PA Medical Assistance Fee-For-Service Quantity Limits & Daily Dose Limits

Effective 01/04/21 Alphabetical by Brand Name (when applicable)

PA Medical Assistance Fee-for-Service Quantity Limits & Daily Dose Limits Maximum Therapy Class Brand Name Generic Name Daily Dose Limit Antipsychotics, Atypical ABILIFY 1 MG/ML SOLUTION ARIPIPRAZOLE 25 Antipsychotics, Atypical ABILIFY 10 MG DISCMELT ARIPIPRAZOLE 2 Antipsychotics, Atypical ABILIFY 10 MG TABLET ARIPIPRAZOLE 1 Antipsychotics, Atypical ABILIFY 15 MG DISCMELT ARIPIPRAZOLE 2 Antipsychotics, Atypical ABILIFY 15 MG TABLET ARIPIPRAZOLE 1 Antipsychotics, Atypical ABILIFY 2 MG TABLET ARIPIPRAZOLE 2 Antipsychotics, Atypical ABILIFY 20 MG TABLET ARIPIPRAZOLE 1 Antipsychotics, Atypical ABILIFY 30 MG TABLET ARIPIPRAZOLE 1 Antipsychotics, Atypical ABILIFY 5 MG TABLET ARIPIPRAZOLE 1.5 Antipsychotics, Atypical ABILIFY 9.75 MG/1.3 ML INJECTION VIAL ARIPIPRAZOLE 3.9 Antipsychotics, Atypical ABILIFY MAINTENA ER 300 MG SYRINGE ARIPIPRAZOLE 0.04 Antipsychotics, Atypical ABILIFY MAINTENA ER 300 MG VIAL ARIPIPRAZOLE 0.04 Antipsychotics, Atypical ABILIFY MAINTENA ER 400 MG SYRINGE ARIPIPRAZOLE 0.04 Antipsychotics, Atypical ABILIFY MAINTENA ER 400 MG VIAL ARIPIPRAZOLE 0.04 Antipsychotics, Atypical ABILIFY MYCITE 10 MG KIT ARIPIPRAZOLE 1 Antipsychotics, Atypical ABILIFY MYCITE 15 MG KIT ARIPIPRAZOLE 1 Antipsychotics, Atypical ABILIFY MYCITE 2 MG KIT ARIPIPRAZOLE 1 Antipsychotics, Atypical ABILIFY MYCITE 20 MG KIT ARIPIPRAZOLE 1 Antipsychotics, Atypical ABILIFY MYCITE 30 MG KIT ARIPIPRAZOLE 1 Antipsychotics, Atypical ABILIFY MYCITE 5 MG KIT ARIPIPRAZOLE 1 Antivirals, Herpes ABREVA 10% CREAM DOCASONAL 1 Analgesics, Opioid Short-Acting ABSTRAL 100 MCG SUBLINGUAL TABLET FENTANYL CITRATE SUBLINGUAL 4 Analgesics, Opioid Short-Acting ABSTRAL 200 MCG SUBLINGUAL TABLET FENTANYL CITRATE SUBLINGUAL 4 Analgesics, Opioid Short-Acting ABSTRAL 300 MCG SUBLINGUAL TABLET FENTANYL CITRATE SUBLINGUAL 4 Analgesics, Opioid Short-Acting ABSTRAL 400 MCG SUBLINGUAL TABLET FENTANYL CITRATE SUBLINGUAL 4 Analgesics, Opioid Short-Acting ABSTRAL 600 MCG SUBLINGUAL TABLET FENTANYL CITRATE SUBLINGUAL 4 Analgesics, Opioid Short-Acting ABSTRAL 800 MCG SUBLINGUAL TABLET FENTANYL CITRATE SUBLINGUAL 4 Leukotriene Modifiers ACCOLATE 10 MG TABLET ZAFIRLUKAST 2 Leukotriene Modifiers ACCOLATE 20 MG TABLET ZAFIRLUKAST 2 Blood Glucose Test Strips ACCU-CHECK ACTIVE BLOOD GLUCOSE TEST STRIPS BLOOD GLUCOSE TEST STRIPS 3.34 Blood Glucose Meters ACCU-CHECK ACTIVE CARE BLOOD GLUCOSE METER BLOOD GLUCOSE METER See footnote2 Blood Glucose Meters ACCU-CHECK ADVANTAGE BLOOD GLUCOSE METER BLOOD GLUCOSE METER See footnote2 Blood Glucose Meters ACCU-CHECK AVIVA PLUS BLOOD GLUCOSE