Plan for your best health

2020 Pharmacy Drug Guide Advanced Control Plan

Aetna.com Health benefits and health insurance plans are offered, administered and/or underwritten by Aetna Health Inc., Aetna Health Insurance Company of New York, Aetna HealthAssurance Pennsylvania Inc., Aetna Health Insurance Company and/or Aetna Life Insurance Company (Aetna). In Florida, by Aetna Health Inc. and/or Aetna Life Insurance Company. In Utah and Wyoming by Aetna Health of Utah Inc. and Aetna Life Insurance Company. In Maryland, by Aetna Health Inc., 151 Farmington Avenue, Hartford, CT 06156. Each insurer has sole financial responsibility for its own products. 2021 Pharmacy Drug Guide - Advanced Control Plan

Table of Contents

INFORMATIONAL SECTION...... 4 ANALGESICS - DRUGS TO TREAT PAIN AND INFLAMMATION...... 14 ANESTHETICS - DRUGS FOR NUMBING...... 23 ANTI-INFECTIVES - DRUGS TO TREAT INFECTIONS...... 24 ANTINEOPLASTIC AGENTS - DRUGS TO TREAT CANCER...... 36 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES...... 45 CARDIOVASCULAR - DRUGS TO TREAT HEART AND CIRCULATION CONDITIONS...... 45 CENTRAL NERVOUS SYSTEM - DRUGS TO TREAT NERVOUS SYSTEM DISORDERS...... 58 ENDOCRINE AND METABOLIC - DRUGS TO TREAT DIABETES AND REGULATE HORMONES...... 83 GASTROINTESTINAL - DRUGS TO TREAT STOMACH AND INTESTINAL DISORDERS...... 113 GENITOURINARY - DRUGS TO TREAT GENITAL AND URINARY TRACT CONDITIONS...121 HEMATOLOGIC - DRUGS TO TREAT BLOOD DISORDERS...... 125 IMMUNOLOGIC AGENTS - DRUGS TO TREAT DISORDERS OF THE IMMUNE SYSTEM.....136 MEDICAL DEVICES...... 143 NUTRITIONAL/SUPPLEMENTS - VITAMINS AND SUPPLEMENTS...... 189 OPHTHALMIC - DRUGS TO TREAT EYE CONDITIONS...... 201 OTHER...... 207 RESPIRATORY - DRUGS TO TREAT BREATHING DISORDERS...... 207 TOPICAL - DRUGS TO TREAT EAR AND SKIN CONDITIONS...... 217

TOC-3 How to use this guide

Your guide includes a list of commonly used drugs covered on your pharmacy plan. The amount you pay depends on the drug your doctor prescribes. It’s either a flat fee or a percentage of the prescription’s price after you meet your deductible, if applicable. Preferred generic drugs cost less. Preferred brand drugs will have a higher cost.

Your plan includes You’re covered for all types of medicine — some more expensive, and some less. • Brand and generic drugs that are hand-picked for their quality and effectiveness • Generic: the lowest cost • A specialty pharmacy that fills specialty prescriptions • Preferred brand: a slightly higher cost (ones that are injected, infused or taken by mouth) — • Non-preferred brand: a higher cost and provides services that include personal • Preferred Specialty: lower cost for specialty drugs support, helpful resources and training, and free secure home delivery • Non-preferred Specialty: higher cost for non-preferred specialty drugs • A home delivery pharmacy that delivers maintenance drugs to your home or wherever Your pharmacy plan may not have all the coverage levels you choose (for drugs that are taken regularly to listed above so check your plan documents to see how treat conditions like diabetes or asthma) much you will pay.

What you can expect to pay For your exact coverage and cost, and to learn more about your plan With your pharmacy plan, the amount you pay depends on the drug your doctor prescribes. It’s either a flat fee or Visit the website that’s on your member ID card. a percentage of the drug’s/medicine’s price. Then log in to your account, where you can:

Each drug is grouped as a generic, a brand or a • Find out the coverage* and estimate of cost for specialty drug. The preferred drugs within these specific drugs groups will generally save you money compared • View your deductibles and plan limits to a non-preferred drug. Typically, generic drugs • Order medications are less expensive than brands. • Check your pharmacy order status Specialty prescription drugs typically include higher-cost • Get a member ID card drugs that require special handling, special storage or • View your claims, Explanation of Benefits and more. monitoring. These types of drugs may include, but are not limited to, drugs that are injected, infused, inhaled or taken by mouth.

* Check your plan documents for coverage information. Your plan may not cover certain drugs such as infertility, erectile dysfunction, weight loss and smoking cessation.

1 Have more questions about your CVS Caremark Mail Service Pharmacy™ pharmacy benefits? You can have maintenance drugs sent right to your home We’re here to help. There are several ways you can or anywhere else you choose by CVS Caremark Mail learn more about your benefits: Service Pharmacy. These are drugs that are taken regularly for chronic conditions like diabetes or asthma. • Check your Plan Design and Benefits Summary in Depending on your plan, you can get up to a 90-day your enrollment kit. supply of medicine for less cost. It’s fast and convenient, • Call the toll-free number on your member ID card. and standard shipping is always free. • Review our pharmacy frequently asked questions (FAQs) and answers. Just visit the website that’s on Get started right away your member ID card to search for the “Pharmacy FAQ.” You can submit your order using one of these options:

Specialty Pharmacy Network 1. Online — Visit your secure member website and An in-network specialty pharmacy can fill your sign in to your account. There you can add or prescriptions for specialty drugs. These are the types remove your prescriptions. of drugs that may be injected, infused or taken by mouth. 2. Phone — Call us toll-free, 24/7 at 1-888-792-3862. They often need special storage and handling. And they If you need the help of a telephone device for the need to be delivered quickly. A nurse or pharmacist may hard of hearing, call 1-877-833-2779. monitor you during your treatment, if needed. With this type of pharmacy, you can get 3. Mail — Get a new prescription from your doctor. Then this medicine sent right to your home. mail it to us with a completed order form. You can find the form on your secure member website. The mailing address is on the form. How to get started with a specialty pharmacy

Ordering your prescriptions through our specialty Your doctor can submit your order using one of pharmacy is easy. And we typically offer a 30-day these options: medicine supply. 1. Online — They can submit your prescriptions using • To transfer your prescription, just call us toll-free the e-prescribe services on our provider website. at 1-866-353-1892. 2. Fax — They can fax your prescription to • For a new prescription, your doctor can send it to 1-877-270-3317. Make sure they include your member us in one of four ways: ID number, date of birth and mailing address on the 1. Electronically: Through e-prescribe fax cover sheet. Only a doctor may fax a prescription. 2. Fax: 1-800-323-2445

3. Phone: 1-800-237-2767

If you mail in your own prescription, please send it with a completed Patient Profile Form. To find this form, just visit the website that’s on your member ID card, to search for the “Patient Profile Form.”

2 Frequently asked questions

How can I save on prescriptions? What is step therapy?

Here are some tips to pay less out of pocket for your Some drugs require step therapy. This means that prescription drugs: you must try one or more prerequisite drug(s) before a step therapy drug is covered. • Ask your doctor to consider prescribing drugs that are on the Pharmacy Drug Guide (formulary). The prerequisite drugs have U.S. Food and Drug • Ask your doctor to consider prescribing generic Administration (FDA) approval and may cost less. They drugs instead of brand-name drugs. treat the same condition as the step therapy drug. • Our home delivery pharmacy may save you money. If you don’t try the appropriate prerequisite drug first, you For more information, visit the website on your may need to pay full cost for the step-therapy drug. member ID card and log in to your account. What are quantity limits? What are generic drugs? Quantity limits help your doctor and pharmacist make Generic drugs are proven to be just as safe and effective sure that you use your drug correctly and safely. We use as brand-name drugs. They contain the same active medical guidelines and FDA-approved recommendations ingredients in the same amounts as the brand-name from drug makers to set these coverage limits. The drugs and work the same way. So they have the same quantity limit program includes: risks and benefits as brand-name drugs. However, they • Dose efficiency edits — Limits prescription coverage typically cost less. to one dose per day for drugs that have approval for When appropriate, your doctor may decide to prescribe once-daily dosing a generic drug or allow the pharmacist to substitute a • Maximum daily dose — If a prescription is lower than generic drug. the minimum or higher than the maximum allowed dose, a message is sent to the pharmacy What is precertification? • Quantity limits over time — Limits prescription Precertification is one way that we can help you and your coverage to a specific number of units over a specific doctor find safe, appropriate drugs and keep costs down. amount of time Precertification means that you or your doctor need to get approval from the plan before certain drugs will be What if I need a drug that requires an exception covered. Generally, precertification applies to drugs that: to the precertification, step therapy or quantity • Are often taken in the wrong way limits requirements? Or what if I need a drug that’s not covered under my plan? • Should only be used for certain conditions • Often cost more than other drugs that are proven In certain cases, you or your prescriber can request a to be just as effective medical exception to the precertification, step therapy or quantity limits requirements or for a drug that’s not Keep in mind that your doctor must contact us to request covered on your plan. You can ask for your request to be approval of coverage for these drugs. expedited. Expedited coverage decisions are made within 24 hours.

We’ll then contact you or your prescriber with our decision. All medically necessary outpatient prescription drugs will be covered. If a medical exception is approved, you only need to pay the copay after the deductible. This amount is based on your pharmacy plan design.

3 How can your provider request a medical Can the formulary change during the year? exception? The formulary can change throughout the year. • Submit their request through our secure provider Some reasons why it can change include: website on www.availity.com. • New drugs are approved. • Call the Aetna Pharmacy Precertification Unit: • Existing drugs are removed from the market. Non-Specialty 1-800-294-5979 or Specialty 1-866-814-5506. • Prescription drugs may become available over the counter (without a prescription). Over-the-counter drugs • Fax the completed request form to: are not generally covered in a formulary. Non-Specialty 1-888-836-0730 or Specialty 1-866-249-6155. • Brand-name drugs lose patent protection and generic versions become available. When this happens, the • Mail the completed request form to: generic drug will be covered in place of the brand- Aetna Pharmacy Management name drug. The brand-name drug is likely to become 1300 East Campbell Road non-formulary or covered at a higher cost. See the Richardson, TX 75081 “What are generic drugs?” section above for more information. Pharmacy and Therapeutics (P&T) committee

The services of an independent National Pharmacy and Therapeutics Committee (“P&T Committee”) are utilized to approve safe and clinically effective drug therapies. The P&T Committee is an external advisory body of clinical professionals from across the United States. The P&T Committee’s voting members include physicians, pharmacists, a pharmacoeconomist and a medical ethicist, all of whom have a broad background of clinical and academic expertise regarding prescription drugs. Voting members of the P&T Committee are not employees of CVS Caremark and must disclose any financial relationship or conflicts of interest with any pharmaceutical manufacturers.

4 Commercial 1557 Nondiscrimination Notice

Aetna complies with applicable Federal civil rights laws and does not discriminate, exclude or treat people differently based on their race, color, national origin, sex, age, or disability.

Aetna provides free aids/services to people with disabilities and to people who need language assistance.

If you need a qualified interpreter, written information in other formats, translation or other services, call the number on your ID card.

If you believe we have failed to provide these services or otherwise discriminated based on a protected class noted above, you can also file a grievance with the Civil Rights Coordinator by contacting:

Civil Rights Coordinator, P.O. Box 14462, Lexington, KY 40512 (CA HMO customers: PO Box 24030 Fresno, CA 93779), 1-800-648-7817, TTY: 711, Fax: 859-425-3379 (CA HMO customers: 860-262-7705), [email protected].

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or at:

U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, or at 1-800-368-1019, 800-537-7697 (TDD).

Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna Life Insurance Company and their affiliates (Aetna).

5 6 7 8 9 Remember to visit the website on your member ID card. Then sign in to your account for the most up-to-date information.

Please note that if your prescription drug benefits plan changes, the information here may no longer apply. Medications on the Aetna Drug Guide, precertification, step-therapy and quantity limits lists are subject to change. Not all health services are covered. Your plan may not cover certain drugs such as infertility, erectile dysfunction, weight loss and smoking cessation. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by location and are subject to change. The drugs on the Pharmacy Drug Guide (formulary), Formulary Exclusions, Precertification, and Quantity Limit Lists are subject to change. The quantity limits and step therapy drug coverage review programs are not available in all service areas. However, these programs are available to self-funded plans. In accordance with state law, commercial fully insured members in Louisiana and Texas (except Federal Employee Health Benefit Plan members) who are receiving coverage for medications that are added or removed from the Pharmacy Drug Guide (formulary), Precertification, Quantity Limits or Step-Therapy Lists during the plan year will continue to have those medications covered at the same benefit level until their plan’s renewal date. In Texas, precertification approval is known as “pre-service utilization review.” It is not “verification” as defined by Texas law. In accordance with state law, certain fully insured commercial California members (except Federal Employee Health Benefit Plan members) who obtained approval from an Aetna plan for coverage of drugs that are later added to the Preauthorization or Step Therapy Lists or removed from the Pharmacy Drug Guide will continue to have those drugs covered, for as long as the treating in-network provider continues prescribing them, provided that the drug is appropriately prescribed and is considered safe and effective for treating the enrollee’s medical condition. Aetna reserves the right to periodically request clinical information from your provider to assess your medical condition and the appropriateness of your ongoing treatment. Failure to provide clinical information could result in subsequent denial of coverage for this medication. In accordance with state law, fully insured Commercial Connecticut preferred provider organization (PPO) members (except Federal Employee Health Benefit Plan members) who are receiving coverage for drugs that are added to the Precertification or Step-Therapy Lists will continue to have those drugs covered for as long as the prescriber prescribes them, provided the drug is medically necessary and more medically beneficial than other covered drugs. Nothing in this section shall preclude the prescribing provider from prescribing another drug covered by the plan that is medically appropriate for the enrollee, nor shall anything in this section be construed to prohibit generic drug substitutions. In certain states, including Arkansas, Colorado, Connecticut, Delaware, Georgia, Illinois, Louisiana, Maryland, Minnesota, North Dakota, Pennsylvania and Texas, step therapy programs do not apply to fully insured members utilizing prescription drugs for the treatment of stage-four advanced, metastatic cancer. This material is for information only. It contains only a partial, general description of plan benefits or programs and does not constitute a contract. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by location and are subject to change. Providers are independent contractors and are not agents of Aetna. Provider participation may change without notice. Aetna does not provide care or guarantee access to health services. Information is subject to change. CVS Caremark Mail Service Pharmacy is part of the CVS Health family of companies.

Aetna.com

©2021 Aetna Inc. Drug Tier CE = Copay Exception: Available to some members at no cost with a prescription from your provider when obtained at an in-network pharmacy. Certain limitations Drug Notes may apply. IBC = Indication Based Coverage G = Generics LGC = Lowest Generic Copay NF = Non-formulary, not covered Applies unless exception request granted N8 = Drug Specific Coverage NPB = Non-Preferred Brands SPC = Select Plan Coverage: lowercase italics = Generic drugs NPSP = Non-Preferred Specialty Only available for select plans. UPPERCASE = Brand name PB = Preferred Brands Refer to member plan documents drugs PSP = Preferred Specialty for coverage. Prescription Drug Name Drug Tier Drug Notes ANALGESICS - DRUGS TO TREAT PAIN AND INFLAMMATION COX-2 INHIBITORS CELEBREX ORAL CAPSULE 100 MG, 200 MG, 400 MG, NF 50 MG (celecoxib) celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mg G GOUT - DRUGS TO TREAT GOUT allopurinol oral tablet 100 mg, 300 mg G colchicine oral capsule 0.6 mg G colchicine oral tablet 0.6 mg G colchicine-probenecid oral tablet 0.5-500 mg G COLCRYS ORAL TABLET 0.6 MG (colchicine) NF febuxostat oral tablet 40 mg, 80 mg G KRYSTEXXA INTRAVENOUS SOLUTION 8 MG/ML NPSP (pegloticase) MITIGARE ORAL CAPSULE 0.6 MG (colchicine) PB probenecid oral tablet 500 mg G ULORIC ORAL TABLET 40 MG, 80 MG (febuxostat) NF MISCELLANEOUS RIDAURA ORAL CAPSULE 3 MG (auranofin) NPB NON-OPIOID ANALGESICS ALLZITAL ORAL TABLET 25-325 MG (butalbital- NF acetaminophen) butalbital-apap-caffeine (Bac Oral Tablet 50-325-40 Mg) G butalbital-acetaminophen (Bupap Oral Tablet 50-300 Mg) NF 2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 14 Prescription Drug Name Drug Tier Drug Notes butalbital-acetaminophen oral capsule 50-300 mg G butalbital-acetaminophen oral tablet 50-300 mg NF butalbital-acetaminophen oral tablet 50-325 mg G butalbital-apap-caffeine oral capsule 50-300-40 mg, 50-325-40 NF mg butalbital-apap-caffeine oral tablet 50-325-40 mg G butalbital-aspirin-caffeine oral capsule 50-325-40 mg G butalbital-apap-caffeine (Esgic Oral Capsule 50-325-40 Mg) NF FIORICET ORAL CAPSULE 50-300-40 MG (butalbital- NF apap-caffeine) TENCON ORAL TABLET 50-325 MG (butalbital- G acetaminophen) butalbital-apap-caffeine (Zebutal Oral Capsule 50-325-40 Mg) NF NSAIDS - DRUGS TO TREAT PAIN AND INFLAMMATION CAMBIA ORAL PACKET 50 MG (diclofenac NF potassium(migraine)) dfs dr/ms/menth/cap pak combination kit 75 mg NF diclofenac potassium oral tablet 50 mg G diclofenac sodium er oral tablet extended release 24 hour 100 G mg diclofenac sodium oral tablet delayed release 25 mg, 50 mg, 75 G mg etodolac er oral tablet extended release 24 hour 400 mg, 500 mg, G 600 mg etodolac oral capsule 200 mg, 300 mg G etodolac oral tablet 400 mg, 500 mg G fenoprofen calcium oral capsule 200 mg, 400 mg NF fenoprofen calcium oral tablet 600 mg NF FENORTHO ORAL CAPSULE 200 MG (fenoprofen NF calcium) flurbiprofen oral tablet 100 mg, 50 mg G ibuprofen (Ibu Oral Tablet 400 Mg, 600 Mg, 800 Mg) G ibuprofen oral suspension 100 mg/5ml G ibuprofen oral tablet 400 mg, 600 mg, 800 mg G INDOCIN ORAL SUSPENSION 25 MG/5ML NF (indomethacin)

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 15 Prescription Drug Name Drug Tier Drug Notes INDOCIN RECTAL SUPPOSITORY 50 MG (indomethacin) NF indomethacin er oral capsule extended release 75 mg G indomethacin oral capsule 20 mg NF indomethacin oral capsule 25 mg, 50 mg G ketoprofen er oral capsule extended release 24 hour 200 mg NF ketoprofen oral capsule 25 mg NF ketorolac tromethamine oral tablet 10 mg G LODINE ORAL TABLET 400 MG (etodolac) NF meclofenamate sodium oral capsule 100 mg, 50 mg G mefenamic acid oral capsule 250 mg NF meloxicam oral tablet 15 mg, 7.5 mg G nabumetone oral tablet 500 mg, 750 mg G NALFON ORAL CAPSULE 400 MG (fenoprofen calcium) NPB NAPRELAN ORAL TABLET EXTENDED RELEASE 24 NF HOUR 375 MG, 500 MG, 750 MG (naproxen sodium) NAPROSYN ORAL SUSPENSION 125 MG/5ML NF (naproxen) naproxen oral suspension 125 mg/5ml NF naproxen oral tablet 250 mg, 375 mg, 500 mg G naproxen oral tablet delayed release 375 mg, 500 mg G naproxen sodium er oral tablet extended release 24 hour 375 mg, NF 500 mg naproxen sodium oral tablet 275 mg, 550 mg G NUDROXIPAK DSDR-50 COMBINATION KIT 50 MG NF (diclofenac sodium-liniment) NUDROXIPAK DSDR-75 COMBINATION KIT 75 MG NF (diclofenac sodium-liniment) NUDROXIPAK M-15 COMBINATION KIT 15 MG NF (meloxicam-liniment) NUDROXIPAK N-500 COMBINATION KIT 500 MG NF (nabumetone-liniment) oxaprozin oral tablet 600 mg G piroxicam oral capsule 10 mg, 20 mg G QMIIZ ODT ORAL TABLET DISPERSIBLE 15 MG, 7.5 NF MG (meloxicam) SPRIX NASAL SOLUTION 15.75 MG/SPRAY (ketorolac NF tromethamine) 2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 16 Prescription Drug Name Drug Tier Drug Notes sulindac oral tablet 150 mg, 200 mg G TIVORBEX ORAL CAPSULE 20 MG (indomethacin) NF VIVLODEX ORAL CAPSULE 10 MG, 5 MG (meloxicam) NF ZIPSOR ORAL CAPSULE 25 MG (diclofenac potassium) NF ZORVOLEX ORAL CAPSULE 18 MG, 35 MG (diclofenac) NF NSAIDS, COMBINATIONS ARTHROTEC ORAL TABLET DELAYED RELEASE 50- NF 0.2 MG, 75-0.2 MG (diclofenac-misoprostol) diclofenac-misoprostol oral tablet delayed release 50-0.2 mg, 75- G 0.2 mg DUEXIS ORAL TABLET 800-26.6 MG (ibuprofen- NPB famotidine) diclofenac sodium-capsaicin (Inflammacin Combination NF Therapy Pack 75 & 0.025 Mg-%) INFLATHERM COMBINATION THERAPY PACK 75 & NF 3-3 MG & % (diclofenac-menthol-camphor) naproxen-esomeprazole oral tablet delayed release 375-20 mg, NF 500-20 mg PREVIDOLRX ANALGESIC COMBINATION THERAPY PACK 75-20-0.025 MG-MG-% (diclofenac- NF omeprazole-capsicum) TORONOVA II SUIK COMBINATION KIT 30 MG/ML NF (ketorolac trometh & anesthetic) TORONOVA SUIK COMBINATION KIT 30 MG/ML NF (ketorolac trometh & anesthetic) VIMOVO ORAL TABLET DELAYED RELEASE 375-20 NPB MG, 500-20 MG (naproxen-esomeprazole) OPIOID AGONIST/ANTAGONIST BUNAVAIL BUCCAL FILM 4.2-0.7 MG, 6.3-1 MG NF (buprenorphine hcl-naloxone hcl) buprenorphine hcl-naloxone hcl sublingual film 12-3 mg, 2-0.5 G mg, 4-1 mg, 8-2 mg buprenorphine hcl-naloxone hcl sublingual tablet sublingual 2- G 0.5 mg, 8-2 mg pentazocine-naloxone hcl oral tablet 50-0.5 mg G SUBOXONE SUBLINGUAL FILM 12-3 MG, 2-0.5 MG, 4- NF 1 MG, 8-2 MG (buprenorphine hcl-naloxone hcl)

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 17 Prescription Drug Name Drug Tier Drug Notes ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 0.7- 0.18 MG, 1.4-0.36 MG, 11.4-2.9 MG, 2.9-0.71 MG, 5.7-1.4 PB MG, 8.6-2.1 MG (buprenorphine hcl-naloxone hcl) OPIOID ANALGESICS - DRUGS TO TREAT PAIN acetaminophen-codeine #3 oral tablet 300-30 mg G acetaminophen-codeine oral solution 120-12 mg/5ml G acetaminophen-codeine oral tablet 300-15 mg, 300-60 mg G ACTIQ BUCCAL LOZENGE ON A HANDLE 1200 MCG, 1600 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG NPB (fentanyl citrate) APADAZ ORAL TABLET 4.08-325 MG, 6.12-325 MG, NF 8.16-325 MG (benzhydrocodone-acetaminophen) apap-caff-dihydrocodeine oral capsule 320.5-30-16 mg G butalbital-asa-caff-codeine (Ascomp-Codeine Oral Capsule 50- G 325-40-30 Mg) butalbital-apap-caff-cod oral capsule 50-300-40-30 mg, 50-325- G 40-30 mg butalbital-asa-caff-codeine oral capsule 50-325-40-30 mg G butorphanol tartrate nasal solution 10 mg/ml G codeine sulfate oral tablet 60 mg NPB CONZIP ORAL CAPSULE EXTENDED RELEASE 24 NPB HOUR 100 MG, 200 MG, 300 MG (tramadol hcl) DILAUDID INJECTION SOLUTION 1 MG/ML, 2 NF MG/ML (hydromorphone hcl) DILAUDID ORAL LIQUID 1 MG/ML (hydromorphone hcl) NPB DILAUDID ORAL TABLET 2 MG, 4 MG, 8 MG NPB (hydromorphone hcl) DSUVIA SUBLINGUAL TABLET SUBLINGUAL 30 NPB MCG (sufentanil citrate) DURAGESIC-100 TRANSDERMAL PATCH 72 HOUR NPB 100 MCG/HR (fentanyl) DURAGESIC-12 TRANSDERMAL PATCH 72 HOUR 12 NPB MCG/HR (fentanyl) DURAGESIC-25 TRANSDERMAL PATCH 72 HOUR 25 NPB MCG/HR (fentanyl) DURAGESIC-50 TRANSDERMAL PATCH 72 HOUR 50 NPB MCG/HR (fentanyl)

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 18 Prescription Drug Name Drug Tier Drug Notes DURAGESIC-75 TRANSDERMAL PATCH 72 HOUR 75 NPB MCG/HR (fentanyl) oxycodone-acetaminophen (Endocet Oral Tablet 10-325 Mg, G 2.5-325 Mg, 5-325 Mg, 7.5-325 Mg) fentanyl citrate buccal lozenge on a handle 1200 mcg, 1600 mcg, G 200 mcg, 400 mcg, 600 mcg, 800 mcg fentanyl citrate buccal tablet 200 mcg, 400 mcg, 600 mcg, 800 G mcg fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 37.5 mcg/hr, 50 mcg/hr, 62.5 mcg/hr, 75 mcg/hr, 87.5 G mcg/hr FENTORA BUCCAL TABLET 100 MCG, 200 MCG, 400 NF MCG, 600 MCG, 800 MCG (fentanyl citrate) hydrocodone bitartrate er oral capsule extended release 12 hour NF 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 50 mg hydrocodone-acetaminophen oral solution 5-217 mg/10ml G hydrocodone-acetaminophen oral tablet 10-300 mg, 10-325 mg, G 5-300 mg, 5-325 mg, 7.5-300 mg, 7.5-325 mg hydrocodone-ibuprofen oral tablet 10-200 mg, 5-200 mg, 7.5-200 G mg hydromorphone hcl er oral tablet extended release 24 hour 12 G mg, 16 mg, 32 mg, 8 mg hydromorphone hcl oral liquid 1 mg/ml G hydromorphone hcl oral tablet 2 mg, 4 mg, 8 mg G hydromorphone hcl rectal suppository 3 mg NPB HYSINGLA ER ORAL TABLET ER 24 HOUR ABUSE- DETERRENT 100 MG, 120 MG, 20 MG, 30 MG, 40 MG, NF 60 MG, 80 MG (hydrocodone bitartrate) LAZANDA NASAL SOLUTION 100 MCG/ACT, 400 NF MCG/ACT (fentanyl citrate) levorphanol tartrate oral tablet 2 mg, 3 mg NF LORTAB ORAL ELIXIR 10-300 MG/15ML (hydrocodone- NPB acetaminophen) meperidine hcl oral solution 50 mg/5ml NF meperidine hcl oral tablet 50 mg NF methadone hcl injection solution 10 mg/ml NPB methadone hcl (Methadone Hcl Intensol Oral Concentrate 10 G Mg/Ml)

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 19 Prescription Drug Name Drug Tier Drug Notes methadone hcl oral concentrate 10 mg/ml G methadone hcl oral solution 10 mg/5ml, 5 mg/5ml G methadone hcl oral tablet 10 mg, 5 mg G methadone hcl oral tablet soluble 40 mg G methadone hcl-nacl intravenous solution prefilled syringe 1-0.9 NPB mg/ml-% METHADOSE ORAL CONCENTRATE 10 MG/ML NPB (methadone hcl) methadone hcl (Methadose Oral Tablet Soluble 40 Mg) G METHADOSE SUGAR-FREE ORAL CONCENTRATE 10 NPB MG/ML (methadone hcl) morphine sulfate (concentrate) oral solution 20 mg/ml G morphine sulfate er beads oral capsule extended release 24 hour G 120 mg, 30 mg, 45 mg, 60 mg, 75 mg, 90 mg morphine sulfate er oral capsule extended release 24 hour 10 mg, G 100 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg, 80 mg morphine sulfate er oral tablet extended release 100 mg, 15 mg, G 200 mg, 30 mg, 60 mg morphine sulfate intravenous solution 1 mg/ml NPB morphine sulfate oral solution 10 mg/5ml, 20 mg/5ml G morphine sulfate oral tablet 15 mg, 30 mg G morphine sulfate rectal suppository 10 mg, 20 mg, 30 mg, 5 mg G MS CONTIN ORAL TABLET EXTENDED RELEASE 100 NPB MG, 15 MG, 200 MG, 30 MG, 60 MG (morphine sulfate) nalocet oral tablet 2.5-300 mg NF NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HOUR 100 MG, 150 MG, 200 MG, 250 MG, 50 MG PB (tapentadol hcl) NUCYNTA ORAL TABLET 100 MG, 50 MG, 75 MG PB (tapentadol hcl) OXAYDO ORAL TABLET 5 MG, 7.5 MG (oxycodone hcl) NF oxycodone hcl er oral tablet er 12 hour abuse-deterrent 10 mg, G 15 mg, 20 mg, 30 mg, 40 mg, 60 mg, 80 mg oxycodone hcl oral capsule 5 mg G oxycodone hcl oral concentrate 100 mg/5ml G oxycodone hcl oral solution 5 mg/5ml G oxycodone hcl oral tablet 10 mg, 15 mg, 20 mg, 30 mg, 5 mg G

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 20 Prescription Drug Name Drug Tier Drug Notes oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5- G 325 mg, 7.5-325 mg OXYCONTIN ORAL TABLET ER 12 HOUR ABUSE- DETERRENT 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60 NF MG, 80 MG (oxycodone hcl) oxymorphone hcl er oral tablet extended release 12 hour 10 mg, NF 15 mg, 20 mg, 30 mg, 40 mg, 5 mg, 7.5 mg oxymorphone hcl oral tablet 10 mg, 5 mg G PERCOCET ORAL TABLET 10-325 MG, 2.5-325 MG, 5- NF 325 MG, 7.5-325 MG (oxycodone-acetaminophen) ROXICODONE ORAL TABLET 15 MG, 30 MG, 5 MG NPB (oxycodone hcl) SUBSYS SUBLINGUAL LIQUID 100 MCG, 1200 (600 X 2) MCG, 1600 (800 X 2) MCG, 200 MCG, 400 MCG, 600 PB MCG, 800 MCG (fentanyl) SYNAPRYN FUSEPAQ ORAL SUSPENSION NF RECONSTITUTED 10 MG/ML (tramadol hcl) tramadol hcl er (biphasic) oral tablet extended release 24 hour G 100 mg, 200 mg, 300 mg tramadol hcl er oral capsule extended release 24 hour 100 mg, NF 200 mg, 300 mg tramadol hcl er oral tablet extended release 24 hour 100 mg, 200 G mg, 300 mg tramadol hcl oral tablet 100 mg NF tramadol hcl oral tablet 50 mg G tramadol-acetaminophen oral tablet 37.5-325 mg G ULTRACET ORAL TABLET 37.5-325 MG (tramadol- NPB acetaminophen) ULTRAM ORAL TABLET 50 MG (tramadol hcl) NPB XTAMPZA ER ORAL CAPSULE ER 12 HOUR ABUSE- DETERRENT 13.5 MG, 18 MG, 27 MG, 36 MG, 9 MG PB (oxycodone) OPIOID PARTIAL AGONISTS BELBUCA BUCCAL FILM 150 MCG, 300 MCG, 450 MCG, 600 MCG, 75 MCG, 750 MCG, 900 MCG PB (buprenorphine hcl) buprenorphine hcl sublingual tablet sublingual 2 mg, 8 mg G

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 21 Prescription Drug Name Drug Tier Drug Notes BUTRANS TRANSDERMAL PATCH WEEKLY 10 MCG/HR, 15 MCG/HR, 20 MCG/HR, 5 MCG/HR, 7.5 NF MCG/HR (buprenorphine) SUBLOCADE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100 MG/0.5ML, 300 MG/1.5ML NPB (buprenorphine) SALICYLATES aspirin adult low dose oral tablet delayed release 81 mg CE aspirin ec low strength oral tablet delayed release 81 mg CE aspirin low dose oral tablet chewable 81 mg CE aspirin low dose oral tablet delayed release 81 mg CE aspirin oral tablet chewable 81 mg CE aspirin oral tablet delayed release 81 mg CE ASPIR-LOW ORAL TABLET DELAYED RELEASE 81 CE MG (aspirin) BAYER ASPIRIN EC LOW DOSE ORAL TABLET CE DELAYED RELEASE 81 MG (aspirin) BAYER LOW DOSE ORAL TABLET CHEWABLE 81 MG CE (aspirin) BAYER LOW DOSE ORAL TABLET DELAYED CE RELEASE 81 MG (aspirin) childrens aspirin oral tablet chewable 81 mg CE cvs aspirin low dose oral tablet delayed release 81 mg CE cvs aspirin low strength oral tablet delayed release 81 mg CE diflunisal oral tablet 500 mg G eql aspirin low dose oral tablet chewable 81 mg CE gnp adult aspirin low strength oral tablet chewable 81 mg CE gnp aspirin oral tablet delayed release 81 mg CE h-e-b aspirin oral tablet delayed release 81 mg CE hm aspirin oral tablet chewable 81 mg CE kls aspirin low dose oral tablet delayed release 81 mg CE kp aspirin oral tablet delayed release 81 mg CE px aspirin oral tablet chewable 81 mg CE px enteric aspirin oral tablet delayed release 81 mg CE qc childrens aspirin oral tablet chewable 81 mg CE ra aspirin adult low dose oral tablet chewable 81 mg CE

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 22 Prescription Drug Name Drug Tier Drug Notes ra aspirin childrens oral tablet chewable 81 mg CE ra aspirin ec adult low st oral tablet delayed release 81 mg CE salsalate oral tablet 500 mg, 750 mg G sb childrens aspirin oral tablet chewable 81 mg CE sm aspirin adult low strength oral tablet chewable 81 mg CE sm aspirin adult low strength oral tablet delayed release 81 mg CE sm childrens aspirin oral tablet chewable 81 mg CE ST JOSEPH LOW DOSE ORAL TABLET CHEWABLE 81 CE MG (aspirin) VISCOSUPPLEMENTS DUROLANE INTRA-ARTICULAR PREFILLED PSP SYRINGE 60 MG/3ML (sodium hyaluronate (viscosup)) EUFLEXXA INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 20 MG/2ML (sodium hyaluronate PSP (viscosup)) GEL-ONE INTRA-ARTICULAR PREFILLED SYRINGE NF 30 MG/3ML (cross-linked hyaluronate) GELSYN-3 INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 16.8 MG/2ML (sodium hyaluronate PSP (viscosup)) GENVISC 850 INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 25 MG/2.5ML (sodium hyaluronate NF (viscosup)) HYALGAN INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 20 MG/2ML (sodium hyaluronate NF (viscosup)) SUPARTZ FX INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 25 MG/2.5ML (sodium hyaluronate PSP (viscosup)) TRIVISC INTRA-ARTICULAR SOLUTION PREFILLED NF SYRINGE 25 MG/2.5ML (sodium hyaluronate (viscosup)) VISCO-3 INTRA-ARTICULAR SOLUTION PREFILLED NF SYRINGE 25 MG/2.5ML (sodium hyaluronate (viscosup)) ANESTHETICS - DRUGS FOR NUMBING LOCAL ANESTHETICS - DRUGS FOR NUMBING bupivacaine hcl injection solution 0.125 % NPB lidocaine in dextrose solution 5-7.5 % NPB lidomark 2/5 injection kit 2 % NPB

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 23 Prescription Drug Name Drug Tier Drug Notes ANTI-INFECTIVES - DRUGS TO TREAT INFECTIONS ANTI-BACTERIALS - MISCELLANEOUS ARIKAYCE INHALATION SUSPENSION 590 MG/8.4ML NPB (amikacin sulfate liposome) BETHKIS INHALATION NEBULIZATION SOLUTION PSP 300 MG/4ML (tobramycin) KITABIS PAK INHALATION NEBULIZATION NPSP SOLUTION 300 MG/5ML (tobramycin) MONUROL ORAL PACKET 3 GM (fosfomycin NPB tromethamine) neomycin sulfate oral tablet 500 mg G paromomycin sulfate oral capsule 250 mg G sulfadiazine oral tablet 500 mg NPB tinidazole oral tablet 250 mg, 500 mg G TOBI PODHALER INHALATION CAPSULE 28 MG NF (tobramycin) tobramycin inhalation nebulization solution 300 mg/5ml G ANTIFUNGALS - DRUGS TO TREAT FUNGAL INFECTIONS BREXAFEMME ORAL TABLET 150 MG (ibrexafungerp NPB citrate) CRESEMBA ORAL CAPSULE 186 MG (isavuconazonium NF sulfate) fluconazole oral suspension reconstituted 10 mg/ml, 40 mg/ml G fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg G flucytosine oral capsule 250 mg G flucytosine oral capsule 500 mg NF griseofulvin microsize oral suspension 125 mg/5ml G griseofulvin microsize oral tablet 500 mg G griseofulvin ultramicrosize oral tablet 125 mg, 250 mg G itraconazole oral capsule 100 mg G itraconazole oral solution 10 mg/ml G KERYDIN EXTERNAL SOLUTION 5 % (tavaborole) NF ketoconazole oral tablet 200 mg G NOXAFIL INTRAVENOUS SOLUTION 300 MG/16.7ML NF (posaconazole) NOXAFIL ORAL SUSPENSION 40 MG/ML (posaconazole) NF 2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 24 Prescription Drug Name Drug Tier Drug Notes NOXAFIL ORAL TABLET DELAYED RELEASE 100 NF MG (posaconazole) nystatin oral tablet 500000 unit G posaconazole oral tablet delayed release 100 mg NF SPORANOX ORAL CAPSULE 100 MG (itraconazole) NF SPORANOX ORAL SOLUTION 10 MG/ML (itraconazole) NF SPORANOX PULSEPAK ORAL CAPSULE 100 MG NF (itraconazole) terbinafine hcl oral tablet 250 mg G tolsura oral capsule 65 mg NF voriconazole oral suspension reconstituted 40 mg/ml G voriconazole oral tablet 200 mg, 50 mg G ANTI-INFECTIVES - MISCELLANEOUS AEMCOLO ORAL TABLET DELAYED RELEASE 194 NPB MG (rifamycin sodium) albendazole oral tablet 200 mg G ALINIA ORAL SUSPENSION RECONSTITUTED 100 NPB MG/5ML (nitazoxanide) ALINIA ORAL TABLET 500 MG (nitazoxanide) NPB atovaquone oral suspension 750 mg/5ml G benznidazole oral tablet 100 mg, 12.5 mg NPB CAYSTON INHALATION SOLUTION NPB RECONSTITUTED 75 MG (aztreonam lysine) clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg G clindamycin palmitate hcl oral solution reconstituted 75 mg/5ml G dapsone oral tablet 100 mg, 25 mg G DARAPRIM ORAL TABLET 25 MG (pyrimethamine) NF EMVERM ORAL TABLET CHEWABLE 100 MG NPB (mebendazole) FIRST-METRONIDAZOLE ORAL SUSPENSION NF RECONSTITUTED 50 MG/ML (metronidazole benzoate) FIRVANQ ORAL SOLUTION RECONSTITUTED 25 NF MG/ML, 50 MG/ML (vancomycin hcl) IMPAVIDO ORAL CAPSULE 50 MG (miltefosine) NPB ivermectin oral tablet 3 mg G LAMPIT ORAL TABLET 120 MG, 30 MG (nifurtimox) NPB

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 25 Prescription Drug Name Drug Tier Drug Notes linezolid oral suspension reconstituted 100 mg/5ml G linezolid oral tablet 600 mg G MACRODANTIN ORAL CAPSULE 100 MG, 25 MG, 50 NF MG (nitrofurantoin macrocrystal) methenamine hippurate oral tablet 1 gm G methenamine mandelate oral tablet 0.5 gm, 1 gm G METRONIDAZOLE BENZO+SYRSPEND ORAL SUSPENSION RECONSTITUTED 50 MG/ML NF (metronidazole benzoate) metronidazole oral capsule 375 mg G metronidazole oral tablet 250 mg, 500 mg G NEBUPENT INHALATION SOLUTION NPB RECONSTITUTED 300 MG (pentamidine isethionate) nitrofurantoin macrocrystal oral capsule 100 mg, 25 mg, 50 mg G nitrofurantoin monohyd macro oral capsule 100 mg G nitrofurantoin oral suspension 25 mg/5ml NF praziquantel oral tablet 600 mg G PRIMSOL ORAL SOLUTION 50 MG/5ML (trimethoprim NPB hcl) RECARBRIO INTRAVENOUS SOLUTION RECONSTITUTED 1.25 GM (imipenem-cilastatin- NPB relebactam) SIVEXTRO ORAL TABLET 200 MG (tedizolid phosphate) NPB SOLOSEC ORAL PACKET 2 GM (secnidazole) NF sulfamethoxazole-trimethoprim oral suspension 200-40 mg/5ml G sulfamethoxazole-trimethoprim oral tablet 400-80 mg, 800-160 G mg sulfamethoxazole-trimethoprim (Sulfatrim Pediatric Oral G Suspension 200-40 Mg/5Ml) trimethoprim oral tablet 100 mg G vancomycin hcl intravenous solution 1250 mg/250ml, 1750 NPB mg/350ml, 500 mg/100ml, 750 mg/150ml vancomycin hcl intravenous solution reconstituted 750 mg NPB vancomycin hcl oral capsule 125 mg, 250 mg G VANCOMYCIN+SYRSPEND SF ORAL SUSPENSION 50 NF MG/ML (vancomycin hcl) XENLETA ORAL TABLET 600 MG (lefamulin acetate) NPB

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 26 Prescription Drug Name Drug Tier Drug Notes XIFAXAN ORAL TABLET 200 MG (rifaximin) NF XIFAXAN ORAL TABLET 550 MG (rifaximin) PB ZYVOX ORAL SUSPENSION RECONSTITUTED 100 NF MG/5ML (linezolid) ZYVOX ORAL TABLET 600 MG (linezolid) NF ANTIMALARIALS - DRUGS TO TREAT MALARIA ARAKODA ORAL TABLET 100 MG (tafenoquine NF succinate) atovaquone-proguanil hcl oral tablet 250-100 mg, 62.5-25 mg G chloroquine phosphate oral tablet 250 mg, 500 mg G COARTEM ORAL TABLET 20-120 MG (artemether- NPB lumefantrine) KRINTAFEL ORAL TABLET 150 MG (tafenoquine NF succinate) mefloquine hcl oral tablet 250 mg G primaquine phosphate oral tablet 26.3 (15 base) mg NPB quinine sulfate oral capsule 324 mg G ANTIRETROVIRAL AGENTS - DRUGS TO SUPPRESS HIV/AIDS INFECTION abacavir sulfate oral solution 20 mg/ml G abacavir sulfate oral tablet 300 mg G APTIVUS ORAL CAPSULE 250 MG (tipranavir) NF atazanavir sulfate oral capsule 150 mg, 200 mg, 300 mg G CRIXIVAN ORAL CAPSULE 400 MG (indinavir sulfate) NPSP EDURANT ORAL TABLET 25 MG (rilpivirine hcl) PSP efavirenz oral capsule 200 mg, 50 mg G efavirenz oral tablet 600 mg G EMTRIVA ORAL CAPSULE 200 MG (emtricitabine) PSP EMTRIVA ORAL SOLUTION 10 MG/ML (emtricitabine) PSP fosamprenavir calcium oral tablet 700 mg G FUZEON SUBCUTANEOUS SOLUTION PSP RECONSTITUTED 90 MG (enfuvirtide) INTELENCE ORAL TABLET 100 MG, 200 MG, 25 MG PSP (etravirine) INVIRASE ORAL TABLET 500 MG (saquinavir mesylate) NF

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 27 Prescription Drug Name Drug Tier Drug Notes ISENTRESS HD ORAL TABLET 600 MG (raltegravir PSP potassium) ISENTRESS ORAL PACKET 100 MG (raltegravir PSP potassium) ISENTRESS ORAL TABLET 400 MG (raltegravir PSP potassium) ISENTRESS ORAL TABLET CHEWABLE 100 MG, 25 PSP MG (raltegravir potassium) lamivudine oral solution 10 mg/ml G lamivudine oral tablet 150 mg, 300 mg G LEXIVA ORAL SUSPENSION 50 MG/ML (fosamprenavir NF calcium) LEXIVA ORAL TABLET 700 MG (fosamprenavir calcium) NF nevirapine er oral tablet extended release 24 hour 100 mg, 400 G mg nevirapine oral suspension 50 mg/5ml G nevirapine oral tablet 200 mg G NORVIR ORAL PACKET 100 MG (ritonavir) PSP NORVIR ORAL SOLUTION 80 MG/ML (ritonavir) PSP PIFELTRO ORAL TABLET 100 MG (doravirine) NF PREZISTA ORAL SUSPENSION 100 MG/ML (darunavir PSP ethanolate) PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 PSP MG (darunavir ethanolate) REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG NPSP (atazanavir sulfate) REYATAZ ORAL PACKET 50 MG (atazanavir sulfate) NPSP ritonavir oral tablet 100 mg G SELZENTRY ORAL SOLUTION 20 MG/ML (maraviroc) NPSP SELZENTRY ORAL TABLET 150 MG, 25 MG, 300 MG, NPSP 75 MG (maraviroc) stavudine oral capsule 15 mg, 20 mg, 30 mg, 40 mg G tenofovir disoproxil fumarate oral tablet 300 mg G TIVICAY ORAL TABLET 10 MG, 25 MG, 50 MG PSP (dolutegravir sodium) TIVICAY PD ORAL TABLET SOLUBLE 5 MG PSP (dolutegravir sodium)

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 28 Prescription Drug Name Drug Tier Drug Notes TYBOST ORAL TABLET 150 MG (cobicistat) NPSP VIRACEPT ORAL TABLET 250 MG, 625 MG (nelfinavir NF mesylate) VIREAD ORAL POWDER 40 MG/GM (tenofovir disoproxil NPSP fumarate) VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG, 300 NPSP MG (tenofovir disoproxil fumarate) zidovudine oral capsule 100 mg G zidovudine oral syrup 50 mg/5ml G zidovudine oral tablet 300 mg G ANTIRETROVIRAL COMBINATION AGENTS - DRUGS TO SUPPRESS HIV/AIDS INFECTION abacavir sulfate-lamivudine oral tablet 600-300 mg G abacavir-lamivudine-zidovudine oral tablet 300-150-300 mg G ATRIPLA ORAL TABLET 600-200-300 MG (efavirenz- NPSP emtricitab-tenofovir) BIKTARVY ORAL TABLET 50-200-25 MG (bictegravir- PSP emtricitab-tenofov) CIMDUO ORAL TABLET 300-300 MG (lamivudine- PSP tenofovir) COMPLERA ORAL TABLET 200-25-300 MG (emtricitab- NF rilpivir-tenofovir) DELSTRIGO ORAL TABLET 100-300-300 MG (doravirin- NF lamivudin-tenofov df) DESCOVY ORAL TABLET 200-25 MG (emtricitabine- PSP tenofovir af) DOVATO ORAL TABLET 50-300 MG (dolutegravir- PSP lamivudine) EVOTAZ ORAL TABLET 300-150 MG (atazanavir- PSP cobicistat) GENVOYA ORAL TABLET 150-150-200-10 MG (elviteg- PSP cobic-emtricit-tenofaf) JULUCA ORAL TABLET 50-25 MG (dolutegravir- NPSP rilpivirine) KALETRA ORAL TABLET 100-25 MG, 200-50 MG NPSP (lopinavir-ritonavir) lamivudine-zidovudine oral tablet 150-300 mg G lopinavir-ritonavir oral solution 400-100 mg/5ml G

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 29 Prescription Drug Name Drug Tier Drug Notes ODEFSEY ORAL TABLET 200-25-25 MG (emtricitab- PSP rilpivir-tenofov af) PREZCOBIX ORAL TABLET 800-150 MG (darunavir- PSP cobicistat) STRIBILD ORAL TABLET 150-150-200-300 MG (elviteg- NF cobic-emtricit-tenofdf) SYMFI LO ORAL TABLET 400-300-300 MG (efavirenz- NPSP lamivudine-tenofovir) SYMFI ORAL TABLET 600-300-300 MG (efavirenz- NPSP lamivudine-tenofovir) SYMTUZA ORAL TABLET 800-150-200-10 MG (darun- PSP cobic-emtricit-tenofaf) TEMIXYS ORAL TABLET 300-300 MG (lamivudine- PSP tenofovir) TRIUMEQ ORAL TABLET 600-50-300 MG (abacavir- PSP dolutegravir-lamivud) TRUVADA ORAL TABLET 100-150 MG, 133-200 MG, PSP 167-250 MG, 200-300 MG (emtricitabine-tenofovir df) ANTITUBERCULAR AGENTS - DRUGS TO TREAT TUBERCULOSIS cycloserine oral capsule 250 mg G ethambutol hcl oral tablet 100 mg, 400 mg G isoniazid oral syrup 50 mg/5ml G isoniazid oral tablet 100 mg, 300 mg G PASER ORAL PACKET 4 GM (aminosalicylic acid) NPB pretomanid oral tablet 200 mg NPB PRIFTIN ORAL TABLET 150 MG (rifapentine) NPB pyrazinamide oral tablet 500 mg G rifabutin oral capsule 150 mg G rifampin oral capsule 150 mg, 300 mg G SIRTURO ORAL TABLET 100 MG, 20 MG (bedaquiline NPB fumarate) TRECATOR ORAL TABLET 250 MG (ethionamide) NPB ANTIVIRALS - DRUGS TO TREAT VIRAL INFECTIONS acyclovir oral capsule 200 mg G acyclovir oral suspension 200 mg/5ml G acyclovir oral tablet 400 mg, 800 mg G

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 30 Prescription Drug Name Drug Tier Drug Notes adefovir dipivoxil oral tablet 10 mg G BARACLUDE ORAL SOLUTION 0.05 MG/ML (entecavir) PSP casirivimab intravenous solution 1332 mg/11.1ml, 300 mg/2.5ml NPB diclofenac sodium external gel 3 % G entecavir oral tablet 0.5 mg, 1 mg G famciclovir oral tablet 125 mg, 250 mg, 500 mg G favipiravir oral tablet 200 mg NPB imdevimab intravenous solution 1332 mg/11.1ml, 300 mg/2.5ml NPB lamivudine oral tablet 100 mg G oseltamivir phosphate oral capsule 30 mg, 45 mg, 75 mg G oseltamivir phosphate oral suspension reconstituted 6 mg/ml G PREVYMIS ORAL TABLET 240 MG, 480 MG (letermovir) NPB RELENZA DISKHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 5 MG/BLISTER PB (zanamivir) ribavirin inhalation solution reconstituted 6 gm G rimantadine hcl oral tablet 100 mg G SITAVIG BUCCAL TABLET 50 MG (acyclovir) NPB SYNAGIS INTRAMUSCULAR SOLUTION 100 MG/ML, NPSP 50 MG/0.5ML (palivizumab) valacyclovir hcl oral tablet 1 gm, 500 mg G VALCYTE ORAL SOLUTION RECONSTITUTED 50 NF MG/ML (valganciclovir hcl) VALCYTE ORAL TABLET 450 MG (valganciclovir hcl) NF valganciclovir hcl oral solution reconstituted 50 mg/ml G valganciclovir hcl oral tablet 450 mg G VALTREX ORAL TABLET 1 GM, 500 MG (valacyclovir NF hcl) VEMLIDY ORAL TABLET 25 MG (tenofovir alafenamide PSP fumarate) XERESE EXTERNAL CREAM 5-1 % (acyclovir- NF hydrocortisone) XOFLUZA (40 MG DOSE) ORAL TABLET THERAPY NF PACK 1 X 40 MG, 2 X 20 MG (baloxavir marboxil) XOFLUZA (80 MG DOSE) ORAL TABLET THERAPY NF PACK 1 X 80 MG, 2 X 40 MG (baloxavir marboxil) ZOVIRAX ORAL SUSPENSION 200 MG/5ML (acyclovir) NF 2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 31 Prescription Drug Name Drug Tier Drug Notes CEPHALOSPORINS - DRUGS TO TREAT INFECTIONS cefaclor er oral tablet extended release 12 hour 500 mg NPB cefaclor oral capsule 250 mg, 500 mg G cefaclor oral suspension reconstituted 125 mg/5ml, 250 mg/5ml, G 375 mg/5ml cefadroxil oral capsule 500 mg G cefadroxil oral suspension reconstituted 250 mg/5ml, 500 G mg/5ml cefadroxil oral tablet 1 gm G cefdinir oral capsule 300 mg G cefdinir oral suspension reconstituted 125 mg/5ml, 250 mg/5ml G cefixime oral capsule 400 mg G cefixime oral suspension reconstituted 100 mg/5ml, 200 mg/5ml G cefpodoxime proxetil oral suspension reconstituted 100 mg/5ml, G 50 mg/5ml cefpodoxime proxetil oral tablet 100 mg, 200 mg G cefprozil oral suspension reconstituted 125 mg/5ml, 250 mg/5ml G cefprozil oral tablet 250 mg, 500 mg G cefuroxime axetil oral tablet 250 mg, 500 mg G cephalexin oral capsule 250 mg, 500 mg, 750 mg G cephalexin oral suspension reconstituted 125 mg/5ml, 250 G mg/5ml cephalexin oral tablet 250 mg, 500 mg G FORTAZ INJECTION SOLUTION RECONSTITUTED 1 NPB GM, 500 MG (ceftazidime) FORTAZ INTRAVENOUS SOLUTION NPB RECONSTITUTED 2 GM (ceftazidime) SUPRAX ORAL SUSPENSION RECONSTITUTED 500 PB MG/5ML (cefixime) SUPRAX ORAL TABLET CHEWABLE 100 MG, 200 MG PB (cefixime) ERYTHROMYCINS/MACROLIDES - DRUGS TO TREAT INFECTIONS azithromycin oral packet 1 gm G azithromycin oral suspension reconstituted 100 mg/5ml, 200 G mg/5ml azithromycin oral tablet 250 mg, 500 mg, 600 mg G

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 32 Prescription Drug Name Drug Tier Drug Notes clarithromycin er oral tablet extended release 24 hour 500 mg G clarithromycin oral suspension reconstituted 125 mg/5ml, 250 G mg/5ml clarithromycin oral tablet 250 mg, 500 mg G DIFICID ORAL SUSPENSION RECONSTITUTED 40 PB MG/ML (fidaxomicin) DIFICID ORAL TABLET 200 MG (fidaxomicin) PB E.E.S. 400 ORAL TABLET 400 MG (erythromycin G ethylsuccinate) E.E.S. GRANULES ORAL SUSPENSION RECONSTITUTED 200 MG/5ML (erythromycin NF ethylsuccinate) ERYPED 200 ORAL SUSPENSION RECONSTITUTED NF 200 MG/5ML (erythromycin ethylsuccinate) ERYPED 400 ORAL SUSPENSION RECONSTITUTED NF 400 MG/5ML (erythromycin ethylsuccinate) erythromycin base (Ery-Tab Oral Tablet Delayed Release 250 G Mg, 333 Mg, 500 Mg) ERYTHROCIN STEARATE ORAL TABLET 250 MG G (erythromycin stearate) erythromycin base oral capsule delayed release particles 250 mg G erythromycin base oral tablet 250 mg, 500 mg G erythromycin ethylsuccinate oral suspension reconstituted 200 G mg/5ml, 400 mg/5ml erythromycin ethylsuccinate oral tablet 400 mg G erythromycin oral tablet delayed release 250 mg, 333 mg, 500 G mg FLUOROQUINOLONES - DRUGS TO TREAT INFECTIONS BAXDELA ORAL TABLET 450 MG (delafloxacin NPB meglumine) CIPRO ORAL SUSPENSION RECONSTITUTED 250 NPB MG/5ML (5%) (ciprofloxacin) ciprofloxacin hcl oral tablet 100 mg, 250 mg, 500 mg, 750 mg G levofloxacin oral solution 25 mg/ml G levofloxacin oral tablet 250 mg, 500 mg, 750 mg G moxifloxacin hcl oral tablet 400 mg G ofloxacin oral tablet 300 mg, 400 mg G

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 33 Prescription Drug Name Drug Tier Drug Notes HEPATITIS C EPCLUSA ORAL TABLET 200-50 MG, 400-100 MG IBC (Preferred for all PSP (sofosbuvir-velpatasvir) genotypes) HARVONI ORAL PACKET 33.75-150 MG, 45-200 MG PSP (ledipasvir-sofosbuvir) HARVONI ORAL TABLET 45-200 MG, 90-400 MG IBC (Preferred for PSP (ledipasvir-sofosbuvir) genotypes 1,4,5,6) ribavirin oral capsule 200 mg G ribavirin oral tablet 200 mg G SOVALDI ORAL PACKET 150 MG, 200 MG (sofosbuvir) NPSP SOVALDI ORAL TABLET 200 MG, 400 MG (sofosbuvir) NPSP VOSEVI ORAL TABLET 400-100-100 MG (sofosbuv- IBC (Preferred for all PSP velpatasv-voxilaprev) genotypes) PENICILLINS - DRUGS TO TREAT INFECTIONS amoxicillin oral capsule 250 mg, 500 mg G amoxicillin oral suspension reconstituted 125 mg/5ml, 200 G mg/5ml, 250 mg/5ml, 400 mg/5ml amoxicillin oral tablet 500 mg, 875 mg G amoxicillin oral tablet chewable 125 mg, 250 mg G amoxicillin-pot clavulanate er oral tablet extended release 12 G hour 1000-62.5 mg amoxicillin-pot clavulanate oral suspension reconstituted 200- 28.5 mg/5ml, 250-62.5 mg/5ml, 400-57 mg/5ml, 600-42.9 G mg/5ml amoxicillin-pot clavulanate oral tablet 250-125 mg, 500-125 mg, G 875-125 mg amoxicillin-pot clavulanate oral tablet chewable 200-28.5 mg, G 400-57 mg ampicillin oral capsule 500 mg G ampicillin-sulbactam sodium intravenous solution reconstituted NPB 1.5 (1-0.5) gm, 3 (2-1) gm AUGMENTIN ORAL SUSPENSION RECONSTITUTED NPB 125-31.25 MG/5ML (amoxicillin-pot clavulanate) dicloxacillin sodium oral capsule 250 mg, 500 mg G penicillin v potassium oral solution reconstituted 125 mg/5ml, G 250 mg/5ml penicillin v potassium oral tablet 250 mg, 500 mg G

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 34 Prescription Drug Name Drug Tier Drug Notes PFIZERPEN INJECTION SOLUTION RECONSTITUTED 20000000 UNIT, 5000000 UNIT NF (penicillin g potassium) TETRACYCLINES - DRUGS TO TREAT INFECTIONS ACTICLATE ORAL TABLET 150 MG, 75 MG (doxycycline NF hyclate) avidoxy oral tablet 100 mg G minocycline hcl (Coremino Oral Tablet Extended Release 24 NF Hour 135 Mg, 45 Mg, 90 Mg) demeclocycline hcl oral tablet 150 mg, 300 mg G DORYX MPC ORAL TABLET DELAYED RELEASE 120 NF MG (doxycycline hyclate) DORYX ORAL TABLET DELAYED RELEASE 200 MG, NF 50 MG, 80 MG (doxycycline hyclate) doxycycline hyclate oral capsule 100 mg, 50 mg G doxycycline hyclate oral tablet 100 mg, 20 mg G doxycycline hyclate oral tablet 150 mg, 50 mg, 75 mg NF doxycycline hyclate oral tablet delayed release 100 mg, 150 mg, G 75 mg doxycycline hyclate oral tablet delayed release 200 mg, 50 mg NF doxycycline monohydrate oral capsule 100 mg, 50 mg G doxycycline monohydrate oral capsule 150 mg, 75 mg NF doxycycline monohydrate oral suspension reconstituted 25 G mg/5ml doxycycline monohydrate oral tablet 100 mg, 150 mg, 50 mg, 75 G mg MINOCIN ORAL CAPSULE 100 MG (minocycline hcl) NF minocycline hcl er oral capsule extended release 24 hour 135 mg, NF 45 mg, 90 mg minocycline hcl er oral tablet extended release 24 hour 105 mg, NF 115 mg, 135 mg, 45 mg, 55 mg, 65 mg, 80 mg, 90 mg minocycline hcl oral capsule 100 mg, 50 mg, 75 mg G minocycline hcl oral tablet 100 mg, 50 mg, 75 mg G MINOLIRA ORAL TABLET EXTENDED RELEASE 24 NF HOUR 105 MG, 135 MG (minocycline hcl) doxycycline monohydrate (Mondoxyne Nl Oral Capsule 100 G Mg)

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 35 Prescription Drug Name Drug Tier Drug Notes doxycycline monohydrate (Mondoxyne Nl Oral Capsule 75 NF Mg) doxycycline hyclate (Morgidox Oral Capsule 100 Mg) G NUZYRA ORAL TABLET 150 MG (omadacycline tosylate) NPB SEYSARA ORAL TABLET 100 MG, 150 MG, 60 MG NF (sarecycline hcl) SOLODYN ORAL TABLET EXTENDED RELEASE 24 HOUR 105 MG, 115 MG, 55 MG, 65 MG, 80 MG NF (minocycline hcl) doxycycline hyclate (Targadox Oral Tablet 50 Mg) NF tetracycline hcl oral capsule 250 mg, 500 mg G VIBRAMYCIN ORAL SYRUP 50 MG/5ML (doxycycline NPB calcium) XIMINO ORAL CAPSULE EXTENDED RELEASE 24 NF HOUR 135 MG, 45 MG, 90 MG (minocycline hcl) ANTINEOPLASTIC AGENTS - DRUGS TO TREAT CANCER ALKYLATING AGENTS - CHEMOTHERAPY DRUGS BELRAPZO INTRAVENOUS SOLUTION 100 MG/4ML NF (bendamustine hcl) cyclophosphamide intravenous solution 1 gm/5ml, 500 mg/2.5ml NPB cyclophosphamide oral capsule 25 mg, 50 mg G cyclophosphamide oral tablet 25 mg, 50 mg NPB EMCYT ORAL CAPSULE 140 MG (estramustine phosphate NPB sodium) EVOMELA INTRAVENOUS SOLUTION NF RECONSTITUTED 50 MG (melphalan hcl) GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG NPB (lomustine) GLIADEL WAFER IMPLANT WAFER 7.7 MG NPB (carmustine in polifeprosan) LEUKERAN ORAL TABLET 2 MG (chlorambucil) PB melphalan oral tablet 2 mg G MYLERAN ORAL TABLET 2 MG (busulfan) PB oxaliplatin intravenous solution 200 mg/40ml NPB PARAPLATIN INTRAVENOUS SOLUTION 1000 G MG/100ML (carboplatin)

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 36 Prescription Drug Name Drug Tier Drug Notes TEMODAR INTRAVENOUS SOLUTION NPSP RECONSTITUTED 100 MG (temozolomide) TEMODAR ORAL CAPSULE 100 MG, 140 MG, 180 MG, NPSP 250 MG (temozolomide) temozolomide oral capsule 100 mg, 140 mg, 180 mg, 20 mg, 250 G mg, 5 mg TREANDA INTRAVENOUS SOLUTION NPSP RECONSTITUTED 100 MG, 25 MG (bendamustine hcl) ANTIMETABOLITES - CHEMOTHERAPY DRUGS capecitabine oral tablet 150 mg, 500 mg G INFUGEM INTRAVENOUS SOLUTION 1200-0.9 MG/120ML-%, 1300-0.9 MG/130ML-%, 1400-0.9 MG/140ML-%, 1500-0.9 MG/150ML-%, 1600-0.9 NF MG/160ML-%, 1700-0.9 MG/170ML-%, 1800-0.9 MG/180ML-%, 1900-0.9 MG/190ML-%, 2000-0.9 MG/200ML-%, 2200-0.9 MG/220ML-% (gemcitabine hcl-nacl) mercaptopurine oral tablet 50 mg G methotrexate sodium (pf) injection solution 1 gm/40ml, 250 G mg/10ml, 50 mg/2ml methotrexate sodium injection solution 250 mg/10ml, 50 mg/2ml G methotrexate sodium injection solution reconstituted 1 gm G methotrexate sodium oral tablet 2.5 mg G PURIXAN ORAL SUSPENSION 2000 MG/100ML NPSP (mercaptopurine) TABLOID ORAL TABLET 40 MG (thioguanine) PB TREXALL ORAL TABLET 10 MG, 15 MG, 5 MG, 7.5 MG PB (methotrexate sodium) XATMEP ORAL SOLUTION 2.5 MG/ML (methotrexate) NPB XELODA ORAL TABLET 150 MG, 500 MG (capecitabine) NPSP BIOLOGIC RESPONSE MODIFIERS AVASTIN INTRAVENOUS SOLUTION 100 MG/4ML, NF 400 MG/16ML (bevacizumab) DAURISMO ORAL TABLET 100 MG, 25 MG (glasdegib NF maleate) ERIVEDGE ORAL CAPSULE 150 MG (vismodegib) PSP FARYDAK ORAL CAPSULE 10 MG, 15 MG, 20 MG NF (panobinostat lactate)

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 37 Prescription Drug Name Drug Tier Drug Notes HERCEPTIN INTRAVENOUS SOLUTION NF RECONSTITUTED 150 MG (trastuzumab) IBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG PSP (palbociclib) IBRANCE ORAL TABLET 100 MG, 125 MG, 75 MG PSP (palbociclib) KANJINTI INTRAVENOUS SOLUTION PSP RECONSTITUTED 150 MG, 420 MG (trastuzumab-anns) KISQALI (200 MG DOSE) ORAL TABLET THERAPY PSP PACK 200 MG (ribociclib succinate) KISQALI (400 MG DOSE) ORAL TABLET THERAPY PSP PACK 200 MG (ribociclib succinate) KISQALI (600 MG DOSE) ORAL TABLET THERAPY PSP PACK 200 MG (ribociclib succinate) KISQALI FEMARA (400 MG DOSE) ORAL TABLET PSP THERAPY PACK 200 & 2.5 MG (ribociclib-letrozole) KISQALI FEMARA (600 MG DOSE) ORAL TABLET PSP THERAPY PACK 200 & 2.5 MG (ribociclib-letrozole) KISQALI FEMARA(200 MG DOSE) ORAL TABLET PSP THERAPY PACK 200 & 2.5 MG (ribociclib-letrozole) LYNPARZA ORAL TABLET 100 MG, 150 MG (olaparib) PSP PERJETA INTRAVENOUS SOLUTION 420 MG/14ML PSP (pertuzumab) POLIVY INTRAVENOUS SOLUTION RECONSTITUTED 140 MG, 30 MG (polatuzumab vedotin- NF piiq) PORTRAZZA INTRAVENOUS SOLUTION 800 NPB MG/50ML (necitumumab) RIABNI INTRAVENOUS SOLUTION 100 MG/10ML, 500 NF MG/50ML (rituximab-arrx) RITUXAN INTRAVENOUS SOLUTION 100 MG/10ML, NF 500 MG/50ML (rituximab) romidepsin intravenous solution 27.5 mg/5.5ml NPSP RUBRACA ORAL TABLET 200 MG, 250 MG, 300 MG PSP (rucaparib camsylate) RUXIENCE INTRAVENOUS SOLUTION 100 MG/10ML, PSP 500 MG/50ML (rituximab-pvvr) RYDAPT ORAL CAPSULE 25 MG (midostaurin) PSP

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 38 Prescription Drug Name Drug Tier Drug Notes SARCLISA INTRAVENOUS SOLUTION 100 MG/5ML, NPSP 500 MG/25ML (isatuximab-irfc) TALZENNA ORAL CAPSULE 0.25 MG, 1 MG (talazoparib NF tosylate) TRAZIMERA INTRAVENOUS SOLUTION PSP RECONSTITUTED 150 MG, 420 MG (trastuzumab-qyyp) TRODELVY INTRAVENOUS SOLUTION NPB RECONSTITUTED 180 MG (sacituzumab govitecan-hziy) TRUXIMA INTRAVENOUS SOLUTION 100 MG/10ML, NF 500 MG/50ML (rituximab-abbs) VERZENIO ORAL TABLET 100 MG, 150 MG, 200 MG, 50 NPSP MG (abemaciclib) ZEJULA ORAL CAPSULE 100 MG (niraparib tosylate) PSP ZOLINZA ORAL CAPSULE 100 MG (vorinostat) PSP HORMONAL ANTINEOPLASTIC AGENTS abiraterone acetate oral tablet 250 mg G anastrozole oral tablet 1 mg CE bicalutamide oral tablet 50 mg G ELIGARD SUBCUTANEOUS KIT 30 MG (leuprolide PSP acetate (4 month)) ERLEADA ORAL TABLET 60 MG (apalutamide) PSP exemestane oral tablet 25 mg CE FASLODEX INTRAMUSCULAR SOLUTION 250 NPB MG/5ML (fulvestrant) FIRMAGON (240 MG DOSE) SUBCUTANEOUS SOLUTION RECONSTITUTED 120 MG/VIAL (degarelix PSP acetate) FIRMAGON SUBCUTANEOUS SOLUTION PSP RECONSTITUTED 80 MG (degarelix acetate) flutamide oral capsule 125 mg G letrozole oral tablet 2.5 mg G leuprolide acetate injection kit 1 mg/0.2ml G LUPRON DEPOT (1-MONTH) INTRAMUSCULAR KIT NF 3.75 MG, 7.5 MG (leuprolide acetate) LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT NF 11.25 MG, 22.5 MG (leuprolide acetate (3 month)) LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT NF 30 MG (leuprolide acetate (4 month))

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 39 Prescription Drug Name Drug Tier Drug Notes LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT NF 45 MG (leuprolide acetate (6 month)) LUPRON DEPOT-PED (1-MONTH) INTRAMUSCULAR NF KIT 11.25 MG, 15 MG, 7.5 MG (leuprolide acetate) LUPRON DEPOT-PED (3-MONTH) INTRAMUSCULAR KIT 11.25 MG (PED), 30 MG (PED) (leuprolide acetate (3 NF month)) LYSODREN ORAL TABLET 500 MG (mitotane) PB megestrol acetate oral suspension 40 mg/ml, 400 mg/10ml, 625 G mg/5ml megestrol acetate oral tablet 20 mg, 40 mg G NILANDRON ORAL TABLET 150 MG (nilutamide) NF nilutamide oral tablet 150 mg G NUBEQA ORAL TABLET 300 MG (darolutamide) PSP SOLTAMOX ORAL SOLUTION 10 MG/5ML (tamoxifen NPB citrate) tamoxifen citrate oral tablet 10 mg, 20 mg CE toremifene citrate oral tablet 60 mg G TRELSTAR MIXJECT INTRAMUSCULAR SUSPENSION RECONSTITUTED 11.25 MG, 22.5 MG, NF 3.75 MG (triptorelin pamoate) VANTAS SUBCUTANEOUS KIT 50 MG (histrelin acetate) NPSP XTANDI ORAL CAPSULE 40 MG (enzalutamide) PSP XTANDI ORAL TABLET 40 MG, 80 MG (enzalutamide) PSP YONSA ORAL TABLET 125 MG (abiraterone acetate) PSP ZOLADEX SUBCUTANEOUS IMPLANT 10.8 MG, 3.6 NF MG (goserelin acetate) KINASE INHIBITORS AFINITOR DISPERZ ORAL TABLET SOLUBLE 2 MG, 3 PSP MG, 5 MG (everolimus) AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 MG, 7.5 PSP MG (everolimus) ALECENSA ORAL CAPSULE 150 MG (alectinib hcl) PSP ALIQOPA INTRAVENOUS SOLUTION NF RECONSTITUTED 60 MG (copanlisib hcl) ALUNBRIG ORAL TABLET 180 MG, 30 MG, 90 MG PSP (brigatinib)

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 40 Prescription Drug Name Drug Tier Drug Notes ALUNBRIG ORAL TABLET THERAPY PACK 90 & 180 PSP MG (brigatinib) BALVERSA ORAL TABLET 3 MG, 4 MG, 5 MG NPB (erdafitinib) BOSULIF ORAL TABLET 100 MG, 400 MG, 500 MG PSP (bosutinib) BRUKINSA ORAL CAPSULE 80 MG (zanubrutinib) NPB CABOMETYX ORAL TABLET 20 MG, 40 MG, 60 MG PSP (cabozantinib s-malate) CALQUENCE ORAL CAPSULE 100 MG (acalabrutinib) NPB CAPRELSA ORAL TABLET 100 MG, 300 MG (vandetanib) NPB COMETRIQ (100 MG DAILY DOSE) ORAL KIT 80 & 20 NPSP MG (cabozantinib s-malate) COMETRIQ (140 MG DAILY DOSE) ORAL KIT 3 X 20 NPSP MG & 80 MG (cabozantinib s-malate) COMETRIQ (60 MG DAILY DOSE) ORAL KIT 20 MG NPSP (cabozantinib s-malate) COPIKTRA ORAL CAPSULE 15 MG, 25 MG (duvelisib) PSP COTELLIC ORAL TABLET 20 MG (cobimetinib fumarate) NPSP erlotinib hcl oral tablet 100 mg, 150 mg, 25 mg G ICLUSIG ORAL TABLET 10 MG, 15 MG, 30 MG, 45 MG NPB (ponatinib hcl) IDHIFA ORAL TABLET 100 MG, 50 MG (enasidenib NPSP mesylate) imatinib mesylate oral tablet 100 mg, 400 mg G IMBRUVICA ORAL CAPSULE 140 MG, 70 MG (ibrutinib) NPB IMBRUVICA ORAL TABLET 140 MG, 280 MG, 420 MG, NPB 560 MG (ibrutinib) INLYTA ORAL TABLET 1 MG, 5 MG (axitinib) NPSP INREBIC ORAL CAPSULE 100 MG (fedratinib hcl) NF IRESSA ORAL TABLET 250 MG (gefitinib) PSP JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 NPSP MG (ruxolitinib phosphate) KOSELUGO ORAL CAPSULE 10 MG, 25 MG (selumetinib NPB sulfate) LENVIMA (10 MG DAILY DOSE) ORAL CAPSULE NPSP THERAPY PACK 10 MG (lenvatinib mesylate)

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 41 Prescription Drug Name Drug Tier Drug Notes LENVIMA (12 MG DAILY DOSE) ORAL CAPSULE NPSP THERAPY PACK 3 X 4 MG (lenvatinib mesylate) LENVIMA (14 MG DAILY DOSE) ORAL CAPSULE NPSP THERAPY PACK 10 & 4 MG (lenvatinib mesylate) LENVIMA (18 MG DAILY DOSE) ORAL CAPSULE NPSP THERAPY PACK 10 MG & 2 X 4 MG (lenvatinib mesylate) LENVIMA (20 MG DAILY DOSE) ORAL CAPSULE NPSP THERAPY PACK 2 X 10 MG (lenvatinib mesylate) LENVIMA (24 MG DAILY DOSE) ORAL CAPSULE NPSP THERAPY PACK 2 X 10 MG & 4 MG (lenvatinib mesylate) LENVIMA (4 MG DAILY DOSE) ORAL CAPSULE NPSP THERAPY PACK 4 MG (lenvatinib mesylate) LENVIMA (8 MG DAILY DOSE) ORAL CAPSULE NPSP THERAPY PACK 2 X 4 MG (lenvatinib mesylate) LORBRENA ORAL TABLET 100 MG, 25 MG (lorlatinib) NPSP LUMAKRAS ORAL TABLET 120 MG (sotorasib) NPSP MEKINIST ORAL TABLET 0.5 MG, 2 MG (trametinib NPSP dimethyl sulfoxide) NERLYNX ORAL TABLET 40 MG (neratinib maleate) NPSP NEXAVAR ORAL TABLET 200 MG (sorafenib tosylate) NPSP PIQRAY (200 MG DAILY DOSE) ORAL TABLET NPSP THERAPY PACK 200 MG (alpelisib) PIQRAY (250 MG DAILY DOSE) ORAL TABLET NPSP THERAPY PACK 200 & 50 MG (alpelisib) PIQRAY (300 MG DAILY DOSE) ORAL TABLET NPSP THERAPY PACK 2 X 150 MG (alpelisib) ROZLYTREK ORAL CAPSULE 100 MG, 200 MG NPSP (entrectinib) SPRYCEL ORAL TABLET 100 MG, 140 MG, 20 MG, 50 PSP MG, 70 MG, 80 MG (dasatinib) STIVARGA ORAL TABLET 40 MG (regorafenib) PSP SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 PSP MG (sunitinib malate) TAFINLAR ORAL CAPSULE 50 MG, 75 MG (dabrafenib NPSP mesylate) TAGRISSO ORAL TABLET 40 MG, 80 MG (osimertinib NPSP mesylate) TARCEVA ORAL TABLET 100 MG, 150 MG, 25 MG NPSP (erlotinib hcl) 2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 42 Prescription Drug Name Drug Tier Drug Notes TUKYSA ORAL TABLET 150 MG, 50 MG (tucatinib) NPB TURALIO ORAL CAPSULE 200 MG (pexidartinib hcl) NF TYKERB ORAL TABLET 250 MG (lapatinib ditosylate) NPSP VITRAKVI ORAL CAPSULE 100 MG, 25 MG (larotrectinib NPSP sulfate) VITRAKVI ORAL SOLUTION 20 MG/ML (larotrectinib NPSP sulfate) VIZIMPRO ORAL TABLET 15 MG, 30 MG, 45 MG NF (dacomitinib) VOTRIENT ORAL TABLET 200 MG (pazopanib hcl) PSP XALKORI ORAL CAPSULE 200 MG, 250 MG (crizotinib) NPSP XOSPATA ORAL TABLET 40 MG (gilteritinib fumarate) PSP ZELBORAF ORAL TABLET 240 MG (vemurafenib) NPSP ZIRABEV INTRAVENOUS SOLUTION 100 MG/4ML, 400 PSP MG/16ML (bevacizumab-bvzr) ZYDELIG ORAL TABLET 100 MG, 150 MG (idelalisib) NF ZYKADIA ORAL TABLET 150 MG (ceritinib) NPSP MISCELLANEOUS ASPARLAS INTRAVENOUS SOLUTION 3750 NPB UNIT/5ML (calaspargase pegol-mknl) bexarotene oral capsule 75 mg G BRAFTOVI ORAL CAPSULE 75 MG (encorafenib) NPB DROXIA ORAL CAPSULE 200 MG, 300 MG, 400 MG NPB (hydroxyurea) ERWINAZE INJECTION SOLUTION RECONSTITUTED NPB 10000 UNIT (asparaginase erwinia chrysanth) GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG NPB (afatinib dimaleate) HERCEPTIN HYLECTA SUBCUTANEOUS SOLUTION NF 600-10000 MG-UNT/5ML (trastuzumab-hyaluronidase-oysk) hydroxyurea oral capsule 500 mg G INGREZZA ORAL CAPSULE 60 MG (valbenazine tosylate) PSP LONSURF ORAL TABLET 15-6.14 MG, 20-8.19 MG PSP (trifluridine-tipiracil) MATULANE ORAL CAPSULE 50 MG (procarbazine hcl) PB MEKTOVI ORAL TABLET 15 MG (binimetinib) NPB ODOMZO ORAL CAPSULE 200 MG (sonidegib phosphate) PSP

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 43 Prescription Drug Name Drug Tier Drug Notes PHESGO SUBCUTANEOUS SOLUTION 60-60-2000 MG- MG-U/ML, 80-40-2000 MG-MG-U/ML (pertuz-trastuz- PSP hyaluron-zzxf) SYNRIBO SUBCUTANEOUS SOLUTION NPB RECONSTITUTED 3.5 MG (omacetaxine mepesuccinate) TARGRETIN ORAL CAPSULE 75 MG (bexarotene) NPSP TIBSOVO ORAL TABLET 250 MG (ivosidenib) NPB TICE BCG INTRAVESICAL SUSPENSION NPB RECONSTITUTED 50 MG (bcg live) tretinoin oral capsule 10 mg G UVADEX INJECTION SOLUTION 20 MCG/ML NPB (methoxsalen (photopheresis)) VISTOGARD ORAL PACKET 10 GM (uridine triacetate) PB XOFIGO INTRAVENOUS SOLUTION 30 MCCI/ML NF (radium ra 223 dichloride) XPOVIO (60 MG TWICE WEEKLY) ORAL TABLET NF THERAPY PACK 20 MG (selinexor) XPOVIO (80 MG TWICE WEEKLY) ORAL TABLET NF THERAPY PACK 20 MG (selinexor) PROTEASOME INHIBITORS bortezomib intravenous solution reconstituted 3.5 mg NF KYPROLIS INTRAVENOUS SOLUTION NF RECONSTITUTED 10 MG, 30 MG, 60 MG (carfilzomib) NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 MG PSP (ixazomib citrate) VELCADE INJECTION SOLUTION RECONSTITUTED PSP 3.5 MG (bortezomib) PROTECTIVE AGENTS KHAPZORY INTRAVENOUS SOLUTION NF RECONSTITUTED 175 MG, 300 MG (levoleucovorin) leucovorin calcium oral tablet 10 mg, 15 mg, 25 mg, 5 mg G MESNEX ORAL TABLET 400 MG (mesna) NPB TOPOISOMERASE INHIBITORS etoposide oral capsule 50 mg G HYCAMTIN ORAL CAPSULE 0.25 MG, 1 MG (topotecan NPSP hcl)

