Drug Name Drug Tier Requirements/ Limits ADHD/ANTI-NARCOLEPSY

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Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ADHD/ANTI-NARCOLEPSY/ANTI- atomoxetine hcl caps F PA OBESITY/ANOREXIANTS - Drugs to Treat ADHD, Sleep and Eating Disorders guanfacine hcl (adhd) tb24 F PA Amphetamines Stimulants - Misc. amphetamine- PA; QL(2 ea dextroamphetamine cp24 daily) armodafinil tabs 200 mg, F PA; QL(1 ea 1.25 mg-1.25 mg-1.25 mg- 150 mg, 250 mg daily) 1.25 mg, 2.5 mg-2.5 mg- F PA; QL(2 ea armodafinil tabs 50 mg daily) 2.5 mg-2.5 mg, 3.75 mg- F 3.75 mg-3.75 mg-3.75 mg, methylphenidate hcl chew F PA 5 mg-5 mg-5 mg-5 mg, 10 mg, 2.5 mg, 5 mg 6.25 mg-6.25 mg-6.25 mg- methylphenidate hcl cp24 PA 6.25 mg, 7.5 mg-7.5 mg- 10 mg, 20 mg, 30 mg, 40 F 7.5 mg-7.5 mg mg, 60 mg amphetamine- PA methylphenidate hcl cpcr PA; QL(1 ea dextroamphetamine tabs 40 mg, 10 mg, 20 mg, 30 F daily) 1.875 mg-1.875 mg-1.875 mg, 50 mg, 60 mg mg-1.875 mg, 3.125 mg- 3.125 mg-3.125 mg-3.125 methylphenidate hcl soln F PA mg, 3.75 mg-3.75 mg-3.75 F 10 mg/5ml, 5 mg/5ml mg-3.75 mg, 1.25 mg-1.25 methylphenidate hcl tabs F PA mg-1.25 mg-1.25 mg, 2.5 10 mg, 20 mg, 5 mg mg-2.5 mg-2.5 mg-2.5 mg, methylphenidate hcl tbcr 10 F PA 5 mg-5 mg-5 mg-5 mg, 7.5 mg mg-7.5 mg-7.5 mg-7.5 mg methylphenidate hcl tbcr 20 F PA; QL(1 ea dextroamphetamine sulfate F PA mg, 54 mg, 18 mg, 27 mg daily) cp24 10 mg, 15 mg, 5 mg methylphenidate hcl tbcr 36 F PA; QL(2 ea dextroamphetamine sulfate F PA mg daily) soln 5 mg/5ml modafinil tabs F PA; QL(2 ea dextroamphetamine sulfate F PA daily) tabs 10 mg, 5 mg PA AMINOGLYCOSIDES - Drugs to Treat Bacterial VYVANSE CAPS F Infections VYVANSE CHEW F PA Aminoglycosides neomycin sulfate tabs F Anorexiants Non-Amphetamine QSYMIA CP24 F PA ANALGESICS - ANTI-INFLAMMATORY - Drugs to Treat Pain, Swelling, Muscle and Joint Anti-Obesity Agents Conditions Gold Compounds ALLI CAPS F PA RIDAURA CAPS F PA BELVIQ TABS F PA Nonsteroidal Anti-inflammatory Agents (NSAIDs) BELVIQ XR TB24 F PA celecoxib caps F QL(2 ea daily) XENICAL CAPS F PA diclofenac potassium tabs F Attention-Deficit/Hyperactivity Disorder (ADHD) Workforce Safety & Insurance Preferred Drug List Updated June 1, 2021 QL - Quantity Limit (There is a limit on the amount of drug covered per prescription, or within a specific time frame); PA - Prior Authorization (Prior Authorization required before prescription can be filled); Drugs not listed are considered Non-Formulary

0 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits diclofenac sodium tb24 F meloxicam tabs 15 mg, 7.5 F QL(2 ea daily) mg diclofenac sodium tbec F nabumetone tabs F diclofenac w/ misoprostol F tbec NALFON CAPS 400 MG F etodolac caps F naproxen sodium caps F etodolac tabs F naproxen sodium tabs F etodolac tb24 F naproxen sodium tb24 F

FENOPROFEN CALCIUM F naproxen susp F CAPS 200 MG fenoprofen calcium caps F naproxen tabs F 200 mg, 400 mg fenoprofen calcium tabs F naproxen tbec F 600 mg oxaprozin tabs F QL(2 ea daily) FENORTHO CAPS F piroxicam caps F flurbiprofen tabs F sulindac tabs F ibuprofen caps 200 mg F tolmetin sodium caps F ibuprofen chew 100 mg F tolmetin sodium tabs F ibuprofen susp 100 mg/5ml F RX/OTC Phosphodiesterase 4 (PDE4) Inhibitors ibuprofen susp 40 mg/ml, F 50 mg/1.25ml OTEZLA TABS F PA ibuprofen tabs 100 mg, 400 mg, 600 mg, 800 mg, 200 F OTEZLA TBPK F PA mg Pyrimidine Synthesis Inhibitors INDOCIN SUSP F F PA; QL(1 ea leflunomide tabs daily) indomethacin caps 25 mg, F 50 mg ANALGESICS - NonNarcotic - Drugs to Treat indomethacin cpcr 75 mg F Pain, Muscle and Joint Conditions Analgesic Combinations ketoprofen caps F acetaminophen-caffeine F tabs ketoprofen cp24 F butalbital-acetaminophen F ketorolac tromethamine F QL(4 ea daily) tabs 325 mg-50 mg tabs or 10 mg butalbital-acetaminophen- meclofenamate sodium F caffeine tabs 325 mg-40 F caps mg-50 mg

Workforce Safety & Insurance Preferred Drug List Updated June 1, 2021 QL - Quantity Limit (There is a limit on the amount of drug covered per prescription, or within a specific time frame); PA - Prior Authorization (Prior Authorization required before prescription can be filled); Drugs not listed are considered Non-Formulary

1 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits butalbital-aspirin-caffeine F F PA; QL(1 ea caps ABSTRAL SUBL daily) CVS TENSION F ARYMO ER TBEA F PA HEADACHE TABS Analgesics Other CODEINE SULFATE TABS F 15 MG, 60 MG acetaminophen caps or F 500 mg codeine sulfate tabs 30 mg F acetaminophen liqd or 160 PA mg/5ml, 1000 mg/30ml, F EMBEDA CPCR F 500 mg/15ml fentanyl citrate lpop F PA; QL(1 ea acetaminophen supp re F daily) 650 mg, 120 mg fentanyl citrate tabs F PA; QL(1 ea acetaminophen tabs or 325 F daily) mg, 500 mg fentanyl pt72 100 mcg/hr, PA; QL(0.5 ea acetaminophen tbcr or 650 F 12 mcg/hr, 25 mcg/hr, 50 F daily) mg mcg/hr, 75 mcg/hr acetaminophen tbdp or 80 F PA; QL(1 ea mg, 160 mg hydrocodone bitartrate t24a F daily,30 ea per 30 days retail) FEVERALL INFANTS F SUPP hydromorphone hcl liqd or F 1 mg/ml FEVERALL JUNIOR F STRENGTH SUPP HYDROMORPHONE HCL F Salicylates SUPP RE 3 MG hydromorphone hcl tabs or aspirin buffered (cal carb- F F mag carb-mag oxide) tabs 2 mg, 4 mg, 8 mg PA aspirin chew or 81 mg F KADIAN CP24 200 MG F

ASPIRIN SUPP RE 300 F levorphanol tartrate tabs F MG, 600 MG methadone hcl conc F PA aspirin tabs or 500 mg, 325 F mg methadone hcl soln F PA aspirin tbec or 325 mg, 81 F mg methadone hcl tabs F PA BUFFERIN EXTRA F STRENGTH TABS methadone hcl tbso F PA BUFFERIN LOW DOSE F TABS morphine sulfate beads F PA; QL(1 ea cp24 daily) diflunisal tabs F morphine sulfate cp24 or PA salsalate tabs F 10 mg, 100 mg, 20 mg, 30 F mg, 50 mg, 60 mg, 80 mg ANALGESICS - OPIOID - Drugs to Treat Pain, morphine sulfate soln or 10 Muscle and Joint Conditions mg/5ml, 20 mg/5ml, 100 F mg/5ml, 20 mg/ml Opioid Agonists morphine sulfate supp re F 10 mg, 20 mg, 30 mg, 5 mg Workforce Safety & Insurance Preferred Drug List Updated June 1, 2021 QL - Quantity Limit (There is a limit on the amount of drug covered per prescription, or within a specific time frame); PA - Prior Authorization (Prior Authorization required before prescription can be filled); Drugs not listed are considered Non-Formulary

2 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits morphine sulfate tabs or 15 F butalbital-acetaminophen- F mg, 30 mg caffeine w/ codeine caps morphine sulfate tbcr or PA butalbital-aspirin-caffeine F 100 mg, 15 mg, 200 mg, 30 F w/cod caps mg, 60 mg hydrocodone- PA PA; QL(2 ea acetaminophen soln 10 F NUCYNTA ER TB12 F daily,60 ea per mg/15ml-325 mg/15ml 30 days retail) hydrocodone- NUCYNTA TABS F acetaminophen tabs 10 F mg-325 mg, 325 mg-5 mg, OXAYDO TABS F 325 mg-7.5 mg hydrocodone-ibuprofen F oxycodone hcl caps 5 mg F tabs 200 mg-7.5 mg LORTAB ELIX F PA oxycodone hcl conc 100 F mg/5ml NALOCET TABS F PA oxycodone hcl soln 5 F mg/5ml oxycodone w/ F oxycodone hcl t12a 15 mg, PA; QL(3 ea acetaminophen tabs 30 mg, 60 mg, 10 mg, 20 F daily) mg, 40 mg oxycodone-ibuprofen tabs F F PA; QL(6 ea OXYCODONE/ACETAMIN F PA oxycodone hcl t12a 80 mg daily) OPHEN TABS oxycodone hcl tabs 10 mg, F PRIMLEV TABS F PA 20 mg, 15 mg, 5 mg OXYCONTIN T12A 15 MG, PA; QL(3 ea PROLATE TABS 10 MG- PA 30 MG, 60 MG, 10 MG, 20 F daily) 300 MG, 300 MG-5 MG, F MG, 40 MG 300 MG-7.5 MG tramadol-acetaminophen QL(10 ea daily) F PA; QL(6 ea F OXYCONTIN T12A 80 MG daily) tabs oxymorphone hcl tabs 10 F Opioid Partial Agonists mg, 5 mg F PA; QL(0.15 ea oxymorphone hcl tb12 10 PA; QL(3 ea buprenorphine ptwk daily) mg, 15 mg, 20 mg, 30 mg, F daily) F QL(0.17 ml 40 mg, 5 mg, 7.5 mg butorphanol tartrate soln daily) QL(8 ea daily) tramadol hcl tabs 50 mg F pentazocine w/ naloxone F tabs PA; QL(1 ea tramadol hcl tb24 100 mg, F daily,30 ea per ANDROGENS-ANABOLIC - Drugs to Regulate 200 mg, 300 mg 30 days retail) Hormones F PA; QL(2 ea Anabolic Steroids XTAMPZA ER C12A daily) oxandrolone tabs F PA Opioid Combinations Androgens acetaminophen w/ codeine F soln ANDRODERM PT24 F PA acetaminophen w/ codeine F tabs Workforce Safety & Insurance Preferred Drug List Updated June 1, 2021 QL - Quantity Limit (There is a limit on the amount of drug covered per prescription, or within a specific time frame); PA - Prior Authorization (Prior Authorization required before prescription can be filled); Drugs not listed are considered Non-Formulary

3 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits danazol caps F PA Lincosamides clindamycin hcl caps F NATESTO GEL F PA clindamycin palmitate F testosterone gel 1.62 %, PA hydrochloride solr 20.25 mg/1.25gm, 25 F mg/2.5gm, 40.5 mg/2.5gm, Oxazolidinones 1 %, 50 mg/5gm linezolid susr 100 mg/5ml F PA ANTI-INFECTIVE AGENTS - MISC. - Drugs to Treat Bacterial Infections F PA; QL(2 ea linezolid tabs 600 mg daily) Anti-infective Agents - Misc. SIVEXTRO TABS F PA; QL(1 ea metronidazole caps F daily) ANTIANGINAL AGENTS - Drugs to Treat Chest metronidazole tabs F Pain pentamidine isethionate F PA Antianginals-Other solr ranolazine tb12 F PA tinidazole tabs F PA Nitrates trimethoprim tabs F isosorbide dinitrate tabs F PA XIFAXAN TABS F PA isosorbide dinitrate tbcr F PA Anti-infective Misc. - Combinations isosorbide mononitrate tabs F PA sulfamethoxazole- F 10 mg, 20 mg trimethoprim susp isosorbide mononitrate F PA; QL(3 ea sulfamethoxazole- F tb24 120 mg daily) trimethoprim tabs isosorbide mononitrate F PA; QL(1.5 ea Antiprotozoal Agents tb24 30 mg, 60 mg daily) PA ALINIA SUSR 100 F PA NITRO-BID OINT F MG/5ML PA NITRO-DUR PT24 0.3 F PA atovaquone susp F MG/HR, 0.8 MG/HR PA nitazoxanide tabs F PA nitroglycerin cpcr F Glycopeptides nitroglycerin pt24 F PA FIRST-VANCOMYCIN 25 F PA SOLN nitroglycerin soln F FIRST-VANCOMYCIN 50 F PA SOLN nitroglycerin subl F VANCOMYCIN HCL + F NITROMIST AERS F PA SYRSPENDSF PH4 SUSP Leprostatics ANTIANXIETY AGENTS - Drugs to Treat Anxiety PA dapsone tabs F Antianxiety Agents - Misc.