METER BLOOD GLUCOSE METER See footnote2 Blood Glucose Test Strips ACCU-CHECK AVIVA PLUS BLOOD GLUCOSE TEST STRIPS BLOOD GLUCOSE TEST STRIPS 3.34 Blood Glucose Test Strips ACCU-CHECK COMFORT CURVE BLOOD GLUCOSE STRIPS BLOOD GLUCOSE TEST STRIPS 3.34 Blood Glucose Test Strips ACCU-CHECK COMPACT BLOOD GLUCOSE TEST STRIPS BLOOD GLUCOSE TEST STRIPS 3.34 Effective 01/04/21 Alphabetical by Brand Name (when applicable)

Blood Glucose Meters ACCU-CHECK COMPACT PLUS BLOOD GLUCOSE METER BLOOD GLUCOSE METER See footnote2 Diabetic Supplies, Miscellaneous ACCU-CHECK FASTCLIX LANCET KIT BLOOD GLUCOSE LANCING DEVICE 1 Diabetic Supplies, Miscellaneous ACCU-CHECK MULTICLIX LANCET KIT BLOOD GLUCOSE LANCING DEVICE 1 Blood Glucose Meters ACCU-CHECK NANO SMARTVIEW BLOOD GLUCOSE METER BLOOD GLUCOSE METER See footnote2 Blood Glucose Test Strips ACCU-CHECK SMARTVIEW BLOOD GLUCOSE TEST STRIPS BLOOD GLUCOSE TEST STRIPS 3.34 Diabetic Supplies, Miscellaneous ACCU-CHECK SOFTCLIX LANCING KIT BLOOD GLUCOSE LANCING DEVICE 1 Blood Glucose Meters ACCU-CHECK VOICEMATE BLOOD GLUCOSE METER BLOOD GLUCOSE METER See footnote2 Angiotensin Modulators ACCUPRIL 10 MG TABLET QUINAPRIL 2 Angiotensin Modulators ACCUPRIL 20 MG TABLET QUINAPRIL 2 Angiotensin Modulators ACCUPRIL 40 MG TABLET QUINAPRIL 2 Angiotensin Modulators ACCUPRIL 5 MG TABLET QUINAPRIL 2 Angiotensin Modulators ACCURETIC 10 MG/12.5 MG TABLET QUINAPRIL/HYDROCHLOROTHIAZIDE 1 Angiotensin Modulators ACCURETIC 20 MG/12.5 MG TABLET QUINAPRIL/HYDROCHLOROTHIAZIDE 2 Angiotensin Modulators ACCURETIC 20 MG/25 MG TABLET QUINAPRIL/HYDROCHLOROTHIAZIDE 1 Angiotensin Modulators ACEON 2 MG TABLET PERINDOPRIL 2 Angiotensin Modulators ACEON 4 MG TABLET PERINDOPRIL 2 Angiotensin Modulators ACEON 8 MG TABLET PERINDOPRIL 2 Analgesics, Opioid Short-Acting ACETAMIN/CAFF/DIHYDROCODEINE 320.5 MG/30 MG/16 MG ACETAMINOPHEN/CAFFEINE/DIHYDROCODEINE 10 Analgesics, Opioid Short-Acting ACETAMIN-CODEIN 300-30 MG/12.5 ML ACETAMINOPHEN/CODEINE 90 Analgesics, Non-Salicylates ACETAMINOPHEN 120 MG TAB/CAP/SUPPOSITORY ACETAMINOPHEN 20 Analgesics, Non-Salicylates ACETAMINOPHEN 160 MG TAB/CAP/SUPPOSITORY ACETAMINOPHEN 20 Analgesics, Non-Salicylates ACETAMINOPHEN 160 MG/5 ML LIQUID ACETAMINOPHEN 75 Analgesics, Non-Salicylates ACETAMINOPHEN 320 MG/10 ML LIQUID ACETAMINOPHEN 100 Analgesics, Non-Salicylates ACETAMINOPHEN 325 MG TAB/CAP/SUPPOSITORY ACETAMINOPHEN 10 Analgesics, Non-Salicylates ACETAMINOPHEN 325 MG/10.15 ML LIQUID ACETAMINOPHEN 100 Analgesics, Non-Salicylates ACETAMINOPHEN 500 MG CAP/TAB/SUPPOSITORY ACETAMINOPHEN 6 Analgesics, Non-Salicylates ACETAMINOPHEN 500 MG/15 ML LIQUID ACETAMINOPHEN 90 Analgesics, Non-Salicylates ACETAMINOPHEN 650 MG TAB/CAP/SUPPOSITORY ACETAMINOPHEN 