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 44 Prescription Drug Name Drug Tier Drug Notes ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES ANTINEOPLASTIC, BCL-2 INHIBITORS VENCLEXTA ORAL TABLET 10 MG, 100 MG, 50 MG NPB (venetoclax) VENCLEXTA STARTING PACK ORAL TABLET NPB THERAPY PACK 10 & 50 & 100 MG (venetoclax) CARDIOVASCULAR - DRUGS TO TREAT HEART AND CIRCULATION CONDITIONS ACE INHIBITOR COMBINATIONS - DRUGS TO TREAT HIGH BLOOD PRESSURE amlodipine besy-benazepril hcl oral capsule 10-20 mg, 10-40 mg, G LGC 2.5-10 mg, 5-10 mg, 5-20 mg, 5-40 mg benazepril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 G LGC mg, 20-25 mg, 5-6.25 mg enalapril-hydrochlorothiazide oral tablet 10-25 mg, 5-12.5 mg G LGC fosinopril sodium-hctz oral tablet 10-12.5 mg, 20-12.5 mg G LGC lisinopril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 G LGC mg, 20-25 mg PRESTALIA ORAL TABLET 14-10 MG, 3.5-2.5 MG, 7-5 NF MG (perindopril arg-amlodipine) quinapril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 G LGC mg, 20-25 mg trandolapril-verapamil hcl er oral tablet extended release 1-240 G mg, 2-180 mg, 2-240 mg, 4-240 mg ZESTORETIC ORAL TABLET 10-12.5 MG, 20-12.5 MG, NF 20-25 MG (lisinopril-hydrochlorothiazide) ACE INHIBITORS - DRUGS TO TREAT HIGH BLOOD PRESSURE benazepril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg G LGC captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg G LGC enalapril maleate oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg G LGC EPANED ORAL SOLUTION 1 MG/ML (enalapril maleate) NPB fosinopril sodium oral tablet 10 mg, 20 mg, 40 mg G LGC lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg G LGC lisinopril oral tablet 30 mg, 40 mg G moexipril hcl oral tablet 15 mg, 7.5 mg G perindopril erbumine oral tablet 2 mg, 4 mg, 8 mg G LGC

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 45 Prescription Drug Name Drug Tier Drug Notes QBRELIS ORAL SOLUTION 1 MG/ML (lisinopril) NPB quinapril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg G LGC ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5 mg G LGC trandolapril oral tablet 1 mg, 2 mg, 4 mg G LGC ALDOSTERONE RECEPTOR ANTAGONISTS - DRUGS TO TREAT HIGH BLOOD PRESSURE eplerenone oral tablet 25 mg, 50 mg G ALPHA BLOCKERS - DRUGS TO TREAT HIGH BLOOD PRESSURE doxazosin mesylate oral tablet 1 mg, 2 mg, 4 mg, 8 mg G prazosin hcl oral capsule 1 mg, 2 mg, 5 mg G terazosin hcl oral capsule 1 mg, 10 mg, 2 mg, 5 mg G LGC ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS - DRUGS TO TREAT HIGH BLOOD PRESSURE amlodipine besylate-valsartan oral tablet 10-160 mg, 10-320 mg, G LGC 5-160 mg, 5-320 mg amlodipine-olmesartan oral tablet 10-20 mg, 10-40 mg, 5-20 mg, G LGC 5-40 mg amlodipine-valsartan-hctz oral tablet 10-160-12.5 mg, 10-160-25 G LGC mg, 10-320-25 mg, 5-160-12.5 mg, 5-160-25 mg ATACAND HCT ORAL TABLET 16-12.5 MG, 32-12.5 NF MG, 32-25 MG (candesartan cilexetil-hctz) AZOR ORAL TABLET 10-20 MG, 10-40 MG, 5-20 MG, 5- NF 40 MG (amlodipine-olmesartan) BENICAR HCT ORAL TABLET 20-12.5 MG, 40-12.5 MG, NF 40-25 MG (olmesartan medoxomil-hctz) candesartan cilexetil-hctz oral tablet 16-12.5 mg, 32-12.5 mg, G LGC 32-25 mg DIOVAN HCT ORAL TABLET 160-12.5 MG, 160-25 MG, 320-12.5 MG, 320-25 MG, 80-12.5 MG (valsartan- NF hydrochlorothiazide) EDARBYCLOR ORAL TABLET 40-12.5 MG, 40-25 MG NF (azilsartan-chlorthalidone) EXFORGE HCT ORAL TABLET 10-160-12.5 MG, 10-160- 25 MG, 10-320-25 MG, 5-160-12.5 MG, 5-160-25 MG NF (amlodipine-valsartan-hctz) EXFORGE ORAL TABLET 10-160 MG, 10-320 MG, 5-160 NF MG, 5-320 MG (amlodipine besylate-valsartan) 2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 46 Prescription Drug Name Drug Tier Drug Notes HYZAAR ORAL TABLET 100-12.5 MG, 100-25 MG, 50- NF 12.5 MG (losartan potassium-hctz) irbesartan-hydrochlorothiazide oral tablet 150-12.5 mg, 300- G LGC 12.5 mg losartan potassium-hctz oral tablet 100-12.5 mg, 100-25 mg, 50- G LGC 12.5 mg MICARDIS HCT ORAL TABLET 40-12.5 MG, 80-12.5 NF MG, 80-25 MG (telmisartan-hctz) olmesartan medoxomil-hctz oral tablet 20-12.5 mg, 40-12.5 mg, G LGC 40-25 mg olmesartan-amlodipine-hctz oral tablet 20-5-12.5 mg, 40-10- G LGC 12.5 mg, 40-10-25 mg, 40-5-12.5 mg, 40-5-25 mg telmisartan-amlodipine oral tablet 40-10 mg, 40-5 mg, 80-10 G LGC mg, 80-5 mg telmisartan-hctz oral tablet 40-12.5 mg, 80-12.5 mg, 80-25 mg G LGC valsartan-hydrochlorothiazide oral tablet 160-12.5 mg, 160-25 G LGC mg, 320-12.5 mg, 320-25 mg, 80-12.5 mg ANGIOTENSIN II RECEPTOR ANTAGONISTS - DRUGS TO TREAT HIGH BLOOD PRESSURE ATACAND ORAL TABLET 16 MG, 32 MG, 4 MG, 8 MG NF (candesartan cilexetil) BENICAR ORAL TABLET 20 MG, 40 MG, 5 MG NF (olmesartan medoxomil) candesartan cilexetil oral tablet 16 mg, 32 mg, 4 mg, 8 mg G LGC COZAAR ORAL TABLET 100 MG, 25 MG, 50 MG NF (losartan potassium) DIOVAN ORAL TABLET 160 MG, 320 MG, 40 MG, 80 NF MG (valsartan) EDARBI ORAL TABLET 40 MG, 80 MG (azilsartan NF medoxomil) irbesartan oral tablet 150 mg, 300 mg, 75 mg G LGC losartan potassium oral tablet 100 mg, 25 mg, 50 mg G LGC MICARDIS ORAL TABLET 20 MG, 40 MG, 80 MG NF (telmisartan) olmesartan medoxomil oral tablet 20 mg, 40 mg, 5 mg G LGC telmisartan oral tablet 20 mg, 40 mg, 80 mg G LGC valsartan oral tablet 160 mg, 320 mg, 40 mg, 80 mg G LGC

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 47 Prescription Drug Name Drug Tier Drug Notes ANTIARRHYTHMICS - DRUGS TO CONTROL HEART RHYTHM amiodarone hcl oral tablet 100 mg, 200 mg, 400 mg G disopyramide phosphate oral capsule 100 mg, 150 mg G dofetilide oral capsule 125 mcg, 250 mcg, 500 mcg G flecainide acetate oral tablet 100 mg, 150 mg, 50 mg G lidocaine hcl (cardiac) pf intravenous solution prefilled syringe NPB 100 mg/5ml mexiletine hcl oral capsule 150 mg, 200 mg, 250 mg NPB MULTAQ ORAL TABLET 400 MG (dronedarone hcl) PB NORPACE CR ORAL CAPSULE EXTENDED RELEASE NPB 12 HOUR 100 MG, 150 MG (disopyramide phosphate) NORPACE ORAL CAPSULE 100 MG, 150 MG NF (disopyramide phosphate) amiodarone hcl (Pacerone Oral Tablet 100 Mg, 200 Mg, 400 G Mg) propafenone hcl er oral capsule extended release 12 hour 225 G mg, 325 mg, 425 mg propafenone hcl oral tablet 150 mg, 225 mg, 300 mg G quinidine gluconate er oral tablet extended release 324 mg G quinidine sulfate oral tablet 200 mg, 300 mg G sotalol hcl (Sorine Oral Tablet 120 Mg, 80 Mg) G LGC sotalol hcl (Sorine Oral Tablet 160 Mg, 240 Mg) G sotalol hcl (af) oral tablet 120 mg G LGC sotalol hcl (af) oral tablet 160 mg, 80 mg G sotalol hcl oral tablet 120 mg, 80 mg G LGC sotalol hcl oral tablet 160 mg, 240 mg G TIKOSYN ORAL CAPSULE 125 MCG, 250 MCG, 500 NPSP MCG (dofetilide) ANTILIPEMICS, ACL INHIBITORS/COMBINATIONS NEXLETOL ORAL TABLET 180 MG (bempedoic acid) PB NEXLIZET ORAL TABLET 180-10 MG (bempedoic acid- PB ezetimibe) ANTILIPEMICS, BILE ACID RESINS cholestyramine light oral packet 4 gm G cholestyramine light oral powder 4 gm/dose G

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 48 Prescription Drug Name Drug Tier Drug Notes cholestyramine oral packet 4 gm G cholestyramine oral powder 4 gm/dose G colesevelam hcl oral packet 3.75 gm G colesevelam hcl oral tablet 625 mg G colestipol hcl oral granules 5 gm G colestipol hcl oral packet 5 gm G colestipol hcl oral tablet 1 gm G cholestyramine light (Prevalite Oral Packet 4 Gm) G cholestyramine light (Prevalite Oral Powder 4 Gm/Dose) G ANTILIPEMICS, CHOLESTEROL ABSORPTION INHIBITOR ezetimibe oral tablet 10 mg G ZETIA ORAL TABLET 10 MG (ezetimibe) NF ANTILIPEMICS, FIBRATES ANTARA ORAL CAPSULE 30 MG, 90 MG (fenofibrate NPB micronized) fenofibrate micronized oral capsule 130 mg NF fenofibrate micronized oral capsule 134 mg, 200 mg, 43 mg, 67 G mg fenofibrate oral capsule 150 mg G fenofibrate oral capsule 50 mg NF fenofibrate oral tablet 120 mg, 40 mg NF fenofibrate oral tablet 145 mg, 48 mg, 54 mg G fenofibrate oral tablet 160 mg NPB fenofibric acid oral capsule delayed release 135 mg, 45 mg G fenofibric acid oral tablet 105 mg G FENOGLIDE ORAL TABLET 120 MG (fenofibrate) NF FIBRICOR ORAL TABLET 105 MG, 35 MG (fenofibric NPB acid) gemfibrozil oral tablet 600 mg G LGC TRICOR ORAL TABLET 145 MG, 48 MG (fenofibrate) NF ANTILIPEMICS, HMG-COA REDUCTASE INHIBITORS ALTOPREV ORAL TABLET EXTENDED RELEASE 24 NF HOUR 20 MG, 40 MG, 60 MG (lovastatin) atorvastatin calcium oral tablet 10 mg, 20 mg CE LGC atorvastatin calcium oral tablet 40 mg, 80 mg G LGC 2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 49 Prescription Drug Name Drug Tier Drug Notes CRESTOR ORAL TABLET 10 MG, 20 MG, 40 MG, 5 MG NF (rosuvastatin calcium) EZALLOR SPRINKLE ORAL CAPSULE SPRINKLE 10 NF MG, 20 MG, 40 MG, 5 MG (rosuvastatin calcium) flolipid oral suspension 20 mg/5ml, 40 mg/5ml NF fluvastatin sodium er oral tablet extended release 24 hour 80 mg G fluvastatin sodium oral capsule 20 mg, 40 mg G LESCOL XL ORAL TABLET EXTENDED RELEASE 24 NF HOUR 80 MG (fluvastatin sodium) LIPITOR ORAL TABLET 10 MG, 20 MG, 40 MG, 80 MG NF (atorvastatin calcium) LIVALO ORAL TABLET 1 MG, 2 MG, 4 MG (pitavastatin NF calcium) lovastatin oral tablet 10 mg, 20 mg, 40 mg G LGC pravastatin sodium oral tablet 10 mg, 20 mg, 40 mg, 80 mg G LGC rosuvastatin calcium oral tablet 10 mg, 20 mg, 40 mg, 5 mg G LGC simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg CE LGC simvastatin oral tablet 80 mg G LGC ZYPITAMAG ORAL TABLET 2 MG, 4 MG (pitavastatin NF magnesium) ANTILIPEMICS, HMG-COA REDUCTASE INHIBITORS/COMBINATIONS ezetimibe-simvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 mg, G 10-80 mg ANTILIPEMICS, MISCELLANEOUS - DRUGS TO TREAT HIGH CHOLESTEROL JUXTAPID ORAL CAPSULE 10 MG, 20 MG, 30 MG, 5 NPSP MG (lomitapide mesylate) niacin (antihyperlipidemic) oral tablet 500 mg NF niacin er (antihyperlipidemic) oral tablet extended release 1000 G mg, 500 mg, 750 mg NIACOR ORAL TABLET 500 MG (niacin NF (antihyperlipidemic)) ANTILIPEMICS, OMEGA-3 FATTY ACIDS icosapent ethyl oral capsule 1 gm NF omega-3-acid ethyl esters oral capsule 1 gm G VASCEPA ORAL CAPSULE 0.5 GM (icosapent ethyl) PB

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 50 Prescription Drug Name Drug Tier Drug Notes N8 (Listing does not include VASCEPA ORAL CAPSULE 1 GM (icosapent ethyl) PB certain NDCs) ANTILIPEMICS, PCSK9 INHIBITORS PRALUENT SUBCUTANEOUS SOLUTION AUTO- PSP INJECTOR 150 MG/ML, 75 MG/ML (alirocumab) REPATHA PUSHTRONEX SYSTEM SUBCUTANEOUS NF SOLUTION CARTRIDGE 420 MG/3.5ML (evolocumab) REPATHA SUBCUTANEOUS SOLUTION PREFILLED NF SYRINGE 140 MG/ML (evolocumab) REPATHA SURECLICK SUBCUTANEOUS SOLUTION NF AUTO-INJECTOR 140 MG/ML (evolocumab) BETA-BLOCKER/DIURETIC COMBINATIONS - DRUGS TO TREAT HIGH BLOOD PRESSURE AND HEART CONDITIONS atenolol-chlorthalidone oral tablet 100-25 mg, 50-25 mg G bisoprolol-hydrochlorothiazide oral tablet 10-6.25 mg, 2.5-6.25 G LGC mg, 5-6.25 mg DUTOPROL ORAL TABLET EXTENDED RELEASE 24 HOUR 100-12.5 MG, 25-12.5 MG, 50-12.5 MG (metoprolol- NF hydrochlorothiazide) metoprolol-hydrochlorothiazide oral tablet 100-25 mg, 100-50 G mg, 50-25 mg BETA-BLOCKERS - DRUGS TO TREAT HIGH BLOOD PRESSURE AND HEART CONDITIONS acebutolol hcl oral capsule 200 mg, 400 mg G atenolol oral tablet 100 mg, 25 mg, 50 mg G LGC BETAPACE AF ORAL TABLET 120 MG, 160 MG, 80 MG NF (sotalol hcl af) BETAPACE ORAL TABLET 120 MG, 160 MG, 80 MG NF (sotalol hcl) betaxolol hcl oral tablet 10 mg, 20 mg G bisoprolol fumarate oral tablet 10 mg, 5 mg G BYSTOLIC ORAL TABLET 10 MG, 2.5 MG, 20 MG, 5 MG NF (nebivolol hcl) carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg G LGC carvedilol phosphate er oral capsule extended release 24 hour 10 G mg, 20 mg, 40 mg, 80 mg COREG CR ORAL CAPSULE EXTENDED RELEASE 24 NF HOUR 10 MG, 20 MG, 40 MG, 80 MG (carvedilol phosphate) 2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 51 Prescription Drug Name Drug Tier Drug Notes HEMANGEOL ORAL SOLUTION 4.28 MG/ML NPB (propranolol hcl) INDERAL LA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 160 MG, 60 MG, 80 MG (propranolol NF hcl) INDERAL XL ORAL CAPSULE EXTENDED RELEASE NF 24 HOUR 120 MG, 80 MG (propranolol hcl sr beads) INNOPRAN XL ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 80 MG (propranolol hcl sr NF beads) KAPSPARGO SPRINKLE ORAL CAPSULE ER 24 HOUR SPRINKLE 100 MG, 200 MG, 25 MG, 50 MG NF (metoprolol succinate) labetalol hcl oral tablet 100 mg, 200 mg, 300 mg G metoprolol succinate er oral tablet extended release 24 hour 100 G mg, 200 mg, 25 mg, 50 mg metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg G LGC metoprolol tartrate oral tablet 37.5 mg, 75 mg G nadolol oral tablet 20 mg, 40 mg, 80 mg G pindolol oral tablet 10 mg, 5 mg G propranolol hcl er oral capsule extended release 24 hour 120 mg, G 160 mg, 60 mg, 80 mg propranolol hcl oral solution 20 mg/5ml, 40 mg/5ml G propranolol hcl oral tablet 10 mg, 20 mg, 40 mg, 80 mg G LGC propranolol hcl oral tablet 60 mg G SOTYLIZE ORAL SOLUTION 5 MG/ML (sotalol hcl) NPB timolol maleate oral tablet 10 mg, 20 mg, 5 mg G TOPROL XL ORAL TABLET EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 25 MG, 50 MG (metoprolol NF succinate) CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS amlodipine-atorvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg, 2.5-10 mg, 2.5-20 mg, 2.5-40 mg, 5-10 mg, 5-20 G LGC mg, 5-40 mg, 5-80 mg CALCIUM CHANNEL BLOCKERS - DRUGS TO TREAT HIGH BLOOD PRESSURE AND HEART CONDITIONS amlodipine besylate oral tablet 10 mg, 2.5 mg, 5 mg G LGC

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 52 Prescription Drug Name Drug Tier Drug Notes CARDIZEM CD ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, NF 360 MG (diltiazem hcl coated beads) CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG, 420 NF MG (diltiazem hcl coated beads) CARDIZEM ORAL TABLET 120 MG, 30 MG, 60 MG NF (diltiazem hcl) diltiazem hcl coated beads (Cartia Xt Oral Capsule Extended G Release 24 Hour 120 Mg, 180 Mg, 240 Mg, 300 Mg) CONSENSI ORAL TABLET 10-200 MG, 2.5-200 MG, 5-200 NF MG (amlodipine besylate-celecoxib) diltiazem hcl er beads oral capsule extended release 24 hour 120 G mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg diltiazem hcl er coated beads oral capsule extended release 24 G hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg diltiazem hcl er coated beads oral tablet extended release 24 NF hour 180 mg, 240 mg, 300 mg, 360 mg, 420 mg diltiazem hcl er oral capsule extended release 12 hour 120 mg, G 60 mg, 90 mg diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg G LGC dilt-xr oral capsule extended release 24 hour 120 mg, 180 mg, G 240 mg felodipine er oral tablet extended release 24 hour 10 mg, 2.5 mg, G 5 mg isradipine oral capsule 2.5 mg, 5 mg G KATERZIA ORAL SUSPENSION 1 MG/ML (amlodipine NF benzoate) diltiazem hcl coated beads (Matzim La Oral Tablet Extended NF Release 24 Hour 180 Mg, 240 Mg, 300 Mg, 360 Mg, 420 Mg) nicardipine hcl oral capsule 20 mg, 30 mg G nifedipine er oral tablet extended release 24 hour 30 mg, 60 mg, G 90 mg nifedipine er osmotic release oral tablet extended release 24 hour G 30 mg, 60 mg, 90 mg nifedipine oral capsule 10 mg, 20 mg G nimodipine oral capsule 30 mg G nisoldipine er oral tablet extended release 24 hour 17 mg, 20 mg, G 25.5 mg, 30 mg, 34 mg, 40 mg, 8.5 mg 2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 53 Prescription Drug Name Drug Tier Drug Notes NORVASC ORAL TABLET 10 MG, 2.5 MG, 5 MG NF (amlodipine besylate) NYMALIZE ORAL SOLUTION 6 MG/ML (nimodipine) NPB diltiazem hcl er beads (Taztia Xt Oral Capsule Extended G Release 24 Hour 120 Mg, 180 Mg, 240 Mg, 300 Mg, 360 Mg) verapamil hcl er oral capsule extended release 24 hour 100 mg, G 120 mg, 180 mg, 200 mg, 240 mg, 300 mg, 360 mg verapamil hcl er oral tablet extended release 120 mg G LGC verapamil hcl er oral tablet extended release 180 mg, 240 mg G verapamil hcl oral tablet 120 mg, 40 mg, 80 mg G LGC DIGITALIS GLYCOSIDES - DRUGS TO TREAT HEART CONDITIONS digoxin (Digitek Oral Tablet 125 Mcg, 250 Mcg) G digoxin (Digox Oral Tablet 125 Mcg, 250 Mcg) G digoxin oral solution 0.05 mg/ml G digoxin oral tablet 125 mcg, 250 mcg G LANOXIN ORAL TABLET 125 MCG, 250 MCG (digoxin) NF LANOXIN ORAL TABLET 62.5 MCG (digoxin) NPB DIRECT RENIN INHIBITORS/COMBINATIONS - DRUGS TO TREAT HEART CONDITIONS aliskiren fumarate oral tablet 150 mg, 300 mg G TEKTURNA HCT ORAL TABLET 150-12.5 MG, 150-25 PB MG, 300-12.5 MG, 300-25 MG (aliskiren-hydrochlorothiazide) TEKTURNA ORAL TABLET 150 MG, 300 MG (aliskiren NPB fumarate) DIURETICS - DRUGS TO TREAT HEART CONDITIONS acetazolamide er oral capsule extended release 12 hour 500 mg G acetazolamide oral tablet 125 mg, 250 mg G ALDACTAZIDE ORAL TABLET 50-50 MG NPB (spironolactone-hctz) amiloride hcl oral tablet 5 mg G amiloride-hydrochlorothiazide oral tablet 5-50 mg G LGC bumetanide oral tablet 0.5 mg, 1 mg, 2 mg G CAROSPIR ORAL SUSPENSION 25 MG/5ML NF (spironolactone) chlorthalidone oral tablet 25 mg, 50 mg G

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 54 Prescription Drug Name Drug Tier Drug Notes DIURIL ORAL SUSPENSION 250 MG/5ML NPB (chlorothiazide) DYRENIUM ORAL CAPSULE 100 MG, 50 MG NF (triamterene) ethacrynic acid oral tablet 25 mg G furosemide oral solution 10 mg/ml, 8 mg/ml G furosemide oral tablet 20 mg, 40 mg, 80 mg G LGC hydrochlorothiazide oral capsule 12.5 mg G LGC hydrochlorothiazide oral tablet 12.5 mg G hydrochlorothiazide oral tablet 25 mg, 50 mg G LGC indapamide oral tablet 1.25 mg, 2.5 mg G KEVEYIS ORAL TABLET 50 MG (dichlorphenamide) NPB methazolamide oral tablet 25 mg, 50 mg G metolazone oral tablet 10 mg, 2.5 mg, 5 mg G spironolactone oral tablet 100 mg, 50 mg G spironolactone oral tablet 25 mg G LGC spironolactone-hctz oral tablet 25-25 mg G torsemide oral tablet 10 mg, 100 mg, 20 mg, 5 mg G triamterene oral capsule 100 mg, 50 mg G triamterene-hctz oral capsule 37.5-25 mg G LGC triamterene-hctz oral tablet 37.5-25 mg, 75-50 mg G LGC MISCELLANEOUS BIDIL ORAL TABLET 20-37.5 MG (isosorb dinitrate- PB hydralazine) clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg G LGC clonidine transdermal patch weekly 0.1 mg/24hr, 0.2 mg/24hr, G 0.3 mg/24hr CORLANOR ORAL SOLUTION 5 MG/5ML (ivabradine NPB hcl) CORLANOR ORAL TABLET 5 MG, 7.5 MG (ivabradine PB hcl) DEMSER ORAL CAPSULE 250 MG (metyrosine) NPB ENTRESTO ORAL TABLET 24-26 MG, 49-51 MG, 97-103 PB MG (sacubitril-valsartan) guanfacine hcl oral tablet 1 mg, 2 mg G hydralazine hcl oral tablet 10 mg, 100 mg, 50 mg G

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 55 Prescription Drug Name Drug Tier Drug Notes hydralazine hcl oral tablet 25 mg G LGC methyldopa oral tablet 250 mg, 500 mg G midodrine hcl oral tablet 10 mg, 2.5 mg, 5 mg G minoxidil oral tablet 10 mg, 2.5 mg G NIPRIDE RTU INTRAVENOUS SOLUTION 20-0.9 MG/100ML-%, 50-0.9 MG/100ML-% (nitroprusside sodium- NF nacl) phenoxybenzamine hcl oral capsule 10 mg G ranolazine er oral tablet extended release 12 hour 1000 mg, 500 G mg VECAMYL ORAL TABLET 2.5 MG (mecamylamine hcl) NPB VYNDAMAX ORAL CAPSULE 61 MG (tafamidis) NPSP VYNDAQEL ORAL CAPSULE 20 MG (tafamidis NF meglumine (cardiac)) NITRATES - DRUGS TO TREAT HEART CONDITIONS DILATRATE-SR ORAL CAPSULE EXTENDED NPB RELEASE 40 MG (isosorbide dinitrate) GONITRO SUBLINGUAL PACKET 400 MCG NF (nitroglycerin) ISORDIL TITRADOSE ORAL TABLET 40 MG, 5 MG NF (isosorbide dinitrate) isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 5 mg G isosorbide dinitrate oral tablet 40 mg NF isosorbide mononitrate er oral tablet extended release 24 hour G 120 mg, 30 mg, 60 mg isosorbide mononitrate oral tablet 10 mg, 20 mg G nitroglycerin (Minitran Transdermal Patch 24 Hour 0.1 G Mg/Hr, 0.2 Mg/Hr, 0.4 Mg/Hr, 0.6 Mg/Hr) NITRO-BID TRANSDERMAL OINTMENT 2 % NPB (nitroglycerin) NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.3 NPB MG/HR, 0.8 MG/HR (nitroglycerin) nitroglycerin sublingual tablet sublingual 0.3 mg, 0.4 mg, 0.6 mg G nitroglycerin transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr, G 0.4 mg/hr, 0.6 mg/hr nitroglycerin translingual solution 0.4 mg/spray G NITROMIST TRANSLINGUAL AEROSOL SOLUTION NF 400 MCG/SPRAY (nitroglycerin) 2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 56 Prescription Drug Name Drug Tier Drug Notes PULMONARY ARTERIAL HYPERTENSION - DRUGS TO TREAT PULMONARY HYPERTENSION ADEMPAS ORAL TABLET 0.5 MG, 1 MG, 1.5 MG, 2 MG, PSP 2.5 MG (riociguat) tadalafil (pah) (Alyq Oral Tablet 20 Mg) G ambrisentan oral tablet 10 mg, 5 mg G bosentan oral tablet 125 mg, 62.5 mg G epoprostenol sodium intravenous solution reconstituted 0.5 mg, G 1.5 mg FLOLAN INTRAVENOUS SOLUTION NPSP RECONSTITUTED 0.5 MG, 1.5 MG (epoprostenol sodium) LETAIRIS ORAL TABLET 10 MG, 5 MG (ambrisentan) NF OPSUMIT ORAL TABLET 10 MG (macitentan) PSP ORENITRAM ORAL TABLET EXTENDED RELEASE 0.125 MG, 0.25 MG, 1 MG, 2.5 MG, 5 MG (treprostinil PSP diolamine) REMODULIN INJECTION SOLUTION 100 MG/20ML, 20 NF MG/20ML, 200 MG/20ML, 50 MG/20ML (treprostinil) sildenafil citrate oral suspension reconstituted 10 mg/ml NF sildenafil citrate oral tablet 20 mg G tadalafil (pah) oral tablet 20 mg G TRACLEER ORAL TABLET 125 MG, 62.5 MG (bosentan) NF TRACLEER ORAL TABLET SOLUBLE 32 MG (bosentan) NF treprostinil injection solution 100 mg/20ml, 20 mg/20ml, 200 G mg/20ml, 50 mg/20ml TYVASO INHALATION SOLUTION 0.6 MG/ML NPSP (treprostinil) TYVASO REFILL INHALATION SOLUTION 0.6 NPSP MG/ML (treprostinil) TYVASO STARTER INHALATION SOLUTION 0.6 NPSP MG/ML (treprostinil) UPTRAVI ORAL TABLET 1000 MCG, 1200 MCG, 1400 MCG, 1600 MCG, 200 MCG, 400 MCG, 600 MCG, 800 PSP MCG (selexipag) UPTRAVI ORAL TABLET THERAPY PACK 200 & 800 PSP MCG (selexipag) VELETRI INTRAVENOUS SOLUTION NPSP RECONSTITUTED 0.5 MG, 1.5 MG (epoprostenol sodium)

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 57 Prescription Drug Name Drug Tier Drug Notes VENTAVIS INHALATION SOLUTION 10 MCG/ML, 20 NPSP MCG/ML (iloprost) CENTRAL NERVOUS SYSTEM - DRUGS TO TREAT NERVOUS SYSTEM DISORDERS ANTIANXIETY - DRUGS TO TREAT ANXIETY alprazolam er oral tablet extended release 24 hour 0.5 mg, 1 mg, G 2 mg, 3 mg ALPRAZOLAM INTENSOL ORAL CONCENTRATE 1 NPB MG/ML (alprazolam) alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg G alprazolam oral tablet dispersible 0.25 mg, 0.5 mg, 1 mg, 2 mg G alprazolam xr oral tablet extended release 24 hour 0.5 mg, 1 mg, G 2 mg, 3 mg ATIVAN INJECTION SOLUTION 2 MG/ML, 4 MG/ML NF (lorazepam) ATIVAN ORAL TABLET 0.5 MG, 1 MG, 2 MG NF (lorazepam) chlordiazepoxide hcl oral capsule 10 mg, 25 mg, 5 mg G lorazepam oral concentrate 2 mg/ml G lorazepam oral tablet 0.5 mg, 1 mg, 2 mg G meprobamate oral tablet 200 mg, 400 mg G oxazepam oral capsule 10 mg, 15 mg, 30 mg G XANAX ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG NF (alprazolam) XANAX XR ORAL TABLET EXTENDED RELEASE 24 NF HOUR 0.5 MG, 1 MG, 2 MG, 3 MG (alprazolam) ANTICONVULSANTS - DRUGS TO TREAT SEIZURES APTIOM ORAL TABLET 200 MG, 400 MG, 600 MG, 800 NF MG (eslicarbazepine acetate) BANZEL ORAL SUSPENSION 40 MG/ML (rufinamide) NF BANZEL ORAL TABLET 200 MG, 400 MG (rufinamide) NPB BRIVIACT INTRAVENOUS SOLUTION 50 MG/5ML NPB (brivaracetam) BRIVIACT ORAL SOLUTION 10 MG/ML (brivaracetam) NPB BRIVIACT ORAL TABLET 10 MG, 100 MG, 25 MG, 50 NPB MG, 75 MG (brivaracetam) carbamazepine er oral capsule extended release 12 hour 100 mg, G 200 mg, 300 mg 2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 58 Prescription Drug Name Drug Tier Drug Notes carbamazepine er oral tablet extended release 12 hour 100 mg, G 200 mg, 400 mg carbamazepine oral suspension 100 mg/5ml G carbamazepine oral tablet 200 mg G carbamazepine oral tablet chewable 100 mg G CELONTIN ORAL CAPSULE 300 MG (methsuximide) NPB clobazam oral suspension 2.5 mg/ml G clobazam oral tablet 10 mg, 20 mg G clonazepam oral tablet 0.5 mg, 1 mg, 2 mg G clonazepam oral tablet dispersible 0.125 mg, 0.25 mg, 0.5 mg, 1 G mg, 2 mg clorazepate dipotassium oral tablet 15 mg, 3.75 mg, 7.5 mg G DIACOMIT ORAL CAPSULE 250 MG, 500 MG NPB (stiripentol) DIACOMIT ORAL PACKET 250 MG, 500 MG (stiripentol) NPB DIASTAT ACUDIAL RECTAL GEL 10 MG, 20 MG NF (diazepam) DIASTAT PEDIATRIC RECTAL GEL 2.5 MG (diazepam) NF diazepam injection solution 5 mg/ml NPB diazepam oral concentrate 5 mg/ml G diazepam oral solution 5 mg/5ml G diazepam oral tablet 10 mg, 2 mg, 5 mg G diazepam rectal gel 10 mg, 2.5 mg, 20 mg G DILANTIN INFATABS ORAL TABLET CHEWABLE 50 NF MG (phenytoin) DILANTIN ORAL CAPSULE 100 MG, 30 MG (phenytoin NF sodium extended) DILANTIN ORAL SUSPENSION 125 MG/5ML (phenytoin) NF divalproex sodium er oral tablet extended release 24 hour 250 G mg, 500 mg divalproex sodium oral capsule delayed release sprinkle 125 mg G divalproex sodium oral tablet delayed release 125 mg, 250 mg, G 500 mg EPIDIOLEX ORAL SOLUTION 100 MG/ML (cannabidiol) NPSP carbamazepine (Epitol Oral Tablet 200 Mg) G ethosuximide oral capsule 250 mg G

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 59 Prescription Drug Name Drug Tier Drug Notes ethosuximide oral solution 250 mg/5ml G FANATREX FUSEPAQ ORAL SUSPENSION 25 MG/ML NF (gabapentin) felbamate oral suspension 600 mg/5ml G felbamate oral tablet 400 mg, 600 mg G FINTEPLA ORAL SOLUTION 2.2 MG/ML (fenfluramine NPB hcl) FYCOMPA ORAL SUSPENSION 0.5 MG/ML (perampanel) PB FYCOMPA ORAL TABLET 10 MG, 12 MG, 2 MG, 4 MG, PB 6 MG, 8 MG (perampanel) gabapentin oral capsule 100 mg, 300 mg, 400 mg G gabapentin oral solution 250 mg/5ml, 300 mg/6ml G gabapentin oral tablet 600 mg, 800 mg G KEPPRA ORAL SOLUTION 100 MG/ML (levetiracetam) NF KEPPRA ORAL TABLET 1000 MG, 250 MG, 500 MG, 750 NF MG (levetiracetam) KEPPRA XR ORAL TABLET EXTENDED RELEASE 24 NF HOUR 500 MG, 750 MG (levetiracetam) LAMICTAL ODT ORAL KIT 21 X 25 MG & 7 X 50 MG, NPB 25 & 50 & 100 MG, 42 X 50 MG & 14X100 MG (lamotrigine) LAMICTAL ODT ORAL TABLET DISPERSIBLE 100 NPB MG, 200 MG, 25 MG, 50 MG (lamotrigine) LAMICTAL ORAL TABLET 100 MG, 150 MG, 200 MG, NPB 25 MG (lamotrigine) LAMICTAL ORAL TABLET CHEWABLE 25 MG, 5 MG NPB (lamotrigine) LAMICTAL STARTER ORAL KIT 35 X 25 MG, 42 X 25 NPB MG & 7 X 100 MG, 84 X 25 MG & 14X100 MG (lamotrigine) LAMICTAL XR ORAL KIT 21 X 25 MG & 7 X 50 MG, 25 NPB & 50 & 100 MG, 50 & 100 & 200 MG (lamotrigine) LAMICTAL XR ORAL TABLET EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 25 MG, 250 MG, 300 MG, 50 NPB MG (lamotrigine) lamotrigine er oral tablet extended release 24 hour 100 mg, 200 G mg, 25 mg, 250 mg, 300 mg, 50 mg lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg G lamotrigine oral tablet chewable 25 mg, 5 mg G

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 60 Prescription Drug Name Drug Tier Drug Notes lamotrigine oral tablet dispersible 100 mg, 200 mg, 25 mg, 50 G mg lamotrigine starter kit-blue oral kit 35 x 25 mg G lamotrigine starter kit-green oral kit 84 x 25 mg & 14x100 mg G lamotrigine starter kit-orange oral kit 42 x 25 mg & 7 x 100 mg G levetiracetam er oral tablet extended release 24 hour 500 mg, G 750 mg levetiracetam oral solution 100 mg/ml G levetiracetam oral tablet 1000 mg, 250 mg, 500 mg, 750 mg G LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 225 NF MG, 25 MG, 300 MG, 50 MG, 75 MG (pregabalin) LYRICA ORAL SOLUTION 20 MG/ML (pregabalin) NF NAYZILAM NASAL SOLUTION 5 MG/0.1ML (midazolam PB (anticonvulsant)) ONFI ORAL SUSPENSION 2.5 MG/ML (clobazam) NF ONFI ORAL TABLET 10 MG, 20 MG (clobazam) NF oxcarbazepine oral suspension 300 mg/5ml G oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg G OXTELLAR XR ORAL TABLET EXTENDED RELEASE PB 24 HOUR 150 MG, 300 MG, 600 MG (oxcarbazepine) phenobarbital oral elixir 20 mg/5ml G phenobarbital oral tablet 100 mg, 15 mg, 16.2 mg, 30 mg, 32.4 G mg, 60 mg, 64.8 mg, 97.2 mg phenytoin oral suspension 125 mg/5ml G phenytoin oral tablet chewable 50 mg G phenytoin sodium extended oral capsule 100 mg, 200 mg, 300 G mg pregabalin oral capsule 100 mg, 150 mg, 200 mg, 225 mg, 25 G mg, 300 mg, 50 mg, 75 mg pregabalin oral solution 20 mg/ml G primidone oral tablet 250 mg, 50 mg G levetiracetam (Roweepra Oral Tablet 500 Mg) G SABRIL ORAL PACKET 500 MG (vigabatrin) NPSP SABRIL ORAL TABLET 500 MG (vigabatrin) NPSP SPRITAM ORAL TABLET DISINTEGRATING SOLUBLE 1000 MG, 250 MG, 500 MG, 750 MG NF (levetiracetam)

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 61 Prescription Drug Name Drug Tier Drug Notes lamotrigine (Subvenite Oral Tablet 100 Mg, 150 Mg, 200 Mg, G 25 Mg) lamotrigine (Subvenite Starter Kit-Blue Oral Kit 35 X 25 Mg) G lamotrigine (Subvenite Starter Kit-Green Oral Kit 84 X 25 Mg G & 14X100 Mg) lamotrigine (Subvenite Starter Kit-Orange Oral Kit 42 X 25 G Mg & 7 X 100 Mg) SYMPAZAN ORAL FILM 10 MG, 20 MG, 5 MG NF (clobazam) tiagabine hcl oral tablet 12 mg, 16 mg, 2 mg, 4 mg G topiramate er oral capsule er 24 hour sprinkle 100 mg, 150 mg, NF 200 mg, 25 mg, 50 mg topiramate oral capsule sprinkle 15 mg, 25 mg G topiramate oral tablet 100 mg, 200 mg, 25 mg, 50 mg G TRILEPTAL ORAL SUSPENSION 300 MG/5ML NPB (oxcarbazepine) TRILEPTAL ORAL TABLET 150 MG, 300 MG, 600 MG NPB (oxcarbazepine) TROKENDI XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 25 MG, 50 MG PB (topiramate) valproic acid oral capsule 250 mg G valproic acid oral solution 250 mg/5ml G VALTOCO 10 MG DOSE NASAL LIQUID 10 MG/0.1ML PB (diazepam) VALTOCO 15 MG DOSE NASAL LIQUID THERAPY PB PACK 7.5 MG/0.1ML (diazepam) VALTOCO 20 MG DOSE NASAL LIQUID THERAPY PB PACK 10 MG/0.1ML (diazepam) VALTOCO 5 MG DOSE NASAL LIQUID 5 MG/0.1ML PB (diazepam) vigabatrin oral packet 500 mg G vigabatrin oral tablet 500 mg G vigabatrin (Vigadrone Oral Packet 500 Mg) G VIMPAT ORAL SOLUTION 10 MG/ML (lacosamide) PB VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG, 50 PB MG (lacosamide)

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 62 Prescription Drug Name Drug Tier Drug Notes XCOPRI (250 MG DAILY DOSE) ORAL TABLET THERAPY PACK 100 & 150 MG, 50 & 200 MG PB (cenobamate) XCOPRI (350 MG DAILY DOSE) ORAL TABLET PB THERAPY PACK 150 & 200 MG (cenobamate) XCOPRI ORAL TABLET 100 MG, 150 MG, 200 MG, 50 PB MG (cenobamate) XCOPRI ORAL TABLET THERAPY PACK 14 X 12.5 MG & 14 X 25 MG, 14 X 150 MG & 14 X200 MG, 14 X 50 MG & PB 14 X100 MG (cenobamate) ZONEGRAN ORAL CAPSULE 100 MG, 25 MG NF (zonisamide) zonisamide oral capsule 100 mg, 25 mg, 50 mg G ANTIDEMENTIA - DRUGS TO TREAT DEMENTIA AND MEMORY LOSS donepezil hcl oral tablet 10 mg, 23 mg, 5 mg G donepezil hcl oral tablet dispersible 10 mg, 5 mg G ergoloid mesylates oral tablet 1 mg G galantamine hydrobromide er oral capsule extended release 24 G hour 16 mg, 24 mg, 8 mg galantamine hydrobromide oral solution 4 mg/ml G galantamine hydrobromide oral tablet 12 mg, 4 mg, 8 mg G memantine hcl er oral capsule extended release 24 hour 14 mg, G 21 mg, 28 mg, 7 mg memantine hcl oral solution 10 mg/5ml, 2 mg/ml G memantine hcl oral tablet 10 mg, 28 x 5 mg & 21 x 10 mg, 5 mg G NAMENDA XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 14 MG, 21 MG, 28 MG, 7 MG NF (memantine hcl) NAMZARIC ORAL CAPSULE ER 24 HOUR THERAPY PB PACK 7 & 14 & 21 &28 -10 MG (memantine hcl-donepezil hcl) NAMZARIC ORAL CAPSULE EXTENDED RELEASE 24 HOUR 14-10 MG, 21-10 MG, 28-10 MG, 7-10 MG PB (memantine hcl-donepezil hcl) rivastigmine tartrate oral capsule 1.5 mg, 3 mg, 4.5 mg, 6 mg G rivastigmine transdermal patch 24 hour 13.3 mg/24hr, 4.6 G mg/24hr, 9.5 mg/24hr

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 63 Prescription Drug Name Drug Tier Drug Notes ANTIDEPRESSANTS - DRUGS TO TREAT DEPRESSION amitriptyline hcl oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 G mg, 75 mg amoxapine oral tablet 100 mg, 150 mg, 25 mg, 50 mg G APLENZIN ORAL TABLET EXTENDED RELEASE 24 NPB HOUR 174 MG, 348 MG, 522 MG (bupropion hbr) bupropion hcl er (sr) oral tablet extended release 12 hour 100 G mg, 150 mg, 200 mg bupropion hcl er (xl) oral tablet extended release 24 hour 150 G mg, 300 mg bupropion hcl er (xl) oral tablet extended release 24 hour 450 NF mg bupropion hcl oral tablet 100 mg, 75 mg G citalopram hydrobromide oral solution 10 mg/5ml G citalopram hydrobromide oral tablet 10 mg, 20 mg, 40 mg G LGC CYMBALTA ORAL CAPSULE DELAYED RELEASE NF PARTICLES 20 MG, 30 MG, 60 MG (duloxetine hcl) desipramine hcl oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 G mg, 75 mg desvenlafaxine succinate er oral tablet extended release 24 hour G 100 mg, 25 mg, 50 mg doxepin hcl oral capsule 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, G 75 mg doxepin hcl oral concentrate 10 mg/ml G duloxetine hcl oral capsule delayed release particles 20 mg, 30 G mg, 40 mg, 60 mg EFFEXOR XR ORAL CAPSULE EXTENDED RELEASE NF 24 HOUR 150 MG, 37.5 MG, 75 MG (venlafaxine hcl) EMSAM TRANSDERMAL PATCH 24 HOUR 12 NPB MG/24HR, 6 MG/24HR, 9 MG/24HR (selegiline) escitalopram oxalate oral solution 5 mg/5ml G escitalopram oxalate oral tablet 10 mg, 20 mg, 5 mg G FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 20 MG, 40 MG, 80 MG (levomilnacipran NF hcl) FETZIMA TITRATION ORAL CAPSULE ER 24 HOUR NF THERAPY PACK 20 & 40 MG (levomilnacipran hcl)

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 64 Prescription Drug Name Drug Tier Drug Notes fluoxetine hcl (pmdd) oral tablet 10 mg, 20 mg NF fluoxetine hcl oral capsule 10 mg, 20 mg, 40 mg G LGC fluoxetine hcl oral capsule delayed release 90 mg G fluoxetine hcl oral solution 20 mg/5ml G fluoxetine hcl oral tablet 10 mg, 20 mg G fluoxetine hcl oral tablet 60 mg NF imipramine hcl oral tablet 10 mg, 25 mg, 50 mg G imipramine pamoate oral capsule 100 mg, 125 mg, 150 mg, 75 G mg LEXAPRO ORAL TABLET 10 MG, 20 MG, 5 MG NF (escitalopram oxalate) MARPLAN ORAL TABLET 10 MG (isocarboxazid) NPB mirtazapine oral tablet 15 mg, 30 mg, 45 mg, 7.5 mg G mirtazapine oral tablet dispersible 15 mg, 30 mg, 45 mg G nefazodone hcl oral tablet 100 mg, 150 mg, 200 mg, 250 mg, 50 G mg nortriptyline hcl oral capsule 10 mg, 25 mg, 50 mg, 75 mg G nortriptyline hcl oral solution 10 mg/5ml G paroxetine hcl er oral tablet extended release 24 hour 12.5 mg, G 25 mg, 37.5 mg paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg G LGC paroxetine mesylate oral capsule 7.5 mg NF PAXIL CR ORAL TABLET EXTENDED RELEASE 24 NF HOUR 12.5 MG, 25 MG, 37.5 MG (paroxetine hcl) PAXIL ORAL SUSPENSION 10 MG/5ML (paroxetine hcl) NF PAXIL ORAL TABLET 10 MG, 20 MG, 30 MG, 40 MG NF (paroxetine hcl) PEXEVA ORAL TABLET 10 MG, 20 MG, 30 MG, 40 MG NF (paroxetine mesylate) phenelzine sulfate oral tablet 15 mg G PRISTIQ ORAL TABLET EXTENDED RELEASE 24 NF HOUR 100 MG, 25 MG, 50 MG (desvenlafaxine succinate) protriptyline hcl oral tablet 10 mg, 5 mg G PROZAC ORAL CAPSULE 10 MG, 20 MG, 40 MG NF (fluoxetine hcl) sertraline hcl oral concentrate 20 mg/ml G sertraline hcl oral tablet 100 mg, 25 mg, 50 mg G LGC 2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 65 Prescription Drug Name Drug Tier Drug Notes SPRAVATO (56 MG DOSE) NASAL SOLUTION NPSP THERAPY PACK 28 MG/DEVICE (esketamine hcl) SPRAVATO (84 MG DOSE) NASAL SOLUTION NPSP THERAPY PACK 28 MG/DEVICE (esketamine hcl) tranylcypromine sulfate oral tablet 10 mg G trazodone hcl oral tablet 100 mg, 150 mg, 300 mg, 50 mg G trimipramine maleate oral capsule 100 mg, 25 mg, 50 mg G TRINTELLIX ORAL TABLET 10 MG, 20 MG, 5 MG PB (vortioxetine hbr) venlafaxine hcl er oral capsule extended release 24 hour 150 mg, G 37.5 mg, 75 mg venlafaxine hcl er oral tablet extended release 24 hour 150 mg, NF 37.5 mg, 75 mg venlafaxine hcl er oral tablet extended release 24 hour 225 mg G venlafaxine hcl oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 G mg VIIBRYD ORAL TABLET 10 MG, 20 MG, 40 MG NF (vilazodone hcl) VIIBRYD STARTER PACK ORAL KIT 10 & 20 MG NF (vilazodone hcl) ZOLOFT ORAL CONCENTRATE 20 MG/ML (sertraline NF hcl) ZOLOFT ORAL TABLET 100 MG, 25 MG, 50 MG NF (sertraline hcl) ZULRESSO INTRAVENOUS SOLUTION 100 MG/20ML NF (brexanolone) ANTIPARKINSONIAN AGENTS - DRUGS TO TREAT PARKINSONS DISEASE amantadine hcl oral capsule 100 mg G amantadine hcl oral syrup 50 mg/5ml G amantadine hcl oral tablet 100 mg G APOKYN SUBCUTANEOUS SOLUTION CARTRIDGE NF 30 MG/3ML (apomorphine hcl) benztropine mesylate oral tablet 0.5 mg, 1 mg, 2 mg G bromocriptine mesylate oral capsule 5 mg G bromocriptine mesylate oral tablet 2.5 mg G carbidopa oral tablet 25 mg G

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 66 Prescription Drug Name Drug Tier Drug Notes carbidopa-levodopa er oral tablet extended release 25-100 mg, G 50-200 mg carbidopa-levodopa oral tablet 10-100 mg, 25-100 mg, 25-250 G mg carbidopa-levodopa oral tablet dispersible 10-100 mg, 25-100 G mg, 25-250 mg carbidopa-levodopa-entacapone oral tablet 12.5-50-200 mg, 18.75-75-200 mg, 25-100-200 mg, 31.25-125-200 mg, 37.5-150- G 200 mg, 50-200-200 mg DUOPA ENTERAL SUSPENSION 4.63-20 MG/ML NPB (carbidopa-levodopa) entacapone oral tablet 200 mg G GOCOVRI ORAL CAPSULE EXTENDED RELEASE 24 NF HOUR 137 MG, 68.5 MG (amantadine hcl) INBRIJA INHALATION CAPSULE 42 MG (levodopa) PSP KYNMOBI SUBLINGUAL FILM 10 MG, 15 MG, 20 MG, PSP 25 MG, 30 MG (apomorphine hcl) NEUPRO TRANSDERMAL PATCH 24 HOUR 1 MG/24HR, 2 MG/24HR, 3 MG/24HR, 4 MG/24HR, 6 PB MG/24HR, 8 MG/24HR (rotigotine) NOURIANZ ORAL TABLET 20 MG, 40 MG (istradefylline) NF OSMOLEX ER ORAL TABLET ER 24 HOUR THERAPY NF PACK 129 & 193 MG (amantadine hcl) OSMOLEX ER ORAL TABLET EXTENDED RELEASE NF 24 HOUR 129 MG, 193 MG, 258 MG (amantadine hcl) pramipexole dihydrochloride er oral tablet extended release 24 G hour 0.375 mg, 0.75 mg, 1.5 mg, 2.25 mg, 3 mg, 3.75 mg, 4.5 mg pramipexole dihydrochloride oral tablet 0.125 mg, 0.25 mg, 0.5 G mg, 0.75 mg, 1 mg, 1.5 mg rasagiline mesylate oral tablet 0.5 mg, 1 mg G ropinirole hcl er oral tablet extended release 24 hour 12 mg, 2 G mg, 4 mg, 6 mg, 8 mg ropinirole hcl oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 G mg, 5 mg RYTARY ORAL CAPSULE EXTENDED RELEASE 23.75-95 MG, 36.25-145 MG, 48.75-195 MG, 61.25-245 MG NF (carbidopa-levodopa) selegiline hcl oral capsule 5 mg G selegiline hcl oral tablet 5 mg G 2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 67 Prescription Drug Name Drug Tier Drug Notes tolcapone oral tablet 100 mg G trihexyphenidyl hcl oral solution 0.4 mg/ml G trihexyphenidyl hcl oral tablet 2 mg, 5 mg G XADAGO ORAL TABLET 100 MG, 50 MG (safinamide NF mesylate) ZELAPAR ORAL TABLET DISPERSIBLE 1.25 MG NF (selegiline hcl) ANTIPSYCHOTICS - DRUGS TO TREAT PSYCHOSES ABILIFY MAINTENA INTRAMUSCULAR PREFILLED PB SYRINGE 300 MG, 400 MG (aripiprazole) ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 300 MG, 400 MG PB (aripiprazole) ABILIFY MYCITE MAINTENANCE KIT ORAL TABLET 10 MG, 15 MG, 2 MG, 20 MG, 30 MG, 5 MG NPB (aripiprazole) ABILIFY MYCITE ORAL TABLET 10 MG, 15 MG, 2 MG, NF 20 MG, 30 MG, 5 MG (aripiprazole) ABILIFY MYCITE STARTER KIT ORAL TABLET 10 NPB MG, 15 MG, 2 MG, 20 MG, 30 MG, 5 MG (aripiprazole) ABILIFY ORAL TABLET 10 MG, 15 MG, 2 MG, 20 MG, NF 30 MG, 5 MG (aripiprazole) ADASUVE INHALATION AEROSOL POWDER NPB BREATH ACTIVATED 10 MG (loxapine) aripiprazole oral solution 1 mg/ml G aripiprazole oral tablet 10 mg, 15 mg, 2 mg, 20 mg, 30 mg, 5 mg G aripiprazole oral tablet dispersible 10 mg, 15 mg G ARISTADA INITIO INTRAMUSCULAR PREFILLED NPB SYRINGE 675 MG/2.4ML (aripiprazole lauroxil) ARISTADA INTRAMUSCULAR PREFILLED SYRINGE 1064 MG/3.9ML, 441 MG/1.6ML, 662 MG/2.4ML, 882 NPB MG/3.2ML (aripiprazole lauroxil) chlorpromazine hcl injection solution 25 mg/ml, 50 mg/2ml NPB chlorpromazine hcl oral tablet 10 mg, 100 mg, 200 mg, 25 mg, G 50 mg clozapine oral tablet 100 mg, 200 mg, 25 mg, 50 mg G clozapine oral tablet dispersible 100 mg, 12.5 mg, 25 mg G clozapine oral tablet dispersible 150 mg, 200 mg NPB

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 68 Prescription Drug Name Drug Tier Drug Notes CLOZARIL ORAL TABLET 200 MG, 50 MG (clozapine) NPB EQUETRO ORAL CAPSULE EXTENDED RELEASE 12 HOUR 100 MG, 200 MG, 300 MG (carbamazepine NPB (antipsychotic)) FANAPT ORAL TABLET 1 MG, 10 MG, 12 MG, 2 MG, 4 NF MG, 6 MG, 8 MG (iloperidone) FANAPT TITRATION PACK ORAL TABLET 1 & 2 & 4 & NF 6 MG (iloperidone) fluphenazine decanoate injection solution 25 mg/ml G fluphenazine hcl injection solution 2.5 mg/ml G fluphenazine hcl oral concentrate 5 mg/ml G fluphenazine hcl oral elixir 2.5 mg/5ml G fluphenazine hcl oral tablet 1 mg, 10 mg, 2.5 mg, 5 mg G GEODON INTRAMUSCULAR SOLUTION NF RECONSTITUTED 20 MG (ziprasidone mesylate) GEODON ORAL CAPSULE 20 MG, 40 MG, 60 MG, 80 NF MG (ziprasidone hcl) haloperidol decanoate intramuscular solution 100 mg/ml, 50 G mg/ml haloperidol lactate injection solution 5 mg/ml G haloperidol lactate oral concentrate 2 mg/ml G haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2 mg, 20 mg, 5 mg G INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 117 MG/0.75ML, NPB 156 MG/ML, 234 MG/1.5ML, 39 MG/0.25ML, 78 MG/0.5ML (paliperidone palmitate) INVEGA TRINZA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 273 MG/0.875ML, 410 NF MG/1.315ML, 546 MG/1.75ML, 819 MG/2.625ML (paliperidone palmitate) LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 PB MG, 80 MG (lurasidone hcl) loxapine succinate oral capsule 10 mg, 25 mg, 5 mg, 50 mg G molindone hcl oral tablet 10 mg, 25 mg, 5 mg G NUPLAZID ORAL CAPSULE 34 MG (pimavanserin NPSP tartrate) NUPLAZID ORAL TABLET 10 MG (pimavanserin tartrate) NPSP olanzapine intramuscular solution reconstituted 10 mg G

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 69 Prescription Drug Name Drug Tier Drug Notes olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 20 mg, 5 mg, 7.5 G mg olanzapine oral tablet dispersible 10 mg, 15 mg, 20 mg, 5 mg G paliperidone er oral tablet extended release 24 hour 1.5 mg, 3 G mg, 6 mg, 9 mg perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg G PERSERIS SUBCUTANEOUS PREFILLED SYRINGE PB 120 MG, 90 MG (risperidone) prochlorperazine edisylate injection solution 10 mg/2ml, 50 G mg/10ml quetiapine fumarate er oral tablet extended release 24 hour 150 G mg, 200 mg, 300 mg, 400 mg, 50 mg quetiapine fumarate oral tablet 100 mg, 200 mg, 25 mg, 300 mg, G 400 mg, 50 mg REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 NPB MG, 3 MG, 4 MG (brexpiprazole) RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 12.5 MG, 25 MG, NPB 37.5 MG, 50 MG (risperidone microspheres) risperidone oral solution 1 mg/ml G risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg G risperidone oral tablet dispersible 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 G mg, 4 mg SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 10 NPB MG, 2.5 MG, 5 MG (asenapine maleate) SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HOUR 150 MG, 200 MG, 300 MG, 400 MG, 50 MG NF (quetiapine fumarate) thioridazine hcl oral tablet 10 mg, 100 mg, 25 mg, 50 mg G thiothixene oral capsule 1 mg, 10 mg, 2 mg, 5 mg G trifluoperazine hcl oral tablet 1 mg, 10 mg, 2 mg, 5 mg G VERSACLOZ ORAL SUSPENSION 50 MG/ML (clozapine) NPB VRAYLAR ORAL CAPSULE 1.5 MG, 3 MG, 4.5 MG, 6 PB MG (cariprazine hcl) VRAYLAR ORAL CAPSULE THERAPY PACK 1.5 & 3 PB MG (cariprazine hcl) ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg G

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 70 Prescription Drug Name Drug Tier Drug Notes ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION RECONSTITUTED 210 MG, 300 MG, 405 NPB MG (olanzapine pamoate) ATTENTION DEFICIT HYPERACTIVITY DISORDER - DRUGS TO TREAT ADHD ADDERALL ORAL TABLET 10 MG, 12.5 MG, 15 MG, 20 MG, 30 MG, 5 MG, 7.5 MG (amphetamine- NF dextroamphetamine) ADDERALL XR ORAL CAPSULE EXTENDED N8 (Listing does not include RELEASE 24 HOUR 10 MG, 15 MG, 20 MG, 25 MG, 30 NPB certain NDCs) MG, 5 MG (amphetamine-dextroamphetamine) ADHANSIA XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 25 MG, 35 MG, 45 MG, 55 MG, 70 NF MG, 85 MG (methylphenidate hcl) ADZENYS ER ORAL SUSPENSION EXTENDED NF RELEASE 1.25 MG/ML (amphetamine) ADZENYS XR-ODT ORAL TABLET EXTENDED RELEASE DISPERSIBLE 12.5 MG, 15.7 MG, 18.8 MG, 3.1 NF MG, 6.3 MG, 9.4 MG (amphetamine) amphetamine sulfate oral tablet 10 mg, 5 mg G amphetamine-dextroamphet er oral capsule extended release 24 N8 (Listing does not include G hour 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 5 mg certain NDCs) amphetamine-dextroamphetamine oral tablet 10 mg, 12.5 mg, G 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg APTENSIO XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 50 MG, NF 60 MG (methylphenidate hcl) atomoxetine hcl oral capsule 10 mg, 100 mg, 18 mg, 25 mg, 40 G mg, 60 mg, 80 mg clonidine hcl er oral tablet extended release 12 hour 0.1 mg G CONCERTA ORAL TABLET EXTENDED RELEASE 18 N8 (Listing does not include NPB MG, 27 MG, 36 MG, 54 MG (methylphenidate hcl) certain NDCs) COTEMPLA XR-ODT ORAL TABLET EXTENDED RELEASE DISPERSIBLE 17.3 MG, 25.9 MG, 8.6 MG NF (methylphenidate) DAYTRANA TRANSDERMAL PATCH 10 MG/9HR, 15 NF MG/9HR, 20 MG/9HR, 30 MG/9HR (methylphenidate) dexmethylphenidate hcl er oral capsule extended release 24 hour G 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 35 mg, 40 mg, 5 mg dexmethylphenidate hcl oral tablet 10 mg, 2.5 mg, 5 mg G 2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 71 Prescription Drug Name Drug Tier Drug Notes dextroamphetamine sulfate er oral capsule extended release 24 G hour 10 mg, 15 mg, 5 mg dextroamphetamine sulfate oral solution 5 mg/5ml G dextroamphetamine sulfate oral tablet 10 mg, 5 mg G DYANAVEL XR ORAL SUSPENSION EXTENDED NPB RELEASE 2.5 MG/ML (amphetamine) EVEKEO ODT ORAL TABLET DISPERSIBLE 10 MG, 15 NF MG, 20 MG, 5 MG (amphetamine sulfate) EVEKEO ORAL TABLET 10 MG, 5 MG (amphetamine NF sulfate) FOCALIN XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 15 MG, 20 MG, 25 MG, 30 MG, 35 MG, NF 40 MG, 5 MG (dexmethylphenidate hcl) guanfacine hcl er oral tablet extended release 24 hour 1 mg, 2 G mg, 3 mg, 4 mg INTUNIV ORAL TABLET EXTENDED RELEASE 24 NF HOUR 1 MG, 2 MG, 3 MG, 4 MG (guanfacine hcl) JORNAY PM ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG, 20 MG, 40 MG, 60 MG, 80 MG NF (methylphenidate hcl) KAPVAY ORAL TABLET EXTENDED RELEASE 12 NF HOUR 0.1 MG (clonidine hcl) methamphetamine hcl oral tablet 5 mg G methylphenidate hcl er (cd) oral capsule extended release 10 G mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg methylphenidate hcl er (la) oral capsule extended release 24 G hour 10 mg, 20 mg, 30 mg, 40 mg, 60 mg methylphenidate hcl er oral tablet extended release 10 mg, 20 G mg methylphenidate hcl er oral tablet extended release 18 mg, 27 N8 (Listing does not include G mg, 36 mg, 54 mg certain NDCs) methylphenidate hcl er oral tablet extended release 24 hour 18 NF mg, 27 mg, 36 mg, 54 mg methylphenidate hcl er oral tablet extended release 72 mg NPB methylphenidate hcl oral solution 10 mg/5ml, 5 mg/5ml G methylphenidate hcl oral tablet 10 mg, 20 mg, 5 mg G methylphenidate hcl oral tablet chewable 10 mg, 2.5 mg, 5 mg G

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 72 Prescription Drug Name Drug Tier Drug Notes MYDAYIS ORAL CAPSULE EXTENDED RELEASE 24 HOUR 12.5 MG, 25 MG, 37.5 MG, 50 MG (amphetamine- PB dextroamphetamine) QUILLICHEW ER ORAL TABLET CHEWABLE EXTENDED RELEASE 20 MG, 30 MG, 40 MG NPB (methylphenidate hcl) QUILLIVANT XR ORAL SUSPENSION NPB RECONSTITUTED ER 25 MG/5ML (methylphenidate hcl) RELEXXII ORAL TABLET EXTENDED RELEASE 72 NF MG (methylphenidate hcl) VYVANSE ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 PB MG, 50 MG, 60 MG, 70 MG (lisdexamfetamine dimesylate) VYVANSE ORAL TABLET CHEWABLE 10 MG, 20 MG, PB 30 MG, 40 MG, 50 MG, 60 MG (lisdexamfetamine dimesylate) dextroamphetamine sulfate (Zenzedi Oral Tablet 10 Mg, 5 Mg) G ZENZEDI ORAL TABLET 15 MG, 2.5 MG, 20 MG, 30 G MG, 7.5 MG (dextroamphetamine sulfate) HYPNOTICS - DRUGS TO TREAT INSOMNIA BELSOMRA ORAL TABLET 10 MG, 15 MG, 20 MG, 5 NF MG (suvorexant) EDLUAR SUBLINGUAL TABLET SUBLINGUAL 10 NF MG, 5 MG (zolpidem tartrate) estazolam oral tablet 1 mg, 2 mg G eszopiclone oral tablet 1 mg, 2 mg, 3 mg G flurazepam hcl oral capsule 15 mg, 30 mg G HETLIOZ LQ ORAL SUSPENSION 4 MG/ML NPB (tasimelteon) HETLIOZ ORAL CAPSULE 20 MG (tasimelteon) NPB LUNESTA ORAL TABLET 1 MG, 2 MG, 3 MG NF (eszopiclone) midazolam hcl (pf) injection solution 5 mg/5ml G midazolam hcl oral syrup 2 mg/ml G PRECEDEX INTRAVENOUS SOLUTION 1000 NPB MCG/250ML (dexmedetomidine hcl in nacl) quazepam oral tablet 15 mg NF ramelteon oral tablet 8 mg G ROZEREM ORAL TABLET 8 MG (ramelteon) NF SILENOR ORAL TABLET 3 MG, 6 MG (doxepin hcl) NF

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 73 Prescription Drug Name Drug Tier Drug Notes temazepam oral capsule 15 mg, 22.5 mg, 30 mg, 7.5 mg G triazolam oral tablet 0.125 mg, 0.25 mg G zaleplon oral capsule 10 mg, 5 mg G zolpidem tartrate er oral tablet extended release 12.5 mg, 6.25 G mg zolpidem tartrate oral tablet 10 mg, 5 mg G zolpidem tartrate sublingual tablet sublingual 1.75 mg, 3.5 mg NF ZOLPIMIST ORAL SOLUTION 5 MG/ACT (zolpidem NF tartrate) MIGRAINE - DRUGS TO TREAT SEVERE HEADACHES AIMOVIG SUBCUTANEOUS SOLUTION AUTO- PB INJECTOR 140 MG/ML, 70 MG/ML (erenumab-aooe) AJOVY SUBCUTANEOUS SOLUTION AUTO- PB INJECTOR 225 MG/1.5ML (fremanezumab-vfrm) AJOVY SUBCUTANEOUS SOLUTION PREFILLED PB SYRINGE 225 MG/1.5ML (fremanezumab-vfrm) almotriptan malate oral tablet 12.5 mg, 6.25 mg G CAFERGOT ORAL TABLET 1-100 MG (ergotamine- NF caffeine) dihydroergotamine mesylate injection solution 1 mg/ml G dihydroergotamine mesylate nasal solution 4 mg/ml NF eletriptan hydrobromide oral tablet 20 mg, 40 mg G EMGALITY (300 MG DOSE) SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100 MG/ML PB (galcanezumab-gnlm) EMGALITY SUBCUTANEOUS SOLUTION AUTO- PB INJECTOR 120 MG/ML (galcanezumab-gnlm) EMGALITY SUBCUTANEOUS SOLUTION PREFILLED PB SYRINGE 120 MG/ML (galcanezumab-gnlm) ERGOMAR SUBLINGUAL TABLET SUBLINGUAL 2 NPB MG (ergotamine tartrate) ergotamine-caffeine oral tablet 1-100 mg NF frovatriptan succinate oral tablet 2.5 mg G MAXALT ORAL TABLET 10 MG (rizatriptan benzoate) NF MAXALT-MLT ORAL TABLET DISPERSIBLE 10 MG NF (rizatriptan benzoate) MIGERGOT RECTAL SUPPOSITORY 2-100 MG NF (ergotamine-caffeine) 2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 74 Prescription Drug Name Drug Tier Drug Notes MIGRAINE PACK COMBINATION THERAPY PACK 50 NF MG (sumatriptan-homeopathic prod) MIGRANAL NASAL SOLUTION 4 MG/ML NF (dihydroergotamine mesylate) MIGRANOW COMBINATION THERAPY PACK 50 & 4- NF 10 MG & % (sumatriptan & camphor-menthol) naratriptan hcl oral tablet 1 mg, 2.5 mg G NURTEC ORAL TABLET DISPERSIBLE 75 MG PB (rimegepant sulfate) ONZETRA XSAIL NASAL EXHALER POWDER 11 NPB MG/NOSEPC (sumatriptan succinate) REYVOW ORAL TABLET 100 MG, 50 MG (lasmiditan PB succinate) rizatriptan benzoate oral tablet 10 mg, 5 mg G rizatriptan benzoate oral tablet dispersible 10 mg, 5 mg G sumatriptan nasal solution 20 mg/act, 5 mg/act G sumatriptan succinate oral tablet 100 mg, 25 mg, 50 mg G sumatriptan succinate refill subcutaneous solution cartridge 4 G mg/0.5ml, 6 mg/0.5ml sumatriptan succinate subcutaneous solution 6 mg/0.5ml G sumatriptan succinate subcutaneous solution auto-injector 4 G mg/0.5ml, 6 mg/0.5ml sumatriptan-naproxen sodium oral tablet 85-500 mg NF TREXIMET ORAL TABLET 85-500 MG (sumatriptan- NF naproxen sodium) UBRELVY ORAL TABLET 100 MG, 50 MG (ubrogepant) PB ZEMBRACE SYMTOUCH SUBCUTANEOUS SOLUTION AUTO-INJECTOR 3 MG/0.5ML (sumatriptan NPB succinate) zolmitriptan oral tablet 2.5 mg, 5 mg G zolmitriptan oral tablet dispersible 2.5 mg, 5 mg G ZOMIG NASAL SOLUTION 2.5 MG, 5 MG (zolmitriptan) PB MISCELLANEOUS AUSTEDO ORAL TABLET 12 MG, 6 MG, 9 MG PSP (deutetrabenazine) buspirone hcl oral tablet 10 mg, 15 mg, 30 mg, 5 mg, 7.5 mg G caffeine citrate oral solution 20 mg/ml, 60 mg/3ml G

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 75 Prescription Drug Name Drug Tier Drug Notes clomipramine hcl oral capsule 25 mg, 50 mg, 75 mg G CONTRAVE ORAL TABLET EXTENDED RELEASE 12 SPC (Only available for NF HOUR 8-90 MG (naltrexone-bupropion hcl) select plans) EVRYSDI ORAL SOLUTION RECONSTITUTED 0.75 NPB MG/ML (risdiplam) FIRDAPSE ORAL TABLET 10 MG (amifampridine NPB phosphate) fluvoxamine maleate er oral capsule extended release 24 hour G 100 mg, 150 mg fluvoxamine maleate oral tablet 100 mg, 25 mg, 50 mg G INGREZZA ORAL CAPSULE 40 MG, 80 MG (valbenazine PSP tosylate) INGREZZA ORAL CAPSULE THERAPY PACK 40 & 80 PSP MG (valbenazine tosylate) lithium carbonate er oral tablet extended release 300 mg, 450 G mg lithium carbonate oral capsule 150 mg, 300 mg, 600 mg G lithium carbonate oral tablet 300 mg G LOMAIRA ORAL TABLET 8 MG (phentermine hcl) NF MESTINON ORAL SOLUTION 60 MG/5ML NF (pyridostigmine bromide) MESTINON ORAL TABLET 60 MG (pyridostigmine NF bromide) NUEDEXTA ORAL CAPSULE 20-10 MG NPB (dextromethorphan-quinidine) pimozide oral tablet 1 mg, 2 mg G pyridostigmine bromide er oral tablet extended release 180 mg G pyridostigmine bromide oral solution 60 mg/5ml G pyridostigmine bromide oral tablet 60 mg G QSYMIA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 11.25-69 MG, 15-92 MG, 3.75-23 MG, 7.5-46 MG PB (phentermine-topiramate) riluzole oral tablet 50 mg G RUZURGI ORAL TABLET 10 MG (amifampridine) NPB SAVELLA ORAL TABLET 100 MG, 12.5 MG, 25 MG, 50 NPB MG (milnacipran hcl) SAVELLA TITRATION PACK ORAL 12.5 & 25 & 50 MG NPB (milnacipran hcl)

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 76 Prescription Drug Name Drug Tier Drug Notes tetrabenazine oral tablet 12.5 mg, 25 mg G TIGLUTIK ORAL SUSPENSION 50 MG/10ML (riluzole) NF XENICAL ORAL CAPSULE 120 MG (orlistat) NF MULTIPLE SCLEROSIS AGENTS - DRUGS TO TREAT MULTIPLE SCLEROSIS AMPYRA ORAL TABLET EXTENDED RELEASE 12 NPSP HOUR 10 MG (dalfampridine) AUBAGIO ORAL TABLET 14 MG, 7 MG (teriflunomide) PSP AVONEX PEN INTRAMUSCULAR AUTO-INJECTOR NF KIT 30 MCG/0.5ML (interferon beta-1a) AVONEX PREFILLED INTRAMUSCULAR PREFILLED NF SYRINGE KIT 30 MCG/0.5ML (interferon beta-1a) BETASERON SUBCUTANEOUS KIT 0.3 MG (interferon PSP beta-1b) COPAXONE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 20 MG/ML, 40 MG/ML PSP (glatiramer acetate) dalfampridine er oral tablet extended release 12 hour 10 mg G dimethyl fumarate oral capsule delayed release 120 mg, 240 mg G dimethyl fumarate starter pack oral 120 & 240 mg G EXTAVIA SUBCUTANEOUS KIT 0.3 MG (interferon beta- NF 1b) GILENYA ORAL CAPSULE 0.5 MG (fingolimod hcl) PSP glatiramer acetate subcutaneous solution prefilled syringe 20 G mg/ml, 40 mg/ml glatiramer acetate (Glatopa Subcutaneous Solution Prefilled G Syringe 20 Mg/Ml, 40 Mg/Ml) KESIMPTA SUBCUTANEOUS SOLUTION AUTO- PSP INJECTOR 20 MG/0.4ML (ofatumumab) MAVENCLAD (10 TABS) ORAL TABLET THERAPY NPSP PACK 10 MG (cladribine) MAVENCLAD (4 TABS) ORAL TABLET THERAPY NPSP PACK 10 MG (cladribine) MAVENCLAD (5 TABS) ORAL TABLET THERAPY NPSP PACK 10 MG (cladribine) MAVENCLAD (6 TABS) ORAL TABLET THERAPY NPSP PACK 10 MG (cladribine)

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 77 Prescription Drug Name Drug Tier Drug Notes MAVENCLAD (7 TABS) ORAL TABLET THERAPY NPSP PACK 10 MG (cladribine) MAVENCLAD (8 TABS) ORAL TABLET THERAPY NPSP PACK 10 MG (cladribine) MAVENCLAD (9 TABS) ORAL TABLET THERAPY NPSP PACK 10 MG (cladribine) MAYZENT ORAL TABLET 0.25 MG, 2 MG (siponimod PSP fumarate) MAYZENT STARTER PACK ORAL TABLET THERAPY PSP PACK 0.25 MG (siponimod fumarate) OCREVUS INTRAVENOUS SOLUTION 300 MG/10ML PSP (ocrelizumab) PLEGRIDY INTRAMUSCULAR SOLUTION PREFILLED SYRINGE 125 MCG/0.5ML (peginterferon NF beta-1a) PLEGRIDY STARTER PACK SUBCUTANEOUS SOLUTION PEN-INJECTOR 63 & 94 MCG/0.5ML NF (peginterferon beta-1a) PLEGRIDY STARTER PACK SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 63 & 94 MCG/0.5ML NF (peginterferon beta-1a) PLEGRIDY SUBCUTANEOUS SOLUTION PEN- NF INJECTOR 125 MCG/0.5ML (peginterferon beta-1a) PLEGRIDY SUBCUTANEOUS SOLUTION PREFILLED NF SYRINGE 125 MCG/0.5ML (peginterferon beta-1a) REBIF REBIDOSE SUBCUTANEOUS SOLUTION AUTO-INJECTOR 22 MCG/0.5ML, 44 MCG/0.5ML PSP (interferon beta-1a) REBIF REBIDOSE TITRATION PACK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 6X8.8 PSP & 6X22 MCG (interferon beta-1a) REBIF SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 22 MCG/0.5ML, 44 MCG/0.5ML (interferon beta- PSP 1a) REBIF TITRATION PACK SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 6X8.8 & 6X22 MCG PSP (interferon beta-1a) TECFIDERA ORAL 120 & 240 MG (dimethyl fumarate) NF TECFIDERA ORAL CAPSULE DELAYED RELEASE 120 NF MG, 240 MG (dimethyl fumarate)

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 78 Prescription Drug Name Drug Tier Drug Notes TYSABRI INTRAVENOUS CONCENTRATE 300 PSP MG/15ML (natalizumab) VUMERITY ORAL CAPSULE DELAYED RELEASE 231 PSP MG (diroximel fumarate) ZEPOSIA 7-DAY STARTER PACK ORAL CAPSULE THERAPY PACK 4 X 0.23MG & 3 X 0.46MG (ozanimod PSP hcl) ZEPOSIA ORAL CAPSULE 0.92 MG (ozanimod hcl) PSP ZEPOSIA STARTER KIT ORAL CAPSULE THERAPY PSP PACK 0.23MG & 0.46MG & 0.92MG (ozanimod hcl) MUSCULOSKELETAL THERAPY AGENTS - DRUGS TO TREAT MUSCLE SPASMS AMRIX ORAL CAPSULE EXTENDED RELEASE 24 NF HOUR 15 MG, 30 MG (cyclobenzaprine hcl) baclofen oral tablet 10 mg, 20 mg, 5 mg G BOTOX INJECTION SOLUTION RECONSTITUTED 100 NPSP UNIT, 200 UNIT (onabotulinumtoxina) BRIDION INTRAVENOUS SOLUTION 200 MG/2ML, 500 NF MG/5ML (sugammadex sodium) carisoprodol oral tablet 250 mg NF carisoprodol oral tablet 350 mg G carisoprodol-aspirin-codeine oral tablet 200-325-16 mg G chlorzoxazone oral tablet 250 mg, 375 mg, 500 mg, 750 mg NF cyclobenzaprine hcl er oral capsule extended release 24 hour 15 NF mg, 30 mg cyclobenzaprine hcl oral tablet 10 mg, 5 mg G cyclobenzaprine hcl oral tablet 7.5 mg NF dantrolene sodium oral capsule 100 mg, 25 mg, 50 mg G DYSPORT INTRAMUSCULAR SOLUTION RECONSTITUTED 300 UNIT, 500 UNIT NPSP (abobotulinumtoxina) FEXMID ORAL TABLET 7.5 MG (cyclobenzaprine hcl) NF FIRST-BACLOFEN ORAL SUSPENSION 1 MG/ML, 5 NF MG/ML (baclofen) chlorzoxazone (Lorzone Oral Tablet 375 Mg, 750 Mg) NF MACI INTRA-ARTICULAR SHEET (autolog cult chond NF coll membr)

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 79 Prescription Drug Name Drug Tier Drug Notes METAXALL CP COMBINATION KIT 800 & 0.025 MG & NF % (metaxalone-capsaicin) metaxalone oral tablet 400 mg NF metaxalone oral tablet 800 mg G methocarbamol oral tablet 500 mg, 750 mg NF norgesic forte oral tablet 50-770-60 mg NF orphenadrine citrate er oral tablet extended release 12 hour 100 G mg orphenadrine-asa-caffeine oral tablet 50-770-60 mg NF orphenadrine-aspirin-caffeine (Orphengesic Forte Oral Tablet NF 50-770-60 Mg) TABRADOL FUSEPAQ ORAL SUSPENSION 1 MG/ML NF (cyclobenzaprine hcl-msm) TABRADOL RAPIDPAQ ORAL SUSPENSION 1 MG/ML NF (cyclobenzaprine hcl-msm) tizanidine hcl oral capsule 2 mg, 4 mg, 6 mg G tizanidine hcl oral tablet 2 mg, 4 mg G XEOMIN INTRAMUSCULAR SOLUTION RECONSTITUTED 100 UNIT, 200 UNIT, 50 UNIT NPSP (incobotulinumtoxina) NARCOLEPSY/CATAPLEXY - DRUGS FOR SLEEP DISORDERS armodafinil oral tablet 150 mg, 200 mg, 250 mg, 50 mg G modafinil oral tablet 100 mg, 200 mg G NUVIGIL ORAL TABLET 150 MG, 200 MG, 250 MG, 50 NF MG (armodafinil) PROVIGIL ORAL TABLET 100 MG, 200 MG (modafinil) NF SUNOSI ORAL TABLET 150 MG, 75 MG (solriamfetol hcl) NF XYREM ORAL SOLUTION 500 MG/ML (sodium oxybate) NPB POLYNEUROPATHY TEGSEDI SUBCUTANEOUS SOLUTION PREFILLED PSP SYRINGE 284 MG/1.5ML (inotersen sodium) POSTHERPETIC NEURALGIA (PHN) CONVENIENCE PAK COMBINATION THERAPY NF PACK 600 & 5 MG & % (gabapentin & lidocaine) HORIZANT ORAL TABLET EXTENDED RELEASE 300 NF MG, 600 MG (gabapentin enacarbil)

