2021 Member Formulary List of Covered Drugs

GHP FAMILY

2021 member formulary List of covered drugs

What is the Statewide PDL and GHP Family Formulary? Geisinger Health Plan, like other Medicaid Managed Care Organizations follows the Statewide Preferred Drug List (PDL). The Statewide PDL is developed by the Department of Human Services’ (DHS) Pharmacy and Therapeutics Committee. A formulary is a list of drugs selected by GHP Family, which represents medications believed to be a necessary part of a quality treatment program. Only medications that are not part of the PDL may be included in the GHP Family formulary.

This formulary is up to date at the time of print. For the most up to date information, please go to our website at https://www.geisinger.org/health-plan/plans/ghp-family and visit https://www.dhs.pa.gov/providers/Pharmacy-Services/Pages/Preferred-Drug-List.aspx for information on the Statewide PDL.

Can the Formulary change? The plan may add or remove drugs from the formulary. If we remove drugs from our formulary or add restrictions on a drug such as a requirement for prior authorization, quantity limits and/or step therapy restrictions on a drug, we must notify affected members of the change at least 30 days before the change becomes effective. See section, “Are there any requirements or limits on my drugs?” for more information.

How do I use the Formulary? There are two ways to find your drug within the formulary:

Drug Class The formulary begins on page 14. The drugs in this formulary are grouped into the class of drugs they belong to. If you know what class your drug belongs to, look for the class name in the list that begins on page 11. Then look under the class name for your drug.

Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that is included at the end of this document. The Index provides an alphabetical list of all the drugs included in this document.

The first column of the formulary lists the formulary drug. Brand drugs are printed in all upper-case letters (e.g. DIURIL ORAL SUSPENSION). Generic drugs are printed in all lower-case italic letters (e.g. furosemide). Drug names that appear in the third column for generic covered drugs are the name of the brand medication. The brand name in the third column appears for reference only to assist in identifying the generic medication and does NOT indicate that the brand name drug is on the formulary.

¹You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document Geisinger Family 2021 Supplemental Formulary Page 2 of 83 Effective Date: 9/22/2021 The second column of the formulary lists the tier the drug is covered on. Tier 1 contains generic medications. Tier 2 contains brand name medications. Drugs listed as OTC are over-the-counter medications.

The fourth and final column of the formulary lists any requirements or limits that may apply to the drug. See the section titled “Are there any requirements or limits on my drugs” below.

Sometimes a drug comes in multiple forms (e.g., drops, liquid, tablet, syrup, etc.). If this column lists a specific drug form, then only that form is included in the formulary.

What are generic drugs? GHP Family covers both brand name drugs and generic drugs. If your doctor prescribes a brand name drug and a generic is available, your pharmacist will give you the generic version of that drug. A generic drug is approved by the Federal Food & Drug Administration (FDA) as having the same active ingredient as the brand name drug and is just as safe and effective. Generally, generic drugs cost less than brand name drugs. Prescriptions written as “brand medically necessary” by your doctor will require prior authorization.

Are Over-the-Counter (OTC) drugs covered? Certain OTC medications are listed on the Statewide PDL or formulary. OTC drugs will require a prescription from your doctor.

Dispensing Limits GHP Family will cover up to a 34-day supply of your medication unless the prescription is written for less by your physician or the medication is subject to a quantity limit restriction. If there are medications you take on a regular basis, such as blood pressure medications or medications to treat cholesterol (maintenance medications), you have the option to obtain a 90-day supply from a participating retail pharmacy or mail order pharmacy. Please call GHP Family Pharmacy services at (855) 552-6028 or (570) 214–3554 for assistance in finding a participating pharmacy. Certain medications such as controlled substances and specialty medications are excluded from this 90-day supply program. If you have questions about which medications are considered maintenance medications you can check online at https://healthplan.geisinger.org/pharmacy/pharmacy.aspx?strip=true&style=OneGeisinger or call GHP Family Pharmacy services at (855) 552-6028 or (570) 214–3554. A medication may be refilled when 85% has been used. Controlled medications, which may cause addiction, such as those used for pain or anxiety, may be refilled when 90% has been used. If for some reason you need a refill

¹You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document Geisinger Family 2021 Supplemental Formulary Page 3 of 83 Effective Date: 9/22/2021 before 85% or 90% of the medication has been used please call GHP Family Pharmacy Services at (855) 552-6028 or (570) 214-3554 for assistance.

GHP Family will grant one early refill if you are traveling outside of Pennsylvania and will run out of medication before you return home. GHP Family will allow this once per medication per member per year. Your pharmacy should contact GHP Family Pharmacy Services at (855) 552-6028 or (570) 214-3554 to obtain a vacation supply. Any additional requests for a vacation supply will require prior authorization.

Requests to replace medications that are lost, stolen, or destroyed must be reviewed by GHP Family Pharmacy Services. Members should contact GHP Family Pharmacy Services at (855) 552-6028 or (570) 214-3554 for more information.

Blood Glucose Monitors and Strips Members are entitled to receive one new blood glucose monitor every two years and 200 strips every month. You can also receive a new monitor if you switch to a different one that is preferred on the PDL.

Medical Benefit Drugs Medical benefit drugs are drugs dispensed and administered in a physician’s office and are not included in the formulary. For some Medical Benefit Drugs, your provider must first obtain prior authorization. Your provider can find a list of medical benefit drugs that require prior authorization here: https://www.geisinger.org/health-plan/providers/pharmacy-forms. Any questions regarding the coverage of medical benefit drugs should be directed to GHP Family Pharmacy Services at (855) 552-6028.

Vaccines The vaccines included in the formulary are available to members at a retail pharmacy without a prescription. The typhoid vaccine (Vivotif) is also available at retail pharmacies but requires a prescription. Other vaccines are considered a medical benefit and should be administered by your physician.

Are there any requirements or limits on my drugs? Some drugs may have additional requirements or limits. These requirements and limits may include:

• Prior Authorization: GHP Family requires your physician to get prior approval for certain drugs. This means that your prescriber will need to get approval from GHP Family before you fill prescriptions for these drugs. Without this approval, GHP Family will not pay for the drug. If GHP denies the prior authorization request, you can appeal the decision. Please see the GHP

¹You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document Geisinger Family 2021 Supplemental Formulary Page 4 of 83 Effective Date: 9/22/2021 member handbook, section 15, Complaint, Appeal and Fair Hearing Processes, for information about filing an appeal.

• Quantity Limits: For certain drugs, there are limits to the amount of the drug that you can get. GHP Family follows DHS’ quantity limits except for blood glucose meters and strips, condoms, spacers (OptiChamber), injectable anticoagulants (Lovenox), vaccines, and medications used to treat low blood sugar (glucagon, GVOKE, etc.). Quantity limits are available at www.dhs.pa.gov/providers/Pharmacy-Services/Pages/Quantity-Limits-and-Daily-Dose- Limits.aspx or https://healthplan.geisinger.org/pharmacy/pharmacy.aspx?strip=true&style=OneGeisinger If your prescriber wants you to have more than the limit, your prescriber must request prior authorization.

• Step Therapy: In some cases, GHP Family requires you to first try certain drugs to treat your medical condition before we will approve another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, GHP Family may not approve Drug B unless you try Drug A first. If Drug A does not work for you, GHP Family will then approve Drug B. Your prescriber may request prior authorization if Drug A does not work for you or if you cannot take Drug A.

• Specialty Pharmacy: Specialty medications can only be filled by certain pharmacies in the GHP Family network. Specialty drugs are medications used to treat complex diseases. These medications usually require specialized handling and monitoring. If you are taking a specialty medicine or if you have a question about finding a specialty pharmacy, please call PerformRx at (844) 399-0477. Specialty medications that are included in this formulary have the initials SP next to them. A complete list of specialty medications and pharmacies that can fill them can be found here: https://www.geisinger.org/health-plan/plans/ghp-family/pharmacy-coverage Any Specialty Medication that is also a Medical Benefit Drug can either be dispensed by a contracted specialty pharmacy or a prescriber can obtain, administer and bill GHP Family for the cost of the medications.

The following abbreviations are found within column three of this formulary and indicate the requirements and limits listed above:

ABBREVIATION DESCRIPTION EXPLANATION Utilization Management Restrictions Your physician is required to get prior authorization from GHP Family before you fill Prior Authorization PA your prescription for this drug. Without prior Restriction approval, GHP Family will not pay for this drug.

¹You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document

Geisinger Family 2021 Supplemental Formulary Page 5 of 83

Effective Date: 9/22 /2021 ABBREVIATION DESCRIPTION EXPLANATION GHP Family limits the amount of this drug that Quantity Limit QL can be obtained per prescription, or within a Restriction specific time frame. Before GHP Family will approve this drug, you must first try another drug(s) to treat your Step Therapy ST medical condition. This drug may only be Restriction approved if the other drug(s) does not work for you. Some drugs are not available at your retail pharmacy. These drugs are called specialty drugs and can be obtained at specialty SP Specialty Pharmacy pharmacies. To find out how and where to obtain a specialty drug, please contact PerformRx at (844) 399-0477. If you are a new member or if you have not taken this Prior Authorization drug before, you (or your physician) are required to PA-NSO Restriction for get prior authorization from GHP Family before you New Starts Only fill your prescription for this drug. Without prior approval, GHP Family will not pay for this drug.

How much will I pay for my drugs? Pharmacy copays will apply to members 18 years of age and older unless otherwise listed below. Brand name prescription drugs have a $3 copayment. Generic prescription and over-the-counter drugs have a $1 copayment. Services cannot be denied if the member is unable to afford the copay.

There are no copays for: • Pregnant women (including the postpartum period which ends 60 days after delivery) • Children under 18 years of age • Medical benefit drugs • Members in a nursing home • Members in an Intermediate Care Facility for Mental Retardation or Intermediate Care Facility for Other Related Conditions • Family planning drugs or supplies • Drugs, including immunizations, when dispensed and/or administered by a physician • Title IV-B Foster Care and IV-E Foster Care and Adoption Assistance • Members eligible under the Breast and Cervical Cancer Prevention and Treatment Programs • There is no copay for the following groups of medications:

¹You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document Geisinger Family 2021 Supplemental Formulary Page 6 of 83 Effective Date: 9/22/2021 o Antihypertensives (high blood pressure) o Antidiabetes (high blood sugar) o Anticonvulsants (seizure) o Cardiovascular preparations (heart disease) o Antipsychotics (except those that are controlled substance antianxiety drugs) o Antineoplastics (cancer drugs) o Antiglaucoma drugs o Anti-Parkinson’s drugs o HIV/AIDS drugs o Preferred naloxone injection/nasal spray for drug overdose

Non-covered medications The following medications are not eligible for coverage under the Medical Assistance Program:

• Drugs that are designated by the FDA as less than effective (DESI) drugs • Any drug marketed by a drug company that does not participate in the Medicaid Rebate Program • Drugs used for weight loss • Drugs used for cosmetic purposes or hair growth • Drugs used for fertility • Drugs used for erectile dysfunction • Cough and cold medications for members over 21 years of age • Drugs and devices classified as experimental • Drugs ordered by a prescriber who has been barred or suspended from participating the MA program

What if my drug requires prior authorization? If you learn that GHP Family requires prior authorization of your drug, you have two options: • You can ask GHP Family Pharmacy Services for a list of similar drugs that are on the GHP Family formulary. You can call GHP Family Pharmacy Services at (855) 552-6028 or (570) 214-3554. When you receive the list, show it to your doctor and ask him or her if one of these drugs will work for you. • Your physician can ask GHP Family for approval of your drug through a prior authorization. See below for information about how your physician can request a prior authorization.

What if I need a drug that is not listed on the Statewide PDL or GHP Family Formulary? • Please check the PDL (https://www.dhs.pa.gov/providers/Pharmacy- Services/Pages/Preferred-Drug-List.aspx) and formulary to see if there is a preferred alternative or formulary alternative that you can ask your physician to switch you to • Your physician can ask us to approve your drug even if it is not on our formulary or the PDL

¹You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document Geisinger Family 2021 Supplemental Formulary Page 7 of 83 Effective Date: 9/22/2021 Generally, GHP Family will only approve your physician’s request if the alternative drugs included on the plan’s formulary would not be as effective in treating your condition and/or would cause you to have a negative medical effect. We must make our decision within 24 hours of getting your prescriber’s request.

If the pharmacy cannot fill your prescription because of the medication being non-formulary or requiring prior authorization, GHP Family will authorize a temporary supply of the medication. If your prescription is for an ongoing medication, a 15-day temporary supply will be authorized. If your prescription is for a new medication, a 5-day temporary supply of medication will be authorized. Members are limited to one emergency supply per medication every 180 days.

A member whose prescription rejects for prior authorization or other utilization management criteria should not be turned away at the pharmacy without receiving a temporary supply of medication unless the dispensing pharmacist feels that dispensing the medication would jeopardize the health and safety of the member.

ADRENALS ...... 14 ALCOHOL DETERRENTS ...... 14 ALKALINIZING AGENTS ...... 14 AMMONIA DETOXICANTS...... 14 ANALGESICS AND ANTIPYRETICS ...... 15 ANDROGENS ...... 16 ANOREXIGENIC AGENTS AND RESPIRATORY AND CNS STIMULANTS ...... 16 ANTACIDS AND ADSORBENTS ...... 16 ANTHELMINTICS...... 17 ANTIANEMIA DRUGS ...... 17 ANTIBACTERIALS ...... 18 ANTICHOLINERGIC AGENTS ...... 18 ANTIDIARRHEA AGENTS...... 18 ANTIDOTES ...... 19 ANTIEMETICS ...... 19 ANTIFLATULENTS...... 20 ANTIFUNGALS...... 20 ANTIGLAUCOMA AGENTS ...... 20 ANTIHEMORRHAGIC AGENTS ...... 20 ANTIHYPOGLYCEMIC AGENTS ...... 20 ANTI-INFECTIVES ...... 20 ANTI-INFLAMMATORY AGENTS ...... 22 ANTIMANIC AGENTS ...... 23 ANTIMYCOBACTERIALS ...... 23 ANTINEOPLASTIC AGENTS ...... 24 ANTIPARKINSONIAN AGENTS ...... 25 ANTIPROTOZOALS ...... 25 ANTIPRURITICS AND LOCAL ANESTHETICS...... 25 ANTISENSE OLIGONUCLEOTIDES ...... 25

¹You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document Geisinger Family Supplemental Formulary Page 11 of 83 Effective Date: 9/22/2021 ANTITHROMBOTIC AGENTS...... 25 ANTITOXINS AND IMMUNE GLOBULINS...... 26 ANTITUSSIVES ...... 26 ANTIULCER AGENTS AND ACID SUPPRESSANTS ...... 26 ANXIOLYTICS, SEDATIVES, AND HYPNOTICS ...... 26 ASTRINGENTS...... 27 AUTONOMIC DRUGS, MISCELLANEOUS ...... 27 CARDIAC DRUGS ...... 27 CARIOSTATIC AGENTS ...... 27 CATHARTICS AND LAXATIVES ...... 28 CENTRAL NERVOUS SYSTEM AGENTS, MISC ...... 30 CONTRACEPTIVES ...... 30 CYSTIC FIBROSIS TRANSMEMBRANE CONDUCTANCE REGULATOR MODULATORS...... 30 DENTAL AGENTS ...... 31 DEVICES ...... 31 DISEASE-MODIFYING ANTIRHEUMATIC DRUGS ...... 51 DIURETICS ...... 51 EENT DRUGS, MISCELLANEOUS...... 52 EMOLLIENTS, DEMULCENTS, AND PROTECTANTS ...... 52 ENZYMES ...... 53 EXPECTORANTS ...... 53 FIRST GENERATION ANTIHISTAMINES ...... 53 GOLD COMPOUNDS ...... 54 HEMORRHEOLOGIC AGENTS ...... 54 HYPOTENSIVE AGENTS ...... 54 IMMUNOMODULATORY AGENTS...... 54 IMMUNOSUPPRESSIVE AGENTS ...... 54 ION-REMOVING AGENTS ...... 54 IRRIGATING SOLUTIONS ...... 55 KERATOLYTIC AGENTS ...... 55 MOUTHWASHES AND GARGLES ...... 55 ¹You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document Geisinger Family Supplemental Formulary Page 12 of 83 Effective Date: 9/22/2021 MUCOLYTIC AGENTS...... 55 MULTIVITAMIN PREPARATIONS ...... 56 MYDRIATICS ...... 58 NON-AHFS SUBCLASS ...... 59 OTHER MISCELLANEOUS THERAPEUTIC AGENTS ...... 59 OXYTOCICS ...... 60 PARASYMPATHOMIMETIC (CHOLINERGIC) AGENTS ...... 60 PARATHYROID AND ANTIPARATHYROID AGENTS...... 60 PITUITARY ...... 60 PROGESTINS ...... 60 PSYCHOTHERAPEUTIC AGENTS...... 60 RENIN-ANGIOTENSIN-ALDOSTERONE SYS INHIB...... 61 REPLACEMENT PREPARATIONS ...... 61 RESPIRATORY SMOOTH MUSCLE RELAXANTS ...... 63 SECOND GENERATION ANTIHISTAMINES...... 63 SKIN AND MUCOUS MEMBRANE AGENTS, MISC ...... 63 SOMATOSTATIN AGONISTS AND ANTAGONISTS ...... 63 SYMPATHOMIMETIC (ADRENERGIC) AGENTS ...... 64 THYROID AND ANTITHYROID AGENTS...... 64 TOXOIDS ...... 64 URINARY ANTI-INFECTIVES ...... 64 URINE AND FECES CONTENTS ...... 64 VACCINES...... 64 VASOCONSTRICTORS...... 66 VASODILATING AGENTS ...... 66 VITAMIN B COMPLEX...... 67 VITAMIN C ...... 67 VITAMIN D ...... 67 VITAMIN E ...... 67 VITAMIN K ACTIVITY ...... 68

F o rm u la ry D ru gL ist Drug Reference Name Drug Name Requirements/Limits1 Tier

THERAPEUTIC CATEGORY Therapeutic Class ADRENALS Adrenals methylprednisolone acetate 40 mg/ml Injection Suspension, 80 mg/ml Injection Suspension 1 DEPO-MEDROL methylprednisolone sodium succ 1000 mg Injection Solution Reconstituted, 125 mg Injection Solution Reconstituted, 40 mg Injection Solution Reconstituted, 500 mg Injection Solution Reconstituted 1 SOLU-MEDROL READYSHARP DEXAMETHASONE 1 SOLU-CORTEF 2 SOLU-MEDROL 1000 mg Injection Solution Reconstituted, 125 mg Injection Solution Reconstituted, 40 mg Injection Solution Reconstituted, 500 mg Injection Solution Reconstituted 2 ALCOHOL DETERRENTS Alcohol Deterrents disulfiram 250 mg Oral Tablet, 500 mg Oral Tablet 1 ANTABUSE ALKALINIZING AGENTS Alkalinizing Agents cytra-2 OTC potassium citrate er 1 UROCIT-K sod citrate-citric acid 500-334 mg/5ml Oral Solution OTC AMMONIA DETOXICANTS Ammonia Detoxicants constulose 1 CONSTULOSE enulose 1 CONSTULOSE generlac 1 CONSTULOSE

lactulose 10 gm/15ml Oral Solution, 20 gm/30ml Oral Solution 1 CONSTULOSE lactulose encephalopathy 1 CONSTULOSE ANALGESICS AND ANTIPYRETICS Analgesics And Antipyretics, Misc ACEPHEN OTC QL(20 EA per 1 days) acetaminophen 650 mg Rectal Suppository OTC QL(6 EA per 1 days) acetaminophen 325 mg Oral Tablet OTC QL(10 EA per 1 days) acetaminophen 120 mg Rectal Suppository, 160 mg Oral Tablet Chewable OTC QL(20 EA per 1 days) acetaminophen 80 mg Oral Tablet Chewable OTC QL(30 EA per 1 days) acetaminophen 160 mg/5ml Oral Liquid, 160 mg/5ml Oral Solution OTC QL(75 ML per 1 days) acetaminophen 650 mg/20.3ml Oral Solution, 650 mg/20.3ml Oral Suspension OTC QL(100 ML per 1 days) acetaminophen extra strength OTC QL(6 EA per 1 days) childrens acetaminophen 80 mg tab disint OTC QL(30 EA per 1 days) childrens acetaminophen 160 mg/5ml Oral Suspension OTC QL(75 ML per 1 days) childrens apap OTC QL(30 EA per 1 days) childrens silapap OTC QL(75 ML per 1 days) childrens tactinal OTC QL(30 EA per 1 days) HEALTHY MAMA SHAKE THAT ACHE OTC QL(6 EA per 1 days) mapap 500 mg Oral Capsule OTC QL(6 EA per 1 days) MAPAP CHILDRENS 80 mg Oral Tablet Chewable OTC QL(30 EA per 1 days) m-pap OTC QL(75 ML per 1 days) non-aspirin extra strength OTC QL(6 EA per 1 days) pain & fever childrens 160 mg Oral Tablet Chewable OTC QL(20 EA per 1 days) pain & fever childrens 160 mg/5ml Oral Solution OTC QL(75 ML per 1 days) pain & fever extra strength OTC QL(6 EA per 1 days) pain reliever extra strength 500 mg Oral Tablet OTC QL(6 EA per 1 days)

