOPRO INSULIN GNP INSULIN GOJJI LANCING SYRINGE/U-100/1ML/30G X SYRINGE/1ML/31G X DEVICE/CLEAR CAP 83 5/16" 103 5/16" 103 GOJJI STERILE LANCETS GLUCOPRO INSULIN GNP LANCETS 83 30G 83 SYRINGE/U-100/1ML/31G X GNP LANCETS 21G 83 GOLYTELY 76 5/16" 103 GNP LANCETS MICRO THIN GOODSENSE CLICKFINE GLUCOTROL 26 33G 83 SAFETY PEN NEEDLE/31G X GLUCOTROL XL 26 GNP LANCETS SUPER THIN 3/16" 104 30G 83 GOODSENSE COLOR glyburide 26 GNP LANCETS THIN 83 LANCETS MICRO-THIN 33G glyburide micronized 26 UNIVERSAL 83 GNP LANCETS THIN 26G 83 glyburide-metformin 24 GOODSENSE LANCETS GNP MICRO THIN LANCETS MICRO-THIN 33G 83 glycine (gu irrigant) 72 33G 83 GOODSENSE LANCETS glycopyrrolate 139 GNP PRENATAL 128 MICRO-THIN 33G UNIVERSAL 83

Index 16 GOODSENSE LANCETS H-E-B INCONTROL LANCETS HEALTHWISE PEN NEEDLES ULTRA-THIN 26G ULTRA THIN 28G 84 29GX12MM 105 UNIVERSAL 83 H-E-B INCONTROL PEN HEALTHWISE SHORT PEN GOODSENSE LANCETS NEEDLES 29GX12MM 104 NEEDLES 31GX8MM 105 ULTRA-THIN 30G 83 HAEGARDA 73 HEALTHWISE SHORT PEN GOODSENSE LANCETS HAEMOLANCE 84 NEEDLES/31G X 3/16" 105 ULTRA-THIN 30G HEALTHWISE SHORT PEN HAEMOLANCE LOW FLOW UNIVERSAL 83 NEEDLES/31G X 5/16" 105 GOODSENSE LANCING LANCETS 84 HEALTHWISE UNIFINE DEVICE 83 HAEMOLANCE PLUS 84 PENTIPS PEN NEEDLES GOODSENSE PEN HAEMOLANCE PLUS HIGH 32GX4MM 105 NEEDLE/PENFINE FLOW 84 HEALTHY ACCENTS AUTOLET CLASSIC/31G X 3/16" 104 HAEMOLANCE PLUS LOW IMPRESSION LANCING GOODSENSE PEN FLOW 84 DEVICE 84 NEEDLE/PENFINE HAEMOLANCE PLUS MAX HEALTHY ACCENTS UNIFINE CLASSIC/31G X 5/16" 104 FLOW 84 PENTIPS PEN NEEDLES GOODSENSE PEN HAEMOLANCE PLUS 29GX12MM 105 NEEDLE/PENFINE PEDIATRIC FLOW 84 HEALTHY ACCENTS UNIFINE CLASSIC/32G X 1/4" 104 HALAVEN 41 PENTIPS PEN NEEDLES GOODSENSE PEN halcinonide 63 31GX5MM 105 NEEDLE/PENFINE HALCION 75 HEALTHY ACCENTS UNIFINE CLASSIC/32G X 5/32" 104 PENTIPS PEN NEEDLES GOODSENSE PRENATAL HALDOL 43 31GX6MM 105 VITAMINS 128 HALDOL DECANOATE HEALTHY ACCENTS UNIFINE granisetron hcl 27 100 43 PENTIPS PEN NEEDLES GRASTEK 3 HALDOL DECANOATE 50 43 31GX8MM 105 halobetasol propionate 63 HEALTHY ACCENTS UNIFINE griseofulvin microsize 28 PENTIPS PEN NEEDLES griseofulvin ultramicrosize 28 HALOG 63 32GX4MM 105 guanfacine hcl 32 haloperidol 43 HEALTHY ACCENTS UNILET LANCETS SUPER THIN guanfacine hcl (adhd) 2 haloperidol decanoate 43 haloperidol lactate 43 30G 84 GUANIDINE HCL 35 HECTOROL 69 HARVONI 47 GVOKE PFS 25 HEMANGEOL 49 GYNAZOLE-1 143 HAVRIX 143 HEALTH CARE LANCING HEPARIN LOCK FLUSH 17 GYNE-LOTRIMIN 143 DEVICE 84 heparin sod (porcine) in d5w 17 H-E-B IN CONTROL PEN HEALTHWISE INSULIN heparin sodium (porcine) 17 NEEDLES 31GX5MM 104 SYRINGE/U-100/0.3ML/30G X HEPARIN SODIUM/NACL H-E-B IN CONTROL PEN 5/16" 104 NEEDLES 31GX6MM 104 0.45% 17 HEALTHWISE INSULIN HEPARIN SODIUM/SODIUM H-E-B IN CONTROL PEN SYRINGE/U-100/0.3ML/31G X NEEDLES 31GX8MM 104 CHLORIDE 0.9% 17 5/16" 104 HEPLISAV-B 143 H-E-B IN CONTROL PEN HEALTHWISE INSULIN NEEDLES/NANO/32GX4MM SYRINGE/U-100/0.5ML/30G X HEPSERA 47 104 5/16" 104 HERCEPTIN 37 H-E-B IN CONTROL HEALTHWISE INSULIN HETLIOZ 76 UNIFINEPENTIPS PLUS SYRINGE/U-100/0.5ML/31G X 31GX5MM 104 5/16" 104 HIBERIX 141 H-E-B IN CONTROL HEALTHWISE INSULIN HIPREX 12 UNIFINEPENTIPS PLUS SYRINGE/U-100/1ML/30G X HIZENTRA 134 32GX4MM 104 5/16" 104 H-E-B INCONTROL HM PRENATAL 128 HEALTHWISE INSULIN HM ULTICARE INSULIN ADVANCEDLANCING SYRINGE/U-100/1ML/31G X SYRINGE/1ML/30G X 1/2" 105 DEVICE 83 5/16" 104 H-E-B INCONTROL LANCETS HM ULTICARE INSULIN HEALTHWISE MICRON PEN SYRINGE/U-100/0.3ML/31G X MICRO THIN 33G 84 NEEDLES/32G X 5/32" 104 H-E-B INCONTROL LANCETS HEALTHWISE MINI PEN 5/16" 105 SUPER THIN 30G 84 NEEDLES 31GX6MM 104

Index 17 HM ULTICARE SHORT PEN hydroxyzine hcl 13 INSULIN SYRINGE/0.3ML/29G X NEEDLES 31GX8MM 105 hydroxyzine pamoate 13 1/2" 105 HORIZANT 137 INSULIN SYRINGE/0.3ML/30G X HYPER-SAL 56 HUMATROPE 68 5/16" 105 HYPERSAL 56 INSULIN SYRINGE/0.3ML/31G X HUMATROPE COMBO HYQVIA 134 5/16" 105 PACK 68 INSULIN SYRINGE/0.5ML/27G X HUMIRA 4 HYZAAR 33 1/2" 105 HUMIRA PEDIATRIC CROHNS ibandronate sodium 67 INSULIN SYRINGE/0.5ML/28G X DISEASE STARTER PACK 3 ibuprofen 5 1/2" 105 HUMIRA PEN 3 icatibant acetate 73 INSULIN SYRINGE/0.5ML/30G X HUMIRA PEN-CD/UC/HS 1/2" 105 STARTER 3,4 ICLUSIG 39 INSULIN SYRINGE/0.5ML/30G X HUMIRA PEN-PS/UV icosapent ethyl 30 5/16" 105 STARTER 4 IDAMYCIN PFS 38 INSULIN SYRINGE/0.5ML/31G X 5/16" 105 HUMULIN R U-500 idarubicin hcl 38 (CONCENTRATED) 25 INSULIN SYRINGE/1ML/28G X HUMULIN R U-500 IFEX 36 1/2" 105 KWIKPEN 25 ifosfamide 36 INSULIN SYRINGE/1ML/29G X HY-VEE LANCETS 84 1/2" 105 ILARIS 4 INSULIN SYRINGE/1ML/30G X HY-VEE THIN LANCETS 84 ILEVRO 133 5/16" 105 HYCAMTIN 41 ILUMYA 61 INSULIN SYRINGE/NEEDLE hydralazine hcl 34 imatinib mesylate 39 0.3ML/30G X 5/16" 105 HYDREA 40 INSULIN SYRINGE/NEEDLE IMBRUVICA 39 0.3ML/31G X 5/16" 105 HYDRO 35 64 imipenem-cilastatin 11 INSULIN SYRINGE/NEEDLE hydrochlorothiazide 67 imipramine hcl 23 0.5ML/29G X 1/2" 105 hydrocodone bitartrate 7 INSULIN SYRINGE/NEEDLE imipramine pamoate 23 0.5ML/30G X 5/16" 105 HYDROCODONE imiquimod 64 BITARTRATE/ACETAMINOPHE INSULIN SYRINGE/NEEDLE 105 N 8 IMITREX 124 0.5ML/31G X 5/16" HYDROCODONE IMITREX STATDOSE INSULIN SYRINGE/NEEDLE REFILL 124 1ML/29G X 1/2" 106 BITARTRATE/GUAIFENESIN INSULIN SYRINGE/NEEDLE 56 IMITREX STATDOSE hydrocodone- SYSTEM 124 1ML/30G X 5/16" 106 IMODIUM A-D 26 INSULIN SYRINGE/NEEDLE acetaminophen 8,9 1ML/31G X 5/16" 106 hydrocodone-ibuprofen 9 IMPAVIDO 11 INSULIN SYRINGE/U- hydrocortisone 55 IMURAN 127 100/0.3ML/29G X 1/2" 106 hydrocortisone (intrarectal) 10 IN TOUCH LANCING INSULIN SYRINGE/U- 100/0.5ML/29G X 1/2" 106 hydrocortisone (rectal) 10 DEVICE 84 IN TOUCH STERILE INSULIN SYRINGE/U- hydrocortisone (topical) 63 LANCETS30G 84 100/1ML/29G X 1/2" 106 hydrocortisone acetate INCRELEX 68 INSULIN SYRINGE/U- (rectal) 10 100/1ML/30G X 5/16" 106 HYDROCORTISONE INCRUSE ELLIPTA 14 INSULIN SYRINGE/U- ACETATE/LIDOCAINE indapamide 67 100/1ML/31G X 5/16" 106 HYDROCHLORIDE 63 INDERAL LA 49 INSULIN hydrocortisone butyrate 63 indomethacin 5 SYRINGES/0.5ML/27GX1/2" hydrocortisone valerate 63 106 INFANRIX 138 INSULIN hydrocortisone w/acetic INFLECTRA 71 SYRINGES/0.5ML/28GX1/2" acid 133 INLYTA 39 106 hydromorphone hcl 7 INSULIN HYDROMORPHONE INREBIC 39 SYRINGES/0.5ML/29GX1/2" HYDROCHLORIDE 7 INSPRA 34 106 hydroxychloroquine sulfate 34 INSULIN SYRINGE/0.3ML/29G hydroxyurea 40 X 1" 105

Index 18 INSULIN ipratropium-albuterol 15 KAZANO 24 SYRINGES/0.5ML/30GX5/16" irbesartan 32 KCL 0.3%/D5W/NACL 106 irbesartan-hydrochlorothiazide 0.9% 125 INSULIN KEFLEX 52 SYRINGES/0.5ML/31GX 33 5/16" 106 irinotecan hcl 41 KENALOG-40 55 INSULIN irrigation solutions, KEPIVANCE 41 SYRINGES/0.5ML/31GX5/16" physiological 127 KEPPRA 18,19 ISENTRESS 45 106 KEPPRA XR 19 INSULIN ISENTRESS HD 45 KERYDIN 58 SYRINGES/1ML/27GX/1/2" ISOLYTE-P/DEXTROSE 106 5% 125 ketoconazole 28 INSULIN ISOLYTE-S 125 ketoconazole (topical) 58 SYRINGES/1ML/27GX1/2" 106 INSULIN isoniazid 35 KETONE 65 SYRINGES/1ML/28GX1/2" 106 ISONIAZID 35 KETONE TEST STRIPS 65 INSULIN isoniazid 35 ketoprofen 5 SYRINGES/1ML/29GX1/2" 106 INSULIN ISOPTO CARPINE 131 ketorolac tromethamine 5 SYRINGES/1ML/30GX1/2" 106 ISORDIL TITRADOSE 12 ketorolac tromethamine (ophth) 133 INSULIN isosorbide dinitrate 12 KETOSTIX 65 SYRINGES/1ML/31GX5/16" isosorbide mononitrate 12 106 ketotifen fumarate (ophth) 133 isotretinoin 57 INSUPEN 29G X 12MM 106 KEVEYIS 66 isradipine 50 INSUPEN 31G X 5MM 106 KEVZARA 4 ISTODAX (OVERFILL) 39 INSUPEN 31G X 8MM 106 KHEDEZLA 23 itraconazole 28 INSUPEN 32G X 4MM 106 KIMONO COLORS 78 ivermectin 10 INSUPEN PEN NEEDLES 32G KIMONO LUBRICATED 78 X4MM 106 IXEMPRA KIT 41 KIMONO MICRO THIN PLUS INSUPEN SENSITIVE JADENU 27 SPERMICIDE LUBRICATED78 32GX6MM 106 KIMONO PLUS SPERMICIDE INSUPEN ULTRAFIN JADENU SPRINKLE 27 JAKAFI 39 LUBRICATED 78 29GX12MM 106 KIMONO PLUS INSUPEN ULTRAFIN JANUMET 24 SPERMICIDE/LUBRICATED 30GX8MM 106 INSUPEN ULTRAFIN JANUMET XR 24 78 31GX6MM 106 JANUVIA 25 KIMONO PS LUBRICATED 78 INSUPEN ULTRAFIN JARDIANCE 26 KIMONO PS PLUS SPERMICIDE/LUBRICATED 31GX8MM 106 JENTADUETO 24 INTELENCE 45 78 JENTADUETO XR 24 KIMONO SENSATION INTRAROSA 143 JEVTANA 41 LUBRICATED 78 INTRON A 40 JUBLIA 58 KIMONO SENSATION PLUS INTUNIV 2 SPERMICIDE LUBRICATED78 JULUCA 45 KIMONO SPECIAL 78 INVANZ 11 JYNARQUE 70 INVEGA 43 KINERET 4 K-TAB 126 KINNEY LANCETS 84 INVIRASE 45 K-Y ME & YOU EXTRA INVOKAMET 24 LUBRICATED 77 KINNEY THIN LANCETS 84 INVOKANA 26 K-Y ME & YOU INTENSE 77 KINRAY INSULIN SYRINGE PREFERRED PLUS/0.3ML/31G IONOSOL-MB/DEXTROSE KADIAN 7 X 5/16" 106 5% 125 KALETRA 46 KINRAY INSULIN SYRINGE IOPIDINE 131 KALYDECO 137 PREFERRED PLUS/0.5ML/31G IPOL INACTIVATED IPV 143 KAMELEON X 5/16" 106 ipratropium bromide 14 LUBRICATED 78 KINRAY INSULIN SYRINGE KAPVAY 2 PREFERRED PLUS/1ML/31G X ipratropium bromide (nasal)129 5/16" 106

