2018 Formulary (List of Covered Drugs)

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN

Assurance Rx (HMO-POS)

Essence Rx (HMO-POS)

Esteem Rx (HMO-POS)

Promise Rx (HMO-POS)

Spirit Rx (HMO-POS)

Surety Rx (HMO-POS)

This formulary was updated on Nov. 21, 2018. For more recent information or other questions, please contact Security Health Plan Customer Service at 1-877-998-0998 or, for TTY users, 711, or visit https://www.securityhealth.org/medicareformulary. We are open 7 days a week, 8 a.m. to 8 p.m., from Oct. 1-March 31; and Monday through Friday, 8 a.m. to 8 p.m., from April 1-Sept. 30.

Y0117_MC-778-0628-C-09-18 Effective date 12/1/2018 Updated 11/21/2018 Formulary ID 00018450, v.20

Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take.

When this drug list (formulary) refers to “we,” “us,” or “our,” it means Security Health Plan. When it refers to “plan” or “our plan,” it means Assurance Rx (HMO-POS), Essence Rx (HMO-POS), Promise Rx (HMO-POS), Spirit Rx (HMO- POS) or Surety Rx (HMO-POS).

This document includes a list of the drugs (formulary) for our plan which is current as of Dec. 1, 2018. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network and/or copayments/coinsurance may change on Jan. 1, 2019, and from time to time during the year.

Security Health Plan of Wisconsin, Inc., is an HMO, MSA and D-SNP plan with a Medicare contract and a contract with the Wisconsin Medicaid program. Enrollment in Security Health Plan depends on contract renewal.

This document is available in alternate formats. Call Customer Service at the number on the covers for more information.

What is the Security Health Plan Formulary? A formulary is a list of covered drugs selected by Security Health Plan in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Security Health Plan will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Security Health Plan network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.

Can the Formulary (drug list) change? Generally, if you are taking a drug on our 2018 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2018 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy restrictions on a drug, or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of Dec. 1, 2018. To get updated information about the drugs covered by Security Health Plan, please contact us. Our contact information appears on the front and back cover pages.

How do I use the Formulary? There are two ways to find your drug within the formulary:

Medical Condition

The formulary begins on page vii. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, “Cardiovascular Agents.” If you know what your drug is used for, look for the category name in the list that begins on page 1. Then look under the category name for your drug.

Alphabetical Listing

If you are not sure what category to look under, you should look for your drug in the Index that begins on page 113. The index provides an alphabetical list of all of the drugs included

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in this document. Both brand name drugs and generic drugs are listed in the index. Look in the index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the index and find the name of your drug in the first column of the list.

What are generic drugs? Security Health Plan covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs.

Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:

• Prior Authorization: Security Health Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Security Health Plan before you fill your prescriptions. If you don’t get approval, Security Health Plan may not cover the drug.

• Quantity Limits: For certain drugs, Security Health Plan limits the amount of the drug that your Medicare Advantage plan will cover. For example, Security Health Plan provides 18 tablets per prescription for sumatriptan. This may be in addition to a standard 1-month or 3- month supply.

You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page vii. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted online a document that explains our prior authorization restriction. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You can ask Security Health Plan to make an exception to these restrictions or limits or for a list of other drugs that may treat your health condition. See the section, “How do I request an exception to Security Health Plan’s formulary?” on page iii for information about how to request an exception.

What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Customer Service and ask if your drug is covered.

If you learn that Security Health Plan does not cover your drug, you have two options:

• You can ask Customer Service for a list of similar drugs that are covered by Security Health Plan. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Security Health Plan.

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• You can ask Security Health Plan to make an exception and cover your drug. See below for information about how to request an exception.

How do I request an exception to the Security Health Plan Formulary? You can ask Security Health Plan to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

• You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level.

• You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug.

• You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Security Health Plan limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.

Generally, Security Health Plan will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you request a formulary, tiering or utilization restriction exception, you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.

What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.

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If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a 93-day transition supply, consistent with dispensing increment (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. There are times outside of your first 90 days of new membership when the prescription drug transition process will also apply. One of the more common examples would be if you experience a change in your level of care (for example, when you are discharged from a hospital to either your home or to a long-term care facility, or if you end your long-term care facility stay and return to your home). Security Health Plan will ensure you have an effective transition of care, including your medication therapy, anytime you experience a change in your level of care.

For more information For more detailed information about your Security Health Plan prescription drug coverage, please review your Evidence of Coverage and other plan materials.

If you have questions about Security Health Plan, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY users should call 1- 877-486-2048. Or, visit http://www.medicare.gov.

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Notice of Nondiscrimination

Discrimination is against the law Security Health Plan of Wisconsin, Inc., complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation or health status in the administration of the plan, including enrollment and benefit determinations. Security Health Plan does not exclude people or treat them differently because of race, color, national origin, disability, age, sex, gender identity, sexual orientation or health status.

Security Health Plan: • Provides free aids and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats, other formats) • Provides free language services to people whose primary language is not English, such as: o Qualified interpreters Information written in other languages •o If you need these services, contact Customer Service at 1-877-998-0998 (TTY: 711). If you believe that Security Health Plan has failed to provide these services or discriminated in another way on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation or health status, you can file a grievance with:

Security Health Plan Attn: Grievances 1515 North Saint Joseph Avenue Marshfield, WI 54449-8000

Phone: 715-221-9596 (TTY: 711) Fax: 715-221-9424 Email: [email protected]

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

U.S. Department of Health and Human Services 200 Independence Avenue SW. Room 509F, HHH Building Washington, DC 20201

Phone: 1–800–368–1019 or 800–537–7697 (TDD)

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

Language Assistance Services

ATTENTION: If you speak a language other than English, language assistance services, free of charge, are available to you. Call 1-877-998-0998 (TTY: 711).

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Hmoob (Hmong) LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau 1-877-998-0998 (TTY: 711).

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繁體中文 (Chinese) 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-877-998-0998 (TTY: 711)。

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�हंद� (Hindi) 鵍यान द�: य�द आप �हंद� बोलते ह� तो आपके िलए मु굍त म� भाषा सहायता सेवाएं उपल녍ध ह�। 1-877-998-0998 (TTY: 711) पर कॉल कर�।

Shqip (Albanian) KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa pagesë. Telefononi në 1-877-998-0998 (TTY: 711).

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Large print – If you require materials in large print, please call 1-877-998-0998 (TTY: 711).

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Security Health Plan Formulary The formulary that begins on the next page provides coverage information about the drugs covered by Security Health Plan. If you have trouble finding your drug in the list, turn to the index that begins on page 113. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., ZETIA) and generic drugs are listed in lower-case italics (e.g., amoxicillin). The information in the Requirements/Limits column tells you if Security Health Plan has any special requirements for coverage of your drug. Deductibles and initial coverage period copay amounts: (30-day supply) Assurance Rx Essence Rx Esteem Rx Promise Rx Surety Rx (HMO-POS) (HMO-POS) (HMO-POS) (HMO-POS) Spirit Rx (HMO-POS) $375 $300 $300 $200 (HMO-POS) $300 Tier deductible deductible deductible deductible No deductible (Tiers 3-5 (Tiers 3-5 (Tiers 3-5 (Tiers 3-5 deductible (Tiers 3-5 only) only) only) only) only) 1 – Preferred $5 $5 $5 $6 $9 $5 generic drugs 2 – Generic $13 $14 $20 $20 $20 $20 drugs 3 – Preferred $45 $45 $45 $45 $47 $45 brand drugs 4 – Non- preferred $98 $100 $100 $100 $100 $100 drugs 5 – Specialty 25% 25% 25% 25% 33% 25% drugs of the cost of the cost of the cost of the cost of the cost of the cost 6 – Select Part $0 $0 $0 $0 $0 $0 D vaccines

Requirements/Limits key:

PA = Prior authorization required

PA NSO = Prior authorization required on new starts only

PA B vs. D = Prior authorization required for Part B vs. Part D coverage

HI = Home infusion coverage This prescription drug may be covered under our medical benefit. For more information call Customer Service at 1-877-998-0998, Monday through Sunday from 8 a.m. to 8 p.m. TTY users should call 711.

LA = Limited access This prescription may be available only at certain pharmacies. For more information, consult your Pharmacy Directory or call Customer Service at 1-877-998-0998, Monday through Sunday from 8 a.m. – 8 p.m. TTY users should call 711.

QL = Quantity limit

NDS = Non-extended day supply (Limited to 30-day supply)

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Table of Contents

Analgesics ...... 3 Anesthetics ...... 6 Anti-Addiction/ Substance Abuse Treatment Agents ...... 7 Antibacterials ...... 8 Anticonvulsants ...... 16 Antidementia Agents ...... 19 Antidepressants ...... 20 Antiemetics ...... 22 Antifungals ...... 24 Antigout Agents ...... 25 Anti-Inflammatory Agents ...... 25 Antimigraine Agents ...... 27 Antimyasthenic Agents ...... 28 Antimycobacterials...... 28 Antineoplastics ...... 29 Antiparasitics ...... 35 Antiparkinson Agents ...... 36 Antipsychotics ...... 37 Antispasticity Agents...... 41 Antivirals ...... 41 Anxiolytics ...... 46 Bipolar Agents ...... 47 Blood Glucose Regulators ...... 47 Blood Products/ Modifiers/ Volume Expanders ...... 52 Cardiovascular Agents ...... 55 Central Nervous System Agents...... 64 Dental And Oral Agents ...... 66

1 Dermatological Agents ...... 67 Electrolytes/Minerals/Metals/Vitamins ...... 69 Gastrointestinal Agents...... 74 Genetic Or Enzyme Disorder: Replacement, Modifiers, Treatment...... 77 Genitourinary Agents ...... 78 Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal) ...... 79 Hormonal Agents, Stimulant/ Replacement/ Modifying (Pituitary) ...... 81 Hormonal Agents, Stimulant/ Replacement/ Modifying (Sex Hormones/ Modifiers) ...... 82 Hormonal Agents, Stimulant/ Replacement/ Modifying (Thyroid) ...... 90 Hormonal Agents, Suppressant (Adrenal) ...... 91 Hormonal Agents, Suppressant (Pituitary) ...... 91 Hormonal Agents, Suppressant (Thyroid) ...... 92 Immunological Agents ...... 92 Inflammatory Bowel Disease Agents ...... 100 Metabolic Bone Disease Agents ...... 100 Ophthalmic Agents ...... 101 Otic Agents ...... 105 Respiratory Tract/ Pulmonary Agents ...... 106 Skeletal Muscle Relaxants ...... 111 Sleep Disorder Agents ...... 111

2 Drug Name Drug Tier Requirements/Limits Analgesics Analgesics acetaminophen-codeine oral solution 120-12 3 mg/5 ml acetaminophen-codeine oral tablet 300-15 mg, 3 300-30 mg, 300-60 mg ascomp with codeine oral capsule 30-50-325-40 4 QL (360 per 30 days) mg butalbital compound w/codeine oral capsule 30- 4 QL (360 per 30 days) 50-325-40 mg butalbital-acetaminop-caf-cod oral capsule 50- 4 QL (360 per 30 days) 300-40-30 mg butalbital-acetaminop-caf-cod oral capsule 50- 4 325-40-30 mg butalbital-acetaminophen oral tablet 50-325 mg 4 QL (180 per 30 days) butalbital-acetaminophen-caff oral capsule 50- 4 QL (180 per 30 days) 300-40 mg butalbital-acetaminophen-caff oral capsule 50- 4 325-40 mg butalbital-acetaminophen-caff oral tablet 50-325- 4 40 mg butalbital-aspirin-caffeine oral capsule 50-325- 4 40 mg butalbital-aspirin-caffeine oral tablet 50-325-40 4 mg capacet oral capsule 50-325-40 mg 4 endocet oral tablet 10-325 mg, 2.5-325 mg, 5-325 3 mg, 7.5-325 mg hydrocodone-acetaminophen oral solution 7.5- 3 325 mg/15 ml hydrocodone-acetaminophen oral tablet 10-300 3 mg, 10-325 mg, 2.5-325 mg, 5-300 mg, 5-325 mg, 7.5-300 mg, 7.5-325 mg hydrocodone-ibuprofen oral tablet 10-200 mg, 5- 3 200 mg, 7.5-200 mg lorcet (hydrocodone) oral tablet 5-325 mg 3 lorcet hd oral tablet 10-325 mg 3 lorcet plus oral tablet 7.5-325 mg 3 marten-tab oral tablet 50-325 mg 4 QL (180 per 30 days) nalocet oral tablet 2.5-300 mg 3 oxycodone-acetaminophen oral tablet 10-325 mg, 3 2.5-325 mg, 5-325 mg, 7.5-325 mg

You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 3 Drug Name Drug Tier Requirements/Limits oxycodone-aspirin oral tablet 4.8355-325 mg 3 phrenilin forte(with caffeine) oral capsule 50- 4 QL (180 per 30 days) 300-40 mg reprexain oral tablet 10-200 mg, 2.5-200 mg, 5- 3 200 mg tencon oral tablet 50-325 mg 4 QL (180 per 30 days) tramadol-acetaminophen oral tablet 37.5-325 mg 3 QL (240 per 30 days) vicodin es oral tablet 7.5-300 mg 3 vicodin hp oral tablet 10-300 mg 3 vicodin oral tablet 5-300 mg 3 xylon 10 oral tablet 10-200 mg 3 Nonsteroidal Anti-Inflammatory Drugs celecoxib oral capsule 100 mg, 200 mg, 400 mg, 3 QL (60 per 30 days) 50 mg diclofenac sodium topical gel 3 % 4 PA diclofenac-misoprostol oral tablet,ir,delayed 4 rel,biphasic 50-200 mg-mcg, 75-200 mg-mcg diflunisal oral tablet 500 mg 4 etodolac oral capsule 200 mg, 300 mg 3 etodolac oral tablet 400 mg, 500 mg 3 etodolac oral tablet extended release 24 hr 400 4 mg, 500 mg, 600 mg flurbiprofen oral tablet 100 mg, 50 mg 2 ibu oral tablet 400 mg, 600 mg, 800 mg 1 ibuprofen oral suspension 100 mg/5 ml 1 ibuprofen oral tablet 400 mg, 600 mg, 800 mg 1 indomethacin oral capsule 25 mg, 50 mg 3 indomethacin oral capsule, extended release 75 3 mg ketorolac injection solution 15 mg/ml 4 QL (20 per 5 days) ketorolac injection solution 30 mg/ml (1 ml) 4 ketorolac injection syringe 15 mg/ml 4 QL (20 per 5 days) ketorolac oral tablet 10 mg 3 QL (120 per 30 days) meloxicam oral tablet 15 mg 1 QL (30 per 30 days) meloxicam oral tablet 7.5 mg 1 QL (60 per 30 days) nabumetone oral tablet 500 mg, 750 mg 2 sulindac oral tablet 150 mg, 200 mg 2 Opioid Analgesics, Long-Acting ARYMO ER ORAL TABLET,ORAL 4 ONLY,EXTND RELEASE 15 MG, 30 MG, 60 MG

You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 4 Drug Name Drug Tier Requirements/Limits buprenorphine transdermal patch weekly 10 4 mcg/hour, 15 mcg/hour, 20 mcg/hour, 5 mcg/hour, 7.5 mcg/hour DURAMORPH (PF) INJECTION SOLUTION 4 0.5 MG/ML, 1 MG/ML fentanyl transdermal patch 72 hour 100 mcg/hr, 3 QL (20 per 30 days) 12 mcg/hr, 37.5 mcg/hour, 50 mcg/hr, 62.5 mcg/hour, 75 mcg/hr fentanyl transdermal patch 72 hour 25 mcg/hr 3 QL (15 per 30 days) hydromorphone (pf) injection solution 10 mg/ml 4 hydromorphone oral tablet extended release 24 4 hr 12 mg, 16 mg, 32 mg, 8 mg levorphanol tartrate oral tablet 2 mg 4 QL (180 per 30 days) methadone injection solution 10 mg/ml 3 QL (300 per 30 days) methadone oral solution 10 mg/5 ml 3 QL (450 per 30 days) methadone oral solution 5 mg/5 ml 3 QL (900 per 30 days) methadone oral tablet 10 mg, 5 mg 3 QL (180 per 30 days) morphine concentrate oral solution 100 mg/5 ml 3 (20 mg/ml) morphine oral solution 10 mg/5 ml, 20 mg/5 ml (4 3 mg/ml) MORPHINE ORAL TABLET 15 MG, 30 MG 3 QL (180 per 30 days) morphine oral tablet extended release 100 mg, 15 3 QL (120 per 30 days) mg, 30 mg, 60 mg morphine oral tablet extended release 200 mg 3 QL (180 per 30 days) NUCYNTA ER ORAL TABLET EXTENDED 4 QL (60 per 30 days) RELEASE 12 HR 100 MG, 150 MG, 200 MG, 250 MG, 50 MG OPANA ER ORAL TABLET,ORAL 4 QL (60 per 30 days) ONLY,EXT.REL.12 HR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 5 MG, 7.5 MG oxycodone oral tablet,oral only,ext.rel.12 hr 10 3 QL (90 per 30 days) mg, 15 mg, 20 mg, 30 mg, 40 mg, 60 mg oxycodone oral tablet,oral only,ext.rel.12 hr 80 3 QL (120 per 30 days) mg OXYCONTIN ORAL TABLET,ORAL 3 QL (90 per 30 days) ONLY,EXT.REL.12 HR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60 MG OXYCONTIN ORAL TABLET,ORAL 3 QL (120 per 30 days) ONLY,EXT.REL.12 HR 80 MG tramadol hcl er 300 mg tablet 300 mg 4 QL (30 per 30 days) tramadol oral tablet extended release 24 hr 100 4 QL (90 per 30 days) mg You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 5 Drug Name Drug Tier Requirements/Limits tramadol oral tablet extended release 24 hr 200 4 QL (60 per 30 days) mg tramadol oral tablet, er multiphase 24 hr 300 mg 4 QL (30 per 30 days) Opioid Analgesics, Short-Acting butorphanol tartrate injection solution 1 mg/ml 4 QL (960 per 30 days) butorphanol tartrate injection solution 2 mg/ml 4 QL (480 per 30 days) butorphanol tartrate nasal spray,non-aerosol 10 4 QL (5 per 28 days) mg/ml codeine sulfate oral tablet 15 mg, 30 mg, 60 mg 3 fentanyl citrate buccal lozenge on a handle 1,200 5 PA; NDS; QL (120 per 30 days) mcg, 1,600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg hydromorphone oral liquid 1 mg/ml 3 hydromorphone oral tablet 2 mg, 4 mg, 8 mg 3 meperidine oral solution 50 mg/5 ml 3 QL (900 per 30 days) meperidine oral tablet 100 mg 3 meperidine oral tablet 50 mg 3 QL (180 per 30 days) morphine 2 mg/ml syringe p/f, suv 2 mg/ml 3 morphine injection solution 10 mg/ml 3 MORPHINE INJECTION SOLUTION 2 4 MG/ML morphine injection syringe 5 mg/ml 4 morphine intravenous cartridge 10 mg/ml, 2 3 mg/ml, 4 mg/ml, 8 mg/ml morphine intravenous solution 10 mg/ml, 4 3 mg/ml, 8 mg/ml morphine intravenous syringe 10 mg/ml, 2 mg/ml, 3 4 mg/ml, 8 mg/ml NUCYNTA ORAL TABLET 100 MG, 50 MG, 4 QL (180 per 30 days) 75 MG oxycodone oral concentrate 20 mg/ml 3 QL (360 per 30 days) oxycodone oral solution 5 mg/5 ml 3 QL (7200 per 30 days) oxycodone oral tablet 10 mg, 15 mg, 20 mg, 30 3 QL (360 per 30 days) mg, 5 mg oxymorphone oral tablet 10 mg, 5 mg 3 tramadol oral tablet 50 mg 3 QL (240 per 30 days) Anesthetics Local Anesthetics lidocaine (pf) injection solution 10 mg/ml (1 %), 2 20 mg/ml (2 %), 5 mg/ml (0.5 %) lidocaine (pf) injection syringe 40 mg/2 ml (2%) 2

You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 6 Drug Name Drug Tier Requirements/Limits lidocaine hcl injection solution 10 mg/ml (1 %), 2 20 mg/ml (2 %), 5 mg/ml (0.5 %) lidocaine hcl mucous membrane jelly 2 % 3 lidocaine hcl mucous membrane solution 4 % (40 2 mg/ml) lidocaine hcl(pf) in 0.9% nacl injection syringe 2 100 mg/10 ml (1 %) lidocaine topical adhesive patch,medicated 5 % 4 PA NSO; QL (90 per 30 days) lidocaine topical ointment 5 % 4 lidocaine viscous mucous membrane solution 2 % 2 lidocaine-prilocaine topical cream 2.5-2.5 % 3 Anti-Addiction/ Substance Abuse Treatment Agents Alcohol Deterrents/Anti-Craving acamprosate oral tablet,delayed release (dr/ec) 4 333 mg disulfiram oral tablet 250 mg, 500 mg 3 Opioid Dependence Treatments buprenorphine hcl injection syringe 0.3 mg/ml 4 buprenorphine hcl sublingual tablet 2 mg, 8 mg 3 QL (90 per 30 days) buprenorphine-naloxone sublingual film 8-2 mg 3 QL (90 per 30 days) buprenorphine-naloxone sublingual tablet 2-0.5 3 mg, 8-2 mg LUCEMYRA ORAL TABLET 0.18 MG 4 QL (224 per 14 days) naltrexone oral tablet 50 mg 2 SUBOXONE SUBLINGUAL FILM 12-3 MG 4 QL (60 per 30 days) SUBOXONE SUBLINGUAL FILM 2-0.5 MG, 4 QL (90 per 30 days) 4-1 MG, 8-2 MG Opioid Reversal Agents naloxone injection solution 0.4 mg/ml 2 naloxone injection syringe 1 mg/ml 2 NARCAN NASAL SPRAY,NON-AEROSOL 4 3 MG/ACTUATION Smoking Cessation Agents bupropion hcl (smoking deter) oral tablet 2 QL (60 per 30 days) extended release 12 hr 150 mg CHANTIX CONTINUING MONTH BOX 4 QL (60 per 30 days) ORAL TABLET 1 MG CHANTIX ORAL TABLET 0.5 MG, 1 MG 4 QL (60 per 30 days) CHANTIX STARTING MONTH BOX ORAL 4 QL (60 per 30 days) TABLETS,DOSE PACK 0.5 MG (11)- 1 MG (42) You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 7 Drug Name Drug Tier Requirements/Limits NICOTROL INHALATION CARTRIDGE 10 4 MG NICOTROL NS NASAL SPRAY,NON- 4 AEROSOL 10 MG/ML Antibacterials Aminoglycosides amikacin injection solution 1,000 mg/4 ml, 500 4 HI mg/2 ml BETHKIS INHALATION SOLUTION FOR 5 PA; LA; NDS; QL (224 per 28 days) NEBULIZATION 300 MG/4 ML gentak ophthalmic (eye) ointment 0.3 % (3 2 mg/gram) gentamicin 80 mg/2 ml vial 25's,mdv,latex-free 40 3 mg/ml gentamicin in nacl (iso-osm) intravenous 3 HI piggyback 100 mg/100 ml, 80 mg/50 ml gentamicin in nacl (iso-osm) intravenous 3 piggyback 60 mg/50 ml gentamicin in nacl (iso-osm) intravenous 2 HI piggyback 80 mg/100 ml gentamicin injection solution 40 mg/ml 3 gentamicin ophthalmic (eye) drops 0.3 % 2 gentamicin ophthalmic (eye) ointment 0.3 % (3 2 mg/gram) gentamicin sulfate (ped) (pf) injection solution 20 3 mg/2 ml gentamicin sulfate (pf) intravenous solution 100 2 mg/10 ml, 60 mg/6 ml, 80 mg/8 ml gentamicin topical cream 0.1 % 3 gentamicin topical ointment 0.1 % 3 neomycin oral tablet 500 mg 3 neomycin-polymyxin b gu irrigation solution 40 3 mg-200,000 unit/ml paromomycin oral capsule 250 mg 4 streptomycin intramuscular recon soln 1 gram 3 TOBRADEX OPHTHALMIC (EYE) 4 OINTMENT 0.3-0.1 % tobramycin in 0.225 % nacl inhalation solution 5 PA; NDS for nebulization 300 mg/5 ml tobramycin ophthalmic (eye) drops 0.3 % 2 tobramycin sulfate injection solution 10 mg/ml, 2 HI 40 mg/ml You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 8 Drug Name Drug Tier Requirements/Limits TOBREX OPHTHALMIC (EYE) OINTMENT 4 0.3 % Antibacterials colistin (colistimethate na) injection recon soln 4 HI 150 mg SYNERCID INTRAVENOUS RECON SOLN 5 HI; NDS 500 MG Antibacterials, Other acetic acid irrigation solution 0.25 % 3 acetic acid otic (ear) solution 2 % 2 ALCOHOL PADS TOPICAL PADS, 1 MEDICATED ALCOHOL PREP PADS 1 aztreonam injection recon soln 2 gram 4 HI baciim intramuscular recon soln 50,000 unit 4 bacitracin intramuscular recon soln 50,000 unit 2 bacitracin ophthalmic (eye) ointment 500 4 unit/gram BACTROBAN NASAL NASAL OINTMENT 2 4 % chloramphenicol sod succinate intravenous recon 3 HI soln 1 gram clindamycin hcl oral capsule 150 mg, 300 mg, 75 2 mg clindamycin in 5 % dextrose intravenous 4 HI piggyback 300 mg/50 ml, 600 mg/50 ml, 900 mg/50 ml clindamycin palmitate hcl oral recon soln 75 4 mg/5 ml clindamycin phosphate injection solution 150 4 HI (mg/ml) (6 ml) clindamycin phosphate injection solution 150 4 HI mg/ml clindamycin phosphate intravenous solution 600 4 HI mg/4 ml clindamycin phosphate topical foam 1 % 4 clindamycin phosphate topical gel 1 % 4 clindamycin phosphate topical lotion 1 % 4 clindamycin phosphate topical solution 1 % 3 clindamycin phosphate topical swab 1 % 2 clindamycin phosphate vaginal cream 2 % 4 daptomycin intravenous recon soln 500 mg 4 HI

You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 9 Drug Name Drug Tier Requirements/Limits lincomycin injection solution 300 mg/ml 4 linezolid 600 mg/300 ml-0.9% nacl 600 mg/300 5 PA; HI; NDS ml linezolid in dextrose 5% intravenous piggyback 5 PA; HI; NDS 600 mg/300 ml linezolid oral suspension for reconstitution 100 5 PA; NDS mg/5 ml linezolid oral tablet 600 mg 5 PA; NDS mafenide acetate topical packet 50 gram 3 methenamine hippurate oral tablet 1 gram 2 metronidazole in nacl (iso-os) intravenous 4 HI piggyback 500 mg/100 ml metronidazole oral capsule 375 mg 4 metronidazole oral tablet 250 mg, 500 mg 2 metronidazole topical cream 0.75 % 3 metronidazole topical gel 0.75 %, 1 % 3 metronidazole topical lotion 0.75 % 3 metronidazole vaginal gel 0.75 % 3 MONUROL ORAL PACKET 3 GRAM 4 mupirocin calcium topical cream 2 % 4 mupirocin topical ointment 2 % 2 nitrofurantoin macrocrystal oral capsule 100 mg, 3 50 mg nitrofurantoin monohyd/m-cryst oral capsule 100 3 mg nitrofurantoin oral suspension 25 mg/5 ml 3 polymyxin b sulfate injection recon soln 500,000 3 HI unit rosadan topical cream 0.75 % 3 SIVEXTRO INTRAVENOUS RECON SOLN 5 PA; HI; NDS; QL (6 per 28 days) 200 MG SIVEXTRO ORAL TABLET 200 MG 5 PA; NDS; QL (6 per 28 days) SULFAMYLON TOPICAL CREAM 85 MG/G 4 SULFAMYLON TOPICAL PACKET 50 GRAM 4 tinidazole oral tablet 250 mg, 500 mg 3 trimethoprim oral tablet 100 mg 2 TRIMPEX ORAL SOLUTION 50 MG/5 ML 4 TYGACIL INTRAVENOUS RECON SOLN 50 5 HI; NDS MG vancomycin intravenous recon soln 1,000 mg, 10 3 PA BvD; HI gram, 5 gram, 500 mg vancomycin intravenous recon soln 250 mg 3 PA BvD You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 10 Drug Name Drug Tier Requirements/Limits vancomycin intravenous recon soln 750 mg 3 vancomycin oral capsule 125 mg, 250 mg 3 XIFAXAN ORAL TABLET 200 MG 5 NDS; QL (9 per 30 days) XIFAXAN ORAL TABLET 550 MG 5 NDS; QL (84 per 28 days) Beta-Lactam, Cephalosporins cefaclor oral capsule 250 mg, 500 mg 3 cefaclor oral suspension for reconstitution 125 4 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml cefadroxil oral capsule 500 mg 2 cefadroxil oral suspension for reconstitution 250 3 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet 1 gram 3 cefazolin in 0.9% sod chloride intravenous 4 HI solution 2 gram/100 ml cefazolin injection recon soln 1 gram, 10 gram, 3 HI 500 mg cefdinir oral capsule 300 mg 2 cefdinir oral suspension for reconstitution 125 3 mg/5 ml, 250 mg/5 ml CEFEPIME 1 GM INJECTION 1 GRAM/50 ML 4 HI CEFEPIME INJECTION RECON SOLN 1 4 HI GRAM, 2 GRAM CEFEPIME-DEXTROSE 2 GM/50 ML 2 4 HI GRAM/50 ML cefixime oral suspension for reconstitution 100 3 mg/5 ml, 200 mg/5 ml cefotaxime injection recon soln 1 gram, 2 gram 2 HI cefotaxime injection recon soln 10 gram 4 cefotaxime injection recon soln 500 mg 2 cefotetan injection recon soln 1 gram, 2 gram 4 cefotetan-dextr 1 g duplex bag 1 gram/50 ml 4 cefotetan-dextr 2 g duplex bag 2 gram/50 ml 4 cefoxitin 2 gm piggyback bag 2 gram/50 ml 4 HI cefoxitin intravenous recon soln 1 gram, 10 gram, 4 HI 2 gram cefpodoxime oral suspension for reconstitution 4 100 mg/5 ml, 50 mg/5 ml cefpodoxime oral tablet 100 mg, 200 mg 4 cefprozil oral suspension for reconstitution 125 4 mg/5 ml, 250 mg/5 ml cefprozil oral tablet 250 mg, 500 mg 3

You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 11 Drug Name Drug Tier Requirements/Limits ceftazidime injection recon soln 1 gram, 2 gram, 4 HI 6 gram ceftriaxone 1 gm piggyback l/f, single use 1 3 HI gram/50 ml ceftriaxone 2 gm piggyback l/f, single use 2 3 HI gram/50 ml ceftriaxone injection recon soln 1 gram, 10 gram, 3 HI 2 gram, 250 mg, 500 mg cefuroxime axetil oral tablet 250 mg, 500 mg 3 cefuroxime sodium injection recon soln 750 mg 3 cefuroxime sodium intravenous recon soln 1.5 3 gram cefuroxime sodium intravenous recon soln 7.5 3 HI gram cephalexin oral capsule 250 mg, 500 mg 1 cephalexin oral suspension for reconstitution 125 1 mg/5 ml, 250 mg/5 ml SUPRAX ORAL CAPSULE 400 MG 4 TEFLARO INTRAVENOUS RECON SOLN 4 HI 400 MG, 600 MG ZERBAXA INTRAVENOUS RECON SOLN 5 NDS 1.5 GRAM Beta-Lactam, Other aztreonam injection recon soln 1 gram 4 HI ertapenem injection recon soln 1 gram 4 imipenem-cilastatin intravenous recon soln 250 4 HI mg imipenem-cilastatin intravenous recon soln 500 3 HI mg INVANZ INJECTION RECON SOLN 1 GRAM 4 HI meropenem intravenous recon soln 1 gram 3 HI meropenem intravenous recon soln 500 mg 4 HI Beta-Lactam, Penicillins amoxicillin oral capsule 250 mg, 500 mg 1 amoxicillin oral suspension for reconstitution 125 1 mg/5 ml, 200 mg/5 ml, 250 mg/5 ml, 400 mg/5 ml amoxicillin oral tablet 500 mg, 875 mg 2 amoxicillin oral tablet,chewable 125 mg, 250 mg 1 amoxicillin-pot clavulanate oral suspension for 2 reconstitution 200-28.5 mg/5 ml, 250-62.5 mg/5 ml, 400-57 mg/5 ml, 600-42.9 mg/5 ml

You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 12 Drug Name Drug Tier Requirements/Limits amoxicillin-pot clavulanate oral tablet 250-125 2 mg, 500-125 mg, 875-125 mg amoxicillin-pot clavulanate oral tablet,chewable 2 200-28.5 mg, 400-57 mg ampicillin oral capsule 250 mg, 500 mg 2 ampicillin oral suspension for reconstitution 125 2 mg/5 ml, 250 mg/5 ml ampicillin sodium injection recon soln 1 gram, 10 4 HI gram, 125 mg, 500 mg ampicillin sodium injection recon soln 250 mg 3 HI ampicillin-sulbactam injection recon soln 1.5 4 HI gram, 15 gram, 3 gram BICILLIN C-R INTRAMUSCULAR SYRINGE 2 1,200,000 UNIT/ 2 ML(600K/600K), 1,200,000 UNIT/ 2 ML(900K/300K) BICILLIN L-A INTRAMUSCULAR SYRINGE 4 1,200,000 UNIT/2 ML, 2,400,000 UNIT/4 ML, 600,000 UNIT/ML dicloxacillin oral capsule 250 mg, 500 mg 2 nafcillin 2 gm vial sterile, latex-free 2 gram 4 HI nafcillin injection recon soln 1 gram, 10 gram 4 HI penicillin g pot in dextrose intravenous piggyback 4 HI 2 million unit/50 ml, 3 million unit/50 ml penicillin g potassium injection recon soln 20 4 HI million unit penicillin v potassium oral recon soln 125 mg/5 2 ml, 250 mg/5 ml penicillin v potassium oral tablet 250 mg, 500 mg 2 pfizerpen-g injection recon soln 20 million unit 4 piperacillin-tazobactam intravenous recon soln 4 HI 2.25 gram, 3.375 gram, 4.5 gram piperacillin-tazobactam intravenous recon soln 4 40.5 gram Macrolides AZASITE OPHTHALMIC (EYE) DROPS 1 % 3 azithromycin intravenous recon soln 500 mg 2 HI azithromycin oral packet 1 gram 3 azithromycin oral suspension for reconstitution 1 100 mg/5 ml, 200 mg/5 ml azithromycin oral tablet 250 mg, 250 mg (6 1 pack), 500 mg, 500 mg (3 pack), 600 mg

You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 13 Drug Name Drug Tier Requirements/Limits clarithromycin oral suspension for reconstitution 4 125 mg/5 ml, 250 mg/5 ml clarithromycin oral tablet 250 mg, 500 mg 3 clarithromycin oral tablet extended release 24 hr 3 500 mg DIFICID ORAL TABLET 200 MG 5 PA; NDS; QL (20 per 10 days) ery pads topical swab 2 % 3 ery-tab oral tablet,delayed release (dr/ec) 250 4 mg, 500 mg ERY-TAB ORAL TABLET,DELAYED 4 RELEASE (DR/EC) 333 MG ERYTHROCIN INTRAVENOUS RECON 1 HI SOLN 500 MG erythromycin ethylsuccinate oral suspension for 4 reconstitution 200 mg/5 ml erythromycin ethylsuccinate oral tablet 400 mg 4 erythromycin ophthalmic (eye) ointment 5 2 mg/gram (0.5 %) erythromycin oral tablet 250 mg, 500 mg 4 erythromycin with ethanol topical gel 2 % 3 erythromycin with ethanol topical solution 2 % 3 erythromycin with ethanol topical swab 2 % 3 Quinolones AVELOX IN NACL (ISO-OSMOTIC) 4 HI INTRAVENOUS PIGGYBACK 400 MG/250 ML BESIVANCE OPHTHALMIC (EYE) 4 DROPS,SUSPENSION 0.6 % CILOXAN OPHTHALMIC (EYE) OINTMENT 3 0.3 % ciprofloxacin hcl ophthalmic (eye) drops 0.3 % 1 ciprofloxacin hcl oral tablet 100 mg, 250 mg, 500 1 mg, 750 mg ciprofloxacin lactate intravenous solution 200 2 HI mg/20 ml, 400 mg/40 ml ciprofloxacin oral suspension,microcapsule recon 2 250 mg/5 ml, 500 mg/5 ml gatifloxacin ophthalmic (eye) drops 0.5 % 4 QL (2.5 per 25 days) levofloxacin 750 mg/30 ml vial suv 25 mg/ml 4 levofloxacin in d5w intravenous piggyback 500 4 HI mg/100 ml

You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 14 Drug Name Drug Tier Requirements/Limits levofloxacin in d5w intravenous piggyback 750 4 mg/150 ml levofloxacin intravenous solution 25 mg/ml 4 HI levofloxacin ophthalmic (eye) drops 0.5 % 3 levofloxacin oral solution 250 mg/10 ml 1 levofloxacin oral tablet 250 mg, 500 mg, 750 mg 1 MOXEZA OPHTHALMIC (EYE) DROPS, 4 VISCOUS 0.5 % moxifloxacin 400 mg/250 ml bag 400 mg/250 ml 2 HI moxifloxacin in nacl (iso-osm) intravenous 2 HI piggyback 400 mg/250 ml moxifloxacin ophthalmic (eye) drops 0.5 % 2 moxifloxacin oral tablet 400 mg 4 ofloxacin ophthalmic (eye) drops 0.3 % 2 ofloxacin oral tablet 400 mg 3 ofloxacin otic (ear) drops 0.3 % 3 Sulfonamides bleph-10 ophthalmic (eye) drops 10 % 2 silver sulfadiazine topical cream 1 % 2 ssd topical cream 1 % 2 sulfacetamide sodium (acne) topical suspension 3 10 % sulfacetamide sodium ophthalmic (eye) drops 10 2 % sulfadiazine oral tablet 500 mg 4 sulfamethoxazole-trimethoprim intravenous 1 HI solution 400-80 mg/5 ml sulfamethoxazole-trimethoprim oral suspension 3 200-40 mg/5 ml sulfamethoxazole-trimethoprim oral tablet 400-80 1 mg, 800-160 mg sulfatrim oral suspension 200-40 mg/5 ml 3 Tetracyclines demeclocycline oral tablet 150 mg, 300 mg 4 doxy-100 intravenous recon soln 100 mg 4 HI doxycycline hyclate intravenous recon soln 100 4 HI mg doxycycline hyclate oral capsule 100 mg, 50 mg 3 doxycycline hyclate oral tablet 100 mg, 20 mg 3 doxycycline monohydrate oral capsule 100 mg, 1 QL (60 per 30 days) 50 mg