4 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits buspirone hcl tabs F PA Antiarrhythmics Type I-C flecainide acetate tabs F PA hydroxyzine hcl soln F Antiarrhythmics Type III hydroxyzine hcl syrp F amiodarone hcl tabs 200 F PA mg hydroxyzine hcl tabs F dofetilide caps F PA hydroxyzine pamoate caps F ANTIASTHMATIC AND BRONCHODILATOR Benzodiazepines AGENTS - Drugs to Treat Lung Conditions ALPRAZOLAM INTENSOL F Anti-Inflammatory Agents CONC cromolyn sodium nebu F PA alprazolam tabs 0.25 mg, F 0.5 mg, 1 mg, 2 mg Antiasthmatic - Monoclonal Antibodies alprazolam tb24 0.5 mg, 1 F mg, 2 mg, 3 mg CINQAIR SOLN F PA chlordiazepoxide hcl caps F NUCALA SOLR 100 MG F PA clorazepate dipotassium F tabs Asthma and Bronchodilator Agent Combinations PA diazepam conc F dyphylline-guaifenesin liqd F Bronchodilators - Anticholinergics diazepam soln F ATROVENT HFA AERS F PA diazepam tabs F ipratropium bromide soln F PA lorazepam conc F SEEBRI NEOHALER F PA lorazepam tabs F CAPS SPIRIVA HANDIHALER F PA oxazepam caps F CAPS SPIRIVA RESPIMAT F PA ANTIARRHYTHMICS - Drugs to treat abnormal AERS heart rhythms TUDORZA PRESSAIR F PA Antiarrhythmics Type I-A AEPB PA disopyramide phosphate F PA YUPELRI SOLN F caps NORPACE CR CP12 F PA Leukotriene Modulators montelukast sodium chew F PA; QL(1 ea quinidine gluconate tbcr F PA daily) montelukast sodium pack F PA; QL(1 ea quinidine sulfate tabs F PA daily) F PA; QL(1 ea Antiarrhythmics Type I-B montelukast sodium tabs daily) PA mexiletine hcl caps F zafirlukast tabs F PA

5 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits zileuton tb12 F PA albuterol sulfate tb12 or 4 F PA mg, 8 mg PA ZYFLO TABS F ANORO ELLIPTA AEPB F PA

Steroid Inhalants BREO ELLIPTA AEPB F PA ALVESCO AERS F PA BROVANA NEBU F PA ASMANEX TWISTHALER PA 120 METERED DOSES F budesonide-formoterol F PA AEPB fumarate dihydrate aero ASMANEX TWISTHALER PA COMBIVENT RESPIMAT F PA; QL(0.98 14 METERED DOSES F AERS gm daily) AEPB fluticasone-salmeterol aepb PA; QL(2 ea ASMANEX TWISTHALER PA 50 mcg/dose-500 daily) 30 METERED DOSES F mcg/dose, 100 mcg/act-50 AEPB mcg/act, 100 mcg/dose-50 F ASMANEX TWISTHALER PA mcg/dose, 250 mcg/act-50 60 METERED DOSES F mcg/act, 250 mcg/dose-50 AEPB mcg/dose ASMANEX TWISTHALER PA ipratropium-albuterol soln F PA 7 METERED DOSES F AEPB levalbuterol hcl nebu F PA budesonide (inhalation) F PA PA susp levalbuterol tartrate aero F F PA; QL(4 ea PA FLOVENT DISKUS AEPB daily) metaproterenol sulfate tabs F F PA; QL(0.87 PERFOROMIST NEBU F PA FLOVENT HFA AERO gm daily) PROAIR RESPICLICK PA PULMICORT FLEXHALER F PA F AEPB AEPB PA SEREVENT DISKUS F PA; QL(4 ea QVAR REDIHALER AERB F AEPB daily) Sympathomimetics STRIVERDI RESPIMAT F PA AERS ADVAIR HFA AERO F PA terbutaline sulfate tabs F PA albuterol sulfate aers in F PA; QL(1.5 gm 108 mcg/act daily) TRELEGY ELLIPTA AEPB F PA albuterol sulfate nebu in PA UTIBRON NEOHALER PA 0.083 %, 0.63 mg/3ml, 1.25 F F mg/3ml, 0.5 %, 2.5 CAPS mg/0.5ml Xanthines ALBUTEROL SULFATE F PA PA NEBU IN 0.5 % ELIXOPHYLLIN ELIX F PA albuterol sulfate syrp or 2 F PA THEO-24 CP24 F mg/5ml PA albuterol sulfate tabs or 2 F PA theophylline soln F mg, 4 mg Workforce Safety & Insurance Preferred Drug List Updated June 1, 2021 QL - Quantity Limit (There is a limit on the amount of drug covered per prescription, or within a specific time frame); PA - Prior Authorization (Prior Authorization required before prescription can be filled); Drugs not listed are considered Non-Formulary

6 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits theophylline tb12 F PA diazepam (anticonvulsant) F gel theophylline tb24 F PA Anticonvulsants - Misc. APTIOM TABS F PA ANTICOAGULANTS - Blood Thinners PA Coumarin Anticoagulants carbamazepine chew F warfarin sodium tabs F carbamazepine cp12 F PA

Direct Factor Xa Inhibitors carbamazepine susp F PA ELIQUIS TABS F PA carbamazepine tabs F PA XARELTO STARTER F PA PACK TBPK carbamazepine tb12 F PA XARELTO TABS F PA gabapentin caps F Heparins And Heparinoid-Like Agents gabapentin soln F enoxaparin sodium soln F gabapentin tabs F fondaparinux sodium soln F LAMICTAL ODT KIT F PA FRAGMIN SOLN F LAMICTAL XR KIT F PA heparin sodium (porcine) F PA lock flush soln lamotrigine chew F PA heparin sodium (porcine) F soln lamotrigine kit F PA Thrombin Inhibitors lamotrigine tabs F PA PRADAXA CAPS F PA lamotrigine tb24 F PA ANTICONVULSANTS - Drugs to Treat Seizures lamotrigine tbdp F PA AMPA Glutamate Receptor Antagonists FYCOMPA SUSP F PA levetiracetam soln F

FYCOMPA TABS F PA levetiracetam tabs F Anticonvulsants - Benzodiazepines levetiracetam tb24 F PA clobazam susp F oxcarbazepine susp F PA PA clobazam tabs F oxcarbazepine tabs F PA clonazepam tabs F pregabalin caps 100 mg, QL(3 ea daily) 150 mg, 200 mg, 25 mg, 50 F clonazepam tbdp F mg, 75 mg

7 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits pregabalin caps 225 mg, F QL(2 ea daily) valproate sodium soln F PA 300 mg PA pregabalin soln 20 mg/ml F valproic acid caps F primidone tabs F PA ANTIDEPRESSANTS - Drugs to Treat Depression topiramate cpsp F PA Alpha-2 Receptor Antagonists (Tetracyclics) PA F PA; QL(1 ea topiramate cs24 F mirtazapine tabs daily) PA F PA; QL(1 ea topiramate tabs F mirtazapine tbdp daily) VIMPAT SOLN F PA Antidepressants - Misc. bupropion hcl tabs 100 mg, F PA VIMPAT TABS F PA 75 mg PA bupropion hcl tb12 100 mg, F PA; QL(2 ea zonisamide caps F 150 mg, 200 mg daily) Carbamates bupropion hcl tb24 300 mg, F PA; QL(1 ea 150 mg daily) PA felbamate susp F Monoamine Oxidase Inhibitors (MAOIs) felbamate tabs F PA MARPLAN TABS F PA

GABA Modulators phenelzine sulfate tabs F PA tiagabine hcl tabs F PA tranylcypromine sulfate F PA tabs Hydantoins Selective Serotonin Reuptake Inhibitors (SSRIs) DILANTIN CAPS 30 MG F PA citalopram hydrobromide F PA soln 10 mg/5ml phenytoin chew F PA citalopram hydrobromide F PA; QL(1 ea tabs 10 mg, 20 mg, 40 mg daily) phenytoin sodium extended F PA caps escitalopram oxalate soln 5 F PA; QL(20 ml mg/5ml daily) phenytoin susp F PA escitalopram oxalate tabs F PA; QL(1.5 ea Succinimides 10 mg daily) PA escitalopram oxalate tabs F PA; QL(1 ea CELONTIN CAPS F 20 mg, 5 mg daily) PA ethosuximide caps F F PA; QL(1 ea fluoxetine hcl caps 10 mg daily) PA ethosuximide soln F F PA; QL(3 ea fluoxetine hcl caps 20 mg daily) Valproic Acid fluoxetine hcl caps 40 mg F PA; QL(2 ea divalproex sodium csdr F PA daily) fluoxetine hcl cpdr 90 mg F PA; QL(0.14 ea divalproex sodium tb24 F PA daily)

8 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits fluoxetine hcl soln 20 F PA amitriptyline hcl tabs F mg/5ml PA fluoxetine hcl tabs 10 mg, F PA; QL(1 ea clomipramine hcl caps F 60 mg daily) F PA; QL(2 ea desipramine hcl tabs F fluoxetine hcl tabs 20 mg daily) doxepin hcl caps F fluvoxamine maleate tabs F PA 100 mg, 25 mg, 50 mg doxepin hcl conc F paroxetine hcl tabs 10 mg, F PA; QL(1 ea 20 mg, 30 mg daily) imipramine hcl tabs F F PA; QL(2 ea paroxetine hcl tabs 40 mg daily) nortriptyline hcl caps F paroxetine hcl tb24 25 mg F PA; QL(2 ea daily) nortriptyline hcl soln F paroxetine hcl tb24 37.5 F PA; QL(1 ea mg, 12.5 mg daily) ANTIDIABETICS - Drugs to Regulate Blood Sugar PAXIL SUSP 10 MG/5ML F PA Alpha-Glucosidase Inhibitors sertraline hcl conc 20 F PA PA mg/ml acarbose tabs F F PA; QL(2 ea PA sertraline hcl tabs 100 mg daily) miglitol tabs F F PA; QL(1 ea Antidiabetic - Amylin Analogs sertraline hcl tabs 25 mg daily) SYMLINPEN 120 SOPN F PA F PA; QL(1.5 ea sertraline hcl tabs 50 mg daily) SYMLINPEN 60 SOPN F PA Serotonin Modulators trazodone hcl tabs F Antidiabetic Combinations alogliptin-metformin hcl F PA Serotonin-Norepinephrine Reuptake Inhibitors tabs PA desvenlafaxine succinate F PA alogliptin-pioglitazone tabs F tb24 PA duloxetine hcl cpep 20 mg, F QL(2 ea daily) glipizide-metformin hcl tabs F 60 mg, 30 mg glyburide-metformin tabs F PA F PA; QL(1 ea FETZIMA CP24 daily) GLYXAMBI TABS F PA FETZIMA TITRATION F PA PACK C4PK INVOKAMET TABS F PA venlafaxine hcl cp24 F INVOKAMET XR TB24 F PA venlafaxine hcl tabs F JANUMET TABS F PA venlafaxine hcl tb24 F JANUMET XR TB24 F PA Tricyclic Agents

9 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits JENTADUETO XR TB24 F PA Insulin ADMELOG SOLN F PA KOMBIGLYZE XR TB24 F PA APIDRA SOLN F PA pioglitazone hcl-glimepiride F PA tabs HUMALOG KWIKPEN F PA pioglitazone hcl-metformin F PA SOPN hcl tabs HUMALOG MIX 50/50 F PA SYNJARDY TABS F PA SUSP HUMALOG MIX 75/25 F PA SYNJARDY XR TB24 F PA SUSP PA TRIJARDY XR TB24 F PA HUMALOG SOLN F PA XIGDUO XR TB24 F PA HUMULIN 70/30 SUSP F PA Biguanides HUMULIN N SUSP F metformin hcl soln 500 F PA PA mg/5ml HUMULIN R SOLN F metformin hcl tabs 1000 F PA HUMULIN R U-500 F PA mg, 500 mg, 850 mg (CONCENTRATED) SOLN metformin hcl tb24 1000 F PA HUMULIN R U-500 F PA mg, 500 mg, 750 mg KWIKPEN SOPN Dipeptidyl Peptidase-4 (DPP-4) Inhibitors INSULIN ASPART PA PROTAMINE/INSULIN F alogliptin benzoate tabs F PA ASPART SUSP PA JANUVIA TABS F PA INSULIN ASPART SOLN F PA ONGLYZA TABS F PA INSULIN LISPRO SOLN F PA TRADJENTA TABS F PA LANTUS SOLN F PA Incretin Mimetic Agents (GLP-1 Receptor LEVEMIR SOLN F PA BYDUREON PEN PEN F NOVOLIN 70/30 RELION F PA SUSP PA BYETTA SOPN F NOVOLIN 70/30 SUSP F PA RYBELSUS TABS F PA NOVOLIN N RELION F PA SUSP VICTOZA SOPN F PA NOVOLIN N SUSP F PA Insulin Sensitizing Agents NOVOLIN R RELION F PA F PA; QL(2 ea SOLN AVANDIA TABS daily) NOVOLIN R SOLN F PA F PA; QL(1 ea pioglitazone hcl tabs daily) NOVOLOG MIX 70/30 F PA SUSP Workforce Safety & Insurance Preferred Drug List Updated June 1, 2021 QL - Quantity Limit (There is a limit on the amount of drug covered per prescription, or within a specific time frame); PA - Prior Authorization (Prior Authorization required before prescription can be filled); Drugs not listed are considered Non-Formulary

10 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NOVOLOG SOLN F PA CULTURELLE DIGESTIVE PA; RX/OTC HEALTH WOMENS F SEMGLEE SOLN F PA HEALTHY BALANCE CAPS TOUJEO MAX SOLOSTAR PA F FLORAJEN ACIDOPHILUS F PA; RX/OTC SOPN CAPS TOUJEO SOLOSTAR PA F FLORAJEN WOMEN F PA; RX/OTC SOPN CAPS TRESIBA FLEXTOUCH PA F LACTO-BIFIDUS-600 F PA SOPN CAPS Meglitinide Analogues lactobacillus caps 10 mg, PA; RX/OTC PA 100 mg, 13.3 mg, 3.5 mg, F nateglinide tabs F 600 mg, 680 mg, PA repaglinide tabs F PA lactobacillus pack F Sodium-Glucose Co-Transporter 2 (SGLT2) lactobacillus rhamnosus F PA (gg) caps PA FARXIGA TABS F lactobacillus tabs 0.2 mg- PA 0.2 mg, 0.5 mg, 1 mg, 10 F INVOKANA TABS F PA mg, 5 mg, PA; RX/OTC JARDIANCE TABS F PA PROBIOTIC CAPS F PROBIOTIC GOLD EXTRA F PA; RX/OTC Sulfonylureas STRENGTH CAPS glimepiride tabs 1 mg, 2 F PA; QL(1.5 ea PA; RX/OTC mg daily) REPHRESH PRO-B CAPS F F PA; QL(2 ea glimepiride tabs 4 mg daily) Antidiarrheal/Probiotic Combinations loperamide-simethicone F PA glipizide tabs F PA tabs glipizide tb24 F PA Antiperistaltic Agents ANTI-DIARRHEAL LIQD F PA glyburide micronized tabs F PA diphenoxylate w/ atropine F PA glyburide tabs F PA liqd diphenoxylate w/ atropine F PA ANTIDIARRHEAL/PROBIOTIC AGENTS - Drugs tabs to Treat Diarrhea loperamide hcl caps 2 mg F PA; RX/OTC Antidiarrheal/Probiotic Agents - Misc. AZO DUAL PROTECTION PA; RX/OTC loperamide hcl liqd 1 F PA URINARY+VAGINAL F mg/7.5ml SUPPORT CAPS loperamide hcl susp 1 F PA mg/7.5ml bismuth subsalicylate chew F PA loperamide hcl tabs 2 mg F PA bismuth subsalicylate susp F PA MOTOFEN TABS F PA bismuth subsalicylate tabs F PA