Nonsteroidal Anti-inflammatory Agents aspirin adult OTC QL(12 EA per 1 days) salsalate 500 mg Oral Tablet, 750 mg Oral Tablet 1 QL(4 EA per 1 days) ANDROGENS Androgens danazol 100 mg Oral Capsule, 200 mg Oral Capsule, 50 mg Oral Capsule 1 DANOCRINE testosterone cypionate 50 mg/ml Injection Solution 1 PA ANOREXIGENIC AGENTS AND RESPIRATORY AND CNS STIMULANTS Respiratory And Cns Stimulants caffeine citrate 20 mg/ml Oral Solution, 60 mg/3ml Oral Solution 1 AL(Max 2 years) ANTACIDS AND ADSORBENTS Antacids And Adsorbents ACID GONE 160-105 mg Oral Tablet Chewable OTC ACID GONE 95-358 mg/15ml Oral Suspension OTC alumina-magnesia-simethicone OTC aluminum hydroxide gel 320 mg/5ml Oral Suspension OTC antacid 500 mg Oral Tablet Chewable OTC antacid 200-200-20 mg/5ml Oral Suspension OTC antacid anti-gas OTC antacid anti-gas reg strength OTC antacid calcium OTC antacid calcium extra strength OTC antacid calcium rich OTC antacid extra strength 750 mg Oral Tablet Chewable OTC antacid fast acting OTC antacid fast relief OTC antacid liquid OTC antacid m OTC antacid maximum OTC antacid plus anti-gas fast act OTC ¹You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document Geisinger Family Supplemental Formulary Page 16 of 83 Effective Date: 9/22/2021 Drug Reference Name Drug Name Requirements/Limits1 Tier

antacid plus anti-gas relief 200- 200-20 mg/5ml Oral Suspension OTC antacid regular strength 500 mg Oral Tablet Chewable OTC antacid regular strength 200-200- 20 mg/5ml Oral Suspension OTC antacid ultra strength 1000 mg Oral Tablet Chewable OTC calcium antacid OTC calcium antacid ultra max st OTC calcium antacid ultra strength OTC calcium carbonate antacid 500 mg Oral Tablet Chewable, 750 mg Oral Tablet Chewable OTC calcium carbonate antacid 1250 mg/5ml Oral Suspension OTC geri-lanta OTC geri-mox OTC goodsense antacid 500 mg Oral Tablet Chewable OTC hm antacid OTC hm antacid/antigas OTC hm calcium antacid 500 mg Oral Tablet Chewable OTC hm calcium antacid ultra st OTC mag-al plus OTC magnesium oxide 400 mg Oral Tablet OTC rulox OTC sodium bicarbonate 325 mg Oral Tablet, 650 mg Oral Tablet OTC ANTHELMINTICS Anthelmintics albendazole 200 mg Oral Tablet 1 ALBENZA QL(4 EA per 1 days) PA, QL(2 EA per 1 EMVERM 2 days) praziquantel 600 mg Oral Tablet 1 BILTRICIDE ANTIANEMIA DRUGS Iron Preparations EZFE 200 OTC FERREX 150 OTC

ferrous gluconate 324 (37.5 Fe) mg Oral Tablet OTC ICAR-C PLUS 1 IFEREX 150 OTC pc pediatric iron drops OTC POLY-IRON 150 OTC purefe plus 1 ANTIBACTERIALS Antibacterials, Miscellaneous clindamycin hcl 150 mg Oral Capsule, 300 mg Oral Capsule, 75 mg Oral Capsule 1 CLEOCIN clindamycin palmitate hcl 1 CLEOCIN linezolid 600 mg Oral Tablet 1 ZYVOX linezolid 100 mg/5ml Oral Suspension Reconstituted 1 ZYVOX PA PA, QL(1 EA per 1 SIVEXTRO 200 mg Oral Tablet 2 days) XENLETA 600 mg Oral Tablet 2 PA Sulfonamides sulfamethoxazole-trimethoprim 400-80 mg Oral Tablet, 800-160 mg Oral Tablet 1 SEPTRA sulfamethoxazole-trimethoprim 200-40 mg/5ml Oral Suspension 1 SEPTRA SULFATRIM PEDIATRIC 1 ANTICHOLINERGIC AGENTS Antimuscarinics/antispasmodics dicyclomine hcl 10 mg Oral Capsule, 20 mg Oral Tablet 1 BENTYL dicyclomine hcl 10 mg/5ml Oral Solution 1 BENTYL glycopyrrolate 1 mg Oral Tablet, 2 mg Oral Tablet 1 ROBINUL propantheline bromide 15 mg Oral Tablet 1 PRO-BANTHINE ANTIDIARRHEA AGENTS Antidiarrhea Agents ALIGN OTC ALIGN JR FOR KIDS OTC

bismatrol 262 mg Oral Tablet Chewable OTC bismatrol 262 mg/15ml Oral Suspension OTC SOOTHE bismatrol maximum strength OTC diphenoxylate-atropine 2.5-0.025 mg Oral Tablet 1 LOMOTIL diphenoxylate-atropine 2.5-0.025 mg/5ml Oral Liquid 1 LOMOTIL geri-pectate OTC SOOTHE hm loperamide hcl 2 mg Oral Capsule OTC IMODIUM QL(8 EA per 1 days) IMODIUM A-D 2 mg Oral Capsule OTC QL(8 EA per 1 days) KAOPECTATE 262 mg/15ml Oral Suspension OTC KAOPECTATE EXTRA STRENGTH OTC KAO-TIN 262 mg/15ml Oral Suspension OTC loperamide hcl 2 mg Oral Capsule 1 IMODIUM QL(8 EA per 1 days) peptic relief OTC SOOTHE 262 mg Oral Tablet, 262 mg Oral Tablet Chewable OTC SOOTHE 262 mg/15ml Oral Suspension OTC stomach relief 262 mg Oral Tablet Chewable OTC SP, PA, QL(3 EA per 1 XERMELO 2 days) ANTIDOTES Antidotes acetylcysteine 200 mg/ml Intravenous Solution 1 ACETADOTE acetylcysteine 10 % Inhalation Solution, 20 % Inhalation Solution 1 MUCOMYST leucovorin calcium 10 mg Oral Tablet, 15 mg Oral Tablet, 25 mg Oral Tablet, 5 mg Oral Tablet 1 ANTIEMETICS 5-ht3 Receptor Antagonists ondansetron hcl 24 mg Oral Tablet 1 ZOFRAN QL(1 EA per 1 days)

Antiemetics, Miscellaneous TRANSDERM SCOP (1.5 MG) 1 QL(0.4 EA per 1 days) ANTIFLATULENTS Antiflatulents gas relief 180 mg Oral Capsule, 250 mg Oral Capsule OTC gas relief extra strength 125 mg Oral Capsule OTC gas relief ultra strength OTC simethicone 125 mg Oral Capsule, 180 mg Oral Capsule OTC ANTIFUNGALS Polyenes nystatin Powder 1 ANTIGLAUCOMA AGENTS Carbonic Anhydrase Inhibitors acetazolamide 125 mg Oral Tablet, 250 mg Oral Tablet 1 DIAMOX acetazolamide er 1 DIAMOX methazolamide 25 mg Oral Tablet, 50 mg Oral Tablet 1 NEPTAZANE ANTIHEMORRHAGIC AGENTS Hemostatics KOATE-DVI 250 unit Intravenous Solution Reconstituted, 500 unit Intravenous Solution Reconstituted 2 SP, PA ANTIHYPOGLYCEMIC AGENTS Antihypoglycemic Agents, Miscellaneous glucose 4 gm Oral Tablet Chewable 2 Glycogenolytic Agents GLUCAGEN DIAGNOSTIC 2 QL(2 EA per 30 days) glucagon emergency 1 mg/ml Injection Solution Reconstituted 2 QL(2 EA per 30 days) ANTI-INFECTIVES Antibacterials bacitracin-neomycin-polymyxin OTC bacitracin-neomycin-polymyxin OTC kp bacitracin zinc OTC

metronidazole 0.75 % External Cream 1 METROCREAM metronidazole 0.75 % External Gel, 1 % External Gel 1 METROGEL metronidazole 0.75 % External Lotion 1 METROLOTION NEOSPORIN + PAIN/ITCH/SCAR OTC Antifungals antifungal 1 % External Aerosol OTC athletes foot 2 % External Powder OTC GYNE-LOTRIMIN OTC jock itch spray powder OTC kp miconazole nitrate OTC kp terbinafine hydrochloride OTC kp tolnaftate OTC LOTRIMIN AF DEODORANT POWDER OTC LOTRIMIN AF JOCK ITCH POWDER OTC LOTRIMIN ULTRA OTC miconazole antifungal OTC Antivirals trifluridine 1 VIROPTIC Eent Anti-infectives, Miscellaneous chlorhexidine gluconate 0.12 % Mouth/Throat Solution 1 PERIOGARD Local Anti-infectives, Miscellaneous acne treatment 10 % External Gel OTC bp gel OTC bp wash 5 % External Liquid OTC kp benzoyl peroxide OTC kp benzoyl peroxide wash OTC selenium sulfide 2.25 % External Shampoo, 2.3 % External Shampoo 1 selenium sulfide 2.5 % External Lotion 1 SELSUN silver sulfadiazine 1 % External Cream 1 SILVADENE SSD 1 Scabicides And Pediculicides

complete lice treatment OTC lice treatment 1 % External Liquid OTC stop lice complete treatment OTC ANTI-INFLAMMATORY AGENTS Anti-inflammatory Agents hydrocortisone 1 % External Lotion OTC Corticosteroids ANTI-ITCH INTENSIVE HEALING OTC beta hc OTC COLOCORT 1 CORTIZONE-10 OTC CORTIZONE-10 DIABETICS SKIN OTC CORTIZONE-10 ECZEMA OTC CORTIZONE-10 PLUS OTC CORTIZONE-10/ALOE 1 % External Cream OTC DERMAREST ECZEMA OTC fluocinolone acetonide 0.01 % Otic Oil 1 DERMOTIC hydrocortisone 1 % External Lotion OTC hydrocortisone 1 % External Lotion OTC hydrocortisone (perianal) 2.5 % External Cream 1 ANUSOL HC hydrocortisone anti-itch OTC ALA-CORT hydrocortisone intensive heal OTC ALA-CORT hydrocortisone plus OTC ALA-CORT hydrocortisone-acetic acid 1 ACETASOL HC kls hydrocortisone plus OTC CORTIZONE 10 kp hydrocortisone OTC ALA-CORT kp hydrocortisone-aloe OTC MONISTAT SOOTHING CARE ITCH OTC NOBLE FORMULA HC 1 % External Cream OTC QL(0.72 GM per 1 ORALONE 1 days) prednisolone acetate p-f 1 PRED FORTE PREPARATION H 1 % External Cream OTC PROCTO-MED HC 2.5 % External Cream 1

PROCTO-PAK 1 % External Cream 1 PROCTOSOL HC 2.5 % External Cream 1 PROCTOZONE-HC 2.5 % External Cream 1 scalp relief maximum strength OTC triamcinolone acetonide 0.1 % KENALOG IN QL(0.72 GM per 1 Mouth/Throat Paste 1 ORABASE days) TRIDESILON 1 VANICREAM HC MAXIMUM STRENGTH OTC Eent Anti-inflammatory Agents, Misc RESTASIS MULTIDOSE 2 Mast-cell Stabilizers cromolyn sodium 100 mg/5ml Oral Concentrate 1 GASTROCROM cromolyn sodium 20 mg/2ml Inhalation Nebulization Solution 1 INTAL ANTIMANIC AGENTS Antimanic Agents lithium 1 lithium carbonate 150 mg Oral Capsule, 600 mg Oral Capsule 1 lithium carbonate 300 mg Oral Capsule 1 ESKALITH lithium carbonate 300 mg Oral Tablet 1 LITHOBID lithium carbonate er 450 mg Oral Tablet Extended Release 1 ESKALITH CR lithium carbonate er 300 mg Oral Tablet Extended Release 1 LITHOBID ANTIMYCOBACTERIALS Antimycobacterials, Miscellaneous dapsone 100 mg Oral Tablet, 25 mg Oral Tablet 1 Antituberculosis Agents ethambutol hcl 100 mg Oral Tablet, 400 mg Oral Tablet 1 MYAMBUTOL isoniazid 100 mg Oral Tablet, 300 mg Oral Tablet 1 isoniazid 50 mg/5ml Oral Syrup 1

pretomanid 2 PA pyrazinamide 500 mg Oral Tablet 1 rifabutin 1 MYCOBUTIN rifampin 150 mg Oral Capsule, 300 mg Oral Capsule 1 RIFADIN ANTINEOPLASTIC AGENTS Antineoplastic Agents ALKERAN 2 mg Oral Tablet 2 bexarotene 75 mg Oral Capsule 1 TARGRETIN SP, PA carboplatin 150 mg/15ml Intravenous Solution, 50 mg/5ml Intravenous Solution, 600 mg/60ml Intravenous Solution 2 PARAPLATIN carboplatin 450 mg/45ml Intravenous Solution 2 PARAPLATIN SP cyclophosphamide 25 mg Oral Capsule, 50 mg Oral Capsule 1 SP EMCYT 2 SP etoposide 50 mg Oral Capsule 1 SP flutamide 1 EULEXIN QL(6 EA per 1 days) HYCAMTIN 0.25 mg Oral Capsule, 1 mg Oral Capsule 2 SP INQOVI 2 PA INTRON A 10000000 unit Injection Solution Reconstituted, 18000000 unit Injection Solution Reconstituted, 50000000 unit Injection Solution Reconstituted 2 SP INTRON A 10000000 unit/ml Injection Solution, 6000000 unit/ml Injection Solution 2 SP LEUKERAN 2 SP LYSODREN 2 SP MATULANE 2 SP megestrol acetate 40 mg Oral Tablet 1 MEGACE megestrol acetate 40 mg/ml Oral Suspension, 400 mg/10ml Oral Suspension 1 MEGACE melphalan 1 ALKERAN mercaptopurine 50 mg Oral Tablet 1 PURINETHOL

MYLERAN 2 SP SP, QL(2 EA per 1 NILANDRON 2 days) SP, QL(2 EA per 1 nilutamide 1 NILANDRON days) SYLATRON 2 SP, PA ANTIPARKINSONIAN AGENTS Dopamine Receptor Agonists cabergoline 1 DOSTINEX ANTIPROTOZOALS Antiprotozoals, Miscellaneous atovaquone 750 mg/5ml Oral Suspension 1 MEPRON QL(20 ML per 1 days) MEPRON 2 QL(20 ML per 1 days) ANTIPRURITICS AND LOCAL ANESTHETICS Antipruritics And Local Anesthetics hemorrhoidal relief 1 lidocaine-hydrocortisone ace 2-2 % Rectal Kit, 3-1 % Rectal Kit, 3-2.5 % Rectal Kit 1 lidopac 1 lidopin 3 % External Cream 1 phenazopyridine hcl 100 mg Oral Tablet, 200 mg Oral Tablet 1 pramoxine hcl (perianal) OTC PRIZOTRAL-II 1 PROCTOFOAM HC 1-1 % External Foam 2 ANTISENSE OLIGONUCLEOTIDES Antisense Oligonucleotides TEGSEDI 2 SP, PA ANTITHROMBOTIC AGENTS Anticoagulants BEVYXXA 80 mg Oral Capsule 2 PA heparin sodium (porcine) 1000 unit/ml Injection Solution, 10000 unit/ml Injection Solution, 20000 unit/ml Injection Solution, 5000 unit/0.5ml Injection Solution Prefilled Syringe, 5000 unit/ml Injection Solution 1 ¹You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document Geisinger Family Supplemental Formulary Page 25 of 83 Effective Date: 9/22/2021 Drug Reference Name Drug Name Requirements/Limits1 Tier

heparin sodium (porcine) pf 1 Antithrombotic Agents, Misc CABLIVI 2 SP, PA Platelet-aggregation Inhibitors cilostazol 1 PLETAL QL(2 EA per 1 days) Platelet-reducing Agents anagrelide hcl 1 mg Oral Capsule 1 AGRYLIN anagrelide hcl 0.5 mg Oral Capsule 1 AGRYLIN SP ANTITOXINS AND IMMUNE GLOBULINS Antitoxins And Immune Globulins WINRHO SDF 2 SP ANTITUSSIVES Antitussives benzonatate 100 mg Oral Capsule, 200 mg Oral Capsule 1 QL(30 ML per 1 days), HYCODAN 1 AL(Max 20 years) hydrocod polst-cpm polst er 10-8 mg/5ml Oral Suspension Extended TUSSIONEX QL(10 ML per 1 days), Release 1 PENNKINETIC EXT AL(Max 20 years) hydrocodone-homatropine 5-1.5 QL(6 EA per 1 days), mg Oral Tablet 1 AL(Max 20 years) hydrocodone-homatropine 5-1.5 QL(30 ML per 1 days), mg/5ml Oral Syrup 1 AL(Max 20 years) QL(30 ML per 1 days), hydromet 1 AL(Max 20 years) QL(30 ML per 1 days), promethazine-codeine 1 AL(Min 18 years) ANTIULCER AGENTS AND ACID SUPPRESSANTS Histamine H2-antagonists cimetidine 200 OTC TAGAMET Prostaglandins misoprostol 100 mcg Oral Tablet, 200 mcg Oral Tablet 1 CYTOTEC Protectants sucralfate 1 gm/10ml Oral Suspension 1 sucralfate 1 gm Oral Tablet 1 CARAFATE ANXIOLYTICS, SEDATIVES, AND HYPNOTICS Anxiolytics, Sedatives, & Hypnotics Misc sleep tabs OTC ¹You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document Geisinger Family Supplemental Formulary Page 26 of 83 Effective Date: 9/22/2021 Drug Reference Name Drug Name Requirements/Limits1 Tier

