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2020 Pharmacy Drug Guide Advanced Control Plan: Sutter Health | Aetna

Visit www.aetna.com/formulary for the most up-to-date information. For a summary of your coverage or benefits plan log in to your secure member site. Or call the toll-free number on your member ID card.

The formulary is updated the first week of each month. The formulary is subject to change. Previous versions are no longer in effect.

The Medical plan names to which this document applies to in the state of California are listed below:

Plan Name Sutter Health OA Elect Choice® EPO Sutter Health OA Managed Choice® POS Sutter Health OA Managed Choice® POS HDHP

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

Table of Contents

INFORMATIONAL SECTION...... 4 ANALGESICS - DRUGS TO TREAT PAIN AND INFLAMMATION...... 15 ANESTHETICS - DRUGS FOR NUMBING...... 24 ANTI-INFECTIVES - DRUGS TO TREAT ...... 25 ANTINEOPLASTIC AGENTS - DRUGS TO TREAT CANCER...... 37 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES...... 46 CARDIOVASCULAR - DRUGS TO TREAT HEART AND CIRCULATION CONDITIONS...... 46 CENTRAL NERVOUS SYSTEM - DRUGS TO TREAT NERVOUS SYSTEM DISORDERS...... 59 ENDOCRINE AND METABOLIC - DRUGS TO TREAT DIABETES AND REGULATE HORMONES...... 84 GASTROINTESTINAL - DRUGS TO TREAT STOMACH AND INTESTINAL DISORDERS...... 114 GENITOURINARY - DRUGS TO TREAT GENITAL AND URINARY TRACT CONDITIONS...122 HEMATOLOGIC - DRUGS TO TREAT BLOOD DISORDERS...... 126 IMMUNOLOGIC AGENTS - DRUGS TO TREAT DISORDERS OF THE IMMUNE SYSTEM.....137 MEDICAL DEVICES...... 144 NUTRITIONAL/SUPPLEMENTS - VITAMINS AND SUPPLEMENTS...... 190 OPHTHALMIC - DRUGS TO TREAT EYE CONDITIONS...... 202 OTHER...... 208 RESPIRATORY - DRUGS TO TREAT BREATHING DISORDERS...... 208 TOPICAL - DRUGS TO TREAT EAR AND SKIN CONDITIONS...... 218

TOC-3 Definitions

Brand name drug means a drug that is marketed under Generic drug means a drug that is the same as its brand a proprietary, trademark-protected name. A brand name name drug equivalent in dosage, strength, effect, how it drug is listed in this formulary in all CAPITAL letters. is taken, quality, safety, and intended use. A generic drug is listed in this formulary in italicized lowercase letters. Coinsurance means a percentage of the cost of a covered health care benefit that you pay after you have Medically Necessary means health care benefits paid the deductible, if a deductible applies to the health needed to diagnose, treat, or prevent a medical condition care benefit. or its symptoms and that meet accepted standards of medicine. Health insurance usually does not cover health Copayment means a fixed dollar amount that you care benefits that are not medically necessary. pay for a covered health care benefit after you have paid the deductible, if a deductible applies to the Non-formulary drug means a prescription drug that is health care benefit. not listed on this formulary.

Deductible means the amount you pay for covered Out-of-pocket costs means your expenses for health health care benefits that are subject to the deductible care benefits that aren’t reimbursed by your health before your health insurer begins to pay. If your health insurance. Out-of-pocket costs include deductibles, insurance policy has a deductible, it may have either one copayments, and coinsurance for covered health care deductible or separate deductibles for medical benefits benefits, plus all costs for health care benefits that are and prescription drug benefits. After you pay your not covered. deductible, you usually pay only a copayment or Prescribing provider means a health care provider who coinsurance for covered health care benefits. Your can write a prescription for a drug to diagnose, treat, or insurance company pays the rest. prevent a medical condition. Drug Tier means a group of prescription drugs that Prescription means an oral, written, or electronic order correspond to a specified cost sharing tier in your from a prescribing provider authorizing a prescription health insurance policy. The drug tier in which a drug to be provided to a specific individual. prescription drug is placed determines your portion of the cost for the drug. Prescription drug means a drug that by law requires a prescription. Enrollee is a person enrolled in a health plan who is entitled to receive services from the plan. Prior Authorization means a decision by your health insurer that a health care benefit is medically necessary Exception request means a request for coverage of for you. If a prescription drug is subject to prior a non-formulary drug. If you, your designee, or your authorization in this formulary, your prescribing provider prescribing health care provider submits a request for must request approval from your health insurer to cover coverage of a non-formulary drug, your insurer must the drug before you fill your prescription. Your health cover the non-formulary drug when it is medically insurer must grant a prior authorization request when necessary for you to take the drug. it is medically necessary for you to take the drug. Exigent circumstances means when you are suffering Step therapy means a specific sequence in which from a medical condition that may seriously jeopardize prescription drugs for a particular medical condition your life, health, or ability to regain maximum function, or must be tried. If a drug is subject to step therapy in this when you are undergoing a current course of treatment formulary, you may have to try one or more other drugs using a non-formulary drug. before your health insurance policy will cover that drug Formulary or prescription drug list means the list of for your medical condition. If your prescribing provider drugs that is covered by your health insurance policy submits a request for an exception to the step therapy under the prescription drug benefit of the policy. requirement, your health insurer must grant the request when it is medically necessary for you to take the drug.

Subscriber means the person who is responsible for payment to a plan or whose employment or other status, except for family dependency, is the basis for eligibility for membership in the plan.

1 How to use this guide

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

Refer to the Summary of Benefits for differences and information about the prescription drugs covered under your Outpatient prescription drugs and medical benefit in your plan.

A prescription drug may be located by looking up Your plan includes the therapeutic category and class to which the drug • Brand and generic drugs that are hand-picked for their belongs or the brand or generic name of the drug quality and effectiveness in the alphabetical index; and • A specialty pharmacy fills specialty drug prescriptions If a generic equivalent for a brand name drug is not (ones that are injected, infused or taken by mouth) — available on the market or is not covered, the drug will and provides services that include personal support, not be separately listed by its generic name. helpful resources and training, and free secure • A drug is listed alphabetically by its brand and generic home delivery names in the therapeutic category and class to which • A home delivery pharmacy that delivers maintenance it belongs; drugs to your home or wherever you choose (for drugs • The generic name for a brand name drug is included that are taken regularly to treat conditions like diabetes after the brand name in parentheses and all lowercase or asthma) italicized letters. (For example: COREG (carvedilol)) • If a generic equivalent for a brand name drug is both What you can expect to pay available and covered, the generic drug will be listed With your pharmacy plan, the amount you pay depends separately from the brand name drug in all lowercase on the drug your doctor prescribes. It’s either a flat fee or italicized letters; and (For example: carvedilol) a percentage of the drug’s/medicine price. • If a generic drug is marketed under a proprietary, trademark-protected brand name, the brand name Each drug is grouped as a generic, a brand or a specialty will be listed after the generic name in parentheses drug. The preferred drugs within these groups will and regular typeface with the first letter of each generally save you money compared to a non-preferred word capitalized. (For example: desogestrel-ethinyl drug. Typically, generic drugs are less expensive estradiol (Azurette)). than brands. • Inclusion of a prescription drug on the formulary Specialty prescription drugs typically include higher-cost does not guarantee that your provider will prescribe drugs that require special handling, special storage or the drug for a particular medical condition. monitoring. These types of drugs may include, but are • Therapeutic categories and classes are based on the not limited to, drugs that are injected, infused, inhaled Medispan therapeutic classification system. or taken by mouth.

2 You’re covered for all types of medicine — some more Specialty Pharmacy Network expensive, and some less. An in-network specialty pharmacy can fill your • Generic – G (tier 1): the lowest cost share prescriptions for specialty drugs. These are the • Preferred brand – PB (tier 2): a slightly higher types of drugs that may be injected, infused or taken cost share by mouth. They often need special storage and handling. And they need to be delivered quickly. A nurse or • Non-preferred brand – NP (tier 3): a higher pharmacist may monitor your treatment, if needed. cost share With this type of pharmacy, you can get this medicine • Preferred Specialty – PSP (tier 4): lower cost share sent right to our mailbox. for specialty drugs • Non-preferred Specialty – NPS (tier 5): higher How to get started with a specialty pharmacy cost share for non-preferred specialty drugs Ordering your prescriptions through our specialty • Copay Exception – CE: Available to some members pharmacy is easy. And we typically offer a 30-day at no cost with a prescription from your provider medicine supply. when obtained at an in-network pharmacy. Certain limitations may apply. • To transfer your prescription, just call us toll-free at 1-866-353-1892. Your pharmacy plan may not have all the coverage levels • For a new prescription, your doctor can send it to listed above so check your plan documents to see how us in one of four ways: much you will pay, for example your copayments and Through e-prescribe maximum dollar amounts. 1. Electronically: 2. Fax: 1-800-323-2445 For your exact coverage and cost, and 3. Phone: 1-800-237-2767 to learn more about your plan If you mail in your own prescription, please send it Visit the website that’s on your member ID card. with a completed Patient Profile Form. To find this Then log in to your account, where you can: form, just visit the website that’s on your member ID • Find out the coverage and estimate of cost for card, to search for the “Patient Profile Form”. specific drugs

• View your deductibles and plan limits

• Order

• Check your pharmacy order status

• Get a member ID card

• View your claims, Explanation of Benefits and more

Have more questions about your pharmacy benefits?

We’re here to help. There are several ways you can learn more about your benefits:

• Check your Plan Design and Benefits Summary in your enrollment kit. • Call the toll-free number on your member ID card. • Review our pharmacy frequently asked questions (FAQs) and answers. Just visit the website that’s on your member ID card to search for the “Pharmacy FAQ”.

3 CVS Caremark Mail Service Pharmacy™

You can have maintenance drugs sent right to your home or anywhere else you choose with CVS Caremark Mail Service Pharmacy. These are drugs that are taken regularly for chronic conditions like diabetes or asthma. Depending on your plan, you can get up to a 90-day supply of medicine for less cost. It’s fast and convenient, and standard shipping is always free.

Get started right away

You can submit your order using one of these options:

1. Online — Visit your secure member website and sign in to your account. There you can add or remove your prescriptions.

2. Phone — Call us toll-free, 24/7 at 1-888-792-3862. If you need the help of a telephone device for the hard of hearing, call 1-877-833-2779.

3. Mail — Get a new prescription from your doctor. Then mail it to us with a completed order form. You can find the form on your secure member website. The mailing address is on the form.

Your doctor can submit your order using one of these options:

1. Online — They can submit your prescriptions using the e-prescribe services on our provider website.

2. Fax — They can fax your prescription to 1-877-270-3317. Make sure they include your member ID number, date of birth and mailing address on the fax cover sheet. Only a doctor may fax a prescription.

4 Frequently asked questions

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

Here are some tips to pay less out of pocket for your Some drugs require step therapy. This means that prescription drugs: you must try one or more prerequisite drug(s) before a step therapy drug is covered. • Ask your doctor to consider prescribing drugs that are on the Pharmacy Drug Guide (formulary). The prerequisite drugs have U.S. Food and Drug • Ask your doctor to consider prescribing generic Administration (FDA) approval and may cost less. drugs instead of brand-name drugs. They treat the same condition as the step therapy drug. • Our home delivery service may save you money. For If you don’t try the appropriate prerequisite drug(s) first, more information, visit the website on your member you may need to pay full cost for the step-therapy drug. ID card and log in to your account. What are quantity limits? What are generic drugs? Quantity limits help your doctor and pharmacist make Generic drugs are proven to be just as safe and effective sure that you use your drug correctly and safely. We use as brand-name drugs. They contain the same active medical guidelines and FDA-approved recommendations ingredients in the same amounts as the brand-name from drug makers to set these coverage limits. The drugs and work the same way. So they have the same quantity limit program includes: risks and benefits as brand-name drugs. However, they • Dose efficiency edits — Limits prescription coverage typically cost less. to one dose per day for drugs that have approval for When appropriate, your doctor may decide to prescribe once-daily dosing a generic drug or allow the pharmacist to substitute a • Maximum daily dose — If a prescription is lower than generic drug. the minimum or higher than the maximum allowed dose, a message is sent to the pharmacy What is prior authorization? • Quantity limits over time — Limits prescription Prior authorization is one way that we can help you and coverage to a specific number of units over a specific your doctor find safe, appropriate drugs and keep costs amount of time down. Prior authorization means that you or your doctor need to get approval from the plan before certain drugs What if I need a drug that requires an exception will be covered. Generally, Prior authorization applies to to the prior authorization, step therapy or drugs that: quantity limits requirements? Or what if I need • Are often taken in the wrong way a drug that’s not covered under my plan? • Should only be used for certain conditions In certain cases, you or your prescriber can request a • Often cost more than other drugs that are proven medical exception to the prior authorization, step therapy to be just as effective or quantity limits requirement or for a drug that’s not covered on your plan. Coverage determinations will be Keep in mind that your doctor must contact us to request made within 72 hours of receiving non-urgent requests. approval of coverage for these drugs. You can ask for your request to be expedited. Expedited coverage decisions are made within 24 hours.

5 We’ll then contact you or your prescriber with our Can the formulary change during the year? decision. All medically necessary outpatient prescription The formulary can change throughout the year. drugs will be covered. If a medical exception is approved, Some reasons why they can change include: you only need to pay the copay after the deductible. This amount is based on your pharmacy plan design. • New drugs are approved.

Medical exceptions which are approved for non-urgent • Existing drugs are removed from the market. requests will cover the duration of the prescription, • Prescription drugs may become available over the including refills. Approved medical exceptions for exigent counter (without a prescription). Over-the-counter circumstances will provide coverage for the duration of drugs are not generally covered in a formulary. the exigency. • Brand-name drugs lose patent protection and If your request is denied you have the right to file an generic versions become available. When this happens, appeal using the process described in the notification the generic drug will be covered in place of the letter. brand-name drug. The brand-name drug is likely to become non-formulary or covered at a higher cost. If a determination is not made for a prior authorization or See the “what are generic drugs?” section above for step therapy exception request within 72 hours of more information. receiving a non-urgent request and 24 hours of receiving a request based on exigent circumstances, the request Pharmacy and Therapeutics (P&T) Committee is deemed approved and we may not deny the request thereafter. The services of an independent National Pharmacy and Therapeutics Committee (“P&T Committee”) are utilized In accordance with state law, members who are covered to approve safe and clinically effective drug therapies. under small group health insurance policies and who The P&T Committee is an external advisory body of have previously received approval from us for coverage clinical professionals from across the United States. The of medications for the members’ medical conditions P&T Committee’s voting members include physicians, will continue to have those medications covered, for pharmacists, a pharmacoeconomist and a medical as long as the prescriber continues prescribing them, ethicist, all of whom have a broad background of clinical provided that the drug is appropriately prescribed and and academic expertise regarding prescription drugs. is considered safe and effective for treating the Voting members of the P&T Committee are not member’s medical condition. employees of CVS Caremark and must disclose any financial relationship or conflicts of interest with any How can your provider request a medical pharmaceutical manufacturers. exception?

The following options will provide detail to help request How do you find a pharmacy? a medical exception. You can find a pharmacy in two ways: • Submit their request through our secure provider • Online: By logging onto your secure member website website on www.availity.com. at Aetna.com. • Call the Aetna Pharmacy prior authorization unit: • By phone: Call the toll-free number on your ID card. Non-Specialty 1-800-294-5979 or During regular business hours, a representative can Specialty 1-866-814-5506. assist you. Our automated telephone assistant can • Fax the completed request form to: give you this information 24 hours a day. Non-Specialty 1-888-836-0730 or Specialty 1-866-249-6155. • Mail the completed request form to: Aetna Pharmacy Management 1300 East Campbell Road Richardson, TX 75081

6 Assistive Technology

Persons using assistive technology may not be able to fully access the following information. For assistance, please call 1-888-802-3862.

Smartphone or Tablet

To view documents from your smartphone or tablet, the free WinZip app is required. It may be available from your App Store.

Non-Discrimination

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

We provide free aids/services to people with disabilities and to people who need language assistance.

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

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

Civil Rights Coordinator, P.O. Box 14462, Lexington, KY 40512, 1-800-648-7817, TTY: 711, Fax: 859-425-3379 [email protected]

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, or at 1-800-368-1019, 800-537-7697 (TDD).

Health benefit plans are administered by Sutter Health and Aetna Administrative Services LLC (Sutter Health|Aetna). Sutter Health|Aetna is an affiliate of Sutter Health and of Aetna Life Insurance Company and its affiliates (Aetna). Aetna provides certain management services to Sutter Health|Aetna.

7 8 9 10 Remember to visit the website on your member ID card. Then sign in to your account for the most up-to-date information.

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

Aetna.com

©2021 Aetna Inc. Drug Tier CE = Copay Exception: Available to some members at no cost with a prescription from your provider when obtained at an in-network pharmacy. Certain limitations Drug Notes may apply. IBC = Indication Based Coverage G = Generics LGC = Lowest Generic Copay NF = Non-formulary, not covered Applies unless exception request granted N8 = Drug Specific Coverage NPB = Non-Preferred Brands SPC = Select Plan Coverage: lowercase italics = Generic drugs NPSP = Non-Preferred Specialty Only available for select plans. UPPERCASE = Brand name PB = Preferred Brands Refer to member plan documents drugs PSP = Preferred Specialty for coverage. Prescription Drug Name Drug Tier Drug Notes ANALGESICS - DRUGS TO TREAT PAIN AND INFLAMMATION COX-2 INHIBITORS CELEBREX ORAL CAPSULE 100 MG, 200 MG, 400 MG, NF 50 MG (celecoxib) celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mg G GOUT - DRUGS TO TREAT GOUT allopurinol oral tablet 100 mg, 300 mg G colchicine oral capsule 0.6 mg G colchicine oral tablet 0.6 mg G colchicine-probenecid oral tablet 0.5-500 mg G COLCRYS ORAL TABLET 0.6 MG (colchicine) NF febuxostat oral tablet 40 mg, 80 mg G KRYSTEXXA INTRAVENOUS SOLUTION 8 MG/ML NPSP (pegloticase) MITIGARE ORAL CAPSULE 0.6 MG (colchicine) PB probenecid oral tablet 500 mg G ULORIC ORAL TABLET 40 MG, 80 MG (febuxostat) NF MISCELLANEOUS RIDAURA ORAL CAPSULE 3 MG (auranofin) NPB NON-OPIOID ANALGESICS ALLZITAL ORAL TABLET 25-325 MG (butalbital- NF acetaminophen) butalbital-apap-caffeine (Bac Oral Tablet 50-325-40 Mg) G butalbital-acetaminophen (Bupap Oral Tablet 50-300 Mg) NF 2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 15 Prescription Drug Name Drug Tier Drug Notes butalbital-acetaminophen oral capsule 50-300 mg G butalbital-acetaminophen oral tablet 50-300 mg NF butalbital-acetaminophen oral tablet 50-325 mg G butalbital-apap-caffeine oral capsule 50-300-40 mg, 50-325-40 NF mg butalbital-apap-caffeine oral tablet 50-325-40 mg G butalbital-aspirin-caffeine oral capsule 50-325-40 mg G butalbital-apap-caffeine (Esgic Oral Capsule 50-325-40 Mg) NF FIORICET ORAL CAPSULE 50-300-40 MG (butalbital- NF apap-caffeine) TENCON ORAL TABLET 50-325 MG (butalbital- G acetaminophen) butalbital-apap-caffeine (Zebutal Oral Capsule 50-325-40 Mg) NF NSAIDS - DRUGS TO TREAT PAIN AND INFLAMMATION CAMBIA ORAL PACKET 50 MG (diclofenac NF potassium(migraine)) dfs dr/ms/menth/cap pak combination kit 75 mg NF diclofenac potassium oral tablet 50 mg G diclofenac sodium er oral tablet extended release 24 hour 100 G mg diclofenac sodium oral tablet delayed release 25 mg, 50 mg, 75 G mg etodolac er oral tablet extended release 24 hour 400 mg, 500 mg, G 600 mg etodolac oral capsule 200 mg, 300 mg G etodolac oral tablet 400 mg, 500 mg G fenoprofen calcium oral capsule 200 mg, 400 mg NF fenoprofen calcium oral tablet 600 mg NF FENORTHO ORAL CAPSULE 200 MG (fenoprofen NF calcium) flurbiprofen oral tablet 100 mg, 50 mg G ibuprofen (Ibu Oral Tablet 400 Mg, 600 Mg, 800 Mg) G ibuprofen oral suspension 100 mg/5ml G ibuprofen oral tablet 400 mg, 600 mg, 800 mg G INDOCIN ORAL SUSPENSION 25 MG/5ML NF (indomethacin)

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 16 Prescription Drug Name Drug Tier Drug Notes INDOCIN RECTAL SUPPOSITORY 50 MG (indomethacin) NF indomethacin er oral capsule extended release 75 mg G indomethacin oral capsule 20 mg NF indomethacin oral capsule 25 mg, 50 mg G ketoprofen er oral capsule extended release 24 hour 200 mg NF ketoprofen oral capsule 25 mg NF ketorolac tromethamine oral tablet 10 mg G LODINE ORAL TABLET 400 MG (etodolac) NF meclofenamate sodium oral capsule 100 mg, 50 mg G mefenamic acid oral capsule 250 mg NF meloxicam oral tablet 15 mg, 7.5 mg G nabumetone oral tablet 500 mg, 750 mg G NALFON ORAL CAPSULE 400 MG (fenoprofen calcium) NPB NAPRELAN ORAL TABLET EXTENDED RELEASE 24 NF HOUR 375 MG, 500 MG, 750 MG (naproxen sodium) NAPROSYN ORAL SUSPENSION 125 MG/5ML NF (naproxen) naproxen oral suspension 125 mg/5ml NF naproxen oral tablet 250 mg, 375 mg, 500 mg G naproxen oral tablet delayed release 375 mg, 500 mg G naproxen sodium er oral tablet extended release 24 hour 375 mg, NF 500 mg naproxen sodium oral tablet 275 mg, 550 mg G NUDROXIPAK DSDR-50 COMBINATION KIT 50 MG NF (diclofenac sodium-liniment) NUDROXIPAK DSDR-75 COMBINATION KIT 75 MG NF (diclofenac sodium-liniment) NUDROXIPAK M-15 COMBINATION KIT 15 MG NF (meloxicam-liniment) NUDROXIPAK N-500 COMBINATION KIT 500 MG NF (nabumetone-liniment) oxaprozin oral tablet 600 mg G piroxicam oral capsule 10 mg, 20 mg G QMIIZ ODT ORAL TABLET DISPERSIBLE 15 MG, 7.5 NF MG (meloxicam) SPRIX NASAL SOLUTION 15.75 MG/SPRAY (ketorolac NF tromethamine) 2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 17 Prescription Drug Name Drug Tier Drug Notes sulindac oral tablet 150 mg, 200 mg G TIVORBEX ORAL CAPSULE 20 MG (indomethacin) NF VIVLODEX ORAL CAPSULE 10 MG, 5 MG (meloxicam) NF ZIPSOR ORAL CAPSULE 25 MG (diclofenac potassium) NF ZORVOLEX ORAL CAPSULE 18 MG, 35 MG (diclofenac) NF NSAIDS, COMBINATIONS ARTHROTEC ORAL TABLET DELAYED RELEASE 50- NF 0.2 MG, 75-0.2 MG (diclofenac-misoprostol) diclofenac-misoprostol oral tablet delayed release 50-0.2 mg, 75- G 0.2 mg DUEXIS ORAL TABLET 800-26.6 MG (ibuprofen- NPB famotidine) diclofenac sodium-capsaicin (Inflammacin Combination NF Therapy Pack 75 & 0.025 Mg-%) INFLATHERM COMBINATION THERAPY PACK 75 & NF 3-3 MG & % (diclofenac-menthol-camphor) naproxen-esomeprazole oral tablet delayed release 375-20 mg, NF 500-20 mg PREVIDOLRX ANALGESIC COMBINATION THERAPY PACK 75-20-0.025 MG-MG-% (diclofenac- NF omeprazole-capsicum) TORONOVA II SUIK COMBINATION KIT 30 MG/ML NF (ketorolac trometh & anesthetic) TORONOVA SUIK COMBINATION KIT 30 MG/ML NF (ketorolac trometh & anesthetic) VIMOVO ORAL TABLET DELAYED RELEASE 375-20 NPB MG, 500-20 MG (naproxen-esomeprazole) OPIOID AGONIST/ANTAGONIST BUNAVAIL BUCCAL FILM 4.2-0.7 MG, 6.3-1 MG NF (buprenorphine hcl-naloxone hcl) buprenorphine hcl-naloxone hcl sublingual film 12-3 mg, 2-0.5 G mg, 4-1 mg, 8-2 mg buprenorphine hcl-naloxone hcl sublingual tablet sublingual 2- G 0.5 mg, 8-2 mg pentazocine-naloxone hcl oral tablet 50-0.5 mg G SUBOXONE SUBLINGUAL FILM 12-3 MG, 2-0.5 MG, 4- NF 1 MG, 8-2 MG (buprenorphine hcl-naloxone hcl)

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 18 Prescription Drug Name Drug Tier Drug Notes ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 0.7- 0.18 MG, 1.4-0.36 MG, 11.4-2.9 MG, 2.9-0.71 MG, 5.7-1.4 PB MG, 8.6-2.1 MG (buprenorphine hcl-naloxone hcl) OPIOID ANALGESICS - DRUGS TO TREAT PAIN acetaminophen-codeine #3 oral tablet 300-30 mg G acetaminophen-codeine oral solution 120-12 mg/5ml G acetaminophen-codeine oral tablet 300-15 mg, 300-60 mg G ACTIQ BUCCAL LOZENGE ON A HANDLE 1200 MCG, 1600 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG NPB (fentanyl citrate) APADAZ ORAL TABLET 4.08-325 MG, 6.12-325 MG, NF 8.16-325 MG (benzhydrocodone-acetaminophen) apap-caff-dihydrocodeine oral capsule 320.5-30-16 mg G butalbital-asa-caff-codeine (Ascomp-Codeine Oral Capsule 50- G 325-40-30 Mg) butalbital-apap-caff-cod oral capsule 50-300-40-30 mg, 50-325- G 40-30 mg butalbital-asa-caff-codeine oral capsule 50-325-40-30 mg G butorphanol tartrate nasal solution 10 mg/ml G codeine sulfate oral tablet 60 mg NPB CONZIP ORAL CAPSULE EXTENDED RELEASE 24 NPB HOUR 100 MG, 200 MG, 300 MG (tramadol hcl) DILAUDID INJECTION SOLUTION 1 MG/ML, 2 NF MG/ML (hydromorphone hcl) DILAUDID ORAL LIQUID 1 MG/ML (hydromorphone hcl) NPB DILAUDID ORAL TABLET 2 MG, 4 MG, 8 MG NPB (hydromorphone hcl) DSUVIA SUBLINGUAL TABLET SUBLINGUAL 30 NPB MCG (sufentanil citrate) DURAGESIC-100 TRANSDERMAL PATCH 72 HOUR NPB 100 MCG/HR (fentanyl) DURAGESIC-12 TRANSDERMAL PATCH 72 HOUR 12 NPB MCG/HR (fentanyl) DURAGESIC-25 TRANSDERMAL PATCH 72 HOUR 25 NPB MCG/HR (fentanyl) DURAGESIC-50 TRANSDERMAL PATCH 72 HOUR 50 NPB MCG/HR (fentanyl)

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 19 Prescription Drug Name Drug Tier Drug Notes DURAGESIC-75 TRANSDERMAL PATCH 72 HOUR 75 NPB MCG/HR (fentanyl) oxycodone-acetaminophen (Endocet Oral Tablet 10-325 Mg, G 2.5-325 Mg, 5-325 Mg, 7.5-325 Mg) fentanyl citrate buccal lozenge on a handle 1200 mcg, 1600 mcg, G 200 mcg, 400 mcg, 600 mcg, 800 mcg fentanyl citrate buccal tablet 200 mcg, 400 mcg, 600 mcg, 800 G mcg fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 37.5 mcg/hr, 50 mcg/hr, 62.5 mcg/hr, 75 mcg/hr, 87.5 G mcg/hr FENTORA BUCCAL TABLET 100 MCG, 200 MCG, 400 NF MCG, 600 MCG, 800 MCG (fentanyl citrate) hydrocodone bitartrate er oral capsule extended release 12 hour NF 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 50 mg hydrocodone-acetaminophen oral solution 5-217 mg/10ml G hydrocodone-acetaminophen oral tablet 10-300 mg, 10-325 mg, G 5-300 mg, 5-325 mg, 7.5-300 mg, 7.5-325 mg hydrocodone-ibuprofen oral tablet 10-200 mg, 5-200 mg, 7.5-200 G mg hydromorphone hcl er oral tablet extended release 24 hour 12 G mg, 16 mg, 32 mg, 8 mg hydromorphone hcl oral liquid 1 mg/ml G hydromorphone hcl oral tablet 2 mg, 4 mg, 8 mg G hydromorphone hcl rectal suppository 3 mg NPB HYSINGLA ER ORAL TABLET ER 24 HOUR ABUSE- DETERRENT 100 MG, 120 MG, 20 MG, 30 MG, 40 MG, NF 60 MG, 80 MG (hydrocodone bitartrate) LAZANDA NASAL SOLUTION 100 MCG/ACT, 400 NF MCG/ACT (fentanyl citrate) levorphanol tartrate oral tablet 2 mg, 3 mg NF LORTAB ORAL ELIXIR 10-300 MG/15ML (hydrocodone- NPB acetaminophen) meperidine hcl oral solution 50 mg/5ml NF meperidine hcl oral tablet 50 mg NF methadone hcl injection solution 10 mg/ml NPB methadone hcl (Methadone Hcl Intensol Oral Concentrate 10 G Mg/Ml)

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

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 21 Prescription Drug Name Drug Tier Drug Notes oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5- G 325 mg, 7.5-325 mg OXYCONTIN ORAL TABLET ER 12 HOUR ABUSE- DETERRENT 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60 NF MG, 80 MG (oxycodone hcl) oxymorphone hcl er oral tablet extended release 12 hour 10 mg, NF 15 mg, 20 mg, 30 mg, 40 mg, 5 mg, 7.5 mg oxymorphone hcl oral tablet 10 mg, 5 mg G PERCOCET ORAL TABLET 10-325 MG, 2.5-325 MG, 5- NF 325 MG, 7.5-325 MG (oxycodone-acetaminophen) ROXICODONE ORAL TABLET 15 MG, 30 MG, 5 MG NPB (oxycodone hcl) SUBSYS SUBLINGUAL LIQUID 100 MCG, 1200 (600 X 2) MCG, 1600 (800 X 2) MCG, 200 MCG, 400 MCG, 600 PB MCG, 800 MCG (fentanyl) SYNAPRYN FUSEPAQ ORAL SUSPENSION NF RECONSTITUTED 10 MG/ML (tramadol hcl) tramadol hcl er (biphasic) oral tablet extended release 24 hour G 100 mg, 200 mg, 300 mg tramadol hcl er oral capsule extended release 24 hour 100 mg, NF 200 mg, 300 mg tramadol hcl er oral tablet extended release 24 hour 100 mg, 200 G mg, 300 mg tramadol hcl oral tablet 100 mg NF tramadol hcl oral tablet 50 mg G tramadol-acetaminophen oral tablet 37.5-325 mg G ULTRACET ORAL TABLET 37.5-325 MG (tramadol- NPB acetaminophen) ULTRAM ORAL TABLET 50 MG (tramadol hcl) NPB XTAMPZA ER ORAL CAPSULE ER 12 HOUR ABUSE- DETERRENT 13.5 MG, 18 MG, 27 MG, 36 MG, 9 MG PB (oxycodone) OPIOID PARTIAL AGONISTS BELBUCA BUCCAL FILM 150 MCG, 300 MCG, 450 MCG, 600 MCG, 75 MCG, 750 MCG, 900 MCG PB (buprenorphine hcl) buprenorphine hcl sublingual tablet sublingual 2 mg, 8 mg G

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 22 Prescription Drug Name Drug Tier Drug Notes BUTRANS TRANSDERMAL PATCH WEEKLY 10 MCG/HR, 15 MCG/HR, 20 MCG/HR, 5 MCG/HR, 7.5 NF MCG/HR (buprenorphine) SUBLOCADE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100 MG/0.5ML, 300 MG/1.5ML NPB (buprenorphine) SALICYLATES aspirin adult low dose oral tablet delayed release 81 mg CE aspirin ec low strength oral tablet delayed release 81 mg CE aspirin low dose oral tablet chewable 81 mg CE aspirin low dose oral tablet delayed release 81 mg CE aspirin oral tablet chewable 81 mg CE aspirin oral tablet delayed release 81 mg CE ASPIR-LOW ORAL TABLET DELAYED RELEASE 81 CE MG (aspirin) BAYER ASPIRIN EC LOW DOSE ORAL TABLET CE DELAYED RELEASE 81 MG (aspirin) BAYER LOW DOSE ORAL TABLET CHEWABLE 81 MG CE (aspirin) BAYER LOW DOSE ORAL TABLET DELAYED CE RELEASE 81 MG (aspirin) childrens aspirin oral tablet chewable 81 mg CE cvs aspirin low dose oral tablet delayed release 81 mg CE cvs aspirin low strength oral tablet delayed release 81 mg CE diflunisal oral tablet 500 mg G eql aspirin low dose oral tablet chewable 81 mg CE gnp adult aspirin low strength oral tablet chewable 81 mg CE gnp aspirin oral tablet delayed release 81 mg CE h-e-b aspirin oral tablet delayed release 81 mg CE hm aspirin oral tablet chewable 81 mg CE kls aspirin low dose oral tablet delayed release 81 mg CE kp aspirin oral tablet delayed release 81 mg CE px aspirin oral tablet chewable 81 mg CE px enteric aspirin oral tablet delayed release 81 mg CE qc childrens aspirin oral tablet chewable 81 mg CE ra aspirin adult low dose oral tablet chewable 81 mg CE

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 23 Prescription Drug Name Drug Tier Drug Notes ra aspirin childrens oral tablet chewable 81 mg CE ra aspirin ec adult low st oral tablet delayed release 81 mg CE salsalate oral tablet 500 mg, 750 mg G sb childrens aspirin oral tablet chewable 81 mg CE sm aspirin adult low strength oral tablet chewable 81 mg CE sm aspirin adult low strength oral tablet delayed release 81 mg CE sm childrens aspirin oral tablet chewable 81 mg CE ST JOSEPH LOW DOSE ORAL TABLET CHEWABLE 81 CE MG (aspirin) VISCOSUPPLEMENTS DUROLANE INTRA-ARTICULAR PREFILLED PSP SYRINGE 60 MG/3ML (sodium hyaluronate (viscosup)) EUFLEXXA INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 20 MG/2ML (sodium hyaluronate PSP (viscosup)) GEL-ONE INTRA-ARTICULAR PREFILLED SYRINGE NF 30 MG/3ML (cross-linked hyaluronate) GELSYN-3 INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 16.8 MG/2ML (sodium hyaluronate PSP (viscosup)) GENVISC 850 INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 25 MG/2.5ML (sodium hyaluronate NF (viscosup)) HYALGAN INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 20 MG/2ML (sodium hyaluronate NF (viscosup)) SUPARTZ FX INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE 25 MG/2.5ML (sodium hyaluronate PSP (viscosup)) TRIVISC INTRA-ARTICULAR SOLUTION PREFILLED NF SYRINGE 25 MG/2.5ML (sodium hyaluronate (viscosup)) VISCO-3 INTRA-ARTICULAR SOLUTION PREFILLED NF SYRINGE 25 MG/2.5ML (sodium hyaluronate (viscosup)) ANESTHETICS - DRUGS FOR NUMBING LOCAL ANESTHETICS - DRUGS FOR NUMBING bupivacaine hcl injection solution 0.125 % NPB lidocaine in dextrose solution 5-7.5 % NPB lidomark 2/5 injection kit 2 % NPB

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

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 26 Prescription Drug Name Drug Tier Drug Notes linezolid oral suspension reconstituted 100 mg/5ml G linezolid oral tablet 600 mg G MACRODANTIN ORAL CAPSULE 100 MG, 25 MG, 50 NF MG (nitrofurantoin macrocrystal) methenamine hippurate oral tablet 1 gm G methenamine mandelate oral tablet 0.5 gm, 1 gm G METRONIDAZOLE BENZO+SYRSPEND ORAL SUSPENSION RECONSTITUTED 50 MG/ML NF (metronidazole benzoate) metronidazole oral capsule 375 mg G metronidazole oral tablet 250 mg, 500 mg G NEBUPENT INHALATION SOLUTION NPB RECONSTITUTED 300 MG ( isethionate) nitrofurantoin macrocrystal oral capsule 100 mg, 25 mg, 50 mg G nitrofurantoin monohyd macro oral capsule 100 mg G nitrofurantoin oral suspension 25 mg/5ml NF praziquantel oral tablet 600 mg G PRIMSOL ORAL SOLUTION 50 MG/5ML (trimethoprim NPB hcl) RECARBRIO INTRAVENOUS SOLUTION RECONSTITUTED 1.25 GM (imipenem-cilastatin- NPB relebactam) SIVEXTRO ORAL TABLET 200 MG (tedizolid phosphate) NPB SOLOSEC ORAL PACKET 2 GM (secnidazole) NF sulfamethoxazole-trimethoprim oral suspension 200-40 mg/5ml G sulfamethoxazole-trimethoprim oral tablet 400-80 mg, 800-160 G mg sulfamethoxazole-trimethoprim (Sulfatrim Pediatric Oral G Suspension 200-40 Mg/5Ml) trimethoprim oral tablet 100 mg G vancomycin hcl intravenous solution 1250 mg/250ml, 1750 NPB mg/350ml, 500 mg/100ml, 750 mg/150ml vancomycin hcl intravenous solution reconstituted 750 mg NPB vancomycin hcl oral capsule 125 mg, 250 mg G VANCOMYCIN+SYRSPEND SF ORAL SUSPENSION 50 NF MG/ML (vancomycin hcl) XENLETA ORAL TABLET 600 MG (lefamulin acetate) NPB

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 27 Prescription Drug Name Drug Tier Drug Notes XIFAXAN ORAL TABLET 200 MG (rifaximin) NF XIFAXAN ORAL TABLET 550 MG (rifaximin) PB ZYVOX ORAL SUSPENSION RECONSTITUTED 100 NF MG/5ML (linezolid) ZYVOX ORAL TABLET 600 MG (linezolid) NF ANTIMALARIALS - DRUGS TO TREAT MALARIA ARAKODA ORAL TABLET 100 MG (tafenoquine NF succinate) atovaquone-proguanil hcl oral tablet 250-100 mg, 62.5-25 mg G chloroquine phosphate oral tablet 250 mg, 500 mg G COARTEM ORAL TABLET 20-120 MG (artemether- NPB lumefantrine) KRINTAFEL ORAL TABLET 150 MG (tafenoquine NF succinate) mefloquine hcl oral tablet 250 mg G primaquine phosphate oral tablet 26.3 (15 base) mg NPB quinine sulfate oral capsule 324 mg G ANTIRETROVIRAL AGENTS - DRUGS TO SUPPRESS HIV/AIDS abacavir sulfate oral solution 20 mg/ml G abacavir sulfate oral tablet 300 mg G APTIVUS ORAL CAPSULE 250 MG (tipranavir) NF atazanavir sulfate oral capsule 150 mg, 200 mg, 300 mg G CRIXIVAN ORAL CAPSULE 400 MG (indinavir sulfate) NPSP EDURANT ORAL TABLET 25 MG (rilpivirine hcl) PSP efavirenz oral capsule 200 mg, 50 mg G efavirenz oral tablet 600 mg G EMTRIVA ORAL CAPSULE 200 MG (emtricitabine) PSP EMTRIVA ORAL SOLUTION 10 MG/ML (emtricitabine) PSP fosamprenavir calcium oral tablet 700 mg G FUZEON SUBCUTANEOUS SOLUTION PSP RECONSTITUTED 90 MG (enfuvirtide) INTELENCE ORAL TABLET 100 MG, 200 MG, 25 MG PSP (etravirine) INVIRASE ORAL TABLET 500 MG (saquinavir mesylate) NF

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 28 Prescription Drug Name Drug Tier Drug Notes ISENTRESS HD ORAL TABLET 600 MG (raltegravir PSP potassium) ISENTRESS ORAL PACKET 100 MG (raltegravir PSP potassium) ISENTRESS ORAL TABLET 400 MG (raltegravir PSP potassium) ISENTRESS ORAL TABLET CHEWABLE 100 MG, 25 PSP MG (raltegravir potassium) lamivudine oral solution 10 mg/ml G lamivudine oral tablet 150 mg, 300 mg G LEXIVA ORAL SUSPENSION 50 MG/ML (fosamprenavir NF calcium) LEXIVA ORAL TABLET 700 MG (fosamprenavir calcium) NF nevirapine er oral tablet extended release 24 hour 100 mg, 400 G mg nevirapine oral suspension 50 mg/5ml G nevirapine oral tablet 200 mg G NORVIR ORAL PACKET 100 MG (ritonavir) PSP NORVIR ORAL SOLUTION 80 MG/ML (ritonavir) PSP PIFELTRO ORAL TABLET 100 MG (doravirine) NF PREZISTA ORAL SUSPENSION 100 MG/ML (darunavir PSP ethanolate) PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 PSP MG (darunavir ethanolate) REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG NPSP (atazanavir sulfate) REYATAZ ORAL PACKET 50 MG (atazanavir sulfate) NPSP ritonavir oral tablet 100 mg G SELZENTRY ORAL SOLUTION 20 MG/ML (maraviroc) NPSP SELZENTRY ORAL TABLET 150 MG, 25 MG, 300 MG, NPSP 75 MG (maraviroc) stavudine oral capsule 15 mg, 20 mg, 30 mg, 40 mg G tenofovir disoproxil fumarate oral tablet 300 mg G TIVICAY ORAL TABLET 10 MG, 25 MG, 50 MG PSP (dolutegravir sodium) TIVICAY PD ORAL TABLET SOLUBLE 5 MG PSP (dolutegravir sodium)

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 29 Prescription Drug Name Drug Tier Drug Notes TYBOST ORAL TABLET 150 MG (cobicistat) NPSP VIRACEPT ORAL TABLET 250 MG, 625 MG (nelfinavir NF mesylate) VIREAD ORAL POWDER 40 MG/GM (tenofovir disoproxil NPSP fumarate) VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG, 300 NPSP MG (tenofovir disoproxil fumarate) zidovudine oral capsule 100 mg G zidovudine oral syrup 50 mg/5ml G zidovudine oral tablet 300 mg G ANTIRETROVIRAL COMBINATION AGENTS - DRUGS TO SUPPRESS HIV/AIDS INFECTION abacavir sulfate-lamivudine oral tablet 600-300 mg G abacavir-lamivudine-zidovudine oral tablet 300-150-300 mg G ATRIPLA ORAL TABLET 600-200-300 MG (efavirenz- NPSP emtricitab-tenofovir) BIKTARVY ORAL TABLET 50-200-25 MG (bictegravir- PSP emtricitab-tenofov) CIMDUO ORAL TABLET 300-300 MG (lamivudine- PSP tenofovir) COMPLERA ORAL TABLET 200-25-300 MG (emtricitab- NF rilpivir-tenofovir) DELSTRIGO ORAL TABLET 100-300-300 MG (doravirin- NF lamivudin-tenofov df) DESCOVY ORAL TABLET 200-25 MG (emtricitabine- PSP tenofovir af) DOVATO ORAL TABLET 50-300 MG (dolutegravir- PSP lamivudine) EVOTAZ ORAL TABLET 300-150 MG (atazanavir- PSP cobicistat) GENVOYA ORAL TABLET 150-150-200-10 MG (elviteg- PSP cobic-emtricit-tenofaf) JULUCA ORAL TABLET 50-25 MG (dolutegravir- NPSP rilpivirine) KALETRA ORAL TABLET 100-25 MG, 200-50 MG NPSP (lopinavir-ritonavir) lamivudine-zidovudine oral tablet 150-300 mg G lopinavir-ritonavir oral solution 400-100 mg/5ml G

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 30 Prescription Drug Name Drug Tier Drug Notes ODEFSEY ORAL TABLET 200-25-25 MG (emtricitab- PSP rilpivir-tenofov af) PREZCOBIX ORAL TABLET 800-150 MG (darunavir- PSP cobicistat) STRIBILD ORAL TABLET 150-150-200-300 MG (elviteg- NF cobic-emtricit-tenofdf) SYMFI LO ORAL TABLET 400-300-300 MG (efavirenz- NPSP lamivudine-tenofovir) SYMFI ORAL TABLET 600-300-300 MG (efavirenz- NPSP lamivudine-tenofovir) SYMTUZA ORAL TABLET 800-150-200-10 MG (darun- PSP cobic-emtricit-tenofaf) TEMIXYS ORAL TABLET 300-300 MG (lamivudine- PSP tenofovir) TRIUMEQ ORAL TABLET 600-50-300 MG (abacavir- PSP dolutegravir-lamivud) TRUVADA ORAL TABLET 100-150 MG, 133-200 MG, PSP 167-250 MG, 200-300 MG (emtricitabine-tenofovir df) ANTITUBERCULAR AGENTS - DRUGS TO TREAT TUBERCULOSIS cycloserine oral capsule 250 mg G ethambutol hcl oral tablet 100 mg, 400 mg G isoniazid oral syrup 50 mg/5ml G isoniazid oral tablet 100 mg, 300 mg G PASER ORAL PACKET 4 GM (aminosalicylic acid) NPB pretomanid oral tablet 200 mg NPB PRIFTIN ORAL TABLET 150 MG (rifapentine) NPB pyrazinamide oral tablet 500 mg G rifabutin oral capsule 150 mg G rifampin oral capsule 150 mg, 300 mg G SIRTURO ORAL TABLET 100 MG, 20 MG (bedaquiline NPB fumarate) TRECATOR ORAL TABLET 250 MG (ethionamide) NPB ANTIVIRALS - DRUGS TO TREAT VIRAL INFECTIONS acyclovir oral capsule 200 mg G acyclovir oral suspension 200 mg/5ml G acyclovir oral tablet 400 mg, 800 mg G

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 31 Prescription Drug Name Drug Tier Drug Notes adefovir dipivoxil oral tablet 10 mg G BARACLUDE ORAL SOLUTION 0.05 MG/ML (entecavir) PSP casirivimab intravenous solution 1332 mg/11.1ml, 300 mg/2.5ml NPB diclofenac sodium external gel 3 % G entecavir oral tablet 0.5 mg, 1 mg G famciclovir oral tablet 125 mg, 250 mg, 500 mg G favipiravir oral tablet 200 mg NPB imdevimab intravenous solution 1332 mg/11.1ml, 300 mg/2.5ml NPB lamivudine oral tablet 100 mg G oseltamivir phosphate oral capsule 30 mg, 45 mg, 75 mg G oseltamivir phosphate oral suspension reconstituted 6 mg/ml G PREVYMIS ORAL TABLET 240 MG, 480 MG (letermovir) NPB RELENZA DISKHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 5 MG/BLISTER PB (zanamivir) ribavirin inhalation solution reconstituted 6 gm G rimantadine hcl oral tablet 100 mg G SITAVIG BUCCAL TABLET 50 MG (acyclovir) NPB SYNAGIS INTRAMUSCULAR SOLUTION 100 MG/ML, NPSP 50 MG/0.5ML (palivizumab) valacyclovir hcl oral tablet 1 gm, 500 mg G VALCYTE ORAL SOLUTION RECONSTITUTED 50 NF MG/ML (valganciclovir hcl) VALCYTE ORAL TABLET 450 MG (valganciclovir hcl) NF valganciclovir hcl oral solution reconstituted 50 mg/ml G valganciclovir hcl oral tablet 450 mg G VALTREX ORAL TABLET 1 GM, 500 MG (valacyclovir NF hcl) VEMLIDY ORAL TABLET 25 MG (tenofovir alafenamide PSP fumarate) XERESE EXTERNAL CREAM 5-1 % (acyclovir- NF hydrocortisone) XOFLUZA (40 MG DOSE) ORAL TABLET THERAPY NF PACK 1 X 40 MG, 2 X 20 MG (baloxavir marboxil) XOFLUZA (80 MG DOSE) ORAL TABLET THERAPY NF PACK 1 X 80 MG, 2 X 40 MG (baloxavir marboxil) ZOVIRAX ORAL SUSPENSION 200 MG/5ML (acyclovir) NF 2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 32 Prescription Drug Name Drug Tier Drug Notes CEPHALOSPORINS - DRUGS TO TREAT INFECTIONS cefaclor er oral tablet extended release 12 hour 500 mg NPB cefaclor oral capsule 250 mg, 500 mg G cefaclor oral suspension reconstituted 125 mg/5ml, 250 mg/5ml, G 375 mg/5ml cefadroxil oral capsule 500 mg G cefadroxil oral suspension reconstituted 250 mg/5ml, 500 G mg/5ml cefadroxil oral tablet 1 gm G cefdinir oral capsule 300 mg G cefdinir oral suspension reconstituted 125 mg/5ml, 250 mg/5ml G cefixime oral capsule 400 mg G cefixime oral suspension reconstituted 100 mg/5ml, 200 mg/5ml G cefpodoxime proxetil oral suspension reconstituted 100 mg/5ml, G 50 mg/5ml cefpodoxime proxetil oral tablet 100 mg, 200 mg G cefprozil oral suspension reconstituted 125 mg/5ml, 250 mg/5ml G cefprozil oral tablet 250 mg, 500 mg G cefuroxime axetil oral tablet 250 mg, 500 mg G cephalexin oral capsule 250 mg, 500 mg, 750 mg G cephalexin oral suspension reconstituted 125 mg/5ml, 250 G mg/5ml cephalexin oral tablet 250 mg, 500 mg G FORTAZ INJECTION SOLUTION RECONSTITUTED 1 NPB GM, 500 MG (ceftazidime) FORTAZ INTRAVENOUS SOLUTION NPB RECONSTITUTED 2 GM (ceftazidime) SUPRAX ORAL SUSPENSION RECONSTITUTED 500 PB MG/5ML (cefixime) SUPRAX ORAL TABLET CHEWABLE 100 MG, 200 MG PB (cefixime) ERYTHROMYCINS/MACROLIDES - DRUGS TO TREAT INFECTIONS azithromycin oral packet 1 gm G azithromycin oral suspension reconstituted 100 mg/5ml, 200 G mg/5ml azithromycin oral tablet 250 mg, 500 mg, 600 mg G

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 33 Prescription Drug Name Drug Tier Drug Notes clarithromycin er oral tablet extended release 24 hour 500 mg G clarithromycin oral suspension reconstituted 125 mg/5ml, 250 G mg/5ml clarithromycin oral tablet 250 mg, 500 mg G DIFICID ORAL SUSPENSION RECONSTITUTED 40 PB MG/ML (fidaxomicin) DIFICID ORAL TABLET 200 MG (fidaxomicin) PB E.E.S. 400 ORAL TABLET 400 MG (erythromycin G ethylsuccinate) E.E.S. GRANULES ORAL SUSPENSION RECONSTITUTED 200 MG/5ML (erythromycin NF ethylsuccinate) ERYPED 200 ORAL SUSPENSION RECONSTITUTED NF 200 MG/5ML (erythromycin ethylsuccinate) ERYPED 400 ORAL SUSPENSION RECONSTITUTED NF 400 MG/5ML (erythromycin ethylsuccinate) erythromycin base (Ery-Tab Oral Tablet Delayed Release 250 G Mg, 333 Mg, 500 Mg) ERYTHROCIN STEARATE ORAL TABLET 250 MG G (erythromycin stearate) erythromycin base oral capsule delayed release particles 250 mg G erythromycin base oral tablet 250 mg, 500 mg G erythromycin ethylsuccinate oral suspension reconstituted 200 G mg/5ml, 400 mg/5ml erythromycin ethylsuccinate oral tablet 400 mg G erythromycin oral tablet delayed release 250 mg, 333 mg, 500 G mg FLUOROQUINOLONES - DRUGS TO TREAT INFECTIONS BAXDELA ORAL TABLET 450 MG (delafloxacin NPB meglumine) CIPRO ORAL SUSPENSION RECONSTITUTED 250 NPB MG/5ML (5%) (ciprofloxacin) ciprofloxacin hcl oral tablet 100 mg, 250 mg, 500 mg, 750 mg G levofloxacin oral solution 25 mg/ml G levofloxacin oral tablet 250 mg, 500 mg, 750 mg G moxifloxacin hcl oral tablet 400 mg G ofloxacin oral tablet 300 mg, 400 mg G

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 34 Prescription Drug Name Drug Tier Drug Notes HEPATITIS C EPCLUSA ORAL TABLET 200-50 MG, 400-100 MG IBC (Preferred for all PSP (sofosbuvir-velpatasvir) genotypes) HARVONI ORAL PACKET 33.75-150 MG, 45-200 MG PSP (ledipasvir-sofosbuvir) HARVONI ORAL TABLET 45-200 MG, 90-400 MG IBC (Preferred for PSP (ledipasvir-sofosbuvir) genotypes 1,4,5,6) ribavirin oral capsule 200 mg G ribavirin oral tablet 200 mg G SOVALDI ORAL PACKET 150 MG, 200 MG (sofosbuvir) NPSP SOVALDI ORAL TABLET 200 MG, 400 MG (sofosbuvir) NPSP VOSEVI ORAL TABLET 400-100-100 MG (sofosbuv- IBC (Preferred for all PSP velpatasv-voxilaprev) genotypes) PENICILLINS - DRUGS TO TREAT INFECTIONS amoxicillin oral capsule 250 mg, 500 mg G amoxicillin oral suspension reconstituted 125 mg/5ml, 200 G mg/5ml, 250 mg/5ml, 400 mg/5ml amoxicillin oral tablet 500 mg, 875 mg G amoxicillin oral tablet chewable 125 mg, 250 mg G amoxicillin-pot clavulanate er oral tablet extended release 12 G hour 1000-62.5 mg amoxicillin-pot clavulanate oral suspension reconstituted 200- 28.5 mg/5ml, 250-62.5 mg/5ml, 400-57 mg/5ml, 600-42.9 G mg/5ml amoxicillin-pot clavulanate oral tablet 250-125 mg, 500-125 mg, G 875-125 mg amoxicillin-pot clavulanate oral tablet chewable 200-28.5 mg, G 400-57 mg ampicillin oral capsule 500 mg G ampicillin-sulbactam sodium intravenous solution reconstituted NPB 1.5 (1-0.5) gm, 3 (2-1) gm AUGMENTIN ORAL SUSPENSION RECONSTITUTED NPB 125-31.25 MG/5ML (amoxicillin-pot clavulanate) dicloxacillin sodium oral capsule 250 mg, 500 mg G penicillin v potassium oral solution reconstituted 125 mg/5ml, G 250 mg/5ml penicillin v potassium oral tablet 250 mg, 500 mg G

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 35 Prescription Drug Name Drug Tier Drug Notes PFIZERPEN INJECTION SOLUTION RECONSTITUTED 20000000 UNIT, 5000000 UNIT NF (penicillin g potassium) TETRACYCLINES - DRUGS TO TREAT INFECTIONS ACTICLATE ORAL TABLET 150 MG, 75 MG (doxycycline NF hyclate) avidoxy oral tablet 100 mg G minocycline hcl (Coremino Oral Tablet Extended Release 24 NF Hour 135 Mg, 45 Mg, 90 Mg) demeclocycline hcl oral tablet 150 mg, 300 mg G DORYX MPC ORAL TABLET DELAYED RELEASE 120 NF MG (doxycycline hyclate) DORYX ORAL TABLET DELAYED RELEASE 200 MG, NF 50 MG, 80 MG (doxycycline hyclate) doxycycline hyclate oral capsule 100 mg, 50 mg G doxycycline hyclate oral tablet 100 mg, 20 mg G doxycycline hyclate oral tablet 150 mg, 50 mg, 75 mg NF doxycycline hyclate oral tablet delayed release 100 mg, 150 mg, G 75 mg doxycycline hyclate oral tablet delayed release 200 mg, 50 mg NF doxycycline monohydrate oral capsule 100 mg, 50 mg G doxycycline monohydrate oral capsule 150 mg, 75 mg NF doxycycline monohydrate oral suspension reconstituted 25 G mg/5ml doxycycline monohydrate oral tablet 100 mg, 150 mg, 50 mg, 75 G mg MINOCIN ORAL CAPSULE 100 MG (minocycline hcl) NF minocycline hcl er oral capsule extended release 24 hour 135 mg, NF 45 mg, 90 mg minocycline hcl er oral tablet extended release 24 hour 105 mg, NF 115 mg, 135 mg, 45 mg, 55 mg, 65 mg, 80 mg, 90 mg minocycline hcl oral capsule 100 mg, 50 mg, 75 mg G minocycline hcl oral tablet 100 mg, 50 mg, 75 mg G MINOLIRA ORAL TABLET EXTENDED RELEASE 24 NF HOUR 105 MG, 135 MG (minocycline hcl) doxycycline monohydrate (Mondoxyne Nl Oral Capsule 100 G Mg)

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 36 Prescription Drug Name Drug Tier Drug Notes doxycycline monohydrate (Mondoxyne Nl Oral Capsule 75 NF Mg) doxycycline hyclate (Morgidox Oral Capsule 100 Mg) G NUZYRA ORAL TABLET 150 MG (omadacycline tosylate) NPB SEYSARA ORAL TABLET 100 MG, 150 MG, 60 MG NF (sarecycline hcl) SOLODYN ORAL TABLET EXTENDED RELEASE 24 HOUR 105 MG, 115 MG, 55 MG, 65 MG, 80 MG NF (minocycline hcl) doxycycline hyclate (Targadox Oral Tablet 50 Mg) NF tetracycline hcl oral capsule 250 mg, 500 mg G VIBRAMYCIN ORAL SYRUP 50 MG/5ML (doxycycline NPB calcium) XIMINO ORAL CAPSULE EXTENDED RELEASE 24 NF HOUR 135 MG, 45 MG, 90 MG (minocycline hcl) ANTINEOPLASTIC AGENTS - DRUGS TO TREAT CANCER ALKYLATING AGENTS - CHEMOTHERAPY DRUGS BELRAPZO INTRAVENOUS SOLUTION 100 MG/4ML NF (bendamustine hcl) cyclophosphamide intravenous solution 1 gm/5ml, 500 mg/2.5ml NPB cyclophosphamide oral capsule 25 mg, 50 mg G cyclophosphamide oral tablet 25 mg, 50 mg NPB EMCYT ORAL CAPSULE 140 MG (estramustine phosphate NPB sodium) EVOMELA INTRAVENOUS SOLUTION NF RECONSTITUTED 50 MG (melphalan hcl) GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG NPB (lomustine) GLIADEL WAFER IMPLANT WAFER 7.7 MG NPB (carmustine in polifeprosan) LEUKERAN ORAL TABLET 2 MG (chlorambucil) PB melphalan oral tablet 2 mg G MYLERAN ORAL TABLET 2 MG (busulfan) PB oxaliplatin intravenous solution 200 mg/40ml NPB PARAPLATIN INTRAVENOUS SOLUTION 1000 G MG/100ML (carboplatin)

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 37 Prescription Drug Name Drug Tier Drug Notes TEMODAR INTRAVENOUS SOLUTION NPSP RECONSTITUTED 100 MG (temozolomide) TEMODAR ORAL CAPSULE 100 MG, 140 MG, 180 MG, NPSP 250 MG (temozolomide) temozolomide oral capsule 100 mg, 140 mg, 180 mg, 20 mg, 250 G mg, 5 mg TREANDA INTRAVENOUS SOLUTION NPSP RECONSTITUTED 100 MG, 25 MG (bendamustine hcl) ANTIMETABOLITES - CHEMOTHERAPY DRUGS capecitabine oral tablet 150 mg, 500 mg G INFUGEM INTRAVENOUS SOLUTION 1200-0.9 MG/120ML-%, 1300-0.9 MG/130ML-%, 1400-0.9 MG/140ML-%, 1500-0.9 MG/150ML-%, 1600-0.9 NF MG/160ML-%, 1700-0.9 MG/170ML-%, 1800-0.9 MG/180ML-%, 1900-0.9 MG/190ML-%, 2000-0.9 MG/200ML-%, 2200-0.9 MG/220ML-% (gemcitabine hcl-nacl) mercaptopurine oral tablet 50 mg G methotrexate sodium (pf) injection solution 1 gm/40ml, 250 G mg/10ml, 50 mg/2ml methotrexate sodium injection solution 250 mg/10ml, 50 mg/2ml G methotrexate sodium injection solution reconstituted 1 gm G methotrexate sodium oral tablet 2.5 mg G PURIXAN ORAL SUSPENSION 2000 MG/100ML NPSP (mercaptopurine) TABLOID ORAL TABLET 40 MG (thioguanine) PB TREXALL ORAL TABLET 10 MG, 15 MG, 5 MG, 7.5 MG PB (methotrexate sodium) XATMEP ORAL SOLUTION 2.5 MG/ML (methotrexate) NPB XELODA ORAL TABLET 150 MG, 500 MG (capecitabine) NPSP BIOLOGIC RESPONSE MODIFIERS AVASTIN INTRAVENOUS SOLUTION 100 MG/4ML, NF 400 MG/16ML (bevacizumab) DAURISMO ORAL TABLET 100 MG, 25 MG (glasdegib NF maleate) ERIVEDGE ORAL CAPSULE 150 MG (vismodegib) PSP FARYDAK ORAL CAPSULE 10 MG, 15 MG, 20 MG NF (panobinostat lactate)

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 38 Prescription Drug Name Drug Tier Drug Notes HERCEPTIN INTRAVENOUS SOLUTION NF RECONSTITUTED 150 MG (trastuzumab) IBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG PSP (palbociclib) IBRANCE ORAL TABLET 100 MG, 125 MG, 75 MG PSP (palbociclib) KANJINTI INTRAVENOUS SOLUTION PSP RECONSTITUTED 150 MG, 420 MG (trastuzumab-anns) KISQALI (200 MG DOSE) ORAL TABLET THERAPY PSP PACK 200 MG (ribociclib succinate) KISQALI (400 MG DOSE) ORAL TABLET THERAPY PSP PACK 200 MG (ribociclib succinate) KISQALI (600 MG DOSE) ORAL TABLET THERAPY PSP PACK 200 MG (ribociclib succinate) KISQALI FEMARA (400 MG DOSE) ORAL TABLET PSP THERAPY PACK 200 & 2.5 MG (ribociclib-letrozole) KISQALI FEMARA (600 MG DOSE) ORAL TABLET PSP THERAPY PACK 200 & 2.5 MG (ribociclib-letrozole) KISQALI FEMARA(200 MG DOSE) ORAL TABLET PSP THERAPY PACK 200 & 2.5 MG (ribociclib-letrozole) LYNPARZA ORAL TABLET 100 MG, 150 MG (olaparib) PSP PERJETA INTRAVENOUS SOLUTION 420 MG/14ML PSP (pertuzumab) POLIVY INTRAVENOUS SOLUTION RECONSTITUTED 140 MG, 30 MG (polatuzumab vedotin- NF piiq) PORTRAZZA INTRAVENOUS SOLUTION 800 NPB MG/50ML (necitumumab) RIABNI INTRAVENOUS SOLUTION 100 MG/10ML, 500 NF MG/50ML (rituximab-arrx) RITUXAN INTRAVENOUS SOLUTION 100 MG/10ML, NF 500 MG/50ML (rituximab) romidepsin intravenous solution 27.5 mg/5.5ml NPSP RUBRACA ORAL TABLET 200 MG, 250 MG, 300 MG PSP (rucaparib camsylate) RUXIENCE INTRAVENOUS SOLUTION 100 MG/10ML, PSP 500 MG/50ML (rituximab-pvvr) RYDAPT ORAL CAPSULE 25 MG (midostaurin) PSP

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 39 Prescription Drug Name Drug Tier Drug Notes SARCLISA INTRAVENOUS SOLUTION 100 MG/5ML, NPSP 500 MG/25ML (isatuximab-irfc) TALZENNA ORAL CAPSULE 0.25 MG, 1 MG (talazoparib NF tosylate) TRAZIMERA INTRAVENOUS SOLUTION PSP RECONSTITUTED 150 MG, 420 MG (trastuzumab-qyyp) TRODELVY INTRAVENOUS SOLUTION NPB RECONSTITUTED 180 MG (sacituzumab govitecan-hziy) TRUXIMA INTRAVENOUS SOLUTION 100 MG/10ML, NF 500 MG/50ML (rituximab-abbs) VERZENIO ORAL TABLET 100 MG, 150 MG, 200 MG, 50 NPSP MG (abemaciclib) ZEJULA ORAL CAPSULE 100 MG (niraparib tosylate) PSP ZOLINZA ORAL CAPSULE 100 MG (vorinostat) PSP HORMONAL ANTINEOPLASTIC AGENTS abiraterone acetate oral tablet 250 mg G anastrozole oral tablet 1 mg CE bicalutamide oral tablet 50 mg G ELIGARD SUBCUTANEOUS KIT 30 MG (leuprolide PSP acetate (4 month)) ERLEADA ORAL TABLET 60 MG (apalutamide) PSP exemestane oral tablet 25 mg CE FASLODEX INTRAMUSCULAR SOLUTION 250 NPB MG/5ML (fulvestrant) FIRMAGON (240 MG DOSE) SUBCUTANEOUS SOLUTION RECONSTITUTED 120 MG/VIAL (degarelix PSP acetate) FIRMAGON SUBCUTANEOUS SOLUTION PSP RECONSTITUTED 80 MG (degarelix acetate) flutamide oral capsule 125 mg G letrozole oral tablet 2.5 mg G leuprolide acetate injection kit 1 mg/0.2ml G LUPRON DEPOT (1-MONTH) INTRAMUSCULAR KIT NF 3.75 MG, 7.5 MG (leuprolide acetate) LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT NF 11.25 MG, 22.5 MG (leuprolide acetate (3 month)) LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT NF 30 MG (leuprolide acetate (4 month))

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

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 41 Prescription Drug Name Drug Tier Drug Notes ALUNBRIG ORAL TABLET THERAPY PACK 90 & 180 PSP MG (brigatinib) BALVERSA ORAL TABLET 3 MG, 4 MG, 5 MG NPB (erdafitinib) BOSULIF ORAL TABLET 100 MG, 400 MG, 500 MG PSP (bosutinib) BRUKINSA ORAL CAPSULE 80 MG (zanubrutinib) NPB CABOMETYX ORAL TABLET 20 MG, 40 MG, 60 MG PSP (cabozantinib s-malate) CALQUENCE ORAL CAPSULE 100 MG (acalabrutinib) NPB CAPRELSA ORAL TABLET 100 MG, 300 MG (vandetanib) NPB COMETRIQ (100 MG DAILY DOSE) ORAL KIT 80 & 20 NPSP MG (cabozantinib s-malate) COMETRIQ (140 MG DAILY DOSE) ORAL KIT 3 X 20 NPSP MG & 80 MG (cabozantinib s-malate) COMETRIQ (60 MG DAILY DOSE) ORAL KIT 20 MG NPSP (cabozantinib s-malate) COPIKTRA ORAL CAPSULE 15 MG, 25 MG (duvelisib) PSP COTELLIC ORAL TABLET 20 MG (cobimetinib fumarate) NPSP erlotinib hcl oral tablet 100 mg, 150 mg, 25 mg G ICLUSIG ORAL TABLET 10 MG, 15 MG, 30 MG, 45 MG NPB (ponatinib hcl) IDHIFA ORAL TABLET 100 MG, 50 MG (enasidenib NPSP mesylate) imatinib mesylate oral tablet 100 mg, 400 mg G IMBRUVICA ORAL CAPSULE 140 MG, 70 MG (ibrutinib) NPB IMBRUVICA ORAL TABLET 140 MG, 280 MG, 420 MG, NPB 560 MG (ibrutinib) INLYTA ORAL TABLET 1 MG, 5 MG (axitinib) NPSP INREBIC ORAL CAPSULE 100 MG (fedratinib hcl) NF IRESSA ORAL TABLET 250 MG (gefitinib) PSP JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 NPSP MG (ruxolitinib phosphate) KOSELUGO ORAL CAPSULE 10 MG, 25 MG (selumetinib NPB sulfate) LENVIMA (10 MG DAILY DOSE) ORAL CAPSULE NPSP THERAPY PACK 10 MG (lenvatinib mesylate)

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 42 Prescription Drug Name Drug Tier Drug Notes LENVIMA (12 MG DAILY DOSE) ORAL CAPSULE NPSP THERAPY PACK 3 X 4 MG (lenvatinib mesylate) LENVIMA (14 MG DAILY DOSE) ORAL CAPSULE NPSP THERAPY PACK 10 & 4 MG (lenvatinib mesylate) LENVIMA (18 MG DAILY DOSE) ORAL CAPSULE NPSP THERAPY PACK 10 MG & 2 X 4 MG (lenvatinib mesylate) LENVIMA (20 MG DAILY DOSE) ORAL CAPSULE NPSP THERAPY PACK 2 X 10 MG (lenvatinib mesylate) LENVIMA (24 MG DAILY DOSE) ORAL CAPSULE NPSP THERAPY PACK 2 X 10 MG & 4 MG (lenvatinib mesylate) LENVIMA (4 MG DAILY DOSE) ORAL CAPSULE NPSP THERAPY PACK 4 MG (lenvatinib mesylate) LENVIMA (8 MG DAILY DOSE) ORAL CAPSULE NPSP THERAPY PACK 2 X 4 MG (lenvatinib mesylate) LORBRENA ORAL TABLET 100 MG, 25 MG (lorlatinib) NPSP LUMAKRAS ORAL TABLET 120 MG (sotorasib) NPSP MEKINIST ORAL TABLET 0.5 MG, 2 MG (trametinib NPSP dimethyl sulfoxide) NERLYNX ORAL TABLET 40 MG (neratinib maleate) NPSP NEXAVAR ORAL TABLET 200 MG (sorafenib tosylate) NPSP PIQRAY (200 MG DAILY DOSE) ORAL TABLET NPSP THERAPY PACK 200 MG (alpelisib) PIQRAY (250 MG DAILY DOSE) ORAL TABLET NPSP THERAPY PACK 200 & 50 MG (alpelisib) PIQRAY (300 MG DAILY DOSE) ORAL TABLET NPSP THERAPY PACK 2 X 150 MG (alpelisib) ROZLYTREK ORAL CAPSULE 100 MG, 200 MG NPSP (entrectinib) SPRYCEL ORAL TABLET 100 MG, 140 MG, 20 MG, 50 PSP MG, 70 MG, 80 MG (dasatinib) STIVARGA ORAL TABLET 40 MG (regorafenib) PSP SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 PSP MG (sunitinib malate) TAFINLAR ORAL CAPSULE 50 MG, 75 MG (dabrafenib NPSP mesylate) TAGRISSO ORAL TABLET 40 MG, 80 MG (osimertinib NPSP mesylate) TARCEVA ORAL TABLET 100 MG, 150 MG, 25 MG NPSP (erlotinib hcl) 2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 43 Prescription Drug Name Drug Tier Drug Notes TUKYSA ORAL TABLET 150 MG, 50 MG (tucatinib) NPB TURALIO ORAL CAPSULE 200 MG (pexidartinib hcl) NF TYKERB ORAL TABLET 250 MG (lapatinib ditosylate) NPSP VITRAKVI ORAL CAPSULE 100 MG, 25 MG (larotrectinib NPSP sulfate) VITRAKVI ORAL SOLUTION 20 MG/ML (larotrectinib NPSP sulfate) VIZIMPRO ORAL TABLET 15 MG, 30 MG, 45 MG NF (dacomitinib) VOTRIENT ORAL TABLET 200 MG (pazopanib hcl) PSP XALKORI ORAL CAPSULE 200 MG, 250 MG (crizotinib) NPSP XOSPATA ORAL TABLET 40 MG (gilteritinib fumarate) PSP ZELBORAF ORAL TABLET 240 MG (vemurafenib) NPSP ZIRABEV INTRAVENOUS SOLUTION 100 MG/4ML, 400 PSP MG/16ML (bevacizumab-bvzr) ZYDELIG ORAL TABLET 100 MG, 150 MG (idelalisib) NF ZYKADIA ORAL TABLET 150 MG (ceritinib) NPSP MISCELLANEOUS ASPARLAS INTRAVENOUS SOLUTION 3750 NPB UNIT/5ML (calaspargase pegol-mknl) bexarotene oral capsule 75 mg G BRAFTOVI ORAL CAPSULE 75 MG (encorafenib) NPB DROXIA ORAL CAPSULE 200 MG, 300 MG, 400 MG NPB (hydroxyurea) ERWINAZE INJECTION SOLUTION RECONSTITUTED NPB 10000 UNIT (asparaginase erwinia chrysanth) GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG NPB (afatinib dimaleate) HERCEPTIN HYLECTA SUBCUTANEOUS SOLUTION NF 600-10000 MG-UNT/5ML (trastuzumab-hyaluronidase-oysk) hydroxyurea oral capsule 500 mg G INGREZZA ORAL CAPSULE 60 MG (valbenazine tosylate) PSP LONSURF ORAL TABLET 15-6.14 MG, 20-8.19 MG PSP (trifluridine-tipiracil) MATULANE ORAL CAPSULE 50 MG (procarbazine hcl) PB MEKTOVI ORAL TABLET 15 MG (binimetinib) NPB ODOMZO ORAL CAPSULE 200 MG (sonidegib phosphate) PSP

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 44 Prescription Drug Name Drug Tier Drug Notes PHESGO SUBCUTANEOUS SOLUTION 60-60-2000 MG- MG-U/ML, 80-40-2000 MG-MG-U/ML (pertuz-trastuz- PSP hyaluron-zzxf) SYNRIBO SUBCUTANEOUS SOLUTION NPB RECONSTITUTED 3.5 MG (omacetaxine mepesuccinate) TARGRETIN ORAL CAPSULE 75 MG (bexarotene) NPSP TIBSOVO ORAL TABLET 250 MG (ivosidenib) NPB TICE BCG INTRAVESICAL SUSPENSION NPB RECONSTITUTED 50 MG (bcg live) tretinoin oral capsule 10 mg G UVADEX INJECTION SOLUTION 20 MCG/ML NPB (methoxsalen (photopheresis)) VISTOGARD ORAL PACKET 10 GM (uridine triacetate) PB XOFIGO INTRAVENOUS SOLUTION 30 MCCI/ML NF (radium ra 223 dichloride) XPOVIO (60 MG TWICE WEEKLY) ORAL TABLET NF THERAPY PACK 20 MG (selinexor) XPOVIO (80 MG TWICE WEEKLY) ORAL TABLET NF THERAPY PACK 20 MG (selinexor) PROTEASOME INHIBITORS bortezomib intravenous solution reconstituted 3.5 mg NF KYPROLIS INTRAVENOUS SOLUTION NF RECONSTITUTED 10 MG, 30 MG, 60 MG (carfilzomib) NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 MG PSP (ixazomib citrate) VELCADE INJECTION SOLUTION RECONSTITUTED PSP 3.5 MG (bortezomib) PROTECTIVE AGENTS KHAPZORY INTRAVENOUS SOLUTION NF RECONSTITUTED 175 MG, 300 MG (levoleucovorin) leucovorin calcium oral tablet 10 mg, 15 mg, 25 mg, 5 mg G MESNEX ORAL TABLET 400 MG (mesna) NPB TOPOISOMERASE INHIBITORS etoposide oral capsule 50 mg G HYCAMTIN ORAL CAPSULE 0.25 MG, 1 MG (topotecan NPSP hcl)

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 45 Prescription Drug Name Drug Tier Drug Notes ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES ANTINEOPLASTIC, BCL-2 INHIBITORS VENCLEXTA ORAL TABLET 10 MG, 100 MG, 50 MG NPB (venetoclax) VENCLEXTA STARTING PACK ORAL TABLET NPB THERAPY PACK 10 & 50 & 100 MG (venetoclax) CARDIOVASCULAR - DRUGS TO TREAT HEART AND CIRCULATION CONDITIONS ACE INHIBITOR COMBINATIONS - DRUGS TO TREAT HIGH BLOOD PRESSURE amlodipine besy-benazepril hcl oral capsule 10-20 mg, 10-40 mg, G LGC 2.5-10 mg, 5-10 mg, 5-20 mg, 5-40 mg benazepril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 G LGC mg, 20-25 mg, 5-6.25 mg enalapril-hydrochlorothiazide oral tablet 10-25 mg, 5-12.5 mg G LGC fosinopril sodium-hctz oral tablet 10-12.5 mg, 20-12.5 mg G LGC lisinopril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 G LGC mg, 20-25 mg PRESTALIA ORAL TABLET 14-10 MG, 3.5-2.5 MG, 7-5 NF MG (perindopril arg-amlodipine) quinapril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 G LGC mg, 20-25 mg trandolapril-verapamil hcl er oral tablet extended release 1-240 G mg, 2-180 mg, 2-240 mg, 4-240 mg ZESTORETIC ORAL TABLET 10-12.5 MG, 20-12.5 MG, NF 20-25 MG (lisinopril-hydrochlorothiazide) ACE INHIBITORS - DRUGS TO TREAT HIGH BLOOD PRESSURE benazepril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg G LGC captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg G LGC enalapril maleate oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg G LGC EPANED ORAL SOLUTION 1 MG/ML (enalapril maleate) NPB fosinopril sodium oral tablet 10 mg, 20 mg, 40 mg G LGC lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg G LGC lisinopril oral tablet 30 mg, 40 mg G moexipril hcl oral tablet 15 mg, 7.5 mg G perindopril erbumine oral tablet 2 mg, 4 mg, 8 mg G LGC