11 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ANTIEMETICS - Drugs to Treat Nausea and Antifungals Vomiting griseofulvin microsize susp F 5-HT3 Receptor Antagonists ANZEMET TABS F PA griseofulvin microsize tabs F PA granisetron hcl tabs F PA nystatin tabs F terbinafine hcl tabs F ondansetron hcl soln 4 F PA mg/5ml Imidazole-Related Antifungals ondansetron hcl tabs 24 F PA mg fluconazole susr 40 mg/ml F ondansetron hcl tabs 4 mg, F 8 mg fluconazole tabs 100 mg, F 200 mg, 50 mg, 150 mg ondansetron tbdp F itraconazole caps 100 mg F PA SANCUSO PTCH F PA ketoconazole tabs F PA Antiemetics - Anticholinergic NOXAFIL SUSP 40 MG/ML F PA dimenhydrinate tabs F posaconazole tbec F PA DRAMAMINE CHEW F voriconazole susr F PA meclizine hcl chew F RX/OTC voriconazole tabs F PA meclizine hcl tabs F RX/OTC ANTIHISTAMINES - Drugs to Treat Allergies scopolamine pt72 F Antihistamines - Alkylamines trimethobenzamide hcl F caps chlorpheniramine maleate F PA tabs 4 mg Antiemetics - Miscellaneous Antihistamines - Ethanolamines CESAMET CAPS F PA ALER-DRYL TABS F PA COCA COLA SYRUP F SYRP diphenhydramine hcl caps F PA 50 mg, 25 mg PA dronabinol caps F diphenhydramine hcl liqd PA 12.5 mg/5ml, 25 mg/10ml, F Substance P/Neurokinin 1 (NK1) Receptor 50 mg/20ml PA; QL(1 ea aprepitant caps F diphenhydramine hcl tbdp F PA daily) 12.5 mg F PA; QL(1 ea aprepitant misc daily) Antihistamines - Non-Sedating ALLEGRA ALLERGY PA; QL(1 ea EMEND SUSR 125 F PA; QL(5 ea F MG/5ML daily) CHILDRENS TBDP 30 MG daily) cetirizine hcl caps 10 mg F PA ANTIFUNGALS - Drugs to Treat Fungal Infections

12 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits cetirizine hcl chew 5 mg, F PA; QL(1 ea ezetimibe-simvastatin tabs F PA 10 mg daily) cetirizine hcl soln 1 mg/ml, F PA; RX/OTC Antihyperlipidemics - Misc. 5 mg/5ml icosapent ethyl caps F PA cetirizine hcl syrp 1 mg/ml, F PA; RX/OTC 5 mg/5ml omega-3-acid ethyl esters F PA caps cetirizine hcl tabs 5 mg, 10 F PA; QL(1 ea mg daily) VASCEPA CAPS F PA CLARITIN REDITABS F PA; QL(1 ea TBDP 5 MG daily) Bile Acid Sequestrants fexofenadine hcl susp 30 F PA PA mg/5ml cholestyramine light pack F PA fexofenadine hcl tabs 180 F PA; QL(1 ea cholestyramine light powd F mg daily) PA fexofenadine hcl tabs 60 F PA; QL(2 ea cholestyramine pack F mg daily) PA F PA; QL(1 ea cholestyramine powd F loratadine caps 10 mg daily) colesevelam hcl pack F PA F PA; QL(1 ea loratadine chew 5 mg daily) colesevelam hcl tabs F PA loratadine soln 5 mg/5ml F PA colestipol hcl gran F PA loratadine syrp 5 mg/5ml F PA colestipol hcl pack F PA F PA; QL(1 ea loratadine tabs 10 mg daily) colestipol hcl tabs F PA loratadine tbdp 10 mg F PA; QL(1 ea daily) Fibric Acid Derivatives Antihistamines - Phenothiazines choline fenofibrate cpdr F PA promethazine hcl soln F PA fenofibrate caps 150 mg, F PA 50 mg promethazine hcl supp F PA fenofibrate micronized caps F PA promethazine hcl syrp F PA fenofibrate tabs 120 mg, 40 PA promethazine hcl tabs F PA mg, 145 mg, 48 mg, 54 mg, F 160 mg Antihistamines - Piperidines FENOFIBRATE TABS 160 F PA MG cyproheptadine hcl syrp F PA FENOFIBRIC ACID TABS F PA cyproheptadine hcl tabs F PA 105 MG fenofibric acid tabs 105 mg, F PA ANTIHYPERLIPIDEMICS - Drugs to Treat High 35 mg Cholesterol TRIGLIDE TABS F PA Antihyperlipidemics - Combinations HMG CoA Reductase Inhibitors

13 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ALTOPREV TB24 F PA F PA; QL(2 ea quinapril hcl tabs daily) atorvastatin calcium tabs PA; QL(1 ea F ramipril caps 1.25 mg, 2.5 F PA; QL(1 ea 10 mg, 20 mg, 80 mg daily) mg, 5 mg daily) atorvastatin calcium tabs PA; QL(1.5 ea F F PA; QL(2 ea 40 mg daily) ramipril caps 10 mg daily) lovastatin tabs 10 mg, 20 PA; QL(1 ea F trandolapril tabs 1 mg, 2 F PA; QL(1 ea mg daily) mg daily) PA; QL(2 ea lovastatin tabs 40 mg F F PA; QL(2 ea daily) trandolapril tabs 4 mg daily) F PA; QL(1 ea Agents for Pheochromocytoma pravastatin sodium tabs daily) metyrosine caps F PA F PA; QL(1 ea rosuvastatin calcium tabs daily) phenoxybenzamine hcl F PA F PA; QL(1.5 ea caps simvastatin tabs 10 mg daily) Angiotensin II Receptor Antagonists simvastatin tabs 80 mg, 20 F PA; QL(1 ea mg, 40 mg, 5 mg daily) candesartan cilexetil tabs F PA; QL(1.5 ea 16 mg, 4 mg, 8 mg daily) Intestinal Cholesterol Absorption Inhibitors candesartan cilexetil tabs F PA; QL(1 ea F PA; QL(1 ea 32 mg daily) ezetimibe tabs daily) eprosartan mesylate tabs F PA Nicotinic Acid Derivatives irbesartan tabs 150 mg, PA; QL(1 ea niacin (antihyperlipidemic) F PA F tbcr 300 mg daily) ANTIHYPERTENSIVES - Drugs to Treat High irbesartan tabs 75 mg F PA; QL(1.5 ea Blood Pressure daily) losartan potassium tabs F PA; QL(1 ea ACE Inhibitors 100 mg daily) PA; QL(2 ea benazepril hcl tabs F losartan potassium tabs 25 F PA; QL(1.5 ea daily) mg, 50 mg daily) PA captopril tabs F olmesartan medoxomil tabs F PA PA enalapril maleate tabs F telmisartan tabs 20 mg, 80 F PA; QL(1 ea mg daily) EPANED SOLN F PA F PA; QL(1.5 ea telmisartan tabs 40 mg daily) fosinopril sodium tabs F PA; QL(2 ea daily) valsartan tabs 160 mg, 40 F PA; QL(1 ea mg, 80 mg daily) lisinopril tabs F PA; QL(2 ea daily) valsartan tabs 320 mg F PA PA moexipril hcl tabs 15 mg F Antiadrenergic Antihypertensives F PA; QL(1.5 ea clonidine hcl tabs F moexipril hcl tabs 7.5 mg daily) QBRELIS SOLN F PA clonidine ptwk F

14 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits doxazosin mesylate tabs 1 F PA; QL(1.5 ea irbesartan- F PA; QL(1 ea mg, 2 mg, 4 mg daily) hydrochlorothiazide tabs daily) doxazosin mesylate tabs 8 F PA; QL(2 ea lisinopril & PA; QL(1 ea mg daily) hydrochlorothiazide tabs 10 F daily) mg-12.5 mg guanfacine hcl tabs F PA lisinopril & PA prazosin hcl caps F PA hydrochlorothiazide tabs F 12.5 mg-20 mg, 20 mg-25 mg terazosin hcl caps 1 mg, 5 F PA; QL(1 ea mg daily) losartan potassium & F PA; QL(1 ea hydrochlorothiazide tabs daily) terazosin hcl caps 10 mg, 2 F PA; QL(2 ea mg daily) methyldopa & F PA Antihypertensive Combinations hydrochlorothiazide tabs metoprolol & PA amlodipine besylate- F PA F benazepril hcl caps hydrochlorothiazide tabs olmesartan medoxomil- PA amlodipine besylate- F PA olmesartan medoxomil tabs amlodipine- F hydrochlorothiazide tabs amlodipine besylate- F PA valsartan tabs olmesartan medoxomil- F PA hydrochlorothiazide tabs amlodipine-valsartan- F PA hydrochlorothiazide tabs propranolol & F PA hydrochlorothiazide tabs atenolol & chlorthalidone F PA tabs quinapril- F PA; QL(2 ea hydrochlorothiazide tabs daily) benazepril & F PA; QL(2 ea hydrochlorothiazide tabs daily) telmisartan-amlodipine tabs F PA bisoprolol & F PA telmisartan- PA; QL(1.5 ea hydrochlorothiazide tabs hydrochlorothiazide tabs F daily) BYVALSON TABS F PA 12.5 mg-40 mg telmisartan- PA; QL(1 ea candesartan cilexetil- PA; QL(1.5 ea hydrochlorothiazide tabs F daily) hydrochlorothiazide tabs F daily) 12.5 mg-80 mg 12.5 mg-16 mg telmisartan- PA candesartan cilexetil- PA; QL(1 ea hydrochlorothiazide tabs 25 F hydrochlorothiazide tabs F daily) mg-80 mg 12.5 mg-32 mg valsartan- PA; QL(1 ea candesartan cilexetil- PA hydrochlorothiazide tabs F daily) hydrochlorothiazide tabs 25 F 12.5 mg-80 mg, 25 mg-320 mg-32 mg mg, 12.5 mg-320 mg captopril & F PA valsartan- PA; QL(2 ea hydrochlorothiazide tabs hydrochlorothiazide tabs F daily) enalapril maleate & F PA 160 mg-25 mg, 12.5 mg- hydrochlorothiazide tabs 160 mg EXFORGE HCT TABS F PA Selective Aldosterone Receptor Antagonists eplerenone tabs F PA fosinopril sodium & F PA hydrochlorothiazide tabs Vasodilators Workforce Safety & Insurance Preferred Drug List Updated June 1, 2021 QL - Quantity Limit (There is a limit on the amount of drug covered per prescription, or within a specific time frame); PA - Prior Authorization (Prior Authorization required before prescription can be filled); Drugs not listed are considered Non-Formulary

15 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits hydralazine hcl tabs F PA TRECATOR TABS F PA minoxidil tabs F PA ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES - Drugs to Treat Cancer ANTIMALARIALS - Drugs to Treat Malaria Alkylating Agents (Parasitic Infections) CYCLOPHOSPHAMIDE F PA Antimalarial Combinations TABS atovaquone-proguanil hcl F PA ANTIPARKINSON AND RELATED THERAPY tabs AGENTS - Drugs to Treat Parkinson's Disease PA COARTEM TABS F Antiparkinson Adjunctive Therapy Antimalarials carbidopa tabs F PA chloroquine phosphate F PA tabs Antiparkinson Anticholinergics PA hydroxychloroquine sulfate F PA benztropine mesylate tabs F tabs trihexyphenidyl hcl tabs F PA mefloquine hcl tabs F PA Antiparkinson COMT Inhibitors primaquine phosphate tabs F PA entacapone tabs F PA quinine sulfate caps F PA Antiparkinson Dopaminergics ANTIMYCOBACTERIAL AGENTS - Drugs to PA Treat Tuberculosis (Bacterial Infections) amantadine hcl caps F Anti TB Combinations amantadine hcl syrp F PA RIFAMATE CAPS F PA amantadine hcl tabs F PA RIFATER TABS F PA bromocriptine mesylate F PA caps Antimycobacterial Agents bromocriptine mesylate F PA cycloserine caps F PA tabs carbidopa-levodopa tabs PA ethambutol hcl tabs F PA 10 mg-100 mg, 100 mg-25 F mg, 25 mg-250 mg PA isoniazid syrp F carbidopa-levodopa tbcr PA PA 100 mg-25 mg, 200 mg-50 F isoniazid tabs F mg PA pyrazinamide tabs F PA DUOPA SUSP F PA pramipexole F PA rifabutin caps F dihydrochloride tabs PA pramipexole F PA rifampin caps F dihydrochloride tb24 SIRTURO TABS F PA

16 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ropinirole hydrochloride PA; QL(2 ea haloperidol tabs F PA tabs 0.25 mg, 3 mg, 0.5 F daily) mg, 1 mg, 2 mg, 4 mg, 5 Dibenzapines mg clozapine tabs 200 mg, 25 F PA ropinirole hydrochloride PA mg, 50 mg, 100 mg tb24 12 mg, 2 mg, 4 mg, 6 F mg, 8 mg F PA; QL(2 ea olanzapine tabs daily) Antiparkinson Monoamine Oxidase Inhibitors olanzapine tbdp F PA; QL(2 ea selegiline hcl caps F PA daily) quetiapine fumarate tabs PA selegiline hcl tabs F PA 100 mg, 300 mg, 400 mg, F 50 mg, 200 mg, 25 mg ZELAPAR TBDP F PA quetiapine fumarate tb24 PA; QL(2 ea 150 mg, 200 mg, 300 mg, F daily) ANTIPSYCHOTICS/ANTIMANIC AGENTS - 400 mg, 50 mg Drugs to Treat Mood Disorders VERSACLOZ SUSP F PA Antimanic Agents lithium carbonate caps F PA Phenothiazines chlorpromazine hcl tabs F PA lithium carbonate tabs F PA perphenazine tabs F PA lithium carbonate tbcr F PA prochlorperazine maleate F LITHIUM SOLN F PA tabs prochlorperazine supp F Antipsychotics - Misc. EQUETRO CP12 F PA Quinolinone Derivatives aripiprazole soln F PA VRAYLAR CAPS F PA aripiprazole tabs F PA VRAYLAR CPPK F PA REXULTI TABS F PA F PA; QL(2 ea ziprasidone hcl caps daily) ANTIVIRALS - Drugs to Treat Viral Infections Benzisoxazoles risperidone soln 1 mg/ml F PA Antiretrovirals PA risperidone tabs 0.25 mg, PA; QL(2 ea PIFELTRO TABS F 0.5 mg, 1 mg, 2 mg, 3 mg, F daily) CMV Agents 4 mg PA risperidone tbdp 0.25 mg, PA; QL(2 ea valganciclovir hcl solr F 0.5 mg, 1 mg, 2 mg, 3 mg, F daily) 4 mg valganciclovir hcl tabs F PA Butyrophenones Hepatitis Agents PA haloperidol lactate conc F adefovir dipivoxil tabs F PA

