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2021 Comprehensive Formulary (List of Covered Drugs)

Small Group and Individual

Eff ective 9/1/2021 2021 SUMMACARE COMPREHENSIVE FORMULARY SMALL GROUP AND INDIVIDUAL

PRESCRIPTION DRUG BENEFITS The following is a listing by drug class of medications most commonly prescribed under the SummaCare Benefit. Brand-name drugs are capitalized and generic drugs are listed in lowercase. Prescription drug benefits vary, but in most cases, brand name medications that have a generic equivalent require the patient to pay the difference in cost between the brand and generic medication. Some benefits may exclude certain drugs on this list. Refer to your plan documents for more coverage information.

ABOUT TIERS Prescription Description Drug Tier Tier 1 Zero Cost Share Preventive Drugs (This tier will contain low cost medications that may be preferred generic, single source, or multi-source Brand Drugs.) Tier 2 Preferred Generics Tier 3 Non-Preferred Generics Tier 4 Preferred Brand Tier 5 Non-Preferred Brand Tier 6 Specialty Drugs

Note: Some benefits may require a deductible be met before copays apply. Refer to your plan documents for further information.

USING YOUR SUMMACARE ID CARD It is important to show your SummaCare ID card when filling prescriptions. When you show your SummaCare ID card, safety checks are performed such as drug-drug interactions, therapeutic duplications and dose checks, even if you use multiple pharmacies, including mail order.

MEDIMPACT MedImpact is SummaCare’s Pharmacy Benefit Manager and is responsible for processing pharmacy claims for SummaCare members. MedImpact also handles pharmacy benefit customer service and utilization management requests on SummaCare’s behalf. To reach MedImpact, members should call the SummaCare customer service number on the back of their ID card.

WOMEN’S PREVENTIVE DRUGS Your cost share for selected women’s preventive care services may be waived when provided by a network pharmacy provider. Please refer to your benefit documents for further information.

PHARMACY UTILIZATION PROGRAMS SummaCare’s Prescription Drug Benefit incorporates utilization management programs (prior authorization, step therapy and quantity limits). Drugs requiring utilization management are indicated on the formulary document with a PA, PA NSO, QL or ST. If you are prescribed one of these drugs, the prescriber may need to contact MedImpact to provide supporting medical information.

Prior Authorization = PA Prior Authorization requirements are placed on medications when they have limited conditions for which they are prescribed, special monitoring or dispensing requirements or an extremely high cost. Guidelines for approving coverage for Prior Authorization drugs are developed and approved by a panel of practicing physicians and pharmacists.

Prior Authorization for New Starts Only = PA NOS If you are a new member, you may be required to get Prior Authorization on particular drugs before you fill your prescription. In this scenario, the same requirements as listed above under Prior Authorization would apply.

Step Therapy = ST Step Therapy is the practice of initiating drug therapy for a medical condition with the most cost- effective and safest drug, and then progressing to other more costly or risky drugs only if necessary (i.e., you must try drug “A” before you can get drug “B”). The goal is to control costs and minimize risks. Step therapy is an automated process. If you present a prescription for a “step therapy” drug (i.e., “B”) to a pharmacy, an automated check of your prescription history will occur. If the system finds that you have received the qualifying drug(s) (i.e., “A”), your prescription will be processed. If the system does not find that you received a qualifying drug (i.e., “A”) in recent history, a prior authorization will be necessary.

Quantity Limit = QL When a drug has a Quantity Limit, the amount of medication per prescription is limited to a specified amount per prescription or within a specific time frame. These limitations are usually in place due to safety issues or because the use of a dose higher than what is recommended has been shown to result in minimal additional benefit to the patient.

Gender Edits = GF or GM Gender edits may be added to certain medications when they are only to be prescribed for a male or female based on FDA prescribing indications. Drugs that are only to be prescribed for females will be indicated with a “GF” and drugs that are only to be prescribed for males will be indicated with a “GM.”

Opioid Edits SummaCare has implemented the following opioid edits:

Enhanced Opioid Cumulative Dosing: This limit is based on MME (Morphine Milligram Equivalent), which is the calculated amount of opioids that you are taking per day. Your opioid prescription will deny at the pharmacy if your total MME is greater than 80 MME. This means that you will need to get approval from SummaCare to fill your opioid prescription(s).

Days Supply Limit Edit: If the course of your opioid treatment continues for more than a 90 days then your opioid prescription will deny at the pharmacy. If you need more than a 90 day supply, you will need to get approval from SummaCare to fill your opioid prescription.

EXCEPTION PROCESS FOR NON-FORMULARY DRUGS What is an exception request? Exception requests are a kind of coverage determination. Exceptions can be requested by you and/or your authorized representative, or your prescribing physician may request an exception to seek coverage of a drug that is not on the formulary (list of drugs the plan covers).

There are two types of exception requests. The first one is an expedited exception request, which is defined under exigent circumstances only and if the drug is not approved may seriously jeopardize life, health or ability to regain maximum function, or may jeopardize undergoing current treatment using a non-formulary drug. The second is a standard exception request.

If SummaCare’s formulary does not include a drug that you or your prescribing physician feel is necessary, then you or your prescribing physician may request an exception so that you may obtain coverage of this drug. The exception request must include your prescribing physician’s statement that he/she has determined that the preferred formulary drug either would not be as effective or would have adverse effects for you. If the Plan does not grant the requested exception, then you or your prescribing physician may file an appeal.

Exception requests can be made verbally by contacting SummaCare’s Pharmacy Benefit Manager, MedImpact Healthcare Systems, Inc., at 800-788-2949 or can be sent via fax to 858- 790-7100. When will I receive a decision on my exception request? SummaCare must notify you and your prescriber of our decision no more than 24 hours following receipt of an Expedited Request and 72 hours following the receipt of a Standard Exception Request. If your request is denied, then you or your prescribing physician may file an appeal. If the exception request is granted, we will treat the excepted drug as an Essential Health Benefit and the cost share will be counted towards your annual limitation on cost-sharing and we will cover the drug for the duration of the prescription including refills.

FOR MORE INFORMATION ABOUT SUMMACARE’S PRESCRIPTION DRUG BENEFIT CALL: • Employers and Members: Please refer to the number on the back of your Member ID card or call Group Customer Service at 800-996-8701 • Persons with Hearing or Speech Disabilities: Call Ohio Relay (TTY) at 800-750-0750 • Providers: Call SummaCare Provider Services at 800-996-8401

To view the most recent formulary, please visit www.summacare.com.

08/2020 SummaCare/Apex Medication Request Form SUM01, 02, 06, 07, 11, 12, 14 Attn: Prior Authorization Department Fax: 858-790-7100

REQUEST FOR EXPEDITED (URGENT) REVIEW: BY CHECKING THIS BOX, I CERTIFY THAT APPLYING THE STANDARD REVIEW TIME FRAME MAY SERIOUSLY JEOPARDIZE THE LIFE OR HEALTH OF THE MEMBER OR THE MEMBER’S ABILITY TO REGAIN MAXIMUM FUNCTION Date: ______Time MRF was taken: ______Physician Signature: ______Physician Cell Phone #: ______

Medication Request Information (please complete each section of this form prior to transmittal): *Denotes Required Fields Status

Patient did not meet Guideline # for the following reason:

PATIENT INFORMATION PHYSICIAN INFORMATION

*Name: *Name:

*ID#: *Specialty:

*Date of Birth: *ID# / DEA#:

*HQ: *Phone: ( ) - *Fax: ( ) - Diagnosis (ICD-10 Code, if known): PHARMACY INFORMATION (If provided)

*Pharmacy Name: *Phone: ( ) - *Fax: ( ) - REQUESTED DRUG INFORMATION

*Requested Drug:

*Dose: *Strength: *Quantity: *Dosage Form: *Length of Treatment: (per month) (Oral, Injection, etc) (Please be specific.) Comments Reason for Medication Request (Please be specific, give detail.):

Other Medications Tried and/or Failed including OTC (Please be specific, give detail. Chart notes preferred):

Other Pertinent History (Relative or pertaining to this request.):

**Note: Specialty Vendor for SUM01, 02, 06, 07, 11, 12 is AcariaHealth: 833-626-8417 Specialty Vendor for SUM14 is SummaHealth Specialty Pharmacy: 888-874-8134 Effective: 6/18/2020 Table of Contents

Analgesics...... 3 ...... 9 Anti-Addiction/Substance Abuse Treatment Agents...... 10 Antianxiety Agents...... 12 Antibacterials...... 13 Anticancer Agents...... 20 Anticholinergic Agents...... 30 ...... 30 Antidementia Agents...... 36 ...... 36 Antidiabetic Agents...... 39 Antifungals...... 46 Antigout Agents...... 49 Antihistamines...... 49 Anti-Infectives (Skin And Mucous Membrane)...... 50 Antimigraine Agents...... 51 Antimycobacterials...... 52 Antinausea Agents...... 53 Antiparasite Agents...... 54 Antiparkinsonian Agents...... 56 Antipsychotic Agents...... 57 Antivirals (Systemic)...... 60 Blood Products/Modifiers/Volume Expanders...... 66 Caloric Agents...... 70 Cardiovascular Agents...... 71 Central Nervous System Agents...... 83 Contraceptives...... 89 Cough And Cold Products...... 100 Dental And Oral Agents...... 103 Dermatological Agents...... 103 Devices...... 115 Enzyme Replacement/Modifiers...... 115 Eye, Ear, Nose, Throat Agents...... 117 Gastrointestinal Agents...... 124 Genitourinary Agents...... 130 Heavy Metal Antagonists...... 131

1 Hormonal Agents, Stimulant/Replacement/Modifying...... 132 Immunological Agents...... 140 Inflammatory Bowel Disease Agents...... 148 Metabolic Bone Disease Agents...... 149 Miscellaneous Therapeutic Agents...... 150 Ophthalmic Agents...... 153 Replacement Preparations...... 155 Respiratory Tract Agents...... 156 Skeletal Muscle Relaxants...... 162 Sleep Disorder Agents...... 163 Vasodilating Agents...... 164 Vitamins And Minerals...... 165

2 Drug Name Drug Tier Requirements/Limits Analgesics Analgesics, Miscellaneous acetaminophen-codeine oral solution 2 QL (2700 per 30 days) 120-12 mg/5 ml acetaminophen-codeine oral tablet 2 QL (360 per 30 days) 300-15 mg, 300-30 mg acetaminophen-codeine oral tablet 2 QL (180 per 30 days) 300-60 mg -caffeine-dihydrocodein oral 3 QL (360 per 30 days) capsule 356.4-30-16 mg belladonna alkaloids-opium rectal 3 suppository 16.2-30 mg, 16.2-60 mg transdermal patch (Butrans) 3 QL (4 per 28 days) weekly 10 mcg/hour, 15 mcg/hour, 20 mcg/hour, 5 mcg/hour, 7.5 mcg/hour butalbital compound w/codeine oral 3 capsule 30-50-325-40 mg butalbital compound-codeine oral 3 capsule 30-50-325-40 mg butalbital-acetaminop-caf-cod oral (Fioricet with Codeine) 3 capsule 50-300-40-30 mg butalbital-acetaminop-caf-cod oral 3 capsule 50-325-40-30 mg butalbital-acetaminophen oral tablet (Bupap) 2 QL (180 per 30 days) 50-300 mg butalbital-acetaminophen oral tablet (Tencon) 2 50-325 mg butalbital-acetaminophen-caff oral (Fioricet) 3 capsule 50-300-40 mg butalbital-acetaminophen-caff oral (Zebutal) 3 capsule 50-325-40 mg butalbital-acetaminophen-caff oral (Esgic) 2 tablet 50-325-40 mg butalbital-aspirin-caffeine oral 3 capsule 50-325-40 mg butalbital-aspirin-caffeine oral 2 tablet 50-325-40 mg butorphanol nasal spray,non-aerosol 3 10 mg/ml

3 Drug Name Drug Tier Requirements/Limits CAPITAL WITH CODEINE 5 QL (2700 per 30 days) ORAL SUSPENSION 120-12 MG/5 ML codeine sulfate oral tablet 15 mg, 30 3 mg, 60 mg EMBEDA ORAL 5 QL (120 per 30 days) CAPSULE,ORAL ONLY,EXT.REL PELL 100-4 MG EMBEDA ORAL 5 QL (60 per 30 days) CAPSULE,ORAL ONLY,EXT.REL PELL 20-0.8 MG, 30-1.2 MG, 50-2 MG, 60-2.4 MG, 80-3.2 MG endocet oral tablet 10-325 mg, 2.5- 2 QL (360 per 30 days) 325 mg, 5-325 mg, 7.5-325 mg fentanyl citrate buccal lozenge on a (Actiq) 3 PA; QL (120 per 30 handle 1,200 mcg, 1,600 mcg, 200 days) mcg, 400 mcg, 600 mcg, 800 mcg fentanyl transdermal patch 72 hour 3 PA; QL (10 per 30 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, days) 37.5 mcg/hour, 50 mcg/hr, 62.5 mcg/hour, 75 mcg/hr, 87.5 mcg/hour hydrocodone bitartrate oral (Hysingla ER) 3 QL (30 per 30 days) tablet,oral only,ext.rel.24 hr 100 mg, 120 mg, 20 mg, 30 mg, 40 mg, 60 mg, 80 mg hydrocodone-acetaminophen oral 2 QL (5520 per 30 days) solution 7.5-325 mg/15 ml hydrocodone-acetaminophen oral (Vicodin HP) 3 QL (390 per 30 days) tablet 10-300 mg hydrocodone-acetaminophen oral 2 QL (360 per 30 days) tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg hydrocodone-acetaminophen oral 3 QL (390 per 30 days) tablet 5-300 mg, 7.5-300 mg hydrocodone- oral tablet 3 10-200 mg, 5-200 mg hydrocodone-ibuprofen oral tablet 2 7.5-200 mg hydromorphone oral liquid 1 mg/ml (Dilaudid) 3

4 Drug Name Drug Tier Requirements/Limits hydromorphone oral tablet 2 mg, 4 (Dilaudid) 2 mg, 8 mg hydromorphone oral tablet extended 3 PA; QL (30 per 30 release 24 hr 12 mg, 16 mg, 8 mg days) hydromorphone oral tablet extended 3 PA; QL (60 per 30 release 24 hr 32 mg days) hydromorphone rectal suppository 3 2 mg ibuprofen-oxycodone oral tablet 2 400-5 mg tartrate oral tablet 2 mg 2 lorcet (hydrocodone) oral tablet 5- 2 QL (360 per 30 days) 325 mg lorcet hd oral tablet 10-325 mg 2 QL (360 per 30 days) lorcet plus oral tablet 7.5-325 mg 2 QL (360 per 30 days) marten-tab oral tablet 50-325 mg 2 meperidine (pf) injection solution 2 100 mg/ml, 50 mg/ml meperidine injection cartridge 10 2 mg/ml meperidine oral solution 50 mg/5 ml 2 QL (900 per 30 days) meperidine oral tablet 100 mg (Demerol) 2 QL (180 per 30 days) meperidine oral tablet 50 mg 2 QL (180 per 30 days) oral concentrate 10 (Methadone Intensol) 2 QL (120 per 30 days) mg/ml methadone oral solution 10 mg/5 ml 2 QL (600 per 30 days) methadone oral solution 5 mg/5 ml 2 QL (1200 per 30 days) methadone oral tablet 10 mg 2 QL (120 per 30 days) methadone oral tablet 5 mg 2 QL (240 per 30 days) methadose oral tablet,soluble 40 mg 2 QL (30 per 30 days) morphine concentrate oral solution 2 100 mg/5 ml (20 mg/ml) morphine in 0.9 % sodium chlor 2 intravenous syringe 2 mg/ml (1 ml) morphine intramuscular pen injector 2 10 mg/0.7 ml morphine oral capsule, er multiphase 3 QL (30 per 30 days) 24 hr 120 mg, 30 mg, 45 mg, 60 mg, 75 mg, 90 mg morphine oral solution 10 mg/5 ml, 2 20 mg/5 ml (4 mg/ml)

5 Drug Name Drug Tier Requirements/Limits MORPHINE ORAL TABLET 15 3 MG, 30 MG morphine oral tablet extended (MS Contin) 3 QL (90 per 30 days) release 100 mg, 15 mg, 200 mg, 30 mg, 60 mg morphine rectal suppository 10 mg, 3 20 mg, 30 mg, 5 mg NUCYNTA ER ORAL TABLET 5 QL (60 per 30 days) EXTENDED RELEASE 12 HR 100 MG, 150 MG, 200 MG, 250 MG, 50 MG NUCYNTA ORAL TABLET 100 5 QL (180 per 30 days) MG, 50 MG, 75 MG OXAYDO ORAL TABLET, 5 ORAL ONLY 5 MG, 7.5 MG oxycodone oral capsule 5 mg 2 oxycodone oral concentrate 20 2 mg/ml oxycodone oral solution 5 mg/5 ml 2 oxycodone oral tablet 10 mg, 20 mg 2 oxycodone oral tablet 15 mg, 30 mg, (Roxicodone) 2 5 mg oxycodone oral tablet,oral (OxyContin) 3 QL (60 per 30 days) only,ext.rel.12 hr 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 60 mg oxycodone oral tablet,oral (OxyContin) 3 QL (120 per 30 days) only,ext.rel.12 hr 80 mg oxycodone-acetaminophen oral (Prolate) 2 QL (360 per 30 days) tablet 10-300 mg, 5-300 mg, 7.5-300 mg oxycodone-acetaminophen oral (Endocet) 2 QL (360 per 30 days) tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg oxycodone-aspirin oral tablet 2 QL (360 per 30 days) 4.8355-325 mg OXYCONTIN ORAL 5 QL (60 per 30 days) TABLET,ORAL ONLY,EXT.REL.12 HR 15 MG, 30 MG, 60 MG oxymorphone oral tablet 10 mg, 5 2 QL (120 per 30 days) mg

6 Drug Name Drug Tier Requirements/Limits oxymorphone oral tablet extended 3 QL (60 per 30 days) release 12 hr 10 mg, 20 mg, 30 mg, 40 mg, 5 mg, 7.5 mg oxymorphone oral tablet extended 3 QL (120 per 30 days) release 12 hr 15 mg pentazocine-naloxone oral tablet 50- 2 0.5 mg phrenilin forte(with caffeine) oral 3 capsule 50-300-40 mg primlev oral tablet 10-300 mg 5 QL (360 per 30 days) PRIMLEV ORAL TABLET 5-300 5 QL (360 per 30 days) MG, 7.5-300 MG prolate oral tablet 10-300 mg, 5-300 2 QL (360 per 30 days) mg, 7.5-300 mg ROXYBOND ORAL TABLET, 5 ORAL ONLY 15 MG, 30 MG, 5 MG tencon oral tablet 50-325 mg 2 oral tablet 50 mg (Ultram) 2 tramadol oral tablet extended 3 QL (30 per 30 days) release 24 hr 100 mg, 200 mg, 300 mg tramadol oral tablet, er multiphase 3 QL (30 per 30 days) 24 hr 100 mg, 200 mg, 300 mg tramadol-acetaminophen oral tablet (Ultracet) 2 37.5-325 mg vicodin es oral tablet 7.5-300 mg 5 QL (390 per 30 days) vicodin hp oral tablet 10-300 mg 5 QL (390 per 30 days) vicodin oral tablet 5-300 mg 5 QL (390 per 30 days) xylon 10 oral tablet 10-200 mg 3 zebutal oral capsule 50-325-40 mg 3 Nonsteroidal Anti-Inflammatory Agents aspirin oral tablet,delayed release 2 (dr/ec) 650 mg aspirin rectal suppository 300 mg, 2 600 mg CAMBIA ORAL POWDER IN 6 QL (9 per 30 days) PACKET 50 MG celecoxib oral capsule 100 mg, 50 (Celebrex) 3 PA; QL (60 per 30 mg days)

7 Drug Name Drug Tier Requirements/Limits celecoxib oral capsule 200 mg, 400 (Celebrex) 3 PA; QL (30 per 30 mg days) choline, salicylate oral 2 liquid 500 mg/5 ml diclofenac epolamine transdermal (Flector) 3 patch 12 hour 1.3 % diclofenac potassium oral tablet 50 (Cataflam) 2 mg diclofenac sodium oral tablet 2 extended release 24 hr 100 mg diclofenac sodium oral 2 tablet,delayed release (dr/ec) 25 mg, 50 mg, 75 mg diclofenac sodium topical gel 1 % (Arthritis Pain 3 (diclofenac)) diclofenac sodium topical gel 3 % (Solaraze) 3 QL (105 per 30 days) diclofenac-misoprostol oral (Arthrotec 50) 3 tablet,ir,delayed rel,biphasic 50-200 mg-mcg diclofenac-misoprostol oral (Arthrotec 75) 3 tablet,ir,delayed rel,biphasic 75-200 mg-mcg diflunisal oral tablet 500 mg 3 etodolac oral capsule 200 mg, 300 2 mg etodolac oral tablet 400 mg (Lodine) 2 etodolac oral tablet 500 mg 2 etodolac oral tablet extended release 3 24 hr 400 mg, 500 mg, 600 mg fenoprofen oral tablet 600 mg (Nalfon) 3 flurbiprofen oral tablet 100 mg, 50 2 mg ibu oral tablet 400 mg, 600 mg, 800 2 mg ibuprofen oral suspension 100 mg/5 (Children's Advil) 2 ml ibuprofen oral tablet 400 mg, 600 (IBU) 2 mg, 800 mg INDOCIN ORAL SUSPENSION 5 25 MG/5 ML indomethacin oral capsule 25 mg, 50 2 mg

8 Drug Name Drug Tier Requirements/Limits indomethacin oral capsule, extended 3 release 75 mg ketoprofen oral capsule 25 mg, 50 2 mg, 75 mg ketoprofen oral capsule,ext rel. 3 pellets 24 hr 200 mg ketorolac oral tablet 10 mg 2 QL (20 per 5 days) meclofenamate oral capsule 100 mg, 2 50 mg oral capsule 250 mg 3 meloxicam oral tablet 15 mg, 7.5 mg (Mobic) 2 nabumetone oral tablet 500 mg, 750 (Relafen) 2 mg NALFON ORAL TABLET 600 5 MG naproxen oral suspension 125 mg/5 (Naprosyn) 2 ml naproxen oral tablet 250 mg, 375 2 mg naproxen oral tablet 500 mg (Naprosyn) 2 naproxen oral tablet,delayed release (EC-Naprosyn) 3 (dr/ec) 375 mg, 500 mg naproxen sodium oral tablet 275 mg 3 naproxen sodium oral tablet 550 mg (Anaprox DS) 2 oxaprozin oral tablet 600 mg (Daypro) 3 piroxicam oral capsule 10 mg, 20 (Feldene) 3 mg PROFENO ORAL TABLET 600 5 MG salsalate oral tablet 500 mg, 750 mg (Disalcid) 2 sulindac oral tablet 150 mg, 200 mg 2 tolmetin oral capsule 400 mg 3 tolmetin oral tablet 200 mg, 600 mg 3 Anesthetics Local Anesthetics glydo mucous membrane jelly in 3 applicator 2 % KOVANAZE NASAL NASAL 5 SPRAY SYRINGE 6-0.1 MG/0.2 ML

9 Drug Name Drug Tier Requirements/Limits LIDO BDK KIT 21 GAUGE X 5 1"- 2.5 %-2.5 % hcl mucous membrane jelly 2 2 % lidocaine hcl mucous membrane 2 solution 4 % (40 mg/ml) lidocaine hcl topical cream 3 % (Lidopin) 2 lidocaine hcl-hydrocortison ac rectal 3 kit 2 %-2 % (7 gram), 3-1 % (7 gram) lidocaine hcl-hydrocortison ac (Lidocort) 2 topical cream 3-0.5 % lidocaine topical adhesive (Lidoderm) 3 patch,medicated 5 % lidocaine topical ointment 5 % 3 QL (240 per 30 days) lidocaine viscous mucous membrane 2 solution 2 % lidocaine-hydrocortisone-aloe rectal 2 kit 3-2.5 % (7 gram) lidocaine- topical cream 2 2.5-2.5 % PRILOVIXIL TOPICAL KIT 2.5- 2 2.5 % SYNERA TOPICAL PATCH, 6 MEDICATED SELF-HEATING 70-70 MG Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents acamprosate oral tablet,delayed 3 release (dr/ec) 333 mg BUNAVAIL BUCCAL FILM 2.1- 5 PA; QL (30 per 30 0.3 MG days) BUNAVAIL BUCCAL FILM 4.2- 5 PA; QL (60 per 30 0.7 MG, 6.3-1 MG days) buprenorphine hcl sublingual tablet 3 PA; QL (90 per 30 2 mg, 8 mg days) buprenorphine-naloxone sublingual (Suboxone) 3 PA; QL (60 per 30 film 12-3 mg, 8-2 mg days) buprenorphine-naloxone sublingual (Suboxone) 3 PA; QL (30 per 30 film 2-0.5 mg, 4-1 mg days)

10 Drug Name Drug Tier Requirements/Limits buprenorphine-naloxone sublingual 3 PA; QL (90 per 30 tablet 2-0.5 mg, 8-2 mg days) bupropion hcl (smoking deter) oral 2 QL (60 per 30 days) tablet extended release 12 hr 150 mg CHANTIX CONTINUING 1 QL (336 per 365 days) MONTH BOX ORAL TABLET 1 MG CHANTIX ORAL TABLET 0.5 1 QL (672 per 365 days) MG CHANTIX ORAL TABLET 1 1 QL (336 per 365 days) MG CHANTIX STARTING MONTH 1 QL (106 per 365 days) BOX ORAL TABLETS,DOSE PACK 0.5 MG (11)- 1 MG (42) disulfiram oral tablet 250 mg, 500 3 mg KLOXXADO NASAL 5 QL (2 per 30 days) SPRAY,NON-AEROSOL 8 MG/ACTUATION LUCEMYRA ORAL TABLET 6 PA; QL (260 per 18 0.18 MG days) naloxone injection solution 0.4 3 mg/ml naloxone injection syringe 1 mg/ml 3 naltrexone oral tablet 50 mg 3 NARCAN NASAL 5 QL (2 per 30 days) SPRAY,NON-AEROSOL 4 MG/ACTUATION NICOTROL INHALATION 1 CARTRIDGE 10 MG NICOTROL NS NASAL 1 SPRAY,NON-AEROSOL 10 MG/ML SUBLOCADE 5 PA SUBCUTANEOUS SOLUTION, EXTENDED REL SYRINGE 100 MG/0.5 ML, 300 MG/1.5 ML varenicline oral tablet 0.5 mg (Chantix) 1 QL (672 per 365 days) varenicline oral tablet 1 mg (Chantix) 1 QL (336 per 365 days)

11 Drug Name Drug Tier Requirements/Limits ZUBSOLV SUBLINGUAL 4 PA; QL (30 per 30 TABLET 0.7-0.18 MG, 1.4-0.36 days) MG, 11.4-2.9 MG, 2.9-0.71 MG, 5.7-1.4 MG ZUBSOLV SUBLINGUAL 4 PA; QL (60 per 30 TABLET 8.6-2.1 MG days) Antianxiety Agents ALPRAZOLAM INTENSOL 3 ORAL CONCENTRATE 1 MG/ML alprazolam oral tablet 0.25 mg, 0.5 (Xanax) 2 mg, 1 mg, 2 mg alprazolam oral tablet extended (Xanax XR) 3 release 24 hr 0.5 mg, 1 mg, 2 mg, 3 mg alprazolam oral tablet,disintegrating 3 0.25 mg, 0.5 mg, 1 mg, 2 mg oral tablet 10 mg, 15 mg, 2 30 mg, 5 mg, 7.5 mg chlordiazepoxide hcl oral capsule 10 2 mg, 25 mg, 5 mg oral tablet 0.5 mg, 1 (Klonopin) 2 mg, 2 mg clonazepam oral 3 tablet,disintegrating 0.125 mg, 0.25 mg, 0.5 mg, 1 mg, 2 mg dipotassium oral tablet 2 15 mg, 3.75 mg clorazepate dipotassium oral tablet (Tranxene T-Tab) 2 7.5 mg intensol oral concentrate 5 2 mg/ml diazepam oral solution 5 mg/5 ml (1 2 mg/ml) diazepam oral tablet 10 mg, 2 mg, 5 (Valium) 2 mg estazolam oral tablet 1 mg, 2 mg 2 flurazepam oral capsule 15 mg, 30 2 mg oral concentrate 2 mg/ml (Lorazepam Intensol) 2

12 Drug Name Drug Tier Requirements/Limits lorazepam oral tablet 0.5 mg, 1 mg, (Ativan) 2 2 mg oral tablet 200 mg, 3 400 mg oral syrup 2 mg/ml 2 oxazepam oral capsule 10 mg, 15 2 mg, 30 mg quazepam oral tablet 15 mg (Doral) 3 oral capsule 15 mg, 22.5 (Restoril) 2 mg, 30 mg, 7.5 mg triazolam oral tablet 0.125 mg 2 triazolam oral tablet 0.25 mg (Halcion) 2 Antibacterials Aminoglycosides ARIKAYCE INHALATION 6 PA; QL (235.2 per 28 SUSPENSION FOR days) NEBULIZATION 590 MG/8.4 ML oral tablet 500 mg 2 TOBI PODHALER 6 PA INHALATION CAPSULE, W/INHALATION DEVICE 28 MG tobramycin in 0.225 % nacl (Tobi) 6 PA inhalation solution for nebulization 300 mg/5 ml tobramycin inhalation solution for (Bethkis) 6 PA nebulization 300 mg/4 ml Antibacterials, Miscellaneous clindamycin hcl oral capsule 150 mg, (Cleocin HCl) 2 300 mg, 75 mg clindamycin pediatric oral recon 2 soln 75 mg/5 ml FIRVANQ ORAL RECON 5 QL (300 per 30 days) SOLN 25 MG/ML fosfomycin tromethamine oral (Monurol) 3 packet 3 gram linezolid oral suspension for (Zyvox) 3 PA reconstitution 100 mg/5 ml linezolid oral tablet 600 mg (Zyvox) 3 PA methenamine hippurate oral tablet 1 (Hiprex) 2 gram

13 Drug Name Drug Tier Requirements/Limits methenamine mandelate oral tablet 2 0.5 g, 1 gram metronidazole oral capsule 375 mg (Flagyl) 2 metronidazole oral tablet 250 mg 2 metronidazole oral tablet 500 mg (Flagyl) 2 MONUROL ORAL PACKET 3 5 GRAM nitrofurantoin macrocrystal oral (Macrodantin) 2 capsule 100 mg, 25 mg, 50 mg nitrofurantoin monohyd/m-cryst oral (Macrobid) 2 capsule 100 mg nitrofurantoin oral suspension 25 (Furadantin) 3 mg/5 ml PHOSPHASAL ORAL TABLET 5 81.6-10.8-40.8 MG PRIMSOL ORAL SOLUTION 50 5 MG/5 ML SIVEXTRO ORAL TABLET 200 6 QL (6 per 6 days) MG SOLOSEC ORAL GRANULES 5 QL (1 per 30 days) DEL RELEASE IN PACKET 2 GRAM trimethoprim oral tablet 100 mg 2 TRIMPEX ORAL SOLUTION 50 5 MG/5 ML ur n-c oral tablet 81.6-10.8-40.8 mg 3 URETRON D-S ORAL TABLET 5 81.6-10.8-40.8 MG URIN DS ORAL TABLET 81.6- 5 10.8-40.8 MG uro-458 oral tablet 81-10.8-40.8 mg 3 urogesic-blue oral tablet 81.6-40.8- 3 0.12 mg UROQID-ACID NO.2 ORAL 5 TABLET 500-500 MG vancomycin oral capsule 125 mg (Vancocin) 3 QL (56 per 30 days) vancomycin oral capsule 250 mg (Vancocin) 3 QL (112 per 30 days) vancomycin oral recon soln 50 (Firvanq) 3 QL (600 per 30 days) mg/ml XIFAXAN ORAL TABLET 200 6 PA; QL (63 per 21 MG days)

14 Drug Name Drug Tier Requirements/Limits XIFAXAN ORAL TABLET 550 6 PA; QL (60 per 30 MG days) Cephalosporins cefaclor oral capsule 250 mg, 500 2 mg cefaclor oral suspension for 2 reconstitution 125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml cefaclor oral tablet extended release 3 12 hr 500 mg cefadroxil oral capsule 500 mg 2 cefadroxil oral suspension for 2 reconstitution 250 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet 1 gram 2 cefdinir oral capsule 300 mg 2 cefdinir oral suspension for 2 reconstitution 125 mg/5 ml, 250 mg/5 ml cefditoren pivoxil oral tablet 200 mg 2 cefditoren pivoxil oral tablet 400 mg (Spectracef) 2 cefixime oral capsule 400 mg (Suprax) 2 cefixime oral suspension for (Suprax) 2 reconstitution 100 mg/5 ml, 200 mg/5 ml cefpodoxime oral suspension for 2 reconstitution 100 mg/5 ml, 50 mg/5 ml cefpodoxime oral tablet 100 mg, 200 2 mg cefprozil oral suspension for 2 reconstitution 125 mg/5 ml, 250 mg/5 ml cefprozil oral tablet 250 mg, 500 mg 2 ceftibuten oral capsule 400 mg 3 ceftibuten oral suspension for 3 reconstitution 180 mg/5 ml CEFTIN ORAL SUSPENSION 4 FOR RECONSTITUTION 125 MG/5 ML, 250 MG/5 ML cefuroxime axetil oral tablet 250 2 mg, 500 mg

15 Drug Name Drug Tier Requirements/Limits cephalexin oral capsule 250 mg, 500 2 mg cephalexin oral capsule 750 mg (Keflex) 2 cephalexin oral suspension for 2 reconstitution 125 mg/5 ml, 250 mg/5 ml cephalexin oral tablet 250 mg, 500 2 mg SUPRAX ORAL SUSPENSION 4 FOR RECONSTITUTION 500 MG/5 ML SUPRAX ORAL 4 TABLET,CHEWABLE 100 MG, 200 MG Macrolides azithromycin oral packet 1 gram (Zithromax) 2 azithromycin oral suspension for (Zithromax) 2 reconstitution 100 mg/5 ml, 200 mg/5 ml azithromycin oral tablet 250 mg, (Zithromax) 2 500 mg azithromycin oral tablet 600 mg 2 oral suspension for 2 reconstitution 125 mg/5 ml, 250 mg/5 ml clarithromycin oral tablet 250 mg, 2 500 mg clarithromycin oral tablet extended 3 release 24 hr 500 mg DIFICID ORAL SUSPENSION 6 ST; QL (136 per 10 FOR RECONSTITUTION 40 days) MG/ML DIFICID ORAL TABLET 200 6 ST; QL (20 per 30 days) MG e.e.s. 400 oral tablet 400 mg 2 ery-tab oral tablet,delayed release 2 (dr/ec) 250 mg ery-tab oral tablet,delayed release 3 (dr/ec) 500 mg erythrocin (as stearate) oral tablet 3 250 mg

16 Drug Name Drug Tier Requirements/Limits ethylsuccinate oral (E.E.S. Granules) 2 suspension for reconstitution 200 mg/5 ml erythromycin ethylsuccinate oral (EryPed 400) 2 suspension for reconstitution 400 mg/5 ml erythromycin ethylsuccinate oral (E.E.S. 400) 2 tablet 400 mg erythromycin oral capsule,delayed 2 release(dr/ec) 250 mg erythromycin oral tablet 250 mg, 2 500 mg erythromycin oral tablet,delayed (Ery-Tab) 2 release (dr/ec) 250 mg, 500 mg erythromycin oral tablet,delayed (Ery-Tab) 3 release (dr/ec) 333 mg PCE ORAL TABLET, 5 PARTICLES/CRYSTALS 333 MG, 500 MG ZMAX ORAL 4 SUSPENSION,EXTENDED REL RECON 2 GRAM/60 ML Miscellaneous B-Lactam Antibiotics CAYSTON INHALATION 6 PA; QL (84 per 56 SOLUTION FOR days) NEBULIZATION 75 MG/ML Penicillins amoxicillin oral capsule 250 mg, 500 2 mg amoxicillin oral suspension for 2 reconstitution 125 mg/5 ml, 200 mg/5 ml, 250 mg/5 ml, 400 mg/5 ml amoxicillin oral tablet 500 mg, 875 2 mg amoxicillin oral tablet,chewable 125 2 mg, 250 mg amoxicillin-pot clavulanate oral 2 suspension for reconstitution 200- 28.5 mg/5 ml, 400-57 mg/5 ml amoxicillin-pot clavulanate oral (Augmentin) 2 suspension for reconstitution 250- 62.5 mg/5 ml

17 Drug Name Drug Tier Requirements/Limits amoxicillin-pot clavulanate oral (Augmentin ES-600) 2 suspension for reconstitution 600- 42.9 mg/5 ml amoxicillin-pot clavulanate oral 2 tablet 250-125 mg amoxicillin-pot clavulanate oral (Augmentin) 2 tablet 500-125 mg, 875-125 mg amoxicillin-pot clavulanate oral (Augmentin XR) 2 tablet extended release 12 hr 1,000- 62.5 mg amoxicillin-pot clavulanate oral 2 tablet,chewable 200-28.5 mg, 400-57 mg ampicillin oral capsule 250 mg, 500 2 mg dicloxacillin oral capsule 250 mg, 2 500 mg penicillin v potassium oral recon soln 2 125 mg/5 ml, 250 mg/5 ml penicillin v potassium oral tablet 250 2 mg, 500 mg Quinolones BAXDELA ORAL TABLET 450 6 PA MG ciprofloxacin (mixture) oral tablet, 2 er multiphase 24 hr 1,000 mg, 500 mg ciprofloxacin hcl oral tablet 100 mg, 2 750 mg ciprofloxacin hcl oral tablet 250 mg, (Cipro) 2 500 mg ciprofloxacin oral (Cipro) 3 suspension,microcapsule recon 250 mg/5 ml, 500 mg/5 ml FACTIVE ORAL TABLET 320 5 MG levofloxacin oral solution 250 mg/10 2 ml levofloxacin oral tablet 250 mg, 500 2 mg, 750 mg moxifloxacin oral tablet 400 mg 3

18 Drug Name Drug Tier Requirements/Limits ofloxacin oral tablet 300 mg, 400 2 mg Sulfonamides sulfadiazine oral tablet 500 mg 2 sulfamethoxazole-trimethoprim oral (Sulfatrim) 2 suspension 200-40 mg/5 ml sulfamethoxazole-trimethoprim oral (Bactrim) 2 tablet 400-80 mg sulfamethoxazole-trimethoprim oral (Bactrim DS) 2 tablet 800-160 mg Tetracyclines demeclocycline oral tablet 150 mg, 2 300 mg doxycycline hyclate oral capsule 100 (Morgidox) 2 QL (60 per 30 days) mg, 50 mg doxycycline hyclate oral tablet 100 2 QL (60 per 30 days) mg doxycycline hyclate oral tablet 150 (Acticlate) 2 QL (60 per 30 days) mg, 75 mg doxycycline hyclate oral tablet 20 2 mg doxycycline hyclate oral tablet 50 (Targadox) 2 QL (60 per 30 days) mg doxycycline hyclate oral 3 QL (60 per 30 days) tablet,delayed release (dr/ec) 100 mg, 150 mg, 75 mg doxycycline hyclate oral (Doryx) 3 PA tablet,delayed release (dr/ec) 200 mg doxycycline hyclate oral (Doryx) 3 PA; QL (60 per 30 tablet,delayed release (dr/ec) 50 days) mg, 80 mg doxycycline monohydrate oral (Mondoxyne NL) 2 QL (60 per 30 days) capsule 100 mg doxycycline monohydrate oral 3 QL (60 per 30 days) capsule 150 mg doxycycline monohydrate oral (Monodox) 2 QL (60 per 30 days) capsule 50 mg doxycycline monohydrate oral (Oracea) 3 QL (30 per 30 days) capsule,ir - delay rel,biphase 40 mg

19 Drug Name Drug Tier Requirements/Limits doxycycline monohydrate oral (Vibramycin) 2 suspension for reconstitution 25 mg/5 ml doxycycline monohydrate oral tablet (Avidoxy) 2 QL (60 per 30 days) 100 mg doxycycline monohydrate oral tablet 2 QL (60 per 30 days) 150 mg, 50 mg, 75 mg oral capsule 100 mg, 50 2 mg, 75 mg minocycline oral tablet 100 mg, 50 3 mg, 75 mg NUZYRA (7 DAY WITH LOAD 6 PA; QL (30 per 14 DOSE) ORAL TABLET 150 MG days) NUZYRA (7 DAY) ORAL 6 PA; QL (30 per 14 TABLET 150 MG days) NUZYRA ORAL TABLET 150 6 PA; QL (30 per 14 MG days) okebo oral capsule 100 mg 2 QL (60 per 30 days) soloxide oral tablet,delayed release 3 QL (60 per 30 days) (dr/ec) 150 mg tetracycline oral capsule 250 mg, 2 500 mg VIBRAMYCIN ORAL SYRUP 4 50 MG/5 ML Anticancer Agents Anticancer Agents abiraterone oral tablet 250 mg (Zytiga) 6 PA; QL (90 per 30 days) abiraterone oral tablet 500 mg (Zytiga) 6 PA; QL (90 per 31 days) AFINITOR DISPERZ ORAL 6 PA TABLET FOR SUSPENSION 2 MG, 3 MG, 5 MG AFINITOR ORAL TABLET 10 6 PA; QL (60 per 30 MG days) AFINITOR ORAL TABLET 2.5 6 PA; QL (30 per 30 MG days) ALECENSA ORAL CAPSULE 6 PA; QL (240 per 30 150 MG days) ALUNBRIG ORAL TABLET 180 6 PA; QL (30 per 30 MG, 90 MG days)

20 Drug Name Drug Tier Requirements/Limits ALUNBRIG ORAL TABLET 30 6 PA; QL (120 per 30 MG days) ALUNBRIG ORAL 6 PA; QL (30 per 30 TABLETS,DOSE PACK 90 MG days) (7)- 180 MG (23) anastrozole oral tablet 1 mg (Arimidex) 2 AROMASIN ORAL TABLET 25 5 PA; ST MG AYVAKIT ORAL TABLET 100 6 PA; QL (30 per 30 MG, 200 MG, 25 MG, 300 MG, 50 days) MG BALVERSA ORAL TABLET 3 6 PA; QL (84 per 28 MG days) BALVERSA ORAL TABLET 4 6 PA; QL (56 per 28 MG days) BALVERSA ORAL TABLET 5 6 PA; QL (28 per 28 MG days) bexarotene oral capsule 75 mg (Targretin) 6 PA; QL (420 per 30 days) bicalutamide oral tablet 50 mg (Casodex) 2 PA BOSULIF ORAL TABLET 100 6 PA; QL (90 per 30 MG days) BOSULIF ORAL TABLET 400 6 PA; QL (30 per 30 MG, 500 MG days) BRAFTOVI ORAL CAPSULE 50 6 PA; QL (180 per 30 MG, 75 MG days) BRUKINSA ORAL CAPSULE 80 6 PA MG CABOMETYX ORAL TABLET 6 PA; QL (30 per 30 20 MG, 60 MG days) CABOMETYX ORAL TABLET 6 PA; QL (60 per 30 40 MG days) CALQUENCE ORAL CAPSULE 6 PA; QL (60 per 30 100 MG days) capecitabine oral tablet 150 mg (Xeloda) 6 PA; QL (56 per 21 days) capecitabine oral tablet 500 mg (Xeloda) 6 PA; QL (112 per 21 days) CAPRELSA ORAL TABLET 100 6 PA; QL (60 per 30 MG days) CAPRELSA ORAL TABLET 300 6 PA; QL (30 per 30 MG days)

21 Drug Name Drug Tier Requirements/Limits CASODEX ORAL TABLET 50 6 PA MG COMETRIQ ORAL CAPSULE 6 PA; QL (112 per 28 100 MG/DAY(80 MG X1-20 MG days) X1), 140 MG/DAY(80 MG X1-20 MG X3), 60 MG/DAY (20 MG X 3/DAY) COPIKTRA ORAL CAPSULE 15 6 PA; QL (56 per 28 MG, 25 MG days) COTELLIC ORAL TABLET 20 6 PA; QL (63 per 28 MG days) CYCLOPHOSPHAMIDE ORAL 6 CAPSULE 25 MG, 50 MG cyclophosphamide oral tablet 25 mg, 4 PA 50 mg DAURISMO ORAL TABLET 6 PA; QL (30 per 30 100 MG days) DAURISMO ORAL TABLET 25 6 PA; QL (60 per 30 MG days) DROXIA ORAL CAPSULE 200 5 MG, 300 MG, 400 MG EMCYT ORAL CAPSULE 140 6 PA MG ERIVEDGE ORAL CAPSULE 6 PA; QL (30 per 30 150 MG days) ERLEADA ORAL TABLET 60 6 PA; QL (120 per 30 MG days) erlotinib oral tablet 100 mg, 25 mg (Tarceva) 6 PA; QL (60 per 30 days) erlotinib oral tablet 150 mg (Tarceva) 6 PA; QL (90 per 30 days) etoposide oral capsule 50 mg 2 PA everolimus (antineoplastic) oral (Afinitor) 6 PA; QL (30 per 30 tablet 2.5 mg, 5 mg days) everolimus (antineoplastic) oral (Afinitor) 6 PA; QL (60 per 30 tablet 7.5 mg days) exemestane oral tablet 25 mg (Aromasin) 2 PA; ST FARYDAK ORAL CAPSULE 10 6 PA; QL (6 per 21 days) MG, 15 MG, 20 MG FIRMAGON KIT W DILUENT 6 PA SYRINGE SUBCUTANEOUS RECON SOLN 120 MG

22 Drug Name Drug Tier Requirements/Limits flutamide oral capsule 125 mg 2 FOTIVDA ORAL CAPSULE 0.89 6 PA MG, 1.34 MG GAVRETO ORAL CAPSULE 6 PA 100 MG GILOTRIF ORAL TABLET 20 6 PA; QL (30 per 30 MG, 30 MG, 40 MG days) GLEEVEC ORAL TABLET 100 6 PA MG GLEEVEC ORAL TABLET 400 6 PA; QL (60 per 30 MG days) GLEOSTINE ORAL CAPSULE 6 PA 10 MG, 100 MG, 40 MG, 5 MG HEXALEN ORAL CAPSULE 50 6 PA MG HYCAMTIN ORAL CAPSULE 6 PA 0.25 MG, 1 MG hydroxyurea oral capsule 500 mg (Hydrea) 2 IBRANCE ORAL CAPSULE 100 4 PA; QL (21 per 28 MG, 125 MG, 75 MG days) IBRANCE ORAL TABLET 100 6 PA; QL (21 per 28 MG, 125 MG, 75 MG days) ICLUSIG ORAL TABLET 10 6 PA; QL (30 per 30 MG, 30 MG, 45 MG days) ICLUSIG ORAL TABLET 15 6 PA; QL (60 per 30 MG days) IDHIFA ORAL TABLET 100 6 PA; QL (30 per 30 MG, 50 MG days) imatinib oral tablet 100 mg, 400 mg (Gleevec) 6 PA; QL (60 per 30 days) IMBRUVICA ORAL CAPSULE 6 PA; QL (120 per 30 140 MG days) IMBRUVICA ORAL CAPSULE 6 PA; QL (30 per 30 70 MG days) IMBRUVICA ORAL TABLET 6 PA; QL (30 per 30 140 MG, 280 MG, 420 MG, 560 days) MG INLYTA ORAL TABLET 1 MG 6 PA; QL (180 per 30 days) INLYTA ORAL TABLET 5 MG 6 PA; QL (120 per 30 days)