ASTRINGENTS Astringents DRYSOL 2 XERAC AC 2 zinc oxide 20 % External Ointment, 25 % External Paste OTC zinc oxide 25 % External Ointment OTC DELAZINC AUTONOMIC DRUGS, MISCELLANEOUS Autonomic Drugs, Miscellaneous KLS QUIT2 2 mg Mouth/Throat Gum OTC QL(24 EA per 1 days) CARDIAC DRUGS Antiarrhythmic Agents amiodarone hcl 200 mg Oral Tablet 1 CORDARONE amiodarone hcl 100 mg Oral Tablet, 400 mg Oral Tablet 1 PACERONE disopyramide phosphate 1 NORPACE dofetilide 1 TIKOSYN QL(2 EA per 1 days) flecainide acetate 1 TAMBOCOR mexiletine hcl 150 mg Oral Capsule, 200 mg Oral Capsule, 250 mg Oral Capsule 1 MEXITIL PACERONE 1 propafenone hcl 1 RYTHMOL quinidine sulfate 200 mg Oral Tablet, 300 mg Oral Tablet 1 Cardiotonic Agents DIGITEK 1 digox 1 LANOXIN digoxin 125 mcg Oral Tablet, 250 mcg Oral Tablet 1 LANOXIN digoxin 0.05 mg/ml Oral Solution 1 LANOXIN CARIOSTATIC AGENTS Cariostatic Agents DENTA 5000 PLUS 1 DENTAGEL 1 FLORIVA 0.25-400 mg-unit/ml Oral Liquid OTC FLUORABON OTC

fluoritab 1.1 (0.5 F) mg Oral Tablet Chewable, 2.2 (1 F) mg Oral Tablet Chewable OTC FLURA-DROPS OTC LUDENT 0.55 (0.25 F) mg Oral Tablet Chewable, 1.1 (0.5 F) mg Oral Tablet Chewable, 2.2 (1 F) mg Oral Tablet Chewable OTC sf 1 sf 5000 plus 1 sodium fluoride 1.1 % Dental Cream, 1.1 % Dental Gel 1 sodium fluoride 0.55 (0.25 F) mg Oral Tablet Chewable, 1.1 (0.5 F) mg Oral Tablet Chewable, 2.2 (1 F) mg Oral Tablet Chewable OTC sodium fluoride 1.1 (0.5 F) mg/ml Oral Solution OTC sodium fluoride 5000 plus 1 sodium fluoride 5000 ppm 1.1 % Dental Cream 1 sodium fluoride 5000 ppm 1.1 % Dental Paste 1 CATHARTICS AND LAXATIVES Cathartics And Laxatives bisacodyl 10 mg Rectal Suppository OTC bisacodyl ec OTC bisacodyl laxative OTC calcium polycarbophil 625 mg Oral Tablet OTC citrate of magnesia Oral Solution, 1.745 gm/30ml Oral Solution OTC CLENPIQ 2 diocto 60 mg/15ml Oral Syrup OTC docuzen OTC DOK PLUS OTC ducodyl OTC easy-lax plus OTC fiber laxative OTC fiber-lax OTC

GAVILYTE-C 1 GAVILYTE-G 1 GAVILYTE-N WITH FLAVOR PACK 1 gentle laxative OTC glycerin (adult) 2 gm Rectal Suppository OTC glycerin (child) OTC glycerin adult OTC goodsense magnesium citrate OTC goodsense stimulant laxative OTC hm fiber 0.52 gm Oral Capsule, 500 mg Oral Tablet OTC hm magnesium citrate OTC hm senna-s OTC hm stool softener/laxative OTC kls fiber-tabs OTC laxacin OTC laxative 10 mg Rectal Suppository OTC magnesium citrate 1.745 gm/30ml Oral Solution OTC milk of magnesia 7.75 % Oral Suspension OTC milk of magnesia concentrate OTC PEDIA-LAX 1 gm Rectal Suppository OTC peg 3350/electrolytes 1 peg 3350-kcl-na bicarb-nacl 1 NULYTELY peg-3350/electrolytes 1 GOLYTELY polyethylene glycol 3350 17 gm Oral Packet 1 MIRALAX polyethylene glycol 3350 17 gm/scoop Oral Powder 1 MIRALAX senexon-s OTC SENEXON-S OTC senna 8.8 mg/5ml Oral Liquid OTC senna plus 8.6-50 mg Oral Tablet OTC senna s OTC senna-docusate sodium OTC senna-plus OTC senna-s OTC

senna-time s OTC sennosides-docusate sodium 8.6- 50 mg Oral Tablet OTC silace 60 mg/15ml Oral Syrup OTC SOLUBLE FIBER THERAPY OTC stimulant laxative 8.6-50 mg Oral Tablet OTC stool softener plus laxative OTC stool softener/laxative 50-8.6 mg Oral Tablet OTC TRILYTE 1 vegetable lax+stool softener OTC CENTRAL NERVOUS SYSTEM AGENTS, MISC Central Nervous System Agents, Misc acamprosate calcium 1 CAMPRAL riluzole 50 mg Oral Tablet 1 RILUTEK QL(2 EA per 1 days) SP, PA, QL(20 ML per TIGLUTIK 2 1 days) CONTRACEPTIVES Contraceptives ECONTRA EZ OTC ECONTRA ONE-STEP OTC levonorgestrel 1.5 mg Oral Tablet OTC MY WAY OTC NEXT CHOICE ONE DOSE OTC OPCICON ONE-STEP OTC OPTION 2 OTC CYSTIC FIBROSIS TRANSMEMBRANE CONDUCTANCE REGULATOR MODULATORS Cystic Fibrosis Transmembrane Conductance Regulator (cftr) Correctors ORKAMBI 100-125 mg Oral SP, PA, QL(2 EA per 1 Packet, 150-188 mg Oral Packet 2 days) ORKAMBI 100-125 mg Oral Tablet, SP, PA, QL(4 EA per 1 200-125 mg Oral Tablet 2 days) SP, PA, QL(2 EA per 1 SYMDEKO 2 days) TRIKAFTA 50-25-37.5 & 75 mg Oral Tablet Therapy Pack 2 PA TRIKAFTA 100-50-75 & 150 mg SP, PA, QL(3 EA per 1 Oral Tablet Therapy Pack 2 days) Cystic Fibrosis Transmembrane Conductance Regulator (cftr) Potentiators

SP, PA, QL(2 EA per 1 KALYDECO 2 days) DENTAL AGENTS Dental Agents sodium fluoride 5000 sensitive 1 DEVICES Devices 1st tier unifine pentips 2 1st tier unifine pentips plus 2 1st tier unilet comfortouch 2 ABOUTTIME PEN NEEDLE 2 ACCU-CHEK FASTCLIX LANCET 2 ACCU-CHEK FASTCLIX LANCETS 2 ACCU-CHEK MULTICLIX LANCET DEV 2 ACCU-CHEK MULTICLIX LANCETS 2 ACCU-CHEK SAFE-T PRO LANCETS 2 ACCU-CHEK SOFT TOUCH LANCETS 2 ACCU-CHEK SOFTCLIX LANCET DEV 2 ACCU-CHEK SOFTCLIX LANCETS 2 acti-lance 28g 2 acti-lance lite lancets 28g 2 acti-lance special lancets 17g 2 acti-lance universal 23g 2 adjustable lancing device 2 QL(1 EA per 1 days) adult mask large 2 QL(2 EA per 365 days) advanced mobile lancet 2 ADVOCATE INSULIN PEN NEEDLES 2 ADVOCATE INSULIN SYRINGE 2 ADVOCATE LANCETS 2 ADVOCATE LANCETS 30G 2 ADVOCATE LANCING DEVICE 2 ADVOCATE RAPID-SAFE LANCING 2

ADVOCATE SAFETY LANCETS 2 ADVOCATE SAFETY LANCETS 26G 2 AGAMATRIX ULTRA-THIN LANCETS 2 aimsco twist lancets 32g 2 AIMSCO TWIST LANCETS 33G 2 alternate site lancing device 2 aqua lance adjustable lancing 2 AQUALANCE LANCETS 30G 2 assure comfort lancets 28g 2 ASSURE HAEMOLANCE PLUS HIGH 2 ASSURE HAEMOLANCE PLUS LOW 2 ASSURE HAEMOLANCE PLUS MICRO 2 ASSURE HAEMOLANCE PLUS NORMAL 2 ASSURE HAEMOLANCE PLUS PED 2 ASSURE ID INSULIN SAFETY SYR 2 ASSURE ID SAFETY PEN NEEDLES 2 ASSURE LANCE LANCETS 2 ASSURE LANCE LANCETS 21G 2 ASSURE LANCE PLUS SAFETY 25G 2 ASSURE LANCE PLUS SAFETY 30G 2 ASSURE LANCE SAFETY LANCET 28G 2 ASSURE LANCETS 2 aurora lancet super thin 30g 2 aurora lancet thin 23g 2 aurora pen needles 2 aurora unifine pentips 2 AUTO-LANCET 2 AUTO-LANCET MINI 2 AUTOLET LANCING DEVICE 2 BD AUTOSHIELD 2 ¹You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document Geisinger Family Supplemental Formulary Page 32 of 83 Effective Date: 9/22/2021 Drug Reference Name Drug Name Requirements/Limits1 Tier

BD AUTOSHIELD DUO 2 BD ECLIPSE SYRINGE 30G X 1/2" 1 ml Miscellaneous 2 BD INSULIN SYR ULTRAFINE II 2 BD INSULIN SYRINGE 2 BD INSULIN SYRINGE HALF- UNIT 2 BD INSULIN SYRINGE MICROFINE 2 BD INSULIN SYRINGE U/F 2 BD INSULIN SYRINGE U/F 1/2UNIT 2 BD INSULIN SYRINGE U-500 2 BD INSULIN SYRINGE ULTRAFINE 2 BD LANCET ULTRAFINE 30G 2 BD LANCET ULTRAFINE 33G 2 BD LUER-LOK SYRINGE 20G X 1" 1 ml Miscellaneous 2 BD MICROTAINER LANCETS 2 BD PEN NEEDLE MICRO U/F 2 BD PEN NEEDLE MINI U/F 2 BD PEN NEEDLE NANO 2ND GEN 2 BD PEN NEEDLE NANO U/F 2 BD PEN NEEDLE ORIGINAL U/F 2 BD PEN NEEDLE SHORT U/F 2 BD SAFETYGLIDE INSULIN SYRINGE 2 BD SAFETYGLIDE NEEDLE 27G X 5/8" Miscellaneous 2 BD SAFETYGLIDE SYRINGE/NEEDLE 27G X 5/8" 1 ml Miscellaneous 2 BD SAFETY-LOK INSULIN SYRINGE 2 BD SYRINGE 50 ML Miscellaneous 2 BD VEO INSULIN SYR U/F 1/2UNIT 2 BD VEO INSULIN SYRINGE U/F 2 CARDIOCOM LANCING DEVICE 2 CAREFINE PEN NEEDLES 2 ¹You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document Geisinger Family Supplemental Formulary Page 33 of 83 Effective Date: 9/22/2021 Drug Reference Name Drug Name Requirements/Limits1 Tier

careone advanced lancing dev 2 careone insulin syringe 2 CAREONE LANCET SUPER THIN 30G 2 careone lancet thin 23g 2 careone unifine pentips 2 careone unifine pentips plus 29G X 12MM Miscellaneous, 31G X 5 MM Miscellaneous, 31G X 6 MM Miscellaneous, 31G X 8 MM Miscellaneous, 32G X 4 MM Miscellaneous 2 CARESENS LANCETS 2 CARETOUCH HYPODERMIC NEEDLE 26G X 1" Miscellaneous 2 CARETOUCH INSULIN SYRINGE 2 CARETOUCH LANCING/EJECTOR 2 CARETOUCH PEN NEEDLES 31G X 5 MM Miscellaneous, 31G X 6 MM Miscellaneous, 31G X 8 MM Miscellaneous, 32G X 4 MM Miscellaneous, 32G X 5 MM Miscellaneous 2 CARETOUCH SAFETY LANCETS 2 CARETOUCH SAFETY LANCETS 26G 2 CARETOUCH TWIST LANCETS 28G 2 CARETOUCH TWIST LANCETS 30G 2 CARETOUCH TWIST LANCETS 33G 2 CLEANLET LANCETS 28G 2 CLEVER CHEK LANCETS 2 CLEVER CHOICE COMFORT EZ 2 CLEVER CHOICE LANCETS 21G 2 CLEVER CHOICE LANCETS 23G 2 CLEVER CHOICE LANCETS 28G 2 clickfine pen needles 31G X 6 MM Miscellaneous, 31G X 8 MM 2

Miscellaneous, 32G X 4 MM Miscellaneous CLICKFINE PEN NEEDLES 2 COAGUCHEK LANCETS 2 COMFORT ASSIST INSULIN SYRINGE 2 comfort assured lancets 28g 2 comfort assured lancets 33g 2 COMFORT EZ INSULIN SYRINGE 2 COMFORT EZ MICRO PEN NEEDLES 2 COMFORT EZ PEN NEEDLES 2 COMFORT EZ SHORT PEN NEEDLES 2 comfort lancets 2 COMFORT TOUCH INSULIN PEN NEED 31G X 4 MM Miscellaneous, 31G X 5 MM Miscellaneous, 31G X 6 MM Miscellaneous, 31G X 8 MM Miscellaneous, 32G X 4 MM Miscellaneous, 32G X 5 MM Miscellaneous, 32G X 6 MM Miscellaneous, 32G X 8 MM Miscellaneous 2 CONTOUR CONTROL Normal In Vitro Liquid 2 CONTOUR NEXT CONTROL Normal In Vitro Solution 2 DIATHRIVE LANCET ULTRA THIN 30 2 DIATHRIVE LANCETS 2 DIATHRIVE LANCING DEVICE 2 DIATHRIVE PEN NEEDLE 2 DROPLET INSULIN SYRINGE 2 DROPLET LANCETS ULTRA THIN 30G 2 DROPLET LANCING DEVICE 2 DROPLET MICRON 2 DROPLET PEN NEEDLES 2 dropsafe safety pen needles 2 easy comfort insulin syringe 2 easy comfort lancets 2 ¹You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document Geisinger Family Supplemental Formulary Page 35 of 83 Effective Date: 9/22/2021 Drug Reference Name Drug Name Requirements/Limits1 Tier

easy comfort lancets twist top 2 easy comfort pen needles 2 easy glide pen needles 2 easy mini eject lancing device 2 easy mini lancing device 2 EASY TOUCH FLIPLOCK INSULIN SY 2 EASY TOUCH INSULIN BARRELS 1ML 2 EASY TOUCH INSULIN SAFETY SYR 2 EASY TOUCH INSULIN SYRINGE 2 EASY TOUCH LANCETS 21G 2 EASY TOUCH LANCETS 23G 2 EASY TOUCH LANCETS 26G 2 EASY TOUCH LANCETS 28G 2 EASY TOUCH LANCETS 28G/TWIST 2 EASY TOUCH LANCETS 30G 2 EASY TOUCH LANCETS 30G/TWIST 2 EASY TOUCH LANCETS 32G 2 EASY TOUCH LANCETS 32G/TWIST 2 EASY TOUCH LANCETS 33G/TWIST 2 EASY TOUCH LANCING DEVICE 2 EASY TOUCH PEN NEEDLES 2 EASY TOUCH SAFETY LANCETS 21G 2 EASY TOUCH SAFETY LANCETS 23G 2 EASY TOUCH SAFETY LANCETS 26G 2 EASY TOUCH SAFETY LANCETS 28G 2 EASY TOUCH SAFETY PEN NEEDLES 2 EASY TOUCH SHEATHLOCK SYRINGE 29G X 1/2" 1 ml Miscellaneous, 30G X 1/2" 1 ml Miscellaneous, 30G X 5/16" 1 ml 2 ¹You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document Geisinger Family Supplemental Formulary Page 36 of 83 Effective Date: 9/22/2021 Drug Reference Name Drug Name Requirements/Limits1 Tier

Miscellaneous, 31G X 5/16" 1 ml Miscellaneous EASY TWIST & CAP LANCETS 2 elite-thin insulin syringe 2 EMBRACE LANCETS ULTRA THIN 30G 2 EXEL COMFORT POINT INSULIN SYR 2 EXEL COMFORT POINT PEN NEEDLE 2 E-Z JECT LANCET MICRO-THIN 33G 2 E-Z JECT LANCET SUPER THIN 30G 2 E-Z JECT LANCETS 2 E-Z JECT LANCETS 21G 2 E-Z JECT LANCETS THIN 26G 2 EZ SMART BLOOD GLUCOSE LANCETS 2 EZ-LETS LANCETS 21G 2 EZ-LETS LANCETS 26G 2 EZ-LETS LANCETS 28G 2 EZ-LETS LANCETS 30G 2 FIFTY50 PEN NEEDLES 2 FIFTY50 SAFETY SEAL LANCETS 2 FIFTY50 SUPERIOR COMFORT SYR 2 FIFTY50 UNILET LANCETS 33G 2 FINE 30 2 FINGERSTIX LANCETS 2 FORA LANCETS 2 FORA LANCING DEVICE 2 FORA V10/V12/D10/D20 TEST 2 FREESTYLE LANCETS 2 FREESTYLE LIBRE 14 DAY READER 2 PA FREESTYLE LIBRE 14 DAY PA, QL(0.15 EA per 1 SENSOR 2 days) FREESTYLE LIBRE 2 READER 2 PA PA, QL(0.15 EA per 1 FREESTYLE LIBRE 2 SENSOR 2 days) FREESTYLE LIBRE READER 2 PA ¹You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document Geisinger Family Supplemental Formulary Page 37 of 83 Effective Date: 9/22/2021 Drug Reference Name Drug Name Requirements/Limits1 Tier