6 Analgesics, Non-Salicylates ACETAMINOPHEN 650 MG/20.3 ML ACETAMINOPHEN 100 Analgesics, Non-Salicylates ACETAMINOPHEN 80 MG TAB/CAP/SUPPOSITORY ACETAMINOPHEN 30 Analgesics, Opioid Short-Acting ACETAMINOPHEN/CAFF/DIHYDROCOD 325-30-16 MG ACETAMINOPHEN/CAFF/DIHYDROCODONE 10 Proton Pump Inhibitors ACIPHEX 10 MG SPRINKLE DR CAPSULE RABEPRAZOLE 2 Proton Pump Inhibitors ACIPHEX 20 MG TABLET EC RABEPRAZOLE 2 Proton Pump Inhibitors ACIPHEX 5 MG SPRINKLE DR CAPSULE RABEPRAZOLE 1 Cytokine & CAM Antagonists ACTEMRA 162 MG/0.9 ML SYRINGE TOCILIZUMAB 0.13 Cytokine & CAM Antagonists ACTEMRA 200 MG/10 ML VIAL TOCILIZUMAB 1.5 Cytokine & CAM Antagonists ACTEMRA 400 MG/20 ML VIAL TOCILIZUMAB 1.5 Cytokine & CAM Antagonists ACTEMRA 80 MG/4 ML VIAL TOCILIZUMAB 1.5 Cytokine & CAM Antagonists ACTEMRA ACTPEN 162 MG/0.9 ML TOCILIZUMAB 0.13 Bile Salts ACTIGALL 300 MG CAPSULE URSODIOL 4 Analgesics, Opioid Short-Acting ACTIQ 1200 MCG LOZENGE FENTANYL CITRATE 4 Effective 01/04/21 Alphabetical by Brand Name (when applicable)

Analgesics, Opioid Short-Acting ACTIQ 1600 MCG LOZENGE FENTANYL CITRATE 4 Analgesics, Opioid Short-Acting ACTIQ 200 MCG LOZENGE FENTANYL CITRATE 4 Analgesics, Opioid Short-Acting ACTIQ 400 MCG LOZENGE FENTANYL CITRATE 4 Analgesics, Opioid Short-Acting ACTIQ 600 MCG LOZENGE FENTANYL CITRATE 4 Analgesics, Opioid Short-Acting ACTIQ 800 MCG LOZENGE FENTANYL CITRATE 4 Estrogens ACTIVELLA 0.5-0.1 MG TABLET ESTRADIOL/NORETHINDRONE ACET 1 Estrogens ACTIVELLA 1MG-0.5 MG TABLET ESTRADIOL/NORETHINDRONE ACET 1 Bone Density Regulators ACTONEL 150 MG TABLET RISEDRONATE 0.04 Bone Density Regulators ACTONEL 30 MG TABLET RISEDRONATE 1 Bone Density Regulators ACTONEL 35 MG TABLET RISEDRONATE 0.15 Bone Density Regulators ACTONEL 5 MG TABLET RISEDRONATE 1 Hypoglycemics, TZDs ACTOPLUS MET 15 MG/500 MG TABLET PIOGLITAZONE/METFORMIN 3 Hypoglycemics, TZDs ACTOPLUS MET 15 MG/850 MG TABLET PIOGLITAZONE/METFORMIN 3 Hypoglycemics, TZDs ACTOS 15 MG TABLET PIOGLITAZONE 1 Hypoglycemics, TZDs ACTOS 30 MG TABLET PIOGLITAZONE 1 Hypoglycemics, TZDs ACTOS 45 MG TABLET PIOGLITAZONE 1 Vaccines ADACEL TDAP VACCINE SYRINGE DIPHTHERIA, PERTUSSIS (ACELL), TETANTUS VACCINE 0.5 Vaccines ADACEL TDAP VACCINE VIAL DIPHTHERIA, PERTUSSIS (ACELL), TETANTUS VACCINE 0.5 Calcium Channel Blockers ADALAT CC 30 MG TABLET NIFEDIPINE 1 Calcium Channel Blockers ADALAT CC 60 MG TABLET NIFEDIPINE 2 Calcium Channel Blockers ADALAT CC 90 MG TABLET NIFEDIPINE 1 Antipsychotics ADASUVE 10 MG INHALATION POWDER LOXAPINE 0.2 Oncology, Other ADCETRIS 50 MG VIAL BRENTUXIMAB VEDOTIN 0.22 PAH Agents, Oral & Inhaled ADCIRCA 20 MG TABLET TADALAFIL 2 Stimulants & Related Agents ADDERALL 10 MG TABLET AMPHETAMINE MIXED SALTS 3 Stimulants & Related Agents ADDERALL 12.5 MG TABLET AMPHETAMINE MIXED SALTS 3 Stimulants & Related Agents ADDERALL 15 MG TABLET AMPHETAMINE MIXED SALTS 3 Stimulants & Related Agents ADDERALL 20 MG TABLET AMPHETAMINE MIXED SALTS 3 Stimulants & Related Agents ADDERALL 30 MG TABLET AMPHETAMINE MIXED SALTS 2 Stimulants & Related Agents ADDERALL 5 MG TABLET AMPHETAMINE MIXED SALTS 3 Stimulants & Related Agents ADDERALL 7.5 MG TABLET AMPHETAMINE MIXED SALTS 3 Stimulants & Related Agents ADDERALL XR 10 MG CAPSULE AMPHETAMINE MIXED SALTS 1 Stimulants & Related Agents ADDERALL XR 15 MG CAPSULE AMPHETAMINE MIXED SALTS 1 Stimulants & Related Agents ADDERALL XR 20 MG CAPSULE AMPHETAMINE MIXED SALTS 2 Stimulants & Related Agents ADDERALL XR 25 MG CAPSULE AMPHETAMINE MIXED SALTS 2 Stimulants & Related Agents ADDERALL XR 30 MG CAPSULE AMPHETAMINE MIXED SALTS 2 Stimulants & Related Agents ADDERALL XR 5 MG CAPSULE AMPHETAMINE MIXED SALTS 1 PAH Agents, Oral & Inhaled ADEMPAS 0.5 MG TABLET RIOCIGUAT 3 PAH Agents, Oral & Inhaled ADEMPAS 1 MG TABLET RIOCIGUAT 3 PAH Agents, Oral & Inhaled ADEMPAS 1.5 MG TABLET RIOCIGUAT 3 PAH Agents, Oral & Inhaled ADEMPAS 2 MG TABLET RIOCIGUAT 3 Effective 01/04/21 Alphabetical by Brand Name (when applicable)

PAH Agents, Oral & Inhaled ADEMPAS 2.5 MG TABLET RIOCIGUAT 3 Stimulants & Related Agents ADHANSIA XR 25 MG CAPSULE METHYLPHENIDATE ER 1 Stimulants & Related Agents ADHANSIA XR 35 MG CAPSULE METHYLPHENIDATE ER 1 Stimulants & Related Agents ADHANSIA XR 45 MG CAPSULE METHYLPHENIDATE ER 1 Stimulants & Related Agents ADHANSIA XR 55 MG CAPSULE METHYLPHENIDATE ER 1 Stimulants & Related Agents ADHANSIA XR 70 MG CAPSULE METHYLPHENIDATE ER 1 Stimulants & Related Agents ADHANSIA XR 85 MG CAPSULE METHYLPHENIDATE ER 1 Hypoglycemics, Incretin Mimetics/Enhancers ADLYXIN 10-20 MCG STARTER PACK LIXISENATIDE 0.11 Hypoglycemics, Incretin Mimetics/Enhancers ADLYXIN 20 MCG MAINTENANCE PACK LIXISENATIDE 0.11 Glucocorticoids, Inhaled ADVAIR 100/50 DISKUS FLUTICASONE/SALMETEROL 2 Glucocorticoids, Inhaled ADVAIR 250/50 DISKUS FLUTICASONE/SALMETEROL 2 Glucocorticoids, Inhaled ADVAIR 500/50 DISKUS FLUTICASONE/SALMETEROL 2 Glucocorticoids, Inhaled ADVAIR HFA 115/21 INHALATION AEROSOL FLUTICASONE/SALMETEROL 0.4 Glucocorticoids, Inhaled ADVAIR HFA 230/21 INHALATION AEROSOL FLUTICASONE/SALMETEROL 0.4 Glucocorticoids, Inhaled ADVAIR HFA 45/21 INHALATION AEROSOL FLUTICASONE/SALMETEROL 0.4 Blood Glucose Meters ADVOCATE BLOOD GLUCOSE METER BLOOD GLUCOSE METER See footnote2 Blood Glucose Test Strips ADVOCATE BLOOD GLUCOSE TEST STRIPS BLOOD GLUCOSE TEST STRIPS 3.34 Blood Glucose Test Strips ADVOCATE REDI-CODE BLOOD GLUCOSE TEST STRIPS BLOOD GLUCOSE TEST STRIPS 3.34 Stimulants & Related