You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 15 Drug Name Drug Tier Requirements/Limits doxycycline monohydrate oral capsule 150 mg, 4 QL (60 per 30 days) 75 mg doxycycline monohydrate oral tablet 100 mg, 150 3 mg, 50 mg, 75 mg minocycline oral capsule 100 mg, 50 mg, 75 mg 2 okebo oral capsule 100 mg 1 QL (60 per 30 days) okebo oral capsule 75 mg 4 QL (60 per 30 days) tetracycline oral capsule 250 mg, 500 mg 4 Anticonvulsants Anticonvulsants, Other BRIVIACT INTRAVENOUS SOLUTION 50 4 MG/5 ML BRIVIACT ORAL SOLUTION 10 MG/ML 5 NDS; QL (600 per 30 days) BRIVIACT ORAL TABLET 10 MG, 100 MG, 5 NDS; QL (60 per 30 days) 25 MG, 50 MG, 75 MG levetiracetam in nacl (iso-os) intravenous 2 piggyback 1,000 mg/100 ml, 1,500 mg/100 ml, 500 mg/100 ml levetiracetam intravenous solution 500 mg/5 ml 4 levetiracetam oral solution 100 mg/ml 2 levetiracetam oral tablet 1,000 mg, 250 mg, 500 2 mg, 750 mg levetiracetam oral tablet extended release 24 hr 3 500 mg, 750 mg POTIGA ORAL TABLET 200 MG, 300 MG, 5 NDS 400 MG, 50 MG ROWEEPRA ORAL TABLET 1,000 MG, 750 2 MG ROWEEPRA XR ORAL TABLET EXTENDED 2 RELEASE 24 HR 500 MG, 750 MG SPRITAM ORAL TABLET FOR SUSPENSION 4 QL (90 per 30 days) 1,000 MG SPRITAM ORAL TABLET FOR SUSPENSION 4 QL (360 per 30 days) 250 MG SPRITAM ORAL TABLET FOR SUSPENSION 4 QL (180 per 30 days) 500 MG SPRITAM ORAL TABLET FOR SUSPENSION 4 QL (120 per 30 days) 750 MG vigadrone oral powder in packet 500 mg 5 NDS Calcium Channel Modifying Agents CELONTIN ORAL CAPSULE 300 MG 4 ethosuximide oral capsule 250 mg 4 You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 16 Drug Name Drug Tier Requirements/Limits ethosuximide oral solution 250 mg/5 ml 4 LYRICA ORAL CAPSULE 100 MG, 150 MG, 3 QL (90 per 30 days) 200 MG, 300 MG, 50 MG, 75 MG LYRICA ORAL CAPSULE 225 MG 3 QL (60 per 30 days) LYRICA ORAL CAPSULE 25 MG 3 LYRICA ORAL SOLUTION 20 MG/ML 3 QL (900 per 30 days) zonisamide oral capsule 100 mg, 25 mg, 50 mg 2 Gamma-Aminobutyric Acid (Gaba) Augmenting Agents clobazam oral suspension 2.5 mg/ml 4 QL (480 per 30 days) clobazam oral tablet 10 mg, 20 mg 4 QL (60 per 30 days) DIASTAT ACUDIAL RECTAL KIT 12.5-15- 3 17.5-20 MG, 5-7.5-10 MG DIASTAT RECTAL KIT 2.5 MG 3 diazepam rectal kit 2.5 mg, 5-7.5-10 mg 3 divalproex oral capsule, delayed rel sprinkle 125 2 mg divalproex oral tablet extended release 24 hr 250 2 mg, 500 mg divalproex oral tablet,delayed release (dr/ec) 125 2 mg, 250 mg, 500 mg gabapentin oral capsule 100 mg, 300 mg, 400 mg 2 QL (270 per 30 days) gabapentin oral solution 250 mg/5 ml 4 gabapentin oral tablet 600 mg, 800 mg 2 QL (180 per 30 days) GABITRIL ORAL TABLET 12 MG, 16 MG 4 ONFI ORAL SUSPENSION 2.5 MG/ML 4 QL (480 per 30 days) ONFI ORAL TABLET 10 MG, 20 MG 4 QL (60 per 30 days) phenobarbital oral elixir 20 mg/5 ml (4 mg/ml) 4 QL (1500 per 30 days) phenobarbital oral tablet 100 mg, 16.2 mg, 32.4 3 QL (90 per 30 days) mg, 64.8 mg, 97.2 mg phenobarbital oral tablet 15 mg, 60 mg 3 QL (120 per 30 days) phenobarbital oral tablet 30 mg 3 QL (300 per 30 days) primidone oral tablet 250 mg, 50 mg 2 SABRIL ORAL POWDER IN PACKET 500 MG 5 NDS; QL (180 per 30 days) SABRIL ORAL TABLET 500 MG 5 NDS; QL (180 per 30 days) tiagabine oral tablet 12 mg, 16 mg, 2 mg, 4 mg 4 valproate sodium intravenous solution 500 mg/5 4 ml (100 mg/ml) valproic acid (as sodium salt) oral solution 500 2 mg/10 ml (10 ml) valproic acid 250 mg/5 ml soln 250 mg/5 ml 2 valproic acid oral capsule 250 mg 2 You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 17 Drug Name Drug Tier Requirements/Limits vigabatrin oral powder in packet 500 mg 5 NDS Glutamate Reducing Agents felbamate oral suspension 600 mg/5 ml 5 NDS felbamate oral tablet 400 mg, 600 mg 4 FYCOMPA ORAL SUSPENSION 0.5 MG/ML 4 QL (680 per 28 days) FYCOMPA ORAL TABLET 10 MG, 12 MG, 2 4 QL (30 per 30 days) MG, 4 MG, 6 MG, 8 MG lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 2 25 mg lamotrigine oral tablet extended release 24hr 100 4 mg, 200 mg, 25 mg, 300 mg, 50 mg lamotrigine oral tablet, chewable dispersible 25 2 mg, 5 mg lamotrigine oral tablets,dose pack 25 mg (35), 25 2 mg (42) -100 mg (7), 25 mg (84) -100 mg (14) topiramate oral capsule, sprinkle 15 mg, 25 mg 2 topiramate oral capsule,sprinkle,er 24hr 100 mg, 3 150 mg, 200 mg, 25 mg, 50 mg topiramate oral tablet 100 mg, 200 mg, 50 mg 2 QL (120 per 30 days) topiramate oral tablet 25 mg 2 QL (90 per 30 days) Sodium Channel Agents APTIOM ORAL TABLET 200 MG, 400 MG, 4 QL (30 per 30 days) 800 MG APTIOM ORAL TABLET 600 MG 4 QL (60 per 30 days) BANZEL ORAL SUSPENSION 40 MG/ML 5 NDS; QL (2760 per 30 days) BANZEL ORAL TABLET 200 MG 5 NDS; QL (480 per 30 days) BANZEL ORAL TABLET 400 MG 5 NDS; QL (240 per 30 days) carbamazepine oral suspension 100 mg/5 ml 3 carbamazepine oral tablet 200 mg 2 carbamazepine oral tablet extended release 12 hr 4 100 mg, 200 mg, 400 mg carbamazepine oral tablet,chewable 100 mg 3 DILANTIN EXTENDED ORAL CAPSULE 100 3 MG DILANTIN INFATABS ORAL 3 TABLET,CHEWABLE 50 MG DILANTIN ORAL CAPSULE 30 MG 3 DILANTIN-125 ORAL SUSPENSION 125 3 MG/5 ML epitol oral tablet 200 mg 3

You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 18 Drug Name Drug Tier Requirements/Limits EQUETRO ORAL CAPSULE, ER 4 MULTIPHASE 12 HR 100 MG, 200 MG, 300 MG fosphenytoin injection solution 100 mg pe/2 ml, 1 500 mg pe/10 ml oxcarbazepine oral suspension 300 mg/5 ml (60 4 mg/ml) oxcarbazepine oral tablet 150 mg, 300 mg, 600 3 mg PEGANONE ORAL TABLET 250 MG 4 PHENYTEK ORAL CAPSULE 200 MG, 300 4 MG phenytoin oral suspension 125 mg/5 ml 2 phenytoin oral tablet,chewable 50 mg 2 phenytoin sodium extended oral capsule 100 mg, 2 200 mg, 300 mg phenytoin sodium intravenous solution 50 mg/ml 4 TEGRETOL ORAL SUSPENSION 100 MG/5 4 ML TEGRETOL ORAL TABLET 200 MG 4 VIMPAT INTRAVENOUS SOLUTION 200 4 MG/20 ML VIMPAT ORAL SOLUTION 10 MG/ML 4 QL (1395 per 30 days) VIMPAT ORAL TABLET 100 MG, 150 MG, 4 200 MG, 50 MG Antidementia Agents Antidementia Agents, Other ergoloid oral tablet 1 mg 3 Cholinesterase Inhibitors donepezil oral tablet 10 mg 1 QL (60 per 30 days) donepezil oral tablet 23 mg 3 QL (30 per 30 days) donepezil oral tablet 5 mg 1 QL (30 per 30 days) donepezil oral tablet,disintegrating 10 mg, 5 mg 1 QL (30 per 30 days) galantamine oral capsule,ext rel. pellets 24 hr 16 4 QL (30 per 30 days) mg, 24 mg, 8 mg galantamine oral solution 4 mg/ml 4 QL (200 per 30 days) galantamine oral tablet 12 mg, 4 mg, 8 mg 4 QL (60 per 30 days) rivastigmine tartrate oral capsule 1.5 mg, 3 mg 4 QL (90 per 30 days) rivastigmine tartrate oral capsule 4.5 mg, 6 mg 4 QL (60 per 30 days) rivastigmine transdermal patch 24 hour 13.3 4 QL (30 per 30 days) mg/24 hour, 4.6 mg/24 hr, 9.5 mg/24 hr

You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 19 Drug Name Drug Tier Requirements/Limits N-Methyl-D-Aspartate (Nmda) Receptor Antagonist memantine oral capsule,sprinkle,er 24hr 14 mg, 4 QL (30 per 30 days) 21 mg, 28 mg, 7 mg memantine oral solution 2 mg/ml 3 QL (360 per 30 days) memantine oral tablet 10 mg, 5 mg 1 QL (60 per 30 days) memantine oral tablets,dose pack 5-10 mg 1 QL (98 per 30 days) NAMENDA XR ORAL CAP,SPRINKLE,ER 4 QL (28 per 30 days) 24HR DOSE PACK 7-14-21-28 MG NAMENDA XR ORAL 4 QL (30 per 30 days) CAPSULE,SPRINKLE,ER 24HR 14 MG, 21 MG, 28 MG, 7 MG NAMZARIC ORAL CAP,SPRINKLE,ER 24HR 4 QL (28 per 28 days) DOSE PACK 7/14/21/28 MG-10 MG NAMZARIC ORAL CAPSULE,SPRINKLE,ER 4 QL (30 per 30 days) 24HR 14-10 MG, 21-10 MG, 28-10 MG, 7-10 MG Antidepressants Antidepressants amitriptyline-chlordiazepoxide oral tablet 12.5-5 3 mg, 25-10 mg perphenazine-amitriptyline oral tablet 2-10 mg, 3 2-25 mg, 4-10 mg, 4-25 mg, 4-50 mg Antidepressants, Other bupropion hcl oral tablet 100 mg 2 QL (180 per 30 days) bupropion hcl oral tablet 75 mg 2 bupropion hcl oral tablet extended release 24 hr 2 QL (90 per 30 days) 150 mg bupropion hcl oral tablet extended release 24 hr 2 QL (60 per 30 days) 300 mg bupropion hcl oral tablet sustained-release 12 hr 2 QL (120 per 30 days) 100 mg bupropion hcl oral tablet sustained-release 12 hr 2 QL (90 per 30 days) 150 mg bupropion hcl oral tablet sustained-release 12 hr 2 QL (60 per 30 days) 200 mg maprotiline oral tablet 25 mg, 50 mg, 75 mg 4 mirtazapine oral tablet 15 mg, 30 mg, 45 mg, 7.5 2 QL (30 per 30 days) mg mirtazapine oral tablet,disintegrating 15 mg, 30 4 QL (30 per 30 days) mg, 45 mg

You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 20 Drug Name Drug Tier Requirements/Limits nefazodone oral tablet 100 mg, 150 mg, 200 mg, 4 250 mg, 50 mg trazodone oral tablet 100 mg, 150 mg, 50 mg 1 trazodone oral tablet 300 mg 2 Monoamine Oxidase Inhibitors EMSAM TRANSDERMAL PATCH 24 HOUR 5 NDS; QL (30 per 30 days) 12 MG/24 HR, 6 MG/24 HR, 9 MG/24 HR MARPLAN ORAL TABLET 10 MG 4 phenelzine oral tablet 15 mg 3 tranylcypromine oral tablet 10 mg 4 Ssris/ Snris citalopram oral solution 10 mg/5 ml 3 citalopram oral tablet 10 mg, 40 mg 1 QL (30 per 30 days) citalopram oral tablet 20 mg 1 QL (60 per 30 days) desvenlafaxine succinate oral tablet extended 3 release 24 hr 100 mg, 25 mg, 50 mg duloxetine oral capsule,delayed release(dr/ec) 20 2 QL (60 per 30 days) mg, 30 mg, 60 mg duloxetine oral capsule,delayed release(dr/ec) 40 3 QL (60 per 30 days) mg escitalopram oxalate oral solution 5 mg/5 ml 4 QL (600 per 30 days) escitalopram oxalate oral tablet 10 mg 1 QL (45 per 30 days) escitalopram oxalate oral tablet 20 mg 1 QL (90 per 30 days) escitalopram oxalate oral tablet 5 mg 1 QL (30 per 30 days) FETZIMA ORAL CAPSULE,EXT REL 24HR 4 QL (28 per 28 days) DOSE PACK 20 MG (2)- 40 MG (26) FETZIMA ORAL CAPSULE,EXTENDED 4 QL (30 per 30 days) RELEASE 24 HR 120 MG, 20 MG, 40 MG, 80 MG fluoxetine oral capsule 10 mg, 40 mg 1 QL (60 per 30 days) fluoxetine oral capsule 20 mg 1 QL (120 per 30 days) fluoxetine oral solution 20 mg/5 ml (4 mg/ml) 2 fluvoxamine oral capsule,extended release 24hr 4 100 mg, 150 mg fluvoxamine oral tablet 100 mg, 25 mg, 50 mg 3 QL (90 per 30 days) paroxetine hcl oral tablet 10 mg, 20 mg 1 QL (30 per 30 days) paroxetine hcl oral tablet 30 mg, 40 mg 1 QL (60 per 30 days) PAXIL ORAL SUSPENSION 10 MG/5 ML 4 sertraline oral concentrate 20 mg/ml 3 sertraline oral tablet 100 mg 1 QL (60 per 30 days) sertraline oral tablet 25 mg, 50 mg 1 QL (300 per 30 days)

You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 21 Drug Name Drug Tier Requirements/Limits TRINTELLIX ORAL TABLET 10 MG, 20 MG, 4 QL (30 per 30 days) 5 MG venlafaxine oral capsule,extended release 24hr 2 QL (60 per 30 days) 150 mg venlafaxine oral capsule,extended release 24hr 2 QL (30 per 30 days) 37.5 mg venlafaxine oral capsule,extended release 24hr 2 QL (90 per 30 days) 75 mg venlafaxine oral tablet 100 mg, 25 mg, 37.5 mg, 2 50 mg, 75 mg VIIBRYD ORAL TABLET 10 MG, 20 MG, 40 4 QL (30 per 30 days) MG VIIBRYD ORAL TABLETS,DOSE PACK 10 4 QL (30 per 30 days) MG (7)- 20 MG (23), 10 MG (7)-20 MG (7)-40 MG (16) Tricyclics amitriptyline oral tablet 10 mg, 100 mg, 150 mg, 3 25 mg, 50 mg, 75 mg amoxapine oral tablet 100 mg, 150 mg, 25 mg, 50 4 mg clomipramine oral capsule 25 mg, 50 mg, 75 mg 4 desipramine oral tablet 10 mg, 100 mg, 150 mg, 2 25 mg, 50 mg, 75 mg doxepin oral capsule 10 mg, 100 mg, 150 mg, 25 3 mg, 50 mg, 75 mg doxepin oral concentrate 10 mg/ml 3 imipramine hcl oral tablet 10 mg, 25 mg, 50 mg 3 imipramine pamoate oral capsule 100 mg, 125 4 mg, 150 mg, 75 mg nortriptyline oral capsule 10 mg, 25 mg, 50 mg, 1 75 mg nortriptyline oral solution 10 mg/5 ml 4 protriptyline oral tablet 10 mg, 5 mg 4 SILENOR ORAL TABLET 3 MG, 6 MG 4 trimipramine oral capsule 100 mg, 25 mg, 50 mg 4 Antiemetics Antiemetics, Other compro rectal suppository 25 mg 2 diphenhydramine hcl injection solution 50 mg/ml 4 diphenhydramine hcl injection syringe 50 mg/ml 4 hydroxyzine hcl intramuscular solution 25 mg/ml 4 hydroxyzine hcl oral solution 10 mg/5 ml 3 You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 22 Drug Name Drug Tier Requirements/Limits hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg 3 hydroxyzine pamoate oral capsule 100 mg, 25 3 mg, 50 mg meclizine oral tablet 12.5 mg, 25 mg 2 perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg 3 phenadoz rectal suppository 12.5 mg 4 phenadoz rectal suppository 25 mg 3 prochlorperazine edisylate injection solution 10 4 mg/2 ml (5 mg/ml), 5 mg/ml prochlorperazine maleate oral tablet 10 mg, 5 mg 1 prochlorperazine rectal suppository 25 mg 3 promethazine injection solution 25 mg/ml, 50 3 mg/ml promethazine oral syrup 6.25 mg/5 ml 3 promethazine oral tablet 12.5 mg, 25 mg, 50 mg 3 promethazine rectal suppository 12.5 mg, 25 mg, 3 50 mg promethegan rectal suppository 12.5 mg, 25 mg, 3 50 mg scopolamine base transdermal patch 3 day 1 mg 2 over 3 days TRANSDERM-SCOP TRANSDERMAL 4 QL (10 per 30 days) PATCH 3 DAY 1 MG OVER 3 DAYS Emetogenic Therapy Adjuncts AKYNZEO (NETUPITANT) ORAL CAPSULE 3 300-0.5 MG ANZEMET ORAL TABLET 100 MG 5 PA BvD; NDS ANZEMET ORAL TABLET 50 MG 4 PA BvD aprepitant oral capsule 125 mg, 40 mg, 80 mg 2 PA BvD aprepitant oral capsule,dose pack 125 mg (1)- 80 3 PA BvD mg (2) CESAMET ORAL CAPSULE 1 MG 5 PA BvD; NDS dronabinol oral capsule 10 mg, 2.5 mg, 5 mg 4 PA BvD; QL (120 per 30 days) granisetron (pf) intravenous solution 100 mcg/ml 4 granisetron hcl intravenous solution 1 mg/ml, 1 4 mg/ml (1 ml) granisetron hcl oral tablet 1 mg 3 PA BvD; QL (28 per 28 days) ondansetron hcl (pf) injection solution 4 mg/2 ml 2 PA BvD; HI ondansetron hcl (pf) injection syringe 4 mg/2 ml 2 PA BvD; HI ondansetron hcl oral solution 4 mg/5 ml 4 PA BvD ondansetron hcl oral tablet 24 mg, 4 mg, 8 mg 2 PA BvD; QL (450 per 30 days) ondansetron oral tablet,disintegrating 4 mg, 8 mg 2 PA BvD; QL (450 per 30 days) You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 23 Drug Name Drug Tier Requirements/Limits Antifungals Antifungals ABELCET INTRAVENOUS SUSPENSION 5 5 PA BvD; NDS MG/ML AMBISOME INTRAVENOUS SUSPENSION 4 PA BvD FOR RECONSTITUTION 50 MG amphotericin b injection recon soln 50 mg 4 PA BvD CANCIDAS INTRAVENOUS RECON SOLN 5 HI; NDS 50 MG, 70 MG caspofungin intravenous recon soln 50 mg, 70 mg 5 NDS ciclopirox topical cream 0.77 % 2 ciclopirox topical gel 0.77 % 4 ciclopirox topical shampoo 1 % 4 ciclopirox topical solution 8 % 2 ciclopirox topical suspension 0.77 % 4 clotrimazole mucous membrane troche 10 mg 2 clotrimazole topical cream 1 % 2 clotrimazole topical solution 1 % 3 econazole topical cream 1 % 4 fluconazole in nacl (iso-osm) intravenous 4 HI piggyback 200 mg/100 ml, 400 mg/200 ml fluconazole oral suspension for reconstitution 10 2 mg/ml, 40 mg/ml fluconazole oral tablet 100 mg, 150 mg, 200 mg, 2 50 mg flucytosine oral capsule 250 mg, 500 mg 5 NDS griseofulvin microsize oral suspension 125 mg/5 4 ml griseofulvin microsize oral tablet 500 mg 4 griseofulvin ultramicrosize oral tablet 125 mg, 4 250 mg itraconazole oral capsule 100 mg 3 PA; QL (120 per 30 days) itraconazole oral solution 10 mg/ml 4 PA ketoconazole oral tablet 200 mg 2 ketoconazole topical cream 2 % 2 ketoconazole topical shampoo 2 % 2 miconazole-3 vaginal suppository 200 mg 3 naftifine topical cream 1 %, 2 % 4 NAFTIN TOPICAL GEL 1 %, 2 % 4 NATACYN OPHTHALMIC (EYE) 4 DROPS,SUSPENSION 5 %

You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 24 Drug Name Drug Tier Requirements/Limits NOXAFIL ORAL SUSPENSION 200 MG/5 ML 5 PA; NDS; QL (840 per 28 days) (40 MG/ML) NOXAFIL ORAL TABLET,DELAYED 5 PA; NDS; QL (93 per 30 days) RELEASE (DR/EC) 100 MG nyamyc topical powder 100,000 unit/gram 2 nyata topical powder 100,000 unit/gram 2 nystatin oral powder 500 million unit 2 nystatin oral suspension 100,000 unit/ml 2 nystatin oral tablet 500,000 unit 3 nystatin topical cream 100,000 unit/gram 2 nystatin topical ointment 100,000 unit/gram 2 nystatin topical powder 100,000 unit/gram 2 nystop topical powder 100,000 unit/gram 2 SPORANOX ORAL SOLUTION 10 MG/ML 5 PA; NDS terbinafine hcl oral tablet 250 mg 2 QL (90 per 365 days) terconazole vaginal cream 0.4 %, 0.8 % 2 terconazole vaginal suppository 80 mg 2 voriconazole intravenous solution 200 mg 4 voriconazole oral suspension for reconstitution 5 PA; NDS; QL (400 per 30 days) 200 mg/5 ml (40 mg/ml) voriconazole oral tablet 200 mg, 50 mg 5 PA; NDS; QL (120 per 30 days) Antigout Agents Antigout Agents allopurinol oral tablet 100 mg, 300 mg 1 colchicine oral capsule 0.6 mg 4 colchicine oral tablet 0.6 mg 4 COLCRYS ORAL TABLET 0.6 MG 4 QL (120 per 30 days) probenecid oral tablet 500 mg 3 probenecid-colchicine oral tablet 500-0.5 mg 3 ULORIC ORAL TABLET 40 MG, 80 MG 3 QL (30 per 30 days) Anti-Inflammatory Agents Glucocorticoids betamethasone dipropionate topical cream 0.05 2 % betamethasone dipropionate topical lotion 0.05 2 % betamethasone dipropionate topical ointment 2 0.05 % betamethasone valerate topical cream 0.1 % 2 betamethasone valerate topical lotion 0.1 % 2 betamethasone valerate topical ointment 0.1 % 2 You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 25 Drug Name Drug Tier Requirements/Limits betamethasone, augmented topical cream 0.05 % 2 betamethasone, augmented topical gel 0.05 % 2 betamethasone, augmented topical lotion 0.05 % 3 betamethasone, augmented topical ointment 0.05 2 % BLEPHAMIDE OPHTHALMIC (EYE) 3 DROPS,SUSPENSION 10-0.2 % BLEPHAMIDE S.O.P. OPHTHALMIC (EYE) 3 OINTMENT 10-0.2 % cortisone oral tablet 25 mg 3 deltasone oral tablet 20 mg 1 DEPO-MEDROL INJECTION SUSPENSION 4 20 MG/ML, 40 MG/ML, 80 MG/ML dexamethasone oral elixir 0.5 mg/5 ml 2 dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 2 1.5 mg, 2 mg, 4 mg, 6 mg dexamethasone sodium phos (pf) injection 2 solution 10 mg/ml dexamethasone sodium phosphate injection 2 solution 10 mg/ml, 4 mg/ml dexamethasone sodium phosphate injection 2 syringe 4 mg/ml hydrocortisone oral tablet 20 mg, 5 mg 2 methylprednisolone acetate injection suspension 4 40 mg/ml, 80 mg/ml methylprednisolone oral tablet 16 mg, 32 mg, 4 2 mg, 8 mg methylprednisolone sodium succ injection recon 4 HI soln 40 mg methylprednisolone sodium succ intravenous 4 recon soln 1,000 mg PRED MILD OPHTHALMIC (EYE) 3 DROPS,SUSPENSION 0.12 % prednisolone 15 mg/5 ml soln a/f, d/f 15 mg/5 ml 2 (3 mg/ml) prednisolone oral solution 15 mg/5 ml 2 prednisone oral tablet 1 mg, 2.5 mg, 20 mg, 5 mg, 1 50 mg prednisone oral tablet 10 mg 1 SOLU-CORTEF (PF) INJECTION RECON 4 SOLN 1,000 MG/8 ML, 100 MG/2 ML, 250 MG/2 ML, 500 MG/4 ML

You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 26 Drug Name Drug Tier Requirements/Limits SOLU-MEDROL (PF) INJECTION RECON 3 HI SOLN 125 MG/2 ML, 40 MG/ML SOLU-MEDROL (PF) INTRAVENOUS 4 RECON SOLN 1,000 MG/8 ML, 500 MG/4 ML SOLU-MEDROL INTRAVENOUS RECON 4 SOLN 1,000 MG, 2 GRAM sulfacetamide-prednisolone ophthalmic (eye) 2 drops 10 %-0.23 % (0.25 %) Nonsteroidal Anti-Inflammatory Drugs diclofenac potassium oral tablet 50 mg 3 diclofenac sodium oral tablet extended release 24 2 hr 100 mg diclofenac sodium oral tablet,delayed release 2 (dr/ec) 25 mg, 50 mg, 75 mg FLECTOR TRANSDERMAL PATCH 12 HOUR 4 PA NSO; QL (60 per 30 days) 1.3 % ketoprofen oral capsule 25 mg, 50 mg, 75 mg 3 naproxen oral suspension 125 mg/5 ml 4 naproxen oral tablet 250 mg, 375 mg, 500 mg 1 naproxen oral tablet,delayed release (dr/ec) 375 2 mg, 500 mg naproxen sodium oral tablet 275 mg, 550 mg 3 naproxen sodium oral tablet, er multiphase 24 hr 4 375 mg, 500 mg oxaprozin oral tablet 600 mg 4 piroxicam oral capsule 10 mg, 20 mg 3 Antimigraine Agents Ergot Alkaloids dihydroergotamine injection solution 1 mg/ml 4 dihydroergotamine nasal spray,non-aerosol 0.5 4 mg/pump act. (4 mg/ml) ergotamine-caffeine oral tablet 1-100 mg 4 MIGERGOT RECTAL SUPPOSITORY 2-100 4 MG Serotonin (5-Ht) 1B/1D Receptor Agonists AIMOVIG 70 MG/ML AUTOINJECTOR 70 4 PA NSO; QL (2 per 28 days) MG/ML AIMOVIG AUTOINJECTOR (2 PACK) 4 PA NSO; QL (2 per 28 days) SUBCUTANEOUS AUTO-INJECTOR 70 MG/ML almotriptan malate oral tablet 12.5 mg, 6.25 mg 3 QL (12 per 30 days) eletriptan oral tablet 20 mg, 40 mg 4 QL (12 per 30 days) You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 27 Drug Name Drug Tier Requirements/Limits frovatriptan oral tablet 2.5 mg 4 QL (12 per 30 days) naratriptan oral tablet 1 mg, 2.5 mg 3 QL (18 per 30 days) rizatriptan oral tablet 10 mg, 5 mg 3 QL (18 per 30 days) rizatriptan oral tablet,disintegrating 10 mg, 5 mg 3 QL (18 per 30 days) sumatriptan nasal spray,non-aerosol 20 4 QL (12 per 30 days) mg/actuation sumatriptan nasal spray,non-aerosol 5 4 QL (6 per 30 days) mg/actuation sumatriptan succinate oral tablet 100 mg, 25 mg, 2 QL (18 per 30 days) 50 mg sumatriptan succinate subcutaneous cartridge 4 4 QL (8 per 30 days) mg/0.5 ml, 6 mg/0.5 ml sumatriptan succinate subcutaneous pen injector 4 QL (8 per 30 days) 4 mg/0.5 ml, 6 mg/0.5 ml sumatriptan succinate subcutaneous solution 6 4 QL (8 per 30 days) mg/0.5 ml sumatriptan succinate subcutaneous syringe 6 4 QL (8 per 30 days) mg/0.5 ml zolmitriptan oral tablet 2.5 mg, 5 mg 3 QL (12 per 30 days) zolmitriptan oral tablet,disintegrating 2.5 mg, 5 3 QL (12 per 30 days) mg Antimyasthenic Agents Parasympathomimetics guanidine oral tablet 125 mg 3 pyridostigmine bromide oral tablet 60 mg 3 pyridostigmine bromide oral tablet extended 4 release 180 mg Antimycobacterials Antimycobacterials, Other dapsone oral tablet 100 mg, 25 mg 3 PRIFTIN ORAL TABLET 150 MG 4 rifabutin oral capsule 150 mg 4 Antituberculars CAPASTAT INJECTION RECON SOLN 1 4 GRAM ethambutol oral tablet 100 mg, 400 mg 4 isoniazid injection solution 100 mg/ml 1 isoniazid oral solution 50 mg/5 ml 4 isoniazid oral tablet 100 mg, 300 mg 1 PASER ORAL GRANULES DR FOR SUSP IN 4 PACKET 4 GRAM

You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 28 Drug Name Drug Tier Requirements/Limits pyrazinamide oral tablet 500 mg 4 rifampin intravenous recon soln 600 mg 4 rifampin oral capsule 150 mg, 300 mg 3 RIFATER ORAL TABLET 50-120-300 MG 4 SIRTURO ORAL TABLET 100 MG 5 NDS; QL (68 per 28 days) TRECATOR ORAL TABLET 250 MG 4 Antineoplastics Alkylating Agents CYCLOPHOSPHAMIDE ORAL CAPSULE 25 4 PA BvD MG, 50 MG HEXALEN ORAL CAPSULE 50 MG 5 NDS LEUKERAN ORAL TABLET 2 MG 4 MATULANE ORAL CAPSULE 50 MG 5 LA; NDS VALCHLOR TOPICAL GEL 0.016 % 5 NDS; QL (60 per 28 days) Antiandrogens bicalutamide oral tablet 50 mg 1 QL (30 per 30 days) ERLEADA ORAL TABLET 60 MG 5 PA NSO; NDS; QL (120 per 30 days) flutamide oral capsule 125 mg 2 nilutamide oral tablet 150 mg 5 NDS; QL (60 per 30 days) XTANDI ORAL CAPSULE 40 MG 5 PA NSO; NDS; QL (120 per 30 days) ZYTIGA ORAL TABLET 250 MG 5 PA NSO; NDS; QL (120 per 30 days) ZYTIGA ORAL TABLET 500 MG 5 PA NSO; NDS; QL (2 per 1 day) Antiangiogenic Agents POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 5 PA NSO; LA; NDS; QL (21 per 28 days) MG, 4 MG REVLIMID ORAL CAPSULE 10 MG, 15 MG, 5 PA NSO; LA; NDS; QL (28 per 28 days) 25 MG, 5 MG THALOMID ORAL CAPSULE 100 MG, 200 5 PA NSO; NDS; QL (30 per 30 days) MG, 50 MG THALOMID ORAL CAPSULE 150 MG 5 PA NSO; NDS; QL (60 per 30 days) Antiestrogens/Modifiers EMCYT ORAL CAPSULE 140 MG 4 FARESTON ORAL TABLET 60 MG 5 NDS; QL (30 per 30 days) SOLTAMOX ORAL SOLUTION 10 MG/5 ML 4 tamoxifen oral tablet 10 mg, 20 mg 1 Antimetabolites DROXIA ORAL CAPSULE 200 MG, 300 MG, 4 400 MG hydroxyurea oral capsule 500 mg 2 LONSURF ORAL TABLET 15-6.14 MG 5 PA NSO; NDS; QL (100 per 30 days) LONSURF ORAL TABLET 20-8.19 MG 5 PA NSO; NDS; QL (80 per 30 days)

You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 29 Drug Name Drug Tier Requirements/Limits PURIXAN ORAL SUSPENSION 20 MG/ML 5 NDS; QL (300 per 30 days) TABLOID ORAL TABLET 40 MG 4 Antineoplastics adrucil intravenous solution 2.5 gram/50 ml 4 adrucil intravenous solution 500 mg/10 ml 4 PA BvD ALIMTA INTRAVENOUS RECON SOLN 100 5 NDS MG, 500 MG arsenic trioxide intravenous solution 1 mg/ml 4 AVASTIN INTRAVENOUS SOLUTION 25 5 NDS MG/ML, 25 MG/ML (16 ML) azacitidine injection recon soln 100 mg 5 NDS BELEODAQ INTRAVENOUS RECON SOLN 5 NDS 500 MG BICNU INTRAVENOUS RECON SOLN 100 4 MG bleomycin injection recon soln 15 unit 4 bleomycin injection recon soln 30 unit 3 PA BvD BORTEZOMIB INTRAVENOUS RECON 5 NDS SOLN 3.5 MG BRAFTOVI ORAL CAPSULE 50 MG 5 PA NSO; NDS; QL (120 per 30 days) BRAFTOVI ORAL CAPSULE 75 MG 5 PA NSO; NDS; QL (180 per 30 days) carboplatin intravenous solution 10 mg/ml 4 carmustine intravenous recon soln 100 mg 4 dexrazoxane hcl intravenous recon soln 250 mg, 4 500 mg doxorubicin, peg-liposomal intravenous 4 suspension 2 mg/ml ELITEK INTRAVENOUS RECON SOLN 1.5 5 NDS MG epirubicin intravenous solution 200 mg/100 ml 4 FASLODEX INTRAMUSCULAR SYRINGE 5 NDS; QL (30 per 30 days) 250 MG/5 ML GLEOSTINE ORAL CAPSULE 10 MG, 100 4 PA NSO MG, 40 MG, 5 MG HERCEPTIN INTRAVENOUS RECON SOLN 5 NDS 150 MG, 440 MG KADCYLA INTRAVENOUS RECON SOLN 5 NDS 100 MG, 160 MG LEVOLEUCOVORIN INTRAVENOUS 4 RECON SOLN 175 MG levoleucovorin intravenous recon soln 50 mg 4 levoleucovorin intravenous solution 10 mg/ml 5 NDS You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 30 Drug Name Drug Tier Requirements/Limits LYNPARZA ORAL CAPSULE 50 MG 5 PA NSO; LA; NDS; QL (448 per 28 days) LYNPARZA ORAL TABLET 100 MG, 150 MG 5 PA NSO; NDS; QL (4 per 1 day) MEKTOVI ORAL TABLET 15 MG 5 PA NSO; NDS; QL (180 per 30 days) mesna intravenous solution 100 mg/ml 4 MESNEX INTRAVENOUS SOLUTION 100 4 MG/ML MESNEX ORAL TABLET 400 MG 4 MUSTARGEN INJECTION RECON SOLN 10 4 MG NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 5 PA NSO; NDS; QL (3 per 28 days) MG oxaliplatin intravenous recon soln 100 mg 4 PA NSO paclitaxel intravenous concentrate 6 mg/ml 4 PERJETA INTRAVENOUS SOLUTION 420 5 PA NSO; NDS MG/14 ML (30 MG/ML) PROLEUKIN INTRAVENOUS RECON SOLN 5 NDS 22 MILLION UNIT RUBRACA ORAL TABLET 200 MG, 300 MG 5 PA NSO; NDS RUBRACA ORAL TABLET 250 MG 5 PA NSO; NDS; QL (60 per 30 days) SYLVANT INTRAVENOUS RECON SOLN 5 PA NSO; NDS 100 MG, 400 MG TREANDA INTRAVENOUS RECON SOLN 5 PA NSO; NDS 100 MG, 25 MG TRISENOX INTRAVENOUS SOLUTION 1 4 MG/ML, 2 MG/ML VELCADE INJECTION RECON SOLN 3.5 MG 5 NDS VENCLEXTA ORAL TABLET 10 MG 4 PA NSO; QL (28 per 28 days) VENCLEXTA ORAL TABLET 100 MG 5 PA NSO; NDS; QL (120 per 30 days) VENCLEXTA ORAL TABLET 50 MG 4 PA NSO; QL (14 per 28 days) VENCLEXTA STARTING PACK ORAL 5 PA NSO; NDS; QL (42 per 28 days) TABLETS,DOSE PACK 10 MG-50 MG- 100 MG VYXEOS INTRAVENOUS RECON SOLN 44- 5 PA BvD; NDS 100 MG YONDELIS INTRAVENOUS RECON SOLN 1 5 PA NSO; NDS MG ZEJULA ORAL CAPSULE 100 MG 5 PA NSO; NDS Antineoplastics, Other ABRAXANE INTRAVENOUS SUSPENSION 5 NDS FOR RECONSTITUTION 100 MG leucovorin calcium 100 mg vial sdv,p/f,latex-free 2 100 mg You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 31 Drug Name Drug Tier Requirements/Limits leucovorin calcium injection recon soln 100 mg, 2 200 mg, 500 mg leucovorin calcium oral tablet 10 mg, 15 mg, 25 3 mg, 5 mg mitoxantrone intravenous concentrate 2 mg/ml 3 NAVELBINE INTRAVENOUS SOLUTION 10 4 PA BvD MG/ML, 50 MG/5 ML REVLIMID ORAL CAPSULE 2.5 MG, 20 MG 5 PA NSO; LA; NDS SYLATRON SUBCUTANEOUS KIT 200 MCG, 5 PA NSO; NDS; QL (4 per 28 days) 300 MCG, 600 MCG SYNRIBO SUBCUTANEOUS RECON SOLN 5 PA NSO; NDS; QL (28 per 28 days) 3.5 MG YERVOY INTRAVENOUS SOLUTION 50 5 NDS; QL (250 per 21 days) MG/10 ML (5 MG/ML) Aromatase Inhibitors, 3Rd Generation anastrozole oral tablet 1 mg 1 QL (30 per 30 days) exemestane oral tablet 25 mg 2 QL (60 per 30 days) letrozole oral tablet 2.5 mg 1 QL (30 per 30 days) Enzyme Inhibitors ALIQOPA INTRAVENOUS RECON SOLN 60 5 PA BvD; NDS MG COPIKTRA ORAL CAPSULE 15 MG, 25 MG 5 PA NSO; NDS; QL (56 per 28 days) ETOPOPHOS INTRAVENOUS RECON SOLN 4 100 MG etoposide intravenous solution 20 mg/ml 3 FARYDAK ORAL CAPSULE 10 MG, 15 MG, 5 PA NSO; NDS; QL (6 per 21 days) 20 MG HYCAMTIN INTRAVENOUS RECON SOLN 4 5 NDS MG IBRANCE ORAL CAPSULE 100 MG, 125 MG, 5 PA NSO; NDS; QL (21 per 28 days) 75 MG IDHIFA ORAL TABLET 100 MG, 50 MG 5 PA NSO; NDS; QL (1 per 1 day) KISQALI FEMARA CO-PACK ORAL 5 PA NSO; NDS TABLET 200 MG/DAY(200 MG X 1)-2.5 MG, 400 MG/DAY(200 MG X 2)-2.5 MG, 600 MG/DAY(200 MG X 3)-2.5 MG KISQALI ORAL TABLET 200 MG/DAY (200 5 PA NSO; NDS MG X 1), 400 MG/DAY (200 MG X 2), 600 MG/DAY (200 MG X 3) TALZENNA ORAL CAPSULE 0.25 MG 5 PA NSO; NDS; QL (90 per 30 days) TALZENNA ORAL CAPSULE 1 MG 5 PA NSO; NDS; QL (30 per 30 days) TIBSOVO ORAL TABLET 250 MG 5 PA NSO; NDS; QL (60 per 30 days)

You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 32 Drug Name Drug Tier Requirements/Limits toposar intravenous solution 20 mg/ml 4 topotecan intravenous recon soln 4 mg 5 NDS topotecan intravenous solution 4 mg/4 ml (1 5 NDS mg/ml) VERZENIO ORAL TABLET 100 MG, 150 MG, 5 PA NSO; NDS; QL (56 per 28 days) 200 MG, 50 MG VIZIMPRO ORAL TABLET 15 MG, 30 MG, 45 5 PA NSO; NDS; QL (30 per 30 days) MG YONSA ORAL TABLET 125 MG 5 PA NSO; NDS; QL (120 per 30 days) ZOLINZA ORAL CAPSULE 100 MG 5 PA NSO; NDS; QL (120 per 30 days) ZYDELIG ORAL TABLET 100 MG, 150 MG 5 PA NSO; NDS; QL (60 per 30 days) Molecular Target Inhibitors AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 5 PA NSO; NDS; QL (30 per 30 days) MG, 7.5 MG ALECENSA ORAL CAPSULE 150 MG 5 PA NSO; NDS ALUNBRIG ORAL TABLET 180 MG, 90 MG 5 PA NSO; NDS; QL (30 per 30 days) ALUNBRIG ORAL TABLET 30 MG 5 PA NSO; NDS ALUNBRIG ORAL TABLETS,DOSE PACK 90 5 PA NSO; NDS; QL (30 per 30 days) MG (7)- 180 MG (23) BOSULIF ORAL TABLET 100 MG 5 PA NSO; NDS; QL (120 per 30 days) BOSULIF ORAL TABLET 400 MG 5 PA NSO; NDS; QL (1 per 1 day) BOSULIF ORAL TABLET 500 MG 5 PA NSO; NDS; QL (30 per 30 days) CABOMETYX ORAL TABLET 20 MG, 40 5 PA NSO; NDS; QL (30 per 30 days) MG, 60 MG CALQUENCE ORAL CAPSULE 100 MG 5 PA NSO; NDS; QL (2 per 1 day) CAPRELSA ORAL TABLET 100 MG 5 PA NSO; LA; NDS; QL (60 per 30 days) CAPRELSA ORAL TABLET 300 MG 5 PA NSO; LA; NDS; QL (30 per 30 days) COMETRIQ ORAL CAPSULE 100 5 PA NSO; LA; NDS; QL (56 per 28 days) MG/DAY(80 MG X1-20 MG X1) COMETRIQ ORAL CAPSULE 140 5 PA NSO; LA; NDS; QL (112 per 28 days) MG/DAY(80 MG X1-20 MG X3) COMETRIQ ORAL CAPSULE 60 MG/DAY (20 5 PA NSO; LA; NDS; QL (84 per 28 days) MG X 3/DAY) COTELLIC ORAL TABLET 20 MG 5 PA NSO; LA; NDS; QL (63 per 28 days) ERIVEDGE ORAL CAPSULE 150 MG 5 PA NSO; NDS; QL (28 per 28 days) GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 5 PA NSO; NDS; QL (30 per 30 days) MG ICLUSIG ORAL TABLET 15 MG, 45 MG 5 PA NSO; LA; NDS; QL (30 per 30 days) imatinib oral tablet 100 mg, 400 mg 5 PA NSO; NDS IMBRUVICA ORAL CAPSULE 140 MG 5 PA NSO; NDS; QL (120 per 30 days) IMBRUVICA ORAL CAPSULE 70 MG 5 PA NSO; NDS; QL (30 per 30 days)