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 46 Prescription Drug Name Drug Tier Drug Notes QBRELIS ORAL SOLUTION 1 MG/ML (lisinopril) NPB quinapril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg G LGC ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5 mg G LGC trandolapril oral tablet 1 mg, 2 mg, 4 mg G LGC ALDOSTERONE RECEPTOR ANTAGONISTS - DRUGS TO TREAT HIGH BLOOD PRESSURE eplerenone oral tablet 25 mg, 50 mg G ALPHA BLOCKERS - DRUGS TO TREAT HIGH BLOOD PRESSURE doxazosin mesylate oral tablet 1 mg, 2 mg, 4 mg, 8 mg G prazosin hcl oral capsule 1 mg, 2 mg, 5 mg G terazosin hcl oral capsule 1 mg, 10 mg, 2 mg, 5 mg G LGC ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS - DRUGS TO TREAT HIGH BLOOD PRESSURE amlodipine besylate-valsartan oral tablet 10-160 mg, 10-320 mg, G LGC 5-160 mg, 5-320 mg amlodipine-olmesartan oral tablet 10-20 mg, 10-40 mg, 5-20 mg, G LGC 5-40 mg amlodipine-valsartan-hctz oral tablet 10-160-12.5 mg, 10-160-25 G LGC mg, 10-320-25 mg, 5-160-12.5 mg, 5-160-25 mg ATACAND HCT ORAL TABLET 16-12.5 MG, 32-12.5 NF MG, 32-25 MG (candesartan cilexetil-hctz) AZOR ORAL TABLET 10-20 MG, 10-40 MG, 5-20 MG, 5- NF 40 MG (amlodipine-olmesartan) BENICAR HCT ORAL TABLET 20-12.5 MG, 40-12.5 MG, NF 40-25 MG (olmesartan medoxomil-hctz) candesartan cilexetil-hctz oral tablet 16-12.5 mg, 32-12.5 mg, G LGC 32-25 mg DIOVAN HCT ORAL TABLET 160-12.5 MG, 160-25 MG, 320-12.5 MG, 320-25 MG, 80-12.5 MG (valsartan- NF hydrochlorothiazide) EDARBYCLOR ORAL TABLET 40-12.5 MG, 40-25 MG NF (azilsartan-chlorthalidone) EXFORGE HCT ORAL TABLET 10-160-12.5 MG, 10-160- 25 MG, 10-320-25 MG, 5-160-12.5 MG, 5-160-25 MG NF (amlodipine-valsartan-hctz) EXFORGE ORAL TABLET 10-160 MG, 10-320 MG, 5-160 NF MG, 5-320 MG (amlodipine besylate-valsartan) 2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 47 Prescription Drug Name Drug Tier Drug Notes HYZAAR ORAL TABLET 100-12.5 MG, 100-25 MG, 50- NF 12.5 MG (losartan potassium-hctz) irbesartan-hydrochlorothiazide oral tablet 150-12.5 mg, 300- G LGC 12.5 mg losartan potassium-hctz oral tablet 100-12.5 mg, 100-25 mg, 50- G LGC 12.5 mg MICARDIS HCT ORAL TABLET 40-12.5 MG, 80-12.5 NF MG, 80-25 MG (telmisartan-hctz) olmesartan medoxomil-hctz oral tablet 20-12.5 mg, 40-12.5 mg, G LGC 40-25 mg olmesartan-amlodipine-hctz oral tablet 20-5-12.5 mg, 40-10- G LGC 12.5 mg, 40-10-25 mg, 40-5-12.5 mg, 40-5-25 mg telmisartan-amlodipine oral tablet 40-10 mg, 40-5 mg, 80-10 G LGC mg, 80-5 mg telmisartan-hctz oral tablet 40-12.5 mg, 80-12.5 mg, 80-25 mg G LGC valsartan-hydrochlorothiazide oral tablet 160-12.5 mg, 160-25 G LGC mg, 320-12.5 mg, 320-25 mg, 80-12.5 mg ANGIOTENSIN II RECEPTOR ANTAGONISTS - DRUGS TO TREAT HIGH BLOOD PRESSURE ATACAND ORAL TABLET 16 MG, 32 MG, 4 MG, 8 MG NF (candesartan cilexetil) BENICAR ORAL TABLET 20 MG, 40 MG, 5 MG NF (olmesartan medoxomil) candesartan cilexetil oral tablet 16 mg, 32 mg, 4 mg, 8 mg G LGC COZAAR ORAL TABLET 100 MG, 25 MG, 50 MG NF (losartan potassium) DIOVAN ORAL TABLET 160 MG, 320 MG, 40 MG, 80 NF MG (valsartan) EDARBI ORAL TABLET 40 MG, 80 MG (azilsartan NF medoxomil) irbesartan oral tablet 150 mg, 300 mg, 75 mg G LGC losartan potassium oral tablet 100 mg, 25 mg, 50 mg G LGC MICARDIS ORAL TABLET 20 MG, 40 MG, 80 MG NF (telmisartan) olmesartan medoxomil oral tablet 20 mg, 40 mg, 5 mg G LGC telmisartan oral tablet 20 mg, 40 mg, 80 mg G LGC valsartan oral tablet 160 mg, 320 mg, 40 mg, 80 mg G LGC

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 48 Prescription Drug Name Drug Tier Drug Notes ANTIARRHYTHMICS - DRUGS TO CONTROL HEART RHYTHM amiodarone hcl oral tablet 100 mg, 200 mg, 400 mg G disopyramide phosphate oral capsule 100 mg, 150 mg G dofetilide oral capsule 125 mcg, 250 mcg, 500 mcg G flecainide acetate oral tablet 100 mg, 150 mg, 50 mg G lidocaine hcl (cardiac) pf intravenous solution prefilled syringe NPB 100 mg/5ml mexiletine hcl oral capsule 150 mg, 200 mg, 250 mg NPB MULTAQ ORAL TABLET 400 MG (dronedarone hcl) PB NORPACE CR ORAL CAPSULE EXTENDED RELEASE NPB 12 HOUR 100 MG, 150 MG (disopyramide phosphate) NORPACE ORAL CAPSULE 100 MG, 150 MG NF (disopyramide phosphate) amiodarone hcl (Pacerone Oral Tablet 100 Mg, 200 Mg, 400 G Mg) propafenone hcl er oral capsule extended release 12 hour 225 G mg, 325 mg, 425 mg propafenone hcl oral tablet 150 mg, 225 mg, 300 mg G quinidine gluconate er oral tablet extended release 324 mg G quinidine sulfate oral tablet 200 mg, 300 mg G sotalol hcl (Sorine Oral Tablet 120 Mg, 80 Mg) G LGC sotalol hcl (Sorine Oral Tablet 160 Mg, 240 Mg) G sotalol hcl (af) oral tablet 120 mg G LGC sotalol hcl (af) oral tablet 160 mg, 80 mg G sotalol hcl oral tablet 120 mg, 80 mg G LGC sotalol hcl oral tablet 160 mg, 240 mg G TIKOSYN ORAL CAPSULE 125 MCG, 250 MCG, 500 NPSP MCG (dofetilide) ANTILIPEMICS, ACL INHIBITORS/COMBINATIONS NEXLETOL ORAL TABLET 180 MG (bempedoic acid) PB NEXLIZET ORAL TABLET 180-10 MG (bempedoic acid- PB ezetimibe) ANTILIPEMICS, BILE ACID RESINS cholestyramine light oral packet 4 gm G cholestyramine light oral powder 4 gm/dose G

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

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 51 Prescription Drug Name Drug Tier Drug Notes N8 (Listing does not include VASCEPA ORAL CAPSULE 1 GM (icosapent ethyl) PB certain NDCs) ANTILIPEMICS, PCSK9 INHIBITORS PRALUENT SUBCUTANEOUS SOLUTION AUTO- PSP INJECTOR 150 MG/ML, 75 MG/ML (alirocumab) REPATHA PUSHTRONEX SYSTEM SUBCUTANEOUS NF SOLUTION CARTRIDGE 420 MG/3.5ML (evolocumab) REPATHA SUBCUTANEOUS SOLUTION PREFILLED NF SYRINGE 140 MG/ML (evolocumab) REPATHA SURECLICK SUBCUTANEOUS SOLUTION NF AUTO-INJECTOR 140 MG/ML (evolocumab) BETA-BLOCKER/DIURETIC COMBINATIONS - DRUGS TO TREAT HIGH BLOOD PRESSURE AND HEART CONDITIONS atenolol-chlorthalidone oral tablet 100-25 mg, 50-25 mg G bisoprolol-hydrochlorothiazide oral tablet 10-6.25 mg, 2.5-6.25 G LGC mg, 5-6.25 mg DUTOPROL ORAL TABLET EXTENDED RELEASE 24 HOUR 100-12.5 MG, 25-12.5 MG, 50-12.5 MG (metoprolol- NF hydrochlorothiazide) metoprolol-hydrochlorothiazide oral tablet 100-25 mg, 100-50 G mg, 50-25 mg BETA-BLOCKERS - DRUGS TO TREAT HIGH BLOOD PRESSURE AND HEART CONDITIONS acebutolol hcl oral capsule 200 mg, 400 mg G atenolol oral tablet 100 mg, 25 mg, 50 mg G LGC BETAPACE AF ORAL TABLET 120 MG, 160 MG, 80 MG NF (sotalol hcl af) BETAPACE ORAL TABLET 120 MG, 160 MG, 80 MG NF (sotalol hcl) betaxolol hcl oral tablet 10 mg, 20 mg G bisoprolol fumarate oral tablet 10 mg, 5 mg G BYSTOLIC ORAL TABLET 10 MG, 2.5 MG, 20 MG, 5 MG NF (nebivolol hcl) carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg G LGC carvedilol phosphate er oral capsule extended release 24 hour 10 G mg, 20 mg, 40 mg, 80 mg COREG CR ORAL CAPSULE EXTENDED RELEASE 24 NF HOUR 10 MG, 20 MG, 40 MG, 80 MG (carvedilol phosphate) 2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 52 Prescription Drug Name Drug Tier Drug Notes HEMANGEOL ORAL SOLUTION 4.28 MG/ML NPB (propranolol hcl) INDERAL LA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 160 MG, 60 MG, 80 MG (propranolol NF hcl) INDERAL XL ORAL CAPSULE EXTENDED RELEASE NF 24 HOUR 120 MG, 80 MG (propranolol hcl sr beads) INNOPRAN XL ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 80 MG (propranolol hcl sr NF beads) KAPSPARGO SPRINKLE ORAL CAPSULE ER 24 HOUR SPRINKLE 100 MG, 200 MG, 25 MG, 50 MG NF (metoprolol succinate) labetalol hcl oral tablet 100 mg, 200 mg, 300 mg G metoprolol succinate er oral tablet extended release 24 hour 100 G mg, 200 mg, 25 mg, 50 mg metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg G LGC metoprolol tartrate oral tablet 37.5 mg, 75 mg G nadolol oral tablet 20 mg, 40 mg, 80 mg G pindolol oral tablet 10 mg, 5 mg G propranolol hcl er oral capsule extended release 24 hour 120 mg, G 160 mg, 60 mg, 80 mg propranolol hcl oral solution 20 mg/5ml, 40 mg/5ml G propranolol hcl oral tablet 10 mg, 20 mg, 40 mg, 80 mg G LGC propranolol hcl oral tablet 60 mg G SOTYLIZE ORAL SOLUTION 5 MG/ML (sotalol hcl) NPB timolol maleate oral tablet 10 mg, 20 mg, 5 mg G TOPROL XL ORAL TABLET EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 25 MG, 50 MG (metoprolol NF succinate) CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS amlodipine-atorvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg, 2.5-10 mg, 2.5-20 mg, 2.5-40 mg, 5-10 mg, 5-20 G LGC mg, 5-40 mg, 5-80 mg CALCIUM CHANNEL BLOCKERS - DRUGS TO TREAT HIGH BLOOD PRESSURE AND HEART CONDITIONS amlodipine besylate oral tablet 10 mg, 2.5 mg, 5 mg G LGC

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 53 Prescription Drug Name Drug Tier Drug Notes CARDIZEM CD ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, NF 360 MG (diltiazem hcl coated beads) CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG, 420 NF MG (diltiazem hcl coated beads) CARDIZEM ORAL TABLET 120 MG, 30 MG, 60 MG NF (diltiazem hcl) diltiazem hcl coated beads (Cartia Xt Oral Capsule Extended G Release 24 Hour 120 Mg, 180 Mg, 240 Mg, 300 Mg) CONSENSI ORAL TABLET 10-200 MG, 2.5-200 MG, 5-200 NF MG (amlodipine besylate-celecoxib) diltiazem hcl er beads oral capsule extended release 24 hour 120 G mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg diltiazem hcl er coated beads oral capsule extended release 24 G hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg diltiazem hcl er coated beads oral tablet extended release 24 NF hour 180 mg, 240 mg, 300 mg, 360 mg, 420 mg diltiazem hcl er oral capsule extended release 12 hour 120 mg, G 60 mg, 90 mg diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg G LGC dilt-xr oral capsule extended release 24 hour 120 mg, 180 mg, G 240 mg felodipine er oral tablet extended release 24 hour 10 mg, 2.5 mg, G 5 mg isradipine oral capsule 2.5 mg, 5 mg G KATERZIA ORAL SUSPENSION 1 MG/ML (amlodipine NF benzoate) diltiazem hcl coated beads (Matzim La Oral Tablet Extended NF Release 24 Hour 180 Mg, 240 Mg, 300 Mg, 360 Mg, 420 Mg) nicardipine hcl oral capsule 20 mg, 30 mg G nifedipine er oral tablet extended release 24 hour 30 mg, 60 mg, G 90 mg nifedipine er osmotic release oral tablet extended release 24 hour G 30 mg, 60 mg, 90 mg nifedipine oral capsule 10 mg, 20 mg G nimodipine oral capsule 30 mg G nisoldipine er oral tablet extended release 24 hour 17 mg, 20 mg, G 25.5 mg, 30 mg, 34 mg, 40 mg, 8.5 mg 2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 54 Prescription Drug Name Drug Tier Drug Notes NORVASC ORAL TABLET 10 MG, 2.5 MG, 5 MG NF (amlodipine besylate) NYMALIZE ORAL SOLUTION 6 MG/ML (nimodipine) NPB diltiazem hcl er beads (Taztia Xt Oral Capsule Extended G Release 24 Hour 120 Mg, 180 Mg, 240 Mg, 300 Mg, 360 Mg) verapamil hcl er oral capsule extended release 24 hour 100 mg, G 120 mg, 180 mg, 200 mg, 240 mg, 300 mg, 360 mg verapamil hcl er oral tablet extended release 120 mg G LGC verapamil hcl er oral tablet extended release 180 mg, 240 mg G verapamil hcl oral tablet 120 mg, 40 mg, 80 mg G LGC DIGITALIS GLYCOSIDES - DRUGS TO TREAT HEART CONDITIONS digoxin (Digitek Oral Tablet 125 Mcg, 250 Mcg) G digoxin (Digox Oral Tablet 125 Mcg, 250 Mcg) G digoxin oral solution 0.05 mg/ml G digoxin oral tablet 125 mcg, 250 mcg G LANOXIN ORAL TABLET 125 MCG, 250 MCG (digoxin) NF LANOXIN ORAL TABLET 62.5 MCG (digoxin) NPB DIRECT RENIN INHIBITORS/COMBINATIONS - DRUGS TO TREAT HEART CONDITIONS aliskiren fumarate oral tablet 150 mg, 300 mg G TEKTURNA HCT ORAL TABLET 150-12.5 MG, 150-25 PB MG, 300-12.5 MG, 300-25 MG (aliskiren-hydrochlorothiazide) TEKTURNA ORAL TABLET 150 MG, 300 MG (aliskiren NPB fumarate) DIURETICS - DRUGS TO TREAT HEART CONDITIONS acetazolamide er oral capsule extended release 12 hour 500 mg G acetazolamide oral tablet 125 mg, 250 mg G ALDACTAZIDE ORAL TABLET 50-50 MG NPB (spironolactone-hctz) amiloride hcl oral tablet 5 mg G amiloride-hydrochlorothiazide oral tablet 5-50 mg G LGC bumetanide oral tablet 0.5 mg, 1 mg, 2 mg G CAROSPIR ORAL SUSPENSION 25 MG/5ML NF (spironolactone) chlorthalidone oral tablet 25 mg, 50 mg G

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 55 Prescription Drug Name Drug Tier Drug Notes DIURIL ORAL SUSPENSION 250 MG/5ML NPB (chlorothiazide) DYRENIUM ORAL CAPSULE 100 MG, 50 MG NF (triamterene) ethacrynic acid oral tablet 25 mg G furosemide oral solution 10 mg/ml, 8 mg/ml G furosemide oral tablet 20 mg, 40 mg, 80 mg G LGC hydrochlorothiazide oral capsule 12.5 mg G LGC hydrochlorothiazide oral tablet 12.5 mg G hydrochlorothiazide oral tablet 25 mg, 50 mg G LGC indapamide oral tablet 1.25 mg, 2.5 mg G KEVEYIS ORAL TABLET 50 MG (dichlorphenamide) NPB methazolamide oral tablet 25 mg, 50 mg G metolazone oral tablet 10 mg, 2.5 mg, 5 mg G spironolactone oral tablet 100 mg, 50 mg G spironolactone oral tablet 25 mg G LGC spironolactone-hctz oral tablet 25-25 mg G torsemide oral tablet 10 mg, 100 mg, 20 mg, 5 mg G triamterene oral capsule 100 mg, 50 mg G triamterene-hctz oral capsule 37.5-25 mg G LGC triamterene-hctz oral tablet 37.5-25 mg, 75-50 mg G LGC MISCELLANEOUS BIDIL ORAL TABLET 20-37.5 MG (isosorb dinitrate- PB hydralazine) clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg G LGC clonidine transdermal patch weekly 0.1 mg/24hr, 0.2 mg/24hr, G 0.3 mg/24hr CORLANOR ORAL SOLUTION 5 MG/5ML (ivabradine NPB hcl) CORLANOR ORAL TABLET 5 MG, 7.5 MG (ivabradine PB hcl) DEMSER ORAL CAPSULE 250 MG (metyrosine) NPB ENTRESTO ORAL TABLET 24-26 MG, 49-51 MG, 97-103 PB MG (sacubitril-valsartan) guanfacine hcl oral tablet 1 mg, 2 mg G hydralazine hcl oral tablet 10 mg, 100 mg, 50 mg G

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 56 Prescription Drug Name Drug Tier Drug Notes hydralazine hcl oral tablet 25 mg G LGC methyldopa oral tablet 250 mg, 500 mg G midodrine hcl oral tablet 10 mg, 2.5 mg, 5 mg G minoxidil oral tablet 10 mg, 2.5 mg G NIPRIDE RTU INTRAVENOUS SOLUTION 20-0.9 MG/100ML-%, 50-0.9 MG/100ML-% (nitroprusside sodium- NF nacl) phenoxybenzamine hcl oral capsule 10 mg G ranolazine er oral tablet extended release 12 hour 1000 mg, 500 G mg VECAMYL ORAL TABLET 2.5 MG (mecamylamine hcl) NPB VYNDAMAX ORAL CAPSULE 61 MG (tafamidis) NPSP VYNDAQEL ORAL CAPSULE 20 MG (tafamidis NF meglumine (cardiac)) NITRATES - DRUGS TO TREAT HEART CONDITIONS DILATRATE-SR ORAL CAPSULE EXTENDED NPB RELEASE 40 MG (isosorbide dinitrate) GONITRO SUBLINGUAL PACKET 400 MCG NF (nitroglycerin) ISORDIL TITRADOSE ORAL TABLET 40 MG, 5 MG NF (isosorbide dinitrate) isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 5 mg G isosorbide dinitrate oral tablet 40 mg NF isosorbide mononitrate er oral tablet extended release 24 hour G 120 mg, 30 mg, 60 mg isosorbide mononitrate oral tablet 10 mg, 20 mg G nitroglycerin (Minitran Transdermal Patch 24 Hour 0.1 G Mg/Hr, 0.2 Mg/Hr, 0.4 Mg/Hr, 0.6 Mg/Hr) NITRO-BID TRANSDERMAL OINTMENT 2 % NPB (nitroglycerin) NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.3 NPB MG/HR, 0.8 MG/HR (nitroglycerin) nitroglycerin sublingual tablet sublingual 0.3 mg, 0.4 mg, 0.6 mg G nitroglycerin transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr, G 0.4 mg/hr, 0.6 mg/hr nitroglycerin translingual solution 0.4 mg/spray G NITROMIST TRANSLINGUAL AEROSOL SOLUTION NF 400 MCG/SPRAY (nitroglycerin) 2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 57 Prescription Drug Name Drug Tier Drug Notes PULMONARY ARTERIAL HYPERTENSION - DRUGS TO TREAT PULMONARY HYPERTENSION ADEMPAS ORAL TABLET 0.5 MG, 1 MG, 1.5 MG, 2 MG, PSP 2.5 MG (riociguat) tadalafil (pah) (Alyq Oral Tablet 20 Mg) G ambrisentan oral tablet 10 mg, 5 mg G bosentan oral tablet 125 mg, 62.5 mg G epoprostenol sodium intravenous solution reconstituted 0.5 mg, G 1.5 mg FLOLAN INTRAVENOUS SOLUTION NPSP RECONSTITUTED 0.5 MG, 1.5 MG (epoprostenol sodium) LETAIRIS ORAL TABLET 10 MG, 5 MG (ambrisentan) NF OPSUMIT ORAL TABLET 10 MG (macitentan) PSP ORENITRAM ORAL TABLET EXTENDED RELEASE 0.125 MG, 0.25 MG, 1 MG, 2.5 MG, 5 MG (treprostinil PSP diolamine) REMODULIN INJECTION SOLUTION 100 MG/20ML, 20 NF MG/20ML, 200 MG/20ML, 50 MG/20ML (treprostinil) sildenafil citrate oral suspension reconstituted 10 mg/ml NF sildenafil citrate oral tablet 20 mg G tadalafil (pah) oral tablet 20 mg G TRACLEER ORAL TABLET 125 MG, 62.5 MG (bosentan) NF TRACLEER ORAL TABLET SOLUBLE 32 MG (bosentan) NF treprostinil injection solution 100 mg/20ml, 20 mg/20ml, 200 G mg/20ml, 50 mg/20ml TYVASO INHALATION SOLUTION 0.6 MG/ML NPSP (treprostinil) TYVASO REFILL INHALATION SOLUTION 0.6 NPSP MG/ML (treprostinil) TYVASO STARTER INHALATION SOLUTION 0.6 NPSP MG/ML (treprostinil) UPTRAVI ORAL TABLET 1000 MCG, 1200 MCG, 1400 MCG, 1600 MCG, 200 MCG, 400 MCG, 600 MCG, 800 PSP MCG (selexipag) UPTRAVI ORAL TABLET THERAPY PACK 200 & 800 PSP MCG (selexipag) VELETRI INTRAVENOUS SOLUTION NPSP RECONSTITUTED 0.5 MG, 1.5 MG (epoprostenol sodium)

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 58 Prescription Drug Name Drug Tier Drug Notes VENTAVIS INHALATION SOLUTION 10 MCG/ML, 20 NPSP MCG/ML (iloprost) CENTRAL NERVOUS SYSTEM - DRUGS TO TREAT NERVOUS SYSTEM DISORDERS ANTIANXIETY - DRUGS TO TREAT ANXIETY alprazolam er oral tablet extended release 24 hour 0.5 mg, 1 mg, G 2 mg, 3 mg ALPRAZOLAM INTENSOL ORAL CONCENTRATE 1 NPB MG/ML (alprazolam) alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg G alprazolam oral tablet dispersible 0.25 mg, 0.5 mg, 1 mg, 2 mg G alprazolam xr oral tablet extended release 24 hour 0.5 mg, 1 mg, G 2 mg, 3 mg ATIVAN INJECTION SOLUTION 2 MG/ML, 4 MG/ML NF (lorazepam) ATIVAN ORAL TABLET 0.5 MG, 1 MG, 2 MG NF (lorazepam) chlordiazepoxide hcl oral capsule 10 mg, 25 mg, 5 mg G lorazepam oral concentrate 2 mg/ml G lorazepam oral tablet 0.5 mg, 1 mg, 2 mg G meprobamate oral tablet 200 mg, 400 mg G oxazepam oral capsule 10 mg, 15 mg, 30 mg G XANAX ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG NF (alprazolam) XANAX XR ORAL TABLET EXTENDED RELEASE 24 NF HOUR 0.5 MG, 1 MG, 2 MG, 3 MG (alprazolam) ANTICONVULSANTS - DRUGS TO TREAT SEIZURES APTIOM ORAL TABLET 200 MG, 400 MG, 600 MG, 800 NF MG (eslicarbazepine acetate) BANZEL ORAL SUSPENSION 40 MG/ML (rufinamide) NF BANZEL ORAL TABLET 200 MG, 400 MG (rufinamide) NPB BRIVIACT INTRAVENOUS SOLUTION 50 MG/5ML NPB (brivaracetam) BRIVIACT ORAL SOLUTION 10 MG/ML (brivaracetam) NPB BRIVIACT ORAL TABLET 10 MG, 100 MG, 25 MG, 50 NPB MG, 75 MG (brivaracetam) carbamazepine er oral capsule extended release 12 hour 100 mg, G 200 mg, 300 mg 2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 59 Prescription Drug Name Drug Tier Drug Notes carbamazepine er oral tablet extended release 12 hour 100 mg, G 200 mg, 400 mg carbamazepine oral suspension 100 mg/5ml G carbamazepine oral tablet 200 mg G carbamazepine oral tablet chewable 100 mg G CELONTIN ORAL CAPSULE 300 MG (methsuximide) NPB clobazam oral suspension 2.5 mg/ml G clobazam oral tablet 10 mg, 20 mg G clonazepam oral tablet 0.5 mg, 1 mg, 2 mg G clonazepam oral tablet dispersible 0.125 mg, 0.25 mg, 0.5 mg, 1 G mg, 2 mg clorazepate dipotassium oral tablet 15 mg, 3.75 mg, 7.5 mg G DIACOMIT ORAL CAPSULE 250 MG, 500 MG NPB (stiripentol) DIACOMIT ORAL PACKET 250 MG, 500 MG (stiripentol) NPB DIASTAT ACUDIAL RECTAL GEL 10 MG, 20 MG NF (diazepam) DIASTAT PEDIATRIC RECTAL GEL 2.5 MG (diazepam) NF diazepam injection solution 5 mg/ml NPB diazepam oral concentrate 5 mg/ml G diazepam oral solution 5 mg/5ml G diazepam oral tablet 10 mg, 2 mg, 5 mg G diazepam rectal gel 10 mg, 2.5 mg, 20 mg G DILANTIN INFATABS ORAL TABLET CHEWABLE 50 NF MG (phenytoin) DILANTIN ORAL CAPSULE 100 MG, 30 MG (phenytoin NF sodium extended) DILANTIN ORAL SUSPENSION 125 MG/5ML (phenytoin) NF divalproex sodium er oral tablet extended release 24 hour 250 G mg, 500 mg divalproex sodium oral capsule delayed release sprinkle 125 mg G divalproex sodium oral tablet delayed release 125 mg, 250 mg, G 500 mg EPIDIOLEX ORAL SOLUTION 100 MG/ML (cannabidiol) NPSP carbamazepine (Epitol Oral Tablet 200 Mg) G ethosuximide oral capsule 250 mg G

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 60 Prescription Drug Name Drug Tier Drug Notes ethosuximide oral solution 250 mg/5ml G FANATREX FUSEPAQ ORAL SUSPENSION 25 MG/ML NF (gabapentin) felbamate oral suspension 600 mg/5ml G felbamate oral tablet 400 mg, 600 mg G FINTEPLA ORAL SOLUTION 2.2 MG/ML (fenfluramine NPB hcl) FYCOMPA ORAL SUSPENSION 0.5 MG/ML (perampanel) PB FYCOMPA ORAL TABLET 10 MG, 12 MG, 2 MG, 4 MG, PB 6 MG, 8 MG (perampanel) gabapentin oral capsule 100 mg, 300 mg, 400 mg G gabapentin oral solution 250 mg/5ml, 300 mg/6ml G gabapentin oral tablet 600 mg, 800 mg G KEPPRA ORAL SOLUTION 100 MG/ML (levetiracetam) NF KEPPRA ORAL TABLET 1000 MG, 250 MG, 500 MG, 750 NF MG (levetiracetam) KEPPRA XR ORAL TABLET EXTENDED RELEASE 24 NF HOUR 500 MG, 750 MG (levetiracetam) LAMICTAL ODT ORAL KIT 21 X 25 MG & 7 X 50 MG, NPB 25 & 50 & 100 MG, 42 X 50 MG & 14X100 MG (lamotrigine) LAMICTAL ODT ORAL TABLET DISPERSIBLE 100 NPB MG, 200 MG, 25 MG, 50 MG (lamotrigine) LAMICTAL ORAL TABLET 100 MG, 150 MG, 200 MG, NPB 25 MG (lamotrigine) LAMICTAL ORAL TABLET CHEWABLE 25 MG, 5 MG NPB (lamotrigine) LAMICTAL STARTER ORAL KIT 35 X 25 MG, 42 X 25 NPB MG & 7 X 100 MG, 84 X 25 MG & 14X100 MG (lamotrigine) LAMICTAL XR ORAL KIT 21 X 25 MG & 7 X 50 MG, 25 NPB & 50 & 100 MG, 50 & 100 & 200 MG (lamotrigine) LAMICTAL XR ORAL TABLET EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 25 MG, 250 MG, 300 MG, 50 NPB MG (lamotrigine) lamotrigine er oral tablet extended release 24 hour 100 mg, 200 G mg, 25 mg, 250 mg, 300 mg, 50 mg lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg G lamotrigine oral tablet chewable 25 mg, 5 mg G

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 61 Prescription Drug Name Drug Tier Drug Notes lamotrigine oral tablet dispersible 100 mg, 200 mg, 25 mg, 50 G mg lamotrigine starter kit-blue oral kit 35 x 25 mg G lamotrigine starter kit-green oral kit 84 x 25 mg & 14x100 mg G lamotrigine starter kit-orange oral kit 42 x 25 mg & 7 x 100 mg G levetiracetam er oral tablet extended release 24 hour 500 mg, G 750 mg levetiracetam oral solution 100 mg/ml G levetiracetam oral tablet 1000 mg, 250 mg, 500 mg, 750 mg G LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 225 NF MG, 25 MG, 300 MG, 50 MG, 75 MG (pregabalin) LYRICA ORAL SOLUTION 20 MG/ML (pregabalin) NF NAYZILAM NASAL SOLUTION 5 MG/0.1ML (midazolam PB (anticonvulsant)) ONFI ORAL SUSPENSION 2.5 MG/ML (clobazam) NF ONFI ORAL TABLET 10 MG, 20 MG (clobazam) NF oxcarbazepine oral suspension 300 mg/5ml G oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg G OXTELLAR XR ORAL TABLET EXTENDED RELEASE PB 24 HOUR 150 MG, 300 MG, 600 MG (oxcarbazepine) phenobarbital oral elixir 20 mg/5ml G phenobarbital oral tablet 100 mg, 15 mg, 16.2 mg, 30 mg, 32.4 G mg, 60 mg, 64.8 mg, 97.2 mg phenytoin oral suspension 125 mg/5ml G phenytoin oral tablet chewable 50 mg G phenytoin sodium extended oral capsule 100 mg, 200 mg, 300 G mg pregabalin oral capsule 100 mg, 150 mg, 200 mg, 225 mg, 25 G mg, 300 mg, 50 mg, 75 mg pregabalin oral solution 20 mg/ml G primidone oral tablet 250 mg, 50 mg G levetiracetam (Roweepra Oral Tablet 500 Mg) G SABRIL ORAL PACKET 500 MG (vigabatrin) NPSP SABRIL ORAL TABLET 500 MG (vigabatrin) NPSP SPRITAM ORAL TABLET DISINTEGRATING SOLUBLE 1000 MG, 250 MG, 500 MG, 750 MG NF (levetiracetam)

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 62 Prescription Drug Name Drug Tier Drug Notes lamotrigine (Subvenite Oral Tablet 100 Mg, 150 Mg, 200 Mg, G 25 Mg) lamotrigine (Subvenite Starter Kit-Blue Oral Kit 35 X 25 Mg) G lamotrigine (Subvenite Starter Kit-Green Oral Kit 84 X 25 Mg G & 14X100 Mg) lamotrigine (Subvenite Starter Kit-Orange Oral Kit 42 X 25 G Mg & 7 X 100 Mg) SYMPAZAN ORAL FILM 10 MG, 20 MG, 5 MG NF (clobazam) tiagabine hcl oral tablet 12 mg, 16 mg, 2 mg, 4 mg G topiramate er oral capsule er 24 hour sprinkle 100 mg, 150 mg, NF 200 mg, 25 mg, 50 mg topiramate oral capsule sprinkle 15 mg, 25 mg G topiramate oral tablet 100 mg, 200 mg, 25 mg, 50 mg G TRILEPTAL ORAL SUSPENSION 300 MG/5ML NPB (oxcarbazepine) TRILEPTAL ORAL TABLET 150 MG, 300 MG, 600 MG NPB (oxcarbazepine) TROKENDI XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 25 MG, 50 MG PB (topiramate) valproic acid oral capsule 250 mg G valproic acid oral solution 250 mg/5ml G VALTOCO 10 MG DOSE NASAL LIQUID 10 MG/0.1ML PB (diazepam) VALTOCO 15 MG DOSE NASAL LIQUID THERAPY PB PACK 7.5 MG/0.1ML (diazepam) VALTOCO 20 MG DOSE NASAL LIQUID THERAPY PB PACK 10 MG/0.1ML (diazepam) VALTOCO 5 MG DOSE NASAL LIQUID 5 MG/0.1ML PB (diazepam) vigabatrin oral packet 500 mg G vigabatrin oral tablet 500 mg G vigabatrin (Vigadrone Oral Packet 500 Mg) G VIMPAT ORAL SOLUTION 10 MG/ML (lacosamide) PB VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG, 50 PB MG (lacosamide)

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 63 Prescription Drug Name Drug Tier Drug Notes XCOPRI (250 MG DAILY DOSE) ORAL TABLET THERAPY PACK 100 & 150 MG, 50 & 200 MG PB (cenobamate) XCOPRI (350 MG DAILY DOSE) ORAL TABLET PB THERAPY PACK 150 & 200 MG (cenobamate) XCOPRI ORAL TABLET 100 MG, 150 MG, 200 MG, 50 PB MG (cenobamate) XCOPRI ORAL TABLET THERAPY PACK 14 X 12.5 MG & 14 X 25 MG, 14 X 150 MG & 14 X200 MG, 14 X 50 MG & PB 14 X100 MG (cenobamate) ZONEGRAN ORAL CAPSULE 100 MG, 25 MG NF (zonisamide) zonisamide oral capsule 100 mg, 25 mg, 50 mg G ANTIDEMENTIA - DRUGS TO TREAT DEMENTIA AND MEMORY LOSS donepezil hcl oral tablet 10 mg, 23 mg, 5 mg G donepezil hcl oral tablet dispersible 10 mg, 5 mg G ergoloid mesylates oral tablet 1 mg G galantamine hydrobromide er oral capsule extended release 24 G hour 16 mg, 24 mg, 8 mg galantamine hydrobromide oral solution 4 mg/ml G galantamine hydrobromide oral tablet 12 mg, 4 mg, 8 mg G memantine hcl er oral capsule extended release 24 hour 14 mg, G 21 mg, 28 mg, 7 mg memantine hcl oral solution 10 mg/5ml, 2 mg/ml G memantine hcl oral tablet 10 mg, 28 x 5 mg & 21 x 10 mg, 5 mg G NAMENDA XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 14 MG, 21 MG, 28 MG, 7 MG NF (memantine hcl) NAMZARIC ORAL CAPSULE ER 24 HOUR THERAPY PB PACK 7 & 14 & 21 &28 -10 MG (memantine hcl-donepezil hcl) NAMZARIC ORAL CAPSULE EXTENDED RELEASE 24 HOUR 14-10 MG, 21-10 MG, 28-10 MG, 7-10 MG PB (memantine hcl-donepezil hcl) rivastigmine tartrate oral capsule 1.5 mg, 3 mg, 4.5 mg, 6 mg G rivastigmine transdermal patch 24 hour 13.3 mg/24hr, 4.6 G mg/24hr, 9.5 mg/24hr

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 64 Prescription Drug Name Drug Tier Drug Notes ANTIDEPRESSANTS - DRUGS TO TREAT DEPRESSION amitriptyline hcl oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 G mg, 75 mg amoxapine oral tablet 100 mg, 150 mg, 25 mg, 50 mg G APLENZIN ORAL TABLET EXTENDED RELEASE 24 NPB HOUR 174 MG, 348 MG, 522 MG (bupropion hbr) bupropion hcl er (sr) oral tablet extended release 12 hour 100 G mg, 150 mg, 200 mg bupropion hcl er (xl) oral tablet extended release 24 hour 150 G mg, 300 mg bupropion hcl er (xl) oral tablet extended release 24 hour 450 NF mg bupropion hcl oral tablet 100 mg, 75 mg G citalopram hydrobromide oral solution 10 mg/5ml G citalopram hydrobromide oral tablet 10 mg, 20 mg, 40 mg G LGC CYMBALTA ORAL CAPSULE DELAYED RELEASE NF PARTICLES 20 MG, 30 MG, 60 MG (duloxetine hcl) desipramine hcl oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 G mg, 75 mg desvenlafaxine succinate er oral tablet extended release 24 hour G 100 mg, 25 mg, 50 mg doxepin hcl oral capsule 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, G 75 mg doxepin hcl oral concentrate 10 mg/ml G duloxetine hcl oral capsule delayed release particles 20 mg, 30 G mg, 40 mg, 60 mg EFFEXOR XR ORAL CAPSULE EXTENDED RELEASE NF 24 HOUR 150 MG, 37.5 MG, 75 MG (venlafaxine hcl) EMSAM TRANSDERMAL PATCH 24 HOUR 12 NPB MG/24HR, 6 MG/24HR, 9 MG/24HR (selegiline) escitalopram oxalate oral solution 5 mg/5ml G escitalopram oxalate oral tablet 10 mg, 20 mg, 5 mg G FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 20 MG, 40 MG, 80 MG (levomilnacipran NF hcl) FETZIMA TITRATION ORAL CAPSULE ER 24 HOUR NF THERAPY PACK 20 & 40 MG (levomilnacipran hcl)

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 65 Prescription Drug Name Drug Tier Drug Notes fluoxetine hcl (pmdd) oral tablet 10 mg, 20 mg NF fluoxetine hcl oral capsule 10 mg, 20 mg, 40 mg G LGC fluoxetine hcl oral capsule delayed release 90 mg G fluoxetine hcl oral solution 20 mg/5ml G fluoxetine hcl oral tablet 10 mg, 20 mg G fluoxetine hcl oral tablet 60 mg NF imipramine hcl oral tablet 10 mg, 25 mg, 50 mg G imipramine pamoate oral capsule 100 mg, 125 mg, 150 mg, 75 G mg LEXAPRO ORAL TABLET 10 MG, 20 MG, 5 MG NF (escitalopram oxalate) MARPLAN ORAL TABLET 10 MG (isocarboxazid) NPB mirtazapine oral tablet 15 mg, 30 mg, 45 mg, 7.5 mg G mirtazapine oral tablet dispersible 15 mg, 30 mg, 45 mg G nefazodone hcl oral tablet 100 mg, 150 mg, 200 mg, 250 mg, 50 G mg nortriptyline hcl oral capsule 10 mg, 25 mg, 50 mg, 75 mg G nortriptyline hcl oral solution 10 mg/5ml G paroxetine hcl er oral tablet extended release 24 hour 12.5 mg, G 25 mg, 37.5 mg paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg G LGC paroxetine mesylate oral capsule 7.5 mg NF PAXIL CR ORAL TABLET EXTENDED RELEASE 24 NF HOUR 12.5 MG, 25 MG, 37.5 MG (paroxetine hcl) PAXIL ORAL SUSPENSION 10 MG/5ML (paroxetine hcl) NF PAXIL ORAL TABLET 10 MG, 20 MG, 30 MG, 40 MG NF (paroxetine hcl) PEXEVA ORAL TABLET 10 MG, 20 MG, 30 MG, 40 MG NF (paroxetine mesylate) phenelzine sulfate oral tablet 15 mg G PRISTIQ ORAL TABLET EXTENDED RELEASE 24 NF HOUR 100 MG, 25 MG, 50 MG (desvenlafaxine succinate) protriptyline hcl oral tablet 10 mg, 5 mg G PROZAC ORAL CAPSULE 10 MG, 20 MG, 40 MG NF (fluoxetine hcl) sertraline hcl oral concentrate 20 mg/ml G sertraline hcl oral tablet 100 mg, 25 mg, 50 mg G LGC 2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 66 Prescription Drug Name Drug Tier Drug Notes SPRAVATO (56 MG DOSE) NASAL SOLUTION NPSP THERAPY PACK 28 MG/DEVICE (esketamine hcl) SPRAVATO (84 MG DOSE) NASAL SOLUTION NPSP THERAPY PACK 28 MG/DEVICE (esketamine hcl) tranylcypromine sulfate oral tablet 10 mg G trazodone hcl oral tablet 100 mg, 150 mg, 300 mg, 50 mg G trimipramine maleate oral capsule 100 mg, 25 mg, 50 mg G TRINTELLIX ORAL TABLET 10 MG, 20 MG, 5 MG PB (vortioxetine hbr) venlafaxine hcl er oral capsule extended release 24 hour 150 mg, G 37.5 mg, 75 mg venlafaxine hcl er oral tablet extended release 24 hour 150 mg, NF 37.5 mg, 75 mg venlafaxine hcl er oral tablet extended release 24 hour 225 mg G venlafaxine hcl oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 G mg VIIBRYD ORAL TABLET 10 MG, 20 MG, 40 MG NF (vilazodone hcl) VIIBRYD STARTER PACK ORAL KIT 10 & 20 MG NF (vilazodone hcl) ZOLOFT ORAL CONCENTRATE 20 MG/ML (sertraline NF hcl) ZOLOFT ORAL TABLET 100 MG, 25 MG, 50 MG NF (sertraline hcl) ZULRESSO INTRAVENOUS SOLUTION 100 MG/20ML NF (brexanolone) ANTIPARKINSONIAN AGENTS - DRUGS TO TREAT PARKINSONS DISEASE amantadine hcl oral capsule 100 mg G amantadine hcl oral syrup 50 mg/5ml G amantadine hcl oral tablet 100 mg G APOKYN SUBCUTANEOUS SOLUTION CARTRIDGE NF 30 MG/3ML (apomorphine hcl) benztropine mesylate oral tablet 0.5 mg, 1 mg, 2 mg G bromocriptine mesylate oral capsule 5 mg G bromocriptine mesylate oral tablet 2.5 mg G carbidopa oral tablet 25 mg G

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 67 Prescription Drug Name Drug Tier Drug Notes carbidopa-levodopa er oral tablet extended release 25-100 mg, G 50-200 mg carbidopa-levodopa oral tablet 10-100 mg, 25-100 mg, 25-250 G mg carbidopa-levodopa oral tablet dispersible 10-100 mg, 25-100 G mg, 25-250 mg carbidopa-levodopa-entacapone oral tablet 12.5-50-200 mg, 18.75-75-200 mg, 25-100-200 mg, 31.25-125-200 mg, 37.5-150- G 200 mg, 50-200-200 mg DUOPA ENTERAL SUSPENSION 4.63-20 MG/ML NPB (carbidopa-levodopa) entacapone oral tablet 200 mg G GOCOVRI ORAL CAPSULE EXTENDED RELEASE 24 NF HOUR 137 MG, 68.5 MG (amantadine hcl) INBRIJA INHALATION CAPSULE 42 MG (levodopa) PSP KYNMOBI SUBLINGUAL FILM 10 MG, 15 MG, 20 MG, PSP 25 MG, 30 MG (apomorphine hcl) NEUPRO TRANSDERMAL PATCH 24 HOUR 1 MG/24HR, 2 MG/24HR, 3 MG/24HR, 4 MG/24HR, 6 PB MG/24HR, 8 MG/24HR (rotigotine) NOURIANZ ORAL TABLET 20 MG, 40 MG (istradefylline) NF OSMOLEX ER ORAL TABLET ER 24 HOUR THERAPY NF PACK 129 & 193 MG (amantadine hcl) OSMOLEX ER ORAL TABLET EXTENDED RELEASE NF 24 HOUR 129 MG, 193 MG, 258 MG (amantadine hcl) pramipexole dihydrochloride er oral tablet extended release 24 G hour 0.375 mg, 0.75 mg, 1.5 mg, 2.25 mg, 3 mg, 3.75 mg, 4.5 mg pramipexole dihydrochloride oral tablet 0.125 mg, 0.25 mg, 0.5 G mg, 0.75 mg, 1 mg, 1.5 mg rasagiline mesylate oral tablet 0.5 mg, 1 mg G ropinirole hcl er oral tablet extended release 24 hour 12 mg, 2 G mg, 4 mg, 6 mg, 8 mg ropinirole hcl oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 G mg, 5 mg RYTARY ORAL CAPSULE EXTENDED RELEASE 23.75-95 MG, 36.25-145 MG, 48.75-195 MG, 61.25-245 MG NF (carbidopa-levodopa) selegiline hcl oral capsule 5 mg G selegiline hcl oral tablet 5 mg G 2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 68 Prescription Drug Name Drug Tier Drug Notes tolcapone oral tablet 100 mg G trihexyphenidyl hcl oral solution 0.4 mg/ml G trihexyphenidyl hcl oral tablet 2 mg, 5 mg G XADAGO ORAL TABLET 100 MG, 50 MG (safinamide NF mesylate) ZELAPAR ORAL TABLET DISPERSIBLE 1.25 MG NF (selegiline hcl) ANTIPSYCHOTICS - DRUGS TO TREAT PSYCHOSES ABILIFY MAINTENA INTRAMUSCULAR PREFILLED PB SYRINGE 300 MG, 400 MG (aripiprazole) ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 300 MG, 400 MG PB (aripiprazole) ABILIFY MYCITE MAINTENANCE KIT ORAL TABLET 10 MG, 15 MG, 2 MG, 20 MG, 30 MG, 5 MG NPB (aripiprazole) ABILIFY MYCITE ORAL TABLET 10 MG, 15 MG, 2 MG, NF 20 MG, 30 MG, 5 MG (aripiprazole) ABILIFY MYCITE STARTER KIT ORAL TABLET 10 NPB MG, 15 MG, 2 MG, 20 MG, 30 MG, 5 MG (aripiprazole) ABILIFY ORAL TABLET 10 MG, 15 MG, 2 MG, 20 MG, NF 30 MG, 5 MG (aripiprazole) ADASUVE INHALATION AEROSOL POWDER NPB BREATH ACTIVATED 10 MG (loxapine) aripiprazole oral solution 1 mg/ml G aripiprazole oral tablet 10 mg, 15 mg, 2 mg, 20 mg, 30 mg, 5 mg G aripiprazole oral tablet dispersible 10 mg, 15 mg G ARISTADA INITIO INTRAMUSCULAR PREFILLED NPB SYRINGE 675 MG/2.4ML (aripiprazole lauroxil) ARISTADA INTRAMUSCULAR PREFILLED SYRINGE 1064 MG/3.9ML, 441 MG/1.6ML, 662 MG/2.4ML, 882 NPB MG/3.2ML (aripiprazole lauroxil) chlorpromazine hcl injection solution 25 mg/ml, 50 mg/2ml NPB chlorpromazine hcl oral tablet 10 mg, 100 mg, 200 mg, 25 mg, G 50 mg clozapine oral tablet 100 mg, 200 mg, 25 mg, 50 mg G clozapine oral tablet dispersible 100 mg, 12.5 mg, 25 mg G clozapine oral tablet dispersible 150 mg, 200 mg NPB

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 69 Prescription Drug Name Drug Tier Drug Notes CLOZARIL ORAL TABLET 200 MG, 50 MG (clozapine) NPB EQUETRO ORAL CAPSULE EXTENDED RELEASE 12 HOUR 100 MG, 200 MG, 300 MG (carbamazepine NPB (antipsychotic)) FANAPT ORAL TABLET 1 MG, 10 MG, 12 MG, 2 MG, 4 NF MG, 6 MG, 8 MG (iloperidone) FANAPT TITRATION PACK ORAL TABLET 1 & 2 & 4 & NF 6 MG (iloperidone) fluphenazine decanoate injection solution 25 mg/ml G fluphenazine hcl injection solution 2.5 mg/ml G fluphenazine hcl oral concentrate 5 mg/ml G fluphenazine hcl oral elixir 2.5 mg/5ml G fluphenazine hcl oral tablet 1 mg, 10 mg, 2.5 mg, 5 mg G GEODON INTRAMUSCULAR SOLUTION NF RECONSTITUTED 20 MG (ziprasidone mesylate) GEODON ORAL CAPSULE 20 MG, 40 MG, 60 MG, 80 NF MG (ziprasidone hcl) haloperidol decanoate intramuscular solution 100 mg/ml, 50 G mg/ml haloperidol lactate injection solution 5 mg/ml G haloperidol lactate oral concentrate 2 mg/ml G haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2 mg, 20 mg, 5 mg G INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 117 MG/0.75ML, NPB 156 MG/ML, 234 MG/1.5ML, 39 MG/0.25ML, 78 MG/0.5ML (paliperidone palmitate) INVEGA TRINZA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 273 MG/0.875ML, 410 NF MG/1.315ML, 546 MG/1.75ML, 819 MG/2.625ML (paliperidone palmitate) LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 PB MG, 80 MG (lurasidone hcl) loxapine succinate oral capsule 10 mg, 25 mg, 5 mg, 50 mg G molindone hcl oral tablet 10 mg, 25 mg, 5 mg G NUPLAZID ORAL CAPSULE 34 MG (pimavanserin NPSP tartrate) NUPLAZID ORAL TABLET 10 MG (pimavanserin tartrate) NPSP olanzapine intramuscular solution reconstituted 10 mg G

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 70 Prescription Drug Name Drug Tier Drug Notes olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 20 mg, 5 mg, 7.5 G mg olanzapine oral tablet dispersible 10 mg, 15 mg, 20 mg, 5 mg G paliperidone er oral tablet extended release 24 hour 1.5 mg, 3 G mg, 6 mg, 9 mg perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg G PERSERIS SUBCUTANEOUS PREFILLED SYRINGE PB 120 MG, 90 MG (risperidone) prochlorperazine edisylate injection solution 10 mg/2ml, 50 G mg/10ml quetiapine fumarate er oral tablet extended release 24 hour 150 G mg, 200 mg, 300 mg, 400 mg, 50 mg quetiapine fumarate oral tablet 100 mg, 200 mg, 25 mg, 300 mg, G 400 mg, 50 mg REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 NPB MG, 3 MG, 4 MG (brexpiprazole) RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 12.5 MG, 25 MG, NPB 37.5 MG, 50 MG (risperidone microspheres) risperidone oral solution 1 mg/ml G risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg G risperidone oral tablet dispersible 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 G mg, 4 mg SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 10 NPB MG, 2.5 MG, 5 MG (asenapine maleate) SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HOUR 150 MG, 200 MG, 300 MG, 400 MG, 50 MG NF (quetiapine fumarate) thioridazine hcl oral tablet 10 mg, 100 mg, 25 mg, 50 mg G thiothixene oral capsule 1 mg, 10 mg, 2 mg, 5 mg G trifluoperazine hcl oral tablet 1 mg, 10 mg, 2 mg, 5 mg G VERSACLOZ ORAL SUSPENSION 50 MG/ML (clozapine) NPB VRAYLAR ORAL CAPSULE 1.5 MG, 3 MG, 4.5 MG, 6 PB MG (cariprazine hcl) VRAYLAR ORAL CAPSULE THERAPY PACK 1.5 & 3 PB MG (cariprazine hcl) ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg G

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

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 73 Prescription Drug Name Drug Tier Drug Notes MYDAYIS ORAL CAPSULE EXTENDED RELEASE 24 HOUR 12.5 MG, 25 MG, 37.5 MG, 50 MG (amphetamine- PB dextroamphetamine) QUILLICHEW ER ORAL TABLET CHEWABLE EXTENDED RELEASE 20 MG, 30 MG, 40 MG NPB (methylphenidate hcl) QUILLIVANT XR ORAL SUSPENSION NPB RECONSTITUTED ER 25 MG/5ML (methylphenidate hcl) RELEXXII ORAL TABLET EXTENDED RELEASE 72 NF MG (methylphenidate hcl) VYVANSE ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 PB MG, 50 MG, 60 MG, 70 MG (lisdexamfetamine dimesylate) VYVANSE ORAL TABLET CHEWABLE 10 MG, 20 MG, PB 30 MG, 40 MG, 50 MG, 60 MG (lisdexamfetamine dimesylate) dextroamphetamine sulfate (Zenzedi Oral Tablet 10 Mg, 5 Mg) G ZENZEDI ORAL TABLET 15 MG, 2.5 MG, 20 MG, 30 G MG, 7.5 MG (dextroamphetamine sulfate) HYPNOTICS - DRUGS TO TREAT INSOMNIA BELSOMRA ORAL TABLET 10 MG, 15 MG, 20 MG, 5 NF MG (suvorexant) EDLUAR SUBLINGUAL TABLET SUBLINGUAL 10 NF MG, 5 MG (zolpidem tartrate) estazolam oral tablet 1 mg, 2 mg G eszopiclone oral tablet 1 mg, 2 mg, 3 mg G flurazepam hcl oral capsule 15 mg, 30 mg G HETLIOZ LQ ORAL SUSPENSION 4 MG/ML NPB (tasimelteon) HETLIOZ ORAL CAPSULE 20 MG (tasimelteon) NPB LUNESTA ORAL TABLET 1 MG, 2 MG, 3 MG NF (eszopiclone) midazolam hcl (pf) injection solution 5 mg/5ml G midazolam hcl oral syrup 2 mg/ml G PRECEDEX INTRAVENOUS SOLUTION 1000 NPB MCG/250ML (dexmedetomidine hcl in nacl) quazepam oral tablet 15 mg NF ramelteon oral tablet 8 mg G ROZEREM ORAL TABLET 8 MG (ramelteon) NF SILENOR ORAL TABLET 3 MG, 6 MG (doxepin hcl) NF

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

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 76 Prescription Drug Name Drug Tier Drug Notes clomipramine hcl oral capsule 25 mg, 50 mg, 75 mg G CONTRAVE ORAL TABLET EXTENDED RELEASE 12 SPC (Only available for NF HOUR 8-90 MG (naltrexone-bupropion hcl) select plans) EVRYSDI ORAL SOLUTION RECONSTITUTED 0.75 NPB MG/ML (risdiplam) FIRDAPSE ORAL TABLET 10 MG (amifampridine NPB phosphate) fluvoxamine maleate er oral capsule extended release 24 hour G 100 mg, 150 mg fluvoxamine maleate oral tablet 100 mg, 25 mg, 50 mg G INGREZZA ORAL CAPSULE 40 MG, 80 MG (valbenazine PSP tosylate) INGREZZA ORAL CAPSULE THERAPY PACK 40 & 80 PSP MG (valbenazine tosylate) lithium carbonate er oral tablet extended release 300 mg, 450 G mg lithium carbonate oral capsule 150 mg, 300 mg, 600 mg G lithium carbonate oral tablet 300 mg G LOMAIRA ORAL TABLET 8 MG (phentermine hcl) NF MESTINON ORAL SOLUTION 60 MG/5ML NF (pyridostigmine bromide) MESTINON ORAL TABLET 60 MG (pyridostigmine NF bromide) NUEDEXTA ORAL CAPSULE 20-10 MG NPB (dextromethorphan-quinidine) pimozide oral tablet 1 mg, 2 mg G pyridostigmine bromide er oral tablet extended release 180 mg G pyridostigmine bromide oral solution 60 mg/5ml G pyridostigmine bromide oral tablet 60 mg G QSYMIA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 11.25-69 MG, 15-92 MG, 3.75-23 MG, 7.5-46 MG PB (phentermine-topiramate) riluzole oral tablet 50 mg G RUZURGI ORAL TABLET 10 MG (amifampridine) NPB SAVELLA ORAL TABLET 100 MG, 12.5 MG, 25 MG, 50 NPB MG (milnacipran hcl) SAVELLA TITRATION PACK ORAL 12.5 & 25 & 50 MG NPB (milnacipran hcl)

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 77 Prescription Drug Name Drug Tier Drug Notes tetrabenazine oral tablet 12.5 mg, 25 mg G TIGLUTIK ORAL SUSPENSION 50 MG/10ML (riluzole) NF XENICAL ORAL CAPSULE 120 MG (orlistat) NF MULTIPLE SCLEROSIS AGENTS - DRUGS TO TREAT MULTIPLE SCLEROSIS AMPYRA ORAL TABLET EXTENDED RELEASE 12 NPSP HOUR 10 MG (dalfampridine) AUBAGIO ORAL TABLET 14 MG, 7 MG (teriflunomide) PSP AVONEX PEN INTRAMUSCULAR AUTO-INJECTOR NF KIT 30 MCG/0.5ML (interferon beta-1a) AVONEX PREFILLED INTRAMUSCULAR PREFILLED NF SYRINGE KIT 30 MCG/0.5ML (interferon beta-1a) BETASERON SUBCUTANEOUS KIT 0.3 MG (interferon PSP beta-1b) COPAXONE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 20 MG/ML, 40 MG/ML PSP (glatiramer acetate) dalfampridine er oral tablet extended release 12 hour 10 mg G dimethyl fumarate oral capsule delayed release 120 mg, 240 mg G dimethyl fumarate starter pack oral 120 & 240 mg G EXTAVIA SUBCUTANEOUS KIT 0.3 MG (interferon beta- NF 1b) GILENYA ORAL CAPSULE 0.5 MG (fingolimod hcl) PSP glatiramer acetate subcutaneous solution prefilled syringe 20 G mg/ml, 40 mg/ml glatiramer acetate (Glatopa Subcutaneous Solution Prefilled G Syringe 20 Mg/Ml, 40 Mg/Ml) KESIMPTA SUBCUTANEOUS SOLUTION AUTO- PSP INJECTOR 20 MG/0.4ML (ofatumumab) MAVENCLAD (10 TABS) ORAL TABLET THERAPY NPSP PACK 10 MG (cladribine) MAVENCLAD (4 TABS) ORAL TABLET THERAPY NPSP PACK 10 MG (cladribine) MAVENCLAD (5 TABS) ORAL TABLET THERAPY NPSP PACK 10 MG (cladribine) MAVENCLAD (6 TABS) ORAL TABLET THERAPY NPSP PACK 10 MG (cladribine)

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 78 Prescription Drug Name Drug Tier Drug Notes MAVENCLAD (7 TABS) ORAL TABLET THERAPY NPSP PACK 10 MG (cladribine) MAVENCLAD (8 TABS) ORAL TABLET THERAPY NPSP PACK 10 MG (cladribine) MAVENCLAD (9 TABS) ORAL TABLET THERAPY NPSP PACK 10 MG (cladribine) MAYZENT ORAL TABLET 0.25 MG, 2 MG (siponimod PSP fumarate) MAYZENT STARTER PACK ORAL TABLET THERAPY PSP PACK 0.25 MG (siponimod fumarate) OCREVUS INTRAVENOUS SOLUTION 300 MG/10ML PSP (ocrelizumab) PLEGRIDY INTRAMUSCULAR SOLUTION PREFILLED SYRINGE 125 MCG/0.5ML (peginterferon NF beta-1a) PLEGRIDY STARTER PACK SUBCUTANEOUS SOLUTION PEN-INJECTOR 63 & 94 MCG/0.5ML NF (peginterferon beta-1a) PLEGRIDY STARTER PACK SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 63 & 94 MCG/0.5ML NF (peginterferon beta-1a) PLEGRIDY SUBCUTANEOUS SOLUTION PEN- NF INJECTOR 125 MCG/0.5ML (peginterferon beta-1a) PLEGRIDY SUBCUTANEOUS SOLUTION PREFILLED NF SYRINGE 125 MCG/0.5ML (peginterferon beta-1a) REBIF REBIDOSE SUBCUTANEOUS SOLUTION AUTO-INJECTOR 22 MCG/0.5ML, 44 MCG/0.5ML PSP (interferon beta-1a) REBIF REBIDOSE TITRATION PACK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 6X8.8 PSP & 6X22 MCG (interferon beta-1a) REBIF SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 22 MCG/0.5ML, 44 MCG/0.5ML (interferon beta- PSP 1a) REBIF TITRATION PACK SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 6X8.8 & 6X22 MCG PSP (interferon beta-1a) TECFIDERA ORAL 120 & 240 MG (dimethyl fumarate) NF TECFIDERA ORAL CAPSULE DELAYED RELEASE 120 NF MG, 240 MG (dimethyl fumarate)

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 79 Prescription Drug Name Drug Tier Drug Notes TYSABRI INTRAVENOUS CONCENTRATE 300 PSP MG/15ML (natalizumab) VUMERITY ORAL CAPSULE DELAYED RELEASE 231 PSP MG (diroximel fumarate) ZEPOSIA 7-DAY STARTER PACK ORAL CAPSULE THERAPY PACK 4 X 0.23MG & 3 X 0.46MG (ozanimod PSP hcl) ZEPOSIA ORAL CAPSULE 0.92 MG (ozanimod hcl) PSP ZEPOSIA STARTER KIT ORAL CAPSULE THERAPY PSP PACK 0.23MG & 0.46MG & 0.92MG (ozanimod hcl) MUSCULOSKELETAL THERAPY AGENTS - DRUGS TO TREAT MUSCLE SPASMS AMRIX ORAL CAPSULE EXTENDED RELEASE 24 NF HOUR 15 MG, 30 MG (cyclobenzaprine hcl) baclofen oral tablet 10 mg, 20 mg, 5 mg G BOTOX INJECTION SOLUTION RECONSTITUTED 100 NPSP UNIT, 200 UNIT (onabotulinumtoxina) BRIDION INTRAVENOUS SOLUTION 200 MG/2ML, 500 NF MG/5ML (sugammadex sodium) carisoprodol oral tablet 250 mg NF carisoprodol oral tablet 350 mg G carisoprodol-aspirin-codeine oral tablet 200-325-16 mg G chlorzoxazone oral tablet 250 mg, 375 mg, 500 mg, 750 mg NF cyclobenzaprine hcl er oral capsule extended release 24 hour 15 NF mg, 30 mg cyclobenzaprine hcl oral tablet 10 mg, 5 mg G cyclobenzaprine hcl oral tablet 7.5 mg NF dantrolene sodium oral capsule 100 mg, 25 mg, 50 mg G DYSPORT INTRAMUSCULAR SOLUTION RECONSTITUTED 300 UNIT, 500 UNIT NPSP (abobotulinumtoxina) FEXMID ORAL TABLET 7.5 MG (cyclobenzaprine hcl) NF FIRST-BACLOFEN ORAL SUSPENSION 1 MG/ML, 5 NF MG/ML (baclofen) chlorzoxazone (Lorzone Oral Tablet 375 Mg, 750 Mg) NF MACI INTRA-ARTICULAR SHEET (autolog cult chond NF coll membr)

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 80 Prescription Drug Name Drug Tier Drug Notes METAXALL CP COMBINATION KIT 800 & 0.025 MG & NF % (metaxalone-capsaicin) metaxalone oral tablet 400 mg NF metaxalone oral tablet 800 mg G methocarbamol oral tablet 500 mg, 750 mg NF norgesic forte oral tablet 50-770-60 mg NF orphenadrine citrate er oral tablet extended release 12 hour 100 G mg orphenadrine-asa-caffeine oral tablet 50-770-60 mg NF orphenadrine-aspirin-caffeine (Orphengesic Forte Oral Tablet NF 50-770-60 Mg) TABRADOL FUSEPAQ ORAL SUSPENSION 1 MG/ML NF (cyclobenzaprine hcl-msm) TABRADOL RAPIDPAQ ORAL SUSPENSION 1 MG/ML NF (cyclobenzaprine hcl-msm) tizanidine hcl oral capsule 2 mg, 4 mg, 6 mg G tizanidine hcl oral tablet 2 mg, 4 mg G XEOMIN INTRAMUSCULAR SOLUTION RECONSTITUTED 100 UNIT, 200 UNIT, 50 UNIT NPSP (incobotulinumtoxina) NARCOLEPSY/CATAPLEXY - DRUGS FOR SLEEP DISORDERS armodafinil oral tablet 150 mg, 200 mg, 250 mg, 50 mg G modafinil oral tablet 100 mg, 200 mg G NUVIGIL ORAL TABLET 150 MG, 200 MG, 250 MG, 50 NF MG (armodafinil) PROVIGIL ORAL TABLET 100 MG, 200 MG (modafinil) NF SUNOSI ORAL TABLET 150 MG, 75 MG (solriamfetol hcl) NF XYREM ORAL SOLUTION 500 MG/ML (sodium oxybate) NPB POLYNEUROPATHY TEGSEDI SUBCUTANEOUS SOLUTION PREFILLED PSP SYRINGE 284 MG/1.5ML (inotersen sodium) POSTHERPETIC NEURALGIA (PHN) CONVENIENCE PAK COMBINATION THERAPY NF PACK 600 & 5 MG & % (gabapentin & lidocaine) HORIZANT ORAL TABLET EXTENDED RELEASE 300 NF MG, 600 MG (gabapentin enacarbil)

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 81 Prescription Drug Name Drug Tier Drug Notes LYRICA CR ORAL TABLET EXTENDED RELEASE 24 NF HOUR 165 MG, 330 MG, 82.5 MG (pregabalin) PSYCHOTHERAPEUTIC-MISC acamprosate calcium oral tablet delayed release 333 mg G ADDYI ORAL TABLET 100 MG (flibanserin) NF bupropion hcl er (smoking det) oral tablet extended release 12 CE hour 150 mg CHANTIX CONTINUING MONTH PAK ORAL TABLET CE 1 MG (varenicline tartrate) CHANTIX ORAL TABLET 0.5 MG, 1 MG (varenicline CE tartrate) CHANTIX STARTING MONTH PAK ORAL TABLET 0.5 CE MG X 11 & 1 MG X 42 (varenicline tartrate) chlordiazepoxide-amitriptyline oral tablet 10-25 mg, 5-12.5 mg G cvs nicotine mouth/throat gum 2 mg, 4 mg CE cvs nicotine polacrilex mouth/throat gum 2 mg, 4 mg CE cvs nicotine polacrilex mouth/throat lozenge 2 mg, 4 mg CE cvs nicotine transdermal patch 24 hour 14 mg/24hr, 21 mg/24hr, CE 7 mg/24hr disulfiram oral tablet 250 mg, 500 mg G eq nicotine mouth/throat lozenge 4 mg CE eq nicotine polacrilex mouth/throat gum 2 mg, 4 mg CE eq nicotine polacrilex mouth/throat lozenge 2 mg, 4 mg CE eq nicotine step 3 transdermal patch 24 hour 7 mg/24hr CE eq nicotine transdermal patch 24 hour 14 mg/24hr, 21 mg/24hr CE eql nicotine polacrilex mouth/throat lozenge 2 mg, 4 mg CE gnp nicotine mini mouth/throat lozenge 2 mg CE gnp nicotine polacrilex mouth/throat gum 2 mg, 4 mg CE gnp nicotine polacrilex mouth/throat lozenge 2 mg, 4 mg CE gnp nicotine transdermal patch 24 hour 14 mg/24hr, 7 mg/24hr CE goodsense nicotine mouth/throat gum 4 mg CE goodsense nicotine mouth/throat lozenge 4 mg CE hm nicotine polacrilex mouth/throat gum 2 mg, 4 mg CE hm nicotine polacrilex mouth/throat lozenge 2 mg, 4 mg CE hm nicotine transdermal patch 24 hour 14 mg/24hr, 21 mg/24hr, CE 7 mg/24hr

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 82 Prescription Drug Name Drug Tier Drug Notes KLS QUIT2 MOUTH/THROAT GUM 2 MG (nicotine CE polacrilex) KLS QUIT2 MOUTH/THROAT LOZENGE 2 MG (nicotine CE polacrilex) KLS QUIT4 MOUTH/THROAT GUM 4 MG (nicotine CE polacrilex) KLS QUIT4 MOUTH/THROAT LOZENGE 4 MG (nicotine CE polacrilex) LUCEMYRA ORAL TABLET 0.18 MG (lofexidine hcl) NF naloxone hcl injection solution 0.4 mg/ml, 4 mg/10ml G naloxone hcl injection solution cartridge 0.4 mg/ml G naloxone hcl injection solution prefilled syringe 2 mg/2ml G naltrexone hcl oral tablet 50 mg G NARCAN NASAL LIQUID 4 MG/0.1ML (naloxone hcl) PB NICORELIEF MOUTH/THROAT GUM 2 MG (nicotine CE polacrilex) nicotine mini mouth/throat lozenge 2 mg CE nicotine polacrilex mouth/throat gum 2 mg, 4 mg CE nicotine polacrilex mouth/throat lozenge 2 mg, 4 mg CE nicotine step 1 transdermal patch 24 hour 21 mg/24hr CE nicotine step 2 transdermal patch 24 hour 14 mg/24hr CE nicotine step 3 transdermal patch 24 hour 7 mg/24hr CE nicotine transdermal patch 24 hour 21 mg/24hr, 7 mg/24hr CE NICOTROL INHALATION INHALER 10 MG (nicotine) CE NICOTROL NS NASAL SOLUTION 10 MG/ML (nicotine) CE olanzapine-fluoxetine hcl oral capsule 12-25 mg, 12-50 mg, 3-25 G mg, 6-25 mg, 6-50 mg perphenazine-amitriptyline oral tablet 2-10 mg, 2-25 mg, 4-10 G mg, 4-25 mg, 4-50 mg ra mini nicotine mouth/throat lozenge 2 mg, 4 mg CE ra nicotine mouth/throat gum 2 mg, 4 mg CE ra nicotine transdermal patch 24 hour 14 mg/24hr, 21 mg/24hr CE sm nicotine mouth/throat gum 4 mg CE sm nicotine mouth/throat lozenge 2 mg CE sm nicotine polacrilex mouth/throat gum 2 mg, 4 mg CE sm nicotine polacrilex mouth/throat lozenge 4 mg CE

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 83 Prescription Drug Name Drug Tier Drug Notes sm nicotine transdermal patch 24 hour 14 mg/24hr, 21 mg/24hr, CE 7 mg/24hr THRIVE MOUTH/THROAT GUM 2 MG (nicotine CE polacrilex) VIVITROL INTRAMUSCULAR SUSPENSION NPSP RECONSTITUTED 380 MG (naltrexone) VYLEESI SUBCUTANEOUS SOLUTION AUTO- NF INJECTOR 1.75 MG/0.3ML (bremelanotide acetate) ENDOCRINE AND METABOLIC - DRUGS TO TREAT DIABETES AND REGULATE HORMONES ANDROGENS - DRUGS TO REGULATE MALE HORMONES ANDRODERM TRANSDERMAL PATCH 24 HOUR 2 PB MG/24HR, 4 MG/24HR (testosterone) ANDROGEL PUMP TRANSDERMAL GEL 20.25 NF MG/ACT (1.62%) (testosterone) ANDROGEL TRANSDERMAL GEL 20.25 MG/1.25GM (1.62%), 25 MG/2.5GM (1%), 40.5 MG/2.5GM (1.62%), 50 NF MG/5GM (1%) (testosterone) DEPO-TESTOSTERONE INTRAMUSCULAR SOLUTION 100 MG/ML, 200 MG/ML (testosterone NPB cypionate) ec-rx testosterone transdermal cream 0.2 %, 0.4 %, 10 %, 20 % NF FORTESTA TRANSDERMAL GEL 10 MG/ACT (2%) NF (testosterone) INTRAROSA VAGINAL INSERT 6.5 MG (prasterone) NF methitest oral tablet 10 mg NPB methyltestosterone oral capsule 10 mg G NATESTO NASAL GEL 5.5 MG/ACT (testosterone) PB oxandrolone oral tablet 10 mg, 2.5 mg G TESTIM TRANSDERMAL GEL 50 MG/5GM (1%) NF (testosterone) TESTONE CIK INTRAMUSCULAR KIT 200 MG/ML NF (testosterone cypionate) TESTOPEL IMPLANT PELLET 75 MG (testosterone) NPB testosterone cypionate intramuscular solution 100 mg/ml, 200 G mg/ml testosterone enanthate intramuscular solution 200 mg/ml G

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 84 Prescription Drug Name Drug Tier Drug Notes testosterone gel 12.5 mg/act (1%) transdermal 12.5 mg/act G (1%) testosterone gel 12.5 mg/act (1%) transdermal 12.5 mg/act NF (1%) testosterone gel 50 mg/5gm (1%) transdermal 50 mg/5gm (1%) G testosterone gel 50 mg/5gm (1%) transdermal 50 mg/5gm (1%) NF testosterone transdermal gel 1.62 %, 10 mg/act (2%), 20.25 mg/1.25gm (1.62%), 25 mg/2.5gm (1%), 40.5 mg/2.5gm G (1.62%) testosterone transdermal solution 30 mg/act G VOGELXO PUMP TRANSDERMAL GEL 12.5 MG/ACT NF (1%) (testosterone) VOGELXO TRANSDERMAL GEL 50 MG/5GM (1%) NF (testosterone) XYOSTED SUBCUTANEOUS SOLUTION AUTO- INJECTOR 100 MG/0.5ML, 50 MG/0.5ML, 75 MG/0.5ML NF (testosterone enanthate) ANTIDIABETICS, ALPHA-GLUCOSIDASE INHIBITORS acarbose oral tablet 100 mg, 25 mg, 50 mg G miglitol oral tablet 100 mg, 25 mg, 50 mg G ANTIDIABETICS, AMYLIN ANALOGS SYMLINPEN 120 SUBCUTANEOUS SOLUTION PEN- PB INJECTOR 2700 MCG/2.7ML (pramlintide acetate) SYMLINPEN 60 SUBCUTANEOUS SOLUTION PEN- PB INJECTOR 1500 MCG/1.5ML (pramlintide acetate) ANTIDIABETICS, BIGUANIDE GLUMETZA ORAL TABLET EXTENDED RELEASE 24 NF HOUR 1000 MG, 500 MG (metformin hcl) metformin hcl er (mod) oral tablet extended release 24 hour NF 1000 mg, 500 mg metformin hcl er (osm) oral tablet extended release 24 hour NF 1000 mg, 500 mg metformin hcl er oral tablet extended release 24 hour 500 mg G LGC metformin hcl er oral tablet extended release 24 hour 750 mg G metformin hcl oral solution 500 mg/5ml NPB metformin hcl oral tablet 1000 mg, 500 mg, 850 mg G LGC RIOMET ORAL SOLUTION 500 MG/5ML (metformin hcl) NF

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 85 Prescription Drug Name Drug Tier Drug Notes ANTIDIABETICS, BIGUANIDE/ SULFONYLUREA COMBINATIONS glipizide-metformin hcl oral tablet 2.5-250 mg, 2.5-500 mg, 5- G LGC 500 mg glyburide-metformin oral tablet 1.25-250 mg, 2.5-500 mg, 5-500 G LGC mg ANTIDIABETICS, DIPEPTIDYL PEPTIDASE-4 INHIBITORS alogliptin benzoate oral tablet 12.5 mg, 25 mg, 6.25 mg NF JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG PB (sitagliptin phosphate) NESINA ORAL TABLET 12.5 MG, 25 MG, 6.25 MG NF (alogliptin benzoate) ONGLYZA ORAL TABLET 2.5 MG, 5 MG (saxagliptin hcl) NF TRADJENTA ORAL TABLET 5 MG (linagliptin) NF ANTIDIABETICS, DOPAMINE RECEPTOR AGONISTS CYCLOSET ORAL TABLET 0.8 MG (bromocriptine NF mesylate) ANTIDIABETICS, DPP-4 INHIBITOR COMBINATIONS alogliptin-metformin hcl oral tablet 12.5-1000 mg, 12.5-500 mg NF alogliptin-pioglitazone oral tablet 12.5-15 mg, 12.5-30 mg, 12.5- NF 45 mg, 25-15 mg, 25-30 mg, 25-45 mg JANUMET ORAL TABLET 50-1000 MG, 50-500 MG PB (sitagliptin-metformin hcl) JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 100-1000 MG, 50-1000 MG, 50-500 MG PB (sitagliptin-metformin hcl) JENTADUETO ORAL TABLET 2.5-1000 MG, 2.5-500 MG, NF 2.5-850 MG (linagliptin-metformin hcl) JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 2.5-1000 MG, 5-1000 MG (linagliptin- NF metformin hcl) KAZANO ORAL TABLET 12.5-1000 MG, 12.5-500 MG NF (alogliptin-metformin hcl) KOMBIGLYZE XR ORAL TABLET EXTENDED RELEASE 24 HOUR 2.5-1000 MG, 5-1000 MG, 5-500 MG NF (saxagliptin-metformin)

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 86 Prescription Drug Name Drug Tier Drug Notes OSENI ORAL TABLET 12.5-15 MG, 12.5-30 MG, 12.5-45 MG, 25-15 MG, 25-30 MG, 25-45 MG (alogliptin- NF pioglitazone) TRIJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-5-1000 MG, 12.5-2.5-1000 MG, 25-5-1000 MG, PB 5-2.5-1000 MG (empagliflozin-linaglip-metform) ANTIDIABETICS, INCRETIN MIMETIC AGENTS ADLYXIN STARTER PACK SUBCUTANEOUS PEN- NF INJECTOR KIT 10 & 20 MCG/0.2ML (lixisenatide) ADLYXIN SUBCUTANEOUS SOLUTION PEN- NF INJECTOR 20 MCG/0.2ML (lixisenatide) BYDUREON BCISE SUBCUTANEOUS AUTO- NF INJECTOR 2 MG/0.85ML (exenatide) BYETTA 10 MCG PEN SUBCUTANEOUS SOLUTION NF PEN-INJECTOR 10 MCG/0.04ML (exenatide) BYETTA 5 MCG PEN SUBCUTANEOUS SOLUTION NF PEN-INJECTOR 5 MCG/0.02ML (exenatide) OZEMPIC (0.25 OR 0.5 MG/DOSE) SUBCUTANEOUS PB SOLUTION PEN-INJECTOR 2 MG/1.5ML (semaglutide) OZEMPIC (1 MG/DOSE) SUBCUTANEOUS SOLUTION PB PEN-INJECTOR 2 MG/1.5ML, 4 MG/3ML (semaglutide) RYBELSUS ORAL TABLET 14 MG, 3 MG, 7 MG PB (semaglutide) TRULICITY SUBCUTANEOUS SOLUTION PEN- INJECTOR 0.75 MG/0.5ML, 1.5 MG/0.5ML, 3 MG/0.5ML, PB 4.5 MG/0.5ML (dulaglutide) VICTOZA SUBCUTANEOUS SOLUTION PEN- PB INJECTOR 18 MG/3ML (liraglutide) ANTIDIABETICS, INCRETIN MIMETIC COMBINATION AGENTS SOLIQUA SUBCUTANEOUS SOLUTION PEN- INJECTOR 100-33 UNT-MCG/ML (insulin glargine- PB lixisenatide) XULTOPHY SUBCUTANEOUS SOLUTION PEN- INJECTOR 100-3.6 UNIT-MG/ML (insulin degludec- PB liraglutide) ANTIDIABETICS, INSULIN ADMELOG SOLOSTAR SUBCUTANEOUS SOLUTION NF PEN-INJECTOR 100 UNIT/ML (insulin lispro)