Index 19 KINRAY INSULIN KROGER LANCING LANCETS 33G UNIVERSAL SYRINGE/0.5ML/29G X DEVICE 84 DESIGN 84 1/2" 107 KROGER PEN NEEDLES 29G LANCETS MICRO THIN KINRIX 139 X12MM 107 33G 84 KITABIS PAK 3 KROGER PEN NEEDLES 31G LANCETS SAFETY SEAL X8MM 107 21G 84 KLARITY-A 131 KROGER PEN NEEDLES LANCETS SAFETY SEAL KLARON 57 31GX1/4" 107 26G 84 KLONOPIN 18 KROGER PEN NEEDLES/31G LANCETS SAFETY SEAL KMART VALU PLUS INSULIN X1/4" 107 28G 85 KROGER PEN NEEDLES/31G LANCETS SAFETY SEAL SYRINGE/1ML/29G 107 KMART VALU PLUS INSULIN X3/16" 107 30G 85 KROGER PEN NEEDLES/31G LANCETS SUPER THIN SYRINGE/1ML/30G 107 KP PRENATAL X5/16" 107 28G 85 KROGER PEN NEEDLES/32G MULTIVITAMINS 128 LANCETS THIN 85 X5/32" 107 KRINTAFEL 34 LANCETS TWIST TOP 85 KRYSTEXXA 73 KROGER AUTOLET LANCING LANCETS ULTRA FINE 85 KUVAN 69 DEVICE 84 LANCETS ULTRA THIN 85 KROGER HEALTHPRO TWIST KYLEENA 54 LANCETS ULTRA THIN LANCETS/26G 84 KYPROLIS 39 30G 85 KROGER INSULIN LANCETSBULLSEYE SYRINGE/0.3ML/29G X labetalol hcl 49 LAC-HYDRIN 64 SAFETY 85 1/2" 107 LANCING DEVICE 85 KROGER INSULIN LAC-HYDRIN TWELVE 64 LANCING DEVICE SYRINGE/0.3ML/30G X LACRISERT 130 5/16" 107 ADJUSTABLE 85 KROGER INSULIN lactated ringer's 125 LANOXIN 50 SYRINGE/0.3ML/31G X lactated ringer's lansoprazole 140 (irrigation) 127 5/16" 107 lanthanum carbonate 72 KROGER INSULIN lactic acid (ammonium SYRINGE/0.5ML/29G X lactate) 64 LANZO 85 1/2" 107 lactulose 76 lapatinib ditosylate 39 KROGER INSULIN lactulose (encephalopathy)72 LASIX 66 SYRINGE/0.5ML/30G X LAMICTAL 19 LASTACAFT 133 5/16" 107 KROGER INSULIN LAMICTAL CHEWABLE latanoprost 133 SYRINGE/0.5ML/31G X DISPERSIBLE 19 LATUDA 43 5/16" 107 LAMICTAL ODT 19 LEADER ADVANCED LANCING KROGER INSULIN lamivudine 46 DEVICE 85 SYRINGE/1ML/29G X 1/2" 107 lamivudine (hbv) 47 LEADER INSULIN KROGER INSULIN lamivudine-zidovudine 46 SYRINGE/0.3ML/29G X SYRINGE/1ML/30G X 1/2" 107 5/16" 107 lamotrigine 19 LEADER INSULIN KROGER INSULIN LANCET DEVICE SYRINGE/0.3ML/30G X SYRINGE/1ML/31G X ADJUSTABLE 84 5/16" 107 5/16" 107 LANCET DEVICE WITH LEADER INSULIN KROGER LANCETS 84 EJECTOR 84 SYRINGE/0.3ML/31G X KROGER LANCETS 21G 84 LANCETS 84 5/16" 107 KROGER LANCETS MICRO LANCETS 26G TWIST LEADER INSULIN THIN33G 84 TOP 84 SYRINGE/0.5ML/28G X KROGER LANCETS SUPER LANCETS 28G 84 1/2" 107 THIN 84 LANCETS 30G 84 LEADER INSULIN SYRINGE/0.5ML/29G X KROGER LANCETS THIN 84 LANCETS 30G TWIST 1/2" 107 KROGER LANCETS THIN TOP 84 LEADER INSULIN 26G 84 LANCETS 30G/TWIST SYRINGE/0.5ML/30G X KROGER LANCETS TOP 84 5/16" 107 ULTRATHIN30G 84 LANCETS 31G TWIST TOP 84

Index 20 LEADER INSULIN levobunolol hcl 130 LITE TOUCH LANCING SYRINGE/0.5ML/31G X levocetirizine PEN 85 5/16" 107 dihydrochloride 29 LITETOUCH INSULIN PEN LEADER INSULIN levofloxacin 71 NEEDLES/32G X SYRINGE/1ML/28G X 1/2" 107 4MM/MINI 108 LEADER INSULIN levofloxacin (ophth) 131 LITETOUCH INSULIN SYRINGE/1ML/29G X 1/2" 107 levofloxacin in d5w 71 SYRINGE/0.3ML/29G X LEADER INSULIN levonorgestrel & eth 1/2" 108 SYRINGE/1ML/30G X estradiol 53 LITETOUCH INSULIN 5/16" 107 levonorgestrel (emergency SYRINGE/0.3ML/30G X LEADER INSULIN oc) 54 5/16" 108 SYRINGE/1ML/31G X levonorgestrel-eth estradiol LITETOUCH INSULIN 5/16" 107 (triphasic) 53 SYRINGE/0.3ML/31G X LEADER UNIFINE PENTIPS levonorgestrel-ethinyl estradiol 5/16" 108 PLUS/MINI/31GX3/16" 107 (91-day) 53 LITETOUCH INSULIN LEADER UNIFINE PENTIPS levonorgestrel-ethinyl estradiol SYRINGE/0.5ML/30G X PLUS/SHORT/31GX5/16" 108 (continuous) 53 5/16" 108 LEADER UNIFINE levorphanol tartrate 7 LITETOUCH INSULIN PENTIPS/MINI/31GX3/16" 108 levothyroxine sodium 138 SYRINGE/0.5ML/31G X LEADER UNIFINE 5/16" 108 PENTIPS/NANO/32GX5/32" LEXAPRO 22 LITETOUCH INSULIN 108 LEXIVA 46 SYRINGE/1ML/30G X LEADER UNIFINE LIALDA 71 5/16" 108 PENTIPS/PLUS/32GX5/32" LIBERTY MEDICAL LANCETS LITETOUCH INSULIN 108 30G 85 SYRINGE/U-100/0.3ML/30G X LEDIPASVIR/SOFOSBUVIR LIBERTY MINI LANCING 5/16" 108 47 DEVICE 85 LITETOUCH INSULIN leflunomide 5 LIBRAX 139 SYRINGE/U-100/0.3ML/31G X LENVIMA 10 MG DAILY 5/16" 108 DOSE 39 lidocaine 64 LITETOUCH INSULIN LENVIMA 12MG DAILY lidocaine hcl 64 SYRINGE/U-100/0.5ML/28G X DOSE 39 lidocaine hcl (local 1/2" 108 LENVIMA 14 MG DAILY anesth.) 76 LITETOUCH INSULIN DOSE 39 lidocaine hcl (mouth- SYRINGE/U-100/0.5ML/29G X LENVIMA 18 MG DAILY throat) 127 1/2" 108 DOSE 39 lidocaine-prilocaine 64 LITETOUCH INSULIN SYRINGE/U-100/0.5ML/30G X LENVIMA 20 MG DAILY LIDODERM 65 DOSE 39 5/16" 108 LENVIMA 24 MG DAILY LIFESCAN UNISTIK 2 DEEP LITETOUCH INSULIN DOSE 39 PENETRATION 85 SYRINGE/U-100/0.5ML/31G X LENVIMA 4 MG DAILY LIFESCAN UNISTIK II 5/16" 108 DOSE 39 LANCETS 85 LITETOUCH INSULIN LENVIMA 8 MG DAILY LILETTA 54 SYRINGE/U-100/1ML/28G X DOSE 39 LINCOCIN 12 1/2" 108 LETAIRIS 51 lincomycin hcl 12 LITETOUCH INSULIN letrozole 37 SYRINGE/U-100/1ML/29G X lindane 65 1/2" 108 leucovorin calcium 41 linezolid 12 LITETOUCH INSULIN LEUKERAN 36 LINZESS 72 SYRINGE/U-100/1ML/30G X LEUKINE 74 liothyronine sodium 138 5/16" 108 LITETOUCH INSULIN leuprolide acetate 38 LIPITOR 31 SYRINGE/U-100/1ML/31G X levalbuterol hcl 15 LIPOFEN 30 5/16" 108 levalbuterol tartrate 15 lisinopril 31 LITETOUCH LANCETS MICRO LEVAQUIN 71 lisinopril & THIN 33G 85 hydrochlorothiazide 33 LITETOUCH PEN NEEDLES LEVEMIR 25 29GX12.7MM 108 LEVEMIR FLEXTOUCH 25 LITE TOUCH LANCETS 85 LITETOUCH PEN NEEDLES levetiracetam 19 31G X 6MM 108

Index 21 LITETOUCH PEN NEEDLES LOTEMAX 132 MAGELLAN INSULIN SAFETY 31G X 6MM/ULTRA LOTENSIN 31 SYRINGE/U-100/0.5ML/29G X SHORT 108 1/2" 109 LITETOUCH PEN NEEDLES LOTENSIN HCT 33 MAGELLAN INSULIN SAFETY 31GX8MM SHORT 108 loteprednol etabonate 132 SYRINGE/U-100/0.5ML/30G X LITETOUCH PEN LOTREL 33 5/16" 109 NEEDLES/31G X 3/16" 108 MAGELLAN INSULIN SAFETY LITETOUCH PEN LOTRIMIN AF 59 SYRINGE/U-100/1ML/29G X NEEDLES/31G X LOTRIMIN AF JOCK ITCH 59 1/2" 109 5MM/MINI 108 LOTRIMIN ULTRA 59 MAGELLAN INSULIN SAFETY LITETOUCH PEN LOTRISONE 59 SYRINGE/U-100/1ML/30G X NEEDLES/31G X 5/16" 109 LOTRONEX 72 8MM/SHORT 108 magnesium sulfate 126 lovastatin 31 LITHIUM 43 MALARONE 34 LOVAZA 30 lithium carbonate 43 malathion 65 LOVENOX 17 LITHOBID 43 maprotiline hcl 21 LIVALO 31 loxapine succinate 44 MARATHON MEDICAL LIVE BETTER ADVANCED LUCEMYRA 135 PENTIPS29GX12MM 109 LANCING DEVICE 85 luliconazole 59 MARATHON MEDICAL LIVE BETTER LANCET PENTIPS31GX5MM 109 SUPERTHIN 30G 85 LUMIGAN 133 MARATHON MEDICAL LIVE BETTER LANCET LUMIZYME 69 PENTIPS31GX8MM 109 ULTRATHIN 28G 85 LUNESTA 75 MARATHON MEDICAL LO LOESTRIN FE 53 LUPANETA PACK 68 PENTIPS32GX4MM 109 LOCOID 63 LUPRON DEPOT (1- MARCAINE 76 LODINE 5 MONTH) 38 MARINOL 28 LODOSYN 41 LUPRON DEPOT (3- MARPLAN 21 MONTH) 38 LOMOTIL 26 LUPRON DEPOT (4- MATULANE 40 LONGS INSULIN MONTH) 38 MAVENCLAD 136 SYRINGE/0.5ML/31G X LUPRON DEPOT (6- MAVYRET 47 5/16" 109 MONTH) 38 MAXALT 124 LONGS LANCETS LUPRON DEPOT-PED (1- STANDARD 85 MONTH) 68 MAXALT-MLT 124 LONGS LANCETS THIN 85 LUPRON DEPOT-PED (3- MAXI-COMFORT INSULIN LONGS LANCETS ULTRA MONTH) 68 SYRINGE/U- THIN 85 LUXIQ 63 100/0.5ML/28GX1/2" 109 MAXI-COMFORT INSULIN loperamide hcl 26 LUZU 59 SYRINGE/U-100/1ML/28GX1/2" LOPID 30 LYNPARZA 39 109 lopinavir-ritonavir 46 LYRICA 19 MAXI-COMFORT SAFETY PEN LOPRESSOR 49 LYRICA CR 136 NEEDLE/29G X 5/16" 109 MAXICOMFORT II PEN LOPRESSOR HCT 33 LYSODREN 38 NEEDLES/31G X 1/4" 109 LOPROX 59 LYSTEDA 75 MAXICOMFORT INSULIN LOPROX SHAMPOO 59 M-M-R II 143 SYRINGES 27G X 1/2" 109 loratadine 29 M-NATAL PLUS 128 MAXIDEX 132 loratadine & MACROBID 12 MAXIPIME 52 pseudoephedrine 56 MACRODANTIN 12 MAXITROL 132 lorazepam 13 mafenide acetate 61 MAXX LUBRICATED 78 LORBRENA 39 MAGELLAN INSULIN SAFETY MAXX PLUS SPERMICIDE LORTAB 9 SYRINGE/U-100/0.3ML/29G X LUBRICATED 78 losartan potassium 32 1/2" 109 MAXZIDE 66 losartan potassium & MAGELLAN INSULIN SAFETY MAXZIDE-25 66 hydrochlorothiazide 33 SYRINGE/U-100/0.3ML/30G X MAYZENT 136 LOSEASONIQUE 53 5/16" 109