You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 33 Drug Name Drug Tier Requirements/Limits IMBRUVICA ORAL TABLET 140 MG, 280 5 PA NSO; NDS; QL (30 per 30 days) MG, 420 MG, 560 MG INLYTA ORAL TABLET 1 MG 5 PA NSO; NDS; QL (180 per 30 days) INLYTA ORAL TABLET 5 MG 5 PA NSO; NDS; QL (60 per 30 days) IRESSA ORAL TABLET 250 MG 5 PA NSO; LA; NDS; QL (30 per 30 days) JAKAFI ORAL TABLET 10 MG, 15 MG, 20 5 PA NSO; NDS; QL (60 per 30 days) MG, 25 MG, 5 MG LENVIMA ORAL CAPSULE 10 MG/DAY (10 5 PA NSO; LA; NDS; QL (30 per 30 days) MG X 1) LENVIMA ORAL CAPSULE 12 MG/DAY (4 5 PA NSO; NDS; QL (30 per 30 days) MG X 3) LENVIMA ORAL CAPSULE 14 MG/DAY(10 5 PA NSO; LA; NDS; QL (60 per 30 days) MG X 1-4 MG X 1), 20 MG/DAY (10 MG X 2), 8 MG/DAY (4 MG X 2) LENVIMA ORAL CAPSULE 18 MG/DAY (10 5 PA NSO; LA; NDS; QL (90 per 30 days) MG X 1-4 MG X2), 24 MG/DAY(10 MG X 2-4 MG X 1) LENVIMA ORAL CAPSULE 4 MG 5 PA NSO; NDS; QL (60 per 30 days) MEKINIST ORAL TABLET 0.5 MG 5 PA NSO; NDS; QL (120 per 30 days) MEKINIST ORAL TABLET 2 MG 5 PA NSO; NDS; QL (30 per 30 days) NERLYNX ORAL TABLET 40 MG 5 PA NSO; NDS; QL (180 per 30 days) NEXAVAR ORAL TABLET 200 MG 5 NDS; QL (120 per 30 days) ODOMZO ORAL CAPSULE 200 MG 5 PA NSO; LA; NDS; QL (30 per 30 days) RYDAPT ORAL CAPSULE 25 MG 5 PA NSO; NDS SPRYCEL ORAL TABLET 100 MG, 50 MG, 70 5 PA NSO; NDS; QL (60 per 30 days) MG, 80 MG SPRYCEL ORAL TABLET 140 MG 5 PA NSO; NDS; QL (30 per 30 days) SPRYCEL ORAL TABLET 20 MG 5 PA NSO; NDS; QL (90 per 30 days) STIVARGA ORAL TABLET 40 MG 5 PA NSO; NDS; QL (84 per 28 days) SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 5 PA NSO; NDS; QL (28 per 28 days) 37.5 MG, 50 MG TAFINLAR ORAL CAPSULE 50 MG 5 PA NSO; NDS; QL (180 per 30 days) TAFINLAR ORAL CAPSULE 75 MG 5 PA NSO; NDS; QL (120 per 30 days) TAGRISSO ORAL TABLET 40 MG, 80 MG 5 PA NSO; LA; NDS; QL (30 per 30 days) TARCEVA ORAL TABLET 100 MG, 150 MG 5 PA NSO; NDS; QL (30 per 30 days) TARCEVA ORAL TABLET 25 MG 5 PA NSO; NDS; QL (90 per 30 days) TASIGNA ORAL CAPSULE 150 MG, 200 MG, 5 PA NSO; NDS 50 MG TYKERB ORAL TABLET 250 MG 5 PA NSO; NDS; QL (150 per 30 days) VOTRIENT ORAL TABLET 200 MG 5 PA NSO; NDS; QL (120 per 30 days) XALKORI ORAL CAPSULE 200 MG, 250 MG 5 PA NSO; NDS; QL (60 per 30 days) ZELBORAF ORAL TABLET 240 MG 5 PA NSO; NDS; QL (240 per 30 days) You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 34 Drug Name Drug Tier Requirements/Limits ZYKADIA ORAL CAPSULE 150 MG 5 PA NSO; NDS; QL (150 per 30 days) Monoclonal Antibody/Antibody-Drug Conjugate BAVENCIO INTRAVENOUS SOLUTION 20 5 PA BvD; NDS MG/ML BESPONSA INTRAVENOUS RECON SOLN 5 PA BvD; NDS 0.9 MG (0.25 MG/ML INITIAL) CYRAMZA INTRAVENOUS SOLUTION 10 5 PA NSO; NDS; QL (200 per 28 days) MG/ML, 10 MG/ML (50 ML) DARZALEX INTRAVENOUS SOLUTION 20 5 PA NSO; LA; NDS; QL (400 per 30 days) MG/ML EMPLICITI INTRAVENOUS RECON SOLN 5 PA NSO; NDS 300 MG, 400 MG IMFINZI INTRAVENOUS SOLUTION 50 5 PA BvD; NDS MG/ML, 50 MG/ML (10 ML) KEYTRUDA INTRAVENOUS RECON SOLN 5 PA NSO; NDS 50 MG KEYTRUDA INTRAVENOUS SOLUTION 25 5 PA NSO; NDS MG/ML LARTRUVO INTRAVENOUS SOLUTION 10 5 PA NSO; NDS MG/ML, 10 MG/ML (19 ML) MYLOTARG INTRAVENOUS RECON SOLN 5 PA BvD; NDS 4.5 MG (1 MG/ML INITIAL CONC) OPDIVO INTRAVENOUS SOLUTION 100 5 NDS; QL (80 per 28 days) MG/10 ML, 240 MG/24 ML, 40 MG/4 ML RITUXAN INTRAVENOUS CONCENTRATE 5 NDS 10 MG/ML, 10 MG/ML (10 ML) TECENTRIQ INTRAVENOUS SOLUTION 5 PA NSO; NDS; QL (20 per 21 days) 1,200 MG/20 ML (60 MG/ML) Retinoids bexarotene oral capsule 75 mg 5 PA NSO; NDS; QL (300 per 30 days) PANRETIN TOPICAL GEL 0.1 % 5 NDS TARGRETIN TOPICAL GEL 1 % 5 NDS tretinoin (chemotherapy) oral capsule 10 mg 5 NDS Antiparasitics Anthelmintics albendazole oral tablet 200 mg 4 ALBENZA ORAL TABLET 200 MG 5 NDS BILTRICIDE ORAL TABLET 600 MG 4 ivermectin oral tablet 3 mg 3 praziquantel oral tablet 600 mg 4 Antiprotozoals You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 35 Drug Name Drug Tier Requirements/Limits ALINIA ORAL SUSPENSION FOR 4 QL (150 per 30 days) RECONSTITUTION 100 MG/5 ML ALINIA ORAL TABLET 500 MG 4 QL (40 per 30 days) atovaquone oral suspension 750 mg/5 ml 5 NDS atovaquone-proguanil oral tablet 250-100 mg, 3 62.5-25 mg chloroquine phosphate oral tablet 250 mg, 500 3 mg COARTEM ORAL TABLET 20-120 MG 4 QL (24 per 30 days) DARAPRIM ORAL TABLET 25 MG 4 PA hydroxychloroquine oral tablet 200 mg 2 mefloquine oral tablet 250 mg 3 MEPRON ORAL SUSPENSION 750 MG/5 ML 5 NDS NEBUPENT INHALATION RECON SOLN 300 4 PA BvD MG PENTAM INJECTION RECON SOLN 300 MG 4 PRIMAQUINE ORAL TABLET 26.3 MG 3 quinine sulfate oral capsule 324 mg 4 PA; QL (42 per 7 days) Pediculicides/Scabicides lindane topical shampoo 1 % 4 malathion topical lotion 0.5 % 4 permethrin topical cream 5 % 3 Antiparkinson Agents Anticholinergics benztropine oral tablet 0.5 mg, 1 mg, 2 mg 3 trihexyphenidyl oral elixir 0.4 mg/ml 3 trihexyphenidyl oral tablet 2 mg, 5 mg 3 Antiparkinson Agents carbidopa oral tablet 25 mg 4 carbidopa-levodopa-entacapone oral tablet 12.5- 4 50-200 mg, 18.75-75-200 mg, 25-100-200 mg, 31.25-125-200 mg, 37.5-150-200 mg, 50-200-200 mg RYTARY ORAL CAPSULE, EXTENDED 4 QL (300 per 30 days) RELEASE 23.75-95 MG, 36.25-145 MG, 48.75- 195 MG, 61.25-245 MG Antiparkinson Agents, Other amantadine hcl oral capsule 100 mg 3 amantadine hcl oral solution 50 mg/5 ml 3 amantadine hcl oral tablet 100 mg 3 entacapone oral tablet 200 mg 4 QL (300 per 30 days) tolcapone oral tablet 100 mg 4 You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 36 Drug Name Drug Tier Requirements/Limits Dopamine Agonists APOKYN SUBCUTANEOUS CARTRIDGE 10 5 NDS; QL (60 per 28 days) MG/ML bromocriptine oral capsule 5 mg 3 bromocriptine oral tablet 2.5 mg 3 NEUPRO TRANSDERMAL PATCH 24 HOUR 4 QL (30 per 30 days) 1 MG/24 HOUR, 2 MG/24 HOUR, 3 MG/24 HOUR, 4 MG/24 HOUR, 6 MG/24 HOUR, 8 MG/24 HOUR pramipexole oral tablet 0.125 mg, 0.25 mg, 0.5 2 mg, 0.75 mg, 1 mg, 1.5 mg pramipexole oral tablet extended release 24 hr 4 0.375 mg, 0.75 mg, 1.5 mg, 2.25 mg, 3 mg, 3.75 mg, 4.5 mg ropinirole oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 2 mg, 3 mg, 4 mg, 5 mg ropinirole oral tablet extended release 24 hr 12 4 mg, 2 mg, 4 mg, 6 mg, 8 mg Dopamine Precursors/ L-Amino Acid Decarboxylase Inhibitors carbidopa-levodopa oral tablet 10-100 mg, 25- 1 100 mg, 25-250 mg carbidopa-levodopa oral tablet extended release 2 25-100 mg, 50-200 mg carbidopa-levodopa oral tablet,disintegrating 10- 2 100 mg, 25-100 mg, 25-250 mg Monoamine Oxidase B (Mao-B) Inhibitors rasagiline oral tablet 0.5 mg, 1 mg 3 selegiline hcl oral capsule 5 mg 4 selegiline hcl oral tablet 5 mg 4 XADAGO ORAL TABLET 100 MG, 50 MG 4 Antipsychotics 1St Generation/Typical chlorpromazine injection solution 25 mg/ml 4 chlorpromazine oral tablet 10 mg, 100 mg, 200 4 mg, 25 mg, 50 mg fluphenazine decanoate injection solution 25 4 mg/ml fluphenazine hcl injection solution 2.5 mg/ml 4 fluphenazine hcl oral concentrate 5 mg/ml 3 fluphenazine hcl oral elixir 2.5 mg/5 ml 3

You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 37 Drug Name Drug Tier Requirements/Limits fluphenazine hcl oral tablet 1 mg, 10 mg, 2.5 mg, 2 5 mg haloperidol decanoate intramuscular solution 4 100 mg/ml, 100 mg/ml (1 ml), 50 mg/ml haloperidol lactate injection solution 5 mg/ml 2 haloperidol lactate intramuscular syringe 5 2 mg/ml haloperidol lactate oral concentrate 2 mg/ml 4 haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2 2 mg, 20 mg, 5 mg loxapine succinate oral capsule 10 mg, 25 mg, 5 2 mg, 50 mg molindone oral tablet 10 mg 4 QL (240 per 30 days) molindone oral tablet 25 mg 4 QL (270 per 30 days) molindone oral tablet 5 mg 4 QL (360 per 30 days) pimozide oral tablet 1 mg, 2 mg 4 thioridazine oral tablet 10 mg, 100 mg, 25 mg, 50 3 mg thiothixene oral capsule 1 mg, 10 mg, 2 mg, 5 mg 4 trifluoperazine oral tablet 1 mg, 10 mg, 2 mg, 5 3 mg 2Nd Generation/Atypical ABILIFY MAINTENA INTRAMUSCULAR 5 NDS; QL (1 per 28 days) SUSPENSION,EXTENDED REL RECON 300 MG ABILIFY MAINTENA INTRAMUSCULAR 5 NDS SUSPENSION,EXTENDED REL RECON 400 MG ABILIFY MAINTENA INTRAMUSCULAR 5 NDS; QL (1 per 28 days) SUSPENSION,EXTENDED REL SYRING 300 MG, 400 MG aripiprazole oral solution 1 mg/ml 4 QL (900 per 30 days) aripiprazole oral tablet 10 mg, 15 mg, 2 mg, 20 3 QL (30 per 30 days) mg, 30 mg, 5 mg aripiprazole oral tablet,disintegrating 10 mg, 15 5 NDS; QL (60 per 30 days) mg ARISTADA INITIO INTRAMUSCULAR 5 NDS; QL (2.4 per 42 days) SUSPENSION,EXTENDED REL SYRING 675 MG/2.4 ML ARISTADA INTRAMUSCULAR 5 NDS SUSPENSION,EXTENDED REL SYRING 1,064 MG/3.9 ML

You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 38 Drug Name Drug Tier Requirements/Limits ARISTADA INTRAMUSCULAR 5 NDS; QL (1.6 per 28 days) SUSPENSION,EXTENDED REL SYRING 441 MG/1.6 ML ARISTADA INTRAMUSCULAR 5 NDS; QL (2.4 per 28 days) SUSPENSION,EXTENDED REL SYRING 662 MG/2.4 ML ARISTADA INTRAMUSCULAR 5 NDS; QL (3.2 per 28 days) SUSPENSION,EXTENDED REL SYRING 882 MG/3.2 ML FANAPT ORAL TABLET 1 MG, 2 MG, 4 MG 4 QL (60 per 30 days) FANAPT ORAL TABLET 10 MG, 12 MG, 6 5 NDS; QL (60 per 30 days) MG, 8 MG FANAPT ORAL TABLETS,DOSE PACK 4 QL (60 per 30 days) 1MG(2)-2MG(2)- 4MG(2)-6MG(2) GEODON INTRAMUSCULAR RECON SOLN 4 20 MG/ML (FINAL CONC.) INVEGA SUSTENNA INTRAMUSCULAR 5 NDS; QL (1.5 per 28 days) SYRINGE 117 MG/0.75 ML, 234 MG/1.5 ML INVEGA SUSTENNA INTRAMUSCULAR 5 NDS; QL (1 per 28 days) SYRINGE 156 MG/ML INVEGA SUSTENNA INTRAMUSCULAR 4 QL (1.5 per 28 days) SYRINGE 39 MG/0.25 ML, 78 MG/0.5 ML INVEGA TRINZA INTRAMUSCULAR 5 NDS; QL (0.87 per 28 days) SYRINGE 273 MG/0.875 ML INVEGA TRINZA INTRAMUSCULAR 5 NDS; QL (1.31 per 28 days) SYRINGE 410 MG/1.315 ML INVEGA TRINZA INTRAMUSCULAR 5 NDS; QL (1.75 per 28 days) SYRINGE 546 MG/1.75 ML INVEGA TRINZA INTRAMUSCULAR 5 NDS; QL (2.62 per 28 days) SYRINGE 819 MG/2.625 ML LATUDA ORAL TABLET 120 MG, 20 MG, 40 5 NDS; QL (30 per 30 days) MG, 60 MG LATUDA ORAL TABLET 80 MG 5 NDS; QL (60 per 30 days) NUPLAZID ORAL CAPSULE 34 MG 5 NDS; QL (30 per 30 days) NUPLAZID ORAL TABLET 10 MG 5 NDS NUPLAZID ORAL TABLET 17 MG 5 NDS; QL (60 per 30 days) olanzapine intramuscular recon soln 10 mg 3 olanzapine oral tablet 10 mg, 2.5 mg, 5 mg, 7.5 3 QL (30 per 30 days) mg olanzapine oral tablet 15 mg, 20 mg 3 QL (60 per 30 days) olanzapine oral tablet,disintegrating 10 mg, 5 mg 4 QL (30 per 30 days) olanzapine oral tablet,disintegrating 15 mg, 20 4 QL (60 per 30 days) mg You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 39 Drug Name Drug Tier Requirements/Limits paliperidone oral tablet extended release 24hr 5 NDS; QL (30 per 30 days) 1.5 mg, 3 mg, 9 mg paliperidone oral tablet extended release 24hr 6 5 NDS; QL (60 per 30 days) mg quetiapine oral tablet 100 mg, 200 mg, 25 mg, 2 300 mg, 400 mg, 50 mg quetiapine oral tablet extended release 24 hr 150 4 QL (90 per 30 days) mg quetiapine oral tablet extended release 24 hr 200 4 QL (30 per 30 days) mg quetiapine oral tablet extended release 24 hr 300 4 QL (60 per 30 days) mg, 400 mg quetiapine oral tablet extended release 24 hr 50 4 QL (120 per 30 days) mg REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 5 NDS; QL (30 per 30 days) MG, 2 MG, 3 MG, 4 MG RISPERDAL CONSTA INTRAMUSCULAR 4 QL (2 per 28 days) SYRINGE 12.5 MG/2 ML, 25 MG/2 ML, 37.5 MG/2 ML RISPERDAL CONSTA INTRAMUSCULAR 5 NDS; QL (2 per 28 days) SYRINGE 50 MG/2 ML risperidone oral solution 1 mg/ml 2 QL (240 per 30 days) risperidone oral tablet 0.25 mg, 1 mg, 2 mg, 3 1 QL (60 per 30 days) mg, 4 mg risperidone oral tablet 0.5 mg 1 QL (120 per 30 days) risperidone oral tablet,disintegrating 0.25 mg, 1 4 QL (60 per 30 days) mg, 2 mg, 3 mg, 4 mg risperidone oral tablet,disintegrating 0.5 mg 4 QL (120 per 30 days) SAPHRIS SUBLINGUAL TABLET 10 MG 5 NDS; QL (60 per 30 days) SAPHRIS SUBLINGUAL TABLET 2.5 MG, 5 4 QL (60 per 30 days) MG VRAYLAR ORAL CAPSULE 1.5 MG, 3 MG, 5 NDS; QL (30 per 30 days) 4.5 MG, 6 MG VRAYLAR ORAL CAPSULE,DOSE PACK 1.5 4 MG (1)- 3 MG (6) ziprasidone hcl oral capsule 20 mg, 40 mg, 60 2 QL (60 per 30 days) mg, 80 mg ZYPREXA RELPREVV INTRAMUSCULAR 4 QL (4 per 28 days) SUSPENSION FOR RECONSTITUTION 210 MG, 300 MG, 405 MG Treatment-Resistant clozapine oral tablet 100 mg, 200 mg, 25 mg, 50 3 mg You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 40 Drug Name Drug Tier Requirements/Limits clozapine oral tablet,disintegrating 100 mg, 12.5 4 mg, 150 mg, 200 mg, 25 mg FAZACLO ORAL 5 NDS TABLET,DISINTEGRATING 100 MG, 150 MG, 200 MG FAZACLO ORAL 4 TABLET,DISINTEGRATING 12.5 MG, 25 MG VERSACLOZ ORAL SUSPENSION 50 MG/ML 4 QL (540 per 30 days) Antispasticity Agents Antispasticity Agents baclofen oral tablet 10 mg, 20 mg 1 dantrolene oral capsule 100 mg, 25 mg, 50 mg 3 tizanidine oral tablet 2 mg, 4 mg 1 Antivirals Anti-Cytomegalovirus (Cmv) Agents cidofovir intravenous solution 75 mg/ml 4 ganciclovir sodium intravenous recon soln 500 3 PA BvD; HI mg ganciclovir sodium intravenous solution 50 4 PA BvD mg/ml valganciclovir oral recon soln 50 mg/ml 5 NDS valganciclovir oral tablet 450 mg 5 NDS ZIRGAN OPHTHALMIC (EYE) GEL 0.15 % 4 QL (5 per 30 days) Anti-Hepatitis B (Hbv) Agents adefovir oral tablet 10 mg 5 NDS BARACLUDE ORAL SOLUTION 0.05 MG/ML 5 NDS; QL (630 per 30 days) entecavir oral tablet 0.5 mg, 1 mg 5 NDS; QL (30 per 30 days) EPIVIR HBV ORAL SOLUTION 25 MG/5 ML 4 (5 MG/ML) INTRON A INJECTION RECON SOLN 10 5 PA NSO; NDS MILLION UNIT (1 ML) INTRON A INJECTION SOLUTION 6 5 PA NSO; NDS MILLION UNIT/ML ribasphere oral capsule 200 mg 3 QL (168 per 28 days) ribasphere oral tablet 200 mg 3 QL (168 per 28 days) VEMLIDY ORAL TABLET 25 MG 5 NDS VIREAD ORAL TABLET 300 MG 5 NDS; QL (30 per 30 days) Anti-Hepatitis C (Hcv) Agents MAVYRET ORAL TABLET 100-40 MG 5 PA; NDS; QL (84 per 28 days) VOSEVI ORAL TABLET 400-100-100 MG 5 PA; NDS; QL (1 per 1 day) Anti-Hepatitis C (Hcv) Agents, Others

You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 41 Drug Name Drug Tier Requirements/Limits EPCLUSA ORAL TABLET 400-100 MG 5 PA; NDS HARVONI ORAL TABLET 90-400 MG 5 PA; NDS; QL (28 per 28 days) INTRON A INJECTION RECON SOLN 18 5 PA NSO; NDS MILLION UNIT (1 ML), 50 MILLION UNIT (1 ML) INTRON A INJECTION SOLUTION 10 5 PA NSO; NDS MILLION UNIT/ML PEGASYS PROCLICK SUBCUTANEOUS PEN 5 PA; NDS; QL (2 per 28 days) INJECTOR 135 MCG/0.5 ML, 180 MCG/0.5 ML PEGASYS SUBCUTANEOUS SOLUTION 180 5 PA; NDS; QL (4 per 28 days) MCG/ML PEGASYS SUBCUTANEOUS SYRINGE 180 5 PA; NDS; QL (2 per 28 days) MCG/0.5 ML PEGINTRON REDIPEN SUBCUTANEOUS 5 PA; NDS; QL (4 per 28 days) PEN INJECTOR KIT 120 MCG/0.5 ML, 150 MCG/0.5 ML, 50 MCG/0.5 ML, 80 MCG/0.5 ML PEGINTRON SUBCUTANEOUS KIT 120 5 PA; NDS; QL (4 per 28 days) MCG/0.5 ML, 150 MCG/0.5 ML, 50 MCG/0.5 ML, 80 MCG/0.5 ML ribavirin oral capsule 200 mg 3 QL (168 per 28 days) ribavirin oral tablet 200 mg 3 QL (168 per 28 days) VIRAZOLE INHALATION RECON SOLN 6 5 NDS GRAM ZEPATIER ORAL TABLET 50-100 MG 5 PA; NDS Antiherpetic Agents acyclovir 1,000 mg/20 ml vial 10's,latex-free,sdv 4 PA BvD 50 mg/ml acyclovir oral capsule 200 mg 2 acyclovir oral suspension 200 mg/5 ml 4 acyclovir oral tablet 400 mg, 800 mg 2 acyclovir sodium intravenous recon soln 500 mg 4 acyclovir sodium intravenous solution 50 mg/ml 4 PA BvD; HI acyclovir topical ointment 5 % 4 famciclovir oral tablet 125 mg, 250 mg, 500 mg 3 QL (90 per 30 days) trifluridine ophthalmic (eye) drops 1 % 3 valacyclovir oral tablet 1 gram, 500 mg 2 QL (120 per 30 days) Anti-Hiv Agents, Integrase Inhibitors (Insti) GENVOYA ORAL TABLET 150-150-200-10 5 NDS; QL (30 per 30 days) MG ISENTRESS HD ORAL TABLET 600 MG 3

You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 42 Drug Name Drug Tier Requirements/Limits ISENTRESS ORAL POWDER IN PACKET 100 3 QL (300 per 30 days) MG ISENTRESS ORAL TABLET 400 MG 5 NDS; QL (120 per 30 days) ISENTRESS ORAL TABLET,CHEWABLE 100 3 QL (180 per 30 days) MG ISENTRESS ORAL TABLET,CHEWABLE 25 4 QL (720 per 30 days) MG STRIBILD ORAL TABLET 150-150-200-300 5 NDS; QL (30 per 30 days) MG TIVICAY ORAL TABLET 10 MG 4 QL (60 per 30 days) TIVICAY ORAL TABLET 25 MG, 50 MG 5 NDS; QL (60 per 30 days) Anti-Hiv Agents, Non-Nucleoside Reverse Transcriptase Inhibitors (Nnrti) COMPLERA ORAL TABLET 200-25-300 MG 5 NDS; QL (30 per 30 days) DELSTRIGO ORAL TABLET 100-300-300 MG 5 NDS; QL (30 per 30 days) EDURANT ORAL TABLET 25 MG 5 NDS; QL (30 per 30 days) efavirenz oral capsule 200 mg, 50 mg 3 efavirenz oral tablet 600 mg 3 INTELENCE ORAL TABLET 100 MG 5 NDS; QL (120 per 30 days) INTELENCE ORAL TABLET 200 MG 5 NDS; QL (60 per 30 days) INTELENCE ORAL TABLET 25 MG 4 QL (120 per 30 days) nevirapine oral suspension 50 mg/5 ml 4 QL (1200 per 30 days) nevirapine oral tablet 200 mg 2 QL (60 per 30 days) nevirapine oral tablet extended release 24 hr 100 4 QL (120 per 30 days) mg nevirapine oral tablet extended release 24 hr 400 4 QL (30 per 30 days) mg PIFELTRO ORAL TABLET 100 MG 5 NDS; QL (30 per 30 days) RESCRIPTOR ORAL TABLET 200 MG 4 QL (180 per 30 days) RESCRIPTOR ORAL TABLET, DISPERSIBLE 4 QL (360 per 30 days) 100 MG SUSTIVA ORAL CAPSULE 200 MG 5 NDS; QL (120 per 30 days) SUSTIVA ORAL CAPSULE 50 MG 4 QL (480 per 30 days) SUSTIVA ORAL TABLET 600 MG 5 NDS; QL (30 per 30 days) VIRAMUNE ORAL SUSPENSION 50 MG/5 4 QL (1200 per 30 days) ML Anti-Hiv Agents, Nucleoside And Nucleotide Reverse Transcriptase Inhibitors (Nrti) abacavir oral solution 20 mg/ml 4 abacavir oral tablet 300 mg 4 QL (60 per 30 days) abacavir-lamivudine oral tablet 600-300 mg 5 NDS; QL (30 per 30 days)

You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 43 Drug Name Drug Tier Requirements/Limits abacavir-lamivudine-zidovudine oral tablet 300- 5 NDS; QL (60 per 30 days) 150-300 mg ATRIPLA ORAL TABLET 600-200-300 MG 5 NDS; QL (30 per 30 days) BIKTARVY ORAL TABLET 50-200-25 MG 5 NDS; QL (30 per 30 days) CIMDUO ORAL TABLET 300-300 MG 5 NDS; QL (30 per 30 days) DESCOVY ORAL TABLET 200-25 MG 5 NDS; QL (30 per 30 days) didanosine oral capsule,delayed release(dr/ec) 4 QL (90 per 30 days) 125 mg didanosine oral capsule,delayed release(dr/ec) 4 QL (60 per 30 days) 200 mg didanosine oral capsule,delayed release(dr/ec) 4 QL (30 per 30 days) 250 mg, 400 mg EMTRIVA ORAL CAPSULE 200 MG 4 QL (30 per 30 days) EMTRIVA ORAL SOLUTION 10 MG/ML 4 QL (680 per 28 days) EPZICOM ORAL TABLET 600-300 MG 5 NDS; QL (30 per 30 days) JULUCA ORAL TABLET 50-25 MG 5 NDS lamivudine oral solution 10 mg/ml 4 QL (960 per 30 days) lamivudine oral tablet 100 mg, 300 mg 4 QL (30 per 30 days) lamivudine oral tablet 150 mg 4 QL (60 per 30 days) lamivudine-zidovudine oral tablet 150-300 mg 4 QL (60 per 30 days) ODEFSEY ORAL TABLET 200-25-25 MG 5 NDS; QL (30 per 30 days) RETROVIR INTRAVENOUS SOLUTION 10 4 MG/ML stavudine oral capsule 15 mg, 20 mg 3 QL (120 per 30 days) stavudine oral capsule 30 mg, 40 mg 3 QL (60 per 30 days) SYMFI LO ORAL TABLET 400-300-300 MG 5 NDS; QL (30 per 30 days) SYMFI ORAL TABLET 600-300-300 MG 5 NDS; QL (30 per 30 days) tenofovir disoproxil fumarate oral tablet 300 mg 4 TROGARZO INTRAVENOUS SOLUTION 200 5 NDS MG/1.33 ML (150 MG/ML) TRUVADA ORAL TABLET 100-150 MG, 133- 5 NDS; QL (30 per 30 days) 200 MG, 167-250 MG, 200-300 MG VIDEX 2 GM PEDIATRIC SOLN 10 MG/ML 4 QL (1200 per 30 days) (FINAL) VIDEX 4 GRAM PEDIATRIC ORAL RECON 4 QL (1200 per 30 days) SOLN 10 MG/ML (FINAL) VIDEX EC ORAL CAPSULE,DELAYED 4 QL (90 per 30 days) RELEASE(DR/EC) 125 MG VIREAD ORAL POWDER 40 MG/SCOOP (40 5 NDS; QL (240 per 30 days) MG/GRAM) VIREAD ORAL TABLET 150 MG, 200 MG, 5 NDS; QL (30 per 30 days) 250 MG You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 44 Drug Name Drug Tier Requirements/Limits ZERIT ORAL RECON SOLN 1 MG/ML 4 ZIAGEN ORAL SOLUTION 20 MG/ML 4 QL (960 per 30 days) zidovudine oral capsule 100 mg 3 QL (180 per 30 days) zidovudine oral syrup 10 mg/ml 3 QL (1680 per 28 days) zidovudine oral tablet 300 mg 2 QL (60 per 30 days) Anti-Hiv Agents, Other FUZEON SUBCUTANEOUS RECON SOLN 90 5 NDS; QL (60 per 30 days) MG SELZENTRY ORAL SOLUTION 20 MG/ML 4 SELZENTRY ORAL TABLET 150 MG 5 NDS; QL (240 per 30 days) SELZENTRY ORAL TABLET 25 MG 4 SELZENTRY ORAL TABLET 300 MG 5 NDS; QL (120 per 30 days) SELZENTRY ORAL TABLET 75 MG 5 NDS SYMTUZA ORAL TABLET 800-150-200-10 5 NDS; QL (30 per 30 days) MG TRIUMEQ ORAL TABLET 600-50-300 MG 5 NDS; QL (30 per 30 days) TYBOST ORAL TABLET 150 MG 4 QL (30 per 30 days) Anti-Hiv Agents, Protease Inhibitors APTIVUS ORAL CAPSULE 250 MG 5 NDS; QL (120 per 30 days) APTIVUS ORAL SOLUTION 100 MG/ML 5 NDS; QL (285 per 28 days) atazanavir oral capsule 150 mg, 200 mg 5 NDS; QL (60 per 30 days) atazanavir oral capsule 300 mg 5 NDS; QL (30 per 30 days) CRIXIVAN ORAL CAPSULE 200 MG 4 QL (450 per 30 days) CRIXIVAN ORAL CAPSULE 400 MG 4 QL (270 per 30 days) EVOTAZ ORAL TABLET 300-150 MG 5 NDS; QL (30 per 30 days) fosamprenavir oral tablet 700 mg 4 INVIRASE ORAL CAPSULE 200 MG 5 NDS; QL (300 per 30 days) INVIRASE ORAL TABLET 500 MG 5 NDS; QL (120 per 30 days) KALETRA ORAL SOLUTION 400-100 MG/5 5 NDS; QL (600 per 30 days) ML KALETRA ORAL TABLET 100-25 MG 4 QL (300 per 30 days) KALETRA ORAL TABLET 200-50 MG 5 NDS; QL (150 per 30 days) LEXIVA ORAL SUSPENSION 50 MG/ML 4 QL (1575 per 28 days) LEXIVA ORAL TABLET 700 MG 5 NDS; QL (120 per 30 days) lopinavir-ritonavir oral solution 400-100 mg/5 ml 4 NORVIR ORAL CAPSULE 100 MG 4 QL (360 per 30 days) NORVIR ORAL POWDER IN PACKET 100 4 QL (360 per 30 days) MG NORVIR ORAL SOLUTION 80 MG/ML 4 QL (480 per 30 days) NORVIR ORAL TABLET 100 MG 4 QL (360 per 30 days) PREZCOBIX ORAL TABLET 800-150 MG-MG 5 NDS; QL (30 per 30 days)

You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 45 Drug Name Drug Tier Requirements/Limits PREZISTA ORAL SUSPENSION 100 MG/ML 5 NDS; QL (360 per 30 days) PREZISTA ORAL TABLET 150 MG 4 QL (240 per 30 days) PREZISTA ORAL TABLET 600 MG 5 NDS; QL (60 per 30 days) PREZISTA ORAL TABLET 75 MG 4 QL (480 per 30 days) PREZISTA ORAL TABLET 800 MG 5 NDS; QL (30 per 30 days) REYATAZ ORAL CAPSULE 150 MG, 200 MG 5 NDS; QL (60 per 30 days) REYATAZ ORAL CAPSULE 300 MG 5 NDS; QL (30 per 30 days) REYATAZ ORAL POWDER IN PACKET 50 5 NDS; QL (240 per 30 days) MG ritonavir oral tablet 100 mg 4 QL (360 per 30 days) VIRACEPT ORAL TABLET 250 MG 5 NDS; QL (300 per 30 days) VIRACEPT ORAL TABLET 625 MG 5 NDS; QL (120 per 30 days) Anti-Influenza Agents oseltamivir oral capsule 30 mg, 45 mg, 75 mg 2 oseltamivir oral suspension for reconstitution 6 2 mg/ml RELENZA DISKHALER INHALATION 4 QL (60 per 180 days) BLISTER WITH DEVICE 5 MG/ACTUATION rimantadine oral tablet 100 mg 4 TAMIFLU ORAL SUSPENSION FOR 4 QL (720 per 365 days) RECONSTITUTION 6 MG/ML XOFLUZA ORAL TABLET 20 MG, 40 MG 4 QL (4 per 180 days) Anxiolytics Anxiolytics, Other buspirone oral tablet 10 mg, 15 mg, 30 mg, 5 mg, 2 7.5 mg meprobamate oral tablet 200 mg, 400 mg 4 oxazepam oral capsule 10 mg, 15 mg, 30 mg 4 Benzodiazepines alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 2 QL (120 per 30 days) mg chlordiazepoxide hcl oral capsule 10 mg, 25 mg, 3 5 mg clonazepam oral tablet 0.5 mg, 1 mg, 2 mg 3 clonazepam oral tablet,disintegrating 0.125 mg, 4 0.25 mg, 0.5 mg, 1 mg, 2 mg clorazepate dipotassium oral tablet 15 mg, 3.75 3 mg, 7.5 mg diazepam intensol oral concentrate 5 mg/ml 3 QL (240 per 30 days) diazepam oral solution 5 mg/5 ml (1 mg/ml) 3 QL (1200 per 30 days) diazepam oral tablet 10 mg 3 QL (120 per 30 days) diazepam oral tablet 2 mg, 5 mg 3 QL (90 per 30 days) You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 46 Drug Name Drug Tier Requirements/Limits diazepam rectal kit 12.5-15-17.5-20 mg 3 lorazepam oral concentrate 2 mg/ml 3 QL (150 per 30 days) lorazepam oral tablet 0.5 mg, 1 mg 2 QL (90 per 30 days) lorazepam oral tablet 2 mg 2 QL (150 per 30 days) Bipolar Agents Mood Stabilizers carbamazepine oral capsule, er multiphase 12 hr 4 100 mg, 200 mg, 300 mg lithium carbonate oral capsule 150 mg, 300 mg, 2 600 mg lithium carbonate oral tablet 300 mg 2 lithium carbonate oral tablet extended release 2 300 mg, 450 mg lithium citrate oral solution 8 meq/5 ml 2 Blood Glucose Regulators Antidiabetic Agents acarbose oral tablet 100 mg, 25 mg, 50 mg 2 ADLYXIN SUBCUTANEOUS PEN INJECTOR 4 10 MCG/0.2 ML- 20 MCG/0.2 ML, 20 MCG/0.2 ML alogliptin oral tablet 12.5 mg, 25 mg, 6.25 mg 4 alogliptin-metformin oral tablet 12.5-1,000 mg, 4 12.5-500 mg alogliptin-pioglitazone oral tablet 12.5-15 mg, 4 12.5-30 mg, 12.5-45 mg, 25-15 mg, 25-30 mg, 25- 45 mg AVANDIA ORAL TABLET 2 MG, 4 MG 4 QL (60 per 30 days) BYDUREON BCISE SUBCUTANEOUS 4 QL (3.4 per 28 days) AUTO-INJECTOR 2 MG/0.85 ML BYDUREON SUBCUTANEOUS PEN 4 QL (4 per 28 days) INJECTOR 2 MG/0.65 ML BYDUREON SUBCUTANEOUS 4 QL (4 per 28 days) SUSPENSION,EXTENDED REL RECON 2 MG BYETTA SUBCUTANEOUS PEN INJECTOR 4 QL (2.4 per 30 days) 10 MCG/DOSE(250 MCG/ML) 2.4 ML, 5 MCG/DOSE (250 MCG/ML) 1.2 ML CYCLOSET ORAL TABLET 0.8 MG 4 QL (180 per 30 days) FARXIGA ORAL TABLET 10 MG, 5 MG 4 QL (30 per 30 days) glimepiride oral tablet 1 mg, 2 mg, 4 mg 1 glipizide oral tablet 10 mg, 5 mg 1 glipizide oral tablet extended release 24hr 10 mg, 1 2.5 mg, 5 mg You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 47 Drug Name Drug Tier Requirements/Limits GLYXAMBI ORAL TABLET 10-5 MG, 25-5 3 MG INVOKAMET ORAL TABLET 150-1,000 MG, 3 QL (60 per 30 days) 150-500 MG, 50-1,000 MG, 50-500 MG INVOKAMET XR ORAL TABLET, IR - ER, 3 QL (60 per 30 days) BIPHASIC 24HR 150-1,000 MG, 150-500 MG, 50-1,000 MG INVOKAMET XR ORAL TABLET, IR - ER, 3 QL (120 per 30 days) BIPHASIC 24HR 50-500 MG INVOKANA ORAL TABLET 100 MG, 300 MG 3 QL (30 per 30 days) JANUVIA ORAL TABLET 100 MG, 25 MG, 50 3 QL (30 per 30 days) MG JARDIANCE ORAL TABLET 10 MG, 25 MG 3 QL (30 per 30 days) JENTADUETO ORAL TABLET 2.5-1,000 MG, 3 QL (60 per 30 days) 2.5-500 MG, 2.5-850 MG JENTADUETO XR ORAL TABLET, IR - ER, 3 QL (60 per 30 days) BIPHASIC 24HR 2.5-1,000 MG JENTADUETO XR ORAL TABLET, IR - ER, 3 QL (30 per 30 days) BIPHASIC 24HR 5-1,000 MG metformin oral tablet 1,000 mg, 500 mg, 850 mg 1 metformin oral tablet extended release 24 hr 500 1 QL (120 per 30 days) mg metformin oral tablet extended release 24 hr 750 1 QL (75 per 30 days) mg miglitol oral tablet 100 mg, 25 mg, 50 mg 4 nateglinide oral tablet 120 mg, 60 mg 3 ONGLYZA ORAL TABLET 2.5 MG, 5 MG 4 QL (30 per 30 days) OZEMPIC SUBCUTANEOUS PEN INJECTOR 3 PA; QL (3 per 28 days) 0.25 MG OR 0.5 MG(2 MG/1.5 ML), 1 MG/0.75 ML (2 MG/1.5 ML) pioglitazone oral tablet 15 mg, 30 mg, 45 mg 1 QL (30 per 30 days) QTERN ORAL TABLET 10-5 MG 4 repaglinide oral tablet 0.5 mg, 1 mg, 2 mg 3 SOLIQUA 100/33 SUBCUTANEOUS INSULIN 4 QL (18 per 30 days) PEN 100 UNIT-33 MCG/ML SYMLINPEN 120 SUBCUTANEOUS PEN 4 QL (10.8 per 30 days) INJECTOR 2,700 MCG/2.7 ML SYMLINPEN 60 SUBCUTANEOUS PEN 4 QL (10.5 per 30 days) INJECTOR 1,500 MCG/1.5 ML SYNJARDY ORAL TABLET 12.5-1,000 MG, 3 QL (60 per 30 days) 12.5-500 MG, 5-1,000 MG, 5-500 MG