23 Drug Name Drug Tier Requirements/Limits INQOVI ORAL TABLET 35-100 6 PA MG INREBIC ORAL CAPSULE 100 6 PA; QL (120 per 30 MG days) IRESSA ORAL TABLET 250 MG 6 PA; QL (60 per 30 days) JAKAFI ORAL TABLET 10 MG, 6 PA; QL (60 per 30 15 MG, 20 MG, 25 MG, 5 MG days) KISQALI FEMARA CO-PACK 6 PA; QL (49 per 28 ORAL TABLET 200 days) MG/DAY(200 MG X 1)-2.5 MG KISQALI FEMARA CO-PACK 6 PA; QL (70 per 28 ORAL TABLET 400 days) MG/DAY(200 MG X 2)-2.5 MG KISQALI FEMARA CO-PACK 6 PA; QL (91 per 28 ORAL TABLET 600 days) MG/DAY(200 MG X 3)-2.5 MG KISQALI ORAL TABLET 200 6 PA; QL (21 per 28 MG/DAY (200 MG X 1) days) KISQALI ORAL TABLET 400 6 PA; QL (42 per 28 MG/DAY (200 MG X 2) days) KISQALI ORAL TABLET 600 6 PA; QL (63 per 28 MG/DAY (200 MG X 3) days) KOSELUGO ORAL CAPSULE 5 PA 10 MG, 25 MG lapatinib oral tablet 250 mg (Tykerb) 6 PA; QL (180 per 30 days) LENVIMA ORAL CAPSULE 10 6 PA; QL (30 per 30 MG/DAY (10 MG X 1), 4 MG days) LENVIMA ORAL CAPSULE 12 6 PA; QL (90 per 30 MG/DAY (4 MG X 3), 18 days) MG/DAY (10 MG X 1-4 MG X2), 24 MG/DAY(10 MG X 2-4 MG X 1) LENVIMA ORAL CAPSULE 14 6 PA; QL (60 per 30 MG/DAY(10 MG X 1-4 MG X 1), days) 20 MG/DAY (10 MG X 2), 8 MG/DAY (4 MG X 2) letrozole oral tablet 2.5 mg (Femara) 2 LEUKERAN ORAL TABLET 2 6 PA MG

24 Drug Name Drug Tier Requirements/Limits leuprolide subcutaneous kit 1 mg/0.2 6 PA ml LONSURF ORAL TABLET 15- 6 PA; QL (100 per 28 6.14 MG days) LONSURF ORAL TABLET 20- 6 PA; QL (80 per 28 8.19 MG days) LORBRENA ORAL TABLET 6 PA; QL (30 per 30 100 MG days) LORBRENA ORAL TABLET 25 6 PA; QL (90 per 30 MG days) LYNPARZA ORAL CAPSULE 6 PA; QL (480 per 30 50 MG days) LYNPARZA ORAL TABLET 6 PA; QL (120 per 30 100 MG, 150 MG days) LYSODREN ORAL TABLET 6 PA 500 MG MATULANE ORAL CAPSULE 6 PA 50 MG megestrol oral tablet 20 mg, 40 mg 2 MEKINIST ORAL TABLET 0.5 6 PA; QL (90 per 30 MG days) MEKINIST ORAL TABLET 2 6 PA; QL (30 per 30 MG days) MEKTOVI ORAL TABLET 15 6 PA; QL (180 per 30 MG days) melphalan oral tablet 2 mg (Alkeran) 2 mercaptopurine oral tablet 50 mg 2 methotrexate sodium (pf) injection 2 recon soln 1 gram methotrexate sodium (pf) injection 2 solution 25 mg/ml methotrexate sodium injection 2 solution 25 mg/ml methotrexate sodium oral tablet 2.5 2 mg MYLERAN ORAL TABLET 2 6 MG NERLYNX ORAL TABLET 40 6 PA; QL (180 per 30 MG days) NEXAVAR ORAL TABLET 200 6 PA; QL (120 per 30 MG days) nilutamide oral tablet 150 mg (Nilandron) 6 QL (60 per 30 days)

25 Drug Name Drug Tier Requirements/Limits NINLARO ORAL CAPSULE 2.3 6 PA; QL (3 per 28 days) MG, 3 MG, 4 MG NUBEQA ORAL TABLET 300 6 PA; QL (120 per 30 MG days) ODOMZO ORAL CAPSULE 200 6 PA; QL (30 per 30 MG days) ONUREG ORAL TABLET 200 6 PA MG, 300 MG PEMAZYRE ORAL TABLET 4 PA 13.5 MG, 4.5 MG, 9 MG PIQRAY ORAL TABLET 200 6 PA; QL (28 per 28 MG/DAY (200 MG X 1) days) PIQRAY ORAL TABLET 250 6 PA; QL (56 per 28 MG/DAY (200 MG X1-50 MG days) X1), 300 MG/DAY (150 MG X 2) POMALYST ORAL CAPSULE 1 6 PA; QL (21 per 28 MG, 2 MG, 3 MG, 4 MG days) PURIXAN ORAL SUSPENSION 5 20 MG/ML QINLOCK ORAL TABLET 50 4 PA MG RETEVMO ORAL CAPSULE 40 5 PA MG, 80 MG REVLIMID ORAL CAPSULE 10 6 PA; QL (28 per 28 MG, 15 MG, 2.5 MG, 20 MG, 25 days) MG, 5 MG ROZLYTREK ORAL CAPSULE 6 PA; QL (30 per 30 100 MG days) ROZLYTREK ORAL CAPSULE 6 PA; QL (90 per 30 200 MG days) RUBRACA ORAL TABLET 200 6 PA; QL (120 per 30 MG, 250 MG, 300 MG days) RYDAPT ORAL CAPSULE 25 6 PA; QL (224 per 28 MG days) SOLTAMOX ORAL SOLUTION 5 20 MG/10 ML SPRYCEL ORAL TABLET 100 6 PA; QL (30 per 30 MG, 140 MG, 50 MG, 70 MG, 80 days) MG SPRYCEL ORAL TABLET 20 6 PA; QL (90 per 30 MG days)

26 Drug Name Drug Tier Requirements/Limits STIVARGA ORAL TABLET 40 6 PA; QL (84 per 28 MG days) SUTENT ORAL CAPSULE 12.5 6 PA; QL (30 per 30 MG, 25 MG, 37.5 MG, 50 MG days) SYLATRON SUBCUTANEOUS 6 PA; QL (4 per 30 days) KIT 200 MCG, 300 MCG, 600 MCG SYNRIBO SUBCUTANEOUS 6 PA; QL (28 per 28 RECON SOLN 3.5 MG days) TABLOID ORAL TABLET 40 6 MG TABRECTA ORAL TABLET 150 5 PA MG, 200 MG TAFINLAR ORAL CAPSULE 50 6 PA; QL (120 per 30 MG, 75 MG days) TAGRISSO ORAL TABLET 40 6 PA; QL (30 per 30 MG, 80 MG days) TALZENNA ORAL CAPSULE 6 PA; QL (90 per 30 0.25 MG days) TALZENNA ORAL CAPSULE 1 6 PA; QL (30 per 30 MG days) tamoxifen oral tablet 10 mg, 20 mg 1 TARCEVA ORAL TABLET 100 6 PA MG, 150 MG, 25 MG TARGRETIN ORAL CAPSULE 6 PA; QL (420 per 30 75 MG days) TARGRETIN TOPICAL GEL 1 6 PA; QL (60 per 30 % days) TASIGNA ORAL CAPSULE 150 6 PA; QL (120 per 30 MG, 200 MG, 50 MG days) TAZVERIK ORAL TABLET 200 6 PA MG TEMODAR ORAL CAPSULE 6 PA 100 MG, 140 MG, 180 MG, 20 MG, 250 MG, 5 MG temozolomide oral capsule 100 mg, (Temodar) 6 PA 140 mg, 180 mg, 250 mg temozolomide oral capsule 20 mg, 5 6 PA mg TEPMETKO ORAL TABLET 6 PA 225 MG

27 Drug Name Drug Tier Requirements/Limits TIBSOVO ORAL TABLET 250 6 PA; QL (60 per 30 MG days) toremifene oral tablet 60 mg (Fareston) 6 PA tretinoin (antineoplastic) oral 6 PA capsule 10 mg TREXALL ORAL TABLET 10 4 MG, 15 MG, 5 MG, 7.5 MG TUKYSA ORAL TABLET 150 4 PA MG, 50 MG TURALIO ORAL CAPSULE 200 6 PA; QL (120 per 30 MG days) TYKERB ORAL TABLET 250 6 PA; QL (180 per 30 MG days) VENCLEXTA ORAL TABLET 6 PA; QL (60 per 30 10 MG days) VENCLEXTA ORAL TABLET 6 PA; QL (120 per 30 100 MG days) VENCLEXTA ORAL TABLET 6 PA; QL (30 per 30 50 MG days) VENCLEXTA STARTING 6 PA; QL (42 per 28 PACK ORAL TABLETS,DOSE days) PACK 10 MG-50 MG- 100 MG VERZENIO ORAL TABLET 100 4 PA; QL (56 per 28 MG, 150 MG, 200 MG, 50 MG days) VITRAKVI ORAL CAPSULE 6 PA 100 MG, 25 MG VITRAKVI ORAL SOLUTION 6 PA 20 MG/ML VIZIMPRO ORAL TABLET 15 6 PA; QL (30 per 30 MG, 30 MG, 45 MG days) VOTRIENT ORAL TABLET 200 6 PA; QL (120 per 30 MG days) XALKORI ORAL CAPSULE 200 6 PA; QL (60 per 30 MG, 250 MG days) XATMEP ORAL SOLUTION 2.5 6 QL (60 per 30 days) MG/ML XELODA ORAL TABLET 150 6 PA MG, 500 MG XOSPATA ORAL TABLET 40 6 PA; QL (90 per 30 MG days)

28 Drug Name Drug Tier Requirements/Limits XPOVIO ORAL TABLET 100 6 PA; QL (20 per 28 MG/WEEK (20 MG X 5), 100 days) MG/WEEK (50 MG X 2) XPOVIO ORAL TABLET 40 6 PA; QL (8 per 28 days) MG/WEEK (20 MG X 2), 40 MG/WEEK (40 MG X 1) XPOVIO ORAL TABLET 40MG 6 PA; QL (16 per 28 TWICE WEEK (40 MG X 2), days) 40MG TWICE WEEK (80 MG/WEEK), 80 MG/WEEK (20 MG X 4), 80 MG/WEEK (40 MG X 2) XPOVIO ORAL TABLET 60 6 PA; QL (12 per 28 MG/WEEK (20 MG X 3), 60 days) MG/WEEK (60 MG X 1) XPOVIO ORAL TABLET 60MG 6 PA; QL (24 per 28 TWICE WEEK (120 MG/WEEK) days) XPOVIO ORAL TABLET 80MG 6 PA; QL (32 per 28 TWICE WEEK (160 MG/WEEK) days) XTANDI ORAL CAPSULE 40 6 PA; QL (120 per 30 MG days) XTANDI ORAL TABLET 40 MG 6 PA; QL (120 per 30 days) XTANDI ORAL TABLET 80 MG 6 PA; QL (60 per 30 days) YONSA ORAL TABLET 125 MG 6 PA; QL (120 per 30 days) ZEJULA ORAL CAPSULE 100 6 PA; QL (90 per 30 MG days) ZELBORAF ORAL TABLET 240 6 PA; QL (240 per 30 MG days) ZOLINZA ORAL CAPSULE 100 6 PA MG ZYDELIG ORAL TABLET 100 6 PA MG, 150 MG ZYKADIA ORAL CAPSULE 150 6 PA; QL (90 per 30 MG days) ZYKADIA ORAL TABLET 150 6 PA; QL (90 per 30 MG days) ZYTIGA ORAL TABLET 250 6 PA; QL (90 per 30 MG days)

29 Drug Name Drug Tier Requirements/Limits ZYTIGA ORAL TABLET 500 6 PA; QL (60 per 30 MG days) Anticholinergic Agents Antimuscarinics/Antispasmodics chlordiazepoxide-clidinium oral (Librax (with 2 capsule 5-2.5 mg clidinium)) Anticonvulsants Anticonvulsants APTIOM ORAL TABLET 200 6 ST; QL (30 per 30 days) MG, 400 MG APTIOM ORAL TABLET 600 6 ST; QL (60 per 30 days) MG, 800 MG BANZEL ORAL SUSPENSION 6 PA; QL (2400 per 30 40 MG/ML days) BANZEL ORAL TABLET 200 6 PA; QL (480 per 30 MG days) BANZEL ORAL TABLET 400 6 PA; QL (240 per 30 MG days) BRIVIACT ORAL SOLUTION 6 ST; QL (600 per 30 10 MG/ML days) BRIVIACT ORAL TABLET 10 6 ST; QL (60 per 30 days) MG, 100 MG, 25 MG, 50 MG, 75 MG oral capsule, er (Carbatrol) 2 multiphase 12 hr 100 mg, 200 mg, 300 mg carbamazepine oral suspension 100 (Tegretol) 2 mg/5 ml carbamazepine oral tablet 200 mg (Epitol) 2 carbamazepine oral tablet extended (Tegretol XR) 2 release 12 hr 100 mg, 200 mg, 400 mg carbamazepine oral tablet,chewable 2 100 mg CELONTIN ORAL CAPSULE 5 300 MG oral suspension 2.5 mg/ml (Onfi) 3 PA; QL (480 per 30 days) clobazam oral tablet 10 mg, 20 mg (Onfi) 3 QL (60 per 30 days) DIACOMIT ORAL CAPSULE 5 PA 250 MG, 500 MG

30 Drug Name Drug Tier Requirements/Limits DIACOMIT ORAL POWDER IN 5 PA PACKET 250 MG, 500 MG diazepam rectal kit 12.5-15-17.5-20 (Diastat AcuDial) 3 QL (1 per 1 day) mg, 5-7.5-10 mg diazepam rectal kit 2.5 mg (Diastat) 3 QL (1 per 1 day) DILANTIN ORAL CAPSULE 30 5 MG divalproex oral capsule, delayed rel (Depakote Sprinkles) 2 sprinkle 125 mg divalproex oral tablet extended (Depakote ER) 3 release 24 hr 250 mg, 500 mg divalproex oral tablet,delayed (Depakote) 2 release (dr/ec) 125 mg, 250 mg, 500 mg EPIDIOLEX ORAL SOLUTION 6 PA 100 MG/ML epitol oral tablet 200 mg 2 EQUETRO ORAL CAPSULE, 5 ER MULTIPHASE 12 HR 100 MG, 200 MG, 300 MG oral capsule 250 mg (Zarontin) 2 ethosuximide oral solution 250 mg/5 (Zarontin) 2 ml oral suspension 600 mg/5 (Felbatol) 2 QL (900 per 30 days) ml felbamate oral tablet 400 mg (Felbatol) 2 QL (270 per 30 days) felbamate oral tablet 600 mg (Felbatol) 2 QL (180 per 30 days) FINTEPLA ORAL SOLUTION 5 PA 2.2 MG/ML FYCOMPA ORAL 5 ST; QL (680 per 28 SUSPENSION 0.5 MG/ML days) FYCOMPA ORAL TABLET 10 6 ST; QL (30 per 30 days) MG, 12 MG, 8 MG FYCOMPA ORAL TABLET 2 5 ST; QL (120 per 30 MG days) FYCOMPA ORAL TABLET 4 6 ST; QL (60 per 30 days) MG, 6 MG oral capsule 100 mg, 300 (Neurontin) 2 mg, 400 mg gabapentin oral solution 250 mg/5 (Neurontin) 2 ml

31 Drug Name Drug Tier Requirements/Limits gabapentin oral tablet 600 mg, 800 (Neurontin) 2 mg LAMICTAL XR STARTER 5 (BLUE) ORAL TABLET EXTENDED REL,DOSE PACK 25 MG (21) -50 MG (7) LAMICTAL XR STARTER 5 (GREEN) ORAL TABLET EXTENDED REL,DOSE PACK 50 MG(14)-100MG (14)-200 MG (7) LAMICTAL XR STARTER 5 (ORANGE) ORAL TABLET EXTENDED REL,DOSE PACK 25MG (14)-50 MG (14)-100MG (7) oral tablet 100 mg, 150 (Subvenite) 2 mg, 200 mg, 25 mg lamotrigine oral tablet (Lamictal ODT Starter 3 disintegrating, dose pk 25 mg (21) - (Blue)) 50 mg (7) lamotrigine oral tablet (Lamictal ODT Starter 3 disintegrating, dose pk 25 mg(14)- (Orange)) 50 mg (14)-100 mg (7) lamotrigine oral tablet (Lamictal ODT Starter 3 disintegrating, dose pk 50 mg (42) - (Green)) 100 mg (14) lamotrigine oral tablet extended (Lamictal XR) 3 QL (90 per 30 days) release 24hr 100 mg lamotrigine oral tablet extended (Lamictal XR) 3 QL (60 per 30 days) release 24hr 200 mg, 250 mg, 300 mg lamotrigine oral tablet extended (Lamictal XR) 3 QL (180 per 30 days) release 24hr 25 mg, 50 mg lamotrigine oral tablet, chewable (Lamictal) 2 dispersible 25 mg, 5 mg lamotrigine oral (Lamictal ODT) 3 QL (90 per 30 days) tablet,disintegrating 100 mg lamotrigine oral (Lamictal ODT) 3 QL (60 per 30 days) tablet,disintegrating 200 mg lamotrigine oral (Lamictal ODT) 3 QL (180 per 30 days) tablet,disintegrating 25 mg, 50 mg

32 Drug Name Drug Tier Requirements/Limits lamotrigine oral tablets,dose pack (Subvenite Starter 2 25 mg (35) (Blue) Kit) lamotrigine oral tablets,dose pack (Subvenite Starter 2 25 mg (42) -100 mg (7) (Orange) Kit) lamotrigine oral tablets,dose pack (Subvenite Starter 2 25 mg (84) -100 mg (14) (Green) Kit) oral solution 100 (Keppra) 2 mg/ml levetiracetam oral tablet 1,000 mg, (Keppra) 2 250 mg, 500 mg, 750 mg levetiracetam oral tablet extended (Keppra XR) 3 release 24 hr 500 mg, 750 mg NAYZILAM NASAL 5 QL (10 per 30 days) SPRAY,NON-AEROSOL 5 MG/SPRAY (0.1 ML) oral suspension 300 (Trileptal) 2 mg/5 ml (60 mg/ml) oxcarbazepine oral tablet 150 mg, (Trileptal) 2 300 mg, 600 mg OXTELLAR XR ORAL TABLET 5 ST; QL (30 per 30 days) EXTENDED RELEASE 24 HR 150 MG, 300 MG OXTELLAR XR ORAL TABLET 5 ST; QL (120 per 30 EXTENDED RELEASE 24 HR days) 600 MG PEGANONE ORAL TABLET 5 250 MG oral elixir 20 mg/5 ml 2 (4 mg/ml) phenobarbital oral tablet 100 mg, 15 2 mg, 16.2 mg, 30 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg oral suspension 125 mg/5 (Dilantin-125) 2 ml phenytoin oral tablet,chewable 50 (Dilantin Infatabs) 2 mg phenytoin sodium extended oral (Dilantin Extended) 2 capsule 100 mg phenytoin sodium extended oral (Phenytek) 2 capsule 200 mg, 300 mg

33 Drug Name Drug Tier Requirements/Limits oral capsule 100 mg, 150 (Lyrica) 2 mg, 200 mg, 225 mg, 25 mg, 300 mg, 50 mg, 75 mg pregabalin oral solution 20 mg/ml (Lyrica) 2 oral tablet 250 mg, 50 mg (Mysoline) 2 rufinamide oral tablet 200 mg (Banzel) 3 PA; QL (480 per 30 days) rufinamide oral tablet 400 mg (Banzel) 3 PA; QL (240 per 30 days) SABRIL ORAL TABLET 500 6 QL (180 per 30 days) MG SPRITAM ORAL TABLET FOR 5 ST; QL (60 per 30 days) SUSPENSION 1,000 MG SPRITAM ORAL TABLET FOR 5 ST; QL (120 per 30 SUSPENSION 250 MG, 500 MG, days) 750 MG subvenite oral tablet 100 mg, 150 2 mg, 200 mg, 25 mg subvenite starter (blue) kit oral 2 tablets,dose pack 25 mg (35) subvenite starter (green) kit oral 2 tablets,dose pack 25 mg (84) -100 mg (14) subvenite starter (orange) kit oral 2 tablets,dose pack 25 mg (42) -100 mg (7) SYMPAZAN ORAL FILM 10 6 PA; QL (60 per 30 MG, 20 MG days) SYMPAZAN ORAL FILM 5 MG 5 PA; QL (60 per 30 days) oral tablet 12 mg, 2 mg, 4 (Gabitril) 3 QL (120 per 30 days) mg tiagabine oral tablet 16 mg (Gabitril) 3 QL (90 per 30 days) oral capsule, sprinkle 15 (Topamax) 2 mg, 25 mg topiramate oral tablet 100 mg, 200 (Topamax) 2 mg, 25 mg, 50 mg TROKENDI XR ORAL 6 ST; QL (30 per 30 days) CAPSULE,EXTENDED RELEASE 24HR 100 MG

34 Drug Name Drug Tier Requirements/Limits TROKENDI XR ORAL 6 ST; QL (60 per 30 days) CAPSULE,EXTENDED RELEASE 24HR 200 MG TROKENDI XR ORAL 4 ST; QL (30 per 30 days) CAPSULE,EXTENDED RELEASE 24HR 25 MG, 50 MG valproic acid (as sodium salt) oral 2 solution 250 mg/5 ml valproic acid oral capsule 250 mg 2 VALTOCO NASAL 5 QL (10 per 30 days) SPRAY,NON-AEROSOL 10 MG/SPRAY (0.1 ML), 15 MG/2 SPRAY (7.5/0.1ML X 2), 20 MG/2 SPRAY (10MG/0.1ML X2), 5 MG/SPRAY (0.1 ML) oral powder in packet 500 (Vigadrone) 6 QL (180 per 30 days) mg vigabatrin oral tablet 500 mg (Sabril) 6 QL (180 per 30 days) vigadrone oral powder in packet 500 6 QL (180 per 30 days) mg VIMPAT ORAL SOLUTION 10 4 PA; QL (1200 per 30 MG/ML days) VIMPAT ORAL TABLET 100 4 PA; QL (60 per 30 MG, 150 MG, 200 MG, 50 MG days) XCOPRI MAINTENANCE 5 PA PACK ORAL TABLET 250 MG/DAY (200 MG X1-50 MG X1), 250MG/DAY(150 MG X1- 100MG X1), 350 MG/DAY (200 MG X1-150MG X1) XCOPRI ORAL TABLET 100 5 PA MG, 150 MG, 200 MG, 50 MG XCOPRI TITRATION PACK 5 PA ORAL TABLETS,DOSE PACK 12.5 MG (14)- 25 MG (14), 150 MG (14)- 200 MG (14), 50 MG (14)- 100 MG (14) oral capsule 100 mg, 25 (Zonegran) 2 mg zonisamide oral capsule 50 mg 2

35 Drug Name Drug Tier Requirements/Limits Antidementia Agents Antidementia Agents donepezil oral tablet 10 mg, 5 mg (Aricept) 2 donepezil oral tablet 23 mg (Aricept) 3 donepezil oral tablet,disintegrating 2 10 mg, 5 mg oral tablet 1 mg 2 galantamine oral capsule,ext rel. (Razadyne ER) 3 QL (30 per 30 days) pellets 24 hr 16 mg, 24 mg, 8 mg galantamine oral solution 4 mg/ml 2 QL (200 per 30 days) galantamine oral tablet 12 mg, 4 2 QL (60 per 30 days) mg, 8 mg oral capsule,sprinkle,er (Namenda XR) 3 QL (30 per 30 days) 24hr 14 mg, 21 mg, 28 mg, 7 mg memantine oral solution 2 mg/ml 2 QL (300 per 30 days) memantine oral tablet 10 mg, 5 mg (Namenda) 2 QL (60 per 30 days) memantine oral tablets,dose pack 5- (Namenda Titration 2 QL (49 per 28 days) 10 mg Pak) NAMENDA XR ORAL 5 QL (28 per 28 days) CAP,SPRINKLE,ER 24HR DOSE PACK 7-14-21-28 MG NAMZARIC ORAL 5 ST; QL (28 per 28 days) CAP,SPRINKLE,ER 24HR DOSE PACK 7/14/21/28 MG-10 MG NAMZARIC ORAL 5 ST; QL (30 per 30 days) CAPSULE,SPRINKLE,ER 24HR 14-10 MG, 21-10 MG, 28-10 MG, 7-10 MG rivastigmine tartrate oral capsule 2 1.5 mg, 3 mg, 4.5 mg, 6 mg rivastigmine transdermal patch 24 (Exelon Patch) 3 QL (30 per 30 days) hour 13.3 mg/24 hour, 4.6 mg/24 hour, 9.5 mg/24 hour Antidepressants Antidepressants oral tablet 10 mg, 100 2 mg, 150 mg, 25 mg, 50 mg, 75 mg amitriptyline-chlordiazepoxide oral 2 tablet 12.5-5 mg, 25-10 mg oral tablet 100 mg, 150 2 mg, 25 mg, 50 mg

36 Drug Name Drug Tier Requirements/Limits bupropion hcl oral tablet 100 mg, 75 2 mg bupropion hcl oral tablet extended (Wellbutrin XL) 2 release 24 hr 150 mg, 300 mg bupropion hcl oral tablet sustained- (Wellbutrin SR) 2 release 12 hr 100 mg, 150 mg, 200 mg citalopram oral solution 10 mg/5 ml 2 citalopram oral tablet 10 mg, 20 mg, (Celexa) 1 40 mg oral capsule 25 mg, 50 (Anafranil) 2 mg, 75 mg oral tablet 10 mg, 25 (Norpramin) 2 mg desipramine oral tablet 100 mg, 150 2 mg, 50 mg, 75 mg desvenlafaxine oral tablet extended 5 ST; QL (30 per 30 days) release 24 hr 100 mg, 50 mg desvenlafaxine succinate oral tablet (Pristiq) 3 ST; QL (30 per 30 days) extended release 24 hr 100 mg, 25 mg, 50 mg oral capsule 10 mg, 100 mg, 2 150 mg, 25 mg, 50 mg, 75 mg doxepin oral concentrate 10 mg/ml 2 duloxetine oral capsule,delayed (Cymbalta) 3 QL (60 per 30 days) release(dr/ec) 20 mg, 30 mg, 60 mg EMSAM TRANSDERMAL 6 QL (30 per 30 days) PATCH 24 HOUR 12 MG/24 HR, 6 MG/24 HR, 9 MG/24 HR escitalopram oxalate oral solution 5 2 mg/5 ml escitalopram oxalate oral tablet 10 (Lexapro) 2 mg, 20 mg, 5 mg FETZIMA ORAL 5 ST; QL (30 per 30 days) CAPSULE,EXT REL 24HR DOSE PACK 20 MG (2)- 40 MG (26) FETZIMA ORAL 5 ST; QL (30 per 30 days) CAPSULE,EXTENDED RELEASE 24 HR 120 MG, 20 MG, 40 MG, 80 MG

37 Drug Name Drug Tier Requirements/Limits oral capsule 10 mg, 20 (Prozac) 2 mg, 40 mg fluoxetine oral capsule,delayed 2 release(dr/ec) 90 mg fluoxetine oral solution 20 mg/5 ml 2 (4 mg/ml) fluoxetine oral tablet 10 mg, 20 mg 1 FLUOXETINE ORAL TABLET 3 60 MG fluvoxamine oral capsule,extended 3 QL (60 per 30 days) release 24hr 100 mg, 150 mg fluvoxamine oral tablet 100 mg, 25 2 mg, 50 mg hcl oral tablet 10 mg, 25 3 mg, 50 mg imipramine pamoate oral capsule 3 100 mg, 125 mg, 150 mg, 75 mg oral tablet 25 mg, 50 2 mg, 75 mg MARPLAN ORAL TABLET 10 5 MG oral tablet 15 mg, 30 (Remeron) 2 mg mirtazapine oral tablet 45 mg, 7.5 2 mg mirtazapine oral (Remeron SolTab) 3 tablet,disintegrating 15 mg, 30 mg, 45 mg oral tablet 100 mg, 150 2 mg, 200 mg, 250 mg, 50 mg oral capsule 10 mg, 25 (Pamelor) 2 mg, 50 mg, 75 mg nortriptyline oral solution 10 mg/5 2 ml -fluoxetine oral capsule 2 QL (30 per 30 days) 12-25 mg olanzapine-fluoxetine oral capsule (Symbyax) 2 QL (30 per 30 days) 12-50 mg, 3-25 mg, 6-25 mg, 6-50 mg paroxetine hcl oral tablet 10 mg, 20 (Paxil) 1 mg, 30 mg, 40 mg

38 Drug Name Drug Tier Requirements/Limits paroxetine hcl oral tablet extended (Paxil CR) 3 release 24 hr 12.5 mg, 25 mg, 37.5 mg PAXIL ORAL SUSPENSION 10 5 MG/5 ML -amitriptyline oral 2 tablet 2-10 mg, 2-25 mg, 4-10 mg, 4- 25 mg, 4-50 mg phenelzine oral tablet 15 mg (Nardil) 2 oral tablet 10 mg, 5 mg 2 sertraline oral concentrate 20 mg/ml (Zoloft) 2 sertraline oral tablet 100 mg, 25 mg, (Zoloft) 2 50 mg tranylcypromine oral tablet 10 mg (Parnate) 2 oral tablet 100 mg, 150 1 mg, 50 mg trazodone oral tablet 300 mg 2 oral capsule 100 mg, 2 25 mg, 50 mg TRINTELLIX ORAL TABLET 4 ST; QL (30 per 30 days) 10 MG, 20 MG, 5 MG venlafaxine oral capsule,extended (Effexor XR) 2 release 24hr 150 mg, 37.5 mg, 75 mg venlafaxine oral tablet 100 mg, 25 2 mg, 37.5 mg, 50 mg, 75 mg venlafaxine oral tablet extended 2 release 24hr 150 mg, 225 mg, 37.5 mg, 75 mg VIIBRYD ORAL TABLET 10 4 ST; QL (30 per 30 days) MG, 20 MG, 40 MG VIIBRYD ORAL 4 ST; QL (30 per 30 days) TABLETS,DOSE PACK 10 MG (7)- 20 MG (23) Antidiabetic Agents Antidiabetic Agents, Miscellaneous acarbose oral tablet 100 mg, 25 mg, (Precose) 2 50 mg ACTOPLUS MET XR ORAL 5 TABLET, ER MULTIPHASE 24 HR 15-1,000 MG, 30-1,000 MG AVANDAMET ORAL TABLET 5 ST 2-1,000 MG

39 Drug Name Drug Tier Requirements/Limits AVANDIA ORAL TABLET 2 5 ST MG, 4 MG BYDUREON BCISE 4 ST; QL (3.4 per 28 SUBCUTANEOUS AUTO- days) INJECTOR 2 MG/0.85 ML BYDUREON SUBCUTANEOUS 4 ST; QL (4 per 28 days) PEN INJECTOR 2 MG/0.65 ML BYDUREON SUBCUTANEOUS 4 ST; QL (4 per 28 days) SUSPENSION,EXTENDED REL RECON 2 MG BYETTA SUBCUTANEOUS 4 ST; QL (2.4 per 30 PEN INJECTOR 10 days) MCG/DOSE(250 MCG/ML) 2.4 ML BYETTA SUBCUTANEOUS 4 ST; QL (1.2 per 30 PEN INJECTOR 5 MCG/DOSE days) (250 MCG/ML) 1.2 ML CYCLOSET ORAL TABLET 0.8 5 MG FARXIGA ORAL TABLET 10 4 ST; QL (30 per 30 days) MG, 5 MG GLYXAMBI ORAL TABLET 10- 5 ST; QL (30 per 30 days) 5 MG, 25-5 MG INVOKAMET ORAL TABLET 5 ST; QL (60 per 30 days) 150-1,000 MG, 150-500 MG, 50- 1,000 MG, 50-500 MG INVOKAMET XR ORAL 5 ST; QL (60 per 30 days) TABLET, IR - ER, BIPHASIC 24HR 150-1,000 MG, 150-500 MG, 50-1,000 MG, 50-500 MG INVOKANA ORAL TABLET 5 ST; QL (30 per 30 days) 100 MG, 300 MG JANUMET ORAL TABLET 50- 4 QL (60 per 30 days) 1,000 MG, 50-500 MG JANUMET XR ORAL TABLET, 4 QL (30 per 30 days) ER MULTIPHASE 24 HR 100- 1,000 MG JANUMET XR ORAL TABLET, 4 QL (60 per 30 days) ER MULTIPHASE 24 HR 50- 1,000 MG, 50-500 MG JANUVIA ORAL TABLET 100 4 QL (30 per 30 days) MG, 25 MG, 50 MG

40 Drug Name Drug Tier Requirements/Limits JARDIANCE ORAL TABLET 10 4 ST; QL (30 per 30 days) MG, 25 MG JENTADUETO ORAL TABLET 5 ST; QL (60 per 30 days) 2.5-1,000 MG, 2.5-500 MG, 2.5- 850 MG JENTADUETO XR ORAL 5 ST; QL (60 per 30 days) TABLET, IR - ER, BIPHASIC 24HR 2.5-1,000 MG JENTADUETO XR ORAL 5 ST; QL (30 per 30 days) TABLET, IR - ER, BIPHASIC 24HR 5-1,000 MG KORLYM ORAL TABLET 300 6 PA; QL (120 per 30 MG days) metformin oral solution 500 mg/5 ml (Riomet) 3 metformin oral tablet 1,000 mg, 500 1 mg, 850 mg metformin oral tablet extended 1 release 24 hr 500 mg metformin oral tablet extended 2 release 24 hr 750 mg metformin oral tablet extended 6 release 24hr 1,000 mg, 500 mg miglitol oral tablet 100 mg, 25 mg, 3 50 mg oral tablet 120 mg, 60 2 mg OZEMPIC SUBCUTANEOUS 4 ST; QL (1.5 per 28 PEN INJECTOR 0.25 MG OR 0.5 days) MG(2 MG/1.5 ML) OZEMPIC SUBCUTANEOUS 4 ST; QL (3 per 28 days) PEN INJECTOR 1 MG/DOSE (2 MG/1.5 ML) OZEMPIC SUBCUTANEOUS 4 QL (3 per 28 days) PEN INJECTOR 1 MG/DOSE (4 MG/3 ML) pioglitazone oral tablet 15 mg, 30 (Actos) 2 mg, 45 mg pioglitazone- oral tablet (DUETACT) 3 30-2 mg, 30-4 mg pioglitazone-metformin oral tablet (Actoplus MET) 3 15-500 mg, 15-850 mg

41 Drug Name Drug Tier Requirements/Limits oral tablet 0.5 mg, 1 mg, 3 2 mg repaglinide-metformin oral tablet 1- 3 500 mg, 2-500 mg RIOMET ER ORAL 5 PA SUSPENSION,EXTENDED REL RECON 500 MG/5 ML RIOMET ORAL SOLUTION 500 5 MG/5 ML RYBELSUS ORAL TABLET 14 4 ST MG, 3 MG, 7 MG SYMLINPEN 120 6 PA; QL (10.8 per 28 SUBCUTANEOUS PEN days) INJECTOR 2,700 MCG/2.7 ML SYMLINPEN 60 6 PA; QL (6 per 28 days) SUBCUTANEOUS PEN INJECTOR 1,500 MCG/1.5 ML SYNJARDY ORAL TABLET 4 ST; QL (60 per 30 days) 12.5-1,000 MG, 12.5-500 MG, 5- 1,000 MG, 5-500 MG SYNJARDY XR ORAL 4 ST; QL (30 per 30 days) TABLET, IR - ER, BIPHASIC 24HR 10-1,000 MG, 25-1,000 MG SYNJARDY XR ORAL 4 ST; QL (60 per 30 days) TABLET, IR - ER, BIPHASIC 24HR 12.5-1,000 MG, 5-1,000 MG TANZEUM SUBCUTANEOUS 5 ST; QL (4 per 28 days) PEN INJECTOR 30 MG/0.5 ML, 50 MG/0.5 ML TRADJENTA ORAL TABLET 5 5 ST; QL (30 per 30 days) MG TRULICITY SUBCUTANEOUS 4 ST; QL (2 per 28 days) PEN INJECTOR 0.75 MG/0.5 ML, 1.5 MG/0.5 ML, 3 MG/0.5 ML, 4.5 MG/0.5 ML VICTOZA SUBCUTANEOUS 4 ST; QL (9 per 28 days) PEN INJECTOR 0.6 MG/0.1 ML (18 MG/3 ML) XIGDUO XR ORAL TABLET, 4 ST; QL (30 per 30 days) IR - ER, BIPHASIC 24HR 10- 1,000 MG, 10-500 MG, 5-500 MG

42 Drug Name Drug Tier Requirements/Limits XIGDUO XR ORAL TABLET, 4 ST; QL (60 per 30 days) IR - ER, BIPHASIC 24HR 2.5- 1,000 MG, 5-1,000 MG Insulins FIASP FLEXTOUCH U-100 5 ST; QL (30 per 28 days) INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) FIASP PENFILL U-100 5 ST; QL (30 per 28 days) INSULIN SUBCUTANEOUS CARTRIDGE 100 UNIT/ML (3 ML) FIASP U-100 INSULIN 5 ST; QL (40 per 28 days) SUBCUTANEOUS SOLUTION 100 UNIT/ML HUMALOG JUNIOR 4 QL (30 per 28 days) KWIKPEN U-100 SUBCUTANEOUS INSULIN PEN, HALF-UNIT 100 UNIT/ML HUMALOG KWIKPEN 4 QL (30 per 28 days) INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML HUMALOG KWIKPEN 4 QL (12 per 28 days) INSULIN SUBCUTANEOUS INSULIN PEN 200 UNIT/ML (3 ML) HUMALOG MIX 50-50 INSULN 4 QL (40 per 28 days) U-100 SUBCUTANEOUS SUSPENSION 100 UNIT/ML (50- 50) HUMALOG MIX 50-50 4 QL (30 per 28 days) KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (50-50) HUMALOG MIX 75-25 4 QL (30 per 28 days) KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (75-25) HUMALOG MIX 75-25(U- 4 QL (40 per 28 days) 100)INSULN SUBCUTANEOUS SUSPENSION 100 UNIT/ML (75- 25)

43 Drug Name Drug Tier Requirements/Limits HUMALOG U-100 INSULIN 4 QL (30 per 28 days) SUBCUTANEOUS CARTRIDGE 100 UNIT/ML HUMALOG U-100 INSULIN 4 QL (40 per 28 days) SUBCUTANEOUS SOLUTION 100 UNIT/ML HUMULIN 70/30 U-100 4 QL (40 per 28 days) INSULIN SUBCUTANEOUS SUSPENSION 100 UNIT/ML (70- 30) HUMULIN 70/30 U-100 4 QL (30 per 28 days) KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-30) HUMULIN N NPH INSULIN 4 QL (30 per 28 days) KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) HUMULIN N NPH U-100 4 QL (40 per 28 days) INSULIN SUBCUTANEOUS SUSPENSION 100 UNIT/ML HUMULIN R REGULAR U-100 4 QL (40 per 28 days) INSULN INJECTION SOLUTION 100 UNIT/ML HUMULIN R U-500 (CONC) 4 QL (40 per 28 days) INSULIN SUBCUTANEOUS SOLUTION 500 UNIT/ML HUMULIN R U-500 (CONC) 4 QL (24 per 28 days) KWIKPEN SUBCUTANEOUS INSULIN PEN 500 UNIT/ML (3 ML) insulin asp prt-insulin aspart (Novolog Mix 70- 3 ST; QL (30 per 28 days) subcutaneous insulin pen 100 unit/ml 30FlexPen U-100) (70-30) insulin asp prt-insulin aspart (Novolog Mix 70-30 U- 3 ST; QL (40 per 28 days) subcutaneous solution 100 unit/ml 100 Insuln) (70-30) insulin aspart u-100 subcutaneous (Novolog PenFill U- 3 ST; QL (30 per 28 days) cartridge 100 unit/ml 100 Insulin) insulin aspart u-100 subcutaneous (Novolog Flexpen U- 3 ST; QL (30 per 28 days) insulin pen 100 unit/ml (3 ml) 100 Insulin) insulin aspart u-100 subcutaneous (Novolog U-100 3 ST; QL (40 per 28 days) solution 100 unit/ml Insulin aspart)

44 Drug Name Drug Tier Requirements/Limits LANTUS SOLOSTAR U-100 4 QL (30 per 28 days) INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) LANTUS U-100 INSULIN 4 QL (40 per 28 days) SUBCUTANEOUS SOLUTION 100 UNIT/ML LEVEMIR FLEXTOUCH U-100 4 QL (30 per 28 days) INSULN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) LEVEMIR U-100 INSULIN 4 QL (40 per 28 days) SUBCUTANEOUS SOLUTION 100 UNIT/ML NOVOLIN 70/30 U-100 INSULIN 5 ST; QL (40 per 28 days) SUBCUTANEOUS SUSPENSION 100 UNIT/ML (70- 30) NOVOLIN 70-30 FLEXPEN U- 5 ST; QL (30 per 28 days) 100 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-30) NOVOLIN N FLEXPEN 5 ST SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) NOVOLIN N NPH U-100 5 ST; QL (40 per 28 days) INSULIN SUBCUTANEOUS SUSPENSION 100 UNIT/ML NOVOLIN R FLEXPEN 5 ST SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) NOVOLIN R REGULAR U-100 5 ST; QL (40 per 28 days) INSULN INJECTION SOLUTION 100 UNIT/ML SOLIQUA 100/33 4 ST; QL (30 per 28 days) SUBCUTANEOUS INSULIN PEN 100 UNIT-33 MCG/ML TOUJEO MAX U-300 4 QL (18 per 28 days) SOLOSTAR SUBCUTANEOUS INSULIN PEN 300 UNIT/ML (3 ML)

45 Drug Name Drug Tier Requirements/Limits TOUJEO SOLOSTAR U-300 4 QL (13.5 per 28 days) INSULIN SUBCUTANEOUS INSULIN PEN 300 UNIT/ML (1.5 ML) TRESIBA FLEXTOUCH U-100 4 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) TRESIBA FLEXTOUCH U-200 4 SUBCUTANEOUS INSULIN PEN 200 UNIT/ML (3 ML) TRESIBA U-100 INSULIN 4 SUBCUTANEOUS SOLUTION 100 UNIT/ML XULTOPHY 100/3.6 4 QL (15 per 28 days) SUBCUTANEOUS INSULIN PEN 100 UNIT-3.6 MG /ML (3 ML) Sulfonylureas oral tablet 100 mg, 3 250 mg glimepiride oral tablet 1 mg, 2 mg, 4 (Amaryl) 1 mg oral tablet 10 mg (Glucotrol) 1 glipizide oral tablet 5 mg 1 glipizide oral tablet extended release (Glucotrol XL) 2 24hr 10 mg, 2.5 mg, 5 mg glipizide-metformin oral tablet 2.5- 2 250 mg, 2.5-500 mg, 5-500 mg glyburide micronized oral tablet 1.5 (Glynase) 2 mg, 3 mg, 6 mg glyburide oral tablet 1.25 mg, 2.5 2 mg, 5 mg glyburide-metformin oral tablet 2 1.25-250 mg, 2.5-500 mg, 5-500 mg oral tablet 250 mg, 500 3 mg oral tablet 500 mg 2 Antifungals Antifungals ciclopirox topical cream 0.77 % (Ciclodan) 2 ciclopirox topical gel 0.77 % 3 ciclopirox topical shampoo 1 % (Loprox) 3

46 Drug Name Drug Tier Requirements/Limits ciclopirox topical solution 8 % (Ciclodan) 2 ciclopirox topical suspension 0.77 % (Loprox (as olamine)) 2 clotrimazole mucous membrane 2 troche 10 mg clotrimazole topical cream 1 % (Antifungal 2 (clotrimazole)) clotrimazole topical solution 1 % 2 clotrimazole-betamethasone topical 2 cream 1-0.05 % clotrimazole-betamethasone topical 3 lotion 1-0.05 % CRESEMBA ORAL CAPSULE 6 186 MG econazole topical cream 1 % 3 EXELDERM TOPICAL CREAM 5 1 % EXELDERM TOPICAL 5 SOLUTION 1 % fluconazole oral suspension for (Diflucan) 2 reconstitution 10 mg/ml, 40 mg/ml fluconazole oral tablet 100 mg, 150 (Diflucan) 2 mg, 200 mg, 50 mg flucytosine oral capsule 250 mg, 500 (Ancobon) 2 mg griseofulvin microsize oral 2 suspension 125 mg/5 ml griseofulvin microsize oral tablet 3 500 mg griseofulvin ultramicrosize oral 3 tablet 125 mg, 250 mg itraconazole oral capsule 100 mg (Sporanox) 2 itraconazole oral solution 10 mg/ml (Sporanox) 3 KERYDIN TOPICAL 6 PA; QL (10 per 30 SOLUTION WITH days) APPLICATOR 5 % oral tablet 200 mg 2 ketoconazole topical cream 2 % 2 ketoconazole topical shampoo 2 % 2 ketoconazole-hydrocortisone topical (Pheyo) 2 cream 2-2.5 % luliconazole topical cream 1 % (Luzu) 3 ST; QL (60 per 28 days)

47 Drug Name Drug Tier Requirements/Limits MENTAX TOPICAL CREAM 1 5 % miconazole nitrate- ox-pet (Vusion) 3 topical ointment 0.25-15-81.35 % miconazole-3 vaginal suppository 2 200 mg naftifine topical cream 1 %, 2 % 3 naftifine topical gel 1 % (Naftin) 3 NOXAFIL ORAL SUSPENSION 6 PA 200 MG/5 ML (40 MG/ML) nyamyc topical powder 100,000 2 unit/gram nystatin oral suspension 100,000 2 unit/ml nystatin oral tablet 500,000 unit 2 nystatin topical cream 100,000 2 unit/gram nystatin topical ointment 100,000 2 unit/gram nystatin topical powder 100,000 (Nyamyc) 2 unit/gram nystatin-triamcinolone topical 3 cream 100,000-0.1 unit/g-% nystatin-triamcinolone topical 3 ointment 100,000-0.1 unit/gram-% nystop topical powder 100,000 2 unit/gram ONMEL ORAL TABLET 200 5 MG ORAVIG BUCCAL MUCO- 6 ADHESIVE BUCCAL TABLET 50 MG oxiconazole topical cream 1 % (Oxistat) 3 OXISTAT TOPICAL LOTION 1 5 % posaconazole oral suspension 200 (Noxafil) 2 PA mg/5 ml (40 mg/ml) posaconazole oral tablet,delayed (Noxafil) 3 PA release (dr/ec) 100 mg sulconazole topical cream 1 % (Exelderm) 3 sulconazole topical solution 1 % (Exelderm) 3