Index 22 MAYZENT STARTER medroxyprogesterone methadone hcl 7 PACK 136 acetate 135 METHADONE HCL 7 meclizine hcl 27 medroxyprogesterone acetate methadone hcl 7 meclofenamate sodium 5 (contraceptive) 54 METHADOSE 7 MEDIC INSULIN mefenamic acid 5 SYRINGE/0.3ML/30G X mefloquine hcl 34 METHADOSE SUGAR-FREE 7 5/16" 109 MEGACE ES 135 methamphetamine hcl 1 MEDIC INSULIN megestrol acetate 38 methazolamide 66 SYRINGE/0.5ML/30G X megestrol acetate 5/16" 109 methenamine hippurate 12 (appetite) 135 methimazole 138 MEDICHOICE PRE-SET MEIJER COLOR LANCETS SAFETY LANCET DUAL UNIVERSAL 33G 86 METHITEST 10 USE 85 methocarbamol 129 MEDICHOICE PRE-SET MEIJER LANCETS 86 SAFETY LANCET LOW MEIJER LANCETS THIN 86 METHOTREXATE 4 FLOW 85 MEIJER LANCETS methotrexate sodium 37 MEDICHOICE PRE-SET UNIVERSAL21G 86 methoxsalen rapid 61 SAFETY LANCET MEDIUM MEIJER LANCETS methscopolamine bromide 139 FLOW 85 UNIVERSAL30G 86 MEDICHOICE PRE-SET MEIJER LANCETS methyclothiazide 67 SAFETY LANCET MODERATE UNIVERSAL33G 86 methyldopa 32 FLOW 85 MEIJER PEN NEEDLES 29G METHYLIN 2 MEDICHOICE SAFETY X12MM 109 LANCETEXTRA 85 MEIJER PEN NEEDLES 31G methylphenidate hcl 2 MEDICHOICE SAFETY X6MM 109 methylprednisolone 55 LANCETNORMAL 85 MEIJER PEN NEEDLES 31G methylprednisolone acetate 55 MEDICINE SHOPPE PEN X8MM 109 methylprednisolone sod NEEDLES 29G X 12MM 109 MEIJER SUPER THIN succ 55 MEDICINE SHOPPE PEN LANCETS 86 metipranolol 130 NEEDLES 31G X 6MM 109 MEKINIST 39 metoclopramide hcl 71 MEDICINE SHOPPE PEN MEKTOVI 39 NEEDLES 31G X 8MM 109 metolazone 67 MEDISENSE THIN meloxicam 5 metoprolol & LANCETS 85 melphalan 36 hydrochlorothiazide 33 MEDLANCE PLUS EXTRA melphalan hcl 36 metoprolol succinate 49 LANCETS 21G 85 MEDLANCE PLUS memantine hcl 135 metoprolol tartrate 49 LANCETS 85 MENACTRA 141 METROCREAM 65 MEDLANCE PLUS LANCETS MENEST 70 METROGEL 65 LITE 25G 85 MENOSTAR 70 MEDLANCE PLUS LITE METROGEL-VAGINAL 143 LANCETS 25G 85 MENQUADFI 141 METROLOTION 65 MEDLANCE PLUS SPECIAL MENVEO 141 metronidazole 11 LANCETS 0.8MM 85 meperidine hcl 7 metronidazole (topical) 65 MEDLANCE PLUS SUPERLITE 30G 85 meprobamate 13 metronidazole vaginal 144 MEDLANCE PLUS SUPERLITE MEPRON 11 mexiletine hcl 13 30G/COMFORT MAX 85 mercaptopurine 36 micafungin sodium 28 MEDLANCE PLUS UNIVERSAL meropenem 11 LANCETS 21G 85 MICARDIS 32 MEDLANCE PLUS/LITE MERREM 11 MICARDIS HCT 33 25G 86 mesalamine 71,72 miconazole nitrate vaginal 144 MEDLANCE/EXTRA 86 MESTINON 35 MICRODOT PEN NEEDLE/31G MEDLANCE/LITE 86 MESTINON TIMESPAN 35 X 6 MM 109 MEDLANCE/UNIVERSAL 86 MICRODOT PEN NEEDLE/32G metaproterenol sulfate 16 X 4 MM 109 MEDROL 55 metaxalone 129 MICROLET LANCETS 86 MEDROL DOSEPAK 55 metformin hcl 24,25 MICROLET NEXT 86

Index 23 MICROTAINER SAFETY FLOW MODERIBA 1200 DOSE MONOJECT INSULIN LANCET/STERILE/SINGLE-USE PACK 47 SYRINGEREGULAR LUER 86 moexipril hcl 31 TIP/SOFTPACK/1ML 110 MICROZIDE 67 mometasone furoate 63 MONOJECT ULTRA COMFORT INSULIN SYRINGE/0.3ML/29G X midodrine hcl 144 mometasone furoate 1/2" 110 miglitol 24 (nasal) 130 MONOJECT ULTRA COMFORT miglustat 74 MONISTAT SOOTHING CARE INSULIN SYRINGE/0.3ML/30G X ITCH RELIEF 63 MIGRANAL 124 MONOJECT INSULIN 5/16" 110 MONOJECT ULTRA COMFORT MILLIPRED 55 SYRINGE/1ML 110 INSULIN SYRINGE/0.3ML/31G X MILLIPRED DP 55 MONOJECT INSULIN SYRINGE/1ML/31G X 5/16" 110 MONOJECT ULTRA COMFORT MINASTRIN 24 FE 53 5/16" 110 MINI LANCING DEVICE 86 MONOJECT INSULIN INSULIN SYRINGE/0.5ML/28G X SYRINGE/DETACH 1/2" 110 MINIPRESS 32 MONOJECT ULTRA COMFORT MINIVELLE 70 NEEDLE/1ML/25G X 5/8" 110 MONOJECT INSULIN INSULIN SYRINGE/0.5ML/29G X MINOCIN 138 SYRINGE/DETACH 1/2" 110 minocycline hcl 138 MONOJECT ULTRA COMFORT NEEDLE/1ML/27G X 1/2" 110 INSULIN SYRINGE/0.5ML/30G X minoxidil 34 MONOJECT INSULIN SYRINGE/PERM 5/16" 111 MONOJECT ULTRA COMFORT MIRAPEX 42 NEEDLE/1ML/28G X 1/2" 110 MIRCERA 74 MONOJECT INSULIN INSULIN SYRINGE/0.5ML/31G X SYRINGE/PERM NEEDLE/U- 5/16" 111 MIRCETTE 53 MONOJECT ULTRA COMFORT MIRENA 54 100/0.5ML/28G X 1/2" 110 MONOJECT INSULIN INSULIN SYRINGE/1ML/28G X mirtazapine 21 SYRINGE/SAFETY/PERM 1/2" 111 MIRVASO 65 MONOJECT ULTRA COMFORT NEEDLE/0.3ML/29G X INSULIN SYRINGE/1ML/29G X 1/2" 110 misoprostol 140 1/2" 111 MITIGARE 73 MONOJECT INSULIN SYRINGE/SAFETY/PERM MONOLET LANCETS 86 mitomycin 38 NEEDLE/0.3ML/29GX1/2" MONOLET OPD LANCETS 86 mitoxantrone hcl 38 110 MONOLETTOR SAFETY MM INSULIN SYRINGE/U- MONOJECT INSULIN LANCETS 86 100/0.3ML/30G X 5/16" 109 SYRINGE/SAFETY/PERM montelukast sodium 14 MM INSULIN SYRINGE/U- NEEDLE/0.5ML/29G X MONUROL 12 100/0.3ML/31G X 5/16" 109 1/2" 110 MM INSULIN SYRINGE/U- MONOJECT INSULIN MORPHABOND ER 7 100/1/2ML/30G X 5/16" 109 SYRINGE/SAFETY/PERM morphine sulfate 7 MM INSULIN SYRINGE/U- NEEDLE/1ML/29G X 1/2" 110 MORPHINE SULFATE 7 100/1/2ML/31G X 5/16" 109 MONOJECT INSULIN MM INSULIN SYRINGE/U- SYRINGE/SOFTPACK/1ML/27 morphine sulfate 7 100/1ML/30G X 5/16" 110 G X 1/2" 110 MOTOFEN 26 MM INSULIN SYRINGE/U- MONOJECT INSULIN MOVIPREP 76 100/1ML/31G X 5/16" 110 SYRINGE/SOFTPACK/U- MOXIFLOXACIN MM LANCING DEVICE 86 100/0.5ML/28G X 1/2" 110 HYDROCHLORIDE/SODIUM MM PEN NEEDLES 31G X MONOJECT INSULIN HYDROCHLORIDE 71 1/4" 110 SYRINGE/U-100/0.3ML/30G X moxifloxacin hcl 71 5/16" 110 MM PEN NEEDLES 31G X moxifloxacin hcl (ophth) 131 3/16" 110 MONOJECT INSULIN MM PEN NEEDLES 31G X SYRINGE/U-100/0.5ML/30G X MOZOBIL 75 5/16" 110 5/16" 110 MPD SAFETY LANCET MM PEN NEEDLES 32G X MONOJECT INSULIN 21G/1.8MM 86 5/32" 110 SYRINGE/U-100/1ML/28G X MPD SAFETY LANCET MM TWIST LANCETS 86 1/2" 110 28G/1.8MM 86 MONOJECT INSULIN MPD SAFETY LANCET MOBIC 5 SYRINGE/U-100/1ML/30G X 30G/1.8MM 86 modafinil 2,3 5/16" 110

Index 24 MPD SAFETY LANCETS NARCAN 27 niacin (antihyperlipidemic) 31 23G/1.8MM 86 NARDIL 21 NIACIN TR 144 MS CONTIN 7 NAROPIN 76 niacinamide 144 MS INSULIN SYRINGE/0.3ML/31G X NASACORT ALLERGY NIASPAN 31 5/16" 111 24HR 130 nicardipine hcl 50 NASACORT ALLERGY 24HR MS INSULIN NICODERM CQ 137 SYRINGE/0.5ML/31G X CHILDRENS 130 5/16" 111 NASONEX 130 NICORETTE 137 MS INSULIN SYRINGE/1ML/31G NATACYN 131 NICORETTE MINI 137 X 5/16" 111 NATAZIA 53 NICORETTE STARTER KIT 137 MULPLETA 74 nateglinide 26 nicotine 137 MULTAQ 14 NATROBA 65 nicotine polacrilex 137 MULTI PRENATAL 128 NATURE-THROID 138 MULTI-LANCET DEVICE 86 NICOTINE TRANSDERMAL NATURE-THROID NT- SYSTEM 137 mupirocin 58 2.5 138 NICOTROL INHALER 137 NAVELBINE 41 MUSTARGEN 36 NICOTROL NS 137 NAYZILAM 18 MVASI 37 nifedipine 50 NEBUPENT 11 MYALEPT 69 NILANDRON 38 NEBUSAL 56 MYAMBUTOL 35 nilutamide 38 nefazodone hcl 23 MYCAMINE 28 nimodipine 50 NEO-SYNALAR 58 MYCOBUTIN 35 NINLARO 40 neomycin sulfate 3 mycophenolate mofetil 127 NIPENT 40 mycophenolate sodium 127 neomycin-bacitracin zn- polymyxin 131 nisoldipine 50 MYDRIACYL 131 neomycin-polymy- nitisinone 69 MYFORTIC 127 dexameth 132 NITRO-BID 13 MYGLUCOHEALTH MGH neomycin-polymyxin-hc SOFTLANCE LANCETS (ophth) 132 NITRO-DUR 13 30G 86 neomycin-polymyxin-hc nitrofurantoin 12 MYLERAN 36 (otic) 133 nitrofurantoin macrocrystal 12 MYRBETRIQ 141 NEONATAL COMPLETE 128 nitrofurantoin monohyd MYSOLINE 19 NEONATAL PLUS 128 macro 12 nitroglycerin 13 nabumetone 5 NEONATAL VITAMIN 128 NITROGLYCERIN 13 nadolol 49 NEORAL 127 nitroglycerin 13 nafcillin sodium 135 NEOSPORIN 131 NEOSTIGMINE NITROSTAT 13 naftifine hcl 59 METHYLSULFATE 35 NIVA-PLUS 128 NAFTIN 59 NESINA 25 NIVESTYM 74 NAGLAZYME 69 NEULASTA 74 NIX CREME RINSE 65 nalbuphine hcl 9 NEULASTA ONPRO KIT 74 NIZATIDINE 139 NALFON 5 NEUPOGEN 74 nizatidine 139 naloxone hcl 27 NEUPRO 42 NIZORAL 59 naltrexone hcl 27 NEURONTIN 19 NORCO 9 NAMENDA 135 NEVANAC 133 NORDITROPIN FLEXPRO 68 NAMENDA TITRATION nevirapine 46 PAK 135 norelgestromin-ethinyl NAPROSYN 5 NEXAVAR 40 estradiol 54 norethin acet & estrad-fe 53 naproxen 5 NEXIUM 140 norethindrone & eth estradiol53 naproxen sodium 5 NEXIUM 24HR 140 NEXPLANON 54 norethindrone & ethinyl estradiol- naratriptan hcl 124 fe 53 niacin 144

Index 25 norethindrone NOVOLOG PENFILL 26 ON CALL LANCING (contraceptive) 54 NOVOTWIST 32GX5MM 111 DEVICE 86 norethindrone acet & eth ON CALL PLUS LANCETS 86 NOXAFIL 28 estra 53 ON CALL PLUS LANCING norethindrone acetate 135 NPLATE 74 DEVICE 86 norethindrone acetate-ethinyl NUBEQA 38 ONCASPAR 40 estradiol 70 NUCALA 14 ondansetron 27 norethindrone acetate-ethinyl estradiol-fe 53 NUCYNTA 7 ondansetron hcl 27 norethindrone-eth estradiol NUCYNTA ER 7 ONE VITE WOMENS (triphasic) 53 NUEDEXTA 137 PRENATALVITAMIN 128 ONE VITE WOMENS norgestimate-ethinyl NULOJIX 127 estradiol 53 PRENATALVITAMIN PLUS 128 norgestimate-ethinyl estradiol NUTROPIN AQ NUSPIN ONETOUCH CLUB LANCETS (triphasic) 53 10 68 FINE POINT 86 norgestrel & ethinyl estradiol 53 NUVARING 54 ONETOUCH DELICA LANCETS EXTRA FINE 33G 86 NORMOSOL-M IN D5W 125 NUVIGIL 3 nystatin 28 ONETOUCH DELICA LANCETS NORMOSOL-R 125 FINE 30G 86 NORPACE 13 nystatin (mouth-throat) 127 ONETOUCH DELICA LANCING NORPRAMIN 23 nystatin (topical) 59 DEVICE 86 nystatin-triamcinolone 59 ONETOUCH DELICA PLUS nortriptyline hcl 23 LANCETS EXTRA FINE NORVASC 50 O-CAL FA 128 33G 86 NORVIR 46 OCREVUS 136 ONETOUCH DELICA PLUS NOVA MAX PLUS KETONE octreotide acetate 69 LANCETS FINE 30G 86 TESTSTRIPS 65 OCUFLOX 131 ONETOUCH DELICA PLUS LANCING DEVICE 86 NOVA SAFETY LANCETS ODEFSEY 46 23G 86 ONETOUCH FINEPOINT NOVA SAFETY LANCETS ODOMZO 37 LANCETS 87 28G 86 OFEV 137 ONETOUCH ULTRASOFT LANCETS 87 NOVA SUREFLEX ofloxacin 71 ONFI 18 LANCETS 86 ofloxacin (ophth) 131 NOVA SUREFLEX LANCING ONGLYZA 25 ofloxacin (otic) 133 DEVICE 86 OPANA 8 olanzapine 44 NOVAREL 68 OPSUMIT 51 olmesartan medoxomil 32 NOVOFINE 32GX6MM 111 ORACEA 65 NOVOFINE AUTOCOVER olmesartan medoxomil- 30GX8MM 111 amlodipine-hydrochlorothiazide ORAP 137 NOVOFINE PLUS 33 ORAPRED ODT 55 32GX4MM 111 olmesartan medoxomil- ORENCIA 5 NOVOLIN 70/30 25 hydrochlorothiazide 33 ORENCIA CLICKJECT 5 olopatadine hcl 133 NOVOLIN 70/30 FLEXPEN 25 ORENITRAM 51 olopatadine hcl (nasal) 129 NOVOLIN 70/30 FLEXPEN ORFADIN 69 RELION 25 OLUMIANT 4 ORKAMBI 137 NOVOLIN 70/30 RELION 25 OLUX 63 orphenadrine citrate 129 NOVOLIN N 25 omega-3-acid ethyl esters 30 ORTHO MICRONOR 54 NOVOLIN N RELION 25 omeprazole 140 ORTHO TRI-CYCLEN 53 NOVOLIN R 25 omeprazole magnesium 140 NOVOLIN R RELION 25 omeprazole-sodium ORTHO TRI-CYCLEN LO 53 NOVOLOG 26 bicarbonate 140 ORTHO-CYCLEN 53 NOVOLOG FLEXPEN 25 OMNIFLEX DIAPHRAGM 78 ORTHO-NOVUM 1/35 53 NOVOLOG MIX 70/30 26 OMNIPRED 132 ORTHO-NOVUM 7/7/7 53 NOVOLOG MIX 70/30 OMNITROPE 68 oseltamivir phosphate 48 PREFILLED FLEXPEN 25 ON CALL LANCETS 86 OSENI 24