You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 48 Drug Name Drug Tier Requirements/Limits SYNJARDY XR ORAL TABLET, IR - ER, 3 QL (60 per 30 days) BIPHASIC 24HR 10-1,000 MG, 12.5-1,000 MG, 5-1,000 MG SYNJARDY XR ORAL TABLET, IR - ER, 3 QL (30 per 30 days) BIPHASIC 24HR 25-1,000 MG TANZEUM SUBCUTANEOUS PEN 4 PA INJECTOR 30 MG/0.5 ML, 50 MG/0.5 ML TRADJENTA ORAL TABLET 5 MG 3 QL (30 per 30 days) TRULICITY SUBCUTANEOUS PEN 3 PA; QL (2 per 28 days) INJECTOR 0.75 MG/0.5 ML, 1.5 MG/0.5 ML VICTOZA SUBCUTANEOUS PEN INJECTOR 3 QL (9 per 30 days) 0.6 MG/0.1 ML (18 MG/3 ML) XIGDUO XR ORAL TABLET, IR - ER, 4 QL (30 per 30 days) BIPHASIC 24HR 10-1,000 MG, 10-500 MG, 5- 1,000 MG XIGDUO XR ORAL TABLET, IR - ER, 4 BIPHASIC 24HR 2.5-1,000 MG, 5-500 MG XULTOPHY 100/3.6 SUBCUTANEOUS 4 QL (15 per 30 days) INSULIN PEN 100 UNIT-3.6 MG /ML (3 ML) Blood Glucose Regulators glipizide-metformin oral tablet 2.5-250 mg, 2.5- 1 500 mg, 5-500 mg JANUMET ORAL TABLET 50-1,000 MG, 50- 3 QL (60 per 30 days) 500 MG JANUMET XR ORAL TABLET, ER 3 QL (30 per 30 days) MULTIPHASE 24 HR 100-1,000 MG JANUMET XR ORAL TABLET, ER 3 QL (60 per 30 days) MULTIPHASE 24 HR 50-1,000 MG, 50-500 MG KOMBIGLYZE XR ORAL TABLET, ER 4 QL (60 per 30 days) MULTIPHASE 24 HR 2.5-1,000 MG KOMBIGLYZE XR ORAL TABLET, ER 4 QL (30 per 30 days) MULTIPHASE 24 HR 5-1,000 MG, 5-500 MG pioglitazone-glimepiride oral tablet 30-2 mg, 30- 4 QL (30 per 30 days) 4 mg pioglitazone-metformin oral tablet 15-500 mg, 4 QL (90 per 30 days) 15-850 mg Glycemic Agents GLUCAGEN HYPOKIT INJECTION RECON 3 SOLN 1 MG GLUCAGON EMERGENCY KIT (HUMAN) 3 INJECTION RECON SOLN 1 MG KORLYM ORAL TABLET 300 MG 5 NDS; QL (120 per 30 days) You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 49 Drug Name Drug Tier Requirements/Limits PROGLYCEM ORAL SUSPENSION 50 4 MG/ML Insulins ASSURE ID INSULIN SAFETY SYRINGE 1 1 ML 29 GAUGE X 1/2" BD UF NANO PEN NEEDLE 4MMX32G 32 1 GAUGE X 5/32" BD VEO INS SYRING 1 ML 6MMX31G 1 ML 1 31 GAUGE X 15/64" BD VEO INS SYRN 0.3 ML 6MMX31G 0.3 ML 1 31 GAUGE X 15/64" BD VEO INS SYRN 0.5 ML 6MMX31G 1/2 ML 1 31 GAUGE X 15/64" FIASP FLEXTOUCH U-100 INSULIN 4 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) FIASP U-100 INSULIN SUBCUTANEOUS 4 SOLUTION 100 UNIT/ML GAUZE PAD TOPICAL BANDAGE 2 X 2 " 1 HUMALOG KWIKPEN INSULIN 4 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML, 200 UNIT/ML (3 ML) HUMALOG MIX 50-50 INSULN U-100 3 SUBCUTANEOUS SUSPENSION 100 UNIT/ML (50-50) HUMALOG MIX 50-50 KWIKPEN 3 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (50-50) HUMALOG MIX 75-25 KWIKPEN 4 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (75-25) HUMALOG MIX 75-25(U-100)INSULN 4 SUBCUTANEOUS SUSPENSION 100 UNIT/ML (75-25) HUMALOG U-100 INSULIN 4 SUBCUTANEOUS CARTRIDGE 100 UNIT/ML HUMALOG U-100 INSULIN 4 SUBCUTANEOUS SOLUTION 100 UNIT/ML HUMULIN 70/30 U-100 INSULIN 4 SUBCUTANEOUS SUSPENSION 100 UNIT/ML (70-30)

You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 50 Drug Name Drug Tier Requirements/Limits HUMULIN 70/30 U-100 KWIKPEN 4 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-30) HUMULIN N NPH INSULIN KWIKPEN 4 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) HUMULIN N NPH U-100 INSULIN 4 SUBCUTANEOUS SUSPENSION 100 UNIT/ML HUMULIN R REGULAR U-100 INSULN 4 INJECTION SOLUTION 100 UNIT/ML HUMULIN R U-500 (CONC) INSULIN 4 SUBCUTANEOUS SOLUTION 500 UNIT/ML HUMULIN R U-500 (CONC) KWIKPEN 4 SUBCUTANEOUS INSULIN PEN 500 UNIT/ML (3 ML) INSULIN SYRINGE-NEEDLE U-100 1 SYRINGE 0.3 ML 29 GAUGE, 1 ML 29 GAUGE X 1/2", 1/2 ML 28 GAUGE LANTUS SOLOSTAR U-100 INSULIN 3 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) LANTUS U-100 INSULIN SUBCUTANEOUS 3 SOLUTION 100 UNIT/ML LEVEMIR FLEXTOUCH U-100 INSULN 3 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) LEVEMIR U-100 INSULIN SUBCUTANEOUS 3 SOLUTION 100 UNIT/ML NOVOLIN 70/30 U-100 INSULIN 3 SUBCUTANEOUS SUSPENSION 100 UNIT/ML (70-30) NOVOLIN 70-30 FLEXPEN U-100 4 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-30) NOVOLIN N NPH U-100 INSULIN 3 SUBCUTANEOUS SUSPENSION 100 UNIT/ML NOVOLIN R REGULAR U-100 INSULN 3 INJECTION SOLUTION 100 UNIT/ML NOVOLOG FLEXPEN U-100 INSULIN 3 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML

You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 51 Drug Name Drug Tier Requirements/Limits NOVOLOG MIX 70-30 U-100 INSULN 3 SUBCUTANEOUS SOLUTION 100 UNIT/ML (70-30) NOVOLOG MIX 70-30FLEXPEN U-100 3 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-30) NOVOLOG PENFILL U-100 INSULIN 3 SUBCUTANEOUS CARTRIDGE 100 UNIT/ML NOVOLOG U-100 INSULIN ASPART 3 SUBCUTANEOUS SOLUTION 100 UNIT/ML PEN NEEDLE, DIABETIC NEEDLE 29 1 GAUGE X 1/2" STERILE PADS 2" X 2" 2 X 2 " 1 TOUJEO MAX U-300 SOLOSTAR 3 SUBCUTANEOUS INSULIN PEN 300 UNIT/ML (3 ML) TOUJEO SOLOSTAR U-300 INSULIN 3 SUBCUTANEOUS INSULIN PEN 300 UNIT/ML (1.5 ML) TRESIBA FLEXTOUCH U-100 3 QL (30 per 30 days) SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) TRESIBA FLEXTOUCH U-200 3 QL (27 per 30 days) SUBCUTANEOUS INSULIN PEN 200 UNIT/ML (3 ML) VGO 40 DISPOSABLE DEVICE 1 Blood Products/ Modifiers/ Volume Expanders Anticoagulants COUMADIN ORAL TABLET 1 MG, 10 MG, 2 3 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG ELIQUIS ORAL TABLET 2.5 MG 3 QL (60 per 30 days) ELIQUIS ORAL TABLET 5 MG 3 QL (74 per 30 days) ELIQUIS ORAL TABLETS,DOSE PACK 5 MG 3 QL (74 per 30 days) (74 TABS) enoxaparin subcutaneous solution 300 mg/3 ml 4 QL (84 per 28 days) enoxaparin subcutaneous syringe 100 mg/ml, 150 4 QL (56 per 28 days) mg/ml enoxaparin subcutaneous syringe 120 mg/0.8 ml, 4 80 mg/0.8 ml

You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 52 Drug Name Drug Tier Requirements/Limits enoxaparin subcutaneous syringe 30 mg/0.3 ml, 4 QL (33.6 per 28 days) 60 mg/0.6 ml enoxaparin subcutaneous syringe 40 mg/0.4 ml 4 QL (22.4 per 28 days) fondaparinux subcutaneous syringe 10 mg/0.8 ml 5 NDS; QL (24 per 30 days) fondaparinux subcutaneous syringe 2.5 mg/0.5 ml 4 QL (15 per 30 days) fondaparinux subcutaneous syringe 5 mg/0.4 ml 5 NDS; QL (12 per 30 days) fondaparinux subcutaneous syringe 7.5 mg/0.6 ml 5 NDS; QL (18 per 30 days) heparin (porcine) in 5 % dex intravenous 1 parenteral solution 20,000 unit/500 ml (40 unit/ml), 25,000 unit/250 ml(100 unit/ml), 25,000 unit/500 ml (50 unit/ml) heparin (porcine) in nacl (pf) intravenous 3 parenteral solution 1,000 unit/500 ml, 2,000 unit/1,000 ml heparin (porcine) injection cartridge 5,000 3 HI unit/ml (1 ml) heparin (porcine) injection solution 1,000 unit/ml 3 heparin (porcine) injection solution 10,000 3 HI unit/ml, 20,000 unit/ml, 5,000 unit/ml heparin (porcine) injection syringe 5,000 unit/ml 3 HI heparin 25,000 unit/250 ml (100 unit/ml)-0.45% 1 nacl bag l/f,inner,single-use 25,000 unit/250 ml heparin sodium 10,000 unit/ml vial 25's,mdv, 3 latex-free 10,000 unit/ml HEPARIN(PORCINE) IN 0.45% NACL 3 INTRAVENOUS PARENTERAL SOLUTION 12,500 UNIT/250 ML heparin, porcine (pf) injection solution 1,000 3 unit/ml, 5,000 unit/0.5 ml heparin-0.45% nacl 25,000 units/500 ml (50 1 units/ml) bag l/f,outer,single-use 25,000 unit/500 ml jantoven oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 1 mg, 4 mg, 5 mg, 6 mg, 7.5 mg PRADAXA ORAL CAPSULE 110 MG, 150 4 QL (60 per 30 days) MG, 75 MG warfarin oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 1 mg, 4 mg, 5 mg, 6 mg, 7.5 mg XARELTO ORAL TABLET 10 MG, 20 MG 3 QL (30 per 30 days) XARELTO ORAL TABLET 15 MG, 2.5 MG 3 QL (60 per 30 days) XARELTO ORAL TABLETS,DOSE PACK 15 3 QL (51 per 30 days) MG (42)- 20 MG (9) Blood Formation Modifiers You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 53 Drug Name Drug Tier Requirements/Limits anagrelide oral capsule 0.5 mg, 1 mg 3 ARANESP (IN POLYSORBATE) INJECTION 5 NDS SOLUTION 100 MCG/ML, 150 MCG/0.75 ML, 200 MCG/ML, 300 MCG/ML, 60 MCG/ML ARANESP (IN POLYSORBATE) INJECTION 4 SOLUTION 25 MCG/ML, 40 MCG/ML ARANESP (IN POLYSORBATE) INJECTION 4 SYRINGE 10 MCG/0.4 ML, 25 MCG/0.42 ML, 40 MCG/0.4 ML ARANESP (IN POLYSORBATE) INJECTION 5 NDS SYRINGE 100 MCG/0.5 ML, 150 MCG/0.3 ML, 200 MCG/0.4 ML, 300 MCG/0.6 ML, 500 MCG/ML, 60 MCG/0.3 ML FULPHILA SUBCUTANEOUS SYRINGE 6 5 PA; NDS; QL (1.2 per 28 days) MG/0.6 ML GRANIX SUBCUTANEOUS SYRINGE 300 5 PA; NDS MCG/0.5 ML, 480 MCG/0.8 ML LEUKINE INJECTION RECON SOLN 250 5 PA; NDS MCG MOZOBIL SUBCUTANEOUS SOLUTION 24 5 NDS; QL (9.6 per 30 days) MG/1.2 ML (20 MG/ML) NEULASTA SUBCUTANEOUS SYRINGE 6 5 PA; NDS; QL (1.2 per 28 days) MG/0.6ML NEUPOGEN INJECTION SOLUTION 300 5 PA; NDS MCG/ML, 480 MCG/1.6 ML NEUPOGEN INJECTION SYRINGE 300 5 PA; NDS MCG/0.5 ML, 480 MCG/0.8 ML NIVESTYM SUBCUTANEOUS SYRINGE 300 5 PA; NDS; QL (7 per 30 days) MCG/0.5 ML NIVESTYM SUBCUTANEOUS SYRINGE 480 5 PA; NDS; QL (11.2 per 30 days) MCG/0.8 ML PROCRIT INJECTION SOLUTION 10,000 4 QL (14 per 30 days) UNIT/ML, 2,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML PROCRIT INJECTION SOLUTION 20,000 5 NDS UNIT/2 ML PROCRIT INJECTION SOLUTION 20,000 5 NDS; QL (14 per 30 days) UNIT/ML, 40,000 UNIT/ML PROMACTA ORAL TABLET 12.5 MG, 75 MG 5 PA; NDS; QL (60 per 30 days) PROMACTA ORAL TABLET 25 MG 5 PA; NDS; QL (30 per 30 days) PROMACTA ORAL TABLET 50 MG 5 PA; NDS; QL (90 per 30 days)

You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 54 Drug Name Drug Tier Requirements/Limits RETACRIT INJECTION SOLUTION 10,000 4 UNIT/ML, 2,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML, 40,000 UNIT/ML ZARXIO INJECTION SYRINGE 300 MCG/0.5 5 PA; NDS; QL (7 per 30 days) ML ZARXIO INJECTION SYRINGE 480 MCG/0.8 5 PA; NDS; QL (11.2 per 30 days) ML Hemostasis Agents tranexamic acid intravenous solution 1,000 4 mg/10 ml (100 mg/ml) tranexamic acid oral tablet 650 mg 4 QL (30 per 5 days) Platelet Modifying Agents aspirin-dipyridamole oral capsule, er multiphase 3 12 hr 25-200 mg BRILINTA ORAL TABLET 60 MG, 90 MG 3 QL (60 per 30 days) cilostazol oral tablet 100 mg, 50 mg 2 clopidogrel oral tablet 300 mg 2 clopidogrel oral tablet 75 mg 1 QL (30 per 30 days) dipyridamole oral tablet 25 mg, 50 mg, 75 mg 3 prasugrel oral tablet 10 mg, 5 mg 3 ZONTIVITY ORAL TABLET 2.08 MG 4 Cardiovascular Agents Alpha-Adrenergic Agonists clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg 2 clonidine transdermal patch weekly 0.1 mg/24 hr, 4 QL (4 per 28 days) 0.2 mg/24 hr, 0.3 mg/24 hr clorpres oral tablet 0.1-15 mg, 0.2-15 mg, 0.3-15 4 mg guanfacine oral tablet 1 mg, 2 mg 2 methyldopa oral tablet 250 mg, 500 mg 3 midodrine oral tablet 10 mg, 2.5 mg, 5 mg 3 NORTHERA ORAL CAPSULE 100 MG, 200 5 NDS; QL (90 per 30 days) MG NORTHERA ORAL CAPSULE 300 MG 5 NDS; QL (180 per 30 days) Alpha-Adrenergic Blocking Agents doxazosin oral tablet 1 mg, 2 mg, 4 mg, 8 mg 2 phenoxybenzamine oral capsule 10 mg 5 NDS prazosin oral capsule 1 mg, 2 mg, 5 mg 2 terazosin oral capsule 1 mg, 10 mg, 2 mg, 5 mg 1 Angiotensin Ii Receptor Antagonists candesartan oral tablet 16 mg, 4 mg, 8 mg 3 QL (60 per 30 days) candesartan oral tablet 32 mg 3 QL (30 per 30 days) You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 55 Drug Name Drug Tier Requirements/Limits ENTRESTO ORAL TABLET 24-26 MG, 49-51 3 QL (60 per 30 days) MG, 97-103 MG eprosartan oral tablet 600 mg 2 irbesartan oral tablet 150 mg, 300 mg, 75 mg 1 QL (30 per 30 days) losartan oral tablet 100 mg, 25 mg, 50 mg 1 QL (60 per 30 days) olmesartan oral tablet 20 mg, 40 mg, 5 mg 4 QL (30 per 30 days) olmesartan-hydrochlorothiazide oral tablet 20- 4 QL (30 per 30 days) 12.5 mg, 40-12.5 mg, 40-25 mg telmisartan oral tablet 20 mg, 40 mg 2 QL (30 per 30 days) telmisartan oral tablet 80 mg 2 QL (60 per 30 days) valsartan oral tablet 160 mg, 320 mg, 40 mg, 80 1 QL (60 per 30 days) mg Angiotensin-Converting Enzyme (Ace) Inhibitors benazepril oral tablet 10 mg, 20 mg, 40 mg, 5 mg 1 captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 3 mg enalapril maleate oral tablet 10 mg, 2.5 mg, 20 1 mg, 5 mg fosinopril oral tablet 10 mg, 20 mg, 40 mg 1 lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30 1 mg, 40 mg, 5 mg moexipril oral tablet 15 mg, 7.5 mg 2 perindopril erbumine oral tablet 2 mg, 4 mg, 8 2 mg quinapril oral tablet 10 mg, 20 mg, 40 mg, 5 mg 1 ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5 1 mg trandolapril oral tablet 1 mg, 2 mg, 4 mg 1 Antiarrhythmics amiodarone oral tablet 100 mg, 400 mg 4 amiodarone oral tablet 200 mg 1 disopyramide phosphate oral capsule 100 mg, 3 150 mg dofetilide oral capsule 125 mcg 2 QL (240 per 30 days) dofetilide oral capsule 250 mcg 2 QL (120 per 30 days) dofetilide oral capsule 500 mcg 2 QL (60 per 30 days) flecainide oral tablet 100 mg, 150 mg, 50 mg 3 mexiletine oral capsule 150 mg, 200 mg, 250 mg 4 MULTAQ ORAL TABLET 400 MG 3 QL (60 per 30 days) pacerone oral tablet 100 mg, 400 mg 4 pacerone oral tablet 200 mg 1 You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 56 Drug Name Drug Tier Requirements/Limits propafenone oral capsule,extended release 12 hr 4 225 mg, 325 mg, 425 mg propafenone oral tablet 150 mg, 225 mg, 300 mg 3 quinidine gluconate oral tablet extended release 4 324 mg quinidine sulfate oral tablet 200 mg, 300 mg 2 sorine oral tablet 120 mg, 160 mg, 240 mg, 80 mg 2 sotalol 120 mg tablet 120 mg 2 sotalol af oral tablet 120 mg 2 sotalol oral tablet 160 mg, 240 mg, 80 mg 2 Beta-Adrenergic Blocking Agents acebutolol oral capsule 200 mg, 400 mg 2 atenolol oral tablet 100 mg, 25 mg, 50 mg 1 betaxolol oral tablet 10 mg, 20 mg 2 bisoprolol fumarate oral tablet 10 mg, 5 mg 2 BYSTOLIC ORAL TABLET 10 MG 4 QL (120 per 30 days) BYSTOLIC ORAL TABLET 2.5 MG, 5 MG 4 QL (30 per 30 days) BYSTOLIC ORAL TABLET 20 MG 4 QL (60 per 30 days) carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 1 6.25 mg carvedilol phosphate oral capsule, er multiphase 3 QL (30 per 30 days) 24 hr 10 mg, 20 mg, 40 mg, 80 mg COREG CR ORAL CAPSULE, ER 4 QL (30 per 30 days) MULTIPHASE 24 HR 10 MG, 20 MG, 40 MG, 80 MG labetalol oral tablet 100 mg, 200 mg, 300 mg 2 metoprolol succinate oral tablet extended release 1 QL (60 per 30 days) 24 hr 100 mg, 200 mg, 25 mg, 50 mg metoprolol tartrate oral tablet 100 mg, 25 mg, 50 1 mg nadolol oral tablet 20 mg, 40 mg, 80 mg 3 pindolol oral tablet 10 mg, 5 mg 3 propranolol oral capsule,extended release 24 hr 2 120 mg, 160 mg, 60 mg, 80 mg propranolol oral solution 20 mg/5 ml (4 mg/ml), 2 40 mg/5 ml (8 mg/ml) propranolol oral tablet 10 mg, 20 mg, 40 mg, 60 2 mg, 80 mg timolol maleate oral tablet 10 mg, 20 mg, 5 mg 3 Calcium Channel Blocking Agents afeditab cr oral tablet extended release 30 mg, 60 2 QL (60 per 30 days) mg You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 57 Drug Name Drug Tier Requirements/Limits amlodipine oral tablet 10 mg, 2.5 mg, 5 mg 1 cartia xt oral capsule,extended release 24hr 120 2 QL (60 per 30 days) mg, 180 mg, 240 mg cartia xt oral capsule,extended release 24hr 300 2 QL (30 per 30 days) mg diltiazem hcl intravenous recon soln 100 mg 4 diltiazem hcl intravenous solution 5 mg/ml 2 diltiazem hcl oral capsule,extended release 12 hr 2 120 mg, 60 mg, 90 mg diltiazem hcl oral capsule,extended release 24 hr 2 QL (30 per 30 days) 360 mg diltiazem hcl oral capsule,extended release 24 hr 2 420 mg diltiazem hcl oral capsule,extended release 24hr 2 QL (60 per 30 days) 120 mg, 180 mg, 240 mg diltiazem hcl oral capsule,extended release 24hr 2 300 mg diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 2 90 mg diltiazem hcl oral tablet extended release 24 hr 2 QL (30 per 30 days) 240 mg, 360 mg, 420 mg dilt-xr oral capsule,ext.rel 24h degradable 120 2 QL (60 per 30 days) mg, 180 mg, 240 mg felodipine oral tablet extended release 24 hr 10 2 QL (30 per 30 days) mg, 2.5 mg, 5 mg matzim la oral tablet extended release 24 hr 240 2 QL (30 per 30 days) mg, 360 mg, 420 mg nicardipine oral capsule 20 mg, 30 mg 4 nifedical xl oral tablet extended release 24hr 30 3 QL (60 per 30 days) mg, 60 mg nifedipine oral tablet extended release 24hr 30 2 QL (60 per 30 days) mg, 60 mg, 90 mg nifedipine oral tablet extended release 30 mg, 60 2 QL (60 per 30 days) mg, 90 mg nimodipine oral capsule 30 mg 4 nisoldipine oral tablet extended release 24 hr 17 4 QL (30 per 30 days) mg, 20 mg, 34 mg, 40 mg, 8.5 mg nisoldipine oral tablet extended release 24 hr 4 QL (60 per 30 days) 25.5 mg, 30 mg taztia xt oral capsule,extended release 24 hr 120 2 QL (60 per 30 days) mg, 180 mg, 240 mg taztia xt oral capsule,extended release 24 hr 300 2 QL (30 per 30 days) mg, 360 mg You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 58 Drug Name Drug Tier Requirements/Limits verapamil intravenous solution 2.5 mg/ml 2 verapamil oral capsule, 24 hr er pellet ct 100 mg, 3 QL (30 per 30 days) 300 mg verapamil oral capsule, 24 hr er pellet ct 200 mg 3 QL (60 per 30 days) verapamil oral capsule,ext rel. pellets 24 hr 120 3 QL (60 per 30 days) mg, 180 mg, 240 mg, 360 mg verapamil oral tablet 120 mg, 40 mg, 80 mg 1 verapamil oral tablet extended release 120 mg, 2 180 mg, 240 mg Cardiovascular Agents amiloride-hydrochlorothiazide oral tablet 5-50 1 mg amlodipine-atorvastatin oral tablet 10-10 mg, 10- 4 QL (30 per 30 days) 20 mg, 10-40 mg, 10-80 mg, 2.5-20 mg, 2.5-40 mg, 5-10 mg, 5-20 mg, 5-40 mg amlodipine-atorvastatin oral tablet 2.5-10 mg, 5- 4 80 mg amlodipine-benazepril oral capsule 10-20 mg, 2 QL (60 per 30 days) 2.5-10 mg amlodipine-benazepril oral capsule 10-40 mg 2 QL (30 per 30 days) amlodipine-benazepril oral capsule 5-10 mg, 5- 2 20 mg, 5-40 mg amlodipine-olmesartan oral tablet 10-20 mg, 10- 4 QL (30 per 30 days) 40 mg, 5-20 mg, 5-40 mg amlodipine-valsartan oral tablet 10-160 mg, 10- 2 QL (30 per 30 days) 320 mg, 5-160 mg amlodipine-valsartan oral tablet 5-320 mg 2 QL (60 per 30 days) atenolol-chlorthalidone oral tablet 100-25 mg, 1 50-25 mg benazepril-hydrochlorothiazide oral tablet 10- 2 12.5 mg, 20-12.5 mg, 20-25 mg, 5-6.25 mg bisoprolol-hydrochlorothiazide oral tablet 10- 1 6.25 mg, 2.5-6.25 mg, 5-6.25 mg candesartan-hydrochlorothiazid oral tablet 16- 3 QL (30 per 30 days) 12.5 mg, 32-12.5 mg, 32-25 mg captopril-hydrochlorothiazide oral tablet 25-15 3 mg, 25-25 mg, 50-15 mg, 50-25 mg DEMSER ORAL CAPSULE 250 MG 5 NDS enalapril-hydrochlorothiazide oral tablet 10-25 1 mg, 5-12.5 mg ezetimibe-simvastatin oral tablet 10-10 mg, 10-20 2 mg, 10-40 mg, 10-80 mg

You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 59 Drug Name Drug Tier Requirements/Limits fosinopril-hydrochlorothiazide oral tablet 10- 1 12.5 mg, 20-12.5 mg irbesartan-hydrochlorothiazide oral tablet 150- 1 QL (30 per 30 days) 12.5 mg, 300-12.5 mg lisinopril-hydrochlorothiazide oral tablet 10-12.5 1 mg, 20-12.5 mg, 20-25 mg losartan-hydrochlorothiazide oral tablet 100-12.5 1 QL (60 per 30 days) mg, 100-25 mg, 50-12.5 mg methyldopa-hydrochlorothiazide oral tablet 250- 3 15 mg, 250-25 mg metoprolol ta-hydrochlorothiaz oral tablet 100- 3 25 mg, 100-50 mg, 50-25 mg moexipril-hydrochlorothiazide oral tablet 15-12.5 2 mg, 15-25 mg, 7.5-12.5 mg nadolol-bendroflumethiazide oral tablet 40-5 mg, 4 80-5 mg olmesartan-amlodipin-hcthiazid oral tablet 20-5- 4 QL (30 per 30 days) 12.5 mg, 40-10-12.5 mg, 40-10-25 mg, 40-5-12.5 mg, 40-5-25 mg propranolol-hydrochlorothiazid oral tablet 40-25 3 mg, 80-25 mg quinapril-hydrochlorothiazide oral tablet 10-12.5 2 mg, 20-12.5 mg, 20-25 mg spironolacton-hydrochlorothiaz oral tablet 25-25 2 mg telmisartan-hydrochlorothiazid oral tablet 40- 4 QL (30 per 30 days) 12.5 mg, 80-25 mg telmisartan-hydrochlorothiazid oral tablet 80- 4 QL (60 per 30 days) 12.5 mg triamterene-hydrochlorothiazid oral capsule 1 37.5-25 mg triamterene-hydrochlorothiazid oral capsule 50- 2 25 mg triamterene-hydrochlorothiazid oral tablet 37.5- 1 25 mg, 75-50 mg valsartan-hydrochlorothiazide oral tablet 160- 1 QL (30 per 30 days) 12.5 mg, 160-25 mg, 320-12.5 mg, 320-25 mg, 80-12.5 mg Cardiovascular Agents, Other CORLANOR ORAL TABLET 5 MG, 7.5 MG 4 QL (60 per 30 days) digitek oral tablet 125 mcg 2 QL (30 per 30 days) digitek oral tablet 250 mcg 2 digox oral tablet 125 mcg 2 QL (30 per 30 days) You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 60 Drug Name Drug Tier Requirements/Limits digox oral tablet 250 mcg 2 digoxin 0.25 mg/ml syringe 250 mcg/ml 4 digoxin injection solution 250 mcg/ml 4 DIGOXIN ORAL SOLUTION 50 MCG/ML 2 digoxin oral tablet 125 mcg 2 QL (30 per 30 days) digoxin oral tablet 250 mcg 2 LANOXIN INJECTION SOLUTION 250 4 MCG/ML LANOXIN ORAL TABLET 187.5 MCG, 62.5 4 QL (30 per 30 days) MCG pentoxifylline oral tablet extended release 400 mg 2 RANEXA ORAL TABLET EXTENDED 3 QL (120 per 30 days) RELEASE 12 HR 1,000 MG, 500 MG UPTRAVI ORAL TABLET 1,000 MCG, 1,200 5 PA; NDS; QL (60 per 30 days) MCG, 1,400 MCG, 1,600 MCG, 800 MCG UPTRAVI ORAL TABLET 200 MCG, 400 5 PA; NDS MCG, 600 MCG UPTRAVI ORAL TABLETS,DOSE PACK 200 5 PA; NDS MCG (140)- 800 MCG (60) Diuretics, Carbonic Anhydrase Inhibitors acetazolamide oral capsule, extended release 500 4 mg acetazolamide oral tablet 125 mg, 250 mg 3 methazolamide oral tablet 25 mg, 50 mg 4 Diuretics, Loop bumetanide injection solution 0.25 mg/ml 2 HI bumetanide oral tablet 0.5 mg, 1 mg, 2 mg 2 ethacrynic acid oral tablet 25 mg 3 furosemide injection solution 10 mg/ml 1 HI furosemide injection syringe 10 mg/ml 1 HI furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 1 mg/ml) furosemide oral tablet 20 mg, 40 mg, 80 mg 1 torsemide oral tablet 10 mg, 100 mg, 20 mg, 5 mg 2 Diuretics, Potassium-Sparing amiloride oral tablet 5 mg 3 eplerenone oral tablet 25 mg, 50 mg 4 spironolactone oral tablet 100 mg, 25 mg, 50 mg 2 Diuretics, Thiazide chlorothiazide oral tablet 250 mg, 500 mg 2 chlorothiazide sodium intravenous recon soln 500 2 HI mg You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 61 Drug Name Drug Tier Requirements/Limits chlorthalidone oral tablet 25 mg, 50 mg 1 DIURIL ORAL SUSPENSION 250 MG/5 ML 4 hydrochlorothiazide oral capsule 12.5 mg 1 hydrochlorothiazide oral tablet 12.5 mg, 25 mg, 1 50 mg indapamide oral tablet 1.25 mg, 2.5 mg 1 methyclothiazide oral tablet 5 mg 3 metolazone oral tablet 10 mg, 2.5 mg, 5 mg 2 Dyslipidemics, Fibric Acid Derivatives fenofibrate micronized oral capsule 134 mg, 200 2 QL (30 per 30 days) mg fenofibrate micronized oral capsule 67 mg 2 QL (60 per 30 days) fenofibrate nanocrystallized oral tablet 145 mg 2 QL (30 per 30 days) fenofibrate nanocrystallized oral tablet 48 mg 2 QL (60 per 30 days) fenofibrate oral tablet 160 mg 2 QL (30 per 30 days) fenofibrate oral tablet 54 mg 2 QL (60 per 30 days) fenofibric acid (choline) oral capsule,delayed 2 QL (30 per 30 days) release(dr/ec) 135 mg, 45 mg fenofibric acid oral tablet 35 mg 2 gemfibrozil oral tablet 600 mg 3 QL (60 per 30 days) Dyslipidemics, Hmg Coa Reductase Inhibitors atorvastatin oral tablet 10 mg, 20 mg, 40 mg 1 QL (60 per 30 days) atorvastatin oral tablet 80 mg 1 QL (30 per 30 days) fluvastatin oral capsule 20 mg, 40 mg 4 QL (60 per 30 days) lovastatin oral tablet 10 mg, 20 mg, 40 mg 1 QL (60 per 30 days) pravastatin oral tablet 10 mg, 20 mg, 40 mg, 80 2 QL (60 per 30 days) mg rosuvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 1 QL (30 per 30 days) mg simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 1 QL (60 per 30 days) mg simvastatin oral tablet 80 mg 1 QL (30 per 30 days) Dyslipidemics, Other cholestyramine (with sugar) oral powder in 3 packet 4 gram cholestyramine light oral powder 4 gram 3 cholestyramine light packet 4 gram 3 colesevelam oral powder in packet 3.75 gram 3 colesevelam oral tablet 625 mg 3 QL (180 per 30 days) colestipol oral packet 5 gram 3 colestipol oral tablet 1 gram 3 ezetimibe oral tablet 10 mg 2 You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 62 Drug Name Drug Tier Requirements/Limits niacin oral tablet extended release 24 hr 1,000 4 mg, 500 mg, 750 mg omega-3 acid ethyl esters oral capsule 1 gram 4 QL (120 per 30 days) PRALUENT PEN SUBCUTANEOUS PEN 5 PA; NDS INJECTOR 150 MG/ML, 75 MG/ML prevalite oral powder in packet 4 gram 3 REPATHA PUSHTRONEX SUBCUTANEOUS 5 PA; NDS; QL (3.5 per 28 days) WEARABLE INJECTOR 420 MG/3.5 ML REPATHA SURECLICK SUBCUTANEOUS 5 PA; NDS; QL (3 per 28 days) PEN INJECTOR 140 MG/ML REPATHA SYRINGE SUBCUTANEOUS 5 PA; NDS; QL (3 per 28 days) SYRINGE 140 MG/ML VASCEPA ORAL CAPSULE 0.5 GRAM 4 QL (240 per 30 days) VASCEPA ORAL CAPSULE 1 GRAM 4 QL (120 per 30 days) WELCHOL ORAL POWDER IN PACKET 3.75 3 GRAM WELCHOL ORAL TABLET 625 MG 3 Vasodilators, Direct-Acting Arterial hydralazine injection solution 20 mg/ml 2 hydralazine oral tablet 10 mg, 100 mg, 25 mg, 50 2 mg minoxidil oral tablet 10 mg, 2.5 mg 2 Vasodilators, Direct-Acting Arterial/ Venous isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 2 mg, 5 mg isosorbide dinitrate oral tablet extended release 4 40 mg isosorbide mononitrate oral tablet 10 mg, 20 mg 2 isosorbide mononitrate oral tablet extended 2 release 24 hr 120 mg, 30 mg, 60 mg NITRO-BID TRANSDERMAL OINTMENT 2 3 % nitroglycerin intravenous solution 50 mg/10 ml (5 2 mg/ml) nitroglycerin sublingual tablet 0.3 mg, 0.4 mg, 2 0.6 mg nitroglycerin transdermal patch 24 hour 0.1 2 QL (30 per 30 days) mg/hr, 0.2 mg/hr, 0.6 mg/hr nitroglycerin transdermal patch 24 hour 0.4 2 QL (60 per 30 days) mg/hr nitroglycerin translingual spray,non-aerosol 400 4 mcg/spray

You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 63 Drug Name Drug Tier Requirements/Limits NITROSTAT SUBLINGUAL TABLET 0.3 MG, 3 0.4 MG, 0.6 MG Central Nervous System Agents Attention Deficit Hyperactivity Disorder Agents, Amphetamines dextroamphetamine oral capsule, extended 4 QL (180 per 30 days) release 10 mg dextroamphetamine oral capsule, extended 4 QL (120 per 30 days) release 15 mg dextroamphetamine oral capsule, extended 4 QL (60 per 30 days) release 5 mg dextroamphetamine oral tablet 10 mg 3 QL (180 per 30 days) dextroamphetamine oral tablet 5 mg 3 QL (150 per 30 days) dextroamphetamine-amphetamine oral 4 QL (30 per 30 days) capsule,extended release 24hr 10 mg, 15 mg, 5 mg dextroamphetamine-amphetamine oral 4 QL (60 per 30 days) capsule,extended release 24hr 20 mg, 25 mg, 30 mg dextroamphetamine-amphetamine oral tablet 10 3 QL (90 per 30 days) mg, 12.5 mg, 15 mg, 20 mg, 5 mg, 7.5 mg dextroamphetamine-amphetamine oral tablet 30 3 QL (60 per 30 days) mg VYVANSE ORAL CAPSULE 10 MG, 20 MG, 4 QL (30 per 30 days) 30 MG, 40 MG, 50 MG, 60 MG, 70 MG VYVANSE ORAL TABLET,CHEWABLE 10 4 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG zenzedi oral tablet 10 mg 3 QL (180 per 30 days) zenzedi oral tablet 5 mg 3 QL (150 per 30 days) Attention Deficit Hyperactivity Disorder Agents, Non-Amphetamines atomoxetine oral capsule 10 mg, 100 mg, 18 mg, 3 25 mg, 40 mg, 60 mg, 80 mg clonidine hcl oral tablet extended release 12 hr 4 QL (120 per 30 days) 0.1 mg dexmethylphenidate oral capsule,er biphasic 50- 4 QL (30 per 30 days) 50 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 35 mg, 40 mg, 5 mg dexmethylphenidate oral tablet 10 mg, 2.5 mg, 5 3 QL (60 per 30 days) mg metadate er oral tablet extended release 20 mg 4 methylphenidate hcl oral capsule, er biphasic 30- 4 70 10 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 64 Drug Name Drug Tier Requirements/Limits methylphenidate hcl oral capsule,er biphasic 50- 4 50 10 mg methylphenidate hcl oral capsule,er biphasic 50- 4 QL (30 per 30 days) 50 20 mg, 30 mg, 40 mg, 60 mg methylphenidate hcl oral solution 10 mg/5 ml, 5 4 mg/5 ml methylphenidate hcl oral tablet 10 mg, 5 mg 3 QL (90 per 30 days) methylphenidate hcl oral tablet 20 mg 3 methylphenidate hcl oral tablet extended release 4 QL (180 per 30 days) 10 mg methylphenidate hcl oral tablet extended release 4 QL (90 per 30 days) 20 mg methylphenidate hcl oral tablet extended release 4 24hr 18 mg, 27 mg, 36 mg, 54 mg methylphenidate hcl oral tablet extended release 4 24hr 72 mg STRATTERA ORAL CAPSULE 10 MG, 100 4 MG, 18 MG, 25 MG, 40 MG, 60 MG, 80 MG Central Nervous System, Other AUSTEDO ORAL TABLET 12 MG, 6 MG, 9 5 PA; NDS MG NUEDEXTA ORAL CAPSULE 20-10 MG 4 PA; QL (60 per 28 days) riluzole oral tablet 50 mg 4 tetrabenazine oral tablet 12.5 mg 5 PA; NDS; QL (240 per 30 days) tetrabenazine oral tablet 25 mg 5 PA; NDS; QL (120 per 30 days) Fibromyalgia Agents SAVELLA ORAL TABLET 100 MG, 12.5 MG, 4 QL (60 per 30 days) 25 MG, 50 MG SAVELLA ORAL TABLETS,DOSE PACK 12.5 4 QL (60 per 30 days) MG (5)-25 MG(8)-50 MG(42) Multiple Sclerosis Agents AMPYRA ORAL TABLET EXTENDED 5 PA; LA; NDS RELEASE 12 HR 10 MG AUBAGIO ORAL TABLET 14 MG, 7 MG 5 PA; LA; NDS AVONEX (WITH ALBUMIN) 5 NDS; QL (4 per 28 days) INTRAMUSCULAR KIT 30 MCG AVONEX INTRAMUSCULAR PEN 5 NDS; QL (1 per 28 days) INJECTOR KIT 30 MCG/0.5 ML AVONEX INTRAMUSCULAR SYRINGE KIT 5 NDS; QL (1 per 28 days) 30 MCG/0.5 ML BETASERON SUBCUTANEOUS KIT 0.3 MG 5 PA; NDS; QL (15 per 30 days)

You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 65 Drug Name Drug Tier Requirements/Limits COPAXONE SUBCUTANEOUS SYRINGE 40 5 NDS; QL (12 per 28 days) MG/ML dalfampridine oral tablet extended release 12 hr 5 PA; NDS; QL (60 per 30 days) 10 mg EXTAVIA SUBCUTANEOUS KIT 0.3 MG 5 NDS GILENYA ORAL CAPSULE 0.25 MG, 0.5 MG 5 NDS; QL (30 per 30 days) glatiramer subcutaneous syringe 20 mg/ml, 40 5 NDS mg/ml glatopa subcutaneous syringe 20 mg/ml, 40 5 NDS mg/ml PLEGRIDY SUBCUTANEOUS PEN 5 PA; LA; NDS INJECTOR 125 MCG/0.5 ML, 63 MCG/0.5 ML- 94 MCG/0.5 ML PLEGRIDY SUBCUTANEOUS SYRINGE 125 5 PA; LA; NDS MCG/0.5 ML PLEGRIDY SUBCUTANEOUS SYRINGE 63 5 PA; NDS MCG/0.5 ML- 94 MCG/0.5 ML REBIF (WITH ALBUMIN) SUBCUTANEOUS 5 PA; NDS; QL (6 per 28 days) SYRINGE 22 MCG/0.5 ML, 44 MCG/0.5 ML REBIF REBIDOSE SUBCUTANEOUS PEN 5 PA; NDS; QL (6 per 28 days) INJECTOR 22 MCG/0.5 ML, 44 MCG/0.5 ML REBIF REBIDOSE SUBCUTANEOUS PEN 5 PA; NDS; QL (4.2 per 28 days) INJECTOR 8.8MCG/0.2ML-22 MCG/0.5ML (6) REBIF TITRATION PACK SUBCUTANEOUS 5 PA; NDS; QL (4.2 per 28 days) SYRINGE 8.8MCG/0.2ML-22 MCG/0.5ML (6) TECFIDERA ORAL CAPSULE,DELAYED 5 LA; NDS RELEASE(DR/EC) 120 MG, 120 MG (14)- 240 MG (46), 240 MG TYSABRI INTRAVENOUS SOLUTION 300 5 PA; NDS MG/15 ML ZINBRYTA SUBCUTANEOUS SYRINGE 150 5 PA; NDS; QL (1 per 30 days) MG/ML Dental And Oral Agents Dental And Oral Agents cevimeline oral capsule 30 mg 4 chlorhexidine gluconate mucous membrane 1 mouthwash 0.12 % denta 5000 plus dental cream 1.1 % 2 dentagel dental gel 1.1 % 2 oralone dental paste 0.1 % 2 paroex oral rinse mucous membrane mouthwash 1 0.12 %