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 87 Prescription Drug Name Drug Tier Drug Notes ADMELOG SUBCUTANEOUS SOLUTION 100 NF UNIT/ML (insulin lispro) AFREZZA INHALATION POWDER 12 UNIT, 4 & 8 & 12 UNIT, 4 UNIT, 8 UNIT, 90 X 4 UNIT & 90X8 UNIT, 90 X 8 NF UNIT & 90X12 UNIT (insulin regular human) APIDRA INJECTION SOLUTION 100 UNIT/ML (insulin NF glulisine) APIDRA SOLOSTAR SUBCUTANEOUS SOLUTION NF PEN-INJECTOR 100 UNIT/ML (insulin glulisine) BASAGLAR KWIKPEN SUBCUTANEOUS SOLUTION PB PEN-INJECTOR 100 UNIT/ML (insulin glargine) FIASP FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML (insulin aspart PB (w/niacinamide)) FIASP PENFILL SUBCUTANEOUS SOLUTION PB CARTRIDGE 100 UNIT/ML (insulin aspart (w/niacinamide)) FIASP SUBCUTANEOUS SOLUTION 100 UNIT/ML PB (insulin aspart (w/niacinamide)) HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML, 200 UNIT/ML (insulin NF lispro) HUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (50-50) 100 UNIT/ML NF (insulin lispro prot & lispro) HUMALOG MIX 50/50 SUBCUTANEOUS SUSPENSION NF (50-50) 100 UNIT/ML (insulin lispro prot & lispro) HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (75-25) 100 UNIT/ML NF (insulin lispro prot & lispro) HUMALOG MIX 75/25 SUBCUTANEOUS SUSPENSION NF (75-25) 100 UNIT/ML (insulin lispro prot & lispro) HUMALOG SUBCUTANEOUS SOLUTION 100 NF UNIT/ML (insulin lispro) HUMALOG SUBCUTANEOUS SOLUTION NF CARTRIDGE 100 UNIT/ML (insulin lispro) HUMULIN 70/30 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML NF (insulin nph isophane & regular) HUMULIN 70/30 SUBCUTANEOUS SUSPENSION (70- NF 30) 100 UNIT/ML (insulin nph isophane & regular)

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 88 Prescription Drug Name Drug Tier Drug Notes HUMULIN N KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR 100 UNIT/ML (insulin nph NF human (isophane)) HUMULIN N SUBCUTANEOUS SUSPENSION 100 NF UNIT/ML (insulin nph human (isophane)) HUMULIN R INJECTION SOLUTION 100 UNIT/ML NF (insulin regular human) HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION 500 UNIT/ML (insulin PB regular human) HUMULIN R U-500 KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 500 UNIT/ML (insulin regular PB human) LANTUS SOLOSTAR SUBCUTANEOUS SOLUTION NF PEN-INJECTOR 100 UNIT/ML (insulin glargine) LANTUS SUBCUTANEOUS SOLUTION 100 UNIT/ML NF (insulin glargine) LEVEMIR FLEXTOUCH SUBCUTANEOUS SOLUTION PB PEN-INJECTOR 100 UNIT/ML (insulin detemir) LEVEMIR SUBCUTANEOUS SOLUTION 100 UNIT/ML PB (insulin detemir) NOVOLIN 70/30 FLEXPEN RELION SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML NF (insulin nph isophane & regular) NOVOLIN 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML PB (insulin nph isophane & regular) NOVOLIN 70/30 RELION SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML (insulin nph isophane & NF regular) NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION (70-30) PB 100 UNIT/ML (insulin nph isophane & regular) NOVOLIN N FLEXPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR 100 UNIT/ML (insulin nph PB human (isophane)) NOVOLIN N RELION SUBCUTANEOUS SUSPENSION NF 100 UNIT/ML (insulin nph human (isophane)) NOVOLIN N SUBCUTANEOUS SUSPENSION 100 PB UNIT/ML (insulin nph human (isophane))

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 89 Prescription Drug Name Drug Tier Drug Notes NOVOLIN R FLEXPEN INJECTION SOLUTION PEN- PB INJECTOR 100 UNIT/ML (insulin regular human) NOVOLIN R FLEXPEN RELION INJECTION SOLUTION PEN-INJECTOR 100 UNIT/ML (insulin regular NF human) NOVOLIN R INJECTION SOLUTION 100 UNIT/ML PB (insulin regular human) NOVOLIN R RELION INJECTION SOLUTION 100 NF UNIT/ML (insulin regular human) NOVOLOG FLEXPEN SUBCUTANEOUS SOLUTION PB PEN-INJECTOR 100 UNIT/ML (insulin aspart) NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML PB (insulin aspart prot & aspart) NOVOLOG MIX 70/30 SUBCUTANEOUS SUSPENSION PB (70-30) 100 UNIT/ML (insulin aspart prot & aspart) NOVOLOG PENFILL SUBCUTANEOUS SOLUTION PB CARTRIDGE 100 UNIT/ML (insulin aspart) NOVOLOG SUBCUTANEOUS SOLUTION 100 UNIT/ML PB (insulin aspart) TOUJEO MAX SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 300 UNIT/ML (insulin PB glargine) TOUJEO SOLOSTAR SUBCUTANEOUS SOLUTION PB PEN-INJECTOR 300 UNIT/ML (insulin glargine) TRESIBA FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML, 200 UNIT/ML (insulin PB degludec) TRESIBA SUBCUTANEOUS SOLUTION 100 UNIT/ML PB (insulin degludec) ANTIDIABETICS, INSULIN SENSITIZER ACTOS ORAL TABLET 15 MG, 30 MG, 45 MG NF (pioglitazone hcl) pioglitazone hcl oral tablet 15 mg, 30 mg, 45 mg G LGC ANTIDIABETICS, INSULIN SENSITIZER/BIGUANIDE COMBINATION pioglitazone hcl-metformin hcl oral tablet 15-500 mg, 15-850 mg G LGC

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 90 Prescription Drug Name Drug Tier Drug Notes ANTIDIABETICS, INSULIN SENSITIZER/SULFONYLUREA COMBINATION pioglitazone hcl-glimepiride oral tablet 30-2 mg, 30-4 mg G ANTIDIABETICS, MEGLITINIDE nateglinide oral tablet 120 mg, 60 mg G LGC repaglinide oral tablet 0.5 mg, 1 mg, 2 mg G LGC ANTIDIABETICS, SODIUM-GLUC CO-TRANSPOR2 (SGLT2) INHIB QTERN ORAL TABLET 10-5 MG, 5-5 MG (dapagliflozin- NPB saxagliptin) STEGLUJAN ORAL TABLET 15-100 MG, 5-100 MG NF (ertugliflozin-sitagliptin) ANTIDIABETICS, SODIUM-GLUC CO-TRANSPOR2 INHIB SYNJARDY ORAL TABLET 12.5-1000 MG, 12.5-500 MG, PB 5-1000 MG, 5-500 MG (empagliflozin-metformin hcl) SYNJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-1000 MG, 12.5-1000 MG, 25-1000 MG, 5-1000 PB MG (empagliflozin-metformin hcl) XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-1000 MG, 10-500 MG, 2.5-1000 MG, 5-1000 MG, PB 5-500 MG (dapagliflozin-metformin hcl) ANTIDIABETICS, SODIUM-GLUC CO-TRANSPOR2 INHIB (SGTL2) COMBO INVOKAMET ORAL TABLET 150-1000 MG, 150-500 MG, NF 50-1000 MG, 50-500 MG (canagliflozin-metformin hcl) INVOKAMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 150-1000 MG, 150-500 MG, 50-1000 NF MG, 50-500 MG (canagliflozin-metformin hcl) SEGLUROMET ORAL TABLET 2.5-1000 MG, 2.5-500 NF MG, 7.5-1000 MG, 7.5-500 MG (ertugliflozin-metformin hcl) ANTIDIABETICS, SODIUM-GLUC CO-TRANSPOR2 INHIB(SGLT2)/DPP-4 INHIBITOR COMBINATIONS GLYXAMBI ORAL TABLET 10-5 MG, 25-5 MG PB (empagliflozin-linagliptin) ANTIDIABETICS, SODIUM-GLUCOSE COTRANSPORTER2 (SGLT2) INHIB FARXIGA ORAL TABLET 10 MG, 5 MG (dapagliflozin PB propanediol)

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 91 Prescription Drug Name Drug Tier Drug Notes INVOKANA ORAL TABLET 100 MG, 300 MG NF (canagliflozin) JARDIANCE ORAL TABLET 10 MG, 25 MG PB (empagliflozin) STEGLATRO ORAL TABLET 15 MG, 5 MG (ertugliflozin NF l-pyroglutamicac) ANTIDIABETICS, SULFONYLUREA glimepiride oral tablet 1 mg, 2 mg, 4 mg G LGC glipizide er oral tablet extended release 24 hour 10 mg, 2.5 mg, 5 G LGC mg glipizide oral tablet 10 mg, 5 mg G LGC glipizide xl oral tablet extended release 24 hour 10 mg, 2.5 mg, 5 G LGC mg glyburide micronized oral tablet 1.5 mg G glyburide micronized oral tablet 3 mg, 6 mg G LGC glyburide oral tablet 1.25 mg, 2.5 mg, 5 mg G LGC tolbutamide oral tablet 500 mg G ANTI-OBESTITY DRUGS SAXENDA SUBCUTANEOUS SOLUTION PEN- PB INJECTOR 18 MG/3ML (liraglutide -weight management) WEGOVY SUBCUTANEOUS SOLUTION AUTO- INJECTOR 0.25 MG/0.5ML, 0.5 MG/0.5ML, 1 MG/0.5ML, NPB 1.7 MG/0.75ML, 2.4 MG/0.75ML (semaglutide-weight management) BISPHOSPHONATES - DRUGS TO TREAT BONE LOSS alendronate sodium oral solution 70 mg/75ml G alendronate sodium oral tablet 10 mg, 35 mg, 5 mg, 70 mg G BINOSTO ORAL TABLET EFFERVESCENT 70 MG NPB (alendronate sodium) FOSAMAX PLUS D ORAL TABLET 70-2800 MG-UNIT, NPB 70-5600 MG-UNIT (alendronate-cholecalciferol) ibandronate sodium oral tablet 150 mg G RECLAST INTRAVENOUS SOLUTION 5 MG/100ML NPSP (zoledronic acid) risedronate sodium oral tablet 150 mg, 30 mg, 35 mg, 5 mg G risedronate sodium oral tablet delayed release 35 mg G zoledronic acid intravenous concentrate 4 mg/5ml G

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 92 Prescription Drug Name Drug Tier Drug Notes zoledronic acid intravenous solution 4 mg/100ml NPSP zoledronic acid intravenous solution 5 mg/100ml G CALCIUM RECEPTOR AGONISTS calcitriol oral capsule 0.25 mcg, 0.5 mcg G calcitriol oral solution 1 mcg/ml G cinacalcet hcl oral tablet 30 mg, 60 mg, 90 mg G doxercalciferol oral capsule 0.5 mcg, 1 mcg, 2.5 mcg G paricalcitol oral capsule 1 mcg, 2 mcg, 4 mcg G RAYALDEE ORAL CAPSULE EXTENDED RELEASE 30 NPB MCG (calcifediol) SENSIPAR ORAL TABLET 30 MG, 60 MG, 90 MG NPSP (cinacalcet hcl) STRENSIQ SUBCUTANEOUS SOLUTION 18 MG/0.45ML, 28 MG/0.7ML, 40 MG/ML, 80 MG/0.8ML NPB (asfotase alfa) CARNITINE DEFICIENCY AGENTS CARNITOR ORAL SOLUTION 1 GM/10ML (levocarnitine) NF CARNITOR ORAL TABLET 330 MG (levocarnitine) NF CARNITOR SF ORAL SOLUTION 1 GM/10ML NF (levocarnitine) levocarnitine oral solution 1 gm/10ml G levocarnitine oral tablet 330 mg G CHELATING AGENTS CHEMET ORAL CAPSULE 100 MG (succimer) NPB CUPRIMINE ORAL CAPSULE 250 MG (penicillamine) NF deferasirox oral tablet soluble 125 mg, 250 mg, 500 mg G deferoxamine mesylate injection solution reconstituted 2 gm NPSP DEPEN TITRATABS ORAL TABLET 250 MG NPB (penicillamine) DESFERAL INJECTION SOLUTION RECONSTITUTED NF 500 MG (deferoxamine mesylate) EXJADE ORAL TABLET SOLUBLE 125 MG, 250 MG, NF 500 MG (deferasirox) FERRIPROX ORAL SOLUTION 100 MG/ML (deferiprone) NF FERRIPROX ORAL TABLET 1000 MG, 500 MG NF (deferiprone)

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 93 Prescription Drug Name Drug Tier Drug Notes FERRIPROX TWICE-A-DAY ORAL TABLET 1000 MG NF (deferiprone) JADENU ORAL TABLET 180 MG, 360 MG, 90 MG NF (deferasirox) JADENU SPRINKLE ORAL PACKET 180 MG, 360 MG, NF 90 MG (deferasirox) LOKELMA ORAL PACKET 10 GM, 5 GM (sodium PB zirconium cyclosilicate) penicillamine oral capsule 250 mg G sodium polystyrene sulfonate oral powder G SPS ORAL SUSPENSION 15 GM/60ML (sodium polystyrene G sulfonate) SYPRINE ORAL CAPSULE 250 MG (trientine hcl) NF trientine hcl oral capsule 250 mg G VELTASSA ORAL PACKET 16.8 GM, 25.2 GM, 8.4 GM PB (patiromer sorbitex calcium) CONTRACEPTIVES - PRODUCTS FOR BIRTH CONTROL levonorgestrel-ethinyl estrad (Afirmelle Oral Tablet 0.1-20 Mg- CE Mcg) AFTERA ORAL TABLET 1.5 MG (levonorgestrel) CE levonorgestrel-ethinyl estrad (Altavera Oral Tablet 0.15-30 Mg- CE Mcg) alyacen 1/35 oral tablet 1-35 mg-mcg CE alyacen 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg CE levonorgest-eth estrad 91-day (Amethia Oral Tablet 0.15-0.03 CE &0.01 Mg) levonorgestrel-ethinyl estrad (Amethyst Oral Tablet 90-20 CE Mcg) ANNOVERA VAGINAL RING 0.013-0.15 MG/24HR CE (segesterone-ethinyl estradiol) desogestrel-ethinyl estradiol (Apri Oral Tablet 0.15-30 Mg- CE Mcg) norethin-eth estrad triphasic (Aranelle Oral Tablet 0.5/1/0.5-35 CE Mg-Mcg) levonorgest-eth estrad 91-day (Ashlyna Oral Tablet 0.15-0.03 CE &0.01 Mg)

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 94 Prescription Drug Name Drug Tier Drug Notes levonorgestrel-ethinyl estrad (Aubra Eq Oral Tablet 0.1-20 Mg- CE Mcg) levonorgestrel-ethinyl estrad (Aubra Oral Tablet 0.1-20 Mg- CE Mcg) norethindrone acet-ethinyl est (Aurovela 1.5/30 Oral Tablet 1.5- CE 30 Mg-Mcg) norethindrone acet-ethinyl est (Aurovela 1/20 Oral Tablet 1-20 CE Mg-Mcg) norethin ace-eth estrad-fe (Aurovela 24 Fe Oral Tablet 1-20 CE Mg-Mcg(24)) norethin ace-eth estrad-fe (Aurovela Fe 1.5/30 Oral Tablet 1.5- CE 30 Mg-Mcg) norethin ace-eth estrad-fe (Aurovela Fe 1/20 Oral Tablet 1-20 CE Mg-Mcg) levonorgestrel-ethinyl estrad (Aviane Oral Tablet 0.1-20 Mg- CE Mcg) levonorgestrel-ethinyl estrad (Ayuna Oral Tablet 0.15-30 Mg- CE Mcg) desogestrel-ethinyl estradiol (Azurette Oral Tablet 0.15- CE 0.02/0.01 Mg (21/5)) BALCOLTRA ORAL TABLET 0.1-20 MG-MCG(21) CE (levonorgest-eth estrad-fe bisg) norethindrone-eth estradiol (Balziva Oral Tablet 0.4-35 Mg- CE Mcg) BEYAZ ORAL TABLET 3-0.02-0.451 MG (drospiren-eth NF estrad-levomefol) norethin ace-eth estrad-fe (Blisovi 24 Fe Oral Tablet 1-20 Mg- CE Mcg(24)) norethin ace-eth estrad-fe (Blisovi Fe 1.5/30 Oral Tablet 1.5-30 CE Mg-Mcg) norethin ace-eth estrad-fe (Blisovi Fe 1/20 Oral Tablet 1-20 CE Mg-Mcg) briellyn oral tablet 0.4-35 mg-mcg CE norethindrone (Camila Oral Tablet 0.35 Mg) CE levonorgest-eth estrad 91-day (Camrese Lo Oral Tablet 0.1- CE 0.02 & 0.01 Mg) levonorgest-eth estrad 91-day (Camrese Oral Tablet 0.15-0.03 CE &0.01 Mg)

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 95 Prescription Drug Name Drug Tier Drug Notes desogestrel-ethinyl estradiol (Caziant Oral Tablet CE 0.1/0.125/0.15 -0.025 Mg) levonorgestrel-ethinyl estrad (Chateal Eq Oral Tablet 0.15-30 CE Mg-Mcg) levonorgestrel-ethinyl estrad (Chateal Oral Tablet 0.15-30 Mg- CE Mcg) norgestrel-ethinyl estradiol (Cryselle-28 Oral Tablet 0.3-30 Mg- CE Mcg) norethindrone-eth estradiol (Cyclafem 1/35 Oral Tablet 1-35 CE Mg-Mcg) norethin-eth estrad triphasic (Cyclafem 7/7/7 Oral Tablet CE 0.5/0.75/1-35 Mg-Mcg) desogestrel-ethinyl estradiol (Cyred Eq Oral Tablet 0.15-30 CE Mg-Mcg) desogestrel-ethinyl estradiol (Cyred Oral Tablet 0.15-30 Mg- CE Mcg) norethindrone-eth estradiol (Dasetta 1/35 Oral Tablet 1-35 Mg- CE Mcg) norethin-eth estrad triphasic (Dasetta 7/7/7 Oral Tablet CE 0.5/0.75/1-35 Mg-Mcg) levonorgest-eth estrad 91-day (Daysee Oral Tablet 0.15-0.03 CE &0.01 Mg) norethindrone (Deblitane Oral Tablet 0.35 Mg) CE levonorgestrel-ethinyl estrad (Delyla Oral Tablet 0.1-20 Mg- CE Mcg) DEPO-SUBQ PROVERA 104 SUBCUTANEOUS SUSPENSION PREFILLED SYRINGE 104 MG/0.65ML CE (medroxyprogesterone acetate) desogestrel-ethinyl estradiol oral tablet 0.15-0.02/0.01 mg CE (21/5) drospiren-eth estrad-levomefol oral tablet 3-0.02-0.451 mg, 3- CE 0.03-0.451 mg drospirenone-ethinyl estradiol oral tablet 3-0.02 mg, 3-0.03 mg CE ECONTRA EZ ORAL TABLET 1.5 MG (levonorgestrel) CE ECONTRA ONE-STEP ORAL TABLET 1.5 MG CE (levonorgestrel) norgestrel-ethinyl estradiol (Elinest Oral Tablet 0.3-30 Mg- CE Mcg) ELLA ORAL TABLET 30 MG (ulipristal acetate) CE 2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 96 Prescription Drug Name Drug Tier Drug Notes etonogestrel-ethinyl estradiol (Eluryng Vaginal Ring 0.12-0.015 CE Mg/24Hr) desogestrel-ethinyl estradiol (Emoquette Oral Tablet 0.15-30 CE Mg-Mcg) levonorg-eth estrad triphasic (Enpresse-28 Oral Tablet 50- CE 30/75-40/ 125-30 Mcg) desogestrel-ethinyl estradiol (Enskyce Oral Tablet 0.15-30 Mg- CE Mcg) norethindrone (Errin Oral Tablet 0.35 Mg) CE norgestimate-eth estradiol (Estarylla Oral Tablet 0.25-35 Mg- CE Mcg) ethynodiol diac-eth estradiol oral tablet 1-35 mg-mcg, 1-50 mg- CE mcg etonogestrel-ethinyl estradiol vaginal ring 0.12-0.015 mg/24hr CE levonorgestrel-ethinyl estrad (Falmina Oral Tablet 0.1-20 Mg- CE Mcg) levonorgest-eth estrad 91-day (Fayosim Oral Tablet 42-21-21-7 CE Days) norgestimate-eth estradiol (Femynor Oral Tablet 0.25-35 Mg- CE Mcg) norethindrone acet-ethinyl est (Hailey 1.5/30 Oral Tablet 1.5-30 CE Mg-Mcg) norethin ace-eth estrad-fe (Hailey 24 Fe Oral Tablet 1-20 Mg- CE Mcg(24)) norethindrone (Heather Oral Tablet 0.35 Mg) CE norethindrone (Incassia Oral Tablet 0.35 Mg) CE levonorgest-eth estrad 91-day (Introvale Oral Tablet 0.15-0.03 CE Mg) desogestrel-ethinyl estradiol (Isibloom Oral Tablet 0.15-30 Mg- CE Mcg) drospirenone-ethinyl estradiol (Jasmiel Oral Tablet 3-0.02 Mg) CE norethindrone (Jencycla Oral Tablet 0.35 Mg) CE levonorgest-eth estrad 91-day (Jolessa Oral Tablet 0.15-0.03 CE Mg) desogestrel-ethinyl estradiol (Juleber Oral Tablet 0.15-30 Mg- CE Mcg) norethindrone acet-ethinyl est (Junel 1.5/30 Oral Tablet 1.5-30 CE Mg-Mcg)

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 97 Prescription Drug Name Drug Tier Drug Notes norethindrone acet-ethinyl est (Junel 1/20 Oral Tablet 1-20 Mg- CE Mcg) norethin ace-eth estrad-fe (Junel Fe 1.5/30 Oral Tablet 1.5-30 CE Mg-Mcg) norethin ace-eth estrad-fe (Junel Fe 1/20 Oral Tablet 1-20 Mg- CE Mcg) norethin ace-eth estrad-fe (Junel Fe 24 Oral Tablet 1-20 Mg- CE Mcg(24)) norethin-eth estradiol-fe (Kaitlib Fe Oral Tablet Chewable 0.8- CE 25 Mg-Mcg) desogestrel-ethinyl estradiol (Kalliga Oral Tablet 0.15-30 Mg- CE Mcg) desogestrel-ethinyl estradiol (Kariva Oral Tablet 0.15-0.02/0.01 CE Mg (21/5)) ethynodiol diac-eth estradiol (Kelnor 1/35 Oral Tablet 1-35 CE Mg-Mcg) ethynodiol diac-eth estradiol (Kelnor 1/50 Oral Tablet 1-50 CE Mg-Mcg) levonorgestrel-ethinyl estrad (Kurvelo Oral Tablet 0.15-30 Mg- CE Mcg) KYLEENA INTRAUTERINE INTRAUTERINE DEVICE CE 19.5 MG (levonorgestrel) norethindrone acet-ethinyl est (Larin 1.5/30 Oral Tablet 1.5-30 CE Mg-Mcg) norethindrone acet-ethinyl est (Larin 1/20 Oral Tablet 1-20 Mg- CE Mcg) norethin ace-eth estrad-fe (Larin 24 Fe Oral Tablet 1-20 Mg- CE Mcg(24)) norethin ace-eth estrad-fe (Larin Fe 1.5/30 Oral Tablet 1.5-30 CE Mg-Mcg) norethin ace-eth estrad-fe (Larin Fe 1/20 Oral Tablet 1-20 Mg- CE Mcg) levonorgestrel-ethinyl estrad (Larissia Oral Tablet 0.1-20 Mg- CE Mcg) norethin-eth estradiol-fe (Layolis Fe Oral Tablet Chewable 0.8- CE 25 Mg-Mcg) norethin-eth estrad triphasic (Leena Oral Tablet 0.5/1/0.5-35 CE Mg-Mcg)

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 98 Prescription Drug Name Drug Tier Drug Notes levonorgestrel-ethinyl estrad (Lessina Oral Tablet 0.1-20 Mg- CE Mcg) levonorg-eth estrad triphasic (Levonest Oral Tablet 50-30/75- CE 40/ 125-30 Mcg) levonorgest-eth est & eth est oral tablet 42-21-21-7 days CE levonorgest-eth estrad 91-day oral tablet 0.1-0.02 & 0.01 mg, CE 0.15-0.03 &0.01 mg, 0.15-0.03 mg levonorgestrel oral tablet 1.5 mg CE levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 0.15-30 CE mg-mcg, 90-20 mcg levonorg-eth estrad triphasic oral tablet 50-30/75-40/ 125-30 CE mcg levonorgestrel-ethinyl estrad (Levora 0.15/30 (28) Oral Tablet CE 0.15-30 Mg-Mcg) levonorgestrel-ethinyl estrad (Lillow Oral Tablet 0.15-30 Mg- CE Mcg) LO LOESTRIN FE ORAL TABLET 1 MG-10 MCG / 10 CE MCG (norethin-eth estrad-fe biphas) drospirenone-ethinyl estradiol (Loryna Oral Tablet 3-0.02 Mg) CE norgestrel-ethinyl estradiol (Low-Ogestrel Oral Tablet 0.3-30 CE Mg-Mcg) drospirenone-ethinyl estradiol (Lo-Zumandimine Oral Tablet CE 3-0.02 Mg) levonorgestrel-ethinyl estrad (Lutera Oral Tablet 0.1-20 Mg- CE Mcg) norethindrone (Lyza Oral Tablet 0.35 Mg) CE marlissa oral tablet 0.15-30 mg-mcg CE medroxyprogesterone acetate intramuscular suspension 150 CE mg/ml medroxyprogesterone acetate intramuscular suspension prefilled CE syringe 150 mg/ml norethindrone acet-ethinyl est (Microgestin 1.5/30 Oral Tablet CE 1.5-30 Mg-Mcg) norethindrone acet-ethinyl est (Microgestin 1/20 Oral Tablet 1- CE 20 Mg-Mcg) norethin ace-eth estrad-fe (Microgestin Fe 1.5/30 Oral Tablet CE 1.5-30 Mg-Mcg) norethin ace-eth estrad-fe (Microgestin Fe 1/20 Oral Tablet 1- CE 20 Mg-Mcg) 2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 99 Prescription Drug Name Drug Tier Drug Notes norgestimate-eth estradiol (Mili Oral Tablet 0.25-35 Mg-Mcg) CE MINASTRIN 24 FE ORAL TABLET CHEWABLE 1-20 NF MG-MCG(24) (norethin ace-eth estrad-fe) MIRENA (52 MG) INTRAUTERINE INTRAUTERINE CE DEVICE 20 MCG/24HR (levonorgestrel) norgestimate-eth estradiol (Mono-Linyah Oral Tablet 0.25-35 CE Mg-Mcg) MY CHOICE ORAL TABLET 1.5 MG (levonorgestrel) CE MY WAY ORAL TABLET 1.5 MG (levonorgestrel) CE NATAZIA ORAL TABLET 3/2-2/2-3/1 MG (estradiol CE valerate-dienogest) norethindrone-eth estradiol (Necon 0.5/35 (28) Oral Tablet 0.5- CE 35 Mg-Mcg) NEW DAY ORAL TABLET 1.5 MG (levonorgestrel) CE NEXPLANON SUBCUTANEOUS IMPLANT 68 MG CE (etonogestrel) drospirenone-ethinyl estradiol (Nikki Oral Tablet 3-0.02 Mg) CE norethindrone (Nora-Be Oral Tablet 0.35 Mg) CE norethin ace-eth estrad-fe oral tablet 1-20 mg-mcg CE norethin ace-eth estrad-fe oral tablet chewable 1-20 mg- CE mcg(24) norethindrone acet-ethinyl est oral tablet 1-20 mg-mcg CE norethindrone oral tablet 0.35 mg CE norethin-eth estradiol-fe oral tablet chewable 0.4-35 mg-mcg, CE 0.8-25 mg-mcg norgestimate-eth estradiol oral tablet 0.25-35 mg-mcg CE norgestim-eth estrad triphasic oral tablet 0.18/0.215/0.25 mg-25 CE mcg, 0.18/0.215/0.25 mg-35 mcg norethindrone (Norlyda Oral Tablet 0.35 Mg) CE norethindrone (Norlyroc Oral Tablet 0.35 Mg) CE norethindrone-eth estradiol (Nortrel 0.5/35 (28) Oral Tablet CE 0.5-35 Mg-Mcg) norethindrone-eth estradiol (Nortrel 1/35 (21) Oral Tablet 1-35 CE Mg-Mcg) norethindrone-eth estradiol (Nortrel 1/35 (28) Oral Tablet 1-35 CE Mg-Mcg) norethin-eth estrad triphasic (Nortrel 7/7/7 Oral Tablet CE 0.5/0.75/1-35 Mg-Mcg) 2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 100 Prescription Drug Name Drug Tier Drug Notes NUVARING VAGINAL RING 0.12-0.015 MG/24HR NF (etonogestrel-ethinyl estradiol) drospirenone-ethinyl estradiol (Ocella Oral Tablet 3-0.03 Mg) CE OPCICON ONE-STEP ORAL TABLET 1.5 MG CE (levonorgestrel) OPTION 2 ORAL TABLET 1.5 MG (levonorgestrel) CE levonorgestrel-ethinyl estrad (Orsythia Oral Tablet 0.1-20 Mg- CE Mcg) ORTHO TRI-CYCLEN LO ORAL TABLET 0.18/0.215/0.25 NF MG-25 MCG (norgestim-eth estrad triphasic) PARAGARD INTRAUTERINE COPPER CE INTRAUTERINE INTRAUTERINE DEVICE (copper) norethindrone-eth estradiol (Philith Oral Tablet 0.4-35 Mg- CE Mcg) desogestrel-ethinyl estradiol (Pimtrea Oral Tablet 0.15- CE 0.02/0.01 Mg (21/5)) norethindrone-eth estradiol (Pirmella 1/35 Oral Tablet 1-35 CE Mg-Mcg) norethin-eth estrad triphasic (Pirmella 7/7/7 Oral Tablet CE 0.5/0.75/1-35 Mg-Mcg) levonorgestrel-ethinyl estrad (Portia-28 Oral Tablet 0.15-30 CE Mg-Mcg) PREVENTEZA ORAL TABLET 1.5 MG (levonorgestrel) CE norgestimate-eth estradiol (Previfem Oral Tablet 0.25-35 Mg- CE Mcg) QUARTETTE ORAL TABLET 42-21-21-7 DAYS NF (levonorgest-eth estrad 91-day) REACT ORAL TABLET 1.5 MG (levonorgestrel) CE desogestrel-ethinyl estradiol (Reclipsen Oral Tablet 0.15-30 CE Mg-Mcg) levonorgest-eth estrad 91-day (Rivelsa Oral Tablet 42-21-21-7 CE Days) SAFYRAL ORAL TABLET 3-0.03-0.451 MG (drospiren-eth NPB estrad-levomefol) SEASONIQUE ORAL TABLET 0.15-0.03 &0.01 MG NF (levonorgest-eth estrad 91-day) levonorgest-eth estrad 91-day (Setlakin Oral Tablet 0.15-0.03 CE Mg) norethindrone (Sharobel Oral Tablet 0.35 Mg) CE 2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 101 Prescription Drug Name Drug Tier Drug Notes desogestrel-ethinyl estradiol (Simliya Oral Tablet 0.15- CE 0.02/0.01 Mg (21/5)) levonorgest-eth estrad 91-day (Simpesse Oral Tablet 0.15-0.03 CE &0.01 Mg) SKYLA INTRAUTERINE INTRAUTERINE DEVICE CE 13.5 MG (levonorgestrel) SLYND ORAL TABLET 4 MG (drospirenone) NF norgestimate-eth estradiol (Sprintec 28 Oral Tablet 0.25-35 CE Mg-Mcg) levonorgestrel-ethinyl estrad (Sronyx Oral Tablet 0.1-20 Mg- CE Mcg) drospirenone-ethinyl estradiol (Syeda Oral Tablet 3-0.03 Mg) CE TAKE ACTION ORAL TABLET 1.5 MG (levonorgestrel) CE norethin ace-eth estrad-fe (Tarina 24 Fe Oral Tablet 1-20 Mg- CE Mcg(24)) norethin ace-eth estrad-fe (Tarina Fe 1/20 Eq Oral Tablet 1-20 CE Mg-Mcg) norethin ace-eth estrad-fe (Tarina Fe 1/20 Oral Tablet 1-20 CE Mg-Mcg) TAYTULLA ORAL CAPSULE 1-20 MG-MCG(24) NF (norethin ace-eth estrad-fe) norethindron-ethinyl estrad-fe (Tilia Fe Oral Tablet 1-20/1- CE 30/1-35 Mg-Mcg) norgestim-eth estrad triphasic (Tri Femynor Oral Tablet CE 0.18/0.215/0.25 Mg-35 Mcg) norgestim-eth estrad triphasic (Tri-Estarylla Oral Tablet CE 0.18/0.215/0.25 Mg-35 Mcg) norethindron-ethinyl estrad-fe (Tri-Legest Fe Oral Tablet 1- CE 20/1-30/1-35 Mg-Mcg) norgestim-eth estrad triphasic (Tri-Linyah Oral Tablet CE 0.18/0.215/0.25 Mg-35 Mcg) norgestim-eth estrad triphasic (Tri-Lo-Estarylla Oral Tablet CE 0.18/0.215/0.25 Mg-25 Mcg) norgestim-eth estrad triphasic (Tri-Lo-Marzia Oral Tablet CE 0.18/0.215/0.25 Mg-25 Mcg) norgestim-eth estrad triphasic (Tri-Lo-Mili Oral Tablet CE 0.18/0.215/0.25 Mg-25 Mcg) norgestim-eth estrad triphasic (Tri-Lo-Sprintec Oral Tablet CE 0.18/0.215/0.25 Mg-25 Mcg) 2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 102 Prescription Drug Name Drug Tier Drug Notes norgestim-eth estrad triphasic (Tri-Mili Oral Tablet CE 0.18/0.215/0.25 Mg-35 Mcg) norgestim-eth estrad triphasic (Tri-Previfem Oral Tablet CE 0.18/0.215/0.25 Mg-35 Mcg) norgestim-eth estrad triphasic (Tri-Sprintec Oral Tablet CE 0.18/0.215/0.25 Mg-35 Mcg) levonorg-eth estrad triphasic (Trivora (28) Oral Tablet 50- CE 30/75-40/ 125-30 Mcg) norgestim-eth estrad triphasic (Tri-Vylibra Lo Oral Tablet CE 0.18/0.215/0.25 Mg-25 Mcg) norgestim-eth estrad triphasic (Tri-Vylibra Oral Tablet CE 0.18/0.215/0.25 Mg-35 Mcg) norethindrone (Tulana Oral Tablet 0.35 Mg) CE drospiren-eth estrad-levomefol (Tydemy Oral Tablet 3-0.03- CE 0.451 Mg) desogestrel-ethinyl estradiol (Velivet Oral Tablet 0.1/0.125/0.15 CE -0.025 Mg) levonorgestrel-ethinyl estrad (Vienva Oral Tablet 0.1-20 Mg- CE Mcg) viorele oral tablet 0.15-0.02/0.01 mg (21/5) CE norethindrone-eth estradiol (Vyfemla Oral Tablet 0.4-35 Mg- CE Mcg) norgestimate-eth estradiol (Vylibra Oral Tablet 0.25-35 Mg- CE Mcg) norethindrone-eth estradiol (Wera Oral Tablet 0.5-35 Mg-Mcg) CE norethin-eth estradiol-fe (Wymzya Fe Oral Tablet Chewable CE 0.4-35 Mg-Mcg) norelgestromin-eth estradiol (Xulane Transdermal Patch CE Weekly 150-35 Mcg/24Hr) YASMIN 28 ORAL TABLET 3-0.03 MG (drospirenone- NF ethinyl estradiol) YAZ ORAL TABLET 3-0.02 MG (drospirenone-ethinyl NF estradiol) drospirenone-ethinyl estradiol (Zarah Oral Tablet 3-0.03 Mg) CE ethynodiol diac-eth estradiol (Zovia 1/35E (28) Oral Tablet 1- CE 35 Mg-Mcg) drospirenone-ethinyl estradiol (Zumandimine Oral Tablet 3- CE 0.03 Mg)

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 103 Prescription Drug Name Drug Tier Drug Notes DIABETIC SUPPLIES COMFORT TOUCH LANCETS 31G (lancets) NPB COMFORT TOUCH PLUS LANCETS 30G (lancets) NPB pure comfort lancets 30g NPB ENDOMETRIOSIS CETROTIDE SUBCUTANEOUS KIT 0.25 MG (cetrorelix SPC (Only available for PSP acetate) select plans) danazol oral capsule 100 mg, 200 mg, 50 mg G FENSOLVI (6 MONTH) SUBCUTANEOUS KIT 45 MG NPB (PED) (leuprolide acetate (6 month)) ORILISSA ORAL TABLET 150 MG, 200 MG (elagolix PB sodium) SUPPRELIN LA SUBCUTANEOUS KIT 50 MG (histrelin PSP acetate (cpp)) SYNAREL NASAL SOLUTION 2 MG/ML (nafarelin NPB acetate) TRIPTODUR INTRAMUSCULAR SUSPENSION PSP RECONSTITUTED ER 22.5 MG (triptorelin pamoate) ENZYME REPLACEMENTS - DRUGS TO TREAT ENZYME DEFICIENCIES CARBAGLU ORAL TABLET 200 MG (carglumic acid) NPB CERDELGA ORAL CAPSULE 84 MG (eliglustat tartrate) PSP CEREZYME INTRAVENOUS SOLUTION PSP RECONSTITUTED 400 UNIT (imiglucerase) CYSTADANE ORAL POWDER (betaine) NPB CYSTAGON ORAL CAPSULE 150 MG, 50 MG PSP (cysteamine bitartrate) KUVAN ORAL PACKET 100 MG, 500 MG (sapropterin NF dihydrochloride) KUVAN ORAL TABLET 100 MG (sapropterin NF dihydrochloride) miglustat oral capsule 100 mg G MYALEPT SUBCUTANEOUS SOLUTION NPB RECONSTITUTED 11.3 MG (metreleptin) NITYR ORAL TABLET 10 MG, 2 MG, 5 MG (nitisinone) NPB ORFADIN ORAL CAPSULE 10 MG, 2 MG, 20 MG, 5 MG PSP (nitisinone) ORFADIN ORAL SUSPENSION 4 MG/ML (nitisinone) PSP 2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 104 Prescription Drug Name Drug Tier Drug Notes sodium phenylbutyrate oral powder 3 gm/tsp G sodium phenylbutyrate oral tablet 500 mg G VPRIV INTRAVENOUS SOLUTION RECONSTITUTED NPSP 400 UNIT (velaglucerase alfa) ZAVESCA ORAL CAPSULE 100 MG (miglustat) NPB ESTROGENS - DRUGS TO REGULATE FEMALE HORMONES ALORA TRANSDERMAL PATCH TWICE WEEKLY 0.025 MG/24HR, 0.05 MG/24HR, 0.075 MG/24HR, 0.1 NF MG/24HR (estradiol) estradiol-norethindrone acet (Amabelz Oral Tablet 0.5-0.1 Mg, G 1-0.5 Mg) ANGELIQ ORAL TABLET 0.25-0.5 MG, 0.5-1 MG NF (drospirenone-estradiol) BIJUVA ORAL CAPSULE 1-100 MG (estradiol- PB progesterone) CLIMARA PRO TRANSDERMAL PATCH WEEKLY PB 0.045-0.015 MG/DAY (estradiol-levonorgestrel) COMBIPATCH TRANSDERMAL PATCH TWICE WEEKLY 0.05-0.14 MG/DAY, 0.05-0.25 MG/DAY NF (estradiol-norethindrone acet) DELESTROGEN INTRAMUSCULAR OIL 10 MG/ML NPB (estradiol valerate) DEPO-ESTRADIOL INTRAMUSCULAR OIL 5 MG/ML NPB (estradiol cypionate) DIVIGEL TRANSDERMAL GEL 0.25 MG/0.25GM, 0.5 MG/0.5GM, 0.75 MG/0.75GM, 1 MG/GM, 1.25 PB MG/1.25GM (estradiol) estradiol (Dotti Transdermal Patch Twice Weekly 0.025 Mg/24Hr, 0.0375 Mg/24Hr, 0.05 Mg/24Hr, 0.075 Mg/24Hr, G 0.1 Mg/24Hr) DUAVEE ORAL TABLET 0.45-20 MG (conj estrogens- NF bazedoxifene) ec-rx estradiol transdermal cream 0.4 %, 0.6 % NF ELESTRIN TRANSDERMAL GEL 0.52 MG/0.87 GM NF (0.06%) (estradiol) estradiol oral tablet 0.5 mg, 1 mg, 2 mg G estradiol transdermal patch twice weekly 0.025 mg/24hr, 0.0375 G mg/24hr, 0.05 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 105 Prescription Drug Name Drug Tier Drug Notes estradiol transdermal patch weekly 0.025 mg/24hr, 0.0375 mg/24hr, 0.05 mg/24hr, 0.06 mg/24hr, 0.075 mg/24hr, 0.1 G mg/24hr estradiol vaginal cream 0.1 mg/gm G estradiol vaginal tablet 10 mcg G estradiol valerate intramuscular oil 20 mg/ml, 40 mg/ml G estradiol-norethindrone acet oral tablet 0.5-0.1 mg, 1-0.5 mg G ESTRING VAGINAL RING 2 MG (estradiol) NF ESTROGEL TRANSDERMAL GEL 0.75 MG/1.25 GM NF (0.06%) (estradiol) EVAMIST TRANSDERMAL SOLUTION 1.53 PB MG/SPRAY (estradiol) FEMRING VAGINAL RING 0.05 MG/24HR, 0.1 NF MG/24HR (estradiol acetate) norethindrone-eth estradiol (Fyavolv Oral Tablet 0.5-2.5 Mg- G Mcg, 1-5 Mg-Mcg) IMVEXXY MAINTENANCE PACK VAGINAL INSERT PB 10 MCG, 4 MCG (estradiol) IMVEXXY STARTER PACK VAGINAL INSERT 10 PB MCG, 4 MCG (estradiol) norethindrone-eth estradiol (Jinteli Oral Tablet 1-5 Mg-Mcg) G MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG NF (esterified estrogens) MENOSTAR TRANSDERMAL PATCH WEEKLY 14 NF MCG/24HR (estradiol) estradiol-norethindrone acet (Mimvey Oral Tablet 1-0.5 Mg) G MINIVELLE TRANSDERMAL PATCH TWICE WEEKLY 0.025 MG/24HR, 0.0375 MG/24HR, 0.05 NF MG/24HR, 0.075 MG/24HR, 0.1 MG/24HR (estradiol) norethindrone-eth estradiol oral tablet 0.5-2.5 mg-mcg, 1-5 mg- G mcg ORIAHNN ORAL CAPSULE THERAPY PACK 300-1-0.5 PB & 300 MG (elagolix-estradiol-norethind) PREFEST ORAL TABLET 1/1-0.09 MG (15/15) (estradiol- NF norgestimate) PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, 0.625 MG, NF 0.9 MG, 1.25 MG (estrogens conjugated) PREMARIN VAGINAL CREAM 0.625 MG/GM (estrogens, NF conjugated) 2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 106 Prescription Drug Name Drug Tier Drug Notes PREMPHASE ORAL TABLET 0.625-5 MG (conj estrog- NF medroxyprogest ace) PREMPRO ORAL TABLET 0.3-1.5 MG, 0.45-1.5 MG, NF 0.625-2.5 MG, 0.625-5 MG (conj estrog-medroxyprogest ace) VAGIFEM VAGINAL TABLET 10 MCG (estradiol) PB VIVELLE-DOT TRANSDERMAL PATCH TWICE NF WEEKLY 0.0375 MG/24HR (estradiol) estradiol (Yuvafem Vaginal Tablet 10 Mcg) G FERTILITY REGULATORS SPC (Only available for clomiphene citrate oral tablet 50 mg G select plans) ganirelix acetate subcutaneous solution prefilled syringe 250 NPSP mcg/0.5ml GONAL-F INJECTION SOLUTION RECONSTITUTED SPC (Only available for PSP 1050 UNIT, 450 UNIT (follitropin alfa) select plans) GONAL-F RFF REDIJECT SUBCUTANEOUS SPC (Only available for SOLUTION 300 UNIT/0.5ML, 450 UNT/0.75ML, 900 PSP select plans) UNIT/1.5ML (follitropin alfa) GONAL-F RFF SUBCUTANEOUS SOLUTION SPC (Only available for PSP RECONSTITUTED 75 UNIT (follitropin alfa) select plans) MENOPUR SUBCUTANEOUS SOLUTION SPC (Only available for NPSP RECONSTITUTED 75 UNIT (menotropins) select plans) OVIDREL SUBCUTANEOUS INJECTABLE 250 SPC (Only available for PSP MCG/0.5ML (choriogonadotropin alfa) select plans) GLUCOCORTICOIDS - DRUGS TO TREAT INFLAMMATORY RESPONSE budesonide er oral tablet extended release 24 hour 9 mg G dexamethasone (Decadron Oral Tablet 0.5 Mg, 0.75 Mg, 4 G Mg, 6 Mg) dexamethasone (la) injection suspension 8 mg/ml NF DEXAMETHASONE INTENSOL ORAL NPB CONCENTRATE 1 MG/ML (dexamethasone) dexamethasone oral elixir 0.5 mg/5ml G dexamethasone oral solution 0.5 mg/5ml G dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 2 mg, G 4 mg, 6 mg dexamethasone oral tablet therapy pack 1.5 mg (21), 1.5 mg G (35), 1.5 mg (51)

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 107 Prescription Drug Name Drug Tier Drug Notes dexamethasone sodium phosphate injection solution 10 mg/ml, 4 NPB mg/ml DEXONTO 0.4% IONTOPHORESIS SOLUTION 20 NF MG/5ML (dexamethasone sodium phosphate) DXEVO 11-DAY ORAL TABLET THERAPY PACK 1.5 NF MG (dexamethasone) EMFLAZA ORAL SUSPENSION 22.75 MG/ML NF (deflazacort) EMFLAZA ORAL TABLET 18 MG, 30 MG, 36 MG, 6 MG NF (deflazacort) fludrocortisone acetate oral tablet 0.1 mg G dexamethasone (Hidex 6-Day Oral Tablet Therapy Pack 1.5 G Mg (21)) hydrocortisone oral tablet 10 mg, 20 mg, 5 mg G MEDROL ORAL TABLET 2 MG (methylprednisolone) NPB methylprednisolone oral tablet 16 mg, 32 mg, 4 mg, 8 mg G methylprednisolone oral tablet therapy pack 4 mg G MILLIPRED ORAL TABLET 5 MG (prednisolone) NF prednisolone oral solution 15 mg/5ml G prednisolone sodium phosphate oral solution 10 mg/5ml, 15 G mg/5ml, 20 mg/5ml, 25 mg/5ml, 6.7 (5 base) mg/5ml prednisolone sodium phosphate oral tablet dispersible 10 mg, 15 G mg, 30 mg PREDNISONE INTENSOL ORAL CONCENTRATE 5 NPB MG/ML (prednisone) prednisone oral solution 5 mg/5ml G prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 mg, 5 mg, 50 mg G prednisone oral tablet therapy pack 10 mg (21), 10 mg (48), 5 G mg (21), 5 mg (48) PRO-C-DURE 6 INJECTION KIT 3 X 40 MG/ML NF (triamcinolone acetonide) RAYOS ORAL TABLET DELAYED RELEASE 1 MG, 2 NF MG, 5 MG (prednisone) READYSHARP DEXAMETHASONE INJECTION KIT 10 NF MG/ML (dexamethasone sodium phosphate) TAPERDEX 12-DAY ORAL TABLET THERAPY PACK NF 1.5 MG (49) (dexamethasone)

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 108 Prescription Drug Name Drug Tier Drug Notes dexamethasone (Taperdex 6-Day Oral Tablet Therapy Pack NF 1.5 Mg) TAPERDEX 7-DAY ORAL TABLET THERAPY PACK NF 1.5 MG (27) (dexamethasone) ZILRETTA INTRA-ARTICULAR SUSPENSION NF RECONSTITUTED ER 32 MG (triamcinolone acetonide) GLUCOSE ELEVATING AGENTS - DRUGS TO TREAT LOW BLOOD SUGAR BAQSIMI ONE PACK NASAL POWDER 3 MG/DOSE PB (glucagon) BAQSIMI TWO PACK NASAL POWDER 3 MG/DOSE PB (glucagon) cvs glucose oral tablet chewable 4-6 gm-mg NPB DEX4 NATURALS ORAL TABLET CHEWABLE 4-6 GM- NPB MG (glucose-vitamin c) DEX4 ORAL TABLET CHEWABLE 4-6 GM-MG (glucose- NPB vitamin c) DEX4 POUCH PACK ORAL TABLET CHEWABLE 4-6 NPB GM-MG (glucose-vitamin c) dextrose intravenous solution 250 mg/ml NPB GLUCAGEN HYPOKIT INJECTION SOLUTION PB RECONSTITUTED 1 MG (glucagon hcl (rdna)) glucagon emergency injection kit 1 mg PB glucose instant energy oral tablet chewable 4-6 gm-mg, 6-4 mg- NPB gm glucose oral tablet chewable 4-6 gm-mg NPB gnp glucose oral tablet chewable 4-6 gm-mg NPB goodsense glucose oral tablet chewable 4-6 gm-mg NPB GVOKE HYPOPEN 1-PACK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 0.5 MG/0.1ML, 1 PB MG/0.2ML (glucagon) GVOKE HYPOPEN 2-PACK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 0.5 MG/0.1ML, 1 PB MG/0.2ML (glucagon) GVOKE PFS SUBCUTANEOUS SOLUTION PREFILLED PB SYRINGE 0.5 MG/0.1ML, 1 MG/0.2ML (glucagon) hm glucose oral tablet chewable 4-6 gm-mg NPB kroger glucose oral tablet chewable 4-6 gm-mg NPB

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 109 Prescription Drug Name Drug Tier Drug Notes meijer glucose oral tablet chewable 4-6 gm-mg NPB PROGLYCEM ORAL SUSPENSION 50 MG/ML NPB (diazoxide) px glucose oral tablet chewable 4-6 gm-mg NPB ra glucose oral tablet chewable 4-6 gm-mg, 6-4 mg-gm NPB RELION GLUCOSE ORAL TABLET CHEWABLE 4-6 NPB GM-MG (glucose-vitamin c) sm glucose oral tablet chewable 4-6 gm-mg NPB SMART SENSE GLUCOSE ORAL TABLET CHEWABLE NPB 4-6 GM-MG (glucose-vitamin c) tgt glucose oral tablet chewable 4-6 gm-mg NPB up & up glucose oral tablet chewable 4-6 gm-mg NPB value plus glucose oral tablet chewable 4-6 gm-mg NPB HUMAN GROWTH HORMONES - DRUGS TO REGULATE PITUITARY HORMONES HUMATROPE INJECTION SOLUTION RECONSTITUTED 12 MG, 24 MG, 5 MG, 6 MG NF (somatropin) NORDITROPIN FLEXPRO SUBCUTANEOUS SOLUTION PEN-INJECTOR 10 MG/1.5ML, 15 PSP MG/1.5ML, 30 MG/3ML, 5 MG/1.5ML (somatropin) OMNITROPE SUBCUTANEOUS SOLUTION NF CARTRIDGE 10 MG/1.5ML, 5 MG/1.5ML (somatropin) SEROSTIM SUBCUTANEOUS SOLUTION RECONSTITUTED 4 MG, 5 MG, 6 MG (somatropin (non- NPSP refrigerated)) ZORBTIVE SUBCUTANEOUS SOLUTION NPSP RECONSTITUTED 8.8 MG (somatropin (non-refrigerated)) MISCELLANEOUS ACTHAR INJECTION GEL 80 UNIT/ML (corticotropin) NPSP cabergoline oral tablet 0.5 mg G calcitonin (salmon) nasal solution 200 unit/act G CERVIDIL VAGINAL INSERT 10 MG (dinoprostone) NPB EVENITY SUBCUTANEOUS SOLUTION PREFILLED NF SYRINGE 105 MG/1.17ML (romosozumab-aqqg) FORTEO SUBCUTANEOUS SOLUTION PEN- PSP INJECTOR 620 MCG/2.48ML (teriparatide (recombinant)) GALAFOLD ORAL CAPSULE 123 MG (migalastat hcl) NPB

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 110 Prescription Drug Name Drug Tier Drug Notes INCRELEX SUBCUTANEOUS SOLUTION 40 MG/4ML NPSP (mecasermin) JYNARQUE ORAL TABLET 15 MG, 30 MG (tolvaptan) NPB JYNARQUE ORAL TABLET THERAPY PACK 15 MG, 30 & 15 MG, 45 & 15 MG, 60 & 30 MG, 90 & 30 MG NPB (tolvaptan) KORLYM ORAL TABLET 300 MG (mifepristone) NPB methylergonovine maleate (Methergine Oral Tablet 0.2 Mg) G methylergonovine maleate oral tablet 0.2 mg G MIACALCIN INJECTION SOLUTION 200 UNIT/ML NF (calcitonin (salmon)) MIACALCIN NASAL SOLUTION 200 UNIT/ACT NF (calcitonin (salmon)) NATPARA SUBCUTANEOUS CARTRIDGE 100 MCG, NPSP 25 MCG, 50 MCG, 75 MCG (parathyroid hormone (recomb)) octreotide acetate injection solution 100 mcg/ml, 1000 mcg/ml, G 200 mcg/ml, 50 mcg/ml, 500 mcg/ml OSPHENA ORAL TABLET 60 MG (ospemifene) NF PREPIDIL VAGINAL GEL 0.5 MG/3GM (dinoprostone) NPB PROLIA SUBCUTANEOUS SOLUTION PREFILLED PSP SYRINGE 60 MG/ML (denosumab) PROSTIN E2 VAGINAL SUPPOSITORY 20 MG NPB (dinoprostone) raloxifene hcl oral tablet 60 mg CE SAMSCA ORAL TABLET 15 MG, 30 MG (tolvaptan) NPSP SANDOSTATIN INJECTION SOLUTION 100 MCG/ML, NPSP 50 MCG/ML, 500 MCG/ML (octreotide acetate) SIGNIFOR LAR INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 10 MG, 20 MG, 30 MG, 40 MG, 60 NF MG (pasireotide pamoate) SIGNIFOR SUBCUTANEOUS SOLUTION 0.3 MG/ML, NPB 0.6 MG/ML, 0.9 MG/ML (pasireotide diaspartate) SOMATULINE DEPOT SUBCUTANEOUS SOLUTION 120 MG/0.5ML, 60 MG/0.2ML, 90 MG/0.3ML (lanreotide PSP acetate) SOMAVERT SUBCUTANEOUS SOLUTION RECONSTITUTED 10 MG, 15 MG, 20 MG, 25 MG, 30 MG NF (pegvisomant)

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 111 Prescription Drug Name Drug Tier Drug Notes TYMLOS SUBCUTANEOUS SOLUTION PEN- PSP INJECTOR 3120 MCG/1.56ML (abaloparatide) XGEVA SUBCUTANEOUS SOLUTION 120 MG/1.7ML NPSP (denosumab) XURIDEN ORAL PACKET 2 GM (uridine triacetate) NPB ZOKINVY ORAL CAPSULE 50 MG, 75 MG (lonafarnib) NPSP PHOSPHATE BINDER AGENTS - DRUGS TO REGULATE CALCIUM AND PHOSPHORUS LEVELS AURYXIA ORAL TABLET 1 GM 210 MG(FE) (ferric NPB citrate) calcium acetate (phos binder) oral capsule 667 mg G calcium acetate (phos binder) oral tablet 667 mg G FOSRENOL ORAL PACKET 1000 MG, 750 MG NF (lanthanum carbonate) FOSRENOL ORAL TABLET CHEWABLE 1000 MG, 500 NF MG, 750 MG (lanthanum carbonate) lanthanum carbonate oral tablet chewable 1000 mg, 500 mg, 750 NF mg MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 PB HOUR 50 MG (mirabegron) PHOSLYRA ORAL SOLUTION 667 MG/5ML (calcium PB acetate (phos binder)) sevelamer carbonate oral packet 0.8 gm, 2.4 gm G sevelamer carbonate oral tablet 800 mg G sevelamer hcl oral tablet 400 mg, 800 mg G VELPHORO ORAL TABLET CHEWABLE 500 MG PB (sucroferric oxyhydroxide) PROGESTINS - DRUGS TO REGULATE FEMALE HORMONES CRINONE VAGINAL GEL 4 %, 8 % (progesterone) NF ec-rx progesterone transdermal cream 20 % NF hydroxyprogesterone caproate intramuscular oil 250 mg/ml G LUPANETA PACK COMBINATION KIT 11.25 & 5 MG, NPSP 3.75 & 5 MG (leuprolide & norethindrone) MAKENA INTRAMUSCULAR OIL 250 MG/ML NPSP (hydroxyprogesterone caproate) MAKENA SUBCUTANEOUS SOLUTION AUTO- NPSP INJECTOR 275 MG/1.1ML (hydroxyprogesterone caproate)

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

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 113 Prescription Drug Name Drug Tier Drug Notes TIROSINT-SOL ORAL SOLUTION 100 MCG/ML, 112 MCG/ML, 125 MCG/ML, 13 MCG/ML, 137 MCG/ML, 150 MCG/ML, 175 MCG/ML, 200 MCG/ML, 25 MCG/ML, 37.5 NF MCG/ML, 44 MCG/ML, 50 MCG/ML, 62.5 MCG/ML, 75 MCG/ML, 88 MCG/ML (levothyroxine sodium) levothyroxine sodium (Unithroid Oral Tablet 100 Mcg, 112 Mcg, 125 Mcg, 137 Mcg, 150 Mcg, 175 Mcg, 200 Mcg, 25 G Mcg, 300 Mcg, 50 Mcg, 75 Mcg, 88 Mcg) WESTHROID ORAL TABLET 130 MG, 195 MG, 32.5 MG, NF 65 MG, 97.5 MG (thyroid) WP THYROID ORAL TABLET 113.75 MG, 130 MG, 16.25 MG, 32.5 MG, 48.75 MG, 65 MG, 81.25 MG, 97.5 MG NF (thyroid) VASOPRESSINS - DRUGS TO REGULATE PITUITARY HORMONES desmopressin ace spray refrig nasal solution 0.01 % G desmopressin acetate oral tablet 0.1 mg, 0.2 mg G desmopressin acetate spray nasal solution 0.01 % G NOCDURNA SUBLINGUAL TABLET SUBLINGUAL NPB 27.7 MCG, 55.3 MCG (desmopressin acetate) STIMATE NASAL SOLUTION 1.5 MG/ML (desmopressin NPSP acetate) GASTROINTESTINAL - DRUGS TO TREAT STOMACH AND INTESTINAL DISORDERS ANTICHOLINERGICS belladonna alkaloids-opium rectal suppository 16.2-30 mg, 16.2- NPB 60 mg chlordiazepoxide-clidinium oral capsule 5-2.5 mg NF CUVPOSA ORAL SOLUTION 1 MG/5ML (glycopyrrolate) NPB dicyclomine hcl oral capsule 10 mg G dicyclomine hcl oral solution 10 mg/5ml G dicyclomine hcl oral tablet 20 mg G ed-spaz oral tablet dispersible 0.125 mg G GLYCATE ORAL TABLET 1.5 MG (glycopyrrolate) NF glycopyrrolate oral tablet 1 mg, 2 mg G GLYRX-PF INJECTION SOLUTION 0.2 MG/ML, 0.4 NF MG/2ML (glycopyrrolate)

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 114 Prescription Drug Name Drug Tier Drug Notes hyoscyamine sulfate er oral tablet extended release 12 hour NF 0.375 mg hyoscyamine sulfate oral elixir 0.125 mg/5ml G hyoscyamine sulfate oral solution 0.125 mg/ml G hyoscyamine sulfate oral tablet 0.125 mg G hyoscyamine sulfate oral tablet dispersible 0.125 mg G hyoscyamine sulfate sublingual tablet sublingual 0.125 mg G LIBRAX ORAL CAPSULE 5-2.5 MG (chlordiazepoxide- NF clidinium) methscopolamine bromide oral tablet 2.5 mg, 5 mg G hyoscyamine sulfate (Nulev Oral Tablet Dispersible 0.125 Mg) G oscimin oral tablet 0.125 mg G oscimin sr oral tablet extended release 12 hour 0.375 mg NF oscimin sublingual tablet sublingual 0.125 mg G SYMAX DUOTAB ORAL TABLET EXTENDED NPB RELEASE 0.375 MG (hyoscyamine sulfate) hyoscyamine sulfate (Symax-Sr Oral Tablet Extended Release NF 12 Hour 0.375 Mg) ANTIEMETICS - DRUGS FOR NAUSEA AND VOMITING AKYNZEO INTRAVENOUS SOLUTION 235-0.25 NF MG/20ML (fosnetupitant-palonosetron) AKYNZEO INTRAVENOUS SOLUTION RECONSTITUTED 235-0.25 MG (fosnetupitant- NF palonosetron) AKYNZEO ORAL CAPSULE 300-0.5 MG (netupitant- NF palonosetron) aprepitant oral capsule 125 mg, 40 mg, 80 & 125 mg, 80 mg G BONJESTA ORAL TABLET EXTENDED RELEASE 20- NPB 20 MG (doxylamine-pyridoxine) CINVANTI INTRAVENOUS EMULSION 130 MG/18ML NF (aprepitant) prochlorperazine (Compro Rectal Suppository 25 Mg) G doxylamine-pyridoxine oral tablet delayed release 10-10 mg G dronabinol oral capsule 10 mg, 2.5 mg, 5 mg G EMEND INTRAVENOUS SOLUTION NF RECONSTITUTED 150 MG (fosaprepitant dimeglumine)

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 115 Prescription Drug Name Drug Tier Drug Notes EMEND ORAL CAPSULE 80 MG (aprepitant) NF EMEND ORAL SUSPENSION RECONSTITUTED 125 NF MG/5ML (aprepitant) EMEND TRI-PACK ORAL CAPSULE 80 & 125 MG NF (aprepitant) granisetron hcl oral tablet 1 mg G meclizine hcl oral tablet 12.5 mg, 25 mg G metoclopramide hcl oral solution 10 mg/10ml, 5 mg/5ml G metoclopramide hcl oral tablet 10 mg, 5 mg G metoclopramide hcl oral tablet dispersible 10 mg NPB metoclopramide hcl oral tablet dispersible 5 mg G ondansetron hcl oral solution 4 mg/5ml G ondansetron hcl oral tablet 24 mg, 4 mg, 8 mg G ondansetron oral tablet dispersible 4 mg, 8 mg G prochlorperazine maleate oral tablet 10 mg, 5 mg G prochlorperazine rectal suppository 25 mg G promethazine hcl oral syrup 6.25 mg/5ml G promethazine hcl oral tablet 12.5 mg, 25 mg, 50 mg G promethazine hcl rectal suppository 12.5 mg, 25 mg G promethazine hcl (Promethegan Rectal Suppository 12.5 Mg, G 25 Mg) PROMETHEGAN RECTAL SUPPOSITORY 50 MG G (promethazine hcl) SANCUSO TRANSDERMAL PATCH 3.1 MG/24HR PB (granisetron) scopolamine transdermal patch 72 hour 1 mg/3days G SUSTOL SUBCUTANEOUS PREFILLED SYRINGE 10 NF MG/0.4ML (granisetron) SYNDROS ORAL SOLUTION 5 MG/ML (dronabinol) NF TRANSDERM-SCOP (1.5 MG) TRANSDERMAL PATCH NF 72 HOUR 1 MG/3DAYS (scopolamine base) trimethobenzamide hcl oral capsule 300 mg G VARUBI (180 MG DOSE) ORAL TABLET THERAPY NF PACK 2 X 90 MG (rolapitant hcl) ZUPLENZ ORAL FILM 4 MG, 8 MG (ondansetron) NF

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 116 Prescription Drug Name Drug Tier Drug Notes H2-RECEPTOR ANTAGONISTS - DRUGS FOR ULCERS AND STOMACH ACID cimetidine hcl oral solution 300 mg/5ml G cimetidine oral tablet 200 mg, 300 mg, 400 mg, 800 mg G eq famotidine max st oral tablet 20 mg G famotidine oral suspension reconstituted 40 mg/5ml G famotidine oral tablet 20 mg, 40 mg G nizatidine oral capsule 150 mg, 300 mg G nizatidine oral solution 15 mg/ml G INFLAMMATORY BOWEL DISEASE - BOWEL, INTESTINE, AND STOMACH CONDITION DRUGS APRISO ORAL CAPSULE EXTENDED RELEASE 24 NPB HOUR 0.375 GM (mesalamine) ASACOL HD ORAL TABLET DELAYED RELEASE 800 PB MG (mesalamine) balsalazide disodium oral capsule 750 mg G budesonide oral capsule delayed release particles 3 mg G CANASA RECTAL SUPPOSITORY 1000 MG (mesalamine) NF COLAZAL ORAL CAPSULE 750 MG (balsalazide disodium) NF CORTIFOAM EXTERNAL FOAM 10 % (hydrocortisone PB acetate) DELZICOL ORAL CAPSULE DELAYED RELEASE 400 NF MG (mesalamine) DIPENTUM ORAL CAPSULE 250 MG (olsalazine sodium) NPB hydrocortisone rectal enema 100 mg/60ml G LIALDA ORAL TABLET DELAYED RELEASE 1.2 GM NF (mesalamine) mesalamine oral capsule delayed release 400 mg G mesalamine oral tablet delayed release 1.2 gm, 800 mg G mesalamine rectal enema 4 gm G mesalamine rectal suppository 1000 mg G mesalamine-cleanser rectal kit 4 gm G PENTASA ORAL CAPSULE EXTENDED RELEASE 250 PB MG, 500 MG (mesalamine) ROWASA RECTAL KIT 4 GM (mesalamine-cleanser) NF SFROWASA RECTAL ENEMA 4 GM/60ML (mesalamine) NF

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 117 Prescription Drug Name Drug Tier Drug Notes sulfasalazine oral tablet 500 mg G sulfasalazine oral tablet delayed release 500 mg G UCERIS ORAL TABLET EXTENDED RELEASE 24 NF HOUR 9 MG (budesonide) UCERIS RECTAL FOAM 2 MG/ACT (budesonide) NF IRRITABLE BOWEL SYNDROME WITH CONSTIPATION AMITIZA ORAL CAPSULE 24 MCG, 8 MCG NF (lubiprostone) LINZESS ORAL CAPSULE 145 MCG, 290 MCG, 72 MCG PB (linaclotide) TRULANCE ORAL TABLET 3 MG (plecanatide) NPB ZELNORM ORAL TABLET 6 MG (tegaserod maleate) NF IRRITABLE BOWEL SYNDROME WITH DIARRHEA alosetron hcl oral tablet 0.5 mg, 1 mg G LOTRONEX ORAL TABLET 0.5 MG, 1 MG (alosetron hcl) NPB VIBERZI ORAL TABLET 100 MG, 75 MG (eluxadoline) PB LAXATIVES - DRUGS FOR CONSTIPATION cascara sagrada oral fluid extract 1 gm/ml NPB CLENPIQ ORAL SOLUTION 10-3.5-12 MG-GM - CE GM/160ML (sod picosulfate-mag ox-cit acd) constulose oral solution 10 gm/15ml G enulose oral solution 10 gm/15ml G generlac oral solution 10 gm/15ml G GIALAX ORAL KIT (polyethylene glycol 3350) NF GOLYTELY ORAL SOLUTION RECONSTITUTED 236 NF GM (peg 3350-kcl-nabcb-nacl-nasulf) KRISTALOSE ORAL PACKET 10 GM, 20 GM (lactulose) NPB lactulose encephalopathy oral solution 10 gm/15ml G lactulose oral packet 10 gm NF lactulose oral solution 10 gm/15ml, 20 gm/30ml G mineral oil heavy oral oil G MOVIPREP ORAL SOLUTION RECONSTITUTED 100 NF GM (peg-kcl-nacl-nasulf-na asc-c) OSMOPREP ORAL TABLET 1.102-0.398 GM (sod phos NF mono-sod phos dibasic)

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 118 Prescription Drug Name Drug Tier Drug Notes PCP 100 COMBINATION KIT (mgcit-bisacod-pet-peg- NF metoclop) PEG-PREP ORAL KIT 5-210 MG-GM (bisacodyl-peg-kcl- CE nabicar-nacl) PLENVU ORAL SOLUTION RECONSTITUTED 140 GM CE (peg-kcl-nacl-nasulf-na asc-c) SUPREP BOWEL PREP KIT ORAL SOLUTION 17.5-3.13- CE 1.6 GM/177ML (na sulfate-k sulfate-mg sulf) MISCELLANEOUS bethanechol chloride oral tablet 10 mg, 25 mg, 5 mg, 50 mg G CARAFATE ORAL SUSPENSION 1 GM/10ML (sucralfate) NF CARAFATE ORAL TABLET 1 GM (sucralfate) NF CHENODAL ORAL TABLET 250 MG (chenodiol) NPB CHOLBAM ORAL CAPSULE 250 MG, 50 MG (cholic acid) NPSP cromolyn sodium oral concentrate 100 mg/5ml G diphenoxylate-atropine oral liquid 2.5-0.025 mg/5ml G diphenoxylate-atropine oral tablet 2.5-0.025 mg G ENTEREG ORAL CAPSULE 12 MG (alvimopan) NPB EVIVO ORAL LIQUID (bifidobacterium longum inf-mct) NF flavoxate hcl oral tablet 100 mg G GATTEX SUBCUTANEOUS KIT 5 MG (teduglutide NPSP (rdna)) loperamide hcl oral capsule 2 mg G misoprostol oral tablet 100 mcg, 200 mcg G MOTEGRITY ORAL TABLET 1 MG, 2 MG (prucalopride NF succinate) MOTOFEN ORAL TABLET 1-0.025 MG (difenoxin- NF atropine) MOVANTIK ORAL TABLET 12.5 MG, 25 MG (naloxegol PB oxalate) MYTESI ORAL TABLET DELAYED RELEASE 125 MG NF (crofelemer) OCALIVA ORAL TABLET 10 MG, 5 MG (obeticholic acid) NPSP opium oral tincture 10 mg/ml (1%) G probichew oral tablet chewable NF prodigen oral capsule NF provad oral capsule NF 2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 119 Prescription Drug Name Drug Tier Drug Notes PYLERA ORAL CAPSULE 140-125-125 MG (bis subcit- PB metronid-tetracyc) RELISTOR ORAL TABLET 150 MG (methylnaltrexone NF bromide) RELISTOR SUBCUTANEOUS SOLUTION 12 MG/0.6ML, NF 8 MG/0.4ML (methylnaltrexone bromide) RESTORA RX ORAL CAPSULE 60-1.25 MG (lactobacillus NF casei-folic acid) sucralfate oral suspension 1 gm/10ml NF sucralfate oral tablet 1 gm G SYMPROIC ORAL TABLET 0.2 MG (naldemedine tosylate) PB ursodiol oral capsule 300 mg G ursodiol oral tablet 250 mg, 500 mg G VSL#3 DS ORAL PACKET (probiotic product) NPB XERMELO ORAL TABLET 250 MG (telotristat etiprate) NPB zelac oral capsule NF PANCREATIC ENZYMES CREON ORAL CAPSULE DELAYED RELEASE PARTICLES 12000-38000 UNIT, 24000-76000 UNIT, 3000- PB 9500 UNIT, 36000-114000 UNIT, 6000-19000 UNIT (pancrelipase (lip-prot-amyl)) enzadyne oral capsule NF PANCREAZE ORAL CAPSULE DELAYED RELEASE PARTICLES 10500-35500 UNIT, 16800-56800 UNIT, 21000- NF 54700 UNIT, 2600-8800 UNIT, 37000-97300 UNIT, 4200- 14200 UNIT (pancrelipase (lip-prot-amyl)) PERTZYE ORAL CAPSULE DELAYED RELEASE PARTICLES 16000-57500 UNIT, 24000-86250 UNIT, 4000- NF 14375 UNIT, 8000-28750 UNIT (pancrelipase (lip-prot-amyl)) SUCRAID ORAL SOLUTION 8500 UNIT/ML (sacrosidase) NPB VIOKACE ORAL TABLET 10440-39150 UNIT, 20880- PB 78300 UNIT (pancrelipase (lip-prot-amyl)) ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 10000-32000 UNIT, 15000-47000 UNIT, 20000- 63000 UNIT, 25000-79000 UNIT, 3000-10000 UNIT, 40000- PB 126000 UNIT, 5000-24000 UNIT (pancrelipase (lip-prot- amyl))

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 120 Prescription Drug Name Drug Tier Drug Notes PROTON PUMP INHIBITORS - DRUGS FOR ULCERS AND STOMACH ACID ACIPHEX ORAL TABLET DELAYED RELEASE 20 MG NF (rabeprazole sodium) ACIPHEX SPRINKLE ORAL CAPSULE SPRINKLE 10 NF MG, 5 MG (rabeprazole sodium) DEXILANT ORAL CAPSULE DELAYED RELEASE 30 PB MG, 60 MG (dexlansoprazole) esomeprazole magnesium oral capsule delayed release 20 mg, 40 G mg lansoprazole oral capsule delayed release 15 mg, 30 mg G lansoprazole oral tablet delayed release dispersible 15 mg, 30 mg G NEXIUM 24HR CLEAR MINIS ORAL CAPSULE NF DELAYED RELEASE 20 MG (esomeprazole magnesium) NEXIUM 24HR ORAL CAPSULE DELAYED RELEASE NF 20 MG (esomeprazole magnesium) NEXIUM ORAL CAPSULE DELAYED RELEASE 20 NF MG, 40 MG (esomeprazole magnesium) NEXIUM ORAL PACKET 10 MG, 2.5 MG, 20 MG, 40 NF MG, 5 MG (esomeprazole magnesium) omeprazole oral capsule delayed release 10 mg, 20 mg, 40 mg G omeprazole-sodium bicarbonate oral capsule 20-1100 mg, 40- NF 1100 mg omeprazole-sodium bicarbonate oral packet 20-1680 mg, 40- NF 1680 mg pantoprazole sodium oral packet 40 mg NF pantoprazole sodium oral tablet delayed release 20 mg, 40 mg G PREVACID 24HR ORAL CAPSULE DELAYED NF RELEASE 15 MG (lansoprazole) PREVACID ORAL CAPSULE DELAYED RELEASE 15 NF MG, 30 MG (lansoprazole) PREVACID SOLUTAB ORAL TABLET DELAYED NF RELEASE DISPERSIBLE 15 MG, 30 MG (lansoprazole) PRILOSEC ORAL PACKET 10 MG, 2.5 MG (omeprazole NF magnesium) PROTONIX ORAL PACKET 40 MG (pantoprazole sodium) NF PROTONIX ORAL TABLET DELAYED RELEASE 20 NF MG, 40 MG (pantoprazole sodium)

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 121 Prescription Drug Name Drug Tier Drug Notes rabeprazole sodium oral capsule sprinkle 10 mg NPB rabeprazole sodium oral tablet delayed release 20 mg G ZEGERID ORAL CAPSULE 20-1100 MG, 40-1100 MG NF (omeprazole-sodium bicarbonate) ZEGERID ORAL PACKET 20-1680 MG, 40-1680 MG NF (omeprazole-sodium bicarbonate) RECTAL,CORTICOSTEROIDS hydrocortisone (perianal) external cream 1 %, 2.5 % G hydrocortisone ace-pramoxine external cream 1-1 % G PROCORT EXTERNAL CREAM 1.85-1.15 % NF (hydrocortisone ace-pramoxine) PROCTOCORT EXTERNAL CREAM 1 % (hydrocortisone) NF PROCTOCORT RECTAL SUPPOSITORY 30 MG NF (hydrocortisone acetate) PROCTOFOAM HC EXTERNAL FOAM 1-1 % PB (hydrocortisone ace-pramoxine) hydrocortisone (Procto-Med Hc External Cream 2.5 %) G hydrocortisone (Procto-Pak External Cream 1 %) G hydrocortisone (Proctozone-Hc External Cream 2.5 %) G RECTIV RECTAL OINTMENT 0.4 % (nitroglycerin) NPB ULCER THERAPY COMBINATIONS amoxicill-clarithro-lansopraz oral G OMECLAMOX-PAK ORAL 500-500-20 MG (amoxicill- NPB clarithro-omeprazole) TALICIA ORAL CAPSULE DELAYED RELEASE 250- NPB 12.5-10 MG (amoxicill-rifabutin-omeprazole) GENITOURINARY - DRUGS TO TREAT GENITAL AND URINARY TRACT CONDITIONS BENIGN PROSTATIC HYPERPLASIA - DRUGS TO TREAT ENLARGED PROSTATE alfuzosin hcl er oral tablet extended release 24 hour 10 mg G CARDURA XL ORAL TABLET EXTENDED RELEASE NPB 24 HOUR 4 MG, 8 MG (doxazosin mesylate) dutasteride oral capsule 0.5 mg G dutasteride-tamsulosin hcl oral capsule 0.5-0.4 mg G finasteride oral tablet 5 mg G

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 122 Prescription Drug Name Drug Tier Drug Notes JALYN ORAL CAPSULE 0.5-0.4 MG (dutasteride- NF tamsulosin hcl) RAPAFLO ORAL CAPSULE 4 MG, 8 MG (silodosin) NF silodosin oral capsule 4 mg, 8 mg G tamsulosin hcl oral capsule 0.4 mg G UROXATRAL ORAL TABLET EXTENDED RELEASE NF 24 HOUR 10 MG (alfuzosin hcl) CONTRACEPTIVES - PRODUCTS FOR BIRTH CONTROL ENCARE VAGINAL SUPPOSITORY 100 MG (nonoxynol- CE 9) OPTIONS GYNOL II CONTRACEPTIVE VAGINAL GEL CE 3 % (nonoxynol-9) SHUR-SEAL CONTRACEPTIVE VAGINAL GEL 2 % CE (nonoxynol-9) VCF VAGINAL CONTRACEPTIVE VAGINAL FILM 28 CE % (nonoxynol-9) VCF VAGINAL CONTRACEPTIVE VAGINAL FOAM CE 12.5 % (nonoxynol-9) VCF VAGINAL CONTRACEPTIVE VAGINAL GEL 4 % CE (nonoxynol-9) ERECTILE DYSFUNCTION SPC (Only available for bi-mix intracavernosal solution reconstituted 150-5 mg NF select plans) CIALIS ORAL TABLET 10 MG, 2.5 MG, 20 MG, 5 MG SPC (Only available for NF (tadalafil) select plans) LEVITRA ORAL TABLET 10 MG, 20 MG (vardenafil hcl) NF quad-mix intracavernosal solution reconstituted 150-10-0.1-1 NF mg STENDRA ORAL TABLET 100 MG, 200 MG, 50 MG SPC (Only available for NF (avanafil) select plans) SPC (Only available for super bi-mix intracavernosal solution reconstituted 150-10 mg NF select plans) super quad-mix intracavernosal solution reconstituted 150-20- SPC (Only available for NF 0.2-2 mg select plans) super tri-mix intracavernosal solution reconstituted 150-10-100 SPC (Only available for NF mg-mg-mcg select plans) tri-mix intracavernosal solution reconstituted 150-5-50 mg-mg- NF mcg 2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 123 Prescription Drug Name Drug Tier Drug Notes VIAGRA ORAL TABLET 100 MG, 25 MG, 50 MG SPC (Only available for NF (sildenafil citrate) select plans) MISCELLANEOUS acetic acid irrigation solution 0.25 % G aminoacetic acid irrigation solution 1.5 % G sodium chloride (gu irrigant) (Argyle Sterile Saline Irrigation G Solution 0.9 %) sodium chloride (gu irrigant) (Curity Sterile Saline Irrigation G Solution 0.9 %) cytra k crystals oral packet 3300-1002 mg G ELMIRON ORAL CAPSULE 100 MG (pentosan polysulfate NF sodium) glycine irrigation solution 1.5 % G K-PHOS NO 2 ORAL TABLET 305-700 MG (pot & sod ac NPB phosphates) LITHOSTAT ORAL TABLET 250 MG (acetohydroxamic NF acid) neomycin-polymyxin b gu irrigation solution 40-200000 G ORACIT ORAL SOLUTION 490-640 MG/5ML (sod citrate- NPB citric acid) phenazopyridine hcl (Phenazo Oral Tablet 200 Mg) G pot & sod cit-cit ac oral solution 550-500-334 mg/5ml G potassium citrate er oral tablet extended release 10 meq (1080 G mg), 15 meq (1620 mg), 5 meq (540 mg) potassium citrate-citric acid oral solution 1100-334 mg/5ml G PROCYSBI ORAL PACKET 300 MG, 75 MG (cysteamine NF bitartrate) RENACIDIN IRRIGATION SOLUTION (citric ac- NPB gluconolact-mg carb) RESECTISOL IRRIGATION SOLUTION 5 % (mannitol NPB (gu irrigant)) RIMSO-50 INTRAVESICAL SOLUTION 50 % (dimethyl NF sulfoxide) sod citrate-citric acid oral solution 500-334 mg/5ml G sodium chloride irrigation solution 0.9 % G sorbitol irrigation solution 3 %, 3.3 % NPB sorbitol-mannitol irrigation solution 2.7-0.54 gm/100ml NPB

