Preferred Drug List the Western Sky Community Care Preferred Drug Locator Instructions: Preferred Drug List Includes a List of Drugs Covered by Your Prescription 1

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Preferred Drug List The Western Sky Community care Preferred Drug Locator Instructions: Preferred Drug List includes a list of drugs covered by your prescription 1. Within the PDF, click on the benefit. This list is updated often and Edit menu, then click Find. may change. 2. In the Find box, type the name of To get the most up-to-date the medication you want to information, you may view the latest locate. Preferred Drug List on our website: WesternSkyCommunityCare.com, 3. Click the Next button or call 1-844-543-8996 (TTY/TDD until you find the drug(s). 711).

What is the Western Sky made to the drug list that may impact you. Community Care Preferred Drug List (PDL)? How do I use the Preferred Drug The preferred drug list (which is also List? called a “formulary”) is a list showing The best way to find your drug is by the drugs that can be covered by your going to the back of this book to the Western Sky Community Health Plan. index and looking it up by name. If the The drug listed will be covered as long drug is in all CAPITAL LETTERS (EX: as you: CIPRO TABS) the drug is a BRAND  Have a medical need for the drug name drug and if the drug is in all lower case letters (ex: ciprofloxacin)  Fill your drugs at a pharmacy the drug is a generic name drug. Next that we cover to your drug, you will see the page  Follow any other rules that number where you can find coverage may apply to you as a member information.

For more information on how to fill your What are generic drugs? drugs, please review your Member A generic drug is approved by the Handbook or call Western Sky Food and Drug Administration Community Care (WSCC) Member (FDA) as having the same active Services at 1-844543-8996 (TTY/TDD ingredient as the BRAND name 711). drug, but often costs less.

How will I know what I will pay? Does the plan cover over–the – In most cases you will not have a counter (OTC) drugs? copay. However, depending on the Yes, Western Sky Community Care category you are eligible for or the covers certain OTC drugs. All drug(s) you are taking, you may have covered OTC drugs appear in the a copay. PDL. All OTC drugs must be written on a valid prescription by a licensed Will the Preferred Drug List provider in order to be covered. change? Yes, it will change if there is a new Are there any limits on my drug drug or there is a less expensive coverage? generic that becomes available. You There may be some limits on covered will be notified if any changes are drugs such as:

PRIOR AUTHORIZATION (PA): HOW MUCH IS 90 MME/DAY FOR Your provider may need to get approval COMMONLY PRESCRIBED OPIOIDS? from us before you fill some of your 90 MME/day: drug orders. Drugs that require prior  90 mg of hydrocodone (9 tablets authorization are found in the PDL by a of hydrocodone/ acetaminophen PA in the Additional Information 10/325 mg) column. To find out more about this process, please call Member Services  60 mg of oxycodone (~2 tablets at 1-844-543-8996 (TTY/ TDD 711) and of oxycodone sustained-release a representative will explain the process 30 mg) to you.  20 mg of methadone (4 tablets of methadone 5 mg) QUANTITY LIMITS (QL): For certain drugs there are limits to SPECIALTY PHARMACY (SP) the amount of a drug that will be DRUGS: Specialty drugs are certain covered for a period of time. You can prescription drugs used to treat special tell if your drug needs a QL in health conditions and often require Additional Information column. special attention. These drugs need a prior authorization before a prescription  You can also contact your provider may be filled. Your prescription can be to decide if you should first try a filled for up to a 30-day supply and different drug on our list or different must be filled at Acaria Specialty dose of the drug before you request Pharmacy. Your drugs will then be an exception. mailed to you. For more information about specialty drugs, contact Member  Contact Member Services at 1- Services at 1-844-543-8996 (TTY/TDD 844-543-8996 (TTY/TDD 711) 711). and ask how you or your provider can submit a quantity limit What if my drug(s) is not on the exception request. Preferred Drug List? Talk to your provider to decide if you MORPHINE MILLIGRAM should first try a different drug on the list EQUIVALENT (MME) DOSING: before you request an exception. MME dosing is a tool used to make Member Services will tell you how you or sure you are taking a safe dose of pain your provider can ask for an exception if drugs. This tool helps WSCC calculate your drug(s) are not covered. Contact the total daily dose of pain drugs a WSCC Member Services at 1-844- 543- member is taking no matter which pain 8996 (TTY/TDD 711) for further drug is prescribed. The current daily assistance. limit is 90MME per day. If you are taking more than 90MME per day of pain drugs, you will need to get a prior authorization.

Which drug categories are not calling Member Services at 1-844543- covered by the Preferred Drug 8996 (TTY/TDD 711). List? Providers: In the event that a The following drug categories provider disagrees with the decision are not part of the benefit: regarding coverage of a drug, the provider may request an appeal by  Fertility drugs submitting additional information to in writing to the Appeals Department  Weight loss, or weight gain drugs at the following address:  Drug Efficacy Study Western Sky Community Care Health Implementation (DESI). These Plan are drugs that are not shown to Appeals Department be safe and effective. 5300 Homestead Rd NE Albuquerque, NM, 87110  Drugs and other agents used for cosmetic purposes or for hair After a decision is made, the provider growth will receive a response by mail. An  Erectile dysfunction drugs expedited appeal may be requested prescribed to treat at any time the provider believes the impotence adverse determination might seriously endanger the life or health  Bulk chemicals/powders of a member by calling Western Sky Community Care Health Plan at 1-  Experimental and investigational 844-5438996 (TTY/TDD 711). drugs Abbreviations: Drugs and devices not approved   AL: Age Limit by the FDA  PA: Prior Authorization Contacts for Pharmacy  QL: Quantity Limit Appeals/Grievances  SP: Specialty Medication Members: In the event that a  MP: Maintenance drug eligible for member disagrees with the decision 90 day supply regarding coverage of a drug, the member may request an appeal by

iii Such services are funded in part with the State of New Mexico Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ADHD/ANTI-NARCOLEPSY/ANTI- QL(2 ea daily); dextroamphetamine sulfate P OBESITY/ANOREXIANTS - Drugs to Treat cp24 10 mg, 15 mg AL(At least 6 ADHD, Sleep and Eating Disorders yrs old) QL(1 ea daily); Amphetamines dextroamphetamine sulfate P AL(At least 6 ADDERALL TABS (Use QL(2 ea daily); cp24 5 mg yrs old) Amphetamine- NP AL(At least 3 Dextroamphetamine) yrs old) dextroamphetamine sulfate P soln 5 mg/5ml ADDERALL XR CP24 (Use QL(1 ea daily); Amphetamine- NP AL(At least 6 dextroamphetamine sulfate QL(3 ea daily); Dextroamphetamine) yrs old) P AL(At least 3 tabs 5 mg, 10 mg yrs old) ADZENYS ER SUER P DYANAVEL XR SUER P ADZENYS XR-ODT TBED P EVEKEO TABS (Use NP Amphetamine Sulfate) amphetamine sulfate tabs P methamphetamine hcl tabs P amphetamine- QL(1 ea daily); dextroamphetamine cp24 AL(At least 6 MYDAYIS CP24 P 5mg-5mg-5mg-5mg, yrs old) 2.5mg-2.5mg-2.5mg- PROCENTRA SOLN (Use Dextroamphetamine NP 2.5mg, 7.5mg-7.5mg- P 7.5mg-7.5mg, 1.25mg- Sulfate) 1.25mg-1.25mg-1.25mg, VYVANSE CAPS 10 MG, PA; QL(1 ea 3.75mg-3.75mg-3.75mg- 20 MG, 30 MG, 40 MG, 50 P daily) 3.75mg, 6.25mg-6.25mg- MG, 60 MG, 70 MG 6.25mg-6.25mg VYVANSE CHEW 10 MG, amphetamine- QL(2 ea daily); 20 MG, 30 MG, 40 MG, 50 P dextroamphetamine tabs AL(At least 3 MG, 60 MG 5mg-5mg-5mg-5mg, yrs old) 2.5mg-2.5mg-2.5mg- ZENZEDI TABS P 2.5mg, 7.5mg-7.5mg- 7.5mg-7.5mg, 1.25mg- Analeptics 1.25mg-1.25mg-1.25mg, P CAFCIT SOLN (Use NP 3.75mg-3.75mg-3.75mg- Caffeine Citrate) 3.75mg, 1.875mg- caffeine citrate soln iv 60 P 1.875mg-1.875mg- mg/3ml 1.875mg, 3.125mg- caffeine citrate soln or 20 P QL(45 ml per 3.125mg-3.125mg- mg/ml, 60 mg/3ml fill retail) 3.125mg caffeine tabs P DESOXYN TABS (Use NP Methamphetamine HCl) CAFFEINE/SODIUM P DEXEDRINE CP24 10 MG, QL(2 ea daily); BENZOATE SOLN 15 MG (Use NP AL(At least 6 Dextroamphetamine yrs old) DOPRAM SOLN P Sulfate) DEXEDRINE CP24 5 MG QL(1 ea daily); ENERGY CHEWS CHEW P (Use Dextroamphetamine NP AL(At least 6 Sulfate) yrs old) RA STAY AWAKE TABS P

Western Sky Updated December 1, 2018 P-Preferred drug, NP-Non-preferred, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, RX/OTC - both Rx and OTC NDCs MP-Maintenance drug eligible for 90 day supply

1 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VIVARIN TABS (Use NP METHYLIN SOLN (Use NP Caffeine) Methylphenidate HCl) Attention-Deficit/Hyperactivity Disorder (ADHD) methylphenidate hcl chew P 5 mg, 10 mg, 2.5 mg P AL(At least 6 atomoxetine hcl caps yrs old) methylphenidate hcl cp24 10 mg, 20 mg, 30 mg, 40 P clonidine hcl (adhd) tb12 P mg QL(1 ea daily) methylphenidate hcl cpcr QL(1 ea daily); guanfacine hcl (adhd) tb24 P 10 mg, 20 mg, 30 mg, 40 P AL(At least 6 mg, 50 mg, 60 mg yrs old) INTUNIV TB24 (Use NP QL(1 ea daily) Guanfacine HCl (ADHD)) methylphenidate hcl soln 5 P mg/5ml, 10 mg/5ml KAPVAY TB12 (Use NP Clonidine HCl (ADHD)) QL(3 ea daily); methylphenidate hcl tabs 5 P AL(At least 3 STRATTERA CAPS (Use NP AL(At least 6 mg, 10 mg, 20 mg Atomoxetine HCl) yrs old) yrs old) QL(2 ea daily); Stimulants - Misc. methylphenidate hcl tbcr 10 P mg, 36 mg AL(At least 6 APTENSIO XR CP24 P yrs old) methylphenidate hcl tbcr 18 QL(1 ea daily); armodafinil tabs P PA; QL(1 ea P AL(At least 6 daily) mg, 20 mg, 27 mg, 54 mg yrs old) CONCERTA TBCR 18 MG, QL(1 ea daily); methylphenidate hcl tbcr 72 P 27 MG, 54 MG (Use NP AL(At least 6 mg Methylphenidate HCl) yrs old) METHYLPHENIDATE QL(2 ea daily); HYDROCHLORIDE ER P CONCERTA TBCR 36 MG NP ) AL(At least 6 (LA) CP24 (Use Methylphenidate HCl yrs old) METHYLPHENIDATE COTEMPLA XR-ODT P HYDROCHLORIDE ER P TBED TB24 QL(1 ea daily) DAYTRANA PTCH P modafinil tabs P QL(1 ea daily) dexmethylphenidate hcl QL(1 ea daily) NUVIGIL TABS (Use NP PA; QL(1 ea cp24 5 mg, 10 mg, 15 mg, P Armodafinil) daily) 20 mg, 25 mg, 30 mg, 35 mg, 40 mg PROVIGIL TABS (Use NP QL(1 ea daily) Modafinil) dexmethylphenidate hcl P QL(2 ea daily) tabs 5 mg, 10 mg, 2.5 mg QUILLICHEW ER CHER P FOCALIN TABS (Use NP QL(2 ea daily) Dexmethylphenidate HCl) QUILLIVANT XR SUSR P FOCALIN XR CP24 (Use QL(1 ea daily) NP RITALIN LA CP24 (Use NP Dexmethylphenidate HCl) Methylphenidate HCl) METADATE CD CPCR QL(1 ea daily); QL(3 ea daily); NP AL(At least 6 RITALIN TABS (Use NP (Use Methylphenidate HCl) ) AL(At least 3 yrs old) Methylphenidate HCl yrs old) METHYLIN CHEW (Use NP Methylphenidate HCl) ALTERNATIVE MEDICINES Alternative Medicine - M's

2 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits melatonin tabs P QL(1 ea daily) ALEVE ARTHRITIS TABS NP QL(2 ea daily); (Use Naproxen Sodium) MP AMINOGLYCOSIDES - Drugs to Treat Bacterial ALEVE TABS (Use NP QL(2 ea daily); Infections Naproxen Sodium) MP Aminoglycosides ANAPROX DS TABS (Use NP MP Naproxen Sodium) KITABIS PAK NEBU P PA; QL(1 ml daily); SP CELEBREX CAPS 400 MG NP PA; QL(2 ea (Use Celecoxib) daily) neomycin sulfate tabs P CELEBREX CAPS 50 MG, PA; QL(1 ea 100 MG, 200 MG (Use NP daily) TOBI NEBU (Use NP PA; QL(1 ml Tobramycin) daily); SP Celecoxib) PA; QL(2 ea P PA; QL(1 ml celecoxib caps 400 mg P tobramycin nebu daily); SP daily) celecoxib caps 50 mg, 100 PA; QL(1 ea P PA; QL(1 ml P TOBRAMYCIN NEBU daily); SP mg, 200 mg daily) TOBRAMYCIN SULFATE CHILDRENS ADVIL SUSP NP RX/OTC; MP SOLN 10 MG/ML, 40 P (Use Ibuprofen) MG/ML CHILDRENS MOTRIN NP RX/OTC; MP tobramycin sulfate soln 40 SUSP (Use Ibuprofen) mg/ml, 80 mg/2ml, 1.2 P DAYPRO TABS (Use NP MP gm/30ml Oxaprozin) MP tobramycin sulfate solr 1.2 P diclofenac potassium tabs P gm MP ANALGESICS - ANTI-INFLAMMATORY - Drugs diclofenac sodium tb24 P to Treat Pain, Swelling, Muscle and Joint Conditions diclofenac sodium tbec P MP Anti-TNF-alpha - Monoclonal Antibodies EC-NAPROSYN TBEC NP QL(2 ea daily); HUMIRA PEDIATRIC PA; SP (Use Naproxen) MP CROHNS DISEASE P MP STARTER PACK PSKT 40 etodolac caps P MG/0.8ML etodolac tabs P MP HUMIRA PEN PNKT 40 P PA; SP MG/0.8ML etodolac tb24 P MP HUMIRA PEN-CD/UC/HS PA; SP STARTER PNKT 40 P FELDENE CAPS (Use NP MP MG/0.8ML Piroxicam) MP HUMIRA PEN-PS/UV P PA; SP flurbiprofen tabs P STARTER PNKT HUMIRA PSKT 10 PA; SP ibuprofen chew 100 mg P MP MG/0.2ML, 20 MG/0.4ML, P 40 MG/0.8ML ibuprofen susp 100 mg/5ml P RX/OTC; MP Nonsteroidal Anti-inflammatory Agents (NSAIDs) ibuprofen susp 40 mg/ml, P MP ADVIL TABS (Use NP MP 50 mg/1.25ml Ibuprofen) ibuprofen tabs 200 mg, 400 P MP mg, 600 mg, 800 mg

3 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits indomethacin caps P MP piroxicam caps P MP indomethacin cpcr P MP PONSTEL CAPS (Use NP Mefenamic Acid) INFANTS ADVIL SUSP NP MP MP (Use Ibuprofen) sulindac tabs P ketoprofen caps 50 mg, 75 P MP TOLMETIN SODIUM P MP mg CAPS 400 MG KETOPROFEN CAPS 50 P MP TOLMETIN SODIUM TABS P MP MG, 75 MG 200 MG KETOPROFEN ER CP24 P TOLMETIN SODIUM TABS P 600 MG ketorolac tromethamine P QL(20 ea per Pyrimidine Synthesis Inhibitors tabs 30 days retail) ARAVA TABS (Use NP MP LODINE TABS (Use NP MP Leflunomide) Etodolac) leflunomide tabs P MP mefenamic acid caps P Soluble Tumor Necrosis Factor Receptor Agents meloxicam tabs P MP ENBREL SOLR P PA; SP MOBIC TABS (Use NP MP Meloxicam) ENBREL SOSY P PA; SP MOTRIN INFANTS MP DROPS SUSP (Use NP ENBREL SURECLICK P PA; SP Ibuprofen) SOAJ nabumetone tabs P MP ANALGESICS - NonNarcotic - Drugs to Treat Pain, Muscle and Joint Conditions NAPRELAN TB24 (Use NP Analgesic Combinations Naproxen Sodium) butalbital-acetaminophen P NAPROSYN SUSP (Use NP MP tabs Naproxen) butalbital-acetaminophen- NAPROSYN TABS (Use NP MP caffeine caps 300mg- P Naproxen) 50mg-40mg naproxen sodium tabs 220 P QL(2 ea daily); butalbital-acetaminophen- QL(4 ea daily) mg MP caffeine caps 325mg- P naproxen sodium tabs 275 P MP 50mg-40mg mg, 550 mg butalbital-acetaminophen- QL(4 ea daily) naproxen sodium tb24 375 P caffeine tabs 325mg-50mg- P mg, 500 mg 40mg MP naproxen susp 125 mg/5ml P butalbital-aspirin-caffeine P QL(4 ea daily) caps naproxen tabs 250 mg, 375 P MP ESGIC TABS (Use QL(4 ea daily) mg, 500 mg Butalbital-Acetaminophen- NP naproxen tbec 375 mg, 500 P QL(2 ea daily); Caffeine) mg MP FIORICET CAPS (Use oxaprozin tabs P MP Butalbital-Acetaminophen- NP Caffeine)

4 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FIORINAL CAPS (Use NP QL(4 ea daily) aspirin supp re 300 mg, P QL(12 ea per Butalbital-Aspirin-Caffeine) 600 mg fill retail) TENCON TABS P aspirin tabs or 325 mg P

Analgesics Other aspirin tbec or 81 mg, 324 P mg, 325 mg, 500 mg acetaminophen chew or 80 P mg, 160 mg BUFFERIN TABS (Use Aspirin Buffered (Cal Carb- NP acetaminophen liqd or 160 P )) mg/5ml Mag Carb-Mag Oxide acetaminophen soln or 160 choline & mag salicylate P mg/5ml, 650 mg/20.3ml, P liqd 325 mg/10.15ml diflunisal tabs P MP acetaminophen supp re P QL(12 ea per 120 mg, 325 mg, 650 mg fill retail) DISALCID TABS (Use NP Salsalate) acetaminophen susp or 160 mg/5ml, 80 mg/0.8ml, P ECOTRIN MAXIMUM 80 mg/2.5ml STRENGTH TBEC (Use NP Aspirin) acetaminophen tabs or 325 P mg, 500 mg ECOTRIN REGULAR STRENGTH TBEC (Use NP NORTEMP INFANTS P Aspirin) SUSP TYLENOL CHILDRENS salsalate tabs P CHEWABLES/PAIN + NP FEVER CHEW (Use ANALGESICS - OPIOID - Drugs to Treat Pain, Acetaminophen) Muscle and Joint Conditions TYLENOL CHILDRENS Opioid Agonists SUSP (Use NP ACTIQ LPOP (Use NP PA Acetaminophen) Fentanyl Citrate) TYLENOL EXTRA QL(2 ea daily); STRENGTH TABS (Use NP codeine sulfate tabs 15 mg, P AL(At least 12 Acetaminophen) 30 mg, 60 mg yrs old) TYLENOL INFANTS CODEINE SULFATE TABS QL(2 ea daily); PAIN+FEVER SUSP (Use NP 15 MG, 30 MG, 60 MG NP AL(At least 12 Acetaminophen) (Use Codeine Sulfate) yrs old) TYLENOL INFANTS SUSP NP DILAUDID LIQD OR 1 PA (Use Acetaminophen) MG/ML (Use NP Hydromorphone HCl) TYLENOL TABS (Use NP Acetaminophen) DILAUDID SOLN IJ 1 PA Salicylates MG/ML, 2 MG/ML, 4 NP MG/ML (Use aspirin buffered (cal carb- P Hydromorphone HCl) mag carb-mag oxide) tabs DILAUDID TABS OR 2 QL(6 ea daily) aspirin chew or 81 mg P MG, 4 MG, 8 MG (Use NP Hydromorphone HCl) ASPIRIN SUPP RE 120 QL(12 ea per MG, 200 MG, 300 MG, 600 P fill retail) DURAGESIC PT72 (Use NP QL(0.34 ea MG Fentanyl) daily)

5 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EXALGO T24A (Use NP PA morphine sulfate soln or 10 P QL(20 ml daily) Hydromorphone HCl) mg/5ml, 20 mg/5ml fentanyl citrate lpop bu 200 PA morphine sulfate soln or 20 P PA; QL(240 ml mcg, 400 mcg, 600 mcg, P mg/ml, 100 mg/5ml per fill retail) 800 mcg, 1200 mcg, 1600 MORPHINE SULFATE QL(24 ea per mcg SUPP RE 5 MG, 10 MG, P fill retail) FENTANYL CITRATE PA 20 MG, 30 MG SOLN IJ 100 MCG/2ML, NP MORPHINE SULFATE P QL(6 ea daily) 250 MCG/5ML (Use TABS OR 15 MG, 30 MG Fentanyl Citrate) morphine sulfate tbcr or 15 QL(3 ea daily) fentanyl citrate soln ij 100 PA mg, 30 mg, 60 mg, 100 mg, P mcg/2ml, 250 mcg/5ml, P 200 mg 1000 mcg/20ml MS CONTIN TBCR (Use NP QL(3 ea daily) P QL(0.34 ea Morphine Sulfate) fentanyl pt72 daily) OPANA TABS (Use NP PA hydromorphone hcl liqd or P PA Oxymorphone HCl) 1 mg/ml QL(6 ea daily) hydromorphone hcl soln ij 1 PA oxycodone hcl caps 5 mg P mg/ml, 2 mg/ml, 10 mg/ml, P oxycodone hcl conc 100 P QL(6 ml daily) 50 mg/5ml, 500 mg/50ml mg/5ml HYDROMORPHONE HCL PA NP oxycodone hcl soln 5 P QL(90 ml daily) SOLN IJ 4 MG/ML mg/5ml HYDROMORPHONE HCL P QL(12 ea per oxycodone hcl tabs 5 mg, QL(6 ea daily) SUPP RE 3 MG fill retail) 10 mg, 15 mg, 20 mg, 30 P hydromorphone hcl t24a or PA mg 8mg, 8 mg, 12 mg, 16 mg, P PA 32 mg oxymorphone hcl tabs P hydromorphone hcl tabs or QL(6 ea daily) P ROXICODONE TABS (Use NP QL(6 ea daily) 2 mg, 4 mg, 8 mg Oxycodone HCl) HYDROMORPHONE PA QL(8 ea daily); HYDROCHLORIDE SOLN NP tramadol hcl tabs 50 mg P AL(At least 18 1 MG/ML, 110 MG/55ML yrs old) HYDROMORPHONE PA tramadol hcl tb24 100 mg, P PA; AL(At least HYDROCHLORIDE SOLN NP 200 mg, 300 mg 18 yrs old) 10 MG/ML (Use QL(8 ea daily); Hydromorphone HCl) ULTRAM TABS (Use NP Tramadol HCl) AL(At least 18 KADIAN CP24 (Use NP PA yrs old) Morphine Sulfate) Opioid Combinations morphine sulfate cp24 or PA 10 mg, 20 mg, 30 mg, 50 P QL(30 ml mg, 60 mg, 80 mg, 100 mg acetaminophen w/ codeine P daily); AL(At soln 120mg/5ml-12mg/5ml least 12 yrs morphine sulfate soln iv 4 P PA old) mg/ml, 8 mg/ml, 10 mg/ml acetaminophen w/ codeine QL(6 ea daily); MORPHINE SULFATE PA tabs 300mg-15mg, 300mg- P AL(At least 12 SOLN IV 4 MG/ML, 8 NP 30mg, 300mg-60mg yrs old) MG/ML, 10 MG/ML (Use Morphine Sulfate)

6 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits butalbital-acetaminophen- PA; AL(At least oxycodone w/ P QL(6 ea daily) caffeine w/ codeine caps P 12 yrs old) acetaminophen tabs 300mg-50mg-40mg-30mg oxycodone-aspirin tabs P QL(6 ea daily) butalbital-acetaminophen- QL(4 ea daily); caffeine w/ codeine caps P AL(At least 12 OXYCODONE/ACETAMIN P QL(30 ml daily) 325mg-50mg-40mg-30mg yrs old) OPHEN SOLN QL(4 ea daily); PERCOCET TABS (Use QL(6 ea daily) butalbital-aspirin-caffeine P w/cod caps AL(At least 12 Oxycodone w/ NP yrs old) Acetaminophen) FIORICET/CODEINE PA; AL(At least REPREXAIN TABS (Use NP PA CAPS (Use Butalbital- NP 12 yrs old) Hydrocodone-Ibuprofen) Acetaminophen-Caffeine QL(4 ea daily); w/ Codeine) tramadol-acetaminophen P AL(At least 18 FIORINAL/CODEINE #3 QL(4 ea daily); tabs yrs old) CAPS (Use Butalbital- NP AL(At least 12 TYLENOL/CODEINE #3 QL(6 ea daily); Aspirin-Caffeine w/Cod) yrs old) TABS (Use Acetaminophen NP AL(At least 12 hydrocodone- QL(180 ml w/ Codeine) yrs old) acetaminophen soln daily) TYLENOL/CODEINE #4 QL(6 ea daily); 2.5mg/5ml-108mg/5ml, P TABS (Use Acetaminophen NP AL(At least 12 5mg/10ml-217mg/10ml, w/ Codeine) yrs old) 7.5mg/15ml-325mg/15ml QL(4 ea daily); hydrocodone- QL(6 ea daily) ULTRACET TABS (Use NP ) AL(At least 18 acetaminophen tabs 10mg- P Tramadol-Acetaminophen yrs old) 325mg XODOL TABS (Use PA hydrocodone- PA Hydrocodone- NP acetaminophen tabs 5mg- P Acetaminophen) 300mg, 10mg-300mg, 7.5mg-300mg Opioid Partial Agonists hydrocodone- QL(12 ea daily) BUNAVAIL FILM P acetaminophen tabs 5mg- P 325mg buprenorphine hcl subl P hydrocodone- QL(8 ea daily) acetaminophen tabs P buprenorphine hcl- P QL(3 ea daily) 7.5mg-325mg naloxone hcl dihydrate film buprenorphine hcl- QL(3 ea daily) hydrocodone-ibuprofen P PA P tabs naloxone hcl dihydrate subl PROBUPHINE IMPLANT SP IBUDONE TABS (Use NP PA P Hydrocodone-Ibuprofen) KIT IMPL NORCO TABS 10MG- QL(6 ea daily) SUBLOCADE SOSY P SP 325MG (Use Hydrocodone- NP Acetaminophen) SUBOXONE FILM P QL(3 ea daily) NORCO TABS 5MG- QL(12 ea daily) 325MG (Use Hydrocodone- NP ZUBSOLV SUBL P QL(3 ea daily) Acetaminophen) NORCO TABS 7.5MG- QL(8 ea daily) ANDROGENS-ANABOLIC - Drugs to Regulate 325MG (Use Hydrocodone- NP Hormones Acetaminophen) Androgens

7 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ANDRODERM PT24 P QL(1 ea daily) ANALPRAM HC SINGLES CREA (Use Hydrocortisone NP Acetate w/ Pramoxine) ANDROID CAPS (Use NP Methyltestosterone) ANALPRAM-HC CREA ANDROXY TABS P (Use Hydrocortisone NP Acetate w/ Pramoxine) AXIRON SOLN (Use PA NP hydrocortisone acetate w/ P Testosterone) pramoxine crea DEPO-TESTOSTERONE PA phenylephrine-shark liver P QL(12 ea per SOLN 100 MG/ML (Use NP oil-cocoa butter supp fill retail) Testosterone Cypionate) phenylephrine-shark liver QL(30 gm per DEPO-TESTOSTERONE PA; Limit 4mls oil-mineral oil-petrolatum P fill retail) SOLN 200 MG/ML (Use NP per oint ) month;QL(0.14 Testosterone Cypionate 29 ml daily) Rectal Local Anesthetics P QL(15 gm per METHITEST TABS P pramoxine hcl (rectal) foam fill retail) PROCTOFOAM FOAM QL(15 gm per METHYLTESTOSTERONE NP CAPS (Use Pramoxine HCl NP fill retail) (Rectal)) testosterone cypionate soln P PA 100 mg/ml Rectal Steroids PA; Limit 4mls ANUSOL-HC CREA (Use NP QL(30 gm per testosterone cypionate soln P per Hydrocortisone (Rectal)) fill retail) 200 mg/ml month;QL(0.14 hydrocortisone (rectal) crea P 29 ml daily) 1 % PA; Limit 4mls TESTOSTERONE hydrocortisone (rectal) crea P QL(30 gm per CYPIONATE SOLN 200 P per 2.5 % fill retail) MG/ML month;QL(0.14 29 ml daily) hydrocortisone acetate P (rectal) supp PA testosterone soln P PROCTOCORT CREA (Use Hydrocortisone NP TESTRED CAPS (Use NP (Rectal)) Methyltestosterone) PROCTOCORT SUPP ANORECTAL AGENTS - Rectal Drugs to Treat (Use Hydrocortisone NP Pain, Swelling and Itching Acetate (Rectal)) Intrarectal Steroids ANTACIDS CORTENEMA ENEM (Use QL(420 ml per Hydrocortisone NP fill retail) Antacid Combinations (Intrarectal)) alum & mag hydrox- QL(24 ml daily) hydrocortisone (intrarectal) QL(420 ml per P simethicone liqd P enem fill retail) 200mg/5ml-20mg/5ml- Rectal Combinations 200mg/5ml ANALPRAM HC CREA (Use Hydrocortisone NP Acetate w/ Pramoxine)

8 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits alum & mag hydrox- QL(24 ml daily) EMVERM CHEW P simethicone susp 200mg/5ml-20mg/5ml- ivermectin tabs P 200mg/5ml, 200mg/5ml- P 200mg/5ml-20mg/5ml- 20mg/5ml-200mg/5ml- pyrantel pamoate susp P 200mg/5ml STROMECTOL TABS (Use NP Antacids - Aluminum Salts Ivermectin) ALUMINUM HYDROXIDE P ANTI-INFECTIVE AGENTS - MISC. - Drugs to SUSP Treat Bacterial Infections Antacids - Bicarbonate Anti-infective Agents - Misc. Limit 496 per colistimethate sodium solr P sodium bicarbonate P (antacid) tabs month;QL(16.5 4 ea daily) COLY-MYCIN M SOLR Antacids - Calcium Salts (Use Colistimethate NP Sodium) calcium carbonate (antacid) chew 500 mg, P FLAGYL CAPS (Use NP 750 mg Metronidazole) TUMS CHEW (Use FLAGYL TABS (Use NP Calcium Carbonate NP Metronidazole) (Antacid)) metronidazole caps P TUMS CHEWY BITES CHEW (Use Calcium NP metronidazole tabs P Carbonate (Antacid)) TINDAMAX TABS (Use NP TUMS E-X 750 CHEW Tinidazole) (Use Calcium Carbonate NP (Antacid)) tinidazole tabs P TUMS EXTRA STRENGTH 750 CHEW (Use Calcium NP trimethoprim tabs P Carbonate (Antacid)) TUMS KIDS CHEW (Use Anti-infective Misc. - Combinations Calcium Carbonate NP BACTRIM DS TABS (Use (Antacid)) Sulfamethoxazole- NP TUMS LASTING EFFECTS Trimethoprim) CHEW (Use Calcium NP BACTRIM TABS (Use Carbonate (Antacid)) Sulfamethoxazole- NP TUMS SMOOTHIES Trimethoprim) CHEW (Use Calcium NP sulfamethoxazole- P Carbonate (Antacid)) trimethoprim susp Antacids - Magnesium Salts sulfamethoxazole- P trimethoprim tabs magnesium oxide tabs P Antiprotozoal Agents ANTHELMINTICS - Drugs to Treat Worm atovaquone susp P Infections MEPRON SUSP (Use NP Anthelmintics Atovaquone)

9 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Carbapenems CLEOCIN PEDIATRIC 1 rtl pack lmt GRANULES SOLR (Use NP per fill, imipenem-cilastatin solr P Clindamycin Palmitate Hydrochloride) meropenem solr P CLEOCIN PHOSPHATE SOLN (Use Clindamycin NP MERREM SOLR (Use NP Meropenem) Phosphate in D5W) CLEOCIN PHOSPHATE PRIMAXIN IV SOLR (Use NP Imipenem-Cilastatin) SOLN (Use Clindamycin NP Phosphate) Cyclic Lipopeptides clindamycin hcl caps P CUBICIN RF SOLR (Use NP Daptomycin) clindamycin palmitate P 1 rtl pack lmt hydrochloride solr per fill, CUBICIN SOLR (Use NP Daptomycin) clindamycin phosphate in P daptomycin solr 500 mg P d5w soln clindamycin phosphate soln P Glycopeptides LINCOCIN SOLN (Use NP FIRVANQ SOLR NP Lincomycin HCl) VANCOCIN HCL CAPS QL(4 ea daily) lincomycin hcl soln P 125 MG (Use Vancomycin NP HCl) Monobactams VANCOCIN HCL CAPS QL(8 ea daily) AZACTAM SOLR (Use NP 250 MG (Use Vancomycin NP Aztreonam) HCl) aztreonam solr P vancomycin hcl caps or P QL(4 ea daily) 125 mg Oxazolidinones vancomycin hcl caps or P QL(8 ea daily) 250 mg linezolid soln P vancomycin hcl solr iv 1 P QL(14 ea per gm, 1000 mg fill retail) linezolid susr P Limit 14 per vancomycin hcl solr iv 500 P month;QL(0.46 linezolid tabs P mg 7 ea daily) SIVEXTRO TABS P PA; QL(6 ea Leprostatics per fill retail) ZYVOX SOLN (Use NP dapsone tabs P Linezolid) Lincosamides ZYVOX SUSR (Use NP Linezolid) CLEOCIN CAPS OR 75 MG, 150 MG, 300 MG (Use NP ZYVOX TABS (Use NP Clindamycin HCl) Linezolid) CLEOCIN IN D5W SOLN ANTIANGINAL AGENTS - Drugs to Treat Chest (Use Clindamycin NP Pain Phosphate in D5W) Nitrates

10 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ISORDIL TITRADOSE MP hydroxyzine pamoate caps P TABS (Use Isosorbide NP 25 mg Dinitrate) hydroxyzine pamoate caps P MP ISOSORBIDE DINITRATE P MP 50 mg ER TBCR meprobamate tabs P isosorbide dinitrate tabs P MP VISTARIL CAPS 25 MG isosorbide mononitrate P QL(2 ea daily); (Use Hydroxyzine NP tabs 10 mg, 20 mg MP Pamoate) isosorbide mononitrate P QL(1 ea daily); VISTARIL CAPS 50 MG MP tb24 30 mg, 60 mg, 120 mg MP (Use Hydroxyzine NP Pamoate) NITRO-BID OINT P MP Benzodiazepines NITRO-DUR PT24 (Use MP NP alprazolam tabs 0.25 mg, P QL(4 ea daily) Nitroglycerin) 0.5 mg, 1 mg, 2 mg nitroglycerin cpcr or 9 mg, MP P alprazolam tb24 0.5 mg, 1 P QL(1 ea daily) 2.5 mg, 6.5 mg mg, 2 mg nitroglycerin pt24 td 0.1 MP QL(2 ea daily) mg/hr, 0.2 mg/hr, 0.4 P alprazolam tb24 3 mg P mg/hr, 0.6 mg/hr ATIVAN SOLN IJ 2 nitroglycerin soln tl 0.4 P MG/ML, 4 MG/ML (Use NP mg/spray Lorazepam) nitroglycerin subl sl 0.3 mg, MP P ATIVAN TABS OR 0.5 MG, NP QL(3 ea daily) 0.4 mg, 0.6 mg 2 MG (Use Lorazepam) NITROLINGUAL ATIVAN TABS OR 1 MG NP QL(4 ea daily) PUMPSPRAY SOLN (Use NP (Use Lorazepam) Nitroglycerin) chlordiazepoxide hcl caps P QL(4 ea daily) NITROSTAT SUBL (Use NP MP Nitroglycerin) clorazepate dipotassium P QL(3 ea daily) ANTIANXIETY AGENTS - Drugs to Treat Anxiety tabs DIAZEPAM SOLN IJ 5 P Antianxiety Agents - Misc. MG/ML P QL(3 ea daily); DIAZEPAM SOLN OR 5 P QL(500 ml per buspirone hcl tabs MP MG/5ML fill retail) droperidol soln P diazepam tabs or 2 mg, 5 P QL(4 ea daily) mg, 10 mg HYDROXYZINE HCL P SOLN IM 25 MG/ML lorazepam conc or 2 mg/ml P hydroxyzine hcl soln im 50 P lorazepam soln ij 2 mg/ml, P mg/ml 4 mg/ml, 20 mg/10ml hydroxyzine hcl syrp or 10 P lorazepam tabs or 0.5 mg, P QL(3 ea daily) mg/5ml 2 mg hydroxyzine hcl tabs or 10 P MP lorazepam tabs or 1 mg P QL(4 ea daily) mg, 25 mg, 50 mg oxazepam caps 10 mg, 15 QL(4 ea daily) HYDROXYZINE P P PAMOATE CAPS 100 MG mg, 30 mg

11 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits OXAZEPAM CAPS 30 MG P QL(4 ea daily) ANTIASTHMATIC AND BRONCHODILATOR AGENTS - Drugs to Treat Lung Conditions TRANXENE T TABS (Use NP QL(3 ea daily) Clorazepate Dipotassium) Anti-Inflammatory Agents QL(8 ml daily) VALIUM TABS (Use NP QL(4 ea daily) cromolyn sodium nebu P Diazepam) Bronchodilators - Anticholinergics XANAX TABS (Use NP QL(4 ea daily) Alprazolam) 1 rtl pack lmt XANAX XR TB24 0.5 MG, QL(1 ea daily) ATROVENT HFA AERS P amt,30 rtl pack 1 MG, 2 MG (Use NP lmt day(s), Alprazolam) INCRUSE ELLIPTA AEPB P QL(1 ea daily) XANAX XR TB24 3 MG NP QL(2 ea daily) (Use Alprazolam) 1 rtl pack lmt ipratropium bromide soln P amt,30 rtl pack ANTIARRHYTHMICS - Drugs to treat abnormal lmt day(s), heart rhythms 1 rtl pack lmt Antiarrhythmics Type I-A TUDORZA PRESSAIR P amt,30 rtl pack AEPB lmt day(s), disopyramide phosphate P MP caps Leukotriene Modulators NORPACE CAPS (Use MP NP ACCOLATE TABS (Use NP Disopyramide Phosphate) Zafirlukast) quinidine gluconate tbcr P montelukast sodium chew P QL(1 ea daily); 4 mg, 5 mg MP QUINIDINE SULFATE P montelukast sodium pack 4 P QL(1 ea daily) TABS mg Antiarrhythmics Type I-B montelukast sodium tabs P QL(1 ea daily); mexiletine hcl caps P MP 10 mg MP SINGULAIR CHEW 4 MG, QL(1 ea daily); Antiarrhythmics Type I-C 5 MG (Use Montelukast NP MP Sodium) flecainide acetate tabs P MP SINGULAIR PACK 4 MG NP QL(1 ea daily) (Use Montelukast Sodium) propafenone hcl cp12 225 P mg, 325 mg, 425 mg SINGULAIR TABS 10 MG NP QL(1 ea daily); (Use Montelukast Sodium) MP propafenone hcl tabs 150 P MP mg, 225 mg, 300 mg zafirlukast tabs P RYTHMOL SR CP12 (Use NP Propafenone HCl) zileuton tb12 P RYTHMOL TABS (Use NP MP Propafenone HCl) ZYFLO CR TB12 (Use NP Zileuton) Antiarrhythmics Type III Steroid Inhalants MP amiodarone hcl tabs P 1 rtl pack lmt AEROSPAN AERS P amt,30 rtl pack dofetilide caps P lmt day(s), QL(4 ml daily); TIKOSYN CAPS (Use NP budesonide (inhalation) Dofetilide) P AL(Up to 6 yrs susp old ) Western Sky Updated December 1, 2018 P-Preferred drug, NP-Non-preferred, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, RX/OTC - both Rx and OTC NDCs MP-Maintenance drug eligible for 90 day supply

12 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FLOVENT DISKUS AEPB P QL(2 ea daily) PROVENTIL HFA AERS NP

1 rtl pack lmt SEREVENT DISKUS P QL(2 ea daily) FLOVENT HFA AERO P amt,30 rtl pack AEPB lmt day(s), 1 rtl pack lmt 1 rtl pack lmt SYMBICORT AERO P amt,30 rtl pack PULMICORT FLEXHALER P amt,30 rtl pack lmt day(s), AEPB lmt day(s), terbutaline sulfate tabs P MP QL(4 ml daily); PULMICORT SUSP (Use NP Budesonide (Inhalation)) AL(Up to 6 yrs 2 rtl pack lmt old ) VENTOLIN HFA AERS P amt,30 rtl pack Sympathomimetics lmt day(s), VOSPIRE ER TB12 (Use ALBUTEROL SULFATE P NP ER TB12 Albuterol Sulfate) XOPENEX albuterol sulfate nebu in P QL(2 ml daily) 0.5 % CONCENTRATE NEBU NP (Use Levalbuterol HCl) albuterol sulfate nebu in QL(12.5 ml 0.63 mg/3ml, 0.083 %, 1.25 P daily) XOPENEX NEBU (Use NP mg/3ml Levalbuterol HCl) Xanthines albuterol sulfate syrp or 2 P mg/5ml ELIXOPHYLLIN ELIX P albuterol sulfate tabs or 2 P mg, 4 mg THEO-24 CP24 P albuterol sulfate tb12 or 4 P mg, 8 mg theophylline soln 80 P QL(475 ml per mg/15ml fill retail); MP COMBIVENT RESPIMAT 1 rtl pack lmt P amt,30 rtl pack theophylline tb12 100 mg, P MP AERS lmt day(s), 200 mg, 300 mg 1 rtl pack lmt theophylline tb12 450 mg P DULERA AERO P amt,30 rtl pack lmt day(s), theophylline tb24 400 mg, P MP 600 mg ipratropium-albuterol soln P QL(12 ml daily) ANTICOAGULANTS - Blood Thinners isoproterenol hcl soln P Coumarin Anticoagulants ISUPREL SOLN (Use NP COUMADIN TABS (Use NP MP Isoproterenol HCl) Warfarin Sodium) levalbuterol hcl nebu P warfarin sodium tabs P MP METAPROTERENOL QL(30 ml daily) Direct Factor Xa Inhibitors SULFATE SYRP 10 P MG/5ML ELIQUIS STARTER PACK P QL(4 ea daily) TABS METAPROTERENOL SULFATE TABS 10 MG, P ELIQUIS TABS P QL(4 ea daily) 20 MG QL(1 ea NP QL(0.57 gm PROAIR HFA AERS daily) XARELTO TABS 10 MG P daily,35 ea per 180 days retail) Western Sky Updated December 1, 2018 P-Preferred drug, NP-Non-preferred, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, RX/OTC - both Rx and OTC NDCs MP-Maintenance drug eligible for 90 day supply

13 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits XARELTO TABS 15 MG P QL(2 ea daily) HEPARIN SODIUM/SODIUM NP XARELTO TABS 20 MG P QL(1 ea daily) CHLORIDE SOLN IJ 2UNIT/ML-0.9% Heparins And Heparinoid-Like Agents QL(42 ml per 7 LOVENOX SOLN IJ 300 days retail)3 rtl ARIXTRA SOLN (Use NP SP Fondaparinux Sodium) MG/3ML (Use Enoxaparin NP MAX fill,180 rtl Sodium) day(s) supply,; QL(42 ml per 7 SP days retail)3 rtl enoxaparin sodium soln ij P MAX fill,180 rtl QL(14 ml per 7 300 mg/3ml day(s) supply,; LOVENOX SOLN SC 100 days retail)3 rtl SP MG/ML, 150 MG/ML (Use NP MAX fill,180 rtl Enoxaparin Sodium) day(s) supply,; QL(14 ml per 7 SP days retail)3 rtl enoxaparin sodium soln sc P MAX fill,180 rtl QL(5 ml per 7 100 mg/ml, 150 mg/ml day(s) supply,; LOVENOX SOLN SC 30 days retail)3 rtl SP MG/0.3ML (Use NP MAX fill,180 rtl Enoxaparin Sodium) day(s) supply,; QL(5 ml per 7 SP days retail)3 rtl enoxaparin sodium soln sc P MAX fill,180 rtl QL(6 ml per 7 30 mg/0.3ml day(s) supply,; LOVENOX SOLN SC 40 days retail)3 rtl SP MG/0.4ML (Use NP MAX fill,180 rtl Enoxaparin Sodium) day(s) supply,; QL(6 ml per 7 SP days retail)3 rtl enoxaparin sodium soln sc P MAX fill,180 rtl QL(9 ml per 7 40 mg/0.4ml day(s) supply,; LOVENOX SOLN SC 60 days retail)3 rtl SP MG/0.6ML (Use NP MAX fill,180 rtl Enoxaparin Sodium) day(s) supply,; QL(9 ml per 7 SP days retail)3 rtl enoxaparin sodium soln sc P MAX fill,180 rtl QL(12 ml per 7 60 mg/0.6ml day(s) supply,; LOVENOX SOLN SC 80 days retail)3 rtl SP MG/0.8ML, 120 MG/0.8ML NP MAX fill,180 rtl (Use Enoxaparin Sodium) day(s) supply,; QL(12 ml per 7 SP enoxaparin sodium soln sc days retail)3 rtl P MAX fill,180 rtl ANTICONVULSANTS - Drugs to Treat Seizures 80 mg/0.8ml, 120 mg/0.8ml day(s) supply,; SP AMPA Glutamate Receptor Antagonists fondaparinux sodium soln P SP FYCOMPA SUSP P heparin (porcine) in sodium P FYCOMPA TABS P chloride soln Anticonvulsants - Benzodiazepines heparin sodium (porcine) P soln clobazam susp P HEPARIN SODIUM/SODIUM clobazam tabs P CHLORIDE 0.9% SOLN NP (Use Heparin (Porcine) in clonazepam tabs 0.5 mg, 1 P QL(4 ea daily) Sodium Chloride) mg, 2 mg