FREESTYLE LIBRE SENSOR PA, QL(0.15 EA per 1 SYSTEM 2 days) FREESTYLE PRECISION INS SYR 2 FREESTYLE UNISTICK II LANCETS 2 GENTEEL BUTTERFLY TOUCH LANCET 2 GENTEEL LANCING DEVICE (GOLD) 2 GENTEEL LANCING DEVICE(PLATNM) 2 GENTEEL LANCING DEVICE(SILVER) 2 GENTEEL LANCING KIT (BLUE) 2 GENTLE-LET GP LANCETS 2 GENTLE-LET LANCETS 2 global ease inject pen needles 2 global easy glide insulin syr 2 global easy glide pen needles 2 global inject ease insulin syr 2 global inject ease lancets 28g 2 global inject ease lancets 30g 2 global insulin syringes 2 global lancing device 2 QL(1 EA per 1 days) GLUCOCOM LANCETS 28G 2 GLUCOCOM LANCETS 30G 2 GLUCOCOM LANCETS 33G 2 GLUCOPRO INSULIN SYRINGE 2 gnp insulin syringes 28gx1/2" 2 gnp insulin syringes 29gx1/2" 29G X 1/2" 0.5 ml Miscellaneous 2 gnp insulin syringes 30gx5/16" 2 gnp insulin syringes 31gx5/16" 2 gnp sterile lancets 28g 2 gnp sterile lancets 30g 2 gnp sterile lancets 33g 2 GOJJI LANCING DEVICE/CLEAR CAP 2 QL(1 EA per 1 days) GOJJI STERILE LANCETS 2 goodsense clickfine pen needle 2

goodsense color lancets 33g 2 goodsense lancets 26g univ 2 goodsense lancets 30g 2 goodsense lancets 30g univ 2 goodsense lancets 33g 2 goodsense lancets 33g univ 2 goodsense lancing device 2 GOODSENSE PEN NEEDLE PENFINE 2 HEALTH CARE LANCING DEVICE 2 healthwise insulin syr/needle 2 healthwise micron pen needles 2 healthwise mini pen needles 2 healthwise pen needles 2 healthwise short pen needles 2 healthwise unifine pentips 2 healthy accents lancing device 2 healthy accents unifine pentip 2 healthy accents unilet lancets 2 HM ULTICARE INSULIN SYRINGE 2 HM ULTICARE SHORT PEN NEEDLES 2 HYPOLANCE AST LANCING 2 HY-VEE LANCETS 2 hy-vee thin lancets 2 IN TOUCH LANCING DEVICE 2 IN TOUCH STERILE LANCETS 30G 2 insulin syringe 2 insulin syringe/needle 2 insulin syringe-needle u-100 29G X 1/2" 0.5 ml Miscellaneous, 29G X 1/2" 1 ml Miscellaneous, 30G X 5/16" 0.3 ml Miscellaneous, 30G X 5/16" 0.5 ml Miscellaneous, 30G X 5/16" 1 ml Miscellaneous, 31G X 1/4" 0.3 ml Miscellaneous, 31G X 1/4" 0.5 ml Miscellaneous, 31G X 1/4" 1 ml Miscellaneous, 31G X 5/16" 0.3 ml Miscellaneous, 31G X 5/16" 0.5 ml Miscellaneous, 31G X 5/16" 1 ml Miscellaneous 2 ¹You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document Geisinger Family Supplemental Formulary Page 39 of 83 Effective Date: 9/22/2021 Drug Reference Name Drug Name Requirements/Limits1 Tier

insupen pen needles 2 INSUPEN SENSITIVE 2 INSUPEN ULTRAFIN 2 kinney lancets 2 kinney thin lancets 2 kinray insulin syringe 2 kmart valu insulin syringe 29g 2 kmart valu insulin syringe 30g 2 lancet device 2 lancet device with ejector 2 QL(1 EA per 1 days) lancet transporter case 2 lancets 2 lancets 28g 2 lancets 30g 2 lancets 33g 2 lancets micro thin 33g 2 lancets super thin 28g 2 lancets thin 2 LANCETS ULTRA FINE 2 LANCETS ULTRA THIN 2 lancets ultra thin 30g 2 lancing device 2 lancing device 2 QL(30 EA per 30 days) LANZO 2 leader advanced lancing device 2 QL(1 EA per 1 days) leader insulin syringe 2 LEADER UNIFINE PENTIPS 2 LEADER UNIFINE PENTIPS PLUS 2 LIBERTY MEDICAL LANCETS 2 LIBERTY MINI LANCING DEVICE 2 LIFESCAN UNISTIK 2 2 LIFESCAN UNISTIK II LANCETS 2 lite touch lancets 2 LITE TOUCH LANCING PEN 2 LITETOUCH INSULIN SYRINGE 2 LITETOUCH LANCETS 2 LITETOUCH PEN NEEDLES 2 live better adv lancing device 2 live better lancet super thin 2 live better lancet ultra thin 2 longs insulin syringe 2

longs lancets standard 2 longs lancets thin 2 longs lancets ultra thin 2 MAGELLAN INSULIN SAFETY SYR 2 MARATHON MEDICAL PENTIPS 2 MAXICOMFORT II PEN NEEDLE 2 MAXI-COMFORT INSULIN SYRINGE 2 MAXI-COMFORT SAFETY PEN NEEDLE 2 MAXICOMFORT SYR 27G X 1/2" 2 medic insulin syringe 2 medichoice safety lancet 2 medichoice safety lancet extra 2 medichoice safety lancet norm 2 medicine shoppe pen needles 2 MEDISENSE THIN LANCETS 2 MEDLANCE EXTRA 21G 2 MEDLANCE LITE 25G 2 MEDLANCE PLUS EXTRA 21G 2 MEDLANCE PLUS LANCETS 2 MEDLANCE PLUS LITE 25G 2 MEDLANCE PLUS SPECIAL 0.8MM 2 MEDLANCE PLUS SUPERLITE 30G 2 MEDLANCE PLUS UNIVERSAL 21G 2 MEDLANCE UNIVERSAL 21G 2 MEIJER LANCETS 2 MEIJER LANCETS THIN 2 MEIJER LANCETS UNIVERSAL 21G 2 MEIJER LANCETS UNIVERSAL 30G 2 MEIJER LANCETS UNIVERSAL 33G 2 MEIJER SUPER THIN LANCETS 2 MICRODOT PEN NEEDLE 2 MICROLET LANCETS 2

MICROLET NEXT LANCING DEVICE 2 mini lancing device 2 mm insulin syringe/needle 2 MM LANCING DEVICE 2 QL(1 EA per 1 days) MM PEN NEEDLES 2 MM TWIST LANCETS 2 MONOJECT INSULIN SYRINGE 2 MONOJECT ULTRA COMFORT SYRINGE 2 MONOLET LANCETS 2 MONOLET OPD LANCETS 2 MONOLETTOR SAFETY LANCETS 2 mpd safety lancet 21g 2 mpd safety lancet 23g 2 mpd safety lancet 28g 2 ms insulin syringe 2 multi-lancet device 2 MULTI-LANCET DEVICE 2 2 MYGLUCOHEALTH LANCETS 30G 2 NOVA SAFETY LANCETS 23G 2 NOVA SAFETY LANCETS 28G 2 NOVA SUREFLEX LANCETS 2 NOVA SUREFLEX LANCING DEVICE 2 NOVOFINE AUTOCOVER PEN NEEDLE 2 NOVOFINE PEN NEEDLE 2 NOVOFINE PLUS PEN NEEDLE 2 NOVOTWIST PEN NEEDLE 2 OMNIPOD 5 PACK 2 OMNIPOD DASH 5 PACK PODS 2 ON CALL LANCETS 2 ON CALL LANCING DEVICE 2 ON CALL PLUS LANCETS 2 ON CALL PLUS LANCING DEVICE 2 ONETOUCH CLUB LANCETS FINE PT 2

ONETOUCH DELICA LANCETS 30G 2 ONETOUCH DELICA LANCETS 33G 2 ONETOUCH DELICA LANCETS FINE 2 ONETOUCH DELICA LANCING DEV 2 QL(1 EA per 1 days) ONETOUCH DELICA PLUS LANCET30G 2 ONETOUCH DELICA PLUS LANCET33G 2 ONETOUCH DELICA PLUS LANCING 2 QL(1 EA per 1 days) ONETOUCH DELICA SAFETY LANCING 2 ONETOUCH FINEPOINT LANCETS 2 ONETOUCH SURESOFT LANCING DEV 2 QL(1 EA per 1 days) ONETOUCH ULTRA CONTROL 2 ONETOUCH ULTRASOFT LANCETS 2 ONETOUCH VERIO In Vitro Solution, High In Vitro Solution 2 OPTICHAMBER DIAMOND 2 QL(2 EA per 365 days) OPTICHAMBER DIAMOND-LG MASK 2 QL(2 EA per 365 days) OPTICHAMBER DIAMOND-MD MASK 2 QL(2 EA per 365 days) OPTICHAMBER DIAMOND-SM MASK 2 QL(2 EA per 365 days) pc lancets super thin 30g 2 pc unifine pentips 29G X 12MM Miscellaneous 2 pediatric medium mask 2 pediatric small mask 2 pen needles 2 pen needles 1/2" 2 pen needles 3/16" 2 pen needles 5/16" 2 PENTIPS 2 ¹You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document Geisinger Family Supplemental Formulary Page 43 of 83 Effective Date: 9/22/2021 Drug Reference Name Drug Name Requirements/Limits1 Tier

PERFECT LANCETS 28G 2 PERFECT LANCETS 30G 2 PHARMACIST CHOICE LANCETS 2 PHARMACY COUNTER LANCETS 2 pip lancets 28g 2 pip lancets 30g 2 PRECISION SUREDOSE PLUS SYR 2 PRECISION SURE-DOSE SYRINGE 2 PRECISION THINS GP LANCETS 2 preferred plus insulin syringe 2 preferred plus lancets colored 2 preferred plus lancets thin 2 preferred plus unifine pentips 31G X 5 MM Miscellaneous, 31G X 6 MM Miscellaneous, 31G X 8 MM Miscellaneous, 32G X 4 MM Miscellaneous 2 pressure activat safety lancet 2 PREVENT SAFETY PEN NEEDLES 2 PRO COMFORT INSULIN SYRINGE 2 pro comfort lancets 30g 2 pro comfort lancets 31g 2 pro comfort pen needles 2 PRODIGY INSULIN SYRINGE 2 PRODIGY LANCETS 28G 2 PRODIGY LANCING DEVICE 2 PRODIGY SAFETY LANCETS 26G 2 PRODIGY TWIST TOP LANCETS 28G 2 PSS SELECT GP LANCETS 2 PSS SELECT SAFETY LANCETS 2 pure comfort pen needle 2 push button safety lancets 2 push button safety lancets 28g 2 px lancets microthin 33g 2 READYLANCE SAFETY LANCETS 2 reality insulin syringe 2

reality lancets 2 reality trigger lancets 2 RELION INSULIN SYRINGE 29G X 1/2" 0.3 ml Miscellaneous, 29G X 1/2" 0.5 ml Miscellaneous, 29G X 1/2" 1 ml Miscellaneous, 30G X 5/16" 0.3 ml Miscellaneous, 30G X 5/16" 0.5 ml Miscellaneous, 30G X 5/16" 1 ml Miscellaneous, 31G X 15/64" 0.3 ml Miscellaneous, 31G X 15/64" 0.5 ml Miscellaneous, 31G X 15/64" 1 ml Miscellaneous, 31G X 5/16" 0.3 ml Miscellaneous, 31G X 5/16" 0.5 ml Miscellaneous, 31G X 5/16" 1 ml Miscellaneous 2 RELI-ON INSULIN SYRINGE 2 RELION LANCET DEVICES 30G 2 QL(1 EA per 1 days) RELION LANCETS MICRO-THIN 33G 2 RELION LANCETS STANDARD 21G 2 RELION LANCETS THIN 26G 2 RELION LANCETS ULTRA-THIN 30G 2 RELION LANCING DEVICE Kit 2 RELION LANCING DEVICE Miscellaneous 2 QL(1 EA per 1 days) RELION MINI PEN NEEDLES 2 RELION PEN NEEDLES 2 RELION SHORT PEN NEEDLES 2 RELION ULTRA THIN LANCETS 30G 2 RELION ULTRA THIN PLUS LANCETS 2 REXALL LANCETS ULTRA THIN 30G 2 RIGHTEST GD500 LANCING DEVICE 2 RIGHTEST GL300 LANCETS 2 SAFESNAP INSULIN SYRINGE 2 SAFE-T-LANCE 2 safety insulin syringes 2 ¹You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document Geisinger Family Supplemental Formulary Page 45 of 83 Effective Date: 9/22/2021 Drug Reference Name Drug Name Requirements/Limits1 Tier

safety lancet 21g/pressure act 2 safety lancet 23g/pressure act 2 safety lancet 28g/pressure act 2 safety lancet 30g/pressure act 2 SAFETY LANCETS 2 SAFETY LANCETS 21G 2 safety lancets 28g 2 SAFETY LET LANCETS 2 SAFETY SEAL LANCETS 2 saps health twist top lancets 2 saps twist top lancets 2 sapscare twist top lancets 2 SECURESAFE INSULIN SYRINGE 2 select-lite device/lancets 2 select-lite lancing device 2 SHOPKO AUTOLET LANCING DEVICE 2 SHOPKO ON-THE-GO LANCETS 30G 2 SHOPKO UNIFINE PENTIPS 2 SHOPKO UNIFINE PENTIPS PLUS 2 SHOPKO UNILET LANCETS 28G 2 SHOPKO UNILET LANCETS 30G 2 side button safety lancet 2 SIMPLE DIAGNOSTICS LANCING DEV 2 QL(1 EA per 1 days) SMART DIABETES VANTAGE LANCING 2 SMART SENSE COLOR LANCETS 33G 2 SMART SENSE STANDARD LANCETS 2 SMART SENSE SUPER THIN LANCETS 2 SMART SENSE THIN LANCETS 26G 2 SMARTEST LANCETS 28G 2 SOLUS V2 LANCETS 28G 2 SOLUS V2 LANCING DEVICE 2 SOLUS V2 TWIST LANCETS 30G 2

STERILANCE PA 2 STERILANCE TL 2 super thin lancets 2 sure comfort insulin syringe 2 sure comfort lancets 18g 2 sure comfort lancets 21g 2 sure comfort lancets 23g 2 sure comfort lancets 28g 2 sure comfort lancets 30g 2 sure comfort lancing pen 2 sure comfort pen needles 2 SURE-FINE PEN NEEDLES 2 SURE-JECT INSULIN SYRINGE 2 SURE-LANCE FLAT LANCETS 2 SURE-LANCE LANCETS 26G 2 SURE-LANCE THIN LANCETS 28G 2 SURE-LANCE ULTRA THIN LANCETS 2 SURELITE LANCETS 2 SURE-TOUCH LANCETS UNIVERSAL 2 TECHLITE AST LANCETS 2 techlite insulin syringe 2 TECHLITE LANCETS 2 TECHLITE LANCETS 30G 2 TECHLITE PEN NEEDLES 2 THINLETS GP LANCETS 2 todays health lancing device 2 QL(1 EA per 1 days) todays health mini pen needles 2 todays health thin lancets 28g 2 todays health thin lancets 30g 2 topcare clickfine pen needles 2 topcare lancets micro-thin 33g 2 topcare ultra comfort ins syr 2 travel lancets 2 TRAVEL LANCETS ADVANCED 28G 2 true comfort insulin syringe 2 true comfort pen needles 2

true comfort pro insulin syr 30G X 1/2" 0.5 ml Miscellaneous, 30G X 1/2" 1 ml Miscellaneous, 30G X 5/16" 0.5 ml Miscellaneous, 30G X 5/16" 1 ml Miscellaneous, 32G X 5/16" 1 ml Miscellaneous 2 true comfort twist top lancets 2 TRUEDRAW LANCING DEVICE 2 TRUEPLUS 5-BEVEL PEN NEEDLES 2 TRUEPLUS INSULIN SYRINGE 2 TRUEPLUS LANCETS 26G 2 TRUEPLUS LANCETS 28G 2 TRUEPLUS LANCETS 30G 2 TRUEPLUS LANCETS 33G 2 TRUEPLUS PEN NEEDLES 2 TRUEPLUS SAFETY LANCETS 28G 2 ULTICARE INSULIN SAFETY SYR 2 ULTICARE INSULIN SYRINGE 2 ULTICARE MICRO PEN NEEDLES 2 ULTICARE MINI PEN NEEDLES 31G X 6 MM Miscellaneous, 32G X 6 MM Miscellaneous 2 ULTICARE PEN NEEDLES 29G X 12.7MM Miscellaneous, 31G X 5 MM Miscellaneous 2 ULTICARE SAFETY SYRINGE 2 ULTICARE SHORT PEN NEEDLES 31G X 8 MM Miscellaneous 2 ultiguard safepack pen needle 31G X 5 MM Miscellaneous, 31G X 6 MM Miscellaneous, 31G X 8 MM Miscellaneous, 32G X 4 MM Miscellaneous, 32G X 6 MM Miscellaneous 2 ULTI-LANCE AUTOMATIC 2 ULTILET CLASSIC LANCETS 2 ULTILET INSULIN SYRINGE 2 ULTILET INSULIN SYRINGE SHORT 2 ¹You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document Geisinger Family Supplemental Formulary Page 48 of 83 Effective Date: 9/22/2021 Drug Reference Name Drug Name Requirements/Limits1 Tier

ULTILET LANCETS 2 ULTILET PEN NEEDLE 2 ULTILET SAFETY LANCETS 2 ULTILET SAFETY LANCETS 23G 2 ultra comfort insulin syringe 2 ULTRA FLO INSULIN PEN NEEDLES 29G X 12MM Miscellaneous 2 ULTRA FLO INSULIN SYRINGE 29G X 1/2" 0.3 ml Miscellaneous 2 ultra thin lancets 31g 2 ULTRA THIN PEN NEEDLES 2 ultracare insulin syringe 2 ultra-care lancets 30g 2 ultracare pen needles 2 ultra-comfort insulin syringe 2 ULTRALANCE 2 QL(1 EA per 1 days) ULTRA-THIN II AUTO LANCET 2 ULTRA-THIN II INS SYR SHORT 2 ULTRA-THIN II INSULIN SYRINGE 2 ULTRA-THIN II LANCETS 2 ULTRA-THIN II MINI PEN NEEDLE 31G X 5 MM Miscellaneous, 31G X 6 MM Miscellaneous 2 ULTRA-THIN II PEN NEEDLE SHORT 2 ULTRA-THIN II PEN NEEDLES 2 UNIFINE PENTIPS 2 UNIFINE PENTIPS PLUS 2 UNIFINE SAFECONTROL PEN NEEDLE 2 UNILET COMFORTOUCH LANCET 2 UNILET EXCELITE 2 UNILET EXCELITE II 2 UNILET G.P. LANCET 2 UNILET G.P. SUPERLITE LANCET 2 UNILET GP 28 ULTRA THIN 2 UNILET LANCET 2 UNILET MICRO-THIN 33G 2

UNILET SUPERLITE LANCET 2 UNILET SUPER-THIN 30G 2 UNILET ULTRA-THIN 28G 2 UNISTIK 1 2 UNISTIK 2 2 UNISTIK 2 COMFORT 2 UNISTIK 2 EXTRA 2 UNISTIK 2 NEONATAL 2 UNISTIK 2 NORMAL 2 UNISTIK 2 SUPER 2 UNISTIK 3 2 UNISTIK 3 COMFORT 2 UNISTIK 3 COMFORT 2 QL(30 EA per 30 days) UNISTIK 3 EXTRA 2 QL(1 EA per 1 days) UNISTIK 3 GENTLE 2 UNISTIK 3 NEONATAL 2 UNISTIK 3 NORMAL 2 UNISTIK CZT COMFORT 2 QL(1 EA per 1 days) UNISTIK CZT NORMAL 2 UNISTIK NORMAL 2 UNISTIK PRO SAFETY LANCET 2 UNISTIK SAFETY LANCETS 28G 2 UNISTIK SAFETY LANCETS 30G 2 UNISTIK TOUCH SAFETY LANC 21G 2 UNISTIK TOUCH SAFETY LANC 23G 2 UNISTIK TOUCH SAFETY LANC 28G 2 UNISTIK TOUCH SAFETY LANC 30G 2 UNIVERSAL 1 LANCETS THIN 26G 2 UNIVERSAL 1 LANCETS THIN 33G 2 UNIVERSAL 1 LANCETS ULTRA THIN 2 value health insulin syringe 2 value plus lancet standard 21g 2 value plus lancets super thin 2 value plus lancets thin 26g 2

value plus lancing device 2 QL(1 EA per 1 days) valumark lancet super thin 30g 2 valumark lancet ultra thin 28g 2 valumark pen needles 2 VANISHPOINT INSULIN SYRINGE 2 VIDA MIA AUTOLET LANCING DEV 2 VIDA MIA UNIFINE PENTIPS 2 VIDA MIA UNILET LANCETS 28G 2 VIDA MIA UNILET LANCETS 30G 2 VIVAGUARD LANCETS 2 VIVAGUARD LANCING DEVICE 2 vp insulin syringe 2 zevrx insulin syringe 2 zevrx twist top lancets 30g 2 DISEASE-MODIFYING ANTIRHEUMATIC DRUGS Disease-modifying Antirheumatic Drugs leflunomide 10 mg Oral Tablet, 20 mg Oral Tablet 1 ARAVA DIURETICS Loop Diuretics bumetanide 0.5 mg Oral Tablet, 1 mg Oral Tablet, 2 mg Oral Tablet 1 BUMEX furosemide 20 mg Oral Tablet, 40 mg Oral Tablet, 80 mg Oral Tablet 1 LASIX furosemide 10 mg/ml Injection Solution, 10 mg/ml Oral Solution, 8 mg/ml Oral Solution 1 LASIX torsemide 1 DEMADEX Potassium-sparing Diuretics amiloride hcl 5 mg Oral Tablet 1 MIDAMOR amiloride-hydrochlorothiazide 1 MODURETIC triamterene-hctz 37.5-25 mg Oral Capsule 1 DYAZIDE triamterene-hctz 37.5-25 mg Oral Tablet, 75-50 mg Oral Tablet 1 MAXZIDE Thiazide Diuretics chlorothiazide 250 mg Oral Tablet, 500 mg Oral Tablet 1 DIURIL DIURIL 2 AL(Max 2 years)