Agents ADZENYS ER 1.25 MG/ML SUSPENSION AMPHETAMINE EXTENDED-RELEASE 15 Stimulants & Related Agents ADZENYS XR-ODT 12.5 MG TABLET AMPHETAMINE 1 Stimulants & Related Agents ADZENYS XR-ODT 15.7 MG TABLET AMPHETAMINE 1 Stimulants & Related Agents ADZENYS XR-ODT 18.8 MG TABLET AMPHETAMINE 1 Stimulants & Related Agents ADZENYS XR-ODT 3.1 MG TABLET AMPHETAMINE 1 Stimulants & Related Agents ADZENYS XR-ODT 6.3 MG TABLET AMPHETAMINE 1 Stimulants & Related Agents ADZENYS XR-ODT 9.4 MG TABLET AMPHETAMINE 1 Oncology Agents, Oral AFINITOR 10 MG TABLET EVEROLIMUS 1 Oncology Agents, Oral AFINITOR 2.5 MG TABLET EVEROLIMUS 1 Oncology Agents, Oral AFINITOR 5 MG TABLET EVEROLIMUS 1 Oncology Agents, Oral AFINITOR 7.5 MG TABLET EVEROLIMUS 1 Platelet Aggregation Inhibitors AGGRENOX 25-200 MG CAPSULE ASPIRIN/DIPYRIDAMOLE 2 Migraine Prevention Agents AIMOVIG 140 MG/ML AUTOINJECTOR ERENUMAB-AOOE 0.04 Migraine Prevention Agents AIMOVIG 70 MG/ML AUTOINJECTOR ERENUMAB-AOOE 0.04 Glucocorticoids, Inhaled AIRDUO DIGIHALER 113-14 MCG FLUTICASONE/SALMETEROL 0.04 Glucocorticoids, Inhaled AIRDUO DIGIHALER 232-14 MCG FLUTICASONE/SALMETEROL 0.04 Glucocorticoids, Inhaled AIRDUO DIGIHALER 55-14 MCG FLUTICASONE/SALMETEROL 0.04 Glucocorticoids, Inhaled AIRDUO RESPICLICK 113-14 MCG FLUTICASONE/SALMETEROL 0.04 Glucocorticoids, Inhaled AIRDUO RESPICLICK 232-14 MCG FLUTICASONE/SALMETEROL 0.04 Glucocorticoids, Inhaled AIRDUO RESPICLICK 55-14 MCG FLUTICASONE/SALMETEROL 0.04 Migraine Prevention Agents AJOVY 225 MG/1.5 ML AUTOINJECT FREMANEZUMAB-VFRM 0.06 Migraine Prevention Agents AJOVY 225 MG/1.5 ML SYRINGE FREMANEZUMAB-VFRM 0.06 Antiemetics/Antivertigo Agents AKYNZEO 235-0.25 MG VIAL NETUPITANT/PALONOSETRON 1 Effective 01/04/21 Alphabetical by Brand Name (when applicable)

Antiemetics/Antivertigo Agents AKYNZEO 300/0.5 MG CAPSULE NETUPITANT/PALONOSETRON 1 Antihistamines, Minimally Sedating ALAVERT 10 MG TABLET LORATADINE 1 Antihistamines, Minimally Sedating ALAVERT CHILDREN'S SYRUP LORATADINE 10 Antihistamines, Minimally Sedating ALAVERT-D 12 HR PSEUDOEPHEDRINE/LORATADINE 2 Antihelmintics ALBENZA 200 MG TABLET ALBENDAZOLE 4 Oncology Agents, Oral ALECENSA 150 MG CAPSULE ALECTINIB HCL 8 Antihistamines, Minimally Sedating ALLEGRA 180 MG TABLET FEXOFENADINE 1 Antihistamines, Minimally Sedating ALLEGRA 30 MG (ODT) TABLET FEXOFENADINE ORALLY DISINTEGRATING 2 Antihistamines, Minimally Sedating ALLEGRA 30 MG/5 ML SUSPENSION FEXOFENADINE ORAL 10 Antihistamines, Minimally Sedating ALLEGRA 60 MG TABLET/CAPSULE FEXOFENADINE 2 Antihistamines, Minimally Sedating ALLEGRA-D 12 HR TABLET PSEUDOEPHEDRINE/FEXOFENADINE 2 Antihistamines, Minimally Sedating ALLEGRA-D 24 HR TABLET PSEUDOEPHEDRINE/FEXOFENADINE 1 