48 Drug Name Drug Tier Requirements/Limits tavaborole topical solution with (Kerydin) 3 PA; QL (10 per 30 applicator 5 % days) terbinafine hcl oral tablet 250 mg 2 TRIACETIN LIQUID 100 % 5 voriconazole oral suspension for (Vfend) 3 reconstitution 200 mg/5 ml (40 mg/ml) voriconazole oral tablet 200 mg, 50 (Vfend) 3 mg Antigout Agents Antigout Agents, Other allopurinol oral tablet 100 mg (Zyloprim) 2 allopurinol oral tablet 300 mg 2 colchicine oral capsule 0.6 mg (Mitigare) 2 colchicine oral tablet 0.6 mg (Colcrys) 3 QL (120 per 30 days) febuxostat oral tablet 40 mg, 80 mg (Uloric) 3 ST; QL (30 per 30 days) GLOPERBA ORAL SOLUTION 5 PA; QL (300 per 30 0.6 MG/5 ML days) probenecid oral tablet 500 mg 2 probenecid-colchicine oral tablet 2 500-0.5 mg Antihistamines Antihistamines carbinoxamine maleate oral liquid 4 2 mg/5 ml carbinoxamine maleate oral tablet 4 2 mg cetirizine oral solution 1 mg/ml (All Day Allergy 2 (cetirizine)) CLARINEX ORAL SYRUP 2.5 5 ST; QL (150 per 30 MG/5 ML (0.5 MG/ML) days) CLARINEX-D 12 HOUR ORAL 5 ST; QL (60 per 30 days) TABLET, ER MULTIPHASE 12 HR 2.5-120 MG clemastine oral tablet 2.68 mg 2 oral syrup 2 mg/5 ml 3 cyproheptadine oral tablet 4 mg 2 desloratadine oral tablet 5 mg (Clarinex) 3 ST; QL (30 per 30 days) desloratadine oral 3 ST; QL (30 per 30 days) tablet,disintegrating 2.5 mg, 5 mg

49 Drug Name Drug Tier Requirements/Limits fexofenadine- oral (Allegra-D 24 Hour) 2 tablet extended release 24 hr 180- 240 mg hcl oral solution 10 2 mg/5 ml hydroxyzine hcl oral tablet 10 mg, 2 25 mg, 50 mg levocetirizine oral solution 2.5 mg/5 (Xyzal) 2 ST; QL (300 per 30 ml days) levocetirizine oral tablet 5 mg (24HR Allergy Relief) 2 ST; QL (30 per 30 days) oral syrup 6.25 mg/5 2 ml promethazine- oral (Promethazine VC) 2 syrup 6.25-5 mg/5 ml respa-ar oral tablet extended release 3 12 hr 8-90-0.24 mg SEMPREX-D ORAL CAPSULE 5 8-60 MG Anti-Infectives (Skin And Mucous Membrane) Anti-Infectives (Skin And Mucous Membrane) AVC VAGINAL VAGINAL 4 CREAM 15 % CLEOCIN VAGINAL 5 QL (3 per 30 days) SUPPOSITORY 100 MG clindamycin phosphate vaginal (Cleocin) 2 cream 2 % CLINDESSE VAGINAL 5 QL (5 per 28 days) CREAM,EXTENDED RELEASE 2 % GYNAZOLE-1 VAGINAL 4 CREAM 2 % metronidazole vaginal gel 0.75 % (Vandazole) 2 terconazole vaginal cream 0.4 %, 0.8 2 % terconazole vaginal suppository 80 2 mg VANDAZOLE VAGINAL GEL 5 0.75 %

50 Drug Name Drug Tier Requirements/Limits Antimigraine Agents Antimigraine Agents AIMOVIG AUTOINJECTOR (2 4 PA; QL (1 per 30 days) PACK) SUBCUTANEOUS AUTO-INJECTOR 70 MG/ML AIMOVIG AUTOINJECTOR 4 PA; QL (1 per 30 days) SUBCUTANEOUS AUTO- INJECTOR 140 MG/ML, 70 MG/ML AJOVY AUTOINJECTOR 6 PA; QL (1.5 per 30 SUBCUTANEOUS AUTO- days) INJECTOR 225 MG/1.5 ML almotriptan malate oral tablet 12.5 3 ST; QL (8 per 30 days) mg, 6.25 mg injection solution (D.H.E.45) 3 ST; QL (15 per 14 days) 1 mg/ml dihydroergotamine nasal spray,non- (Migranal) 3 ST; QL (8 per 28 days) aerosol 0.5 mg/pump act. (4 mg/ml) eletriptan oral tablet 20 mg, 40 mg (Relpax) 3 QL (6 per 30 days) EMGALITY PEN 4 PA SUBCUTANEOUS PEN INJECTOR 120 MG/ML EMGALITY SYRINGE 4 PA SUBCUTANEOUS SYRINGE 120 MG/ML, 300 MG/3 ML (100 MG/ML X 3) ERGOMAR SUBLINGUAL 5 QL (40 per 28 days) TABLET 2 MG -caffeine oral tablet 1- (Cafergot) 2 QL (40 per 28 days) 100 mg frovatriptan oral tablet 2.5 mg (Frova) 3 ST; QL (12 per 30 days) isometh-dichloral-acetaminophn oral 2 capsule 65-100-325 mg MIGERGOT RECTAL 5 QL (20 per 28 days) SUPPOSITORY 2-100 MG naratriptan oral tablet 1 mg, 2.5 mg (Amerge) 3 QL (8 per 30 days) nodolor oral capsule 65-100-325 mg 2 rizatriptan oral tablet 10 mg (Maxalt) 2 QL (12 per 30 days) rizatriptan oral tablet 5 mg 2 QL (12 per 30 days) rizatriptan oral tablet,disintegrating (Maxalt-MLT) 2 QL (12 per 30 days) 10 mg

51 Drug Name Drug Tier Requirements/Limits rizatriptan oral tablet,disintegrating 2 QL (12 per 30 days) 5 mg sumatriptan nasal spray,non-aerosol (Imitrex) 2 QL (12 per 30 days) 20 mg/actuation, 5 mg/actuation sumatriptan succinate oral tablet (Imitrex) 2 QL (18 per 30 days) 100 mg, 25 mg, 50 mg sumatriptan succinate subcutaneous (Imitrex STATdose 3 QL (4 per 28 days) cartridge 4 mg/0.5 ml, 6 mg/0.5 ml Refill) sumatriptan succinate subcutaneous (Imitrex STATdose 3 QL (4 per 28 days) pen injector 4 mg/0.5 ml, 6 mg/0.5 Pen) ml sumatriptan succinate subcutaneous (Imitrex) 2 QL (4 per 28 days) solution 6 mg/0.5 ml sumatriptan succinate subcutaneous 3 QL (4 per 28 days) syringe 6 mg/0.5 ml UBRELVY ORAL TABLET 100 5 PA; QL (16 per 30 MG, 50 MG days) zolmitriptan nasal spray,non-aerosol (Zomig) 3 ST; QL (12 per 30 days) 2.5 mg, 5 mg zolmitriptan oral tablet 2.5 mg, 5 (Zomig) 3 QL (8 per 30 days) mg zolmitriptan oral (Zomig ZMT) 3 QL (8 per 30 days) tablet,disintegrating 2.5 mg, 5 mg ZOMIG NASAL SPRAY,NON- 5 ST; QL (12 per 30 days) AEROSOL 2.5 MG, 5 MG Antimycobacterials Antimycobacterials dapsone oral tablet 100 mg, 25 mg 2 ethambutol oral tablet 100 mg 2 ethambutol oral tablet 400 mg (Myambutol) 2 isoniazid oral solution 50 mg/5 ml 2 isoniazid oral tablet 100 mg, 300 mg 2 PASER ORAL GRANULES DR 5 FOR SUSP IN PACKET 4 GRAM PRETOMANID ORAL TABLET 5 QL (30 per 30 days) 200 MG PRIFTIN ORAL TABLET 150 5 MG pyrazinamide oral tablet 500 mg 2 rifabutin oral capsule 150 mg (Mycobutin) 3

52 Drug Name Drug Tier Requirements/Limits RIFAMATE ORAL CAPSULE 5 300-150 MG rifampin oral capsule 150 mg, 300 2 mg RIFATER ORAL TABLET 50- 5 120-300 MG SIRTURO ORAL TABLET 100 6 PA; QL (188 per 168 MG days) SIRTURO ORAL TABLET 20 6 PA; QL (940 per 168 MG days) TRECATOR ORAL TABLET 250 5 MG Antinausea Agents Antinausea Agents AKYNZEO (NETUPITANT) 5 PA; QL (1 per 21 days) ORAL CAPSULE 300-0.5 MG ANZEMET ORAL TABLET 100 4 QL (5 per 30 days) MG, 50 MG aprepitant oral capsule 125 mg 3 PA; QL (1 per 1 day) aprepitant oral capsule 40 mg 3 PA; QL (4 per 1 day) aprepitant oral capsule 80 mg (Emend) 3 PA; QL (2 per 1 day) aprepitant oral capsule,dose pack (Emend) 3 PA; QL (3 per 1 day) 125 mg (1)- 80 mg (2) BONJESTA ORAL 5 TABLET,IR,DELAYED REL,BIPHASIC 20-20 MG CESAMET ORAL CAPSULE 1 6 PA; QL (20 per 1 day) MG compro rectal suppository 25 mg 2 DICLEGIS ORAL 5 TABLET,DELAYED RELEASE (DR/EC) 10-10 MG doxylamine-pyridoxine (vit b6) oral (Diclegis) 3 tablet,delayed release (dr/ec) 10-10 mg dronabinol oral capsule 10 mg, 2.5 (Marinol) 3 QL (60 per 30 days) mg, 5 mg EMEND ORAL CAPSULE 40 5 PA; QL (4 per 1 day) MG EMEND ORAL CAPSULE 80 5 PA; QL (2 per 1 day) MG

53 Drug Name Drug Tier Requirements/Limits EMEND ORAL 5 PA; QL (3 per 1 day) CAPSULE,DOSE PACK 125 MG (1)- 80 MG (2) EMEND ORAL SUSPENSION 5 PA; QL (3 per 3 days) FOR RECONSTITUTION 125 MG (25 MG/ ML FINAL CONC.) granisetron hcl oral tablet 1 mg 3 QL (8 per 28 days) oral tablet 12.5 mg 2 meclizine oral tablet 25 mg (Dramamine Less 2 Drowsy) ondansetron hcl oral solution 4 mg/5 2 QL (50 per 15 days) ml ondansetron hcl oral tablet 24 mg, 8 2 mg ondansetron hcl oral tablet 4 mg (Zofran) 2 ondansetron oral 2 tablet,disintegrating 4 mg, 8 mg phenadoz rectal suppository 12.5 2 mg, 25 mg maleate oral tablet (Compazine) 2 10 mg, 5 mg prochlorperazine rectal suppository (Compro) 2 25 mg promethazine oral tablet 12.5 mg, 2 25 mg, 50 mg promethazine rectal suppository (Promethegan) 2 12.5 mg, 25 mg, 50 mg promethegan rectal suppository 12.5 2 mg, 25 mg, 50 mg SANCUSO TRANSDERMAL 6 PA; QL (4 per 28 days) PATCH WEEKLY 3.1 MG/24 HOUR scopolamine base transdermal patch (Transderm-Scop) 3 3 day 1 mg over 3 days SYNDROS ORAL SOLUTION 5 6 QL (60 per 30 days) MG/ML trimethobenzamide oral capsule 300 3 mg VARUBI ORAL TABLET 90 MG 5 PA; QL (4 per 28 days) Antiparasite Agents Antiparasite Agents albendazole oral tablet 200 mg (Albenza) 6

54 Drug Name Drug Tier Requirements/Limits ALINIA ORAL SUSPENSION 6 FOR RECONSTITUTION 100 MG/5 ML ALINIA ORAL TABLET 500 6 MG atovaquone oral suspension 750 (Mepron) 6 mg/5 ml atovaquone-proguanil oral tablet (Malarone) 3 250-100 mg atovaquone-proguanil oral tablet (Malarone Pediatric) 3 62.5-25 mg benznidazole oral tablet 100 mg, 2 12.5 mg chloroquine phosphate oral tablet 2 QL (36 per 16 days) 250 mg chloroquine phosphate oral tablet 2 QL (18 per 16 days) 500 mg COARTEM ORAL TABLET 20- 5 120 MG DARAPRIM ORAL TABLET 25 6 PA; QL (30 per 30 MG days) EGATEN ORAL TABLET 250 5 MG EMVERM ORAL 6 PA TABLET,CHEWABLE 100 MG hydroxychloroquine oral tablet 200 (Plaquenil) 3 QL (90 per 30 days) mg IMPAVIDO ORAL CAPSULE 50 6 PA MG ivermectin oral tablet 3 mg (Stromectol) 3 KRINTAFEL ORAL TABLET 5 150 MG oral tablet 250 mg 3 paromomycin oral capsule 250 mg (Humatin) 3 praziquantel oral tablet 600 mg (Biltricide) 3 PRIMAQUINE ORAL TABLET 5 26.3 MG pyrimethamine oral tablet 25 mg (Daraprim) 6 PA; QL (30 per 30 days) quinine sulfate oral capsule 324 mg (Qualaquin) 3 tinidazole oral tablet 250 mg, 500 3 mg

55 Drug Name Drug Tier Requirements/Limits Antiparkinsonian Agents Antiparkinsonian Agents hcl oral capsule 100 mg 2 amantadine hcl oral solution 50 2 mg/5 ml amantadine hcl oral tablet 100 mg 2 APOKYN SUBCUTANEOUS 6 PA; QL (60 per 30 CARTRIDGE 10 MG/ML days) benztropine oral tablet 0.5 mg, 1 2 mg, 2 mg oral capsule 5 mg (Parlodel) 2 bromocriptine oral tablet 2.5 mg (Parlodel) 2 oral tablet 0.5 mg 2 carbidopa oral tablet 25 mg (Lodosyn) 3 carbidopa-levodopa oral tablet 10- (Sinemet) 2 100 mg, 25-100 mg carbidopa-levodopa oral tablet 25- 2 250 mg carbidopa-levodopa oral tablet 2 extended release 25-100 mg, 50-200 mg carbidopa-levodopa oral 2 tablet,disintegrating 10-100 mg, 25- 100 mg, 25-250 mg carbidopa-levodopa-entacapone oral (Stalevo 50) 2 tablet 12.5-50-200 mg carbidopa-levodopa-entacapone oral (Stalevo 75) 2 tablet 18.75-75-200 mg carbidopa-levodopa-entacapone oral (Stalevo 100) 2 tablet 25-100-200 mg carbidopa-levodopa-entacapone oral (Stalevo 125) 2 tablet 31.25-125-200 mg carbidopa-levodopa-entacapone oral (Stalevo 150) 2 tablet 37.5-150-200 mg carbidopa-levodopa-entacapone oral (Stalevo 200) 2 tablet 50-200-200 mg entacapone oral tablet 200 mg (Comtan) 2 INBRIJA INHALATION 6 PA; QL (300 per 30 CAPSULE 42 MG days)

56 Drug Name Drug Tier Requirements/Limits NEUPRO TRANSDERMAL 5 ST; QL (30 per 30 days) PATCH 24 HOUR 1 MG/24 HOUR, 2 MG/24 HOUR, 3 MG/24 HOUR, 4 MG/24 HOUR, 6 MG/24 HOUR, 8 MG/24 HOUR NOURIANZ ORAL TABLET 20 6 PA; QL (30 per 30 MG, 40 MG days) ONGENTYS ORAL CAPSULE 5 PA 25 MG, 50 MG pramipexole oral tablet 0.125 mg, (Mirapex) 2 QL (30 per 30 days) 0.25 mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 mg pramipexole oral tablet extended (Mirapex ER) 3 QL (30 per 30 days) release 24 hr 0.375 mg, 0.75 mg, 1.5 mg, 2.25 mg, 3 mg, 3.75 mg, 4.5 mg rasagiline oral tablet 0.5 mg, 1 mg (Azilect) 2 QL (30 per 30 days) ropinirole oral tablet 0.25 mg, 0.5 2 mg, 1 mg, 2 mg, 3 mg, 4 mg, 5 mg ropinirole oral tablet extended 3 QL (30 per 30 days) release 24 hr 12 mg, 2 mg, 4 mg, 6 mg, 8 mg selegiline hcl oral capsule 5 mg 2 selegiline hcl oral tablet 5 mg 2 tolcapone oral tablet 100 mg (Tasmar) 3 QL (90 per 30 days) trihexyphenidyl oral elixir 0.4 2 mg/ml trihexyphenidyl oral tablet 2 mg, 5 2 mg XADAGO ORAL TABLET 100 6 ST; QL (30 per 30 days) MG, 50 MG ZELAPAR ORAL 6 QL (60 per 30 days) TABLET,DISINTEGRATING 1.25 MG Antipsychotic Agents Antipsychotic Agents ABILIFY MYCITE ORAL 5 PA; QL (30 per 30 TABLET WITH SENSOR AND days) PATCH 10 MG, 15 MG, 2 MG, 20 MG, 30 MG, 5 MG ADASUVE INHALATION 6 AEROSOL POWDR BREATH ACTIVATED 10 MG

57 Drug Name Drug Tier Requirements/Limits oral solution 1 mg/ml 3 QL (900 per 30 days) aripiprazole oral tablet 10 mg, 15 (Abilify) 3 QL (30 per 30 days) mg, 2 mg, 20 mg, 30 mg, 5 mg aripiprazole oral 3 QL (90 per 30 days) tablet,disintegrating 10 mg aripiprazole oral 3 QL (60 per 30 days) tablet,disintegrating 15 mg CAPLYTA ORAL CAPSULE 42 5 ST MG oral tablet 10 mg, 2 100 mg, 200 mg, 25 mg, 50 mg oral tablet 100 mg, 200 (Clozaril) 2 mg, 25 mg, 50 mg clozapine oral tablet,disintegrating 3 ST 100 mg, 12.5 mg, 150 mg, 200 mg, 25 mg FANAPT ORAL TABLET 1 MG, 5 ST; QL (60 per 30 days) 2 MG, 4 MG FANAPT ORAL TABLET 10 6 ST; QL (60 per 30 days) MG, 12 MG, 6 MG, 8 MG FANAPT ORAL 5 ST; QL (8 per 28 days) TABLETS,DOSE PACK 1MG(2)- 2MG(2)- 4MG(2)-6MG(2) hcl oral concentrate 5 2 mg/ml fluphenazine hcl oral elixir 2.5 mg/5 2 ml fluphenazine hcl oral tablet 1 mg, 10 2 mg, 2.5 mg, 5 mg lactate oral concentrate 2 2 mg/ml haloperidol oral tablet 0.5 mg, 1 mg 1 haloperidol oral tablet 10 mg, 2 mg, 2 20 mg, 5 mg LATUDA ORAL TABLET 120 5 PA NSO; QL (30 per 30 MG, 20 MG, 40 MG, 60 MG days) LATUDA ORAL TABLET 80 5 PA NSO; QL (60 per 30 MG days) succinate oral capsule 10 2 mg, 25 mg, 5 mg, 50 mg molindone oral tablet 10 mg 3 QL (240 per 30 days) molindone oral tablet 25 mg 3 QL (270 per 30 days)

58 Drug Name Drug Tier Requirements/Limits molindone oral tablet 5 mg 3 QL (120 per 30 days) NUPLAZID ORAL CAPSULE 34 6 PA; QL (30 per 30 MG days) NUPLAZID ORAL TABLET 10 6 PA; QL (30 per 30 MG days) NUPLAZID ORAL TABLET 17 6 PA; QL (60 per 30 MG days) olanzapine oral tablet 10 mg, 15 mg, (Zyprexa) 2 QL (30 per 30 days) 2.5 mg, 20 mg, 5 mg, 7.5 mg olanzapine oral tablet,disintegrating (Zyprexa Zydis) 2 QL (30 per 30 days) 10 mg, 15 mg, 20 mg, 5 mg oral tablet extended (Invega) 3 ST; QL (30 per 30 days) release 24hr 1.5 mg, 3 mg, 9 mg paliperidone oral tablet extended (Invega) 3 ST; QL (60 per 30 days) release 24hr 6 mg perphenazine oral tablet 16 mg, 2 2 mg, 4 mg, 8 mg oral tablet 1 mg, 2 mg 2 oral tablet 100 mg, 200 (Seroquel) 2 QL (90 per 30 days) mg, 25 mg, 300 mg, 400 mg, 50 mg quetiapine oral tablet extended (Seroquel XR) 3 QL (30 per 30 days) release 24 hr 150 mg, 200 mg, 300 mg, 400 mg, 50 mg REXULTI ORAL TABLET 0.25 6 PA NSO; QL (30 per 30 MG, 0.5 MG, 1 MG, 2 MG, 3 days) MG, 4 MG oral solution 1 mg/ml (Risperdal) 2 risperidone oral tablet 0.25 mg 2 QL (60 per 30 days) risperidone oral tablet 0.5 mg, 1 mg, (Risperdal) 2 QL (60 per 30 days) 2 mg, 3 mg, 4 mg risperidone oral tablet,disintegrating 2 QL (60 per 30 days) 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg SAPHRIS SUBLINGUAL 6 ST; QL (60 per 30 days) TABLET 10 MG, 2.5 MG, 5 MG SECUADO TRANSDERMAL 6 PA; QL (30 per 30 PATCH 24 HOUR 3.8 MG/24 days) HOUR, 5.7 MG/24 HOUR, 7.6 MG/24 HOUR oral tablet 10 mg, 100 2 mg, 25 mg, 50 mg

59 Drug Name Drug Tier Requirements/Limits thiothixene oral capsule 1 mg, 10 2 mg, 2 mg, 5 mg oral tablet 1 mg, 10 2 mg, 2 mg, 5 mg VRAYLAR ORAL CAPSULE 1.5 6 ST; QL (30 per 30 days) MG, 3 MG, 4.5 MG, 6 MG VRAYLAR ORAL 6 ST; QL (7 per 30 days) CAPSULE,DOSE PACK 1.5 MG (1)- 3 MG (6) hcl oral capsule 20 mg, (Geodon) 2 QL (60 per 30 days) 40 mg, 60 mg, 80 mg Antivirals (Systemic) Antiretrovirals abacavir oral solution 20 mg/ml (Ziagen) 6 QL (960 per 30 days) abacavir oral tablet 300 mg (Ziagen) 3 QL (60 per 30 days) abacavir-lamivudine oral tablet 600- (Epzicom) 6 QL (30 per 30 days) 300 mg abacavir-lamivudine-zidovudine oral (Trizivir) 6 QL (60 per 30 days) tablet 300-150-300 mg APTIVUS (WITH VITAMIN E) 6 QL (380 per 30 days) ORAL SOLUTION 100 MG/ML APTIVUS ORAL CAPSULE 250 6 QL (120 per 30 days) MG atazanavir oral capsule 150 mg, 200 (Reyataz) 6 QL (60 per 30 days) mg atazanavir oral capsule 300 mg (Reyataz) 6 QL (30 per 30 days) ATRIPLA ORAL TABLET 600- 6 QL (30 per 30 days) 200-300 MG BIKTARVY ORAL TABLET 50- 6 QL (30 per 30 days) 200-25 MG CIMDUO ORAL TABLET 300- 6 QL (30 per 30 days) 300 MG COMPLERA ORAL TABLET 6 QL (30 per 30 days) 200-25-300 MG CRIXIVAN ORAL CAPSULE 4 200 MG, 400 MG DELSTRIGO ORAL TABLET 6 QL (30 per 30 days) 100-300-300 MG DESCOVY ORAL TABLET 200- 6 QL (30 per 30 days) 25 MG didanosine oral capsule,delayed 2 QL (60 per 30 days) release(dr/ec) 125 mg, 200 mg

60 Drug Name Drug Tier Requirements/Limits didanosine oral capsule,delayed 2 QL (30 per 30 days) release(dr/ec) 250 mg, 400 mg DOVATO ORAL TABLET 50- 6 QL (30 per 30 days) 300 MG EDURANT ORAL TABLET 25 6 QL (30 per 30 days) MG efavirenz oral capsule 200 mg, 50 (Sustiva) 6 mg efavirenz oral tablet 600 mg (Sustiva) 6 efavirenz-emtricitabin-tenofov oral (Atripla) 6 QL (30 per 30 days) tablet 600-200-300 mg efavirenz-lamivu-tenofov disop oral (Symfi Lo) 6 QL (30 per 30 days) tablet 400-300-300 mg efavirenz-lamivu-tenofov disop oral (Symfi) 6 QL (30 per 30 days) tablet 600-300-300 mg emtricitabine oral capsule 200 mg (Emtriva) 2 QL (30 per 30 days) emtricitabine-tenofovir (tdf) oral (Truvada) 6 QL (30 per 30 days) tablet 100-150 mg, 133-200 mg, 167-250 mg, 200-300 mg EMTRIVA ORAL CAPSULE 200 4 QL (30 per 30 days) MG EMTRIVA ORAL SOLUTION 10 4 QL (850 per 30 days) MG/ML EPIVIR HBV ORAL SOLUTION 4 QL (720 per 30 days) 25 MG/5 ML (5 MG/ML) etravirine oral tablet 100 mg (Intelence) 6 QL (120 per 30 days) etravirine oral tablet 200 mg (Intelence) 6 QL (60 per 30 days) EVOTAZ ORAL TABLET 300- 6 QL (30 per 30 days) 150 MG fosamprenavir oral tablet 700 mg (Lexiva) 6 QL (120 per 30 days) FUZEON SUBCUTANEOUS 6 QL (60 per 30 days) RECON SOLN 90 MG GENVOYA ORAL TABLET 150- 6 QL (30 per 30 days) 150-200-10 MG INTELENCE ORAL TABLET 6 QL (120 per 30 days) 100 MG, 25 MG INTELENCE ORAL TABLET 6 QL (60 per 30 days) 200 MG INVIRASE ORAL CAPSULE 200 6 QL (300 per 30 days) MG INVIRASE ORAL TABLET 500 6 QL (120 per 30 days) MG

61 Drug Name Drug Tier Requirements/Limits ISENTRESS HD ORAL TABLET 6 QL (60 per 30 days) 600 MG ISENTRESS ORAL POWDER 6 QL (60 per 30 days) IN PACKET 100 MG ISENTRESS ORAL TABLET 400 6 QL (60 per 30 days) MG ISENTRESS ORAL 6 QL (180 per 30 days) TABLET,CHEWABLE 100 MG, 25 MG JULUCA ORAL TABLET 50-25 6 QL (30 per 30 days) MG KALETRA ORAL TABLET 100- 6 QL (60 per 30 days) 25 MG KALETRA ORAL TABLET 200- 6 QL (120 per 30 days) 50 MG lamivudine oral solution 10 mg/ml (Epivir) 3 QL (960 per 30 days) lamivudine oral tablet 100 mg (Epivir HBV) 3 QL (30 per 30 days) lamivudine oral tablet 150 mg (Epivir) 3 QL (60 per 30 days) lamivudine oral tablet 300 mg (Epivir) 3 QL (30 per 30 days) lamivudine-zidovudine oral tablet (Combivir) 3 QL (60 per 30 days) 150-300 mg LEXIVA ORAL SUSPENSION 6 QL (1800 per 30 days) 50 MG/ML lopinavir-ritonavir oral solution 400- (Kaletra) 6 QL (480 per 30 days) 100 mg/5 ml lopinavir-ritonavir oral tablet 100-25 (Kaletra) 6 QL (60 per 30 days) mg lopinavir-ritonavir oral tablet 200-50 (Kaletra) 6 QL (120 per 30 days) mg nevirapine oral suspension 50 mg/5 (Viramune) 2 QL (1200 per 30 days) ml nevirapine oral tablet 200 mg 2 QL (60 per 30 days) nevirapine oral tablet extended 3 QL (90 per 30 days) release 24 hr 100 mg nevirapine oral tablet extended (Viramune XR) 3 QL (30 per 30 days) release 24 hr 400 mg NORVIR ORAL POWDER IN 4 QL (360 per 30 days) PACKET 100 MG NORVIR ORAL SOLUTION 80 4 QL (480 per 30 days) MG/ML ODEFSEY ORAL TABLET 200- 6 QL (30 per 30 days) 25-25 MG

62 Drug Name Drug Tier Requirements/Limits PIFELTRO ORAL TABLET 100 6 QL (60 per 30 days) MG PREZCOBIX ORAL TABLET 6 QL (30 per 30 days) 800-150 MG-MG PREZISTA ORAL SUSPENSION 6 QL (400 per 30 days) 100 MG/ML PREZISTA ORAL TABLET 150 6 QL (240 per 30 days) MG PREZISTA ORAL TABLET 600 6 QL (60 per 30 days) MG PREZISTA ORAL TABLET 75 6 QL (480 per 30 days) MG PREZISTA ORAL TABLET 800 6 QL (30 per 30 days) MG RESCRIPTOR ORAL TABLET 4 200 MG RESCRIPTOR ORAL TABLET, 4 DISPERSIBLE 100 MG REYATAZ ORAL POWDER IN 6 QL (150 per 30 days) PACKET 50 MG ritonavir oral tablet 100 mg (Norvir) 2 QL (360 per 30 days) RUKOBIA ORAL TABLET 6 PA EXTENDED RELEASE 12 HR 600 MG SELZENTRY ORAL 6 QL (920 per 30 days) SOLUTION 20 MG/ML SELZENTRY ORAL TABLET 6 QL (60 per 30 days) 150 MG, 75 MG SELZENTRY ORAL TABLET 25 6 QL (120 per 30 days) MG, 300 MG stavudine oral capsule 15 mg, 20 mg, 2 QL (60 per 30 days) 30 mg, 40 mg STRIBILD ORAL TABLET 150- 6 QL (30 per 30 days) 150-200-300 MG SUSTIVA ORAL CAPSULE 200 6 MG SYMFI LO ORAL TABLET 400- 6 QL (30 per 30 days) 300-300 MG SYMFI ORAL TABLET 600-300- 6 QL (30 per 30 days) 300 MG SYMTUZA ORAL TABLET 800- 6 QL (30 per 30 days) 150-200-10 MG

63 Drug Name Drug Tier Requirements/Limits TEMIXYS ORAL TABLET 300- 6 QL (30 per 30 days) 300 MG tenofovir disoproxil fumarate oral (Viread) 6 QL (30 per 30 days) tablet 300 mg TIVICAY ORAL TABLET 10 6 QL (60 per 30 days) MG, 25 MG, 50 MG TIVICAY PD ORAL TABLET 6 QL (180 per 30 days) FOR SUSPENSION 5 MG TRIUMEQ ORAL TABLET 600- 6 QL (30 per 30 days) 50-300 MG TRUVADA ORAL TABLET 100- 6 QL (30 per 30 days) 150 MG, 133-200 MG, 167-250 MG, 200-300 MG VEMLIDY ORAL TABLET 25 6 QL (30 per 30 days) MG VIDEX 2 GRAM PEDIATRIC 4 QL (600 per 30 days) ORAL RECON SOLN 10 MG/ML (FINAL) VIRACEPT ORAL TABLET 250 6 MG, 625 MG VIREAD ORAL POWDER 40 6 QL (240 per 30 days) MG/SCOOP (40 MG/GRAM) VIREAD ORAL TABLET 150 6 QL (30 per 30 days) MG, 200 MG, 250 MG zidovudine oral capsule 100 mg (Retrovir) 2 QL (180 per 30 days) zidovudine oral syrup 10 mg/ml (Retrovir) 2 QL (1920 per 30 days) zidovudine oral tablet 300 mg 2 QL (60 per 30 days) Antivirals, Miscellaneous oseltamivir oral capsule 30 mg (Tamiflu) 3 QL (20 per 180 days) oseltamivir oral capsule 45 mg, 75 (Tamiflu) 3 QL (10 per 180 days) mg oseltamivir oral suspension for (Tamiflu) 3 QL (180 per 180 days) reconstitution 6 mg/ml PREVYMIS ORAL TABLET 240 6 PA; QL (28 per 28 MG, 480 MG days) RELENZA DISKHALER 5 QL (20 per 180 days) INHALATION BLISTER WITH DEVICE 5 MG/ACTUATION oral tablet 100 mg (Flumadine) 2 XOFLUZA ORAL TABLET 20 5 QL (2 per 180 days) MG, 40 MG, 80 MG

64 Drug Name Drug Tier Requirements/Limits Hcv Antivirals DAKLINZA ORAL TABLET 30 6 PA; QL (28 per 28 MG, 60 MG, 90 MG days) EPCLUSA ORAL TABLET 200- 6 PA; QL (30 per 30 50 MG, 400-100 MG days) HARVONI ORAL PELLETS IN 6 PA; QL (30 per 30 PACKET 33.75-150 MG, 45-200 days) MG HARVONI ORAL TABLET 45- 6 PA; QL (30 per 30 200 MG, 90-400 MG days) MAVYRET ORAL TABLET 100- 6 PA; QL (84 per 28 40 MG days) OLYSIO ORAL CAPSULE 150 6 PA; QL (28 per 28 MG days) SOVALDI ORAL PELLETS IN 6 PA; QL (28 per 28 PACKET 150 MG, 200 MG days) SOVALDI ORAL TABLET 200 6 PA; QL (28 per 28 MG, 400 MG days) TECHNIVIE ORAL TABLET 6 PA; QL (56 per 28 12.5-75-50 MG days) VOSEVI ORAL TABLET 400- 6 PA; QL (30 per 30 100-100 MG days) Interferons INTRON A INJECTION 6 PA RECON SOLN 10 MILLION UNIT (1 ML), 18 MILLION UNIT (1 ML), 50 MILLION UNIT (1 ML) INTRON A INJECTION 6 PA SOLUTION 10 MILLION UNIT/ML, 6 MILLION UNIT/ML PEGASYS PROCLICK 6 PA; QL (2 per 28 days) SUBCUTANEOUS PEN INJECTOR 135 MCG/0.5 ML, 180 MCG/0.5 ML PEGASYS SUBCUTANEOUS 6 PA; QL (4 per 28 days) SOLUTION 180 MCG/ML PEGASYS SUBCUTANEOUS 6 PA; QL (2 per 28 days) SYRINGE 180 MCG/0.5 ML

65 Drug Name Drug Tier Requirements/Limits PEGINTRON 6 PA SUBCUTANEOUS KIT 50 MCG/0.5 ML Nucleosides And Nucleotides acyclovir oral capsule 200 mg 2 acyclovir oral suspension 200 mg/5 (Zovirax) 2 ml acyclovir oral tablet 400 mg, 800 mg 2 adefovir oral tablet 10 mg (Hepsera) 6 QL (30 per 30 days) BARACLUDE ORAL 6 QL (630 per 30 days) SOLUTION 0.05 MG/ML entecavir oral tablet 0.5 mg, 1 mg (Baraclude) 6 QL (30 per 30 days) famciclovir oral tablet 125 mg, 250 3 mg, 500 mg REBETOL ORAL SOLUTION 40 5 MG/ML ribasphere oral capsule 200 mg 3 ribasphere oral tablet 200 mg, 400 3 mg, 600 mg ribasphere ribapak oral tablets,dose 3 pack 200 mg (7)- 400 mg (7), 400 mg (7)- 400 mg (7), 600 mg (7)- 400 mg (7), 600 mg (7)- 600 mg (7) ribavirin oral capsule 200 mg 2 ribavirin oral tablet 200 mg 3 valacyclovir oral tablet 1 gram, 500 (Valtrex) 2 mg valganciclovir oral recon soln 50 (Valcyte) 2 mg/ml valganciclovir oral tablet 450 mg (Valcyte) 2 Blood Products/Modifiers/Volume Expanders Anticoagulants BEVYXXA ORAL CAPSULE 40 5 QL (43 per 42 days) MG, 80 MG ELIQUIS DVT-PE TREAT 30D 4 QL (74 per 30 days) START ORAL TABLETS,DOSE PACK 5 MG (74 TABS)

66 Drug Name Drug Tier Requirements/Limits ELIQUIS ORAL TABLET 2.5 4 QL (60 per 30 days) MG, 5 MG enoxaparin subcutaneous solution (Lovenox) 3 300 mg/3 ml enoxaparin subcutaneous syringe (Lovenox) 6 100 mg/ml, 120 mg/0.8 ml, 150 mg/ml, 80 mg/0.8 ml enoxaparin subcutaneous syringe 30 (Lovenox) 3 mg/0.3 ml, 40 mg/0.4 ml, 60 mg/0.6 ml fondaparinux subcutaneous syringe (Arixtra) 6 10 mg/0.8 ml, 2.5 mg/0.5 ml, 5 mg/0.4 ml, 7.5 mg/0.6 ml FRAGMIN SUBCUTANEOUS 6 SOLUTION 25,000 ANTI-XA UNIT/ML FRAGMIN SUBCUTANEOUS 6 SYRINGE 10,000 ANTI-XA UNIT/ML, 12,500 ANTI-XA UNIT/0.5 ML, 15,000 ANTI-XA UNIT/0.6 ML, 18,000 ANTI-XA UNIT/0.72 ML, 2,500 ANTI-XA UNIT/0.2 ML, 5,000 ANTI-XA UNIT/0.2 ML, 7,500 ANTI-XA UNIT/0.3 ML heparin, porcine (pf) injection 2 solution 5,000 unit/0.5 ml heparin, porcine (pf) injection 2 syringe 5,000 unit/0.5 ml heparin, porcine (pf) subcutaneous 2 syringe 5,000 unit/0.5 ml jantoven oral tablet 1 mg, 10 mg, 2 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg warfarin oral tablet 1 mg, 10 mg, 2 (Jantoven) 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg XARELTO DVT-PE TREAT 30D 4 QL (51 per 30 days) START ORAL TABLETS,DOSE PACK 15 MG (42)- 20 MG (9) XARELTO ORAL TABLET 10 4 QL (30 per 30 days) MG, 20 MG

67 Drug Name Drug Tier Requirements/Limits XARELTO ORAL TABLET 15 4 QL (60 per 30 days) MG, 2.5 MG Blood Formation Modifiers ARANESP (IN POLYSORBATE) 6 PA; QL (4 per 28 days) INJECTION SOLUTION 100 MCG/ML, 150 MCG/0.75 ML, 200 MCG/ML, 25 MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 MCG/ML ARANESP (IN POLYSORBATE) 6 PA; QL (1.6 per 28 INJECTION SYRINGE 10 days) MCG/0.4 ML, 200 MCG/0.4 ML, 40 MCG/0.4 ML ARANESP (IN POLYSORBATE) 6 PA; QL (2 per 28 days) INJECTION SYRINGE 100 MCG/0.5 ML ARANESP (IN POLYSORBATE) 6 PA; QL (1.2 per 28 INJECTION SYRINGE 150 days) MCG/0.3 ML, 60 MCG/0.3 ML ARANESP (IN POLYSORBATE) 6 PA; QL (1.68 per 28 INJECTION SYRINGE 25 days) MCG/0.42 ML ARANESP (IN POLYSORBATE) 6 PA; QL (2.4 per 28 INJECTION SYRINGE 300 days) MCG/0.6 ML ARANESP (IN POLYSORBATE) 6 PA; QL (4 per 28 days) INJECTION SYRINGE 500 MCG/ML DOPTELET (10 TAB PACK) 6 PA; QL (15 per 1 day) ORAL TABLET 20 MG DOPTELET (15 TAB PACK) 6 PA; QL (15 per 1 day) ORAL TABLET 20 MG DOPTELET (30 TAB PACK) 6 PA; QL (15 per 1 day) ORAL TABLET 20 MG EPOGEN INJECTION 6 PA; QL (12 per 28 SOLUTION 10,000 UNIT/ML, days) 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML FULPHILA SUBCUTANEOUS 6 PA SYRINGE 6 MG/0.6 ML LEUKINE INJECTION RECON 6 PA SOLN 250 MCG

68 Drug Name Drug Tier Requirements/Limits MIRCERA INJECTION 5 PA; QL (0.6 per 28 SYRINGE 100 MCG/0.3 ML, 150 days) MCG/0.3 ML, 200 MCG/0.3 ML, 30 MCG/0.3 ML, 50 MCG/0.3 ML, 75 MCG/0.3 ML MULPLETA ORAL TABLET 3 6 PA; QL (7 per 1 day) MG NEULASTA SUBCUTANEOUS 6 PA SYRINGE 6 MG/0.6 ML NEUPOGEN INJECTION 6 PA SOLUTION 300 MCG/ML, 480 MCG/1.6 ML NEUPOGEN INJECTION 6 PA SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML NIVESTYM INJECTION 6 PA SOLUTION 300 MCG/ML, 480 MCG/1.6 ML NIVESTYM SUBCUTANEOUS 6 PA SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML NYVEPRIA SUBCUTANEOUS 6 PA SYRINGE 6 MG/0.6 ML PROCRIT INJECTION 6 PA; QL (12 per 28 SOLUTION 10,000 UNIT/ML, days) 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML PROCRIT INJECTION 6 PA; QL (6 per 28 days) SOLUTION 40,000 UNIT/ML PROMACTA ORAL POWDER 6 PA; QL (180 per 30 IN PACKET 12.5 MG days) PROMACTA ORAL POWDER 6 PA; QL (30 per 30 IN PACKET 25 MG days) PROMACTA ORAL TABLET 6 PA; QL (30 per 30 12.5 MG, 25 MG, 50 MG, 75 MG days) RETACRIT INJECTION 6 PA SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML, 40,000 UNIT/ML

69 Drug Name Drug Tier Requirements/Limits UDENYCA SUBCUTANEOUS 6 PA SYRINGE 6 MG/0.6 ML ZARXIO INJECTION SYRINGE 6 PA 300 MCG/0.5 ML, 480 MCG/0.8 ML ZIEXTENZO SUBCUTANEOUS 6 PA SYRINGE 6 MG/0.6 ML Hematologic Agents, Miscellaneous aminocaproic acid oral solution 250 (Amicar) 3 mg/ml (25 %) aminocaproic acid oral tablet 1,000 (Amicar) 2 mg, 500 mg anagrelide oral capsule 0.5 mg (Agrylin) 3 anagrelide oral capsule 1 mg 3 OXBRYTA ORAL TABLET 500 6 PA MG SIKLOS ORAL TABLET 1,000 5 MG SIKLOS ORAL TABLET 100 MG 5 QL (60 per 30 days) TAVALISSE ORAL TABLET 100 6 PA; QL (60 per 30 MG, 150 MG days) tranexamic acid oral tablet 650 mg (Lysteda) 3 QL (30 per 30 days) Platelet-Aggregation Inhibitors aspirin-dipyridamole oral capsule, er 3 multiphase 12 hr 25-200 mg BRILINTA ORAL TABLET 60 5 QL (60 per 30 days) MG, 90 MG cilostazol oral tablet 100 mg, 50 mg 2 clopidogrel oral tablet 300 mg 2 clopidogrel oral tablet 75 mg (Plavix) 2 dipyridamole oral tablet 25 mg, 50 2 mg, 75 mg oral tablet extended 2 release 400 mg prasugrel oral tablet 10 mg, 5 mg (Effient) 3 QL (30 per 30 days) ticlopidine oral tablet 250 mg 2 ZONTIVITY ORAL TABLET 5 QL (30 per 30 days) 2.08 MG Caloric Agents Caloric Agents glucose oral tablet,chewable 4 gram (Dex4 Glucose) 4

70 Drug Name Drug Tier Requirements/Limits Cardiovascular Agents Alpha- Agents CARDURA XL ORAL TABLET 5 EXTENDED RELEASE 24HR 4 MG, 8 MG hcl oral tablet 0.1 mg, 0.2 2 mg, 0.3 mg clonidine transdermal patch weekly (Catapres-TTS-1) 2 0.1 mg/24 hr clonidine transdermal patch weekly (Catapres-TTS-2) 2 0.2 mg/24 hr clonidine transdermal patch weekly (Catapres-TTS-3) 2 0.3 mg/24 hr oral tablet 1 mg, 2 mg, 4 (Cardura) 2 mg, 8 mg oral tablet 1 mg, 2 mg 2 oral tablet 250 mg, 500 2 mg methyldopa- 2 oral tablet 250-15 mg, 250-25 mg oral tablet 10 mg, 2.5 mg, 2 5 mg oral capsule 10 (Dibenzyline) 6 PA mg oral capsule 1 mg, 2 mg, 5 (Minipress) 2 mg Angiotensin Ii Receptor Antagonists candesartan oral tablet 16 mg, 32 (Atacand) 3 ST mg, 4 mg, 8 mg candesartan-hydrochlorothiazid oral (Atacand HCT) 3 ST tablet 16-12.5 mg, 32-12.5 mg, 32- 25 mg EDARBI ORAL TABLET 40 5 ST MG, 80 MG EDARBYCLOR ORAL TABLET 5 ST 40-12.5 MG, 40-25 MG ENTRESTO ORAL TABLET 24- 4 QL (60 per 30 days) 26 MG, 49-51 MG, 97-103 MG eprosartan oral tablet 600 mg 3 ST irbesartan oral tablet 150 mg, 300 (Avapro) 2 mg, 75 mg

71 Drug Name Drug Tier Requirements/Limits irbesartan-hydrochlorothiazide oral (Avalide) 2 tablet 150-12.5 mg, 300-12.5 mg losartan oral tablet 100 mg, 25 mg, (Cozaar) 2 50 mg losartan-hydrochlorothiazide oral (Hyzaar) 2 tablet 100-12.5 mg, 100-25 mg, 50- 12.5 mg olmesartan oral tablet 20 mg, 40 (Benicar) 3 mg, 5 mg olmesartan-amlodipin-hcthiazid oral (Tribenzor) 3 tablet 20-5-12.5 mg, 40-10-12.5 mg, 40-10-25 mg, 40-5-12.5 mg, 40-5-25 mg olmesartan-hydrochlorothiazide oral (Benicar HCT) 3 tablet 20-12.5 mg, 40-12.5 mg, 40- 25 mg telmisartan oral tablet 20 mg, 40 (Micardis) 3 ST mg, 80 mg telmisartan- oral tablet (Twynsta) 3 ST 40-10 mg, 40-5 mg, 80-10 mg, 80-5 mg telmisartan-hydrochlorothiazid oral (Micardis HCT) 3 ST tablet 40-12.5 mg, 80-12.5 mg, 80- 25 mg valsartan oral tablet 160 mg, 320 (Diovan) 2 mg, 40 mg, 80 mg valsartan-hydrochlorothiazide oral (Diovan HCT) 2 tablet 160-12.5 mg, 160-25 mg, 320- 12.5 mg, 320-25 mg, 80-12.5 mg Angiotensin-Converting Enzyme Inhibitors benazepril oral tablet 10 mg, 20 mg, (Lotensin) 1 40 mg benazepril oral tablet 5 mg 1 benazepril-hydrochlorothiazide oral (Lotensin HCT) 2 tablet 10-12.5 mg, 20-12.5 mg, 20- 25 mg benazepril-hydrochlorothiazide oral 2 tablet 5-6.25 mg captopril oral tablet 100 mg, 12.5 3 mg, 25 mg, 50 mg

72 Drug Name Drug Tier Requirements/Limits captopril-hydrochlorothiazide oral 3 tablet 25-15 mg, 25-25 mg, 50-15 mg, 50-25 mg enalapril maleate oral tablet 10 mg, (Vasotec) 2 2.5 mg, 20 mg, 5 mg enalapril-hydrochlorothiazide oral (Vaseretic) 2 tablet 10-25 mg enalapril-hydrochlorothiazide oral 2 tablet 5-12.5 mg fosinopril oral tablet 10 mg, 20 mg, 2 40 mg fosinopril-hydrochlorothiazide oral 2 tablet 10-12.5 mg, 20-12.5 mg lisinopril oral tablet 10 mg, 2.5 mg, (Zestril) 1 30 mg, 40 mg, 5 mg lisinopril oral tablet 20 mg (Prinivil) 1 lisinopril-hydrochlorothiazide oral (Zestoretic) 1 tablet 10-12.5 mg, 20-12.5 mg, 20- 25 mg moexipril oral tablet 15 mg, 7.5 mg 2 moexipril-hydrochlorothiazide oral 2 tablet 15-12.5 mg, 15-25 mg, 7.5- 12.5 mg perindopril erbumine oral tablet 2 2 mg, 4 mg, 8 mg QBRELIS ORAL SOLUTION 1 6 QL (1200 per 30 days) MG/ML quinapril oral tablet 10 mg, 20 mg, (Accupril) 2 40 mg, 5 mg quinapril-hydrochlorothiazide oral (Accuretic) 2 tablet 10-12.5 mg, 20-12.5 mg, 20- 25 mg ramipril oral capsule 1.25 mg, 10 (Altace) 2 mg, 2.5 mg, 5 mg trandolapril oral tablet 1 mg, 2 mg, 2 4 mg trandolapril- oral tablet, ir 3 - er, biphasic 24hr 1-240 mg, 2-180 mg, 4-240 mg trandolapril-verapamil oral tablet, ir (Tarka) 3 - er, biphasic 24hr 2-240 mg