hydrochlorothiazide 25 mg Oral Tablet, 50 mg Oral Tablet 1 HYDRODIURIL hydrochlorothiazide 12.5 mg Oral Capsule, 12.5 mg Oral Tablet 1 MICROZIDE Thiazide-like Diuretics chlorthalidone 1 HYGROTON indapamide 1 LOZOL metolazone 1 ZAROXOLYN Vasopressin Antagonists JYNARQUE 15 mg Oral Tablet Therapy Pack, 30 & 15 mg Oral Tablet Therapy Pack, 45 & 15 mg Oral Tablet Therapy Pack, 60 & 30 mg Oral Tablet Therapy Pack, 90 & 30 mg Oral Tablet Therapy Pack 2 SP, PA SP, PA, QL(1 EA per 1 JYNARQUE 15 mg Oral Tablet 2 days) SP, PA, QL(2 EA per 1 JYNARQUE 30 mg Oral Tablet 2 days) SP, PA, QL(1 EA per 1 tolvaptan 15 mg Oral Tablet 1 days) SP, PA, QL(2 EA per 1 tolvaptan 30 mg Oral Tablet 1 SAMSCA days) EENT DRUGS, MISCELLANEOUS Eent Drugs, Miscellaneous acetic acid 2 % Otic Solution 1 VOSOL ALTACHLORE 5 % Ophthalmic Ointment OTC ALTACHLORE 5 % Ophthalmic Solution OTC hm saline nasal spray OTC nasal moisturizing spray OTC saline mist spray OTC saline nasal spray OTC sodium chloride (hypertonic) 5 % Ophthalmic Ointment OTC sodium chloride (hypertonic) 5 % Ophthalmic Solution OTC EMOLLIENTS, DEMULCENTS, AND PROTECTANTS Basic Lotions And Liniments

ammonium lactate 12 % External Cream, 12 % External Lotion 1 LAC-HYDRIN ENZYMES Enzymes PALYNZIQ 2.5 mg/0.5ml Subcutaneous Solution Prefilled SP, PA, QL(0.15 ML Syringe 2 per 1 days) PALYNZIQ 10 mg/0.5ml Subcutaneous Solution Prefilled SP, PA, QL(0.5 ML per Syringe 2 1 days) PALYNZIQ 20 mg/ml Subcutaneous Solution Prefilled SP, PA, QL(3 ML per 1 Syringe 2 days) STRENSIQ 2 SP, PA EXPECTORANTS Expectorants iodine strong 5 % Oral Solution 1 FIRST GENERATION ANTIHISTAMINES Derivatives, Miscellaneous cyproheptadine hcl 4 mg Oral Tablet 1 PERIACTIN cyproheptadine hcl 2 mg/5ml Oral Syrup 1 PERIACTIN Ethanolamine Derivatives ALKA-SELTZER PLUS ALLERGY OTC allergy 25 mg Oral Capsule OTC allergy childrens 12.5 mg/5ml Oral Liquid OTC complete allergy medicine 25 mg Oral Capsule OTC complete allergy relief OTC DAYHIST ALLERGY 12 HOUR RELIEF OTC diphen 12.5 mg/5ml Oral Elixir 1 BENADRYL diphenhydramine hcl 25 mg Oral Capsule, 25 mg Oral Tablet, 50 mg Oral Capsule OTC diphenhydramine hcl 12.5 mg/5ml Oral Liquid OTC diphenhydramine hcl 12.5 mg/5ml Oral Elixir 1 BENADRYL

geri-dryl 25 mg Oral Tablet OTC NARAMIN OTC pharbedryl 50 mg Oral Capsule OTC total allergy OTC Propylamine Derivatives allergy 12 mg Oral Tablet Extended Release OTC CHLORPHEN SR OTC chlorpheniramine maleate er OTC GOLD COMPOUNDS Gold Compounds RIDAURA 2 HEMORRHEOLOGIC AGENTS Hemorrheologic Agents pentoxifylline er 1 TRENTAL HYPOTENSIVE AGENTS Direct Vasodilators hydralazine hcl 10 mg Oral Tablet, 100 mg Oral Tablet, 25 mg Oral Tablet, 50 mg Oral Tablet 1 APRESOLINE minoxidil 10 mg Oral Tablet, 2.5 mg Oral Tablet 1 LONITEN IMMUNOMODULATORY AGENTS Immunomodulatory Agents ENSPRYNG 2 PA IMMUNOSUPPRESSIVE AGENTS Immunosuppressive Agents BENLYSTA 200 mg/ml Subcutaneous Solution Auto- injector, 200 mg/ml Subcutaneous Solution Prefilled Syringe 2 SP, PA ION-REMOVING AGENTS Potassium-removing Agents KIONEX 1 sodium polystyrene sulfonate Oral Powder 1 KAYEXALATE sodium polystyrene sulfonate 15 gm/60ml Oral Suspension, 30 gm/120ml Rectal Suspension, 50 gm/200ml Rectal Suspension 1 SPS

SPS 1 IRRIGATING SOLUTIONS Irrigating Solutions sterile water for irrigation 1 KERATOLYTIC AGENTS Keratolytic Agents CEM-UREA 1 METOPIC 1 salicylic acid 6 % External Lotion 1 salicylic acid 6 % External Lotion, 6 % External Shampoo 1 salicylic acid-cleanser 6 % (lotion) External Kit 1 SULFACLEANSE 8/4 1 urea 39 % External Cream, 40 % External Cream, 40 % External Lotion, 41 % External Cream 1 urea 40 % External Lotion 1 urea hydrating 1 urea nail 1 xurea 1 MOUTHWASHES AND GARGLES Mouthwashes And Gargles goodsense sore throat spray OTC hm sore throat spray OTC oral relief OTC phenaseptic OTC sore throat Mouth/Throat Liquid, 1.4 % Mouth/Throat Liquid OTC sore throat spray OTC MUCOLYTIC AGENTS Mucolytic Agents NEBUSAL 3 % Inhalation Nebulization Solution 1 SP, PA, QL(5 ML per 1 PULMOZYME 2 days) sodium chloride 0.9 % Inhalation Nebulization Solution, 10 % Inhalation Nebulization Solution, 3 % Inhalation Nebulization Solution, 1

7 % Inhalation Nebulization Solution MULTIVITAMIN PREPARATIONS Multivitamin Preparations ATABEX EC 1 azesco 1 BAL-CARE DHA 1 cadeau dha 1 CEROVITE SENIOR OTC CERTAVITE/ANTIOXIDANTS OTC dothelle dha 1 DUET DHA 400 1 DUET DHA BALANCED 1 FLORIVA 0.25 mg Oral Tablet Chewable, 0.5 mg Oral Tablet Chewable, 1 mg Oral Tablet Chewable OTC FOLET ONE 1 hemenatal ob + dha 1 kosher prenatal plus iron 1 MARNATAL-F 1 multi-vit/iron/fluoride OTC multivitamin + fluoride OTC multivitamin select/fluoride OTC multivitamin/fluoride 0.25 mg Oral Tablet Chewable, 0.5 mg Oral Tablet Chewable, 1 mg Oral Tablet Chewable OTC multivitamin/fluoride 0.25 mg/ml Oral Solution, 0.5 mg/ml Oral Solution OTC multivitamin/fluoride/iron OTC multi-vitamin/fluoride/iron OTC MVC-FLUORIDE OTC MYNATAL 1 MYNATAL ADVANCE 1 mynatal plus 1 mynatal-z 1 mynate 90 plus 1 mynephrocaps OTC MYNEPHRON OTC

NATACHEW 1 NATELLE ONE 1 NEEVO DHA 1 NESTABS ABC 1 NEXA PLUS 1 OBSTETRIX DHA 1 OBSTETRIX EC 1 OBSTETRIX ONE 1 OBTREX DHA 1 pnv ob+dha 1 POLY-VI-FLOR 0.25 mg Oral Tablet Chewable, 0.5 mg Oral Tablet Chewable, 1 mg Oral Tablet Chewable OTC POLY-VI-FLOR 0.25 mg/ml Oral Suspension OTC POLY-VI-FLOR/IRON 0.5-10 mg Oral Tablet Chewable OTC POLY-VI-FLOR/IRON 0.25-7 mg/ml Oral Suspension OTC POLY-VI-SOL/IRON OTC PR NATAL 400 1 PR NATAL 400 EC 1 PR NATAL 430 1 PR NATAL 430 EC 1 prena 1 true 1 prena1 1 prenatabs fa 1 PRENATABS RX 1 prenatal 19 29-1 mg Oral Tablet, 29-1 mg Oral Tablet Chewable 1 prenatal 19 Oral Tablet OTC prenatal low iron 27-1 mg Oral Tablet 1 prenatal multi +dha 27-0.8-228 mg Oral Capsule OTC prenatal plus iron 1 PRENATAL-U 1 QUFLORA FE OTC QUFLORA FE PEDIATRIC OTC

QUFLORA PEDIATRIC 0.25 mg Oral Tablet Chewable, 0.5 mg Oral Tablet Chewable, 1 mg Oral Tablet Chewable OTC QUFLORA PEDIATRIC 0.25 mg/ml Oral Solution, 0.5 mg/ml Oral Solution OTC relnate dha 1 RENAL OTC reno caps OTC R-NATAL OB 1 therapeutic-m OTC TRICARE PRENATAL DHA ONE 1 TRINATE 1 triphrocaps OTC TRI-VI-FLOR 0.25 mg/ml Oral Suspension OTC tri-vitamin/fluoride 0.25 mg/ml Oral Solution, 0.5 mg/ml Oral Solution OTC ultimatecare one 1 vena-bal dha 1 VINATE CARE 1 VINATE II 1 VINATE M 1 VINATE ONE 1 virt-caps OTC vision vitamins OTC VITAMEDMD ONE RX/QUATREFOLIC 1 VITAMEDMD REDICHEW RX 1 vitamins acd-fluoride OTC VITAPEARL 1 VITATRUE 1 VIVA DHA 1 vol-nate 1 vol-tab rx 1 MYDRIATICS Mydriatics atropine sulfate 1 % Ophthalmic Ointment 1

atropine sulfate 1 % Ophthalmic Solution 1 cyclopentolate hcl 0.5 % Ophthalmic Solution, 1 % Ophthalmic Solution, 2 % Ophthalmic Solution 1 HOMATROPAIRE 1 homatropine hbr 1 NON-AHFS SUBCLASS Unknown Therapeutic Class INQOVI 2 PA OTHER MISCELLANEOUS THERAPEUTIC AGENTS Other Miscellaneous Therapeutic Agents CYSTAGON 2 SP EVRYSDI 2 PA FIRDAPSE 2 SP, PA fish oil 1000 mg Oral Capsule OTC KUVAN 100 mg Oral Packet, 100 mg Oral Tablet, 500 mg Oral Packet 2 SP, PA levocarnitine 330 mg Oral Tablet 1 CARNITOR levocarnitine 1 gm/10ml Oral Solution 1 CARNITOR levocarnitine sf 1 CARNITOR l-methylfolate 15 mg Oral Tablet, 7.5 mg Oral Tablet OTC melatonin 3 mg Oral Tablet OTC melatonin/vitamin b-6 ex st 3-1 mg Oral Tablet OTC melatonin-pyridoxine 5-10 mg Oral Tablet OTC NITYR 2 SP, PA octreotide acetate 500 mcg/ml Injection Solution 1 SANDOSTATIN SP omega 3 1000 mg Oral Capsule OTC omega iii epa+dha OTC omega-3 1000 mg Oral Capsule OTC omega-3 fish oil 1000 mg Oral Capsule, 500 mg Oral Capsule OTC

sapropterin dihydrochloride 100 mg Oral Packet, 100 mg Oral Tablet, 500 mg Oral Packet 1 SP, PA SUPER OMEGA-3 1000 mg Oral Capsule OTC ZOKINVY 2 PA OXYTOCICS Oxytocics methylergonovine maleate 0.2 mg Oral Tablet 1 METHERGINE PARASYMPATHOMIMETIC (CHOLINERGIC) AGENTS Parasympathomimetic (cholinergic) Agents bethanechol chloride 10 mg Oral Tablet, 25 mg Oral Tablet, 5 mg Oral Tablet, 50 mg Oral Tablet 1 URECHOLINE pilocarpine hcl 5 mg Oral Tablet, 7.5 mg Oral Tablet 1 SALAGEN pyridostigmine bromide 30 mg Oral Tablet 1 pyridostigmine bromide 60 mg Oral Tablet 1 MESTINON PARATHYROID AND ANTIPARATHYROID AGENTS Antiparathyroid Agents SP, PA, QL(4 EA per 1 cinacalcet hcl 1 SENSIPAR days) PITUITARY Pituitary desmopressin acetate 0.1 mg Oral Tablet, 0.2 mg Oral Tablet 1 DDAVP desmopressin acetate spray 1 DDVAP QL(0.4 ML per 1 days) PROGESTINS Progestins megestrol acetate 20 mg Oral Tablet, 40 mg Oral Tablet 1 MEGACE megestrol acetate 40 mg/ml Oral Suspension, 400 mg/10ml Oral Suspension 1 MEGACE PSYCHOTHERAPEUTIC AGENTS Antidepressants chlordiazepoxide-amitriptyline 1 LIMBITROL

Antipsychotics prochlorperazine edisylate 50 mg/10ml Injection Solution 1 RENIN-ANGIOTENSIN-ALDOSTERONE SYS INHIB Mineralocorticoid (aldost) Recept Antag eplerenone 50 mg Oral Tablet 1 INSPRA QL(2 EA per 1 days) eplerenone 25 mg Oral Tablet 1 INSPRA QL(4 EA per 1 days) spironolactone 100 mg Oral Tablet, 25 mg Oral Tablet, 50 mg Oral Tablet 1 ALDACTONE spironolactone-hctz 25-25 mg Oral Tablet 1 ALDACTAZIDE REPLACEMENT PREPARATIONS Replacement Preparations CALCITRATE 315-250 mg-unit Oral Tablet OTC calcium + vitamin d3 500-400 mg- unit Oral Tablet Chewable, 600-10 mg-mcg Oral Tablet OTC calcium 500/d 500-400 mg-unit Oral Tablet Chewable OTC calcium 600+d 600-400 mg-unit Oral Tablet OTC calcium 600+d high potency OTC calcium 600+d3 600-400 mg-unit Oral Tablet OTC calcium 600-d OTC calcium carb-cholecalciferol 500-10 mg-mcg Oral Tablet Chewable, 600-400 mg-unit Oral Tablet OTC calcium carbonate 1250 (500 Ca) mg Oral Tablet Chewable OTC calcium carbonate-vitamin d 600- 400 mg-unit Oral Tablet OTC calcium carbonate-vitamin d3 OTC calcium citrate + d 250-200 mg-unit Oral Tablet, 315-200 mg-unit Oral Tablet OTC calcium citrate + d3 315-5 mg-mcg Oral Tablet OTC calcium citrate + d3 maximum OTC

calcium citrate-vitamin d 315-200 mg-unit Oral Tablet OTC calcium citrate-vitamin d3 315-6.25 mg-mcg Oral Tablet OTC calcium-vitamin d 600-400 mg-unit Oral Tablet OTC citrus calcium +d OTC hm calcium citrate+vitamin d OTC KLOR-CON 1 KLOR-CON 10 1 KLOR-CON M10 1 KLOR-CON M15 1 KLOR-CON M20 1 KLOR-CON SPRINKLE 1 kp mag-oxide magnesium OTC K-PHOS 2 magnesium 400 mg Oral Tablet OTC magnesium oxide 400 (240 Mg) mg Oral Tablet OTC MAGNESIUM-OXIDE OTC MAGOX 400 OTC oyster shell calcium 500+d OTC PHOSPHA 250 NEUTRAL OTC potassium chloride 20 meq Oral Packet 1 potassium chloride 20 MEQ/15ML (10%) Oral Solution, 40 MEQ/15ML (20%) Oral Solution 1 K-SOL potassium chloride crys er 10 meq Oral Tablet Extended Release, 15 meq Oral Tablet Extended Release 1 potassium chloride crys er 20 meq Oral Tablet Extended Release 1 KLOR-CON potassium chloride er 20 meq Oral Tablet Extended Release 1 K-TAB potassium chloride er 10 meq Oral Tablet Extended Release, 8 meq Oral Tablet Extended Release 1 KLOR-CON potassium chloride er 10 meq Oral Capsule Extended Release, 8 meq Oral Capsule Extended Release 1 MICRO-K super calcium 600 + d 400 OTC ¹You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document Geisinger Family Supplemental Formulary Page 62 of 83 Effective Date: 9/22/2021 Drug Reference Name Drug Name Requirements/Limits1 Tier

RESPIRATORY SMOOTH MUSCLE RELAXANTS Respiratory Smooth Muscle Relaxants ELIXOPHYLLIN 1 theophylline 80 mg/15ml Oral Solution 1 theophylline er 100 mg Oral Tablet Extended Release 12 Hour, 200 mg Oral Tablet Extended Release 12 Hour, 300 mg Oral Tablet Extended Release 12 Hour, 450 mg Oral Tablet Extended Release 12 Hour 1 THEO-DUR theophylline er 400 mg Oral Tablet Extended Release 24 Hour, 600 mg Oral Tablet Extended Release 24 Hour 1 UNIPHYL SECOND GENERATION ANTIHISTAMINES Second Generation Antihistamines cetirizine hcl 5 mg/5ml Oral Solution 1 ZYRTEC SKIN AND MUCOUS MEMBRANE AGENTS, MISC Skin And Mucous Membrane Agents, Misc azelaic acid 15 % External Gel 1 FINACEA CUTTER BACKWOODS External Aerosol OTC QL(31 GM per 1 days) CUTTER BACKWOODS External Liquid OTC QL(31 ML per 1 days) fluorouracil 0.5 % External Cream 1 CARAC fluorouracil 5 % External Cream 1 EFUDEX fluorouracil 2 % External Solution, 5 % External Solution 1 EFUDEX OFF DEEP WOODS DRY OTC QL(31 GM per 1 days) podofilox 0.5 % External Solution 1 CONDYLOX QBREXZA 2 PA REPEL SPORTSMEN MAX 40 % External Aerosol OTC QL(31 GM per 1 days) REPEL SPORTSMEN MAX 40 % External Liquid OTC QL(31 ML per 1 days) SOMATOSTATIN AGONISTS AND ANTAGONISTS Somatostatin Agonists

octreotide acetate 100 mcg/ml Injection Solution, 1000 mcg/ml Injection Solution, 200 mcg/ml Injection Solution, 50 mcg/ml Injection Solution, 500 mcg/ml Injection Solution 1 SANDOSTATIN SP SYMPATHOMIMETIC (ADRENERGIC) AGENTS Alpha-adrenergic Agonists midodrine hcl 1 PROAMATINE VICKS SINEX DAYTIME OTC THYROID AND ANTITHYROID AGENTS Antithyroid Agents methimazole 10 mg Oral Tablet, 5 mg Oral Tablet 1 TAPAZOLE propylthiouracil 50 mg Oral Tablet 1 TOXOIDS Toxoids AL(Min 19 years and ADACEL 2 Max 64 years) BOOSTRIX 2 AL(Min 19 years) TDVAX 2 AL(Min 19 years) TENIVAC 2 AL(Min 19 years) tetanus-diphtheria toxoids td 2-2 lf/0.5ml Intramuscular Suspension 2 AL(Min 19 years) URINARY ANTI-INFECTIVES Urinary Anti-infectives trimethoprim 100 mg Oral Tablet 1 PROLOPRIM URINE AND FECES CONTENTS Ketones KETOSTIX OTC VACCINES Vaccines AFLURIA 2 AFLURIA PRESERVATIVE FREE 2 AFLURIA QUADRIVALENT 2 astrazeneca covid-19 vaccine 2 AL(Min 19 years and BEXSERO 2 Max 25 years) ENGERIX-B 10 mcg/0.5ml Injection AL(Min 19 years and Suspension 2 Max 19 years)