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 80 Prescription Drug Name Drug Tier Drug Notes LYRICA CR ORAL TABLET EXTENDED RELEASE 24 NF HOUR 165 MG, 330 MG, 82.5 MG (pregabalin) PSYCHOTHERAPEUTIC-MISC acamprosate calcium oral tablet delayed release 333 mg G ADDYI ORAL TABLET 100 MG (flibanserin) NF bupropion hcl er (smoking det) oral tablet extended release 12 CE hour 150 mg CHANTIX CONTINUING MONTH PAK ORAL TABLET CE 1 MG (varenicline tartrate) CHANTIX ORAL TABLET 0.5 MG, 1 MG (varenicline CE tartrate) CHANTIX STARTING MONTH PAK ORAL TABLET 0.5 CE MG X 11 & 1 MG X 42 (varenicline tartrate) chlordiazepoxide-amitriptyline oral tablet 10-25 mg, 5-12.5 mg G cvs nicotine mouth/throat gum 2 mg, 4 mg CE cvs nicotine polacrilex mouth/throat gum 2 mg, 4 mg CE cvs nicotine polacrilex mouth/throat lozenge 2 mg, 4 mg CE cvs nicotine transdermal patch 24 hour 14 mg/24hr, 21 mg/24hr, CE 7 mg/24hr disulfiram oral tablet 250 mg, 500 mg G eq nicotine mouth/throat lozenge 4 mg CE eq nicotine polacrilex mouth/throat gum 2 mg, 4 mg CE eq nicotine polacrilex mouth/throat lozenge 2 mg, 4 mg CE eq nicotine step 3 transdermal patch 24 hour 7 mg/24hr CE eq nicotine transdermal patch 24 hour 14 mg/24hr, 21 mg/24hr CE eql nicotine polacrilex mouth/throat lozenge 2 mg, 4 mg CE gnp nicotine mini mouth/throat lozenge 2 mg CE gnp nicotine polacrilex mouth/throat gum 2 mg, 4 mg CE gnp nicotine polacrilex mouth/throat lozenge 2 mg, 4 mg CE gnp nicotine transdermal patch 24 hour 14 mg/24hr, 7 mg/24hr CE goodsense nicotine mouth/throat gum 4 mg CE goodsense nicotine mouth/throat lozenge 4 mg CE hm nicotine polacrilex mouth/throat gum 2 mg, 4 mg CE hm nicotine polacrilex mouth/throat lozenge 2 mg, 4 mg CE hm nicotine transdermal patch 24 hour 14 mg/24hr, 21 mg/24hr, CE 7 mg/24hr

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 81 Prescription Drug Name Drug Tier Drug Notes KLS QUIT2 MOUTH/THROAT GUM 2 MG (nicotine CE polacrilex) KLS QUIT2 MOUTH/THROAT LOZENGE 2 MG (nicotine CE polacrilex) KLS QUIT4 MOUTH/THROAT GUM 4 MG (nicotine CE polacrilex) KLS QUIT4 MOUTH/THROAT LOZENGE 4 MG (nicotine CE polacrilex) LUCEMYRA ORAL TABLET 0.18 MG (lofexidine hcl) NF naloxone hcl injection solution 0.4 mg/ml, 4 mg/10ml G naloxone hcl injection solution cartridge 0.4 mg/ml G naloxone hcl injection solution prefilled syringe 2 mg/2ml G naltrexone hcl oral tablet 50 mg G NARCAN NASAL LIQUID 4 MG/0.1ML (naloxone hcl) PB NICORELIEF MOUTH/THROAT GUM 2 MG (nicotine CE polacrilex) nicotine mini mouth/throat lozenge 2 mg CE nicotine polacrilex mouth/throat gum 2 mg, 4 mg CE nicotine polacrilex mouth/throat lozenge 2 mg, 4 mg CE nicotine step 1 transdermal patch 24 hour 21 mg/24hr CE nicotine step 2 transdermal patch 24 hour 14 mg/24hr CE nicotine step 3 transdermal patch 24 hour 7 mg/24hr CE nicotine transdermal patch 24 hour 21 mg/24hr, 7 mg/24hr CE NICOTROL INHALATION INHALER 10 MG (nicotine) CE NICOTROL NS NASAL SOLUTION 10 MG/ML (nicotine) CE olanzapine-fluoxetine hcl oral capsule 12-25 mg, 12-50 mg, 3-25 G mg, 6-25 mg, 6-50 mg perphenazine-amitriptyline oral tablet 2-10 mg, 2-25 mg, 4-10 G mg, 4-25 mg, 4-50 mg ra mini nicotine mouth/throat lozenge 2 mg, 4 mg CE ra nicotine mouth/throat gum 2 mg, 4 mg CE ra nicotine transdermal patch 24 hour 14 mg/24hr, 21 mg/24hr CE sm nicotine mouth/throat gum 4 mg CE sm nicotine mouth/throat lozenge 2 mg CE sm nicotine polacrilex mouth/throat gum 2 mg, 4 mg CE sm nicotine polacrilex mouth/throat lozenge 4 mg CE

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 82 Prescription Drug Name Drug Tier Drug Notes sm nicotine transdermal patch 24 hour 14 mg/24hr, 21 mg/24hr, CE 7 mg/24hr THRIVE MOUTH/THROAT GUM 2 MG (nicotine CE polacrilex) VIVITROL INTRAMUSCULAR SUSPENSION NPSP RECONSTITUTED 380 MG (naltrexone) VYLEESI SUBCUTANEOUS SOLUTION AUTO- NF INJECTOR 1.75 MG/0.3ML (bremelanotide acetate) ENDOCRINE AND METABOLIC - DRUGS TO TREAT DIABETES AND REGULATE HORMONES ANDROGENS - DRUGS TO REGULATE MALE HORMONES ANDRODERM TRANSDERMAL PATCH 24 HOUR 2 PB MG/24HR, 4 MG/24HR (testosterone) ANDROGEL PUMP TRANSDERMAL GEL 20.25 NF MG/ACT (1.62%) (testosterone) ANDROGEL TRANSDERMAL GEL 20.25 MG/1.25GM (1.62%), 25 MG/2.5GM (1%), 40.5 MG/2.5GM (1.62%), 50 NF MG/5GM (1%) (testosterone) DEPO-TESTOSTERONE INTRAMUSCULAR SOLUTION 100 MG/ML, 200 MG/ML (testosterone NPB cypionate) ec-rx testosterone transdermal cream 0.2 %, 0.4 %, 10 %, 20 % NF FORTESTA TRANSDERMAL GEL 10 MG/ACT (2%) NF (testosterone) INTRAROSA VAGINAL INSERT 6.5 MG (prasterone) NF methitest oral tablet 10 mg NPB methyltestosterone oral capsule 10 mg G NATESTO NASAL GEL 5.5 MG/ACT (testosterone) PB oxandrolone oral tablet 10 mg, 2.5 mg G TESTIM TRANSDERMAL GEL 50 MG/5GM (1%) NF (testosterone) TESTONE CIK INTRAMUSCULAR KIT 200 MG/ML NF (testosterone cypionate) TESTOPEL IMPLANT PELLET 75 MG (testosterone) NPB testosterone cypionate intramuscular solution 100 mg/ml, 200 G mg/ml testosterone enanthate intramuscular solution 200 mg/ml G

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 83 Prescription Drug Name Drug Tier Drug Notes testosterone gel 12.5 mg/act (1%) transdermal 12.5 mg/act G (1%) testosterone gel 12.5 mg/act (1%) transdermal 12.5 mg/act NF (1%) testosterone gel 50 mg/5gm (1%) transdermal 50 mg/5gm (1%) G testosterone gel 50 mg/5gm (1%) transdermal 50 mg/5gm (1%) NF testosterone transdermal gel 1.62 %, 10 mg/act (2%), 20.25 mg/1.25gm (1.62%), 25 mg/2.5gm (1%), 40.5 mg/2.5gm G (1.62%) testosterone transdermal solution 30 mg/act G VOGELXO PUMP TRANSDERMAL GEL 12.5 MG/ACT NF (1%) (testosterone) VOGELXO TRANSDERMAL GEL 50 MG/5GM (1%) NF (testosterone) XYOSTED SUBCUTANEOUS SOLUTION AUTO- INJECTOR 100 MG/0.5ML, 50 MG/0.5ML, 75 MG/0.5ML NF (testosterone enanthate) ANTIDIABETICS, ALPHA-GLUCOSIDASE INHIBITORS acarbose oral tablet 100 mg, 25 mg, 50 mg G miglitol oral tablet 100 mg, 25 mg, 50 mg G ANTIDIABETICS, AMYLIN ANALOGS SYMLINPEN 120 SUBCUTANEOUS SOLUTION PEN- PB INJECTOR 2700 MCG/2.7ML (pramlintide acetate) SYMLINPEN 60 SUBCUTANEOUS SOLUTION PEN- PB INJECTOR 1500 MCG/1.5ML (pramlintide acetate) ANTIDIABETICS, BIGUANIDE GLUMETZA ORAL TABLET EXTENDED RELEASE 24 NF HOUR 1000 MG, 500 MG (metformin hcl) metformin hcl er (mod) oral tablet extended release 24 hour NF 1000 mg, 500 mg metformin hcl er (osm) oral tablet extended release 24 hour NF 1000 mg, 500 mg metformin hcl er oral tablet extended release 24 hour 500 mg G LGC metformin hcl er oral tablet extended release 24 hour 750 mg G metformin hcl oral solution 500 mg/5ml NPB metformin hcl oral tablet 1000 mg, 500 mg, 850 mg G LGC RIOMET ORAL SOLUTION 500 MG/5ML (metformin hcl) NF

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 84 Prescription Drug Name Drug Tier Drug Notes ANTIDIABETICS, BIGUANIDE/ SULFONYLUREA COMBINATIONS glipizide-metformin hcl oral tablet 2.5-250 mg, 2.5-500 mg, 5- G LGC 500 mg glyburide-metformin oral tablet 1.25-250 mg, 2.5-500 mg, 5-500 G LGC mg ANTIDIABETICS, DIPEPTIDYL PEPTIDASE-4 INHIBITORS alogliptin benzoate oral tablet 12.5 mg, 25 mg, 6.25 mg NF JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG PB (sitagliptin phosphate) NESINA ORAL TABLET 12.5 MG, 25 MG, 6.25 MG NF (alogliptin benzoate) ONGLYZA ORAL TABLET 2.5 MG, 5 MG (saxagliptin hcl) NF TRADJENTA ORAL TABLET 5 MG (linagliptin) NF ANTIDIABETICS, DOPAMINE RECEPTOR AGONISTS CYCLOSET ORAL TABLET 0.8 MG (bromocriptine NF mesylate) ANTIDIABETICS, DPP-4 INHIBITOR COMBINATIONS alogliptin-metformin hcl oral tablet 12.5-1000 mg, 12.5-500 mg NF alogliptin-pioglitazone oral tablet 12.5-15 mg, 12.5-30 mg, 12.5- NF 45 mg, 25-15 mg, 25-30 mg, 25-45 mg JANUMET ORAL TABLET 50-1000 MG, 50-500 MG PB (sitagliptin-metformin hcl) JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 100-1000 MG, 50-1000 MG, 50-500 MG PB (sitagliptin-metformin hcl) JENTADUETO ORAL TABLET 2.5-1000 MG, 2.5-500 MG, NF 2.5-850 MG (linagliptin-metformin hcl) JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 2.5-1000 MG, 5-1000 MG (linagliptin- NF metformin hcl) KAZANO ORAL TABLET 12.5-1000 MG, 12.5-500 MG NF (alogliptin-metformin hcl) KOMBIGLYZE XR ORAL TABLET EXTENDED RELEASE 24 HOUR 2.5-1000 MG, 5-1000 MG, 5-500 MG NF (saxagliptin-metformin)

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 85 Prescription Drug Name Drug Tier Drug Notes OSENI ORAL TABLET 12.5-15 MG, 12.5-30 MG, 12.5-45 MG, 25-15 MG, 25-30 MG, 25-45 MG (alogliptin- NF pioglitazone) TRIJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-5-1000 MG, 12.5-2.5-1000 MG, 25-5-1000 MG, PB 5-2.5-1000 MG (empagliflozin-linaglip-metform) ANTIDIABETICS, INCRETIN MIMETIC AGENTS ADLYXIN STARTER PACK SUBCUTANEOUS PEN- NF INJECTOR KIT 10 & 20 MCG/0.2ML (lixisenatide) ADLYXIN SUBCUTANEOUS SOLUTION PEN- NF INJECTOR 20 MCG/0.2ML (lixisenatide) BYDUREON BCISE SUBCUTANEOUS AUTO- NF INJECTOR 2 MG/0.85ML (exenatide) BYETTA 10 MCG PEN SUBCUTANEOUS SOLUTION NF PEN-INJECTOR 10 MCG/0.04ML (exenatide) BYETTA 5 MCG PEN SUBCUTANEOUS SOLUTION NF PEN-INJECTOR 5 MCG/0.02ML (exenatide) OZEMPIC (0.25 OR 0.5 MG/DOSE) SUBCUTANEOUS PB SOLUTION PEN-INJECTOR 2 MG/1.5ML (semaglutide) OZEMPIC (1 MG/DOSE) SUBCUTANEOUS SOLUTION PB PEN-INJECTOR 2 MG/1.5ML, 4 MG/3ML (semaglutide) RYBELSUS ORAL TABLET 14 MG, 3 MG, 7 MG PB (semaglutide) TRULICITY SUBCUTANEOUS SOLUTION PEN- INJECTOR 0.75 MG/0.5ML, 1.5 MG/0.5ML, 3 MG/0.5ML, PB 4.5 MG/0.5ML (dulaglutide) VICTOZA SUBCUTANEOUS SOLUTION PEN- PB INJECTOR 18 MG/3ML (liraglutide) ANTIDIABETICS, INCRETIN MIMETIC COMBINATION AGENTS SOLIQUA SUBCUTANEOUS SOLUTION PEN- INJECTOR 100-33 UNT-MCG/ML (insulin glargine- PB lixisenatide) XULTOPHY SUBCUTANEOUS SOLUTION PEN- INJECTOR 100-3.6 UNIT-MG/ML (insulin degludec- PB liraglutide) ANTIDIABETICS, INSULIN ADMELOG SOLOSTAR SUBCUTANEOUS SOLUTION NF PEN-INJECTOR 100 UNIT/ML (insulin lispro)

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 86 Prescription Drug Name Drug Tier Drug Notes ADMELOG SUBCUTANEOUS SOLUTION 100 NF UNIT/ML (insulin lispro) AFREZZA INHALATION POWDER 12 UNIT, 4 & 8 & 12 UNIT, 4 UNIT, 8 UNIT, 90 X 4 UNIT & 90X8 UNIT, 90 X 8 NF UNIT & 90X12 UNIT (insulin regular human) APIDRA INJECTION SOLUTION 100 UNIT/ML (insulin NF glulisine) APIDRA SOLOSTAR SUBCUTANEOUS SOLUTION NF PEN-INJECTOR 100 UNIT/ML (insulin glulisine) BASAGLAR KWIKPEN SUBCUTANEOUS SOLUTION PB PEN-INJECTOR 100 UNIT/ML (insulin glargine) FIASP FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML (insulin aspart PB (w/niacinamide)) FIASP PENFILL SUBCUTANEOUS SOLUTION PB CARTRIDGE 100 UNIT/ML (insulin aspart (w/niacinamide)) FIASP SUBCUTANEOUS SOLUTION 100 UNIT/ML PB (insulin aspart (w/niacinamide)) HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML, 200 UNIT/ML (insulin NF lispro) HUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (50-50) 100 UNIT/ML NF (insulin lispro prot & lispro) HUMALOG MIX 50/50 SUBCUTANEOUS SUSPENSION NF (50-50) 100 UNIT/ML (insulin lispro prot & lispro) HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (75-25) 100 UNIT/ML NF (insulin lispro prot & lispro) HUMALOG MIX 75/25 SUBCUTANEOUS SUSPENSION NF (75-25) 100 UNIT/ML (insulin lispro prot & lispro) HUMALOG SUBCUTANEOUS SOLUTION 100 NF UNIT/ML (insulin lispro) HUMALOG SUBCUTANEOUS SOLUTION NF CARTRIDGE 100 UNIT/ML (insulin lispro) HUMULIN 70/30 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML NF (insulin nph isophane & regular) HUMULIN 70/30 SUBCUTANEOUS SUSPENSION (70- NF 30) 100 UNIT/ML (insulin nph isophane & regular)

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 87 Prescription Drug Name Drug Tier Drug Notes HUMULIN N KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR 100 UNIT/ML (insulin nph NF human (isophane)) HUMULIN N SUBCUTANEOUS SUSPENSION 100 NF UNIT/ML (insulin nph human (isophane)) HUMULIN R INJECTION SOLUTION 100 UNIT/ML NF (insulin regular human) HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION 500 UNIT/ML (insulin PB regular human) HUMULIN R U-500 KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 500 UNIT/ML (insulin regular PB human) LANTUS SOLOSTAR SUBCUTANEOUS SOLUTION NF PEN-INJECTOR 100 UNIT/ML (insulin glargine) LANTUS SUBCUTANEOUS SOLUTION 100 UNIT/ML NF (insulin glargine) LEVEMIR FLEXTOUCH SUBCUTANEOUS SOLUTION PB PEN-INJECTOR 100 UNIT/ML (insulin detemir) LEVEMIR SUBCUTANEOUS SOLUTION 100 UNIT/ML PB (insulin detemir) NOVOLIN 70/30 FLEXPEN RELION SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML NF (insulin nph isophane & regular) NOVOLIN 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML PB (insulin nph isophane & regular) NOVOLIN 70/30 RELION SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML (insulin nph isophane & NF regular) NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION (70-30) PB 100 UNIT/ML (insulin nph isophane & regular) NOVOLIN N FLEXPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR 100 UNIT/ML (insulin nph PB human (isophane)) NOVOLIN N RELION SUBCUTANEOUS SUSPENSION NF 100 UNIT/ML (insulin nph human (isophane)) NOVOLIN N SUBCUTANEOUS SUSPENSION 100 PB UNIT/ML (insulin nph human (isophane))

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 88 Prescription Drug Name Drug Tier Drug Notes NOVOLIN R FLEXPEN INJECTION SOLUTION PEN- PB INJECTOR 100 UNIT/ML (insulin regular human) NOVOLIN R FLEXPEN RELION INJECTION SOLUTION PEN-INJECTOR 100 UNIT/ML (insulin regular NF human) NOVOLIN R INJECTION SOLUTION 100 UNIT/ML PB (insulin regular human) NOVOLIN R RELION INJECTION SOLUTION 100 NF UNIT/ML (insulin regular human) NOVOLOG FLEXPEN SUBCUTANEOUS SOLUTION PB PEN-INJECTOR 100 UNIT/ML (insulin aspart) NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML PB (insulin aspart prot & aspart) NOVOLOG MIX 70/30 SUBCUTANEOUS SUSPENSION PB (70-30) 100 UNIT/ML (insulin aspart prot & aspart) NOVOLOG PENFILL SUBCUTANEOUS SOLUTION PB CARTRIDGE 100 UNIT/ML (insulin aspart) NOVOLOG SUBCUTANEOUS SOLUTION 100 UNIT/ML PB (insulin aspart) TOUJEO MAX SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 300 UNIT/ML (insulin PB glargine) TOUJEO SOLOSTAR SUBCUTANEOUS SOLUTION PB PEN-INJECTOR 300 UNIT/ML (insulin glargine) TRESIBA FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML, 200 UNIT/ML (insulin PB degludec) TRESIBA SUBCUTANEOUS SOLUTION 100 UNIT/ML PB (insulin degludec) ANTIDIABETICS, INSULIN SENSITIZER ACTOS ORAL TABLET 15 MG, 30 MG, 45 MG NF (pioglitazone hcl) pioglitazone hcl oral tablet 15 mg, 30 mg, 45 mg G LGC ANTIDIABETICS, INSULIN SENSITIZER/BIGUANIDE COMBINATION pioglitazone hcl-metformin hcl oral tablet 15-500 mg, 15-850 mg G LGC

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 89 Prescription Drug Name Drug Tier Drug Notes ANTIDIABETICS, INSULIN SENSITIZER/SULFONYLUREA COMBINATION pioglitazone hcl-glimepiride oral tablet 30-2 mg, 30-4 mg G ANTIDIABETICS, MEGLITINIDE nateglinide oral tablet 120 mg, 60 mg G LGC repaglinide oral tablet 0.5 mg, 1 mg, 2 mg G LGC ANTIDIABETICS, SODIUM-GLUC CO-TRANSPOR2 (SGLT2) INHIB QTERN ORAL TABLET 10-5 MG, 5-5 MG (dapagliflozin- NPB saxagliptin) STEGLUJAN ORAL TABLET 15-100 MG, 5-100 MG NF (ertugliflozin-sitagliptin) ANTIDIABETICS, SODIUM-GLUC CO-TRANSPOR2 INHIB SYNJARDY ORAL TABLET 12.5-1000 MG, 12.5-500 MG, PB 5-1000 MG, 5-500 MG (empagliflozin-metformin hcl) SYNJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-1000 MG, 12.5-1000 MG, 25-1000 MG, 5-1000 PB MG (empagliflozin-metformin hcl) XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-1000 MG, 10-500 MG, 2.5-1000 MG, 5-1000 MG, PB 5-500 MG (dapagliflozin-metformin hcl) ANTIDIABETICS, SODIUM-GLUC CO-TRANSPOR2 INHIB (SGTL2) COMBO INVOKAMET ORAL TABLET 150-1000 MG, 150-500 MG, NF 50-1000 MG, 50-500 MG (canagliflozin-metformin hcl) INVOKAMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 150-1000 MG, 150-500 MG, 50-1000 NF MG, 50-500 MG (canagliflozin-metformin hcl) SEGLUROMET ORAL TABLET 2.5-1000 MG, 2.5-500 NF MG, 7.5-1000 MG, 7.5-500 MG (ertugliflozin-metformin hcl) ANTIDIABETICS, SODIUM-GLUC CO-TRANSPOR2 INHIB(SGLT2)/DPP-4 INHIBITOR COMBINATIONS GLYXAMBI ORAL TABLET 10-5 MG, 25-5 MG PB (empagliflozin-linagliptin) ANTIDIABETICS, SODIUM-GLUCOSE COTRANSPORTER2 (SGLT2) INHIB FARXIGA ORAL TABLET 10 MG, 5 MG (dapagliflozin PB propanediol)

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 90 Prescription Drug Name Drug Tier Drug Notes INVOKANA ORAL TABLET 100 MG, 300 MG NF (canagliflozin) JARDIANCE ORAL TABLET 10 MG, 25 MG PB (empagliflozin) STEGLATRO ORAL TABLET 15 MG, 5 MG (ertugliflozin NF l-pyroglutamicac) ANTIDIABETICS, SULFONYLUREA glimepiride oral tablet 1 mg, 2 mg, 4 mg G LGC glipizide er oral tablet extended release 24 hour 10 mg, 2.5 mg, 5 G LGC mg glipizide oral tablet 10 mg, 5 mg G LGC glipizide xl oral tablet extended release 24 hour 10 mg, 2.5 mg, 5 G LGC mg glyburide micronized oral tablet 1.5 mg G glyburide micronized oral tablet 3 mg, 6 mg G LGC glyburide oral tablet 1.25 mg, 2.5 mg, 5 mg G LGC tolbutamide oral tablet 500 mg G ANTI-OBESTITY DRUGS SAXENDA SUBCUTANEOUS SOLUTION PEN- PB INJECTOR 18 MG/3ML (liraglutide -weight management) WEGOVY SUBCUTANEOUS SOLUTION AUTO- INJECTOR 0.25 MG/0.5ML, 0.5 MG/0.5ML, 1 MG/0.5ML, NPB 1.7 MG/0.75ML, 2.4 MG/0.75ML (semaglutide-weight management) BISPHOSPHONATES - DRUGS TO TREAT BONE LOSS alendronate sodium oral solution 70 mg/75ml G alendronate sodium oral tablet 10 mg, 35 mg, 5 mg, 70 mg G BINOSTO ORAL TABLET EFFERVESCENT 70 MG NPB (alendronate sodium) FOSAMAX PLUS D ORAL TABLET 70-2800 MG-UNIT, NPB 70-5600 MG-UNIT (alendronate-cholecalciferol) ibandronate sodium oral tablet 150 mg G RECLAST INTRAVENOUS SOLUTION 5 MG/100ML NPSP (zoledronic acid) risedronate sodium oral tablet 150 mg, 30 mg, 35 mg, 5 mg G risedronate sodium oral tablet delayed release 35 mg G zoledronic acid intravenous concentrate 4 mg/5ml G

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 91 Prescription Drug Name Drug Tier Drug Notes zoledronic acid intravenous solution 4 mg/100ml NPSP zoledronic acid intravenous solution 5 mg/100ml G CALCIUM RECEPTOR AGONISTS calcitriol oral capsule 0.25 mcg, 0.5 mcg G calcitriol oral solution 1 mcg/ml G cinacalcet hcl oral tablet 30 mg, 60 mg, 90 mg G doxercalciferol oral capsule 0.5 mcg, 1 mcg, 2.5 mcg G paricalcitol oral capsule 1 mcg, 2 mcg, 4 mcg G RAYALDEE ORAL CAPSULE EXTENDED RELEASE 30 NPB MCG (calcifediol) SENSIPAR ORAL TABLET 30 MG, 60 MG, 90 MG NPSP (cinacalcet hcl) STRENSIQ SUBCUTANEOUS SOLUTION 18 MG/0.45ML, 28 MG/0.7ML, 40 MG/ML, 80 MG/0.8ML NPB (asfotase alfa) CARNITINE DEFICIENCY AGENTS CARNITOR ORAL SOLUTION 1 GM/10ML (levocarnitine) NF CARNITOR ORAL TABLET 330 MG (levocarnitine) NF CARNITOR SF ORAL SOLUTION 1 GM/10ML NF (levocarnitine) levocarnitine oral solution 1 gm/10ml G levocarnitine oral tablet 330 mg G CHELATING AGENTS CHEMET ORAL CAPSULE 100 MG (succimer) NPB CUPRIMINE ORAL CAPSULE 250 MG (penicillamine) NF deferasirox oral tablet soluble 125 mg, 250 mg, 500 mg G deferoxamine mesylate injection solution reconstituted 2 gm NPSP DEPEN TITRATABS ORAL TABLET 250 MG NPB (penicillamine) DESFERAL INJECTION SOLUTION RECONSTITUTED NF 500 MG (deferoxamine mesylate) EXJADE ORAL TABLET SOLUBLE 125 MG, 250 MG, NF 500 MG (deferasirox) FERRIPROX ORAL SOLUTION 100 MG/ML (deferiprone) NF FERRIPROX ORAL TABLET 1000 MG, 500 MG NF (deferiprone)

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 92 Prescription Drug Name Drug Tier Drug Notes FERRIPROX TWICE-A-DAY ORAL TABLET 1000 MG NF (deferiprone) JADENU ORAL TABLET 180 MG, 360 MG, 90 MG NF (deferasirox) JADENU SPRINKLE ORAL PACKET 180 MG, 360 MG, NF 90 MG (deferasirox) LOKELMA ORAL PACKET 10 GM, 5 GM (sodium PB zirconium cyclosilicate) penicillamine oral capsule 250 mg G sodium polystyrene sulfonate oral powder G SPS ORAL SUSPENSION 15 GM/60ML (sodium polystyrene G sulfonate) SYPRINE ORAL CAPSULE 250 MG (trientine hcl) NF trientine hcl oral capsule 250 mg G VELTASSA ORAL PACKET 16.8 GM, 25.2 GM, 8.4 GM PB (patiromer sorbitex calcium) CONTRACEPTIVES - PRODUCTS FOR BIRTH CONTROL levonorgestrel-ethinyl estrad (Afirmelle Oral Tablet 0.1-20 Mg- CE Mcg) AFTERA ORAL TABLET 1.5 MG (levonorgestrel) CE levonorgestrel-ethinyl estrad (Altavera Oral Tablet 0.15-30 Mg- CE Mcg) alyacen 1/35 oral tablet 1-35 mg-mcg CE alyacen 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg CE levonorgest-eth estrad 91-day (Amethia Oral Tablet 0.15-0.03 CE &0.01 Mg) levonorgestrel-ethinyl estrad (Amethyst Oral Tablet 90-20 CE Mcg) ANNOVERA VAGINAL RING 0.013-0.15 MG/24HR CE (segesterone-ethinyl estradiol) desogestrel-ethinyl estradiol (Apri Oral Tablet 0.15-30 Mg- CE Mcg) norethin-eth estrad triphasic (Aranelle Oral Tablet 0.5/1/0.5-35 CE Mg-Mcg) levonorgest-eth estrad 91-day (Ashlyna Oral Tablet 0.15-0.03 CE &0.01 Mg)

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 93 Prescription Drug Name Drug Tier Drug Notes levonorgestrel-ethinyl estrad (Aubra Eq Oral Tablet 0.1-20 Mg- CE Mcg) levonorgestrel-ethinyl estrad (Aubra Oral Tablet 0.1-20 Mg- CE Mcg) norethindrone acet-ethinyl est (Aurovela 1.5/30 Oral Tablet 1.5- CE 30 Mg-Mcg) norethindrone acet-ethinyl est (Aurovela 1/20 Oral Tablet 1-20 CE Mg-Mcg) norethin ace-eth estrad-fe (Aurovela 24 Fe Oral Tablet 1-20 CE Mg-Mcg(24)) norethin ace-eth estrad-fe (Aurovela Fe 1.5/30 Oral Tablet 1.5- CE 30 Mg-Mcg) norethin ace-eth estrad-fe (Aurovela Fe 1/20 Oral Tablet 1-20 CE Mg-Mcg) levonorgestrel-ethinyl estrad (Aviane Oral Tablet 0.1-20 Mg- CE Mcg) levonorgestrel-ethinyl estrad (Ayuna Oral Tablet 0.15-30 Mg- CE Mcg) desogestrel-ethinyl estradiol (Azurette Oral Tablet 0.15- CE 0.02/0.01 Mg (21/5)) BALCOLTRA ORAL TABLET 0.1-20 MG-MCG(21) CE (levonorgest-eth estrad-fe bisg) norethindrone-eth estradiol (Balziva Oral Tablet 0.4-35 Mg- CE Mcg) BEYAZ ORAL TABLET 3-0.02-0.451 MG (drospiren-eth NF estrad-levomefol) norethin ace-eth estrad-fe (Blisovi 24 Fe Oral Tablet 1-20 Mg- CE Mcg(24)) norethin ace-eth estrad-fe (Blisovi Fe 1.5/30 Oral Tablet 1.5-30 CE Mg-Mcg) norethin ace-eth estrad-fe (Blisovi Fe 1/20 Oral Tablet 1-20 CE Mg-Mcg) briellyn oral tablet 0.4-35 mg-mcg CE norethindrone (Camila Oral Tablet 0.35 Mg) CE levonorgest-eth estrad 91-day (Camrese Lo Oral Tablet 0.1- CE 0.02 & 0.01 Mg) levonorgest-eth estrad 91-day (Camrese Oral Tablet 0.15-0.03 CE &0.01 Mg)

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 94 Prescription Drug Name Drug Tier Drug Notes desogestrel-ethinyl estradiol (Caziant Oral Tablet CE 0.1/0.125/0.15 -0.025 Mg) levonorgestrel-ethinyl estrad (Chateal Eq Oral Tablet 0.15-30 CE Mg-Mcg) levonorgestrel-ethinyl estrad (Chateal Oral Tablet 0.15-30 Mg- CE Mcg) norgestrel-ethinyl estradiol (Cryselle-28 Oral Tablet 0.3-30 Mg- CE Mcg) norethindrone-eth estradiol (Cyclafem 1/35 Oral Tablet 1-35 CE Mg-Mcg) norethin-eth estrad triphasic (Cyclafem 7/7/7 Oral Tablet CE 0.5/0.75/1-35 Mg-Mcg) desogestrel-ethinyl estradiol (Cyred Eq Oral Tablet 0.15-30 CE Mg-Mcg) desogestrel-ethinyl estradiol (Cyred Oral Tablet 0.15-30 Mg- CE Mcg) norethindrone-eth estradiol (Dasetta 1/35 Oral Tablet 1-35 Mg- CE Mcg) norethin-eth estrad triphasic (Dasetta 7/7/7 Oral Tablet CE 0.5/0.75/1-35 Mg-Mcg) levonorgest-eth estrad 91-day (Daysee Oral Tablet 0.15-0.03 CE &0.01 Mg) norethindrone (Deblitane Oral Tablet 0.35 Mg) CE levonorgestrel-ethinyl estrad (Delyla Oral Tablet 0.1-20 Mg- CE Mcg) DEPO-SUBQ PROVERA 104 SUBCUTANEOUS SUSPENSION PREFILLED SYRINGE 104 MG/0.65ML CE (medroxyprogesterone acetate) desogestrel-ethinyl estradiol oral tablet 0.15-0.02/0.01 mg CE (21/5) drospiren-eth estrad-levomefol oral tablet 3-0.02-0.451 mg, 3- CE 0.03-0.451 mg drospirenone-ethinyl estradiol oral tablet 3-0.02 mg, 3-0.03 mg CE ECONTRA EZ ORAL TABLET 1.5 MG (levonorgestrel) CE ECONTRA ONE-STEP ORAL TABLET 1.5 MG CE (levonorgestrel) norgestrel-ethinyl estradiol (Elinest Oral Tablet 0.3-30 Mg- CE Mcg) ELLA ORAL TABLET 30 MG (ulipristal acetate) CE 2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 95 Prescription Drug Name Drug Tier Drug Notes etonogestrel-ethinyl estradiol (Eluryng Vaginal Ring 0.12-0.015 CE Mg/24Hr) desogestrel-ethinyl estradiol (Emoquette Oral Tablet 0.15-30 CE Mg-Mcg) levonorg-eth estrad triphasic (Enpresse-28 Oral Tablet 50- CE 30/75-40/ 125-30 Mcg) desogestrel-ethinyl estradiol (Enskyce Oral Tablet 0.15-30 Mg- CE Mcg) norethindrone (Errin Oral Tablet 0.35 Mg) CE norgestimate-eth estradiol (Estarylla Oral Tablet 0.25-35 Mg- CE Mcg) ethynodiol diac-eth estradiol oral tablet 1-35 mg-mcg, 1-50 mg- CE mcg etonogestrel-ethinyl estradiol vaginal ring 0.12-0.015 mg/24hr CE levonorgestrel-ethinyl estrad (Falmina Oral Tablet 0.1-20 Mg- CE Mcg) levonorgest-eth estrad 91-day (Fayosim Oral Tablet 42-21-21-7 CE Days) norgestimate-eth estradiol (Femynor Oral Tablet 0.25-35 Mg- CE Mcg) norethindrone acet-ethinyl est (Hailey 1.5/30 Oral Tablet 1.5-30 CE Mg-Mcg) norethin ace-eth estrad-fe (Hailey 24 Fe Oral Tablet 1-20 Mg- CE Mcg(24)) norethindrone (Heather Oral Tablet 0.35 Mg) CE norethindrone (Incassia Oral Tablet 0.35 Mg) CE levonorgest-eth estrad 91-day (Introvale Oral Tablet 0.15-0.03 CE Mg) desogestrel-ethinyl estradiol (Isibloom Oral Tablet 0.15-30 Mg- CE Mcg) drospirenone-ethinyl estradiol (Jasmiel Oral Tablet 3-0.02 Mg) CE norethindrone (Jencycla Oral Tablet 0.35 Mg) CE levonorgest-eth estrad 91-day (Jolessa Oral Tablet 0.15-0.03 CE Mg) desogestrel-ethinyl estradiol (Juleber Oral Tablet 0.15-30 Mg- CE Mcg) norethindrone acet-ethinyl est (Junel 1.5/30 Oral Tablet 1.5-30 CE Mg-Mcg)

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 96 Prescription Drug Name Drug Tier Drug Notes norethindrone acet-ethinyl est (Junel 1/20 Oral Tablet 1-20 Mg- CE Mcg) norethin ace-eth estrad-fe (Junel Fe 1.5/30 Oral Tablet 1.5-30 CE Mg-Mcg) norethin ace-eth estrad-fe (Junel Fe 1/20 Oral Tablet 1-20 Mg- CE Mcg) norethin ace-eth estrad-fe (Junel Fe 24 Oral Tablet 1-20 Mg- CE Mcg(24)) norethin-eth estradiol-fe (Kaitlib Fe Oral Tablet Chewable 0.8- CE 25 Mg-Mcg) desogestrel-ethinyl estradiol (Kalliga Oral Tablet 0.15-30 Mg- CE Mcg) desogestrel-ethinyl estradiol (Kariva Oral Tablet 0.15-0.02/0.01 CE Mg (21/5)) ethynodiol diac-eth estradiol (Kelnor 1/35 Oral Tablet 1-35 CE Mg-Mcg) ethynodiol diac-eth estradiol (Kelnor 1/50 Oral Tablet 1-50 CE Mg-Mcg) levonorgestrel-ethinyl estrad (Kurvelo Oral Tablet 0.15-30 Mg- CE Mcg) KYLEENA INTRAUTERINE INTRAUTERINE DEVICE CE 19.5 MG (levonorgestrel) norethindrone acet-ethinyl est (Larin 1.5/30 Oral Tablet 1.5-30 CE Mg-Mcg) norethindrone acet-ethinyl est (Larin 1/20 Oral Tablet 1-20 Mg- CE Mcg) norethin ace-eth estrad-fe (Larin 24 Fe Oral Tablet 1-20 Mg- CE Mcg(24)) norethin ace-eth estrad-fe (Larin Fe 1.5/30 Oral Tablet 1.5-30 CE Mg-Mcg) norethin ace-eth estrad-fe (Larin Fe 1/20 Oral Tablet 1-20 Mg- CE Mcg) levonorgestrel-ethinyl estrad (Larissia Oral Tablet 0.1-20 Mg- CE Mcg) norethin-eth estradiol-fe (Layolis Fe Oral Tablet Chewable 0.8- CE 25 Mg-Mcg) norethin-eth estrad triphasic (Leena Oral Tablet 0.5/1/0.5-35 CE Mg-Mcg)

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 97 Prescription Drug Name Drug Tier Drug Notes levonorgestrel-ethinyl estrad (Lessina Oral Tablet 0.1-20 Mg- CE Mcg) levonorg-eth estrad triphasic (Levonest Oral Tablet 50-30/75- CE 40/ 125-30 Mcg) levonorgest-eth est & eth est oral tablet 42-21-21-7 days CE levonorgest-eth estrad 91-day oral tablet 0.1-0.02 & 0.01 mg, CE 0.15-0.03 &0.01 mg, 0.15-0.03 mg levonorgestrel oral tablet 1.5 mg CE levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 0.15-30 CE mg-mcg, 90-20 mcg levonorg-eth estrad triphasic oral tablet 50-30/75-40/ 125-30 CE mcg levonorgestrel-ethinyl estrad (Levora 0.15/30 (28) Oral Tablet CE 0.15-30 Mg-Mcg) levonorgestrel-ethinyl estrad (Lillow Oral Tablet 0.15-30 Mg- CE Mcg) LO LOESTRIN FE ORAL TABLET 1 MG-10 MCG / 10 CE MCG (norethin-eth estrad-fe biphas) drospirenone-ethinyl estradiol (Loryna Oral Tablet 3-0.02 Mg) CE norgestrel-ethinyl estradiol (Low-Ogestrel Oral Tablet 0.3-30 CE Mg-Mcg) drospirenone-ethinyl estradiol (Lo-Zumandimine Oral Tablet CE 3-0.02 Mg) levonorgestrel-ethinyl estrad (Lutera Oral Tablet 0.1-20 Mg- CE Mcg) norethindrone (Lyza Oral Tablet 0.35 Mg) CE marlissa oral tablet 0.15-30 mg-mcg CE medroxyprogesterone acetate intramuscular suspension 150 CE mg/ml medroxyprogesterone acetate intramuscular suspension prefilled CE syringe 150 mg/ml norethindrone acet-ethinyl est (Microgestin 1.5/30 Oral Tablet CE 1.5-30 Mg-Mcg) norethindrone acet-ethinyl est (Microgestin 1/20 Oral Tablet 1- CE 20 Mg-Mcg) norethin ace-eth estrad-fe (Microgestin Fe 1.5/30 Oral Tablet CE 1.5-30 Mg-Mcg) norethin ace-eth estrad-fe (Microgestin Fe 1/20 Oral Tablet 1- CE 20 Mg-Mcg) 2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 98 Prescription Drug Name Drug Tier Drug Notes norgestimate-eth estradiol (Mili Oral Tablet 0.25-35 Mg-Mcg) CE MINASTRIN 24 FE ORAL TABLET CHEWABLE 1-20 NF MG-MCG(24) (norethin ace-eth estrad-fe) MIRENA (52 MG) INTRAUTERINE INTRAUTERINE CE DEVICE 20 MCG/24HR (levonorgestrel) norgestimate-eth estradiol (Mono-Linyah Oral Tablet 0.25-35 CE Mg-Mcg) MY CHOICE ORAL TABLET 1.5 MG (levonorgestrel) CE MY WAY ORAL TABLET 1.5 MG (levonorgestrel) CE NATAZIA ORAL TABLET 3/2-2/2-3/1 MG (estradiol CE valerate-dienogest) norethindrone-eth estradiol (Necon 0.5/35 (28) Oral Tablet 0.5- CE 35 Mg-Mcg) NEW DAY ORAL TABLET 1.5 MG (levonorgestrel) CE NEXPLANON SUBCUTANEOUS IMPLANT 68 MG CE (etonogestrel) drospirenone-ethinyl estradiol (Nikki Oral Tablet 3-0.02 Mg) CE norethindrone (Nora-Be Oral Tablet 0.35 Mg) CE norethin ace-eth estrad-fe oral tablet 1-20 mg-mcg CE norethin ace-eth estrad-fe oral tablet chewable 1-20 mg- CE mcg(24) norethindrone acet-ethinyl est oral tablet 1-20 mg-mcg CE norethindrone oral tablet 0.35 mg CE norethin-eth estradiol-fe oral tablet chewable 0.4-35 mg-mcg, CE 0.8-25 mg-mcg norgestimate-eth estradiol oral tablet 0.25-35 mg-mcg CE norgestim-eth estrad triphasic oral tablet 0.18/0.215/0.25 mg-25 CE mcg, 0.18/0.215/0.25 mg-35 mcg norethindrone (Norlyda Oral Tablet 0.35 Mg) CE norethindrone (Norlyroc Oral Tablet 0.35 Mg) CE norethindrone-eth estradiol (Nortrel 0.5/35 (28) Oral Tablet CE 0.5-35 Mg-Mcg) norethindrone-eth estradiol (Nortrel 1/35 (21) Oral Tablet 1-35 CE Mg-Mcg) norethindrone-eth estradiol (Nortrel 1/35 (28) Oral Tablet 1-35 CE Mg-Mcg) norethin-eth estrad triphasic (Nortrel 7/7/7 Oral Tablet CE 0.5/0.75/1-35 Mg-Mcg) 2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 99 Prescription Drug Name Drug Tier Drug Notes NUVARING VAGINAL RING 0.12-0.015 MG/24HR NF (etonogestrel-ethinyl estradiol) drospirenone-ethinyl estradiol (Ocella Oral Tablet 3-0.03 Mg) CE OPCICON ONE-STEP ORAL TABLET 1.5 MG CE (levonorgestrel) OPTION 2 ORAL TABLET 1.5 MG (levonorgestrel) CE levonorgestrel-ethinyl estrad (Orsythia Oral Tablet 0.1-20 Mg- CE Mcg) ORTHO TRI-CYCLEN LO ORAL TABLET 0.18/0.215/0.25 NF MG-25 MCG (norgestim-eth estrad triphasic) PARAGARD INTRAUTERINE COPPER CE INTRAUTERINE INTRAUTERINE DEVICE (copper) norethindrone-eth estradiol (Philith Oral Tablet 0.4-35 Mg- CE Mcg) desogestrel-ethinyl estradiol (Pimtrea Oral Tablet 0.15- CE 0.02/0.01 Mg (21/5)) norethindrone-eth estradiol (Pirmella 1/35 Oral Tablet 1-35 CE Mg-Mcg) norethin-eth estrad triphasic (Pirmella 7/7/7 Oral Tablet CE 0.5/0.75/1-35 Mg-Mcg) levonorgestrel-ethinyl estrad (Portia-28 Oral Tablet 0.15-30 CE Mg-Mcg) PREVENTEZA ORAL TABLET 1.5 MG (levonorgestrel) CE norgestimate-eth estradiol (Previfem Oral Tablet 0.25-35 Mg- CE Mcg) QUARTETTE ORAL TABLET 42-21-21-7 DAYS NF (levonorgest-eth estrad 91-day) REACT ORAL TABLET 1.5 MG (levonorgestrel) CE desogestrel-ethinyl estradiol (Reclipsen Oral Tablet 0.15-30 CE Mg-Mcg) levonorgest-eth estrad 91-day (Rivelsa Oral Tablet 42-21-21-7 CE Days) SAFYRAL ORAL TABLET 3-0.03-0.451 MG (drospiren-eth NPB estrad-levomefol) SEASONIQUE ORAL TABLET 0.15-0.03 &0.01 MG NF (levonorgest-eth estrad 91-day) levonorgest-eth estrad 91-day (Setlakin Oral Tablet 0.15-0.03 CE Mg) norethindrone (Sharobel Oral Tablet 0.35 Mg) CE 2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 100 Prescription Drug Name Drug Tier Drug Notes desogestrel-ethinyl estradiol (Simliya Oral Tablet 0.15- CE 0.02/0.01 Mg (21/5)) levonorgest-eth estrad 91-day (Simpesse Oral Tablet 0.15-0.03 CE &0.01 Mg) SKYLA INTRAUTERINE INTRAUTERINE DEVICE CE 13.5 MG (levonorgestrel) SLYND ORAL TABLET 4 MG (drospirenone) NF norgestimate-eth estradiol (Sprintec 28 Oral Tablet 0.25-35 CE Mg-Mcg) levonorgestrel-ethinyl estrad (Sronyx Oral Tablet 0.1-20 Mg- CE Mcg) drospirenone-ethinyl estradiol (Syeda Oral Tablet 3-0.03 Mg) CE TAKE ACTION ORAL TABLET 1.5 MG (levonorgestrel) CE norethin ace-eth estrad-fe (Tarina 24 Fe Oral Tablet 1-20 Mg- CE Mcg(24)) norethin ace-eth estrad-fe (Tarina Fe 1/20 Eq Oral Tablet 1-20 CE Mg-Mcg) norethin ace-eth estrad-fe (Tarina Fe 1/20 Oral Tablet 1-20 CE Mg-Mcg) TAYTULLA ORAL CAPSULE 1-20 MG-MCG(24) NF (norethin ace-eth estrad-fe) norethindron-ethinyl estrad-fe (Tilia Fe Oral Tablet 1-20/1- CE 30/1-35 Mg-Mcg) norgestim-eth estrad triphasic (Tri Femynor Oral Tablet CE 0.18/0.215/0.25 Mg-35 Mcg) norgestim-eth estrad triphasic (Tri-Estarylla Oral Tablet CE 0.18/0.215/0.25 Mg-35 Mcg) norethindron-ethinyl estrad-fe (Tri-Legest Fe Oral Tablet 1- CE 20/1-30/1-35 Mg-Mcg) norgestim-eth estrad triphasic (Tri-Linyah Oral Tablet CE 0.18/0.215/0.25 Mg-35 Mcg) norgestim-eth estrad triphasic (Tri-Lo-Estarylla Oral Tablet CE 0.18/0.215/0.25 Mg-25 Mcg) norgestim-eth estrad triphasic (Tri-Lo-Marzia Oral Tablet CE 0.18/0.215/0.25 Mg-25 Mcg) norgestim-eth estrad triphasic (Tri-Lo-Mili Oral Tablet CE 0.18/0.215/0.25 Mg-25 Mcg) norgestim-eth estrad triphasic (Tri-Lo-Sprintec Oral Tablet CE 0.18/0.215/0.25 Mg-25 Mcg) 2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 101 Prescription Drug Name Drug Tier Drug Notes norgestim-eth estrad triphasic (Tri-Mili Oral Tablet CE 0.18/0.215/0.25 Mg-35 Mcg) norgestim-eth estrad triphasic (Tri-Previfem Oral Tablet CE 0.18/0.215/0.25 Mg-35 Mcg) norgestim-eth estrad triphasic (Tri-Sprintec Oral Tablet CE 0.18/0.215/0.25 Mg-35 Mcg) levonorg-eth estrad triphasic (Trivora (28) Oral Tablet 50- CE 30/75-40/ 125-30 Mcg) norgestim-eth estrad triphasic (Tri-Vylibra Lo Oral Tablet CE 0.18/0.215/0.25 Mg-25 Mcg) norgestim-eth estrad triphasic (Tri-Vylibra Oral Tablet CE 0.18/0.215/0.25 Mg-35 Mcg) norethindrone (Tulana Oral Tablet 0.35 Mg) CE drospiren-eth estrad-levomefol (Tydemy Oral Tablet 3-0.03- CE 0.451 Mg) desogestrel-ethinyl estradiol (Velivet Oral Tablet 0.1/0.125/0.15 CE -0.025 Mg) levonorgestrel-ethinyl estrad (Vienva Oral Tablet 0.1-20 Mg- CE Mcg) viorele oral tablet 0.15-0.02/0.01 mg (21/5) CE norethindrone-eth estradiol (Vyfemla Oral Tablet 0.4-35 Mg- CE Mcg) norgestimate-eth estradiol (Vylibra Oral Tablet 0.25-35 Mg- CE Mcg) norethindrone-eth estradiol (Wera Oral Tablet 0.5-35 Mg-Mcg) CE norethin-eth estradiol-fe (Wymzya Fe Oral Tablet Chewable CE 0.4-35 Mg-Mcg) norelgestromin-eth estradiol (Xulane Transdermal Patch CE Weekly 150-35 Mcg/24Hr) YASMIN 28 ORAL TABLET 3-0.03 MG (drospirenone- NF ethinyl estradiol) YAZ ORAL TABLET 3-0.02 MG (drospirenone-ethinyl NF estradiol) drospirenone-ethinyl estradiol (Zarah Oral Tablet 3-0.03 Mg) CE ethynodiol diac-eth estradiol (Zovia 1/35E (28) Oral Tablet 1- CE 35 Mg-Mcg) drospirenone-ethinyl estradiol (Zumandimine Oral Tablet 3- CE 0.03 Mg)

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 102 Prescription Drug Name Drug Tier Drug Notes DIABETIC SUPPLIES COMFORT TOUCH LANCETS 31G (lancets) NPB COMFORT TOUCH PLUS LANCETS 30G (lancets) NPB pure comfort lancets 30g NPB ENDOMETRIOSIS CETROTIDE SUBCUTANEOUS KIT 0.25 MG (cetrorelix SPC (Only available for PSP acetate) select plans) danazol oral capsule 100 mg, 200 mg, 50 mg G FENSOLVI (6 MONTH) SUBCUTANEOUS KIT 45 MG NPB (PED) (leuprolide acetate (6 month)) ORILISSA ORAL TABLET 150 MG, 200 MG (elagolix PB sodium) SUPPRELIN LA SUBCUTANEOUS KIT 50 MG (histrelin PSP acetate (cpp)) SYNAREL NASAL SOLUTION 2 MG/ML (nafarelin NPB acetate) TRIPTODUR INTRAMUSCULAR SUSPENSION PSP RECONSTITUTED ER 22.5 MG (triptorelin pamoate) ENZYME REPLACEMENTS - DRUGS TO TREAT ENZYME DEFICIENCIES CARBAGLU ORAL TABLET 200 MG (carglumic acid) NPB CERDELGA ORAL CAPSULE 84 MG (eliglustat tartrate) PSP CEREZYME INTRAVENOUS SOLUTION PSP RECONSTITUTED 400 UNIT (imiglucerase) CYSTADANE ORAL POWDER (betaine) NPB CYSTAGON ORAL CAPSULE 150 MG, 50 MG PSP (cysteamine bitartrate) KUVAN ORAL PACKET 100 MG, 500 MG (sapropterin NF dihydrochloride) KUVAN ORAL TABLET 100 MG (sapropterin NF dihydrochloride) miglustat oral capsule 100 mg G MYALEPT SUBCUTANEOUS SOLUTION NPB RECONSTITUTED 11.3 MG (metreleptin) NITYR ORAL TABLET 10 MG, 2 MG, 5 MG (nitisinone) NPB ORFADIN ORAL CAPSULE 10 MG, 2 MG, 20 MG, 5 MG PSP (nitisinone) ORFADIN ORAL SUSPENSION 4 MG/ML (nitisinone) PSP 2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 103 Prescription Drug Name Drug Tier Drug Notes sodium phenylbutyrate oral powder 3 gm/tsp G sodium phenylbutyrate oral tablet 500 mg G VPRIV INTRAVENOUS SOLUTION RECONSTITUTED NPSP 400 UNIT (velaglucerase alfa) ZAVESCA ORAL CAPSULE 100 MG (miglustat) NPB ESTROGENS - DRUGS TO REGULATE FEMALE HORMONES ALORA TRANSDERMAL PATCH TWICE WEEKLY 0.025 MG/24HR, 0.05 MG/24HR, 0.075 MG/24HR, 0.1 NF MG/24HR (estradiol) estradiol-norethindrone acet (Amabelz Oral Tablet 0.5-0.1 Mg, G 1-0.5 Mg) ANGELIQ ORAL TABLET 0.25-0.5 MG, 0.5-1 MG NF (drospirenone-estradiol) BIJUVA ORAL CAPSULE 1-100 MG (estradiol- PB progesterone) CLIMARA PRO TRANSDERMAL PATCH WEEKLY PB 0.045-0.015 MG/DAY (estradiol-levonorgestrel) COMBIPATCH TRANSDERMAL PATCH TWICE WEEKLY 0.05-0.14 MG/DAY, 0.05-0.25 MG/DAY NF (estradiol-norethindrone acet) DELESTROGEN INTRAMUSCULAR OIL 10 MG/ML NPB (estradiol valerate) DEPO-ESTRADIOL INTRAMUSCULAR OIL 5 MG/ML NPB (estradiol cypionate) DIVIGEL TRANSDERMAL GEL 0.25 MG/0.25GM, 0.5 MG/0.5GM, 0.75 MG/0.75GM, 1 MG/GM, 1.25 PB MG/1.25GM (estradiol) estradiol (Dotti Transdermal Patch Twice Weekly 0.025 Mg/24Hr, 0.0375 Mg/24Hr, 0.05 Mg/24Hr, 0.075 Mg/24Hr, G 0.1 Mg/24Hr) DUAVEE ORAL TABLET 0.45-20 MG (conj estrogens- NF bazedoxifene) ec-rx estradiol transdermal cream 0.4 %, 0.6 % NF ELESTRIN TRANSDERMAL GEL 0.52 MG/0.87 GM NF (0.06%) (estradiol) estradiol oral tablet 0.5 mg, 1 mg, 2 mg G estradiol transdermal patch twice weekly 0.025 mg/24hr, 0.0375 G mg/24hr, 0.05 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 104 Prescription Drug Name Drug Tier Drug Notes estradiol transdermal patch weekly 0.025 mg/24hr, 0.0375 mg/24hr, 0.05 mg/24hr, 0.06 mg/24hr, 0.075 mg/24hr, 0.1 G mg/24hr estradiol vaginal cream 0.1 mg/gm G estradiol vaginal tablet 10 mcg G estradiol valerate intramuscular oil 20 mg/ml, 40 mg/ml G estradiol-norethindrone acet oral tablet 0.5-0.1 mg, 1-0.5 mg G ESTRING VAGINAL RING 2 MG (estradiol) NF ESTROGEL TRANSDERMAL GEL 0.75 MG/1.25 GM NF (0.06%) (estradiol) EVAMIST TRANSDERMAL SOLUTION 1.53 PB MG/SPRAY (estradiol) FEMRING VAGINAL RING 0.05 MG/24HR, 0.1 NF MG/24HR (estradiol acetate) norethindrone-eth estradiol (Fyavolv Oral Tablet 0.5-2.5 Mg- G Mcg, 1-5 Mg-Mcg) IMVEXXY MAINTENANCE PACK VAGINAL INSERT PB 10 MCG, 4 MCG (estradiol) IMVEXXY STARTER PACK VAGINAL INSERT 10 PB MCG, 4 MCG (estradiol) norethindrone-eth estradiol (Jinteli Oral Tablet 1-5 Mg-Mcg) G MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG NF (esterified estrogens) MENOSTAR TRANSDERMAL PATCH WEEKLY 14 NF MCG/24HR (estradiol) estradiol-norethindrone acet (Mimvey Oral Tablet 1-0.5 Mg) G MINIVELLE TRANSDERMAL PATCH TWICE WEEKLY 0.025 MG/24HR, 0.0375 MG/24HR, 0.05 NF MG/24HR, 0.075 MG/24HR, 0.1 MG/24HR (estradiol) norethindrone-eth estradiol oral tablet 0.5-2.5 mg-mcg, 1-5 mg- G mcg ORIAHNN ORAL CAPSULE THERAPY PACK 300-1-0.5 PB & 300 MG (elagolix-estradiol-norethind) PREFEST ORAL TABLET 1/1-0.09 MG (15/15) (estradiol- NF norgestimate) PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, 0.625 MG, NF 0.9 MG, 1.25 MG (estrogens conjugated) PREMARIN VAGINAL CREAM 0.625 MG/GM (estrogens, NF conjugated) 2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 105 Prescription Drug Name Drug Tier Drug Notes PREMPHASE ORAL TABLET 0.625-5 MG (conj estrog- NF medroxyprogest ace) PREMPRO ORAL TABLET 0.3-1.5 MG, 0.45-1.5 MG, NF 0.625-2.5 MG, 0.625-5 MG (conj estrog-medroxyprogest ace) VAGIFEM VAGINAL TABLET 10 MCG (estradiol) PB VIVELLE-DOT TRANSDERMAL PATCH TWICE NF WEEKLY 0.0375 MG/24HR (estradiol) estradiol (Yuvafem Vaginal Tablet 10 Mcg) G FERTILITY REGULATORS SPC (Only available for clomiphene citrate oral tablet 50 mg G select plans) ganirelix acetate subcutaneous solution prefilled syringe 250 NPSP mcg/0.5ml GONAL-F INJECTION SOLUTION RECONSTITUTED SPC (Only available for PSP 1050 UNIT, 450 UNIT (follitropin alfa) select plans) GONAL-F RFF REDIJECT SUBCUTANEOUS SPC (Only available for SOLUTION 300 UNIT/0.5ML, 450 UNT/0.75ML, 900 PSP select plans) UNIT/1.5ML (follitropin alfa) GONAL-F RFF SUBCUTANEOUS SOLUTION SPC (Only available for PSP RECONSTITUTED 75 UNIT (follitropin alfa) select plans) MENOPUR SUBCUTANEOUS SOLUTION SPC (Only available for NPSP RECONSTITUTED 75 UNIT (menotropins) select plans) OVIDREL SUBCUTANEOUS INJECTABLE 250 SPC (Only available for PSP MCG/0.5ML (choriogonadotropin alfa) select plans) GLUCOCORTICOIDS - DRUGS TO TREAT INFLAMMATORY RESPONSE budesonide er oral tablet extended release 24 hour 9 mg G dexamethasone (Decadron Oral Tablet 0.5 Mg, 0.75 Mg, 4 G Mg, 6 Mg) dexamethasone (la) injection suspension 8 mg/ml NF DEXAMETHASONE INTENSOL ORAL NPB CONCENTRATE 1 MG/ML (dexamethasone) dexamethasone oral elixir 0.5 mg/5ml G dexamethasone oral solution 0.5 mg/5ml G dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 2 mg, G 4 mg, 6 mg dexamethasone oral tablet therapy pack 1.5 mg (21), 1.5 mg G (35), 1.5 mg (51)

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 106 Prescription Drug Name Drug Tier Drug Notes dexamethasone sodium phosphate injection solution 10 mg/ml, 4 NPB mg/ml DEXONTO 0.4% IONTOPHORESIS SOLUTION 20 NF MG/5ML (dexamethasone sodium phosphate) DXEVO 11-DAY ORAL TABLET THERAPY PACK 1.5 NF MG (dexamethasone) EMFLAZA ORAL SUSPENSION 22.75 MG/ML NF (deflazacort) EMFLAZA ORAL TABLET 18 MG, 30 MG, 36 MG, 6 MG NF (deflazacort) fludrocortisone acetate oral tablet 0.1 mg G dexamethasone (Hidex 6-Day Oral Tablet Therapy Pack 1.5 G Mg (21)) hydrocortisone oral tablet 10 mg, 20 mg, 5 mg G MEDROL ORAL TABLET 2 MG (methylprednisolone) NPB methylprednisolone oral tablet 16 mg, 32 mg, 4 mg, 8 mg G methylprednisolone oral tablet therapy pack 4 mg G MILLIPRED ORAL TABLET 5 MG (prednisolone) NF prednisolone oral solution 15 mg/5ml G prednisolone sodium phosphate oral solution 10 mg/5ml, 15 G mg/5ml, 20 mg/5ml, 25 mg/5ml, 6.7 (5 base) mg/5ml prednisolone sodium phosphate oral tablet dispersible 10 mg, 15 G mg, 30 mg PREDNISONE INTENSOL ORAL CONCENTRATE 5 NPB MG/ML (prednisone) prednisone oral solution 5 mg/5ml G prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 mg, 5 mg, 50 mg G prednisone oral tablet therapy pack 10 mg (21), 10 mg (48), 5 G mg (21), 5 mg (48) PRO-C-DURE 6 INJECTION KIT 3 X 40 MG/ML NF (triamcinolone acetonide) RAYOS ORAL TABLET DELAYED RELEASE 1 MG, 2 NF MG, 5 MG (prednisone) READYSHARP DEXAMETHASONE INJECTION KIT 10 NF MG/ML (dexamethasone sodium phosphate) TAPERDEX 12-DAY ORAL TABLET THERAPY PACK NF 1.5 MG (49) (dexamethasone)

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 107 Prescription Drug Name Drug Tier Drug Notes dexamethasone (Taperdex 6-Day Oral Tablet Therapy Pack NF 1.5 Mg) TAPERDEX 7-DAY ORAL TABLET THERAPY PACK NF 1.5 MG (27) (dexamethasone) ZILRETTA INTRA-ARTICULAR SUSPENSION NF RECONSTITUTED ER 32 MG (triamcinolone acetonide) GLUCOSE ELEVATING AGENTS - DRUGS TO TREAT LOW BLOOD SUGAR BAQSIMI ONE PACK NASAL POWDER 3 MG/DOSE PB (glucagon) BAQSIMI TWO PACK NASAL POWDER 3 MG/DOSE PB (glucagon) cvs glucose oral tablet chewable 4-6 gm-mg NPB DEX4 NATURALS ORAL TABLET CHEWABLE 4-6 GM- NPB MG (glucose-vitamin c) DEX4 ORAL TABLET CHEWABLE 4-6 GM-MG (glucose- NPB vitamin c) DEX4 POUCH PACK ORAL TABLET CHEWABLE 4-6 NPB GM-MG (glucose-vitamin c) dextrose intravenous solution 250 mg/ml NPB GLUCAGEN HYPOKIT INJECTION SOLUTION PB RECONSTITUTED 1 MG (glucagon hcl (rdna)) glucagon emergency injection kit 1 mg PB glucose instant energy oral tablet chewable 4-6 gm-mg, 6-4 mg- NPB gm glucose oral tablet chewable 4-6 gm-mg NPB gnp glucose oral tablet chewable 4-6 gm-mg NPB goodsense glucose oral tablet chewable 4-6 gm-mg NPB GVOKE HYPOPEN 1-PACK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 0.5 MG/0.1ML, 1 PB MG/0.2ML (glucagon) GVOKE HYPOPEN 2-PACK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 0.5 MG/0.1ML, 1 PB MG/0.2ML (glucagon) GVOKE PFS SUBCUTANEOUS SOLUTION PREFILLED PB SYRINGE 0.5 MG/0.1ML, 1 MG/0.2ML (glucagon) hm glucose oral tablet chewable 4-6 gm-mg NPB kroger glucose oral tablet chewable 4-6 gm-mg NPB

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 108 Prescription Drug Name Drug Tier Drug Notes meijer glucose oral tablet chewable 4-6 gm-mg NPB PROGLYCEM ORAL SUSPENSION 50 MG/ML NPB (diazoxide) px glucose oral tablet chewable 4-6 gm-mg NPB ra glucose oral tablet chewable 4-6 gm-mg, 6-4 mg-gm NPB RELION GLUCOSE ORAL TABLET CHEWABLE 4-6 NPB GM-MG (glucose-vitamin c) sm glucose oral tablet chewable 4-6 gm-mg NPB SMART SENSE GLUCOSE ORAL TABLET CHEWABLE NPB 4-6 GM-MG (glucose-vitamin c) tgt glucose oral tablet chewable 4-6 gm-mg NPB up & up glucose oral tablet chewable 4-6 gm-mg NPB value plus glucose oral tablet chewable 4-6 gm-mg NPB HUMAN GROWTH HORMONES - DRUGS TO REGULATE PITUITARY HORMONES HUMATROPE INJECTION SOLUTION RECONSTITUTED 12 MG, 24 MG, 5 MG, 6 MG NF (somatropin) NORDITROPIN FLEXPRO SUBCUTANEOUS SOLUTION PEN-INJECTOR 10 MG/1.5ML, 15 PSP MG/1.5ML, 30 MG/3ML, 5 MG/1.5ML (somatropin) OMNITROPE SUBCUTANEOUS SOLUTION NF CARTRIDGE 10 MG/1.5ML, 5 MG/1.5ML (somatropin) SEROSTIM SUBCUTANEOUS SOLUTION RECONSTITUTED 4 MG, 5 MG, 6 MG (somatropin (non- NPSP refrigerated)) ZORBTIVE SUBCUTANEOUS SOLUTION NPSP RECONSTITUTED 8.8 MG (somatropin (non-refrigerated)) MISCELLANEOUS ACTHAR INJECTION GEL 80 UNIT/ML (corticotropin) NPSP cabergoline oral tablet 0.5 mg G calcitonin (salmon) nasal solution 200 unit/act G CERVIDIL VAGINAL INSERT 10 MG (dinoprostone) NPB EVENITY SUBCUTANEOUS SOLUTION PREFILLED NF SYRINGE 105 MG/1.17ML (romosozumab-aqqg) FORTEO SUBCUTANEOUS SOLUTION PEN- PSP INJECTOR 620 MCG/2.48ML (teriparatide (recombinant)) GALAFOLD ORAL CAPSULE 123 MG (migalastat hcl) NPB

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 109 Prescription Drug Name Drug Tier Drug Notes INCRELEX SUBCUTANEOUS SOLUTION 40 MG/4ML NPSP (mecasermin) JYNARQUE ORAL TABLET 15 MG, 30 MG (tolvaptan) NPB JYNARQUE ORAL TABLET THERAPY PACK 15 MG, 30 & 15 MG, 45 & 15 MG, 60 & 30 MG, 90 & 30 MG NPB (tolvaptan) KORLYM ORAL TABLET 300 MG (mifepristone) NPB methylergonovine maleate (Methergine Oral Tablet 0.2 Mg) G methylergonovine maleate oral tablet 0.2 mg G MIACALCIN INJECTION SOLUTION 200 UNIT/ML NF (calcitonin (salmon)) MIACALCIN NASAL SOLUTION 200 UNIT/ACT NF (calcitonin (salmon)) NATPARA SUBCUTANEOUS CARTRIDGE 100 MCG, NPSP 25 MCG, 50 MCG, 75 MCG (parathyroid hormone (recomb)) octreotide acetate injection solution 100 mcg/ml, 1000 mcg/ml, G 200 mcg/ml, 50 mcg/ml, 500 mcg/ml OSPHENA ORAL TABLET 60 MG (ospemifene) NF PREPIDIL VAGINAL GEL 0.5 MG/3GM (dinoprostone) NPB PROLIA SUBCUTANEOUS SOLUTION PREFILLED PSP SYRINGE 60 MG/ML (denosumab) PROSTIN E2 VAGINAL SUPPOSITORY 20 MG NPB (dinoprostone) raloxifene hcl oral tablet 60 mg CE SAMSCA ORAL TABLET 15 MG, 30 MG (tolvaptan) NPSP SANDOSTATIN INJECTION SOLUTION 100 MCG/ML, NPSP 50 MCG/ML, 500 MCG/ML (octreotide acetate) SIGNIFOR LAR INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 10 MG, 20 MG, 30 MG, 40 MG, 60 NF MG (pasireotide pamoate) SIGNIFOR SUBCUTANEOUS SOLUTION 0.3 MG/ML, NPB 0.6 MG/ML, 0.9 MG/ML (pasireotide diaspartate) SOMATULINE DEPOT SUBCUTANEOUS SOLUTION 120 MG/0.5ML, 60 MG/0.2ML, 90 MG/0.3ML (lanreotide PSP acetate) SOMAVERT SUBCUTANEOUS SOLUTION RECONSTITUTED 10 MG, 15 MG, 20 MG, 25 MG, 30 MG NF (pegvisomant)

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 110 Prescription Drug Name Drug Tier Drug Notes TYMLOS SUBCUTANEOUS SOLUTION PEN- PSP INJECTOR 3120 MCG/1.56ML (abaloparatide) XGEVA SUBCUTANEOUS SOLUTION 120 MG/1.7ML NPSP (denosumab) XURIDEN ORAL PACKET 2 GM (uridine triacetate) NPB ZOKINVY ORAL CAPSULE 50 MG, 75 MG (lonafarnib) NPSP PHOSPHATE BINDER AGENTS - DRUGS TO REGULATE CALCIUM AND PHOSPHORUS LEVELS AURYXIA ORAL TABLET 1 GM 210 MG(FE) (ferric NPB citrate) calcium acetate (phos binder) oral capsule 667 mg G calcium acetate (phos binder) oral tablet 667 mg G FOSRENOL ORAL PACKET 1000 MG, 750 MG NF (lanthanum carbonate) FOSRENOL ORAL TABLET CHEWABLE 1000 MG, 500 NF MG, 750 MG (lanthanum carbonate) lanthanum carbonate oral tablet chewable 1000 mg, 500 mg, 750 NF mg MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 PB HOUR 50 MG (mirabegron) PHOSLYRA ORAL SOLUTION 667 MG/5ML (calcium PB acetate (phos binder)) sevelamer carbonate oral packet 0.8 gm, 2.4 gm G sevelamer carbonate oral tablet 800 mg G sevelamer hcl oral tablet 400 mg, 800 mg G VELPHORO ORAL TABLET CHEWABLE 500 MG PB (sucroferric oxyhydroxide) PROGESTINS - DRUGS TO REGULATE FEMALE HORMONES CRINONE VAGINAL GEL 4 %, 8 % (progesterone) NF ec-rx progesterone transdermal cream 20 % NF hydroxyprogesterone caproate intramuscular oil 250 mg/ml G LUPANETA PACK COMBINATION KIT 11.25 & 5 MG, NPSP 3.75 & 5 MG (leuprolide & norethindrone) MAKENA INTRAMUSCULAR OIL 250 MG/ML NPSP (hydroxyprogesterone caproate) MAKENA SUBCUTANEOUS SOLUTION AUTO- NPSP INJECTOR 275 MG/1.1ML (hydroxyprogesterone caproate)

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 111 Prescription Drug Name Drug Tier Drug Notes medroxyprogesterone acetate oral tablet 10 mg, 2.5 mg, 5 mg G norethindrone acetate oral tablet 5 mg G progesterone intramuscular oil 50 mg/ml G progesterone oral capsule 100 mg, 200 mg G PROMETRIUM ORAL CAPSULE 100 MG, 200 MG NF (progesterone) THYROID AGENTS - DRUGS TO REGULATE THYROID LEVELS ARMOUR THYROID ORAL TABLET 180 MG, 240 MG, NPB 300 MG (thyroid) CYTOMEL ORAL TABLET 25 MCG, 5 MCG, 50 MCG NF (liothyronine sodium) levothyroxine sodium (Euthyrox Oral Tablet 100 Mcg, 112 Mcg, 125 Mcg, 137 Mcg, 150 Mcg, 175 Mcg, 200 Mcg, 25 G Mcg, 50 Mcg, 75 Mcg, 88 Mcg) levothyroxine sodium (Levo-T Oral Tablet 100 Mcg, 112 Mcg, 125 Mcg, 137 Mcg, 150 Mcg, 175 Mcg, 200 Mcg, 25 Mcg, 300 G Mcg, 50 Mcg, 75 Mcg, 88 Mcg) levothyroxine sodium intravenous solution reconstituted 100 NPB mcg, 500 mcg levothyroxine sodium oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, G 75 mcg, 88 mcg levothyroxine sodium (Levoxyl Oral Tablet 100 Mcg, 112 Mcg, 125 Mcg, 137 Mcg, 150 Mcg, 175 Mcg, 200 Mcg, 25 Mcg, 50 G Mcg, 75 Mcg, 88 Mcg) liothyronine sodium oral tablet 25 mcg, 5 mcg, 50 mcg G methimazole oral tablet 10 mg, 5 mg G NATURE-THROID ORAL TABLET 113.75 MG, 130 MG, 146.25 MG, 16.25 MG, 162.5 MG, 195 MG, 260 MG, 32.5 NF MG, 325 MG, 48.75 MG, 65 MG, 81.25 MG, 97.5 MG (thyroid) np thyroid oral tablet 120 mg, 15 mg, 30 mg, 60 mg, 90 mg G propylthiouracil oral tablet 50 mg G TIROSINT ORAL CAPSULE 100 MCG, 112 MCG, 125 MCG, 13 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, NF 25 MCG, 50 MCG, 75 MCG, 88 MCG (levothyroxine sodium)

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 112 Prescription Drug Name Drug Tier Drug Notes TIROSINT-SOL ORAL SOLUTION 100 MCG/ML, 112 MCG/ML, 125 MCG/ML, 13 MCG/ML, 137 MCG/ML, 150 MCG/ML, 175 MCG/ML, 200 MCG/ML, 25 MCG/ML, 37.5 NF MCG/ML, 44 MCG/ML, 50 MCG/ML, 62.5 MCG/ML, 75 MCG/ML, 88 MCG/ML (levothyroxine sodium) levothyroxine sodium (Unithroid Oral Tablet 100 Mcg, 112 Mcg, 125 Mcg, 137 Mcg, 150 Mcg, 175 Mcg, 200 Mcg, 25 G Mcg, 300 Mcg, 50 Mcg, 75 Mcg, 88 Mcg) WESTHROID ORAL TABLET 130 MG, 195 MG, 32.5 MG, NF 65 MG, 97.5 MG (thyroid) WP THYROID ORAL TABLET 113.75 MG, 130 MG, 16.25 MG, 32.5 MG, 48.75 MG, 65 MG, 81.25 MG, 97.5 MG NF (thyroid) VASOPRESSINS - DRUGS TO REGULATE PITUITARY HORMONES desmopressin ace spray refrig nasal solution 0.01 % G desmopressin acetate oral tablet 0.1 mg, 0.2 mg G desmopressin acetate spray nasal solution 0.01 % G NOCDURNA SUBLINGUAL TABLET SUBLINGUAL NPB 27.7 MCG, 55.3 MCG (desmopressin acetate) STIMATE NASAL SOLUTION 1.5 MG/ML (desmopressin NPSP acetate) GASTROINTESTINAL - DRUGS TO TREAT STOMACH AND INTESTINAL DISORDERS ANTICHOLINERGICS belladonna alkaloids-opium rectal suppository 16.2-30 mg, 16.2- NPB 60 mg chlordiazepoxide-clidinium oral capsule 5-2.5 mg NF CUVPOSA ORAL SOLUTION 1 MG/5ML (glycopyrrolate) NPB dicyclomine hcl oral capsule 10 mg G dicyclomine hcl oral solution 10 mg/5ml G dicyclomine hcl oral tablet 20 mg G ed-spaz oral tablet dispersible 0.125 mg G GLYCATE ORAL TABLET 1.5 MG (glycopyrrolate) NF glycopyrrolate oral tablet 1 mg, 2 mg G GLYRX-PF INJECTION SOLUTION 0.2 MG/ML, 0.4 NF MG/2ML (glycopyrrolate)

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 113 Prescription Drug Name Drug Tier Drug Notes hyoscyamine sulfate er oral tablet extended release 12 hour NF 0.375 mg hyoscyamine sulfate oral elixir 0.125 mg/5ml G hyoscyamine sulfate oral solution 0.125 mg/ml G hyoscyamine sulfate oral tablet 0.125 mg G hyoscyamine sulfate oral tablet dispersible 0.125 mg G hyoscyamine sulfate sublingual tablet sublingual 0.125 mg G LIBRAX ORAL CAPSULE 5-2.5 MG (chlordiazepoxide- NF clidinium) methscopolamine bromide oral tablet 2.5 mg, 5 mg G hyoscyamine sulfate (Nulev Oral Tablet Dispersible 0.125 Mg) G oscimin oral tablet 0.125 mg G oscimin sr oral tablet extended release 12 hour 0.375 mg NF oscimin sublingual tablet sublingual 0.125 mg G SYMAX DUOTAB ORAL TABLET EXTENDED NPB RELEASE 0.375 MG (hyoscyamine sulfate) hyoscyamine sulfate (Symax-Sr Oral Tablet Extended Release NF 12 Hour 0.375 Mg) ANTIEMETICS - DRUGS FOR NAUSEA AND VOMITING AKYNZEO INTRAVENOUS SOLUTION 235-0.25 NF MG/20ML (fosnetupitant-palonosetron) AKYNZEO INTRAVENOUS SOLUTION RECONSTITUTED 235-0.25 MG (fosnetupitant- NF palonosetron) AKYNZEO ORAL CAPSULE 300-0.5 MG (netupitant- NF palonosetron) aprepitant oral capsule 125 mg, 40 mg, 80 & 125 mg, 80 mg G BONJESTA ORAL TABLET EXTENDED RELEASE 20- NPB 20 MG (doxylamine-pyridoxine) CINVANTI INTRAVENOUS EMULSION 130 MG/18ML NF (aprepitant) prochlorperazine (Compro Rectal Suppository 25 Mg) G doxylamine-pyridoxine oral tablet delayed release 10-10 mg G dronabinol oral capsule 10 mg, 2.5 mg, 5 mg G EMEND INTRAVENOUS SOLUTION NF RECONSTITUTED 150 MG (fosaprepitant dimeglumine)

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 114 Prescription Drug Name Drug Tier Drug Notes EMEND ORAL CAPSULE 80 MG (aprepitant) NF EMEND ORAL SUSPENSION RECONSTITUTED 125 NF MG/5ML (aprepitant) EMEND TRI-PACK ORAL CAPSULE 80 & 125 MG NF (aprepitant) granisetron hcl oral tablet 1 mg G meclizine hcl oral tablet 12.5 mg, 25 mg G metoclopramide hcl oral solution 10 mg/10ml, 5 mg/5ml G metoclopramide hcl oral tablet 10 mg, 5 mg G metoclopramide hcl oral tablet dispersible 10 mg NPB metoclopramide hcl oral tablet dispersible 5 mg G ondansetron hcl oral solution 4 mg/5ml G ondansetron hcl oral tablet 24 mg, 4 mg, 8 mg G ondansetron oral tablet dispersible 4 mg, 8 mg G prochlorperazine maleate oral tablet 10 mg, 5 mg G prochlorperazine rectal suppository 25 mg G promethazine hcl oral syrup 6.25 mg/5ml G promethazine hcl oral tablet 12.5 mg, 25 mg, 50 mg G promethazine hcl rectal suppository 12.5 mg, 25 mg G promethazine hcl (Promethegan Rectal Suppository 12.5 Mg, G 25 Mg) PROMETHEGAN RECTAL SUPPOSITORY 50 MG G (promethazine hcl) SANCUSO TRANSDERMAL PATCH 3.1 MG/24HR PB (granisetron) scopolamine transdermal patch 72 hour 1 mg/3days G SUSTOL SUBCUTANEOUS PREFILLED SYRINGE 10 NF MG/0.4ML (granisetron) SYNDROS ORAL SOLUTION 5 MG/ML (dronabinol) NF TRANSDERM-SCOP (1.5 MG) TRANSDERMAL PATCH NF 72 HOUR 1 MG/3DAYS (scopolamine base) trimethobenzamide hcl oral capsule 300 mg G VARUBI (180 MG DOSE) ORAL TABLET THERAPY NF PACK 2 X 90 MG (rolapitant hcl) ZUPLENZ ORAL FILM 4 MG, 8 MG (ondansetron) NF

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 115 Prescription Drug Name Drug Tier Drug Notes H2-RECEPTOR ANTAGONISTS - DRUGS FOR ULCERS AND STOMACH ACID cimetidine hcl oral solution 300 mg/5ml G cimetidine oral tablet 200 mg, 300 mg, 400 mg, 800 mg G eq famotidine max st oral tablet 20 mg G famotidine oral suspension reconstituted 40 mg/5ml G famotidine oral tablet 20 mg, 40 mg G nizatidine oral capsule 150 mg, 300 mg G nizatidine oral solution 15 mg/ml G INFLAMMATORY BOWEL DISEASE - BOWEL, INTESTINE, AND STOMACH CONDITION DRUGS APRISO ORAL CAPSULE EXTENDED RELEASE 24 NPB HOUR 0.375 GM (mesalamine) ASACOL HD ORAL TABLET DELAYED RELEASE 800 PB MG (mesalamine) balsalazide disodium oral capsule 750 mg G budesonide oral capsule delayed release particles 3 mg G CANASA RECTAL SUPPOSITORY 1000 MG (mesalamine) NF COLAZAL ORAL CAPSULE 750 MG (balsalazide disodium) NF CORTIFOAM EXTERNAL FOAM 10 % (hydrocortisone PB acetate) DELZICOL ORAL CAPSULE DELAYED RELEASE 400 NF MG (mesalamine) DIPENTUM ORAL CAPSULE 250 MG (olsalazine sodium) NPB hydrocortisone rectal enema 100 mg/60ml G LIALDA ORAL TABLET DELAYED RELEASE 1.2 GM NF (mesalamine) mesalamine oral capsule delayed release 400 mg G mesalamine oral tablet delayed release 1.2 gm, 800 mg G mesalamine rectal enema 4 gm G mesalamine rectal suppository 1000 mg G mesalamine-cleanser rectal kit 4 gm G PENTASA ORAL CAPSULE EXTENDED RELEASE 250 PB MG, 500 MG (mesalamine) ROWASA RECTAL KIT 4 GM (mesalamine-cleanser) NF SFROWASA RECTAL ENEMA 4 GM/60ML (mesalamine) NF