14 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits clonazepam tbdp 0.125 FANATREX FUSEPAQ P mg, 0.25 mg, 0.5 mg, 1 mg, P SUSP 2 mg gabapentin caps 100 mg, P QL(4 ea daily); QL(1 ea per fill 300 mg, 400 mg MP DIASTAT ACUDIAL GEL P retail); AL(Up to gabapentin soln 250 P MP 21 yrs old ) mg/5ml, 300 mg/6ml QL(1 ea per fill gabapentin tabs 600 mg, P QL(4 ea daily); DIASTAT PEDIATRIC GEL P retail); AL(Up to 800 mg MP 21 yrs old ) KEPPRA SOLN IV 500 DIAZEPAM GEL RE 10 QL(1 ea per fill MG/5ML (Use NP P retail); AL(Up to Levetiracetam) MG, 20 MG, 2.5 MG 21 yrs old ) KEPPRA SOLN OR 100 QL(30 ml DIAZEPAM RECTAL GEL QL(1 ea per fill MG/ML (Use NP daily); MP P retail); AL(Up to Levetiracetam) GEL 21 yrs old ) KEPPRA TABS OR 1000 NP MP KLONOPIN TABS (Use NP QL(4 ea daily) MG (Use Levetiracetam) Clonazepam) KEPPRA TABS OR 250 QL(4 ea daily); ONFI SUSP (Use NP MG, 500 MG, 750 MG (Use NP MP Clobazam) Levetiracetam) ONFI TABS (Use NP KEPPRA XR TB24 (Use NP MP Clobazam) Levetiracetam) Anticonvulsants - Misc. LAMICTAL CHEWABLE MP PA; DISPERSIBLE CHEW (Use NP APTIOM TABS P Lamotrigine) BANZEL SUSP P SP LAMICTAL ODT KIT P

BANZEL TABS P SP LAMICTAL ODT TBDP 25 MG, 50 MG, 100 MG, 200 NP MG (Use Lamotrigine) BRIVIACT SOLN IV 50 P SP MG/5ML LAMICTAL STARTER/NOT TAKING BRIVIACT SOLN OR 10 P NP MG/ML CARBAMAZEPINE KIT BRIVIACT TABS OR 10 (Use Lamotrigine) MG, 25 MG, 50 MG, 75 P LAMICTAL MG, 100 MG STARTER/TAKING MP CARBAMAZEPINE/NOT NP carbamazepine chew P TAKING VALPROATE KIT MP (Use Lamotrigine) carbamazepine cp12 P LAMICTAL MP STARTER/TAKING NP carbamazepine susp P VALPROATE KIT (Use Lamotrigine) carbamazepine tabs P MP LAMICTAL TABS (Use NP MP Lamotrigine) carbamazepine tb12 P MP LAMICTAL XR KIT P CARBATROL CP12 (Use NP MP Carbamazepine)

15 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LAMICTAL XR TB24 25 NEURONTIN TABS 600 QL(4 ea daily); MG, 50 MG, 100 MG, 200 NP MG, 800 MG (Use NP MP MG, 250 MG, 300 MG (Use Gabapentin) Lamotrigine) oxcarbazepine susp P MP lamotrigine chew 5 mg, 25 P MP mg oxcarbazepine tabs P MP lamotrigine kit 25 mg, P OXTELLAR XR TB24 P lamotrigine tabs 25 mg, P MP 100 mg, 150 mg, 200 mg POTIGA TABS P PA; lamotrigine tb24 25 mg, 50 mg, 100 mg, 200 mg, 250 P primidone tabs P MP mg, 300 mg QUDEXY XR CS24 P lamotrigine tbdp 25 mg, 50 P mg, 100 mg, 200 mg SPRITAM TB3D P levetiracetam in sodium P chloride soln TEGRETOL SUSP (Use NP MP levetiracetam soln iv 500 P Carbamazepine) mg/5ml TEGRETOL TABS (Use NP MP LEVETIRACETAM SOLN Carbamazepine) IV 500MG/100ML- TEGRETOL-XR TB12 (Use NP MP 820MG/100ML, Carbamazepine) 1000MG/100ML- 750MG/100ML, NP TOPAMAX SPRINKLE QL(6 ea daily); 1500MG/100ML- CPSP 15 MG (Use NP MP 540MG/100ML (Use Topiramate) Levetiracetam in Sodium TOPAMAX SPRINKLE QL(8 ea daily); Chloride) CPSP 25 MG (Use NP MP Topiramate) levetiracetam soln or 100 P QL(30 ml mg/ml, 500 mg/5ml daily); MP TOPAMAX TABS (Use NP QL(3 ea daily); Topiramate) MP levetiracetam tabs or 1000 P MP mg P QL(6 ea daily); topiramate cpsp 15 mg MP levetiracetam tabs or 250 P QL(4 ea daily); mg, 500 mg, 750 mg MP P QL(8 ea daily); topiramate cpsp 25 mg MP levetiracetam tb24 or 500 P MP mg, 750 mg TOPIRAMATE ER CS24 P LYRICA CAPS P topiramate tabs 25 mg, 50 P QL(3 ea daily); mg, 100 mg, 200 mg MP LYRICA SOLN P TRILEPTAL SUSP (Use NP MP Oxcarbazepine) MYSOLINE TABS (Use NP MP Primidone) TRILEPTAL TABS (Use NP MP NEURONTIN CAPS 100 QL(4 ea daily); Oxcarbazepine) MG, 300 MG, 400 MG (Use NP MP Gabapentin) TROKENDI XR CP24 P VIMPAT SOLN IV 200 NEURONTIN SOLN 250 NP MP P MG/5ML (Use Gabapentin) MG/20ML

16 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VIMPAT SOLN OR 10 P fosphenytoin sodium soln P MG/ML PHENYTEK CAPS (Use MP VIMPAT TABS OR 50 MG, P PA; 100 MG, 150 MG, 200 MG Phenytoin Sodium NP Extended) ZONEGRAN CAPS (Use NP MP Zonisamide) phenytoin chew P MP zonisamide caps P MP phenytoin sodium extended P MP caps Carbamates phenytoin sodium soln P felbamate susp P phenytoin susp P MP felbamate tabs P Succinimides FELBATOL SUSP (Use NP Felbamate) ethosuximide caps P MP FELBATOL TABS (Use NP Felbamate) ethosuximide soln P MP GABA Modulators ZARONTIN CAPS (Use NP MP GABITRIL TABS 12 MG, Ethosuximide) 16 MG (Use Tiagabine NP ZARONTIN SOLN (Use NP MP HCl) Ethosuximide) GABITRIL TABS 2 MG, 4 NP MP Valproic Acid MG (Use Tiagabine HCl) DEPACON SOLN (Use NP SABRIL PACK (Use NP SP Valproate Sodium) Vigabatrin) DEPAKENE CAPS 250 MG NP MP SABRIL TABS P SP (Use Valproic Acid) DEPAKENE SOLN 250 tiagabine hcl tabs 12 mg, P 16 mg MG/5ML (Use Valproate NP Sodium) tiagabine hcl tabs 2 mg, 4 P MP mg DEPAKOTE ER TB24 (Use NP MP Divalproex Sodium) SP vigabatrin pack P DEPAKOTE SPRINKLES MP CSDR (Use Divalproex NP Hydantoins Sodium) CEREBYX SOLN (Use NP DEPAKOTE TBEC (Use NP MP Fosphenytoin Sodium) Divalproex Sodium) DILANTIN CAPS 100 MG MP MP (Use Phenytoin Sodium NP divalproex sodium csdr P Extended) divalproex sodium tb24 P MP DILANTIN CAPS 30 MG P divalproex sodium tbec P MP DILANTIN INFATABS NP MP CHEW (Use Phenytoin) valproate sodium soln P DILANTIN-125 SUSP (Use NP MP Phenytoin) valproic acid caps P MP

17 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ANTIDEPRESSANTS - Drugs to Treat citalopram hydrobromide P QL(1.5 ea Depression tabs 10 mg, 20 mg daily); MP citalopram hydrobromide P QL(1 ea daily); Alpha-2 Receptor Antagonists (Tetracyclics) tabs 40 mg MP mirtazapine tabs 15 mg, 30 P QL(1 ea daily); mg, 45 mg MP escitalopram oxalate soln 5 P mg/5ml mirtazapine tabs 7.5 mg P QL(1 ea daily) escitalopram oxalate tabs P QL(1.5 ea 10 mg daily) mirtazapine tbdp 15 mg, 30 P QL(1 ea daily) mg, 45 mg escitalopram oxalate tabs 5 P QL(1 ea daily); mg, 20 mg MP REMERON SOLTAB TBDP NP QL(1 ea daily) (Use Mirtazapine) fluoxetine hcl caps 10 mg, P QL(4 ea daily); 20 mg MP REMERON TABS (Use NP QL(1 ea daily); Mirtazapine) MP P QL(2 ea daily); fluoxetine hcl caps 40 mg MP Antidepressants - Misc. fluoxetine hcl soln 20 QL(4 ml daily); bupropion hcl tabs 75 mg, P QL(3 ea daily); P AL(At least 7 100 mg MP mg/5ml yrs old) bupropion hcl tb12 100 mg, P QL(2 ea daily); QL(1 ea daily); 150 mg, 200 mg MP fluoxetine hcl tabs 10 mg P AL(At least 13 yrs old); MP bupropion hcl tb24 150 mg, P QL(1 ea daily); 300 mg MP fluoxetine hcl tabs 20 mg, P MAPROTILINE HCL TABS P 60 mg FLUOXETINE P WELLBUTRIN SR TB12 NP QL(2 ea daily); HYDROCHLORIDE TABS (Use Bupropion HCl) MP FLUOXETINE WELLBUTRIN XL TB24 NP QL(1 ea daily); HYDROCHLORIDE TABS NP (Use Bupropion HCl) MP (Use Fluoxetine HCl) Monoamine Oxidase Inhibitors (MAOIs) fluvoxamine maleate cp24 P 100 mg, 150 mg NARDIL TABS (Use NP Phenelzine Sulfate) fluvoxamine maleate tabs P QL(3 ea daily) 100 mg PARNATE TABS (Use NP Tranylcypromine Sulfate) fluvoxamine maleate tabs P QL(2 ea daily) 25 mg, 50 mg phenelzine sulfate tabs P LEXAPRO SOLN 5 MG/5ML (Use Escitalopram NP tranylcypromine sulfate P tabs Oxalate) Selective Serotonin Reuptake Inhibitors (SSRIs) LEXAPRO TABS 10 MG NP QL(1.5 ea (Use Escitalopram Oxalate) daily) CELEXA TABS 10 MG, 20 QL(1.5 ea MG (Use Citalopram NP daily); MP LEXAPRO TABS 5 MG, 20 QL(1 ea daily); Hydrobromide) MG (Use Escitalopram NP MP Oxalate) CELEXA TABS 40 MG QL(1 ea daily); (Use Citalopram NP MP paroxetine hcl tabs 10 mg, P QL(2 ea daily); Hydrobromide) 20 mg, 30 mg, 40 mg MP paroxetine hcl tb24 25 mg, citalopram hydrobromide P QL(8 ml daily) P soln 10 mg/5ml 12.5 mg, 37.5 mg

18 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PAXIL CR TB24 (Use NP PRISTIQ TB24 (Use NP Paroxetine HCl) Desvenlafaxine Succinate) PAXIL SUSP 10 MG/5ML P QL(40 ml daily) venlafaxine hcl cp24 75 P QL(1 ea daily); mg, 150 mg, 37.5 mg MP PAXIL TABS 10 MG, 20 QL(2 ea daily); venlafaxine hcl tabs 25 mg, P MG, 30 MG, 40 MG (Use NP MP 50 mg, 100 mg Paroxetine HCl) venlafaxine hcl tabs 75 mg, P MP PROZAC CAPS 10 MG, 20 NP QL(4 ea daily); 37.5 mg MG (Use Fluoxetine HCl) MP venlafaxine hcl tb24 75 mg, P QL(1 ea daily) PROZAC CAPS 40 MG NP QL(2 ea daily); 150 mg, 225 mg, 37.5 mg (Use Fluoxetine HCl) MP Tricyclic Agents sertraline hcl conc 20 P QL(10 ml daily) mg/ml amitriptyline hcl tabs P P QL(2 ea daily); sertraline hcl tabs 100 mg MP AMOXAPINE TABS P sertraline hcl tabs 25 mg, QL(1.5 ea P ANAFRANIL CAPS (Use NP 50 mg daily); MP Clomipramine HCl) ZOLOFT CONC 20 MG/ML NP QL(10 ml daily) (Use Sertraline HCl) clomipramine hcl caps P ZOLOFT TABS 100 MG NP QL(2 ea daily); desipramine hcl tabs 10 (Use Sertraline HCl) MP mg, 50 mg, 75 mg, 100 mg, P 150 mg ZOLOFT TABS 25 MG, 50 NP QL(1.5 ea MG (Use Sertraline HCl) daily); MP desipramine hcl tabs 25 mg P QL(2 ea daily) Serotonin Modulators doxepin hcl caps P NEFAZODONE HCL TABS P 100 MG, 150 MG doxepin hcl conc P nefazodone hcl tabs 50 P mg, 250 mg ELAVIL TABS (Use NP NEFAZODONE P Amitriptyline HCl) HYDROCHLORIDE TABS imipramine hcl tabs P trazodone hcl tabs 300 mg P QL(2 ea daily) imipramine pamoate caps P trazodone hcl tabs 50 mg, P MP 100 mg, 150 mg NORPRAMIN TABS 10 MG NP (Use Desipramine HCl) P PA; QL(1 ea VIIBRYD TABS daily) NORPRAMIN TABS 25 MG NP QL(2 ea daily) Serotonin-Norepinephrine Reuptake Inhibitors (Use Desipramine HCl) nortriptyline hcl caps 10 CYMBALTA CPEP (Use NP QL(1 ea daily); P Duloxetine HCl) MP mg, 25 mg, 50 mg, 75 mg NORTRIPTYLINE HCL QL(20 ml daily) desvenlafaxine succinate P P tb24 SOLN 10 MG/5ML nortriptyline hcl soln 10 QL(20 ml daily) P QL(1 ea daily); P duloxetine hcl cpep MP mg/5ml PAMELOR CAPS (Use EFFEXOR XR CP24 (Use NP QL(1 ea daily); NP Venlafaxine HCl) MP Nortriptyline HCl)

19 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits protriptyline hcl tabs P P QL(2 ea daily); JENTADUETO TABS MP SURMONTIL CAPS (Use NP QL(2 ea daily) Trimipramine Maleate) JENTADUETO XR TB24 P TOFRANIL TABS (Use NP KAZANO TABS (Use NF QL(1 ea daily); Imipramine HCl) Alogliptin-Metformin HCl) MP trimipramine maleate caps P OSENI TABS (Use NF QL(1 ea daily); Alogliptin-Pioglitazone) MP ANTIDIABETICS - Drugs to Regulate Blood pioglitazone hcl-glimepiride P Sugar tabs Alpha-Glucosidase Inhibitors pioglitazone hcl-metformin P QL(2 ea daily); hcl tabs MP acarbose tabs P Biguanides GLYSET TABS (Use NP FORTAMET TB24 (Use NP PA Miglitol) Metformin HCl) miglitol tabs P GLUCOPHAGE TABS QL(2 ea daily); 1000 MG (Use Metformin NP MP PRECOSE TABS (Use NP HCl) Acarbose) GLUCOPHAGE TABS 500 NP QL(5 ea daily); Antidiabetic - Amylin Analogs MG (Use Metformin HCl) MP Limit 4 pens GLUCOPHAGE TABS 850 NP QL(3 ea daily); MG (Use Metformin HCl) MP SYMLINPEN 120 SOPN P per month;QL(0.36 GLUCOPHAGE XR TB24 QL(4 ea daily); ml daily) 500 MG (Use Metformin NP MP Limit 4 pens HCl) SYMLINPEN 60 SOPN P per GLUCOPHAGE XR TB24 QL(2 ea daily); month;QL(0.2 750 MG (Use Metformin NP MP ml daily) HCl) Antidiabetic Combinations GLUMETZA TB24 (Use NP PA ACTOPLUS MET TABS QL(2 ea daily); Metformin HCl) (Use Pioglitazone HCl- NP MP metformin hcl tabs 1000 P QL(2 ea daily); Metformin HCl) mg MP QL(5 ea daily); alogliptin-metformin hcl P QL(1 ea daily); metformin hcl tabs 500 mg P tabs MP MP QL(3 ea daily); P QL(1 ea daily); metformin hcl tabs 850 mg P alogliptin-pioglitazone tabs MP MP DUETACT TABS (Use metformin hcl tb24 500 mg P QL(4 ea daily); Pioglitazone HCl- NP MP Glimepiride) metformin hcl tb24 500 mg, P PA 1000 mg glipizide-metformin hcl tabs P MP metformin hcl tb24 750 mg P QL(2 ea daily); GLUCOVANCE TABS (Use NP MP MP Glyburide-Metformin) Diabetic Other glyburide-metformin tabs P MP BD GLUCOSE CHEW P

20 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limit 50 per PA; Limit 1 CVS GLUCOSE CHEW P month;QL(1.67 P syringe per ea daily) BYDUREON PEN PEN month;QL(0.14 Limit 50 per 3 ea daily) DEX4 QUICK DISSOLVE P GLUCOSE CHEW month;QL(1.67 PA; Limit 1 ea daily) P syringe per BYDUREON SRER month;QL(0.14 GLUCAGEN HYPOKIT P QL(1 ea per fill SOLR retail) 3 ea daily) PA; Limit 1 GLUCAGON P QL(1 ea per fill EMERGENCY KIT KIT retail) BYETTA SOPN 10 P syringe per MCG/0.04ML month;QL(0.08 Limit 50 per ml daily) GLUCOSE CHEW P month;QL(1.67 ea daily) PA; Limit 1 BYETTA SOPN 5 P syringe per Limit 50 per MCG/0.02ML month;QL(0.04 GNP GLUCOSE CHEW P month;QL(1.67 ml daily) ea daily) PA Limit 50 per OZEMPIC SOPN P GNP QUICK DISSOLVE P month;QL(1.67 GLUCOSE CHEW ea daily) TANZEUM PEN P PA LEADER QUICK Limit 50 per PA DISSOLVE GLUCOSE P month;QL(1.67 TRULICITY SOPN P CHEW ea daily) PA; Limit 3 PROGLYCEM SUSP P P syringes per VICTOZA SOPN month;QL(0.3 Limit 50 per ml daily) SM GLUCOSE CHEW P month;QL(1.67 ea daily) Insulin Sensitizing Agents Limit 50 per ACTOS TABS (Use NP QL(1 ea daily); WALGREENS GLUCOSE P Pioglitazone HCl) MP CHEW month;QL(1.67 ea daily) P QL(1 ea daily); AVANDIA TABS MP Dipeptidyl Peptidase-4 (DPP-4) Inhibitors pioglitazone hcl tabs P QL(1 ea daily); P QL(1 ea daily); MP alogliptin benzoate tabs MP Insulin NESINA TABS (Use NF QL(1 ea daily); Alogliptin Benzoate) MP Limit 40mls per QL(1 ea daily); ADMELOG SOLN P month;QL(1.34 TRADJENTA TABS P AL(At least 18 ml daily) yrs old); MP ADMELOG SOLOSTAR P QL(1 ml daily) SOPN Incretin Mimetic Agents (GLP-1 Receptor Limit 30mls per ADLYXIN SOPN P PA APIDRA SOLN P month;QL(1 ml daily) ADLYXIN STARTER PACK P PA PNKT APIDRA SOLOSTAR P QL(1 ml daily) SOPN BYDUREON BCISE AUIJ P PA BASAGLAR KWIKPEN P SOPN

21 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FIASP FLEXTOUCH QL(1 ml daily) Limit 40mls per P NOVOLIN 70/30 RELION P SOPN SUSP month;QL(1.34 Limit 30mls per ml daily) FIASP SOLN P month;QL(1 ml Limit 40mls per daily) NOVOLIN 70/30 SUSP P month;QL(1.34 ml daily) HUMALOG JUNIOR P QL(1 ml daily) KWIKPEN SOPN Limit 40mls per NOVOLIN N RELION P month;QL(1.34 HUMALOG KWIKPEN P QL(1 ml daily) SUSP SOPN ml daily) Limit 40mls per HUMALOG MIX 50/50 P QL(1 ml daily) KWIKPEN SUPN NOVOLIN N SUSP P month;QL(1.34 ml daily) HUMALOG MIX 50/50 Limit 40mls per P month;QL(1.34 NOVOLIN R RELION Limit 40mls per SUSP ml daily) P month;QL(1.34 SOLN ml daily) HUMALOG MIX 75/25 P QL(1 ml daily) KWIKPEN SUPN Limit 40mls per NOVOLIN R SOLN P month;QL(1.34 Limit 40mls per ml daily) HUMALOG MIX 75/25 P SUSP month;QL(1.34 ml daily) NOVOLOG FLEXPEN P QL(1 ml daily) SOPN QL(1 ml daily) HUMALOG SOCT P NOVOLOG MIX 70/30 QL(1 ml daily) Limit 40mls per PREFILLED FLEXPEN P HUMALOG SOLN P month;QL(1.34 SUPN ml daily) Limit 40mls per NOVOLOG MIX 70/30 P month;QL(1.34 HUMULIN 70/30 KWIKPEN P QL(1 ml daily) SUSP SUPN ml daily) Limit 40mls per NOVOLOG PENFILL P QL(1 ml daily) HUMULIN 70/30 SUSP P month;QL(1.34 SOCT ml daily) Limit 30mls per NOVOLOG SOLN P month;QL(1 ml HUMULIN N KWIKPEN P QL(1 ml daily) SUPN daily) Limit 40mls per Meglitinide Analogues HUMULIN N SUSP P month;QL(1.34 P QL(3 ea daily); ml daily) nateglinide tabs MP Limit 40mls per PRANDIN TABS (Use NP HUMULIN R SOLN P month;QL(1.34 Repaglinide) ml daily) repaglinide tabs P HUMULIN R U-500 P QL(1.34 ml (CONCENTRATED) SOLN daily) STARLIX TABS (Use NP QL(3 ea daily); Nateglinide) MP HUMULIN R U-500 P QL(1.34 ml KWIKPEN SOPN daily) Sodium-Glucose Co-Transporter 2 (SGLT2) LANTUS SOLOSTAR NP PA MP SOPN INVOKANA TABS P NOVOLIN 70/30 FLEXPEN P QL(1 ml daily) QL(1 ea daily) RELION SUPN JARDIANCE TABS P NOVOLIN 70/30 FLEXPEN P QL(1 ml daily) Sulfonylureas SUPN Western Sky Updated December 1, 2018 P-Preferred drug, NP-Non-preferred, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, RX/OTC - both Rx and OTC NDCs MP-Maintenance drug eligible for 90 day supply

22 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AMARYL TABS 1 MG, 2 NP QL(1 ea daily); DIPHENOXYLATE/ATROP P MG (Use Glimepiride) MP INE LIQD AMARYL TABS 4 MG (Use NP QL(2 ea daily); IMODIUM A-D CAPS (Use NP RX/OTC Glimepiride) MP Loperamide HCl) glimepiride tabs 1 mg, 2 P QL(1 ea daily); IMODIUM A-D TABS (Use NP QL(2 ea daily) mg MP Loperamide HCl) P QL(2 ea daily); LOMOTIL TABS (Use NP glimepiride tabs 4 mg MP Diphenoxylate w/ Atropine) glipizide tabs P MP loperamide hcl caps 2 mg P RX/OTC glipizide tb24 P MP loperamide hcl liqd 1 P mg/5ml GLUCOTROL TABS (Use NP MP QL(2 ea daily) Glipizide) loperamide hcl tabs 2 mg P GLUCOTROL XL TB24 NP MP (Use Glipizide) ANTIDOTES AND SPECIFIC ANTAGONISTS glyburide micronized tabs P MP Antidotes - Chelating Agents CHEMET CAPS P glyburide tabs P MP JADENU SPRINKLE PACK P PA; SP GLYNASE TABS (Use NP MP Glyburide Micronized) JADENU TABS P PA; SP ANTIDIARRHEAL/PROBIOTIC AGENTS - Drugs to Treat Diarrhea Opioid Antagonists Antidiarrheal/Probiotic Agents - Misc. 2 rtl pack lmt naloxone hcl soln 0.4 P amt,30 rtl pack Acidophilus cap-misc P mg/ml lmt day(s), NALOXONE HCL SOSY 2 QL(8 ml per 30 bismuth subsalicylate chew P P 262 mg MG/2ML days retail) bismuth subsalicylate susp P naltrexone hcl tabs P 525 mg/15ml PEPTO-BISMOL CHEW NARCAN LIQD P 262 MG (Use Bismuth NP Subsalicylate) VIVITROL SUSR P SP PEPTO-BISMOL INSTACOOL CHEW (Use NP ANTIEMETICS - Drugs to Treat Nausea and Bismuth Subsalicylate) Vomiting PEPTO-BISMOL MAX 5-HT3 Receptor Antagonists STRENGTH SUSP (Use NP ondansetron hcl soln ij 4 P Bismuth Subsalicylate) mg/2ml, 40 mg/20ml PEPTO-BISMOL TO-GO ondansetron hcl soln or 4 P QL(30 ml daily) CHEW (Use Bismuth NP mg/5ml Subsalicylate) ondansetron hcl tabs or 24 P QL(1 ea daily) Antiperistaltic Agents mg diphenoxylate w/ atropine P ondansetron hcl tabs or 4 P QL(3 ea daily) tabs mg, 8 mg

23 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ONDANSETRON P griseofulvin microsize susp P HYDROCHLORIDE SOLN ondansetron tbdp P QL(3 ea daily) griseofulvin microsize tabs P griseofulvin ultramicrosize ZOFRAN ODT TBDP (Use NP QL(3 ea daily) P Ondansetron) tabs ZOFRAN SOLN 4 MG/5ML QL(30 ml daily) QL(1 ea NP LAMISIL TABS (Use NP (Use Ondansetron HCl) Terbinafine HCl) daily,90 ea per ZOFRAN TABS 4 MG, 8 QL(3 ea daily) 120 days retail) MG (Use Ondansetron NP nystatin tabs P QL(6 ea daily) HCl) QL(1 ea Antiemetics - Anticholinergic terbinafine hcl tabs P daily,90 ea per dimenhydrinate tabs P 120 days retail) Imidazole-Related Antifungals DRAMAMINE TABS (Use NP Dimenhydrinate) DIFLUCAN SUSR 10 1 rtl pack lmt MG/ML, 40 MG/ML (Use NP per fill, meclizine hcl chew 25 mg P Fluconazole) DIFLUCAN TABS 100 MG QL(1 ea daily) meclizine hcl tabs 25 mg, P RX/OTC NP 12.5 mg (Use Fluconazole) DIFLUCAN TABS 150 MG QL(2 ea per fill TIGAN CAPS (Use NP NP Trimethobenzamide HCl) (Use Fluconazole) retail) DIFLUCAN TABS 200 MG QL(2 ea daily) trimethobenzamide hcl P NP caps (Use Fluconazole) DIFLUCAN TABS 50 MG NP QL(7 ea per fill Antiemetics - Miscellaneous (Use Fluconazole) retail) dronabinol caps P PA fluconazole susr 10 mg/ml, P 1 rtl pack lmt 40 mg/ml per fill, MARINOL CAPS (Use NP PA Dronabinol) fluconazole tabs 100 mg P QL(1 ea daily) Substance P/Neurokinin 1 (NK1) Receptor fluconazole tabs 150 mg P QL(2 ea per fill aprepitant caps P PA retail) fluconazole tabs 200 mg P QL(2 ea daily) EMEND CAPS (Use NP PA Aprepitant) fluconazole tabs 50 mg P QL(7 ea per fill EMEND TRIPACK CAPS NP PA retail) (Use Aprepitant) P PA; QL(1 ea itraconazole caps daily) ANTIFUNGALS - Drugs to Treat Fungal Infections SPORANOX CAPS (Use NP PA; QL(1 ea Antifungals Itraconazole) daily) SPORANOX PULSEPAK PA; QL(1 ea ANCOBON CAPS (Use NP NP Flucytosine) CAPS (Use Itraconazole) daily) flucytosine caps P VFEND IV SOLR (Use NP Voriconazole) GRIS-PEG TABS (Use NP VFEND SUSR (Use NP Griseofulvin Ultramicrosize) Voriconazole)

24 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VFEND TABS (Use NP TAVIST ALLERGY TABS NP QL(2 ea daily) Voriconazole) (Use Clemastine Fumarate) voriconazole solr P Antihistamines - Non-Sedating ALLEGRA ALLERGY QL(1 ea daily) voriconazole susr P TABS 180 MG (Use NP Fexofenadine HCl) voriconazole tabs P ALLEGRA ALLERGY QL(2 ea daily) TABS 60 MG (Use NP ANTIHISTAMINES - Drugs to Treat Allergies Fexofenadine HCl) cetirizine hcl chew 5 mg, 10 P QL(1 ea daily) Antihistamines - Alkylamines mg CHLOR-TRIMETON SYRP QL(60 ml daily) QL(240 ml per 2 MG/5ML (Use NP cetirizine hcl soln 1 mg/ml, P fill retail); Chlorpheniramine Maleate) 5 mg/5ml AL(Up to 12 yrs CHLOR-TRIMETON TABS QL(120 ea per old ); RX/OTC 4 MG (Use NP fill retail) QL(240 ml per Chlorpheniramine Maleate) cetirizine hcl syrp 1 mg/ml, P fill retail); chlorpheniramine maleate P QL(60 ml daily) 5 mg/5ml AL(Up to 12 yrs syrp 2 mg/5ml old ); RX/OTC chlorpheniramine maleate QL(120 ea per P cetirizine hcl tabs 5 mg, 10 P QL(1 ea daily) tabs 4 mg fill retail) mg Antihistamines - Ethanolamines CLARINEX TABS (Use NP BENADRYL ALLERGY QL(4 ea daily) Desloratadine) CAPS (Use NP CLARITIN ALLERGY QL(240 ml per Diphenhydramine HCl) CHILDRENS SYRP (Use NP fill retail) BENADRYL ALLERGY QL(240 ml per Loratadine) CHILDRENS LIQD (Use NP fill retail) CLARITIN REDITABS NP Diphenhydramine HCl) TBDP (Use Loratadine) BENADRYL ALLERGY QL(4 ea daily) CLARITIN SYRP 5 NP QL(240 ml per TABS (Use NP MG/5ML (Use Loratadine) fill retail) Diphenhydramine HCl) CLARITIN TABS 10 MG NP clemastine fumarate tabs P QL(2 ea daily) (Use Loratadine) desloratadine tabs P diphenhydramine hcl caps P QL(4 ea daily) 25 mg fexofenadine hcl tabs 180 P QL(1 ea daily) mg diphenhydramine hcl caps P QL(4 ea daily); 50 mg RX/OTC fexofenadine hcl tabs 60 P QL(2 ea daily) QL(240 ml per mg diphenhydramine hcl elix P fill retail); 12.5 mg/5ml levocetirizine P RX/OTC RX/OTC dihydrochloride tabs diphenhydramine hcl liqd QL(240 ml per P QL(240 ml per 25 mg/10ml, 50 mg/20ml, P fill retail) loratadine soln 5 mg/5ml fill retail) 12.5 mg/5ml loratadine syrp 5 mg/5ml P QL(240 ml per diphenhydramine hcl tabs P QL(4 ea daily) fill retail) 25 mg loratadine tabs 10 mg P P QL(240 ml per SILPHEN COUGH SYRP fill retail) Western Sky Updated December 1, 2018 P-Preferred drug, NP-Non-preferred, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, RX/OTC - both Rx and OTC NDCs MP-Maintenance drug eligible for 90 day supply

25 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits loratadine tbdp 10 mg P omega-3-acid ethyl esters P caps XYZAL ALLERGY 24HR RX/OTC Bile Acid Sequestrants TABS (Use Levocetirizine NP Dihydrochloride) cholestyramine light pack P MP XYZAL TABS (Use RX/OTC Levocetirizine NP cholestyramine light powd P MP Dihydrochloride) cholestyramine pack P MP ZYRTEC ALLERGY TABS NP QL(1 ea daily) (Use Cetirizine HCl) cholestyramine powd P MP ZYRTEC CHILDRENS QL(240 ml per ALLERGY SOLN (Use NP fill retail); COLESTID FLAVORED MP Cetirizine HCl) AL(Up to 12 yrs GRAN 5 GM (Use NP old ); RX/OTC Colestipol HCl) Antihistamines - Phenothiazines COLESTID FLAVORED PACK 5 GM/7.5GM (Use NP PHENERGAN SOLN (Use NP Promethazine HCl) Colestipol HCl) COLESTID GRAN 5 GM MP promethazine hcl soln ij 25 P NP mg/ml, 50 mg/ml (Use Colestipol HCl) QL(240 ml per COLESTID PACK 5 GM NP promethazine hcl soln or P (Use Colestipol HCl) 6.25 mg/5ml fill retail); AL(At least 2 yrs old) COLESTID TABS 1 GM NP MP (Use Colestipol HCl) promethazine hcl supp re QL(12 ea per P fill retail); AL(At colestipol hcl gran 5 gm P MP 25 mg, 50 mg, 12.5 mg least 2 yrs old) QL(240 ml per colestipol hcl pack 5 gm P promethazine hcl syrp or P 6.25 mg/5ml fill retail); AL(At least 2 yrs old) colestipol hcl tabs 1 gm P MP promethazine hcl tabs or P AL(At least 2 25 mg, 50 mg, 12.5 mg yrs old) QUESTRAN LIGHT POWD NP MP (Use Cholestyramine Light) Antihistamines - Piperidines QUESTRAN PACK (Use NP MP cyproheptadine hcl syrp P Cholestyramine) QUESTRAN POWD (Use NP MP cyproheptadine hcl tabs P Cholestyramine) ANTIHYPERLIPIDEMICS - Drugs to Treat High Fibric Acid Derivatives Cholesterol choline fenofibrate cpdr P Antihyperlipidemics - Combinations fenofibrate micronized caps P QL(1 ea daily); P PA; QL(1 ea 134 mg, 200 mg MP ezetimibe-simvastatin tabs daily) fenofibrate micronized caps P QL(2 ea daily); VYTORIN TABS (Use NP PA; QL(1 ea 67 mg MP Ezetimibe-Simvastatin) daily) FENOFIBRATE TABS 160 P QL(1 ea daily); Antihyperlipidemics - Misc. MG MP LOVAZA CAPS (Use fenofibrate tabs 160 mg P QL(1 ea daily); Omega-3-acid Ethyl NP MP Esters) Western Sky Updated December 1, 2018 P-Preferred drug, NP-Non-preferred, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, RX/OTC - both Rx and OTC NDCs MP-Maintenance drug eligible for 90 day supply

26 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits fenofibrate tabs 40 mg, 48 P ZOCOR TABS 80 MG (Use NP MP mg, 120 mg, 145 mg Simvastatin) P QL(3 ea daily); Intestinal Cholesterol Absorption Inhibitors fenofibrate tabs 54 mg MP ezetimibe tabs P PA FENOGLIDE TABS (Use NP Fenofibrate) ZETIA TABS (Use NP PA P QL(2 ea daily); Ezetimibe) gemfibrozil tabs MP Nicotinic Acid Derivatives LOFIBRA CAPS (Use NP QL(1 ea daily); Fenofibrate Micronized) MP niacin (antihyperlipidemic) P tbcr LOFIBRA TABS (Use NP QL(1 ea daily); Fenofibrate) MP NIACOR TABS P MP LOPID TABS (Use QL(2 ea daily); NP NIASPAN TBCR (Use NP Gemfibrozil) MP Niacin (Antihyperlipidemic)) TRICOR TABS (Use NP Fenofibrate) ANTIHYPERTENSIVES - Drugs to Treat High Blood Pressure P QL(1 ea daily); TRIGLIDE TABS MP ACE Inhibitors ACCUPRIL TABS (Use QL(1 ea daily); TRILIPIX CPDR (Use NP NP Choline Fenofibrate) Quinapril HCl) MP HMG CoA Reductase Inhibitors ACEON TABS (Use NP Perindopril Erbumine) atorvastatin calcium tabs P QL(1 ea daily); MP ALTACE CAPS (Use NP QL(2 ea daily); Ramipril) MP fluvastatin sodium tb24 P P QL(2 ea daily); benazepril hcl tabs 40 mg MP LESCOL XL TB24 (Use NP Fluvastatin Sodium) benazepril hcl tabs 5 mg, P QL(1 ea daily); 10 mg, 20 mg MP LIPITOR TABS (Use NP QL(1 ea daily); Atorvastatin Calcium) MP P QL(3 ea daily); captopril tabs MP lovastatin tabs 10 mg, 20 P QL(1 ea daily); mg MP P QL(2 ea daily); enalapril maleate tabs MP lovastatin tabs 40 mg P QL(2 ea daily); MP P AL(Up to 8 yrs EPANED SOLR old ) MEVACOR TABS (Use NP QL(2 ea daily); Lovastatin) MP P QL(1 ea daily); fosinopril sodium tabs MP PRAVACHOL TABS (Use NP QL(1 ea daily); Pravastatin Sodium) MP P QL(1 ea daily); lisinopril tabs 2.5 mg MP pravastatin sodium tabs P QL(1 ea daily); MP lisinopril tabs 5 mg, 10 mg, P QL(2 ea daily); 20 mg, 30 mg, 40 mg MP simvastatin tabs 5 mg, 10 P QL(1 ea daily); mg, 20 mg, 40 mg MP LOTENSIN TABS 10 MG, QL(1 ea daily); MP 20 MG (Use Benazepril NP MP simvastatin tabs 80 mg P HCl) ZOCOR TABS 5 MG, 10 QL(1 ea daily); LOTENSIN TABS 40 MG NP QL(2 ea daily); MG, 20 MG, 40 MG (Use NP MP (Use Benazepril HCl) MP Simvastatin) Western Sky Updated December 1, 2018 P-Preferred drug, NP-Non-preferred, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, RX/OTC - both Rx and OTC NDCs MP-Maintenance drug eligible for 90 day supply

27 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MAVIK TABS (Use NP QL(1 ea daily); olmesartan medoxomil tabs P Trandolapril) MP QL(1 ea daily) perindopril erbumine tabs P telmisartan tabs P QL(1 ea daily); PRINIVIL TABS (Use NP QL(2 ea daily); valsartan tabs P Lisinopril) MP MP P QL(1 ea daily); Antiadrenergic Antihypertensives quinapril hcl tabs MP CARDURA TABS (Use NP MP P QL(2 ea daily); Doxazosin Mesylate) ramipril caps MP CATAPRES TABS (Use NP MP trandolapril tabs 1 mg, 2 P QL(1 ea daily); Clonidine HCl) mg MP clonidine hcl tabs P MP P QL(2 ea daily); trandolapril tabs 4 mg MP doxazosin mesylate tabs P MP VASOTEC TABS (Use NP QL(2 ea daily); Enalapril Maleate) MP guanfacine hcl tabs P MP ZESTRIL TABS 2.5 MG NP QL(1 ea daily); (Use Lisinopril) MP methyldopa tabs P MP ZESTRIL TABS 5 MG, 10 QL(2 ea daily); MG, 20 MG, 30 MG, 40 MG NP MP MINIPRESS CAPS (Use NP MP (Use Lisinopril) Prazosin HCl) MP Agents for Pheochromocytoma prazosin hcl caps P DIBENZYLINE CAPS (Use NP TENEX TABS (Use NP MP Phenoxybenzamine HCl) Guanfacine HCl) phenoxybenzamine hcl P MP caps terazosin hcl caps P Angiotensin II Receptor Antagonists Antihypertensive Combinations ACCURETIC TABS 10MG- QL(3 ea daily) ATACAND TABS (Use NP Candesartan Cilexetil) 12.5MG (Use Quinapril- NP Hydrochlorothiazide) AVAPRO TABS (Use NP QL(1 ea daily); Irbesartan) MP ACCURETIC TABS 20MG- QL(4 ea daily) 12.5MG (Use Quinapril- NP BENICAR TABS (Use NP Olmesartan Medoxomil) Hydrochlorothiazide) ACCURETIC TABS 20MG- QL(2 ea daily) candesartan cilexetil tabs P 25MG (Use Quinapril- NP Hydrochlorothiazide) COZAAR TABS (Use NP QL(1 ea daily); Losartan Potassium) MP amlodipine besylate- QL(1 ea daily); benazepril hcl caps 5mg- MP DIOVAN TABS (Use NP QL(1 ea daily); P Valsartan) MP 10mg, 5mg-20mg, 10mg- 20mg, 2.5mg-10mg P QL(1 ea daily); irbesartan tabs MP amlodipine besylate- MP benazepril hcl caps 5mg- P P QL(1 ea daily); 40mg, 10mg-40mg losartan potassium tabs MP amlodipine besylate- P MICARDIS TABS (Use NP QL(1 ea daily) olmesartan medoxomil tabs Telmisartan)

28 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits amlodipine besylate- P EXFORGE HCT TABS valsartan tabs (Use Amlodipine-Valsartan- NP Hydrochlorothiazide) amlodipine-valsartan- P hydrochlorothiazide tabs EXFORGE TABS (Use ATACAND HCT TABS Amlodipine Besylate- NP (Use Candesartan Cilexetil- NP Valsartan) Hydrochlorothiazide) fosinopril sodium & P QL(1 ea daily); hydrochlorothiazide tabs MP atenolol & chlorthalidone P QL(1 ea daily); tabs MP HYZAAR TABS (Use QL(1 ea daily); AVALIDE TABS (Use QL(1 ea daily); Losartan Potassium & NP MP Irbesartan- NP MP Hydrochlorothiazide) Hydrochlorothiazide) irbesartan- P QL(1 ea daily); AZOR TABS (Use hydrochlorothiazide tabs MP Amlodipine Besylate- NP lisinopril & QL(2 ea daily); Olmesartan Medoxomil) hydrochlorothiazide tabs P MP 10mg-12.5mg, 20mg- benazepril & P QL(1 ea daily); hydrochlorothiazide tabs MP 12.5mg BENICAR HCT TABS (Use lisinopril & QL(1 ea daily); Olmesartan Medoxomil- NP hydrochlorothiazide tabs P MP Hydrochlorothiazide) 20mg-25mg bisoprolol & MP LOPRESSOR HCT TABS QL(2 ea daily); hydrochlorothiazide tabs P (Use Metoprolol & NP MP 2.5mg-6.25mg Hydrochlorothiazide) bisoprolol & QL(1 ea daily); losartan potassium & P QL(1 ea daily); hydrochlorothiazide tabs MP hydrochlorothiazide tabs P MP 5mg-6.25mg, 10mg- LOTENSIN HCT TABS QL(1 ea daily); 6.25mg (Use Benazepril & NP MP Hydrochlorothiazide) candesartan cilexetil- P hydrochlorothiazide tabs LOTREL CAPS 10MG- MP 40MG (Use Amlodipine NP CAPTOPRIL/HYDROCHL P QL(2 ea daily); OROTHIAZIDE TABS MP Besylate-Benazepril HCl) CORZIDE TABS 40MG- LOTREL CAPS 5MG- QL(1 ea daily); 5MG (Use Nadolol & NP 10MG, 5MG-20MG, 10MG- NP MP Bendroflumethiazide) 20MG (Use Amlodipine Besylate-Benazepril HCl) CORZIDE TABS 80MG- NP 5MG metoprolol & P QL(2 ea daily); hydrochlorothiazide tabs MP DIOVAN HCT TABS (Use QL(1 ea daily); Valsartan- NP MP METOPROLOL QL(1 ea daily); Hydrochlorothiazide) SUCCINATE P MP ER/HYDROCHLOROTHIA DUTOPROL TB24 25MG- P QL(1 ea daily); ZIDE TB24 25MG-12.5MG 12.5MG MP METOPROLOL QL(1 ea daily) DUTOPROL TB24 50MG- P QL(1 ea daily) SUCCINATE 12.5MG, 100MG-12.5MG ER/HYDROCHLOROTHIA P enalapril maleate & P QL(2 ea daily); ZIDE TB24 50MG-12.5MG, hydrochlorothiazide tabs MP 100MG-12.5MG METOPROLOL/HYDROCH P QL(2 ea daily); LOROTHIAZIDE TABS MP Western Sky Updated December 1, 2018 P-Preferred drug, NP-Non-preferred, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, RX/OTC - both Rx and OTC NDCs MP-Maintenance drug eligible for 90 day supply

29 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MICARDIS HCT TABS QL(1 ea daily) VASERETIC TABS (Use QL(2 ea daily); (Use Telmisartan- NP Enalapril Maleate & NP MP Hydrochlorothiazide) Hydrochlorothiazide) nadolol & P ZESTORETIC TABS QL(2 ea daily); bendroflumethiazide tabs 10MG-12.5MG, 20MG- NP MP olmesartan medoxomil- 12.5MG (Use Lisinopril & amlodipine- P Hydrochlorothiazide) hydrochlorothiazide tabs ZESTORETIC TABS QL(1 ea daily); 20MG-25MG (Use MP olmesartan medoxomil- P NP hydrochlorothiazide tabs Lisinopril & Hydrochlorothiazide) PROPRANOLOL/HYDROC P MP HLOROTHIAZIDE TABS ZIAC TABS 2.5MG- MP 6.25MG (Use Bisoprolol & NP quinapril- QL(3 ea daily) Hydrochlorothiazide) hydrochlorothiazide tabs P 10mg-12.5mg ZIAC TABS 5MG-6.25MG, QL(1 ea daily); 10MG-6.25MG (Use NP MP quinapril- QL(4 ea daily) Bisoprolol & hydrochlorothiazide tabs P Hydrochlorothiazide) 20mg-12.5mg quinapril- QL(2 ea daily) Selective Aldosterone Receptor Antagonists hydrochlorothiazide tabs P eplerenone tabs P 20mg-25mg TARKA TBCR (Use INSPRA TABS (Use NP Trandolapril-Verapamil NP Eplerenone) HCl) Vasodilators telmisartan-amlodipine tabs P hydralazine hcl tabs P MP telmisartan- P QL(1 ea daily) MP hydrochlorothiazide tabs minoxidil tabs P TENORETIC 100 TABS QL(1 ea daily); NITROPRESS SOLN (Use NP (Use Atenolol & NP MP Nitroprusside Sodium) Chlorthalidone) nitroprusside sodium soln P TENORETIC 50 TABS QL(1 ea daily); (Use Atenolol & NP MP ANTIMALARIALS - Drugs to Treat Malaria Chlorthalidone) (Parasitic Infections) trandolapril-verapamil hcl P tbcr Antimalarial Combinations atovaquone-proguanil hcl TRANDOLAPRIL/VERAPA P P MIL HCL ER TBCR tabs TRIBENZOR TABS (Use P QL(24 ea per COARTEM TABS fill retail) Olmesartan Medoxomil- NP Amlodipine- MALARONE TABS (Use NP Hydrochlorothiazide) Atovaquone-Proguanil HCl) TWYNSTA TABS (Use NP Antimalarials Telmisartan-Amlodipine) CHLOROQUINE QL(2 ea daily) valsartan- P QL(1 ea daily); PHOSPHATE TABS 250 P hydrochlorothiazide tabs MP MG