17 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BARACLUDE SOLN 0.05 F PA BETA BLOCKERS - Drugs to Treat High Blood MG/ML Pressure DAKLINZA TABS F PA Alpha-Beta Blockers PA entecavir tabs F PA carvedilol phosphate cp24 F PA EPCLUSA TABS F PA carvedilol tabs F PA EPIVIR HBV SOLN 5 F PA labetalol hcl tabs F MG/ML Beta Blockers Cardio-Selective HARVONI TABS F PA acebutolol hcl caps F PA lamivudine (hbv) tabs F PA atenolol tabs F PA LEDIPASVIR/SOFOSBUVI F PA R TABS bisoprolol fumarate tabs F PA RIBASPHERE TABS F PA BYSTOLIC TABS F PA ribavirin (hepatitis c) caps F PA metoprolol succinate tb24 F PA; QL(1.5 ea 100 mg, 25 mg, 50 mg daily) ribavirin (hepatitis c) tabs F PA metoprolol succinate tb24 F PA; QL(2 ea 200 mg daily) SOFOSBUVIR/VELPATAS F PA VIR TABS metoprolol tartrate tabs 100 F PA mg, 25 mg, 50 mg SOVALDI TABS F PA Beta Blockers Non-Selective VEMLIDY TABS F PA nadolol tabs F PA ZEPATIER TABS F PA pindolol tabs F PA Herpes Agents propranolol hcl cp24 F PA acyclovir caps F PA propranolol hcl soln F PA acyclovir susp F PA propranolol hcl tabs F PA acyclovir tabs F PA sotalol hcl (afib/afl) tabs F PA famciclovir tabs F PA sotalol hcl tabs F PA valacyclovir hcl tabs F PA timolol maleate tabs F PA Influenza Agents CALCIUM CHANNEL BLOCKERS - Drugs to oseltamivir phosphate caps F PA 30 mg, 45 mg, 75 mg Treat High Blood Pressure oseltamivir phosphate susr F Calcium Channel Blockers 6 mg/ml amlodipine besylate tabs F PA RELENZA DISKHALER F PA 10 mg AEPB Workforce Safety & Insurance Preferred Drug List Updated June 1, 2021 QL - Quantity Limit (There is a limit on the amount of drug covered per prescription, or within a specific time frame); PA - Prior Authorization (Prior Authorization required before prescription can be filled); Drugs not listed are considered Non-Formulary

18 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits amlodipine besylate tabs F PA; QL(1 ea verapamil hcl tabs 40 mg, F PA 2.5 mg daily) 120 mg, 80 mg amlodipine besylate tabs 5 F PA; QL(1.5 ea verapamil hcl tbcr 120 mg, F PA; QL(2 ea mg daily) 180 mg, 240 mg daily) CARDIZEM LA TB24 120 F PA; QL(1 ea CARDIOTONICS - Drugs to Treat Heart Failure MG daily) and Abnormal Heart Rhythm diltiazem hcl coated beads PA; QL(1 ea cp24 120 mg, 240 mg, 300 F daily) Cardiac Glycosides mg, 360 mg digoxin soln F PA diltiazem hcl coated beads F PA; QL(2 ea cp24 180 mg daily) digoxin tabs F PA diltiazem hcl coated beads PA; QL(1 ea tb24 180 mg, 240 mg, 300 F daily) CARDIOVASCULAR AGENTS - MISC. - Drugs to mg, 360 mg, 420 mg Treat Heart and Circulation Conditions Cardiovascular Agents Misc. - Combinations F PA; QL(1 ea diltiazem hcl cp12 120 mg daily) BIDIL TABS F PA diltiazem hcl cp12 60 mg, F PA 90 mg Impotence Agents diltiazem hcl cp24 120 mg, PA; QL(1 ea F F PA; QL(0.2 ea 240 mg daily) MUSE PLLT daily) PA; QL(2 ea diltiazem hcl cp24 180 mg F F PA; QL(0.2 ea daily) sildenafil citrate tabs daily) diltiazem hcl extended PA; QL(2 ea PA release beads cp24 180 F daily) STENDRA TABS F mg tadalafil tabs 10 mg, 20 mg F PA; QL(0.2 ea diltiazem hcl extended PA; QL(1 ea daily) release beads cp24 420 daily) F F PA; QL(1 ea mg, 120 mg, 240 mg, 300 tadalafil tabs 2.5 mg, 5 mg daily) mg, 360 mg vardenafil hcl tabs F PA; QL(0.2 ea diltiazem hcl tabs 120 mg, F PA daily) 30 mg, 60 mg, 90 mg vardenafil hcl tbdp F PA; QL(0.2 ea F PA; QL(2 ea daily) felodipine tb24 daily) Peripheral Vasodilators nifedipine caps 10 mg, 20 F PA mg isoxsuprine hcl tabs F PA nifedipine tb24 30 mg, 90 F PA; QL(1 ea mg daily) Prostaglandin Vasodilators PA F PA; QL(2 ea ORENITRAM TBCR F nifedipine tb24 60 mg daily) PA nimodipine caps F PA TYVASO REFILL SOLN F PA NYMALIZE SOLN F PA TYVASO SOLN F verapamil hcl cp24 100 mg, PA; QL(2 ea TYVASO STARTER SOLN F PA 300 mg, 360 mg, 120 mg, F daily) 180 mg, 200 mg, 240 mg VENTAVIS SOLN F PA

19 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Pulmonary Hypertension - Endothelin Receptor Cephalosporins - 3rd Generation ambrisentan tabs F PA cefdinir caps 300 mg F bosentan tabs F PA cefdinir susr 250 mg/5ml F

OPSUMIT TABS F PA CORTICOSTEROIDS - Steroid Hormone Drugs to Treat Systemic Swelling Conditions PA TRACLEER TBSO 32 MG F Glucocorticosteroids Pulmonary Hypertension - Phosphodiesterase budesonide cpep F PA sildenafil citrate (pulmonary F PA PA hypertension) susr budesonide tb24 F sildenafil citrate (pulmonary F PA hypertension) tabs cortisone acetate tabs F tadalafil (pulmonary F PA dexamethasone elix F hypertension) tabs Pulmonary Hypertension - Prostacyclin Receptor DEXAMETHASONE F INTENSOL CONC UPTRAVI TABS F PA dexamethasone soln F UPTRAVI TBPK F PA dexamethasone tabs F Pulmonary Hypertension - Sol Guanylate Cyclase dexamethasone tbpk F ADEMPAS TABS F PA HEMADY TABS F PA CEPHALOSPORINS - Drugs to Treat Bacterial Infections hydrocortisone tabs F Cephalosporins - 1st Generation methylprednisolone tabs 16 F cefadroxil caps 500 mg F mg, 8 mg, 4 mg methylprednisolone tbpk 4 F cefadroxil susr 500 mg/5ml F mg cefadroxil tabs 1 gm F MILLIPRED TABS 5 MG F prednisolone sodium cephalexin caps 750 mg, F 250 mg, 500 mg phosphate soln or 5 F mg/5ml, 6.7 mg/5ml cephalexin susr 250 F mg/5ml prednisolone soln F PA cephalexin tabs 250 mg, F PREDNISONE INTENSOL F 500 mg CONC Cephalosporins - 2nd Generation prednisone soln F cefprozil susr 250 mg/5ml F prednisone tabs F cefprozil tabs 250 mg, 500 F mg Mineralocorticoids cefuroxime axetil tabs F

20 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits fludrocortisone acetate F neomycin-bacitracin- F tabs polymyxin oint DERMATOLOGICALS - Drugs to Treat Skin neomycin-bacitracin- F Conditions polymyxin w/ lidocaine oint neomycin-bacitracin- F Analgesics - Topical polymyxin-pramoxine oint BAMA FREEZE GEL F PA neomycin-polymyxin w/ F pramoxine crea BENGAY COLD THERAPY F PA GEL Antifungals - Topical PA COLD THERAPY PAIN F PA ALA-QUIN CREA F RELIEF GEL AZOLEN TINCTURE PA menthol (topical analgesic) F PA F gel SOLN PA menthol (topical analgesic) F PA BLIS-TO-SOL POWD F ptch PA POLAR FROST GEL F PA BREEZEE MIST AERP F PA; RX/OTC ULTRACIN M GEL F PA butenafine hcl crea F PA ZIMS MAX-FREEZE GEL F PA castellani paint liqd F PA Anti-inflammatory Agents - Topical ciclopirox gel 0.77 % F QL(2 ea daily) diclofenac epolamine ptch F ciclopirox olamine crea F PA diclofenac sodium (topical) F RX/OTC PA gel 1 % ciclopirox olamine susp F PA diclofenac sodium (topical) F ciclopirox sham 1 % F soln 1.5 % Antibiotics - Topical F PA; QL(0.24 ml ciclopirox soln 8 % daily) bacitracin (topical) oint F clotrimazole (topical) crea F PA; RX/OTC bacitracin zinc oint F clotrimazole (topical) soln F PA; RX/OTC bacitracin-polymyxin b oint F clotrimazole w/ F PA betamethasone crea CENTANY OINT F clotrimazole w/ F PA betamethasone lotn gentamicin sulfate (topical) F crea econazole nitrate crea F PA gentamicin sulfate (topical) F oint ERTACZO CREA F PA mupirocin calcium (topical) F crea EXODERM LOTN F PA mupirocin oint F FUNGI-NAIL SOLN F PA

21 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FUNGOID TINCTURE F PA oxiconazole nitrate crea F PA SOLN PA GENTIAN VIOLET SOLN 1 F PA OXISTAT LOTN F % PA RA ANTI-FUNGAL FOOT F PA gentian violet soln 2 % F CARE SOLN PA GNP GENTIAN VIOLET F PA sulconazole nitrate crea F SOLN PA GORDOCHOM SOLN F PA sulconazole nitrate soln F PA GORDONS NO 5 AERP F PA terbinafine hcl (topical) crea F PA iodoquinol-hc crea F PA tolnaftate aero F PA ketoconazole (topical) crea F PA tolnaftate aerp F PA ketoconazole (topical) F PA tolnaftate crea F sham tolnaftate liqd F PA LAMISIL AT SPRAY SOLN F PA tolnaftate powd F PA MENTAX CREA F PA; RX/OTC tolnaftate soln F PA miconazole nitrate (topical) F PA aerp undecylenic acid liqd F PA miconazole nitrate (topical) F PA crea UNDELENIC TINCTURE F PA miconazole nitrate (topical) F PA TINC oint Antineoplastic or Premalignant Lesion Agents - miconazole nitrate (topical) F PA powd diclofenac sodium (actinic F PA keratoses) gel MYCO NAIL A SOLN F PA FLUOROPLEX CREA F PA naftifine hcl crea F PA fluorouracil (topical) crea F PA naftifine hcl gel F PA fluorouracil (topical) soln F PA PA NAFTIN GEL 2 % F Antipruritics - Topical nystatin (topical) crea F PA camphor & menthol lotn F PA nystatin (topical) oint F PA camphor & phenol gel F PA nystatin (topical) powd F PA camphor & phenol liqd F PA nystatin-triamcinolone crea F PA Antipsoriatics acitretin caps F PA nystatin-triamcinolone oint F PA

22 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits methoxsalen rapid caps F PA betamethasone dipropionate augmented F Antivirals - Topical lotn PA betamethasone acyclovir topical crea F dipropionate augmented F oint acyclovir topical oint F PA betamethasone valerate F crea 0.1 % F PA; QL(0.05 DENAVIR CREA gm daily) betamethasone valerate F foam 0.12 % docosanol crea F PA betamethasone valerate F PA Burn Products lotn 0.1 % betamethasone valerate F PA mafenide acetate pack F oint 0.1 % silver sulfadiazine crea F calcipotriene- betamethasone F dipropionate oint SULFAMYLON CREA 85 F MG/GM calcipotriene- betamethasone F UNGUENTINE MAXIMUM F STRENGTH OINT dipropionate susp UNGUENTINE OINT F clobetasol propionate crea F Corticosteroids - Topical clobetasol propionate foam F

ALA-SCALP LOTN F clobetasol propionate gel F alclometasone dipropionate F crea clobetasol propionate lotn F alclometasone dipropionate F oint clobetasol propionate oint F amcinonide crea F clocortolone pivalate crea F amcinonide lotn F PA CLODAN KIT KIT F

AMCINONIDE OINT F PA CLODERM CREA F betamethasone F CLODERM PUMP CREA F dipropionate (topical) crea CORDRAN TAPE 4 betamethasone F F dipropionate (topical) lotn MCG/SQCM betamethasone F CORTANE-B LOTN F dipropionate (topical) oint betamethasone desonide crea F dipropionate augmented F crea desonide lotn F betamethasone dipropionate augmented F desonide oint F gel Workforce Safety & Insurance Preferred Drug List Updated June 1, 2021 QL - Quantity Limit (There is a limit on the amount of drug covered per prescription, or within a specific time frame); PA - Prior Authorization (Prior Authorization required before prescription can be filled); Drugs not listed are considered Non-Formulary