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 116 Prescription Drug Name Drug Tier Drug Notes sulfasalazine oral tablet 500 mg G sulfasalazine oral tablet delayed release 500 mg G UCERIS ORAL TABLET EXTENDED RELEASE 24 NF HOUR 9 MG (budesonide) UCERIS RECTAL FOAM 2 MG/ACT (budesonide) NF IRRITABLE BOWEL SYNDROME WITH CONSTIPATION AMITIZA ORAL CAPSULE 24 MCG, 8 MCG NF (lubiprostone) LINZESS ORAL CAPSULE 145 MCG, 290 MCG, 72 MCG PB (linaclotide) TRULANCE ORAL TABLET 3 MG (plecanatide) NPB ZELNORM ORAL TABLET 6 MG (tegaserod maleate) NF IRRITABLE BOWEL SYNDROME WITH DIARRHEA alosetron hcl oral tablet 0.5 mg, 1 mg G LOTRONEX ORAL TABLET 0.5 MG, 1 MG (alosetron hcl) NPB VIBERZI ORAL TABLET 100 MG, 75 MG (eluxadoline) PB LAXATIVES - DRUGS FOR CONSTIPATION cascara sagrada oral fluid extract 1 gm/ml NPB CLENPIQ ORAL SOLUTION 10-3.5-12 MG-GM - CE GM/160ML (sod picosulfate-mag ox-cit acd) constulose oral solution 10 gm/15ml G enulose oral solution 10 gm/15ml G generlac oral solution 10 gm/15ml G GIALAX ORAL KIT (polyethylene glycol 3350) NF GOLYTELY ORAL SOLUTION RECONSTITUTED 236 NF GM (peg 3350-kcl-nabcb-nacl-nasulf) KRISTALOSE ORAL PACKET 10 GM, 20 GM (lactulose) NPB lactulose encephalopathy oral solution 10 gm/15ml G lactulose oral packet 10 gm NF lactulose oral solution 10 gm/15ml, 20 gm/30ml G mineral oil heavy oral oil G MOVIPREP ORAL SOLUTION RECONSTITUTED 100 NF GM (peg-kcl-nacl-nasulf-na asc-c) OSMOPREP ORAL TABLET 1.102-0.398 GM (sod phos NF mono-sod phos dibasic)

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 117 Prescription Drug Name Drug Tier Drug Notes PCP 100 COMBINATION KIT (mgcit-bisacod-pet-peg- NF metoclop) PEG-PREP ORAL KIT 5-210 MG-GM (bisacodyl-peg-kcl- CE nabicar-nacl) PLENVU ORAL SOLUTION RECONSTITUTED 140 GM CE (peg-kcl-nacl-nasulf-na asc-c) SUPREP BOWEL PREP KIT ORAL SOLUTION 17.5-3.13- CE 1.6 GM/177ML (na sulfate-k sulfate-mg sulf) MISCELLANEOUS bethanechol chloride oral tablet 10 mg, 25 mg, 5 mg, 50 mg G CARAFATE ORAL SUSPENSION 1 GM/10ML (sucralfate) NF CARAFATE ORAL TABLET 1 GM (sucralfate) NF CHENODAL ORAL TABLET 250 MG (chenodiol) NPB CHOLBAM ORAL CAPSULE 250 MG, 50 MG (cholic acid) NPSP cromolyn sodium oral concentrate 100 mg/5ml G diphenoxylate-atropine oral liquid 2.5-0.025 mg/5ml G diphenoxylate-atropine oral tablet 2.5-0.025 mg G ENTEREG ORAL CAPSULE 12 MG (alvimopan) NPB EVIVO ORAL LIQUID (bifidobacterium longum inf-mct) NF flavoxate hcl oral tablet 100 mg G GATTEX SUBCUTANEOUS KIT 5 MG (teduglutide NPSP (rdna)) loperamide hcl oral capsule 2 mg G misoprostol oral tablet 100 mcg, 200 mcg G MOTEGRITY ORAL TABLET 1 MG, 2 MG (prucalopride NF succinate) MOTOFEN ORAL TABLET 1-0.025 MG (difenoxin- NF atropine) MOVANTIK ORAL TABLET 12.5 MG, 25 MG (naloxegol PB oxalate) MYTESI ORAL TABLET DELAYED RELEASE 125 MG NF (crofelemer) OCALIVA ORAL TABLET 10 MG, 5 MG (obeticholic acid) NPSP opium oral tincture 10 mg/ml (1%) G probichew oral tablet chewable NF prodigen oral capsule NF provad oral capsule NF 2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 118 Prescription Drug Name Drug Tier Drug Notes PYLERA ORAL CAPSULE 140-125-125 MG (bis subcit- PB metronid-tetracyc) RELISTOR ORAL TABLET 150 MG (methylnaltrexone NF bromide) RELISTOR SUBCUTANEOUS SOLUTION 12 MG/0.6ML, NF 8 MG/0.4ML (methylnaltrexone bromide) RESTORA RX ORAL CAPSULE 60-1.25 MG (lactobacillus NF casei-folic acid) sucralfate oral suspension 1 gm/10ml NF sucralfate oral tablet 1 gm G SYMPROIC ORAL TABLET 0.2 MG (naldemedine tosylate) PB ursodiol oral capsule 300 mg G ursodiol oral tablet 250 mg, 500 mg G VSL#3 DS ORAL PACKET (probiotic product) NPB XERMELO ORAL TABLET 250 MG (telotristat etiprate) NPB zelac oral capsule NF PANCREATIC ENZYMES CREON ORAL CAPSULE DELAYED RELEASE PARTICLES 12000-38000 UNIT, 24000-76000 UNIT, 3000- PB 9500 UNIT, 36000-114000 UNIT, 6000-19000 UNIT (pancrelipase (lip-prot-amyl)) enzadyne oral capsule NF PANCREAZE ORAL CAPSULE DELAYED RELEASE PARTICLES 10500-35500 UNIT, 16800-56800 UNIT, 21000- NF 54700 UNIT, 2600-8800 UNIT, 37000-97300 UNIT, 4200- 14200 UNIT (pancrelipase (lip-prot-amyl)) PERTZYE ORAL CAPSULE DELAYED RELEASE PARTICLES 16000-57500 UNIT, 24000-86250 UNIT, 4000- NF 14375 UNIT, 8000-28750 UNIT (pancrelipase (lip-prot-amyl)) SUCRAID ORAL SOLUTION 8500 UNIT/ML (sacrosidase) NPB VIOKACE ORAL TABLET 10440-39150 UNIT, 20880- PB 78300 UNIT (pancrelipase (lip-prot-amyl)) ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 10000-32000 UNIT, 15000-47000 UNIT, 20000- 63000 UNIT, 25000-79000 UNIT, 3000-10000 UNIT, 40000- PB 126000 UNIT, 5000-24000 UNIT (pancrelipase (lip-prot- amyl))

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 119 Prescription Drug Name Drug Tier Drug Notes PROTON PUMP INHIBITORS - DRUGS FOR ULCERS AND STOMACH ACID ACIPHEX ORAL TABLET DELAYED RELEASE 20 MG NF (rabeprazole sodium) ACIPHEX SPRINKLE ORAL CAPSULE SPRINKLE 10 NF MG, 5 MG (rabeprazole sodium) DEXILANT ORAL CAPSULE DELAYED RELEASE 30 PB MG, 60 MG (dexlansoprazole) esomeprazole magnesium oral capsule delayed release 20 mg, 40 G mg lansoprazole oral capsule delayed release 15 mg, 30 mg G lansoprazole oral tablet delayed release dispersible 15 mg, 30 mg G NEXIUM 24HR CLEAR MINIS ORAL CAPSULE NF DELAYED RELEASE 20 MG (esomeprazole magnesium) NEXIUM 24HR ORAL CAPSULE DELAYED RELEASE NF 20 MG (esomeprazole magnesium) NEXIUM ORAL CAPSULE DELAYED RELEASE 20 NF MG, 40 MG (esomeprazole magnesium) NEXIUM ORAL PACKET 10 MG, 2.5 MG, 20 MG, 40 NF MG, 5 MG (esomeprazole magnesium) omeprazole oral capsule delayed release 10 mg, 20 mg, 40 mg G omeprazole-sodium bicarbonate oral capsule 20-1100 mg, 40- NF 1100 mg omeprazole-sodium bicarbonate oral packet 20-1680 mg, 40- NF 1680 mg pantoprazole sodium oral packet 40 mg NF pantoprazole sodium oral tablet delayed release 20 mg, 40 mg G PREVACID 24HR ORAL CAPSULE DELAYED NF RELEASE 15 MG (lansoprazole) PREVACID ORAL CAPSULE DELAYED RELEASE 15 NF MG, 30 MG (lansoprazole) PREVACID SOLUTAB ORAL TABLET DELAYED NF RELEASE DISPERSIBLE 15 MG, 30 MG (lansoprazole) PRILOSEC ORAL PACKET 10 MG, 2.5 MG (omeprazole NF magnesium) PROTONIX ORAL PACKET 40 MG (pantoprazole sodium) NF PROTONIX ORAL TABLET DELAYED RELEASE 20 NF MG, 40 MG (pantoprazole sodium)

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 120 Prescription Drug Name Drug Tier Drug Notes rabeprazole sodium oral capsule sprinkle 10 mg NPB rabeprazole sodium oral tablet delayed release 20 mg G ZEGERID ORAL CAPSULE 20-1100 MG, 40-1100 MG NF (omeprazole-sodium bicarbonate) ZEGERID ORAL PACKET 20-1680 MG, 40-1680 MG NF (omeprazole-sodium bicarbonate) RECTAL,CORTICOSTEROIDS hydrocortisone (perianal) external cream 1 %, 2.5 % G hydrocortisone ace-pramoxine external cream 1-1 % G PROCORT EXTERNAL CREAM 1.85-1.15 % NF (hydrocortisone ace-pramoxine) PROCTOCORT EXTERNAL CREAM 1 % (hydrocortisone) NF PROCTOCORT RECTAL SUPPOSITORY 30 MG NF (hydrocortisone acetate) PROCTOFOAM HC EXTERNAL FOAM 1-1 % PB (hydrocortisone ace-pramoxine) hydrocortisone (Procto-Med Hc External Cream 2.5 %) G hydrocortisone (Procto-Pak External Cream 1 %) G hydrocortisone (Proctozone-Hc External Cream 2.5 %) G RECTIV RECTAL OINTMENT 0.4 % (nitroglycerin) NPB ULCER THERAPY COMBINATIONS amoxicill-clarithro-lansopraz oral G OMECLAMOX-PAK ORAL 500-500-20 MG (amoxicill- NPB clarithro-omeprazole) TALICIA ORAL CAPSULE DELAYED RELEASE 250- NPB 12.5-10 MG (amoxicill-rifabutin-omeprazole) GENITOURINARY - DRUGS TO TREAT GENITAL AND URINARY TRACT CONDITIONS BENIGN PROSTATIC HYPERPLASIA - DRUGS TO TREAT ENLARGED PROSTATE alfuzosin hcl er oral tablet extended release 24 hour 10 mg G CARDURA XL ORAL TABLET EXTENDED RELEASE NPB 24 HOUR 4 MG, 8 MG (doxazosin mesylate) dutasteride oral capsule 0.5 mg G dutasteride-tamsulosin hcl oral capsule 0.5-0.4 mg G finasteride oral tablet 5 mg G

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 121 Prescription Drug Name Drug Tier Drug Notes JALYN ORAL CAPSULE 0.5-0.4 MG (dutasteride- NF tamsulosin hcl) RAPAFLO ORAL CAPSULE 4 MG, 8 MG (silodosin) NF silodosin oral capsule 4 mg, 8 mg G tamsulosin hcl oral capsule 0.4 mg G UROXATRAL ORAL TABLET EXTENDED RELEASE NF 24 HOUR 10 MG (alfuzosin hcl) CONTRACEPTIVES - PRODUCTS FOR BIRTH CONTROL ENCARE VAGINAL SUPPOSITORY 100 MG (nonoxynol- CE 9) OPTIONS GYNOL II CONTRACEPTIVE VAGINAL GEL CE 3 % (nonoxynol-9) SHUR-SEAL CONTRACEPTIVE VAGINAL GEL 2 % CE (nonoxynol-9) VCF VAGINAL CONTRACEPTIVE VAGINAL FILM 28 CE % (nonoxynol-9) VCF VAGINAL CONTRACEPTIVE VAGINAL FOAM CE 12.5 % (nonoxynol-9) VCF VAGINAL CONTRACEPTIVE VAGINAL GEL 4 % CE (nonoxynol-9) ERECTILE DYSFUNCTION SPC (Only available for bi-mix intracavernosal solution reconstituted 150-5 mg NF select plans) CIALIS ORAL TABLET 10 MG, 2.5 MG, 20 MG, 5 MG SPC (Only available for NF (tadalafil) select plans) LEVITRA ORAL TABLET 10 MG, 20 MG (vardenafil hcl) NF quad-mix intracavernosal solution reconstituted 150-10-0.1-1 NF mg STENDRA ORAL TABLET 100 MG, 200 MG, 50 MG SPC (Only available for NF (avanafil) select plans) SPC (Only available for super bi-mix intracavernosal solution reconstituted 150-10 mg NF select plans) super quad-mix intracavernosal solution reconstituted 150-20- SPC (Only available for NF 0.2-2 mg select plans) super tri-mix intracavernosal solution reconstituted 150-10-100 SPC (Only available for NF mg-mg-mcg select plans) tri-mix intracavernosal solution reconstituted 150-5-50 mg-mg- NF mcg 2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 122 Prescription Drug Name Drug Tier Drug Notes VIAGRA ORAL TABLET 100 MG, 25 MG, 50 MG SPC (Only available for NF (sildenafil citrate) select plans) MISCELLANEOUS acetic acid irrigation solution 0.25 % G aminoacetic acid irrigation solution 1.5 % G sodium chloride (gu irrigant) (Argyle Sterile Saline Irrigation G Solution 0.9 %) sodium chloride (gu irrigant) (Curity Sterile Saline Irrigation G Solution 0.9 %) cytra k crystals oral packet 3300-1002 mg G ELMIRON ORAL CAPSULE 100 MG (pentosan polysulfate NF sodium) glycine irrigation solution 1.5 % G K-PHOS NO 2 ORAL TABLET 305-700 MG (pot & sod ac NPB phosphates) LITHOSTAT ORAL TABLET 250 MG (acetohydroxamic NF acid) neomycin-polymyxin b gu irrigation solution 40-200000 G ORACIT ORAL SOLUTION 490-640 MG/5ML (sod citrate- NPB citric acid) phenazopyridine hcl (Phenazo Oral Tablet 200 Mg) G pot & sod cit-cit ac oral solution 550-500-334 mg/5ml G potassium citrate er oral tablet extended release 10 meq (1080 G mg), 15 meq (1620 mg), 5 meq (540 mg) potassium citrate-citric acid oral solution 1100-334 mg/5ml G PROCYSBI ORAL PACKET 300 MG, 75 MG (cysteamine NF bitartrate) RENACIDIN IRRIGATION SOLUTION (citric ac- NPB gluconolact-mg carb) RESECTISOL IRRIGATION SOLUTION 5 % (mannitol NPB (gu irrigant)) RIMSO-50 INTRAVESICAL SOLUTION 50 % (dimethyl NF sulfoxide) sod citrate-citric acid oral solution 500-334 mg/5ml G sodium chloride irrigation solution 0.9 % G sorbitol irrigation solution 3 %, 3.3 % NPB sorbitol-mannitol irrigation solution 2.7-0.54 gm/100ml NPB

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 123 Prescription Drug Name Drug Tier Drug Notes THIOLA EC ORAL TABLET DELAYED RELEASE 100 NF MG, 300 MG (tiopronin) THIOLA ORAL TABLET 100 MG (tiopronin) NF tricitrates oral solution 550-500-334 mg/5ml G TRIMO-SAN VAGINAL GEL 0.025-0.01 % (oxyquinoline- NF sod lauryl sulf) PROGESTINS - DRUGS TO REGULATE FEMALE HORMONES ENDOMETRIN VAGINAL INSERT 100 MG PB (progesterone) URINARY ANTISPASMODICS - DRUGS TO TREAT URINARY INCONTINENCE darifenacin hydrobromide er oral tablet extended release 24 G hour 15 mg, 7.5 mg DETROL LA ORAL CAPSULE EXTENDED RELEASE NF 24 HOUR 2 MG, 4 MG (tolterodine tartrate) ENABLEX ORAL TABLET EXTENDED RELEASE 24 NF HOUR 15 MG (darifenacin hydrobromide) GELNIQUE TRANSDERMAL GEL 10 % (oxybutynin NF chloride) MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 PB HOUR 25 MG (mirabegron) oxybutynin chloride er oral tablet extended release 24 hour 10 G mg, 15 mg, 5 mg oxybutynin chloride oral syrup 5 mg/5ml G oxybutynin chloride oral tablet 5 mg G OXYTROL FOR WOMEN TRANSDERMAL PATCH NF TWICE WEEKLY 3.9 MG/24HR (oxybutynin) OXYTROL TRANSDERMAL PATCH TWICE WEEKLY NF 3.9 MG/24HR (oxybutynin) solifenacin succinate oral tablet 10 mg, 5 mg G tolterodine tartrate er oral capsule extended release 24 hour 2 G mg, 4 mg tolterodine tartrate oral tablet 1 mg, 2 mg G TOVIAZ ORAL TABLET EXTENDED RELEASE 24 PB HOUR 4 MG, 8 MG (fesoterodine fumarate) trospium chloride er oral capsule extended release 24 hour 60 G mg

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 124 Prescription Drug Name Drug Tier Drug Notes trospium chloride oral tablet 20 mg G VESICARE LS ORAL SUSPENSION 5 MG/5ML NPB (solifenacin succinate) VESICARE ORAL TABLET 10 MG, 5 MG (solifenacin NF succinate) VAGINAL ANTI-INFECTIVES - DRUGS TO TREAT VAGINAL INFECTIONS CLEOCIN VAGINAL SUPPOSITORY 100 MG NPB (clindamycin phosphate) clindamycin phosphate vaginal cream 2 % G CLINDESSE VAGINAL CREAM 2 % (clindamycin NPB phosphate (1 dose)) GYNAZOLE-1 VAGINAL CREAM 2 % (butoconazole NPB nitrate (1 dose)) metronidazole vaginal gel 0.75 % G miconazole 3 vaginal suppository 200 mg G NUVESSA VAGINAL GEL 1.3 % (metronidazole) NF terconazole vaginal cream 0.4 %, 0.8 % G terconazole vaginal suppository 80 mg G metronidazole (Vandazole Vaginal Gel 0.75 %) G HEMATOLOGIC - DRUGS TO TREAT BLOOD DISORDERS ANTICOAGULANTS - BLOOD THINNERS acd formula a in vitro solution 0.73-2.45-2.2 gm/100ml NPB ACD-A NOCLOT-50 IN VITRO SOLUTION 0.73-2.45-2.2 NPB GM/100ML (anticoagulant cit dext soln a) anticoagulant sodium citrate in vitro solution 4 gm/100ml NPB bivalirudin rtu intravenous solution 250 mg/50ml NPB DEFITELIO INTRAVENOUS SOLUTION 200 MG/2.5ML NF (defibrotide sodium) ELIQUIS DVT/PE STARTER PACK ORAL TABLET PB THERAPY PACK 5 MG (apixaban) ELIQUIS ORAL TABLET 2.5 MG, 5 MG (apixaban) PB enoxaparin sodium injection solution 300 mg/3ml G enoxaparin sodium subcutaneous solution 100 mg/ml, 120 mg/0.8ml, 150 mg/ml, 30 mg/0.3ml, 40 mg/0.4ml, 60 mg/0.6ml, G 80 mg/0.8ml

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 125 Prescription Drug Name Drug Tier Drug Notes fondaparinux sodium subcutaneous solution 10 mg/0.8ml, 2.5 G mg/0.5ml, 5 mg/0.4ml, 7.5 mg/0.6ml FRAGMIN SUBCUTANEOUS SOLUTION 10000 UNIT/ML, 12500 UNIT/0.5ML, 15000 UNIT/0.6ML, 18000 NF UNT/0.72ML, 2500 UNIT/0.2ML, 5000 UNIT/0.2ML, 7500 UNIT/0.3ML, 95000 UNIT/3.8ML (dalteparin sodium) heparin sodium (porcine) injection solution 1000 unit/ml, 10000 G unit/ml, 20000 unit/ml, 5000 unit/ml heparin sodium (porcine) pf injection solution 5000 unit/0.5ml G hepmed combination kit 100&0.9&2.5-2.5 ut/ml&% NF warfarin sodium (Jantoven Oral Tablet 1 Mg, 10 Mg, 2 Mg, 2.5 G LGC Mg, 3 Mg, 4 Mg, 5 Mg, 6 Mg, 7.5 Mg) PRADAXA ORAL CAPSULE 110 MG, 150 MG, 75 MG NF (dabigatran etexilate mesylate) REGIOCIT IN VITRO SOLUTION 0.529 % (anticoagulant NPB na cit (crrt)) SAVAYSA ORAL TABLET 15 MG, 30 MG, 60 MG NF (edoxaban tosylate) TRICITRASOL IN VITRO CONCENTRATE 46.7 % NPB (anticoagulant sodium citrate) warfarin sodium oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 G LGC mg, 5 mg, 6 mg, 7.5 mg XARELTO ORAL TABLET 10 MG, 15 MG, 2.5 MG, 20 PB MG (rivaroxaban) XARELTO STARTER PACK ORAL TABLET THERAPY PB PACK 15 & 20 MG (rivaroxaban) ANTI-VON WILLEBRAND FACTOR AGENTS CABLIVI INJECTION KIT 11 MG (caplacizumab-yhdp) NF BLEEDING DISORDERS AGENTS ALPHANATE INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, NPSP 250 UNIT, 500 UNIT (antihemophilic factor-vwf) FEIBA INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2500 UNIT, 500 UNIT (antiinhibitor coagulant NPSP cmplx) HUMATE-P INTRAVENOUS SOLUTION RECONSTITUTED 1000-2400 UNIT, 250-600 UNIT, 500- NPSP 1200 UNIT (antihemophilic factor-vwf)

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 126 Prescription Drug Name Drug Tier Drug Notes NOVOSEVEN RT INTRAVENOUS SOLUTION RECONSTITUTED 1 MG, 2 MG, 5 MG, 8 MG (coagulation NPSP factor viia recomb) WILATE INTRAVENOUS KIT 1000-1000 UNIT, 500-500 NPSP UNIT (antihemophilic factor-vwf) HEMATOPOIETIC GROWTH FACTORS ARANESP (ALBUMIN FREE) INJECTION SOLUTION 100 MCG/ML, 200 MCG/ML, 25 MCG/ML, 300 MCG/ML, PSP 40 MCG/ML, 60 MCG/ML (darbepoetin alfa) ARANESP (ALBUMIN FREE) INJECTION SOLUTION PREFILLED SYRINGE 10 MCG/0.4ML, 100 MCG/0.5ML, 150 MCG/0.3ML, 200 MCG/0.4ML, 25 MCG/0.42ML, 300 PSP MCG/0.6ML, 40 MCG/0.4ML, 500 MCG/ML, 60 MCG/0.3ML (darbepoetin alfa) DOPTELET ORAL TABLET 20 MG (avatrombopag PSP maleate) LEUKINE INJECTION SOLUTION RECONSTITUTED NPSP 250 MCG (sargramostim) MIRCERA INJECTION SOLUTION PREFILLED SYRINGE 100 MCG/0.3ML, 150 MCG/0.3ML, 200 NF MCG/0.3ML, 30 MCG/0.3ML, 50 MCG/0.3ML, 75 MCG/0.3ML (methoxy peg-epoetin beta) MULPLETA ORAL TABLET 3 MG (lusutrombopag) PSP NEULASTA ONPRO SUBCUTANEOUS PREFILLED NF SYRINGE KIT 6 MG/0.6ML (pegfilgrastim) NEULASTA SUBCUTANEOUS SOLUTION PREFILLED NF SYRINGE 6 MG/0.6ML (pegfilgrastim) NIVESTYM INJECTION SOLUTION 300 MCG/ML, 480 PSP MCG/1.6ML (filgrastim-aafi) NIVESTYM INJECTION SOLUTION PREFILLED SYRINGE 300 MCG/0.5ML, 480 MCG/0.8ML (filgrastim- PSP aafi) NPLATE SUBCUTANEOUS SOLUTION RECONSTITUTED 125 MCG, 250 MCG, 500 MCG NPSP (romiplostim) PROMACTA ORAL PACKET 12.5 MG, 25 MG NPSP (eltrombopag olamine) PROMACTA ORAL TABLET 12.5 MG, 25 MG, 50 MG, 75 NPSP MG (eltrombopag olamine)

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 127 Prescription Drug Name Drug Tier Drug Notes RETACRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 PSP UNIT/ML, 40000 UNIT/ML (epoetin alfa-epbx) UDENYCA SUBCUTANEOUS SOLUTION PREFILLED NF SYRINGE 6 MG/0.6ML (pegfilgrastim-cbqv) ZIEXTENZO SUBCUTANEOUS SOLUTION PSP PREFILLED SYRINGE 6 MG/0.6ML (pegfilgrastim-bmez) HEMOPHILIA A AGENTS ADVATE INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, PSP 250 UNIT, 3000 UNIT, 4000 UNIT, 500 UNIT (antihemophil factor (rahf-pfm)) adynovate intravenous solution reconstituted 1000 unit, 1500 PSP unit, 2000 unit, 250 unit, 3000 unit, 500 unit, 750 unit AFSTYLA INTRAVENOUS KIT 1000 UNIT, 1500 UNIT, 2000 UNIT, 250 UNIT, 2500 UNIT, 3000 UNIT, 500 UNIT PSP (antihemophil fact single chain) ELOCTATE INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, PSP 250 UNIT, 3000 UNIT, 4000 UNIT, 500 UNIT, 5000 UNIT, 6000 UNIT, 750 UNIT (antihem fact (bdd-rfviiifc)) ESPEROCT INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, PSP 3000 UNIT, 500 UNIT (antihemoph fact rcmb gpeg-exei) HEMOFIL M INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1700 UNIT, 250 UNIT, 500 NPSP UNIT (antihemophilic factor) JIVI INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 3000 UNIT, 500 UNIT (ahf (bdd- PSP rfviii peg-aucl)) KOATE INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 250 UNIT, 500 UNIT NPSP (antihemophilic factor) KOATE-DVI INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 500 UNIT (antihemophilic NPSP factor) KOGENATE FS INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT (antihem factor PSP recomb (rfviii))

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 128 Prescription Drug Name Drug Tier Drug Notes KOVALTRY INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT, PSP 3000 UNIT, 500 UNIT (antihemophil factor (rahf-pfm)) NOVOEIGHT INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, PSP 250 UNIT, 3000 UNIT, 500 UNIT (antihemophil fact bd truncated) NUWIQ INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 250 UNIT, 2500 UNIT, 3000 UNIT, 4000 UNIT, 500 UNIT PSP (antihem fact (bdd-rfviii,sim)) NUWIQ INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT, PSP 2500 UNIT, 3000 UNIT, 4000 UNIT, 500 UNIT (antihem fact (bdd-rfviii,sim)) RECOMBINATE INTRAVENOUS SOLUTION RECONSTITUTED 1241-1800 UNIT, 1801-2400 UNIT, NPSP 220-400 UNIT, 401-800 UNIT, 801-1240 UNIT (antihem factor recomb (rfviii)) XYNTHA INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, NPSP 250 UNIT, 500 UNIT (antihem fact (bdd-rfviii,mor)) XYNTHA SOLOFUSE INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT (antihem fact NPSP (bdd-rfviii,mor)) HEMOPHILIA B AGENTS ALPHANINE SD INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 500 UNIT NPSP (coagulation factor ix) ALPROLIX INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT, NF 3000 UNIT, 4000 UNIT, 500 UNIT (coagulation factor ix (rfixfc)) BENEFIX INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT (coagulation factor ix NPSP (recomb)) COAGADEX INTRAVENOUS SOLUTION RECONSTITUTED 250 UNIT, 500 UNIT (coagulation NPSP factor x (human)) IDELVION INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT, NPSP 3500 UNIT, 500 UNIT (coagulation factor ix (rix-fp))

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 129 Prescription Drug Name Drug Tier Drug Notes IXINITY INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, NPSP 250 UNIT, 3000 UNIT, 500 UNIT (coagulation factor ix (recomb)) MONONINE INTRAVENOUS SOLUTION NPSP RECONSTITUTED 1000 UNIT (coagulation factor ix) PROFILNINE INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 500 UNIT NPSP (factor ix complex) REBINYN INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 500 UNIT PSP (coagulation factor ix glycopeg) rixubis intravenous solution reconstituted 1000 unit, 2000 unit, NPSP 250 unit, 3000 unit, 500 unit VONVENDI INTRAVENOUS SOLUTION RECONSTITUTED 1300 UNIT, 650 UNIT (von willebrand NF factor (recomb)) MISCELLANEOUS cyanocobalamin-methylcobalamin (Abaneu-Sl Sublingual G Tablet Sublingual 600-600 Mcg) active fe oral tablet 75-1.25 mg NPB ADAKVEO INTRAVENOUS SOLUTION 100 MG/10ML NPB (crizanlizumab-tmca) folic acid-vit b6-vit b12 (Airavite Oral Tablet 2.5-25-1 Mg) G AKTEN OPHTHALMIC GEL 3.5 % (lidocaine hcl) NPB tetracaine hcl (Altacaine Ophthalmic Solution 0.5 %) G altafluor benox ophthalmic solution 0.25-0.4 % G phenylephrine hcl (Altafrin Ophthalmic Solution 10 %, 2.5 %) G AMICAR ORAL SOLUTION 0.25 GM/ML (aminocaproic NF acid) aminocaproic acid oral tablet 1000 mg, 500 mg G anagrelide hcl oral capsule 0.5 mg, 1 mg G ARTISS EXTERNAL SOLUTION (fibrin sealant component) NPB atropine sulfate ophthalmic ointment 1 % G atropine sulfate ophthalmic solution 1 % NPB b-6 folic acid oral capsule 8.333-100-1 mg NPB bp vit 3 oral capsule 1 mg NPB

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 130 Prescription Drug Name Drug Tier Drug Notes CENFOL ORAL TABLET 2.3-24.5-2 MG (folic acid-vit b6- NPB vit b12) CEQUA OPHTHALMIC SOLUTION 0.09 % (cyclosporine) NF CIFEREX ORAL CAPSULE 1-3775 MG-UNIT (folic acid- NF cholecalciferol) cilostazol oral tablet 100 mg, 50 mg G CINRYZE INTRAVENOUS SOLUTION RECONSTITUTED 500 UNIT (c1 esterase inhibitor NPSP (human)) CORVITE 150 ORAL TABLET (iron combinations) NPB corvite fe oral tablet NPB CYCLOMYDRIL OPHTHALMIC SOLUTION 0.2-1 % NPB (cyclopentolate-phenylephrine) cyclopentolate hcl ophthalmic solution 0.5 %, 1 %, 2 % G CYCLOSPORINE IN KLARITY OPHTHALMIC NF EMULSION 0.1 % (cyclosporine) CYSTARAN OPHTHALMIC SOLUTION 0.44 % NPB (cysteamine hcl) DURLAZA ORAL CAPSULE EXTENDED RELEASE 24 NF HOUR 162.5 MG (aspirin) ENDARI ORAL PACKET 5 GM (glutamine (sickle cell)) NPB fabb oral tablet 2.2-25-1 mg G fa-vitamin b-6-vitamin b-12 oral tablet 2.2-25-0.5 mg G FERIVA 21/7 ORAL TABLET 75-1 MG (feasp-b12-fa-c-dss- NF succac-zn) ferocon oral capsule G ferotrinsic oral capsule G ferraplus 90 oral tablet 90-1 mg NPB fe fum-fa-b cmp-c-zn-mg-mn-cu (Ferrocite Plus Oral Tablet G 106-1 Mg) FERRO-PLEX HEMATINIC ORAL TABLET 115-1 MG NPB (fe fum-dss-c-e-b12-if-fa) FIRAZYR SUBCUTANEOUS SOLUTION 30 MG/3ML NPSP (icatibant acetate) fluorescein-benoxinate ophthalmic solution 0.25-0.4 % G fluorescein sodium (Fluor-I-Strips A.T. Ophthalmic Strip 1 G Mg)

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 131 Prescription Drug Name Drug Tier Drug Notes FLURA-SAFE OPHTHALMIC SOLUTION 0.35-0.4 % NPB (fluorexon-benoxinate) folbee oral tablet 2.5-25-1 mg G FOLI-D ORAL TABLET 1-2000 MG-UNIT (folic acid- NF cholecalciferol) folite oral tablet NF folplex 2.2 oral tablet 2.2-25-0.5 mg G foltrin oral capsule G folic acid-cholecalciferol (Folvite-D Oral Tablet 1-3775 Mg- NF Unit) FUSION PLUS ORAL CAPSULE (iron-fa-b cmp-c-biot- NPB probiotic) GELFILM OPHTHALMIC FILM (gelatin adsorbable) NPB GEL-FLOW EXTERNAL KIT (gelatin absorb-thrombin) NF GELFOAM-JMI POWDER EXTERNAL KIT (gelatin NF absorb-thrombin) GELFOAM-JMI SPONGE EXTERNAL KIT (gelatin NF absorb-thrombin) GENICIN VITA-D ORAL TABLET 1-3775 MG-UNIT NF (folic acid-cholecalciferol) GREEN GLO LISSAMINE GREEN OPHTHALMIC NPB STRIP 1.5 MG (lissamine green) HAEGARDA SUBCUTANEOUS SOLUTION RECONSTITUTED 2000 UNIT, 3000 UNIT (c1 esterase NPSP inhibitor (human)) hematinic plus vit/minerals oral tablet 106-1 mg G hematinic/folic acid oral tablet 324-1 mg G HEMLIBRA SUBCUTANEOUS SOLUTION 105 MG/0.7ML, 150 MG/ML, 30 MG/ML, 60 MG/0.4ML NPSP (emicizumab-kxwh) HEMOCYTE PLUS ORAL CAPSULE 106-1 MG (fe fum-fa- NPB b cmp-c-zn-mg-mn-cu) ferrous fumarate-folic acid (Hemocyte-F Oral Tablet 324-1 G Mg) ICAR-C PLUS ORAL TABLET 100-250-0.025-1 MG (iron- NF vit c-vit b12-folic acid) icatibant acetate subcutaneous solution 30 mg/3ml G

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 132 Prescription Drug Name Drug Tier Drug Notes iron polysacch cmplx-b12-fa (Iferex 150 Forte Oral Capsule G 150-25-1 Mg-Mcg-Mg) INTEGRA F ORAL CAPSULE 125-1 MG (fe fum-fepoly-fa- NPB vit c-vit b3) INTEGRA PLUS ORAL CAPSULE (fefum-fepoly-fa-b cmp- NPB c-biot) ISOPTO ATROPINE OPHTHALMIC SOLUTION 1 % NPB (atropine sulfate) fefum-fepo-fa-b cmp-c-zn-mn-cu (K-Tan Plus Oral Capsule G 162-115.2-1 Mg) LACRISERT OPHTHALMIC INSERT 5 MG (artificial tear NF insert) MULTIGEN FOLIC ORAL TABLET 70-150-2-1 MG (fe NPB asp gly-succ-c-thre-b12-fa) MULTIGEN ORAL TABLET 70 MG (fe-succ-c-thre-b12-des NPB stomach) MULTIGEN PLUS ORAL TABLET 50-101-1 MG (feasp- NPB fefum -suc-c-thre-b12-fa) NUFERA ORAL TABLET (iron combinations) NPB folic acid-vit b6-vit b12 (Nufol Oral Tablet 2.5-25-1 Mg) G ortho df oral capsule 1-3775 mg-unit NF PAREMYD OPHTHALMIC SOLUTION 1-0.25 % NPB (hydroxyamphetamine-tropicamide) pentoxifylline er oral tablet extended release 400 mg G phenylephrine hcl ophthalmic solution 10 %, 2.5 % G PHOTREXA VISCOUS OPHTHALMIC SOLUTION PREFILLED SYRINGE 0.146-20 % (riboflavin 5-phosphate- NF dextran) PHOTREXA-PHOTREXA VISCOUS KIT OPHTHALMIC SOLUTION PREFILLED SYRINGE 0.146 &0.146-20 % NF (riboflav5 & riboflav5-dextran) poly-iron 150 forte oral capsule 150-25-1 mg-mcg-mg G polysaccharide iron forte oral capsule 150-25-1 mg-mcg-mg G proparacaine hcl ophthalmic solution 0.5 % G proparacaine-fluorescein ophthalmic solution 0.5-0.25 % G PROVAYBLUE INTRAVENOUS SOLUTION 50 NF MG/10ML (methylene blue (antidote))

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 133 Prescription Drug Name Drug Tier Drug Notes RADIOGARDASE ORAL CAPSULE 0.5 GM (prussian blue NPB insoluble) RECOTHROM EXTERNAL SOLUTION NPB RECONSTITUTED 5000 UNIT (thrombin (recombinant)) RECOTHROM SPRAY KIT EXTERNAL SOLUTION NPB RECONSTITUTED 20000 UNIT (thrombin (recombinant)) RESTASIS MULTIDOSE OPHTHALMIC EMULSION NF 0.05 % (cyclosporine) RESTASIS OPHTHALMIC EMULSION 0.05 % NF (cyclosporine) revesta oral capsule 1-5750 mg-unit NF RUCONEST INTRAVENOUS SOLUTION RECONSTITUTED 2100 UNIT (c1 esterase inhibitor PSP (recomb)) SIKLOS ORAL TABLET 100 MG, 1000 MG (hydroxyurea) NPB TAKHZYRO SUBCUTANEOUS SOLUTION 300 PSP MG/2ML (lanadelumab-flyo) TALIVA ORAL CAPSULE 1 MG (fa-b6-b12-omega 3- NF phytosterols) tetracaine hcl ophthalmic solution 0.5 % G THROMBIN-JMI EPISTAXIS EXTERNAL KIT 5000 NPB UNIT (thrombin) THROMBIN-JMI EXTERNAL KIT 20000 UNIT, 5000 NPB UNIT (thrombin) THROMBIN-JMI EXTERNAL SOLUTION NPB RECONSTITUTED 20000 UNIT, 5000 UNIT (thrombin) THROMBOGEN EXTERNAL KIT 10000 UNIT (thrombin) NPB THROMBOGEN EXTERNAL SOLUTION NPB RECONSTITUTED 1000 UNIT, 10000 UNIT (thrombin) TISSEEL EXTERNAL KIT 10 ML, 2 ML, 4 ML (fibrin NPB sealant component) TISSEEL EXTERNAL SOLUTION (fibrin sealant NPB component) tl-hem 150 oral tablet 150-1 mg G tranexamic acid oral tablet 650 mg G fe fumarate-b12-vit c-fa-ifc (Tricon Oral Capsule) G tropicamide ophthalmic solution 0.5 %, 1 % G

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 134 Prescription Drug Name Drug Tier Drug Notes ULTOMIRIS INTRAVENOUS SOLUTION 1100 NF MG/11ML, 300 MG/3ML (ravulizumab-cwvz) virt-fefa plus oral capsule NF folic acid-vit b6-vit b12 (Virt-Gard Oral Tablet 2.2-25-1 Mg) G VITAMEZ ORAL CAPSULE 1 MG (fa-b6-b12-omega 3- NPB phytosterols) PLASMA PROTEINS ALBUKED 25 INTRAVENOUS SOLUTION 25 % (albumin NPB human) ALBUKED 5 INTRAVENOUS SOLUTION 5 % (albumin NPB human) albumin human intravenous solution 25 %, 5 % NPB albumin-zlb intravenous solution 25 %, 5 % NPB alburx intravenous solution 5 % NPB ALBUTEIN INTRAVENOUS SOLUTION 25 %, 5 % NPB (albumin human) FLEXBUMIN INTRAVENOUS SOLUTION 25 %, 5 % NPB (albumin human) HUMAN ALBUMIN GRIFOLS INTRAVENOUS NPB SOLUTION 25 % (albumin human) kedbumin intravenous solution 25 % NPB PLASBUMIN-25 INTRAVENOUS SOLUTION 25 % NPB (albumin human) PLASBUMIN-5 INTRAVENOUS SOLUTION 5 % (albumin NPB human) PLATELET AGGREGATION INHIBITORS - BLOOD THINNERS AGGRASTAT INTRAVENOUS CONCENTRATE 3.75 NF MG/15ML (tirofiban hcl) aspirin-dipyridamole er oral capsule extended release 12 hour G 25-200 mg BRILINTA ORAL TABLET 60 MG, 90 MG (ticagrelor) PB clopidogrel bisulfate oral tablet 300 mg, 75 mg G dipyridamole oral tablet 25 mg, 50 mg, 75 mg G PLAVIX ORAL TABLET 75 MG (clopidogrel bisulfate) NF prasugrel hcl oral tablet 10 mg, 5 mg G YOSPRALA ORAL TABLET DELAYED RELEASE 325- NF 40 MG, 81-40 MG (aspirin-omeprazole) 2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 135 Prescription Drug Name Drug Tier Drug Notes ZONTIVITY ORAL TABLET 2.08 MG (vorapaxar sulfate) NF IMMUNOLOGIC AGENTS - DRUGS TO TREAT DISORDERS OF THE IMMUNE SYSTEM ALLERGENIC EXTRACTS GRASTEK SUBLINGUAL TABLET SUBLINGUAL 2800 PB BAU (timothy grass pollen allergen) ODACTRA SUBLINGUAL TABLET SUBLINGUAL 12 NPB SQ-HDM (dust mite mixed allergen ext) ORALAIR SUBLINGUAL TABLET SUBLINGUAL 300 PB IR (grass mix pollens allergen ext) RAGWITEK SUBLINGUAL TABLET SUBLINGUAL 12 PB AMB A 1-U (short ragweed pollen ext) sorrel/dock mix subcutaneous solution 1:20 NF BIOLOGIC DISEASE-MODIFYING AGENTS ACTEMRA ACTPEN SUBCUTANEOUS SOLUTION NF AUTO-INJECTOR 162 MG/0.9ML (tocilizumab) AVSOLA INTRAVENOUS SOLUTION NF RECONSTITUTED 100 MG (infliximab-axxq) ENBREL MINI SUBCUTANEOUS SOLUTION IBC (Preferred agent for all PSP CARTRIDGE 50 MG/ML (etanercept) conditions except Psoriasis) ENBREL SUBCUTANEOUS SOLUTION 25 MG/0.5ML IBC (Preferred agent for all PSP (etanercept) conditions except Psoriasis) ENBREL SUBCUTANEOUS SOLUTION PREFILLED IBC (Preferred agent for all PSP SYRINGE 25 MG/0.5ML, 50 MG/ML (etanercept) conditions except Psoriasis) ENBREL SUBCUTANEOUS SOLUTION IBC (Preferred agent for all PSP RECONSTITUTED 25 MG (etanercept) conditions except Psoriasis) ENBREL SURECLICK SUBCUTANEOUS SOLUTION IBC (Preferred agent for all PSP AUTO-INJECTOR 50 MG/ML (etanercept) conditions except Psoriasis) IBC (Available as NPSP ENTYVIO INTRAVENOUS SOLUTION NF with PA for Ulcerative RECONSTITUTED 300 MG (vedolizumab) Colitis) HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 80 PSP MG/0.8ML, 80 MG/0.8ML & 40MG/0.4ML (adalimumab) HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT PSP 40 MG/0.4ML, 40 MG/0.8ML, 80 MG/0.8ML (adalimumab) HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML, 80 MG/0.8ML PSP (adalimumab)

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 136 Prescription Drug Name Drug Tier Drug Notes HUMIRA PEN-PS/UV/ADOL HS START SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML PSP (adalimumab) HUMIRA PEN-PSOR/UVEIT STARTER SUBCUTANEOUS PEN-INJECTOR KIT 80 MG/0.8ML & PSP 40MG/0.4ML (adalimumab) HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 MG/0.1ML, 20 MG/0.2ML, 40 MG/0.4ML, 40 PSP MG/0.8ML (adalimumab) ILARIS SUBCUTANEOUS SOLUTION 150 MG/ML NPSP (canakinumab) INFLECTRA INTRAVENOUS SOLUTION NF RECONSTITUTED 100 MG (infliximab-dyyb) KEVZARA SUBCUTANEOUS SOLUTION AUTO- IBC (Preferred agent for PSP INJECTOR 150 MG/1.14ML, 200 MG/1.14ML (sarilumab) Rheumatoid Arthritis) KEVZARA SUBCUTANEOUS SOLUTION PREFILLED IBC (Preferred agent for PSP SYRINGE 150 MG/1.14ML, 200 MG/1.14ML (sarilumab) Rheumatoid Arthritis) OLUMIANT ORAL TABLET 1 MG (baricitinib) NF IBC (Preferred agent for ORENCIA CLICKJECT SUBCUTANEOUS SOLUTION Rheumatoid Arthritis. Not PSP AUTO-INJECTOR 125 MG/ML (abatacept) covered for other conditions) IBC (Preferred agent for ORENCIA SUBCUTANEOUS SOLUTION PREFILLED Rheumatoid Arthritis. Not SYRINGE 125 MG/ML, 50 MG/0.4ML, 87.5 MG/0.7ML PSP covered for other (abatacept) conditions) REMICADE INTRAVENOUS SOLUTION PSP RECONSTITUTED 100 MG (infliximab) RENFLEXIS INTRAVENOUS SOLUTION NF RECONSTITUTED 100 MG (infliximab-abda) RINVOQ ORAL TABLET EXTENDED RELEASE 24 IBC (Preferred agent for PSP HOUR 15 MG (upadacitinib) Rheumatoid Arthritis) SIMPONI ARIA INTRAVENOUS SOLUTION 50 PSP MG/4ML (golimumab) SIMPONI SUBCUTANEOUS SOLUTION AUTO- NPSP INJECTOR 100 MG/ML, 50 MG/0.5ML (golimumab) SIMPONI SUBCUTANEOUS SOLUTION PREFILLED NPSP SYRINGE 100 MG/ML, 50 MG/0.5ML (golimumab)

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 137 Prescription Drug Name Drug Tier Drug Notes SKYRIZI (150 MG DOSE) SUBCUTANEOUS IBC (Preferred agent for PREFILLED SYRINGE KIT 75 MG/0.83ML (risankizumab- PSP Psoriasis) rzaa) SKYRIZI PEN SUBCUTANEOUS SOLUTION AUTO- IBC (Preferred agent for PSP INJECTOR 150 MG/ML (risankizumab-rzaa) Psoriasis) SKYRIZI SUBCUTANEOUS SOLUTION PREFILLED IBC (Preferred agent for PSP SYRINGE 150 MG/ML (risankizumab-rzaa) Psoriasis) IBC (Preferred agent for Psoriasis. Preferred agent for Crohn's Disease and STELARA INTRAVENOUS SOLUTION 130 MG/26ML PSP Ulcerative Colitis after (ustekinumab) failure of Humira. Not covered for Psoriatic Arthritis.) IBC (Preferred agent for Psoriasis. Preferred agent for Crohn's Disease and STELARA SUBCUTANEOUS SOLUTION 45 MG/0.5ML PSP Ulcerative Colitis after (ustekinumab) failure of Humira. Not covered for Psoriatic Arthritis.) IBC (Preferred agent for Psoriasis. Preferred agent for Crohn's Disease and STELARA SUBCUTANEOUS SOLUTION PREFILLED PSP Ulcerative Colitis after SYRINGE 45 MG/0.5ML, 90 MG/ML (ustekinumab) failure of Humira. Not covered for Psoriatic Arthritis.) IBC (Preferred agent for TALTZ SUBCUTANEOUS SOLUTION AUTO- Psoriasis. Not covered for PSP INJECTOR 80 MG/ML (ixekizumab) Psoriatic Arthritis or Ankylosing Spondylitis) IBC (Preferred agent for TALTZ SUBCUTANEOUS SOLUTION PREFILLED Psoriasis. Not covered for PSP SYRINGE 80 MG/ML (ixekizumab) Psoriatic Arthritis or Ankylosing Spondylitis) IBC (Preferred agent for TREMFYA SUBCUTANEOUS SOLUTION PEN- PSP Psoriasis.Not covered for INJECTOR 100 MG/ML (guselkumab) Psoriatic Arthritis) IBC (Preferred agent for TREMFYA SUBCUTANEOUS SOLUTION PREFILLED PSP Psoriasis.Not covered for SYRINGE 100 MG/ML (guselkumab) Psoriatic Arthritis)

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 138 Prescription Drug Name Drug Tier Drug Notes IBC (Preferred agent for Rheumatoid Arthritis. Preferred agent for XELJANZ ORAL SOLUTION 1 MG/ML (tofacitinib citrate) PSP Ulcerative Colitis (after failure of Humira). Not covered for Psoriatic Arthritis.) IBC (Preferred agent for Rheumatoid Arthritis. Preferred agent for XELJANZ ORAL TABLET 10 MG, 5 MG (tofacitinib PSP Ulcerative Colitis (after citrate) failure of Humira). Not covered for Psoriatic Arthritis.) IBC (Preferred agent for Rheumatoid Arthritis. Preferred agent for XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 PSP Ulcerative Colitis (after HOUR 11 MG, 22 MG (tofacitinib citrate) failure of Humira). Not covered for Psoriatic Arthritis.) DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS) - DRUGS TO TREAT RHEUMATOID ARTHRITIS hydroxychloroquine sulfate oral tablet 200 mg G leflunomide oral tablet 10 mg, 20 mg G IBC (Preferred agent for OTEZLA ORAL TABLET 30 MG (apremilast) PSP Psoriasis and Psoriatic Arthritis) IBC (Preferred agent for OTEZLA ORAL TABLET THERAPY PACK 10 & 20 & 30 PSP Psoriasis and Psoriatic MG (apremilast) Arthritis) RASUVO SUBCUTANEOUS SOLUTION AUTO- INJECTOR 10 MG/0.2ML, 12.5 MG/0.25ML, 15 MG/0.3ML, 17.5 MG/0.35ML, 20 MG/0.4ML, 22.5 PSP MG/0.45ML, 25 MG/0.5ML, 30 MG/0.6ML, 7.5 MG/0.15ML (methotrexate (anti-rheumatic)) IMMUNOGLOBULIN BIVIGAM INTRAVENOUS SOLUTION 5 GM/50ML NPSP (immune globulin (human))

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 139 Prescription Drug Name Drug Tier Drug Notes CUTAQUIG SUBCUTANEOUS SOLUTION 1 GM/6ML, 1.65 GM/10ML, 2 GM/12ML, 3.3 GM/20ML, 4 GM/24ML, 8 PSP GM/48ML (immune globulin (human)-hipp) CUVITRU SUBCUTANEOUS SOLUTION 1 GM/5ML, 10 GM/50ML, 2 GM/10ML, 4 GM/20ML, 8 GM/40ML (immune NF globulin (human)) FLEBOGAMMA DIF INTRAVENOUS SOLUTION 0.5 GM/10ML, 10 GM/100ML, 10 GM/200ML, 2.5 GM/50ML, NPSP 20 GM/200ML, 20 GM/400ML, 5 GM/100ML, 5 GM/50ML (immune globulin (human)) GAMMAGARD INJECTION SOLUTION 1 GM/10ML, 10 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 30 GM/300ML, NPSP 5 GM/50ML (immune globulin (human)) GAMMAGARD S/D LESS IGA INTRAVENOUS SOLUTION RECONSTITUTED 10 GM, 5 GM (immune NPSP globulin (human)) GAMMAKED INJECTION SOLUTION 1 GM/10ML, 10 GM/100ML, 20 GM/200ML, 5 GM/50ML (immune globulin NPSP (human)) GAMMAPLEX INTRAVENOUS SOLUTION 10 GM/100ML, 10 GM/200ML, 20 GM/200ML, 20 GM/400ML, NPSP 5 GM/100ML, 5 GM/50ML (immune globulin (human)) GAMUNEX-C INJECTION SOLUTION 1 GM/10ML, 10 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 40 GM/400ML, NPSP 5 GM/50ML (immune globulin (human)) HIZENTRA SUBCUTANEOUS SOLUTION 1 GM/5ML, 10 GM/50ML, 2 GM/10ML, 4 GM/20ML (immune globulin NPSP (human)) HIZENTRA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 1 GM/5ML, 2 GM/10ML, 4 GM/20ML (immune NPSP globulin (human)) HYQVIA SUBCUTANEOUS KIT 10 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 30 GM/300ML, 5 GM/50ML NF (immune globulin-hyaluronidase) OCTAGAM INTRAVENOUS SOLUTION 1 GM/20ML, 10 GM/100ML, 10 GM/200ML, 2 GM/20ML, 2.5 GM/50ML, 20 NPSP GM/200ML, 25 GM/500ML, 30 GM/300ML, 5 GM/100ML, 5 GM/50ML (immune globulin (human)) PANZYGA INTRAVENOUS SOLUTION 1 GM/10ML, 10 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 30 GM/300ML, NF 5 GM/50ML (immune globulin (human)-ifas)

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 140 Prescription Drug Name Drug Tier Drug Notes PRIVIGEN INTRAVENOUS SOLUTION 10 GM/100ML, 20 GM/200ML, 40 GM/400ML, 5 GM/50ML (immune NPSP globulin (human)) IMMUNOMODULATORS ACTIMMUNE SUBCUTANEOUS SOLUTION 2000000 NPSP UNIT/0.5ML (interferon gamma-1b) ARCALYST SUBCUTANEOUS SOLUTION NPSP RECONSTITUTED 220 MG (rilonacept) INTRON A INJECTION SOLUTION 10000000 UNIT/ML, NPSP 6000000 UNIT/ML (interferon alfa-2b) INTRON A INJECTION SOLUTION RECONSTITUTED 10000000 UNIT, 18000000 UNIT, 50000000 UNIT (interferon NPSP alfa-2b) POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG NPSP (pomalidomide) REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 20 PSP MG, 25 MG, 5 MG (lenalidomide) THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG, PSP 50 MG (thalidomide) IMMUNOSUPPRESSANTS AZASAN ORAL TABLET 100 MG, 75 MG (azathioprine) NPB azathioprine oral tablet 50 mg G BENLYSTA INTRAVENOUS SOLUTION NPSP RECONSTITUTED 120 MG, 400 MG (belimumab) BENLYSTA SUBCUTANEOUS SOLUTION AUTO- NPSP INJECTOR 200 MG/ML (belimumab) BENLYSTA SUBCUTANEOUS SOLUTION PREFILLED NPSP SYRINGE 200 MG/ML (belimumab) cyclosporine modified oral capsule 100 mg, 25 mg, 50 mg G cyclosporine modified oral solution 100 mg/ml G cyclosporine oral capsule 100 mg, 25 mg G GAMIFANT INTRAVENOUS SOLUTION 100 MG/20ML NPSP (emapalumab-lzsg) cyclosporine modified (Gengraf Oral Capsule 100 Mg, 25 Mg) G cyclosporine modified (Gengraf Oral Solution 100 Mg/Ml) G mycophenolate mofetil oral capsule 250 mg G mycophenolate mofetil oral suspension reconstituted 200 mg/ml G mycophenolate mofetil oral tablet 500 mg G

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 141 Prescription Drug Name Drug Tier Drug Notes mycophenolate sodium oral tablet delayed release 180 mg, 360 G mg SANDIMMUNE ORAL SOLUTION 100 MG/ML NPSP (cyclosporine) sirolimus oral solution 1 mg/ml G sirolimus oral tablet 0.5 mg, 1 mg, 2 mg G tacrolimus oral capsule 0.5 mg, 1 mg, 5 mg G MONOCLONAL ANTIBODIES etesevimab intravenous solution 700 mg/20ml NPB NSAIDS - DRUGS TO TREAT PAIN AND INFLAMMATION CALDOLOR INTRAVENOUS SOLUTION 800 NPB MG/200ML (ibuprofen) NUDROXIPAK E-400 COMBINATION KIT 400 MG NF (etodolac-liniment) NUDROXIPAK I-800 COMBINATION KIT 800 MG NF (ibuprofen-liniment) NSAIDS, COMBINATIONS diclofenac sodium-capsaicin (Nudiclo Tabpak Combination NF Therapy Pack 75 & 0.025 Mg-%) NUDROXIPAK COMBINATION THERAPY PACK 200 NF MG (celecoxib-capsaic-men-methsal) READYSHARP ANESTH + KETOROLAC INJECTION KIT 15 & 0.5 & 1 MG/ML-%-% (ketorolac & bupivacaine & NF lido) VACCINES FLUAD QUADRIVALENT INTRAMUSCULAR PREFILLED SYRINGE 0.5 ML (influenza vac a&b sa adj NPB quad) MENQUADFI INTRAMUSCULAR INJECTABLE NPB (meningococcal a c y&w-135 conj) ROTARIX ORAL SUSPENSION RECONSTITUTED NPB (rotavirus vaccine live oral) ROTATEQ ORAL SOLUTION (rotavirus vac live NPB pentavalent) VAXCHORA ORAL SUSPENSION RECONSTITUTED NPB (cholera vac live attenuated) VAXELIS INTRAMUSCULAR SUSPENSION (dtap-ipv- NPB hib-hepatitis b recmb) 2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 142 Prescription Drug Name Drug Tier Drug Notes VAXELIS INTRAMUSCULAR SUSPENSION NPB PREFILLED SYRINGE (dtap-ipv-hib-hepatitis b recmb) MEDICAL DEVICES CONTRACEPTIVES - PRODUCTS FOR BIRTH CONTROL CAYA VAGINAL DIAPHRAGM (diaphragm arc-spring) CE FC FEMALE CONDOM (condoms - female) CE FC2 FEMALE CONDOM (condoms - female) CE FEMCAP VAGINAL DEVICE 22 MM, 26 MM, 30 MM CE (cervical caps) OMNIFLEX DIAPHRAGM VAGINAL DIAPHRAGM CE (diaphragms) WIDE-SEAL DIAPHRAGM 60 VAGINAL DIAPHRAGM CE 2 % (diaphragm wide seal) WIDE-SEAL DIAPHRAGM 65 VAGINAL DIAPHRAGM CE 2 % (diaphragm wide seal) WIDE-SEAL DIAPHRAGM 70 VAGINAL DIAPHRAGM CE 2 % (diaphragm wide seal) WIDE-SEAL DIAPHRAGM 75 VAGINAL DIAPHRAGM CE 2 % (diaphragm wide seal) WIDE-SEAL DIAPHRAGM 80 VAGINAL DIAPHRAGM CE 2 % (diaphragm wide seal) WIDE-SEAL DIAPHRAGM 85 VAGINAL DIAPHRAGM CE 2 % (diaphragm wide seal) WIDE-SEAL DIAPHRAGM 90 VAGINAL DIAPHRAGM CE 2 % (diaphragm wide seal) WIDE-SEAL DIAPHRAGM 95 VAGINAL DIAPHRAGM CE 2 % (diaphragm wide seal) DIABETIC SUPPLIES 12-PANEL POC TOXICOLOGY SYSTEM IN VITRO KIT NPB (drug assay (urine)) 1st tier unifine pentips 29g x 12mm , 31g x 5 mm , 31g x 6 mm , NF 31g x 8 mm , 32g x 4 mm , 32g x 6 mm , 33g x 4 mm 1st tier unifine pentips plus 29g x 12mm , 31g x 5 mm , 31g x 6 NF mm , 31g x 8 mm , 32g x 4 mm , 33g x 4 mm 1st tier unilet comfortouch NPB ABOUTTIME PEN NEEDLE 30G X 8 MM , 31G X 5 MM , NF 31G X 8 MM , 32G X 4 MM (insulin pen needle)

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 143 Prescription Drug Name Drug Tier Drug Notes ACCU-CHEK AVIVA PLUS IN VITRO STRIP (glucose PB blood) ACCU-CHEK AVIVA PLUS KIT W/DEVICE (blood PB glucose monitoring suppl) ACCU-CHEK COMPACT PLUS IN VITRO STRIP (glucose PB blood) ACCU-CHEK FASTCLIX LANCET KIT (lancets misc.) NPB ACCU-CHEK FASTCLIX LANCETS (lancets) NPB ACCU-CHEK GUIDE IN VITRO STRIP (glucose blood) PB ACCU-CHEK GUIDE KIT W/DEVICE (blood glucose PB monitoring suppl) ACCU-CHEK GUIDE ME KIT W/DEVICE (blood glucose PB monitoring suppl) ACCU-CHEK LINKASSIST (insulin pump accessories) NPB ACCU-CHEK MULTICLIX LANCETS (lancets) NPB ACCU-CHEK PLASTIC CARTRIDGE (insulin infusion NPB pump supplies) ACCU-CHEK SAFE-T PRO LANCETS (lancets) NPB ACCU-CHEK SMARTVIEW IN VITRO STRIP (glucose PB blood) ACCU-CHEK SOFTCLIX LANCET DEV KIT (lancets NPB misc.) ACCU-CHEK SOFTCLIX LANCETS (lancets) NPB ACCU-CHEK ULTRAFLEX INF SET (insulin infusion NPB pump supplies) ACCU-CHEK ULTRAFLEX-1 INF SET (insulin infusion NPB pump supplies) ACCUTREND GLUCOSE IN VITRO STRIP (glucose NF blood) acti-lance 28g NPB acti-lance lite lancets 28g NPB acti-lance special lancets 17g NPB acti-lance universal 23g NPB adjustable lancing device NPB ADVANCE INTUITION METER DEVICE (blood glucose NF monitoring suppl) ADVANCE INTUITION MONITOR KIT (blood glucose NF monitoring suppl) 2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 144 Prescription Drug Name Drug Tier Drug Notes ADVANCE INTUITION TEST IN VITRO STRIP (glucose NF blood) ADVANCE MICRO-DRAW METER DEVICE (blood NF glucose monitoring suppl) ADVANCE MICRO-DRAW TEST IN VITRO STRIP NF (glucose blood) ADVOCATE BLOOD GLUCOSE MONITOR DEVICE NF (blood glucose monitoring suppl) ADVOCATE BLOOD GLUCOSE SYSTEM KIT NF W/DEVICE (blood glucose monitoring suppl) ADVOCATE INSULIN PEN NEEDLES 29G X 12.7MM , 31G X 5 MM , 31G X 8 MM , 33G X 4 MM (insulin pen NF needle) ADVOCATE INSULIN SYRINGE 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, NF 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe-needle u-100) ADVOCATE LANCETS 30G (lancets) NPB ADVOCATE LANCING DEVICE (lancet devices) NPB ADVOCATE RAPID-SAFE LANCING (lancet devices) NPB ADVOCATE REDI-CODE DEVICE (blood glucose NF monitoring suppl) ADVOCATE REDI-CODE IN VITRO STRIP (glucose NF blood) ADVOCATE REDI-CODE KIT W/DEVICE (blood glucose NF monitoring suppl) ADVOCATE REDI-CODE+ DEVICE (blood glucose NF monitoring suppl) ADVOCATE REDI-CODE+ TEST IN VITRO STRIP NF (glucose blood) ADVOCATE SAFETY LANCETS (lancets) NPB ADVOCATE SAFETY LANCETS 26G (lancets) NPB ADVOCATE TEST IN VITRO STRIP (glucose blood) NF AGAMATRIX AMP DEVICE (blood glucose monitoring NF suppl) AGAMATRIX AMP TEST IN VITRO STRIP (glucose NF blood)

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 145 Prescription Drug Name Drug Tier Drug Notes AGAMATRIX JAZZ TEST IN VITRO STRIP (glucose NF blood) AGAMATRIX JAZZ WIRELESS 2 KIT W/DEVICE (blood NF glucose monitoring suppl) AGAMATRIX KEYNOTE TEST IN VITRO STRIP NF (glucose blood) AGAMATRIX PRESTO KIT W/DEVICE (blood glucose NF monitoring suppl) AGAMATRIX PRESTO PRO METER DEVICE (blood NF glucose monitoring suppl) AGAMATRIX PRESTO TEST IN VITRO STRIP (glucose NF blood) AGAMATRIX ULTRA-THIN LANCETS (lancets) NPB aimsco twist lancets 32g NPB AIMSCO TWIST LANCETS 33G (lancets) NPB ALCOH-GLOVE CONTOURED WIPE PAD (alcohol NPB swabs) alcohol pads pad 70 % NPB alcohol prep pad NPB alcohol prep pad 70 % NPB alcohol swabs pad NPB alcoh-wipe sheet NPB AQUALANCE LANCETS 30G (lancets) NPB ASSURE 3 METER KIT (blood glucose monitoring suppl) NF ASSURE 3 TEST IN VITRO STRIP (glucose blood) NF ASSURE 4 METER DEVICE (blood glucose monitoring NF suppl) ASSURE 4 TEST IN VITRO STRIP (glucose blood) NF assure comfort lancets 28g NPB ASSURE ID INSULIN SAFETY SYR 29G X 1/2" 0.5 ML, NF 29G X 1/2" 1 ML (insulin syringe-needle u-100) ASSURE ID SAFETY PEN NEEDLES 30G X 5 MM , 30G NF X 8 MM , 31G X 5 MM (insulin pen needle) ASSURE II CHECK IN VITRO STRIP (glucose blood) NF ASSURE II IN VITRO STRIP (glucose blood) NF ASSURE PLATINUM IN VITRO STRIP (glucose blood) NF

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 146 Prescription Drug Name Drug Tier Drug Notes ASSURE PLATINUM METER DEVICE (blood glucose NF monitoring suppl) ASSURE PRISM MULTI TEST IN VITRO STRIP (glucose NF blood) ASSURE PRO BLOOD GLUCOSE METER DEVICE NF (blood glucose monitoring suppl) ASSURE PRO TEST IN VITRO STRIP (glucose blood) NF aurora lancet super thin 30g NPB aurora lancet thin 23g NPB aurora pen needles 29g x 12mm , 31g x 6 mm , 31g x 8 mm NF aurora unifine pentips 31g x 5 mm , 32g x 4 mm NF AUTO-LANCET (lancet devices) NPB AUTO-LANCET MINI (lancet devices) NPB AUTOLET II CLINISAFE KIT (lancets misc.) NPB AUTOLET LITE CLINISAFE KIT (lancets misc.) NPB AUTOLET LITE STARTER PACK KIT (lancets misc.) NPB AUTOLET MINI (lancet devices) NPB AUTOLET PLATFORMS (lancets misc.) NPB AUTOLET PLUS (lancet devices) NPB autopen device NPB AUTOSOFT 30 INFUSION SET (insulin infusion pump NPB supplies) AUTOSOFT 90 INFUSION SET (insulin infusion pump NPB supplies) AUTOSOFT XC INFUSION SET (insulin infusion pump NPB supplies) BD AUTOSHIELD 29G X 5MM , 29G X 8MM (insulin pen PB needle) BD AUTOSHIELD DUO 30G X 5 MM (insulin pen needle) PB BD INSULIN SYRINGE 25G X 1" 1 ML, 25G X 5/8" 1 ML, 26G X 1/2" 1 ML, 27.5G X 5/8" 2 ML, 27G X 1/2" 1 ML, 29G PB X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML (insulin syringe-needle u-100) BD INSULIN SYRINGE MICROFINE 27G X 5/8" 1 ML, 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML (insulin syringe-needle PB u-100)

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 147 Prescription Drug Name Drug Tier Drug Notes BD INSULIN SYRINGE U/F 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 31G X 5/16" 1 ML (insulin PB syringe-needle u-100) BD INSULIN SYRINGE U-100 1 ML (insulin syringes PB (disposable)) BD INSULIN SYRINGE U-500 31G X 6MM 0.5 ML PB (insulin syringe/needle u-500) BD INSULIN SYRINGE ULTRAFINE 31G X 5/16" 0.5 PB ML (insulin syringe-needle u-100) BD LANCET ULTRAFINE 30G (lancets) NPB BD LANCET ULTRAFINE 33G (lancets) NPB BD LATITUDE DIABETES KIT (blood glucose monitoring NF suppl) BD LATITUDE DIABETES SYSTEM KIT (blood glucose NF monitoring suppl) BD LOGIC BLOOD GLUCOSE MONITOR KIT NF W/DEVICE (blood glucose monitoring suppl) BD MICROTAINER LANCETS (lancets) NPB BD PEN (injection device for insulin) NPB BD PEN MINI (injection device for insulin) NPB BD PEN NEEDLE MICRO U/F 32G X 6 MM (insulin pen PB needle) BD PEN NEEDLE MINI U/F 31G X 5 MM (insulin pen PB needle) BD PEN NEEDLE NANO 2ND GEN 32G X 4 MM (insulin PB pen needle) BD PEN NEEDLE NANO U/F 32G X 4 MM (insulin pen PB needle) BD PEN NEEDLE ORIGINAL U/F 29G X 12.7MM (insulin PB pen needle) BD PEN NEEDLE SHORT U/F 31G X 8 MM (insulin pen PB needle) BD SAFETYGLIDE INSULIN SYRINGE 30G X 5/16" 0.5 ML, 31G X 15/64" 0.3 ML, 31G X 15/64" 0.5 ML, 31G X PB 15/64" 1 ML (insulin syringe-needle u-100) BD SWABS SINGLE USE BUTTERFLY PAD (alcohol NPB swabs) BD VEO INSULIN SYR U/F 1/2UNIT 31G X 15/64" 0.3 ML PB (insulin syringe-needle u-100) 2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 148 Prescription Drug Name Drug Tier Drug Notes BD VEO INSULIN SYRINGE U/F 31G X 15/64" 0.3 ML PB (insulin syringe-needle u-100) BIOSCANNER GLUCOSE TEST IN VITRO STRIP NF (glucose blood) BIOTEL CARE BLOOD GLUCOSE SYST KIT W/DEVICE NF (blood glucose monitoring suppl) blood glucose monitor system kit w/device NF blood glucose system pak kit NF blood glucose test in vitro strip NF BLULINK GLUCOSE MONITORING SYS DEVICE NF (blood glucose monitoring suppl) BLULINK GLUCOSE TEST IN VITRO STRIP (glucose NF blood) CARDIOCOM LANCING DEVICE (lancet devices) NPB CAREFINE PEN NEEDLES 29G X 12MM , 30G X 8 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM , 32G X 5 MM , NF 32G X 6 MM (insulin pen needle) careone advanced lancing dev NPB CAREONE BLOOD GLUCOSE SYSTEM KIT W/DEVICE NF (blood glucose monitoring suppl) CAREONE BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) careone insulin syringe 30g x 1/2" 0.3 ml, 30g x 1/2" 0.5 ml, 30g x 1/2" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" NF 1 ml CAREONE LANCET SUPER THIN 30G (lancets) NPB careone lancet thin 23g NPB careone unifine pentips 29g x 12mm , 31g x 5 mm , 31g x 6 mm , NF 31g x 8 mm , 32g x 4 mm careone unifine pentips plus 29g x 12mm , 31g x 5 mm , 31g x 6 NF mm , 31g x 8 mm , 32g x 4 mm CARESENS N GLUCOSE SYSTEM DEVICE (blood NF glucose monitoring suppl) CARESENS N GLUCOSE TEST IN VITRO STRIP (glucose NF blood) CARESENS N VOICE SYSTEM DEVICE (blood glucose NF monitoring suppl) CARETOUCH ALCOHOL PREP PAD 70 % (alcohol swabs) NPB

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 149 Prescription Drug Name Drug Tier Drug Notes CARETOUCH INSULIN SYRINGE 28G X 5/16" 1 ML, NF 29G X 5/16" 1 ML (insulin syringe-needle u-100) CARETOUCH LANCING/EJECTOR (lancet devices) NPB CARETOUCH MONITOR SYSTEM KIT W/DEVICE NF (blood glucose monitoring suppl) CARETOUCH PEN NEEDLES 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM , 32G X 5 MM (insulin NF pen needle) CARETOUCH SAFETY LANCETS (lancets) NPB CARETOUCH SAFETY LANCETS 26G (lancets) NPB CARETOUCH TEST IN VITRO STRIP (glucose blood) NF CARETOUCH TWIST LANCETS 28G (lancets) NPB CARETOUCH TWIST LANCETS 30G (lancets) NPB CARETOUCH TWIST LANCETS 33G (lancets) NPB CEQUR SIMPLICITY INSERTER (injection device for NPB insulin) CHEMSTRIP K IN VITRO STRIP (acetone (urine) test) NPB CHEMSTRIP UGK IN VITRO STRIP (urine glucose-ketones NPB test) CLEANLET LANCETS 28G (lancets) NPB CLEVER CHEK AUTO-CODE SYSTEM DEVICE (blood NF glucose monitoring suppl) CLEVER CHEK AUTO-CODE TEST IN VITRO STRIP NF (glucose blood) CLEVER CHEK AUTO-CODE VOICE DEVICE (blood NF glucose monitoring suppl) CLEVER CHEK AUTO-CODE VOICE IN VITRO STRIP NF (glucose blood) CLEVER CHEK LANCETS (lancets) NPB CLEVER CHEK SYSTEM KIT W/DEVICE (blood glucose NF monitoring suppl) CLEVER CHEK TEST IN VITRO STRIP (glucose blood) NF CLEVER CHOICE AUTO-CODE SYSTEM DEVICE NF (blood glucose monitoring suppl) CLEVER CHOICE AUTO-CODE TEST IN VITRO STRIP NF (glucose blood) CLEVER CHOICE COMFORT EZ 29G X 12MM , 33G X 4 NF MM (insulin pen needle)

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 150 Prescription Drug Name Drug Tier Drug Notes CLEVER CHOICE LANCETS 21G (lancets) NPB CLEVER CHOICE LANCETS 23G (lancets) NPB CLEVER CHOICE LANCETS 28G (lancets) NPB CLEVER CHOICE MICRO SYSTEM KIT W/DEVICE NF (blood glucose monitoring suppl) CLEVER CHOICE MICRO TEST IN VITRO STRIP NF (glucose blood) CLEVER CHOICE MINI SYSTEM DEVICE (blood glucose NF monitoring suppl) CLEVER CHOICE NO CODING IN VITRO STRIP NF (glucose blood) CLEVER CHOICE TALK SYSTEM DEVICE (blood glucose NF monitoring suppl) CLEVER CHOICE TALK SYSTEM IN VITRO STRIP NF (glucose blood) CLICKFINE PEN NEEDLES 31G X 5 MM (insulin pen NF needle) clickfine pen needles 31g x 6 mm , 31g x 8 mm , 32g x 4 mm NF COAGUCHEK LANCETS (lancets) NPB COMFORT ASSIST INSULIN SYRINGE 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" NF 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe-needle u-100) comfort assured lancets 28g NPB comfort assured lancets 33g NPB COMFORT EZ INSULIN SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, NF 30G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe-needle u-100) COMFORT EZ MICRO PEN NEEDLES 32G X 4 MM NF (insulin pen needle) COMFORT EZ PEN NEEDLES 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM , 32G X 5 MM , 32G X 6 NF MM , 32G X 8 MM , 33G X 4 MM , 33G X 5 MM , 33G X 6 MM , 33G X 8 MM (insulin pen needle) COMFORT EZ SHORT PEN NEEDLES 31G X 8 MM NF (insulin pen needle) 2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 151 Prescription Drug Name Drug Tier Drug Notes comfort lancets NPB CONTOUR MONITOR DEVICE (blood glucose monitoring NF suppl) CONTOUR NEXT EZ KIT W/DEVICE (blood glucose NF monitoring suppl) CONTOUR NEXT LINK KIT W/DEVICE (blood glucose NF monitoring suppl) CONTOUR NEXT MONITOR KIT W/DEVICE (blood NF glucose monitoring suppl) CONTOUR NEXT ONE KIT (blood glucose monitoring NF suppl) CONTOUR NEXT TEST IN VITRO STRIP (glucose blood) NF CONTOUR TEST IN VITRO STRIP (glucose blood) NF COOL BLOOD GLUCOSE TEST STRIPS IN VITRO NF STRIP (glucose blood) COOL MONITOR DEVICE (blood glucose monitoring suppl) NF COOL MONITOR KIT KIT W/DEVICE (blood glucose NF monitoring suppl) CURITY ALCOHOL PREPS PAD 70 % (alcohol swabs) NPB CURITY ALCOHOL SWABS PAD (alcohol swabs) NPB CVS ADVANCED GLUCOSE TEST IN VITRO STRIP NF (glucose blood) CVS BLOOD GLUCOSE METER KIT W/DEVICE (blood NF glucose monitoring suppl) cvs glucose meter test strips in vitro strip NF CVS KETONE CARE IN VITRO STRIP (urine glucose- NPB ketones test) cvs lancets 21g NPB cvs lancets micro thin 33g NPB cvs lancets original NPB cvs lancets thin 26g NPB cvs lancets ultra thin 30g NPB cvs lancets ultra-thin 30g NPB cvs lancing device NPB cvs prep pad 70 % NPB cvs ultra thin lancets NPB

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 152 Prescription Drug Name Drug Tier Drug Notes D-CARE BLOOD GLUCOSE IN VITRO STRIP (glucose NF blood) D-CARE GLUCOMETER KIT W/DEVICE (blood glucose NF monitoring suppl) DEXCOM G4 PLAT PED RCV/SHARE DEVICE PB (continuous blood gluc receiver) DEXCOM G4 PLAT PED RECEIVER DEVICE (continuous PB blood gluc receiver) DEXCOM G4 PLATINUM RCV/SHARE DEVICE PB (continuous blood gluc receiver) DEXCOM G4 PLATINUM RECEIVER DEVICE PB (continuous blood gluc receiver) DEXCOM G4 PLATINUM TRANSMITTER (continuous PB blood gluc transmit) DEXCOM G4 SENSOR (continuous blood gluc sensor) PB DEXCOM G5 MOB/G4 PLAT SENSOR (continuous blood PB gluc sensor) DEXCOM G5 MOBILE RECEIVER DEVICE (continuous PB blood gluc receiver) DEXCOM G5 MOBILE TRANSMITTER (continuous blood PB gluc transmit) DEXCOM G5 RECEIVER KIT DEVICE (continuous blood PB gluc receiver) DEXCOM G6 RECEIVER DEVICE (continuous blood gluc PB receiver) DEXCOM G6 SENSOR (continuous blood gluc sensor) PB DEXCOM G6 TRANSMITTER (continuous blood gluc PB transmit) DIASTIX IN VITRO STRIP (glucose urine test-glucose ox) NPB DIATHRIVE BLOOD GLUCOSE METER DEVICE (blood NF glucose monitoring suppl) DIATHRIVE BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) DIATHRIVE GLUCOSE TEST IN VITRO STRIP (glucose NF blood) DIATHRIVE LANCET ULTRA THIN 30 (lancets) NPB DIATHRIVE LANCETS (lancets) NPB DIATHRIVE LANCING DEVICE (lancet devices) NPB

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 153 Prescription Drug Name Drug Tier Drug Notes DIATHRIVE PEN NEEDLE 31G X 5 MM , 31G X 6 MM , NF 31G X 8 MM , 32G X 4 MM (insulin pen needle) DIATHRIVE+ GLUCOSE MONITOR DEVICE (blood NF glucose monitoring suppl) DIATHRIVE+ GLUCOSE TEST IN VITRO STRIP (glucose NF blood) diatrue plus blood glucose device NF diatrue plus test in vitro strip NF DROPLET INSULIN SYRINGE 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 15/64" 0.3 ML, 31G NF X 15/64" 0.5 ML, 31G X 15/64" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe-needle u-100) DROPLET LANCETS ULTRA THIN 30G (lancets) NPB DROPLET LANCING DEVICE (lancet devices) NPB DROPLET MICRON 34G X 3.5 MM (insulin pen needle) NF DROPLET PEN NEEDLES 29G X 10MM , 29G X 12MM , 30G X 8 MM , 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , NF 32G X 4 MM , 32G X 5 MM , 32G X 6 MM , 32G X 8 MM (insulin pen needle) DROPLET PERSONAL LANCETS 30G (lancets) NPB dropsafe safety pen needles 31g x 6 mm , 31g x 8 mm NF drug mart lancets thin 26g NPB DRUG MART ON-THE-GO LANCET 30G (lancets) NPB drug mart unifine pentips 29g x 12mm , 31g x 5 mm , 31g x 6 NF mm , 31g x 8 mm , 32g x 4 mm drug mart unifine pentips plus 32g x 4 mm NF DUO-CARE TEST IN VITRO STRIP (glucose blood) NF d-xylose powder NPB easy comfort alcohol pads pad NPB easy comfort insulin syringe 30g x 1/2" 0.5 ml, 30g x 1/2" 1 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.5 ml, 31g x NF 5/16" 1 ml, 32g x 5/16" 0.5 ml, 32g x 5/16" 1 ml easy comfort lancets NPB easy comfort lancets twist top NPB

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 154 Prescription Drug Name Drug Tier Drug Notes easy comfort pen needles 31g x 5 mm , 31g x 6 mm , 31g x 8 mm NF , 32g x 4 mm , 33g x 4 mm , 33g x 5 mm , 33g x 6 mm easy glide pen needles 33g x 4 mm NF easy mini eject lancing device NPB easy mini lancing device NPB easy plus ii glucose system device NF easy plus ii glucose test in vitro strip NF EASY STEP GLUCOSE MONITOR DEVICE (blood glucose NF monitoring suppl) EASY STEP TEST IN VITRO STRIP (glucose blood) NF easy talk blood glucose system device NF easy talk blood glucose test in vitro strip NF EASY TOUCH ALCOHOL PREP MEDIUM PAD 70 % NPB (alcohol swabs) EASY TOUCH FLIPLOCK INSULIN SY 29G X 1/2" 1 ML, 30G X 1/2" 1 ML, 30G X 5/16" 1 ML, 31G X 5/16" 1 ML NF (insulin syringe-needle u-100) EASY TOUCH GLUCOSE SYSTEM KIT W/DEVICE NF (blood glucose monitoring suppl) EASY TOUCH INSULIN SAFETY SYR 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 1 ML, 30G X 5/16" 0.5 NF ML (insulin syringe-needle u-100) EASY TOUCH INSULIN SYRINGE 27G X 1/2" 0.5 ML, 27G X 1/2" 1 ML, 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X NF 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe-needle u- 100) EASY TOUCH LANCETS 21G (lancets) NPB EASY TOUCH LANCETS 23G (lancets) NPB EASY TOUCH LANCETS 28G (lancets) NPB EASY TOUCH LANCETS 30G (lancets) NPB EASY TOUCH LANCETS 32G (lancets) NPB EASY TOUCH LANCING DEVICE (lancet devices) NPB EASY TOUCH PEN NEEDLES 29G X 12MM , 30G X 8 MM , 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 NF MM , 32G X 5 MM , 32G X 6 MM (insulin pen needle)