You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 66 Drug Name Drug Tier Requirements/Limits periogard mucous membrane mouthwash 0.12 % 1 pilocarpine hcl oral tablet 5 mg, 7.5 mg 3 sf 5000 plus dental cream 1.1 % 2 triamcinolone acetonide dental paste 0.1 % 2 Dermatological Agents Dermatological Agents acitretin oral capsule 10 mg, 17.5 mg, 25 mg 5 NDS adapalene topical cream 0.1 % 3 PA adapalene topical gel 0.1 %, 0.3 % 3 PA ammonium lactate topical cream 12 % 3 ammonium lactate topical lotion 12 % 3 amnesteem oral capsule 10 mg, 20 mg, 40 mg 4 avita topical cream 0.025 % 4 PA avita topical gel 0.025 % 4 PA AZELEX TOPICAL CREAM 20 % 4 calcipotriene scalp solution 0.005 % 4 QL (60 per 30 days) calcipotriene topical cream 0.005 % 4 QL (120 per 30 days) calcipotriene topical ointment 0.005 % 3 QL (120 per 30 days) calcitriol topical ointment 3 mcg/gram 4 claravis oral capsule 10 mg, 20 mg, 30 mg, 40 mg 4 clindamycin-benzoyl peroxide topical gel 1-5 %, 4 1.2 %(1 % base) -5 % clindamycin-benzoyl peroxide topical gel with 4 pump 1.2-2.5 % clobetasol topical spray,non-aerosol 0.05 % 3 clotrimazole-betamethasone topical cream 1-0.05 3 % clotrimazole-betamethasone topical lotion 1-0.05 4 % CORTISPORIN TOPICAL CREAM 3.5-10,000- 4 0.5 MG/G-UNIT/G-% CORTISPORIN TOPICAL OINTMENT 1 % 4 COSENTYX (2 SYRINGES) 5 PA; LA; NDS; QL (32 per 365 days) SUBCUTANEOUS SYRINGE 150 MG/ML COSENTYX PEN (2 PENS) SUBCUTANEOUS 5 PA; LA; NDS; QL (32 per 365 days) PEN INJECTOR 150 MG/ML dapsone topical gel 5 % 4 diclofenac sodium topical gel 1 % 2 ELIDEL TOPICAL CREAM 1 % 4 erythromycin-benzoyl peroxide topical gel 3-5 % 4 FINACEA TOPICAL FOAM 15 % 4

You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 67 Drug Name Drug Tier Requirements/Limits FINACEA TOPICAL GEL 15 % 4 fluocinonide topical cream 0.1 % 3 fluorouracil topical cream 0.5 % 4 fluorouracil topical cream 5 % 3 fluorouracil topical solution 2 %, 5 % 3 fluticasone topical cream 0.05 % 2 fluticasone topical ointment 0.005 % 2 imiquimod topical cream in metered-dose pump 4 QL (28 per 28 days) 3.75 % imiquimod topical cream in packet 5 % 4 QL (12 per 30 days) isotretinoin oral capsule 10 mg, 20 mg, 30 mg, 40 4 mg methoxsalen oral capsule,liqd-filled,rapid rel 10 5 NDS mg myorisan oral capsule 10 mg, 20 mg, 30 mg, 40 4 mg neuac topical gel 1.2 %(1 % base) -5 % 4 nystatin-triamcinolone topical cream 100,000-0.1 4 unit/g-% nystatin-triamcinolone topical ointment 100,000- 4 0.1 unit/gram-% oxiconazole topical cream 1 % 4 PICATO TOPICAL GEL 0.015 % 4 QL (3 per 30 days) PICATO TOPICAL GEL 0.05 % 4 QL (2 per 30 days) podofilox topical solution 0.5 % 4 prednicarbate topical cream 0.1 % 4 REGRANEX TOPICAL GEL 0.01 % 5 PA; NDS SANTYL TOPICAL OINTMENT 250 4 UNIT/GRAM selenium sulfide topical lotion 2.5 % 2 SILIQ SUBCUTANEOUS SYRINGE 210 5 PA; NDS MG/1.5 ML STELARA SUBCUTANEOUS SOLUTION 45 5 PA; NDS MG/0.5 ML STELARA SUBCUTANEOUS SYRINGE 45 5 PA; NDS MG/0.5 ML, 90 MG/ML tacrolimus topical ointment 0.03 %, 0.1 % 4 TALTZ AUTOINJECTOR SUBCUTANEOUS 5 PA; LA; NDS AUTO-INJECTOR 80 MG/ML TALTZ SYRINGE SUBCUTANEOUS 5 PA; LA; NDS SYRINGE 80 MG/ML tazarotene topical cream 0.1 % 3 You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 68 Drug Name Drug Tier Requirements/Limits TAZORAC TOPICAL CREAM 0.05 %, 0.1 % 4 PA TAZORAC TOPICAL GEL 0.05 %, 0.1 % 4 PA TOLAK TOPICAL CREAM 4 % 4 tretinoin topical cream 0.025 %, 0.05 %, 0.1 % 3 PA tretinoin topical gel 0.01 %, 0.025 % 3 PA zenatane oral capsule 10 mg, 20 mg, 30 mg, 40 4 mg ZYCLARA TOPICAL CREAM IN METERED- 4 QL (7.5 per 28 days) DOSE PUMP 2.5 % ZYCLARA TOPICAL CREAM IN METERED- 4 QL (28 per 28 days) DOSE PUMP 3.75 % Electrolytes/Minerals/Metals/Vitamins Electrolyte/ Mineral Replacement CARBAGLU ORAL TABLET, DISPERSIBLE 5 PA; NDS 200 MG fluoride (sodium) oral tablet 1 mg (2.2 mg sod. 1 fluoride) KLOR-CON 10 ORAL TABLET EXTENDED 2 RELEASE 10 MEQ KLOR-CON 8 ORAL TABLET EXTENDED 2 RELEASE 8 MEQ klor-con m10 oral tablet,er particles/crystals 10 2 meq klor-con m15 oral tablet,er particles/crystals 15 2 meq klor-con m20 oral tablet,er particles/crystals 20 2 meq klor-con sprinkle oral capsule, extended release 2 10 meq, 8 meq K-SOL ORAL LIQUID 40 MEQ/15 ML 4 K-TAB ORAL TABLET EXTENDED 4 RELEASE 10 MEQ, 20 MEQ, 8 MEQ magnesium sulfate injection solution 4 meq/ml 2 HI (50 %) magnesium sulfate injection syringe 4 meq/ml 2 HI PHYSIOSOL IRRIGATION IRRIGATION 4 SOLUTION 140-5-3-98 MEQ/L potassium chloride in water intravenous 4 piggyback 20 meq/100 ml, 40 meq/100 ml potassium chloride intravenous solution 2 meq/ml 4 potassium chloride oral capsule, extended release 2 10 meq, 8 meq You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 69 Drug Name Drug Tier Requirements/Limits potassium chloride oral liquid 20 meq/15 ml, 40 4 meq/15 ml potassium chloride oral packet 20 meq 4 potassium chloride oral tablet extended release 2 10 meq, 20 meq, 8 meq potassium chloride oral tablet,er 2 particles/crystals 10 meq, 20 meq sodium chloride 0.45 % intravenous parenteral 2 solution 0.45 % sodium chloride 0.45 % intravenous piggyback 2 0.45 % sodium chloride 0.9 % intravenous parenteral 2 solution sodium chloride 3 % intravenous parenteral 2 solution 3 % sodium chloride 5 % intravenous parenteral 2 solution 5 % sodium chloride intravenous parenteral solution 2 2.5 meq/ml sodium chloride irrigation solution 0.9 % 2 sodium fluoride 0.5 mg/ml drop d/f, s/f,gluten-free 1 (otc) 0.5 mg (1.1 mg sod.fluorid)/ml SUPREP BOWEL PREP KIT ORAL RECON 3 SOLN 17.5-3.13-1.6 GRAM Electrolyte/Mineral/Metal Modifiers AMINOSYN 7 % WITH ELECTROLYTES 4 PA BvD; HI INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN-RF 5.2 % INTRAVENOUS 4 PA BvD; HI PARENTERAL SOLUTION 5.2 % DEPEN TITRATABS ORAL TABLET 250 MG 5 NDS EXJADE ORAL TABLET, DISPERSIBLE 125 5 PA; LA; NDS MG, 250 MG, 500 MG FERRIPROX ORAL SOLUTION 100 MG/ML 5 PA; NDS FERRIPROX ORAL TABLET 500 MG 5 PA; NDS FREAMINE HBC 6.9 % INTRAVENOUS 4 PA BvD; HI PARENTERAL SOLUTION 6.9 % JADENU ORAL TABLET 180 MG, 360 MG, 90 5 PA; NDS MG JADENU SPRINKLE ORAL GRANULES IN 5 PA; NDS PACKET 180 MG, 360 MG, 90 MG kionex (with sorbitol) oral suspension 15-19.3 3 gram/60 ml You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 70 Drug Name Drug Tier Requirements/Limits PLENAMINE INTRAVENOUS PARENTERAL 4 PA BvD SOLUTION 15 % SAMSCA ORAL TABLET 15 MG, 30 MG 5 PA; NDS sod polystyren sulf 15 g/60 ml sorbitol free 15 3 gram/60 ml sodium polystyrene sulfonate oral powder 3 sps (with sorbitol) oral suspension 15-20 gram/60 3 ml SYPRINE ORAL CAPSULE 250 MG 5 NDS Electrolytes/Minerals/Metals/Vitamins AMINOSYN 8.5 % INTRAVENOUS 4 PA BvD PARENTERAL SOLUTION 8.5 % AMINOSYN 8.5 %-ELECTROLYTES 4 PA BvD; HI INTRAVENOUS PARENTERAL SOLUTION 8.5 % AMINOSYN II 10 % INTRAVENOUS 4 PA BvD; HI PARENTERAL SOLUTION 10 % AMINOSYN II 15 % INTRAVENOUS 4 PA BvD; HI PARENTERAL SOLUTION 15 % AMINOSYN II 7 % INTRAVENOUS 4 PA BvD; HI PARENTERAL SOLUTION 7 % AMINOSYN II 8.5 % INTRAVENOUS 4 PA BvD; HI PARENTERAL SOLUTION 8.5 % AMINOSYN II 8.5 %-ELECTROLYTES 4 PA BvD; HI INTRAVENOUS PARENTERAL SOLUTION 8.5 % AMINOSYN-HBC 7% INTRAVENOUS 4 PA BvD; HI PARENTERAL SOLUTION 7 % AMINOSYN-PF 10 % INTRAVENOUS 4 PA BvD; HI PARENTERAL SOLUTION 10 % AMINOSYN-PF 7 % (SULFITE-FREE) 4 PA BvD; HI INTRAVENOUS PARENTERAL SOLUTION 7 % CLINIMIX 5%/D15W SULFITE FREE 4 PA BvD INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX 5%/D25W SULFITE-FREE 4 PA BvD INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX 2.75%/D5W SULFIT FREE 4 PA BvD INTRAVENOUS PARENTERAL SOLUTION 2.75 %

You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 71 Drug Name Drug Tier Requirements/Limits CLINIMIX 4.25%/D10W SULF FREE 4 PA BvD INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX 4.25%/D5W SULFIT FREE 4 PA BvD INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX 4.25%-D20W SULF-FREE 4 PA BvD INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX 4.25%-D25W SULF-FREE 4 PA BvD INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX 5%-D20W(SULFITE-FREE) 4 PA BvD INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX E 2.75%/D10W SUL FREE 4 PA BvD INTRAVENOUS PARENTERAL SOLUTION 2.75 % CLINIMIX E 2.75%/D5W SULF FREE 4 PA BvD INTRAVENOUS PARENTERAL SOLUTION 2.75 % CLINIMIX E 4.25%/D10W SUL FREE 4 PA BvD INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX E 4.25%/D25W SUL FREE 4 PA BvD INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX E 4.25%/D5W SULF FREE 4 PA BvD INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX E 5%/D15W SULFIT FREE 4 PA BvD INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX E 5%/D20W SULFIT FREE 4 PA BvD INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX E 5%/D25W SULFIT FREE 4 PA BvD INTRAVENOUS PARENTERAL SOLUTION 5 % d10 %-0.45 % sodium chloride intravenous 2 parenteral solution d2.5 %-0.45 % sodium chloride intravenous 2 parenteral solution

You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 72 Drug Name Drug Tier Requirements/Limits d5 % and 0.9 % sodium chloride intravenous 2 parenteral solution d5 %-0.45 % sodium chloride intravenous 2 parenteral solution dextrose 10 % and 0.2 % nacl intravenous 2 parenteral solution dextrose 10 % in water (d10w) intravenous 2 parenteral solution 10 % dextrose 5 % in water (d5w) intravenous 2 parenteral solution dextrose 5 % in water (d5w) intravenous 2 piggyback 5 % dextrose 5 %-lactated ringers intravenous 2 parenteral solution dextrose 5%-0.2 % sod chloride intravenous 2 parenteral solution dextrose 5%-0.3 % sod.chloride intravenous 2 parenteral solution HEPATAMINE 8% INTRAVENOUS 4 PA BvD; HI PARENTERAL SOLUTION 8 % INTRALIPID INTRAVENOUS EMULSION 20 4 PA BvD; HI %, 30 % LACTATED RINGERS INTRAVENOUS 2 PARENTERAL SOLUTION LACTATED RINGERS IRRIGATION 2 SOLUTION levocarnitine (with sugar) oral solution 100 3 mg/ml levocarnitine oral tablet 330 mg 3 NEPHRAMINE 5.4 % INTRAVENOUS 4 PA BvD; HI PARENTERAL SOLUTION 5.4 % NUTRILIPID INTRAVENOUS EMULSION 20 4 PA BvD; HI % pnv prenatal plus multivit tab s/f, gluten-free 27 2 mg iron- 1 mg potassium chlorid-d5-0.45%nacl intravenous 4 parenteral solution 10 meq/l, 20 meq/l, 30 meq/l potassium chloride in lr-d5 intravenous 2 parenteral solution 40 meq/l potassium chloride intravenous solution 2 meq/ml 4 potassium chloride intravenous solution 2 meq/ml 4 (20 ml)

You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 73 Drug Name Drug Tier Requirements/Limits potassium chloride-d5-0.3%nacl intravenous 2 parenteral solution 20 meq/l potassium chloride-d5-0.9%nacl intravenous 4 parenteral solution 20 meq/l PREMASOL 10 % INTRAVENOUS 1 PA BvD; HI PARENTERAL SOLUTION 10 % PREMASOL 6 % INTRAVENOUS 1 PA BvD; HI PARENTERAL SOLUTION 6 % prenatal vitamin plus low iron oral tablet 27 mg 2 iron- 1 mg PROSOL 20 % INTRAVENOUS 4 PA BvD; HI PARENTERAL SOLUTION ringer's irrigation solution 1 sodium chloride 100 meq/40 ml 25's, sdv 2.5 2 meq/ml TPN ELECTROLYTES II IV SOLN 4 25'S,20ML/50ML FTV 18-18-5-4.5-35 MEQ/20 ML TPN ELECTROLYTES INTRAVENOUS 4 SOLUTION 35-20-5 MEQ/20 ML TRAVASOL 10 % INTRAVENOUS 4 PA BvD; HI PARENTERAL SOLUTION 10 % trientine oral capsule 250 mg 5 NDS TROPHAMINE 10 % INTRAVENOUS 4 PA BvD; HI PARENTERAL SOLUTION 10 % TROPHAMINE 6% INTRAVENOUS 4 PA BvD; HI PARENTERAL SOLUTION 6 % water for irrigation, sterile irrigation solution 2 Gastrointestinal Agents Antispasmodics, Gastrointestinal chlordiazepoxide-clidinium oral capsule 5-2.5 mg 4 QL (240 per 30 days) dicyclomine oral capsule 10 mg 2 dicyclomine oral solution 10 mg/5 ml 3 dicyclomine oral tablet 20 mg 2 glycopyrrolate oral tablet 1 mg, 2 mg 4 methscopolamine oral tablet 2.5 mg, 5 mg 4 propantheline oral tablet 15 mg 3 Gastrointestinal Agents amoxicil-clarithromy-lansopraz oral combo pack 4 500-500-30 mg budesonide oral tablet,delayed and ext.release 9 4 QL (30 per 30 days) mg You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 74 Drug Name Drug Tier Requirements/Limits UCERIS ORAL TABLET,DELAYED AND 5 NDS EXT.RELEASE 9 MG UCERIS RECTAL FOAM 2 MG/ACTUATION 4 Gastrointestinal Agents, Other CHOLBAM ORAL CAPSULE 250 MG, 50 MG 5 PA; NDS diphenoxylate-atropine oral liquid 2.5-0.025 3 mg/5 ml diphenoxylate-atropine oral tablet 2.5-0.025 mg 3 GATTEX 30-VIAL SUBCUTANEOUS KIT 5 5 PA; NDS MG loperamide oral capsule 2 mg 2 metoclopramide hcl injection solution 5 mg/ml 2 HI metoclopramide hcl injection syringe 5 mg/ml 2 HI metoclopramide hcl oral solution 5 mg/5 ml 2 metoclopramide hcl oral tablet 10 mg, 5 mg 2 MOVANTIK ORAL TABLET 12.5 MG, 25 MG 4 RELISTOR ORAL TABLET 150 MG 5 NDS; QL (90 per 30 days) RELISTOR SUBCUTANEOUS SOLUTION 12 5 NDS; QL (36 per 28 days) MG/0.6 ML RELISTOR SUBCUTANEOUS SYRINGE 12 5 NDS; QL (36 per 28 days) MG/0.6 ML RELISTOR SUBCUTANEOUS SYRINGE 8 5 NDS; QL (12 per 30 days) MG/0.4 ML ursodiol oral capsule 300 mg 3 ursodiol oral tablet 250 mg, 500 mg 3 Histamine2 (H2) Receptor Antagonists cimetidine hcl oral solution 300 mg/5 ml 4 cimetidine oral tablet 200 mg, 300 mg, 400 mg, 4 800 mg famotidine (pf) intravenous solution 20 mg/2 ml 2 famotidine (pf)-nacl (iso-os) intravenous 2 piggyback 20 mg/50 ml famotidine oral suspension 40 mg/5 ml (8 mg/ml) 4 famotidine oral tablet 20 mg, 40 mg 1 nizatidine oral capsule 300 mg 3 nizatidine oral solution 150 mg/10 ml 3 ranitidine hcl injection solution 50 mg/2 ml (25 2 mg/ml) ranitidine hcl oral syrup 15 mg/ml 1 ranitidine hcl oral tablet 150 mg, 300 mg 1 Irritable Bowel Syndrome Agents alosetron oral tablet 0.5 mg, 1 mg 5 NDS; QL (60 per 30 days) You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 75 Drug Name Drug Tier Requirements/Limits AMITIZA ORAL CAPSULE 24 MCG, 8 MCG 4 QL (60 per 30 days) DELZICOL ORAL CAPSULE (WITH DEL REL 3 TABLETS) 400 MG GIAZO ORAL TABLET 1.1 GRAM 5 NDS LINZESS ORAL CAPSULE 145 MCG, 290 4 QL (30 per 30 days) MCG, 72 MCG VIBERZI ORAL TABLET 100 MG, 75 MG 4 QL (60 per 30 days) Laxatives COLYTE WITH FLAVOR PACKS ORAL 4 RECON SOLN 240-22.72-6.72 -5.84 GRAM constulose oral solution 10 gram/15 ml 2 enulose oral solution 10 gram/15 ml 2 gavilyte-c oral recon soln 240-22.72-6.72 -5.84 2 gram gavilyte-g oral recon soln 236-22.74-6.74 -5.86 2 gram gavilyte-h and bisacodyl oral kit 5-210 mg-gram 2 gavilyte-n oral recon soln 420 gram 2 generlac oral solution 10 gram/15 ml 2 GOLYTELY ORAL POWDER IN PACKET 4 227.1-21.5-6.36 GRAM GOLYTELY ORAL RECON SOLN 236-22.74- 4 6.74 -5.86 GRAM lactulose oral packet 10 gram 2 lactulose oral solution 10 gram/15 ml 2 peg 3350-electrolytes oral recon soln 236-22.74- 2 6.74 -5.86 gram, 240-22.72-6.72 -5.84 gram peg-electrolyte soln oral recon soln 420 gram 2 polyethylene glycol 3350 oral powder 17 2 gram/dose trilyte with flavor packets oral recon soln 420 2 gram Protectants CARAFATE ORAL SUSPENSION 100 MG/ML 3 misoprostol oral tablet 100 mcg, 200 mcg 3 sucralfate oral tablet 1 gram 2 Proton Pump Inhibitors esomeprazole magnesium oral capsule,delayed 2 QL (30 per 30 days) release(dr/ec) 20 mg, 40 mg lansoprazole oral capsule,delayed release(dr/ec) 3 QL (60 per 30 days) 15 mg

You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 76 Drug Name Drug Tier Requirements/Limits lansoprazole oral capsule,delayed release(dr/ec) 3 QL (30 per 30 days) 30 mg lansoprazole oral tablet,disintegrat, delay rel 15 4 QL (60 per 30 days) mg lansoprazole oral tablet,disintegrat, delay rel 30 4 QL (30 per 30 days) mg omeprazole oral capsule,delayed release(dr/ec) 1 QL (60 per 30 days) 10 mg, 20 mg, 40 mg pantoprazole oral tablet,delayed release (dr/ec) 1 QL (60 per 30 days) 20 mg, 40 mg rabeprazole oral tablet,delayed release (dr/ec) 20 2 QL (30 per 30 days) mg Genetic Or Enzyme Disorder: Replacement, Modifiers, Treatment Genetic Or Enzyme Disorder: Replacement, Modifiers, Treatment ADAGEN INTRAMUSCULAR SOLUTION 250 5 NDS UNIT/ML CEREZYME INTRAVENOUS RECON SOLN 5 NDS 400 UNIT CREON ORAL CAPSULE,DELAYED 3 RELEASE(DR/EC) 12,000-38,000 -60,000 UNIT, 24,000-76,000 -120,000 UNIT, 3,000- 9,500- 15,000 UNIT, 36,000-114,000- 180,000 UNIT, 6,000-19,000 -30,000 UNIT CYSTADANE ORAL POWDER 1 GRAM/1.7 5 NDS ML FABRAZYME INTRAVENOUS RECON SOLN 5 NDS 35 MG KUVAN ORAL POWDER IN PACKET 100 5 PA; NDS MG, 500 MG KUVAN ORAL TABLET,SOLUBLE 100 MG 5 PA; NDS miglustat oral capsule 100 mg 5 NDS; QL (90 per 30 days) NAGLAZYME INTRAVENOUS SOLUTION 5 5 NDS MG/5 ML PANCREAZE ORAL CAPSULE,DELAYED 3 RELEASE(DR/EC) 10,500-35,500- 61,500 UNIT, 16,800-56,800- 98,400 UNIT, 2,600- 6,200- 10,850 UNIT, 21,000-54,700- 83,900 UNIT, 4,200-14,200- 24,600 UNIT PROCYSBI ORAL CAPSULE, DELAYED REL 5 NDS SPRINKLE 25 MG, 75 MG RAVICTI ORAL LIQUID 1.1 GRAM/ML 5 PA; NDS You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 77 Drug Name Drug Tier Requirements/Limits STRENSIQ SUBCUTANEOUS SOLUTION 100 5 PA; NDS MG/ML, 40 MG/ML SUCRAID ORAL SOLUTION 8,500 UNIT/ML 5 NDS VPRIV INTRAVENOUS RECON SOLN 400 5 NDS UNIT ZAVESCA ORAL CAPSULE 100 MG 5 NDS; QL (90 per 30 days) ZENPEP ORAL CAPSULE,DELAYED 3 RELEASE(DR/EC) 10,000-32,000 -42,000 UNIT, 10,000-34,000 -55,000 UNIT, 15,000- 47,000 -63,000 UNIT, 15,000-51,000 -82,000 UNIT, 20,000-63,000- 84,000 UNIT, 20,000- 68,000 -109,000 UNIT, 25,000-79,000- 105,000 UNIT, 25,000-85,000- 136,000 UNIT, 3,000- 10,000 -14,000-UNIT, 3,000-10,000- 16,000 UNIT, 40,000-126,000- 168,000 UNIT, 40,000- 136,000- 218,000 UNIT, 5,000-17,000 -27,000 UNIT, 5,000-17,000- 24,000 UNIT Genitourinary Agents Antispasmodics, Urinary darifenacin oral tablet extended release 24 hr 15 3 QL (30 per 30 days) mg, 7.5 mg flavoxate oral tablet 100 mg 3 MYRBETRIQ ORAL TABLET EXTENDED 4 QL (30 per 30 days) RELEASE 24 HR 25 MG, 50 MG oxybutynin chloride oral syrup 5 mg/5 ml 2 oxybutynin chloride oral tablet 5 mg 2 oxybutynin chloride oral tablet extended release 3 QL (60 per 30 days) 24hr 10 mg, 15 mg, 5 mg tolterodine oral capsule,extended release 24hr 2 2 QL (30 per 30 days) mg, 4 mg tolterodine oral tablet 1 mg, 2 mg 2 QL (60 per 30 days) TOVIAZ ORAL TABLET EXTENDED 3 QL (30 per 30 days) RELEASE 24 HR 4 MG, 8 MG trospium oral capsule,extended release 24hr 60 3 QL (30 per 30 days) mg trospium oral tablet 20 mg 3 VESICARE ORAL TABLET 10 MG, 5 MG 4 QL (30 per 30 days) Benign Prostatic Hypertrophy Agents alfuzosin oral tablet extended release 24 hr 10 2 QL (30 per 30 days) mg CIALIS ORAL TABLET 2.5 MG, 5 MG 4 PA dutasteride oral capsule 0.5 mg 2 QL (30 per 30 days)

You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 78 Drug Name Drug Tier Requirements/Limits dutasteride-tamsulosin oral capsule, er 4 QL (30 per 30 days) multiphase 24 hr 0.5-0.4 mg finasteride oral tablet 5 mg 1 QL (30 per 30 days) RAPAFLO ORAL CAPSULE 4 MG, 8 MG 4 QL (30 per 30 days) tadalafil oral tablet 2.5 mg, 5 mg 3 PA; QL (30 per 30 days) tamsulosin oral capsule 0.4 mg 1 QL (60 per 30 days) Genitourinary Agents, Other bethanechol chloride oral tablet 10 mg, 25 mg, 5 3 mg, 50 mg ELMIRON ORAL CAPSULE 100 MG 4 potassium citrate oral tablet extended release 10 3 meq (1,080 mg), 15 meq, 5 meq (540 mg) sodium phenylbutyrate oral powder 0.94 5 NDS gram/gram Phosphate Binders calcium acetate oral capsule 667 mg 3 calcium acetate oral tablet 667 mg 3 eliphos oral tablet 667 mg 3 FOSRENOL ORAL POWDER IN PACKET 5 NDS 1,000 MG, 750 MG FOSRENOL ORAL TABLET,CHEWABLE 5 NDS 1,000 MG, 500 MG, 750 MG lanthanum oral tablet,chewable 1,000 mg, 500 2 mg, 750 mg PHOSLYRA ORAL SOLUTION 667 MG (169 3 MG CALCIUM)/5 ML RENAGEL ORAL TABLET 400 MG, 800 MG 4 RENVELA ORAL POWDER IN PACKET 0.8 4 QL (540 per 30 days) GRAM RENVELA ORAL POWDER IN PACKET 2.4 4 QL (180 per 30 days) GRAM RENVELA ORAL TABLET 800 MG 4 QL (540 per 30 days) sevelamer carbonate oral powder in packet 0.8 3 gram, 2.4 gram sevelamer carbonate oral tablet 800 mg 2 Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal) Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal) ala-cort topical cream 1 %, 2.5 % 2 alclometasone topical cream 0.05 % 3 alclometasone topical ointment 0.05 % 3 You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 79 Drug Name Drug Tier Requirements/Limits ANALPRAM-HC RECTAL CREAM 1-1 % 4 ANALPRAM-HC TOPICAL LOTION 2.5-1 % 4 clobetasol scalp solution 0.05 % 3 clobetasol topical cream 0.05 % 3 clobetasol topical foam 0.05 % 3 clobetasol topical gel 0.05 % 3 clobetasol topical lotion 0.05 % 3 clobetasol topical ointment 0.05 % 3 clobetasol topical shampoo 0.05 % 3 clobetasol-emollient topical cream 0.05 % 3 clobetasol-emollient topical foam 0.05 % 3 CORDRAN TAPE LARGE ROLL TOPICAL 4 TAPE 4 MCG/CM2 cormax scalp solution 0.05 % 3 desonide topical cream 0.05 % 3 desonide topical lotion 0.05 % 3 desonide topical ointment 0.05 % 3 desoximetasone topical cream 0.05 %, 0.25 % 4 desoximetasone topical gel 0.05 % 4 desoximetasone topical ointment 0.05 %, 0.25 % 4 EMFLAZA ORAL SUSPENSION 22.75 5 PA; NDS MG/ML EMFLAZA ORAL TABLET 18 MG, 30 MG, 36 5 PA; NDS MG, 6 MG fludrocortisone oral tablet 0.1 mg 2 fluocinolone 0.01% body oil 0.01 % 4 fluocinolone acetonide oil otic (ear) drops 0.01 % 3 fluocinolone and shower cap scalp oil 0.01 % 4 fluocinolone topical cream 0.01 %, 0.025 % 4 fluocinolone topical ointment 0.025 % 4 fluocinolone topical solution 0.01 % 4 fluocinonide topical cream 0.05 % 3 fluocinonide topical gel 0.05 % 3 fluocinonide topical ointment 0.05 % 3 fluocinonide topical solution 0.05 % 4 fluocinonide-e topical cream 0.05 % 4 halobetasol propionate topical cream 0.05 % 4 halobetasol propionate topical ointment 0.05 % 4 hydrocortisone butyrate topical cream 0.1 % 4 hydrocortisone butyrate topical ointment 0.1 % 4 hydrocortisone butyrate topical solution 0.1 % 4 You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 80 Drug Name Drug Tier Requirements/Limits hydrocortisone oral tablet 10 mg 2 hydrocortisone topical cream 1 %, 2.5 % 2 hydrocortisone topical lotion 2.5 % 2 hydrocortisone topical ointment 1 %, 2.5 % 2 hydrocortisone valerate topical cream 0.2 % 3 hydrocortisone valerate topical ointment 0.2 % 3 hydrocortisone-pramoxine rectal cream 1-1 % 4 methylprednisolone oral tablets,dose pack 4 mg 2 methylprednisolone sodium succ injection recon 4 HI soln 125 mg mometasone topical cream 0.1 % 2 mometasone topical ointment 0.1 % 2 mometasone topical solution 0.1 % 2 PRAMOSONE TOPICAL CREAM 1-1 % 4 PRAMOSONE TOPICAL LOTION 1-1 % 4 prednicarbate topical ointment 0.1 % 4 prednisolone sodium phosphate oral solution 25 3 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml) prednisone oral solution 5 mg/5 ml 3 procto-pak topical cream with perineal 2 applicator 1 % proctozone-hc topical cream with perineal 3 applicator 2.5 % triamcinolone acet 40 mg/ml vl sdv,inner,latex- 4 free 40 mg/ml triamcinolone acetonide injection suspension 40 4 mg/ml triamcinolone acetonide topical cream 0.025 %, 2 0.1 %, 0.5 % triamcinolone acetonide topical lotion 0.025 %, 2 0.1 % triamcinolone acetonide topical ointment 0.025 2 %, 0.1 %, 0.5 % triderm topical cream 0.1 %, 0.5 % 2 tridesilon topical cream 0.05 % 3 Hormonal Agents, Stimulant/ Replacement/ Modifying (Pituitary) Hormonal Agents, Stimulant/ Replacement/ Modifying (Pituitary) desmopressin 10 mcg/0.1 ml spr 10 mcg/spray 3 (0.1 ml) desmopressin injection solution 4 mcg/ml 4 You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 81 Drug Name Drug Tier Requirements/Limits desmopressin nasal solution 0.1 mg/ml 3 (refrigerate) desmopressin nasal spray,non-aerosol 10 3 mcg/spray (0.1 ml) desmopressin oral tablet 0.1 mg, 0.2 mg 3 EGRIFTA SUBCUTANEOUS RECON SOLN 1 5 PA; LA; NDS; QL (60 per 30 days) MG INCRELEX SUBCUTANEOUS SOLUTION 10 5 PA; NDS MG/ML methylergonovine oral tablet 0.2 mg 4 MYALEPT SUBCUTANEOUS RECON SOLN 5 PA; NDS; QL (30 per 30 days) 5 MG/ML (FINAL CONC.) NORDITROPIN FLEXPRO SUBCUTANEOUS 5 PA; NDS PEN INJECTOR 10 MG/1.5 ML (6.7 MG/ML), 15 MG/1.5 ML (10 MG/ML), 30 MG/3 ML (10 MG/ML), 5 MG/1.5 ML (3.3 MG/ML) STIMATE NASAL SPRAY,NON-AEROSOL 4 150 MCG/SPRAY (0.1 ML) Hormonal Agents, Stimulant/ Replacement/ Modifying (Sex Hormones/ Modifiers) Anabolic Steroids ANADROL-50 ORAL TABLET 50 MG 5 NDS oxandrolone oral tablet 10 mg 5 NDS; QL (60 per 30 days) oxandrolone oral tablet 2.5 mg 3 QL (120 per 30 days) Androgens ANDRODERM TRANSDERMAL PATCH 24 4 PA NSO; QL (60 per 30 days) HOUR 2 MG/24 HOUR ANDRODERM TRANSDERMAL PATCH 24 4 PA NSO; QL (30 per 30 days) HOUR 4 MG/24 HR ANDROGEL TRANSDERMAL GEL IN 4 PA NSO; QL (150 per 30 days) METERED-DOSE PUMP 20.25 MG/1.25 GRAM (1.62 %) ANDROGEL TRANSDERMAL GEL IN 4 PA NSO; QL (37.5 per 30 days) PACKET 1.62 % (20.25 MG/1.25 GRAM) ANDROGEL TRANSDERMAL GEL IN 4 PA NSO; QL (150 per 30 days) PACKET 1.62 % (40.5 MG/2.5 GRAM) danazol oral capsule 100 mg, 200 mg, 50 mg 4 DEPO-TESTOSTERONE INTRAMUSCULAR 4 PA NSO OIL 200 MG/ML testosterone cyp 200 mg/ml sdv, latex-free 200 3 PA NSO mg/ml

You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 82 Drug Name Drug Tier Requirements/Limits testosterone cypionate intramuscular oil 100 3 mg/ml testosterone cypionate intramuscular oil 200 3 PA NSO mg/ml testosterone enanthate intramuscular oil 200 3 PA NSO; QL (4.5 per 30 days) mg/ml testosterone transdermal gel in metered-dose 3 PA NSO; QL (300 per 30 days) pump 12.5 mg/ 1.25 gram (1 %) testosterone transdermal gel in metered-dose 4 PA NSO; QL (150 per 30 days) pump 20.25 mg/1.25 gram (1.62 %) testosterone transdermal gel in packet 1 % (25 3 PA NSO; QL (300 per 30 days) mg/2.5gram), 1 % (50 mg/5 gram) testosterone transdermal gel in packet 1.62 % 3 PA NSO; QL (37.5 per 30 days) (20.25 mg/1.25 gram) testosterone transdermal gel in packet 1.62 % 3 PA NSO; QL (150 per 30 days) (40.5 mg/2.5 gram) Estrogens ALORA TRANSDERMAL PATCH 4 QL (8 per 28 days) SEMIWEEKLY 0.025 MG/24 HR, 0.05 MG/24 HR, 0.075 MG/24 HR, 0.1 MG/24 HR ESTRACE VAGINAL CREAM 0.01 % (0.1 3 MG/GRAM) estradiol oral tablet 0.5 mg, 1 mg, 2 mg 3 estradiol transdermal patch semiweekly 0.025 3 mg/24 hr estradiol transdermal patch semiweekly 0.0375 3 QL (8 per 28 days) mg/24 hr, 0.05 mg/24 hr, 0.075 mg/24 hr, 0.1 mg/24 hr estradiol transdermal patch weekly 0.025 mg/24 3 QL (4 per 28 days) hr, 0.0375 mg/24 hr, 0.05 mg/24 hr, 0.06 mg/24 hr, 0.075 mg/24 hr, 0.1 mg/24 hr estradiol vaginal cream 0.01 % (0.1 mg/gram) 2 ESTRING VAGINAL RING 2 MG (7.5 MCG 4 QL (1 per 90 days) /24 HOUR) estropipate oral tablet 0.75 mg, 1.5 mg, 3 mg 3 MENEST ORAL TABLET 0.3 MG, 0.625 MG, 4 1.25 MG, 2.5 MG PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, 3 0.625 MG, 0.9 MG, 1.25 MG PREMARIN VAGINAL CREAM 0.625 3 MG/GRAM yuvafem vaginal tablet 10 mcg 2

You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 83 Drug Name Drug Tier Requirements/Limits Hormonal Agents, Stimulant/ Replacement/ Modifying (Sex Hormones/ Modifiers) altavera (28) oral tablet 0.15-0.03 mg 4 alyacen 1/35 (28) oral tablet 1-35 mg-mcg 4 alyacen 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 4 mcg amabelz oral tablet 0.5-0.1 mg, 1-0.5 mg 4 amethia lo oral tablets,dose pack,3 month 0.10 4 QL (91 per 90 days) mg-20 mcg (84)/10 mcg (7) amethia oral tablets,dose pack,3 month 0.15 mg- 4 QL (91 per 90 days) 30 mcg (84)/10 mcg (7) amethyst oral tablet 90-20 mcg 4 apri oral tablet 0.15-0.03 mg 4 aranelle (28) oral tablet 0.5/1/0.5-35 mg-mcg 4 ashlyna oral tablets,dose pack,3 month 0.15 mg- 4 30 mcg (84)/10 mcg (7) aubra oral tablet 0.1-20 mg-mcg 4 aviane oral tablet 0.1-20 mg-mcg 4 azurette (28) oral tablet 0.15-0.02 mgx21 /0.01 4 mg x 5 balziva (28) oral tablet 0.4-35 mg-mcg 4 bekyree (28) oral tablet 0.15-0.02 mgx21 /0.01 4 mg x 5 blisovi 24 fe oral tablet 1 mg-20 mcg (24)/75 mg 4 (4) blisovi fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg 4 (21)/75 mg (7) blisovi fe 1/20 (28) oral tablet 1 mg-20 mcg 4 (21)/75 mg (7) brevicon (28) oral tablet 0.5-35 mg-mcg 4 briellyn oral tablet 0.4-35 mg-mcg 4 camrese lo oral tablets,dose pack,3 month 0.10 4 mg-20 mcg (84)/10 mcg (7) camrese oral tablets,dose pack,3 month 0.15 mg- 4 QL (91 per 90 days) 30 mcg (84)/10 mcg (7) caziant (28) oral tablet 0.1/.125/.15-25 mg-mcg 4 chateal oral tablet 0.15-0.03 mg 4 CLIMARA PRO TRANSDERMAL PATCH 4 WEEKLY 0.045-0.015 MG/24 HR cryselle (28) oral tablet 0.3-30 mg-mcg 4 cyclafem 1/35 (28) oral tablet 1-35 mg-mcg 4

You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 84 Drug Name Drug Tier Requirements/Limits cyclafem 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 4 mcg cyred oral tablet 0.15-0.03 mg 4 dasetta 1/35 (28) oral tablet 1-35 mg-mcg 4 dasetta 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 4 mcg deblitane oral tablet 0.35 mg 4 delyla (28) oral tablet 0.1-20 mg-mcg 4 desog-e.estradiol/e.estradiol oral tablet 0.15-0.02 4 mgx21 /0.01 mg x 5 desogestrel-ethinyl estradiol oral tablet 0.15-0.03 4 mg drospirenone-e.estradiol-lm.fa oral tablet 3-0.02- 4 0.451 mg (24) (4), 3-0.03-0.451 mg (21) (7) drospirenone-ethinyl estradiol oral tablet 3-0.02 4 mg, 3-0.03 mg elinest oral tablet 0.3-30 mg-mcg 4 emoquette oral tablet 0.15-0.03 mg 4 enpresse oral tablet 50-30 (6)/75-40 (5)/125- 4 30(10) enskyce oral tablet 0.15-0.03 mg 4 estarylla oral tablet 0.25-35 mg-mcg 4 estradiol vaginal tablet 10 mcg 2 estradiol-norethindrone acet oral tablet 0.5-0.1 3 mg estradiol-norethindrone acet oral tablet 1-0.5 mg 4 ethynodiol diac-eth estradiol oral tablet 1-35 mg- 4 mcg, 1-50 mg-mcg falmina (28) oral tablet 0.1-20 mg-mcg 4 fayosim oral tablets,dose pack,3 month 0.15 mg- 4 20 mcg/ 0.15 mg-25 mcg femynor oral tablet 0.25-35 mg-mcg 4 fyavolv oral tablet 0.5-2.5 mg-mcg, 1-5 mg-mcg 4 gianvi (28) oral tablet 3-0.02 mg 4 gildagia oral tablet 0.4-35 mg-mcg 4 gildess 1.5/30 (21) oral tablet 1.5-30 mg-mcg 4 gildess 24 fe oral tablet 1 mg-20 mcg (24)/75 mg 4 (4) heather oral tablet 0.35 mg 4 introvale oral tablets,dose pack,3 month 0.15 mg- 4 QL (91 per 30 days) 30 mcg isibloom oral tablet 0.15-0.03 mg 4 You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 85 Drug Name Drug Tier Requirements/Limits jencycla oral tablet 0.35 mg 4 jinteli oral tablet 1-5 mg-mcg 4 jolessa oral tablets,dose pack,3 month 0.15 mg- 4 QL (91 per 90 days) 30 mcg juleber oral tablet 0.15-0.03 mg 4 junel 1.5/30 (21) oral tablet 1.5-30 mg-mcg 4 junel 1/20 (21) oral tablet 1-20 mg-mcg 4 junel fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg 4 (21)/75 mg (7) junel fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75 4 mg (7) junel fe 24 oral tablet 1 mg-20 mcg (24)/75 mg 4 (4) kaitlib fe oral tablet,chewable 0.8mg-25mcg(24) 4 and 75 mg (4) kariva (28) oral tablet 0.15-0.02 mgx21 /0.01 mg 4 x 5 kelnor 1/35 (28) oral tablet 1-35 mg-mcg 4 kelnor 1-50 oral tablet 1-50 mg-mcg 4 kimidess (28) oral tablet 0.15-0.02 mgx21 /0.01 4 mg x 5 kurvelo oral tablet 0.15-0.03 mg 4 l norgest/e.estradiol-e.estrad oral tablets,dose 4 QL (91 per 90 days) pack,3 month 0.10 mg-20 mcg (84)/10 mcg (7) l norgest/e.estradiol-e.estrad oral tablets,dose 4 pack,3 month 0.15 mg-20 mcg/ 0.15 mg-25 mcg, 0.15 mg-30 mcg (84)/10 mcg (7) larin 1.5/30 (21) oral tablet 1.5-30 mg-mcg 4 larin 1/20 (21) oral tablet 1-20 mg-mcg 4 larin 24 fe oral tablet 1 mg-20 mcg (24)/75 mg 4 (4) larin fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg 4 (21)/75 mg (7) larin fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75 4 mg (7) larissia oral tablet 0.1-20 mg-mcg 4 layolis fe oral tablet,chewable 0.8mg-25mcg(24) 4 and 75 mg (4) leena 28 oral tablet 0.5/1/0.5-35 mg-mcg 4 lessina oral tablet 0.1-20 mg-mcg 4 levonest (28) oral tablet 50-30 (6)/75-40 (5)/125- 4 30(10)