30 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits chloroquine phosphate P RIFADIN SOLR (Use NP tabs 500 mg Rifampin) hydroxychloroquine sulfate P MP rifampin caps P tabs MEFLOQUINE HCL TABS P rifampin solr P mefloquine hcl tabs P TRECATOR TABS P PLAQUENIL TABS (Use MP ANTINEOPLASTICS AND ADJUNCTIVE Hydroxychloroquine NP THERAPIES - Drugs to Treat Cancer Sulfate) Alkylating Agents QUALAQUIN CAPS (Use NP Quinine Sulfate) ALKERAN SOLR IV 50 MG NP SP (Use Melphalan HCl) quinine sulfate caps P ALKERAN TABS OR 2 MG NP (Use Melphalan) ANTIMYASTHENIC/CHOLINERGIC AGENTS cyclophosphamide caps 25 P mg, 50 mg Antimyasthenic/Cholinergic Agents CYCLOPHOSPHAMIDE MESTINON TABS (Use NP CAPS 25 MG, 50 MG (Use NP Pyridostigmine Bromide) Cyclophosphamide) MESTINON TIMESPAN TBCR (Use Pyridostigmine NP LEUKERAN TABS P Bromide) melphalan hcl solr P SP pyridostigmine bromide P tabs melphalan tabs P pyridostigmine bromide P tbcr MYLERAN TABS P ANTIMYCOBACTERIAL AGENTS - Drugs to Treat Tuberculosis (Bacterial Infections) TEMODAR CAPS OR 5 PA; SP MG, 20 MG, 100 MG, 140 NP Antimycobacterial Agents MG, 180 MG, 250 MG (Use ethambutol hcl tabs P MP Temozolomide) TEMODAR SOLR IV 100 P PA; SP ISONIAZID SYRP 50 P MP MG MG/5ML temozolomide caps P PA; SP isoniazid tabs 100 mg, 300 P MP mg Antimetabolites MYAMBUTOL TABS (Use NP MP PA; SP Ethambutol HCl) capecitabine tabs P MYCOBUTIN CAPS (Use NP Rifabutin) mercaptopurine tabs P pyrazinamide tabs P methotrexate sodium soln ij 1 gm/40ml, 50 mg/2ml, 200 P rifabutin caps P mg/8ml, 250 mg/10ml METHOTREXATE RIFADIN CAPS (Use NP SODIUM SOLN IJ 250 P Rifampin) MG/10ML

31 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits methotrexate sodium tabs P megestrol acetate susp P or 2.5 mg P AL(Up to 8 yrs megestrol acetate tabs P PURIXAN SUSP old ) NILANDRON TABS (Use NP TREXALL TABS P Nilutamide) XELODA TABS (Use NP PA; SP nilutamide tabs P Capecitabine) MP Antineoplastic - Hedgehog Pathway Inhibitors tamoxifen citrate tabs P PA; SP ERIVEDGE CAPS P XTANDI CAPS P PA; SP PA; SP ODOMZO CAPS P ZYTIGA TABS (Use NP PA; SP Abiraterone Acetate) Antineoplastic - Hormonal and Related Agents Antineoplastic - Immunomodulators PA; SP abiraterone acetate tabs P POMALYST CAPS P PA; SP anastrozole tabs P Antineoplastic Enzyme Inhibitors PA; SP ARIMIDEX TABS (Use NP AFINITOR DISPERZ TBSO P Anastrozole) PA; SP AROMASIN TABS (Use NP SP AFINITOR TABS P Exemestane) BOSULIF TABS P PA; SP bicalutamide tabs P QL(1 ea daily) COTELLIC TABS P PA; SP CASODEX TABS (Use NP QL(1 ea daily) Bicalutamide) FARYDAK CAPS P PA; SP EMCYT CAPS P SP GILOTRIF TABS P PA; SP exemestane tabs P SP GLEEVEC TABS (Use NP PA; SP FARESTON TABS P PA Imatinib Mesylate) IBRANCE CAPS P PA; SP FEMARA TABS (Use NP Letrozole) ICLUSIG TABS P PA; SP flutamide caps P PA; SP Limit 5ml per imatinib mesylate tabs P HYDROXYPROGESTERO month;QL(0.16 PA; SP NE CAPROATE SOLN P 7 ml daily); INLYTA TABS P 1.25 GM/5ML AL(At least 16 PA; SP yrs old); SP JAKAFI TABS P letrozole tabs P MEKINIST TABS P PA; SP SP LYSODREN TABS P NEXAVAR TABS P PA; SP MEGACE ORAL SUSP NP PA; SP (Use Megestrol Acetate) NINLARO CAPS P

32 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SPRYCEL TABS P PA; SP mesna soln P SP

STIVARGA TABS P PA; SP MESNEX SOLN IV 100 NP SP MG/ML (Use Mesna) PA; SP SUTENT CAPS P MESNEX TABS OR 400 P PA; SP MG PA; SP TAFINLAR CAPS P ZINECARD SOLR (Use NP SP Dexrazoxane) PA; SP TARCEVA TABS P Mitotic Inhibitors TASIGNA CAPS P PA; SP ETOPOSIDE CAPS P SP

TYKERB TABS P PA; SP Topoisomerase I Inhibitors CAMPTOSAR SOLN (Use NP SP VOTRIENT TABS P PA; SP Irinotecan HCl) PA; SP HYCAMTIN CAPS OR 0.25 P PA; SP XALKORI CAPS P MG, 1 MG PA; SP HYCAMTIN SOLR IV 4 MG NP SP ZELBORAF TABS P (Use Topotecan HCl) ZOLINZA CAPS P PA; SP irinotecan hcl soln P SP

ZYKADIA CAPS P PA; SP topotecan hcl solr P SP Antineoplastics Misc. ANTIPARKINSON AND RELATED THERAPY AGENTS - Drugs to Treat Parkinson's Disease bexarotene caps P PA; SP Antiparkinson Adjuvants HYDREA CAPS (Use NP Hydroxyurea) carbidopa tabs P hydroxyurea caps P LODOSYN TABS (Use NP Carbidopa) PA; SP MATULANE CAPS P Antiparkinson Anticholinergics benztropine mesylate soln TARGRETIN CAPS (Use NP PA; SP P Bexarotene) ij 1 mg/ml benztropine mesylate tabs MP tretinoin (chemotherapy) P PA; SP P caps or 0.5 mg, 1 mg, 2 mg Chemotherapy Rescue/Antidote Agents COGENTIN SOLN (Use NP Benztropine Mesylate) dexrazoxane solr P SP trihexyphenidyl hcl elix 0.4 P QL(16.67 ml mg/ml daily); MP FUSILEV SOLR (Use NP SP Levoleucovorin Calcium) trihexyphenidyl hcl tabs 2 P MP mg, 5 mg LEUCOVORIN CALCIUM P TABS OR 10 MG, 15 MG Antiparkinson COMT Inhibitors leucovorin calcium tabs or P COMTAN TABS (Use NP 5 mg, 25 mg Entacapone) levoleucovorin calcium solr P SP entacapone tabs P

33 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TASMAR TABS (Use NP REQUIP XL TB24 (Use NP Tolcapone) Ropinirole Hydrochloride) tolcapone tabs P ropinirole hydrochloride P QL(6 ea daily); tabs 0.25 mg MP Antiparkinson Dopaminergics ropinirole hydrochloride P QL(3 ea daily); tabs 0.5 mg, 1 mg, 2 mg MP amantadine hcl caps P MP ropinirole hydrochloride P QL(6 ea daily) tabs 3 mg, 4 mg amantadine hcl syrp P MP ropinirole hydrochloride P QL(3 ea daily) bromocriptine mesylate P tabs 5 mg caps ropinirole hydrochloride bromocriptine mesylate P tb24 2 mg, 4 mg, 6 mg, 8 P tabs mg, 12 mg MP carbidopa-levodopa tabs P SINEMET CR TBCR (Use NP MP Carbidopa-Levodopa) MP carbidopa-levodopa tbcr P SINEMET TABS (Use NP MP Carbidopa-Levodopa) MIRAPEX ER TB24 (Use Pramipexole NP Antiparkinson Monoamine Oxidase Inhibitors Dihydrochloride) AZILECT TABS (Use NP MIRAPEX TABS (Use QL(3 ea daily) Rasagiline Mesylate) Pramipexole NP ELDEPRYL CAPS (Use NP MP Dihydrochloride) Selegiline HCl) PARLODEL CAPS (Use NP rasagiline mesylate tabs P Bromocriptine Mesylate) MP PARLODEL TABS (Use NP selegiline hcl caps P Bromocriptine Mesylate) pramipexole QL(3 ea daily) selegiline hcl tabs P MP dihydrochloride tabs 0.125 P mg, 0.25 mg, 0.75 mg, 0.5 ANTIPSYCHOTICS/ANTIMANIC AGENTS - mg, 1 mg, 1.5 mg Drugs to Treat Mood Disorders pramipexole Antimanic Agents dihydrochloride tb24 0.375 P lithium carbonate caps 150 P mg, 0.75 mg, 3 mg, 1.5 mg, mg, 300 mg, 600 mg 4.5 mg, 2.25 mg, 3.75 mg LITHIUM CARBONATE REQUIP TABS 0.25 MG QL(6 ea daily); CAPS 150 MG, 600 MG NP (Use Ropinirole NP MP (Use Lithium Carbonate) Hydrochloride) lithium carbonate tabs 300 P REQUIP TABS 0.5 MG, 1 QL(3 ea daily); mg MG, 2 MG (Use Ropinirole NP MP Hydrochloride) lithium carbonate tbcr 300 P mg, 450 mg REQUIP TABS 3 MG, 4 QL(6 ea daily) MG (Use Ropinirole NP LITHIUM SOLN P Hydrochloride) LITHOBID TBCR (Use NP REQUIP TABS 5 MG (Use NP QL(3 ea daily) Lithium Carbonate) Ropinirole Hydrochloride) Antipsychotics - Misc.

34 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(2 ea daily); Limit 1 syringe GEODON CAPS (Use NP ) AL(At least 18 every 3 Ziprasidone HCl yrs old) INVEGA TRINZA SUSP P months;QL(3 819 MG/2.625ML ml per 84 days LATUDA TABS P retail) NUPLAZID TABS P QL(2 ea daily) paliperidone tb24 P

VRAYLAR CPPK P Limit 2 vials per RISPERDAL CONSTA P SUSR month;QL(0.07 QL(2 ea daily); 2 ea daily) ziprasidone hcl caps P AL(At least 18 QL(2 ea daily); yrs old) RISPERDAL M-TAB TBDP NP (Use Risperidone) AL(At least 5 Benzisoxazoles yrs old) Limit 1 syringe QL(4 ml daily); RISPERDAL SOLN 1 NP AL(At least 5 INVEGA SUSTENNA P per MG/ML (Use Risperidone) SUSP 117 MG/0.75ML month;QL(0.02 yrs old) 7 ml daily) RISPERDAL TABS 0.25 QL(2 ea daily); Limit 1 syringe MG, 0.5 MG, 1 MG, 2 MG, NP AL(At least 5 3 MG, 4 MG (Use yrs old) INVEGA SUSTENNA P per SUSP 156 MG/ML month;QL(0.03 Risperidone) 6 ml daily) QL(1 ea daily); Limit 1 syringe RISPERIDONE ODT TBDP P AL(At least 5 yrs old) INVEGA SUSTENNA P per SUSP 234 MG/1.5ML month;QL(0.05 QL(4 ml daily); 4 ml daily) risperidone soln 1 mg/ml P AL(At least 5 Limit 1 syringe yrs old) risperidone tabs 0.25 mg, QL(2 ea daily); INVEGA SUSTENNA P per SUSP 39 MG/0.25ML month;QL(0.00 0.5 mg, 1 mg, 2 mg, 3 mg, P AL(At least 5 9 ml daily) 4 mg yrs old) Limit 1 syringe QL(1 ea daily); risperidone tbdp 0.25 mg P AL(At least 5 INVEGA SUSTENNA P per SUSP 78 MG/0.5ML month;QL(0.01 yrs old) 8 ml daily) QL(2 ea daily); risperidone tbdp 0.5 mg, 1 P AL(At least 5 INVEGA TB24 (Use NP mg, 2 mg, 3 mg, 4 mg Paliperidone) yrs old) Limit 1 syringe Butyrophenones every 3 HALDOL DECANOATE INVEGA TRINZA SUSP P 273 MG/0.875ML months;QL(1 100 SOLN (Use NP ml per 84 days Haloperidol Decanoate) retail) HALDOL DECANOATE 50 Limit 1 syringe SOLN (Use Haloperidol NP INVEGA TRINZA SUSP every 3 Decanoate) 546 MG/1.75ML, 410 P months;QL(2 MG/1.315ML ml per 84 days HALDOL SOLN (Use NP retail) Haloperidol Lactate) haloperidol decanoate soln P

haloperidol lactate conc P

35 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits haloperidol lactate soln P chlorpromazine hcl tabs or QL(3 ea daily) 25 mg, 50 mg, 100 mg, 200 P mg haloperidol tabs 0.5 mg, 1 P QL(3 ea daily) mg, 10 mg fluphenazine decanoate P soln haloperidol tabs 2 mg, 5 P mg, 20 mg fluphenazine hcl tabs P Dibenzapines P QL(4 ea daily) ADASUVE AEPB P perphenazine tabs QL(9 ea daily); prochlorperazine maleate P clozapine tabs 100 mg P AL(At least 18 tabs yrs old) prochlorperazine supp P QL(3 ea daily); clozapine tabs 25 mg, 50 P AL(At least 18 thioridazine hcl tabs P QL(3 ea daily) mg, 200 mg yrs old) QL(3 ea daily) QL(9 ea daily); trifluoperazine hcl tabs P CLOZARIL TABS 100 MG NP ) AL(At least 18 (Use Clozapine yrs old) Quinolinone Derivatives QL(3 ea daily); ABILIFY MAINTENA PRSY P CLOZARIL TABS 25 MG NP (Use Clozapine) AL(At least 18 yrs old) ABILIFY MAINTENA SRER P loxapine succinate caps P QL(4 ea daily) ABILIFY TABS (Use NP QL(1 ea daily) QL(1 ea daily); Aripiprazole) olanzapine tabs P AL(At least 13 QL(25 ml yrs old) aripiprazole soln 1 mg/ml P daily); AL(At quetiapine fumarate tabs QL(2 ea daily) least 6 yrs old) 25 mg, 50 mg, 100 mg, 200 P aripiprazole tabs 2 mg, 5 QL(1 ea daily) mg, 300 mg, 400 mg mg, 10 mg, 15 mg, 20 mg, P quetiapine fumarate tb24 30 mg 50 mg, 150 mg, 200 mg, P aripiprazole tbdp 10 mg, 15 P QL(1 ea daily) 300 mg, 400 mg mg ARISTADA PRSY 1064 SEROQUEL TABS (Use NP QL(2 ea daily) P Quetiapine Fumarate) MG/3.9ML Limit 1 syringe SEROQUEL XR TB24 (Use NP Quetiapine Fumarate) ARISTADA PRSY 441 P per Limit 2 vials per MG/1.6ML month;QL(0.05 ZYPREXA RELPREVV P month;QL(0.07 7 ml daily) SUSR 2 ea daily) Limit 1 syringe QL(1 ea daily); ARISTADA PRSY 662 P per ZYPREXA TABS (Use NP MG/2.4ML month;QL(0.08 ) AL(At least 13 Olanzapine yrs old) 6 ml daily) Limit 1 syringe Phenothiazines ARISTADA PRSY 882 P per CHLORPROMAZINE HCL P MG/3.2ML month;QL(0.11 SOLN IJ 50 MG/2ML 4 ml daily) chlorpromazine hcl tabs or P QL(10 ea daily) Thioxanthenes 10 mg Western Sky Updated December 1, 2018 P-Preferred drug, NP-Non-preferred, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, RX/OTC - both Rx and OTC NDCs MP-Maintenance drug eligible for 90 day supply

36 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits thiothixene caps P QL(3 ea daily) COMBIVIR TABS (Use NP QL(2 ea daily) Lamivudine-Zidovudine) ANTISEPTICS & DISINFECTANTS COMPLERA TABS P QL(1 ea daily)

Antiseptics & Disinfectants CRIXIVAN CAPS 200 MG P QL(9 ea daily) formaldehyde soln P QL(90 ml per fill retail) CRIXIVAN CAPS 400 MG P QL(6 ea daily) Chlorine Antiseptics DELSTRIGO TABS P QL(1 ea daily) chlorhexidine gluconate P liqd DESCOVY TABS P QL(1 ea daily) dakin's solution soln P didanosine cpdr P QL(1 ea daily) DAKINS SOLUTION FULL STRENGTH SOLN (Use NP EDURANT TABS P QL(1 ea daily) Dakin's Solution) DAKINS SOLUTION HALF efavirenz caps 200 mg P QL(1 ea daily) STRENGTH SOLN (Use NP Dakin's Solution) efavirenz caps 50 mg P QL(2 ea daily) DAKINS SOLUTION QL(1 ea daily) QUARTER STRENGTH NP efavirenz tabs 600 mg P SOLN (Use Dakin's Solution) EMTRIVA CAPS 200 MG P QL(1 ea daily) HIBICLENS LIQD (Use NP Chlorhexidine Gluconate) EMTRIVA SOLN 10 P QL(24 ml daily) MG/ML ANTIVIRALS - Drugs to Treat Viral Infections EPIVIR SOLN 10 MG/ML NP QL(30 ml daily) (Use Lamivudine) Antiretrovirals EPIVIR TABS 150 MG NP QL(2 ea daily) abacavir sulfate soln 20 P QL(30 ml daily) (Use Lamivudine) mg/ml EPIVIR TABS 300 MG NP QL(1 ea daily) abacavir sulfate tabs 300 P QL(2 ea daily) (Use Lamivudine) mg EPZICOM TABS (Use QL(1 ea daily) abacavir sulfate-lamivudine P QL(1 ea daily) Abacavir Sulfate- NP tabs Lamivudine) abacavir sulfate- P QL(2 ea daily) QL(1 ea daily) lamivudine-zidovudine tabs EVOTAZ TABS P APTIVUS CAPS 250 MG P QL(4 ea daily) fosamprenavir calcium tabs P QL(4 ea daily)

APTIVUS SOLN 100 P QL(10 ml daily) 1 rtl pack lmt MG/ML FUZEON SOLR P amt,30 rtl pack lmt day(s), atazanavir sulfate caps P QL(2 ea daily) GENVOYA TABS P QL(1 ea daily) ATRIPLA TABS P QL(1 ea daily) INTELENCE TABS 200 P QL(2 ea daily) BIKTARVY TABS P MG INTELENCE TABS 25 MG, P QL(4 ea daily) CIMDUO TABS P 100 MG

37 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits INVIRASE CAPS 200 MG P QL(10 ea daily) NORVIR PACK 100 MG P QL(12 ea daily)

INVIRASE TABS 500 MG P QL(4 ea daily) NORVIR SOLN 80 MG/ML P QL(15 ml daily)

ISENTRESS CHEW 100 P QL(6 ea daily) NORVIR TABS 100 MG NP QL(12 ea daily) MG (Use Ritonavir) ISENTRESS CHEW 25 MG P QL(12 ea daily) ODEFSEY TABS P

ISENTRESS HD TABS P PIFELTRO TABS P QL(1 ea daily)

ISENTRESS PACK 100 P QL(2 ea daily) PREZCOBIX TABS P MG PREZISTA SUSP 100 QL(12 ml daily) ISENTRESS TABS 400 P QL(2 ea daily) P MG MG/ML QL(3 ea daily) JULUCA TABS P PREZISTA TABS 150 MG P KALETRA SOLN 1 rtl pack lmt PREZISTA TABS 75 MG, P QL(2 ea daily) 400MG/5ML-100MG/5ML NP per fill, 600 MG (Use Lopinavir-Ritonavir) PREZISTA TABS 800 MG P QL(1 ea daily) KALETRA TABS 100MG- P QL(4 ea daily) 25MG RESCRIPTOR TABS 100 P QL(12 ea daily) MG KALETRA TABS 200MG- P QL(6 ea daily) 50MG RESCRIPTOR TABS 200 P QL(6 ea daily) MG lamivudine soln 10 mg/ml P QL(30 ml daily) RETROVIR CAPS 100 MG NP QL(6 ea daily) (Use Zidovudine) lamivudine tabs 150 mg P QL(2 ea daily) RETROVIR SYRP 50 NP QL(60 ml daily) lamivudine tabs 300 mg P QL(1 ea daily) MG/5ML (Use Zidovudine) REYATAZ CAPS 150 MG, QL(2 ea daily) lamivudine-zidovudine tabs P QL(2 ea daily) 200 MG, 300 MG (Use NP Atazanavir Sulfate) QL(56 ml daily) LEXIVA SUSP 50 MG/ML P REYATAZ PACK 50 MG P QL(6 ea daily) LEXIVA TABS 700 MG QL(4 ea daily) QL(12 ea daily) (Use Fosamprenavir NP ritonavir tabs P Calcium) SELZENTRY SOLN 20 P P 1 rtl pack lmt MG/ML lopinavir-ritonavir soln per fill, SELZENTRY TABS 25 P QL(2 ea daily) nevirapine susp 50 mg/5ml P QL(40 ml daily) MG, 75 MG, 150 MG SELZENTRY TABS 300 P QL(4 ea daily) nevirapine tabs 200 mg P QL(2 ea daily) MG QL(2 ea daily) nevirapine tb24 100 mg P QL(3 ea daily) stavudine caps P QL(1 ea daily) nevirapine tb24 400 mg P QL(1 ea daily) STRIBILD TABS P QL(12 ea daily) SUSTIVA CAPS 200 MG NP QL(1 ea daily) NORVIR CAPS 100 MG P (Use Efavirenz)

38 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SUSTIVA CAPS 50 MG NP QL(2 ea daily) VIREAD POWD 40 MG/GM P QL(8 gm daily) (Use Efavirenz) VIREAD TABS 150 MG, QL(1 ea daily) SUSTIVA TABS 600 MG NP QL(1 ea daily) P (Use Efavirenz) 200 MG, 250 MG VIREAD TABS 300 MG QL(1 ea daily) SYMFI LO TABS P (Use Tenofovir Disoproxil NP Fumarate) SYMFI TABS P VITEKTA TABS P QL(1 ea daily) SYMTUZA TABS P QL(1 ea daily) ZERIT CAPS 15 MG, 20 QL(2 ea daily) MG, 30 MG, 40 MG (Use NP tenofovir disoproxil P QL(1 ea daily) fumarate tabs Stavudine) TIVICAY TABS P QL(1 ea daily) ZERIT SOLR 1 MG/ML P QL(80 ml daily)

TRIUMEQ TABS P ZIAGEN SOLN 20 MG/ML NP QL(30 ml daily) (Use Abacavir Sulfate) TRIZIVIR TABS (Use QL(2 ea daily) ZIAGEN TABS 300 MG NP QL(2 ea daily) Abacavir Sulfate- NP (Use Abacavir Sulfate) Lamivudine-Zidovudine) zidovudine caps 100 mg P QL(6 ea daily) TROGARZO SOLN P QL(60 ml daily) TRUVADA TABS 150MG- zidovudine syrp 50 mg/5ml P 100MG, 200MG-133MG, P QL(2 ea daily) 250MG-167MG zidovudine tabs 300 mg P TRUVADA TABS 300MG- P QL(1 ea daily) CMV Agents 200MG CYTOVENE SOLR (Use NP TYBOST TABS P QL(1 ea daily) Ganciclovir Sodium) ganciclovir sodium solr P VIDEX EC CPDR 125 MG P QL(1 ea daily) VALCYTE SOLR 50 VIDEX EC CPDR 200 MG, QL(1 ea daily) MG/ML (Use Valganciclovir NP 250 MG, 400 MG (Use NP HCl) Didanosine) VALCYTE TABS 450 MG NP QL(2 ea daily) VIDEXPEDIATRIC SOLR P QL(20 ml daily) (Use Valganciclovir HCl) QL(9 ea daily) valganciclovir hcl solr 50 P VIRACEPT TABS 250 MG P mg/ml QL(4 ea daily) valganciclovir hcl tabs 450 P QL(2 ea daily) VIRACEPT TABS 625 MG P mg VIRAMUNE SUSP 50 NP QL(40 ml daily) Hepatitis Agents MG/5ML (Use Nevirapine) adefovir dipivoxil tabs P SP VIRAMUNE TABS 200 MG NP QL(2 ea daily) (Use Nevirapine) BARACLUDE TABS (Use NP SP VIRAMUNE XR TB24 100 NP QL(3 ea daily) Entecavir) MG (Use Nevirapine) COPEGUS TABS (Use NP PA; SP VIRAMUNE XR TB24 400 NP QL(1 ea daily) Ribavirin (Hepatitis C)) MG (Use Nevirapine) entecavir tabs P SP

39 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EPIVIR HBV TABS (Use NP SP ZOVIRAX TABS OR 400 NP QL(3 ea daily) Lamivudine (HBV)) MG (Use Acyclovir) HEPSERA TABS (Use SP Limit 50 per NP ZOVIRAX TABS OR 800 NP Adefovir Dipivoxil) ) month;QL(1.67 MG (Use Acyclovir ea daily) lamivudine (hbv) tabs P SP Influenza Agents MAVYRET TABS P PA; QL(3 ea FLUMADINE TABS (Use daily); SP Rimantadine NP REBETOL CAPS (Use NP PA; SP Hydrochloride) Ribavirin (Hepatitis C)) oseltamivir phosphate caps P ribavirin (hepatitis c) caps P PA; SP or 30 mg, 45 mg, 75 mg oseltamivir phosphate susr P ribavirin (hepatitis c) tabs P PA; SP or 6 mg/ml 1 rtl pack lmt Herpes Agents amt,30 rtl pack Limit 50 per RELENZA DISKHALER P lmt day(s),; acyclovir caps 200 mg P month;QL(1.67 AEPB AL(At least 6 ea daily) yrs old) Limit 400ml per rimantadine hydrochloride P acyclovir susp 200 mg/5ml P month;QL(13.3 tabs 4 ml daily) TAMIFLU CAPS (Use NP acyclovir tabs 400 mg P QL(3 ea daily) Oseltamivir Phosphate) TAMIFLU SUSR (Use NP Limit 50 per Oseltamivir Phosphate) acyclovir tabs 800 mg P month;QL(1.67 ea daily) Respiratory Syncytial Virus (RSV) Agents famciclovir tabs P ribavirin solr P VIRAZOLE SOLR (Use FAMVIR TABS (Use NP NP Famciclovir) Ribavirin) Limit 21 per BETA BLOCKERS - Drugs to Treat High Blood valacyclovir hcl tabs 1 gm, P Pressure 1000 mg month;QL(1 ea daily) Alpha-Beta Blockers valacyclovir hcl tabs 500 P QL(2 ea daily) QL(1 ea daily) mg carvedilol phosphate cp24 P Limit 21 per carvedilol tabs 12.5 mg, QL(3 ea daily); VALTREX TABS 1 GM NP P ) month;QL(1 ea 6.25 mg, 3.125 mg MP (Use Valacyclovir HCl daily) carvedilol tabs 25 mg P QL(4 ea daily); VALTREX TABS 500 MG NP QL(2 ea daily) MP (Use Valacyclovir HCl) COREG CR CP24 (Use NP QL(1 ea daily) Limit 50 per Carvedilol Phosphate) ZOVIRAX CAPS OR 200 NP ) month;QL(1.67 MG (Use Acyclovir ea daily) COREG TABS 12.5 MG, QL(3 ea daily); 6.25 MG, 3.125 MG (Use NP MP Limit 400ml per Carvedilol) ZOVIRAX SUSP OR 200 NP MG/5ML (Use Acyclovir) month;QL(13.3 4 ml daily) COREG TABS 25 MG (Use NP QL(4 ea daily); Carvedilol) MP

40 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits P QL(3 ea daily); BETAPACE TABS (Use NP QL(2 ea daily); labetalol hcl tabs 100 mg MP Sotalol HCl) MP P QL(6 ea daily); CORGARD TABS (Use NP QL(2 ea daily); labetalol hcl tabs 200 mg MP Nadolol) MP P QL(8 ea daily); HEMANGEOL SOLN P PA labetalol hcl tabs 300 mg MP Beta Blockers Cardio-Selective INDERAL LA CP24 (Use NP QL(2 ea daily); Propranolol HCl) MP acebutolol hcl caps P MP P QL(2 ea daily); nadolol tabs MP atenolol tabs P QL(2 ea daily); MP pindolol tabs P MP P QL(1 ea daily); bisoprolol fumarate tabs MP propranolol hcl cp24 60 QL(2 ea daily); mg, 80 mg, 120 mg, 160 P MP BREVIBLOC SOLN (Use NP mg Esmolol HCl) PROPRANOLOL HCL MP esmolol hcl soln P SOLN 20 MG/5ML, 40 P MG/5ML LOPRESSOR TABS 100 QL(2 ea daily); propranolol hcl tabs 10 mg, MP MG (Use Metoprolol NP MP P ) 20 mg, 40 mg, 60 mg, 80 Tartrate mg LOPRESSOR TABS 50 QL(3 ea daily); MG (Use Metoprolol NP MP sotalol hcl (afib/afl) tabs P QL(2 ea daily); Tartrate) MP sotalol hcl tabs 240 mg P MP metoprolol succinate tb24 P QL(2 ea daily); 200 mg MP sotalol hcl tabs 80 mg, 120 P QL(2 ea daily); metoprolol succinate tb24 P QL(1 ea daily); mg, 160 mg MP 25 mg, 50 mg, 100 mg MP TIMOLOL MALEATE TABS P MP metoprolol tartrate tabs 25 P QL(2 ea daily); mg, 100 mg MP CALCIUM CHANNEL BLOCKERS - Drugs to metoprolol tartrate tabs 50 P QL(3 ea daily); Treat High Blood Pressure mg MP Calcium Channel Blockers SECTRAL CAPS (Use NP MP Acebutolol HCl) ADALAT CC TB24 30 MG, NP QL(1 ea daily); 90 MG (Use Nifedipine) MP TENORMIN TABS (Use NP QL(2 ea daily); Atenolol) MP ADALAT CC TB24 60 MG NP QL(2 ea daily); (Use Nifedipine) MP TOPROL XL TB24 200 MG NP QL(2 ea daily); (Use Metoprolol Succinate) MP amlodipine besylate tabs P QL(1 ea daily); TOPROL XL TB24 25 MG, QL(1 ea daily); MP 50 MG, 100 MG (Use NP MP CALAN SR TBCR (Use NP QL(2 ea daily); Metoprolol Succinate) Verapamil HCl) MP CALAN TABS (Use QL(3 ea daily); ZEBETA TABS (Use NP QL(1 ea daily); NP Bisoprolol Fumarate) MP Verapamil HCl) MP Beta Blockers Non-Selective CARDIZEM CD CP24 120 QL(1 ea daily); MG, 180 MG, 300 MG (Use NP MP BETAPACE AF TABS (Use NP QL(2 ea daily); Diltiazem HCl Coated Sotalol HCl (AFIB/AFL)) MP Beads)

41 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CARDIZEM CD CP24 240 QL(2 ea daily); PROCARDIA XL TB24 30 QL(1 ea daily); MG (Use Diltiazem HCl NP MP MG, 90 MG (Use NP MP Coated Beads) Nifedipine) CARDIZEM CD CP24 360 PA PROCARDIA XL TB24 60 NP QL(2 ea daily); MG (Use Diltiazem HCl NP MG (Use Nifedipine) MP Coated Beads) SULAR TB24 (Use NP CARDIZEM LA TB24 (Use PA Nisoldipine) Diltiazem HCl Coated NP TIAZAC CP24 (Use QL(1 ea daily); Beads) Diltiazem HCl Extended NP MP CARDIZEM TABS (Use NP QL(3 ea daily); Release Beads) Diltiazem HCl) MP verapamil hcl cp24 100 mg, P MP diltiazem hcl coated beads QL(1 ea daily); 200 mg, 300 mg cp24 120 mg, 180 mg, 300 P MP verapamil hcl cp24 120 mg, P QL(2 ea daily); mg 180 mg, 240 mg MP diltiazem hcl coated beads QL(2 ea daily); P VERAPAMIL HCL SR P QL(1 ea daily); cp24 240 mg MP CP24 MP diltiazem hcl coated beads PA P verapamil hcl tabs 40 mg, P QL(3 ea daily); cp24 360 mg 80 mg, 120 mg MP diltiazem hcl coated beads PA verapamil hcl tbcr 120 mg, P QL(2 ea daily); tb24 180 mg, 240 mg, 300 P 180 mg, 240 mg MP mg, 360 mg, 420 mg VERELAN CP24 120 MG, QL(2 ea daily); diltiazem hcl cp12 60 mg, P QL(2 ea daily); 180 MG, 240 MG (Use NP MP 90 mg, 120 mg MP Verapamil HCl) diltiazem hcl cp24 120 mg, QL(1 ea daily); P P QL(1 ea daily); 180 mg MP VERELAN CP24 360 MG MP QL(2 ea daily); diltiazem hcl cp24 240 mg P VERELAN PM CP24 (Use NP MP MP Verapamil HCl) diltiazem hcl extended P QL(1 ea daily); release beads cp24 MP CARDIOTONICS - Drugs to Treat Heart Failure and Abnormal Heart Rhythm diltiazem hcl tabs 30 mg, P QL(3 ea daily); 60 mg, 90 mg, 120 mg MP Cardiac Glycosides P QL(1 ea daily); digoxin soln ij 0.25 mg/ml P felodipine tb24 MP DIGOXIN SOLN OR 0.05 P MP nicardipine hcl caps P MG/ML digoxin tabs or 0.125 mg, MP nifedipine caps 10 mg, 20 P QL(4 ea daily); mg MP 0.25 mg, 125 mcg, 250 P mcg nifedipine tb24 30 mg, 90 P QL(1 ea daily); mg MP LANOXIN SOLN IJ 0.25 NP MG/ML (Use Digoxin) P QL(2 ea daily); nifedipine tb24 60 mg MP LANOXIN TABS OR 125 MP MCG, 250 MCG (Use NP nisoldipine tb24 P Digoxin) CARDIOVASCULAR AGENTS - MISC. - Drugs to NORVASC TABS (Use NP QL(1 ea daily); Amlodipine Besylate) MP Treat Heart and Circulation Conditions PROCARDIA CAPS (Use NP QL(4 ea daily); Cardiovascular Agents Misc. - Combinations Nifedipine) MP Western Sky Updated December 1, 2018 P-Preferred drug, NP-Non-preferred, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, RX/OTC - both Rx and OTC NDCs MP-Maintenance drug eligible for 90 day supply

42 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits amlodipine besylate- P ZINACEF SOLR (Use NP atorvastatin calcium tabs Cefuroxime Sodium) CADUET TABS (Use Cephalosporins - 3rd Generation Amlodipine Besylate- NP ) P QL(20 ea per Atorvastatin Calcium cefdinir caps 300 mg fill retail) Peripheral Vasodilators cefdinir susr 125 mg/5ml, P 1 rtl pack lmt isoxsuprine hcl tabs P 250 mg/5ml per fill, cefixime susr P CEPHALOSPORINS - Drugs to Treat Bacterial Infections ceftazidime solr P Cephalosporins - 1st Generation ceftriaxone sodium solr 1 P cefadroxil caps P gm, 500 mg ceftriaxone sodium solr 250 P QL(3 ea per fill cefadroxil susr P mg retail) FORTAZ SOLR (Use NP cefadroxil tabs P Ceftazidime) SUPRAX SUSR (Use NP cephalexin caps P Cefixime) cephalexin susr P Cephalosporins - 4th Generation cefepime hcl solr P KEFLEX CAPS (Use NP Cephalexin) MAXIPIME SOLR (Use NP Cephalosporins - 2nd Generation Cefepime HCl) cefaclor caps 250 mg, 500 P CONTRACEPTIVES - Drugs to Prevent mg Pregnancy CEFACLOR SUSR 125 MG/5ML, 250 MG/5ML, P Combination Contraceptives - Oral 375 MG/5ML BEYAZ TABS (Use Drospirenone-Ethinyl CEFOTAN SOLR (Use NP NP Cefotetan Disodium) Estradiol-Levomefolate Calcium) cefotetan disodium solr P BREVICON-28 TABS (Use QL(1 ea daily); Norethindrone & Eth NP MP 1 rtl pack lmt Estradiol) cefprozil susr 125 mg/5ml, P per fill,; AL(Up 250 mg/5ml to 12 yrs old ) CYCLESSA TABS (Use QL(1 ea daily); Desogestrel-Ethinyl NP MP cefprozil tabs 250 mg, 500 P QL(20 ea per Estradiol (Triphasic)) mg fill retail) DESOGEN TABS (Use QL(1 ea daily); 1 rtl pack lmt Desogestrel & Ethinyl NP MP CEFTIN SUSR P per fill,; AL(Up Estradiol) to 12 yrs old ) desogestrel & ethinyl P QL(1 ea daily); P QL(20 ea per estradiol tabs MP cefuroxime axetil tabs fill retail) desogestrel-ethinyl P QL(1 ea daily); cefuroxime sodium solr P estradiol (biphasic) tabs MP desogestrel-ethinyl P QL(1 ea daily); estradiol (triphasic) tabs MP Western Sky Updated December 1, 2018 P-Preferred drug, NP-Non-preferred, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, RX/OTC - both Rx and OTC NDCs MP-Maintenance drug eligible for 90 day supply

43 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits drospirenone-ethinyl P QL(1 ea daily); MIRCETTE TABS (Use QL(1 ea daily); estradiol tabs MP Desogestrel-Ethinyl NP MP drospirenone-ethinyl Estradiol (Biphasic)) estradiol-levomefolate P NATAZIA TABS P calcium tabs ESTROSTEP FE TABS P QL(1 ea daily); NECON 1/50-28 TABS MP (Use Norethindrone NP Acetate-Ethinyl Estradiol- P QL(1 ea daily); Fe) NECON 10/11-28 TABS MP ethynodiol diacet & eth QL(1 ea daily); P norethin acet & estrad-fe P estrad tabs MP chew 75mg-20mcg-1mg FEMCON FE CHEW (Use norethin acet & estrad-fe QL(1 ea daily); Norethindrone & Ethinyl NP tabs 75mg-20mcg-1mg, P MP Estradiol-Fe) 75mg-30mcg-1.5mg GENERESS FE CHEW norethindrone & eth P QL(1 ea daily); (Use Norethindrone & NP estradiol tabs MP Ethinyl Estradiol-Fe) norethindrone & ethinyl P levonorgestrel & eth P QL(1 ea daily); estradiol-fe chew estradiol tabs MP norethindrone acet & eth P QL(1 ea daily); levonorgestrel-eth estradiol P QL(1 ea daily); estra tabs MP (triphasic) tabs MP norethindrone acetate- P levonorgestrel-ethinyl P QL(1 ea daily) ethinyl estradiol-fe tabs estradiol (91-day) tabs norethindrone-eth estradiol P QL(1 ea daily); levonorgestrel-ethinyl P (triphasic) tabs MP estradiol (91-day) tabs norgestimate-ethinyl P QL(1 ea daily); LO LOESTRIN FE TABS P estradiol (triphasic) tabs MP norgestimate-ethinyl P QL(1 ea daily) LOESTRIN 1.5/30-21 QL(1 ea daily); estradiol (triphasic) tabs TABS (Use Norethindrone NP MP Acet & Eth Estra) norgestimate-ethinyl P QL(1 ea daily); estradiol tabs MP LOESTRIN 1/20-21 TABS QL(1 ea daily); (Use Norethindrone Acet & NP MP norgestrel & ethinyl P QL(1 ea daily); Eth Estra) estradiol tabs MP LOESTRIN FE 1.5/30 QL(1 ea daily); NORINYL 1+35 TABS (Use QL(1 ea daily); TABS (Use Norethin Acet & NP MP Norethindrone & Eth NP MP Estrad-Fe) Estradiol) LOESTRIN FE 1/20 TABS QL(1 ea daily); OGESTREL TABS P QL(1 ea daily); (Use Norethin Acet & NP MP MP Estrad-Fe) ORTHO TRI-CYCLEN LO QL(1 ea daily) LOSEASONIQUE TABS TABS (Use Norgestimate- NP (Use Levonorgestrel- NP Ethinyl Estradiol Ethinyl Estradiol (91-Day)) (Triphasic)) MINASTRIN 24 FE CHEW ORTHO TRI-CYCLEN QL(1 ea daily); (Use Norethin Acet & NP TABS (Use Norgestimate- NP MP Estrad-Fe) Ethinyl Estradiol (Triphasic))

44 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ORTHO-CYCLEN TABS QL(1 ea daily); Emergency Contraceptives (Use Norgestimate-Ethinyl NP MP ) P QL(4 ea per Estradiol ELLA TABS 365 days retail) ORTHO-NOVUM 1/35 QL(1 ea daily); TABS (Use Norethindrone NP MP levonorgestrel (emergency P QL(1 ea per 21 & Eth Estradiol) oc) tabs days retail) ORTHO-NOVUM 7/7/7 QL(1 ea daily); PLAN B ONE-STEP TABS QL(1 ea per 21 NP (Use Levonorgestrel NP days retail) TABS (Use Norethindrone- MP )) Eth Estradiol (Triphasic)) (Emergency OC OVCON-35 TABS (Use QL(1 ea daily); Progestin Contraceptives - IUD Norethindrone & Eth NP MP KYLEENA IUD P SP Estradiol) QUARTETTE TABS (Use LILETTA IUD P SP Levonorgestrel-Ethinyl NP Estradiol (91-Day)) MIRENA IUD P SP SAFYRAL TABS (Use SP Drospirenone-Ethinyl NP SKYLA IUD P Estradiol-Levomefolate Calcium) Progestin Contraceptives - Implants SEASONIQUE TABS (Use QL(1 ea daily) NEXPLANON IMPL P SP Levonorgestrel-Ethinyl NP Estradiol (91-Day)) Progestin Contraceptives - Injectable TAYTULLA CAPS P DEPO-PROVERA QL(1 ml per fill CONTRACEPTIVE SUSP NP retail) TRI-NORINYL 28 TABS QL(1 ea daily); (Use Medroxyprogesterone (Use Norethindrone-Eth NP MP Acetate (Contraceptive)) Estradiol (Triphasic)) DEPO-PROVERA YASMIN 28 TABS (Use QL(1 ea daily); CONTRACEPTIVE SUSY NP Drospirenone-Ethinyl NP MP (Use Medroxyprogesterone Estradiol) Acetate (Contraceptive)) YAZ TABS (Use QL(1 ea daily); DEPO-SUBQ PROVERA P PA Drospirenone-Ethinyl NP MP 104 SUSY Estradiol) medroxyprogesterone QL(1 ml per fill Combination Contraceptives - Transdermal acetate (contraceptive) P retail) Limit 3 patches susp XULANE PTWK P per medroxyprogesterone month;QL(0.11 acetate (contraceptive) P ea daily) susy Combination Contraceptives - Vaginal Progestin Contraceptives - Oral NUVARING RING P QL(1 ea per fill NOR-QD TABS (Use QL(1 ea daily) retail) Norethindrone NP (Contraceptive)) Copper Contraceptives - IUD PARAGARD norethindrone P QL(1 ea daily) (contraceptive) tabs INTRAUTERINE COPPER P CONTRACEPTIVE T380A ORTHO MICRONOR QL(1 ea daily) IUD TABS (Use Norethindrone NP (Contraceptive))

45 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CORTICOSTEROIDS - Steroid Hormone Drugs to methylprednisolone tbpk P Treat Systemic Swelling Conditions MILLIPRED SOLN (Use Glucocorticosteroids Prednisolone Sodium NP budesonide cpep P Phosphate) ORAPRED ODT TBDP CORTEF TABS (Use NP (Use Prednisolone Sodium NP Hydrocortisone) Phosphate) CORTISONE ACETATE P PEDIAPRED SOLN (Use TABS Prednisolone Sodium NP DEPO-MEDROL SUSP Phosphate) (Use Methylprednisolone NP prednisolone sodium QL(240 ml per Acetate) phosphate soln or 15 P fill retail) mg/5ml dexamethasone elix 0.5 P mg/5ml prednisolone sodium QL(150 ml per phosphate soln or 20 P fill retail) DEXAMETHASONE P INTENSOL CONC mg/5ml dexamethasone sodium QL(5 ml daily) prednisolone sodium phosphate soln ij 4 mg/ml, P phosphate soln or 5 P 20 mg/5ml, 120 mg/30ml mg/5ml, 10 mg/5ml prednisolone sodium DEXAMETHASONE SOLN P 0.5 MG/5ML phosphate tbdp or 10 mg, P dexamethasone tabs 0.75 15 mg, 30 mg mg, 0.5 mg, 4 mg, 6 mg, P PREDNISOLONE SOLN P 1.5 mg DEXAMETHASONE TABS P prednisolone soln P 1 MG, 2 MG ENTOCORT EC CPEP NP prednisolone syrp P (Use Budesonide) PREDNISONE INTENSOL P hydrocortisone tabs P CONC PREDNISONE SOLN 5 KENALOG-40 SUSP (Use NP P Triamcinolone Acetonide) MG/5ML prednisone tabs 1 mg, 5 MEDROL DOSEPAK TBPK NP P (Use Methylprednisolone) mg, 10 mg, 20 mg, 2.5 mg PREDNISONE TABS 50 MEDROL TABS (Use NP P Methylprednisolone) MG SOLU-MEDROL SOLR methylprednisolone acetate P susp 40 mg/ml (Use Methylprednisolone NP Sod Succ) METHYLPREDNISOLONE ACETATE SUSP 40 NP triamcinolone acetonide P MG/ML susp TRIAMCINOLONE methylprednisolone sod P NP succ solr ACETONIDE SUSP VERIPRED 20 SOLN (Use QL(150 ml per methylprednisolone tabs P Prednisolone Sodium NP fill retail) Phosphate)