ENGERIX-B 20 mcg/ml Injection Suspension 2 AL(Min 20 years) EZ FLU SHOT-FLUCELVAX QUAD 2 FLUAD 2 FLUAD QUADRIVALENT 2 FLUARIX QUADRIVALENT 2 FLUBLOK QUADRIVALENT 2 FLUCELVAX QUADRIVALENT 2 FLULAVAL QUADRIVALENT 2 FLUMIST QUADRIVALENT 2 FLUZONE HIGH-DOSE 2 FLUZONE HIGH-DOSE QUADRIVALENT 2 FLUZONE QUADRIVALENT 2 AL(Min 19 years and GARDASIL 9 2 Max 45 years) HAVRIX 1440 el u/ml Intramuscular Suspension 2 AL(Min 19 years) HEPLISAV-B 2 AL(Min 19 years) QL(0.5 ML per 180 janssen covid-19 vaccine 2 days) MENACTRA 2 AL(Min 19 years) MENQUADFI 2 AL(Min 19 years) AL(Min 19 years and MENVEO 2 Max 55 years) M-M-R II 2 AL(Min 19 years) novavax covid-19 vaccine 2 PNEUMOVAX 23 2 AL(Min 19 years) PREVNAR 13 2 AL(Min 19 years) PREVNAR 20 2 AL(Min 19 years) PROQUAD 2 AL(Min 19 years) RECOMBIVAX HB 5 mcg/0.5ml AL(Min 19 years and Injection Suspension 2 Max 19 years) RECOMBIVAX HB 40 mcg/ml Injection Suspension 2 AL(Min 19 years) RECOMBIVAX HB 10 mcg/ml Injection Suspension 2 AL(Min 20 years) QL(2 EA per 365 days), SHINGRIX 2 AL(Min 19 years) AL(Min 19 years and TRUMENBA 2 Max 25 years) TWINRIX 2 AL(Min 19 years) ¹You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document Geisinger Family Supplemental Formulary Page 65 of 83 Effective Date: 9/22/2021 Drug Reference Name Drug Name Requirements/Limits1 Tier

VAQTA 50 unit/ml Intramuscular Suspension 2 AL(Min 19 years) VARIVAX 2 AL(Min 19 years) VIVOTIF 2 QL(0.58 EA per 1 days) ZOSTAVAX 2 AL(Min 49 years) VASOCONSTRICTORS Vasoconstrictors 12 hour decongestant 0.05 % Nasal Solution OTC 12 hour nasal decongestant 0.05 % Nasal Solution OTC 12 hour nasal relief spray OTC 12 hour nasal spray OTC anefrin spray OTC hm nasal spray OTC hm sinus nasal spray OTC kls nasal decongestant spray OTC MUCINEX SINUS-MAX CLEAR & COOL OTC MUCINEX SINUS-MAX FULL FORCE OTC nasal decongestant spray OTC nasal four OTC nasal relief OTC nasal spray OTC nasal spray 12 hour OTC nasal spray extra moisturizing OTC nasal spray no drip OTC nasal spray sinus OTC no drip nasal spray OTC phenylephrine hcl 2.5 % Ophthalmic Solution 1 phenylephrine hcl 10 % Ophthalmic Solution, 2.5 % Ophthalmic Solution 1 sinus nasal spray OTC sinus relief 0.05 % Nasal Solution OTC sinus relief extra strength OTC VASODILATING AGENTS Vasodilating Agents

treprostinil 100 mg/20ml Injection Solution, 20 mg/20ml Injection Solution, 200 mg/20ml Injection Solution, 50 mg/20ml Injection Solution 1 REMODULIN SP, PA VITAMIN B COMPLEX Vitamin B Complex b-2 50 mg Oral Tablet OTC cyanocobalamin 1000 mcg/ml Injection Solution 1 folic acid 1 mg Oral Tablet 1 folic acid 0.8 mg Oral Capsule, 1 mg Oral Tablet, 800 mcg Oral Tablet OTC FOLTANX OTC kp folic acid 1 mg Oral Tablet OTC vitamin b1 50 mg Oral Tablet OTC vitamin b12 100 mcg Oral Tablet OTC vitamin b-12 500 mcg Oral Tablet OTC vitamin b-2 25 mg Oral Tablet OTC vitamin b-6 100 mg Oral Tablet OTC VITAMIN C Vitamin C vitamin c 250 mg Oral Tablet OTC VITAMIN D Vitamin D d 400 10 MCG (400 unit) Oral Tablet OTC d-400 OTC ergocalciferol 200 mcg/ml Oral Solution OTC vitamin d (ergocalciferol) 1.25 MG (50000 ut) Oral Capsule 1 vitamin d3 10 MCG (400 unit) Oral Tablet OTC VITAMIN E Vitamin E e200 OTC vitamin e 200 unit Oral Capsule OTC vitamin e-200 OTC