Analgesics, Non-Opioid Barbiturate Combos ALLZITAL 25 MG/325 MG TABLET BUTALBITAL/ACETAMINOPHEN 0.6 Estrogens ALORA 0.01 MG PATCH ESTRADIOL 0.29 Estrogens ALORA 0.025 MG PATCH ESTRADIOL 0.29 Estrogens ALORA 0.05 MG PATCH ESTRADIOL 0.29 Estrogens ALORA 0.075 MG PATCH ESTRADIOL 0.29 Anxiolytics ALPRAZOLAM INTENSOL 1 MG/ML CONCENTRATE ALPRAZOLAM 6 Angiotensin Modulators ALTACE 1.25 MG CAPSULE RAMIPRIL 1 Angiotensin Modulators ALTACE 10 MG CAPSULE RAMIPRIL 2 Angiotensin Modulators ALTACE 2.5 MG CAPSULE RAMIPRIL 4 Angiotensin Modulators ALTACE 5 MG CAPSULE RAMIPRIL 4 Lipotropics, Statins ALTOPREV 10 MG TABLET LOVASTATIN ER 1 Lipotropics, Statins ALTOPREV 20 MG TABLET LOVASTATIN ER 1 Lipotropics, Statins ALTOPREV 40 MG TABLET LOVASTATIN ER 1 Lipotropics, Statins ALTOPREV 60 MG TABLET LOVASTATIN ER 1 Oncology Agents, Oral ALUNBRIG 180 MG TABLET BRIGATINIB 1 Oncology Agents, Oral ALUNBRIG 30 MG TABLET BRIGATINIB 4 Oncology Agents, Oral ALUNBRIG 90 MG TABLET BRIGATINIB 1 Oncology Agents, Oral ALUNBRIG 90-180 MG TAB PACK BRIGATINIB 1 Glucocorticoids, Inhaled ALVESCO INHALER 160 MCG/INHALATION CICLESONIDE 0.41 Glucocorticoids, Inhaled ALVESCO INHALER 80 MCG/INHALATION CICLESONIDE 0.21 Hypoglycemics, Sulfonylureas AMARYL 1 MG TABLET GLIMEPIRIDE 2 Hypoglycemics, Sulfonylureas AMARYL 2 MG TABLET GLIMEPIRIDE 2 Hypoglycemics, Sulfonylureas AMARYL 4 MG TABLET GLIMEPIRIDE 2 Sedative Hypnotics AMBIEN 10 MG TABLET ZOLPIDEM 1-See footnote3 Sedative Hypnotics AMBIEN 5 MG TABLET ZOLPIDEM 1 Sedative Hypnotics AMBIEN CR 12.5 MG ZOLPIDEM ER 1-See footnote3 Sedative Hypnotics AMBIEN CR 6.25 MG ZOLPIDEM ER 1 Migraine Acute Treatment Agents AMERGE 1 MG TABLET NARATRIPTAN 0.3 Migraine Acute Treatment Agents AMERGE 2.5 MG TABLET NARATRIPTAN 0.3 Effective 01/04/21 Alphabetical by Brand Name (when applicable)

Insect Repellent NOT for Skin Application AMERISOURCE LICE BEDING SPRAY PERMETHRIN 0.5% 29 GI Motility, Chronic AMITIZA 24 MCG CAPSULE LUBIPROSTONE 2 GI Motility, Chronic AMITIZA 8 MCG CAPSULE LUBIPROSTONE 4 Multiple Sclerosis Agents AMPYRA ER 10 MG TABLET DALFAMPRIDINE 2 Skeletal Muscle Relaxants AMRIX 15 MG ER CAPSULE CYCLOBENZAPRINE ER 1 Skeletal Muscle Relaxants AMRIX 30 MG ER CAPSULE CYCLOBENZAPRINE ER 1 NSAIDs ANAPROX 275 MG TABLET NAPROXEN 3 NSAIDs ANAPROX DS 550 MG TABLET NAPROXEN 3 Androgenic Agents ANDRODERM 2 MG/24 HR PATCH TESTOSTERONE 1 Androgenic Agents ANDRODERM 4 MG/24 HR PATCH TESTOSTERONE 1 Androgenic Agents ANDROGEL 1% (2.5 GM) GEL PACKET TESTOSTERONE 7.5 Androgenic Agents ANDROGEL 1% (5 GM) GEL PACKET TESTOSTERONE 10 Androgenic Agents ANDROGEL 1% GEL PUMP TESTOSTERONE 7.5 Androgenic Agents ANDROGEL 1.62% (1.25 GM) GEL PACKET TESTOSTERONE 1.25 Androgenic Agents ANDROGEL 