73 Drug Name Drug Tier Requirements/Limits Antiarrhythmic Agents oral tablet 100 mg, 200 (Pacerone) 2 mg, 400 mg phosphate oral capsule (Norpace) 2 100 mg, 150 mg oral capsule 125 mcg, 250 (Tikosyn) 3 mcg, 500 mcg oral tablet 100 mg, 150 2 mg, 50 mg oral capsule 150 mg, 200 2 mg, 250 mg MULTAQ ORAL TABLET 400 4 MG NORPACE CR ORAL 5 CAPSULE, EXTENDED RELEASE 100 MG, 150 MG pacerone oral tablet 100 mg, 200 2 mg, 400 mg oral capsule,extended (Rythmol SR) 2 release 12 hr 225 mg, 325 mg, 425 mg propafenone oral tablet 150 mg, 225 2 mg, 300 mg gluconate oral tablet 2 extended release 324 mg quinidine sulfate oral tablet 200 mg, 2 300 mg Beta-Adrenergic Blocking Agents oral capsule 200 mg, 400 2 mg oral tablet 100 mg, 25 mg, (Tenormin) 1 50 mg atenolol-chlorthalidone oral tablet (Tenoretic 100) 2 100-25 mg atenolol-chlorthalidone oral tablet (Tenoretic 50) 2 50-25 mg oral tablet 10 mg, 20 mg 2 fumarate oral tablet 10 2 mg, 5 mg bisoprolol-hydrochlorothiazide oral (Ziac) 1 tablet 10-6.25 mg, 2.5-6.25 mg, 5- 6.25 mg

74 Drug Name Drug Tier Requirements/Limits BYSTOLIC ORAL TABLET 10 4 MG, 2.5 MG, 20 MG, 5 MG BYVALSON ORAL TABLET 5- 4 80 MG oral tablet 12.5 mg, 25 (Coreg) 1 mg, 3.125 mg, 6.25 mg carvedilol phosphate oral capsule, er (Coreg CR) 2 multiphase 24 hr 10 mg, 20 mg, 40 mg, 80 mg HEMANGEOL ORAL 5 PA; QL (360 per 30 SOLUTION 4.28 MG/ML days) oral tablet 100 mg, 200 2 mg, 300 mg LEVATOL ORAL TABLET 20 5 MG succinate oral tablet (Toprol XL) 2 extended release 24 hr 100 mg, 200 mg, 25 mg, 50 mg metoprolol ta-hydrochlorothiaz oral 2 tablet 100-25 mg, 100-50 mg metoprolol ta-hydrochlorothiaz oral (Lopressor HCT) 2 tablet 50-25 mg metoprolol tartrate oral tablet 100 (Lopressor) 1 mg, 50 mg metoprolol tartrate oral tablet 25 1 mg metoprolol tartrate oral tablet 37.5 2 mg, 75 mg oral tablet 20 mg, 40 mg, 80 (Corgard) 3 mg nadolol-bendroflumethiazide oral 3 tablet 40-5 mg, 80-5 mg oral tablet 10 mg, 5 mg 2 oral capsule,extended (Inderal LA) 3 release 24 hr 120 mg, 160 mg, 60 mg, 80 mg propranolol oral solution 20 mg/5 ml 2 (4 mg/ml), 40 mg/5 ml (8 mg/ml) propranolol oral tablet 10 mg, 20 2 mg, 40 mg, 60 mg, 80 mg propranolol-hydrochlorothiazid oral 2 tablet 40-25 mg, 80-25 mg

75 Drug Name Drug Tier Requirements/Limits sorine oral tablet 120 mg, 160 mg, 2 240 mg, 80 mg af oral tablet 120 mg, 160 2 mg, 80 mg sotalol oral tablet 120 mg, 160 mg, (Sorine) 2 240 mg, 80 mg maleate oral tablet 10 mg, 3 20 mg, 5 mg Calcium-Channel Blocking Agents CARDIZEM LA ORAL TABLET 5 EXTENDED RELEASE 24 HR 120 MG cartia xt oral capsule,extended 2 release 24hr 120 mg, 180 mg, 240 mg, 300 mg hcl oral capsule,extended 2 release 12 hr 120 mg, 60 mg, 90 mg diltiazem hcl oral capsule,extended (Taztia XT) 2 release 24 hr 360 mg diltiazem hcl oral capsule,extended (Tiadylt ER) 2 release 24 hr 420 mg diltiazem hcl oral capsule,extended (Cartia XT) 2 release 24hr 120 mg, 180 mg, 240 mg, 300 mg diltiazem hcl oral tablet 120 mg, 30 (Cardizem) 2 mg, 60 mg diltiazem hcl oral tablet 90 mg 2 diltiazem hcl oral tablet extended (Matzim LA) 3 release 24 hr 180 mg, 240 mg, 300 mg, 360 mg, 420 mg dilt-xr oral capsule,ext.rel 24h 2 degradable 120 mg, 180 mg, 240 mg matzim la oral tablet extended 2 release 24 hr 180 mg, 240 mg, 300 mg, 360 mg, 420 mg taztia xt oral capsule,extended 2 release 24 hr 120 mg, 180 mg, 240 mg, 300 mg, 360 mg tiadylt er oral capsule,extended 2 release 24 hr 120 mg, 180 mg, 240 mg, 300 mg, 420 mg

76 Drug Name Drug Tier Requirements/Limits tiadylt er oral capsule,extended 3 release 24 hr 360 mg verapamil oral capsule, 24 hr er (Verelan PM) 2 pellet ct 100 mg, 200 mg, 300 mg verapamil oral capsule,ext rel. (Verelan) 2 pellets 24 hr 120 mg, 180 mg, 240 mg, 360 mg verapamil oral tablet 120 mg, 40 2 mg, 80 mg verapamil oral tablet extended (Calan SR) 2 release 120 mg, 180 mg, 240 mg Cardiovascular Agents, Miscellaneous CORLANOR ORAL SOLUTION 4 QL (300 per 30 days) 5 MG/5 ML CORLANOR ORAL TABLET 5 4 QL (60 per 30 days) MG, 7.5 MG DEMSER ORAL CAPSULE 250 6 MG digitek oral tablet 125 mcg (0.125 2 mg), 250 mcg (0.25 mg) digox oral tablet 125 mcg (0.125 2 mg), 250 mcg (0.25 mg) DIGOXIN ORAL SOLUTION 50 3 MCG/ML (0.05 MG/ML) digoxin oral tablet 125 mcg (0.125 (Digitek) 2 mg), 250 mcg (0.25 mg) epinephrine injection auto-injector (Auvi-Q) 2 QL (4 per 1 day) 0.15 mg/0.15 ml, 0.3 mg/0.3 ml epinephrine injection auto-injector (EpiPen Jr) 2 QL (4 per 1 day) 0.15 mg/0.3 ml hydralazine oral tablet 10 mg, 100 2 mg, 25 mg, 50 mg icatibant subcutaneous syringe 30 (Firazyr) 6 PA mg/3 ml isoxsuprine oral tablet 10 mg, 20 mg 2 LANOXIN ORAL TABLET 187.5 5 MCG (0.1875 MG), 62.5 MCG (0.0625 MG) metyrosine oral capsule 250 mg (Demser) 6 oral tablet extended (Ranexa) 3 QL (60 per 30 days) release 12 hr 1,000 mg

77 Drug Name Drug Tier Requirements/Limits ranolazine oral tablet extended (Ranexa) 3 QL (120 per 30 days) release 12 hr 500 mg VYNDAQEL ORAL CAPSULE 6 PA; QL (120 per 30 20 MG days) Dihydropyridines afeditab cr oral tablet extended 2 release 30 mg amlodipine oral tablet 10 mg, 2.5 (Norvasc) 2 mg, 5 mg amlodipine-benazepril oral capsule (Lotrel) 2 10-20 mg, 10-40 mg, 5-10 mg, 5-20 mg amlodipine-benazepril oral capsule 2 2.5-10 mg, 5-40 mg amlodipine-olmesartan oral tablet (Azor) 3 10-20 mg, 10-40 mg, 5-20 mg, 5-40 mg amlodipine-valsartan oral tablet 10- (Exforge) 3 160 mg, 10-320 mg, 5-160 mg, 5-320 mg amlodipine-valsartan-hcthiazid oral (Exforge HCT) 3 tablet 10-160-12.5 mg, 10-160-25 mg, 10-320-25 mg, 5-160-12.5 mg, 5-160-25 mg oral tablet extended 2 release 24 hr 10 mg, 2.5 mg, 5 mg oral capsule 2.5 mg, 5 mg 2 oral capsule 20 mg, 30 2 mg oral capsule 10 mg, 20 mg 2 nifedipine oral tablet extended (Procardia XL) 2 release 24hr 30 mg, 60 mg, 90 mg nifedipine oral tablet extended (Adalat CC) 2 release 30 mg, 60 mg, 90 mg oral capsule 30 mg 2 oral tablet extended (Sular) 3 release 24 hr 17 mg, 34 mg, 8.5 mg nisoldipine oral tablet extended 3 release 24 hr 20 mg, 25.5 mg, 30 mg, 40 mg NYMALIZE ORAL SOLUTION 6 PA 60 MG/20 ML

78 Drug Name Drug Tier Requirements/Limits NYMALIZE ORAL SYRINGE 6 PA 30 MG/5 ML Diuretics ALDACTAZIDE ORAL 5 TABLET 50-50 MG oral tablet 5 mg 2 amiloride-hydrochlorothiazide oral 2 tablet 5-50 mg oral tablet 0.5 mg, 1 mg, 2 2 mg chlorothiazide oral tablet 250 mg, 2 500 mg chlorthalidone oral tablet 25 mg, 50 2 mg DIURIL ORAL SUSPENSION 5 250 MG/5 ML ethacrynic acid oral tablet 25 mg (Edecrin) 3 oral solution 10 mg/ml, 2 40 mg/5 ml (8 mg/ml) furosemide oral tablet 20 mg, 40 mg, (Lasix) 1 80 mg hydrochlorothiazide oral capsule 2 12.5 mg hydrochlorothiazide oral tablet 12.5 1 mg, 25 mg, 50 mg indapamide oral tablet 1.25 mg, 2.5 1 mg JYNARQUE ORAL TABLET 15 6 PA; QL (60 per 30 MG days) JYNARQUE ORAL TABLET 30 6 PA; QL (30 per 30 MG days) JYNARQUE ORAL TABLETS, 6 PA; QL (56 per 28 SEQUENTIAL 15 MG (AM)/ 15 days) MG (PM), 30 MG (AM)/ 15 MG (PM), 45 MG (AM)/ 15 MG (PM), 60 MG (AM)/ 30 MG (PM), 90 MG (AM)/ 30 MG (PM) methyclothiazide oral tablet 5 mg 2 metolazone oral tablet 10 mg, 2.5 2 mg, 5 mg SAMSCA ORAL TABLET 15 6 PA; QL (30 per 365 MG days)

79 Drug Name Drug Tier Requirements/Limits SAMSCA ORAL TABLET 30 6 PA; QL (60 per 365 MG days) spironolactone oral tablet 100 mg, (Aldactone) 2 25 mg, 50 mg spironolacton-hydrochlorothiaz oral (Aldactazide) 2 tablet 25-25 mg tolvaptan oral tablet 15 mg (Samsca) 6 PA; QL (30 per 365 days) tolvaptan oral tablet 30 mg (Samsca) 6 PA; QL (60 per 365 days) torsemide oral tablet 10 mg, 100 mg, 2 20 mg, 5 mg oral capsule 100 mg, 50 (Dyrenium) 3 mg triamterene-hydrochlorothiazid oral 2 capsule 37.5-25 mg, 50-25 mg triamterene-hydrochlorothiazid oral (Maxzide-25mg) 2 tablet 37.5-25 mg triamterene-hydrochlorothiazid oral (Maxzide) 2 tablet 75-50 mg Dyslipidemics amlodipine-atorvastatin oral tablet (Caduet) 3 QL (30 per 30 days) 10-10 mg, 10-20 mg, 10-40 mg, 10- 80 mg, 5-10 mg, 5-20 mg, 5-40 mg, 5-80 mg amlodipine-atorvastatin oral tablet 3 QL (30 per 30 days) 2.5-10 mg, 2.5-20 mg, 2.5-40 mg atorvastatin oral tablet 10 mg, 20 (Lipitor) 1 QL (30 per 30 days) mg, 40 mg, 80 mg cholestyramine (with sugar) oral (Questran) 2 powder in packet 4 gram cholestyramine light oral powder in 2 packet 4 gram colesevelam oral powder in packet (WelChol) 3 3.75 gram colesevelam oral tablet 625 mg (WelChol) 3 colestipol oral packet 5 gram (Colestid) 2 colestipol oral tablet 1 gram (Colestid) 2 ezetimibe oral tablet 10 mg (Zetia) 2 QL (30 per 30 days) ezetimibe-simvastatin oral tablet 10- (Vytorin 10-10) 3 QL (30 per 30 days) 10 mg

80 Drug Name Drug Tier Requirements/Limits ezetimibe-simvastatin oral tablet 10- (Vytorin 10-20) 3 QL (30 per 30 days) 20 mg ezetimibe-simvastatin oral tablet 10- (Vytorin 10-40) 3 QL (30 per 30 days) 40 mg ezetimibe-simvastatin oral tablet 10- (Vytorin 10-80) 3 PA NSO; QL (30 per 30 80 mg days) fenofibrate micronized oral capsule 2 134 mg, 200 mg, 67 mg fenofibrate nanocrystallized oral (Tricor) 2 tablet 145 mg, 48 mg fenofibrate oral capsule 150 mg, 50 (Lipofen) 3 mg fenofibrate oral tablet 120 mg, 40 (Fenoglide) 3 mg fenofibrate oral tablet 160 mg, 54 2 mg fenofibric acid (choline) oral (Trilipix) 3 capsule,delayed release(dr/ec) 135 mg, 45 mg fenofibric acid oral tablet 105 mg, (Fibricor) 2 35 mg fluvastatin oral capsule 20 mg, 40 3 QL (30 per 30 days) mg gemfibrozil oral tablet 600 mg (Lopid) 2 JUXTAPID ORAL CAPSULE 10 6 PA MG, 20 MG, 30 MG, 40 MG, 5 MG, 60 MG KYNAMRO SUBCUTANEOUS 6 PA; QL (4 per 28 days) SYRINGE 200 MG/ML LIVALO ORAL TABLET 1 MG, 5 ST; QL (30 per 30 days) 2 MG, 4 MG lovastatin oral tablet 10 mg, 20 mg, 1 QL (60 per 30 days) 40 mg NEXLETOL ORAL TABLET 180 5 PA MG oral tablet 500 mg (Niacor) 3 niacin oral tablet extended release (Niaspan Extended- 3 24 hr 1,000 mg, 500 mg, 750 mg Release) niacor oral tablet 500 mg 2 omega-3 acid ethyl esters oral (Lovaza) 3 QL (120 per 30 days) capsule 1 gram

81 Drug Name Drug Tier Requirements/Limits PRALUENT PEN 4 PA; QL (2 per 28 days) SUBCUTANEOUS PEN INJECTOR 150 MG/ML, 75 MG/ML pravastatin oral tablet 10 mg, 20 1 QL (30 per 30 days) mg, 40 mg, 80 mg prevalite oral powder in packet 4 2 gram REPATHA PUSHTRONEX 4 PA; QL (3.5 per 28 SUBCUTANEOUS WEARABLE days) INJECTOR 420 MG/3.5 ML REPATHA SURECLICK 4 PA; QL (2 per 28 days) SUBCUTANEOUS PEN INJECTOR 140 MG/ML REPATHA SYRINGE 4 PA; QL (2 per 28 days) SUBCUTANEOUS SYRINGE 140 MG/ML rosuvastatin oral tablet 10 mg, 20 (Crestor) 2 QL (30 per 30 days) mg, 40 mg, 5 mg simvastatin oral tablet 10 mg, 20 (Zocor) 1 QL (30 per 30 days) mg, 40 mg simvastatin oral tablet 5 mg 1 QL (30 per 30 days) simvastatin oral tablet 80 mg (Zocor) 1 PA NSO; QL (30 per 30 days) ZYPITAMAG ORAL TABLET 1 5 ST; QL (30 per 30 days) MG, 2 MG, 4 MG Renin-Angiotensin-Aldosterone System Inhibitors aliskiren oral tablet 150 mg, 300 mg (Tekturna) 3 PA NSO; QL (30 per 30 days) eplerenone oral tablet 25 mg, 50 mg (Inspra) 2 ST TEKTURNA HCT ORAL 5 PA NSO; QL (30 per 30 TABLET 150-12.5 MG, 150-25 days) MG, 300-12.5 MG, 300-25 MG Vasodilators BIDIL ORAL TABLET 20-37.5 5 MG DILATRATE-SR ORAL 5 CAPSULE, EXTENDED RELEASE 40 MG ISORDIL ORAL TABLET 40 5 MG

82 Drug Name Drug Tier Requirements/Limits isosorbide dinitrate oral tablet 10 2 mg, 20 mg, 30 mg isosorbide dinitrate oral tablet 40 (Isordil) 3 mg isosorbide dinitrate oral tablet 5 mg (Isordil Titradose) 2 isosorbide dinitrate oral tablet 2 extended release 40 mg isosorbide mononitrate oral tablet 2 10 mg, 20 mg isosorbide mononitrate oral tablet 2 extended release 24 hr 120 mg, 30 mg, 60 mg minitran transdermal patch 24 hour 2 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr oral tablet 10 mg, 2.5 mg 2 NITRO-BID TRANSDERMAL 4 OINTMENT 2 % NITRO-DUR TRANSDERMAL 4 PATCH 24 HOUR 0.3 MG/HR, 0.8 MG/HR nitroglycerin sublingual tablet 0.3 (Nitrostat) 2 mg, 0.4 mg, 0.6 mg nitroglycerin transdermal patch 24 (Minitran) 2 hour 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr nitroglycerin translingual spray,non- (Nitrolingual) 3 aerosol 400 mcg/spray nitro-time oral capsule, extended 2 release 2.5 mg, 6.5 mg, 9 mg Central Nervous System Agents Central Nervous System Agents ADDERALL XR ORAL 3 CAPSULE,EXTENDED RELEASE 24HR 10 MG, 15 MG, 20 MG, 25 MG, 30 MG, 5 MG amphetamine sulfate oral tablet 10 (Evekeo) 3 PA; QL (120 per 30 mg, 5 mg days) oral capsule 10 mg, 18 (Strattera) 3 QL (60 per 30 days) mg, 25 mg, 40 mg atomoxetine oral capsule 100 mg, 60 (Strattera) 3 QL (30 per 30 days) mg, 80 mg

83 Drug Name Drug Tier Requirements/Limits AUBAGIO ORAL TABLET 14 6 PA; QL (30 per 30 MG, 7 MG days) AUSTEDO ORAL TABLET 12 6 PA; QL (120 per 30 MG, 9 MG days) AUSTEDO ORAL TABLET 6 6 PA; QL (60 per 30 MG days) AVONEX (WITH ALBUMIN) 6 PA; QL (1 per 30 days) INTRAMUSCULAR KIT 30 MCG AVONEX INTRAMUSCULAR 6 PA; QL (1 per 30 days) PEN INJECTOR KIT 30 MCG/0.5 ML AVONEX INTRAMUSCULAR 6 PA; QL (1 per 30 days) SYRINGE KIT 30 MCG/0.5 ML BETASERON 6 PA; QL (14 per 28 SUBCUTANEOUS KIT 0.3 MG days) caffeine citrate oral solution 60 2 mg/3 ml (20 mg/ml) clonidine hcl oral tablet extended (Kapvay) 3 QL (120 per 30 days) release 12 hr 0.1 mg CONCERTA ORAL TABLET 3 EXTENDED RELEASE 24HR 18 MG, 27 MG, 36 MG, 54 MG CONTRAVE ORAL TABLET 5 PA; QL (120 per 30 EXTENDED RELEASE 8-90 MG days) dalfampridine oral tablet extended (Ampyra) 6 PA; QL (60 per 30 release 12 hr 10 mg days) DAYTRANA TRANSDERMAL 5 QL (30 per 30 days) PATCH 24 HOUR 10 MG/9 HR, 15 MG/9 HR, 20 MG/9 HR, 30 MG/9 HR dexmethylphenidate oral capsule,er (Focalin XR) 3 QL (30 per 30 days) biphasic 50-50 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 35 mg, 40 mg, 5 mg dexmethylphenidate oral tablet 10 (Focalin) 2 QL (60 per 30 days) mg, 2.5 mg, 5 mg dextroamphetamine oral capsule, (Dexedrine Spansule) 3 QL (60 per 30 days) extended release 10 mg, 5 mg dextroamphetamine oral capsule, (Dexedrine Spansule) 3 QL (120 per 30 days) extended release 15 mg dextroamphetamine oral solution 5 (ProCentra) 3 QL (1800 per 30 days) mg/5 ml

84 Drug Name Drug Tier Requirements/Limits dextroamphetamine oral tablet 10 (Zenzedi) 2 QL (180 per 30 days) mg dextroamphetamine oral tablet 5 mg (Zenzedi) 2 QL (90 per 30 days) dextroamphetamine-amphetamine (Adderall) 2 QL (60 per 30 days) oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg dimethyl fumarate oral (Tecfidera) 6 PA; QL (60 per 30 capsule,delayed release(dr/ec) 120 days) mg, 120 mg (14)- 240 mg (46), 240 mg EVEKEO ODT ORAL 5 PA; QL (120 per 30 TABLET,DISINTEGRATING 10 days) MG, 5 MG EVEKEO ODT ORAL 5 PA; QL (60 per 30 TABLET,DISINTEGRATING 15 days) MG, 20 MG GILENYA ORAL CAPSULE 6 PA; QL (30 per 30 0.25 MG, 0.5 MG days) glatiramer subcutaneous syringe 20 (Glatopa) 6 PA; QL (30 per 30 mg/ml days) glatiramer subcutaneous syringe 40 (Glatopa) 6 PA; QL (12 per 28 mg/ml days) glatopa subcutaneous syringe 20 6 PA; QL (30 per 30 mg/ml days) glatopa subcutaneous syringe 40 6 PA; QL (12 per 28 mg/ml days) guanfacine oral tablet extended (Intuniv ER) 3 QL (30 per 30 days) release 24 hr 1 mg, 2 mg, 3 mg, 4 mg INGREZZA INITIATION PACK 6 PA; QL (28 per 28 ORAL CAPSULE,DOSE PACK days) 40 MG (7)- 80 MG (21) INGREZZA ORAL CAPSULE 40 6 PA; QL (30 per 30 MG, 60 MG, 80 MG days) KESIMPTA PEN 6 PA SUBCUTANEOUS PEN INJECTOR 20 MG/0.4 ML lithium carbonate oral capsule 150 2 mg, 300 mg, 600 mg lithium carbonate oral tablet 300 mg 2 lithium carbonate oral tablet (Lithobid) 2 extended release 300 mg

85 Drug Name Drug Tier Requirements/Limits lithium carbonate oral tablet 2 extended release 450 mg lithium citrate oral solution 8 meq/5 2 ml lomaira oral tablet 8 mg 3 PA; QL (30 per 30 days) MAVENCLAD (10 TABLET 6 PA; QL (20 per 336 PACK) ORAL TABLET 10 MG days) MAVENCLAD (4 TABLET 6 PA; QL (20 per 336 PACK) ORAL TABLET 10 MG days) MAVENCLAD (5 TABLET 6 PA; QL (20 per 336 PACK) ORAL TABLET 10 MG days) MAVENCLAD (6 TABLET 6 PA; QL (20 per 336 PACK) ORAL TABLET 10 MG days) MAVENCLAD (7 TABLET 6 PA; QL (20 per 336 PACK) ORAL TABLET 10 MG days) MAVENCLAD (8 TABLET 6 PA; QL (20 per 336 PACK) ORAL TABLET 10 MG days) MAVENCLAD (9 TABLET 6 PA; QL (20 per 336 PACK) ORAL TABLET 10 MG days) MAYZENT ORAL TABLET 0.25 6 PA; QL (120 per 30 MG days) MAYZENT ORAL TABLET 2 6 PA; QL (30 per 30 MG days) MAYZENT STARTER PACK 6 PA; QL (12 per 1 day) ORAL TABLETS,DOSE PACK 0.25 MG (12 TABS) metadate er oral tablet extended 2 PA NSO; QL (90 per 30 release 20 mg days) methamphetamine oral tablet 5 mg (Desoxyn) 2 PA; QL (150 per 30 days) methylphenidate hcl oral capsule, er 3 QL (30 per 30 days) biphasic 30-70 10 mg, 20 mg, 40 mg, 50 mg, 60 mg methylphenidate hcl oral capsule, er 3 QL (60 per 30 days) biphasic 30-70 30 mg methylphenidate hcl oral capsule,er (Ritalin LA) 3 QL (30 per 30 days) biphasic 50-50 10 mg, 20 mg, 40 mg methylphenidate hcl oral capsule,er (Ritalin LA) 3 QL (60 per 30 days) biphasic 50-50 30 mg methylphenidate hcl oral capsule,er 3 QL (30 per 30 days) biphasic 50-50 60 mg

86 Drug Name Drug Tier Requirements/Limits methylphenidate hcl oral solution 10 (Methylin) 2 mg/5 ml, 5 mg/5 ml methylphenidate hcl oral tablet 10 (Ritalin) 2 QL (90 per 30 days) mg, 20 mg, 5 mg methylphenidate hcl oral tablet 2 QL (90 per 30 days) extended release 10 mg methylphenidate hcl oral tablet (Metadate ER) 2 QL (90 per 30 days) extended release 20 mg methylphenidate hcl oral 2 QL (90 per 30 days) tablet,chewable 10 mg, 2.5 mg, 5 mg NUEDEXTA ORAL CAPSULE 5 PA; QL (60 per 30 20-10 MG days) phendimetrazine tartrate oral 3 QL (30 per 30 days) capsule, extended release 105 mg phendimetrazine tartrate oral tablet 3 QL (90 per 30 days) 35 mg phentermine oral capsule 15 mg, 30 3 PA; QL (30 per 30 mg days) phentermine oral capsule 37.5 mg (Adipex-P) 3 PA; QL (30 per 30 days) phentermine oral tablet 37.5 mg (Adipex-P) 3 PA; QL (30 per 30 days) PLEGRIDY SUBCUTANEOUS 6 PA; QL (1 per 28 days) PEN INJECTOR 125 MCG/0.5 ML, 63 MCG/0.5 ML- 94 MCG/0.5 ML PLEGRIDY SUBCUTANEOUS 6 PA; QL (1 per 28 days) SYRINGE 125 MCG/0.5 ML, 63 MCG/0.5 ML- 94 MCG/0.5 ML pregabalin oral tablet extended (Lyrica CR) 3 QL (60 per 30 days) release 24 hr 165 mg, 330 mg, 82.5 mg QUILLICHEW ER ORAL 5 PA NSO; QL (30 per 30 TABLET,CHEW,IR- days) ER.BIPHASIC24HR 20 MG, 40 MG QUILLICHEW ER ORAL 5 PA NSO; QL (60 per 30 TABLET,CHEW,IR- days) ER.BIPHASIC24HR 30 MG

87 Drug Name Drug Tier Requirements/Limits QUILLIVANT XR ORAL 5 PA NSO; QL (360 per SUSPENSION,EXT REL 30 days) 24HR,RECON 5 MG/ML (25 MG/5 ML) REBIF (WITH ALBUMIN) 6 PA; QL (4 per 30 days) SUBCUTANEOUS SYRINGE 22 MCG/0.5 ML REBIF (WITH ALBUMIN) 6 PA; QL (6 per 30 days) SUBCUTANEOUS SYRINGE 44 MCG/0.5 ML REBIF REBIDOSE 6 PA; QL (4 per 30 days) SUBCUTANEOUS PEN INJECTOR 22 MCG/0.5 ML REBIF REBIDOSE 6 PA; QL (6 per 30 days) SUBCUTANEOUS PEN INJECTOR 44 MCG/0.5 ML REBIF REBIDOSE 6 PA; QL (4.2 per 28 SUBCUTANEOUS PEN days) INJECTOR 8.8MCG/0.2ML-22 MCG/0.5ML (6) REBIF TITRATION PACK 6 PA; QL (4.2 per 28 SUBCUTANEOUS SYRINGE days) 8.8MCG/0.2ML-22 MCG/0.5ML (6) oral tablet 50 mg (Rilutek) 6 PA SAVELLA ORAL TABLET 100 5 ST; QL (60 per 30 days) MG, 12.5 MG, 25 MG, 50 MG SAVELLA ORAL 5 ST; QL (55 per 28 days) TABLETS,DOSE PACK 12.5 MG (5)-25 MG(8)-50 MG(42) TECFIDERA ORAL 6 PA; QL (60 per 30 CAPSULE,DELAYED days) RELEASE(DR/EC) 120 MG, 120 MG (14)- 240 MG (46), 240 MG tetrabenazine oral tablet 12.5 mg (Xenazine) 6 PA; QL (90 per 30 days) tetrabenazine oral tablet 25 mg (Xenazine) 6 PA; QL (120 per 30 days) TIGLUTIK ORAL 6 PA SUSPENSION 50 MG/10 ML VUMERITY ORAL 6 PA CAPSULE,DELAYED RELEASE(DR/EC) 231 MG

88 Drug Name Drug Tier Requirements/Limits VYVANSE ORAL CAPSULE 10 5 PA NSO; QL (30 per 30 MG, 20 MG, 30 MG, 40 MG, 50 days) MG, 60 MG, 70 MG VYVANSE ORAL 5 PA NSO; QL (30 per 30 TABLET,CHEWABLE 10 MG, days) 20 MG, 30 MG, 40 MG, 50 MG, 60 MG zenzedi oral tablet 10 mg 5 QL (180 per 30 days) zenzedi oral tablet 15 mg, 2.5 mg, 5 5 QL (90 per 30 days) mg, 7.5 mg zenzedi oral tablet 20 mg, 30 mg 5 QL (60 per 30 days) Contraceptives Contraceptives afirmelle oral tablet 0.1-20 mg-mcg 1 after pill oral tablet 1.5 mg 1 aftera oral tablet 1.5 mg 1 altavera (28) oral tablet 0.15-0.03 1 mg alyacen 1/35 (28) oral tablet 1-35 1 mg-mcg alyacen 7/7/7 (28) oral tablet 1 0.5/0.75/1 mg- 35 mcg amethia lo oral tablets,dose pack,3 1 month 0.10 mg-20 mcg (84)/10 mcg (7) amethia oral tablets,dose pack,3 1 month 0.15 mg-30 mcg (84)/10 mcg (7) amethyst (28) oral tablet 90-20 mcg 5 (28) ANNOVERA VAGINAL RING 1 0.15-0.013 MG/24 HOUR apri oral tablet 0.15-0.03 mg 1 aranelle (28) oral tablet 0.5/1/0.5- 1 35 mg-mcg ashlyna oral tablets,dose pack,3 1 month 0.15 mg-30 mcg (84)/10 mcg (7) aubra oral tablet 0.1-20 mg-mcg 1 aurovela 1.5/30 (21) oral tablet 1.5- 1 30 mg-mcg

89 Drug Name Drug Tier Requirements/Limits aurovela 1/20 (21) oral tablet 1-20 1 mg-mcg aurovela 24 fe oral tablet 1 mg-20 1 mcg (24)/75 mg (4) aurovela fe 1.5/30 (28) oral tablet 1 1.5 mg-30 mcg (21)/75 mg (7) aurovela fe 1-20 (28) oral tablet 1 1 mg-20 mcg (21)/75 mg (7) aviane oral tablet 0.1-20 mg-mcg 1 ayuna oral tablet 0.15-0.03 mg 1 azurette (28) oral tablet 0.15-0.02 1 mgx21 /0.01 mg x 5 BALCOLTRA ORAL TABLET 1 0.1 MG-0.02 MG (21)/36.5 MG(7) balziva (28) oral tablet 0.4-35 mg- 1 mcg bekyree (28) oral tablet 0.15-0.02 1 mgx21 /0.01 mg x 5 blisovi 24 fe oral tablet 1 mg-20 mcg 1 (24)/75 mg (4) blisovi fe 1.5/30 (28) oral tablet 1.5 1 mg-30 mcg (21)/75 mg (7) blisovi fe 1/20 (28) oral tablet 1 mg- 1 20 mcg (21)/75 mg (7) brevicon (28) oral tablet 0.5-35 mg- 1 mcg briellyn oral tablet 0.4-35 mg-mcg 1 camila oral tablet 0.35 mg 1 camrese lo oral tablets,dose pack,3 1 month 0.10 mg-20 mcg (84)/10 mcg (7) camrese oral tablets,dose pack,3 1 month 0.15 mg-30 mcg (84)/10 mcg (7) CAYA CONTOURED 1 VAGINAL DIAPHRAGM 65-80 MM caziant (28) oral tablet 1 0.1/.125/.15-25 mg-mcg charlotte 24 fe oral tablet,chewable 1 1 mg-20 mcg(24) /75 mg (4)

90 Drug Name Drug Tier Requirements/Limits chateal (28) oral tablet 0.15-0.03 1 mg CONCEPTROL VAGINAL GEL 1 4 % cryselle (28) oral tablet 0.3-30 mg- 1 mcg cyclafem 1/35 (28) oral tablet 1-35 1 mg-mcg cyclafem 7/7/7 (28) oral tablet 1 0.5/0.75/1 mg- 35 mcg cyred oral tablet 0.15-0.03 mg 1 dasetta 1/35 (28) oral tablet 1-35 1 mg-mcg dasetta 7/7/7 (28) oral tablet 1 0.5/0.75/1 mg- 35 mcg daysee oral tablets,dose pack,3 1 month 0.15 mg-30 mcg (84)/10 mcg (7) deblitane oral tablet 0.35 mg 1 delyla (28) oral tablet 0.1-20 mg- 1 mcg desog-e.estradiol/e.estradiol oral (Azurette (28)) 1 tablet 0.15-0.02 mgx21 /0.01 mg x 5 desogestrel-ethinyl estradiol oral (Apri) 1 tablet 0.15-0.03 mg dolishale oral tablet 90-20 mcg (28) 1 drospirenone-e.estradiol-lm.fa oral (Beyaz) 1 tablet 3-0.02-0.451 mg (24) (4) drospirenone-e.estradiol-lm.fa oral (Tydemy) 1 tablet 3-0.03-0.451 mg (21) (7) drospirenone-ethinyl estradiol oral (Jasmiel (28)) 1 tablet 3-0.02 mg drospirenone-ethinyl estradiol oral (Ocella) 1 tablet 3-0.03 mg econtra ez oral tablet 1.5 mg 1 elinest oral tablet 0.3-30 mg-mcg 1 ELLA ORAL TABLET 30 MG 1 eluryng vaginal ring 0.12-0.015 1 QL (1 per 28 days) mg/24 hr emoquette oral tablet 0.15-0.03 mg 1 enpresse oral tablet 50-30 (6)/75-40 1 (5)/125-30(10)

91 Drug Name Drug Tier Requirements/Limits enskyce oral tablet 0.15-0.03 mg 1 errin oral tablet 0.35 mg 1 estarylla oral tablet 0.25-35 mg-mcg 1 ethynodiol diac-eth estradiol oral (Kelnor 1/35 (28)) 1 tablet 1-35 mg-mcg ethynodiol diac-eth estradiol oral (Kelnor 1-50 (28)) 1 tablet 1-50 mg-mcg etonogestrel-ethinyl estradiol (EluRyng) 1 QL (1 per 28 days) vaginal ring 0.12-0.015 mg/24 hr fallback solo oral tablet 1.5 mg 1 falmina (28) oral tablet 0.1-20 mg- 1 mcg fayosim oral tablets,dose pack,3 1 month 0.15 mg-20 mcg/ 0.15 mg-25 mcg FC2 FEMALE CONDOM 1 FEMCAP VAGINAL DEVICE 22 1 MM, 26 MM, 30 MM femynor oral tablet 0.25-35 mg-mcg 1 gemmily oral capsule 1 mg-20 mcg 1 (24)/75 mg (4) gianvi (28) oral tablet 3-0.02 mg 1 gildagia oral tablet 0.4-35 mg-mcg 1 GYNOL II VAGINAL GEL 3 % 1 hailey 24 fe oral tablet 1 mg-20 mcg 1 (24)/75 mg (4) hailey fe 1.5/30 (28) oral tablet 1.5 1 mg-30 mcg (21)/75 mg (7) hailey fe 1/20 (28) oral tablet 1 mg- 1 20 mcg (21)/75 mg (7) hailey oral tablet 1.5-30 mg-mcg 1 heather oral tablet 0.35 mg 1 iclevia oral tablets,dose pack,3 1 month 0.15 mg-30 mcg (91) incassia oral tablet 0.35 mg 1 introvale oral tablets,dose pack,3 1 month 0.15 mg-30 mcg (91) isibloom oral tablet 0.15-0.03 mg 1 jaimiess oral tablets,dose pack,3 1 month 0.15 mg-30 mcg (84)/10 mcg (7)

92 Drug Name Drug Tier Requirements/Limits jasmiel (28) oral tablet 3-0.02 mg 1 jencycla oral tablet 0.35 mg 1 jolessa oral tablets,dose pack,3 1 month 0.15 mg-30 mcg (91) jolivette oral tablet 0.35 mg 1 juleber oral tablet 0.15-0.03 mg 1 junel 1.5/30 (21) oral tablet 1.5-30 1 mg-mcg junel 1/20 (21) oral tablet 1-20 mg- 1 mcg junel fe 1.5/30 (28) oral tablet 1.5 1 mg-30 mcg (21)/75 mg (7) junel fe 1/20 (28) oral tablet 1 mg- 1 20 mcg (21)/75 mg (7) junel fe 24 oral tablet 1 mg-20 mcg 1 (24)/75 mg (4) kaitlib fe oral tablet,chewable 1 0.8mg-25mcg(24) and 75 mg (4) kalliga oral tablet 0.15-0.03 mg 1 kariva (28) oral tablet 0.15-0.02 1 mgx21 /0.01 mg x 5 kelnor 1/35 (28) oral tablet 1-35 1 mg-mcg kelnor 1-50 (28) oral tablet 1-50 1 mg-mcg kimidess (28) oral tablet 0.15-0.02 1 mgx21 /0.01 mg x 5 kurvelo (28) oral tablet 0.15-0.03 1 mg KYLEENA INTRAUTERINE 1 INTRAUTERINE DEVICE 17.5 MCG/24 HRS (5 YRS) 19.5 MG l norgest/e.estradiol-e.estrad oral (Camrese Lo) 1 tablets,dose pack,3 month 0.10 mg- 20 mcg (84)/10 mcg (7) l norgest/e.estradiol-e.estrad oral (Fayosim) 1 tablets,dose pack,3 month 0.15 mg- 20 mcg/ 0.15 mg-25 mcg l norgest/e.estradiol-e.estrad oral (Amethia) 1 tablets,dose pack,3 month 0.15 mg- 30 mcg (84)/10 mcg (7)

93 Drug Name Drug Tier Requirements/Limits larin 1.5/30 (21) oral tablet 1.5-30 1 mg-mcg larin 1/20 (21) oral tablet 1-20 mg- 1 mcg larin 24 fe oral tablet 1 mg-20 mcg 1 (24)/75 mg (4) larin fe 1.5/30 (28) oral tablet 1.5 1 mg-30 mcg (21)/75 mg (7) larin fe 1/20 (28) oral tablet 1 mg- 1 20 mcg (21)/75 mg (7) larissia oral tablet 0.1-20 mg-mcg 1 layolis fe oral tablet,chewable 1 0.8mg-25mcg(24) and 75 mg (4) leena 28 oral tablet 0.5/1/0.5-35 mg- 1 mcg lessina oral tablet 0.1-20 mg-mcg 1 levonest (28) oral tablet 50-30 1 (6)/75-40 (5)/125-30(10) levonorgestrel oral tablet 1.5 mg (After Pill) 1 levonorgestrel-ethinyl estrad oral (Afirmelle) 1 tablet 0.1-20 mg-mcg levonorgestrel-ethinyl estrad oral (Altavera (28)) 1 tablet 0.15-0.03 mg levonorgestrel-ethinyl estrad oral (Dolishale) 1 tablet 90-20 mcg (28) levonorgestrel-ethinyl estrad oral (Iclevia) 1 tablets,dose pack,3 month 0.15 mg- 30 mcg (91) levonorg-eth estrad triphasic oral (Enpresse) 1 tablet 50-30 (6)/75-40 (5)/125- 30(10) levora-28 oral tablet 0.15-0.03 mg 1 LILETTA INTRAUTERINE 1 INTRAUTERINE DEVICE 20.1 MCG/24 HRS (6 YRS) 52 MG lillow (28) oral tablet 0.15-0.03 mg 1 LO LOESTRIN FE ORAL 1 TABLET 1 MG-10 MCG (24)/10 MCG (2) lojaimiess oral tablets,dose pack,3 1 month 0.10 mg-20 mcg (84)/10 mcg (7)

94 Drug Name Drug Tier Requirements/Limits lomedia 24 fe oral tablet 1 mg-20 1 mcg (24)/75 mg (4) loryna (28) oral tablet 3-0.02 mg 1 low-ogestrel (28) oral tablet 0.3-30 1 mg-mcg lo-zumandimine (28) oral tablet 3- 1 0.02 mg lutera (28) oral tablet 0.1-20 mg- 1 mcg lyleq oral tablet 0.35 mg 1 lyza oral tablet 0.35 mg 1 marlissa (28) oral tablet 0.15-0.03 1 mg melodetta 24 fe oral tablet,chewable 1 1 mg-20 mcg(24) /75 mg (4) mibelas 24 fe oral tablet,chewable 1 1 mg-20 mcg(24) /75 mg (4) microgestin 1.5/30 (21) oral tablet 1 1.5-30 mg-mcg microgestin 1/20 (21) oral tablet 1- 1 20 mg-mcg microgestin 24 fe oral tablet 1 mg- 1 20 mcg (24)/75 mg (4) microgestin fe 1.5/30 (28) oral 1 tablet 1.5 mg-30 mcg (21)/75 mg (7) microgestin fe 1/20 (28) oral tablet 1 1 mg-20 mcg (21)/75 mg (7) mili oral tablet 0.25-35 mg-mcg 1 MIRENA INTRAUTERINE 1 INTRAUTERINE DEVICE 20 MCG/24 HOURS (6 YRS) 52 MG mono-linyah oral tablet 0.25-35 mg- 1 mcg mononessa (28) oral tablet 0.25-35 1 mg-mcg my choice oral tablet 1.5 mg 1 my way oral tablet 1.5 mg 1 myzilra oral tablet 50-30 (6)/75-40 1 (5)/125-30(10)

95 Drug Name Drug Tier Requirements/Limits NATAZIA ORAL TABLET 3 1 MG/2 MG-2 MG/ 2 MG-3 MG/1 MG necon 0.5/35 (28) oral tablet 0.5-35 1 mg-mcg necon 1/50 (28) oral tablet 1-50 mg- 1 mcg necon 7/7/7 (28) oral tablet 1 0.5/0.75/1 mg- 35 mcg new day oral tablet 1.5 mg 1 NEXPLANON SUBDERMAL 1 QL (1 per 365 days) IMPLANT 68 MG next choice one dose oral tablet 1.5 1 mg nikki (28) oral tablet 3-0.02 mg 1 nora-be oral tablet 0.35 mg 1 noreth-ethinyl estradiol-iron oral (Wymzya Fe) 1 tablet,chewable 0.4mg-35mcg(21) and 75 mg (7) noreth-ethinyl estradiol-iron oral (Kaitlib Fe) 1 tablet,chewable 0.8mg-25mcg(24) and 75 mg (4) norethindrone (contraceptive) oral (Camila) 1 tablet 0.35 mg norethindrone ac-eth estradiol oral (Aurovela 1.5/30 (21)) 1 tablet 1.5-30 mg-mcg norethindrone ac-eth estradiol oral (Aurovela 1/20 (21)) 1 tablet 1-20 mg-mcg norethindrone-e.estradiol-iron oral (Gemmily) 1 capsule 1 mg-20 mcg (24)/75 mg (4) norethindrone-e.estradiol-iron oral (Aurovela Fe 1-20 (28)) 1 tablet 1 mg-20 mcg (21)/75 mg (7) norethindrone-e.estradiol-iron oral (Aurovela 24 Fe) 1 tablet 1 mg-20 mcg (24)/75 mg (4) norethindrone-e.estradiol-iron oral (Aurovela Fe 1.5/30 1 tablet 1.5 mg-30 mcg (21)/75 mg (28)) (7) norethindrone-e.estradiol-iron oral (Charlotte 24 Fe) 1 tablet,chewable 1 mg-20 mcg(24) /75 mg (4)

96 Drug Name Drug Tier Requirements/Limits norgestimate-ethinyl estradiol oral (Tri-Lo-Estarylla) 1 tablet 0.18/0.215/0.25 mg-25 mcg norgestimate-ethinyl estradiol oral (Tri Femynor) 1 tablet 0.18/0.215/0.25 mg-35 mcg (28) norgestimate-ethinyl estradiol oral (Estarylla) 1 tablet 0.25-35 mg-mcg norlyda oral tablet 0.35 mg 1 norlyroc oral tablet 0.35 mg 1 nortrel 0.5/35 (28) oral tablet 0.5- 1 35 mg-mcg nortrel 1/35 (21) oral tablet 1-35 1 mg-mcg (21) nortrel 1/35 (28) oral tablet 1-35 1 mg-mcg nortrel 7/7/7 (28) oral tablet 1 0.5/0.75/1 mg- 35 mcg nylia 7/7/7 (28) oral tablet 1 0.5/0.75/1 mg- 35 mcg nymyo oral tablet 0.25-35 mg-mcg 1 ocella oral tablet 3-0.03 mg 1 ogestrel (28) oral tablet 0.5-50 mg- 1 mcg opcicon one-step oral tablet 1.5 mg 1 option-2 oral tablet 1.5 mg 1 orsythia oral tablet 0.1-20 mg-mcg 1 PARAGARD T 380A 1 INTRAUTERINE INTRAUTERINE DEVICE 380 SQUARE MM philith oral tablet 0.4-35 mg-mcg 1 pimtrea (28) oral tablet 0.15-0.02 1 mgx21 /0.01 mg x 5 pirmella oral tablet 0.5/0.75/1 mg- 1 35 mcg, 1-35 mg-mcg PLAN B ONE-STEP ORAL 5 TABLET 1.5 MG portia 28 oral tablet 0.15-0.03 mg 1 previfem oral tablet 0.25-35 mg-mcg 1 quasense oral tablets,dose pack,3 1 month 0.15 mg-30 mcg (91)