You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 86 Drug Name Drug Tier Requirements/Limits levonorgestrel-ethinyl estrad oral tablet 0.1-20 4 mg-mcg, 0.15-0.03 mg, 90-20 mcg levonorgestrel-ethinyl estrad oral tablets,dose 4 pack,3 month 0.15 mg-30 mcg levonorg-eth estrad triphasic oral tablet 50-30 4 (6)/75-40 (5)/125-30(10) levora-28 oral tablet 0.15-0.03 mg 4 lillow oral tablet 0.15-0.03 mg 4 lomedia 24 fe oral tablet 1 mg-20 mcg (24)/75 mg 4 (4) lopreeza oral tablet 0.5-0.1 mg, 1-0.5 mg 4 loryna (28) oral tablet 3-0.02 mg 3 low-ogestrel (28) oral tablet 0.3-30 mg-mcg 4 lutera (28) oral tablet 0.1-20 mg-mcg 4 marlissa oral tablet 0.15-0.03 mg 4 melodetta 24 fe oral tablet,chewable 1 mg-20 4 mcg(24) /75 mg (4) mibelas 24 fe oral tablet,chewable 1 mg-20 4 mcg(24) /75 mg (4) microgestin 1.5/30 (21) oral tablet 1.5-30 mg- 4 mcg microgestin 1/20 (21) oral tablet 1-20 mg-mcg 4 microgestin 24 fe oral tablet 1 mg-20 mcg (24)/75 4 mg (4) microgestin fe 1.5/30 (28) oral tablet 1.5 mg-30 4 mcg (21)/75 mg (7) microgestin fe 1/20 (28) oral tablet 1 mg-20 mcg 4 (21)/75 mg (7) mili oral tablet 0.25-35 mg-mcg 4 mimvey lo oral tablet 0.5-0.1 mg 4 mimvey oral tablet 1-0.5 mg 4 mono-linyah oral tablet 0.25-35 mg-mcg 4 mononessa (28) oral tablet 0.25-35 mg-mcg 4 myzilra oral tablet 50-30 (6)/75-40 (5)/125- 4 30(10) NATAZIA ORAL TABLET 3 MG/2 MG-2 MG/ 4 2 MG-3 MG/1 MG necon 0.5/35 (28) oral tablet 0.5-35 mg-mcg 4 necon 1/50 (28) oral tablet 1-50 mg-mcg 4 necon 10/11 (28) oral tablet 0.5-35/1-35 mg- 4 mcg/mg-mcg

You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 87 Drug Name Drug Tier Requirements/Limits necon 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 4 mcg nikki (28) oral tablet 3-0.02 mg 4 nora-be oral tablet 0.35 mg 4 noreth-ethinyl estradiol-iron oral tablet,chewable 4 0.4mg-35mcg(21) and 75 mg (7), 0.8mg- 25mcg(24) and 75 mg (4) norethindrone ac-eth estradiol oral tablet 0.5-2.5 4 mg-mcg, 1-20 mg-mcg, 1-5 mg-mcg norethindrone-e.estradiol-iron oral tablet 1 mg- 4 20 mcg (21)/75 mg (7), 1 mg-20 mcg (24)/75 mg (4) norethindrone-e.estradiol-iron oral 4 tablet,chewable 1 mg-20 mcg(24) /75 mg (4) norgestimate-ethinyl estradiol oral tablet 4 0.18/0.215/0.25 mg-25 mcg, 0.18/0.215/0.25 mg- 35 mcg (28), 0.25-35 mg-mcg norinyl 1/35 (28) oral tablet 1-35 mg-mcg 4 norlyda oral tablet 0.35 mg 4 norlyroc oral tablet 0.35 mg 4 nortrel 0.5/35 (28) oral tablet 0.5-35 mg-mcg 4 nortrel 1/35 (21) oral tablet 1-35 mg-mcg 4 nortrel 1/35 (28) oral tablet 1-35 mg-mcg 4 nortrel 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 4 mcg ocella oral tablet 3-0.03 mg 4 ogestrel (28) oral tablet 0.5-50 mg-mcg 4 orsythia oral tablet 0.1-20 mg-mcg 4 philith oral tablet 0.4-35 mg-mcg 4 pimtrea (28) oral tablet 0.15-0.02 mgx21 /0.01 4 mg x 5 pirmella oral tablet 0.5/0.75/1 mg- 35 mcg, 1-35 4 mg-mcg portia oral tablet 0.15-0.03 mg 4 PREMPHASE ORAL TABLET 0.625 MG (14)/ 3 0.625MG-5MG(14) PREMPRO ORAL TABLET 0.3-1.5 MG, 0.45- 3 1.5 MG, 0.625-2.5 MG, 0.625-5 MG previfem oral tablet 0.25-35 mg-mcg 4 quasense oral tablets,dose pack,3 month 0.15 mg- 4 30 mcg rajani oral tablet 3-0.02-0.451 mg (24) (4) 4

You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 88 Drug Name Drug Tier Requirements/Limits reclipsen (28) oral tablet 0.15-0.03 mg 4 rivelsa oral tablets,dose pack,3 month 0.15 mg-20 4 mcg/ 0.15 mg-25 mcg setlakin oral tablets,dose pack,3 month 0.15 mg- 4 QL (91 per 90 days) 30 mcg sharobel oral tablet 0.35 mg 4 sprintec (28) oral tablet 0.25-35 mg-mcg 4 sronyx oral tablet 0.1-20 mg-mcg 4 syeda oral tablet 3-0.03 mg 4 tarina fe 1/20 (28) oral tablet 1 mg-20 mcg 4 (21)/75 mg (7) tilia fe oral tablet 1-20(5)/1-30(7) /1mg-35mcg 4 (9) tri femynor oral tablet 0.18/0.215/0.25 mg-35 4 mcg (28) tri-estarylla oral tablet 0.18/0.215/0.25 mg-35 4 mcg (28) tri-legest fe oral tablet 1-20(5)/1-30(7) /1mg- 4 35mcg (9) tri-linyah oral tablet 0.18/0.215/0.25 mg-35 mcg 4 (28) tri-lo-estarylla oral tablet 0.18/0.215/0.25 mg-25 4 mcg tri-lo-sprintec oral tablet 0.18/0.215/0.25 mg-25 4 mcg tri-mili oral tablet 0.18/0.215/0.25 mg-35 mcg 4 (28) trinessa (28) oral tablet 0.18/0.215/0.25 mg-35 4 mcg (28) trinessa lo oral tablet 0.18/0.215/0.25 mg-25 mcg 4 tri-previfem (28) oral tablet 0.18/0.215/0.25 mg- 4 35 mcg (28) tri-sprintec (28) oral tablet 0.18/0.215/0.25 mg- 4 35 mcg (28) trivora (28) oral tablet 50-30 (6)/75-40 (5)/125- 4 30(10) tri-vylibra oral tablet 0.18/0.215/0.25 mg-35 mcg 4 (28) tydemy oral tablet 3-0.03-0.451 mg (21) (7) 4 velivet triphasic regimen (28) oral tablet 4 0.1/.125/.15-25 mg-mcg vestura (28) oral tablet 3-0.02 mg 4

You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 89 Drug Name Drug Tier Requirements/Limits vienva oral tablet 0.1-20 mg-mcg 4 vyfemla (28) oral tablet 0.4-35 mg-mcg 4 vylibra oral tablet 0.25-35 mg-mcg 4 wera (28) oral tablet 0.5-35 mg-mcg 4 wymzya fe oral tablet,chewable 0.4mg-35mcg(21) 4 and 75 mg (7) xulane transdermal patch weekly 150-35 mcg/24 4 QL (3 per 28 days) hr zarah oral tablet 3-0.03 mg 4 zenchent (28) oral tablet 0.4-35 mg-mcg 4 zenchent fe oral tablet,chewable 0.4mg- 4 35mcg(21) and 75 mg (7) zovia 1/35e (28) oral tablet 1-35 mg-mcg 4 zovia 1/50e (28) oral tablet 1-50 mg-mcg 4 Progestins camila oral tablet 0.35 mg 4 DEPO-PROVERA INTRAMUSCULAR 4 SUSPENSION 150 MG/ML, 400 MG/ML DEPO-SUBQ PROVERA 104 4 QL (0.65 per 90 days) SUBCUTANEOUS SYRINGE 104 MG/0.65 ML errin oral tablet 0.35 mg 4 incassia oral tablet 0.35 mg 4 jolivette oral tablet 0.35 mg 4 lyza oral tablet 0.35 mg 4 medroxyprogesterone intramuscular suspension 4 150 mg/ml medroxyprogesterone oral tablet 10 mg, 2.5 mg, 2 5 mg megestrol oral suspension 400 mg/10 ml (40 3 mg/ml), 625 mg/5 ml megestrol oral tablet 20 mg, 40 mg 3 norethindrone (contraceptive) oral tablet 0.35 mg 4 norethindrone acetate oral tablet 5 mg 3 progesterone micronized oral capsule 100 mg, 3 200 mg tulana oral tablet 0.35 mg 4 Selective Estrogen Receptor Modifying Agents raloxifene oral tablet 60 mg 3 QL (30 per 30 days) Hormonal Agents, Stimulant/ Replacement/ Modifying (Thyroid) Hormonal Agents, Stimulant/ Replacement/ Modifying (Thyroid) You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 90 Drug Name Drug Tier Requirements/Limits levothyroxine intravenous recon soln 100 mcg 4 levothyroxine oral tablet 100 mcg, 112 mcg, 125 1 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg LEVOXYL ORAL TABLET 100 MCG, 112 3 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG liothyronine intravenous solution 10 mcg/ml 2 liothyronine oral tablet 25 mcg, 5 mcg, 50 mcg 3 SYNTHROID ORAL TABLET 100 MCG, 112 3 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG THYROLAR-1 ORAL TABLET 12.5-50 MCG 3 THYROLAR-1/2 ORAL TABLET 6.25-25 MCG 3 THYROLAR-1/4 ORAL TABLET 3.1-12.5 3 MCG THYROLAR-2 ORAL TABLET 25-100 MCG 3 THYROLAR-3 ORAL TABLET 37.5-150 MCG 3 Hormonal Agents, Suppressant (Adrenal) Hormonal Agents, Suppressant (Adrenal) LYSODREN ORAL TABLET 500 MG 5 NDS Hormonal Agents, Suppressant (Pituitary) Hormonal Agents, Suppressant (Pituitary) cabergoline oral tablet 0.5 mg 4 QL (16 per 28 days) FIRMAGON KIT W DILUENT SYRINGE 5 NDS SUBCUTANEOUS RECON SOLN 120 MG FIRMAGON KIT W DILUENT SYRINGE 4 SUBCUTANEOUS RECON SOLN 80 MG leuprolide subcutaneous kit 1 mg/0.2 ml 4 LUPRON DEPOT (3 MONTH) 4 QL (1 per 90 days) INTRAMUSCULAR SYRINGE KIT 11.25 MG, 22.5 MG LUPRON DEPOT (4 MONTH) 4 QL (1 per 112 days) INTRAMUSCULAR SYRINGE KIT 30 MG LUPRON DEPOT (6 MONTH) 5 NDS; QL (1 per 168 days) INTRAMUSCULAR SYRINGE KIT 45 MG LUPRON DEPOT INTRAMUSCULAR 4 QL (1 per 30 days) SYRINGE KIT 3.75 MG You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 91 Drug Name Drug Tier Requirements/Limits LUPRON DEPOT INTRAMUSCULAR 5 NDS; QL (1 per 30 days) SYRINGE KIT 7.5 MG octreotide acetate injection solution 1,000 4 PA mcg/ml, 100 mcg/ml, 200 mcg/ml, 50 mcg/ml, 500 mcg/ml octreotide acetate injection syringe 100 mcg/ml 4 PA (1 ml), 50 mcg/ml (1 ml), 500 mcg/ml (1 ml) SANDOSTATIN LAR DEPOT 5 PA; NDS INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 10 MG, 20 MG, 30 MG SIGNIFOR SUBCUTANEOUS SOLUTION 0.3 5 NDS; QL (60 per 30 days) MG/ML (1 ML), 0.6 MG/ML (1 ML), 0.9 MG/ML (1 ML) SOMATULINE DEPOT SUBCUTANEOUS 5 PA NSO; NDS SYRINGE 120 MG/0.5 ML, 60 MG/0.2 ML, 90 MG/0.3 ML SOMAVERT SUBCUTANEOUS RECON 5 NDS; QL (60 per 30 days) SOLN 10 MG, 15 MG, 20 MG SOMAVERT SUBCUTANEOUS RECON 5 NDS; QL (30 per 30 days) SOLN 25 MG, 30 MG SYNAREL NASAL SPRAY,NON-AEROSOL 2 5 NDS MG/ML Hormonal Agents, Suppressant (Thyroid) Antithyroid Agents methimazole oral tablet 10 mg, 5 mg 2 propylthiouracil oral tablet 50 mg 3 Immunological Agents Angioedema Agents CINRYZE INTRAVENOUS RECON SOLN 500 5 PA; NDS; QL (20 per 30 days) UNIT (5 ML) FIRAZYR SUBCUTANEOUS SYRINGE 30 5 PA; NDS; QL (18 per 30 days) MG/3 ML Immune Suppressants ACTEMRA SUBCUTANEOUS SYRINGE 162 5 PA; NDS MG/0.9 ML AFINITOR DISPERZ ORAL TABLET FOR 5 PA NSO; NDS SUSPENSION 2 MG, 3 MG, 5 MG ATGAM INTRAVENOUS SOLUTION 50 4 HI MG/ML azathioprine oral tablet 50 mg 1 PA BvD

You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 92 Drug Name Drug Tier Requirements/Limits azathioprine sodium injection recon soln 100 mg 4 PA BvD BENLYSTA INTRAVENOUS RECON SOLN 5 HI; NDS; QL (20 per 28 days) 120 MG BENLYSTA INTRAVENOUS RECON SOLN 5 HI; NDS; QL (6 per 28 days) 400 MG BENLYSTA SUBCUTANEOUS AUTO- 5 NDS INJECTOR 200 MG/ML BENLYSTA SUBCUTANEOUS SYRINGE 200 5 NDS MG/ML CELLCEPT ORAL CAPSULE 250 MG 4 PA BvD CELLCEPT ORAL SUSPENSION FOR 5 PA BvD; NDS RECONSTITUTION 200 MG/ML CELLCEPT ORAL TABLET 500 MG 5 PA BvD; NDS CIMZIA POWDER FOR RECONST 5 PA; NDS SUBCUTANEOUS KIT 400 MG (200 MG X 2 VIALS) CIMZIA SUBCUTANEOUS SYRINGE KIT 400 5 PA; NDS MG/2 ML (200 MG/ML X 2) cyclosporine modified oral capsule 100 mg, 25 3 PA BvD mg, 50 mg cyclosporine modified oral solution 100 mg/ml 3 PA BvD cyclosporine oral capsule 100 mg, 25 mg 3 PA BvD ENBREL SUBCUTANEOUS RECON SOLN 25 5 PA; NDS; QL (8 per 28 days) MG (1 ML) ENBREL SUBCUTANEOUS SYRINGE 25 5 PA; NDS; QL (4.08 per 28 days) MG/0.5ML (0.51) ENBREL SUBCUTANEOUS SYRINGE 50 5 PA; NDS; QL (7.84 per 28 days) MG/ML (0.98 ML) ENBREL SURECLICK SUBCUTANEOUS 5 PA; NDS; QL (7.84 per 28 days) PEN INJECTOR 50 MG/ML (0.98 ML) ENVARSUS XR ORAL TABLET EXTENDED 4 PA BvD RELEASE 24 HR 0.75 MG, 1 MG, 4 MG gengraf oral capsule 100 mg, 25 mg, 50 mg 3 PA BvD gengraf oral solution 100 mg/ml 3 PA BvD HUMIRA PEDIATRIC CROHN'S START 5 PA; NDS; QL (6 per 28 days) SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML HUMIRA PEDIATRIC CROHN'S START 5 PA; NDS; QL (3 per 28 days) SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML HUMIRA PEDIATRIC CROHN'S START 5 PA; NDS; QL (2 per 28 days) SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML-40 MG/0.4 ML You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 93 Drug Name Drug Tier Requirements/Limits HUMIRA PEN CROHN'S-UC-HS START 5 PA; NDS; QL (6 per 28 days) SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML HUMIRA PEN CROHN'S-UC-HS START 5 PA; NDS; QL (3 per 28 days) SUBCUTANEOUS PEN INJECTOR KIT 80 MG/0.8 ML HUMIRA PEN PSORIASIS-UVEITIS 5 PA; NDS; QL (6 per 28 days) SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML HUMIRA PEN PSORIASIS-UVEITIS 5 PA; NDS; QL (3 per 28 days) SUBCUTANEOUS PEN INJECTOR KIT 80 MG/0.8 ML-40 MG/0.4 ML HUMIRA PEN SUBCUTANEOUS PEN 5 PA; NDS; QL (6 per 28 days) INJECTOR KIT 40 MG/0.4 ML, 40 MG/0.8 ML HUMIRA SUBCUTANEOUS SYRINGE KIT 10 5 PA; NDS; QL (2 per 28 days) MG/0.1 ML, 10 MG/0.2 ML, 20 MG/0.2 ML HUMIRA SUBCUTANEOUS SYRINGE KIT 20 5 PA; NDS; QL (6 per 28 days) MG/0.4 ML, 40 MG/0.4 ML, 40 MG/0.8 ML KEVZARA SUBCUTANEOUS SYRINGE 150 5 PA; NDS MG/1.14 ML, 200 MG/1.14 ML KINERET SUBCUTANEOUS SYRINGE 100 5 PA; NDS MG/0.67 ML mercaptopurine oral tablet 50 mg 3 methotrexate sodium (pf) injection recon soln 1 2 gram methotrexate sodium (pf) injection solution 25 2 mg/ml, 25 mg/ml (10 ml) methotrexate sodium injection solution 25 mg/ml 2 methotrexate sodium oral tablet 2.5 mg 1 mycophenolate mofetil hcl intravenous recon soln 4 PA BvD 500 mg mycophenolate mofetil oral capsule 250 mg 3 PA BvD mycophenolate mofetil oral suspension for 4 PA BvD reconstitution 200 mg/ml mycophenolate mofetil oral tablet 500 mg 3 PA BvD mycophenolate sodium oral tablet,delayed 4 PA BvD release (dr/ec) 180 mg, 360 mg NULOJIX INTRAVENOUS RECON SOLN 250 5 PA BvD; NDS; QL (20 per 30 days) MG ORENCIA CLICKJECT SUBCUTANEOUS 5 PA; NDS AUTO-INJECTOR 125 MG/ML ORENCIA SUBCUTANEOUS SYRINGE 125 5 PA; NDS MG/ML, 50 MG/0.4 ML, 87.5 MG/0.7 ML You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 94 Drug Name Drug Tier Requirements/Limits OTEZLA ORAL TABLET 30 MG 5 PA; NDS OTEZLA STARTER ORAL TABLETS,DOSE 5 PA; NDS PACK 10 MG (4)-20 MG (4)-30 MG (47), 10 MG (4)-20 MG (4)-30 MG(19) PROGRAF INTRAVENOUS SOLUTION 5 4 PA BvD MG/ML RAPAMUNE ORAL SOLUTION 1 MG/ML 4 PA BvD RAPAMUNE ORAL TABLET 0.5 MG, 1 MG, 2 4 PA BvD MG REMICADE INTRAVENOUS RECON SOLN 5 NDS 100 MG RENFLEXIS INTRAVENOUS RECON SOLN 5 NDS 100 MG SANDIMMUNE INTRAVENOUS SOLUTION 4 PA BvD 250 MG/5 ML SANDIMMUNE ORAL SOLUTION 100 4 PA BvD MG/ML SIMPONI ARIA INTRAVENOUS SOLUTION 5 PA; NDS 12.5 MG/ML SIMPONI SUBCUTANEOUS PEN INJECTOR 5 PA; NDS; QL (1 per 30 days) 100 MG/ML, 50 MG/0.5 ML SIMPONI SUBCUTANEOUS SYRINGE 50 5 PA; NDS; QL (1 per 30 days) MG/0.5 ML sirolimus oral tablet 0.5 mg, 1 mg, 2 mg 4 PA BvD tacrolimus oral capsule 0.5 mg, 1 mg, 5 mg 3 PA BvD TREXALL ORAL TABLET 10 MG, 15 MG, 5 4 MG, 7.5 MG XATMEP ORAL SOLUTION 2.5 MG/ML 4 PA BvD XELJANZ ORAL TABLET 10 MG, 5 MG 5 PA; NDS; QL (60 per 30 days) XELJANZ XR ORAL TABLET EXTENDED 5 PA; NDS; QL (30 per 30 days) RELEASE 24 HR 11 MG ZORTRESS ORAL TABLET 0.25 MG, 0.75 4 PA BvD; QL (60 per 30 days) MG, 1 MG ZORTRESS ORAL TABLET 0.5 MG 4 PA BvD; QL (120 per 30 days) Immunizing Agents, Passive CARIMUNE NF NANOFILTERED 5 PA BvD; NDS INTRAVENOUS RECON SOLN 12 GRAM, 6 GRAM GAMASTAN S/D INTRAMUSCULAR 3 PA BvD SOLUTION 15-18 % RANGE GAMASTAN S/D INTRAMUSCULAR 3 PA BvD SOLUTION 15-18 % RANGE (2 ML)

You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 95 Drug Name Drug Tier Requirements/Limits GAMMAGARD LIQUID INJECTION 5 PA BvD; NDS SOLUTION 10 % GAMMAPLEX (WITH SORBITOL) 5 PA BvD; NDS INTRAVENOUS SOLUTION 5 % GAMMAPLEX INTRAVENOUS SOLUTION 5 PA BvD; NDS 10 %, 10 % (100 ML), 10 % (200 ML) GAMUNEX-C INJECTION SOLUTION 1 5 PA BvD; NDS GRAM/10 ML (10 %) PRIVIGEN INTRAVENOUS SOLUTION 10 % 5 PA BvD; NDS THYMOGLOBULIN INTRAVENOUS RECON 5 NDS SOLN 25 MG Immunological Agents KEDRAB (PF) INTRAMUSCULAR 3 SOLUTION 150 UNIT/ML leflunomide oral tablet 10 mg, 20 mg 2 QL (30 per 30 days) SYNAGIS INTRAMUSCULAR SOLUTION 5 NDS; QL (4 per 28 days) 100 MG/ML SYNAGIS INTRAMUSCULAR SOLUTION 50 5 NDS MG/0.5 ML Immunomodulators ACTIMMUNE SUBCUTANEOUS SOLUTION 5 NDS 100 MCG/0.5 ML ARCALYST SUBCUTANEOUS RECON SOLN 5 NDS 220 MG RIDAURA ORAL CAPSULE 3 MG 5 NDS SIMPONI SUBCUTANEOUS SYRINGE 100 5 PA; NDS MG/ML Vaccines ACTHIB (PF) INTRAMUSCULAR RECON 6 NDS SOLN 10 MCG/0.5 ML ADACEL(TDAP ADOLESN/ADULT)(PF) 6 NDS INTRAMUSCULAR SUSPENSION 2 LF-(2.5- 5-3-5 MCG)-5LF/0.5 ML ADACEL(TDAP ADOLESN/ADULT)(PF) 6 NDS INTRAMUSCULAR SYRINGE 2 LF-(2.5-5-3-5 MCG)-5LF/0.5 ML BCG VACCINE, LIVE (PF) PERCUTANEOUS 3 SUSPENSION FOR RECONSTITUTION 50 MG BEXSERO INTRAMUSCULAR SYRINGE 50- 3 50-50-25 MCG/0.5 ML BOOSTRIX TDAP INTRAMUSCULAR 6 NDS SUSPENSION 2.5-8-5 LF-MCG-LF/0.5ML You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 96 Drug Name Drug Tier Requirements/Limits BOOSTRIX TDAP INTRAMUSCULAR 6 NDS SYRINGE 2.5-8-5 LF-MCG-LF/0.5ML CERVARIX VACCINE (PF) 3 INTRAMUSCULAR SYRINGE 20-20 MCG/0.5 ML DAPTACEL (DTAP PEDIATRIC) (PF) 6 NDS INTRAMUSCULAR SUSPENSION 15-10-5 LF-MCG-LF/0.5ML ENGERIX-B (PF) INTRAMUSCULAR 3 PA BvD SUSPENSION 20 MCG/ML ENGERIX-B (PF) INTRAMUSCULAR 3 PA BvD SYRINGE 20 MCG/ML ENGERIX-B PEDIATRIC (PF) 3 PA BvD INTRAMUSCULAR SUSPENSION 10 MCG/0.5 ML ENGERIX-B PEDIATRIC (PF) 3 PA BvD INTRAMUSCULAR SYRINGE 10 MCG/0.5 ML GARDASIL (PF) INTRAMUSCULAR 3 QL (1.5 per 365 days) SUSPENSION 20-40-40-20 MCG/0.5 ML GARDASIL (PF) INTRAMUSCULAR 3 SYRINGE 20-40-40-20 MCG/0.5 ML GARDASIL 9 (PF) INTRAMUSCULAR 3 QL (1.5 per 365 days) SUSPENSION 0.5 ML GARDASIL 9 (PF) INTRAMUSCULAR 3 QL (1.5 per 365 days) SYRINGE 0.5 ML HAVRIX (PF) INTRAMUSCULAR 3 SUSPENSION 1,440 ELISA UNIT/ML, 720 ELISA UNIT/0.5 ML HAVRIX (PF) INTRAMUSCULAR SYRINGE 3 1,440 ELISA UNIT/ML, 720 ELISA UNIT/0.5 ML HIBERIX (PF) INTRAMUSCULAR RECON 6 NDS SOLN 10 MCG/0.5 ML IMOVAX RABIES VACCINE (PF) 3 INTRAMUSCULAR RECON SOLN 2.5 UNIT INFANRIX (DTAP) (PF) INTRAMUSCULAR 6 NDS SUSPENSION 25-58-10 LF-MCG-LF/0.5ML INFANRIX (DTAP) (PF) INTRAMUSCULAR 6 NDS SYRINGE 25-58-10 LF-MCG-LF/0.5ML IPOL INJECTION SUSPENSION 40-8-32 4 UNIT/0.5 ML

You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 97 Drug Name Drug Tier Requirements/Limits IPOL INJECTION SYRINGE 40-8-32 UNIT/0.5 4 ML IXIARO (PF) INTRAMUSCULAR SYRINGE 6 4 MCG/0.5 ML KINRIX (PF) INTRAMUSCULAR 6 NDS SUSPENSION 25 LF-58 MCG-10 LF/0.5 ML KINRIX (PF) INTRAMUSCULAR SYRINGE 6 NDS 25 LF-58 MCG-10 LF/0.5 ML MENACTRA (PF) INTRAMUSCULAR 3 SOLUTION 4 MCG/0.5 ML MENHIBRIX (PF) INTRAMUSCULAR 3 RECON SOLN 5-2.5 MCG/0.5 ML MENOMUNE - A/C/Y/W-135 (PF) 3 SUBCUTANEOUS RECON SOLN 50 MCG MENOMUNE - A/C/Y/W-135 3 SUBCUTANEOUS RECON SOLN 50 MCG MENVEO A-C-Y-W-135-DIP (PF) 3 INTRAMUSCULAR KIT 10-5 MCG/0.5 ML M-M-R II (PF) SUBCUTANEOUS RECON 3 SOLN 1,000-12,500 TCID50/0.5 ML PEDIARIX (PF) INTRAMUSCULAR 6 NDS SYRINGE 10 MCG-25LF-25 MCG-10LF/0.5 ML PEDVAX HIB (PF) INTRAMUSCULAR 3 SOLUTION 7.5 MCG/0.5 ML PENTACEL (PF) INTRAMUSCULAR KIT 15 6 NDS LF UNIT-20 MCG-5 LF/0.5 ML PENTACEL DTAP-IPV COMPNT (PF) 6 NDS INTRAMUSCULAR SUSPENSION 15 LF-48 MCG- 5 LF UNIT/0.5ML PROQUAD (PF) SUBCUTANEOUS 3 SUSPENSION FOR RECONSTITUTION 10EXP3-4.3-3- 3.99 TCID50/0.5 QUADRACEL (PF) INTRAMUSCULAR 6 NDS SUSPENSION 15 LF-48 MCG- 5 LF UNIT/0.5ML RABAVERT (PF) INTRAMUSCULAR 3 SUSPENSION FOR RECONSTITUTION 2.5 UNIT RECOMBIVAX HB (PF) INTRAMUSCULAR 3 PA BvD SUSPENSION 10 MCG/ML, 40 MCG/ML, 5 MCG/0.5 ML

You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 98 Drug Name Drug Tier Requirements/Limits RECOMBIVAX HB (PF) INTRAMUSCULAR 3 PA BvD SYRINGE 10 MCG/ML, 5 MCG/0.5 ML ROTARIX ORAL SUSPENSION FOR 4 RECONSTITUTION 10EXP6 CCID50/ML ROTATEQ VACCINE ORAL SOLUTION 2 ML 4 SHINGRIX (PF) INTRAMUSCULAR 6 NDS; QL (2 per 365 days); AGE (Min 50 SUSPENSION FOR RECONSTITUTION 50 Years) MCG/0.5 ML TENIVAC (PF) INTRAMUSCULAR 6 NDS SUSPENSION 5 LF UNIT- 2 LF UNIT/0.5ML TENIVAC (PF) INTRAMUSCULAR SYRINGE 6 NDS 5-2 LF UNIT/0.5 ML TETANUS,DIPHTHERIA TOX PED(PF) 6 NDS INTRAMUSCULAR SUSPENSION 5-25 LF UNIT/0.5 ML TETANUS-DIPHTHERIA TOXOIDS-TD 6 NDS INTRAMUSCULAR SUSPENSION 2-2 LF UNIT/0.5 ML TICE BCG INTRAVESICAL SUSPENSION 3 FOR RECONSTITUTION 50 MG TRUMENBA INTRAMUSCULAR SYRINGE 3 120 MCG/0.5 ML TWINRIX (PF) INTRAMUSCULAR 3 SUSPENSION 720 ELISA UNIT- 20 MCG/ML TWINRIX (PF) INTRAMUSCULAR SYRINGE 3 720 ELISA UNIT- 20 MCG/ML TYPHIM VI INTRAMUSCULAR SOLUTION 3 25 MCG/0.5 ML TYPHIM VI INTRAMUSCULAR SYRINGE 25 3 MCG/0.5 ML VAQTA (PF) INTRAMUSCULAR 3 SUSPENSION 25 UNIT/0.5 ML, 50 UNIT/ML VAQTA (PF) INTRAMUSCULAR SYRINGE 3 25 UNIT/0.5 ML, 50 UNIT/ML VARIVAX (PF) SUBCUTANEOUS 3 SUSPENSION FOR RECONSTITUTION 1,350 UNIT/0.5 ML YF-VAX (PF) SUBCUTANEOUS 3 SUSPENSION FOR RECONSTITUTION 10 EXP4.74 UNIT/0.5 ML ZOSTAVAX (PF) SUBCUTANEOUS 6 NDS; QL (1 per 365 days); AGE (Min 49 SUSPENSION FOR RECONSTITUTION Years) 19,400 UNIT/0.65 ML You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 99 Drug Name Drug Tier Requirements/Limits Inflammatory Bowel Disease Agents Aminosalicylates balsalazide oral capsule 750 mg 2 CANASA RECTAL SUPPOSITORY 1,000 MG 3 QL (30 per 30 days) LIALDA ORAL TABLET,DELAYED 4 QL (120 per 30 days) RELEASE (DR/EC) 1.2 GRAM mesalamine oral tablet,delayed release (dr/ec) 3 1.2 gram, 800 mg mesalamine rectal enema 4 gram/60 ml 4 PENTASA ORAL CAPSULE, EXTENDED 4 QL (150 per 30 days) RELEASE 250 MG PENTASA ORAL CAPSULE, EXTENDED 4 QL (300 per 30 days) RELEASE 500 MG Glucocorticoids budesonide oral capsule,delayed,extend.release 3 4 mg colocort rectal enema 100 mg/60 ml 3 hydrocortisone rectal enema 100 mg/60 ml 3 procto-med hc topical cream with perineal 3 applicator 2.5 % proctosol hc topical cream with perineal 3 applicator 2.5 % Sulfonamides sulfasalazine oral tablet 500 mg 1 sulfasalazine oral tablet,delayed release (dr/ec) 1 500 mg Metabolic Bone Disease Agents Metabolic Bone Disease Agents alendronate oral solution 70 mg/75 ml 4 alendronate oral tablet 10 mg, 40 mg, 5 mg 1 QL (30 per 30 days) alendronate oral tablet 35 mg, 70 mg 1 QL (12 per 84 days) calcitonin (salmon) nasal spray,non-aerosol 200 3 QL (3.7 per 28 days) unit/actuation calcitriol intravenous solution 1 mcg/ml 4 calcitriol oral capsule 0.25 mcg, 0.5 mcg 2 calcitriol oral solution 1 mcg/ml 2 doxercalciferol oral capsule 0.5 mcg, 1 mcg, 2.5 3 mcg etidronate disodium oral tablet 200 mg, 400 mg 4 FORTEO SUBCUTANEOUS PEN INJECTOR 4 PA; QL (2.4 per 28 days) 20 MCG/DOSE - 600 MCG/2.4 ML ibandronate oral tablet 150 mg 2 QL (1 per 28 days) You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 100 Drug Name Drug Tier Requirements/Limits MIACALCIN INJECTION SOLUTION 200 4 UNIT/ML NATPARA SUBCUTANEOUS CARTRIDGE 5 NDS; QL (2 per 28 days) 100 MCG/DOSE, 25 MCG/DOSE, 50 MCG/DOSE, 75 MCG/DOSE pamidronate intravenous recon soln 30 mg, 90 3 mg pamidronate intravenous solution 30 mg/10 ml (3 3 mg/ml), 60 mg/10 ml (6 mg/ml), 90 mg/10 ml (9 mg/ml) paricalcitol 2 mcg/ml vial sdv,inner,latex-free 2 3 mcg/ml PARICALCITOL HEMODIALYSIS PORT 3 INJECTION SOLUTION 5 MCG/ML paricalcitol intravenous solution 2 mcg/ml 3 PARICALCITOL INTRAVENOUS SOLUTION 3 5 MCG/ML paricalcitol oral capsule 1 mcg, 2 mcg, 4 mcg 3 PROLIA SUBCUTANEOUS SYRINGE 60 4 PA; QL (1 per 180 days) MG/ML RAYALDEE ORAL CAPSULE,EXTENDED 5 NDS RELEASE 24 HR 30 MCG risedronate oral tablet 150 mg 3 QL (1 per 30 days) risedronate oral tablet 30 mg, 5 mg 3 QL (30 per 30 days) risedronate oral tablet 35 mg (12 pack) 3 QL (12 per 84 days) risedronate oral tablet 35 mg, 35 mg (4 pack) 3 QL (4 per 28 days) risedronate oral tablet,delayed release (dr/ec) 35 3 QL (4 per 28 days) mg SENSIPAR ORAL TABLET 30 MG, 60 MG 3 PA BvD; QL (120 per 30 days) SENSIPAR ORAL TABLET 90 MG 3 PA BvD TYMLOS SUBCUTANEOUS PEN INJECTOR 5 PA; NDS 80 MCG (3,120 MCG/1.56 ML) XGEVA SUBCUTANEOUS SOLUTION 120 5 PA; NDS; QL (1.7 per 28 days) MG/1.7 ML (70 MG/ML) zoledronic acid intravenous recon soln 4 mg 4 QL (15 per 21 days) zoledronic acid intravenous solution 4 mg/5 ml 4 QL (15 per 21 days) zoledronic acid-mannitol-water intravenous 4 QL (100 per 365 days) piggyback 5 mg/100 ml zoledronic ac-mannitol-0.9nacl intravenous 4 PA BvD piggyback 4 mg/100 ml Ophthalmic Agents Ophthalmic Agents You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 101 Drug Name Drug Tier Requirements/Limits bacitracin-polymyxin b ophthalmic (eye) ointment 2 500-10,000 unit/gram naphazoline ophthalmic (eye) drops 0.1 % 2 neomycin-bacitracin-poly-hc ophthalmic (eye) 3 ointment 3.5-400-10,000 mg-unit/g-1% neomycin-bacitracin-polymyxin ophthalmic (eye) 3 ointment 3.5-400-10,000 mg-unit-unit/g neomycin-polymyxin b-dexameth ophthalmic 2 (eye) drops,suspension 3.5mg/ml-10,000 unit/ml- 0.1 % neomycin-polymyxin b-dexameth ophthalmic 2 (eye) ointment 3.5 mg/g-10,000 unit/g-0.1 % neomycin-polymyxin-gramicidin ophthalmic (eye) 3 drops 1.75 mg-10,000 unit-0.025mg/ml neomycin-polymyxin-hc ophthalmic (eye) 4 drops,suspension 3.5-10,000-10 mg-unit-mg/ml neo-polycin hc ophthalmic (eye) ointment 3.5- 3 400-10,000 mg-unit/g-1% neo-polycin ophthalmic (eye) ointment 3.5-400- 3 10,000 mg-unit-unit/g NEOSPORIN (NEO-POLYM-GRAMICID) 2 OPHTHALMIC (EYE) DROPS 1.75 MG-10,000 UNIT-0.025MG/ML polycin ophthalmic (eye) ointment 500-10,000 2 unit/gram polymyxin b sulf-trimethoprim ophthalmic (eye) 1 drops 10,000 unit- 1 mg/ml RHOPRESSA OPHTHALMIC (EYE) DROPS 4 0.02 % TOBRADEX ST OPHTHALMIC (EYE) 4 DROPS,SUSPENSION 0.3-0.05 % tobramycin-dexamethasone ophthalmic (eye) 2 drops,suspension 0.3-0.1 % ZYLET OPHTHALMIC (EYE) 4 DROPS,SUSPENSION 0.3-0.5 % Ophthalmic Agents, Other atropine ophthalmic (eye) drops 1 % 2 CYSTARAN OPHTHALMIC (EYE) DROPS 5 NDS; QL (60 per 28 days) 0.44 % proparacaine ophthalmic (eye) drops 0.5 % 1 RESTASIS OPHTHALMIC (EYE) 3 QL (60 per 30 days) DROPPERETTE 0.05 %

You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 102 Drug Name Drug Tier Requirements/Limits sulfacetamide sodium ophthalmic (eye) ointment 3 10 % Ophthalmic Anti-Allergy Agents ALOCRIL OPHTHALMIC (EYE) DROPS 2 % 4 ALOMIDE OPHTHALMIC (EYE) DROPS 0.1 3 % azelastine ophthalmic (eye) drops 0.05 % 3 BEPREVE OPHTHALMIC (EYE) DROPS 1.5 4 % cromolyn ophthalmic (eye) drops 4 % 2 epinastine ophthalmic (eye) drops 0.05 % 3 LASTACAFT OPHTHALMIC (EYE) DROPS 4 0.25 % olopatadine ophthalmic (eye) drops 0.1 % 4 olopatadine ophthalmic (eye) drops 0.2 % 3 PATADAY OPHTHALMIC (EYE) DROPS 0.2 4 % Ophthalmic Antiglaucoma Agents ALPHAGAN P OPHTHALMIC (EYE) DROPS 3 0.1 % apraclonidine ophthalmic (eye) drops 0.5 % 4 AZOPT OPHTHALMIC (EYE) 4 DROPS,SUSPENSION 1 % betaxolol ophthalmic (eye) drops 0.5 % 3 BETOPTIC S OPHTHALMIC (EYE) 4 DROPS,SUSPENSION 0.25 % bimatoprost ophthalmic (eye) drops 0.03 % 4 brimonidine ophthalmic (eye) drops 0.15 % 3 brimonidine ophthalmic (eye) drops 0.2 % 2 carteolol ophthalmic (eye) drops 1 % 2 COMBIGAN OPHTHALMIC (EYE) DROPS 3 0.2-0.5 % COSOPT (PF) OPHTHALMIC (EYE) 3 QL (60 per 30 days) DROPPERETTE 2-0.5 % COSOPT OPHTHALMIC (EYE) DROPS 22.3- 3 QL (10 per 30 days) 6.8 MG/ML cyclopentolate ophthalmic (eye) drops 0.5 %, 1 2 %, 2 % dorzolamide ophthalmic (eye) drops 2 % 2 QL (10 per 30 days) dorzolamide-timolol (pf) ophthalmic (eye) 3 QL (60 per 30 days) dropperette 2-0.5 %