Index 26 OSMOPREP 76 PATANOL 133 PEN NEEDLES 32G X OSPHENA 68 PAXIL 22 6MM 111 PEN NEEDLES 32GX4MM 111 OTEZLA 5 PAXIL CR 22 PEN NEEDLES/29G X 1/2" 111 OTOVEL 133 PC LANCETS SUPER THIN PEN NEEDLES/31G X 1/4" 111 OVIDE 65 30G 87 PC UNIFINE PENTIPS 29G PEN NEEDLES/31G X oxacillin sodium 135 X1/2" 111 3/16" 111 oxaliplatin 36 PC UNIFINE PENTIPS 31G PEN NEEDLES/31G X oxandrolone 10 X5MM MINI 111 5/16" 111 PC UNIFINE PENTIPS 31G PEN NEEDLES/31G X oxaprozin 5 X6MM ULTRA SHORT 111 6MM 111 OXAYDO 8 PC UNIFINE PENTIPS 31G PEN NEEDLES/32G X oxazepam 13 X8MM SHORT 111 5/32" 111 OXBRYTA 74 PEDIAPRED 55 penicillamine 126 oxcarbazepine 19 PEDIARIX 139 penicillin g potassium 134 OXERVATE 132 PEDVAX HIB 141 PENICILLIN G POTASSIUM IN ISO-OSMOTIC oxiconazole nitrate 59 peg 3350-kcl-nacl-na sulfate-na ascorbate-ascorbic acid 76 DEXTROSE 134 OXISTAT 59 peg 3350-kcl-sod bicarb-sod PENICILLIN G PROCAINE 134 OXSORALEN ULTRA 61 chloride-sod sulfate 76 penicillin g sodium 134 oxybutynin chloride 141 PEGANONE 20 penicillin v potassium 134 oxycodone hcl 8 PEGASYS 48 PENLAC NAIL LACQUER 60 oxycodone w/ acetaminophen 9 PEGASYS PROCLICK 48 PENTACEL 139 oxycodone-ibuprofen 9 PEGINTRON 48 PENTAM 300 11 OXYCONTIN 8 PEN NEEDLES 29G X pentamidine isethionate 11 12MM 111 oxymorphone hcl 8 PEN NEEDLES pentazocine w/ naloxone 9 paclitaxel 41 29GX1/2" 111 PENTIPS 29G X 12MM 111 paliperidone 43 PEN NEEDLES PENTIPS 29GX12MM 112 29GX12MM 111 palonosetron hcl 27 PEN NEEDLES PENTIPS 31G X 5MM 112 PALYNZIQ 69 30GX5/16" 111 PENTIPS 31G X 8MM 112 PAMELOR 23 PEN NEEDLES PENTIPS 31GX5MM 112 pamidronate disodium 67 30GX8MM 111 PEN NEEDLES 31G X 1/4" PENTIPS 31GX6MM 112 PAMIDRONATE DISODIUM 67 SHORT 111 PENTIPS 31GX8MM 112 pamidronate disodium 67 PEN NEEDLES 31G X PENTIPS 32G X 4MM 112 PANOXYL-4 CREAMY 3/16" 111 PENTIPS 32GX4MM 112 WASH 57 PEN NEEDLES 31G X pentoxifylline 73 PANRETIN 60 5MM 111 PEN NEEDLES 31G X PEPCID 139 pantoprazole sodium 140 6MM 111 PEPCID AC MAXIMUM PARAGARD INTRAUTERINE PEN NEEDLES 31G X STRENGTH 139 COPPER CONTRACEPTIVE 8MM 111 PERCOCET 9 T380A 54 PEN NEEDLES parenteral electrolytes 125 31GX5/16" 111 PERFECT LANCETS 30G 87 paricalcitol 69 PEN NEEDLES 31GX6MM PERFECT PRESSURE ACTIVATED SAFETY LANCETS PARLODEL 42 (1/4") 111 PEN NEEDLES 28G 87 PARNATE 21 31GX8MM 111 PERIDEX 127 paromomycin sulfate 3 PEN NEEDLES 31GX8MM perindopril erbumine 31 paroxetine hcl 22 (5/16") 111 PERJETA 37 PEN NEEDLES 32G X PASER 35 4MM 111 permethrin 65 PATADAY 133 PEN NEEDLES 32G X perphenazine 44 PATANASE 129 5MM 111 perphenazine-amitriptyline 136

Index 27 PERSERIS 43 PLASMA-LYTE A 125 PRECISION SURE-DOSE PHARMACIST CHOICE ULTRA PLASMA-LYTE-148 125 INSULIN SYRINGE/0.5ML/29G X 1/2" 112 THIN LANCETS 87 PLAVIX 74 PHARMACIST CHOICE ULTRA PRECISION SURE-DOSE THIN LANCETS 28G 87 PLEGISOL 50 INSULIN SYRINGE/0.5ML/30G X PHARMACIST CHOICE ULTRA PLEGRIDY 136 3/8" 112 THIN LANCETS 30G 87 PLEGRIDY STARTER PRECISION SURE-DOSE PHARMACIST CHOICE ULTRA PACK 136 INSULIN SYRINGE/1ML/28G X THIN LANCETS 31G 87 PNEUMOVAX 23 141 1/2" 112 PHARMACIST CHOICE ULTRA PRECISION SURE-DOSE PNEUMOVAX 23/1 PLUSINSULIN THIN LANCETS 33G 87 DOSE 141 PHARMACY COUNTER SYRINGE/0.3ML/29G X LANCETS 87 podofilox 64 1/2" 112 phenazopyridine hcl 73 polymyxin b sulfate 12 PRECISION SURE-DOSE polymyxin b-trimethoprim 131 PLUSINSULIN phendimetrazine tartrate 1 SYRINGE/1ML/29G X 1/2" 112 phenelzine sulfate 21 POLYTRIM 131 PRECISION THINS GP PHENERGAN 30 POMALYST 38 LANCET 87 phenobarbital 75 potassium acetate 126 PRECISION XTRA 65 phenoxybenzamine hcl 32 potassium bicarb & PRECOSE 24 chloride 126 PRED FORTE 132 phentermine hcl 2 potassium bicarbonate 126 PRED MILD 132 PHENYTEK 20 potassium chloride 126 prednicarbate 63 phenytoin 20 POTASSIUM CHLORIDE 126 prednisolone 55 phenytoin sodium 20 potassium chloride 126 phenytoin sodium extended 20 prednisolone acetate potassium chloride in (ophth) 132 PHOSLYRA 72 dextrose 126 PREDNISOLONE ACETATE P- PHOSPHOLINE IODIDE 131 potassium chloride in dextrose F 132 & sodium chloride 125 PHOTOFRIN 40 prednisolone sodium potassium chloride in phosphate 55 PICATO 60 nacl 126 PREDNISOLONE SODIUM PIFELTRO 46 potassium chloride PHOSPHATE 132 pilocarpine hcl 131 microencapsulated crystals prednisone 55 er 126 pilocarpine hcl (oral) 128 POTASSIUM PREFERRED PLUS INSULIN pimecrolimus 64 CHLORIDE/DEXTROSE/LACT SYRINGE/U-100/0.3ML/29G X 1/2" 112 pimozide 137 ATED RINGERS 126 potassium citrate PREFERRED PLUS INSULIN pindolol 49 (alkalinizer) 72 SYRINGE/U-100/0.3ML/30G X pioglitazone hcl 25 5/16" 112 potassium phosphates 126 PREFERRED PLUS INSULIN pioglitazone hcl-glimepiride 24 PRADAXA 17 SYRINGE/U-100/0.5ML/28G X pioglitazone hcl-metformin pramipexole 1/2" 112 hcl 24 dihydrochloride 42 PREFERRED PLUS INSULIN PIP LANCETS/28G 87 PRANDIN 26 SYRINGE/U-100/0.5ML/29G X PIP LANCETS/30G 87 prasugrel hcl 74 1/2" 112 PREFERRED PLUS INSULIN piperacillin sodium-tazobactam PRAVACHOL 31 sodium 134 SYRINGE/U-100/0.5ML/30G X PIQRAY 200MG DAILY pravastatin sodium 31 5/16" 112 DOSE 40 praziquantel 10 PREFERRED PLUS INSULIN PIQRAY 250MG DAILY prazosin hcl 32 SYRINGE/U-100/1ML/28G X DOSE 40 1/2" 112 PRECISION SURE-DOSE PREFERRED PLUS INSULIN PIQRAY 300MG DAILY INSULIN SYRINGE/0.3ML/30G DOSE 40 SYRINGE/U-100/1ML/29G X X 5/16" 112 piroxicam 5 1/2" 112 PRECISION SURE-DOSE PREFERRED PLUS INSULIN PLAN B ONE-STEP 54 INSULIN SYRINGE/0.5ML/28G SYRINGE/U-100/1ML/30G X PLAQUENIL 35 X 1/2" 112 5/16" 112

Index 28 PREFERRED PLUS LANCETS PRIFTIN 35 PRODIGY INSULIN COLORED 21G 87 PRILOSEC OTC 140 SYRINGE/1ML/28G X 1/2" 113 PREFERRED PLUS LANCETS PRODIGY LANCING SUPER THIN 30G 87 primaquine phosphate 35 DEVICE 87 PREFERRED PLUS LANCETS PRIMAQUINE PRODIGY PRESSURE THIN 26G 87 PHOSPHATE 35 ACTIVATED SAFETY PREFERRED PLUS UNIFINE PRIMAXIN IV 11 LANCETS 87 PENTIPS 29G X 12MM 112 primidone 19 PRODIGY SAFETY PREFERRED PLUS UNIFINE LANCETS 87 PENTIPS 31G X 6MM ULTRA PRINIVIL 31 PRODIGY TWIST TOP SHORT 112 PRISTIQ 23 LANCETS 87 PREFERRED PLUS UNIFINE PRO COMFORT INSULIN progesterone micronized 135 PENTIPS 31G X 8MM SYRINGES/0.5ML/30G X PROGLYCEM 25 SHORT 112 1/2" 113 PREFERRED PLUS UNIFINE PRO COMFORT INSULIN PROGRAF 127 PENTIPS 32GX4MM 112 SYRINGES/0.5ML/30G X PROLASTIN-C 137 PREFERRED PLUS UNIFINE 5/16" 113 PROLEUKIN 41 PENTIPS/MINI/31GX5MM 112 PRO COMFORT INSULIN PROLIA 67 pregabalin 19 SYRINGES/0.5ML/31G X PREGNYL W/DILUENT 5/16" 113 PROMACTA 74 BENZYLALCOHOL/NACL 68 PRO COMFORT INSULIN promethazine hcl 30 PREMARIN 70 SYRINGES/1ML/30G X PROMETRIUM 135 PREMIUM CONDOMS 1/2" 113 PRO COMFORT INSULIN propafenone hcl 14 LUBRICATED 78 SYRINGES/1ML/30G X proparacaine hcl 132 PREMPHASE 70 5/16" 113 propranolol hcl 49 PREMPRO 70 PRO COMFORT INSULIN propylthiouracil 138 PRENATAL 128 SYRINGES/1ML/31G X PROSCAR 73 PRENATAL LOW IRON 128 5/16" 113 PRO COMFORT LANCETS PROTONIX 140 PRENATAL 30G 87 PROTOPIC 64 MULTIVITAMIN 128 PRO COMFORT LANCETS PRENATAL ONE DAILY 128 31G 87 protriptyline hcl 24 PRENATAL PLUS 128 PRO COMFORT PEN PROVENTIL HFA 16 PRENATAL VITAMIN 128 NEEDLES/31G X 8MM 113 PROVERA 135 PRENATAL VITAMIN & PRO COMFORT PEN PROVIGIL 3 NEEDLES/32G X 4MM 113 MINERAL 128 PROZAC 22 PRENATAL PRO COMFORT PEN VITAMIN/IRON 129 NEEDLES/32G X 5MM 113 PRUDOXIN 60 PRO COMFORT PEN PSORCON 63 PRENATAL VITAMINS 129 NEEDLES/32G X 6MM 113 PSS SELECT GP LANCETS 87 PRENATAL VITAMINS PLUS PROAIR HFA 16 LOW IRON 129 PSS SELECT SAFETY PRENATRIX 129 probenecid 73 LANCETS 87 PREPLUS 129 procainamide hcl 13 PTS PANELS KETONE PROCARDIA 50 TEST 66 PREPOPIK 76 PULMICORT 15 PRESSURE ACTIVATED PROCARDIA XL 50 SAFETYLANCET 21G 87 prochlorperazine 44 PULMICORT FLEXHALER 15 PREVACID 140 prochlorperazine maleate 44 PULMOZYME 137 PREVACID 24HR 140 PURE COMFORT PEN NEEDLE PROCRIT 74 32G X6MM 113 PREVENT SAFETY PEN PROCTOCORT 10 PURE COMFORT PEN NEEDLES 31GX1/4" 112 PRODIGY INSULIN NEEDLE/32G X 5MM 113 PREVENT SAFETY PEN SYRING/U-100/0.3ML/31G X PURE COMFORT PEN NEEDLES 31GX5/16" 112 5/16" 113 NEEDLE/32G X4MM 113 PREVNAR 13 141 PRODIGY INSULIN PUSH BUTTON SAFETY PREZCOBIX 46 SYRINGE/1/2ML/31G X LANCETS 21G 87 PREZISTA 46 5/16" 113 PUSH BUTTON SAFETY LANCETS 28G 87