23 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits desoximetasone crea 0.05 F hydrocortisone (topical) F RX/OTC %, 0.25 % crea 1 % desoximetasone gel 0.05 F hydrocortisone (topical) gel F % 1 % desoximetasone liqd 0.25 F PA hydrocortisone (topical) lotn F % 2 %, 1 % desoximetasone oint 0.05 F hydrocortisone (topical) lotn F PA %, 0.25 % 2.5 % diflorasone diacetate crea F hydrocortisone (topical) oint F PA 0.5 % diflorasone diacetate oint F hydrocortisone (topical) oint F RX/OTC 1 % EPIFOAM FOAM F hydrocortisone (topical) oint F 2.5 % fluocinolone acetonide crea F hydrocortisone (topical) F soln 1 % fluocinolone acetonide oil F hydrocortisone acetate F (topical) crea fluocinolone acetonide oint F HYDROCORTISONE F BUTYRATE CREA fluocinolone acetonide soln F hydrocortisone butyrate F fluocinonide crea 0.1 %, F crea 0.05 % hydrocortisone butyrate F PA fluocinonide gel 0.05 % F PA oint hydrocortisone butyrate F fluocinonide oint 0.05 % F soln hydrocortisone valerate F fluocinonide soln 0.05 % F crea flurandrenolide crea F hydrocortisone valerate oint F PA flurandrenolide lotn F PA LIDOSOL-HC CREA F fluticasone propionate crea F mometasone furoate crea F fluticasone propionate oint F mometasone furoate oint F halcinonide crea F mometasone furoate soln F halobetasol propionate F NOVACORT GEL F crea PANDEL CREA F halobetasol propionate oint F PRAMOSONE CREA 1 %- F HALOG OINT F PA 1 % PRAMOSONE LOTN 1 %- hydrocortisone (topical) F F crea 0.5 % 1 %, 1 %-2.5 %

24 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PRAMOSONE OINT 1 %-1 F capsaicin crea F PA %, 1 %-2.5 % CERAVE ITCH RELIEF F PA pramoxine-hc crea F CREA pramoxine-hc gel F CERAVE ITCH RELIEF F PA MOISTURIZING CREA prednicarbate crea F CETACAINE AERO F PA prednicarbate oint F COCAINE HCL POWD XX F PA

PSORCON CREA F cocaine hcl soln ex F PA PA SYNALAR CREAM KIT KIT F dibucaine oint F PA triamcinolone acetonide F PA (topical) aers ethyl chloride aero F triamcinolone acetonide F ETHYL CHLORIDE/FINE F PA (topical) crea PINPOINT AERO triamcinolone acetonide F ETHYL CHLORIDE/FINE F PA (topical) lotn STREAM AERO triamcinolone acetonide F ETHYL PA (topical) oint CHLORIDE/MEDIUM JET F STREAM AERO TRIANEX OINT F ETHYL PA Immunomodulating Agents - Topical CHLORIDE/MEDIUM F STREAM AERO imiquimod crea F PA ETHYL CHLORIDE/MIST F PA AERO Immunosuppressive Agents - Topical FOILLE OINT F PA pimecrolimus crea F PA GEBAUERS INSTANT ICE F PA; RX/OTC tacrolimus (topical) oint F PA AERO GEBAUERS PAIN EASE F PA; RX/OTC Liniments AERO capsaicin-menthol-methyl PA F GEBAUERS SPRAY AND F PA; RX/OTC salicylate lotn STRETCH AERO Local Anesthetics - Topical lidocaine aero 0.5 % F PA AMERICAINE AERO F PA lidocaine crea 4 % F ARTHRITIS PAIN F PA RELIEVING CREA lidocaine hcl gel 0.5 % F PA AVEENO ANTI-ITCH F PA LOTN lidocaine hcl gel 2 % F PA; RX/OTC BAND-AID ANTISEPTIC F PA WASHHURT-FREE LIQD lidocaine hcl lotn 3 % F PA PA benzocaine (topical) oint F lidocaine hcl soln 4 % F PA

25 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits lidocaine oint 5 % F bumetanide tabs F PA lidocaine ptch 5 % F QL(3 ea daily) furosemide soln F PA lidocaine-prilocaine crea F PA furosemide tabs F PA

OUTGRO PAIN RELIEF F PA Potassium Sparing Diuretics LIQD amiloride hcl tabs F PA PRAMOX GEL GEL F PA spironolactone tabs F PA pramoxine hcl lotn F PA Thiazides and Thiazide-Like Diuretics pramoxine hcl misc F PA chlorthalidone tabs F PA pramoxine-zinc acetate lotn F PA hydrochlorothiazide caps F PA REGENECARE HA LIQD F PA hydrochlorothiazide tabs F PA ZOSTRIX-HP STCK F PA metolazone tabs F PA Scabicides & Pediculicides ENDOCRINE AND METABOLIC AGENTS - pyrethrins-piperonyl F PA MISC. - Drugs to Treat Bone Disease and butoxide sham Regulate Hormones PA VANALICE GEL F Bone Density Regulators DIURETICS - Drugs to Treat Heart, Circulation alendronate sodium soln 70 F PA Conditions and Blood Pressure mg/75ml alendronate sodium tabs F PA; QL(1 ea Carbonic Anhydrase Inhibitors 40 mg, 10 mg, 5 mg daily) acetazolamide cp12 F PA alendronate sodium tabs F PA; QL(0.14 ea 70 mg, 35 mg daily) acetazolamide tabs F PA etidronate disodium tabs F PA methazolamide tabs F PA FOSAMAX PLUS D TABS F PA Diuretic Combinations ibandronate sodium tabs F PA ALDACTAZIDE TABS 50 F PA MG-50 MG PROLIA SOSY F PA amiloride & F PA hydrochlorothiazide tabs risedronate sodium tabs 30 F PA mg, 150 mg, 35 mg, 5 mg spironolactone & F PA hydrochlorothiazide tabs XGEVA SOLN F PA triamterene & F PA hydrochlorothiazide caps F PA; QL(0.07 ml zoledronic acid conc daily) triamterene & F PA hydrochlorothiazide tabs FLUOROQUINOLONES - Drugs to Treat Bacterial Loop Diuretics Infections

26 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Fluoroquinolones metoclopramide hcl soln 10 F mg/10ml, 5 mg/5ml CIPRO SUSR 5 F GM/100ML, 500 MG/5ML metoclopramide hcl tabs 10 F mg, 5 mg ciprofloxacin hcl tabs F metoclopramide hcl tbdp 5 F PA mg ciprofloxacin susr F METOCLOPRAMIDE ODT F PA TBDP levofloxacin soln 25 mg/ml F Inflammatory Bowel Agents levofloxacin tabs 250 mg, F QL(1 ea daily) 500 mg, 750 mg F PA; QL(0.18 ea REMICADE SOLR daily) moxifloxacin hcl tabs F Intestinal Acidifiers GASTROINTESTINAL AGENTS - MISC. - lactulose (encephalopathy) F Miscellaneous Gastrointestinal Drugs soln Agents for Chronic Idiopathic Constipation (CIC) Irritable Bowel Syndrome (IBS) Agents PA TRULANCE TABS F PA alosetron hcl tabs 0.5 mg F F PA; QL(2 ea Antiflatulents alosetron hcl tabs 1 mg daily) BEANO MELTAWAYS F TABS F PA; QL(1 ea LINZESS CAPS daily) BEANO TABS F F PA; QL(2 ea VIBERZI TABS daily) BEANO TO GO TABS F ZELNORM TABS F PA BEANO ULTRA 800 TABS F Peripheral Opioid Receptor Antagonists GAS-X EXTRA PA STRENGTH STRP 62.5 F alvimopan caps F MG MOVANTIK TABS F PA simethicone caps F RELISTOR TABS F PA simethicone chew F Phosphate Binder Agents simethicone susp F calcium acetate (phosphate F binder) caps Farnesoid X Receptor (FXR) Agonists calcium acetate (phosphate F PA; RX/OTC OCALIVA TABS F PA binder) tabs FOSRENOL PACK 1000 F PA Gastrointestinal Antiallergy Agents MG, 750 MG cromolyn sodium F PA lanthanum carbonate chew F PA (mastocytosis) conc Gastrointestinal Chloride Channel Activators PHOSLYRA SOLN F PA PA lubiprostone caps F sevelamer carbonate pack F PA Gastrointestinal Stimulants Workforce Safety & Insurance Preferred Drug List Updated June 1, 2021 QL - Quantity Limit (There is a limit on the amount of drug covered per prescription, or within a specific time frame); PA - Prior Authorization (Prior Authorization required before prescription can be filled); Drugs not listed are considered Non-Formulary

27 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits sevelamer carbonate tabs F PA anagrelide hcl caps F PA sevelamer hcl tabs F PA aspirin-dipyridamole cp12 F PA

GENITOURINARY AGENTS - MISCELLANEOUS cilostazol tabs F PA - Miscellaneous Drugs to Treat Reproductive Organs and Urinary System clopidogrel bisulfate tabs F PA Prostatic Hypertrophy Agents prasugrel hcl tabs F PA alfuzosin hcl tb24 F PA ZONTIVITY TABS F PA CARDURA XL TB24 F PA HEMATOPOIETIC AGENTS - Drugs to Treat dutasteride caps F PA Blood Disorders Hematopoietic Growth Factors finasteride tabs F PA NPLATE SOLR F PA silodosin caps F PA ZIEXTENZO SOSY F PA tamsulosin hcl caps F PA HYPNOTICS/SEDATIVES/SLEEP DISORDER Urinary Stone Agents AGENTS THIOLA EC TBEC F PA Antihistamine Hypnotics diphenhydramine- F PA GOUT AGENTS - Drugs to Treat Gout acetaminophen (sleep) liqd diphenhydramine- PA Gout Agent Combinations acetaminophen (sleep) F colchicine w/ probenecid F PA tabs tabs ibuprofen-diphenhydramine F PA Gout Agents citrate tabs PA ibuprofen-diphenhydramine F PA allopurinol tabs F hcl caps colchicine caps F PA Barbiturate Hypnotics F PA colchicine tabs F PA phenobarbital elix F PA febuxostat tabs F PA phenobarbital soln PA Uricosurics phenobarbital tabs F probenecid tabs F PA Non-Barbiturate Hypnotics F PA; QL(2 ea HEMATOLOGICAL AGENTS - MISC. - Drugs to eszopiclone tabs daily) Treat Blood Disorders temazepam caps F Hematorheologic Agents QL(2 ea daily) pentoxifylline tbcr F PA zaleplon caps 10 mg F Platelet Aggregation Inhibitors Workforce Safety & Insurance Preferred Drug List Updated June 1, 2021 QL - Quantity Limit (There is a limit on the amount of drug covered per prescription, or within a specific time frame); PA - Prior Authorization (Prior Authorization required before prescription can be filled); Drugs not listed are considered Non-Formulary

28 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits zaleplon caps 5 mg F QL(1 ea daily) METAMUCIL MULTIHEALTH FIBER F SINGLES PACK zolpidem tartrate subl sl F PA; QL(0.5 ea 1.75 mg, 3.5 mg daily) METAMUCIL PACK 28 % F zolpidem tartrate tabs or 10 F QL(2 ea daily) mg METAMUCIL WAFR F zolpidem tartrate tabs or 5 F QL(1 ea daily) mg methylcellulose (laxative) F powd zolpidem tartrate tbcr or F QL(2 ea daily) 12.5 mg methylcellulose (laxative) F tabs zolpidem tartrate tbcr or F QL(1 ea daily) 6.25 mg MUCILIN SF PACK F Orexin Receptor Antagonists psyllium caps F BELSOMRA TABS F PA psyllium powd F Selective Melatonin Receptor Agonists ramelteon tabs F PA Laxative Combinations GOLYTELY SOLR F LAXATIVES - Bowel Treatment Drugs peg 3350-kcl-nacl-na Bulk Laxatives sulfate-na ascorbate- F ascorbic acid solr calcium polycarbophil tabs F peg 3350-kcl-sod bicarb- sod chloride-sod sulfate F CVS NATURAL FIBER F SUPPLEMENT PACK solr peg 3350-potassium EQUALACTIN CHEW F chloride-sod bicarbonate- F sod chloride solr HYDROCIL INSTANT F PACK PLENVU SOLR F KONSYL DAILY FIBER PACK 100 %, 28.3 %, 60.3 F sennosides-docusate F % sodium tabs SUPREP BOWEL PREP KONSYL DAILY FIBER F F POWD 60.3 % KIT SOLN KONSYL ORIGINAL DAILY F Laxatives - Miscellaneous FIBER PACK glycerin (laxative) supp F KONSYL PACK F KRISTALOSE PACK 10 F KONSYL POWD F GM, 20 GM LACTULOSE PACK 10 GM F KONSYL-D POWD F lactulose soln 10 gm/15ml, F METAMUCIL 20 gm/30ml MULTIHEALTH FIBER F polyethylene glycol 3350 F POWD pack

29 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits polyethylene glycol 3350 F MACROLIDES - Drugs to Treat Bacterial powd Infections SORBITOL SOLN F Azithromycin azithromycin susr 200 F Lubricant Laxatives mg/5ml KONDREMUL EMUL F azithromycin tabs 250 mg, F 500 mg, 600 mg mineral oil enem F Clarithromycin Saline Laxatives clarithromycin susr 250 F mg/5ml OSMOPREP TABS F clarithromycin tabs 250 mg, F 500 mg sodium phosphates enem F clarithromycin tb24 500 mg F Stimulant Laxatives Erythromycins bisacodyl supp F erythromycin base cpep F bisacodyl tbec F erythromycin base tabs F BLACK DRAUGHT CHEW F erythromycin base tbec F castor oil oil F erythromycin EVAC-U-GEN CHEW F ethylsuccinate susr 200 F mg/5ml SENNA SYRP F erythromycin F ethylsuccinate tabs 400 mg sennosides chew F erythromycin stearate tabs F sennosides liqd F MIGRAINE PRODUCTS - Drugs to Treat Migraine Headaches sennosides syrp F Calcitonin Gene-Related Peptide (CGRP) sennosides tabs F AIMOVIG SOAJ F PA Surfactant Laxatives Migraine Combinations docusate calcium caps F ergotamine w/ caffeine F PA supp docusate sodium caps F ergotamine w/ caffeine tabs F PA docusate sodium enem F sumatriptan-naproxen F PA; QL(0.14 ea sodium tabs daily) docusate sodium liqd F Migraine Products docusate sodium syrp F ERGOMAR SUBL F PA docusate sodium tabs F Serotonin Agonists