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 124 Prescription Drug Name Drug Tier Drug Notes THIOLA EC ORAL TABLET DELAYED RELEASE 100 NF MG, 300 MG (tiopronin) THIOLA ORAL TABLET 100 MG (tiopronin) NF tricitrates oral solution 550-500-334 mg/5ml G TRIMO-SAN VAGINAL GEL 0.025-0.01 % (oxyquinoline- NF sod lauryl sulf) PROGESTINS - DRUGS TO REGULATE FEMALE HORMONES ENDOMETRIN VAGINAL INSERT 100 MG PB (progesterone) URINARY ANTISPASMODICS - DRUGS TO TREAT URINARY INCONTINENCE darifenacin hydrobromide er oral tablet extended release 24 G hour 15 mg, 7.5 mg DETROL LA ORAL CAPSULE EXTENDED RELEASE NF 24 HOUR 2 MG, 4 MG (tolterodine tartrate) ENABLEX ORAL TABLET EXTENDED RELEASE 24 NF HOUR 15 MG (darifenacin hydrobromide) GELNIQUE TRANSDERMAL GEL 10 % (oxybutynin NF chloride) MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 PB HOUR 25 MG (mirabegron) oxybutynin chloride er oral tablet extended release 24 hour 10 G mg, 15 mg, 5 mg oxybutynin chloride oral syrup 5 mg/5ml G oxybutynin chloride oral tablet 5 mg G OXYTROL FOR WOMEN TRANSDERMAL PATCH NF TWICE WEEKLY 3.9 MG/24HR (oxybutynin) OXYTROL TRANSDERMAL PATCH TWICE WEEKLY NF 3.9 MG/24HR (oxybutynin) solifenacin succinate oral tablet 10 mg, 5 mg G tolterodine tartrate er oral capsule extended release 24 hour 2 G mg, 4 mg tolterodine tartrate oral tablet 1 mg, 2 mg G TOVIAZ ORAL TABLET EXTENDED RELEASE 24 PB HOUR 4 MG, 8 MG (fesoterodine fumarate) trospium chloride er oral capsule extended release 24 hour 60 G mg

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 125 Prescription Drug Name Drug Tier Drug Notes trospium chloride oral tablet 20 mg G VESICARE LS ORAL SUSPENSION 5 MG/5ML NPB (solifenacin succinate) VESICARE ORAL TABLET 10 MG, 5 MG (solifenacin NF succinate) VAGINAL ANTI-INFECTIVES - DRUGS TO TREAT VAGINAL INFECTIONS CLEOCIN VAGINAL SUPPOSITORY 100 MG NPB (clindamycin phosphate) clindamycin phosphate vaginal cream 2 % G CLINDESSE VAGINAL CREAM 2 % (clindamycin NPB phosphate (1 dose)) GYNAZOLE-1 VAGINAL CREAM 2 % ( NPB nitrate (1 dose)) metronidazole vaginal gel 0.75 % G 3 vaginal suppository 200 mg G NUVESSA VAGINAL GEL 1.3 % (metronidazole) NF vaginal cream 0.4 %, 0.8 % G terconazole vaginal suppository 80 mg G metronidazole (Vandazole Vaginal Gel 0.75 %) G HEMATOLOGIC - DRUGS TO TREAT BLOOD DISORDERS ANTICOAGULANTS - BLOOD THINNERS acd formula a in vitro solution 0.73-2.45-2.2 gm/100ml NPB ACD-A NOCLOT-50 IN VITRO SOLUTION 0.73-2.45-2.2 NPB GM/100ML (anticoagulant cit dext soln a) anticoagulant sodium citrate in vitro solution 4 gm/100ml NPB bivalirudin rtu intravenous solution 250 mg/50ml NPB DEFITELIO INTRAVENOUS SOLUTION 200 MG/2.5ML NF (defibrotide sodium) ELIQUIS DVT/PE STARTER PACK ORAL TABLET PB THERAPY PACK 5 MG (apixaban) ELIQUIS ORAL TABLET 2.5 MG, 5 MG (apixaban) PB enoxaparin sodium injection solution 300 mg/3ml G enoxaparin sodium subcutaneous solution 100 mg/ml, 120 mg/0.8ml, 150 mg/ml, 30 mg/0.3ml, 40 mg/0.4ml, 60 mg/0.6ml, G 80 mg/0.8ml

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 126 Prescription Drug Name Drug Tier Drug Notes fondaparinux sodium subcutaneous solution 10 mg/0.8ml, 2.5 G mg/0.5ml, 5 mg/0.4ml, 7.5 mg/0.6ml FRAGMIN SUBCUTANEOUS SOLUTION 10000 UNIT/ML, 12500 UNIT/0.5ML, 15000 UNIT/0.6ML, 18000 NF UNT/0.72ML, 2500 UNIT/0.2ML, 5000 UNIT/0.2ML, 7500 UNIT/0.3ML, 95000 UNIT/3.8ML (dalteparin sodium) heparin sodium (porcine) injection solution 1000 unit/ml, 10000 G unit/ml, 20000 unit/ml, 5000 unit/ml heparin sodium (porcine) pf injection solution 5000 unit/0.5ml G hepmed combination kit 100&0.9&2.5-2.5 ut/ml&% NF warfarin sodium (Jantoven Oral Tablet 1 Mg, 10 Mg, 2 Mg, 2.5 G LGC Mg, 3 Mg, 4 Mg, 5 Mg, 6 Mg, 7.5 Mg) PRADAXA ORAL CAPSULE 110 MG, 150 MG, 75 MG NF (dabigatran etexilate mesylate) REGIOCIT IN VITRO SOLUTION 0.529 % (anticoagulant NPB na cit (crrt)) SAVAYSA ORAL TABLET 15 MG, 30 MG, 60 MG NF (edoxaban tosylate) TRICITRASOL IN VITRO CONCENTRATE 46.7 % NPB (anticoagulant sodium citrate) warfarin sodium oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 G LGC mg, 5 mg, 6 mg, 7.5 mg XARELTO ORAL TABLET 10 MG, 15 MG, 2.5 MG, 20 PB MG (rivaroxaban) XARELTO STARTER PACK ORAL TABLET THERAPY PB PACK 15 & 20 MG (rivaroxaban) ANTI-VON WILLEBRAND FACTOR AGENTS CABLIVI INJECTION KIT 11 MG (caplacizumab-yhdp) NF BLEEDING DISORDERS AGENTS ALPHANATE INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, NPSP 250 UNIT, 500 UNIT (antihemophilic factor-vwf) FEIBA INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2500 UNIT, 500 UNIT (antiinhibitor coagulant NPSP cmplx) HUMATE-P INTRAVENOUS SOLUTION RECONSTITUTED 1000-2400 UNIT, 250-600 UNIT, 500- NPSP 1200 UNIT (antihemophilic factor-vwf)

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 127 Prescription Drug Name Drug Tier Drug Notes NOVOSEVEN RT INTRAVENOUS SOLUTION RECONSTITUTED 1 MG, 2 MG, 5 MG, 8 MG (coagulation NPSP factor viia recomb) WILATE INTRAVENOUS KIT 1000-1000 UNIT, 500-500 NPSP UNIT (antihemophilic factor-vwf) HEMATOPOIETIC GROWTH FACTORS ARANESP (ALBUMIN FREE) INJECTION SOLUTION 100 MCG/ML, 200 MCG/ML, 25 MCG/ML, 300 MCG/ML, PSP 40 MCG/ML, 60 MCG/ML (darbepoetin alfa) ARANESP (ALBUMIN FREE) INJECTION SOLUTION PREFILLED SYRINGE 10 MCG/0.4ML, 100 MCG/0.5ML, 150 MCG/0.3ML, 200 MCG/0.4ML, 25 MCG/0.42ML, 300 PSP MCG/0.6ML, 40 MCG/0.4ML, 500 MCG/ML, 60 MCG/0.3ML (darbepoetin alfa) DOPTELET ORAL TABLET 20 MG (avatrombopag PSP maleate) LEUKINE INJECTION SOLUTION RECONSTITUTED NPSP 250 MCG (sargramostim) MIRCERA INJECTION SOLUTION PREFILLED SYRINGE 100 MCG/0.3ML, 150 MCG/0.3ML, 200 NF MCG/0.3ML, 30 MCG/0.3ML, 50 MCG/0.3ML, 75 MCG/0.3ML (methoxy peg-epoetin beta) MULPLETA ORAL TABLET 3 MG (lusutrombopag) PSP NEULASTA ONPRO SUBCUTANEOUS PREFILLED NF SYRINGE KIT 6 MG/0.6ML (pegfilgrastim) NEULASTA SUBCUTANEOUS SOLUTION PREFILLED NF SYRINGE 6 MG/0.6ML (pegfilgrastim) NIVESTYM INJECTION SOLUTION 300 MCG/ML, 480 PSP MCG/1.6ML (filgrastim-aafi) NIVESTYM INJECTION SOLUTION PREFILLED SYRINGE 300 MCG/0.5ML, 480 MCG/0.8ML (filgrastim- PSP aafi) NPLATE SUBCUTANEOUS SOLUTION RECONSTITUTED 125 MCG, 250 MCG, 500 MCG NPSP (romiplostim) PROMACTA ORAL PACKET 12.5 MG, 25 MG NPSP (eltrombopag olamine) PROMACTA ORAL TABLET 12.5 MG, 25 MG, 50 MG, 75 NPSP MG (eltrombopag olamine)

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 128 Prescription Drug Name Drug Tier Drug Notes RETACRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 PSP UNIT/ML, 40000 UNIT/ML (epoetin alfa-epbx) UDENYCA SUBCUTANEOUS SOLUTION PREFILLED NF SYRINGE 6 MG/0.6ML (pegfilgrastim-cbqv) ZIEXTENZO SUBCUTANEOUS SOLUTION PSP PREFILLED SYRINGE 6 MG/0.6ML (pegfilgrastim-bmez) HEMOPHILIA A AGENTS ADVATE INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, PSP 250 UNIT, 3000 UNIT, 4000 UNIT, 500 UNIT (antihemophil factor (rahf-pfm)) adynovate intravenous solution reconstituted 1000 unit, 1500 PSP unit, 2000 unit, 250 unit, 3000 unit, 500 unit, 750 unit AFSTYLA INTRAVENOUS KIT 1000 UNIT, 1500 UNIT, 2000 UNIT, 250 UNIT, 2500 UNIT, 3000 UNIT, 500 UNIT PSP (antihemophil fact single chain) ELOCTATE INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, PSP 250 UNIT, 3000 UNIT, 4000 UNIT, 500 UNIT, 5000 UNIT, 6000 UNIT, 750 UNIT (antihem fact (bdd-rfviiifc)) ESPEROCT INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, PSP 3000 UNIT, 500 UNIT (antihemoph fact rcmb gpeg-exei) HEMOFIL M INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1700 UNIT, 250 UNIT, 500 NPSP UNIT (antihemophilic factor) JIVI INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 3000 UNIT, 500 UNIT (ahf (bdd- PSP rfviii peg-aucl)) KOATE INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 250 UNIT, 500 UNIT NPSP (antihemophilic factor) KOATE-DVI INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 500 UNIT (antihemophilic NPSP factor) KOGENATE FS INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT (antihem factor PSP recomb (rfviii))

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 129 Prescription Drug Name Drug Tier Drug Notes KOVALTRY INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT, PSP 3000 UNIT, 500 UNIT (antihemophil factor (rahf-pfm)) NOVOEIGHT INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, PSP 250 UNIT, 3000 UNIT, 500 UNIT (antihemophil fact bd truncated) NUWIQ INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 250 UNIT, 2500 UNIT, 3000 UNIT, 4000 UNIT, 500 UNIT PSP (antihem fact (bdd-rfviii,sim)) NUWIQ INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT, PSP 2500 UNIT, 3000 UNIT, 4000 UNIT, 500 UNIT (antihem fact (bdd-rfviii,sim)) RECOMBINATE INTRAVENOUS SOLUTION RECONSTITUTED 1241-1800 UNIT, 1801-2400 UNIT, NPSP 220-400 UNIT, 401-800 UNIT, 801-1240 UNIT (antihem factor recomb (rfviii)) XYNTHA INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, NPSP 250 UNIT, 500 UNIT (antihem fact (bdd-rfviii,mor)) XYNTHA SOLOFUSE INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT (antihem fact NPSP (bdd-rfviii,mor)) HEMOPHILIA B AGENTS ALPHANINE SD INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 500 UNIT NPSP (coagulation factor ix) ALPROLIX INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT, NF 3000 UNIT, 4000 UNIT, 500 UNIT (coagulation factor ix (rfixfc)) BENEFIX INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT (coagulation factor ix NPSP (recomb)) COAGADEX INTRAVENOUS SOLUTION RECONSTITUTED 250 UNIT, 500 UNIT (coagulation NPSP factor x (human)) IDELVION INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT, NPSP 3500 UNIT, 500 UNIT (coagulation factor ix (rix-fp))

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 130 Prescription Drug Name Drug Tier Drug Notes IXINITY INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT, NPSP 250 UNIT, 3000 UNIT, 500 UNIT (coagulation factor ix (recomb)) MONONINE INTRAVENOUS SOLUTION NPSP RECONSTITUTED 1000 UNIT (coagulation factor ix) PROFILNINE INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 1500 UNIT, 500 UNIT NPSP (factor ix complex) REBINYN INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 500 UNIT PSP (coagulation factor ix glycopeg) rixubis intravenous solution reconstituted 1000 unit, 2000 unit, NPSP 250 unit, 3000 unit, 500 unit VONVENDI INTRAVENOUS SOLUTION RECONSTITUTED 1300 UNIT, 650 UNIT (von willebrand NF factor (recomb)) MISCELLANEOUS cyanocobalamin-methylcobalamin (Abaneu-Sl Sublingual G Tablet Sublingual 600-600 Mcg) active fe oral tablet 75-1.25 mg NPB ADAKVEO INTRAVENOUS SOLUTION 100 MG/10ML NPB (crizanlizumab-tmca) folic acid-vit b6-vit b12 (Airavite Oral Tablet 2.5-25-1 Mg) G AKTEN OPHTHALMIC GEL 3.5 % (lidocaine hcl) NPB tetracaine hcl (Altacaine Ophthalmic Solution 0.5 %) G altafluor benox ophthalmic solution 0.25-0.4 % G phenylephrine hcl (Altafrin Ophthalmic Solution 10 %, 2.5 %) G AMICAR ORAL SOLUTION 0.25 GM/ML (aminocaproic NF acid) aminocaproic acid oral tablet 1000 mg, 500 mg G anagrelide hcl oral capsule 0.5 mg, 1 mg G ARTISS EXTERNAL SOLUTION (fibrin sealant component) NPB atropine sulfate ophthalmic ointment 1 % G atropine sulfate ophthalmic solution 1 % NPB b-6 folic acid oral capsule 8.333-100-1 mg NPB bp vit 3 oral capsule 1 mg NPB

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 131 Prescription Drug Name Drug Tier Drug Notes CENFOL ORAL TABLET 2.3-24.5-2 MG (folic acid-vit b6- NPB vit b12) CEQUA OPHTHALMIC SOLUTION 0.09 % (cyclosporine) NF CIFEREX ORAL CAPSULE 1-3775 MG-UNIT (folic acid- NF cholecalciferol) cilostazol oral tablet 100 mg, 50 mg G CINRYZE INTRAVENOUS SOLUTION RECONSTITUTED 500 UNIT (c1 esterase inhibitor NPSP (human)) CORVITE 150 ORAL TABLET (iron combinations) NPB corvite fe oral tablet NPB CYCLOMYDRIL OPHTHALMIC SOLUTION 0.2-1 % NPB (cyclopentolate-phenylephrine) cyclopentolate hcl ophthalmic solution 0.5 %, 1 %, 2 % G CYCLOSPORINE IN KLARITY OPHTHALMIC NF EMULSION 0.1 % (cyclosporine) CYSTARAN OPHTHALMIC SOLUTION 0.44 % NPB (cysteamine hcl) DURLAZA ORAL CAPSULE EXTENDED RELEASE 24 NF HOUR 162.5 MG (aspirin) ENDARI ORAL PACKET 5 GM (glutamine (sickle cell)) NPB fabb oral tablet 2.2-25-1 mg G fa-vitamin b-6-vitamin b-12 oral tablet 2.2-25-0.5 mg G FERIVA 21/7 ORAL TABLET 75-1 MG (feasp-b12-fa-c-dss- NF succac-zn) ferocon oral capsule G ferotrinsic oral capsule G ferraplus 90 oral tablet 90-1 mg NPB fe fum-fa-b cmp-c-zn-mg-mn-cu (Ferrocite Plus Oral Tablet G 106-1 Mg) FERRO-PLEX HEMATINIC ORAL TABLET 115-1 MG NPB (fe fum-dss-c-e-b12-if-fa) FIRAZYR SUBCUTANEOUS SOLUTION 30 MG/3ML NPSP (icatibant acetate) fluorescein-benoxinate ophthalmic solution 0.25-0.4 % G fluorescein sodium (Fluor-I-Strips A.T. Ophthalmic Strip 1 G Mg)

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 132 Prescription Drug Name Drug Tier Drug Notes FLURA-SAFE OPHTHALMIC SOLUTION 0.35-0.4 % NPB (fluorexon-benoxinate) folbee oral tablet 2.5-25-1 mg G FOLI-D ORAL TABLET 1-2000 MG-UNIT (folic acid- NF cholecalciferol) folite oral tablet NF folplex 2.2 oral tablet 2.2-25-0.5 mg G foltrin oral capsule G folic acid-cholecalciferol (Folvite-D Oral Tablet 1-3775 Mg- NF Unit) FUSION PLUS ORAL CAPSULE (iron-fa-b cmp-c-biot- NPB probiotic) GELFILM OPHTHALMIC FILM (gelatin adsorbable) NPB GEL-FLOW EXTERNAL KIT (gelatin absorb-thrombin) NF GELFOAM-JMI POWDER EXTERNAL KIT (gelatin NF absorb-thrombin) GELFOAM-JMI SPONGE EXTERNAL KIT (gelatin NF absorb-thrombin) GENICIN VITA-D ORAL TABLET 1-3775 MG-UNIT NF (folic acid-cholecalciferol) GREEN GLO LISSAMINE GREEN OPHTHALMIC NPB STRIP 1.5 MG (lissamine green) HAEGARDA SUBCUTANEOUS SOLUTION RECONSTITUTED 2000 UNIT, 3000 UNIT (c1 esterase NPSP inhibitor (human)) hematinic plus vit/minerals oral tablet 106-1 mg G hematinic/folic acid oral tablet 324-1 mg G HEMLIBRA SUBCUTANEOUS SOLUTION 105 MG/0.7ML, 150 MG/ML, 30 MG/ML, 60 MG/0.4ML NPSP (emicizumab-kxwh) HEMOCYTE PLUS ORAL CAPSULE 106-1 MG (fe fum-fa- NPB b cmp-c-zn-mg-mn-cu) ferrous fumarate-folic acid (Hemocyte-F Oral Tablet 324-1 G Mg) ICAR-C PLUS ORAL TABLET 100-250-0.025-1 MG (iron- NF vit c-vit b12-folic acid) icatibant acetate subcutaneous solution 30 mg/3ml G

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 133 Prescription Drug Name Drug Tier Drug Notes iron polysacch cmplx-b12-fa (Iferex 150 Forte Oral Capsule G 150-25-1 Mg-Mcg-Mg) INTEGRA F ORAL CAPSULE 125-1 MG (fe fum-fepoly-fa- NPB vit c-vit b3) INTEGRA PLUS ORAL CAPSULE (fefum-fepoly-fa-b cmp- NPB c-biot) ISOPTO ATROPINE OPHTHALMIC SOLUTION 1 % NPB (atropine sulfate) fefum-fepo-fa-b cmp-c-zn-mn-cu (K-Tan Plus Oral Capsule G 162-115.2-1 Mg) LACRISERT OPHTHALMIC INSERT 5 MG (artificial tear NF insert) MULTIGEN FOLIC ORAL TABLET 70-150-2-1 MG (fe NPB asp gly-succ-c-thre-b12-fa) MULTIGEN ORAL TABLET 70 MG (fe-succ-c-thre-b12-des NPB stomach) MULTIGEN PLUS ORAL TABLET 50-101-1 MG (feasp- NPB fefum -suc-c-thre-b12-fa) NUFERA ORAL TABLET (iron combinations) NPB folic acid-vit b6-vit b12 (Nufol Oral Tablet 2.5-25-1 Mg) G ortho df oral capsule 1-3775 mg-unit NF PAREMYD OPHTHALMIC SOLUTION 1-0.25 % NPB (hydroxyamphetamine-tropicamide) pentoxifylline er oral tablet extended release 400 mg G phenylephrine hcl ophthalmic solution 10 %, 2.5 % G PHOTREXA VISCOUS OPHTHALMIC SOLUTION PREFILLED SYRINGE 0.146-20 % (riboflavin 5-phosphate- NF dextran) PHOTREXA-PHOTREXA VISCOUS KIT OPHTHALMIC SOLUTION PREFILLED SYRINGE 0.146 &0.146-20 % NF (riboflav5 & riboflav5-dextran) poly-iron 150 forte oral capsule 150-25-1 mg-mcg-mg G polysaccharide iron forte oral capsule 150-25-1 mg-mcg-mg G proparacaine hcl ophthalmic solution 0.5 % G proparacaine-fluorescein ophthalmic solution 0.5-0.25 % G PROVAYBLUE INTRAVENOUS SOLUTION 50 NF MG/10ML (methylene blue (antidote))

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 134 Prescription Drug Name Drug Tier Drug Notes RADIOGARDASE ORAL CAPSULE 0.5 GM (prussian blue NPB insoluble) RECOTHROM EXTERNAL SOLUTION NPB RECONSTITUTED 5000 UNIT (thrombin (recombinant)) RECOTHROM SPRAY KIT EXTERNAL SOLUTION NPB RECONSTITUTED 20000 UNIT (thrombin (recombinant)) RESTASIS MULTIDOSE OPHTHALMIC EMULSION NF 0.05 % (cyclosporine) RESTASIS OPHTHALMIC EMULSION 0.05 % NF (cyclosporine) revesta oral capsule 1-5750 mg-unit NF RUCONEST INTRAVENOUS SOLUTION RECONSTITUTED 2100 UNIT (c1 esterase inhibitor PSP (recomb)) SIKLOS ORAL TABLET 100 MG, 1000 MG (hydroxyurea) NPB TAKHZYRO SUBCUTANEOUS SOLUTION 300 PSP MG/2ML (lanadelumab-flyo) TALIVA ORAL CAPSULE 1 MG (fa-b6-b12-omega 3- NF phytosterols) tetracaine hcl ophthalmic solution 0.5 % G THROMBIN-JMI EPISTAXIS EXTERNAL KIT 5000 NPB UNIT (thrombin) THROMBIN-JMI EXTERNAL KIT 20000 UNIT, 5000 NPB UNIT (thrombin) THROMBIN-JMI EXTERNAL SOLUTION NPB RECONSTITUTED 20000 UNIT, 5000 UNIT (thrombin) THROMBOGEN EXTERNAL KIT 10000 UNIT (thrombin) NPB THROMBOGEN EXTERNAL SOLUTION NPB RECONSTITUTED 1000 UNIT, 10000 UNIT (thrombin) TISSEEL EXTERNAL KIT 10 ML, 2 ML, 4 ML (fibrin NPB sealant component) TISSEEL EXTERNAL SOLUTION (fibrin sealant NPB component) tl-hem 150 oral tablet 150-1 mg G tranexamic acid oral tablet 650 mg G fe fumarate-b12-vit c-fa-ifc (Tricon Oral Capsule) G tropicamide ophthalmic solution 0.5 %, 1 % G

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 135 Prescription Drug Name Drug Tier Drug Notes ULTOMIRIS INTRAVENOUS SOLUTION 1100 NF MG/11ML, 300 MG/3ML (ravulizumab-cwvz) virt-fefa plus oral capsule NF folic acid-vit b6-vit b12 (Virt-Gard Oral Tablet 2.2-25-1 Mg) G VITAMEZ ORAL CAPSULE 1 MG (fa-b6-b12-omega 3- NPB phytosterols) PLASMA PROTEINS ALBUKED 25 INTRAVENOUS SOLUTION 25 % (albumin NPB human) ALBUKED 5 INTRAVENOUS SOLUTION 5 % (albumin NPB human) albumin human intravenous solution 25 %, 5 % NPB albumin-zlb intravenous solution 25 %, 5 % NPB alburx intravenous solution 5 % NPB ALBUTEIN INTRAVENOUS SOLUTION 25 %, 5 % NPB (albumin human) FLEXBUMIN INTRAVENOUS SOLUTION 25 %, 5 % NPB (albumin human) HUMAN ALBUMIN GRIFOLS INTRAVENOUS NPB SOLUTION 25 % (albumin human) kedbumin intravenous solution 25 % NPB PLASBUMIN-25 INTRAVENOUS SOLUTION 25 % NPB (albumin human) PLASBUMIN-5 INTRAVENOUS SOLUTION 5 % (albumin NPB human) PLATELET AGGREGATION INHIBITORS - BLOOD THINNERS AGGRASTAT INTRAVENOUS CONCENTRATE 3.75 NF MG/15ML (tirofiban hcl) aspirin-dipyridamole er oral capsule extended release 12 hour G 25-200 mg BRILINTA ORAL TABLET 60 MG, 90 MG (ticagrelor) PB clopidogrel bisulfate oral tablet 300 mg, 75 mg G dipyridamole oral tablet 25 mg, 50 mg, 75 mg G PLAVIX ORAL TABLET 75 MG (clopidogrel bisulfate) NF prasugrel hcl oral tablet 10 mg, 5 mg G YOSPRALA ORAL TABLET DELAYED RELEASE 325- NF 40 MG, 81-40 MG (aspirin-omeprazole) 2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 136 Prescription Drug Name Drug Tier Drug Notes ZONTIVITY ORAL TABLET 2.08 MG (vorapaxar sulfate) NF IMMUNOLOGIC AGENTS - DRUGS TO TREAT DISORDERS OF THE IMMUNE SYSTEM ALLERGENIC EXTRACTS GRASTEK SUBLINGUAL TABLET SUBLINGUAL 2800 PB BAU (timothy grass pollen allergen) ODACTRA SUBLINGUAL TABLET SUBLINGUAL 12 NPB SQ-HDM (dust mite mixed allergen ext) ORALAIR SUBLINGUAL TABLET SUBLINGUAL 300 PB IR (grass mix pollens allergen ext) RAGWITEK SUBLINGUAL TABLET SUBLINGUAL 12 PB AMB A 1-U (short ragweed pollen ext) sorrel/dock mix subcutaneous solution 1:20 NF BIOLOGIC DISEASE-MODIFYING AGENTS ACTEMRA ACTPEN SUBCUTANEOUS SOLUTION NF AUTO-INJECTOR 162 MG/0.9ML (tocilizumab) AVSOLA INTRAVENOUS SOLUTION NF RECONSTITUTED 100 MG (infliximab-axxq) ENBREL MINI SUBCUTANEOUS SOLUTION IBC (Preferred agent for all PSP CARTRIDGE 50 MG/ML (etanercept) conditions except Psoriasis) ENBREL SUBCUTANEOUS SOLUTION 25 MG/0.5ML IBC (Preferred agent for all PSP (etanercept) conditions except Psoriasis) ENBREL SUBCUTANEOUS SOLUTION PREFILLED IBC (Preferred agent for all PSP SYRINGE 25 MG/0.5ML, 50 MG/ML (etanercept) conditions except Psoriasis) ENBREL SUBCUTANEOUS SOLUTION IBC (Preferred agent for all PSP RECONSTITUTED 25 MG (etanercept) conditions except Psoriasis) ENBREL SURECLICK SUBCUTANEOUS SOLUTION IBC (Preferred agent for all PSP AUTO-INJECTOR 50 MG/ML (etanercept) conditions except Psoriasis) IBC (Available as NPSP ENTYVIO INTRAVENOUS SOLUTION NF with PA for Ulcerative RECONSTITUTED 300 MG (vedolizumab) Colitis) HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 80 PSP MG/0.8ML, 80 MG/0.8ML & 40MG/0.4ML (adalimumab) HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT PSP 40 MG/0.4ML, 40 MG/0.8ML, 80 MG/0.8ML (adalimumab) HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML, 80 MG/0.8ML PSP (adalimumab)

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 137 Prescription Drug Name Drug Tier Drug Notes HUMIRA PEN-PS/UV/ADOL HS START SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML PSP (adalimumab) HUMIRA PEN-PSOR/UVEIT STARTER SUBCUTANEOUS PEN-INJECTOR KIT 80 MG/0.8ML & PSP 40MG/0.4ML (adalimumab) HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 MG/0.1ML, 20 MG/0.2ML, 40 MG/0.4ML, 40 PSP MG/0.8ML (adalimumab) ILARIS SUBCUTANEOUS SOLUTION 150 MG/ML NPSP (canakinumab) INFLECTRA INTRAVENOUS SOLUTION NF RECONSTITUTED 100 MG (infliximab-dyyb) KEVZARA SUBCUTANEOUS SOLUTION AUTO- IBC (Preferred agent for PSP INJECTOR 150 MG/1.14ML, 200 MG/1.14ML (sarilumab) Rheumatoid Arthritis) KEVZARA SUBCUTANEOUS SOLUTION PREFILLED IBC (Preferred agent for PSP SYRINGE 150 MG/1.14ML, 200 MG/1.14ML (sarilumab) Rheumatoid Arthritis) OLUMIANT ORAL TABLET 1 MG (baricitinib) NF IBC (Preferred agent for ORENCIA CLICKJECT SUBCUTANEOUS SOLUTION Rheumatoid Arthritis. Not PSP AUTO-INJECTOR 125 MG/ML (abatacept) covered for other conditions) IBC (Preferred agent for ORENCIA SUBCUTANEOUS SOLUTION PREFILLED Rheumatoid Arthritis. Not SYRINGE 125 MG/ML, 50 MG/0.4ML, 87.5 MG/0.7ML PSP covered for other (abatacept) conditions) REMICADE INTRAVENOUS SOLUTION PSP RECONSTITUTED 100 MG (infliximab) RENFLEXIS INTRAVENOUS SOLUTION NF RECONSTITUTED 100 MG (infliximab-abda) RINVOQ ORAL TABLET EXTENDED RELEASE 24 IBC (Preferred agent for PSP HOUR 15 MG (upadacitinib) Rheumatoid Arthritis) SIMPONI ARIA INTRAVENOUS SOLUTION 50 PSP MG/4ML (golimumab) SIMPONI SUBCUTANEOUS SOLUTION AUTO- NPSP INJECTOR 100 MG/ML, 50 MG/0.5ML (golimumab) SIMPONI SUBCUTANEOUS SOLUTION PREFILLED NPSP SYRINGE 100 MG/ML, 50 MG/0.5ML (golimumab)

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 138 Prescription Drug Name Drug Tier Drug Notes SKYRIZI (150 MG DOSE) SUBCUTANEOUS IBC (Preferred agent for PREFILLED SYRINGE KIT 75 MG/0.83ML (risankizumab- PSP Psoriasis) rzaa) SKYRIZI PEN SUBCUTANEOUS SOLUTION AUTO- IBC (Preferred agent for PSP INJECTOR 150 MG/ML (risankizumab-rzaa) Psoriasis) SKYRIZI SUBCUTANEOUS SOLUTION PREFILLED IBC (Preferred agent for PSP SYRINGE 150 MG/ML (risankizumab-rzaa) Psoriasis) IBC (Preferred agent for Psoriasis. Preferred agent for Crohn's Disease and STELARA INTRAVENOUS SOLUTION 130 MG/26ML PSP Ulcerative Colitis after (ustekinumab) failure of Humira. Not covered for Psoriatic Arthritis.) IBC (Preferred agent for Psoriasis. Preferred agent for Crohn's Disease and STELARA SUBCUTANEOUS SOLUTION 45 MG/0.5ML PSP Ulcerative Colitis after (ustekinumab) failure of Humira. Not covered for Psoriatic Arthritis.) IBC (Preferred agent for Psoriasis. Preferred agent for Crohn's Disease and STELARA SUBCUTANEOUS SOLUTION PREFILLED PSP Ulcerative Colitis after SYRINGE 45 MG/0.5ML, 90 MG/ML (ustekinumab) failure of Humira. Not covered for Psoriatic Arthritis.) IBC (Preferred agent for TALTZ SUBCUTANEOUS SOLUTION AUTO- Psoriasis. Not covered for PSP INJECTOR 80 MG/ML (ixekizumab) Psoriatic Arthritis or Ankylosing Spondylitis) IBC (Preferred agent for TALTZ SUBCUTANEOUS SOLUTION PREFILLED Psoriasis. Not covered for PSP SYRINGE 80 MG/ML (ixekizumab) Psoriatic Arthritis or Ankylosing Spondylitis) IBC (Preferred agent for TREMFYA SUBCUTANEOUS SOLUTION PEN- PSP Psoriasis.Not covered for INJECTOR 100 MG/ML (guselkumab) Psoriatic Arthritis) IBC (Preferred agent for TREMFYA SUBCUTANEOUS SOLUTION PREFILLED PSP Psoriasis.Not covered for SYRINGE 100 MG/ML (guselkumab) Psoriatic Arthritis)

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 139 Prescription Drug Name Drug Tier Drug Notes IBC (Preferred agent for Rheumatoid Arthritis. Preferred agent for XELJANZ ORAL SOLUTION 1 MG/ML (tofacitinib citrate) PSP Ulcerative Colitis (after failure of Humira). Not covered for Psoriatic Arthritis.) IBC (Preferred agent for Rheumatoid Arthritis. Preferred agent for XELJANZ ORAL TABLET 10 MG, 5 MG (tofacitinib PSP Ulcerative Colitis (after citrate) failure of Humira). Not covered for Psoriatic Arthritis.) IBC (Preferred agent for Rheumatoid Arthritis. Preferred agent for XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 PSP Ulcerative Colitis (after HOUR 11 MG, 22 MG (tofacitinib citrate) failure of Humira). Not covered for Psoriatic Arthritis.) DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS) - DRUGS TO TREAT RHEUMATOID ARTHRITIS hydroxychloroquine sulfate oral tablet 200 mg G leflunomide oral tablet 10 mg, 20 mg G IBC (Preferred agent for OTEZLA ORAL TABLET 30 MG (apremilast) PSP Psoriasis and Psoriatic Arthritis) IBC (Preferred agent for OTEZLA ORAL TABLET THERAPY PACK 10 & 20 & 30 PSP Psoriasis and Psoriatic MG (apremilast) Arthritis) RASUVO SUBCUTANEOUS SOLUTION AUTO- INJECTOR 10 MG/0.2ML, 12.5 MG/0.25ML, 15 MG/0.3ML, 17.5 MG/0.35ML, 20 MG/0.4ML, 22.5 PSP MG/0.45ML, 25 MG/0.5ML, 30 MG/0.6ML, 7.5 MG/0.15ML (methotrexate (anti-rheumatic)) IMMUNOGLOBULIN BIVIGAM INTRAVENOUS SOLUTION 5 GM/50ML NPSP (immune globulin (human))

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 140 Prescription Drug Name Drug Tier Drug Notes CUTAQUIG SUBCUTANEOUS SOLUTION 1 GM/6ML, 1.65 GM/10ML, 2 GM/12ML, 3.3 GM/20ML, 4 GM/24ML, 8 PSP GM/48ML (immune globulin (human)-hipp) CUVITRU SUBCUTANEOUS SOLUTION 1 GM/5ML, 10 GM/50ML, 2 GM/10ML, 4 GM/20ML, 8 GM/40ML (immune NF globulin (human)) FLEBOGAMMA DIF INTRAVENOUS SOLUTION 0.5 GM/10ML, 10 GM/100ML, 10 GM/200ML, 2.5 GM/50ML, NPSP 20 GM/200ML, 20 GM/400ML, 5 GM/100ML, 5 GM/50ML (immune globulin (human)) GAMMAGARD INJECTION SOLUTION 1 GM/10ML, 10 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 30 GM/300ML, NPSP 5 GM/50ML (immune globulin (human)) GAMMAGARD S/D LESS IGA INTRAVENOUS SOLUTION RECONSTITUTED 10 GM, 5 GM (immune NPSP globulin (human)) GAMMAKED INJECTION SOLUTION 1 GM/10ML, 10 GM/100ML, 20 GM/200ML, 5 GM/50ML (immune globulin NPSP (human)) GAMMAPLEX INTRAVENOUS SOLUTION 10 GM/100ML, 10 GM/200ML, 20 GM/200ML, 20 GM/400ML, NPSP 5 GM/100ML, 5 GM/50ML (immune globulin (human)) GAMUNEX-C INJECTION SOLUTION 1 GM/10ML, 10 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 40 GM/400ML, NPSP 5 GM/50ML (immune globulin (human)) HIZENTRA SUBCUTANEOUS SOLUTION 1 GM/5ML, 10 GM/50ML, 2 GM/10ML, 4 GM/20ML (immune globulin NPSP (human)) HIZENTRA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 1 GM/5ML, 2 GM/10ML, 4 GM/20ML (immune NPSP globulin (human)) HYQVIA SUBCUTANEOUS KIT 10 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 30 GM/300ML, 5 GM/50ML NF (immune globulin-hyaluronidase) OCTAGAM INTRAVENOUS SOLUTION 1 GM/20ML, 10 GM/100ML, 10 GM/200ML, 2 GM/20ML, 2.5 GM/50ML, 20 NPSP GM/200ML, 25 GM/500ML, 30 GM/300ML, 5 GM/100ML, 5 GM/50ML (immune globulin (human)) PANZYGA INTRAVENOUS SOLUTION 1 GM/10ML, 10 GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 30 GM/300ML, NF 5 GM/50ML (immune globulin (human)-ifas)

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 141 Prescription Drug Name Drug Tier Drug Notes PRIVIGEN INTRAVENOUS SOLUTION 10 GM/100ML, 20 GM/200ML, 40 GM/400ML, 5 GM/50ML (immune NPSP globulin (human)) IMMUNOMODULATORS ACTIMMUNE SUBCUTANEOUS SOLUTION 2000000 NPSP UNIT/0.5ML (interferon gamma-1b) ARCALYST SUBCUTANEOUS SOLUTION NPSP RECONSTITUTED 220 MG (rilonacept) INTRON A INJECTION SOLUTION 10000000 UNIT/ML, NPSP 6000000 UNIT/ML (interferon alfa-2b) INTRON A INJECTION SOLUTION RECONSTITUTED 10000000 UNIT, 18000000 UNIT, 50000000 UNIT (interferon NPSP alfa-2b) POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG NPSP (pomalidomide) REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 20 PSP MG, 25 MG, 5 MG (lenalidomide) THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG, PSP 50 MG (thalidomide) IMMUNOSUPPRESSANTS AZASAN ORAL TABLET 100 MG, 75 MG (azathioprine) NPB azathioprine oral tablet 50 mg G BENLYSTA INTRAVENOUS SOLUTION NPSP RECONSTITUTED 120 MG, 400 MG (belimumab) BENLYSTA SUBCUTANEOUS SOLUTION AUTO- NPSP INJECTOR 200 MG/ML (belimumab) BENLYSTA SUBCUTANEOUS SOLUTION PREFILLED NPSP SYRINGE 200 MG/ML (belimumab) cyclosporine modified oral capsule 100 mg, 25 mg, 50 mg G cyclosporine modified oral solution 100 mg/ml G cyclosporine oral capsule 100 mg, 25 mg G GAMIFANT INTRAVENOUS SOLUTION 100 MG/20ML NPSP (emapalumab-lzsg) cyclosporine modified (Gengraf Oral Capsule 100 Mg, 25 Mg) G cyclosporine modified (Gengraf Oral Solution 100 Mg/Ml) G mycophenolate mofetil oral capsule 250 mg G mycophenolate mofetil oral suspension reconstituted 200 mg/ml G mycophenolate mofetil oral tablet 500 mg G

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 142 Prescription Drug Name Drug Tier Drug Notes mycophenolate sodium oral tablet delayed release 180 mg, 360 G mg SANDIMMUNE ORAL SOLUTION 100 MG/ML NPSP (cyclosporine) sirolimus oral solution 1 mg/ml G sirolimus oral tablet 0.5 mg, 1 mg, 2 mg G tacrolimus oral capsule 0.5 mg, 1 mg, 5 mg G MONOCLONAL ANTIBODIES etesevimab intravenous solution 700 mg/20ml NPB NSAIDS - DRUGS TO TREAT PAIN AND INFLAMMATION CALDOLOR INTRAVENOUS SOLUTION 800 NPB MG/200ML (ibuprofen) NUDROXIPAK E-400 COMBINATION KIT 400 MG NF (etodolac-liniment) NUDROXIPAK I-800 COMBINATION KIT 800 MG NF (ibuprofen-liniment) NSAIDS, COMBINATIONS diclofenac sodium-capsaicin (Nudiclo Tabpak Combination NF Therapy Pack 75 & 0.025 Mg-%) NUDROXIPAK COMBINATION THERAPY PACK 200 NF MG (celecoxib-capsaic-men-methsal) READYSHARP ANESTH + KETOROLAC INJECTION KIT 15 & 0.5 & 1 MG/ML-%-% (ketorolac & bupivacaine & NF lido) VACCINES FLUAD QUADRIVALENT INTRAMUSCULAR PREFILLED SYRINGE 0.5 ML (influenza vac a&b sa adj NPB quad) MENQUADFI INTRAMUSCULAR INJECTABLE NPB (meningococcal a c y&w-135 conj) ROTARIX ORAL SUSPENSION RECONSTITUTED NPB (rotavirus vaccine live oral) ROTATEQ ORAL SOLUTION (rotavirus vac live NPB pentavalent) VAXCHORA ORAL SUSPENSION RECONSTITUTED NPB (cholera vac live attenuated) VAXELIS INTRAMUSCULAR SUSPENSION (dtap-ipv- NPB hib-hepatitis b recmb) 2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 143 Prescription Drug Name Drug Tier Drug Notes VAXELIS INTRAMUSCULAR SUSPENSION NPB PREFILLED SYRINGE (dtap-ipv-hib-hepatitis b recmb) MEDICAL DEVICES CONTRACEPTIVES - PRODUCTS FOR BIRTH CONTROL CAYA VAGINAL DIAPHRAGM (diaphragm arc-spring) CE FC FEMALE CONDOM (condoms - female) CE FC2 FEMALE CONDOM (condoms - female) CE FEMCAP VAGINAL DEVICE 22 MM, 26 MM, 30 MM CE (cervical caps) OMNIFLEX DIAPHRAGM VAGINAL DIAPHRAGM CE (diaphragms) WIDE-SEAL DIAPHRAGM 60 VAGINAL DIAPHRAGM CE 2 % (diaphragm wide seal) WIDE-SEAL DIAPHRAGM 65 VAGINAL DIAPHRAGM CE 2 % (diaphragm wide seal) WIDE-SEAL DIAPHRAGM 70 VAGINAL DIAPHRAGM CE 2 % (diaphragm wide seal) WIDE-SEAL DIAPHRAGM 75 VAGINAL DIAPHRAGM CE 2 % (diaphragm wide seal) WIDE-SEAL DIAPHRAGM 80 VAGINAL DIAPHRAGM CE 2 % (diaphragm wide seal) WIDE-SEAL DIAPHRAGM 85 VAGINAL DIAPHRAGM CE 2 % (diaphragm wide seal) WIDE-SEAL DIAPHRAGM 90 VAGINAL DIAPHRAGM CE 2 % (diaphragm wide seal) WIDE-SEAL DIAPHRAGM 95 VAGINAL DIAPHRAGM CE 2 % (diaphragm wide seal) DIABETIC SUPPLIES 12-PANEL POC TOXICOLOGY SYSTEM IN VITRO KIT NPB (drug assay (urine)) 1st tier unifine pentips 29g x 12mm , 31g x 5 mm , 31g x 6 mm , NF 31g x 8 mm , 32g x 4 mm , 32g x 6 mm , 33g x 4 mm 1st tier unifine pentips plus 29g x 12mm , 31g x 5 mm , 31g x 6 NF mm , 31g x 8 mm , 32g x 4 mm , 33g x 4 mm 1st tier unilet comfortouch NPB ABOUTTIME PEN NEEDLE 30G X 8 MM , 31G X 5 MM , NF 31G X 8 MM , 32G X 4 MM (insulin pen needle)

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 144 Prescription Drug Name Drug Tier Drug Notes ACCU-CHEK AVIVA PLUS IN VITRO STRIP (glucose PB blood) ACCU-CHEK AVIVA PLUS KIT W/DEVICE (blood PB glucose monitoring suppl) ACCU-CHEK COMPACT PLUS IN VITRO STRIP (glucose PB blood) ACCU-CHEK FASTCLIX LANCET KIT (lancets misc.) NPB ACCU-CHEK FASTCLIX LANCETS (lancets) NPB ACCU-CHEK GUIDE IN VITRO STRIP (glucose blood) PB ACCU-CHEK GUIDE KIT W/DEVICE (blood glucose PB monitoring suppl) ACCU-CHEK GUIDE ME KIT W/DEVICE (blood glucose PB monitoring suppl) ACCU-CHEK LINKASSIST (insulin pump accessories) NPB ACCU-CHEK MULTICLIX LANCETS (lancets) NPB ACCU-CHEK PLASTIC CARTRIDGE (insulin infusion NPB pump supplies) ACCU-CHEK SAFE-T PRO LANCETS (lancets) NPB ACCU-CHEK SMARTVIEW IN VITRO STRIP (glucose PB blood) ACCU-CHEK SOFTCLIX LANCET DEV KIT (lancets NPB misc.) ACCU-CHEK SOFTCLIX LANCETS (lancets) NPB ACCU-CHEK ULTRAFLEX INF SET (insulin infusion NPB pump supplies) ACCU-CHEK ULTRAFLEX-1 INF SET (insulin infusion NPB pump supplies) ACCUTREND GLUCOSE IN VITRO STRIP (glucose NF blood) acti-lance 28g NPB acti-lance lite lancets 28g NPB acti-lance special lancets 17g NPB acti-lance universal 23g NPB adjustable lancing device NPB ADVANCE INTUITION METER DEVICE (blood glucose NF monitoring suppl) ADVANCE INTUITION MONITOR KIT (blood glucose NF monitoring suppl) 2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 145 Prescription Drug Name Drug Tier Drug Notes ADVANCE INTUITION TEST IN VITRO STRIP (glucose NF blood) ADVANCE MICRO-DRAW METER DEVICE (blood NF glucose monitoring suppl) ADVANCE MICRO-DRAW TEST IN VITRO STRIP NF (glucose blood) ADVOCATE BLOOD GLUCOSE MONITOR DEVICE NF (blood glucose monitoring suppl) ADVOCATE BLOOD GLUCOSE SYSTEM KIT NF W/DEVICE (blood glucose monitoring suppl) ADVOCATE INSULIN PEN NEEDLES 29G X 12.7MM , 31G X 5 MM , 31G X 8 MM , 33G X 4 MM (insulin pen NF needle) ADVOCATE INSULIN SYRINGE 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, NF 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe-needle u-100) ADVOCATE LANCETS 30G (lancets) NPB ADVOCATE LANCING DEVICE (lancet devices) NPB ADVOCATE RAPID-SAFE LANCING (lancet devices) NPB ADVOCATE REDI-CODE DEVICE (blood glucose NF monitoring suppl) ADVOCATE REDI-CODE IN VITRO STRIP (glucose NF blood) ADVOCATE REDI-CODE KIT W/DEVICE (blood glucose NF monitoring suppl) ADVOCATE REDI-CODE+ DEVICE (blood glucose NF monitoring suppl) ADVOCATE REDI-CODE+ TEST IN VITRO STRIP NF (glucose blood) ADVOCATE SAFETY LANCETS (lancets) NPB ADVOCATE SAFETY LANCETS 26G (lancets) NPB ADVOCATE TEST IN VITRO STRIP (glucose blood) NF AGAMATRIX AMP DEVICE (blood glucose monitoring NF suppl) AGAMATRIX AMP TEST IN VITRO STRIP (glucose NF blood)

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 146 Prescription Drug Name Drug Tier Drug Notes AGAMATRIX JAZZ TEST IN VITRO STRIP (glucose NF blood) AGAMATRIX JAZZ WIRELESS 2 KIT W/DEVICE (blood NF glucose monitoring suppl) AGAMATRIX KEYNOTE TEST IN VITRO STRIP NF (glucose blood) AGAMATRIX PRESTO KIT W/DEVICE (blood glucose NF monitoring suppl) AGAMATRIX PRESTO PRO METER DEVICE (blood NF glucose monitoring suppl) AGAMATRIX PRESTO TEST IN VITRO STRIP (glucose NF blood) AGAMATRIX ULTRA-THIN LANCETS (lancets) NPB aimsco twist lancets 32g NPB AIMSCO TWIST LANCETS 33G (lancets) NPB ALCOH-GLOVE CONTOURED WIPE PAD (alcohol NPB swabs) alcohol pads pad 70 % NPB alcohol prep pad NPB alcohol prep pad 70 % NPB alcohol swabs pad NPB alcoh-wipe sheet NPB AQUALANCE LANCETS 30G (lancets) NPB ASSURE 3 METER KIT (blood glucose monitoring suppl) NF ASSURE 3 TEST IN VITRO STRIP (glucose blood) NF ASSURE 4 METER DEVICE (blood glucose monitoring NF suppl) ASSURE 4 TEST IN VITRO STRIP (glucose blood) NF assure comfort lancets 28g NPB ASSURE ID INSULIN SAFETY SYR 29G X 1/2" 0.5 ML, NF 29G X 1/2" 1 ML (insulin syringe-needle u-100) ASSURE ID SAFETY PEN NEEDLES 30G X 5 MM , 30G NF X 8 MM , 31G X 5 MM (insulin pen needle) ASSURE II CHECK IN VITRO STRIP (glucose blood) NF ASSURE II IN VITRO STRIP (glucose blood) NF ASSURE PLATINUM IN VITRO STRIP (glucose blood) NF

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 147 Prescription Drug Name Drug Tier Drug Notes ASSURE PLATINUM METER DEVICE (blood glucose NF monitoring suppl) ASSURE PRISM MULTI TEST IN VITRO STRIP (glucose NF blood) ASSURE PRO BLOOD GLUCOSE METER DEVICE NF (blood glucose monitoring suppl) ASSURE PRO TEST IN VITRO STRIP (glucose blood) NF aurora lancet super thin 30g NPB aurora lancet thin 23g NPB aurora pen needles 29g x 12mm , 31g x 6 mm , 31g x 8 mm NF aurora unifine pentips 31g x 5 mm , 32g x 4 mm NF AUTO-LANCET (lancet devices) NPB AUTO-LANCET MINI (lancet devices) NPB AUTOLET II CLINISAFE KIT (lancets misc.) NPB AUTOLET LITE CLINISAFE KIT (lancets misc.) NPB AUTOLET LITE STARTER PACK KIT (lancets misc.) NPB AUTOLET MINI (lancet devices) NPB AUTOLET PLATFORMS (lancets misc.) NPB AUTOLET PLUS (lancet devices) NPB autopen device NPB AUTOSOFT 30 INFUSION SET (insulin infusion pump NPB supplies) AUTOSOFT 90 INFUSION SET (insulin infusion pump NPB supplies) AUTOSOFT XC INFUSION SET (insulin infusion pump NPB supplies) BD AUTOSHIELD 29G X 5MM , 29G X 8MM (insulin pen PB needle) BD AUTOSHIELD DUO 30G X 5 MM (insulin pen needle) PB BD INSULIN SYRINGE 25G X 1" 1 ML, 25G X 5/8" 1 ML, 26G X 1/2" 1 ML, 27.5G X 5/8" 2 ML, 27G X 1/2" 1 ML, 29G PB X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML (insulin syringe-needle u-100) BD INSULIN SYRINGE MICROFINE 27G X 5/8" 1 ML, 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML (insulin syringe-needle PB u-100)

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 148 Prescription Drug Name Drug Tier Drug Notes BD INSULIN SYRINGE U/F 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 31G X 5/16" 1 ML (insulin PB syringe-needle u-100) BD INSULIN SYRINGE U-100 1 ML (insulin syringes PB (disposable)) BD INSULIN SYRINGE U-500 31G X 6MM 0.5 ML PB (insulin syringe/needle u-500) BD INSULIN SYRINGE ULTRAFINE 31G X 5/16" 0.5 PB ML (insulin syringe-needle u-100) BD LANCET ULTRAFINE 30G (lancets) NPB BD LANCET ULTRAFINE 33G (lancets) NPB BD LATITUDE DIABETES KIT (blood glucose monitoring NF suppl) BD LATITUDE DIABETES SYSTEM KIT (blood glucose NF monitoring suppl) BD LOGIC BLOOD GLUCOSE MONITOR KIT NF W/DEVICE (blood glucose monitoring suppl) BD MICROTAINER LANCETS (lancets) NPB BD PEN (injection device for insulin) NPB BD PEN MINI (injection device for insulin) NPB BD PEN NEEDLE MICRO U/F 32G X 6 MM (insulin pen PB needle) BD PEN NEEDLE MINI U/F 31G X 5 MM (insulin pen PB needle) BD PEN NEEDLE NANO 2ND GEN 32G X 4 MM (insulin PB pen needle) BD PEN NEEDLE NANO U/F 32G X 4 MM (insulin pen PB needle) BD PEN NEEDLE ORIGINAL U/F 29G X 12.7MM (insulin PB pen needle) BD PEN NEEDLE SHORT U/F 31G X 8 MM (insulin pen PB needle) BD SAFETYGLIDE INSULIN SYRINGE 30G X 5/16" 0.5 ML, 31G X 15/64" 0.3 ML, 31G X 15/64" 0.5 ML, 31G X PB 15/64" 1 ML (insulin syringe-needle u-100) BD SWABS SINGLE USE BUTTERFLY PAD (alcohol NPB swabs) BD VEO INSULIN SYR U/F 1/2UNIT 31G X 15/64" 0.3 ML PB (insulin syringe-needle u-100) 2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 149 Prescription Drug Name Drug Tier Drug Notes BD VEO INSULIN SYRINGE U/F 31G X 15/64" 0.3 ML PB (insulin syringe-needle u-100) BIOSCANNER GLUCOSE TEST IN VITRO STRIP NF (glucose blood) BIOTEL CARE BLOOD GLUCOSE SYST KIT W/DEVICE NF (blood glucose monitoring suppl) blood glucose monitor system kit w/device NF blood glucose system pak kit NF blood glucose test in vitro strip NF BLULINK GLUCOSE MONITORING SYS DEVICE NF (blood glucose monitoring suppl) BLULINK GLUCOSE TEST IN VITRO STRIP (glucose NF blood) CARDIOCOM LANCING DEVICE (lancet devices) NPB CAREFINE PEN NEEDLES 29G X 12MM , 30G X 8 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM , 32G X 5 MM , NF 32G X 6 MM (insulin pen needle) careone advanced lancing dev NPB CAREONE BLOOD GLUCOSE SYSTEM KIT W/DEVICE NF (blood glucose monitoring suppl) CAREONE BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) careone insulin syringe 30g x 1/2" 0.3 ml, 30g x 1/2" 0.5 ml, 30g x 1/2" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" NF 1 ml CAREONE LANCET SUPER THIN 30G (lancets) NPB careone lancet thin 23g NPB careone unifine pentips 29g x 12mm , 31g x 5 mm , 31g x 6 mm , NF 31g x 8 mm , 32g x 4 mm careone unifine pentips plus 29g x 12mm , 31g x 5 mm , 31g x 6 NF mm , 31g x 8 mm , 32g x 4 mm CARESENS N GLUCOSE SYSTEM DEVICE (blood NF glucose monitoring suppl) CARESENS N GLUCOSE TEST IN VITRO STRIP (glucose NF blood) CARESENS N VOICE SYSTEM DEVICE (blood glucose NF monitoring suppl) CARETOUCH ALCOHOL PREP PAD 70 % (alcohol swabs) NPB

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 150 Prescription Drug Name Drug Tier Drug Notes CARETOUCH INSULIN SYRINGE 28G X 5/16" 1 ML, NF 29G X 5/16" 1 ML (insulin syringe-needle u-100) CARETOUCH LANCING/EJECTOR (lancet devices) NPB CARETOUCH MONITOR SYSTEM KIT W/DEVICE NF (blood glucose monitoring suppl) CARETOUCH PEN NEEDLES 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM , 32G X 5 MM (insulin NF pen needle) CARETOUCH SAFETY LANCETS (lancets) NPB CARETOUCH SAFETY LANCETS 26G (lancets) NPB CARETOUCH TEST IN VITRO STRIP (glucose blood) NF CARETOUCH TWIST LANCETS 28G (lancets) NPB CARETOUCH TWIST LANCETS 30G (lancets) NPB CARETOUCH TWIST LANCETS 33G (lancets) NPB CEQUR SIMPLICITY INSERTER (injection device for NPB insulin) CHEMSTRIP K IN VITRO STRIP (acetone (urine) test) NPB CHEMSTRIP UGK IN VITRO STRIP (urine glucose-ketones NPB test) CLEANLET LANCETS 28G (lancets) NPB CLEVER CHEK AUTO-CODE SYSTEM DEVICE (blood NF glucose monitoring suppl) CLEVER CHEK AUTO-CODE TEST IN VITRO STRIP NF (glucose blood) CLEVER CHEK AUTO-CODE VOICE DEVICE (blood NF glucose monitoring suppl) CLEVER CHEK AUTO-CODE VOICE IN VITRO STRIP NF (glucose blood) CLEVER CHEK LANCETS (lancets) NPB CLEVER CHEK SYSTEM KIT W/DEVICE (blood glucose NF monitoring suppl) CLEVER CHEK TEST IN VITRO STRIP (glucose blood) NF CLEVER CHOICE AUTO-CODE SYSTEM DEVICE NF (blood glucose monitoring suppl) CLEVER CHOICE AUTO-CODE TEST IN VITRO STRIP NF (glucose blood) CLEVER CHOICE COMFORT EZ 29G X 12MM , 33G X 4 NF MM (insulin pen needle)

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 151 Prescription Drug Name Drug Tier Drug Notes CLEVER CHOICE LANCETS 21G (lancets) NPB CLEVER CHOICE LANCETS 23G (lancets) NPB CLEVER CHOICE LANCETS 28G (lancets) NPB CLEVER CHOICE MICRO SYSTEM KIT W/DEVICE NF (blood glucose monitoring suppl) CLEVER CHOICE MICRO TEST IN VITRO STRIP NF (glucose blood) CLEVER CHOICE MINI SYSTEM DEVICE (blood glucose NF monitoring suppl) CLEVER CHOICE NO CODING IN VITRO STRIP NF (glucose blood) CLEVER CHOICE TALK SYSTEM DEVICE (blood glucose NF monitoring suppl) CLEVER CHOICE TALK SYSTEM IN VITRO STRIP NF (glucose blood) CLICKFINE PEN NEEDLES 31G X 5 MM (insulin pen NF needle) clickfine pen needles 31g x 6 mm , 31g x 8 mm , 32g x 4 mm NF COAGUCHEK LANCETS (lancets) NPB COMFORT ASSIST INSULIN SYRINGE 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" NF 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe-needle u-100) comfort assured lancets 28g NPB comfort assured lancets 33g NPB COMFORT EZ INSULIN SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, NF 30G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe-needle u-100) COMFORT EZ MICRO PEN NEEDLES 32G X 4 MM NF (insulin pen needle) COMFORT EZ PEN NEEDLES 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM , 32G X 5 MM , 32G X 6 NF MM , 32G X 8 MM , 33G X 4 MM , 33G X 5 MM , 33G X 6 MM , 33G X 8 MM (insulin pen needle) COMFORT EZ SHORT PEN NEEDLES 31G X 8 MM NF (insulin pen needle) 2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 152 Prescription Drug Name Drug Tier Drug Notes comfort lancets NPB CONTOUR MONITOR DEVICE (blood glucose monitoring NF suppl) CONTOUR NEXT EZ KIT W/DEVICE (blood glucose NF monitoring suppl) CONTOUR NEXT LINK KIT W/DEVICE (blood glucose NF monitoring suppl) CONTOUR NEXT MONITOR KIT W/DEVICE (blood NF glucose monitoring suppl) CONTOUR NEXT ONE KIT (blood glucose monitoring NF suppl) CONTOUR NEXT TEST IN VITRO STRIP (glucose blood) NF CONTOUR TEST IN VITRO STRIP (glucose blood) NF COOL BLOOD GLUCOSE TEST STRIPS IN VITRO NF STRIP (glucose blood) COOL MONITOR DEVICE (blood glucose monitoring suppl) NF COOL MONITOR KIT KIT W/DEVICE (blood glucose NF monitoring suppl) CURITY ALCOHOL PREPS PAD 70 % (alcohol swabs) NPB CURITY ALCOHOL SWABS PAD (alcohol swabs) NPB CVS ADVANCED GLUCOSE TEST IN VITRO STRIP NF (glucose blood) CVS BLOOD GLUCOSE METER KIT W/DEVICE (blood NF glucose monitoring suppl) cvs glucose meter test strips in vitro strip NF CVS KETONE CARE IN VITRO STRIP (urine glucose- NPB ketones test) cvs lancets 21g NPB cvs lancets micro thin 33g NPB cvs lancets original NPB cvs lancets thin 26g NPB cvs lancets ultra thin 30g NPB cvs lancets ultra-thin 30g NPB cvs lancing device NPB cvs prep pad 70 % NPB cvs ultra thin lancets NPB

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 153 Prescription Drug Name Drug Tier Drug Notes D-CARE BLOOD GLUCOSE IN VITRO STRIP (glucose NF blood) D-CARE GLUCOMETER KIT W/DEVICE (blood glucose NF monitoring suppl) DEXCOM G4 PLAT PED RCV/SHARE DEVICE PB (continuous blood gluc receiver) DEXCOM G4 PLAT PED RECEIVER DEVICE (continuous PB blood gluc receiver) DEXCOM G4 PLATINUM RCV/SHARE DEVICE PB (continuous blood gluc receiver) DEXCOM G4 PLATINUM RECEIVER DEVICE PB (continuous blood gluc receiver) DEXCOM G4 PLATINUM TRANSMITTER (continuous PB blood gluc transmit) DEXCOM G4 SENSOR (continuous blood gluc sensor) PB DEXCOM G5 MOB/G4 PLAT SENSOR (continuous blood PB gluc sensor) DEXCOM G5 MOBILE RECEIVER DEVICE (continuous PB blood gluc receiver) DEXCOM G5 MOBILE TRANSMITTER (continuous blood PB gluc transmit) DEXCOM G5 RECEIVER KIT DEVICE (continuous blood PB gluc receiver) DEXCOM G6 RECEIVER DEVICE (continuous blood gluc PB receiver) DEXCOM G6 SENSOR (continuous blood gluc sensor) PB DEXCOM G6 TRANSMITTER (continuous blood gluc PB transmit) DIASTIX IN VITRO STRIP (glucose urine test-glucose ox) NPB DIATHRIVE BLOOD GLUCOSE METER DEVICE (blood NF glucose monitoring suppl) DIATHRIVE BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) DIATHRIVE GLUCOSE TEST IN VITRO STRIP (glucose NF blood) DIATHRIVE LANCET ULTRA THIN 30 (lancets) NPB DIATHRIVE LANCETS (lancets) NPB DIATHRIVE LANCING DEVICE (lancet devices) NPB

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 154 Prescription Drug Name Drug Tier Drug Notes DIATHRIVE PEN NEEDLE 31G X 5 MM , 31G X 6 MM , NF 31G X 8 MM , 32G X 4 MM (insulin pen needle) DIATHRIVE+ GLUCOSE MONITOR DEVICE (blood NF glucose monitoring suppl) DIATHRIVE+ GLUCOSE TEST IN VITRO STRIP (glucose NF blood) diatrue plus blood glucose device NF diatrue plus test in vitro strip NF DROPLET INSULIN SYRINGE 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 15/64" 0.3 ML, 31G NF X 15/64" 0.5 ML, 31G X 15/64" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe-needle u-100) DROPLET LANCETS ULTRA THIN 30G (lancets) NPB DROPLET LANCING DEVICE (lancet devices) NPB DROPLET MICRON 34G X 3.5 MM (insulin pen needle) NF DROPLET PEN NEEDLES 29G X 10MM , 29G X 12MM , 30G X 8 MM , 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , NF 32G X 4 MM , 32G X 5 MM , 32G X 6 MM , 32G X 8 MM (insulin pen needle) DROPLET PERSONAL LANCETS 30G (lancets) NPB dropsafe safety pen needles 31g x 6 mm , 31g x 8 mm NF drug mart lancets thin 26g NPB DRUG MART ON-THE-GO LANCET 30G (lancets) NPB drug mart unifine pentips 29g x 12mm , 31g x 5 mm , 31g x 6 NF mm , 31g x 8 mm , 32g x 4 mm drug mart unifine pentips plus 32g x 4 mm NF DUO-CARE TEST IN VITRO STRIP (glucose blood) NF d-xylose powder NPB easy comfort alcohol pads pad NPB easy comfort insulin syringe 30g x 1/2" 0.5 ml, 30g x 1/2" 1 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.5 ml, 31g x NF 5/16" 1 ml, 32g x 5/16" 0.5 ml, 32g x 5/16" 1 ml easy comfort lancets NPB easy comfort lancets twist top NPB

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 155 Prescription Drug Name Drug Tier Drug Notes easy comfort pen needles 31g x 5 mm , 31g x 6 mm , 31g x 8 mm NF , 32g x 4 mm , 33g x 4 mm , 33g x 5 mm , 33g x 6 mm easy glide pen needles 33g x 4 mm NF easy mini eject lancing device NPB easy mini lancing device NPB easy plus ii glucose system device NF easy plus ii glucose test in vitro strip NF EASY STEP GLUCOSE MONITOR DEVICE (blood glucose NF monitoring suppl) EASY STEP TEST IN VITRO STRIP (glucose blood) NF easy talk blood glucose system device NF easy talk blood glucose test in vitro strip NF EASY TOUCH ALCOHOL PREP MEDIUM PAD 70 % NPB (alcohol swabs) EASY TOUCH FLIPLOCK INSULIN SY 29G X 1/2" 1 ML, 30G X 1/2" 1 ML, 30G X 5/16" 1 ML, 31G X 5/16" 1 ML NF (insulin syringe-needle u-100) EASY TOUCH GLUCOSE SYSTEM KIT W/DEVICE NF (blood glucose monitoring suppl) EASY TOUCH INSULIN SAFETY SYR 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 1 ML, 30G X 5/16" 0.5 NF ML (insulin syringe-needle u-100) EASY TOUCH INSULIN SYRINGE 27G X 1/2" 0.5 ML, 27G X 1/2" 1 ML, 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X NF 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe-needle u- 100) EASY TOUCH LANCETS 21G (lancets) NPB EASY TOUCH LANCETS 23G (lancets) NPB EASY TOUCH LANCETS 28G (lancets) NPB EASY TOUCH LANCETS 30G (lancets) NPB EASY TOUCH LANCETS 32G (lancets) NPB EASY TOUCH LANCING DEVICE (lancet devices) NPB EASY TOUCH PEN NEEDLES 29G X 12MM , 30G X 8 MM , 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 NF MM , 32G X 5 MM , 32G X 6 MM (insulin pen needle)

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 156 Prescription Drug Name Drug Tier Drug Notes EASY TOUCH SAFETY PEN NEEDLES 29G X 5MM , NF 29G X 8MM , 30G X 8 MM (insulin pen needle) EASY TOUCH SHEATHLOCK SYRINGE 29G X 1/2" 1 ML, 30G X 1/2" 1 ML, 30G X 5/16" 1 ML, 31G X 5/16" 1 ML NF (insulin syringe-needle u-100) EASY TOUCH TEST IN VITRO STRIP (glucose blood) NF easy trak blood glucose system device NF easy trak blood glucose test in vitro strip NF easy trak ii blood glucose sys device NF easy trak ii glucose test in vitro strip NF EASYGLUCO IN VITRO STRIP (glucose blood) NF EASYGLUCO KIT (blood glucose monitoring suppl) NF EASYMAX 15 TEST IN VITRO STRIP (glucose blood) NF EASYMAX NG BLOOD GLUCOSE DEVICE (blood NF glucose monitoring suppl) EASYMAX NG BLOOD GLUCOSE KIT W/DEVICE NF (blood glucose monitoring suppl) EASYMAX TEST IN VITRO STRIP (glucose blood) NF EASYMAX V BLOOD GLUCOSE DEVICE (blood glucose NF monitoring suppl) EASYMAX V BLOOD GLUCOSE KIT W/DEVICE (blood NF glucose monitoring suppl) EASYPRO BLOOD GLUCOSE MONITOR KIT NF W/DEVICE (blood glucose monitoring suppl) EASYPRO BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) EASYPRO PLUS IN VITRO STRIP (glucose blood) NF EASYPRO PLUS KIT W/DEVICE (blood glucose monitoring NF suppl) ELEMENT AUTOCODE SYSTEM KIT W/DEVICE (blood NF glucose monitoring suppl) element compact glucose system device NF element compact test in vitro strip NF element compact v glucose sys device NF ELEMENT PLUS DEVICE (blood glucose monitoring suppl) NF ELEMENT TEST IN VITRO STRIP (glucose blood) NF

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 157 Prescription Drug Name Drug Tier Drug Notes EMBRACE BLOOD GLUCOSE MONITOR DEVICE NF (blood glucose monitoring suppl) EMBRACE BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) EMBRACE EVO BLOOD GLUCOSE TEST IN VITRO NF STRIP (glucose blood) EMBRACE EVO GLUCOSE MONITORING KIT NF W/DEVICE (blood glucose monitoring suppl) EMBRACE LANCETS ULTRA THIN 30G (lancets) NPB EMBRACE PRO GLUCOSE METER DEVICE (blood NF glucose monitoring suppl) EMBRACE PRO GLUCOSE TEST IN VITRO STRIP NF (glucose blood) EMBRACE TALK BLOOD GLUCOSE DEVICE (blood NF glucose monitoring suppl) EMBRACE TALK GLUCOSE TEST IN VITRO STRIP NF (glucose blood) EMBRACE TALK MONITORING SYSTEM KIT NF W/DEVICE (blood glucose monitoring suppl) ENLITE GLUCOSE SENSOR (continuous blood gluc sensor) NF ENLITE SERTER (insulin infusion pump supplies) NPB eq blood glucose test in vitro strip NF eql alcohol swabs pad 70 % NPB eql color lancets 21g NPB eql color lancets micro 33g NPB eql insulin syringe 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 NF ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml eql super thin lancets 30g NPB eql thin lancets 26g NPB EVERSENSE SENSOR/HOLDER (continuous blood gluc NF sensor) EVERSENSE SMART TRANSMITTER (continuous blood NF gluc transmit) EVOLUTION AUTOCODE DEVICE (blood glucose NF monitoring suppl) EVOLUTION AUTOCODE IN VITRO STRIP (glucose NF blood)

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 158 Prescription Drug Name Drug Tier Drug Notes EXACTECH R-S-G TEST IN VITRO STRIP (glucose blood) NF EXACTECH TEST IN VITRO STRIP (glucose blood) NF EXEL COMFORT POINT INSULIN SYR 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 NF ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML (insulin syringe-needle u-100) EXEL COMFORT POINT PEN NEEDLE 29G X 12MM , 31G X 4 MM , 31G X 6 MM , 31G X 8 MM (insulin pen NF needle) E-Z JECT LANCET MICRO-THIN 33G (lancets) NPB E-Z JECT LANCET SUPER THIN 30G (lancets) NPB E-Z JECT LANCETS (lancets) NPB E-Z JECT LANCETS 21G (lancets) NPB E-Z JECT LANCETS THIN 26G (lancets) NPB EZ-LETS LANCETS 21G (lancets) NPB EZ-LETS LANCETS 26G (lancets) NPB EZ-LETS LANCETS 28G (lancets) NPB EZ-LETS LANCETS 30G (lancets) NPB FIFTY50 GLUCOSE METER 2.0 KIT W/DEVICE (blood NF glucose monitoring suppl) FIFTY50 GLUCOSE TEST 2.0 IN VITRO STRIP (glucose NF blood) FIFTY50 PEN NEEDLES 31G X 5 MM , 31G X 8 MM , NF 32G X 4 MM , 32G X 6 MM (insulin pen needle) FIFTY50 SUPERIOR COMFORT SYR 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe- NF needle u-100) FIFTY50 UNILET LANCETS 33G (lancets) NPB FINGERSTIX LANCETS (lancets) NPB FORA 6 CONNECT IN VITRO STRIP (glucose blood) NF FORA BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) FORA D15G BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) FORA D20 BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) FORA D40 GLUCOSE/PRESSURE DEVICE (blood NF glucose-bp monitor)

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 159 Prescription Drug Name Drug Tier Drug Notes FORA D40/G31 BLOOD GLUCOSE IN VITRO STRIP NF (glucose blood) FORA D40G GLUCOSE/PRESSURE DEVICE (blood NF glucose-bp monitor) FORA G20 BLOOD GLUCOSE SYSTEM KIT W/DEVICE NF (blood glucose monitoring suppl) FORA G20 BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) FORA G30/PREM V10 GLUCOSE TEST IN VITRO STRIP NF (glucose blood) FORA G30A BLOOD GLUCOSE SYSTEM DEVICE (blood NF glucose monitoring suppl) FORA GD20 BLOOD GLUCOSE SYSTEM DEVICE (blood NF glucose monitoring suppl) FORA GD20 TEST IN VITRO STRIP (glucose blood) NF FORA GD50 BLOOD GLUCOSE SYSTEM DEVICE (blood NF glucose monitoring suppl) FORA GD50 BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) FORA GTEL BLOOD GLUCOSE SYSTEM DEVICE NF (blood glucose monitoring suppl) FORA GTEL BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) FORA GTEL BLOOD KETONE TEST IN VITRO STRIP NPB (ketone blood test) FORA LANCETS (lancets) NPB FORA LANCING DEVICE (lancet devices) NPB FORA PREMIUM V10 BLE SYSTEM DEVICE (blood NF glucose monitoring suppl) FORA TEST N' GO MONITOR DEVICE (blood glucose NF monitoring suppl) FORA TN'G VOICE KIT W/DEVICE (blood glucose NF monitoring suppl) FORA TN'G/TN'G VOICE IN VITRO STRIP (glucose NF blood) FORA V10 BLOOD GLUCOSE SYSTEM DEVICE (blood NF glucose monitoring suppl) FORA V10 BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) 2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 160 Prescription Drug Name Drug Tier Drug Notes FORA V12 BLOOD GLUCOSE SYSTEM DEVICE (blood NF glucose monitoring suppl) FORA V12 BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) FORA V20 BLOOD GLUCOSE SYSTEM DEVICE (blood NF glucose monitoring suppl) FORA V20 BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) FORA V30A BLOOD GLUCOSE SYSTEM DEVICE (blood NF glucose monitoring suppl) FORA V30A BLOOD GLUCOSE SYSTEM KIT NF W/DEVICE (blood glucose monitoring suppl) FORA V30A BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) FORACARE GD40 MONITOR DEVICE (blood glucose NF monitoring suppl) FORACARE GD40 TEST IN VITRO STRIP (glucose blood) NF FORACARE PREMIUM V10 DEVICE (blood glucose NF monitoring suppl) FORACARE PREMIUM V10 TEST IN VITRO STRIP NF (glucose blood) FORACARE TEST N GO MONITOR DEVICE (blood NF glucose monitoring suppl) FORACARE TEST N GO TEST IN VITRO STRIP (glucose NF blood) FORTISCARE G1 TEST STRIP IN VITRO STRIP (glucose NF blood) FORTISCARE GLUCOSE SYSTEM DEVICE (blood NF glucose monitoring suppl) FORTISCARE GLUCOSE SYSTEM KIT W/DEVICE NF (blood glucose monitoring suppl) FORTISCARE T1 GLUCOSE SYSTEM DEVICE (blood NF glucose monitoring suppl) FORTISCARE TEST IN VITRO STRIP (glucose blood) NF freds pharmacy autolet lancing NPB freds pharmacy unifine pentip+ 31g x 5 mm , 31g x 8 mm NF freds pharmacy unifine pentips 32g x 4 mm NF FREESTYLE FREEDOM KIT (blood glucose monitoring NF suppl) 2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 161 Prescription Drug Name Drug Tier Drug Notes FREESTYLE FREEDOM LITE KIT W/DEVICE (blood NF glucose monitoring suppl) FREESTYLE INSULINX SYSTEM KIT W/DEVICE (blood NF glucose monitoring suppl) FREESTYLE INSULINX TEST IN VITRO STRIP (glucose NF blood) FREESTYLE LIBRE 14 DAY READER DEVICE NF (continuous blood gluc receiver) FREESTYLE LIBRE 14 DAY SENSOR (continuous blood NF gluc sensor) FREESTYLE LIBRE 2 READER DEVICE (continuous NF blood gluc receiver) FREESTYLE LIBRE 2 SENSOR (continuous blood gluc NF sensor) FREESTYLE LIBRE READER DEVICE (continuous blood NF gluc receiver) FREESTYLE LIBRE SENSOR SYSTEM (continuous blood NF gluc sensor) FREESTYLE LITE DEVICE (blood glucose monitoring suppl) NF FREESTYLE LITE TEST IN VITRO STRIP (glucose blood) NF FREESTYLE PRECISION INS SYR 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML NF (insulin syringe-needle u-100) FREESTYLE PRECISION NEO SYSTEM KIT W/DEVICE NF (blood glucose monitoring suppl) FREESTYLE PRECISION NEO TEST IN VITRO STRIP NF (glucose blood) FREESTYLE SIDEKICK II KIT (blood glucose monitoring NF suppl) FREESTYLE TEST IN VITRO STRIP (glucose blood) NF FREESTYLE UNISTICK II LANCETS (lancets) NPB ge100 blood glucose system device NF ge100 blood glucose system kit w/device NF ge100 blood glucose test in vitro strip NF GENTEEL BUTTERFLY TOUCH LANCET (lancets) NPB GENTEEL CONTACT TIPS (BLUE) (lancets misc.) NPB GENTEEL CONTACT TIPS (CLEAR) (lancets misc.) NPB GENTEEL CONTACT TIPS (GREEN) (lancets misc.) NPB