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 155 Prescription Drug Name Drug Tier Drug Notes EASY TOUCH SAFETY PEN NEEDLES 29G X 5MM , NF 29G X 8MM , 30G X 8 MM (insulin pen needle) EASY TOUCH SHEATHLOCK SYRINGE 29G X 1/2" 1 ML, 30G X 1/2" 1 ML, 30G X 5/16" 1 ML, 31G X 5/16" 1 ML NF (insulin syringe-needle u-100) EASY TOUCH TEST IN VITRO STRIP (glucose blood) NF easy trak blood glucose system device NF easy trak blood glucose test in vitro strip NF easy trak ii blood glucose sys device NF easy trak ii glucose test in vitro strip NF EASYGLUCO IN VITRO STRIP (glucose blood) NF EASYGLUCO KIT (blood glucose monitoring suppl) NF EASYMAX 15 TEST IN VITRO STRIP (glucose blood) NF EASYMAX NG BLOOD GLUCOSE DEVICE (blood NF glucose monitoring suppl) EASYMAX NG BLOOD GLUCOSE KIT W/DEVICE NF (blood glucose monitoring suppl) EASYMAX TEST IN VITRO STRIP (glucose blood) NF EASYMAX V BLOOD GLUCOSE DEVICE (blood glucose NF monitoring suppl) EASYMAX V BLOOD GLUCOSE KIT W/DEVICE (blood NF glucose monitoring suppl) EASYPRO BLOOD GLUCOSE MONITOR KIT NF W/DEVICE (blood glucose monitoring suppl) EASYPRO BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) EASYPRO PLUS IN VITRO STRIP (glucose blood) NF EASYPRO PLUS KIT W/DEVICE (blood glucose monitoring NF suppl) ELEMENT AUTOCODE SYSTEM KIT W/DEVICE (blood NF glucose monitoring suppl) element compact glucose system device NF element compact test in vitro strip NF element compact v glucose sys device NF ELEMENT PLUS DEVICE (blood glucose monitoring suppl) NF ELEMENT TEST IN VITRO STRIP (glucose blood) NF

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 156 Prescription Drug Name Drug Tier Drug Notes EMBRACE BLOOD GLUCOSE MONITOR DEVICE NF (blood glucose monitoring suppl) EMBRACE BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) EMBRACE EVO BLOOD GLUCOSE TEST IN VITRO NF STRIP (glucose blood) EMBRACE EVO GLUCOSE MONITORING KIT NF W/DEVICE (blood glucose monitoring suppl) EMBRACE LANCETS ULTRA THIN 30G (lancets) NPB EMBRACE PRO GLUCOSE METER DEVICE (blood NF glucose monitoring suppl) EMBRACE PRO GLUCOSE TEST IN VITRO STRIP NF (glucose blood) EMBRACE TALK BLOOD GLUCOSE DEVICE (blood NF glucose monitoring suppl) EMBRACE TALK GLUCOSE TEST IN VITRO STRIP NF (glucose blood) EMBRACE TALK MONITORING SYSTEM KIT NF W/DEVICE (blood glucose monitoring suppl) ENLITE GLUCOSE SENSOR (continuous blood gluc sensor) NF ENLITE SERTER (insulin infusion pump supplies) NPB eq blood glucose test in vitro strip NF eql alcohol swabs pad 70 % NPB eql color lancets 21g NPB eql color lancets micro 33g NPB eql insulin syringe 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 NF ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml eql super thin lancets 30g NPB eql thin lancets 26g NPB EVERSENSE SENSOR/HOLDER (continuous blood gluc NF sensor) EVERSENSE SMART TRANSMITTER (continuous blood NF gluc transmit) EVOLUTION AUTOCODE DEVICE (blood glucose NF monitoring suppl) EVOLUTION AUTOCODE IN VITRO STRIP (glucose NF blood)

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 157 Prescription Drug Name Drug Tier Drug Notes EXACTECH R-S-G TEST IN VITRO STRIP (glucose blood) NF EXACTECH TEST IN VITRO STRIP (glucose blood) NF EXEL COMFORT POINT INSULIN SYR 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 NF ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML (insulin syringe-needle u-100) EXEL COMFORT POINT PEN NEEDLE 29G X 12MM , 31G X 4 MM , 31G X 6 MM , 31G X 8 MM (insulin pen NF needle) E-Z JECT LANCET MICRO-THIN 33G (lancets) NPB E-Z JECT LANCET SUPER THIN 30G (lancets) NPB E-Z JECT LANCETS (lancets) NPB E-Z JECT LANCETS 21G (lancets) NPB E-Z JECT LANCETS THIN 26G (lancets) NPB EZ-LETS LANCETS 21G (lancets) NPB EZ-LETS LANCETS 26G (lancets) NPB EZ-LETS LANCETS 28G (lancets) NPB EZ-LETS LANCETS 30G (lancets) NPB FIFTY50 GLUCOSE METER 2.0 KIT W/DEVICE (blood NF glucose monitoring suppl) FIFTY50 GLUCOSE TEST 2.0 IN VITRO STRIP (glucose NF blood) FIFTY50 PEN NEEDLES 31G X 5 MM , 31G X 8 MM , NF 32G X 4 MM , 32G X 6 MM (insulin pen needle) FIFTY50 SUPERIOR COMFORT SYR 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe- NF needle u-100) FIFTY50 UNILET LANCETS 33G (lancets) NPB FINGERSTIX LANCETS (lancets) NPB FORA 6 CONNECT IN VITRO STRIP (glucose blood) NF FORA BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) FORA D15G BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) FORA D20 BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) FORA D40 GLUCOSE/PRESSURE DEVICE (blood NF glucose-bp monitor)

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 158 Prescription Drug Name Drug Tier Drug Notes FORA D40/G31 BLOOD GLUCOSE IN VITRO STRIP NF (glucose blood) FORA D40G GLUCOSE/PRESSURE DEVICE (blood NF glucose-bp monitor) FORA G20 BLOOD GLUCOSE SYSTEM KIT W/DEVICE NF (blood glucose monitoring suppl) FORA G20 BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) FORA G30/PREM V10 GLUCOSE TEST IN VITRO STRIP NF (glucose blood) FORA G30A BLOOD GLUCOSE SYSTEM DEVICE (blood NF glucose monitoring suppl) FORA GD20 BLOOD GLUCOSE SYSTEM DEVICE (blood NF glucose monitoring suppl) FORA GD20 TEST IN VITRO STRIP (glucose blood) NF FORA GD50 BLOOD GLUCOSE SYSTEM DEVICE (blood NF glucose monitoring suppl) FORA GD50 BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) FORA GTEL BLOOD GLUCOSE SYSTEM DEVICE NF (blood glucose monitoring suppl) FORA GTEL BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) FORA GTEL BLOOD KETONE TEST IN VITRO STRIP NPB (ketone blood test) FORA LANCETS (lancets) NPB FORA LANCING DEVICE (lancet devices) NPB FORA PREMIUM V10 BLE SYSTEM DEVICE (blood NF glucose monitoring suppl) FORA TEST N' GO MONITOR DEVICE (blood glucose NF monitoring suppl) FORA TN'G VOICE KIT W/DEVICE (blood glucose NF monitoring suppl) FORA TN'G/TN'G VOICE IN VITRO STRIP (glucose NF blood) FORA V10 BLOOD GLUCOSE SYSTEM DEVICE (blood NF glucose monitoring suppl) FORA V10 BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) 2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 159 Prescription Drug Name Drug Tier Drug Notes FORA V12 BLOOD GLUCOSE SYSTEM DEVICE (blood NF glucose monitoring suppl) FORA V12 BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) FORA V20 BLOOD GLUCOSE SYSTEM DEVICE (blood NF glucose monitoring suppl) FORA V20 BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) FORA V30A BLOOD GLUCOSE SYSTEM DEVICE (blood NF glucose monitoring suppl) FORA V30A BLOOD GLUCOSE SYSTEM KIT NF W/DEVICE (blood glucose monitoring suppl) FORA V30A BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) FORACARE GD40 MONITOR DEVICE (blood glucose NF monitoring suppl) FORACARE GD40 TEST IN VITRO STRIP (glucose blood) NF FORACARE PREMIUM V10 DEVICE (blood glucose NF monitoring suppl) FORACARE PREMIUM V10 TEST IN VITRO STRIP NF (glucose blood) FORACARE TEST N GO MONITOR DEVICE (blood NF glucose monitoring suppl) FORACARE TEST N GO TEST IN VITRO STRIP (glucose NF blood) FORTISCARE G1 TEST STRIP IN VITRO STRIP (glucose NF blood) FORTISCARE GLUCOSE SYSTEM DEVICE (blood NF glucose monitoring suppl) FORTISCARE GLUCOSE SYSTEM KIT W/DEVICE NF (blood glucose monitoring suppl) FORTISCARE T1 GLUCOSE SYSTEM DEVICE (blood NF glucose monitoring suppl) FORTISCARE TEST IN VITRO STRIP (glucose blood) NF freds pharmacy autolet lancing NPB freds pharmacy unifine pentip+ 31g x 5 mm , 31g x 8 mm NF freds pharmacy unifine pentips 32g x 4 mm NF FREESTYLE FREEDOM KIT (blood glucose monitoring NF suppl) 2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 160 Prescription Drug Name Drug Tier Drug Notes FREESTYLE FREEDOM LITE KIT W/DEVICE (blood NF glucose monitoring suppl) FREESTYLE INSULINX SYSTEM KIT W/DEVICE (blood NF glucose monitoring suppl) FREESTYLE INSULINX TEST IN VITRO STRIP (glucose NF blood) FREESTYLE LIBRE 14 DAY READER DEVICE NF (continuous blood gluc receiver) FREESTYLE LIBRE 14 DAY SENSOR (continuous blood NF gluc sensor) FREESTYLE LIBRE 2 READER DEVICE (continuous NF blood gluc receiver) FREESTYLE LIBRE 2 SENSOR (continuous blood gluc NF sensor) FREESTYLE LIBRE READER DEVICE (continuous blood NF gluc receiver) FREESTYLE LIBRE SENSOR SYSTEM (continuous blood NF gluc sensor) FREESTYLE LITE DEVICE (blood glucose monitoring suppl) NF FREESTYLE LITE TEST IN VITRO STRIP (glucose blood) NF FREESTYLE PRECISION INS SYR 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML NF (insulin syringe-needle u-100) FREESTYLE PRECISION NEO SYSTEM KIT W/DEVICE NF (blood glucose monitoring suppl) FREESTYLE PRECISION NEO TEST IN VITRO STRIP NF (glucose blood) FREESTYLE SIDEKICK II KIT (blood glucose monitoring NF suppl) FREESTYLE TEST IN VITRO STRIP (glucose blood) NF FREESTYLE UNISTICK II LANCETS (lancets) NPB ge100 blood glucose system device NF ge100 blood glucose system kit w/device NF ge100 blood glucose test in vitro strip NF GENTEEL BUTTERFLY TOUCH LANCET (lancets) NPB GENTEEL CONTACT TIPS (BLUE) (lancets misc.) NPB GENTEEL CONTACT TIPS (CLEAR) (lancets misc.) NPB GENTEEL CONTACT TIPS (GREEN) (lancets misc.) NPB

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 161 Prescription Drug Name Drug Tier Drug Notes GENTEEL CONTACT TIPS (ORANGE) (lancets misc.) NPB GENTEEL CONTACT TIPS (RAINBOW) (lancets misc.) NPB GENTEEL CONTACT TIPS (VIOLET) (lancets misc.) NPB GENTEEL CONTACT TIPS (YELLOW) (lancets misc.) NPB GENTEEL LANCING KIT (BLUE) KIT (lancets misc.) NPB GENTEEL NOZZLES (lancets misc.) NPB GENTEEL PLUS LANCING (BLACK) (lancet devices) NPB GENTEEL PLUS LANCING (PURPLE) (lancet devices) NPB GENTEEL PLUS LANCING (WHITE) (lancet devices) NPB GENTEEL PLUS LANCING DEV(BLUE) (lancet devices) NPB GENTEEL PLUS LANCING DEV(PINK) (lancet devices) NPB GENTLE-LET GP LANCETS (lancets) NPB GENTLE-LET LANCETS (lancets) NPB GENTLE-LET PLATFORMS (lancets misc.) NPB GENULTIMATE TEST IN VITRO STRIP (glucose blood) NPB ght blood glucose monitor kit w/device NF ght test in vitro strip NF GLEOLAN ORAL SOLUTION RECONSTITUTED 1.5 NPB GM (aminolevulinic acid hcl) global alcohol prep ease pad 70 % NPB global ease inject pen needles 29g x 12mm , 31g x 5 mm , 31g x NF 8 mm , 32g x 4 mm global easy glide insulin syr 31g x 15/64" 0.3 ml, 31g x 15/64" NF 0.5 ml, 31g x 15/64" 1 ml, 31g x 5/16" 0.3 ml global easy glide pen needles 32g x 4 mm NF global inject ease insulin syr 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 1/2" 0.3 ml, 30g x 1/2" 0.5 ml, 30g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, NF 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml global inject ease lancets 28g NPB global inject ease lancets 30g NPB global insulin syringes 30g x 1/2" 0.3 ml, 30g x 5/16" 0.3 ml NF global lancing device NPB GLUCO PERFECT 3 METER DEVICE (blood glucose NF monitoring suppl)

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 162 Prescription Drug Name Drug Tier Drug Notes GLUCO PERFECT 3 TEST IN VITRO STRIP (glucose NF blood) GLUCOCARD 01 BLOOD GLUCOSE DEVICE (blood NF glucose monitoring suppl) GLUCOCARD 01 BLOOD GLUCOSE KIT W/DEVICE NF (blood glucose monitoring suppl) GLUCOCARD 01 SENSOR PLUS IN VITRO STRIP NF (glucose blood) GLUCOCARD 01-MINI GLUCOSE KIT W/DEVICE NF (blood glucose monitoring suppl) GLUCOCARD EXPRESSION MONITOR KIT NF W/DEVICE (blood glucose monitoring suppl) GLUCOCARD EXPRESSION TEST IN VITRO STRIP NF (glucose blood) GLUCOCARD SHINE CONNEX KIT W/DEVICE (blood NF glucose monitoring suppl) GLUCOCARD SHINE EXPRESS KIT W/DEVICE (blood NF glucose monitoring suppl) GLUCOCARD SHINE TEST IN VITRO STRIP (glucose NPB blood) GLUCOCARD SHINE XL DEVICE (blood glucose NF monitoring suppl) GLUCOCARD VITAL MONITOR KIT W/DEVICE (blood NF glucose monitoring suppl) GLUCOCARD VITAL TEST IN VITRO STRIP (glucose NF blood) GLUCOCARD X-METER KIT W/DEVICE (blood glucose NF monitoring suppl) GLUCOCARD X-SENSOR IN VITRO STRIP (glucose NF blood) GLUCOCOM BLOOD GLUCOSE MONITOR DEVICE NF (blood glucose monitoring suppl) GLUCOCOM LANCETS 28G (lancets) NPB GLUCOCOM LANCETS 30G (lancets) NPB GLUCOCOM LANCETS 33G (lancets) NPB GLUCOCOM MONITOR KIT W/DEVICE (blood glucose NF monitoring suppl) GLUCOCOM TEST IN VITRO STRIP (glucose blood) NF

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 163 Prescription Drug Name Drug Tier Drug Notes GLUCONAVII BLOOD GLUCOSE SYS KIT W/DEVICE NF (blood glucose monitoring suppl) GLUCONAVII BLOOD GLUCOSE TEST IN VITRO NF STRIP (glucose blood) GLUCOPRO INSULIN SYRINGE 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, NF 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe-needle u-100) GLUCOPRO SYR RES 3ML 22GX3/8" (insulin infusion NPB pump supplies) glucose meter test in vitro strip NF gnp alcohol swabs pad 70 % NPB gnp clickfine pen needles 31g x 6 mm , 31g x 8 mm NF GNP EASY TOUCH GLUCOSE METER DEVICE (blood NF glucose monitoring suppl) gnp easy touch glucose test in vitro strip NF gnp insulin syringe 28g x 1/2" 0.5 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 NF ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml gnp lancets 21g NPB gnp lancets micro thin 33g NPB gnp lancets thin NPB gnp lancets thin 26g NPB gnp ulticare pen needles 31g x 5 mm , 31g x 8 mm , 32g x 4 mm , NF 32g x 6 mm gnp ultra com insulin syringe 28g x 1/2" 1 ml NF GOJJI BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) GOJJI BLOOD TEST STRIP/LANCETS IN VITRO STRIP NF (glucose blood) GOJJI STERILE LANCETS (lancets) NPB goodsense blood glucose in vitro strip NF goodsense blood glucose kit w/device NF goodsense clickfine pen needle 31g x 5 mm NF goodsense lancets 26g univ NPB goodsense lancets 30g univ NPB

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 164 Prescription Drug Name Drug Tier Drug Notes goodsense lancets 33g univ NPB goodsense lancing device NPB GOODSENSE PEN NEEDLE PENFINE 31G X 5 MM , 31G X 8 MM , 32G X 4 MM , 32G X 6 MM (insulin pen NF needle) GUARDIAN CONNECT TRANSMITTER (continuous NF blood gluc transmit) GUARDIAN LINK 3 TRANSMITTER (continuous blood NF gluc transmit) GUARDIAN REAL-TIME CHARGER (continuous glucose NPB monitor sup) GUARDIAN REAL-TIME TEST PLUG (continuous glucose NPB monitor sup) GUARDIAN SENSOR (3) (continuous blood gluc sensor) NF guardian sensor 3 NF HEALTH CARE LANCING DEVICE (lancet devices) NPB healthwise insulin syr/needle 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g NF x 5/16" 1 ml healthwise micron pen needles 32g x 4 mm NF healthwise mini pen needles 31g x 6 mm NF healthwise pen needles 29g x 12mm NF healthwise short pen needles 31g x 5 mm , 31g x 8 mm NF healthwise unifine pentips 32g x 4 mm NF healthy accents lancing device NPB healthy accents unifine pentip 29g x 12mm , 31g x 5 mm , 31g x NF 6 mm , 31g x 8 mm , 32g x 4 mm healthy accents unilet lancets NPB h-e-b incontrol adv lancing NPB h-e-b incontrol alcohol pad NPB h-e-b incontrol lancets 28g NPB h-e-b incontrol lancets 30g NPB h-e-b incontrol lancets 33g NPB h-e-b incontrol pen needles 29g x 12mm , 31g x 5 mm , 31g x 6 NF mm , 31g x 8 mm , 32g x 4 mm H-E-B INCONTROL UNIFINE PENTIP 32G X 4 MM NF (insulin pen needle)

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 165 Prescription Drug Name Drug Tier Drug Notes HM EMBRACE TALK SYSTEM KIT W/DEVICE (blood NF glucose monitoring suppl) hm sterile alcohol prep pad NPB HM ULTICARE INSULIN SYRINGE 30G X 1/2" 1 ML, NF 31G X 5/16" 0.3 ML (insulin syringe-needle u-100) HM ULTICARE SHORT PEN NEEDLES 31G X 8 MM NF (insulin pen needle) HW EMBRACE PRO GLUCOSE METER DEVICE (blood NF glucose monitoring suppl) HW EMBRACE PRO GLUCOSE TEST IN VITRO STRIP NF (glucose blood) HW EMBRACE TALK BLOOD GLUCOSE DEVICE NF (blood glucose monitoring suppl) HW EMBRACE TALK GLUCOSE TEST IN VITRO NF STRIP (glucose blood) HY-VEE LANCETS (lancets) NPB hy-vee thin lancets NPB IGLUCOSE MONITORING SYSTEM KIT W/DEVICE NF (blood glucose monitoring suppl) IGLUCOSE TEST STRIPS IN VITRO STRIP (glucose NF blood) IN TOUCH BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) IN TOUCH DEVICE (blood glucose monitoring suppl) NF IN TOUCH LANCING DEVICE (lancet devices) NPB IN TOUCH STERILE LANCETS 30G (lancets) NPB INFINITY BLOOD GLUCOSE SYSTEM KIT W/DEVICE NF (blood glucose monitoring suppl) INFINITY BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) INFINITY VOICE IN VITRO STRIP (glucose blood) NF INFINITY VOICE KIT W/DEVICE (blood glucose NF monitoring suppl) INPEN 100-BLUE-LILLY DEVICE (injection device for NPB insulin) INPEN 100-BLUE-NOVO DEVICE (injection device for NPB insulin)

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 166 Prescription Drug Name Drug Tier Drug Notes INPEN 100-GRAY-LILLY DEVICE (injection device for NPB insulin) INPEN 100-GREY-NOVO DEVICE (injection device for NPB insulin) INPEN 100-PINK-LILLY DEVICE (injection device for NPB insulin) INPEN 100-PINK-NOVO DEVICE (injection device for NPB insulin) insulin syringe 27g x 1/2" 0.5 ml, 27g x 1/2" 1 ml, 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 NF ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml insulin syringe/needle 27g x 1/2" 0.5 ml, 28g x 1/2" 0.5 ml, 28g x NF 1/2" 1 ml insulin syringe-needle u-100 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x NF 1/4" 0.3 ml, 31g x 1/4" 0.5 ml, 31g x 1/4" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml insupen pen needles 29g x 12mm , 31g x 5 mm , 31g x 8 mm , NF 32g x 4 mm , 33g x 4 mm INSUPEN SENSITIVE 32G X 6 MM , 32G X 8 MM (insulin NF pen needle) INSUPEN ULTRAFIN 30G X 8 MM , 31G X 6 MM , 31G NF X 8 MM (insulin pen needle) KETO-DIASTIX IN VITRO STRIP (urine glucose-ketones NPB test) ketone test in vitro strip NPB KETOSTIX IN VITRO STRIP (acetone (urine) test) NPB kinney lancets NPB kinney thin lancets NPB kinray insulin syringe 29g x 1/2" 0.5 ml, 31g x 5/16" 0.3 ml, 31g NF x 5/16" 0.5 ml, 31g x 5/16" 1 ml kmart valu insulin syringe 29g u-100 0.5 ml, u-100 1 ml NF kmart valu insulin syringe 30g u-100 0.3 ml, u-100 0.5 ml, u-100 NF 1 ml kroger blood glucose kit , w/device NF kroger blood glucose test in vitro strip NF

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 167 Prescription Drug Name Drug Tier Drug Notes KROGER HEALTHPRO GLUCOSE TEST IN VITRO NF STRIP (glucose blood) kroger insulin syringe 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 NF ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml kroger lancets NPB kroger lancets super thin NPB kroger lancets thin NPB kroger pen needles 29g x 12mm , 31g x 5 mm , 31g x 6 mm , 31g NF x 8 mm , 32g x 4 mm , 33g x 4 mm kroger premium blood glucose kit w/device NF kroger premium glucose test in vitro strip NF kroger test in vitro strip NF lancet device NPB lancet device with ejector NPB lancet transporter case NPB lancets NPB lancets 30g NPB lancets 33g NPB lancets micro thin 33g NPB lancets thin NPB lancets ultra thin 30g NPB lancing device NPB LANZO (lancet devices) NPB ldr blood glucose truetest kit w/device NF leader insulin syringe 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.3 NF ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml LEADER UNIFINE PENTIPS 31G X 5 MM , 32G X 4 MM NF (insulin pen needle) LEADER UNIFINE PENTIPS PLUS 31G X 5 MM , 31G X NF 8 MM , 32G X 4 MM (insulin pen needle) liberty blood glucose meter device NF LIBERTY NEXT GENERATION TEST IN VITRO STRIP NF (glucose blood)

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 168 Prescription Drug Name Drug Tier Drug Notes LIBERTY NXT GENERATION MONITOR DEVICE NF (blood glucose monitoring suppl) liberty test in vitro strip NF LIFESCAN UNISTIK 2 (lancets) NPB LIFESCAN UNISTIK II LANCETS (lancets) NPB lite touch lancets NPB LITE TOUCH LANCING PEN (lancet devices) NPB LITETOUCH INSULIN SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, NF 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe-needle u-100) LITETOUCH LANCETS (lancets) NPB LITETOUCH PEN NEEDLES 29G X 12.7MM , 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM (insulin NF pen needle) live better adv lancing device NPB live better lancet ultra thin NPB longs insulin syringe 31g x 5/16" 0.5 ml NF longs lancets standard NPB longs lancets thin NPB longs lancets ultra thin NPB MAGELLAN INSULIN SAFETY SYR 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, NF 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML (insulin syringe-needle u-100) MARATHON MEDICAL PENTIPS 29G X 12MM , 31G X NF 5 MM , 31G X 8 MM , 32G X 4 MM (insulin pen needle) MAXICOMFORT II PEN NEEDLE 31G X 6 MM (insulin NF pen needle) MAXI-COMFORT INSULIN SYRINGE 28G X 1/2" 0.5 NF ML, 28G X 1/2" 1 ML (insulin syringe-needle u-100) MAXI-COMFORT SAFETY PEN NEEDLE 29G X 5MM , NF 29G X 8MM (insulin pen needle) MAXICOMFORT SYR 27G X 1/2" 27G X 1/2" 0.5 ML, 27G NF X 1/2" 1 ML (insulin syringe-needle u-100) medic insulin syringe 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml NF medichoice safety lancet extra NPB

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 169 Prescription Drug Name Drug Tier Drug Notes medicine shoppe pen needles 29g x 12mm , 31g x 6 mm , 31g x 8 NF mm MEDISENSE THIN LANCETS (lancets) NPB MEDLANCE PLUS EXTRA 21G (lancets) NPB MEDLANCE PLUS LANCETS (lancets) NPB MEDLANCE PLUS LITE 25G (lancets) NPB MEDLANCE PLUS SPECIAL 0.8MM (lancets) NPB MEDLANCE PLUS SUPERLITE 30G (lancets) NPB MEDLANCE PLUS UNIVERSAL 21G (lancets) NPB meijer blood glucose kit w/device NF meijer blood glucose test in vitro strip NF meijer essential blood glucose kit w/device NF meijer essential glucose test in vitro strip NF MEIJER LANCETS THIN (lancets) NPB MEIJER LANCETS UNIVERSAL 21G (lancets) NPB MEIJER LANCETS UNIVERSAL 30G (lancets) NPB MEIJER LANCETS UNIVERSAL 33G (lancets) NPB meijer pen needles 29g x 12mm , 31g x 6 mm , 31g x 8 mm NF meijer premium blood glucose kit w/device NF meijer premium glucose test in vitro strip NF MEIJER SUPER THIN LANCETS (lancets) NPB MEIJER TRUE2GO BLOOD GLUCOSE KIT W/DEVICE NF (blood glucose monitoring suppl) MEIJER TRUERESULT GLUCOSE SYS KIT W/DEVICE NF (blood glucose monitoring suppl) MEIJER TRUETEST TEST IN VITRO STRIP (glucose NF blood) MEIJER TRUETRACK GLUCOSE SYS KIT W/DEVICE NF (blood glucose monitoring suppl) MEIJER TRUETRACK TEST IN VITRO STRIP (glucose NF blood) MICRODOT BLOOD GLUCOSE SYSTEM KIT NF W/DEVICE (blood glucose monitoring suppl) MICRODOT PEN NEEDLE 31G X 6 MM , 32G X 4 MM , NF 33G X 4 MM (insulin pen needle) MICRODOT TEST IN VITRO STRIP (glucose blood) NF

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 170 Prescription Drug Name Drug Tier Drug Notes MICROLET LANCETS (lancets) NPB MICROLET NEXT LANCING DEVICE (lancet devices) NPB mini lancing device NPB MINILINK REAL-TIME TRANSMITTER (continuous NF blood gluc transmit) MINIMED 630G GUARDIAN PRESS (continuous blood NF gluc transmit) MINIMED GUARDIAN LINK 3 (continuous blood gluc NF transmit) MINIMED PUMP RESERVOIR 3ML (insulin infusion pump NPB supplies) MINIMED RESERVOIR 1.8ML (insulin infusion pump NPB supplies) MINIMED RESERVOIR 3ML (insulin infusion pump NPB supplies) MIO INFUSION SET 18" 6MM (insulin infusion pump NPB supplies) MIO INFUSION SET 23" 6MM (insulin infusion pump NPB supplies) MIO INFUSION SET 32" 6MM (insulin infusion pump NPB supplies) MIO INFUSION SET 32" 9MM (insulin infusion pump NPB supplies) MM EASY TOUCH GLUCOSE IN VITRO STRIP (glucose NF blood) MM EASY TOUCH GLUCOSE METER KIT W/DEVICE NF (blood glucose monitoring suppl) mm insulin syringe/needle 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g NF x 5/16" 1 ml MM PEN NEEDLES 31G X 5 MM , 31G X 6 MM , 31G X 8 NF MM , 32G X 4 MM (insulin pen needle) MONOJECT INSULIN SYRINGE 25G X 5/8" 1 ML, 27G X 1/2" 1 ML, 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" NF 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 1 ML (insulin syringe-needle u-100) MONOJECT INSULIN SYRINGE U-100 1 ML (insulin NF syringes (disposable))

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 171 Prescription Drug Name Drug Tier Drug Notes MONOJECT ULTRA COMFORT SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" NF 0.5 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML (insulin syringe-needle u-100) MONOLET LANCETS (lancets) NPB MONOLET OPD LANCETS (lancets) NPB MONOLETTOR SAFETY LANCETS (lancets) NPB mpd safety lancet 21g NPB mpd safety lancet 23g NPB mpd safety lancet 28g NPB mpd safety lancet 30g NPB ms insulin syringe 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x NF 5/16" 1 ml MULTI-LANCET DEVICE 2 KIT (lancets misc.) NPB MYGLUCOHEALTH BLOOD GLUCOSE KIT NF W/DEVICE (blood glucose monitoring suppl) MYGLUCOHEALTH LANCETS 30G (lancets) NPB MYGLUCOHEALTH TEST IN VITRO STRIP (glucose NF blood) NEUTEK 2TEK TEST IN VITRO STRIP (glucose blood) NF NOVA MAX BLOOD GLUCOSE SYSTEM DEVICE (blood NF glucose monitoring suppl) NOVA MAX BLOOD GLUCOSE SYSTEM KIT NF W/DEVICE (blood glucose monitoring suppl) NOVA MAX GLUCOSE TEST IN VITRO STRIP (glucose NF blood) NOVA MAX PLUS KETONE TEST IN VITRO STRIP NPB (ketone blood test) NOVA SAFETY LANCETS 23G (lancets) NPB NOVA SAFETY LANCETS 28G (lancets) NPB NOVA SUREFLEX LANCETS (lancets) NPB NOVA SUREFLEX LANCING DEVICE (lancet devices) NPB NOVOFINE 32G X 6 MM (insulin pen needle) NF NOVOFINE AUTOCOVER 30G X 8 MM (insulin pen NF needle) NOVOFINE PLUS 32G X 4 MM (insulin pen needle) NF

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 172 Prescription Drug Name Drug Tier Drug Notes NOVOPEN ECHO DEVICE (injection device for insulin) NPB NOVOTWIST 32G X 5 MM (insulin pen needle) NF OMNIPOD 5 PACK (insulin disposable pump) PB OMNIPOD DASH 5 PACK PODS (insulin disposable pump) PB OMNIPOD STARTER KIT (insulin disposable pump) PB one drop blood glucose monitor kit w/device NF one drop test in vitro strip NF ONETOUCH CLUB LANCETS FINE PT (lancets) PB ONETOUCH DELICA LANCETS 30G (lancets) PB ONETOUCH DELICA LANCETS 33G (lancets) PB ONETOUCH DELICA LANCING DEV (lancet devices) PB ONETOUCH DELICA PLUS LANCET30G (lancets) PB ONETOUCH DELICA PLUS LANCET33G (lancets) PB ONETOUCH DELICA PLUS LANCING (lancet devices) PB ONETOUCH FINEPOINT LANCETS (lancets) PB ONETOUCH SURESOFT LANCING DEV (lancets misc.) PB ONETOUCH ULTRA IN VITRO STRIP (glucose blood) PB ONETOUCH ULTRALINK KIT W/DEVICE (blood glucose PB monitoring suppl) ONETOUCH ULTRASOFT LANCETS (lancets) PB ONETOUCH VERIO FLEX SYSTEM KIT W/DEVICE PB (blood glucose monitoring suppl) ONETOUCH VERIO IN VITRO STRIP (glucose blood) PB ONETOUCH VERIO KIT W/DEVICE (blood glucose PB monitoring suppl) ONETOUCH VERIO REFLECT KIT W/DEVICE (blood PB glucose monitoring suppl) ONETOUCH VERIO SYNC SYSTEM KIT W/DEVICE PB (blood glucose monitoring suppl) OPTIUM BLOOD GLUCOSE MONITOR KIT W/DEVICE NF (blood glucose monitoring suppl) OPTIUM GLUCOSE MONITOR SYSTEM DEVICE (blood NF glucose monitoring suppl) OPTIUM TEST IN VITRO STRIP (glucose blood) NF OPTIUMEZ TEST IN VITRO STRIP (glucose blood) NF

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 173 Prescription Drug Name Drug Tier Drug Notes PARADIGM PUMP RESERVOIR 1.8ML (insulin infusion NPB pump supplies) PARADIGM PUMP RESERVOIR 3ML (insulin infusion NPB pump supplies) PARADIGM REAL-TIME TRANSMITTER (continuous NF blood gluc transmit) PARADIGM SILHOUETTE COMBO 23" (insulin infusion NPB pump supplies) PARADIGM SURE-T 23" 6MM (insulin infusion pump NPB supplies) pc lancets super thin 30g NPB pc unifine pentips 29g x 12mm , 31g x 5 mm , 31g x 6 mm , 31g NF x 8 mm pen needles 1/2" 29g x 12mm NF pen needles 29g x 12mm , 30g x 5 mm , 30g x 8 mm , 31g x 5 mm , 31g x 6 mm , 31g x 8 mm , 32g x 4 mm , 32g x 5 mm , 32g NF x 6 mm , 33g x 4 mm pen needles 5/16" 31g x 8 mm NF PENLET II BLOOD SAMPLER KIT (lancets misc.) NPB PENLET II REPLACEMENT CAP (lancets misc.) NPB PENTIPS 29G X 12MM , 31G X 5 MM , 31G X 6 MM , 31G NF X 8 MM , 32G X 4 MM (insulin pen needle) PERFECT LANCETS 28G (lancets) NPB PERFECT LANCETS 30G (lancets) NPB ph strips in vitro diagnostic test NPB PHARMACIST CHOICE AUTOCODE IN VITRO STRIP NF (glucose blood) PHARMACIST CHOICE AUTOCODE SYS KIT NF W/DEVICE (blood glucose monitoring suppl) PHARMACIST CHOICE LANCETS (lancets) NPB PHARMACIST CHOICE MINI SYSTEM DEVICE (blood NF glucose monitoring suppl) pharmacist choice no coding in vitro strip NF PHARMACY COUNTER LANCETS (lancets) NPB pip lancets 28g NPB pip lancets 30g NPB POCKETCHEM EZ SYSTEM KIT W/DEVICE (blood NF glucose monitoring suppl) 2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 174 Prescription Drug Name Drug Tier Drug Notes POCKETCHEM EZ TEST IN VITRO STRIP (glucose blood) NF PRECISION LINK KIT (blood glucose monitoring suppl) NF PRECISION PCX IN VITRO STRIP (glucose blood) NF PRECISION PCX PLUS TEST IN VITRO STRIP (glucose NF blood) PRECISION POINT OF CARE TEST IN VITRO STRIP NF (glucose blood) PRECISION QID MONITOR DEVICE (blood glucose NF monitoring suppl) PRECISION QID TEST IN VITRO STRIP (glucose blood) NF PRECISION SOF-TACT MONITOR DEVICE (blood NF glucose monitoring suppl) PRECISION SOF-TACT TEST IN VITRO STRIP (glucose NF blood) PRECISION SUREDOSE PLUS SYR 29G X 1/2" 0.3 ML, NF 29G X 1/2" 1 ML (insulin syringe-needle u-100) PRECISION SURE-DOSE SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.5 ML, 30G X 3/8" 0.5 ML, NF 30G X 5/16" 0.3 ML (insulin syringe-needle u-100) PRECISION XTRA BLOOD GLUCOSE IN VITRO STRIP NF (glucose blood) PRECISION XTRA DEVICE (blood glucose monitoring NF suppl) PRECISION XTRA KETONE IN VITRO STRIP (ketone NPB blood test) PRECISION XTRA KIT , W/DEVICE (blood glucose NF monitoring suppl) PRECISION XTRA MONITOR DEVICE (blood glucose NF monitoring suppl) preferred plus insulin syringe 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x NF 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml preferred plus lancets colored NPB preferred plus lancets thin NPB preferred plus unifine pentips 29g x 12mm , 31g x 5 mm , 31g x NF 6 mm , 31g x 8 mm , 32g x 4 mm premium blood glucose test in vitro strip NF PREVENT SAFETY PEN NEEDLES 31G X 6 MM , 31G X NF 8 MM (insulin pen needle) 2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 175 Prescription Drug Name Drug Tier Drug Notes pro comfort alcohol pad 70 % NPB PRO COMFORT INSULIN SYRINGE 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, NF 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe-needle u-100) pro comfort lancets 30g NPB pro comfort lancets 31g NPB pro comfort pen needles 31g x 8 mm , 32g x 4 mm , 32g x 5 mm , NF 32g x 6 mm pro voice v8 glucose system device NF pro voice v8/v9 glucose in vitro strip NF pro voice v9 glucose system device NF PRODIGY AUTOCODE BLOOD GLUCOSE DEVICE NF (blood glucose monitoring suppl) PRODIGY AUTOCODE BLOOD GLUCOSE KIT NF W/DEVICE (blood glucose monitoring suppl) PRODIGY INSULIN SYRINGE 28G X 1/2" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML (insulin syringe-needle u- NF 100) PRODIGY LANCETS 28G (lancets) NPB PRODIGY LANCING DEVICE (lancet devices) NPB PRODIGY NO CODING BLOOD GLUC IN VITRO NF STRIP (glucose blood) PRODIGY POCKET BLOOD GLUCOSE KIT W/DEVICE NF (blood glucose monitoring suppl) PRODIGY SAFETY LANCETS 26G (lancets) NPB PRODIGY VOICE BLOOD GLUCOSE KIT W/DEVICE NF (blood glucose monitoring suppl) PSS SELECT GP LANCETS (lancets) NPB PSS SELECT PLATFORMS (lancets misc.) NPB PSS SELECT SAFETY LANCETS (lancets) NPB PTS PANELS GLUCOSE TEST IN VITRO STRIP (glucose NF blood) PTS PANELS KETONE TEST IN VITRO STRIP (ketone NPB blood test) px extra short pen needles 31g x 6 mm NF px insulin syringe 30g x 1/2" 0.5 ml NF px lancet auto injector NPB 2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 176 Prescription Drug Name Drug Tier Drug Notes px lancets microthin 33g NPB px lancets ultra thin NPB px mini pen needles 31g x 5 mm NF px pen needle 29g x 12mm , 31g x 8 mm NF px shortlength pen needles 31g x 8 mm NF qc advanced lancing device NPB qc alcohol swabs pad 70 % NPB qc lancets super thin 30g NPB qc lancets ultra thin NPB qc pen needles 29g x 12mm , 31g x 6 mm , 31g x 8 mm NF qc unifine pentips 32g x 4 mm NF qc unilet lancets 28g NPB qc unilet lancets micro thin NPB QUICKTEK KIT (blood glucose monitoring suppl) NF QUICKTEK TEST IN VITRO STRIP (glucose blood) NF QUICKTEK/METER KIT (blood glucose monitoring suppl) NF QUINTET AC BLOOD GLUCOSE DEVICE (blood glucose NF monitoring suppl) QUINTET AC BLOOD GLUCOSE TEST IN VITRO NF STRIP (glucose blood) QUINTET BLOOD GLUCOSE SYSTEM DEVICE (blood NF glucose monitoring suppl) QUINTET BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) ra alcohol swabs pad 70 % NPB RA E-ZJECT LANCETS 28G (lancets) NPB RA E-ZJECT LANCETS THIN 26G (lancets) NPB RA E-ZJECT LANCETS THIN 28G (lancets) NPB RA E-ZJECT LANCETS ULTRA THIN (lancets) NPB ra insulin syringe 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" NF 0.5 ml, 30g x 5/16" 1 ml ra pen needles 31g x 5 mm , 31g x 8 mm NF RAPPORT RLS KIT (impotence aid device) NPB RAPPORT VTD KIT (impotence aid device) NPB READYLANCE SAFETY LANCETS (lancets) NPB

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 177 Prescription Drug Name Drug Tier Drug Notes reality insulin syringe 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x NF 1/2" 0.5 ml, 29g x 1/2" 1 ml reality lancets NPB reality swabs pad NPB reality trigger lancets NPB REFUAH PLUS BLOOD GLUCOSE TEST IN VITRO NF STRIP (glucose blood) REFUAH PLUS MONITORING SYSTEM KIT NF W/DEVICE (blood glucose monitoring suppl) RELION BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) RELION CONFIRM GLUCOSE MONITOR KIT NF W/DEVICE (blood glucose monitoring suppl) RELION CONFIRM/MICRO TEST IN VITRO STRIP NF (glucose blood) RELION INSULIN SYRINGE 29G X 1/2" 0.5 ML, 31G X 15/64" 0.3 ML, 31G X 15/64" 0.5 ML, 31G X 15/64" 1 ML, NF 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe-needle u-100) RELION KETONE TEST IN VITRO STRIP (acetone NPB (urine) test) RELION LANCET DEVICES 30G (lancet devices) NPB RELION LANCETS MICRO-THIN 33G (lancets) NPB RELION LANCETS THIN 26G (lancets) NPB RELION LANCETS ULTRA-THIN 30G (lancets) NPB RELION LANCING DEVICE (lancet devices) NPB RELION LANCING DEVICE KIT (lancets misc.) NPB RELION MICRO KIT W/DEVICE (blood glucose monitoring NF suppl) RELION MINI PEN NEEDLES 31G X 6 MM (insulin pen NF needle) RELION PEN NEEDLES 29G X 12MM , 31G X 6 MM , NF 31G X 8 MM , 32G X 4 MM (insulin pen needle) RELION PREMIER BLU MONITOR DEVICE (blood NF glucose monitoring suppl) RELION PREMIER COMPACT SYSTEM KIT NF W/DEVICE (blood glucose monitoring suppl)

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 178 Prescription Drug Name Drug Tier Drug Notes RELION PREMIER VOICE MONITOR DEVICE (blood NF glucose monitoring suppl) RELION PRIME MONITOR DEVICE (blood glucose NF monitoring suppl) RELION PRIME TEST IN VITRO STRIP (glucose blood) NF RELION SHORT PEN NEEDLES 31G X 8 MM (insulin pen NF needle) RELION ULTIMA GLUCOSE SYSTEM KIT W/DEVICE NF (blood glucose monitoring suppl) RELION ULTIMA TEST IN VITRO STRIP (glucose blood) NF RELION ULTRA THIN LANCETS 30G (lancets) NPB RELION ULTRA THIN PLUS LANCETS (lancets) NPB REXALL BLOOD GLUCOSE SYSTEM KIT W/DEVICE NF (blood glucose monitoring suppl) REXALL BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) RIGHTEST ALTERNATE SITE ADAPT (lancets misc.) NPB RIGHTEST GD500 LANCING DEVICE (lancet devices) NPB RIGHTEST GL300 LANCETS (lancets) NPB RIGHTEST GM100 BLOOD GLUCOSE KIT W/DEVICE NF (blood glucose monitoring suppl) RIGHTEST GM300 BLOOD GLUCOSE KIT W/DEVICE NF (blood glucose monitoring suppl) RIGHTEST GM550 BLOOD GLUCOSE KIT W/DEVICE NF (blood glucose monitoring suppl) RIGHTEST GS100 BLOOD GLUCOSE IN VITRO STRIP NF (glucose blood) RIGHTEST GS300 BLOOD GLUCOSE IN VITRO STRIP NF (glucose blood) RIGHTEST GS550 BLOOD GLUCOSE IN VITRO STRIP NF (glucose blood) SAFE-T-LANCE (lancets) NPB SAFE-T-LANCE PLUS (lancets) NPB safety insulin syringes 27g x 1/2" 1 ml, 29g x 1/2" 0.5 ml, 29g x NF 1/2" 1 ml, 30g x 1/2" 1 ml, 30g x 5/16" 0.5 ml safety lancet 30g/pressure act NPB saps care alcohol prep pad 70 % NPB saps health care alcohol prep pad 70 % NPB 2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 179 Prescription Drug Name Drug Tier Drug Notes saps health twist top lancets NPB saps twist top lancets NPB sapscare twist top lancets NPB sb alcohol prep pad 70 % NPB sb insulin syringe 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" NF 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 1 ml sb lancets thin NPB sb lancets ultra thin NPB SECURESAFE INSULIN SYRINGE 29G X 1/2" 0.5 ML, NF 29G X 1/2" 1 ML (insulin syringe-needle u-100) select-lite lancing device NPB SHOPKO AUTOLET LANCING DEVICE (lancet devices) NPB SHOPKO UNIFINE PENTIPS 29G X 12MM , 31G X 5 MM NF , 31G X 8 MM , 32G X 4 MM (insulin pen needle) SHOPKO UNIFINE PENTIPS PLUS 29G X 12MM , 31G X NF 5 MM , 31G X 8 MM , 32G X 4 MM (insulin pen needle) SILHOUETTE 13MM (insulin infusion pump supplies) NPB SILHOUETTE 17MM (insulin infusion pump supplies) NPB SILHOUETTE INFUSION SET 23" (insulin infusion pump NPB supplies) SILHOUETTE INFUSION SET 43" (insulin infusion pump NPB supplies) SIMPLE DIAGNOSTICS LANCING DEV (lancet devices) NPB SINGLE-LET (lancets) NPB sm alcohol prep pad 70 % NPB sm lancets 33g NPB SM TRUEDRAW LANCING DEVICE (lancet devices) NPB SMART DIABETES VANTAGE LANCING (lancet devices) NPB SMART SENSE COLOR LANCETS 33G (lancets) NPB SMART SENSE PREMIUM SYSTEM KIT W/DEVICE NF (blood glucose monitoring suppl) SMART SENSE PREMIUM TEST IN VITRO STRIP NF (glucose blood) SMART SENSE STANDARD LANCETS (lancets) NPB SMART SENSE SUPER THIN LANCETS (lancets) NPB SMART SENSE THIN LANCETS 26G (lancets) NPB

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 180 Prescription Drug Name Drug Tier Drug Notes SMART SENSE VALUE GLUCOSE SYS KIT W/DEVICE NF (blood glucose monitoring suppl) SMART SENSE VALUE TEST IN VITRO STRIP (glucose NF blood) SMARTEST BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) SMARTEST EJECT DEVICE (blood glucose monitoring NF suppl) SMARTEST EJECT STARTER KIT W/DEVICE (blood NF glucose monitoring suppl) SMARTEST LANCETS 28G (lancets) NPB SMARTEST PERSONA STARTER KIT W/DEVICE (blood NF glucose monitoring suppl) SMARTEST PRONTO STARTER KIT W/DEVICE (blood NF glucose monitoring suppl) SMARTEST PROTEGE DEVICE (blood glucose monitoring NF suppl) SMARTEST PROTEGE STARTER KIT W/DEVICE (blood NF glucose monitoring suppl) SOLUS V2 BLOOD GLUCOSE SYSTEM DEVICE (blood NF glucose monitoring suppl) SOLUS V2 BLOOD GLUCOSE SYSTEM KIT W/DEVICE NF (blood glucose monitoring suppl) SOLUS V2 LANCETS 28G (lancets) NPB SOLUS V2 LANCING DEVICE (lancet devices) NPB SOLUS V2 TEST IN VITRO STRIP (glucose blood) NF SOLUS V2 TWIST LANCETS 30G (lancets) NPB STERILANCE PA (lancets misc.) NPB STERILANCE TL (lancets) NPB super thin lancets NPB SUPREME TEST IN VITRO STRIP (glucose blood) NF sure comfort alcohol prep pad 70 % NPB sure comfort insulin syringe 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 1/2" 0.3 ml, 30g x 1/2" 0.5 ml, 30g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, NF 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 1/4" 0.3 ml, 31g x 1/4" 0.5 ml, 31g x 1/4" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 181 Prescription Drug Name Drug Tier Drug Notes sure comfort lancets 18g NPB sure comfort lancets 21g NPB sure comfort lancets 23g NPB sure comfort lancets 30g NPB sure comfort lancing pen NPB sure comfort pen needles 29g x 12.7mm , 30g x 8 mm , 31g x 5 NF mm , 31g x 8 mm , 32g x 6 mm SURE-FINE PEN NEEDLES 29G X 12.7MM , 31G X 5 NF MM , 31G X 8 MM (insulin pen needle) SURE-JECT INSULIN SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X NF 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe-needle u-100) SURE-LANCE FLAT LANCETS (lancets) NPB SURE-LANCE LANCETS 26G (lancets) NPB SURELITE LANCETS (lancets) NPB SURE-PEN (lancet devices) NPB SURE-T INFUSION SET 18" (insulin infusion pump supplies) NPB SURE-T INFUSION SET 23" (insulin infusion pump supplies) NPB SURE-T INFUSION SET 32" (insulin infusion pump supplies) NPB SURE-T INFUSION SET 6MM (insulin infusion pump NPB supplies) SURE-T INFUSION SET 8MM (insulin infusion pump NPB supplies) SURE-TEST EASYPLUS MINI METER DEVICE (blood NF glucose monitoring suppl) SURE-TEST EASYPLUS MINI TEST IN VITRO STRIP NF (glucose blood) SURE-TOUCH LANCETS UNIVERSAL (lancets) NPB T:FLEX T:LOCK CARTRIDGE 4.8ML (insulin infusion NPB pump supplies) techlite insulin syringe 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 1/2" 0.3 ml, 30g x 1/2" 0.5 ml, 30g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g NF x 15/64" 0.3 ml, 31g x 15/64" 0.5 ml, 31g x 15/64" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 182 Prescription Drug Name Drug Tier Drug Notes TECHLITE PEN NEEDLES 29G X 10MM , 29G X 12MM , 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM , NF 32G X 6 MM , 32G X 8 MM (insulin pen needle) tgt blood glucose monitoring kit w/device NF tgt blood glucose test in vitro strip NF tgt lancet micro thin 33g NPB tgt lancet thin 26g NPB tgt lancet ultra thin 30g NPB tgt lancing device NPB THINLETS GP LANCETS (lancets) NPB todays health mini pen needles 31g x 6 mm NF todays health pen needles 29g x 12mm NF todays health short pen needle 31g x 8 mm NF topcare clickfine pen needles 31g x 6 mm , 31g x 8 mm NF topcare lancets micro-thin 33g NPB topcare ultra comfort ins syr 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g NF x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml TOXICOLOGY MED COLLECTION SYS IN VITRO KIT NPB (drug assay (urine)) travel lancets NPB TRAVEL LANCETS ADVANCED 28G (lancets) NPB true comfort insulin syringe 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml NF true comfort pen needles 31g x 5 mm , 31g x 6 mm , 32g x 4 mm NF true comfort pro insulin syr 30g x 1/2" 0.5 ml, 30g x 1/2" 1 ml, NF 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 32g x 5/16" 1 ml true comfort twist top lancets NPB TRUE FOCUS BLOOD GLUCOSE METER DEVICE NF (blood glucose monitoring suppl) true focus blood glucose strip in vitro strip NF TRUE METRIX AIR GLUCOSE METER KIT W/DEVICE NF (blood glucose monitoring suppl) TRUE METRIX BLOOD GLUCOSE TEST IN VITRO NF STRIP (glucose blood) TRUE METRIX GO GLUCOSE METER KIT W/DEVICE NF (blood glucose monitoring suppl)

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 183 Prescription Drug Name Drug Tier Drug Notes TRUE METRIX METER DEVICE (blood glucose monitoring NF suppl) TRUE METRIX METER KIT W/DEVICE (blood glucose NF monitoring suppl) TRUEPLUS 5-BEVEL PEN NEEDLES 29G X 12.7MM , 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM NF (insulin pen needle) TRUEPLUS INSULIN SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X NF 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe-needle u-100) TRUEPLUS LANCETS 26G (lancets) NPB TRUEPLUS LANCETS 28G (lancets) NPB TRUEPLUS LANCETS 30G (lancets) NPB TRUEPLUS LANCETS 33G (lancets) NPB TRUEPLUS PEN NEEDLES 31G X 6 MM (insulin pen NF needle) TRUEPLUS SAFETY LANCETS 28G (lancets) NPB TRUERESULT BLOOD GLUCOSE KIT W/DEVICE NF (blood glucose monitoring suppl) TRUETEST TEST IN VITRO STRIP (glucose blood) NF TRUETRACK BLOOD GLUCOSE DEVICE (blood glucose NF monitoring suppl) TRUETRACK BLOOD GLUCOSE KIT W/DEVICE (blood NF glucose monitoring suppl) TRUETRACK SMART SYSTEM KIT (blood glucose NF monitoring suppl) TRUETRACK TEST IN VITRO STRIP (glucose blood) NF TRUSTEEL INFUSION SET (insulin infusion pump supplies) NPB ULTICARE ALCOHOL SWABS PAD (alcohol swabs) NPB ULTICARE INSULIN SAFETY SYR 29G X 1/2" 0.5 ML, NF 29G X 1/2" 1 ML (insulin syringe-needle u-100)

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 184 Prescription Drug Name Drug Tier Drug Notes ULTICARE INSULIN SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X NF 5/16" 1 ML, 31G X 1/4" 0.3 ML, 31G X 1/4" 0.5 ML, 31G X 1/4" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe-needle u-100) ULTICARE MICRO PEN NEEDLES 31G X 6 MM , 31G X NF 8 MM , 32G X 4 MM (insulin pen needle) ULTICARE MINI PEN NEEDLES 31G X 6 MM , 32G X 6 NF MM (insulin pen needle) ULTICARE PEN NEEDLES 29G X 12.7MM , 31G X 5 MM NF (insulin pen needle) ULTICARE SHORT PEN NEEDLES 31G X 8 MM (insulin NF pen needle) ultiguard safepack pen needle 31g x 5 mm , 31g x 6 mm , 31g x NF 8 mm , 32g x 4 mm , 32g x 6 mm ULTI-LANCE AUTOMATIC (lancet devices) NPB ultilet alcohol swabs pad NPB ULTILET CLASSIC LANCETS (lancets) NPB ULTILET INSULIN SYRINGE 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 1/4" 0.3 ML, 31G X 1/4" 1 ML, 31G X NF 15/64" 0.3 ML, 31G X 15/64" 0.5 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 1 ML (insulin syringe-needle u-100) ULTILET INSULIN SYRINGE SHORT 30G X 1/2" 0.3 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" NF 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe-needle u-100) ULTILET LANCETS (lancets) NPB ULTILET PEN NEEDLE 29G X 12.7MM , 31G X 5 MM , NF 31G X 8 MM , 32G X 4 MM (insulin pen needle) ULTILET SAFETY LANCETS (lancets) NPB ULTILET SAFETY LANCETS 23G (lancets) NPB ULTIMA KIT (blood glucose monitoring suppl) NF ultra comfort insulin syringe 30g x 5/16" 0.3 ml NF ultra thin lancets 31g NPB ULTRA THIN PEN NEEDLES 32G X 4 MM (insulin pen NF needle)

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 185 Prescription Drug Name Drug Tier Drug Notes ultracare insulin syringe 30g x 1/2" 0.5 ml, 30g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" NF 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml ultra-care lancets 30g NPB ultracare pen needles 31g x 5 mm , 31g x 6 mm , 31g x 8 mm , NF 32g x 4 mm , 32g x 5 mm , 32g x 6 mm , 33g x 4 mm ultra-comfort insulin syringe 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x NF 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml ULTRA-THIN II AUTO LANCET (lancets) NPB ULTRA-THIN II INS SYR SHORT 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 NF ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe- needle u-100) ULTRA-THIN II INSULIN SYRINGE 29G X 1/2" 0.5 ML, NF 29G X 1/2" 1 ML (insulin syringe-needle u-100) ULTRA-THIN II LANCETS (lancets) NPB ULTRA-THIN II MINI PEN NEEDLE 31G X 5 MM NF (insulin pen needle) ULTRA-THIN II PEN NEEDLE SHORT 31G X 8 MM NF (insulin pen needle) ULTRA-THIN II PEN NEEDLES 29G X 12.7MM (insulin NF pen needle) UNIFINE PENTIPS 29G X 12MM , 30G X 5 MM , 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM , 32G X 6 NF MM , 33G X 4 MM (insulin pen needle) UNIFINE PENTIPS PLUS 29G X 12MM , 30G X 5 MM , 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM , NF 33G X 4 MM (insulin pen needle) UNIFINE SAFECONTROL PEN NEEDLE 30G X 5 MM , NF 30G X 8 MM (insulin pen needle) UNILET COMFORTOUCH LANCET (lancets) NPB UNILET EXCELITE (lancets) NPB UNILET EXCELITE II (lancets) NPB UNILET G.P. LANCET (lancets) NPB UNILET G.P. SUPERLITE LANCET (lancets) NPB UNILET GP 28 ULTRA THIN (lancets) NPB UNILET LANCET (lancets) NPB 2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 186 Prescription Drug Name Drug Tier Drug Notes UNILET MICRO-THIN 33G (lancets) NPB UNILET SUPERLITE LANCET (lancets) NPB UNILET SUPER-THIN 30G (lancets) NPB UNILET ULTRA-THIN 28G (lancets) NPB UNISTIK 1 (lancets misc.) NPB UNISTIK 2 (lancets misc.) NPB UNISTIK 2 COMFORT (lancets misc.) NPB UNISTIK 2 EXTRA (lancets misc.) NPB UNISTIK 2 NEONATAL (lancets misc.) NPB UNISTIK 2 NORMAL (lancets misc.) NPB UNISTIK 2 SUPER (lancets misc.) NPB UNISTIK 3 (lancets misc.) NPB UNISTIK 3 COMFORT (lancets misc.) NPB UNISTIK 3 EXTRA (lancets misc.) NPB UNISTIK 3 GENTLE (lancets) NPB UNISTIK 3 NEONATAL (lancets misc.) NPB UNISTIK 3 NORMAL (lancets misc.) NPB UNISTIK CZT COMFORT (lancets misc.) NPB UNISTIK CZT NORMAL (lancets misc.) NPB UNISTIK NORMAL (lancets misc.) NPB UNISTIK PRO SAFETY LANCET (lancets) NPB UNISTIK SAFETY LANCETS 28G (lancets) NPB UNISTIK SAFETY LANCETS 30G (lancets) NPB UNISTIK TOUCH SAFETY LANC 21G (lancets) NPB UNISTIK TOUCH SAFETY LANC 23G (lancets) NPB UNISTIK TOUCH SAFETY LANC 28G (lancets) NPB UNISTIK TOUCH SAFETY LANC 30G (lancets) NPB UNISTRIP1 GENERIC IN VITRO STRIP (glucose blood) NF UNIVERSAL 1 LANCETS THIN 26G (lancets) NPB UNIVERSAL 1 LANCETS THIN 33G (lancets) NPB UNIVERSAL 1 LANCETS ULTRA THIN (lancets) NPB value health insulin syringe 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml NF value plus lancet standard 21g NPB value plus lancets super thin NPB valumark lancet ultra thin 28g NPB 2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 187 Prescription Drug Name Drug Tier Drug Notes valumark pen needles 29g x 12mm , 31g x 6 mm , 31g x 8 mm NF VANISHPOINT INSULIN SYRINGE 29G X 1/2" 1 ML, 29G X 5/16" 1 ML, 30G X 1/2" 0.5 ML, 30G X 3/16" 0.5 ML, NF 30G X 3/16" 1 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML (insulin syringe-needle u-100) VARISOFT INFUSION SET (insulin infusion pump supplies) NPB verasens blood glucose meter device NF verasens blood glucose system kit w/device NF verasens blood glucose test in vitro strip NF V-GO 20 KIT (insulin disposable pump) PB V-GO 30 KIT (insulin disposable pump) PB V-GO 40 KIT (insulin disposable pump) PB VIDA MIA UNIFINE PENTIPS 29G X 12MM , 31G X 6 NF MM , 31G X 8 MM , 32G X 4 MM (insulin pen needle) VIVAGUARD INO GLUCOSE METER DEVICE (blood NF glucose monitoring suppl) VIVAGUARD INO TEST STRIPS IN VITRO STRIP NF (glucose blood) VIVAGUARD LANCETS (lancets) NPB VIVAGUARD LANCING DEVICE (lancet devices) NPB vp insulin syringe 29g x 1/2" 0.3 ml NF walgreens adv travel lancets NPB WALGREENS LANCETS (lancets) NPB walgreens lancets micro thin NPB walgreens lancets super thin NPB WALGREENS THIN LANCETS (lancets) NPB WALGREENS ULTRA THIN LANCETS (lancets) NPB WAVESENSE AMP KIT W/DEVICE (blood glucose NF monitoring suppl) WEBCOL ALCOHOL PREP LARGE PAD 70 % (alcohol NPB swabs) WEBCOL ALCOHOL PREP MEDIUM PAD 70 % (alcohol NPB swabs) wegmans unifine pentips plus 31g x 5 mm , 31g x 6 mm , 31g x 8 NF mm , 32g x 4 mm zevrx twist top lancets 30g NPB

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 188 Prescription Drug Name Drug Tier Drug Notes NUTRITIONAL/SUPPLEMENTS - VITAMINS AND SUPPLEMENTS ELECTROLYTES dextrose-nacl intravenous solution 2.5-0.45 % NPB dextrose-sodium chloride intravenous solution 5-0.225 % NPB EFFER-K ORAL TABLET EFFERVESCENT 10 MEQ, 20 NPB MEQ (potassium bicarb-citric acid) potassium bicarbonate (Effer-K Oral Tablet Effervescent 25 G Meq) GALZIN ORAL CAPSULE 25 MG, 50 MG (zinc acetate NPB (oral)) iodine strong oral solution 5 % G potassium chloride (Klor-Con 10 Oral Tablet Extended G Release 10 Meq) potassium chloride crys er (Klor-Con M10 Oral Tablet G Extended Release 10 Meq) potassium chloride crys er (Klor-Con M15 Oral Tablet G Extended Release 15 Meq) potassium chloride crys er (Klor-Con M20 Oral Tablet G Extended Release 20 Meq) potassium chloride (Klor-Con Oral Packet 20 Meq) G potassium chloride (Klor-Con Oral Tablet Extended Release 8 G Meq) potassium bicarbonate (Klor-Con/Ef Oral Tablet Effervescent G 25 Meq) K-PHOS ORAL TABLET 500 MG (potassium phosphate NPB monobasic) potassium bicarbonate (K-Prime Oral Tablet Effervescent 25 G Meq) k phos mono-sod phos di & mono (Phospha 250 Neutral Oral G Tablet 155-852-130 Mg) phosphorous oral tablet 155-852-130 mg G k phos mono-sod phos di & mono (Phospho-Trin 250 Neutral G Oral Tablet 155-852-130 Mg) POTABA ORAL CAPSULE 500 MG (potassium NPB aminobenzoate) potassium chloride crys er oral tablet extended release 10 meq, G 20 meq

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 189 Prescription Drug Name Drug Tier Drug Notes potassium chloride er oral capsule extended release 10 meq, 8 G meq potassium chloride er oral tablet extended release 10 meq, 20 G meq, 8 meq potassium chloride in nacl intravenous solution 20-0.45 meq/l-%, NPB 40-0.9 meq/l-% potassium chloride oral packet 20 meq G potassium chloride oral solution 20 meq/15ml (10%), 40 G meq/15ml (20%) THE LIQUILIFT TRACE INTRAVENOUS KIT 10-1000- NF 500-60 MCG/ML (trace minerals cr-cu-mn-se-zn) virt-phos 250 neutral oral tablet 155-852-130 mg G zinc sulfate intravenous solution 3 mg/ml NPB VITAMINS - VITAMINS AND SUPPLEMENTS activite oral tablet 1 mg NF adc/f (0.5mg/ml) oral solution 0.5 mg/ml G ADRENAL C FORMULA ORAL TABLET (bioflavonoid NPB products) AMINOPMRMS ORAL CAPSULE (nutritional supplements) NPB APP SLIM RMS ORAL CAPSULE (nutritional supp - diet NPB aids) ASCOR INTRAVENOUS SOLUTION 25000 MG/50ML NF (ascorbic acid) nutritional supplements (Asilnasalrms Oral Capsule) G ASTAMED MYO ORAL CAPSULE (astaxanthin- NF tocotrienol-zn-d3) ATABEX EC ORAL TABLET DELAYED RELEASE 29-1 NF MG (prenatal vit-dss-fe cbn-fa) ATABEX OB ORAL TABLET 29-1 MG (prenatal vit w/ fe NF bisg-fa) azeschew prenatal/postnatal oral tablet chewable 13-1 mg NF azesco oral tablet 13-1 mg NF biocel oral tablet G b-plex oral tablet G b-plex plus oral tablet G CALCIFOL ORAL WAFER 1342-1.6 MG (ca carb-fa-d-b6- NPB b12-boron-mg)

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 190 Prescription Drug Name Drug Tier Drug Notes calcium gluconate intravenous solution 10 % NPB CAMINO PRO COMPLETE/GLYTACTIN ORAL BAR NPB (nutritional supplements) CHOLEXMAX ORAL POWDER (dietary management NF product) CHOLEXTRA T/F ORAL POWDER (dietary management NF product) CITRANATAL 90 DHA ORAL 90-1 & 300 MG (prenat w/o PB a-fecbgl-dss-fa-dha) CITRANATAL ASSURE ORAL 35-1 & 300 MG (prenat w/o PB a-fecbgl-dss-fa-dha) CITRANATAL B-CALM ORAL 20-1 MG & 2 X 25 MG PB (prenat w/o a fecbnfeglu-fa &b6) CITRANATAL BLOOM DHA ORAL 90-1 & 300 MG PB (prenat w/o a-fecbgl-dss-fa-dha) CITRANATAL BLOOM ORAL TABLET 90-1 MG PB (prenatal-dss-fecb-fegl-fa) CITRANATAL DHA ORAL 27-1 & 250 MG (prenat w/o a- PB fecbgl-dss-fa-dha) CITRANATAL ESSENCE ORAL THERAPY PACK 35-1 PB & 300 MG (prenat w/o a-fecbgl-fa-dha) CITRANATAL HARMONY ORAL CAPSULE 27-1-260 PB MG (prenat-fefmcb-dss-fa-dha w/o a) CITRANATAL MEDLEY ORAL CAPSULE 27-1-200 MG PB (prenat-fecb-fefum-fa-dha w/o a) CITRANATAL RX ORAL TABLET 27-1 MG (prenat w/o a- PB fecb-fegl-dss-fa) c-nate dha oral capsule 28-1-200 mg NF cod liver oil oral oil NPB complete natal dha oral 29-1-200 & 250 mg NF completenate oral tablet chewable 29-1 mg NF CO-NATAL FA ORAL TABLET (prenatal vit-fe fumarate- NF fa) CONCEPT DHA ORAL CAPSULE 53.5-38-1 MG (prenat- NF fefum-fepo-fa-omega 3) CONCEPT OB ORAL CAPSULE 130-92.4-1 MG (prenat w/o NF a vit-fefum-fepo-fa) cvs folic acid oral tablet 800 mcg CE

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 191 Prescription Drug Name Drug Tier Drug Notes cyanocobalamin injection solution 1000 mcg/ml G b complex-c-folic acid (Dexifol Oral Tablet 5 Mg) NF DUET DHA 400 ORAL 25-1 & 400 MG (prenat-fepoly-fered- NF fa-omega 3) DUET DHA BALANCED ORAL 25-1 & 267 MG (prenat- NF fepoly-fered-fa-omega 3) ENBRACE HR ORAL CAPSULE (prenat vit-fe gly cys-fa- NF omega) ENTERAGAM ORAL PACKET 5 GM (sbi/protein isolate) NF ergocal oral capsule 62.5 mcg (2500 ut) NF ergocalciferol oral capsule 1.25 mg (50000 ut) G FA-8 ORAL CAPSULE 0.8 MG (folic acid) CE FLORIVA ORAL LIQUID 0.25-400 MG-UNIT/ML (sodium NF fluoride-vitamin d) FLORIVA ORAL TABLET CHEWABLE 0.25 MG (ped NPB multiple vit-minerals-fl) FLORIVA ORAL TABLET CHEWABLE 0.5 MG, 1 MG NF (ped multiple vit-minerals-fl) FLORIVA PLUS ORAL SOLUTION 0.25 MG/ML NPB (pediatric multivitamins-fl) fluoritab oral solution 0.275 (0.125 f) mg/drop CE FOLBEE PLUS CZ ORAL TABLET 5 MG (b-complex-c- G biotin-minerals-fa) folbee plus oral tablet G FOLGARD OS ORAL TABLET 500-1.1 MG (multiple vit- NPB min-calcium-fa) folic acid injection solution 5 mg/ml G folic acid oral capsule 0.8 mg CE folic-k oral capsule 1 mg NF FOLIVANE-OB ORAL CAPSULE 130-92.4-1 MG (prenat NF w/o a vit-fefum-fepo-fa) FOSTEUM ORAL CAPSULE 27-20-200 MG-MG-UNIT NF (genistein-zn chelate-vit d) FOSTEUM PLUS ORAL CAPSULE (dietary management NF product) GALAXTRA ORAL POWDER (galactose) NF GENICIN VITA-Q ORAL TABLET 1 MG (multiple vitamins NF with fa) 2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 192 Prescription Drug Name Drug Tier Drug Notes b complex-c-folic acid (Genicin Vita-S Oral Tablet 1 Mg) NF GLYTACTIN BUILD 10PE ORAL PACKET (nutritional NPB supplements) GLYTACTIN COMPLETE 10PE ORAL BAR (nutritional NPB supplements) GLYTACTIN SWIRL 15PE ORAL PACKET (nutritional NPB supplements) HCU EASY ORAL TABLET (nutritional supplements) NF hydroxocobalamin acetate intramuscular solution 1000 mcg/ml G hylavite oral tablet NF INATAL GT ORAL TABLET (prenatal vit-dss-fe cbn-fa) G INFUVITE ADULT INTRAVENOUS INJECTABLE NPB (multiple vitamin) INFUVITE PEDIATRIC INTRAVENOUS SOLUTION NPB (pediatric multiple vitamins) jenliva prenatal/postnatal oral capsule 1 mg NF KETOVIE ORAL LIQUID (nutritional supplements) NPB KETOVIE PEPTIDE ORAL LIQUID (nutritional NPB supplements) kosher prenatal plus iron oral tablet 30-1 mg NF LDL CARE ORAL POWDER (dietary management product) NF lecithin oral granules NPB lipo-c intramuscular solution NF l-methylfolate calcium oral tablet 15 mg, 7.5 mg NPB lorid oral tablet 1 mg NF multiple vitamins-minerals (Lysiplex Plus Oral Tablet) G M.V.I. ADULT INTRAVENOUS INJECTABLE (multiple NPB vitamin) M.V.I. PEDIATRIC INTRAVENOUS SOLUTION NPB RECONSTITUTED (pediatric multiple vitamins) m-natal plus oral tablet 27-1 mg NF MSUD EASY ORAL TABLET (nutritional supplements) NF multipro oral capsule NF multi-vit/iron/fluoride oral solution 0.25-10 mg/ml G multivitamin/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml G multi-vitamin/fluoride oral solution 0.5 mg/ml G

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 193 Prescription Drug Name Drug Tier Drug Notes multivitamin/fluoride oral tablet chewable 0.25 mg, 0.5 mg, 1 mg G multivitamin/fluoride oral tablet chewable 0.25-0.3 mg, 0.5-0.3 NF mg, 1-0.3 mg multi-vitamin/fluoride/iron oral solution 0.25-10 mg/ml G MYNATAL ORAL CAPSULE (prenatal multivit-min-fe-fa) NF mynatal plus oral tablet NF mynatal-z oral tablet NF sodium fluoride (Nafrinse Drops Oral Solution 0.275 (0.125 F) CE Mg/Drop) NASCOBAL NASAL SOLUTION 500 MCG/0.1ML NPB (cyanocobalamin) NATACHEW ORAL TABLET CHEWABLE 28-1 MG NF (prenatal vit-fe fum-fe bisg-fa) NATALVIT ORAL TABLET (prenatal vit-fe fumarate-fa) NF NEEVO DHA ORAL CAPSULE 27-1.13 MG (prenat w/oa- NF fefum-methf-omegas) NEOKE BCAA4 ORAL POWDER (dietary management NF product) neoke bhb oral powder NF neonatal + dha oral 29-1 & 200 mg NF neonatal 19 oral tablet 1 mg NF neonatal complete oral tablet 27-1 mg, 29-1 mg NF neonatal fe oral tablet 90-1 mg NF NEONATAL PLUS ORAL TABLET 27-1 MG (prenatal vit- NF fe fumarate-fa) b complex-c-folic acid (Nephronex Oral Tablet) G NESTABS DHA ORAL 32-1 MG (prenat-w/oa-fe bisgly-fa- NF omega) NESTABS ONE ORAL CAPSULE 38-1-225 MG (prenat-fe- NF methylfol-dha w/o a) NESTABS ORAL TABLET 32-1 MG (prenat-fe bisgly-fa-w/o NF vit a) NICADAN ORAL TABLET (multiple vitamins-minerals) NF NICAPRIN ORAL TABLET (dietary management product) NF NICAZEL FORTE ORAL TABLET (multiple vitamins- NF minerals) NICAZEL ORAL TABLET (multiple vitamins-minerals) NF

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 194 Prescription Drug Name Drug Tier Drug Notes nicazyme oral tablet NF NICOMIDE ORAL TABLET 750-27-2-0.5 MG (niacinamide- NF zn-cu-methfo-se-cr) NIVA-PLUS ORAL TABLET 27-1 MG (prenatal vit-fe NF fumarate-fa) NOURISH ORAL LIQUID (nutritional supplements) NPB NUTRICAP ORAL TABLET (multiple vitamins-minerals) NPB multiple vitamins-minerals (Nutrifac Zx Oral Tablet) G NUTRIVIT ORAL LIQUID (b complex-lysine-min-fe-fa) NPB OB COMPLETE ONE ORAL CAPSULE 50-1-476 MG NF (prenat-fecbn-feaspgl-fa-fish) OB COMPLETE ORAL TABLET 50-1.25 MG (prenatal vit- NF iron carbonyl-fa) OB COMPLETE PETITE ORAL CAPSULE 35-5-1-200 MG NF (prenat-fecbn-feaspgl-fa-omega) OB COMPLETE PREMIER ORAL TABLET 30-20-1 MG NF (prenatal-fe cbn-fe asp gly-fa) OB COMPLETE/DHA ORAL CAPSULE 30-10-1-200 MG NF (prenat-fecbn-feaspgl-fa-omega) OBSTETRIX DHA ORAL 29-1 & 387 MG (prenatal-fecbn- NF fa-dss-omega 3) OBSTETRIX EC ORAL TABLET 29-1 MG (prenatal vit-dss- NF fe cbn-fa) OBSTETRIX ONE ORAL CAPSULE 38-1-225 MG (prenat- NF fe-methyl-dss-dha w/o a) O-CAL PRENATAL ORAL TABLET (prenatal vit-fe NF fumarate-fa) OCUVEL ORAL CAPSULE 0.5 MG (multiple vitamins- NF minerals-fa) OMEGAVEN INTRAVENOUS EMULSION 10 NF GM/100ML, 5 GM/50ML (fish oil triglyceride based) omnivex oral tablet NF one vite womens plus oral tablet 27-1 mg NF onevite oral tablet 1 mg NPB phytonadione injection solution 1 mg/0.5ml, 10 mg/ml G phytonadione oral tablet 5 mg G PKU EASY MICROTABS ORAL TABLET DELAYED NF RELEASE (nutritional supplements)

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 195 Prescription Drug Name Drug Tier Drug Notes PKU EASY ORAL TABLET (nutritional supplements) NF pnv prenatal plus multivitamin oral tablet 27-1 mg NPB pnv tabs 20-1 oral tablet 20-1 mg NF pnv tabs 29-1 oral tablet 29-1 mg NF pnv-dha oral capsule 27-0.6-0.4-300 mg G pnv-dha+docusate oral capsule 27-1.25-300 mg NF pnv-omega oral capsule 28-0.6-0.4-340 mg NF pnv-select oral tablet 27-0.6-0.4 mg G POLY-VI-FLOR ORAL SUSPENSION 0.25 MG/ML NPB (pediatric multivitamins-fl) POLY-VI-FLOR ORAL TABLET CHEWABLE 0.25 MG, NPB 0.5 MG, 1 MG (pediatric multivitamins-fl) POLY-VI-FLOR/IRON ORAL SUSPENSION 0.25-7 NPB MG/ML (ped multivitamins-fl-iron) POLY-VI-FLOR/IRON ORAL TABLET CHEWABLE 0.5- NPB 10 MG (ped multivitamins-fl-iron) pregen dha oral capsule 28-1-35 mg NF pregenna oral tablet 20-1 mg NF PREMESISRX ORAL TABLET 1 MG (prenatal ca-b6-b12- NF fa-ginger) prena 1 true oral 30-1.4 & 300 mg NF prena1 oral tablet chewable 1.4 mg NF prena1 pearl oral capsule extended release 30-1.4-200 mg NF prenaissance oral capsule 29-1.25-325 mg NF prenaissance plus oral capsule 28-1-250 mg NF prenara oral capsule 15-1 mg NF PRENATABS RX ORAL TABLET 29-1 MG (prenatal vit- G iron carbonyl-fa) prenatal 19 oral tablet NPB prenatal 19 oral tablet 29-1 mg NF prenatal 19 oral tablet chewable G prenatal 19 oral tablet chewable 29-1 mg NF prenatal oral tablet 27-1 mg NF prenatal plus iron oral tablet 29-1 mg NF prenatal plus oral tablet 27-1 mg NPB prenatal vitamin plus low iron oral tablet 27-1 mg NF

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 196 Prescription Drug Name Drug Tier Drug Notes PRENATAL-U ORAL CAPSULE 106.5-1 MG (prenatal w/o NF a vit-fe fum-fa) PRENATE AM ORAL TABLET 1 MG (prenatal ca-b6-b12- NF fa-ginger) PRENATE DHA ORAL CAPSULE 18-0.6-0.4-300 MG NF (prenat-feasp-meth-fa-dha w/o a) PRENATE ELITE ORAL TABLET 20-0.6-0.4 MG NF (prenatal-feaspgly-methylfol-fa) PRENATE ENHANCE ORAL CAPSULE 28-0.6-0.4-400 NF MG (prenat w/o a-fe-methfol-fa-dha) PRENATE ESSENTIAL ORAL CAPSULE 18-0.6-0.4-300 NF MG (prenat-feasp-meth-fa-dha w/o a) PRENATE MINI ORAL CAPSULE 18-0.6-0.4-350 MG NF (prenat-fecbn-feasp-meth-fa-dha) PRENATE ORAL TABLET CHEWABLE 0.6-0.4 MG NF (prenat mv-min-methylfolate-fa) PRENATE PIXIE ORAL CAPSULE 10-0.6-0.4-200 MG NF (prenat-feasp-meth-fa-dha w/o a) PRENATE RESTORE ORAL CAPSULE 27-0.6-0.4-400 NF MG (prenat w/o a-fe-methfol-fa-dha) PRENATRIX ORAL TABLET 27-1 MG (prenatal vit-fe NF fumarate-fa) PRENATRYL ORAL TABLET 27-1 MG (prenatal vit-fe NF fumarate-fa) prenatvite complete oral tablet 1 mg NF prenatvite plus oral tablet 1 mg NF prenatvite rx oral tablet 0.8 mg NF preplus oral tablet 27-1 mg NF pretab oral tablet 29-1 mg NF PRIMACARE ORAL CAPSULE 30-1-470 MG (pren-fe- NF meth-fa-omeg w/o a) PROVIDA OB ORAL CAPSULE 20-20-1.25 MG (prenat w/o NF a vit-fefum-fepo-fa) pyridoxine hcl injection solution 100 mg/ml NPB QUFLORA FE ORAL TABLET CHEWABLE 0.25 MG NF (multi vit-min-fluoride-fe-fa) QUFLORA FE PEDIATRIC ORAL LIQUID 0.25-9.5 NF MG/ML (ped multivitamins-fl-iron)