46 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Mineralocorticoids dextromethorphan- guaifenesin soln 10mg/5ml- P fludrocortisone acetate P 100mg/5ml, 20mg/10ml- tabs 200mg/10ml COUGH/COLD/ALLERGY - Drugs to Treat DIMETAPP COLD & QL(120 ml per Cough, Cold and Allergy Symptoms ALLERGY ELIX (Use NP fill retail) Antitussives Brompheniramine & Phenyleph) benzonatate caps 100 mg P AL(At least 10 yrs old) P QL(240 ml per guaifenesin-codeine liqd fill retail) QL(1 ea daily); benzonatate caps 200 mg P AL(At least 10 guaifenesin-codeine soln P QL(240 ml per yrs old) fill retail) QL(240 ml per hydrocodone w/ P AL(At least 18 guaifenesin-codeine syrp P homatropine syrp yrs old) fill retail) loratadine & QL(2 ea daily) TESSALON PERLES NP AL(At least 10 CAPS (Use Benzonatate) yrs old) pseudoephedrine tb12 P 5mg-120mg Cough/Cold/Allergy Combinations loratadine & QL(1 ea daily) brompheniramine & QL(120 ml per P pseudoephedrine tb24 P phenyleph elix fill retail) 10mg-240mg, 10mg-10mg- 240mg-240mg brompheniramine & P QL(120 ml per pseudoeph elix fill retail) P QL(240 ml per phenylephrine-dm liqd fill retail) brompheniramine & P QL(120 ml per pseudoeph liqd fill retail) P QL(240 ml per phenylephrine-dm soln fill retail) cetirizine-pseudoephedrine P QL(2 ea daily) tb12 QL(240 ml per promethazine & P CHERACOL PLUS LIQD phenylephrine soln fill retail); AL(At (Use Dextromethorphan- NP least 2 yrs old) Guaifenesin) QL(240 ml per CHERACOL-D COUGH promethazine w/codeine P fill retail); AL(At soln least 18 yrs LIQD (Use NP Dextromethorphan- old) Guaifenesin) QL(240 ml per CLARITIN-D 12 HOUR QL(2 ea daily) promethazine w/codeine P fill retail); AL(At TB12 (Use Loratadine & NP syrp least 18 yrs Pseudoephedrine) old) CLARITIN-D 24 HOUR QL(1 ea daily) QL(240 ml per TB24 (Use Loratadine & NP promethazine- P fill retail); AL(At Pseudoephedrine) phenylephrine-codeine syrp least 18 yrs dextromethorphan- old) guaifenesin liqd 10mg/5ml- QL(240 ml per PROMETHAZINE/PHENYL P 100mg/5ml, 20mg/10ml- EPHRINE SYRP fill retail); AL(At 200mg/10ml, 15mg/7.5ml- P least 2 yrs old) 150mg/7.5ml, 10mg/5ml- QL(240 ml per 10mg/5ml-100mg/5ml- PROMETHAZINE/PHENYL P fill retail); AL(At 100mg/5ml EPHRINE/CODEINE SYRP least 18 yrs old)

47 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SCOT-TUSSIN LIQD (Use AVAR-E LS CREA (Use Pheniramine-PE w/ Sod NP Sulfacetamide Sodium w/ NP Salicylate & Caffeine Sulfur) Citrate) BENZAC AC WASH LIQD NP RX/OTC ZYRTEC-D QL(2 ea daily) (Use Benzoyl Peroxide) ALLERGY/CONGESTION NP BENZACLIN GEL (Use TB12 (Use Cetirizine- Clindamycin Phosphate- NP Pseudoephedrine) Benzoyl Peroxide) Misc. Respiratory Inhalants BENZACLIN WITH PUMP GEL (Use Clindamycin sodium chloride (inhalant) P NP aers Phosphate-Benzoyl Peroxide) sodium chloride (inhalant) P nebu BENZAMYCIN GEL (Use Benzoyl Peroxide- NP Mucolytics Erythromycin) acetylcysteine soln P BENZEFOAM ULTRA FOAM (Use Benzoyl NP DERMATOLOGICALS - Drugs to Treat Skin Peroxide) Conditions benzoyl peroxide bar 10 % P Acne Products PA; QL(2 ea benzoyl peroxide crea 10 P daily); AL(At % ABSORICA CAPS NP least 12 yrs old benzoyl peroxide foam 9.8 P - Up to 22 yrs % old) benzoyl peroxide gel 10 % P RX/OTC ACNE MEDICATION 10 P LOTN BENZOYL PEROXIDE P GEL 2.5 % ACNE MEDICATION 5 P LOTN benzoyl peroxide gel 5 % P ACZONE GEL (Use NP Dapsone (Topical)) benzoyl peroxide liqd 4 % P adapalene crea 0.1 % P benzoyl peroxide liqd 5 %, P RX/OTC 10 % QL(45 gm per 30 days retail); benzoyl peroxide- P adapalene gel 0.1 % P AL(At least 12 erythromycin gel yrs old); CLEAN & CLEAR RX/OTC ADVANTAGE 3-IN-1 P EXFOLIATING CLEANSER adapalene gel 0.3 % P LOTN CLEOCIN-T LOTN (Use QL(60 ml per adapalene-benzoyl P peroxide gel Clindamycin Phosphate NP fill retail) (Topical)) ATRALIN GEL (Use NP Tretinoin) CLEOCIN-T SOLN (Use AVAR LS CLEANSER Clindamycin Phosphate NP LIQD (Use Sulfacetamide NP (Topical)) Sodium w/ Sulfur)

48 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CLEOCIN-T SWAB (Use PA; QL(2 ea Clindamycin Phosphate NP daily); AL(At (Topical)) isotretinoin caps P least 12 yrs old - Up to 22 yrs clindamycin phosphate P (topical) foam old) KLARON LOTN (Use QL(120 ml per clindamycin phosphate P QL(60 ml per (topical) lotn fill retail) Sulfacetamide Sodium NP fill retail) (Acne)) clindamycin phosphate P (topical) soln PANOXYL-4 CREAMY WASH LIQD (Use Benzoyl NP clindamycin phosphate P Peroxide) (topical) swab PLEXION CLEANSER clindamycin phosphate- LIQD (Use Sulfacetamide NP benzoyl peroxide P Sodium w/ Sulfur) (refrigerate) gel PLEXION CREA (Use clindamycin phosphate- P Sulfacetamide Sodium w/ NP benzoyl peroxide gel Sulfur) dapsone (topical) gel P PLEXION LOTN (Use Sulfacetamide Sodium w/ NP DESQUAM-X WASH LIQD NP RX/OTC Sulfur) (Use Benzoyl Peroxide) RETIN-A CREA 0.025 %, QL(20 gm per DIFFERIN CREA 0.1 % NP fill retail); (Use Adapalene) 0.05 %, 0.1 % (Use NP ) AL(Up to 21 yrs QL(45 gm per Tretinoin old ) 30 days retail); QL(15 gm per DIFFERIN GEL 0.1 % (Use NP AL(At least 12 Adapalene) RETIN-A GEL 0.01 % (Use NP fill retail); yrs old); Tretinoin) AL(Up to 21 yrs RX/OTC old ) DIFFERIN GEL 0.3 % (Use NP QL(20 gm per Adapalene) RETIN-A GEL 0.025 % NP fill retail); DUAC GEL (Use (Use Tretinoin) AL(Up to 21 yrs Clindamycin Phosphate- NP old ) Benzoyl Peroxide RETIN-A MICRO GEL (Use NP (Refrigerate)) Tretinoin Microsphere) EPIDUO GEL (Use RETIN-A MICRO PUMP Adapalene-Benzoyl NP GEL (Use Tretinoin NP Peroxide) Microsphere) ERYGEL GEL (Use NP QL(60 gm per SODIUM QL(60 gm per Erythromycin (Acne Aid)) fill retail) SULFACETAMIDE/SULFU P fill retail) erythromycin (acne aid) gel P QL(60 gm per R LOTN fill retail) SODIUM QL(30 gm per erythromycin (acne aid) P SULFACETAMIDE/SULFU P fill retail) soln R SUSP EVOCLIN FOAM (Use sulfacetamide sodium P QL(120 ml per Clindamycin Phosphate NP (acne) lotn fill retail) (Topical)) sulfacetamide sodium w/ P sulfur crea

49 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits sulfacetamide sodium w/ P P QL(30 gm per sulfur liqd bacitracin zinc oint fill retail) sulfacetamide sodium w/ P bacitracin-polymyxin b oint P sulfur lotn BACTROBAN CREA (Use QL(30 gm per sulfacetamide sodium w/ P sulfur pads Mupirocin Calcium NP fill retail) (Topical)) sulfacetamide sodium w/ P sulfur susp CENTANY OINT P QL(30 gm per SUMADAN WASH LIQD fill retail) (Use Sulfacetamide NP gentamicin sulfate (topical) P QL(30 gm per Sodium w/ Sulfur) crea fill retail) SUMAXIN PADS (Use gentamicin sulfate (topical) P QL(30 gm per Sulfacetamide Sodium w/ NP oint fill retail) Sulfur) mupirocin calcium (topical) P QL(30 gm per SUMAXIN TS SUSP (Use crea fill retail) Sulfacetamide Sodium w/ NP P QL(30 gm per Sulfur) mupirocin oint fill retail) SUMAXIN WASH LIQD neomycin-bacitracin- P QL(30 gm per (Use Sulfacetamide NP polymyxin oint fill retail) Sodium w/ Sulfur) neomycin-polymyxin w/ P QL(30 gm per QL(20 gm per pramoxine crea fill retail) tretinoin crea 0.025 %, 0.05 P fill retail); NEOSPORIN ORIGINAL QL(30 gm per %, 0.1 % AL(Up to 21 yrs OINT (Use Neomycin- NP fill retail) old ) Bacitracin-Polymyxin) QL(15 gm per NEOSPORIN PLUS PAIN QL(30 gm per tretinoin gel 0.01 % P fill retail); RELIEF MAXIMUM fill retail) AL(Up to 21 yrs STRENGTH CREA (Use NP old ) Neomycin-Polymyxin w/ QL(20 gm per Pramoxine) fill retail); tretinoin gel 0.025 % P POLYSPORIN OINT (Use NP AL(Up to 21 yrs Bacitracin-Polymyxin B) old ) Antifungals - Topical tretinoin gel 0.05 % P CICLODAN SOLUTION NP KIT KIT (Use Ciclopirox) tretinoin microsphere gel P ciclopirox kit P Anti-inflammatory Agents - Topical ciclopirox olamine crea P diclofenac sodium (topical) P gel VOLTAREN GEL (Use ciclopirox olamine susp P Diclofenac Sodium NP (Topical)) ciclopirox sham P Antibiotics - Topical ciclopirox soln P BACIGUENT OINT (Use NP QL(30 gm per Bacitracin (Topical)) fill retail) QL(30 gm per clotrimazole (topical) crea P fill retail); P QL(30 gm per bacitracin (topical) oint fill retail) RX/OTC Western Sky Updated December 1, 2018 P-Preferred drug, NP-Non-preferred, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, RX/OTC - both Rx and OTC NDCs MP-Maintenance drug eligible for 90 day supply

50 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(30 ml per naftifine hcl crea P clotrimazole (topical) soln P fill retail); RX/OTC NAFTIN CREA (Use NP Naftifine HCl) clotrimazole w/ P QL(45 gm per betamethasone crea fill retail) NIZORAL SHAM (Use NP QL(120 ml per Ketoconazole (Topical)) fill retail) clotrimazole w/ P QL(30 ml per betamethasone lotn fill retail) P QL(30 gm per nystatin (topical) crea fill retail) P QL(30 gm per econazole nitrate crea fill retail) P QL(30 gm per nystatin (topical) oint fill retail) EXTINA FOAM (Use NP Ketoconazole (Topical)) P QL(60 gm per nystatin (topical) powd fill retail) iodoquinol-hydrocortisone P in aloe vehicle crea P QL(30 gm per nystatin-triamcinolone crea fill retail) P 1 rtl pack lmt ketoconazole (topical) crea per fill, P QL(30 gm per nystatin-triamcinolone oint fill retail) ketoconazole (topical) foam P oxiconazole nitrate crea P ketoconazole (topical) P QL(120 ml per sham fill retail) OXISTAT CREA (Use NP Oxiconazole Nitrate) LAMISIL AT CREA (Use NP QL(30 gm per Terbinafine HCl (Topical)) fill retail) PENLAC NAIL LACQUER NP LAMISIL AT JOCK ITCH QL(30 gm per SOLN (Use Ciclopirox) CREA (Use Terbinafine NP fill retail) P QL(30 gm per HCl (Topical)) terbinafine hcl (topical) crea fill retail) LOPROX CREA (Use NP TINACTIN CREA (Use NP QL(30 gm per Ciclopirox Olamine) Tolnaftate) fill retail) LOPROX SHAMPOO NP TINACTIN JOCK ITCH NP QL(30 gm per SHAM (Use Ciclopirox) CREA (Use Tolnaftate) fill retail) LOPROX SUSP (Use NP P QL(30 gm per Ciclopirox Olamine) tolnaftate crea fill retail) QL(30 gm per VYTONE CREA (Use LOTRIMIN AF CREA (Use NP Clotrimazole (Topical)) fill retail); Iodoquinol-Hydrocortisone NP RX/OTC in Aloe Vehicle) LOTRIMIN AF FOR HER QL(30 gm per Antihistamines-Topical CREA (Use Clotrimazole NP fill retail); (Topical)) RX/OTC diphenhydramine hcl P (topical) crea LOTRIMIN AF JOCK ITCH QL(30 gm per CREA (Use Clotrimazole NP fill retail); ITCH RELIEF CREA P (Topical)) RX/OTC LOTRISONE CREA (Use QL(45 gm per Antineoplastic or Premalignant Lesion Agents - Clotrimazole w/ NP fill retail) CARAC CREA P QL(30 gm per Betamethasone) fill retail) MICATIN CREA (Use QL(45 ml per diclofenac sodium (actinic P PA Miconazole Nitrate NP fill retail) keratoses) gel (Topical)) EFUDEX CREA (Use NP QL(40 gm per Fluorouracil (Topical)) fill retail) miconazole nitrate (topical) P QL(45 ml per crea fill retail) Western Sky Updated December 1, 2018 P-Preferred drug, NP-Non-preferred, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, RX/OTC - both Rx and OTC NDCs MP-Maintenance drug eligible for 90 day supply

51 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits P QL(40 gm per Antiseborrheic Products fluorouracil (topical) crea fill retail) OVACE PLUS SHAM (Use NP FLUOROURACIL CREA P QL(30 gm per Sulfacetamide Sodium) 0.5 % fill retail) OVACE PLUS WASH GEL FLUOROURACIL SOLN 2 P QL(10 ml per (Use Sulfacetamide NP %, 5 % fill retail) Sodium) SOLARAZE GEL (Use PA OVACE PLUS WASH LIQD QL(360 ml per Diclofenac Sodium (Actinic NP (Use Sulfacetamide NP fill retail) Keratoses)) Sodium) Antipruritics - Topical OVACE WASH LIQD (Use NP QL(360 ml per Sulfacetamide Sodium) fill retail) camphor & menthol lotn P QL(222 ml per fill retail) P QL(240 ml per selenium sulfide lotn 1 % fill retail) SARNA LOTN (Use NP QL(222 ml per Camphor & Menthol) fill retail) P QL(120 ml per selenium sulfide lotn 2.5 % fill retail) Antipsoriatics P QL(240 ml per acitretin caps P selenium sulfide sham 1 % fill retail) SELSUN BLUE DAILY QL(240 ml per P QL(60 gm per calcipotriene crea fill retail) LOTN (Use Selenium NP fill retail) Sulfide) calcipotriene soln P QL(60 ml per fill retail) SELSUN BLUE LOTN (Use NP QL(240 ml per Selenium Sulfide) fill retail) DOVONEX CREA (Use NP QL(60 gm per Calcipotriene) fill retail) SELSUN BLUE QL(240 ml per MEDICATED LOTN (Use NP fill retail) methoxsalen rapid caps P Selenium Sulfide) OXSORALEN ULTRA SELSUN BLUE QL(240 ml per CAPS (Use Methoxsalen NP MOISTURIZING LOTN NP fill retail) Rapid) (Use Selenium Sulfide) SORIATANE CAPS (Use NP sulfacetamide sodium gel P Acitretin) P QL(360 ml per PA; QL(60 gm sulfacetamide sodium liqd fill retail) tazarotene crea P per fill retail); AL(Up to 21 yrs sulfacetamide sodium P old ) sham PA; QL(60 gm Antivirals - Topical TAZORAC CREA 0.05 % P per fill retail); 1 rtl pack lmt AL(Up to 21 yrs acyclovir topical oint P amt,30 rtl pack old ) lmt day(s), PA; QL(60 gm ZOVIRAX CREA EX 5 % P QL(5 gm per fill TAZORAC CREA 0.1 % NP per fill retail); retail) (Use Tazarotene) AL(Up to 21 yrs 1 rtl pack lmt old ) ZOVIRAX OINT EX 5 % NP ) amt,30 rtl pack PA; QL(60 gm (Use Acyclovir Topical lmt day(s), TAZORAC GEL 0.05 %, P per fill retail); 0.1 % AL(Up to 21 yrs Burn Products old ) mafenide acetate pack P

52 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SILVADENE CREA (Use NP QL(50 gm per clobetasol propionate liqd P Silver Sulfadiazine) fill retail) P QL(50 gm per clobetasol propionate lotn P silver sulfadiazine crea fill retail) QL(60 gm per SULFAMYLON PACK (Use NP clobetasol propionate oint P Mafenide Acetate) fill retail) Corticosteroids - Topical clobetasol propionate sham P ACLOVATE CREA (Use P QL(25 ml per Alclometasone NP clobetasol propionate soln fill retail) Dipropionate) CLOBEX LIQD (Use NP ALA SCALP LOTN NP Clobetasol Propionate) CLOBEX LOTN (Use NP alclometasone dipropionate P Clobetasol Propionate) crea CLOBEX SHAM (Use NP P QL(60 gm per Clobetasol Propionate) APEXICON E CREA fill retail) CORDRAN CREA 0.05 % NP betamethasone QL(50 gm per (Use Flurandrenolide) dipropionate augmented P fill retail) crea CORDRAN LOTN 0.05 % NP (Use Flurandrenolide) betamethasone dipropionate augmented P CORDRAN OINT 0.05 % NP lotn (Use Flurandrenolide) betamethasone CUTIVATE LOTN (Use NP dipropionate augmented P Fluticasone Propionate) oint DERMA-SMOOTHE/FS BODY OIL (Use NP betamethasone valerate P QL(45 gm per crea 0.1 % fill retail) Fluocinolone Acetonide) DERMA-SMOOTHE/FS betamethasone valerate P foam 0.12 % SCALP OIL (Use NP Fluocinolone Acetonide) betamethasone valerate P QL(60 ml per lotn 0.1 % fill retail) DERMATOP CREA (Use NP QL(60 gm per Prednicarbate) fill retail) betamethasone valerate P QL(45 gm per oint 0.1 % fill retail) DERMATOP OINT (Use NP QL(60 gm per Prednicarbate) fill retail) calcipotriene- betamethasone P desonide crea P dipropionate oint desonide lotn P P QL(45 gm per clobetasol propionate crea fill retail) DESOWEN CREA (Use NP clobetasol propionate P QL(60 gm per Desonide) emollient base crea fill retail) DESOWEN LOTN (Use NP clobetasol propionate P Desonide) emulsion foam desoximetasone crea 0.05 P QL(60 gm per clobetasol propionate foam P % fill retail) desoximetasone crea 0.25 P P QL(60 gm per % clobetasol propionate gel fill retail)

53 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits desoximetasone gel 0.05 P flurandrenolide oint P % 1 rtl pack lmt desoximetasone oint 0.05 P fluticasone propionate crea %, 0.25 % P amt,30 rtl pack 0.05 % lmt day(s), DIFLORASONE P QL(60 gm per DIACETATE CREA fill retail) fluticasone propionate lotn P 0.05 % diflorasone diacetate oint P QL(60 gm per fill retail) fluticasone propionate oint P QL(60 gm per DIPROLENE AF CREA QL(50 gm per 0.005 % fill retail) (Use Betamethasone NP fill retail) halobetasol propionate P Dipropionate Augmented) crea DIPROLENE LOTN (Use halobetasol propionate oint P Betamethasone NP Dipropionate Augmented) hydrocortisone (topical) P QL(30 gm per DIPROLENE OINT (Use crea 0.5 %, 2.5 % fill retail) Betamethasone NP hydrocortisone (topical) QL(60 gm per Dipropionate Augmented) P fill retail); crea 1%, 1 % RX/OTC ELOCON CREA (Use NP QL(45 gm per Mometasone Furoate) fill retail) hydrocortisone (topical) lotn P QL(60 ml per 1 %, 2.5 % fill retail) ELOCON OINT (Use NP QL(45 gm per Mometasone Furoate) fill retail) hydrocortisone (topical) oint P 0.5 % EPIFOAM FOAM P 1 rtl pack lmt hydrocortisone (topical) oint P amt,30 rtl pack fluocinolone acetonide crea P 1 % lmt day(s),; RX/OTC fluocinolone acetonide oil P hydrocortisone (topical) oint 1 rtl pack lmt fluocinolone acetonide oint P P amt,30 rtl pack 2.5 % lmt day(s), fluocinolone acetonide soln P hydrocortisone butyrate P crea QL(60 gm per fluocinonide crea 0.05 % P hydrocortisone butyrate P fill retail) hydrophilic lipo base crea fluocinonide crea 0.1 % P hydrocortisone butyrate P lotn fluocinonide emulsified QL(60 gm per P hydrocortisone butyrate P base crea fill retail) oint QL(60 gm per fluocinonide gel 0.05 % P hydrocortisone butyrate P QL(60 ml per fill retail) soln fill retail) P QL(60 gm per fluocinonide oint 0.05 % fill retail) hydrocortisone valerate oint P QL(60 ml per fluocinonide soln 0.05 % P hydrocortisone-aloe vera P QL(60 gm per fill retail) crea fill retail) flurandrenolide crea P KENALOG AERS (Use Triamcinolone Acetonide NP flurandrenolide lotn P (Topical))

54 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LOCOID CREA (Use NP SYNALAR OINT (Use NP Hydrocortisone Butyrate) Fluocinolone Acetonide) LOCOID LIPOCREAM SYNALAR SOLN (Use NP CREA (Use Hydrocortisone NP Fluocinolone Acetonide) Butyrate Hydrophilic Lipo TACLONEX OINT (Use Base) Calcipotriene- NP LOCOID LOTN (Use NP Betamethasone Hydrocortisone Butyrate) Dipropionate) LOCOID OINT (Use NP TEMOVATE CREA (Use NP QL(45 gm per Hydrocortisone Butyrate) Clobetasol Propionate) fill retail) LOCOID SOLN (Use NP QL(60 ml per TEMOVATE E CREA (Use QL(60 gm per Hydrocortisone Butyrate) fill retail) Clobetasol Propionate NP fill retail) Emollient Base) LUXIQ FOAM (Use NP Betamethasone Valerate) TEMOVATE OINT (Use NP QL(60 gm per Clobetasol Propionate) fill retail) mometasone furoate crea P QL(45 gm per fill retail) TOPICORT CREA 0.05 % NP QL(60 gm per (Use Desoximetasone) fill retail) mometasone furoate oint P QL(45 gm per fill retail) TOPICORT CREA 0.25 % NP (Use Desoximetasone) mometasone furoate soln P QL(60 ml per fill retail) TOPICORT GEL 0.05 % NP MONISTAT SOOTHING QL(60 gm per (Use Desoximetasone) CARE ITCH RELIEF CREA NP fill retail); TOPICORT OINT 0.05 %, (Use Hydrocortisone RX/OTC 0.25 % (Use NP (Topical)) Desoximetasone) NOVACORT GEL NP triamcinolone acetonide P (topical) aers 0.147 mg/gm OLUX FOAM (Use NP triamcinolone acetonide P QL(454 gm per Clobetasol Propionate) (topical) crea 0.025 % fill retail) OLUX-E FOAM (Use triamcinolone acetonide P QL(30 gm per Clobetasol Propionate NP (topical) crea 0.1 % fill retail) Emulsion) triamcinolone acetonide P QL(15 gm per PRAMOSONE CREA (Use NP (topical) crea 0.5 % fill retail) Pramoxine-HC) triamcinolone acetonide QL(60 ml per pramoxine-hc crea P (topical) lotn 0.025 %, 0.1 P fill retail) % pramoxine-hc gel P triamcinolone acetonide QL(80 gm per (topical) oint 0.025 %, 0.1 P fill retail) P QL(60 gm per % PREDNICARBATE CREA fill retail) triamcinolone acetonide P QL(15 gm per P QL(60 gm per (topical) oint 0.5 % fill retail) prednicarbate crea fill retail) TRIDESILON CREA (Use NP P QL(60 gm per Desonide) PREDNICARBATE OINT fill retail) ULTRAVATE CREA (Use NP P QL(60 gm per Halobetasol Propionate) PSORCON CREA fill retail) ULTRAVATE OINT (Use NP SYNALAR CREA (Use NP Halobetasol Propionate) Fluocinolone Acetonide) Western Sky Updated December 1, 2018 P-Preferred drug, NP-Non-preferred, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, RX/OTC - both Rx and OTC NDCs MP-Maintenance drug eligible for 90 day supply

55 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VANOS CREA (Use NP AQUAPHOR ADVANCED P Fluocinonide) THERAPY OINT WESTCORT OINT (Use NP AQUAPHOR OINT P Hydrocortisone Valerate) Emollient/Keratolytic Agents AVEENO ACTIVE NATURALS DAILY NP HYDRO 35 FOAM (Use NP MOISTURIZING BODY Urea in Lactic Acid Vehicle) YOGURT LOTN HYDRO 40 FOAM FOAM NP AVEENO ACTIVE (Use Urea) NATURALS DAILY NP KERALAC CREA (Use NP MOISTURIZING BODY Urea) YOGURT/APRICO LOTN URAMAXIN GEL (Use NP AVEENO DAILY Urea) MOISTURIZINGSPF 15 NP LOTN URAMAXIN GT GEL (Use NP Urea) AVEENO POSITIVELY AGELESSFIRMING BODY NP urea crea 39 %, 47 % P LOTN QL(210 gm per AVEENO POSITIVELY NP urea crea 40 % P fill retail); RADIANT LOTN RX/OTC AVEENO STRESS RELIEF NP urea foam 40 % P MOISTURIZING LOTN BETA CARE LOTN NP urea gel 45 % P BOUDREAUXS BABY urea in lactic acid vehicle P BUTT SMOOTH DRY SKIN P foam OINT P QL(240 ml per urea lotn 40 % fill retail) CAM LOTN NP Emollients CERAVE AM SPF 30 NP LOTN A + D PERSONAL CARE NP LOTION LOTN CERAVE LOTN NP ALOE AFTERSUN NP LOTION LOTN CERAVE PM LOTN NP AMLACTIN CERAPEUTIC NP CERAVE SA RENEWING NP LOTN LOTN AQUA GLYCOLIC HAND & NP CETAPHIL DAILY BODYLOTION LOTN ADVANCE ULTRA NP AQUA LACTEN LOTN NP HYDRATING LOTN CETAPHIL DAILY FACIAL NP AQUADERM MOISTURIZER LOTN TREATMENT/MOISTURIZ NP ER LOTN CETAPHIL DERMACONTROL NP AQUAMED LOTN NP MOISTURIZER/SPF 30 LOTN AQUAPHILIC OINT P CETAPHIL NP MOISTURIZING LOTN Western Sky Updated December 1, 2018 P-Preferred drug, NP-Non-preferred, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, RX/OTC - both Rx and OTC NDCs MP-Maintenance drug eligible for 90 day supply

56 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CETAPHIL NP EUCERIN DAILY RESTORADERM LOTN PROTECTION/SPF 30 NP CLN FACIAL LOTN MOISTURIZER NP EUCERIN INTENSIVE NP NOURISHING LOTN REPAIR LOTN COCOA BUTTER HAND & NP EUCERIN LOTN NP BODYLOTION LOTN EUCERIN ORIGINAL COCOA BUTTER LOTN NP HEALINGSOOTHING NP REPAIR LOTN CVS DAILY ULTRA NP MOISTURELOTION LOTN EUCERIN PLUS LOTN NP DAILY CONDITIONING P TREATMENT OINT EUCERIN DERMAL THERAPY PROFESSIONAL REPAIR NP EXTRA STRENGTH BODY NP RICH FEEL LOTN LOTION LOTN EUCERIN SMOOTHING DERMAL THERAPY FACE REPAIRADVANCED NP CAREMOISTURIZING NP FORMULA LOTN LOTION LOTN FORMULA 405 NP MOISTURIZING LOTN DERMAL THERAPY FOOT NP MASSAGE LOTN GNP ADVANCED NP DERMAL THERAPY HAND RECOVERY LOTN ELBOW & KNEE CREAM NP GOLD BOND MEDICATED LOTN BODYLOTION EXTRA NP STRENGTH LOTN DERMAL THERAPY HEEL NP CARE LOTN GOLD BOND MEDICATED NP BODYLOTION LOTN DIABETIDERM HAND & NP BODY LOTN GOLD BOND ULTIMATE DIABETICS DRY SKIN NP DIABETIDERM LOTN NP RELIEF LOTN GOLD BOND ULTIMATE EMOLLIA-LOTION LOTN NP DIABETICS' DRY RELIEF NP LOTN emollient lotn P GOLD BOND ULTIMATE NP HEALING LOTN emollient oint P GOLD BOND ULTIMATE P EPILYT LOTN NP HEALING OINT GOLD BOND ULTIMATE NP EQL ADVANCED LOTN RECOVERY SKIN CARE NP GOLD BOND ULTIMATE NP LOTN OVERNIGHT LOTN EQL ULTRA GOLD BOND ULTIMATE NP MOISTURIZING DAILY NP PROTECTION LOTN LOTION LOTN GOLD BOND ULTIMATE NP EUCERIN BABY LOTN NP RESTORING LOTN

57 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GOLD BOND ULTIMATE 1 rtl pack lmt NP LAC-HYDRIN TWELVE SHEERRIBBONS LOTN (Use Lactic Acid NP amt,30 rtl pack PEARLRADIANCE LOTN (Ammonium Lactate)) lmt day(s),; GOLD BOND ULTIMATE RX/OTC SHEERRIBBONS NP QL(140 gm per SILKSOFTNESS LOTN lactic acid (ammonium P fill retail); lactate) crea RX/OTC GOLD BOND ULTIMATE NP SOFTENING LOTN 1 rtl pack lmt lactic acid (ammonium amt,30 rtl pack GOLD BOND ULTIMATE NP P SOOTHING LOTN lactate) lotn lmt day(s),; RX/OTC GRX VITAMIN E LOTN NP LANAPHILIC OINT P hyaluronate sodium P (emollient) gel LUBRIDERM ADVANCED NP THERAPY LOTN HYDRAZONE LOTION NP LOTN LUBRIDERM DAILY MOISTURE/NORMAL TO NP HYLIRA GEL (Use DRY SKIN LOTN Hyaluronate Sodium NP (Emollient)) LUBRIDERM DAILY MOISTURESHEA + NP KERI ADVANCED CALMING LAVENDER MOISTURE THERAPY NP JASMINE LOTN LOTN LUBRIDERM INTENSE NP KERI BASIC ESSENTIALS NP SKIN REPAIR LOTN LOTN LUBRIDERM LOTN NP KERI NOURISHING SHEA NP BUTTER LOTN LUBRIDERM MENS 3-IN-1 NP KERI ORIGINAL LOTN NP LOTN LUBRIDERM SERIOUSLY NP KERI OVERNIGHT LOTN NP SENSITIVE LOTN LUBRIDERM SKIN KERI RENEWAL MILK NP BODY LOTN NOURISHINGWITH SHEA NP AND COCOA BUTTERS KERI RENEWAL SKIN NP LOTN FIRMING LOTN KERI RENEWAL LUBRISOFT LOTN NP STRETCH MARK NP MINIMIZER LOTN MAXAM LOTN NP KERI SENSITIVE SKIN NP MEDERMA AG HAND & NP LOTN BODY LOTION LOTN LAC-HYDRIN CREA (Use QL(140 gm per Lactic Acid (Ammonium NP fill retail); MOTHERS FRIEND LOTN NP Lactate)) RX/OTC MSM SKIN LOTION LOTN NP LAC-HYDRIN LOTN (Use 1 rtl pack lmt Lactic Acid (Ammonium NP amt,30 rtl pack NEUTROGENA BODY Lactate)) lmt day(s),; LIGHT SESAME NP RX/OTC FORMULA LOTN

58 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NEUTROGENA HEALTHY NP ST IVES SWISS SKIN FACE SPF 15 LOTN FORMULA 24HOUR NP NEUTROGENA MOISTURE LOTN MOISTURE SENSITIVE NP STUDIO 35 EXTRA SKIN LOTN MOISTURIZING LOTION NP LOTN NIVEA EXTRA ENRICHED NP LOTION LOTN THERABETIC SKIN CARE NP LOTN NIVEA EXTRA ENRICHED NP LOTN THERAPLEX NP HYDROLOTION LOTN NIVEA GENTLE BODY NP EXFOLIATOR LOTN VANICREAM LITE LOTN NP NIVEA LIGHT LOTN NP WIBI LOTN NP NIVEA LOTN NP Immunomodulating Agents - Topical NIVEA ORIGINAL LOTN NP ALDARA CREA (Use NP Imiquimod) NIVEA ORIGINAL NP MOISTURE LOTN imiquimod crea P NIVEA VISAGE LOTN NP Immunosuppressive Agents - Topical PA; 1 rtl pack NUTRADERM ADVANCED NP FORMULA LOTN P lmt amt,30 rtl ELIDEL CREA pack lmt NUTRADERM LOTN NP day(s), PA; 1 rtl pack OINTMENT BASE OINT P PROTOPIC OINT (Use NP lmt amt,30 rtl Tacrolimus (Topical)) pack lmt RA ADVANCED HEALING P day(s), OINT PA; 1 rtl pack RA DAYLOGIC HEALING P lmt amt,30 rtl DRY SKIN THERAPY NP tacrolimus (topical) oint pack lmt LOTN day(s), RA RENEWAL DRY SKIN NP THERAPY LOTN Keratolytic/Antimitotic Agents CONDYLOX SOLN (Use QL(4 ml per fill RADIAGUARD NP NP ADVANCED LOTN Podofilox) retail) KERALYT GEL (Use NP QL(40 gm per RESTA LITE LOTN NP Salicylic Acid) fill retail) QL(4 ml per fill ROC DEEP WRINKLE NP podofilox soln P SERUM LOTN retail) SALEX SHAM (Use NP ROSE MILK LOTN NP Salicylic Acid) SKIN REPAIR LOTN NP salicylic acid foam 6 % P SOOTHE & COOL salicylic acid gel 6 % P QL(40 gm per MOISTURIZING BODY NP fill retail) LOTION WITH ALOE LOTN salicylic acid liqd 27.5 % P Western Sky Updated December 1, 2018 P-Preferred drug, NP-Non-preferred, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, RX/OTC - both Rx and OTC NDCs MP-Maintenance drug eligible for 90 day supply

59 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits salicylic acid sham 6 % P PREDATOR CREA (Use NP QL(65 ml per Lidocaine HCl) fill retail) salicylic acid soln 28.5 % P Misc. Topical QL(60 ml per SALVAX FOAM (Use NP DRYSOL SOLN P Salicylic Acid) fill retail) QL(60 gm per ULTRASAL-ER SOLN NP zinc oxide (topical) oint P (Use Salicylic Acid) fill retail) Rosacea Agents VIRASAL LIQD (Use NP Salicylic Acid) METROCREAM CREA QL(45 gm per Local Anesthetics - Topical (Use Metronidazole NP fill retail) (Topical)) ARTHRITIS PAIN P QL(60 gm per RELIEVING CREA fill retail) METROGEL GEL (Use NP Metronidazole (Topical)) capsaicin crea 0.025 % P METROLOTION LOTN (Use Metronidazole NP P QL(42.5 gm per capsaicin crea 0.1 % fill retail) (Topical)) metronidazole (topical) QL(45 gm per CAPZASIN-HP CREA (Use NP QL(42.5 gm per P Capsaicin) fill retail) crea 0.75 % fill retail) metronidazole (topical) gel QL(45 gm per P QL(30 gm per P dibucaine oint fill retail) 0.75 % fill retail) metronidazole (topical) gel P QL(30 gm per P lidocaine crea 4 % fill retail) 1 % QL(30 gm per metronidazole (topical) lotn P lidocaine hcl crea ex 3 % P fill retail); 0.75 % RX/OTC Scabicides & Pediculicides lidocaine hcl crea ex 3.88 P P QL(60 gm per % crotamiton lotn fill retail) QL(65 ml per lidocaine hcl crea ex 4 % P ELIMITE CREA (Use NP QL(60 gm per fill retail) Permethrin) fill retail) QL(30 ml per P QL(60 gm per lidocaine hcl gel ex 2 % P fill retail); EURAX CREA fill retail) RX/OTC EURAX LOTN (Use NP QL(60 gm per lidocaine hcl soln ex 4 % P Crotamiton) fill retail) malathion lotn P QL(59 ml per lidocaine ptch 5 % P PA fill retail) QL(120 ml per lidocaine-prilocaine crea P QL(30 gm per NATROBA SUSP P fill retail); AL(At fill retail) least 1 yrs old) LIDODERM PTCH (Use PA NP NIX CREME RINSE LIQD NP Lidocaine) (Use Permethrin) LIDOTRAL CREA (Use NP OVIDE LOTN (Use NP QL(59 ml per Lidocaine HCl) Malathion) fill retail) LMX 4 CREA (Use QL(30 gm per NP P QL(60 gm per Lidocaine) fill retail) permethrin crea 5 % fill retail)

60 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits permethrin liqd 1 % P DIAGNOSTIC PRODUCTS permethrin lotn 1 % P QL(120 ml per Diagnostic Tests fill retail) CHEK-STIX COMBO PAK pyrethrins-piperonyl P QL(60 ml per URINALYSIS CONTROL P butoxide liqd 0.33%-4% fill retail) STRP pyrethrins-piperonyl CHEK-STIX CONTROL P butoxide liqd 1.2%-0.3%- P STRP 0.3%-2.4%-3% pyrethrins-piperonyl CHEMSTRIP-K STRP P butoxide sham 0.3%- P 0.33%-4%, 0.33%-4% KETOCARE STRP P pyrethrins-piperonyl QL(60 ml per P KETONE TEST STRIPS P butoxide sham 0.33%-4% fill retail) STRP pyrethrins-piperonyl butoxide-permethrin-nit P KETOSTIX STRP P remover kit NOVA MAX PLUS QL(1 ea daily) RID COMPLETE LICE KETONE TESTSTRIPS P ELIMINATION KIT (Use STRP Pyrethrins-Piperonyl NP PRECISION XTRA STRP P QL(1 ea daily) Butoxide-Permethrin-Nit VI Remover) PTS PANELS KETONE P QL(1 ea daily) RID LIQD (Use Pyrethrins- NP QL(60 ml per TEST STRP Piperonyl Butoxide) fill retail) QL(120 ml per RELION KETONE STRP P SPINOSAD SUSP P fill retail); AL(At RELION KETONE TEST P least 1 yrs old) STRIPS STRP Tar Products INSULIN USERS coal tar extract sham P LIMITED TO 200 PER 30 DHS TAR GEL SHAM (Use NP TRUE METRIX BLOOD Coal Tar Extract) GLUCOSETEST STRIPS P DAYS, NON- STRP INSULIN DHS TAR SHAM (Use Coal NP USERS Tar Extract) LIMITED TO NEUTROGENA T/GEL 100 PER 90 SHAM (Use Coal Tar NP DAYS;RX/OTC Extract) INSULIN NEUTROGENA T/GEL USERS STUBBORN ITCH NP LIMITED TO CONTROL SHAM (Use 200 PER 30 Coal Tar Extract) TRUE METRIX SELF MONITORING BLOOD P DAYS, NON- Wound Care Products INSULIN GLUCOSE STRIPS STRP USERS HYGEL GEL NP LIMITED TO 100 PER 90 THERAPEVO GEL NP DAYS;RX/OTC

61 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits INSULIN DIGESTIVE AIDS - Drugs to Treat Low Digestive USERS Enzymes LIMITED TO Digestive Enzymes TRUETEST BLOOD 200 PER 30 P DAYS, NON- CREON CPEP P GLUCOSE TEST STRIPS INSULIN STRP USERS LIMITED TO PANCREAZE CPEP P 100 PER 90 DIURETICS - Drugs to Treat Heart, Circulation DAYS;RX/OTC Conditions and Blood Pressure INSULIN USERS Carbonic Anhydrase Inhibitors LIMITED TO acetazolamide cp12 P MP 200 PER 30 TRUETEST BLOOD P DAYS, NON- acetazolamide tabs P MP GLUCOSE TEST STRP INSULIN USERS DIAMOX CP12 (Use NP MP LIMITED TO Acetazolamide) 100 PER 90 DAYS;RX/OTC methazolamide tabs P INSULIN NEPTAZANE TABS (Use NP USERS Methazolamide) LIMITED TO 200 PER 30 Diuretic Combinations ALDACTAZIDE TABS (Use MP P DAYS, NON- TRUETEST STRIPS STRP INSULIN Spironolactone & NP USERS Hydrochlorothiazide) LIMITED TO amiloride & P QL(1 ea daily) 100 PER 90 hydrochlorothiazide tabs DAYS;RX/OTC DYAZIDE CAPS (Use QL(1 ea daily); INSULIN Triamterene & NP MP USERS Hydrochlorothiazide) LIMITED TO 200 PER 30 MAXZIDE TABS (Use QL(1 ea daily); Triamterene & NP MP TRUETRACK BLOOD P DAYS, NON- GLUCOSE TEST STRP INSULIN Hydrochlorothiazide) USERS MAXZIDE-25 TABS (Use QL(1 ea daily); LIMITED TO Triamterene & NP MP 100 PER 90 Hydrochlorothiazide) DAYS;RX/OTC spironolactone & P MP INSULIN hydrochlorothiazide tabs USERS triamterene & P QL(1 ea daily); LIMITED TO hydrochlorothiazide caps MP 200 PER 30 triamterene & P QL(1 ea daily); P DAYS, NON- hydrochlorothiazide tabs MP TRUETRACK TEST STRP INSULIN USERS TRIAMTERENE/HYDROC P QL(1 ea daily); LIMITED TO HLOROTHIAZIDE CAPS MP 100 PER 90 Loop Diuretics DAYS;RX/OTC

62 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits bumetanide tabs P MP indapamide tabs P MP

BUMEX TABS (Use NP MP metolazone tabs P MP Bumetanide) MICROZIDE CAPS (Use MP DEMADEX TABS (Use NP QL(1 ea daily); NP Torsemide) MP Hydrochlorothiazide) SODIUM DIURIL SOLR EDECRIN TABS (Use NP Ethacrynic Acid) (Use Chlorothiazide NP Sodium) ethacrynate sodium solr P ENDOCRINE AND METABOLIC AGENTS - ethacrynic acid tabs P MISC. - Drugs to Treat Bone Disease and Regulate Hormones furosemide soln ij 10 mg/ml P Bone Density Regulators ACTONEL TABS 150 MG furosemide soln or 10 P MP NP mg/ml (Use Risedronate Sodium) FUROSEMIDE SOLN OR 8 MP PA; Limit 4 per P ACTONEL TABS 35 MG NP MG/ML ) month;QL(0.13 (Use Risedronate Sodium 4 ea daily) furosemide tabs or 20 mg, P MP 40 mg, 80 mg ACTONEL TABS 5 MG, 30 PA; QL(1 ea MG (Use Risedronate NP daily) LASIX TABS (Use NP MP Sodium) Furosemide) ALENDRONATE SODIUM P QL(10.8 ml SODIUM EDECRIN SOLR NP SOLN 70 MG/75ML daily); MP (Use Ethacrynate Sodium) alendronate sodium tabs Limit 4 per torsemide tabs P QL(1 ea daily); P month;QL(0.13 MP 35 mg, 70 mg 4 ea daily); MP Potassium Sparing Diuretics ALENDRONATE SODIUM P QL(1 ea daily); TABS 40 MG MP ALDACTONE TABS (Use NP MP Spironolactone) alendronate sodium tabs 5 P QL(1 ea daily); mg, 10 mg MP amiloride hcl tabs P QL(4 ea daily) BONIVA SOLN IV 3 SP spironolactone tabs P MP MG/3ML (Use Ibandronate NP Sodium) Thiazides and Thiazide-Like Diuretics BONIVA TABS OR 150 MG NP (Use Ibandronate Sodium) chlorothiazide sodium solr P P QL(0.143 ml calcitonin (salmon) soln daily) CHLOROTHIAZIDE TABS P QL(2 ea daily); 250 MG MP Limit 4 per FOSAMAX TABS (Use NP month;QL(0.13 P QL(4 ea daily); Alendronate Sodium) chlorothiazide tabs 500 mg MP 4 ea daily); MP MP ibandronate sodium soln iv P SP chlorthalidone tabs P 3 mg/3ml MP hydrochlorothiazide caps P ibandronate sodium tabs or P 150 mg hydrochlorothiazide tabs P MP

63 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(2 ml per fill CARNITOR SF SOLN (Use QL(30 ml daily) retail)1 rtl pack Levocarnitine (Metabolic NP MIACALCIN SOLN IJ 200 P )) UNIT/ML lmt amt,30 rtl Modifiers pack lmt CARNITOR SOLN 1 QL(30 ml daily) day(s), GM/10ML (Use NP MIACALCIN SOLN NA 200 QL(0.143 ml Levocarnitine (Metabolic UNIT/ACT (Use Calcitonin NP daily) Modifiers)) (Salmon)) CARNITOR TABS 330 MG QL(3 ea daily); RECLAST SOLN (Use NP SP (Use Levocarnitine NP RX/OTC Zoledronic Acid) (Metabolic Modifiers)) risedronate sodium tabs P doxercalciferol caps P 150 mg PA; Limit 4 per doxercalciferol soln P risedronate sodium tabs 35 P mg month;QL(0.13 4 ea daily) HECTOROL CAPS (Use NP Doxercalciferol) risedronate sodium tabs 5 P PA; QL(1 ea mg, 30 mg daily) HECTOROL SOLN (Use NP Doxercalciferol) zoledronic acid conc P SP levocarnitine (metabolic P QL(30 ml daily) modifiers) soln 1 gm/10ml zoledronic acid soln P SP levocarnitine (metabolic P QL(3 ea daily); ZOMETA CONC (Use NP SP modifiers) tabs 330 mg RX/OTC Zoledronic Acid) paricalcitol caps or 1 mcg, P Growth Hormones 2 mcg paricalcitol soln iv 2 SP NORDITROPIN FLEXPRO P PA; SP P SOLN mcg/ml, 5 mcg/ml ROCALTROL CAPS (Use NUTROPIN AQ NUSPIN P PA; SP NP 10 SOLN Calcitriol) ROCALTROL SOLN (Use NUTROPIN AQ NUSPIN P PA; SP NP 20 SOLN Calcitriol) sodium phenylbutyrate SP NUTROPIN AQ NUSPIN 5 P PA; SP P SOLN powd Hormone Receptor Modulators XURIDEN PACK P EVISTA TABS (Use NP QL(1 ea daily) ZEMPLAR CAPS OR 1 Raloxifene HCl) MCG, 2 MCG (Use NP raloxifene hcl tabs P QL(1 ea daily) Paricalcitol) ZEMPLAR SOLN IV 2 SP Metabolic Modifiers MCG/ML, 5 MCG/ML (Use NP Paricalcitol) BUPHENYL POWD (Use NP SP Sodium Phenylbutyrate) Posterior Pituitary Hormones calcitriol caps P P QL(5 ml per fill DDAVP SOLN NA 0.01 % retail) calcitriol soln P DDAVP SOLN NA 0.01 % PA; QL(5 ml (Use Desmopressin NP per fill retail) Acetate Spray)