Index 29 PX ADVANCED LANCING QVAR REDIHALER 15 REALITY INSULIN SYRINGE/U- DEVICE 87 RA E-ZJECT COLOR 100/0.5ML/29G X 1/2" 113 PX EXTRA SHORT PEN LANCETSMICRO-THIN REALITY INSULIN SYRINGE/U- NEEDLES 31GX6MM 113 33G 87 100/1ML/28G X 1/2" 114 PX INSULIN SYRINGE/U- RA E-ZJECT LANCETS REALITY INSULIN SYRINGE/U- 100/0.5ML/30G X 1/2" 113 28G 87 100/1ML/29G X 1/2" 114 PX LANCET AUTO RA E-ZJECT LANCETS THIN REALITY LANCETS 88 INJECTOR 87 26G 87 REALITY LATEX PX LANCETS ULTRA THIN 87 RA E-ZJECT LANCETS THIN CONDOMS/LUBRICATED 78 PX LANCETS ULTRA THIN 28G 87 REALITY LATEX/ULTRA 28G 87 RA E-ZJECT LANCETS TEXTURED 78 PX MINI PEN NEEDLES ULTRATHIN 30G 88 REALITY LATEX/ULTRA 31GX5MM 113 RA INSULIN THIN 78 PX PEN NEEDLE SYRINGE/0.5ML/29G X REALITY TRIGGER 29GX12MM 113 1/2" 113 LANCETS 88 PX PEN NEEDLE RA INSULIN REBETOL 48 31GX8MM 113 SYRINGE/1ML/29G X REBIF 136 PX PRENATAL 1/2" 113 MULTIVITAMINS 129 RA INSULIN SYRINGE/U- REBIF REBIDOSE 136 PX SHORTLENGTH PEN 100/0.5ML/30G X 5/16" 113 REBIF REBIDOSE NEEDLES/31GX8MM 113 RA INSULIN SYRINGE/U- TITRATIONPACK 136 pyrazinamide 35 100/1 ML/30G X 5/16" 113 REBIF TITRATION PACK 136 PYRIDIUM 73 RA LANCING DEVICE 88 RECLAST 67 pyridostigmine bromide 35 RA PEN NEEDLES 31G X RECOMBIVAX HB 143 5MM3/16" 113 pyrimethamine 35 RA PEN NEEDLES 31G X RECTIV 10 QC ADVANCED LANCING 8MM5/16" 113 REGLAN 71 DEVICE 87 RA PRENATAL 129 REGRANEX 65 QC LANCETS SUPER THIN 87 RA PRENATAL RELENZA DISKHALER 48 QC LANCETS ULTRA THIN 87 FORMULA/FOLICACID 129 RELION 2-IN-1 LANCET QC PEN NEEDLES 29G X rabeprazole sodium 140 DEVICES 30G 88 12MM 113 raloxifene hcl 68 RELION 2-IN-1 LANCING QC PEN NEEDLES 31G X DEVICE 25G 88 6MM 113 ramelteon 76 RELION 2-IN-1 LANCING QC PEN NEEDLES 31G X ramipril 31 DEVICE 30G 88 8MM 113 RANEXA 12 RELION INSULIN SYRINGE QC PRENATAL 129 ranitidine hcl 139 1ML/31GX15/64" 114 QC UNIFINE PENTIPS RELION INSULIN SYRINGE/U- 32GX4MM 113 ranolazine 12 00/1ML/29G X 1/2" 114 QC UNILET LANCETS RAPAFLO 73 RELION INSULIN SYRINGE/U- 28G/ULTRA THIN 87 RAPAMUNE 127 100/0.3ML/29G X 1/2" 114 RELION INSULIN SYRINGE/U- QC UNILET LANCETS rasagiline mesylate 42 33G/MICRO THIN 87 100/0.3ML/30G X 5/16" 114 QUADRACEL 139 RAZADYNE 135 RELION INSULIN SYRINGE/U- 100/0.3ML/31G X 5/16" 114 QUALAQUIN 35 RAZADYNE ER 135 READYLANCE SAFETY RELION INSULIN SYRINGE/U- QUARTETTE 53 LANCETS/21G/2.2MM 88 100/0.5ML/29G X 1/2" 114 QUDEXY XR 19 READYLANCE SAFETY RELION INSULIN SYRINGE/U- QUESTRAN 30 LANCETS/23G/1.8MM 88 100/0.5ML/30G X 5/16" 114 RELION INSULIN SYRINGE/U- QUESTRAN LIGHT 30 READYLANCE SAFETY LANCETS/26G/1.8MM 88 100/0.5ML/31G X 5/16" 114 quetiapine fumarate 44 READYLANCE SAFETY RELION INSULIN SYRINGE/U- quinapril hcl 31 LANCETS/28G/1.8MM 88 100/1ML/30G X 5/16" 114 quinapril-hydrochlorothiazide READYLANCE SAFETY RELION INSULIN SYRINGE/U- 33 LANCETS/30G/1.6MM 88 100/1ML/31G X 15/64" 114 RELION INSULIN SYRINGE/U- quinidine sulfate 13 REALITY INSULIN SYRINGE/U-100/0.5ML/28G X 100/1ML/31G X 5/16" 114 quinine sulfate 35 1/2" 113 RELION KETONE 66

Index 30 RELION KETONE TEST RESTASIS 131 ROBAXIN-750 129 STRIPS 66 RESTASIS MULTIDOSE 131 ROCALTROL 69 RELION LANCETS MICRO- THIN33G 88 RESTORIL 75 ROMIDEPSIN 40 RELION LANCETS STANDARD RETACRIT 75 ropinirole hydrochloride 42 21G 88 RETEVMO 40 rosuvastatin calcium 31 RELION LANCETS THIN 26G 88 RETIN-A 57 ROTARIX 143 RELION LANCETS ULTRA- RETIN-A MICRO 57 ROTATEQ 143 THIN30G 88 RETIN-A MICRO PUMP 57 ROXICET 9 RELION LANCING DEVICE 88 RETROVIR 46 ROXICODONE 8 RELION MINI PEN NEEDLES RETROVIR IV INFUSION 46 ROZEREM 76 31GX6MM 114 RELION PEN NEEDLES REVATIO 51 ROZLYTREK 40 29GX12MM 114 REVLIMID 126 RUCONEST 73 RELION PEN NEEDLES REXALL LANCETS ULTRA rufinamide 19 31GX5/16" 114 THIN 88 RUXIENCE 37 RELION PEN NEEDLES REXULTI 44 31GX6MM 114 RUZURGI 35 REYATAZ 46 RELION PEN NEEDLES RYTHMOL SR 14 RIBASPHERE 48 31GX8MM 114 SABRIL 20 RELION PEN NEEDLES 32G RIBASPHERE RIBAPAK 48 X5/32" 114 SAFE-T-LANCE LOW FLOW RELION PEN NEEDLES ribavirin (hepatitis c) 48 25G 88 32GX4MM 114 RIDAURA 4 SAFE-T-LANCE NORMAL RELION PEN NEEDLES/31G rifabutin 35 FLOW21G 88 SAFE-T-LANCE PLUS X1/4" 114 RIFADIN 35 RELION SHORT PEN SAFETYLANCET HIGH NEEDLES31GX8MM 114 RIFAMATE 35 FLOW 88 RELION ULTRA THIN rifampin 35 SAFE-T-LANCE PLUS SAFETYLANCET LOW LANCETS/30G 88 RIFATER 35 RELION ULTRA THIN FLOW 88 RIGHT STEP SAFE-T-LANCE PLUS LANCETS30G 88 PRENATAL 129 RELION ULTRA THIN PLUS SAFETYLANCET NORMAL RIGHTEST GD500 LANCING FLOW 88 LANCETS 32G 88 DEVICE 88 RELION ULTRA THIN PLUS SAFESNAP INSULIN RIGHTEST GL300 SYRINGE/0.3ML/30G X LANCETS 33G 88 LANCETS 88 RELISTOR 72 5/16" 114 RILUTEK 130 SAFESNAP INSULIN RELPAX 124 riluzole 130 SYRINGE/0.5ML/29G X REMERON 21 rimantadine hydrochloride 48 1/2" 114 SAFESNAP INSULIN REMERON SOLTAB 21 ringer's 126 REMICADE 72 SYRINGE/0.5ML/30G X ringer's irrigation 127 5/16" 114 REMODULIN 51 RINVOQ 4 SAFESNAP INSULIN RENFLEXIS 72 risedronate sodium 67 SYRINGE/1ML/28G X 1/2" 114 RENVELA 72 SAFESNAP INSULIN RISPERDAL 43 SYRINGE/1ML/29G X 1/2" 114 REOPRO 74 RISPERDAL CONSTA 43 SAFETY INSULIN SYRINGES repaglinide 26 risperidone 43 0.5ML/29GX1/2" 114 repaglinide-metformin hcl 24 SAFETY INSULIN SYRINGES RITALIN 3 0.5ML/30GX5/16" 114 REPATHA 31 RITALIN LA 3 SAFETY INSULIN SYRINGES REPATHA SURECLICK 31 ritonavir 46 1ML/27GX1/2" 114 REQUIP 42 RITUXAN 37 SAFETY INSULIN SYRINGES REQUIP XL 42 1ML/29GX1/2" 114 rivastigmine tartrate 135 SAFETY INSULIN SYRINGES RESCRIPTOR 46 rizatriptan benzoate 124 1ML/30GX1/2" 114 RESECTISOL 72 ROBAXIN 129

Index 31 SAFETY LANCET SEASONIQUE 53 SHOPKO UNIFINE PENTIPS 21G/PRESSURE SECURESAFE SAFETY PLUS PEN ACTIVATED 88 INSULIN SYRINGES/U- NEEDLES/SHORT/REMOVR/31 SAFETY LANCET 100/0.5ML/29GX1/2" 115 GX8MM 115 23G/PRESSURE SECURESAFE SAFETY SHOPKO UNILET LANCETS ACTIVATED 88 INSULIN SYRINGES/U- SUPER THIN 30G 89 SAFETY LANCET 100/1ML/29GX1/2" 115 SHOPKO UNILET LANCETS 28G/PRESSURE SEGLUROMET 24 ULTRA THIN 28G 89 ACTIVATED 88 SELECT-LITE LANCING SHUR-SEAL 143 SAFETY LANCET SIDE BUTTON SAFETY 30G/PRESSURE DEVICE 89 selegiline hcl 43 LANCET21G 89 ACTIVATED 88 SIGNIFOR 69 SAFETY LANCETS 88 selenium sulfide 61 sildenafil citrate 51 SELZENTRY 46 SAFETY LANCETS 21G 88 sildenafil citrate (pulmonary SAFETY LANCETS 28G 88 SENSIPAR 69 hypertension) 51 SAFETY LET LANCETS 88 SEREVENT DISKUS 16 SILENOR 75 SAFETY SEAL LANCETS SEROQUEL 44 SILIQ 61 28G 88 SEROQUEL XR 44 silodosin 73 SAFETY SEAL LANCETS 30G 88 SEROSTIM 68 SILVADENE 61 SAFYRAL 53 sertraline hcl 22,23 silver sulfadiazine 61 SAIZEN 68 sevelamer carbonate 72 SIMBRINZA 131 SAIZENPREP SHINGRIX 143 SIMCOR 31 RECONSTITUTIONKIT 68 SHOPKO AUTOLET LANCING SIMPLE DIAGNOSTICS SALAGEN 128 DEVICE 89 LANCING DEVICE 89 salsalate 6 SHOPKO ON-THE-GO SIMPONI 4 COMFORTLANCETS 30G 89 SAMSCA 70 SHOPKO UNIFINE PENTIPS SIMPONI ARIA 4 SANDIMMUNE 127 PEN SIMULECT 127 SANDOSTATIN 69 NEEDLES/MICRO/32GX4MM simvastatin 31 115 SINEMET 42 SANTYL 64 SHOPKO UNIFINE PENTIPS SAPHRIS 44 PEN SINEMET CR 42 sapropterin dihydrochloride 69 NEEDLES/MINI/31GX5MM SINGLE-LET 89 SAPS HEALTH CARE TWIST 115 SINGULAIR 14 TOP LANCETS 89 SHOPKO UNIFINE PENTIPS sirolimus 127 SAPS HEALTH TWIST TOP PEN LANCETS 30G 89 NEEDLES/ORIGINAL/29GX12 SIRTURO 35 SAPSCARE TWIST TOP MM 115 SIVEXTRO 12 LANCETS 30G 89 SHOPKO UNIFINE PENTIPS SKELAXIN 129 SAVELLA 136 PEN NEEDLES/SHORT/31GX8MM SKLICE 65 SAVELLA TITRATION SKYLA 54 PACK 136 115 SB INSULIN SYRINGE/U- SHOPKO UNIFINE PENTIPS SKYRIZI 61 100/0.5ML/29G X 1/2" 115 PLUS PEN SLO-NIACIN 144 NEEDLES/MICRO/REMOVR/3 SB INSULIN SYRINGE/U- SLYND 54 100/0.5ML/30G X 5/16" 115 2GX4MM 115 SHOPKO UNIFINE PENTIPS SM MICRO THIN LANCETS SB INSULIN SYRINGE/U- 33G 89 100/1ML/29G X 1/2" 115 PLUS PEN SB INSULIN SYRINGE/U- NEEDLES/MINI/REMOVER/31 SM PRENATAL VITAMINS 129 100/1ML/30G X 5/16" 115 GX5MM 115 SM TRUEDRAW LANCING SB INSULIN SYRINGE/U- SHOPKO UNIFINE PENTIPS DEVICE 89 100/1ML/31G X 5/16" 115 PLUS PEN SMART DIABETES VANTAGE SB LANCETS THIN 89 NEEDLES/REMOVER/29GX12 LANCING DEVICE 89 MM 115 SMART SENSE COLOR SB LANCETS ULTRA THIN 89 LANCETS UNIVERSAL 33G 89 scopolamine 27

Index 32 SMART SENSE STANDARD SPRAVATO 84MG DOSE 22 SUPREP BOWEL PREP KIT76 LANCETS UNIVERSAL 21G 89 SPRYCEL 40 SURE COMFORT INSULIN SMART SENSE SUPER THIN STALEVO 100 42 SYRINGE/U-100/0.3ML/29G X LANCETS UNIVERSAL 30G 89 1/2" 115 SMART SENSE THIN STALEVO 125 42 SURE COMFORT INSULIN LANCETSUNIVERSAL 26G 89 STALEVO 150 42 SYRINGE/U-100/0.3ML/30G X SMARTEST LANCETS 28G 89 STALEVO 200 42 1/2" 115 SURE COMFORT INSULIN SODIUM ACETATE 125 STALEVO 50 42 sodium acetate 125 SYRINGE/U-100/0.3ML/30G X STALEVO 75 42 5/16" 115 sodium chloride 126 stannous fluoride 128 SURE COMFORT INSULIN sodium chloride (gu irrigant) 72 STARLIX 26 SYRINGE/U-100/0.3ML/31G X 5/16 115 sodium chloride (inhalant) 56 stavudine 46 sodium citrate & citric acid 72 SURE COMFORT INSULIN STEGLATRO 26 SYRINGE/U-100/0.3ML/31G X sodium phenylbutyrate 69 STELARA 61,72 5/16" 115 sodium polystyrene STENDRA 51 SURE COMFORT INSULIN sulfonate 127 SYRINGE/U-100/0.5ML/28G X SOFOSBUVIR/VELPATASVIR STERILANCE TL 89 1/2" 115 48 STIMATE 69 SURE COMFORT INSULIN solifenacin succinate 141 STIVARGA 40 SYRINGE/U-100/0.5ML/29G X SOLIRIS 73 1/2" 115 STRATTERA 2 SURE COMFORT INSULIN SOLOSEC 3 streptomycin sulfate 3 SYRINGE/U-100/0.5ML/30G X SOLU-CORTEF 55 STRIBILD 46 1/2" 115 SOLU-MEDROL 55 STRIVERDI RESPIMAT 16 SURE COMFORT INSULIN SYRINGE/U-100/0.5ML/30G X SOLUS V2 LANCING STROMECTOL 10 DEVICE 89 5/16" 115 SOLUS V2 PRESSURE SUBOXONE 10 SURE COMFORT INSULIN ACTIVATED SAFETY LANCETS SUBSYS 8 SYRINGE/U-100/0.5ML/31G X 28G 89 SUCRAID 66 5/16 115 SOLUS V2 TWIST LANCETS SURE COMFORT INSULIN 30G 89 sucralfate 140 SYRINGE/U-100/1ML/28G X SOMA 129 SULAR 50 1/2" 115 sulconazole nitrate 60 SURE COMFORT INSULIN SOMATULINE DEPOT 70 SYRINGE/U-100/1ML/29G X SOMAVERT 68 sulfacetamide sodium (acne) 57 1/2" 116 SOOLANTRA 65 sulfacetamide sodium SURE COMFORT INSULIN SORBITOL 72 (ophth) 131 SYRINGE/U-100/1ML/30G X 1/2" 116 SORBITOL-MANNITOL 72 sulfacetamide sodium w/ sulfur 57,58 SURE COMFORT INSULIN SORBITOL/MANNITOL SYRINGE/U-100/1ML/30G X IRRIGATION 72 sulfacetamide sodium-sulfur in urea vehicle 58 5/16" 116 SORIATANE 61 SURE COMFORT INSULIN SULFADIAZINE 137 sotalol hcl 49 SYRINGE/U-100/1ML/31G X sulfamethoxazole-trimethoprim 5/16" 116 sotalol hcl (afib/afl) 49 11 SURE COMFORT LANCETS SOVALDI 48 SULFAMYLON 61 18G 89 spinosad 65 sulfasalazine 72 SURE COMFORT LANCETS SPIRIVA HANDIHALER 14 sulindac 5 21G 89 SURE COMFORT LANCETS SPIRIVA RESPIMAT 14 SUMADAN WASH 58 23G 89 spironolactone 66 sumatriptan 125 SURE COMFORT LANCETS spironolactone & sumatriptan succinate 125 28G 89 SURE COMFORT LANCETS hydrochlorothiazide 66 SUNOSI 2 SPORANOX 28 30G 89 SUPER THIN LANCETS 89 SURE COMFORT LANCING SPORANOX PULSEPAK 28 SUPRAX 52 PEN 89 SPRAVATO 56MG DOSE 22