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 197 Prescription Drug Name Drug Tier Drug Notes QUFLORA GUMMIES ORAL TABLET CHEWABLE NF 0.125 MG (pediatric multivitamins-fl) QUFLORA PEDIATRIC ORAL SOLUTION 0.25 MG/ML, NPB 0.5 MG/ML (pediatric multivitamins-fl) QUFLORA PEDIATRIC ORAL TABLET CHEWABLE NPB 0.25 MG, 0.5 MG, 1 MG (pediatric multivitamins-fl) relnate dha oral capsule 28-1-200 mg NF REMEDIENT ORAL CAPSULE 1 MG (multiple vitamins- NF minerals-fa) RENATABS ORAL TABLET 1 MG (b complex-c-biotin-e-fa) NPB RENATABS WITH IRON ORAL 1 & 100 MG (b complex-c- NPB biotin-e-fa-fe cbn) reno caps oral capsule 1 mg G REQ 49+ ORAL TABLET (multiple vitamins-minerals) NPB RHEUMATE ORAL CAPSULE (dietary management NF product) ribozel oral capsule NF SELECT-OB ORAL TABLET CHEWABLE 29-0.6-0.4 MG NF (prenat vit-fepoly-methylfol-fa) SELECT-OB ORAL TABLET CHEWABLE 29-1 MG NF (prenatal vit-fe psac cmplx-fa) SELECT-OB+DHA ORAL 29-1 & 250 MG (prenatal vit- NF fepoly-fa-dha) se-natal 19 oral tablet 29-1 mg NF se-natal 19 oral tablet chewable 29-1 mg NF sm folic acid oral tablet 400 mcg CE sodium bicarbonate intravenous solution 7.5 %, 8.4 % NPB sodium fluoride oral solution 1.1 (0.5 f) mg/ml CE sodium fluoride oral tablet 1.1 (0.5 f) mg CE sodium fluoride oral tablet chewable 0.55 (0.25 f) mg, 1.1 (0.5 CE f) mg STROVITE FORTE ORAL SYRUP (multiple vitamins- NPB minerals-fa) SUPERVITE ORAL LIQUID (b complex-lysine-zn-fa) NPB TARON-C DHA ORAL CAPSULE 53.5-38-1 MG (prenat- NF fefum-fepo-fa-omega 3) TARON-PREX ORAL CAPSULE 30-1.2-265 MG (prenat- NF fefum-dss-fa-dha w/o a) 2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 198 Prescription Drug Name Drug Tier Drug Notes THERANATAL CORE NUTRITION ORAL TABLET 27-1 NPB MG (prenatal vit-fe fumarate-fa) thiamine hcl injection solution 100 mg/ml G thrivacin 30 oral liquid NPB thrivacin detox oral liquid NPB thrivite 19 oral tablet 1 mg NPB thrivite rx oral tablet 29-1 mg NF TOBAKIENT ORAL CAPSULE (dietary management NF product) tri-amino injection solution 100-100-100 mg/ml NF TRICARE ORAL TABLET (prenatal vit-fe fumarate-fa) NF TRICARE PRENATAL DHA ONE ORAL CAPSULE 27-1- NF 500 MG (prenatal-fefum-fa-dss-fish oil) trinatal rx 1 oral tablet 60-1 mg NF TRINATE ORAL TABLET (prenatal vit-fe fumarate-fa) G trinaz oral tablet 12-1 mg NF tristart dha oral capsule 31-0.6-0.4-200 mg NF TRISTART FREE ORAL CAPSULE 33-1 MG (prenat w/o NF a-fecbn-meth-fa-dha) TRISTART ONE ORAL CAPSULE 35-1-215 MG (prenat NF w/o a-fecbn-meth-fa-dha) TRIVEEN-DUO DHA ORAL 29-1-200 & 400 MG (prenat- NF febis-fepro-fa-ca-omega) TRI-VI-FLOR ORAL SUSPENSION 0.25 MG/ML, 0.5 NPB MG/ML (ped vit a-c-d-methylfolate-fl) tri-vi-floro oral suspension 0.25 mg/ml, 0.5 mg/ml NPB tri-vite/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml G tronvite oral tablet 1 mg NF TYLACTIN COMPLETE 15 PE ORAL BAR (nutritional NPB supplements) TYR EASY ORAL TABLET (nutritional supplements) NF UDAMIN SP ORAL TABLET 1 MG (multiple vitamins- NPB minerals-fa) urosex oral tablet G VASCULERA ORAL TABLET (dietary management NF product) vb6 p5p oral powder NF

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 199 Prescription Drug Name Drug Tier Drug Notes v-c forte oral capsule G multiple vitamins-minerals (Vic-Forte Oral Capsule) G VINATE DHA RF ORAL CAPSULE 27-1.13 MG (prenat NF w/oa-fefum-methf-omegas) VINATE II ORAL TABLET 29-1 MG (prenatal vit w/ fe bisg- NF fa) VINATE ONE ORAL TABLET 60-1 MG (prenatal vit-fe NF fumarate-fa) virt-c dha oral capsule 53.5-38-1 mg NF virt-caps oral capsule 1 mg G virt-nate dha oral capsule 28-1-200 mg NF virt-pn dha oral capsule 27-0.6-0.4-300 mg NF virt-pn plus oral capsule 28-0.6-0.4-340 mg NF multiple vitamins-minerals (Vita S Forte Oral Tablet) G multiple vitamins-minerals (Vitacel Oral Tablet) G VITAFOL FE+ ORAL CAPSULE 90-0.6-0.4-200 MG NF (prenat-fe poly-methfol-fa-dha) VITAFOL GUMMIES ORAL TABLET CHEWABLE 3.33- NF 0.333-34.8 MG (prenatal vit-fe phos-fa-omega) VITAFOL STRIPS ORAL FILM 1 MG (prenatal-b6-b12-d3- NF folic acid) VITAFOL ULTRA ORAL CAPSULE 29-0.6-0.4-200 MG NF (prenat-fe poly-methfol-fa-dha) VITAFOL-NANO ORAL TABLET 18-0.6-0.4 MG (prenatal- NF fe fum-methf-fa w/o a) VITAFOL-OB ORAL TABLET (prenatal vit-fe fumarate-fa) NF VITAFOL-OB+DHA ORAL 65-1 & 250 MG (prenatal mv- NF min-fe fum-fa-dha) VITAFOL-ONE ORAL CAPSULE 29-1-200 MG (prenatal NF vit-fepoly-fa-dha) VITAMEDMD ONE RX/QUATREFOLIC ORAL CAPSULE 30-0.6-0.4-200 MG (prenat w/o a-fe-methfol-fa- NF dha) VITAMEDMD REDICHEW RX ORAL TABLET NF CHEWABLE 1.4 MG (prenat-b2-b6-b12-d3-fa) vitamin d (ergocalciferol) oral capsule 1.25 mg (50000 ut) G vitamin k1 injection solution 1 mg/0.5ml, 10 mg/ml G vita-min oral capsule G 2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 200 Prescription Drug Name Drug Tier Drug Notes vitamins acd-fluoride oral solution 0.25 mg/ml G VITAPEARL ORAL CAPSULE EXTENDED RELEASE NF 30-1.4-200 MG (prenat-fefum-fered-fa-dha w/oa) vitasure oral tablet 1 mg NF VITATHELY WITH GINGER ORAL TABLET 27-1 MG NF (prenatal vit-fe fumarate-fa) VITATRUE ORAL 30-1.4 & 300 MG (prenat-fechel-fa-dha NF w/o vit a) VIVA DHA ORAL CAPSULE 28-1-200 MG (prenatal vit-fe NF fum-fa-omega) vp-pnv-dha oral capsule 28-1-215.8 mg NF vp-vite rx oral tablet 1 mg G westab plus oral tablet 27-1 mg NF westgel dha oral capsule 31-0.6-0.4-200 mg NF wheat germ oil oral oil NPB XAQUIL XR ORAL TABLET EXTENDED RELEASE 30 NF MG (levomefolate glucosamine) xvite oral tablet 1 mg NF xyzbac oral tablet NF yl folic acid oral tablet 400 mcg CE zalvit oral tablet 13-1 mg NF ZATEAN-PN DHA ORAL CAPSULE 27-0.6-0.4-300 MG NF (prenat w/o a-fe-methfol-fa-dha) ZATEAN-PN PLUS ORAL CAPSULE 28-0.6-0.4-340 MG NF (prenat w/o a-fe-methf-fa-omega) zyvit oral tablet NF OPHTHALMIC - DRUGS TO TREAT EYE CONDITIONS ANTIALLERGICS - DRUGS TO TREAT ALLERGIES ALOCRIL OPHTHALMIC SOLUTION 2 % (nedocromil NPB sodium) ALOMIDE OPHTHALMIC SOLUTION 0.1 % (lodoxamide NPB tromethamine) azelastine hcl ophthalmic solution 0.05 % G BEPREVE OPHTHALMIC SOLUTION 1.5 % (bepotastine NF besilate) cromolyn sodium ophthalmic solution 4 % G epinastine hcl ophthalmic solution 0.05 % G

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 201 Prescription Drug Name Drug Tier Drug Notes LASTACAFT OPHTHALMIC SOLUTION 0.25 % NF (alcaftadine) olopatadine hcl ophthalmic solution 0.1 %, 0.2 % G ANTIGLAUCOMA - DRUGS TO TREAT GLAUCOMA ALPHAGAN P OPHTHALMIC SOLUTION 0.1 % PB (brimonidine tartrate) apraclonidine hcl ophthalmic solution 0.5 % G AZOPT OPHTHALMIC SUSPENSION 1 % (brinzolamide) NF betaxolol hcl ophthalmic solution 0.5 % G BETIMOL OPHTHALMIC SOLUTION 0.25 %, 0.5 % NF (timolol hemihydrate) BETOPTIC-S OPHTHALMIC SUSPENSION 0.25 % NF (betaxolol hcl) bimatoprost external solution 0.03 % NF bimatoprost ophthalmic solution 0.03 % NF brimonidine tartrate ophthalmic solution 0.15 %, 0.2 % G carteolol hcl ophthalmic solution 1 % G COMBIGAN OPHTHALMIC SOLUTION 0.2-0.5 % PB (brimonidine tartrate-timolol) COSOPT PF OPHTHALMIC SOLUTION 2-0.5 % NF (dorzolamide hcl-timolol mal) dorzolamide hcl ophthalmic solution 2 % NPB dorzolamide hcl-timolol mal ophthalmic solution 22.3-6.8 mg/ml G dorzolamide hcl-timolol mal pf ophthalmic solution 2-0.5 % G IOPIDINE OPHTHALMIC SOLUTION 1 % (apraclonidine NPB hcl) ISTALOL OPHTHALMIC SOLUTION 0.5 % (timolol NF maleate) latanoprost ophthalmic solution 0.005 % G levobunolol hcl ophthalmic solution 0.5 % G LUMIGAN OPHTHALMIC SOLUTION 0.01 % NF (bimatoprost) pilocarpine hcl ophthalmic solution 1 %, 2 %, 4 % G SIMBRINZA OPHTHALMIC SUSPENSION 1-0.2 % PB (brinzolamide-brimonidine) timolol maleate ophthalmic gel forming solution 0.25 %, 0.5 % G

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 202 Prescription Drug Name Drug Tier Drug Notes timolol maleate ophthalmic solution 0.25 %, 0.5 %, 0.5 % G (daily) TIMOPTIC OCUDOSE OPHTHALMIC SOLUTION 0.25 NF %, 0.5 % (timolol maleate) TRAVATAN Z OPHTHALMIC SOLUTION 0.004 % NF (travoprost) VYZULTA OPHTHALMIC SOLUTION 0.024 % NF (latanoprostene bunod) XELPROS OPHTHALMIC EMULSION 0.005 % NF (latanoprost) ZIOPTAN OPHTHALMIC SOLUTION 0.0015 % PB (tafluprost) ANTI-INFECTIVE/ANTI-INFLAMMATORY - DRUGS TO TREAT INFECTIONS AND INFLAMMATION bacitra-neomycin-polymyxin-hc ophthalmic ointment 1 % G BLEPHAMIDE OPHTHALMIC SUSPENSION 10-0.2 % NPB (sulfacetamide-prednisolone) BLEPHAMIDE S.O.P. OPHTHALMIC OINTMENT 10-0.2 NPB % (sulfacetamide-prednisolone) double pm ophthalmic solution reconstituted 1-0.5 % NF neomycin-polymyxin-dexameth ophthalmic ointment 3.5-10000- G 0.1 neomycin-polymyxin-dexameth ophthalmic suspension 3.5- G 10000-0.1 neomycin-polymyxin-hc ophthalmic suspension 3.5-10000-1 G bacitracin-polymyx-neo-hc (Neo-Polycin Hc Ophthalmic G Ointment 1 %) PRED-G OPHTHALMIC SUSPENSION 0.3-1 % NPB (gentamicin-prednisolone acet) PRED-G S.O.P. OPHTHALMIC OINTMENT 0.3-0.6 % NPB (gentamicin-prednisolone acet) prednisolone-gatifloxacin ophthalmic suspension 1-0.5 % NF sulfacetamide-prednisolone ophthalmic solution 10-0.23 % G TOBRADEX OPHTHALMIC OINTMENT 0.3-0.1 % NF (tobramycin-dexamethasone) TOBRADEX OPHTHALMIC SUSPENSION 0.3-0.1 % NF (tobramycin-dexamethasone) TOBRADEX ST OPHTHALMIC SUSPENSION 0.3-0.05 % NF (tobramycin-dexamethasone) 2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 203 Prescription Drug Name Drug Tier Drug Notes tobramycin-dexamethasone ophthalmic suspension 0.3-0.1 % G triple pmb ophthalmic solution reconstituted 1-0.5-0.09 % NF triple pmk ophthalmic solution reconstituted 1-0.5-0.5 % NF ZYLET OPHTHALMIC SUSPENSION 0.5-0.3 % NPB (loteprednol-tobramycin) ANTI-INFECTIVES - DRUGS TO TREAT INFECTIONS ak-poly-bac ophthalmic ointment 500-10000 unit/gm G AZASITE OPHTHALMIC SOLUTION 1 % (azithromycin) NF bacitracin ophthalmic ointment 500 unit/gm G bacitracin-polymyxin b ophthalmic ointment 500-10000 unit/gm G BESIVANCE OPHTHALMIC SUSPENSION 0.6 % NF (besifloxacin hcl) BETADINE OPHTHALMIC PREP OPHTHALMIC NPB SOLUTION 5 % (povidone-iodine) CILOXAN OPHTHALMIC OINTMENT 0.3 % NF (ciprofloxacin hcl) CILOXAN OPHTHALMIC SOLUTION 0.3 % NF (ciprofloxacin hcl) ciprofloxacin hcl ophthalmic solution 0.3 % G erythromycin ophthalmic ointment 5 mg/gm G gatifloxacin ophthalmic solution 0.5 % G GENTAK OPHTHALMIC OINTMENT 0.3 % (gentamicin G sulfate) gentamicin sulfate ophthalmic solution 0.3 % G levofloxacin ophthalmic solution 0.5 % G MITOSOL OPHTHALMIC KIT 0.2 MG (mitomycin) NPB MOXEZA OPHTHALMIC SOLUTION 0.5 % (moxifloxacin NPB hcl) moxifloxacin hcl ophthalmic solution 0.5 % G NATACYN OPHTHALMIC SUSPENSION 5 % NPB (natamycin) neomycin-bacitracin zn-polymyx ophthalmic ointment 3.5-400- G 10000 , 5-400-10000 neomycin-polymyxin-gramicidin ophthalmic solution 1.75- G 10000-.025 neomycin-bacitracin zn-polymyx (Neo-Polycin Ophthalmic G Ointment 3.5-400-10000)

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 204 Prescription Drug Name Drug Tier Drug Notes ofloxacin ophthalmic solution 0.3 % G bacitracin-polymyxin b (Polycin Ophthalmic Ointment 500- G 10000 Unit/Gm) polymyxin b-trimethoprim ophthalmic solution 10000-0.1 G unit/ml-% povidone-iodine ophthalmic solution 5 % NPB sulfacetamide sodium ophthalmic ointment 10 % G sulfacetamide sodium ophthalmic solution 10 % G tobramycin ophthalmic solution 0.3 % G TOBREX OPHTHALMIC OINTMENT 0.3 % (tobramycin) NPB trifluridine ophthalmic solution 1 % G ZIRGAN OPHTHALMIC GEL 0.15 % (ganciclovir) NF ZYMAXID OPHTHALMIC SOLUTION 0.5 % NF (gatifloxacin) ANTI-INFLAMMATORIES - DRUGS TO TREAT INFLAMMATION ALREX OPHTHALMIC SUSPENSION 0.2 % (loteprednol NPB etabonate) bromfenac sodium (once-daily) ophthalmic solution 0.09 % G BROMSITE OPHTHALMIC SOLUTION 0.075 % NF (bromfenac sodium) dexamethasone sodium phosphate ophthalmic solution 0.1 % G DEXTENZA OPHTHALMIC INSERT 0.4 MG NF (dexamethasone) DEXYCU INTRAOCULAR SUSPENSION 9 % NF (dexamethasone) diclofenac sodium ophthalmic solution 0.1 % G DUREZOL OPHTHALMIC EMULSION 0.05 % PB (difluprednate) FLAREX OPHTHALMIC SUSPENSION 0.1 % NF (fluorometholone acetate) fluorometholone ophthalmic suspension 0.1 % G flurbiprofen sodium ophthalmic solution 0.03 % G FML FORTE OPHTHALMIC SUSPENSION 0.25 % NF (fluorometholone) FML LIQUIFILM OPHTHALMIC SUSPENSION 0.1 % NF (fluorometholone)

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 205 Prescription Drug Name Drug Tier Drug Notes FML OPHTHALMIC OINTMENT 0.1 % (fluorometholone) NF ILEVRO OPHTHALMIC SUSPENSION 0.3 % (nepafenac) NF INVELTYS OPHTHALMIC SUSPENSION 1 % (loteprednol NF etabonate) ketorolac tromethamine ophthalmic solution 0.4 %, 0.5 % G KLARITY-L OPHTHALMIC EMULSION 0.2 %, 0.5 % NF (loteprednol etabonate) LOTEMAX OPHTHALMIC GEL 0.5 % (loteprednol NF etabonate) LOTEMAX OPHTHALMIC OINTMENT 0.5 % (loteprednol NF etabonate) LOTEMAX OPHTHALMIC SUSPENSION 0.5 % NF (loteprednol etabonate) LOTEMAX SM OPHTHALMIC GEL 0.38 % (loteprednol NF etabonate) loteprednol etabonate ophthalmic suspension 0.5 % G MAXIDEX OPHTHALMIC SUSPENSION 0.1 % NF (dexamethasone) NEVANAC OPHTHALMIC SUSPENSION 0.1 % NF (nepafenac) OZURDEX INTRAVITREAL IMPLANT 0.7 MG NPSP (dexamethasone) PRED FORTE OPHTHALMIC SUSPENSION 1 % NF (prednisolone acetate) PRED MILD OPHTHALMIC SUSPENSION 0.12 % NF (prednisolone acetate) prednisolone acetate ophthalmic suspension 1 % G prednisolone acetate p-f ophthalmic suspension 1 % NF prednisolone sodium phosphate ophthalmic solution 1 % NPB PROLENSA OPHTHALMIC SOLUTION 0.07 % NF (bromfenac sodium) YUTIQ INTRAVITREAL IMPLANT 0.18 MG (fluocinolone NF acetonide) DRY EYE DISEASE XIIDRA OPHTHALMIC SOLUTION 5 % (lifitegrast) PB MISCELLANEOUS DUOVISC INTRAOCULAR KIT 0.85-0.5 ML (na hyalur & NPB na chond-na hyalur)

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 206 Prescription Drug Name Drug Tier Drug Notes HEALON DUET PRO INTRAOCULAR SOLUTION NPB PREFILLED SYRINGE 1 & 3 % (sodium hyaluronate) HEALON GV PRO INTRAOCULAR SOLUTION 18 NPB MG/ML (sodium hyaluronate) RHOPRESSA OPHTHALMIC SOLUTION 0.02 % PB (netarsudil dimesylate) ROCKLATAN OPHTHALMIC SOLUTION 0.02-0.005 % NF (netarsudil-latanoprost) RETINAL DISORDERS EYLEA INTRAVITREAL SOLUTION 2 MG/0.05ML PSP (aflibercept) EYLEA INTRAVITREAL SOLUTION PREFILLED PSP SYRINGE 2 MG/0.05ML (aflibercept) LUCENTIS INTRAVITREAL SOLUTION 0.3 PSP MG/0.05ML, 0.5 MG/0.05ML (ranibizumab) LUCENTIS INTRAVITREAL SOLUTION PREFILLED PSP SYRINGE 0.3 MG/0.05ML, 0.5 MG/0.05ML (ranibizumab) OTHER IRRIGATION SOLUTIONS water for irrigation, sterile (Argyle Sterile Water Irrigation G Solution) lactated ringers irrigation solution G irrigation solns physiological (Physiolyte Irrigation Solution) G irrigation solns physiological (Physiosol Irrigation Irrigation G Solution) ringers irrigation irrigation solution G sterile water for irrigation irrigation solution G ringers irrigation (Tis-U-Sol Irrigation Solution) G RESPIRATORY - DRUGS TO TREAT BREATHING DISORDERS ANAPHYLAXIS TREATMENT AGENTS ADRENALIN INJECTION SOLUTION 1 MG/ML, 30 NPB MG/30ML (epinephrine) ADYPHREN AMP II INJECTION KIT 1 MG/ML NF (epinephrine) ADYPHREN AMP INJECTION KIT 1 MG/ML NF (epinephrine) ADYPHREN II INJECTION KIT 1 MG/ML (epinephrine) NF

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 207 Prescription Drug Name Drug Tier Drug Notes ADYPHREN INJECTION KIT 1 MG/ML (epinephrine) NF AUVI-Q INJECTION SOLUTION AUTO-INJECTOR 0.1 NF MG/0.1ML, 0.15 MG/0.15ML, 0.3 MG/0.3ML (epinephrine) epinephrine injection solution auto-injector 0.15 mg/0.15ml, 0.15 G mg/0.3ml, 0.3 mg/0.3ml epinephrine intravenous solution 1 mg/10ml NPB epinephrine intravenous solution prefilled syringe 1 mg/10ml NPB epinephrine professional injection kit 1 mg/ml NF EPINEPHRINESNAP-EMS INJECTION KIT 1 MG/ML NF (epinephrine) EPINEPHRINESNAP-V INJECTION KIT 1 MG/ML NF (epinephrine) EPISNAP INJECTION KIT 1 MG/ML (epinephrine) NF SYMJEPI INJECTION SOLUTION PREFILLED PB SYRINGE 0.15 MG/0.3ML, 0.3 MG/0.3ML (epinephrine) ANTIALLERGICS - DRUGS TO TREAT ALLERGIES acetylcysteine inhalation solution 10 % G ANTICHOLINERGIC/BETA AGONIST COMBINATIONS - DRUGS TO TREAT COPD AIRDUO RESPICLICK 113/14 INHALATION AEROSOL POWDER BREATH ACTIVATED 113-14 MCG/ACT NF (fluticasone-salmeterol) AIRDUO RESPICLICK 232/14 INHALATION AEROSOL POWDER BREATH ACTIVATED 232-14 MCG/ACT NF (fluticasone-salmeterol) AIRDUO RESPICLICK 55/14 INHALATION AEROSOL POWDER BREATH ACTIVATED 55-14 MCG/ACT NF (fluticasone-salmeterol) ANORO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 62.5-25 MCG/INH (umeclidinium- PB vilanterol) BEVESPI AEROSPHERE INHALATION AEROSOL 9-4.8 NF MCG/ACT (glycopyrrolate-formoterol) BREZTRI AEROSPHERE INHALATION AEROSOL 160- NPB 9-4.8 MCG/ACT (budeson-glycopyrrol-formoterol) COMBIVENT RESPIMAT INHALATION AEROSOL NPB SOLUTION 20-100 MCG/ACT (ipratropium-albuterol)

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 208 Prescription Drug Name Drug Tier Drug Notes DULERA INHALATION AEROSOL 100-5 MCG/ACT, 200-5 MCG/ACT, 50-5 MCG/ACT (mometasone furo- NF formoterol fum) fluticasone-salmeterol inhalation aerosol powder breath NF activated 113-14 mcg/act, 232-14 mcg/act, 55-14 mcg/act ipratropium-albuterol inhalation solution 0.5-2.5 (3) mg/3ml G STIOLTO RESPIMAT INHALATION AEROSOL SOLUTION 2.5-2.5 MCG/ACT (tiotropium bromide- PB olodaterol) TRELEGY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100-62.5-25 MCG/INH, PB 200-62.5-25 MCG/INH (fluticasone-umeclidin-vilant) ANTICHOLINERGICS - DRUGS TO TREAT COPD ATROVENT HFA INHALATION AEROSOL SOLUTION NF 17 MCG/ACT (ipratropium bromide hfa) INCRUSE ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 62.5 MCG/INH (umeclidinium NF bromide) ipratropium bromide inhalation solution 0.02 % G ipratropium bromide nasal solution 0.03 %, 0.06 % G LONHALA MAGNAIR REFILL KIT INHALATION NF SOLUTION 25 MCG/ML (glycopyrrolate) LONHALA MAGNAIR STARTER KIT INHALATION NF SOLUTION 25 MCG/ML (glycopyrrolate) SPIRIVA HANDIHALER INHALATION CAPSULE 18 PB MCG (tiotropium bromide monohydrate) SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 1.25 MCG/ACT, 2.5 MCG/ACT (tiotropium PB bromide monohydrate) TUDORZA PRESSAIR INHALATION AEROSOL POWDER BREATH ACTIVATED 400 MCG/ACT NF (aclidinium bromide) YUPELRI INHALATION SOLUTION 175 MCG/3ML PB (revefenacin) ANTIHISTAMINE COMBINATIONS DERMACINRX AZENASE PAK NASAL THERAPY NF PACK 137 & 50 MCG/ACT (azelastine-fluticasone) DYMISTA NASAL SUSPENSION 137-50 MCG/ACT PB (azelastine-fluticasone)

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 209 Prescription Drug Name Drug Tier Drug Notes ANTIHISTAMINES - DRUGS TO TREAT ALLERGIES azelastine hcl nasal solution 0.15 %, 137 mcg/spray G carbinoxamine maleate oral solution 4 mg/5ml G carbinoxamine maleate oral tablet 4 mg G carbinoxamine maleate oral tablet 6 mg NF cetirizine hcl oral solution 1 mg/ml G clemastine fumarate oral tablet 2.68 mg G cyproheptadine hcl oral syrup 2 mg/5ml G cyproheptadine hcl oral tablet 4 mg G desloratadine oral tablet 5 mg G desloratadine oral tablet dispersible 2.5 mg, 5 mg G dexchlorpheniramine maleate oral solution 2 mg/5ml NF diphen oral elixir 12.5 mg/5ml NF diphenhydramine hcl oral elixir 12.5 mg/5ml G hydroxyzine hcl oral syrup 10 mg/5ml G hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg G hydroxyzine pamoate oral capsule 100 mg, 25 mg, 50 mg G KARBINAL ER ORAL SUSPENSION EXTENDED NPB RELEASE 4 MG/5ML (carbinoxamine maleate) levocetirizine dihydrochloride oral solution 2.5 mg/5ml G levocetirizine dihydrochloride oral tablet 5 mg G olopatadine hcl nasal solution 0.6 % G RYCLORA ORAL SOLUTION 2 MG/5ML NF (dexchlorpheniramine maleate) RYVENT ORAL TABLET 6 MG (carbinoxamine maleate) G BETA AGONISTS - DRUGS TO TREAT ASTHMA AND COPD albuterol sulfate hfa inhalation aerosol solution 108 (90 base) G mcg/act albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) G 0.083%, 0.63 mg/3ml, 1.25 mg/3ml, 2.5 mg/0.5ml albuterol sulfate oral syrup 2 mg/5ml G albuterol sulfate oral tablet 2 mg, 4 mg G BROVANA INHALATION NEBULIZATION SOLUTION NF 15 MCG/2ML (arformoterol tartrate)

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 210 Prescription Drug Name Drug Tier Drug Notes levalbuterol hcl inhalation nebulization solution 0.31 mg/3ml, G 0.63 mg/3ml, 1.25 mg/0.5ml, 1.25 mg/3ml levalbuterol tartrate inhalation aerosol 45 mcg/act G PERFOROMIST INHALATION NEBULIZATION PB SOLUTION 20 MCG/2ML (formoterol fumarate) PROAIR DIGIHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 108 (90 BASE) NF MCG/ACT (albuterol sulfate) PROAIR HFA INHALATION AEROSOL SOLUTION 108 NPB (90 BASE) MCG/ACT (albuterol sulfate) PROAIR RESPICLICK INHALATION AEROSOL POWDER BREATH ACTIVATED 108 (90 BASE) NPB MCG/ACT (albuterol sulfate) PROVENTIL HFA INHALATION AEROSOL SOLUTION NF 108 (90 BASE) MCG/ACT (albuterol sulfate) SEREVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 50 MCG/DOSE NF (salmeterol xinafoate) STRIVERDI RESPIMAT INHALATION AEROSOL PB SOLUTION 2.5 MCG/ACT (olodaterol hcl) terbutaline sulfate oral tablet 2.5 mg, 5 mg G VENTOLIN HFA INHALATION AEROSOL SOLUTION NF 108 (90 BASE) MCG/ACT (albuterol sulfate) XOPENEX HFA INHALATION AEROSOL 45 MCG/ACT NF (levalbuterol tartrate) BIOLOGIC RESPONSE MODIFIERS FASENRA PEN SUBCUTANEOUS SOLUTION AUTO- PSP INJECTOR 30 MG/ML (benralizumab) FASENRA SUBCUTANEOUS SOLUTION PREFILLED PSP SYRINGE 30 MG/ML (benralizumab) NUCALA SUBCUTANEOUS SOLUTION PSP RECONSTITUTED 100 MG (mepolizumab) XOLAIR SUBCUTANEOUS SOLUTION PREFILLED PSP SYRINGE 150 MG/ML, 75 MG/0.5ML (omalizumab) XOLAIR SUBCUTANEOUS SOLUTION PSP RECONSTITUTED 150 MG (omalizumab) COLD/COUGH benzonatate oral capsule 100 mg, 200 mg G

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 211 Prescription Drug Name Drug Tier Drug Notes CLARINEX-D 12 HOUR ORAL TABLET EXTENDED RELEASE 12 HOUR 2.5-120 MG (desloratadine- NPB pseudoephedrine) g tussin ac oral solution 100-10 mg/5ml G GILPHEX TR ORAL TABLET 10-388 MG (phenylephrine- NPB guaifenesin) guaiatussin ac oral syrup 100-10 mg/5ml G guaifenesin-codeine oral solution 100-10 mg/5ml G hydrocod polst-cpm polst er oral suspension extended release 10- G 8 mg/5ml hydrocodone-homatropine oral syrup 5-1.5 mg/5ml G hydrocodone-homatropine oral tablet 5-1.5 mg G hydromet oral syrup 5-1.5 mg/5ml G promethazine-codeine oral solution 6.25-10 mg/5ml G promethazine-codeine oral syrup 6.25-10 mg/5ml G promethazine-dm oral syrup 6.25-15 mg/5ml G promethazine-phenyleph-codeine oral syrup 6.25-5-10 mg/5ml G promethazine-phenylephrine oral syrup 6.25-5 mg/5ml G pseudoeph-bromphen-dm oral syrup 30-2-10 mg/5ml G TUSNEL C ORAL SYRUP 30-10-100 MG/5ML NPB (pseudoephedrine-codeine-gg) TUSSICAPS ORAL CAPSULE EXTENDED RELEASE 12 NPB HOUR 10-8 MG (hydrocod polst-chlorphen polst) TUXARIN ER ORAL TABLET EXTENDED RELEASE NF 12 HOUR 54.3-8 MG (chlorpheniramine-codeine) TUZISTRA XR ORAL SUSPENSION EXTENDED NF RELEASE 14.7-2.8 MG/5ML (codeine polst-chlorphen polst) virtussin a/c oral solution 100-10 mg/5ml G virtussin dac oral solution 30-10-100 mg/5ml G LEUKOTRIENE MODIFIERS zileuton er oral tablet extended release 12 hour 600 mg NF ZYFLO ORAL TABLET 600 MG (zileuton) NPB LEUKOTRIENE RECEPTOR ANTAGONISTS - DRUGS TO TREAT ASTHMA AND ALLERGIES montelukast sodium oral packet 4 mg G montelukast sodium oral tablet 10 mg G montelukast sodium oral tablet chewable 4 mg, 5 mg G 2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 212 Prescription Drug Name Drug Tier Drug Notes SINGULAIR ORAL PACKET 4 MG (montelukast sodium) NF SINGULAIR ORAL TABLET 10 MG (montelukast sodium) NF SINGULAIR ORAL TABLET CHEWABLE 4 MG, 5 MG NF (montelukast sodium) zafirlukast oral tablet 10 mg, 20 mg G MAST CELL STABILIZERS - DRUGS TO TREAT ALLERGIES cromolyn sodium inhalation nebulization solution 20 mg/2ml G MISCELLANEOUS acetylcysteine inhalation solution 20 % G ADRENALIN NASAL SOLUTION 0.1 % (epinephrine hcl NPB (nasal)) AKOVAZ INTRAVENOUS SOLUTION 50 MG/ML NF (ephedrine sulfate (pressors)) ARALAST NP INTRAVENOUS SOLUTION RECONSTITUTED 1000 MG, 500 MG (alpha1-proteinase NF inhibitor) CUROSURF INTRATRACHEAL SUSPENSION 120 NPB MG/1.5ML, 240 MG/3ML (poractant alfa) DALIRESP ORAL TABLET 250 MCG, 500 MCG PB (roflumilast) epinephrine intravenous solution prefilled syringe 0.1 mg/10ml NPB ESBRIET ORAL CAPSULE 267 MG (pirfenidone) PSP ESBRIET ORAL TABLET 267 MG, 801 MG (pirfenidone) PSP GIAPREZA INTRAVENOUS SOLUTION 2.5 MG/ML NF (angiotensin ii acetate) GLASSIA INTRAVENOUS SOLUTION 1000 MG/50ML NF (alpha1-proteinase inhibitor) HYPERSAL INHALATION NEBULIZATION NPB SOLUTION 3.5 % (sodium chloride) INFASURF INTRATRACHEAL SUSPENSION 35-0.9 NPB MG/ML-% (calfactant in nacl) KALYDECO ORAL PACKET 25 MG, 50 MG, 75 MG NPB (ivacaftor) ORKAMBI ORAL PACKET 100-125 MG, 150-188 MG NPB (lumacaftor-ivacaftor) ORKAMBI ORAL TABLET 100-125 MG, 200-125 MG NPB (lumacaftor-ivacaftor)

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 213 Prescription Drug Name Drug Tier Drug Notes phenylephrine hcl (pressors) intravenous solution 0.8 mg/10ml NPB phenylephrine hcl intravenous solution 1 mg/10ml NPB PROLASTIN-C INTRAVENOUS SOLUTION 1000 PSP MG/20ML (alpha1-proteinase inhibitor) PROLASTIN-C INTRAVENOUS SOLUTION PSP RECONSTITUTED 1000 MG (alpha1-proteinase inhibitor) sodium chloride inhalation nebulization solution 0.9 %, 10 %, 3 G %, 7 % SURVANTA INTRATRACHEAL SUSPENSION 25-0.9 NPB MG/ML-% (beractant in nacl) SYMDEKO ORAL TABLET THERAPY PACK 100-150 & NPB 150 MG, 50-75 & 75 MG (tezacaftor-ivacaftor) TRIKAFTA ORAL TABLET THERAPY PACK 100-50-75 & 150 MG, 50-25-37.5 & 75 MG (elexacaftor-tezacaftor- NPB ivacaft) ZEMAIRA INTRAVENOUS SOLUTION NF RECONSTITUTED 1000 MG (alpha1-proteinase inhibitor) NASAL STEROIDS - DRUGS TO TREAT ALLERGIES BECONASE AQ NASAL SUSPENSION 42 MCG/SPRAY NF (beclomethasone diprop monohyd) flunisolide nasal solution 25 mcg/act (0.025%) G fluticasone propionate nasal suspension 50 mcg/act G mometasone furoate nasal suspension 50 mcg/act G OMNARIS NASAL SUSPENSION 50 MCG/ACT NF (ciclesonide) QNASL CHILDRENS NASAL AEROSOL SOLUTION 40 NF MCG/ACT (beclomethasone diprop (nasal)) QNASL NASAL AEROSOL SOLUTION 80 MCG/ACT NF (beclomethasone diprop (nasal)) SINUVA NASAL IMPLANT 1350 MCG (mometasone NF furoate) XHANCE NASAL EXHALER SUSPENSION 93 NPB MCG/ACT (fluticasone propionate) ZETONNA NASAL AEROSOL SOLUTION 37 MCG/ACT NF (ciclesonide) PULMONARY FIBROSIS AGENTS OFEV ORAL CAPSULE 100 MG, 150 MG (nintedanib PSP esylate)

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 214 Prescription Drug Name Drug Tier Drug Notes SEVERE ASTHMA AGENTS DUPIXENT SOLUTION PEN-INJECTOR 200 MG/1.14ML SUBCUTANEOUS 200 MG/1.14ML PSP (dupilumab) DUPIXENT SOLUTION PEN-INJECTOR 300 MG/2ML PSP SUBCUTANEOUS 300 MG/2ML (dupilumab) DUPIXENT SOLUTION PREFILLED SYRINGE 200 MG/1.14ML SUBCUTANEOUS 200 MG/1.14ML PSP (dupilumab) DUPIXENT SOLUTION PREFILLED SYRINGE 300 PSP MG/2ML SUBCUTANEOUS 300 MG/2ML (dupilumab) STEROID INHALANTS - DRUGS TO TREAT ASTHMA ALVESCO INHALATION AEROSOL SOLUTION 160 NF MCG/ACT, 80 MCG/ACT (ciclesonide) ARNUITY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/ACT, 200 PB MCG/ACT, 50 MCG/ACT (fluticasone furoate) ASMANEX (120 METERED DOSES) INHALATION AEROSOL POWDER BREATH ACTIVATED 220 NPB MCG/INH (mometasone furoate) ASMANEX (14 METERED DOSES) INHALATION AEROSOL POWDER BREATH ACTIVATED 220 NPB MCG/INH (mometasone furoate) ASMANEX (30 METERED DOSES) INHALATION AEROSOL POWDER BREATH ACTIVATED 110 NPB MCG/INH, 220 MCG/INH (mometasone furoate) ASMANEX (60 METERED DOSES) INHALATION AEROSOL POWDER BREATH ACTIVATED 220 NPB MCG/INH (mometasone furoate) ASMANEX (7 METERED DOSES) INHALATION AEROSOL POWDER BREATH ACTIVATED 110 NPB MCG/INH (mometasone furoate) ASMANEX HFA INHALATION AEROSOL 100 NPB MCG/ACT, 200 MCG/ACT (mometasone furoate) ASMANEX HFA INHALATION AEROSOL 50 NF MCG/ACT (mometasone furoate) budesonide inhalation suspension 0.25 mg/2ml, 0.5 mg/2ml, 1 G mg/2ml

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 215 Prescription Drug Name Drug Tier Drug Notes FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/BLIST, 250 PB MCG/BLIST, 50 MCG/BLIST (fluticasone propionate (inhal)) FLOVENT HFA INHALATION AEROSOL 110 MCG/ACT, 220 MCG/ACT, 44 MCG/ACT (fluticasone PB propionate hfa) PULMICORT FLEXHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 180 MCG/ACT, 90 PB MCG/ACT (budesonide) PULMICORT INHALATION SUSPENSION 0.25 NF MG/2ML, 0.5 MG/2ML, 1 MG/2ML (budesonide) PULMOZYME INHALATION SOLUTION 1 MG/ML NPSP (dornase alfa) QVAR REDIHALER INHALATION AEROSOL BREATH ACTIVATED 40 MCG/ACT, 80 MCG/ACT (beclomethasone PB diprop hfa) STEROID/BETA-AGONIST COMBINATIONS - DRUGS TO TREAT ASTHMA AND COPD ADVAIR HFA INHALATION AEROSOL 115-21 N8 (Listing does not include MCG/ACT, 230-21 MCG/ACT, 45-21 MCG/ACT PB certain NDCs) (fluticasone-salmeterol) BREO ELLIPTA INHALATION AEROSOL POWDER N8 (Listing does not include BREATH ACTIVATED 100-25 MCG/INH, 200-25 PB certain NDCs) MCG/INH (fluticasone furoate-vilanterol) SYMBICORT INHALATION AEROSOL 160-4.5 MCG/ACT, 80-4.5 MCG/ACT (budesonide-formoterol PB fumarate) XANTHINES - DRUGS TO TREAT COPD ELIXOPHYLLIN ORAL ELIXIR 80 MG/15ML NPB (theophylline) THEO-24 ORAL CAPSULE EXTENDED RELEASE 24 NF HOUR 100 MG, 200 MG, 300 MG, 400 MG (theophylline) theophylline er oral tablet extended release 12 hour 300 mg, 450 G mg theophylline er oral tablet extended release 24 hour 400 mg, 600 G mg theophylline oral solution 80 mg/15ml G

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 216 Prescription Drug Name Drug Tier Drug Notes TOPICAL - DRUGS TO TREAT EAR AND SKIN CONDITIONS DERMATOLOGY, ACNE ABSORICA ORAL CAPSULE 10 MG, 20 MG, 25 MG, 30 NPB MG, 35 MG, 40 MG (isotretinoin) ACANYA EXTERNAL GEL 1.2-2.5 % (clindamycin phos- NF benzoyl perox) ACZONE EXTERNAL GEL 7.5 % (dapsone) NPB adapalene external cream 0.1 % G adapalene external gel 0.1 %, 0.3 % G adapalene external pad 0.1 % NF adapalene-benzoyl peroxide external gel 0.1-2.5 % G ALTRENO EXTERNAL LOTION 0.05 % (tretinoin) NF isotretinoin (Amnesteem Oral Capsule 10 Mg, 20 Mg, 40 Mg) G ARAZLO EXTERNAL LOTION 0.045 % (tazarotene) NPB ATRALIN EXTERNAL GEL 0.05 % (tretinoin) NF tretinoin (Avita External Cream 0.025 %) G tretinoin (Avita External Gel 0.025 %) G AZELEX EXTERNAL CREAM 20 % (azelaic acid) NF BENZACLIN EXTERNAL GEL 1-5 % (clindamycin phos- NF benzoyl perox) BENZACLIN WITH PUMP EXTERNAL GEL 1-5 % NF (clindamycin phos-benzoyl perox) benzoyl peroxide (Benzepro External Foam 5.3 %) G benzoyl peroxide (Benzepro Short Contact External Foam 9.8 G %) benzoyl perox-hydrocortisone external lotion 5-0.5 % G benzoyl peroxide external foam 9.8 % G benzoyl peroxide-erythromycin external gel 5-3 % G bp wash external liquid 2.5 %, 7 % G isotretinoin (Claravis Oral Capsule 10 Mg, 20 Mg, 30 Mg, 40 G Mg) clindamycin phosphate (Clindacin Etz External Swab 1 %) G clindamycin phosphate (Clindacin-P External Swab 1 %) G CLINDAGEL EXTERNAL GEL 1 % (clindamycin NF phosphate)

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 217 Prescription Drug Name Drug Tier Drug Notes clindamycin phos-benzoyl perox external gel 1-5 %, 1.2-2.5 %, G 1.2-5 % clindamycin phosphate external foam 1 % G clindamycin phosphate external gel 1 % NF clindamycin phosphate external lotion 1 % G clindamycin phosphate external solution 1 % G clindamycin phosphate external swab 1 % G clindamycin-tretinoin external gel 1.2-0.025 % G CLINOIN EXTERNAL CREAM 1.25-0.025-1 % NF (clindamycin-tretinoin-cholesty) dapsone external gel 5 % G DIFFERIN EXTERNAL LOTION 0.1 % (adapalene) NF EPIDUO FORTE EXTERNAL GEL 0.3-2.5 % (adapalene- PB benzoyl peroxide) ery external pad 2 % G erythromycin external gel 2 % G erythromycin external solution 2 % G FABIOR EXTERNAL FOAM 0.1 % (tazarotene) NF isotretinoin oral capsule 10 mg, 20 mg, 30 mg, 40 mg G isotretinoin (Myorisan Oral Capsule 10 Mg, 20 Mg, 30 Mg, 40 G Mg) clindamycin-benzoyl per (refr) (Neuac External Gel 1.2-5 %) G NEUAC EXTERNAL KIT 1.2-5 % (clindamycin-benzoyl per- NF moist) NUCARACLINPAK EXTERNAL KIT 1 % (clindamycin NF phos- moisturizer) NUCARARXPAK EXTERNAL KIT 1-2.5 % (clindamycin- NF benzoyl per-moist) ONEXTON EXTERNAL GEL 1.2-3.75 % (clindamycin phos- PB benzoyl perox) PR BENZOYL PEROXIDE EXTERNAL LIQUID 6.9 % NPB (benzoyl peroxide) benzoyl peroxide (Pr Benzoyl Peroxide Wash External Liquid 7 G %) resorcinol-sulfur external lotion 2-5 % G RETIN-A MICRO EXTERNAL GEL 0.04 %, 0.1 % NPB (tretinoin microsphere)

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 218 Prescription Drug Name Drug Tier Drug Notes RETIN-A MICRO PUMP EXTERNAL GEL 0.04 %, 0.06 NPB %, 0.08 %, 0.1 % (tretinoin microsphere) RIAX EXTERNAL FOAM 5.5 %, 9.5 % (benzoyl peroxide) NPB sodium sulfacetamide-bakuchiol external liquid 10 % NPB sulfacetamide sodium (acne) external lotion 10 % G sulfacetamide sodium-sulfur external pad 10-4 % G sulfamez wash external emulsion 10-1 % G tretinoin external cream 0.025 %, 0.05 %, 0.1 % G tretinoin external gel 0.01 %, 0.025 %, 0.05 % G tretinoin microsphere external gel 0.04 %, 0.1 % G tretinoin microsphere pump external gel 0.04 % G benzoyl perox-hydrocortisone (Vanoxide-Hc External Lotion 5- NF 0.5 %) VELTIN EXTERNAL GEL 1.2-0.025 % (clindamycin- NF tretinoin) zaclir cleansing external lotion 8 % NPB isotretinoin (Zenatane Oral Capsule 10 Mg, 20 Mg, 30 Mg, 40 G Mg) ZIANA EXTERNAL GEL 1.2-0.025 % (clindamycin- NF tretinoin) DERMATOLOGY, ACTINIC KERATOSIS CARAC EXTERNAL CREAM 0.5 % (fluorouracil) NF FLUOROPLEX EXTERNAL CREAM 1 % (fluorouracil) NF fluorouracil external cream 0.5 % NF fluorouracil external cream 5 % G fluorouracil external solution 2 %, 5 % G imiquimod external cream 5 % G imiquimod pump external cream 3.75 % G ZYCLARA EXTERNAL CREAM 3.75 % (imiquimod) NF ZYCLARA PUMP EXTERNAL CREAM 2.5 % (imiquimod) NF DERMATOLOGY, ANTIBIOTICS ALTABAX EXTERNAL OINTMENT 1 % (retapamulin) NPB CENTANY EXTERNAL OINTMENT 2 % (mupirocin) NPB gentamicin sulfate external cream 0.1 % G gentamicin sulfate external ointment 0.1 % G mafenide acetate external packet 5 % G 2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 219 Prescription Drug Name Drug Tier Drug Notes mupirocin calcium external cream 2 % NF mupirocin external ointment 2 % G NEO-SYNALAR EXTERNAL CREAM 0.5-0.025 % NF (neomycin-fluocinolone) NEO-SYNALAR EXTERNAL KIT 0.5-0.025 % (neo- NF fluocinolone & emollient) silver sulfadiazine external cream 1 % G silver sulfadiazine (Ssd External Cream 1 %) G SULFAMYLON EXTERNAL CREAM 85 MG/GM NPB (mafenide acetate) XEPI EXTERNAL CREAM 1 % (ozenoxacin) NPB DERMATOLOGY, ANTIFUNGALS ALA-QUIN EXTERNAL CREAM 3-0.5 % (clioquinol-hc) NF ALCORTIN A EXTERNAL GEL 1-2-1 % (iodoquinol-hc- NF aloe polysacch) ciclopirox (Ciclodan External Solution 8 %) G ciclopirox external gel 0.77 % G ciclopirox external shampoo 1 % G ciclopirox external solution 8 % G ciclopirox olamine external cream 0.77 % G ciclopirox olamine external suspension 0.77 % G clotrimazole external cream 1 % G clotrimazole external solution 1 % G clotrimazole-betamethasone external cream 1-0.05 % G clotrimazole-betamethasone external lotion 1-0.05 % G DERMACINRX THERAZOLE PAK EXTERNAL THERAPY PACK 1-0.05 & 20 % (clotrimazole-betameth & zn NF ox) econazole nitrate external cream 1 % G ECOZA EXTERNAL FOAM 1 % (econazole nitrate) NF ERTACZO EXTERNAL CREAM 2 % (sertaconazole nitrate) NF EXELDERM EXTERNAL CREAM 1 % (sulconazole NPB nitrate) EXELDERM EXTERNAL SOLUTION 1 % (sulconazole NPB nitrate) EXTINA EXTERNAL FOAM 2 % (ketoconazole) NPB

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 220 Prescription Drug Name Drug Tier Drug Notes fungimez external solution NF g-myco nail external solution NF JUBLIA EXTERNAL SOLUTION 10 % (efinaconazole) NF ketoconazole external cream 2 % G ketoconazole external foam 2 % NF ketoconazole (Ketodan External Foam 2 %) NF LOPROX EXTERNAL CREAM 0.77 % (ciclopirox olamine) NF LOPROX EXTERNAL KIT 0.77 % (SUSP) (ciclopirox NF olamine-cleanser) LOPROX EXTERNAL SUSPENSION 0.77 % (ciclopirox NF olamine) luliconazole external cream 1 % NF LUZU EXTERNAL CREAM 1 % (luliconazole) NF MENTAX EXTERNAL CREAM 1 % (butenafine hcl) NPB miconazole-zinc oxide-petrolat external ointment 0.25-15-81.35 G % MYCO NAIL EXTERNAL SOLUTION , 25 % (misc NF antifungal combo products) naftifine hcl external cream 1 %, 2 % G NAFTIN EXTERNAL GEL 1 %, 2 % (naftifine hcl) NF nystatin (Nyamyc External Powder 100000 Unit/Gm) G nystatin external cream 100000 unit/gm G nystatin external ointment 100000 unit/gm G nystatin external powder 100000 unit/gm G nystatin-triamcinolone external cream 100000-0.1 unit/gm-% G nystatin-triamcinolone external ointment 100000-0.1 unit/gm-% G nystatin (Nystop External Powder 100000 Unit/Gm) G oxiconazole nitrate external cream 1 % NF OXISTAT EXTERNAL CREAM 1 % (oxiconazole nitrate) NF OXISTAT EXTERNAL LOTION 1 % (oxiconazole nitrate) NF QUINJA EXTERNAL GEL 1.25-1 % (iodoquinol-aloe NF polysaccharide) RECURA EXTERNAL CREAM (misc antifungal combo NF products) VUSION EXTERNAL OINTMENT 0.25-15-81.35 % NF (miconazole-zinc oxide-petrolat)

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 221 Prescription Drug Name Drug Tier Drug Notes XOLEGEL COREPAK EXTERNAL KIT 2 & 1 % NF (ketoconazole-hydrocortisone) XOLEGEL DUO/HEAD & SHOULDERS EXTERNAL NF KIT 2 & 1 % (ketoconazole & pyrithione zinc) XOLEGEL DUO/XOLEX EXTERNAL KIT 2 & 1 % NF (ketoconazole & pyrithione zinc) XOLEGEL EXTERNAL GEL 2 % (ketoconazole) NF DERMATOLOGY, ANTIPRURITIC doxepin hcl external cream 5 % NF DERMATOLOGY, ANTIPSORIATICS acitretin oral capsule 10 mg, 17.5 mg, 25 mg G calcipotriene external cream 0.005 % NF calcipotriene external ointment 0.005 % G calcipotriene external solution 0.005 % G calcipotriene (Calcitrene External Ointment 0.005 %) G calcitriol external ointment 3 mcg/gm NF IBC (Preferred agent for COSENTYX (300 MG DOSE) SUBCUTANEOUS Ankylosing Spondylitis and SOLUTION PREFILLED SYRINGE 150 MG/ML PSP Psoriatic Arthritis. Not (secukinumab) covered for Psoriasis) IBC (Preferred agent for COSENTYX SENSOREADY (300 MG) SUBCUTANEOUS Ankylosing Spondylitis and PSP SOLUTION AUTO-INJECTOR 150 MG/ML (secukinumab) Psoriatic Arthritis. Not covered for Psoriasis) IBC (Preferred agent for COSENTYX SENSOREADY PEN SUBCUTANEOUS Ankylosing Spondylitis and PSP SOLUTION AUTO-INJECTOR 150 MG/ML (secukinumab) Psoriatic Arthritis. Not covered for Psoriasis.) IBC (Preferred agent for COSENTYX SUBCUTANEOUS SOLUTION PREFILLED Ankylosing Spondylitis and PSP SYRINGE 150 MG/ML (secukinumab) Psoriatic Arthritis. Not covered for Psoriasis) COSENTYX SUBCUTANEOUS SOLUTION PREFILLED PSP SYRINGE 75 MG/0.5ML (secukinumab) ILUMYA SUBCUTANEOUS SOLUTION PREFILLED NF SYRINGE 100 MG/ML (tildrakizumab-asmn) methoxsalen rapid oral capsule 10 mg G NUDERMRXPAK 120 EXTERNAL THERAPY PACK NF 0.005-5 % (calcipotriene-dimethicone) 2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 222 Prescription Drug Name Drug Tier Drug Notes NUDERMRXPAK 60 EXTERNAL THERAPY PACK NF 0.005-5 % (calcipotriene-dimethicone) SILIQ SUBCUTANEOUS SOLUTION PREFILLED NF SYRINGE 210 MG/1.5ML (brodalumab) SORIATANE ORAL CAPSULE 10 MG, 25 MG (acitretin) NPB SORILUX EXTERNAL FOAM 0.005 % (calcipotriene) NF tazarotene external cream 0.1 % G TAZORAC EXTERNAL CREAM 0.05 %, 0.1 % (tazarotene) NF TAZORAC EXTERNAL GEL 0.05 %, 0.1 % (tazarotene) NF VECTICAL EXTERNAL OINTMENT 3 MCG/GM NF (calcitriol) DERMATOLOGY, ANTISEBORRHEICS ESKATA EXTERNAL SOLUTION 40 % (hydrogen NF peroxide) glycolic acid solution 70 % NPB ketoconazole external shampoo 2 % G NUTRASEB EXTERNAL CREAM (antiseborrheic products, NPB misc.) OVACE PLUS EXTERNAL FOAM 9.8 % (sulfacetamide NF sodium) PROMISEB EXTERNAL CREAM (antiseborrheic products, NPB misc.) selenium sulfide external lotion 2.5 % G sodium sulfacetamide wash external liquid 10 % NPB DERMATOLOGY, ATOPIC DERMATITIS DUPIXENT SUBCUTANEOUS SOLUTION PEN- PSP INJECTOR 200 MG/1.14ML, 300 MG/2ML (dupilumab) DUPIXENT SUBCUTANEOUS SOLUTION PREFILLED PSP SYRINGE 200 MG/1.14ML, 300 MG/2ML (dupilumab) DERMATOLOGY, CORTICOSTEROIDS ADVANCED ALLERGY COLLECTION EXTERNAL NF KIT 2.5 % (hydrocortisone) ALA SCALP EXTERNAL LOTION 2 % (hydrocortisone) NPB ala-cort external cream 1 %, 2.5 % G alclometasone dipropionate external cream 0.05 % G alclometasone dipropionate external ointment 0.05 % G amcinonide external cream 0.1 % G

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 223 Prescription Drug Name Drug Tier Drug Notes amcinonide external lotion 0.1 % G amcinonide external ointment 0.1 % NPB APEXICON E EXTERNAL CREAM 0.05 % (diflorasone NF diacet emoll base) BESER EXTERNAL KIT 0.05 % (fluticasone-emollient) NF fluticasone propionate (Beser External Lotion 0.05 %) G betamethasone dipropionate aug external cream 0.05 % G betamethasone dipropionate aug external gel 0.05 % G betamethasone dipropionate aug external lotion 0.05 % G betamethasone dipropionate aug external ointment 0.05 % G betamethasone dipropionate external cream 0.05 % G betamethasone dipropionate external lotion 0.05 % G betamethasone dipropionate external ointment 0.05 % G betamethasone valerate external cream 0.1 % G betamethasone valerate external foam 0.12 % G betamethasone valerate external lotion 0.1 % G betamethasone valerate external ointment 0.1 % G BRYHALI EXTERNAL LOTION 0.01 % (halobetasol PB propionate) calcipotriene-betameth diprop external ointment 0.005-0.064 % NF calcipotriene-betameth diprop external suspension 0.005-0.064 NF % CAPEX EXTERNAL SHAMPOO 0.01 % (fluocinolone NF acetonide) clobetasol prop emollient base external cream 0.05 % G clobetasol propionate e external cream 0.05 % G clobetasol propionate emulsion external foam 0.05 % G clobetasol propionate external cream 0.05 % G clobetasol propionate external foam 0.05 % G clobetasol propionate external gel 0.05 % G clobetasol propionate external liquid 0.05 % NF clobetasol propionate external lotion 0.05 % G clobetasol propionate external ointment 0.05 % G clobetasol propionate external shampoo 0.05 % G clobetasol propionate external solution 0.05 % G

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 224 Prescription Drug Name Drug Tier Drug Notes CLOBEX SPRAY EXTERNAL LIQUID 0.05 % (clobetasol NF propionate) clocortolone pivalate external cream 0.1 % NF CLODAN EXTERNAL KIT 0.05 % (clobetasol prop & NF cleanser) clobetasol propionate (Clodan External Shampoo 0.05 %) G CLODERM EXTERNAL CREAM 0.1 % (clocortolone NPB pivalate) CORDRAN EXTERNAL CREAM 0.025 % (flurandrenolide) NPB CORDRAN EXTERNAL OINTMENT 0.05 % NF (flurandrenolide) CORDRAN EXTERNAL TAPE 4 MCG/SQCM NF (flurandrenolide) DESONATE EXTERNAL GEL 0.05 % (desonide) NPB desonide external cream 0.05 % G desonide external lotion 0.05 % G desonide external ointment 0.05 % G desoximetasone external cream 0.05 %, 0.25 % G desoximetasone external gel 0.05 % G desoximetasone external liquid 0.25 % G desoximetasone external ointment 0.05 % NF desoximetasone external ointment 0.25 % G diflorasone diacetate external cream 0.05 % NF diflorasone diacetate external ointment 0.05 % NF DUOBRII EXTERNAL LOTION 0.01-0.045 % (halobetasol PB prop-tazarotene) ENSTILAR EXTERNAL FOAM 0.005-0.064 % PB (calcipotriene-betameth diprop) fluocinolone acetonide body external oil 0.01 % G fluocinolone acetonide external cream 0.01 %, 0.025 % G fluocinolone acetonide external ointment 0.025 % G fluocinolone acetonide external solution 0.01 % G fluocinolone acetonide scalp external oil 0.01 % G fluocinonide emulsified base external cream 0.05 % G fluocinonide external cream 0.05 % G fluocinonide external cream 0.1 % NF

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 225 Prescription Drug Name Drug Tier Drug Notes fluocinonide external gel 0.05 % G fluocinonide external ointment 0.05 % G fluocinonide external solution 0.05 % G fluovix external therapy pack 0.1 % NF flurandrenolide external cream 0.05 % NF flurandrenolide external lotion 0.05 % NF flurandrenolide external ointment 0.05 % NF fluticasone propionate external cream 0.05 % G fluticasone propionate external lotion 0.05 % G fluticasone propionate external ointment 0.005 % G halcinonide external cream 0.1 % NF halobetasol propionate external cream 0.05 % G halobetasol propionate external foam 0.05 % NF halobetasol propionate external ointment 0.05 % G HALOG EXTERNAL CREAM 0.1 % (halcinonide) NF HALOG EXTERNAL OINTMENT 0.1 % (halcinonide) NF HALOG EXTERNAL SOLUTION 0.1 % (halcinonide) NF hydrocortisone butyr lipo base external cream 0.1 % NF hydrocortisone butyrate external cream 0.1 % NF hydrocortisone butyrate external lotion 0.1 % NF hydrocortisone butyrate external ointment 0.1 % G hydrocortisone butyrate external solution 0.1 % G hydrocortisone external cream 1 %, 2.5 % G hydrocortisone external lotion 2.5 % G hydrocortisone external ointment 1 %, 2.5 % G hydrocortisone valerate external cream 0.2 % G hydrocortisone valerate external ointment 0.2 % G IMPOYZ EXTERNAL CREAM 0.025 % (clobetasol NF propionate) KENALOG EXTERNAL AEROSOL SOLUTION 0.147 NF MG/GM (triamcinolone acetonide) LEXETTE EXTERNAL FOAM 0.05 % (halobetasol NF propionate) LUXIQ EXTERNAL FOAM 0.12 % (betamethasone valerate) NF mometasone furoate external cream 0.1 % G

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 226 Prescription Drug Name Drug Tier Drug Notes mometasone furoate external ointment 0.1 % G mometasone furoate external solution 0.1 % G flurandrenolide (Nolix External Cream 0.05 %) NF flurandrenolide (Nolix External Lotion 0.05 %) NF OLUX-E EXTERNAL FOAM 0.05 % (clobetasol propionate NF emulsion) PANDEL EXTERNAL CREAM 0.1 % (hydrocortisone NPB probutate) prednicarbate external ointment 0.1 % G psorcon external cream 0.05 % NF SCARZEN SKIN REPAIR EXTERNAL KIT 0.1 & 5 % NF (LOTION) (triamcinolone-dimeth-silicone) SERNIVO EXTERNAL EMULSION 0.05 % (betamethasone NPB dipropionate) TACLONEX EXTERNAL OINTMENT 0.005-0.064 % PB (calcipotriene-betameth diprop) TACLONEX EXTERNAL SUSPENSION 0.005-0.064 % PB (calcipotriene-betameth diprop) TEXACORT EXTERNAL SOLUTION 2.5 % NPB (hydrocortisone) triamcinolone acetonide external aerosol solution 0.147 mg/gm NF triamcinolone acetonide external cream 0.025 %, 0.1 %, 0.5 % G triamcinolone acetonide external lotion 0.025 %, 0.1 % G triamcinolone acetonide external ointment 0.025 %, 0.1 %, 0.5 G % triamcinolone acetonide external ointment 0.05 % NF triamcinolone acetonide (Trianex External Ointment 0.05 %) NF triamcinolone acetonide (Triderm External Cream 0.1 %, 0.5 G %) ULTRAVATE EXTERNAL LOTION 0.05 % (halobetasol NF propionate) VANOS EXTERNAL CREAM 0.1 % (fluocinonide) NF VERDESO EXTERNAL FOAM 0.05 % (desonide) NF DERMATOLOGY, LOCAL ANESTHETICS 1st relief spray external liquid 4-1 % NF lidocaine hcl (7T Lido External Gel 2 %) G

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 227 Prescription Drug Name Drug Tier Drug Notes ACCUCAINE COMBINATION KIT 1 % (lido-pentaf- NF tetrafl-ultrasound) ALOCANE EMERGENCY BURN MAX STR NF EXTERNAL GEL 4 % (lidocaine hcl) ANACAINE EXTERNAL OINTMENT 10 % (benzocaine) NPB APRIZIO PAK EXTERNAL KIT 2.5-2.5 % (lidocaine- NF prilocaine-dressing) ASTERO EXTERNAL GEL 4 % (lidocaine hcl) NF CADIRAMD EXTERNAL KIT 2.5-2.5 % (lido-prilocaine- NF blood collect) CETACAINE EXTERNAL LIQUID 2-2-14 % (butamben- NF tetracaine-benzocaine) CRYODOSE TA EXTERNAL AEROSOL (pentafluoroprop- NPB tetrafluoroeth) DERMACINRX PHN EXTERNAL THERAPY PACK 5 & NF 5 % (lidocaine-dimethicone) DERMACINRX ZRM EXTERNAL THERAPY PACK 5 % NF (lidocaine-emollient) EPIFOAM EXTERNAL FOAM 1-1 % (pramoxine-hc) NPB GEBAUERS PAIN EASE EXTERNAL AEROSOL NPB (pentafluoroprop-tetrafluoroeth) GEBAUERS SPRAY AND STRETCH EXTERNAL NPB AEROSOL (pentafluoroprop-tetrafluoroeth) lidocaine hcl (Glydo External Prefilled Syringe 2 %) G goprelto nasal solution 40 mg/ml NF ICY HOT PM EXTERNAL PATCH 0.025-5 % (capsaicin- NF menthol) L.E.T. EXTERNAL GEL 4-0.05-0.5 % (lido-epinephrine- NF tetracaine) LDO PLUS EXTERNAL GEL 4 % (lidocaine hcl) NF lidocaine external ointment 5 % G lidocaine external patch 5 % G lidocaine hcl external solution 4 % G lidocaine hcl urethral/mucosal external gel 2 % G lidocaine hcl urethral/mucosal external prefilled syringe 2 % G lidocaine-prilocaine external cream 2.5-2.5 % G lidocaine-tetracaine external cream 7-7 % NF

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 228 Prescription Drug Name Drug Tier Drug Notes LIDOCARE ARM/NECK/LEG EXTERNAL PATCH 4 % NF (lidocaine) LIDOCARE BACK/SHOULDER EXTERNAL PATCH 4 NF % (lidocaine) LIDODERM EXTERNAL PATCH 5 % (lidocaine) NPB lidopac external kit 5 % NF lidopin external cream 3.25 % NF LIDOPURE PATCH EXTERNAL KIT 5 % (lidocaine- NF adhesive sheets) LIDOTHOL EXTERNAL GEL 4.5-5 % (lidocaine-menthol) NF LIDOTHOL EXTERNAL PATCH 4.5-5 % (lidocaine- NF menthol) LIDOTRAL EXTERNAL CREAM 3.88 % (lidocaine hcl) NF LMR PLUS EXTERNAL KIT 5 & 0.5-0.5 % (lidocaine- NF camphor-menthol) NOVACORT EXTERNAL GEL 1-2 % (pramoxine-hc) NF paingo kft external kit 2.5-2.5-10-30 % NF PLIAGLIS EXTERNAL CREAM 7-7 % (lidocaine- NF tetracaine) premium scar external patch 2-4-30 % NF prepiv supply combination kit 2.5-2.5 & 0.9 % NF QUTENZA (2 PATCH) EXTERNAL KIT 8 % (capsaicin- NPB cleansing gel) QUTENZA EXTERNAL KIT 8 % (capsaicin-cleansing gel) NPB SX1 MEDICATED POST-OPERATIVE EXTERNAL KIT NF 2 % (lidocaine hcl & post-op system) SYNERA EXTERNAL PATCH 70-70 MG (lidocaine- NPB tetracaine) VENIPUNCTURE PX1 PHLEBOTOMY EXTERNAL KIT NF 2 % (lidocaine hcl-blood collection) wpr plus wound healing system external therapy pack 4 & 10-30 NF % ZILACAINE PATCH EXTERNAL THERAPY PACK 5 % NF (lidocaine-silicone) ZTLIDO EXTERNAL PATCH 1.8 % (lidocaine) NF DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE ACUICYN EXTERNAL SOLUTION (eyelid cleansers) NF 2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 229 Prescription Drug Name Drug Tier Drug Notes acyclovir external cream 5 % NF acyclovir external ointment 5 % G ALDARA EXTERNAL CREAM 5 % (imiquimod) NF alevamax external cream NPB ALEVICYN ANTIPRURITIC EXTERNAL GEL NF (dermatological products, misc.) ALEVICYN ANTIPRURITIC SG EXTERNAL GEL NF (dermatological products, misc.) AMELUZ EXTERNAL GEL 10 % (aminolevulinic acid hcl) NF ammonium lactate external cream 12 % G ammonium lactate external lotion 12 % G ANASEPT EXTERNAL LIQUID 0.057 % (sodium NF hypochlorite) arnica flower tincture NPB atopaderm external cream NF ATOPICLAIR EXTERNAL CREAM (dermatological NPB products, misc.) AVENOVA EXTERNAL SOLUTION 0.01 % (eyelid NF cleansers) beau rx external gel NF bensal hp external ointment 3 % NF benzalkonium chloride external solution , 50 % NPB benzoin external tincture NPB boric acid external granules NPB scar treatment products (Celacyn External Gel) G CERACADE EXTERNAL EMULSION (dermatological NF products, misc.) chlorhexidine gluconate solution 20 % NPB coal tar external solution 20 % G CONDYLOX EXTERNAL GEL 0.5 % (podofilox) NPB COPASIL EXTERNAL GEL (scar treatment products) NPB DENAVIR EXTERNAL CREAM 1 % (penciclovir) NF DERMACINRX CLORHEXACIN EXTERNAL KIT 4 & 2 NF & 5 % (OINT) (chlorhex-mupir-dimeth-silicone) DERMACINRX LEXITRAL PHARMAPAK COMBINATION THERAPY PACK 1.5 & 0.025 % NF (diclofenac sodium-capsaicin) 2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 230 Prescription Drug Name Drug Tier Drug Notes dermacinrx surgical combopak combination kit NF dermovix external patch 2-30 % NF DEXERYL EXTERNAL CREAM (dermatological products, NPB misc.) dfs/ms/menth/cap pak combination kit 1.5 % NF diclofenac epolamine external patch 1.3 % G diclofenac sodium external solution 1.5 % G DICLOFONO EXTERNAL GEL 1.6 % (diclofenac sodium) NF diclopr external kit 1 & 10-30 % NF diclovix combination kit 1.5 & 2-2.5-4 % NF diclozor external therapy pack 1 % NF dimentho external therapy pack 1.5 & 10 % NF DRYSOL EXTERNAL SOLUTION 20 % (aluminum NPB chloride) dual complex formula 1 kit external cream NF ELETONE EXTERNAL CREAM (dermatological products, NPB misc.) ELIDEL EXTERNAL CREAM 1 % (pimecrolimus) NPB EMULSION SB EXTERNAL EMULSION (dermatological NPB products, misc.) enovarx-diclofenac sodium external cream 2.5 % NF ENTTY SPRAY EXTERNAL EMULSION (dermatological NF products, misc.) EPICERAM EXTERNAL EMULSION (dermatological NF products, misc.) EPICYN EXTERNAL SOLUTION (hypochlorous acid) NF essentra wipes 9x9" sheet 70 % NPB EUCRISA EXTERNAL OINTMENT 2 % (crisaborole) PB FLECTOR EXTERNAL PATCH 1.3 % (diclofenac NF epolamine) formaldehyde external solution 10 % G formaldehyde external solution 37 % NPB GENADUR EXTERNAL LIQUID (dermatological products, NPB misc.) glutaraldehyde external solution 25 % NPB GORDOFILM EXTERNAL SOLUTION 16.7-16.7 % NPB (salicylic acid-lactic acid) 2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 231 Prescription Drug Name Drug Tier Drug Notes HPR PLUS EXTERNAL CREAM (dermatological products, NPB misc.) HPR PLUS EXTERNAL FOAM (dermatological products, NPB misc.) HPR PLUS HYDROGEL EXTERNAL KIT (dermatological NPB products, misc.) HYCLODEX EXTERNAL SOLUTION 0.012 % NF (hypochlorous acid) hydrogen peroxide solution 30 % G HYLATOPIC PLUS EXTERNAL CREAM (dermatological NPB products, misc.) HYPOCYN EXTERNAL SOLUTION (eyelid cleansers) NF iodine tincture external tincture 2 % NPB KAMDOY EXTERNAL EMULSION (dermatological NF products, misc.) KELARX EXTERNAL GEL (scar treatment products) NF KETOPHENE RAPIDPAQ EXTERNAL CREAM 20 % NF (ketoprofen) KIVIK EXTERNAL EMULSION (dermatological products, NF misc.) lactic acid e external cream 10-3500 %-unt/30gm NPB lactic acid external lotion 10 % NPB LEVICYN EXTERNAL GEL (dermatological products, NF misc.) LEVULAN KERASTICK EXTERNAL SOLUTION NPB RECONSTITUTED 20 % (aminolevulinic acid hcl) LOYON EXTERNAL SOLUTION (dermatological products, NPB misc.) MIMYX EXTERNAL CREAM (dermatological products, NPB misc.) NEOSALUS EXTERNAL CREAM (dermatological NPB products, misc.) NEOSALUS EXTERNAL FOAM (dermatological products, NPB misc.) NEOSALUS EXTERNAL LOTION (dermatological NPB products, misc.) diclofenac sodium-capsaicin (Nudiclo Solupak Combination NF Therapy Pack 1.5 & 0.025 %)

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 232 Prescription Drug Name Drug Tier Drug Notes NUSURGEPAK SURGICAL PREP/CARE EXTERNAL NF KIT 4 & 2 & 5 % (OINT) (chlorhex-mupir-dimeth-silicone) NUVAIL EXTERNAL SOLUTION (dermatological NPB products, misc.) ORMECA COMBINATION KIT 3 & 46-0.4-1.1 %-MG NF (diclofenac-b6-fa-b12) PALMERS SCAR SERUM EXTERNAL LIQUID (scar NF treatment products) PANRETIN EXTERNAL GEL 0.1 % (alitretinoin) NPB PENLEN EXTERNAL EMULSION (dermatological NF products, misc.) PENNSAID EXTERNAL SOLUTION 2 % (diclofenac NF sodium) PHLAG SPRAY EXTERNAL EMULSION (dermatological NPB products, misc.) pimecrolimus external cream 1 % G podofilox external solution 0.5 % G PR CREAM EXTERNAL KIT (dermatological products, NPB misc.) PRE & POST SX POUCH EXTERNAL THERAPY PACK NF 4 & 2 & 5 % (chlorhex-mupirocin-dimethicone) PRESERA EXTERNAL FOAM (dermatological products, NPB misc.) PROTOPIC EXTERNAL OINTMENT 0.03 %, 0.1 % NPB (tacrolimus) PRUCLAIR EXTERNAL CREAM (dermatological products, NPB misc.) PRUMYX EXTERNAL CREAM (dermatological products, NPB misc.) pyrogallic acid external ointment 25-2 % NPB QBREXZA EXTERNAL PAD 2.4 % (glycopyrronium NPB tosylate) RECEDO EXTERNAL GEL (scar treatment products) NF remigen external cream NPB salimez forte external cream 10 % NPB SANTYL EXTERNAL OINTMENT 250 UNIT/GM NPB (collagenase) scarcin external gel NPB

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 233 Prescription Drug Name Drug Tier Drug Notes scarcin external liquid NF scarsilk external gel NF SEBUDERM EXTERNAL GEL (dermatological products, NPB misc.) silipac external kit NF suvicort external emulsion NF SYNERDERM EXTERNAL EMULSION (dermatological NF products, misc.) tacrolimus external ointment 0.03 %, 0.1 % G TARGRETIN EXTERNAL GEL 1 % (bexarotene) NPSP TETRIX EXTERNAL CREAM (dermatological products, NPB misc.) triple complex formula 3 kit external cream 20-2-10 % NF turpentine external spirit NPB urea (Uredeb External Cream 39 %) G URESOL EXTERNAL CREAM 42.5 % (urea) NF VALCHLOR EXTERNAL GEL 0.016 % (mechlorethamine NPB hcl (topical)) VAROPHEN EXTERNAL KIT 1.5-10-15 % (diclofenac& NF menthol-methyl sal) VEREGEN EXTERNAL OINTMENT 15 % (sinecatechins) NF VOLTAREN EXTERNAL GEL 1 % (diclofenac sodium) NPB vp fc kit external cream NF XALIX EXTERNAL SOLUTION 28 % (salicylic acid) NF XERAC AC EXTERNAL SOLUTION 6.25 % (aluminum NPB chloride in alcohol) XERALUX EXTERNAL CREAM (dermatological products, NPB misc.) XRYLIX EXTERNAL THERAPY PACK 1.5 % (diclofenac NF sod-adhesive sheet) ZOVIRAX EXTERNAL CREAM 5 % (acyclovir) NF ZOVIRAX EXTERNAL OINTMENT 5 % (acyclovir) NF ZYCLARA PUMP EXTERNAL CREAM 3.75 % NF (imiquimod) DERMATOLOGY, ROSACEA azelaic acid external gel 15 % G doxycycline oral capsule delayed release 40 mg NF 2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 234 Prescription Drug Name Drug Tier Drug Notes FINACEA EXTERNAL FOAM 15 % (azelaic acid) PB FINACEA EXTERNAL GEL 15 % (azelaic acid) NF METROGEL EXTERNAL GEL 1 % (metronidazole) NF metronidazole external cream 0.75 % G metronidazole external gel 0.75 %, 1 % G metronidazole external lotion 0.75 % G MIRVASO EXTERNAL GEL 0.33 % (brimonidine tartrate) NF NORITATE EXTERNAL CREAM 1 % (metronidazole) NF ORACEA ORAL CAPSULE DELAYED RELEASE 40 MG PB (doxycycline) RHOFADE EXTERNAL CREAM 1 % (oxymetazoline hcl) NF metronidazole (Rosadan External Cream 0.75 %) G metronidazole (Rosadan External Gel 0.75 %) G SOOLANTRA EXTERNAL CREAM 1 % (ivermectin) NF DERMATOLOGY, SCABICIDES AND PEDICULIDES CROTAN EXTERNAL LOTION 10 % (crotamiton) G lindane external shampoo 1 % G malathion external lotion 0.5 % G permethrin external cream 5 % G spinosad external suspension 0.9 % G sulfurated lime external solution NPB DERMATOLOGY, WOUND CARE AGENTS aceso ag external pad 4"x4" NF ACTICOAT 7 EXTERNAL PAD 2"X2" , 4"X5" (silver) NPB ACTICOAT ANTIMICROBIAL EXTERNAL PAD 2"X2" , NPB 4"X4" (silver) ACTICOAT FLEX 3 4"X4" EXTERNAL PAD (wound NPB dressings) ALEVICYN DERMAL SPRAY EXTERNAL SOLUTION NF (wound cleansers) ALLEVYN AG ADHESIVE EXTERNAL PAD NPB 12.5X12.5CM , 17.5X17.5CM , 7.5X7.5CM (silver) ALLEVYN AG NON-ADHESIVE EXTERNAL PAD NPB 2"X2" , 4"X4" , 6"X6" , 8"X8" (silver) ALLEVYN AG SACRUM 6-3/4" EXTERNAL (silver) NPB ALLEVYN AG SACRUM 9"X9" EXTERNAL (silver) NPB

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 235 Prescription Drug Name Drug Tier Drug Notes ALLEVYN GENTLE EXTERNAL PAD (wound dressings) NPB AQUACEL AG BURN EXTERNAL PAD 4"X5" (silver- NF carboxymethylcellulose) ATRAPRO HYDROGEL EXTERNAL GEL (wound NF dressings) balsam peru-castor oil external ointment NF BIONECT EXTERNAL FOAM 0.2 % (hyaluronate sodium) NF bpco external ointment NF COLLATYL EXTERNAL GEL (silver) NF CURITY HYPERTONIC NACL STRIP EXTERNAL NPB (wound dressings) CURITY NACL DRESSING 6"X6-3/4" EXTERNAL PAD NPB (wound dressings) HYDROFERA BLUE 6"X6" EXTERNAL PAD (wound NPB dressings) HYDROFERA BLUE FOAM DRESSING EXTERNAL NPB PAD (wound dressings) HYDROFERA BLUE FOAM/TUNNELING EXTERNAL NPB PAD (wound dressings) HYDROFERA BLUE MRF DRESSING EXTERNAL NPB PAD (wound dressings) HYDROFERA BLUE READY FOAM EXTERNAL PAD NPB (wound dressings) hygel external gel 2.5 % NF KENDALL ALGINATE 12" ROPE EXTERNAL (wound NPB dressings) KENDALL ALGINATE DRESS 2"X2" EXTERNAL PAD NPB (wound dressings) KENDALL ALGINATE DRESS 4"X4" EXTERNAL PAD NPB (hydroactive dressings) KENDALL ALGINATE DRESS 4"X8" EXTERNAL PAD NPB (wound dressings) KENDALL AMORPHOUS WOUND EXTERNAL GEL NPB (wound dressings) KENDALL HYDROGEL GAUZE 2"X2" EXTERNAL NPB PAD (hydroactive dressings) KENDALL HYDROGEL GAUZE 4"X4" EXTERNAL NPB PAD (hydroactive dressings)

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 236 Prescription Drug Name Drug Tier Drug Notes KENDALL HYDROGEL GAUZE 4"X8" EXTERNAL NPB PAD (hydroactive dressings) KENDALL HYDROGEL WOUND DRESS EXTERNAL NPB (hydroactive dressings) KENDALL ZINC CA ALGINATE 4"X4" EXTERNAL NPB PAD (wound dressings) KERAGEL EXTERNAL GEL (wound dressings) NPB KERAGELT EXTERNAL GEL (wound dressings) NPB KERAMATRIX REPLICINE 10CMX10CM EXTERNAL NPB SHEET (wound dressings) KERAMATRIX REPLICINE 5CMX5CM EXTERNAL NPB SHEET (wound dressings) LIDOTREX (ALOE VERA) EXTERNAL GEL 2 % NF (lidocaine-collagen-aloe vera) LUXAMEND EXTERNAL CREAM (wound dressings) NPB MICROCYN EXTERNAL LIQUID 0.023 % (wound NPB cleansers) PROTYL AG EXTERNAL GEL 1 % (silver) NF REGENECARE EXTERNAL GEL 2 % (lidocaine-collagen- NPB aloe vera) REGRANEX EXTERNAL GEL 0.01 % (becaplermin) NPB RESTORE SILVER DRESSING EXTERNAL PAD 2"X2" , NPB 4"X4.75" (calcium alginate-silver) RESTORE SILVER DRESSING EXTERNAL PAD 4"X4" , NPB 4"X5" , 6"X8" (silver) REXASIL PATCH & VITAMIN E LIQ EXTERNAL KIT NF (silicone-vitamin e) RTD WOUND CARE DRESSING EXTERNAL PAD NPB (wound dressings) TEGADERM AG MESH EXTERNAL PAD 2"X2" , 4"X5" , NPB 4"X8" , 8"X8" (silver) VENELEX EXTERNAL OINTMENT (balsam peru-castor NPB oil) vexasyn external gel NF XEROFORM OIL EMULSION 2"X2" EXTERNAL PAD NPB (bismuth tribromoph-petrolatum) XEROFORM OIL EMULSION GAUZE EXTERNAL NPB PAD (bismuth tribromoph-petrolatum)