64 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DDAVP TABS OR 0.1 MG, QL(3 ea daily) Limit 8 patches 0.2 MG (Use NP P per Desmopressin Acetate) ALORA PTTW month;QL(0.29 ea daily); MP desmopressin acetate P QL(5 ml per fill spray refrigerated soln retail) Limit 4 patches CLIMARA PTWK (Use per desmopressin acetate P PA; QL(5 ml NP spray soln per fill retail) Estradiol) month;QL(0.14 3 ea daily); MP desmopressin acetate tabs P QL(3 ea daily) DELESTROGEN OIL (Use NP Estradiol Valerate) Somatostatic Agents ESTRACE TABS OR 0.5 MP octreotide acetate soln P SP MG, 1 MG, 2 MG (Use NP Estradiol) SANDOSTATIN SOLN NP SP (Use Octreotide Acetate) estradiol pttw td 0.025 Limit 8 patches P per ESTROGENS - Hormone Replacement/Modifying mg/24hr, 0.075 mg/24hr, month;QL(0.29 Drugs 0.05 mg/24hr, 0.1 mg/24hr ea daily); MP Estrogen Combinations estradiol pttw td 0.0375 P QL(0.29 ea ACTIVELLA TABS (Use QL(1 ea daily) mg/24hr daily); MP Estradiol & Norethindrone NP estradiol ptwk td 0.025 Limit 4 patches Acetate) mg/24hr, 0.075 mg/24hr, per 0.05 mg/24hr, 0.06 P month;QL(0.14 ANGELIQ TABS P mg/24hr, 0.1 mg/24hr, 37.5 3 ea daily); MP mcg/24hr CLIMARA PRO PTWK P estradiol tabs or 0.5 mg, 1 P MP Limit 8 patches mg, 2 mg P per estradiol valerate oil P COMBIPATCH PTTW month;QL(0.29 ea daily) ESTROPIPATE TABS 0.75 P QL(1 ea daily); MG, 1.5 MG MP DUAVEE TABS P ESTROPIPATE TABS 3 P QL(2 ea daily); MG MP esterified estrogens & P QL(1 ea daily) methyltestosterone tabs MENEST TABS NP estradiol & norethindrone P QL(1 ea daily) acetate tabs MINIVELLE PTTW 0.025 Limit 8 patches FEMHRT LOW DOSE MG/24HR, 0.075 per TABS (Use Norethindrone NP MG/24HR, 0.05 MG/24HR, NP month;QL(0.29 Acetate-Ethinyl Estradiol) 0.1 MG/24HR (Use ea daily); MP Estradiol) norethindrone acetate- P ethinyl estradiol tabs MINIVELLE PTTW 0.0375 NP QL(0.29 ea MG/24HR (Use Estradiol) daily); MP PREFEST TABS P PREMARIN TABS OR QL(1 ea daily) QL(1 ea daily) 0.625 MG, 0.45 MG, 0.3 P PREMPHASE TABS P MG, 0.9 MG, 1.25 MG PREMPRO TABS P QL(1 ea daily) Estrogens

65 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VIVELLE-DOT PTTW Limit 8 patches GASTROINTESTINAL AGENTS - MISC. - 0.025 MG/24HR, 0.075 per Miscellaneous Gastrointestinal Drugs MG/24HR, 0.05 MG/24HR, NP month;QL(0.29 0.1 MG/24HR (Use ea daily); MP Antiflatulents Estradiol) GAS-X CHEW (Use NP VIVELLE-DOT PTTW QL(0.29 ea Simethicone) 0.0375 MG/24HR (Use NP daily); MP MYLICON INFANTS GAS QL(30 ml per Estradiol) RELIEF SUSP (Use NP fill retail) ) FLUOROQUINOLONES - Drugs to Treat Bacterial Simethicone Infections MYLICON SUSP (Use NP QL(30 ml per Simethicone) fill retail) Fluoroquinolones simethicone chew 80 mg P AVELOX ABC PACK TABS NP (Use Moxifloxacin HCl) simethicone liqd 20 P AVELOX TABS (Use NP mg/0.3ml, 40 mg/0.6ml Moxifloxacin HCl) simethicone susp 20 P QL(30 ml per CIPRO I.V.-IN D5W SOLN NP mg/0.3ml, 40 mg/0.6ml fill retail) (Use Ciprofloxacin in D5W) Gallstone Solubilizing Agents CIPRO SUSR (Use NP Ciprofloxacin) ACTIGALL CAPS (Use NP QL(3 ea daily); Ursodiol) MP CIPRO TABS (Use NP Ciprofloxacin HCl) URSO 250 TABS (Use NP QL(7 ea daily); Ursodiol) MP CIPRO XR TB24 (Use Ciprofloxacin-Ciprofloxacin NP URSO FORTE TABS (Use NP HCl) Ursodiol) QL(3 ea daily); CIPROFLOXACIN ER NP ursodiol caps 300 mg P TB24 MP QL(7 ea daily); CIPROFLOXACIN HCL P QL(6 ea per fill ursodiol tabs 250 mg P TABS 100 MG retail) MP ursodiol tabs 500 mg P ciprofloxacin hcl tabs 250 P mg, 500 mg, 750 mg Gastrointestinal Antiallergy Agents ciprofloxacin in d5w soln P cromolyn sodium P (mastocytosis) conc ciprofloxacin susr P GASTROCROM CONC QL(1 ea (Use Cromolyn Sodium NP LEVAQUIN TABS (Use NP ) daily,14 ea per (Mastocytosis)) Levofloxacin fill retail) Gastrointestinal Stimulants QL(1 ea levofloxacin tabs P daily,14 ea per metoclopramide hcl soln P fill retail) metoclopramide hcl tabs P moxifloxacin hcl tabs P REGLAN TABS (Use NP OFLOXACIN TABS 300 P QL(56 ea per Metoclopramide HCl) MG fill retail) Inflammatory Bowel Agents ofloxacin tabs 400 mg P QL(56 ea per fill retail) AZULFIDINE EN-TABS NP MP TBEC (Use Sulfasalazine) Western Sky Updated December 1, 2018 P-Preferred drug, NP-Non-preferred, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, RX/OTC - both Rx and OTC NDCs MP-Maintenance drug eligible for 90 day supply

66 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AZULFIDINE TABS (Use NP MP GENITOURINARY AGENTS - MISCELLANEOUS Sulfasalazine) - Miscellaneous Drugs to Treat Reproductive balsalazide disodium caps P QL(9 ea daily) Organs and Urinary System Alkalinizers COLAZAL CAPS (Use NP QL(9 ea daily) Balsalazide Disodium) potassium citrate P (alkalinizer) tbcr DELZICOL CPDR P PA; QL(6 ea daily) potassium citrate-citric acid P pack PA; SP INFLECTRA SOLR P SHOHLS SOLUTION 1 rtl pack lmt QL(60 ml daily) MODIFIED SOLN (Use NP amt,30 rtl pack mesalamine enem P Sodium Citrate & Citric lmt day(s),; Acid) RX/OTC mesalamine w/ cleanser kit P 1 rtl pack lmt PA; SP sodium citrate & citric acid P amt,30 rtl pack RENFLEXIS SOLR P soln lmt day(s),; RX/OTC ROWASA KIT (Use NP Mesalamine w/ Cleanser) UROCIT-K 10 TBCR (Use Potassium Citrate NP SFROWASA ENEM P (Alkalinizer)) MP UROCIT-K 15 TBCR (Use sulfasalazine tabs P Potassium Citrate NP (Alkalinizer)) sulfasalazine tbec P MP UROCIT-K 5 TBCR (Use Intestinal Acidifiers Potassium Citrate NP (Alkalinizer)) lactulose (encephalopathy) P soln Genitourinary Irrigants Irritable Bowel Syndrome (IBS) Agents neomycin/polymyxin b gu P soln alosetron hcl tabs P NEOSPORIN GU IRRIGANT SOLN (Use LOTRONEX TABS (Use NP NP Alosetron HCl) Neomycin/Polymyxin B GU) Phosphate Binder Agents sodium chloride (gu P calcium acetate (phosphate P irrigant) soln binder) caps Interstitial Cystitis Agents FOSRENOL CHEW (Use NP Lanthanum Carbonate) ELMIRON CAPS P QL(3 ea daily) lanthanum carbonate chew P Prostatic Hypertrophy Agents RENVELA PACK (Use NP alfuzosin hcl tb24 P Sevelamer Carbonate) AVODART CAPS (Use RENVELA TABS (Use NP NP Sevelamer Carbonate) Dutasteride) sevelamer carbonate pack P dutasteride caps P dutasteride-tamsulosin hcl P sevelamer carbonate tabs P caps

67 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits P QL(1 ea daily); ADVATE SOLR P PA; SP finasteride tabs MP PA; SP FLOMAX CAPS (Use NP QL(2 ea daily); ADYNOVATE SOLR P Tamsulosin HCl) MP JALYN CAPS (Use AFSTYLA KIT P PA; SP Dutasteride-Tamsulosin NP HCl) ALPHANATE/VON PA; SP WILLEBRANDFACTOR P PROSCAR TABS (Use NP QL(1 ea daily); COMPLEX/HUMAN SOLR Finasteride) MP ALPHANINE SD SOLR P PA; SP P QL(2 ea daily); tamsulosin hcl caps MP ALPROLIX SOLR P PA; SP UROXATRAL TB24 (Use NP Alfuzosin HCl) BEBULIN SOLR P PA; SP Urinary Analgesics PA; SP phenazopyridine hcl tabs P BENEFIX KIT P PA; SP PYRIDIUM TABS (Use NP COAGADEX SOLR P Phenazopyridine HCl) CORIFACT KIT P PA; SP GOUT AGENTS - Drugs to Treat Gout PA; SP Gout Agent Combinations ELOCTATE SOLR P colchicine w/ probenecid P FEIBA SOLR P PA; SP tabs Gout Agents FIBRYGA SOLR P PA; SP allopurinol sodium solr P HELIXATE FS KIT P PA; SP MP allopurinol tabs P HEMOFIL M SOLR P PA; SP ALOPRIM SOLR (Use NP PA; SP Allopurinol Sodium) HUMATE-P SOLR P PA; Limit 6 per IDELVION SOLR 250 PA; SP COLCHICINE TABS P claim;QL(6 ea UNIT, 500 UNIT, 1000 P per fill retail) UNIT, 2000 UNIT PA; Limit 6 per PA; SP COLCRYS TABS P claim;QL(6 ea IXINITY SOLR P per fill retail) KCENTRA KIT P PA; SP ZYLOPRIM TABS (Use NP MP Allopurinol) KOATE SOLR P PA; SP Uricosurics KOATE-DVI SOLR P PA; SP probenecid tabs P KOGENATE FS BIO-SET P PA; SP HEMATOLOGICAL AGENTS - MISC. - Drugs to KIT Treat Blood Disorders KOGENATE FS KIT P PA; SP Antihemophilic Products

68 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits KOVALTRY SOLR P PA; SP clopidogrel bisulfate tabs P QL(1 ea daily); 75 mg MP PA; SP MONOCLATE-P KIT P dipyridamole tabs P MP PA; SP MONONINE SOLR P EFFIENT TABS (Use NP QL(1 ea daily) Prasugrel HCl) PA; SP NOVOEIGHT SOLR P PLAVIX TABS 300 MG NP (Use Clopidogrel Bisulfate) NOVOSEVEN RT SOLR P PA; SP PLAVIX TABS 75 MG (Use NP QL(1 ea daily); Clopidogrel Bisulfate) MP NUWIQ KIT P PA; SP prasugrel hcl tabs P QL(1 ea daily) NUWIQ SOLR P PA; SP HEMATOPOIETIC AGENTS - Drugs to Treat OBIZUR SOLR P PA; SP Blood Disorders Agents for Sickle Cell Anemia PROFILNINE SD SOLR P PA; SP DROXIA CAPS P PA; SP PROFILNINE SOLR P Cobalamins REBINYN SOLR P PA; SP cyanocobalamin soln P

RECOMBINATE SOLR P PA; SP cyanocobalamin tabs P

RIASTAP SOLR P PA; SP Folic Acid/Folates folic acid tabs 1 mg P RX/OTC; MP RIXUBIS SOLR P PA; SP folic acid tabs 400 mcg, P QL(1 ea daily) TRETTEN SOLR P PA; SP 800 mcg Hematopoietic Growth Factors VONVENDI SOLR P PA; SP ZARXIO SOSY P PA; SP WILATE KIT P PA; SP Hematopoietic Mixtures PA; SP XYNTHA KIT P CORVITE 150 TABS (Use Iron-Folic Acid-Vitamin C- NP XYNTHA SOLOFUSE KIT P PA; SP Vitamin B6-Vitamin B12- Zinc) Hematorheologic Agents fe fum-iron polysacch pentoxifylline tbcr P MP complex-fa-b complex-c- P zn-mn-cu caps Platelet Aggregation Inhibitors ferrous fumarate-fa-b QL(1 ea daily) QL(2 ea daily) complex-c-zn-mg-mn-cu P BRILINTA TABS P tabs cilostazol tabs P QL(2 ea daily); FOLGARD RX TABS (Use MP Folic Acid-Vitamin B6- NP Vitamin B12) clopidogrel bisulfate tabs P 300 mg folic acid-vitamin b6-vitamin P b12 tabs Western Sky Updated December 1, 2018 P-Preferred drug, NP-Non-preferred, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, RX/OTC - both Rx and OTC NDCs MP-Maintenance drug eligible for 90 day supply

69 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits iron-folic acid-vitamin c- P QL(30 ea per 5 vitamin b6-vitamin b12-zinc P tranexamic acid tabs days retail) tabs HYPNOTICS/SEDATIVES/SLEEP DISORDER TANDEM PLUS CAPS AGENTS (Use Fe Fum-Iron NP Polysacch Complex-FA-B Antihistamine Hypnotics Complex-C-Zn-Mn-Cu) diphenhydramine hcl P Iron (sleep) caps 50 mg diphenhydramine hcl QL(1 ea daily) FER-IN-SOL SOLN (Use NP QL(3.4 ml P Ferrous Sulfate) daily); MP (sleep) tabs 25 mg QL(2 ea daily) diphenhydramine hcl P FERRETTS TABS P (sleep) tabs 50 mg FERRLECIT SOLN (Use doxylamine succinate P Sodium Ferric Gluconate NP (sleep) tabs Complex in Sucrose) NYTOL MAXIMUM STRENGTH TABS (Use ferrous gluconate tabs 27 P NP mg, 240 mg Diphenhydramine HCl (Sleep)) FERROUS GLUCONATE P AL(Up to 50 yrs TABS 324 MG old ) UNISOM SLEEPGELS CAPS (Use NP ferrous sulfate dried tbcr P Diphenhydramine HCl (Sleep)) ferrous sulfate elix 220 P QL(16 ml mg/5ml daily); MP UNISOM SLEEPTABS TABS (Use Doxylamine NP ferrous sulfate soln 15 P QL(3.4 ml Succinate (Sleep)) mg/ml daily); MP Barbiturate Hypnotics ferrous sulfate tabs 28 mg P NEMBUTAL SODIUM SOLN (Use Pentobarbital NP ferrous sulfate tabs 65 mg, P MP 325 mg Sodium) FERROUS SULFATE P MP pentobarbital sodium soln P TBEC 324 MG ferrous sulfate tbec 325 mg P MP phenobarbital elix P phenobarbital soln P IRON CHEWS PEDIATRIC P CHEW phenobarbital tabs P polysaccharide iron P QL(1 ea daily) complex caps Hypnotics - Tricyclic Agents sodium ferric gluconate P complex in sucrose soln SILENOR TABS P HEMOSTATICS - Drugs to Stop Bleeding/Treat Blood Disorders Non-Barbiturate Hypnotics AMBIEN CR TBCR (Use NP Hemostatics - Systemic Zolpidem Tartrate) QL(24 ea per AMICAR TABS P AMBIEN TABS (Use NP QL(1 ea daily) fill retail); SP Zolpidem Tartrate) LYSTEDA TABS (Use NP QL(30 ea per 5 Tranexamic Acid) days retail) dexmedetomidine hcl soln P

70 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DORAL TABS P zolpidem tartrate tabs or 5 P QL(1 ea daily) mg, 10 mg EDLUAR SUBL P zolpidem tartrate tbcr or P 12.5 mg, 6.25 mg estazolam tabs P Orexin Receptor Antagonists FLURAZEPAM HCL CAPS P QL(1 ea daily) BELSOMRA TABS P

HALCION TABS (Use NP QL(1 ea daily) Selective Melatonin Receptor Agonists Triazolam) HETLIOZ CAPS P SP INTERMEZZO SUBL (Use NP Zolpidem Tartrate) ROZEREM TABS P midazolam hcl soln P LAXATIVES - Bowel Treatment Drugs MIDAZOLAM/SYRSPEND P SF PH4 SUSP Bulk Laxatives PRECEDEX SOLN (Use NP QL(10 ea daily) Dexmedetomidine HCl) calcium polycarbophil tabs P QUAZEPAM TABS P EVAC POWD (Use NP Psyllium) QL(1 ea daily); FIBERCON TABS (Use QL(10 ea daily) RESTORIL CAPS 15 MG NP NP ) AL(At least 18 Calcium Polycarbophil) (Use Temazepam yrs old) KONSYL DAILY FIBER P QL(2 ea daily); PACK RESTORIL CAPS 30 MG NP AL(At least 18 (Use Temazepam) KONSYL DAILY FIBER NP yrs old) POWD (Use Psyllium) RESTORIL CAPS 7.5 MG, KONSYL ORIGINAL 22.5 MG (Use NP FORMULADAILY FIBER NP Temazepam) POWD (Use Psyllium) QL(1 ea daily); METAMUCIL CAPS (Use SONATA CAPS (Use NP NP ) AL(At least 18 Psyllium) Zaleplon yrs old) METAMUCIL ORIGINAL QL(1 ea daily); TEXTURE POWD (Use NP temazepam caps 15 mg P AL(At least 18 Psyllium) yrs old) METAMUCIL POWD (Use NP QL(2 ea daily); Psyllium) temazepam caps 30 mg P AL(At least 18 yrs old) psyllium caps P temazepam caps 7.5 mg, P 22.5 mg psyllium powd P QL(1 ea daily) triazolam tabs P Laxative Combinations QL(1 ea daily); COLYTE-FLAVOR PACKS QL(4000 ml per zaleplon caps P AL(At least 18 SOLR (Use PEG 3350-KCl- NP fill retail) yrs old) Sod Bicarb-Sod Chloride- Sod Sulfate) zolpidem tartrate subl sl 3.5 P mg, 1.75 mg

71 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GOLYTELY SOLR (Use QL(4000 ml per FLEET ENEMA SIX PACK PEG 3350-KCl-Sod Bicarb- NP fill retail) ENEM (Use Sodium NP Sod Chloride-Sod Sulfate) Phosphates) NULYTELY/FLAVOR QL(4000 ml per FLEET PEDIATRIC ENEM NP PACKS SOLR (Use PEG fill retail) (Use Sodium Phosphates) 3350-Potassium Chloride- NP Sod Bicarbonate-Sod magnesium citrate soln P Chloride) magnesium hydroxide susp P QL(33 ml daily) peg 3350-kcl-sod bicarb- QL(4000 ml per sod chloride-sod sulfate P fill retail) MILK OF MAGNESIA P solr CONCENTRATE SUSP peg 3350-potassium QL(4000 ml per chloride-sod bicarbonate- P fill retail) sodium phosphates enem P sod chloride solr Stimulant Laxatives PREPOPIK PACK P P QL(12 ea per bisacodyl supp re 10 mg fill retail) sennosides-docusate P QL(4 ea daily) sodium tabs bisacodyl tbec or 5 mg P QL(1 ea daily) SENOKOT S TABS (Use QL(4 ea daily) DULCOLAX SUPP RE 10 NP QL(12 ea per Sennosides-Docusate NP MG (Use Bisacodyl) fill retail) Sodium) DULCOLAX TBEC OR 5 NP QL(1 ea daily) SUPREP BOWEL PREP P MG (Use Bisacodyl) KIT SOLN EX-LAX TABS (Use NP Laxatives - Miscellaneous Sennosides) glycerin (laxative) supp P SENNA SYRP P GLYCERIN ADULT SUPP NP (Use Glycerin (Laxative)) sennosides liqd P lactulose soln P sennosides syrp P

MIRALAX PACK (Use NP RX/OTC sennosides tabs P Polyethylene Glycol 3350) SENOKOT TABS (Use MIRALAX POWD (Use NP QL(34 gm NP Polyethylene Glycol 3350) daily); RX/OTC Sennosides) SENOKOT XTRA TABS NP PEDIA-LAX SUPP P (Use Sennosides) polyethylene glycol 3350 P RX/OTC Surfactant Laxatives pack COLACE CAPS (Use NP QL(3 ea daily) polyethylene glycol 3350 P QL(34 gm Docusate Sodium) powd daily); RX/OTC COLACE CLEAR CAPS NP SORBITOL SOLN P (Use Docusate Sodium) Saline Laxatives docusate calcium caps P FLEET ENEMA ENEM NP docusate sodium caps 100 P QL(3 ea daily) (Use Sodium Phosphates) mg, 250 mg docusate sodium caps 50 P mg Western Sky Updated December 1, 2018 P-Preferred drug, NP-Non-preferred, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, RX/OTC - both Rx and OTC NDCs MP-Maintenance drug eligible for 90 day supply

72 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits docusate sodium liqd 50 P ROPIVACAINE mg/5ml, 150 mg/15ml HYDROCHLORIDE SOLN NP IJ 2 MG/ML docusate sodium syrp 60 P mg/15ml XYLOCAINE SOLN (Use Lidocaine HCl (Local NP docusate sodium tabs 100 P mg Anesth.)) XYLOCAINE-MPF SOLN LOCAL ANESTHETICS-Parenteral - Drugs for (Use Lidocaine HCl (Local NP Numbing Anesth.)) Local Anesthetic Combinations Local Anesthetics - Esters bupivacaine w/ epinephrine P soln chloroprocaine hcl soln P lidocaine w/ epinephrine P NESACAINE-MPF SOLN NP soln (Use Chloroprocaine HCl) MARCAINE/EPINEPHRIN E SOLN (Use Bupivacaine NP MACROLIDES - Drugs to Treat Bacterial w/ Epinephrine) Infections XYLOCAINE- Azithromycin MPF/EPINEPHRINE SOLN NP AZITHROMYCIN PACK P QL(2 ea per fill (Use Lidocaine w/ OR 1 GM retail) Epinephrine) azithromycin solr iv 500 mg P XYLOCAINE/EPINEPHRIN E SOLN (Use Lidocaine w/ NP azithromycin susr or 100 P 1 rtl pack lmt Epinephrine) mg/5ml, 200 mg/5ml per fill, Local Anesthetics - Amides azithromycin tabs or 250 P QL(6 ea per fill mg retail) bupivacaine hcl soln P azithromycin tabs or 500 P QL(4 ea daily) mg bupivacaine in dextrose P soln Limit 8 per 28 azithromycin tabs or 600 P days;QL(0.286 CARBOCAINE SOLN (Use NP mg Mepivacaine HCl) ea daily) ZITHROMAX PACK OR 1 QL(2 ea per fill lidocaine hcl (local anesth.) P P soln GM retail) ZITHROMAX SOLR IV 500 LIDOCAINE HCL SOLN IJ NP NP 4 % MG (Use Azithromycin) ZITHROMAX SUSR OR 1 rtl pack lmt MARCAINE SOLN (Use NP Bupivacaine HCl) 100 MG/5ML, 200 MG/5ML NP per fill, MARCAINE SPINAL SOLN (Use Azithromycin) (Use Bupivacaine in NP ZITHROMAX TABS OR NP QL(6 ea per fill Dextrose) 250 MG (Use Azithromycin) retail) ZITHROMAX TABS OR NP QL(4 ea daily) mepivacaine hcl soln P 500 MG (Use Azithromycin) NAROPIN SOLN (Use Limit 8 per 28 NP ZITHROMAX TABS OR NP Ropivacaine HCl) ) days;QL(0.286 600 MG (Use Azithromycin ea daily) ropivacaine hcl soln P ZITHROMAX TRI-PAK NP QL(4 ea daily) TABS (Use Azithromycin)

73 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ZITHROMAX Z-PAK TABS NP QL(6 ea per fill (Use Azithromycin) retail) MEDICAL DEVICES AND SUPPLIES Clarithromycin Bandages-Dressings-Tape BIAXIN SUSR 250 Gauze Pads & Dressings- P RX/OTC MG/5ML (Use NP Misc Clarithromycin) Contraceptives BIAXIN TABS 250 MG, 500 QL(28 ea per NP Condoms Latex Lubricated- P QL(36 ea per MG (Use Clarithromycin) fill retail) Misc fill retail) CLARITHROMYCIN SUSR P 1 rtl pack lmt 125 MG/5ML per fill, Diabetic Supplies Lancet Devices-Misc P clarithromycin susr 125 P 1 rtl pack lmt mg/5ml per fill, Lancets-Misc P QL(5 ea daily) CLARITHROMYCIN SUSR P 250 MG/5ML TRUECONTROL clarithromycin susr 250 P GLUCOSE CONTROL P mg/5ml LEVEL 0 LIQD clarithromycin tabs 250 mg, P QL(28 ea per TRUECONTROL 500 mg fill retail) GLUCOSE CONTROL P LEVEL 1 LIQD P QL(14 ea per clarithromycin tb24 500 mg fill retail) TRUETEST GLUCOSE P Erythromycins CONTROLLEVEL 1 LIQD TRUETEST GLUCOSE P E.E.S. 400 TABS P CONTROLLEVEL 2 LIQD E.E.S. GRANULES SUSR TRUETEST GLUCOSE P (Use Erythromycin NP CONTROLLEVEL 3 LIQD Ethylsuccinate) Misc. Devices ERY-TAB TBEC P QL(400 ea per Alcohol Swabs-Misc P fill retail); ERYPED 200 SUSR (Use RX/OTC Erythromycin NP Ethylsuccinate) Parenteral Therapy Supplies P QL(5 ea daily); ERYPED 400 SUSR P Insulin Pen Needle-Misc RX/OTC Insulin Syringe/Needle- QL(5 ea daily); ERYTHROCIN STEARATE P P TABS Misc RX/OTC erythromycin base cpep P Respiratory Therapy Supplies Spacer/Aerosol Holding P RX/OTC erythromycin base tabs P Chambers-Misc erythromycin MIGRAINE PRODUCTS - Drugs to Treat Migraine ethylsuccinate susr 200 P Headaches mg/5ml Migraine Combinations ERYTHROMYCIN CAFERGOT TABS (Use NP ETHYLSUCCINATE TABS P Ergotamine w/ Caffeine) 400 MG ergotamine w/ caffeine tabs P PCE TBEC P

74 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Migraine Products IMITREX STATDOSE D.H.E. 45 SOLN (Use AL(At least 18 SYSTEM SOAJ 4 NP NP MG/0.5ML (Use Dihydroergotamine yrs old) ) Mesylate) Sumatriptan Succinate Limit 2 syringes dihydroergotamine P AL(At least 18 mesylate soln ij 1 mg/ml yrs old) IMITREX STATDOSE per SYSTEM SOAJ 6 NP month;QL(0.06 DIHYDROERGOTAMINE AL(At least 18 MG/0.5ML (Use 7 ml daily); MESYLATE SOLN NA 4 P yrs old) Sumatriptan Succinate) AL(At least 12 MG/ML yrs old) MIGRANAL SOLN P AL(At least 18 Limit 9 per yrs old) IMITREX TABS OR 25 MG, month;QL(0.3 Serotonin Agonists 50 MG, 100 MG (Use NP ea daily); AL(At Sumatriptan Succinate) least 12 yrs almotriptan malate tabs P old) Limit 9 per Limit 12 per month;QL(0.3 MAXALT TABS (Use NP month;QL(0.4 AMERGE TABS (Use NP Rizatriptan Benzoate) ea daily); AL(At ) ea daily); AL(At Naratriptan HCl least 18 yrs least 6 yrs old) old) MAXALT-MLT TBDP (Use NP Rizatriptan Benzoate) AXERT TABS (Use NP Almotriptan Malate) Limit 9 per Limit 6 per month;QL(0.3 month;QL(0.2 naratriptan hcl tabs P ea daily); AL(At eletriptan hydrobromide P ea daily); AL(At least 18 yrs tabs least 18 yrs old) old) Limit 6 per FROVA TABS (Use month;QL(0.2 NP RELPAX TABS (Use NP Frovatriptan Succinate) ) ea daily); AL(At Eletriptan Hydrobromide least 18 yrs frovatriptan succinate tabs P old) Limit 6 per Limit 12 per IMITREX SOLN NA 5 month;QL(0.2 rizatriptan benzoate tabs 5 P month;QL(0.4 MG/ACT, 20 MG/ACT (Use NP ea daily); AL(At mg, 10 mg ea daily); AL(At Sumatriptan) least 12 yrs least 6 yrs old) old) rizatriptan benzoate tbdp 5 P Limit 2 per mg, 10 mg IMITREX SOLN SC 6 month;QL(0.06 Limit 6 per MG/0.5ML (Use NP 7 ml daily); month;QL(0.2 Sumatriptan Succinate) AL(At least 12 sumatriptan soln P ea daily); AL(At yrs old) least 12 yrs Limit 2 per old) IMITREX STATDOSE month;QL(0.06 sumatriptan succinate soaj P REFILL SOCT (Use NP 7 ml daily); sc 4 mg/0.5ml Sumatriptan Succinate) AL(At least 12 yrs old)

75 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limit 2 syringes Limit 6 per per month;QL(0.2 ZOMIG ZMT TBDP (Use NP sumatriptan succinate soaj P month;QL(0.06 ) ea daily); AL(At sc 6 mg/0.5ml 7 ml daily); Zolmitriptan least 18 yrs AL(At least 12 old) yrs old) Limit 2 per MINERALS & ELECTROLYTES month;QL(0.06 Calcium sumatriptan succinate soct P 7 ml daily); sc 6 mg/0.5ml AL(At least 12 CALCI-CHEW CHEW P yrs old) Limit 2 per calcium carbonate tabs P month;QL(0.06 sumatriptan succinate soln calcium carbonate- P P 7 ml daily); cholecalciferol chew sc 6 mg/0.5ml AL(At least 12 yrs old) calcium carbonate- P cholecalciferol tabs Limit 2 syringes per calcium carbonate-vitamin SUMATRIPTAN d tabs 125unit-250mg, P month;QL(0.06 SUCCINATE SOSY SC 6 7 ml daily); 125unit-500mg, 200unit- MG/0.5ML AL(At least 12 500mg, 250mg-125unit, P yrs old) 500mg-125unit, 500mg- 200unit, 500mg-500mg- Limit 9 per 200unit-200unit month;QL(0.3 sumatriptan succinate tabs P calcium carbonate-vitamin QL(2 ea daily) or 25 mg, 50 mg, 100 mg ea daily); AL(At least 12 yrs d tabs 200unit-600mg, P old) 400unit-600mg, 600mg- 200unit, 600mg-400unit Limit 6 per month;QL(0.2 calcium citrate tabs P zolmitriptan tabs P ea daily); AL(At least 18 yrs CALCIUM TABS P old) Limit 6 per calcium w/ vitamin d tabs P month;QL(0.2 zolmitriptan tbdp P ea daily); AL(At CALTRATE 600+D TABS least 18 yrs (Use Calcium Carbonate- NP old) Cholecalciferol) Limit 6 per oyster shell tabs P month;QL(0.2 ZOMIG SOLN NA 5 MG P ea daily); AL(At PARVA-CAL TABS P least 12 yrs old) RA OYSTER SHELL Limit 6 per CALCIUM/VITAMIN D NP month;QL(0.2 TABS ZOMIG TABS OR 5 MG, NP ) ea daily); AL(At Electrolyte Mixtures 2.5 MG (Use Zolmitriptan least 18 yrs old) CERASPORT EX1 SOLN P CERASPORT SOLN P

76 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ENFAMIL ENFALYTE P pot phosphate monobasic QL(8 ea daily) SOLN w/ sod phosphate dibasic & P monobasic tabs EQUALYTE SOLN (Use NP Oral Electrolytes) Potassium HYDRALYTE FREEZER P K-TAB TBCR 10 MEQ (Use NP MP POPS SOLN Potassium Chloride) HYDRALYTE SOLN P K-TAB TBCR 8 MEQ P MP oral electrolytes soln P KLOR-CON M15 TBCR P PEDIALYTE ADVANCED CARE SOLN (Use Oral NP KLOR-CON/25 PACK P Electrolytes) MICRO-K CPCR 10 MEQ NP MP PEDIALYTE FREEZER (Use Potassium Chloride) POPS SOLN (Use Oral NP MICRO-K CPCR 8 MEQ NP QL(1 ea daily); Electrolytes) (Use Potassium Chloride) MP PEDIALYTE SINGLES SOLN (Use Oral NP potassium acetate soln P Electrolytes) potassium bicarbonate tbef P PEDIALYTE SOLN (Use NP Oral Electrolytes) potassium chloride cpcr or P MP Fluoride 10 meq potassium chloride cpcr or P QL(1 ea daily); FLORIVA LIQD P 8 meq MP POTASSIUM CHLORIDE P MP FLUORABON SOLN P ER TBCR FLURA-DROPS SOLN P potassium chloride MP microencapsulated crystals P LURIDE SOLN (Use NP AL(Up to 15 yrs er tbcr Sodium Fluoride) old ) potassium chloride pack or P sodium fluoride chew 0.25 AL(Up to 15 yrs 20 meq mg, 0.5 mg, 1 mg, 1.1 mg, P old ) potassium chloride tbcr or 8 P MP 2.2 mg meq, 10 meq sodium fluoride soln 0.125 P AL(Up to 15 yrs mg/drop, 0.5 mg/ml old ) Zinc zinc sulfate caps P SODIUM FLUORIDE TABS P 0.5 MG Magnesium MISCELLANEOUS THERAPEUTIC CLASSES magnesium oxide (mg P Chelating Agents supplement) tabs 400 mg DEPEN TITRATABS TABS P Phosphate K-PHOS NEUTRAL TABS QL(8 ea daily) SYPRINE CAPS (Use NP PA; SP (Use Pot Phosphate Trientine HCl) Monobasic w/ Sod NP trientine hcl caps P PA; SP Phosphate Dibasic & Monobasic) Immunosuppressive Agents

77 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AZASAN TABS P QL(3 ea daily) NEORAL CAPS 25 MG, QL(4 ea daily); 100 MG (Use Cyclosporine NP SP azathioprine tabs P Modified (For Microemulsion)) CELLCEPT CAPS 250 MG QL(2 ea daily); NEORAL SOLN 100 QL(8 ml daily); (Use Mycophenolate NP SP MG/ML (Use Cyclosporine NP SP Mofetil) Modified (For CELLCEPT SUSR 200 QL(15 ml Microemulsion)) MG/ML (Use NP daily); SP PROGRAF CAPS OR 0.5 QL(3 ea daily); Mycophenolate Mofetil) MG, 1 MG, 5 MG (Use NP SP CELLCEPT TABS 500 MG QL(4 ea daily); Tacrolimus) (Use Mycophenolate NP SP RAPAMUNE SOLN 1 P SP Mofetil) MG/ML cyclosporine caps or 25 P QL(4 ea daily); RAPAMUNE TABS 0.5 SP mg, 100 mg SP MG, 1 MG, 2 MG (Use NP cyclosporine modified (for QL(4 ea daily); Sirolimus) microemulsion) caps 25 P SP SANDIMMUNE CAPS OR QL(4 ea daily); mg, 50 mg, 100 mg 25 MG, 100 MG (Use NP SP cyclosporine modified (for QL(8 ml daily); Cyclosporine) microemulsion) soln 100 P SP SANDIMMUNE SOLN OR P QL(8 ml daily); mg/ml 100 MG/ML SP CYCLOSPORINE P QL(4 ea daily); SP MODIFIED CAPS SP sirolimus tabs P CYCLOSPORINE QL(4 ea daily); P QL(3 ea daily); tacrolimus caps SP MODIFIED CAPS (Use NP SP Cyclosporine Modified (For Potassium Removing Agents Microemulsion)) KAYEXALATE POWD (Use QL(454 gm per IMURAN TABS (Use NP Sodium Polystyrene NP fill retail) Azathioprine) Sulfonate) mycophenolate mofetil QL(2 ea daily); P sodium polystyrene P QL(454 gm per caps 250 mg SP sulfonate powd fill retail) mycophenolate mofetil susr QL(15 ml P sodium polystyrene P 200 mg/ml daily); SP sulfonate susp mycophenolate mofetil tabs P QL(4 ea daily); 500 mg SP Prostaglandins mycophenolate sodium P QL(2 ea daily); alprostadil soln P tbec 180 mg SP PROSTIN VR PEDIATRIC NP mycophenolate sodium P QL(4 ea daily); SOLN (Use Alprostadil) tbec 360 mg SP MYFORTIC TBEC 180 MG QL(2 ea daily); MOUTH/THROAT/DENTAL AGENTS (Use Mycophenolate NP SP Sodium) Anesthetics Topical Oral MYFORTIC TBEC 360 MG QL(4 ea daily); lidocaine hcl (mouth-throat) P QL(100 ml per (Use Mycophenolate NP SP soln fill retail) Sodium) Anti-infectives - Throat nystatin (mouth-throat) P QL(120 ml per susp fill retail)

78 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Antiseptics - Mouth/Throat stannous fluoride conc P RX/OTC chlorhexidine gluconate P (mouth-throat) soln THERA-FLUR-N GEL (Use NP QL(60 ml per Sodium Fluoride (Dental)) fill retail) PERIDEX SOLN (Use Chlorhexidine Gluconate NP Steroids - Mouth/Throat (Mouth-Throat)) triamcinolone acetonide P QL(5 gm per fill Dental Products (mouth) pste retail) GEL-KAM ORAL CARE RX/OTC Throat Products - Misc. RINSE CONC (Use NP QL(900 ml per Stannous Fluoride) AQUORAL SOLN P fill retail); PREVIDENT 5000 RX/OTC BOOSTER PLUS PSTE NP BIOTENE DRY MOUTH QL(900 ml per (Use Sodium Fluoride MOISTURIZING SPRAY P fill retail); (Dental)) SOLN RX/OTC PREVIDENT 5000 QL(900 ml per BOOSTER PSTE (Use NP CAPHOSOL SOLN P fill retail); Sodium Fluoride (Dental)) RX/OTC PREVIDENT 5000 DRY QL(60 ml per cevimeline hcl caps P MOUTH GEL (Use Sodium NP fill retail) Fluoride (Dental)) CVS DRY MOUTH SPRAY QL(900 ml per PREVIDENT 5000 P fill retail); SOLN RX/OTC ENAMEL PROTECT PSTE NP (Use Sodium Fluoride- QL(900 ml per Potassium Nitrate) EQL DRY MOUTH ORAL P RINSE SOLN fill retail); PREVIDENT 5000 PLUS QL(60 gm per RX/OTC CREA (Use Sodium NP fill retail) EVOXAC CAPS (Use NP Fluoride (Dental)) Cevimeline HCl) PREVIDENT 5000 QL(900 ml per SENSITIVE PSTE (Use NP MOI-STIR SOLN P fill retail); Sodium Fluoride- RX/OTC Potassium Nitrate) QL(900 ml per PREVIDENT FLUORIDE QL(60 ml per MOUTHKOTE SOLN P fill retail); GEL (Use Sodium Fluoride NP fill retail) RX/OTC (Dental)) QL(900 ml per PREVIDENT RINSE SOLN NUMOISYN LIQD P fill retail); (Use Sodium Fluoride NP RX/OTC (Dental)) ORAL RELIEF SPRAY QL(900 ml per sodium fluoride (dental) P QL(60 gm per FOR DRYMOUTH & P fill retail); crea dt 1.1 % fill retail) DISCOMFORT SOLN RX/OTC sodium fluoride (dental) gel QL(60 ml per P pilocarpine hcl (oral) tabs 5 P QL(6 ea daily) dt 1.1 % fill retail) mg sodium fluoride (dental) P pilocarpine hcl (oral) tabs P pste dt 1.1 % 7.5 mg sodium fluoride (dental) P QL(900 ml per soln mt 0.2 % RA DRY MOUTH SOLN P fill retail); RX/OTC sodium fluoride-potassium P nitrate pste Western Sky Updated December 1, 2018 P-Preferred drug, NP-Non-preferred, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, RX/OTC - both Rx and OTC NDCs MP-Maintenance drug eligible for 90 day supply

79 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SALAGEN TABS 5 MG QL(6 ea daily) Multiple Vitamins w/ Iron (Use Pilocarpine HCl NP )) multiple vitamins w/ iron P QL(1 ea daily) (Oral tabs SALAGEN TABS 7.5 MG (Use Pilocarpine HCl NP Multiple Vitamins w/ Minerals (Oral)) Multiple Vitamins w/ P QL(1 ea daily); Minerals Tab-Misc RX/OTC XEROSTOMIA RELIEF QL(900 ml per P fill retail); Multiple Vitamins w/ P QL(1 ea daily); SPRAY SOLN RX/OTC Minerals-Misc RX/OTC MULTIVITAMINS Multivitamins CARDENZ TABS (Use NP QL(1 ea daily) B-Complex Vitamins Multiple Vitamin) QL(1 ea daily) b-complex vitamins caps P ESTROFACTORS TABS P QL(1 ea daily) QL(1 ea daily) b-complex vitamins tabs P MULTI VITAMIN TABS P QL(1 ea daily)

B-Complex w/ Folic Acid MULTI VITAMIN/D-3 TABS P QL(1 ea daily) b-complex w/ c & folic acid QL(1 ea daily); caps 1.5mg-5mg-20mg- RX/OTC multiple vitamin tabs P QL(1 ea daily) 1.7mg-6mcg-1mg-150mcg- P 10mg-100mg, 5mg-1.7mg- NEOMULTIVITE TABS P QL(1 ea daily) 6mcg-20mg-1.5mg-1mg- 150mcg-10mg-100mg OMNICAP TABS P QL(1 ea daily) b-complex w/ c & folic acid RX/OTC tabs 1.5mg-10mg-20mg- ONE-A-DAY ESSENTIAL QL(1 ea daily) 1.7mg-6mcg-1mg-300mcg- TABS (Use Multiple NP 10mg-60mg, 30mcg- Vitamin) 1.5mg-20mg-1.7mg-1mg- ONE-A-DAY MENS TABS NP QL(1 ea daily) 1mg-300mcg-8mg-200mg, (Use Multiple Vitamin) 10mg-20mg-1.7mg-6mcg- QL(1 ea daily) 1.5mg-1mg-300mcg-10mg- QUINTABS TABS P 100mg, 6mcg-1.5mg- THERA TABS P QL(1 ea daily) 10mg-20mg-1.7mg-1mg- P 300mcg-10mg-100mg, 1.5mg-1.7mg-10mg- Ped MV w/ Fluoride 0.01mcg-20mg-1mg- QL(1 ea daily); Pediatric Multiple Vitamins P AL: Up to 13 300mcg-10mg-60mg, w/ FluorideChew 20mg-1.7mg-10mg- yrs old 0.006mg-1.5mg-1mg- QL(50ml per fill 0.3mg-10mg-100mg, Pediatric Multiple Vitamins P retail); AL: Up 6mcg-1.5mg-10mg-20mg- w/ FluorideSoln to 13 yrs old 1.7mg-1000mcg-300mcg- 10mg-100mg Ped MV w/ Iron NEPHRO-VITE RX TABS RX/OTC pediatric multiple vitamins QL(50 ml per (Use B-Complex w/ C & NP w/ iron soln 0.6mg/ml- fill retail) Folic Acid) 10mg/ml-5unit/ml-8mg/ml- P 1500unit/ml-400unit/ml- NEPHROCAPS CAPS QL(1 ea daily); 0.5mg/ml-0.4mg/ml- (Use B-Complex w/ C & NP RX/OTC 35mg/ml Folic Acid) Western Sky Updated December 1, 2018 P-Preferred drug, NP-Non-preferred, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, RX/OTC - both Rx and OTC NDCs MP-Maintenance drug eligible for 90 day supply

80 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits POLY-VI-SOL/IRON SOLN QL(50 ml per CITRANATAL ASSURE P (Use Pediatric Multiple NP fill retail) MISC Vitamins w/ Iron) CITRANATAL B-CALM P Ped Multi Vitamins w/Fl & FE MISC QL(50 ml per CITRANATAL BLOOM P DHA MISC ped multivitamins w/fl & P fill retail); iron soln AL(Up to 13 yrs CITRANATAL BLOOM P old ) TABS QL(50 ml per CITRANATAL DHA MISC P TRI-VIT/FLUORIDE/IRON P fill retail); SOLN AL(Up to 13 yrs CITRANATAL HARMONY P old ) CAPS Pediatric Multiple Vitamins CITRANATAL RX TABS P ONE-A-DAY VITACRAVES QL(1 ea daily) GUMMIES+OMEGA-3 QL(1 ea daily); NP CLASSIC PRENATAL P DHA CHEW (Use Pediatric TABS AL(Up to 45 yrs Multiple Vitamin w/ C & FA) old ); MP pediatric multiple vitamin w/ P QL(1 ea daily) CO-NATAL FA TABS P c & fa chew COMPLETE NATAL DHA pediatric multiple vitamin w/ P QL(50 ml per P c soln fill retail) MISC POLY-VI-SOL SOLN (Use QL(50 ml per COMPLETENATE CHEW P Pediatric Multiple Vitamin NP fill retail) w/ C) CONCEPT DHA CAPS P Pediatric Vitamins CONCEPT OB CAPS P P QL(50 ml per pediatric vitamins adc soln fill retail) QL(1 ea daily); CVS PRENATAL TABS P AL(Up to 45 yrs Prenatal Vitamins old ); MP P ACTIVE OB CAPS DOTHELLE DHA CAPS P P ATABEX EC TBEC DUET DHA 400 MISC P ATABEX OB TABS P DUET DHA BALANCED P MISC BAL-CARE DHA MISC P ELITE-OB TABS P BP FOLINATAL PLUS B P TABS ENBRACE HR CAPS P BP MULTINATAL PLUS P QL(1 ea daily); TABS EQL PRENATAL P FORMULA TABS AL(Up to 45 yrs C-NATE DHA CAPS P old ); MP EXTRA-VIRT PLUS DHA P CALCIUM PNV CAPS P CAPS

