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2021 Formulary (List of Covered Drugs) Oscar 2021 Formulary

What is the Oscar Formulary?

A formulary is a list of covered drugs selected by Oscar in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Oscar will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at an Oscar network pharmacy, and other plan rules are followed. This Formulary was updated as of 01/01/2021.

The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., BYSTOLIC) and generic drugs are listed in lower-case italics (e.g., carvedilol). There are two ways to find your drug within the formulary:

01 Medical Condition 02 Alphabetical Listing

The formulary begins on page 1. The If you are not sure what category to drugs in this formulary are grouped look under, you should look for your into categories depending on the type drug in the Index that begins on page of medical conditions that they are 89. The Index provides an alphabetical used to treat. For example, drugs used list of all of the drugs included in this to treat a heart condition are listed document. Both brand name drugs and under the category, Antiarrhythmics. generic drugs are listed in the Index. If you know what your drug is used for, Look in the Index and find your drug. look for the category name in the list Next to your drug, you will see the page that begins page 1. Then look under number where you can find coverage the category name for your drug. information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.

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What are generic drugs?

Oscar covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs.

Are there any restrictions on my coverage?

Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:

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

• Quantity Limits: For certain drugs, Oscar limits the amount of the drug being filled. For example Oscar may limit a drug to only 48 pills in a 1-month timeframe. These amounts will be listed in the formulary below if they are applicable to your medication.

• Step Therapy: In some cases, Oscar requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Oscar may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Oscar will then cover Drug B.

You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1.

What if my drug is not on the Formulary?

If your drug is not included in this formulary , you should first contact Concierge and ask if your drug is covered.

If you learn that Oscar does not cover your drug, you can ask Concierge for similar drugs that are covered by Oscar. Discuss these alternatives with your doctor and ask him or her to prescribe one of the alternatives that are covered by Oscar.

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How do I request an exception to the Oscar Formulary?

Your Doctor can ask Oscar to make an exception to our coverage rules.

Generally, Oscar will only approve your request for an exception if the alternative drugs included on the plan’s formulary, or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

Can the Formulary change?

Most changes in drug coverage happen on January 1, but during the year Oscar may add or remove drugs on the Drug List during the year, move them to different cost-sharing tiers, or add new restrictions. You can contact Concierge to find out if your drug is still covered, visit hioscar. com and log in to your plan specific account, or use the Oscar app drug search feature. Changes that can affect you this year: • New generic drugs. We may immediately remove a brand name drug on our Drug List if we are replacing it with a new generic drug that will appear on the same or lower cost sharing tier and with the same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand name drug on our Drug List, but immediately move it to a different cost-sharing tier or add new restrictions. If you are currently taking that brand name drug, we may not tell you in advance before we make that change, but we will later provide you with information about the specific change(s) we have made. If we make such a change, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. You can find information in the section above entitled “How do I request an exception to the Oscar Formulary?” • Drugs removed from the market. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug.

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For more information

For more detailed information about your Oscar prescription drug coverage, please visit www.hioscar.com or call Concierge at 1-855-OSCAR-88. You can also find your plan specific information on our Oscar app available through iTunes or Google Play.

Formulary Terminology

The formulary that begins on page 1 provides coverage information about the drugs covered by Oscar. If you have trouble finding your drug in the list, turn to the Index that begins on page 89.

The information in the Requirements/Limits column tells you if Oscar has any special requirements for coverage of your drug.

Abbreviation Term Description

Your Physician must get approval from Oscar to PA Prior Authorization cover this medication

Some drugs have a limit of how much you can fill at QL Quantity Limits a time

For some drugs you must first try certain drugs to ST Step Therapy treat your medical condition before we will cover another drug for that condition

Medications that can be purchased with1 or OTC Over-the-counter without a prescription from your Physician

Prior Authorization if A Prior authorization will be needed if you do not PA** Step Therapy is not meet the step therapy met

1 to be covered at the pharmacy a prescription from your doctor is required Learn more at hioscar.com EXCH_CVSC CA 4T STND eff 01/01/2021 Drug Name Drug Tier Requirements/Limits ANALGESICS - DRUGS TO TREAT PAIN AND INFLAMMATION COX-2 INHIBITORS celecoxib CAPS 50mg, 100mg, 200mg 1 GOUT - DRUGS TO TREAT GOUT allopurinol TABS 100mg, 300mg 1 colchicine TABS .6mg 1 colchicine w/ probenecid tab 0.5-500 mg 1 febuxostat TABS 40mg, 80mg 1 ST; PA** probenecid TABS 500mg 1 NON- ANALGESICS§ butalbital-acetaminophen-caffeine cap 50- 1 QL (48 caps / 25 days) 300-40 mg butalbital-acetaminophen-caffeine cap 50- 1 QL (48 caps / 25 days) 325-40 mg butalbital-acetaminophen-caffeine tab 50- 1 QL (48 tabs / 25 days) 325-40 mg butalbital-aspirin-caffeine cap 50-325-40 1 QL (48 caps / 25 days) mg tencon (Tencon) 1 QL (48 tabs / 25 days) NSAIDS, COMBINATIONS§ diclofenac w/ misoprostol tab delayed 1 release 50-0.2 mg diclofenac w/ misoprostol tab delayed 1 release 75-0.2 mg NSAIDS§ - DRUGS TO TREAT PAIN AND INFLAMMATION diclofenac potassium TABS 50mg 1 diclofenac sodium TB24 100mg; TBEC 1 25mg, 50mg, 75mg etodolac CAPS 200mg, 300mg; TABS 1 400mg, 500mg; TB24 400mg, 500mg, 600mg fenoprofen calcium TABS 600mg 3 flurbiprofen TABS 50mg, 100mg 1 ibuprofen SUSP 100mg/5ml; TABS 1 400mg, 600mg, 800mg ketoprofen CAPS 50mg, 75mg 1 ketorolac tromethamine SOLN 15mg/ml, 1 30mg/ml ketorolac tromethamine TABS 10mg 1 QL (20 tabs / 25 days) meclofenamate sodium CAPS 50mg, 1 100mg mefenamic acid CAPS 250mg 1 meloxicam TABS 7.5mg, 15mg 1 nabumetone TABS 500mg, 750mg 1

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 1 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits naproxen TABS 250mg, 375mg, 500mg 1 oxaprozin TABS 600mg 1 piroxicam CAPS 10mg, 20mg 1 sulindac TABS 150mg, 200mg 1 tolmetin sodium CAPS 400mg; TABS 1 600mg OPIOID AGONIST/ANTAGONIST§ buprenorphine hcl-naloxone hcl sl film 2- 1 QL (90 units / 25 days) 0.5 mg (base equiv) buprenorphine hcl-naloxone hcl sl film 4-1 1 QL (90 units / 25 days) mg (base equiv) buprenorphine hcl-naloxone hcl sl film 8-2 1 QL (90 units / 25 days) mg (base equiv) buprenorphine hcl-naloxone hcl sl film 12-3 1 QL (60 units / 25 days) mg (base equiv) buprenorphine hcl-naloxone hcl sl tab 2- PV QL (90 tabs / 25 days); 0.5 mg (base equiv) $0 copay buprenorphine hcl-naloxone hcl sl tab 8-2 PV QL (90 tabs / 25 days); mg (base equiv) $0 copay ZUBSOLV SUB 0.7-0.18 (buprenorphine 2 QL (90 units / 25 days) hcl-naloxone hcl dihydrate) ZUBSOLV SUB 1.4-0.36 (buprenorphine 2 QL (90 units / 25 days) hcl-naloxone hcl dihydrate) ZUBSOLV SUB 2.9-0.71 (buprenorphine 2 QL (90 units / 25 days) hcl-naloxone hcl dihydrate) ZUBSOLV SUB 5.7-1.4 (buprenorphine hcl- 2 QL (90 units / 25 days) naloxone hcl dihydrate) ZUBSOLV SUB 8.6-2.1 (buprenorphine hcl- 2 QL (60 units / 25 days) naloxone hcl dihydrate) ZUBSOLV SUB 11.4-2.9 (buprenorphine 2 QL (30 units / 25 days) hcl-naloxone hcl dihydrate) OPIOID ANALGESICS§ - DRUGS TO TREAT PAIN acetaminophen w/ soln 120-12 1 QL (2700 ml / 25 days), mg/5ml ST; Subject to initial 7- day limit acetaminophen w/ codeine tab 300-15 mg 1 QL (400 tabs / 25 days), ST; Subject to initial 7- day limit acetaminophen w/ codeine tab 300-30 mg 1 QL (360 tabs / 25 days), ST; Subject to initial 7- day limit acetaminophen w/ codeine tab 300-60 mg 1 QL (180 tabs / 25 days), ST; Subject to initial 7- day limit butalbital-acetaminophen-caff w/ cod cap 1 QL (48 caps / 25 days) 50-300-40-30 mg

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 2 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits butorphanol tartrate SOLN 1mg/ml, 1 2mg/ml butorphanol tartrate SOLN 10mg/ml 1 QL (2 bottles / 25 days) codeine sulfate TABS 30mg 1 QL (42 tabs / 25 days), ST; Subject to initial 7- day limit CODEINE SULFATE TABS 60mg 3 QL (42 tabs / 25 days), ST; Subject to initial 7- day limit endocet (Endocet) 1 QL (180 tabs / 25 days), ST; Subject to initial 7- day limit endocet (Endocet) 1 QL (240 tabs / 25 days), ST; Subject to initial 7- day limit endocet (Endocet) 1 QL (360 tabs / 25 days), ST; Subject to initial 7- day limit fentanyl PT72 12mcg/hr, 25mcg/hr 1 QL (10 patches / 25 days), ST fentanyl PT72 50mcg/hr, 75mcg/hr, 1 PA, ST; High Strength 100mcg/hr Requires PA fentanyl citrate LPOP 200mcg, 400mcg, 1 QL (120 lozenges / 25 600mcg, 800mcg, 1200mcg, 1600mcg days), PA hydrocodone-acetaminophen soln 7.5-325 1 QL (2700 ml / 25 days), mg/15ml ST; Subject to initial 7- day limit hydrocodone-acetaminophen tab 5-325 mg 1 QL (240 tabs / 25 days), ST; Subject to initial 7- day limit hydrocodone-acetaminophen tab 7.5-325 1 QL (180 tabs / 25 days), mg ST; Subject to initial 7- day limit hydrocodone-acetaminophen tab 10-325 1 QL (180 tabs / 25 days), mg ST; Subject to initial 7- day limit hydrocodone-ibuprofen tab 10-200 mg 1 QL (50 tabs / 25 days), ST; Subject to initial 7- day limit hydromorphone hcl SOLN 2mg/ml 1 HYDROMORPHONE HCL SUPP 3mg 3 QL (120 suppositories / 25 days), ST; Subject to initial 7-day limit hydromorphone hcl T24A 8mg, 12mg, 1 QL (30 tabs / 25 days), 16mg ST hydromorphone hcl T24A 32mg 1 PA, ST; High Strength Requires PA

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 3 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits hydromorphone hcl TABS 2mg 1 QL (180 tabs / 25 days), ST; Subject to initial 7- day limit hydromorphone hcl TABS 4mg 1 QL (150 tabs / 25 days), ST; Subject to initial 7- day limit hydromorphone hcl TABS 8mg 1 QL (60 tabs / 25 days), ST; Subject to initial 7- day limit methadone hcl CONC 10mg/ml 1 QL (30 ml / 25 days); (indicated for opioid addiction) methadone hcl SOLN 5mg/5ml 1 QL (450 ml / 25 days), ST methadone hcl SOLN 10mg/5ml 1 QL (300 mL / 25 days), ST methadone hcl TABS 5mg 1 QL (90 tabs / 25 days), ST methadone hcl TABS 10mg 1 QL (60 tabs / 25 days), ST methadone hcl TBSO 40mg 1 QL (9 tabs / 25 days) methadone hcl intensol CONC 10mg/ml 1 QL (60 mL / 25 days), (Methadone Hcl Intensol) ST; (generic of Methadone Intensol, indicated for pain) methadose TBSO 40mg (Methadose) 1 QL (9 tabs / 25 days) sulfate CP24 10mg, 20mg, 1 QL (60 caps / 25 days), 30mg ST morphine sulfate CP24 50mg, 60mg, 1 QL (30 caps / 25 days), 80mg ST morphine sulfate CP24 100mg; TBCR 1 PA, ST; High Strength 60mg, 100mg, 200mg Requires PA morphine sulfate SOLN 4mg/ml, 10mg/ml 1 morphine sulfate SOLN 10mg/5ml 1 QL (900 ml / 25 days), ST; Subject to initial 7- day limit morphine sulfate SOLN 20mg/5ml 1 QL (675 mL / 25 days), ST; Subject to initial 7- day limit morphine sulfate SOLN 100mg/5ml 1 QL (135 mL / 25 days), ST; Subject to initial 7- day limit morphine sulfate SUPP 5mg, 10mg 1 QL (180 suppositories / 25 days), ST; Subject to initial 7-day limit morphine sulfate SUPP 20mg 1 QL (120 supp / 25 days), ST; Subject to initial 7-day limit

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 4 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits morphine sulfate SUPP 30mg 1 QL (90 supp / 25 days), ST; Subject to initial 7- day limit morphine sulfate TABS 15mg 1 QL (180 tabs / 25 days), ST; Subject to initial 7- day limit morphine sulfate TABS 30mg 1 QL (90 tabs / 25 days), ST; Subject to initial 7- day limit morphine sulfate TBCR 15mg, 30mg 1 QL (90 tabs / 25 days), ST morphine sulfate beads CP24 30mg, 1 QL (30 caps / 25 days), 45mg, 60mg, 75mg, 90mg ST morphine sulfate beads CP24 120mg 1 PA, ST; High Strength Requires PA nalbuphine hcl SOLN 10mg/ml, 20mg/ml 1 NUCYNTA TABS 50mg (tapentadol hcl) 2 QL (120 tabs / 25 days), ST; Subject to initial 7- day limit NUCYNTA TABS 75mg (tapentadol hcl) 2 QL (90 tabs / 25 days), ST; Subject to initial 7- day limit NUCYNTA TABS 100mg (tapentadol hcl) 2 QL (60 tabs / 25 days), ST; Subject to initial 7- day limit NUCYNTA ER TB12 50mg, 100mg 3 QL (60 tabs / 25 days), (tapentadol hcl) ST NUCYNTA ER TB12 150mg, 200mg, 3 PA, ST; High Strength 250mg (tapentadol hcl) Requires PA oxycodone hcl CAPS 5mg 1 QL (180 caps / 25 days), ST; Subject to initial 7-day limit oxycodone hcl CONC 100mg/5ml 1 QL (90 mL / 25 days), ST; Subject to initial 7- day limit oxycodone hcl SOLN 5mg/5ml 1 QL (900 ml / 25 days), ST; Subject to initial 7- day limit oxycodone hcl T12A 10mg, 15mg, 20mg, 1 QL (60 tabs / 25 days), 30mg ST oxycodone hcl T12A 40mg, 60mg, 80mg 1 PA, ST; High Strength Requires PA oxycodone hcl TABS 5mg, 10mg 1 QL (180 tabs / 25 days), ST; Subject to initial 7- day limit oxycodone hcl TABS 15mg 1 QL (120 tabs / 25 days), ST; Subject to initial 7- day limit

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 5 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits oxycodone hcl TABS 20mg 1 QL (90 tabs / 25 days), ST; Subject to initial 7- day limit oxycodone hcl TABS 30mg 1 QL (60 tabs / 25 days), ST; Subject to initial 7- day limit oxycodone w/ acetaminophen tab 2.5-325 1 QL (360 tabs / 25 days), mg ST; Subject to initial 7- day limit oxycodone w/ acetaminophen tab 5-325 1 QL (360 tabs / 25 days), mg ST; Subject to initial 7- day limit oxycodone w/ acetaminophen tab 7.5-325 1 QL (240 tabs / 25 days), mg ST; Subject to initial 7- day limit oxycodone w/ acetaminophen tab 10-325 1 QL (180 tabs / 25 days), mg ST; Subject to initial 7- day limit oxycodone-aspirin tab 4.8355-325 mg 1 QL (360 tabs / 25 days), ST; Subject to initial 7- day limit oxycodone-ibuprofen tab 5-400 mg 1 QL (28 tabs / 25 days), ST; Subject to initial 7- day limit oxymorphone hcl TABS 5mg 1 QL (180 tabs / 25 days), ST; Subject to initial 7- day limit oxymorphone hcl TABS 10mg 1 QL (90 tabs / 25 days), ST; Subject to initial 7- day limit oxymorphone hcl TB12 5mg, 7.5mg, 1 QL (60 tabs / 25 days), 10mg, 15mg ST oxymorphone hcl TB12 20mg, 30mg, 1 PA, ST; High Strength 40mg Requires PA tramadol hcl TABS 50mg 1 QL (180 tabs / 25 days), ST; Subject to initial 7- day limit tramadol hcl TB24 100mg 1 QL (30 tabs / 25 days), ST tramadol hcl TB24 200mg, 300mg 1 PA, ST; High Strength Requires PA tramadol-acetaminophen tab 37.5-325 mg 1 QL (40 tabs / 25 days), ST; Subject to initial 7- day limit XTAMPZA ER C12A 9mg, 13.5mg, 18mg, 2 QL (60 caps / 25 days), 27mg (oxycodone) ST XTAMPZA ER C12A 36mg (oxycodone) 2 PA, ST; High Strength Requires Prior Auth

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 6 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits OPIOID PARTIAL AGONISTS§ BELBUCA FILM 75mcg, 150mcg, 300mcg, 2 QL (60 films / 25 days), 450mcg (buprenorphine hcl) ST BELBUCA FILM 600mcg, 750mcg, 900mcg 2 PA, ST; High Strength (buprenorphine hcl) Requires Prior Auth buprenorphine PTWK 5mcg/hr, 7.5mcg/hr, 1 QL (4 patches / 25 10mcg/hr days), ST buprenorphine PTWK 15mcg/hr, 20mcg/hr 1 PA, ST; High Strength Requires Prior Auth buprenorphine hcl SOLN .3mg/ml 1 buprenorphine hcl SUBL 2mg, 8mg PV QL (90 tabs / 25 days); $0 copay; Must obtain approval after the first 30 day supply SUBLOCADE SOSY 100mg/0.5ml, 4 300mg/1.5ml (buprenorphine) SALICYLATES aspirin enteric coated ad TBEC 81mg PV OTC, QL (100 tabs / 30 (Aspirin Enteric Coated Ad) days); $0 copay for members age 50-59 or members at risk for preeclampsia, otherwise not covered diflunisal TABS 500mg 1 goodsense aspirin CHEW 81mg PV OTC, QL (100 tabs / 30 (Goodsense Aspirin) days); $0 copay for members age 50-59 or members at risk for preeclampsia, otherwise not covered ANESTHETICS - DRUGS FOR NUMBING LOCAL ANESTHETICS - DRUGS FOR NUMBING lidocaine hcl (local anesth.) SOLN .5%, 1 1%, 2% ANTI-INFECTIVES - DRUGS TO TREAT ANTI-BACTERIALS - MISCELLANEOUS amikacin sulfate SOLN 1gm/4ml, 1 500mg/2ml gentamicin sulfate SOLN 40mg/ml 1 MONUROL PACK 5.631gm (fosfomycin 3 tromethamine) sulfate TABS 500mg 1 sulfate CAPS 250mg 1 SULFADIAZINE TABS 500mg 3 tinidazole TABS 250mg, 500mg 1

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 7 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits tobramycin NEBU 300mg/5ml 4 QL (280 mL / 28 days), PA tobramycin sulfate SOLN 40mg/ml, 1 80mg/2ml; SOLR 1.2gm ANTI-INFECTIVES - MISCELLANEOUS ALINIA SUSR 100mg/5ml (nitazoxanide) 3 QL (540mL / 25 days) ALINIA TABS 500mg (nitazoxanide) 3 QL (20 tabs / 25 days) atovaquone SUSP 750mg/5ml 1 aztreonam SOLR 1gm, 2gm 1 CAYSTON SOLR 75mg (aztreonam lysine) 4 QL (84 vials / 28 days), PA clindamycin hcl CAPS 75mg, 150mg, 1 300mg clindamycin palmitate hydrochloride SOLR 1 75mg/5ml clindamycin phosphate SOLN 9gm/60ml, 1 300mg/2ml, 600mg/4ml, 9000mg/60ml dapsone TABS 25mg, 100mg 1 DARAPRIM TABS 25mg () 3 PA EMVERM CHEW 100mg (mebendazole) 3 QL (12 tabs / 365 days) ertapenem sodium SOLR 1gm 1 ivermectin TABS 3mg 1 linezolid SOLN 600mg/300ml; SUSR 1 100mg/5ml; TABS 600mg linezolid in sodium chloride iv soln 600 1 mg/300ml-0.9% meropenem SOLR 1gm, 500mg 1 methenamine hippurate TABS 1gm 1 metronidazole CAPS 375mg; TABS 1 250mg, 500mg metronidazole in nacl 0.79% iv soln 500 1 mg/100ml nitrofurantoin SUSP 25mg/5ml 1 PA; High Risk Medications require PA for members age 70 and older nitrofurantoin macrocrystal CAPS 25mg, 1 PA; High Risk 50mg, 100mg Medications require PA for members age 70 and older nitrofurantoin monohyd macro CAPS 1 PA; High Risk 100mg Medications require PA for members age 70 and older pentamidine isethionate SOLR 300mg 1 sulfate SOLR 500000unit 1 praziquantel TABS 600mg 1 QL (24 tabs / 365 days)

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 8 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits PRIMSOL SOLN 50mg/5ml (trimethoprim 2 hcl) sulfamethoxazole-trimethoprim susp 200- 1 40 mg/5ml sulfamethoxazole-trimethoprim tab 400-80 1 mg sulfamethoxazole-trimethoprim tab 800- 1 160 mg trimethoprim TABS 100mg 1 hcl CAPS 125mg, 250mg 1 QL (80 caps / 10 days) vancomycin hcl SOLR 1gm, 5gm, 10gm, 1 500mg, 750mg XIFAXAN TABS 200mg () 2 QL (9 tabs / 25 days) XIFAXAN TABS 550mg (rifaximin) 2 PA ANTIFUNGALS - DRUGS TO TREAT FUNGAL INFECTIONS SOLR 50mg 1 bio-statin (Bio-statin) 1 BIO-STATIN CAPS 500000unit, 2 1000000unit () CRESEMBA CAPS 186mg 3 (isavuconazonium sulfate) fluconazole SUSR 10mg/ml, 40mg/ml; 1 TABS 50mg, 100mg, 150mg, 200mg griseofulvin microsize SUSP 125mg/5ml; 1 TABS 500mg griseofulvin ultramicrosize TABS 125mg, 1 250mg itraconazole CAPS 100mg; SOLN 10mg/ml 1 PA NOXAFIL SUSP 40mg/ml (posaconazole) 2 PA nystatin TABS 500000unit 1 posaconazole TBEC 100mg 3 PA terbinafine hcl TABS 250mg 1 voriconazole SUSR 40mg/ml; TABS 50mg, 2 PA 200mg ANTIMALARIALS - DRUGS TO TREAT MALARIA atovaquone-proguanil hcl tab 62.5-25 mg 1 atovaquone-proguanil hcl tab 250-100 mg 1 chloroquine phosphate TABS 250mg, 1 500mg COARTEM TAB 20-120MG (artemether- 3 lumefantrine) mefloquine hcl TABS 250mg 1 primaquine phosphate TABS 26.3mg 1 quinine sulfate CAPS 324mg 1

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 9 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits ANTIRETROVIRAL AGENTS - DRUGS TO SUPPRESS HIV/AIDS abacavir sulfate SOLN 20mg/ml 1 QL (900 mL / 30 days) abacavir sulfate TABS 300mg 1 QL (60 tabs / 30 days) APTIVUS CAPS 250mg (tipranavir) 2 QL (120 caps / 30 days) APTIVUS SOLN 100mg/ml (tipranavir) 2 QL (285 mL / 28 days) atazanavir sulfate CAPS 150mg, 300mg 1 QL (30 caps / 30 days) atazanavir sulfate CAPS 200mg 1 QL (60 caps / 30 days) CRIXIVAN CAPS 200mg (indinavir sulfate) 2 QL (450 caps / 30 days) CRIXIVAN CAPS 400mg (indinavir sulfate) 2 QL (180 caps / 30 days) didanosine CPDR 200mg, 250mg, 400mg 1 QL (30 caps / 30 days) EDURANT TABS 25mg (rilpivirine hcl) 2 QL (60 tabs / 30 days) efavirenz CAPS 50mg, 200mg 1 QL (90 caps / 30 days) efavirenz TABS 600mg 1 QL (30 tabs / 30 days) EMTRIVA CAPS 200mg (emtricitabine) 2 QL (30 caps / 30 days) EMTRIVA SOLN 10mg/ml (emtricitabine) 2 QL (680 ml / 28 days) fosamprenavir calcium TABS 700mg 1 QL (120 tabs / 30 days) FUZEON SOLR 90mg (enfuvirtide) 4 QL (60 vials / 30 days), PA INTELENCE TABS 25mg, 100mg 2 QL (120 tabs / 30 days) (etravirine) INTELENCE TABS 200mg (etravirine) 2 QL (60 tabs / 30 days) INVIRASE TABS 500mg (saquinavir 2 QL (120 tabs / 30 days) mesylate) ISENTRESS CHEW 25mg, 100mg 2 QL (180 tabs / 30 days) (raltegravir potassium) ISENTRESS PACK 100mg (raltegravir 2 QL (60 packets / 30 potassium) days) ISENTRESS TABS 400mg (raltegravir 2 QL (120 tabs / 30 days) potassium) ISENTRESS HD TABS 600mg (raltegravir 2 QL (60 tabs / 30 days) potassium) lamivudine SOLN 10mg/ml 1 QL (900 ml / 30 days) lamivudine TABS 150mg 1 QL (60 tabs / 30 days) lamivudine TABS 300mg 1 QL (30 tabs / 30 days) LEXIVA SUSP 50mg/ml (fosamprenavir 2 QL (1575 mL / 28 days) calcium) nevirapine SUSP 50mg/5ml 1 QL (1200 mL / 30 days) nevirapine TABS 200mg 1 QL (60 tabs / 30 days) nevirapine TB24 100mg 1 QL (90 tabs / 30 days) nevirapine TB24 400mg 1 QL (30 tabs / 30 days) NORVIR PACK 100mg (ritonavir) 2 QL (360 packets / 30 days) NORVIR SOLN 80mg/ml (ritonavir) 2 QL (480 mL / 30 days) PREZISTA SUSP 100mg/ml (darunavir 2 QL (400 ml / 30 days) ethanolate)

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 10 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits PREZISTA TABS 75mg (darunavir 2 QL (300 tabs / 30 days) ethanolate) PREZISTA TABS 150mg (darunavir 2 QL (180 tabs / 30 days) ethanolate) PREZISTA TABS 600mg (darunavir 2 QL (60 tabs / 30 days) ethanolate) PREZISTA TABS 800mg (darunavir 2 QL (30 tabs / 30 days) ethanolate) RETROVIR IV INFUSION SOLN 10mg/ml 2 (zidovudine) REYATAZ PACK 50mg (atazanavir sulfate) 2 QL (180 packets / 30 days) ritonavir TABS 100mg 1 QL (360 tabs / 30 days) SELZENTRY SOLN 20mg/ml (maraviroc) 2 QL (1840 mL / 30 days) SELZENTRY TABS 25mg (maraviroc) 2 QL (240 tabs / 30 days) SELZENTRY TABS 75mg, 150mg 2 QL (60 tabs / 30 days) (maraviroc) SELZENTRY TABS 300mg (maraviroc) 2 QL (120 tabs / 30 days) stavudine CAPS 15mg, 20mg, 30mg, 1 QL (60 caps / 30 days) 40mg tenofovir disoproxil fumarate TABS 300mg 1 QL (30 tabs / 30 days) TIVICAY TABS 10mg, 25mg, 50mg 2 QL (60 tabs / 30 days) (dolutegravir sodium) TROGARZO SOLN 200mg/1.33ml 4 (ibalizumab-uiyk) TYBOST TABS 150mg (cobicistat) 2 QL (30 tabs / 30 days) VIDEX EC CPDR 125mg (didanosine) 2 QL (30 caps / 30 days) VIDEX PEDIATRIC SOLR 2gm (didanosine) 2 QL (1200 ml / 30 days) VIRACEPT TABS 250mg (nelfinavir 2 QL (300 tabs / 30 days) mesylate) VIRACEPT TABS 625mg (nelfinavir 2 QL (120 tabs / 30 days) mesylate) VIREAD POWD 40mg/gm (tenofovir 2 QL (240 gm / 30 days) disoproxil fumarate) VIREAD TABS 150mg, 200mg, 250mg 2 QL (30 tabs / 30 days) (tenofovir disoproxil fumarate) zidovudine CAPS 100mg 1 QL (180 caps / 30 days) zidovudine SYRP 50mg/5ml 1 QL (1800 ml / 30 days) zidovudine TABS 300mg 1 QL (60 tabs / 30 days) ANTIRETROVIRAL COMBINATION AGENTS - DRUGS TO SUPPRESS HIV/AIDS INFECTION abacavir sulfate-lamivudine tab 600-300 1 QL (30 tabs / 30 days) mg abacavir sulfate-lamivudine-zidovudine tab 1 QL (60 tabs / 30 days) 300-150-300 mg

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 11 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits BIKTARVY TAB (bictegravir-emtricitabine- 2 QL (30 tabs / 30 days) tenofovir alafenamide fumarate) CIMDUO TAB 300-300 (lamivudine- 2 QL (30 tabs / 30 days) tenofovir disoproxil fumarate) DESCOVY TAB 200/25 (emtricitabine- 2 QL (30 tabs / 30 days) tenofovir alafenamide fumarate) DOVATO TAB 50-300MG (dolutegravir 2 QL (30 tabs / 30 days) sodium-lamivudine) EVOTAZ TAB 300-150 (atazanavir sulfate- 2 QL (30 tabs / 30 days) cobicistat) GENVOYA TAB (elvitegravir-cobicistat- 2 QL (30 tabs / 30 days) emtricitabine-tenofovir alafenamide) KALETRA TAB 100-25MG (lopinavir- 2 QL (240 tabs / 30 days) ritonavir) KALETRA TAB 200-50MG (lopinavir- 2 QL (120 tabs / 30 days) ritonavir) lamivudine-zidovudine tab 150-300 mg 1 QL (60 tabs / 30 days) lopinavir-ritonavir soln 400-100 mg/5ml 1 QL (390 mL / 30 days) (80-20 mg/ml) ODEFSEY TAB (emtricitabine-rilpivirine- 2 QL (30 tabs / 30 days) tenofovir alafenamide fumarate) PREZCOBIX TAB 800-150 (darunavir- 2 QL (30 tabs / 30 days) cobicistat) SYMFI LO TAB (efavirenz-lamivudine- 2 QL (30 tabs / 30 days) tenofovir disoproxil fumarate) SYMFI TAB (efavirenz-lamivudine-tenofovir 2 QL (30 tabs / 30 days) disoproxil fumarate) TEMIXYS TAB 300-300 (lamivudine- 2 QL (30 tabs / 30 days) tenofovir disoproxil fumarate) TRIUMEQ TAB (abacavir-dolutegravir- 2 QL (30 tabs / 30 days) lamivudine) TRUVADA TAB 100-150 (emtricitabine- 2 QL (30 tabs / 30 days) tenofovir disoproxil fumarate) TRUVADA TAB 133-200 (emtricitabine- 2 QL (30 tabs / 30 days) tenofovir disoproxil fumarate) TRUVADA TAB 167-250 (emtricitabine- 2 QL (30 tabs / 30 days) tenofovir disoproxil fumarate) TRUVADA TAB 200-300 (emtricitabine- PV QL (30 tabs / 30 days), tenofovir disoproxil fumarate) ST; PA**; $0 copay; coverage for pre and post-exposure prophylaxis only ANTITUBERCULAR AGENTS - DRUGS TO TREAT TUBERCULOSIS cycloserine CAPS 250mg 1 ethambutol hcl TABS 100mg, 400mg 1 isoniazid SOLN 100mg/ml; SYRP 1 50mg/5ml; TABS 100mg, 300mg

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 12 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits PASER PACK 4gm (aminosalicylic acid) 3 PRIFTIN TABS 150mg (rifapentine) 2 pyrazinamide TABS 500mg 1 rifabutin CAPS 150mg 1 RIFAMATE CAP (isoniazid & rifampin) 2 rifampin CAPS 150mg, 300mg; SOLR 1 600mg RIFATER TAB (isoniazid-rifampin w/ 2 pyrazinamide) SIRTURO TABS 100mg (bedaquiline 4 PA fumarate) TRECATOR TABS 250mg (ethionamide) 2 ANTIVIRALS§ - DRUGS TO TREAT VIRAL INFECTIONS acyclovir CAPS 200mg; SUSP 200mg/5ml; 1 TABS 400mg, 800mg adefovir dipivoxil TABS 10mg 4 BARACLUDE SOLN .05mg/ml (entecavir) 3 cidofovir SOLN 75mg/ml 1 entecavir TABS .5mg, 1mg 4 EPIVIR HBV SOLN 5mg/ml (lamivudine 2 (hbv)) famciclovir TABS 125mg, 250mg, 500mg 1 lamivudine (hbv) TABS 100mg 1 oseltamivir phosphate CAPS 30mg 1 QL (40 caps / 90 days) oseltamivir phosphate CAPS 45mg, 75mg 1 QL (20 caps / 90 days) oseltamivir phosphate SUSR 6mg/ml 1 QL (360 mL / 90 days) RELENZA DISKHALER AEPB 5mg/blister 2 QL (2 inhalers / 90 () days) ribavirin SOLR 6gm 1 rimantadine hydrochloride TABS 100mg 1 valacyclovir hcl TABS 500mg, 1000mg 1 valganciclovir hcl SOLR 50mg/ml 4 QL (1000 mL / 30 days), PA valganciclovir hcl TABS 450mg 4 QL (102 tabs / 30 days), PA CEPHALOSPORINS - DRUGS TO TREAT INFECTIONS cefaclor CAPS 250mg, 500mg; SUSR 1 125mg/5ml, 250mg/5ml, 375mg/5ml cefadroxil CAPS 500mg; SUSR 1 250mg/5ml, 500mg/5ml; TABS 1gm cefazolin sodium SOLR 1gm 1 cefdinir CAPS 300mg; SUSR 125mg/5ml, 1 250mg/5ml cefditoren pivoxil TABS 200mg, 400mg 1 cefepime hcl SOLR 1gm, 2gm 1

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 13 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits cefixime CAPS 400mg; SUSR 100mg/5ml, 1 200mg/5ml cefpodoxime proxetil SUSR 50mg/5ml, 1 100mg/5ml; TABS 100mg, 200mg cefprozil SUSR 125mg/5ml, 250mg/5ml; 1 TABS 250mg, 500mg ceftazidime SOLR 2gm 1 ceftriaxone sodium SOLR 1gm, 2gm, 1 10gm, 250mg, 500mg cefuroxime axetil TABS 250mg, 500mg 1 cephalexin CAPS 250mg, 500mg, 750mg; 1 SUSR 125mg/5ml, 250mg/5ml; TABS 250mg, 500mg SUPRAX CHEW 100mg, 200mg; SUSR 2 500mg/5ml (cefixime) tazicef SOLR 1gm (Tazicef) 1 ERYTHROMYCINS/MACROLIDES - DRUGS TO TREAT INFECTIONS azithromycin PACK 1gm; SUSR 1 100mg/5ml, 200mg/5ml; TABS 250mg, 500mg, 600mg clarithromycin SUSR 125mg/5ml, 1 250mg/5ml; TABS 250mg, 500mg; TB24 500mg DIFICID TABS 200mg () 2 PA e.e.s. 400 TABS 400mg (E.e.s. 400) 1 ery-tab TBEC 250mg, 333mg, 500mg 1 (Ery-tab) erythrocin stearate TABS 250mg 1 (Erythrocin Stearate) erythromycin base CPEP 250mg; TABS 1 250mg, 500mg erythromycin ethylsuccinate SUSR 1 200mg/5ml, 400mg/5ml; TABS 400mg FLUOROQUINOLONES - DRUGS TO TREAT INFECTIONS CIPRO SUSR 500mg/5ml (ciprofloxacin) 3 ciprofloxacin hcl TABS 100mg, 250mg, 1 500mg, 750mg levofloxacin SOLN 25mg/ml; TABS 1 250mg, 500mg, 750mg moxifloxacin hcl TABS 400mg 1 ofloxacin TABS 300mg, 400mg 1 HEPATITIS C EPCLUSA TAB 400-100 (sofosbuvir- 4 QL (28 tabs / 28 days), velpatasvir) PA HARVONI PAK (ledipasvir-sofosbuvir) 4 QL (28 pellets / 28 days), PA

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 14 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits HARVONI PAK 45-200MG (ledipasvir- 4 QL (28 pellets / 28 sofosbuvir) days), PA HARVONI TAB 45-200MG (ledipasvir- 4 QL (28 tabs / 28 days), sofosbuvir) PA HARVONI TAB 90-400MG (ledipasvir- 4 QL (28 tabs / 28 days), sofosbuvir) PA PEGASYS SOLN 180mcg/0.5ml, 4 PA 180mcg/ml (peginterferon alfa-2a) ribavirin (hepatitis c) CAPS 200mg; TABS 1 PA 200mg SOVALDI PACK 150mg, 200mg 4 QL (28 pellets / 28 (sofosbuvir) days), PA, ST SOVALDI TABS 200mg, 400mg 4 QL (28 tabs / 28 days), (sofosbuvir) PA, ST VOSEVI TAB (sofosbuvir-velpatasvir- 4 QL (28 tabs / 28 days), voxilaprevir) PA PENICILLINS - DRUGS TO TREAT INFECTIONS amoxicillin CAPS 250mg, 500mg; CHEW 1 125mg, 250mg; SUSR 125mg/5ml, 200mg/5ml, 250mg/5ml, 400mg/5ml; TABS 500mg, 875mg amoxicillin & k clavulanate chew tab 200- 1 28.5 mg amoxicillin & k clavulanate chew tab 400- 1 57 mg amoxicillin & k clavulanate for susp 200- 1 28.5 mg/5ml amoxicillin & k clavulanate for susp 250- 1 62.5 mg/5ml amoxicillin & k clavulanate for susp 400-57 1 mg/5ml amoxicillin & k clavulanate for susp 600- 1 42.9 mg/5ml amoxicillin & k clavulanate tab 250-125 mg 1 amoxicillin & k clavulanate tab 500-125 mg 1 amoxicillin & k clavulanate tab 875-125 mg 1 amoxicillin & k clavulanate tab er 12hr 1 1000-62.5 mg ampicillin CAPS 500mg 1 ampicillin sodium SOLR 1gm, 2gm 1 dicloxacillin sodium CAPS 250mg, 500mg 1 penicillin g potassium SOLR 5000000unit, 1 20000000unit penicillin g sodium SOLR 5000000unit 1 penicillin v potassium SOLR 125mg/5ml, 1 250mg/5ml; TABS 250mg, 500mg pfizerpen SOLR 20mu (Pfizerpen) 1

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 15 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits piperacillin sod-tazobactam na for inj 3.375 1 gm (3-0.375 gm) piperacillin sod-tazobactam sod for inj 2.25 1 gm (2-0.25 gm) piperacillin sod-tazobactam sod for inj 40.5 1 gm (36-4.5 gm) TETRACYCLINES - DRUGS TO TREAT INFECTIONS avidoxy TABS 100mg (Avidoxy) 1 demeclocycline hcl TABS 150mg, 300mg 1 doxy 100 SOLR 100mg (Doxy 100) 1 doxycycline (monohydrate) CAPS 50mg, 1 100mg; SUSR 25mg/5ml; TABS 50mg, 75mg, 150mg doxycycline hyclate CAPS 50mg, 100mg; 1 SOLR 100mg; TABS 20mg, 100mg; TBEC 75mg, 100mg, 150mg minocycline hcl CAPS 50mg, 75mg, 1 100mg; TABS 50mg, 75mg, 100mg morgidox 1x100mg CAPS 100mg 1 (Morgidox 1x100mg) tetracycline hcl CAPS 250mg, 500mg 1 VIBRAMYCIN SYRP 50mg/5ml (doxycycline 3 calcium) ANTINEOPLASTIC AGENTS - DRUGS TO TREAT CANCER ALKYLATING AGENTS - CHEMOTHERAPY DRUGS busulfan SOLN 6mg/ml 1 carmustine SOLR 100mg 1 cyclophosphamide CAPS 25mg, 50mg 1 OAC cyclophosphamide SOLR 1gm, 2gm, 4 500mg dacarbazine SOLR 100mg, 200mg 1 EMCYT CAPS 140mg (estramustine 4 OAC phosphate sodium) GLEOSTINE CAPS 10mg, 40mg, 100mg 4 OAC (lomustine) GLIADEL WAF 7.7MG (carmustine in 2 polifeprosan) ifosfamide SOLN 1gm/20ml, 3gm/60ml; 1 SOLR 1gm LEUKERAN TABS 2mg (chlorambucil) 2 OAC melphalan TABS 2mg 1 OAC melphalan hcl SOLR 50mg 1 TEMODAR SOLR 100mg (temozolomide) 4 PA temozolomide CAPS 5mg, 20mg, 100mg, 4 PA; OAC 140mg, 180mg, 250mg