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 237 Prescription Drug Name Drug Tier Drug Notes XEROFORM OIL EMULSION STRIP EXTERNAL NPB (bismuth tribromoph-petrolatum) XEROFORM OIL ROLL 4"X9' EXTERNAL 3 % (bismuth NPB tribromoph-petrolatum) XEROFORM PETROLAT GAUZE 1"X8" EXTERNAL NPB (bismuth tribromoph-petrolatum) XEROFORM PETROLAT GAUZE 5"X9" EXTERNAL NPB (bismuth tribromoph-petrolatum) XEROFORM PETROLAT PATCH 2"X2" EXTERNAL NPB PAD (bismuth tribromoph-petrolatum) XEROFORM PETROLAT PATCH 4"X4" EXTERNAL NPB PAD (bismuth tribromoph-petrolatum) XEROFORM PETROLATUM ROLL 4"X9' EXTERNAL NPB (bismuth tribromoph-petrolatum) zanabin hydrogel external gel NPB MOUTH/THROAT/DENTAL AGENTS AQUORAL MOUTH/THROAT SOLUTION (artificial NPB saliva) BOCASAL MOUTH/THROAT PACKET (artificial saliva) NPB CAPHOSOL MOUTH/THROAT SOLUTION (artificial NPB saliva) cevimeline hcl oral capsule 30 mg G chlorhexidine gluconate mouth/throat solution 0.12 % G clotrimazole mouth/throat troche 10 mg G GELCLAIR MOUTH/THROAT GEL (povidone-nahyaluron- NPB glycyrrhet) lidocaine hcl mouth/throat solution 4 % G lidocaine viscous hcl mouth/throat solution 2 % G NEUTRASAL MOUTH/THROAT PACKET (artificial NPB saliva) NUMOISYN MOUTH/THROAT LIQUID (artificial saliva) NPB nystatin mouth/throat suspension 100000 unit/ml G ORAFATE MOUTH/THROAT PASTE 10 % (sucralfate- NPB malate) triamcinolone acetonide (Oralone Mouth/Throat Paste 0.1 %) G ORAVIG BUCCAL TABLET 50 MG (miconazole) NPB chlorhexidine gluconate (Paroex Mouth/Throat Solution 0.12 G %) 2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 238 Prescription Drug Name Drug Tier Drug Notes chlorhexidine gluconate (Periogard Mouth/Throat Solution G 0.12 %) pilocarpine hcl oral tablet 5 mg, 7.5 mg G PREVIDENT 5000 BOOSTER PLUS DENTAL PASTE 1.1 NF % (sodium fluoride) PREVIDENT 5000 DRY MOUTH DENTAL GEL 1.1 % NF (sodium fluoride) PREVIDENT 5000 ENAMEL PROTECT DENTAL PASTE NF 1.1-5 % (sod fluoride-potassium nitrate) PREVIDENT 5000 ORTHO DEFENSE DENTAL PASTE NF 1.1 % (sodium fluoride) PREVIDENT 5000 PLUS DENTAL CREAM 1.1 % (sodium NF fluoride) PREVIDENT 5000 SENSITIVE DENTAL PASTE 1.1-5 % NF (sod fluoride-potassium nitrate) PREVIDENT DENTAL GEL 1.1 % (sodium fluoride) NF PREVIDENT MOUTH/THROAT SOLUTION 0.2 % NF (sodium fluoride) PROTHELIAL MOUTH/THROAT PASTE 10 % NPB (sucralfate-malate) SALIVAMAX MOUTH/THROAT PACKET (artificial NPB saliva) triamcinolone acetonide mouth/throat paste 0.1 % G XEROSTOMIA RELIEF SPRAY MOUTH/THROAT NPB SOLUTION (artificial saliva) OTIC - DRUGS TO TREAT CONDITIONS OF THE EAR acetic acid otic solution 2 % G CIPRO HC OTIC SUSPENSION 0.2-1 % (ciprofloxacin- NF hydrocortisone) CIPRODEX OTIC SUSPENSION 0.3-0.1 % (ciprofloxacin- NF dexamethasone) ciprofloxacin hcl otic solution 0.2 % G ciprofloxacin-fluocinolone pf otic solution 0.3-0.025 % NF CORTISPORIN-TC OTIC SUSPENSION 3.3-3-10-0.5 NPB MG/ML (neomycin-colist-hc-thonzonium) fluocinolone acetonide (Flac Otic Oil 0.01 %) G fluocinolone acetonide otic oil 0.01 % G hydrocortisone-acetic acid otic solution 1-2 % G

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 239 Prescription Drug Name Drug Tier Drug Notes neomycin-polymyxin-hc otic solution 3.5-10000-1 G neomycin-polymyxin-hc otic suspension 3.5-10000-1 G ofloxacin otic solution 0.3 % G OTIPRIO INTRATYMPANIC SUSPENSION 6 % NF (ciprofloxacin) OTOVEL OTIC SOLUTION 0.3-0.025 % (ciprofloxacin- NF fluocinolone)