CITRANATAL 90 DHA P FOCALGIN 90 DHA MISC P MISC

81 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FOCALGIN CA MISC P MARNATAL-F CAPS P

FOLCAL DHA CAPS P QL(1 ea daily); MULTI PRENATAL TABS P AL(Up to 45 yrs old ); MP FOLCAPS OMEGA 3 P CAPS MYNATAL ADVANCE P FOLET ONE CAPS P TABS QL(1 ea daily); FOLIVANE-OB CAPS P MYNATAL CAPS P AL(Up to 45 yrs old ) QL(1 ea daily); GNP PRENATAL TABS P AL(Up to 45 yrs MYNATAL PLUS TABS P old ); MP MYNATAL ULTRACAPLET P QL(1 ea daily); TABS GOODSENSE PRENATAL P AL(Up to 45 yrs VITAMINS TABS old ); MP MYNATAL-Z TABS P HEMENATAL OB + DHA P MISC MYNATE 90 PLUS TBCR P HEMENATAL OB TABS P QL(1 ea daily); NAT-RUL PRENATAL P VITAMINS TABS AL(Up to 45 yrs QL(1 ea daily); old ); MP HM PRENATAL TABS P AL(Up to 45 yrs old ); MP NATACHEW CHEW P INATAL GT TABS P NATALVIT TABS P

INFANATE BALANCE P NATELLE ONE CAPS P CAPS KOSHER PRENATAL P NEEVO DHA CAPS P PLUS IRON TABS QL(1 ea daily); KP PRENATAL QL(1 ea daily); P AL(Up to 45 yrs NEONATAL PLUS TABS P AL(Up to 45 yrs MULTIVITAMINS TABS old ); MP old ); RX/OTC; MP QL(1 ea daily); KPN PRENATAL TABS P AL(Up to 45 yrs NEONATAL VITAMIN QL(1 ea daily); old ) P AL(Up to 45 yrs TABS old ); MP LEVOMEFOLATE DHA P CAPS NESTABS ABC MISC P QL(1 ea daily); NESTABS DHA MISC P P AL(Up to 45 yrs M-NATAL PLUS TABS old ); RX/OTC; MP NESTABS ONE CAPS P QL(1 ea daily); NESTABS TABS P P AL(Up to 45 yrs M-VIT TABS old ); RX/OTC; MP NEWGEN TABS P MACNATAL CN DHA P CAPS NEXA PLUS CAPS P

82 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(1 ea daily); PNV-TOTAL CAPS P NIVA-PLUS TABS P AL(Up to 45 yrs old ); RX/OTC; PNV-VP-U CAPS P MP QL(1 ea daily); PR NATAL 400 EC MISC P O-CAL FA TABS P AL(Up to 45 yrs old ); RX/OTC; PR NATAL 400 MISC P MP O-CAL PRENATAL TABS P PR NATAL 430 EC MISC P

OB COMPLETE P PR NATAL 430 MISC P ADVANCED CAPS QL(1 ea daily); OB COMPLETE GOLD P PRE-NATAL FORMULA CAPS P AL(Up to 45 yrs TABS old ) OB COMPLETE ONE P CAPS PREFERA OB TABS P OB COMPLETE PETITE P CAPS PREFERAOB +DHA MISC P OB COMPLETE PREMIER P TABS PREFERAOB ONE CAPS P OB COMPLETE TABS P PREMESISRX TABS P

OB COMPLETE/DHA P PRENA 1 TRUE MISC P CAPS OBSTETRIX ONE CAPS P PRENA1 CHEW CHEW P PNV FERROUS PRENA1 PEARL CPCR P FUMARATE/DOCUSATE/F P OLIC ACID TABS PRENAISSANCE P QL(1 ea daily); BALANCE CAPS PNV FOLIC ACID + IRON P AL(Up to 45 yrs PRENAISSANCE CAPS P MULTIVITAMIN TABS old ); RX/OTC; MP PRENAISSANCE P HARMONY DHA MISC PNV OB+DHA MISC P PRENAISSANCE NEXT P PNV PRENATAL PLUS TABS MULTIVITAMIN + DHA P PRENAISSANCE NEXT-B P MISC TABS QL(1 ea daily); PRENAISSANCE PLUS P PNV PRENATAL PLUS P AL(Up to 45 yrs CAPS MULTIVITAMIN TABS old ); RX/OTC; MP PRENATA CHEW P PNV TABS 29-1 TABS P PRENATABS FA TABS P PNV-DHA+DOCUSATE P CAPS PRENATABS RX TABS P PNV-OMEGA CAPS P PRENATAL 19 CHEW P

83 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PRENATAL 19 TABS P PRENATAL TABS 11UNIT- QL(1 ea daily); 263MG-25MG-1.5MG- AL(Up to 45 yrs QL(1 ea daily); 27MG-4000UNIT-18MG- old ); MP PRENATAL AND IRON P AL(Up to 45 yrs 1.7MG-4MCG-400UNIT- TABS old ) 0.8MG-2.6MG-100MG, QL(1 ea daily); 30UNIT-4000UNIT-25MG- PRENATAL FORTE TABS P AL(Up to 45 yrs 1.8MG-200MG-28MG- old ) 20MG-1.7MG-8MCG- 400UNIT-0.8MG-2.6MG- QL(1 ea daily); 120MG, 30UNIT-25MG- PRENATAL LOW IRON P TABS AL(Up to 45 yrs 1.8MG-200MG-28MG- old ); MP 20MG-1.7MG-4000UNIT- QL(1 ea daily); 8MCG-400UNIT-800MCG- PRENATAL P MULTIVITAMIN TABS AL(Up to 45 yrs 2.6MG-120MG, 30UNIT- old ); MP 4000UNIT-25MG-1.8MG- QL(1 ea daily); 200MG-28MG-20MG- P PRENATAL ONE DAILY P AL(Up to 45 yrs 1.7MG-8MCG-400UNIT- TABS old ); MP 800MCG-2.6MG-120MG, 4000UNIT-30UNIT-200MG- PRENATAL PLUS IRON P TABS 25MG-1.8MG-28MG- 20MG-1.7MG-8MCG- QL(1 ea daily); 400UNIT-800MCG-2.6MG- PRENATAL PLUS TABS P AL(Up to 45 yrs 120MG, 4000UNIT- old ); RX/OTC; 30UNIT-25MG-1.8MG- MP 200MG-28MG-20MG- 1.7MG-8MCG-400UNIT- 800MCG-2.6MG-120MG, 160MG-11UNIT-200MG- 25MG-1.84MG-27MG- 4000UNIT-18MG-1.7MG- 4MCG-400UNIT-800MCG- 2.6MG-100MG PRENATAL TABS 22MG- QL(1 ea daily); 2MG-25MG-1.84MG- AL(Up to 45 yrs 200MG-27MG-4000UNIT- P old ); RX/OTC; 20MG-3MG-12MCG- MP 400UNIT-1MG-10MG- 120MG PRENATAL TABS QL(1 ea daily); 4000UNIT-200MG-11UNIT- AL(Up to 45 yrs 27MG-25MG-1.84MG- P old ) 18MG-1.7MG-4MCG- 400UNIT-0.8MG-2.6MG- 100MG QL(1 ea daily); PRENATAL VITAMIN & P AL(Up to 45 yrs MINERAL TABS old ); MP QL(1 ea daily); PRENATAL VITAMIN P AL(Up to 45 yrs TABS old ); MP

84 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(1 ea daily); QL(1 ea daily); PRENATAL P AL(Up to 45 yrs PX PRENATAL P AL(Up to 45 yrs VITAMIN/IRON TABS old ); MP MULTIVITAMINS TABS old ); MP QL(1 ea daily); QL(1 ea daily); PRENATAL VITAMINS P AL(Up to 45 yrs QC PRENATAL TABS P AL(Up to 45 yrs PLUS LOW IRON TABS old ); RX/OTC; old ); MP MP R-NATAL OB CAPS P QL(1 ea daily); PRENATAL VITAMINS P TABS AL(Up to 45 yrs RA PRENATAL QL(1 ea daily); old ); MP FORMULA/FOLICACID P AL(Up to 45 yrs TABS old ); MP PRENATAL-U CAPS P QL(1 ea daily); PRENATE AM TABS P RA PRENATAL TABS P AL(Up to 45 yrs old ); MP PRENATE CHEW P RELNATE DHA CAPS P PRENATE DHA CAPS P QL(1 ea daily); RIGHT STEP PRENATAL P TABS AL(Up to 45 yrs PRENATE ELITE TABS P old ); MP SE-NATAL 19 CHEW P PRENATE ENHANCE P CAPS SE-NATAL 19 TABS P PRENATE ESSENTIAL P CAPS SELECT-OB CHEW P PRENATE MINI CAPS P SELECT-OB+DHA MISC P PRENATE PIXIE CAPS P QL(1 ea daily); SM PRENATAL VITAMINS P AL(Up to 45 yrs PRENATE RESTORE P TABS CAPS old ); MP PRENATE STAR TABS P TARON-BC MISC P QL(1 ea daily); TARON-C DHA CAPS P PREPLUS TABS P AL(Up to 45 yrs old ); RX/OTC; TARON-PREX CAPS P MP QL(1 ea daily); PREQUE 10 TABS P THERANATAL CORE P AL(Up to 45 yrs NUTRITION TABS old ); RX/OTC; PRETAB TABS P MP PRIMACARE CAPS P THRIVITE 19 TABS P

PROVIDA DHA CAPS P THRIVITE RX TABS P

PROVIDA OB CAPS P TL FOLATE TABS P

PUREFE OB PLUS CAPS P TL-CARE DHA CAPS P

85 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TL-SELECT CAPS P VINATE ONE TABS P

TRI-TABS DHA MISC P VIRT NATE TABS P

TRIADVANCE TABS P VIRT-ADVANCE TABS P

TRICARE PRENATAL P VIRT-C DHA CAPS P CHEW TRICARE PRENATAL P VIRT-NATE DHA CAPS P COMPLEAT MISC TRICARE PRENATAL P VIRT-PN PLUS CAPS P DHA ONE CAPS VIRT-SELECT CAPS P TRICARE PRENATAL P DHA ONE/FOLATE CAPS QL(1 ea daily); VIRT-VITE GT TABS P P AL(Up to 45 yrs TRICARE TABS old ); RX/OTC; VIRTPREX CAPS P MP VITA-PREN TABS P TRINATAL GT TABS P VITAFOL GUMMIES P TRINATAL RX 1 TABS P CHEW VITAFOL ULTRA CAPS P TRINATE TABS P VITAFOL-NANO TABS P TRISTART DHA CAPS P VITAFOL-OB TABS P TRISTART ONE CAPS P VITAFOL-OB+DHA MISC P TRIVEEN-DUO DHA MISC P VITAFOL-ONE CAPS P TRIVEEN-PRX RNF CAPS P VITAMEDMD ONE P ULTIMATECARE ONE P RX/QUATREFOLIC CAPS CAPS VITAMEDMD PLUS P ULTIMATECARE ONE NF P RX/QUATREFOLIC MISC CAPS VITAMEDMD REDICHEW P VEMAVITE-PRX 2 CAPS P RX CHEW

VENA-BAL DHA MISC P VITAPEARL CPCR P

VIL-RX TABS P VITATRUE MISC P

VINATE DHA RF CAPS P VIVA DHA CAPS P

VINATE II TABS P VOL-NATE TABS P

VINATE M TABS P

86 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(1 ea daily); methocarbamol tabs P VOL-PLUS TABS P AL(Up to 45 yrs old ); RX/OTC; orphenadrine citrate tb12 P MP PARAFON FORTE DSC NP VOL-TAB RX TABS P TABS (Use Chlorzoxazone) VP-CH PLUS CAPS P ROBAXIN SOLN (Use NP Methocarbamol) VP-CH-PNV CAPS P ROBAXIN TABS (Use NP Methocarbamol) VP-GGR-B6 PRENATAL P ROBAXIN-750 TABS (Use NP TABS Methocarbamol) VP-HEME OB + DHA P SKELAXIN TABS (Use NP MISC Metaxalone) VP-HEME OB TABS P SOMA TABS (Use NP Carisoprodol) VP-HEME ONE CAPS P tizanidine hcl caps P VP-PNV-DHA CAPS P tizanidine hcl tabs P ZATEAN-CH CAPS P ZANAFLEX CAPS (Use NP Tizanidine HCl) ZATEAN-PN PLUS CAPS P ZANAFLEX TABS (Use NP Vitamins w/ Lipotropics Tizanidine HCl) Direct Muscle Relaxants vitamins w/ lipotropics caps P QL(1 ea daily) DANTRIUM CAPS (Use NP MUSCULOSKELETAL THERAPY AGENTS - Dantrolene Sodium) Drugs to Treat Spasms DANTRIUM IV SOLR (Use NP Dantrolene Sodium) Central Muscle Relaxants dantrolene sodium caps P baclofen tabs 10 mg, 20 P MP mg dantrolene sodium solr P carisoprodol tabs P NASAL AGENTS - SYSTEMIC AND TOPICAL - CHLORZOXAZONE TABS P Drugs to treat the Nose or Sinus Nasal Agents - Misc. cyclobenzaprine hcl tabs 5 P QL(3 ea daily) mg, 10 mg OCEAN NASAL SPRAY NP QL(90 ml per SOLN (Use Saline) fill retail) cyclobenzaprine hcl tabs P 7.5 mg P QL(90 ml per saline soln fill retail) FEXMID TABS (Use NP Cyclobenzaprine HCl) Nasal Anti-infectives metaxalone tabs P BACTROBAN NASAL P OINT methocarbamol soln P Nasal Antiallergy

87 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 1 rtl pack lmt NASONEX SUSP (Use QL(17 gm per ASTEPRO SOLN (Use NP NP ) amt,30 rtl pack Mometasone Furoate fill retail); AL(At Azelastine HCl lmt day(s), (Nasal)) least 2 yrs old) 1 rtl pack lmt QL(17 ml per azelastine hcl soln P amt,30 rtl pack triamcinolone acetonide P fill retail); AL(At lmt day(s), (nasal) aero least 2 yrs old); RX/OTC cromolyn sodium (nasal) P QL(26 ml per aers fill retail) Sympathomimetic Decongestants NASALCROM AERS (Use NP QL(26 ml per Cromolyn Sodium (Nasal)) fill retail) ADRENALIN SOLN P olopatadine hcl (nasal) soln P phenylephrine hcl (oral) P QL(24 ea per tabs fill retail) PATANASE SOLN (Use NP SUDAFED PE QL(24 ea per Olopatadine HCl (Nasal)) CONGESTION TABS (Use NP fill retail) Nasal Anticholinergics Phenylephrine HCl (Oral)) 1 rtl pack lmt NEUROMUSCULAR AGENTS - Drugs to ipratropium bromide (nasal) P Relax/Paralyze Muscles soln amt,30 rtl pack lmt day(s), ALS Agents Nasal Steroids RILUTEK TABS (Use NP FLONASE ALLERGY QL(16 ml per Riluzole) RELIEF CHILDRENS NP fill retail); SUSP (Use Fluticasone RX/OTC riluzole tabs P Propionate (Nasal)) FLONASE ALLERGY QL(16 ml per NUTRIENTS RELIEF SUSP (Use NP fill retail); Misc. Nutritional Substances Fluticasone Propionate RX/OTC (Nasal)) omega-3 fatty acids caps P QL(6 ea daily) P QL(25 ml per FLUNISOLIDE SOLN fill retail) OPHTHALMIC AGENTS - Drugs to Treat the Eye QL(16 ml per fluticasone propionate P Artificial Tears and Lubricants (nasal) susp fill retail); RX/OTC P QL(4 gm per fill artificial tear ointment oint retail) mometasone furoate QL(17 gm per P fill retail); AL(At polyvinyl alcohol soln P QL(15 ml per (nasal) susp least 2 yrs old) fill retail) QL(17 ml per TEARS NATURALE PM QL(4 gm per fill OINT (Use White NP retail) NASACORT ALLERGY P fill retail); AL(At 24HR AERO least 2 yrs old); Petrolatum-Mineral Oil) RX/OTC white petrolatum-mineral oil P QL(4 gm per fill NASACORT ALLERGY QL(17 ml per oint retail) 24HR AERO (Use NP fill retail); AL(At Beta-blockers - Ophthalmic Triamcinolone Acetonide least 2 yrs old); (Nasal)) RX/OTC BETAGAN SOLN (Use NP QL(10 ml per Levobunolol HCl) fill retail) NASACORT ALLERGY QL(17 ml per QL(10 ml per 24HR CHILDRENS AERO NP fill retail); AL(At betaxolol hcl (ophth) soln P (Use Triamcinolone least 2 yrs old); fill retail) Acetonide (Nasal)) RX/OTC

88 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 1 rtl pack lmt cyclopentolate hcl soln 0.5 P QL(15 ml per carteolol hcl (ophth) soln P amt,30 rtl pack %, 1 % fill retail) lmt day(s), cyclopentolate hcl soln 2 % P 1 rtl pack lmt CARTEOLOL HCL SOLN P amt,30 rtl pack P QL(15 ml per lmt day(s), ISOPTO ATROPINE SOLN fill retail) COSOPT SOLN (Use QL(10 ml per MYDRIACYL SOLN (Use NP QL(15 ml per Dorzolamide HCl-Timolol NP fill retail) Tropicamide) fill retail) Maleate) tropicamide soln P QL(15 ml per dorzolamide hcl-timolol P QL(10 ml per fill retail) maleate soln fill retail) Miotics DORZOLAMIDE QL(10 ml per HCL/TIMOLOL MALEATE P fill retail) ISOPTO CARPINE SOLN NP SOLN (Use Pilocarpine HCl) pilocarpine hcl soln P P QL(10 ml per levobunolol hcl soln fill retail) Ophthalmic Adrenergic Agents METIPRANOLOL SOLN P ALPHAGAN P SOLN (Use NP Brimonidine Tartrate) timolol maleate (ophth) P QL(5 ml per fill solg 0.5 % retail) apraclonidine hcl soln P timolol maleate (ophth) P QL(10 ml per soln 0.25 % fill retail) brimonidine tartrate soln P 0.15 % timolol maleate (ophth) P QL(15 ml per soln 0.5 % fill retail) brimonidine tartrate soln P QL(15 ml per TIMOLOL MALEATE QL(5 ml per fill 0.2 % fill retail) OPHTHALMIC GEL P retail) IOPIDINE SOLN 0.5 % NP FORMING SOLG (Use Apraclonidine HCl) TIMOPTIC OCUDOSE P QL(60 ea per IOPIDINE SOLN 1 % P SOLN fill retail) TIMOPTIC SOLN 0.25 % QL(10 ml per Ophthalmic Anti-infectives (Use Timolol Maleate NP fill retail) bacitracin-polymyxin b P QL(4 gm per fill (Ophth)) (ophth) oint retail) TIMOPTIC SOLN 0.5 % QL(15 ml per BLEPH-10 SOLN (Use QL(15 ml per (Use Timolol Maleate NP fill retail) Sulfacetamide Sodium NP fill retail) (Ophth)) (Ophth)) QL(5 ml per fill TIMOPTIC-XE SOLG P CILOXAN SOLN (Use NP retail) Ciprofloxacin HCl (Ophth)) Cycloplegic Mydriatics ciprofloxacin hcl (ophth) P soln ATROPINE SULFATE P QL(4 gm per fill OINT OP 1 % retail) P QL(4 gm per fill erythromycin (ophth) oint retail) ATROPINE SULFATE P QL(15 ml per SOLN OP 1 % fill retail) gatifloxacin (ophth) soln P CYCLOGYL SOLN 0.5 %, QL(15 ml per 1 % (Use Cyclopentolate NP fill retail) GENTAK OINT P QL(4 gm per fill HCl) retail) gentamicin sulfate (ophth) QL(4 gm per fill CYCLOGYL SOLN 2 % NP P (Use Cyclopentolate HCl) oint retail) Western Sky Updated December 1, 2018 P-Preferred drug, NP-Non-preferred, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, RX/OTC - both Rx and OTC NDCs MP-Maintenance drug eligible for 90 day supply

89 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits gentamicin sulfate (ophth) P QL(15 ml per ALCAINE SOLN (Use NP soln fill retail) Proparacaine HCl) moxifloxacin hcl (ophth) P QL(3 ml per fill proparacaine hcl soln P soln retail) neomycin-bacitracin zn- P QL(4 gm per fill Ophthalmic Steroids polymyxin oint retail) BLEPHAMIDE S.O.P. P QL(4 gm per fill neomycin-polymyxin- P QL(10 ml per OINT retail) gramicidin soln fill retail) P QL(10 ml per NEOSPORIN SOLN (Use QL(10 ml per BLEPHAMIDE SUSP fill retail) Neomycin-Polymyxin- NP fill retail) DEXAMETHASONE QL(5 ml per fill Gramicidin) SODIUM PHOSPHATE P retail) OCUFLOX SOLN (Use NP QL(10 ml per SOLN OP 0.1 % Ofloxacin (Ophth)) fill retail) fluorometholone (ophth) P QL(15 ml per ofloxacin (ophth) soln P QL(10 ml per susp fill retail) fill retail) FML LIQUIFILM SUSP QL(15 ml per polymyxin b-trimethoprim P QL(10 ml per (Use Fluorometholone NP fill retail) soln fill retail) (Ophth)) POLYTRIM SOLN (Use QL(10 ml per NP P QL(4 gm per fill Polymyxin B-Trimethoprim) fill retail) FML OINT retail) sulfacetamide sodium P QL(15 ml per MAXITROL OINT QL(4 gm per fill (ophth) soln fill retail) 10000UNIT/GM- retail) 3.5MG/GM-0.1% (Use NP P QL(5 ml per fill tobramycin (ophth) soln retail) Neomycin-Polymy- Dexameth) P QL(4 gm per fill TOBREX OINT retail) MAXITROL SUSP QL(5 ml per fill 10000UNIT/ML-3.5MG/ML- NP retail) TOBREX SOLN (Use NP QL(5 ml per fill 0.1% (Use Neomycin- Tobramycin (Ophth)) retail) Polymy-Dexameth) P QL(8 ml per fill neomycin-polymy- QL(4 gm per fill trifluridine soln retail) dexameth oint P retail) VIGAMOX SOLN (Use NP QL(3 ml per fill 10000unit/gm-3.5mg/gm- Moxifloxacin HCl (Ophth)) retail) 0.1% VIROPTIC SOLN (Use NP QL(8 ml per fill neomycin-polymy- QL(5 ml per fill Trifluridine) retail) dexameth susp P retail) 10000unit/ml-3.5mg/ml- ZYMAXID SOLN (Use NP Gatifloxacin (Ophth)) 0.1% Ophthalmic Decongestants NEOMYCIN/POLYMYXIN/ QL(8 ml per fill HYDROCORTISONE P retail) phenylephrine hcl (ophth) P QL(15 ml per SUSP soln fill retail) OMNIPRED SUSP (Use QL(15 ml per tetrahydrozoline hcl (ophth) 1 rtl pack lmt Prednisolone Acetate NP fill retail) P amt,30 rtl pack (Ophth)) soln lmt day(s), PRED FORTE SUSP (Use QL(15 ml per VISINE SOLN (Use 1 rtl pack lmt Prednisolone Acetate NP fill retail) Tetrahydrozoline HCl NP amt,30 rtl pack (Ophth)) (Ophth)) lmt day(s), P QL(10 ml per Ophthalmic Local Anesthetics PRED MILD SUSP fill retail)

90 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits P QL(5 ml per fill ketorolac tromethamine P PRED-G SUSP retail) (ophth) soln 0.4 % prednisolone acetate P QL(15 ml per ketorolac tromethamine P QL(10 ml per (ophth) susp fill retail) (ophth) soln 0.5 % fill retail) PREDNISOLONE P QL(15 ml per ketotifen fumarate (ophth) P QL(10 ml per ACETATE P-F SUSP fill retail) soln fill retail) PREDNISOLONE SODIUM 1 rtl pack lmt OCUFEN SOLN (Use NP QL(3 ml per fill PHOSPHATE SOLN OP 1 P amt,30 rtl pack Flurbiprofen Sodium) retail) % lmt day(s), olopatadine hcl soln P sulfacetamide sod- P QL(10 ml per prednisolone soln fill retail) ophthalmic irrigation P solution - intraocular soln P QL(4 gm per fill TOBRADEX OINT retail) PATADAY SOLN (Use NP TOBRADEX SUSP (Use QL(10 ml per Olopatadine HCl) Tobramycin- NP fill retail) PATANOL SOLN (Use NP Dexamethasone) Olopatadine HCl) tobramycin- QL(10 ml per P TRUSOPT SOLN (Use NP QL(10 ml per dexamethasone susp fill retail) Dorzolamide HCl) fill retail) Ophthalmics - Misc. ZADITOR SOLN (Use QL(10 ml per ACULAR LS SOLN (Use Ketotifen Fumarate NP fill retail) Ketorolac Tromethamine NP (Ophth)) (Ophth)) Prostaglandins - Ophthalmic ACULAR SOLN (Use QL(10 ml per P QL(3 ml per fill Ketorolac Tromethamine NP fill retail) latanoprost soln retail) (Ophth)) LATANOPROST SOLN P QL(3 ml per fill P QL(15 ml per retail) AZOPT SUSP fill retail) XALATAN SOLN (Use NP QL(3 ml per fill BSS PLUS SOLN NP Latanoprost) retail) BSS SOLN (Use OTIC AGENTS - Drugs to Treat the Ear Ophthalmic Irrigation NP Solution - Intraocular) Otic Agents - Miscellaneous QL(15 ml per cromolyn sodium (ophth) P QL(10 ml per acetic acid (otic) soln P soln fill retail) fill retail) 1 rtl pack lmt diclofenac sodium (ophth) P QL(5 ml per fill carbamide peroxide (otic) soln retail) P amt,30 rtl pack soln lmt day(s), DORZOLAMIDE HCL P QL(10 ml per SOLN fill retail) 1 rtl pack lmt DEBROX SOLN (Use NP Carbamide Peroxide (Otic)) amt,30 rtl pack P QL(10 ml per lmt day(s), dorzolamide hcl soln fill retail) Otic Anti-infectives ELESTAT SOLN (Use NP Epinastine HCl (Ophth)) FLOXIN OTIC SOLN (Use NP QL(10 ml per Ofloxacin (Otic)) fill retail) epinastine hcl (ophth) soln P P QL(10 ml per ofloxacin (otic) soln fill retail) flurbiprofen sodium soln P QL(3 ml per fill retail) Otic Combinations

91 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CORTANE-B-OTIC SOLN 1 rtl pack lmt amoxicillin susr 125 (Use Pramoxine-HC- NP amt,30 rtl pack mg/5ml, 200 mg/5ml, 250 P Chloroxylenol) lmt day(s), mg/5ml, 400 mg/5ml neomycin-polymyxin-hc P QL(10 ml per amoxicillin tabs 875 mg P (otic) soln fill retail) ampicillin caps 250 mg, neomycin-polymyxin-hc P QL(10 ml per P (otic) susp fill retail) 500 mg OTICIN HC NR SOLN (Use 1 rtl pack lmt AMPICILLIN CAPS 500 P Pramoxine-HC- NP amt,30 rtl pack MG Chloroxylenol) lmt day(s), Natural Penicillins 1 rtl pack lmt pramoxine-hc-chloroxylenol P penicillin g potassium solr P soln amt,30 rtl pack lmt day(s), PENICILLIN V Otic Steroids POTASSIUM SOLR 125 P DERMOTIC OIL (Use 1 rtl pack lmt MG/5ML, 250 MG/5ML Fluocinolone Acetonide NP amt,30 rtl pack penicillin v potassium solr P (Otic)) lmt day(s), 125 mg/5ml, 250 mg/5ml 1 rtl pack lmt penicillin v potassium tabs P fluocinolone acetonide P amt,30 rtl pack 250 mg, 500 mg (otic) oil lmt day(s), PFIZERPEN SOLR (Use NP Penicillin G Potassium) hydrocortisone w/acetic P QL(10 ml per acid soln fill retail) Penicillin Combinations OXYTOCICS - Drugs to Prevent/Control Uterine amoxicillin & pot 1 rtl pack lmt Bleeding clavulanate susr P per fill, Oxytocics 200mg/5ml-28.5mg/5ml, 250mg/5ml-62.5mg/5ml methylergonovine maleate P tabs amoxicillin & pot clavulanate susr P oxytocin soln P 400mg/5ml-57mg/5ml amoxicillin & pot 2 rtl pack lmt PITOCIN SOLN (Use NP Oxytocin) clavulanate susr P per fill, 600mg/5ml-42.9mg/5ml PASSIVE IMMUNIZING AND TREATMENT amoxicillin & pot QL(30 ea per AGENTS - Antibody Drugs to Treat Low Immune clavulanate tabs 250mg- P fill retail) System 125mg Monoclonal Antibodies amoxicillin & pot QL(20 ea per PA; SP clavulanate tabs 500mg- P fill retail) SYNAGIS SOLN P 125mg, 875mg-125mg amoxicillin & pot Limit 40 per 30 PENICILLINS - Drugs to Treat Bacterial Infections clavulanate tb12 1000mg- P days;QL(1.34 Aminopenicillins 62.5mg ea daily) AMOXICILLIN/CLAVULAN QL(20 ea per amoxicillin caps 250 mg, P P 500 mg ATE POTASSIUM CHEW fill retail) ampicillin & sulbactam AMOXICILLIN CHEW 125 P P MG, 250 MG sodium solr

92 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AUGMENTIN ES-600 2 rtl pack lmt hydroxyprogesterone P SP SUSR (Use Amoxicillin & NP per fill, caproate oil 250 mg/ml Pot Clavulanate) MAKENA OIL IM 250 SP AUGMENTIN SUSR 1 rtl pack lmt MG/ML (Use NP 250MG/5ML-62.5MG/5ML NP per fill, Hydroxyprogesterone (Use Amoxicillin & Pot Caproate) Clavulanate) MAKENA SOAJ SC 275 P PA; SP AUGMENTIN TABS QL(20 ea per MG/1.1ML 500MG-125MG, 875MG- fill retail) NP medroxyprogesterone P MP 125MG (Use Amoxicillin & acetate tabs Pot Clavulanate) MEGACE ES SUSP (Use AUGMENTIN XR TB12 Limit 40 per 30 Megestrol Acetate NP (Use Amoxicillin & Pot NP days;QL(1.34 (Appetite)) Clavulanate) ea daily) megestrol acetate P piperacillin sodium- P (appetite) susp tazobactam sodium solr UNASYN BULK PACK norethindrone acetate tabs P SOLR (Use Ampicillin & NP progesterone micronized P QL(1 ea daily) Sulbactam Sodium) caps 100 mg UNASYN SOLR (Use Limit 20 per Ampicillin & Sulbactam NP progesterone micronized P month;QL(0.67 Sodium) caps 200 mg ea daily) ZOSYN SOLR (Use PROMETRIUM CAPS 100 QL(1 ea daily) Piperacillin Sodium- NP MG (Use Progesterone NP Tazobactam Sodium) Micronized) Penicillinase-Resistant Penicillins PROMETRIUM CAPS 200 Limit 20 per MG (Use Progesterone NP month;QL(0.67 dicloxacillin sodium caps P Micronized) ea daily) PHARMACEUTICAL ADJUVANTS PROVERA TABS (Use MP Medroxyprogesterone NP Internal Vehicle Ingredients/Agents Acetate) PSYCHOTHERAPEUTIC AND NEUROLOGICAL RESOURCE THICKENUP P POWD AGENTS - MISC. - Drugs to Treat Mental and Emotional Conditions starch-maltodextrin P (thickening) powd Agents for Chemical Dependency THICK-IT #2 POWD P acamprosate calcium tbec P THICK-IT ORIGINAL ANTABUSE TABS (Use NP POWD (Use Starch- NP Disulfiram) Maltodextrin (Thickening)) disulfiram tabs P PROGESTINS - Hormone Replacement/Modifying Drugs Anti-Cataplectic Agents Progestins XYREM SOLN P SP AYGESTIN TABS (Use NP Norethindrone Acetate) Antidementia Agents

93 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ACETYL L-CARNITINE P NAMENDA XR TITRATION P CAPS PACK CP24 ARICEPT TABS 23 MG NAMZARIC C4PK P (Use Donepezil NP Hydrochloride) NAMZARIC CP24 P ARICEPT TABS 5 MG, 10 QL(1 ea daily) MG (Use Donepezil NP RAZADYNE ER CP24 (Use QL(1 ea daily) Hydrochloride) Galantamine NP Hydrobromide) donepezil hydrochloride P tabs 23 mg RAZADYNE TABS (Use QL(2 ea daily) Galantamine NP donepezil hydrochloride P QL(1 ea daily) tabs 5 mg, 10 mg Hydrobromide) QL(1 ea daily) donepezil hydrochloride P rivastigmine pt24 P tbdp 5 mg, 10 mg QL(2 ea daily) EXELON CAPS OR 1.5 QL(2 ea daily) rivastigmine tartrate caps P MG (Use Rivastigmine NP Tartrate) Combination Psychotherapeutics EXELON PT24 TD 4.6 QL(1 ea daily) CHLORDIAZEPOXIDE/AMI P TRIPTYLINE TABS MG/24HR, 9.5 MG/24HR, NP 13.3 MG/24HR (Use DERMACINRX DPN PAK P Rivastigmine) THPK galantamine hydrobromide QL(1 ea daily) P olanzapine-fluoxetine hcl P cp24 8 mg, 16 mg, 24 mg caps GALANTAMINE QL(6 ml daily) PERPHENAZINE/AMITRIP P QL(4 ea daily) HYDROBROMIDE SOLN 4 P TYLINE TABS MG/ML SYMBYAX CAPS (Use NP galantamine hydrobromide P QL(2 ea daily) Olanzapine-Fluoxetine HCl) tabs 4 mg, 8 mg, 12 mg Fibromyalgia Agents memantine hcl cp24 7 mg, P 14 mg, 21 mg, 28 mg P PA; QL(2 ea SAVELLA TABS daily) memantine hcl soln 2 P QL(10 ml daily) mg/ml PA; QL(55 ea SAVELLA TITRATION P per 365 days 1 rtl pack lmt PACK MISC retail) memantine hcl tabs P amt,28 rtl pack lmt day(s), Hypoactive Sexual Desire Disorder (HSDD) memantine hcl tabs 5 mg, P QL(2 ea daily) ADDYI TABS P 10 mg NAMENDA SOLN 10 QL(10 ml daily) Movement Disorder Drug Therapy MG/5ML (Use Memantine NP AUSTEDO TABS P SP HCl) SP NAMENDA TABS 5 MG, 10 NP QL(2 ea daily) INGREZZA CAPS P MG (Use Memantine HCl) NAMENDA TITRATION 1 rtl pack lmt tetrabenazine tabs P SP PAK TABS (Use NP amt,28 rtl pack Memantine HCl) lmt day(s), XENAZINE TABS (Use NP SP Tetrabenazine) NAMENDA XR CP24 (Use NP Memantine HCl) Multiple Sclerosis Agents Western Sky Updated December 1, 2018 P-Preferred drug, NP-Non-preferred, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, RX/OTC - both Rx and OTC NDCs MP-Maintenance drug eligible for 90 day supply

94 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AUBAGIO TABS P SP SARAFEM TABS (Use NP Fluoxetine HCl (PMDD)) AVONEX PEN AJKT P PA; SP Pseudobulbar Affect (PBA) Agents

AVONEX PSKT P PA; SP NUEDEXTA CAPS P Psychotherapeutic and Neurological Agents - BETASERON KIT P SP ERGOLOID MESYLATES P COPAXONE SOSY (Use NP PA; SP TABS Glatiramer Acetate) ORAP TABS (Use NP EXTAVIA KIT P SP Pimozide) pimozide tabs P GILENYA CAPS 0.5 MG P PA; SP Restless Leg Syndrome (RLS) Agents glatiramer acetate sosy P PA; SP HORIZANT TBCR P OCREVUS SOLN P SP Smoking Deterrents PA; SP PLEGRIDY SOPN P bupropion hcl (smoking P QL(2 ea daily) deterrent) tb12 PA; SP PLEGRIDY SOSY P CHANTIX CONTINUING P MONTHPAK TABS PLEGRIDY STARTER P PA; SP PACK SOPN CHANTIX STARTING P MONTH PAK TABS PLEGRIDY STARTER P PA; SP PACK SOSY CHANTIX TABS P PA; SP TECFIDERA CPDR P NICODERM CQ PT24 (Use NP Nicotine) TECFIDERA STARTER P PA; SP PACK MISC NICORETTE GUM (Use NP Nicotine Polacrilex) Postherpetic Neuralgia (PHN)/Neuropathic Pain NICORETTE LOZG (Use NP ACTIVE- P Nicotine Polacrilex) PAC/GABAPENTIN THPK NICORETTE MINI LOZG NP CONVENIENCE PAK P (Use Nicotine Polacrilex) THPK NICORETTE STARTER GRALISE STARTER MISC P KIT GUM (Use Nicotine NP Polacrilex) GRALISE TABS P nicotine polacrilex gum P

LYRICA CR TB24 P nicotine polacrilex lozg P SMARTRX GABA KIT P THPK nicotine pt24 P SMARTRX GABA-V KIT P NICOTINE THPK TRANSDERMAL SYSTEM P KIT Premenstrual Dysphoric Disorder (PMDD) Agents NICOTROL INHALER P fluoxetine hcl (pmdd) tabs P INHA Western Sky Updated December 1, 2018 P-Preferred drug, NP-Non-preferred, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, RX/OTC - both Rx and OTC NDCs MP-Maintenance drug eligible for 90 day supply

95 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NICOTROL NS SOLN P doxycycline hyclate caps P

ZYBAN TB12 (Use QL(2 ea daily) doxycycline hyclate tabs P Bupropion HCl (Smoking NP Deterrent)) doxycycline hyclate tbec P Vasomotor Symptom Agents MINOCIN CAPS (Use NP BRISDELLE CAPS (Use Minocycline HCl) Paroxetine Mesylate NP (Vasomotor)) minocycline hcl caps P paroxetine mesylate P (vasomotor) caps minocycline hcl tb24 P RESPIRATORY AGENTS - MISC. - Drugs to MONODOX CAPS (Use Treat Lung Conditions Doxycycline NP Cystic Fibrosis Agents (Monohydrate)) PA; SP SOLODYN TB24 (Use NP KALYDECO PACK P Minocycline HCl) PA; SP tetracycline hcl caps 250 P KALYDECO TABS P mg, 500 mg TETRACYCLINE HCL ORKAMBI TABS 100MG- P PA; SP 125MG, 200MG-125MG CAPS 250 MG, 500 MG NP (Use Tetracycline HCl) TETRACYCLINES - Drugs to Treat Bacterial Infections VIBRAMYCIN CAPS (Use NP Doxycycline Hyclate) Tetracyclines VIBRAMYCIN SUSR (Use ACTICLATE TABS (Use NP Doxycycline NP Doxycycline Hyclate) (Monohydrate)) ADOXA PAK 1/100 TABS THYROID AGENTS - Drugs to Regulate Thyroid (Use Doxycycline NP Hormones (Monohydrate)) ADOXA PAK 1/150 TABS Antithyroid Agents (Use Doxycycline NP methimazole tabs P MP (Monohydrate)) ADOXA PAK 2/100 TABS propylthiouracil tabs P MP (Use Doxycycline NP (Monohydrate)) TAPAZOLE TABS (Use NP MP ADOXA TABS (Use Methimazole) Doxycycline NP Thyroid Hormones (Monohydrate)) ARMOUR THYROID TABS DORYX TBEC (Use NP 15 MG, 30 MG, 60 MG, 90 NP Doxycycline Hyclate) MG, 120 MG (Use Thyroid) doxycycline (monohydrate) P ARMOUR THYROID TABS P caps 180 MG, 240 MG, 300 MG doxycycline (monohydrate) P CYTOMEL TABS (Use NP MP susr Liothyronine Sodium) doxycycline (monohydrate) P levothyroxine sodium tabs P MP tabs

96 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits liothyronine sodium soln iv P P AL(At least 19 10 mcg/ml TENIVAC INJ yrs old) liothyronine sodium tabs or P MP TETANUS/DIPHTHERIA AL(At least 19 5 mcg, 25 mcg, 50 mcg TOXOIDS-ADSORBED P yrs old) SUSP NATURE-THROID TABS P ULCER DRUGS - Drugs to Treat Bowel, Intestine SYNTHROID TABS (Use NP MP and Stomach Conditions Levothyroxine Sodium) Proton Pump Inhibitors thyroid tabs P Omeprazole Delayed P QL(1 ea daily); Release Tab 20mg THYROLAR-1 TABS P Antispasmodics THYROLAR-1/2 TABS P ANASPAZ TBDP (Use NP Hyoscyamine Sulfate) THYROLAR-1/4 TABS P BENTYL CAPS (Use NP Dicyclomine HCl) THYROLAR-2 TABS P BENTYL SOLN (Use NP Dicyclomine HCl) THYROLAR-3 TABS P BENTYL TABS (Use NP Dicyclomine HCl) TRIOSTAT SOLN (Use NP Liothyronine Sodium) chlordiazepoxide hcl- P clidinium bromide caps WESTHROID TABS P dicyclomine hcl caps or 10 P WP THYROID TABS P mg dicyclomine hcl soln im 10 P TOXOIDS mg/ml dicyclomine hcl soln or 10 P QL(40 ml daily) Toxoid Combinations mg/5ml AL(At least 19 ADACEL SUSP P dicyclomine hcl tabs or 20 P yrs old) mg P AL(At least 19 DONNATAL TABS (Use BOOSTRIX SUSP yrs old) Phenobarbital- NP Hyoscyamine-Atropine- DAPTACEL SUSP P Scopolamine) DIPHTHERIA/TETANUS glycopyrrolate soln ij 0.4 TOXOIDS ADSORBED P mg/2ml, 0.2 mg/ml, 1 P PEDIATRIC SUSP mg/5ml, 4 mg/20ml INFANRIX SUSP P glycopyrrolate tabs or 1 P QL(4 ea daily) mg, 2 mg KINRIX SUSP P hyoscyamine sulfate elix or P 0.125 mg/5ml PEDIARIX SUSP P hyoscyamine sulfate soln P or 0.125 mg/ml PENTACEL SUSR P hyoscyamine sulfate subl sl P 0.125 mg QUADRACEL SUSP P

97 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits hyoscyamine sulfate tabs P PEPCID SUSR 40 MG/5ML NP or 0.125 mg (Use Famotidine) hyoscyamine sulfate tb12 P QL(4 ea daily) PEPCID TABS 20 MG (Use NP RX/OTC or 0.375 mg Famotidine) hyoscyamine sulfate tbdp P PEPCID TABS 40 MG (Use NP or 0.125 mg Famotidine) LEVBID TB12 (Use NP QL(4 ea daily) ranitidine hcl caps or 150 P QL(2 ea daily) Hyoscyamine Sulfate) mg LEVSIN TABS (Use NP ranitidine hcl caps or 300 P QL(1 ea daily) Hyoscyamine Sulfate) mg LEVSIN/SL SUBL (Use NP ranitidine hcl soln ij 50 P Hyoscyamine Sulfate) mg/2ml, 150 mg/6ml LIBRAX CAPS (Use ranitidine hcl syrp or 15 QL(20 ml Chlordiazepoxide HCl- NP mg/ml, 75 mg/5ml, 150 P daily); AL(Up to Clidinium Bromide) mg/10ml 6 yrs old ) methscopolamine bromide P ranitidine hcl tabs or 150 P QL(2 ea daily); tabs mg RX/OTC phenobarbital- ranitidine hcl tabs or 75 mg, P QL(2 ea daily) hyoscyamine-atropine- P 300 mg scopolamine tabs TAGAMET HB TABS (Use NP RX/OTC ROBINUL FORTE TABS NP QL(4 ea daily) Cimetidine) (Use Glycopyrrolate) ZANTAC 150 MAXIMUM QL(2 ea daily); ROBINUL SOLN IJ 0.4 STRENGTH TABS (Use NP RX/OTC MG/2ML, 0.2 MG/ML, 1 NP Ranitidine HCl) MG/5ML, 4 MG/20ML (Use ZANTAC 75 TABS (Use NP QL(2 ea daily) Glycopyrrolate) Ranitidine HCl) ROBINUL TABS OR 1 MG NP QL(4 ea daily) ZANTAC SOLN IJ 25 (Use Glycopyrrolate) MG/ML, 50 MG/2ML (Use NP H-2 Antagonists Ranitidine HCl) QL(27 ml daily) ZANTAC TABS OR 150 NP QL(2 ea daily); CIMETIDINE HCL SOLN P MG (Use Ranitidine HCl) RX/OTC cimetidine tabs 200 mg P RX/OTC ZANTAC TABS OR 300 NP QL(2 ea daily) MG (Use Ranitidine HCl) cimetidine tabs 300 mg, P Misc. Anti-Ulcer 400 mg, 800 mg QL(420 ml per famotidine susr 40 mg/5ml P CARAFATE SUSP 1 P fill retail); GM/10ML AL(Up to 6 yrs famotidine tabs 10 mg, 40 P old ) mg CARAFATE TABS 1 GM NP QL(4 ea daily) famotidine tabs 20 mg P RX/OTC (Use Sucralfate) QL(4 ea daily) PEPCID AC MAXIMUM RX/OTC sucralfate tabs P STRENGTH TABS (Use NP Famotidine) Proton Pump Inhibitors ACIPHEX TBEC (Use PA PEPCID AC TABS (Use NP NP Famotidine) Rabeprazole Sodium)