You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 103 Drug Name Drug Tier Requirements/Limits dorzolamide-timolol ophthalmic (eye) drops 22.3- 2 QL (10 per 30 days) 6.8 mg/ml levobunolol ophthalmic (eye) drops 0.5 % 2 metipranolol ophthalmic (eye) drops 0.3 % 2 PHOSPHOLINE IODIDE OPHTHALMIC 4 (EYE) DROPS 0.125 % pilocarpine hcl ophthalmic (eye) drops 1 %, 2 %, 2 4 % SIMBRINZA OPHTHALMIC (EYE) 3 DROPS,SUSPENSION 1-0.2 % timolol maleate ophthalmic (eye) drops 0.25 %, 1 0.5 % timolol maleate ophthalmic (eye) drops, once 1 daily 0.5 % timolol maleate ophthalmic (eye) gel forming 2 solution 0.25 %, 0.5 % TRAVATAN Z OPHTHALMIC (EYE) DROPS 3 0.004 % TRUSOPT OPHTHALMIC (EYE) DROPS 2 % 3 Ophthalmic Anti-Inflammatories ACUVAIL (PF) OPHTHALMIC (EYE) 3 DROPPERETTE 0.45 % ALREX OPHTHALMIC (EYE) 4 DROPS,SUSPENSION 0.2 % bromfenac ophthalmic (eye) drops 0.09 % 3 dexamethasone sodium phosphate ophthalmic 2 (eye) drops 0.1 % diclofenac sodium ophthalmic (eye) drops 0.1 % 2 DUREZOL OPHTHALMIC (EYE) DROPS 0.05 3 % FLAREX OPHTHALMIC (EYE) 3 DROPS,SUSPENSION 0.1 % fluorometholone ophthalmic (eye) 3 drops,suspension 0.1 % flurbiprofen sodium ophthalmic (eye) drops 0.03 2 % FML FORTE OPHTHALMIC (EYE) 3 DROPS,SUSPENSION 0.25 % FML LIQUIFILM OPHTHALMIC (EYE) 4 DROPS,SUSPENSION 0.1 % FML S.O.P. OPHTHALMIC (EYE) OINTMENT 3 0.1 %

You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 104 Drug Name Drug Tier Requirements/Limits ILEVRO OPHTHALMIC (EYE) 4 DROPS,SUSPENSION 0.3 % ketorolac ophthalmic (eye) drops 0.4 %, 0.5 % 2 LOTEMAX OPHTHALMIC (EYE) 4 DROPS,GEL 0.5 % LOTEMAX OPHTHALMIC (EYE) 4 DROPS,SUSPENSION 0.5 % LOTEMAX OPHTHALMIC (EYE) OINTMENT 4 0.5 % MAXIDEX OPHTHALMIC (EYE) 4 DROPS,SUSPENSION 0.1 % NEVANAC OPHTHALMIC (EYE) 4 DROPS,SUSPENSION 0.1 % prednisolone acetate ophthalmic (eye) 3 drops,suspension 1 % prednisolone sodium phosphate ophthalmic (eye) 3 drops 1 % XIIDRA OPHTHALMIC (EYE) 4 DROPPERETTE 5 % Ophthalmic Prostaglandin And Prostamide Analogs latanoprost ophthalmic (eye) drops 0.005 % 1 QL (5 per 25 days) LUMIGAN OPHTHALMIC (EYE) DROPS 0.01 4 QL (2.5 per 25 days) % travoprost (benzalkonium) ophthalmic (eye) 3 drops 0.004 % ZIOPTAN (PF) OPHTHALMIC (EYE) 3 DROPPERETTE 0.0015 % Otic Agents Otic Agents acetasol hc otic (ear) drops 1-2 % 4 CETRAXAL OTIC (EAR) DROPPERETTE 0.2 4 % CIPRO HC OTIC (EAR) DROPS,SUSPENSION 4 0.2-1 % CIPRODEX OTIC (EAR) 3 DROPS,SUSPENSION 0.3-0.1 % COLY-MYCIN S OTIC (EAR) 3 DROPS,SUSPENSION 3.3-3-10-0.5 MG/ML hydrocortisone-acetic acid otic (ear) drops 1-2 % 4 neomycin-polymyxin-hc otic (ear) 2 drops,suspension 3.5-10,000-1 mg/ml-unit/ml-%

You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 105 Drug Name Drug Tier Requirements/Limits neomycin-polymyxin-hc otic (ear) solution 3.5- 3 10,000-1 mg/ml-unit/ml-% ofloxacin oral tablet 300 mg 3 Respiratory Tract/ Pulmonary Agents Antihistamines azelastine nasal aerosol,spray 137 mcg (0.1 %) 3 QL (30 per 25 days) azelastine nasal spray,non-aerosol 0.15 % (205.5 4 QL (30 per 25 days) mcg) cetirizine oral solution 1 mg/ml 2 QL (300 per 30 days) clemastine oral tablet 2.68 mg 4 cyproheptadine oral syrup 2 mg/5 ml 3 cyproheptadine oral tablet 4 mg 3 desloratadine oral tablet 5 mg 2 QL (30 per 30 days) levocetirizine oral tablet 5 mg 1 QL (30 per 30 days) olopatadine nasal spray,non-aerosol 0.6 % 4 QL (30.5 per 30 days) Anti-Inflammatories, Inhaled Corticosteroids ADVAIR DISKUS INHALATION BLISTER 3 QL (60 per 30 days) WITH DEVICE 100-50 MCG/DOSE, 250-50 MCG/DOSE, 500-50 MCG/DOSE ADVAIR HFA INHALATION HFA AEROSOL 3 QL (12 per 30 days) INHALER 115-21 MCG/ACTUATION, 230-21 MCG/ACTUATION, 45-21 MCG/ACTUATION AEROSPAN INHALATION HFA AEROSOL 4 INHALER 80 MCG/ACTUATION ALVESCO INHALATION HFA AEROSOL 4 INHALER 160 MCG/ACTUATION, 80 MCG/ACTUATION ARMONAIR RESPICLICK INHALATION 4 AEROSOL POWDR BREATH ACTIVATED 113 MCG/ACTUATION, 232 MCG/ACTUATION, 55 MCG/ACTUATION ARNUITY ELLIPTA INHALATION BLISTER 3 QL (30 per 30 days) WITH DEVICE 100 MCG/ACTUATION, 200 MCG/ACTUATION, 50 MCG/ACTUATION ASMANEX HFA INHALATION HFA 4 AEROSOL INHALER 100 MCG/ACTUATION, 200 MCG/ACTUATION ASMANEX TWISTHALER INHALATION 4 AEROSOL POWDR BREATH ACTIVATED 110 MCG (30 DOSES), 220 MCG (120 DOSES), 220 MCG (14 DOSES), 220 MCG (30 DOSES), 220 MCG (60 DOSES)

You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 106 Drug Name Drug Tier Requirements/Limits BECONASE AQ NASAL SPRAY,NON- 4 AEROSOL 42 MCG (0.042 %) budesonide inhalation suspension for 4 PA BvD nebulization 0.25 mg/2 ml, 0.5 mg/2 ml, 1 mg/2 ml FLOVENT DISKUS INHALATION BLISTER 3 QL (60 per 30 days) WITH DEVICE 100 MCG/ACTUATION, 250 MCG/ACTUATION FLOVENT DISKUS INHALATION BLISTER 3 QL (60 per 30 days) WITH DEVICE 50 MCG/ACTUATION FLOVENT HFA INHALATION HFA 3 QL (24 per 30 days) AEROSOL INHALER 110 MCG/ACTUATION, 220 MCG/ACTUATION, 44 MCG/ACTUATION flunisolide nasal spray,non-aerosol 25 mcg 2 QL (50 per 30 days) (0.025 %) fluticasone nasal spray,suspension 50 1 QL (16 per 30 days) mcg/actuation mometasone nasal spray,non-aerosol 50 4 QL (34 per 30 days) mcg/actuation OMNARIS NASAL SPRAY,NON-AEROSOL 4 QL (12.5 per 30 days) 50 MCG PULMICORT FLEXHALER INHALATION 3 AEROSOL POWDR BREATH ACTIVATED 180 MCG/ACTUATION, 90 MCG/ACTUATION QNASL NASAL HFA AEROSOL INHALER 40 4 MCG/ACTUATION, 80 MCG/ACTUATION Antileukotrienes montelukast oral granules in packet 4 mg 4 QL (30 per 30 days) montelukast oral tablet 10 mg 1 QL (30 per 30 days) montelukast oral tablet,chewable 4 mg, 5 mg 1 QL (30 per 30 days) zafirlukast oral tablet 10 mg, 20 mg 4 QL (60 per 30 days) zileuton oral tablet, er multiphase 12 hr 600 mg 5 NDS ZYFLO ORAL TABLET 600 MG 5 NDS Bronchodilators, Anticholinergic ATROVENT HFA INHALATION HFA 4 QL (25.8 per 30 days) AEROSOL INHALER 17 MCG/ACTUATION INCRUSE ELLIPTA INHALATION BLISTER 3 QL (30 per 30 days) WITH DEVICE 62.5 MCG/ACTUATION ipratropium bromide inhalation solution 0.02 % 2 PA BvD ipratropium bromide nasal spray,non-aerosol 2 QL (30 per 30 days) 0.03 % You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 107 Drug Name Drug Tier Requirements/Limits ipratropium bromide nasal spray,non-aerosol 42 2 QL (45 per 30 days) mcg (0.06 %) SPIRIVA RESPIMAT INHALATION MIST 3 QL (4 per 28 days) 1.25 MCG/ACTUATION SPIRIVA RESPIMAT INHALATION MIST 2.5 3 QL (4 per 28 days) MCG/ACTUATION SPIRIVA WITH HANDIHALER INHALATION 3 QL (30 per 30 days) CAPSULE, W/INHALATION DEVICE 18 MCG TUDORZA PRESSAIR INHALATION 4 QL (1 per 30 days) AEROSOL POWDR BREATH ACTIVATED 400 MCG/ACTUATION, 400 MCG/ACTUATION (30 ACTUAT) Bronchodilators, Sympathomimetic albuterol sulfate inhalation solution for 2 PA BvD nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3 ml (0.083 %), 5 mg/ml albuterol sulfate oral syrup 2 mg/5 ml 2 albuterol sulfate oral tablet 2 mg, 4 mg 4 albuterol sulfate oral tablet extended release 12 4 hr 4 mg, 8 mg ARCAPTA NEOHALER INHALATION 4 CAPSULE, W/INHALATION DEVICE 75 MCG BREO ELLIPTA INHALATION BLISTER 3 QL (60 per 30 days) WITH DEVICE 100-25 MCG/DOSE, 200-25 MCG/DOSE BROVANA INHALATION SOLUTION FOR 4 PA BvD; QL (120 per 30 days) NEBULIZATION 15 MCG/2 ML DULERA INHALATION HFA AEROSOL 4 INHALER 100-5 MCG/ACTUATION, 200-5 MCG/ACTUATION epinephrine injection auto-injector 0.15 mg/0.15 3 ml, 0.15 mg/0.3 ml, 0.3 mg/0.3 ml fluticasone-salmeterol inhalation aerosol powdr 2 breath activated 113-14 mcg/actuation, 232-14 mcg/actuation, 55-14 mcg/actuation levalbuterol hcl inhalation solution for 4 PA BvD nebulization 0.31 mg/3 ml, 0.63 mg/3 ml, 1.25 mg/0.5 ml levalbuterol tartrate inhalation hfa aerosol 4 QL (30 per 30 days) inhaler 45 mcg/actuation metaproterenol oral syrup 10 mg/5 ml 4 metaproterenol oral tablet 10 mg, 20 mg 4

You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 108 Drug Name Drug Tier Requirements/Limits PERFOROMIST INHALATION SOLUTION 4 PA BvD; QL (120 per 30 days) FOR NEBULIZATION 20 MCG/2 ML PROAIR HFA INHALATION HFA AEROSOL 3 INHALER 90 MCG/ACTUATION PROAIR RESPICLICK INHALATION 3 AEROSOL POWDR BREATH ACTIVATED 90 MCG/ACTUATION SEREVENT DISKUS INHALATION BLISTER 3 QL (60 per 30 days) WITH DEVICE 50 MCG/DOSE STRIVERDI RESPIMAT INHALATION MIST 3 2.5 MCG/ACTUATION terbutaline oral tablet 2.5 mg, 5 mg 4 terbutaline subcutaneous solution 1 mg/ml 5 NDS VENTOLIN HFA INHALATION HFA 3 QL (36 per 30 days) AEROSOL INHALER 90 MCG/ACTUATION Cystic Fibrosis Agents CAYSTON INHALATION SOLUTION FOR 5 PA; NDS; QL (84 per 28 days) NEBULIZATION 75 MG/ML KALYDECO ORAL GRANULES IN PACKET 5 PA; NDS; QL (56 per 28 days) 50 MG, 75 MG KALYDECO ORAL TABLET 150 MG 5 PA; NDS; QL (60 per 30 days) ORKAMBI ORAL GRANULES IN PACKET 5 PA; NDS; QL (56 per 28 days) 100-125 MG, 150-188 MG ORKAMBI ORAL TABLET 100-125 MG, 200- 5 PA; LA; NDS; QL (112 per 28 days) 125 MG PULMOZYME INHALATION SOLUTION 1 5 PA; NDS; QL (150 per 30 days) MG/ML SYMDEKO ORAL TABLETS, SEQUENTIAL 5 PA; NDS; QL (60 per 30 days) 100-150 MG (D)/ 150 MG (N) TOBI PODHALER INHALATION CAPSULE, 5 PA; NDS; QL (224 per 28 days) W/INHALATION DEVICE 28 MG Mast Cell Stabilizers cromolyn inhalation solution for nebulization 20 3 PA BvD mg/2 ml cromolyn oral concentrate 100 mg/5 ml 4 Phosphodiesterase Inhibitors, Airways Disease DALIRESP ORAL TABLET 250 MCG, 500 4 QL (30 per 30 days) MCG theophylline oral tablet extended release 12 hr 2 100 mg, 200 mg, 450 mg theophylline oral tablet extended release 12 hr 2 300 mg

You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 109 Drug Name Drug Tier Requirements/Limits theophylline oral tablet extended release 24 hr 2 400 mg, 600 mg Pulmonary Antihypertensives ADCIRCA ORAL TABLET 20 MG 5 PA; NDS; QL (60 per 30 days) ADEMPAS ORAL TABLET 0.5 MG, 1 MG, 1.5 5 PA; NDS; QL (90 per 30 days) MG, 2 MG, 2.5 MG LETAIRIS ORAL TABLET 10 MG, 5 MG 5 NDS; QL (30 per 30 days) OPSUMIT ORAL TABLET 10 MG 5 PA; NDS; QL (30 per 28 days) ORENITRAM ORAL TABLET EXTENDED 4 PA RELEASE 0.125 MG ORENITRAM ORAL TABLET EXTENDED 5 PA; NDS RELEASE 0.25 MG, 1 MG, 2.5 MG, 5 MG REVATIO ORAL SUSPENSION FOR 5 PA; NDS; QL (180 per 30 days) RECONSTITUTION 10 MG/ML sildenafil (antihypertensive) oral tablet 20 mg 3 PA; QL (90 per 30 days) tadalafil (antihypertensive) oral tablet 20 mg 3 PA; QL (60 per 30 days) TRACLEER ORAL TABLET 125 MG, 62.5 MG 5 LA; NDS; QL (60 per 30 days) VENTAVIS INHALATION SOLUTION FOR 5 PA BvD; NDS; QL (270 per 30 days) NEBULIZATION 10 MCG/ML VENTAVIS INHALATION SOLUTION FOR 5 PA BvD; NDS; QL (90 per 30 days) NEBULIZATION 20 MCG/ML Respiratory Tract Agents, Other acetylcysteine solution 100 mg/ml (10 %), 200 3 PA BvD mg/ml (20 %) ANORO ELLIPTA INHALATION BLISTER 3 WITH DEVICE 62.5-25 MCG/ACTUATION ARALAST NP INTRAVENOUS RECON SOLN 5 PA; NDS 1,000 MG BEVESPI AEROSPHERE INHALATION HFA 4 AEROSOL INHALER 9-4.8 MCG GLASSIA INTRAVENOUS SOLUTION 1 5 PA; NDS GRAM/50 ML (2 %) LUMIZYME INTRAVENOUS RECON SOLN 5 NDS 50 MG PROLASTIN-C INTRAVENOUS RECON 5 PA; NDS SOLN 1,000 MG STIOLTO RESPIMAT INHALATION MIST 3 QL (4 per 28 days) 2.5-2.5 MCG/ACTUATION TRELEGY ELLIPTA INHALATION BLISTER 3 WITH DEVICE 100-62.5-25 MCG ZEMAIRA INTRAVENOUS RECON SOLN 5 PA; NDS 1,000 MG Respiratory Tract/ Pulmonary Agents You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 110 Drug Name Drug Tier Requirements/Limits COMBIVENT RESPIMAT INHALATION 3 QL (4 per 20 days) MIST 20-100 MCG/ACTUATION DYMISTA NASAL SPRAY,NON-AEROSOL 4 137-50 MCG/SPRAY ESBRIET ORAL CAPSULE 267 MG 5 PA; NDS; QL (270 per 30 days) ESBRIET ORAL TABLET 267 MG, 801 MG 5 PA; NDS ipratropium-albuterol inhalation solution for 1 PA BvD nebulization 0.5 mg-3 mg(2.5 mg base)/3 ml OFEV ORAL CAPSULE 100 MG, 150 MG 5 PA; NDS; QL (60 per 30 days) SYMBICORT 160-4.5 MCG INHALER 60 3 QL (12 per 30 days) INHALATIONS 160-4.5 MCG/ACTUATION SYMBICORT 80-4.5 MCG INHALER 60 3 QL (13.8 per 30 days) INHALATIONS 80-4.5 MCG/ACTUATION SYMBICORT INHALATION HFA AEROSOL 3 QL (10.2 per 30 days) INHALER 160-4.5 MCG/ACTUATION, 80-4.5 MCG/ACTUATION XOLAIR SUBCUTANEOUS RECON SOLN 5 NDS; QL (6 per 28 days) 150 MG Skeletal Muscle Relaxants Skeletal Muscle Relaxants carisoprodol oral tablet 250 mg, 350 mg 3 PA; AGE (Max 64 Years) chlorzoxazone oral tablet 250 mg, 500 mg 3 cyclobenzaprine oral tablet 10 mg, 5 mg 3 PA; AGE (Max 64 Years) metaxall oral tablet 800 mg 4 QL (120 per 30 days) metaxalone oral tablet 400 mg 4 metaxalone oral tablet 800 mg 4 QL (120 per 30 days) methocarbamol oral tablet 500 mg, 750 mg 3 orphenadrine citrate oral tablet extended release 3 100 mg Sleep Disorder Agents Gaba Receptor Modulators eszopiclone oral tablet 1 mg, 2 mg, 3 mg 4 QL (30 per 30 days) flurazepam oral capsule 15 mg, 30 mg 3 temazepam oral capsule 15 mg, 30 mg 2 QL (30 per 30 days) zaleplon oral capsule 10 mg, 5 mg 3 QL (30 per 30 days) zolpidem oral tablet 10 mg 3 QL (30 per 30 days) zolpidem oral tablet 5 mg 3 QL (60 per 30 days) zolpidem oral tablet,ext release multiphase 12.5 4 QL (30 per 30 days) mg zolpidem oral tablet,ext release multiphase 6.25 4 QL (60 per 30 days) mg

You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 111 Drug Name Drug Tier Requirements/Limits Sleep Disorders, Other armodafinil oral tablet 150 mg, 200 mg, 250 mg 4 PA; QL (30 per 30 days) armodafinil oral tablet 50 mg 4 PA; QL (60 per 30 days) BELSOMRA ORAL TABLET 10 MG, 15 MG, 4 QL (30 per 30 days) 20 MG, 5 MG HETLIOZ ORAL CAPSULE 20 MG 5 PA; NDS; QL (30 per 28 days) modafinil oral tablet 100 mg, 200 mg 3 PA; QL (60 per 30 days) ROZEREM ORAL TABLET 8 MG 4 QL (30 per 30 days) XYREM ORAL SOLUTION 500 MG/ML 5 PA; LA; NDS; QL (540 per 30 days)

You can find information on what the symbols and abbreviations in this table mean by going to page vii in the introduction pages of this document 112 INDEX

A AIMOVIG AUTOINJECTOR27 amethia lo ...... 84 abacavir ...... 43 AIMOVIG AUTOINJECTOR amethyst ...... 84 abacavir-lamivudine ...... 43 (2 PACK) ...... 27 amikacin ...... 8 abacavir-lamivudine-zidovudine AKYNZEO (NETUPITANT) 23 amiloride ...... 61 ...... 44 ala-cort ...... 79 amiloride-hydrochlorothiazide59 ABELCET ...... 24 albendazole ...... 35 AMINOSYN 7 % WITH ABILIFY MAINTENA ...... 38 ALBENZA ...... 35 ELECTROLYTES ...... 70 ABRAXANE ...... 31 albuterol sulfate ...... 108 AMINOSYN 8.5 % ...... 71 acamprosate ...... 7 alclometasone ...... 79 AMINOSYN 8.5 %- acarbose ...... 47 ALCOHOL PADS ...... 9 ELECTROLYTES ...... 71 acebutolol ...... 57 ALCOHOL PREP PADS ...... 9 AMINOSYN II 10 %...... 71 acetaminophen-codeine ...... 3 ALECENSA ...... 33 AMINOSYN II 15 %...... 71 acetasol hc ...... 105 alendronate ...... 100 AMINOSYN II 7 %...... 71 acetazolamide ...... 61 alfuzosin ...... 78 AMINOSYN II 8.5 %...... 71 acetic acid ...... 9 ALIMTA ...... 30 AMINOSYN II 8.5 %- acetylcysteine ...... 110 ALINIA ...... 36 ELECTROLYTES ...... 71 acitretin ...... 67 ALIQOPA ...... 32 AMINOSYN-HBC 7% ...... 71 ACTEMRA ...... 92 allopurinol ...... 25 AMINOSYN-PF 10 % ...... 71 ACTHIB (PF) ...... 96 almotriptan malate ...... 27 AMINOSYN-PF 7 % ACTIMMUNE ...... 96 ALOCRIL ...... 103 (SULFITE-FREE) ...... 71 ACUVAIL (PF) ...... 104 alogliptin ...... 47 AMINOSYN-RF 5.2 % ...... 70 acyclovir ...... 42 alogliptin-metformin ...... 47 amiodarone ...... 56 acyclovir sodium ...... 42 alogliptin-pioglitazone...... 47 AMITIZA ...... 76 ADACEL(TDAP ALOMIDE...... 103 amitriptyline ...... 22 ADOLESN/ADULT)(PF) .. 96 ALORA ...... 83 amitriptyline-chlordiazepoxide ADAGEN ...... 77 alosetron ...... 75 ...... 20 adapalene ...... 67 ALPHAGAN P ...... 103 amlodipine ...... 58 ADCIRCA ...... 110 alprazolam ...... 46 amlodipine-atorvastatin ...... 59 adefovir...... 41 ALREX ...... 104 amlodipine-benazepril ...... 59 ADEMPAS ...... 110 altavera (28) ...... 84 amlodipine-olmesartan ...... 59 ADLYXIN ...... 47 ALUNBRIG ...... 33 amlodipine-valsartan ...... 59 adrucil ...... 30 ALVESCO...... 106 ammonium lactate ...... 67 ADVAIR DISKUS ...... 106 alyacen 1/35 (28) ...... 84 amnesteem ...... 67 ADVAIR HFA ...... 106 alyacen 7/7/7 (28) ...... 84 amoxapine...... 22 AEROSPAN ...... 106 amabelz ...... 84 amoxicil-clarithromy-lansopraz afeditab cr ...... 57 amantadine hcl ...... 36 ...... 74 AFINITOR ...... 33 AMBISOME ...... 24 amoxicillin ...... 12 AFINITOR DISPERZ ...... 92 amethia ...... 84

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amoxicillin-pot clavulanate ... 12, atazanavir...... 45 BARACLUDE ...... 41 13 atenolol ...... 57 BAVENCIO ...... 35 amphotericin b ...... 24 atenolol-chlorthalidone ...... 59 BCG VACCINE, LIVE (PF) .. 96 ampicillin ...... 13 ATGAM ...... 92 BD ULTRA-FINE NANO PEN ampicillin sodium ...... 13 atomoxetine ...... 64 NEEDLE...... 50 ampicillin-sulbactam ...... 13 atorvastatin ...... 62 BD VEO INSULIN SYRINGE AMPYRA ...... 65 atovaquone...... 36 UF ...... 50 ANADROL-50 ...... 82 atovaquone-proguanil ...... 36 BECONASE AQ ...... 107 anagrelide ...... 54 ATRIPLA ...... 44 bekyree (28) ...... 84 ANALPRAM-HC...... 80 atropine ...... 102 BELEODAQ...... 30 anastrozole ...... 32 ATROVENT HFA ...... 107 BELSOMRA ...... 112 ANDRODERM ...... 82 AUBAGIO...... 65 benazepril ...... 56 ANDROGEL ...... 82 aubra ...... 84 benazepril-hydrochlorothiazide ANORO ELLIPTA ...... 110 AUSTEDO ...... 65 ...... 59 ANZEMET ...... 23 AVANDIA ...... 47 BENLYSTA ...... 93 APOKYN ...... 37 AVASTIN ...... 30 benztropine ...... 36 apraclonidine ...... 103 AVELOX IN NACL (ISO- BEPREVE ...... 103 aprepitant ...... 23 OSMOTIC) ...... 14 BESIVANCE ...... 14 apri ...... 84 aviane...... 84 BESPONSA ...... 35 APTIOM...... 18 avita ...... 67 betamethasone dipropionate ... 25 APTIVUS ...... 45 AVONEX ...... 65 betamethasone valerate ...... 25 ARALAST NP ...... 110 AVONEX (WITH ALBUMIN) betamethasone, augmented ..... 26 aranelle (28)...... 84 ...... 65 BETASERON...... 65 ARANESP (IN azacitidine ...... 30 betaxolol ...... 57, 103 POLYSORBATE) ...... 54 AZASITE ...... 13 bethanechol chloride ...... 79 ARCALYST ...... 96 azathioprine ...... 92 BETHKIS ...... 8 ARCAPTA NEOHALER ..... 108 azathioprine sodium ...... 93 BETOPTIC S ...... 103 aripiprazole ...... 38 azelastine ...... 103, 106 BEVESPI AEROSPHERE ... 110 ARISTADA ...... 38, 39 AZELEX ...... 67 bexarotene...... 35 ARISTADA INITIO ...... 38 azithromycin ...... 13 BEXSERO ...... 96 armodafinil ...... 112 AZOPT ...... 103 bicalutamide ...... 29 ARMONAIR RESPICLICK 106 aztreonam ...... 9, 12 BICILLIN C-R ...... 13 ARNUITY ELLIPTA ...... 106 azurette (28) ...... 84 BICILLIN L-A ...... 13 arsenic trioxide ...... 30 B BICNU ...... 30 ARYMO ER ...... 4 baciim ...... 9 BIKTARVY ...... 44 ascomp with codeine ...... 3 bacitracin ...... 9 BILTRICIDE ...... 35 ashlyna ...... 84 bacitracin-polymyxin b...... 102 bimatoprost ...... 103 ASMANEX HFA ...... 106 baclofen ...... 41 bisoprolol fumarate ...... 57 ASMANEX TWISTHALER 106 BACTROBAN NASAL ...... 9 bisoprolol-hydrochlorothiazide aspirin-dipyridamole ...... 55 balsalazide ...... 100 ...... 59 ASSURE ID INSULIN balziva (28) ...... 84 bleomycin ...... 30 SAFETY ...... 50 BANZEL ...... 18 bleph-10 ...... 15

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BLEPHAMIDE ...... 26 calcium acetate ...... 79 CEFEPIME IN BLEPHAMIDE S.O.P...... 26 CALQUENCE ...... 33 DEXTROSE,ISO-OSM ...... 11 blisovi 24 fe ...... 84 camila ...... 90 cefixime ...... 11 blisovi fe 1.5/30 (28) ...... 84 camrese ...... 84 cefotaxime ...... 11 blisovi fe 1/20 (28) ...... 84 camrese lo ...... 84 cefotetan ...... 11 BOOSTRIX TDAP ...... 96, 97 CANASA...... 100 cefotetan in dextrose, iso-osm 11 BORTEZOMIB ...... 30 CANCIDAS...... 24 cefoxitin ...... 11 BOSULIF ...... 33 candesartan ...... 55 cefoxitin in dextrose, iso-osm. 11 BRAFTOVI ...... 30 candesartan-hydrochlorothiazid cefpodoxime ...... 11 BREO ELLIPTA ...... 108 ...... 59 cefprozil ...... 11 brevicon (28) ...... 84 capacet ...... 3 ceftazidime ...... 12 briellyn ...... 84 CAPASTAT ...... 28 ceftriaxone ...... 12 BRILINTA ...... 55 CAPRELSA...... 33 ceftriaxone in dextrose,iso-os . 12 brimonidine ...... 103 captopril ...... 56 cefuroxime axetil ...... 12 BRIVIACT ...... 16 captopril-hydrochlorothiazide 59 cefuroxime sodium ...... 12 bromfenac ...... 104 CARAFATE ...... 76 celecoxib ...... 4 bromocriptine ...... 37 CARBAGLU ...... 69 CELLCEPT ...... 93 BROVANA ...... 108 carbamazepine ...... 18, 47 CELONTIN ...... 16 budesonide ...... 74, 100, 107 carbidopa ...... 36 cephalexin ...... 12 bumetanide ...... 61 carbidopa-levodopa ...... 37 CEREZYME...... 77 buprenorphine...... 5 carbidopa-levodopa-entacapone CERVARIX VACCINE (PF) . 97 buprenorphine hcl ...... 7 ...... 36 CESAMET ...... 23 buprenorphine-naloxone...... 7 carboplatin ...... 30 cetirizine ...... 106 bupropion hcl...... 20 CARIMUNE NF CETRAXAL ...... 105 bupropion hcl (smoking deter) . 7 NANOFILTERED...... 95 cevimeline...... 66 buspirone ...... 46 carisoprodol ...... 111 CHANTIX ...... 7 butalbital compound w/codeine 3 carmustine ...... 30 CHANTIX CONTINUING butalbital-acetaminop-caf-cod .. 3 carteolol ...... 103 MONTH BOX ...... 7 butalbital-acetaminophen ...... 3 cartia xt ...... 58 CHANTIX STARTING butalbital-acetaminophen-caff .. 3 carvedilol ...... 57 MONTH BOX ...... 7 butalbital-aspirin-caffeine ...... 3 carvedilol phosphate ...... 57 chateal ...... 84 butorphanol tartrate ...... 6 caspofungin ...... 24 chloramphenicol sod succinate . 9 BYDUREON ...... 47 CAYSTON ...... 109 chlordiazepoxide hcl ...... 46 BYDUREON BCISE ...... 47 caziant (28) ...... 84 chlordiazepoxide-clidinium .... 74 BYETTA ...... 47 cefaclor ...... 11 chlorhexidine gluconate...... 66 BYSTOLIC ...... 57 cefadroxil ...... 11 chloroquine phosphate ...... 36 C cefazolin ...... 11 chlorothiazide ...... 61 cabergoline ...... 91 cefazolin in 0.9% sod chloride11 chlorothiazide sodium ...... 61 CABOMETYX...... 33 cefdinir...... 11 chlorpromazine ...... 37 calcipotriene ...... 67 CEFEPIME ...... 11 chlorthalidone ...... 62 calcitonin (salmon) ...... 100 CEFEPIME IN DEXTROSE 5 chlorzoxazone ...... 111 calcitriol ...... 67, 100 % ...... 11 CHOLBAM ...... 75

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cholestyramine (with sugar) ... 62 CLINIMIX 4.25%-D25W COLYTE WITH FLAVOR cholestyramine light ...... 62 SULF-FREE ...... 72 PACKS ...... 76 CIALIS ...... 78 CLINIMIX 5%- COMBIGAN ...... 103 ciclopirox ...... 24 D20W(SULFITE-FREE).... 72 COMBIVENT RESPIMAT.. 111 cidofovir ...... 41 CLINIMIX E 2.75%/D10W COMETRIQ ...... 33 cilostazol...... 55 SUL FREE ...... 72 COMPLERA ...... 43 CILOXAN ...... 14 CLINIMIX E 2.75%/D5W compro ...... 22 CIMDUO ...... 44 SULF FREE ...... 72 constulose ...... 76 cimetidine ...... 75 CLINIMIX E 4.25%/D10W COPAXONE ...... 66 cimetidine hcl ...... 75 SUL FREE ...... 72 COPIKTRA ...... 32 CIMZIA ...... 93 CLINIMIX E 4.25%/D25W CORDRAN TAPE LARGE CIMZIA POWDER FOR SUL FREE ...... 72 ROLL ...... 80 RECONST ...... 93 CLINIMIX E 4.25%/D5W COREG CR ...... 57 CINRYZE...... 92 SULF FREE ...... 72 CORLANOR ...... 60 CIPRO HC...... 105 CLINIMIX E 5%/D15W cormax ...... 80 CIPRODEX ...... 105 SULFIT FREE ...... 72 cortisone ...... 26 ciprofloxacin...... 14 CLINIMIX E 5%/D20W CORTISPORIN ...... 67 ciprofloxacin hcl ...... 14 SULFIT FREE ...... 72 COSENTYX (2 SYRINGES). 67 ciprofloxacin lactate ...... 14 CLINIMIX E 5%/D25W COSENTYX PEN (2 PENS) .. 67 citalopram ...... 21 SULFIT FREE ...... 72 COSOPT ...... 103 claravis ...... 67 clobazam ...... 17 COSOPT (PF) ...... 103 clarithromycin ...... 14 clobetasol ...... 67, 80 COTELLIC ...... 33 clemastine ...... 106 clobetasol-emollient ...... 80 COUMADIN ...... 52 CLIMARA PRO ...... 84 clomipramine ...... 22 CREON...... 77 clindamycin hcl ...... 9 clonazepam ...... 46 CRIXIVAN...... 45 clindamycin in 5 % dextrose .... 9 clonidine ...... 55 cromolyn ...... 103, 109 clindamycin palmitate hcl ...... 9 clonidine hcl ...... 55, 64 cryselle (28) ...... 84 clindamycin phosphate ...... 9 clopidogrel ...... 55 cyclafem 1/35 (28) ...... 84 clindamycin-benzoyl peroxide67 clorazepate dipotassium ...... 46 cyclafem 7/7/7 (28)...... 85 CLINIMIX 5%/D15W clorpres ...... 55 cyclobenzaprine ...... 111 SULFITE FREE ...... 71 clotrimazole ...... 24 cyclopentolate ...... 103 CLINIMIX 5%/D25W clotrimazole-betamethasone ... 67 CYCLOPHOSPHAMIDE ...... 29 SULFITE-FREE ...... 71 clozapine ...... 40, 41 CYCLOSET ...... 47 CLINIMIX 2.75%/D5W COARTEM ...... 36 cyclosporine ...... 93 SULFIT FREE...... 71 codeine sulfate ...... 6 cyclosporine modified ...... 93 CLINIMIX 4.25%/D10W SULF colchicine...... 25 cyproheptadine ...... 106 FREE ...... 72 COLCRYS...... 25 CYRAMZA ...... 35 CLINIMIX 4.25%/D5W colesevelam ...... 62 cyred ...... 85 SULFIT FREE...... 72 colestipol ...... 62 CYSTADANE ...... 77 CLINIMIX 4.25%-D20W colistin (colistimethate na) ...... 9 CYSTARAN...... 102 SULF-FREE ...... 72 colocort ...... 100 COLY-MYCIN S ...... 105

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D desonide ...... 80 DILANTIN-125 ...... 18 d10 %-0.45 % sodium chloride desoximetasone ...... 80 diltiazem hcl ...... 58 ...... 72 desvenlafaxine succinate ...... 21 dilt-xr ...... 58 d2.5 %-0.45 % sodium chloride dexamethasone ...... 26 diphenhydramine hcl ...... 22 ...... 72 dexamethasone sodium phos diphenoxylate-atropine ...... 75 d5 % and 0.9 % sodium chloride (pf) ...... 26 dipyridamole ...... 55 ...... 73 dexamethasone sodium disopyramide phosphate ...... 56 d5 %-0.45 % sodium chloride 73 phosphate ...... 26, 104 disulfiram ...... 7 dalfampridine ...... 66 dexmethylphenidate...... 64 DIURIL...... 62 DALIRESP ...... 109 dexrazoxane hcl ...... 30 divalproex ...... 17 danazol ...... 82 dextroamphetamine ...... 64 dofetilide ...... 56 dantrolene ...... 41 dextroamphetamine- donepezil...... 19 dapsone ...... 28, 67 amphetamine ...... 64 dorzolamide ...... 103 DAPTACEL (DTAP dextrose 10 % and 0.2 % nacl 73 dorzolamide-timolol ...... 104 PEDIATRIC) (PF)...... 97 dextrose 10 % in water (d10w) dorzolamide-timolol (pf) ...... 103 daptomycin ...... 9 ...... 73 doxazosin ...... 55 DARAPRIM ...... 36 dextrose 5 % in water (d5w)... 73 doxepin ...... 22 darifenacin ...... 78 dextrose 5 %-lactated ringers . 73 doxercalciferol ...... 100 DARZALEX ...... 35 dextrose 5%-0.2 % sod chloride doxorubicin, peg-liposomal .... 30 dasetta 1/35 (28) ...... 85 ...... 73 doxy-100 ...... 15 dasetta 7/7/7 (28) ...... 85 dextrose 5%-0.3 % sod.chloride doxycycline hyclate ...... 15 deblitane ...... 85 ...... 73 doxycycline monohydrate 15, 16 DELSTRIGO ...... 43 DIASTAT ...... 17 dronabinol ...... 23 deltasone ...... 26 DIASTAT ACUDIAL ...... 17 drospirenone-e.estradiol-lm.fa 85 delyla (28) ...... 85 diazepam ...... 17, 46, 47 drospirenone-ethinyl estradiol 85 DELZICOL ...... 76 diazepam intensol ...... 46 DROXIA...... 29 demeclocycline ...... 15 diclofenac potassium ...... 27 DULERA ...... 108 DEMSER ...... 59 diclofenac sodium. 4, 27, 67, 104 duloxetine ...... 21 denta 5000 plus...... 66 diclofenac-misoprostol ...... 4 DURAMORPH (PF) ...... 5 dentagel ...... 66 dicloxacillin ...... 13 DUREZOL ...... 104 DEPEN TITRATABS ...... 70 dicyclomine ...... 74 dutasteride...... 78 DEPO-MEDROL ...... 26 didanosine ...... 44 dutasteride-tamsulosin ...... 79 DEPO-PROVERA ...... 90 DIFICID ...... 14 DYMISTA ...... 111 DEPO-SUBQ PROVERA 104 diflunisal ...... 4 E ...... 90 digitek ...... 60 econazole ...... 24 DEPO-TESTOSTERONE ...... 82 digox ...... 60, 61 EDURANT ...... 43 DESCOVY ...... 44 digoxin ...... 61 efavirenz ...... 43 desipramine ...... 22 DIGOXIN ...... 61 EGRIFTA ...... 82 desloratadine...... 106 dihydroergotamine...... 27 eletriptan ...... 27 desmopressin ...... 81, 82 DILANTIN ...... 18 ELIDEL ...... 67 desog-e.estradiol/e.estradiol ... 85 DILANTIN EXTENDED...... 18 elinest ...... 85 desogestrel-ethinyl estradiol ... 85 DILANTIN INFATABS ...... 18 eliphos...... 79

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ELIQUIS ...... 52 ery-tab ...... 14 FARYDAK ...... 32 ELITEK ...... 30 ERY-TAB ...... 14 FASLODEX ...... 30 ELMIRON ...... 79 ERYTHROCIN ...... 14 fayosim ...... 85 EMCYT ...... 29 erythromycin ...... 14 FAZACLO ...... 41 EMFLAZA ...... 80 erythromycin ethylsuccinate... 14 felbamate ...... 18 emoquette ...... 85 erythromycin with ethanol...... 14 felodipine ...... 58 EMPLICITI ...... 35 erythromycin-benzoyl peroxide femynor...... 85 EMSAM ...... 21 ...... 67 fenofibrate...... 62 EMTRIVA ...... 44 ESBRIET ...... 111 fenofibrate micronized ...... 62 enalapril maleate ...... 56 escitalopram oxalate ...... 21 fenofibrate nanocrystallized ... 62 enalapril-hydrochlorothiazide 59 esomeprazole magnesium...... 76 fenofibric acid ...... 62 ENBREL ...... 93 estarylla ...... 85 fenofibric acid (choline) ...... 62 ENBREL SURECLICK ...... 93 ESTRACE ...... 83 fentanyl ...... 5 endocet ...... 3 estradiol ...... 83, 85 fentanyl citrate ...... 6 ENGERIX-B (PF) ...... 97 estradiol-norethindrone acet ... 85 FERRIPROX ...... 70 ENGERIX-B PEDIATRIC (PF) ESTRING ...... 83 FETZIMA ...... 21 ...... 97 estropipate ...... 83 FIASP FLEXTOUCH U-100 enoxaparin ...... 52, 53 eszopiclone ...... 111 INSULIN ...... 50 enpresse ...... 85 ethacrynic acid ...... 61 FIASP U-100 INSULIN ...... 50 enskyce ...... 85 ethambutol ...... 28 FINACEA ...... 67, 68 entacapone ...... 36 ethosuximide ...... 16, 17 finasteride ...... 79 entecavir ...... 41 ethynodiol diac-eth estradiol .. 85 FIRAZYR ...... 92 ENTRESTO ...... 56 etidronate disodium ...... 100 FIRMAGON KIT W DILUENT enulose ...... 76 etodolac ...... 4 SYRINGE ...... 91 ENVARSUS XR ...... 93 ETOPOPHOS ...... 32 FLAREX...... 104 EPCLUSA ...... 42 etoposide ...... 32 flavoxate ...... 78 epinastine ...... 103 EVOTAZ ...... 45 flecainide ...... 56 epinephrine ...... 108 exemestane ...... 32 FLECTOR ...... 27 epirubicin ...... 30 EXJADE ...... 70 FLOVENT DISKUS ...... 107 epitol ...... 18 EXTAVIA ...... 66 FLOVENT HFA ...... 107 EPIVIR HBV...... 41 ezetimibe ...... 62 fluconazole ...... 24 eplerenone ...... 61 ezetimibe-simvastatin ...... 59 fluconazole in nacl (iso-osm) . 24 eprosartan ...... 56 F flucytosine ...... 24 EPZICOM ...... 44 FABRAZYME ...... 77 fludrocortisone ...... 80 EQUETRO ...... 19 falmina (28) ...... 85 flunisolide ...... 107 ergoloid...... 19 famciclovir...... 42 fluocinolone ...... 80 ergotamine-caffeine ...... 27 famotidine ...... 75 fluocinolone acetonide oil ...... 80 ERIVEDGE ...... 33 famotidine (pf) ...... 75 fluocinolone and shower cap .. 80 ERLEADA ...... 29 famotidine (pf)-nacl (iso-os) . 75 fluocinonide ...... 68, 80 errin ...... 90 FANAPT ...... 39 fluocinonide-e ...... 80 ertapenem ...... 12 FARESTON ...... 29 fluoride (sodium) ...... 69, 70 ery pads ...... 14 FARXIGA ...... 47 fluorometholone ...... 104