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 16 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits ANTHRACYCLINES daunorubicin hcl SOLN 20mg/4ml 1 doxorubicin hcl SOLN 2mg/ml 1 doxorubicin hcl SOLR 10mg, 50mg 1 (Adriamycin) doxorubicin hcl liposomal INJ 2mg/ml 1 epirubicin hcl SOLN 50mg/25ml, 1 200mg/100ml idarubicin hcl SOLN 5mg/5ml, 10mg/10ml, 1 20mg/20ml bleomycin sulfate SOLR 15unit, 30unit 1 mitomycin SOLR 5mg, 20mg, 40mg 1 ANTIMETABOLITES - CHEMOTHERAPY DRUGS adrucil SOLN 500mg/10ml (Adrucil) 1 ALIMTA SOLR 100mg, 500mg 4 (pemetrexed disodium) azacitidine SUSR 100mg 4 PA capecitabine TABS 150mg 4 QL (120 tabs / 30 days), PA; OAC capecitabine TABS 500mg 4 QL (300 tabs / 30 days), PA; OAC cladribine SOLN 10mg/10ml 1 clofarabine SOLN 1mg/ml 1 cytarabine SOLN 20mg/ml, 100mg/ml 1 decitabine SOLR 50mg 4 PA floxuridine SOLR .5gm 1 fludarabine phosphate SOLN 50mg/2ml; 1 SOLR 50mg fluorouracil SOLN 1gm/20ml, 2.5gm/50ml, 1 5gm/100ml, 500mg/10ml gemcitabine hcl SOLN 1gm/26.3ml, 4 2gm/52.6ml, 200mg/5.26ml; SOLR 1gm, 2gm, 200mg mercaptopurine TABS 50mg 1 OAC methotrexate sodium SOLN 1gm/40ml, 1 50mg/2ml, 250mg/10ml; SOLR 1gm NIPENT SOLR 10mg (pentostatin) 2 TABLOID TABS 40mg (thioguanine) 2 OAC ANTIMITOTIC, TAXOIDS ABRAXANE INJ 100MG (paclitaxel - 2 bound particles) docetaxel CONC 20mg/ml, 80mg/4ml, 1 160mg/8ml; SOLN 20mg/2ml, 80mg/8ml, 160mg/16ml

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 17 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits paclitaxel CONC 30mg/5ml, 1 100mg/16.7ml, 150mg/25ml, 300mg/50ml ANTIMITOTIC, VINCA ALKALOIDS vinblastine sulfate SOLN 1mg/ml 1 vincristine sulfate SOLN 1mg/ml 1 vinorelbine tartrate SOLN 10mg/ml, 1 50mg/5ml BIOLOGIC RESPONSE MODIFIERS ERBITUX SOLN 100mg/50ml, 4 PA 200mg/100ml (cetuximab) ERIVEDGE CAPS 150mg (vismodegib) 4 QL (30 caps / 30 days), PA; OAC FARYDAK CAPS 10mg, 15mg, 20mg 4 QL (6 caps / 21 days), (panobinostat lactate) PA; OAC GAZYVA SOLN 1000mg/40ml 4 PA (obinutuzumab) IBRANCE CAPS 75mg, 100mg, 125mg 4 QL (21 caps / 28 days), (palbociclib) PA; OAC IBRANCE TABS 75mg, 100mg, 125mg 4 QL (21 tabs / 28 days), (palbociclib) PA; OAC KADCYLA SOLR 100mg, 160mg (ado- 4 PA trastuzumab emtansine) KEYTRUDA SOLN 100mg/4ml 4 PA (pembrolizumab) KISQALI TBPK 200mg (ribociclib 4 QL (21 tabs / 28 days), succinate) PA; 200 mg dose; OAC KISQALI TBPK 200mg (ribociclib 4 QL (42 tabs / 28 days), succinate) PA; 400 mg dose; OAC KISQALI TBPK 200mg (ribociclib 4 QL (63 tabs / 28 days), succinate) PA; 600 mg dose; OAC LYNPARZA TABS 100mg, 150mg 4 QL (120 tabs / 30 days), (olaparib) PA; OAC RYDAPT CAPS 25mg (midostaurin) 4 QL (224 caps / 28 days), PA; OAC ZEJULA CAPS 100mg (niraparib tosylate) 4 QL (90 caps / 30 days), PA; OAC ZOLINZA CAPS 100mg (vorinostat) 4 QL (120 caps / 30 days), PA; OAC HORMONAL ANTINEOPLASTIC AGENTS abiraterone acetate TABS 250mg 4 QL (120 tabs / 30 days), PA; OAC anastrozole TABS 1mg 1 OAC; $0 copay for women ages 35 and older for the primary prevention of breast cancer bicalutamide TABS 50mg 1 OAC

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 18 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits DEPO-PROVERA SUSP 400mg/ml 3 (medroxyprogesterone acetate (antineoplastic)) ELIGARD KIT 7.5mg (leuprolide acetate) 4 PA ELIGARD KIT 22.5mg (leuprolide acetate 4 PA (3 month)) ELIGARD KIT 30mg (leuprolide acetate (4 4 PA month)) ELIGARD KIT 45mg (leuprolide acetate (6 4 PA month)) ERLEADA TABS 60mg (apalutamide) 4 QL (120 tabs / 30 days), PA; OAC exemestane TABS 25mg 1 OAC; $0 copay for women ages 35 and older for the primary prevention of breast cancer flutamide CAPS 125mg 1 OAC fulvestrant SOLN 250mg/5ml 4 PA letrozole TABS 2.5mg 1 OAC leuprolide acetate KIT 1mg/0.2ml 4 PA LUPRON DEPOT-PED (1-MONTH KIT 4 PA 7.5mg, 11.25mg, 15mg (leuprolide acetate (cpp)) LUPRON DEPOT-PED (3-MONTH KIT 4 PA 11.25mg, 30mg (leuprolide acetate (cpp) (3 month)) LYSODREN TABS 500mg (mitotane) 2 OAC megestrol acetate SUSP 40mg/ml; TABS 1 OAC 20mg, 40mg megestrol acetate (appetite) SUSP 1 OAC 625mg/5ml nilutamide TABS 150mg 1 OAC NUBEQA TABS 300mg (darolutamide) 4 QL (120 tabs / 30 days), PA; OAC tamoxifen citrate TABS 10mg, 20mg 1 OAC; $0 copay for women ages 35 and older for the primary prevention of breast cancer toremifene citrate TABS 60mg 1 OAC XTANDI CAPS 40mg (enzalutamide) 4 QL (120 caps / 30 days), PA; OAC YONSA TABS 125mg (abiraterone acetate) 4 QL (120 tabs / 30 days), PA; OAC ZYTIGA TABS 500mg (abiraterone 4 QL (60 tabs / 30 days), acetate) PA; OAC

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 19 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits KINASE INHIBITORS AFINITOR TABS 10mg (everolimus) 4 QL (30 tabs / 30 days), PA; OAC AFINITOR DISPERZ TBSO 2mg, 5mg 4 QL (60 tabs / 30 days), (everolimus) PA; OAC AFINITOR DISPERZ TBSO 3mg 4 QL (90 tabs / 30 days), (everolimus) PA; OAC ALECENSA CAPS 150mg (alectinib hcl) 4 QL (240 caps / 30 days), PA; OAC BOSULIF TABS 100mg (bosutinib) 4 QL (90 tabs / 30 days), PA; OAC BOSULIF TABS 400mg, 500mg (bosutinib) 4 QL (30 tabs / 30 days), PA; OAC CALQUENCE CAPS 100mg (acalabrutinib) 4 QL (60 caps / 30 days), PA; OAC CAPRELSA TABS 100mg (vandetanib) 4 QL (60 tabs / 30 days), PA; OAC CAPRELSA TABS 300mg (vandetanib) 4 QL (30 tabs / 30 days), PA; OAC COMETRIQ KIT 20mg (cabozantinib s- 4 QL (1 kit / 28 days), PA; malate) OAC COMETRIQ KIT 100MG (cabozantinib s- 4 QL (1 kit / 28 days), PA; malate) OAC COMETRIQ KIT 140MG (cabozantinib s- 4 QL (1 kit / 28 days), PA; malate) OAC erlotinib hcl TABS 25mg 4 QL (60 tabs / 30 days), PA; OAC erlotinib hcl TABS 100mg, 150mg 4 QL (30 tabs / 30 days), PA; OAC everolimus TABS 2.5mg, 5mg, 7.5mg 4 QL (30 tabs / 30 days), PA; OAC ICLUSIG TABS 15mg (ponatinib hcl) 4 QL (60 tabs / 30 days), PA; OAC ICLUSIG TABS 45mg (ponatinib hcl) 4 QL (30 tabs / 30 days), PA; OAC IDHIFA TABS 50mg, 100mg (enasidenib 4 QL (30 tabs / 30 days), mesylate) PA; OAC imatinib mesylate TABS 100mg 4 QL (90 tabs / 30 days), PA; OAC imatinib mesylate TABS 400mg 4 QL (60 tabs / 30 days), PA; OAC IMBRUVICA CAPS 70mg (ibrutinib) 4 QL (30 caps / 30 days), PA; OAC IMBRUVICA CAPS 140mg (ibrutinib) 4 QL (90 caps / 30 days), PA; OAC IMBRUVICA TABS 140mg, 280mg, 420mg, 4 QL (30 tabs / 30 days), 560mg (ibrutinib) PA; OAC

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 20 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits INLYTA TABS 1mg (axitinib) 4 QL (240 tabs / 30 days), PA; OAC INLYTA TABS 5mg (axitinib) 4 QL (120 tabs / 30 days), PA; OAC JAKAFI TABS 5mg, 10mg, 15mg, 20mg, 4 QL (60 tabs / 30 days), 25mg (ruxolitinib phosphate) PA; OAC LENVIMA 4 MG DAILY DOSE CPPK 4mg 4 QL (30 caps / 30 days), (lenvatinib mesylate) PA; OAC LENVIMA 8 MG DAILY DOSE CPPK 4mg 4 QL (60 caps / 30 days), (lenvatinib mesylate) PA; OAC LENVIMA 10 MG DAILY DOSE CPPK 10mg 4 QL (30 caps / 30 days), (lenvatinib mesylate) PA; OAC LENVIMA 12MG DAILY DOSE CPPK 4mg 4 QL (90 caps / 30 days), (lenvatinib mesylate) PA; OAC LENVIMA 20 MG DAILY DOSE CPPK 10mg 4 QL (60 caps / 30 days), (lenvatinib mesylate) PA; OAC LENVIMA CAP 14 MG (lenvatinib mesylate) 4 QL (60 caps / 30 days), PA; OAC LENVIMA CAP 18 MG (lenvatinib mesylate) 4 QL (90 caps / 30 days), PA; OAC LENVIMA CAP 24 MG (lenvatinib mesylate) 4 QL (90 caps / 30 days), PA; OAC LORBRENA TABS 25mg (lorlatinib) 4 QL (90 tabs / 30 days), PA; OAC LORBRENA TABS 100mg (lorlatinib) 4 QL (30 tabs / 30 days), PA; OAC MEKINIST TABS 2mg (trametinib dimethyl 4 QL (30 tabs / 30 days), sulfoxide) PA; OAC MEKINIST TABS .5mg (trametinib 4 QL (90 tabs / 30 days), dimethyl sulfoxide) PA; OAC NEXAVAR TABS 200mg (sorafenib 4 QL (120 tabs / 30 days), tosylate) PA; OAC SPRYCEL TABS 20mg (dasatinib) 4 QL (90 tabs / 30 days), PA; OAC SPRYCEL TABS 50mg, 70mg, 80mg, 4 QL (30 tabs / 30 days), 100mg, 140mg (dasatinib) PA; OAC STIVARGA TABS 40mg (regorafenib) 4 QL (84 tabs / 28 days), PA; OAC SUTENT CAPS 12.5mg, 25mg, 37.5mg, 4 QL (30 caps / 30 days), 50mg (sunitinib malate) PA; OAC TAFINLAR CAPS 50mg, 75mg (dabrafenib 4 QL (120 caps / 30 mesylate) days), PA; OAC TYKERB TABS 250mg (lapatinib ditosylate) 4 QL (180 tabs / 30 days), PA; OAC VITRAKVI CAPS 25mg (larotrectinib 4 QL (180 caps / 30 sulfate) days), PA; OAC VITRAKVI CAPS 100mg (larotrectinib 4 QL (60 caps / 30 days), sulfate) PA; OAC PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 21 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits VITRAKVI SOLN 20mg/ml (larotrectinib 4 QL (300 mL / 30 days), sulfate) PA; OAC VOTRIENT TABS 200mg (pazopanib hcl) 4 QL (120 tabs / 30 days), PA; OAC XALKORI CAPS 200mg, 250mg (crizotinib) 4 QL (60 caps / 30 days), PA; OAC ZELBORAF TABS 240mg (vemurafenib) 4 QL (240 tabs / 30 days), PA; OAC ZYDELIG TABS 100mg, 150mg (idelalisib) 4 QL (60 tabs / 30 days), PA; OAC ZYKADIA TABS 150mg (ceritinib) 4 QL (90 tabs / 30 days), PA; OAC MISCELLANEOUS arsenic trioxide SOLN 10mg/10ml, 1 12mg/6ml bexarotene CAPS 75mg 4 PA; OAC DROXIA CAPS 200mg, 300mg, 400mg 2 (hydroxyurea (sickle cell anemia)) hydroxyurea CAPS 500mg 1 OAC MATULANE CAPS 50mg (procarbazine hcl) 2 OAC mitoxantrone hcl CONC 2mg/ml 4 PA ODOMZO CAPS 200mg (sonidegib 4 QL (30 caps / 30 days), phosphate) PA; OAC ONCASPAR SOLN 750unit/ml 4 PA (pegaspargase) PHOTOFRIN SOLR 75mg (porfimer 2 sodium) QUADRAMET SOLN 1850mbq/ml 2 (samarium sm 153 lexidronam) TICE BCG SUSR 50mg (bcg live 2 intravesical) tretinoin (chemotherapy) CAPS 10mg 1 OAC VISTOGARD PACK 10gm (uridine 4 QL (20 packets / 5 days) triacetate (emergency treatment)) PLATINUM-BASED AGENTS carboplatin SOLN 50mg/5ml, 1 150mg/15ml, 450mg/45ml, 600mg/60ml cisplatin SOLN 50mg/50ml, 100mg/100ml, 1 200mg/200ml oxaliplatin SOLN 50mg/10ml, 4 100mg/20ml; SOLR 50mg, 100mg PROTECTIVE AGENTS dexrazoxane hcl SOLR 250mg, 500mg 1 leucovorin calcium SOLR 50mg, 100mg, 1 200mg, 350mg, 500mg leucovorin calcium TABS 5mg, 10mg, 1 OAC 15mg, 25mg PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 22 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits mesna SOLN 100mg/ml 1 MESNEX TABS 400mg (mesna) 4 OAC TOPOISOMERASE INHIBITORS CAMPTOSAR SOLN 300mg/15ml 2 (irinotecan hcl) etoposide CAPS 50mg 1 OAC etoposide SOLN 100mg/5ml 1 irinotecan hcl SOLN 40mg/2ml, 4 100mg/5ml, 500mg/25ml TENIPOSIDE SOLN 10mg/ml 2 toposar SOLN 1gm/50ml, 100mg/5ml, 1 500mg/25ml (Toposar) topotecan hcl SOLR 4mg 1 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES ANTINEOPLASTIC, BCL-2 INHIBITORS VENCLEXTA TABS 10mg, 50mg 4 QL (120 tabs / 30 days), (venetoclax) PA; OAC VENCLEXTA TABS 100mg (venetoclax) 4 QL (180 tabs / 30 days), PA; OAC VENCLEXTA TAB START PK (venetoclax) 4 PA; OAC CARDIOVASCULAR - DRUGS TO TREAT HEART AND CIRCULATION CONDITIONS ACE INHIBITOR COMBINATIONS - DRUGS TO TREAT HIGH BLOOD PRESSURE amlodipine besylate-benazepril hcl cap 2.5- 1 10 mg amlodipine besylate-benazepril hcl cap 5- 1 10 mg amlodipine besylate-benazepril hcl cap 5- 1 20 mg amlodipine besylate-benazepril hcl cap 5- 1 40 mg amlodipine besylate-benazepril hcl cap 10- 1 20 mg amlodipine besylate-benazepril hcl cap 10- 1 40 mg benazepril & hydrochlorothiazide tab 5- 1 6.25 mg benazepril & hydrochlorothiazide tab 10- 1 12.5 mg benazepril & hydrochlorothiazide tab 20- 1 12.5 mg benazepril & hydrochlorothiazide tab 20-25 1 mg captopril & hydrochlorothiazide tab 25-15 1 mg

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 23 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits captopril & hydrochlorothiazide tab 25-25 1 mg captopril & hydrochlorothiazide tab 50-15 1 mg captopril & hydrochlorothiazide tab 50-25 1 mg enalapril maleate & hydrochlorothiazide tab 1 5-12.5 mg enalapril maleate & hydrochlorothiazide tab 1 10-25 mg fosinopril sodium & hydrochlorothiazide tab 1 10-12.5 mg fosinopril sodium & hydrochlorothiazide tab 1 20-12.5 mg lisinopril & hydrochlorothiazide tab 10-12.5 1 mg lisinopril & hydrochlorothiazide tab 20-12.5 1 mg lisinopril & hydrochlorothiazide tab 20-25 1 mg quinapril-hydrochlorothiazide tab 10-12.5 1 mg quinapril-hydrochlorothiazide tab 20-12.5 1 mg quinapril-hydrochlorothiazide tab 20-25 mg 1 trandolapril-verapamil hcl tab er 1-240 mg 1 trandolapril-verapamil hcl tab er 2-180 mg 1 trandolapril-verapamil hcl tab er 2-240 mg 1 trandolapril-verapamil hcl tab er 4-240 mg 1 ACE INHIBITORS - DRUGS TO TREAT HIGH BLOOD PRESSURE benazepril hcl TABS 5mg, 10mg, 20mg, 1 40mg captopril TABS 12.5mg, 25mg, 50mg, 1 100mg enalapril maleate TABS 2.5mg, 5mg, 1 10mg, 20mg fosinopril sodium TABS 10mg, 20mg, 1 40mg lisinopril TABS 2.5mg, 5mg, 10mg, 20mg, 1 30mg, 40mg moexipril hcl TABS 7.5mg, 15mg 1 perindopril erbumine TABS 2mg, 4mg, 1 8mg quinapril hcl TABS 5mg, 10mg, 20mg, 1 40mg ramipril CAPS 1.25mg, 2.5mg, 5mg, 10mg 1 trandolapril TABS 1mg, 2mg, 4mg 1

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 24 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits ALDOSTERONE RECEPTOR ANTAGONISTS - DRUGS TO TREAT HIGH BLOOD PRESSURE eplerenone TABS 25mg, 50mg 1 ALPHA BLOCKERS - DRUGS TO TREAT HIGH BLOOD PRESSURE mesylate TABS 1mg, 2mg, 1 4mg, 8mg hcl CAPS 1mg, 2mg, 5mg 1 terazosin hcl CAPS 1mg, 2mg, 5mg, 10mg 1 ANGIOTENSIN II COMBINATIONS - DRUGS TO TREAT HIGH BLOOD PRESSURE amlodipine besylate-olmesartan medoxomil 1 tab 5-20 mg amlodipine besylate-olmesartan medoxomil 1 tab 5-40 mg amlodipine besylate-olmesartan medoxomil 1 tab 10-20 mg amlodipine besylate-olmesartan medoxomil 1 tab 10-40 mg amlodipine besylate-valsartan tab 5-160 1 mg amlodipine besylate-valsartan tab 5-320 1 mg amlodipine besylate-valsartan tab 10-160 1 mg amlodipine besylate-valsartan tab 10-320 1 mg amlodipine-valsartan-hydrochlorothiazide 1 tab 5-160-12.5 mg amlodipine-valsartan-hydrochlorothiazide 1 tab 5-160-25 mg amlodipine-valsartan-hydrochlorothiazide 1 tab 10-160-12.5 mg amlodipine-valsartan-hydrochlorothiazide 1 tab 10-160-25 mg amlodipine-valsartan-hydrochlorothiazide 1 tab 10-320-25 mg candesartan cilexetil-hydrochlorothiazide 1 tab 16-12.5 mg candesartan cilexetil-hydrochlorothiazide 1 tab 32-12.5 mg candesartan cilexetil-hydrochlorothiazide 1 tab 32-25 mg irbesartan-hydrochlorothiazide tab 150- 1 12.5 mg irbesartan-hydrochlorothiazide tab 300- 1 12.5 mg

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 25 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits losartan potassium & hydrochlorothiazide 1 tab 50-12.5 mg losartan potassium & hydrochlorothiazide 1 tab 100-12.5 mg losartan potassium & hydrochlorothiazide 1 tab 100-25 mg olmesartan medoxomil-hydrochlorothiazide 1 tab 20-12.5 mg olmesartan medoxomil-hydrochlorothiazide 1 tab 40-12.5 mg olmesartan medoxomil-hydrochlorothiazide 1 tab 40-25 mg olmesartan-amlodipine-hydrochlorothiazide 1 tab 20-5-12.5 mg olmesartan-amlodipine-hydrochlorothiazide 1 tab 40-5-12.5 mg olmesartan-amlodipine-hydrochlorothiazide 1 tab 40-5-25 mg olmesartan-amlodipine-hydrochlorothiazide 1 tab 40-10-12.5 mg olmesartan-amlodipine-hydrochlorothiazide 1 tab 40-10-25 mg telmisartan-amlodipine tab 40-5 mg 1 telmisartan-amlodipine tab 40-10 mg 1 telmisartan-amlodipine tab 80-5 mg 1 telmisartan-amlodipine tab 80-10 mg 1 telmisartan-hydrochlorothiazide tab 40- 1 12.5 mg telmisartan-hydrochlorothiazide tab 80- 1 12.5 mg telmisartan-hydrochlorothiazide tab 80-25 1 mg valsartan-hydrochlorothiazide tab 80-12.5 1 mg valsartan-hydrochlorothiazide tab 160-12.5 1 mg valsartan-hydrochlorothiazide tab 160-25 1 mg valsartan-hydrochlorothiazide tab 320-12.5 1 mg valsartan-hydrochlorothiazide tab 320-25 1 mg ANGIOTENSIN II RECEPTOR ANTAGONISTS - DRUGS TO TREAT HIGH BLOOD PRESSURE candesartan cilexetil TABS 4mg, 8mg, 1 16mg, 32mg eprosartan mesylate TABS 600mg 1

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 26 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits irbesartan TABS 75mg, 150mg, 300mg 1 losartan potassium TABS 25mg, 50mg, 1 100mg olmesartan medoxomil TABS 5mg, 20mg, 1 40mg telmisartan TABS 20mg, 40mg, 80mg 1 valsartan TABS 40mg, 80mg, 160mg, 1 320mg ANTIARRHYTHMICS - DRUGS TO CONTROL HEART RHYTHM amiodarone hcl TABS 200mg, 400mg 1 disopyramide phosphate CAPS 100mg, 1 150mg dofetilide CAPS 125mcg, 250mcg, 500mcg 1 PA flecainide acetate TABS 50mg, 100mg, 1 150mg lidocaine hcl (cardiac) SOSY 50mg/5ml, 1 100mg/5ml mexiletine hcl CAPS 150mg, 200mg, 1 250mg MULTAQ TABS 400mg (dronedarone hcl) 3 PA NORPACE CR CP12 100mg, 150mg 2 (disopyramide phosphate) pacerone TABS 100mg, 200mg (Pacerone) 1 procainamide hcl SOLN 100mg/ml 1 propafenone hcl CP12 225mg, 325mg, 1 425mg; TABS 150mg, 225mg, 300mg sorine TABS 80mg, 120mg, 160mg, 1 240mg (Sorine) sotalol hcl TABS 80mg, 120mg, 160mg, 1 240mg sotalol hcl (afib/afl) TABS 80mg, 120mg, 1 160mg ANTILIPEMICS, BILE ACID RESINS cholestyramine PACK 4gm; POWD 1 4gm/dose cholestyramine light PACK 4gm; POWD 1 4gm/dose colestipol hcl GRAN 5gm; PACK 5gm; 1 TABS 1gm prevalite POWD 4gm/dose (Prevalite) 1 ANTILIPEMICS, CHOLESTEROL ABSORPTION INHIBITOR ezetimibe TABS 10mg 1 ANTILIPEMICS, FIBRATES fenofibrate CPDR 45mg, 135mg 1 fenofibrate CAPS 50mg, 150mg; TABS 1 48mg, 54mg, 145mg, 160mg

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 27 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits fenofibrate micronized CAPS 43mg, 67mg, 1 130mg, 134mg, 200mg gemfibrozil TABS 600mg 1 ANTILIPEMICS, HMG-COA REDUCTASE INHIBITORS/COMBINATIONS ezetimibe-simvastatin tab 10-10 mg 1 ezetimibe-simvastatin tab 10-20 mg 1 ezetimibe-simvastatin tab 10-40 mg 1 ezetimibe-simvastatin tab 10-80 mg 1 ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS atorvastatin calcium TABS 10mg, 20mg 1 $0 copay for members age 40 through 75 atorvastatin calcium TABS 40mg, 80mg 1 fluvastatin sodium CAPS 20mg, 40mg; 1 $0 copay for members TB24 80mg age 40 through 75 lovastatin TABS 10mg, 20mg, 40mg 1 $0 copay for members age 40 through 75 pravastatin sodium TABS 10mg, 20mg, 1 $0 copay for members 40mg, 80mg age 40 through 75 rosuvastatin calcium TABS 5mg, 10mg 1 ST; $0 copay for members age 40 through 75; PA** rosuvastatin calcium TABS 20mg, 40mg 1 simvastatin TABS 5mg, 10mg, 20mg, 1 $0 copay for members 40mg age 40 through 75 simvastatin TABS 80mg 1 ST; PA** ANTILIPEMICS, MISCELLANEOUS - DRUGS TO TREAT HIGH CHOLESTEROL niacin (antihyperlipidemic) TBCR 500mg, 1 750mg, 1000mg ANTILIPEMICS, OMEGA-3 FATTY ACIDS omega-3-acid ethyl esters cap 1 gm 1 PA VASCEPA CAPS .5gm, 1gm (icosapent 2 ethyl) ANTILIPEMICS, PCSK9 INHIBITORS PRALUENT SOAJ 75mg/ml, 150mg/ml 4 QL (2 pens / 28 days), (alirocumab) PA BETA-BLOCKER/DIURETIC COMBINATIONS - DRUGS TO TREAT HIGH BLOOD PRESSURE AND HEART CONDITIONS atenolol & chlorthalidone tab 50-25 mg 1 atenolol & chlorthalidone tab 100-25 mg 1 bisoprolol & hydrochlorothiazide tab 2.5- 1 6.25 mg bisoprolol & hydrochlorothiazide tab 5-6.25 1 mg

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 28 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits bisoprolol & hydrochlorothiazide tab 10- 1 6.25 mg metoprolol & hydrochlorothiazide tab 50- 1 25 mg metoprolol & hydrochlorothiazide tab 100- 1 25 mg metoprolol & hydrochlorothiazide tab 100- 1 50 mg propranolol & hydrochlorothiazide tab 40- 1 25 mg propranolol & hydrochlorothiazide tab 80- 1 25 mg BETA-BLOCKERS - DRUGS TO TREAT HIGH BLOOD PRESSURE AND HEART CONDITIONS acebutolol hcl CAPS 200mg, 400mg 1 atenolol TABS 25mg, 50mg, 100mg 1 betaxolol hcl TABS 10mg, 20mg 1 bisoprolol fumarate TABS 5mg, 10mg 1 BYSTOLIC TABS 2.5mg, 5mg, 10mg, 3 20mg (nebivolol hcl) carvedilol TABS 3.125mg, 6.25mg, 1 12.5mg, 25mg carvedilol phosphate CP24 10mg, 20mg, 1 40mg, 80mg labetalol hcl TABS 100mg, 200mg, 300mg 1 metoprolol succinate TB24 25mg, 50mg, 1 100mg, 200mg metoprolol tartrate TABS 25mg, 50mg, 1 100mg nadolol TABS 20mg, 40mg, 80mg 1 pindolol TABS 5mg, 10mg 1 propranolol hcl CP24 60mg, 80mg, 1 120mg, 160mg; SOLN 20mg/5ml, 40mg/5ml; TABS 10mg, 20mg, 40mg, 60mg, 80mg timolol maleate TABS 5mg, 10mg, 20mg 1 CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS amlodipine besylate-atorvastatin calcium 1 tab 2.5-10 mg amlodipine besylate-atorvastatin calcium 1 tab 2.5-20 mg amlodipine besylate-atorvastatin calcium 1 tab 2.5-40 mg amlodipine besylate-atorvastatin calcium 1 tab 5-10 mg

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 29 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits amlodipine besylate-atorvastatin calcium 1 tab 5-20 mg amlodipine besylate-atorvastatin calcium 1 tab 5-40 mg amlodipine besylate-atorvastatin calcium 1 tab 5-80 mg amlodipine besylate-atorvastatin calcium 1 tab 10-10 mg amlodipine besylate-atorvastatin calcium 1 tab 10-20 mg amlodipine besylate-atorvastatin calcium 1 tab 10-40 mg amlodipine besylate-atorvastatin calcium 1 tab 10-80 mg CALCIUM CHANNEL BLOCKERS - DRUGS TO TREAT HIGH BLOOD PRESSURE AND HEART CONDITIONS amlodipine besylate TABS 2.5mg, 5mg, 1 10mg CARDIZEM LA TB24 120mg (diltiazem hcl 3 coated beads) cartia xt CP24 120mg, 180mg, 240mg, 1 300mg (Cartia Xt) diltiazem hcl CP12 60mg, 90mg, 120mg; 1 SOLN 25mg/5ml, 125mg/25ml; TABS 30mg, 60mg, 90mg, 120mg diltiazem hcl CP24 120mg, 180mg, 240mg 1 (Dilt-xr) diltiazem hcl coated beads CP24 120mg, 1 180mg, 240mg, 300mg, 360mg diltiazem hcl extended release beads CP24 1 120mg, 180mg, 240mg, 300mg, 360mg, 420mg felodipine TB24 2.5mg, 5mg, 10mg 1 isradipine CAPS 2.5mg, 5mg 1 matzim la TB24 180mg, 240mg, 300mg, 1 360mg, 420mg (Matzim La) nicardipine hcl CAPS 20mg, 30mg 1 nifedipine TB24 30mg, 60mg, 90mg 1 nimodipine CAPS 30mg 1 nisoldipine TB24 8.5mg, 17mg, 20mg, 1 25.5mg, 30mg, 34mg, 40mg taztia xt CP24 120mg, 180mg, 240mg, 1 300mg, 360mg (Taztia Xt) verapamil hcl CP24 100mg, 120mg, 1 180mg, 200mg, 240mg, 300mg, 360mg; TABS 40mg, 80mg, 120mg; TBCR 120mg, 180mg, 240mg

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 30 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits DIGITALIS GLYCOSIDES - DRUGS TO TREAT HEART CONDITIONS digox TABS 125mcg, 250mcg (Digox) 1 digoxin SOLN .05mg/ml; TABS 125mcg, 1 250mcg LANOXIN TABS 62.5mcg (digoxin) 2 DIRECT RENIN INHIBITORS/COMBINATIONS - DRUGS TO TREAT HEART CONDITIONS aliskiren fumarate TABS 150mg, 300mg 1 DIURETICS - DRUGS TO TREAT HEART CONDITIONS acetazolamide CP12 500mg; TABS 1 125mg, 250mg ALDACTAZIDE TAB 50/50 (spironolactone 2 & hydrochlorothiazide) & hydrochlorothiazide tab 5-50 1 mg amiloride hcl TABS 5mg 1 bumetanide TABS .5mg, 1mg, 2mg 1 chlorothiazide TABS 250mg, 500mg 1 chlorthalidone TABS 25mg, 50mg 1 DIURIL SUSP 250mg/5ml (chlorothiazide) 3 ethacrynic acid TABS 25mg 3 furosemide SOLN 8mg/ml, 10mg/ml; 1 TABS 20mg, 40mg, 80mg hydrochlorothiazide CAPS 12.5mg; TABS 1 12.5mg, 25mg, 50mg indapamide TABS 1.25mg, 2.5mg 1 methazolamide TABS 25mg, 50mg 1 metolazone TABS 2.5mg, 5mg, 10mg 1 spironolactone TABS 25mg, 50mg, 100mg 1 spironolactone & hydrochlorothiazide tab 1 25-25 mg torsemide TABS 5mg, 10mg, 20mg, 1 100mg triamterene CAPS 50mg, 100mg 1 triamterene & hydrochlorothiazide cap 1 37.5-25 mg triamterene & hydrochlorothiazide tab 1 37.5-25 mg triamterene & hydrochlorothiazide tab 75- 1 50 mg MISCELLANEOUS hcl PTWK .1mg/24hr, 1 .2mg/24hr, .3mg/24hr; TABS .1mg, .2mg, .3mg ENTRESTO TAB 24-26MG (sacubitril- 2 valsartan)

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 31 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits ENTRESTO TAB 49-51MG (sacubitril- 2 valsartan) ENTRESTO TAB 97-103MG (sacubitril- 2 valsartan) hcl TABS 1mg, 2mg 1 hydralazine hcl TABS 10mg, 25mg, 50mg, 1 100mg TABS 250mg, 500mg 1 midodrine hcl TABS 2.5mg, 5mg, 10mg 1 minoxidil TABS 2.5mg, 10mg 1 phenoxybenzamine hcl CAPS 10mg 4 QL (360 caps / 25 days), PA ranolazine TB12 500mg, 1000mg 1 ST; PA** NITRATES - DRUGS TO TREAT HEART CONDITIONS DILATRATE SR CPCR 40mg (isosorbide 3 dinitrate) isosorbide dinitrate TABS 5mg, 10mg, 1 20mg, 30mg, 40mg isosorbide mononitrate TABS 10mg, 1 20mg; TB24 30mg, 60mg, 120mg minitran PT24 .1mg/hr, .2mg/hr, .4mg/hr, 1 .6mg/hr (Minitran) NITRO-BID OINT 2% (nitroglycerin) 3 NITRO-DUR PT24 .3mg/hr, .8mg/hr 2 (nitroglycerin) nitroglycerin PT24 .1mg/hr, .2mg/hr, 1 .4mg/hr, .6mg/hr; SOLN .4mg/spray; SUBL .3mg, .4mg, .6mg PULMONARY ARTERIAL HYPERTENSION - DRUGS TO TREAT ADEMPAS TABS .5mg, 1mg, 1.5mg, 2mg, 4 QL (90 tabs / 30 days), 2.5mg (riociguat) PA TABS 5mg, 10mg 4 QL (30 tabs / 30 days), PA TABS 62.5mg, 125mg 4 QL (60 tabs / 30 days), PA OPSUMIT TABS 10mg () 4 QL (30 tabs / 30 days), PA ORENITRAM TBCR .125mg, .25mg, 1mg, 4 PA 2.5mg, 5mg (treprostinil diolamine) REMODULIN SOLN 20mg/20ml, 4 PA 50mg/20ml, 100mg/20ml, 200mg/20ml (treprostinil) sildenafil citrate (pulmonary hypertension) 4 PA SOLN 10mg/12.5ml sildenafil citrate (pulmonary hypertension) 4 QL (90 tabs / 30 days), TABS 20mg PA

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 32 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits tadalafil (pulmonary hypertension) TABS 4 QL (60 tabs / 30 days), 20mg PA TRACLEER TBSO 32mg (bosentan) 4 QL (112 tabs / 28 days), PA TYVASO STARTER SOLN .6mg/ml 4 QL (28 ampules / 28 (treprostinil) days), PA UPTRAVI TABS 200mcg (selexipag) 4 QL (140 tabs / 28 days), PA UPTRAVI TABS 400mcg, 600mcg, 4 QL (60 tabs / 30 days), 800mcg, 1000mcg, 1200mcg, 1400mcg, PA 1600mcg (selexipag) UPTRAVI TAB 200/800 (selexipag) 4 PA VENTAVIS SOLN 10mcg/ml, 20mcg/ml 4 QL (270 ampules / 30 (iloprost) days), PA CENTRAL NERVOUS SYSTEM - DRUGS TO TREAT NERVOUS SYSTEM DISORDERS ANTIANXIETY§ - DRUGS TO TREAT ANXIETY alprazolam TABS .25mg, .5mg, 1mg, 1 QL (150 tabs / 25 days) 2mg; TBDP .25mg, .5mg, 1mg, 2mg ALPRAZOLAM INTENSOL CONC 1mg/ml 2 QL (300 mL / 25 days) (alprazolam) lorazepam CONC 2mg/ml 1 QL (150 mL / 25 days) lorazepam TABS .5mg, 1mg, 2mg 1 QL (150 tabs / 25 days) meprobamate TABS 200mg, 400mg 1 oxazepam CAPS 10mg, 15mg, 30mg 1 QL (120 caps / 25 days) ANTICONVULSANTS§ - DRUGS TO TREAT SEIZURES APTIOM TABS 200mg, 400mg, 600mg, 3 PA 800mg (eslicarbazepine acetate) carbamazepine CHEW 100mg; CP12 1 100mg, 200mg, 300mg; SUSP 100mg/5ml; TABS 200mg; TB12 100mg, 200mg, 400mg CELONTIN CAPS 300mg (methsuximide) 3 clobazam SUSP 2.5mg/ml; TABS 10mg, 1 PA 20mg clonazepam TABS .5mg, 1mg, 2mg 1 clorazepate dipotassium TABS 3.75mg, 1 QL (180 tabs / 25 days) 7.5mg, 15mg diazepam SOLN 5mg/5ml 1 QL (1200 mL / 25 days) diazepam SOLN 5mg/ml 1 diazepam TABS 2mg, 5mg, 10mg 1 QL (120 tabs / 25 days) diazepam intensol CONC 5mg/ml 1 QL (240 mL / 25 days) (Diazepam Intensol) DILANTIN CAPS 30mg (phenytoin sodium 3 extended)

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 33 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits divalproex sodium CSDR 125mg; TB24 1 250mg, 500mg; TBEC 125mg, 250mg, 500mg epitol TABS 200mg (Epitol) 1 ethosuximide CAPS 250mg; SOLN 1 250mg/5ml felbamate SUSP 600mg/5ml; TABS 1 400mg, 600mg fosphenytoin sodium SOLN 100mgpe/2ml, 1 500mgpe/10ml FYCOMPA SUSP .5mg/ml; TABS 2mg, 2 4mg, 6mg, 8mg, 10mg, 12mg (perampanel) gabapentin CAPS 100mg, 300mg, 400mg; 1 SOLN 250mg/5ml; TABS 600mg, 800mg lamotrigine CHEW 5mg, 25mg; KIT 25mg; 1 TABS 25mg, 100mg, 150mg, 200mg; TB24 25mg, 50mg, 100mg, 200mg, 250mg, 300mg; TBDP 25mg, 50mg, 100mg, 200mg lamotrigine tab 25 mg (42) & 100 mg (7) 1 starter kit lamotrigine tab 84 x 25 mg & 14 x 100 mg 1 starter kit levetiracetam SOLN 100mg/ml, 1 500mg/5ml; TABS 250mg, 500mg, 750mg, 1000mg; TB24 500mg, 750mg levetiracetam in sodium chloride iv soln 1 500 mg/100ml levetiracetam in sodium chloride iv soln 1 1000 mg/100ml levetiracetam in sodium chloride iv soln 1 1500 mg/100ml oxcarbazepine SUSP 60mg/ml; TABS 1 150mg, 300mg, 600mg PEGANONE TABS 250mg (ethotoin) 3 phenobarbital ELIX 20mg/5ml; TABS 1 15mg, 16.2mg, 30mg, 32.4mg, 60mg, 64.8mg, 97.2mg, 100mg phenytoin CHEW 50mg; SUSP 125mg/5ml 1 phenytoin sodium SOLN 50mg/ml 1 phenytoin sodium extended CAPS 100mg, 1 200mg, 300mg pregabalin CAPS 25mg, 50mg, 75mg, 1 ST; PA** 100mg, 150mg, 200mg, 225mg, 300mg; SOLN 20mg/ml primidone TABS 50mg, 250mg 1