98 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits esomeprazole magnesium P RX/OTC Ulcer Drugs - Prostaglandins cpdr CYTOTEC TABS (Use NP P QL(4 ea daily); Misoprostol) lansoprazole cpdr 15 mg RX/OTC misoprostol tabs P lansoprazole cpdr 30 mg P URINARY ANTI-INFECTIVES - Drugs to Treat lansoprazole tbdp 15 mg, P PA Bladder/Kidney Infections 30 mg NEXIUM 24HR CLEAR RX/OTC Urinary Anti-infective Combinations MINIS CPDR (Use NP methenamine-hyosc- Esomeprazole Magnesium) methylene blue-sod phos- P phenyl sal tabs NEXIUM 24HR CPDR (Use NP RX/OTC Esomeprazole Magnesium) Urinary Anti-infectives NEXIUM CPDR (Use NP RX/OTC QL(40 ml Esomeprazole Magnesium) FURADANTIN SUSP (Use NP Nitrofurantoin) daily); AL(Up to omeprazole cpdr 10 mg P 6 yrs old ) HIPREX TABS (Use NP omeprazole cpdr 20 mg P QL(1 ea daily); Methenamine Hippurate) RX/OTC MACROBID CAPS (Use omeprazole cpdr 40 mg P QL(1 ea daily) Nitrofurantoin Monohyd NP Macro) pantoprazole sodium tbec P QL(1 ea daily) MACRODANTIN CAPS 20 mg (Use Nitrofurantoin NP pantoprazole sodium tbec P QL(2 ea daily) Macrocrystal) 40 mg methenamine hippurate P PREVACID 24HR CPDR NP QL(4 ea daily); tabs (Use Lansoprazole) RX/OTC methenamine mandelate P PREVACID CPDR 15 MG NP QL(4 ea daily); tabs (Use Lansoprazole) RX/OTC nitrofurantoin macrocrystal P PREVACID CPDR 30 MG NP caps (Use Lansoprazole) nitrofurantoin monohyd P PREVACID SOLUTAB NP PA macro caps TBDP (Use Lansoprazole) QL(40 ml PRILOSEC CPDR 10 MG NP nitrofurantoin susp P daily); AL(Up to (Use Omeprazole) 6 yrs old ) PRILOSEC CPDR 20 MG NP QL(1 ea daily); URINARY ANTISPASMODICS - Drugs to Treat (Use Omeprazole) RX/OTC Miscellaneous Bladder Spasms PRILOSEC CPDR 40 MG NP QL(1 ea daily) (Use Omeprazole) Urinary Antispasmodic - Antimuscarinics PROTONIX TBEC 20 MG QL(1 ea daily) darifenacin hydrobromide P (Use Pantoprazole NP tb24 Sodium) DETROL LA CP24 (Use NP QL(1 ea daily) PROTONIX TBEC 40 MG QL(2 ea daily) Tolterodine Tartrate) (Use Pantoprazole NP DETROL TABS (Use NP QL(2 ea daily) Sodium) Tolterodine Tartrate) PA DITROPAN XL TB24 (Use NP QL(2 ea daily); rabeprazole sodium tbec P Oxybutynin Chloride) MP Western Sky Updated December 1, 2018 P-Preferred drug, NP-Non-preferred, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, RX/OTC - both Rx and OTC NDCs MP-Maintenance drug eligible for 90 day supply

99 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ENABLEX TB24 (Use NP One per Darifenacin Hydrobromide) lifetime;QL(1 ml per 999 days oxybutynin chloride syrp 5 P QL(16 ml PNEUMOVAX 23 INJ P mg/5ml daily); MP retail); AL(At least 65 yrs oxybutynin chloride tabs 5 P QL(3 ea daily); old) mg MP One per oxybutynin chloride tb24 5 P QL(2 ea daily); lifetime;QL(1 ml mg, 10 mg, 15 mg MP PNEUMOVAX 23/1 DOSE P per 999 days tolterodine tartrate cp24 2 P QL(1 ea daily) INJ retail); AL(At mg, 4 mg least 65 yrs old) tolterodine tartrate tabs 1 P QL(2 ea daily) mg, 2 mg One per trospium chloride tabs P QL(2 ea daily) lifetime;QL(1 ml PREVNAR 13 SUSP P per 999 days Urinary Antispasmodics - Cholinergic Agonists retail); AL(At least 65 yrs bethanechol chloride tabs P MP old) AL(At least 19 URECHOLINE TABS (Use NP MP TRUMENBA SUSY P Bethanechol Chloride) yrs old) Urinary Antispasmodics - Direct Muscle Relaxants Viral Vaccines flavoxate hcl tabs P CERVARIX SUSP P ENGERIX-B INJ P AL(At least 19 VACCINES yrs old) P AL(At least 19 Bacterial Vaccines ENGERIX-B SUSP yrs old) ACTHIB SOLR P AL(At least 19 1 rtl MAX yrs old) fill,180 rtl AL(At least 19 BEXSERO SUSY P FLUMIST P day(s) supply,; yrs old) QUADRIVALENT SUSP AL(At least 2 yrs old - Up to P AL(At least 19 HIBERIX SOLR yrs old) 49 yrs old) AL(At least 19 P AL(At least 19 MENACTRA INJ yrs old) GARDASIL 9 SUSP P yrs old - Up to 26 yrs old) MENHIBRIX SOLR P AL(At least 19 GARDASIL 9 SUSY P yrs old - Up to MENOMUNE-A/C/Y/W-135 P INJ 26 yrs old) AL(At least 19 P AL(At least 19 MENVEO SOLR yrs old) GARDASIL SUSP P yrs old - Up to 26 yrs old) PEDVAX HIB SUSP P AL(At least 19 yrs old) P AL(At least 19 HAVRIX SUSP yrs old) P QL(1 ml per Influenza Vaccine 180 days retail) IPOL INACTIVATED IPV P AL(At least 19 INJ yrs old) Western Sky Updated December 1, 2018 P-Preferred drug, NP-Non-preferred, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, RX/OTC - both Rx and OTC NDCs MP-Maintenance drug eligible for 90 day supply

100 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits P AL(At least 19 GYNE-LOTRIMIN 3 CREA NP QL(20 gm per M-M-R II INJ yrs old) (Use Clotrimazole Vaginal) fill retail) P AL(At least 19 GYNE-LOTRIMIN CREA NP QL(45 gm per RECOMBIVAX HB SUSP yrs old) (Use Clotrimazole Vaginal) fill retail) ROTARIX SUSR P METROGEL-VAGINAL QL(70 gm per GEL (Use Metronidazole NP fill retail) ROTATEQ SOLN P Vaginal) metronidazole vaginal gel P QL(70 gm per P AL(At least 50 fill retail) SHINGRIX SUSR yrs old) MICONAZOLE 3 SUPP P QL(3 ea per fill P AL(At least 19 retail) TWINRIX SUSP yrs old) miconazole nitrate vaginal P QL(45 gm per P AL(At least 19 crea 2 % fill retail) VAQTA SUSP yrs old) miconazole nitrate vaginal 1 rtl pack lmt VARIVAX INJ P AL(At least 19 P amt,30 rtl pack yrs old) crea 4 % lmt day(s), AL(At least 60 ZOSTAVAX SUSR P miconazole nitrate vaginal P QL(1 gm per fill yrs old) kit retail) VAGINAL PRODUCTS - Drugs to Treat Vaginal miconazole nitrate vaginal P Infections and Low Hormones kit Spermicides miconazole nitrate vaginal P QL(7 ea per fill supp 100 mg retail) ENCARE SUPP P MONISTAT 1 COMBO PACK KIT (Use Miconazole NP nonoxynol-9 gel P Nitrate Vaginal) OPTIONS CONCEPTROL MONISTAT 1 DAY OR NIGHT COMBO PACK KIT VAGINAL NP NP CONTRACEPTIVE GEL (Use Miconazole Nitrate (Use Nonoxynol-9) Vaginal) OPTIONS GYNOL II MONISTAT 3 QL(1 gm per fill VAGINALCONTRACEPTIV P COMBINATION PACK KIT NP retail) E GEL (Use Miconazole Nitrate Vaginal) SHUR-SEAL GEL P 1 rtl pack lmt MONISTAT 3 CREA (Use NP ) amt,30 rtl pack Vaginal Anti-infectives Miconazole Nitrate Vaginal lmt day(s), CLEOCIN CREA VA 2 % QL(40 gm per MONISTAT 7 SIMPLY QL(45 gm per (Use Clindamycin NP fill retail) CURE CREA (Use NP fill retail) Phosphate Vaginal) Miconazole Nitrate Vaginal) clindamycin phosphate QL(40 gm per P TERAZOL 7 CREA (Use NP QL(45 gm per vaginal crea fill retail) Terconazole Vaginal) fill retail) clotrimazole vaginal crea 1 QL(45 gm per P P QL(20 gm per % fill retail) TERCONAZOLE CREA fill retail) clotrimazole vaginal crea 2 QL(20 gm per P terconazole vaginal crea P QL(45 gm per % fill retail) 0.4 % fill retail) GYNAZOLE-1 CREA P terconazole vaginal crea P QL(20 gm per 0.8 % fill retail) Western Sky Updated December 1, 2018 P-Preferred drug, NP-Non-preferred, AL-Age Limit, PA-Prior Authorization QL-Quantity limit, SP-Specialty drug, RX/OTC - both Rx and OTC NDCs MP-Maintenance drug eligible for 90 day supply

101 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits terconazole vaginal supp P QL(3 ea per fill cholecalciferol caps 5000 P QL(2 ea daily) 80 mg retail) unit P QL(5 gm per fill Limit 8 per tioconazole vaginal oint retail) cholecalciferol caps 50000 P month;QL(0.26 unit 7 ea daily) VAGISTAT-1 OINT (Use NP QL(5 gm per fill Tioconazole Vaginal) retail) cholecalciferol chew 400 P unit Vaginal Estrogens ESTRACE CREA VA 0.1 1 rtl pack lmt cholecalciferol liqd 400 P MG/GM (Use Estradiol NP amt,30 rtl pack unit/ml Vaginal) lmt day(s), cholecalciferol tabs 400 P unit estradiol vaginal crea 0.1 1 rtl pack lmt P amt,30 rtl pack D-VI-SOL LIQD (Use NP mg/gm lmt day(s), Cholecalciferol) DRISDOL CAPS (Use estradiol vaginal tabs 10 P NP mcg Ergocalciferol) 1 rtl pack lmt ergocalciferol caps 50000 P PREMARIN CREA VA P amt,30 rtl pack unit 0.625 MG/GM lmt day(s), MEPHYTON TABS (Use NP Phytonadione) VAGIFEM TABS (Use NP Estradiol Vaginal) phytonadione tabs P VASOPRESSORS - Drugs to Treat Heart and Circulation Conditions vitamin e caps 100 unit, P QL(2 ea daily) 200 unit, 400 unit Anaphylaxis Therapy Agents Water Soluble Vitamins PA; QL(4 ea ADRENACLICK SOAJ NP per 365 days ascorbic acid tabs 500mg, retail) 1000mg, 250 mg, 500 mg, 1000 mg, 10mg-500mg, P PA; QL(4 ea 37mg-500mg, 37mg- AUVI-Q SOAJ NP per 365 days 1000mg, 14mg-25mg- retail) 500mg epinephrine (anaphylaxis) P soaj niacin cpcr P PA; QL(4 ea EPIPEN 2-PAK SOAJ NP per 365 days niacin tabs P retail) niacin tbcr P EPIPEN-JR 2-PAK SOAJ NP PA NIACIN TR TBCR P Vasopressors pyridoxine hcl tabs 25 mg, P midodrine hcl tabs P 50 mg, 100 mg

VITAMINS riboflavin tabs P SLO-NIACIN TBCR (Use NP Oil Soluble Vitamins Niacin) cholecalciferol caps 1000 P unit, 2000 unit thiamine hcl tabs P

102 Drug Requirements/ Drug Name Tier Limits thiamine mononitrate tabs P

103 Index A + D PERSONAL CARE adapalene48 allopurinol68 LOTION56 adapalene-benzoyl allopurinol sodium68 abacavir sulfate37 peroxide48 almotriptan malate75 abacavir sulfate-lamivudine37 ADASUVE36 ALOE AFTERSUN LOTION56 abacavir sulfate-lamivudine- ADDERALL1 alogliptin benzoate21 zidovudine 37 ADDERALL XR1 ABILIFY36 alogliptin-metformin hcl20 ADDYI94 ABILIFY MAINTENA36 alogliptin-pioglitazone20 adefovir dipivoxil39 abiraterone acetate32 ALOPRIM68 ADLYXIN21 ALORA65 ABSORICA48 ADLYXIN STARTER acamprosate calcium93 PACK21 alosetron hcl67 acarbose20 ADMELOG21 ALPHAGAN P89 ACCOLATE12 ADMELOG SOLOSTAR21 ALPHANATE/VON WILLEBRANDFACTOR ACCUPRIL27 ADOXA96 COMPLEX/HUMAN68 ACCURETIC28 ADOXA PAK 1/10096 ALPHANINE SD68 acebutolol hcl41 ADOXA PAK 1/15096 alprazolam11 ACEON27 ADOXA PAK 2/10096 ALPROLIX68 acetaminophen5 ADRENACLICK102 alprostadil78 acetaminophen w/ codeine6 ADRENALIN88 ALTACE27 acetazolamide62 ADVATE68 alum & mag hydrox- acetic acid (otic)91 ADVIL3 simethicone8,9 ACETYL L-CARNITINE94 ADYNOVATE68 ALUMINUM HYDROXIDE9 acetylcysteine48 ADZENYS ER1 amantadine hcl34 Acidophilus cap-misc23 ADZENYS XR-ODT1 AMARYL23 ACIPHEX98 AEROSPAN12 AMBIEN70 acitretin52 AFINITOR32 AMBIEN CR70 ACLOVATE53 AFINITOR DISPERZ32 AMERGE75 ACNE MEDICATION 1048 AFSTYLA68 AMICAR70 ACNE MEDICATION 548 ALA SCALP53 amiloride & hydrochlorothiazide62 ACTHIB100 albuterol sulfate13 amiloride hcl63 ALBUTEROL SULFATE ACTICLATE96 amiodarone hcl12 ACTIGALL66 ER13 ALCAINE90 amitriptyline hcl19 ACTIQ5 alclometasone AMLACTIN CERAPEUTIC56 ACTIVE OB81 dipropionate53 amlodipine besylate41 ACTIVE-PAC/GABAPENTIN Alcohol Swabs-Misc74 amlodipine besylate-atorvastatin 95 ALDACTAZIDE62 calcium43 ACTIVELLA65 ALDACTONE63 amlodipine besylate-benazepril ACTONEL63 hcl28 ALDARA59 ACTOPLUS MET20 amlodipine besylate-olmesartan ALENDRONATE SODIUM63 medoxomil28 ACTOS21 alendronate sodium63 amlodipine besylate- ACULAR91 valsartan29 ALENDRONATE SODIUM63 ACULAR LS91 amlodipine-valsartan- alendronate sodium63 acyclovir40 hydrochlorothiazide 29 ALEVE3 AMOXAPINE19 acyclovir topical52 ALEVE ARTHRITIS3 amoxicillin92 ACZONE48 alfuzosin hcl67 AMOXICILLIN92 ADACEL97 ALKERAN31 amoxicillin92 ADALAT CC41 ALLEGRA ALLERGY25 amoxicillin & pot clavulanate92

Index 1 AMOXICILLIN/CLAVULANATE armodafinil2 AVEENO POSITIVELY POTASSIUM92 ARMOUR THYROID96 AGELESSFIRMING BODY56 amphetamine sulfate1 AVEENO POSITIVELY AROMASIN32 amphetamine- RADIANT56 dextroamphetamine1 ARTHRITIS PAIN AVEENO STRESS RELIEF RELIEVING60 ampicillin92 MOISTURIZING56 artificial tear ointment88 AVELOX66 AMPICILLIN92 ascorbic acid102 ampicillin & sulbactam AVELOX ABC PACK66 sodium92 aspirin5 AVODART67 ANAFRANIL19 ASPIRIN5 AVONEX95 ANALPRAM HC8 aspirin5 AVONEX PEN95 ANALPRAM HC SINGLES8 aspirin buffered (cal carb-mag AXERT75 carb-mag oxide)5 ANALPRAM-HC8 AXIRON8 ASTEPRO88 ANAPROX DS3 AYGESTIN93 ATABEX EC81 ANASPAZ97 AZACTAM10 ATABEX OB81 anastrozole32 AZASAN78 ATACAND28 ANCOBON24 azathioprine78 ATACAND HCT29 ANDRODERM8 azelastine hcl88 atazanavir sulfate37 ANDROID8 AZILECT34 atenolol41 ANDROXY8 AZITHROMYCIN73 atenolol & chlorthalidone29 ANGELIQ65 azithromycin73 ATIVAN11 ANTABUSE93 AZOPT91 atomoxetine hcl2 ANUSOL-HC8 AZOR29 atorvastatin calcium27 APEXICON E53 aztreonam10 atovaquone9 APIDRA21 AZULFIDINE67 atovaquone-proguanil hcl30 APIDRA SOLOSTAR21 AZULFIDINE EN-TABS66 ATRALIN48 apraclonidine hcl89 b-complex vitamins80 ATRIPLA37 aprepitant24 b-complex w/ c & folic acid80 ATROPINE SULFATE89 APTENSIO XR2 BACIGUENT50 ATROVENT HFA12 APTIOM15 bacitracin (topical)50 AUBAGIO95 APTIVUS37 bacitracin zinc50 AUGMENTIN93 AQUA GLYCOLIC HAND & bacitracin-polymyxin b50 AUGMENTIN ES-60093 BODYLOTION56 bacitracin-polymyxin b AQUA LACTEN56 AUGMENTIN XR93 (ophth)89 AQUADERM AUSTEDO94 baclofen87 TREATMENT/MOISTURIZER AUVI-Q102 BACTRIM9 56 AVALIDE29 AQUAMED56 BACTRIM DS9 AVANDIA21 AQUAPHILIC56 BACTROBAN50 AVAPRO28 AQUAPHOR56 BACTROBAN NASAL87 AQUAPHOR ADVANCED AVAR LS CLEANSER48 BAL-CARE DHA81 THERAPY56 AVAR-E LS48 balsalazide disodium67 AQUORAL79 AVEENO ACTIVE NATURALS BANZEL15 ARAVA4 DAILY MOISTURIZING BODY YOGURT56 BARACLUDE39 ARICEPT94 AVEENO ACTIVE NATURALS BASAGLAR KWIKPEN21 ARIMIDEX32 DAILY MOISTURIZING BODY BD GLUCOSE20 aripiprazole36 YOGURT/APRICO56 BEBULIN68 AVEENO DAILY ARISTADA36 MOISTURIZINGSPF 1556 BELSOMRA71 ARIXTRA14 BENADRYL ALLERGY25

Index 2 BENADRYL ALLERGY BOSULIF32 CAFCIT1 CHILDRENS25 BOUDREAUXS BABY BUTT CAFERGOT74 benazepril & SMOOTH DRY SKIN56 caffeine1 hydrochlorothiazide29 BP FOLINATAL PLUS B81 benazepril hcl27 caffeine citrate1 BP MULTINATAL PLUS81 BENEFIX68 CAFFEINE/SODIUM BREVIBLOC41 BENZOATE1 BENICAR28 BREVICON-2843 CALAN41 BENICAR HCT29 BRILINTA69 CALAN SR41 BENTYL97 brimonidine tartrate89 CALCI-CHEW76 BENZAC AC WASH48 BRISDELLE96 calcipotriene52 BENZACLIN48 BRIVIACT15 calcipotriene-betamethasone BENZACLIN WITH PUMP48 bromocriptine mesylate34 dipropionate53 BENZAMYCIN48 brompheniramine & calcitonin (salmon)63 BENZEFOAM ULTRA48 phenyleph47 calcitriol64 benzonatate47 brompheniramine & CALCIUM76 benzoyl peroxide48 pseudoeph47 calcium acetate (phosphate BSS91 BENZOYL PEROXIDE48 binder)67 BSS PLUS91 calcium carbonate76 benzoyl peroxide48 benzoyl peroxide- budesonide46 calcium carbonate (antacid)9 erythromycin48 budesonide (inhalation)12 calcium carbonate- benztropine mesylate33 BUFFERIN5 cholecalciferol76 calcium carbonate-vitamin d76 BETA CARE56 bumetanide63 calcium citrate76 BETAGAN88 BUMEX63 CALCIUM PNV81 betamethasone dipropionate BUNAVAIL7 calcium polycarbophil71 augmented53 BUPHENYL64 betamethasone valerate53 calcium w/ vitamin d76 bupivacaine hcl73 BETAPACE41 CALTRATE 600+D76 bupivacaine in dextrose73 BETAPACE AF41 bupivacaine w/ CAM56 BETASERON95 epinephrine73 camphor & menthol52 betaxolol hcl (ophth)88 buprenorphine hcl7 CAMPTOSAR33 bethanechol chloride100 buprenorphine hcl-naloxone hcl candesartan cilexetil28 bexarotene33 dihydrate7 candesartan cilexetil- bupropion hcl18 BEXSERO100 hydrochlorothiazide 29 bupropion hcl (smoking capecitabine31 BEYAZ43 deterrent)95 CAPHOSOL79 BIAXIN74 buspirone hcl11 capsaicin60 bicalutamide32 butalbital-acetaminophen4 captopril27 BIKTARVY37 butalbital-acetaminophen- caffeine4 CAPTOPRIL/HYDROCHLOROT BIOTENE DRY MOUTH HIAZIDE 29 MOISTURIZING SPRAY79 butalbital-acetaminophen- CAPZASIN-HP60 bisacodyl72 caffeine w/ codeine7 CARAC51 bismuth subsalicylate23 butalbital-aspirin-caffeine4 bisoprolol & butalbital-aspirin-caffeine CARAFATE98 hydrochlorothiazide29 w/cod7 carbamazepine15 bisoprolol fumarate41 BYDUREON21 carbamide peroxide (otic)91 BLEPH-1089 BYDUREON BCISE21 CARBATROL15 BLEPHAMIDE90 BYDUREON PEN21 carbidopa33 BLEPHAMIDE S.O.P.90 BYETTA21 carbidopa-levodopa34 BONIVA63 C-NATE DHA81 CARBOCAINE73 BOOSTRIX97 CADUET43 CARDENZ80

Index 3 CARDIZEM42 CETAPHIL ciclopirox olamine50 CARDIZEM CD41,42 MOISTURIZING56 cilostazol69 CETAPHIL CARDIZEM LA42 RESTORADERM57 CILOXAN89 CARDURA28 cetirizine hcl25 CIMDUO37 carisoprodol87 cetirizine-pseudoephedrine cimetidine98 CARNITOR64 47 CIMETIDINE HCL98 CARNITOR SF64 cevimeline hcl79 CIPRO66 CARTEOLOL HCL89 CHANTIX95 CIPRO I.V.-IN D5W66 CHANTIX CONTINUING carteolol hcl (ophth)89 MONTHPAK95 CIPRO XR66 carvedilol40 CHANTIX STARTING MONTH ciprofloxacin66 carvedilol phosphate40 PAK95 CIPROFLOXACIN ER66 CASODEX32 CHEK-STIX COMBO PAK CIPROFLOXACIN HCL66 URINALYSIS CONTROL61 CATAPRES28 CHEK-STIX CONTROL61 ciprofloxacin hcl66 cefaclor43 CHEMET23 ciprofloxacin hcl (ophth)89 CEFACLOR43 CHEMSTRIP-K61 ciprofloxacin in d5w66 cefadroxil43 CHERACOL PLUS47 citalopram hydrobromide18 cefdinir43 CHERACOL-D COUGH47 CITRANATAL 90 DHA81 cefepime hcl43 CHILDRENS ADVIL3 CITRANATAL ASSURE81 cefixime43 CHILDRENS MOTRIN3 CITRANATAL B-CALM81 CEFOTAN43 CHLOR-TRIMETON25 CITRANATAL BLOOM81 cefotetan disodium43 chlordiazepoxide hcl11 CITRANATAL BLOOM DHA81 cefprozil43 chlordiazepoxide hcl-clidinium CITRANATAL DHA81 ceftazidime43 bromide97 CITRANATAL HARMONY81 CEFTIN43 CHLORDIAZEPOXIDE/AMITRI CITRANATAL RX81 PTYLINE 94 ceftriaxone sodium43 CLARINEX25 chlorhexidine gluconate37 cefuroxime axetil43 chlorhexidine gluconate CLARITHROMYCIN74 cefuroxime sodium43 (mouth-throat)79 clarithromycin74 CELEBREX3 chloroprocaine hcl73 CLARITHROMYCIN74 celecoxib3 CHLOROQUINE clarithromycin74 CELEXA18 PHOSPHATE30 CLARITIN25 chloroquine phosphate31 CELLCEPT78 CLARITIN ALLERGY CHLOROTHIAZIDE63 CENTANY50 CHILDRENS25 chlorothiazide63 CLARITIN REDITABS25 cephalexin43 chlorothiazide sodium63 CLARITIN-D 12 HOUR47 CERASPORT76 chlorpheniramine maleate25 CLARITIN-D 24 HOUR47 CERASPORT EX176 CHLORPROMAZINE HCL36 CLASSIC PRENATAL81 CERAVE56 chlorpromazine hcl36 CLEAN & CLEAR ADVANTAGE CERAVE AM SPF 3056 chlorthalidone63 3-IN-1 EXFOLIATING CERAVE PM56 CLEANSER48 CHLORZOXAZONE87 CERAVE SA RENEWING56 clemastine fumarate25 cholecalciferol102 CEREBYX17 CLEOCIN10,101 cholestyramine26 CERVARIX100 CLEOCIN IN D5W10 CETAPHIL DAILY ADVANCE cholestyramine light26 CLEOCIN PEDIATRIC ULTRA HYDRATING56 choline & mag salicylate5 GRANULES10 CETAPHIL DAILY FACIAL choline fenofibrate26 CLEOCIN PHOSPHATE10 MOISTURIZER56 CICLODAN SOLUTION CLEOCIN-T48 CETAPHIL DERMACONTROL KIT50 MOISTURIZER/SPF 3056 CLIMARA65 ciclopirox50 CLIMARA PRO65

Index 4 clindamycin hcl10 COLESTID26 CUBICIN RF10 clindamycin palmitate COLESTID FLAVORED26 CUTIVATE53 hydrochloride10 colestipol hcl26 CVS DAILY ULTRA clindamycin phosphate10 colistimethate sodium9 MOISTURELOTION57 clindamycin phosphate CVS DRY MOUTH SPRAY79 COLY-MYCIN M9 (topical)49 CVS GLUCOSE21 clindamycin phosphate in COLYTE-FLAVOR PACKS71 CVS PRENATAL81 d5w10 COMBIPATCH65 clindamycin phosphate cyanocobalamin69 COMBIVENT RESPIMAT13 vaginal101 CYCLESSA43 clindamycin phosphate-benzoyl COMBIVIR37 cyclobenzaprine hcl87 peroxide49 COMPLERA37 CYCLOGYL89 clindamycin phosphate-benzoyl COMPLETE NATAL DHA81 peroxide (refrigerate)49 cyclopentolate hcl89 COMPLETENATE81 CLN FACIAL MOISTURIZER cyclophosphamide31 NOURISHING57 COMTAN33 CYCLOPHOSPHAMIDE31 clobazam14 CONCEPT DHA81 cyclosporine78 clobetasol propionate53 CONCEPT OB81 CYCLOSPORINE clobetasol propionate emollient CONCERTA2 base53 MODIFIED78 Condoms Latex Lubricated- cyclosporine modified (for clobetasol propionate Misc74 emulsion53 microemulsion)78 CONDYLOX59 CLOBEX53 CYMBALTA19 CONVENIENCE PAK95 clomipramine hcl19 cyproheptadine hcl26 COPAXONE95 clonazepam14,15 CYTOMEL96 COPEGUS39 clonidine hcl28 CYTOTEC99 CORDRAN53 clonidine hcl (adhd)2 CYTOVENE39 COREG40 clopidogrel bisulfate69 D-VI-SOL102 COREG CR40 clorazepate dipotassium11 D.H.E. 4575 CORGARD41 DAILY CONDITIONING clotrimazole (topical)50 CORIFACT68 TREATMENT57 clotrimazole vaginal101 CORTANE-B-OTIC92 dakin's solution37 clotrimazole w/ DAKINS SOLUTION FULL betamethasone51 CORTEF46 STRENGTH37 clozapine36 CORTENEMA8 DAKINS SOLUTION HALF CLOZARIL36 CORTISONE ACETATE46 STRENGTH37 CO-NATAL FA81 CORVITE 15069 DAKINS SOLUTION QUARTER STRENGTH37 COAGADEX68 CORZIDE29 DANTRIUM87 coal tar extract61 COSOPT89 DANTRIUM IV87 COARTEM30 COTELLIC32 dantrolene sodium87 COCOA BUTTER57 COTEMPLA XR-ODT2 dapsone10 COCOA BUTTER HAND & COUMADIN13 dapsone (topical)49 BODYLOTION57 COZAAR28 codeine sulfate5 DAPTACEL97 CREON62 CODEINE SULFATE5 daptomycin10 CRIXIVAN37 COGENTIN33 darifenacin hydrobromide99 cromolyn sodium12 DAYPRO3 COLACE72 cromolyn sodium COLACE CLEAR72 (mastocytosis)66 DAYTRANA2 COLAZAL67 cromolyn sodium (nasal)88 DDAVP64,65 COLCHICINE68 cromolyn sodium (ophth)91 DEBROX91 colchicine w/ probenecid68 crotamiton60 DELESTROGEN65 COLCRYS68 CUBICIN10 DELSTRIGO37

Index 5 DELZICOL67 DETROL99 digoxin42 DEMADEX63 DETROL LA99 DIGOXIN42 DEPACON17 DEX4 QUICK DISSOLVE digoxin42 DEPAKENE17 GLUCOSE21 dihydroergotamine mesylate75 dexamethasone46 DEPAKOTE17 DIHYDROERGOTAMINE DEXAMETHASONE46 DEPAKOTE ER17 MESYLATE75 dexamethasone46 DILANTIN17 DEPAKOTE SPRINKLES17 DEXAMETHASONE46 DILANTIN INFATABS17 DEPEN TITRATABS77 DEXAMETHASONE DILANTIN-12517 DEPO-MEDROL46 INTENSOL46 DILAUDID5 DEPO-PROVERA dexamethasone sodium CONTRACEPTIVE45 phosphate46 diltiazem hcl42 DEPO-SUBQ PROVERA DEXAMETHASONE SODIUM diltiazem hcl coated beads42 10445 PHOSPHATE90 diltiazem hcl extended release DEPO-TESTOSTERONE8 DEXEDRINE1 beads42 DERMA-SMOOTHE/FS dexmedetomidine hcl70 dimenhydrinate24 BODY53 dexmethylphenidate hcl2 DIMETAPP COLD & DERMA-SMOOTHE/FS ALLERGY47 dexrazoxane33 SCALP53 DIOVAN28 DERMACINRX DPN PAK94 dextroamphetamine sulfate1 DIOVAN HCT29 DERMAL THERAPY EXTRA dextromethorphan-guaifenesin STRENGTH BODY LOTION57 47 diphenhydramine hcl25 DERMAL THERAPY FACE DHS TAR61 diphenhydramine hcl (sleep)70 CAREMOISTURIZING DHS TAR GEL61 diphenhydramine hcl LOTION57 (topical)51 DIABETIDERM57 DERMAL THERAPY FOOT diphenoxylate w/ atropine23 MASSAGE57 DIABETIDERM HAND & BODY57 DIPHENOXYLATE/ATROPINE DERMAL THERAPY HAND 23 ELBOW & KNEE CREAM57 DIAMOX62 DIPHTHERIA/TETANUS DERMAL THERAPY HEEL DIASTAT ACUDIAL15 TOXOIDS ADSORBED CARE57 DIASTAT PEDIATRIC15 PEDIATRIC97 DERMATOP53 DIAZEPAM11 DIPROLENE54 DERMOTIC92 diazepam11 DIPROLENE AF54 DESCOVY37 DIAZEPAM15 dipyridamole69 desipramine hcl19 DIAZEPAM RECTAL GEL15 DISALCID5 desloratadine25 DIBENZYLINE28 disopyramide phosphate12 desmopressin acetate65 dibucaine60 disulfiram93 desmopressin acetate spray65 DITROPAN XL99 desmopressin acetate spray diclofenac potassium3 refrigerated65 diclofenac sodium3 divalproex sodium17 DESOGEN43 diclofenac sodium (actinic docusate calcium72 desogestrel & ethinyl keratoses)51 docusate sodium72,73 estradiol43 diclofenac sodium (ophth)91 dofetilide12 desogestrel-ethinyl estradiol diclofenac sodium (topical)50 donepezil hydrochloride94 (biphasic)43 dicloxacillin sodium93 desogestrel-ethinyl estradiol DONNATAL97 (triphasic)43 dicyclomine hcl97 DOPRAM1 desonide53 didanosine37 DORAL71 DESOWEN53 DIFFERIN49 DORYX96 desoximetasone53,54 DIFLORASONE DORZOLAMIDE HCL91 DIACETATE54 DESOXYN1 diflorasone diacetate54 dorzolamide hcl91 DESQUAM-X WASH49 dorzolamide hcl-timolol DIFLUCAN24 desvenlafaxine succinate19 maleate89 diflunisal5

Index 6 DORZOLAMIDE HCL/TIMOLOL EFUDEX51 EPIVIR HBV40 MALEATE89 ELAVIL19 eplerenone30 DOTHELLE DHA81 ELDEPRYL34 EPZICOM37 DOVONEX52 ELESTAT91 EQL ADVANCED RECOVERY doxazosin mesylate28 eletriptan hydrobromide75 SKIN CARE57 doxepin hcl19 EQL DRY MOUTH ORAL ELIDEL59 doxercalciferol64 RINSE79 ELIMITE60 EQL PRENATAL FORMULA81 doxycycline (monohydrate)96 ELIQUIS13 EQL ULTRA MOISTURIZING doxycycline hyclate96 ELIQUIS STARTER PACK13 DAILY LOTION57 doxylamine succinate EQUALYTE77 (sleep)70 ELITE-OB81 ergocalciferol102 DRAMAMINE24 ELIXOPHYLLIN13 ERGOLOID MESYLATES95 DRISDOL102 ELLA45 ergotamine w/ caffeine74 dronabinol24 ELMIRON67 ERIVEDGE32 droperidol11 ELOCON54 drospirenone-ethinyl ELOCTATE68 ERY-TAB74 estradiol44 EMCYT32 ERYGEL49 drospirenone-ethinyl estradiol- EMEND24 ERYPED 20074 levomefolate calcium44 ERYPED 40074 DROXIA69 EMEND TRIPACK24 ERYTHROCIN STEARATE74 DRYSOL60 EMOLLIA-LOTION57 erythromycin (acne aid)49 DUAC49 emollient57 erythromycin (ophth)89 DUAVEE65 EMTRIVA37 erythromycin base74 DUET DHA 40081 EMVERM9 ENABLEX100 erythromycin ethylsuccinate74 DUET DHA BALANCED81 ERYTHROMYCIN DUETACT20 enalapril maleate27 ETHYLSUCCINATE74 DULCOLAX72 enalapril maleate & escitalopram oxalate18 hydrochlorothiazide29 DULERA13 ENBRACE HR81 ESGIC4 duloxetine hcl19 ENBREL4 esmolol hcl41 DURAGESIC5 ENBREL SURECLICK4 esomeprazole magnesium99 dutasteride67 ENCARE101 estazolam71 esterified estrogens & dutasteride-tamsulosin hcl67 ENERGY CHEWS1 DUTOPROL29 methyltestosterone65 ENFAMIL ENFALYTE77 ESTRACE65,102 DYANAVEL XR1 ENGERIX-B100 estradiol65 DYAZIDE62 enoxaparin sodium14 estradiol & norethindrone E.E.S. 40074 entacapone33 acetate65 E.E.S. GRANULES74 entecavir39 estradiol vaginal102 EC-NAPROSYN3 ENTOCORT EC46 estradiol valerate65 econazole nitrate51 EPANED27 ESTROFACTORS80 ECOTRIN MAXIMUM ESTROPIPATE65 STRENGTH5 EPIDUO49 ECOTRIN REGULAR EPIFOAM54 ESTROSTEP FE44 STRENGTH5 EPILYT57 ethacrynate sodium63 EDECRIN63 epinastine hcl (ophth)91 ethacrynic acid63 EDLUAR71 epinephrine (anaphylaxis)102 ethambutol hcl31 EDURANT37 EPIPEN 2-PAK102 ethosuximide17 efavirenz37 EPIPEN-JR 2-PAK102 ethynodiol diacet & eth EFFEXOR XR19 estrad44 EPIVIR37 etodolac3 EFFIENT69

Index 7 ETOPOSIDE33 FEMHRT LOW DOSE65 fluconazole24 EUCERIN57 FENOFIBRATE26 flucytosine24 EUCERIN BABY57 fenofibrate26,27 fludrocortisone acetate47 EUCERIN DAILY fenofibrate micronized26 FLUMADINE40 PROTECTION/SPF 3057 FENOGLIDE27 FLUMIST QUADRIVALENT100 EUCERIN INTENSIVE REPAIR57 fentanyl6 FLUNISOLIDE88 EUCERIN ORIGINAL fentanyl citrate6 fluocinolone acetonide54 HEALINGSOOTHING FENTANYL CITRATE6 fluocinolone acetonide (otic)92 REPAIR57 fentanyl citrate6 fluocinonide54 EUCERIN PLUS57 EUCERIN PROFESSIONAL FER-IN-SOL70 fluocinonide emulsified base54 REPAIR RICH FEEL57 FERRETTS70 FLUORABON77 EUCERIN SMOOTHING FERRLECIT70 fluorometholone (ophth)90 REPAIRADVANCED ferrous fumarate-fa-b complex- FLUOROURACIL52 FORMULA57 c-zn-mg-mn-cu69 fluorouracil (topical)52 EURAX60 ferrous gluconate70 fluoxetine hcl18 EVAC71 FERROUS GLUCONATE70 EVEKEO1 fluoxetine hcl (pmdd)95 ferrous sulfate70 FLUOXETINE EVISTA64 FERROUS SULFATE70 HYDROCHLORIDE18 EVOCLIN49 ferrous sulfate70 fluphenazine decanoate36 EVOTAZ37 ferrous sulfate dried70 fluphenazine hcl36 EVOXAC79 FEXMID87 FLURA-DROPS77 EX-LAX72 fexofenadine hcl25 flurandrenolide54 EXALGO6 FIASP22 FLURAZEPAM HCL71 EXELON94 FIASP FLEXTOUCH22 flurbiprofen3 exemestane32 FIBERCON71 flurbiprofen sodium91 EXFORGE29 FIBRYGA68 flutamide32 EXFORGE HCT29 finasteride68 fluticasone propionate54 EXTAVIA95 FIORICET4 fluticasone propionate EXTINA51 FIORICET/CODEINE7 (nasal)88 fluvastatin sodium27 EXTRA-VIRT PLUS DHA81 FIORINAL5 fluvoxamine maleate18 ezetimibe27 FIORINAL/CODEINE #37 FML90 ezetimibe-simvastatin26 FIRVANQ10 FML LIQUIFILM90 famciclovir40 FLAGYL9 FOCALGIN 90 DHA81 famotidine98 flavoxate hcl100 FOCALGIN CA82 FAMVIR40 flecainide acetate12 FOCALIN2 FANATREX FUSEPAQ15 FLEET ENEMA72 FOCALIN XR2 FARESTON32 FLEET ENEMA SIX PACK72 FOLCAL DHA82 FARYDAK32 FLEET PEDIATRIC72 FOLCAPS OMEGA 382 fe fum-iron polysacch complex-fa- FLOMAX68 b complex-c-zn-mn-cu69 FLONASE ALLERGY FOLET ONE82 FEIBA68 RELIEF88 FOLGARD RX69 felbamate17 FLONASE ALLERGY RELIEF folic acid69 FELBATOL17 CHILDRENS88 folic acid-vitamin b6-vitamin FELDENE3 FLORIVA77 b1269 felodipine42 FLOVENT DISKUS13 FOLIVANE-OB82 FEMARA32 FLOVENT HFA13 fondaparinux sodium14 FEMCON FE44 FLOXIN OTIC91 formaldehyde37

Index 8 FORMULA 405 glipizide23 GOLD BOND ULTIMATE MOISTURIZING57 glipizide-metformin hcl20 SOOTHING58 FORTAMET20 GOLYTELY72 GLUCAGEN HYPOKIT21 FORTAZ43 GOODSENSE PRENATAL GLUCAGON EMERGENCY VITAMINS82 FOSAMAX63 KIT21 GRALISE95 fosamprenavir calcium37 GLUCOPHAGE20 GRALISE STARTER95 fosinopril sodium27 GLUCOPHAGE XR20 GRIS-PEG24 fosinopril sodium & GLUCOSE21 griseofulvin microsize24 hydrochlorothiazide29 GLUCOTROL23 fosphenytoin sodium17 griseofulvin ultramicrosize24 GLUCOTROL XL23 FOSRENOL67 GRX VITAMIN E58 GLUCOVANCE20 FROVA75 guaifenesin-codeine47 GLUMETZA20 frovatriptan succinate75 guanfacine hcl28 glyburide23 FURADANTIN99 guanfacine hcl (adhd)2 glyburide micronized23 furosemide63 GYNAZOLE-1101 glyburide-metformin20 FUROSEMIDE63 GYNE-LOTRIMIN101 glycerin (laxative)72 furosemide63 GYNE-LOTRIMIN 3101 GLYCERIN ADULT72 FUSILEV33 HALCION71 glycopyrrolate97 FUZEON37 HALDOL35 GLYNASE23 FYCOMPA14 HALDOL DECANOATE 10035 GLYSET20 gabapentin15 GNP ADVANCED HALDOL DECANOATE 5035 GABITRIL17 RECOVERY57 halobetasol propionate54 galantamine hydrobromide94 GNP GLUCOSE21 haloperidol36 GALANTAMINE GNP PRENATAL82 haloperidol decanoate35 HYDROBROMIDE94 GNP QUICK DISSOLVE haloperidol lactate35 galantamine hydrobromide94 GLUCOSE21 HAVRIX100 ganciclovir sodium39 GOLD BOND MEDICATED HECTOROL64 GARDASIL100 BODYLOTION57 GOLD BOND MEDICATED HELIXATE FS68 GARDASIL 9100 BODYLOTION EXTRA HEMANGEOL41 GAS-X66 STRENGTH57 HEMENATAL OB82 GASTROCROM66 GOLD BOND ULTIMATE57 HEMENATAL OB + DHA82 gatifloxacin (ophth)89 GOLD BOND ULTIMATE HEMOFIL M68 Gauze Pads & Dressings- DIABETICS DRY SKIN Misc74 RELIEF57 heparin (porcine) in sodium GEL-KAM ORAL CARE GOLD BOND ULTIMATE chloride14 RINSE79 DIABETICS' DRY RELIEF57 heparin sodium (porcine)14 GOLD BOND ULTIMATE gemfibrozil27 HEPARIN SODIUM/SODIUM HEALING57 CHLORIDE14 GENERESS FE44 GOLD BOND ULTIMATE HEPARIN SODIUM/SODIUM GENTAK89 OVERNIGHT57 CHLORIDE 0.9%14 gentamicin sulfate (ophth)89 GOLD BOND ULTIMATE HEPSERA40 PROTECTION57 gentamicin sulfate (topical)50 GOLD BOND ULTIMATE HETLIOZ71 GENVOYA37 RESTORING57 HIBERIX100 GEODON35 GOLD BOND ULTIMATE HIBICLENS37 SHEERRIBBONS GILENYA95 PEARLRADIANCE58 HIPREX99 GILOTRIF32 GOLD BOND ULTIMATE HM PRENATAL82 glatiramer acetate95 SHEERRIBBONS HORIZANT95 GLEEVEC32 SILKSOFTNESS58 HUMALOG22 GOLD BOND ULTIMATE glimepiride23 HUMALOG JUNIOR SOFTENING58 KWIKPEN22

Index 9 HUMALOG KWIKPEN22 hydrocortisone valerate54 INFANTS ADVIL4 HUMALOG MIX 50/5022 hydrocortisone w/acetic INFLECTRA67 HUMALOG MIX 50/50 acid92 Influenza Vaccine100 hydrocortisone-aloe vera54 KWIKPEN22 INGREZZA94 HUMALOG MIX 75/2522 hydromorphone hcl6 INLYTA32 HUMALOG MIX 75/25 HYDROMORPHONE HCL6 INSPRA30 KWIKPEN22 hydromorphone hcl6 Insulin Pen Needle-Misc74 HUMATE-P68 HYDROMORPHONE HUMIRA3 HYDROCHLORIDE6 Insulin Syringe/Needle-Misc 74 HUMIRA PEDIATRIC CROHNS hydroxychloroquine sulfate31 INTELENCE37 DISEASE STARTER PACK3 HYDROXYPROGESTERONE INTERMEZZO71 HUMIRA PEN3 CAPROATE32 INTUNIV2 HUMIRA PEN-CD/UC/HS hydroxyprogesterone STARTER3 caproate93 INVEGA35 HUMIRA PEN-PS/UV hydroxyurea33 INVEGA SUSTENNA35 STARTER3 HYDROXYZINE HCL11 INVEGA TRINZA35 HUMULIN 70/3022 hydroxyzine hcl11 INVIRASE38 HUMULIN 70/30 KWIKPEN22 HYDROXYZINE INVOKANA22 HUMULIN N22 PAMOATE11 iodoquinol-hydrocortisone in aloe HUMULIN N KWIKPEN22 hydroxyzine pamoate11 vehicle51 HUMULIN R22 HYGEL61 IOPIDINE89 HUMULIN R U-500 HYLIRA58 IPOL INACTIVATED IPV100 (CONCENTRATED)22 hyoscyamine sulfate97,98 ipratropium bromide12 HUMULIN R U-500 ipratropium bromide (nasal)88 KWIKPEN22 HYZAAR29 hyaluronate sodium ibandronate sodium63 ipratropium-albuterol13 (emollient)58 IBRANCE32 irbesartan28 HYCAMTIN33 IBUDONE7 irbesartan-hydrochlorothiazide hydralazine hcl30 29 ibuprofen3 irinotecan hcl33 HYDRALYTE77 ICLUSIG32 HYDRALYTE FREEZER IRON CHEWS PEDIATRIC70 POPS77 IDELVION68 iron-folic acid-vitamin c-vitamin HYDRAZONE LOTION58 imatinib mesylate32 b6-vitamin b12-zinc70 HYDREA33 imipenem-cilastatin10 ISENTRESS38 HYDRO 3556 imipramine hcl19 ISENTRESS HD38 HYDRO 40 FOAM56 imipramine pamoate19 ISONIAZID31 hydrochlorothiazide63 imiquimod59 isoniazid31 hydrocodone w/ IMITREX75 isoproterenol hcl13 homatropine47 IMITREX STATDOSE ISOPTO ATROPINE89 hydrocodone-acetaminophen7 REFILL75 ISOPTO CARPINE89 hydrocodone-ibuprofen7 IMITREX STATDOSE SYSTEM75 ISORDIL TITRADOSE11 hydrocortisone46 IMODIUM A-D23 isosorbide dinitrate11 hydrocortisone (intrarectal)8 IMURAN78 ISOSORBIDE DINITRATE hydrocortisone (rectal)8 ER11 INATAL GT82 isosorbide mononitrate11 hydrocortisone (topical)54 INCRUSE ELLIPTA12 hydrocortisone acetate isotretinoin49 (rectal)8 indapamide63 isoxsuprine hcl43 hydrocortisone acetate w/ INDERAL LA41 ISUPREL13 pramoxine8 indomethacin4 ITCH RELIEF51 hydrocortisone butyrate54 INFANATE BALANCE82 itraconazole24 hydrocortisone butyrate INFANRIX97 hydrophilic lipo base54 ivermectin9