97 Drug Name Drug Tier Requirements/Limits rajani oral tablet 3-0.02-0.451 mg 1 (24) (4) reclipsen (28) oral tablet 0.15-0.03 1 mg rivelsa oral tablets,dose pack,3 1 month 0.15 mg-20 mcg/ 0.15 mg-25 mcg setlakin oral tablets,dose pack,3 1 month 0.15 mg-30 mcg (91) sharobel oral tablet 0.35 mg 1 simliya (28) oral tablet 0.15-0.02 1 mgx21 /0.01 mg x 5 simpesse oral tablets,dose pack,3 1 month 0.15 mg-30 mcg (84)/10 mcg (7) SKYLA INTRAUTERINE 1 INTRAUTERINE DEVICE 14 MCG/24 HRS (3 YRS) 13.5 MG SLYND ORAL TABLET 4 MG 1 (28) sprintec (28) oral tablet 0.25-35 1 mg-mcg sronyx oral tablet 0.1-20 mg-mcg 1 syeda oral tablet 3-0.03 mg 1 take action oral tablet 1.5 mg 5 tarina 24 fe oral tablet 1 mg-20 mcg 1 (24)/75 mg (4) tarina fe 1/20 (28) oral tablet 1 mg- 1 20 mcg (21)/75 mg (7) taysofy oral capsule 1 mg-20 mcg 1 (24)/75 mg (4) TAYTULLA ORAL CAPSULE 1 1 MG-20 MCG (24)/75 MG (4) tilia fe oral tablet 1-20(5)/1-30(7) 1 /1mg-35mcg (9) TODAY CONTRACEPTIVE 1 SPONGE VAGINAL CONTRACEPTIVE SPONGE 1,000 MG tri femynor oral tablet 1 0.18/0.215/0.25 mg-35 mcg (28)

98 Drug Name Drug Tier Requirements/Limits tri-estarylla oral tablet 1 0.18/0.215/0.25 mg-35 mcg (28) tri-legest fe oral tablet 1-20(5)/1- 1 30(7) /1mg-35mcg (9) tri-linyah oral tablet 0.18/0.215/0.25 1 mg-35 mcg (28) tri-lo-estarylla oral tablet 1 0.18/0.215/0.25 mg-25 mcg tri-lo-marzia oral tablet 1 0.18/0.215/0.25 mg-25 mcg tri-lo-mili oral tablet 0.18/0.215/0.25 1 mg-25 mcg tri-lo-sprintec oral tablet 1 0.18/0.215/0.25 mg-25 mcg tri-mili oral tablet 0.18/0.215/0.25 1 mg-35 mcg (28) trinessa (28) oral tablet 1 0.18/0.215/0.25 mg-35 mcg (28) trinessa lo oral tablet 1 0.18/0.215/0.25 mg-25 mcg tri-nymyo oral tablet 1 0.18/0.215/0.25 mg-35 mcg (28) tri-previfem (28) oral tablet 1 0.18/0.215/0.25 mg-35 mcg (28) tri-sprintec (28) oral tablet 1 0.18/0.215/0.25 mg-35 mcg (28) trivora (28) oral tablet 50-30 1 (6)/75-40 (5)/125-30(10) tri-vylibra lo oral tablet 1 0.18/0.215/0.25 mg-25 mcg tri-vylibra oral tablet 1 0.18/0.215/0.25 mg-35 mcg (28) tulana oral tablet 0.35 mg 1 tyblume oral tablet,chewable 0.1 1 mg- 20 mcg tydemy oral tablet 3-0.03-0.451 mg 1 (21) (7) VAGINAL CONTRACEPTIVE 1 FILM VAGINAL FILM 28 % vaginal contraceptive foam vaginal 1 foam 12.5 % vcf contraceptive gel vaginal gel 4 % 1

99 Drug Name Drug Tier Requirements/Limits velivet triphasic regimen (28) oral 1 tablet 0.1/.125/.15-25 mg-mcg vestura (28) oral tablet 3-0.02 mg 1 vienva oral tablet 0.1-20 mg-mcg 1 viorele (28) oral tablet 0.15-0.02 1 mgx21 /0.01 mg x 5 volnea (28) oral tablet 0.15-0.02 1 mgx21 /0.01 mg x 5 vyfemla (28) oral tablet 0.4-35 mg- 1 mcg vylibra oral tablet 0.25-35 mg-mcg 1 wera (28) oral tablet 0.5-35 mg- 1 mcg WIDE-SEAL DIAPHRAGM 70 1 VAGINAL DIAPHRAGM 70 MM wymzya fe oral tablet,chewable 1 0.4mg-35mcg(21) and 75 mg (7) xulane transdermal patch weekly 1 QL (3 per 28 days) 150-35 mcg/24 hr zafemy transdermal patch weekly 1 QL (3 per 28 days) 150-35 mcg/24 hr zarah oral tablet 3-0.03 mg 1 zenchent (28) oral tablet 0.4-35 mg- 1 mcg zenchent fe oral tablet,chewable 1 0.4mg-35mcg(21) and 75 mg (7) zovia 1/35e (28) oral tablet 1-35 1 mg-mcg zovia 1/50e (28) oral tablet 1-50 1 mg-mcg zumandimine (28) oral tablet 3-0.03 1 mg Cough And Cold Products Cough And Cold Products benzonatate oral capsule 100 mg (Tessalon Perles) 2 benzonatate oral capsule 150 mg, 2 200 mg bromfed dm oral syrup 2-30-10 mg/5 2 ml brompheniramine-pseudoeph-dm (Bromfed DM) 2 oral syrup 2-30-10 mg/5 ml

100 Drug Name Drug Tier Requirements/Limits cheratussin ac oral liquid 10-100 2 AGE (Min 18 Years) mg/5 ml codeine-guaifenesin oral liquid 10- (G Tussin AC) 2 AGE (Min 18 Years) 100 mg/5 ml guaifenesin dac oral syrup 30-10-100 2 AGE (Min 18 Years) mg/5 ml hydrocodone-chlorpheniramine oral 3 AGE (Min 18 Years) suspension,extended rel 12 hr 10-8 mg/5 ml hydrocodone-cpm-pseudoephed oral 3 AGE (Min 18 Years) solution 5-4-60 mg/5 ml hydrocodone-homatropine oral (Hydromet) 2 AGE (Min 18 Years) syrup 5-1.5 mg/5 ml hydrocodone-homatropine oral 2 AGE (Min 18 Years) tablet 5-1.5 mg hydromet oral syrup 5-1.5 mg/5 ml 2 AGE (Min 18 Years) lohist-dm oral liquid 2-5-10 mg/5 ml 2 mar-cof bp oral liquid 2-30-7.5 mg/5 3 AGE (Min 18 Years) ml mar-cof cg oral liquid 7.5-225 mg/5 3 AGE (Min 18 Years) ml POLY-TUSSIN AC ORAL 5 AGE (Min 18 Years) LIQUID 4-10-10 MG/5 ML promethazine-codeine oral syrup 2 AGE (Min 18 Years) 6.25-10 mg/5 ml promethazine-dm oral syrup 6.25-15 2 mg/5 ml promethazine-phenyleph-codeine (Promethazine VC- 2 AGE (Min 18 Years) oral syrup 6.25-5-10 mg/5 ml Codeine) PRO-RED AC (W/ 5 AGE (Min 18 Years) DEXCHLORPHENIR) ORAL LIQUID 1-5-9 MG/5 ML REZIRA ORAL SOLUTION 60-5 5 AGE (Min 18 Years) MG/5 ML TUSSICAPS ORAL 5 AGE (Min 18 Years) CAPSULE,EXTENDED RELEASE 12 HR 10-8 MG, 5-4 MG VITUZ ORAL SOLUTION 5-4 5 AGE (Min 18 Years) MG/5 ML ZODRYL AC 25 ORAL 5 AGE (Min 18 Years) SUSPENSION 1-3 MG/3 ML

101 Drug Name Drug Tier Requirements/Limits ZODRYL AC 30 ORAL 5 AGE (Min 18 Years) SUSPENSION 1-3.5 MG/3.5 ML ZODRYL AC 35 ORAL 5 AGE (Min 18 Years) SUSPENSION 1-4 MG/4 ML ZODRYL AC 40 ORAL 5 AGE (Min 18 Years) SUSPENSION 1-4.5 MG/4.5 ML ZODRYL AC 50 ORAL 5 AGE (Min 18 Years) SUSPENSION 2-5 MG/5 ML ZODRYL AC 60 ORAL 5 AGE (Min 18 Years) SUSPENSION 2-7.5 MG/7.5 ML ZODRYL AC 80 ORAL 5 AGE (Min 18 Years) SUSPENSION 2-10 MG/10 ML ZODRYL DAC 50 ORAL 5 AGE (Min 18 Years) SUSPENSION 2-30-5 MG/5 ML ZODRYL DAC 60 ORAL 5 AGE (Min 18 Years) SUSPENSION 2-30-7.5 MG/7.5 ML ZODRYL DAC 80 ORAL 5 AGE (Min 18 Years) SUSPENSION 2-30-10 MG/10 ML ZODRYL DEC 25 ORAL 5 AGE (Min 18 Years) SUSPENSION 15-3-60 MG/3 ML ZODRYL DEC 30 ORAL 5 AGE (Min 18 Years) SUSPENSION 15-3.5-70 MG/3.5 ML ZODRYL DEC 35 ORAL 5 AGE (Min 18 Years) SUSPENSION 15-4-80 MG/4 ML ZODRYL DEC 40 ORAL 5 AGE (Min 18 Years) SUSPENSION 15-4.5-90 MG/4.5 ML ZODRYL DEC 50 ORAL 5 AGE (Min 18 Years) SUSPENSION 30-5-100 MG/5 ML ZODRYL DEC 60 ORAL 5 AGE (Min 18 Years) SUSPENSION 30-7.5-150 MG/7.5 ML ZODRYL DEC 80 ORAL 5 AGE (Min 18 Years) SUSPENSION 30-10-200 MG/10 ML Z-TUSS AC ORAL LIQUID 2-9 5 AGE (Min 18 Years) MG/5 ML

102 Drug Name Drug Tier Requirements/Limits Dental And Oral Agents Dental And Oral Agents cevimeline oral capsule 30 mg (Evoxac) 3 chlorhexidine gluconate mucous (Paroex Oral Rinse) 2 membrane mouthwash 0.12 % DEBACTEROL MUCOUS 5 MEMBRANE SOLUTION 30-50 % DEBACTEROL MUCOUS 5 MEMBRANE SWAB 30-50 % denta 5000 plus dental cream 1.1 % 2 dentagel dental gel 1.1 % 2 FLUORIDEX DAILY DEFENSE 3 DENTAL PASTE 1.1 % oralone dental paste 0.1 % 2 paroex oral rinse mucous membrane 2 mouthwash 0.12 % periogard mucous membrane 2 mouthwash 0.12 % pilocarpine hcl oral tablet 5 mg, 7.5 (Salagen (pilocarpine)) 2 mg PREVIDENT 5000 SENSITIVE 5 DENTAL PASTE 1.1-5 % sf 5000 plus dental cream 1.1 % 2 sodium fluoride-pot nitrate dental (PreviDent 5000 3 paste 1.1-5 % Sensitive) triamcinolone acetonide dental paste (Oralone) 2 0.1 % Dermatological Agents Dermatological Agents, Other acitretin oral capsule 10 mg, 25 mg (Soriatane) 6 PA acitretin oral capsule 17.5 mg 6 PA acne medication topical gel 10 % 2 acyclovir topical ointment 5 % (Zovirax) 3 QL (30 per 10 days) ACZONE TOPICAL GEL WITH 5 PUMP 7.5 % ammonium lactate topical cream 12 2 % ammonium lactate topical lotion 12 (Skin Treatment) 2 %

103 Drug Name Drug Tier Requirements/Limits amnesteem oral capsule 10 mg, 20 3 PA mg, 40 mg ANACAINE TOPICAL 5 OINTMENT 10 % AVAR LS TOPICAL PADS, 5 MEDICATED 10-2 % AVAR TOPICAL PADS, 5 MEDICATED 9.5-5 % azelaic acid topical gel 15 % (Finacea) 3 AZELEX TOPICAL CREAM 20 5 % benzoyl peroxide topical gel 10 % (Acne Medication) 2 bp 10-1 topical cleanser 10-1 % 2 bpo topical gel 4 %, 8 % 3 calcipotriene scalp solution 0.005 % 2 calcipotriene topical cream 0.005 % (Dovonex) 2 calcipotriene topical foam 0.005 % (Sorilux) 3 calcipotriene topical ointment 0.005 2 % calcipotriene-betamethasone topical (Taclonex) 3 ointment 0.005-0.064 % calcipotriene-betamethasone topical (Taclonex) 6 ST suspension 0.005-0.064 % calcitrene topical ointment 0.005 % 2 calcitriol topical ointment 3 (Vectical) 3 mcg/gram cem-urea topical gel 45 % 2 CETACAINE 5 TOPICAL LIQUID 2-2-14 % CETACAINE TOPICAL 5 AEROSOL,SPRAY 2 %-2 %-14 % (200 MG/SEC) claravis oral capsule 10 mg, 20 mg, 3 PA 30 mg, 40 mg cleansing wash topical cleanser 10- 3 4-10 % CONDYLOX TOPICAL GEL 0.5 5 % dapsone topical gel 5 % (Aczone) 3 dapsone topical gel with pump 7.5 % (Aczone) 3

104 Drug Name Drug Tier Requirements/Limits DENAVIR TOPICAL CREAM 1 5 % DRITHOCREME HP TOPICAL 5 ST CREAM 1 % EFUDEX TOPICAL CREAM 5 5 PA % ENSTILAR TOPICAL FOAM 6 ST 0.005-0.064 % exoderm topical lotion 25-1 % 2 FINACEA TOPICAL FOAM 15 5 % FLUOROPLEX TOPICAL 6 CREAM 1 % fluorouracil topical cream 0.5 % (Carac) 3 PA fluorouracil topical cream 5 % (Efudex) 2 PA fluorouracil topical solution 2 % 2 fluorouracil topical solution 5 % 2 PA GORDONS UREA TOPICAL 5 OINTMENT 22 %, 40 % HYDRO 35 TOPICAL FOAM 35 5 % imiquimod topical cream in packet 5 (Aldara) 2 QL (24 per 30 days) % INOVA 4-1 TOPICAL COMBO 5 PACK 1-4-5 % INOVA 8-2 TOPICAL COMBO 5 PACK 2-8-5 % isotretinoin oral capsule 10 mg, 20 (Amnesteem) 3 PA mg, 40 mg isotretinoin oral capsule 25 mg, 35 (Absorica) 3 PA mg isotretinoin oral capsule 30 mg (Claravis) 3 PA KERAFOAM TOPICAL FOAM 5 30 %, 42 % KERALYT SCALP COMPLETE 5 TOPICAL KIT,SHAMPOO AND GEL 6-6 % lidocaine-hydrocortisone-aloe rectal 2 gel 2.8-0.55 % mafenide acetate topical packet 50 (Sulfamylon) 3 gram

105 Drug Name Drug Tier Requirements/Limits methoxsalen oral capsule,liqd- 3 filled,rapid rel 10 mg MIRVASO TOPICAL GEL 5 QL (30 per 30 days) WITH PUMP 0.33 % myorisan oral capsule 10 mg, 20 mg, 3 PA 30 mg, 40 mg NUOX TOPICAL GEL 6-3 % 5 PACNEX HP TOPICAL PADS, 5 MEDICATED 7 % PACNEX LP TOPICAL PADS, 5 MEDICATED 4.25 % PANRETIN TOPICAL GEL 0.1 6 % PICATO TOPICAL GEL 0.015 % 5 QL (3 per 28 days) PICATO TOPICAL GEL 0.05 % 5 QL (2 per 28 days) podocon topical liquid 25 % 2 podofilox topical solution 0.5 % 2 pr cream topical cream 2 QBREXZA TOPICAL 5 PA; QL (30 per 30 TOWELETTE 2.4 % days) REGRANEX TOPICAL GEL 6 0.01 % RHOFADE TOPICAL CREAM 1 5 % ROSANIL TOPICAL 5 CLEANSER 10-5 % (W/W) ROSULA TOPICAL CLEANSER 5 10-4.5 % salicylic acid topical film forming (Virasal) 2 liquid w/appl 27.5 % salicylic acid topical foam 6 % (Salvax) 2 salicylic acid topical liquid 26 % 2 salicylic acid topical lotion 6 % 2 salicylic acid topical shampoo 6 % (Keralyt) 2 SANTYL TOPICAL OINTMENT 5 QL (180 per 25 days) 250 UNIT/GRAM seb-prev topical cleanser 10 % 2 SORIATANE ORAL CAPSULE 6 PA 10 MG, 17.5 MG, 25 MG SORILUX TOPICAL FOAM 5 0.005 %

106 Drug Name Drug Tier Requirements/Limits sss 10-5 topical foam 10-5 % 2 sulfacetamide sodium topical (Ovace) 2 cleanser 10 % sulfacetamide sodium-sulfur topical (Avar LS) 2 cleanser 10-2 % sulfacetamide sodium-sulfur topical (Rosanil) 2 cleanser 10-5 % (w/w) sulfacetamide sodium-sulfur topical (Sumaxin) 2 cleanser 9-4 % sulfacetamide sodium-sulfur topical (Sumadan) 2 cleanser 9-4.5 % sulfacetamide sodium-sulfur topical (Avar-E LS) 2 cream 10-2 % sulfacetamide sodium-sulfur topical (Avar-E) 2 cream 10-5 % (w/w) sulfacetamide sodium-sulfur topical 3 lotion 10-5 % (w/w) sulfacetamide sodium-sulfur topical (Plexion) 2 lotion 9.8-4.8 % sulfacetamide sodium-sulfur topical (Sumaxin) 2 pads, medicated 10-4 % sulfacetamide-niacinamide topical (Eceoxia) 3 cream 10-4 % SULFAMYLON TOPICAL 5 CREAM 85 MG/G SULFAMYLON TOPICAL 5 PACKET 50 GRAM TOLAK TOPICAL CREAM 4 % 5 URAMAXIN TOPICAL FOAM 5 20 % urea nail stick topical solution 50 % 2 urea topical cream 39 % (Uredeb) 2 urea topical cream 40 % 2 urea topical cream 45 % (Uramaxin) 2 urea topical foam 35 % (Hydro 35) 2 urea topical gel 45 % (CEM-Urea) 2 urea topical lotion 40 % 2 urea topical lotion 45 % (Uramaxin) 2 VALCHLOR TOPICAL GEL 6 PA 0.016 %

107 Drug Name Drug Tier Requirements/Limits VANOXIDE-HC TOPICAL 5 SUSPENSION 5-0.5 % zenatane oral capsule 10 mg, 20 mg, 3 PA 30 mg, 40 mg Dermatological Antibacterials ALTABAX TOPICAL 5 OINTMENT 1 % bacitracin topical ointment 500 (Bacitraycin Plus) 2 unit/gram bacitracin zinc topical ointment 500 (Antibiotic (bacitracin 2 unit/gram zinc)) BACTROBAN NASAL NASAL 5 OINTMENT 2 % clindamycin phosphate topical foam (Evoclin) 3 1 % clindamycin phosphate topical gel 1 2 % clindamycin phosphate topical lotion (Cleocin T) 2 1 % clindamycin phosphate topical (Cleocin T) 2 solution 1 % clindamycin phosphate topical swab (Clindacin ETZ) 2 1 % clindamycin-benzoyl peroxide (Neuac) 3 topical gel 1.2 %(1 % base) -5 % clindamycin-benzoyl peroxide (Benzaclin) 3 topical gel 1-5 % clindamycin-benzoyl peroxide (Acanya) 3 topical gel with pump 1.2-2.5 % CORTISPORIN TOPICAL 5 CREAM 3.5-10,000-0.5 MG/G- UNIT/G-% CORTISPORIN TOPICAL 5 OINTMENT 1 % ery pads topical swab 2 % 2 erythromycin with ethanol topical (Erygel) 2 gel 2 % erythromycin with ethanol topical 2 solution 2 % erythromycin with ethanol topical (Ery Pads) 2 swab 2 %

108 Drug Name Drug Tier Requirements/Limits erythromycin-benzoyl peroxide (Benzamycin) 2 topical gel 3-5 % gentamicin topical cream 0.1 % 2 gentamicin topical ointment 0.1 % 2 metronidazole topical cream 0.75 % (Rosadan) 2 metronidazole topical gel 0.75 % (Rosadan) 2 metronidazole topical gel 1 % (Metrogel) 3 metronidazole topical lotion 0.75 % (MetroLotion) 2 mupirocin calcium topical cream 2 3 % mupirocin topical ointment 2 % (Centany) 2 NEO-SYNALAR TOPICAL 5 ST CREAM 0.5 % (0.35 % BASE)- 0.025 % rosadan topical cream 0.75 % 2 selenium sulfide topical lotion 2.5 % 2 silver nitrate applicators topical 3 stick 75-25 % silver nitrate topical ointment 10 % 2 silver sulfadiazine topical cream 1 % (SSD) 2 ssd topical cream 1 % 2 sulfacetamide sodium (acne) topical (Klaron) 2 suspension 10 % TERSI FOAM TOPICAL FOAM 5 2.25 % XEPI TOPICAL CREAM 1 % 5 Dermatological Anti-Inflammatory Agents ala-cort topical cream 1 %, 2.5 % 2 ala-scalp topical lotion 2 % 2 alclometasone topical cream 0.05 % 2 alclometasone topical ointment 0.05 2 % amcinonide topical cream 0.1 % 3 amcinonide topical lotion 0.1 % 3 amcinonide topical ointment 0.1 % 3 ANALPRAM-HC TOPICAL 5 LOTION 2.5-1 % anucort-hc rectal suppository 25 mg 2 betamethasone dipropionate topical 2 cream 0.05 %

109 Drug Name Drug Tier Requirements/Limits betamethasone dipropionate topical 2 lotion 0.05 % betamethasone dipropionate topical 2 ointment 0.05 % betamethasone valerate topical 2 cream 0.1 % betamethasone valerate topical foam (Luxiq) 3 0.12 % betamethasone valerate topical 2 lotion 0.1 % betamethasone valerate topical 2 ointment 0.1 % betamethasone, augmented topical 2 cream 0.05 % betamethasone, augmented topical 2 gel 0.05 % betamethasone, augmented topical 2 lotion 0.05 % betamethasone, augmented topical (Diprolene 2 ointment 0.05 % (augmented)) CAPEX TOPICAL SHAMPOO 5 0.01 % clobetasol scalp solution 0.05 % 2 clobetasol topical cream 0.05 % (Temovate) 3 clobetasol topical foam 0.05 % (Olux) 3 clobetasol topical gel 0.05 % 3 clobetasol topical lotion 0.05 % (Clobex) 3 clobetasol topical ointment 0.05 % (Temovate) 3 clobetasol topical shampoo 0.05 % (Clobex) 3 clobetasol topical spray,non-aerosol (Clobex) 3 0.05 % clobetasol-emollient topical cream 3 0.05 % clobetasol-emollient topical foam (Olux-E) 3 0.05 % clocortolone pivalate topical cream (Cloderm) 3 0.1 % CORDRAN TAPE LARGE 5 ROLL TOPICAL TAPE 4 MCG/CM2 CORDRAN TOPICAL CREAM 5 0.025 %

110 Drug Name Drug Tier Requirements/Limits cormax scalp solution 0.05 % 3 CORTIFOAM RECTAL FOAM 5 10 % (80 MG) DERMAZENE TOPICAL 2 CREAM IN PACKET 1-1 % DESONATE TOPICAL GEL 0.05 5 % desonide topical cream 0.05 % (DesOwen) 3 desonide topical gel 0.05 % (Desonate) 3 desonide topical lotion 0.05 % (DesOwen) 3 desonide topical ointment 0.05 % 3 desoximetasone topical cream 0.05 (Topicort) 3 %, 0.25 % desoximetasone topical gel 0.05 % (Topicort) 3 desoximetasone topical ointment (Topicort) 3 0.05 %, 0.25 % desoximetasone topical spray,non- (Topicort) 3 aerosol 0.25 % EPIFOAM TOPICAL FOAM 1-1 5 % fluocinolone topical cream 0.01 % 2 fluocinolone topical cream 0.025 % (Synalar) 2 fluocinolone topical oil 0.01 % (Derma-Smoothe/FS 3 Body Oil) fluocinolone topical ointment 0.025 (Synalar) 2 % fluocinolone topical solution 0.01 % (Synalar) 3 fluocinonide topical cream 0.05 % 2 fluocinonide topical cream 0.1 % (Vanos) 3 fluocinonide topical gel 0.05 % 3 fluocinonide topical ointment 0.05 % 3 fluocinonide topical solution 0.05 % 2 fluocinonide-e topical cream 0.05 % 2 flurandrenolide topical cream 0.05 (Cordran) 3 % flurandrenolide topical lotion 0.05 % (Cordran) 3 flurandrenolide topical ointment (Cordran) 3 0.05 % fluticasone propionate topical cream (Cutivate) 2 0.05 %

111 Drug Name Drug Tier Requirements/Limits fluticasone propionate topical lotion (Beser) 3 0.05 % fluticasone propionate topical 2 ointment 0.005 % halcinonide topical cream 0.1 % (Halog) 3 halobetasol propionate topical 3 cream 0.05 % halobetasol propionate topical 3 ointment 0.05 % HALOG TOPICAL OINTMENT 5 0.1 % HALOG TOPICAL SOLUTION 5 0.1 % hydrocortisone acetate rectal (Anucort-HC) 2 suppository 25 mg hydrocortisone acetate rectal (Hemmorex-HC) 2 suppository 30 mg hydrocortisone butyrate topical 3 cream 0.1 % hydrocortisone butyrate topical (Locoid) 3 lotion 0.1 % hydrocortisone butyrate topical 3 ointment 0.1 % hydrocortisone butyrate topical 3 solution 0.1 % hydrocortisone topical cream 1 % (Ala-Cort) 2 hydrocortisone topical cream 2.5 % 2 hydrocortisone topical lotion 1 % (Anti-Itch (HC)) 2 hydrocortisone topical lotion 2.5 % 2 hydrocortisone topical ointment 1 % (Anti-Itch (HC)) 2 hydrocortisone topical ointment 2.5 2 % hydrocortisone valerate topical 3 cream 0.2 % hydrocortisone valerate topical 3 ointment 0.2 % hydrocortisone-iodoquinol topical (Corti-Sav) 2 cream 1-1 % hydrocortisone-pramoxine rectal (Analpram-HC) 2 cream 1-1 %, 2.5-1 % hydrocortisone-pramoxine topical 2 cream 2.35-1 %

112 Drug Name Drug Tier Requirements/Limits hydrocortisone-pramoxine topical (Pramosone) 2 cream 2.5-1 % MEZPAROX-HC TOPICAL 2 CREAM 2.5-1 % mometasone topical cream 0.1 % 2 mometasone topical ointment 0.1 % 2 mometasone topical solution 0.1 % 2 NUCORT TOPICAL LOTION 2 5 % pimecrolimus topical cream 1 % (Elidel) 3 ST PRAMOSONE E TOPICAL 5 CREAM 2.5-1 % PRAMOSONE TOPICAL 5 LOTION 1-1 %, 2.5-1 % PRAMOSONE TOPICAL 5 OINTMENT 1-1 %, 2.5-1 % prednicarbate topical cream 0.1 % 3 prednicarbate topical ointment 0.1 3 % PROCORT RECTAL CREAM 5 1.85-1.15 % PROCTOFOAM HC RECTAL 5 FOAM 1-1 % procto-med hc topical cream with 2 perineal applicator 2.5 % procto-pak topical cream with 2 perineal applicator 1 % proctosol hc topical cream with 2 perineal applicator 2.5 % proctozone-hc topical cream with 2 perineal applicator 2.5 % SERNIVO TOPICAL SPRAY 6 ST WITH PUMP 0.05 % tacrolimus topical ointment 0.03 %, (Protopic) 3 0.1 % triamcinolone acetonide topical (Kenalog) 3 aerosol 0.147 mg/gram triamcinolone acetonide topical 2 cream 0.025 % triamcinolone acetonide topical (Triderm) 2 cream 0.1 %, 0.5 %

113 Drug Name Drug Tier Requirements/Limits triamcinolone acetonide topical 2 lotion 0.025 %, 0.1 % triamcinolone acetonide topical 2 ointment 0.025 %, 0.1 %, 0.5 % triderm topical cream 0.1 %, 0.5 % 2 Dermatological Retinoids adapalene topical cream 0.1 % (Differin) 2 AGE (Max 25 Years) adapalene topical gel 0.1 % (Differin) 2 AGE (Max 25 Years) adapalene topical gel 0.3 % (Differin) 3 AGE (Max 25 Years) adapalene topical lotion 0.1 % (Differin) 3 AGE (Max 25 Years) adapalene-benzoyl peroxide topical (Epiduo) 3 QL (45 per 30 days); gel with pump 0.1-2.5 % AGE (Max 25 Years) ALTRENO TOPICAL LOTION 5 0.05 % avita topical cream 0.025 % 2 AGE (Max 25 Years) avita topical gel 0.025 % 2 AGE (Max 25 Years) EPIDUO FORTE TOPICAL GEL 5 ST; QL (45 per 30 WITH PUMP 0.3-2.5 % days); AGE (Max 25 Years) tazarotene topical cream 0.1 % (Tazorac) 3 TAZORAC TOPICAL CREAM 5 AGE (Max 25 Years) 0.05 % TAZORAC TOPICAL GEL 0.05 5 AGE (Max 25 Years) %, 0.1 % tretinoin microspheres topical gel (Retin-A Micro) 3 AGE (Max 25 Years) 0.04 %, 0.1 % tretinoin topical cream 0.025 % (Avita) 2 AGE (Max 25 Years) tretinoin topical cream 0.05 % (Retin-A) 2 AGE (Max 25 Years) tretinoin topical cream 0.1 % (Retin-A) 3 AGE (Max 25 Years) tretinoin topical gel 0.01 % (Retin-A) 2 AGE (Max 25 Years) tretinoin topical gel 0.025 % (Avita) 2 AGE (Max 25 Years) tretinoin topical gel 0.05 % (Atralin) 3 AGE (Max 25 Years) TRETIN-X CREAM KIT 5 AGE (Max 25 Years) TOPICAL COMBO PACK 0.025 %, 0.05 %, 0.1 % Scabicides And Pediculicides ivermectin topical lotion 0.5 % (Sklice) 3 QL (117 per 30 days) lindane topical shampoo 1 % 2 malathion topical lotion 0.5 % (Ovide) 3 permethrin topical cream 5 % (Elimite) 2

114 Drug Name Drug Tier Requirements/Limits SKLICE TOPICAL LOTION 0.5 5 QL (117 per 30 days) % SOOLANTRA TOPICAL 3 ST CREAM 1 % spinosad topical suspension 0.9 % (Natroba) 3 Devices Devices BD LUER-LOK SYRINGE 4 SYRINGE 1 ML 20 GAUGE X 1" BD ULTRA-FINE NANO PEN 4 NEEDLE NEEDLE 32 GAUGE X 5/32" BD VEO INSULIN SYR (HALF 4 UNIT) SYRINGE 0.3 ML 31 GAUGE X 15/64" BD VEO INSULIN SYRINGE 4 UF SYRINGE 1 ML 31 GAUGE X 15/64", 1/2 ML 31 GAUGE X 15/64" LANCING DEVICE WITH (Accu-Chek FastClix 4 LANCETS KIT Lancing Dev) SURE COMFORT INS. SYR. U- 4 100 SYRINGE 0.5 ML 29 GAUGE X 1/2" Enzyme Replacement/Modifiers Enzyme Replacement/Modifiers CERDELGA ORAL CAPSULE 6 PA; QL (60 per 30 84 MG days) CHENODAL ORAL TABLET 6 PA 250 MG CREON ORAL 4 CAPSULE,DELAYED RELEASE(DR/EC) 12,000-38,000 -60,000 UNIT, 24,000-76,000 - 120,000 UNIT, 3,000-9,500- 15,000 UNIT, 36,000-114,000- 180,000 UNIT, 6,000-19,000 -30,000 UNIT ENZADYNE ORAL CAPSULE 5 9,000-112,500- 112,500 UNIT GALAFOLD ORAL CAPSULE 6 PA; QL (14 per 28 123 MG days)

115 Drug Name Drug Tier Requirements/Limits KUVAN ORAL POWDER IN 6 PA PACKET 100 MG, 500 MG KUVAN ORAL 6 PA TABLET,SOLUBLE 100 MG miglustat oral capsule 100 mg (Zavesca) 6 PA; QL (90 per 30 days) nitisinone oral capsule 10 mg, 2 mg, (Orfadin) 6 PA 5 mg NITYR ORAL TABLET 10 MG, 6 PA 2 MG, 5 MG ORFADIN ORAL CAPSULE 10 6 PA MG, 2 MG, 20 MG, 5 MG ORFADIN ORAL SUSPENSION 6 PA 4 MG/ML PALYNZIQ SUBCUTANEOUS 6 PA; QL (15 per 30 SYRINGE 10 MG/0.5 ML days) PALYNZIQ SUBCUTANEOUS 6 PA; QL (4 per 30 days) SYRINGE 2.5 MG/0.5 ML PALYNZIQ SUBCUTANEOUS 6 PA; QL (60 per 30 SYRINGE 20 MG/ML days) PULMOZYME INHALATION 6 PA SOLUTION 1 MG/ML REVCOVI INTRAMUSCULAR 6 PA SOLUTION 2.4 MG/1.5 ML (1.6 MG/ML) sapropterin oral powder in packet (Kuvan) 6 PA 100 mg, 500 mg sapropterin oral tablet,soluble 100 (Kuvan) 6 PA mg STRENSIQ SUBCUTANEOUS 6 PA SOLUTION 18 MG/0.45 ML, 28 MG/0.7 ML, 40 MG/ML, 80 MG/0.8 ML SUCRAID ORAL SOLUTION 6 PA 8,500 UNIT/ML VIOKACE ORAL TABLET 5 10,440-39,150- 39,150 UNIT, 20,880-78,300- 78,300 UNIT

116 Drug Name Drug Tier Requirements/Limits ZENPEP ORAL 4 CAPSULE,DELAYED RELEASE(DR/EC) 10,000-32,000 -42,000 UNIT, 10,000-34,000 - 55,000 UNIT, 15,000-47,000 - 63,000 UNIT, 15,000-51,000 - 82,000 UNIT, 20,000-63,000- 84,000 UNIT, 20,000-68,000 - 109,000 UNIT, 25,000-79,000- 105,000 UNIT, 25,000-85,000- 136,000 UNIT, 3,000-10,000 - 14,000-UNIT, 3,000-10,000- 16,000 UNIT, 40,000-126,000- 168,000 UNIT, 40,000-136,000- 218,000 UNIT, 5,000-17,000 -27,000 UNIT, 5,000-17,000- 24,000 UNIT Eye, Ear, Nose, Throat Agents Eye, Ear, Nose, Throat Agents, Miscellaneous AKTEN (PF) OPHTHALMIC 5 (EYE) GEL 3.5 % ALOMIDE OPHTHALMIC 5 (EYE) DROPS 0.1 % ophthalmic (eye) 2 drops 0.5 % atropine ophthalmic (eye) drops 1 (Isopto Atropine) 2 % atropine ophthalmic (eye) ointment 2 1 % azelastine nasal aerosol,spray 137 2 QL (60 per 30 days) mcg (0.1 %) azelastine nasal spray,non-aerosol 3 QL (60 per 30 days) 205.5 mcg (0.15 %) azelastine ophthalmic (eye) drops 2 0.05 % azelastine-fluticasone nasal (Dymista) 3 ST; QL (23 per 30 days) spray,non-aerosol 137-50 mcg/spray bepotastine besilate ophthalmic (Bepreve) 3 QL (10 per 30 days) (eye) drops 1.5 % BEPREVE OPHTHALMIC 5 QL (10 per 30 days) (EYE) DROPS 1.5 %

117 Drug Name Drug Tier Requirements/Limits ciprofloxacin-fluocinolone otic (Otovel) 3 (ear) solution 0.3-0.025 % (0.25 ml) cromolyn ophthalmic (eye) drops 4 2 % CYSTADROPS OPHTHALMIC 6 PA; QL (60 per 28 (EYE) DROPS 0.37 % days) CYSTARAN OPHTHALMIC 6 PA; QL (60 per 28 (EYE) DROPS 0.44 % days) DYMISTA NASAL 5 ST; QL (23 per 30 days) SPRAY,NON-AEROSOL 137-50 MCG/SPRAY EMADINE OPHTHALMIC 5 QL (10 per 30 days) (EYE) DROPS 0.05 % epinastine ophthalmic (eye) drops 2 0.05 % GELFILM OPHTHALMIC 5 (EYE) FILM homatropaire ophthalmic (eye) 2 drops 5 % homatropine hbr ophthalmic (eye) (Homatropaire) 3 drops 5 % IOPIDINE OPHTHALMIC 5 (EYE) DROPPERETTE 1 % ipratropium nasal 2 spray,non-aerosol 21 mcg (0.03 %), 42 mcg (0.06 %) LACRISERT OPHTHALMIC 5 (EYE) INSERT 5 MG LASTACAFT OPHTHALMIC 5 QL (3 per 30 days) (EYE) DROPS 0.25 % olopatadine nasal spray,non-aerosol (Patanase) 3 QL (30.5 per 30 days) 0.6 % olopatadine ophthalmic (eye) drops (Eye Allergy Itch- 3 0.1 % Redness Rlf) olopatadine ophthalmic (eye) drops (Eye Allergy Itch 3 QL (3 per 30 days) 0.2 % Relief) OTOVEL OTIC (EAR) 5 SOLUTION 0.3-0.025 % (0.25 ML) OXERVATE OPHTHALMIC 6 PA; QL (56 per 28 (EYE) DROPS 0.002 % days)

118 Drug Name Drug Tier Requirements/Limits phenylephrine hcl ophthalmic (eye) 2 drops 10 %, 2.5 % proparacaine ophthalmic (eye) (Alcaine) 2 drops 0.5 % TYZINE NASAL DROPS 0.1 % 5 TYZINE NASAL SPRAY,NON- 5 AEROSOL 0.1 % ZERVIATE OPHTHALMIC 5 QL (60 per 30 days) (EYE) DROPPERETTE 0.24 % Eye, Ear, Nose, Throat Anti- Infectives Agents acetic acid otic (ear) solution 2 % 2 acetic acid-aluminum acetate otic 2 (ear) drops 2 % AZASITE OPHTHALMIC (EYE) 5 DROPS 1 % bacitracin ophthalmic (eye) 2 ointment 500 unit/gram bacitracin-polymyxin b ophthalmic (Polycin) 2 (eye) ointment 500-10,000 unit/gram BESIVANCE OPHTHALMIC 4 (EYE) DROPS,SUSPENSION 0.6 % bleph-10 ophthalmic (eye) drops 10 3 % BLEPHAMIDE OPHTHALMIC 4 (EYE) DROPS,SUSPENSION 10- 0.2 % BLEPHAMIDE S.O.P. 4 OPHTHALMIC (EYE) OINTMENT 10-0.2 % CILOXAN OPHTHALMIC 5 (EYE) OINTMENT 0.3 % CIPRO HC OTIC (EAR) 5 DROPS,SUSPENSION 0.2-1 % CIPRODEX OTIC (EAR) 4 DROPS,SUSPENSION 0.3-0.1 % ciprofloxacin hcl ophthalmic (eye) (Ciloxan) 2 drops 0.3 % ciprofloxacin hcl otic (ear) (Cetraxal) 3 dropperette 0.2 %

119 Drug Name Drug Tier Requirements/Limits ciprofloxacin-dexamethasone otic (Ciprodex) 2 (ear) drops,suspension 0.3-0.1 % COLY-MYCIN S OTIC (EAR) 5 DROPS,SUSPENSION 3.3-3-10- 0.5 MG/ML CORTISPORIN-TC OTIC (EAR) 5 DROPS,SUSPENSION 3.3-3-10- 0.5 MG/ML erythromycin ophthalmic (eye) 2 ointment 5 mg/gram (0.5 %) gatifloxacin ophthalmic (eye) drops (Zymaxid) 3 0.5 % gentak ophthalmic (eye) ointment 2 0.3 % (3 mg/gram) gentamicin ophthalmic (eye) drops 2 0.3 % gentamicin ophthalmic (eye) (Gentak) 2 ointment 0.3 % (3 mg/gram) hydrocortisone-acetic acid otic 2 (ear) drops 1-2 % levofloxacin ophthalmic (eye) drops 2 0.5 % moxifloxacin ophthalmic (eye) (Vigamox) 2 drops 0.5 % NATACYN OPHTHALMIC 5 (EYE) DROPS,SUSPENSION 5 % neomycin-bacitracin-poly-hc (Neo-Polycin HC) 2 ophthalmic (eye) ointment 3.5-400- 10,000 mg-unit/g-1% neomycin-bacitracin-polymyxin (Neo-Polycin) 2 ophthalmic (eye) ointment 3.5-400- 10,000 mg-unit-unit/g neomycin-polymyxin b-dexameth (Maxitrol) 2 ophthalmic (eye) drops,suspension 3.5mg/ml-10,000 unit/ml-0.1 % neomycin-polymyxin b-dexameth (Maxitrol) 2 ophthalmic (eye) ointment 3.5 mg/g-10,000 unit/g-0.1 % neomycin-polymyxin-gramicidin 2 ophthalmic (eye) drops 1.75 mg- 10,000 unit-0.025mg/ml

120 Drug Name Drug Tier Requirements/Limits neomycin-polymyxin-hc ophthalmic 2 (eye) drops,suspension 3.5-10,000- 10 mg-unit-mg/ml neomycin-polymyxin-hc otic (ear) 2 drops,suspension 3.5-10,000-1 mg/ml-unit/ml-% neomycin-polymyxin-hc otic (ear) 2 solution 3.5-10,000-1 mg/ml-unit/ml- % neo-polycin hc ophthalmic (eye) 2 ointment 3.5-400-10,000 mg-unit/g- 1% neo-polycin ophthalmic (eye) 3 ointment 3.5-400-10,000 mg-unit- unit/g ofloxacin ophthalmic (eye) drops (Ocuflox) 2 0.3 % ofloxacin otic (ear) drops 0.3 % 2 polycin ophthalmic (eye) ointment 2 500-10,000 unit/gram polymyxin b sulf-trimethoprim (Polytrim) 2 ophthalmic (eye) drops 10,000 unit- 1 mg/ml PRED-G OPHTHALMIC (EYE) 5 DROPS,SUSPENSION 0.3-1 % PRED-G S.O.P. OPHTHALMIC 5 (EYE) OINTMENT 0.3-0.6 % sulfacetamide sodium ophthalmic (Bleph-10) 2 (eye) drops 10 % sulfacetamide sodium ophthalmic 2 (eye) ointment 10 % sulfacetamide-prednisolone 2 ophthalmic (eye) drops 10 %-0.23 % (0.25 %) TOBRADEX OPHTHALMIC 5 (EYE) OINTMENT 0.3-0.1 % TOBRADEX ST OPHTHALMIC 5 (EYE) DROPS,SUSPENSION 0.3-0.05 % tobramycin ophthalmic (eye) drops (Tobrex) 2 0.3 %

121 Drug Name Drug Tier Requirements/Limits tobramycin-dexamethasone (TobraDex) 2 ophthalmic (eye) drops,suspension 0.3-0.1 % TOBREX OPHTHALMIC (EYE) 5 OINTMENT 0.3 % trifluridine ophthalmic (eye) drops 2 1 % ZIRGAN OPHTHALMIC (EYE) 4 GEL 0.15 % ZYLET OPHTHALMIC (EYE) 5 DROPS,SUSPENSION 0.3-0.5 % Eye, Ear, Nose, Throat Anti- Inflammatory Agents ACUVAIL (PF) OPHTHALMIC 5 (EYE) DROPPERETTE 0.45 % ALOCRIL OPHTHALMIC 5 (EYE) DROPS 2 % ALREX OPHTHALMIC (EYE) 4 DROPS,SUSPENSION 0.2 % bromfenac ophthalmic (eye) drops 3 0.09 % BROMSITE OPHTHALMIC 5 (EYE) DROPS 0.075 % budesonide nasal spray,non-aerosol (Rhinocort Allergy) 3 QL (17.2 per 30 days) 32 mcg/actuation dexamethasone sodium phosphate 2 ophthalmic (eye) drops 0.1 % diclofenac sodium ophthalmic (eye) 2 drops 0.1 % DUREZOL OPHTHALMIC 5 (EYE) DROPS 0.05 % EYSUVIS OPHTHALMIC (EYE) 5 QL (8.3 per 30 days) DROPS,SUSPENSION 0.25 % FLAREX OPHTHALMIC (EYE) 4 DROPS,SUSPENSION 0.1 % flunisolide nasal spray,non-aerosol 2 QL (50 per 25 days) 25 mcg (0.025 %) fluocinolone acetonide oil otic (ear) (DermOtic Oil) 2 drops 0.01 % fluorometholone ophthalmic (eye) (FML Liquifilm) 2 drops,suspension 0.1 %

122 Drug Name Drug Tier Requirements/Limits flurbiprofen sodium ophthalmic 2 (eye) drops 0.03 % fluticasone propionate nasal (24 Hour Allergy 2 QL (16 per 30 days) spray,suspension 50 mcg/actuation Relief) FML FORTE OPHTHALMIC 4 (EYE) DROPS,SUSPENSION 0.25 % FML S.O.P. OPHTHALMIC 4 (EYE) OINTMENT 0.1 % ILEVRO OPHTHALMIC (EYE) 5 DROPS,SUSPENSION 0.3 % INVELTYS OPHTHALMIC 5 QL (5.6 per 14 days) (EYE) DROPS,SUSPENSION 1 % ketorolac ophthalmic (eye) drops (Acular LS) 2 0.4 % ketorolac ophthalmic (eye) drops (Acular) 2 0.5 % LOTEMAX OPHTHALMIC 4 (EYE) DROPS,GEL 0.5 % LOTEMAX OPHTHALMIC 4 (EYE) OINTMENT 0.5 % LOTEMAX SM OPHTHALMIC 4 (EYE) DROPS,GEL 0.38 % loteprednol etabonate ophthalmic (Lotemax) 3 (eye) drops,gel 0.5 % loteprednol etabonate ophthalmic (Lotemax) 2 (eye) drops,suspension 0.5 % MAXIDEX OPHTHALMIC 5 (EYE) DROPS,SUSPENSION 0.1 % mometasone nasal spray,non-aerosol (Nasonex) 3 QL (17 per 30 days) 50 mcg/actuation nasal allergy nasal aerosol,spray 55 3 QL (16.5 per 30 days) mcg NEVANAC OPHTHALMIC 5 (EYE) DROPS,SUSPENSION 0.1 % PRED MILD OPHTHALMIC 4 (EYE) DROPS,SUSPENSION 0.12 %

123 Drug Name Drug Tier Requirements/Limits prednisolone acetate ophthalmic (Pred Forte) 2 (eye) drops,suspension 1 % prednisolone sodium phosphate 2 ophthalmic (eye) drops 1 % PROLENSA OPHTHALMIC 4 (EYE) DROPS 0.07 % QNASL NASAL HFA AEROSOL 5 ST; QL (4.9 per 30 INHALER 40 days) MCG/ACTUATION QNASL NASAL HFA AEROSOL 5 ST; QL (8.7 per 30 INHALER 80 days) MCG/ACTUATION RESTASIS OPHTHALMIC 4 QL (60 per 30 days) (EYE) DROPPERETTE 0.05 % triamcinolone acetonide nasal (Nasal Allergy) 3 QL (16.5 per 30 days) aerosol,spray 55 mcg XIIDRA OPHTHALMIC (EYE) 4 DROPPERETTE 5 % Gastrointestinal Agents Antiulcer Agents And Acid Suppressants ACIPHEX SPRINKLE ORAL 5 ST; QL (30 per 30 days) CAPSULE, DELAYED REL SPRINKLE 10 MG, 5 MG amoxicil-clarithromy-lansopraz oral 3 QL (112 per 10 days) combo pack 500-500-30 mg cimetidine hcl oral solution 300 mg/5 2 ml cimetidine oral tablet 200 mg (Acid Reducer 2 (cimetidine)) cimetidine oral tablet 300 mg, 400 2 mg, 800 mg DEXILANT ORAL 5 ST; QL (30 per 30 days) CAPSULE,BIPHASE DELAYED RELEAS 30 MG, 60 MG esomeprazole magnesium oral (Nexium Packet) 3 ST; QL (30 per 30 days) granules dr for susp in packet 10 mg, 20 mg, 40 mg famotidine oral suspension 40 mg/5 3 ml (8 mg/ml) famotidine oral tablet 20 mg (Acid Controller) 1 famotidine oral tablet 40 mg (Pepcid) 2