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 34 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits tiagabine hcl TABS 2mg, 4mg, 12mg, 1 16mg topiramate CPSP 15mg, 25mg; TABS 1 25mg, 50mg, 100mg, 200mg valproate sodium SOLN 100mg/ml, 1 250mg/5ml valproic acid CAPS 250mg 1 vigabatrin PACK 500mg 4 QL (180 packets / 30 days), PA vigabatrin TABS 500mg 4 QL (180 tabs / 30 days), PA VIMPAT SOLN 10mg/ml, 200mg/20ml; 3 TABS 50mg, 100mg, 150mg, 200mg (lacosamide) zonisamide CAPS 25mg, 50mg, 100mg 1 ANTIDEMENTIA - DRUGS TO TREAT DEMENTIA AND MEMORY LOSS donepezil hydrochloride TABS 5mg, 10mg, 1 23mg; TBDP 5mg, 10mg ergoloid mesylates TABS 1mg 1 galantamine hydrobromide CP24 8mg, 1 16mg, 24mg; SOLN 4mg/ml; TABS 4mg, 8mg, 12mg memantine hcl CP24 7mg, 14mg, 21mg, 1 PA; PA applies for 28mg; SOLN 2mg/ml; TABS 5mg, 10mg members less than 30 years of age memantine hcl tab 28 x 5 mg & 21 x 10 1 PA; PA applies for mg titration pack members less than 30 years of age NAMENDA XR CAP TITRATIO (memantine 2 PA; PA applies for hcl) members less than 30 years of age rivastigmine PT24 4.6mg/24hr, 1 PA 9.5mg/24hr, 13.3mg/24hr rivastigmine tartrate CAPS 1.5mg, 3mg, 1 PA 4.5mg, 6mg ANTIDEPRESSANTS§ - DRUGS TO TREAT DEPRESSION amitriptyline hcl TABS 10mg 1 QL (150 tabs / 25 days); QL applies to members age 65 and older amitriptyline hcl TABS 25mg 1 QL (60 tabs / 25 days); QL applies to members age 65 and older amitriptyline hcl TABS 50mg 1 QL (30 tabs / 25 days); QL applies to members age 65 and older amitriptyline hcl TABS 75mg, 100mg, 1 PA; Members 70 and 150mg older subject to PA

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 35 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits amoxapine TABS 25mg, 50mg, 100mg 1 QL (90 tabs / 25 days); QL applies to members age 65 and older amoxapine TABS 150mg 1 QL (60 tabs / 25 days); QL applies to members age 65 and older bupropion hcl TABS 75mg, 100mg; TB12 1 100mg, 150mg, 200mg; TB24 150mg, 300mg citalopram hydrobromide SOLN 1 10mg/5ml; TABS 10mg, 20mg, 40mg desipramine hcl TABS 10mg, 25mg, 50mg 1 QL (90 tabs / 25 days); QL applies to members age 65 and older desipramine hcl TABS 75mg 1 QL (60 tabs / 25 days); QL applies to members age 65 and older desipramine hcl TABS 100mg, 150mg 1 QL (30 tabs / 25 days); QL applies to members age 65 and older desvenlafaxine succinate TB24 25mg, 1 QL (30 tabs / 25 days), 50mg, 100mg ST; (generic of Pristiq) PA** doxepin hcl CAPS 10mg, 25mg, 50mg 1 QL (90 caps / 25 days); QL applies to members age 65 and older doxepin hcl CAPS 75mg 1 QL (60 caps / 25 days); QL applies to members age 65 and older doxepin hcl CAPS 100mg, 150mg 1 QL (30 caps / 25 days); QL applies to members age 65 and older doxepin hcl CONC 10mg/ml 1 QL (450 mL / 25 days); QL applies to members age 65 and older duloxetine hcl CPEP 20mg, 30mg, 60mg 1 EMSAM PT24 6mg/24hr, 9mg/24hr, 3 PA 12mg/24hr (selegiline) escitalopram oxalate SOLN 5mg/5ml; 1 TABS 5mg, 10mg, 20mg FETZIMA CP24 20mg, 40mg, 80mg, 3 QL (30 caps / 25 days), 120mg (levomilnacipran hcl) ST; PA** FETZIMA CAP TITRATIO (levomilnacipran 3 QL (30 caps / 25 days), hcl) ST; PA** fluoxetine hcl CAPS 10mg, 20mg, 40mg; 1 CPDR 90mg; SOLN 20mg/5ml fluoxetine hcl TABS 10mg, 20mg 1 (generic Sarafem not covered)

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 36 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits imipramine hcl TABS 10mg, 25mg 1 QL (120 tabs / 25 days); QL applies to members age 65 and older imipramine hcl TABS 50mg 1 QL (60 tabs / 25 days); QL applies to members age 65 and older imipramine pamoate CAPS 75mg, 100mg 1 QL (30 caps / 25 days); QL applies to members age 65 and older imipramine pamoate CAPS 125mg, 150mg 1 PA; Members 70 and older subject to PA maprotiline hcl TABS 25mg, 50mg, 75mg 1 MARPLAN TABS 10mg (isocarboxazid) 3 mirtazapine TABS 7.5mg, 15mg, 30mg, 1 45mg; TBDP 15mg, 30mg, 45mg nefazodone hcl TABS 50mg, 100mg, 1 150mg, 200mg, 250mg nortriptyline hcl CAPS 10mg 1 QL (150 caps / 25 days); QL applies to members age 65 and older nortriptyline hcl CAPS 25mg 1 QL (60 caps / 25 days); QL applies to members age 65 and older nortriptyline hcl CAPS 50mg 1 QL (30 caps / 25 days); QL applies to members age 65 and older nortriptyline hcl CAPS 75mg 1 PA; Members 70 and older subject to PA nortriptyline hcl SOLN 10mg/5ml 1 QL (750 mL / 25 days); QL applies to members age 65 and older paroxetine hcl TABS 10mg, 20mg, 30mg, 1 40mg; TB24 12.5mg, 25mg, 37.5mg phenelzine sulfate TABS 15mg 1 protriptyline hcl TABS 5mg 1 QL (90 tabs / 25 days); QL applies to members age 65 and older protriptyline hcl TABS 10mg 1 QL (60 tabs / 25 days); QL applies to members age 65 and older sertraline hcl CONC 20mg/ml; TABS 1 25mg, 50mg, 100mg tranylcypromine sulfate TABS 10mg 1 trazodone hcl TABS 50mg, 100mg, 1 150mg, 300mg

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 37 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits trimipramine maleate CAPS 25mg, 50mg 1 QL (60 caps / 25 days); QL applies to members age 65 and older trimipramine maleate CAPS 100mg 1 QL (30 caps / 25 days); QL applies to members age 65 and older venlafaxine hcl CP24 37.5mg, 75mg, 1 150mg; TABS 25mg, 37.5mg, 50mg, 75mg, 100mg; TB24 37.5mg, 75mg, 150mg VIIBRYD TABS 10mg, 20mg, 40mg 3 ST; PA** (vilazodone hcl) VIIBRYD KIT STARTER (vilazodone hcl) 3 ST; PA** ANTIPARKINSONIAN AGENTS - DRUGS TO TREAT PARKINSONS DISEASE amantadine hcl CAPS 100mg; SYRP 1 50mg/5ml; TABS 100mg APOKYN SOCT 30mg/3ml (apomorphine 4 PA hydrochloride) benztropine mesylate SOLN 1mg/ml; 1 TABS .5mg, 1mg, 2mg bromocriptine mesylate CAPS 5mg; TABS 1 2.5mg carbidopa TABS 25mg 1 carbidopa & levodopa orally disintegrating 1 tab 10-100 mg carbidopa & levodopa orally disintegrating 1 tab 25-100 mg carbidopa & levodopa orally disintegrating 1 tab 25-250 mg carbidopa & levodopa tab 10-100 mg 1 carbidopa & levodopa tab 25-100 mg 1 carbidopa & levodopa tab 25-250 mg 1 carbidopa & levodopa tab er 25-100 mg 1 carbidopa & levodopa tab er 50-200 mg 1 carbidopa-levodopa-entacapone tabs 12.5- 1 50-200 mg carbidopa-levodopa-entacapone tabs 1 18.75-75-200 mg carbidopa-levodopa-entacapone tabs 25- 1 100-200 mg carbidopa-levodopa-entacapone tabs 1 31.25-125-200 mg carbidopa-levodopa-entacapone tabs 37.5- 1 150-200 mg carbidopa-levodopa-entacapone tabs 50- 1 200-200 mg

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 38 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits entacapone TABS 200mg 1 NEUPRO PT24 1mg/24hr, 2mg/24hr, 2 3mg/24hr, 4mg/24hr, 6mg/24hr, 8mg/24hr (rotigotine) pramipexole dihydrochloride TABS 1 .125mg, .25mg, .5mg, .75mg, 1mg, 1.5mg; TB24 .375mg, .75mg, 1.5mg, 2.25mg, 3mg, 3.75mg, 4.5mg rasagiline mesylate TABS .5mg, 1mg 1 ropinirole hydrochloride TABS .25mg, 1 .5mg, 1mg, 2mg, 3mg, 4mg, 5mg selegiline hcl CAPS 5mg; TABS 5mg 1 tolcapone TABS 100mg 1 trihexyphenidyl hcl SOLN .4mg/ml; TABS 1 2mg, 5mg ANTIPSYCHOTICS - DRUGS TO TREAT PSYCHOSES aripiprazole SOLN 1mg/ml; TABS 2mg, 1 5mg, 10mg, 15mg, 20mg, 30mg; TBDP 10mg, 15mg ARISTADA PRSY 441mg/1.6ml, 2 662mg/2.4ml, 882mg/3.2ml, 1064mg/3.9ml (aripiprazole lauroxil) ARISTADA INITIO PRSY 675mg/2.4ml 2 (aripiprazole lauroxil) CHLORPROMAZINE HCL SOLN 25mg/ml, 3 50mg/2ml chlorpromazine hcl TABS 10mg, 25mg, 1 50mg, 100mg, 200mg clozapine TABS 25mg, 50mg, 100mg, 1 200mg; TBDP 12.5mg, 25mg, 100mg, 150mg, 200mg fluphenazine decanoate SOLN 25mg/ml 1 fluphenazine hcl CONC 5mg/ml; ELIX 1 2.5mg/5ml; SOLN 2.5mg/ml; TABS 1mg, 2.5mg, 5mg, 10mg haloperidol TABS .5mg, 1mg, 2mg, 5mg, 1 10mg, 20mg haloperidol decanoate SOLN 50mg/ml, 1 100mg/ml haloperidol lactate CONC 2mg/ml; SOLN 1 5mg/ml LATUDA TABS 20mg, 40mg, 60mg, 80mg, 2 ST; PA** 120mg (lurasidone hcl) loxapine succinate CAPS 5mg, 10mg, 1 25mg, 50mg

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 39 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits olanzapine SOLR 10mg; TABS 2.5mg, 1 5mg, 7.5mg, 10mg, 15mg, 20mg; TBDP 5mg, 10mg, 15mg, 20mg paliperidone TB24 1.5mg, 3mg, 6mg, 9mg 1 perphenazine TABS 2mg, 4mg, 8mg, 1 16mg quetiapine fumarate TABS 25mg, 50mg, 1 100mg, 200mg, 300mg, 400mg quetiapine fumarate er TB24 50mg, 1 150mg, 200mg, 300mg, 400mg REXULTI TABS .25mg, .5mg, 1mg, 2mg, 3 ST; PA** 3mg, 4mg (brexpiprazole) risperidone SOLN 1mg/ml; TABS .25mg, 1 .5mg, 1mg, 2mg, 3mg, 4mg; TBDP .25mg, .5mg, 1mg, 2mg, 3mg, 4mg SAPHRIS SUBL 2.5mg, 5mg, 10mg 3 ST; PA** (asenapine maleate) thioridazine hcl TABS 10mg, 25mg, 50mg, 1 100mg thiothixene CAPS 1mg, 2mg, 5mg, 10mg 1 trifluoperazine hcl TABS 1mg, 2mg, 5mg, 1 10mg ziprasidone hcl CAPS 20mg, 40mg, 60mg, 1 80mg ATTENTION DEFICIT HYPERACTIVITY DISORDER§ - DRUGS TO TREAT ADHD amphetamine-dextroamphetamine cap er 1 QL (90 caps / 25 days) 24hr 5 mg amphetamine-dextroamphetamine cap er 1 QL (90 caps / 25 days) 24hr 10 mg amphetamine-dextroamphetamine cap er 1 QL (30 caps / 25 days) 24hr 15 mg amphetamine-dextroamphetamine cap er 1 QL (30 caps / 25 days) 24hr 20 mg amphetamine-dextroamphetamine cap er 1 QL (30 caps / 25 days) 24hr 25 mg amphetamine-dextroamphetamine cap er 1 QL (30 caps / 25 days) 24hr 30 mg amphetamine-dextroamphetamine tab 5 1 QL (90 tabs / 25 days) mg amphetamine-dextroamphetamine tab 7.5 1 QL (90 tabs / 25 days) mg amphetamine-dextroamphetamine tab 10 1 QL (90 tabs / 25 days) mg amphetamine-dextroamphetamine tab 1 QL (90 tabs / 25 days) 12.5 mg

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 40 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits amphetamine-dextroamphetamine tab 15 1 QL (60 tabs / 25 days) mg amphetamine-dextroamphetamine tab 20 1 QL (60 tabs / 25 days) mg amphetamine-dextroamphetamine tab 30 1 QL (30 tabs / 25 days) mg atomoxetine hcl CAPS 10mg, 18mg, 1 25mg, 40mg, 60mg, 80mg, 100mg dexmethylphenidate hcl CP24 5mg, 10mg, 1 QL (60 caps / 25 days) 15mg, 20mg dexmethylphenidate hcl CP24 25mg, 1 QL (30 caps / 25 days) 30mg, 35mg, 40mg dexmethylphenidate hcl TABS 2.5mg, 5mg 1 QL (120 tabs / 25 days) dexmethylphenidate hcl TABS 10mg 1 QL (60 tabs / 25 days) dextroamphetamine sulfate CP24 5mg, 1 QL (120 caps / 25 days) 10mg dextroamphetamine sulfate CP24 15mg 1 QL (60 caps / 25 days) dextroamphetamine sulfate SOLN 1 QL (1,200 mL / 25 days) 5mg/5ml dextroamphetamine sulfate TABS 5mg, 1 QL (120 tabs / 25 days) 10mg guanfacine hcl (adhd) TB24 1mg, 2mg, 1 ST; PA** 3mg, 4mg methamphetamine hcl TABS 5mg 1 QL (150 tabs / 25 days) methylphenidate hcl CHEW 2.5mg, 5mg, 1 QL (180 chew tabs / 25 10mg days) methylphenidate hcl CP24 20mg, 30mg; 1 QL (60 caps / 25 days) CPCR 10mg, 20mg, 30mg methylphenidate hcl CP24 40mg, 60mg; 1 QL (30 caps / 25 days) CPCR 40mg, 50mg, 60mg methylphenidate hcl SOLN 5mg/5ml 1 QL (1800 mL / 25 days) methylphenidate hcl SOLN 10mg/5ml 1 QL (900 mL / 25 days) methylphenidate hcl TABS 5mg, 10mg 1 QL (180 tabs / 25 days) methylphenidate hcl TABS 20mg; TBCR 1 QL (90 tabs / 25 days) 10mg, 20mg methylphenidate hcl TB24 18mg, 27mg, 1 QL (60 tabs / 25 days) 36mg; TBCR 18mg, 27mg, 36mg methylphenidate hcl TB24 54mg; TBCR 1 QL (30 tabs / 25 days) 54mg VYVANSE CAPS 10mg, 20mg, 30mg 2 QL (60 caps / 25 days) (lisdexamfetamine dimesylate) VYVANSE CAPS 40mg, 50mg, 60mg, 2 QL (30 caps / 25 days) 70mg (lisdexamfetamine dimesylate) VYVANSE CHEW 10mg, 20mg, 30mg 2 QL (60 tabs / 25 days) (lisdexamfetamine dimesylate) VYVANSE CHEW 40mg, 50mg, 60mg 2 QL (30 tabs / 25 days) (lisdexamfetamine dimesylate)

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 41 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits zenzedi TABS 2.5mg, 7.5mg (Zenzedi) 1 QL (120 tabs / 25 days) zenzedi TABS 15mg, 20mg (Zenzedi) 1 QL (60 tabs / 25 days) zenzedi TABS 30mg (Zenzedi) 1 QL (30 tabs / 25 days) HYPNOTICS§ - DRUGS TO TREAT INSOMNIA BELSOMRA TABS 5mg, 10mg, 15mg, 2 ST; PA** 20mg (suvorexant) cvs sleep-aid nighttime TABS 25mg (Cvs 1 OTC Sleep-aid Nighttime) eszopiclone TABS 1mg, 2mg, 3mg 1 QL (15 tabs / 25 days) HETLIOZ CAPS 20mg (tasimelteon) 4 QL (30 caps / 30 days), PA ramelteon TABS 8mg 1 QL (15 tabs / 25 days) temazepam CAPS 7.5mg, 15mg, 22.5mg, 1 QL (15 caps / 25 days) 30mg zaleplon CAPS 5mg, 10mg 1 QL (15 caps / 25 days) zolpidem tartrate TABS 5mg, 10mg; TBCR 1 QL (15 tabs / 25 days) 6.25mg, 12.5mg MIGRAINE§ - DRUGS TO TREAT SEVERE HEADACHES AIMOVIG SOAJ 70mg/ml (erenumab- 2 QL (2 injections / 25 aooe) days), ST; PA** AIMOVIG SOAJ 140mg/ml (erenumab- 2 QL (1 injection / 25 aooe) days), ST; PA** AJOVY SOAJ 225mg/1.5ml; SOSY 2 QL (3 injections / 75 225mg/1.5ml (fremanezumab-vfrm) days), ST; PA** almotriptan malate TABS 6.25mg, 12.5mg 1 QL (12 tabs / 25 days) dihydroergotamine mesylate SOLN 1 1mg/ml eletriptan hydrobromide TABS 20mg, 1 QL (12 tabs / 25 days) 40mg EMGALITY SOAJ 120mg/ml; SOSY 2 QL (2 injections / 25 120mg/ml (galcanezumab-gnlm) days), ST; PA** EMGALITY SOSY 100mg/ml 2 QL (3 injections / 25 (galcanezumab-gnlm) days), ST; PA** ergotamine w/ caffeine tab 1-100 mg 3 frovatriptan succinate TABS 2.5mg 1 QL (18 tabs / 25 days) naratriptan hcl TABS 1mg, 2.5mg 1 QL (12 tabs / 25 days) rizatriptan benzoate TABS 5mg, 10mg; 1 QL (18 tabs / 25 days) TBDP 5mg, 10mg sumatriptan SOLN 5mg/act 1 QL (24 sprays / 25 days) sumatriptan SOLN 20mg/act 1 QL (12 sprays / 25 days) sumatriptan succinate SOAJ 4mg/0.5ml; 1 QL (18 syringes / 25 SOCT 4mg/0.5ml days) sumatriptan succinate SOAJ 6mg/0.5ml; 1 QL (12 units / 25 days) SOCT 6mg/0.5ml; SOSY 6mg/0.5ml

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 42 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits sumatriptan succinate SOLN 6mg/0.5ml 1 QL (12 vials / 25 days) sumatriptan succinate TABS 25mg, 50mg, 1 QL (12 tabs / 25 days) 100mg zolmitriptan TABS 2.5mg, 5mg; TBDP 1 QL (12 tabs / 25 days) 2.5mg, 5mg ZOMIG SOLN 2.5mg, 5mg (zolmitriptan) 3 QL (12 sprays / 25 days) MISCELLANEOUS buspirone hcl TABS 5mg, 7.5mg, 10mg, 1 15mg, 30mg clomipramine hcl CAPS 25mg, 50mg 1 QL (150 caps / 25 days); QL applies to members age 65 and older clomipramine hcl CAPS 75mg 1 QL (90 caps / 25 days); QL applies to members age 65 and older fluvoxamine maleate CP24 100mg, 1 150mg; TABS 25mg, 50mg, 100mg GUANIDINE HCL TABS 125mg 3 LITHIUM SOLN 8meq/5ml 3 lithium carbonate CAPS 150mg, 300mg, 1 600mg; TABS 300mg; TBCR 300mg, 450mg NUEDEXTA CAP 20-10MG 2 PA (dextromethorphan hbr-quinidine sulfate) pimozide TABS 1mg, 2mg 1 pyridostigmine bromide SOLN 60mg/5ml; 1 TABS 60mg; TBCR 180mg riluzole TABS 50mg 1 tetrabenazine TABS 12.5mg 4 QL (120 tabs / 30 days), PA tetrabenazine TABS 25mg 4 QL (60 tabs / 30 days), PA MULTIPLE SCLEROSIS AGENTS - DRUGS TO TREAT MULTIPLE SCLEROSIS AUBAGIO TABS 7mg, 14mg 4 QL (30 tabs / 30 days), (teriflunomide) PA AVONEX PSKT 30mcg/0.5ml (interferon 4 QL (4 injections / 28 beta-1a) days), PA, ST AVONEX PEN AJKT 30mcg/0.5ml 4 QL (4 injections / 28 (interferon beta-1a) days), PA, ST BETASERON KIT .3mg (interferon beta- 4 QL (14 injections / 28 1b) days), PA COPAXONE INJ 20MG/ML SOSY 20mg/ml 4 QL (30 injections / 30 (glatiramer acetate) days), PA

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 43 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits COPAXONE INJ 40MG/ML SOSY 40mg/ml 4 QL (12 syringes / 28 (glatiramer acetate) days), PA dalfampridine TB12 10mg 4 QL (60 tabs / 30 days), PA GILENYA CAPS .5mg (fingolimod hcl) 4 QL (30 caps / 30 days), PA glatiramer acetate SOSY 40mg/ml 2 QL (12 syringes / 28 days), PA glatopa SOSY 20mg/ml (Glatopa) 2 QL (30 injections / 30 days), PA PLEGRIDY SOPN 125mcg/0.5ml; SOSY 4 QL (1 carton / 28 days), 125mcg/0.5ml (peginterferon beta-1a) PA, ST PLEGRIDY INJ STARTER (peginterferon 4 QL (1 kit / 28 days), PA, beta-1a) ST PLEGRIDY PEN INJ STARTER (peginterferon 4 QL (1 pack / 28 days), beta-1a) PA, ST REBIF SOSY 22mcg/0.5ml, 44mcg/0.5ml 4 QL (12 syringes / 28 (interferon beta-1a) days), PA REBIF REBIDO INJ TITRATN (interferon 4 QL (1 box / 28 days), PA beta-1a) REBIF REBIDOSE SOAJ 22mcg/0.5ml, 4 QL (12 syringes / 28 44mcg/0.5ml (interferon beta-1a) days), PA REBIF TITRTN INJ PACK (interferon beta- 4 QL (1 box / 28 days), PA 1a) TECFIDERA CPDR 120mg (dimethyl 4 QL (14 caps / 28 days), fumarate) PA TECFIDERA CPDR 240mg (dimethyl 4 QL (60 caps / 30 days), fumarate) PA TECFIDERA MIS STARTER (dimethyl 4 QL (1 kit / 30 days), PA fumarate) TYSABRI CONC 300mg/15ml 4 QL (1 vial / 28 days), PA (natalizumab) MUSCULOSKELETAL THERAPY AGENTS - DRUGS TO TREAT MUSCLE SPASMS baclofen TABS 5mg, 10mg, 20mg 1 carisoprodol TABS 250mg, 350mg 1 PA; High Risk Medications require PA for members age 70 and older chlorzoxazone TABS 500mg 1 PA; High Risk Medications require PA for members age 70 and older cyclobenzaprine hcl TABS 5mg, 10mg 1 PA; High Risk Medications require PA for members age 70 and older

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 44 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits dantrolene sodium CAPS 25mg, 50mg, 1 100mg metaxalone TABS 400mg, 800mg 1 PA; High Risk Medications require PA for members age 70 and older methocarbamol TABS 500mg, 750mg 1 PA; High Risk Medications require PA for members age 70 and older orphenadrine citrate SOLN 30mg/ml 1 orphenadrine citrate TB12 100mg 1 PA; High Risk Medications require PA for members age 70 and older tizanidine hcl TABS 2mg, 4mg 1 NARCOLEPSY/CATAPLEXY - DRUGS FOR SLEEP DISORDERS armodafinil TABS 50mg, 150mg, 200mg, 1 PA 250mg modafinil TABS 100mg, 200mg 1 PA PSYCHOTHERAPEUTIC-MISC acamprosate calcium TBEC 333mg 1 PA bupropion hcl (smoking deterrent) TB12 PV $0 limited to 2 150mg treatment cycles/year CHANTIX TABS .5mg, 1mg (varenicline PV $0 limited to 2 tartrate) treatment cycles/year CHANTIX CONTINUING MONTH TABS 1mg PV $0 limited to 2 (varenicline tartrate) treatment cycles/year CHANTIX PAK 0.5& 1MG (varenicline PV $0 limited to 2 tartrate) treatment cycles/year disulfiram TABS 250mg, 500mg 1 goodsense nicotine polacr LOZG 4mg PV OTC; $0 limited to 2 (Goodsense Nicotine Polacr) treatment cycles/year naloxone hcl SOCT .4mg/ml; SOLN 1 .4mg/ml, 4mg/10ml; SOSY 2mg/2ml naltrexone hcl TABS 50mg PV $0 copay NARCAN LIQD 4mg/0.1ml (naloxone hcl) 2 nicotine PT24 7mg/24hr, 14mg/24hr, PV OTC; $0 limited to 2 21mg/24hr treatment cycles/year nicotine polacrilex GUM 2mg, 4mg; LOZG PV OTC; $0 limited to 2 2mg treatment cycles/year nicotine polacrilex GUM 4mg (Goodsense PV OTC; $0 limited to 2 Nicotine Polacr) treatment cycles/year nicotine step 3 PT24 7mg/24hr (Nicotine PV OTC; $0 limited to 2 Step 3) treatment cycles/year

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 45 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits NICOTROL INHALER INHA 10mg (nicotine) PV QL (max 168 days / year); $0 limited to 2 treatment cycles/year NICOTROL NS SOLN 10mg/ml (nicotine) PV QL (max 168 days / year); $0 limited to 2 treatment cycles/year sm nicotine transdermal s PT24 PV OTC; $0 limited to 2 7mg/24hr, 14mg/24hr, 21mg/24hr (Sm treatment cycles/year Nicotine Transdermal S) VIVITROL SUSR 380mg (naltrexone) 4 QL (1 vial / 28 days), PA ENDOCRINE AND METABOLIC - DRUGS TO TREAT DIABETES AND REGULATE HORMONES ANDROGENS - DRUGS TO REGULATE MALE HORMONES INTRAROSA INST 6.5mg (prasterone 3 vaginal) methyltestosterone CAPS 10mg 1 PA testosterone GEL 10mg/act, 25mg/2.5gm 1 PA testosterone cypionate SOLN 100mg/ml, 1 PA 200mg/ml testosterone enanthate SOLN 200mg/ml 1 PA ANTIDIABETICS, ALPHA-GLUCOSIDASE INHIBITORS acarbose TABS 25mg, 50mg, 100mg 1 miglitol TABS 25mg, 50mg, 100mg 1 ANTIDIABETICS, AMYLIN ANALOGS SYMLINPEN 60 SOPN 1500mcg/1.5ml 3 ST; PA** (pramlintide acetate) SYMLINPEN 120 SOPN 2700mcg/2.7ml 3 ST; PA** (pramlintide acetate) ANTIDIABETICS, hcl TABS 500mg, 850mg, 1 1000mg; TB24 500mg, 750mg ANTIDIABETICS, BIGUANIDE/ SULFONYLUREA COMBINATIONS glipizide-metformin hcl tab 2.5-250 mg 1 glipizide-metformin hcl tab 2.5-500 mg 1 glipizide-metformin hcl tab 5-500 mg 1 ANTIDIABETICS, DIPEPTIDYL PEPTIDASE-4 INHIBITORS alogliptin benzoate TABS 6.25mg, 1 ST; PA** 12.5mg, 25mg JANUVIA TABS 25mg, 50mg, 100mg 2 ST; PA** (sitagliptin phosphate) ANTIDIABETICS, DOPAMINE RECEPTOR AGONISTS CYCLOSET TABS .8mg (bromocriptine 3 mesylate (diabetes))

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 46 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits ANTIDIABETICS, DPP-4 INHIBITOR COMBINATIONS JANUMET TAB 50-500MG (sitagliptin- 2 ST; PA** metformin hcl) JANUMET TAB 50-1000 (sitagliptin- 2 ST; PA** metformin hcl) JANUMET XR TAB 50-500MG (sitagliptin- 2 ST; PA** metformin hcl) JANUMET XR TAB 50-1000 (sitagliptin- 2 ST; PA** metformin hcl) JANUMET XR TAB 100-1000 (sitagliptin- 2 ST; PA** metformin hcl) JENTADUETO XR TAB 2.5-1000MG 3 ST; PA** (linagliptin-metformin hcl) JENTADUETO XR TAB 5-1000MG 3 ST; PA** (linagliptin-metformin hcl) ANTIDIABETICS, INCRETIN MIMETIC AGENTS OZEMPIC SOPN 2mg/1.5ml (semaglutide) 2 ST; PA** TRULICITY SOPN .75mg/0.5ml, 2 ST; PA** 1.5mg/0.5ml (dulaglutide) VICTOZA SOPN 18mg/3ml (liraglutide) 2 ST; PA** ANTIDIABETICS, INCRETIN MIMETIC COMBINATION AGENTS SOLIQUA INJ 100/33 (insulin glargine- 2 ST; PA** lixisenatide) XULTOPHY INJ 100/3.6 (insulin degludec- 2 ST; PA** liraglutide) ANTIDIABETICS, INSULIN BASAGLAR KWIKPEN SOPN 100unit/ml 2 (insulin glargine) FIASP FLEX INJ TOUCH (insulin aspart 2 (with niacinamide)) FIASP INJ 100/ML (insulin aspart (with 2 niacinamide)) FIASP PENFIL INJ U-100 (insulin aspart 2 (with niacinamide)) HUMULIN INJ 70/30 (insulin nph isophane 3 OTC & reg (human)) HUMULIN INJ 70/30KWP (insulin nph 3 OTC isophane & reg (human)) HUMULIN N SUSP 100unit/ml (insulin nph 3 OTC (human) (isophane)) HUMULIN N KWIKPEN SUPN 100unit/ml 3 OTC (insulin nph (human) (isophane)) HUMULIN R SOLN 100unit/ml (insulin 3 OTC regular (human)) HUMULIN R U-500 (CONCENTR SOLN 2 500unit/ml (insulin regular (human))

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 47 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits HUMULIN R U-500 KWIKPEN SOPN 2 500unit/ml (insulin regular (human)) LEVEMIR SOLN 100unit/ml (insulin 2 detemir) LEVEMIR FLEXTOUCH SOPN 100unit/ml 2 (insulin detemir) NOVOLIN INJ 70/30 (insulin nph isophane 2 OTC; RELION not & reg (human)) covered NOVOLIN INJ 70/30 FP (insulin nph 2 OTC; RELION not isophane & reg (human)) covered NOVOLIN N SUSP 100unit/ml (insulin nph 2 OTC; RELION not (human) (isophane)) covered NOVOLIN N FLEXPEN SUPN 100unit/ml 2 OTC; RELION not (insulin nph (human) (isophane)) covered NOVOLIN R SOLN 100unit/ml (insulin 2 OTC; RELION not regular (human)) covered NOVOLIN R FLEXPEN SOPN 100unit/ml 2 OTC; RELION not (insulin regular (human)) covered NOVOLOG SOLN 100unit/ml (insulin 2 aspart) NOVOLOG FLEXPEN SOPN 100unit/ml 2 (insulin aspart) NOVOLOG MIX 70/30 FLEXPEN (insulin 2 aspart protamine & aspart (human)) NOVOLOG MIX INJ 70/30 (insulin aspart 2 protamine & aspart (human)) NOVOLOG PENFILL SOCT 100unit/ml 2 (insulin aspart) TRESIBA SOLN 100unit/ml (insulin 2 degludec) TRESIBA FLEXTOUCH SOPN 100unit/ml, 2 200unit/ml (insulin degludec) ANTIDIABETICS, INSULIN SENSITIZER pioglitazone hcl TABS 15mg, 30mg, 45mg 1 ANTIDIABETICS, INSULIN SENSITIZER/BIGUANIDE COMBINATION pioglitazone hcl-metformin hcl tab 15-500 1 mg pioglitazone hcl-metformin hcl tab 15-850 1 mg ANTIDIABETICS, INSULIN SENSITIZER/SULFONYLUREA COMBINATION pioglitazone hcl-glimepiride tab 30-2 mg 1 pioglitazone hcl-glimepiride tab 30-4 mg 1 ANTIDIABETICS, MEGLITINIDE nateglinide TABS 60mg, 120mg 1 repaglinide TABS .5mg, 1mg, 2mg 1

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 48 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits ANTIDIABETICS, SODIUM-GLUC CO-TRANSPOR2 INHIB (SGLT2) COMBO SYNJARDY TAB 5-500MG (empagliflozin- 2 ST; PA** metformin hcl) SYNJARDY TAB 5-1000MG (empagliflozin- 2 ST; PA** metformin hcl) SYNJARDY TAB 12.5-500 (empagliflozin- 2 ST; PA** metformin hcl) SYNJARDY TAB 12.5-1000MG 2 ST; PA** (empagliflozin-metformin hcl) SYNJARDY XR TAB 5-1000MG 2 ST; PA** (empagliflozin-metformin hcl) SYNJARDY XR TAB 10-1000 (empagliflozin- 2 ST; PA** metformin hcl) SYNJARDY XR TAB 12.5-1000MG 2 ST; PA** (empagliflozin-metformin hcl) SYNJARDY XR TAB 25-1000 (empagliflozin- 2 ST; PA** metformin hcl) XIGDUO XR TAB 2.5-1000 (dapagliflozin- 2 ST; PA** metformin hcl) XIGDUO XR TAB 5-500MG (dapagliflozin- 2 ST; PA** metformin hcl) XIGDUO XR TAB 5-1000MG (dapagliflozin- 2 ST; PA** metformin hcl) XIGDUO XR TAB 10-500MG (dapagliflozin- 2 ST; PA** metformin hcl) XIGDUO XR TAB 10-1000 (dapagliflozin- 2 ST; PA** metformin hcl) ANTIDIABETICS, SODIUM-GLUC CO-TRANSPOR2 INHIB (SGLT2)/DPP-4 INHIBITOR COMBINATIONS GLYXAMBI TAB 10-5 MG (empagliflozin- 2 ST; PA** linagliptin) GLYXAMBI TAB 25-5 MG (empagliflozin- 2 ST; PA** linagliptin) ANTIDIABETICS, SODIUM-GLUCOSE COTRANSPORTER2(SGLT2) INHIB FARXIGA TABS 5mg, 10mg (dapagliflozin 2 ST; PA** propanediol) JARDIANCE TABS 10mg, 25mg 2 ST; PA** (empagliflozin) ANTIDIABETICS, SULFONYLUREA glimepiride TABS 1mg, 2mg, 4mg 1 glipizide TABS 5mg, 10mg; TB24 2.5mg, 1 5mg, 10mg

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 49 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits BISPHOSPHONATES - DRUGS TO TREAT BONE LOSS alendronate sodium SOLN 70mg/75ml; 1 TABS 5mg, 10mg, 35mg, 70mg FOSAMAX + D TAB 70-2800 (alendronate 3 ST; PA** sodium-cholecalciferol) FOSAMAX + D TAB 70-5600 (alendronate 3 ST; PA** sodium-cholecalciferol) ibandronate sodium SOLN 3mg/3ml; TABS 1 150mg pamidronate disodium SOLN 30mg/10ml 1 risedronate sodium TABS 5mg, 30mg, 1 35mg, 150mg; TBEC 35mg zoledronic acid CONC 4mg/5ml; SOLN 4 PA 5mg/100ml CALCIUM RECEPTOR AGONISTS cinacalcet hcl TABS 30mg, 60mg 4 QL (60 tabs / 30 days), PA cinacalcet hcl TABS 90mg 4 QL (120 tabs / 30 days), PA CHELATING AGENTS CHEMET CAPS 100mg (succimer) 3 FERRIPROX SOLN 100mg/ml; TABS 4 PA 500mg, 1000mg (deferiprone) FERRIPROX TWICE-A-DAY TABS 1000mg 4 PA (deferiprone) kionex SUSP 15gm/60ml (Kionex) 1 penicillamine TABS 250mg 1 PA sodium polystyrene sulfonate SUSP 1 15gm/60ml, 30gm/120ml CONTRACEPTIVES - PRODUCTS FOR BIRTH CONTROL altavera (Altavera) PV alyacen 1/35 (Alyacen 1/35) PV alyacen 7/7/7 (Alyacen 7/7/7) PV amethia (Amethia) PV amethyst (Amethyst) PV ANNOVERA MIS (segesterone acetate- PV QL (1 / 300 days) ethinyl estradiol) apri (Apri) PV aranelle (Aranelle) PV ashlyna (Ashlyna) PV aviane (Aviane) PV azurette (Azurette) PV BALCOLTRA TAB 0.1-20 (levonorgestrel- PV ethinyl estradiol-ferrous bisglycinate) camila TABS .35mg (Camila) PV caziant (Caziant) PV

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 50 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits chateal (Chateal) PV cryselle-28 (Cryselle-28) PV cyclafem 1/35 (Cyclafem 1/35) PV cyclafem 7/7/7 (Cyclafem 7/7/7) PV dasetta 1/35 (Dasetta 1/35) PV dasetta 7/7/7 (Dasetta 7/7/7) PV delyla (Delyla) PV DEPO-SUBQ PROVERA 104 SUSY PV QL (4 inj / 300 days) 104mg/0.65ml (medroxyprogesterone acetate (contraceptive)) drospirenone-ethinyl estrad-levomefolate PV tab 3-0.02-0.451 mg drospirenone-ethinyl estrad-levomefolate PV tab 3-0.03-0.451 mg drospirenone-ethinyl estradiol tab 3-0.03 PV mg elinest (Elinest) PV ELLA TABS 30mg (ulipristal acetate) PV emoquette (Emoquette) PV enpresse-28 (Enpresse-28) PV enskyce (Enskyce) PV errin TABS .35mg (Errin) PV ethynodiol diacetate & ethinyl estradiol tab PV 1 mg-50 mcg etonogestrel-ethinyl estradiol va ring PV QL (13 / 300 days) 0.120-0.015 mg/24hr falmina (Falmina) PV fayosim (Fayosim) PV gianvi (Gianvi) PV heather TABS .35mg (Heather) PV introvale (Introvale) PV jolessa (Jolessa) PV junel 1.5/30 (Junel 1.5/30) PV junel 1/20 (Junel 1/20) PV junel fe 1.5/30 (Junel Fe 1.5/30) PV junel fe 1/20 (Junel Fe 1/20) PV kariva (Kariva) PV kelnor 1/35 (Kelnor 1/35) PV kurvelo (Kurvelo) PV KYLEENA IUD 19.5mg (levonorgestrel PV QL (1 / 300 days) (iud)) larin 1.5/30 (Larin 1.5/30) PV leena (Leena) PV lessina (Lessina) PV levonest (Levonest) PV

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 51 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits levonorg-eth est tab 0.1-0.02mg(84) & eth PV est tab 0.01mg(7) levonorgestrel & ethinyl estradiol (91-day) PV tab 0.15-0.03 mg levonorgestrel & ethinyl estradiol tab 0.15 PV mg-30 mcg levora 0.15/30-28 (Levora 0.15/30-28) PV LILETTA IUD 19.5mcg/day (levonorgestrel PV QL (1 / 300 days) (iud)) LO LOESTRIN TAB 1-10-10 (norethindrone PV acetate-ethinyl estradiol-fe fum (biphasic)) loryna (Loryna) PV low-ogestrel (Low-ogestrel) PV lutera (Lutera) PV marlissa (Marlissa) PV medroxyprogesterone acetate PV QL (4 inj / 300 days) (contraceptive) SUSP 150mg/ml; SUSY 150mg/ml mibelas 24 fe (Mibelas 24 Fe) PV microgestin 1.5/30 (Microgestin 1.5/30) PV MIRENA IUD 20mcg/24hr (levonorgestrel PV QL (1 / 300 days) (iud)) mono-linyah (Mono-linyah) PV NATAZIA TAB (estradiol valerate- PV dienogest) necon 0.5/35-28 (Necon 0.5/35-28) PV NEXPLANON IMPL 68mg (etonogestrel) PV QL (1 / 300 days) nikki (Nikki) PV nora-be TABS .35mg (Nora-be) PV norethindrone & ethinyl estradiol tab 0.4 PV mg-35 mcg (Vyfemla) norethindrone & ethinyl estradiol-fe chew PV tab 0.4 mg-35 mcg norethindrone & ethinyl estradiol-fe chew PV tab 0.8 mg-25 mcg norethindrone (contraceptive) TABS PV .35mg norethindrone ace & ethinyl estradiol tab 1 PV mg-20 mcg norethindrone ace-ethinyl estradiol-fe tab PV 1 mg-20 mcg (24) norgestimate & ethinyl estradiol tab 0.25 PV mg-35 mcg norgestimate-eth estrad tab 0.18- PV 25/0.215-25/0.25-25 mg-mcg norgestimate-eth estrad tab 0.18- PV 35/0.215-35/0.25-35 mg-mcg