Index 10 IXINITY68 ketotifen fumarate (ophth)91 Lancets-Misc74 JADENU23 KINRIX97 LANOXIN42 JADENU SPRINKLE23 KITABIS PAK3 lansoprazole99 JAKAFI32 KLARON49 lanthanum carbonate67 JALYN68 KLONOPIN15 LANTUS SOLOSTAR22 JARDIANCE22 KLOR-CON M1577 LASIX63 JENTADUETO20 KLOR-CON/2577 latanoprost91 JENTADUETO XR20 KOATE68 LATANOPROST91 JULUCA38 KOATE-DVI68 LATUDA35 K-PHOS NEUTRAL77 KOGENATE FS68 LEADER QUICK DISSOLVE K-TAB77 KOGENATE FS BIO-SET68 GLUCOSE21 leflunomide4 KADIAN6 KONSYL DAILY FIBER71 LESCOL XL27 KALETRA38 KONSYL ORIGINAL letrozole32 KALYDECO96 FORMULADAILY FIBER71 KOSHER PRENATAL PLUS LEUCOVORIN CALCIUM33 KAPVAY2 IRON82 leucovorin calcium33 KAYEXALATE78 KOVALTRY69 LEUKERAN31 KAZANO20 KP PRENATAL levalbuterol hcl13 KCENTRA68 MULTIVITAMINS82 LEVAQUIN66 KEFLEX43 KPN PRENATAL82 LEVBID98 KENALOG54 KYLEENA45 levetiracetam16 KENALOG-4046 labetalol hcl41 LEVETIRACETAM16 KEPPRA15 LAC-HYDRIN58 levetiracetam16 KEPPRA XR15 LAC-HYDRIN TWELVE58 lactic acid (ammonium levetiracetam in sodium KERALAC56 lactate)58 chloride16 KERALYT59 lactulose72 levobunolol hcl89 KERI ADVANCED MOISTURE lactulose (encephalopathy)67 levocarnitine (metabolic THERAPY58 modifiers)64 LAMICTAL15 KERI BASIC ESSENTIALS58 levocetirizine dihydrochloride25 LAMICTAL CHEWABLE KERI NOURISHING SHEA levofloxacin66 BUTTER58 DISPERSIBLE15 levoleucovorin calcium33 KERI ORIGINAL58 LAMICTAL ODT15 LAMICTAL STARTER/NOT LEVOMEFOLATE DHA82 KERI OVERNIGHT58 TAKING levonorgestrel & eth KERI RENEWAL MILK CARBAMAZEPINE15 estradiol44 BODY58 LAMICTAL STARTER/TAKING levonorgestrel (emergency KERI RENEWAL SKIN CARBAMAZEPINE/NOT oc)45 FIRMING58 TAKING VALPROATE15 levonorgestrel-eth estradiol KERI RENEWAL STRETCH LAMICTAL STARTER/TAKING (triphasic)44 MARK MINIMIZER58 VALPROATE15 levonorgestrel-ethinyl estradiol KERI SENSITIVE SKIN58 LAMICTAL XR15,16 (91-day)44 KETOCARE61 LAMISIL24 levothyroxine sodium96 ketoconazole (topical)51 LAMISIL AT51 LEVSIN98 KETONE TEST STRIPS61 LAMISIL AT JOCK ITCH51 LEVSIN/SL98 ketoprofen4 lamivudine38 LEXAPRO18 KETOPROFEN4 lamivudine (hbv)40 LEXIVA38 KETOPROFEN ER4 lamivudine-zidovudine38 LIBRAX98 ketorolac tromethamine4 lamotrigine16 lidocaine60 ketorolac tromethamine LANAPHILIC58 lidocaine hcl60 (ophth)91 LIDOCAINE HCL73 KETOSTIX61 Lancet Devices-Misc74

Index 11 lidocaine hcl (local anesth.)73 LOTENSIN27 MALARONE30 lidocaine hcl (mouth-throat)78 LOTENSIN HCT29 malathion60 lidocaine w/ epinephrine73 LOTREL29 MAPROTILINE HCL18 lidocaine-prilocaine60 LOTRIMIN AF51 MARCAINE73 LIDODERM60 LOTRIMIN AF FOR HER51 MARCAINE SPINAL73 LIDOTRAL60 LOTRIMIN AF JOCK ITCH51 MARCAINE/EPINEPHRINE 73 LILETTA45 LOTRISONE51 MARINOL24 LINCOCIN10 LOTRONEX67 MARNATAL-F82 lincomycin hcl10 lovastatin27 MATULANE33 linezolid10 LOVAZA26 MAVIK28 liothyronine sodium97 LOVENOX14 MAVYRET40 LIPITOR27 loxapine succinate36 MAXALT75 lisinopril27 LUBRIDERM58 MAXALT-MLT75 lisinopril & LUBRIDERM ADVANCED MAXAM58 hydrochlorothiazide29 THERAPY58 MAXIPIME43 LITHIUM34 LUBRIDERM DAILY MAXITROL90 lithium carbonate34 MOISTURE/NORMAL TO DRY SKIN58 MAXZIDE62 LITHIUM CARBONATE34 LUBRIDERM DAILY MAXZIDE-2562 lithium carbonate34 MOISTURESHEA + CALMING meclizine hcl24 LITHOBID34 LAVENDER JASMINE58 LUBRIDERM INTENSE SKIN MEDERMA AG HAND & BODY LMX 460 REPAIR58 LOTION58 LO LOESTRIN FE44 LUBRIDERM MENS 3-IN- MEDROL46 LOCOID55 158 MEDROL DOSEPAK46 LOCOID LIPOCREAM55 LUBRIDERM SERIOUSLY medroxyprogesterone SENSITIVE58 LODINE4 acetate93 LUBRIDERM SKIN medroxyprogesterone acetate LODOSYN33 NOURISHINGWITH SHEA (contraceptive)45 LOESTRIN 1.5/30-2144 AND COCOA BUTTERS58 mefenamic acid4 LOESTRIN 1/20-2144 LUBRISOFT58 MEFLOQUINE HCL31 LOESTRIN FE 1.5/3044 LURIDE77 mefloquine hcl31 LOESTRIN FE 1/2044 LUXIQ55 MEGACE ES93 LOFIBRA27 LYRICA16 MEGACE ORAL32 LOMOTIL23 LYRICA CR95 megestrol acetate32 loperamide hcl23 LYSODREN32 megestrol acetate (appetite)93 LOPID27 LYSTEDA70 MEKINIST32 lopinavir-ritonavir38 M-M-R II101 melatonin3 LOPRESSOR41 M-NATAL PLUS82 meloxicam4 LOPRESSOR HCT29 M-VIT82 melphalan31 LOPROX51 MACNATAL CN DHA82 melphalan hcl31 LOPROX SHAMPOO51 MACROBID99 memantine hcl94 loratadine25 MACRODANTIN99 MENACTRA100 loratadine & mafenide acetate52 MENEST65 pseudoephedrine47 magnesium citrate72 MENHIBRIX100 lorazepam11 magnesium hydroxide72 MENOMUNE-A/C/Y/W-135 losartan potassium28 magnesium oxide9 100 losartan potassium & magnesium oxide (mg MENVEO100 hydrochlorothiazide29 supplement)77 MEPHYTON102 LOSEASONIQUE44 MAKENA93 mepivacaine hcl73

Index 12 meprobamate11 metoclopramide hcl66 MIRENA45 MEPRON9 metolazone63 mirtazapine18 mercaptopurine31 metoprolol & misoprostol99 meropenem10 hydrochlorothiazide29 MOBIC4 metoprolol succinate41 MERREM10 modafinil2 METOPROLOL SUCCINATE mesalamine67 ER/HYDROCHLOROTHIAZIDE MOI-STIR79 mesalamine w/ cleanser67 29 mometasone furoate55 mesna33 metoprolol tartrate41 mometasone furoate (nasal)88 MESNEX33 METOPROLOL/HYDROCHLO MONISTAT 1 COMBO ROTHIAZIDE 29 MESTINON31 PACK101 METROCREAM60 MONISTAT 1 DAY OR NIGHT MESTINON TIMESPAN31 METROGEL60 COMBO PACK101 METADATE CD2 METROGEL-VAGINAL101 MONISTAT 3101 METAMUCIL71 MONISTAT 3 COMBINATION METROLOTION60 METAMUCIL ORIGINAL PACK101 TEXTURE71 metronidazole9 MONISTAT 7 SIMPLY METAPROTERENOL metronidazole (topical)60 CURE101 SULFATE13 metronidazole vaginal101 MONISTAT SOOTHING CARE metaxalone87 ITCH RELIEF55 MEVACOR27 MONOCLATE-P69 metformin hcl20 mexiletine hcl12 methamphetamine hcl1 MONODOX96 MIACALCIN64 MONONINE69 methazolamide62 MICARDIS28 methenamine hippurate99 montelukast sodium12 MICARDIS HCT30 morphine sulfate6 methenamine mandelate99 MICATIN51 methenamine-hyosc-methylene MORPHINE SULFATE6 blue-sod phos-phenyl sal99 MICONAZOLE 3101 morphine sulfate6 methimazole96 miconazole nitrate (topical)51 MORPHINE SULFATE6 METHITEST8 miconazole nitrate vaginal101 morphine sulfate6 methocarbamol87 MICRO-K77 MOTHERS FRIEND58 methotrexate sodium31 MICROZIDE63 MOTRIN INFANTS DROPS4 METHOTREXATE SODIUM31 midazolam hcl71 MOUTHKOTE79 methotrexate sodium32 MIDAZOLAM/SYRSPEND SF moxifloxacin hcl66 methoxsalen rapid52 PH471 moxifloxacin hcl (ophth)90 methscopolamine bromide98 midodrine hcl102 MS CONTIN6 methyldopa28 miglitol20 MSM SKIN LOTION58 methylergonovine maleate92 MIGRANAL75 MULTI PRENATAL82 METHYLIN2 MILK OF MAGNESIA MULTI VITAMIN80 CONCENTRATE72 methylphenidate hcl2 MILLIPRED46 MULTI VITAMIN/D-380 METHYLPHENIDATE multiple vitamin80 HYDROCHLORIDE ER2 MINASTRIN 24 FE44 METHYLPHENIDATE MINIPRESS28 multiple vitamins w/ iron80 Multiple Vitamins w/ Minerals HYDROCHLORIDE ER (LA)2 MINIVELLE65 methylprednisolone46 Tab-Misc80 MINOCIN96 Multiple Vitamins w/ Minerals- methylprednisolone acetate46 minocycline hcl96 Misc80 METHYLPREDNISOLONE mupirocin50 ACETATE46 minoxidil30 methylprednisolone sod MIRALAX72 mupirocin calcium (topical)50 succ46 MIRAPEX34 MYAMBUTOL31 METHYLTESTOSTERONE8 MIRAPEX ER34 MYCOBUTIN31 METIPRANOLOL89 MIRCETTE44 mycophenolate mofetil78

Index 13 mycophenolate sodium78 nateglinide22 NEUTROGENA HEALTHY SKIN MYDAYIS1 NATELLE ONE82 FACE SPF 1559 NEUTROGENA MOISTURE MYDRIACYL89 NATROBA60 SENSITIVE SKIN59 MYFORTIC78 NATURE-THROID97 NEUTROGENA T/GEL61 MYLERAN31 NECON 1/50-2844 NEUTROGENA T/GEL MYLICON66 NECON 10/11-2844 STUBBORN ITCH CONTROL61 MYLICON INFANTS GAS NEEVO DHA82 nevirapine38 RELIEF66 NEFAZODONE HCL19 MYNATAL82 NEWGEN82 nefazodone hcl19 NEXA PLUS82 MYNATAL ADVANCE82 NEFAZODONE MYNATAL PLUS82 HYDROCHLORIDE19 NEXAVAR32 MYNATAL ULTRACAPLET82 NEMBUTAL SODIUM70 NEXIUM99 MYNATAL-Z82 NEOMULTIVITE80 NEXIUM 24HR99 MYNATE 90 PLUS82 neomycin sulfate3 NEXIUM 24HR CLEAR MINIS99 MYSOLINE16 neomycin-bacitracin zn- NEXPLANON45 nabumetone4 polymyxin90 neomycin-bacitracin-polymyxin niacin102 nadolol41 50 niacin (antihyperlipidemic)27 nadolol & neomycin-polymy- bendroflumethiazide30 dexameth90 NIACIN TR102 naftifine hcl51 neomycin-polymyxin w/ NIACOR27 NAFTIN51 pramoxine50 NIASPAN27 neomycin-polymyxin-gramicidin nicardipine hcl42 naloxone hcl23 90 NALOXONE HCL23 neomycin-polymyxin-hc NICODERM CQ95 naltrexone hcl23 (otic)92 NICORETTE95 NAMENDA94 neomycin/polymyxin b gu67 NICORETTE MINI95 NAMENDA TITRATION PAK94 NEOMYCIN/POLYMYXIN/HYD NICORETTE STARTER KIT95 ROCORTISONE 90 nicotine95 NAMENDA XR94 NEONATAL PLUS82 NAMENDA XR TITRATION nicotine polacrilex95 NEONATAL VITAMIN82 PACK94 NICOTINE TRANSDERMAL NAMZARIC94 NEORAL78 SYSTEM95 NAPRELAN4 NEOSPORIN90 NICOTROL INHALER95 NAPROSYN4 NEOSPORIN GU NICOTROL NS96 IRRIGANT67 nifedipine42 naproxen4 NEOSPORIN ORIGINAL50 naproxen sodium4 NEOSPORIN PLUS PAIN NILANDRON32 naratriptan hcl75 RELIEF MAXIMUM nilutamide32 NARCAN23 STRENGTH50 NINLARO32 NARDIL18 NEPHRO-VITE RX80 nisoldipine42 NAROPIN73 NEPHROCAPS80 NITRO-BID11 NASACORT ALLERGY NEPTAZANE62 NITRO-DUR11 24HR88 NESACAINE-MPF73 nitrofurantoin99 NASACORT ALLERGY 24HR NESINA21 CHILDRENS88 nitrofurantoin macrocrystal99 NESTABS82 NASALCROM88 nitrofurantoin monohyd NESTABS ABC82 macro99 NASONEX88 nitroglycerin11 NAT-RUL PRENATAL NESTABS DHA82 NESTABS ONE82 NITROLINGUAL VITAMINS82 PUMPSPRAY11 NATACHEW82 NEURONTIN16 NITROPRESS30 NEUTROGENA BODY LIGHT NATALVIT82 nitroprusside sodium30 NATAZIA44 SESAME FORMULA58

Index 14 NITROSTAT11 NOVOEIGHT69 OBIZUR69 NIVA-PLUS83 NOVOLIN 70/3022 OBSTETRIX ONE83 NIVEA59 NOVOLIN 70/30 OCEAN NASAL SPRAY87 NIVEA EXTRA ENRICHED59 FLEXPEN22 OCREVUS95 NOVOLIN 70/30 FLEXPEN NIVEA EXTRA ENRICHED RELION22 octreotide acetate65 LOTION59 OCUFEN91 NIVEA GENTLE BODY NOVOLIN 70/30 RELION22 EXFOLIATOR59 NOVOLIN N22 OCUFLOX90 NIVEA LIGHT59 NOVOLIN N RELION22 ODEFSEY38 NIVEA ORIGINAL59 NOVOLIN R22 ODOMZO32 NIVEA ORIGINAL NOVOLIN R RELION22 OFLOXACIN66 MOISTURE59 NOVOLOG22 ofloxacin66 NIVEA VISAGE59 NOVOLOG FLEXPEN22 ofloxacin (ophth)90 NIX CREME RINSE60 NOVOLOG MIX 70/3022 ofloxacin (otic)91 NIZORAL51 NOVOLOG MIX 70/30 OGESTREL44 nonoxynol-9101 PREFILLED FLEXPEN22 OINTMENT BASE59 NOR-QD45 NOVOLOG PENFILL22 olanzapine36 NORCO7 NOVOSEVEN RT69 olanzapine-fluoxetine hcl94 NORDITROPIN FLEXPRO64 NUEDEXTA95 olmesartan medoxomil28 norethin acet & estrad-fe44 NULYTELY/FLAVOR olmesartan medoxomil- norethindrone & eth estradiol44 PACKS72 amlodipine-hydrochlorothiazide norethindrone & ethinyl estradiol- NUMOISYN79 30 fe44 NUPLAZID35 olmesartan medoxomil- norethindrone NUTRADERM59 hydrochlorothiazide 30 (contraceptive)45 NUTRADERM ADVANCED olopatadine hcl91 norethindrone acet & eth FORMULA59 olopatadine hcl (nasal)88 estra44 NUTROPIN AQ NUSPIN OLUX55 norethindrone acetate93 1064 norethindrone acetate-ethinyl NUTROPIN AQ NUSPIN OLUX-E55 estradiol65 2064 omega-3 fatty acids88 norethindrone acetate-ethinyl NUTROPIN AQ NUSPIN 564 omega-3-acid ethyl esters26 estradiol-fe44 NUVARING45 norethindrone-eth estradiol omeprazole99 (triphasic)44 NUVIGIL2 Omeprazole Delayed Release norgestimate-ethinyl NUWIQ69 Tab 20mg97 OMNICAP80 estradiol44 nystatin24 norgestimate-ethinyl estradiol OMNIPRED90 nystatin (mouth-throat)78 (triphasic)44 ondansetron24 nystatin (topical)51 norgestrel & ethinyl estradiol44 ondansetron hcl23 nystatin-triamcinolone51 NORINYL 1+3544 ONDANSETRON NORPACE12 NYTOL MAXIMUM HYDROCHLORIDE24 STRENGTH70 ONE-A-DAY ESSENTIAL80 NORPRAMIN19 O-CAL FA83 ONE-A-DAY MENS80 NORTEMP INFANTS5 O-CAL PRENATAL83 ONE-A-DAY VITACRAVES nortriptyline hcl19 OB COMPLETE83 NORTRIPTYLINE HCL19 GUMMIES+OMEGA-3 DHA81 OB COMPLETE ONFI15 nortriptyline hcl19 ADVANCED83 OPANA6 OB COMPLETE GOLD83 NORVASC42 ophthalmic irrigation solution - NORVIR38 OB COMPLETE ONE83 intraocular91 NOVA MAX PLUS KETONE OB COMPLETE PETITE83 OPTIONS CONCEPTROL TESTSTRIPS61 OB COMPLETE PREMIER83 VAGINAL NOVACORT55 OB COMPLETE/DHA83 CONTRACEPTIVE101

Index 15 OPTIONS GYNOL II pantoprazole sodium99 pentobarbital sodium70 VAGINALCONTRACEPTIVE PARAFON FORTE DSC87 pentoxifylline69 101 PARAGARD INTRAUTERINE oral electrolytes77 PEPCID98 COPPER CONTRACEPTIVE PEPCID AC98 ORAL RELIEF SPRAY FOR 45 T380A PEPCID AC MAXIMUM DRYMOUTH & paricalcitol64 DISCOMFORT79 STRENGTH98 ORAP95 PARLODEL34 PEPTO-BISMOL23 ORAPRED ODT46 PARNATE18 PEPTO-BISMOL INSTACOOL23 ORKAMBI96 paroxetine hcl18 paroxetine mesylate PEPTO-BISMOL MAX orphenadrine citrate87 (vasomotor)96 STRENGTH23 ORTHO MICRONOR45 PARVA-CAL76 PEPTO-BISMOL TO-GO23 ORTHO TRI-CYCLEN44 PATADAY91 PERCOCET7 ORTHO TRI-CYCLEN LO44 PATANASE88 PERIDEX79 ORTHO-CYCLEN45 PATANOL91 perindopril erbumine28 ORTHO-NOVUM 1/3545 PAXIL19 permethrin60,61 ORTHO-NOVUM 7/7/745 PAXIL CR19 perphenazine36 oseltamivir phosphate40 PCE74 PERPHENAZINE/AMITRIPTYLIN E 94 OSENI20 ped multivitamins w/fl & PFIZERPEN92 OTICIN HC NR92 iron81 phenazopyridine hcl68 OVACE PLUS52 PEDIA-LAX72 phenelzine sulfate18 OVACE PLUS WASH52 PEDIALYTE77 PHENERGAN26 OVACE WASH52 PEDIALYTE ADVANCED CARE77 phenobarbital70 OVCON-3545 PEDIALYTE FREEZER phenobarbital-hyoscyamine- OVIDE60 POPS77 atropine-scopolamine 98 oxaprozin4 PEDIALYTE SINGLES77 phenoxybenzamine hcl28 oxazepam11 PEDIAPRED46 phenylephrine hcl (ophth)90 OXAZEPAM12 PEDIARIX97 phenylephrine hcl (oral)88 oxcarbazepine16 pediatric multiple vitamin w/ phenylephrine-dm47 c81 oxiconazole nitrate51 pediatric multiple vitamin w/ c & phenylephrine-shark liver oil- OXISTAT51 81 cocoa butter8 fa phenylephrine-shark liver oil- OXSORALEN ULTRA52 Pediatric Multiple Vitamins w/ FluorideChew80 mineral oil-petrolatum8 OXTELLAR XR16 Pediatric Multiple Vitamins w/ PHENYTEK17 oxybutynin chloride100 FluorideSoln80 phenytoin17 oxycodone hcl6 pediatric multiple vitamins w/ phenytoin sodium17 iron80 oxycodone w/ acetaminophen7 phenytoin sodium extended17 pediatric vitamins adc81 oxycodone-aspirin7 phytonadione102 PEDVAX HIB100 OXYCODONE/ACETAMINOPHE PIFELTRO38 N7 peg 3350-kcl-sod bicarb-sod oxymorphone hcl6 chloride-sod sulfate72 pilocarpine hcl89 peg 3350-potassium chloride- oxytocin92 pilocarpine hcl (oral)79 sod bicarbonate-sod pimozide95 oyster shell76 chloride72 OZEMPIC21 penicillin g potassium92 pindolol41 paliperidone35 PENICILLIN V pioglitazone hcl21 PAMELOR19 POTASSIUM92 pioglitazone hcl-glimepiride20 penicillin v potassium92 pioglitazone hcl-metformin PANCREAZE62 PENLAC NAIL LACQUER51 hcl20 PANOXYL-4 CREAMY piperacillin sodium-tazobactam WASH49 PENTACEL97 sodium93

Index 16 piroxicam4 potassium citrate-citric acid67 PREMPRO65 PITOCIN92 POTIGA16 PRENA 1 TRUE83 PLAN B ONE-STEP45 PR NATAL 40083 PRENA1 CHEW83 PLAQUENIL31 PR NATAL 400 EC83 PRENA1 PEARL83 PLAVIX69 PR NATAL 43083 PRENAISSANCE83 PLEGRIDY95 PR NATAL 430 EC83 PRENAISSANCE BALANCE83 PLEGRIDY STARTER pramipexole PRENAISSANCE HARMONY PACK95 dihydrochloride34 DHA83 PLEXION49 PRAMOSONE55 PRENAISSANCE NEXT83 PLEXION CLEANSER49 pramoxine hcl (rectal)8 PRENAISSANCE NEXT-B83 PNEUMOVAX 23100 pramoxine-hc55 PRENAISSANCE PLUS83 PNEUMOVAX 23/1 DOSE100 pramoxine-hc-chloroxylenol PRENATA83 PNV FERROUS 92 PRENATABS FA83 PRANDIN22 FUMARATE/DOCUSATE/FOLIC PRENATABS RX83 ACID83 prasugrel hcl69 PRENATAL84 PNV FOLIC ACID + IRON PRAVACHOL27 MULTIVITAMIN83 PRENATAL 1983 pravastatin sodium27 PNV OB+DHA83 PRENATAL AND IRON84 prazosin hcl28 PNV PRENATAL PLUS PRENATAL FORTE84 MULTIVITAMIN83 PRE-NATAL FORMULA83 PRENATAL LOW IRON84 PNV PRENATAL PLUS PRECEDEX71 MULTIVITAMIN + DHA83 PRENATAL MULTIVITAMIN84 PRECISION XTRA61 PNV TABS 29-183 PRENATAL ONE DAILY84 PRECOSE20 PNV-DHA+DOCUSATE83 PRENATAL PLUS84 PRED FORTE90 PNV-OMEGA83 PRENATAL PLUS IRON84 PRED MILD90 PNV-TOTAL83 PRENATAL VITAMIN84 PRED-G91 PNV-VP-U83 PRENATAL VITAMIN & PREDATOR60 podofilox59 MINERAL84 PREDNICARBATE55 PRENATAL VITAMIN/IRON85 POLY-VI-SOL81 prednicarbate55 PRENATAL VITAMINS85 POLY-VI-SOL/IRON81 PREDNISOLONE46 PRENATAL VITAMINS PLUS polyethylene glycol 335072 prednisolone46 LOW IRON85 polymyxin b-trimethoprim90 prednisolone acetate PRENATAL-U85 polysaccharide iron complex70 (ophth)91 PRENATE85 POLYSPORIN50 PREDNISOLONE ACETATE P- PRENATE AM85 POLYTRIM90 F91 PRENATE DHA85 prednisolone sodium polyvinyl alcohol88 phosphate46 PRENATE ELITE85 POMALYST32 PREDNISOLONE SODIUM PRENATE ENHANCE85 PONSTEL4 PHOSPHATE91 PRENATE ESSENTIAL85 pot phosphate monobasic w/ sod PREDNISONE46 PRENATE MINI85 phosphate dibasic & prednisone46 PRENATE PIXIE85 monobasic77 PREDNISONE46 77 PRENATE RESTORE85 potassium acetate PREDNISONE INTENSOL46 77 PRENATE STAR85 potassium bicarbonate PREFERA OB83 77 PREPLUS85 potassium chloride PREFERAOB +DHA83 POTASSIUM CHLORIDE PREPOPIK72 ER77 PREFERAOB ONE83 PREQUE 1085 potassium chloride PREFEST65 PRETAB85 microencapsulated crystals PREMARIN65,102 er77 PREVACID99 potassium citrate PREMESISRX83 PREVACID 24HR99 (alkalinizer)67 PREMPHASE65

Index 17 PREVACID SOLUTAB99 proparacaine hcl90 quinapril hcl28 PREVIDENT 5000 propranolol hcl41 quinapril-hydrochlorothiazide BOOSTER79 PROPRANOLOL HCL41 30 PREVIDENT 5000 BOOSTER quinidine gluconate12 propranolol hcl41 PLUS79 QUINIDINE SULFATE12 PREVIDENT 5000 DRY PROPRANOLOL/HYDROCHL MOUTH79 OROTHIAZIDE 30 quinine sulfate31 PREVIDENT 5000 ENAMEL propylthiouracil96 QUINTABS80 PROTECT79 PROSCAR68 R-NATAL OB85 PREVIDENT 5000 PLUS79 PROSTIN VR PEDIATRIC78 RA ADVANCED HEALING59 PREVIDENT 5000 RA DAYLOGIC HEALING DRY SENSITIVE79 PROTONIX99 PROTOPIC59 SKIN THERAPY59 PREVIDENT FLUORIDE79 RA DRY MOUTH79 protriptyline hcl20 PREVIDENT RINSE79 RA OYSTER SHELL PREVNAR 13100 PROVENTIL HFA13 CALCIUM/VITAMIN D76 PREZCOBIX38 PROVERA93 RA PRENATAL85 PREZISTA38 PROVIDA DHA85 RA PRENATAL PROVIDA OB85 FORMULA/FOLICACID85 PRILOSEC99 RA RENEWAL DRY SKIN PRIMACARE85 PROVIGIL2 THERAPY59 PRIMAXIN IV10 PROZAC19 RA STAY AWAKE1 primidone16 PSORCON55 rabeprazole sodium99 PRINIVIL28 psyllium71 RADIAGUARD ADVANCED59 PRISTIQ19 PTS PANELS KETONE raloxifene hcl64 TEST61 PROAIR HFA13 PULMICORT13 ramipril28 probenecid68 PULMICORT FLEXHALER13 ranitidine hcl98 PROBUPHINE IMPLANT KIT7 PUREFE OB PLUS85 RAPAMUNE78 PROCARDIA42 PURIXAN32 rasagiline mesylate34 PROCARDIA XL42 PX PRENATAL RAZADYNE94 PROCENTRA1 MULTIVITAMINS85 RAZADYNE ER94 prochlorperazine36 pyrantel pamoate9 REBETOL40 prochlorperazine maleate36 pyrazinamide31 REBINYN69 PROCTOCORT8 pyrethrins-piperonyl RECLAST64 butoxide61 PROCTOFOAM8 pyrethrins-piperonyl butoxide- RECOMBINATE69 PROFILNINE69 permethrin-nit remover61 RECOMBIVAX HB101 PROFILNINE SD69 PYRIDIUM68 REGLAN66 progesterone micronized93 pyridostigmine bromide31 RELENZA DISKHALER40 PROGLYCEM21 pyridoxine hcl102 RELION KETONE61 PROGRAF78 QC PRENATAL85 RELION KETONE TEST promethazine & QUADRACEL97 STRIPS61 RELNATE DHA85 phenylephrine47 QUALAQUIN31 promethazine hcl26 RELPAX75 QUARTETTE45 promethazine w/codeine47 REMERON18 QUAZEPAM71 promethazine-phenylephrine- REMERON SOLTAB18 QUDEXY XR16 codeine 47 RENFLEXIS67 PROMETHAZINE/PHENYLEPHR QUESTRAN26 RENVELA67 INE 47 QUESTRAN LIGHT26 PROMETHAZINE/PHENYLEPHR repaglinide22 quetiapine fumarate36 INE/CODEINE 47 REPREXAIN7 QUILLICHEW ER2 PROMETRIUM93 REQUIP34 QUILLIVANT XR2 propafenone hcl12 REQUIP XL34

Index 18 RESCRIPTOR38 ROSE MILK59 sertraline hcl19 RESOURCE THICKENUP93 ROTARIX101 sevelamer carbonate67 RESTA LITE59 ROTATEQ101 SFROWASA67 RESTORIL71 ROWASA67 SHINGRIX101 RETIN-A49 ROXICODONE6 SHOHLS SOLUTION RETIN-A MICRO49 ROZEREM71 MODIFIED67 SHUR-SEAL101 RETIN-A MICRO PUMP49 RYTHMOL12 SILENOR70 RETROVIR38 RYTHMOL SR12 SILPHEN COUGH25 REYATAZ38 SABRIL17 SILVADENE53 RIASTAP69 SAFYRAL45 silver sulfadiazine53 ribavirin40 SALAGEN80 simethicone66 ribavirin (hepatitis c)40 SALEX59 simvastatin27 riboflavin102 salicylic acid59,60 SINEMET34 RID61 saline87 SINEMET CR34 RID COMPLETE LICE salsalate5 SINGULAIR12 ELIMINATION61 SALVAX60 rifabutin31 sirolimus78 SANDIMMUNE78 RIFADIN31 SIVEXTRO10 SANDOSTATIN65 rifampin31 SKELAXIN87 SARAFEM95 RIGHT STEP PRENATAL85 SKIN REPAIR59 SARNA52 RILUTEK88 SKYLA45 SAVELLA94 riluzole88 SAVELLA TITRATION SLO-NIACIN102 rimantadine hydrochloride40 PACK94 SM GLUCOSE21 risedronate sodium64 SCOT-TUSSIN48 SM PRENATAL VITAMINS85 RISPERDAL35 SE-NATAL 1985 SMARTRX GABA KIT95 RISPERDAL CONSTA35 SEASONIQUE45 SMARTRX GABA-V KIT95 RISPERDAL M-TAB35 SECTRAL41 sodium bicarbonate (antacid)9 risperidone35 SELECT-OB85 sodium chloride (gu irrigant)67 RISPERIDONE ODT35 SELECT-OB+DHA85 sodium chloride (inhalant)48 RITALIN2 selegiline hcl34 sodium citrate & citric acid67 RITALIN LA2 selenium sulfide52 SODIUM DIURIL63 ritonavir38 SELSUN BLUE52 SODIUM EDECRIN63 rivastigmine94 SELSUN BLUE DAILY52 sodium ferric gluconate complex rivastigmine tartrate94 SELSUN BLUE in sucrose70 sodium fluoride77 RIXUBIS69 MEDICATED52 SELSUN BLUE SODIUM FLUORIDE77 rizatriptan benzoate75 MOISTURIZING52 sodium fluoride (dental)79 ROBAXIN87 SELZENTRY38 sodium fluoride-potassium ROBAXIN-75087 SENNA72 nitrate79 ROBINUL98 sennosides72 sodium phenylbutyrate64 ROBINUL FORTE98 sennosides-docusate sodium phosphates72 ROC DEEP WRINKLE sodium72 sodium polystyrene SERUM59 SENOKOT72 sulfonate78 ROCALTROL64 SENOKOT S72 SODIUM ropinirole hydrochloride34 SENOKOT XTRA72 SULFACETAMIDE/SULFUR 49 ropivacaine hcl73 SEREVENT DISKUS13 SOLARAZE52 ROPIVACAINE SEROQUEL36 HYDROCHLORIDE73 SOLODYN96 SEROQUEL XR36

Index 19 SOLU-MEDROL46 sulindac4 TAYTULLA45 SOMA87 SUMADAN WASH50 tazarotene52 SONATA71 sumatriptan75 TAZORAC52 SOOTHE & COOL sumatriptan succinate75,76 TEARS NATURALE PM88 MOISTURIZING BODY LOTION SUMATRIPTAN TECFIDERA95 59 WITH ALOE SUCCINATE76 TECFIDERA STARTER SORBITOL72 sumatriptan succinate76 PACK95 SORIATANE52 SUMAXIN50 TEGRETOL16 sotalol hcl41 SUMAXIN TS50 TEGRETOL-XR16 sotalol hcl (afib/afl)41 SUMAXIN WASH50 telmisartan28 Spacer/Aerosol Holding SUPRAX43 telmisartan-amlodipine30 74 Chambers-Misc SUPREP BOWEL PREP telmisartan-hydrochlorothiazide SPINOSAD61 KIT72 30 spironolactone63 SURMONTIL20 temazepam71 spironolactone & SUSTIVA38,39 TEMODAR31 hydrochlorothiazide62 SPORANOX24 SUTENT33 TEMOVATE55 SPORANOX PULSEPAK24 SYMBICORT13 TEMOVATE E55 SPRITAM16 SYMBYAX94 temozolomide31 SPRYCEL33 SYMFI39 TENCON5 ST IVES SWISS FORMULA SYMFI LO39 TENEX28 24HOUR MOISTURE59 SYMLINPEN 12020 TENIVAC97 stannous fluoride79 SYMLINPEN 6020 tenofovir disoproxil fumarate39 starch-maltodextrin SYMTUZA39 TENORETIC 10030 (thickening)93 SYNAGIS92 TENORETIC 5030 STARLIX22 SYNALAR55 TENORMIN41 stavudine38 SYNTHROID97 TERAZOL 7101 STIVARGA33 SYPRINE77 terazosin hcl28 STRATTERA2 TACLONEX55 terbinafine hcl24 STRIBILD38 tacrolimus78 terbinafine hcl (topical)51 STROMECTOL9 STUDIO 35 EXTRA tacrolimus (topical)59 terbutaline sulfate13 MOISTURIZING LOTION59 TAFINLAR33 TERCONAZOLE101 SUBLOCADE7 TAGAMET HB98 terconazole vaginal101,102 SUBOXONE7 TAMIFLU40 TESSALON PERLES47 sucralfate98 tamoxifen citrate32 testosterone8 SUDAFED PE tamsulosin hcl68 testosterone cypionate8 CONGESTION88 TANDEM PLUS70 TESTOSTERONE SULAR42 TANZEUM21 CYPIONATE8 sulfacetamide sod- TESTRED8 TAPAZOLE96 prednisolone91 TETANUS/DIPHTHERIA sulfacetamide sodium52 TARCEVA33 TOXOIDS-ADSORBED97 sulfacetamide sodium (acne)49 TARGRETIN33 tetrabenazine94 sulfacetamide sodium TARKA30 tetracycline hcl96 (ophth)90 TARON-BC85 TETRACYCLINE HCL96 sulfacetamide sodium w/ sulfur49 TARON-C DHA85 tetrahydrozoline hcl (ophth)90 sulfamethoxazole- TARON-PREX85 THEO-2413 trimethoprim9 TASIGNA33 theophylline13 SULFAMYLON53 TASMAR34 THERA80 sulfasalazine67 TAVIST ALLERGY25 THERA-FLUR-N79

Index 20 THERABETIC SKIN CARE59 tobramycin sulfate3 TRIAMTERENE/HYDROCHLOR THERANATAL CORE tobramycin- OTHIAZIDE 62 NUTRITION85 dexamethasone91 triazolam71 THERAPEVO61 TOBREX90 TRIBENZOR30 THERAPLEX TOFRANIL20 TRICARE86 HYDROLOTION59 tolcapone34 TRICARE PRENATAL86 thiamine hcl102 TOLMETIN SODIUM4 TRICARE PRENATAL thiamine mononitrate103 tolnaftate51 COMPLEAT86 THICK-IT #293 TRICARE PRENATAL DHA tolterodine tartrate100 THICK-IT ORIGINAL93 ONE86 TOPAMAX16 TRICARE PRENATAL DHA thioridazine hcl36 TOPAMAX SPRINKLE16 ONE/FOLATE86 thiothixene37 TOPICORT55 TRICOR27 THRIVITE 1985 topiramate16 TRIDESILON55 THRIVITE RX85 TOPIRAMATE ER16 trientine hcl77 thyroid97 topotecan hcl33 trifluoperazine hcl36 THYROLAR-197 TOPROL XL41 trifluridine90 THYROLAR-1/297 torsemide63 TRIGLIDE27 THYROLAR-1/497 TRADJENTA21 trihexyphenidyl hcl33 THYROLAR-297 tramadol hcl6 TRILEPTAL16 THYROLAR-397 tramadol-acetaminophen7 TRILIPIX27 tiagabine hcl17 trandolapril28 trimethobenzamide hcl24 TIAZAC42 trandolapril-verapamil hcl30 trimethoprim9 TIGAN24 TRANDOLAPRIL/VERAPAMIL trimipramine maleate20 TIKOSYN12 HCL ER30 TRINATAL GT86 TIMOLOL MALEATE41 tranexamic acid70 TRINATAL RX 186 timolol maleate (ophth)89 TRANXENE T12 TRINATE86 TIMOLOL MALEATE tranylcypromine sulfate18 TRIOSTAT97 OPHTHALMIC GEL trazodone hcl19 FORMING89 TRISTART DHA86 TIMOPTIC89 TRECATOR31 TRISTART ONE86 TIMOPTIC OCUDOSE89 tretinoin50 TRIUMEQ39 TIMOPTIC-XE89 tretinoin (chemotherapy)33 TRIVEEN-DUO DHA86 TINACTIN51 tretinoin microsphere50 TRIVEEN-PRX RNF86 TINACTIN JOCK ITCH51 TRETTEN69 TRIZIVIR39 TINDAMAX9 TREXALL32 TROGARZO39 tinidazole9 TRI-NORINYL 2845 TROKENDI XR16 tioconazole vaginal102 TRI-TABS DHA86 tropicamide89 TIVICAY39 TRI-VIT/FLUORIDE/IRON 81 trospium chloride100 tizanidine hcl87 TRIADVANCE86 TRUE METRIX BLOOD GLUCOSETEST STRIPS61 TL FOLATE85 triamcinolone acetonide46 TRIAMCINOLONE TRUE METRIX SELF TL-CARE DHA85 ACETONIDE46 MONITORING BLOOD TL-SELECT86 triamcinolone acetonide GLUCOSE STRIPS61 (mouth)79 TRUECONTROL GLUCOSE TOBI3 CONTROL LEVEL 074 TOBRADEX91 triamcinolone acetonide (nasal)88 TRUECONTROL GLUCOSE tobramycin3 triamcinolone acetonide CONTROL LEVEL 174 TOBRAMYCIN3 (topical)55 TRUETEST BLOOD GLUCOSE TEST62 tobramycin (ophth)90 triamterene & hydrochlorothiazide62 TRUETEST BLOOD GLUCOSE TOBRAMYCIN SULFATE3 TEST STRIPS62

Index 21 TRUETEST GLUCOSE urea56 VIGAMOX90 CONTROLLEVEL 174 urea in lactic acid vehicle56 VIIBRYD19 TRUETEST GLUCOSE CONTROLLEVEL 274 URECHOLINE100 VIL-RX86 TRUETEST GLUCOSE UROCIT-K 1067 VIMPAT16,17 CONTROLLEVEL 374 UROCIT-K 1567 VINATE DHA RF86 TRUETEST STRIPS62 UROCIT-K 567 VINATE II86 TRUETRACK BLOOD GLUCOSE TEST62 UROXATRAL68 VINATE M86 TRUETRACK TEST62 URSO 25066 VINATE ONE86 TRULICITY21 URSO FORTE66 VIRACEPT39 TRUMENBA100 ursodiol66 VIRAMUNE39 TRUSOPT91 VAGIFEM102 VIRAMUNE XR39 TRUVADA39 VAGISTAT-1102 VIRASAL60 TUDORZA PRESSAIR12 valacyclovir hcl40 VIRAZOLE40 TUMS9 VALCYTE39 VIREAD39 TUMS CHEWY BITES9 valganciclovir hcl39 VIROPTIC90 TUMS E-X 7509 VALIUM12 VIRT NATE86 TUMS EXTRA STRENGTH valproate sodium17 VIRT-ADVANCE86 7509 valproic acid17 VIRT-C DHA86 TUMS KIDS9 valsartan28 VIRT-NATE DHA86 TUMS LASTING EFFECTS9 valsartan-hydrochlorothiazide VIRT-PN PLUS86 TUMS SMOOTHIES9 30 VIRT-SELECT86 VALTREX40 TWINRIX101 VIRT-VITE GT86 VANCOCIN HCL10 TWYNSTA30 VIRTPREX86 vancomycin hcl10 TYBOST39 VISINE90 VANICREAM LITE59 TYKERB33 VISTARIL11 VANOS56 TYLENOL5 VITA-PREN86 VAQTA101 TYLENOL CHILDRENS5 VITAFOL GUMMIES86 VARIVAX101 TYLENOL CHILDRENS VITAFOL ULTRA86 CHEWABLES/PAIN + FEVER5 VASERETIC30 VITAFOL-NANO86 TYLENOL EXTRA VASOTEC28 STRENGTH5 VITAFOL-OB86 VEMAVITE-PRX 286 TYLENOL INFANTS5 VITAFOL-OB+DHA86 VENA-BAL DHA86 TYLENOL INFANTS VITAFOL-ONE86 PAIN+FEVER5 venlafaxine hcl19 VITAMEDMD ONE TYLENOL/CODEINE #37 VENTOLIN HFA13 RX/QUATREFOLIC86 TYLENOL/CODEINE #47 verapamil hcl42 VITAMEDMD PLUS ULTIMATECARE ONE86 VERAPAMIL HCL SR42 RX/QUATREFOLIC86 VITAMEDMD REDICHEW ULTIMATECARE ONE NF86 VERELAN42 RX86 ULTRACET7 VERELAN PM42 vitamin e102 ULTRAM6 VERIPRED 2046 vitamins w/ lipotropics87 ULTRASAL-ER60 VFEND24 VITAPEARL86 ULTRAVATE55 VFEND IV24 VITATRUE86 UNASYN93 VIBRAMYCIN96 VITEKTA39 UNASYN BULK PACK93 VICTOZA21 VIVA DHA86 UNISOM SLEEPGELS70 VIDEX EC39 VIVARIN2 UNISOM SLEEPTABS70 VIDEXPEDIATRIC39 VIVELLE-DOT66 URAMAXIN56 vigabatrin17 VIVITROL23 URAMAXIN GT56

Index 22 VOL-NATE86 XYLOCAINE- ZOLINZA33 VOL-PLUS87 MPF/EPINEPHRINE 73 zolmitriptan76 XYLOCAINE/EPINEPHRINE VOL-TAB RX87 73 ZOLOFT19 VOLTAREN50 XYNTHA69 zolpidem tartrate71 VONVENDI69 XYNTHA SOLOFUSE69 ZOMETA64 voriconazole25 XYREM93 ZOMIG76 VOSPIRE ER13 XYZAL26 ZOMIG ZMT76 VOTRIENT33 XYZAL ALLERGY 24HR26 ZONEGRAN17 VP-CH PLUS87 YASMIN 2845 zonisamide17 VP-CH-PNV87 YAZ45 ZOSTAVAX101 VP-GGR-B6 PRENATAL87 ZADITOR91 ZOSYN93 VP-HEME OB87 zafirlukast12 ZOVIRAX40,52 VP-HEME OB + DHA87 zaleplon71 ZUBSOLV7 VP-HEME ONE87 ZANAFLEX87 ZYBAN96 VP-PNV-DHA87 ZANTAC98 ZYFLO CR12 VRAYLAR35 ZANTAC 150 MAXIMUM ZYKADIA33 VYTONE51 STRENGTH98 ZYLOPRIM68 VYTORIN26 ZANTAC 7598 ZYMAXID90 VYVANSE1 ZARONTIN17 ZYPREXA36 WALGREENS GLUCOSE21 ZARXIO69 ZYPREXA RELPREVV36 warfarin sodium13 ZATEAN-CH87 ZYRTEC ALLERGY26 WELLBUTRIN SR18 ZATEAN-PN PLUS87 ZYRTEC CHILDRENS WELLBUTRIN XL18 ZEBETA41 ALLERGY26 ZELBORAF33 ZYRTEC-D WESTCORT56 ALLERGY/CONGESTION48 ZEMPLAR64 WESTHROID97 ZYTIGA32 ZENZEDI1 white petrolatum-mineral oil88 ZYVOX10 WIBI59 ZERIT39 WILATE69 ZESTORETIC30 WP THYROID97 ZESTRIL28 XALATAN91 ZETIA27 XALKORI33 ZIAC30 XANAX12 ZIAGEN39 XANAX XR12 zidovudine39 XARELTO13,14 zileuton12 XELODA32 ZINACEF43 XENAZINE94 zinc oxide (topical)60 XEROSTOMIA RELIEF zinc sulfate77 SPRAY80 ZINECARD33 XODOL7 ziprasidone hcl35 XOPENEX13 ZITHROMAX73 XOPENEX CONCENTRATE13 ZITHROMAX TRI-PAK73 XTANDI32 ZITHROMAX Z-PAK74 XULANE45 ZOCOR27 XURIDEN64 ZOFRAN24 XYLOCAINE73 ZOFRAN ODT24 XYLOCAINE-MPF73 zoledronic acid64

Index 23