124 Drug Name Drug Tier Requirements/Limits lansoprazole oral capsule,delayed (Prevacid 24Hr) 3 ST; QL (30 per 30 days) release(dr/ec) 15 mg lansoprazole oral capsule,delayed (Prevacid) 3 ST; QL (30 per 30 days) release(dr/ec) 30 mg lansoprazole oral tablet,disintegrat, (Prevacid SoluTab) 3 ST; QL (30 per 30 days) delay rel 15 mg, 30 mg misoprostol oral tablet 100 mcg, 200 (Cytotec) 2 mcg NEXIUM PACKET ORAL 5 ST; QL (30 per 30 days) GRANULES DR FOR SUSP IN PACKET 10 MG, 2.5 MG, 20 MG, 40 MG, 5 MG nizatidine oral capsule 150 mg, 300 3 mg nizatidine oral solution 150 mg/10 3 ml OMECLAMOX-PAK ORAL 5 QL (240 per 365 days) COMBO PACK 20 MG-500 MG- 500 MG (40) omeprazole oral capsule,delayed 2 QL (30 per 30 days) release(dr/ec) 10 mg, 20 mg, 40 mg pantoprazole oral granules dr for (Protonix) 3 ST; QL (30 per 30 days) susp in packet 40 mg pantoprazole oral tablet,delayed (Protonix) 2 QL (30 per 30 days) release (dr/ec) 20 mg, 40 mg PRILOSEC ORAL 5 ST; QL (30 per 30 days) SUSP,DELAYED RELEASE FOR RECON 10 MG, 2.5 MG PROTONIX ORAL GRANULES 5 ST; QL (30 per 30 days) DR FOR SUSP IN PACKET 40 MG rabeprazole oral tablet,delayed (AcipHex) 3 ST; QL (30 per 30 days) release (dr/ec) 20 mg ranitidine hcl oral syrup 15 mg/ml 2 ranitidine hcl oral tablet 150 mg, 1 300 mg sucralfate oral suspension 100 (Carafate) 2 mg/ml sucralfate oral tablet 1 gram (Carafate) 2 Gastrointestinal Agents, Other AMITIZA ORAL CAPSULE 24 5 QL (60 per 30 days) MCG, 8 MCG

125 Drug Name Drug Tier Requirements/Limits CARBAGLU ORAL TABLET, 6 DISPERSIBLE 200 MG CHOLBAM ORAL CAPSULE 6 PA 250 MG, 50 MG constulose oral solution 10 gram/15 2 ml cromolyn oral concentrate 100 mg/5 (Gastrocrom) 2 ml CUVPOSA ORAL SOLUTION 1 5 MG/5 ML (0.2 MG/ML) dicyclomine oral capsule 10 mg 2 dicyclomine oral solution 10 mg/5 ml 2 dicyclomine oral tablet 20 mg 2 diphenoxylate-atropine oral liquid 2 2.5-0.025 mg/5 ml diphenoxylate-atropine oral tablet (Lomotil) 2 2.5-0.025 mg ed-spaz oral tablet,disintegrating 2 0.125 mg enulose oral solution 10 gram/15 ml 2 GATTEX 30-VIAL 6 PA SUBCUTANEOUS KIT 5 MG generlac oral solution 10 gram/15 ml 2 glycopyrrolate oral tablet 1 mg, 2 2 mg hyoscyamine sulfate oral elixir (Hyosyne) 2 0.125 mg/5 ml hyoscyamine sulfate oral tablet (Oscimin) 2 0.125 mg hyoscyamine sulfate oral tablet (Oscimin SR) 2 extended release 12 hr 0.375 mg hyoscyamine sulfate oral (Ed-Spaz) 2 tablet,disintegrating 0.125 mg hyoscyamine sulfate sublingual (Oscimin SL) 2 tablet 0.125 mg hyosyne oral drops 0.125 mg/ml 2 kionex (with sorbitol) oral 2 suspension 15-19.3 gram/60 ml kionex oral powder 2 lactulose oral solution 10 gram/15 (Constulose) 2 ml

126 Drug Name Drug Tier Requirements/Limits LINZESS ORAL CAPSULE 145 4 QL (30 per 30 days) MCG, 290 MCG, 72 MCG LOKELMA ORAL POWDER IN 5 PA PACKET 10 GRAM, 5 GRAM oral capsule 2 mg (Anti-Diarrheal 2 (loperamide)) loperamide oral liquid 1 mg/7.5 ml (Anti-Diarrheal 2 (loperamide)) lubiprostone oral capsule 24 mcg, 8 (Amitiza) 3 QL (60 per 30 days) mcg methscopolamine oral tablet 2.5 mg, 2 5 mg metoclopramide hcl oral solution 5 2 mg/5 ml metoclopramide hcl oral tablet 10 (Reglan) 2 mg, 5 mg MOVANTIK ORAL TABLET 5 PA; QL (30 per 30 12.5 MG, 25 MG days) MYTESI ORAL 5 PA TABLET,DELAYED RELEASE (DR/EC) 125 MG OCALIVA ORAL TABLET 10 6 PA; QL (30 per 30 MG, 5 MG days) opium tincture oral tincture 10 3 mg/ml (morphine) oscimin oral tablet 0.125 mg 2 oscimin oral tablet,disintegrating 2 0.125 mg oscimin sl sublingual tablet 0.125 mg 2 oscimin sr oral tablet extended 2 release 12 hr 0.375 mg paregoric oral liquid 2 mg/5 ml 2 propantheline oral tablet 15 mg 2 PYLERA ORAL CAPSULE 140- 6 125-125 MG RELISTOR ORAL TABLET 150 6 PA; QL (90 per 30 MG days) RELISTOR SUBCUTANEOUS 6 PA; QL (28 per 28 SOLUTION 12 MG/0.6 ML days) RELISTOR SUBCUTANEOUS 6 PA; QL (16.8 per 28 SYRINGE 12 MG/0.6 ML days)

127 Drug Name Drug Tier Requirements/Limits RELISTOR SUBCUTANEOUS 6 PA; QL (11.2 per 28 SYRINGE 8 MG/0.4 ML days) sodium phenylbutyrate oral powder (Buphenyl) 6 PA 0.94 gram/gram sodium phenylbutyrate oral tablet (Buphenyl) 6 PA 500 mg sodium polystyrene (sorb free) oral 2 suspension 15 gram/60 ml sodium polystyrene sulfonate oral 2 powder sps (with sorbitol) oral suspension 2 15-20 gram/60 ml ursodiol oral capsule 300 mg 3 ursodiol oral tablet 250 mg (URSO 250) 3 ursodiol oral tablet 500 mg (URSO Forte) 3 VELTASSA ORAL POWDER IN 6 PA; QL (30 per 30 PACKET 16.8 GRAM, 25.2 days) GRAM, 8.4 GRAM XERMELO ORAL TABLET 250 6 PA; QL (90 per 30 MG days) Laxatives CLENPIQ ORAL SOLUTION 10 5 MG-3.5 GRAM -12 GRAM/160 ML gavilyte-c oral recon soln 240-22.72- 2 6.72 -5.84 gram gavilyte-g oral recon soln 236-22.74- 2 6.74 -5.86 gram gavilyte-n oral recon soln 420 gram 2 GIALAX ORAL KIT 17 GRAM/ 4 SCOOP GOLYTELY ORAL POWDER 4 IN PACKET 227.1-21.5-6.36 GRAM MOVIPREP ORAL POWDER IN 5 PACKET 100-7.5-2.691 GRAM OSMOPREP ORAL TABLET 1.5 5 GRAM peg 3350-electrolytes oral recon soln (GaviLyte-G) 2 236-22.74-6.74 -5.86 gram peg 3350-electrolytes oral recon soln (Gavilyte-C) 2 240-22.72-6.72 -5.84 gram

128 Drug Name Drug Tier Requirements/Limits peg3350-sod sul-nacl-kcl-asb-c oral (MoviPrep) 3 powder in packet 100-7.5-2.691 gram peg-electrolyte soln oral recon soln (GaviLyte-N) 2 420 gram PLENVU ORAL POWDER IN 5 PACKET, SEQUENTIAL 140-9- 5.2 GRAM PREPOPIK ORAL POWDER IN 5 PACKET 10 MG-3.5 GRAM-12 GRAM SUPREP BOWEL PREP KIT 5 ORAL RECON SOLN 17.5-3.13- 1.6 GRAM trilyte with flavor packets oral recon 2 soln 420 gram Phosphate Binders calcium acetate(phosphat bind) oral 2 capsule 667 mg calcium acetate(phosphat bind) oral 2 tablet 667 mg eliphos oral tablet 667 mg 2 FOSRENOL ORAL POWDER 6 IN PACKET 1,000 MG, 750 MG lanthanum oral tablet,chewable (Fosrenol) 3 1,000 mg, 500 mg, 750 mg PHOSLYRA ORAL SOLUTION 5 667 MG (169 MG CALCIUM)/5 ML RENAGEL ORAL TABLET 400 5 MG sevelamer carbonate oral powder in (Renvela) 3 packet 0.8 gram, 2.4 gram sevelamer carbonate oral tablet 800 (Renvela) 3 mg sevelamer hcl oral tablet 400 mg 3 sevelamer hcl oral tablet 800 mg (Renagel) 3 VELPHORO ORAL 5 TABLET,CHEWABLE 500 MG

129 Drug Name Drug Tier Requirements/Limits Genitourinary Agents Antispasmodics, Urinary bethanechol chloride oral tablet 10 2 mg, 25 mg, 5 mg, 50 mg oral tablet extended 3 ST; QL (30 per 30 days) release 24 hr 15 mg, 7.5 mg flavoxate oral tablet 100 mg 2 GELNIQUE TRANSDERMAL 5 ST GEL IN PACKET 10 % (100 MG/GRAM) MYRBETRIQ ORAL TABLET 4 QL (30 per 30 days) EXTENDED RELEASE 24 HR 25 MG, 50 MG oxybutynin chloride oral syrup 5 2 mg/5 ml oxybutynin chloride oral tablet 5 mg 2 oxybutynin chloride oral tablet (Ditropan XL) 3 extended release 24hr 10 mg, 5 mg oxybutynin chloride oral tablet 3 extended release 24hr 15 mg OXYTROL TRANSDERMAL 6 ST PATCH SEMIWEEKLY 3.9 MG/24 HR oral tablet 10 mg, 5 mg (Vesicare) 2 oral capsule,extended (Detrol LA) 3 ST; QL (30 per 30 days) release 24hr 2 mg, 4 mg tolterodine oral tablet 1 mg, 2 mg (Detrol) 3 ST; QL (60 per 30 days) TOVIAZ ORAL TABLET 4 ST; QL (30 per 30 days) EXTENDED RELEASE 24 HR 4 MG, 8 MG trospium oral capsule,extended 3 release 24hr 60 mg trospium oral tablet 20 mg 2 VESICARE LS ORAL 4 SUSPENSION 1 MG/ML Genitourinary Agents, Miscellaneous oral tablet extended (Uroxatral) 2 release 24 hr 10 mg CYSTAGON ORAL CAPSULE 5 150 MG, 50 MG dutasteride oral capsule 0.5 mg (Avodart) 3

130 Drug Name Drug Tier Requirements/Limits dutasteride- oral capsule, (Jalyn) 3 er multiphase 24 hr 0.5-0.4 mg finasteride oral tablet 5 mg (Proscar) 2 hyophen oral tablet 81.6-0.12-10.8 3 mg LITHOSTAT ORAL TABLET 6 250 MG phenazopyridine oral tablet 100 mg, (Pyridium) 2 200 mg PROCYSBI ORAL CAPSULE, 6 PA DELAYED REL SPRINKLE 25 MG, 75 MG oral capsule 4 mg, 8 mg (Rapaflo) 3 QL (30 per 30 days) tamsulosin oral capsule 0.4 mg (Flomax) 2 oral capsule 1 mg, 10 mg, 2 2 mg, 5 mg THIOLA EC ORAL 6 TABLET,DELAYED RELEASE (DR/EC) 100 MG, 300 MG THIOLA ORAL TABLET 100 6 MG tiopronin oral tablet 100 mg (Thiola) 6 PA uro-mp oral capsule 118-10-40.8-36 3 mg ustell oral capsule 120-0.12 mg 3 Heavy Metal Antagonists Heavy Metal Antagonists CHEMET ORAL CAPSULE 100 6 MG clovique oral capsule 250 mg 6 PA deferasirox oral granules in packet (Jadenu Sprinkle) 6 PA 180 mg, 360 mg, 90 mg deferasirox oral tablet 180 mg, 360 (Jadenu) 6 PA mg, 90 mg deferasirox oral tablet, dispersible (Exjade) 6 PA 125 mg, 250 mg, 500 mg d-penamine oral tablet 125 mg 6 PA; QL (480 per 30 days) JADENU ORAL TABLET 180 6 PA MG

131 Drug Name Drug Tier Requirements/Limits JADENU SPRINKLE ORAL 6 PA GRANULES IN PACKET 180 MG, 360 MG, 90 MG penicillamine oral capsule 250 mg (Cuprimine) 6 PA; QL (240 per 30 days) penicillamine oral tablet 250 mg (Depen Titratabs) 6 PA; QL (240 per 30 days) trientine oral capsule 250 mg (Clovique) 6 PA Hormonal Agents, Stimulant/Replacement/Modifyi ng Androgens ANADROL-50 ORAL TABLET 6 PA 50 MG ANDRODERM 5 PA NSO; QL (30 per 30 TRANSDERMAL PATCH 24 days) HOUR 2 MG/24 HOUR, 4 MG/24 HR androxy oral tablet 10 mg 3 PA; QL (120 per 30 days) covaryx h.s. oral tablet 0.625-1.25 2 mg covaryx oral tablet 1.25-2.5 mg 2 danazol oral capsule 100 mg, 200 2 mg, 50 mg estrogens-methyltestosterone oral (Covaryx H.S.) 2 tablet 0.625-1.25 mg estrogens-methyltestosterone oral (Covaryx) 2 tablet 1.25-2.5 mg METHITEST ORAL TABLET 10 5 PA NSO; QL (20 per 10 MG days) methyltestosterone oral capsule 10 3 PA NSO; QL (150 per mg 30 days) oxandrolone oral tablet 10 mg, 2.5 (Oxandrin) 2 PA mg STRIANT BUCCAL 5 PA NSO; QL (60 per 30 MUCOADHESIVE SYSTEM ER days) 12 HR 30 MG testosterone cypionate (Depo-Testosterone) 2 PA NSO; QL (10 per 30 intramuscular oil 100 mg/ml, 200 days) mg/ml

132 Drug Name Drug Tier Requirements/Limits testosterone enanthate 2 PA NSO; QL (10 per 30 intramuscular oil 200 mg/ml days) testosterone transdermal gel in (AndroGel) 3 PA NSO; QL (150 per packet 1 % (25 mg/2.5gram), 1.62 30 days) % (40.5 mg/2.5 gram) testosterone transdermal gel in (AndroGel) 3 PA NSO; QL (300 per packet 1 % (50 mg/5 gram) 30 days) testosterone transdermal gel in (AndroGel) 3 PA NSO; QL (37.5 per packet 1.62 % (20.25 mg/1.25 30 days) gram) testosterone transdermal solution in 3 PA NSO; QL (180 per metered pump w/app 30 30 days) mg/actuation (1.5 ml) Estrogens And Antiestrogens ALORA TRANSDERMAL 5 QL (8 per 30 days) PATCH SEMIWEEKLY 0.025 MG/24 HR, 0.05 MG/24 HR, 0.075 MG/24 HR, 0.1 MG/24 HR amabelz oral tablet 0.5-0.1 mg, 1- 2 0.5 mg ANGELIQ ORAL TABLET 0.25- 5 0.5 MG, 0.5-1 MG BIJUVA ORAL CAPSULE 1-100 5 MG CLIMARA PRO 5 QL (4 per 28 days) TRANSDERMAL PATCH WEEKLY 0.045-0.015 MG/24 HR COMBIPATCH 5 QL (4 per 28 days) TRANSDERMAL PATCH SEMIWEEKLY 0.05-0.14 MG/24 HR, 0.05-0.25 MG/24 HR DIVIGEL TRANSDERMAL 4 GEL IN PACKET 1 MG/GRAM (0.1 %) dotti transdermal patch semiweekly 3 QL (9 per 30 days) 0.025 mg/24 hr, 0.0375 mg/24 hr, 0.05 mg/24 hr, 0.075 mg/24 hr, 0.1 mg/24 hr DUAVEE ORAL TABLET 0.45- 5 20 MG

133 Drug Name Drug Tier Requirements/Limits ELESTRIN TRANSDERMAL 5 GEL IN METERED-DOSE PUMP 0.87 GRAM/ACTUATION estradiol oral tablet 0.5 mg, 1 mg, 2 (Estrace) 2 mg estradiol transdermal patch (Dotti) 3 QL (9 per 30 days) semiweekly 0.025 mg/24 hr, 0.0375 mg/24 hr, 0.05 mg/24 hr, 0.075 mg/24 hr, 0.1 mg/24 hr estradiol transdermal patch weekly (Climara) 2 QL (4 per 28 days) 0.025 mg/24 hr, 0.0375 mg/24 hr, 0.05 mg/24 hr, 0.06 mg/24 hr, 0.075 mg/24 hr, 0.1 mg/24 hr estradiol vaginal cream 0.01 % (0.1 (Estrace) 2 mg/gram) estradiol vaginal tablet 10 mcg (Yuvafem) 2 estradiol-norethindrone acet oral (Amabelz) 2 tablet 0.5-0.1 mg, 1-0.5 mg ESTRING VAGINAL RING 2 5 QL (1 per 90 days) MG (7.5 MCG /24 HOUR) estropipate oral tablet 0.75 mg, 1.5 2 mg, 3 mg EVAMIST TRANSDERMAL 5 QL (16.2 per 30 days) SPRAY,NON-AEROSOL 1.53 MG/SPRAY (1.7%) FEMRING VAGINAL RING 5 QL (1 per 84 days) 0.05 MG/24 HR, 0.1 MG/24 HR fyavolv oral tablet 0.5-2.5 mg-mcg, 2 1-5 mg-mcg IMVEXXY MAINTENANCE 5 QL (18 per 28 days) PACK VAGINAL INSERT 10 MCG, 4 MCG IMVEXXY STARTER PACK 5 QL (18 per 28 days) VAGINAL INSERT, DOSE PACK 10 MCG, 4 MCG jinteli oral tablet 1-5 mg-mcg 2 lopreeza oral tablet 0.5-0.1 mg, 1- 2 0.5 mg MENEST ORAL TABLET 0.3 5 MG, 0.625 MG, 1.25 MG, 2.5 MG

134 Drug Name Drug Tier Requirements/Limits MENOSTAR TRANSDERMAL 5 QL (4 per 28 days) PATCH WEEKLY 14 MCG/24 HR mimvey lo oral tablet 0.5-0.1 mg 2 mimvey oral tablet 1-0.5 mg 2 norethindrone ac-eth estradiol oral (Fyavolv) 2 tablet 0.5-2.5 mg-mcg, 1-5 mg-mcg OSPHENA ORAL TABLET 60 5 PA; QL (30 per 30 MG days) PREFEST ORAL TABLET 1 MG 5 (15)/1 MG- 0.09 MG (15) PREMARIN ORAL TABLET 0.3 4 MG, 0.45 MG, 0.625 MG, 0.9 MG, 1.25 MG PREMARIN VAGINAL CREAM 4 0.625 MG/GRAM PREMPHASE ORAL TABLET 4 0.625 MG (14)/ 0.625MG- 5MG(14) PREMPRO ORAL TABLET 0.3- 4 1.5 MG, 0.45-1.5 MG, 0.625-2.5 MG, 0.625-5 MG raloxifene oral tablet 60 mg (Evista) 3 PA yuvafem vaginal tablet 10 mcg 2 Glucocorticoids/Mineralocorticoids cortisone oral tablet 25 mg 2 decadron oral elixir 0.5 mg/5 ml 5 decadron oral tablet 0.5 mg, 0.75 5 mg, 4 mg, 6 mg deltasone oral tablet 20 mg 1 DEXAMETHASONE 3 INTENSOL ORAL DROPS 1 MG/ML dexamethasone oral elixir 0.5 mg/5 2 ml dexamethasone oral tablet 0.5 mg, (Decadron) 1 0.75 mg, 4 mg dexamethasone oral tablet 1 mg, 2 1 mg dexamethasone oral tablet 1.5 mg 2 dexamethasone oral tablet 6 mg (Decadron) 2

135 Drug Name Drug Tier Requirements/Limits EMFLAZA ORAL 6 PA; QL (39 per 30 SUSPENSION 22.75 MG/ML days) EMFLAZA ORAL TABLET 18 6 PA; QL (30 per 30 MG days) EMFLAZA ORAL TABLET 30 6 PA; QL (60 per 30 MG, 36 MG, 6 MG days) fludrocortisone oral tablet 0.1 mg 2 HEMADY ORAL TABLET 20 5 MG hydrocortisone oral tablet 10 mg, 20 (Cortef) 2 mg, 5 mg MEDROL ORAL TABLET 2 MG 5 methylprednisolone oral tablet 16 (Medrol) 2 mg, 32 mg, 4 mg, 8 mg methylprednisolone oral tablets,dose (Medrol (Pak)) 2 pack 4 mg MILLIPRED DP ORAL 5 TABLETS,DOSE PACK 5 MG (21 TABS), 5 MG (48 TABS) MILLIPRED ORAL TABLET 5 5 MG prednisolone sodium phosphate oral 2 solution 10 mg/5 ml, 15 mg/5 ml (3 mg/ml), 25 mg/5 ml (5 mg/ml) prednisolone sodium phosphate oral (Veripred 20) 2 solution 20 mg/5 ml (4 mg/ml) prednisolone sodium phosphate oral (Pediapred) 2 solution 5 mg base/5 ml (6.7 mg/5 ml) prednisolone sodium phosphate oral (Orapred ODT) 3 tablet,disintegrating 10 mg, 15 mg, 30 mg PREDNISONE INTENSOL 3 ORAL CONCENTRATE 5 MG/ML prednisone oral solution 5 mg/5 ml 2 prednisone oral tablet 1 mg, 10 mg, 1 2.5 mg, 20 mg, 5 mg prednisone oral tablet 50 mg 2 prednisone oral tablets,dose pack 10 2 mg, 5 mg

136 Drug Name Drug Tier Requirements/Limits Pituitary BYNFEZIA SUBCUTANEOUS 6 PA PEN INJECTOR 2,500 MCG/ML desmopressin injection solution 4 (DDAVP) 3 mcg/ml desmopressin nasal spray with pump 2 10 mcg/spray (0.1 ml) desmopressin oral tablet 0.1 mg, 0.2 (DDAVP) 2 mg LUPANETA PACK (1 MONTH) 6 PA KIT. SYRINGE AND TABLET 3.75 MG -5 MG (30) LUPANETA PACK (3 MONTH) 6 PA KIT. SYRINGE AND TABLET 11.25 MG -5 MG (90) NORDITROPIN FLEXPRO 6 PA SUBCUTANEOUS PEN INJECTOR 10 MG/1.5 ML (6.7 MG/ML), 15 MG/1.5 ML (10 MG/ML), 30 MG/3 ML (10 MG/ML), 5 MG/1.5 ML (3.3 MG/ML) octreotide acetate injection solution 6 PA 1,000 mcg/ml, 200 mcg/ml octreotide acetate injection solution (Sandostatin) 6 PA 100 mcg/ml, 50 mcg/ml, 500 mcg/ml octreotide acetate injection syringe 6 PA 100 mcg/ml (1 ml), 50 mcg/ml (1 ml), 500 mcg/ml (1 ml) ORILISSA ORAL TABLET 150 6 PA; QL (30 per 30 MG days) ORILISSA ORAL TABLET 200 6 PA; QL (60 per 30 MG days) SIGNIFOR SUBCUTANEOUS 6 PA; QL (60 per 30 SOLUTION 0.3 MG/ML (1 ML), days) 0.6 MG/ML (1 ML), 0.9 MG/ML (1 ML) SOMAVERT SUBCUTANEOUS 6 PA RECON SOLN 10 MG, 15 MG, 20 MG, 25 MG, 30 MG STIMATE NASAL 5 SPRAY,NON-AEROSOL 150 MCG/SPRAY (0.1 ML)

137 Drug Name Drug Tier Requirements/Limits SYNAREL NASAL 6 PA SPRAY,NON-AEROSOL 2 MG/ML Progestins CRINONE VAGINAL GEL 4 % 5 QL (6 per 1 day) CRINONE VAGINAL GEL 8 % 5 PA; QL (6 per 1 day) DEPO-PROVERA 5 INTRAMUSCULAR SUSPENSION 400 MG/ML DEPO-SUBQ PROVERA 104 5 SUBCUTANEOUS SYRINGE 104 MG/0.65 ML ENDOMETRIN VAGINAL 5 PA; QL (60 per 30 INSERT 100 MG days) medroxyprogesterone intramuscular (Depo-Provera) 1 suspension 150 mg/ml medroxyprogesterone intramuscular (Depo-Provera) 1 syringe 150 mg/ml medroxyprogesterone oral tablet 10 (Provera) 2 mg, 2.5 mg, 5 mg megestrol oral suspension 400 mg/10 2 ml (40 mg/ml), 625 mg/5 ml (125 mg/ml) norethindrone acetate oral tablet 5 (Aygestin) 2 mg progesterone micronized oral (Prometrium) 2 capsule 100 mg, 200 mg Thyroid And Antithyroid Agents ARMOUR THYROID ORAL 4 TABLET 120 MG, 15 MG, 180 MG, 240 MG, 30 MG, 300 MG, 60 MG, 90 MG euthyrox oral tablet 100 mcg, 112 2 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg levothyroxine oral tablet 100 mcg, (Euthyrox) 2 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg levothyroxine oral tablet 300 mcg (Synthroid) 2

138 Drug Name Drug Tier Requirements/Limits LEVOXYL ORAL TABLET 100 5 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG liothyronine oral tablet 25 mcg, 5 (Cytomel) 2 mcg, 50 mcg methimazole oral tablet 10 mg, 5 mg (Tapazole) 2 nature-throid oral tablet 113.75 mg, 3 130 mg, 146.25 mg, 16.25 mg, 162.5 mg, 195 mg, 260 mg, 32.5 mg, 325 mg, 48.75 mg, 65 mg, 81.25 mg, 97.5 mg np thyroid oral tablet 120 mg, 15 3 mg, 30 mg, 60 mg, 90 mg propylthiouracil oral tablet 50 mg 2 sski oral solution 1 gram/ml 2 strong iodine oral solution 5 % 2 SYNTHROID ORAL TABLET 5 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG thyroid (pork) oral tablet 120 mg, (NP Thyroid) 3 15 mg, 30 mg, 60 mg, 90 mg THYROLAR-1 ORAL TABLET 5 12.5-50 MCG THYROLAR-1/2 ORAL 5 TABLET 6.25-25 MCG THYROLAR-1/4 ORAL 5 TABLET 3.1-12.5 MCG THYROLAR-2 ORAL TABLET 5 25-100 MCG THYROLAR-3 ORAL TABLET 5 37.5-150 MCG UNITHROID ORAL TABLET 5 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG westhroid oral tablet 130 mg, 195 2 mg, 32.5 mg, 65 mg

139 Drug Name Drug Tier Requirements/Limits westhroid oral tablet 97.5 mg 3 wp thyroid oral tablet 113.75 mg, 3 130 mg, 16.25 mg, 32.5 mg, 48.75 mg, 65 mg, 81.25 mg, 97.5 mg Immunological Agents Immunological Agents ACTEMRA ACTPEN 6 PA; QL (4 per 28 days) SUBCUTANEOUS PEN INJECTOR 162 MG/0.9 ML ACTEMRA SUBCUTANEOUS 6 PA; QL (4 per 28 days) SYRINGE 162 MG/0.9 ML ARCALYST SUBCUTANEOUS 6 PA RECON SOLN 220 MG AZASAN ORAL TABLET 100 5 MG, 75 MG azathioprine oral tablet 50 mg (Imuran) 2 CIMZIA POWDER FOR 6 PA; QL (1 per 28 days) RECONST SUBCUTANEOUS KIT 400 MG (200 MG X 2 VIALS) CIMZIA SUBCUTANEOUS 6 PA; QL (3 per 28 days) SYRINGE KIT 400 MG/2 ML (200 MG/ML X 2) COSENTYX (2 SYRINGES) 6 PA SUBCUTANEOUS SYRINGE 150 MG/ML COSENTYX PEN (2 PENS) 6 PA SUBCUTANEOUS PEN INJECTOR 150 MG/ML COSENTYX SUBCUTANEOUS 6 PA SYRINGE 75 MG/0.5 ML CUTAQUIG SUBCUTANEOUS 6 PA SOLUTION 16.5 % CUVITRU SUBCUTANEOUS 6 PA SOLUTION 1 GRAM/5 ML (20 %), 10 GRAM/50 ML (20 %), 2 GRAM/10 ML (20 %), 4 GRAM/20 ML (20 %), 8 GRAM/40 ML (20 %) cyclosporine modified oral capsule (Gengraf) 2 100 mg, 25 mg

140 Drug Name Drug Tier Requirements/Limits cyclosporine modified oral capsule 2 50 mg cyclosporine modified oral solution (Gengraf) 2 100 mg/ml cyclosporine oral capsule 100 mg, 25 (Sandimmune) 2 mg DUPIXENT PEN 6 PA; QL (4 per 28 days) SUBCUTANEOUS PEN INJECTOR 200 MG/1.14 ML, 300 MG/2 ML DUPIXENT SYRINGE 6 PA; QL (2.28 per 28 SUBCUTANEOUS SYRINGE days) 200 MG/1.14 ML DUPIXENT SYRINGE 6 PA; QL (4 per 28 days) SUBCUTANEOUS SYRINGE 300 MG/2 ML ENBREL MINI 6 PA SUBCUTANEOUS CARTRIDGE 50 MG/ML (1 ML) ENBREL SUBCUTANEOUS 6 PA RECON SOLN 25 MG (1 ML) ENBREL SUBCUTANEOUS 6 PA SOLUTION 25 MG/0.5 ML ENBREL SUBCUTANEOUS 6 PA SYRINGE 25 MG/0.5 ML (0.5), 50 MG/ML (1 ML) ENBREL SURECLICK 6 PA SUBCUTANEOUS PEN INJECTOR 50 MG/ML (1 ML) everolimus (immunosuppressive) (Zortress) 6 oral tablet 0.25 mg, 0.5 mg, 0.75 mg gengraf oral capsule 100 mg, 25 mg, 2 50 mg gengraf oral solution 100 mg/ml 2 HIZENTRA SUBCUTANEOUS 6 PA SOLUTION 1 GRAM/5 ML (20 %), 10 GRAM/50 ML (20 %), 2 GRAM/10 ML (20 %), 4 GRAM/20 ML (20 %)

141 Drug Name Drug Tier Requirements/Limits HIZENTRA SUBCUTANEOUS 6 PA SYRINGE 1 GRAM/5 ML (20 %), 2 GRAM/10 ML (20 %), 4 GRAM/20 ML (20 %) HUMIRA PEDIATRIC 6 PA; QL (2 per 28 days) CROHNS START SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML HUMIRA PEN CROHNS-UC- 6 PA; QL (6 per 28 days) HS START SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML HUMIRA PEN PSOR-UVEITS- 6 PA; QL (4 per 28 days) ADOL HS SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML HUMIRA PEN 6 PA; QL (4 per 28 days) SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML HUMIRA SUBCUTANEOUS 6 PA; QL (2 per 28 days) SYRINGE KIT 10 MG/0.2 ML, 20 MG/0.4 ML, 40 MG/0.8 ML HUMIRA(CF) PEDI CROHNS 6 PA; QL (2 per 28 days) STARTER SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML, 80 MG/0.8 ML-40 MG/0.4 ML HUMIRA(CF) PEN CROHNS- 6 PA; QL (3 per 28 days) UC-HS SUBCUTANEOUS PEN INJECTOR KIT 80 MG/0.8 ML HUMIRA(CF) PEN PEDIATRIC 6 PA; QL (2 per 28 days) UC SUBCUTANEOUS PEN INJECTOR KIT 80 MG/0.8 ML HUMIRA(CF) PEN PSOR-UV- 6 PA; QL (3 per 28 days) ADOL HS SUBCUTANEOUS PEN INJECTOR KIT 80 MG/0.8 ML-40 MG/0.4 ML HUMIRA(CF) PEN 6 PA; QL (4 per 28 days) SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.4 ML HUMIRA(CF) PEN 6 PA; QL (3 per 28 days) SUBCUTANEOUS PEN INJECTOR KIT 80 MG/0.8 ML

142 Drug Name Drug Tier Requirements/Limits HUMIRA(CF) 6 PA; QL (2 per 28 days) SUBCUTANEOUS SYRINGE KIT 10 MG/0.1 ML, 20 MG/0.2 ML, 40 MG/0.4 ML HYQVIA IG COMPONENT 6 PA SUBCUTANEOUS SOLUTION 10 GRAM/100 ML (10 %), 2.5 GRAM/25 ML (10 %), 20 GRAM/200 ML (10 %), 30 GRAM/300 ML (10 %), 5 GRAM/50 ML (10 %) HYQVIA SUBCUTANEOUS 6 PA SOLUTION 10 GRAM /100 ML (10 %), 2.5 GRAM /25 ML (10 %), 20 GRAM /200 ML (10 %), 30 GRAM /300 ML (10 %), 5 GRAM /50 ML (10 %) KINERET SUBCUTANEOUS 6 PA; QL (28 per 28 SYRINGE 100 MG/0.67 ML days) leflunomide oral tablet 10 mg, 20 mg (Arava) 2 ST mycophenolate mofetil oral capsule (CellCept) 2 250 mg mycophenolate mofetil oral (CellCept) 3 suspension for reconstitution 200 mg/ml mycophenolate mofetil oral tablet (CellCept) 2 500 mg mycophenolate sodium oral (Myfortic) 3 tablet,delayed release (dr/ec) 180 mg, 360 mg ORENCIA CLICKJECT 6 PA; QL (4 per 28 days) SUBCUTANEOUS AUTO- INJECTOR 125 MG/ML ORENCIA SUBCUTANEOUS 6 PA; QL (4 per 28 days) SYRINGE 125 MG/ML ORENCIA SUBCUTANEOUS 6 PA; QL (1.6 per 28 SYRINGE 50 MG/0.4 ML days) ORENCIA SUBCUTANEOUS 6 PA; QL (2.8 per 28 SYRINGE 87.5 MG/0.7 ML days) OTEZLA ORAL TABLET 30 MG 6 PA; QL (60 per 30 days)

143 Drug Name Drug Tier Requirements/Limits OTEZLA STARTER ORAL 6 PA; QL (55 per 28 TABLETS,DOSE PACK 10 MG days) (4)-20 MG (4)-30 MG (47) OTEZLA STARTER ORAL 6 PA; QL (27 per 14 TABLETS,DOSE PACK 10 MG days) (4)-20 MG (4)-30 MG(19) OTREXUP (PF) 5 ST; QL (1.6 per 28 SUBCUTANEOUS AUTO- days) INJECTOR 10 MG/0.4 ML, 12.5 MG/0.4 ML, 15 MG/0.4 ML, 17.5 MG/0.4 ML, 20 MG/0.4 ML, 22.5 MG/0.4 ML, 25 MG/0.4 ML PROGRAF ORAL GRANULES 6 IN PACKET 0.2 MG, 1 MG RIDAURA ORAL CAPSULE 3 6 MG RINVOQ ORAL TABLET 6 PA; QL (30 per 30 EXTENDED RELEASE 24 HR days) 15 MG SANDIMMUNE ORAL 5 SOLUTION 100 MG/ML SILIQ SUBCUTANEOUS 6 PA; QL (3 per 28 days) SYRINGE 210 MG/1.5 ML SIMPONI SUBCUTANEOUS 6 PA; QL (1 per 28 days) PEN INJECTOR 100 MG/ML SIMPONI SUBCUTANEOUS 6 PA; QL (0.5 per 28 PEN INJECTOR 50 MG/0.5 ML days) SIMPONI SUBCUTANEOUS 6 PA; QL (1 per 28 days) SYRINGE 100 MG/ML SIMPONI SUBCUTANEOUS 6 PA; QL (0.5 per 28 SYRINGE 50 MG/0.5 ML days) sirolimus oral solution 1 mg/ml (Rapamune) 6 sirolimus oral tablet 0.5 mg, 1 mg, 2 (Rapamune) 6 mg SKYRIZI SUBCUTANEOUS 6 PA PEN INJECTOR 150 MG/ML SKYRIZI SUBCUTANEOUS 6 PA SYRINGE 150 MG/ML, 75 MG/0.83 ML

144 Drug Name Drug Tier Requirements/Limits SKYRIZI SUBCUTANEOUS 6 PA SYRINGE KIT 150MG/1.66ML(75 MG/0.83 ML X2) STELARA SUBCUTANEOUS 6 PA; QL (1 per 28 days) SOLUTION 45 MG/0.5 ML STELARA SUBCUTANEOUS 6 PA; QL (1 per 28 days) SYRINGE 45 MG/0.5 ML STELARA SUBCUTANEOUS 6 PA; QL (1 per 84 days) SYRINGE 90 MG/ML tacrolimus oral capsule 0.5 mg, 1 (Prograf) 6 mg, 5 mg TREMFYA SUBCUTANEOUS 6 PA; QL (1 per 56 days) AUTO-INJECTOR 100 MG/ML TREMFYA SUBCUTANEOUS 6 PA; QL (1 per 56 days) SYRINGE 100 MG/ML XELJANZ ORAL SOLUTION 1 6 PA; QL (300 per 30 MG/ML days) XELJANZ ORAL TABLET 10 6 PA; QL (60 per 30 MG, 5 MG days) XELJANZ XR ORAL TABLET 6 PA; QL (30 per 30 EXTENDED RELEASE 24 HR days) 11 MG, 22 MG XEMBIFY SUBCUTANEOUS 6 PA SOLUTION 1 GRAM/5 ML (20 %), 10 GRAM/50 ML (20 %), 2 GRAM/10 ML (20 %), 4 GRAM/20 ML (20 %) ZORTRESS ORAL TABLET 0.25 6 MG, 0.5 MG, 0.75 MG, 1 MG Vaccines ADACEL(TDAP 1 QL (0.5 per 365 days); ADOLESN/ADULT)(PF) AGE (Min 7 Years) INTRAMUSCULAR SUSPENSION 2 LF-(2.5-5-3-5 MCG)-5LF/0.5 ML ADACEL(TDAP 1 QL (0.5 per 365 days); ADOLESN/ADULT)(PF) AGE (Min 7 Years) INTRAMUSCULAR SYRINGE 2 LF-(2.5-5-3-5 MCG)-5LF/0.5 ML

145 Drug Name Drug Tier Requirements/Limits BEXSERO INTRAMUSCULAR 1 QL (1 per 365 days); SYRINGE 50-50-50-25 MCG/0.5 AGE (Min 10 Years ML and Max 25 Years) BOOSTRIX TDAP 1 QL (0.5 per 365 days); INTRAMUSCULAR AGE (Min 7 Years) SUSPENSION 2.5-8-5 LF-MCG- LF/0.5ML BOOSTRIX TDAP 1 QL (0.5 per 365 days); INTRAMUSCULAR SYRINGE AGE (Min 7 Years) 2.5-8-5 LF-MCG-LF/0.5ML ENGERIX-B (PF) 1 QL (3 per 365 days) INTRAMUSCULAR SUSPENSION 20 MCG/ML ENGERIX-B (PF) 1 QL (3 per 365 days) INTRAMUSCULAR SYRINGE 20 MCG/ML GARDASIL 9 (PF) 1 QL (1.5 per 365 days); INTRAMUSCULAR AGE (Min 9 Years and SUSPENSION 0.5 ML Max 45 Years) GARDASIL 9 (PF) 1 QL (1.5 per 365 days); INTRAMUSCULAR SYRINGE AGE (Min 9 Years and 0.5 ML Max 45 Years) HAVRIX (PF) 1 QL (2 per 365 days) INTRAMUSCULAR SUSPENSION 1,440 ELISA UNIT/ML, 720 ELISA UNIT/0.5 ML HAVRIX (PF) 1 QL (2 per 365 days) INTRAMUSCULAR SYRINGE 1,440 ELISA UNIT/ML, 720 ELISA UNIT/0.5 ML HEPLISAV-B (PF) 1 QL (1 per 365 days) INTRAMUSCULAR SOLUTION 20 MCG/0.5 ML HEPLISAV-B (PF) 1 QL (1 per 365 days) INTRAMUSCULAR SYRINGE 20 MCG/0.5 ML MENACTRA (PF) 1 QL (0.5 per 365 days); INTRAMUSCULAR AGE (Min 11 Years SOLUTION 4 MCG/0.5 ML and Max 23 Years) MENQUADFI (PF) 1 QL (1 per 365 days); INTRAMUSCULAR AGE (Min 2 Years) SOLUTION 10 MCG/0.5 ML

146 Drug Name Drug Tier Requirements/Limits MENVEO A-C-Y-W-135-DIP 1 QL (1 per 365 days); (PF) INTRAMUSCULAR KIT AGE (Min 11 Years 10-5 MCG/0.5 ML and Max 23 Years) M-M-R II (PF) 1 QL (2 per 365 days) SUBCUTANEOUS RECON SOLN 1,000-12,500 TCID50/0.5 ML PNEUMOVAX-23 INJECTION 1 QL (0.5 per 365 days) SOLUTION 25 MCG/0.5 ML PNEUMOVAX-23 INJECTION 1 QL (0.5 per 365 days) SYRINGE 25 MCG/0.5 ML PREVNAR 13 (PF) 1 QL (0.5 per 365 days) INTRAMUSCULAR SYRINGE 0.5 ML PREVNAR 20 (PF) 1 QL (0.5 per 365 days) INTRAMUSCULAR SYRINGE 0.5 ML PROQUAD (PF) 1 QL (2 per 365 days) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10EXP3- 4.3-3- 3.99 TCID50/0.5 RECOMBIVAX HB (PF) 1 QL (3 per 365 days) INTRAMUSCULAR SUSPENSION 10 MCG/ML, 40 MCG/ML, 5 MCG/0.5 ML RECOMBIVAX HB (PF) 1 QL (3 per 365 days) INTRAMUSCULAR SYRINGE 10 MCG/ML, 5 MCG/0.5 ML SHINGRIX (PF) 1 QL (2 per 365 days) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 50 MCG/0.5 ML TDVAX INTRAMUSCULAR 1 QL (0.5 per 365 days); SUSPENSION 2-2 LF UNIT/0.5 AGE (Min 7 Years) ML TENIVAC (PF) 1 QL (0.5 per 365 days); INTRAMUSCULAR AGE (Min 7 Years) SUSPENSION 5 LF UNIT- 2 LF UNIT/0.5ML

147 Drug Name Drug Tier Requirements/Limits TENIVAC (PF) 1 QL (0.5 per 365 days); INTRAMUSCULAR SYRINGE AGE (Min 7 Years) 5-2 LF UNIT/0.5 ML TRUMENBA 1 QL (1.5 per 365 days); INTRAMUSCULAR SYRINGE AGE (Min 10 Years 120 MCG/0.5 ML and Max 25 Years) TWINRIX (PF) 1 QL (4 per 365 days) INTRAMUSCULAR SYRINGE 720 ELISA UNIT- 20 MCG/ML VAQTA (PF) 1 QL (2 per 365 days) INTRAMUSCULAR SUSPENSION 25 UNIT/0.5 ML, 50 UNIT/ML VAQTA (PF) 1 QL (2 per 365 days) INTRAMUSCULAR SYRINGE 25 UNIT/0.5 ML, 50 UNIT/ML VARIVAX (PF) 1 QL (2 per 365 days) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 1,350 UNIT/0.5 ML ZOSTAVAX (PF) 1 QL (1 per 365 days); SUBCUTANEOUS AGE (Min 60 Years) SUSPENSION FOR RECONSTITUTION 19,400 UNIT/0.65 ML Inflammatory Bowel Disease Agents Inflammatory Bowel Disease Agents alosetron oral tablet 0.5 mg, 1 mg (Lotronex) 6 APRISO ORAL 4 CAPSULE,EXTENDED RELEASE 24HR 0.375 GRAM balsalazide oral capsule 750 mg (Colazal) 2 budesonide oral (Entocort EC) 3 capsule,delayed,extend.release 3 mg colocort rectal enema 100 mg/60 ml 2 DIPENTUM ORAL CAPSULE 6 ST 250 MG hydrocortisone rectal enema 100 (Cortenema) 2 mg/60 ml

148 Drug Name Drug Tier Requirements/Limits LIALDA ORAL 3 TABLET,DELAYED RELEASE (DR/EC) 1.2 GRAM mesalamine oral capsule,extended (Apriso) 2 release 24hr 0.375 gram mesalamine oral tablet,delayed (Asacol HD) 3 ST release (dr/ec) 800 mg mesalamine rectal enema 4 gram/60 (Rowasa) 2 ml mesalamine rectal suppository 1,000 (Canasa) 3 mg PENTASA ORAL CAPSULE, 5 EXTENDED RELEASE 250 MG, 500 MG sulfasalazine oral tablet 500 mg (Azulfidine) 2 sulfasalazine oral tablet,delayed (Azulfidine EN-tabs) 2 release (dr/ec) 500 mg Metabolic Bone Disease Agents Metabolic Bone Disease Agents alendronate oral solution 70 mg/75 2 QL (300 per 30 days) ml alendronate oral tablet 10 mg, 35 2 mg, 40 mg, 5 mg alendronate oral tablet 70 mg (Fosamax) 2 calcitonin (salmon) nasal 2 spray,non-aerosol 200 unit/actuation calcitriol oral capsule 0.25 mcg, 0.5 (Rocaltrol) 2 mcg calcitriol oral solution 1 mcg/ml (Rocaltrol) 2 cinacalcet oral tablet 30 mg, 60 mg (Sensipar) 6 QL (60 per 30 days) cinacalcet oral tablet 90 mg (Sensipar) 6 QL (120 per 30 days) doxercalciferol oral capsule 0.5 mcg, 3 1 mcg, 2.5 mcg etidronate disodium oral tablet 200 3 mg, 400 mg FORTEO SUBCUTANEOUS 6 PA; QL (2.4 per 28 PEN INJECTOR 20 MCG/DOSE days) (620MCG/2.48ML) FOSAMAX PLUS D ORAL 5 TABLET 70 MG- 2,800 UNIT, 70 MG- 5,600 UNIT ibandronate oral tablet 150 mg (Boniva) 3