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 52 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits nortrel 0.5/35 (28) (Nortrel 0.5/35 (28)) PV nortrel 1/35 (Nortrel 1/35) PV nortrel 7/7/7 (Nortrel 7/7/7) PV ocella (Ocella) PV ogestrel (Ogestrel) PV orsythia (Orsythia) PV PARAGARD IUD T380A (copper (iud)) PV QL (1 unit / 300 days) pirmella 1/35 (Pirmella 1/35) PV pirmella 7/7/7 (Pirmella 7/7/7) PV portia-28 (Portia-28) PV previfem (Previfem) PV reclipsen (Reclipsen) PV rivelsa (Rivelsa) PV SKYLA IUD 13.5mg (levonorgestrel (iud)) PV QL (1 / 300 days) SLYND TABS 4mg (drospirenone) PV sprintec 28 (Sprintec 28) PV sronyx (Sronyx) PV syeda (Syeda) PV take action TABS 1.5mg (Take Action) PV OTC TAYTULLA CAP 1MG/20MC (norethin acet & PV estrad-fe) tilia fe (Tilia Fe) PV tri-linyah (Tri-linyah) PV tri-sprintec (Tri-sprintec) PV trivora-28 (Trivora-28) PV velivet (Velivet) PV viorele (Viorele) PV wera (Wera) PV xulane (Xulane) PV zarah (Zarah) PV zovia 1/35e (Zovia 1/35e) PV ENDOMETRIOSIS danazol CAPS 50mg, 100mg, 200mg 1 ORILISSA TABS 150mg, 200mg (elagolix 2 sodium) SYNAREL SOLN 2mg/ml (nafarelin 4 PA acetate) ENZYME REPLACEMENTS - DRUGS TO TREAT ENZYME DEFICIENCIES CARBAGLU TABS 200mg (carglumic acid) 4 PA CERDELGA CAPS 84mg (eliglustat 4 QL (60 caps / 30 days), tartrate) PA CYSTADANE POW (betaine) 4 PA CYSTAGON CAPS 50mg, 150mg 4 PA (cysteamine bitartrate)

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 53 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits KUVAN PACK 100mg, 500mg; TBSO 4 PA 100mg (sapropterin dihydrochloride) nitisinone CAPS 2mg, 5mg, 10mg 4 PA ORFADIN CAPS 20mg; SUSP 4mg/ml 4 PA (nitisinone) sodium phenylbutyrate TABS 500mg 4 QL (1200 tabs / 30 days), PA sodium phenylbutyrate oral powder 3 4 QL (600g / 30 days), PA gm/teaspoonful POWD 3gm/tsp ESTROGENS - DRUGS TO REGULATE FEMALE HORMONES CLIMARA PRO DIS WEEKLY (estradiol- 2 levonorgestrel) DEPO-ESTRADIOL OIL 5mg/ml (estradiol 3 cypionate) DIVIGEL GEL .25mg/0.25gm, 3 PA; High Risk .5mg/0.5gm, .75mg/0.75gm, 1mg/gm, Medications require PA 1.25mg/1.25gm (estradiol) for members age 70 and older DUAVEE TAB 0.45-20 (conjugated 2 estrogens-bazedoxifene) ELESTRIN GEL .06% (estradiol) 3 PA; High Risk Medications require PA for members age 70 and older estradiol PTTW .025mg/24hr, 1 PA; High Risk .037mg/24hr, .05mg/24hr, .075mg/24hr, Medications require PA .1mg/24hr; PTWK .025mg/24hr, for members age 70 and .05mg/24hr, .06mg/24hr, .075mg/24hr, older .1mg/24hr, 37.5mcg/24hr; TABS .5mg, 1mg, 2mg estradiol & norethindrone acetate tab 0.5- 1 0.1 mg estradiol & norethindrone acetate tab 1-0.5 1 mg estradiol vaginal cream CREA .1mg/gm 1 estradiol valerate OIL 20mg/ml, 40mg/ml 1 ESTROGEL GEL .06% (estradiol) 3 PA; High Risk Medications require PA for members age 70 and older EVAMIST SOLN 1.53mg/spray (estradiol) 3 PA; High Risk Medications require PA for members age 70 and older jinteli (Jinteli) 1

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 54 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits MENEST TABS .3mg, .625mg, 1.25mg 3 PA; High Risk (esterified estrogens) Medications require PA for members age 70 and older mimvey (Mimvey) 1 norethindrone acetate-ethinyl estradiol tab 1 0.5 mg-2.5 mcg PREMARIN CREA .625mg/gm (estrogens, 3 conjugated vaginal) PREMARIN TABS .3mg, .45mg, .625mg, 3 PA; High Risk .9mg, 1.25mg (estrogens, conjugated) Medications require PA for members age 70 and older yuvafem TABS 10mcg (Yuvafem) 1 GLUCOCORTICOIDS - DRUGS TO TREAT INFLAMMATORY RESPONSE cortisone acetate TABS 25mg 1 DEPO-MEDROL SUSP 20mg/ml 3 (methylprednisolone acetate) dexamethasone ELIX .5mg/5ml; SOLN 1 .5mg/5ml; TABS .5mg, .75mg, 1mg, 1.5mg, 2mg, 4mg, 6mg DEXAMETHASONE INTENSOL CONC 2 1mg/ml (dexamethasone) dexamethasone sodium phosphate SOLN 1 4mg/ml, 10mg/ml, 20mg/5ml, 100mg/10ml, 120mg/30ml fludrocortisone acetate TABS .1mg 1 hydrocortisone TABS 5mg, 10mg, 20mg 1 MEDROL TABS 2mg (methylprednisolone) 2 methylprednisolone TABS 4mg, 8mg, 1 16mg, 32mg; TBPK 4mg methylprednisolone acetate SUSP 1 40mg/ml, 80mg/ml methylprednisolone sod succ SOLR 1 125mg, 1000mg SOLN 15mg/5ml 1 prednisolone sodium phosphate SOLN 1 5mg/5ml, 10mg/5ml, 15mg/5ml, 20mg/5ml, 25mg/5ml; TBDP 10mg, 15mg, 30mg SOLN 5mg/5ml; TABS 1mg, 1 2.5mg, 5mg, 10mg, 20mg, 50mg; TBPK 5mg, 10mg PREDNISONE INTENSOL CONC 5mg/ml 2 (prednisone)

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 55 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits SOLU-CORTEF SOLR 100mg, 250mg, 3 500mg, 1000mg (hydrocortisone sod succinate) SOLU-MEDROL SOLR 2gm 3 (methylprednisolone sod succ) GLUCOSE ELEVATING AGENTS - DRUGS TO TREAT LOW BLOOD SUGAR GLUCAGON EMERGENCY KIT KIT 1mg 2 (glucagon (rdna)) INSTA-GLUCOSE GEL 77.4% (dextrose 2 OTC (diabetic use)) HUMAN GROWTH HORMONES - DRUGS TO REGULATE PITUITARY HORMONES HUMATROPE SOLR 6mg, 12mg, 24mg 4 PA (somatropin) HUMATROPE COMBO PACK SOLR 5mg 4 PA (somatropin) MISCELLANEOUS cabergoline TABS .5mg 1 calcitonin (salmon) SOLN 200unit/act 1 INCRELEX SOLN 40mg/4ml (mecasermin) 4 PA acetate SOLN 50mcg/ml, 4 QL (90 ml / 30 days), 100mcg/ml, 500mcg/ml PA octreotide acetate SOLN 200mcg/ml 4 QL (225 ml / 30 days), PA octreotide acetate SOLN 1000mcg/ml 4 QL (45 ml / 30 days), PA OSPHENA TABS 60mg (ospemifene) 2 PROLIA SOSY 60mg/ml (denosumab) 4 QL (60mg / 24 weeks), PA raloxifene hcl TABS 60mg 1 $0 copay for women ages 35 and older for the primary prevention of breast cancer SAMSCA TABS 15mg (tolvaptan) 4 PA SIGNIFOR SOLN .3mg/ml, .6mg/ml, 4 QL (60 ampules / 30 .9mg/ml (pasireotide diaspartate) days), PA SOMATULINE DEPOT SOLN 60mg/0.2ml, 4 QL (1 injection / 28 90mg/0.3ml, 120mg/0.5ml (lanreotide days), PA acetate) SOMAVERT SOLR 10mg, 15mg, 20mg, 4 QL (30 vials / 30 days), 25mg, 30mg (pegvisomant) PA tolvaptan TABS 30mg 4 PA TYMLOS SOPN 3120mcg/1.56ml 4 QL (1 pen / 30 days), PA (abaloparatide)

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 56 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits PHOSPHATE BINDER AGENTS - DRUGS TO REGULATE CALCIUM AND PHOSPHORUS LEVELS calcium acetate (phosphate binder) CAPS 1 667mg; TABS 667mg FOSRENOL PACK 750mg, 1000mg 3 (lanthanum carbonate) PHOSLYRA SOLN 667mg/5ml (calcium 2 acetate (phosphate binder)) sevelamer carbonate PACK .8gm, 2.4gm; 1 TABS 800mg VELPHORO CHEW 500mg (sucroferric 3 oxyhydroxide) PROGESTINS - DRUGS TO REGULATE FEMALE HORMONES CRINONE GEL 4%, 8% (progesterone 2 (vaginal)) LUPANETA KIT 3.75-5 (leuprolide acetate & 4 PA norethindrone acetate) LUPANETA KIT 11.25-5 (leuprolide acetate 4 PA & norethindrone acetate) medroxyprogesterone acetate TABS 1 2.5mg, 5mg, 10mg norethindrone acetate TABS 5mg 1 progesterone micronized CAPS 100mg, 1 200mg THYROID AGENTS - DRUGS TO REGULATE THYROID LEVELS levothyroxine sodium TABS 25mcg, 1 50mcg, 75mcg, 88mcg, 100mcg, 112mcg, 125mcg, 137mcg, 150mcg, 175mcg, 200mcg, 300mcg levoxyl TABS 25mcg, 50mcg, 75mcg, 1 88mcg, 100mcg, 112mcg, 125mcg, 137mcg, 150mcg, 175mcg, 200mcg (Levoxyl) liothyronine sodium TABS 5mcg, 25mcg, 1 50mcg methimazole TABS 5mg, 10mg 1 propylthiouracil TABS 50mg 1 SYNTHROID TABS 25mcg, 50mcg, 75mcg, 2 88mcg, 100mcg, 112mcg, 125mcg, 137mcg, 150mcg, 175mcg, 200mcg, 300mcg (levothyroxine sodium) unithroid TABS 25mcg, 50mcg, 75mcg, 1 88mcg, 100mcg, 112mcg, 125mcg, 200mcg, 300mcg (Unithroid) VASOPRESSINS - DRUGS TO REGULATE PITUITARY HORMONES desmopressin acetate SOLN 4mcg/ml; 1 TABS .1mg, .2mg PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 57 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits desmopressin acetate spray SOLN .01% 1 desmopressin acetate spray refrigerated 1 SOLN .01% GASTROINTESTINAL - DRUGS TO TREAT STOMACH AND INTESTINAL DISORDERS ANTICHOLINERGICS atropine sulfate SOSY .25mg/5ml, 1 1mg/10ml CUVPOSA SOLN 1mg/5ml (glycopyrrolate) 2 dicyclomine hcl CAPS 10mg; SOLN 1 10mg/5ml, 10mg/ml; TABS 20mg ed-spaz TBDP .125mg (Ed-spaz) 1 glycopyrrolate SOLN 1mg/5ml, 4mg/20ml; 1 TABS 1mg, 2mg hyoscyamine sulfate SUBL .125mg; TABS 1 .125mg; TB12 .375mg; TBDP .125mg methscopolamine bromide TABS 2.5mg, 1 PA; High Risk 5mg Medications require PA for members age 70 and older nulev TBDP .125mg (Nulev) 1 oscimin SUBL .125mg; TABS .125mg 1 (Oscimin) oscimin sr TB12 .375mg (Oscimin Sr) 1 symax-sl SUBL .125mg (Symax-sl) 1 ANTIEMETICS§ - DRUGS FOR NAUSEA AND VOMITING AKYNZEO CAP 300-0.5 (netupitant- 3 QL (2 caps / 21 days) palonosetron) aprepitant CAPS 40mg 1 QL (3 caps / 180 days) aprepitant CAPS 80mg 1 QL (4 caps / 21 days) aprepitant CAPS 125mg 1 QL (2 caps / 21 days) aprepitant pak 80 & 125 1 QL (2 packs / 21 days) compro SUPP 25mg (Compro) 1 dronabinol CAPS 2.5mg, 5mg, 10mg 1 QL (60 caps / 25 days) granisetron hcl SOLN 1mg/ml 1 QL (2 mL / 21 days) granisetron hcl TABS 1mg 1 QL (12 tabs / 21 days) meclizine hcl TABS 12.5mg, 25mg 1 metoclopramide hcl SOLN 5mg/ml, 1 10mg/10ml; TABS 5mg, 10mg; TBDP 5mg ondansetron TBDP 4mg, 8mg 1 QL (18 tabs / 21 days) ondansetron hcl SOLN 4mg/2ml, 1 QL (20 mL / 21 days) 40mg/20ml ondansetron hcl SOLN 4mg/5ml 1 QL (200 mL / 21 days) ondansetron hcl TABS 4mg, 8mg 1 QL (18 tabs / 21 days) ondansetron hcl TABS 24mg 1 QL (2 tabs / 21 days) phenadoz SUPP 25mg (Phenadoz) 1

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 58 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits prochlorperazine SUPP 25mg 1 prochlorperazine maleate TABS 5mg, 1 10mg promethazine hcl SOLN 25mg/ml, 1 50mg/ml; SUPP 12.5mg, 25mg promethazine hcl SYRP 6.25mg/5ml; 1 PA; High Risk TABS 12.5mg, 25mg, 50mg Medications require PA for members age 70 and older promethegan SUPP 12.5mg, 25mg, 50mg 1 (Promethegan) SANCUSO PTCH 3.1mg/24hr (granisetron) 2 QL (2 patches / 21 days) scopolamine PT72 1mg/3days 1 trimethobenzamide hcl CAPS 300mg 1 VARUBI TBPK 90mg (rolapitant hcl) 2 H2-RECEPTOR ANTAGONISTS - DRUGS FOR ULCERS AND STOMACH ACID TABS 200mg, 300mg, 400mg, 1 800mg cimetidine hcl SOLN 300mg/5ml 1 famotidine SOLN 20mg/2ml; SUSR 1 40mg/5ml; TABS 20mg, 40mg famotidine in nacl 0.9% iv soln 20 1 mg/50ml nizatidine CAPS 150mg, 300mg; SOLN 1 15mg/ml ranitidine hcl SOLN 50mg/2ml 1 INFLAMMATORY BOWEL DISEASE - BOWEL, INTESTINE, AND STOMACH CONDITION DRUGS disodium CAPS 750mg 1 CPEP 3mg 1 colocort ENEM 100mg/60ml (Colocort) 1 DIPENTUM CAPS 250mg ( 3 PA sodium) mesalamine CP24 .375gm; CPDR 400mg; 1 ENEM 4gm; SUPP 1000mg; TBEC 1.2gm, 800mg mesalamine w/ cleanser KIT 4gm 1 TABS 500mg; TBEC 500mg 1 IRRITABLE BOWEL SYNDROME WITH CONSTIPATION AMITIZA CAPS 8mcg, 24mcg 2 (lubiprostone) LINZESS CAPS 72mcg, 145mcg, 290mcg 2 (linaclotide)

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 59 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits IRRITABLE BOWEL SYNDROME WITH DIARRHEA alosetron hcl TABS .5mg, 1mg 1 PA LAXATIVES - DRUGS FOR CONSTIPATION CLENPIQ SOL (sodium picosulfate- PV $0 copay for members magnesium oxide-anhydrous citric acid) age 50 through 74, otherwise not covered enulose SOLN 10gm/15ml (Enulose) 1 gavilyte-c (Gavilyte-c) 1 gavilyte-g (Gavilyte-g) 1 gavilyte-h (Gavilyte-h) PV $0 copay for members age 50 through 74, otherwise not covered gavilyte-n/flavor pack (Gavilyte-n/flavor 1 Pack) generlac SOLN 10gm/15ml (Generlac) 1 GOLYTELY SOL (peg 3350-kcl-sod bicarb- 2 sod chloride-sod sulfate) lactulose SOLN 10gm/15ml 1 MOVIPREP SOL (peg 3350-kcl-nacl-na PV $0 copay for members sulfate-na ascorbate-ascorbic acid) age 50 through 74; Tier 2 for all others OSMOPREP TAB 1.5GM (sodium phosphate 3 monobasic-sodium phosphate dibasic) peg 3350-kcl-na bicarb-nacl-na sulfate for 1 soln 236 gm peg 3350-kcl-sod bicarb-nacl for soln 420 1 gm PLENVU SOL (peg 3350-kcl-nacl-na PV $0 copay for members sulfate-na ascorbate-ascorbic acid) age 50 through 74, otherwise not covered polyethylene glycol 3350 POWD 1 OTC 17gm/scoop PREPOPIK PAK (sodium picosulfate- PV $0 copay for members magnesium oxide-anhydrous citric acid) age 50 through 74, otherwise not covered SUPREP BOWEL SOL PREP KIT (sodium PV $0 copay for members sulfate-potassium sulfate-magnesium age 50 through 74; Tier sulfate) 2 for all others MISCELLANEOUS cromolyn sodium (mastocytosis) CONC 1 100mg/5ml w/ atropine liq 2.5-0.025 1 mg/5ml diphenoxylate w/ atropine tab 2.5-0.025 1 mg hcl CAPS 2mg 1 misoprostol TABS 100mcg, 200mcg 1 PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 60 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits MOTOFEN TAB 1-0.025 ( w/ 3 atropine) MOVANTIK TABS 12.5mg, 25mg 2 (naloxegol oxalate) SUCRAID SOLN 8500unit/ml (sacrosidase) 3 QL (354 mL / 25 days), PA sucralfate TABS 1gm 1 ursodiol CAPS 300mg; TABS 250mg, 1 500mg PANCREATIC ENZYMES CREON CAP 3000UNIT (pancrelipase 2 PA (lipase-protease-amylase)) CREON CAP 6000UNIT (pancrelipase 2 PA (lipase-protease-amylase)) CREON CAP 12000UNT (pancrelipase 2 PA (lipase-protease-amylase)) CREON CAP 24000UNT (pancrelipase 2 PA (lipase-protease-amylase)) CREON CAP 36000UNT (pancrelipase 2 PA (lipase-protease-amylase)) VIOKACE TAB 10440 (pancrelipase (lipase- 2 PA protease-amylase)) VIOKACE TAB 20880 (pancrelipase (lipase- 2 PA protease-amylase)) ZENPEP CAP 3000UNIT (pancrelipase 2 PA (lipase-protease-amylase)) ZENPEP CAP 5000UNIT (pancrelipase 2 PA (lipase-protease-amylase)) ZENPEP CAP 10000UNT (pancrelipase 2 PA (lipase-protease-amylase)) ZENPEP CAP 15000UNT (pancrelipase 2 PA (lipase-protease-amylase)) ZENPEP CAP 20000UNT (pancrelipase 2 PA (lipase-protease-amylase)) ZENPEP CAP 25000 (pancrelipase (lipase- 2 PA protease-amylase)) ZENPEP CAP 40000 (pancrelipase (lipase- 2 PA protease-amylase)) PROTON PUMP INHIBITORS§ - DRUGS FOR ULCERS AND STOMACH ACID DEXILANT CPDR 30mg, 60mg 3 QL (90 caps / 365 (dexlansoprazole) days), ST; PA** esomeprazole magnesium CPDR 20mg, 1 QL (90 caps / 365 days) 40mg lansoprazole CPDR 15mg, 30mg 1 QL (90 caps / 365 days) omeprazole CPDR 10mg, 20mg, 40mg 1 QL (90 caps / 365 days) pantoprazole sodium TBEC 20mg, 40mg 1 QL (90 tabs / 365 days)

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 61 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits rabeprazole sodium TBEC 20mg 1 QL (90 tabs / 365 days) RECTAL, procto-pak CREA 1% (Procto-pak) 1 proctosol hc CREA 2.5% (Proctosol Hc) 1 proctozone-hc CREA 2.5% (Proctozone- 1 hc) GENITOURINARY - DRUGS TO TREAT GENITAL AND URINARY TRACT CONDITIONS BENIGN PROSTATIC HYPERPLASIA - DRUGS TO TREAT ENLARGED PROSTATE alfuzosin hcl TB24 10mg 1 CARDURA XL TB24 4mg, 8mg (doxazosin 3 ST; PA** mesylate (bph)) dutasteride CAPS .5mg 1 dutasteride-tamsulosin hcl cap 0.5-0.4 mg 1 finasteride TABS 5mg 1 silodosin CAPS 4mg, 8mg 1 tadalafil TABS 2.5mg, 5mg 1 QL (30 tabs / 25 days), PA tamsulosin hcl CAPS .4mg 1 CONTRACEPTIVES - PRODUCTS FOR BIRTH CONTROL ENCARE SUPP 100mg (nonoxynol-9) PV OTC OPTIONS CONCEPTROL VAGINA GEL 4% PV OTC (nonoxynol-9) OPTIONS GYNOL II VAGINAL GEL 3% PV OTC (nonoxynol-9) SHUR-SEAL GEL 2% (nonoxynol-9) PV OTC TODAY SPONGE MISC 1000mg PV OTC (nonoxynol-9) VCF VAGINAL CONTRACEPTIVE FILM 28%; PV OTC FOAM 12.5% (nonoxynol-9) MISCELLANEOUS bethanechol chloride TABS 5mg, 10mg, 1 25mg, 50mg ELMIRON CAPS 100mg (pentosan 3 polysulfate sodium) flavoxate hcl TABS 100mg 1 phenazopyridine tab 95mg TABS 95mg 1 OTC (Urinary Pain Relief) potassium citrate (alkalinizer) TBCR 1 15meq, 540mg, 1080mg URINARY ANTISPASMODICS - DRUGS TO TREAT URINARY INCONTINENCE darifenacin hydrobromide TB24 7.5mg, 1 15mg

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 62 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits oxybutynin chloride SYRP 5mg/5ml; TABS 1 5mg; TB24 5mg, 10mg, 15mg solifenacin succinate TABS 5mg, 10mg 1 tolterodine tartrate CP24 2mg, 4mg; TABS 1 1mg, 2mg TOVIAZ TB24 4mg, 8mg (fesoterodine 2 fumarate) trospium chloride CP24 60mg; TABS 20mg 1 VAGINAL ANTI-INFECTIVES - DRUGS TO TREAT VAGINAL INFECTIONS CLEOCIN SUPP 100mg (clindamycin 2 phosphate vaginal) clindamycin phosphate vaginal CREA 2% 1 GYNAZOLE-1 CREA 2% (butoconazole 3 nitrate (one dose)) metronidazole vaginal GEL .75% 1 3 SUPP 200mg (Miconazole 3) 1 terconazole vaginal CREA .4%, .8%; SUPP 1 80mg vandazole GEL .75% (Vandazole) 1 HEMATOLOGIC - DRUGS TO TREAT BLOOD DISORDERS ANTICOAGULANTS - BLOOD THINNERS ELIQUIS TABS 2.5mg, 5mg (apixaban) 2 enoxaparin sodium SOLN 30mg/0.3ml, 1 40mg/0.4ml, 60mg/0.6ml, 80mg/0.8ml, 100mg/ml, 120mg/0.8ml, 150mg/ml, 300mg/3ml fondaparinux sodium SOLN 2.5mg/0.5ml, 1 5mg/0.4ml, 7.5mg/0.6ml, 10mg/0.8ml FRAGMIN SOLN 2500unit/0.2ml, 3 5000unit/0.2ml, 7500unit/0.3ml, 10000unit/ml, 12500unit/0.5ml, 15000unit/0.6ml, 18000unt/0.72ml, 95000unit/3.8ml (dalteparin sodium) heparin sodium (porcine) SOLN 1 1000unit/ml, 5000unit/0.5ml, 5000unit/ml, 10000unit/ml, 20000unit/ml jantoven TABS 1mg, 2mg, 2.5mg, 3mg, 1 4mg, 5mg, 6mg, 7.5mg, 10mg (Jantoven) PRADAXA CAPS 75mg, 110mg, 150mg 3 (dabigatran etexilate mesylate) warfarin sodium TABS 1mg, 2mg, 2.5mg, 1 3mg, 4mg, 5mg, 6mg, 7.5mg, 10mg XARELTO TABS 2.5mg, 10mg, 15mg, 2 20mg (rivaroxaban)

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 63 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits XARELTO STAR TAB 15/20MG 2 (rivaroxaban) HEMATOPOIETIC GROWTH FACTORS ARANESP ALBUMIN FREE SOLN 25mcg/ml, 4 PA 40mcg/ml, 60mcg/ml, 100mcg/ml, 200mcg/ml, 300mcg/ml; SOSY 10mcg/0.4ml, 25mcg/0.42ml, 40mcg/0.4ml, 60mcg/0.3ml, 100mcg/0.5ml, 150mcg/0.3ml, 200mcg/0.4ml, 300mcg/0.6ml, 500mcg/ml (darbepoetin alfa) MIRCERA SOSY 30mcg/0.3ml, 4 PA 50mcg/0.3ml, 75mcg/0.3ml, 100mcg/0.3ml, 150mcg/0.3ml, 200mcg/0.3ml (methoxy polyethylene glycol-epoetin beta) NEULASTA SOSY 6mg/0.6ml 4 QL (2 injections / 28 (pegfilgrastim) days), PA NEULASTA ONPRO KIT PSKT 6mg/0.6ml 4 QL (2 injections / 28 (pegfilgrastim) days), PA NIVESTYM SOLN 300mcg/ml, 4 PA 480mcg/1.6ml; SOSY 300mcg/0.5ml, 480mcg/0.8ml (filgrastim-aafi) PROMACTA TABS 12.5mg, 25mg 4 QL (30 tabs / 30 days), (eltrombopag olamine) PA PROMACTA TABS 50mg, 75mg 4 QL (60 tabs / 30 days), (eltrombopag olamine) PA RETACRIT SOLN 2000unit/ml, 4 PA 3000unit/ml, 4000unit/ml, 10000unit/ml, 40000unit/ml (epoetin alfa-epbx) UDENYCA SOSY 6mg/0.6ml 4 QL (2 injections / 28 (pegfilgrastim-cbqv) days), PA MISCELLANEOUS anagrelide hcl CAPS .5mg, 1mg 1 cilostazol TABS 50mg, 100mg 1 HEMLIBRA SOLN 30mg/ml, 60mg/0.4ml, 4 PA 105mg/0.7ml, 150mg/ml (emicizumab- kxwh) icatibant acetate SOLN 30mg/3ml 4 QL (45 syringes / 90 days), PA pentoxifylline TBCR 400mg 1 tranexamic acid SOLN 1000mg/10ml; 1 TABS 650mg PLATELET AGGREGATION INHIBITORS - BLOOD THINNERS aspirin-dipyridamole cap er 12hr 25-200 1 mg BRILINTA TABS 60mg, 90mg (ticagrelor) 2

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 64 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits clopidogrel bisulfate TABS 75mg, 300mg 1 dipyridamole TABS 25mg, 50mg, 75mg 1 PA; High Risk Medications require PA for members age 70 and older prasugrel hcl TABS 5mg, 10mg 1 ZONTIVITY TABS 2.08mg (vorapaxar 2 sulfate) IMMUNOLOGIC AGENTS - DRUGS TO TREAT DISORDERS OF THE IMMUNE SYSTEM BIOLOGIC DISEASE-MODIFYING AGENTS ACTEMRA SOLN 80mg/4ml (tocilizumab) 4 QL (5 vials / 28 days), PA, ST ACTEMRA SOLN 200mg/10ml 4 QL (4 vials / 14 days), (tocilizumab) PA, ST ACTEMRA SOLN 400mg/20ml 4 QL (2 vials / 14 days), (tocilizumab) PA, ST ACTEMRA SOSY 162mg/0.9ml 4 QL (4 syringes / 28 (tocilizumab) days), PA, ST ENBREL SOLR 25mg; SOSY 25mg/0.5ml, 4 QL (8 syringes / 28 50mg/ml (etanercept) days), PA; Preferred agent for Ankylosing Spondylitis, Psoriatic Arthritis, and Rheumatoid Arthritis ENBREL MINI SOCT 50mg/ml (etanercept) 4 QL (8 cartridges / 28 days), PA; Preferred agent for Ankylosing Spondylitis, Psoriatic Arthritis, and Rheumatoid Arthritis ENBREL SURECLICK SOAJ 50mg/ml 4 QL (8 syringes / 28 (etanercept) days), PA; Preferred agent for Ankylosing Spondylitis, Psoriatic Arthritis, and Rheumatoid Arthritis HUMIRA PSKT 10mg/0.1ml, 10mg/0.2ml, 4 QL (2 injections / 28 20mg/0.2ml, 20mg/0.4ml (adalimumab) days), PA HUMIRA PSKT 40mg/0.4ml, 40mg/0.8ml 4 QL (4 injections / 28 (adalimumab) days), PA HUMIRA PEDIA INJ CROHNS (adalimumab) 4 QL (2 injections / 28 days), PA; (80mg and 40mg dual strength kit) HUMIRA PEDIATRIC CROHNS D PSKT 4 QL (3 injections / 28 80mg/0.8ml (adalimumab) days), PA; (80mg single strength kit)

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 65 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits HUMIRA PEN PNKT 40mg/0.4ml 4 QL (4 injections / 28 (adalimumab) days), PA HUMIRA PEN KIT PS/UV (adalimumab) 4 QL (1 kit / 28 days), PA HUMIRA PEN-CD/UC/HS START PNKT 4 QL (6 pens / 28 days), 40mg/0.8ml (adalimumab) PA HUMIRA PEN-CD/UC/HS START PNKT 4 QL (1 kit / 28 days), PA 80mg/0.8ml (adalimumab) HUMIRA PEN-PS/UV STARTER PNKT 4 QL (4 pens / 28 days), 40mg/0.8ml (adalimumab) PA KEVZARA SOAJ 150mg/1.14ml, 4 QL (2 pens / 28 days), 200mg/1.14ml (sarilumab) PA; Preferred agent for Rheumatoid Arthritis (after failure of 2 other preferred agents) KEVZARA SOSY 150mg/1.14ml, 4 QL (2 syringes / 4 200mg/1.14ml (sarilumab) weeks), PA; Preferred agent for Rheumatoid Arthritis (after failure of 2 other preferred agents) RINVOQ TB24 15mg (upadacitinib) 4 QL (30 tabs / 30 days), PA; Preferred agent for Rheumatoid Arthritis SIMPONI SOAJ 50mg/0.5ml, 100mg/ml; 4 QL (1 injection / 28 SOSY 50mg/0.5ml, 100mg/ml days), PA, ST (golimumab) SIMPONI ARIA SOLN 50mg/4ml 4 QL (200 mg / 8 weeks), (golimumab) PA SKYRIZI PSKT 75mg/0.83ml 4 QL (2 syringes / 12 (risankizumab-rzaa) weeks), PA; Preferred agent for Psoriasis STELARA SOSY 45mg/0.5ml 4 QL (1 syringe / 84 (ustekinumab) days), PA; Preferred agent for Crohn's Disease (after failure of Humira) and Psoriasis STELARA SOSY 90mg/ml (ustekinumab) 4 QL (1 syringe / 56 days), PA; Preferred agent for Crohn's Disease (after failure of Humira) and Psoriasis TALTZ SOAJ 80mg/ml; SOSY 80mg/ml 4 QL (1 injection / 28 (ixekizumab) days), PA; Preferred agent for Psoriasis TREMFYA SOPN 100mg/ml; SOSY 4 QL (1 injection / 56 100mg/ml (guselkumab) days), PA; Preferred agent for Psoriasis

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 66 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits XELJANZ TABS 5mg (tofacitinib citrate) 4 QL (60 tabs / 30 days), PA; Preferred agent for Rheumatoid Arthritis XELJANZ TABS 10mg (tofacitinib citrate) 4 QL (60 tabs / 30 days), PA; Preferred agent for Ulcerative Colitis (after failure of Humira) XELJANZ XR TB24 11mg (tofacitinib 4 QL (30 tabs / 30 days), citrate) PA; Preferred agent for Rheumatoid Arthritis XELJANZ XR TB24 22mg (tofacitinib 4 QL (30 tabs / 30 days), citrate) PA; Preferred agent for Ulcerative Colitis (after failure of Humira) DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS) - DRUGS TO TREAT RHEUMATOID ARTHRITIS hydroxychloroquine sulfate TABS 200mg 1 leflunomide TABS 10mg, 20mg 1 methotrexate sodium TABS 2.5mg 1 OAC OTEZLA TABS 30mg (apremilast) 4 QL (60 tabs / 30 days), PA; Preferred agent for Psoriasis and Psoriatic Arthritis OTEZLA TAB 10/20/30 (apremilast) 4 QL (55 tabs / 28 days), PA; Preferred agent for Psoriasis and Psoriatic Arthritis IMMUNOGLOBULIN HYQVIA INJ 2.5-200 (immune globulin 4 PA (human)-hyaluronidase (human recombinant)) HYQVIA INJ 5-400 (immune globulin 4 PA (human)-hyaluronidase (human recombinant)) HYQVIA INJ 10-800 (immune globulin 4 PA (human)-hyaluronidase (human recombinant)) HYQVIA INJ 20-1600 (immune globulin 4 PA (human)-hyaluronidase (human recombinant)) HYQVIA INJ 30-2400 (immune globulin 4 PA (human)-hyaluronidase (human recombinant)) IMMUNOMODULATORS ACTIMMUNE SOLN 2000000unit/0.5ml 4 PA (interferon gamma-1b)

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 67 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits ARCALYST SOLR 220mg (rilonacept) 4 QL (4 vials / 28 days), PA INTRON A SOLN 10mu/ml, 4 PA 6000000unit/ml (interferon alfa-2b) INTRON A W/DILUENT SOLR 10mu, 18mu, 4 PA 50mu (interferon alfa-2b) POMALYST CAPS 1mg, 2mg 4 QL (21 caps / 21 days), (pomalidomide) PA; OAC POMALYST CAPS 3mg, 4mg 4 QL (21 caps / 28 days), (pomalidomide) PA; OAC REVLIMID CAPS 2.5mg, 5mg, 10mg, 4 QL (28 caps / 28 days), 15mg (lenalidomide) PA; OAC REVLIMID CAPS 20mg, 25mg 4 QL (21 caps / 28 days), (lenalidomide) PA; OAC THALOMID CAPS 50mg, 100mg 4 QL (28 caps / 28 days), (thalidomide) PA; OAC THALOMID CAPS 150mg, 200mg 4 QL (56 caps / 28 days), (thalidomide) PA; OAC IMMUNOSUPPRESSANTS AZASAN TABS 75mg, 100mg 3 (azathioprine) azathioprine TABS 50mg 1 cyclosporine CAPS 25mg, 100mg; SOLN 1 50mg/ml cyclosporine modified (for microemulsion) 1 CAPS 25mg, 50mg, 100mg; SOLN 100mg/ml everolimus (immunosuppressant) TABS 1 .25mg, .5mg, .75mg gengraf CAPS 25mg, 100mg; SOLN 1 100mg/ml (Gengraf) mycophenolate mofetil CAPS 250mg; 1 SUSR 200mg/ml; TABS 500mg mycophenolate mofetil hcl SOLR 500mg 1 mycophenolate sodium TBEC 180mg, 1 360mg PROGRAF SOLN 5mg/ml (tacrolimus) 3 SANDIMMUNE SOLN 100mg/ml 3 (cyclosporine) sirolimus SOLN 1mg/ml; TABS .5mg, 1 1mg, 2mg tacrolimus CAPS .5mg, 1mg, 5mg 1 ZORTRESS TABS 1mg (everolimus 2 (immunosuppressant))

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 68 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits VACCINES ACTHIB INJ (haemophilus b polysac conj PV $0 copay for members vac) age 18 and younger, otherwise not covered ADACEL INJ (tetanus toxoid-diphtheria- PV acellular pertussis adsorb (tdap)) AFLURIA QUAD INJ 2019-20 (influenza PV virus vaccine split quadrivalent) BEXSERO INJ (meningococcal vac group b PV (recombant omv adjuvanted)) BOOSTRIX INJ (tetanus toxoid-diphtheria- PV acellular pertussis adsorb (tdap)) DAPTACEL INJ (diphtheria, acellular PV $0 copay for members pertussis & tetanus toxoids) age 18 and younger, otherwise not covered DIP/TET PED INJ 25-5LFU PV $0 copay for members age 18 and younger, otherwise not covered ENGERIX-B INJ 10mcg/0.5ml, 20mcg/ml; PV SUSP 10mcg/0.5ml, 20mcg/ml (hepatitis b vaccine (recomb)) FLUAD INJ 2019-20 (influenza virus PV vaccine types a & b surface antigen adjuvant) FLUAD QUADRIVALENT INFLUE PRSY .5ml PV (influenza virus vacc types a & b surf antigen adjuvant quad) FLUARIX QUAD INJ 2019-20 (influenza PV virus vaccine split quadrivalent) FLUBLOK QUAD INJ 2019-20 (influenza PV virus vac recomb hemagglutinin (ha) quadrivalent) FLUCLVX QUAD INJ 2019-20 (influenza PV virus vaccine tissue-cultured subunit quadrivalent) FLULAVAL QUA INJ 2019-20 (influenza PV virus vaccine split quadrivalent) FLUMIST QUAD SUS 2019-20 (influenza PV virus vaccine live quadrivalent) FLUZONE HD INJ PF 19-20 (influenza virus PV vaccine split high-dose preservative free) FLUZONE QUAD INJ 2019-20 (influenza PV virus vaccine split quadrivalent) GARDASIL 9 INJ (human papillomavirus PV (hpv) 9-valent recombinant vaccine) HAVRIX SUSP 720elu/0.5ml, 1440elu/ml PV (hepatitis a vaccine)

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 69 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits HEPLISAV-B SOSY 20mcg/0.5ml (hepatitis PV b vaccine recombinant adjuvanted) HIBERIX SOLR 10mcg (haemophilus b PV $0 copay for members polysac conj vac) age 18 and younger, otherwise not covered INFANRIX INJ (diphtheria, acellular PV $0 copay for members pertussis & tetanus toxoids) age 18 and younger, otherwise not covered IPOL INJ INACTIVE (poliovirus vaccine, ipv) PV $0 copay for members age 18 and younger, otherwise not covered KINRIX INJ (diph-tetanus tox ad-acell PV $0 copay for members pertussis & polio virus, ipv vac) age 18 and younger, otherwise not covered M-M-R II INJ (measles, mumps & rubella PV virus vaccines) MENACTRA INJ (meningococcal (a,c,y&w- PV 135) polysaccharide conjugate vaccine) MENVEO INJ (meningococcal (a,c,y&w- PV 135) oligosaccharide conjugate vac) PEDIARIX INJ 0.5ML (diph-tetanus tox- PV $0 copay for members acell pert-hepatitis b recomb-polio ipv vac) age 18 and younger, otherwise not covered PEDVAX HIB SUSP 7.5mcg/0.5ml PV $0 copay for members (haemophilus b polysac conj vac) age 18 and younger, otherwise not covered PENTACEL INJ (diph-ac pert-tet tox ad- PV $0 copay for members polio ipv-haemophil b poly vac) age 18 and younger, otherwise not covered PNEUMOVAX 23/1 DOSE INJ 25mcg/0.5ml PV (pneumococcal vac polyvalent) PREVNAR 13 INJ (pneumococcal 13-valent PV conjugate vaccine) PROQUAD INJ (measles-mumps-rubella- PV $0 copay for members varicella virus vaccines) age 18 and younger, otherwise not covered RECOMBIVAX HB SUSP 5mcg/0.5ml, PV 10mcg/ml, 40mcg/ml (hepatitis b vaccine (recomb)) ROTARIX SUS (rotavirus vaccine, live oral) PV $0 copay for members age 18 and younger, otherwise not covered ROTATEQ SOL (rotavirus vaccine, live oral PV $0 copay for members pentavalent) age 18 and younger, otherwise not covered SHINGRIX SUSR 50mcg/0.5ml (zoster PV $0 copay for members vaccine recombinant adjuvanted) age 19 and older, otherwise not covered