1.62% (2.5 GM) GEL PACKET TESTOSTERONE 5 Androgenic Agents ANDROGEL 1.62% GEL PUMP TESTOSTERONE 5 Androgenic Agents ANDROID 10 MG CAPSULE METHYLTESTOSTERONE 5 Estrogens ANGELIQ 0.25 MG-0.5 MG TABLET DROSPIRENONE/ESTRADIOL 1 Estrogens ANGELIQ 0.5 MG-1 MG TABLET DROSPIRENONE/ESTRADIOL 1 Contraceptives, Other ANNOVERA VAGINAL RING SEGESTERONE/ETHINYL ESTRADIOL 0.01 COPD Agents ANORO ELLIPTA #30 UMECLIDINIUM/VILANTEROL 2 COPD Agents ANORO ELLIPTA #7 UMECLIDINIUM/VILANTEROL 2 Lipotropics, Other ANTARA 130 MG CAPSULE FENOFIBRATE MICRONIZED 1 Lipotropics, Other ANTARA 30 MG CAPSULE FENOFIBRATE MICRONIZED 2 Lipotropics, Other ANTARA 43 MG CAPSULE FENOFIBRATE MICRONIZED 2 Lipotropics, Other ANTARA 90 MG CAPSULE FENOFIBRATE MICRONIZED 1 Antiemetics/Antivertigo Agents ANZEMET 100 MG TABLET DOLASETRON 1 Antiemetics/Antivertigo Agents ANZEMET 50 MG TABLET DOLASETRON 2 Analgesics, Opioid Short-Acting APADAZ 4.08-325 MG TABLET BENZHYDROCODONE/ACETAMINOPHEN 10 Analgesics, Opioid Short-Acting APADAZ 6.12-325 MG TABLET BENZHYDROCODONE/ACETAMINOPHEN 6 Analgesics, Opioid Short-Acting APADAZ 8.16-325 MG TABLET BENZHYDROCODONE/ACETAMINOPHEN 5 Antidepressants, Other APLENZIN ER 174 MG TABLET BUPROPION HYDROBROMIDE 1 Antidepressants, Other APLENZIN ER 348 MG TABLET BUPROPION HYDROBROMIDE 1 Antidepressants, Other APLENZIN ER 522 MG TABLET BUPROPION HYDROBROMIDE 1 Antigenic Skin Tests APLISOL 5 TUBERCULIN UNITS/0.1 ML VIAL TUBERCULIN PPD INTRADERMAL 0.1 Ulcerative Colitis Agents APRISO 0.375 GRAM ER CAPSULE MESALAMINE 4 Stimulants & Related Agents APTENSIO XR 10 MG CAPSULE METHYLPHENIDATE 1 Stimulants & Related Agents APTENSIO XR 15 MG CAPSULE METHYLPHENIDATE 1 Stimulants & Related Agents APTENSIO XR 20 MG CAPSULE METHYLPHENIDATE 1 Stimulants & Related Agents APTENSIO XR 30 MG CAPSULE METHYLPHENIDATE 1 Stimulants & Related Agents APTENSIO XR 40 MG CAPSULE METHYLPHENIDATE 1 Effective 01/04/21 Alphabetical by Brand Name (when applicable)

Stimulants & Related Agents APTENSIO XR 50 MG CAPSULE METHYLPHENIDATE 1 Stimulants & Related Agents APTENSIO XR 60 MG CAPSULE METHYLPHENIDATE 1 Anticonvulsants APTIOM 200 MG TABLET ESLICARBAZEPINE 1 Anticonvulsants APTIOM 400 MG TABLET ESLICARBAZEPINE 1 Anticonvulsants APTIOM 600 MG TABLET ESLICARBAZEPINE 2 Anticonvulsants APTIOM 800 MG TABLET ESLICARBAZEPINE 2 HIV/AIDS Antiretrovirals APTIVUS 100 MG/ML ORAL SOLUTION TIPRANAVIR 10 HIV/AIDS Antiretrovirals APTIVUS 250 MG CAPSULE TIPRANAVIR 4 Cytokine & CAM Antagonists ARCALYST 220 MG INJECTION RILONACEPT 0.18 Alzheimer's Agents ARICEPT 10 MG ODT DONEPEZIL 1 Alzheimer's Agents ARICEPT 10 MG TABLET DONEPEZIL 2 Alzheimer's Agents ARICEPT 23 MG TABLET DONEPEZIL 1 Alzheimer's Agents ARICEPT 5 MG ODT