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 162 Prescription Drug Name Drug Tier Drug Notes GENTEEL CONTACT TIPS (ORANGE) (lancets misc.) NPB GENTEEL CONTACT TIPS (RAINBOW) (lancets misc.) NPB GENTEEL CONTACT TIPS (VIOLET) (lancets misc.) NPB GENTEEL CONTACT TIPS (YELLOW) (lancets misc.) NPB GENTEEL LANCING KIT (BLUE) KIT (lancets misc.) NPB GENTEEL NOZZLES (lancets misc.) NPB GENTEEL PLUS LANCING (BLACK) (lancet devices) NPB GENTEEL PLUS LANCING (PURPLE) (lancet devices) NPB GENTEEL PLUS LANCING (WHITE) (lancet devices) NPB GENTEEL PLUS LANCING DEV(BLUE) (lancet devices) NPB GENTEEL PLUS LANCING DEV(PINK) (lancet devices) NPB GENTLE-LET GP LANCETS (lancets) NPB GENTLE-LET LANCETS (lancets) NPB GENTLE-LET PLATFORMS (lancets misc.) NPB GENULTIMATE TEST IN VITRO STRIP (glucose blood) NPB ght blood glucose monitor kit w/device NF ght test in vitro strip NF GLEOLAN ORAL SOLUTION RECONSTITUTED 1.5 NPB GM (aminolevulinic acid hcl) global alcohol prep ease pad 70 % NPB global ease inject pen needles 29g x 12mm , 31g x 5 mm , 31g x NF 8 mm , 32g x 4 mm global easy glide insulin syr 31g x 15/64" 0.3 ml, 31g x 15/64" NF 0.5 ml, 31g x 15/64" 1 ml, 31g x 5/16" 0.3 ml global easy glide pen needles 32g x 4 mm NF global inject ease insulin syr 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 1/2" 0.3 ml, 30g x 1/2" 0.5 ml, 30g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, NF 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml global inject ease lancets 28g NPB global inject ease lancets 30g NPB global insulin syringes 30g x 1/2" 0.3 ml, 30g x 5/16" 0.3 ml NF global lancing device NPB GLUCO PERFECT 3 METER DEVICE (blood glucose NF monitoring suppl)

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 163 Prescription Drug Name Drug Tier Drug Notes GLUCO PERFECT 3 TEST IN VITRO STRIP (glucose NF blood) GLUCOCARD 01 BLOOD GLUCOSE DEVICE (blood NF glucose monitoring suppl) GLUCOCARD 01 BLOOD GLUCOSE KIT W/DEVICE NF (blood glucose monitoring suppl) GLUCOCARD 01 SENSOR PLUS IN VITRO STRIP NF (glucose blood) GLUCOCARD 01-MINI GLUCOSE KIT W/DEVICE NF (blood glucose monitoring suppl) GLUCOCARD EXPRESSION MONITOR KIT NF W/DEVICE (blood glucose monitoring suppl) GLUCOCARD EXPRESSION TEST IN VITRO STRIP NF (glucose blood) GLUCOCARD SHINE CONNEX KIT W/DEVICE (blood NF glucose monitoring suppl) GLUCOCARD SHINE EXPRESS KIT W/DEVICE (blood NF glucose monitoring suppl) GLUCOCARD SHINE TEST IN VITRO STRIP (glucose NPB blood) GLUCOCARD SHINE XL DEVICE (blood glucose NF monitoring suppl) GLUCOCARD VITAL MONITOR KIT W/DEVICE (blood NF glucose monitoring suppl) GLUCOCARD VITAL TEST IN VITRO STRIP (glucose NF blood) GLUCOCARD X-METER KIT W/DEVICE (blood glucose NF monitoring suppl) GLUCOCARD X-SENSOR IN VITRO STRIP (glucose NF blood) GLUCOCOM BLOOD GLUCOSE MONITOR DEVICE NF (blood glucose monitoring suppl) GLUCOCOM LANCETS 28G (lancets) NPB GLUCOCOM LANCETS 30G (lancets) NPB GLUCOCOM LANCETS 33G (lancets) NPB GLUCOCOM MONITOR KIT W/DEVICE (blood glucose NF monitoring suppl) GLUCOCOM TEST IN VITRO STRIP (glucose blood) NF

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 164 Prescription Drug Name Drug Tier Drug Notes GLUCONAVII BLOOD GLUCOSE SYS KIT W/DEVICE NF (blood glucose monitoring suppl) GLUCONAVII BLOOD GLUCOSE TEST IN VITRO NF STRIP (glucose blood) GLUCOPRO INSULIN SYRINGE 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, NF 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe-needle u-100) GLUCOPRO SYR RES 3ML 22GX3/8" (insulin infusion NPB pump supplies) glucose meter test in vitro strip NF gnp alcohol swabs pad 70 % NPB gnp clickfine pen needles 31g x 6 mm , 31g x 8 mm NF GNP EASY TOUCH GLUCOSE METER DEVICE (blood NF glucose monitoring suppl) gnp easy touch glucose test in vitro strip NF gnp insulin syringe 28g x 1/2" 0.5 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 NF ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml gnp lancets 21g NPB gnp lancets micro thin 33g NPB gnp lancets thin NPB gnp lancets thin 26g NPB gnp ulticare pen needles 31g x 5 mm , 31g x 8 mm , 32g x 4 mm , NF 32g x 6 mm gnp ultra com insulin syringe 28g x 1/2" 1 ml NF GOJJI BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) GOJJI BLOOD TEST STRIP/LANCETS IN VITRO STRIP NF (glucose blood) GOJJI STERILE LANCETS (lancets) NPB goodsense blood glucose in vitro strip NF goodsense blood glucose kit w/device NF goodsense clickfine pen needle 31g x 5 mm NF goodsense lancets 26g univ NPB goodsense lancets 30g univ NPB

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 165 Prescription Drug Name Drug Tier Drug Notes goodsense lancets 33g univ NPB goodsense lancing device NPB GOODSENSE PEN NEEDLE PENFINE 31G X 5 MM , 31G X 8 MM , 32G X 4 MM , 32G X 6 MM (insulin pen NF needle) GUARDIAN CONNECT TRANSMITTER (continuous NF blood gluc transmit) GUARDIAN LINK 3 TRANSMITTER (continuous blood NF gluc transmit) GUARDIAN REAL-TIME CHARGER (continuous glucose NPB monitor sup) GUARDIAN REAL-TIME TEST PLUG (continuous glucose NPB monitor sup) GUARDIAN SENSOR (3) (continuous blood gluc sensor) NF guardian sensor 3 NF HEALTH CARE LANCING DEVICE (lancet devices) NPB healthwise insulin syr/needle 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g NF x 5/16" 1 ml healthwise micron pen needles 32g x 4 mm NF healthwise mini pen needles 31g x 6 mm NF healthwise pen needles 29g x 12mm NF healthwise short pen needles 31g x 5 mm , 31g x 8 mm NF healthwise unifine pentips 32g x 4 mm NF healthy accents lancing device NPB healthy accents unifine pentip 29g x 12mm , 31g x 5 mm , 31g x NF 6 mm , 31g x 8 mm , 32g x 4 mm healthy accents unilet lancets NPB h-e-b incontrol adv lancing NPB h-e-b incontrol alcohol pad NPB h-e-b incontrol lancets 28g NPB h-e-b incontrol lancets 30g NPB h-e-b incontrol lancets 33g NPB h-e-b incontrol pen needles 29g x 12mm , 31g x 5 mm , 31g x 6 NF mm , 31g x 8 mm , 32g x 4 mm H-E-B INCONTROL UNIFINE PENTIP 32G X 4 MM NF (insulin pen needle)

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 166 Prescription Drug Name Drug Tier Drug Notes HM EMBRACE TALK SYSTEM KIT W/DEVICE (blood NF glucose monitoring suppl) hm sterile alcohol prep pad NPB HM ULTICARE INSULIN SYRINGE 30G X 1/2" 1 ML, NF 31G X 5/16" 0.3 ML (insulin syringe-needle u-100) HM ULTICARE SHORT PEN NEEDLES 31G X 8 MM NF (insulin pen needle) HW EMBRACE PRO GLUCOSE METER DEVICE (blood NF glucose monitoring suppl) HW EMBRACE PRO GLUCOSE TEST IN VITRO STRIP NF (glucose blood) HW EMBRACE TALK BLOOD GLUCOSE DEVICE NF (blood glucose monitoring suppl) HW EMBRACE TALK GLUCOSE TEST IN VITRO NF STRIP (glucose blood) HY-VEE LANCETS (lancets) NPB hy-vee thin lancets NPB IGLUCOSE MONITORING SYSTEM KIT W/DEVICE NF (blood glucose monitoring suppl) IGLUCOSE TEST STRIPS IN VITRO STRIP (glucose NF blood) IN TOUCH BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) IN TOUCH DEVICE (blood glucose monitoring suppl) NF IN TOUCH LANCING DEVICE (lancet devices) NPB IN TOUCH STERILE LANCETS 30G (lancets) NPB INFINITY BLOOD GLUCOSE SYSTEM KIT W/DEVICE NF (blood glucose monitoring suppl) INFINITY BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) INFINITY VOICE IN VITRO STRIP (glucose blood) NF INFINITY VOICE KIT W/DEVICE (blood glucose NF monitoring suppl) INPEN 100-BLUE-LILLY DEVICE (injection device for NPB insulin) INPEN 100-BLUE-NOVO DEVICE (injection device for NPB insulin)

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 167 Prescription Drug Name Drug Tier Drug Notes INPEN 100-GRAY-LILLY DEVICE (injection device for NPB insulin) INPEN 100-GREY-NOVO DEVICE (injection device for NPB insulin) INPEN 100-PINK-LILLY DEVICE (injection device for NPB insulin) INPEN 100-PINK-NOVO DEVICE (injection device for NPB insulin) insulin syringe 27g x 1/2" 0.5 ml, 27g x 1/2" 1 ml, 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 NF ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml insulin syringe/needle 27g x 1/2" 0.5 ml, 28g x 1/2" 0.5 ml, 28g x NF 1/2" 1 ml insulin syringe-needle u-100 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x NF 1/4" 0.3 ml, 31g x 1/4" 0.5 ml, 31g x 1/4" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml insupen pen needles 29g x 12mm , 31g x 5 mm , 31g x 8 mm , NF 32g x 4 mm , 33g x 4 mm INSUPEN SENSITIVE 32G X 6 MM , 32G X 8 MM (insulin NF pen needle) INSUPEN ULTRAFIN 30G X 8 MM , 31G X 6 MM , 31G NF X 8 MM (insulin pen needle) KETO-DIASTIX IN VITRO STRIP (urine glucose-ketones NPB test) ketone test in vitro strip NPB KETOSTIX IN VITRO STRIP (acetone (urine) test) NPB kinney lancets NPB kinney thin lancets NPB kinray insulin syringe 29g x 1/2" 0.5 ml, 31g x 5/16" 0.3 ml, 31g NF x 5/16" 0.5 ml, 31g x 5/16" 1 ml kmart valu insulin syringe 29g u-100 0.5 ml, u-100 1 ml NF kmart valu insulin syringe 30g u-100 0.3 ml, u-100 0.5 ml, u-100 NF 1 ml kroger blood glucose kit , w/device NF kroger blood glucose test in vitro strip NF

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 168 Prescription Drug Name Drug Tier Drug Notes KROGER HEALTHPRO GLUCOSE TEST IN VITRO NF STRIP (glucose blood) kroger insulin syringe 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 NF ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml kroger lancets NPB kroger lancets super thin NPB kroger lancets thin NPB kroger pen needles 29g x 12mm , 31g x 5 mm , 31g x 6 mm , 31g NF x 8 mm , 32g x 4 mm , 33g x 4 mm kroger premium blood glucose kit w/device NF kroger premium glucose test in vitro strip NF kroger test in vitro strip NF lancet device NPB lancet device with ejector NPB lancet transporter case NPB lancets NPB lancets 30g NPB lancets 33g NPB lancets micro thin 33g NPB lancets thin NPB lancets ultra thin 30g NPB lancing device NPB LANZO (lancet devices) NPB ldr blood glucose truetest kit w/device NF leader insulin syringe 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.3 NF ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml LEADER UNIFINE PENTIPS 31G X 5 MM , 32G X 4 MM NF (insulin pen needle) LEADER UNIFINE PENTIPS PLUS 31G X 5 MM , 31G X NF 8 MM , 32G X 4 MM (insulin pen needle) liberty blood glucose meter device NF LIBERTY NEXT GENERATION TEST IN VITRO STRIP NF (glucose blood)

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 169 Prescription Drug Name Drug Tier Drug Notes LIBERTY NXT GENERATION MONITOR DEVICE NF (blood glucose monitoring suppl) liberty test in vitro strip NF LIFESCAN UNISTIK 2 (lancets) NPB LIFESCAN UNISTIK II LANCETS (lancets) NPB lite touch lancets NPB LITE TOUCH LANCING PEN (lancet devices) NPB LITETOUCH INSULIN SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, NF 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe-needle u-100) LITETOUCH LANCETS (lancets) NPB LITETOUCH PEN NEEDLES 29G X 12.7MM , 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM (insulin NF pen needle) live better adv lancing device NPB live better lancet ultra thin NPB longs insulin syringe 31g x 5/16" 0.5 ml NF longs lancets standard NPB longs lancets thin NPB longs lancets ultra thin NPB MAGELLAN INSULIN SAFETY SYR 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, NF 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML (insulin syringe-needle u-100) MARATHON MEDICAL PENTIPS 29G X 12MM , 31G X NF 5 MM , 31G X 8 MM , 32G X 4 MM (insulin pen needle) MAXICOMFORT II PEN NEEDLE 31G X 6 MM (insulin NF pen needle) MAXI-COMFORT INSULIN SYRINGE 28G X 1/2" 0.5 NF ML, 28G X 1/2" 1 ML (insulin syringe-needle u-100) MAXI-COMFORT SAFETY PEN NEEDLE 29G X 5MM , NF 29G X 8MM (insulin pen needle) MAXICOMFORT SYR 27G X 1/2" 27G X 1/2" 0.5 ML, 27G NF X 1/2" 1 ML (insulin syringe-needle u-100) medic insulin syringe 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml NF medichoice safety lancet extra NPB

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 170 Prescription Drug Name Drug Tier Drug Notes medicine shoppe pen needles 29g x 12mm , 31g x 6 mm , 31g x 8 NF mm MEDISENSE THIN LANCETS (lancets) NPB MEDLANCE PLUS EXTRA 21G (lancets) NPB MEDLANCE PLUS LANCETS (lancets) NPB MEDLANCE PLUS LITE 25G (lancets) NPB MEDLANCE PLUS SPECIAL 0.8MM (lancets) NPB MEDLANCE PLUS SUPERLITE 30G (lancets) NPB MEDLANCE PLUS UNIVERSAL 21G (lancets) NPB meijer blood glucose kit w/device NF meijer blood glucose test in vitro strip NF meijer essential blood glucose kit w/device NF meijer essential glucose test in vitro strip NF MEIJER LANCETS THIN (lancets) NPB MEIJER LANCETS UNIVERSAL 21G (lancets) NPB MEIJER LANCETS UNIVERSAL 30G (lancets) NPB MEIJER LANCETS UNIVERSAL 33G (lancets) NPB meijer pen needles 29g x 12mm , 31g x 6 mm , 31g x 8 mm NF meijer premium blood glucose kit w/device NF meijer premium glucose test in vitro strip NF MEIJER SUPER THIN LANCETS (lancets) NPB MEIJER TRUE2GO BLOOD GLUCOSE KIT W/DEVICE NF (blood glucose monitoring suppl) MEIJER TRUERESULT GLUCOSE SYS KIT W/DEVICE NF (blood glucose monitoring suppl) MEIJER TRUETEST TEST IN VITRO STRIP (glucose NF blood) MEIJER TRUETRACK GLUCOSE SYS KIT W/DEVICE NF (blood glucose monitoring suppl) MEIJER TRUETRACK TEST IN VITRO STRIP (glucose NF blood) MICRODOT BLOOD GLUCOSE SYSTEM KIT NF W/DEVICE (blood glucose monitoring suppl) MICRODOT PEN NEEDLE 31G X 6 MM , 32G X 4 MM , NF 33G X 4 MM (insulin pen needle) MICRODOT TEST IN VITRO STRIP (glucose blood) NF

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 171 Prescription Drug Name Drug Tier Drug Notes MICROLET LANCETS (lancets) NPB MICROLET NEXT LANCING DEVICE (lancet devices) NPB mini lancing device NPB MINILINK REAL-TIME TRANSMITTER (continuous NF blood gluc transmit) MINIMED 630G GUARDIAN PRESS (continuous blood NF gluc transmit) MINIMED GUARDIAN LINK 3 (continuous blood gluc NF transmit) MINIMED PUMP RESERVOIR 3ML (insulin infusion pump NPB supplies) MINIMED RESERVOIR 1.8ML (insulin infusion pump NPB supplies) MINIMED RESERVOIR 3ML (insulin infusion pump NPB supplies) MIO INFUSION SET 18" 6MM (insulin infusion pump NPB supplies) MIO INFUSION SET 23" 6MM (insulin infusion pump NPB supplies) MIO INFUSION SET 32" 6MM (insulin infusion pump NPB supplies) MIO INFUSION SET 32" 9MM (insulin infusion pump NPB supplies) MM EASY TOUCH GLUCOSE IN VITRO STRIP (glucose NF blood) MM EASY TOUCH GLUCOSE METER KIT W/DEVICE NF (blood glucose monitoring suppl) mm insulin syringe/needle 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g NF x 5/16" 1 ml MM PEN NEEDLES 31G X 5 MM , 31G X 6 MM , 31G X 8 NF MM , 32G X 4 MM (insulin pen needle) MONOJECT INSULIN SYRINGE 25G X 5/8" 1 ML, 27G X 1/2" 1 ML, 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" NF 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 1 ML (insulin syringe-needle u-100) MONOJECT INSULIN SYRINGE U-100 1 ML (insulin NF syringes (disposable))

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 172 Prescription Drug Name Drug Tier Drug Notes MONOJECT ULTRA COMFORT SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" NF 0.5 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML (insulin syringe-needle u-100) MONOLET LANCETS (lancets) NPB MONOLET OPD LANCETS (lancets) NPB MONOLETTOR SAFETY LANCETS (lancets) NPB mpd safety lancet 21g NPB mpd safety lancet 23g NPB mpd safety lancet 28g NPB mpd safety lancet 30g NPB ms insulin syringe 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x NF 5/16" 1 ml MULTI-LANCET DEVICE 2 KIT (lancets misc.) NPB MYGLUCOHEALTH BLOOD GLUCOSE KIT NF W/DEVICE (blood glucose monitoring suppl) MYGLUCOHEALTH LANCETS 30G (lancets) NPB MYGLUCOHEALTH TEST IN VITRO STRIP (glucose NF blood) NEUTEK 2TEK TEST IN VITRO STRIP (glucose blood) NF NOVA MAX BLOOD GLUCOSE SYSTEM DEVICE (blood NF glucose monitoring suppl) NOVA MAX BLOOD GLUCOSE SYSTEM KIT NF W/DEVICE (blood glucose monitoring suppl) NOVA MAX GLUCOSE TEST IN VITRO STRIP (glucose NF blood) NOVA MAX PLUS KETONE TEST IN VITRO STRIP NPB (ketone blood test) NOVA SAFETY LANCETS 23G (lancets) NPB NOVA SAFETY LANCETS 28G (lancets) NPB NOVA SUREFLEX LANCETS (lancets) NPB NOVA SUREFLEX LANCING DEVICE (lancet devices) NPB NOVOFINE 32G X 6 MM (insulin pen needle) NF NOVOFINE AUTOCOVER 30G X 8 MM (insulin pen NF needle) NOVOFINE PLUS 32G X 4 MM (insulin pen needle) NF

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 173 Prescription Drug Name Drug Tier Drug Notes NOVOPEN ECHO DEVICE (injection device for insulin) NPB NOVOTWIST 32G X 5 MM (insulin pen needle) NF OMNIPOD 5 PACK (insulin disposable pump) PB OMNIPOD DASH 5 PACK PODS (insulin disposable pump) PB OMNIPOD STARTER KIT (insulin disposable pump) PB one drop blood glucose monitor kit w/device NF one drop test in vitro strip NF ONETOUCH CLUB LANCETS FINE PT (lancets) PB ONETOUCH DELICA LANCETS 30G (lancets) PB ONETOUCH DELICA LANCETS 33G (lancets) PB ONETOUCH DELICA LANCING DEV (lancet devices) PB ONETOUCH DELICA PLUS LANCET30G (lancets) PB ONETOUCH DELICA PLUS LANCET33G (lancets) PB ONETOUCH DELICA PLUS LANCING (lancet devices) PB ONETOUCH FINEPOINT LANCETS (lancets) PB ONETOUCH SURESOFT LANCING DEV (lancets misc.) PB ONETOUCH ULTRA IN VITRO STRIP (glucose blood) PB ONETOUCH ULTRALINK KIT W/DEVICE (blood glucose PB monitoring suppl) ONETOUCH ULTRASOFT LANCETS (lancets) PB ONETOUCH VERIO FLEX SYSTEM KIT W/DEVICE PB (blood glucose monitoring suppl) ONETOUCH VERIO IN VITRO STRIP (glucose blood) PB ONETOUCH VERIO KIT W/DEVICE (blood glucose PB monitoring suppl) ONETOUCH VERIO REFLECT KIT W/DEVICE (blood PB glucose monitoring suppl) ONETOUCH VERIO SYNC SYSTEM KIT W/DEVICE PB (blood glucose monitoring suppl) OPTIUM BLOOD GLUCOSE MONITOR KIT W/DEVICE NF (blood glucose monitoring suppl) OPTIUM GLUCOSE MONITOR SYSTEM DEVICE (blood NF glucose monitoring suppl) OPTIUM TEST IN VITRO STRIP (glucose blood) NF OPTIUMEZ TEST IN VITRO STRIP (glucose blood) NF

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 174 Prescription Drug Name Drug Tier Drug Notes PARADIGM PUMP RESERVOIR 1.8ML (insulin infusion NPB pump supplies) PARADIGM PUMP RESERVOIR 3ML (insulin infusion NPB pump supplies) PARADIGM REAL-TIME TRANSMITTER (continuous NF blood gluc transmit) PARADIGM SILHOUETTE COMBO 23" (insulin infusion NPB pump supplies) PARADIGM SURE-T 23" 6MM (insulin infusion pump NPB supplies) pc lancets super thin 30g NPB pc unifine pentips 29g x 12mm , 31g x 5 mm , 31g x 6 mm , 31g NF x 8 mm pen needles 1/2" 29g x 12mm NF pen needles 29g x 12mm , 30g x 5 mm , 30g x 8 mm , 31g x 5 mm , 31g x 6 mm , 31g x 8 mm , 32g x 4 mm , 32g x 5 mm , 32g NF x 6 mm , 33g x 4 mm pen needles 5/16" 31g x 8 mm NF PENLET II BLOOD SAMPLER KIT (lancets misc.) NPB PENLET II REPLACEMENT CAP (lancets misc.) NPB PENTIPS 29G X 12MM , 31G X 5 MM , 31G X 6 MM , 31G NF X 8 MM , 32G X 4 MM (insulin pen needle) PERFECT LANCETS 28G (lancets) NPB PERFECT LANCETS 30G (lancets) NPB ph strips in vitro diagnostic test NPB PHARMACIST CHOICE AUTOCODE IN VITRO STRIP NF (glucose blood) PHARMACIST CHOICE AUTOCODE SYS KIT NF W/DEVICE (blood glucose monitoring suppl) PHARMACIST CHOICE LANCETS (lancets) NPB PHARMACIST CHOICE MINI SYSTEM DEVICE (blood NF glucose monitoring suppl) pharmacist choice no coding in vitro strip NF PHARMACY COUNTER LANCETS (lancets) NPB pip lancets 28g NPB pip lancets 30g NPB POCKETCHEM EZ SYSTEM KIT W/DEVICE (blood NF glucose monitoring suppl) 2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 175 Prescription Drug Name Drug Tier Drug Notes POCKETCHEM EZ TEST IN VITRO STRIP (glucose blood) NF PRECISION LINK KIT (blood glucose monitoring suppl) NF PRECISION PCX IN VITRO STRIP (glucose blood) NF PRECISION PCX PLUS TEST IN VITRO STRIP (glucose NF blood) PRECISION POINT OF CARE TEST IN VITRO STRIP NF (glucose blood) PRECISION QID MONITOR DEVICE (blood glucose NF monitoring suppl) PRECISION QID TEST IN VITRO STRIP (glucose blood) NF PRECISION SOF-TACT MONITOR DEVICE (blood NF glucose monitoring suppl) PRECISION SOF-TACT TEST IN VITRO STRIP (glucose NF blood) PRECISION SUREDOSE PLUS SYR 29G X 1/2" 0.3 ML, NF 29G X 1/2" 1 ML (insulin syringe-needle u-100) PRECISION SURE-DOSE SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.5 ML, 30G X 3/8" 0.5 ML, NF 30G X 5/16" 0.3 ML (insulin syringe-needle u-100) PRECISION XTRA BLOOD GLUCOSE IN VITRO STRIP NF (glucose blood) PRECISION XTRA DEVICE (blood glucose monitoring NF suppl) PRECISION XTRA KETONE IN VITRO STRIP (ketone NPB blood test) PRECISION XTRA KIT , W/DEVICE (blood glucose NF monitoring suppl) PRECISION XTRA MONITOR DEVICE (blood glucose NF monitoring suppl) preferred plus insulin syringe 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x NF 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml preferred plus lancets colored NPB preferred plus lancets thin NPB preferred plus unifine pentips 29g x 12mm , 31g x 5 mm , 31g x NF 6 mm , 31g x 8 mm , 32g x 4 mm premium blood glucose test in vitro strip NF PREVENT SAFETY PEN NEEDLES 31G X 6 MM , 31G X NF 8 MM (insulin pen needle) 2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 176 Prescription Drug Name Drug Tier Drug Notes pro comfort alcohol pad 70 % NPB PRO COMFORT INSULIN SYRINGE 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, NF 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe-needle u-100) pro comfort lancets 30g NPB pro comfort lancets 31g NPB pro comfort pen needles 31g x 8 mm , 32g x 4 mm , 32g x 5 mm , NF 32g x 6 mm pro voice v8 glucose system device NF pro voice v8/v9 glucose in vitro strip NF pro voice v9 glucose system device NF PRODIGY AUTOCODE BLOOD GLUCOSE DEVICE NF (blood glucose monitoring suppl) PRODIGY AUTOCODE BLOOD GLUCOSE KIT NF W/DEVICE (blood glucose monitoring suppl) PRODIGY INSULIN SYRINGE 28G X 1/2" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML (insulin syringe-needle u- NF 100) PRODIGY LANCETS 28G (lancets) NPB PRODIGY LANCING DEVICE (lancet devices) NPB PRODIGY NO CODING BLOOD GLUC IN VITRO NF STRIP (glucose blood) PRODIGY POCKET BLOOD GLUCOSE KIT W/DEVICE NF (blood glucose monitoring suppl) PRODIGY SAFETY LANCETS 26G (lancets) NPB PRODIGY VOICE BLOOD GLUCOSE KIT W/DEVICE NF (blood glucose monitoring suppl) PSS SELECT GP LANCETS (lancets) NPB PSS SELECT PLATFORMS (lancets misc.) NPB PSS SELECT SAFETY LANCETS (lancets) NPB PTS PANELS GLUCOSE TEST IN VITRO STRIP (glucose NF blood) PTS PANELS KETONE TEST IN VITRO STRIP (ketone NPB blood test) px extra short pen needles 31g x 6 mm NF px insulin syringe 30g x 1/2" 0.5 ml NF px lancet auto injector NPB 2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 177 Prescription Drug Name Drug Tier Drug Notes px lancets microthin 33g NPB px lancets ultra thin NPB px mini pen needles 31g x 5 mm NF px pen needle 29g x 12mm , 31g x 8 mm NF px shortlength pen needles 31g x 8 mm NF qc advanced lancing device NPB qc alcohol swabs pad 70 % NPB qc lancets super thin 30g NPB qc lancets ultra thin NPB qc pen needles 29g x 12mm , 31g x 6 mm , 31g x 8 mm NF qc unifine pentips 32g x 4 mm NF qc unilet lancets 28g NPB qc unilet lancets micro thin NPB QUICKTEK KIT (blood glucose monitoring suppl) NF QUICKTEK TEST IN VITRO STRIP (glucose blood) NF QUICKTEK/METER KIT (blood glucose monitoring suppl) NF QUINTET AC BLOOD GLUCOSE DEVICE (blood glucose NF monitoring suppl) QUINTET AC BLOOD GLUCOSE TEST IN VITRO NF STRIP (glucose blood) QUINTET BLOOD GLUCOSE SYSTEM DEVICE (blood NF glucose monitoring suppl) QUINTET BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) ra alcohol swabs pad 70 % NPB RA E-ZJECT LANCETS 28G (lancets) NPB RA E-ZJECT LANCETS THIN 26G (lancets) NPB RA E-ZJECT LANCETS THIN 28G (lancets) NPB RA E-ZJECT LANCETS ULTRA THIN (lancets) NPB ra insulin syringe 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" NF 0.5 ml, 30g x 5/16" 1 ml ra pen needles 31g x 5 mm , 31g x 8 mm NF RAPPORT RLS KIT (impotence aid device) NPB RAPPORT VTD KIT (impotence aid device) NPB READYLANCE SAFETY LANCETS (lancets) NPB

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 178 Prescription Drug Name Drug Tier Drug Notes reality insulin syringe 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x NF 1/2" 0.5 ml, 29g x 1/2" 1 ml reality lancets NPB reality swabs pad NPB reality trigger lancets NPB REFUAH PLUS BLOOD GLUCOSE TEST IN VITRO NF STRIP (glucose blood) REFUAH PLUS MONITORING SYSTEM KIT NF W/DEVICE (blood glucose monitoring suppl) RELION BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) RELION CONFIRM GLUCOSE MONITOR KIT NF W/DEVICE (blood glucose monitoring suppl) RELION CONFIRM/MICRO TEST IN VITRO STRIP NF (glucose blood) RELION INSULIN SYRINGE 29G X 1/2" 0.5 ML, 31G X 15/64" 0.3 ML, 31G X 15/64" 0.5 ML, 31G X 15/64" 1 ML, NF 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe-needle u-100) RELION KETONE TEST IN VITRO STRIP (acetone NPB (urine) test) RELION LANCET DEVICES 30G (lancet devices) NPB RELION LANCETS MICRO-THIN 33G (lancets) NPB RELION LANCETS THIN 26G (lancets) NPB RELION LANCETS ULTRA-THIN 30G (lancets) NPB RELION LANCING DEVICE (lancet devices) NPB RELION LANCING DEVICE KIT (lancets misc.) NPB RELION MICRO KIT W/DEVICE (blood glucose monitoring NF suppl) RELION MINI PEN NEEDLES 31G X 6 MM (insulin pen NF needle) RELION PEN NEEDLES 29G X 12MM , 31G X 6 MM , NF 31G X 8 MM , 32G X 4 MM (insulin pen needle) RELION PREMIER BLU MONITOR DEVICE (blood NF glucose monitoring suppl) RELION PREMIER COMPACT SYSTEM KIT NF W/DEVICE (blood glucose monitoring suppl)

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 179 Prescription Drug Name Drug Tier Drug Notes RELION PREMIER VOICE MONITOR DEVICE (blood NF glucose monitoring suppl) RELION PRIME MONITOR DEVICE (blood glucose NF monitoring suppl) RELION PRIME TEST IN VITRO STRIP (glucose blood) NF RELION SHORT PEN NEEDLES 31G X 8 MM (insulin pen NF needle) RELION ULTIMA GLUCOSE SYSTEM KIT W/DEVICE NF (blood glucose monitoring suppl) RELION ULTIMA TEST IN VITRO STRIP (glucose blood) NF RELION ULTRA THIN LANCETS 30G (lancets) NPB RELION ULTRA THIN PLUS LANCETS (lancets) NPB REXALL BLOOD GLUCOSE SYSTEM KIT W/DEVICE NF (blood glucose monitoring suppl) REXALL BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) RIGHTEST ALTERNATE SITE ADAPT (lancets misc.) NPB RIGHTEST GD500 LANCING DEVICE (lancet devices) NPB RIGHTEST GL300 LANCETS (lancets) NPB RIGHTEST GM100 BLOOD GLUCOSE KIT W/DEVICE NF (blood glucose monitoring suppl) RIGHTEST GM300 BLOOD GLUCOSE KIT W/DEVICE NF (blood glucose monitoring suppl) RIGHTEST GM550 BLOOD GLUCOSE KIT W/DEVICE NF (blood glucose monitoring suppl) RIGHTEST GS100 BLOOD GLUCOSE IN VITRO STRIP NF (glucose blood) RIGHTEST GS300 BLOOD GLUCOSE IN VITRO STRIP NF (glucose blood) RIGHTEST GS550 BLOOD GLUCOSE IN VITRO STRIP NF (glucose blood) SAFE-T-LANCE (lancets) NPB SAFE-T-LANCE PLUS (lancets) NPB safety insulin syringes 27g x 1/2" 1 ml, 29g x 1/2" 0.5 ml, 29g x NF 1/2" 1 ml, 30g x 1/2" 1 ml, 30g x 5/16" 0.5 ml safety lancet 30g/pressure act NPB saps care alcohol prep pad 70 % NPB saps health care alcohol prep pad 70 % NPB 2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 180 Prescription Drug Name Drug Tier Drug Notes saps health twist top lancets NPB saps twist top lancets NPB sapscare twist top lancets NPB sb alcohol prep pad 70 % NPB sb insulin syringe 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" NF 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 1 ml sb lancets thin NPB sb lancets ultra thin NPB SECURESAFE INSULIN SYRINGE 29G X 1/2" 0.5 ML, NF 29G X 1/2" 1 ML (insulin syringe-needle u-100) select-lite lancing device NPB SHOPKO AUTOLET LANCING DEVICE (lancet devices) NPB SHOPKO UNIFINE PENTIPS 29G X 12MM , 31G X 5 MM NF , 31G X 8 MM , 32G X 4 MM (insulin pen needle) SHOPKO UNIFINE PENTIPS PLUS 29G X 12MM , 31G X NF 5 MM , 31G X 8 MM , 32G X 4 MM (insulin pen needle) SILHOUETTE 13MM (insulin infusion pump supplies) NPB SILHOUETTE 17MM (insulin infusion pump supplies) NPB SILHOUETTE INFUSION SET 23" (insulin infusion pump NPB supplies) SILHOUETTE INFUSION SET 43" (insulin infusion pump NPB supplies) SIMPLE DIAGNOSTICS LANCING DEV (lancet devices) NPB SINGLE-LET (lancets) NPB sm alcohol prep pad 70 % NPB sm lancets 33g NPB SM TRUEDRAW LANCING DEVICE (lancet devices) NPB SMART DIABETES VANTAGE LANCING (lancet devices) NPB SMART SENSE COLOR LANCETS 33G (lancets) NPB SMART SENSE PREMIUM SYSTEM KIT W/DEVICE NF (blood glucose monitoring suppl) SMART SENSE PREMIUM TEST IN VITRO STRIP NF (glucose blood) SMART SENSE STANDARD LANCETS (lancets) NPB SMART SENSE SUPER THIN LANCETS (lancets) NPB SMART SENSE THIN LANCETS 26G (lancets) NPB

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 181 Prescription Drug Name Drug Tier Drug Notes SMART SENSE VALUE GLUCOSE SYS KIT W/DEVICE NF (blood glucose monitoring suppl) SMART SENSE VALUE TEST IN VITRO STRIP (glucose NF blood) SMARTEST BLOOD GLUCOSE TEST IN VITRO STRIP NF (glucose blood) SMARTEST EJECT DEVICE (blood glucose monitoring NF suppl) SMARTEST EJECT STARTER KIT W/DEVICE (blood NF glucose monitoring suppl) SMARTEST LANCETS 28G (lancets) NPB SMARTEST PERSONA STARTER KIT W/DEVICE (blood NF glucose monitoring suppl) SMARTEST PRONTO STARTER KIT W/DEVICE (blood NF glucose monitoring suppl) SMARTEST PROTEGE DEVICE (blood glucose monitoring NF suppl) SMARTEST PROTEGE STARTER KIT W/DEVICE (blood NF glucose monitoring suppl) SOLUS V2 BLOOD GLUCOSE SYSTEM DEVICE (blood NF glucose monitoring suppl) SOLUS V2 BLOOD GLUCOSE SYSTEM KIT W/DEVICE NF (blood glucose monitoring suppl) SOLUS V2 LANCETS 28G (lancets) NPB SOLUS V2 LANCING DEVICE (lancet devices) NPB SOLUS V2 TEST IN VITRO STRIP (glucose blood) NF SOLUS V2 TWIST LANCETS 30G (lancets) NPB STERILANCE PA (lancets misc.) NPB STERILANCE TL (lancets) NPB super thin lancets NPB SUPREME TEST IN VITRO STRIP (glucose blood) NF sure comfort alcohol prep pad 70 % NPB sure comfort insulin syringe 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 1/2" 0.3 ml, 30g x 1/2" 0.5 ml, 30g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, NF 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 1/4" 0.3 ml, 31g x 1/4" 0.5 ml, 31g x 1/4" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 182 Prescription Drug Name Drug Tier Drug Notes sure comfort lancets 18g NPB sure comfort lancets 21g NPB sure comfort lancets 23g NPB sure comfort lancets 30g NPB sure comfort lancing pen NPB sure comfort pen needles 29g x 12.7mm , 30g x 8 mm , 31g x 5 NF mm , 31g x 8 mm , 32g x 6 mm SURE-FINE PEN NEEDLES 29G X 12.7MM , 31G X 5 NF MM , 31G X 8 MM (insulin pen needle) SURE-JECT INSULIN SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X NF 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe-needle u-100) SURE-LANCE FLAT LANCETS (lancets) NPB SURE-LANCE LANCETS 26G (lancets) NPB SURELITE LANCETS (lancets) NPB SURE-PEN (lancet devices) NPB SURE-T INFUSION SET 18" (insulin infusion pump supplies) NPB SURE-T INFUSION SET 23" (insulin infusion pump supplies) NPB SURE-T INFUSION SET 32" (insulin infusion pump supplies) NPB SURE-T INFUSION SET 6MM (insulin infusion pump NPB supplies) SURE-T INFUSION SET 8MM (insulin infusion pump NPB supplies) SURE-TEST EASYPLUS MINI METER DEVICE (blood NF glucose monitoring suppl) SURE-TEST EASYPLUS MINI TEST IN VITRO STRIP NF (glucose blood) SURE-TOUCH LANCETS UNIVERSAL (lancets) NPB T:FLEX T:LOCK CARTRIDGE 4.8ML (insulin infusion NPB pump supplies) techlite insulin syringe 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 1/2" 0.3 ml, 30g x 1/2" 0.5 ml, 30g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g NF x 15/64" 0.3 ml, 31g x 15/64" 0.5 ml, 31g x 15/64" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 183 Prescription Drug Name Drug Tier Drug Notes TECHLITE PEN NEEDLES 29G X 10MM , 29G X 12MM , 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM , NF 32G X 6 MM , 32G X 8 MM (insulin pen needle) tgt blood glucose monitoring kit w/device NF tgt blood glucose test in vitro strip NF tgt lancet micro thin 33g NPB tgt lancet thin 26g NPB tgt lancet ultra thin 30g NPB tgt lancing device NPB THINLETS GP LANCETS (lancets) NPB todays health mini pen needles 31g x 6 mm NF todays health pen needles 29g x 12mm NF todays health short pen needle 31g x 8 mm NF topcare clickfine pen needles 31g x 6 mm , 31g x 8 mm NF topcare lancets micro-thin 33g NPB topcare ultra comfort ins syr 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g NF x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml TOXICOLOGY MED COLLECTION SYS IN VITRO KIT NPB (drug assay (urine)) travel lancets NPB TRAVEL LANCETS ADVANCED 28G (lancets) NPB true comfort insulin syringe 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml NF true comfort pen needles 31g x 5 mm , 31g x 6 mm , 32g x 4 mm NF true comfort pro insulin syr 30g x 1/2" 0.5 ml, 30g x 1/2" 1 ml, NF 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 32g x 5/16" 1 ml true comfort twist top lancets NPB TRUE FOCUS BLOOD GLUCOSE METER DEVICE NF (blood glucose monitoring suppl) true focus blood glucose strip in vitro strip NF TRUE METRIX AIR GLUCOSE METER KIT W/DEVICE NF (blood glucose monitoring suppl) TRUE METRIX BLOOD GLUCOSE TEST IN VITRO NF STRIP (glucose blood) TRUE METRIX GO GLUCOSE METER KIT W/DEVICE NF (blood glucose monitoring suppl)

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 184 Prescription Drug Name Drug Tier Drug Notes TRUE METRIX METER DEVICE (blood glucose monitoring NF suppl) TRUE METRIX METER KIT W/DEVICE (blood glucose NF monitoring suppl) TRUEPLUS 5-BEVEL PEN NEEDLES 29G X 12.7MM , 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM NF (insulin pen needle) TRUEPLUS INSULIN SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X NF 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe-needle u-100) TRUEPLUS LANCETS 26G (lancets) NPB TRUEPLUS LANCETS 28G (lancets) NPB TRUEPLUS LANCETS 30G (lancets) NPB TRUEPLUS LANCETS 33G (lancets) NPB TRUEPLUS PEN NEEDLES 31G X 6 MM (insulin pen NF needle) TRUEPLUS SAFETY LANCETS 28G (lancets) NPB TRUERESULT BLOOD GLUCOSE KIT W/DEVICE NF (blood glucose monitoring suppl) TRUETEST TEST IN VITRO STRIP (glucose blood) NF TRUETRACK BLOOD GLUCOSE DEVICE (blood glucose NF monitoring suppl) TRUETRACK BLOOD GLUCOSE KIT W/DEVICE (blood NF glucose monitoring suppl) TRUETRACK SMART SYSTEM KIT (blood glucose NF monitoring suppl) TRUETRACK TEST IN VITRO STRIP (glucose blood) NF TRUSTEEL INFUSION SET (insulin infusion pump supplies) NPB ULTICARE ALCOHOL SWABS PAD (alcohol swabs) NPB ULTICARE INSULIN SAFETY SYR 29G X 1/2" 0.5 ML, NF 29G X 1/2" 1 ML (insulin syringe-needle u-100)

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 185 Prescription Drug Name Drug Tier Drug Notes ULTICARE INSULIN SYRINGE 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X NF 5/16" 1 ML, 31G X 1/4" 0.3 ML, 31G X 1/4" 0.5 ML, 31G X 1/4" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe-needle u-100) ULTICARE MICRO PEN NEEDLES 31G X 6 MM , 31G X NF 8 MM , 32G X 4 MM (insulin pen needle) ULTICARE MINI PEN NEEDLES 31G X 6 MM , 32G X 6 NF MM (insulin pen needle) ULTICARE PEN NEEDLES 29G X 12.7MM , 31G X 5 MM NF (insulin pen needle) ULTICARE SHORT PEN NEEDLES 31G X 8 MM (insulin NF pen needle) ultiguard safepack pen needle 31g x 5 mm , 31g x 6 mm , 31g x NF 8 mm , 32g x 4 mm , 32g x 6 mm ULTI-LANCE AUTOMATIC (lancet devices) NPB ultilet alcohol swabs pad NPB ULTILET CLASSIC LANCETS (lancets) NPB ULTILET INSULIN SYRINGE 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 1/4" 0.3 ML, 31G X 1/4" 1 ML, 31G X NF 15/64" 0.3 ML, 31G X 15/64" 0.5 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 1 ML (insulin syringe-needle u-100) ULTILET INSULIN SYRINGE SHORT 30G X 1/2" 0.3 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" NF 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe-needle u-100) ULTILET LANCETS (lancets) NPB ULTILET PEN NEEDLE 29G X 12.7MM , 31G X 5 MM , NF 31G X 8 MM , 32G X 4 MM (insulin pen needle) ULTILET SAFETY LANCETS (lancets) NPB ULTILET SAFETY LANCETS 23G (lancets) NPB ULTIMA KIT (blood glucose monitoring suppl) NF ultra comfort insulin syringe 30g x 5/16" 0.3 ml NF ultra thin lancets 31g NPB ULTRA THIN PEN NEEDLES 32G X 4 MM (insulin pen NF needle)

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 186 Prescription Drug Name Drug Tier Drug Notes ultracare insulin syringe 30g x 1/2" 0.5 ml, 30g x 1/2" 1 ml, 30g x 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" NF 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml ultra-care lancets 30g NPB ultracare pen needles 31g x 5 mm , 31g x 6 mm , 31g x 8 mm , NF 32g x 4 mm , 32g x 5 mm , 32g x 6 mm , 33g x 4 mm ultra-comfort insulin syringe 28g x 1/2" 0.5 ml, 28g x 1/2" 1 ml, 29g x 1/2" 0.3 ml, 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml, 30g x NF 5/16" 0.3 ml, 30g x 5/16" 0.5 ml, 30g x 5/16" 1 ml, 31g x 5/16" 0.3 ml, 31g x 5/16" 0.5 ml, 31g x 5/16" 1 ml ULTRA-THIN II AUTO LANCET (lancets) NPB ULTRA-THIN II INS SYR SHORT 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 NF ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (insulin syringe- needle u-100) ULTRA-THIN II INSULIN SYRINGE 29G X 1/2" 0.5 ML, NF 29G X 1/2" 1 ML (insulin syringe-needle u-100) ULTRA-THIN II LANCETS (lancets) NPB ULTRA-THIN II MINI PEN NEEDLE 31G X 5 MM NF (insulin pen needle) ULTRA-THIN II PEN NEEDLE SHORT 31G X 8 MM NF (insulin pen needle) ULTRA-THIN II PEN NEEDLES 29G X 12.7MM (insulin NF pen needle) UNIFINE PENTIPS 29G X 12MM , 30G X 5 MM , 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM , 32G X 6 NF MM , 33G X 4 MM (insulin pen needle) UNIFINE PENTIPS PLUS 29G X 12MM , 30G X 5 MM , 31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM , NF 33G X 4 MM (insulin pen needle) UNIFINE SAFECONTROL PEN NEEDLE 30G X 5 MM , NF 30G X 8 MM (insulin pen needle) UNILET COMFORTOUCH LANCET (lancets) NPB UNILET EXCELITE (lancets) NPB UNILET EXCELITE II (lancets) NPB UNILET G.P. LANCET (lancets) NPB UNILET G.P. SUPERLITE LANCET (lancets) NPB UNILET GP 28 ULTRA THIN (lancets) NPB UNILET LANCET (lancets) NPB 2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 187 Prescription Drug Name Drug Tier Drug Notes UNILET MICRO-THIN 33G (lancets) NPB UNILET SUPERLITE LANCET (lancets) NPB UNILET SUPER-THIN 30G (lancets) NPB UNILET ULTRA-THIN 28G (lancets) NPB UNISTIK 1 (lancets misc.) NPB UNISTIK 2 (lancets misc.) NPB UNISTIK 2 COMFORT (lancets misc.) NPB UNISTIK 2 EXTRA (lancets misc.) NPB UNISTIK 2 NEONATAL (lancets misc.) NPB UNISTIK 2 NORMAL (lancets misc.) NPB UNISTIK 2 SUPER (lancets misc.) NPB UNISTIK 3 (lancets misc.) NPB UNISTIK 3 COMFORT (lancets misc.) NPB UNISTIK 3 EXTRA (lancets misc.) NPB UNISTIK 3 GENTLE (lancets) NPB UNISTIK 3 NEONATAL (lancets misc.) NPB UNISTIK 3 NORMAL (lancets misc.) NPB UNISTIK CZT COMFORT (lancets misc.) NPB UNISTIK CZT NORMAL (lancets misc.) NPB UNISTIK NORMAL (lancets misc.) NPB UNISTIK PRO SAFETY LANCET (lancets) NPB UNISTIK SAFETY LANCETS 28G (lancets) NPB UNISTIK SAFETY LANCETS 30G (lancets) NPB UNISTIK TOUCH SAFETY LANC 21G (lancets) NPB UNISTIK TOUCH SAFETY LANC 23G (lancets) NPB UNISTIK TOUCH SAFETY LANC 28G (lancets) NPB UNISTIK TOUCH SAFETY LANC 30G (lancets) NPB UNISTRIP1 GENERIC IN VITRO STRIP (glucose blood) NF UNIVERSAL 1 LANCETS THIN 26G (lancets) NPB UNIVERSAL 1 LANCETS THIN 33G (lancets) NPB UNIVERSAL 1 LANCETS ULTRA THIN (lancets) NPB value health insulin syringe 29g x 1/2" 0.5 ml, 29g x 1/2" 1 ml NF value plus lancet standard 21g NPB value plus lancets super thin NPB valumark lancet ultra thin 28g NPB 2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 188 Prescription Drug Name Drug Tier Drug Notes valumark pen needles 29g x 12mm , 31g x 6 mm , 31g x 8 mm NF VANISHPOINT INSULIN SYRINGE 29G X 1/2" 1 ML, 29G X 5/16" 1 ML, 30G X 1/2" 0.5 ML, 30G X 3/16" 0.5 ML, NF 30G X 3/16" 1 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML (insulin syringe-needle u-100) VARISOFT INFUSION SET (insulin infusion pump supplies) NPB verasens blood glucose meter device NF verasens blood glucose system kit w/device NF verasens blood glucose test in vitro strip NF V-GO 20 KIT (insulin disposable pump) PB V-GO 30 KIT (insulin disposable pump) PB V-GO 40 KIT (insulin disposable pump) PB VIDA MIA UNIFINE PENTIPS 29G X 12MM , 31G X 6 NF MM , 31G X 8 MM , 32G X 4 MM (insulin pen needle) VIVAGUARD INO GLUCOSE METER DEVICE (blood NF glucose monitoring suppl) VIVAGUARD INO TEST STRIPS IN VITRO STRIP NF (glucose blood) VIVAGUARD LANCETS (lancets) NPB VIVAGUARD LANCING DEVICE (lancet devices) NPB vp insulin syringe 29g x 1/2" 0.3 ml NF walgreens adv travel lancets NPB WALGREENS LANCETS (lancets) NPB walgreens lancets micro thin NPB walgreens lancets super thin NPB WALGREENS THIN LANCETS (lancets) NPB WALGREENS ULTRA THIN LANCETS (lancets) NPB WAVESENSE AMP KIT W/DEVICE (blood glucose NF monitoring suppl) WEBCOL ALCOHOL PREP LARGE PAD 70 % (alcohol NPB swabs) WEBCOL ALCOHOL PREP MEDIUM PAD 70 % (alcohol NPB swabs) wegmans unifine pentips plus 31g x 5 mm , 31g x 6 mm , 31g x 8 NF mm , 32g x 4 mm zevrx twist top lancets 30g NPB

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 189 Prescription Drug Name Drug Tier Drug Notes NUTRITIONAL/SUPPLEMENTS - VITAMINS AND SUPPLEMENTS ELECTROLYTES dextrose-nacl intravenous solution 2.5-0.45 % NPB dextrose-sodium chloride intravenous solution 5-0.225 % NPB EFFER-K ORAL TABLET EFFERVESCENT 10 MEQ, 20 NPB MEQ (potassium bicarb-citric acid) potassium bicarbonate (Effer-K Oral Tablet Effervescent 25 G Meq) GALZIN ORAL CAPSULE 25 MG, 50 MG (zinc acetate NPB (oral)) iodine strong oral solution 5 % G potassium chloride (Klor-Con 10 Oral Tablet Extended G Release 10 Meq) potassium chloride crys er (Klor-Con M10 Oral Tablet G Extended Release 10 Meq) potassium chloride crys er (Klor-Con M15 Oral Tablet G Extended Release 15 Meq) potassium chloride crys er (Klor-Con M20 Oral Tablet G Extended Release 20 Meq) potassium chloride (Klor-Con Oral Packet 20 Meq) G potassium chloride (Klor-Con Oral Tablet Extended Release 8 G Meq) potassium bicarbonate (Klor-Con/Ef Oral Tablet Effervescent G 25 Meq) K-PHOS ORAL TABLET 500 MG (potassium phosphate NPB monobasic) potassium bicarbonate (K-Prime Oral Tablet Effervescent 25 G Meq) k phos mono-sod phos di & mono (Phospha 250 Neutral Oral G Tablet 155-852-130 Mg) phosphorous oral tablet 155-852-130 mg G k phos mono-sod phos di & mono (Phospho-Trin 250 Neutral G Oral Tablet 155-852-130 Mg) POTABA ORAL CAPSULE 500 MG (potassium NPB aminobenzoate) potassium chloride crys er oral tablet extended release 10 meq, G 20 meq

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 190 Prescription Drug Name Drug Tier Drug Notes potassium chloride er oral capsule extended release 10 meq, 8 G meq potassium chloride er oral tablet extended release 10 meq, 20 G meq, 8 meq potassium chloride in nacl intravenous solution 20-0.45 meq/l-%, NPB 40-0.9 meq/l-% potassium chloride oral packet 20 meq G potassium chloride oral solution 20 meq/15ml (10%), 40 G meq/15ml (20%) THE LIQUILIFT TRACE INTRAVENOUS KIT 10-1000- NF 500-60 MCG/ML (trace minerals cr-cu-mn-se-zn) virt-phos 250 neutral oral tablet 155-852-130 mg G zinc sulfate intravenous solution 3 mg/ml NPB VITAMINS - VITAMINS AND SUPPLEMENTS activite oral tablet 1 mg NF adc/f (0.5mg/ml) oral solution 0.5 mg/ml G ADRENAL C FORMULA ORAL TABLET (bioflavonoid NPB products) AMINOPMRMS ORAL CAPSULE (nutritional supplements) NPB APP SLIM RMS ORAL CAPSULE (nutritional supp - diet NPB aids) ASCOR INTRAVENOUS SOLUTION 25000 MG/50ML NF (ascorbic acid) nutritional supplements (Asilnasalrms Oral Capsule) G ASTAMED MYO ORAL CAPSULE (astaxanthin- NF tocotrienol-zn-d3) ATABEX EC ORAL TABLET DELAYED RELEASE 29-1 NF MG (prenatal vit-dss-fe cbn-fa) ATABEX OB ORAL TABLET 29-1 MG (prenatal vit w/ fe NF bisg-fa) azeschew prenatal/postnatal oral tablet chewable 13-1 mg NF azesco oral tablet 13-1 mg NF biocel oral tablet G b-plex oral tablet G b-plex plus oral tablet G CALCIFOL ORAL WAFER 1342-1.6 MG (ca carb-fa-d-b6- NPB b12-boron-mg)

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 191 Prescription Drug Name Drug Tier Drug Notes calcium gluconate intravenous solution 10 % NPB CAMINO PRO COMPLETE/GLYTACTIN ORAL BAR NPB (nutritional supplements) CHOLEXMAX ORAL POWDER (dietary management NF product) CHOLEXTRA T/F ORAL POWDER (dietary management NF product) CITRANATAL 90 DHA ORAL 90-1 & 300 MG (prenat w/o PB a-fecbgl-dss-fa-dha) CITRANATAL ASSURE ORAL 35-1 & 300 MG (prenat w/o PB a-fecbgl-dss-fa-dha) CITRANATAL B-CALM ORAL 20-1 MG & 2 X 25 MG PB (prenat w/o a fecbnfeglu-fa &b6) CITRANATAL BLOOM DHA ORAL 90-1 & 300 MG PB (prenat w/o a-fecbgl-dss-fa-dha) CITRANATAL BLOOM ORAL TABLET 90-1 MG PB (prenatal-dss-fecb-fegl-fa) CITRANATAL DHA ORAL 27-1 & 250 MG (prenat w/o a- PB fecbgl-dss-fa-dha) CITRANATAL ESSENCE ORAL THERAPY PACK 35-1 PB & 300 MG (prenat w/o a-fecbgl-fa-dha) CITRANATAL HARMONY ORAL CAPSULE 27-1-260 PB MG (prenat-fefmcb-dss-fa-dha w/o a) CITRANATAL MEDLEY ORAL CAPSULE 27-1-200 MG PB (prenat-fecb-fefum-fa-dha w/o a) CITRANATAL RX ORAL TABLET 27-1 MG (prenat w/o a- PB fecb-fegl-dss-fa) c-nate dha oral capsule 28-1-200 mg NF cod liver oil oral oil NPB complete natal dha oral 29-1-200 & 250 mg NF completenate oral tablet chewable 29-1 mg NF CO-NATAL FA ORAL TABLET (prenatal vit-fe fumarate- NF fa) CONCEPT DHA ORAL CAPSULE 53.5-38-1 MG (prenat- NF fefum-fepo-fa-omega 3) CONCEPT OB ORAL CAPSULE 130-92.4-1 MG (prenat w/o NF a vit-fefum-fepo-fa) cvs folic acid oral tablet 800 mcg CE

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 192 Prescription Drug Name Drug Tier Drug Notes cyanocobalamin injection solution 1000 mcg/ml G b complex-c-folic acid (Dexifol Oral Tablet 5 Mg) NF DUET DHA 400 ORAL 25-1 & 400 MG (prenat-fepoly-fered- NF fa-omega 3) DUET DHA BALANCED ORAL 25-1 & 267 MG (prenat- NF fepoly-fered-fa-omega 3) ENBRACE HR ORAL CAPSULE (prenat vit-fe gly cys-fa- NF omega) ENTERAGAM ORAL PACKET 5 GM (sbi/protein isolate) NF ergocal oral capsule 62.5 mcg (2500 ut) NF ergocalciferol oral capsule 1.25 mg (50000 ut) G FA-8 ORAL CAPSULE 0.8 MG (folic acid) CE FLORIVA ORAL LIQUID 0.25-400 MG-UNIT/ML (sodium NF fluoride-vitamin d) FLORIVA ORAL TABLET CHEWABLE 0.25 MG (ped NPB multiple vit-minerals-fl) FLORIVA ORAL TABLET CHEWABLE 0.5 MG, 1 MG NF (ped multiple vit-minerals-fl) FLORIVA PLUS ORAL SOLUTION 0.25 MG/ML NPB (pediatric multivitamins-fl) fluoritab oral solution 0.275 (0.125 f) mg/drop CE FOLBEE PLUS CZ ORAL TABLET 5 MG (b-complex-c- G biotin-minerals-fa) folbee plus oral tablet G FOLGARD OS ORAL TABLET 500-1.1 MG (multiple vit- NPB min-calcium-fa) folic acid injection solution 5 mg/ml G folic acid oral capsule 0.8 mg CE folic-k oral capsule 1 mg NF FOLIVANE-OB ORAL CAPSULE 130-92.4-1 MG (prenat NF w/o a vit-fefum-fepo-fa) FOSTEUM ORAL CAPSULE 27-20-200 MG-MG-UNIT NF (genistein-zn chelate-vit d) FOSTEUM PLUS ORAL CAPSULE (dietary management NF product) GALAXTRA ORAL POWDER (galactose) NF GENICIN VITA-Q ORAL TABLET 1 MG (multiple vitamins NF with fa) 2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 193 Prescription Drug Name Drug Tier Drug Notes b complex-c-folic acid (Genicin Vita-S Oral Tablet 1 Mg) NF GLYTACTIN BUILD 10PE ORAL PACKET (nutritional NPB supplements) GLYTACTIN COMPLETE 10PE ORAL BAR (nutritional NPB supplements) GLYTACTIN SWIRL 15PE ORAL PACKET (nutritional NPB supplements) HCU EASY ORAL TABLET (nutritional supplements) NF hydroxocobalamin acetate intramuscular solution 1000 mcg/ml G hylavite oral tablet NF INATAL GT ORAL TABLET (prenatal vit-dss-fe cbn-fa) G INFUVITE ADULT INTRAVENOUS INJECTABLE NPB (multiple vitamin) INFUVITE PEDIATRIC INTRAVENOUS SOLUTION NPB (pediatric multiple vitamins) jenliva prenatal/postnatal oral capsule 1 mg NF KETOVIE ORAL LIQUID (nutritional supplements) NPB KETOVIE PEPTIDE ORAL LIQUID (nutritional NPB supplements) kosher prenatal plus iron oral tablet 30-1 mg NF LDL CARE ORAL POWDER (dietary management product) NF lecithin oral granules NPB lipo-c intramuscular solution NF l-methylfolate calcium oral tablet 15 mg, 7.5 mg NPB lorid oral tablet 1 mg NF multiple vitamins-minerals (Lysiplex Plus Oral Tablet) G M.V.I. ADULT INTRAVENOUS INJECTABLE (multiple NPB vitamin) M.V.I. PEDIATRIC INTRAVENOUS SOLUTION NPB RECONSTITUTED (pediatric multiple vitamins) m-natal plus oral tablet 27-1 mg NF MSUD EASY ORAL TABLET (nutritional supplements) NF multipro oral capsule NF multi-vit/iron/fluoride oral solution 0.25-10 mg/ml G multivitamin/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml G multi-vitamin/fluoride oral solution 0.5 mg/ml G

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 194 Prescription Drug Name Drug Tier Drug Notes multivitamin/fluoride oral tablet chewable 0.25 mg, 0.5 mg, 1 mg G multivitamin/fluoride oral tablet chewable 0.25-0.3 mg, 0.5-0.3 NF mg, 1-0.3 mg multi-vitamin/fluoride/iron oral solution 0.25-10 mg/ml G MYNATAL ORAL CAPSULE (prenatal multivit-min-fe-fa) NF mynatal plus oral tablet NF mynatal-z oral tablet NF sodium fluoride (Nafrinse Drops Oral Solution 0.275 (0.125 F) CE Mg/Drop) NASCOBAL NASAL SOLUTION 500 MCG/0.1ML NPB (cyanocobalamin) NATACHEW ORAL TABLET CHEWABLE 28-1 MG NF (prenatal vit-fe fum-fe bisg-fa) NATALVIT ORAL TABLET (prenatal vit-fe fumarate-fa) NF NEEVO DHA ORAL CAPSULE 27-1.13 MG (prenat w/oa- NF fefum-methf-omegas) NEOKE BCAA4 ORAL POWDER (dietary management NF product) neoke bhb oral powder NF neonatal + dha oral 29-1 & 200 mg NF neonatal 19 oral tablet 1 mg NF neonatal complete oral tablet 27-1 mg, 29-1 mg NF neonatal fe oral tablet 90-1 mg NF NEONATAL PLUS ORAL TABLET 27-1 MG (prenatal vit- NF fe fumarate-fa) b complex-c-folic acid (Nephronex Oral Tablet) G NESTABS DHA ORAL 32-1 MG (prenat-w/oa-fe bisgly-fa- NF omega) NESTABS ONE ORAL CAPSULE 38-1-225 MG (prenat-fe- NF methylfol-dha w/o a) NESTABS ORAL TABLET 32-1 MG (prenat-fe bisgly-fa-w/o NF vit a) NICADAN ORAL TABLET (multiple vitamins-minerals) NF NICAPRIN ORAL TABLET (dietary management product) NF NICAZEL FORTE ORAL TABLET (multiple vitamins- NF minerals) NICAZEL ORAL TABLET (multiple vitamins-minerals) NF

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 195 Prescription Drug Name Drug Tier Drug Notes nicazyme oral tablet NF NICOMIDE ORAL TABLET 750-27-2-0.5 MG (niacinamide- NF zn-cu-methfo-se-cr) NIVA-PLUS ORAL TABLET 27-1 MG (prenatal vit-fe NF fumarate-fa) NOURISH ORAL LIQUID (nutritional supplements) NPB NUTRICAP ORAL TABLET (multiple vitamins-minerals) NPB multiple vitamins-minerals (Nutrifac Zx Oral Tablet) G NUTRIVIT ORAL LIQUID (b complex-lysine-min-fe-fa) NPB OB COMPLETE ONE ORAL CAPSULE 50-1-476 MG NF (prenat-fecbn-feaspgl-fa-fish) OB COMPLETE ORAL TABLET 50-1.25 MG (prenatal vit- NF iron carbonyl-fa) OB COMPLETE PETITE ORAL CAPSULE 35-5-1-200 MG NF (prenat-fecbn-feaspgl-fa-omega) OB COMPLETE PREMIER ORAL TABLET 30-20-1 MG NF (prenatal-fe cbn-fe asp gly-fa) OB COMPLETE/DHA ORAL CAPSULE 30-10-1-200 MG NF (prenat-fecbn-feaspgl-fa-omega) OBSTETRIX DHA ORAL 29-1 & 387 MG (prenatal-fecbn- NF fa-dss-omega 3) OBSTETRIX EC ORAL TABLET 29-1 MG (prenatal vit-dss- NF fe cbn-fa) OBSTETRIX ONE ORAL CAPSULE 38-1-225 MG (prenat- NF fe-methyl-dss-dha w/o a) O-CAL PRENATAL ORAL TABLET (prenatal vit-fe NF fumarate-fa) OCUVEL ORAL CAPSULE 0.5 MG (multiple vitamins- NF minerals-fa) OMEGAVEN INTRAVENOUS EMULSION 10 NF GM/100ML, 5 GM/50ML (fish oil triglyceride based) omnivex oral tablet NF one vite womens plus oral tablet 27-1 mg NF onevite oral tablet 1 mg NPB phytonadione injection solution 1 mg/0.5ml, 10 mg/ml G phytonadione oral tablet 5 mg G PKU EASY MICROTABS ORAL TABLET DELAYED NF RELEASE (nutritional supplements)

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 196 Prescription Drug Name Drug Tier Drug Notes PKU EASY ORAL TABLET (nutritional supplements) NF pnv prenatal plus multivitamin oral tablet 27-1 mg NPB pnv tabs 20-1 oral tablet 20-1 mg NF pnv tabs 29-1 oral tablet 29-1 mg NF pnv-dha oral capsule 27-0.6-0.4-300 mg G pnv-dha+docusate oral capsule 27-1.25-300 mg NF pnv-omega oral capsule 28-0.6-0.4-340 mg NF pnv-select oral tablet 27-0.6-0.4 mg G POLY-VI-FLOR ORAL SUSPENSION 0.25 MG/ML NPB (pediatric multivitamins-fl) POLY-VI-FLOR ORAL TABLET CHEWABLE 0.25 MG, NPB 0.5 MG, 1 MG (pediatric multivitamins-fl) POLY-VI-FLOR/IRON ORAL SUSPENSION 0.25-7 NPB MG/ML (ped multivitamins-fl-iron) POLY-VI-FLOR/IRON ORAL TABLET CHEWABLE 0.5- NPB 10 MG (ped multivitamins-fl-iron) pregen dha oral capsule 28-1-35 mg NF pregenna oral tablet 20-1 mg NF PREMESISRX ORAL TABLET 1 MG (prenatal ca-b6-b12- NF fa-ginger) prena 1 true oral 30-1.4 & 300 mg NF prena1 oral tablet chewable 1.4 mg NF prena1 pearl oral capsule extended release 30-1.4-200 mg NF prenaissance oral capsule 29-1.25-325 mg NF prenaissance plus oral capsule 28-1-250 mg NF prenara oral capsule 15-1 mg NF PRENATABS RX ORAL TABLET 29-1 MG (prenatal vit- G iron carbonyl-fa) prenatal 19 oral tablet NPB prenatal 19 oral tablet 29-1 mg NF prenatal 19 oral tablet chewable G prenatal 19 oral tablet chewable 29-1 mg NF prenatal oral tablet 27-1 mg NF prenatal plus iron oral tablet 29-1 mg NF prenatal plus oral tablet 27-1 mg NPB prenatal vitamin plus low iron oral tablet 27-1 mg NF

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 197 Prescription Drug Name Drug Tier Drug Notes PRENATAL-U ORAL CAPSULE 106.5-1 MG (prenatal w/o NF a vit-fe fum-fa) PRENATE AM ORAL TABLET 1 MG (prenatal ca-b6-b12- NF fa-ginger) PRENATE DHA ORAL CAPSULE 18-0.6-0.4-300 MG NF (prenat-feasp-meth-fa-dha w/o a) PRENATE ELITE ORAL TABLET 20-0.6-0.4 MG NF (prenatal-feaspgly-methylfol-fa) PRENATE ENHANCE ORAL CAPSULE 28-0.6-0.4-400 NF MG (prenat w/o a-fe-methfol-fa-dha) PRENATE ESSENTIAL ORAL CAPSULE 18-0.6-0.4-300 NF MG (prenat-feasp-meth-fa-dha w/o a) PRENATE MINI ORAL CAPSULE 18-0.6-0.4-350 MG NF (prenat-fecbn-feasp-meth-fa-dha) PRENATE ORAL TABLET CHEWABLE 0.6-0.4 MG NF (prenat mv-min-methylfolate-fa) PRENATE PIXIE ORAL CAPSULE 10-0.6-0.4-200 MG NF (prenat-feasp-meth-fa-dha w/o a) PRENATE RESTORE ORAL CAPSULE 27-0.6-0.4-400 NF MG (prenat w/o a-fe-methfol-fa-dha) PRENATRIX ORAL TABLET 27-1 MG (prenatal vit-fe NF fumarate-fa) PRENATRYL ORAL TABLET 27-1 MG (prenatal vit-fe NF fumarate-fa) prenatvite complete oral tablet 1 mg NF prenatvite plus oral tablet 1 mg NF prenatvite rx oral tablet 0.8 mg NF preplus oral tablet 27-1 mg NF pretab oral tablet 29-1 mg NF PRIMACARE ORAL CAPSULE 30-1-470 MG (pren-fe- NF meth-fa-omeg w/o a) PROVIDA OB ORAL CAPSULE 20-20-1.25 MG (prenat w/o NF a vit-fefum-fepo-fa) pyridoxine hcl injection solution 100 mg/ml NPB QUFLORA FE ORAL TABLET CHEWABLE 0.25 MG NF (multi vit-min-fluoride-fe-fa) QUFLORA FE PEDIATRIC ORAL LIQUID 0.25-9.5 NF MG/ML (ped multivitamins-fl-iron)

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 198 Prescription Drug Name Drug Tier Drug Notes QUFLORA GUMMIES ORAL TABLET CHEWABLE NF 0.125 MG (pediatric multivitamins-fl) QUFLORA PEDIATRIC ORAL SOLUTION 0.25 MG/ML, NPB 0.5 MG/ML (pediatric multivitamins-fl) QUFLORA PEDIATRIC ORAL TABLET CHEWABLE NPB 0.25 MG, 0.5 MG, 1 MG (pediatric multivitamins-fl) relnate dha oral capsule 28-1-200 mg NF REMEDIENT ORAL CAPSULE 1 MG (multiple vitamins- NF minerals-fa) RENATABS ORAL TABLET 1 MG (b complex-c-biotin-e-fa) NPB RENATABS WITH IRON ORAL 1 & 100 MG (b complex-c- NPB biotin-e-fa-fe cbn) reno caps oral capsule 1 mg G REQ 49+ ORAL TABLET (multiple vitamins-minerals) NPB RHEUMATE ORAL CAPSULE (dietary management NF product) ribozel oral capsule NF SELECT-OB ORAL TABLET CHEWABLE 29-0.6-0.4 MG NF (prenat vit-fepoly-methylfol-fa) SELECT-OB ORAL TABLET CHEWABLE 29-1 MG NF (prenatal vit-fe psac cmplx-fa) SELECT-OB+DHA ORAL 29-1 & 250 MG (prenatal vit- NF fepoly-fa-dha) se-natal 19 oral tablet 29-1 mg NF se-natal 19 oral tablet chewable 29-1 mg NF sm folic acid oral tablet 400 mcg CE sodium bicarbonate intravenous solution 7.5 %, 8.4 % NPB sodium fluoride oral solution 1.1 (0.5 f) mg/ml CE sodium fluoride oral tablet 1.1 (0.5 f) mg CE sodium fluoride oral tablet chewable 0.55 (0.25 f) mg, 1.1 (0.5 CE f) mg STROVITE FORTE ORAL SYRUP (multiple vitamins- NPB minerals-fa) SUPERVITE ORAL LIQUID (b complex-lysine-zn-fa) NPB TARON-C DHA ORAL CAPSULE 53.5-38-1 MG (prenat- NF fefum-fepo-fa-omega 3) TARON-PREX ORAL CAPSULE 30-1.2-265 MG (prenat- NF fefum-dss-fa-dha w/o a) 2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 199 Prescription Drug Name Drug Tier Drug Notes THERANATAL CORE NUTRITION ORAL TABLET 27-1 NPB MG (prenatal vit-fe fumarate-fa) thiamine hcl injection solution 100 mg/ml G thrivacin 30 oral liquid NPB thrivacin detox oral liquid NPB thrivite 19 oral tablet 1 mg NPB thrivite rx oral tablet 29-1 mg NF TOBAKIENT ORAL CAPSULE (dietary management NF product) tri-amino injection solution 100-100-100 mg/ml NF TRICARE ORAL TABLET (prenatal vit-fe fumarate-fa) NF TRICARE PRENATAL DHA ONE ORAL CAPSULE 27-1- NF 500 MG (prenatal-fefum-fa-dss-fish oil) trinatal rx 1 oral tablet 60-1 mg NF TRINATE ORAL TABLET (prenatal vit-fe fumarate-fa) G trinaz oral tablet 12-1 mg NF tristart dha oral capsule 31-0.6-0.4-200 mg NF TRISTART FREE ORAL CAPSULE 33-1 MG (prenat w/o NF a-fecbn-meth-fa-dha) TRISTART ONE ORAL CAPSULE 35-1-215 MG (prenat NF w/o a-fecbn-meth-fa-dha) TRIVEEN-DUO DHA ORAL 29-1-200 & 400 MG (prenat- NF febis-fepro-fa-ca-omega) TRI-VI-FLOR ORAL SUSPENSION 0.25 MG/ML, 0.5 NPB MG/ML (ped vit a-c-d-methylfolate-fl) tri-vi-floro oral suspension 0.25 mg/ml, 0.5 mg/ml NPB tri-vite/fluoride oral solution 0.25 mg/ml, 0.5 mg/ml G tronvite oral tablet 1 mg NF TYLACTIN COMPLETE 15 PE ORAL BAR (nutritional NPB supplements) TYR EASY ORAL TABLET (nutritional supplements) NF UDAMIN SP ORAL TABLET 1 MG (multiple vitamins- NPB minerals-fa) urosex oral tablet G VASCULERA ORAL TABLET (dietary management NF product) vb6 p5p oral powder NF

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 200 Prescription Drug Name Drug Tier Drug Notes v-c forte oral capsule G multiple vitamins-minerals (Vic-Forte Oral Capsule) G VINATE DHA RF ORAL CAPSULE 27-1.13 MG (prenat NF w/oa-fefum-methf-omegas) VINATE II ORAL TABLET 29-1 MG (prenatal vit w/ fe bisg- NF fa) VINATE ONE ORAL TABLET 60-1 MG (prenatal vit-fe NF fumarate-fa) virt-c dha oral capsule 53.5-38-1 mg NF virt-caps oral capsule 1 mg G virt-nate dha oral capsule 28-1-200 mg NF virt-pn dha oral capsule 27-0.6-0.4-300 mg NF virt-pn plus oral capsule 28-0.6-0.4-340 mg NF multiple vitamins-minerals (Vita S Forte Oral Tablet) G multiple vitamins-minerals (Vitacel Oral Tablet) G VITAFOL FE+ ORAL CAPSULE 90-0.6-0.4-200 MG NF (prenat-fe poly-methfol-fa-dha) VITAFOL GUMMIES ORAL TABLET CHEWABLE 3.33- NF 0.333-34.8 MG (prenatal vit-fe phos-fa-omega) VITAFOL STRIPS ORAL FILM 1 MG (prenatal-b6-b12-d3- NF folic acid) VITAFOL ULTRA ORAL CAPSULE 29-0.6-0.4-200 MG NF (prenat-fe poly-methfol-fa-dha) VITAFOL-NANO ORAL TABLET 18-0.6-0.4 MG (prenatal- NF fe fum-methf-fa w/o a) VITAFOL-OB ORAL TABLET (prenatal vit-fe fumarate-fa) NF VITAFOL-OB+DHA ORAL 65-1 & 250 MG (prenatal mv- NF min-fe fum-fa-dha) VITAFOL-ONE ORAL CAPSULE 29-1-200 MG (prenatal NF vit-fepoly-fa-dha) VITAMEDMD ONE RX/QUATREFOLIC ORAL CAPSULE 30-0.6-0.4-200 MG (prenat w/o a-fe-methfol-fa- NF dha) VITAMEDMD REDICHEW RX ORAL TABLET NF CHEWABLE 1.4 MG (prenat-b2-b6-b12-d3-fa) vitamin d (ergocalciferol) oral capsule 1.25 mg (50000 ut) G vitamin k1 injection solution 1 mg/0.5ml, 10 mg/ml G vita-min oral capsule G 2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 201 Prescription Drug Name Drug Tier Drug Notes vitamins acd-fluoride oral solution 0.25 mg/ml G VITAPEARL ORAL CAPSULE EXTENDED RELEASE NF 30-1.4-200 MG (prenat-fefum-fered-fa-dha w/oa) vitasure oral tablet 1 mg NF VITATHELY WITH GINGER ORAL TABLET 27-1 MG NF (prenatal vit-fe fumarate-fa) VITATRUE ORAL 30-1.4 & 300 MG (prenat-fechel-fa-dha NF w/o vit a) VIVA DHA ORAL CAPSULE 28-1-200 MG (prenatal vit-fe NF fum-fa-omega) vp-pnv-dha oral capsule 28-1-215.8 mg NF vp-vite rx oral tablet 1 mg G westab plus oral tablet 27-1 mg NF westgel dha oral capsule 31-0.6-0.4-200 mg NF wheat germ oil oral oil NPB XAQUIL XR ORAL TABLET EXTENDED RELEASE 30 NF MG (levomefolate glucosamine) xvite oral tablet 1 mg NF xyzbac oral tablet NF yl folic acid oral tablet 400 mcg CE zalvit oral tablet 13-1 mg NF ZATEAN-PN DHA ORAL CAPSULE 27-0.6-0.4-300 MG NF (prenat w/o a-fe-methfol-fa-dha) ZATEAN-PN PLUS ORAL CAPSULE 28-0.6-0.4-340 MG NF (prenat w/o a-fe-methf-fa-omega) zyvit oral tablet NF OPHTHALMIC - DRUGS TO TREAT EYE CONDITIONS ANTIALLERGICS - DRUGS TO TREAT ALLERGIES ALOCRIL OPHTHALMIC SOLUTION 2 % (nedocromil NPB sodium) ALOMIDE OPHTHALMIC SOLUTION 0.1 % (lodoxamide NPB tromethamine) azelastine hcl ophthalmic solution 0.05 % G BEPREVE OPHTHALMIC SOLUTION 1.5 % (bepotastine NF besilate) cromolyn sodium ophthalmic solution 4 % G epinastine hcl ophthalmic solution 0.05 % G