149 Drug Name Drug Tier Requirements/Limits NATPARA SUBCUTANEOUS 6 PA; QL (2 per 28 days) CARTRIDGE 100 MCG/DOSE, 25 MCG/DOSE, 50 MCG/DOSE, 75 MCG/DOSE paricalcitol oral capsule 1 mcg, 2 (Zemplar) 3 mcg paricalcitol oral capsule 4 mcg 3 risedronate oral tablet 150 mg (Actonel) 3 QL (1 per 30 days) risedronate oral tablet 30 mg, 5 mg 3 QL (30 per 30 days) risedronate oral tablet 35 mg (Actonel) 3 QL (4 per 28 days) risedronate oral tablet,delayed (Atelvia) 3 QL (4 per 28 days) release (dr/ec) 35 mg teriparatide subcutaneous pen (Forteo) 6 PA; QL (2.4 per 28 injector 20 mcg/dose days) (620mcg/2.48ml) TYMLOS SUBCUTANEOUS 6 PA; QL (1.56 per 28 PEN INJECTOR 80 MCG (3,120 days) MCG/1.56 ML) Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents ACTHAR INJECTION GEL 80 6 PA; QL (40 per 28 UNIT/ML days) ACTIMMUNE 6 PA; QL (12 per 30 SUBCUTANEOUS SOLUTION days) 100 MCG/0.5 ML BAQSIMI NASAL SPRAY,NON- 4 QL (4 per 1 day) AEROSOL 3 MG/ACTUATION BENLYSTA SUBCUTANEOUS 6 PA; QL (4 per 28 days) AUTO-INJECTOR 200 MG/ML BENLYSTA SUBCUTANEOUS 6 PA; QL (4 per 28 days) SYRINGE 200 MG/ML CETYLEV ORAL TABLET, 5 EFFERVESCENT 2.5 GRAM, 500 MG CYSTADANE ORAL POWDER 6 1 GRAM/1.7 ML oral suspension 50 mg/ml (Proglycem) 3 ELMIRON ORAL CAPSULE 100 5 MG EVRYSDI ORAL RECON SOLN 6 PA 0.75 MG/ML

150 Drug Name Drug Tier Requirements/Limits FIRDAPSE ORAL TABLET 10 6 PA; QL (240 per 30 MG days) GLUCAGEN HYPOKIT 5 INJECTION RECON SOLN 1 MG GLUCAGON EMERGENCY 4 QL (2 per 28 days) KIT (HUMAN) INJECTION RECON SOLN 1 MG guanidine oral tablet 125 mg 2 GVOKE HYPOPEN 1-PACK 5 SUBCUTANEOUS AUTO- INJECTOR 0.5 MG/0.1 ML, 1 MG/0.2 ML hydroxyzine pamoate oral capsule 2 100 mg hydroxyzine pamoate oral capsule (Vistaril) 2 25 mg, 50 mg ISTURISA ORAL TABLET 1 5 PA MG, 10 MG, 5 MG KEVEYIS ORAL TABLET 50 6 PA MG leucovorin calcium oral tablet 10 2 PA mg, 15 mg, 25 mg, 5 mg levocarnitine (with sugar) oral (Carnitor) 2 solution 100 mg/ml levocarnitine oral tablet 330 mg (Carnitor) 2 MESNEX ORAL TABLET 400 5 MG methylergonovine oral tablet 0.2 mg (Methergine) 2 PALFORZIA (LEVEL 1) ORAL 6 PA CAPSULE, SPRINKLE 3 MG (1 MG X 3) PALFORZIA (LEVEL 2) ORAL 6 PA CAPSULE, SPRINKLE 6 MG (1 MG X 6) PALFORZIA (LEVEL 3) ORAL 6 PA CAPSULE, SPRINKLE 12 MG (1 MG X 2, 10 MG X 1) PALFORZIA (LEVEL 4) ORAL 6 PA CAPSULE, SPRINKLE 20 MG

151 Drug Name Drug Tier Requirements/Limits PALFORZIA (LEVEL 5) ORAL 6 PA CAPSULE, SPRINKLE 40 MG (20 MG X 2) PALFORZIA (LEVEL 6) ORAL 6 PA CAPSULE, SPRINKLE 80 MG (20 MG X 4) PALFORZIA (LEVEL 7) ORAL 6 PA CAPSULE, SPRINKLE 120 MG (20 MG X 1, 100 MG X 1) PALFORZIA (LEVEL 8) ORAL 6 PA CAPSULE, SPRINKLE 160 MG (20 MG X 3, 100 MG X1) PALFORZIA (LEVEL 9) ORAL 6 PA CAPSULE, SPRINKLE 200 MG (100 MG X 2) PALFORZIA (LEVEL 10) ORAL 6 PA CAPSULE, SPRINKLE 240 MG (20 MG X 2, 100 MG X 2) PALFORZIA (LEVEL 11 UP- 6 PA DOSE) ORAL POWDER IN PACKET 300 MG PALFORZIA INITIAL DOSE 6 PA ORAL CAPSULE, SPRINKLE 0.5/1/1.5/3/6 MG PROCYSBI ORAL GRANULES 6 PA DEL RELEASE IN PACKET 300 MG, 75 MG PROGLYCEM ORAL 5 SUSPENSION 50 MG/ML pyridostigmine bromide oral syrup (Mestinon) 3 60 mg/5 ml pyridostigmine bromide oral tablet 2 30 mg pyridostigmine bromide oral tablet (Mestinon) 2 60 mg pyridostigmine bromide oral tablet (Mestinon Timespan) 2 extended release 180 mg RECTIV RECTAL OINTMENT 5 0.4 % (W/W) TAKHZYRO SUBCUTANEOUS 6 PA; QL (4 per 28 days) SOLUTION 300 MG/2 ML (150 MG/ML)

152 Drug Name Drug Tier Requirements/Limits TEGSEDI SUBCUTANEOUS 6 PA SYRINGE 284 MG/1.5 ML THALOMID ORAL CAPSULE 6 PA; QL (60 per 30 100 MG, 150 MG, 200 MG, 50 days) MG TYBOST ORAL TABLET 150 5 QL (30 per 30 days) MG ULESFIA TOPICAL LOTION 5 5 % VISTOGARD ORAL 6 QL (24 per 14 days) GRANULES IN PACKET 10 GRAM XCLAIR TOPICAL CREAM 5 XURIDEN ORAL GRANULES 6 PA IN PACKET 2 GRAM Ophthalmic Agents Antiglaucoma Agents oral capsule, 3 extended release 500 mg acetazolamide oral tablet 125 mg, 2 250 mg ALPHAGAN P OPHTHALMIC 5 (EYE) DROPS 0.1 % AZOPT OPHTHALMIC (EYE) 3 DROPS,SUSPENSION 1 % betaxolol ophthalmic (eye) drops 2 0.5 % BETIMOL OPHTHALMIC 5 (EYE) DROPS 0.25 %, 0.5 % BETOPTIC S OPHTHALMIC 5 (EYE) DROPS,SUSPENSION 0.25 % bimatoprost ophthalmic (eye) drops 3 ST; QL (2.5 per 25 0.03 % days) ophthalmic (eye) drops (Alphagan P) 2 0.15 % brimonidine ophthalmic (eye) drops 2 0.2 % ophthalmic (eye) drops 1 2 % COMBIGAN OPHTHALMIC 5 (EYE) DROPS 0.2-0.5 %

153 Drug Name Drug Tier Requirements/Limits dorzolamide ophthalmic (eye) drops (Trusopt) 2 2 % dorzolamide-timolol (pf) (Cosopt (PF)) 3 QL (60 per 30 days) ophthalmic (eye) dropperette 2-0.5 % dorzolamide-timolol ophthalmic (Cosopt) 2 (eye) drops 22.3-6.8 mg/ml latanoprost ophthalmic (eye) drops (Xalatan) 2 0.005 % ophthalmic (eye) drops 2 0.5 % LUMIGAN OPHTHALMIC 5 ST; QL (2.5 per 25 (EYE) DROPS 0.01 % days) methazolamide oral tablet 25 mg, 50 3 mg ophthalmic (eye) 2 drops 0.3 % PHOSPHOLINE IODIDE 5 OPHTHALMIC (EYE) DROPS 0.125 % pilocarpine hcl ophthalmic (eye) (Isopto Carpine) 2 drops 1 %, 2 %, 4 % RHOPRESSA OPHTHALMIC 5 ST; QL (2.5 per 30 (EYE) DROPS 0.02 % days) ROCKLATAN OPHTHALMIC 5 QL (2.5 per 25 days) (EYE) DROPS 0.02-0.005 % SIMBRINZA OPHTHALMIC 5 (EYE) DROPS,SUSPENSION 1- 0.2 % timolol maleate (pf) ophthalmic (Timoptic Ocudose 3 QL (60 per 30 days) (eye) dropperette 0.5 % (PF)) timolol maleate ophthalmic (eye) (Timoptic) 2 drops 0.25 %, 0.5 % timolol maleate ophthalmic (eye) (Istalol) 2 drops, once daily 0.5 % timolol maleate ophthalmic (eye) (Timoptic-XE) 3 gel forming solution 0.25 %, 0.5 % TIMOPTIC OCUDOSE (PF) 5 QL (60 per 30 days) OPHTHALMIC (EYE) DROPPERETTE 0.25 % travoprost (benzalkonium) 3 QL (2.5 per 25 days) ophthalmic (eye) drops 0.004 %

154 Drug Name Drug Tier Requirements/Limits travoprost ophthalmic (eye) drops (Travatan Z) 3 QL (2.5 per 25 days) 0.004 % VYZULTA OPHTHALMIC 5 QL (2.5 per 25 days) (EYE) DROPS 0.024 % ZIOPTAN (PF) OPHTHALMIC 5 QL (30 per 30 days) (EYE) DROPPERETTE 0.0015 % Replacement Preparations Replacement Preparations cytra k crystals oral packet 3,300- 2 1,002 mg cytra-2 oral solution 500-334 mg/5 2 ml cytra-3 oral solution 550-500-334 2 mg/5 ml cytra-k oral solution 1,100-334 mg/5 2 ml EFFER-K ORAL TABLET, 5 EFFERVESCENT 10 MEQ, 20 MEQ effer-k oral tablet, effervescent 25 2 meq k-effervescent oral tablet, 2 effervescent 25 meq klor-con m10 oral tablet,er 2 particles/crystals 10 meq klor-con m15 oral tablet,er 2 particles/crystals 15 meq klor-con m20 oral tablet,er 2 particles/crystals 20 meq klor-con sprinkle oral capsule, 2 extended release 10 meq, 8 meq KLOR-CON/25 ORAL PACKET 2 25 MEQ K-PHOS NO 2 ORAL TABLET 5 305-700 MG K-PHOS ORIGINAL ORAL 5 TABLET,SOLUBLE 500 MG ORACIT ORAL SOLUTION 490- 5 640 MG/5 ML phospha 250 neutral oral tablet 250 2 mg

155 Drug Name Drug Tier Requirements/Limits potassium bicarb and chloride oral 2 tablet, effervescent 25 meq potassium bicarb-citric acid oral (Effer-K) 2 tablet, effervescent 25 meq potassium chloride oral capsule, 2 extended release 10 meq, 8 meq potassium chloride oral liquid 20 2 meq/15 ml, 40 meq/15 ml potassium chloride oral packet 20 (Klor-Con) 3 meq potassium chloride oral tablet (K-Tab) 2 extended release 10 meq, 20 meq, 8 meq potassium chloride oral tablet,er (Klor-Con M10) 2 particles/crystals 10 meq potassium chloride oral tablet,er (Klor-Con M15) 2 particles/crystals 15 meq potassium chloride oral tablet,er (Klor-Con M20) 2 particles/crystals 20 meq potassium citrate oral tablet (Urocit-K 10) 2 extended release 10 meq (1,080 mg) potassium citrate oral tablet (Urocit-K 15) 3 extended release 15 meq potassium citrate oral tablet (Urocit-K 5) 2 extended release 5 meq (540 mg) potassium citrate-citric acid oral (Cytra-K) 2 solution 1,100-334 mg/5 ml sodium citrate-citric acid oral (Cytra-2) 2 solution 500-334 mg/5 ml tricitrates oral solution 550-500-334 2 mg/5 ml virt-phos 250 neutral oral tablet 250 3 mg Respiratory Tract Agents Anti-Inflammatories, Inhaled Corticosteroids ADVAIR DISKUS 3 INHALATION BLISTER WITH DEVICE 100-50 MCG/DOSE, 250-50 MCG/DOSE, 500-50 MCG/DOSE

156 Drug Name Drug Tier Requirements/Limits ADVAIR HFA INHALATION 4 QL (12 per 28 days) HFA AEROSOL INHALER 115- 21 MCG/ACTUATION, 230-21 MCG/ACTUATION, 45-21 MCG/ACTUATION AEROSPAN INHALATION 5 QL (17.8 per 30 days) HFA AEROSOL INHALER 80 MCG/ACTUATION ARNUITY ELLIPTA 4 QL (30 per 30 days) INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 200 MCG/ACTUATION, 50 MCG/ACTUATION ASMANEX HFA INHALATION 5 QL (13 per 30 days) HFA AEROSOL INHALER 100 MCG/ACTUATION, 200 MCG/ACTUATION, 50 MCG/ACTUATION ASMANEX TWISTHALER 5 QL (1 per 30 days) INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG/ ACTUATION (30), 110 MCG/ ACTUATION (7), 220 MCG/ ACTUATION (120), 220 MCG/ ACTUATION (14), 220 MCG/ ACTUATION (30), 220 MCG/ ACTUATION (60) BREO ELLIPTA INHALATION 4 QL (60 per 30 days) BLISTER WITH DEVICE 100-25 MCG/DOSE, 200-25 MCG/DOSE budesonide inhalation suspension for (Pulmicort) 3 QL (120 per 30 days) nebulization 0.25 mg/2 ml, 0.5 mg/2 ml budesonide inhalation suspension for (Pulmicort) 3 QL (60 per 30 days) nebulization 1 mg/2 ml budesonide- inhalation (Symbicort) 3 hfa aerosol inhaler 160-4.5 mcg/actuation, 80-4.5 mcg/actuation

157 Drug Name Drug Tier Requirements/Limits DULERA INHALATION HFA 5 QL (13 per 28 days) AEROSOL INHALER 100-5 MCG/ACTUATION, 200-5 MCG/ACTUATION, 50-5 MCG/ACTUATION FLOVENT DISKUS 4 QL (60 per 30 days) INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 50 MCG/ACTUATION FLOVENT DISKUS 4 QL (120 per 30 days) INHALATION BLISTER WITH DEVICE 250 MCG/ACTUATION FLOVENT HFA INHALATION 4 QL (12 per 28 days) HFA AEROSOL INHALER 110 MCG/ACTUATION FLOVENT HFA INHALATION 4 QL (24 per 28 days) HFA AEROSOL INHALER 220 MCG/ACTUATION FLOVENT HFA INHALATION 4 QL (21.2 per 28 days) HFA AEROSOL INHALER 44 MCG/ACTUATION PULMICORT FLEXHALER 5 QL (1 per 30 days) INHALATION AEROSOL POWDR BREATH ACTIVATED 180 MCG/ACTUATION, 90 MCG/ACTUATION QVAR INHALATION 4 QL (17.4 per 25 days) AEROSOL 40 MCG/ACTUATION, 80 MCG/ACTUATION QVAR REDIHALER 4 QL (21.2 per 25 days) INHALATION HFA AEROSOL BREATH ACTIVATED 40 MCG/ACTUATION, 80 MCG/ACTUATION Antileukotrienes montelukast oral granules in packet (Singulair) 3 4 mg montelukast oral tablet 10 mg (Singulair) 3 montelukast oral tablet,chewable 4 (Singulair) 3 mg, 5 mg

158 Drug Name Drug Tier Requirements/Limits zafirlukast oral tablet 10 mg, 20 mg (Accolate) 2 ZYFLO ORAL TABLET 600 MG 6 PA Bronchodilators albuterol sulfate inhalation hfa (ProAir HFA) 3 aerosol inhaler 90 mcg/actuation albuterol sulfate inhalation solution 2 for nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 5 mg/ml albuterol sulfate inhalation solution 1 for nebulization 2.5 mg /3 ml (0.083 %) albuterol sulfate oral syrup 2 mg/5 2 ml albuterol sulfate oral tablet 2 mg 2 albuterol sulfate oral tablet 4 mg 1 albuterol sulfate oral tablet 3 extended release 12 hr 4 mg, 8 mg ANORO ELLIPTA 4 QL (60 per 30 days) INHALATION BLISTER WITH DEVICE 62.5-25 MCG/ACTUATION ARCAPTA NEOHALER 5 ST; QL (30 per 30 days) INHALATION CAPSULE, W/INHALATION DEVICE 75 MCG inhalation solution for (Brovana) 3 QL (120 per 30 days) nebulization 15 mcg/2 ml ATROVENT HFA 5 QL (25.8 per 30 days) INHALATION HFA AEROSOL INHALER 17 MCG/ACTUATION BEVESPI AEROSPHERE 4 QL (10.7 per 30 days) INHALATION HFA AEROSOL INHALER 9-4.8 MCG BROVANA INHALATION 5 QL (120 per 30 days) SOLUTION FOR NEBULIZATION 15 MCG/2 ML COMBIVENT RESPIMAT 4 QL (8 per 30 days) INHALATION MIST 20-100 MCG/ACTUATION

159 Drug Name Drug Tier Requirements/Limits formoterol fumarate inhalation (Perforomist) 2 QL (120 per 30 days) solution for nebulization 20 mcg/2 ml INCRUSE ELLIPTA 4 QL (30 per 30 days) INHALATION BLISTER WITH DEVICE 62.5 MCG/ACTUATION ipratropium bromide inhalation 2 solution 0.02 % ipratropium-albuterol inhalation 1 solution for nebulization 0.5 mg-3 mg(2.5 mg base)/3 ml levalbuterol hcl inhalation solution (Xopenex) 3 for nebulization 0.31 mg/3 ml, 0.63 mg/3 ml, 1.25 mg/3 ml levalbuterol hcl inhalation solution (Xopenex Concentrate) 3 for nebulization 1.25 mg/0.5 ml levalbuterol tartrate inhalation hfa (Xopenex HFA) 3 QL (30 per 30 days) aerosol inhaler 45 mcg/actuation LONHALA MAGNAIR 5 QL (60 per 30 days) STARTER INHALATION SOLUTION FOR NEBULIZATION 25 MCG/ML metaproterenol oral syrup 10 mg/5 2 ml metaproterenol oral tablet 10 mg, 20 2 mg PERFOROMIST INHALATION 4 QL (120 per 30 days) SOLUTION FOR NEBULIZATION 20 MCG/2 ML PROAIR RESPICLICK 4 QL (2 per 25 days) INHALATION AEROSOL POWDR BREATH ACTIVATED 90 MCG/ACTUATION SEREVENT DISKUS 4 QL (60 per 30 days) INHALATION BLISTER WITH DEVICE 50 MCG/DOSE SPIRIVA RESPIMAT 4 QL (4 per 30 days) INHALATION MIST 1.25 MCG/ACTUATION, 2.5 MCG/ACTUATION

160 Drug Name Drug Tier Requirements/Limits SPIRIVA WITH HANDIHALER 4 QL (30 per 30 days) INHALATION CAPSULE, W/INHALATION DEVICE 18 MCG STIOLTO RESPIMAT 4 QL (4 per 30 days) INHALATION MIST 2.5-2.5 MCG/ACTUATION STRIVERDI RESPIMAT 4 QL (4 per 30 days) INHALATION MIST 2.5 MCG/ACTUATION oral tablet 2.5 mg, 5 mg 2 THEO-24 ORAL 4 CAPSULE,EXTENDED RELEASE 24HR 100 MG, 200 MG, 300 MG, 400 MG theochron oral tablet extended 2 release 12 hr 100 mg, 200 mg, 300 mg theophylline oral solution 80 mg/15 2 ml theophylline oral tablet extended 2 release 12 hr 100 mg, 200 mg, 300 mg, 450 mg theophylline oral tablet extended 2 release 24 hr 400 mg, 600 mg TRELEGY ELLIPTA 4 QL (60 per 30 days) INHALATION BLISTER WITH DEVICE 100-62.5-25 MCG, 200- 62.5-25 MCG Respiratory Tract Agents, Other cromolyn inhalation solution for 2 nebulization 20 mg/2 ml DALIRESP ORAL TABLET 250 5 ST; QL (30 per 30 days) MCG, 500 MCG ESBRIET ORAL CAPSULE 267 6 PA MG ESBRIET ORAL TABLET 267 6 PA MG, 801 MG FASENRA PEN 6 PA; QL (1 per 28 days) SUBCUTANEOUS AUTO- INJECTOR 30 MG/ML

161 Drug Name Drug Tier Requirements/Limits HYPER-SAL INHALATION 5 SOLUTION FOR NEBULIZATION 3.5 % KALYDECO ORAL 6 PA; QL (60 per 30 GRANULES IN PACKET 25 days) MG, 50 MG, 75 MG KALYDECO ORAL TABLET 6 PA; QL (60 per 30 150 MG days) NEBUSAL INHALATION 5 SOLUTION FOR NEBULIZATION 6 % NUCALA SUBCUTANEOUS 6 PA; QL (3 per 28 days) AUTO-INJECTOR 100 MG/ML NUCALA SUBCUTANEOUS 6 PA; QL (3 per 28 days) SYRINGE 100 MG/ML OFEV ORAL CAPSULE 100 6 PA; QL (60 per 30 MG, 150 MG days) ORKAMBI ORAL GRANULES 6 PA; QL (56 per 28 IN PACKET 100-125 MG, 150- days) 188 MG ORKAMBI ORAL TABLET 100- 6 PA; QL (120 per 30 125 MG, 200-125 MG days) sodium chloride inhalation solution 3 for nebulization 0.9 % sodium chloride inhalation solution (Pulmosal) 2 for nebulization 7 % SYMDEKO ORAL TABLETS, 6 PA; QL (56 per 28 SEQUENTIAL 100-150 MG (D)/ days) 150 MG (N), 50-75 MG (D)/ 75 MG (N) TRIKAFTA ORAL TABLETS, 6 PA SEQUENTIAL 100-50-75 MG(D) /150 MG (N), 50-25-37.5 MG (D)/75 MG (N) Skeletal Muscle Relaxants Skeletal Muscle Relaxants oral tablet 10 mg, 20 mg, 5 2 mg oral tablet 250 mg, 350 (Soma) 3 QL (120 per 30 days) mg carisoprodol-aspirin oral tablet 200- 3 325 mg

162 Drug Name Drug Tier Requirements/Limits carisoprodol-aspirin-codeine oral 3 tablet 200-325-16 mg oral tablet 500 mg 2 oral tablet 10 mg, 5 2 mg dantrolene oral capsule 100 mg 2 dantrolene oral capsule 25 mg, 50 (Dantrium) 2 mg metaxall oral tablet 800 mg 3 metaxalone oral tablet 400 mg 3 metaxalone oral tablet 800 mg (Skelaxin) 3 methocarbamol oral tablet 500 mg, 2 750 mg citrate oral tablet 2 extended release 100 mg oral capsule 2 mg, 4 mg, 6 (Zanaflex) 3 mg tizanidine oral tablet 2 mg 2 tizanidine oral tablet 4 mg (Zanaflex) 2 Sleep Disorder Agents Sleep Disorder Agents armodafinil oral tablet 150 mg, 200 (Nuvigil) 3 PA; QL (30 per 30 mg, 250 mg days) armodafinil oral tablet 50 mg (Nuvigil) 3 PA; QL (90 per 30 days) BELSOMRA ORAL TABLET 10 5 ST; QL (30 per 30 days) MG, 15 MG, 20 MG, 5 MG BUTISOL ORAL TABLET 30 5 MG doxepin oral tablet 3 mg, 6 mg (Silenor) 3 ST; QL (30 per 30 days) eszopiclone oral tablet 1 mg, 2 mg, 3 (Lunesta) 3 ST; QL (30 per 30 days) mg modafinil oral tablet 100 mg, 200 (Provigil) 3 PA; QL (60 per 30 mg days) SECONAL SODIUM ORAL 5 CAPSULE 100 MG SILENOR ORAL TABLET 3 5 ST; QL (30 per 30 days) MG, 6 MG WAKIX ORAL TABLET 17.8 6 PA; QL (60 per 30 MG, 4.45 MG days)

163 Drug Name Drug Tier Requirements/Limits XYREM ORAL SOLUTION 500 6 PA; QL (540 per 30 MG/ML days) zaleplon oral capsule 10 mg, 5 mg 2 QL (30 per 30 days) zolpidem oral tablet 10 mg, 5 mg (Ambien) 2 QL (30 per 30 days) zolpidem oral tablet,ext release (Ambien CR) 3 ST; QL (30 per 30 days) multiphase 12.5 mg, 6.25 mg Vasodilating Agents Vasodilating Agents ADEMPAS ORAL TABLET 0.5 6 PA; QL (90 per 30 MG, 1 MG, 1.5 MG, 2 MG, 2.5 days) MG alyq oral tablet 20 mg 6 PA; QL (60 per 30 days) ambrisentan oral tablet 10 mg, 5 mg (Letairis) 6 PA; QL (30 per 30 days) bosentan oral tablet 125 mg, 62.5 (Tracleer) 6 PA; QL (60 per 30 mg days) LETAIRIS ORAL TABLET 10 6 PA; QL (30 per 30 MG, 5 MG days) OPSUMIT ORAL TABLET 10 6 PA; QL (30 per 30 MG days) ORENITRAM ORAL TABLET 6 PA EXTENDED RELEASE 0.125 MG, 0.25 MG, 1 MG, 2.5 MG, 5 MG sildenafil (pulm.hypertension) oral (Revatio) 6 PA; QL (224 per 30 suspension for reconstitution 10 days) mg/ml sildenafil (pulm.hypertension) oral (Revatio) 6 PA; QL (90 per 30 tablet 20 mg days) sildenafil oral tablet 100 mg, 25 mg, (Viagra) 3 PA; QL (8 per 30 days) 50 mg tadalafil (pulm. hypertension) oral (Alyq) 6 PA; QL (60 per 30 tablet 20 mg days) tadalafil oral tablet 10 mg, 20 mg (Cialis) 3 PA; QL (8 per 30 days) tadalafil oral tablet 2.5 mg, 5 mg (Cialis) 3 PA; QL (30 per 30 days) TRACLEER ORAL TABLET 125 6 PA; QL (60 per 30 MG, 62.5 MG days) TRACLEER ORAL TABLET 6 PA; QL (120 per 30 FOR SUSPENSION 32 MG days)

164 Drug Name Drug Tier Requirements/Limits TYVASO INHALATION 6 PA SOLUTION FOR NEBULIZATION 1.74 MG/2.9 ML (0.6 MG/ML) TYVASO REFILL KIT 6 PA INHALATION SOLUTION FOR NEBULIZATION 1.74 MG/2.9 ML (0.6 MG/ML) TYVASO STARTER KIT 6 PA INHALATION SOLUTION FOR NEBULIZATION 1.74 MG/2.9 ML UPTRAVI ORAL TABLET 1,000 6 PA; QL (60 per 30 MCG, 1,200 MCG, 1,400 MCG, days) 1,600 MCG, 400 MCG, 600 MCG, 800 MCG UPTRAVI ORAL TABLET 200 6 PA; QL (240 per 30 MCG days) UPTRAVI ORAL 6 PA; QL (200 per 365 TABLETS,DOSE PACK 200 days) MCG (140)- 800 MCG (60) VENTAVIS INHALATION 6 PA SOLUTION FOR NEBULIZATION 10 MCG/ML, 20 MCG/ML Vitamins And Minerals Vitamins And Minerals ACTIVE FE ORAL TABLET 75 5 MG IRON- 1,250 MCG cholecalciferol (vitamin d3) oral (Decara) 1 capsule 1,250 mcg (50,000 unit) decara oral capsule 1,250 mcg 1 (50,000 unit) folic acid oral tablet 1 mg 2 FUSION PLUS ORAL 5 CAPSULE 130 MG IRON -1,250 MCG weekly-d oral capsule 1,250 mcg 1 (50,000 unit)

165 166 INDEX abacavir...... 60 AFINITOR DISPERZ...... 20 alyacen 1/35 (28)...... 89 abacavir-lamivudine...... 60 afirmelle...... 89 alyacen 7/7/7 (28)...... 89 abacavir-lamivudine- after pill...... 89 alyq...... 164 zidovudine...... 60 aftera...... 89 amabelz...... 133 ABILIFY MYCITE...... 57 AIMOVIG amantadine hcl...... 56 abiraterone...... 20 AUTOINJECTOR...... 51 ambrisentan...... 164 acamprosate...... 10 AIMOVIG amcinonide...... 109 acarbose...... 39 AUTOINJECTOR (2 PACK).51 amethia...... 89 acebutolol...... 74 AJOVY AUTOINJECTOR....51 amethia lo...... 89 acetaminophen-codeine...... 3 AKTEN (PF)...... 117 amethyst (28)...... 89 acetazolamide...... 153 AKYNZEO amiloride...... 79 acetic acid...... 119 (NETUPITANT)...... 53 amiloride-hydrochlorothiazide.. 79 acetic acid-aluminum acetate..119 ala-cort...... 109 aminocaproic acid...... 70 ACIPHEX SPRINKLE...... 124 ala-scalp...... 109 amiodarone...... 74 acitretin...... 103 albendazole...... 54 AMITIZA...... 125 acne medication...... 103 albuterol sulfate...... 159 amitriptyline...... 36 ACTEMRA...... 140 alclometasone...... 109 amitriptyline-chlordiazepoxide. 36 ACTEMRA ACTPEN...... 140 ALDACTAZIDE...... 79 amlodipine...... 78 ACTHAR...... 150 ALECENSA...... 20 amlodipine-atorvastatin...... 80 ACTIMMUNE...... 150 alendronate...... 149 amlodipine-benazepril...... 78 ACTIVE FE...... 165 alfuzosin...... 130 amlodipine-olmesartan...... 78 ACTOPLUS MET XR...... 39 ALINIA...... 55 amlodipine-valsartan...... 78 ACUVAIL (PF)...... 122 aliskiren...... 82 amlodipine-valsartan-hcthiazid.78 acyclovir...... 66, 103 allopurinol...... 49 ammonium lactate...... 103 ACZONE...... 103 almotriptan malate...... 51 amnesteem...... 104 ADACEL(TDAP ALOCRIL...... 122 amoxapine...... 36 ADOLESN/ADULT)(PF).... 145 ALOMIDE...... 117 amoxicil-clarithromy- adapalene...... 114 ALORA...... 133 lansopraz...... 124 adapalene-benzoyl peroxide....114 alosetron...... 148 amoxicillin...... 17 ADASUVE...... 57 ALPHAGAN P...... 153 amoxicillin-pot clavulanate. 17, 18 ADDERALL XR...... 83 alprazolam...... 12 amphetamine sulfate...... 83 adefovir...... 66 ALPRAZOLAM ampicillin...... 18 ADEMPAS...... 164 INTENSOL...... 12 ANACAINE...... 104 ADVAIR DISKUS...... 156 ALREX...... 122 ANADROL-50...... 132 ADVAIR HFA...... 157 ALTABAX...... 108 anagrelide...... 70 AEROSPAN...... 157 altavera (28)...... 89 ANALPRAM-HC...... 109 afeditab cr...... 78 ALTRENO...... 114 anastrozole...... 21 AFINITOR...... 20 ALUNBRIG...... 20, 21 ANDRODERM...... 132

I-1 androxy...... 132 ATRIPLA...... 60 BALVERSA...... 21 ANGELIQ...... 133 atropine...... 117 balziva (28)...... 90 ANNOVERA...... 89 ATROVENT HFA...... 159 BANZEL...... 30 ANORO ELLIPTA...... 159 AUBAGIO...... 84 BAQSIMI...... 150 anucort-hc...... 109 aubra...... 89 BARACLUDE...... 66 ANZEMET...... 53 aurovela 1.5/30 (21)...... 89 BAXDELA...... 18 APOKYN...... 56 aurovela 1/20 (21)...... 90 BD LUER-LOK SYRINGE.115 apraclonidine...... 117 aurovela 24 fe...... 90 BD ULTRA-FINE NANO aprepitant...... 53 aurovela fe 1.5/30 (28)...... 90 PEN NEEDLE...... 115 apri...... 89 aurovela fe 1-20 (28)...... 90 BD VEO INSULIN SYR APRISO...... 148 AUSTEDO...... 84 (HALF UNIT)...... 115 APTIOM...... 30 AVANDAMET...... 39 BD VEO INSULIN APTIVUS...... 60 AVANDIA...... 40 SYRINGE UF...... 115 APTIVUS (WITH VITAMIN AVAR...... 104 bekyree (28)...... 90 E)...... 60 AVAR LS...... 104 belladonna alkaloids-opium...... 3 aranelle (28)...... 89 AVC VAGINAL...... 50 BELSOMRA...... 163 ARANESP (IN aviane...... 90 benazepril...... 72 POLYSORBATE)...... 68 avita...... 114 benazepril-hydrochlorothiazide.72 ARCALYST...... 140 AVONEX...... 84 BENLYSTA...... 150 ARCAPTA NEOHALER.....159 AVONEX (WITH benznidazole...... 55 arformoterol...... 159 ALBUMIN)...... 84 benzonatate...... 100 ARIKAYCE...... 13 ayuna...... 90 benzoyl peroxide...... 104 aripiprazole...... 58 AYVAKIT...... 21 benztropine...... 56 armodafinil...... 163 AZASAN...... 140 bepotastine besilate...... 117 ARMOUR THYROID...... 138 AZASITE...... 119 BEPREVE...... 117 ARNUITY ELLIPTA...... 157 azathioprine...... 140 BESIVANCE...... 119 AROMASIN...... 21 azelaic acid...... 104 betamethasone dipropionate ashlyna...... 89 azelastine...... 117 ...... 109, 110 ASMANEX HFA...... 157 azelastine-fluticasone...... 117 betamethasone valerate...... 110 ASMANEX TWISTHALER 157 AZELEX...... 104 betamethasone, augmented..... 110 aspirin...... 7 azithromycin...... 16 BETASERON...... 84 aspirin-caffeine-dihydrocodein....3 AZOPT...... 153 betaxolol...... 74, 153 aspirin-dipyridamole...... 70 azurette (28)...... 90 bethanechol chloride...... 130 atazanavir...... 60 bacitracin...... 108, 119 BETIMOL...... 153 atenolol...... 74 bacitracin zinc...... 108 BETOPTIC S...... 153 atenolol-chlorthalidone...... 74 bacitracin-polymyxin b...... 119 BEVESPI AEROSPHERE... 159 atomoxetine...... 83 baclofen...... 162 BEVYXXA...... 66 atorvastatin...... 80 BACTROBAN NASAL...... 108 bexarotene...... 21 atovaquone...... 55 BALCOLTRA...... 90 BEXSERO...... 146 atovaquone-proguanil...... 55 balsalazide...... 148 bicalutamide...... 21

I-2 BIDIL...... 82 bupropion hcl...... 37 captopril...... 72 BIJUVA...... 133 bupropion hcl (smoking deter). 11 captopril-hydrochlorothiazide...73 BIKTARVY...... 60 buspirone...... 12 CARBAGLU...... 126 bimatoprost...... 153 butalbital compound w/codeine...3 carbamazepine...... 30 bisoprolol fumarate...... 74 butalbital compound-codeine...... 3 carbidopa...... 56 bisoprolol-hydrochlorothiazide. 74 butalbital-acetaminop-caf-cod....3 carbidopa-levodopa...... 56 bleph-10...... 119 butalbital-acetaminophen...... 3 carbidopa-levodopa- BLEPHAMIDE...... 119 butalbital-acetaminophen-caff....3 entacapone...... 56 BLEPHAMIDE S.O.P...... 119 butalbital-aspirin-caffeine...... 3 carbinoxamine maleate...... 49 blisovi 24 fe...... 90 BUTISOL...... 163 CARDIZEM LA...... 76 blisovi fe 1.5/30 (28)...... 90 butorphanol...... 3 CARDURA XL...... 71 blisovi fe 1/20 (28)...... 90 BYDUREON...... 40 carisoprodol...... 162 BONJESTA...... 53 BYDUREON BCISE...... 40 carisoprodol-aspirin...... 162 BOOSTRIX TDAP...... 146 BYETTA...... 40 carisoprodol-aspirin-codeine... 163 bosentan...... 164 BYNFEZIA...... 137 carteolol...... 153 BOSULIF...... 21 BYSTOLIC...... 75 cartia xt...... 76 bp 10-1...... 104 BYVALSON...... 75 carvedilol...... 75 bpo...... 104 cabergoline...... 56 carvedilol phosphate...... 75 BRAFTOVI...... 21 CABOMETYX...... 21 CASODEX...... 22 BREO ELLIPTA...... 157 caffeine citrate...... 84 CAYA CONTOURED...... 90 brevicon (28)...... 90 calcipotriene...... 104 CAYSTON...... 17 briellyn...... 90 calcipotriene-betamethasone...104 caziant (28)...... 90 BRILINTA...... 70 calcitonin (salmon)...... 149 cefaclor...... 15 brimonidine...... 153 calcitrene...... 104 cefadroxil...... 15 BRIVIACT...... 30 calcitriol...... 104, 149 cefdinir...... 15 bromfed dm...... 100 calcium acetate(phosphat cefditoren pivoxil...... 15 bromfenac...... 122 bind)...... 129 cefixime...... 15 bromocriptine...... 56 CALQUENCE...... 21 cefpodoxime...... 15 brompheniramine-pseudoeph- CAMBIA...... 7 cefprozil...... 15 dm...... 100 camila...... 90 ceftibuten...... 15 BROMSITE...... 122 camrese...... 90 CEFTIN...... 15 BROVANA...... 159 camrese lo...... 90 cefuroxime axetil...... 15 BRUKINSA...... 21 candesartan...... 71 celecoxib...... 7, 8 budesonide...... 122, 148, 157 candesartan- CELONTIN...... 30 budesonide-formoterol...... 157 hydrochlorothiazid...... 71 cem-urea...... 104 bumetanide...... 79 capecitabine...... 21 cephalexin...... 16 BUNAVAIL...... 10 CAPEX...... 110 CERDELGA...... 115 buprenorphine...... 3 CAPITAL WITH CODEINE...4 CESAMET...... 53 buprenorphine hcl...... 10 CAPLYTA...... 58 CETACAINE...... 104 buprenorphine-naloxone..... 10, 11 CAPRELSA...... 21

I-3 CETACAINE CIPRODEX...... 119 colestipol...... 80 ANESTHETIC...... 104 ciprofloxacin...... 18 colocort...... 148 cetirizine...... 49 ciprofloxacin (mixture)...... 18 COLY-MYCIN S...... 120 CETYLEV...... 150 ciprofloxacin hcl...... 18, 119 COMBIGAN...... 153 cevimeline...... 103 ciprofloxacin-dexamethasone. 120 COMBIPATCH...... 133 CHANTIX...... 11 ciprofloxacin-fluocinolone...... 118 COMBIVENT RESPIMAT..159 CHANTIX CONTINUING citalopram...... 37 COMETRIQ...... 22 MONTH BOX...... 11 claravis...... 104 COMPLERA...... 60 CHANTIX STARTING CLARINEX...... 49 compro...... 53 MONTH BOX...... 11 CLARINEX-D 12 HOUR...... 49 CONCEPTROL...... 91 charlotte 24 fe...... 90 clarithromycin...... 16 CONCERTA...... 84 chateal (28)...... 91 cleansing wash...... 104 CONDYLOX...... 104 CHEMET...... 131 clemastine...... 49 constulose...... 126 CHENODAL...... 115 CLENPIQ...... 128 CONTRAVE...... 84 cheratussin ac...... 101 CLEOCIN...... 50 COPIKTRA...... 22 chlordiazepoxide hcl...... 12 CLIMARA PRO...... 133 CORDRAN...... 110 chlordiazepoxide-clidinium...... 30 clindamycin hcl...... 13 CORDRAN TAPE LARGE chlorhexidine gluconate...... 103 clindamycin pediatric...... 13 ROLL...... 110 chloroquine phosphate...... 55 clindamycin phosphate...... 50, 108 CORLANOR...... 77 chlorothiazide...... 79 clindamycin-benzoyl peroxide.108 cormax...... 111 chlorpromazine...... 58 CLINDESSE...... 50 CORTIFOAM...... 111 chlorpropamide...... 46 clobazam...... 30 cortisone...... 135 chlorthalidone...... 79 clobetasol...... 110 CORTISPORIN...... 108 chlorzoxazone...... 163 clobetasol-emollient...... 110 CORTISPORIN-TC...... 120 CHOLBAM...... 126 clocortolone pivalate...... 110 COSENTYX...... 140 cholecalciferol (vitamin d3)... 165 clomipramine...... 37 COSENTYX (2 SYRINGES) cholestyramine (with sugar).....80 clonazepam...... 12 ...... 140 cholestyramine light...... 80 clonidine...... 71 COSENTYX PEN (2 PENS) 140 choline,magnesium salicylate...... 8 clonidine hcl...... 71, 84 COTELLIC...... 22 ciclopirox...... 46, 47 clopidogrel...... 70 covaryx...... 132 cilostazol...... 70 clorazepate dipotassium...... 12 covaryx h.s...... 132 CILOXAN...... 119 clotrimazole...... 47 CREON...... 115 CIMDUO...... 60 clotrimazole-betamethasone..... 47 CRESEMBA...... 47 cimetidine...... 124 clovique...... 131 CRINONE...... 138 cimetidine hcl...... 124 clozapine...... 58 CRIXIVAN...... 60 CIMZIA...... 140 COARTEM...... 55 cromolyn...... 118, 126, 161 CIMZIA POWDER FOR codeine sulfate...... 4 cryselle (28)...... 91 RECONST...... 140 codeine-guaifenesin...... 101 CUTAQUIG...... 140 cinacalcet...... 149 colchicine...... 49 CUVITRU...... 140 CIPRO HC...... 119 colesevelam...... 80 CUVPOSA...... 126

I-4 cyclafem 1/35 (28)...... 91 DEMSER...... 77 didanosine...... 60, 61 cyclafem 7/7/7 (28)...... 91 DENAVIR...... 105 DIFICID...... 16 cyclobenzaprine...... 163 denta 5000 plus...... 103 diflunisal...... 8 CYCLOPHOSPHAMIDE...... 22 dentagel...... 103 digitek...... 77 cyclophosphamide...... 22 DEPO-PROVERA...... 138 digox...... 77 CYCLOSET...... 40 DEPO-SUBQ PROVERA DIGOXIN...... 77 cyclosporine...... 141 104...... 138 digoxin...... 77 cyclosporine modified...... 140, 141 DERMAZENE...... 111 dihydroergotamine...... 51 cyproheptadine...... 49 DESCOVY...... 60 DILANTIN...... 31 cyred...... 91 desipramine...... 37 DILATRATE-SR...... 82 CYSTADANE...... 150 desloratadine...... 49 diltiazem hcl...... 76 CYSTADROPS...... 118 desmopressin...... 137 dilt-xr...... 76 CYSTAGON...... 130 desog-e.estradiol/e.estradiol..... 91 dimethyl fumarate...... 85 CYSTARAN...... 118 desogestrel-ethinyl estradiol..... 91 DIPENTUM...... 148 cytra k crystals...... 155 DESONATE...... 111 diphenoxylate-atropine...... 126 cytra-2...... 155 desonide...... 111 dipyridamole...... 70 cytra-3...... 155 desoximetasone...... 111 disopyramide phosphate...... 74 cytra-k...... 155 desvenlafaxine...... 37 disulfiram...... 11 DAKLINZA...... 65 desvenlafaxine succinate...... 37 DIURIL...... 79 dalfampridine...... 84 dexamethasone...... 135 divalproex...... 31 DALIRESP...... 161 DEXAMETHASONE DIVIGEL...... 133 danazol...... 132 INTENSOL...... 135 dofetilide...... 74 dantrolene...... 163 dexamethasone sodium dolishale...... 91 dapsone...... 52, 104 phosphate...... 122 donepezil...... 36 DARAPRIM...... 55 DEXILANT...... 124 DOPTELET (10 TAB PACK) 68 darifenacin...... 130 dexmethylphenidate...... 84 DOPTELET (15 TAB PACK) 68 dasetta 1/35 (28)...... 91 dextroamphetamine...... 84, 85 DOPTELET (30 TAB PACK) 68 dasetta 7/7/7 (28)...... 91 dextroamphetamine- dorzolamide...... 154 DAURISMO...... 22 amphetamine...... 85 dorzolamide-timolol...... 154 daysee...... 91 DIACOMIT...... 30, 31 dorzolamide-timolol (pf)...... 154 DAYTRANA...... 84 diazepam...... 12, 31 dotti...... 133 DEBACTEROL...... 103 diazepam intensol...... 12 DOVATO...... 61 deblitane...... 91 diazoxide...... 150 doxazosin...... 71 decadron...... 135 DICLEGIS...... 53 doxepin...... 37, 163 decara...... 165 diclofenac epolamine...... 8 doxercalciferol...... 149 deferasirox...... 131 diclofenac potassium...... 8 doxycycline hyclate...... 19 DELSTRIGO...... 60 diclofenac sodium...... 8, 122 doxycycline monohydrate... 19, 20 deltasone...... 135 diclofenac-misoprostol...... 8 doxylamine-pyridoxine (vit delyla (28)...... 91 dicloxacillin...... 18 b6)...... 53 demeclocycline...... 19 dicyclomine...... 126 d-penamine...... 131

I-5 DRITHOCREME HP...... 105 EMCYT...... 22 ergoloid...... 36 dronabinol...... 53 EMEND...... 53, 54 ERGOMAR...... 51 drospirenone-e.estradiol-lm.fa.. 91 EMFLAZA...... 136 ergotamine-caffeine...... 51 drospirenone-ethinyl estradiol...91 EMGALITY PEN...... 51 ERIVEDGE...... 22 DROXIA...... 22 EMGALITY SYRINGE...... 51 ERLEADA...... 22 DUAVEE...... 133 emoquette...... 91 erlotinib...... 22 DULERA...... 158 EMSAM...... 37 errin...... 92 duloxetine...... 37 emtricitabine...... 61 ery pads...... 108 DUPIXENT PEN...... 141 emtricitabine-tenofovir (tdf).... 61 ery-tab...... 16 DUPIXENT SYRINGE...... 141 EMTRIVA...... 61 erythrocin (as stearate)...... 16 DUREZOL...... 122 EMVERM...... 55 erythromycin...... 17, 120 dutasteride...... 130 enalapril maleate...... 73 erythromycin ethylsuccinate..... 17 dutasteride-tamsulosin...... 131 enalapril-hydrochlorothiazide... 73 erythromycin with ethanol...... 108 DYMISTA...... 118 ENBREL...... 141 erythromycin-benzoyl peroxide e.e.s. 400...... 16 ENBREL MINI...... 141 ...... 109 econazole...... 47 ENBREL SURECLICK...... 141 ESBRIET...... 161 econtra ez...... 91 endocet...... 4 escitalopram oxalate...... 37 EDARBI...... 71 ENDOMETRIN...... 138 esomeprazole magnesium...... 124 EDARBYCLOR...... 71 ENGERIX-B (PF)...... 146 estarylla...... 92 ed-spaz...... 126 enoxaparin...... 67 estazolam...... 12 EDURANT...... 61 enpresse...... 91 estradiol...... 134 efavirenz...... 61 enskyce...... 92 estradiol-norethindrone acet... 134 efavirenz-emtricitabin-tenofov.. 61 ENSTILAR...... 105 ESTRING...... 134 efavirenz-lamivu-tenofov disop. 61 entacapone...... 56 estrogens-methyltestosterone..132 EFFER-K...... 155 entecavir...... 66 estropipate...... 134 effer-k...... 155 ENTRESTO...... 71 eszopiclone...... 163 EFUDEX...... 105 enulose...... 126 ethacrynic acid...... 79 EGATEN...... 55 ENZADYNE...... 115 ethambutol...... 52 ELESTRIN...... 134 EPCLUSA...... 65 ethosuximide...... 31 eletriptan...... 51 EPIDIOLEX...... 31 ethynodiol diac-eth estradiol.....92 elinest...... 91 EPIDUO FORTE...... 114 etidronate disodium...... 149 eliphos...... 129 EPIFOAM...... 111 etodolac...... 8 ELIQUIS...... 67 epinastine...... 118 etonogestrel-ethinyl estradiol....92 ELIQUIS DVT-PE TREAT epinephrine...... 77 etoposide...... 22 30D START...... 66 epitol...... 31 etravirine...... 61 ELLA...... 91 EPIVIR HBV...... 61 euthyrox...... 138 ELMIRON...... 150 eplerenone...... 82 EVAMIST...... 134 eluryng...... 91 EPOGEN...... 68 EVEKEO ODT...... 85 EMADINE...... 118 eprosartan...... 71 everolimus (antineoplastic)...... 22 EMBEDA...... 4 EQUETRO...... 31