Index 33 SURE COMFORT PEN SURE-LANCE THIN LANCETS TASIGNA 40 NEEDLES29GX1/2" 28G 89 TASMAR 42 12.7MM 116 SURE-LANCE ULTRA THIN SURE COMFORT PEN LANCETS 89 tavaborole 60 NEEDLES30GX5/16" SURE-PEN 89 TAXOTERE 41 SHORT 116 SURE-TOUCH LANCETS TAYTULLA 53 SURE COMFORT PEN UNIVERSAL 89 tazarotene 61 NEEDLES31GX3/16" SURELITE LANCETS 89 (5MM) 116 TAZORAC 61 SURE COMFORT PEN SURMONTIL 24 TAZVERIK 40 NEEDLES31GX5/16" SUSTIVA 46 TDVAX 139 (8MM) 116 SUTENT 40 TECFIDERA 136 SURE COMFORT PEN SYLATRON 41 NEEDLES32GX5/32" 116 TECFIDERA STARTER SURE COMFORT PEN SYMBICORT 16 PACK 136 NEEDLES32GX6MM 116 SYMFI 46 TECHLITE AST LANCETS 89 SURE-FINE PEN NEEDLES SYMFI LO 46 TECHLITE INSULIN SYRINGEU- 29GX1/2" 12.7MM 116 100/0.3ML/29G X 1/2" 116 SURE-FINE PEN NEEDLES SYMLINPEN 120 24 TECHLITE INSULIN SYRINGEU- 31GX3/16" 5MM 116 SYMLINPEN 60 24 100/0.3ML/30G X 1/2" 116 SURE-FINE PEN NEEDLES SYMTUZA 46 TECHLITE INSULIN SYRINGEU- 31GX5/16" 8MM 116 SYNALAR 63 100/0.3ML/30G X 5/16" 116 SURE-JECT INSULIN TECHLITE INSULIN SYRINGEU- SYRINGE/U-100/0.3ML/29G X SYNAREL 68 100/0.3ML/31G X 5/16" 116 1/2" 116 SYNERA 65 TECHLITE INSULIN SYRINGEU- SURE-JECT INSULIN SYNJARDY 24 100/0.5ML/29G X 1/2" 117 SYRINGE/U-100/0.3ML/30G X TECHLITE INSULIN SYRINGEU- 5/16" 116 SYNJARDY XR 24 100/0.5ML/30G X 1/2" 117 SURE-JECT INSULIN SYNRIBO 41 TECHLITE INSULIN SYRINGEU- SYRINGE/U-100/0.3ML/31G X SYNTHROID 138 100/0.5ML/30G X 5/16" 117 5/16" 116 SYPRINE 126 TECHLITE INSULIN SYRINGEU- SURE-JECT INSULIN 100/0.5ML/31G X 5/16" 117 SYRINGE/U-100/0.5ML/28G X TABLOID 37 TECHLITE INSULIN SYRINGEU- 1/2" 116 TABRECTA 40 100/1ML/29G X 1/2" 117 SURE-JECT INSULIN TACLONEX 64 TECHLITE INSULIN SYRINGEU- SYRINGE/U-100/0.5ML/29G X 100/1ML/30G X 1/2" 117 1/2" 116 tacrolimus 127 TECHLITE INSULIN SYRINGEU- SURE-JECT INSULIN tacrolimus (topical) 64 100/1ML/30G X 5/16" 117 SYRINGE/U-100/0.5ML/30G X tadalafil 51 TECHLITE INSULIN SYRINGEU- 5/16" 116 tadalafil (pulmonary 100/1ML/31G X 15/64" 117 SURE-JECT INSULIN hypertension) 51 TECHLITE INSULIN SYRINGEU- SYRINGE/U-100/0.5ML/31G X TAFINLAR 40 100/1ML/31G X 5/16" 117 5/16" 116 TECHLITE LANCETS 90 TAGAMET HB 139 SURE-JECT INSULIN TECHLITE LANCETS 30G 89 SYRINGE/U-100/1ML/28G X TAKHZYRO 73 TECHLITE PEN NEEDLES 29GX 1/2" 116 TALTZ 61 12 MM 117 SURE-JECT INSULIN TALZENNA 40 TECHLITE PEN NEEDLES 31GX SYRINGE/U-100/1ML/29G X TAMIFLU 49 5MM 117 1/2" 116 TECHLITE PEN NEEDLES/31GX SURE-JECT INSULIN tamoxifen citrate 38 5MM 117 SYRINGE/U-100/1ML/30G X tamsulosin hcl 73 TECHLITE PEN NEEDLES/31GX 5/16" 116 TANZEUM 25 6 MM 117 SURE-JECT INSULIN TECHLITE PEN NEEDLES/31GX SYRINGE/U-100/1ML/31G X TAPAZOLE 138 8MM 117 5/16" 116 TARCEVA 40 TECHLITE PEN NEEDLES/32GX SURE-LANCE FLAT TARGADOX 138 4MM 117 LANCETS 89 TARGRETIN 41,60 TECHLITE PEN NEEDLES/32GX SURE-LANCE LANCETS 6MM 117 26G 89 TARKA 33

Index 34 TEFLARO 52 thiotepa 36 TOPCARE CLICKFINE TEGRETOL 19 thiothixene 44 UNIVERSAL PEN EEDLES 31GX1/4" 117 TEGRETOL-XR 19 THYMOGLOBULIN 127 TOPCARE CLICKFINE TEGSEDI 137 thyroid 138 UNIVERSAL PEN EEDLES TEKTURNA 34 tiagabine hcl 20 31GX5/16" 117 TOPCARE LANCETS MICRO- telmisartan 32 TIAZAC 50 THIN 33G 90 telmisartan-amlodipine 33 TIBSOVO 40 TOPCARE ULTRA COMFORT telmisartan-hydrochlorothiazide TIGAN 27 INSULIN SYRINGE/0.3ML/30G X 33 tigecycline 137 5/16" 117 temazepam 75 TOPCARE ULTRA COMFORT TIGECYCLINE 138 TEMIXYS 46 INSULIN SYRINGE/0.3ML/31G X TIKOSYN 14 5/16" 117 TEMODAR 36 timolol maleate 49 TOPCARE ULTRA COMFORT TEMOVATE 64 timolol maleate (ophth) 130 INSULIN SYRINGE/0.5ML/30G X temozolomide 36 5/16" 117 TIMOPTIC 131 temsirolimus 40 TOPCARE ULTRA COMFORT TIMOPTIC-XE 131 INSULIN SYRINGE/0.5ML/31G X TENIPOSIDE 41 TIVICAY 46 5/16" 117 TENIVAC 139 TOPCARE ULTRA COMFORT tizanidine hcl 129 tenofovir disoproxil fumarate 46 INSULIN SYRINGE/1ML/30G X TOBI 3 5/16" 117 TENORETIC 100 33 TOBRADEX 132 TOPCARE ULTRA COMFORT TENORETIC 50 33 tobramycin 3 INSULIN SYRINGE/1ML/31G X TENORMIN 49 5/16" 117 tobramycin (ophth) 131 TEPADINA 36 TOPCARE ULTRA COMFORT tobramycin sulfate 3 INSULIN SYRINGE/U- terazosin hcl 32 tobramycin- 100/0.3ML/29G X 1/2" 117 terbinafine hcl 28 dexamethasone 132 TOPCARE ULTRA COMFORT terbutaline sulfate 16 TOBREX 131 INSULIN SYRINGE/U- 100/0.5ML/29G X 1/2" 118 terconazole vaginal 144 TODAY SPONGE 143 TOPCARE ULTRA COMFORT TESSALON PERLES 56 TODAYS HEALTH ADVANCED INSULIN SYRINGE/U- TESTIM 10 LANCING DEVICE 90 100/1ML/29G X 1/2" 118 TODAYS HEALTH MINI PEN TESTOSTERONE NEEDLES 31G X 1/4" 117 TOPICORT 64 CYPIONATE 10 TODAYS HEALTH ORIGINAL topiramate 20 testosterone cypionate 10 PEN NEEDLES 29G X topotecan hcl 41 testosterone enanthate 10 1/2" 117 TOPROL XL 49 TETANUS/DIPHTHERIA TODAYS HEALTH SHORT TOXOIDS-ADSORBED PEN NEEDLES 31G X toremifene citrate 38 ADULT 139 5/16" 117 TORISEL 40 tetrabenazine 136 TODAYS HEALTH SUPER torsemide 66 THINLANCETS 30G 90 tetracycline hcl 138 TODAYS HEALTH ULTRA TOVIAZ 141 TGT LANCET MICRO THIN THINLANCETS 28G 90 TRACLEER 51 33G 90 TOFRANIL 24 TRADJENTA 25 TGT LANCET THIN 26G 90 tolazamide 26 tramadol hcl 8 TGT LANCET ULTRA THIN 30G 90 tolbutamide 26 tramadol-acetaminophen 9 TGT LANCING DEVICE 90 tolcapone 42 trandolapril 31 THALOMID 126 tolmetin sodium 5 trandolapril-verapamil hcl 33 theophylline 16 TOLSURA 28 tranexamic acid 75 THERANATAL CORE tolterodine tartrate 141 TRANSDERM SCOP 27 NUTRITION 129 tolvaptan 70 TRANSDERM-SCOP 27 THINLETS GP LANCETS 90 TOPAMAX 19,20 TRANXENE T 13 thioridazine hcl 44 TOPAMAX SPRINKLE 19 tranylcypromine sulfate 21

Index 35 TRAVATAN Z 133 tropicamide 131 TRUEPLUS INSULIN TRAVEL LANCETS 30G 90 trospium chloride 141 SYRINGE/U-100/1ML/29G X 1/2" 118 TRAVEL LANCETS ADVANCED TRUE COMFORT INSULIN TRUEPLUS INSULIN 28G 90 SYRINGE/0.5ML/31G X SYRINGE/U-100/1ML/30G X travoprost 133 5/16" 118 5/16" 118 trazodone hcl 23 TRUE COMFORT INSULIN TRUEPLUS INSULIN SYRINGE/1ML/31G X TREANDA 36 SYRINGE/U-100/1ML/31G X 5/16" 118 5/16" 118 TRECATOR 35 TRUE COMFORT PEN TRUEPLUS LANCETS 26G 90 TRELEGY ELLIPTA 16 NEEDLES31G X 5MM 118 TRUE COMFORT PEN TRUEPLUS LANCETS 28G 90 TRELSTAR MIXJECT 38 NEEDLES31G X 6MM 118 TRUEPLUS LANCETS 28G TREMFYA 61 TRUE COMFORT PEN SUPER THIN 90 treprostinil 51 NEEDLES32G X 4MM 118 TRUEPLUS LANCETS 30G 90 TRESIBA 26 TRUE COMFORT TWIST TOP TRUEPLUS LANCETS 30G LANCETS 30G 90 TRESIBA FLEXTOUCH 26 ULTRA THIN 90 TRUE METRIX BLOOD TRUEPLUS LANCETS 33G 90 tretinoin 58 GLUCOSETEST STRIPS 66 TRUEPLUS LANCETS 33G tretinoin (chemotherapy) 41 TRUE METRIX CONTROL SOLUTION LEVEL 3 90 MICRO THIN 90 tretinoin microsphere 58 TRUEDRAW LANCING TRUEPLUS PEN NEEDLES TREXALL 37 DEVICE 90 29GX12MM 118 TRUEPLUS 5-BEVEL PEN TRUEPLUS PEN NEEDLES TRI-NORINYL 28 53 31GX5MM 118 triamcinolone acetonide 55 NEEDLES 29GX12.7MM 118 TRUEPLUS 5-BEVEL PEN TRUEPLUS PEN NEEDLES triamcinolone acetonide NEEDLES 31GX5MM 118 31GX6MM 118 (mouth) 128 TRUEPLUS 5-BEVEL PEN TRUEPLUS PEN NEEDLES triamcinolone acetonide NEEDLES 31GX6MM 118 31GX8MM 118 (nasal) 130 TRUEPLUS 5-BEVEL PEN TRUEPLUS PEN NEEDLES triamcinolone acetonide NEEDLES 31GX8MM 118 32GX4MM 118 (topical) 64 TRUEPLUS 5-BEVEL PEN TRUEPLUS SAFETY LANCETS triamcinolone acetonide- NEEDLES 32GX4MM 118 28G 90 dimethicone-silicone 64 TRUEPLUS INSULIN TRUETRACK TEST 66 triamterene 66 SYRINGE/U-100/0.3ML/29G X TRULICITY 25 triamterene & 1/2" 118 TRUMENBA 141 hydrochlorothiazide 66 TRUEPLUS INSULIN triazolam 75 SYRINGE/U-100/0.3ML/30G X TRUSOPT 133 TRUSTEX COLOR CONDOMS + TRIBENZOR 33 5/16" 118 TRUEPLUS INSULIN LUBE 78 TRICARE 129 SYRINGE/U-100/0.3ML/31G X TRUSTEX LUBRICATED 78 TRICOR 30 5/16" 118 TRUSTEX LUBRICATED TRIDESILON 64 TRUEPLUS INSULIN EXTRALARGE 78 trientine hcl 126 SYRINGE/U-100/0.5ML/28G X TRUSTEX LUBRICATED 1/2" 118 EXTRASTRENGTH 78 trifluoperazine hcl 44 TRUEPLUS INSULIN TRUSTEX trifluridine 131 SYRINGE/U-100/0.5ML/29G X LUBRICATED/RIBBED/STUDDE trihexyphenidyl hcl 41 1/2" 118 D 78 TRUSTEX TRIKAFTA 137 TRUEPLUS INSULIN SYRINGE/U-100/0.5ML/30G X LUBRICATED/SPERMICIDE TRILEPTAL 20 5/16" 118 78 trimethobenzamide hcl 27 TRUEPLUS INSULIN TRUSTEX trimethoprim 11 SYRINGE/U-100/0.5ML/31G X LUBRICATED/SPERMICIDE 5/16" 118 EXTRA LARGE 78 trimipramine maleate 24 TRUEPLUS INSULIN TRUSTEX TRINTELLIX 23 SYRINGE/U-100/1ML/28G X LUBRICATED/SPERMICIDE TRIOSTAT 138 1/2" 118 EXTRA STRENGTH 78 TRIUMEQ 47 TRUSTEX NATURAL CONDOMS TRIZIVIR 47 +LUBE/LUBRICATED 78