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 202 Prescription Drug Name Drug Tier Drug Notes LASTACAFT OPHTHALMIC SOLUTION 0.25 % NF (alcaftadine) olopatadine hcl ophthalmic solution 0.1 %, 0.2 % G ANTIGLAUCOMA - DRUGS TO TREAT GLAUCOMA ALPHAGAN P OPHTHALMIC SOLUTION 0.1 % PB (brimonidine tartrate) apraclonidine hcl ophthalmic solution 0.5 % G AZOPT OPHTHALMIC SUSPENSION 1 % (brinzolamide) NF betaxolol hcl ophthalmic solution 0.5 % G BETIMOL OPHTHALMIC SOLUTION 0.25 %, 0.5 % NF (timolol hemihydrate) BETOPTIC-S OPHTHALMIC SUSPENSION 0.25 % NF (betaxolol hcl) bimatoprost external solution 0.03 % NF bimatoprost ophthalmic solution 0.03 % NF brimonidine tartrate ophthalmic solution 0.15 %, 0.2 % G carteolol hcl ophthalmic solution 1 % G COMBIGAN OPHTHALMIC SOLUTION 0.2-0.5 % PB (brimonidine tartrate-timolol) COSOPT PF OPHTHALMIC SOLUTION 2-0.5 % NF (dorzolamide hcl-timolol mal) dorzolamide hcl ophthalmic solution 2 % NPB dorzolamide hcl-timolol mal ophthalmic solution 22.3-6.8 mg/ml G dorzolamide hcl-timolol mal pf ophthalmic solution 2-0.5 % G IOPIDINE OPHTHALMIC SOLUTION 1 % (apraclonidine NPB hcl) ISTALOL OPHTHALMIC SOLUTION 0.5 % (timolol NF maleate) latanoprost ophthalmic solution 0.005 % G levobunolol hcl ophthalmic solution 0.5 % G LUMIGAN OPHTHALMIC SOLUTION 0.01 % NF (bimatoprost) pilocarpine hcl ophthalmic solution 1 %, 2 %, 4 % G SIMBRINZA OPHTHALMIC SUSPENSION 1-0.2 % PB (brinzolamide-brimonidine) timolol maleate ophthalmic gel forming solution 0.25 %, 0.5 % G

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 203 Prescription Drug Name Drug Tier Drug Notes timolol maleate ophthalmic solution 0.25 %, 0.5 %, 0.5 % G (daily) TIMOPTIC OCUDOSE OPHTHALMIC SOLUTION 0.25 NF %, 0.5 % (timolol maleate) TRAVATAN Z OPHTHALMIC SOLUTION 0.004 % NF (travoprost) VYZULTA OPHTHALMIC SOLUTION 0.024 % NF (latanoprostene bunod) XELPROS OPHTHALMIC EMULSION 0.005 % NF (latanoprost) ZIOPTAN OPHTHALMIC SOLUTION 0.0015 % PB (tafluprost) ANTI-INFECTIVE/ANTI-INFLAMMATORY - DRUGS TO TREAT INFECTIONS AND INFLAMMATION bacitra-neomycin-polymyxin-hc ophthalmic ointment 1 % G BLEPHAMIDE OPHTHALMIC SUSPENSION 10-0.2 % NPB (sulfacetamide-prednisolone) BLEPHAMIDE S.O.P. OPHTHALMIC OINTMENT 10-0.2 NPB % (sulfacetamide-prednisolone) double pm ophthalmic solution reconstituted 1-0.5 % NF neomycin-polymyxin-dexameth ophthalmic ointment 3.5-10000- G 0.1 neomycin-polymyxin-dexameth ophthalmic suspension 3.5- G 10000-0.1 neomycin-polymyxin-hc ophthalmic suspension 3.5-10000-1 G bacitracin-polymyx-neo-hc (Neo-Polycin Hc Ophthalmic G Ointment 1 %) PRED-G OPHTHALMIC SUSPENSION 0.3-1 % NPB (gentamicin-prednisolone acet) PRED-G S.O.P. OPHTHALMIC OINTMENT 0.3-0.6 % NPB (gentamicin-prednisolone acet) prednisolone-gatifloxacin ophthalmic suspension 1-0.5 % NF sulfacetamide-prednisolone ophthalmic solution 10-0.23 % G TOBRADEX OPHTHALMIC OINTMENT 0.3-0.1 % NF (tobramycin-dexamethasone) TOBRADEX OPHTHALMIC SUSPENSION 0.3-0.1 % NF (tobramycin-dexamethasone) TOBRADEX ST OPHTHALMIC SUSPENSION 0.3-0.05 % NF (tobramycin-dexamethasone) 2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 204 Prescription Drug Name Drug Tier Drug Notes tobramycin-dexamethasone ophthalmic suspension 0.3-0.1 % G triple pmb ophthalmic solution reconstituted 1-0.5-0.09 % NF triple pmk ophthalmic solution reconstituted 1-0.5-0.5 % NF ZYLET OPHTHALMIC SUSPENSION 0.5-0.3 % NPB (loteprednol-tobramycin) ANTI-INFECTIVES - DRUGS TO TREAT INFECTIONS ak-poly-bac ophthalmic ointment 500-10000 unit/gm G AZASITE OPHTHALMIC SOLUTION 1 % (azithromycin) NF bacitracin ophthalmic ointment 500 unit/gm G bacitracin-polymyxin b ophthalmic ointment 500-10000 unit/gm G BESIVANCE OPHTHALMIC SUSPENSION 0.6 % NF (besifloxacin hcl) BETADINE OPHTHALMIC PREP OPHTHALMIC NPB SOLUTION 5 % (povidone-iodine) CILOXAN OPHTHALMIC OINTMENT 0.3 % NF (ciprofloxacin hcl) CILOXAN OPHTHALMIC SOLUTION 0.3 % NF (ciprofloxacin hcl) ciprofloxacin hcl ophthalmic solution 0.3 % G erythromycin ophthalmic ointment 5 mg/gm G gatifloxacin ophthalmic solution 0.5 % G GENTAK OPHTHALMIC OINTMENT 0.3 % (gentamicin G sulfate) gentamicin sulfate ophthalmic solution 0.3 % G levofloxacin ophthalmic solution 0.5 % G MITOSOL OPHTHALMIC KIT 0.2 MG (mitomycin) NPB MOXEZA OPHTHALMIC SOLUTION 0.5 % (moxifloxacin NPB hcl) moxifloxacin hcl ophthalmic solution 0.5 % G NATACYN OPHTHALMIC SUSPENSION 5 % NPB () neomycin-bacitracin zn-polymyx ophthalmic ointment 3.5-400- G 10000 , 5-400-10000 neomycin-polymyxin-gramicidin ophthalmic solution 1.75- G 10000-.025 neomycin-bacitracin zn-polymyx (Neo-Polycin Ophthalmic G Ointment 3.5-400-10000)

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 205 Prescription Drug Name Drug Tier Drug Notes ofloxacin ophthalmic solution 0.3 % G bacitracin-polymyxin b (Polycin Ophthalmic Ointment 500- G 10000 Unit/Gm) polymyxin b-trimethoprim ophthalmic solution 10000-0.1 G unit/ml-% povidone-iodine ophthalmic solution 5 % NPB sulfacetamide sodium ophthalmic ointment 10 % G sulfacetamide sodium ophthalmic solution 10 % G tobramycin ophthalmic solution 0.3 % G TOBREX OPHTHALMIC OINTMENT 0.3 % (tobramycin) NPB trifluridine ophthalmic solution 1 % G ZIRGAN OPHTHALMIC GEL 0.15 % (ganciclovir) NF ZYMAXID OPHTHALMIC SOLUTION 0.5 % NF (gatifloxacin) ANTI-INFLAMMATORIES - DRUGS TO TREAT INFLAMMATION ALREX OPHTHALMIC SUSPENSION 0.2 % (loteprednol NPB etabonate) bromfenac sodium (once-daily) ophthalmic solution 0.09 % G BROMSITE OPHTHALMIC SOLUTION 0.075 % NF (bromfenac sodium) dexamethasone sodium phosphate ophthalmic solution 0.1 % G DEXTENZA OPHTHALMIC INSERT 0.4 MG NF (dexamethasone) DEXYCU INTRAOCULAR SUSPENSION 9 % NF (dexamethasone) diclofenac sodium ophthalmic solution 0.1 % G DUREZOL OPHTHALMIC EMULSION 0.05 % PB (difluprednate) FLAREX OPHTHALMIC SUSPENSION 0.1 % NF (fluorometholone acetate) fluorometholone ophthalmic suspension 0.1 % G flurbiprofen sodium ophthalmic solution 0.03 % G FML FORTE OPHTHALMIC SUSPENSION 0.25 % NF (fluorometholone) FML LIQUIFILM OPHTHALMIC SUSPENSION 0.1 % NF (fluorometholone)

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 206 Prescription Drug Name Drug Tier Drug Notes FML OPHTHALMIC OINTMENT 0.1 % (fluorometholone) NF ILEVRO OPHTHALMIC SUSPENSION 0.3 % (nepafenac) NF INVELTYS OPHTHALMIC SUSPENSION 1 % (loteprednol NF etabonate) ketorolac tromethamine ophthalmic solution 0.4 %, 0.5 % G KLARITY-L OPHTHALMIC EMULSION 0.2 %, 0.5 % NF (loteprednol etabonate) LOTEMAX OPHTHALMIC GEL 0.5 % (loteprednol NF etabonate) LOTEMAX OPHTHALMIC OINTMENT 0.5 % (loteprednol NF etabonate) LOTEMAX OPHTHALMIC SUSPENSION 0.5 % NF (loteprednol etabonate) LOTEMAX SM OPHTHALMIC GEL 0.38 % (loteprednol NF etabonate) loteprednol etabonate ophthalmic suspension 0.5 % G MAXIDEX OPHTHALMIC SUSPENSION 0.1 % NF (dexamethasone) NEVANAC OPHTHALMIC SUSPENSION 0.1 % NF (nepafenac) OZURDEX INTRAVITREAL IMPLANT 0.7 MG NPSP (dexamethasone) PRED FORTE OPHTHALMIC SUSPENSION 1 % NF (prednisolone acetate) PRED MILD OPHTHALMIC SUSPENSION 0.12 % NF (prednisolone acetate) prednisolone acetate ophthalmic suspension 1 % G prednisolone acetate p-f ophthalmic suspension 1 % NF prednisolone sodium phosphate ophthalmic solution 1 % NPB PROLENSA OPHTHALMIC SOLUTION 0.07 % NF (bromfenac sodium) YUTIQ INTRAVITREAL IMPLANT 0.18 MG (fluocinolone NF acetonide) DRY EYE DISEASE XIIDRA OPHTHALMIC SOLUTION 5 % (lifitegrast) PB MISCELLANEOUS DUOVISC INTRAOCULAR KIT 0.85-0.5 ML (na hyalur & NPB na chond-na hyalur)

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 207 Prescription Drug Name Drug Tier Drug Notes HEALON DUET PRO INTRAOCULAR SOLUTION NPB PREFILLED SYRINGE 1 & 3 % (sodium hyaluronate) HEALON GV PRO INTRAOCULAR SOLUTION 18 NPB MG/ML (sodium hyaluronate) RHOPRESSA OPHTHALMIC SOLUTION 0.02 % PB (netarsudil dimesylate) ROCKLATAN OPHTHALMIC SOLUTION 0.02-0.005 % NF (netarsudil-latanoprost) RETINAL DISORDERS EYLEA INTRAVITREAL SOLUTION 2 MG/0.05ML PSP (aflibercept) EYLEA INTRAVITREAL SOLUTION PREFILLED PSP SYRINGE 2 MG/0.05ML (aflibercept) LUCENTIS INTRAVITREAL SOLUTION 0.3 PSP MG/0.05ML, 0.5 MG/0.05ML (ranibizumab) LUCENTIS INTRAVITREAL SOLUTION PREFILLED PSP SYRINGE 0.3 MG/0.05ML, 0.5 MG/0.05ML (ranibizumab) OTHER IRRIGATION SOLUTIONS water for irrigation, sterile (Argyle Sterile Water Irrigation G Solution) lactated ringers irrigation solution G irrigation solns physiological (Physiolyte Irrigation Solution) G irrigation solns physiological (Physiosol Irrigation Irrigation G Solution) ringers irrigation irrigation solution G sterile water for irrigation irrigation solution G ringers irrigation (Tis-U-Sol Irrigation Solution) G RESPIRATORY - DRUGS TO TREAT BREATHING DISORDERS ANAPHYLAXIS TREATMENT AGENTS ADRENALIN INJECTION SOLUTION 1 MG/ML, 30 NPB MG/30ML (epinephrine) ADYPHREN AMP II INJECTION KIT 1 MG/ML NF (epinephrine) ADYPHREN AMP INJECTION KIT 1 MG/ML NF (epinephrine) ADYPHREN II INJECTION KIT 1 MG/ML (epinephrine) NF

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 208 Prescription Drug Name Drug Tier Drug Notes ADYPHREN INJECTION KIT 1 MG/ML (epinephrine) NF AUVI-Q INJECTION SOLUTION AUTO-INJECTOR 0.1 NF MG/0.1ML, 0.15 MG/0.15ML, 0.3 MG/0.3ML (epinephrine) epinephrine injection solution auto-injector 0.15 mg/0.15ml, 0.15 G mg/0.3ml, 0.3 mg/0.3ml epinephrine intravenous solution 1 mg/10ml NPB epinephrine intravenous solution prefilled syringe 1 mg/10ml NPB epinephrine professional injection kit 1 mg/ml NF EPINEPHRINESNAP-EMS INJECTION KIT 1 MG/ML NF (epinephrine) EPINEPHRINESNAP-V INJECTION KIT 1 MG/ML NF (epinephrine) EPISNAP INJECTION KIT 1 MG/ML (epinephrine) NF SYMJEPI INJECTION SOLUTION PREFILLED PB SYRINGE 0.15 MG/0.3ML, 0.3 MG/0.3ML (epinephrine) ANTIALLERGICS - DRUGS TO TREAT ALLERGIES acetylcysteine inhalation solution 10 % G ANTICHOLINERGIC/BETA AGONIST COMBINATIONS - DRUGS TO TREAT COPD AIRDUO RESPICLICK 113/14 INHALATION AEROSOL POWDER BREATH ACTIVATED 113-14 MCG/ACT NF (fluticasone-salmeterol) AIRDUO RESPICLICK 232/14 INHALATION AEROSOL POWDER BREATH ACTIVATED 232-14 MCG/ACT NF (fluticasone-salmeterol) AIRDUO RESPICLICK 55/14 INHALATION AEROSOL POWDER BREATH ACTIVATED 55-14 MCG/ACT NF (fluticasone-salmeterol) ANORO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 62.5-25 MCG/INH (umeclidinium- PB vilanterol) BEVESPI AEROSPHERE INHALATION AEROSOL 9-4.8 NF MCG/ACT (glycopyrrolate-formoterol) BREZTRI AEROSPHERE INHALATION AEROSOL 160- NPB 9-4.8 MCG/ACT (budeson-glycopyrrol-formoterol) COMBIVENT RESPIMAT INHALATION AEROSOL NPB SOLUTION 20-100 MCG/ACT (ipratropium-albuterol)

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 209 Prescription Drug Name Drug Tier Drug Notes DULERA INHALATION AEROSOL 100-5 MCG/ACT, 200-5 MCG/ACT, 50-5 MCG/ACT (mometasone furo- NF formoterol fum) fluticasone-salmeterol inhalation aerosol powder breath NF activated 113-14 mcg/act, 232-14 mcg/act, 55-14 mcg/act ipratropium-albuterol inhalation solution 0.5-2.5 (3) mg/3ml G STIOLTO RESPIMAT INHALATION AEROSOL SOLUTION 2.5-2.5 MCG/ACT (tiotropium bromide- PB olodaterol) TRELEGY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100-62.5-25 MCG/INH, PB 200-62.5-25 MCG/INH (fluticasone-umeclidin-vilant) ANTICHOLINERGICS - DRUGS TO TREAT COPD ATROVENT HFA INHALATION AEROSOL SOLUTION NF 17 MCG/ACT (ipratropium bromide hfa) INCRUSE ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 62.5 MCG/INH (umeclidinium NF bromide) ipratropium bromide inhalation solution 0.02 % G ipratropium bromide nasal solution 0.03 %, 0.06 % G LONHALA MAGNAIR REFILL KIT INHALATION NF SOLUTION 25 MCG/ML (glycopyrrolate) LONHALA MAGNAIR STARTER KIT INHALATION NF SOLUTION 25 MCG/ML (glycopyrrolate) SPIRIVA HANDIHALER INHALATION CAPSULE 18 PB MCG (tiotropium bromide monohydrate) SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 1.25 MCG/ACT, 2.5 MCG/ACT (tiotropium PB bromide monohydrate) TUDORZA PRESSAIR INHALATION AEROSOL POWDER BREATH ACTIVATED 400 MCG/ACT NF (aclidinium bromide) YUPELRI INHALATION SOLUTION 175 MCG/3ML PB (revefenacin) ANTIHISTAMINE COMBINATIONS DERMACINRX AZENASE PAK NASAL THERAPY NF PACK 137 & 50 MCG/ACT (azelastine-fluticasone) DYMISTA NASAL SUSPENSION 137-50 MCG/ACT PB (azelastine-fluticasone)

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 210 Prescription Drug Name Drug Tier Drug Notes ANTIHISTAMINES - DRUGS TO TREAT ALLERGIES azelastine hcl nasal solution 0.15 %, 137 mcg/spray G carbinoxamine maleate oral solution 4 mg/5ml G carbinoxamine maleate oral tablet 4 mg G carbinoxamine maleate oral tablet 6 mg NF cetirizine hcl oral solution 1 mg/ml G clemastine fumarate oral tablet 2.68 mg G cyproheptadine hcl oral syrup 2 mg/5ml G cyproheptadine hcl oral tablet 4 mg G desloratadine oral tablet 5 mg G desloratadine oral tablet dispersible 2.5 mg, 5 mg G dexchlorpheniramine maleate oral solution 2 mg/5ml NF diphen oral elixir 12.5 mg/5ml NF diphenhydramine hcl oral elixir 12.5 mg/5ml G hydroxyzine hcl oral syrup 10 mg/5ml G hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg G hydroxyzine pamoate oral capsule 100 mg, 25 mg, 50 mg G KARBINAL ER ORAL SUSPENSION EXTENDED NPB RELEASE 4 MG/5ML (carbinoxamine maleate) levocetirizine dihydrochloride oral solution 2.5 mg/5ml G levocetirizine dihydrochloride oral tablet 5 mg G olopatadine hcl nasal solution 0.6 % G RYCLORA ORAL SOLUTION 2 MG/5ML NF (dexchlorpheniramine maleate) RYVENT ORAL TABLET 6 MG (carbinoxamine maleate) G BETA AGONISTS - DRUGS TO TREAT ASTHMA AND COPD albuterol sulfate hfa inhalation aerosol solution 108 (90 base) G mcg/act albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) G 0.083%, 0.63 mg/3ml, 1.25 mg/3ml, 2.5 mg/0.5ml albuterol sulfate oral syrup 2 mg/5ml G albuterol sulfate oral tablet 2 mg, 4 mg G BROVANA INHALATION NEBULIZATION SOLUTION NF 15 MCG/2ML (arformoterol tartrate)

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 211 Prescription Drug Name Drug Tier Drug Notes levalbuterol hcl inhalation nebulization solution 0.31 mg/3ml, G 0.63 mg/3ml, 1.25 mg/0.5ml, 1.25 mg/3ml levalbuterol tartrate inhalation aerosol 45 mcg/act G PERFOROMIST INHALATION NEBULIZATION PB SOLUTION 20 MCG/2ML (formoterol fumarate) PROAIR DIGIHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 108 (90 BASE) NF MCG/ACT (albuterol sulfate) PROAIR HFA INHALATION AEROSOL SOLUTION 108 NPB (90 BASE) MCG/ACT (albuterol sulfate) PROAIR RESPICLICK INHALATION AEROSOL POWDER BREATH ACTIVATED 108 (90 BASE) NPB MCG/ACT (albuterol sulfate) PROVENTIL HFA INHALATION AEROSOL SOLUTION NF 108 (90 BASE) MCG/ACT (albuterol sulfate) SEREVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 50 MCG/DOSE NF (salmeterol xinafoate) STRIVERDI RESPIMAT INHALATION AEROSOL PB SOLUTION 2.5 MCG/ACT (olodaterol hcl) terbutaline sulfate oral tablet 2.5 mg, 5 mg G VENTOLIN HFA INHALATION AEROSOL SOLUTION NF 108 (90 BASE) MCG/ACT (albuterol sulfate) XOPENEX HFA INHALATION AEROSOL 45 MCG/ACT NF (levalbuterol tartrate) BIOLOGIC RESPONSE MODIFIERS FASENRA PEN SUBCUTANEOUS SOLUTION AUTO- PSP INJECTOR 30 MG/ML (benralizumab) FASENRA SUBCUTANEOUS SOLUTION PREFILLED PSP SYRINGE 30 MG/ML (benralizumab) NUCALA SUBCUTANEOUS SOLUTION PSP RECONSTITUTED 100 MG (mepolizumab) XOLAIR SUBCUTANEOUS SOLUTION PREFILLED PSP SYRINGE 150 MG/ML, 75 MG/0.5ML (omalizumab) XOLAIR SUBCUTANEOUS SOLUTION PSP RECONSTITUTED 150 MG (omalizumab) COLD/COUGH benzonatate oral capsule 100 mg, 200 mg G

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 212 Prescription Drug Name Drug Tier Drug Notes CLARINEX-D 12 HOUR ORAL TABLET EXTENDED RELEASE 12 HOUR 2.5-120 MG (desloratadine- NPB pseudoephedrine) g tussin ac oral solution 100-10 mg/5ml G GILPHEX TR ORAL TABLET 10-388 MG (phenylephrine- NPB guaifenesin) guaiatussin ac oral syrup 100-10 mg/5ml G guaifenesin-codeine oral solution 100-10 mg/5ml G hydrocod polst-cpm polst er oral suspension extended release 10- G 8 mg/5ml hydrocodone-homatropine oral syrup 5-1.5 mg/5ml G hydrocodone-homatropine oral tablet 5-1.5 mg G hydromet oral syrup 5-1.5 mg/5ml G promethazine-codeine oral solution 6.25-10 mg/5ml G promethazine-codeine oral syrup 6.25-10 mg/5ml G promethazine-dm oral syrup 6.25-15 mg/5ml G promethazine-phenyleph-codeine oral syrup 6.25-5-10 mg/5ml G promethazine-phenylephrine oral syrup 6.25-5 mg/5ml G pseudoeph-bromphen-dm oral syrup 30-2-10 mg/5ml G TUSNEL C ORAL SYRUP 30-10-100 MG/5ML NPB (pseudoephedrine-codeine-gg) TUSSICAPS ORAL CAPSULE EXTENDED RELEASE 12 NPB HOUR 10-8 MG (hydrocod polst-chlorphen polst) TUXARIN ER ORAL TABLET EXTENDED RELEASE NF 12 HOUR 54.3-8 MG (chlorpheniramine-codeine) TUZISTRA XR ORAL SUSPENSION EXTENDED NF RELEASE 14.7-2.8 MG/5ML (codeine polst-chlorphen polst) virtussin a/c oral solution 100-10 mg/5ml G virtussin dac oral solution 30-10-100 mg/5ml G LEUKOTRIENE MODIFIERS zileuton er oral tablet extended release 12 hour 600 mg NF ZYFLO ORAL TABLET 600 MG (zileuton) NPB LEUKOTRIENE RECEPTOR ANTAGONISTS - DRUGS TO TREAT ASTHMA AND ALLERGIES montelukast sodium oral packet 4 mg G montelukast sodium oral tablet 10 mg G montelukast sodium oral tablet chewable 4 mg, 5 mg G 2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 213 Prescription Drug Name Drug Tier Drug Notes SINGULAIR ORAL PACKET 4 MG (montelukast sodium) NF SINGULAIR ORAL TABLET 10 MG (montelukast sodium) NF SINGULAIR ORAL TABLET CHEWABLE 4 MG, 5 MG NF (montelukast sodium) zafirlukast oral tablet 10 mg, 20 mg G MAST CELL STABILIZERS - DRUGS TO TREAT ALLERGIES cromolyn sodium inhalation nebulization solution 20 mg/2ml G MISCELLANEOUS acetylcysteine inhalation solution 20 % G ADRENALIN NASAL SOLUTION 0.1 % (epinephrine hcl NPB (nasal)) AKOVAZ INTRAVENOUS SOLUTION 50 MG/ML NF (ephedrine sulfate (pressors)) ARALAST NP INTRAVENOUS SOLUTION RECONSTITUTED 1000 MG, 500 MG (alpha1-proteinase NF inhibitor) CUROSURF INTRATRACHEAL SUSPENSION 120 NPB MG/1.5ML, 240 MG/3ML (poractant alfa) DALIRESP ORAL TABLET 250 MCG, 500 MCG PB (roflumilast) epinephrine intravenous solution prefilled syringe 0.1 mg/10ml NPB ESBRIET ORAL CAPSULE 267 MG (pirfenidone) PSP ESBRIET ORAL TABLET 267 MG, 801 MG (pirfenidone) PSP GIAPREZA INTRAVENOUS SOLUTION 2.5 MG/ML NF (angiotensin ii acetate) GLASSIA INTRAVENOUS SOLUTION 1000 MG/50ML NF (alpha1-proteinase inhibitor) HYPERSAL INHALATION NEBULIZATION NPB SOLUTION 3.5 % (sodium chloride) INFASURF INTRATRACHEAL SUSPENSION 35-0.9 NPB MG/ML-% (calfactant in nacl) KALYDECO ORAL PACKET 25 MG, 50 MG, 75 MG NPB (ivacaftor) ORKAMBI ORAL PACKET 100-125 MG, 150-188 MG NPB (lumacaftor-ivacaftor) ORKAMBI ORAL TABLET 100-125 MG, 200-125 MG NPB (lumacaftor-ivacaftor)

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 214 Prescription Drug Name Drug Tier Drug Notes phenylephrine hcl (pressors) intravenous solution 0.8 mg/10ml NPB phenylephrine hcl intravenous solution 1 mg/10ml NPB PROLASTIN-C INTRAVENOUS SOLUTION 1000 PSP MG/20ML (alpha1-proteinase inhibitor) PROLASTIN-C INTRAVENOUS SOLUTION PSP RECONSTITUTED 1000 MG (alpha1-proteinase inhibitor) sodium chloride inhalation nebulization solution 0.9 %, 10 %, 3 G %, 7 % SURVANTA INTRATRACHEAL SUSPENSION 25-0.9 NPB MG/ML-% (beractant in nacl) SYMDEKO ORAL TABLET THERAPY PACK 100-150 & NPB 150 MG, 50-75 & 75 MG (tezacaftor-ivacaftor) TRIKAFTA ORAL TABLET THERAPY PACK 100-50-75 & 150 MG, 50-25-37.5 & 75 MG (elexacaftor-tezacaftor- NPB ivacaft) ZEMAIRA INTRAVENOUS SOLUTION NF RECONSTITUTED 1000 MG (alpha1-proteinase inhibitor) NASAL STEROIDS - DRUGS TO TREAT ALLERGIES BECONASE AQ NASAL SUSPENSION 42 MCG/SPRAY NF (beclomethasone diprop monohyd) flunisolide nasal solution 25 mcg/act (0.025%) G fluticasone propionate nasal suspension 50 mcg/act G mometasone furoate nasal suspension 50 mcg/act G OMNARIS NASAL SUSPENSION 50 MCG/ACT NF (ciclesonide) QNASL CHILDRENS NASAL AEROSOL SOLUTION 40 NF MCG/ACT (beclomethasone diprop (nasal)) QNASL NASAL AEROSOL SOLUTION 80 MCG/ACT NF (beclomethasone diprop (nasal)) SINUVA NASAL IMPLANT 1350 MCG (mometasone NF furoate) XHANCE NASAL EXHALER SUSPENSION 93 NPB MCG/ACT (fluticasone propionate) ZETONNA NASAL AEROSOL SOLUTION 37 MCG/ACT NF (ciclesonide) PULMONARY FIBROSIS AGENTS OFEV ORAL CAPSULE 100 MG, 150 MG (nintedanib PSP esylate)

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 215 Prescription Drug Name Drug Tier Drug Notes SEVERE ASTHMA AGENTS DUPIXENT SOLUTION PEN-INJECTOR 200 MG/1.14ML SUBCUTANEOUS 200 MG/1.14ML PSP (dupilumab) DUPIXENT SOLUTION PEN-INJECTOR 300 MG/2ML PSP SUBCUTANEOUS 300 MG/2ML (dupilumab) DUPIXENT SOLUTION PREFILLED SYRINGE 200 MG/1.14ML SUBCUTANEOUS 200 MG/1.14ML PSP (dupilumab) DUPIXENT SOLUTION PREFILLED SYRINGE 300 PSP MG/2ML SUBCUTANEOUS 300 MG/2ML (dupilumab) STEROID INHALANTS - DRUGS TO TREAT ASTHMA ALVESCO INHALATION AEROSOL SOLUTION 160 NF MCG/ACT, 80 MCG/ACT (ciclesonide) ARNUITY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/ACT, 200 PB MCG/ACT, 50 MCG/ACT (fluticasone furoate) ASMANEX (120 METERED DOSES) INHALATION AEROSOL POWDER BREATH ACTIVATED 220 NPB MCG/INH (mometasone furoate) ASMANEX (14 METERED DOSES) INHALATION AEROSOL POWDER BREATH ACTIVATED 220 NPB MCG/INH (mometasone furoate) ASMANEX (30 METERED DOSES) INHALATION AEROSOL POWDER BREATH ACTIVATED 110 NPB MCG/INH, 220 MCG/INH (mometasone furoate) ASMANEX (60 METERED DOSES) INHALATION AEROSOL POWDER BREATH ACTIVATED 220 NPB MCG/INH (mometasone furoate) ASMANEX (7 METERED DOSES) INHALATION AEROSOL POWDER BREATH ACTIVATED 110 NPB MCG/INH (mometasone furoate) ASMANEX HFA INHALATION AEROSOL 100 NPB MCG/ACT, 200 MCG/ACT (mometasone furoate) ASMANEX HFA INHALATION AEROSOL 50 NF MCG/ACT (mometasone furoate) budesonide inhalation suspension 0.25 mg/2ml, 0.5 mg/2ml, 1 G mg/2ml

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 216 Prescription Drug Name Drug Tier Drug Notes FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/BLIST, 250 PB MCG/BLIST, 50 MCG/BLIST (fluticasone propionate (inhal)) FLOVENT HFA INHALATION AEROSOL 110 MCG/ACT, 220 MCG/ACT, 44 MCG/ACT (fluticasone PB propionate hfa) PULMICORT FLEXHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 180 MCG/ACT, 90 PB MCG/ACT (budesonide) PULMICORT INHALATION SUSPENSION 0.25 NF MG/2ML, 0.5 MG/2ML, 1 MG/2ML (budesonide) PULMOZYME INHALATION SOLUTION 1 MG/ML NPSP (dornase alfa) QVAR REDIHALER INHALATION AEROSOL BREATH ACTIVATED 40 MCG/ACT, 80 MCG/ACT (beclomethasone PB diprop hfa) STEROID/BETA-AGONIST COMBINATIONS - DRUGS TO TREAT ASTHMA AND COPD ADVAIR HFA INHALATION AEROSOL 115-21 N8 (Listing does not include MCG/ACT, 230-21 MCG/ACT, 45-21 MCG/ACT PB certain NDCs) (fluticasone-salmeterol) BREO ELLIPTA INHALATION AEROSOL POWDER N8 (Listing does not include BREATH ACTIVATED 100-25 MCG/INH, 200-25 PB certain NDCs) MCG/INH (fluticasone furoate-vilanterol) SYMBICORT INHALATION AEROSOL 160-4.5 MCG/ACT, 80-4.5 MCG/ACT (budesonide-formoterol PB fumarate) XANTHINES - DRUGS TO TREAT COPD ELIXOPHYLLIN ORAL ELIXIR 80 MG/15ML NPB (theophylline) THEO-24 ORAL CAPSULE EXTENDED RELEASE 24 NF HOUR 100 MG, 200 MG, 300 MG, 400 MG (theophylline) theophylline er oral tablet extended release 12 hour 300 mg, 450 G mg theophylline er oral tablet extended release 24 hour 400 mg, 600 G mg theophylline oral solution 80 mg/15ml G

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 217 Prescription Drug Name Drug Tier Drug Notes TOPICAL - DRUGS TO TREAT EAR AND SKIN CONDITIONS DERMATOLOGY, ACNE ABSORICA ORAL CAPSULE 10 MG, 20 MG, 25 MG, 30 NPB MG, 35 MG, 40 MG (isotretinoin) ACANYA EXTERNAL GEL 1.2-2.5 % (clindamycin phos- NF benzoyl perox) ACZONE EXTERNAL GEL 7.5 % (dapsone) NPB adapalene external cream 0.1 % G adapalene external gel 0.1 %, 0.3 % G adapalene external pad 0.1 % NF adapalene-benzoyl peroxide external gel 0.1-2.5 % G ALTRENO EXTERNAL LOTION 0.05 % (tretinoin) NF isotretinoin (Amnesteem Oral Capsule 10 Mg, 20 Mg, 40 Mg) G ARAZLO EXTERNAL LOTION 0.045 % (tazarotene) NPB ATRALIN EXTERNAL GEL 0.05 % (tretinoin) NF tretinoin (Avita External Cream 0.025 %) G tretinoin (Avita External Gel 0.025 %) G AZELEX EXTERNAL CREAM 20 % (azelaic acid) NF BENZACLIN EXTERNAL GEL 1-5 % (clindamycin phos- NF benzoyl perox) BENZACLIN WITH PUMP EXTERNAL GEL 1-5 % NF (clindamycin phos-benzoyl perox) benzoyl peroxide (Benzepro External Foam 5.3 %) G benzoyl peroxide (Benzepro Short Contact External Foam 9.8 G %) benzoyl perox-hydrocortisone external lotion 5-0.5 % G benzoyl peroxide external foam 9.8 % G benzoyl peroxide-erythromycin external gel 5-3 % G bp wash external liquid 2.5 %, 7 % G isotretinoin (Claravis Oral Capsule 10 Mg, 20 Mg, 30 Mg, 40 G Mg) clindamycin phosphate (Clindacin Etz External Swab 1 %) G clindamycin phosphate (Clindacin-P External Swab 1 %) G CLINDAGEL EXTERNAL GEL 1 % (clindamycin NF phosphate)

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 218 Prescription Drug Name Drug Tier Drug Notes clindamycin phos-benzoyl perox external gel 1-5 %, 1.2-2.5 %, G 1.2-5 % clindamycin phosphate external foam 1 % G clindamycin phosphate external gel 1 % NF clindamycin phosphate external lotion 1 % G clindamycin phosphate external solution 1 % G clindamycin phosphate external swab 1 % G clindamycin-tretinoin external gel 1.2-0.025 % G CLINOIN EXTERNAL CREAM 1.25-0.025-1 % NF (clindamycin-tretinoin-cholesty) dapsone external gel 5 % G DIFFERIN EXTERNAL LOTION 0.1 % (adapalene) NF EPIDUO FORTE EXTERNAL GEL 0.3-2.5 % (adapalene- PB benzoyl peroxide) ery external pad 2 % G erythromycin external gel 2 % G erythromycin external solution 2 % G FABIOR EXTERNAL FOAM 0.1 % (tazarotene) NF isotretinoin oral capsule 10 mg, 20 mg, 30 mg, 40 mg G isotretinoin (Myorisan Oral Capsule 10 Mg, 20 Mg, 30 Mg, 40 G Mg) clindamycin-benzoyl per (refr) (Neuac External Gel 1.2-5 %) G NEUAC EXTERNAL KIT 1.2-5 % (clindamycin-benzoyl per- NF moist) NUCARACLINPAK EXTERNAL KIT 1 % (clindamycin NF phos- moisturizer) NUCARARXPAK EXTERNAL KIT 1-2.5 % (clindamycin- NF benzoyl per-moist) ONEXTON EXTERNAL GEL 1.2-3.75 % (clindamycin phos- PB benzoyl perox) PR BENZOYL PEROXIDE EXTERNAL LIQUID 6.9 % NPB (benzoyl peroxide) benzoyl peroxide (Pr Benzoyl Peroxide Wash External Liquid 7 G %) resorcinol-sulfur external lotion 2-5 % G RETIN-A MICRO EXTERNAL GEL 0.04 %, 0.1 % NPB (tretinoin microsphere)

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 219 Prescription Drug Name Drug Tier Drug Notes RETIN-A MICRO PUMP EXTERNAL GEL 0.04 %, 0.06 NPB %, 0.08 %, 0.1 % (tretinoin microsphere) RIAX EXTERNAL FOAM 5.5 %, 9.5 % (benzoyl peroxide) NPB sodium sulfacetamide-bakuchiol external liquid 10 % NPB sulfacetamide sodium (acne) external lotion 10 % G sulfacetamide sodium-sulfur external pad 10-4 % G sulfamez wash external emulsion 10-1 % G tretinoin external cream 0.025 %, 0.05 %, 0.1 % G tretinoin external gel 0.01 %, 0.025 %, 0.05 % G tretinoin microsphere external gel 0.04 %, 0.1 % G tretinoin microsphere pump external gel 0.04 % G benzoyl perox-hydrocortisone (Vanoxide-Hc External Lotion 5- NF 0.5 %) VELTIN EXTERNAL GEL 1.2-0.025 % (clindamycin- NF tretinoin) zaclir cleansing external lotion 8 % NPB isotretinoin (Zenatane Oral Capsule 10 Mg, 20 Mg, 30 Mg, 40 G Mg) ZIANA EXTERNAL GEL 1.2-0.025 % (clindamycin- NF tretinoin) DERMATOLOGY, ACTINIC KERATOSIS CARAC EXTERNAL CREAM 0.5 % (fluorouracil) NF FLUOROPLEX EXTERNAL CREAM 1 % (fluorouracil) NF fluorouracil external cream 0.5 % NF fluorouracil external cream 5 % G fluorouracil external solution 2 %, 5 % G imiquimod external cream 5 % G imiquimod pump external cream 3.75 % G ZYCLARA EXTERNAL CREAM 3.75 % (imiquimod) NF ZYCLARA PUMP EXTERNAL CREAM 2.5 % (imiquimod) NF DERMATOLOGY, ANTIBIOTICS ALTABAX EXTERNAL OINTMENT 1 % (retapamulin) NPB CENTANY EXTERNAL OINTMENT 2 % (mupirocin) NPB gentamicin sulfate external cream 0.1 % G gentamicin sulfate external ointment 0.1 % G mafenide acetate external packet 5 % G 2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 220 Prescription Drug Name Drug Tier Drug Notes mupirocin calcium external cream 2 % NF mupirocin external ointment 2 % G NEO-SYNALAR EXTERNAL CREAM 0.5-0.025 % NF (neomycin-fluocinolone) NEO-SYNALAR EXTERNAL KIT 0.5-0.025 % (neo- NF fluocinolone & emollient) silver sulfadiazine external cream 1 % G silver sulfadiazine (Ssd External Cream 1 %) G SULFAMYLON EXTERNAL CREAM 85 MG/GM NPB (mafenide acetate) XEPI EXTERNAL CREAM 1 % (ozenoxacin) NPB DERMATOLOGY, ANTIFUNGALS ALA-QUIN EXTERNAL CREAM 3-0.5 % (clioquinol-hc) NF ALCORTIN A EXTERNAL GEL 1-2-1 % (iodoquinol-hc- NF aloe polysacch) (Ciclodan External Solution 8 %) G ciclopirox external gel 0.77 % G ciclopirox external shampoo 1 % G ciclopirox external solution 8 % G ciclopirox olamine external cream 0.77 % G ciclopirox olamine external suspension 0.77 % G external cream 1 % G clotrimazole external solution 1 % G clotrimazole-betamethasone external cream 1-0.05 % G clotrimazole-betamethasone external lotion 1-0.05 % G DERMACINRX THERAZOLE PAK EXTERNAL THERAPY PACK 1-0.05 & 20 % (clotrimazole-betameth & zn NF ox) nitrate external cream 1 % G ECOZA EXTERNAL FOAM 1 % (econazole nitrate) NF ERTACZO EXTERNAL CREAM 2 % ( nitrate) NF EXELDERM EXTERNAL CREAM 1 % ( NPB nitrate) EXELDERM EXTERNAL SOLUTION 1 % (sulconazole NPB nitrate) EXTINA EXTERNAL FOAM 2 % (ketoconazole) NPB

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 221 Prescription Drug Name Drug Tier Drug Notes fungimez external solution NF g-myco nail external solution NF JUBLIA EXTERNAL SOLUTION 10 % () NF ketoconazole external cream 2 % G ketoconazole external foam 2 % NF ketoconazole (Ketodan External Foam 2 %) NF LOPROX EXTERNAL CREAM 0.77 % (ciclopirox olamine) NF LOPROX EXTERNAL KIT 0.77 % (SUSP) (ciclopirox NF olamine-cleanser) LOPROX EXTERNAL SUSPENSION 0.77 % (ciclopirox NF olamine) external cream 1 % NF LUZU EXTERNAL CREAM 1 % (luliconazole) NF MENTAX EXTERNAL CREAM 1 % ( hcl) NPB miconazole-zinc oxide-petrolat external ointment 0.25-15-81.35 G % MYCO NAIL EXTERNAL SOLUTION , 25 % (misc NF combo products) hcl external cream 1 %, 2 % G NAFTIN EXTERNAL GEL 1 %, 2 % (naftifine hcl) NF nystatin (Nyamyc External Powder 100000 Unit/Gm) G nystatin external cream 100000 unit/gm G nystatin external ointment 100000 unit/gm G nystatin external powder 100000 unit/gm G nystatin-triamcinolone external cream 100000-0.1 unit/gm-% G nystatin-triamcinolone external ointment 100000-0.1 unit/gm-% G nystatin (Nystop External Powder 100000 Unit/Gm) G nitrate external cream 1 % NF OXISTAT EXTERNAL CREAM 1 % (oxiconazole nitrate) NF OXISTAT EXTERNAL LOTION 1 % (oxiconazole nitrate) NF QUINJA EXTERNAL GEL 1.25-1 % (iodoquinol-aloe NF polysaccharide) RECURA EXTERNAL CREAM (misc antifungal combo NF products) VUSION EXTERNAL OINTMENT 0.25-15-81.35 % NF (miconazole-zinc oxide-petrolat)

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 222 Prescription Drug Name Drug Tier Drug Notes XOLEGEL COREPAK EXTERNAL KIT 2 & 1 % NF (ketoconazole-hydrocortisone) XOLEGEL DUO/HEAD & SHOULDERS EXTERNAL NF KIT 2 & 1 % (ketoconazole & pyrithione zinc) XOLEGEL DUO/XOLEX EXTERNAL KIT 2 & 1 % NF (ketoconazole & pyrithione zinc) XOLEGEL EXTERNAL GEL 2 % (ketoconazole) NF DERMATOLOGY, ANTIPRURITIC doxepin hcl external cream 5 % NF DERMATOLOGY, ANTIPSORIATICS acitretin oral capsule 10 mg, 17.5 mg, 25 mg G calcipotriene external cream 0.005 % NF calcipotriene external ointment 0.005 % G calcipotriene external solution 0.005 % G calcipotriene (Calcitrene External Ointment 0.005 %) G calcitriol external ointment 3 mcg/gm NF IBC (Preferred agent for COSENTYX (300 MG DOSE) SUBCUTANEOUS Ankylosing Spondylitis and SOLUTION PREFILLED SYRINGE 150 MG/ML PSP Psoriatic Arthritis. Not (secukinumab) covered for Psoriasis) IBC (Preferred agent for COSENTYX SENSOREADY (300 MG) SUBCUTANEOUS Ankylosing Spondylitis and PSP SOLUTION AUTO-INJECTOR 150 MG/ML (secukinumab) Psoriatic Arthritis. Not covered for Psoriasis) IBC (Preferred agent for COSENTYX SENSOREADY PEN SUBCUTANEOUS Ankylosing Spondylitis and PSP SOLUTION AUTO-INJECTOR 150 MG/ML (secukinumab) Psoriatic Arthritis. Not covered for Psoriasis.) IBC (Preferred agent for COSENTYX SUBCUTANEOUS SOLUTION PREFILLED Ankylosing Spondylitis and PSP SYRINGE 150 MG/ML (secukinumab) Psoriatic Arthritis. Not covered for Psoriasis) COSENTYX SUBCUTANEOUS SOLUTION PREFILLED PSP SYRINGE 75 MG/0.5ML (secukinumab) ILUMYA SUBCUTANEOUS SOLUTION PREFILLED NF SYRINGE 100 MG/ML (tildrakizumab-asmn) methoxsalen rapid oral capsule 10 mg G NUDERMRXPAK 120 EXTERNAL THERAPY PACK NF 0.005-5 % (calcipotriene-dimethicone) 2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 223 Prescription Drug Name Drug Tier Drug Notes NUDERMRXPAK 60 EXTERNAL THERAPY PACK NF 0.005-5 % (calcipotriene-dimethicone) SILIQ SUBCUTANEOUS SOLUTION PREFILLED NF SYRINGE 210 MG/1.5ML (brodalumab) SORIATANE ORAL CAPSULE 10 MG, 25 MG (acitretin) NPB SORILUX EXTERNAL FOAM 0.005 % (calcipotriene) NF tazarotene external cream 0.1 % G TAZORAC EXTERNAL CREAM 0.05 %, 0.1 % (tazarotene) NF TAZORAC EXTERNAL GEL 0.05 %, 0.1 % (tazarotene) NF VECTICAL EXTERNAL OINTMENT 3 MCG/GM NF (calcitriol) DERMATOLOGY, ANTISEBORRHEICS ESKATA EXTERNAL SOLUTION 40 % (hydrogen NF peroxide) glycolic acid solution 70 % NPB ketoconazole external shampoo 2 % G NUTRASEB EXTERNAL CREAM (antiseborrheic products, NPB misc.) OVACE PLUS EXTERNAL FOAM 9.8 % (sulfacetamide NF sodium) PROMISEB EXTERNAL CREAM (antiseborrheic products, NPB misc.) selenium sulfide external lotion 2.5 % G sodium sulfacetamide wash external liquid 10 % NPB DERMATOLOGY, ATOPIC DERMATITIS DUPIXENT SUBCUTANEOUS SOLUTION PEN- PSP INJECTOR 200 MG/1.14ML, 300 MG/2ML (dupilumab) DUPIXENT SUBCUTANEOUS SOLUTION PREFILLED PSP SYRINGE 200 MG/1.14ML, 300 MG/2ML (dupilumab) DERMATOLOGY, CORTICOSTEROIDS ADVANCED ALLERGY COLLECTION EXTERNAL NF KIT 2.5 % (hydrocortisone) ALA SCALP EXTERNAL LOTION 2 % (hydrocortisone) NPB ala-cort external cream 1 %, 2.5 % G alclometasone dipropionate external cream 0.05 % G alclometasone dipropionate external ointment 0.05 % G amcinonide external cream 0.1 % G

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 224 Prescription Drug Name Drug Tier Drug Notes amcinonide external lotion 0.1 % G amcinonide external ointment 0.1 % NPB APEXICON E EXTERNAL CREAM 0.05 % (diflorasone NF diacet emoll base) BESER EXTERNAL KIT 0.05 % (fluticasone-emollient) NF fluticasone propionate (Beser External Lotion 0.05 %) G betamethasone dipropionate aug external cream 0.05 % G betamethasone dipropionate aug external gel 0.05 % G betamethasone dipropionate aug external lotion 0.05 % G betamethasone dipropionate aug external ointment 0.05 % G betamethasone dipropionate external cream 0.05 % G betamethasone dipropionate external lotion 0.05 % G betamethasone dipropionate external ointment 0.05 % G betamethasone valerate external cream 0.1 % G betamethasone valerate external foam 0.12 % G betamethasone valerate external lotion 0.1 % G betamethasone valerate external ointment 0.1 % G BRYHALI EXTERNAL LOTION 0.01 % (halobetasol PB propionate) calcipotriene-betameth diprop external ointment 0.005-0.064 % NF calcipotriene-betameth diprop external suspension 0.005-0.064 NF % CAPEX EXTERNAL SHAMPOO 0.01 % (fluocinolone NF acetonide) clobetasol prop emollient base external cream 0.05 % G clobetasol propionate e external cream 0.05 % G clobetasol propionate emulsion external foam 0.05 % G clobetasol propionate external cream 0.05 % G clobetasol propionate external foam 0.05 % G clobetasol propionate external gel 0.05 % G clobetasol propionate external liquid 0.05 % NF clobetasol propionate external lotion 0.05 % G clobetasol propionate external ointment 0.05 % G clobetasol propionate external shampoo 0.05 % G clobetasol propionate external solution 0.05 % G

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 225 Prescription Drug Name Drug Tier Drug Notes CLOBEX SPRAY EXTERNAL LIQUID 0.05 % (clobetasol NF propionate) clocortolone pivalate external cream 0.1 % NF CLODAN EXTERNAL KIT 0.05 % (clobetasol prop & NF cleanser) clobetasol propionate (Clodan External Shampoo 0.05 %) G CLODERM EXTERNAL CREAM 0.1 % (clocortolone NPB pivalate) CORDRAN EXTERNAL CREAM 0.025 % (flurandrenolide) NPB CORDRAN EXTERNAL OINTMENT 0.05 % NF (flurandrenolide) CORDRAN EXTERNAL TAPE 4 MCG/SQCM NF (flurandrenolide) DESONATE EXTERNAL GEL 0.05 % (desonide) NPB desonide external cream 0.05 % G desonide external lotion 0.05 % G desonide external ointment 0.05 % G desoximetasone external cream 0.05 %, 0.25 % G desoximetasone external gel 0.05 % G desoximetasone external liquid 0.25 % G desoximetasone external ointment 0.05 % NF desoximetasone external ointment 0.25 % G diflorasone diacetate external cream 0.05 % NF diflorasone diacetate external ointment 0.05 % NF DUOBRII EXTERNAL LOTION 0.01-0.045 % (halobetasol PB prop-tazarotene) ENSTILAR EXTERNAL FOAM 0.005-0.064 % PB (calcipotriene-betameth diprop) fluocinolone acetonide body external oil 0.01 % G fluocinolone acetonide external cream 0.01 %, 0.025 % G fluocinolone acetonide external ointment 0.025 % G fluocinolone acetonide external solution 0.01 % G fluocinolone acetonide scalp external oil 0.01 % G fluocinonide emulsified base external cream 0.05 % G fluocinonide external cream 0.05 % G fluocinonide external cream 0.1 % NF

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 226 Prescription Drug Name Drug Tier Drug Notes fluocinonide external gel 0.05 % G fluocinonide external ointment 0.05 % G fluocinonide external solution 0.05 % G fluovix external therapy pack 0.1 % NF flurandrenolide external cream 0.05 % NF flurandrenolide external lotion 0.05 % NF flurandrenolide external ointment 0.05 % NF fluticasone propionate external cream 0.05 % G fluticasone propionate external lotion 0.05 % G fluticasone propionate external ointment 0.005 % G halcinonide external cream 0.1 % NF halobetasol propionate external cream 0.05 % G halobetasol propionate external foam 0.05 % NF halobetasol propionate external ointment 0.05 % G HALOG EXTERNAL CREAM 0.1 % (halcinonide) NF HALOG EXTERNAL OINTMENT 0.1 % (halcinonide) NF HALOG EXTERNAL SOLUTION 0.1 % (halcinonide) NF hydrocortisone butyr lipo base external cream 0.1 % NF hydrocortisone butyrate external cream 0.1 % NF hydrocortisone butyrate external lotion 0.1 % NF hydrocortisone butyrate external ointment 0.1 % G hydrocortisone butyrate external solution 0.1 % G hydrocortisone external cream 1 %, 2.5 % G hydrocortisone external lotion 2.5 % G hydrocortisone external ointment 1 %, 2.5 % G hydrocortisone valerate external cream 0.2 % G hydrocortisone valerate external ointment 0.2 % G IMPOYZ EXTERNAL CREAM 0.025 % (clobetasol NF propionate) KENALOG EXTERNAL AEROSOL SOLUTION 0.147 NF MG/GM (triamcinolone acetonide) LEXETTE EXTERNAL FOAM 0.05 % (halobetasol NF propionate) LUXIQ EXTERNAL FOAM 0.12 % (betamethasone valerate) NF mometasone furoate external cream 0.1 % G

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 227 Prescription Drug Name Drug Tier Drug Notes mometasone furoate external ointment 0.1 % G mometasone furoate external solution 0.1 % G flurandrenolide (Nolix External Cream 0.05 %) NF flurandrenolide (Nolix External Lotion 0.05 %) NF OLUX-E EXTERNAL FOAM 0.05 % (clobetasol propionate NF emulsion) PANDEL EXTERNAL CREAM 0.1 % (hydrocortisone NPB probutate) prednicarbate external ointment 0.1 % G psorcon external cream 0.05 % NF SCARZEN SKIN REPAIR EXTERNAL KIT 0.1 & 5 % NF (LOTION) (triamcinolone-dimeth-silicone) SERNIVO EXTERNAL EMULSION 0.05 % (betamethasone NPB dipropionate) TACLONEX EXTERNAL OINTMENT 0.005-0.064 % PB (calcipotriene-betameth diprop) TACLONEX EXTERNAL SUSPENSION 0.005-0.064 % PB (calcipotriene-betameth diprop) TEXACORT EXTERNAL SOLUTION 2.5 % NPB (hydrocortisone) triamcinolone acetonide external aerosol solution 0.147 mg/gm NF triamcinolone acetonide external cream 0.025 %, 0.1 %, 0.5 % G triamcinolone acetonide external lotion 0.025 %, 0.1 % G triamcinolone acetonide external ointment 0.025 %, 0.1 %, 0.5 G % triamcinolone acetonide external ointment 0.05 % NF triamcinolone acetonide (Trianex External Ointment 0.05 %) NF triamcinolone acetonide (Triderm External Cream 0.1 %, 0.5 G %) ULTRAVATE EXTERNAL LOTION 0.05 % (halobetasol NF propionate) VANOS EXTERNAL CREAM 0.1 % (fluocinonide) NF VERDESO EXTERNAL FOAM 0.05 % (desonide) NF DERMATOLOGY, LOCAL ANESTHETICS 1st relief spray external liquid 4-1 % NF lidocaine hcl (7T Lido External Gel 2 %) G

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 228 Prescription Drug Name Drug Tier Drug Notes ACCUCAINE COMBINATION KIT 1 % (lido-pentaf- NF tetrafl-ultrasound) ALOCANE EMERGENCY BURN MAX STR NF EXTERNAL GEL 4 % (lidocaine hcl) ANACAINE EXTERNAL OINTMENT 10 % (benzocaine) NPB APRIZIO PAK EXTERNAL KIT 2.5-2.5 % (lidocaine- NF prilocaine-dressing) ASTERO EXTERNAL GEL 4 % (lidocaine hcl) NF CADIRAMD EXTERNAL KIT 2.5-2.5 % (lido-prilocaine- NF blood collect) CETACAINE EXTERNAL LIQUID 2-2-14 % (butamben- NF tetracaine-benzocaine) CRYODOSE TA EXTERNAL AEROSOL (pentafluoroprop- NPB tetrafluoroeth) DERMACINRX PHN EXTERNAL THERAPY PACK 5 & NF 5 % (lidocaine-dimethicone) DERMACINRX ZRM EXTERNAL THERAPY PACK 5 % NF (lidocaine-emollient) EPIFOAM EXTERNAL FOAM 1-1 % (pramoxine-hc) NPB GEBAUERS PAIN EASE EXTERNAL AEROSOL NPB (pentafluoroprop-tetrafluoroeth) GEBAUERS SPRAY AND STRETCH EXTERNAL NPB AEROSOL (pentafluoroprop-tetrafluoroeth) lidocaine hcl (Glydo External Prefilled Syringe 2 %) G goprelto nasal solution 40 mg/ml NF ICY HOT PM EXTERNAL PATCH 0.025-5 % (capsaicin- NF menthol) L.E.T. EXTERNAL GEL 4-0.05-0.5 % (lido-epinephrine- NF tetracaine) LDO PLUS EXTERNAL GEL 4 % (lidocaine hcl) NF lidocaine external ointment 5 % G lidocaine external patch 5 % G lidocaine hcl external solution 4 % G lidocaine hcl urethral/mucosal external gel 2 % G lidocaine hcl urethral/mucosal external prefilled syringe 2 % G lidocaine-prilocaine external cream 2.5-2.5 % G lidocaine-tetracaine external cream 7-7 % NF

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 229 Prescription Drug Name Drug Tier Drug Notes LIDOCARE ARM/NECK/LEG EXTERNAL PATCH 4 % NF (lidocaine) LIDOCARE BACK/SHOULDER EXTERNAL PATCH 4 NF % (lidocaine) LIDODERM EXTERNAL PATCH 5 % (lidocaine) NPB lidopac external kit 5 % NF lidopin external cream 3.25 % NF LIDOPURE PATCH EXTERNAL KIT 5 % (lidocaine- NF adhesive sheets) LIDOTHOL EXTERNAL GEL 4.5-5 % (lidocaine-menthol) NF LIDOTHOL EXTERNAL PATCH 4.5-5 % (lidocaine- NF menthol) LIDOTRAL EXTERNAL CREAM 3.88 % (lidocaine hcl) NF LMR PLUS EXTERNAL KIT 5 & 0.5-0.5 % (lidocaine- NF camphor-menthol) NOVACORT EXTERNAL GEL 1-2 % (pramoxine-hc) NF paingo kft external kit 2.5-2.5-10-30 % NF PLIAGLIS EXTERNAL CREAM 7-7 % (lidocaine- NF tetracaine) premium scar external patch 2-4-30 % NF prepiv supply combination kit 2.5-2.5 & 0.9 % NF QUTENZA (2 PATCH) EXTERNAL KIT 8 % (capsaicin- NPB cleansing gel) QUTENZA EXTERNAL KIT 8 % (capsaicin-cleansing gel) NPB SX1 MEDICATED POST-OPERATIVE EXTERNAL KIT NF 2 % (lidocaine hcl & post-op system) SYNERA EXTERNAL PATCH 70-70 MG (lidocaine- NPB tetracaine) VENIPUNCTURE PX1 PHLEBOTOMY EXTERNAL KIT NF 2 % (lidocaine hcl-blood collection) wpr plus wound healing system external therapy pack 4 & 10-30 NF % ZILACAINE PATCH EXTERNAL THERAPY PACK 5 % NF (lidocaine-silicone) ZTLIDO EXTERNAL PATCH 1.8 % (lidocaine) NF DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE ACUICYN EXTERNAL SOLUTION (eyelid cleansers) NF 2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 230 Prescription Drug Name Drug Tier Drug Notes acyclovir external cream 5 % NF acyclovir external ointment 5 % G ALDARA EXTERNAL CREAM 5 % (imiquimod) NF alevamax external cream NPB ALEVICYN ANTIPRURITIC EXTERNAL GEL NF (dermatological products, misc.) ALEVICYN ANTIPRURITIC SG EXTERNAL GEL NF (dermatological products, misc.) AMELUZ EXTERNAL GEL 10 % (aminolevulinic acid hcl) NF ammonium lactate external cream 12 % G ammonium lactate external lotion 12 % G ANASEPT EXTERNAL LIQUID 0.057 % (sodium NF hypochlorite) arnica flower tincture NPB atopaderm external cream NF ATOPICLAIR EXTERNAL CREAM (dermatological NPB products, misc.) AVENOVA EXTERNAL SOLUTION 0.01 % (eyelid NF cleansers) beau rx external gel NF bensal hp external ointment 3 % NF benzalkonium chloride external solution , 50 % NPB benzoin external tincture NPB boric acid external granules NPB scar treatment products (Celacyn External Gel) G CERACADE EXTERNAL EMULSION (dermatological NF products, misc.) chlorhexidine gluconate solution 20 % NPB coal tar external solution 20 % G CONDYLOX EXTERNAL GEL 0.5 % (podofilox) NPB COPASIL EXTERNAL GEL (scar treatment products) NPB DENAVIR EXTERNAL CREAM 1 % (penciclovir) NF DERMACINRX CLORHEXACIN EXTERNAL KIT 4 & 2 NF & 5 % (OINT) (chlorhex-mupir-dimeth-silicone) DERMACINRX LEXITRAL PHARMAPAK COMBINATION THERAPY PACK 1.5 & 0.025 % NF (diclofenac sodium-capsaicin) 2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 231 Prescription Drug Name Drug Tier Drug Notes dermacinrx surgical combopak combination kit NF dermovix external patch 2-30 % NF DEXERYL EXTERNAL CREAM (dermatological products, NPB misc.) dfs/ms/menth/cap pak combination kit 1.5 % NF diclofenac epolamine external patch 1.3 % G diclofenac sodium external solution 1.5 % G DICLOFONO EXTERNAL GEL 1.6 % (diclofenac sodium) NF diclopr external kit 1 & 10-30 % NF diclovix combination kit 1.5 & 2-2.5-4 % NF diclozor external therapy pack 1 % NF dimentho external therapy pack 1.5 & 10 % NF DRYSOL EXTERNAL SOLUTION 20 % (aluminum NPB chloride) dual complex formula 1 kit external cream NF ELETONE EXTERNAL CREAM (dermatological products, NPB misc.) ELIDEL EXTERNAL CREAM 1 % (pimecrolimus) NPB EMULSION SB EXTERNAL EMULSION (dermatological NPB products, misc.) enovarx-diclofenac sodium external cream 2.5 % NF ENTTY SPRAY EXTERNAL EMULSION (dermatological NF products, misc.) EPICERAM EXTERNAL EMULSION (dermatological NF products, misc.) EPICYN EXTERNAL SOLUTION (hypochlorous acid) NF essentra wipes 9x9" sheet 70 % NPB EUCRISA EXTERNAL OINTMENT 2 % (crisaborole) PB FLECTOR EXTERNAL PATCH 1.3 % (diclofenac NF epolamine) formaldehyde external solution 10 % G formaldehyde external solution 37 % NPB GENADUR EXTERNAL LIQUID (dermatological products, NPB misc.) glutaraldehyde external solution 25 % NPB GORDOFILM EXTERNAL SOLUTION 16.7-16.7 % NPB (-lactic acid) 2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 232 Prescription Drug Name Drug Tier Drug Notes HPR PLUS EXTERNAL CREAM (dermatological products, NPB misc.) HPR PLUS EXTERNAL FOAM (dermatological products, NPB misc.) HPR PLUS HYDROGEL EXTERNAL KIT (dermatological NPB products, misc.) HYCLODEX EXTERNAL SOLUTION 0.012 % NF (hypochlorous acid) hydrogen peroxide solution 30 % G HYLATOPIC PLUS EXTERNAL CREAM (dermatological NPB products, misc.) HYPOCYN EXTERNAL SOLUTION (eyelid cleansers) NF iodine tincture external tincture 2 % NPB KAMDOY EXTERNAL EMULSION (dermatological NF products, misc.) KELARX EXTERNAL GEL (scar treatment products) NF KETOPHENE RAPIDPAQ EXTERNAL CREAM 20 % NF (ketoprofen) KIVIK EXTERNAL EMULSION (dermatological products, NF misc.) lactic acid e external cream 10-3500 %-unt/30gm NPB lactic acid external lotion 10 % NPB LEVICYN EXTERNAL GEL (dermatological products, NF misc.) LEVULAN KERASTICK EXTERNAL SOLUTION NPB RECONSTITUTED 20 % (aminolevulinic acid hcl) LOYON EXTERNAL SOLUTION (dermatological products, NPB misc.) MIMYX EXTERNAL CREAM (dermatological products, NPB misc.) NEOSALUS EXTERNAL CREAM (dermatological NPB products, misc.) NEOSALUS EXTERNAL FOAM (dermatological products, NPB misc.) NEOSALUS EXTERNAL LOTION (dermatological NPB products, misc.) diclofenac sodium-capsaicin (Nudiclo Solupak Combination NF Therapy Pack 1.5 & 0.025 %)

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 233 Prescription Drug Name Drug Tier Drug Notes NUSURGEPAK SURGICAL PREP/CARE EXTERNAL NF KIT 4 & 2 & 5 % (OINT) (chlorhex-mupir-dimeth-silicone) NUVAIL EXTERNAL SOLUTION (dermatological NPB products, misc.) ORMECA COMBINATION KIT 3 & 46-0.4-1.1 %-MG NF (diclofenac-b6-fa-b12) PALMERS SCAR SERUM EXTERNAL LIQUID (scar NF treatment products) PANRETIN EXTERNAL GEL 0.1 % (alitretinoin) NPB PENLEN EXTERNAL EMULSION (dermatological NF products, misc.) PENNSAID EXTERNAL SOLUTION 2 % (diclofenac NF sodium) PHLAG SPRAY EXTERNAL EMULSION (dermatological NPB products, misc.) pimecrolimus external cream 1 % G podofilox external solution 0.5 % G PR CREAM EXTERNAL KIT (dermatological products, NPB misc.) PRE & POST SX POUCH EXTERNAL THERAPY PACK NF 4 & 2 & 5 % (chlorhex-mupirocin-dimethicone) PRESERA EXTERNAL FOAM (dermatological products, NPB misc.) PROTOPIC EXTERNAL OINTMENT 0.03 %, 0.1 % NPB (tacrolimus) PRUCLAIR EXTERNAL CREAM (dermatological products, NPB misc.) PRUMYX EXTERNAL CREAM (dermatological products, NPB misc.) pyrogallic acid external ointment 25-2 % NPB QBREXZA EXTERNAL PAD 2.4 % (glycopyrronium NPB tosylate) RECEDO EXTERNAL GEL (scar treatment products) NF remigen external cream NPB salimez forte external cream 10 % NPB SANTYL EXTERNAL OINTMENT 250 UNIT/GM NPB (collagenase) scarcin external gel NPB

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 234 Prescription Drug Name Drug Tier Drug Notes scarcin external liquid NF scarsilk external gel NF SEBUDERM EXTERNAL GEL (dermatological products, NPB misc.) silipac external kit NF suvicort external emulsion NF SYNERDERM EXTERNAL EMULSION (dermatological NF products, misc.) tacrolimus external ointment 0.03 %, 0.1 % G TARGRETIN EXTERNAL GEL 1 % (bexarotene) NPSP TETRIX EXTERNAL CREAM (dermatological products, NPB misc.) triple complex formula 3 kit external cream 20-2-10 % NF turpentine external spirit NPB urea (Uredeb External Cream 39 %) G URESOL EXTERNAL CREAM 42.5 % (urea) NF VALCHLOR EXTERNAL GEL 0.016 % (mechlorethamine NPB hcl (topical)) VAROPHEN EXTERNAL KIT 1.5-10-15 % (diclofenac& NF menthol-methyl sal) VEREGEN EXTERNAL OINTMENT 15 % (sinecatechins) NF VOLTAREN EXTERNAL GEL 1 % (diclofenac sodium) NPB vp fc kit external cream NF XALIX EXTERNAL SOLUTION 28 % (salicylic acid) NF XERAC AC EXTERNAL SOLUTION 6.25 % (aluminum NPB chloride in alcohol) XERALUX EXTERNAL CREAM (dermatological products, NPB misc.) XRYLIX EXTERNAL THERAPY PACK 1.5 % (diclofenac NF sod-adhesive sheet) ZOVIRAX EXTERNAL CREAM 5 % (acyclovir) NF ZOVIRAX EXTERNAL OINTMENT 5 % (acyclovir) NF ZYCLARA PUMP EXTERNAL CREAM 3.75 % NF (imiquimod) DERMATOLOGY, ROSACEA azelaic acid external gel 15 % G doxycycline oral capsule delayed release 40 mg NF 2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 235 Prescription Drug Name Drug Tier Drug Notes FINACEA EXTERNAL FOAM 15 % (azelaic acid) PB FINACEA EXTERNAL GEL 15 % (azelaic acid) NF METROGEL EXTERNAL GEL 1 % (metronidazole) NF metronidazole external cream 0.75 % G metronidazole external gel 0.75 %, 1 % G metronidazole external lotion 0.75 % G MIRVASO EXTERNAL GEL 0.33 % (brimonidine tartrate) NF NORITATE EXTERNAL CREAM 1 % (metronidazole) NF ORACEA ORAL CAPSULE DELAYED RELEASE 40 MG PB (doxycycline) RHOFADE EXTERNAL CREAM 1 % (oxymetazoline hcl) NF metronidazole (Rosadan External Cream 0.75 %) G metronidazole (Rosadan External Gel 0.75 %) G SOOLANTRA EXTERNAL CREAM 1 % (ivermectin) NF DERMATOLOGY, SCABICIDES AND PEDICULIDES CROTAN EXTERNAL LOTION 10 % (crotamiton) G lindane external shampoo 1 % G malathion external lotion 0.5 % G permethrin external cream 5 % G spinosad external suspension 0.9 % G sulfurated lime external solution NPB DERMATOLOGY, WOUND CARE AGENTS aceso ag external pad 4"x4" NF ACTICOAT 7 EXTERNAL PAD 2"X2" , 4"X5" (silver) NPB ACTICOAT ANTIMICROBIAL EXTERNAL PAD 2"X2" , NPB 4"X4" (silver) ACTICOAT FLEX 3 4"X4" EXTERNAL PAD (wound NPB dressings) ALEVICYN DERMAL SPRAY EXTERNAL SOLUTION NF (wound cleansers) ALLEVYN AG ADHESIVE EXTERNAL PAD NPB 12.5X12.5CM , 17.5X17.5CM , 7.5X7.5CM (silver) ALLEVYN AG NON-ADHESIVE EXTERNAL PAD NPB 2"X2" , 4"X4" , 6"X6" , 8"X8" (silver) ALLEVYN AG SACRUM 6-3/4" EXTERNAL (silver) NPB ALLEVYN AG SACRUM 9"X9" EXTERNAL (silver) NPB

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 236 Prescription Drug Name Drug Tier Drug Notes ALLEVYN GENTLE EXTERNAL PAD (wound dressings) NPB AQUACEL AG BURN EXTERNAL PAD 4"X5" (silver- NF carboxymethylcellulose) ATRAPRO HYDROGEL EXTERNAL GEL (wound NF dressings) balsam peru-castor oil external ointment NF BIONECT EXTERNAL FOAM 0.2 % (hyaluronate sodium) NF bpco external ointment NF COLLATYL EXTERNAL GEL (silver) NF CURITY HYPERTONIC NACL STRIP EXTERNAL NPB (wound dressings) CURITY NACL DRESSING 6"X6-3/4" EXTERNAL PAD NPB (wound dressings) HYDROFERA BLUE 6"X6" EXTERNAL PAD (wound NPB dressings) HYDROFERA BLUE FOAM DRESSING EXTERNAL NPB PAD (wound dressings) HYDROFERA BLUE FOAM/TUNNELING EXTERNAL NPB PAD (wound dressings) HYDROFERA BLUE MRF DRESSING EXTERNAL NPB PAD (wound dressings) HYDROFERA BLUE READY FOAM EXTERNAL PAD NPB (wound dressings) hygel external gel 2.5 % NF KENDALL ALGINATE 12" ROPE EXTERNAL (wound NPB dressings) KENDALL ALGINATE DRESS 2"X2" EXTERNAL PAD NPB (wound dressings) KENDALL ALGINATE DRESS 4"X4" EXTERNAL PAD NPB (hydroactive dressings) KENDALL ALGINATE DRESS 4"X8" EXTERNAL PAD NPB (wound dressings) KENDALL AMORPHOUS WOUND EXTERNAL GEL NPB (wound dressings) KENDALL HYDROGEL GAUZE 2"X2" EXTERNAL NPB PAD (hydroactive dressings) KENDALL HYDROGEL GAUZE 4"X4" EXTERNAL NPB PAD (hydroactive dressings)

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 237 Prescription Drug Name Drug Tier Drug Notes KENDALL HYDROGEL GAUZE 4"X8" EXTERNAL NPB PAD (hydroactive dressings) KENDALL HYDROGEL WOUND DRESS EXTERNAL NPB (hydroactive dressings) KENDALL ZINC CA ALGINATE 4"X4" EXTERNAL NPB PAD (wound dressings) KERAGEL EXTERNAL GEL (wound dressings) NPB KERAGELT EXTERNAL GEL (wound dressings) NPB KERAMATRIX REPLICINE 10CMX10CM EXTERNAL NPB SHEET (wound dressings) KERAMATRIX REPLICINE 5CMX5CM EXTERNAL NPB SHEET (wound dressings) LIDOTREX (ALOE VERA) EXTERNAL GEL 2 % NF (lidocaine-collagen-aloe vera) LUXAMEND EXTERNAL CREAM (wound dressings) NPB MICROCYN EXTERNAL LIQUID 0.023 % (wound NPB cleansers) PROTYL AG EXTERNAL GEL 1 % (silver) NF REGENECARE EXTERNAL GEL 2 % (lidocaine-collagen- NPB aloe vera) REGRANEX EXTERNAL GEL 0.01 % (becaplermin) NPB RESTORE SILVER DRESSING EXTERNAL PAD 2"X2" , NPB 4"X4.75" (calcium alginate-silver) RESTORE SILVER DRESSING EXTERNAL PAD 4"X4" , NPB 4"X5" , 6"X8" (silver) REXASIL PATCH & VITAMIN E LIQ EXTERNAL KIT NF (silicone-vitamin e) RTD WOUND CARE DRESSING EXTERNAL PAD NPB (wound dressings) TEGADERM AG MESH EXTERNAL PAD 2"X2" , 4"X5" , NPB 4"X8" , 8"X8" (silver) VENELEX EXTERNAL OINTMENT (balsam peru-castor NPB oil) vexasyn external gel NF XEROFORM OIL EMULSION 2"X2" EXTERNAL PAD NPB (bismuth tribromoph-petrolatum) XEROFORM OIL EMULSION GAUZE EXTERNAL NPB PAD (bismuth tribromoph-petrolatum)

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 238 Prescription Drug Name Drug Tier Drug Notes XEROFORM OIL EMULSION STRIP EXTERNAL NPB (bismuth tribromoph-petrolatum) XEROFORM OIL ROLL 4"X9' EXTERNAL 3 % (bismuth NPB tribromoph-petrolatum) XEROFORM PETROLAT GAUZE 1"X8" EXTERNAL NPB (bismuth tribromoph-petrolatum) XEROFORM PETROLAT GAUZE 5"X9" EXTERNAL NPB (bismuth tribromoph-petrolatum) XEROFORM PETROLAT PATCH 2"X2" EXTERNAL NPB PAD (bismuth tribromoph-petrolatum) XEROFORM PETROLAT PATCH 4"X4" EXTERNAL NPB PAD (bismuth tribromoph-petrolatum) XEROFORM PETROLATUM ROLL 4"X9' EXTERNAL NPB (bismuth tribromoph-petrolatum) zanabin hydrogel external gel NPB MOUTH/THROAT/DENTAL AGENTS AQUORAL MOUTH/THROAT SOLUTION (artificial NPB saliva) BOCASAL MOUTH/THROAT PACKET (artificial saliva) NPB CAPHOSOL MOUTH/THROAT SOLUTION (artificial NPB saliva) cevimeline hcl oral capsule 30 mg G chlorhexidine gluconate mouth/throat solution 0.12 % G clotrimazole mouth/throat troche 10 mg G GELCLAIR MOUTH/THROAT GEL (povidone-nahyaluron- NPB glycyrrhet) lidocaine hcl mouth/throat solution 4 % G lidocaine viscous hcl mouth/throat solution 2 % G NEUTRASAL MOUTH/THROAT PACKET (artificial NPB saliva) NUMOISYN MOUTH/THROAT LIQUID (artificial saliva) NPB nystatin mouth/throat suspension 100000 unit/ml G ORAFATE MOUTH/THROAT PASTE 10 % (sucralfate- NPB malate) triamcinolone acetonide (Oralone Mouth/Throat Paste 0.1 %) G ORAVIG BUCCAL TABLET 50 MG (miconazole) NPB chlorhexidine gluconate (Paroex Mouth/Throat Solution 0.12 G %) 2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 239 Prescription Drug Name Drug Tier Drug Notes chlorhexidine gluconate (Periogard Mouth/Throat Solution G 0.12 %) pilocarpine hcl oral tablet 5 mg, 7.5 mg G PREVIDENT 5000 BOOSTER PLUS DENTAL PASTE 1.1 NF % (sodium fluoride) PREVIDENT 5000 DRY MOUTH DENTAL GEL 1.1 % NF (sodium fluoride) PREVIDENT 5000 ENAMEL PROTECT DENTAL PASTE NF 1.1-5 % (sod fluoride-potassium nitrate) PREVIDENT 5000 ORTHO DEFENSE DENTAL PASTE NF 1.1 % (sodium fluoride) PREVIDENT 5000 PLUS DENTAL CREAM 1.1 % (sodium NF fluoride) PREVIDENT 5000 SENSITIVE DENTAL PASTE 1.1-5 % NF (sod fluoride-potassium nitrate) PREVIDENT DENTAL GEL 1.1 % (sodium fluoride) NF PREVIDENT MOUTH/THROAT SOLUTION 0.2 % NF (sodium fluoride) PROTHELIAL MOUTH/THROAT PASTE 10 % NPB (sucralfate-malate) SALIVAMAX MOUTH/THROAT PACKET (artificial NPB saliva) triamcinolone acetonide mouth/throat paste 0.1 % G XEROSTOMIA RELIEF SPRAY MOUTH/THROAT NPB SOLUTION (artificial saliva) OTIC - DRUGS TO TREAT CONDITIONS OF THE EAR acetic acid otic solution 2 % G CIPRO HC OTIC SUSPENSION 0.2-1 % (ciprofloxacin- NF hydrocortisone) CIPRODEX OTIC SUSPENSION 0.3-0.1 % (ciprofloxacin- NF dexamethasone) ciprofloxacin hcl otic solution 0.2 % G ciprofloxacin-fluocinolone pf otic solution 0.3-0.025 % NF CORTISPORIN-TC OTIC SUSPENSION 3.3-3-10-0.5 NPB MG/ML (neomycin-colist-hc-thonzonium) fluocinolone acetonide (Flac Otic Oil 0.01 %) G fluocinolone acetonide otic oil 0.01 % G hydrocortisone-acetic acid otic solution 1-2 % G

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 240 Prescription Drug Name Drug Tier Drug Notes neomycin-polymyxin-hc otic solution 3.5-10000-1 G neomycin-polymyxin-hc otic suspension 3.5-10000-1 G ofloxacin otic solution 0.3 % G OTIPRIO INTRATYMPANIC SUSPENSION 6 % NF (ciprofloxacin) OTOVEL OTIC SOLUTION 0.3-0.025 % (ciprofloxacin- NF fluocinolone)