30 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits F PA; QL(0.4 ea dantrolene sodium caps F PA almotriptan malate tabs daily) eletriptan hydrobromide F PA; QL(0.4 ea Muscle Relaxant Combinations tabs daily) orphenadrine w/ aspirin & F F PA; QL(0.6 ea caff tabs naratriptan hcl tabs daily) NASAL AGENTS - SYSTEMIC AND TOPICAL - F PA; QL(0.4 ea Drugs to treat the Nose or Sinus rizatriptan benzoate tabs daily) Nasal Antiallergy rizatriptan benzoate tbdp F PA; QL(0.4 ea daily) azelastine hcl soln 0.1 %, F PA; QL(1.21 ml 137 mcg/spray daily) sumatriptan soln F PA; QL(0.4 ea daily) azelastine hcl soln 0.15 % F PA sumatriptan succinate soaj F PA; QL(0.1 ml sc 4 mg/0.5ml, 6 mg/0.5ml daily) cromolyn sodium (nasal) F PA aers sumatriptan succinate soct F PA; QL(0.1 ml sc 4 mg/0.5ml, 6 mg/0.5ml daily) olopatadine hcl (nasal) soln F PA sumatriptan succinate soln F PA sc 6 mg/0.5ml Nasal Anticholinergics ipratropium bromide (nasal) PA sumatriptan succinate sosy F PA F sc 6 mg/0.5ml soln Nasal Steroids sumatriptan succinate tabs F PA; QL(0.6 ea or 50 mg, 100 mg, 25 mg daily) F PA; QL(0.83 BECONASE AQ SUSP gm daily) zolmitriptan soln na 5 mg F PA budesonide (nasal) susp F PA; QL(0.51 ml zolmitriptan tabs or 2.5 mg, F PA; QL(0.4 ea daily) 5 mg daily) FLONASE SENSIMIST F PA F PA; QL(0.4 ea SUSP zolmitriptan tbdp or 2.5 mg daily) flunisolide (nasal) soln F PA; QL(0.83 ml F PA; QL(0.2 ea daily) zolmitriptan tbdp or 5 mg daily) fluticasone propionate F PA; QL(1.07 ml MUSCULOSKELETAL THERAPY AGENTS - (nasal) susp daily); RX/OTC Drugs to Treat Spasms mometasone furoate F PA; QL(0.57 Central Muscle Relaxants (nasal) susp gm daily) NASACORT ALLERGY F PA; QL(0.55 ml baclofen tabs F 24HR AERO daily) PA cyclobenzaprine hcl tabs F QL(3 ea daily) OMNARIS SUSP F 10 mg, 5 mg, 7.5 mg triamcinolone acetonide F PA; QL(0.55 ml metaxalone tabs 800 mg F (nasal) aero daily) PA methocarbamol tabs F ZETONNA AERS F orphenadrine citrate tb12 F OPHTHALMIC AGENTS - Drugs to Treat the Eye tizanidine hcl tabs 4 mg, 2 F Artificial Tears and Lubricants mg artificial tear solution soln F PA Direct Muscle Relaxants Workforce Safety & Insurance Preferred Drug List Updated June 1, 2021 QL - Quantity Limit (There is a limit on the amount of drug covered per prescription, or within a specific time frame); PA - Prior Authorization (Prior Authorization required before prescription can be filled); Drugs not listed are considered Non-Formulary

31 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits carboxymethylcellulose F PA gentamicin sulfate (ophth) F sodium (ophth) soln 0.5 % soln CVS LUBRICANT GEL F PA KLARITY-A SOLN F PA DROPS GEL PA polyvinyl alcohol soln F PA levofloxacin (ophth) soln F moxifloxacin hcl (ophth) PA PURE & GENTLE F PA F LUBRICANT SOLN soln RETAINE HPMC SOLN F PA NATACYN SUSP F Beta-blockers - Ophthalmic neomycin-bacitracin zn- F polymyxin oint COMBIGAN SOLN F neomycin-polymyxin- F gramicidin soln dorzolamide hcl-timolol F maleate soln ofloxacin (ophth) soln F Cycloplegic Mydriatics polymyxin b-trimethoprim F atropine sulfate F soln (ophthalmic) oint POVIDONE IODINE SOLN F PA ATROPINE SULFATE F SOLN sulfacetamide sodium F (ophth) oint cyclopentolate hcl soln F sulfacetamide sodium F homatropine hbr soln F (ophth) soln tobramycin (ophth) soln F ISOPTO ATROPINE SOLN F TOBREX OINT F Ophthalmic Anti-infectives AZASITE SOLN F PA Ophthalmic Decongestants naphazoline w/ PA BACIGUENT OINT OP F pheniramine soln 0.027 %- F 0.315 % bacitracin (ophthalmic) oint F tetrahydrozoline hcl (ophth) F PA soln bacitracin-polymyxin b F (ophth) oint Ophthalmic Immunomodulators PA F PA; QL(2 ml BESIVANCE SUSP F RESTASIS EMUL daily) BETADINE OPHTHALMIC PA F RESTASIS MULTIDOSE F PA; QL(2 ml PREP SOLN EMUL daily) CILOXAN OINT F Ophthalmic Integrin Antagonists XIIDRA SOLN F PA ciprofloxacin hcl (ophth) F soln Ophthalmic Steroids erythromycin (ophth) oint F bacitracin-poly-neomycin- F hc oint gentamicin sulfate (ophth) F oint Workforce Safety & Insurance Preferred Drug List Updated June 1, 2021 QL - Quantity Limit (There is a limit on the amount of drug covered per prescription, or within a specific time frame); PA - Prior Authorization (Prior Authorization required before prescription can be filled); Drugs not listed are considered Non-Formulary

32 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits dexamethasone sodium F PA flurbiprofen sodium soln F phosphate (ophth) soln PA ketorolac tromethamine F DUREZOL EMUL F (ophth) soln 0.4 % FLAREX SUSP F PA ketorolac tromethamine F PA (ophth) soln 0.5 % fluorometholone (ophth) PA F ketotifen fumarate (ophth) F susp soln PA MAXIDEX SUSP F MURO 128 SOLN 2 % F PA neomycin-polymy- F sodium chloride hypertonic F PA dexameth oint oint neomycin-polymy- F sodium chloride hypertonic F PA dexameth susp soln neomycin-polymyxin-hc F Prostaglandins - Ophthalmic (ophth) susp F QL(0.09 ml PRED MILD SUSP F PA latanoprost soln daily)

PRED-G S.O.P. OINT F PA OTIC AGENTS - Drugs to Treat the Ear Otic Anti-infectives PRED-G SUSP F PA ofloxacin (otic) soln F PA prednisolone acetate F (ophth) susp Otic Combinations PREDNISOLONE F neomycin-polymyxin-hc F PA ACETATE P-F SUSP (otic) soln PREDNISOLONE SODIUM neomycin-polymyxin-hc F PA PHOSPHATE SOLN OP 1 F (otic) susp % pramoxine-hc-chloroxylenol F PA sulfacetamide sod- F soln prednisolone soln PENICILLINS - Drugs to Treat Bacterial Infections TOBRADEX OINT F Aminopenicillins TOBRADEX ST SUSP F amoxicillin caps 250 mg, F 500 mg tobramycin- F dexamethasone susp amoxicillin chew 250 mg F Ophthalmics - Misc. amoxicillin susr 200 cromolyn sodium (ophth) F PA mg/5ml, 250 mg/5ml, 400 F soln mg/5ml, 125 mg/5ml diclofenac sodium (ophth) F amoxicillin tabs 500 mg, F soln 875 mg DORZOLAMIDE HCL F SOLN ampicillin caps F dorzolamide hcl soln F Natural Penicillins

33 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits penicillin v potassium solr F Psychotherapeutic and Neurological Agents - 250 mg/5ml ergoloid mesylates tabs F PA penicillin v potassium tabs F 250 mg, 500 mg Restless Leg Syndrome (RLS) Agents Penicillin Combinations HORIZANT TBCR F PA amoxicillin & pot clavulanate chew 400 mg- F Smoking Deterrents 57 mg bupropion hcl (smoking F PA amoxicillin & pot deterrent) tb12 clavulanate susr 250 mg/5ml-62.5 mg/5ml, 400 F CHANTIX CONTINUING F PA mg/5ml-57 mg/5ml, 42.9 MONTHPAK TABS mg/5ml-600 mg/5ml CHANTIX STARTING F PA amoxicillin & pot MONTH PAK TABS clavulanate tabs 125 mg- F CHANTIX TABS F PA 875 mg, 125 mg-500 mg amoxicillin & pot nicotine polacrilex gum F PA clavulanate tb12 1000 mg- F 62.5 mg nicotine polacrilex lozg F PA Penicillinase-Resistant Penicillins nicotine pt24 F PA dicloxacillin sodium caps F NICOTINE PA PSYCHOTHERAPEUTIC AND NEUROLOGICAL TRANSDERMAL SYSTEM F AGENTS - MISC. - Drugs to Treat Mental and KIT Emotional Conditions TETRACYCLINES - Drugs to Treat Bacterial Agents for Chemical Dependency Infections acamprosate calcium tbec F PA Tetracyclines doxycycline (monohydrate) disulfiram tabs F PA caps 50 mg, 100 mg, 75 F mg Antidementia Agents doxycycline (monohydrate) tabs 150 mg, 50 mg, 75 F memantine hcl soln 10 F PA mg/5ml, 2 mg/ml mg, 100 mg memantine hcl tabs F PA doxycycline hyclate caps F 50 mg, 100 mg memantine hcl tabs 10 mg, PA; QL(2 ea F doxycycline hyclate tabs F 5 mg daily) 100 mg Fibromyalgia Agents minocycline hcl caps 100 F mg, 50 mg, 75 mg SAVELLA TABS F PA minocycline hcl tb24 135 F PA mg, 45 mg, 90 mg SAVELLA TITRATION F PA PACK MISC tetracycline hcl caps F Postherpetic Neuralgia (PHN)/Neuropathic Pain THYROID AGENTS - Drugs to Regulate Thyroid pregabalin (once-daily) F QL(1 ea daily) tb24 Hormones

34 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Antithyroid Agents phenobarbital- hyoscyamine-atropine- F methimazole tabs F PA scopolamine elix PA phenobarbital- propylthiouracil tabs F hyoscyamine-atropine- F scopolamine tabs Thyroid Hormones levothyroxine sodium tabs PA propantheline bromide tabs F 300 mcg, 100 mcg, 112 H-2 Antagonists mcg, 125 mcg, 137 mcg, F 150 mcg, 175 mcg, 200 cimetidine hcl soln F mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg F QL(1 ea daily); cimetidine tabs 200 mg RX/OTC liothyronine sodium tabs F PA cimetidine tabs 300 mg, F QL(2 ea daily) ULCER DRUGS - Drugs to Treat Bowel, Intestine 400 mg, 800 mg and Stomach Conditions famotidine susr 40 mg/5ml F Antispasmodics famotidine tabs 20 mg F QL(2 ea daily); BELLADONNA/OPIUM F PA RX/OTC SUPP 16.2 MG-60 MG famotidine tabs 40 mg, 10 F QL(2 ea daily) chlordiazepoxide hcl- F mg clidinium bromide caps GNP ACID CONTROL 150 QL(2 ea daily); CUVPOSA SOLN F PA MAXIMUM STRENGTH F RX/OTC TABS dicyclomine hcl caps F nizatidine caps 150 mg, F QL(2 ea daily) 300 mg dicyclomine hcl soln F nizatidine soln 15 mg/ml F dicyclomine hcl tabs F ranitidine hcl caps 150 mg, F 300 mg glycopyrrolate tabs 1 mg, 2 F mg ranitidine hcl syrp 15 mg/ml, 150 mg/10ml, 75 F hyoscyamine sulfate elix F mg/5ml F QL(2 ea daily); hyoscyamine sulfate soln F ranitidine hcl tabs 150 mg RX/OTC hyoscyamine sulfate subl F ranitidine hcl tabs 300 mg, F QL(2 ea daily) 75 mg hyoscyamine sulfate tabs F Misc. Anti-Ulcer hyoscyamine sulfate tb12 F sucralfate susp F hyoscyamine sulfate tbdp F sucralfate tabs F Proton Pump Inhibitors methscopolamine bromide F tabs F PA; QL(1 ea DEXILANT CPDR daily)

35 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits esomeprazole magnesium F QL(1 ea daily); omeprazole-sodium PA cpdr 20 mg RX/OTC bicarbonate pack 1680 mg- F 20 mg, 1680 mg-40 mg esomeprazole magnesium F QL(1 ea daily) cpdr 40 mg PYLERA CAPS F PA esomeprazole magnesium F PA; QL(1 ea pack 10 mg, 20 mg, 40 mg daily) URINARY ANTISPASMODICS - Drugs to Treat Miscellaneous Bladder Spasms lansoprazole cpdr 15 mg F QL(2 ea daily); RX/OTC Urinary Antispasmodic - Antimuscarinics QL(2 ea daily) lansoprazole cpdr 30 mg F darifenacin hydrobromide F PA tb24 NEXIUM PACK 2.5 MG, 5 F PA PA MG GELNIQUE GEL F omeprazole cpdr 10 mg, 40 F QL(2 ea daily) PA mg GELNIQUE PUMP GEL F QL(2 ea daily); omeprazole cpdr 20 mg F oxybutynin chloride syrp 5 F RX/OTC mg/5ml omeprazole magnesium F oxybutynin chloride tabs 5 F cpdr mg QL(2 ea daily) omeprazole tbec 20 mg F oxybutynin chloride tb24 10 F QL(2 ea daily) mg, 15 mg pantoprazole sodium pack PA F oxybutynin chloride tb24 5 F QL(1 ea daily) 40 mg mg pantoprazole sodium tbec QL(1 ea daily) F OXYTROL FOR WOMEN F PA; QL(0.29 ea 20 mg PTTW daily); RX/OTC pantoprazole sodium tbec QL(2 ea daily) F F PA; QL(0.29 ea 40 mg OXYTROL PTTW daily); RX/OTC PA PRILOSEC PACK F solifenacin succinate tabs F PA QL(4 ea daily) rabeprazole sodium tbec F tolterodine tartrate cp24 2 F PA; QL(1 ea mg, 4 mg daily) Ulcer Drugs - Prostaglandins tolterodine tartrate tabs 1 F PA; QL(2 ea misoprostol tabs F mg, 2 mg daily) TOVIAZ TB24 F PA Ulcer Therapy Combinations PA amoxicillin-clarithromycin F PA trospium chloride cp24 F w/ lansoprazole misc famotidine-calcium PA trospium chloride tabs F PA carbonate-magnesium F hydroxide chew Urinary Antispasmodics - Beta-3 Adrenergic omeprazole-sodium PA; RX/OTC MYRBETRIQ TB24 F PA; QL(1 ea bicarbonate caps 1100 mg- F daily) 20 mg Urinary Antispasmodics - Cholinergic Agonists omeprazole-sodium PA bicarbonate caps 1100 mg- F bethanechol chloride tabs F 40 mg Urinary Antispasmodics - Direct Muscle Relaxants

36 Drug Requirements/ Drug Name Tier Limits flavoxate hcl tabs F VASOPRESSORS - Drugs to Treat Heart and Circulation Conditions Anaphylaxis Therapy Agents AUVI-Q SOAJ F PA epinephrine (anaphylaxis) F PA soaj Vasopressors midodrine hcl tabs F PA