Index 36 TRUSTEX WITH NONOXYNOL- ULTICARE INSULIN ULTICARE MICRO PEN 9/RIBBED/STUDDED 78 SYRINGE/1ML/29G X NEEDLES/31G X 1/4" 120 TRUSTEX/RIA 1/2" 119 ULTICARE MICRO PEN LUBRICATED 78 ULTICARE INSULIN NEEDLES/31G X 5/16" 120 TRUSTEX/RIA LUBRICATED SYRINGE/1ML/30G X ULTICARE MICRO PEN SPERMICIDE 78 1/2" 119 NEEDLES/32G X 4MM 120 TRUSTEX/RIA ULTICARE INSULIN ULTICARE MICRO PEN LUBRICATED/SPERMICIDE SYRINGE/1ML/30G X NEEDLES/32G X 5/32" 120 78 5/16" 119 ULTICARE MINI PEN NEEDLES TRUVADA 47 ULTICARE INSULIN 31GX6MM 120 TURALIO 40 SYRINGE/SHORT/0.3ML/30G ULTICARE MINI PEN NEEDLES X 5/16" 119 ULTI-FINE IV 120 TWINRIX 143 ULTICARE INSULIN ULTICARE MINI PEN TWYNSTA 33 SYRINGE/SHORT/0.3ML/31G NEEDLES/31G X 6MM 120 TYBLUME 54 X 5/16" 119 ULTICARE MINI PEN NEEDLES/32G X 1/4" 120 TYBOST 47 ULTICARE INSULIN SYRINGE/SHORT/0.5ML/30G ULTICARE MINI PEN TYGACIL 138 X 5/16" 119 NEEDLES31GX6MM 120 TYKERB 40 ULTICARE INSULIN ULTICARE ORIGINAL PEN TYLENOL/CODEINE #3 9 SYRINGE/SHORT/0.5ML/31G NEEDLES ULTI-FINE 120 X 5/16" 119 ULTICARE PEN NEEDLES TYLENOL/CODEINE #4 9 ULTICARE INSULIN 31GX 5MM 120 TYMLOS 67 SYRINGE/SHORT/1ML/30G X ULTICARE PEN NEEDLES TYSABRI 136 5/16" 119 31GX 5MM/MINI 120 ULTICARE PEN UCERIS 10 ULTICARE INSULIN SYRINGE/SHORT/1ML/31G X NEEDLES/29GX 12.7MM 120 UDENYCA 75 5/16" 119 ULTICARE SHORT PEN ULESFIA 65 ULTICARE INSULIN NEEDLES 31GX8MM 120 ULTICARE SHORT PEN ULORIC 73 SYRINGE/U-100/0.3ML/30G X 1/2" 119 NEEDLES ULTI-FINE IV 120 ULTI-LANCE AUTOMATIC/ ULTICARE SHORT PEN CLEAR TIP 90 ULTICARE INSULIN SYRINGE/U-100/0.3ML/31G X NEEDLES/31G X 8MM 120 ULTICARE INSULIN SAFETY ULTIGUARD SYRINGE/0.5ML/29G X 5/16" 119 ULTICARE INSULIN SAFEPACK/MICROPEN 1/2" 119 NEEDLE/32G X 5/32"/SHARPS ULTICARE INSULIN SAFETY SYRINGE/U-100/0.5ML/30G X 1/2" 119 CONTA 120 SYRINGE/1ML/29G X 1/2" 119 ULTIGUARD SAFEPACK/MINI ULTICARE INSULIN ULTICARE INSULIN SYRINGE/U-100/0.5ML/31G X PEN NEEDLE/31G X SYRINGE/0.3ML/29G X 1/4"/SHARPS CONTAIN 120 1/2" 119 5/16" 119 ULTICARE INSULIN ULTIGUARD SAFEPACK/MINI ULTICARE INSULIN PEN NEEDLE/31G X SYRINGE/0.3ML/30G X SYRINGE/U-100/1ML/30G X 1/2" 119 3/16"/SHARPS CONTAI 120 1/2" 119 ULTIGUARD SAFEPACK/MINI ULTICARE INSULIN ULTICARE INSULIN SYRINGE/U-100/1ML/31G X PEN NEEDLE/32G X SYRINGE/0.3ML/30G X 1/4"/SHARPS CONTAIN 120 5/16" 119 5/16" 119 ULTICARE INSULIN ULTIGUARD ULTICARE INSULIN SAFEPACK/SHORTPEN SYRINGE/0.5ML/28G X SYRINGEULTRAFINE U- 100/0.3ML/31G X 5/16" 119 NEEDLE/31G X 5/16"/SHARPS 1/2" 119 CONTA 120 ULTICARE INSULIN ULTICARE INSULIN SYRINGEULTRAFINE U- ULTILET CLASSIC SYRINGE/0.5ML/29G X LANCETS 90 1/2" 119 100/0.5ML/31G X 5/16" 119 ULTICARE INSULIN ULTILET INSULIN ULTICARE INSULIN SYRINGE/0.3ML/30G X SYRINGE/0.5ML/30G X SYRINGEULTRAFINE U- 100/1ML/31G X 5/16" 119 8MM 120 1/2" 119 ULTILET INSULIN ULTICARE INSULIN ULTICARE MICRO PEN NEEDLES 31G X 8MM 120 SYRINGE/0.3ML/31G X SYRINGE/0.5ML/30G X 8MM 120 5/16" 119 ULTICARE MICRO PEN ULTICARE INSULIN NEEDLES 32G X 4MM 120 SYRINGE/1ML/28G X 1/2" 119

Index 37 ULTILET INSULIN ULTRA THIN LANCETS ULTRA-THIN II INSULIN SYRINGE/0.5ML/30G X 31G 90 SYRINGE/U- 8MM 120 ULTRA THIN PEN NEEDLES 100/0.5ML/29GX1/2" 122 ULTILET INSULIN 32G X 4MM 121 ULTRA-THIN II INSULIN SYRINGE/1ML/30G X 8MM120 ULTRA-CARE LANCETS SYRINGE/U-100/1ML/29GX1/2" ULTILET INSULIN 30G 90 122 SYRINGE/1ML/31G X 8MM120 ULTRA-COMFORT INSULIN ULTRA-THIN II LANCETS ULTILET INSULIN SYRINGE/U-100/0.3ML/29G X 28G 90 SYRINGE/SHORT/0.3ML/30G X 1/2" 121 ULTRA-THIN II LANCETS 12.7MM 121 ULTRA-COMFORT INSULIN 30G 90 ULTILET INSULIN SYRINGE/U-100/0.3ML/30G X ULTRA-THIN II MINI PEN SYRINGE/SHORT/0.3ML/30G X 5/16" 121 NEEEDLES/31GX3/16" 122 5/16" 121 ULTRA-COMFORT INSULIN ULTRA-THIN II PEN NEEDLES ULTILET INSULIN SYRINGE/U-100/0.3ML/31G X 29GX1/2" 122 SYRINGE/SHORT/0.3ML/31G X 5/16" 121 ULTRA-THIN II PEN 5/16" 121 ULTRA-COMFORT INSULIN NEEDLES/SHORT/31GX5/16" ULTILET INSULIN SYRINGE/U-100/0.5ML/28G X 122 SYRINGE/SHORT/0.5ML/30G X 1/2" 121 ULTRACARE INSULIN 5/16" 121 ULTRA-COMFORT INSULIN SYRINGE/U-100/0.3ML/30G X ULTILET INSULIN SYRINGE/U-100/0.5ML/29G X 5/16" 122 SYRINGE/SHORT/0.5ML/31G X 1/2" 121 ULTRACARE INSULIN 5/16" 121 ULTRA-COMFORT INSULIN SYRINGE/U-100/0.3ML/31G X ULTILET INSULIN SYRINGE/U-100/0.5ML/30G X 5/16" 122 SYRINGE/SHORT/1ML/30G X 5/16" 121 ULTRACARE INSULIN 5/16" 121 ULTRA-COMFORT INSULIN SYRINGE/U-100/0.5ML/30G X ULTILET INSULIN SYRINGE/U-100/0.5ML/31G X 1/2" 122 SYRINGE/SHORT/1ML/31G X 5/16" 121 ULTRACARE INSULIN 5/16" 121 ULTRA-COMFORT INSULIN SYRINGE/U-100/0.5ML/30G X ULTILET INSULIN SYRINGE/U- SYRINGE/U-100/1ML/28G X 5/16" 122 100/0.5ML/30G X 1/2" 121 1/2" 121 ULTRACARE INSULIN ULTILET INSULIN SYRINGE/U- ULTRA-COMFORT INSULIN SYRINGE/U-100/0.5ML/31G X 100/1ML/30G X 1/2" 121 SYRINGE/U-100/1ML/29G X 5/16" 122 ULTILET LANCETS 90 1/2" 121 ULTRACARE INSULIN ULTILET LANCETS 33G 90 ULTRA-COMFORT INSULIN SYRINGE/U-100/1ML/30G X SYRINGE/U-100/1ML/30G X 1/2" 122 ULTILET PEN NEEDLE 5/16" 122 ULTRACARE INSULIN 29GX12.7MM 121 ULTILET PEN NEEDLE ULTRA-COMFORT INSULIN SYRINGE/U-100/1ML/30G X SYRINGE/U-100/1ML/31G X 5/16" 122 31GX5MM 121 ULTRACARE INSULIN ULTILET PEN NEEDLE 5/16" 122 31GX8MM 121 ULTRA-THIN II AUTO SYRINGE/U-100/1ML/31G X LANCET 90 5/16" 122 ULTILET PEN NEEDLE ULTRA-THIN II INSULIN ULTRACARE PEN 32GX4MM 121 ULTILET PEN NEEDLE SYRINGE SHORT/U- NEEDLES/31G X 1/4" 122 32GX4MM/SHORT 121 100/0.3ML/30GX5/16" 122 ULTRACARE PEN ULTRA-THIN II INSULIN NEEDLES/31G X 3/16" 122 ULTILET SAFETY LANCETS ULTRACARE PEN 21G X 2.2MM 90 SYRINGE SHORT/U- 100/0.3ML/31GX5/16" 122 NEEDLES/31G X 5/16" 122 ULTILET SAFETY LANCETS ULTRACARE PEN 23G 90 ULTRA-THIN II INSULIN SYRINGE SHORT/U- NEEDLES/32G X 1/14" 122 ULTILET SHORT PEN ULTRACARE PEN NEEDLES 31GX5/16" 121 100/0.5ML/30GX5/16" 122 ULTRA-THIN II INSULIN NEEDLES/32G X 3/16" 122 ULTILET SHORT PEN ULTRACARE PEN NEEDLES31GX3/16" 121 SYRINGE SHORT/U- ULTRA COMFORT INSULIN 100/0.5ML/31GX5/16" 122 NEEDLES/32G X 5/32" 122 SYRINGE/U-100/0.3ML/30G X ULTRA-THIN II INSULIN ULTRACET 9 5/16" 121 SYRINGE SHORT/U- ULTRAM 8 100/1ML/30GX5/16" 122 ULTRA FLO INSULIN PEN ULTRAVATE 64 NEEDLES 121 ULTRA-THIN II INSULIN ULTRA FLO INSULIN SYRINGE SYRINGE SHORT/U- UNASYN 134 0.3ML/29G X 1/2" 121 100/1ML/31GX5/16" 122 UNASYN BULK PACK 134

Index 38 UNIFINE PENTIPS UNISTIK TOUCH SAFETY VALUMARK PEN NEEDLES 29GX12MM 122 LANCETS 28G 91 31GX 8MM 123 UNIFINE PENTIPS 31G X UNISTIK TOUCH SAFETY VANCOCIN 11 3/16" 122 LANCETS 30G 91 VANCOCIN HCL 11 UNIFINE PENTIPS UNIVERSAL 1 LANCETS 31GX5MM 123 THIN26G 91 vancomycin hcl 11 UNIFINE PENTIPS UNIVERSAL 1 LANCETS VANCOMYCIN 31GX6MM 123 ULTRA THIN 30G 91 HYDROCHLORIDE 11 UNIFINE PENTIPS UNIVERSAL 1 VANISHPOINT INSULIN 31GX8MM 123 LANCETS/33G/MICRO-THIN SYRINGE/0.5ML/30G X UNIFINE PENTIPS 91 1/2" 123 32GX4MM 123 URECHOLINE 141 VANISHPOINT INSULIN SYRINGE/0.5ML/30G X UNIFINE PENTIPS UROCIT-K 10 72 32GX6MM 123 5/16" 123 UNIFINE PENTIPS PLUS UROXATRAL 73 VANISHPOINT INSULIN 29GX12MM 123 URSO 250 71 SYRINGE/1ML/29G X 1/2" 123 UNIFINE PENTIPS PLUS URSO FORTE 71 VANISHPOINT INSULIN 31GX5MM 123 SYRINGE/1ML/30G X UNIFINE PENTIPS PLUS ursodiol 71 5/16" 123 31GX6MM 123 UTIBRON NEOHALER 16 VAQTA 143 UNIFINE PENTIPS PLUS VAGIFEM 144 VARIVAX 143 31GX8MM 123 UNIFINE PENTIPS PLUS valacyclovir hcl 48 VARUBI 28 32GX4MM 123 VALCYTE 47 VASCEPA 30 UNIFINE SAFECONTROL PEN valganciclovir hcl 47 VASERETIC 34 NEEDLE/30G X 5/16" 123 VALIUM 13 UNILET COMFORTOUCH VASOTEC 31 LANCET 90 valproate sodium 21 VECAMYL 34 UNILET EXCELITE 90 valproic acid 21 VECTIBIX 37 UNILET EXCELITE II 90 valrubicin 38 VECTICAL 61 UNILET G.P. LANCET 90 valsartan 32 VELCADE 40 UNILET G.P. SUPERLITE valsartan-hydrochlorothiazide VELPHORO 72 33 LANCET 90 VEMLIDY 48 UNILET GP 28 ULTRA THIN90 VALSTAR 39 venlafaxine hcl 23 UNILET LANCET 90 VALTOCO 18 VENTAVIS 51 UNILET LANCETS MICRO- VALTREX 48 THIN33G 90 VALUE HEALTH INSULIN VENTOLIN HFA 16 UNILET LANCETS SUPER- SYRINGE/U-100/0.5ML/29G X verapamil hcl 50 THIN30G 90 1/2" 123 VEREGEN 58 UNILET LANCETS ULTRA-THIN VALUE HEALTH INSULIN VERELAN 50 28G 90 SYRINGE/U-100/1ML/29G X UNILET SUPERLITE 1/2" 123 VERELAN PM 50 LANCET 91 VALUE PLUS LANCETS VERIPRED 20 55 UNISTIK 3 GENTLE 91 STANDARD 21G 91 VESICARE 141 VALUE PLUS LANCETS UNISTIK PRO SAFETY LANCET VFEND 28 21G 91 SUPERTHIN 30G 91 UNISTIK PRO SAFETY LANCET VALUE PLUS LANCETS THIN VIAGRA 51 25G 91 26G 91 VIBRAMYCIN 138 UNISTIK PRO SAFETY LANCET VALUE PLUS LANCING VICTOZA 25 28G 91 DEVICE 91 VALUMARK LANCET SUPER VIDA MIA AUTOLET UNISTIK SAFETY LANCETS LANCINGDEVICE 91 28G 91 THIN 30G 91 VALUMARK LANCET ULTRA VIDA MIA UNIFINE UNISTIK SAFETY LANCETS PENTIPS32GX4MM 123 30G 91 THIN 28G 91 VALUMARK PEN NEEDLES VIDA MIA UNIFINE UNISTIK TOUCH SAFETY PENTIPSMINI 31GX6MM 123 LANCETS 21G 91 29GX12MM 123 UNISTIK TOUCH SAFETY VALUMARK PEN NEEDLES LANCETS 23G 91 31GX 6MM 123