VITAMIN K ACTIVITY Vitamin K Activity MEPHYTON 2 phytonadione 5 mg Oral Tablet 1

1 AFLURIA...... 64 12 hour decongestant ...... 66 AFLURIA PRESERVATIVE FREE ...... 64 12 hour nasal decongestant ...... 66 AFLURIA QUADRIVALENT ...... 64 12 hour nasal relief spray...... 66 AGAMATRIX ULTRA-THIN LANCETS...... 32 12 hour nasal spray ...... 66 aimsco twist lancets 32g ...... 32 1st tier unifine pentips...... 31 AIMSCO TWIST LANCETS 33G ...... 32 1st tier unifine pentips plus ...... 31 albendazole ...... 17 1st tier unilet comfortouch ...... 31 ALIGN...... 18 ALIGN JR FOR KIDS...... 18 A ALKA-SELTZER PLUS ALLERGY ...... 53 ABOUTTIME PEN NEEDLE ...... 31 ALKERAN ...... 24 acamprosate calcium ...... 30 allergy ...... 53, 54 ACCU-CHEK FASTCLIX LANCET...... 31 allergy childrens...... 53 ACCU-CHEK FASTCLIX LANCETS ...... 31 ALTACHLORE ...... 52 ACCU-CHEK MULTICLIX LANCET DEV...... 31 alternate site lancing device ...... 32 ACCU-CHEK MULTICLIX LANCETS ...... 31 alumina-magnesia-simethicone ...... 16 ACCU-CHEK SAFE-T PRO LANCETS ...... 31 aluminum hydroxide gel ...... 16 ACCU-CHEK SOFT TOUCH LANCETS ...... 31 amiloride hcl ...... 51 ACCU-CHEK SOFTCLIX LANCET DEV ...... 31 amiloride-hydrochlorothiazide ...... 51 ACCU-CHEK SOFTCLIX LANCETS...... 31 amiodarone hcl ...... 27 ACEPHEN ...... 15 ammonium lactate ...... 53 acetaminophen ...... 15 anagrelide hcl...... 26 acetaminophen extra strength...... 15 anefrin spray ...... 66 acetazolamide ...... 20 antacid...... 16 acetazolamide er ...... 20 antacid anti-gas ...... 16 acetic acid...... 52 antacid anti-gas reg strength ...... 16 acetylcysteine ...... 19 antacid calcium ...... 16 ACID GONE ...... 16 antacid calcium extra strength ...... 16 acne treatment ...... 21 antacid calcium rich ...... 16 acti-lance 28g...... 31 antacid extra strength ...... 16 acti-lance lite lancets 28g...... 31 antacid fast acting ...... 16 acti-lance special lancets 17g ...... 31 antacid fast relief ...... 16 acti-lance universal 23g...... 31 antacid liquid ...... 16 ADACEL...... 64 antacid m ...... 16 adjustable lancing device ...... 31 antacid maximum ...... 16 adult mask large ...... 31 antacid plus anti-gas fast act ...... 16 advanced mobile lancet...... 31 antacid plus anti-gas relief ...... 17 ADVOCATE INSULIN PEN NEEDLES...... 31 antacid regular strength...... 17 ADVOCATE INSULIN SYRINGE...... 31 antacid ultra strength ...... 17 ADVOCATE LANCETS ...... 31 antifungal ...... 21 ADVOCATE LANCETS 30G ...... 31 ANTI-ITCH INTENSIVE HEALING ...... 22 ADVOCATE LANCING DEVICE...... 31 aqua lance adjustable lancing ...... 32 ADVOCATE RAPID-SAFE LANCING...... 31 AQUALANCE LANCETS 30G...... 32 ADVOCATE SAFETY LANCETS ...... 32 aspirin adult ...... 16 ADVOCATE SAFETY LANCETS 26G...... 32 assure comfort lancets 28g...... 32 ¹You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document Geisinger Family Supplemental Formulary Page 69 of 83 Effective Date: 9/22/2021 ASSURE HAEMOLANCE PLUS HIGH ...... 32 BD PEN NEEDLE MICRO U/F...... 33 ASSURE HAEMOLANCE PLUS LOW ...... 32 BD PEN NEEDLE MINI U/F ...... 33 ASSURE HAEMOLANCE PLUS MICRO ...... 32 BD PEN NEEDLE NANO 2ND GEN ...... 33 ASSURE HAEMOLANCE PLUS NORMAL ... 32 BD PEN NEEDLE NANO U/F ...... 33 ASSURE HAEMOLANCE PLUS PED ...... 32 BD PEN NEEDLE ORIGINAL U/F ...... 33 ASSURE ID INSULIN SAFETY SYR ...... 32 BD PEN NEEDLE SHORT U/F ...... 33 ASSURE ID SAFETY PEN NEEDLES ...... 32 BD SAFETYGLIDE INSULIN SYRINGE ...... 33 ASSURE LANCE LANCETS ...... 32 BD SAFETYGLIDE NEEDLE ...... 33 ASSURE LANCE LANCETS 21G ...... 32 BD SAFETYGLIDE SYRINGE/NEEDLE ...... 33 ASSURE LANCE PLUS SAFETY 25G ...... 32 BD SAFETY-LOK INSULIN SYRINGE ...... 33 ASSURE LANCE PLUS SAFETY 30G ...... 32 BD SYRINGE ...... 33 ASSURE LANCE SAFETY LANCET 28G ..... 32 BD VEO INSULIN SYR U/F 1/2UNIT...... 33 ASSURE LANCETS...... 32 BD VEO INSULIN SYRINGE U/F ...... 33 astrazeneca covid-19 vaccine ...... 64 BENLYSTA...... 54 ATABEX EC ...... 56 benzonatate...... 26 athletes foot ...... 21 beta hc ...... 22 atovaquone...... 25 bethanechol chloride...... 60 atropine sulfate ...... 58, 59 BEVYXXA ...... 25 aurora lancet super thin 30g ...... 32 bexarotene...... 24 aurora lancet thin 23g ...... 32 BEXSERO ...... 64 aurora pen needles ...... 32 bisacodyl ...... 28 aurora unifine pentips ...... 32 bisacodyl ec...... 28 AUTO-LANCET ...... 32 bisacodyl laxative ...... 28 AUTO-LANCET MINI ...... 32 bismatrol ...... 19 AUTOLET LANCING DEVICE ...... 32 bismatrol maximum strength ...... 19 azelaic acid...... 63 BOOSTRIX ...... 64 azesco ...... 56 bp gel...... 21 B bp wash...... 21 bumetanide...... 51 b-2 ...... 67 bacitracin-neomycin-polymyxin ...... 20 C BAL-CARE DHA ...... 56 cabergoline ...... 25 BD AUTOSHIELD ...... 32 CABLIVI ...... 26 BD AUTOSHIELD DUO ...... 33 cadeau dha...... 56 BD ECLIPSE SYRINGE ...... 33 caffeine citrate...... 16 BD INSULIN SYR ULTRAFINE II ...... 33 CALCITRATE...... 61 BD INSULIN SYRINGE ...... 33 calcium + vitamin d3 ...... 61 BD INSULIN SYRINGE HALF-UNIT ...... 33 calcium 500/d ...... 61 BD INSULIN SYRINGE MICROFINE ...... 33 calcium 600+d...... 61 BD INSULIN SYRINGE U/F ...... 33 calcium 600+d high potency ...... 61 BD INSULIN SYRINGE U/F 1/2UNIT ...... 33 calcium 600+d3 ...... 61 BD INSULIN SYRINGE U-500 ...... 33 calcium 600-d...... 61 BD INSULIN SYRINGE ULTRAFINE...... 33 calcium antacid ...... 17 BD LANCET ULTRAFINE 30G ...... 33 calcium antacid ultra max st ...... 17 BD LANCET ULTRAFINE 33G ...... 33 calcium antacid ultra strength...... 17 BD LUER-LOK SYRINGE ...... 33 calcium carb-cholecalciferol ...... 61 BD MICROTAINER LANCETS ...... 33 calcium carbonate ...... 61 ¹You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document Geisinger Family Supplemental Formulary Page 70 of 83 Effective Date: 9/22/2021 calcium carbonate antacid ...... 17 citrate of magnesia ...... 28 calcium carbonate-vitamin d ...... 61 citrus calcium +d...... 62 calcium carbonate-vitamin d3...... 61 CLEANLET LANCETS 28G...... 34 calcium citrate + d ...... 61 CLENPIQ ...... 28 calcium citrate + d3 ...... 61 CLEVER CHEK LANCETS ...... 34 calcium citrate + d3 maximum...... 61 CLEVER CHOICE COMFORT EZ ...... 34 calcium citrate-vitamin d...... 62 CLEVER CHOICE LANCETS 21G...... 34 calcium citrate-vitamin d3 ...... 62 CLEVER CHOICE LANCETS 23G...... 34 calcium polycarbophil ...... 28 CLEVER CHOICE LANCETS 28G...... 34 calcium-vitamin d...... 62 clickfine pen needles ...... 34 carboplatin ...... 24 CLICKFINE PEN NEEDLES...... 35 CARDIOCOM LANCING DEVICE ...... 33 clindamycin hcl ...... 18 CAREFINE PEN NEEDLES ...... 33 clindamycin palmitate hcl ...... 18 careone advanced lancing dev ...... 34 COAGUCHEK LANCETS ...... 35 careone insulin syringe...... 34 COLOCORT ...... 22 CAREONE LANCET SUPER THIN 30G ...... 34 COMFORT ASSIST INSULIN SYRINGE ...... 35 careone lancet thin 23g ...... 34 comfort assured lancets 28g ...... 35 careone unifine pentips ...... 34 comfort assured lancets 33g ...... 35 careone unifine pentips plus ...... 34 COMFORT EZ INSULIN SYRINGE ...... 35 CARESENS LANCETS ...... 34 COMFORT EZ MICRO PEN NEEDLES...... 35 CARETOUCH HYPODERMIC NEEDLE ...... 34 COMFORT EZ PEN NEEDLES ...... 35 CARETOUCH INSULIN SYRINGE ...... 34 COMFORT EZ SHORT PEN NEEDLES ...... 35 CARETOUCH LANCING/EJECTOR...... 34 comfort lancets ...... 35 CARETOUCH PEN NEEDLES ...... 34 COMFORT TOUCH INSULIN PEN NEED..... 35 CARETOUCH SAFETY LANCETS ...... 34 complete allergy medicine ...... 53 CARETOUCH SAFETY LANCETS 26G ...... 34 complete allergy relief...... 53 CARETOUCH TWIST LANCETS 28G ...... 34 complete lice treatment ...... 22 CARETOUCH TWIST LANCETS 30G ...... 34 constulose ...... 14 CARETOUCH TWIST LANCETS 33G ...... 34 CONTOUR CONTROL...... 35 CEM-UREA ...... 55 CONTOUR NEXT CONTROL ...... 35 CEROVITE SENIOR...... 56 CORTIZONE-10 ...... 22 CERTAVITE/ANTIOXIDANTS ...... 56 CORTIZONE-10 DIABETICS SKIN...... 22 cetirizine hcl...... 63 CORTIZONE-10 ECZEMA ...... 22 childrens acetaminophen ...... 15 CORTIZONE-10 PLUS...... 22 childrens apap...... 15 CORTIZONE-10/ALOE ...... 22 childrens silapap ...... 15 cromolyn sodium ...... 23 childrens tactinal ...... 15 CUTTER BACKWOODS ...... 63 chlordiazepoxide-amitriptyline ...... 60 cyanocobalamin...... 67 chlorhexidine gluconate...... 21 cyclopentolate hcl ...... 59 chlorothiazide ...... 51 cyclophosphamide ...... 24 CHLORPHEN SR ...... 54 cyproheptadine hcl ...... 53 chlorpheniramine maleate er ...... 54 CYSTAGON ...... 59 chlorthalidone...... 52 cytra-2 ...... 14 cilostazol ...... 26 D cimetidine 200 ...... 26 d 400...... 67 cinacalcet hcl...... 60 d-400 ...... 67 ¹You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document Geisinger Family Supplemental Formulary Page 71 of 83 Effective Date: 9/22/2021 danazol...... 16 EASY TOUCH FLIPLOCK INSULIN SY ...... 36 dapsone ...... 23 EASY TOUCH INSULIN BARRELS 1ML ...... 36 DAYHIST ALLERGY 12 HOUR RELIEF ...... 53 EASY TOUCH INSULIN SAFETY SYR...... 36 DENTA 5000 PLUS ...... 27 EASY TOUCH INSULIN SYRINGE...... 36 DENTAGEL ...... 27 EASY TOUCH LANCETS 21G ...... 36 DERMAREST ECZEMA...... 22 EASY TOUCH LANCETS 23G ...... 36 desmopressin acetate ...... 60 EASY TOUCH LANCETS 26G ...... 36 desmopressin acetate spray...... 60 EASY TOUCH LANCETS 28G ...... 36 DIATHRIVE LANCET ULTRA THIN 30 ...... 35 EASY TOUCH LANCETS 28G/TWIST ...... 36 DIATHRIVE LANCETS...... 35 EASY TOUCH LANCETS 30G ...... 36 DIATHRIVE LANCING DEVICE ...... 35 EASY TOUCH LANCETS 30G/TWIST ...... 36 DIATHRIVE PEN NEEDLE ...... 35 EASY TOUCH LANCETS 32G ...... 36 dicyclomine hcl ...... 18 EASY TOUCH LANCETS 32G/TWIST ...... 36 DIGITEK...... 27 EASY TOUCH LANCETS 33G/TWIST ...... 36 digox ...... 27 EASY TOUCH LANCING DEVICE...... 36 digoxin ...... 27 EASY TOUCH PEN NEEDLES ...... 36 diocto ...... 28 EASY TOUCH SAFETY LANCETS 21G...... 36 diphen...... 53 EASY TOUCH SAFETY LANCETS 23G...... 36 diphenhydramine hcl...... 53 EASY TOUCH SAFETY LANCETS 26G...... 36 diphenoxylate-atropine ...... 19 EASY TOUCH SAFETY LANCETS 28G...... 36 disopyramide phosphate ...... 27 EASY TOUCH SAFETY PEN NEEDLES ...... 36 disulfiram...... 14 EASY TOUCH SHEATHLOCK SYRINGE ..... 36 DIURIL...... 51 EASY TWIST & CAP LANCETS...... 37 docuzen ...... 28 easy-lax plus ...... 28 dofetilide...... 27 ECONTRA EZ ...... 30 DOK PLUS ...... 28 ECONTRA ONE-STEP ...... 30 dothelle dha ...... 56 elite-thin insulin syringe ...... 37 DROPLET INSULIN SYRINGE...... 35 ELIXOPHYLLIN ...... 63 DROPLET LANCETS ULTRA THIN 30G ...... 35 EMBRACE LANCETS ULTRA THIN 30G ...... 37 DROPLET LANCING DEVICE ...... 35 EMCYT...... 24 DROPLET MICRON ...... 35 EMVERM ...... 17 DROPLET PEN NEEDLES...... 35 ENGERIX-B...... 64, 65 dropsafe safety pen needles ...... 35 ENSPRYNG ...... 54 DRYSOL ...... 27 enulose...... 14 ducodyl ...... 28 eplerenone...... 61 DUET DHA 400 ...... 56 ergocalciferol ...... 67 DUET DHA BALANCED ...... 56 ethambutol hcl...... 23 E etoposide ...... 24 EVRYSDI ...... 59 e200...... 67 EXEL COMFORT POINT INSULIN SYR ...... 37 easy comfort insulin syringe ...... 35 EXEL COMFORT POINT PEN NEEDLE ...... 37 easy comfort lancets ...... 35 EZ FLU SHOT-FLUCELVAX QUAD ...... 65 easy comfort lancets twist top ...... 36 E-Z JECT LANCET MICRO-THIN 33G ...... 37 easy comfort pen needles ...... 36 E-Z JECT LANCET SUPER THIN 30G ...... 37 easy glide pen needles...... 36 E-Z JECT LANCETS ...... 37 easy mini eject lancing device...... 36 E-Z JECT LANCETS 21G ...... 37 easy mini lancing device ...... 36 ¹You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document Geisinger Family Supplemental Formulary Page 72 of 83 Effective Date: 9/22/2021 E-Z JECT LANCETS THIN 26G ...... 37 FREESTYLE LIBRE 14 DAY SENSOR...... 37 EZ SMART BLOOD GLUCOSE LANCETS ... 37 FREESTYLE LIBRE 2 READER ...... 37 EZFE 200...... 17 FREESTYLE LIBRE 2 SENSOR ...... 37 EZ-LETS LANCETS 21G ...... 37 FREESTYLE LIBRE READER ...... 37 EZ-LETS LANCETS 26G ...... 37 FREESTYLE LIBRE SENSOR SYSTEM ...... 38 EZ-LETS LANCETS 28G ...... 37 FREESTYLE PRECISION INS SYR ...... 38 EZ-LETS LANCETS 30G ...... 37 FREESTYLE UNISTICK II LANCETS...... 38 F furosemide ...... 51 FERREX 150...... 17 G ferrous gluconate...... 18 GARDASIL 9 ...... 65 fiber laxative ...... 28 gas relief ...... 20 fiber-lax ...... 28 gas relief extra strength ...... 20 FIFTY50 PEN NEEDLES ...... 37 gas relief ultra strength ...... 20 FIFTY50 SAFETY SEAL LANCETS ...... 37 GAVILYTE-C ...... 29 FIFTY50 SUPERIOR COMFORT SYR ...... 37 GAVILYTE-G...... 29 FIFTY50 UNILET LANCETS 33G ...... 37 GAVILYTE-N WITH FLAVOR PACK ...... 29 FINE 30 ...... 37 generlac ...... 14 FINGERSTIX LANCETS ...... 37 GENTEEL BUTTERFLY TOUCH LANCET ... 38 FIRDAPSE...... 59 GENTEEL LANCING DEVICE (GOLD) ...... 38 fish oil ...... 59 GENTEEL LANCING DEVICE(PLATNM) ...... 38 flecainide acetate ...... 27 GENTEEL LANCING DEVICE(SILVER) ...... 38 FLORIVA...... 27, 56 GENTEEL LANCING KIT (BLUE) ...... 38 FLUAD...... 65 gentle laxative ...... 29 FLUAD QUADRIVALENT ...... 65 GENTLE-LET GP LANCETS ...... 38 FLUARIX QUADRIVALENT ...... 65 GENTLE-LET LANCETS ...... 38 FLUBLOK QUADRIVALENT ...... 65 geri-dryl ...... 54 FLUCELVAX QUADRIVALENT ...... 65 geri-lanta ...... 17 FLULAVAL QUADRIVALENT ...... 65 geri-mox ...... 17 FLUMIST QUADRIVALENT ...... 65 geri-pectate ...... 19 fluocinolone acetonide ...... 22 global ease inject pen needles ...... 38 FLUORABON...... 27 global easy glide insulin syr ...... 38 fluoritab ...... 28 global easy glide pen needles ...... 38 fluorouracil ...... 63 global inject ease insulin syr ...... 38 FLURA-DROPS ...... 28 global inject ease lancets 28g ...... 38 flutamide ...... 24 global inject ease lancets 30g ...... 38 FLUZONE HIGH-DOSE ...... 65 global insulin syringes ...... 38 FLUZONE HIGH-DOSE QUADRIVALENT .... 65 global lancing device ...... 38 FLUZONE QUADRIVALENT...... 65 GLUCAGEN DIAGNOSTIC ...... 20 FOLET ONE ...... 56 glucagon emergency ...... 20 folic acid ...... 67 GLUCOCOM LANCETS 28G ...... 38 FOLTANX ...... 67 GLUCOCOM LANCETS 30G ...... 38 FORA LANCETS ...... 37 GLUCOCOM LANCETS 33G ...... 38 FORA LANCING DEVICE...... 37 GLUCOPRO INSULIN SYRINGE...... 38 FORA V10/V12/D10/D20 TEST ...... 37 glucose ...... 20 FREESTYLE LANCETS...... 37 glycerin (adult) ...... 29 FREESTYLE LIBRE 14 DAY READER ...... 37 glycerin (child) ...... 29 ¹You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document Geisinger Family Supplemental Formulary Page 73 of 83 Effective Date: 9/22/2021 glycerin adult ...... 29 hm calcium antacid ultra st ...... 17 glycopyrrolate...... 18 hm calcium citrate+vitamin d ...... 62 gnp insulin syringes 28gx1/2 ...... 38 hm fiber ...... 29 gnp insulin syringes 29gx1/2 ...... 38 hm loperamide hcl ...... 19 gnp insulin syringes 30gx5/16 ...... 38 hm magnesium citrate ...... 29 gnp insulin syringes 31gx5/16 ...... 38 hm nasal spray ...... 66 gnp sterile lancets 28g...... 38 hm saline nasal spray ...... 52 gnp sterile lancets 30g...... 38 hm senna-s...... 29 gnp sterile lancets 33g...... 38 hm sinus nasal spray ...... 66 GOJJI LANCING DEVICE/CLEAR CAP...... 38 hm sore throat spray ...... 55 GOJJI STERILE LANCETS ...... 38 hm stool softener/laxative ...... 29 goodsense antacid ...... 17 HM ULTICARE INSULIN SYRINGE ...... 39 goodsense clickfine pen needle ...... 38 HM ULTICARE SHORT PEN NEEDLES ...... 39 goodsense color lancets 33g...... 39 HOMATROPAIRE ...... 59 goodsense lancets 26g univ ...... 39 homatropine hbr ...... 59 goodsense lancets 30g ...... 39 HYCAMTIN...... 24 goodsense lancets 30g univ ...... 39 HYCODAN...... 26 goodsense lancets 33g ...... 39 hydralazine hcl ...... 54 goodsense lancets 33g univ ...... 39 hydrochlorothiazide ...... 52 goodsense lancing device...... 39 hydrocod polst-cpm polst er ...... 26 goodsense magnesium citrate ...... 29 hydrocodone-homatropine ...... 26 GOODSENSE PEN NEEDLE PENFINE ...... 39 hydrocortisone ...... 22 goodsense sore throat spray ...... 55 hydrocortisone (perianal) ...... 22 goodsense stimulant laxative ...... 29 hydrocortisone anti-itch ...... 22 GYNE-LOTRIMIN ...... 21 hydrocortisone intensive heal ...... 22 H hydrocortisone plus ...... 22 hydrocortisone-acetic acid ...... 22 HAVRIX...... 65 hydromet ...... 26 HEALTH CARE LANCING DEVICE...... 39 HYPOLANCE AST LANCING ...... 39 healthwise insulin syr/needle...... 39 healthwise micron pen needles...... 39 HY-VEE LANCETS ...... 39 hy-vee thin lancets ...... 39 healthwise mini pen needles ...... 39 healthwise pen needles ...... 39 I healthwise short pen needles ...... 39 ICAR-C PLUS ...... 18 healthwise unifine pentips ...... 39 IFEREX 150 ...... 18 healthy accents lancing device ...... 39 IMODIUM A-D ...... 19 healthy accents unifine pentip ...... 39 IN TOUCH LANCING DEVICE ...... 39 healthy accents unilet lancets ...... 39 IN TOUCH STERILE LANCETS 30G ...... 39 HEALTHY MAMA SHAKE THAT ACHE...... 15 indapamide ...... 52 hemenatal ob + dha ...... 56 INQOVI...... 24, 59 hemorrhoidal relief ...... 25 insulin syringe ...... 39 heparin sodium (porcine) ...... 25 insulin syringe/needle ...... 39 heparin sodium (porcine) pf ...... 26 insulin syringe-needle u-100...... 39 HEPLISAV-B ...... 65 insupen pen needles...... 40 hm antacid ...... 17 INSUPEN SENSITIVE ...... 40 hm antacid/antigas ...... 17 INSUPEN ULTRAFIN ...... 40 hm calcium antacid ...... 17 INTRON A...... 24 ¹You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document Geisinger Family Supplemental Formulary Page 74 of 83 Effective Date: 9/22/2021 iodine strong...... 53 lancet device ...... 40 isoniazid ...... 23 lancet device with ejector ...... 40 J lancet transporter case ...... 40 lancets ...... 40 janssen covid-19 vaccine ...... 65 lancets 28g ...... 40 jock itch spray powder ...... 21 lancets 30g ...... 40 JYNARQUE ...... 52 lancets 33g ...... 40 K lancets micro thin 33g...... 40 KALYDECO ...... 31 lancets super thin 28g ...... 40 KAOPECTATE...... 19 lancets thin ...... 40 KAOPECTATE EXTRA STRENGTH ...... 19 LANCETS ULTRA FINE...... 40 KAO-TIN ...... 19 LANCETS ULTRA THIN ...... 40 KETOSTIX ...... 64 lancets ultra thin 30g...... 40 kinney lancets ...... 40 lancing device ...... 40 kinney thin lancets...... 40 LANZO ...... 40 kinray insulin syringe ...... 40 laxacin ...... 29 KIONEX...... 54 laxative ...... 29 KLOR-CON...... 62 leader advanced lancing device...... 40 KLOR-CON 10 ...... 62 leader insulin syringe ...... 40 KLOR-CON M10...... 62 LEADER UNIFINE PENTIPS ...... 40 KLOR-CON M15...... 62 LEADER UNIFINE PENTIPS PLUS...... 40 KLOR-CON M20...... 62 leflunomide ...... 51 KLOR-CON SPRINKLE...... 62 leucovorin calcium...... 19 kls fiber-tabs ...... 29 LEUKERAN ...... 24 kls hydrocortisone plus ...... 22 levocarnitine ...... 59 kls nasal decongestant spray ...... 66 levocarnitine sf ...... 59 KLS QUIT2 ...... 27 levonorgestrel ...... 30 kmart valu insulin syringe 29g ...... 40 LIBERTY MEDICAL LANCETS ...... 40 kmart valu insulin syringe 30g ...... 40 LIBERTY MINI LANCING DEVICE ...... 40 KOATE-DVI ...... 20 lice treatment...... 22 kosher prenatal plus iron ...... 56 lidocaine-hydrocortisone ace...... 25 kp bacitracin zinc ...... 20 lidopac ...... 25 kp benzoyl peroxide ...... 21 lidopin ...... 25 kp benzoyl peroxide wash...... 21 LIFESCAN UNISTIK 2 ...... 40 kp folic acid...... 67 LIFESCAN UNISTIK II LANCETS ...... 40 kp hydrocortisone ...... 22 linezolid ...... 18 kp hydrocortisone-aloe ...... 22 lite touch lancets ...... 40 kp mag-oxide magnesium ...... 62 LITE TOUCH LANCING PEN...... 40 kp miconazole nitrate ...... 21 LITETOUCH INSULIN SYRINGE ...... 40 kp terbinafine hydrochloride ...... 21 LITETOUCH LANCETS ...... 40 kp tolnaftate ...... 21 LITETOUCH PEN NEEDLES ...... 40 K-PHOS ...... 62 lithium ...... 23 KUVAN ...... 59 lithium carbonate ...... 23 L lithium carbonate er ...... 23 live better adv lancing device ...... 40 lactulose ...... 15 live better lancet super thin ...... 40 lactulose encephalopathy ...... 15 ¹You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document Geisinger Family Supplemental Formulary Page 75 of 83 Effective Date: 9/22/2021 live better lancet ultra thin ...... 40 MEIJER LANCETS THIN ...... 41 l-methylfolate ...... 59 MEIJER LANCETS UNIVERSAL 21G ...... 41 longs insulin syringe...... 40 MEIJER LANCETS UNIVERSAL 30G ...... 41 longs lancets standard...... 41 MEIJER LANCETS UNIVERSAL 33G ...... 41 longs lancets thin...... 41 MEIJER SUPER THIN LANCETS ...... 41 longs lancets ultra thin ...... 41 melatonin ...... 59 loperamide hcl...... 19 melatonin/vitamin b-6 ex st ...... 59 LOTRIMIN AF DEODORANT POWDER ...... 21 melatonin-pyridoxine...... 59 LOTRIMIN AF JOCK ITCH POWDER ...... 21 melphalan ...... 24 LOTRIMIN ULTRA ...... 21 MENACTRA ...... 65 LUDENT...... 28 MENQUADFI...... 65 LYSODREN...... 24 MENVEO ...... 65 M MEPHYTON ...... 68 MEPRON ...... 25 mag-al plus ...... 17 mercaptopurine ...... 24 MAGELLAN INSULIN SAFETY SYR ...... 41 methazolamide ...... 20 magnesium ...... 62 methimazole ...... 64 magnesium citrate ...... 29 methylergonovine maleate...... 60 magnesium oxide ...... 17, 62 methylprednisolone acetate...... 14 MAGNESIUM-OXIDE ...... 62 methylprednisolone sodium succ...... 14 MAGOX 400 ...... 62 metolazone ...... 52 mapap ...... 15 METOPIC ...... 55 MAPAP CHILDRENS ...... 15 metronidazole ...... 21 MARATHON MEDICAL PENTIPS...... 41 mexiletine hcl ...... 27 MARNATAL-F ...... 56 miconazole antifungal ...... 21 MATULANE ...... 24 MICRODOT PEN NEEDLE ...... 41 MAXICOMFORT II PEN NEEDLE ...... 41 MICROLET LANCETS ...... 41 MAXI-COMFORT INSULIN SYRINGE ...... 41 MICROLET NEXT LANCING DEVICE ...... 42 MAXI-COMFORT SAFETY PEN NEEDLE .... 41 midodrine hcl ...... 64 MAXICOMFORT SYR 27G X 1/2 ...... 41 milk of magnesia...... 29 medic insulin syringe ...... 41 milk of magnesia concentrate...... 29 medichoice safety lancet ...... 41 mini lancing device ...... 42 medichoice safety lancet extra ...... 41 minoxidil ...... 54 medichoice safety lancet norm...... 41 misoprostol ...... 26 medicine shoppe pen needles ...... 41 mm insulin syringe/needle ...... 42 MEDISENSE THIN LANCETS ...... 41 MM LANCING DEVICE ...... 42 MEDLANCE EXTRA 21G ...... 41 MM PEN NEEDLES ...... 42 MEDLANCE LITE 25G ...... 41 MM TWIS T LANCETS ...... 42 MEDLANCE PLUS EXTRA 21G...... 41 M-M-R II ...... 65 MEDLANCE PLUS LANCETS ...... 41 MONISTAT SOOTHING CARE ITCH ...... 22 MEDLANCE PLUS LITE 25G...... 41 MONOJECT INSULIN SYRINGE ...... 42 MEDLANCE PLUS SPECIAL 0.8MM ...... 41 MONOJECT ULTRA COMFORT SYRINGE . 42 MEDLANCE PLUS SUPERLITE 30G ...... 41 MONOLET LANCETS ...... 42 MEDLANCE PLUS UNIVERSAL 21G ...... 41 MONOLET OPD LANCETS ...... 42 MEDLANCE UNIVERSAL 21G ...... 41 MONOLETTOR SAFETY LANCETS ...... 42 megestrol acetate ...... 24, 60 m-pap ...... 15 MEIJER LANCETS ...... 41 ¹You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document Geisinger Family Supplemental Formulary Page 76 of 83 Effective Date: 9/22/2021 mpd safety lancet 21g ...... 42 NITYR...... 59 mpd safety lancet 23g ...... 42 no drip nasal spray ...... 66 mpd safety lancet 28g ...... 42 NOBLE FORMULA HC ...... 22 ms insulin syringe ...... 42 non-aspirin extra strength ...... 15 MUCINEX SINUS-MAX CLEAR & COOL ...... 66 NOVA SAFETY LANCETS 23G ...... 42 MUCINEX SINUS-MAX FULL FORCE ...... 66 NOVA SAFETY LANCETS 28G ...... 42 multi-lancet device ...... 42 NOVA SUREFLEX LANCETS ...... 42 MULTI-LANCET DEVICE 2 ...... 42 NOVA SUREFLEX LANCING DEVICE ...... 42 multi-vit/iron/fluoride ...... 56 novavax covid-19 vaccine ...... 65 multivitamin + fluoride ...... 56 NOVOFINE AUTOCOVER PEN NEEDLE ..... 42 multivitamin select/fluoride...... 56 NOVOFINE PEN NEEDLE ...... 42 multivitamin/fluoride ...... 56 NOVOFINE PLUS PEN NEEDLE...... 42 multivitamin/fluoride/iron ...... 56 NOVOTWIST PEN NEEDLE ...... 42 multi-vitamin/fluoride/iron ...... 56 nystatin ...... 20 MVC-FLUORIDE ...... 56 O MY WAY ...... 30 OBSTETRIX DHA ...... 57 MYGLUCOHEALTH LANCETS 30G ...... 42 OBSTETRIX EC ...... 57 MYLERAN ...... 25 OBSTETRIX ONE ...... 57 MYNATAL...... 56 OBTREX DHA...... 57 MYNATAL ADVANCE ...... 56 octreotide acetate ...... 59, 64 mynatal plus ...... 56 OFF DEEP WOODS DRY ...... 63 mynatal-z ...... 56 omega 3 ...... 59 mynate 90 plus ...... 56 omega iii epa+dha ...... 59 mynephrocaps ...... 56 omega-3 ...... 59 MYNEPHRON...... 56 omega-3 fish oil ...... 59 N OMNIPOD 5 PACK ...... 42 NARAMIN ...... 54 OMNIPOD DASH 5 PACK PODS ...... 42 nasal decongestant spray ...... 66 ON CALL LANCETS ...... 42 nasal four ...... 66 ON CALL LANCING DEVICE...... 42 nasal moisturizing spray...... 52 ON CALL PLUS LANCETS ...... 42 nasal relief ...... 66 ON CALL PLUS LANCING DEVICE ...... 42 nasal spray ...... 66 ondansetron hcl ...... 19 nasal spray 12 hour ...... 66 ONETOUCH CLUB LANCETS FINE PT ...... 42 nasal spray extra moisturizing...... 66 ONETOUCH DELICA LANCETS 30G ...... 43 nasal spray no drip ...... 66 ONETOUCH DELICA LANCETS 33G ...... 43 nasal spray sinus...... 66 ONETOUCH DELICA LANCETS FINE ...... 43 NATACHEW...... 57 ONETOUCH DELICA LANCING DEV ...... 43 NATELLE ONE ...... 57 ONETOUCH DELICA PLUS LANCET30G .... 43 NEBUSAL ...... 55 ONETOUCH DELICA PLUS LANCET33G .... 43 NEEVO DHA ...... 57 ONETOUCH DELICA PLUS LANCING...... 43 NEOSPORIN + PAIN/ITCH/SCAR ...... 21 ONETOUCH DELICA SAFETY LANCING..... 43 NESTABS ABC...... 57 ONETOUCH FINEPOINT LANCETS...... 43 NEXA PLUS ...... 57 ONETOUCH SURESOFT LANCING DEV..... 43 NEXT CHOICE ONE DOSE ...... 30 ONETOUCH ULTRA CONTROL ...... 43 NILANDRON ...... 25 ONETOUCH ULTRASOFT LANCETS ...... 43 nilutamide ...... 25 ONETOUCH VERIO ...... 43 ¹You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document Geisinger Family Supplemental Formulary Page 77 of 83 Effective Date: 9/22/2021 OPCICON ONE-STEP ...... 30 pnv ob+dha...... 57 OPTICHAMBER DIAMOND ...... 43 podofilox...... 63 OPTICHAMBER DIAMOND-LG MASK ...... 43 polyethylene glycol 3350 ...... 29 OPTICHAMBER DIAMOND-MD MASK ...... 43 POLY-IRON 150 ...... 18 OPTICHAMBER DIAMOND-SM MASK ...... 43 POLY-VI-FLOR ...... 57 OPTION 2 ...... 30 POLY-VI-FLOR/IRON...... 57 oral relief ...... 55 POLY-VI-SOL/IRON ...... 57 ORALONE ...... 22 potassium chloride ...... 62 ORKAMBI ...... 30 potassium chloride crys er ...... 62 oyster shell calcium 500+d ...... 62 potassium chloride er...... 62 P potassium citrate er...... 14 PR NATAL 400 ...... 57 PACERONE ...... 27 PR NATAL 400 EC...... 57 pain & fever childrens ...... 15 PR NATAL 430 ...... 57 pain & fever extra strength...... 15 pain reliever extra strength ...... 15 PR NATAL 430 EC...... 57 pramoxine hcl (perianal)...... 25 PALYNZIQ ...... 53 praziquantel ...... 17 pc lancets super thin 30g ...... 43 PRECISION SUREDOSE PLUS SYR ...... 44 pc pediatric iron drops ...... 18 PRECISION SURE-DOSE SYRINGE...... 44 pc unifine pentips ...... 43 PEDIA-LAX...... 29 PRECISION THINS GP LANCETS ...... 44 prednisolone acetate p-f...... 22 pediatric medium mask ...... 43 preferred plus insulin syringe ...... 44 pediatric small mask ...... 43 preferred plus lancets colored ...... 44 peg 3350/electrolytes...... 29 preferred plus lancets thin...... 44 peg 3350-kcl-na bicarb-nacl ...... 29 peg-3350/electrolytes ...... 29 preferred plus unifine pentips ...... 44 prena 1 true ...... 57 pen needles ...... 43 prena1 ...... 57 pen needles 1/2 ...... 43 prenatabs fa ...... 57 pen needles 3/16 ...... 43 PRENATABS RX...... 57 pen needles 5/16 ...... 43 PENTIPS...... 43 prenatal 19...... 57 prenatal low iron ...... 57 pentoxifylline er ...... 54 prenatal multi +dha ...... 57 peptic relief ...... 19 prenatal plus iron ...... 57 PERFECT LANCETS 28G...... 44 PRENATAL-U ...... 57 PERFECT LANCETS 30G...... 44 pharbedryl...... 54 PREPARATION H ...... 22 pressure activat safety lancet ...... 44 PHARMACIST CHOICE LANCETS ...... 44 pretomanid...... 24 PHARMACY COUNTER LANCETS ...... 44 PREVENT SAFETY PEN NEEDLES ...... 44 phenaseptic ...... 55 PREVNAR 13...... 65 phenazopyridine hcl ...... 25 phenylephrine hcl ...... 66 PREVNAR 20...... 65 PRIZOTRAL-II...... 25 PHOSPHA 250 NEUTRAL ...... 62 PRO COMFORT INSULIN SYRINGE...... 44 phytonadione...... 68 pro comfort lancets 30g ...... 44 pilocarpine hcl ...... 60 pro comfort lancets 31g ...... 44 pip lancets 28g...... 44 pip lancets 30g...... 44 pro comfort pen needles ...... 44 prochlorperazine edisylate ...... 61 PNEUMOVAX 23 ...... 65 ¹You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document Geisinger Family Supplemental Formulary Page 78 of 83 Effective Date: 9/22/2021 PROCTOFOAM HC ...... 25 RELION LANCING DEVICE ...... 45 PROCTO-MED HC ...... 22 RELION MINI PEN NEEDLES ...... 45 PROCTO-PAK ...... 23 RELION PEN NEEDLES...... 45 PROCTOSOL HC...... 23 RELION SHORT PEN NEEDLES ...... 45 PROCTOZONE-HC ...... 23 RELION ULTRA THIN LANCETS 30G ...... 45 PRODIGY INSULIN SYRINGE ...... 44 RELION ULTRA THIN PLUS LANCETS ...... 45 PRODIGY LANCETS 28G ...... 44 relnate dha...... 58 PRODIGY LANCING DEVICE ...... 44 RENAL ...... 58 PRODIGY SAFETY LANCETS 26G ...... 44 reno caps ...... 58 PRODIGY TWIST TOP LANCETS 28G ...... 44 REPEL SPORTSMEN MAX ...... 63 promethazine-codeine ...... 26 RESTASIS MULTIDOSE ...... 23 propafenone hcl ...... 27 REXALL LANCETS ULTRA THIN 30G ...... 45 propantheline bromide ...... 18 RIDAURA...... 54 propylthiouracil...... 64 rifabutin ...... 24 PROQUAD ...... 65 rifampin ...... 24 PSS SELECT GP LANCETS ...... 44 RIGHTEST GD500 LANCING DEVICE...... 45 PSS SELECT SAFETY LANCETS...... 44 RIGHTEST GL300 LANCETS...... 45 PULMOZYME ...... 55 riluzole ...... 30 pure comfort pen needle ...... 44 R-NATAL OB...... 58 purefe plus ...... 18 rulox ...... 17 push button safety lancets ...... 44 S push button safety lancets 28g ...... 44 SAFESNAP INSULIN SYRINGE ...... 45 px lancets microthin 33g ...... 44 SAFE-T-LANCE...... 45 pyrazinamide ...... 24 safety insulin syringes ...... 45 pyridostigmine bromide ...... 60 safety lancet 21g/pressure act ...... 46 Q safety lancet 23g/pressure act ...... 46 QBREXZA...... 63 safety lancet 28g/pressure act ...... 46 QUFLORA FE ...... 57 safety lancet 30g/pressure act ...... 46 QUFLORA FE PEDIATRIC...... 57 SAFETY LANCETS ...... 46 QUFLORA PEDIATRIC ...... 58 SAFETY LANCETS 21G ...... 46 quinidine sulfate...... 27 safety lancets 28g ...... 46 R SAFETY LET LANCETS ...... 46 SAFETY SEAL LANCETS ...... 46 READYLANCE SAFETY LANCETS ...... 44 salicylic acid ...... 55 READYSHARP DEXAMETHASONE...... 14 salicylic acid-cleanser ...... 55 reality insulin syringe ...... 44 saline mist spray ...... 52 reality lancets ...... 45 saline nasal spray...... 52 reality trigger lancets...... 45 salsalate ...... 16 RECOMBIVAX HB ...... 65 sapropterin dihydrochloride ...... 60 RELION INSULIN SYRINGE...... 45 saps health twist top lancets...... 46 RELI-ON INSULIN SYRINGE ...... 45 saps twist top lancets...... 46 RELION LANCET DEVICES 30G ...... 45 sapscare twist top lancets ...... 46 RELION LANCETS MICRO-THIN 33G ...... 45 scalp relief maximum strength ...... 23 RELION LANCETS STANDARD 21G ...... 45 SECURESAFE INSULIN SYRINGE ...... 46 RELION LANCETS THIN 26G ...... 45 select-lite device/lancets ...... 46 RELION LANCETS ULTRA-THIN 30G...... 45 select-lite lancing device ...... 46 ¹You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document Geisinger Family Supplemental Formulary Page 79 of 83 Effective Date: 9/22/2021 selenium sulfide ...... 21 SOLU-CORTEF ...... 14 senexon-s ...... 29 SOLU-MEDROL ...... 14 SENEXON-S ...... 29 SOLUS V2 LANCETS 28G ...... 46 senna...... 29 SOLUS V2 LANCING DEVICE ...... 46 senna plus ...... 29 SOLUS V2 TWIST LANCETS 30G ...... 46 senna s...... 29 SOOTHE...... 19 senna-docusate sodium ...... 29 sore throat ...... 55 senna-plus ...... 29 sore throat spray...... 55 senna-s ...... 29 spironolactone...... 61 senna-time s...... 30 spironolactone-hctz ...... 61 sennosides-docusate sodium ...... 30 SPS...... 55 sf 28 SSD ...... 21 sf 5000 plus ...... 28 STERILANCE PA ...... 47 SHINGRIX ...... 65 STERILANCE TL...... 47 SHOPKO AUTOLET LANCING DEVICE ...... 46 sterile water for irrigation ...... 55 SHOPKO ON-THE-GO LANCETS 30G ...... 46 stimulant laxative ...... 30 SHOPKO UNIFINE PENTIPS ...... 46 stomach relief...... 19 SHOPKO UNIFINE PENTIPS PLUS...... 46 stool softener plus laxative ...... 30 SHOPKO UNILET LANCETS 28G ...... 46 stool softener/laxative ...... 30 SHOPKO UNILET LANCETS 30G ...... 46 stop lice complete treatment...... 22 side button safety lancet ...... 46 STRENSIQ ...... 53 silace ...... 30 sucralfate ...... 26 silver sulfadiazine ...... 21 SULFACLEANSE 8/4 ...... 55 simethicone ...... 20 sulfamethoxazole-trimethoprim ...... 18 SIMPLE DIAGNOSTICS LANCING DEV ...... 46 SULFATRIM PEDIATRIC ...... 18 sinus nasal spray...... 66 super calcium 600 + d 400...... 62 sinus relief ...... 66 SUPER OMEGA-3 ...... 60 sinus relief extra strength ...... 66 super thin lancets ...... 47 SIVEXTRO ...... 18 sure comfort insulin syringe ...... 47 sleep tabs ...... 26 sure comfort lancets 18g ...... 47 SMART DIABETES VANTAGE LANCING..... 46 sure comfort lancets 21g ...... 47 SMART SENSE COLOR LANCETS 33G ...... 46 sure comfort lancets 23g ...... 47 SMART SENSE STANDARD LANCETS ...... 46 sure comfort lancets 28g ...... 47 SMART SENSE SUPER THIN LANCETS ..... 46 sure comfort lancets 30g ...... 47 SMART SENSE THIN LANCETS 26G ...... 46 sure comfort lancing pen ...... 47 SMARTEST LANCETS 28G...... 46 sure comfort pen needles ...... 47 sod citrate-citric acid ...... 14 SURE-FINE PEN NEEDLES ...... 47 sodium bicarbonate...... 17 SURE-JECT INSULIN SYRINGE ...... 47 sodium chloride...... 55 SURE-LANCE FLAT LANCETS ...... 47 sodium chloride (hypertonic) ...... 52 SURE-LANCE LANCETS 26G...... 47 sodium fluoride ...... 28 SURE-LANCE THIN LANCETS 28G ...... 47 sodium fluoride 5000 plus ...... 28 SURE-LANCE ULTRA THIN LANCETS...... 47 sodium fluoride 5000 ppm...... 28 SURELITE LANCETS ...... 47 sodium fluoride 5000 sensitive ...... 31 SURE-TOUCH LANCETS UNIVERSAL...... 47 sodium polystyrene sulfonate ...... 54 SYLATRON ...... 25 SOLUBLE FIBER THERAPY ...... 30 SYMDEKO...... 30