2021 Pharmacy Drug Guide - Advanced Control Plan: Sutter Health | Aetna The formulary is updated the first week of each month 09/01/2021 241 Index 12-PANEL POC ACCU-CHEK SOFTCLIX ADHANSIA XR...... 72 TOXICOLOGY SYSTEM....144 LANCETS...... 145 adjustable lancing device...... 145 1st relief spray...... 228 ACCU-CHEK ADLYXIN...... 87 1st tier unifine pentips...... 144 ULTRAFLEX INF SET...... 145 ADLYXIN STARTER 1st tier unifine pentips plus...... 144 ACCU-CHEK PACK...... 87 1st tier unilet comfortouch...... 144 ULTRAFLEX-1 INF SET....145 ADMELOG...... 88 7T Lido...... 228 ACCUTREND GLUCOSE..145 ADMELOG SOLOSTAR...... 87 abacavir sulfate...... 28 acd formula a...... 126 ADRENAL C FORMULA.. 191 abacavir sulfate-lamivudine...... 30 ACD-A NOCLOT-50...... 126 ADRENALIN...... 208, 214 abacavir-lamivudine-zidovudine 30 acebutolol hcl...... 52 ADVAIR HFA...... 217 Abaneu-Sl...... 131 aceso ag...... 236 ADVANCE INTUITION ABILIFY...... 69 acetaminophen-codeine...... 19 METER...... 145 ABILIFY MAINTENA...... 69 acetaminophen-codeine #3...... 19 ADVANCE INTUITION ABILIFY MYCITE...... 69 acetazolamide...... 55 MONITOR...... 145 ABILIFY MYCITE acetazolamide er...... 55 ADVANCE INTUITION MAINTENANCE KIT...... 69 acetic acid...... 124, 240 TEST...... 146 ABILIFY MYCITE acetylcysteine...... 209, 214 ADVANCE MICRO-DRAW STARTER KIT...... 69 ACIPHEX...... 121 METER...... 146 abiraterone acetate...... 40 ACIPHEX SPRINKLE...... 121 ADVANCE MICRO-DRAW ABOUTTIME PEN acitretin...... 223 TEST...... 146 NEEDLE...... 144 ACTEMRA ACTPEN...... 137 ADVANCED ALLERGY ABSORICA...... 218 ACTHAR...... 110 COLLECTION...... 224 acamprosate calcium...... 82 ACTICLATE...... 36 ADVATE...... 129 ACANYA...... 218 ACTICOAT 7...... 236 ADVOCATE BLOOD acarbose...... 85 ACTICOAT GLUCOSE MONITOR...... 146 ACCUCAINE...... 229 ANTIMICROBIAL...... 236 ADVOCATE BLOOD ACCU-CHEK AVIVA PLUS ACTICOAT FLEX 3 4"X4"..236 GLUCOSE SYSTEM...... 146 ...... 145 acti-lance 28g...... 145 ADVOCATE INSULIN PEN ACCU-CHEK COMPACT acti-lance lite lancets 28g...... 145 NEEDLES...... 146 PLUS...... 145 acti-lance special lancets 17g.. 145 ADVOCATE INSULIN ACCU-CHEK FASTCLIX acti-lance universal 23g...... 145 SYRINGE...... 146 LANCET...... 145 ACTIMMUNE...... 142 ADVOCATE LANCETS ACCU-CHEK FASTCLIX ACTIQ...... 19 30G...... 146 LANCETS...... 145 active fe...... 131 ADVOCATE LANCING ACCU-CHEK GUIDE...... 145 activite...... 191 DEVICE...... 146 ACCU-CHEK GUIDE ME..145 ACTOS...... 90 ADVOCATE RAPID-SAFE ACCU-CHEK LINKASSIST ACUICYN...... 230 LANCING...... 146 ...... 145 acyclovir...... 31, 231 ADVOCATE REDI-CODE..146 ACCU-CHEK MULTICLIX ACZONE...... 218 ADVOCATE REDI-CODE+146 LANCETS...... 145 ADAKVEO...... 131 ADVOCATE REDI-CODE+ ACCU-CHEK PLASTIC adapalene...... 218 TEST...... 146 CARTRIDGE...... 145 adapalene-benzoyl peroxide.... 218 ADVOCATE SAFETY ACCU-CHEK SAFE-T PRO ADASUVE...... 69 LANCETS...... 146 LANCETS...... 145 adc/f (0.5mg/ml)...... 191 ADVOCATE SAFETY ACCU-CHEK ADDERALL...... 72 LANCETS 26G...... 146 SMARTVIEW...... 145 ADDERALL XR...... 72 ADVOCATE TEST...... 146 ACCU-CHEK SOFTCLIX ADDYI...... 82 adynovate...... 129 LANCET DEV...... 145 adefovir dipivoxil...... 32 ADYPHREN...... 209 ADEMPAS...... 58 ADYPHREN AMP...... 208 242 ADYPHREN AMP II...... 208 alburx...... 136 alprazolam...... 59 ADYPHREN II...... 208 ALBUTEIN...... 136 alprazolam er...... 59 ADZENYS ER...... 72 albuterol sulfate...... 211 ALPRAZOLAM INTENSOL 59 ADZENYS XR-ODT...... 72 albuterol sulfate hfa...... 211 alprazolam xr...... 59 AEMCOLO...... 26 alclometasone dipropionate.....224 ALPROLIX...... 130 AFINITOR...... 41 ALCOH-GLOVE ALREX...... 206 AFINITOR DISPERZ...... 41 CONTOURED WIPE...... 147 ALTABAX...... 220 Afirmelle...... 94 alcohol pads...... 147 Altacaine...... 131 AFREZZA...... 88 alcohol prep...... 147 altafluor benox...... 131 AFSTYLA...... 129 alcohol swabs...... 147 Altafrin...... 131 AFTERA...... 94 alcoh-wipe...... 147 Altavera...... 94 AGAMATRIX AMP...... 146 ALCORTIN A...... 221 ALTOPREV...... 50 AGAMATRIX AMP TEST..146 ALDACTAZIDE...... 55 ALTRENO...... 218 AGAMATRIX JAZZ TEST.147 ALDARA...... 231 ALUNBRIG...... 41, 42 AGAMATRIX JAZZ ALECENSA...... 41 ALVESCO...... 216 WIRELESS 2...... 147 alendronate sodium...... 92 alyacen 1/35...... 94 AGAMATRIX KEYNOTE alevamax...... 231 alyacen 7/7/7...... 94 TEST...... 147 ALEVICYN Alyq...... 58 AGAMATRIX PRESTO...... 147 ANTIPRURITIC...... 231 Amabelz...... 105 AGAMATRIX PRESTO ALEVICYN amantadine hcl...... 67 PRO METER...... 147 ANTIPRURITIC SG...... 231 ambrisentan...... 58 AGAMATRIX PRESTO ALEVICYN DERMAL amcinonide...... 224, 225 TEST...... 147 SPRAY...... 236 AMELUZ...... 231 AGAMATRIX ULTRA- alfuzosin hcl er...... 122 Amethia...... 94 THIN LANCETS...... 147 ALINIA...... 26 Amethyst...... 94 AGGRASTAT...... 136 ALIQOPA...... 41 AMICAR...... 131 AIMOVIG...... 75 aliskiren fumarate...... 55 amiloride hcl...... 55 aimsco twist lancets 32g...... 147 ALLEVYN AG ADHESIVE 236 amiloride-hydrochlorothiazide.. 55 AIMSCO TWIST LANCETS ALLEVYN AG NON- aminoacetic acid...... 124 33G...... 147 ADHESIVE...... 236 aminocaproic acid...... 131 Airavite...... 131 ALLEVYN AG SACRUM 6- AMINOPMRMS...... 191 AIRDUO RESPICLICK 3/4"...... 236 amiodarone hcl...... 49 113/14...... 209 ALLEVYN AG SACRUM AMITIZA...... 118 AIRDUO RESPICLICK 9"X9"...... 236 amitriptyline hcl...... 65 232/14...... 209 ALLEVYN GENTLE...... 237 amlodipine besy-benazepril hcl..46 AIRDUO RESPICLICK allopurinol...... 15 amlodipine besylate...... 53 55/14...... 209 ALLZITAL...... 15 amlodipine besylate-valsartan...47 AJOVY...... 75 almotriptan malate...... 75 amlodipine-atorvastatin...... 53 AKOVAZ...... 214 ALOCANE EMERGENCY amlodipine-olmesartan...... 47 ak-poly-bac...... 205 BURN MAX STR...... 229 amlodipine-valsartan-hctz...... 47 AKTEN...... 131 ALOCRIL...... 202 ammonium lactate...... 231 AKYNZEO...... 115 alogliptin benzoate...... 86 Amnesteem...... 218 ALA SCALP...... 224 alogliptin-metformin hcl...... 86 amoxapine...... 65 ala-cort...... 224 alogliptin-pioglitazone...... 86 amoxicill-clarithro-lansopraz..122 ALA-QUIN...... 221 ALOMIDE...... 202 amoxicillin...... 35 albendazole...... 26 ALORA...... 105 amoxicillin-pot clavulanate...... 35 ALBUKED 25...... 136 alosetron hcl...... 118 amoxicillin-pot clavulanate er...35 ALBUKED 5...... 136 ALPHAGAN P...... 203 amphetamine sulfate...... 72 albumin human...... 136 ALPHANATE...... 127 amphetamine-dextroamphet er. 72 albumin-zlb...... 136 ALPHANINE SD...... 130 243 amphetamine- ARISTADA INITIO...... 69 ASTERO...... 229 dextroamphetamine...... 72 armodafinil...... 81 ATABEX EC...... 191 ampicillin...... 35 ARMOUR THYROID...... 113 ATABEX OB...... 191 ampicillin-sulbactam sodium.....35 arnica flower...... 231 ATACAND...... 48 AMPYRA...... 78 ARNUITY ELLIPTA...... 216 ATACAND HCT...... 47 AMRIX...... 80 ARTHROTEC...... 18 atazanavir sulfate...... 28 ANACAINE...... 229 ARTISS...... 131 atenolol...... 52 anagrelide hcl...... 131 ASACOL HD...... 117 atenolol-chlorthalidone...... 52 ANASEPT...... 231 Ascomp-Codeine...... 19 ATIVAN...... 59 anastrozole...... 40 ASCOR...... 191 atomoxetine hcl...... 72 ANDRODERM...... 84 Ashlyna...... 94 atopaderm...... 231 ANDROGEL...... 84 Asilnasalrms...... 191 ATOPICLAIR...... 231 ANDROGEL PUMP...... 84 ASMANEX (120 METERED atorvastatin calcium...... 50 ANGELIQ...... 105 DOSES)...... 216 atovaquone...... 26 ANNOVERA...... 94 ASMANEX (14 METERED atovaquone-proguanil hcl...... 28 ANORO ELLIPTA...... 209 DOSES)...... 216 ATRALIN...... 218 ANTARA...... 50 ASMANEX (30 METERED ATRAPRO HYDROGEL....237 anticoagulant sodium citrate...126 DOSES)...... 216 ATRIPLA...... 30 APADAZ...... 19 ASMANEX (60 METERED atropine sulfate...... 131 apap-caff-dihydrocodeine...... 19 DOSES)...... 216 ATROVENT HFA...... 210 APEXICON E...... 225 ASMANEX (7 METERED AUBAGIO...... 78 APIDRA...... 88 DOSES)...... 216 Aubra...... 95 APIDRA SOLOSTAR...... 88 ASMANEX HFA...... 216 Aubra Eq...... 95 APLENZIN...... 65 ASPARLAS...... 44 AUGMENTIN...... 35 APOKYN...... 67 aspirin...... 23 aurora lancet super thin 30g....148 APP SLIM RMS...... 191 aspirin adult low dose...... 23 aurora lancet thin 23g...... 148 apraclonidine hcl...... 203 aspirin ec low strength...... 23 aurora pen needles...... 148 aprepitant...... 115 aspirin low dose...... 23 aurora unifine pentips...... 148 Apri...... 94 aspirin-dipyridamole er...... 136 Aurovela 1.5/30...... 95 APRISO...... 117 ASPIR-LOW...... 23 Aurovela 1/20...... 95 APRIZIO PAK...... 229 ASSURE 3 METER...... 147 Aurovela 24 Fe...... 95 APTENSIO XR...... 72 ASSURE 3 TEST...... 147 Aurovela Fe 1.5/30...... 95 APTIOM...... 59 ASSURE 4 METER...... 147 Aurovela Fe 1/20...... 95 APTIVUS...... 28 ASSURE 4 TEST...... 147 AURYXIA...... 112 AQUACEL AG BURN...... 237 assure comfort lancets 28g...... 147 AUSTEDO...... 76 AQUALANCE LANCETS ASSURE ID INSULIN AUTO-LANCET...... 148 30G...... 147 SAFETY SYR...... 147 AUTO-LANCET MINI...... 148 AQUORAL...... 239 ASSURE ID SAFETY PEN AUTOLET II CLINISAFE.. 148 ARAKODA...... 28 NEEDLES...... 147 AUTOLET LITE ARALAST NP...... 214 ASSURE II...... 147 CLINISAFE...... 148 Aranelle...... 94 ASSURE II CHECK...... 147 AUTOLET LITE STARTER ARANESP (ALBUMIN ASSURE PLATINUM...... 147 PACK...... 148 FREE)...... 128 ASSURE PLATINUM AUTOLET MINI...... 148 ARAZLO...... 218 METER...... 148 AUTOLET PLATFORMS... 148 ARCALYST...... 142 ASSURE PRISM MULTI AUTOLET PLUS...... 148 Argyle Sterile Saline...... 124 TEST...... 148 autopen...... 148 Argyle Sterile Water...... 208 ASSURE PRO BLOOD AUTOSOFT 30 INFUSION ARIKAYCE...... 25 GLUCOSE METER...... 148 SET...... 148 aripiprazole...... 69 ASSURE PRO TEST...... 148 AUTOSOFT 90 INFUSION ARISTADA...... 69 ASTAMED MYO...... 191 SET...... 148 244 AUTOSOFT XC INFUSION BD INSULIN SYRINGE BENICAR...... 48 SET...... 148 MICROFINE...... 148 BENICAR HCT...... 47 AUVI-Q...... 209 BD INSULIN SYRINGE BENLYSTA...... 142 AVASTIN...... 38 U/F...... 149 bensal hp...... 231 AVENOVA...... 231 BD INSULIN SYRINGE U- BENZACLIN...... 218 Aviane...... 95 500...... 149 BENZACLIN WITH PUMP 218 avidoxy...... 36 BD INSULIN SYRINGE benzalkonium chloride...... 231 Avita...... 218 ULTRAFINE...... 149 Benzepro...... 218 AVONEX PEN...... 78 BD LANCET ULTRAFINE Benzepro Short Contact...... 218 AVONEX PREFILLED...... 78 30G...... 149 benznidazole...... 26 AVSOLA...... 137 BD LANCET ULTRAFINE benzoin...... 231 Ayuna...... 95 33G...... 149 benzonatate...... 212 AZASAN...... 142 BD LATITUDE DIABETES149 benzoyl perox-hydrocortisone. 218 AZASITE...... 205 BD LATITUDE DIABETES benzoyl peroxide...... 218 azathioprine...... 142 SYSTEM...... 149 benzoyl peroxide-erythromycin azelaic acid...... 235 BD LOGIC BLOOD ...... 218 azelastine hcl...... 202, 211 GLUCOSE MONITOR...... 149 benztropine mesylate...... 67 AZELEX...... 218 BD MICROTAINER BEPREVE...... 202 azeschew prenatal/postnatal....191 LANCETS...... 149 BESER...... 225 azesco...... 191 BD PEN...... 149 Beser...... 225 azithromycin...... 33 BD PEN MINI...... 149 BESIVANCE...... 205 AZOPT...... 203 BD PEN NEEDLE MICRO BETADINE OPHTHALMIC AZOR...... 47 U/F...... 149 PREP...... 205 Azurette...... 95 BD PEN NEEDLE MINI betamethasone dipropionate....225 b-6 folic acid...... 131 U/F...... 149 betamethasone dipropionate Bac...... 15 BD PEN NEEDLE NANO aug...... 225 bacitracin...... 205 2ND GEN...... 149 betamethasone valerate...... 225 bacitracin-polymyxin b...... 205 BD PEN NEEDLE NANO BETAPACE...... 52 bacitra-neomycin-polymyxin- U/F...... 149 BETAPACE AF...... 52 hc...... 204 BD PEN NEEDLE BETASERON...... 78 baclofen...... 80 ORIGINAL U/F...... 149 betaxolol hcl...... 52, 203 BALCOLTRA...... 95 BD PEN NEEDLE SHORT bethanechol chloride...... 119 balsalazide disodium...... 117 U/F...... 149 BETHKIS...... 25 balsam peru-castor oil...... 237 BD SAFETYGLIDE BETIMOL...... 203 BALVERSA...... 42 INSULIN SYRINGE...... 149 BETOPTIC-S...... 203 Balziva...... 95 BD SWABS SINGLE USE BEVESPI AEROSPHERE....209 BANZEL...... 59 BUTTERFLY...... 149 bexarotene...... 44 BAQSIMI ONE PACK...... 109 BD VEO INSULIN SYR U/F BEYAZ...... 95 BAQSIMI TWO PACK...... 109 1/2UNIT...... 149 bicalutamide...... 40 BARACLUDE...... 32 BD VEO INSULIN BIDIL...... 56 BASAGLAR KWIKPEN...... 88 SYRINGE U/F...... 150 BIJUVA...... 105 BAXDELA...... 34 beau rx...... 231 BIKTARVY...... 30 BAYER ASPIRIN EC LOW BECONASE AQ...... 215 bimatoprost...... 203 DOSE...... 23 BELBUCA...... 22 bi-mix...... 123 BAYER LOW DOSE...... 23 belladonna alkaloids-opium.....114 BINOSTO...... 92 BD AUTOSHIELD...... 148 BELRAPZO...... 37 biocel...... 191 BD AUTOSHIELD DUO.... 148 BELSOMRA...... 74 BIONECT...... 237 BD INSULIN SYRINGE benazepril hcl...... 46 BIOSCANNER GLUCOSE ...... 148, 149 benazepril-hydrochlorothiazide.46 TEST...... 150 BENEFIX...... 130 245 BIOTEL CARE BLOOD Bupap...... 15 CARAC...... 220 GLUCOSE SYST...... 150 bupivacaine hcl...... 24 CARAFATE...... 119 bisoprolol fumarate...... 52 buprenorphine hcl...... 22 CARBAGLU...... 104 bisoprolol-hydrochlorothiazide..52 buprenorphine hcl-naloxone hcl.18 carbamazepine...... 60 bivalirudin rtu...... 126 bupropion hcl...... 65 carbamazepine er...... 59, 60 BIVIGAM...... 140 bupropion hcl er (smoking det).82 carbidopa...... 67 BLEPHAMIDE...... 204 bupropion hcl er (sr)...... 65 carbidopa-levodopa...... 68 BLEPHAMIDE S.O.P...... 204 bupropion hcl er (xl)...... 65 carbidopa-levodopa er...... 68 Blisovi 24 Fe...... 95 buspirone hcl...... 76 carbidopa-levodopa-entacapone 68 Blisovi Fe 1.5/30...... 95 butalbital-acetaminophen...... 16 carbinoxamine maleate...... 211 Blisovi Fe 1/20...... 95 butalbital-apap-caff-cod...... 19 CARDIOCOM LANCING blood glucose monitor system..150 butalbital-apap-caffeine...... 16 DEVICE...... 150 blood glucose system pak...... 150 butalbital-asa-caff-codeine...... 19 CARDIZEM...... 54 blood glucose test...... 150 butalbital-aspirin-caffeine...... 16 CARDIZEM CD...... 54 BLULINK GLUCOSE butorphanol tartrate...... 19 CARDIZEM LA...... 54 MONITORING SYS...... 150 BUTRANS...... 23 CARDURA XL...... 122 BLULINK GLUCOSE TEST BYDUREON BCISE...... 87 CAREFINE PEN NEEDLES ...... 150 BYETTA 10 MCG PEN...... 87 ...... 150 BOCASAL...... 239 BYETTA 5 MCG PEN...... 87 careone advanced lancing dev..150 BONJESTA...... 115 BYSTOLIC...... 52 CAREONE BLOOD boric acid...... 231 cabergoline...... 110 GLUCOSE SYSTEM...... 150 bortezomib...... 45 CABLIVI...... 127 CAREONE BLOOD bosentan...... 58 CABOMETYX...... 42 GLUCOSE TEST...... 150 BOSULIF...... 42 CADIRAMD...... 229 careone insulin syringe...... 150 BOTOX...... 80 CAFERGOT...... 75 CAREONE LANCET bp vit 3...... 131 caffeine citrate...... 76 SUPER THIN 30G...... 150 bp wash...... 218 CALCIFOL...... 191 careone lancet thin 23g...... 150 bpco...... 237 calcipotriene...... 223 careone unifine pentips...... 150 b-plex...... 191 calcipotriene-betameth diprop.225 careone unifine pentips plus.....150 b-plex plus...... 191 calcitonin (salmon)...... 110 CARESENS N GLUCOSE BRAFTOVI...... 44 Calcitrene...... 223 SYSTEM...... 150 BREO ELLIPTA...... 217 calcitriol...... 93, 223 CARESENS N GLUCOSE BREXAFEMME...... 25 calcium acetate (phos binder).112 TEST...... 150 BREZTRI AEROSPHERE.. 209 calcium gluconate...... 192 CARESENS N VOICE BRIDION...... 80 CALDOLOR...... 143 SYSTEM...... 150 briellyn...... 95 CALQUENCE...... 42 CARETOUCH ALCOHOL BRILINTA...... 136 CAMBIA...... 16 PREP...... 150 brimonidine tartrate...... 203 Camila...... 95 CARETOUCH INSULIN BRIVIACT...... 59 CAMINO PRO SYRINGE...... 151 bromfenac sodium (once-daily) COMPLETE/GLYTACTIN.192 CARETOUCH ...... 206 Camrese...... 95 LANCING/EJECTOR...... 151 bromocriptine mesylate...... 67 Camrese Lo...... 95 CARETOUCH MONITOR BROMSITE...... 206 CANASA...... 117 SYSTEM...... 151 BROVANA...... 211 candesartan cilexetil...... 48 CARETOUCH PEN BRUKINSA...... 42 candesartan cilexetil-hctz...... 47 NEEDLES...... 151 BRYHALI...... 225 capecitabine...... 38 CARETOUCH SAFETY budesonide...... 117, 216 CAPEX...... 225 LANCETS...... 151 budesonide er...... 107 CAPHOSOL...... 239 CARETOUCH SAFETY bumetanide...... 55 CAPRELSA...... 42 LANCETS 26G...... 151 BUNAVAIL...... 18 captopril...... 46 CARETOUCH TEST...... 151 246 CARETOUCH TWIST CHANTIX STARTING CITRANATAL HARMONY LANCETS 28G...... 151 MONTH PAK...... 82 ...... 192 CARETOUCH TWIST Chateal...... 96 CITRANATAL MEDLEY...192 LANCETS 30G...... 151 Chateal Eq...... 96 CITRANATAL RX...... 192 CARETOUCH TWIST CHEMET...... 93 Claravis...... 218 LANCETS 33G...... 151 CHEMSTRIP K...... 151 CLARINEX-D 12 HOUR.... 213 carisoprodol...... 80 CHEMSTRIP UGK...... 151 clarithromycin...... 34 carisoprodol-aspirin-codeine..... 80 CHENODAL...... 119 clarithromycin er...... 34 CARNITOR...... 93 childrens aspirin...... 23 CLEANLET LANCETS 28G CARNITOR SF...... 93 chlordiazepoxide hcl...... 59 ...... 151 CAROSPIR...... 55 chlordiazepoxide-amitriptyline. 82 clemastine fumarate...... 211 carteolol hcl...... 203 chlordiazepoxide-clidinium..... 114 CLENPIQ...... 118 Cartia Xt...... 54 chlorhexidine gluconate...231, 239 CLEOCIN...... 126 carvedilol...... 52 chloroquine phosphate...... 28 CLEVER CHEK AUTO- carvedilol phosphate er...... 52 chlorpromazine hcl...... 69 CODE SYSTEM...... 151 cascara sagrada...... 118 chlorthalidone...... 55 CLEVER CHEK AUTO- casirivimab...... 32 chlorzoxazone...... 80 CODE TEST...... 151 CAYA...... 144 CHOLBAM...... 119 CLEVER CHEK AUTO- CAYSTON...... 26 cholestyramine...... 50 CODE VOICE...... 151 Caziant...... 96 cholestyramine light...... 49 CLEVER CHEK LANCETS 151 cefaclor...... 33 CHOLEXMAX...... 192 CLEVER CHEK SYSTEM.. 151 cefaclor er...... 33 CHOLEXTRA T/F...... 192 CLEVER CHEK TEST...... 151 cefadroxil...... 33 CIALIS...... 123 CLEVER CHOICE AUTO- cefdinir...... 33 Ciclodan...... 221 CODE SYSTEM...... 151 cefixime...... 33 ciclopirox...... 221 CLEVER CHOICE AUTO- cefpodoxime proxetil...... 33 ciclopirox olamine...... 221 CODE TEST...... 151 cefprozil...... 33 CIFEREX...... 132 CLEVER CHOICE cefuroxime axetil...... 33 cilostazol...... 132 COMFORT EZ...... 151 Celacyn...... 231 CILOXAN...... 205 CLEVER CHOICE CELEBREX...... 15 CIMDUO...... 30 LANCETS 21G...... 152 celecoxib...... 15 cimetidine...... 117 CLEVER CHOICE CELONTIN...... 60 cimetidine hcl...... 117 LANCETS 23G...... 152 CENFOL...... 132 cinacalcet hcl...... 93 CLEVER CHOICE CENTANY...... 220 CINRYZE...... 132 LANCETS 28G...... 152 cephalexin...... 33 CINVANTI...... 115 CLEVER CHOICE MICRO CEQUA...... 132 CIPRO...... 34 SYSTEM...... 152 CEQUR SIMPLICITY CIPRO HC...... 240 CLEVER CHOICE MICRO INSERTER...... 151 CIPRODEX...... 240 TEST...... 152 CERACADE...... 231 ciprofloxacin hcl...... 34, 205, 240 CLEVER CHOICE MINI CERDELGA...... 104 ciprofloxacin-fluocinolone pf.. 240 SYSTEM...... 152 CEREZYME...... 104 citalopram hydrobromide...... 65 CLEVER CHOICE NO CERVIDIL...... 110 CITRANATAL 90 DHA...... 192 CODING...... 152 CETACAINE...... 229 CITRANATAL ASSURE.... 192 CLEVER CHOICE TALK cetirizine hcl...... 211 CITRANATAL B-CALM.... 192 SYSTEM...... 152 CETROTIDE...... 104 CITRANATAL BLOOM..... 192 CLICKFINE PEN cevimeline hcl...... 239 CITRANATAL BLOOM NEEDLES...... 152 CHANTIX...... 82 DHA...... 192 clickfine pen needles...... 152 CHANTIX CONTINUING CITRANATAL DHA...... 192 CLIMARA PRO...... 105 MONTH PAK...... 82 CITRANATAL ESSENCE.. 192 Clindacin Etz...... 218 Clindacin-P...... 218 247 CLINDAGEL...... 218 COMETRIQ (140 MG CORDRAN...... 226 clindamycin hcl...... 26 DAILY DOSE)...... 42 COREG CR...... 52 clindamycin palmitate hcl...... 26 COMETRIQ (60 MG DAILY Coremino...... 36 clindamycin phos-benzoyl DOSE)...... 42 CORLANOR...... 56 perox...... 219 COMFORT ASSIST CORTIFOAM...... 117 clindamycin phosphate.... 126, 219 INSULIN SYRINGE...... 152 CORTISPORIN-TC...... 240 clindamycin-tretinoin...... 219 comfort assured lancets 28g.... 152 CORVITE 150...... 132 CLINDESSE...... 126 comfort assured lancets 33g.... 152 corvite fe...... 132 CLINOIN...... 219 COMFORT EZ INSULIN COSENTYX...... 223 clobazam...... 60 SYRINGE...... 152 COSENTYX (300 MG clobetasol prop emollient base.225 COMFORT EZ MICRO DOSE)...... 223 clobetasol propionate...... 225 PEN NEEDLES...... 152 COSENTYX clobetasol propionate e...... 225 COMFORT EZ PEN SENSOREADY (300 MG)... 223 clobetasol propionate emulsion225 NEEDLES...... 152 COSENTYX CLOBEX SPRAY...... 226 COMFORT EZ SHORT SENSOREADY PEN...... 223 clocortolone pivalate...... 226 PEN NEEDLES...... 152 COSOPT PF...... 203 CLODAN...... 226 comfort lancets...... 153 COTELLIC...... 42 Clodan...... 226 COMFORT TOUCH COTEMPLA XR-ODT...... 72 CLODERM...... 226 LANCETS 31G...... 104 COZAAR...... 48 clomiphene citrate...... 107 COMFORT TOUCH PLUS CREON...... 120 clomipramine hcl...... 77 LANCETS 30G...... 104 CRESEMBA...... 25 clonazepam...... 60 COMPLERA...... 30 CRESTOR...... 51 clonidine...... 56 complete natal dha...... 192 CRINONE...... 112 clonidine hcl...... 56 completenate...... 192 CRIXIVAN...... 28 clonidine hcl er...... 72 Compro...... 115 cromolyn sodium..... 119, 202, 214 clopidogrel bisulfate...... 136 CO-NATAL FA...... 192 CROTAN...... 236 clorazepate dipotassium...... 60 CONCEPT DHA...... 192 CRYODOSE TA...... 229 clotrimazole...... 221, 239 CONCEPT OB...... 192 Cryselle-28...... 96 clotrimazole-betamethasone....221 CONCERTA...... 72 CUPRIMINE...... 93 clozapine...... 69 CONDYLOX...... 231 CURITY ALCOHOL PREPS CLOZARIL...... 70 CONSENSI...... 54 ...... 153 c-nate dha...... 192 constulose...... 118 CURITY ALCOHOL COAGADEX...... 130 CONTOUR MONITOR...... 153 SWABS...... 153 COAGUCHEK LANCETS..152 CONTOUR NEXT EZ...... 153 CURITY HYPERTONIC coal tar...... 231 CONTOUR NEXT LINK.... 153 NACL STRIP...... 237 COARTEM...... 28 CONTOUR NEXT CURITY NACL DRESSING cod liver oil...... 192 MONITOR...... 153 6"X6-3/4"...... 237 codeine sulfate...... 19 CONTOUR NEXT ONE...... 153 Curity Sterile Saline...... 124 COLAZAL...... 117 CONTOUR NEXT TEST.....153 CUROSURF...... 214 colchicine...... 15 CONTOUR TEST...... 153 CUTAQUIG...... 141 colchicine-probenecid...... 15 CONTRAVE...... 77 CUVITRU...... 141 COLCRYS...... 15 CONVENIENCE PAK...... 81 CUVPOSA...... 114 colesevelam hcl...... 50 CONZIP...... 19 CVS ADVANCED colestipol hcl...... 50 COOL BLOOD GLUCOSE GLUCOSE TEST...... 153 COLLATYL...... 237 TEST STRIPS...... 153 cvs aspirin low dose...... 23 COMBIGAN...... 203 COOL MONITOR...... 153 cvs aspirin low strength...... 23 COMBIPATCH...... 105 COOL MONITOR KIT...... 153 CVS BLOOD GLUCOSE COMBIVENT RESPIMAT..209 COPASIL...... 231 METER...... 153 COMETRIQ (100 MG COPAXONE...... 78 cvs folic acid...... 192 DAILY DOSE)...... 42 COPIKTRA...... 42 cvs glucose...... 109 248 cvs glucose meter test strips.... 153 D-CARE GLUCOMETER.. 154 dexamethasone sodium CVS KETONE CARE...... 153 Deblitane...... 96 phosphate...... 108, 206 cvs lancets 21g...... 153 Decadron...... 107 dexchlorpheniramine maleate. 211 cvs lancets micro thin 33g...... 153 deferasirox...... 93 DEXCOM G4 PLAT PED cvs lancets original...... 153 deferoxamine mesylate...... 93 RCV/SHARE...... 154 cvs lancets thin 26g...... 153 DEFITELIO...... 126 DEXCOM G4 PLAT PED cvs lancets ultra thin 30g...... 153 DELESTROGEN...... 105 RECEIVER...... 154 cvs lancets ultra-thin 30g...... 153 DELSTRIGO...... 30 DEXCOM G4 PLATINUM cvs lancing device...... 153 Delyla...... 96 RCV/SHARE...... 154 cvs nicotine...... 82 DELZICOL...... 117 DEXCOM G4 PLATINUM cvs nicotine polacrilex...... 82 demeclocycline hcl...... 36 RECEIVER...... 154 cvs prep...... 153 DEMSER...... 56 DEXCOM G4 PLATINUM cvs ultra thin lancets...... 153 DENAVIR...... 231 TRANSMITTER...... 154 cyanocobalamin...... 193 DEPEN TITRATABS...... 93 DEXCOM G4 SENSOR...... 154 Cyclafem 1/35...... 96 DEPO-ESTRADIOL...... 105 DEXCOM G5 MOB/G4 Cyclafem 7/7/7...... 96 DEPO-SUBQ PROVERA PLAT SENSOR...... 154 cyclobenzaprine hcl...... 80 104...... 96 DEXCOM G5 MOBILE cyclobenzaprine hcl er...... 80 DEPO-TESTOSTERONE...... 84 RECEIVER...... 154 CYCLOMYDRIL...... 132 DERMACINRX AZENASE DEXCOM G5 MOBILE cyclopentolate hcl...... 132 PAK...... 210 TRANSMITTER...... 154 cyclophosphamide...... 37 DERMACINRX DEXCOM G5 RECEIVER cycloserine...... 31 CLORHEXACIN...... 231 KIT...... 154 CYCLOSET...... 86 DERMACINRX DEXCOM G6 RECEIVER.. 154 cyclosporine...... 142 LEXITRAL PHARMAPAK 231 DEXCOM G6 SENSOR...... 154 CYCLOSPORINE IN DERMACINRX PHN...... 229 DEXCOM G6 KLARITY...... 132 dermacinrx surgical combopak232 TRANSMITTER...... 154 cyclosporine modified...... 142 DERMACINRX DEXERYL...... 232 CYMBALTA...... 65 THERAZOLE PAK...... 221 Dexifol...... 193 cyproheptadine hcl...... 211 DERMACINRX ZRM...... 229 DEXILANT...... 121 Cyred...... 96 dermovix...... 232 dexmethylphenidate hcl...... 72 Cyred Eq...... 96 DESCOVY...... 30 dexmethylphenidate hcl er...... 72 CYSTADANE...... 104 DESFERAL...... 93 DEXONTO 0.4%...... 108 CYSTAGON...... 104 desipramine hcl...... 65 DEXTENZA...... 206 CYSTARAN...... 132 desloratadine...... 211 dextroamphetamine sulfate...... 73 CYTOMEL...... 113 desmopressin ace spray refrig. 114 dextroamphetamine sulfate er...73 cytra k crystals...... 124 desmopressin acetate...... 114 dextrose...... 109 dalfampridine er...... 78 desmopressin acetate spray..... 114 dextrose-nacl...... 190 DALIRESP...... 214 desogestrel-ethinyl estradiol...... 96 dextrose-sodium chloride...... 190 danazol...... 104 DESONATE...... 226 DEXYCU...... 206 dantrolene sodium...... 80 desonide...... 226 dfs dr/ms/menth/cap pak...... 16 dapsone...... 26, 219 desoximetasone...... 226 dfs/ms/menth/cap pak...... 232 DARAPRIM...... 26 desvenlafaxine succinate er...... 65 DIACOMIT...... 60 darifenacin hydrobromide er... 125 DETROL LA...... 125 DIASTAT ACUDIAL...... 60 Dasetta 1/35...... 96 DEX4...... 109 DIASTAT PEDIATRIC...... 60 Dasetta 7/7/7...... 96 DEX4 NATURALS...... 109 DIASTIX...... 154 DAURISMO...... 38 DEX4 POUCH PACK...... 109 DIATHRIVE BLOOD Daysee...... 96 dexamethasone...... 107 GLUCOSE METER...... 154 DAYTRANA...... 72 dexamethasone (la)...... 107 DIATHRIVE BLOOD D-CARE BLOOD DEXAMETHASONE GLUCOSE TEST...... 154 GLUCOSE...... 154 INTENSOL...... 107 249 DIATHRIVE GLUCOSE diphen...... 211 dual complex formula 1 kit..... 232 TEST...... 154 diphenhydramine hcl...... 211 DUAVEE...... 105 DIATHRIVE LANCET diphenoxylate-atropine...... 119 DUET DHA 400...... 193 ULTRA THIN 30...... 154 dipyridamole...... 136 DUET DHA BALANCED...193 DIATHRIVE LANCETS..... 154 disopyramide phosphate...... 49 DUEXIS...... 18 DIATHRIVE LANCING disulfiram...... 82 DULERA...... 210 DEVICE...... 154 DIURIL...... 56 duloxetine hcl...... 65 DIATHRIVE PEN NEEDLE divalproex sodium...... 60 DUOBRII...... 226 ...... 155 divalproex sodium er...... 60 DUO-CARE TEST...... 155 DIATHRIVE+ GLUCOSE DIVIGEL...... 105 DUOPA...... 68 MONITOR...... 155 dofetilide...... 49 DUOVISC...... 207 DIATHRIVE+ GLUCOSE donepezil hcl...... 64 DUPIXENT...... 216, 224 TEST...... 155 DOPTELET...... 128 DURAGESIC-100...... 19 diatrue plus blood glucose...... 155 DORYX...... 36 DURAGESIC-12...... 19 diatrue plus test...... 155 DORYX MPC...... 36 DURAGESIC-25...... 19 diazepam...... 60 dorzolamide hcl...... 203 DURAGESIC-50...... 19 diclofenac epolamine...... 232 dorzolamide hcl-timolol mal....203 DURAGESIC-75...... 20 diclofenac potassium...... 16 dorzolamide hcl-timolol mal pf203 DUREZOL...... 206 diclofenac sodium.16, 32, 206, 232 Dotti...... 105 DURLAZA...... 132 diclofenac sodium er...... 16 double pm...... 204 DUROLANE...... 24 diclofenac-misoprostol...... 18 DOVATO...... 30 dutasteride...... 122 DICLOFONO...... 232 doxazosin mesylate...... 47 dutasteride-tamsulosin hcl...... 122 diclopr...... 232 doxepin hcl...... 65, 223 DUTOPROL...... 52 diclovix...... 232 doxercalciferol...... 93 DXEVO 11-DAY...... 108 dicloxacillin sodium...... 35 doxycycline...... 235 d-xylose...... 155 diclozor...... 232 doxycycline hyclate...... 36 DYANAVEL XR...... 73 dicyclomine hcl...... 114 doxycycline monohydrate...... 36 DYMISTA...... 210 DIFFERIN...... 219 doxylamine-pyridoxine...... 115 DYRENIUM...... 56 DIFICID...... 34 dronabinol...... 115 DYSPORT...... 80 diflorasone diacetate...... 226 DROPLET INSULIN E.E.S. 400...... 34 diflunisal...... 23 SYRINGE...... 155 E.E.S. GRANULES...... 34 Digitek...... 55 DROPLET LANCETS easy comfort alcohol pads...... 155 Digox...... 55 ULTRA THIN 30G...... 155 easy comfort insulin syringe....155 digoxin...... 55 DROPLET LANCING easy comfort lancets...... 155 dihydroergotamine mesylate..... 75 DEVICE...... 155 easy comfort lancets twist top. 155 DILANTIN...... 60 DROPLET MICRON...... 155 easy comfort pen needles...... 156 DILANTIN INFATABS...... 60 DROPLET PEN NEEDLES 155 easy glide pen needles...... 156 DILATRATE-SR...... 57 DROPLET PERSONAL easy mini eject lancing device..156 DILAUDID...... 19 LANCETS 30G...... 155 easy mini lancing device...... 156 diltiazem hcl...... 54 dropsafe safety pen needles..... 155 easy plus ii glucose system...... 156 diltiazem hcl er...... 54 drospiren-eth estrad-levomefol..96 easy plus ii glucose test...... 156 diltiazem hcl er beads...... 54 drospirenone-ethinyl estradiol...96 EASY STEP GLUCOSE diltiazem hcl er coated beads.... 54 DROXIA...... 44 MONITOR...... 156 dilt-xr...... 54 drug mart lancets thin 26g...... 155 EASY STEP TEST...... 156 dimentho...... 232 DRUG MART ON-THE-GO easy talk blood glucose system 156 dimethyl fumarate...... 78 LANCET 30G...... 155 easy talk blood glucose test.....156 dimethyl fumarate starter pack.78 drug mart unifine pentips...... 155 EASY TOUCH ALCOHOL DIOVAN...... 48 drug mart unifine pentips plus. 155 PREP MEDIUM...... 156 DIOVAN HCT...... 47 DRYSOL...... 232 EASY TOUCH FLIPLOCK DIPENTUM...... 117 DSUVIA...... 19 INSULIN SY...... 156 250 EASY TOUCH GLUCOSE EDLUAR...... 74 EMEND...... 115, 116 SYSTEM...... 156 ed-spaz...... 114 EMEND TRI-PACK...... 116 EASY TOUCH INSULIN EDURANT...... 28 EMFLAZA...... 108 SAFETY SYR...... 156 efavirenz...... 28 EMGALITY...... 75 EASY TOUCH INSULIN EFFER-K...... 190 EMGALITY (300 MG SYRINGE...... 156 Effer-K...... 190 DOSE)...... 75 EASY TOUCH LANCETS EFFEXOR XR...... 65 Emoquette...... 97 21G...... 156 ELEMENT AUTOCODE EMSAM...... 65 EASY TOUCH LANCETS SYSTEM...... 157 EMTRIVA...... 28 23G...... 156 element compact glucose EMULSION SB...... 232 EASY TOUCH LANCETS system...... 157 EMVERM...... 26 28G...... 156 element compact test...... 157 ENABLEX...... 125 EASY TOUCH LANCETS element compact v glucose sys.157 enalapril maleate...... 46 30G...... 156 ELEMENT PLUS...... 157 enalapril-hydrochlorothiazide... 46 EASY TOUCH LANCETS ELEMENT TEST...... 157 ENBRACE HR...... 193 32G...... 156 ELESTRIN...... 105 ENBREL...... 137 EASY TOUCH LANCING ELETONE...... 232 ENBREL MINI...... 137 DEVICE...... 156 eletriptan hydrobromide...... 75 ENBREL SURECLICK...... 137 EASY TOUCH PEN ELIDEL...... 232 ENCARE...... 123 NEEDLES...... 156 ELIGARD...... 40 ENDARI...... 132 EASY TOUCH SAFETY Elinest...... 96 Endocet...... 20 PEN NEEDLES...... 157 ELIQUIS...... 126 ENDOMETRIN...... 125 EASY TOUCH ELIQUIS DVT/PE ENLITE GLUCOSE SHEATHLOCK SYRINGE.157 STARTER PACK...... 126 SENSOR...... 158 EASY TOUCH TEST...... 157 ELIXOPHYLLIN...... 217 ENLITE SERTER...... 158 easy trak blood glucose system157 ELLA...... 96 enovarx-diclofenac sodium...... 232 easy trak blood glucose test.... 157 ELMIRON...... 124 enoxaparin sodium...... 126 easy trak ii blood glucose sys.. 157 ELOCTATE...... 129 Enpresse-28...... 97 easy trak ii glucose test...... 157 Eluryng...... 97 Enskyce...... 97 EASYGLUCO...... 157 EMBRACE BLOOD ENSTILAR...... 226 EASYMAX 15 TEST...... 157 GLUCOSE MONITOR...... 158 entacapone...... 68 EASYMAX NG BLOOD EMBRACE BLOOD entecavir...... 32 GLUCOSE...... 157 GLUCOSE TEST...... 158 ENTERAGAM...... 193 EASYMAX TEST...... 157 EMBRACE EVO BLOOD ENTEREG...... 119 EASYMAX V BLOOD GLUCOSE TEST...... 158 ENTRESTO...... 56 GLUCOSE...... 157 EMBRACE EVO GLUCOSE ENTTY SPRAY...... 232 EASYPRO BLOOD MONITORING...... 158 ENTYVIO...... 137 GLUCOSE MONITOR...... 157 EMBRACE LANCETS enulose...... 118 EASYPRO BLOOD ULTRA THIN 30G...... 158 enzadyne...... 120 GLUCOSE TEST...... 157 EMBRACE PRO GLUCOSE EPANED...... 46 EASYPRO PLUS...... 157 METER...... 158 EPCLUSA...... 35 econazole nitrate...... 221 EMBRACE PRO GLUCOSE EPICERAM...... 232 ECONTRA EZ...... 96 TEST...... 158 EPICYN...... 232 ECONTRA ONE-STEP...... 96 EMBRACE TALK BLOOD EPIDIOLEX...... 60 ECOZA...... 221 GLUCOSE...... 158 EPIDUO FORTE...... 219 ec-rx estradiol...... 105 EMBRACE TALK EPIFOAM...... 229 ec-rx progesterone...... 112 GLUCOSE TEST...... 158 epinastine hcl...... 202 ec-rx testosterone...... 84 EMBRACE TALK epinephrine...... 209, 214 EDARBI...... 48 MONITORING SYSTEM... 158 epinephrine professional...... 209 EDARBYCLOR...... 47 EMCYT...... 37 EPINEPHRINESNAP-EMS 209 251 EPINEPHRINESNAP-V...... 209 ESTRING...... 106 EZALLOR SPRINKLE...... 51 EPISNAP...... 209 ESTROGEL...... 106 ezetimibe...... 50 Epitol...... 60 eszopiclone...... 74 ezetimibe-simvastatin...... 51 eplerenone...... 47 etesevimab...... 143 EZ-LETS LANCETS 21G.... 159 epoprostenol sodium...... 58 ethacrynic acid...... 56 EZ-LETS LANCETS 26G.... 159 eq blood glucose test...... 158 ethambutol hcl...... 31 EZ-LETS LANCETS 28G.... 159 eq famotidine max st...... 117 ethosuximide...... 60, 61 EZ-LETS LANCETS 30G.... 159 eq nicotine...... 82 ethynodiol diac-eth estradiol..... 97 FA-8...... 193 eq nicotine polacrilex...... 82 etodolac...... 16 fabb...... 132 eq nicotine step 3...... 82 etodolac er...... 16 FABIOR...... 219 eql alcohol swabs...... 158 etonogestrel-ethinyl estradiol....97 Falmina...... 97 eql aspirin low dose...... 23 etoposide...... 45 famciclovir...... 32 eql color lancets 21g...... 158 EUCRISA...... 232 famotidine...... 117 eql color lancets micro 33g...... 158 EUFLEXXA...... 24 FANAPT...... 70 eql insulin syringe...... 158 Euthyrox...... 113 FANAPT TITRATION eql nicotine polacrilex...... 82 EVAMIST...... 106 PACK...... 70 eql super thin lancets 30g...... 158 EVEKEO...... 73 FANATREX FUSEPAQ...... 61 eql thin lancets 26g...... 158 EVEKEO ODT...... 73 FARXIGA...... 91 EQUETRO...... 70 EVENITY...... 110 FARYDAK...... 38 ergocal...... 193 EVERSENSE FASENRA...... 212 ergocalciferol...... 193 SENSOR/HOLDER...... 158 FASENRA PEN...... 212 ergoloid mesylates...... 64 EVERSENSE SMART FASLODEX...... 40 ERGOMAR...... 75 TRANSMITTER...... 158 favipiravir...... 32 ergotamine-caffeine...... 75 EVIVO...... 119 fa-vitamin b-6-vitamin b-12.....132 ERIVEDGE...... 38 EVOLUTION AUTOCODE 158 Fayosim...... 97 ERLEADA...... 40 EVOMELA...... 37 FC FEMALE CONDOM..... 144 erlotinib hcl...... 42 EVOTAZ...... 30 FC2 FEMALE CONDOM... 144 Errin...... 97 EVRYSDI...... 77 febuxostat...... 15 ERTACZO...... 221 EXACTECH R-S-G TEST... 159 FEIBA...... 127 ERWINAZE...... 44 EXACTECH TEST...... 159 felbamate...... 61 ery...... 219 EXEL COMFORT POINT felodipine er...... 54 ERYPED 200...... 34 INSULIN SYR...... 159 FEMCAP...... 144 ERYPED 400...... 34 EXEL COMFORT POINT FEMRING...... 106 Ery-Tab...... 34 PEN NEEDLE...... 159 Femynor...... 97 ERYTHROCIN STEARATE 34 EXELDERM...... 221 fenofibrate...... 50 erythromycin...... 34, 205, 219 exemestane...... 40 fenofibrate micronized...... 50 erythromycin base...... 34 EXFORGE...... 47 fenofibric acid...... 50 erythromycin ethylsuccinate..... 34 EXFORGE HCT...... 47 FENOGLIDE...... 50 ESBRIET...... 214 EXJADE...... 93 fenoprofen calcium...... 16 escitalopram oxalate...... 65 EXTAVIA...... 78 FENORTHO...... 16 Esgic...... 16 EXTINA...... 221 FENSOLVI (6 MONTH)...... 104 ESKATA...... 224 EYLEA...... 208 fentanyl...... 20 esomeprazole magnesium...... 121 E-Z JECT LANCET fentanyl citrate...... 20 ESPEROCT...... 129 MICRO-THIN 33G...... 159 FENTORA...... 20 essentra wipes 9x9"...... 232 E-Z JECT LANCET SUPER FERIVA 21/7...... 132 Estarylla...... 97 THIN 30G...... 159 ferocon...... 132 estazolam...... 74 E-Z JECT LANCETS...... 159 ferotrinsic...... 132 estradiol...... 105, 106 E-Z JECT LANCETS 21G....159 ferraplus 90...... 132 estradiol valerate...... 106 E-Z JECT LANCETS THIN FERRIPROX...... 93 estradiol-norethindrone acet... 106 26G...... 159 252 FERRIPROX TWICE-A- fludrocortisone acetate...... 108 FORA D15G BLOOD DAY...... 94 flunisolide...... 215 GLUCOSE TEST...... 159 Ferrocite Plus...... 132 fluocinolone acetonide..... 226, 240 FORA D20 BLOOD FERRO-PLEX fluocinolone acetonide body.... 226 GLUCOSE TEST...... 159 HEMATINIC...... 132 fluocinolone acetonide scalp....226 FORA D40 FETZIMA...... 65 fluocinonide...... 226, 227 GLUCOSE/PRESSURE...... 159 FETZIMA TITRATION...... 65 fluocinonide emulsified base....226 FORA D40/G31 BLOOD FEXMID...... 80 fluorescein-benoxinate...... 132 GLUCOSE...... 160 FIASP...... 88 Fluor-I-Strips A.T...... 132 FORA D40G FIASP FLEXTOUCH...... 88 fluoritab...... 193 GLUCOSE/PRESSURE...... 160 FIASP PENFILL...... 88 fluorometholone...... 206 FORA G20 BLOOD FIBRICOR...... 50 FLUOROPLEX...... 220 GLUCOSE SYSTEM...... 160 FIFTY50 GLUCOSE fluorouracil...... 220 FORA G20 BLOOD METER 2.0...... 159 fluovix...... 227 GLUCOSE TEST...... 160 FIFTY50 GLUCOSE TEST fluoxetine hcl...... 66 FORA G30/PREM V10 2.0...... 159 fluoxetine hcl (pmdd)...... 66 GLUCOSE TEST...... 160 FIFTY50 PEN NEEDLES... 159 fluphenazine decanoate...... 70 FORA G30A BLOOD FIFTY50 SUPERIOR fluphenazine hcl...... 70 GLUCOSE SYSTEM...... 160 COMFORT SYR...... 159 flurandrenolide...... 227 FORA GD20 BLOOD FIFTY50 UNILET FLURA-SAFE...... 133 GLUCOSE SYSTEM...... 160 LANCETS 33G...... 159 flurazepam hcl...... 74 FORA GD20 TEST...... 160 FINACEA...... 236 flurbiprofen...... 16 FORA GD50 BLOOD finasteride...... 122 flurbiprofen sodium...... 206 GLUCOSE SYSTEM...... 160 FINGERSTIX LANCETS... 159 flutamide...... 40 FORA GD50 BLOOD FINTEPLA...... 61 fluticasone propionate..... 215, 227 GLUCOSE TEST...... 160 FIORICET...... 16 fluticasone-salmeterol...... 210 FORA GTEL BLOOD FIRAZYR...... 132 fluvastatin sodium...... 51 GLUCOSE SYSTEM...... 160 FIRDAPSE...... 77 fluvastatin sodium er...... 51 FORA GTEL BLOOD FIRMAGON...... 40 fluvoxamine maleate...... 77 GLUCOSE TEST...... 160 FIRMAGON (240 MG fluvoxamine maleate er...... 77 FORA GTEL BLOOD DOSE)...... 40 FML...... 207 KETONE TEST...... 160 FIRST-BACLOFEN...... 80 FML FORTE...... 206 FORA LANCETS...... 160 FIRST-METRONIDAZOLE.26 FML LIQUIFILM...... 206 FORA LANCING DEVICE 160 FIRVANQ...... 26 FOCALIN XR...... 73 FORA PREMIUM V10 BLE Flac...... 240 folbee...... 133 SYSTEM...... 160 FLAREX...... 206 folbee plus...... 193 FORA TEST N' GO flavoxate hcl...... 119 FOLBEE PLUS CZ...... 193 MONITOR...... 160 FLEBOGAMMA DIF...... 141 FOLGARD OS...... 193 FORA TN'G VOICE...... 160 flecainide acetate...... 49 folic acid...... 193 FORA TN'G/TN'G VOICE.. 160 FLECTOR...... 232 folic-k...... 193 FORA V10 BLOOD FLEXBUMIN...... 136 FOLI-D...... 133 GLUCOSE SYSTEM...... 160 FLOLAN...... 58 folite...... 133 FORA V10 BLOOD flolipid...... 51 FOLIVANE-OB...... 193 GLUCOSE TEST...... 160 FLORIVA...... 193 folplex 2.2...... 133 FORA V12 BLOOD FLORIVA PLUS...... 193 foltrin...... 133 GLUCOSE SYSTEM...... 161 FLOVENT DISKUS...... 217 Folvite-D...... 133 FORA V12 BLOOD FLOVENT HFA...... 217 fondaparinux sodium...... 127 GLUCOSE TEST...... 161 FLUAD QUADRIVALENT143 FORA 6 CONNECT...... 159 FORA V20 BLOOD fluconazole...... 25 FORA BLOOD GLUCOSE GLUCOSE SYSTEM...... 161 flucytosine...... 25 TEST...... 159 253 FORA V20 BLOOD FREESTYLE LIBRE 14 GEBAUERS SPRAY AND GLUCOSE TEST...... 161 DAY SENSOR...... 162 STRETCH...... 229 FORA V30A BLOOD FREESTYLE LIBRE 2 GELCLAIR...... 239 GLUCOSE SYSTEM...... 161 READER...... 162 GELFILM...... 133 FORA V30A BLOOD FREESTYLE LIBRE 2 GEL-FLOW...... 133 GLUCOSE TEST...... 161 SENSOR...... 162 GELFOAM-JMI POWDER.133 FORACARE GD40 FREESTYLE LIBRE GELFOAM-JMI SPONGE.. 133 MONITOR...... 161 READER...... 162 GELNIQUE...... 125 FORACARE GD40 TEST....161 FREESTYLE LIBRE GEL-ONE...... 24 FORACARE PREMIUM SENSOR SYSTEM...... 162 GELSYN-3...... 24 V10...... 161 FREESTYLE LITE...... 162 gemfibrozil...... 50 FORACARE PREMIUM FREESTYLE LITE TEST....162 GENADUR...... 232 V10 TEST...... 161 FREESTYLE PRECISION generlac...... 118 FORACARE TEST N GO INS SYR...... 162 Gengraf...... 142 MONITOR...... 161 FREESTYLE PRECISION GENICIN VITA-D...... 133 FORACARE TEST N GO NEO SYSTEM...... 162 GENICIN VITA-Q...... 193 TEST...... 161 FREESTYLE PRECISION Genicin Vita-S...... 194 formaldehyde...... 232 NEO TEST...... 162 GENTAK...... 205 FORTAZ...... 33 FREESTYLE SIDEKICK II 162 gentamicin sulfate...... 205, 220 FORTEO...... 110 FREESTYLE TEST...... 162 GENTEEL BUTTERFLY FORTESTA...... 84 FREESTYLE UNISTICK II TOUCH LANCET...... 162 FORTISCARE G1 TEST LANCETS...... 162 GENTEEL CONTACT TIPS STRIP...... 161 frovatriptan succinate...... 75 (BLUE)...... 162 FORTISCARE GLUCOSE fungimez...... 222 GENTEEL CONTACT TIPS SYSTEM...... 161 furosemide...... 56 (CLEAR)...... 162 FORTISCARE T1 FUSION PLUS...... 133 GENTEEL CONTACT TIPS GLUCOSE SYSTEM...... 161 FUZEON...... 28 (GREEN)...... 162 FORTISCARE TEST...... 161 Fyavolv...... 106 GENTEEL CONTACT TIPS FOSAMAX PLUS D...... 92 FYCOMPA...... 61 (ORANGE)...... 163 fosamprenavir calcium...... 28 g tussin ac...... 213 GENTEEL CONTACT TIPS fosinopril sodium...... 46 gabapentin...... 61 (RAINBOW)...... 163 fosinopril sodium-hctz...... 46 GALAFOLD...... 110 GENTEEL CONTACT TIPS FOSRENOL...... 112 galantamine hydrobromide...... 64 (VIOLET)...... 163 FOSTEUM...... 193 galantamine hydrobromide er... 64 GENTEEL CONTACT TIPS FOSTEUM PLUS...... 193 GALAXTRA...... 193 (YELLOW)...... 163 FRAGMIN...... 127 GALZIN...... 190 GENTEEL LANCING KIT freds pharmacy autolet lancing161 GAMIFANT...... 142 (BLUE)...... 163 freds pharmacy unifine pentip+ GAMMAGARD...... 141 GENTEEL NOZZLES...... 163 ...... 161 GAMMAGARD S/D LESS GENTEEL PLUS freds pharmacy unifine pentips 161 IGA...... 141 LANCING (BLACK)...... 163 FREESTYLE FREEDOM... 161 GAMMAKED...... 141 GENTEEL PLUS FREESTYLE FREEDOM GAMMAPLEX...... 141 LANCING (PURPLE)...... 163 LITE...... 162 GAMUNEX-C...... 141 GENTEEL PLUS FREESTYLE INSULINX ganirelix acetate...... 107 LANCING (WHITE)...... 163 SYSTEM...... 162 gatifloxacin...... 205 GENTEEL PLUS FREESTYLE INSULINX GATTEX...... 119 LANCING DEV(BLUE)...... 163 TEST...... 162 ge100 blood glucose system.....162 GENTEEL PLUS FREESTYLE LIBRE 14 ge100 blood glucose test...... 162 LANCING DEV(PINK)...... 163 DAY READER...... 162 GEBAUERS PAIN EASE.... 229 GENTLE-LET GP LANCETS...... 163 254 GENTLE-LET LANCETS...163 GLUCOCARD SHINE g-myco nail...... 222 GENTLE-LET CONNEX...... 164 gnp adult aspirin low strength... 23 PLATFORMS...... 163 GLUCOCARD SHINE gnp alcohol swabs...... 165 GENULTIMATE TEST...... 163 EXPRESS...... 164 gnp aspirin...... 23 GENVISC 850...... 24 GLUCOCARD SHINE gnp clickfine pen needles...... 165 GENVOYA...... 30 TEST...... 164 GNP EASY TOUCH GEODON...... 70 GLUCOCARD SHINE XL..164 GLUCOSE METER...... 165 ght blood glucose monitor...... 163 GLUCOCARD VITAL gnp easy touch glucose test..... 165 ght test...... 163 MONITOR...... 164 gnp glucose...... 109 GIALAX...... 118 GLUCOCARD VITAL gnp insulin syringe...... 165 GIAPREZA...... 214 TEST...... 164 gnp lancets 21g...... 165 GILENYA...... 78 GLUCOCARD X-METER.. 164 gnp lancets micro thin 33g...... 165 GILOTRIF...... 44 GLUCOCARD X-SENSOR.164 gnp lancets thin...... 165 GILPHEX TR...... 213 GLUCOCOM BLOOD gnp lancets thin 26g...... 165 GLASSIA...... 214 GLUCOSE MONITOR...... 164 gnp nicotine...... 82 glatiramer acetate...... 78 GLUCOCOM LANCETS gnp nicotine mini...... 82 Glatopa...... 78 28G...... 164 gnp nicotine polacrilex...... 82 GLEOLAN...... 163 GLUCOCOM LANCETS gnp ulticare pen needles...... 165 GLEOSTINE...... 37 30G...... 164 gnp ultra com insulin syringe...165 GLIADEL WAFER...... 37 GLUCOCOM LANCETS GOCOVRI...... 68 glimepiride...... 92 33G...... 164 GOJJI BLOOD GLUCOSE glipizide...... 92 GLUCOCOM MONITOR... 164 TEST...... 165 glipizide er...... 92 GLUCOCOM TEST...... 164 GOJJI BLOOD TEST glipizide xl...... 92 GLUCONAVII BLOOD STRIP/LANCETS...... 165 glipizide-metformin hcl...... 86 GLUCOSE SYS...... 165 GOJJI STERILE LANCETS 165 global alcohol prep ease...... 163 GLUCONAVII BLOOD GOLYTELY...... 118 global ease inject pen needles.. 163 GLUCOSE TEST...... 165 GONAL-F...... 107 global easy glide insulin syr.....163 GLUCOPRO INSULIN GONAL-F RFF...... 107 global easy glide pen needles... 163 SYRINGE...... 165 GONAL-F RFF REDIJECT 107 global inject ease insulin syr....163 GLUCOPRO SYR RES 3ML GONITRO...... 57 global inject ease lancets 28g.. 163 22GX3/8"...... 165 goodsense blood glucose...... 165 global inject ease lancets 30g.. 163 glucose...... 109 goodsense clickfine pen needle.165 global insulin syringes...... 163 glucose instant energy...... 109 goodsense glucose...... 109 global lancing device...... 163 glucose meter test...... 165 goodsense lancets 26g univ...... 165 GLUCAGEN HYPOKIT..... 109 GLUMETZA...... 85 goodsense lancets 30g univ...... 165 glucagon emergency...... 109 glutaraldehyde...... 232 goodsense lancets 33g univ...... 166 GLUCO PERFECT 3 glyburide...... 92 goodsense lancing device...... 166 METER...... 163 glyburide micronized...... 92 goodsense nicotine...... 82 GLUCO PERFECT 3 TEST.164 glyburide-metformin...... 86 GOODSENSE PEN GLUCOCARD 01 BLOOD GLYCATE...... 114 NEEDLE PENFINE...... 166 GLUCOSE...... 164 glycine...... 124 goprelto...... 229 GLUCOCARD 01 SENSOR glycolic acid...... 224 GORDOFILM...... 232 PLUS...... 164 glycopyrrolate...... 114 granisetron hcl...... 116 GLUCOCARD 01-MINI Glydo...... 229 GRASTEK...... 137 GLUCOSE...... 164 GLYRX-PF...... 114 GREEN GLO LISSAMINE GLUCOCARD GLYTACTIN BUILD 10PE.194 GREEN...... 133 EXPRESSION MONITOR.. 164 GLYTACTIN COMPLETE griseofulvin microsize...... 25 GLUCOCARD 10PE...... 194 griseofulvin ultramicrosize...... 25 EXPRESSION TEST...... 164 GLYTACTIN SWIRL 15PE.194 guaiatussin ac...... 213 GLYXAMBI...... 91 guaifenesin-codeine...... 213 255 guanfacine hcl...... 56 H-E-B INCONTROL HUMIRA PEN- guanfacine hcl er...... 73 UNIFINE PENTIP...... 166 PS/UV/ADOL HS START....138 GUARDIAN CONNECT HEMANGEOL...... 53 HUMIRA PEN- TRANSMITTER...... 166 hematinic plus vit/minerals...... 133 PSOR/UVEIT STARTER.... 138 GUARDIAN LINK 3 hematinic/folic acid...... 133 HUMULIN 70/30...... 88 TRANSMITTER...... 166 HEMLIBRA...... 133 HUMULIN 70/30 GUARDIAN REAL-TIME HEMOCYTE PLUS...... 133 KWIKPEN...... 88 CHARGER...... 166 Hemocyte-F...... 133 HUMULIN N...... 89 GUARDIAN REAL-TIME HEMOFIL M...... 129 HUMULIN N KWIKPEN.....89 TEST PLUG...... 166 heparin sodium (porcine)...... 127 HUMULIN R...... 89 GUARDIAN SENSOR (3)...166 heparin sodium (porcine) pf... 127 HUMULIN R U-500 guardian sensor 3...... 166 hepmed...... 127 (CONCENTRATED)...... 89 GVOKE HYPOPEN 1- HERCEPTIN...... 39 HUMULIN R U-500 PACK...... 109 HERCEPTIN HYLECTA...... 44 KWIKPEN...... 89 GVOKE HYPOPEN 2- HETLIOZ...... 74 HW EMBRACE PRO PACK...... 109 HETLIOZ LQ...... 74 GLUCOSE METER...... 167 GVOKE PFS...... 109 Hidex 6-Day...... 108 HW EMBRACE PRO GYNAZOLE-1...... 126 HIZENTRA...... 141 GLUCOSE TEST...... 167 HAEGARDA...... 133 hm aspirin...... 23 HW EMBRACE TALK Hailey 1.5/30...... 97 HM EMBRACE TALK BLOOD GLUCOSE...... 167 Hailey 24 Fe...... 97 SYSTEM...... 167 HW EMBRACE TALK halcinonide...... 227 hm glucose...... 109 GLUCOSE TEST...... 167 halobetasol propionate...... 227 hm nicotine...... 82 HYALGAN...... 24 HALOG...... 227 hm nicotine polacrilex...... 82 HYCAMTIN...... 45 haloperidol...... 70 hm sterile alcohol prep...... 167 HYCLODEX...... 233 haloperidol decanoate...... 70 HM ULTICARE INSULIN hydralazine hcl...... 56, 57 haloperidol lactate...... 70 SYRINGE...... 167 hydrochlorothiazide...... 56 HARVONI...... 35 HM ULTICARE SHORT hydrocod polst-cpm polst er.... 213 HCU EASY...... 194 PEN NEEDLES...... 167 hydrocodone bitartrate er...... 20 HEALON DUET PRO...... 208 HORIZANT...... 81 hydrocodone-acetaminophen.....20 HEALON GV PRO...... 208 HPR PLUS...... 233 hydrocodone-homatropine...... 213 HEALTH CARE LANCING HPR PLUS HYDROGEL.... 233 hydrocodone-ibuprofen...... 20 DEVICE...... 166 HUMALOG...... 88 hydrocortisone...... 108, 117, 227 healthwise insulin syr/needle... 166 HUMALOG KWIKPEN...... 88 hydrocortisone (perianal)...... 122 healthwise micron pen needles.166 HUMALOG MIX 50/50...... 88 hydrocortisone ace-pramoxine 122 healthwise mini pen needles.....166 HUMALOG MIX 50/50 hydrocortisone butyr lipo base 227 healthwise pen needles...... 166 KWIKPEN...... 88 hydrocortisone butyrate...... 227 healthwise short pen needles....166 HUMALOG MIX 75/25...... 88 hydrocortisone valerate...... 227 healthwise unifine pentips...... 166 HUMALOG MIX 75/25 hydrocortisone-acetic acid...... 240 healthy accents lancing device.166 KWIKPEN...... 88 HYDROFERA BLUE 6"X6"237 healthy accents unifine pentip. 166 HUMAN ALBUMIN HYDROFERA BLUE healthy accents unilet lancets.. 166 GRIFOLS...... 136 FOAM DRESSING...... 237 Heather...... 97 HUMATE-P...... 127 HYDROFERA BLUE h-e-b aspirin...... 23 HUMATROPE...... 110 FOAM/TUNNELING...... 237 h-e-b incontrol adv lancing...... 166 HUMIRA...... 138 HYDROFERA BLUE MRF h-e-b incontrol alcohol...... 166 HUMIRA PEDIATRIC DRESSING...... 237 h-e-b incontrol lancets 28g...... 166 CROHNS START...... 137 HYDROFERA BLUE h-e-b incontrol lancets 30g...... 166 HUMIRA PEN...... 137 READY FOAM...... 237 h-e-b incontrol lancets 33g...... 166 HUMIRA PEN-CD/UC/HS hydrogen peroxide...... 233 h-e-b incontrol pen needles...... 166 STARTER...... 137 hydromet...... 213 256 hydromorphone hcl...... 20 IMVEXXY STARTER INTELENCE...... 28 hydromorphone hcl er...... 20 PACK...... 106 INTRAROSA...... 84 hydroxocobalamin acetate...... 194 IN TOUCH...... 167 INTRON A...... 142 hydroxychloroquine sulfate.....140 IN TOUCH BLOOD Introvale...... 97 hydroxyprogesterone caproate 112 GLUCOSE TEST...... 167 INTUNIV...... 73 hydroxyurea...... 44 IN TOUCH LANCING INVEGA SUSTENNA...... 70 hydroxyzine hcl...... 211 DEVICE...... 167 INVEGA TRINZA...... 70 hydroxyzine pamoate...... 211 IN TOUCH STERILE INVELTYS...... 207 hygel...... 237 LANCETS 30G...... 167 INVIRASE...... 28 HYLATOPIC PLUS...... 233 INATAL GT...... 194 INVOKAMET...... 91 hylavite...... 194 INBRIJA...... 68 INVOKAMET XR...... 91 hyoscyamine sulfate...... 115 Incassia...... 97 INVOKANA...... 92 hyoscyamine sulfate er...... 115 INCRELEX...... 111 iodine strong...... 190 HYPERSAL...... 214 INCRUSE ELLIPTA...... 210 iodine tincture...... 233 HYPOCYN...... 233 indapamide...... 56 IOPIDINE...... 203 HYQVIA...... 141 INDERAL LA...... 53 ipratropium bromide...... 210 HYSINGLA ER...... 20 INDERAL XL...... 53 ipratropium-albuterol...... 210 HY-VEE LANCETS...... 167 INDOCIN...... 16, 17 irbesartan...... 48 hy-vee thin lancets...... 167 indomethacin...... 17 irbesartan-hydrochlorothiazide. 48 HYZAAR...... 48 indomethacin er...... 17 IRESSA...... 42 ibandronate sodium...... 92 INFASURF...... 214 ISENTRESS...... 29 IBRANCE...... 39 INFINITY BLOOD ISENTRESS HD...... 29 Ibu...... 16 GLUCOSE SYSTEM...... 167 Isibloom...... 97 ibuprofen...... 16 INFINITY BLOOD isoniazid...... 31 ICAR-C PLUS...... 133 GLUCOSE TEST...... 167 ISOPTO ATROPINE...... 134 icatibant acetate...... 133 INFINITY VOICE...... 167 ISORDIL TITRADOSE...... 57 ICLUSIG...... 42 Inflammacin...... 18 isosorbide dinitrate...... 57 icosapent ethyl...... 51 INFLATHERM...... 18 isosorbide mononitrate...... 57 ICY HOT PM...... 229 INFLECTRA...... 138 isosorbide mononitrate er...... 57 IDELVION...... 130 INFUGEM...... 38 isotretinoin...... 219 IDHIFA...... 42 INFUVITE ADULT...... 194 isradipine...... 54 Iferex 150 Forte...... 134 INFUVITE PEDIATRIC..... 194 ISTALOL...... 203 IGLUCOSE MONITORING INGREZZA...... 44, 77 itraconazole...... 25 SYSTEM...... 167 INLYTA...... 42 ivermectin...... 26 IGLUCOSE TEST STRIPS.. 167 INNOPRAN XL...... 53 IXINITY...... 131 ILARIS...... 138 INPEN 100-BLUE-LILLY... 167 JADENU...... 94 ILEVRO...... 207 INPEN 100-BLUE-NOVO... 167 JADENU SPRINKLE...... 94 ILUMYA...... 223 INPEN 100-GRAY-LILLY.. 168 JAKAFI...... 42 imatinib mesylate...... 42 INPEN 100-GREY-NOVO...168 JALYN...... 123 IMBRUVICA...... 42 INPEN 100-PINK-LILLY....168 Jantoven...... 127 imdevimab...... 32 INPEN 100-PINK-NOVO.... 168 JANUMET...... 86 imipramine hcl...... 66 INREBIC...... 42 JANUMET XR...... 86 imipramine pamoate...... 66 insulin syringe...... 168 JANUVIA...... 86 imiquimod...... 220 insulin syringe/needle...... 168 JARDIANCE...... 92 imiquimod pump...... 220 insulin syringe-needle u-100.... 168 Jasmiel...... 97 IMPAVIDO...... 26 insupen pen needles...... 168 Jencycla...... 97 IMPOYZ...... 227 INSUPEN SENSITIVE...... 168 jenliva prenatal/postnatal...... 194 IMVEXXY INSUPEN ULTRAFIN...... 168 JENTADUETO...... 86 MAINTENANCE PACK.....106 INTEGRA F...... 134 JENTADUETO XR...... 86 INTEGRA PLUS...... 134 Jinteli...... 106 257 JIVI...... 129 KEPPRA...... 61 KOATE...... 129 Jolessa...... 97 KEPPRA XR...... 61 KOATE-DVI...... 129 JORNAY PM...... 73 KERAGEL...... 238 KOGENATE FS...... 129 JUBLIA...... 222 KERAGELT...... 238 KOMBIGLYZE XR...... 86 Juleber...... 97 KERAMATRIX KORLYM...... 111 JULUCA...... 30 REPLICINE 10CMX10CM..238 KOSELUGO...... 42 Junel 1.5/30...... 97 KERAMATRIX kosher prenatal plus iron...... 194 Junel 1/20...... 98 REPLICINE 5CMX5CM..... 238 KOVALTRY...... 130 Junel Fe 1.5/30...... 98 KERYDIN...... 25 kp aspirin...... 23 Junel Fe 1/20...... 98 KESIMPTA...... 78 K-PHOS...... 190 Junel Fe 24...... 98 ketoconazole...... 25, 222, 224 K-PHOS NO 2...... 124 JUXTAPID...... 51 Ketodan...... 222 K-Prime...... 190 JYNARQUE...... 111 KETO-DIASTIX...... 168 KRINTAFEL...... 28 Kaitlib Fe...... 98 ketone test...... 168 KRISTALOSE...... 118 KALETRA...... 30 KETOPHENE RAPIDPAQ. 233 kroger blood glucose...... 168 Kalliga...... 98 ketoprofen...... 17 kroger blood glucose test...... 168 KALYDECO...... 214 ketoprofen er...... 17 kroger glucose...... 109 KAMDOY...... 233 ketorolac tromethamine.... 17, 207 KROGER HEALTHPRO KANJINTI...... 39 KETOSTIX...... 168 GLUCOSE TEST...... 169 KAPSPARGO SPRINKLE....53 KETOVIE...... 194 kroger insulin syringe...... 169 KAPVAY...... 73 KETOVIE PEPTIDE...... 194 kroger lancets...... 169 KARBINAL ER...... 211 KEVEYIS...... 56 kroger lancets super thin...... 169 Kariva...... 98 KEVZARA...... 138 kroger lancets thin...... 169 KATERZIA...... 54 KHAPZORY...... 45 kroger pen needles...... 169 KAZANO...... 86 kinney lancets...... 168 kroger premium blood glucose.169 kedbumin...... 136 kinney thin lancets...... 168 kroger premium glucose test... 169 KELARX...... 233 kinray insulin syringe...... 168 kroger test...... 169 Kelnor 1/35...... 98 KISQALI (200 MG DOSE).... 39 KRYSTEXXA...... 15 Kelnor 1/50...... 98 KISQALI (400 MG DOSE).... 39 K-Tan Plus...... 134 KENALOG...... 227 KISQALI (600 MG DOSE).... 39 Kurvelo...... 98 KENDALL ALGINATE 12" KISQALI FEMARA (400 KUVAN...... 104 ROPE...... 237 MG DOSE)...... 39 KYLEENA...... 98 KENDALL ALGINATE KISQALI FEMARA (600 KYNMOBI...... 68 DRESS 2"X2"...... 237 MG DOSE)...... 39 KYPROLIS...... 45 KENDALL ALGINATE KISQALI FEMARA(200 L.E.T...... 229 DRESS 4"X4"...... 237 MG DOSE)...... 39 labetalol hcl...... 53 KENDALL ALGINATE KITABIS PAK...... 25 LACRISERT...... 134 DRESS 4"X8"...... 237 KIVIK...... 233 lactated ringers...... 208 KENDALL AMORPHOUS KLARITY-L...... 207 lactic acid...... 233 WOUND...... 237 Klor-Con...... 190 lactic acid e...... 233 KENDALL HYDROGEL Klor-Con 10...... 190 lactulose...... 118 GAUZE 2"X2"...... 237 Klor-Con M10...... 190 lactulose encephalopathy...... 118 KENDALL HYDROGEL Klor-Con M15...... 190 LAMICTAL...... 61 GAUZE 4"X4"...... 237 Klor-Con M20...... 190 LAMICTAL ODT...... 61 KENDALL HYDROGEL Klor-Con/Ef...... 190 LAMICTAL STARTER...... 61 GAUZE 4"X8"...... 238 kls aspirin low dose...... 23 LAMICTAL XR...... 61 KENDALL HYDROGEL KLS QUIT2...... 83 lamivudine...... 29, 32 WOUND DRESS...... 238 KLS QUIT4...... 83 lamivudine-zidovudine...... 30 KENDALL ZINC CA kmart valu insulin syringe 29g.168 lamotrigine...... 61, 62 ALGINATE 4"X4"...... 238 kmart valu insulin syringe 30g.168 lamotrigine er...... 61 258 lamotrigine starter kit-blue...... 62 LENVIMA (20 MG DAILY LIBRAX...... 115 lamotrigine starter kit-green.....62 DOSE)...... 43 lidocaine...... 229 lamotrigine starter kit-orange...62 LENVIMA (24 MG DAILY lidocaine hcl...... 229, 239 LAMPIT...... 26 DOSE)...... 43 lidocaine hcl (cardiac) pf...... 49 lancet device...... 169 LENVIMA (4 MG DAILY lidocaine hcl urethral/mucosal.229 lancet device with ejector...... 169 DOSE)...... 43 lidocaine in dextrose...... 24 lancet transporter case...... 169 LENVIMA (8 MG DAILY lidocaine viscous hcl...... 239 lancets...... 169 DOSE)...... 43 lidocaine-prilocaine...... 229 lancets 30g...... 169 LESCOL XL...... 51 lidocaine-tetracaine...... 229 lancets 33g...... 169 Lessina...... 99 LIDOCARE lancets micro thin 33g...... 169 LETAIRIS...... 58 ARM/NECK/LEG...... 230 lancets thin...... 169 letrozole...... 40 LIDOCARE lancets ultra thin 30g...... 169 leucovorin calcium...... 45 BACK/SHOULDER...... 230 lancing device...... 