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fluorouracil ...... 68 GARDASIL 9 (PF) ...... 97 griseofulvin ultramicrosize ..... 24 fluoxetine ...... 21 gatifloxacin ...... 14 guanfacine...... 55 fluphenazine decanoate ...... 37 GATTEX 30-VIAL ...... 75 guanidine ...... 28 fluphenazine hcl ...... 37, 38 GAUZE PAD ...... 50 H flurazepam ...... 111 gavilyte-c ...... 76 halobetasol propionate ...... 80 flurbiprofen...... 4 gavilyte-g ...... 76 haloperidol ...... 38 flurbiprofen sodium ...... 104 gavilyte-h and bisacodyl ...... 76 haloperidol decanoate ...... 38 flutamide...... 29 gavilyte-n ...... 76 haloperidol lactate ...... 38 fluticasone ...... 68, 107 gemfibrozil ...... 62 HARVONI ...... 42 fluticasone-salmeterol ...... 108 generlac ...... 76 HAVRIX (PF) ...... 97 fluvastatin ...... 62 gengraf ...... 93 heather ...... 85 fluvoxamine ...... 21 gentak ...... 8 heparin (porcine) ...... 53 FML FORTE ...... 104 gentamicin ...... 8 heparin (porcine) in 5 % dex .. 53 FML LIQUIFILM ...... 104 gentamicin in nacl (iso-osm) .... 8 heparin (porcine) in nacl (pf) .. 53 FML S.O.P...... 104 gentamicin sulfate (ped) (pf) .... 8 heparin(porcine) in 0.45% nacl fondaparinux...... 53 gentamicin sulfate (pf)...... 8 ...... 53 FORTEO ...... 100 GENVOYA ...... 42 HEPARIN(PORCINE) IN fosamprenavir ...... 45 GEODON ...... 39 0.45% NACL ...... 53 fosinopril ...... 56 gianvi (28) ...... 85 heparin, porcine (pf) ...... 53 fosinopril-hydrochlorothiazide GIAZO...... 76 HEPATAMINE 8% ...... 73 ...... 60 gildagia ...... 85 HERCEPTIN ...... 30 fosphenytoin ...... 19 gildess 1.5/30 (21) ...... 85 HETLIOZ ...... 112 FOSRENOL ...... 79 gildess 24 fe ...... 85 HEXALEN ...... 29 FREAMINE HBC 6.9 % ...... 70 GILENYA ...... 66 HIBERIX (PF) ...... 97 frovatriptan ...... 28 GILOTRIF ...... 33 HUMALOG KWIKPEN FULPHILA...... 54 GLASSIA ...... 110 INSULIN ...... 50 furosemide ...... 61 glatiramer...... 66 HUMALOG MIX 50-50 FUZEON ...... 45 glatopa ...... 66 INSULN U-100 ...... 50 fyavolv ...... 85 GLEOSTINE ...... 30 HUMALOG MIX 50-50 FYCOMPA ...... 18 glimepiride...... 47 KWIKPEN ...... 50 G glipizide ...... 47 HUMALOG MIX 75-25 gabapentin ...... 17 glipizide-metformin ...... 49 KWIKPEN ...... 50 GABITRIL ...... 17 GLUCAGEN HYPOKIT ...... 49 HUMALOG MIX 75-25(U- galantamine ...... 19 GLUCAGON EMERGENCY 100)INSULN ...... 50 GAMASTAN S/D ...... 95 KIT (HUMAN)...... 49 HUMALOG U-100 INSULIN 50 GAMMAGARD LIQUID ...... 96 glycopyrrolate ...... 74 HUMIRA ...... 94 GAMMAPLEX ...... 96 GLYXAMBI ...... 48 HUMIRA PEDIATRIC GAMMAPLEX (WITH GOLYTELY ...... 76 CROHN'S START ...... 93 SORBITOL) ...... 96 granisetron (pf) ...... 23 HUMIRA PEN ...... 94 GAMUNEX-C ...... 96 granisetron hcl ...... 23 HUMIRA PEN CROHN'S-UC- ganciclovir sodium ...... 41 GRANIX ...... 54 HS START ...... 94 GARDASIL (PF)...... 97 griseofulvin microsize ...... 24

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HUMIRA PEN PSORIASIS- IMFINZI ...... 35 ivermectin ...... 35 UVEITIS ...... 94 imipenem-cilastatin ...... 12 IXIARO (PF) ...... 98 HUMULIN 70/30 U-100 imipramine hcl ...... 22 J INSULIN ...... 50 imipramine pamoate ...... 22 JADENU...... 70 HUMULIN 70/30 U-100 imiquimod ...... 68 JADENU SPRINKLE ...... 70 KWIKPEN ...... 51 IMOVAX RABIES VACCINE JAKAFI ...... 34 HUMULIN N NPH INSULIN (PF) ...... 97 jantoven ...... 53 KWIKPEN ...... 51 incassia ...... 90 JANUMET ...... 49 HUMULIN N NPH U-100 INCRELEX ...... 82 JANUMET XR ...... 49 INSULIN ...... 51 INCRUSE ELLIPTA ...... 107 JANUVIA ...... 48 HUMULIN R REGULAR U- indapamide ...... 62 JARDIANCE ...... 48 100 INSULN ...... 51 indomethacin ...... 4 jencycla ...... 86 HUMULIN R U-500 (CONC) INFANRIX (DTAP) (PF) ...... 97 JENTADUETO ...... 48 INSULIN ...... 51 INLYTA ...... 34 JENTADUETO XR ...... 48 HUMULIN R U-500 (CONC) INSULIN SYRINGE-NEEDLE jinteli ...... 86 KWIKPEN ...... 51 U-100 ...... 51 jolessa ...... 86 HYCAMTIN ...... 32 INTELENCE ...... 43 jolivette ...... 90 hydralazine ...... 63 INTRALIPID...... 73 juleber ...... 86 hydrochlorothiazide ...... 62 INTRON A ...... 41, 42 JULUCA ...... 44 hydrocodone-acetaminophen ... 3 introvale ...... 85 junel 1.5/30 (21) ...... 86 hydrocodone-ibuprofen ...... 3 INVANZ ...... 12 junel 1/20 (21) ...... 86 hydrocortisone ...... 26, 81, 100 INVEGA SUSTENNA ...... 39 junel fe 1.5/30 (28) ...... 86 hydrocortisone butyrate ...... 80 INVEGA TRINZA ...... 39 junel fe 1/20 (28) ...... 86 hydrocortisone valerate ...... 81 INVIRASE ...... 45 junel fe 24 ...... 86 hydrocortisone-acetic acid.... 105 INVOKAMET ...... 48 K hydrocortisone-pramoxine ..... 81 INVOKAMET XR ...... 48 KADCYLA...... 30 hydromorphone ...... 5, 6 INVOKANA ...... 48 kaitlib fe ...... 86 hydromorphone (pf) ...... 5 IPOL ...... 97, 98 KALETRA ...... 45 hydroxychloroquine ...... 36 ipratropium bromide ..... 107, 108 KALYDECO ...... 109 hydroxyurea ...... 29 ipratropium-albuterol...... 111 kariva (28) ...... 86 hydroxyzine hcl ...... 22, 23 irbesartan ...... 56 KEDRAB (PF)...... 96 hydroxyzine pamoate ...... 23 irbesartan-hydrochlorothiazide kelnor 1/35 (28) ...... 86 I ...... 60 kelnor 1-50...... 86 ibandronate ...... 100 IRESSA ...... 34 ketoconazole ...... 24 IBRANCE ...... 32 ISENTRESS ...... 43 ketoprofen ...... 27 ibu ...... 4 ISENTRESS HD ...... 42 ketorolac ...... 4, 105 ibuprofen ...... 4 isibloom ...... 85 KEVZARA ...... 94 ICLUSIG ...... 33 isoniazid...... 28 KEYTRUDA ...... 35 IDHIFA ...... 32 isosorbide dinitrate ...... 63 kimidess (28) ...... 86 ILEVRO ...... 105 isosorbide mononitrate ...... 63 KINERET ...... 94 imatinib...... 33 isotretinoin ...... 68 KINRIX (PF) ...... 98 IMBRUVICA ...... 33, 34 itraconazole ...... 24 kionex (with sorbitol) ...... 70

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KISQALI ...... 32 LENVIMA...... 34 linezolid in dextrose 5% ...... 10 KISQALI FEMARA CO-PACK lessina ...... 86 linezolid-0.9% sodium chloride ...... 32 LETAIRIS ...... 110 ...... 10 KLOR-CON 10 ...... 69 letrozole ...... 32 LINZESS ...... 76 KLOR-CON 8 ...... 69 leucovorin calcium ...... 31, 32 liothyronine...... 91 klor-con m10 ...... 69 LEUKERAN ...... 29 lisinopril ...... 56 klor-con m15 ...... 69 LEUKINE ...... 54 lisinopril-hydrochlorothiazide 60 klor-con m20 ...... 69 leuprolide ...... 91 lithium carbonate ...... 47 klor-con sprinkle ...... 69 levalbuterol hcl ...... 108 lithium citrate...... 47 KOMBIGLYZE XR ...... 49 levalbuterol tartrate...... 108 lomedia 24 fe ...... 87 KORLYM...... 49 LEVEMIR FLEXTOUCH U- LONSURF ...... 29 K-SOL ...... 69 100 INSULN ...... 51 loperamide ...... 75 K-TAB ...... 69 LEVEMIR U-100 INSULIN .. 51 lopinavir-ritonavir...... 45 kurvelo ...... 86 levetiracetam ...... 16 lopreeza...... 87 KUVAN ...... 77 levetiracetam in nacl (iso-os) . 16 lorazepam ...... 47 L levobunolol ...... 104 lorcet (hydrocodone) ...... 3 l norgest/e.estradiol-e.estrad ... 86 levocarnitine ...... 73 lorcet hd ...... 3 labetalol ...... 57 levocarnitine (with sugar) ...... 73 lorcet plus ...... 3 LACTATED RINGERS ...... 73 levocetirizine ...... 106 loryna (28) ...... 87 lactulose ...... 76 levofloxacin ...... 14, 15 losartan ...... 56 lamivudine ...... 44 levofloxacin in d5w ...... 14, 15 losartan-hydrochlorothiazide .. 60 lamivudine-zidovudine ...... 44 levoleucovorin ...... 30 LOTEMAX...... 105 lamotrigine ...... 18 LEVOLEUCOVORIN ...... 30 lovastatin...... 62 LANOXIN ...... 61 levonest (28) ...... 86 low-ogestrel (28) ...... 87 lansoprazole ...... 76, 77 levonorgestrel-ethinyl estrad .. 87 loxapine succinate ...... 38 lanthanum ...... 79 levonorg-eth estrad triphasic .. 87 LUCEMYRA ...... 7 LANTUS SOLOSTAR U-100 levora-28 ...... 87 LUMIGAN ...... 105 INSULIN ...... 51 levorphanol tartrate...... 5 LUMIZYME...... 110 LANTUS U-100 INSULIN .... 51 levothyroxine ...... 91 LUPRON DEPOT ...... 91, 92 larin 1.5/30 (21) ...... 86 LEVOXYL ...... 91 LUPRON DEPOT (3 MONTH) larin 1/20 (21) ...... 86 LEXIVA ...... 45 ...... 91 larin 24 fe ...... 86 LIALDA ...... 100 LUPRON DEPOT (4 MONTH) larin fe 1.5/30 (28) ...... 86 lidocaine ...... 7 ...... 91 larin fe 1/20 (28) ...... 86 lidocaine (pf) ...... 6 LUPRON DEPOT (6 MONTH) larissia...... 86 lidocaine hcl ...... 7 ...... 91 LARTRUVO ...... 35 lidocaine hcl(pf) in 0.9% nacl .. 7 lutera (28) ...... 87 LASTACAFT ...... 103 lidocaine viscous ...... 7 LYNPARZA ...... 31 latanoprost ...... 105 lidocaine-prilocaine ...... 7 LYRICA ...... 17 LATUDA ...... 39 lillow ...... 87 LYSODREN ...... 91 layolis fe ...... 86 lincomycin ...... 10 lyza ...... 90 leena 28 ...... 86 lindane ...... 36 M leflunomide...... 96 linezolid ...... 10 mafenide acetate ...... 10

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magnesium sulfate ...... 69 methazolamide...... 61 mimvey lo ...... 87 malathion ...... 36 methenamine hippurate ...... 10 minocycline ...... 16 maprotiline ...... 20 methimazole ...... 92 minoxidil...... 63 marlissa...... 87 methocarbamol ...... 111 mirtazapine ...... 20 MARPLAN ...... 21 methotrexate sodium ...... 94 misoprostol ...... 76 marten-tab...... 3 methotrexate sodium (pf) ...... 94 mitoxantrone ...... 32 MATULANE ...... 29 methoxsalen ...... 68 M-M-R II (PF) ...... 98 matzim la ...... 58 methscopolamine ...... 74 modafinil...... 112 MAVYRET ...... 41 methyclothiazide ...... 62 moexipril...... 56 MAXIDEX ...... 105 methyldopa ...... 55 moexipril-hydrochlorothiazide meclizine ...... 23 methyldopa-hydrochlorothiazide ...... 60 medroxyprogesterone ...... 90 ...... 60 molindone ...... 38 mefloquine ...... 36 methylergonovine ...... 82 mometasone ...... 81, 107 megestrol ...... 90 methylphenidate hcl ...... 64, 65 mono-linyah ...... 87 MEKINIST ...... 34 methylprednisolone ...... 26, 81 mononessa (28) ...... 87 MEKTOVI ...... 31 methylprednisolone acetate .... 26 montelukast...... 107 melodetta 24 fe ...... 87 methylprednisolone sodium succ MONUROL ...... 10 meloxicam ...... 4 ...... 26, 81 morphine ...... 5, 6 memantine ...... 20 metipranolol...... 104 MORPHINE ...... 5, 6 MENACTRA (PF) ...... 98 metoclopramide hcl ...... 75 morphine concentrate ...... 5 MENEST ...... 83 metolazone...... 62 MOVANTIK ...... 75 MENHIBRIX (PF) ...... 98 metoprolol succinate...... 57 MOXEZA ...... 15 MENOMUNE - A/C/Y/W-135 metoprolol ta-hydrochlorothiaz moxifloxacin ...... 15 ...... 98 ...... 60 moxifloxacin in nacl (iso-osm) MENOMUNE - A/C/Y/W-135 metoprolol tartrate ...... 57 ...... 15 (PF) ...... 98 metronidazole ...... 10 moxifloxacin-sod.ace,sul-water MENVEO A-C-Y-W-135-DIP metronidazole in nacl (iso-os) 10 ...... 15 (PF) ...... 98 mexiletine ...... 56 MOZOBIL ...... 54 meperidine ...... 6 MIACALCIN ...... 101 MULTAQ ...... 56 meprobamate ...... 46 mibelas 24 fe ...... 87 mupirocin ...... 10 MEPRON ...... 36 miconazole-3 ...... 24 mupirocin calcium ...... 10 mercaptopurine ...... 94 microgestin 1.5/30 (21) ...... 87 MUSTARGEN ...... 31 meropenem ...... 12 microgestin 1/20 (21) ...... 87 MYALEPT ...... 82 mesalamine ...... 100 microgestin 24 fe ...... 87 mycophenolate mofetil ...... 94 mesna ...... 31 microgestin fe 1.5/30 (28) ...... 87 mycophenolate mofetil hcl ..... 94 MESNEX ...... 31 microgestin fe 1/20 (28) ...... 87 mycophenolate sodium ...... 94 metadate er ...... 64 midodrine...... 55 MYLOTARG ...... 35 metaproterenol ...... 108 MIGERGOT ...... 27 myorisan ...... 68 metaxall ...... 111 miglitol ...... 48 MYRBETRIQ...... 78 metaxalone ...... 111 miglustat ...... 77 myzilra ...... 87 metformin ...... 48 mili...... 87 N methadone ...... 5 mimvey ...... 87 nabumetone...... 4

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nadolol ...... 57 NEPHRAMINE 5.4 % ...... 73 nortrel 1/35 (21) ...... 88 nadolol-bendroflumethiazide . 60 NERLYNX ...... 34 nortrel 1/35 (28) ...... 88 nafcillin...... 13 neuac ...... 68 nortrel 7/7/7 (28)...... 88 naftifine ...... 24 NEULASTA ...... 54 nortriptyline ...... 22 NAFTIN ...... 24 NEUPOGEN ...... 54 NORVIR ...... 45 NAGLAZYME...... 77 NEUPRO ...... 37 NOVOLIN 70/30 U-100 nalocet ...... 3 NEVANAC ...... 105 INSULIN ...... 51 naloxone ...... 7 nevirapine ...... 43 NOVOLIN 70-30 FLEXPEN U- naltrexone ...... 7 NEXAVAR ...... 34 100 ...... 51 NAMENDA XR ...... 20 niacin ...... 63 NOVOLIN N NPH U-100 NAMZARIC...... 20 nicardipine ...... 58 INSULIN ...... 51 naphazoline...... 102 NICOTROL ...... 8 NOVOLIN R REGULAR U- naproxen ...... 27 NICOTROL NS ...... 8 100 INSULN ...... 51 naproxen sodium ...... 27 nifedical xl ...... 58 NOVOLOG FLEXPEN U-100 naratriptan...... 28 nifedipine ...... 58 INSULIN ...... 51 NARCAN ...... 7 nikki (28) ...... 88 NOVOLOG MIX 70-30 U-100 NATACYN ...... 24 nilutamide ...... 29 INSULN ...... 52 NATAZIA ...... 87 nimodipine ...... 58 NOVOLOG MIX 70- nateglinide ...... 48 NINLARO ...... 31 30FLEXPEN U-100 ...... 52 NATPARA ...... 101 nisoldipine ...... 58 NOVOLOG PENFILL U-100 NAVELBINE ...... 32 NITRO-BID...... 63 INSULIN ...... 52 NEBUPENT ...... 36 nitrofurantoin ...... 10 NOVOLOG U-100 INSULIN necon 0.5/35 (28)...... 87 nitrofurantoin macrocrystal .... 10 ASPART ...... 52 necon 1/50 (28)...... 87 nitrofurantoin monohyd/m-cryst NOXAFIL...... 25 necon 10/11 (28)...... 87 ...... 10 NUCYNTA...... 6 necon 7/7/7 (28) ...... 88 nitroglycerin ...... 63 NUCYNTA ER ...... 5 nefazodone ...... 21 NITROSTAT ...... 64 NUEDEXTA ...... 65 neomycin ...... 8 NIVESTYM ...... 54 NULOJIX ...... 94 neomycin-bacitracin-poly-hc 102 nizatidine ...... 75 NUPLAZID ...... 39 neomycin-bacitracin-polymyxin nora-be ...... 88 NUTRILIPID ...... 73 ...... 102 NORDITROPIN FLEXPRO .. 82 nyamyc ...... 25 neomycin-polymyxin b gu ...... 8 noreth-ethinyl estradiol-iron ... 88 nyata ...... 25 neomycin-polymyxin b- norethindrone (contraceptive) 90 nystatin ...... 25 dexameth ...... 102 norethindrone acetate ...... 90 nystatin-triamcinolone ...... 68 neomycin-polymyxin- norethindrone ac-eth estradiol 88 nystop ...... 25 gramicidin...... 102 norethindrone-e.estradiol-iron 88 O neomycin-polymyxin-hc ..... 102, norgestimate-ethinyl estradiol 88 ocella...... 88 105, 106 norinyl 1/35 (28) ...... 88 octreotide acetate ...... 92 neo-polycin ...... 102 norlyda ...... 88 ODEFSEY ...... 44 neo-polycin hc ...... 102 norlyroc ...... 88 ODOMZO...... 34 NEOSPORIN (NEO-POLYM- NORTHERA ...... 55 OFEV ...... 111 GRAMICID) ...... 102 nortrel 0.5/35 (28)...... 88 ofloxacin ...... 15, 106

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ogestrel (28)...... 88 OZEMPIC ...... 48 perphenazine-amitriptyline ..... 20 okebo ...... 16 P pfizerpen-g ...... 13 olanzapine...... 39 pacerone...... 56 phenadoz ...... 23 olmesartan ...... 56 paclitaxel ...... 31 phenelzine ...... 21 olmesartan-amlodipin-hcthiazid paliperidone ...... 40 phenobarbital ...... 17 ...... 60 pamidronate ...... 101 phenoxybenzamine ...... 55 olmesartan-hydrochlorothiazide PANCREAZE ...... 77 PHENYTEK ...... 19 ...... 56 PANRETIN ...... 35 phenytoin ...... 19 olopatadine ...... 103, 106 pantoprazole ...... 77 phenytoin sodium ...... 19 omega-3 acid ethyl esters ...... 63 paricalcitol ...... 101 phenytoin sodium extended .... 19 omeprazole ...... 77 PARICALCITOL ...... 101 philith ...... 88 OMNARIS ...... 107 paroex oral rinse ...... 66 PHOSLYRA ...... 79 ondansetron ...... 23 paromomycin ...... 8 PHOSPHOLINE IODIDE .... 104 ondansetron hcl ...... 23 paroxetine hcl ...... 21 phrenilin forte(with caffeine) ... 4 ondansetron hcl (pf) ...... 23 PASER...... 28 PHYSIOSOL IRRIGATION .. 69 ONFI...... 17 PATADAY ...... 103 PICATO ...... 68 ONGLYZA...... 48 PAXIL ...... 21 PIFELTRO ...... 43 OPANA ER ...... 5 PEDIARIX (PF) ...... 98 pilocarpine hcl ...... 67, 104 OPDIVO ...... 35 PEDVAX HIB (PF) ...... 98 pimozide ...... 38 OPSUMIT ...... 110 peg 3350-electrolytes ...... 76 pimtrea (28) ...... 88 oralone ...... 66 PEGANONE ...... 19 pindolol ...... 57 ORENCIA ...... 94 PEGASYS ...... 42 pioglitazone ...... 48 ORENCIA CLICKJECT ...... 94 PEGASYS PROCLICK ...... 42 pioglitazone-glimepiride...... 49 ORENITRAM ...... 110 peg-electrolyte soln ...... 76 pioglitazone-metformin ...... 49 ORKAMBI ...... 109 PEGINTRON ...... 42 piperacillin-tazobactam ...... 13 orphenadrine citrate ...... 111 PEGINTRON REDIPEN ...... 42 pirmella ...... 88 orsythia ...... 88 PEN NEEDLE, DIABETIC ... 52 piroxicam ...... 27 oseltamivir ...... 46 penicillin g pot in dextrose ..... 13 PLEGRIDY ...... 66 OTEZLA ...... 95 penicillin g potassium ...... 13 PLENAMINE ...... 71 OTEZLA STARTER...... 95 penicillin v potassium ...... 13 podofilox...... 68 oxaliplatin ...... 31 PENTACEL (PF) ...... 98 polycin ...... 102 oxandrolone ...... 82 PENTACEL DTAP-IPV polyethylene glycol 3350 ...... 76 oxaprozin ...... 27 COMPNT (PF) ...... 98 polymyxin b sulfate ...... 10 oxazepam ...... 46 PENTAM...... 36 polymyxin b sulf-trimethoprim oxcarbazepine ...... 19 PENTASA ...... 100 ...... 102 oxiconazole...... 68 pentoxifylline...... 61 POMALYST...... 29 oxybutynin chloride...... 78 PERFOROMIST ...... 109 portia ...... 88 oxycodone ...... 5, 6 perindopril erbumine ...... 56 potassium chlorid-d5-0.45%nacl oxycodone-acetaminophen ...... 3 periogard ...... 67 ...... 73 oxycodone-aspirin ...... 4 PERJETA ...... 31 potassium chloride ...... 69, 70, 73 OXYCONTIN ...... 5 permethrin ...... 36 potassium chloride in lr-d5 ..... 73 oxymorphone ...... 6 perphenazine ...... 23 potassium chloride in water .... 69

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potassium chloride-d5-0.3%nacl prochlorperazine maleate ...... 23 quinine sulfate ...... 36 ...... 74 PROCRIT ...... 54 R potassium chloride-d5-0.9%nacl procto-med hc ...... 100 RABAVERT (PF) ...... 98 ...... 74 procto-pak ...... 81 rabeprazole ...... 77 potassium citrate ...... 79 proctosol hc ...... 100 rajani ...... 88 POTIGA ...... 16 proctozone-hc ...... 81 raloxifene ...... 90 PRADAXA...... 53 PROCYSBI ...... 77 ramipril ...... 56 PRALUENT PEN ...... 63 progesterone micronized ...... 90 RANEXA ...... 61 pramipexole ...... 37 PROGLYCEM ...... 50 ranitidine hcl ...... 75 PRAMOSONE ...... 81 PROGRAF...... 95 RAPAFLO ...... 79 prasugrel ...... 55 PROLASTIN-C ...... 110 RAPAMUNE ...... 95 pravastatin ...... 62 PROLEUKIN ...... 31 rasagiline...... 37 praziquantel ...... 35 PROLIA...... 101 RAVICTI ...... 77 prazosin ...... 55 PROMACTA ...... 54 RAYALDEE...... 101 PRED MILD ...... 26 promethazine ...... 23 REBIF (WITH ALBUMIN) ... 66 prednicarbate ...... 68, 81 promethegan ...... 23 REBIF REBIDOSE ...... 66 prednisolone ...... 26 propafenone ...... 57 REBIF TITRATION PACK ... 66 prednisolone acetate ...... 105 propantheline ...... 74 reclipsen (28) ...... 89 prednisolone sodium phosphate proparacaine ...... 102 RECOMBIVAX HB (PF). 98, 99 ...... 26, 81, 105 propranolol ...... 57 REGRANEX ...... 68 prednisone ...... 26, 81 propranolol-hydrochlorothiazid RELENZA DISKHALER ...... 46 PREMARIN ...... 83 ...... 60 RELISTOR ...... 75 PREMASOL 10 % ...... 74 propylthiouracil ...... 92 REMICADE ...... 95 PREMASOL 6 % ...... 74 PROQUAD (PF)...... 98 RENAGEL ...... 79 PREMPHASE ...... 88 PROSOL 20 % ...... 74 RENFLEXIS...... 95 PREMPRO ...... 88 protriptyline ...... 22 RENVELA ...... 79 prenatal plus (calcium carb) ... 73 PULMICORT FLEXHALER repaglinide ...... 48 prenatal vitamin plus low iron 74 ...... 107 REPATHA PUSHTRONEX .. 63 prevalite ...... 63 PULMOZYME ...... 109 REPATHA SURECLICK ...... 63 previfem ...... 88 PURIXAN ...... 30 REPATHA SYRINGE ...... 63 PREZCOBIX ...... 45 pyrazinamide ...... 29 reprexain ...... 4 PREZISTA ...... 46 pyridostigmine bromide ...... 28 RESCRIPTOR ...... 43 PRIFTIN ...... 28 Q RESTASIS ...... 102 PRIMAQUINE ...... 36 QNASL ...... 107 RETACRIT...... 55 primidone ...... 17 QTERN ...... 48 RETROVIR ...... 44 PRIVIGEN ...... 96 QUADRACEL (PF) ...... 98 REVATIO...... 110 PROAIR HFA ...... 109 quasense...... 88 REVLIMID...... 29, 32 PROAIR RESPICLICK ...... 109 quetiapine ...... 40 REXULTI ...... 40 probenecid ...... 25 quinapril...... 56 REYATAZ ...... 46 probenecid-colchicine ...... 25 quinapril-hydrochlorothiazide 60 RHOPRESSA ...... 102 prochlorperazine ...... 23 quinidine gluconate ...... 57 ribasphere ...... 41 prochlorperazine edisylate...... 23 quinidine sulfate ...... 57 ribavirin ...... 42

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RIDAURA ...... 96 sertraline ...... 21 spironolacton-hydrochlorothiaz rifabutin ...... 28 setlakin...... 89 ...... 60 rifampin ...... 29 sevelamer carbonate ...... 79 SPORANOX...... 25 RIFATER ...... 29 sf 5000 plus ...... 67 sprintec (28) ...... 89 riluzole ...... 65 sharobel ...... 89 SPRITAM ...... 16 rimantadine ...... 46 SHINGRIX (PF) ...... 99 SPRYCEL...... 34 ringer's ...... 74 SIGNIFOR...... 92 sps (with sorbitol) ...... 71 risedronate ...... 101 sildenafil (antihypertensive) . 110 sronyx ...... 89 RISPERDAL CONSTA ...... 40 SILENOR ...... 22 ssd ...... 15 risperidone ...... 40 SILIQ ...... 68 stavudine ...... 44 ritonavir ...... 46 silver sulfadiazine ...... 15 STELARA ...... 68 RITUXAN ...... 35 SIMBRINZA ...... 104 STERILE PADS ...... 52 rivastigmine ...... 19 SIMPONI...... 95, 96 STIMATE ...... 82 rivastigmine tartrate...... 19 SIMPONI ARIA ...... 95 STIOLTO RESPIMAT ...... 110 rivelsa ...... 89 simvastatin ...... 62 STIVARGA ...... 34 rizatriptan ...... 28 sirolimus ...... 95 STRATTERA ...... 65 ropinirole ...... 37 SIRTURO ...... 29 STRENSIQ ...... 78 rosadan ...... 10 SIVEXTRO ...... 10 streptomycin ...... 8 rosuvastatin...... 62 sodium chloride ...... 70, 74 STRIBILD ...... 43 ROTARIX ...... 99 sodium chloride 0.45 % ...... 70 STRIVERDI RESPIMAT .... 109 ROTATEQ VACCINE ...... 99 sodium chloride 0.9 % ...... 70 SUBOXONE ...... 7 ROWEEPRA ...... 16 sodium chloride 3 % ...... 70 SUCRAID...... 78 ROWEEPRA XR ...... 16 sodium chloride 5 % ...... 70 sucralfate...... 76 ROZEREM ...... 112 sodium phenylbutyrate ...... 79 sulfacetamide sodium ..... 15, 103 RUBRACA...... 31 sodium polystyrene (sorb free) sulfacetamide sodium (acne) .. 15 RYDAPT ...... 34 ...... 71 sulfacetamide-prednisolone .... 27 RYTARY ...... 36 sodium polystyrene sulfonate . 71 sulfadiazine ...... 15 S SOLIQUA 100/33 ...... 48 sulfamethoxazole-trimethoprim SABRIL ...... 17 SOLTAMOX ...... 29 ...... 15 SAMSCA ...... 71 SOLU-CORTEF (PF) ...... 26 SULFAMYLON ...... 10 SANDIMMUNE ...... 95 SOLU-MEDROL ...... 27 sulfasalazine ...... 100 SANDOSTATIN LAR DEPOT SOLU-MEDROL (PF) ...... 27 sulfatrim ...... 15 ...... 92 SOMATULINE DEPOT ...... 92 sulindac ...... 4 SANTYL ...... 68 SOMAVERT ...... 92 sumatriptan ...... 28 SAPHRIS ...... 40 sorine ...... 57 sumatriptan succinate ...... 28 SAVELLA ...... 65 sotalol ...... 57 SUPRAX ...... 12 scopolamine base...... 23 sotalol af ...... 57 SUPREP BOWEL PREP KIT 70 selegiline hcl ...... 37 SPIRIVA RESPIMAT ...... 108 SUSTIVA ...... 43 selenium sulfide...... 68 SPIRIVA WITH SUTENT ...... 34 SELZENTRY ...... 45 HANDIHALER ...... 108 syeda ...... 89 SENSIPAR ...... 101 spironolactone ...... 61 SYLATRON ...... 32 SEREVENT DISKUS ...... 109 SYLVANT ...... 31

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SYMBICORT...... 111 telmisartan-hydrochlorothiazid tobramycin sulfate ...... 8 SYMDEKO ...... 109 ...... 60 tobramycin-dexamethasone .. 102 SYMFI ...... 44 temazepam ...... 111 TOBREX ...... 9 SYMFI LO ...... 44 tencon ...... 4 TOLAK...... 69 SYMLINPEN 120 ...... 48 TENIVAC (PF) ...... 99 tolcapone...... 36 SYMLINPEN 60 ...... 48 tenofovir disoproxil fumarate . 44 tolterodine ...... 78 SYMTUZA...... 45 terazosin...... 55 topiramate ...... 18 SYNAGIS...... 96 terbinafine hcl ...... 25 toposar ...... 33 SYNAREL ...... 92 terbutaline ...... 109 topotecan...... 33 SYNERCID ...... 9 terconazole...... 25 torsemide ...... 61 SYNJARDY ...... 48 testosterone ...... 83 TOUJEO MAX U-300 SYNJARDY XR ...... 49 testosterone cypionate ...... 82, 83 SOLOSTAR ...... 52 SYNRIBO ...... 32 testosterone enanthate...... 83 TOUJEO SOLOSTAR U-300 SYNTHROID ...... 91 TETANUS,DIPHTHERIA TOX INSULIN ...... 52 SYPRINE ...... 71 PED(PF) ...... 99 TOVIAZ ...... 78 T TETANUS-DIPHTHERIA TPN ELECTROLYTES ...... 74 TABLOID ...... 30 TOXOIDS-TD ...... 99 TPN ELECTROLYTES II ..... 74 tacrolimus ...... 68, 95 tetrabenazine ...... 65 TRACLEER ...... 110 tadalafil ...... 79 tetracycline ...... 16 TRADJENTA ...... 49 tadalafil (antihypertensive) ... 110 THALOMID ...... 29 tramadol ...... 5, 6 TAFINLAR ...... 34 theophylline ...... 109, 110 tramadol-acetaminophen ...... 4 TAGRISSO ...... 34 thioridazine ...... 38 trandolapril ...... 56 TALTZ AUTOINJECTOR .... 68 thiothixene ...... 38 tranexamic acid ...... 55 TALTZ SYRINGE ...... 68 THYMOGLOBULIN ...... 96 TRANSDERM-SCOP ...... 23 TALZENNA...... 32 THYROLAR-1 ...... 91 tranylcypromine ...... 21 TAMIFLU ...... 46 THYROLAR-1/2 ...... 91 TRAVASOL 10 % ...... 74 tamoxifen ...... 29 THYROLAR-1/4 ...... 91 TRAVATAN Z ...... 104 tamsulosin...... 79 THYROLAR-2 ...... 91 travoprost (benzalkonium).... 105 TANZEUM ...... 49 THYROLAR-3 ...... 91 trazodone ...... 21 TARCEVA ...... 34 tiagabine ...... 17 TREANDA ...... 31 TARGRETIN ...... 35 TIBSOVO ...... 32 TRECATOR ...... 29 tarina fe 1/20 (28) ...... 89 TICE BCG ...... 99 TRELEGY ELLIPTA ...... 110 TASIGNA ...... 34 tilia fe ...... 89 TRESIBA FLEXTOUCH U-100 tazarotene ...... 68 timolol maleate ...... 57, 104 ...... 52 TAZORAC ...... 69 tinidazole ...... 10 TRESIBA FLEXTOUCH U-200 taztia xt ...... 58 TIVICAY...... 43 ...... 52 TECENTRIQ ...... 35 tizanidine ...... 41 tretinoin...... 69 TECFIDERA ...... 66 TOBI PODHALER ...... 109 tretinoin (chemotherapy) ...... 35 TEFLARO ...... 12 TOBRADEX ...... 8 TREXALL ...... 95 TEGRETOL ...... 19 TOBRADEX ST...... 102 tri femynor ...... 89 telmisartan ...... 56 tobramycin ...... 8 triamcinolone acetonide.... 67, 81 tobramycin in 0.225 % nacl ...... 8

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triamterene-hydrochlorothiazid TYMLOS...... 101 VIDEX 2 GRAM PEDIATRIC ...... 60 TYPHIM VI ...... 99 ...... 44 triderm ...... 81 TYSABRI ...... 66 VIDEX 4 GRAM PEDIATRIC tridesilon ...... 81 U ...... 44 trientine...... 74 UCERIS ...... 75 VIDEX EC...... 44 tri-estarylla ...... 89 ULORIC ...... 25 vienva ...... 90 trifluoperazine ...... 38 UPTRAVI ...... 61 vigabatrin ...... 18 trifluridine...... 42 ursodiol ...... 75 vigadrone ...... 16 trihexyphenidyl...... 36 V VIIBRYD ...... 22 tri-legest fe...... 89 valacyclovir ...... 42 VIMPAT ...... 19 tri-linyah ...... 89 VALCHLOR ...... 29 VIRACEPT...... 46 tri-lo-estarylla ...... 89 valganciclovir ...... 41 VIRAMUNE...... 43 tri-lo-sprintec ...... 89 valproate sodium ...... 17 VIRAZOLE ...... 42 trilyte with flavor packets ...... 76 valproic acid ...... 17 VIREAD ...... 41, 44 trimethoprim ...... 10 valproic acid (as sodium salt) . 17 VIZIMPRO ...... 33 tri-mili...... 89 valsartan...... 56 voriconazole ...... 25 trimipramine ...... 22 valsartan-hydrochlorothiazide 60 VOSEVI ...... 41 TRIMPEX ...... 10 vancomycin ...... 10, 11 VOTRIENT ...... 34 trinessa (28) ...... 89 VAQTA (PF) ...... 99 VPRIV ...... 78 trinessa lo...... 89 VARIVAX (PF) ...... 99 VRAYLAR ...... 40 TRINTELLIX...... 22 VASCEPA ...... 63 vyfemla (28) ...... 90 tri-previfem (28) ...... 89 VELCADE ...... 31 vylibra ...... 90 TRISENOX ...... 31 velivet triphasic regimen (28). 89 VYVANSE ...... 64 tri-sprintec (28) ...... 89 VEMLIDY...... 41 VYXEOS ...... 31 TRIUMEQ ...... 45 VENCLEXTA ...... 31 W trivora (28)...... 89 VENCLEXTA STARTING warfarin...... 53 tri-vylibra ...... 89 PACK ...... 31 water for irrigation, sterile ...... 74 TROGARZO ...... 44 venlafaxine ...... 22 WELCHOL...... 63 TROPHAMINE 10 % ...... 74 VENTAVIS ...... 110 wera (28) ...... 90 TROPHAMINE 6% ...... 74 VENTOLIN HFA ...... 109 wymzya fe ...... 90 trospium ...... 78 verapamil ...... 59 X TRULICITY ...... 49 VERSACLOZ ...... 41 XADAGO ...... 37 TRUMENBA ...... 99 VERZENIO ...... 33 XALKORI ...... 34 TRUSOPT ...... 104 VESICARE ...... 78 XARELTO ...... 53 TRUVADA ...... 44 vestura (28) ...... 89 XATMEP ...... 95 TUDORZA PRESSAIR ...... 108 VGO 40 ...... 52 XELJANZ...... 95 tulana ...... 90 VIBERZI ...... 76 XELJANZ XR ...... 95 TWINRIX (PF) ...... 99 vicodin ...... 4 XGEVA ...... 101 TYBOST ...... 45 vicodin es ...... 4 XIFAXAN ...... 11 tydemy ...... 89 vicodin hp ...... 4 XIGDUO XR ...... 49 TYGACIL ...... 10 VICTOZA ...... 49 XIIDRA ...... 105 TYKERB ...... 34 XOFLUZA ...... 46

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XOLAIR ...... 111 ZEMAIRA ...... 110 zoledronic ac-mannitol-0.9nacl XTANDI...... 29 zenatane ...... 69 ...... 101 xulane ...... 90 zenchent (28) ...... 90 ZOLINZA ...... 33 XULTOPHY 100/3.6 ...... 49 zenchent fe ...... 90 zolmitriptan...... 28 xylon 10 ...... 4 ZENPEP ...... 78 zolpidem ...... 111 XYREM ...... 112 zenzedi ...... 64 zonisamide ...... 17 Y ZEPATIER ...... 42 ZONTIVITY...... 55 YERVOY ...... 32 ZERBAXA ...... 12 ZORTRESS ...... 95 YF-VAX (PF) ...... 99 ZERIT ...... 45 ZOSTAVAX (PF) ...... 99 YONDELIS ...... 31 ZIAGEN ...... 45 zovia 1/35e (28) ...... 90 YONSA ...... 33 zidovudine ...... 45 zovia 1/50e (28) ...... 90 yuvafem ...... 83 zileuton ...... 107 ZYCLARA ...... 69 Z ZINBRYTA ...... 66 ZYDELIG ...... 33 zafirlukast ...... 107 ZIOPTAN (PF) ...... 105 ZYFLO ...... 107 zaleplon ...... 111 ziprasidone hcl ...... 40 ZYKADIA ...... 35 zarah ...... 90 ZIRGAN ...... 41 ZYLET ...... 102 ZARXIO ...... 55 zoledronic acid ...... 101 ZYPREXA RELPREVV ...... 40 ZAVESCA ...... 78 zoledronic acid-mannitol-water ZYTIGA ...... 29 ZEJULA ...... 31 ...... 101 ZELBORAF ...... 34

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This formulary was updated on Nov. 21, 2018. For more recent information or other questions, please contact Security Health Plan Customer Service at 1-877-998-0998 or, for TTY users, 711, or visit https://www.securityhealth.org/medicareformulary. We are open 7 days a week, 8 a.m. to 8 p.m., from Oct. 1-March 31; and Monday through Friday, 8 a.m. to 8 p.m., from April 1-Sept. 30.

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