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 70 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits TDVAX INJ 2-2 LF (tetanus-diphtheria PV $0 copay for members toxoids (td)) age 19 and older, otherwise not covered TENIVAC INJ 5-2LF (tetanus-diphtheria PV $0 copay for members toxoids (td)) age 19 and older, otherwise not covered TRUMENBA INJ (meningococcal group b PV vaccine (recombinant)) TWINRIX INJ (hepatitis a (inactivated)- PV $0 copay for members hepatitis b (recombinant) vaccines) age 19 and older, otherwise not covered VAQTA SUSP 25unit/0.5ml, 50unit/ml PV (hepatitis a vaccine) VARIVAX INJ 1350pfu/0.5ml (varicella PV virus vaccine live) ZOSTAVAX SUSR 19400unt/0.65ml PV $0 copay for members (zoster vaccine live) age 19 and older, otherwise not covered MEDICAL DEVICES CONTRACEPTIVES - PRODUCTS FOR BIRTH CONTROL CAYA DPR (diaphragm arc-spring) PV QL (1 / 300 days) FC2 FEMALE MIS CONDOM (condoms - PV OTC female) FEMCAP MIS 22MM (cervical caps) PV QL (1 / 300 days) FEMCAP MIS 26MM (cervical caps) PV QL (1 / 300 days) FEMCAP MIS 30MM (cervical caps) PV QL (1 / 300 days) OMNIFLEX DPR (diaphragms) PV QL (1 / 300 days) WIDE-SEAL SILICONE DIAPHR DPRH 2% PV QL (1 / 300 days) (diaphragm wide seal) DIABETIC SUPPLIES ACCU-CHEK BLOOD GLUCOSE TEST KITS 2 OTC (blood glucose monitoring supplies) ACCU-CHEK BLOOD GLUCOSE TEST 2 OTC, QL (204 Test STRIPS (glucose blood) Strips / 25 days) ALCOHOL PREP PAD (alcohol swabs) 2 OTC BLOOD GLUCOSE CALIBRATION SOLUTION 2 OTC (blood glucose calibration) DEXCOM G5 MIS RECEIVER (continuous 2 blood glucose system receiver) DEXCOM G5 MIS TRANSMIT (continuous 2 blood glucose system transmitter) DEXCOM G6 MIS RECEIVER (continuous 2 blood glucose system receiver) DEXCOM G6 MIS SENSOR (continuous 2 blood glucose system sensor) DEXCOM G6 MIS TRANSMIT (continuous 2 blood glucose system transmitter)

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 71 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits G4 PLAT PED MIS RVC/SHAR (continuous 2 blood glucose system receiver) G4 PLATINUM MIS PEDIATRC (continuous 2 blood glucose system receiver) G4 PLATINUM MIS RCV/SHAR (continuous 2 blood glucose system receiver) G4 PLATINUM MIS RECEIVER (continuous 2 blood glucose system receiver) G4 PLATINUM MIS TRANSMIT (continuous 2 blood glucose system transmitter) G4 SENSOR MIS (continuous blood glucose 2 system sensor) G5/G4 MIS SENSOR (continuous blood 2 glucose system sensor) GLUCOSE TEST STRIPS (glucose 2 OTC urine test-(glucose oxidase)) INSULIN PEN NEEDLES (insulin pen 2 OTC needle) INSULIN PEN NEEDLES/SYRINGES (insulin 2 OTC syringe/needle u-100) KETONE URINE TEST STRIPS (urine 2 OTC glucose-ketones test) LANCETS (lancets) 2 OTC LANCING DEVICE 2 OTC OMNIPOD DASH (insulin infusion 2 disposable pump) OMNIPOD KIT STARTER (insulin infusion 2 disposable pump) OMNIPOD MIS 5 PACK (insulin infusion 2 disposable pump) SHARPS CONTAINER (sharps container) 2 OTC ULTRALANCE MIS 1.8MM (lancets misc.) 2 OTC URINE GLUCOSE MONITORING SUPPLIES 2 OTC (urine glucose monitoring supplies) URINE TEST STRIPS (multiple urine tests) 2 OTC V-GO 20 KIT (insulin infusion disposable 2 pump) V-GO 30 KIT (insulin infusion disposable 2 pump) V-GO 40 KIT (insulin infusion disposable 2 pump) MISCELLANEOUS ADULT RESPIRATORY MASK 2 (spacer/aerosol-holding chambers) ADULT RESPIRATORY MASK 2 OTC (spacer/aerosol-holding chambers) HUMATROPEN (injection device) 2 OTC

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 72 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits PEDIATRIC RESPIRATORY MASK 2 (spacer/aerosol-holding chamber supplies - masks) PEDIATRIC RESPIRATORY MASK 2 OTC (spacer/aerosol-holding chamber supplies - masks) NUTRITIONAL/SUPPLEMENTS - VITAMINS AND SUPPLEMENTS ELECTROLYTES FLUORABON SOLN .55mg/0.6ml (sodium PV $0 applies for ages 5 fluoride) and under, otherwise not covered fluoritab CHEW 1mg (Fluoritab) 1 fluoritab CHEW .25mg, .5mg; SOLN PV $0 applies for ages 5 .125mg/drop (Fluoritab) and under, otherwise not covered flura-drops SOLN .25mg/drop (Flura- PV $0 applies for ages 5 drops) and under, otherwise not covered k-effervescent TBEF 25meq (Effer-k) 1 klor-con 8 TBCR 8meq (Klor-con 8) 1 klor-con 10 TBCR 10meq (Klor-con 10) 1 klor-con m15 TBCR 15meq (Klor-con M15) 1 klor-con m20 TBCR 20meq (Klor-con M20) 1 ludent CHEW 1mg (Ludent) 1 ludent CHEW .25mg, .5mg (Ludent) PV $0 applies for ages 5 and under, otherwise not covered magnesium sulfate SOLN 2gm/50ml, 50% 1 magnesium sulfate in dextrose 5% iv soln 1 1 gm/100ml nafrinse CHEW 2.2mg (Nafrinse) 1 nafrinse drops SOLN .125mg/drop PV $0 applies for ages 5 (Nafrinse Drops) and under, otherwise not covered potassium chloride CPCR 8meq, 10meq; 1 SOLN 10%, 20%; TBCR 8meq, 10meq, 20meq potassium chloride microencapsulated 1 crystals er TBCR 10meq, 20meq sodium chloride SOLN 2.5meq/ml 1 sodium chloride flush SOLN .9% (Monoject 1 Sodium Chloride) sodium fluoride CHEW 1mg; TABS 1mg 1 sodium fluoride CHEW .25mg, .5mg; PV $0 applies for ages 5 SOLN .5mg/ml; TABS .5mg and under, otherwise not covered

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 73 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits IV REPLACEMENT SOLUTIONS potassium chloride SOLN 2meq/ml 1 sodium chloride SOLN .45%, .9%, 3%, 1 5% VITAMINS - VITAMINS AND SUPPLEMENTS calcitriol CAPS .25mcg, .5mcg; SOLN 1 1mcg/ml cholecalciferol CAPS 50000unit 1 OTC CITRANATAL CAP HARMONY (prenatal w/o 2 vit a w/ fe fumarate-fe carbonyl-dss-fa- dha) CITRANATAL CAP MEDLEY (prenatal w/o vit 2 a w/ fe fumarate-fe carbonyl-fa-dha) CITRANATAL MIS (prenatal w/o vit a w/ fe 2 carbonyl-fe gluconate-dss-fa-dha) CITRANATAL MIS 90 DHA (prenatal w/o vit 2 a w/ fe carbonyl-fe gluconate-dss-fa-dha) CITRANATAL MIS B-CALM (prenatal w/o vit 2 a w/ fe carbonyl-fe gluconate-fa & vit b6) CITRANATAL PAK ASSURE (prenatal w/o 2 vit a w/ fe carbonyl-fe gluconate-dss-fa- dha) CITRANATAL PAK DHA (prenatal w/o vit a 2 w/ fe carbonyl-fe gluconate-dss-fa-dha) CITRANATAL TAB BLOOM (prenatal vit w/ 2 docusate-fe carbonyl-fe gluconate-folic acid) CITRANATAL TAB RX (prenatal without vit 2 a w/ fe carbonyl-fe gluc-docusate-fa) cyanocobalamin SOLN 1000mcg/ml 1 doxercalciferol CAPS .5mcg, 1mcg, 1 2.5mcg elite-ob (Elite-ob) 1 ergocalciferol CAPS 50000unit 1 folic acid CAPS 800mcg PV OTC, QL (100 caps / 30 days); $0 copay for women ages 55 and under, otherwise not covered folic acid TABS 1mg 1 folic acid TABS 400mcg, 800mcg PV OTC, QL (100 tabs / 30 days); $0 copay for women ages 55 and under, otherwise not covered folic acid-pyridoxine-cyanocobalamin tab 1 2.5-25-2 mg (Westab Max)

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 74 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits multi-vit/fluoride (Multi-vitamin/fluoride 1 Dr) multi-vit/iron/fluoride (Multi- 1 vit/iron/fluoride) multi-vitamin/fluoride/ir (Multi- 1 vitamin/fluoride/ir) multivitamin with fluorid (Multivitamin With 1 Fluorid) mvc-fluoride (Mvc-fluoride) 1 paricalcitol CAPS 1mcg, 2mcg, 4mcg 1 *pediatric multiple vitamins w/ fluoride 1 soln 0.25 mg/ml*** (Multi-vitamin/fluoride Dr) *pediatric vitamins acd w/ fluoride soln 0.5 1 mg/ml*** (Tri-vite/fluoride) *pediatric vitamins acd w/ fluoride soln 1 0.25 mg/ml*** (Tri-vite/fluoride) phytonadione TABS 5mg 1 prenatabs rx (Prenatabs Rx) 1 pyridoxine hcl TABS 25mg, 50mg 1 OTC vitamins a/c/d/fluoride (Vitamins 1 A/c/d/fluoride) OPHTHALMIC - DRUGS TO TREAT EYE CONDITIONS ANTI-INFECTIVE/ANTI-INFLAMMATORY - DRUGS TO TREAT INFECTIONS AND INFLAMMATION bacitracin-polymyxin-neomycin-hc ophth 1 oint 1% BLEPHAMIDE OIN S.O.P. (sulfacetamide 2 sod-prednisolone) BLEPHAMIDE SUS OP (sulfacetamide sod- 2 prednisolone) neomycin-polymyxin-dexamethasone 1 ophth oint 0.1% neomycin-polymyxin-dexamethasone 1 ophth susp 0.1% neomycin-polymyxin-hc ophth susp 1 sulfacetamide sodium-prednisolone ophth 1 soln 10-0.23(0.25)% TOBRADEX OIN 0.3-0.1% (tobramycin- 2 dexamethasone) TOBRADEX ST SUS 0.3-0.05 (tobramycin- 2 dexamethasone) tobramycin-dexamethasone ophth susp 1 0.3-0.1% ANTI-INFECTIVES - DRUGS TO TREAT INFECTIONS AZASITE SOLN 1% (azithromycin (ophth)) 2

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 75 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits bacitracin (ophthalmic) OINT 500unit/gm 1 bacitracin-polymyxin b ophth oint 1 BESIVANCE SUSP .6% (besifloxacin hcl) 3 ciprofloxacin hcl (ophth) SOLN .3% 1 erythromycin (ophth) OINT 5mg/gm 1 gatifloxacin (ophth) SOLN .5% 1 gentak OINT .3% (Gentak) 1 gentamicin sulfate (ophth) SOLN .3% 1 levofloxacin (ophth) SOLN .5% 1 moxifloxacin hcl (ophth) SOLN .5% 1 NATACYN SUSP 5% () 2 neomycin-polymy-gramicid op sol 1.75- 1 10000-0.025mg-unt-mg/ml ofloxacin (ophth) SOLN .3% 1 polycin (Polycin) 1 polymyxin b-trimethoprim ophth soln 1 10000 unit/ml-0.1% sulfacetamide sodium (ophth) OINT 10%; 1 SOLN 10% tobramycin (ophth) SOLN .3% 1 trifluridine SOLN 1% 1 ZIRGAN GEL .15% (ganciclovir 3 ophthalmic) ANTI-INFLAMMATORIES - DRUGS TO TREAT INFLAMMATION ACUVAIL SOLN .45% (ketorolac 2 tromethamine (ophth)) bromfenac sodium (ophth) SOLN .09% 1 dexamethasone sodium phosphate (ophth) 1 SOLN .1% diclofenac sodium (ophth) SOLN .1% 1 DUREZOL EMUL .05% (difluprednate) 2 flurbiprofen sodium SOLN .03% 1 FML OINT .1% (fluorometholone (ophth)) 2 FML FORTE SUSP .25% (fluorometholone 2 (ophth)) ILEVRO SUSP .3% (nepafenac) 2 ketorolac tromethamine (ophth) SOLN 1 .4%, .5% loteprednol etabonate SUSP .5% 1 MAXIDEX SUSP .1% (dexamethasone 2 (ophth)) NEVANAC SUSP .1% (nepafenac) 2 PRED MILD SUSP .12% (prednisolone 2 acetate (ophth)) prednisolone acetate (ophth) SUSP 1% 1 PREDNISOLONE SODIUM PHOSP SOLN 1% 2

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 76 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits ANTIALLERGICS - DRUGS TO TREAT ALLERGIES ALOCRIL SOLN 2% (nedocromil sodium 3 (ophth)) ALOMIDE SOLN .1% (lodoxamide 3 tromethamine) azelastine hcl (ophth) SOLN .05% 1 BEPREVE SOLN 1.5% (bepotastine 3 besilate) cromolyn sodium (ophth) SOLN 4% 1 epinastine hcl (ophth) SOLN .05% 1 LASTACAFT SOLN .25% (alcaftadine) 2 olopatadine hcl SOLN .1% 1 olopatadine hydrochloride SOLN .2% 1 PAZEO SOLN .7% (olopatadine hcl) 2 ANTIGLAUCOMA - DRUGS TO TREAT GLAUCOMA ALPHAGAN P SOLN .1% (brimonidine 3 tartrate) apraclonidine hcl SOLN .5% 1 AZOPT SUSP 1% (brinzolamide) 2 betaxolol hcl (ophth) SOLN .5% 1 BETIMOL SOLN .25%, .5% (timolol) 3 BETOPTIC-S SUSP .25% (betaxolol hcl 2 (ophth)) bimatoprost SOLN .03% 3 brimonidine tartrate SOLN .15%, .2% 1 carteolol hcl (ophth) SOLN 1% 1 COMBIGAN SOL 0.2/0.5% (brimonidine 2 tartrate-timolol maleate) dorzolamide hcl SOLN 2% 1 dorzolamide hcl-timolol maleate ophth soln 1 22.3-6.8 mg/ml IOPIDINE SOLN 1% (apraclonidine hcl) 3 latanoprost SOLN .005% 1 levobunolol hcl SOLN .5% 1 LUMIGAN SOLN .01% (bimatoprost) 2 ST; PA** PHOSPHOLINE IODIDE SOLR .125% 3 (echothiophate iodide) pilocarpine hcl SOLN 1% 1 SIMBRINZA SUS 1-0.2% (brinzolamide- 2 brimonidine tartrate) timolol maleate (ophth) SOLG .25%, .5%; 1 SOLN .25%, .5% travoprost SOLN .004% 1 ZIOPTAN SOLN .015mg/ml (tafluprost) 3 ST; PA** MISCELLANEOUS ATROPINE SULFATE SOLN 1% 3

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 77 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits CYSTARAN SOLN .44% (cysteamine hcl) 4 QL (4 bottles / 28 days), PA LACRISERT INST 5mg (artificial tear 3 insert) phenylephrine hcl (mydriatic) SOLN 2.5%, 1 10% proparacaine hcl SOLN .5% 1 RESTASIS EMUL .05% (cyclosporine 2 (ophth)) tropicamide SOLN .5%, 1% 1 OTHER IRRIGATION SOLUTIONS physiolyte (Physiolyte) 1 physiosol irrigation (Physiosol Irrigation) 1 RESPIRATORY - DRUGS TO TREAT BREATHING DISORDERS ANAPHYLAXIS TREATMENT AGENTS epinephrine (anaphylaxis) SOAJ 1 QL (4 auto-injectors / 25 .15mg/0.3ml, .3mg/0.3ml days) epinephrine (anaphylaxis) SOAJ 1 QL (4 auto-injectors / 25 .15mg/0.15ml days); (generic of Adrenaclick) EPIPEN 2-PAK SOAJ .3mg/0.3ml 2 QL (4 auto-injectors / 25 (epinephrine (anaphylaxis)) days) EPIPEN-JR 2-PAK SOAJ .15mg/0.3ml 2 QL (4 auto-injectors / 25 (epinephrine (anaphylaxis)) days) ANTICHOLINERGIC/BETA AGONIST COMBINATIONS§ - DRUGS TO TREAT COPD BEVESPI AER 9-4.8MCG (glycopyrrolate- 2 QL (1 package / 25 formoterol fumarate) days) ipratropium-albuterol nebu soln 0.5-2.5(3) 1 QL (6 boxes / 25 days) mg/3ml TRELEGY AER ELLIPTA (fluticasone- 2 QL (1 package / 25 umeclidinium-vilanterol) days) ANTICHOLINERGICS§ - DRUGS TO TREAT PARKINSONS DISEASE INCRUSE ELLIPTA AEPB 62.5mcg/inh 2 QL (1 package / 25 (umeclidinium bromide) days) ipratropium bromide SOLN .02% 1 QL (5 boxes / 25 days) ipratropium bromide (nasal) SOLN .03%, 1 .06% SPIRIVA HANDIHALER CAPS 18mcg 2 QL (1 package / 25 (tiotropium bromide monohydrate) days) SPIRIVA RESPIMAT AERS 1.25mcg/act, 2 QL (1 package / 25 2.5mcg/act (tiotropium bromide days) monohydrate)

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 78 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits ANTIHISTAMINE COMBINATIONS azelastine hcl-fluticasone prop nasal spray 1 QL (1 package / 25 137-50 mcg/act days) ANTIHISTAMINES§ - DRUGS TO TREAT ALLERGIES azelastine hcl SOLN .1%, .15% 1 QL (2 bottles / 25 days) brompheniramine tannate CHEW 12mg 1 carbinoxamine maleate SOLN 4mg/5ml; 1 TABS 4mg clemastine fumarate TABS 2.68mg 1 PA; High Risk Medications require PA for members age 70 and older cyproheptadine hcl SYRP 2mg/5ml; TABS 1 4mg desloratadine TABS 5mg; TBDP 2.5mg, 1 5mg diphenhydramine hcl ELIX 12.5mg/5ml 1 PA; High Risk Medications require PA for members age 70 and older diphenhydramine hcl SOLN 50mg/ml 1 hydroxyzine hcl SOLN 25mg/ml, 1 PA; High Risk 50mg/ml; SYRP 10mg/5ml; TABS 10mg, Medications require PA 25mg, 50mg for members age 70 and older hydroxyzine pamoate CAPS 25mg, 50mg, 1 PA; High Risk 100mg Medications require PA for members age 70 and older levocetirizine dihydrochloride SOLN 1 2.5mg/5ml; TABS 5mg olopatadine hcl (nasal) SOLN .6% 1 QL (1 container / 25 days) BETA AGONISTS§ - DRUGS TO TREAT ASTHMA AND COPD albuterol sulfate AERS 108mcg/act 1 QL (2 inhalers / 25 days) albuterol sulfate NEBU 2.5mg/0.5ml 1 QL (60 mL / 25 days) albuterol sulfate NEBU .083%, 1 QL (5 boxes / 25 days) .63mg/3ml, 1.25mg/3ml albuterol sulfate SYRP 2mg/5ml; TABS 1 2mg, 4mg; TB12 4mg, 8mg levalbuterol hcl NEBU 1.25mg/0.5ml 1 QL (45 mL / 25 days) levalbuterol hcl NEBU .31mg/3ml, 1 QL (300 mL / 25 days) .63mg/3ml, 1.25mg/3ml levalbuterol tartrate AERO 45mcg/act 1 QL (2 inhalers / 25 days) metaproterenol sulfate SYRP 10mg/5ml 1

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 79 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits PERFOROMIST NEBU 20mcg/2ml 2 QL (2 boxes / 25 days) (formoterol fumarate) STRIVERDI RESPIMAT AERS 2.5mcg/act 2 QL (1 package / 25 (olodaterol hcl) days) terbutaline sulfate TABS 2.5mg, 5mg 1 BIOLOGIC RESPONSE MODIFIERS NUCALA SOAJ 100mg/ml; SOLR 100mg; 4 QL (3 injections / 28 SOSY 100mg/ml (mepolizumab) days), PA XOLAIR SOLR 150mg (omalizumab) 4 QL (6 vials / 28 days), PA XOLAIR SOSY 75mg/0.5ml (omalizumab) 4 QL (2 syringes / 28 days), PA XOLAIR SOSY 150mg/ml (omalizumab) 4 QL (4 syringes / 28 days), PA COLD/COUGH benzonatate CAPS 100mg, 200mg 1 guaifenesin-codeine soln 100-10 mg/5ml 1 OTC (Guaifenesin Ac) hydrocodone w/ homatropine syrup 5-1.5 1 mg/5ml hydrocodone w/ homatropine tab 5-1.5 mg 1 hydromet (Hydromet) 1 promethazine & phenylephrine syrup 6.25- 1 5 mg/5ml promethazine w/ codeine syrup 6.25-10 1 mg/5ml promethazine-dm syrup 6.25-15 mg/5ml 1 promethazine-phenylephrine-codeine syrup 1 6.25-5-10 mg/5ml pseudoephed-bromphen-dm syrup 30-2-10 1 mg/5ml TUZISTRA XR SUS (codeine polistirex- 3 chlorpheniramine polistirex) LEUKOTRIENE MODIFIERS zileuton TB12 600mg 2 LEUKOTRIENE RECEPTOR ANTAGONISTS - DRUGS TO TREAT ASTHMA AND ALLERGIES montelukast sodium CHEW 4mg, 5mg; 1 PACK 4mg; TABS 10mg zafirlukast TABS 10mg, 20mg 1 MAST CELL STABILIZERS§ - DRUGS TO TREAT ALLERGIES cromolyn sodium NEBU 20mg/2ml 1 QL (2 boxes / 25 days) MISCELLANEOUS acetylcysteine SOLN 10%, 20% 1 DALIRESP TABS 250mcg, 500mcg 3 PA (roflumilast) PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 80 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits ESBRIET CAPS 267mg (pirfenidone) 4 QL (270 caps / 30 days), PA ESBRIET TABS 267mg (pirfenidone) 4 QL (270 tabs / 30 days), PA ESBRIET TABS 801mg (pirfenidone) 4 QL (90 tabs / 30 days), PA KALYDECO PACK 25mg, 50mg, 75mg 4 QL (56 packets / 28 (ivacaftor) days), PA KALYDECO TABS 150mg (ivacaftor) 4 QL (56 tabs / 28 days), PA; carton consists of 56 tablets KALYDECO TABS 150mg (ivacaftor) 4 QL (60 tabs / 30 days), PA; packet consists of 60 tablets ORKAMBI GRA 100-125 (lumacaftor- 4 QL (56 packets / 28 ivacaftor) days), PA ORKAMBI GRA 150-188 (lumacaftor- 4 QL (56 packets / 28 ivacaftor) days), PA ORKAMBI TAB 100-125 (lumacaftor- 4 QL (112 tabs / 28 days), ivacaftor) PA ORKAMBI TAB 200-125 (lumacaftor- 4 QL (112 tabs / 28 days), ivacaftor) PA PROLASTIN-C SOLN 1000mg/20ml; SOLR 4 PA 1000mg (alpha1-proteinase inhibitor (human)) sodium chloride (inhalant) NEBU .9%, 3%, 1 7%, 10% SYMDEKO TAB 50-75MG (tezacaftor- 4 QL (56 tabs / 28 days), ivacaftor) PA SYMDEKO TAB 100-150 (tezacaftor- 4 QL (56 tabs / 28 days), ivacaftor) PA TRIKAFTA TAB (elexacaftor-tezacaftor- 4 QL (84 tabs / 28 days), ivacaftor) PA NASAL STEROIDS§ - DRUGS TO TREAT ALLERGIES flunisolide (nasal) SOLN .025% 1 QL (3 containers / 25 days) fluticasone propionate (nasal) SUSP 1 QL (1 container / 25 50mcg/act days) OMNARIS SUSP 50mcg/act (ciclesonide 3 QL (1 package / 25 (nasal)) days), ST; PA** triamcinolone acetonide (nasal) AERO 1 OTC, QL (1 bottle / 25 55mcg/act days) STEROID INHALANTS§ - DRUGS TO TREAT ASTHMA ARNUITY ELLIPTA AEPB 50mcg/act, 2 QL (1 package / 25 100mcg/act, 200mcg/act (fluticasone days) furoate (inhalation)) budesonide (inhalation) SUSP 1mg/2ml 1 QL (1 box / 25 days)

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 81 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits budesonide (inhalation) SUSP .5mg/2ml 1 QL (2 boxes / 25 days) budesonide (inhalation) SUSP .25mg/2ml 1 QL (3 boxes / 25 days) QVAR REDIHALER AERB 40mcg/act, 2 QL (2 packages / 25 80mcg/act (beclomethasone dipropionate days) hfa) STEROID/BETA-AGONIST COMBINATIONS§ - DRUGS TO TREAT ASTHMA AND COPD ADVAIR DISKU AER 100/50 (fluticasone- 1 QL (1 package / 25 salmeterol) days) ADVAIR DISKU AER 250/50 (fluticasone- 1 QL (1 package / 25 salmeterol) days) ADVAIR DISKU AER 500/50 (fluticasone- 1 QL (1 package / 25 salmeterol) days) ADVAIR HFA AER 45/21 (fluticasone- 2 QL (1 package / 25 salmeterol) days) ADVAIR HFA AER 115/21 (fluticasone- 2 QL (1 package / 25 salmeterol) days) ADVAIR HFA AER 230/21 (fluticasone- 2 QL (1 package / 25 salmeterol) days) BREO ELLIPTA INH 100-25 (fluticasone 2 QL (1 package / 25 furoate-vilanterol) days) BREO ELLIPTA INH 200-25 (fluticasone 2 QL (1 package / 25 furoate-vilanterol) days) SYMBICORT AER 80-4.5 (budesonide- 2 QL (1 package / 25 formoterol fumarate dihydrate) days) SYMBICORT AER 160-4.5 (budesonide- 2 QL (1 package / 25 formoterol fumarate dihydrate) days) XANTHINES - DRUGS TO TREAT COPD aminophylline SOLN 25mg/ml 1 ELIXOPHYLLIN ELIX 80mg/15ml 3 (theophylline) THEO-24 CP24 100mg, 200mg, 300mg, 3 400mg (theophylline) theophylline SOLN 80mg/15ml; TB12 1 300mg, 450mg; TB24 400mg, 600mg TOPICAL - DRUGS TO TREAT EAR AND SKIN CONDITIONS DERMATOLOGY, ACNE adapalene CREA .1%; GEL .1%, .3% 1 PA; PA applies for members age 35 and older adapalene-benzoyl peroxide gel 0.1-2.5% 1 avita CREA .025%; GEL .025% (Avita) 1 PA; PA applies for members age 35 and older BENZIQ GEL 5.25% (benzoyl peroxide) 2 BENZIQ LS GEL 2.75% (benzoyl peroxide) 2

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 82 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits benziq wash LIQD 5.25% (Benziq Wash) 1 benzoyl peroxide-erythromycin gel 5-3% 1 bp wash LIQD 2.5% (Bp Wash) 1 clindamycin phosph-benzoyl peroxide 1 (refrig) gel 1.2 (1)-5% clindamycin phosphate (topical) FOAM 1 1%; SWAB 1% clindamycin phosphate (topical) GEL 1% 1 QL (75g / 25 days) clindamycin phosphate (topical) LOTN 1 QL (60mL / 25 days) 1%; SOLN 1% clindamycin phosphate-benzoyl peroxide 1 gel 1-5% clindamycin phosphate-benzoyl peroxide 1 gel 1.2-2.5% EPIDUO FORTE GEL 0.3-2.5% (adapalene- 3 benzoyl peroxide) ery PADS 2% (Ery) 1 erythromycin (acne aid) GEL 2% 1 QL (60g / 25 days) erythromycin (acne aid) SOLN 2% 1 QL (60mL / 25 days) isotretinoin CAPS 10mg, 20mg, 30mg, 1 PA 40mg sulfacetamide sodium (acne) LOTN 10% 1 tretinoin CREA .025%, .05%, .1%; GEL 1 PA; PA applies for .01%, .025%, .05% members age 35 and older tretinoin microsphere GEL .04%, .1% 1 PA; PA applies for members age 35 and older DERMATOLOGY, ACTINIC KERATOSIS fluorouracil (topical) CREA 5%; SOLN 2%, 1 5% imiquimod CREA 5% 1 PICATO GEL .015%, .05% (ingenol 3 mebutate) DERMATOLOGY, ANTIBIOTICS gentamicin sulfate (topical) CREA .1%; 1 OINT .1% IV PREP WIPE PAD 2 OTC mupirocin OINT 2% 1 QL (30g / 25 days) silver sulfadiazine CREA 1% 1 ssd CREA 1% (Ssd) 1 SULFAMYLON CREA 85mg/gm (mafenide 3 acetate) DERMATOLOGY, ANTIFUNGALS ciclopirox GEL .77% 1 QL (120g / 25 days) ciclopirox SHAM 1% 1 QL (120mL / 25 days)

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 83 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits ciclopirox SOLN 8% 1 ciclopirox olamine CREA .77% 1 QL (120g / 25 days) ciclopirox olamine SUSP .77% 1 QL (120mL / 25 days) clotrimazole (topical) CREA 1% 1 QL (120g / 25 days) clotrimazole (topical) SOLN 1% 1 QL (120mL / 25 days) clotrimazole w/ cream 1- 1 QL (60g / 25 days) 0.05% clotrimazole w/ betamethasone lotion 1- 1 QL (60mL / 25 days) 0.05% econazole nitrate CREA 1% 1 QL (60g / 25 days) ERTACZO CREA 2% (sertaconazole 3 QL (60g / 25 days) nitrate) EXELDERM SOLN 1% (sulconazole nitrate) 3 QL (60mL / 25 days), ST; PA** JUBLIA SOLN 10% (efinaconazole) 3 QL (4mL / 21 days), PA ketoconazole (topical) CREA 2% 1 QL (120g / 25 days) MENTAX CREA 1% (butenafine hcl) 3 QL (60g / 25 days) naftifine hcl CREA 1%, 2% 1 QL (60g / 25 days) nyamyc POWD 100000unit/gm (Nyamyc) 1 QL (120g / 25 days) nystatin (topical) CREA 100000unit/gm; 1 QL (120g / 25 days) OINT 100000unit/gm; POWD 100000unit/gm nystatin-triamcinolone cream 100000-0.1 1 QL (60g / 25 days) unit/gm-% nystatin-triamcinolone oint 100000-0.1 1 QL (60g / 25 days) unit/gm-% nystop POWD 100000unit/gm (Nystop) 1 QL (120g / 25 days) oxiconazole nitrate CREA 1% 1 QL (60g / 25 days) sulconazole nitrate CREA 1% 1 QL (60g / 25 days) DERMATOLOGY, ANTIPRURITIC doxepin hcl (antipruritic) CREA 5% 3 QL (90 grams / 25 days), ST; PA** DERMATOLOGY, ANTIPSORIATICS acitretin CAPS 10mg, 17.5mg, 25mg 1 calcipotriene SOLN .005% 1 calcitriol (topical) OINT 3mcg/gm 3 COSENTYX SOSY 150mg/ml 4 QL (1 box / 28 days), (secukinumab) PA; Preferred agent for Ankylosing Spondylitis and Psoriatic Arthritis COSENTYX SENSOREADY PEN SOAJ 4 QL (1 box / 28 days), 150mg/ml (secukinumab) PA; Preferred agent for Ankylosing Spondylitis and Psoriatic Arthritis methoxsalen rapid CAPS 10mg 1 tazarotene CREA .1% 1 PA

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 84 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits TAZORAC CREA .05%; GEL .05%, .1% 2 PA (tazarotene) DERMATOLOGY, ANTISEBORRHEICS ketoconazole (topical) SHAM 2% 1 selenium sulfide LOTN 2.5% 1 DERMATOLOGY, CORTICOSTEROIDS ala-cort CREA 1% (Ala-cort) 1 QL (120g / 25 days) alclometasone dipropionate CREA .05%; 1 QL (120g / 25 days) OINT .05% amcinonide CREA .1% 1 QL (120g / 25 days) amcinonide LOTN .1% 1 QL (120mL / 25 days) AMCINONIDE OINT .1% 2 QL (120g / 25 days) betamethasone dipropionate (topical) 1 QL (120g / 25 days) CREA .05%; OINT .05% betamethasone dipropionate (topical) 1 QL (120mL / 25 days) LOTN .05% betamethasone dipropionate augmented 1 QL (120g / 25 days) CREA .05%; GEL .05%; OINT .05% betamethasone dipropionate augmented 1 QL (120mL / 25 days) LOTN .05% betamethasone valerate CREA .1%; FOAM 1 QL (120g / 25 days) .12%; OINT .1% betamethasone valerate LOTN .1% 1 QL (120mL / 25 days) calcipotriene-betamethasone dipropionate 2 oint 0.005-0.064% clobetasol propionate CREA .05%; FOAM 1 QL (120g / 25 days) .05%; GEL .05%; OINT .05% clobetasol propionate LIQD .05%; LOTN 1 QL (120mL / 25 days) .05%; SHAM .05%; SOLN .05% clocortolone pivalate CREA .1% 1 QL (120g / 25 days) desonide CREA .05%; OINT .05% 1 QL (120g / 25 days) desonide LOTN .05% 1 QL (120mL / 25 days) desoximetasone CREA .05%, .25%; GEL 1 QL (120g / 25 days) .05%; OINT .05%, .25% diflorasone diacetate CREA .05%; OINT 3 QL (120g / 25 days) .05% fluocinolone acetonide CREA .01%, 1 QL (120g / 25 days) .025%; OINT .025% fluocinolone acetonide OIL .01%; SOLN 1 QL (120mL / 25 days) .01% fluocinonide CREA .05%; GEL .05%; OINT 1 QL (120g / 25 days) .05% fluocinonide SOLN .05% 1 QL (120mL / 25 days) fluticasone propionate CREA .05%; OINT 1 QL (120g / 25 days) .005% fluticasone propionate LOTN .05% 1 QL (120mL / 25 days)

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 85 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits halobetasol propionate CREA .05%; OINT 1 QL (120g / 25 days) .05% hydrocortisone (topical) CREA 1%, 2.5%; 1 QL (120g / 25 days) OINT 2.5% hydrocortisone (topical) LOTN 2.5% 1 QL (120mL / 25 days) hydrocortisone butyrate CREA .1%; OINT 1 QL (120g / 25 days) .1% hydrocortisone butyrate SOLN .1% 1 QL (120mL / 25 days) hydrocortisone valerate CREA .2%; OINT 1 QL (120g / 25 days) .2% mometasone furoate CREA .1%; OINT 1 QL (120g / 25 days) .1% mometasone furoate SOLN .1% 1 QL (120mL / 25 days) prednicarbate CREA .1%; OINT .1% 1 QL (120g / 25 days) triamcinolone acetonide (topical) CREA 1 QL (120g / 25 days) .025%, .1%, .5%; OINT .025%, .1%, .5% triamcinolone acetonide (topical) LOTN 1 QL (120mL / 25 days) .025%, .1% triderm CREA .1% (Triderm) 1 QL (120g / 25 days) DERMATOLOGY, LOCAL ANESTHETICS lidocaine OINT 5% 1 QL (50gm / 25 days) lidocaine PTCH 5% 1 QL (90 patches / 25 days), PA lidocaine hcl GEL 2%; PRSY 2% 1 QL (60mL / 25 days) lidocaine hcl SOLN 4% 1 QL (50mL / 25 days) lidocaine pain relief pat PTCH 4% 1 OTC, QL (30 patches / (Lidocaine Pain Relief Pat) 25 days) lidocaine-prilocaine cream 2.5-2.5% 1 QL (30gm / 25 days) lidocaine-prilocaine cream kit 2.5-2.5% 1 pramox gel GEL 1% (Pramox Gel) 1 SYNERA DIS 70-70MG (lidocaine- 3 QL (2 patches / 25 tetracaine) days) DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE CONDYLOX GEL .5% (podofilox) 3 DENAVIR CREA 1% (penciclovir) 3 diclofenac sodium (topical) GEL 1% 1 QL (300g / 25 days) EUCRISA OINT 2% (crisaborole) 2 QL (60 grams / 25 days), ST; PA** lactic acid ( lactate) CREA 1 12%; LOTN 10%, 12% podofilox SOLN .5% 1 RECTIV OINT .4% (nitroglycerin (intra- 3 anal)) tacrolimus (topical) OINT .03%, .1% 1 TARGRETIN GEL 1% (bexarotene 4 PA (topical))

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 86 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits VOLTAREN GEL 1% (diclofenac sodium 1 OTC, QL (300g / 25 (topical)) days) DERMATOLOGY, ROSACEA azelaic acid GEL 15% 1 FINACEA AER 15% FOAM 15% (azelaic 2 acid) metronidazole (topical) CREA .75%; GEL 1 .75%, 1%; LOTN .75% MIRVASO GEL .33% (brimonidine tartrate 3 PA (topical)) rosadan CREA .75% (Rosadan) 1 DERMATOLOGY, SCABICIDES AND PEDICULIDES crotan LOTN 10% (Crotan) 1 EURAX CREA 10% (crotamiton) 3 lice treatment LOTN 1% (Lice Treatment) 1 OTC lindane SHAM 1% 1 malathion LOTN .5% 1 permethrin CREA 5% 1 permethrin LIQD 1% (Sb Lice Treatment) 1 OTC SKLICE LOTN .5% (ivermectin 3 ST; PA** (pediculicide)) spinosad SUSP .9% 1 DERMATOLOGY, WOUND CARE AGENTS REGRANEX GEL .01% (becaplermin) 3 PA sodium chloride (gu irrigant) SOLN .9% 1 MOUTH/THROAT/DENTAL AGENTS cevimeline hcl CAPS 30mg 1 chlorhexidine gluconate (mouth-throat) 1 SOLN .12% clotrimazole TROC 10mg 1 lidocaine hcl (mouth-throat) SOLN 2%, 1 4% nystatin (mouth-throat) SUSP 1 100000unit/ml oralone dental paste PSTE .1% (Oralone 1 Dental Paste) ORAVIG TABS 50mg (miconazole (mouth- 3 QL (14 tabs / 25 days) throat)) periogard SOLN .12% (Periogard) 1 pilocarpine hcl (oral) TABS 5mg, 7.5mg 1 triamcinolone acetonide (mouth) PSTE 1 .1% OTIC - DRUGS TO TREAT CONDITIONS OF THE EAR acetic acid (otic) SOLN 2% 1

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 87 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Drug Name Drug Tier Requirements/Limits CIPRODEX SUS 0.3-0.1% (ciprofloxacin- 2 dexamethasone) ciprofloxacin hcl (otic) SOLN .2% 1 COLY-MYCIN S SUS OTIC (neomycin- 3 -hc-thonzonium) fluocinolone acetonide (otic) OIL .01% 1 hydrocortisone w/ acetic acid otic soln 1- 1 2% neomycin-polymyxin-hc otic soln 1% 1 neomycin-polymyxin-hc otic susp 3.5 1 mg/ml-10000 unit/ml-1% ofloxacin (otic) SOLN .3% 1