2021 Pharmacy Drug Guide - Advanced Control Plan The formulary is updated the first week of each month 09/01/2021 240 Index 12-PANEL POC ACCU-CHEK SOFTCLIX ADHANSIA XR...... 71 TOXICOLOGY SYSTEM....143 LANCETS...... 144 adjustable lancing device...... 144 1st relief spray...... 227 ACCU-CHEK ADLYXIN...... 86 1st tier unifine pentips...... 143 ULTRAFLEX INF SET...... 144 ADLYXIN STARTER 1st tier unifine pentips plus...... 143 ACCU-CHEK PACK...... 86 1st tier unilet comfortouch...... 143 ULTRAFLEX-1 INF SET....144 ADMELOG...... 87 7T Lido...... 227 ACCUTREND GLUCOSE..144 ADMELOG SOLOSTAR...... 86 abacavir sulfate...... 27 acd formula a...... 125 ADRENAL C FORMULA.. 190 abacavir sulfate-lamivudine...... 29 ACD-A NOCLOT-50...... 125 ADRENALIN...... 207, 213 abacavir-lamivudine-zidovudine 29 acebutolol hcl...... 51 ADVAIR HFA...... 216 Abaneu-Sl...... 130 aceso ag...... 235 ADVANCE INTUITION ABILIFY...... 68 acetaminophen-codeine...... 18 METER...... 144 ABILIFY MAINTENA...... 68 acetaminophen-codeine #3...... 18 ADVANCE INTUITION ABILIFY MYCITE...... 68 acetazolamide...... 54 MONITOR...... 144 ABILIFY MYCITE acetazolamide er...... 54 ADVANCE INTUITION MAINTENANCE KIT...... 68 acetic acid...... 123, 239 TEST...... 145 ABILIFY MYCITE acetylcysteine...... 208, 213 ADVANCE MICRO-DRAW STARTER KIT...... 68 ACIPHEX...... 120 METER...... 145 abiraterone acetate...... 39 ACIPHEX SPRINKLE...... 120 ADVANCE MICRO-DRAW ABOUTTIME PEN acitretin...... 222 TEST...... 145 NEEDLE...... 143 ACTEMRA ACTPEN...... 136 ADVANCED ALLERGY ABSORICA...... 217 ACTHAR...... 109 COLLECTION...... 223 acamprosate calcium...... 81 ACTICLATE...... 35 ADVATE...... 128 ACANYA...... 217 ACTICOAT 7...... 235 ADVOCATE BLOOD acarbose...... 84 ACTICOAT GLUCOSE MONITOR...... 145 ACCUCAINE...... 228 ANTIMICROBIAL...... 235 ADVOCATE BLOOD ACCU-CHEK AVIVA PLUS ACTICOAT FLEX 3 4"X4"..235 GLUCOSE SYSTEM...... 145 ...... 144 acti-lance 28g...... 144 ADVOCATE INSULIN PEN ACCU-CHEK COMPACT acti-lance lite lancets 28g...... 144 NEEDLES...... 145 PLUS...... 144 acti-lance special lancets 17g.. 144 ADVOCATE INSULIN ACCU-CHEK FASTCLIX acti-lance universal 23g...... 144 SYRINGE...... 145 LANCET...... 144 ACTIMMUNE...... 141 ADVOCATE LANCETS ACCU-CHEK FASTCLIX ACTIQ...... 18 30G...... 145 LANCETS...... 144 active fe...... 130 ADVOCATE LANCING ACCU-CHEK GUIDE...... 144 activite...... 190 DEVICE...... 145 ACCU-CHEK GUIDE ME..144 ACTOS...... 89 ADVOCATE RAPID-SAFE ACCU-CHEK LINKASSIST ACUICYN...... 229 LANCING...... 145 ...... 144 acyclovir...... 30, 230 ADVOCATE REDI-CODE..145 ACCU-CHEK MULTICLIX ACZONE...... 217 ADVOCATE REDI-CODE+145 LANCETS...... 144 ADAKVEO...... 130 ADVOCATE REDI-CODE+ ACCU-CHEK PLASTIC adapalene...... 217 TEST...... 145 CARTRIDGE...... 144 adapalene-benzoyl peroxide.... 217 ADVOCATE SAFETY ACCU-CHEK SAFE-T PRO ADASUVE...... 68 LANCETS...... 145 LANCETS...... 144 adc/f (0.5mg/ml)...... 190 ADVOCATE SAFETY ACCU-CHEK ADDERALL...... 71 LANCETS 26G...... 145 SMARTVIEW...... 144 ADDERALL XR...... 71 ADVOCATE TEST...... 145 ACCU-CHEK SOFTCLIX ADDYI...... 81 adynovate...... 128 LANCET DEV...... 144 adefovir dipivoxil...... 31 ADYPHREN...... 208 ADEMPAS...... 57 ADYPHREN AMP...... 207 241 ADYPHREN AMP II...... 207 alburx...... 135 alprazolam...... 58 ADYPHREN II...... 207 ALBUTEIN...... 135 alprazolam er...... 58 ADZENYS ER...... 71 albuterol sulfate...... 210 ALPRAZOLAM INTENSOL 58 ADZENYS XR-ODT...... 71 albuterol sulfate hfa...... 210 alprazolam xr...... 58 AEMCOLO...... 25 alclometasone dipropionate.....223 ALPROLIX...... 129 AFINITOR...... 40 ALCOH-GLOVE ALREX...... 205 AFINITOR DISPERZ...... 40 CONTOURED WIPE...... 146 ALTABAX...... 219 Afirmelle...... 93 alcohol pads...... 146 Altacaine...... 130 AFREZZA...... 87 alcohol prep...... 146 altafluor benox...... 130 AFSTYLA...... 128 alcohol swabs...... 146 Altafrin...... 130 AFTERA...... 93 alcoh-wipe...... 146 Altavera...... 93 AGAMATRIX AMP...... 145 ALCORTIN A...... 220 ALTOPREV...... 49 AGAMATRIX AMP TEST..145 ALDACTAZIDE...... 54 ALTRENO...... 217 AGAMATRIX JAZZ TEST.146 ALDARA...... 230 ALUNBRIG...... 40, 41 AGAMATRIX JAZZ ALECENSA...... 40 ALVESCO...... 215 WIRELESS 2...... 146 alendronate sodium...... 91 alyacen 1/35...... 93 AGAMATRIX KEYNOTE alevamax...... 230 alyacen 7/7/7...... 93 TEST...... 146 ALEVICYN Alyq...... 57 AGAMATRIX PRESTO...... 146 ANTIPRURITIC...... 230 Amabelz...... 104 AGAMATRIX PRESTO ALEVICYN amantadine hcl...... 66 PRO METER...... 146 ANTIPRURITIC SG...... 230 ambrisentan...... 57 AGAMATRIX PRESTO ALEVICYN DERMAL amcinonide...... 223, 224 TEST...... 146 SPRAY...... 235 AMELUZ...... 230 AGAMATRIX ULTRA- alfuzosin hcl er...... 121 Amethia...... 93 THIN LANCETS...... 146 ALINIA...... 25 Amethyst...... 93 AGGRASTAT...... 135 ALIQOPA...... 40 AMICAR...... 130 AIMOVIG...... 74 aliskiren fumarate...... 54 amiloride hcl...... 54 aimsco twist lancets 32g...... 146 ALLEVYN AG ADHESIVE 235 amiloride-hydrochlorothiazide.. 54 AIMSCO TWIST LANCETS ALLEVYN AG NON- aminoacetic acid...... 123 33G...... 146 ADHESIVE...... 235 aminocaproic acid...... 130 Airavite...... 130 ALLEVYN AG SACRUM 6- AMINOPMRMS...... 190 AIRDUO RESPICLICK 3/4"...... 235 amiodarone hcl...... 48 113/14...... 208 ALLEVYN AG SACRUM AMITIZA...... 117 AIRDUO RESPICLICK 9"X9"...... 235 amitriptyline hcl...... 64 232/14...... 208 ALLEVYN GENTLE...... 236 amlodipine besy-benazepril hcl..45 AIRDUO RESPICLICK allopurinol...... 14 amlodipine besylate...... 52 55/14...... 208 ALLZITAL...... 14 amlodipine besylate-valsartan...46 AJOVY...... 74 almotriptan malate...... 74 amlodipine-atorvastatin...... 52 AKOVAZ...... 213 ALOCANE EMERGENCY amlodipine-olmesartan...... 46 ak-poly-bac...... 204 BURN MAX STR...... 228 amlodipine-valsartan-hctz...... 46 AKTEN...... 130 ALOCRIL...... 201 ammonium lactate...... 230 AKYNZEO...... 114 alogliptin benzoate...... 85 Amnesteem...... 217 ALA SCALP...... 223 alogliptin-metformin hcl...... 85 amoxapine...... 64 ala-cort...... 223 alogliptin-pioglitazone...... 85 amoxicill-clarithro-lansopraz..121 ALA-QUIN...... 220 ALOMIDE...... 201 amoxicillin...... 34 albendazole...... 25 ALORA...... 104 amoxicillin-pot clavulanate...... 34 ALBUKED 25...... 135 alosetron hcl...... 117 amoxicillin-pot clavulanate er...34 ALBUKED 5...... 135 ALPHAGAN P...... 202 amphetamine sulfate...... 71 albumin human...... 135 ALPHANATE...... 126 amphetamine-dextroamphet er. 71 albumin-zlb...... 135 ALPHANINE SD...... 129 242 amphetamine- ARISTADA INITIO...... 68 ASTERO...... 228 dextroamphetamine...... 71 armodafinil...... 80 ATABEX EC...... 190 ampicillin...... 34 ARMOUR THYROID...... 112 ATABEX OB...... 190 ampicillin-sulbactam sodium.....34 arnica flower...... 230 ATACAND...... 47 AMPYRA...... 77 ARNUITY ELLIPTA...... 215 ATACAND HCT...... 46 AMRIX...... 79 ARTHROTEC...... 17 atazanavir sulfate...... 27 ANACAINE...... 228 ARTISS...... 130 atenolol...... 51 anagrelide hcl...... 130 ASACOL HD...... 116 atenolol-chlorthalidone...... 51 ANASEPT...... 230 Ascomp-Codeine...... 18 ATIVAN...... 58 anastrozole...... 39 ASCOR...... 190 atomoxetine hcl...... 71 ANDRODERM...... 83 Ashlyna...... 93 atopaderm...... 230 ANDROGEL...... 83 Asilnasalrms...... 190 ATOPICLAIR...... 230 ANDROGEL PUMP...... 83 ASMANEX (120 METERED atorvastatin calcium...... 49 ANGELIQ...... 104 DOSES)...... 215 atovaquone...... 25 ANNOVERA...... 93 ASMANEX (14 METERED atovaquone-proguanil hcl...... 27 ANORO ELLIPTA...... 208 DOSES)...... 215 ATRALIN...... 217 ANTARA...... 49 ASMANEX (30 METERED ATRAPRO HYDROGEL....236 anticoagulant sodium citrate...125 DOSES)...... 215 ATRIPLA...... 29 APADAZ...... 18 ASMANEX (60 METERED atropine sulfate...... 130 apap-caff-dihydrocodeine...... 18 DOSES)...... 215 ATROVENT HFA...... 209 APEXICON E...... 224 ASMANEX (7 METERED AUBAGIO...... 77 APIDRA...... 87 DOSES)...... 215 Aubra...... 94 APIDRA SOLOSTAR...... 87 ASMANEX HFA...... 215 Aubra Eq...... 94 APLENZIN...... 64 ASPARLAS...... 43 AUGMENTIN...... 34 APOKYN...... 66 aspirin...... 22 aurora lancet super thin 30g....147 APP SLIM RMS...... 190 aspirin adult low dose...... 22 aurora lancet thin 23g...... 147 apraclonidine hcl...... 202 aspirin ec low strength...... 22 aurora pen needles...... 147 aprepitant...... 114 aspirin low dose...... 22 aurora unifine pentips...... 147 Apri...... 93 aspirin-dipyridamole er...... 135 Aurovela 1.5/30...... 94 APRISO...... 116 ASPIR-LOW...... 22 Aurovela 1/20...... 94 APRIZIO PAK...... 228 ASSURE 3 METER...... 146 Aurovela 24 Fe...... 94 APTENSIO XR...... 71 ASSURE 3 TEST...... 146 Aurovela Fe 1.5/30...... 94 APTIOM...... 58 ASSURE 4 METER...... 146 Aurovela Fe 1/20...... 94 APTIVUS...... 27 ASSURE 4 TEST...... 146 AURYXIA...... 111 AQUACEL AG BURN...... 236 assure comfort lancets 28g...... 146 AUSTEDO...... 75 AQUALANCE LANCETS ASSURE ID INSULIN AUTO-LANCET...... 147 30G...... 146 SAFETY SYR...... 146 AUTO-LANCET MINI...... 147 AQUORAL...... 238 ASSURE ID SAFETY PEN AUTOLET II CLINISAFE.. 147 ARAKODA...... 27 NEEDLES...... 146 AUTOLET LITE ARALAST NP...... 213 ASSURE II...... 146 CLINISAFE...... 147 Aranelle...... 93 ASSURE II CHECK...... 146 AUTOLET LITE STARTER ARANESP (ALBUMIN ASSURE PLATINUM...... 146 PACK...... 147 FREE)...... 127 ASSURE PLATINUM AUTOLET MINI...... 147 ARAZLO...... 217 METER...... 147 AUTOLET PLATFORMS... 147 ARCALYST...... 141 ASSURE PRISM MULTI AUTOLET PLUS...... 147 Argyle Sterile Saline...... 123 TEST...... 147 autopen...... 147 Argyle Sterile Water...... 207 ASSURE PRO BLOOD AUTOSOFT 30 INFUSION ARIKAYCE...... 24 GLUCOSE METER...... 147 SET...... 147 aripiprazole...... 68 ASSURE PRO TEST...... 147 AUTOSOFT 90 INFUSION ARISTADA...... 68 ASTAMED MYO...... 190 SET...... 147 243 AUTOSOFT XC INFUSION BD INSULIN SYRINGE BENICAR...... 47 SET...... 147 MICROFINE...... 147 BENICAR HCT...... 46 AUVI-Q...... 208 BD INSULIN SYRINGE BENLYSTA...... 141 AVASTIN...... 37 U/F...... 148 bensal hp...... 230 AVENOVA...... 230 BD INSULIN SYRINGE U- BENZACLIN...... 217 Aviane...... 94 500...... 148 BENZACLIN WITH PUMP 217 avidoxy...... 35 BD INSULIN SYRINGE benzalkonium chloride...... 230 Avita...... 217 ULTRAFINE...... 148 Benzepro...... 217 AVONEX PEN...... 77 BD LANCET ULTRAFINE Benzepro Short Contact...... 217 AVONEX PREFILLED...... 77 30G...... 148 benznidazole...... 25 AVSOLA...... 136 BD LANCET ULTRAFINE benzoin...... 230 Ayuna...... 94 33G...... 148 benzonatate...... 211 AZASAN...... 141 BD LATITUDE DIABETES148 benzoyl perox-hydrocortisone. 217 AZASITE...... 204 BD LATITUDE DIABETES benzoyl peroxide...... 217 azathioprine...... 141 SYSTEM...... 148 benzoyl peroxide-erythromycin azelaic acid...... 234 BD LOGIC BLOOD ...... 217 azelastine hcl...... 201, 210 GLUCOSE MONITOR...... 148 benztropine mesylate...... 66 AZELEX...... 217 BD MICROTAINER BEPREVE...... 201 azeschew prenatal/postnatal....190 LANCETS...... 148 BESER...... 224 azesco...... 190 BD PEN...... 148 Beser...... 224 azithromycin...... 32 BD PEN MINI...... 148 BESIVANCE...... 204 AZOPT...... 202 BD PEN NEEDLE MICRO BETADINE OPHTHALMIC AZOR...... 46 U/F...... 148 PREP...... 204 Azurette...... 94 BD PEN NEEDLE MINI betamethasone dipropionate....224 b-6 folic acid...... 130 U/F...... 148 betamethasone dipropionate Bac...... 14 BD PEN NEEDLE NANO aug...... 224 bacitracin...... 204 2ND GEN...... 148 betamethasone valerate...... 224 bacitracin-polymyxin b...... 204 BD PEN NEEDLE NANO BETAPACE...... 51 bacitra-neomycin-polymyxin- U/F...... 148 BETAPACE AF...... 51 hc...... 203 BD PEN NEEDLE BETASERON...... 77 baclofen...... 79 ORIGINAL U/F...... 148 betaxolol hcl...... 51, 202 BALCOLTRA...... 94 BD PEN NEEDLE SHORT bethanechol chloride...... 118 balsalazide disodium...... 116 U/F...... 148 BETHKIS...... 24 balsam peru-castor oil...... 236 BD SAFETYGLIDE BETIMOL...... 202 BALVERSA...... 41 INSULIN SYRINGE...... 148 BETOPTIC-S...... 202 Balziva...... 94 BD SWABS SINGLE USE BEVESPI AEROSPHERE....208 BANZEL...... 58 BUTTERFLY...... 148 bexarotene...... 43 BAQSIMI ONE PACK...... 108 BD VEO INSULIN SYR U/F BEYAZ...... 94 BAQSIMI TWO PACK...... 108 1/2UNIT...... 148 bicalutamide...... 39 BARACLUDE...... 31 BD VEO INSULIN BIDIL...... 55 BASAGLAR KWIKPEN...... 87 SYRINGE U/F...... 149 BIJUVA...... 104 BAXDELA...... 33 beau rx...... 230 BIKTARVY...... 29 BAYER ASPIRIN EC LOW BECONASE AQ...... 214 bimatoprost...... 202 DOSE...... 22 BELBUCA...... 21 bi-mix...... 122 BAYER LOW DOSE...... 22 belladonna alkaloids-opium.....113 BINOSTO...... 91 BD AUTOSHIELD...... 147 BELRAPZO...... 36 biocel...... 190 BD AUTOSHIELD DUO.... 147 BELSOMRA...... 73 BIONECT...... 236 BD INSULIN SYRINGE benazepril hcl...... 45 BIOSCANNER GLUCOSE ...... 147, 148 benazepril-hydrochlorothiazide.45 TEST...... 149 BENEFIX...... 129 244 BIOTEL CARE BLOOD Bupap...... 14 CARAC...... 219 GLUCOSE SYST...... 149 bupivacaine hcl...... 23 CARAFATE...... 118 bisoprolol fumarate...... 51 buprenorphine hcl...... 21 CARBAGLU...... 103 bisoprolol-hydrochlorothiazide..51 buprenorphine hcl-naloxone hcl.17 carbamazepine...... 59 bivalirudin rtu...... 125 bupropion hcl...... 64 carbamazepine er...... 58, 59 BIVIGAM...... 139 bupropion hcl er (smoking det).81 carbidopa...... 66 BLEPHAMIDE...... 203 bupropion hcl er (sr)...... 64 carbidopa-levodopa...... 67 BLEPHAMIDE S.O.P...... 203 bupropion hcl er (xl)...... 64 carbidopa-levodopa er...... 67 Blisovi 24 Fe...... 94 buspirone hcl...... 75 carbidopa-levodopa-entacapone 67 Blisovi Fe 1.5/30...... 94 butalbital-acetaminophen...... 15 carbinoxamine maleate...... 210 Blisovi Fe 1/20...... 94 butalbital-apap-caff-cod...... 18 CARDIOCOM LANCING blood glucose monitor system..149 butalbital-apap-caffeine...... 15 DEVICE...... 149 blood glucose system pak...... 149 butalbital-asa-caff-codeine...... 18 CARDIZEM...... 53 blood glucose test...... 149 butalbital-aspirin-caffeine...... 15 CARDIZEM CD...... 53 BLULINK GLUCOSE butorphanol tartrate...... 18 CARDIZEM LA...... 53 MONITORING SYS...... 149 BUTRANS...... 22 CARDURA XL...... 121 BLULINK GLUCOSE TEST BYDUREON BCISE...... 86 CAREFINE PEN NEEDLES ...... 149 BYETTA 10 MCG PEN...... 86 ...... 149 BOCASAL...... 238 BYETTA 5 MCG PEN...... 86 careone advanced lancing dev..149 BONJESTA...... 114 BYSTOLIC...... 51 CAREONE BLOOD boric acid...... 230 cabergoline...... 109 GLUCOSE SYSTEM...... 149 bortezomib...... 44 CABLIVI...... 126 CAREONE BLOOD bosentan...... 57 CABOMETYX...... 41 GLUCOSE TEST...... 149 BOSULIF...... 41 CADIRAMD...... 228 careone insulin syringe...... 149 BOTOX...... 79 CAFERGOT...... 74 CAREONE LANCET bp vit 3...... 130 caffeine citrate...... 75 SUPER THIN 30G...... 149 bp wash...... 217 CALCIFOL...... 190 careone lancet thin 23g...... 149 bpco...... 236 calcipotriene...... 222 careone unifine pentips...... 149 b-plex...... 190 calcipotriene-betameth diprop.224 careone unifine pentips plus.....149 b-plex plus...... 190 calcitonin (salmon)...... 109 CARESENS N GLUCOSE BRAFTOVI...... 43 Calcitrene...... 222 SYSTEM...... 149 BREO ELLIPTA...... 216 calcitriol...... 92, 222 CARESENS N GLUCOSE BREXAFEMME...... 24 calcium acetate (phos binder).111 TEST...... 149 BREZTRI AEROSPHERE.. 208 calcium gluconate...... 191 CARESENS N VOICE BRIDION...... 79 CALDOLOR...... 142 SYSTEM...... 149 briellyn...... 94 CALQUENCE...... 41 CARETOUCH ALCOHOL BRILINTA...... 135 CAMBIA...... 15 PREP...... 149 brimonidine tartrate...... 202 Camila...... 94 CARETOUCH INSULIN BRIVIACT...... 58 CAMINO PRO SYRINGE...... 150 bromfenac sodium (once-daily) COMPLETE/GLYTACTIN.191 CARETOUCH ...... 205 Camrese...... 94 LANCING/EJECTOR...... 150 bromocriptine mesylate...... 66 Camrese Lo...... 94 CARETOUCH MONITOR BROMSITE...... 205 CANASA...... 116 SYSTEM...... 150 BROVANA...... 210 candesartan cilexetil...... 47 CARETOUCH PEN BRUKINSA...... 41 candesartan cilexetil-hctz...... 46 NEEDLES...... 150 BRYHALI...... 224 capecitabine...... 37 CARETOUCH SAFETY budesonide...... 116, 215 CAPEX...... 224 LANCETS...... 150 budesonide er...... 106 CAPHOSOL...... 238 CARETOUCH SAFETY bumetanide...... 54 CAPRELSA...... 41 LANCETS 26G...... 150 BUNAVAIL...... 17 captopril...... 45 CARETOUCH TEST...... 150 245 CARETOUCH TWIST CHANTIX STARTING CITRANATAL HARMONY LANCETS 28G...... 150 MONTH PAK...... 81 ...... 191 CARETOUCH TWIST Chateal...... 95 CITRANATAL MEDLEY...191 LANCETS 30G...... 150 Chateal Eq...... 95 CITRANATAL RX...... 191 CARETOUCH TWIST CHEMET...... 92 Claravis...... 217 LANCETS 33G...... 150 CHEMSTRIP K...... 150 CLARINEX-D 12 HOUR.... 212 carisoprodol...... 79 CHEMSTRIP UGK...... 150 clarithromycin...... 33 carisoprodol-aspirin-codeine..... 79 CHENODAL...... 118 clarithromycin er...... 33 CARNITOR...... 92 childrens aspirin...... 22 CLEANLET LANCETS 28G CARNITOR SF...... 92 chlordiazepoxide hcl...... 58 ...... 150 CAROSPIR...... 54 chlordiazepoxide-amitriptyline. 81 clemastine fumarate...... 210 carteolol hcl...... 202 chlordiazepoxide-clidinium..... 113 CLENPIQ...... 117 Cartia Xt...... 53 chlorhexidine gluconate...230, 238 CLEOCIN...... 125 carvedilol...... 51 chloroquine phosphate...... 27 CLEVER CHEK AUTO- carvedilol phosphate er...... 51 chlorpromazine hcl...... 68 CODE SYSTEM...... 150 cascara sagrada...... 117 chlorthalidone...... 54 CLEVER CHEK AUTO- casirivimab...... 31 chlorzoxazone...... 79 CODE TEST...... 150 CAYA...... 143 CHOLBAM...... 118 CLEVER CHEK AUTO- CAYSTON...... 25 cholestyramine...... 49 CODE VOICE...... 150 Caziant...... 95 cholestyramine light...... 48 CLEVER CHEK LANCETS 150 cefaclor...... 32 CHOLEXMAX...... 191 CLEVER CHEK SYSTEM.. 150 cefaclor er...... 32 CHOLEXTRA T/F...... 191 CLEVER CHEK TEST...... 150 cefadroxil...... 32 CIALIS...... 122 CLEVER CHOICE AUTO- cefdinir...... 32 Ciclodan...... 220 CODE SYSTEM...... 150 cefixime...... 32 ciclopirox...... 220 CLEVER CHOICE AUTO- cefpodoxime proxetil...... 32 ciclopirox olamine...... 220 CODE TEST...... 150 cefprozil...... 32 CIFEREX...... 131 CLEVER CHOICE cefuroxime axetil...... 32 cilostazol...... 131 COMFORT EZ...... 150 Celacyn...... 230 CILOXAN...... 204 CLEVER CHOICE CELEBREX...... 14 CIMDUO...... 29 LANCETS 21G...... 151 celecoxib...... 14 cimetidine...... 116 CLEVER CHOICE CELONTIN...... 59 cimetidine hcl...... 116 LANCETS 23G...... 151 CENFOL...... 131 cinacalcet hcl...... 92 CLEVER CHOICE CENTANY...... 219 CINRYZE...... 131 LANCETS 28G...... 151 cephalexin...... 32 CINVANTI...... 114 CLEVER CHOICE MICRO CEQUA...... 131 CIPRO...... 33 SYSTEM...... 151 CEQUR SIMPLICITY CIPRO HC...... 239 CLEVER CHOICE MICRO INSERTER...... 150 CIPRODEX...... 239 TEST...... 151 CERACADE...... 230 ciprofloxacin hcl...... 33, 204, 239 CLEVER CHOICE MINI CERDELGA...... 103 ciprofloxacin-fluocinolone pf.. 239 SYSTEM...... 151 CEREZYME...... 103 citalopram hydrobromide...... 64 CLEVER CHOICE NO CERVIDIL...... 109 CITRANATAL 90 DHA...... 191 CODING...... 151 CETACAINE...... 228 CITRANATAL ASSURE.... 191 CLEVER CHOICE TALK cetirizine hcl...... 210 CITRANATAL B-CALM.... 191 SYSTEM...... 151 CETROTIDE...... 103 CITRANATAL BLOOM..... 191 CLICKFINE PEN cevimeline hcl...... 238 CITRANATAL BLOOM NEEDLES...... 151 CHANTIX...... 81 DHA...... 191 clickfine pen needles...... 151 CHANTIX CONTINUING CITRANATAL DHA...... 191 CLIMARA PRO...... 104 MONTH PAK...... 81 CITRANATAL ESSENCE.. 191 Clindacin Etz...... 217 Clindacin-P...... 217 246 CLINDAGEL...... 217 COMETRIQ (140 MG CORDRAN...... 225 clindamycin hcl...... 25 DAILY DOSE)...... 41 COREG CR...... 51 clindamycin palmitate hcl...... 25 COMETRIQ (60 MG DAILY Coremino...... 35 clindamycin phos-benzoyl DOSE)...... 41 CORLANOR...... 55 perox...... 218 COMFORT ASSIST CORTIFOAM...... 116 clindamycin phosphate.... 125, 218 INSULIN SYRINGE...... 151 CORTISPORIN-TC...... 239 clindamycin-tretinoin...... 218 comfort assured lancets 28g.... 151 CORVITE 150...... 131 CLINDESSE...... 125 comfort assured lancets 33g.... 151 corvite fe...... 131 CLINOIN...... 218 COMFORT EZ INSULIN COSENTYX...... 222 clobazam...... 59 SYRINGE...... 151 COSENTYX (300 MG clobetasol prop emollient base.224 COMFORT EZ MICRO DOSE)...... 222 clobetasol propionate...... 224 PEN NEEDLES...... 151 COSENTYX clobetasol propionate e...... 224 COMFORT EZ PEN SENSOREADY (300 MG)... 222 clobetasol propionate emulsion224 NEEDLES...... 151 COSENTYX CLOBEX SPRAY...... 225 COMFORT EZ SHORT SENSOREADY PEN...... 222 clocortolone pivalate...... 225 PEN NEEDLES...... 151 COSOPT PF...... 202 CLODAN...... 225 comfort lancets...... 152 COTELLIC...... 41 Clodan...... 225 COMFORT TOUCH COTEMPLA XR-ODT...... 71 CLODERM...... 225 LANCETS 31G...... 103 COZAAR...... 47 clomiphene citrate...... 106 COMFORT TOUCH PLUS CREON...... 119 clomipramine hcl...... 76 LANCETS 30G...... 103 CRESEMBA...... 24 clonazepam...... 59 COMPLERA...... 29 CRESTOR...... 50 clonidine...... 55 complete natal dha...... 191 CRINONE...... 111 clonidine hcl...... 55 completenate...... 191 CRIXIVAN...... 27 clonidine hcl er...... 71 Compro...... 114 cromolyn sodium..... 118, 201, 213 clopidogrel bisulfate...... 135 CO-NATAL FA...... 191 CROTAN...... 235 clorazepate dipotassium...... 59 CONCEPT DHA...... 191 CRYODOSE TA...... 228 clotrimazole...... 220, 238 CONCEPT OB...... 191 Cryselle-28...... 95 clotrimazole-betamethasone....220 CONCERTA...... 71 CUPRIMINE...... 92 clozapine...... 68 CONDYLOX...... 230 CURITY ALCOHOL PREPS CLOZARIL...... 69 CONSENSI...... 53 ...... 152 c-nate dha...... 191 constulose...... 117 CURITY ALCOHOL COAGADEX...... 129 CONTOUR MONITOR...... 152 SWABS...... 152 COAGUCHEK LANCETS..151 CONTOUR NEXT EZ...... 152 CURITY HYPERTONIC coal tar...... 230 CONTOUR NEXT LINK.... 152 NACL STRIP...... 236 COARTEM...... 27 CONTOUR NEXT CURITY NACL DRESSING cod liver oil...... 191 MONITOR...... 152 6"X6-3/4"...... 236 codeine sulfate...... 18 CONTOUR NEXT ONE...... 152 Curity Sterile Saline...... 123 COLAZAL...... 116 CONTOUR NEXT TEST.....152 CUROSURF...... 213 colchicine...... 14 CONTOUR TEST...... 152 CUTAQUIG...... 140 colchicine-probenecid...... 14 CONTRAVE...... 76 CUVITRU...... 140 COLCRYS...... 14 CONVENIENCE PAK...... 80 CUVPOSA...... 113 colesevelam hcl...... 49 CONZIP...... 18 CVS ADVANCED colestipol hcl...... 49 COOL BLOOD GLUCOSE GLUCOSE TEST...... 152 COLLATYL...... 236 TEST STRIPS...... 152 cvs aspirin low dose...... 22 COMBIGAN...... 202 COOL MONITOR...... 152 cvs aspirin low strength...... 22 COMBIPATCH...... 104 COOL MONITOR KIT...... 152 CVS BLOOD GLUCOSE COMBIVENT RESPIMAT..208 COPASIL...... 230 METER...... 152 COMETRIQ (100 MG COPAXONE...... 77 cvs folic acid...... 191 DAILY DOSE)...... 41 COPIKTRA...... 41 cvs glucose...... 108 247 cvs glucose meter test strips.... 152 D-CARE GLUCOMETER.. 153 dexamethasone sodium CVS KETONE CARE...... 152 Deblitane...... 95 phosphate...... 107, 205 cvs lancets 21g...... 152 Decadron...... 106 dexchlorpheniramine maleate. 210 cvs lancets micro thin 33g...... 152 deferasirox...... 92 DEXCOM G4 PLAT PED cvs lancets original...... 152 deferoxamine mesylate...... 92 RCV/SHARE...... 153 cvs lancets thin 26g...... 152 DEFITELIO...... 125 DEXCOM G4 PLAT PED cvs lancets ultra thin 30g...... 152 DELESTROGEN...... 104 RECEIVER...... 153 cvs lancets ultra-thin 30g...... 152 DELSTRIGO...... 29 DEXCOM G4 PLATINUM cvs lancing device...... 152 Delyla...... 95 RCV/SHARE...... 153 cvs nicotine...... 81 DELZICOL...... 116 DEXCOM G4 PLATINUM cvs nicotine polacrilex...... 81 demeclocycline hcl...... 35 RECEIVER...... 153 cvs prep...... 152 DEMSER...... 55 DEXCOM G4 PLATINUM cvs ultra thin lancets...... 152 DENAVIR...... 230 TRANSMITTER...... 153 cyanocobalamin...... 192 DEPEN TITRATABS...... 92 DEXCOM G4 SENSOR...... 153 Cyclafem 1/35...... 95 DEPO-ESTRADIOL...... 104 DEXCOM G5 MOB/G4 Cyclafem 7/7/7...... 95 DEPO-SUBQ PROVERA PLAT SENSOR...... 153 cyclobenzaprine hcl...... 79 104...... 95 DEXCOM G5 MOBILE cyclobenzaprine hcl er...... 79 DEPO-TESTOSTERONE...... 83 RECEIVER...... 153 CYCLOMYDRIL...... 131 DERMACINRX AZENASE DEXCOM G5 MOBILE cyclopentolate hcl...... 131 PAK...... 209 TRANSMITTER...... 153 cyclophosphamide...... 36 DERMACINRX DEXCOM G5 RECEIVER cycloserine...... 30 CLORHEXACIN...... 230 KIT...... 153 CYCLOSET...... 85 DERMACINRX DEXCOM G6 RECEIVER.. 153 cyclosporine...... 141 LEXITRAL PHARMAPAK 230 DEXCOM G6 SENSOR...... 153 CYCLOSPORINE IN DERMACINRX PHN...... 228 DEXCOM G6 KLARITY...... 131 dermacinrx surgical combopak231 TRANSMITTER...... 153 cyclosporine modified...... 141 DERMACINRX DEXERYL...... 231 CYMBALTA...... 64 THERAZOLE PAK...... 220 Dexifol...... 192 cyproheptadine hcl...... 210 DERMACINRX ZRM...... 228 DEXILANT...... 120 Cyred...... 95 dermovix...... 231 dexmethylphenidate hcl...... 71 Cyred Eq...... 95 DESCOVY...... 29 dexmethylphenidate hcl er...... 71 CYSTADANE...... 103 DESFERAL...... 92 DEXONTO 0.4%...... 107 CYSTAGON...... 103 desipramine hcl...... 64 DEXTENZA...... 205 CYSTARAN...... 131 desloratadine...... 210 dextroamphetamine sulfate...... 72 CYTOMEL...... 112 desmopressin ace spray refrig. 113 dextroamphetamine sulfate er...72 cytra k crystals...... 123 desmopressin acetate...... 113 dextrose...... 108 dalfampridine er...... 77 desmopressin acetate spray..... 113 dextrose-nacl...... 189 DALIRESP...... 213 desogestrel-ethinyl estradiol...... 95 dextrose-sodium chloride...... 189 danazol...... 103 DESONATE...... 225 DEXYCU...... 205 dantrolene sodium...... 79 desonide...... 225 dfs dr/ms/menth/cap pak...... 15 dapsone...... 25, 218 desoximetasone...... 225 dfs/ms/menth/cap pak...... 231 DARAPRIM...... 25 desvenlafaxine succinate er...... 64 DIACOMIT...... 59 darifenacin hydrobromide er... 124 DETROL LA...... 124 DIASTAT ACUDIAL...... 59 Dasetta 1/35...... 95 DEX4...... 108 DIASTAT PEDIATRIC...... 59 Dasetta 7/7/7...... 95 DEX4 NATURALS...... 108 DIASTIX...... 153 DAURISMO...... 37 DEX4 POUCH PACK...... 108 DIATHRIVE BLOOD Daysee...... 95 dexamethasone...... 106 GLUCOSE METER...... 153 DAYTRANA...... 71 dexamethasone (la)...... 106 DIATHRIVE BLOOD D-CARE BLOOD DEXAMETHASONE GLUCOSE TEST...... 153 GLUCOSE...... 153 INTENSOL...... 106 248 DIATHRIVE GLUCOSE diphen...... 210 dual complex formula 1 kit..... 231 TEST...... 153 diphenhydramine hcl...... 210 DUAVEE...... 104 DIATHRIVE LANCET diphenoxylate-atropine...... 118 DUET DHA 400...... 192 ULTRA THIN 30...... 153 dipyridamole...... 135 DUET DHA BALANCED...192 DIATHRIVE LANCETS..... 153 disopyramide phosphate...... 48 DUEXIS...... 17 DIATHRIVE LANCING disulfiram...... 81 DULERA...... 209 DEVICE...... 153 DIURIL...... 55 duloxetine hcl...... 64 DIATHRIVE PEN NEEDLE divalproex sodium...... 59 DUOBRII...... 225 ...... 154 divalproex sodium er...... 59 DUO-CARE TEST...... 154 DIATHRIVE+ GLUCOSE DIVIGEL...... 104 DUOPA...... 67 MONITOR...... 154 dofetilide...... 48 DUOVISC...... 206 DIATHRIVE+ GLUCOSE donepezil hcl...... 63 DUPIXENT...... 215, 223 TEST...... 154 DOPTELET...... 127 DURAGESIC-100...... 18 diatrue plus blood glucose...... 154 DORYX...... 35 DURAGESIC-12...... 18 diatrue plus test...... 154 DORYX MPC...... 35 DURAGESIC-25...... 18 diazepam...... 59 dorzolamide hcl...... 202 DURAGESIC-50...... 18 diclofenac epolamine...... 231 dorzolamide hcl-timolol mal....202 DURAGESIC-75...... 19 diclofenac potassium...... 15 dorzolamide hcl-timolol mal pf202 DUREZOL...... 205 diclofenac sodium.15, 31, 205, 231 Dotti...... 104 DURLAZA...... 131 diclofenac sodium er...... 15 double pm...... 203 DUROLANE...... 23 diclofenac-misoprostol...... 17 DOVATO...... 29 dutasteride...... 121 DICLOFONO...... 231 doxazosin mesylate...... 46 dutasteride-tamsulosin hcl...... 121 diclopr...... 231 doxepin hcl...... 64, 222 DUTOPROL...... 51 diclovix...... 231 doxercalciferol...... 92 DXEVO 11-DAY...... 107 dicloxacillin sodium...... 34 doxycycline...... 234 d-xylose...... 154 diclozor...... 231 doxycycline hyclate...... 35 DYANAVEL XR...... 72 dicyclomine hcl...... 113 doxycycline monohydrate...... 35 DYMISTA...... 209 DIFFERIN...... 218 doxylamine-pyridoxine...... 114 DYRENIUM...... 55 DIFICID...... 33 dronabinol...... 114 DYSPORT...... 79 diflorasone diacetate...... 225 DROPLET INSULIN E.E.S. 400...... 33 diflunisal...... 22 SYRINGE...... 154 E.E.S. GRANULES...... 33 Digitek...... 54 DROPLET LANCETS easy comfort alcohol pads...... 154 Digox...... 54 ULTRA THIN 30G...... 154 easy comfort insulin syringe....154 digoxin...... 54 DROPLET LANCING easy comfort lancets...... 154 dihydroergotamine mesylate..... 74 DEVICE...... 154 easy comfort lancets twist top. 154 DILANTIN...... 59 DROPLET MICRON...... 154 easy comfort pen needles...... 155 DILANTIN INFATABS...... 59 DROPLET PEN NEEDLES 154 easy glide pen needles...... 155 DILATRATE-SR...... 56 DROPLET PERSONAL easy mini eject lancing device..155 DILAUDID...... 18 LANCETS 30G...... 154 easy mini lancing device...... 155 diltiazem hcl...... 53 dropsafe safety pen needles..... 154 easy plus ii glucose system...... 155 diltiazem hcl er...... 53 drospiren-eth estrad-levomefol..95 easy plus ii glucose test...... 155 diltiazem hcl er beads...... 53 drospirenone-ethinyl estradiol...95 EASY STEP GLUCOSE diltiazem hcl er coated beads.... 53 DROXIA...... 43 MONITOR...... 155 dilt-xr...... 53 drug mart lancets thin 26g...... 154 EASY STEP TEST...... 155 dimentho...... 231 DRUG MART ON-THE-GO easy talk blood glucose system 155 dimethyl fumarate...... 77 LANCET 30G...... 154 easy talk blood glucose test.....155 dimethyl fumarate starter pack.77 drug mart unifine pentips...... 154 EASY TOUCH ALCOHOL DIOVAN...... 47 drug mart unifine pentips plus. 154 PREP MEDIUM...... 155 DIOVAN HCT...... 46 DRYSOL...... 231 EASY TOUCH FLIPLOCK DIPENTUM...... 116 DSUVIA...... 18 INSULIN SY...... 155 249 EASY TOUCH GLUCOSE EDLUAR...... 73 EMEND...... 114, 115 SYSTEM...... 155 ed-spaz...... 113 EMEND TRI-PACK...... 115 EASY TOUCH INSULIN EDURANT...... 27 EMFLAZA...... 107 SAFETY SYR...... 155 efavirenz...... 27 EMGALITY...... 74 EASY TOUCH INSULIN EFFER-K...... 189 EMGALITY (300 MG SYRINGE...... 155 Effer-K...... 189 DOSE)...... 74 EASY TOUCH LANCETS EFFEXOR XR...... 64 Emoquette...... 96 21G...... 155 ELEMENT AUTOCODE EMSAM...... 64 EASY TOUCH LANCETS SYSTEM...... 156 EMTRIVA...... 27 23G...... 155 element compact glucose EMULSION SB...... 231 EASY TOUCH LANCETS system...... 156 EMVERM...... 25 28G...... 155 element compact test...... 156 ENABLEX...... 124 EASY TOUCH LANCETS element compact v glucose sys.156 enalapril maleate...... 45 30G...... 155 ELEMENT PLUS...... 156 enalapril-hydrochlorothiazide... 45 EASY TOUCH LANCETS ELEMENT TEST...... 156 ENBRACE HR...... 192 32G...... 155 ELESTRIN...... 104 ENBREL...... 136 EASY TOUCH LANCING ELETONE...... 231 ENBREL MINI...... 136 DEVICE...... 155 eletriptan hydrobromide...... 74 ENBREL SURECLICK...... 136 EASY TOUCH PEN ELIDEL...... 231 ENCARE...... 122 NEEDLES...... 155 ELIGARD...... 39 ENDARI...... 131 EASY TOUCH SAFETY Elinest...... 95 Endocet...... 19 PEN NEEDLES...... 156 ELIQUIS...... 125 ENDOMETRIN...... 124 EASY TOUCH ELIQUIS DVT/PE ENLITE GLUCOSE SHEATHLOCK SYRINGE.156 STARTER PACK...... 125 SENSOR...... 157 EASY TOUCH TEST...... 156 ELIXOPHYLLIN...... 216 ENLITE SERTER...... 157 easy trak blood glucose system156 ELLA...... 95 enovarx-diclofenac sodium...... 231 easy trak blood glucose test.... 156 ELMIRON...... 123 enoxaparin sodium...... 125 easy trak ii blood glucose sys.. 156 ELOCTATE...... 128 Enpresse-28...... 96 easy trak ii glucose test...... 156 Eluryng...... 96 Enskyce...... 96 EASYGLUCO...... 156 EMBRACE BLOOD ENSTILAR...... 225 EASYMAX 15 TEST...... 156 GLUCOSE MONITOR...... 157 entacapone...... 67 EASYMAX NG BLOOD EMBRACE BLOOD entecavir...... 31 GLUCOSE...... 156 GLUCOSE TEST...... 157 ENTERAGAM...... 192 EASYMAX TEST...... 156 EMBRACE EVO BLOOD ENTEREG...... 118 EASYMAX V BLOOD GLUCOSE TEST...... 157 ENTRESTO...... 55 GLUCOSE...... 156 EMBRACE EVO GLUCOSE ENTTY SPRAY...... 231 EASYPRO BLOOD MONITORING...... 157 ENTYVIO...... 136 GLUCOSE MONITOR...... 156 EMBRACE LANCETS enulose...... 117 EASYPRO BLOOD ULTRA THIN 30G...... 157 enzadyne...... 119 GLUCOSE TEST...... 156 EMBRACE PRO GLUCOSE EPANED...... 45 EASYPRO PLUS...... 156 METER...... 157 EPCLUSA...... 34 econazole nitrate...... 220 EMBRACE PRO GLUCOSE EPICERAM...... 231 ECONTRA EZ...... 95 TEST...... 157 EPICYN...... 231 ECONTRA ONE-STEP...... 95 EMBRACE TALK BLOOD EPIDIOLEX...... 59 ECOZA...... 220 GLUCOSE...... 157 EPIDUO FORTE...... 218 ec-rx estradiol...... 104 EMBRACE TALK EPIFOAM...... 228 ec-rx progesterone...... 111 GLUCOSE TEST...... 157 epinastine hcl...... 201 ec-rx testosterone...... 83 EMBRACE TALK epinephrine...... 208, 213 EDARBI...... 47 MONITORING SYSTEM... 157 epinephrine professional...... 208 EDARBYCLOR...... 46 EMCYT...... 36 EPINEPHRINESNAP-EMS 208 250 EPINEPHRINESNAP-V...... 208 ESTRING...... 105 EZALLOR SPRINKLE...... 50 EPISNAP...... 208 ESTROGEL...... 105 ezetimibe...... 49 Epitol...... 59 eszopiclone...... 73 ezetimibe-simvastatin...... 50 eplerenone...... 46 etesevimab...... 142 EZ-LETS LANCETS 21G.... 158 epoprostenol sodium...... 57 ethacrynic acid...... 55 EZ-LETS LANCETS 26G.... 158 eq blood glucose test...... 157 ethambutol hcl...... 30 EZ-LETS LANCETS 28G.... 158 eq famotidine max st...... 116 ethosuximide...... 59, 60 EZ-LETS LANCETS 30G.... 158 eq nicotine...... 81 ethynodiol diac-eth estradiol..... 96 FA-8...... 192 eq nicotine polacrilex...... 81 etodolac...... 15 fabb...... 131 eq nicotine step 3...... 81 etodolac er...... 15 FABIOR...... 218 eql alcohol swabs...... 157 etonogestrel-ethinyl estradiol....96 Falmina...... 96 eql aspirin low dose...... 22 etoposide...... 44 famciclovir...... 31 eql color lancets 21g...... 157 EUCRISA...... 231 famotidine...... 116 eql color lancets micro 33g...... 157 EUFLEXXA...... 23 FANAPT...... 69 eql insulin syringe...... 157 Euthyrox...... 112 FANAPT TITRATION eql nicotine polacrilex...... 81 EVAMIST...... 105 PACK...... 69 eql super thin lancets 30g...... 157 EVEKEO...... 72 FANATREX FUSEPAQ...... 60 eql thin lancets 26g...... 157 EVEKEO ODT...... 72 FARXIGA...... 90 EQUETRO...... 69 EVENITY...... 109 FARYDAK...... 37 ergocal...... 192 EVERSENSE FASENRA...... 211 ergocalciferol...... 192 SENSOR/HOLDER...... 157 FASENRA PEN...... 211 ergoloid mesylates...... 63 EVERSENSE SMART FASLODEX...... 39 ERGOMAR...... 74 TRANSMITTER...... 157 favipiravir...... 31 ergotamine-caffeine...... 74 EVIVO...... 118 fa-vitamin b-6-vitamin b-12.....131 ERIVEDGE...... 37 EVOLUTION AUTOCODE 157 Fayosim...... 96 ERLEADA...... 39 EVOMELA...... 36 FC FEMALE CONDOM..... 143 erlotinib hcl...... 41 EVOTAZ...... 29 FC2 FEMALE CONDOM... 143 Errin...... 96 EVRYSDI...... 76 febuxostat...... 14 ERTACZO...... 220 EXACTECH R-S-G TEST... 158 FEIBA...... 126 ERWINAZE...... 43 EXACTECH TEST...... 158 felbamate...... 60 ery...... 218 EXEL COMFORT POINT felodipine er...... 53 ERYPED 200...... 33 INSULIN SYR...... 158 FEMCAP...... 143 ERYPED 400...... 33 EXEL COMFORT POINT FEMRING...... 105 Ery-Tab...... 33 PEN NEEDLE...... 158 Femynor...... 96 ERYTHROCIN STEARATE 33 EXELDERM...... 220 fenofibrate...... 49 erythromycin...... 33, 204, 218 exemestane...... 39 fenofibrate micronized...... 49 erythromycin base...... 33 EXFORGE...... 46 fenofibric acid...... 49 erythromycin ethylsuccinate..... 33 EXFORGE HCT...... 46 FENOGLIDE...... 49 ESBRIET...... 213 EXJADE...... 92 fenoprofen calcium...... 15 escitalopram oxalate...... 64 EXTAVIA...... 77 FENORTHO...... 15 Esgic...... 15 EXTINA...... 220 FENSOLVI (6 MONTH)...... 103 ESKATA...... 223 EYLEA...... 207 fentanyl...... 19 esomeprazole magnesium...... 120 E-Z JECT LANCET fentanyl citrate...... 19 ESPEROCT...... 128 MICRO-THIN 33G...... 158 FENTORA...... 19 essentra wipes 9x9"...... 231 E-Z JECT LANCET SUPER FERIVA 21/7...... 131 Estarylla...... 96 THIN 30G...... 158 ferocon...... 131 estazolam...... 73 E-Z JECT LANCETS...... 158 ferotrinsic...... 131 estradiol...... 104, 105 E-Z JECT LANCETS 21G....158 ferraplus 90...... 131 estradiol valerate...... 105 E-Z JECT LANCETS THIN FERRIPROX...... 92 estradiol-norethindrone acet... 105 26G...... 158 251 FERRIPROX TWICE-A- fludrocortisone acetate...... 107 FORA D15G BLOOD DAY...... 93 flunisolide...... 214 GLUCOSE TEST...... 158 Ferrocite Plus...... 131 fluocinolone acetonide..... 225, 239 FORA D20 BLOOD FERRO-PLEX fluocinolone acetonide body.... 225 GLUCOSE TEST...... 158 HEMATINIC...... 131 fluocinolone acetonide scalp....225 FORA D40 FETZIMA...... 64 fluocinonide...... 225, 226 GLUCOSE/PRESSURE...... 158 FETZIMA TITRATION...... 64 fluocinonide emulsified base....225 FORA D40/G31 BLOOD FEXMID...... 79 fluorescein-benoxinate...... 131 GLUCOSE...... 159 FIASP...... 87 Fluor-I-Strips A.T...... 131 FORA D40G FIASP FLEXTOUCH...... 87 fluoritab...... 192 GLUCOSE/PRESSURE...... 159 FIASP PENFILL...... 87 fluorometholone...... 205 FORA G20 BLOOD FIBRICOR...... 49 FLUOROPLEX...... 219 GLUCOSE SYSTEM...... 159 FIFTY50 GLUCOSE fluorouracil...... 219 FORA G20 BLOOD METER 2.0...... 158 fluovix...... 226 GLUCOSE TEST...... 159 FIFTY50 GLUCOSE TEST fluoxetine hcl...... 65 FORA G30/PREM V10 2.0...... 158 fluoxetine hcl (pmdd)...... 65 GLUCOSE TEST...... 159 FIFTY50 PEN NEEDLES... 158 fluphenazine decanoate...... 69 FORA G30A BLOOD FIFTY50 SUPERIOR fluphenazine hcl...... 69 GLUCOSE SYSTEM...... 159 COMFORT SYR...... 158 flurandrenolide...... 226 FORA GD20 BLOOD FIFTY50 UNILET FLURA-SAFE...... 132 GLUCOSE SYSTEM...... 159 LANCETS 33G...... 158 flurazepam hcl...... 73 FORA GD20 TEST...... 159 FINACEA...... 235 flurbiprofen...... 15 FORA GD50 BLOOD finasteride...... 121 flurbiprofen sodium...... 205 GLUCOSE SYSTEM...... 159 FINGERSTIX LANCETS... 158 flutamide...... 39 FORA GD50 BLOOD FINTEPLA...... 60 fluticasone propionate..... 214, 226 GLUCOSE TEST...... 159 FIORICET...... 15 fluticasone-salmeterol...... 209 FORA GTEL BLOOD FIRAZYR...... 131 fluvastatin sodium...... 50 GLUCOSE SYSTEM...... 159 FIRDAPSE...... 76 fluvastatin sodium er...... 50 FORA GTEL BLOOD FIRMAGON...... 39 fluvoxamine maleate...... 76 GLUCOSE TEST...... 159 FIRMAGON (240 MG fluvoxamine maleate er...... 76 FORA GTEL BLOOD DOSE)...... 39 FML...... 206 KETONE TEST...... 159 FIRST-BACLOFEN...... 79 FML FORTE...... 205 FORA LANCETS...... 159 FIRST-METRONIDAZOLE.25 FML LIQUIFILM...... 205 FORA LANCING DEVICE 159 FIRVANQ...... 25 FOCALIN XR...... 72 FORA PREMIUM V10 BLE Flac...... 239 folbee...... 132 SYSTEM...... 159 FLAREX...... 205 folbee plus...... 192 FORA TEST N' GO flavoxate hcl...... 118 FOLBEE PLUS CZ...... 192 MONITOR...... 159 FLEBOGAMMA DIF...... 140 FOLGARD OS...... 192 FORA TN'G VOICE...... 159 flecainide acetate...... 48 folic acid...... 192 FORA TN'G/TN'G VOICE.. 159 FLECTOR...... 231 folic-k...... 192 FORA V10 BLOOD FLEXBUMIN...... 135 FOLI-D...... 132 GLUCOSE SYSTEM...... 159 FLOLAN...... 57 folite...... 132 FORA V10 BLOOD flolipid...... 50 FOLIVANE-OB...... 192 GLUCOSE TEST...... 159 FLORIVA...... 192 folplex 2.2...... 132 FORA V12 BLOOD FLORIVA PLUS...... 192 foltrin...... 132 GLUCOSE SYSTEM...... 160 FLOVENT DISKUS...... 216 Folvite-D...... 132 FORA V12 BLOOD FLOVENT HFA...... 216 fondaparinux sodium...... 126 GLUCOSE TEST...... 160 FLUAD QUADRIVALENT142 FORA 6 CONNECT...... 158 FORA V20 BLOOD fluconazole...... 24 FORA BLOOD GLUCOSE GLUCOSE SYSTEM...... 160 flucytosine...... 24 TEST...... 158 252 FORA V20 BLOOD FREESTYLE LIBRE 14 GEBAUERS SPRAY AND GLUCOSE TEST...... 160 DAY SENSOR...... 161 STRETCH...... 228 FORA V30A BLOOD FREESTYLE LIBRE 2 GELCLAIR...... 238 GLUCOSE SYSTEM...... 160 READER...... 161 GELFILM...... 132 FORA V30A BLOOD FREESTYLE LIBRE 2 GEL-FLOW...... 132 GLUCOSE TEST...... 160 SENSOR...... 161 GELFOAM-JMI POWDER.132 FORACARE GD40 FREESTYLE LIBRE GELFOAM-JMI SPONGE.. 132 MONITOR...... 160 READER...... 161 GELNIQUE...... 124 FORACARE GD40 TEST....160 FREESTYLE LIBRE GEL-ONE...... 23 FORACARE PREMIUM SENSOR SYSTEM...... 161 GELSYN-3...... 23 V10...... 160 FREESTYLE LITE...... 161 gemfibrozil...... 49 FORACARE PREMIUM FREESTYLE LITE TEST....161 GENADUR...... 231 V10 TEST...... 160 FREESTYLE PRECISION generlac...... 117 FORACARE TEST N GO INS SYR...... 161 Gengraf...... 141 MONITOR...... 160 FREESTYLE PRECISION GENICIN VITA-D...... 132 FORACARE TEST N GO NEO SYSTEM...... 161 GENICIN VITA-Q...... 192 TEST...... 160 FREESTYLE PRECISION Genicin Vita-S...... 193 formaldehyde...... 231 NEO TEST...... 161 GENTAK...... 204 FORTAZ...... 32 FREESTYLE SIDEKICK II 161 gentamicin sulfate...... 204, 219 FORTEO...... 109 FREESTYLE TEST...... 161 GENTEEL BUTTERFLY FORTESTA...... 83 FREESTYLE UNISTICK II TOUCH LANCET...... 161 FORTISCARE G1 TEST LANCETS...... 161 GENTEEL CONTACT TIPS STRIP...... 160 frovatriptan succinate...... 74 (BLUE)...... 161 FORTISCARE GLUCOSE fungimez...... 221 GENTEEL CONTACT TIPS SYSTEM...... 160 furosemide...... 55 (CLEAR)...... 161 FORTISCARE T1 FUSION PLUS...... 132 GENTEEL CONTACT TIPS GLUCOSE SYSTEM...... 160 FUZEON...... 27 (GREEN)...... 161 FORTISCARE TEST...... 160 Fyavolv...... 105 GENTEEL CONTACT TIPS FOSAMAX PLUS D...... 91 FYCOMPA...... 60 (ORANGE)...... 162 fosamprenavir calcium...... 27 g tussin ac...... 212 GENTEEL CONTACT TIPS fosinopril sodium...... 45 gabapentin...... 60 (RAINBOW)...... 162 fosinopril sodium-hctz...... 45 GALAFOLD...... 109 GENTEEL CONTACT TIPS FOSRENOL...... 111 galantamine hydrobromide...... 63 (VIOLET)...... 162 FOSTEUM...... 192 galantamine hydrobromide er... 63 GENTEEL CONTACT TIPS FOSTEUM PLUS...... 192 GALAXTRA...... 192 (YELLOW)...... 162 FRAGMIN...... 126 GALZIN...... 189 GENTEEL LANCING KIT freds pharmacy autolet lancing160 GAMIFANT...... 141 (BLUE)...... 162 freds pharmacy unifine pentip+ GAMMAGARD...... 140 GENTEEL NOZZLES...... 162 ...... 160 GAMMAGARD S/D LESS GENTEEL PLUS freds pharmacy unifine pentips 160 IGA...... 140 LANCING (BLACK)...... 162 FREESTYLE FREEDOM... 160 GAMMAKED...... 140 GENTEEL PLUS FREESTYLE FREEDOM GAMMAPLEX...... 140 LANCING (PURPLE)...... 162 LITE...... 161 GAMUNEX-C...... 140 GENTEEL PLUS FREESTYLE INSULINX ganirelix acetate...... 106 LANCING (WHITE)...... 162 SYSTEM...... 161 gatifloxacin...... 204 GENTEEL PLUS FREESTYLE INSULINX GATTEX...... 118 LANCING DEV(BLUE)...... 162 TEST...... 161 ge100 blood glucose system.....161 GENTEEL PLUS FREESTYLE LIBRE 14 ge100 blood glucose test...... 161 LANCING DEV(PINK)...... 162 DAY READER...... 161 GEBAUERS PAIN EASE.... 228 GENTLE-LET GP LANCETS...... 162 253 GENTLE-LET LANCETS...162 GLUCOCARD SHINE g-myco nail...... 221 GENTLE-LET CONNEX...... 163 gnp adult aspirin low strength... 22 PLATFORMS...... 162 GLUCOCARD SHINE gnp alcohol swabs...... 164 GENULTIMATE TEST...... 162 EXPRESS...... 163 gnp aspirin...... 22 GENVISC 850...... 23 GLUCOCARD SHINE gnp clickfine pen needles...... 164 GENVOYA...... 29 TEST...... 163 GNP EASY TOUCH GEODON...... 69 GLUCOCARD SHINE XL..163 GLUCOSE METER...... 164 ght blood glucose monitor...... 162 GLUCOCARD VITAL gnp easy touch glucose test..... 164 ght test...... 162 MONITOR...... 163 gnp glucose...... 108 GIALAX...... 117 GLUCOCARD VITAL gnp insulin syringe...... 164 GIAPREZA...... 213 TEST...... 163 gnp lancets 21g...... 164 GILENYA...... 77 GLUCOCARD X-METER.. 163 gnp lancets micro thin 33g...... 164 GILOTRIF...... 43 GLUCOCARD X-SENSOR.163 gnp lancets thin...... 164 GILPHEX TR...... 212 GLUCOCOM BLOOD gnp lancets thin 26g...... 164 GLASSIA...... 213 GLUCOSE MONITOR...... 163 gnp nicotine...... 81 glatiramer acetate...... 77 GLUCOCOM LANCETS gnp nicotine mini...... 81 Glatopa...... 77 28G...... 163 gnp nicotine polacrilex...... 81 GLEOLAN...... 162 GLUCOCOM LANCETS gnp ulticare pen needles...... 164 GLEOSTINE...... 36 30G...... 163 gnp ultra com insulin syringe...164 GLIADEL WAFER...... 36 GLUCOCOM LANCETS GOCOVRI...... 67 glimepiride...... 91 33G...... 163 GOJJI BLOOD GLUCOSE glipizide...... 91 GLUCOCOM MONITOR... 163 TEST...... 164 glipizide er...... 91 GLUCOCOM TEST...... 163 GOJJI BLOOD TEST glipizide xl...... 91 GLUCONAVII BLOOD STRIP/LANCETS...... 164 glipizide-metformin hcl...... 85 GLUCOSE SYS...... 164 GOJJI STERILE LANCETS 164 global alcohol prep ease...... 162 GLUCONAVII BLOOD GOLYTELY...... 117 global ease inject pen needles.. 162 GLUCOSE TEST...... 164 GONAL-F...... 106 global easy glide insulin syr.....162 GLUCOPRO INSULIN GONAL-F RFF...... 106 global easy glide pen needles... 162 SYRINGE...... 164 GONAL-F RFF REDIJECT 106 global inject ease insulin syr....162 GLUCOPRO SYR RES 3ML GONITRO...... 56 global inject ease lancets 28g.. 162 22GX3/8"...... 164 goodsense blood glucose...... 164 global inject ease lancets 30g.. 162 glucose...... 108 goodsense clickfine pen needle.164 global insulin syringes...... 162 glucose instant energy...... 108 goodsense glucose...... 108 global lancing device...... 162 glucose meter test...... 164 goodsense lancets 26g univ...... 164 GLUCAGEN HYPOKIT..... 108 GLUMETZA...... 84 goodsense lancets 30g univ...... 164 glucagon emergency...... 108 glutaraldehyde...... 231 goodsense lancets 33g univ...... 165 GLUCO PERFECT 3 glyburide...... 91 goodsense lancing device...... 165 METER...... 162 glyburide micronized...... 91 goodsense nicotine...... 81 GLUCO PERFECT 3 TEST.163 glyburide-metformin...... 85 GOODSENSE PEN GLUCOCARD 01 BLOOD GLYCATE...... 113 NEEDLE PENFINE...... 165 GLUCOSE...... 163 glycine...... 123 goprelto...... 228 GLUCOCARD 01 SENSOR glycolic acid...... 223 GORDOFILM...... 231 PLUS...... 163 glycopyrrolate...... 113 granisetron hcl...... 115 GLUCOCARD 01-MINI Glydo...... 228 GRASTEK...... 136 GLUCOSE...... 163 GLYRX-PF...... 113 GREEN GLO LISSAMINE GLUCOCARD GLYTACTIN BUILD 10PE.193 GREEN...... 132 EXPRESSION MONITOR.. 163 GLYTACTIN COMPLETE griseofulvin microsize...... 24 GLUCOCARD 10PE...... 193 griseofulvin ultramicrosize...... 24 EXPRESSION TEST...... 163 GLYTACTIN SWIRL 15PE.193 guaiatussin ac...... 212 GLYXAMBI...... 90 guaifenesin-codeine...... 212 254 guanfacine hcl...... 55 H-E-B INCONTROL HUMIRA PEN- guanfacine hcl er...... 72 UNIFINE PENTIP...... 165 PS/UV/ADOL HS START....137 GUARDIAN CONNECT HEMANGEOL...... 52 HUMIRA PEN- TRANSMITTER...... 165 hematinic plus vit/minerals...... 132 PSOR/UVEIT STARTER.... 137 GUARDIAN LINK 3 hematinic/folic acid...... 132 HUMULIN 70/30...... 87 TRANSMITTER...... 165 HEMLIBRA...... 132 HUMULIN 70/30 GUARDIAN REAL-TIME HEMOCYTE PLUS...... 132 KWIKPEN...... 87 CHARGER...... 165 Hemocyte-F...... 132 HUMULIN N...... 88 GUARDIAN REAL-TIME HEMOFIL M...... 128 HUMULIN N KWIKPEN.....88 TEST PLUG...... 165 heparin sodium (porcine)...... 126 HUMULIN R...... 88 GUARDIAN SENSOR (3)...165 heparin sodium (porcine) pf... 126 HUMULIN R U-500 guardian sensor 3...... 165 hepmed...... 126 (CONCENTRATED)...... 88 GVOKE HYPOPEN 1- HERCEPTIN...... 38 HUMULIN R U-500 PACK...... 108 HERCEPTIN HYLECTA...... 43 KWIKPEN...... 88 GVOKE HYPOPEN 2- HETLIOZ...... 73 HW EMBRACE PRO PACK...... 108 HETLIOZ LQ...... 73 GLUCOSE METER...... 166 GVOKE PFS...... 108 Hidex 6-Day...... 107 HW EMBRACE PRO GYNAZOLE-1...... 125 HIZENTRA...... 140 GLUCOSE TEST...... 166 HAEGARDA...... 132 hm aspirin...... 22 HW EMBRACE TALK Hailey 1.5/30...... 96 HM EMBRACE TALK BLOOD GLUCOSE...... 166 Hailey 24 Fe...... 96 SYSTEM...... 166 HW EMBRACE TALK halcinonide...... 226 hm glucose...... 108 GLUCOSE TEST...... 166 halobetasol propionate...... 226 hm nicotine...... 81 HYALGAN...... 23 HALOG...... 226 hm nicotine polacrilex...... 81 HYCAMTIN...... 44 haloperidol...... 69 hm sterile alcohol prep...... 166 HYCLODEX...... 232 haloperidol decanoate...... 69 HM ULTICARE INSULIN hydralazine hcl...... 55, 56 haloperidol lactate...... 69 SYRINGE...... 166 hydrochlorothiazide...... 55 HARVONI...... 34 HM ULTICARE SHORT hydrocod polst-cpm polst er.... 212 HCU EASY...... 193 PEN NEEDLES...... 166 hydrocodone bitartrate er...... 19 HEALON DUET PRO...... 207 HORIZANT...... 80 hydrocodone-acetaminophen.....19 HEALON GV PRO...... 207 HPR PLUS...... 232 hydrocodone-homatropine...... 212 HEALTH CARE LANCING HPR PLUS HYDROGEL.... 232 hydrocodone-ibuprofen...... 19 DEVICE...... 165 HUMALOG...... 87 hydrocortisone...... 107, 116, 226 healthwise insulin syr/needle... 165 HUMALOG KWIKPEN...... 87 hydrocortisone (perianal)...... 121 healthwise micron pen needles.165 HUMALOG MIX 50/50...... 87 hydrocortisone ace-pramoxine 121 healthwise mini pen needles.....165 HUMALOG MIX 50/50 hydrocortisone butyr lipo base 226 healthwise pen needles...... 165 KWIKPEN...... 87 hydrocortisone butyrate...... 226 healthwise short pen needles....165 HUMALOG MIX 75/25...... 87 hydrocortisone valerate...... 226 healthwise unifine pentips...... 165 HUMALOG MIX 75/25 hydrocortisone-acetic acid...... 239 healthy accents lancing device.165 KWIKPEN...... 87 HYDROFERA BLUE 6"X6"236 healthy accents unifine pentip. 165 HUMAN ALBUMIN HYDROFERA BLUE healthy accents unilet lancets.. 165 GRIFOLS...... 135 FOAM DRESSING...... 236 Heather...... 96 HUMATE-P...... 126 HYDROFERA BLUE h-e-b aspirin...... 22 HUMATROPE...... 109 FOAM/TUNNELING...... 236 h-e-b incontrol adv lancing...... 165 HUMIRA...... 137 HYDROFERA BLUE MRF h-e-b incontrol alcohol...... 165 HUMIRA PEDIATRIC DRESSING...... 236 h-e-b incontrol lancets 28g...... 165 CROHNS START...... 136 HYDROFERA BLUE h-e-b incontrol lancets 30g...... 165 HUMIRA PEN...... 136 READY FOAM...... 236 h-e-b incontrol lancets 33g...... 165 HUMIRA PEN-CD/UC/HS hydrogen peroxide...... 232 h-e-b incontrol pen needles...... 165 STARTER...... 136 hydromet...... 212 255 hydromorphone hcl...... 19 IMVEXXY STARTER INTELENCE...... 27 hydromorphone hcl er...... 19 PACK...... 105 INTRAROSA...... 83 hydroxocobalamin acetate...... 193 IN TOUCH...... 166 INTRON A...... 141 hydroxychloroquine sulfate.....139 IN TOUCH BLOOD Introvale...... 96 hydroxyprogesterone caproate 111 GLUCOSE TEST...... 166 INTUNIV...... 72 hydroxyurea...... 43 IN TOUCH LANCING INVEGA SUSTENNA...... 69 hydroxyzine hcl...... 210 DEVICE...... 166 INVEGA TRINZA...... 69 hydroxyzine pamoate...... 210 IN TOUCH STERILE INVELTYS...... 206 hygel...... 236 LANCETS 30G...... 166 INVIRASE...... 27 HYLATOPIC PLUS...... 232 INATAL GT...... 193 INVOKAMET...... 90 hylavite...... 193 INBRIJA...... 67 INVOKAMET XR...... 90 hyoscyamine sulfate...... 114 Incassia...... 96 INVOKANA...... 91 hyoscyamine sulfate er...... 114 INCRELEX...... 110 iodine strong...... 189 HYPERSAL...... 213 INCRUSE ELLIPTA...... 209 iodine tincture...... 232 HYPOCYN...... 232 indapamide...... 55 IOPIDINE...... 202 HYQVIA...... 140 INDERAL LA...... 52 ipratropium bromide...... 209 HYSINGLA ER...... 19 INDERAL XL...... 52 ipratropium-albuterol...... 209 HY-VEE LANCETS...... 166 INDOCIN...... 15, 16 irbesartan...... 47 hy-vee thin lancets...... 166 indomethacin...... 16 irbesartan-hydrochlorothiazide. 47 HYZAAR...... 47 indomethacin er...... 16 IRESSA...... 41 ibandronate sodium...... 91 INFASURF...... 213 ISENTRESS...... 28 IBRANCE...... 38 INFINITY BLOOD ISENTRESS HD...... 28 Ibu...... 15 GLUCOSE SYSTEM...... 166 Isibloom...... 96 ibuprofen...... 15 INFINITY BLOOD isoniazid...... 30 ICAR-C PLUS...... 132 GLUCOSE TEST...... 166 ISOPTO ATROPINE...... 133 icatibant acetate...... 132 INFINITY VOICE...... 166 ISORDIL TITRADOSE...... 56 ICLUSIG...... 41 Inflammacin...... 17 isosorbide dinitrate...... 56 icosapent ethyl...... 50 INFLATHERM...... 17 isosorbide mononitrate...... 56 ICY HOT PM...... 228 INFLECTRA...... 137 isosorbide mononitrate er...... 56 IDELVION...... 129 INFUGEM...... 37 isotretinoin...... 218 IDHIFA...... 41 INFUVITE ADULT...... 193 isradipine...... 53 Iferex 150 Forte...... 133 INFUVITE PEDIATRIC..... 193 ISTALOL...... 202 IGLUCOSE MONITORING INGREZZA...... 43, 76 itraconazole...... 24 SYSTEM...... 166 INLYTA...... 41 ivermectin...... 25 IGLUCOSE TEST STRIPS.. 166 INNOPRAN XL...... 52 IXINITY...... 130 ILARIS...... 137 INPEN 100-BLUE-LILLY... 166 JADENU...... 93 ILEVRO...... 206 INPEN 100-BLUE-NOVO... 166 JADENU SPRINKLE...... 93 ILUMYA...... 222 INPEN 100-GRAY-LILLY.. 167 JAKAFI...... 41 imatinib mesylate...... 41 INPEN 100-GREY-NOVO...167 JALYN...... 122 IMBRUVICA...... 41 INPEN 100-PINK-LILLY....167 Jantoven...... 126 imdevimab...... 31 INPEN 100-PINK-NOVO.... 167 JANUMET...... 85 imipramine hcl...... 65 INREBIC...... 41 JANUMET XR...... 85 imipramine pamoate...... 65 insulin syringe...... 167 JANUVIA...... 85 imiquimod...... 219 insulin syringe/needle...... 167 JARDIANCE...... 91 imiquimod pump...... 219 insulin syringe-needle u-100.... 167 Jasmiel...... 96 IMPAVIDO...... 25 insupen pen needles...... 167 Jencycla...... 96 IMPOYZ...... 226 INSUPEN SENSITIVE...... 167 jenliva prenatal/postnatal...... 193 IMVEXXY INSUPEN ULTRAFIN...... 167 JENTADUETO...... 85 MAINTENANCE PACK.....105 INTEGRA F...... 133 JENTADUETO XR...... 85 INTEGRA PLUS...... 133 Jinteli...... 105 256 JIVI...... 128 KEPPRA...... 60 KOATE...... 128 Jolessa...... 96 KEPPRA XR...... 60 KOATE-DVI...... 128 JORNAY PM...... 72 KERAGEL...... 237 KOGENATE FS...... 128 JUBLIA...... 221 KERAGELT...... 237 KOMBIGLYZE XR...... 85 Juleber...... 96 KERAMATRIX KORLYM...... 110 JULUCA...... 29 REPLICINE 10CMX10CM..237 KOSELUGO...... 41 Junel 1.5/30...... 96 KERAMATRIX kosher prenatal plus iron...... 193 Junel 1/20...... 97 REPLICINE 5CMX5CM..... 237 KOVALTRY...... 129 Junel Fe 1.5/30...... 97 KERYDIN...... 24 kp aspirin...... 22 Junel Fe 1/20...... 97 KESIMPTA...... 77 K-PHOS...... 189 Junel Fe 24...... 97 ketoconazole...... 24, 221, 223 K-PHOS NO 2...... 123 JUXTAPID...... 50 Ketodan...... 221 K-Prime...... 189 JYNARQUE...... 110 KETO-DIASTIX...... 167 KRINTAFEL...... 27 Kaitlib Fe...... 97 ketone test...... 167 KRISTALOSE...... 117 KALETRA...... 29 KETOPHENE RAPIDPAQ. 232 kroger blood glucose...... 167 Kalliga...... 97 ketoprofen...... 16 kroger blood glucose test...... 167 KALYDECO...... 213 ketoprofen er...... 16 kroger glucose...... 108 KAMDOY...... 232 ketorolac tromethamine.... 16, 206 KROGER HEALTHPRO KANJINTI...... 38 KETOSTIX...... 167 GLUCOSE TEST...... 168 KAPSPARGO SPRINKLE....52 KETOVIE...... 193 kroger insulin syringe...... 168 KAPVAY...... 72 KETOVIE PEPTIDE...... 193 kroger lancets...... 168 KARBINAL ER...... 210 KEVEYIS...... 55 kroger lancets super thin...... 168 Kariva...... 97 KEVZARA...... 137 kroger lancets thin...... 168 KATERZIA...... 53 KHAPZORY...... 44 kroger pen needles...... 168 KAZANO...... 85 kinney lancets...... 167 kroger premium blood glucose.168 kedbumin...... 135 kinney thin lancets...... 167 kroger premium glucose test... 168 KELARX...... 232 kinray insulin syringe...... 167 kroger test...... 168 Kelnor 1/35...... 97 KISQALI (200 MG DOSE).... 38 KRYSTEXXA...... 14 Kelnor 1/50...... 97 KISQALI (400 MG DOSE).... 38 K-Tan Plus...... 133 KENALOG...... 226 KISQALI (600 MG DOSE).... 38 Kurvelo...... 97 KENDALL ALGINATE 12" KISQALI FEMARA (400 KUVAN...... 103 ROPE...... 236 MG DOSE)...... 38 KYLEENA...... 97 KENDALL ALGINATE KISQALI FEMARA (600 KYNMOBI...... 67 DRESS 2"X2"...... 236 MG DOSE)...... 38 KYPROLIS...... 44 KENDALL ALGINATE KISQALI FEMARA(200 L.E.T...... 228 DRESS 4"X4"...... 236 MG DOSE)...... 38 labetalol hcl...... 52 KENDALL ALGINATE KITABIS PAK...... 24 LACRISERT...... 133 DRESS 4"X8"...... 236 KIVIK...... 232 lactated ringers...... 207 KENDALL AMORPHOUS KLARITY-L...... 206 lactic acid...... 232 WOUND...... 236 Klor-Con...... 189 lactic acid e...... 232 KENDALL HYDROGEL Klor-Con 10...... 189 lactulose...... 117 GAUZE 2"X2"...... 236 Klor-Con M10...... 189 lactulose encephalopathy...... 117 KENDALL HYDROGEL Klor-Con M15...... 189 LAMICTAL...... 60 GAUZE 4"X4"...... 236 Klor-Con M20...... 189 LAMICTAL ODT...... 60 KENDALL HYDROGEL Klor-Con/Ef...... 189 LAMICTAL STARTER...... 60 GAUZE 4"X8"...... 237 kls aspirin low dose...... 22 LAMICTAL XR...... 60 KENDALL HYDROGEL KLS QUIT2...... 82 lamivudine...... 28, 31 WOUND DRESS...... 237 KLS QUIT4...... 82 lamivudine-zidovudine...... 29 KENDALL ZINC CA kmart valu insulin syringe 29g.167 lamotrigine...... 60, 61 ALGINATE 4"X4"...... 237 kmart valu insulin syringe 30g.167 lamotrigine er...... 60 257 lamotrigine starter kit-blue...... 61 LENVIMA (20 MG DAILY LIBRAX...... 114 lamotrigine starter kit-green.....61 DOSE)...... 42 lidocaine...... 228 lamotrigine starter kit-orange...61 LENVIMA (24 MG DAILY lidocaine hcl...... 228, 238 LAMPIT...... 25 DOSE)...... 42 lidocaine hcl (cardiac) pf...... 48 lancet device...... 168 LENVIMA (4 MG DAILY lidocaine hcl urethral/mucosal.228 lancet device with ejector...... 168 DOSE)...... 42 lidocaine in dextrose...... 23 lancet transporter case...... 168 LENVIMA (8 MG DAILY lidocaine viscous hcl...... 238 lancets...... 168 DOSE)...... 42 lidocaine-prilocaine...... 228 lancets 30g...... 168 LESCOL XL...... 50 lidocaine-tetracaine...... 228 lancets 33g...... 168 Lessina...... 98 LIDOCARE lancets micro thin 33g...... 168 LETAIRIS...... 57 ARM/NECK/LEG...... 229 lancets thin...... 168 letrozole...... 39 LIDOCARE lancets ultra thin 30g...... 168 leucovorin calcium...... 44 BACK/SHOULDER...... 229 lancing device...... 168 LEUKERAN...... 36 LIDODERM...... 229 LANOXIN...... 54 LEUKINE...... 127 lidomark 2/5...... 23 lansoprazole...... 120 leuprolide acetate...... 39 lidopac...... 229 lanthanum carbonate...... 111 levalbuterol hcl...... 211 lidopin...... 229 LANTUS...... 88 levalbuterol tartrate...... 211 LIDOPURE PATCH...... 229 LANTUS SOLOSTAR...... 88 LEVEMIR...... 88 LIDOTHOL...... 229 LANZO...... 168 LEVEMIR FLEXTOUCH..... 88 LIDOTRAL...... 229 Larin 1.5/30...... 97 levetiracetam...... 61 LIDOTREX (ALOE VERA) 237 Larin 1/20...... 97 levetiracetam er...... 61 LIFESCAN UNISTIK 2...... 169 Larin 24 Fe...... 97 LEVICYN...... 232 LIFESCAN UNISTIK II Larin Fe 1.5/30...... 97 LEVITRA...... 122 LANCETS...... 169 Larin Fe 1/20...... 97 levobunolol hcl...... 202 Lillow...... 98 Larissia...... 97 levocarnitine...... 92 lindane...... 235 LASTACAFT...... 202 levocetirizine dihydrochloride..210 linezolid...... 26 latanoprost...... 202 levofloxacin...... 33, 204 LINZESS...... 117 LATUDA...... 69 Levonest...... 98 liothyronine sodium...... 112 Layolis Fe...... 97 levonorgest-eth est & eth est..... 98 LIPITOR...... 50 LAZANDA...... 19 levonorgest-eth estrad 91-day... 98 lipo-c...... 193 LDL CARE...... 193 levonorgestrel...... 98 lisinopril...... 45 LDO PLUS...... 228 levonorgestrel-ethinyl estrad.....98 lisinopril-hydrochlorothiazide... 45 ldr blood glucose truetest...... 168 levonorg-eth estrad triphasic.....98 lite touch lancets...... 169 leader insulin syringe...... 168 Levora 0.15/30 (28)...... 98 LITE TOUCH LANCING LEADER UNIFINE levorphanol tartrate...... 19 PEN...... 169 PENTIPS...... 168 Levo-T...... 112 LITETOUCH INSULIN LEADER UNIFINE levothyroxine sodium...... 112 SYRINGE...... 169 PENTIPS PLUS...... 168 Levoxyl...... 112 LITETOUCH LANCETS.....169 lecithin...... 193 LEVULAN KERASTICK....232 LITETOUCH PEN Leena...... 97 LEXAPRO...... 65 NEEDLES...... 169 leflunomide...... 139 LEXETTE...... 226 lithium carbonate...... 76 LENVIMA (10 MG DAILY LEXIVA...... 28 lithium carbonate er...... 76 DOSE)...... 41 LIALDA...... 116 LITHOSTAT...... 123 LENVIMA (12 MG DAILY liberty blood glucose meter..... 168 LIVALO...... 50 DOSE)...... 42 LIBERTY NEXT live better adv lancing device...169 LENVIMA (14 MG DAILY GENERATION TEST...... 168 live better lancet ultra thin...... 169 DOSE)...... 42 LIBERTY NXT l-methylfolate calcium...... 193 LENVIMA (18 MG DAILY GENERATION MONITOR 169 LMR PLUS...... 229 DOSE)...... 42 liberty test...... 169 LO LOESTRIN FE...... 98 258 LODINE...... 16 LUPRON DEPOT-PED (3- medic insulin syringe...... 169 LOKELMA...... 93 MONTH)...... 40 medichoice safety lancet extra 169 LOMAIRA...... 76 Lutera...... 98 medicine shoppe pen needles....170 longs insulin syringe...... 169 LUXAMEND...... 237 MEDISENSE THIN longs lancets standard...... 169 LUXIQ...... 226 LANCETS...... 170 longs lancets thin...... 169 LUZU...... 221 MEDLANCE PLUS EXTRA longs lancets ultra thin...... 169 LYNPARZA...... 38 21G...... 170 LONHALA MAGNAIR LYRICA...... 61 MEDLANCE PLUS REFILL KIT...... 209 LYRICA CR...... 81 LANCETS...... 170 LONHALA MAGNAIR Lysiplex Plus...... 193 MEDLANCE PLUS LITE STARTER KIT...... 209 LYSODREN...... 40 25G...... 170 LONSURF...... 43 Lyza...... 98 MEDLANCE PLUS loperamide hcl...... 118 M.V.I. ADULT...... 193 SPECIAL 0.8MM...... 170 lopinavir-ritonavir...... 29 M.V.I. PEDIATRIC...... 193 MEDLANCE PLUS LOPROX...... 221 MACI...... 79 SUPERLITE 30G...... 170 lorazepam...... 58 MACRODANTIN...... 26 MEDLANCE PLUS LORBRENA...... 42 mafenide acetate...... 219 UNIVERSAL 21G...... 170 lorid...... 193 MAGELLAN INSULIN MEDROL...... 107 LORTAB...... 19 SAFETY SYR...... 169 medroxyprogesterone acetate Loryna...... 98 MAKENA...... 111 ...... 98, 112 Lorzone...... 79 malathion...... 235 mefenamic acid...... 16 losartan potassium...... 47 MARATHON MEDICAL mefloquine hcl...... 27 losartan potassium-hctz...... 47 PENTIPS...... 169 megestrol acetate...... 40 LOTEMAX...... 206 marlissa...... 98 meijer blood glucose...... 170 LOTEMAX SM...... 206 MARPLAN...... 65 meijer blood glucose test...... 170 loteprednol etabonate...... 206 MATULANE...... 43 meijer essential blood glucose..170 LOTRONEX...... 117 Matzim La...... 53 meijer essential glucose test.... 170 lovastatin...... 50 MAVENCLAD (10 TABS).....77 meijer glucose...... 109 Low-Ogestrel...... 98 MAVENCLAD (4 TABS)...... 77 MEIJER LANCETS THIN.. 170 loxapine succinate...... 69 MAVENCLAD (5 TABS)...... 77 MEIJER LANCETS LOYON...... 232 MAVENCLAD (6 TABS)...... 77 UNIVERSAL 21G...... 170 Lo-Zumandimine...... 98 MAVENCLAD (7 TABS)...... 78 MEIJER LANCETS LUCEMYRA...... 82 MAVENCLAD (8 TABS)...... 78 UNIVERSAL 30G...... 170 LUCENTIS...... 207 MAVENCLAD (9 TABS)...... 78 MEIJER LANCETS luliconazole...... 221 MAXALT...... 74 UNIVERSAL 33G...... 170 LUMAKRAS...... 42 MAXALT-MLT...... 74 meijer pen needles...... 170 LUMIGAN...... 202 MAXICOMFORT II PEN meijer premium blood glucose. 170 LUNESTA...... 73 NEEDLE...... 169 meijer premium glucose test.... 170 LUPANETA PACK...... 111 MAXI-COMFORT MEIJER SUPER THIN LUPRON DEPOT (1- INSULIN SYRINGE...... 169 LANCETS...... 170 MONTH)...... 39 MAXI-COMFORT SAFETY MEIJER TRUE2GO LUPRON DEPOT (3- PEN NEEDLE...... 169 BLOOD GLUCOSE...... 170 MONTH)...... 39 MAXICOMFORT SYR 27G MEIJER TRUERESULT LUPRON DEPOT (4- X 1/2"...... 169 GLUCOSE SYS...... 170 MONTH)...... 39 MAXIDEX...... 206 MEIJER TRUETEST TEST 170 LUPRON DEPOT (6- MAYZENT...... 78 MEIJER TRUETRACK MONTH)...... 40 MAYZENT STARTER GLUCOSE SYS...... 170 LUPRON DEPOT-PED (1- PACK...... 78 MEIJER TRUETRACK MONTH)...... 40 meclizine hcl...... 115 TEST...... 170 meclofenamate sodium...... 16 MEKINIST...... 42 259 MEKTOVI...... 43 metoclopramide hcl...... 115 MINIMED PUMP meloxicam...... 16 metolazone...... 55 RESERVOIR 3ML...... 171 melphalan...... 36 metoprolol succinate er...... 52 MINIMED RESERVOIR memantine hcl...... 63 metoprolol tartrate...... 52 1.8ML...... 171 memantine hcl er...... 63 metoprolol-hydrochlorothiazide 51 MINIMED RESERVOIR MENEST...... 105 METROGEL...... 235 3ML...... 171 MENOPUR...... 106 metronidazole...... 26, 125, 235 Minitran...... 56 MENOSTAR...... 105 METRONIDAZOLE MINIVELLE...... 105 MENQUADFI...... 142 BENZO+SYRSPEND...... 26 MINOCIN...... 35 MENTAX...... 221 mexiletine hcl...... 48 minocycline hcl...... 35 meperidine hcl...... 19 MIACALCIN...... 110 minocycline hcl er...... 35 meprobamate...... 58 MICARDIS...... 47 MINOLIRA...... 35 mercaptopurine...... 37 MICARDIS HCT...... 47 minoxidil...... 56 mesalamine...... 116 miconazole 3...... 125 MIO INFUSION SET 18" mesalamine-cleanser...... 116 miconazole-zinc oxide-petrolat221 6MM...... 171 MESNEX...... 44 MICROCYN...... 237 MIO INFUSION SET 23" MESTINON...... 76 MICRODOT BLOOD 6MM...... 171 METAXALL CP...... 80 GLUCOSE SYSTEM...... 170 MIO INFUSION SET 32" metaxalone...... 80 MICRODOT PEN NEEDLE 6MM...... 171 metformin hcl...... 84 ...... 170 MIO INFUSION SET 32" metformin hcl er...... 84 MICRODOT TEST...... 170 9MM...... 171 metformin hcl er (mod)...... 84 Microgestin 1.5/30...... 98 MIRCERA...... 127 metformin hcl er (osm)...... 84 Microgestin 1/20...... 98 MIRENA (52 MG)...... 99 methadone hcl...... 19, 20 Microgestin Fe 1.5/30...... 98 mirtazapine...... 65 Methadone Hcl Intensol...... 19 Microgestin Fe 1/20...... 98 MIRVASO...... 235 methadone hcl-nacl...... 20 MICROLET LANCETS...... 171 misoprostol...... 118 METHADOSE...... 20 MICROLET NEXT MITIGARE...... 14 Methadose...... 20 LANCING DEVICE...... 171 MITOSOL...... 204 METHADOSE SUGAR- midazolam hcl...... 73 MM EASY TOUCH FREE...... 20 midazolam hcl (pf)...... 73 GLUCOSE...... 171 methamphetamine hcl...... 72 midodrine hcl...... 56 MM EASY TOUCH methazolamide...... 55 MIGERGOT...... 74 GLUCOSE METER...... 171 methenamine hippurate...... 26 miglitol...... 84 mm insulin syringe/needle...... 171 methenamine mandelate...... 26 miglustat...... 103 MM PEN NEEDLES...... 171 Methergine...... 110 MIGRAINE PACK...... 75 m-natal plus...... 193 methimazole...... 112 MIGRANAL...... 75 modafinil...... 80 methitest...... 83 MIGRANOW...... 75 moexipril hcl...... 45 methocarbamol...... 80 Mili...... 99 molindone hcl...... 69 methotrexate sodium...... 37 MILLIPRED...... 107 mometasone furoate.214, 226, 227 methotrexate sodium (pf)...... 37 Mimvey...... 105 Mondoxyne Nl...... 35, 36 methoxsalen rapid...... 222 MIMYX...... 232 MONOJECT INSULIN methscopolamine bromide...... 114 MINASTRIN 24 FE...... 99 SYRINGE...... 171 methyldopa...... 56 mineral oil heavy...... 117 MONOJECT ULTRA methylergonovine maleate...... 110 mini lancing device...... 171 COMFORT SYRINGE...... 172 methylphenidate hcl...... 72 MINILINK REAL-TIME MONOLET LANCETS...... 172 methylphenidate hcl er...... 72 TRANSMITTER...... 171 MONOLET OPD LANCETS methylphenidate hcl er (cd)...... 72 MINIMED 630G ...... 172 methylphenidate hcl er (la)...... 72 GUARDIAN PRESS...... 171 MONOLETTOR SAFETY methylprednisolone...... 107 MINIMED GUARDIAN LANCETS...... 172 methyltestosterone...... 83 LINK 3...... 171 Mono-Linyah...... 99 260 MONONINE...... 130 mynatal plus...... 194 neonatal 19...... 194 montelukast sodium...... 212 mynatal-z...... 194 neonatal complete...... 194 MONUROL...... 24 Myorisan...... 218 neonatal fe...... 194 Morgidox...... 36 MYRBETRIQ...... 111, 124 NEONATAL PLUS...... 194 morphine sulfate...... 20 MYTESI...... 118 Neo-Polycin...... 204 morphine sulfate (concentrate).20 nabumetone...... 16 Neo-Polycin Hc...... 203 morphine sulfate er...... 20 nadolol...... 52 NEOSALUS...... 232 morphine sulfate er beads...... 20 Nafrinse Drops...... 194 NEO-SYNALAR...... 220 MOTEGRITY...... 118 naftifine hcl...... 221 Nephronex...... 194 MOTOFEN...... 118 NAFTIN...... 221 NERLYNX...... 42 MOVANTIK...... 118 NALFON...... 16 NESINA...... 85 MOVIPREP...... 117 nalocet...... 20 NESTABS...... 194 MOXEZA...... 204 naloxone hcl...... 82 NESTABS DHA...... 194 moxifloxacin hcl...... 33, 204 naltrexone hcl...... 82 NESTABS ONE...... 194 mpd safety lancet 21g...... 172 NAMENDA XR...... 63 Neuac...... 218 mpd safety lancet 23g...... 172 NAMZARIC...... 63 NEUAC...... 218 mpd safety lancet 28g...... 172 NAPRELAN...... 16 NEULASTA...... 127 mpd safety lancet 30g...... 172 NAPROSYN...... 16 NEULASTA ONPRO...... 127 MS CONTIN...... 20 naproxen...... 16 NEUPRO...... 67 ms insulin syringe...... 172 naproxen sodium...... 16 NEUTEK 2TEK TEST...... 172 MSUD EASY...... 193 naproxen sodium er...... 16 NEUTRASAL...... 238 MULPLETA...... 127 naproxen-esomeprazole...... 17 NEVANAC...... 206 MULTAQ...... 48 naratriptan hcl...... 75 nevirapine...... 28 MULTIGEN...... 133 NARCAN...... 82 nevirapine er...... 28 MULTIGEN FOLIC...... 133 NASCOBAL...... 194 NEW DAY...... 99 MULTIGEN PLUS...... 133 NATACHEW...... 194 NEXAVAR...... 42 MULTI-LANCET DEVICE NATACYN...... 204 NEXIUM...... 120 2...... 172 NATALVIT...... 194 NEXIUM 24HR...... 120 multipro...... 193 NATAZIA...... 99 NEXIUM 24HR CLEAR multi-vit/iron/fluoride...... 193 nateglinide...... 90 MINIS...... 120 multivitamin/fluoride...... 193, 194 NATESTO...... 83 NEXLETOL...... 48 multi-vitamin/fluoride...... 193 NATPARA...... 110 NEXLIZET...... 48 multi-vitamin/fluoride/iron...... 194 NATURE-THROID...... 112 NEXPLANON...... 99 mupirocin...... 220 NAYZILAM...... 61 niacin (antihyperlipidemic)...... 50 mupirocin calcium...... 220 NEBUPENT...... 26 niacin er (antihyperlipidemic).. 50 MY CHOICE...... 99 Necon 0.5/35 (28)...... 99 NIACOR...... 50 MY WAY...... 99 NEEVO DHA...... 194 NICADAN...... 194 MYALEPT...... 103 nefazodone hcl...... 65 NICAPRIN...... 194 MYCO NAIL...... 221 NEOKE BCAA4...... 194 nicardipine hcl...... 53 mycophenolate mofetil...... 141 neoke bhb...... 194 NICAZEL...... 194 mycophenolate sodium...... 142 neomycin sulfate...... 24 NICAZEL FORTE...... 194 MYDAYIS...... 73 neomycin-bacitracin zn- nicazyme...... 195 MYGLUCOHEALTH polymyx...... 204 NICOMIDE...... 195 BLOOD GLUCOSE...... 172 neomycin-polymyxin b gu...... 123 NICORELIEF...... 82 MYGLUCOHEALTH neomycin-polymyxin-dexameth nicotine...... 82 LANCETS 30G...... 172 ...... 203 nicotine mini...... 82 MYGLUCOHEALTH TEST neomycin-polymyxin- nicotine polacrilex...... 82 ...... 172 gramicidin...... 204 nicotine step 1...... 82 MYLERAN...... 36 neomycin-polymyxin-hc.. 203, 240 nicotine step 2...... 82 MYNATAL...... 194 neonatal + dha...... 194 nicotine step 3...... 82 261 NICOTROL...... 82 NOVA MAX BLOOD NUDERMRXPAK 120...... 222 NICOTROL NS...... 82 GLUCOSE SYSTEM...... 172 NUDERMRXPAK 60...... 223 nifedipine...... 53 NOVA MAX GLUCOSE Nudiclo Solupak...... 232 nifedipine er...... 53 TEST...... 172 Nudiclo Tabpak...... 142 nifedipine er osmotic release..... 53 NOVA MAX PLUS NUDROXIPAK...... 142 Nikki...... 99 KETONE TEST...... 172 NUDROXIPAK DSDR-50.... 16 NILANDRON...... 40 NOVA SAFETY LANCETS NUDROXIPAK DSDR-75.... 16 nilutamide...... 40 23G...... 172 NUDROXIPAK E-400...... 142 nimodipine...... 53 NOVA SAFETY LANCETS NUDROXIPAK I-800...... 142 NINLARO...... 44 28G...... 172 NUDROXIPAK M-15...... 16 NIPRIDE RTU...... 56 NOVA SUREFLEX NUDROXIPAK N-500...... 16 nisoldipine er...... 53 LANCETS...... 172 NUEDEXTA...... 76 NITRO-BID...... 56 NOVA SUREFLEX NUFERA...... 133 NITRO-DUR...... 56 LANCING DEVICE...... 172 Nufol...... 133 nitrofurantoin...... 26 NOVACORT...... 229 Nulev...... 114 nitrofurantoin macrocrystal...... 26 NOVOEIGHT...... 129 NUMOISYN...... 238 nitrofurantoin monohyd macro. 26 NOVOFINE...... 172 NUPLAZID...... 69 nitroglycerin...... 56 NOVOFINE AUTOCOVER 172 NURTEC...... 75 NITROMIST...... 56 NOVOFINE PLUS...... 172 NUSURGEPAK NITYR...... 103 NOVOLIN 70/30...... 88 SURGICAL PREP/CARE....233 NIVA-PLUS...... 195 NOVOLIN 70/30 FLEXPEN..88 NUTRASEB...... 223 NIVESTYM...... 127 NOVOLIN 70/30 FLEXPEN NUTRICAP...... 195 nizatidine...... 116 RELION...... 88 Nutrifac Zx...... 195 NOCDURNA...... 113 NOVOLIN 70/30 RELION.....88 NUTRIVIT...... 195 Nolix...... 227 NOVOLIN N...... 88 NUVAIL...... 233 Nora-Be...... 99 NOVOLIN N FLEXPEN...... 88 NUVARING...... 100 NORDITROPIN FLEXPRO109 NOVOLIN N RELION...... 88 NUVESSA...... 125 norethin ace-eth estrad-fe...... 99 NOVOLIN R...... 89 NUVIGIL...... 80 norethindrone...... 99 NOVOLIN R FLEXPEN...... 89 NUWIQ...... 129 norethindrone acetate...... 112 NOVOLIN R FLEXPEN NUZYRA...... 36 norethindrone acet-ethinyl est...99 RELION...... 89 Nyamyc...... 221 norethindrone-eth estradiol..... 105 NOVOLIN R RELION...... 89 NYMALIZE...... 54 norethin-eth estradiol-fe...... 99 NOVOLOG...... 89 nystatin...... 25, 221, 238 norgesic forte...... 80 NOVOLOG FLEXPEN...... 89 nystatin-triamcinolone...... 221 norgestimate-eth estradiol...... 99 NOVOLOG MIX 70/30...... 89 Nystop...... 221 norgestim-eth estrad triphasic...99 NOVOLOG MIX 70/30 OB COMPLETE...... 195 NORITATE...... 235 FLEXPEN...... 89 OB COMPLETE ONE...... 195 Norlyda...... 99 NOVOLOG PENFILL...... 89 OB COMPLETE PETITE.... 195 Norlyroc...... 99 NOVOPEN ECHO...... 173 OB COMPLETE PREMIER 195 NORPACE...... 48 NOVOSEVEN RT...... 127 OB COMPLETE/DHA...... 195 NORPACE CR...... 48 NOVOTWIST...... 173 OBSTETRIX DHA...... 195 Nortrel 0.5/35 (28)...... 99 NOXAFIL...... 24, 25 OBSTETRIX EC...... 195 Nortrel 1/35 (21)...... 99 np thyroid...... 112 OBSTETRIX ONE...... 195 Nortrel 1/35 (28)...... 99 NPLATE...... 127 O-CAL PRENATAL...... 195 Nortrel 7/7/7...... 99 NUBEQA...... 40 OCALIVA...... 118 nortriptyline hcl...... 65 NUCALA...... 211 Ocella...... 100 NORVASC...... 54 NUCARACLINPAK...... 218 OCREVUS...... 78 NORVIR...... 28 NUCARARXPAK...... 218 OCTAGAM...... 140 NOURIANZ...... 67 NUCYNTA...... 20 octreotide acetate...... 110 NOURISH...... 195 NUCYNTA ER...... 20 OCUVEL...... 195 262 ODACTRA...... 136 ONETOUCH SURESOFT oscimin...... 114 ODEFSEY...... 30 LANCING DEV...... 173 oscimin sr...... 114 ODOMZO...... 43 ONETOUCH ULTRA...... 173 oseltamivir phosphate...... 31 OFEV...... 214 ONETOUCH ULTRALINK173 OSENI...... 86 ofloxacin...... 33, 205, 240 ONETOUCH ULTRASOFT OSMOLEX ER...... 67 olanzapine...... 69, 70 LANCETS...... 173 OSMOPREP...... 117 olanzapine-fluoxetine hcl...... 82 ONETOUCH VERIO...... 173 OSPHENA...... 110 olmesartan medoxomil...... 47 ONETOUCH VERIO FLEX OTEZLA...... 139 olmesartan medoxomil-hctz...... 47 SYSTEM...... 173 OTIPRIO...... 240 olmesartan-amlodipine-hctz...... 47 ONETOUCH VERIO OTOVEL...... 240 olopatadine hcl...... 202, 210 REFLECT...... 173 OVACE PLUS...... 223 OLUMIANT...... 137 ONETOUCH VERIO SYNC OVIDREL...... 106 OLUX-E...... 227 SYSTEM...... 173 oxaliplatin...... 36 OMECLAMOX-PAK...... 121 onevite...... 195 oxandrolone...... 83 omega-3-acid ethyl esters...... 50 ONEXTON...... 218 oxaprozin...... 16 OMEGAVEN...... 195 ONFI...... 61 OXAYDO...... 20 omeprazole...... 120 ONGLYZA...... 85 oxazepam...... 58 omeprazole-sodium ONZETRA XSAIL...... 75 oxcarbazepine...... 61 bicarbonate...... 120 OPCICON ONE-STEP...... 100 oxiconazole nitrate...... 221 OMNARIS...... 214 opium...... 118 OXISTAT...... 221 OMNIFLEX DIAPHRAGM143 OPSUMIT...... 57 OXTELLAR XR...... 61 OMNIPOD 5 PACK...... 173 OPTION 2...... 100 oxybutynin chloride...... 124 OMNIPOD DASH 5 PACK OPTIONS GYNOL II oxybutynin chloride er...... 124 PODS...... 173 CONTRACEPTIVE...... 122 oxycodone hcl...... 20 OMNIPOD STARTER...... 173 OPTIUM BLOOD oxycodone hcl er...... 20 OMNITROPE...... 109 GLUCOSE MONITOR...... 173 oxycodone-acetaminophen...... 21 omnivex...... 195 OPTIUM GLUCOSE OXYCONTIN...... 21 ondansetron...... 115 MONITOR SYSTEM...... 173 oxymorphone hcl...... 21 ondansetron hcl...... 115 OPTIUM TEST...... 173 oxymorphone hcl er...... 21 one drop blood glucose monitor OPTIUMEZ TEST...... 173 OXYTROL...... 124 ...... 173 ORACEA...... 235 OXYTROL FOR WOMEN..124 one drop test...... 173 ORACIT...... 123 OZEMPIC (0.25 OR 0.5 one vite womens plus...... 195 ORAFATE...... 238 MG/DOSE)...... 86 ONETOUCH CLUB ORALAIR...... 136 OZEMPIC (1 MG/DOSE)...... 86 LANCETS FINE PT...... 173 Oralone...... 238 OZURDEX...... 206 ONETOUCH DELICA ORAVIG...... 238 Pacerone...... 48 LANCETS 30G...... 173 ORENCIA...... 137 paingo kft...... 229 ONETOUCH DELICA ORENCIA CLICKJECT...... 137 paliperidone er...... 70 LANCETS 33G...... 173 ORENITRAM...... 57 PALMERS SCAR SERUM..233 ONETOUCH DELICA ORFADIN...... 103 PANCREAZE...... 119 LANCING DEV...... 173 ORIAHNN...... 105 PANDEL...... 227 ONETOUCH DELICA ORILISSA...... 103 PANRETIN...... 233 PLUS LANCET30G...... 173 ORKAMBI...... 213 pantoprazole sodium...... 120 ONETOUCH DELICA ORMECA...... 233 PANZYGA...... 140 PLUS LANCET33G...... 173 orphenadrine citrate er...... 80 PARADIGM PUMP ONETOUCH DELICA orphenadrine-asa-caffeine...... 80 RESERVOIR 1.8ML...... 174 PLUS LANCING...... 173 Orphengesic Forte...... 80 PARADIGM PUMP ONETOUCH FINEPOINT Orsythia...... 100 RESERVOIR 3ML...... 174 LANCETS...... 173 ortho df...... 133 PARADIGM REAL-TIME ORTHO TRI-CYCLEN LO. 100 TRANSMITTER...... 174 263 PARADIGM SILHOUETTE ph strips...... 174 Pirmella 1/35...... 100 COMBO 23"...... 174 PHARMACIST CHOICE Pirmella 7/7/7...... 100 PARADIGM SURE-T 23" AUTOCODE...... 174 piroxicam...... 16 6MM...... 174 PHARMACIST CHOICE PKU EASY...... 196 PARAGARD AUTOCODE SYS...... 174 PKU EASY MICROTABS...195 INTRAUTERINE COPPER 100 PHARMACIST CHOICE PLASBUMIN-25...... 135 PARAPLATIN...... 36 LANCETS...... 174 PLASBUMIN-5...... 135 PAREMYD...... 133 PHARMACIST CHOICE PLAVIX...... 135 paricalcitol...... 92 MINI SYSTEM...... 174 PLEGRIDY...... 78 Paroex...... 238 pharmacist choice no coding... 174 PLEGRIDY STARTER paromomycin sulfate...... 24 PHARMACY COUNTER PACK...... 78 paroxetine hcl...... 65 LANCETS...... 174 PLENVU...... 118 paroxetine hcl er...... 65 Phenazo...... 123 PLIAGLIS...... 229 paroxetine mesylate...... 65 phenelzine sulfate...... 65 pnv prenatal plus multivitamin 196 PASER...... 30 phenobarbital...... 61 pnv tabs 20-1...... 196 PAXIL...... 65 phenoxybenzamine hcl...... 56 pnv tabs 29-1...... 196 PAXIL CR...... 65 phenylephrine hcl...... 133, 214 pnv-dha...... 196 pc lancets super thin 30g...... 174 phenylephrine hcl (pressors)...214 pnv-dha+docusate...... 196 pc unifine pentips...... 174 phenytoin...... 61 pnv-omega...... 196 PCP 100...... 118 phenytoin sodium extended...... 61 pnv-select...... 196 PEG-PREP...... 118 PHESGO...... 44 POCKETCHEM EZ pen needles...... 174 Philith...... 100 SYSTEM...... 174 pen needles 1/2"...... 174 PHLAG SPRAY...... 233 POCKETCHEM EZ TEST...175 pen needles 5/16"...... 174 PHOSLYRA...... 111 podofilox...... 233 penicillamine...... 93 Phospha 250 Neutral...... 189 POLIVY...... 38 penicillin v potassium...... 34 phosphorous...... 189 Polycin...... 205 PENLEN...... 233 Phospho-Trin 250 Neutral.....189 poly-iron 150 forte...... 133 PENLET II BLOOD PHOTREXA VISCOUS...... 133 polymyxin b-trimethoprim...... 205 SAMPLER...... 174 PHOTREXA-PHOTREXA polysaccharide iron forte...... 133 PENLET II VISCOUS KIT...... 133 POLY-VI-FLOR...... 196 REPLACEMENT CAP...... 174 Physiolyte...... 207 POLY-VI-FLOR/IRON...... 196 PENNSAID...... 233 Physiosol Irrigation...... 207 POMALYST...... 141 PENTASA...... 116 phytonadione...... 195 Portia-28...... 100 pentazocine-naloxone hcl...... 17 PIFELTRO...... 28 PORTRAZZA...... 38 PENTIPS...... 174 pilocarpine hcl...... 202, 239 posaconazole...... 25 pentoxifylline er...... 133 pimecrolimus...... 233 pot & sod cit-cit ac...... 123 PERCOCET...... 21 pimozide...... 76 POTABA...... 189 PERFECT LANCETS 28G.. 174 Pimtrea...... 100 potassium chloride...... 190 PERFECT LANCETS 30G.. 174 pindolol...... 52 potassium chloride crys er...... 189 PERFOROMIST...... 211 pioglitazone hcl...... 89 potassium chloride er...... 190 perindopril erbumine...... 45 pioglitazone hcl-glimepiride...... 90 potassium chloride in nacl...... 190 Periogard...... 239 pioglitazone hcl-metformin hcl..89 potassium citrate er...... 123 PERJETA...... 38 pip lancets 28g...... 174 potassium citrate-citric acid....123 permethrin...... 235 pip lancets 30g...... 174 povidone-iodine...... 205 perphenazine...... 70 PIQRAY (200 MG DAILY PR BENZOYL PEROXIDE.218 perphenazine-amitriptyline...... 82 DOSE)...... 42 Pr Benzoyl Peroxide Wash.....218 PERSERIS...... 70 PIQRAY (250 MG DAILY PR CREAM...... 233 PERTZYE...... 119 DOSE)...... 42 PRADAXA...... 126 PEXEVA...... 65 PIQRAY (300 MG DAILY PRALUENT...... 51 PFIZERPEN...... 35 DOSE)...... 42 pramipexole dihydrochloride.....67 264 pramipexole dihydrochloride er.67 pregen dha...... 196 PREVIDENT 5000 prasugrel hcl...... 135 pregenna...... 196 BOOSTER PLUS...... 239 pravastatin sodium...... 50 PREMARIN...... 105 PREVIDENT 5000 DRY praziquantel...... 26 PREMESISRX...... 196 MOUTH...... 239 prazosin hcl...... 46 premium blood glucose test..... 175 PREVIDENT 5000 PRE & POST SX POUCH.... 233 premium scar...... 229 ENAMEL PROTECT...... 239 PRECEDEX...... 73 PREMPHASE...... 106 PREVIDENT 5000 ORTHO PRECISION LINK...... 175 PREMPRO...... 106 DEFENSE...... 239 PRECISION PCX...... 175 prena 1 true...... 196 PREVIDENT 5000 PLUS.....239 PRECISION PCX PLUS prena1...... 196 PREVIDENT 5000 TEST...... 175 prena1 pearl...... 196 SENSITIVE...... 239 PRECISION POINT OF prenaissance...... 196 PREVIDOLRX CARE TEST...... 175 prenaissance plus...... 196 ANALGESIC...... 17 PRECISION QID prenara...... 196 Previfem...... 100 MONITOR...... 175 PRENATABS RX...... 196 PREVYMIS...... 31 PRECISION QID TEST...... 175 prenatal...... 196 PREZCOBIX...... 30 PRECISION SOF-TACT prenatal 19...... 196 PREZISTA...... 28 MONITOR...... 175 prenatal plus...... 196 PRIFTIN...... 30 PRECISION SOF-TACT prenatal plus iron...... 196 PRILOSEC...... 120 TEST...... 175 prenatal vitamin plus low iron. 196 PRIMACARE...... 197 PRECISION SUREDOSE PRENATAL-U...... 197 primaquine phosphate...... 27 PLUS SYR...... 175 PRENATE...... 197 primidone...... 61 PRECISION SURE-DOSE PRENATE AM...... 197 PRIMSOL...... 26 SYRINGE...... 175 PRENATE DHA...... 197 PRISTIQ...... 65 PRECISION XTRA...... 175 PRENATE ELITE...... 197 PRIVIGEN...... 141 PRECISION XTRA BLOOD PRENATE ENHANCE...... 197 pro comfort alcohol...... 176 GLUCOSE...... 175 PRENATE ESSENTIAL...... 197 PRO COMFORT INSULIN PRECISION XTRA PRENATE MINI...... 197 SYRINGE...... 176 KETONE...... 175 PRENATE PIXIE...... 197 pro comfort lancets 30g...... 176 PRECISION XTRA PRENATE RESTORE...... 197 pro comfort lancets 31g...... 176 MONITOR...... 175 PRENATRIX...... 197 pro comfort pen needles...... 176 PRED FORTE...... 206 PRENATRYL...... 197 pro voice v8 glucose system.....176 PRED MILD...... 206 prenatvite complete...... 197 pro voice v8/v9 glucose...... 176 PRED-G...... 203 prenatvite plus...... 197 pro voice v9 glucose system.....176 PRED-G S.O.P...... 203 prenatvite rx...... 197 PROAIR DIGIHALER...... 211 prednicarbate...... 227 PREPIDIL...... 110 PROAIR HFA...... 211 prednisolone...... 107 prepiv supply...... 229 PROAIR RESPICLICK...... 211 prednisolone acetate...... 206 preplus...... 197 probenecid...... 14 prednisolone acetate p-f...... 206 PRESERA...... 233 probichew...... 118 prednisolone sodium phosphate PRESTALIA...... 45 PRO-C-DURE 6...... 107 ...... 107, 206 pretab...... 197 prochlorperazine...... 115 prednisolone-gatifloxacin...... 203 pretomanid...... 30 prochlorperazine edisylate...... 70 prednisone...... 107 PREVACID...... 120 prochlorperazine maleate...... 115 PREDNISONE INTENSOL 107 PREVACID 24HR...... 120 PROCORT...... 121 preferred plus insulin syringe...175 PREVACID SOLUTAB...... 120 PROCTOCORT...... 121 preferred plus lancets colored..175 Prevalite...... 49 PROCTOFOAM HC...... 121 preferred plus lancets thin...... 175 PREVENT SAFETY PEN Procto-Med Hc...... 121 preferred plus unifine pentips.. 175 NEEDLES...... 175 Procto-Pak...... 121 PREFEST...... 105 PREVENTEZA...... 100 Proctozone-Hc...... 121 pregabalin...... 61 PREVIDENT...... 239 PROCYSBI...... 123 265 prodigen...... 118 PROVIGIL...... 80 QNASL CHILDRENS...... 214 PRODIGY AUTOCODE PROZAC...... 65 QSYMIA...... 76 BLOOD GLUCOSE...... 176 PRUCLAIR...... 233 QTERN...... 90 PRODIGY INSULIN PRUMYX...... 233 quad-mix...... 122 SYRINGE...... 176 pseudoeph-bromphen-dm...... 212 QUARTETTE...... 100 PRODIGY LANCETS 28G..176 psorcon...... 227 quazepam...... 73 PRODIGY LANCING PSS SELECT GP LANCETS176 quetiapine fumarate...... 70 DEVICE...... 176 PSS SELECT PLATFORMS 176 quetiapine fumarate er...... 70 PRODIGY NO CODING PSS SELECT SAFETY QUFLORA FE...... 197 BLOOD GLUC...... 176 LANCETS...... 176 QUFLORA FE PEDIATRIC PRODIGY POCKET PTS PANELS GLUCOSE ...... 197 BLOOD GLUCOSE...... 176 TEST...... 176 QUFLORA GUMMIES...... 198 PRODIGY SAFETY PTS PANELS KETONE QUFLORA PEDIATRIC.....198 LANCETS 26G...... 176 TEST...... 176 QUICKTEK...... 177 PRODIGY VOICE BLOOD PULMICORT...... 216 QUICKTEK TEST...... 177 GLUCOSE...... 176 PULMICORT QUICKTEK/METER...... 177 PROFILNINE...... 130 FLEXHALER...... 216 QUILLICHEW ER...... 73 progesterone...... 112 PULMOZYME...... 216 QUILLIVANT XR...... 73 PROGLYCEM...... 109 pure comfort lancets 30g...... 103 quinapril hcl...... 46 PROLASTIN-C...... 214 PURIXAN...... 37 quinapril-hydrochlorothiazide...45 PROLENSA...... 206 px aspirin...... 22 quinidine gluconate er...... 48 PROLIA...... 110 px enteric aspirin...... 22 quinidine sulfate...... 48 PROMACTA...... 127 px extra short pen needles...... 176 quinine sulfate...... 27 promethazine hcl...... 115 px glucose...... 109 QUINJA...... 221 promethazine-codeine...... 212 px insulin syringe...... 176 QUINTET AC BLOOD promethazine-dm...... 212 px lancet auto injector...... 176 GLUCOSE...... 177 promethazine-phenyleph- px lancets microthin 33g...... 177 QUINTET AC BLOOD codeine...... 212 px lancets ultra thin...... 177 GLUCOSE TEST...... 177 promethazine-phenylephrine... 212 px mini pen needles...... 177 QUINTET BLOOD Promethegan...... 115 px pen needle...... 177 GLUCOSE SYSTEM...... 177 PROMETHEGAN...... 115 px shortlength pen needles...... 177 QUINTET BLOOD PROMETRIUM...... 112 PYLERA...... 119 GLUCOSE TEST...... 177 PROMISEB...... 223 pyrazinamide...... 30 QUTENZA...... 229 propafenone hcl...... 48 pyridostigmine bromide...... 76 QUTENZA (2 PATCH)...... 229 propafenone hcl er...... 48 pyridostigmine bromide er...... 76 QVAR REDIHALER...... 216 proparacaine hcl...... 133 pyridoxine hcl...... 197 ra alcohol swabs...... 177 proparacaine-fluorescein...... 133 pyrogallic acid...... 233 ra aspirin adult low dose...... 22 propranolol hcl...... 52 QBRELIS...... 46 ra aspirin childrens...... 23 propranolol hcl er...... 52 QBREXZA...... 233 ra aspirin ec adult low st...... 23 propylthiouracil...... 112 qc advanced lancing device...... 177 RA E-ZJECT LANCETS PROSTIN E2...... 110 qc alcohol swabs...... 177 28G...... 177 PROTHELIAL...... 239 qc childrens aspirin...... 22 RA E-ZJECT LANCETS PROTONIX...... 120 qc lancets super thin 30g...... 177 THIN 26G...... 177 PROTOPIC...... 233 qc lancets ultra thin...... 177 RA E-ZJECT LANCETS protriptyline hcl...... 65 qc pen needles...... 177 THIN 28G...... 177 PROTYL AG...... 237 qc unifine pentips...... 177 RA E-ZJECT LANCETS provad...... 118 qc unilet lancets 28g...... 177 ULTRA THIN...... 177 PROVAYBLUE...... 133 qc unilet lancets micro thin..... 177 ra glucose...... 109 PROVENTIL HFA...... 211 QMIIZ ODT...... 16 ra insulin syringe...... 177 PROVIDA OB...... 197 QNASL...... 214 ra mini nicotine...... 82 266 ra nicotine...... 82 RELENZA DISKHALER...... 31 RENACIDIN...... 123 ra pen needles...... 177 RELEXXII...... 73 RENATABS...... 198 rabeprazole sodium...... 121 RELION BLOOD RENATABS WITH IRON...198 RADIOGARDASE...... 134 GLUCOSE TEST...... 178 RENFLEXIS...... 137 RAGWITEK...... 136 RELION CONFIRM reno caps...... 198 raloxifene hcl...... 110 GLUCOSE MONITOR...... 178 repaglinide...... 90 ramelteon...... 73 RELION REPATHA...... 51 ramipril...... 46 CONFIRM/MICRO TEST...178 REPATHA PUSHTRONEX ranolazine er...... 56 RELION GLUCOSE...... 109 SYSTEM...... 51 RAPAFLO...... 122 RELION INSULIN REPATHA SURECLICK...... 51 RAPPORT RLS...... 177 SYRINGE...... 178 REQ 49+...... 198 RAPPORT VTD...... 177 RELION KETONE TEST....178 RESECTISOL...... 123 rasagiline mesylate...... 67 RELION LANCET resorcinol-sulfur...... 218 RASUVO...... 139 DEVICES 30G...... 178 RESTASIS...... 134 RAYALDEE...... 92 RELION LANCETS RESTASIS MULTIDOSE....134 RAYOS...... 107 MICRO-THIN 33G...... 178 RESTORA RX...... 119 REACT...... 100 RELION LANCETS THIN RESTORE SILVER READYLANCE SAFETY 26G...... 178 DRESSING...... 237 LANCETS...... 177 RELION LANCETS RETACRIT...... 128 READYSHARP ANESTH + ULTRA-THIN 30G...... 178 RETIN-A MICRO...... 218 KETOROLAC...... 142 RELION LANCING RETIN-A MICRO PUMP....219 READYSHARP DEVICE...... 178 revesta...... 134 DEXAMETHASONE...... 107 RELION MICRO...... 178 REVLIMID...... 141 reality insulin syringe...... 178 RELION MINI PEN REXALL BLOOD reality lancets...... 178 NEEDLES...... 178 GLUCOSE SYSTEM...... 179 reality swabs...... 178 RELION PEN NEEDLES....178 REXALL BLOOD reality trigger lancets...... 178 RELION PREMIER BLU GLUCOSE TEST...... 179 REBIF...... 78 MONITOR...... 178 REXASIL PATCH & REBIF REBIDOSE...... 78 RELION PREMIER VITAMIN E LIQ...... 237 REBIF REBIDOSE COMPACT SYSTEM...... 178 REXULTI...... 70 TITRATION PACK...... 78 RELION PREMIER VOICE REYATAZ...... 28 REBIF TITRATION PACK.. 78 MONITOR...... 179 REYVOW...... 75 REBINYN...... 130 RELION PRIME RHEUMATE...... 198 RECARBRIO...... 26 MONITOR...... 179 RHOFADE...... 235 RECEDO...... 233 RELION PRIME TEST...... 179 RHOPRESSA...... 207 RECLAST...... 91 RELION SHORT PEN RIABNI...... 38 Reclipsen...... 100 NEEDLES...... 179 RIAX...... 219 RECOMBINATE...... 129 RELION ULTIMA ribavirin...... 31, 34 RECOTHROM...... 134 GLUCOSE SYSTEM...... 179 ribozel...... 198 RECOTHROM SPRAY KIT RELION ULTIMA TEST.... 179 RIDAURA...... 14 ...... 134 RELION ULTRA THIN rifabutin...... 30 RECTIV...... 121 LANCETS 30G...... 179 rifampin...... 30 RECURA...... 221 RELION ULTRA THIN RIGHTEST ALTERNATE REFUAH PLUS BLOOD PLUS LANCETS...... 179 SITE ADAPT...... 179 GLUCOSE TEST...... 178 RELISTOR...... 119 RIGHTEST GD500 REFUAH PLUS relnate dha...... 198 LANCING DEVICE...... 179 MONITORING SYSTEM... 178 REMEDIENT...... 198 RIGHTEST GL300 REGENECARE...... 237 REMICADE...... 137 LANCETS...... 179 REGIOCIT...... 126 remigen...... 233 RIGHTEST GM100 BLOOD REGRANEX...... 237 REMODULIN...... 57 GLUCOSE...... 179 267 RIGHTEST GM300 BLOOD SABRIL...... 61 SEROQUEL XR...... 70 GLUCOSE...... 179 SAFE-T-LANCE...... 179 SEROSTIM...... 109 RIGHTEST GM550 BLOOD SAFE-T-LANCE PLUS...... 179 sertraline hcl...... 65 GLUCOSE...... 179 safety insulin syringes...... 179 Setlakin...... 100 RIGHTEST GS100 BLOOD safety lancet 30g/pressure act. 179 sevelamer carbonate...... 111 GLUCOSE...... 179 SAFYRAL...... 100 sevelamer hcl...... 111 RIGHTEST GS300 BLOOD salimez forte...... 233 SEYSARA...... 36 GLUCOSE...... 179 SALIVAMAX...... 239 SFROWASA...... 116 RIGHTEST GS550 BLOOD salsalate...... 23 Sharobel...... 100 GLUCOSE...... 179 SAMSCA...... 110 SHOPKO AUTOLET riluzole...... 76 SANCUSO...... 115 LANCING DEVICE...... 180 rimantadine hcl...... 31 SANDIMMUNE...... 142 SHOPKO UNIFINE RIMSO-50...... 123 SANDOSTATIN...... 110 PENTIPS...... 180 ringers irrigation...... 207 SANTYL...... 233 SHOPKO UNIFINE RINVOQ...... 137 SAPHRIS...... 70 PENTIPS PLUS...... 180 RIOMET...... 84 saps care alcohol prep...... 179 SHUR-SEAL risedronate sodium...... 91 saps health care alcohol prep...179 CONTRACEPTIVE...... 122 RISPERDAL CONSTA...... 70 saps health twist top lancets....180 SIGNIFOR...... 110 risperidone...... 70 saps twist top lancets...... 180 SIGNIFOR LAR...... 110 ritonavir...... 28 sapscare twist top lancets...... 180 SIKLOS...... 134 RITUXAN...... 38 SARCLISA...... 39 sildenafil citrate...... 57 rivastigmine...... 63 SAVAYSA...... 126 SILENOR...... 73 rivastigmine tartrate...... 63 SAVELLA...... 76 SILHOUETTE 13MM...... 180 Rivelsa...... 100 SAVELLA TITRATION SILHOUETTE 17MM...... 180 rixubis...... 130 PACK...... 76 SILHOUETTE INFUSION rizatriptan benzoate...... 75 SAXENDA...... 91 SET 23"...... 180 ROCKLATAN...... 207 sb alcohol prep...... 180 SILHOUETTE INFUSION romidepsin...... 38 sb childrens aspirin...... 23 SET 43"...... 180 ropinirole hcl...... 67 sb insulin syringe...... 180 silipac...... 234 ropinirole hcl er...... 67 sb lancets thin...... 180 SILIQ...... 223 Rosadan...... 235 sb lancets ultra thin...... 180 silodosin...... 122 rosuvastatin calcium...... 50 scarcin...... 233, 234 silver sulfadiazine...... 220 ROTARIX...... 142 scarsilk...... 234 SIMBRINZA...... 202 ROTATEQ...... 142 SCARZEN SKIN REPAIR.. 227 Simliya...... 101 ROWASA...... 116 scopolamine...... 115 Simpesse...... 101 Roweepra...... 61 SEASONIQUE...... 100 SIMPLE DIAGNOSTICS ROXICODONE...... 21 SEBUDERM...... 234 LANCING DEV...... 180 ROZEREM...... 73 SECURESAFE INSULIN SIMPONI...... 137 ROZLYTREK...... 42 SYRINGE...... 180 SIMPONI ARIA...... 137 RTD WOUND CARE SEGLUROMET...... 90 simvastatin...... 50 DRESSING...... 237 select-lite lancing device...... 180 SINGLE-LET...... 180 RUBRACA...... 38 SELECT-OB...... 198 SINGULAIR...... 213 RUCONEST...... 134 SELECT-OB+DHA...... 198 SINUVA...... 214 RUXIENCE...... 38 selegiline hcl...... 67 sirolimus...... 142 RUZURGI...... 76 selenium sulfide...... 223 SIRTURO...... 30 RYBELSUS...... 86 SELZENTRY...... 28 SITAVIG...... 31 RYCLORA...... 210 se-natal 19...... 198 SIVEXTRO...... 26 RYDAPT...... 38 SENSIPAR...... 92 SKYLA...... 101 RYTARY...... 67 SEREVENT DISKUS...... 211 SKYRIZI...... 138 RYVENT...... 210 SERNIVO...... 227 SKYRIZI (150 MG DOSE).. 138 268 SKYRIZI PEN...... 138 sodium polystyrene sulfonate.... 93 STELARA...... 138 SLYND...... 101 sodium sulfacetamide wash..... 223 STENDRA...... 122 sm alcohol prep...... 180 sodium sulfacetamide- STERILANCE PA...... 181 sm aspirin adult low strength.... 23 bakuchiol...... 219 STERILANCE TL...... 181 sm childrens aspirin...... 23 solifenacin succinate...... 124 sterile water for irrigation...... 207 sm folic acid...... 198 SOLIQUA...... 86 STIMATE...... 113 sm glucose...... 109 SOLODYN...... 36 STIOLTO RESPIMAT...... 209 sm lancets 33g...... 180 SOLOSEC...... 26 STIVARGA...... 42 sm nicotine...... 82, 83 SOLTAMOX...... 40 STRENSIQ...... 92 sm nicotine polacrilex...... 82 SOLUS V2 BLOOD STRIBILD...... 30 SM TRUEDRAW GLUCOSE SYSTEM...... 181 STRIVERDI RESPIMAT.... 211 LANCING DEVICE...... 180 SOLUS V2 LANCETS 28G.. 181 STROVITE FORTE...... 198 SMART DIABETES SOLUS V2 LANCING SUBLOCADE...... 22 VANTAGE LANCING...... 180 DEVICE...... 181 SUBOXONE...... 17 SMART SENSE COLOR SOLUS V2 TEST...... 181 SUBSYS...... 21 LANCETS 33G...... 180 SOLUS V2 TWIST Subvenite...... 62 SMART SENSE GLUCOSE 109 LANCETS 30G...... 181 Subvenite Starter Kit-Blue...... 62 SMART SENSE PREMIUM SOMATULINE DEPOT...... 110 Subvenite Starter Kit-Green....62 SYSTEM...... 180 SOMAVERT...... 110 Subvenite Starter Kit-Orange.. 62 SMART SENSE PREMIUM SOOLANTRA...... 235 SUCRAID...... 119 TEST...... 180 sorbitol...... 123 sucralfate...... 119 SMART SENSE sorbitol-mannitol...... 123 sulfacetamide sodium...... 205 STANDARD LANCETS..... 180 SORIATANE...... 223 sulfacetamide sodium (acne).. 219 SMART SENSE SUPER SORILUX...... 223 sulfacetamide sodium-sulfur....219 THIN LANCETS...... 180 Sorine...... 48 sulfacetamide-prednisolone..... 203 SMART SENSE THIN sorrel/dock mix...... 136 sulfadiazine...... 24 LANCETS 26G...... 180 sotalol hcl...... 48 sulfamethoxazole-trimethoprim 26 SMART SENSE VALUE sotalol hcl (af)...... 48 sulfamez wash...... 219 GLUCOSE SYS...... 181 SOTYLIZE...... 52 SULFAMYLON...... 220 SMART SENSE VALUE SOVALDI...... 34 sulfasalazine...... 117 TEST...... 181 spinosad...... 235 Sulfatrim Pediatric...... 26 SMARTEST BLOOD SPIRIVA HANDIHALER...209 sulfurated lime...... 235 GLUCOSE TEST...... 181 SPIRIVA RESPIMAT...... 209 sulindac...... 17 SMARTEST EJECT...... 181 spironolactone...... 55 sumatriptan...... 75 SMARTEST EJECT spironolactone-hctz...... 55 sumatriptan succinate...... 75 STARTER...... 181 SPORANOX...... 25 sumatriptan succinate refill...... 75 SMARTEST LANCETS 28G SPORANOX PULSEPAK..... 25 sumatriptan-naproxen sodium...75 ...... 181 SPRAVATO (56 MG DOSE). 66 SUNOSI...... 80 SMARTEST PERSONA SPRAVATO (84 MG DOSE). 66 SUPARTZ FX...... 23 STARTER...... 181 Sprintec 28...... 101 super bi-mix...... 122 SMARTEST PRONTO SPRITAM...... 61 super quad-mix...... 122 STARTER...... 181 SPRIX...... 16 super thin lancets...... 181 SMARTEST PROTEGE...... 181 SPRYCEL...... 42 super tri-mix...... 122 SMARTEST PROTEGE SPS...... 93 SUPERVITE...... 198 STARTER...... 181 Sronyx...... 101 SUPPRELIN LA...... 103 sod citrate-citric acid...... 123 Ssd...... 220 SUPRAX...... 32 sodium bicarbonate...... 198 ST JOSEPH LOW DOSE...... 23 SUPREME TEST...... 181 sodium chloride...... 123, 214 stavudine...... 28 SUPREP BOWEL PREP KIT sodium fluoride...... 198 STEGLATRO...... 91 ...... 118 sodium phenylbutyrate...... 104 STEGLUJAN...... 90 sure comfort alcohol prep...... 181 269 sure comfort insulin syringe.... 181 SYMPROIC...... 119 TEKTURNA...... 54 sure comfort lancets 18g...... 182 SYMTUZA...... 30 TEKTURNA HCT...... 54 sure comfort lancets 21g...... 182 SYNAGIS...... 31 telmisartan...... 47 sure comfort lancets 23g...... 182 SYNAPRYN FUSEPAQ...... 21 telmisartan-amlodipine...... 47 sure comfort lancets 30g...... 182 SYNAREL...... 103 telmisartan-hctz...... 47 sure comfort lancing pen...... 182 SYNDROS...... 115 temazepam...... 74 sure comfort pen needles...... 182 SYNERA...... 229 TEMIXYS...... 30 SURE-FINE PEN SYNERDERM...... 234 TEMODAR...... 37 NEEDLES...... 182 SYNJARDY...... 90 temozolomide...... 37 SURE-JECT INSULIN SYNJARDY XR...... 90 TENCON...... 15 SYRINGE...... 182 SYNRIBO...... 44 tenofovir disoproxil fumarate....28 SURE-LANCE FLAT SYPRINE...... 93 terazosin hcl...... 46 LANCETS...... 182 T:FLEX T:LOCK terbinafine hcl...... 25 SURE-LANCE LANCETS CARTRIDGE 4.8ML...... 182 terbutaline sulfate...... 211 26G...... 182 TABLOID...... 37 terconazole...... 125 SURELITE LANCETS...... 182 TABRADOL FUSEPAQ...... 80 TESTIM...... 83 SURE-PEN...... 182 TABRADOL RAPIDPAQ..... 80 TESTONE CIK...... 83 SURE-T INFUSION SET TACLONEX...... 227 TESTOPEL...... 83 18"...... 182 tacrolimus...... 142, 234 testosterone...... 84 SURE-T INFUSION SET tadalafil (pah)...... 57 testosterone cypionate...... 83 23"...... 182 TAFINLAR...... 42 testosterone enanthate...... 83 SURE-T INFUSION SET TAGRISSO...... 42 tetrabenazine...... 77 32"...... 182 TAKE ACTION...... 101 tetracaine hcl...... 134 SURE-T INFUSION SET TAKHZYRO...... 134 tetracycline hcl...... 36 6MM...... 182 TALICIA...... 121 TETRIX...... 234 SURE-T INFUSION SET TALIVA...... 134 TEXACORT...... 227 8MM...... 182 TALTZ...... 138 tgt blood glucose monitoring... 183 SURE-TEST EASYPLUS TALZENNA...... 39 tgt blood glucose test...... 183 MINI METER...... 182 tamoxifen citrate...... 40 tgt glucose...... 109 SURE-TEST EASYPLUS tamsulosin hcl...... 122 tgt lancet micro thin 33g...... 183 MINI TEST...... 182 TAPERDEX 12-DAY...... 107 tgt lancet thin 26g...... 183 SURE-TOUCH LANCETS Taperdex 6-Day...... 108 tgt lancet ultra thin 30g...... 183 UNIVERSAL...... 182 TAPERDEX 7-DAY...... 108 tgt lancing device...... 183 SURVANTA...... 214 TARCEVA...... 42 THALOMID...... 141 SUSTOL...... 115 Targadox...... 36 THE LIQUILIFT TRACE... 190 SUTENT...... 42 TARGRETIN...... 44, 234 THEO-24...... 216 suvicort...... 234 Tarina 24 Fe...... 101 theophylline...... 216 SX1 MEDICATED POST- Tarina Fe 1/20...... 101 theophylline er...... 216 OPERATIVE...... 229 Tarina Fe 1/20 Eq...... 101 THERANATAL CORE Syeda...... 101 TARON-C DHA...... 198 NUTRITION...... 199 SYMAX DUOTAB...... 114 TARON-PREX...... 198 thiamine hcl...... 199 Symax-Sr...... 114 TAYTULLA...... 101 THINLETS GP LANCETS..183 SYMBICORT...... 216 tazarotene...... 223 THIOLA...... 124 SYMDEKO...... 214 TAZORAC...... 223 THIOLA EC...... 124 SYMFI...... 30 Taztia Xt...... 54 thioridazine hcl...... 70 SYMFI LO...... 30 TECFIDERA...... 78 thiothixene...... 70 SYMJEPI...... 208 techlite insulin syringe...... 182 thrivacin 30...... 199 SYMLINPEN 120...... 84 TECHLITE PEN NEEDLES183 thrivacin detox...... 199 SYMLINPEN 60...... 84 TEGADERM AG MESH.....237 THRIVE...... 83 SYMPAZAN...... 62 TEGSEDI...... 80 thrivite 19...... 199 270 thrivite rx...... 199 TOVIAZ...... 124 Tri-Estarylla...... 101 THROMBIN-JMI...... 134 TOXICOLOGY MED trifluoperazine hcl...... 70 THROMBIN-JMI COLLECTION SYS...... 183 trifluridine...... 205 EPISTAXIS...... 134 TRACLEER...... 57 trihexyphenidyl hcl...... 68 THROMBOGEN...... 134 TRADJENTA...... 85 TRIJARDY XR...... 86 tiagabine hcl...... 62 tramadol hcl...... 21 TRIKAFTA...... 214 TIBSOVO...... 44 tramadol hcl er...... 21 Tri-Legest Fe...... 101 TICE BCG...... 44 tramadol hcl er (biphasic)...... 21 TRILEPTAL...... 62 TIGLUTIK...... 77 tramadol-acetaminophen...... 21 Tri-Linyah...... 101 TIKOSYN...... 48 trandolapril...... 46 Tri-Lo-Estarylla...... 101 Tilia Fe...... 101 trandolapril-verapamil hcl er.... 45 Tri-Lo-Marzia...... 101 timolol maleate...... 52, 202, 203 tranexamic acid...... 134 Tri-Lo-Mili...... 101 TIMOPTIC OCUDOSE...... 203 TRANSDERM-SCOP (1.5 Tri-Lo-Sprintec...... 101 tinidazole...... 24 MG)...... 115 trimethobenzamide hcl...... 115 TIROSINT...... 112 tranylcypromine sulfate...... 66 trimethoprim...... 26 TIROSINT-SOL...... 113 TRAVATAN Z...... 203 Tri-Mili...... 102 TISSEEL...... 134 travel lancets...... 183 trimipramine maleate...... 66 Tis-U-Sol...... 207 TRAVEL LANCETS tri-mix...... 122 TIVICAY...... 28 ADVANCED 28G...... 183 TRIMO-SAN...... 124 TIVICAY PD...... 28 TRAZIMERA...... 39 trinatal rx 1...... 199 TIVORBEX...... 17 trazodone hcl...... 66 TRINATE...... 199 tizanidine hcl...... 80 TREANDA...... 37 trinaz...... 199 tl-hem 150...... 134 TRECATOR...... 30 TRINTELLIX...... 66 TOBAKIENT...... 199 TRELEGY ELLIPTA...... 209 triple complex formula 3 kit....234 TOBI PODHALER...... 24 TRELSTAR MIXJECT...... 40 triple pmb...... 204 TOBRADEX...... 203 TREMFYA...... 138 triple pmk...... 204 TOBRADEX ST...... 203 treprostinil...... 57 Tri-Previfem...... 102 tobramycin...... 24, 205 TRESIBA...... 89 TRIPTODUR...... 103 tobramycin-dexamethasone.... 204 TRESIBA FLEXTOUCH...... 89 Tri-Sprintec...... 102 TOBREX...... 205 tretinoin...... 44, 219 tristart dha...... 199 todays health mini pen needles 183 tretinoin microsphere...... 219 TRISTART FREE...... 199 todays health pen needles...... 183 tretinoin microsphere pump.....219 TRISTART ONE...... 199 todays health short pen needle.183 TREXALL...... 37 TRIUMEQ...... 30 tolbutamide...... 91 TREXIMET...... 75 TRIVEEN-DUO DHA...... 199 tolcapone...... 68 Tri Femynor...... 101 TRI-VI-FLOR...... 199 tolsura...... 25 triamcinolone acetonide...227, 239 tri-vi-floro...... 199 tolterodine tartrate...... 124 tri-amino...... 199 TRIVISC...... 23 tolterodine tartrate er...... 124 triamterene...... 55 tri-vite/fluoride...... 199 topcare clickfine pen needles... 183 triamterene-hctz...... 55 Trivora (28)...... 102 topcare lancets micro-thin 33g 183 Trianex...... 227 Tri-Vylibra...... 102 topcare ultra comfort ins syr...183 triazolam...... 74 Tri-Vylibra Lo...... 102 topiramate...... 62 TRICARE...... 199 TRODELVY...... 39 topiramate er...... 62 TRICARE PRENATAL TROKENDI XR...... 62 TOPROL XL...... 52 DHA ONE...... 199 tronvite...... 199 toremifene citrate...... 40 TRICITRASOL...... 126 tropicamide...... 134 TORONOVA II SUIK...... 17 tricitrates...... 124 trospium chloride...... 125 TORONOVA SUIK...... 17 Tricon...... 134 trospium chloride er...... 124 torsemide...... 55 TRICOR...... 49 true comfort insulin syringe.....183 TOUJEO MAX SOLOSTAR. 89 Triderm...... 227 true comfort pen needles...... 183 TOUJEO SOLOSTAR...... 89 trientine hcl...... 93 true comfort pro insulin syr.....183 271 true comfort twist top lancets..183 TYLACTIN COMPLETE 15 ultra-care lancets 30g...... 186 TRUE FOCUS BLOOD PE...... 199 ultracare pen needles...... 186 GLUCOSE METER...... 183 TYMLOS...... 111 ULTRACET...... 21 true focus blood glucose strip.. 183 TYR EASY...... 199 ultra-comfort insulin syringe...186 TRUE METRIX AIR TYSABRI...... 79 ULTRAM...... 21 GLUCOSE METER...... 183 TYVASO...... 57 ULTRA-THIN II AUTO TRUE METRIX BLOOD TYVASO REFILL...... 57 LANCET...... 186 GLUCOSE TEST...... 183 TYVASO STARTER...... 57 ULTRA-THIN II INS SYR TRUE METRIX GO UBRELVY...... 75 SHORT...... 186 GLUCOSE METER...... 183 UCERIS...... 117 ULTRA-THIN II INSULIN TRUE METRIX METER.... 184 UDAMIN SP...... 199 SYRINGE...... 186 TRUEPLUS 5-BEVEL PEN UDENYCA...... 128 ULTRA-THIN II LANCETS NEEDLES...... 184 ULORIC...... 14 ...... 186 TRUEPLUS INSULIN ULTICARE ALCOHOL ULTRA-THIN II MINI PEN SYRINGE...... 184 SWABS...... 184 NEEDLE...... 186 TRUEPLUS LANCETS 26G184 ULTICARE INSULIN ULTRA-THIN II PEN TRUEPLUS LANCETS 28G184 SAFETY SYR...... 184 NEEDLE SHORT...... 186 TRUEPLUS LANCETS 30G184 ULTICARE INSULIN ULTRA-THIN II PEN TRUEPLUS LANCETS 33G184 SYRINGE...... 185 NEEDLES...... 186 TRUEPLUS PEN NEEDLES ULTICARE MICRO PEN ULTRAVATE...... 227 ...... 184 NEEDLES...... 185 UNIFINE PENTIPS...... 186 TRUEPLUS SAFETY ULTICARE MINI PEN UNIFINE PENTIPS PLUS.. 186 LANCETS 28G...... 184 NEEDLES...... 185 UNIFINE SAFECONTROL TRUERESULT BLOOD ULTICARE PEN NEEDLES PEN NEEDLE...... 186 GLUCOSE...... 184 ...... 185 UNILET COMFORTOUCH TRUETEST TEST...... 184 ULTICARE SHORT PEN LANCET...... 186 TRUETRACK BLOOD NEEDLES...... 185 UNILET EXCELITE...... 186 GLUCOSE...... 184 ultiguard safepack pen needle..185 UNILET EXCELITE II...... 186 TRUETRACK SMART ULTI-LANCE UNILET G.P. LANCET...... 186 SYSTEM...... 184 AUTOMATIC...... 185 UNILET G.P. SUPERLITE TRUETRACK TEST...... 184 ultilet alcohol swabs...... 185 LANCET...... 186 TRULANCE...... 117 ULTILET CLASSIC UNILET GP 28 ULTRA TRULICITY...... 86 LANCETS...... 185 THIN...... 186 TRUSTEEL INFUSION ULTILET INSULIN UNILET LANCET...... 186 SET...... 184 SYRINGE...... 185 UNILET MICRO-THIN 33G TRUVADA...... 30 ULTILET INSULIN ...... 187 TRUXIMA...... 39 SYRINGE SHORT...... 185 UNILET SUPERLITE TUDORZA PRESSAIR...... 209 ULTILET LANCETS...... 185 LANCET...... 187 TUKYSA...... 43 ULTILET PEN NEEDLE.... 185 UNILET SUPER-THIN 30G Tulana...... 102 ULTILET SAFETY ...... 187 TURALIO...... 43 LANCETS...... 185 UNILET ULTRA-THIN turpentine...... 234 ULTILET SAFETY 28G...... 187 TUSNEL C...... 212 LANCETS 23G...... 185 UNISTIK 1...... 187 TUSSICAPS...... 212 ULTIMA...... 185 UNISTIK 2...... 187 TUXARIN ER...... 212 ULTOMIRIS...... 135 UNISTIK 2 COMFORT...... 187 TUZISTRA XR...... 212 ultra comfort insulin syringe... 185 UNISTIK 2 EXTRA...... 187 TYBOST...... 29 ultra thin lancets 31g...... 185 UNISTIK 2 NEONATAL.... 187 Tydemy...... 102 ULTRA THIN PEN UNISTIK 2 NORMAL...... 187 TYKERB...... 43 NEEDLES...... 185 UNISTIK 2 SUPER...... 187 ultracare insulin syringe...... 186 UNISTIK 3...... 187 272 UNISTIK 3 COMFORT...... 187 VALTREX...... 31 verasens blood glucose system.188 UNISTIK 3 EXTRA...... 187 value health insulin syringe..... 187 verasens blood glucose test...... 188 UNISTIK 3 GENTLE...... 187 value plus glucose...... 109 VERDESO...... 227 UNISTIK 3 NEONATAL.... 187 value plus lancet standard 21g.187 VEREGEN...... 234 UNISTIK 3 NORMAL...... 187 value plus lancets super thin.... 187 VERSACLOZ...... 70 UNISTIK CZT COMFORT.187 valumark lancet ultra thin 28g 187 VERZENIO...... 39 UNISTIK CZT NORMAL...187 valumark pen needles...... 188 VESICARE...... 125 UNISTIK NORMAL...... 187 vancomycin hcl...... 26 VESICARE LS...... 125 UNISTIK PRO SAFETY VANCOMYCIN+SYRSPEN vexasyn...... 237 LANCET...... 187 D SF...... 26 V-GO 20...... 188 UNISTIK SAFETY Vandazole...... 125 V-GO 30...... 188 LANCETS 28G...... 187 VANISHPOINT INSULIN V-GO 40...... 188 UNISTIK SAFETY SYRINGE...... 188 VIAGRA...... 123 LANCETS 30G...... 187 VANOS...... 227 VIBERZI...... 117 UNISTIK TOUCH SAFETY Vanoxide-Hc...... 219 VIBRAMYCIN...... 36 LANC 21G...... 187 VANTAS...... 40 Vic-Forte...... 200 UNISTIK TOUCH SAFETY VARISOFT INFUSION SET VICTOZA...... 86 LANC 23G...... 187 ...... 188 VIDA MIA UNIFINE UNISTIK TOUCH SAFETY VAROPHEN...... 234 PENTIPS...... 188 LANC 28G...... 187 VARUBI (180 MG DOSE)... 115 Vienva...... 102 UNISTIK TOUCH SAFETY VASCEPA...... 50, 51 vigabatrin...... 62 LANC 30G...... 187 VASCULERA...... 199 Vigadrone...... 62 UNISTRIP1 GENERIC...... 187 VAXCHORA...... 142 VIIBRYD...... 66 Unithroid...... 113 VAXELIS...... 142, 143 VIIBRYD STARTER PACK.66 UNIVERSAL 1 LANCETS vb6 p5p...... 199 VIMOVO...... 17 THIN 26G...... 187 v-c forte...... 200 VIMPAT...... 62 UNIVERSAL 1 LANCETS VCF VAGINAL VINATE DHA RF...... 200 THIN 33G...... 187 CONTRACEPTIVE...... 122 VINATE II...... 200 UNIVERSAL 1 LANCETS VECAMYL...... 56 VINATE ONE...... 200 ULTRA THIN...... 187 VECTICAL...... 223 VIOKACE...... 119 up & up glucose...... 109 VELCADE...... 44 viorele...... 102 UPTRAVI...... 57 VELETRI...... 57 VIRACEPT...... 29 Uredeb...... 234 Velivet...... 102 VIREAD...... 29 URESOL...... 234 VELPHORO...... 111 virt-c dha...... 200 urosex...... 199 VELTASSA...... 93 virt-caps...... 200 UROXATRAL...... 122 VELTIN...... 219 virt-fefa plus...... 135 ursodiol...... 119 VEMLIDY...... 31 Virt-Gard...... 135 UVADEX...... 44 VENCLEXTA...... 45 virt-nate dha...... 200 VAGIFEM...... 106 VENCLEXTA STARTING virt-phos 250 neutral...... 190 valacyclovir hcl...... 31 PACK...... 45 virt-pn dha...... 200 VALCHLOR...... 234 VENELEX...... 237 virt-pn plus...... 200 VALCYTE...... 31 VENIPUNCTURE PX1 virtussin a/c...... 212 valganciclovir hcl...... 31 PHLEBOTOMY...... 229 virtussin dac...... 212 valproic acid...... 62 venlafaxine hcl...... 66 VISCO-3...... 23 valsartan...... 47 venlafaxine hcl er...... 66 VISTOGARD...... 44 valsartan-hydrochlorothiazide...47 VENTAVIS...... 58 Vita S Forte...... 200 VALTOCO 10 MG DOSE...... 62 VENTOLIN HFA...... 211 Vitacel...... 200 VALTOCO 15 MG DOSE...... 62 verapamil hcl...... 54 VITAFOL FE+...... 200 VALTOCO 20 MG DOSE...... 62 verapamil hcl er...... 54 VITAFOL GUMMIES...... 200 VALTOCO 5 MG DOSE...... 62 verasens blood glucose meter...188 VITAFOL STRIPS...... 200 273 VITAFOL ULTRA...... 200 Vylibra...... 102 XANAX XR...... 58 VITAFOL-NANO...... 200 VYNDAMAX...... 56 XAQUIL XR...... 201 VITAFOL-OB...... 200 VYNDAQEL...... 56 XARELTO...... 126 VITAFOL-OB+DHA...... 200 VYVANSE...... 73 XARELTO STARTER VITAFOL-ONE...... 200 VYZULTA...... 203 PACK...... 126 VITAMEDMD ONE walgreens adv travel lancets....188 XATMEP...... 37 RX/QUATREFOLIC...... 200 WALGREENS LANCETS...188 XCOPRI...... 63 VITAMEDMD REDICHEW walgreens lancets micro thin... 188 XCOPRI (250 MG DAILY RX...... 200 walgreens lancets super thin....188 DOSE)...... 63 VITAMEZ...... 135 WALGREENS THIN XCOPRI (350 MG DAILY vita-min...... 200 LANCETS...... 188 DOSE)...... 63 vitamin d (ergocalciferol)...... 200 WALGREENS ULTRA XELJANZ...... 139 vitamin k1...... 200 THIN LANCETS...... 188 XELJANZ XR...... 139 vitamins acd-fluoride...... 201 warfarin sodium...... 126 XELODA...... 37 VITAPEARL...... 201 WAVESENSE AMP...... 188 XELPROS...... 203 vitasure...... 201 WEBCOL ALCOHOL PREP XENICAL...... 77 VITATHELY WITH LARGE...... 188 XENLETA...... 26 GINGER...... 201 WEBCOL ALCOHOL PREP XEOMIN...... 80 VITATRUE...... 201 MEDIUM...... 188 XEPI...... 220 VITRAKVI...... 43 wegmans unifine pentips plus.. 188 XERAC AC...... 234 VIVA DHA...... 201 WEGOVY...... 91 XERALUX...... 234 VIVAGUARD INO Wera...... 102 XERESE...... 31 GLUCOSE METER...... 188 westab plus...... 201 XERMELO...... 119 VIVAGUARD INO TEST westgel dha...... 201 XEROFORM OIL STRIPS...... 188 WESTHROID...... 113 EMULSION 2"X2"...... 237 VIVAGUARD LANCETS... 188 wheat germ oil...... 201 XEROFORM OIL VIVAGUARD LANCING WIDE-SEAL DIAPHRAGM EMULSION GAUZE...... 237 DEVICE...... 188 60...... 143 XEROFORM OIL VIVELLE-DOT...... 106 WIDE-SEAL DIAPHRAGM EMULSION STRIP...... 238 VIVITROL...... 83 65...... 143 XEROFORM OIL ROLL VIVLODEX...... 17 WIDE-SEAL DIAPHRAGM 4"X9'...... 238 VIZIMPRO...... 43 70...... 143 XEROFORM PETROLAT VOGELXO...... 84 WIDE-SEAL DIAPHRAGM GAUZE 1"X8"...... 238 VOGELXO PUMP...... 84 75...... 143 XEROFORM PETROLAT VOLTAREN...... 234 WIDE-SEAL DIAPHRAGM GAUZE 5"X9"...... 238 VONVENDI...... 130 80...... 143 XEROFORM PETROLAT voriconazole...... 25 WIDE-SEAL DIAPHRAGM PATCH 2"X2"...... 238 VOSEVI...... 34 85...... 143 XEROFORM PETROLAT VOTRIENT...... 43 WIDE-SEAL DIAPHRAGM PATCH 4"X4"...... 238 vp fc kit...... 234 90...... 143 XEROFORM vp insulin syringe...... 188 WIDE-SEAL DIAPHRAGM PETROLATUM ROLL vp-pnv-dha...... 201 95...... 143 4"X9'...... 238 VPRIV...... 104 WILATE...... 127 XEROSTOMIA RELIEF vp-vite rx...... 201 WP THYROID...... 113 SPRAY...... 239 VRAYLAR...... 70 wpr plus wound healing system229 XGEVA...... 111 VSL#3 DS...... 119 Wymzya Fe...... 102 XHANCE...... 214 VUMERITY...... 79 XADAGO...... 68 XIFAXAN...... 27 VUSION...... 221 XALIX...... 234 XIGDUO XR...... 90 Vyfemla...... 102 XALKORI...... 43 XIIDRA...... 206 VYLEESI...... 83 XANAX...... 58 XIMINO...... 36 274 XOFIGO...... 44 ZELNORM...... 117 ZYCLARA PUMP...... 219, 234 XOFLUZA (40 MG DOSE)... 31 ZEMAIRA...... 214 ZYDELIG...... 43 XOFLUZA (80 MG DOSE)... 31 ZEMBRACE SYMTOUCH...75 ZYFLO...... 212 XOLAIR...... 211 Zenatane...... 219 ZYKADIA...... 43 XOLEGEL...... 222 ZENPEP...... 119 ZYLET...... 204 XOLEGEL COREPAK...... 222 Zenzedi...... 73 ZYMAXID...... 205 XOLEGEL DUO/HEAD & ZENZEDI...... 73 ZYPITAMAG...... 50 SHOULDERS...... 222 ZEPOSIA...... 79 ZYPREXA RELPREVV...... 71 XOLEGEL DUO/XOLEX... 222 ZEPOSIA 7-DAY STARTER zyvit...... 201 XOPENEX HFA...... 211 PACK...... 79 ZYVOX...... 27 XOSPATA...... 43 ZEPOSIA STARTER KIT..... 79 XPOVIO (60 MG TWICE ZESTORETIC...... 45 WEEKLY)...... 44 ZETIA...... 49 XPOVIO (80 MG TWICE ZETONNA...... 214 WEEKLY)...... 44 zevrx twist top lancets 30g...... 188 XRYLIX...... 234 ZIANA...... 219 XTAMPZA ER...... 21 zidovudine...... 29 XTANDI...... 40 ZIEXTENZO...... 128 Xulane...... 102 ZILACAINE PATCH...... 229 XULTOPHY...... 86 zileuton er...... 212 XURIDEN...... 111 ZILRETTA...... 108 xvite...... 201 zinc sulfate...... 190 XYNTHA...... 129 ZIOPTAN...... 203 XYNTHA SOLOFUSE...... 129 ziprasidone hcl...... 70 XYOSTED...... 84 ZIPSOR...... 17 XYREM...... 80 ZIRABEV...... 43 xyzbac...... 201 ZIRGAN...... 205 YASMIN 28...... 102 ZOKINVY...... 111 YAZ...... 102 ZOLADEX...... 40 yl folic acid...... 201 zoledronic acid...... 91, 92 YONSA...... 40 ZOLINZA...... 39 YOSPRALA...... 135 zolmitriptan...... 75 YUPELRI...... 209 ZOLOFT...... 66 YUTIQ...... 206 zolpidem tartrate...... 74 Yuvafem...... 106 zolpidem tartrate er...... 74 zaclir cleansing...... 219 ZOLPIMIST...... 74 zafirlukast...... 213 ZOMIG...... 75 zaleplon...... 74 ZONEGRAN...... 63 zalvit...... 201 zonisamide...... 63 zanabin hydrogel...... 238 ZONTIVITY...... 136 Zarah...... 102 ZORBTIVE...... 109 ZATEAN-PN DHA...... 201 ZORVOLEX...... 17 ZATEAN-PN PLUS...... 201 Zovia 1/35E (28)...... 102 ZAVESCA...... 104 ZOVIRAX...... 31, 234 Zebutal...... 15 ZTLIDO...... 229 ZEGERID...... 121 ZUBSOLV...... 18 ZEJULA...... 39 ZULRESSO...... 66 zelac...... 119 Zumandimine...... 102 ZELAPAR...... 68 ZUPLENZ...... 115 ZELBORAF...... 43 ZYCLARA...... 219 275