I-6 everolimus FIASP PENFILL U-100 FML FORTE...... 123 (immunosuppressive)...... 141 INSULIN...... 43 FML S.O.P...... 123 EVOTAZ...... 61 FIASP U-100 INSULIN...... 43 folic acid...... 165 EVRYSDI...... 150 FINACEA...... 105 fondaparinux...... 67 EXELDERM...... 47 finasteride...... 131 formoterol fumarate...... 160 exemestane...... 22 FINTEPLA...... 31 FORTEO...... 149 exoderm...... 105 FIRDAPSE...... 151 FOSAMAX PLUS D...... 149 EYSUVIS...... 122 FIRMAGON KIT W fosamprenavir...... 61 ezetimibe...... 80 DILUENT SYRINGE...... 22 fosfomycin tromethamine...... 13 ezetimibe-simvastatin...... 80, 81 FIRVANQ...... 13 fosinopril...... 73 FACTIVE...... 18 FLAREX...... 122 fosinopril-hydrochlorothiazide..73 fallback solo...... 92 flavoxate...... 130 FOSRENOL...... 129 falmina (28)...... 92 flecainide...... 74 FOTIVDA...... 23 famciclovir...... 66 FLOVENT DISKUS...... 158 FRAGMIN...... 67 famotidine...... 124 FLOVENT HFA...... 158 frovatriptan...... 51 FANAPT...... 58 fluconazole...... 47 FULPHILA...... 68 FARXIGA...... 40 flucytosine...... 47 furosemide...... 79 FARYDAK...... 22 fludrocortisone...... 136 FUSION PLUS...... 165 FASENRA PEN...... 161 flunisolide...... 122 FUZEON...... 61 fayosim...... 92 fluocinolone...... 111 fyavolv...... 134 FC2 FEMALE CONDOM.....92 fluocinolone acetonide oil...... 122 FYCOMPA...... 31 febuxostat...... 49 fluocinonide...... 111 gabapentin...... 31, 32 felbamate...... 31 fluocinonide-e...... 111 GALAFOLD...... 115 felodipine...... 78 FLUORIDEX DAILY galantamine...... 36 FEMCAP...... 92 DEFENSE...... 103 GARDASIL 9 (PF)...... 146 FEMRING...... 134 fluorometholone...... 122 gatifloxacin...... 120 femynor...... 92 FLUOROPLEX...... 105 GATTEX 30-VIAL...... 126 fenofibrate...... 81 fluorouracil...... 105 gavilyte-c...... 128 fenofibrate micronized...... 81 fluoxetine...... 38 gavilyte-g...... 128 fenofibrate nanocrystallized...... 81 FLUOXETINE...... 38 gavilyte-n...... 128 fenofibric acid...... 81 fluphenazine hcl...... 58 GAVRETO...... 23 fenofibric acid (choline)...... 81 flurandrenolide...... 111 GELFILM...... 118 fenoprofen...... 8 flurazepam...... 12 GELNIQUE...... 130 fentanyl...... 4 flurbiprofen...... 8 gemfibrozil...... 81 fentanyl citrate...... 4 flurbiprofen sodium...... 123 gemmily...... 92 FETZIMA...... 37 flutamide...... 23 generlac...... 126 fexofenadine-pseudoephedrine.. 50 fluticasone propionate gengraf...... 141 FIASP FLEXTOUCH U-100 ...... 111, 112, 123 gentak...... 120 INSULIN...... 43 fluvastatin...... 81 gentamicin...... 109, 120 fluvoxamine...... 38 GENVOYA...... 61

I-7 GIALAX...... 128 halcinonide...... 112 HUMIRA(CF) PEDI gianvi (28)...... 92 halobetasol propionate...... 112 CROHNS STARTER...... 142 gildagia...... 92 HALOG...... 112 HUMIRA(CF) PEN...... 142 GILENYA...... 85 haloperidol...... 58 HUMIRA(CF) PEN GILOTRIF...... 23 haloperidol lactate...... 58 CROHNS-UC-HS...... 142 glatiramer...... 85 HARVONI...... 65 HUMIRA(CF) PEN glatopa...... 85 HAVRIX (PF)...... 146 PEDIATRIC UC...... 142 GLEEVEC...... 23 heather...... 92 HUMIRA(CF) PEN PSOR- GLEOSTINE...... 23 HEMADY...... 136 UV-ADOL HS...... 142 glimepiride...... 46 HEMANGEOL...... 75 HUMULIN 70/30 U-100 glipizide...... 46 heparin, porcine (pf)...... 67 INSULIN...... 44 glipizide-metformin...... 46 HEPLISAV-B (PF)...... 146 HUMULIN 70/30 U-100 GLOPERBA...... 49 HEXALEN...... 23 KWIKPEN...... 44 GLUCAGEN HYPOKIT.....151 HIZENTRA...... 141, 142 HUMULIN N NPH GLUCAGON homatropaire...... 118 INSULIN KWIKPEN...... 44 EMERGENCY KIT homatropine hbr...... 118 HUMULIN N NPH U-100 (HUMAN)...... 151 HUMALOG JUNIOR INSULIN...... 44 glucose...... 70 KWIKPEN U-100...... 43 HUMULIN R REGULAR glyburide...... 46 HUMALOG KWIKPEN U-100 INSULN...... 44 glyburide micronized...... 46 INSULIN...... 43 HUMULIN R U-500 glyburide-metformin...... 46 HUMALOG MIX 50-50 (CONC) INSULIN...... 44 glycopyrrolate...... 126 INSULN U-100...... 43 HUMULIN R U-500 glydo...... 9 HUMALOG MIX 50-50 (CONC) KWIKPEN...... 44 GLYXAMBI...... 40 KWIKPEN...... 43 HYCAMTIN...... 23 GOLYTELY...... 128 HUMALOG MIX 75-25 hydralazine...... 77 GORDONS UREA...... 105 KWIKPEN...... 43 HYDRO 35...... 105 granisetron hcl...... 54 HUMALOG MIX 75-25(U- hydrochlorothiazide...... 79 griseofulvin microsize...... 47 100)INSULN...... 43 hydrocodone bitartrate...... 4 griseofulvin ultramicrosize...... 47 HUMALOG U-100 hydrocodone-acetaminophen...... 4 guaifenesin dac...... 101 INSULIN...... 44 hydrocodone-chlorpheniramine guanfacine...... 71, 85 HUMIRA...... 142 ...... 101 guanidine...... 151 HUMIRA PEDIATRIC hydrocodone-cpm-pseudoephed GVOKE HYPOPEN 1- CROHNS START...... 142 ...... 101 PACK...... 151 HUMIRA PEN...... 142 hydrocodone-homatropine...... 101 GYNAZOLE-1...... 50 HUMIRA PEN CROHNS- hydrocodone-ibuprofen...... 4 GYNOL II...... 92 UC-HS START...... 142 hydrocortisone...... 112, 136, 148 hailey...... 92 HUMIRA PEN PSOR- hydrocortisone acetate...... 112 hailey 24 fe...... 92 UVEITS-ADOL HS...... 142 hydrocortisone butyrate...... 112 hailey fe 1.5/30 (28)...... 92 HUMIRA(CF)...... 143 hydrocortisone valerate...... 112 hailey fe 1/20 (28)...... 92 hydrocortisone-acetic acid...... 120

I-8 hydrocortisone-iodoquinol...... 112 INDOCIN...... 8 ivermectin...... 55, 114 hydrocortisone-pramoxine indomethacin...... 8, 9 JADENU...... 131 ...... 112, 113 INGREZZA...... 85 JADENU SPRINKLE...... 132 hydromet...... 101 INGREZZA INITIATION jaimiess...... 92 hydromorphone...... 4, 5 PACK...... 85 JAKAFI...... 24 hydroxychloroquine...... 55 INLYTA...... 23 jantoven...... 67 hydroxyurea...... 23 INOVA 4-1...... 105 JANUMET...... 40 hydroxyzine hcl...... 50 INOVA 8-2...... 105 JANUMET XR...... 40 hydroxyzine pamoate...... 151 INQOVI...... 24 JANUVIA...... 40 hyophen...... 131 INREBIC...... 24 JARDIANCE...... 41 hyoscyamine sulfate...... 126 insulin asp prt-insulin aspart.....44 jasmiel (28)...... 93 hyosyne...... 126 insulin aspart u-100...... 44 jencycla...... 93 HYPER-SAL...... 162 INTELENCE...... 61 JENTADUETO...... 41 HYQVIA...... 143 INTRON A...... 65 JENTADUETO XR...... 41 HYQVIA IG COMPONENT introvale...... 92 jinteli...... 134 ...... 143 INVELTYS...... 123 jolessa...... 93 ibandronate...... 149 INVIRASE...... 61 jolivette...... 93 IBRANCE...... 23 INVOKAMET...... 40 juleber...... 93 ibu...... 8 INVOKAMET XR...... 40 JULUCA...... 62 ibuprofen...... 8 INVOKANA...... 40 junel 1.5/30 (21)...... 93 ibuprofen-oxycodone...... 5 IOPIDINE...... 118 junel 1/20 (21)...... 93 icatibant...... 77 ipratropium bromide...... 118, 160 junel fe 1.5/30 (28)...... 93 iclevia...... 92 ipratropium-albuterol...... 160 junel fe 1/20 (28)...... 93 ICLUSIG...... 23 irbesartan...... 71 junel fe 24...... 93 IDHIFA...... 23 irbesartan-hydrochlorothiazide.72 JUXTAPID...... 81 ILEVRO...... 123 IRESSA...... 24 JYNARQUE...... 79 imatinib...... 23 ISENTRESS...... 62 kaitlib fe...... 93 IMBRUVICA...... 23 ISENTRESS HD...... 62 KALETRA...... 62 imipramine hcl...... 38 isibloom...... 92 kalliga...... 93 imipramine pamoate...... 38 isometh-dichloral- KALYDECO...... 162 imiquimod...... 105 acetaminophn...... 51 kariva (28)...... 93 IMPAVIDO...... 55 isoniazid...... 52 k-effervescent...... 155 IMVEXXY ISORDIL...... 82 kelnor 1/35 (28)...... 93 MAINTENANCE PACK.....134 isosorbide dinitrate...... 83 kelnor 1-50 (28)...... 93 IMVEXXY STARTER isosorbide mononitrate...... 83 KERAFOAM...... 105 PACK...... 134 isotretinoin...... 105 KERALYT SCALP INBRIJA...... 56 isoxsuprine...... 77 COMPLETE...... 105 incassia...... 92 isradipine...... 78 KERYDIN...... 47 INCRUSE ELLIPTA...... 160 ISTURISA...... 151 KESIMPTA PEN...... 85 indapamide...... 79 itraconazole...... 47 ketoconazole...... 47

I-9 ketoconazole-hydrocortisone.... 47 LANCING DEVICE WITH levofloxacin...... 18, 120 ketoprofen...... 9 LANCETS...... 115 levonest (28)...... 94 ketorolac...... 9, 123 LANOXIN...... 77 levonorgestrel...... 94 KEVEYIS...... 151 lansoprazole...... 125 levonorgestrel-ethinyl estrad.....94 kimidess (28)...... 93 lanthanum...... 129 levonorg-eth estrad triphasic.....94 KINERET...... 143 LANTUS SOLOSTAR U-100 levora-28...... 94 kionex...... 126 INSULIN...... 45 levorphanol tartrate...... 5 kionex (with sorbitol)...... 126 LANTUS U-100 INSULIN.... 45 levothyroxine...... 138 KISQALI...... 24 lapatinib...... 24 LEVOXYL...... 139 KISQALI FEMARA CO- larin 1.5/30 (21)...... 94 LEXIVA...... 62 PACK...... 24 larin 1/20 (21)...... 94 LIALDA...... 149 klor-con m10...... 155 larin 24 fe...... 94 LIDO BDK...... 10 klor-con m15...... 155 larin fe 1.5/30 (28)...... 94 lidocaine...... 10 klor-con m20...... 155 larin fe 1/20 (28)...... 94 lidocaine hcl...... 10 klor-con sprinkle...... 155 larissia...... 94 lidocaine hcl-hydrocortison ac.. 10 KLOR-CON/25...... 155 LASTACAFT...... 118 lidocaine viscous...... 10 KLOXXADO...... 11 latanoprost...... 154 lidocaine-hydrocortisone-aloe KORLYM...... 41 LATUDA...... 58 ...... 10, 105 KOSELUGO...... 24 layolis fe...... 94 lidocaine-prilocaine...... 10 KOVANAZE...... 9 leena 28...... 94 LILETTA...... 94 K-PHOS NO 2...... 155 leflunomide...... 143 lillow (28)...... 94 K-PHOS ORIGINAL...... 155 LENVIMA...... 24 lindane...... 114 KRINTAFEL...... 55 lessina...... 94 linezolid...... 13 kurvelo (28)...... 93 LETAIRIS...... 164 LINZESS...... 127 KUVAN...... 116 letrozole...... 24 liothyronine...... 139 KYLEENA...... 93 leucovorin calcium...... 151 lisinopril...... 73 KYNAMRO...... 81 LEUKERAN...... 24 lisinopril-hydrochlorothiazide... 73 l norgest/e.estradiol-e.estrad.....93 LEUKINE...... 68 lithium carbonate...... 85, 86 labetalol...... 75 leuprolide...... 25 lithium citrate...... 86 LACRISERT...... 118 levalbuterol hcl...... 160 LITHOSTAT...... 131 lactulose...... 126 levalbuterol tartrate...... 160 LIVALO...... 81 LAMICTAL XR STARTER LEVATOL...... 75 LO LOESTRIN FE...... 94 (BLUE)...... 32 LEVEMIR FLEXTOUCH lohist-dm...... 101 LAMICTAL XR STARTER U-100 INSULN...... 45 lojaimiess...... 94 (GREEN)...... 32 LEVEMIR U-100 INSULIN..45 LOKELMA...... 127 LAMICTAL XR STARTER levetiracetam...... 33 lomaira...... 86 (ORANGE)...... 32 levobunolol...... 154 lomedia 24 fe...... 95 lamivudine...... 62 levocarnitine...... 151 LONHALA MAGNAIR lamivudine-zidovudine...... 62 levocarnitine (with sugar)...... 151 STARTER...... 160 lamotrigine...... 32, 33 levocetirizine...... 50 LONSURF...... 25

I-10 loperamide...... 127 matzim la...... 76 meperidine...... 5 lopinavir-ritonavir...... 62 MAVENCLAD (10 TABLET meperidine (pf)...... 5 lopreeza...... 134 PACK)...... 86 meprobamate...... 13 lorazepam...... 12, 13 MAVENCLAD (4 TABLET mercaptopurine...... 25 LORBRENA...... 25 PACK)...... 86 mesalamine...... 149 lorcet (hydrocodone)...... 5 MAVENCLAD (5 TABLET MESNEX...... 151 lorcet hd...... 5 PACK)...... 86 metadate er...... 86 lorcet plus...... 5 MAVENCLAD (6 TABLET metaproterenol...... 160 loryna (28)...... 95 PACK)...... 86 metaxall...... 163 losartan...... 72 MAVENCLAD (7 TABLET metaxalone...... 163 losartan-hydrochlorothiazide....72 PACK)...... 86 metformin...... 41 LOTEMAX...... 123 MAVENCLAD (8 TABLET methadone...... 5 LOTEMAX SM...... 123 PACK)...... 86 methadose...... 5 loteprednol etabonate...... 123 MAVENCLAD (9 TABLET methamphetamine...... 86 lovastatin...... 81 PACK)...... 86 methazolamide...... 154 low-ogestrel (28)...... 95 MAVYRET...... 65 methenamine hippurate...... 13 loxapine succinate...... 58 MAXIDEX...... 123 methenamine mandelate...... 14 lo-zumandimine (28)...... 95 MAYZENT...... 86 methimazole...... 139 lubiprostone...... 127 MAYZENT STARTER METHITEST...... 132 LUCEMYRA...... 11 PACK...... 86 methocarbamol...... 163 luliconazole...... 47 meclizine...... 54 methotrexate sodium...... 25 LUMIGAN...... 154 meclofenamate...... 9 methotrexate sodium (pf)...... 25 LUPANETA PACK (1 MEDROL...... 136 methoxsalen...... 106 MONTH)...... 137 medroxyprogesterone...... 138 methscopolamine...... 127 LUPANETA PACK (3 mefenamic acid...... 9 methyclothiazide...... 79 MONTH)...... 137 mefloquine...... 55 methyldopa...... 71 lutera (28)...... 95 megestrol...... 25, 138 methyldopa- lyleq...... 95 MEKINIST...... 25 hydrochlorothiazide...... 71 LYNPARZA...... 25 MEKTOVI...... 25 methylergonovine...... 151 LYSODREN...... 25 melodetta 24 fe...... 95 methylphenidate hcl...... 86, 87 lyza...... 95 meloxicam...... 9 methylprednisolone...... 136 mafenide acetate...... 105 melphalan...... 25 methyltestosterone...... 132 malathion...... 114 memantine...... 36 metipranolol...... 154 maprotiline...... 38 MENACTRA (PF)...... 146 metoclopramide hcl...... 127 mar-cof bp...... 101 MENEST...... 134 metolazone...... 79 mar-cof cg...... 101 MENOSTAR...... 135 metoprolol succinate...... 75 marlissa (28)...... 95 MENQUADFI (PF)...... 146 metoprolol ta-hydrochlorothiaz 75 MARPLAN...... 38 MENTAX...... 48 metoprolol tartrate...... 75 marten-tab...... 5 MENVEO A-C-Y-W-135- metronidazole...... 14, 50, 109 MATULANE...... 25 DIP (PF)...... 147 metyrosine...... 77

I-11 mexiletine...... 74 morphine concentrate...... 5 necon 0.5/35 (28)...... 96 MEZPAROX-HC...... 113 morphine in 0.9 % sodium necon 1/50 (28)...... 96 mibelas 24 fe...... 95 chlor...... 5 necon 7/7/7 (28)...... 96 miconazole nitrate-zinc ox-pet..48 MOVANTIK...... 127 nefazodone...... 38 miconazole-3...... 48 MOVIPREP...... 128 neomycin...... 13 microgestin 1.5/30 (21)...... 95 moxifloxacin...... 18, 120 neomycin-bacitracin-poly-hc...120 microgestin 1/20 (21)...... 95 MULPLETA...... 69 neomycin-bacitracin- microgestin 24 fe...... 95 MULTAQ...... 74 polymyxin...... 120 microgestin fe 1.5/30 (28)...... 95 mupirocin...... 109 neomycin-polymyxin b- microgestin fe 1/20 (28)...... 95 mupirocin calcium...... 109 dexameth...... 120 midazolam...... 13 my choice...... 95 neomycin-polymyxin- midodrine...... 71 my way...... 95 gramicidin...... 120 MIGERGOT...... 51 mycophenolate mofetil...... 143 neomycin-polymyxin-hc...... 121 miglitol...... 41 mycophenolate sodium...... 143 neo-polycin...... 121 miglustat...... 116 MYLERAN...... 25 neo-polycin hc...... 121 mili...... 95 myorisan...... 106 NEO-SYNALAR...... 109 MILLIPRED...... 136 MYRBETRIQ...... 130 NERLYNX...... 25 MILLIPRED DP...... 136 MYTESI...... 127 NEULASTA...... 69 mimvey...... 135 myzilra...... 95 NEUPOGEN...... 69 mimvey lo...... 135 nabumetone...... 9 NEUPRO...... 57 minitran...... 83 nadolol...... 75 NEVANAC...... 123 minocycline...... 20 nadolol-bendroflumethiazide.....75 nevirapine...... 62 minoxidil...... 83 naftifine...... 48 new day...... 96 MIRCERA...... 69 NALFON...... 9 NEXAVAR...... 25 MIRENA...... 95 naloxone...... 11 NEXIUM PACKET...... 125 mirtazapine...... 38 naltrexone...... 11 NEXLETOL...... 81 MIRVASO...... 106 NAMENDA XR...... 36 NEXPLANON...... 96 misoprostol...... 125 NAMZARIC...... 36 next choice one dose...... 96 M-M-R II (PF)...... 147 naproxen...... 9 niacin...... 81 modafinil...... 163 naproxen sodium...... 9 niacor...... 81 moexipril...... 73 naratriptan...... 51 nicardipine...... 78 moexipril-hydrochlorothiazide..73 NARCAN...... 11 NICOTROL...... 11 molindone...... 58, 59 nasal allergy...... 123 NICOTROL NS...... 11 mometasone...... 113, 123 NATACYN...... 120 nifedipine...... 78 mono-linyah...... 95 NATAZIA...... 96 nikki (28)...... 96 mononessa (28)...... 95 nateglinide...... 41 nilutamide...... 25 montelukast...... 158 NATPARA...... 150 nimodipine...... 78 MONUROL...... 14 nature-throid...... 139 NINLARO...... 26 morphine...... 5, 6 NAYZILAM...... 33 nisoldipine...... 78 MORPHINE...... 6 NEBUSAL...... 162 nitisinone...... 116

I-12 NITRO-BID...... 83 NOVOLIN R REGULAR U- olopatadine...... 118 NITRO-DUR...... 83 100 INSULN...... 45 OLYSIO...... 65 nitrofurantoin...... 14 NOXAFIL...... 48 OMECLAMOX-PAK...... 125 nitrofurantoin macrocrystal...... 14 np thyroid...... 139 omega-3 acid ethyl esters...... 81 nitrofurantoin monohyd/m- NUBEQA...... 26 omeprazole...... 125 cryst...... 14 NUCALA...... 162 ondansetron...... 54 nitroglycerin...... 83 NUCORT...... 113 ondansetron hcl...... 54 nitro-time...... 83 NUCYNTA...... 6 ONGENTYS...... 57 NITYR...... 116 NUCYNTA ER...... 6 ONMEL...... 48 NIVESTYM...... 69 NUEDEXTA...... 87 ONUREG...... 26 nizatidine...... 125 NUOX...... 106 opcicon one-step...... 97 nodolor...... 51 NUPLAZID...... 59 opium tincture...... 127 nora-be...... 96 NUZYRA...... 20 OPSUMIT...... 164 NORDITROPIN FLEXPRO NUZYRA (7 DAY WITH option-2...... 97 ...... 137 LOAD DOSE)...... 20 ORACIT...... 155 noreth-ethinyl estradiol-iron..... 96 NUZYRA (7 DAY)...... 20 oralone...... 103 norethindrone (contraceptive)..96 nyamyc...... 48 ORAVIG...... 48 norethindrone acetate...... 138 nylia 7/7/7 (28)...... 97 ORENCIA...... 143 norethindrone ac-eth estradiol NYMALIZE...... 78, 79 ORENCIA CLICKJECT...... 143 ...... 96, 135 nymyo...... 97 ORENITRAM...... 164 norethindrone-e.estradiol-iron.. 96 nystatin...... 48 ORFADIN...... 116 norgestimate-ethinyl estradiol.. 97 nystatin-triamcinolone...... 48 ORILISSA...... 137 norlyda...... 97 nystop...... 48 ORKAMBI...... 162 norlyroc...... 97 NYVEPRIA...... 69 orphenadrine citrate...... 163 NORPACE CR...... 74 OCALIVA...... 127 orsythia...... 97 nortrel 0.5/35 (28)...... 97 ocella...... 97 oscimin...... 127 nortrel 1/35 (21)...... 97 octreotide acetate...... 137 oscimin sl...... 127 nortrel 1/35 (28)...... 97 ODEFSEY...... 62 oscimin sr...... 127 nortrel 7/7/7 (28)...... 97 ODOMZO...... 26 oseltamivir...... 64 nortriptyline...... 38 OFEV...... 162 OSMOPREP...... 128 NORVIR...... 62 ofloxacin...... 19, 121 OSPHENA...... 135 NOURIANZ...... 57 ogestrel (28)...... 97 OTEZLA...... 143 NOVOLIN 70/30 U-100 okebo...... 20 OTEZLA STARTER...... 144 INSULIN...... 45 olanzapine...... 59 OTOVEL...... 118 NOVOLIN 70-30 FLEXPEN olanzapine-fluoxetine...... 38 OTREXUP (PF)...... 144 U-100...... 45 olmesartan...... 72 oxandrolone...... 132 NOVOLIN N FLEXPEN...... 45 olmesartan-amlodipin- oxaprozin...... 9 NOVOLIN N NPH U-100 hcthiazid...... 72 OXAYDO...... 6 INSULIN...... 45 olmesartan- oxazepam...... 13 NOVOLIN R FLEXPEN...... 45 hydrochlorothiazide...... 72 OXBRYTA...... 70

I-13 oxcarbazepine...... 33 PASER...... 52 pilocarpine hcl...... 103, 154 OXERVATE...... 118 PAXIL...... 39 pimecrolimus...... 113 oxiconazole...... 48 PCE...... 17 pimozide...... 59 OXISTAT...... 48 peg 3350-electrolytes...... 128 pimtrea (28)...... 97 OXTELLAR XR...... 33 peg3350-sod sul-nacl-kcl-asb-c129 pindolol...... 75 oxybutynin chloride...... 130 PEGANONE...... 33 pioglitazone...... 41 oxycodone...... 6 PEGASYS...... 65 pioglitazone-glimepiride...... 41 oxycodone-acetaminophen...... 6 PEGASYS PROCLICK...... 65 pioglitazone-metformin...... 41 oxycodone-aspirin...... 6 peg-electrolyte soln...... 129 PIQRAY...... 26 OXYCONTIN...... 6 PEGINTRON...... 66 pirmella...... 97 oxymorphone...... 6, 7 PEMAZYRE...... 26 piroxicam...... 9 OXYTROL...... 130 penicillamine...... 132 PLAN B ONE-STEP...... 97 OZEMPIC...... 41 penicillin v potassium...... 18 PLEGRIDY...... 87 pacerone...... 74 PENTASA...... 149 PLENVU...... 129 PACNEX HP...... 106 pentazocine-naloxone...... 7 PNEUMOVAX-23...... 147 PACNEX LP...... 106 pentoxifylline...... 70 podocon...... 106 PALFORZIA (LEVEL 1).... 151 PERFOROMIST...... 160 podofilox...... 106 PALFORZIA (LEVEL 2).... 151 perindopril erbumine...... 73 polycin...... 121 PALFORZIA (LEVEL 3).... 151 periogard...... 103 polymyxin b sulf-trimethoprim121 PALFORZIA (LEVEL 4).... 151 permethrin...... 114 POLY-TUSSIN AC...... 101 PALFORZIA (LEVEL 5).... 152 perphenazine...... 59 POMALYST...... 26 PALFORZIA (LEVEL 6).... 152 perphenazine-amitriptyline...... 39 portia 28...... 97 PALFORZIA (LEVEL 7).... 152 phenadoz...... 54 posaconazole...... 48 PALFORZIA (LEVEL 8).... 152 phenazopyridine...... 131 potassium bicarb and chloride.156 PALFORZIA (LEVEL 9).... 152 phendimetrazine tartrate...... 87 potassium bicarb-citric acid.... 156 PALFORZIA (LEVEL 10)... 152 phenelzine...... 39 potassium chloride...... 156 PALFORZIA (LEVEL 11 phenobarbital...... 33 potassium citrate...... 156 UP-DOSE)...... 152 phenoxybenzamine...... 71 potassium citrate-citric acid....156 PALFORZIA INITIAL phentermine...... 87 pr cream...... 106 DOSE...... 152 phenylephrine hcl...... 119 PRALUENT PEN...... 82 paliperidone...... 59 phenytoin...... 33 pramipexole...... 57 PALYNZIQ...... 116 phenytoin sodium extended...... 33 PRAMOSONE...... 113 PANRETIN...... 106 philith...... 97 PRAMOSONE E...... 113 pantoprazole...... 125 PHOSLYRA...... 129 prasugrel...... 70 PARAGARD T 380A...... 97 phospha 250 neutral...... 155 pravastatin...... 82 paregoric...... 127 PHOSPHASAL...... 14 praziquantel...... 55 paricalcitol...... 150 PHOSPHOLINE IODIDE... 154 prazosin...... 71 paroex oral rinse...... 103 phrenilin forte(with caffeine)..... 7 PRED MILD...... 123 paromomycin...... 55 PICATO...... 106 PRED-G...... 121 paroxetine hcl...... 38, 39 PIFELTRO...... 63 PRED-G S.O.P...... 121

I-14 prednicarbate...... 113 proctosol hc...... 113 quasense...... 97 prednisolone acetate...... 124 proctozone-hc...... 113 quazepam...... 13 prednisolone sodium phosphate PROCYSBI...... 131, 152 quetiapine...... 59 ...... 124, 136 PROFENO...... 9 QUILLICHEW ER...... 87 prednisone...... 136 progesterone micronized...... 138 QUILLIVANT XR...... 88 PREDNISONE INTENSOL 136 PROGLYCEM...... 152 quinapril...... 73 PREFEST...... 135 PROGRAF...... 144 quinapril-hydrochlorothiazide...73 pregabalin...... 34, 87 prolate...... 7 quinidine gluconate...... 74 PREMARIN...... 135 PROLENSA...... 124 quinidine sulfate...... 74 PREMPHASE...... 135 PROMACTA...... 69 quinine sulfate...... 55 PREMPRO...... 135 promethazine...... 50, 54 QVAR...... 158 PREPOPIK...... 129 promethazine-codeine...... 101 QVAR REDIHALER...... 158 PRETOMANID...... 52 promethazine-dm...... 101 rabeprazole...... 125 prevalite...... 82 promethazine-phenyleph- rajani...... 98 PREVIDENT 5000 codeine...... 101 raloxifene...... 135 SENSITIVE...... 103 promethazine-phenylephrine..... 50 ramipril...... 73 previfem...... 97 promethegan...... 54 ranitidine hcl...... 125 PREVNAR 13 (PF)...... 147 propafenone...... 74 ranolazine...... 77, 78 PREVNAR 20 (PF)...... 147 propantheline...... 127 rasagiline...... 57 PREVYMIS...... 64 proparacaine...... 119 REBETOL...... 66 PREZCOBIX...... 63 propranolol...... 75 REBIF (WITH ALBUMIN)...88 PREZISTA...... 63 propranolol-hydrochlorothiazid 75 REBIF REBIDOSE...... 88 PRIFTIN...... 52 propylthiouracil...... 139 REBIF TITRATION PACK..88 PRILOSEC...... 125 PROQUAD (PF)...... 147 reclipsen (28)...... 98 PRILOVIXIL...... 10 PRO-RED AC (W/ RECOMBIVAX HB (PF)..... 147 PRIMAQUINE...... 55 DEXCHLORPHENIR)...... 101 RECTIV...... 152 primidone...... 34 PROTONIX...... 125 REGRANEX...... 106 primlev...... 7 protriptyline...... 39 RELENZA DISKHALER..... 64 PRIMLEV...... 7 PULMICORT RELISTOR...... 127, 128 PRIMSOL...... 14 FLEXHALER...... 158 RENAGEL...... 129 PROAIR RESPICLICK...... 160 PULMOZYME...... 116 repaglinide...... 42 probenecid...... 49 PURIXAN...... 26 repaglinide-metformin...... 42 probenecid-colchicine...... 49 PYLERA...... 127 REPATHA PUSHTRONEX..82 prochlorperazine...... 54 pyrazinamide...... 52 REPATHA SURECLICK...... 82 prochlorperazine maleate...... 54 pyridostigmine bromide...... 152 REPATHA SYRINGE...... 82 PROCORT...... 113 pyrimethamine...... 55 RESCRIPTOR...... 63 PROCRIT...... 69 QBRELIS...... 73 respa-ar...... 50 PROCTOFOAM HC...... 113 QBREXZA...... 106 RESTASIS...... 124 procto-med hc...... 113 QINLOCK...... 26 RETACRIT...... 69 procto-pak...... 113 QNASL...... 124 RETEVMO...... 26

I-15 REVCOVI...... 116 SABRIL...... 34 SIMPONI...... 144 REVLIMID...... 26 salicylic acid...... 106 simvastatin...... 82 REXULTI...... 59 salsalate...... 9 sirolimus...... 144 REYATAZ...... 63 SAMSCA...... 79, 80 SIRTURO...... 53 REZIRA...... 101 SANCUSO...... 54 SIVEXTRO...... 14 RHOFADE...... 106 SANDIMMUNE...... 144 SKLICE...... 115 RHOPRESSA...... 154 SANTYL...... 106 SKYLA...... 98 ribasphere...... 66 SAPHRIS...... 59 SKYRIZI...... 144, 145 ribasphere ribapak...... 66 sapropterin...... 116 SLYND...... 98 ribavirin...... 66 SAVELLA...... 88 sodium chloride...... 162 RIDAURA...... 144 scopolamine base...... 54 sodium citrate-citric acid...... 156 rifabutin...... 52 seb-prev...... 106 sodium fluoride-pot nitrate..... 103 RIFAMATE...... 53 SECONAL SODIUM...... 163 sodium phenylbutyrate...... 128 rifampin...... 53 SECUADO...... 59 sodium polystyrene (sorb free) RIFATER...... 53 selegiline hcl...... 57 ...... 128 riluzole...... 88 selenium sulfide...... 109 sodium polystyrene sulfonate.. 128 rimantadine...... 64 SELZENTRY...... 63 solifenacin...... 130 RINVOQ...... 144 SEMPREX-D...... 50 SOLIQUA 100/33...... 45 RIOMET...... 42 SEREVENT DISKUS...... 160 SOLOSEC...... 14 RIOMET ER...... 42 SERNIVO...... 113 soloxide...... 20 risedronate...... 150 sertraline...... 39 SOLTAMOX...... 26 risperidone...... 59 setlakin...... 98 SOMAVERT...... 137 ritonavir...... 63 sevelamer carbonate...... 129 SOOLANTRA...... 115 rivastigmine...... 36 sevelamer hcl...... 129 SORIATANE...... 106 rivastigmine tartrate...... 36 sf 5000 plus...... 103 SORILUX...... 106 rivelsa...... 98 sharobel...... 98 sorine...... 76 rizatriptan...... 51, 52 SHINGRIX (PF)...... 147 sotalol...... 76 ROCKLATAN...... 154 SIGNIFOR...... 137 sotalol af...... 76 ropinirole...... 57 SIKLOS...... 70 SOVALDI...... 65 rosadan...... 109 sildenafil...... 164 spinosad...... 115 ROSANIL...... 106 sildenafil (pulm.hypertension) 164 SPIRIVA RESPIMAT...... 160 ROSULA...... 106 SILENOR...... 163 SPIRIVA WITH rosuvastatin...... 82 SILIQ...... 144 HANDIHALER...... 161 ROXYBOND...... 7 silodosin...... 131 spironolactone...... 80 ROZLYTREK...... 26 silver nitrate...... 109 spironolacton-hydrochlorothiaz 80 RUBRACA...... 26 silver nitrate applicators...... 109 sprintec (28)...... 98 rufinamide...... 34 silver sulfadiazine...... 109 SPRITAM...... 34 RUKOBIA...... 63 SIMBRINZA...... 154 SPRYCEL...... 26 RYBELSUS...... 42 simliya (28)...... 98 sps (with sorbitol)...... 128 RYDAPT...... 26 simpesse...... 98 sronyx...... 98

I-16 ssd...... 109 SUTENT...... 27 TAZORAC...... 114 sski...... 139 syeda...... 98 taztia xt...... 76 sss 10-5...... 107 SYLATRON...... 27 TAZVERIK...... 27 stavudine...... 63 SYMDEKO...... 162 TDVAX...... 147 STELARA...... 145 SYMFI...... 63 TECFIDERA...... 88 STIMATE...... 137 SYMFI LO...... 63 TECHNIVIE...... 65 STIOLTO RESPIMAT...... 161 SYMLINPEN 120...... 42 TEGSEDI...... 153 STIVARGA...... 27 SYMLINPEN 60...... 42 TEKTURNA HCT...... 82 STRENSIQ...... 116 SYMPAZAN...... 34 telmisartan...... 72 STRIANT...... 132 SYMTUZA...... 63 telmisartan-amlodipine...... 72 STRIBILD...... 63 SYNAREL...... 138 telmisartan-hydrochlorothiazid.72 STRIVERDI RESPIMAT.... 161 SYNDROS...... 54 temazepam...... 13 strong iodine...... 139 SYNERA...... 10 TEMIXYS...... 64 SUBLOCADE...... 11 SYNJARDY...... 42 TEMODAR...... 27 subvenite...... 34 SYNJARDY XR...... 42 temozolomide...... 27 subvenite starter (blue) kit...... 34 SYNRIBO...... 27 tencon...... 7 subvenite starter (green) kit.....34 SYNTHROID...... 139 TENIVAC (PF)...... 147, 148 subvenite starter (orange) kit...34 TABLOID...... 27 tenofovir disoproxil fumarate... 64 SUCRAID...... 116 TABRECTA...... 27 TEPMETKO...... 27 sucralfate...... 125 tacrolimus...... 113, 145 terazosin...... 131 sulconazole...... 48 tadalafil...... 164 terbinafine hcl...... 49 sulfacetamide sodium...... 107, 121 tadalafil (pulm. hypertension) 164 terbutaline...... 161 sulfacetamide sodium (acne)..109 TAFINLAR...... 27 terconazole...... 50 sulfacetamide sodium-sulfur... 107 TAGRISSO...... 27 teriparatide...... 150 sulfacetamide-niacinamide...... 107 take action...... 98 TERSI FOAM...... 109 sulfacetamide-prednisolone.....121 TAKHZYRO...... 152 testosterone...... 133 sulfadiazine...... 19 TALZENNA...... 27 testosterone cypionate...... 132 sulfamethoxazole- tamoxifen...... 27 testosterone enanthate...... 133 trimethoprim...... 19 tamsulosin...... 131 tetrabenazine...... 88 SULFAMYLON...... 107 TANZEUM...... 42 tetracycline...... 20 sulfasalazine...... 149 TARCEVA...... 27 THALOMID...... 153 sulindac...... 9 TARGRETIN...... 27 THEO-24...... 161 sumatriptan...... 52 tarina 24 fe...... 98 theochron...... 161 sumatriptan succinate...... 52 tarina fe 1/20 (28)...... 98 theophylline...... 161 SUPRAX...... 16 TASIGNA...... 27 THIOLA...... 131 SUPREP BOWEL PREP tavaborole...... 49 THIOLA EC...... 131 KIT...... 129 TAVALISSE...... 70 thioridazine...... 59 SURE COMFORT INS. taysofy...... 98 thiothixene...... 60 SYR. U-100...... 115 TAYTULLA...... 98 thyroid (pork)...... 139 SUSTIVA...... 63 tazarotene...... 114 THYROLAR-1...... 139

I-17 THYROLAR-1/2...... 139 TOUJEO MAX U-300 trifluoperazine...... 60 THYROLAR-1/4...... 139 SOLOSTAR...... 45 trifluridine...... 122 THYROLAR-2...... 139 TOUJEO SOLOSTAR U-300 trihexyphenidyl...... 57 THYROLAR-3...... 139 INSULIN...... 46 TRIKAFTA...... 162 tiadylt er...... 76, 77 TOVIAZ...... 130 tri-legest fe...... 99 tiagabine...... 34 TRACLEER...... 164 tri-linyah...... 99 TIBSOVO...... 28 TRADJENTA...... 42 tri-lo-estarylla...... 99 ticlopidine...... 70 tramadol...... 7 tri-lo-marzia...... 99 TIGLUTIK...... 88 tramadol-acetaminophen...... 7 tri-lo-mili...... 99 tilia fe...... 98 trandolapril...... 73 tri-lo-sprintec...... 99 timolol maleate...... 76, 154 trandolapril-verapamil...... 73 trilyte with flavor packets...... 129 timolol maleate (pf)...... 154 tranexamic acid...... 70 trimethobenzamide...... 54 TIMOPTIC OCUDOSE (PF) tranylcypromine...... 39 trimethoprim...... 14 ...... 154 travoprost...... 155 tri-mili...... 99 tinidazole...... 55 travoprost (benzalkonium).....154 trimipramine...... 39 tiopronin...... 131 trazodone...... 39 TRIMPEX...... 14 TIVICAY...... 64 TRECATOR...... 53 trinessa (28)...... 99 TIVICAY PD...... 64 TRELEGY ELLIPTA...... 161 trinessa lo...... 99 tizanidine...... 163 TREMFYA...... 145 TRINTELLIX...... 39 TOBI PODHALER...... 13 TRESIBA FLEXTOUCH U- tri-nymyo...... 99 TOBRADEX...... 121 100...... 46 tri-previfem (28)...... 99 TOBRADEX ST...... 121 TRESIBA FLEXTOUCH U- tri-sprintec (28)...... 99 tobramycin...... 13, 121 200...... 46 TRIUMEQ...... 64 tobramycin in 0.225 % nacl...... 13 TRESIBA U-100 INSULIN... 46 trivora (28)...... 99 tobramycin-dexamethasone.... 122 tretinoin...... 114 tri-vylibra...... 99 TOBREX...... 122 tretinoin (antineoplastic)...... 28 tri-vylibra lo...... 99 TODAY tretinoin microspheres...... 114 TROKENDI XR...... 34, 35 CONTRACEPTIVE TRETIN-X CREAM KIT.... 114 trospium...... 130 SPONGE...... 98 TREXALL...... 28 TRULICITY...... 42 TOLAK...... 107 tri femynor...... 98 TRUMENBA...... 148 tolazamide...... 46 TRIACETIN...... 49 TRUVADA...... 64 tolbutamide...... 46 triamcinolone acetonide TUKYSA...... 28 tolcapone...... 57 ...... 103, 113, 114, 124 tulana...... 99 tolmetin...... 9 triamterene...... 80 TURALIO...... 28 tolterodine...... 130 triamterene-hydrochlorothiazid 80 TUSSICAPS...... 101 tolvaptan...... 80 triazolam...... 13 TWINRIX (PF)...... 148 topiramate...... 34 tricitrates...... 156 tyblume...... 99 toremifene...... 28 triderm...... 114 TYBOST...... 153 torsemide...... 80 trientine...... 132 tydemy...... 99 tri-estarylla...... 99 TYKERB...... 28

I-18 TYMLOS...... 150 vcf contraceptive gel...... 99 VUMERITY...... 88 TYVASO...... 165 velivet triphasic regimen (28).100 vyfemla (28)...... 100 TYVASO REFILL KIT...... 165 VELPHORO...... 129 vylibra...... 100 TYVASO STARTER KIT....165 VELTASSA...... 128 VYNDAQEL...... 78 TYZINE...... 119 VEMLIDY...... 64 VYVANSE...... 89 UBRELVY...... 52 VENCLEXTA...... 28 VYZULTA...... 155 UDENYCA...... 70 VENCLEXTA STARTING WAKIX...... 163 ULESFIA...... 153 PACK...... 28 warfarin...... 67 UNITHROID...... 139 venlafaxine...... 39 weekly-d...... 165 UPTRAVI...... 165 VENTAVIS...... 165 wera (28)...... 100 ur n-c...... 14 verapamil...... 77 westhroid...... 139, 140 URAMAXIN...... 107 VERZENIO...... 28 WIDE-SEAL DIAPHRAGM urea...... 107 VESICARE LS...... 130 70...... 100 urea nail stick...... 107 vestura (28)...... 100 wp thyroid...... 140 URETRON D-S...... 14 VIBRAMYCIN...... 20 wymzya fe...... 100 URIN DS...... 14 vicodin...... 7 XADAGO...... 57 uro-458...... 14 vicodin es...... 7 XALKORI...... 28 urogesic-blue...... 14 vicodin hp...... 7 XARELTO...... 67, 68 uro-mp...... 131 VICTOZA...... 42 XARELTO DVT-PE TREAT UROQID-ACID NO.2...... 14 VIDEX 2 GRAM 30D START...... 67 ursodiol...... 128 PEDIATRIC...... 64 XATMEP...... 28 ustell...... 131 vienva...... 100 XCLAIR...... 153 VAGINAL vigabatrin...... 35 XCOPRI...... 35 CONTRACEPTIVE FILM.... 99 vigadrone...... 35 XCOPRI MAINTENANCE vaginal contraceptive foam...... 99 VIIBRYD...... 39 PACK...... 35 valacyclovir...... 66 VIMPAT...... 35 XCOPRI TITRATION VALCHLOR...... 107 VIOKACE...... 116 PACK...... 35 valganciclovir...... 66 viorele (28)...... 100 XELJANZ...... 145 valproic acid...... 35 VIRACEPT...... 64 XELJANZ XR...... 145 valproic acid (as sodium salt)...35 VIREAD...... 64 XELODA...... 28 valsartan...... 72 virt-phos 250 neutral...... 156 XEMBIFY...... 145 valsartan-hydrochlorothiazide.. 72 VISTOGARD...... 153 XEPI...... 109 VALTOCO...... 35 VITRAKVI...... 28 XERMELO...... 128 vancomycin...... 14 VITUZ...... 101 XIFAXAN...... 14, 15 VANDAZOLE...... 50 VIZIMPRO...... 28 XIGDUO XR...... 42, 43 VANOXIDE-HC...... 108 volnea (28)...... 100 XIIDRA...... 124 VAQTA (PF)...... 148 voriconazole...... 49 XOFLUZA...... 64 varenicline...... 11 VOSEVI...... 65 XOSPATA...... 28 VARIVAX (PF)...... 148 VOTRIENT...... 28 XPOVIO...... 29 VARUBI...... 54 VRAYLAR...... 60 XTANDI...... 29

I-19 xulane...... 100 ZODRYL DEC 35...... 102 XULTOPHY 100/3.6...... 46 ZODRYL DEC 40...... 102 XURIDEN...... 153 ZODRYL DEC 50...... 102 xylon 10...... 7 ZODRYL DEC 60...... 102 XYREM...... 164 ZODRYL DEC 80...... 102 YONSA...... 29 ZOLINZA...... 29 yuvafem...... 135 zolmitriptan...... 52 zafemy...... 100 zolpidem...... 164 zafirlukast...... 159 ZOMIG...... 52 zaleplon...... 164 zonisamide...... 35 zarah...... 100 ZONTIVITY...... 70 ZARXIO...... 70 ZORTRESS...... 145 zebutal...... 7 ZOSTAVAX (PF)...... 148 ZEJULA...... 29 zovia 1/35e (28)...... 100 ZELAPAR...... 57 zovia 1/50e (28)...... 100 ZELBORAF...... 29 Z-TUSS AC...... 102 zenatane...... 108 ZUBSOLV...... 12 zenchent (28)...... 100 zumandimine (28)...... 100 zenchent fe...... 100 ZYDELIG...... 29 ZENPEP...... 117 ZYFLO...... 159 zenzedi...... 89 ZYKADIA...... 29 ZERVIATE...... 119 ZYLET...... 122 zidovudine...... 64 ZYPITAMAG...... 82 ZIEXTENZO...... 70 ZYTIGA...... 29, 30 ZIOPTAN (PF)...... 155 ziprasidone hcl...... 60 ZIRGAN...... 122 ZMAX...... 17 ZODRYL AC 25...... 101 ZODRYL AC 30...... 102 ZODRYL AC 35...... 102 ZODRYL AC 40...... 102 ZODRYL AC 50...... 102 ZODRYL AC 60...... 102 ZODRYL AC 80...... 102 ZODRYL DAC 50...... 102 ZODRYL DAC 60...... 102 ZODRYL DAC 80...... 102 ZODRYL DEC 25...... 102 ZODRYL DEC 30...... 102

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