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 88 counter OAC - Oral Anti-Cancer PA** - PA Applies if Step is Not Met Index * acyclovir ...... 13 *pediatric multiple vitamins w/ fluoride ADACEL INJ ...... 69 soln 0.25 mg/ml*** ...... 75 adalimumab *pediatric vitamins acd w/ fluoride soln see HUMIRA ...... 65 0.25 mg/ml*** ...... 75 see HUMIRA PEDIA INJ CROHNS ...65 *pediatric vitamins acd w/ fluoride soln see HUMIRA PEDIATRIC CROHNS D 0.5 mg/ml*** ...... 75 ...... 65 A see HUMIRA PEN ...... 66 abacavir-dolutegravir-lamivudine see HUMIRA PEN-CD/UC/HS START see TRIUMEQ TAB ...... 12 ...... 66 abacavir sulfate ...... 10 see HUMIRA PEN KIT PS/UV ...... 66 abacavir sulfate-lamivudine tab 600- see HUMIRA PEN-PS/UV STARTER .66 300 mg ...... 11 adapalene ...... 82 abacavir sulfate-lamivudine-zidovudine adapalene-benzoyl peroxide tab 300-150-300 mg ...... 11 see EPIDUO FORTE GEL 0.3-2.5% .83 abaloparatide adapalene-benzoyl peroxide gel 0.1- see TYMLOS ...... 56 2.5% ...... 82 abiraterone acetate ...... 18 adefovir dipivoxil ...... 13 see YONSA ...... 19 ADEMPAS ...... 32 see ZYTIGA ...... 19 ado-trastuzumab emtansine ABRAXANE INJ 100MG ...... 17 see KADCYLA ...... 18 acalabrutinib Adriamycin see CALQUENCE ...... 20 see doxorubicin hcl ...... 17 acamprosate calcium ...... 45 adrucil ...... 17 acarbose ...... 46 Adrucil ACCU-CHEK BLOOD GLUCOSE TEST see adrucil ...... 17 KITS ...... 71 ADULT RESPIRATORY MASK ...... 72 ACCU-CHEK BLOOD GLUCOSE TEST ADVAIR DISKU AER 100/50 ...... 82 STRIPS ...... 71 ADVAIR DISKU AER 250/50 ...... 82 acebutolol hcl ...... 29 ADVAIR DISKU AER 500/50 ...... 82 acetaminophen w/ codeine soln 120-12 ADVAIR HFA AER 115/21 ...... 82 mg/5ml ...... 2 ADVAIR HFA AER 230/21 ...... 82 acetaminophen w/ codeine tab 300-15 ADVAIR HFA AER 45/21 ...... 82 mg ...... 2 AFINITOR ...... 20 acetaminophen w/ codeine tab 300-30 AFINITOR DISPERZ ...... 20 mg ...... 2 AFLURIA QUAD INJ 2019-20 ...... 69 acetaminophen w/ codeine tab 300-60 AIMOVIG ...... 42 mg ...... 2 AJOVY ...... 42 acetazolamide ...... 31 AKYNZEO CAP 300-0.5 ...... 58 acetic acid (otic) ...... 87 ala-cort ...... 85 acetylcysteine ...... 80 Ala-cort acitretin ...... 84 see ala-cort ...... 85 ACTEMRA ...... 65 albuterol sulfate ...... 79 ACTHIB INJ ...... 69 alcaftadine ACTIMMUNE ...... 67 see LASTACAFT ...... 77 ACUVAIL ...... 76 alclometasone dipropionate ...... 85 89 ALCOHOL PREP PAD ...... 71 see amethyst ...... 50 alcohol swabs amikacin sulfate ...... 7 see ALCOHOL PREP PAD ...... 71 amiloride & hydrochlorothiazide tab 5- ALDACTAZIDE TAB 50/50 ...... 31 50 mg ...... 31 ALECENSA ...... 20 amiloride hcl ...... 31 alectinib hcl aminophylline ...... 82 see ALECENSA ...... 20 aminosalicylic acid alendronate sodium ...... 50 see PASER ...... 13 alendronate sodium-cholecalciferol amiodarone hcl ...... 27 see FOSAMAX + D TAB 70-2800 ....50 AMITIZA ...... 59 see FOSAMAX + D TAB 70-5600 ....50 amitriptyline hcl ...... 35 alfuzosin hcl ...... 62 amlodipine besylate ...... 30 ALIMTA ...... 17 amlodipine besylate-atorvastatin ALINIA ...... 8 calcium tab 10-10 mg ...... 30 alirocumab amlodipine besylate-atorvastatin see PRALUENT ...... 28 calcium tab 10-20 mg ...... 30 aliskiren fumarate ...... 31 amlodipine besylate-atorvastatin allopurinol ...... 1 calcium tab 10-40 mg ...... 30 almotriptan malate ...... 42 amlodipine besylate-atorvastatin ALOCRIL ...... 77 calcium tab 10-80 mg ...... 30 alogliptin benzoate ...... 46 amlodipine besylate-atorvastatin ALOMIDE ...... 77 calcium tab 2.5-10 mg ...... 29 alosetron hcl ...... 60 amlodipine besylate-atorvastatin alpha1-proteinase inhibitor (human) calcium tab 2.5-20 mg ...... 29 see PROLASTIN-C ...... 81 amlodipine besylate-atorvastatin ALPHAGAN P ...... 77 calcium tab 2.5-40 mg ...... 29 alprazolam ...... 33 amlodipine besylate-atorvastatin see ALPRAZOLAM INTENSOL ...... 33 calcium tab 5-10 mg ...... 29 ALPRAZOLAM INTENSOL ...... 33 amlodipine besylate-atorvastatin altavera ...... 50 calcium tab 5-20 mg ...... 30 Altavera amlodipine besylate-atorvastatin see altavera ...... 50 calcium tab 5-40 mg ...... 30 alyacen 1/35 ...... 50 amlodipine besylate-atorvastatin Alyacen 1/35 calcium tab 5-80 mg ...... 30 see alyacen 1/35 ...... 50 amlodipine besylate-benazepril hcl cap alyacen 7/7/7 ...... 50 10-20 mg ...... 23 Alyacen 7/7/7 amlodipine besylate-benazepril hcl cap see alyacen 7/7/7 ...... 50 10-40 mg ...... 23 amantadine hcl ...... 38 amlodipine besylate-benazepril hcl cap ambrisentan ...... 32 2.5-10 mg ...... 23 amcinonide ...... 85 amlodipine besylate-benazepril hcl cap AMCINONIDE ...... 85 5-10 mg ...... 23 amethia ...... 50 amlodipine besylate-benazepril hcl cap Amethia 5-20 mg ...... 23 see amethia ...... 50 amlodipine besylate-benazepril hcl cap amethyst ...... 50 5-40 mg ...... 23 Amethyst 90 amlodipine besylate-olmesartan amoxicillin & k clavulanate tab 500-125 medoxomil tab 10-20 mg ...... 25 mg ...... 15 amlodipine besylate-olmesartan amoxicillin & k clavulanate tab 875-125 medoxomil tab 10-40 mg ...... 25 mg ...... 15 amlodipine besylate-olmesartan amoxicillin & k clavulanate tab er 12hr medoxomil tab 5-20 mg ...... 25 1000-62.5 mg ...... 15 amlodipine besylate-olmesartan amphetamine-dextroamphetamine cap medoxomil tab 5-40 mg ...... 25 er 24hr 10 mg ...... 40 amlodipine besylate-valsartan tab 10- amphetamine-dextroamphetamine cap 160 mg ...... 25 er 24hr 15 mg ...... 40 amlodipine besylate-valsartan tab 10- amphetamine-dextroamphetamine cap 320 mg ...... 25 er 24hr 20 mg ...... 40 amlodipine besylate-valsartan tab 5- amphetamine-dextroamphetamine cap 160 mg ...... 25 er 24hr 25 mg ...... 40 amlodipine besylate-valsartan tab 5- amphetamine-dextroamphetamine cap 320 mg ...... 25 er 24hr 30 mg ...... 40 amlodipine-valsartan- amphetamine-dextroamphetamine cap hydrochlorothiazide tab 10-160-12.5 er 24hr 5 mg ...... 40 mg ...... 25 amphetamine-dextroamphetamine tab amlodipine-valsartan- 10 mg ...... 40 hydrochlorothiazide tab 10-160-25 amphetamine-dextroamphetamine tab mg ...... 25 12.5 mg ...... 40 amlodipine-valsartan- amphetamine-dextroamphetamine tab hydrochlorothiazide tab 10-320-25 15 mg ...... 41 mg ...... 25 amphetamine-dextroamphetamine tab amlodipine-valsartan- 20 mg ...... 41 hydrochlorothiazide tab 5-160-12.5 amphetamine-dextroamphetamine tab mg ...... 25 30 mg ...... 41 amlodipine-valsartan- amphetamine-dextroamphetamine tab hydrochlorothiazide tab 5-160-25 mg 5 mg ...... 40 ...... 25 amphetamine-dextroamphetamine tab amoxapine ...... 36 7.5 mg ...... 40 amoxicillin ...... 15 amphotericin b ...... 9 amoxicillin & k clavulanate chew tab ampicillin ...... 15 200-28.5 mg ...... 15 ampicillin sodium ...... 15 amoxicillin & k clavulanate chew tab anagrelide hcl ...... 64 400-57 mg ...... 15 anastrozole ...... 18 amoxicillin & k clavulanate for susp ANNOVERA MIS ...... 50 200-28.5 mg/5ml ...... 15 apalutamide amoxicillin & k clavulanate for susp see ERLEADA ...... 19 250-62.5 mg/5ml ...... 15 apixaban amoxicillin & k clavulanate for susp see ELIQUIS ...... 63 400-57 mg/5ml ...... 15 APOKYN ...... 38 amoxicillin & k clavulanate for susp apomorphine hydrochloride 600-42.9 mg/5ml ...... 15 see APOKYN ...... 38 amoxicillin & k clavulanate tab 250-125 apraclonidine hcl ...... 77 mg ...... 15 see IOPIDINE ...... 77 91 apremilast atomoxetine hcl ...... 41 see OTEZLA ...... 67 atorvastatin calcium ...... 28 see OTEZLA TAB 10/20/30 ...... 67 atovaquone ...... 8 aprepitant ...... 58 atovaquone-proguanil hcl tab 250-100 aprepitant pak 80 & 125 ...... 58 mg ...... 9 apri ...... 50 atovaquone-proguanil hcl tab 62.5-25 Apri mg ...... 9 see apri ...... 50 atropine sulfate ...... 58 APTIOM ...... 33 ATROPINE SULFATE ...... 77 APTIVUS ...... 10 AUBAGIO ...... 43 aranelle ...... 50 aviane ...... 50 Aranelle Aviane see aranelle ...... 50 see aviane ...... 50 ARANESP ALBUMIN FREE ...... 64 avidoxy ...... 16 ARCALYST ...... 68 Avidoxy aripiprazole ...... 39 see avidoxy ...... 16 aripiprazole lauroxil avita ...... 82 see ARISTADA ...... 39 Avita see ARISTADA INITIO ...... 39 see avita ...... 82 ARISTADA ...... 39 AVONEX ...... 43 ARISTADA INITIO ...... 39 AVONEX PEN ...... 43 armodafinil ...... 45 axitinib ARNUITY ELLIPTA ...... 81 see INLYTA ...... 21 arsenic trioxide ...... 22 azacitidine ...... 17 artemether-lumefantrine AZASAN ...... 68 see COARTEM TAB 20-120MG ...... 9 AZASITE ...... 75 artificial tear insert azathioprine ...... 68 see LACRISERT ...... 78 see AZASAN ...... 68 asenapine maleate azelaic acid ...... 87 see SAPHRIS ...... 40 see FINACEA AER 15% ...... 87 ashlyna ...... 50 azelastine hcl ...... 79 Ashlyna azelastine hcl (ophth) ...... 77 see ashlyna ...... 50 azelastine hcl-fluticasone prop nasal aspirin-dipyridamole cap er 12hr 25- spray 137-50 mcg/act ...... 79 200 mg ...... 64 azithromycin ...... 14 aspirin enteric coated ad ...... 7 azithromycin (ophth) Aspirin Enteric Coated Ad see AZASITE ...... 75 see aspirin enteric coated ad ...... 7 AZOPT ...... 77 atazanavir sulfate ...... 10 aztreonam ...... 8 see REYATAZ ...... 11 aztreonam lysine atazanavir sulfate-cobicistat see CAYSTON ...... 8 see EVOTAZ TAB 300-150 ...... 12 azurette ...... 50 atenolol ...... 29 Azurette atenolol & chlorthalidone tab 100-25 see azurette ...... 50 mg ...... 28 B atenolol & chlorthalidone tab 50-25 mg bacitracin (ophthalmic) ...... 76 ...... 28 bacitracin-polymyxin b ophth oint ....76 92 bacitracin-polymyxin-neomycin-hc betamethasone dipropionate (topical) ophth oint 1% ...... 75 ...... 85 baclofen ...... 44 betamethasone dipropionate BALCOLTRA TAB 0.1-20 ...... 50 augmented ...... 85 balsalazide disodium ...... 59 betamethasone valerate ...... 85 BARACLUDE ...... 13 BETASERON ...... 43 BASAGLAR KWIKPEN ...... 47 betaxolol hcl ...... 29 bcg live intravesical betaxolol hcl (ophth) ...... 77 see TICE BCG ...... 22 see BETOPTIC-S ...... 77 becaplermin bethanechol chloride ...... 62 see REGRANEX ...... 87 BETIMOL ...... 77 beclomethasone dipropionate hfa BETOPTIC-S ...... 77 see QVAR REDIHALER ...... 82 BEVESPI AER 9-4.8MCG ...... 78 bedaquiline fumarate bexarotene ...... 22 see SIRTURO ...... 13 bexarotene (topical) BELBUCA ...... 7 see TARGRETIN ...... 86 BELSOMRA ...... 42 BEXSERO INJ ...... 69 benazepril & hydrochlorothiazide tab bicalutamide ...... 18 10-12.5 mg ...... 23 bictegravir-emtricitabine-tenofovir benazepril & hydrochlorothiazide tab alafenamide fumarate 20-12.5 mg ...... 23 see BIKTARVY TAB ...... 12 benazepril & hydrochlorothiazide tab BIKTARVY TAB ...... 12 20-25 mg ...... 23 bimatoprost ...... 77 benazepril & hydrochlorothiazide tab 5- see LUMIGAN ...... 77 6.25 mg ...... 23 bio-statin ...... 9 benazepril hcl ...... 24 Bio-statin BENZIQ ...... 82 see bio-statin ...... 9 BENZIQ LS ...... 82 BIO-STATIN ...... 9 benziq wash ...... 83 bisoprolol & hydrochlorothiazide tab Benziq Wash 10-6.25 mg ...... 29 see benziq wash ...... 83 bisoprolol & hydrochlorothiazide tab benzonatate ...... 80 2.5-6.25 mg ...... 28 benzoyl peroxide bisoprolol & hydrochlorothiazide tab 5- see BENZIQ ...... 82 6.25 mg ...... 28 see BENZIQ LS ...... 82 bisoprolol fumarate ...... 29 benzoyl peroxide-erythromycin gel 5- bleomycin sulfate ...... 17 3% ...... 83 BLEPHAMIDE OIN S.O.P...... 75 benztropine mesylate ...... 38 BLEPHAMIDE SUS OP ...... 75 bepotastine besilate blood glucose calibration see BEPREVE ...... 77 see BLOOD GLUCOSE CALIBRATION BEPREVE ...... 77 SOLUTION ...... 71 besifloxacin hcl BLOOD GLUCOSE CALIBRATION see BESIVANCE ...... 76 SOLUTION ...... 71 BESIVANCE ...... 76 blood glucose monitoring supplies betaine see ACCU-CHEK BLOOD GLUCOSE see CYSTADANE POW ...... 53 TEST KITS ...... 71 BOOSTRIX INJ ...... 69 93 bosentan ...... 32 buprenorphine hcl-naloxone hcl sl film see TRACLEER ...... 33 12-3 mg (base equiv) ...... 2 BOSULIF ...... 20 buprenorphine hcl-naloxone hcl sl film bosutinib 2-0.5 mg (base equiv) ...... 2 see BOSULIF ...... 20 buprenorphine hcl-naloxone hcl sl film bp wash ...... 83 4-1 mg (base equiv) ...... 2 Bp Wash buprenorphine hcl-naloxone hcl sl film see bp wash ...... 83 8-2 mg (base equiv) ...... 2 BREO ELLIPTA INH 100-25 ...... 82 buprenorphine hcl-naloxone hcl sl tab BREO ELLIPTA INH 200-25 ...... 82 2-0.5 mg (base equiv) ...... 2 brexpiprazole buprenorphine hcl-naloxone hcl sl tab see REXULTI ...... 40 8-2 mg (base equiv) ...... 2 BRILINTA ...... 64 bupropion hcl ...... 36 brimonidine tartrate ...... 77 bupropion hcl (smoking deterrent) ...45 see ALPHAGAN P ...... 77 buspirone hcl ...... 43 brimonidine tartrate (topical) busulfan ...... 16 see MIRVASO ...... 87 butalbital-acetaminophen-caffeine cap brimonidine tartrate-timolol maleate 50-300-40 mg ...... 1 see COMBIGAN SOL 0.2/0.5% ...... 77 butalbital-acetaminophen-caffeine cap brinzolamide 50-325-40 mg ...... 1 see AZOPT ...... 77 butalbital-acetaminophen-caffeine tab brinzolamide-brimonidine tartrate 50-325-40 mg ...... 1 see SIMBRINZA SUS 1-0.2% ...... 77 butalbital-acetaminophen-caff w/ cod bromfenac sodium (ophth) ...... 76 cap 50-300-40-30 mg ...... 2 bromocriptine mesylate ...... 38 butalbital-aspirin-caffeine cap 50-325- bromocriptine mesylate (diabetes) 40 mg ...... 1 see CYCLOSET ...... 46 butenafine hcl brompheniramine tannate ...... 79 see MENTAX ...... 84 budesonide ...... 59 butoconazole nitrate (one dose) budesonide (inhalation) ...... 81, 82 see GYNAZOLE-1 ...... 63 budesonide-formoterol fumarate butorphanol tartrate ...... 3 dihydrate BYSTOLIC ...... 29 see SYMBICORT AER 160-4.5 ...... 82 C see SYMBICORT AER 80-4.5 ...... 82 cabergoline ...... 56 bumetanide ...... 31 cabozantinib s-malate buprenorphine ...... 7 see COMETRIQ ...... 20 see SUBLOCADE ...... 7 see COMETRIQ KIT 100MG ...... 20 buprenorphine hcl ...... 7 see COMETRIQ KIT 140MG ...... 20 see BELBUCA ...... 7 calcipotriene ...... 84 buprenorphine hcl-naloxone hcl calcipotriene-betamethasone dihydrate dipropionate oint 0.005-0.064% ....85 see ZUBSOLV SUB 0.7-0.18 ...... 2 calcitonin (salmon) ...... 56 see ZUBSOLV SUB 1.4-0.36 ...... 2 calcitriol ...... 74 see ZUBSOLV SUB 11.4-2.9 ...... 2 calcitriol (topical) ...... 84 see ZUBSOLV SUB 2.9-0.71 ...... 2 calcium acetate (phosphate binder) ..57 see ZUBSOLV SUB 5.7-1.4 ...... 2 see PHOSLYRA ...... 57 see ZUBSOLV SUB 8.6-2.1 ...... 2 CALQUENCE ...... 20 94 camila ...... 50 carbidopa-levodopa-entacapone tabs Camila 31.25-125-200 mg ...... 38 see camila ...... 50 carbidopa-levodopa-entacapone tabs CAMPTOSAR ...... 23 37.5-150-200 mg ...... 38 candesartan cilexetil ...... 26 carbidopa-levodopa-entacapone tabs candesartan cilexetil- 50-200-200 mg ...... 38 hydrochlorothiazide tab 16-12.5 mg carbinoxamine maleate ...... 79 ...... 25 carboplatin ...... 22 candesartan cilexetil- CARDIZEM LA ...... 30 hydrochlorothiazide tab 32-12.5 mg CARDURA XL ...... 62 ...... 25 carglumic acid candesartan cilexetil- see CARBAGLU ...... 53 hydrochlorothiazide tab 32-25 mg .25 carisoprodol ...... 44 capecitabine ...... 17 carmustine ...... 16 CAPRELSA ...... 20 carmustine in polifeprosan captopril ...... 24 see GLIADEL WAF 7.7MG ...... 16 captopril & hydrochlorothiazide tab 25- carteolol hcl (ophth) ...... 77 15 mg ...... 23 cartia xt ...... 30 captopril & hydrochlorothiazide tab 25- Cartia Xt 25 mg ...... 24 see cartia xt ...... 30 captopril & hydrochlorothiazide tab 50- carvedilol ...... 29 15 mg ...... 24 carvedilol phosphate ...... 29 captopril & hydrochlorothiazide tab 50- CAYA DPR ...... 71 25 mg ...... 24 CAYSTON ...... 8 CARBAGLU ...... 53 caziant ...... 50 carbamazepine ...... 33 Caziant carbidopa ...... 38 see caziant ...... 50 carbidopa & levodopa orally cefaclor ...... 13 disintegrating tab 10-100 mg ...... 38 cefadroxil ...... 13 carbidopa & levodopa orally cefazolin sodium ...... 13 disintegrating tab 25-100 mg ...... 38 cefdinir ...... 13 carbidopa & levodopa orally cefditoren pivoxil ...... 13 disintegrating tab 25-250 mg ...... 38 cefepime hcl ...... 13 carbidopa & levodopa tab 10-100 mg 38 cefixime ...... 14 carbidopa & levodopa tab 25-100 mg 38 see SUPRAX ...... 14 carbidopa & levodopa tab 25-250 mg 38 cefpodoxime proxetil ...... 14 carbidopa & levodopa tab er 25-100 cefprozil ...... 14 mg ...... 38 ceftazidime ...... 14 carbidopa & levodopa tab er 50-200 ceftriaxone sodium ...... 14 mg ...... 38 cefuroxime axetil ...... 14 carbidopa-levodopa-entacapone tabs celecoxib ...... 1 12.5-50-200 mg ...... 38 CELONTIN ...... 33 carbidopa-levodopa-entacapone tabs cephalexin ...... 14 18.75-75-200 mg ...... 38 CERDELGA ...... 53 carbidopa-levodopa-entacapone tabs ceritinib 25-100-200 mg ...... 38 see ZYKADIA ...... 22 cervical caps 95 see FEMCAP MIS 22MM ...... 71 cisplatin ...... 22 see FEMCAP MIS 26MM ...... 71 citalopram hydrobromide ...... 36 see FEMCAP MIS 30MM ...... 71 CITRANATAL CAP HARMONY ...... 74 cetuximab CITRANATAL CAP MEDLEY ...... 74 see ERBITUX ...... 18 CITRANATAL MIS ...... 74 cevimeline hcl ...... 87 CITRANATAL MIS 90 DHA ...... 74 CHANTIX ...... 45 CITRANATAL MIS B-CALM ...... 74 CHANTIX CONTINUING MONTH ...... 45 CITRANATAL PAK ASSURE ...... 74 CHANTIX PAK 0.5& 1MG ...... 45 CITRANATAL PAK DHA ...... 74 chateal ...... 51 CITRANATAL TAB BLOOM ...... 74 Chateal CITRANATAL TAB RX ...... 74 see chateal ...... 51 cladribine ...... 17 CHEMET ...... 50 clarithromycin ...... 14 chlorambucil clemastine fumarate ...... 79 see LEUKERAN ...... 16 CLENPIQ SOL ...... 60 chlorhexidine gluconate (mouth-throat) CLEOCIN ...... 63 ...... 87 CLIMARA PRO DIS WEEKLY ...... 54 chloroquine phosphate ...... 9 clindamycin hcl ...... 8 chlorothiazide ...... 31 clindamycin palmitate hydrochloride ...8 see DIURIL ...... 31 clindamycin phosphate ...... 8 chlorpromazine hcl ...... 39 clindamycin phosphate (topical) ...... 83 CHLORPROMAZINE HCL ...... 39 clindamycin phosphate-benzoyl chlorthalidone ...... 31 peroxide gel 1.2-2.5% ...... 83 chlorzoxazone ...... 44 clindamycin phosphate-benzoyl cholecalciferol ...... 74 peroxide gel 1-5% ...... 83 cholestyramine ...... 27 clindamycin phosphate vaginal ...... 63 cholestyramine light ...... 27 see CLEOCIN ...... 63 choline fenofibrate ...... 27 clindamycin phosph-benzoyl peroxide ciclesonide (nasal) (refrig) gel 1.2 (1)-5% ...... 83 see OMNARIS ...... 81 clobazam ...... 33 ciclopirox ...... 83, 84 clobetasol propionate ...... 85 ciclopirox olamine ...... 84 clocortolone pivalate ...... 85 cidofovir ...... 13 clofarabine ...... 17 cilostazol ...... 64 clomipramine hcl ...... 43 CIMDUO TAB 300-300 ...... 12 clonazepam ...... 33 cimetidine ...... 59 clonidine hcl ...... 31 cimetidine hcl ...... 59 clopidogrel bisulfate ...... 65 cinacalcet hcl ...... 50 clorazepate dipotassium ...... 33 CIPRO ...... 14 clotrimazole ...... 87 CIPRODEX SUS 0.3-0.1% ...... 88 clotrimazole (topical) ...... 84 ciprofloxacin clotrimazole w/ betamethasone cream see CIPRO ...... 14 1-0.05% ...... 84 ciprofloxacin-dexamethasone clotrimazole w/ betamethasone lotion see CIPRODEX SUS 0.3-0.1% ...... 88 1-0.05% ...... 84 ciprofloxacin hcl ...... 14 clozapine ...... 39 ciprofloxacin hcl (ophth) ...... 76 COARTEM TAB 20-120MG ...... 9 ciprofloxacin hcl (otic) ...... 88 cobicistat 96 see TYBOST ...... 11 see PARAGARD IUD T380A ...... 53 codeine polistirex-chlorpheniramine cortisone acetate ...... 55 polistirex COSENTYX ...... 84 see TUZISTRA XR SUS ...... 80 COSENTYX SENSOREADY PEN ...... 84 codeine sulfate ...... 3 CREON CAP 12000UNT ...... 61 CODEINE SULFATE ...... 3 CREON CAP 24000UNT ...... 61 colchicine ...... 1 CREON CAP 3000UNIT ...... 61 colchicine w/ probenecid tab 0.5-500 CREON CAP 36000UNT ...... 61 mg ...... 1 CREON CAP 6000UNIT ...... 61 colestipol hcl ...... 27 CRESEMBA ...... 9 colocort ...... 59 CRINONE ...... 57 Colocort crisaborole see colocort ...... 59 see EUCRISA ...... 86 COLY-MYCIN S SUS OTIC ...... 88 CRIXIVAN ...... 10 COMBIGAN SOL 0.2/0.5% ...... 77 crizotinib COMETRIQ ...... 20 see XALKORI ...... 22 COMETRIQ KIT 100MG ...... 20 cromolyn sodium ...... 80 COMETRIQ KIT 140MG ...... 20 cromolyn sodium (mastocytosis) ...... 60 compro ...... 58 cromolyn sodium (ophth) ...... 77 Compro crotamiton see compro ...... 58 see EURAX ...... 87 condoms - female crotan ...... 87 see FC2 FEMALE MIS CONDOM ...... 71 Crotan CONDYLOX ...... 86 see crotan ...... 87 conjugated estrogens-bazedoxifene cryselle-28 ...... 51 see DUAVEE TAB 0.45-20 ...... 54 Cryselle-28 continuous blood glucose system see cryselle-28 ...... 51 receiver CUVPOSA ...... 58 see DEXCOM G5 MIS RECEIVER ....71 cvs sleep-aid nighttime ...... 42 see DEXCOM G6 MIS RECEIVER ....71 Cvs Sleep-aid Nighttime see G4 PLATINUM MIS PEDIATRC ..72 see cvs sleep-aid nighttime ...... 42 see G4 PLATINUM MIS RCV/SHAR ..72 cyanocobalamin ...... 74 see G4 PLATINUM MIS RECEIVER ..72 cyclafem 1/35 ...... 51 see G4 PLAT PED MIS RVC/SHAR ...72 Cyclafem 1/35 continuous blood glucose system see cyclafem 1/35 ...... 51 sensor cyclafem 7/7/7 ...... 51 see DEXCOM G6 MIS SENSOR ...... 71 Cyclafem 7/7/7 see G4 SENSOR MIS ...... 72 see cyclafem 7/7/7 ...... 51 see G5/G4 MIS SENSOR ...... 72 cyclobenzaprine hcl ...... 44 continuous blood glucose system cyclophosphamide ...... 16 transmitter cycloserine ...... 12 see DEXCOM G5 MIS TRANSMIT ....71 CYCLOSET ...... 46 see DEXCOM G6 MIS TRANSMIT ....71 cyclosporine ...... 68 see G4 PLATINUM MIS TRANSMIT ..72 see SANDIMMUNE ...... 68 COPAXONE INJ 20MG/ML ...... 43 cyclosporine (ophth) COPAXONE INJ 40MG/ML ...... 44 see RESTASIS ...... 78 copper (iud) 97 cyclosporine modified (for see dasetta 1/35 ...... 51 microemulsion) ...... 68 dasetta 7/7/7 ...... 51 cyproheptadine hcl ...... 79 Dasetta 7/7/7 CYSTADANE POW ...... 53 see dasetta 7/7/7 ...... 51 CYSTAGON ...... 53 daunorubicin hcl ...... 17 CYSTARAN ...... 78 decitabine ...... 17 cysteamine bitartrate deferiprone see CYSTAGON ...... 53 see FERRIPROX ...... 50 cysteamine hcl see FERRIPROX TWICE-A-DAY ...... 50 see CYSTARAN ...... 78 delyla ...... 51 cytarabine ...... 17 Delyla D see delyla ...... 51 dabigatran etexilate mesylate demeclocycline hcl ...... 16 see PRADAXA ...... 63 DENAVIR ...... 86 dabrafenib mesylate denosumab see TAFINLAR ...... 21 see PROLIA ...... 56 dacarbazine ...... 16 DEPO-ESTRADIOL ...... 54 dalfampridine ...... 44 DEPO-MEDROL ...... 55 DALIRESP ...... 80 DEPO-PROVERA ...... 19 dalteparin sodium DEPO-SUBQ PROVERA 104 ...... 51 see FRAGMIN ...... 63 DESCOVY TAB 200/25 ...... 12 danazol ...... 53 desipramine hcl ...... 36 dantrolene sodium ...... 45 desloratadine ...... 79 dapagliflozin-metformin hcl desmopressin acetate ...... 57 see XIGDUO XR TAB 10-1000 ...... 49 desmopressin acetate spray ...... 58 see XIGDUO XR TAB 10-500MG .....49 desmopressin acetate spray see XIGDUO XR TAB 2.5-1000 ...... 49 refrigerated ...... 58 see XIGDUO XR TAB 5-1000MG .....49 desonide ...... 85 see XIGDUO XR TAB 5-500MG ...... 49 desoximetasone ...... 85 dapagliflozin propanediol desvenlafaxine succinate ...... 36 see FARXIGA ...... 49 dexamethasone ...... 55 dapsone ...... 8 see DEXAMETHASONE INTENSOL ..55 DAPTACEL INJ ...... 69 dexamethasone (ophth) DARAPRIM ...... 8 see MAXIDEX ...... 76 darbepoetin alfa DEXAMETHASONE INTENSOL ...... 55 see ARANESP ALBUMIN FREE ...... 64 dexamethasone sodium phosphate ...55 darifenacin hydrobromide ...... 62 dexamethasone sodium phosphate darolutamide (ophth) ...... 76 see NUBEQA ...... 19 DEXCOM G5 MIS RECEIVER ...... 71 darunavir-cobicistat DEXCOM G5 MIS TRANSMIT ...... 71 see PREZCOBIX TAB 800-150 ...... 12 DEXCOM G6 MIS RECEIVER ...... 71 darunavir ethanolate DEXCOM G6 MIS SENSOR ...... 71 see PREZISTA ...... 10, 11 DEXCOM G6 MIS TRANSMIT ...... 71 dasatinib DEXILANT ...... 61 see SPRYCEL ...... 21 dexlansoprazole dasetta 1/35 ...... 51 see DEXILANT ...... 61 Dasetta 1/35 dexmethylphenidate hcl ...... 41 98 dexrazoxane hcl ...... 22 diltiazem hcl coated beads ...... 30 dextroamphetamine sulfate ...... 41 see CARDIZEM LA ...... 30 dextromethorphan hbr-quinidine diltiazem hcl extended release beads 30 sulfate Dilt-xr see NUEDEXTA CAP 20-10MG ...... 43 see diltiazem hcl ...... 30 dextrose (diabetic use) dimethyl fumarate see INSTA-GLUCOSE ...... 56 see TECFIDERA ...... 44 diaphragm arc-spring see TECFIDERA MIS STARTER ...... 44 see CAYA DPR ...... 71 DIP/TET PED INJ 25-5LFU ...... 69 diaphragms DIPENTUM ...... 59 see OMNIFLEX DPR ...... 71 diph-ac pert-tet tox ad-polio ipv- diaphragm wide seal haemophil b poly vac see WIDE-SEAL SILICONE DIAPHR 71 see PENTACEL INJ ...... 70 diazepam ...... 33 diphenhydramine hcl ...... 79 diazepam intensol ...... 33 diphenoxylate w/ atropine liq 2.5-0.025 Diazepam Intensol mg/5ml ...... 60 see diazepam intensol ...... 33 diphenoxylate w/ atropine tab 2.5- diclofenac potassium ...... 1 0.025 mg ...... 60 diclofenac sodium ...... 1 diph-tetanus tox-acell pert-hepatitis b diclofenac sodium (ophth) ...... 76 recomb-polio ipv vac diclofenac sodium (topical) ...... 86 see PEDIARIX INJ 0.5ML ...... 70 see VOLTAREN ...... 87 diph-tetanus tox ad-acell pertussis & diclofenac w/ misoprostol tab delayed polio virus, ipv vac release 50-0.2 mg ...... 1 see KINRIX INJ ...... 70 diclofenac w/ misoprostol tab delayed diphtheria, acellular pertussis & tetanus release 75-0.2 mg ...... 1 toxoids dicloxacillin sodium ...... 15 see DAPTACEL INJ ...... 69 dicyclomine hcl ...... 58 see INFANRIX INJ ...... 70 didanosine ...... 10 dipyridamole ...... 65 see VIDEX EC ...... 11 disopyramide phosphate ...... 27 see VIDEX PEDIATRIC ...... 11 see NORPACE CR ...... 27 difenoxin w/ atropine disulfiram ...... 45 see MOTOFEN TAB 1-0.025 ...... 61 DIURIL ...... 31 DIFICID ...... 14 divalproex sodium ...... 34 diflorasone diacetate ...... 85 DIVIGEL ...... 54 diflunisal ...... 7 docetaxel ...... 17 difluprednate dofetilide ...... 27 see DUREZOL ...... 76 dolutegravir sodium digox ...... 31 see TIVICAY ...... 11 Digox dolutegravir sodium-lamivudine see digox ...... 31 see DOVATO TAB 50-300MG ...... 12 digoxin ...... 31 donepezil hydrochloride ...... 35 see LANOXIN ...... 31 dorzolamide hcl ...... 77 dihydroergotamine mesylate ...... 42 dorzolamide hcl-timolol maleate ophth DILANTIN ...... 33 soln 22.3-6.8 mg/ml ...... 77 DILATRATE SR ...... 32 DOVATO TAB 50-300MG ...... 12 diltiazem hcl ...... 30 doxazosin mesylate ...... 25 99 doxazosin mesylate (bph) efavirenz-lamivudine-tenofovir see CARDURA XL ...... 62 disoproxil fumarate doxepin hcl ...... 36 see SYMFI LO TAB ...... 12 doxepin hcl (antipruritic) ...... 84 see SYMFI TAB ...... 12 doxercalciferol ...... 74 Effer-k doxorubicin hcl ...... 17 see k-effervescent ...... 73 doxorubicin hcl liposomal ...... 17 efinaconazole doxy 100 ...... 16 see JUBLIA ...... 84 Doxy 100 elagolix sodium see doxy 100 ...... 16 see ORILISSA ...... 53 doxycycline (monohydrate) ...... 16 ELESTRIN ...... 54 doxycycline calcium eletriptan hydrobromide ...... 42 see VIBRAMYCIN ...... 16 elexacaftor-tezacaftor-ivacaftor doxycycline hyclate ...... 16 see TRIKAFTA TAB ...... 81 dronabinol ...... 58 ELIGARD ...... 19 dronedarone hcl eliglustat tartrate see MULTAQ ...... 27 see CERDELGA ...... 53 drospirenone elinest ...... 51 see SLYND ...... 53 Elinest drospirenone-ethinyl estradiol tab 3- see elinest ...... 51 0.03 mg ...... 51 ELIQUIS ...... 63 drospirenone-ethinyl estrad- elite-ob ...... 74 levomefolate tab 3-0.02-0.451 mg 51 Elite-ob drospirenone-ethinyl estrad- see elite-ob ...... 74 levomefolate tab 3-0.03-0.451 mg 51 ELIXOPHYLLIN ...... 82 DROXIA ...... 22 ELLA ...... 51 DUAVEE TAB 0.45-20 ...... 54 ELMIRON ...... 62 dulaglutide eltrombopag olamine see TRULICITY ...... 47 see PROMACTA ...... 64 duloxetine hcl ...... 36 elvitegravir-cobicistat-emtricitabine- DUREZOL ...... 76 tenofovir alafenamide dutasteride ...... 62 see GENVOYA TAB ...... 12 dutasteride-tamsulosin hcl cap 0.5-0.4 EMCYT ...... 16 mg ...... 62 EMGALITY ...... 42 E emicizumab-kxwh e.e.s. 400 ...... 14 see HEMLIBRA ...... 64 E.e.s. 400 emoquette ...... 51 see e.e.s. 400 ...... 14 Emoquette echothiophate iodide see emoquette ...... 51 see PHOSPHOLINE IODIDE ...... 77 empagliflozin econazole nitrate ...... 84 see JARDIANCE ...... 49 ed-spaz ...... 58 empagliflozin-linagliptin Ed-spaz see GLYXAMBI TAB 10-5 MG ...... 49 see ed-spaz ...... 58 see GLYXAMBI TAB 25-5 MG ...... 49 EDURANT ...... 10 empagliflozin-metformin hcl efavirenz ...... 10 see SYNJARDY TAB 12.5-1000MG ..49 see SYNJARDY TAB 12.5-500 ...... 49 100 see SYNJARDY TAB 5-1000MG ...... 49 see enskyce ...... 51 see SYNJARDY TAB 5-500MG ...... 49 entacapone ...... 39 see SYNJARDY XR TAB 10-1000 ....49 entecavir ...... 13 see SYNJARDY XR TAB 12.5-1000MG see BARACLUDE ...... 13 ...... 49 ENTRESTO TAB 24-26MG ...... 31 see SYNJARDY XR TAB 25-1000 ....49 ENTRESTO TAB 49-51MG ...... 32 see SYNJARDY XR TAB 5-1000MG ..49 ENTRESTO TAB 97-103MG ...... 32 EMSAM ...... 36 enulose ...... 60 emtricitabine Enulose see EMTRIVA ...... 10 see enulose ...... 60 emtricitabine-rilpivirine-tenofovir enzalutamide alafenamide fumarate see XTANDI ...... 19 see ODEFSEY TAB ...... 12 EPCLUSA TAB 400-100 ...... 14 emtricitabine-tenofovir alafenamide EPIDUO FORTE GEL 0.3-2.5% ...... 83 fumarate epinastine hcl (ophth) ...... 77 see DESCOVY TAB 200/25 ...... 12 epinephrine (anaphylaxis) ...... 78 emtricitabine-tenofovir disoproxil see EPIPEN 2-PAK ...... 78 fumarate see EPIPEN-JR 2-PAK ...... 78 see TRUVADA TAB 100-150 ...... 12 EPIPEN 2-PAK ...... 78 see TRUVADA TAB 133-200 ...... 12 EPIPEN-JR 2-PAK ...... 78 see TRUVADA TAB 167-250 ...... 12 epirubicin hcl ...... 17 see TRUVADA TAB 200-300 ...... 12 epitol ...... 34 EMTRIVA ...... 10 Epitol EMVERM ...... 8 see epitol ...... 34 enalapril maleate ...... 24 EPIVIR HBV ...... 13 enalapril maleate & hydrochlorothiazide eplerenone ...... 25 tab 10-25 mg ...... 24 epoetin alfa-epbx enalapril maleate & hydrochlorothiazide see RETACRIT ...... 64 tab 5-12.5 mg ...... 24 eprosartan mesylate ...... 26 enasidenib mesylate ERBITUX ...... 18 see IDHIFA ...... 20 erenumab-aooe ENBREL ...... 65 see AIMOVIG ...... 42 ENBREL MINI ...... 65 ergocalciferol ...... 74 ENBREL SURECLICK ...... 65 ergoloid mesylates ...... 35 ENCARE ...... 62 ergotamine w/ caffeine tab 1-100 mg endocet ...... 