¹You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document Geisinger Family Supplemental Formulary Page 80 of 83 Effective Date: 9/22/2021 T TRUEDRAW LANCING DEVICE...... 48 TDVAX ...... 64 TRUEPLUS 5-BEVEL PEN NEEDLES...... 48 TECHLITE AST LANCETS ...... 47 TRUEPLUS INSULIN SYRINGE ...... 48 techlite insulin syringe ...... 47 TRUEPLUS LANCETS 26G ...... 48 TECHLITE LANCETS...... 47 TRUEPLUS LANCETS 28G ...... 48 TECHLITE LANCETS 30G ...... 47 TRUEPLUS LANCETS 30G ...... 48 TECHLITE PEN NEEDLES ...... 47 TRUEPLUS LANCETS 33G ...... 48 TEGSEDI ...... 25 TRUEPLUS PEN NEEDLES ...... 48 TENIVAC ...... 64 TRUEPLUS SAFETY LANCETS 28G ...... 48 testosterone cypionate ...... 16 TRUMENBA ...... 65 tetanus-diphtheria toxoids td ...... 64 TWINRIX...... 65 theophylline ...... 63 U theophylline er...... 63 ULTICARE INSULIN SAFETY SYR ...... 48 therapeutic-m ...... 58 ULTICARE INSULIN SYRINGE ...... 48 THINLETS GP LANCETS ...... 47 ULTICARE MICRO PEN NEEDLES ...... 48 TIGLUTIK ...... 30 ULTICARE MINI PEN NEEDLES ...... 48 todays health lancing device ...... 47 ULTICARE PEN NEEDLES...... 48 todays health mini pen needles ...... 47 ULTICARE SAFETY SYRINGE ...... 48 todays health thin lancets 28g...... 47 ULTICARE SHORT PEN NEEDLES...... 48 todays health thin lancets 30g...... 47 ultiguard safepack pen needle ...... 48 tolvaptan ...... 52 ULTI-LANCE AUTOMATIC...... 48 topcare clickfine pen needles ...... 47 ULTILET CLASSIC LANCETS ...... 48 topcare lancets micro-thin 33g ...... 47 ULTILET INSULIN SYRINGE...... 48 topcare ultra comfort ins syr ...... 47 ULTILET INSULIN SYRINGE SHORT ...... 48 torsemide ...... 51 ULTILET LANCETS ...... 49 total allergy ...... 54 ULTILET PEN NEEDLE ...... 49 TRANSDERM SCOP (1.5 MG) ...... 20 ULTILET SAFETY LANCETS ...... 49 travel lancets ...... 47 ULTILET SAFETY LANCETS 23G...... 49 TRAVEL LANCETS ADVANCED 28G ...... 47 ultimatecare one ...... 58 treprostinil ...... 67 ultra comfort insulin syringe ...... 49 triamcinolone acetonide ...... 23 ULTRA FLO INSULIN PEN NEEDLES...... 49 triamterene-hctz...... 51 ULTRA FLO INSULIN SYRINGE...... 49 TRICARE PRENATAL DHA ONE ...... 58 ultra thin lancets 31g...... 49 TRIDESILON...... 23 ULTRA THIN PEN NEEDLES ...... 49 trifluridine ...... 21 ultracare insulin syringe...... 49 TRIKAFTA ...... 30 ultra-care lancets 30g ...... 49 TRILYTE ...... 30 ultracare pen needles ...... 49 trimethoprim ...... 64 ultra-comfort insulin syringe...... 49 TRINATE...... 58 ULTRALANCE ...... 49 triphrocaps ...... 58 ULTRA-THIN II AUTO LANCET ...... 49 TRI-VI-FLOR ...... 58 ULTRA-THIN II INS SYR SHORT ...... 49 tri-vitamin/fluoride ...... 58 ULTRA-THIN II INSULIN SYRINGE ...... 49 true comfort insulin syringe ...... 47 ULTRA-THIN II LANCETS ...... 49 true comfort pen needles ...... 47 ULTRA-THIN II MINI PEN NEEDLE ...... 49 true comfort pro insulin syr ...... 48 ULTRA-THIN II PEN NEEDLE SHORT ...... 49 true comfort twist top lancets...... 48 ULTRA-THIN II PEN NEEDLES ...... 49 ¹You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document Geisinger Family Supplemental Formulary Page 81 of 83 Effective Date: 9/22/2021 UNIFINE PENTIPS ...... 49 value plus lancets super thin ...... 50 UNIFINE PENTIPS PLUS ...... 49 value plus lancets thin 26g ...... 50 UNIFINE SAFECONTROL PEN NEEDLE ..... 49 value plus lancing device ...... 51 UNILET COMFORTOUCH LANCET ...... 49 valumark lancet super thin 30g ...... 51 UNILET EXCELITE ...... 49 valumark lancet ultra thin 28g ...... 51 UNILET EXCELITE II...... 49 valumark pen needles ...... 51 UNILET G.P. LANCET ...... 49 VANICREAM HC MAXIMUM STRENGTH .... 23 UNILET G.P. SUPERLITE LANCET ...... 49 VANISHPOINT INSULIN SYRINGE ...... 51 UNILET GP 28 ULTRA THIN ...... 49 VAQTA ...... 66 UNILET LANCET ...... 49 VARIVAX ...... 66 UNILET MICRO-THIN 33G...... 49 vegetable lax+stool softener...... 30 UNILET SUPERLITE LANCET ...... 50 vena-bal dha ...... 58 UNILET SUPER-THIN 30G ...... 50 VICKS SINEX DAYTIME...... 64 UNILET ULTRA-THIN 28G ...... 50 VIDA MIA AUTOLET LANCING DEV ...... 51 UNISTIK 1...... 50 VIDA MIA UNIFINE PENTIPS...... 51 UNISTIK 2...... 50 VIDA MIA UNILET LANCETS 28G ...... 51 UNISTIK 2 COMFORT ...... 50 VIDA MIA UNILET LANCETS 30G ...... 51 UNISTIK 2 EXTRA ...... 50 VINATE CARE ...... 58 UNISTIK 2 NEONATAL ...... 50 VINATE II ...... 58 UNISTIK 2 NORMAL ...... 50 VINATE M...... 58 UNISTIK 2 SUPER...... 50 VINATE ONE ...... 58 UNISTIK 3...... 50 virt-caps...... 58 UNISTIK 3 COMFORT ...... 50 vision vitamins...... 58 UNISTIK 3 EXTRA ...... 50 VITAMEDMD ONE RX/QUATREFOLIC...... 58 UNISTIK 3 GENTLE ...... 50 VITAMEDMD REDICHEW RX ...... 58 UNISTIK 3 NEONATAL ...... 50 vitamin b1 ...... 67 UNISTIK 3 NORMAL ...... 50 vitamin b12 ...... 67 UNISTIK CZT COMFORT...... 50 vitamin b-12 ...... 67 UNISTIK CZT NORMAL...... 50 vitamin b-2 ...... 67 UNISTIK NORMAL...... 50 vitamin b-6 ...... 67 UNISTIK PRO SAFETY LANCET ...... 50 vitamin c ...... 67 UNISTIK SAFETY LANCETS 28G ...... 50 vitamin d (ergocalciferol) ...... 67 UNISTIK SAFETY LANCETS 30G ...... 50 vitamin d3 ...... 67 UNISTIK TOUCH SAFETY LANC 21G ...... 50 vitamin e...... 67 UNISTIK TOUCH SAFETY LANC 23G ...... 50 vitamin e-200...... 67 UNISTIK TOUCH SAFETY LANC 28G ...... 50 vitamins acd-fluoride ...... 58 UNISTIK TOUCH SAFETY LANC 30G ...... 50 VITAPEARL...... 58 UNIVERSAL 1 LANCETS THIN 26G ...... 50 VITATRUE ...... 58 UNIVERSAL 1 LANCETS THIN 33G ...... 50 VIVA DHA ...... 58 UNIVERSAL 1 LANCETS ULTRA THIN ...... 50 VIVAGUARD LANCETS ...... 51 urea...... 55 VIVAGUARD LANCING DEVICE ...... 51 urea hydrating ...... 55 VIVOTIF ...... 66 urea nail ...... 55 vol-nate ...... 58 V vol-tab rx ...... 58 value health insulin syringe...... 50 vp insulin syringe ...... 51 value plus lancet standard 21g ...... 50 ¹You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document Geisinger Family Supplemental Formulary Page 82 of 83 Effective Date: 9/22/2021 W Z WINRHO SDF ...... 26 zevrx insulin syringe...... 51 X zevrx twist top lancets 30g...... 51 zinc oxide ...... 27 XENLETA ...... 18 XERAC AC ...... 27 ZOKINVY ...... 60 ZOSTAVAX ...... 66 XERMELO ...... 19 xurea...... 55