37 Index ABSTRAL2 amiloride & atenolol & chlorthalidone15 acamprosate calcium34 hydrochlorothiazide26 atomoxetine hcl0 amiloride hcl26 acarbose9 atorvastatin calcium14 amiodarone hcl5 acebutolol hcl18 atovaquone4 amitriptyline hcl9 acetaminophen2 atovaquone-proguanil hcl16 amlodipine besylate18,19 acetaminophen w/ codeine3 ATROPINE SULFATE32 amlodipine besylate-benazepril acetaminophen-caffeine1 hcl15 atropine sulfate (ophthalmic)32 acetazolamide26 amlodipine besylate-olmesartan ATROVENT HFA5 acitretin22 medoxomil15 AUVI-Q37 amlodipine besylate- acyclovir18 valsartan15 AVANDIA10 acyclovir topical23 amlodipine-valsartan- AVEENO ANTI-ITCH25 adefovir dipivoxil17 hydrochlorothiazide 15 AZASITE32 ADEMPAS20 amoxicillin33 azelastine hcl31 ADMELOG10 amoxicillin & pot azithromycin30 clavulanate34 ADVAIR HFA6 amoxicillin-clarithromycin w/ AZO DUAL PROTECTION AIMOVIG30 lansoprazole36 URINARY+VAGINAL SUPPORT11 ALA-QUIN21 amphetamine- dextroamphetamine0 AZOLEN TINCTURE21 ALA-SCALP23 ampicillin33 BACIGUENT32 albuterol sulfate6 anagrelide hcl28 bacitracin (ophthalmic)32 ALBUTEROL SULFATE6 ANDRODERM3 bacitracin (topical)21 albuterol sulfate6 ANORO ELLIPTA6 bacitracin zinc21 alclometasone dipropionate23 ANTI-DIARRHEAL11 bacitracin-poly-neomycin-hc 32 ALDACTAZIDE26 ANZEMET12 bacitracin-polymyxin b21 alendronate sodium26 APIDRA10 bacitracin-polymyxin b ALER-DRYL12 aprepitant12 (ophth)32 alfuzosin hcl28 baclofen31 APTIOM7 ALINIA4 BAMA FREEZE21 aripiprazole17 ALLEGRA ALLERGY BAND-AID ANTISEPTIC CHILDRENS12 armodafinil0 WASHHURT-FREE25 ALLI0 ARTHRITIS PAIN BARACLUDE18 RELIEVING25 allopurinol28 BEANO27 artificial tear solution31 almotriptan malate31 BEANO MELTAWAYS27 ARYMO ER2 alogliptin benzoate10 ASMANEX TWISTHALER 120 BEANO TO GO27 alogliptin-metformin hcl9 METERED DOSES6 BEANO ULTRA 80027 alogliptin-pioglitazone9 ASMANEX TWISTHALER 14 BECONASE AQ31 METERED DOSES6 BELLADONNA/OPIUM35 alosetron hcl27 ASMANEX TWISTHALER 30 alprazolam5 METERED DOSES6 BELSOMRA29 ALPRAZOLAM INTENSOL5 ASMANEX TWISTHALER 60 BELVIQ0 ALTOPREV14 METERED DOSES6 BELVIQ XR0 ASMANEX TWISTHALER 7 ALVESCO6 benazepril & METERED DOSES6 hydrochlorothiazide15 alvimopan27 aspirin2 benazepril hcl14 amantadine hcl16 ASPIRIN2 BENGAY COLD THERAPY21 ambrisentan20 aspirin2 benzocaine (topical)25 amcinonide23 aspirin buffered (cal carb-mag benztropine mesylate16 AMCINONIDE23 carb-mag oxide)2 BESIVANCE32 AMERICAINE25 aspirin-dipyridamole28 atenolol18

Index 1 BETADINE OPHTHALMIC calcium acetate (phosphate chlorthalidone26 PREP32 binder)27 cholestyramine13 betamethasone dipropionate calcium polycarbophil29 cholestyramine light13 (topical)23 camphor & menthol22 betamethasone dipropionate choline fenofibrate13 camphor & phenol22 augmented23 ciclopirox21 candesartan cilexetil14 betamethasone valerate23 ciclopirox olamine21 bethanechol chloride36 candesartan cilexetil- hydrochlorothiazide 15 cilostazol28 BIDIL19 capsaicin25 CILOXAN32 bisacodyl30 capsaicin-menthol-methyl cimetidine35 bismuth subsalicylate11 salicylate25 cimetidine hcl35 bisoprolol & captopril14 CINQAIR5 hydrochlorothiazide15 captopril & bisoprolol fumarate18 hydrochlorothiazide15 CIPRO27 BLACK DRAUGHT30 carbamazepine7 ciprofloxacin27 BLIS-TO-SOL21 carbidopa16 ciprofloxacin hcl27 bosentan20 carbidopa-levodopa16 ciprofloxacin hcl (ophth)32 BREEZEE MIST21 carboxymethylcellulose sodium citalopram hydrobromide8 BREO ELLIPTA6 (ophth)32 clarithromycin30 CARDIZEM LA19 bromocriptine mesylate16 CLARITIN REDITABS13 CARDURA XL28 BROVANA6 clindamycin hcl4 carvedilol18 budesonide20 clindamycin palmitate carvedilol phosphate18 hydrochloride4 budesonide (inhalation)6 castellani paint21 clobazam7 budesonide (nasal)31 clobetasol propionate23 budesonide-formoterol fumarate castor oil30 dihydrate6 cefadroxil20 clocortolone pivalate23 BUFFERIN EXTRA cefdinir20 CLODAN KIT23 STRENGTH2 cefprozil20 CLODERM23 BUFFERIN LOW DOSE2 cefuroxime axetil20 CLODERM PUMP23 bumetanide26 celecoxib0 clomipramine hcl9 buprenorphine3 CELONTIN8 clonazepam7 bupropion hcl8 CENTANY21 clonidine14 bupropion hcl (smoking clonidine hcl14 deterrent)34 cephalexin20 buspirone hcl5 CERAVE ITCH RELIEF25 clopidogrel bisulfate28 butalbital-acetaminophen1 CERAVE ITCH RELIEF clorazepate dipotassium5 butalbital-acetaminophen- MOISTURIZING25 clotrimazole (topical)21 caffeine1 CESAMET12 clotrimazole w/ butalbital-acetaminophen- CETACAINE25 betamethasone21 caffeine w/ codeine3 cetirizine hcl12,13 clozapine17 butalbital-aspirin-caffeine2 CHANTIX34 COARTEM16 butalbital-aspirin-caffeine CHANTIX CONTINUING COCA COLA SYRUP12 w/cod3 MONTHPAK34 COCAINE HCL25 butenafine hcl21 CHANTIX STARTING MONTH cocaine hcl25 butorphanol tartrate3 PAK34 CODEINE SULFATE2 BYDUREON PEN10 chlordiazepoxide hcl5 codeine sulfate2 BYETTA10 chlordiazepoxide hcl-clidinium bromide35 colchicine28 BYSTOLIC18 chloroquine phosphate16 colchicine w/ probenecid28 BYVALSON15 chlorpheniramine maleate12 COLD THERAPY PAIN calcipotriene-betamethasone RELIEF21 dipropionate23 chlorpromazine hcl17

Index 2 colesevelam hcl13 diclofenac sodium (actinic enalapril maleate14 colestipol hcl13 keratoses)22 enalapril maleate & diclofenac sodium (ophth)33 COMBIGAN32 hydrochlorothiazide15 diclofenac sodium (topical)21 enoxaparin sodium7 COMBIVENT RESPIMAT6 diclofenac w/ misoprostol1 entacapone16 CORDRAN23 dicloxacillin sodium34 entecavir18 CORTANE-B23 dicyclomine hcl35 EPANED14 cortisone acetate20 diflorasone diacetate24 EPCLUSA18 cromolyn sodium5 cromolyn sodium diflunisal2 EPIFOAM24 (mastocytosis)27 digoxin19 epinephrine (anaphylaxis)37 cromolyn sodium (nasal)31 DILANTIN8 EPIVIR HBV18 cromolyn sodium (ophth)33 diltiazem hcl19 eplerenone15 CULTURELLE DIGESTIVE diltiazem hcl coated beads19 eprosartan mesylate14 HEALTH WOMENS HEALTHY diltiazem hcl extended release EQUALACTIN29 BALANCE11 beads19 EQUETRO17 CUVPOSA35 dimenhydrinate12 ergoloid mesylates34 CVS LUBRICANT GEL diphenhydramine hcl12 32 ERGOMAR30 DROPS diphenhydramine- CVS NATURAL FIBER ergotamine w/ caffeine30 SUPPLEMENT29 acetaminophen (sleep)28 ERTACZO21 CVS TENSION HEADACHE2 diphenoxylate w/ atropine11 erythromycin (ophth)32 cyclobenzaprine hcl31 disopyramide phosphate5 erythromycin base30 cyclopentolate hcl32 disulfiram34 erythromycin ethylsuccinate30 CYCLOPHOSPHAMIDE16 divalproex sodium8 erythromycin stearate30 cycloserine16 docosanol23 escitalopram oxalate8 cyproheptadine hcl13 docusate calcium30 esomeprazole magnesium36 DAKLINZA18 docusate sodium30 eszopiclone28 danazol4 dofetilide5 ethambutol hcl16 dantrolene sodium31 DORZOLAMIDE HCL33 ethosuximide8 dapsone4 dorzolamide hcl33 dorzolamide hcl-timolol ethyl chloride25 darifenacin hydrobromide36 maleate32 ETHYL CHLORIDE/FINE DENAVIR23 doxazosin mesylate15 PINPOINT25 desipramine hcl9 doxepin hcl9 ETHYL CHLORIDE/FINE desonide23 STREAM25 doxycycline (monohydrate)34 ETHYL CHLORIDE/MEDIUM desoximetasone24 doxycycline hyclate34 JET STREAM25 desvenlafaxine succinate9 DRAMAMINE12 ETHYL CHLORIDE/MEDIUM dexamethasone20 dronabinol12 STREAM25 ETHYL CHLORIDE/MIST25 DEXAMETHASONE duloxetine hcl9 INTENSOL20 etidronate disodium26 DUOPA16 dexamethasone sodium etodolac1 phosphate (ophth)33 DUREZOL33 EVAC-U-GEN30 DEXILANT35 dutasteride28 EXFORGE HCT15 dextroamphetamine sulfate0 dyphylline-guaifenesin5 EXODERM21 diazepam5 econazole nitrate21 ezetimibe14 diazepam (anticonvulsant)7 eletriptan hydrobromide31 ezetimibe-simvastatin13 dibucaine25 ELIQUIS7 famciclovir18 diclofenac epolamine21 ELIXOPHYLLIN6 famotidine35 diclofenac potassium0 EMBEDA2 famotidine-calcium carbonate- diclofenac sodium1 EMEND12 magnesium hydroxide36

Index 3 FARXIGA11 fluvoxamine maleate9 haloperidol17 febuxostat28 FOILLE25 haloperidol lactate17 felbamate8 fondaparinux sodium7 HARVONI18 felodipine19 FOSAMAX PLUS D26 HEMADY20 fenofibrate13 fosinopril sodium14 heparin sodium (porcine)7 FENOFIBRATE13 fosinopril sodium & heparin sodium (porcine) lock fenofibrate micronized13 hydrochlorothiazide15 flush7 FOSRENOL27 homatropine hbr32 FENOFIBRIC ACID13 FRAGMIN7 HORIZANT34 fenofibric acid13 FUNGI-NAIL21 HUMALOG10 FENOPROFEN CALCIUM1 FUNGOID TINCTURE22 HUMALOG KWIKPEN10 fenoprofen calcium1 furosemide26 HUMALOG MIX 50/5010 FENORTHO1 FYCOMPA7 HUMALOG MIX 75/2510 fentanyl2 gabapentin7 HUMULIN 70/3010 fentanyl citrate2 GAS-X EXTRA HUMULIN N10 FETZIMA9 STRENGTH27 HUMULIN R10 FETZIMA TITRATION PACK9 GEBAUERS INSTANT ICE25 HUMULIN R U-500 FEVERALL INFANTS2 GEBAUERS PAIN EASE25 (CONCENTRATED)10 FEVERALL JUNIOR GEBAUERS SPRAY AND HUMULIN R U-500 STRENGTH2 STRETCH25 KWIKPEN10 fexofenadine hcl13 GELNIQUE36 hydralazine hcl16 finasteride28 GELNIQUE PUMP36 hydrochlorothiazide26 FIRST-VANCOMYCIN 254 gentamicin sulfate (ophth)32 HYDROCIL INSTANT29 FIRST-VANCOMYCIN 504 gentamicin sulfate (topical)21 hydrocodone bitartrate2 FLAREX33 GENTIAN VIOLET22 hydrocodone-acetaminophen3 flavoxate hcl37 gentian violet22 hydrocodone-ibuprofen3 flecainide acetate5 glimepiride11 hydrocortisone20 FLONASE SENSIMIST31 glipizide11 hydrocortisone (topical)24 FLORAJEN ACIDOPHILUS11 glipizide-metformin hcl9 hydrocortisone acetate FLORAJEN WOMEN11 glyburide11 (topical)24 HYDROCORTISONE FLOVENT DISKUS6 glyburide micronized11 BUTYRATE24 FLOVENT HFA6 glyburide-metformin9 hydrocortisone butyrate24 fluconazole12 glycerin (laxative)29 hydrocortisone valerate24 fludrocortisone acetate21 glycopyrrolate35 hydromorphone hcl2 flunisolide (nasal)31 GLYXAMBI9 HYDROMORPHONE HCL2 fluocinolone acetonide24 GNP ACID CONTROL 150 hydromorphone hcl2 MAXIMUM STRENGTH35 fluocinonide24 hydroxychloroquine sulfate16 GNP GENTIAN VIOLET22 fluorometholone (ophth)33 hydroxyzine hcl5 GOLYTELY29 FLUOROPLEX22 hydroxyzine pamoate5 GORDOCHOM22 fluorouracil (topical)22 hyoscyamine sulfate35 GORDONS NO 522 fluoxetine hcl8,9 ibandronate sodium26 granisetron hcl12 flurandrenolide24 ibuprofen1 griseofulvin microsize12 flurbiprofen1 ibuprofen-diphenhydramine flurbiprofen sodium33 guanfacine hcl15 citrate28 fluticasone propionate24 guanfacine hcl (adhd)0 ibuprofen-diphenhydramine hcl28 fluticasone propionate halcinonide24 (nasal)31 halobetasol propionate24 icosapent ethyl13 fluticasone-salmeterol6 HALOG24 imipramine hcl9