3 ...... 42 Endocet ERIVEDGE ...... 18 see endocet ...... 3 ERLEADA ...... 19 enfuvirtide erlotinib hcl ...... 20 see FUZEON ...... 10 errin ...... 51 ENGERIX-B ...... 69 Errin enoxaparin sodium ...... 63 see errin ...... 51 enpresse-28 ...... 51 ERTACZO ...... 84 Enpresse-28 ertapenem sodium ...... 8 see enpresse-28 ...... 51 ery ...... 83 enskyce ...... 51 Ery Enskyce see ery ...... 83 101 ery-tab ...... 14 ethambutol hcl ...... 12 Ery-tab ethionamide see ery-tab ...... 14 see TRECATOR ...... 13 erythrocin stearate ...... 14 ethosuximide ...... 34 Erythrocin Stearate ethotoin see erythrocin stearate ...... 14 see PEGANONE ...... 34 erythromycin (acne aid) ...... 83 ethynodiol diacetate & ethinyl estradiol erythromycin (ophth) ...... 76 tab 1 mg-50 mcg ...... 51 erythromycin base ...... 14 etodolac ...... 1 erythromycin ethylsuccinate ...... 14 etonogestrel ESBRIET ...... 81 see NEXPLANON ...... 52 escitalopram oxalate ...... 36 etonogestrel-ethinyl estradiol va ring eslicarbazepine acetate 0.120-0.015 mg/24hr ...... 51 see APTIOM ...... 33 etoposide ...... 23 esomeprazole magnesium ...... 61 etravirine esterified estrogens see INTELENCE ...... 10 see MENEST ...... 55 EUCRISA ...... 86 estradiol ...... 54 EURAX ...... 87 see DIVIGEL ...... 54 EVAMIST ...... 54 see ELESTRIN ...... 54 everolimus ...... 20 see ESTROGEL ...... 54 see AFINITOR ...... 20 see EVAMIST ...... 54 see AFINITOR DISPERZ ...... 20 estradiol & norethindrone acetate tab everolimus (immunosuppressant) .....68 0.5-0.1 mg ...... 54 see ZORTRESS ...... 68 estradiol & norethindrone acetate tab EVOTAZ TAB 300-150 ...... 12 1-0.5 mg ...... 54 EXELDERM ...... 84 estradiol cypionate exemestane ...... 19 see DEPO-ESTRADIOL ...... 54 ezetimibe ...... 27 estradiol-levonorgestrel ezetimibe-simvastatin tab 10-10 mg .28 see CLIMARA PRO DIS WEEKLY .....54 ezetimibe-simvastatin tab 10-20 mg .28 estradiol vaginal cream ...... 54 ezetimibe-simvastatin tab 10-40 mg .28 estradiol valerate ...... 54 ezetimibe-simvastatin tab 10-80 mg .28 estradiol valerate-dienogest F see NATAZIA TAB ...... 52 falmina ...... 51 estramustine phosphate sodium Falmina see EMCYT ...... 16 see falmina ...... 51 ESTROGEL ...... 54 famciclovir ...... 13 estrogens, conjugated famotidine ...... 59 see PREMARIN ...... 55 famotidine in nacl 0.9% iv soln 20 estrogens, conjugated vaginal mg/50ml ...... 59 see PREMARIN ...... 55 FARXIGA ...... 49 eszopiclone ...... 42 FARYDAK ...... 18 etanercept fayosim ...... 51 see ENBREL ...... 65 Fayosim see ENBREL MINI ...... 65 see fayosim ...... 51 see ENBREL SURECLICK ...... 65 FC2 FEMALE MIS CONDOM ...... 71 ethacrynic acid ...... 31 febuxostat ...... 1 102 felbamate ...... 34 see fluoritab ...... 73 felodipine ...... 30 fluorometholone (ophth) FEMCAP MIS 22MM ...... 71 see FML ...... 76 FEMCAP MIS 26MM ...... 71 see FML FORTE ...... 76 FEMCAP MIS 30MM ...... 71 fluorouracil ...... 17 fenofibrate ...... 27 fluorouracil (topical) ...... 83 fenofibrate micronized ...... 28 fluoxetine hcl ...... 36 fenoprofen calcium ...... 1 fluphenazine decanoate ...... 39 fentanyl ...... 3 fluphenazine hcl ...... 39 fentanyl citrate ...... 3 flura-drops ...... 73 FERRIPROX ...... 50 Flura-drops FERRIPROX TWICE-A-DAY ...... 50 see flura-drops ...... 73 fesoterodine fumarate flurbiprofen ...... 1 see TOVIAZ ...... 63 flurbiprofen sodium ...... 76 FETZIMA ...... 36 flutamide ...... 19 FETZIMA CAP TITRATIO ...... 36 fluticasone furoate (inhalation) FIASP FLEX INJ TOUCH ...... 47 see ARNUITY ELLIPTA ...... 81 FIASP INJ 100/ML ...... 47 fluticasone furoate-vilanterol FIASP PENFIL INJ U-100 ...... 47 see BREO ELLIPTA INH 100-25 ...... 82 fidaxomicin see BREO ELLIPTA INH 200-25 ...... 82 see DIFICID ...... 14 fluticasone propionate ...... 85 filgrastim-aafi fluticasone propionate (nasal) ...... 81 see NIVESTYM ...... 64 fluticasone-salmeterol FINACEA AER 15% ...... 87 see ADVAIR DISKU AER 100/50 ....82 finasteride ...... 62 see ADVAIR DISKU AER 250/50 ....82 fingolimod hcl see ADVAIR DISKU AER 500/50 ....82 see GILENYA ...... 44 see ADVAIR HFA AER 115/21 ...... 82 flavoxate hcl ...... 62 see ADVAIR HFA AER 230/21 ...... 82 flecainide acetate ...... 27 see ADVAIR HFA AER 45/21 ...... 82 floxuridine ...... 17 fluticasone-umeclidinium-vilanterol FLUAD INJ 2019-20 ...... 69 see TRELEGY AER ELLIPTA ...... 78 FLUAD QUADRIVALENT INFLUE ...... 69 fluvastatin sodium ...... 28 FLUARIX QUAD INJ 2019-20 ...... 69 fluvoxamine maleate ...... 43 FLUBLOK QUAD INJ 2019-20 ...... 69 FLUZONE HD INJ PF 19-20 ...... 69 FLUCLVX QUAD INJ 2019-20 ...... 69 FLUZONE QUAD INJ 2019-20 ...... 69 fluconazole ...... 9 FML ...... 76 fludarabine phosphate ...... 17 FML FORTE ...... 76 fludrocortisone acetate ...... 55 folic acid ...... 74 FLULAVAL QUA INJ 2019-20 ...... 69 folic acid-pyridoxine-cyanocobalamin FLUMIST QUAD SUS 2019-20 ...... 69 tab 2.5-25-2 mg ...... 74 flunisolide (nasal) ...... 81 fondaparinux sodium ...... 63 fluocinolone acetonide ...... 85 formoterol fumarate fluocinolone acetonide (otic) ...... 88 see PERFOROMIST ...... 80 fluocinonide ...... 85 FOSAMAX + D TAB 70-2800 ...... 50 FLUORABON ...... 73 FOSAMAX + D TAB 70-5600 ...... 50 fluoritab ...... 73 fosamprenavir calcium ...... 10 Fluoritab see LEXIVA ...... 10 103 fosfomycin tromethamine gemfibrozil ...... 28 see MONUROL ...... 7 generlac ...... 60 fosinopril sodium ...... 24 Generlac fosinopril sodium & hydrochlorothiazide see generlac ...... 60 tab 10-12.5 mg ...... 24 gengraf ...... 68 fosinopril sodium & hydrochlorothiazide Gengraf tab 20-12.5 mg ...... 24 see gengraf ...... 68 fosphenytoin sodium ...... 34 gentak ...... 76 FOSRENOL ...... 57 Gentak FRAGMIN ...... 63 see gentak ...... 76 fremanezumab-vfrm gentamicin sulfate ...... 7 see AJOVY ...... 42 gentamicin sulfate (ophth) ...... 76 frovatriptan succinate ...... 42 gentamicin sulfate (topical) ...... 83 fulvestrant ...... 19 GENVOYA TAB ...... 12 furosemide ...... 31 gianvi ...... 51 FUZEON ...... 10 Gianvi FYCOMPA ...... 34 see gianvi ...... 51 G GILENYA ...... 44 G4 PLATINUM MIS PEDIATRC ...... 72 glatiramer acetate ...... 44 G4 PLATINUM MIS RCV/SHAR ...... 72 see COPAXONE INJ 20MG/ML ...... 43 G4 PLATINUM MIS RECEIVER ...... 72 see COPAXONE INJ 40MG/ML ...... 44 G4 PLATINUM MIS TRANSMIT ...... 72 glatopa ...... 44 G4 PLAT PED MIS RVC/SHAR ...... 72 Glatopa G4 SENSOR MIS ...... 72 see glatopa ...... 44 G5/G4 MIS SENSOR ...... 72 GLEOSTINE ...... 16 gabapentin ...... 34 GLIADEL WAF 7.7MG ...... 16 galantamine hydrobromide ...... 35 glimepiride ...... 49 galcanezumab-gnlm glipizide ...... 49 see EMGALITY ...... 42 glipizide-metformin hcl tab 2.5-250 mg ganciclovir ophthalmic ...... 46 see ZIRGAN ...... 76 glipizide-metformin hcl tab 2.5-500 mg GARDASIL 9 INJ ...... 69 ...... 46 gatifloxacin (ophth) ...... 76 glipizide-metformin hcl tab 5-500 mg 46 gavilyte-c ...... 60 glucagon (rdna) Gavilyte-c see GLUCAGON EMERGENCY KIT ...56 see gavilyte-c ...... 60 GLUCAGON EMERGENCY KIT ...... 56 gavilyte-g ...... 60 glucose blood Gavilyte-g see ACCU-CHEK BLOOD GLUCOSE see gavilyte-g ...... 60 TEST STRIPS ...... 71 gavilyte-h ...... 60 glucose urine test-(glucose oxidase) Gavilyte-h see GLUCOSE URINE TEST STRIPS 72 see gavilyte-h ...... 60 GLUCOSE URINE TEST STRIPS ...... 72 gavilyte-n/flavor pack ...... 60 glycopyrrolate ...... 58 Gavilyte-n/flavor Pack see CUVPOSA ...... 58 see gavilyte-n/flavor pack ...... 60 glycopyrrolate-formoterol fumarate GAZYVA ...... 18 see BEVESPI AER 9-4.8MCG ...... 78 gemcitabine hcl ...... 17 GLYXAMBI TAB 10-5 MG ...... 49 104 GLYXAMBI TAB 25-5 MG ...... 49 hepatitis a (inactivated)-hepatitis b golimumab (recombinant) vaccines see SIMPONI ...... 66 see TWINRIX INJ ...... 71 see SIMPONI ARIA ...... 66 hepatitis a vaccine GOLYTELY SOL ...... 60 see HAVRIX ...... 69 goodsense aspirin ...... 7 see VAQTA ...... 71 Goodsense Aspirin hepatitis b vaccine (recomb) see goodsense aspirin ...... 7 see ENGERIX-B ...... 69 goodsense nicotine polacr ...... 45 see RECOMBIVAX HB ...... 70 Goodsense Nicotine Polacr hepatitis b vaccine recombinant see goodsense nicotine polacr ...... 45 adjuvanted see nicotine polacrilex ...... 45 see HEPLISAV-B ...... 70 granisetron HEPLISAV-B ...... 70 see SANCUSO ...... 59 HETLIOZ ...... 42 granisetron hcl ...... 58 HIBERIX ...... 70 griseofulvin microsize ...... 9 human papillomavirus (hpv) 9-valent griseofulvin ultramicrosize ...... 9 recombinant vaccine Guaifenesin Ac see GARDASIL 9 INJ ...... 69 see guaifenesin-codeine soln 100-10 HUMATROPE ...... 56 mg/5ml ...... 80 HUMATROPE COMBO PACK ...... 56 guaifenesin-codeine soln 100-10 HUMATROPEN ...... 72 mg/5ml ...... 80 HUMIRA ...... 65 guanfacine hcl ...... 32 HUMIRA PEDIA INJ CROHNS ...... 65 guanfacine hcl (adhd) ...... 41 HUMIRA PEDIATRIC CROHNS D ...... 65 GUANIDINE HCL ...... 43 HUMIRA PEN ...... 66 guselkumab HUMIRA PEN-CD/UC/HS START ...... 66 see TREMFYA ...... 66 HUMIRA PEN KIT PS/UV ...... 66 GYNAZOLE-1 ...... 63 HUMIRA PEN-PS/UV STARTER ...... 66 H HUMULIN INJ 70/30 ...... 47 haemophilus b polysac conj vac HUMULIN INJ 70/30KWP ...... 47 see ACTHIB INJ ...... 69 HUMULIN N ...... 47 see HIBERIX ...... 70 HUMULIN N KWIKPEN ...... 47 see PEDVAX HIB ...... 70 HUMULIN R ...... 47 halobetasol propionate ...... 86 HUMULIN R U-500 (CONCENTR ...... 47 haloperidol ...... 39 HUMULIN R U-500 KWIKPEN ...... 48 haloperidol decanoate ...... 39 hydralazine hcl ...... 32 haloperidol lactate ...... 39 hydrochlorothiazide ...... 31 HARVONI PAK ...... 14 hydrocodone-acetaminophen soln 7.5- HARVONI PAK 45-200MG ...... 15 325 mg/15ml ...... 3 HARVONI TAB 45-200MG ...... 15 hydrocodone-acetaminophen tab 10- HARVONI TAB 90-400MG ...... 15 325 mg ...... 3 HAVRIX ...... 69 hydrocodone-acetaminophen tab 5-325 heather ...... 51 mg ...... 3 Heather hydrocodone-acetaminophen tab 7.5- see heather ...... 51 325 mg ...... 3 HEMLIBRA ...... 64 hydrocodone-ibuprofen tab 10-200 mg heparin sodium (porcine) ...... 63 ...... 3 105 hydrocodone w/ homatropine syrup 5- iloprost 1.5 mg/5ml ...... 80 see VENTAVIS ...... 33 hydrocodone w/ homatropine tab 5-1.5 imatinib mesylate ...... 20 mg ...... 80 IMBRUVICA ...... 20 hydrocortisone ...... 55 imipramine hcl ...... 37 hydrocortisone (topical) ...... 86 imipramine pamoate ...... 37 hydrocortisone butyrate ...... 86 imiquimod ...... 83 hydrocortisone sod succinate immune globulin (human)- see SOLU-CORTEF ...... 56 hyaluronidase (human recombinant) hydrocortisone valerate ...... 86 see HYQVIA INJ 10-800 ...... 67 hydrocortisone w/ acetic acid otic soln see HYQVIA INJ 2.5-200 ...... 67 1-2% ...... 88 see HYQVIA INJ 20-1600 ...... 67 hydromet ...... 80 see HYQVIA INJ 30-2400 ...... 67 Hydromet see HYQVIA INJ 5-400 ...... 67 see hydromet ...... 80 INCRELEX ...... 56 hydromorphone hcl ...... 3, 4 INCRUSE ELLIPTA ...... 78 HYDROMORPHONE HCL ...... 3 indapamide ...... 31 hydroxychloroquine sulfate ...... 67 indinavir sulfate hydroxyurea ...... 22 see CRIXIVAN ...... 10 hydroxyurea (sickle cell anemia) INFANRIX INJ ...... 70 see DROXIA ...... 22 influenza virus vaccine live hydroxyzine hcl ...... 79 quadrivalent hydroxyzine pamoate ...... 79 see FLUMIST QUAD SUS 2019-20 ..69 hyoscyamine sulfate ...... 58 influenza virus vaccine split high-dose HYQVIA INJ 10-800 ...... 67 preservative free HYQVIA INJ 2.5-200 ...... 67 see FLUZONE HD INJ PF 19-20 ...... 69 HYQVIA INJ 20-1600 ...... 67 influenza virus vaccine split HYQVIA INJ 30-2400 ...... 67 quadrivalent HYQVIA INJ 5-400 ...... 67 see AFLURIA QUAD INJ 2019-20 ...69 I see FLUARIX QUAD INJ 2019-20 ...69 ibalizumab-uiyk see FLULAVAL QUA INJ 2019-20 ....69 see TROGARZO ...... 11 see FLUZONE QUAD INJ 2019-20 ..69 ibandronate sodium ...... 50 influenza virus vaccine tissue-cultured IBRANCE ...... 18 subunit quadrivalent ibrutinib see FLUCLVX QUAD INJ 2019-20 ...69 see IMBRUVICA ...... 20 influenza virus vaccine types a & b ibuprofen ...... 1 surface antigen adjuvant icatibant acetate ...... 64 see FLUAD INJ 2019-20 ...... 69 ICLUSIG ...... 20 influenza virus vacc types a & b surf icosapent ethyl antigen adjuvant quad see VASCEPA ...... 28 see FLUAD QUADRIVALENT INFLUE 69 idarubicin hcl ...... 17 influenza virus vac recomb idelalisib hemagglutinin (ha) quadrivalent see ZYDELIG ...... 22 see FLUBLOK QUAD INJ 2019-20 ...69 IDHIFA ...... 20 ingenol mebutate ifosfamide ...... 16 see PICATO ...... 83 ILEVRO ...... 76 injection device 106 see HUMATROPEN ...... 72 INSULIN PEN NEEDLES/SYRINGES ...72 INLYTA ...... 21 insulin regular (human) INSTA-GLUCOSE ...... 56 see HUMULIN R ...... 47 insulin aspart see HUMULIN R U-500 (CONCENTR 47 see NOVOLOG ...... 48 see HUMULIN R U-500 KWIKPEN ...48 see NOVOLOG FLEXPEN ...... 48 see NOVOLIN R ...... 48 see NOVOLOG PENFILL ...... 48 see NOVOLIN R FLEXPEN ...... 48 insulin aspart (with niacinamide) insulin syringe/needle u-100 see FIASP FLEX INJ TOUCH ...... 47 see INSULIN PEN see FIASP INJ 100/ML ...... 47 NEEDLES/SYRINGES ...... 72 see FIASP PENFIL INJ U-100 ...... 47 INTELENCE ...... 10 insulin aspart protamine & aspart interferon alfa-2b (human) see INTRON A ...... 68 see NOVOLOG MIX 70/30 FLEXPEN 48 see INTRON A W/DILUENT ...... 68 see NOVOLOG MIX INJ 70/30 ...... 48 interferon beta-1a insulin degludec see AVONEX ...... 43 see TRESIBA ...... 48 see AVONEX PEN ...... 43 see TRESIBA FLEXTOUCH ...... 48 see REBIF ...... 44 insulin degludec-liraglutide see REBIF REBIDO INJ TITRATN ....44 see XULTOPHY INJ 100/3.6 ...... 47 see REBIF REBIDOSE ...... 44 insulin detemir see REBIF TITRTN INJ PACK ...... 44 see LEVEMIR ...... 48 interferon beta-1b see LEVEMIR FLEXTOUCH ...... 48 see BETASERON ...... 43 insulin glargine interferon gamma-1b see BASAGLAR KWIKPEN ...... 47 see ACTIMMUNE ...... 67 insulin glargine-lixisenatide INTRAROSA ...... 46 see SOLIQUA INJ 100/33 ...... 47 INTRON A ...... 68 insulin infusion disposable pump INTRON A W/DILUENT ...... 68 see OMNIPOD DASH ...... 72 introvale ...... 51 see OMNIPOD KIT STARTER ...... 72 Introvale see OMNIPOD MIS 5 PACK ...... 72 see introvale ...... 51 see V-GO 20 KIT ...... 72 INVIRASE ...... 10 see V-GO 30 KIT ...... 72 IOPIDINE ...... 77 see V-GO 40 KIT ...... 72 IPOL INJ INACTIVE ...... 70 insulin nph (human) (isophane) ipratropium-albuterol nebu soln 0.5- see HUMULIN N ...... 47 2.5(3) mg/3ml ...... 78 see HUMULIN N KWIKPEN ...... 47 ipratropium bromide ...... 78 see NOVOLIN N ...... 48 ipratropium bromide (nasal) ...... 78 see NOVOLIN N FLEXPEN ...... 48 irbesartan ...... 27 insulin nph isophane & reg (human) irbesartan-hydrochlorothiazide tab see HUMULIN INJ 70/30 ...... 47 150-12.5 mg ...... 25 see HUMULIN INJ 70/30KWP ...... 47 irbesartan-hydrochlorothiazide tab see NOVOLIN INJ 70/30 ...... 48 300-12.5 mg ...... 25 see NOVOLIN INJ 70/30 FP ...... 48 irinotecan hcl ...... 23 insulin pen needle see CAMPTOSAR ...... 23 see INSULIN PEN NEEDLES ...... 72 isavuconazonium sulfate INSULIN PEN NEEDLES ...... 72 see CRESEMBA ...... 9 107 ISENTRESS ...... 10 junel 1.5/30 ...... 51 ISENTRESS HD ...... 10 Junel 1.5/30 isocarboxazid see junel 1.5/30 ...... 51 see MARPLAN ...... 37 junel fe 1/20 ...... 51 isoniazid ...... 12 Junel Fe 1/20 isoniazid & rifampin see junel fe 1/20 ...... 51 see RIFAMATE CAP ...... 13 junel fe 1.5/30 ...... 51 isoniazid-rifampin w/ pyrazinamide Junel Fe 1.5/30 see RIFATER TAB ...... 13 see junel fe 1.5/30 ...... 51 isosorbide dinitrate ...... 32 K see DILATRATE SR ...... 32 KADCYLA ...... 18 isosorbide mononitrate ...... 32 KALETRA TAB 100-25MG ...... 12 isotretinoin ...... 83 KALETRA TAB 200-50MG ...... 12 isradipine ...... 30 KALYDECO ...... 81 itraconazole ...... 9 kariva ...... 51 ivacaftor Kariva see KALYDECO ...... 81 see kariva ...... 51 ivermectin ...... 8 k-effervescent ...... 73 ivermectin (pediculicide) kelnor 1/35 ...... 51 see SKLICE ...... 87 Kelnor 1/35 IV PREP WIPE PAD ...... 83 see kelnor 1/35 ...... 51 ixekizumab ketoconazole (topical) ...... 84, 85 see TALTZ ...... 66 KETONE URINE TEST STRIPS ...... 72 J ketoprofen ...... 1 JAKAFI ...... 21 ketorolac tromethamine ...... 1 jantoven ...... 63 ketorolac tromethamine (ophth) ...... 76 Jantoven see ACUVAIL ...... 76 see jantoven ...... 63 KEVZARA ...... 66 JANUMET TAB 50-1000 ...... 47 KEYTRUDA ...... 18 JANUMET TAB 50-500MG ...... 47 KINRIX INJ ...... 70 JANUMET XR TAB 100-1000 ...... 47 kionex ...... 50 JANUMET XR TAB 50-1000 ...... 47 Kionex JANUMET XR TAB 50-500MG ...... 47 see kionex ...... 50 JANUVIA ...... 46 KISQALI ...... 18 JARDIANCE ...... 49 klor-con 10 ...... 73 JENTADUETO XR TAB 2.5-1000MG ...47 Klor-con 10 JENTADUETO XR TAB 5-1000MG ...... 47 see klor-con 10 ...... 73 jinteli ...... 54 klor-con 8 ...... 73 Jinteli Klor-con 8 see jinteli ...... 54 see klor-con 8 ...... 73 jolessa ...... 51 klor-con m15 ...... 73 Jolessa Klor-con M15 see jolessa ...... 51 see klor-con m15 ...... 73 JUBLIA ...... 84 klor-con m20 ...... 73 junel 1/20 ...... 51 Klor-con M20 Junel 1/20 see klor-con m20 ...... 73 see junel 1/20 ...... 51 kurvelo ...... 51 108 Kurvelo ledipasvir-sofosbuvir see kurvelo ...... 51 see HARVONI PAK ...... 14 KUVAN ...... 54 see HARVONI PAK 45-200MG ...... 15 KYLEENA ...... 51 see HARVONI TAB 45-200MG ...... 15 L see HARVONI TAB 90-400MG ...... 15 labetalol hcl ...... 29 leena ...... 51 lacosamide Leena see VIMPAT ...... 35 see leena ...... 51 LACRISERT ...... 78 leflunomide ...... 67 lactic acid (ammonium lactate) ...... 86 lenalidomide lactulose ...... 60 see REVLIMID ...... 68 lamivudine ...... 10 lenvatinib mesylate lamivudine (hbv) ...... 13 see LENVIMA 10 MG DAILY DOSE ..21 see EPIVIR HBV ...... 13 see LENVIMA 12MG DAILY DOSE ...21 lamivudine-tenofovir disoproxil see LENVIMA 20 MG DAILY DOSE ..21 fumarate see LENVIMA 4 MG DAILY DOSE ....21 see CIMDUO TAB 300-300 ...... 12 see LENVIMA 8 MG DAILY DOSE ....21 see TEMIXYS TAB 300-300 ...... 12 see LENVIMA CAP 14 MG ...... 21 lamivudine-zidovudine tab 150-300 mg see LENVIMA CAP 18 MG ...... 21 ...... 12 see LENVIMA CAP 24 MG ...... 21 lamotrigine ...... 34 LENVIMA 10 MG DAILY DOSE ...... 21 lamotrigine tab 25 mg (42) & 100 mg LENVIMA 12MG DAILY DOSE ...... 21 (7) starter kit ...... 34 LENVIMA 20 MG DAILY DOSE ...... 21 lamotrigine tab 84 x 25 mg & 14 x 100 LENVIMA 4 MG DAILY DOSE ...... 21 mg starter kit ...... 34 LENVIMA 8 MG DAILY DOSE ...... 21 lancets LENVIMA CAP 14 MG ...... 21 see LANCETS ...... 72 LENVIMA CAP 18 MG ...... 21 LANCETS ...... 72 LENVIMA CAP 24 MG ...... 21 lancets misc. lessina ...... 51 see ULTRALANCE MIS 1.8MM ...... 72 Lessina LANCING DEVICE ...... 72 see lessina ...... 51 LANOXIN ...... 31 letrozole ...... 19 lanreotide acetate leucovorin calcium ...... 22 see SOMATULINE DEPOT ...... 56 LEUKERAN ...... 16 lansoprazole ...... 61 leuprolide acetate ...... 19 lanthanum carbonate see ELIGARD ...... 19 see FOSRENOL ...... 57 leuprolide acetate (3 month) lapatinib ditosylate see ELIGARD ...... 19 see TYKERB ...... 21 leuprolide acetate (4 month) larin 1.5/30 ...... 51 see ELIGARD ...... 19 Larin 1.5/30 leuprolide acetate (6 month) see larin 1.5/30 ...... 51 see ELIGARD ...... 19 larotrectinib sulfate leuprolide acetate (cpp) see VITRAKVI ...... 21, 22 see LUPRON DEPOT-PED (1-MONTH LASTACAFT ...... 77 ...... 19 latanoprost ...... 77 leuprolide acetate (cpp) (3 month) LATUDA ...... 39 109 see LUPRON DEPOT-PED (3-MONTH Levoxyl ...... 19 see levoxyl ...... 57 leuprolide acetate & norethindrone LEXIVA ...... 10 acetate lice treatment ...... 87 see LUPANETA KIT 11.25-5 ...... 57 Lice Treatment see LUPANETA KIT 3.75-5 ...... 57 see lice treatment ...... 87 levalbuterol hcl ...... 79 lidocaine ...... 86 levalbuterol tartrate ...... 79 lidocaine hcl ...... 86 LEVEMIR ...... 48 lidocaine hcl (cardiac) ...... 27 LEVEMIR FLEXTOUCH ...... 48 lidocaine hcl (local anesth.) ...... 7 levetiracetam ...... 34 lidocaine hcl (mouth-throat) ...... 87 levetiracetam in sodium chloride iv soln lidocaine pain relief pat ...... 86 1000 mg/100ml ...... 34 Lidocaine Pain Relief Pat levetiracetam in sodium chloride iv soln see lidocaine pain relief pat ...... 86 1500 mg/100ml ...... 34 lidocaine-prilocaine cream 2.5-2.5% .86 levetiracetam in sodium chloride iv soln lidocaine-prilocaine cream kit 2.5-2.5% 500 mg/100ml ...... 34 ...... 86 levobunolol hcl ...... 77 lidocaine-tetracaine levocetirizine dihydrochloride ...... 79 see SYNERA DIS 70-70MG ...... 86 levofloxacin ...... 14 LILETTA ...... 52 levofloxacin (ophth) ...... 76 linaclotide levomilnacipran hcl see LINZESS ...... 59 see FETZIMA ...... 36 linagliptin-metformin hcl see FETZIMA CAP TITRATIO ...... 36 see JENTADUETO XR TAB 2.5- levonest ...... 51 1000MG ...... 47 Levonest see JENTADUETO XR TAB 5-1000MG see levonest ...... 51 ...... 47 levonorgestrel (iud) lindane ...... 87 see KYLEENA ...... 51 linezolid ...... 8 see LILETTA ...... 52 linezolid in sodium chloride iv soln 600 see MIRENA ...... 52 mg/300ml-0.9% ...... 8 see SKYLA ...... 53 LINZESS ...... 59 levonorgestrel & ethinyl estradiol (91- liothyronine sodium ...... 57 day) tab 0.15-0.03 mg ...... 52 liraglutide levonorgestrel & ethinyl estradiol tab see VICTOZA ...... 47 0.15 mg-30 mcg ...... 52 lisdexamfetamine dimesylate levonorgestrel-ethinyl estradiol-ferrous see VYVANSE ...... 41 bisglycinate lisinopril ...... 24 see BALCOLTRA TAB 0.1-20 ...... 50 lisinopril & hydrochlorothiazide tab 10- levonorg-eth est tab 0.1-0.02mg(84) & 12.5 mg ...... 24 eth est tab 0.01mg(7) ...... 52 lisinopril & hydrochlorothiazide tab 20- levora 0.15/30-28 ...... 52 12.5 mg ...... 24 Levora 0.15/30-28 lisinopril & hydrochlorothiazide tab 20- see levora 0.15/30-28 ...... 52 25 mg ...... 24 levothyroxine sodium ...... 57 LITHIUM ...... 43 see SYNTHROID ...... 57 lithium carbonate ...... 43 levoxyl ...... 57 lodoxamide tromethamine 110 see ALOMIDE ...... 77 lurasidone hcl LO LOESTRIN TAB 1-10-10 ...... 52 see LATUDA ...... 39 lomustine lutera ...... 52 see GLEOSTINE ...... 16 Lutera loperamide hcl ...... 60 see lutera ...... 52 lopinavir-ritonavir LYNPARZA ...... 18 see KALETRA TAB 100-25MG ...... 12 LYSODREN ...... 19 see KALETRA TAB 200-50MG ...... 12 M lopinavir-ritonavir soln 400-100 macitentan mg/5ml (80-20 mg/ml) ...... 12 see OPSUMIT ...... 32 lorazepam ...... 33 mafenide acetate LORBRENA ...... 21 see SULFAMYLON ...... 83 lorlatinib magnesium sulfate ...... 73 see LORBRENA ...... 21 magnesium sulfate in dextrose 5% iv loryna ...... 52 soln 1 gm/100ml ...... 73 Loryna malathion ...... 87 see loryna ...... 52 maprotiline hcl ...... 37 losartan potassium ...... 27 maraviroc losartan potassium & see SELZENTRY ...... 11 hydrochlorothiazide tab 100-12.5 mg marlissa ...... 52 ...... 26 Marlissa losartan potassium & see marlissa ...... 52 hydrochlorothiazide tab 100-25 mg 26 MARPLAN ...... 37 losartan potassium & MATULANE ...... 22 hydrochlorothiazide tab 50-12.5 mg matzim la ...... 30 ...... 26 Matzim La loteprednol etabonate ...... 76 see matzim la ...... 30 lovastatin ...... 28 MAXIDEX ...... 76 low-ogestrel ...... 52 measles, mumps & rubella virus Low-ogestrel vaccines see low-ogestrel ...... 52 see M-M-R II INJ ...... 70 loxapine succinate ...... 39 measles-mumps-rubella-varicella virus lubiprostone vaccines see AMITIZA ...... 59 see PROQUAD INJ ...... 70 ludent ...... 73 mebendazole Ludent see EMVERM ...... 8 see ludent ...... 73 mecasermin lumacaftor-ivacaftor see INCRELEX ...... 56 see ORKAMBI GRA 100-125 ...... 81 meclizine hcl ...... 58 see ORKAMBI GRA 150-188 ...... 81 meclofenamate sodium ...... 1 see ORKAMBI TAB 100-125 ...... 81 MEDROL ...... 55 see ORKAMBI TAB 200-125 ...... 81 medroxyprogesterone acetate ...... 57 LUMIGAN ...... 77 medroxyprogesterone acetate LUPANETA KIT 11.25-5 ...... 57 (antineoplastic) LUPANETA KIT 3.75-5 ...... 57 see DEPO-PROVERA ...... 19 LUPRON DEPOT-PED (1-MONTH ...... 19 medroxyprogesterone acetate LUPRON DEPOT-PED (3-MONTH ...... 19 (contraceptive) ...... 52 111 see DEPO-SUBQ PROVERA 104 ...... 51 Methadose mefenamic acid ...... 1 see methadose ...... 4 mefloquine hcl ...... 9 methamphetamine hcl ...... 41 megestrol acetate ...... 19 methazolamide ...... 31 megestrol acetate (appetite) ...... 19 methenamine hippurate ...... 8 MEKINIST ...... 21 methimazole ...... 57 meloxicam ...... 1 methocarbamol ...... 45 melphalan ...... 16 methotrexate sodium ...... 17, 67 melphalan hcl ...... 16 methoxsalen rapid ...... 84 memantine hcl ...... 35 methoxy polyethylene glycol-epoetin see NAMENDA XR CAP TITRATIO ...35 beta memantine hcl tab 28 x 5 mg & 21 x see MIRCERA ...... 64 10 mg titration pack ...... 35 methscopolamine bromide ...... 58 MENACTRA INJ ...... 70 methsuximide MENEST ...... 55 see CELONTIN ...... 33 meningococcal (a,c,y&w-135) methyldopa ...... 32 oligosaccharide conjugate vac methylphenidate hcl ...... 41 see MENVEO INJ ...... 70 methylprednisolone ...... 55 meningococcal (a,c,y&w-135) see MEDROL ...... 55 polysaccharide conjugate vaccine methylprednisolone acetate ...... 55 see MENACTRA INJ ...... 70 see DEPO-MEDROL ...... 55 meningococcal group b vaccine methylprednisolone sod succ ...... 55 (recombinant) see SOLU-MEDROL ...... 56 see TRUMENBA INJ ...... 71 methyltestosterone ...... 46 meningococcal vac group b (recombant metoclopramide hcl ...... 58 omv adjuvanted) metolazone ...... 31 see BEXSERO INJ ...... 69 metoprolol & hydrochlorothiazide tab MENTAX ...... 84 100-25 mg ...... 29 MENVEO INJ ...... 70 metoprolol & hydrochlorothiazide tab mepolizumab 100-50 mg ...... 29 see NUCALA ...... 80 metoprolol & hydrochlorothiazide tab meprobamate ...... 33 50-25 mg ...... 29 mercaptopurine ...... 17 metoprolol succinate ...... 29 meropenem ...... 8 metoprolol tartrate ...... 29 mesalamine ...... 59 metronidazole ...... 8 mesalamine w/ cleanser ...... 59 metronidazole (topical) ...... 87 mesna ...... 23 metronidazole in nacl 0.79% iv soln see MESNEX ...... 23 500 mg/100ml ...... 8 MESNEX ...... 23 metronidazole vaginal ...... 63 metaproterenol sulfate ...... 79 mexiletine hcl ...... 27 metaxalone ...... 45 mibelas 24 fe ...... 52 metformin hcl ...... 46 Mibelas 24 Fe methadone hcl ...... 4 see mibelas 24 fe ...... 52 methadone hcl intensol ...... 4 miconazole (mouth-throat) Methadone Hcl Intensol see ORAVIG ...... 87 see methadone hcl intensol ...... 4 miconazole 3 ...... 63 methadose ...... 4 Miconazole 3 112 see miconazole 3 ...... 63 multiple urine tests microgestin 1.5/30 ...... 52 see URINE TEST STRIPS ...... 72 Microgestin 1.5/30 multi-vit/fluoride ...... 75 see microgestin 1.5/30 ...... 52 multi-vit/iron/fluoride ...... 75 midodrine hcl ...... 32 Multi-vit/iron/fluoride midostaurin see multi-vit/iron/fluoride ...... 75 see RYDAPT ...... 18 multi-vitamin/fluoride/ir ...... 75 miglitol ...... 46 Multi-vitamin/fluoride/ir mimvey ...... 55 see multi-vitamin/fluoride/ir ...... 75 Mimvey Multi-vitamin/fluoride Dr see mimvey ...... 55 see *pediatric multiple vitamins w/ minitran ...... 32 fluoride soln 0.25 mg/ml*** ...... 75 Minitran see multi-vit/fluoride ...... 75 see minitran ...... 32 multivitamin with fluorid ...... 75 minocycline hcl ...... 16 Multivitamin With Fluorid minoxidil ...... 32 see multivitamin with fluorid ...... 75 MIRCERA ...... 64 mupirocin ...... 83 MIRENA ...... 52 mvc-fluoride ...... 75 mirtazapine ...... 37 Mvc-fluoride MIRVASO ...... 87 see mvc-fluoride ...... 75 misoprostol ...... 60 mycophenolate mofetil ...... 68 mitomycin ...... 17 mycophenolate mofetil hcl ...... 68 mitotane mycophenolate sodium ...... 68 see LYSODREN ...... 19 N mitoxantrone hcl ...... 22 nabumetone ...... 1 M-M-R II INJ ...... 70 nadolol ...... 29 modafinil ...... 45 nafarelin acetate moexipril hcl ...... 24 see SYNAREL ...... 53 mometasone furoate ...... 86 nafrinse ...... 73 Monoject Sodium Chloride Nafrinse see sodium chloride flush ...... 73 see nafrinse ...... 73 mono-linyah ...... 52 nafrinse drops ...... 73 Mono-linyah Nafrinse Drops see mono-linyah ...... 52 see nafrinse drops ...... 73 montelukast sodium ...... 80 naftifine hcl ...... 84 MONUROL ...... 7 nalbuphine hcl ...... 5 morgidox 1x100mg ...... 16 naloxegol oxalate Morgidox 1x100mg see MOVANTIK ...... 61 see morgidox 1x100mg ...... 16 naloxone hcl ...... 45 morphine sulfate ...... 4, 5 see NARCAN ...... 45 morphine sulfate beads ...... 5 naltrexone MOTOFEN TAB 1-0.025 ...... 61 see VIVITROL ...... 46 MOVANTIK ...... 61 naltrexone hcl ...... 45 MOVIPREP SOL ...... 60 NAMENDA XR CAP TITRATIO ...... 35 moxifloxacin hcl ...... 14 naproxen ...... 2 moxifloxacin hcl (ophth) ...... 76 naratriptan hcl ...... 42 MULTAQ ...... 27 NARCAN ...... 45 113 NATACYN ...... 76 nicotine polacrilex ...... 45 natalizumab nicotine step 3 ...... 45 see TYSABRI ...... 44 Nicotine Step 3 natamycin see nicotine step 3 ...... 45 see NATACYN ...... 76 NICOTROL INHALER ...... 46 NATAZIA TAB ...... 52 NICOTROL NS ...... 46 nateglinide ...... 48 nifedipine ...... 30 nebivolol hcl nikki ...... 52 see BYSTOLIC ...... 29 Nikki necon 0.5/35-28 ...... 52 see nikki ...... 52 Necon 0.5/35-28 nilutamide ...... 19 see necon 0.5/35-28 ...... 52 nimodipine ...... 30 nedocromil sodium (ophth) NIPENT ...... 17 see ALOCRIL ...... 77 niraparib tosylate nefazodone hcl ...... 37 see ZEJULA ...... 18 nelfinavir mesylate nisoldipine ...... 30 see VIRACEPT ...... 11 nitazoxanide neomycin-colistin-hc-thonzonium see ALINIA ...... 8 see COLY-MYCIN S SUS OTIC ...... 88 nitisinone ...... 54 neomycin-polymy-gramicid op sol see ORFADIN ...... 54 1.75-10000-0.025mg-unt-mg/ml ..76 NITRO-BID ...... 32 neomycin-polymyxin-dexamethasone NITRO-DUR ...... 32 ophth oint 0.1% ...... 75 nitrofurantoin ...... 8 neomycin-polymyxin-dexamethasone nitrofurantoin macrocrystal ...... 8 ophth susp 0.1% ...... 75 nitrofurantoin monohyd macro ...... 8 neomycin-polymyxin-hc ophth susp ..75 nitroglycerin ...... 32 neomycin-polymyxin-hc otic soln 1% 88 see NITRO-BID ...... 32 neomycin-polymyxin-hc otic susp 3.5 see NITRO-DUR ...... 32 mg/ml-10000 unit/ml-1% ...... 88 nitroglycerin (intra-anal) neomycin sulfate ...... 7 see RECTIV ...... 86 nepafenac NIVESTYM ...... 64 see ILEVRO ...... 76 nizatidine ...... 59 see NEVANAC ...... 