169 LEUKERAN...... 37 LIDODERM...... 230 LANOXIN...... 55 LEUKINE...... 128 lidomark 2/5...... 24 lansoprazole...... 121 leuprolide acetate...... 40 lidopac...... 230 lanthanum carbonate...... 112 levalbuterol hcl...... 212 lidopin...... 230 LANTUS...... 89 levalbuterol tartrate...... 212 LIDOPURE PATCH...... 230 LANTUS SOLOSTAR...... 89 LEVEMIR...... 89 LIDOTHOL...... 230 LANZO...... 169 LEVEMIR FLEXTOUCH..... 89 LIDOTRAL...... 230 Larin 1.5/30...... 98 levetiracetam...... 62 LIDOTREX (ALOE VERA) 238 Larin 1/20...... 98 levetiracetam er...... 62 LIFESCAN UNISTIK 2...... 170 Larin 24 Fe...... 98 LEVICYN...... 233 LIFESCAN UNISTIK II Larin Fe 1.5/30...... 98 LEVITRA...... 123 LANCETS...... 170 Larin Fe 1/20...... 98 levobunolol hcl...... 203 Lillow...... 99 Larissia...... 98 levocarnitine...... 93 lindane...... 236 LASTACAFT...... 203 levocetirizine dihydrochloride..211 linezolid...... 27 latanoprost...... 203 levofloxacin...... 34, 205 LINZESS...... 118 LATUDA...... 70 Levonest...... 99 liothyronine sodium...... 113 Layolis Fe...... 98 levonorgest-eth est & eth est..... 99 LIPITOR...... 51 LAZANDA...... 20 levonorgest-eth estrad 91-day... 99 lipo-c...... 194 LDL CARE...... 194 levonorgestrel...... 99 lisinopril...... 46 LDO PLUS...... 229 levonorgestrel-ethinyl estrad.....99 lisinopril-hydrochlorothiazide... 46 ldr blood glucose truetest...... 169 levonorg-eth estrad triphasic.....99 lite touch lancets...... 170 leader insulin syringe...... 169 Levora 0.15/30 (28)...... 99 LITE TOUCH LANCING LEADER UNIFINE levorphanol tartrate...... 20 PEN...... 170 PENTIPS...... 169 Levo-T...... 113 LITETOUCH INSULIN LEADER UNIFINE levothyroxine sodium...... 113 SYRINGE...... 170 PENTIPS PLUS...... 169 Levoxyl...... 113 LITETOUCH LANCETS.....170 lecithin...... 194 LEVULAN KERASTICK....233 LITETOUCH PEN Leena...... 98 LEXAPRO...... 66 NEEDLES...... 170 leflunomide...... 140 LEXETTE...... 227 lithium carbonate...... 77 LENVIMA (10 MG DAILY LEXIVA...... 29 lithium carbonate er...... 77 DOSE)...... 42 LIALDA...... 117 LITHOSTAT...... 124 LENVIMA (12 MG DAILY liberty blood glucose meter..... 169 LIVALO...... 51 DOSE)...... 43 LIBERTY NEXT live better adv lancing device...170 LENVIMA (14 MG DAILY GENERATION TEST...... 169 live better lancet ultra thin...... 170 DOSE)...... 43 LIBERTY NXT l-methylfolate calcium...... 194 LENVIMA (18 MG DAILY GENERATION MONITOR 170 LMR PLUS...... 230 DOSE)...... 43 liberty test...... 170 LO LOESTRIN FE...... 99 259 LODINE...... 17 LUPRON DEPOT-PED (3- medic insulin syringe...... 170 LOKELMA...... 94 MONTH)...... 41 medichoice safety lancet extra 170 LOMAIRA...... 77 Lutera...... 99 medicine shoppe pen needles....171 longs insulin syringe...... 170 LUXAMEND...... 238 MEDISENSE THIN longs lancets standard...... 170 LUXIQ...... 227 LANCETS...... 171 longs lancets thin...... 170 LUZU...... 222 MEDLANCE PLUS EXTRA longs lancets ultra thin...... 170 LYNPARZA...... 39 21G...... 171 LONHALA MAGNAIR LYRICA...... 62 MEDLANCE PLUS REFILL KIT...... 210 LYRICA CR...... 82 LANCETS...... 171 LONHALA MAGNAIR Lysiplex Plus...... 194 MEDLANCE PLUS LITE STARTER KIT...... 210 LYSODREN...... 41 25G...... 171 LONSURF...... 44 Lyza...... 99 MEDLANCE PLUS loperamide hcl...... 119 M.V.I. ADULT...... 194 SPECIAL 0.8MM...... 171 lopinavir-ritonavir...... 30 M.V.I. PEDIATRIC...... 194 MEDLANCE PLUS LOPROX...... 222 MACI...... 80 SUPERLITE 30G...... 171 lorazepam...... 59 MACRODANTIN...... 27 MEDLANCE PLUS LORBRENA...... 43 mafenide acetate...... 220 UNIVERSAL 21G...... 171 lorid...... 194 MAGELLAN INSULIN MEDROL...... 108 LORTAB...... 20 SAFETY SYR...... 170 medroxyprogesterone acetate Loryna...... 99 MAKENA...... 112 ...... 99, 113 Lorzone...... 80 malathion...... 236 mefenamic acid...... 17 losartan potassium...... 48 MARATHON MEDICAL mefloquine hcl...... 28 losartan potassium-hctz...... 48 PENTIPS...... 170 megestrol acetate...... 41 LOTEMAX...... 207 marlissa...... 99 meijer blood glucose...... 171 LOTEMAX SM...... 207 MARPLAN...... 66 meijer blood glucose test...... 171 loteprednol etabonate...... 207 MATULANE...... 44 meijer essential blood glucose..171 LOTRONEX...... 118 Matzim La...... 54 meijer essential glucose test.... 171 lovastatin...... 51 MAVENCLAD (10 TABS).....78 meijer glucose...... 110 Low-Ogestrel...... 99 MAVENCLAD (4 TABS)...... 78 MEIJER LANCETS THIN.. 171 loxapine succinate...... 70 MAVENCLAD (5 TABS)...... 78 MEIJER LANCETS LOYON...... 233 MAVENCLAD (6 TABS)...... 78 UNIVERSAL 21G...... 171 Lo-Zumandimine...... 99 MAVENCLAD (7 TABS)...... 79 MEIJER LANCETS LUCEMYRA...... 83 MAVENCLAD (8 TABS)...... 79 UNIVERSAL 30G...... 171 LUCENTIS...... 208 MAVENCLAD (9 TABS)...... 79 MEIJER LANCETS luliconazole...... 222 MAXALT...... 75 UNIVERSAL 33G...... 171 LUMAKRAS...... 43 MAXALT-MLT...... 75 meijer pen needles...... 171 LUMIGAN...... 203 MAXICOMFORT II PEN meijer premium blood glucose. 171 LUNESTA...... 74 NEEDLE...... 170 meijer premium glucose test.... 171 LUPANETA PACK...... 112 MAXI-COMFORT MEIJER SUPER THIN LUPRON DEPOT (1- INSULIN SYRINGE...... 170 LANCETS...... 171 MONTH)...... 40 MAXI-COMFORT SAFETY MEIJER TRUE2GO LUPRON DEPOT (3- PEN NEEDLE...... 170 BLOOD GLUCOSE...... 171 MONTH)...... 40 MAXICOMFORT SYR 27G MEIJER TRUERESULT LUPRON DEPOT (4- X 1/2"...... 170 GLUCOSE SYS...... 171 MONTH)...... 40 MAXIDEX...... 207 MEIJER TRUETEST TEST 171 LUPRON DEPOT (6- MAYZENT...... 79 MEIJER TRUETRACK MONTH)...... 41 MAYZENT STARTER GLUCOSE SYS...... 171 LUPRON DEPOT-PED (1- PACK...... 79 MEIJER TRUETRACK MONTH)...... 41 meclizine hcl...... 116 TEST...... 171 meclofenamate sodium...... 17 MEKINIST...... 43 260 MEKTOVI...... 44 metoclopramide hcl...... 116 MINIMED PUMP meloxicam...... 17 metolazone...... 56 RESERVOIR 3ML...... 172 melphalan...... 37 metoprolol succinate er...... 53 MINIMED RESERVOIR memantine hcl...... 64 metoprolol tartrate...... 53 1.8ML...... 172 memantine hcl er...... 64 metoprolol-hydrochlorothiazide 52 MINIMED RESERVOIR MENEST...... 106 METROGEL...... 236 3ML...... 172 MENOPUR...... 107 metronidazole...... 27, 126, 236 Minitran...... 57 MENOSTAR...... 106 METRONIDAZOLE MINIVELLE...... 106 MENQUADFI...... 143 BENZO+SYRSPEND...... 27 MINOCIN...... 36 MENTAX...... 222 mexiletine hcl...... 49 minocycline hcl...... 36 meperidine hcl...... 20 MIACALCIN...... 111 minocycline hcl er...... 36 meprobamate...... 59 MICARDIS...... 48 MINOLIRA...... 36 mercaptopurine...... 38 MICARDIS HCT...... 48 minoxidil...... 57 mesalamine...... 117 miconazole 3...... 126 MIO INFUSION SET 18" mesalamine-cleanser...... 117 miconazole-zinc oxide-petrolat222 6MM...... 172 MESNEX...... 45 MICROCYN...... 238 MIO INFUSION SET 23" MESTINON...... 77 MICRODOT BLOOD 6MM...... 172 METAXALL CP...... 81 GLUCOSE SYSTEM...... 171 MIO INFUSION SET 32" metaxalone...... 81 MICRODOT PEN NEEDLE 6MM...... 172 metformin hcl...... 85 ...... 171 MIO INFUSION SET 32" metformin hcl er...... 85 MICRODOT TEST...... 171 9MM...... 172 metformin hcl er (mod)...... 85 Microgestin 1.5/30...... 99 MIRCERA...... 128 metformin hcl er (osm)...... 85 Microgestin 1/20...... 99 MIRENA (52 MG)...... 100 methadone hcl...... 20, 21 Microgestin Fe 1.5/30...... 99 mirtazapine...... 66 Methadone Hcl Intensol...... 20 Microgestin Fe 1/20...... 99 MIRVASO...... 236 methadone hcl-nacl...... 21 MICROLET LANCETS...... 172 misoprostol...... 119 METHADOSE...... 21 MICROLET NEXT MITIGARE...... 15 Methadose...... 21 LANCING DEVICE...... 172 MITOSOL...... 205 METHADOSE SUGAR- midazolam hcl...... 74 MM EASY TOUCH FREE...... 21 midazolam hcl (pf)...... 74 GLUCOSE...... 172 methamphetamine hcl...... 73 midodrine hcl...... 57 MM EASY TOUCH methazolamide...... 56 MIGERGOT...... 75 GLUCOSE METER...... 172 methenamine hippurate...... 27 miglitol...... 85 mm insulin syringe/needle...... 172 methenamine mandelate...... 27 miglustat...... 104 MM PEN NEEDLES...... 172 Methergine...... 111 MIGRAINE PACK...... 76 m-natal plus...... 194 methimazole...... 113 MIGRANAL...... 76 modafinil...... 81 methitest...... 84 MIGRANOW...... 76 moexipril hcl...... 46 methocarbamol...... 81 Mili...... 100 molindone hcl...... 70 methotrexate sodium...... 38 MILLIPRED...... 108 mometasone furoate.215, 227, 228 methotrexate sodium (pf)...... 38 Mimvey...... 106 Mondoxyne Nl...... 36, 37 methoxsalen rapid...... 223 MIMYX...... 233 MONOJECT INSULIN methscopolamine bromide...... 115 MINASTRIN 24 FE...... 100 SYRINGE...... 172 methyldopa...... 57 mineral oil heavy...... 118 MONOJECT ULTRA methylergonovine maleate...... 111 mini lancing device...... 172 COMFORT SYRINGE...... 173 methylphenidate hcl...... 73 MINILINK REAL-TIME MONOLET LANCETS...... 173 methylphenidate hcl er...... 73 TRANSMITTER...... 172 MONOLET OPD LANCETS methylphenidate hcl er (cd)...... 73 MINIMED 630G ...... 173 methylphenidate hcl er (la)...... 73 GUARDIAN PRESS...... 172 MONOLETTOR SAFETY methylprednisolone...... 108 MINIMED GUARDIAN LANCETS...... 173 methyltestosterone...... 84 LINK 3...... 172 Mono-Linyah...... 100 261 MONONINE...... 131 mynatal plus...... 195 neonatal 19...... 195 montelukast sodium...... 213 mynatal-z...... 195 neonatal complete...... 195 MONUROL...... 25 Myorisan...... 219 neonatal fe...... 195 Morgidox...... 37 MYRBETRIQ...... 112, 125 NEONATAL PLUS...... 195 morphine sulfate...... 21 MYTESI...... 119 Neo-Polycin...... 205 morphine sulfate (concentrate).21 nabumetone...... 17 Neo-Polycin Hc...... 204 morphine sulfate er...... 21 nadolol...... 53 NEOSALUS...... 233 morphine sulfate er beads...... 21 Nafrinse Drops...... 195 NEO-SYNALAR...... 221 MOTEGRITY...... 119 naftifine hcl...... 222 Nephronex...... 195 MOTOFEN...... 119 NAFTIN...... 222 NERLYNX...... 43 MOVANTIK...... 119 NALFON...... 17 NESINA...... 86 MOVIPREP...... 118 nalocet...... 21 NESTABS...... 195 MOXEZA...... 205 naloxone hcl...... 83 NESTABS DHA...... 195 moxifloxacin hcl...... 34, 205 naltrexone hcl...... 83 NESTABS ONE...... 195 mpd safety lancet 21g...... 173 NAMENDA XR...... 64 Neuac...... 219 mpd safety lancet 23g...... 173 NAMZARIC...... 64 NEUAC...... 219 mpd safety lancet 28g...... 173 NAPRELAN...... 17 NEULASTA...... 128 mpd safety lancet 30g...... 173 NAPROSYN...... 17 NEULASTA ONPRO...... 128 MS CONTIN...... 21 naproxen...... 17 NEUPRO...... 68 ms insulin syringe...... 173 naproxen sodium...... 17 NEUTEK 2TEK TEST...... 173 MSUD EASY...... 194 naproxen sodium er...... 17 NEUTRASAL...... 239 MULPLETA...... 128 naproxen-esomeprazole...... 18 NEVANAC...... 207 MULTAQ...... 49 naratriptan hcl...... 76 nevirapine...... 29 MULTIGEN...... 134 NARCAN...... 83 nevirapine er...... 29 MULTIGEN FOLIC...... 134 NASCOBAL...... 195 NEW DAY...... 100 MULTIGEN PLUS...... 134 NATACHEW...... 195 NEXAVAR...... 43 MULTI-LANCET DEVICE NATACYN...... 205 NEXIUM...... 121 2...... 173 NATALVIT...... 195 NEXIUM 24HR...... 121 multipro...... 194 NATAZIA...... 100 NEXIUM 24HR CLEAR multi-vit/iron/fluoride...... 194 nateglinide...... 91 MINIS...... 121 multivitamin/fluoride...... 194, 195 NATESTO...... 84 NEXLETOL...... 49 multi-vitamin/fluoride...... 194 NATPARA...... 111 NEXLIZET...... 49 multi-vitamin/fluoride/iron...... 195 NATURE-THROID...... 113 NEXPLANON...... 100 mupirocin...... 221 NAYZILAM...... 62 niacin (antihyperlipidemic)...... 51 mupirocin calcium...... 221 NEBUPENT...... 27 niacin er (antihyperlipidemic).. 51 MY CHOICE...... 100 Necon 0.5/35 (28)...... 100 NIACOR...... 51 MY WAY...... 100 NEEVO DHA...... 195 NICADAN...... 195 MYALEPT...... 104 nefazodone hcl...... 66 NICAPRIN...... 195 MYCO NAIL...... 222 NEOKE BCAA4...... 195 nicardipine hcl...... 54 mycophenolate mofetil...... 142 neoke bhb...... 195 NICAZEL...... 195 mycophenolate sodium...... 143 neomycin sulfate...... 25 NICAZEL FORTE...... 195 MYDAYIS...... 74 neomycin-bacitracin zn- nicazyme...... 196 MYGLUCOHEALTH polymyx...... 205 NICOMIDE...... 196 BLOOD GLUCOSE...... 173 neomycin-polymyxin b gu...... 124 NICORELIEF...... 83 MYGLUCOHEALTH neomycin-polymyxin-dexameth nicotine...... 83 LANCETS 30G...... 173 ...... 204 nicotine mini...... 83 MYGLUCOHEALTH TEST neomycin-polymyxin- nicotine polacrilex...... 83 ...... 173 gramicidin...... 205 nicotine step 1...... 83 MYLERAN...... 37 neomycin-polymyxin-hc.. 204, 241 nicotine step 2...... 83 MYNATAL...... 195 neonatal + dha...... 195 nicotine step 3...... 83 262 NICOTROL...... 83 NOVA MAX BLOOD NUDERMRXPAK 120...... 223 NICOTROL NS...... 83 GLUCOSE SYSTEM...... 173 NUDERMRXPAK 60...... 224 nifedipine...... 54 NOVA MAX GLUCOSE Nudiclo Solupak...... 233 nifedipine er...... 54 TEST...... 173 Nudiclo Tabpak...... 143 nifedipine er osmotic release..... 54 NOVA MAX PLUS NUDROXIPAK...... 143 Nikki...... 100 KETONE TEST...... 173 NUDROXIPAK DSDR-50.... 17 NILANDRON...... 41 NOVA SAFETY LANCETS NUDROXIPAK DSDR-75.... 17 nilutamide...... 41 23G...... 173 NUDROXIPAK E-400...... 143 nimodipine...... 54 NOVA SAFETY LANCETS NUDROXIPAK I-800...... 143 NINLARO...... 45 28G...... 173 NUDROXIPAK M-15...... 17 NIPRIDE RTU...... 57 NOVA SUREFLEX NUDROXIPAK N-500...... 17 nisoldipine er...... 54 LANCETS...... 173 NUEDEXTA...... 77 NITRO-BID...... 57 NOVA SUREFLEX NUFERA...... 134 NITRO-DUR...... 57 LANCING DEVICE...... 173 Nufol...... 134 nitrofurantoin...... 27 NOVACORT...... 230 Nulev...... 115 nitrofurantoin macrocrystal...... 27 NOVOEIGHT...... 130 NUMOISYN...... 239 nitrofurantoin monohyd macro. 27 NOVOFINE...... 173 NUPLAZID...... 70 nitroglycerin...... 57 NOVOFINE AUTOCOVER 173 NURTEC...... 76 NITROMIST...... 57 NOVOFINE PLUS...... 173 NUSURGEPAK NITYR...... 104 NOVOLIN 70/30...... 89 SURGICAL PREP/CARE....234 NIVA-PLUS...... 196 NOVOLIN 70/30 FLEXPEN..89 NUTRASEB...... 224 NIVESTYM...... 128 NOVOLIN 70/30 FLEXPEN NUTRICAP...... 196 nizatidine...... 117 RELION...... 89 Nutrifac Zx...... 196 NOCDURNA...... 114 NOVOLIN 70/30 RELION.....89 NUTRIVIT...... 196 Nolix...... 228 NOVOLIN N...... 89 NUVAIL...... 234 Nora-Be...... 100 NOVOLIN N FLEXPEN...... 89 NUVARING...... 101 NORDITROPIN FLEXPRO110 NOVOLIN N RELION...... 89 NUVESSA...... 126 norethin ace-eth estrad-fe...... 100 NOVOLIN R...... 90 NUVIGIL...... 81 norethindrone...... 100 NOVOLIN R FLEXPEN...... 90 NUWIQ...... 130 norethindrone acetate...... 113 NOVOLIN R FLEXPEN NUZYRA...... 37 norethindrone acet-ethinyl est. 100 RELION...... 90 Nyamyc...... 222 norethindrone-eth estradiol..... 106 NOVOLIN R RELION...... 90 NYMALIZE...... 55 norethin-eth estradiol-fe...... 100 NOVOLOG...... 90 nystatin...... 26, 222, 239 norgesic forte...... 81 NOVOLOG FLEXPEN...... 90 nystatin-triamcinolone...... 222 norgestimate-eth estradiol...... 100 NOVOLOG MIX 70/30...... 90 Nystop...... 222 norgestim-eth estrad triphasic.100 NOVOLOG MIX 70/30 OB COMPLETE...... 196 NORITATE...... 236 FLEXPEN...... 90 OB COMPLETE ONE...... 196 Norlyda...... 100 NOVOLOG PENFILL...... 90 OB COMPLETE PETITE.... 196 Norlyroc...... 100 NOVOPEN ECHO...... 174 OB COMPLETE PREMIER 196 NORPACE...... 49 NOVOSEVEN RT...... 128 OB COMPLETE/DHA...... 196 NORPACE CR...... 49 NOVOTWIST...... 174 OBSTETRIX DHA...... 196 Nortrel 0.5/35 (28)...... 100 NOXAFIL...... 25, 26 OBSTETRIX EC...... 196 Nortrel 1/35 (21)...... 100 np thyroid...... 113 OBSTETRIX ONE...... 196 Nortrel 1/35 (28)...... 100 NPLATE...... 128 O-CAL PRENATAL...... 196 Nortrel 7/7/7...... 100 NUBEQA...... 41 OCALIVA...... 119 nortriptyline hcl...... 66 NUCALA...... 212 Ocella...... 101 NORVASC...... 55 NUCARACLINPAK...... 219 OCREVUS...... 79 NORVIR...... 29 NUCARARXPAK...... 219 OCTAGAM...... 141 NOURIANZ...... 68 NUCYNTA...... 21 octreotide acetate...... 111 NOURISH...... 196 NUCYNTA ER...... 21 OCUVEL...... 196 263 ODACTRA...... 137 ONETOUCH SURESOFT oscimin...... 115 ODEFSEY...... 31 LANCING DEV...... 174 oscimin sr...... 115 ODOMZO...... 44 ONETOUCH ULTRA...... 174 oseltamivir phosphate...... 32 OFEV...... 215 ONETOUCH ULTRALINK174 OSENI...... 87 ofloxacin...... 34, 206, 241 ONETOUCH ULTRASOFT OSMOLEX ER...... 68 olanzapine...... 70, 71 LANCETS...... 174 OSMOPREP...... 118 olanzapine-fluoxetine hcl...... 83 ONETOUCH VERIO...... 174 OSPHENA...... 111 olmesartan medoxomil...... 48 ONETOUCH VERIO FLEX OTEZLA...... 140 olmesartan medoxomil-hctz...... 48 SYSTEM...... 174 OTIPRIO...... 241 olmesartan-amlodipine-hctz...... 48 ONETOUCH VERIO OTOVEL...... 241 olopatadine hcl...... 203, 211 REFLECT...... 174 OVACE PLUS...... 224 OLUMIANT...... 138 ONETOUCH VERIO SYNC OVIDREL...... 107 OLUX-E...... 228 SYSTEM...... 174 oxaliplatin...... 37 OMECLAMOX-PAK...... 122 onevite...... 196 oxandrolone...... 84 omega-3-acid ethyl esters...... 51 ONEXTON...... 219 oxaprozin...... 17 OMEGAVEN...... 196 ONFI...... 62 OXAYDO...... 21 omeprazole...... 121 ONGLYZA...... 86 oxazepam...... 59 omeprazole-sodium ONZETRA XSAIL...... 76 oxcarbazepine...... 62 bicarbonate...... 121 OPCICON ONE-STEP...... 101 oxiconazole nitrate...... 222 OMNARIS...... 215 opium...... 119 OXISTAT...... 222 OMNIFLEX DIAPHRAGM144 OPSUMIT...... 58 OXTELLAR XR...... 62 OMNIPOD 5 PACK...... 174 OPTION 2...... 101 oxybutynin chloride...... 125 OMNIPOD DASH 5 PACK OPTIONS GYNOL II oxybutynin chloride er...... 125 PODS...... 174 CONTRACEPTIVE...... 123 oxycodone hcl...... 21 OMNIPOD STARTER...... 174 OPTIUM BLOOD oxycodone hcl er...... 21 OMNITROPE...... 110 GLUCOSE MONITOR...... 174 oxycodone-acetaminophen...... 22 omnivex...... 196 OPTIUM GLUCOSE OXYCONTIN...... 22 ondansetron...... 116 MONITOR SYSTEM...... 174 oxymorphone hcl...... 22 ondansetron hcl...... 116 OPTIUM TEST...... 174 oxymorphone hcl er...... 22 one drop blood glucose monitor OPTIUMEZ TEST...... 174 OXYTROL...... 125 ...... 174 ORACEA...... 236 OXYTROL FOR WOMEN..125 one drop test...... 174 ORACIT...... 124 OZEMPIC (0.25 OR 0.5 one vite womens plus...... 196 ORAFATE...... 239 MG/DOSE)...... 87 ONETOUCH CLUB ORALAIR...... 137 OZEMPIC (1 MG/DOSE)...... 87 LANCETS FINE PT...... 174 Oralone...... 239 OZURDEX...... 207 ONETOUCH DELICA ORAVIG...... 239 Pacerone...... 49 LANCETS 30G...... 174 ORENCIA...... 138 paingo kft...... 230 ONETOUCH DELICA ORENCIA CLICKJECT...... 138 paliperidone er...... 71 LANCETS 33G...... 174 ORENITRAM...... 58 PALMERS SCAR SERUM..234 ONETOUCH DELICA ORFADIN...... 104 PANCREAZE...... 120 LANCING DEV...... 174 ORIAHNN...... 106 PANDEL...... 228 ONETOUCH DELICA ORILISSA...... 104 PANRETIN...... 234 PLUS LANCET30G...... 174 ORKAMBI...... 214 pantoprazole sodium...... 121 ONETOUCH DELICA ORMECA...... 234 PANZYGA...... 141 PLUS LANCET33G...... 174 orphenadrine citrate er...... 81 PARADIGM PUMP ONETOUCH DELICA orphenadrine-asa-caffeine...... 81 RESERVOIR 1.8ML...... 175 PLUS LANCING...... 174 Orphengesic Forte...... 81 PARADIGM PUMP ONETOUCH FINEPOINT Orsythia...... 101 RESERVOIR 3ML...... 175 LANCETS...... 174 ortho df...... 134 PARADIGM REAL-TIME ORTHO TRI-CYCLEN LO. 101 TRANSMITTER...... 175 264 PARADIGM SILHOUETTE ph strips...... 175 Pirmella 1/35...... 101 COMBO 23"...... 175 PHARMACIST CHOICE Pirmella 7/7/7...... 101 PARADIGM SURE-T 23" AUTOCODE...... 175 piroxicam...... 17 6MM...... 175 PHARMACIST CHOICE PKU EASY...... 197 PARAGARD AUTOCODE SYS...... 175 PKU EASY MICROTABS...196 INTRAUTERINE COPPER 101 PHARMACIST CHOICE PLASBUMIN-25...... 136 PARAPLATIN...... 37 LANCETS...... 175 PLASBUMIN-5...... 136 PAREMYD...... 134 PHARMACIST CHOICE PLAVIX...... 136 paricalcitol...... 93 MINI SYSTEM...... 175 PLEGRIDY...... 79 Paroex...... 239 pharmacist choice no coding... 175 PLEGRIDY STARTER paromomycin sulfate...... 25 PHARMACY COUNTER PACK...... 79 paroxetine hcl...... 66 LANCETS...... 175 PLENVU...... 119 paroxetine hcl er...... 66 Phenazo...... 124 PLIAGLIS...... 230 paroxetine mesylate...... 66 phenelzine sulfate...... 66 pnv prenatal plus multivitamin 197 PASER...... 31 phenobarbital...... 62 pnv tabs 20-1...... 197 PAXIL...... 66 phenoxybenzamine hcl...... 57 pnv tabs 29-1...... 197 PAXIL CR...... 66 phenylephrine hcl...... 134, 215 pnv-dha...... 197 pc lancets super thin 30g...... 175 phenylephrine hcl (pressors)...215 pnv-dha+docusate...... 197 pc unifine pentips...... 175 phenytoin...... 62 pnv-omega...... 197 PCP 100...... 119 phenytoin sodium extended...... 62 pnv-select...... 197 PEG-PREP...... 119 PHESGO...... 45 POCKETCHEM EZ pen needles...... 175 Philith...... 101 SYSTEM...... 175 pen needles 1/2"...... 175 PHLAG SPRAY...... 234 POCKETCHEM EZ TEST...176 pen needles 5/16"...... 175 PHOSLYRA...... 112 podofilox...... 234 penicillamine...... 94 Phospha 250 Neutral...... 190 POLIVY...... 39 penicillin v potassium...... 35 phosphorous...... 190 Polycin...... 206 PENLEN...... 234 Phospho-Trin 250 Neutral.....190 poly-iron 150 forte...... 134 PENLET II BLOOD PHOTREXA VISCOUS...... 134 polymyxin b-trimethoprim...... 206 SAMPLER...... 175 PHOTREXA-PHOTREXA polysaccharide iron forte...... 134 PENLET II VISCOUS KIT...... 134 POLY-VI-FLOR...... 197 REPLACEMENT CAP...... 175 Physiolyte...... 208 POLY-VI-FLOR/IRON...... 197 PENNSAID...... 234 Physiosol Irrigation...... 208 POMALYST...... 142 PENTASA...... 117 phytonadione...... 196 Portia-28...... 101 pentazocine-naloxone hcl...... 18 PIFELTRO...... 29 PORTRAZZA...... 39 PENTIPS...... 175 pilocarpine hcl...... 203, 240 posaconazole...... 26 pentoxifylline er...... 134 pimecrolimus...... 234 pot & sod cit-cit ac...... 124 PERCOCET...... 22 pimozide...... 77 POTABA...... 190 PERFECT LANCETS 28G.. 175 Pimtrea...... 101 potassium chloride...... 191 PERFECT LANCETS 30G.. 175 pindolol...... 53 potassium chloride crys er...... 190 PERFOROMIST...... 212 pioglitazone hcl...... 90 potassium chloride er...... 191 perindopril erbumine...... 46 pioglitazone hcl-glimepiride...... 91 potassium chloride in nacl...... 191 Periogard...... 240 pioglitazone hcl-metformin hcl..90 potassium citrate er...... 124 PERJETA...... 39 pip lancets 28g...... 175 potassium citrate-citric acid....124 permethrin...... 236 pip lancets 30g...... 175 povidone-iodine...... 206 perphenazine...... 71 PIQRAY (200 MG DAILY PR BENZOYL PEROXIDE.219 perphenazine-amitriptyline...... 83 DOSE)...... 43 Pr Benzoyl Peroxide Wash.....219 PERSERIS...... 71 PIQRAY (250 MG DAILY PR CREAM...... 234 PERTZYE...... 120 DOSE)...... 43 PRADAXA...... 127 PEXEVA...... 66 PIQRAY (300 MG DAILY PRALUENT...... 52 PFIZERPEN...... 36 DOSE)...... 43 pramipexole dihydrochloride.....68 265 pramipexole dihydrochloride er.68 pregen dha...... 197 PREVIDENT 5000 prasugrel hcl...... 136 pregenna...... 197 BOOSTER PLUS...... 240 pravastatin sodium...... 51 PREMARIN...... 106 PREVIDENT 5000 DRY praziquantel...... 27 PREMESISRX...... 197 MOUTH...... 240 prazosin hcl...... 47 premium blood glucose test..... 176 PREVIDENT 5000 PRE & POST SX POUCH.... 234 premium scar...... 230 ENAMEL PROTECT...... 240 PRECEDEX...... 74 PREMPHASE...... 107 PREVIDENT 5000 ORTHO PRECISION LINK...... 176 PREMPRO...... 107 DEFENSE...... 240 PRECISION PCX...... 176 prena 1 true...... 197 PREVIDENT 5000 PLUS.....240 PRECISION PCX PLUS prena1...... 197 PREVIDENT 5000 TEST...... 176 prena1 pearl...... 197 SENSITIVE...... 240 PRECISION POINT OF prenaissance...... 197 PREVIDOLRX CARE TEST...... 176 prenaissance plus...... 197 ANALGESIC...... 18 PRECISION QID prenara...... 197 Previfem...... 101 MONITOR...... 176 PRENATABS RX...... 197 PREVYMIS...... 32 PRECISION QID TEST...... 176 prenatal...... 197 PREZCOBIX...... 31 PRECISION SOF-TACT prenatal 19...... 197 PREZISTA...... 29 MONITOR...... 176 prenatal plus...... 197 PRIFTIN...... 31 PRECISION SOF-TACT prenatal plus iron...... 197 PRILOSEC...... 121 TEST...... 176 prenatal vitamin plus low iron. 197 PRIMACARE...... 198 PRECISION SUREDOSE PRENATAL-U...... 198 primaquine phosphate...... 28 PLUS SYR...... 176 PRENATE...... 198 primidone...... 62 PRECISION SURE-DOSE PRENATE AM...... 198 PRIMSOL...... 27 SYRINGE...... 176 PRENATE DHA...... 198 PRISTIQ...... 66 PRECISION XTRA...... 176 PRENATE ELITE...... 198 PRIVIGEN...... 142 PRECISION XTRA BLOOD PRENATE ENHANCE...... 198 pro comfort alcohol...... 177 GLUCOSE...... 176 PRENATE ESSENTIAL...... 198 PRO COMFORT INSULIN PRECISION XTRA PRENATE MINI...... 198 SYRINGE...... 177 KETONE...... 176 PRENATE PIXIE...... 198 pro comfort lancets 30g...... 177 PRECISION XTRA PRENATE RESTORE...... 198 pro comfort lancets 31g...... 177 MONITOR...... 176 PRENATRIX...... 198 pro comfort pen needles...... 177 PRED FORTE...... 207 PRENATRYL...... 198 pro voice v8 glucose system.....177 PRED MILD...... 207 prenatvite complete...... 198 pro voice v8/v9 glucose...... 177 PRED-G...... 204 prenatvite plus...... 198 pro voice v9 glucose system.....177 PRED-G S.O.P...... 204 prenatvite rx...... 198 PROAIR DIGIHALER...... 212 prednicarbate...... 228 PREPIDIL...... 111 PROAIR HFA...... 212 prednisolone...... 108 prepiv supply...... 230 PROAIR RESPICLICK...... 212 prednisolone acetate...... 207 preplus...... 198 probenecid...... 15 prednisolone acetate p-f...... 207 PRESERA...... 234 probichew...... 119 prednisolone sodium phosphate PRESTALIA...... 46 PRO-C-DURE 6...... 108 ...... 108, 207 pretab...... 198 prochlorperazine...... 116 prednisolone-gatifloxacin...... 204 pretomanid...... 31 prochlorperazine edisylate...... 71 prednisone...... 108 PREVACID...... 121 prochlorperazine maleate...... 116 PREDNISONE INTENSOL 108 PREVACID 24HR...... 121 PROCORT...... 122 preferred plus insulin syringe...176 PREVACID SOLUTAB...... 121 PROCTOCORT...... 122 preferred plus lancets colored..176 Prevalite...... 50 PROCTOFOAM HC...... 122 preferred plus lancets thin...... 176 PREVENT SAFETY PEN Procto-Med Hc...... 122 preferred plus unifine pentips.. 176 NEEDLES...... 176 Procto-Pak...... 122 PREFEST...... 106 PREVENTEZA...... 101 Proctozone-Hc...... 122 pregabalin...... 62 PREVIDENT...... 240 PROCYSBI...... 124 266 prodigen...... 119 PROVIGIL...... 81 QNASL CHILDRENS...... 215 PRODIGY AUTOCODE PROZAC...... 66 QSYMIA...... 77 BLOOD GLUCOSE...... 177 PRUCLAIR...... 234 QTERN...... 91 PRODIGY INSULIN PRUMYX...... 234 quad-mix...... 123 SYRINGE...... 177 pseudoeph-bromphen-dm...... 213 QUARTETTE...... 101 PRODIGY LANCETS 28G..177 psorcon...... 228 quazepam...... 74 PRODIGY LANCING PSS SELECT GP LANCETS177 quetiapine fumarate...... 71 DEVICE...... 177 PSS SELECT PLATFORMS 177 quetiapine fumarate er...... 71 PRODIGY NO CODING PSS SELECT SAFETY QUFLORA FE...... 198 BLOOD GLUC...... 177 LANCETS...... 177 QUFLORA FE PEDIATRIC PRODIGY POCKET PTS PANELS GLUCOSE ...... 198 BLOOD GLUCOSE...... 177 TEST...... 177 QUFLORA GUMMIES...... 199 PRODIGY SAFETY PTS PANELS KETONE QUFLORA PEDIATRIC.....199 LANCETS 26G...... 177 TEST...... 177 QUICKTEK...... 178 PRODIGY VOICE BLOOD PULMICORT...... 217 QUICKTEK TEST...... 178 GLUCOSE...... 177 PULMICORT QUICKTEK/METER...... 178 PROFILNINE...... 131 FLEXHALER...... 217 QUILLICHEW ER...... 74 progesterone...... 113 PULMOZYME...... 217 QUILLIVANT XR...... 74 PROGLYCEM...... 110 pure comfort lancets 30g...... 104 quinapril hcl...... 47 PROLASTIN-C...... 215 PURIXAN...... 38 quinapril-hydrochlorothiazide...46 PROLENSA...... 207 px aspirin...... 23 quinidine gluconate er...... 49 PROLIA...... 111 px enteric aspirin...... 23 quinidine sulfate...... 49 PROMACTA...... 128 px extra short pen needles...... 177 quinine sulfate...... 28 promethazine hcl...... 116 px glucose...... 110 QUINJA...... 222 promethazine-codeine...... 213 px insulin syringe...... 177 QUINTET AC BLOOD promethazine-dm...... 213 px lancet auto injector...... 177 GLUCOSE...... 178 promethazine-phenyleph- px lancets microthin 33g...... 178 QUINTET AC BLOOD codeine...... 213 px lancets ultra thin...... 178 GLUCOSE TEST...... 178 promethazine-phenylephrine... 213 px mini pen needles...... 178 QUINTET BLOOD Promethegan...... 116 px pen needle...... 178 GLUCOSE SYSTEM...... 178 PROMETHEGAN...... 116 px shortlength pen needles...... 178 QUINTET BLOOD PROMETRIUM...... 113 PYLERA...... 120 GLUCOSE TEST...... 178 PROMISEB...... 224 pyrazinamide...... 31 QUTENZA...... 230 propafenone hcl...... 49 pyridostigmine bromide...... 77 QUTENZA (2 PATCH)...... 230 propafenone hcl er...... 49 pyridostigmine bromide er...... 77 QVAR REDIHALER...... 217 proparacaine hcl...... 134 pyridoxine hcl...... 198 ra alcohol swabs...... 178 proparacaine-fluorescein...... 134 pyrogallic acid...... 234 ra aspirin adult low dose...... 23 propranolol hcl...... 53 QBRELIS...... 47 ra aspirin childrens...... 24 propranolol hcl er...... 53 QBREXZA...... 234 ra aspirin ec adult low st...... 24 propylthiouracil...... 113 qc advanced lancing device...... 178 RA E-ZJECT LANCETS PROSTIN E2...... 111 qc alcohol swabs...... 178 28G...... 178 PROTHELIAL...... 240 qc childrens aspirin...... 23 RA E-ZJECT LANCETS PROTONIX...... 121 qc lancets super thin 30g...... 178 THIN 26G...... 178 PROTOPIC...... 234 qc lancets ultra thin...... 178 RA E-ZJECT LANCETS protriptyline hcl...... 66 qc pen needles...... 178 THIN 28G...... 178 PROTYL AG...... 238 qc unifine pentips...... 178 RA E-ZJECT LANCETS provad...... 119 qc unilet lancets 28g...... 178 ULTRA THIN...... 178 PROVAYBLUE...... 134 qc unilet lancets micro thin..... 178 ra glucose...... 110 PROVENTIL HFA...... 212 QMIIZ ODT...... 17 ra insulin syringe...... 178 PROVIDA OB...... 198 QNASL...... 215 ra mini nicotine...... 83 267 ra nicotine...... 83 RELENZA DISKHALER...... 32 RENACIDIN...... 124 ra pen needles...... 178 RELEXXII...... 74 RENATABS...... 199 rabeprazole sodium...... 122 RELION BLOOD RENATABS WITH IRON...199 RADIOGARDASE...... 135 GLUCOSE TEST...... 179 RENFLEXIS...... 138 RAGWITEK...... 137 RELION CONFIRM reno caps...... 199 raloxifene hcl...... 111 GLUCOSE MONITOR...... 179 repaglinide...... 91 ramelteon...... 74 RELION REPATHA...... 52 ramipril...... 47 CONFIRM/MICRO TEST...179 REPATHA PUSHTRONEX ranolazine er...... 57 RELION GLUCOSE...... 110 SYSTEM...... 52 RAPAFLO...... 123 RELION INSULIN REPATHA SURECLICK...... 52 RAPPORT RLS...... 178 SYRINGE...... 179 REQ 49+...... 199 RAPPORT VTD...... 178 RELION KETONE TEST....179 RESECTISOL...... 124 rasagiline mesylate...... 68 RELION LANCET resorcinol-sulfur...... 219 RASUVO...... 140 DEVICES 30G...... 179 RESTASIS...... 135 RAYALDEE...... 93 RELION LANCETS RESTASIS MULTIDOSE....135 RAYOS...... 108 MICRO-THIN 33G...... 179 RESTORA RX...... 120 REACT...... 101 RELION LANCETS THIN RESTORE SILVER READYLANCE SAFETY 26G...... 179 DRESSING...... 238 LANCETS...... 178 RELION LANCETS RETACRIT...... 129 READYSHARP ANESTH + ULTRA-THIN 30G...... 179 RETIN-A MICRO...... 219 KETOROLAC...... 143 RELION LANCING RETIN-A MICRO PUMP....220 READYSHARP DEVICE...... 179 revesta...... 135 DEXAMETHASONE...... 108 RELION MICRO...... 179 REVLIMID...... 142 reality insulin syringe...... 179 RELION MINI PEN REXALL BLOOD reality lancets...... 179 NEEDLES...... 179 GLUCOSE SYSTEM...... 180 reality swabs...... 179 RELION PEN NEEDLES....179 REXALL BLOOD reality trigger lancets...... 179 RELION PREMIER BLU GLUCOSE TEST...... 180 REBIF...... 79 MONITOR...... 179 REXASIL PATCH & REBIF REBIDOSE...... 79 RELION PREMIER VITAMIN E LIQ...... 238 REBIF REBIDOSE COMPACT SYSTEM...... 179 REXULTI...... 71 TITRATION PACK...... 79 RELION PREMIER VOICE REYATAZ...... 29 REBIF TITRATION PACK.. 79 MONITOR...... 180 REYVOW...... 76 REBINYN...... 131 RELION PRIME RHEUMATE...... 199 RECARBRIO...... 27 MONITOR...... 180 RHOFADE...... 236 RECEDO...... 234 RELION PRIME TEST...... 180 RHOPRESSA...... 208 RECLAST...... 92 RELION SHORT PEN RIABNI...... 39 Reclipsen...... 101 NEEDLES...... 180 RIAX...... 220 RECOMBINATE...... 130 RELION ULTIMA ribavirin...... 32, 35 RECOTHROM...... 135 GLUCOSE SYSTEM...... 180 ribozel...... 199 RECOTHROM SPRAY KIT RELION ULTIMA TEST.... 180 RIDAURA...... 15 ...... 135 RELION ULTRA THIN rifabutin...... 31 RECTIV...... 122 LANCETS 30G...... 180 rifampin...... 31 RECURA...... 222 RELION ULTRA THIN RIGHTEST ALTERNATE REFUAH PLUS BLOOD PLUS LANCETS...... 180 SITE ADAPT...... 180 GLUCOSE TEST...... 179 RELISTOR...... 120 RIGHTEST GD500 REFUAH PLUS relnate dha...... 199 LANCING DEVICE...... 180 MONITORING SYSTEM... 179 REMEDIENT...... 199 RIGHTEST GL300 REGENECARE...... 238 REMICADE...... 138 LANCETS...... 180 REGIOCIT...... 127 remigen...... 234 RIGHTEST GM100 BLOOD REGRANEX...... 238 REMODULIN...... 58 GLUCOSE...... 180 268 RIGHTEST GM300 BLOOD SABRIL...... 62 SEROQUEL XR...... 71 GLUCOSE...... 180 SAFE-T-LANCE...... 180 SEROSTIM...... 110 RIGHTEST GM550 BLOOD SAFE-T-LANCE PLUS...... 180 sertraline hcl...... 66 GLUCOSE...... 180 safety insulin syringes...... 180 Setlakin...... 101 RIGHTEST GS100 BLOOD safety lancet 30g/pressure act. 180 sevelamer carbonate...... 112 GLUCOSE...... 180 SAFYRAL...... 101 sevelamer hcl...... 112 RIGHTEST GS300 BLOOD salimez forte...... 234 SEYSARA...... 37 GLUCOSE...... 180 SALIVAMAX...... 240 SFROWASA...... 117 RIGHTEST GS550 BLOOD salsalate...... 24 Sharobel...... 101 GLUCOSE...... 180 SAMSCA...... 111 SHOPKO AUTOLET riluzole...... 77 SANCUSO...... 116 LANCING DEVICE...... 181 rimantadine hcl...... 32 SANDIMMUNE...... 143 SHOPKO UNIFINE RIMSO-50...... 124 SANDOSTATIN...... 111 PENTIPS...... 181 ringers irrigation...... 208 SANTYL...... 234 SHOPKO UNIFINE RINVOQ...... 138 SAPHRIS...... 71 PENTIPS PLUS...... 181 RIOMET...... 85 saps care alcohol prep...... 180 SHUR-SEAL risedronate sodium...... 92 saps health care alcohol prep...180 CONTRACEPTIVE...... 123 RISPERDAL CONSTA...... 71 saps health twist top lancets....181 SIGNIFOR...... 111 risperidone...... 71 saps twist top lancets...... 181 SIGNIFOR LAR...... 111 ritonavir...... 29 sapscare twist top lancets...... 181 SIKLOS...... 135 RITUXAN...... 39 SARCLISA...... 40 sildenafil citrate...... 58 rivastigmine...... 64 SAVAYSA...... 127 SILENOR...... 74 rivastigmine tartrate...... 64 SAVELLA...... 77 SILHOUETTE 13MM...... 181 Rivelsa...... 101 SAVELLA TITRATION SILHOUETTE 17MM...... 181 rixubis...... 131 PACK...... 77 SILHOUETTE INFUSION rizatriptan benzoate...... 76 SAXENDA...... 92 SET 23"...... 181 ROCKLATAN...... 208 sb alcohol prep...... 181 SILHOUETTE INFUSION romidepsin...... 39 sb childrens aspirin...... 24 SET 43"...... 181 ropinirole hcl...... 68 sb insulin syringe...... 181 silipac...... 235 ropinirole hcl er...... 68 sb lancets thin...... 181 SILIQ...... 224 Rosadan...... 236 sb lancets ultra thin...... 181 silodosin...... 123 rosuvastatin calcium...... 51 scarcin...... 234, 235 silver sulfadiazine...... 221 ROTARIX...... 143 scarsilk...... 235 SIMBRINZA...... 203 ROTATEQ...... 143 SCARZEN SKIN REPAIR.. 228 Simliya...... 102 ROWASA...... 117 scopolamine...... 116 Simpesse...... 102 Roweepra...... 62 SEASONIQUE...... 101 SIMPLE DIAGNOSTICS ROXICODONE...... 22 SEBUDERM...... 235 LANCING DEV...... 181 ROZEREM...... 74 SECURESAFE INSULIN SIMPONI...... 138 ROZLYTREK...... 43 SYRINGE...... 181 SIMPONI ARIA...... 138 RTD WOUND CARE SEGLUROMET...... 91 simvastatin...... 51 DRESSING...... 238 select-lite lancing device...... 181 SINGLE-LET...... 181 RUBRACA...... 39 SELECT-OB...... 199 SINGULAIR...... 214 RUCONEST...... 135 SELECT-OB+DHA...... 199 SINUVA...... 215 RUXIENCE...... 39 selegiline hcl...... 68 sirolimus...... 143 RUZURGI...... 77 selenium sulfide...... 224 SIRTURO...... 31 RYBELSUS...... 87 SELZENTRY...... 29 SITAVIG...... 32 RYCLORA...... 211 se-natal 19...... 199 SIVEXTRO...... 27 RYDAPT...... 39 SENSIPAR...... 93 SKYLA...... 102 RYTARY...... 68 SEREVENT DISKUS...... 212 SKYRIZI...... 139 RYVENT...... 211 SERNIVO...... 228 SKYRIZI (150 MG DOSE).. 139 269 SKYRIZI PEN...... 139 sodium polystyrene sulfonate.... 94 STELARA...... 139 SLYND...... 102 sodium sulfacetamide wash..... 224 STENDRA...... 123 sm alcohol prep...... 181 sodium sulfacetamide- STERILANCE PA...... 182 sm aspirin adult low strength.... 24 bakuchiol...... 220 STERILANCE TL...... 182 sm childrens aspirin...... 24 solifenacin succinate...... 125 sterile water for irrigation...... 208 sm folic acid...... 199 SOLIQUA...... 87 STIMATE...... 114 sm glucose...... 110 SOLODYN...... 37 STIOLTO RESPIMAT...... 210 sm lancets 33g...... 181 SOLOSEC...... 27 STIVARGA...... 43 sm nicotine...... 83, 84 SOLTAMOX...... 41 STRENSIQ...... 93 sm nicotine polacrilex...... 83 SOLUS V2 BLOOD STRIBILD...... 31 SM TRUEDRAW GLUCOSE SYSTEM...... 182 STRIVERDI RESPIMAT.... 212 LANCING DEVICE...... 181 SOLUS V2 LANCETS 28G.. 182 STROVITE FORTE...... 199 SMART DIABETES SOLUS V2 LANCING SUBLOCADE...... 23 VANTAGE LANCING...... 181 DEVICE...... 182 SUBOXONE...... 18 SMART SENSE COLOR SOLUS V2 TEST...... 182 SUBSYS...... 22 LANCETS 33G...... 181 SOLUS V2 TWIST Subvenite...... 63 SMART SENSE GLUCOSE 110 LANCETS 30G...... 182 Subvenite Starter Kit-Blue...... 63 SMART SENSE PREMIUM SOMATULINE DEPOT...... 111 Subvenite Starter Kit-Green....63 SYSTEM...... 181 SOMAVERT...... 111 Subvenite Starter Kit-Orange.. 63 SMART SENSE PREMIUM SOOLANTRA...... 236 SUCRAID...... 120 TEST...... 181 sorbitol...... 124 sucralfate...... 120 SMART SENSE sorbitol-mannitol...... 124 sulfacetamide sodium...... 206 STANDARD LANCETS..... 181 SORIATANE...... 224 sulfacetamide sodium (acne).. 220 SMART SENSE SUPER SORILUX...... 224 sulfacetamide sodium-sulfur....220 THIN LANCETS...... 181 Sorine...... 49 sulfacetamide-prednisolone..... 204 SMART SENSE THIN sorrel/dock mix...... 137 sulfadiazine...... 25 LANCETS 26G...... 181 sotalol hcl...... 49 sulfamethoxazole-trimethoprim 27 SMART SENSE VALUE sotalol hcl (af)...... 49 sulfamez wash...... 220 GLUCOSE SYS...... 182 SOTYLIZE...... 53 SULFAMYLON...... 221 SMART SENSE VALUE SOVALDI...... 35 sulfasalazine...... 118 TEST...... 182 spinosad...... 236 Sulfatrim Pediatric...... 27 SMARTEST BLOOD SPIRIVA HANDIHALER...210 sulfurated lime...... 236 GLUCOSE TEST...... 182 SPIRIVA RESPIMAT...... 210 sulindac...... 18 SMARTEST EJECT...... 182 spironolactone...... 56 sumatriptan...... 76 SMARTEST EJECT spironolactone-hctz...... 56 sumatriptan succinate...... 76 STARTER...... 182 SPORANOX...... 26 sumatriptan succinate refill...... 76 SMARTEST LANCETS 28G SPORANOX PULSEPAK..... 26 sumatriptan-naproxen sodium...76 ...... 182 SPRAVATO (56 MG DOSE). 67 SUNOSI...... 81 SMARTEST PERSONA SPRAVATO (84 MG DOSE). 67 SUPARTZ FX...... 24 STARTER...... 182 Sprintec 28...... 102 super bi-mix...... 123 SMARTEST PRONTO SPRITAM...... 62 super quad-mix...... 123 STARTER...... 182 SPRIX...... 17 super thin lancets...... 182 SMARTEST PROTEGE...... 182 SPRYCEL...... 43 super tri-mix...... 123 SMARTEST PROTEGE SPS...... 94 SUPERVITE...... 199 STARTER...... 182 Sronyx...... 102 SUPPRELIN LA...... 104 sod citrate-citric acid...... 124 Ssd...... 221 SUPRAX...... 33 sodium bicarbonate...... 199 ST JOSEPH LOW DOSE...... 24 SUPREME TEST...... 182 sodium chloride...... 124, 215 stavudine...... 29 SUPREP BOWEL PREP KIT sodium fluoride...... 199 STEGLATRO...... 92 ...... 119 sodium phenylbutyrate...... 105 STEGLUJAN...... 91 sure comfort alcohol prep...... 182 270 sure comfort insulin syringe.... 182 SYMPROIC...... 120 TEKTURNA...... 55 sure comfort lancets 18g...... 183 SYMTUZA...... 31 TEKTURNA HCT...... 55 sure comfort lancets 21g...... 183 SYNAGIS...... 32 telmisartan...... 48 sure comfort lancets 23g...... 183 SYNAPRYN FUSEPAQ...... 22 telmisartan-amlodipine...... 48 sure comfort lancets 30g...... 183 SYNAREL...... 104 telmisartan-hctz...... 48 sure comfort lancing pen...... 183 SYNDROS...... 116 temazepam...... 75 sure comfort pen needles...... 183 SYNERA...... 230 TEMIXYS...... 31 SURE-FINE PEN SYNERDERM...... 235 TEMODAR...... 38 NEEDLES...... 183 SYNJARDY...... 91 temozolomide...... 38 SURE-JECT INSULIN SYNJARDY XR...... 91 TENCON...... 16 SYRINGE...... 183 SYNRIBO...... 45 tenofovir disoproxil fumarate....29 SURE-LANCE FLAT SYPRINE...... 94 terazosin hcl...... 47 LANCETS...... 183 T:FLEX T:LOCK terbinafine hcl...... 26 SURE-LANCE LANCETS CARTRIDGE 4.8ML...... 183 terbutaline sulfate...... 212 26G...... 183 TABLOID...... 38 terconazole...... 126 SURELITE LANCETS...... 183 TABRADOL FUSEPAQ...... 81 TESTIM...... 84 SURE-PEN...... 183 TABRADOL RAPIDPAQ..... 81 TESTONE CIK...... 84 SURE-T INFUSION SET TACLONEX...... 228 TESTOPEL...... 84 18"...... 183 tacrolimus...... 143, 235 testosterone...... 85 SURE-T INFUSION SET tadalafil (pah)...... 58 testosterone cypionate...... 84 23"...... 183 TAFINLAR...... 43 testosterone enanthate...... 84 SURE-T INFUSION SET TAGRISSO...... 43 tetrabenazine...... 78 32"...... 183 TAKE ACTION...... 102 tetracaine hcl...... 135 SURE-T INFUSION SET TAKHZYRO...... 135 tetracycline hcl...... 37 6MM...... 183 TALICIA...... 122 TETRIX...... 235 SURE-T INFUSION SET TALIVA...... 135 TEXACORT...... 228 8MM...... 183 TALTZ...... 139 tgt blood glucose monitoring... 184 SURE-TEST EASYPLUS TALZENNA...... 40 tgt blood glucose test...... 184 MINI METER...... 183 tamoxifen citrate...... 41 tgt glucose...... 110 SURE-TEST EASYPLUS tamsulosin hcl...... 123 tgt lancet micro thin 33g...... 184 MINI TEST...... 183 TAPERDEX 12-DAY...... 108 tgt lancet thin 26g...... 184 SURE-TOUCH LANCETS Taperdex 6-Day...... 109 tgt lancet ultra thin 30g...... 184 UNIVERSAL...... 183 TAPERDEX 7-DAY...... 109 tgt lancing device...... 184 SURVANTA...... 215 TARCEVA...... 43 THALOMID...... 142 SUSTOL...... 116 Targadox...... 37 THE LIQUILIFT TRACE... 191 SUTENT...... 43 TARGRETIN...... 45, 235 THEO-24...... 217 suvicort...... 235 Tarina 24 Fe...... 102 theophylline...... 217 SX1 MEDICATED POST- Tarina Fe 1/20...... 102 theophylline er...... 217 OPERATIVE...... 230 Tarina Fe 1/20 Eq...... 102 THERANATAL CORE Syeda...... 102 TARON-C DHA...... 199 NUTRITION...... 200 SYMAX DUOTAB...... 115 TARON-PREX...... 199 thiamine hcl...... 200 Symax-Sr...... 115 TAYTULLA...... 102 THINLETS GP LANCETS..184 SYMBICORT...... 217 tazarotene...... 224 THIOLA...... 125 SYMDEKO...... 215 TAZORAC...... 224 THIOLA EC...... 125 SYMFI...... 31 Taztia Xt...... 55 thioridazine hcl...... 71 SYMFI LO...... 31 TECFIDERA...... 79 thiothixene...... 71 SYMJEPI...... 209 techlite insulin syringe...... 183 thrivacin 30...... 200 SYMLINPEN 120...... 85 TECHLITE PEN NEEDLES184 thrivacin detox...... 200 SYMLINPEN 60...... 85 TEGADERM AG MESH.....238 THRIVE...... 84 SYMPAZAN...... 63 TEGSEDI...... 81 thrivite 19...... 200 271 thrivite rx...... 200 TOVIAZ...... 125 Tri-Estarylla...... 102 THROMBIN-JMI...... 135 TOXICOLOGY MED trifluoperazine hcl...... 71 THROMBIN-JMI COLLECTION SYS...... 184 trifluridine...... 206 EPISTAXIS...... 135 TRACLEER...... 58 trihexyphenidyl hcl...... 69 THROMBOGEN...... 135 TRADJENTA...... 86 TRIJARDY XR...... 87 tiagabine hcl...... 63 tramadol hcl...... 22 TRIKAFTA...... 215 TIBSOVO...... 45 tramadol hcl er...... 22 Tri-Legest Fe...... 102 TICE BCG...... 45 tramadol hcl er (biphasic)...... 22 TRILEPTAL...... 63 TIGLUTIK...... 78 tramadol-acetaminophen...... 22 Tri-Linyah...... 102 TIKOSYN...... 49 trandolapril...... 47 Tri-Lo-Estarylla...... 102 Tilia Fe...... 102 trandolapril-verapamil hcl er.... 46 Tri-Lo-Marzia...... 102 timolol maleate...... 53, 203, 204 tranexamic acid...... 135 Tri-Lo-Mili...... 102 TIMOPTIC OCUDOSE...... 204 TRANSDERM-SCOP (1.5 Tri-Lo-Sprintec...... 102 tinidazole...... 25 MG)...... 116 trimethobenzamide hcl...... 116 TIROSINT...... 113 tranylcypromine sulfate...... 67 trimethoprim...... 27 TIROSINT-SOL...... 114 TRAVATAN Z...... 204 Tri-Mili...... 103 TISSEEL...... 135 travel lancets...... 184 trimipramine maleate...... 67 Tis-U-Sol...... 208 TRAVEL LANCETS tri-mix...... 123 TIVICAY...... 29 ADVANCED 28G...... 184 TRIMO-SAN...... 125 TIVICAY PD...... 29 TRAZIMERA...... 40 trinatal rx 1...... 200 TIVORBEX...... 18 trazodone hcl...... 67 TRINATE...... 200 tizanidine hcl...... 81 TREANDA...... 38 trinaz...... 200 tl-hem 150...... 135 TRECATOR...... 31 TRINTELLIX...... 67 TOBAKIENT...... 200 TRELEGY ELLIPTA...... 210 triple complex formula 3 kit....235 TOBI PODHALER...... 25 TRELSTAR MIXJECT...... 41 triple pmb...... 205 TOBRADEX...... 204 TREMFYA...... 139 triple pmk...... 205 TOBRADEX ST...... 204 treprostinil...... 58 Tri-Previfem...... 103 tobramycin...... 25, 206 TRESIBA...... 90 TRIPTODUR...... 104 tobramycin-dexamethasone.... 205 TRESIBA FLEXTOUCH...... 90 Tri-Sprintec...... 103 TOBREX...... 206 tretinoin...... 45, 220 tristart dha...... 200 todays health mini pen needles 184 tretinoin microsphere...... 220 TRISTART FREE...... 200 todays health pen needles...... 184 tretinoin microsphere pump.....220 TRISTART ONE...... 200 todays health short pen needle.184 TREXALL...... 38 TRIUMEQ...... 31 tolbutamide...... 92 TREXIMET...... 76 TRIVEEN-DUO DHA...... 200 tolcapone...... 69 Tri Femynor...... 102 TRI-VI-FLOR...... 200 tolsura...... 26 triamcinolone acetonide...228, 240 tri-vi-floro...... 200 tolterodine tartrate...... 125 tri-amino...... 200 TRIVISC...... 24 tolterodine tartrate er...... 125 triamterene...... 56 tri-vite/fluoride...... 200 topcare clickfine pen needles... 184 triamterene-hctz...... 56 Trivora (28)...... 103 topcare lancets micro-thin 33g 184 Trianex...... 228 Tri-Vylibra...... 103 topcare ultra comfort ins syr...184 triazolam...... 75 Tri-Vylibra Lo...... 103 topiramate...... 63 TRICARE...... 200 TRODELVY...... 40 topiramate er...... 63 TRICARE PRENATAL TROKENDI XR...... 63 TOPROL XL...... 53 DHA ONE...... 200 tronvite...... 200 toremifene citrate...... 41 TRICITRASOL...... 127 tropicamide...... 135 TORONOVA II SUIK...... 18 tricitrates...... 125 trospium chloride...... 126 TORONOVA SUIK...... 18 Tricon...... 135 trospium chloride er...... 125 torsemide...... 56 TRICOR...... 50 true comfort insulin syringe.....184 TOUJEO MAX SOLOSTAR. 90 Triderm...... 228 true comfort pen needles...... 184 TOUJEO SOLOSTAR...... 90 trientine hcl...... 94 true comfort pro insulin syr.....184 272 true comfort twist top lancets..184 TYLACTIN COMPLETE 15 ultra-care lancets 30g...... 187 TRUE FOCUS BLOOD PE...... 200 ultracare pen needles...... 187 GLUCOSE METER...... 184 TYMLOS...... 112 ULTRACET...... 22 true focus blood glucose strip.. 184 TYR EASY...... 200 ultra-comfort insulin syringe...187 TRUE METRIX AIR TYSABRI...... 80 ULTRAM...... 22 GLUCOSE METER...... 184 TYVASO...... 58 ULTRA-THIN II AUTO TRUE METRIX BLOOD TYVASO REFILL...... 58 LANCET...... 187 GLUCOSE TEST...... 184 TYVASO STARTER...... 58 ULTRA-THIN II INS SYR TRUE METRIX GO UBRELVY...... 76 SHORT...... 187 GLUCOSE METER...... 184 UCERIS...... 118 ULTRA-THIN II INSULIN TRUE METRIX METER.... 185 UDAMIN SP...... 200 SYRINGE...... 187 TRUEPLUS 5-BEVEL PEN UDENYCA...... 129 ULTRA-THIN II LANCETS NEEDLES...... 185 ULORIC...... 15 ...... 187 TRUEPLUS INSULIN ULTICARE ALCOHOL ULTRA-THIN II MINI PEN SYRINGE...... 185 SWABS...... 185 NEEDLE...... 187 TRUEPLUS LANCETS 26G185 ULTICARE INSULIN ULTRA-THIN II PEN TRUEPLUS LANCETS 28G185 SAFETY SYR...... 185 NEEDLE SHORT...... 187 TRUEPLUS LANCETS 30G185 ULTICARE INSULIN ULTRA-THIN II PEN TRUEPLUS LANCETS 33G185 SYRINGE...... 186 NEEDLES...... 187 TRUEPLUS PEN NEEDLES ULTICARE MICRO PEN ULTRAVATE...... 228 ...... 185 NEEDLES...... 186 UNIFINE PENTIPS...... 187 TRUEPLUS SAFETY ULTICARE MINI PEN UNIFINE PENTIPS PLUS.. 187 LANCETS 28G...... 185 NEEDLES...... 186 UNIFINE SAFECONTROL TRUERESULT BLOOD ULTICARE PEN NEEDLES PEN NEEDLE...... 187 GLUCOSE...... 185 ...... 186 UNILET COMFORTOUCH TRUETEST TEST...... 185 ULTICARE SHORT PEN LANCET...... 187 TRUETRACK BLOOD NEEDLES...... 186 UNILET EXCELITE...... 187 GLUCOSE...... 185 ultiguard safepack pen needle..186 UNILET EXCELITE II...... 187 TRUETRACK SMART ULTI-LANCE UNILET G.P. LANCET...... 187 SYSTEM...... 185 AUTOMATIC...... 186 UNILET G.P. SUPERLITE TRUETRACK TEST...... 185 ultilet alcohol swabs...... 186 LANCET...... 187 TRULANCE...... 118 ULTILET CLASSIC UNILET GP 28 ULTRA TRULICITY...... 87 LANCETS...... 186 THIN...... 187 TRUSTEEL INFUSION ULTILET INSULIN UNILET LANCET...... 187 SET...... 185 SYRINGE...... 186 UNILET MICRO-THIN 33G TRUVADA...... 31 ULTILET INSULIN ...... 188 TRUXIMA...... 40 SYRINGE SHORT...... 186 UNILET SUPERLITE TUDORZA PRESSAIR...... 210 ULTILET LANCETS...... 186 LANCET...... 188 TUKYSA...... 44 ULTILET PEN NEEDLE.... 186 UNILET SUPER-THIN 30G Tulana...... 103 ULTILET SAFETY ...... 188 TURALIO...... 44 LANCETS...... 186 UNILET ULTRA-THIN turpentine...... 235 ULTILET SAFETY 28G...... 188 TUSNEL C...... 213 LANCETS 23G...... 186 UNISTIK 1...... 188 TUSSICAPS...... 213 ULTIMA...... 186 UNISTIK 2...... 188 TUXARIN ER...... 213 ULTOMIRIS...... 136 UNISTIK 2 COMFORT...... 188 TUZISTRA XR...... 213 ultra comfort insulin syringe... 186 UNISTIK 2 EXTRA...... 188 TYBOST...... 30 ultra thin lancets 31g...... 186 UNISTIK 2 NEONATAL.... 188 Tydemy...... 103 ULTRA THIN PEN UNISTIK 2 NORMAL...... 188 TYKERB...... 44 NEEDLES...... 186 UNISTIK 2 SUPER...... 188 ultracare insulin syringe...... 187 UNISTIK 3...... 188 273 UNISTIK 3 COMFORT...... 188 VALTREX...... 32 verasens blood glucose system.189 UNISTIK 3 EXTRA...... 188 value health insulin syringe..... 188 verasens blood glucose test...... 189 UNISTIK 3 GENTLE...... 188 value plus glucose...... 110 VERDESO...... 228 UNISTIK 3 NEONATAL.... 188 value plus lancet standard 21g.188 VEREGEN...... 235 UNISTIK 3 NORMAL...... 188 value plus lancets super thin.... 188 VERSACLOZ...... 71 UNISTIK CZT COMFORT.188 valumark lancet ultra thin 28g 188 VERZENIO...... 40 UNISTIK CZT NORMAL...188 valumark pen needles...... 189 VESICARE...... 126 UNISTIK NORMAL...... 188 vancomycin hcl...... 27 VESICARE LS...... 126 UNISTIK PRO SAFETY VANCOMYCIN+SYRSPEN vexasyn...... 238 LANCET...... 188 D SF...... 27 V-GO 20...... 189 UNISTIK SAFETY Vandazole...... 126 V-GO 30...... 189 LANCETS 28G...... 188 VANISHPOINT INSULIN V-GO 40...... 189 UNISTIK SAFETY SYRINGE...... 189 VIAGRA...... 124 LANCETS 30G...... 188 VANOS...... 228 VIBERZI...... 118 UNISTIK TOUCH SAFETY Vanoxide-Hc...... 220 VIBRAMYCIN...... 37 LANC 21G...... 188 VANTAS...... 41 Vic-Forte...... 201 UNISTIK TOUCH SAFETY VARISOFT INFUSION SET VICTOZA...... 87 LANC 23G...... 188 ...... 189 VIDA MIA UNIFINE UNISTIK TOUCH SAFETY VAROPHEN...... 235 PENTIPS...... 189 LANC 28G...... 188 VARUBI (180 MG DOSE)... 116 Vienva...... 103 UNISTIK TOUCH SAFETY VASCEPA...... 51, 52 vigabatrin...... 63 LANC 30G...... 188 VASCULERA...... 200 Vigadrone...... 63 UNISTRIP1 GENERIC...... 188 VAXCHORA...... 143 VIIBRYD...... 67 Unithroid...... 114 VAXELIS...... 143, 144 VIIBRYD STARTER PACK.67 UNIVERSAL 1 LANCETS vb6 p5p...... 200 VIMOVO...... 18 THIN 26G...... 188 v-c forte...... 201 VIMPAT...... 63 UNIVERSAL 1 LANCETS VCF VAGINAL VINATE DHA RF...... 201 THIN 33G...... 188 CONTRACEPTIVE...... 123 VINATE II...... 201 UNIVERSAL 1 LANCETS VECAMYL...... 57 VINATE ONE...... 201 ULTRA THIN...... 188 VECTICAL...... 224 VIOKACE...... 120 up & up glucose...... 110 VELCADE...... 45 viorele...... 103 UPTRAVI...... 58 VELETRI...... 58 VIRACEPT...... 30 Uredeb...... 235 Velivet...... 103 VIREAD...... 30 URESOL...... 235 VELPHORO...... 112 virt-c dha...... 201 urosex...... 200 VELTASSA...... 94 virt-caps...... 201 UROXATRAL...... 123 VELTIN...... 220 virt-fefa plus...... 136 ursodiol...... 120 VEMLIDY...... 32 Virt-Gard...... 136 UVADEX...... 45 VENCLEXTA...... 46 virt-nate dha...... 201 VAGIFEM...... 107 VENCLEXTA STARTING virt-phos 250 neutral...... 191 valacyclovir hcl...... 32 PACK...... 46 virt-pn dha...... 201 VALCHLOR...... 235 VENELEX...... 238 virt-pn plus...... 201 VALCYTE...... 32 VENIPUNCTURE PX1 virtussin a/c...... 213 valganciclovir hcl...... 32 PHLEBOTOMY...... 230 virtussin dac...... 213 valproic acid...... 63 venlafaxine hcl...... 67 VISCO-3...... 24 valsartan...... 48 venlafaxine hcl er...... 67 VISTOGARD...... 45 valsartan-hydrochlorothiazide...48 VENTAVIS...... 59 Vita S Forte...... 201 VALTOCO 10 MG DOSE...... 63 VENTOLIN HFA...... 212 Vitacel...... 201 VALTOCO 15 MG DOSE...... 63 verapamil hcl...... 55 VITAFOL FE+...... 201 VALTOCO 20 MG DOSE...... 63 verapamil hcl er...... 55 VITAFOL GUMMIES...... 201 VALTOCO 5 MG DOSE...... 63 verasens blood glucose meter...189 VITAFOL STRIPS...... 201 274 VITAFOL ULTRA...... 201 Vylibra...... 103 XANAX XR...... 59 VITAFOL-NANO...... 201 VYNDAMAX...... 57 XAQUIL XR...... 202 VITAFOL-OB...... 201 VYNDAQEL...... 57 XARELTO...... 127 VITAFOL-OB+DHA...... 201 VYVANSE...... 74 XARELTO STARTER VITAFOL-ONE...... 201 VYZULTA...... 204 PACK...... 127 VITAMEDMD ONE walgreens adv travel lancets....189 XATMEP...... 38 RX/QUATREFOLIC...... 201 WALGREENS LANCETS...189 XCOPRI...... 64 VITAMEDMD REDICHEW walgreens lancets micro thin... 189 XCOPRI (250 MG DAILY RX...... 201 walgreens lancets super thin....189 DOSE)...... 64 VITAMEZ...... 136 WALGREENS THIN XCOPRI (350 MG DAILY vita-min...... 201 LANCETS...... 189 DOSE)...... 64 vitamin d (ergocalciferol)...... 201 WALGREENS ULTRA XELJANZ...... 140 vitamin k1...... 201 THIN LANCETS...... 189 XELJANZ XR...... 140 vitamins acd-fluoride...... 202 warfarin sodium...... 127 XELODA...... 38 VITAPEARL...... 202 WAVESENSE AMP...... 189 XELPROS...... 204 vitasure...... 202 WEBCOL ALCOHOL PREP XENICAL...... 78 VITATHELY WITH LARGE...... 189 XENLETA...... 27 GINGER...... 202 WEBCOL ALCOHOL PREP XEOMIN...... 81 VITATRUE...... 202 MEDIUM...... 189 XEPI...... 221 VITRAKVI...... 44 wegmans unifine pentips plus.. 189 XERAC AC...... 235 VIVA DHA...... 202 WEGOVY...... 92 XERALUX...... 235 VIVAGUARD INO Wera...... 103 XERESE...... 32 GLUCOSE METER...... 189 westab plus...... 202 XERMELO...... 120 VIVAGUARD INO TEST westgel dha...... 202 XEROFORM OIL STRIPS...... 189 WESTHROID...... 114 EMULSION 2"X2"...... 238 VIVAGUARD LANCETS... 189 wheat germ oil...... 202 XEROFORM OIL VIVAGUARD LANCING WIDE-SEAL DIAPHRAGM EMULSION GAUZE...... 238 DEVICE...... 189 60...... 144 XEROFORM OIL VIVELLE-DOT...... 107 WIDE-SEAL DIAPHRAGM EMULSION STRIP...... 239 VIVITROL...... 84 65...... 144 XEROFORM OIL ROLL VIVLODEX...... 18 WIDE-SEAL DIAPHRAGM 4"X9'...... 239 VIZIMPRO...... 44 70...... 144 XEROFORM PETROLAT VOGELXO...... 85 WIDE-SEAL DIAPHRAGM GAUZE 1"X8"...... 239 VOGELXO PUMP...... 85 75...... 144 XEROFORM PETROLAT VOLTAREN...... 235 WIDE-SEAL DIAPHRAGM GAUZE 5"X9"...... 239 VONVENDI...... 131 80...... 144 XEROFORM PETROLAT voriconazole...... 26 WIDE-SEAL DIAPHRAGM PATCH 2"X2"...... 239 VOSEVI...... 35 85...... 144 XEROFORM PETROLAT VOTRIENT...... 44 WIDE-SEAL DIAPHRAGM PATCH 4"X4"...... 239 vp fc kit...... 235 90...... 144 XEROFORM vp insulin syringe...... 189 WIDE-SEAL DIAPHRAGM PETROLATUM ROLL vp-pnv-dha...... 202 95...... 144 4"X9'...... 239 VPRIV...... 105 WILATE...... 128 XEROSTOMIA RELIEF vp-vite rx...... 202 WP THYROID...... 114 SPRAY...... 240 VRAYLAR...... 71 wpr plus wound healing system230 XGEVA...... 112 VSL#3 DS...... 120 Wymzya Fe...... 103 XHANCE...... 215 VUMERITY...... 80 XADAGO...... 69 XIFAXAN...... 28 VUSION...... 222 XALIX...... 235 XIGDUO XR...... 91 Vyfemla...... 103 XALKORI...... 44 XIIDRA...... 207 VYLEESI...... 84 XANAX...... 59 XIMINO...... 37 275 XOFIGO...... 45 ZELNORM...... 118 ZYCLARA PUMP...... 220, 235 XOFLUZA (40 MG DOSE)... 32 ZEMAIRA...... 215 ZYDELIG...... 44 XOFLUZA (80 MG DOSE)... 32 ZEMBRACE SYMTOUCH...76 ZYFLO...... 213 XOLAIR...... 212 Zenatane...... 220 ZYKADIA...... 44 XOLEGEL...... 223 ZENPEP...... 120 ZYLET...... 205 XOLEGEL COREPAK...... 223 Zenzedi...... 74 ZYMAXID...... 206 XOLEGEL DUO/HEAD & ZENZEDI...... 74 ZYPITAMAG...... 51 SHOULDERS...... 223 ZEPOSIA...... 80 ZYPREXA RELPREVV...... 72 XOLEGEL DUO/XOLEX... 223 ZEPOSIA 7-DAY STARTER zyvit...... 202 XOPENEX HFA...... 212 PACK...... 80 ZYVOX...... 28 XOSPATA...... 44 ZEPOSIA STARTER KIT..... 80 XPOVIO (60 MG TWICE ZESTORETIC...... 46 WEEKLY)...... 45 ZETIA...... 50 XPOVIO (80 MG TWICE ZETONNA...... 215 WEEKLY)...... 45 zevrx twist top lancets 30g...... 189 XRYLIX...... 235 ZIANA...... 220 XTAMPZA ER...... 22 zidovudine...... 30 XTANDI...... 41 ZIEXTENZO...... 129 Xulane...... 103 ZILACAINE PATCH...... 230 XULTOPHY...... 87 zileuton er...... 213 XURIDEN...... 112 ZILRETTA...... 109 xvite...... 202 zinc sulfate...... 191 XYNTHA...... 130 ZIOPTAN...... 204 XYNTHA SOLOFUSE...... 130 ziprasidone hcl...... 71 XYOSTED...... 85 ZIPSOR...... 18 XYREM...... 81 ZIRABEV...... 44 xyzbac...... 202 ZIRGAN...... 206 YASMIN 28...... 103 ZOKINVY...... 112 YAZ...... 103 ZOLADEX...... 41 yl folic acid...... 202 zoledronic acid...... 92, 93 YONSA...... 41 ZOLINZA...... 40 YOSPRALA...... 136 zolmitriptan...... 76 YUPELRI...... 210 ZOLOFT...... 67 YUTIQ...... 207 zolpidem tartrate...... 75 Yuvafem...... 107 zolpidem tartrate er...... 75 zaclir cleansing...... 220 ZOLPIMIST...... 75 zafirlukast...... 214 ZOMIG...... 76 zaleplon...... 75 ZONEGRAN...... 64 zalvit...... 202 zonisamide...... 64 zanabin hydrogel...... 239 ZONTIVITY...... 137 Zarah...... 103 ZORBTIVE...... 110 ZATEAN-PN DHA...... 202 ZORVOLEX...... 18 ZATEAN-PN PLUS...... 202 Zovia 1/35E (28)...... 103 ZAVESCA...... 105 ZOVIRAX...... 32, 235 Zebutal...... 16 ZTLIDO...... 230 ZEGERID...... 122 ZUBSOLV...... 19 ZEJULA...... 40 ZULRESSO...... 67 zelac...... 120 Zumandimine...... 103 ZELAPAR...... 69 ZUPLENZ...... 116 ZELBORAF...... 44 ZYCLARA...... 220 276