Index 4 imiquimod25 lactobacillus11 mafenide acetate23 INDOCIN1 lactobacillus rhamnosus MARPLAN8 indomethacin1 (gg)11 MAXIDEX33 LACTULOSE29 INSULIN ASPART10 meclizine hcl12 lactulose29 INSULIN ASPART meclofenamate sodium1 lactulose (encephalopathy)27 PROTAMINE/INSULIN mefloquine hcl16 ASPART10 LAMICTAL ODT7 meloxicam1 INSULIN LISPRO10 LAMICTAL XR7 memantine hcl34 INVOKAMET9 LAMISIL AT SPRAY22 MENTAX22 INVOKAMET XR9 lamivudine (hbv)18 menthol (topical analgesic)21 INVOKANA11 lamotrigine7 iodoquinol-hc22 METAMUCIL29 lansoprazole36 METAMUCIL MULTIHEALTH ipratropium bromide5 lanthanum carbonate27 FIBER29 ipratropium bromide (nasal)31 LANTUS10 METAMUCIL MULTIHEALTH ipratropium-albuterol6 latanoprost33 FIBER SINGLES29 irbesartan14 LEDIPASVIR/SOFOSBUVIR metaproterenol sulfate6 irbesartan-hydrochlorothiazide 18 metaxalone31 15 leflunomide1 metformin hcl10 isoniazid16 levalbuterol hcl6 methadone hcl2 ISOPTO ATROPINE32 levalbuterol tartrate6 methazolamide26 isosorbide dinitrate4 LEVEMIR10 methimazole35 isosorbide mononitrate4 levetiracetam7 methocarbamol31 isoxsuprine hcl19 levofloxacin27 methoxsalen rapid23 itraconazole12 levofloxacin (ophth)32 methscopolamine bromide35 JANUMET9 levorphanol tartrate2 methylcellulose (laxative)29 JANUMET XR9 levothyroxine sodium35 methyldopa & JANUVIA10 lidocaine25,26 hydrochlorothiazide15 methylphenidate hcl0 JARDIANCE11 lidocaine hcl25 methylprednisolone20 JENTADUETO XR10 lidocaine-prilocaine26 metoclopramide hcl27 KADIAN2 LIDOSOL-HC24 METOCLOPRAMIDE ODT27 ketoconazole12 linezolid4 metolazone26 ketoconazole (topical)22 LINZESS27 ketoprofen1 metoprolol & liothyronine sodium35 hydrochlorothiazide15 ketorolac tromethamine1 lisinopril14 metoprolol succinate18 ketorolac tromethamine lisinopril & metoprolol tartrate18 (ophth)33 hydrochlorothiazide15 metronidazole4 ketotifen fumarate (ophth)33 LITHIUM17 metyrosine14 KLARITY-A32 lithium carbonate17 mexiletine hcl5 KOMBIGLYZE XR10 loperamide hcl11 miconazole nitrate (topical)22 KONDREMUL30 loperamide-simethicone11 midodrine hcl37 KONSYL29 loratadine13 miglitol9 KONSYL DAILY FIBER29 lorazepam5 MILLIPRED20 KONSYL ORIGINAL DAILY LORTAB3 FIBER29 mineral oil30 KONSYL-D29 losartan potassium14 losartan potassium & minocycline hcl34 KRISTALOSE29 hydrochlorothiazide15 minoxidil16 labetalol hcl18 lovastatin14 mirtazapine8 LACTO-BIFIDUS-60011 lubiprostone27 misoprostol36

Index 5 modafinil0 neomycin-polymyxin-hc omeprazole36 moexipril hcl14 (otic)33 omeprazole magnesium36 NEXIUM36 mometasone furoate24 omeprazole-sodium niacin (antihyperlipidemic)14 mometasone furoate (nasal)31 bicarbonate36 nicotine34 OMNARIS31 montelukast sodium5 nicotine polacrilex34 ondansetron12 morphine sulfate2,3 NICOTINE TRANSDERMAL ondansetron hcl12 morphine sulfate beads2 SYSTEM34 ONGLYZA10 MOTOFEN11 nifedipine19 OPSUMIT20 MOVANTIK27 nimodipine19 ORENITRAM19 moxifloxacin hcl27 nitazoxanide4 orphenadrine citrate31 moxifloxacin hcl (ophth)32 NITRO-BID4 orphenadrine w/ aspirin & MUCILIN SF29 NITRO-DUR4 caff31 mupirocin21 nitroglycerin4 oseltamivir phosphate18 mupirocin calcium (topical)21 NITROMIST4 OSMOPREP30 MURO 12833 nizatidine35 OTEZLA1 MUSE19 NORPACE CR5 OUTGRO PAIN RELIEF26 MYCO NAIL A22 nortriptyline hcl9 oxandrolone3 MYRBETRIQ36 NOVACORT24 oxaprozin1 nabumetone1 NOVOLIN 70/3010 OXAYDO3 nadolol18 NOVOLIN 70/30 RELION10 oxazepam5 naftifine hcl22 NOVOLIN N10 oxcarbazepine7 NAFTIN22 NOVOLIN N RELION10 oxiconazole nitrate22 NALFON1 NOVOLIN R10 OXISTAT22 NALOCET3 NOVOLIN R RELION10 oxybutynin chloride36 naphazoline w/ pheniramine32 NOVOLOG11 oxycodone hcl3 naproxen1 NOVOLOG MIX 70/3010 oxycodone w/ acetaminophen3 naproxen sodium1 NOXAFIL12 oxycodone-ibuprofen3 naratriptan hcl31 NPLATE28 OXYCODONE/ACETAMINOPHE NASACORT ALLERGY NUCALA5 N3 24HR31 OXYCONTIN3 NUCYNTA3 NATACYN32 oxymorphone hcl3 NUCYNTA ER3 nateglinide11 OXYTROL36 NYMALIZE19 NATESTO4 OXYTROL FOR WOMEN36 nystatin12 neomycin sulfate0 PANDEL24 nystatin (topical)22 neomycin-bacitracin zn- pantoprazole sodium36 polymyxin32 nystatin-triamcinolone22 paroxetine hcl9 neomycin-bacitracin-polymyxin OCALIVA27 PAXIL9 21 ofloxacin (ophth)32 neomycin-bacitracin-polymyxin w/ peg 3350-kcl-nacl-na sulfate-na lidocaine21 ofloxacin (otic)33 ascorbate-ascorbic acid29 neomycin-bacitracin-polymyxin- olanzapine17 peg 3350-kcl-sod bicarb-sod pramoxine 21 olmesartan medoxomil14 chloride-sod sulfate29 neomycin-polymy-dexameth33 olmesartan medoxomil- peg 3350-potassium chloride-sod neomycin-polymyxin w/ amlodipine-hydrochlorothiazide bicarbonate-sod chloride29 pramoxine21 15 penicillin v potassium34 neomycin-polymyxin-gramicidin olmesartan medoxomil- pentamidine isethionate4 32 hydrochlorothiazide 15 pentazocine w/ naloxone3 neomycin-polymyxin-hc olopatadine hcl (nasal)31 (ophth)33 pentoxifylline28 omega-3-acid ethyl esters13 PERFOROMIST6

Index 6 perphenazine17 PREDNISONE INTENSOL20 RELENZA DISKHALER18 phenelzine sulfate8 pregabalin7,8 RELISTOR27 phenobarbital28 pregabalin (once-daily)34 REMICADE27 phenobarbital-hyoscyamine- PRILOSEC36 repaglinide11 atropine-scopolamine 35 primaquine phosphate16 REPHRESH PRO-B11 phenoxybenzamine hcl14 primidone8 RESTASIS32 phenytoin8 PRIMLEV3 RESTASIS MULTIDOSE32 phenytoin sodium extended8 PROAIR RESPICLICK6 RETAINE HPMC32 PHOSLYRA27 probenecid28 REXULTI17 PIFELTRO17 PROBIOTIC11 RIBASPHERE18 pimecrolimus25 PROBIOTIC GOLD EXTRA ribavirin (hepatitis c)18 pindolol18 STRENGTH11 RIDAURA0 pioglitazone hcl10 prochlorperazine17 rifabutin16 pioglitazone hcl-glimepiride10 prochlorperazine maleate17 RIFAMATE16 pioglitazone hcl-metformin PROLATE3 rifampin16 hcl10 PROLIA26 piroxicam1 RIFATER16 promethazine hcl13 PLENVU29 risedronate sodium26 propantheline bromide35 risperidone17 POLAR FROST21 propranolol & polyethylene glycol 335029 hydrochlorothiazide15 rizatriptan benzoate31 polymyxin b-trimethoprim32 propranolol hcl18 ropinirole hydrochloride17 polyvinyl alcohol32 propylthiouracil35 rosuvastatin calcium14 posaconazole12 PSORCON25 RYBELSUS10 POVIDONE IODINE32 psyllium29 salsalate2 PRADAXA7 PULMICORT FLEXHALER6 SANCUSO12 pramipexole dihydrochloride16 PURE & GENTLE SAVELLA34 PRAMOSONE24 LUBRICANT32 SAVELLA TITRATION PYLERA36 PACK34 PRAMOX GEL26 pyrazinamide16 scopolamine12 pramoxine hcl26 pyrethrins-piperonyl SEEBRI NEOHALER5 pramoxine-hc25 butoxide26 selegiline hcl17 pramoxine-hc-chloroxylenol 33 QBRELIS14 SEMGLEE11 pramoxine-zinc acetate26 QSYMIA0 SENNA30 prasugrel hcl28 quetiapine fumarate17 sennosides30 pravastatin sodium14 quinapril hcl14 sennosides-docusate prazosin hcl15 quinapril-hydrochlorothiazide sodium29 PRED MILD33 15 SEREVENT DISKUS6 PRED-G33 quinidine gluconate5 sertraline hcl9 PRED-G S.O.P.33 quinidine sulfate5 sevelamer carbonate27 prednicarbate25 quinine sulfate16 sevelamer hcl28 prednisolone20 QVAR REDIHALER6 sildenafil citrate19 RA ANTI-FUNGAL FOOT prednisolone acetate (ophth)33 sildenafil citrate (pulmonary CARE22 hypertension)20 PREDNISOLONE ACETATE P- rabeprazole sodium36 F33 silodosin28 prednisolone sodium ramelteon29 silver sulfadiazine23 phosphate20 ramipril14 simethicone27 PREDNISOLONE SODIUM ranitidine hcl35 PHOSPHATE33 simvastatin14 ranolazine4 prednisone20 SIRTURO16 REGENECARE HA26

Index 7 SIVEXTRO4 terbutaline sulfate6 TRULANCE27 sodium chloride hypertonic33 testosterone4 TUDORZA PRESSAIR5 sodium phosphates30 tetracycline hcl34 TYVASO19 SOFOSBUVIR/VELPATASVIR tetrahydrozoline hcl TYVASO REFILL19 18 (ophth)32 TYVASO STARTER19 solifenacin succinate36 THEO-246 ULTRACIN M21 SORBITOL30 theophylline6 undecylenic acid22 sotalol hcl18 THIOLA EC28 UNDELENIC TINCTURE22 sotalol hcl (afib/afl)18 tiagabine hcl8 UNGUENTINE23 SOVALDI18 timolol maleate18 UNGUENTINE MAXIMUM SPIRIVA HANDIHALER5 tinidazole4 STRENGTH23 SPIRIVA RESPIMAT5 tizanidine hcl31 UPTRAVI20 spironolactone26 TOBRADEX33 UTIBRON NEOHALER6 spironolactone & TOBRADEX ST33 valacyclovir hcl18 hydrochlorothiazide26 tobramycin (ophth)32 valganciclovir hcl17 STENDRA19 tobramycin- valproate sodium8 STRIVERDI RESPIMAT6 dexamethasone33 valproic acid8 sucralfate35 TOBREX32 valsartan14 sulconazole nitrate22 tolmetin sodium1 valsartan-hydrochlorothiazide sulfacetamide sod- tolnaftate22 15 prednisolone33 tolterodine tartrate36 VANALICE26 sulfacetamide sodium (ophth)32 topiramate8 VANCOMYCIN HCL + sulfamethoxazole- TOUJEO MAX SYRSPENDSF PH44 trimethoprim4 SOLOSTAR11 vardenafil hcl19 SULFAMYLON23 TOUJEO SOLOSTAR11 VASCEPA13 sulindac1 TOVIAZ36 VEMLIDY18 sumatriptan31 TRACLEER20 venlafaxine hcl9 sumatriptan succinate31 TRADJENTA10 VENTAVIS19 sumatriptan-naproxen tramadol hcl3 verapamil hcl19 sodium30 tramadol-acetaminophen3 VERSACLOZ17 SUPREP BOWEL PREP KIT29 trandolapril14 VIBERZI27 SYMLINPEN 1209 tranylcypromine sulfate8 VICTOZA10 SYMLINPEN 609 trazodone hcl9 VIMPAT8 SYNALAR CREAM KIT25 TRECATOR16 voriconazole12 SYNJARDY10 TRELEGY ELLIPTA6 VRAYLAR17 SYNJARDY XR10 TRESIBA FLEXTOUCH11 VYVANSE0 tacrolimus (topical)25 triamcinolone acetonide warfarin sodium7 tadalafil19 (nasal)31 XARELTO7 tadalafil (pulmonary triamcinolone acetonide hypertension)20 (topical)25 XARELTO STARTER PACK7 tamsulosin hcl28 triamterene & XENICAL0 hydrochlorothiazide26 telmisartan14 XGEVA26 TRIANEX25 telmisartan-amlodipine15 XIFAXAN4 TRIGLIDE13 telmisartan-hydrochlorothiazide XIGDUO XR10 15 trihexyphenidyl hcl16 XIIDRA32 temazepam28 TRIJARDY XR10 XTAMPZA ER3 terazosin hcl15 trimethobenzamide hcl12 YUPELRI5 terbinafine hcl12 trimethoprim4 zafirlukast5 terbinafine hcl (topical)22 trospium chloride36

Index 8 zaleplon28,29 ZELAPAR17 ZELNORM27 ZEPATIER18 ZETONNA31 ZIEXTENZO28 zileuton6 ZIMS MAX-FREEZE21 ziprasidone hcl17 zoledronic acid26 zolmitriptan31 zolpidem tartrate29 zonisamide8 ZONTIVITY28 ZOSTRIX-HP26 ZYFLO6

Index 9