76 nonoxynol-9 netupitant-palonosetron see ENCARE ...... 62 see AKYNZEO CAP 300-0.5 ...... 58 see OPTIONS CONCEPTROL VAGINA NEULASTA ...... 64 ...... 62 NEULASTA ONPRO KIT ...... 64 see OPTIONS GYNOL II VAGINAL ...62 NEUPRO ...... 39 see SHUR-SEAL ...... 62 NEVANAC ...... 76 see TODAY SPONGE ...... 62 nevirapine ...... 10 see VCF VAGINAL CONTRACEPTIVE 62 NEXAVAR ...... 21 nora-be ...... 52 NEXPLANON ...... 52 Nora-be niacin (antihyperlipidemic) ...... 28 see nora-be ...... 52 nicardipine hcl ...... 30 norethin acet & estrad-fe nicotine ...... 45 see TAYTULLA CAP 1MG/20MC ...... 53 see NICOTROL INHALER ...... 46 norethindrone (contraceptive) ...... 52 see NICOTROL NS ...... 46 114 norethindrone & ethinyl estradiol-fe NUCALA ...... 80 chew tab 0.4 mg-35 mcg ...... 52 NUCYNTA ...... 5 norethindrone & ethinyl estradiol-fe NUCYNTA ER ...... 5 chew tab 0.8 mg-25 mcg ...... 52 NUEDEXTA CAP 20-10MG ...... 43 norethindrone & ethinyl estradiol tab nulev ...... 58 0.4 mg-35 mcg ...... 52 Nulev norethindrone ace & ethinyl estradiol see nulev ...... 58 tab 1 mg-20 mcg ...... 52 nyamyc ...... 84 norethindrone ace-ethinyl estradiol-fe Nyamyc tab 1 mg-20 mcg (24) ...... 52 see nyamyc ...... 84 norethindrone acetate ...... 57 nystatin ...... 9 norethindrone acetate-ethinyl see BIO-STATIN ...... 9 estradiol-fe fum (biphasic) nystatin (mouth-throat) ...... 87 see LO LOESTRIN TAB 1-10-10 .....52 nystatin (topical) ...... 84 norethindrone acetate-ethinyl estradiol nystatin-triamcinolone cream 100000- tab 0.5 mg-2.5 mcg ...... 55 0.1 unit/gm-% ...... 84 norgestimate & ethinyl estradiol tab nystatin-triamcinolone oint 100000-0.1 0.25 mg-35 mcg ...... 52 unit/gm-% ...... 84 norgestimate-eth estrad tab 0.18- nystop ...... 84 25/0.215-25/0.25-25 mg-mcg ...... 52 Nystop norgestimate-eth estrad tab 0.18- see nystop ...... 84 35/0.215-35/0.25-35 mg-mcg ...... 52 O NORPACE CR ...... 27 obinutuzumab nortrel 0.5/35 (28) ...... 53 see GAZYVA ...... 18 Nortrel 0.5/35 (28) ocella ...... 53 see nortrel 0.5/35 (28) ...... 53 Ocella nortrel 1/35 ...... 53 see ocella ...... 53 Nortrel 1/35 octreotide acetate ...... 56 see nortrel 1/35 ...... 53 ODEFSEY TAB ...... 12 nortrel 7/7/7 ...... 53 ODOMZO ...... 22 Nortrel 7/7/7 ofloxacin ...... 14 see nortrel 7/7/7 ...... 53 ofloxacin (ophth) ...... 76 nortriptyline hcl ...... 37 ofloxacin (otic) ...... 88 NORVIR ...... 10 ogestrel ...... 53 NOVOLIN INJ 70/30 ...... 48 Ogestrel NOVOLIN INJ 70/30 FP ...... 48 see ogestrel ...... 53 NOVOLIN N ...... 48 olanzapine ...... 40 NOVOLIN N FLEXPEN ...... 48 olaparib NOVOLIN R ...... 48 see LYNPARZA ...... 18 NOVOLIN R FLEXPEN ...... 48 olmesartan-amlodipine- NOVOLOG ...... 48 hydrochlorothiazide tab 20-5-12.5 NOVOLOG FLEXPEN ...... 48 mg ...... 26 NOVOLOG MIX 70/30 FLEXPEN ...... 48 olmesartan-amlodipine- NOVOLOG MIX INJ 70/30 ...... 48 hydrochlorothiazide tab 40-10-12.5 NOVOLOG PENFILL ...... 48 mg ...... 26 NOXAFIL ...... 9 NUBEQA ...... 19 115 olmesartan-amlodipine- ORILISSA ...... 53 hydrochlorothiazide tab 40-10-25 mg ORKAMBI GRA 100-125 ...... 81 ...... 26 ORKAMBI GRA 150-188 ...... 81 olmesartan-amlodipine- ORKAMBI TAB 100-125 ...... 81 hydrochlorothiazide tab 40-5-12.5 ORKAMBI TAB 200-125 ...... 81 mg ...... 26 orphenadrine citrate ...... 45 olmesartan-amlodipine- orsythia ...... 53 hydrochlorothiazide tab 40-5-25 mg Orsythia ...... 26 see orsythia ...... 53 olmesartan medoxomil ...... 27 oscimin ...... 58 olmesartan medoxomil- Oscimin hydrochlorothiazide tab 20-12.5 mg see oscimin ...... 58 ...... 26 oscimin sr ...... 58 olmesartan medoxomil- Oscimin Sr hydrochlorothiazide tab 40-12.5 mg see oscimin sr ...... 58 ...... 26 oseltamivir phosphate ...... 13 olmesartan medoxomil- OSMOPREP TAB 1.5GM ...... 60 hydrochlorothiazide tab 40-25 mg .26 ospemifene olodaterol hcl see OSPHENA ...... 56 see STRIVERDI RESPIMAT ...... 80 OSPHENA ...... 56 olopatadine hcl ...... 77 OTEZLA ...... 67 see PAZEO ...... 77 OTEZLA TAB 10/20/30 ...... 67 olopatadine hcl (nasal) ...... 79 oxaliplatin ...... 22 olopatadine hydrochloride ...... 77 oxaprozin ...... 2 olsalazine sodium oxazepam ...... 33 see DIPENTUM ...... 59 oxcarbazepine ...... 34 omalizumab oxiconazole nitrate ...... 84 see XOLAIR ...... 80 oxybutynin chloride ...... 63 omega-3-acid ethyl esters cap 1 gm .28 oxycodone omeprazole ...... 61 see XTAMPZA ER ...... 6 OMNARIS ...... 81 oxycodone-aspirin tab 4.8355-325 mg 6 OMNIFLEX DPR ...... 71 oxycodone hcl ...... 5, 6 OMNIPOD DASH ...... 72 oxycodone-ibuprofen tab 5-400 mg ....6 OMNIPOD KIT STARTER ...... 72 oxycodone w/ acetaminophen tab 10- OMNIPOD MIS 5 PACK ...... 72 325 mg ...... 6 ONCASPAR ...... 22 oxycodone w/ acetaminophen tab 2.5- ondansetron ...... 58 325 mg ...... 6 ondansetron hcl ...... 58 oxycodone w/ acetaminophen tab 5- OPSUMIT ...... 32 325 mg ...... 6 OPTIONS CONCEPTROL VAGINA ...... 62 oxycodone w/ acetaminophen tab 7.5- OPTIONS GYNOL II VAGINAL ...... 62 325 mg ...... 6 oralone dental paste ...... 87 oxymorphone hcl ...... 6 Oralone Dental Paste OZEMPIC ...... 47 see oralone dental paste ...... 87 P ORAVIG ...... 87 pacerone ...... 27 ORENITRAM ...... 32 Pacerone ORFADIN ...... 54 see pacerone ...... 27 116 paclitaxel ...... 18 peg 3350-kcl-sod bicarb-sod chloride- paclitaxel protein-bound particles sod sulfate see ABRAXANE INJ 100MG ...... 17 see GOLYTELY SOL ...... 60 palbociclib PEGANONE ...... 34 see IBRANCE ...... 18 pegaspargase paliperidone ...... 40 see ONCASPAR ...... 22 pamidronate disodium ...... 50 PEGASYS ...... 15 pancrelipase (lipase-protease-amylase) pegfilgrastim see CREON CAP 12000UNT ...... 61 see NEULASTA ...... 64 see CREON CAP 24000UNT ...... 61 see NEULASTA ONPRO KIT ...... 64 see CREON CAP 3000UNIT ...... 61 pegfilgrastim-cbqv see CREON CAP 36000UNT ...... 61 see UDENYCA ...... 64 see CREON CAP 6000UNIT ...... 61 peginterferon alfa-2a see VIOKACE TAB 10440 ...... 61 see PEGASYS ...... 15 see VIOKACE TAB 20880 ...... 61 peginterferon beta-1a see ZENPEP CAP 10000UNT ...... 61 see PLEGRIDY ...... 44 see ZENPEP CAP 15000UNT ...... 61 see PLEGRIDY INJ STARTER ...... 44 see ZENPEP CAP 20000UNT ...... 61 see PLEGRIDY PEN INJ STARTER ...44 see ZENPEP CAP 25000 ...... 61 pegvisomant see ZENPEP CAP 3000UNIT ...... 61 see SOMAVERT ...... 56 see ZENPEP CAP 40000 ...... 61 pembrolizumab see ZENPEP CAP 5000UNIT ...... 61 see KEYTRUDA ...... 18 panobinostat lactate pemetrexed disodium see FARYDAK ...... 18 see ALIMTA ...... 17 pantoprazole sodium ...... 61 penciclovir PARAGARD IUD T380A ...... 53 see DENAVIR ...... 86 paricalcitol ...... 75 penicillamine ...... 50 paromomycin sulfate ...... 7 penicillin g potassium ...... 15 paroxetine hcl ...... 37 penicillin g sodium ...... 15 PASER ...... 13 penicillin v potassium ...... 15 pasireotide diaspartate PENTACEL INJ ...... 70 see SIGNIFOR ...... 56 pentamidine isethionate ...... 8 PAZEO ...... 77 pentosan polysulfate sodium pazopanib hcl see ELMIRON ...... 62 see VOTRIENT ...... 22 pentostatin PEDIARIX INJ 0.5ML ...... 70 see NIPENT ...... 17 PEDIATRIC RESPIRATORY MASK ...... 73 pentoxifylline ...... 64 PEDVAX HIB ...... 70 perampanel peg 3350-kcl-na bicarb-nacl-na sulfate see FYCOMPA ...... 34 for soln 236 gm ...... 60 PERFOROMIST ...... 80 peg 3350-kcl-nacl-na sulfate-na perindopril erbumine ...... 24 ascorbate-ascorbic acid periogard ...... 87 see MOVIPREP SOL ...... 60 Periogard see PLENVU SOL ...... 60 see periogard ...... 87 peg 3350-kcl-sod bicarb-nacl for soln permethrin ...... 87 420 gm ...... 60 perphenazine ...... 40 pfizerpen ...... 15 117 Pfizerpen Pirmella 1/35 see pfizerpen ...... 15 see pirmella 1/35 ...... 53 phenadoz ...... 58 pirmella 7/7/7 ...... 53 Phenadoz Pirmella 7/7/7 see phenadoz ...... 58 see pirmella 7/7/7 ...... 53 phenazopyridine tab 95mg ...... 62 piroxicam ...... 2 phenelzine sulfate ...... 37 PLEGRIDY ...... 44 phenobarbital ...... 34 PLEGRIDY INJ STARTER ...... 44 phenoxybenzamine hcl ...... 32 PLEGRIDY PEN INJ STARTER ...... 44 phenylephrine hcl (mydriatic) ...... 78 PLENVU SOL ...... 60 phenytoin ...... 34 pneumococcal 13-valent conjugate phenytoin sodium ...... 34 vaccine phenytoin sodium extended ...... 34 see PREVNAR 13 INJ ...... 70 see DILANTIN ...... 33 pneumococcal vac polyvalent PHOSLYRA ...... 57 see PNEUMOVAX 23/1 DOSE ...... 70 PHOSPHOLINE IODIDE ...... 77 PNEUMOVAX 23/1 DOSE ...... 70 PHOTOFRIN ...... 22 podofilox ...... 86 physiolyte ...... 78 see CONDYLOX ...... 86 Physiolyte poliovirus vaccine, ipv see physiolyte ...... 78 see IPOL INJ INACTIVE ...... 70 physiosol irrigation ...... 78 polycin ...... 76 Physiosol Irrigation Polycin see physiosol irrigation ...... 78 see polycin ...... 76 phytonadione ...... 75 polyethylene glycol 3350 ...... 60 PICATO ...... 83 polymyxin b sulfate ...... 8 pilocarpine hcl ...... 77 polymyxin b-trimethoprim ophth soln pilocarpine hcl (oral) ...... 87 10000 unit/ml-0.1% ...... 76 pimozide ...... 43 pomalidomide pindolol ...... 29 see POMALYST ...... 68 pioglitazone hcl ...... 48 POMALYST ...... 68 pioglitazone hcl-glimepiride tab 30-2 ponatinib hcl mg ...... 48 see ICLUSIG ...... 20 pioglitazone hcl-glimepiride tab 30-4 porfimer sodium mg ...... 48 see PHOTOFRIN ...... 22 pioglitazone hcl-metformin hcl tab 15- portia-28 ...... 53 500 mg ...... 48 Portia-28 pioglitazone hcl-metformin hcl tab 15- see portia-28 ...... 53 850 mg ...... 48 posaconazole ...... 9 piperacillin sod-tazobactam na for inj see NOXAFIL ...... 9 3.375 gm (3-0.375 gm) ...... 16 potassium chloride ...... 73, 74 piperacillin sod-tazobactam sod for inj potassium chloride microencapsulated 2.25 gm (2-0.25 gm) ...... 16 crystals er ...... 73 piperacillin sod-tazobactam sod for inj potassium citrate (alkalinizer) ...... 62 40.5 gm (36-4.5 gm) ...... 16 PRADAXA ...... 63 pirfenidone PRALUENT ...... 28 see ESBRIET ...... 81 pramipexole dihydrochloride ...... 39 pirmella 1/35 ...... 53 pramlintide acetate 118 see SYMLINPEN 120 ...... 46 PREPOPIK PAK ...... 60 see SYMLINPEN 60 ...... 46 prevalite ...... 27 pramox gel ...... 86 Prevalite Pramox Gel see prevalite ...... 27 see pramox gel ...... 86 previfem ...... 53 prasterone vaginal Previfem see INTRAROSA ...... 46 see previfem ...... 53 prasugrel hcl ...... 65 PREVNAR 13 INJ ...... 70 pravastatin sodium ...... 28 PREZCOBIX TAB 800-150 ...... 12 praziquantel ...... 8 PREZISTA ...... 10, 11 prazosin hcl ...... 25 PRIFTIN ...... 13 PRED MILD ...... 76 primaquine phosphate ...... 9 prednicarbate ...... 86 primidone ...... 34 prednisolone ...... 55 PRIMSOL ...... 9 prednisolone acetate (ophth) ...... 76 probenecid ...... 1 see PRED MILD ...... 76 procainamide hcl ...... 27 PREDNISOLONE SODIUM PHOSP ...... 76 procarbazine hcl prednisolone sodium phosphate ...... 55 see MATULANE ...... 22 prednisone ...... 55 prochlorperazine ...... 59 see PREDNISONE INTENSOL ...... 55 prochlorperazine maleate ...... 59 PREDNISONE INTENSOL ...... 55 procto-pak ...... 62 pregabalin ...... 34 Procto-pak PREMARIN ...... 55 see procto-pak ...... 62 prenatabs rx ...... 75 proctosol hc ...... 62 Prenatabs Rx Proctosol Hc see prenatabs rx ...... 75 see proctosol hc ...... 62 prenatal vit w/ docusate-fe carbonyl-fe proctozone-hc ...... 62 gluconate-folic acid Proctozone-hc see CITRANATAL TAB BLOOM ...... 74 see proctozone-hc ...... 62 prenatal w/o vit a w/ fe carbonyl-fe progesterone (vaginal) gluconate-dss-fa-dha see CRINONE ...... 57 see CITRANATAL MIS ...... 74 progesterone micronized ...... 57 see CITRANATAL MIS 90 DHA ...... 74 PROGRAF ...... 68 see CITRANATAL PAK ASSURE ...... 74 PROLASTIN-C ...... 81 see CITRANATAL PAK DHA ...... 74 PROLIA ...... 56 prenatal w/o vit a w/ fe carbonyl-fe PROMACTA ...... 64 gluconate-fa & vit b6 promethazine & phenylephrine syrup see CITRANATAL MIS B-CALM ...... 74 6.25-5 mg/5ml ...... 80 prenatal w/o vit a w/ fe fumarate-fe promethazine-dm syrup 6.25-15 carbonyl-dss-fa-dha mg/5ml ...... 80 see CITRANATAL CAP HARMONY ....74 promethazine hcl ...... 59 prenatal w/o vit a w/ fe fumarate-fe promethazine-phenylephrine-codeine carbonyl-fa-dha syrup 6.25-5-10 mg/5ml ...... 80 see CITRANATAL CAP MEDLEY ...... 74 promethazine w/ codeine syrup 6.25- prenatal without vit a w/ fe carbonyl-fe 10 mg/5ml ...... 80 gluc-docusate-fa promethegan ...... 59 see CITRANATAL TAB RX ...... 74 Promethegan 119 see promethegan ...... 59 Reclipsen propafenone hcl ...... 27 see reclipsen ...... 53 proparacaine hcl ...... 78 RECOMBIVAX HB ...... 70 propranolol & hydrochlorothiazide tab RECTIV ...... 86 40-25 mg ...... 29 regorafenib propranolol & hydrochlorothiazide tab see STIVARGA ...... 21 80-25 mg ...... 29 REGRANEX ...... 87 propranolol hcl ...... 29 RELENZA DISKHALER ...... 13 propylthiouracil ...... 57 REMODULIN ...... 32 PROQUAD INJ ...... 70 repaglinide ...... 48 protriptyline hcl ...... 37 RESTASIS ...... 78 pseudoephed-bromphen-dm syrup 30- RETACRIT ...... 64 2-10 mg/5ml ...... 80 RETROVIR IV INFUSION ...... 11 pyrazinamide ...... 13 REVLIMID ...... 68 pyridostigmine bromide ...... 43 REXULTI ...... 40 pyridoxine hcl ...... 75 REYATAZ ...... 11 pyrimethamine ribavirin ...... 13 see DARAPRIM ...... 8 ribavirin (hepatitis c) ...... 15 Q ribociclib succinate QUADRAMET ...... 22 see KISQALI ...... 18 quetiapine fumarate ...... 40 rifabutin ...... 13 quetiapine fumarate er ...... 40 RIFAMATE CAP ...... 13 quinapril hcl ...... 24 rifampin ...... 13 quinapril-hydrochlorothiazide tab 10- rifapentine 12.5 mg ...... 24 see PRIFTIN ...... 13 quinapril-hydrochlorothiazide tab 20- RIFATER TAB ...... 13 12.5 mg ...... 24 rifaximin quinapril-hydrochlorothiazide tab 20-25 see XIFAXAN ...... 9 mg ...... 24 rilonacept quinine sulfate ...... 9 see ARCALYST ...... 68 QVAR REDIHALER ...... 82 rilpivirine hcl R see EDURANT ...... 10 rabeprazole sodium ...... 62 riluzole ...... 43 raloxifene hcl ...... 56 rimantadine hydrochloride ...... 13 raltegravir potassium RINVOQ ...... 66 see ISENTRESS ...... 10 riociguat see ISENTRESS HD ...... 10 see ADEMPAS ...... 32 ramelteon ...... 42 risankizumab-rzaa ramipril ...... 24 see SKYRIZI ...... 66 ranitidine hcl ...... 59 risedronate sodium ...... 50 ranolazine ...... 32 risperidone ...... 40 rasagiline mesylate ...... 39 ritonavir ...... 11 REBIF ...... 44 see NORVIR ...... 10 REBIF REBIDO INJ TITRATN ...... 44 rivaroxaban REBIF REBIDOSE ...... 44 see XARELTO ...... 63 REBIF TITRTN INJ PACK ...... 44 see XARELTO STAR TAB 15/20MG .64 reclipsen ...... 53 rivastigmine ...... 35 120 rivastigmine tartrate ...... 35 secukinumab rivelsa ...... 53 see COSENTYX ...... 84 Rivelsa see COSENTYX SENSOREADY PEN .84 see rivelsa ...... 53 segesterone acetate-ethinyl estradiol rizatriptan benzoate ...... 42 see ANNOVERA MIS ...... 50 roflumilast selegiline see DALIRESP ...... 80 see EMSAM ...... 36 rolapitant hcl selegiline hcl ...... 39 see VARUBI ...... 59 selenium sulfide ...... 85 ropinirole hydrochloride ...... 39 selexipag rosadan ...... 87 see UPTRAVI ...... 33 Rosadan see UPTRAVI TAB 200/800 ...... 33 see rosadan ...... 87 SELZENTRY ...... 11 rosuvastatin calcium ...... 28 semaglutide ROTARIX SUS ...... 70 see OZEMPIC ...... 47 ROTATEQ SOL ...... 70 sertaconazole nitrate rotavirus vaccine, live oral see ERTACZO ...... 84 see ROTARIX SUS ...... 70 sertraline hcl ...... 37 rotavirus vaccine, live oral pentavalent sevelamer carbonate ...... 57 see ROTATEQ SOL ...... 70 sharps container rotigotine see SHARPS CONTAINER ...... 72 see NEUPRO ...... 39 SHARPS CONTAINER ...... 72 ruxolitinib phosphate SHINGRIX ...... 70 see JAKAFI ...... 21 SHUR-SEAL ...... 62 RYDAPT ...... 18 SIGNIFOR ...... 56 S sildenafil citrate (pulmonary sacrosidase hypertension) ...... 32 see SUCRAID ...... 61 silodosin ...... 62 sacubitril-valsartan silver sulfadiazine ...... 83 see ENTRESTO TAB 24-26MG ...... 31 SIMBRINZA SUS 1-0.2% ...... 77 see ENTRESTO TAB 49-51MG ...... 32 SIMPONI ...... 66 see ENTRESTO TAB 97-103MG ...... 32 SIMPONI ARIA ...... 66 samarium sm 153 lexidronam simvastatin ...... 28 see QUADRAMET ...... 22 sirolimus ...... 68 SAMSCA ...... 56 SIRTURO ...... 13 SANCUSO ...... 59 sitagliptin-metformin hcl SANDIMMUNE ...... 68 see JANUMET TAB 50-1000 ...... 47 SAPHRIS ...... 40 see JANUMET TAB 50-500MG ...... 47 sapropterin dihydrochloride see JANUMET XR TAB 100-1000 ....47 see KUVAN ...... 54 see JANUMET XR TAB 50-1000 ...... 47 saquinavir mesylate see JANUMET XR TAB 50-500MG ...47 see INVIRASE ...... 10 sitagliptin phosphate sarilumab see JANUVIA ...... 46 see KEVZARA ...... 66 SKLICE ...... 87 Sb Lice Treatment SKYLA ...... 53 see permethrin ...... 87 SKYRIZI ...... 66 scopolamine ...... 59 SLYND ...... 53 121 sm nicotine transdermal s ...... 46 SOVALDI ...... 15 Sm Nicotine Transdermal S spacer/aerosol-holding chambers see sm nicotine transdermal s ...... 46 see ADULT RESPIRATORY MASK ....72 sodium chloride ...... 73, 74 spacer/aerosol-holding chamber sodium chloride (gu irrigant) ...... 87 supplies - masks sodium chloride (inhalant) ...... 81 see PEDIATRIC RESPIRATORY MASK sodium chloride flush ...... 73 ...... 73 sodium fluoride ...... 73 spinosad ...... 87 see FLUORABON ...... 73 SPIRIVA HANDIHALER ...... 78 sodium phenylbutyrate ...... 54 SPIRIVA RESPIMAT ...... 78 sodium phenylbutyrate oral powder 3 spironolactone ...... 31 gm/teaspoonful ...... 54 spironolactone & hydrochlorothiazide sodium phosphate monobasic-sodium see ALDACTAZIDE TAB 50/50 ...... 31 phosphate dibasic spironolactone & hydrochlorothiazide see OSMOPREP TAB 1.5GM ...... 60 tab 25-25 mg ...... 31 sodium picosulfate-magnesium oxide- sprintec 28 ...... 53 anhydrous citric acid Sprintec 28 see CLENPIQ SOL ...... 60 see sprintec 28 ...... 53 see PREPOPIK PAK ...... 60 SPRYCEL ...... 21 sodium polystyrene sulfonate ...... 50 sronyx ...... 53 sodium sulfate-potassium sulfate- Sronyx magnesium sulfate see sronyx ...... 53 see SUPREP BOWEL SOL PREP KIT .60 ssd ...... 83 sofosbuvir Ssd see SOVALDI ...... 15 see ssd ...... 83 sofosbuvir-velpatasvir stavudine ...... 11 see EPCLUSA TAB 400-100 ...... 14 STELARA ...... 66 sofosbuvir-velpatasvir-voxilaprevir STIVARGA ...... 21 see VOSEVI TAB ...... 15 STRIVERDI RESPIMAT ...... 80 solifenacin succinate ...... 63 SUBLOCADE ...... 7 SOLIQUA INJ 100/33 ...... 47 succimer SOLU-CORTEF ...... 56 see CHEMET ...... 50 SOLU-MEDROL ...... 56 SUCRAID ...... 61 somatropin sucralfate ...... 61 see HUMATROPE ...... 56 sucroferric oxyhydroxide see HUMATROPE COMBO PACK ...... 56 see VELPHORO ...... 57 SOMATULINE DEPOT ...... 56 sulconazole nitrate ...... 84 SOMAVERT ...... 56 see EXELDERM ...... 84 sonidegib phosphate sulfacetamide sodium (acne) ...... 83 see ODOMZO ...... 22 sulfacetamide sodium (ophth) ...... 76 sorafenib tosylate sulfacetamide sodium-prednisolone see NEXAVAR ...... 21 ophth soln 10-0.23(0.25)% ...... 75 sorine ...... 27 sulfacetamide sod-prednisolone Sorine see BLEPHAMIDE OIN S.O.P...... 75 see sorine ...... 27 see BLEPHAMIDE SUS OP ...... 75 sotalol hcl ...... 27 SULFADIAZINE ...... 7 sotalol hcl (afib/afl) ...... 27 122 sulfamethoxazole-trimethoprim susp tacrolimus (topical) ...... 86 200-40 mg/5ml ...... 9 tadalafil ...... 62 sulfamethoxazole-trimethoprim tab tadalafil (pulmonary hypertension) ...33 400-80 mg ...... 9 TAFINLAR ...... 21 sulfamethoxazole-trimethoprim tab tafluprost 800-160 mg ...... 9 see ZIOPTAN ...... 77 SULFAMYLON ...... 83 take action ...... 53 sulfasalazine ...... 59 Take Action sulindac ...... 2 see take action ...... 53 sumatriptan ...... 42 TALTZ ...... 66 sumatriptan succinate ...... 42, 43 tamoxifen citrate ...... 19 sunitinib malate tamsulosin hcl ...... 62 see SUTENT ...... 21 tapentadol hcl SUPRAX ...... 14 see NUCYNTA ...... 5 SUPREP BOWEL SOL PREP KIT ...... 60 see NUCYNTA ER ...... 5 SUTENT ...... 21 TARGRETIN ...... 86 suvorexant tasimelteon see BELSOMRA ...... 42 see HETLIOZ ...... 42 syeda ...... 53 TAYTULLA CAP 1MG/20MC ...... 53 Syeda tazarotene ...... 84 see syeda ...... 53 see TAZORAC ...... 85 symax-sl ...... 58 tazicef ...... 14 Symax-sl Tazicef see symax-sl ...... 58 see tazicef ...... 14 SYMBICORT AER 160-4.5 ...... 82 TAZORAC ...... 85 SYMBICORT AER 80-4.5 ...... 82 taztia xt ...... 30 SYMDEKO TAB 100-150 ...... 81 Taztia Xt SYMDEKO TAB 50-75MG ...... 81 see taztia xt ...... 30 SYMFI LO TAB ...... 12 TDVAX INJ 2-2 LF ...... 71 SYMFI TAB ...... 12 TECFIDERA ...... 44 SYMLINPEN 120 ...... 46 TECFIDERA MIS STARTER ...... 44 SYMLINPEN 60 ...... 46 telmisartan ...... 27 SYNAREL ...... 53 telmisartan-amlodipine tab 40-10 mg SYNERA DIS 70-70MG ...... 86 ...... 26 SYNJARDY TAB 12.5-1000MG ...... 49 telmisartan-amlodipine tab 40-5 mg .26 SYNJARDY TAB 12.5-500 ...... 49 telmisartan-amlodipine tab 80-10 mg SYNJARDY TAB 5-1000MG ...... 49 ...... 26 SYNJARDY TAB 5-500MG ...... 49 telmisartan-amlodipine tab 80-5 mg .26 SYNJARDY XR TAB 10-1000 ...... 49 telmisartan-hydrochlorothiazide tab 40- SYNJARDY XR TAB 12.5-1000MG ...... 49 12.5 mg ...... 26 SYNJARDY XR TAB 25-1000 ...... 49 telmisartan-hydrochlorothiazide tab 80- SYNJARDY XR TAB 5-1000MG ...... 49 12.5 mg ...... 26 SYNTHROID ...... 57 telmisartan-hydrochlorothiazide tab 80- T 25 mg ...... 26 TABLOID ...... 17 temazepam ...... 42 tacrolimus ...... 68 TEMIXYS TAB 300-300 ...... 12 see PROGRAF ...... 68 TEMODAR ...... 16 123 temozolomide ...... 16 see tilia fe ...... 53 see TEMODAR ...... 16 timolol tencon ...... 1 see BETIMOL ...... 77 Tencon timolol maleate ...... 29 see tencon ...... 1 timolol maleate (ophth) ...... 77 TENIPOSIDE ...... 23 tinidazole ...... 7 TENIVAC INJ 5-2LF ...... 71 tiotropium bromide monohydrate tenofovir disoproxil fumarate ...... 11 see SPIRIVA HANDIHALER ...... 78 see VIREAD ...... 11 see SPIRIVA RESPIMAT ...... 78 terazosin hcl ...... 25 tipranavir terbinafine hcl ...... 9 see APTIVUS ...... 10 terbutaline sulfate ...... 80 TIVICAY ...... 11 terconazole vaginal ...... 63 tizanidine hcl ...... 45 teriflunomide TOBRADEX OIN 0.3-0.1% ...... 75 see AUBAGIO ...... 43 TOBRADEX ST SUS 0.3-0.05 ...... 75 testosterone ...... 46 tobramycin ...... 8 testosterone cypionate ...... 46 tobramycin (ophth) ...... 76 testosterone enanthate ...... 46 tobramycin-dexamethasone tetanus-diphtheria toxoids (td) see TOBRADEX OIN 0.3-0.1% ...... 75 see TDVAX INJ 2-2 LF ...... 71 see TOBRADEX ST SUS 0.3-0.05 ...75 see TENIVAC INJ 5-2LF ...... 71 tobramycin-dexamethasone ophth susp tetanus toxoid-diphtheria-acellular 0.3-0.1% ...... 75 pertussis adsorb (tdap) tobramycin sulfate ...... 8 see ADACEL INJ ...... 69 tocilizumab see BOOSTRIX INJ ...... 69 see ACTEMRA ...... 65 tetrabenazine ...... 43 TODAY SPONGE ...... 62 tetracycline hcl ...... 16 tofacitinib citrate tezacaftor-ivacaftor see XELJANZ ...... 67 see SYMDEKO TAB 100-150 ...... 81 see XELJANZ XR ...... 67 see SYMDEKO TAB 50-75MG ...... 81 tolcapone ...... 39 thalidomide tolmetin sodium ...... 2 see THALOMID ...... 68 tolterodine tartrate ...... 63 THALOMID ...... 68 tolvaptan ...... 56 THEO-24 ...... 82 see SAMSCA ...... 56 theophylline ...... 82 topiramate ...... 35 see ELIXOPHYLLIN ...... 82 toposar ...... 23 see THEO-24 ...... 82 Toposar thioguanine see toposar ...... 23 see TABLOID ...... 17 topotecan hcl ...... 23 thioridazine hcl ...... 40 toremifene citrate ...... 19 thiothixene ...... 40 torsemide ...... 31 tiagabine hcl ...... 35 TOVIAZ ...... 63 ticagrelor TRACLEER ...... 33 see BRILINTA ...... 64 tramadol-acetaminophen tab 37.5-325 TICE BCG ...... 22 mg ...... 6 tilia fe ...... 53 tramadol hcl ...... 6 Tilia Fe trametinib dimethyl sulfoxide 124 see MEKINIST ...... 21 trimethobenzamide hcl ...... 59 trandolapril ...... 24 trimethoprim ...... 9 trandolapril-verapamil hcl tab er 1-240 trimethoprim hcl mg ...... 24 see PRIMSOL ...... 9 trandolapril-verapamil hcl tab er 2-180 trimipramine maleate ...... 38 mg ...... 24 tri-sprintec ...... 53 trandolapril-verapamil hcl tab er 2-240 Tri-sprintec mg ...... 24 see tri-sprintec ...... 53 trandolapril-verapamil hcl tab er 4-240 TRIUMEQ TAB ...... 12 mg ...... 24 Tri-vite/fluoride tranexamic acid ...... 64 see *pediatric vitamins acd w/ tranylcypromine sulfate ...... 37 fluoride soln 0.25 mg/ml*** ...... 75 travoprost ...... 77 see *pediatric vitamins acd w/ trazodone hcl ...... 37 fluoride soln 0.5 mg/ml*** ...... 75 TRECATOR ...... 13 trivora-28 ...... 53 TRELEGY AER ELLIPTA ...... 78 Trivora-28 TREMFYA ...... 66 see trivora-28 ...... 53 treprostinil TROGARZO ...... 11 see REMODULIN ...... 32 tropicamide ...... 78 see TYVASO STARTER ...... 33 trospium chloride ...... 63 treprostinil diolamine TRULICITY ...... 47 see ORENITRAM ...... 32 TRUMENBA INJ ...... 71 TRESIBA ...... 48 TRUVADA TAB 100-150 ...... 12 TRESIBA FLEXTOUCH ...... 48 TRUVADA TAB 133-200 ...... 12 tretinoin ...... 83 TRUVADA TAB 167-250 ...... 12 tretinoin (chemotherapy) ...... 22 TRUVADA TAB 200-300 ...... 12 tretinoin microsphere ...... 83 TUZISTRA XR SUS ...... 80 triamcinolone acetonide (mouth) ...... 87 TWINRIX INJ ...... 71 triamcinolone acetonide (nasal) ...... 81 TYBOST ...... 11 triamcinolone acetonide (topical) ...... 86 TYKERB ...... 21 triamterene ...... 31 TYMLOS ...... 56 triamterene & hydrochlorothiazide cap TYSABRI ...... 44 37.5-25 mg ...... 31 TYVASO STARTER ...... 33 triamterene & hydrochlorothiazide tab U 37.5-25 mg ...... 31 UDENYCA ...... 64 triamterene & hydrochlorothiazide tab ulipristal acetate 75-50 mg ...... 31 see ELLA ...... 51 triderm ...... 86 ULTRALANCE MIS 1.8MM ...... 72 Triderm umeclidinium bromide see triderm ...... 86 see INCRUSE ELLIPTA ...... 78 trifluoperazine hcl ...... 40 unithroid ...... 57 trifluridine ...... 76 Unithroid trihexyphenidyl hcl ...... 39 see unithroid ...... 57 TRIKAFTA TAB ...... 81 upadacitinib tri-linyah ...... 53 see RINVOQ ...... 66 Tri-linyah UPTRAVI ...... 33 see tri-linyah ...... 53 UPTRAVI TAB 200/800 ...... 33 125 uridine triacetate (emergency VASCEPA ...... 28 treatment) VCF VAGINAL CONTRACEPTIVE ...... 62 see VISTOGARD ...... 22 velivet ...... 53 Urinary Pain Relief Velivet see phenazopyridine tab 95mg ...... 62 see velivet ...... 53 urine glucose-ketones test VELPHORO ...... 57 see KETONE URINE TEST STRIPS ..72 vemurafenib urine glucose monitoring supplies see ZELBORAF ...... 22 see URINE GLUCOSE MONITORING VENCLEXTA ...... 23 SUPPLIES ...... 72 VENCLEXTA TAB START PK ...... 23 URINE GLUCOSE MONITORING venetoclax SUPPLIES ...... 72 see VENCLEXTA ...... 23 URINE TEST STRIPS ...... 72 see VENCLEXTA TAB START PK .....23 ursodiol ...... 61 venlafaxine hcl ...... 38 ustekinumab VENTAVIS ...... 33 see STELARA ...... 66 verapamil hcl ...... 30 V V-GO 20 KIT ...... 72 valacyclovir hcl ...... 13 V-GO 30 KIT ...... 72 valganciclovir hcl ...... 13 V-GO 40 KIT ...... 72 valproate sodium ...... 35 VIBRAMYCIN ...... 16 valproic acid ...... 35 VICTOZA ...... 47 valsartan ...... 27 VIDEX EC ...... 11 valsartan-hydrochlorothiazide tab 160- VIDEX PEDIATRIC ...... 11 12.5 mg ...... 26 vigabatrin ...... 35 valsartan-hydrochlorothiazide tab 160- VIIBRYD ...... 38 25 mg ...... 26 VIIBRYD KIT STARTER ...... 38 valsartan-hydrochlorothiazide tab 320- vilazodone hcl 12.5 mg ...... 26 see VIIBRYD ...... 38 valsartan-hydrochlorothiazide tab 320- see VIIBRYD KIT STARTER ...... 38 25 mg ...... 26 VIMPAT ...... 35 valsartan-hydrochlorothiazide tab 80- vinblastine sulfate ...... 18 12.5 mg ...... 26 vincristine sulfate ...... 18 vancomycin hcl ...... 9 vinorelbine tartrate ...... 18 vandazole ...... 63 VIOKACE TAB 10440 ...... 61 Vandazole VIOKACE TAB 20880 ...... 61 see vandazole ...... 63 viorele ...... 53 vandetanib Viorele see CAPRELSA ...... 20 see viorele ...... 53 VAQTA ...... 71 VIRACEPT ...... 11 varenicline tartrate VIREAD ...... 11 see CHANTIX ...... 45 vismodegib see CHANTIX CONTINUING MONTH 45 see ERIVEDGE ...... 18 see CHANTIX PAK 0.5& 1MG ...... 45 VISTOGARD ...... 22 varicella virus vaccine live vitamins a/c/d/fluoride ...... 75 see VARIVAX ...... 71 Vitamins A/c/d/fluoride VARIVAX ...... 71 see vitamins a/c/d/fluoride ...... 75 VARUBI ...... 59 VITRAKVI ...... 21, 22 126 VIVITROL ...... 46 Z VOLTAREN ...... 87 zafirlukast ...... 80 vorapaxar sulfate zaleplon ...... 42 see ZONTIVITY ...... 65 zanamivir voriconazole ...... 9 see RELENZA DISKHALER ...... 13 vorinostat zarah ...... 53 see ZOLINZA ...... 18 Zarah VOSEVI TAB ...... 15 see zarah ...... 53 VOTRIENT ...... 22 ZEJULA ...... 18 Vyfemla ZELBORAF ...... 22 see norethindrone & ethinyl estradiol ZENPEP CAP 10000UNT ...... 61 tab 0.4 mg-35 mcg ...... 52 ZENPEP CAP 15000UNT ...... 61 VYVANSE ...... 41 ZENPEP CAP 20000UNT ...... 61 W ZENPEP CAP 25000 ...... 61 warfarin sodium ...... 63 ZENPEP CAP 3000UNIT ...... 61 wera ...... 53 ZENPEP CAP 40000 ...... 61 Wera ZENPEP CAP 5000UNIT ...... 61 see wera ...... 53 zenzedi ...... 42 Westab Max Zenzedi see folic acid-pyridoxine- see zenzedi ...... 42 cyanocobalamin tab 2.5-25-2 mg 74 zidovudine ...... 11 WIDE-SEAL SILICONE DIAPHR ...... 71 see RETROVIR IV INFUSION ...... 11 X zileuton ...... 80 XALKORI ...... 22 ZIOPTAN ...... 77 XARELTO ...... 63 ziprasidone hcl ...... 40 XARELTO STAR TAB 15/20MG ...... 64 ZIRGAN ...... 76 XELJANZ ...... 67 zoledronic acid ...... 50 XELJANZ XR ...... 67 ZOLINZA ...... 18 XIFAXAN ...... 9 zolmitriptan ...... 43 XIGDUO XR TAB 10-1000 ...... 49 see ZOMIG ...... 43 XIGDUO XR TAB 10-500MG ...... 49 zolpidem tartrate ...... 42 XIGDUO XR TAB 2.5-1000 ...... 49 ZOMIG ...... 43 XIGDUO XR TAB 5-1000MG ...... 49 zonisamide ...... 35 XIGDUO XR TAB 5-500MG ...... 49 ZONTIVITY ...... 65 XOLAIR ...... 80 ZORTRESS ...... 68 XTAMPZA ER ...... 6 ZOSTAVAX ...... 71 XTANDI ...... 19 zoster vaccine live xulane ...... 53 see ZOSTAVAX ...... 71 Xulane zoster vaccine recombinant adjuvanted see xulane ...... 53 see SHINGRIX ...... 70 XULTOPHY INJ 100/3.6 ...... 47 zovia 1/35e ...... 53 Y Zovia 1/35e YONSA ...... 19 see zovia 1/35e ...... 53 yuvafem ...... 55 ZUBSOLV SUB 0.7-0.18 ...... 2 Yuvafem ZUBSOLV SUB 1.4-0.36 ...... 2 see yuvafem ...... 55 ZUBSOLV SUB 11.4-2.9 ...... 2 ZUBSOLV SUB 2.9-0.71 ...... 2 127 ZUBSOLV SUB 5.7-1.4 ...... 2 ZUBSOLV SUB 8.6-2.1 ...... 2 ZYDELIG ...... 22 ZYKADIA ...... 22 ZYTIGA ...... 19

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