Index 39 VIDA MIA UNIFINE VYNDAMAX 51 XARELTO 16 PENTIPSORIGINAL VYNDAQEL 52 XARELTO STARTER PACK 16 29GX12MM 123 VIDA MIA UNILET LANCETS VYTORIN 30 XELJANZ 4 SUPER THIN 30G 91 VYVANSE 1 XELJANZ XR 4 VIDA MIA UNILET LANCETS WALGREENS ADVANCED XELODA 37 ULTRA THIN 28G 91 TRAVELLANCETS 28G 91 XENAZINE 136 VIDA MIA UNIPFINE WALGREENS COMFORT PENTIPSSHORT ASSUREDLANCETS MICRO XEOMIN 130 31GX8MM 123 THIN/33G 91 XGEVA 67 VIDAZA 37 WALGREENS COMFORT XIFAXAN 11 VIDEX EC 47 ASSUREDLANCETS SUPER THIN/28G 91 XIGDUO XR 24 VIDEXPEDIATRIC 47 WALGREENS LANCETS 91 XIMINO 138 vigabatrin 20 WALGREENS THIN XOLAIR 14 VIGAMOX 131 LANCETS 91 XOPENEX 16 VIIBRYD 23 WALGREENS ULTRA THIN XOPENEX CONCENTRATE 16 VIIBRYD STARTER PACK 23 LANCETS 91 warfarin sodium 16 XOPENEX HFA 16 VIMPAT 20 water for irrigation, sterile 127 XOSPATA 40 vincristine sulfate 41 WEGMANS UNIFINE PENTIPS XPOVIO 100 MG ONCE vinorelbine tartrate 41 PLUS 32GX4MM 123 WEEKLY 38 VIRACEPT 47 WEGMANS UNIFINE PENTIPS XPOVIO 60 MG ONCE WEEKLY 38 VIRAMUNE 47 PLUS/MINI/31GX5MM 123 WEGMANS UNIFINE PENTIPS XPOVIO 80 MG ONCE VIRAMUNE XR 47 PLUS/SHORT/31GX8MM123 WEEKLY 38 VIREAD 47 WEGMANS UNIFINE PENTIPS XPOVIO 80 MG TWICE WEEKLY 38 VIROPTIC 131 PLUS/ULTRA XTAMPZA ER 8 VISTARIL 13 SHORT/31GX6MM 123 WELCHOL 30 XTANDI 38 VISTOGARD 27 WELLBUTRIN SR 21 XULTOPHY 100/3.6 24 VITALET PRO LANCETS 91 XYLOCAINE 76 VITALET PRO PLUS WELLBUTRIN XL 21 LANCETS 91 WESTAB PLUS 129 XYLOCAINE-MPF 76 VITAMIN D2 144 WESTHROID 138 XYREM 135 VITATHELY/GINGER 129 WIDE-SEAL SILICONE XYZAL ALLERGY 24HR 29 VITRAKVI 40 DIAPHRAGM KIT 60 78 XYZAL ALLERGY 24HR WIDE-SEAL SILICONE CHILDRENS 29 VIVAGUARD LANCETS 91 DIAPHRAGM KIT 65 78 YASMIN 28 54 VIVAGUARD LANCING WIDE-SEAL SILICONE DEVICE 91 DIAPHRAGM KIT 70 78 YAZ 54 VIVELLE-DOT 70 WIDE-SEAL SILICONE YERVOY 37 VIZIMPRO 40 DIAPHRAGM KIT 75 78 YONSA 38 WIDE-SEAL SILICONE ZADITOR 133 VOGELXO 10 DIAPHRAGM KIT 80 78 VOGELXO PUMP 10 WIDE-SEAL SILICONE zafirlukast 14 VOL-PLUS 129 DIAPHRAGM KIT 85 79 zaleplon 75 VOLTAREN 58 WIDE-SEAL SILICONE ZALTRAP 37 DIAPHRAGM KIT 90 79 VORAXAZE 41 WIDE-SEAL SILICONE ZANAFLEX 129 voriconazole 28 DIAPHRAGM KIT 95 79 ZANOSAR 36 VOSEVI 48 WP THYROID 138 ZANTAC 139 VOTRIENT 40 XALATAN 133 ZANTAC 150 MAXIMUM VP INSULIN SYRINGE/U- XALKORI 40 STRENGTH 139 ZARONTIN 20,21 100/0.3ML/29G X 1/2" 123 XANAX 13 ZARXIO 75 VPRIV 74 XANAX XR 13 VUSION 60 ZAVESCA 74

Index 40 ZEGERID 140 ZOSYN 135 ZELBORAF 40 ZOVIRAX 48,61 ZEMAIRA 137 ZURAMPIC 73 ZEMPLAR 69 ZYBAN 137 ZENPEP 66 ZYCLARA 64 ZEPATIER 48 ZYCLARA PUMP 64 ZERIT 47 ZYDELIG 40 ZERVIATE 133 ZYFLO CR 14 ZESTORETIC 34 ZYKADIA 40 ZESTRIL 31 ZYLOPRIM 73 ZETIA 31 ZYMAXID 131 ZIAC 34 ZYPREXA 44 ZIAGEN 47 ZYPREXA ZYDIS 44 ZIANA 58 ZYRTEC ALLERGY 29 zidovudine 47 ZYRTEC CHILDRENS zileuton 14 ALLERGY 30 ZYRTEC-D ZIOPTAN 133 ALLERGY/CONGESTION 56 ziprasidone hcl 43 ZYTIGA 38 ZIRABEV 37 ZYVOX 12 ZIRGAN 131 ZITHROMAX 77 ZITHROMAX TRI-PAK 77 ZITHROMAX Z-PAK 77 ZOCOR 31 ZOFRAN 27 ZOHYDRO ER 8 ZOLADEX 38 zoledronic acid 67 ZOLEDRONIC ACID 67 zoledronic acid 67 ZOLEDRONIC ACID 67 ZOLINZA 40 zolmitriptan 125 ZOLOFT 23 zolpidem tartrate 76 ZOMACTON 68 ZOMETA 67,68 ZOMIG 125 ZOMIG ZMT 125 ZONALON 60 ZONEGRAN 20 zonisamide 20 ZONTIVITY 74 ZORBTIVE 68 ZORTRESS 127 ZOSTAVAX 143

Index 41 superior~ - FROM I healthplan.

© 2019 Celtic Insurance Company. All rights reserved. AMB19-TX-C-00236 Statement of Non-Discrimination

Ambetter from Superior HealthPlan complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Ambetter from Superior HealthPlan does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Ambetter from Superior HealthPlan:

 Provides free aids and services to people with disabilities to communicate effectively with us, such as:

 Qualified sign language interpreters  Written information in other formats (large print, audio, accessible electronic formats, other formats)

 Provides free language services to people whose primary language is not English, such as:

 Qualified interpreters  Information written in other languages

If you need these services, contact Ambetter from Superior HealthPlan at 1-877-687-1196 (Relay Texas/TTY: 1-800-735-2989).

If you believe that Ambetter from Superior HealthPlan has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Superior HealthPlan Complaint Department, 5900 E Ben White Blvd., Austin, TX 78741, 1-877-687-1196 (Relay Texas/TTY: 1-800-735-2989), Fax 1-866-683-5369. You can file a grievance by mail, fax, or email. If you need help filing a grievance, Ambetter from Superior HealthPlan is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 800-537-7697 (TDD).

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

AMB18-TX-C-00019 © 2018 Celtic Insurance Company. All rights reserved.

Si usted, o alguien a quien está ayudando, tiene preguntas acerca de Ambetter from Superior HealthPlan, tiene derecho a obtener Spanish: ayuda e informacin en su idioma sin costo alguno. Para hablar con un intérprete, llame al 1-877-687-1196 (Relay Texas/TTY 1-800-735-2989).

Nếu qu vị, hay người mà qu vị đang giúp đỡ, c câu hỏi về Ambetter from Superior HealthPlan, qu vị sẽ c quyền được gip và c Vietnamese: thêm thng tin bằng ngn ngữ của mình miễn phí. Để ni chuyện với một thng dịch viên, xin gọi 1-877-687-1196 (Relay Texas/TTY 1-800-735-2989).

如果您，或是您正在協助的對象，有關於 Ambetter from Superior HealthPlan 方面的問題，您有權利免費以您的母語得到幫助和訊息。如 Chinese: 果要與一位翻譯員講話，請撥電話 1-877-687-1196 (Relay Texas/TTY 1-800-735-2989)。

만약 귀하 또는 귀하가 돕고 있는 어떤 사람이 Ambetter from Superior HealthPlan 에 관해서 질문이 있다면 귀하는 그러한 도움과 정보를 Korean: 귀하의 언어로 비용 부담없이 얻을 수 있는 권리가 있습니다. 그렇게 통역사와 얘기하기 위해서는 1-877-687-1196 (Relay Texas/TTY 1-800-735-2989) 로 전화하십시오 . ذإ ا كان دل يك أ و لدى شخص عتسا ده ئأس لة حول Ambetter from Superior HealthPlan ، دل يك فيحلا ق لا حصول على عساملا دة ماولعملاو ت ا رورضل ية تكغلب من Arabic: ود ن يةأ كت لفة . دحتلل ث م ع تم رجم تا صل ـب Relay Texas/TTY 1-800-735-2989) 1-877-687-1196) .

رگا Ambetter from Superior HealthPlan کے رےبا آںیم پ، یا نج کی کددمپآ ررہے ناںیہ کے س و،تںوہتالاو وکپآ ضہوعامبال نیپا رواددمںیمنباز تامولعم حاصل کرنے کا ہےح ۔ق کسی مجرتم سے تبا کرنے ےک لیے، Relay Texas/TTY 1-800-735-2989 )، 1-877-687-1196) رپ کال ۔ںیرک :Urdu

Kung ikaw, o ang iyong tinutulangan, ay may mga katanungan tungkol sa Ambetter from Superior HealthPlan, may karapatan ka na Tagalog: makakuha nang tulong at impormasyon sa iyong wika ng walang gastos. Upang makausap ang isang tagasalin, tumawag sa 1-877-687-1196 (Relay Texas/TTY 1-800-735-2989).

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आप या जिसकी आप मदद कर रहे हℂ उनके , Ambetter from Superior HealthPlan के बारे मᴂ कोई सवाल हⴂ, तो आपको बबना ककसी ख셍च के Hindi: अपनी भाषा मᴂ मदद और िानकारी प्राꥍत करने का अधिकार है। ककसी दभाषषयेु से बात करने के ललए 1-877-687-1196 (Relay Texas/TTY 1-800-735-2989) पर कॉल करᴂ। رگا ما،ش يا کسي که به او ک مک مي کنيد لياؤس در دروم Ambetter from Superior HealthPlan يد،راد از نيا حق ديرادروخرب که مکک و تعاطالا را تروصب Persian: نايگار به نباز دوخ افيرد ت کنيد۔ رب اي تبحص ندرک با مجرتم با ش ماره Relay Texas/TTY 1-800-735-2989) 1-877-687-1196) سمات ديريگب ۔

Falls Sie oder jemand, dem Sie helfen, Fragen zu Ambetter from Superior HealthPlan hat, haben Sie das Recht, kostenlose Hilfe und German: Informationen in Ihrer Sprache zu erhalten. Um mit einem Dolmetscher zu sprechen, rufen Sie bitte die Nummer 1-877-687-1196 (Relay Texas/TTY 1-800-735-2989) an.

狇 તમને અથવા તમે 狇મની મદદ કરી રહ્યા હોય તેમને, Ambetter from Superior HealthPlan વવશે કોઈ પ્રશ્ન હોય તો તમને, કોઈ ખર્ચ વવના તમારી Gujarati: ભાષામા廒 મદદ અને માહહતી પ્રા꫍ત કરવાનો અવિકાર છે. દુ ભાવષયા સાથે વાત કરવા માટે 1-877-687-1196 (Relay Texas/TTY 1-800-735-2989) ઉપર કૉલ કરો. В случае возникновения у вас или у лица, которому вы помогаете, каких-либо вопросов о программе страхования Ambetter from Russian: Superior HealthPlan вы имеете право получить бесплатную помощь и информацию на своем родном языке. Чтобы поговорить с переводчиком, позвоните по телефону 1-877-687-1196 (Relay Texas/TTY 1-800-735-2989).

Ambetter from Superior HealthPlan について何かご質問がございましたらご連絡ください。 ご希望の言語によるサポートや情報を無料でご提供いたしま Japanese: す。 通訳が必要な場合は、1 -877-687-1196 (Relay Texas/TTY 1-800-735-2989) までお電話ください。

່ Ambetter from Superior HealthPlan, ່ ້ Laotian: ຖ້າທານ່ ຫ ຄົ ນທ ທ່ ານກາລງຊວຍເຫອໍ ັ ່  ມຄາຖາມໍ ກຽວກບ່ ັ ທານ່ ມສດິ ທຈະໄດ້ຮັ ບການຊວຍເຫອ່  ແລະໍຂມູ ນ ຂ່າວສານ ່ທເປັນພາສາຂອງທ່ານ ໂດຍບໍ່ ມຄ່າໃຊ້ຈ່າຍ. ເພອຈະ່ ເວົ້າກັ ບນາຍພາສາ, ໃຫ້ໂທຫາ 1-877-687-1196 (Relay Texas/TTY 1-800-735-2989).

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