DONEPEZIL 1 Alzheimer's Agents ARICEPT 5 MG TABLET DONEPEZIL 1 Oncology Agents, Breast Cancer ARIMIDEX 1 MG TABLET ANASTROZOLE 1 Antipsychotics, Atypical ARISTADA ER 1064 MG/3.9 ML ARIPIPRAZOLE LAUROXIL 0.07 Antipsychotics, Atypical ARISTADA ER 441 MG/1.6 ML SYRINGE ARIPIPRAZOLE LAUROXIL 0.06 Antipsychotics, Atypical ARISTADA ER 662 MG/2.4 ML SYRINGE ARIPIPRAZOLE LAUROXIL 0.08 Antipsychotics, Atypical ARISTADA ER 882 MG/3.2 ML SYRINGE ARIPIPRAZOLE LAUROXIL 0.11 Antipsychotics, Atypical ARISTADA INITIO ER 675 MG/2.4 ML SYRINGE ARIPIPRAZOLE LAUROXIL 0.08 Anticoagulants, Injectable ARIXTRA 10 MG/0.8 ML INJECTION SYRINGE FONDAPARINUX See footnote1 Anticoagulants, Injectable ARIXTRA 2.5 MG/0.5 ML INJECTION SYRINGE FONDAPARINUX See footnote1 Anticoagulants, Injectable ARIXTRA 5 MG/0.4 ML INJECTION SYRINGE FONDAPARINUX See footnote1 Anticoagulants, Injectable ARIXTRA 7.5 MG/0.6 ML INJECTION SYRINGE FONDAPARINUX See footnote1 Glucocorticoids, Inhaled ARMONAIR DIGIHALER 113 MCG FLUTICASONE PROPIONATE 0.04 Glucocorticoids, Inhaled ARMONAIR DIGIHALER 232 MCG FLUTICASONE PROPIONATE 0.04 Glucocorticoids, Inhaled ARMONAIR DIGIHALER 55 MCG FLUTICASONE PROPIONATE 0.04 Glucocorticoids, Inhaled ARNUITY ELLIPTA 100 MCG INHALER FLUTICASONE FUROATE 1 Glucocorticoids, Inhaled ARNUITY ELLIPTA 200 MCG INHALER FLUTICASONE FUROATE 1 Glucocorticoids, Inhaled ARNUITY ELLIPTA 50 MCG INHALER FLUTICASONE FUROATE 1 Oncology Agents, Breast Cancer AROMASIN 25 MG TABLET EXEMESTANE 2 Antiparkinson's Agents ARTANE 2 MG TABLET TRIHEXYPHENIDYL 6 Antiparkinson's Agents ARTANE 2 MG/5 ML ELIXIR TRIHEXYPHENIDYL 40 Antiparkinson's Agents ARTANE 5 MG TABLET TRIHEXYPHENIDYL 3 NSAIDs ARTHROTEC EC 50 MG/200 MCG DICLOFENAC SODIUM/MISOPROSTOL 4 NSAIDs ARTHROTEC EC 75 MG/200 MCG DICLOFENAC SODIUM/MISOPROSTOL 3 Analgesics, Opioid Long-Acting ARYMO ER 15 MG TABLET MORPHINE SULFATE 3 Analgesics, Opioid Long-Acting ARYMO ER 30 MG TABLET MORPHINE SULFATE 2 Analgesics, Opioid Long-Acting ARYMO ER 60 MG TABLET MORPHINE SULFATE 2 Ulcerative Colitis Agents ASACOL 400 MG EC TABLET MESALAMINE 6 Ulcerative Colitis Agents ASACOL HD 800 MG TABLET MESALAMINE 6 Effective 01/04/21 Alphabetical by Brand Name (when applicable)

Analgesics, Opioid Short-Acting ASCOMP WITH CODEINE CAPSULE BUTALBITAL/ASA/CAFFEINE/CODEINE 0.6 Glucocorticoids, Inhaled ASMANEX HFA 100 MCG INHALER MOMETASONE FUROATE 0.44 Glucocorticoids, Inhaled ASMANEX HFA 200 MCG INHALER MOMETASONE FUROATE 0.44 Glucocorticoids, Inhaled ASMANEX TWISTHALER 110 MCG #30 MOMETASONE FUROATE 0.04 Glucocorticoids, Inhaled ASMANEX TWISTHALER 220 MCG #120 MOMETASONE FUROATE 0.04 Glucocorticoids, Inhaled ASMANEX TWISTHALER 220 MCG #30 MOMETASONE FUROATE 0.04 Glucocorticoids, Inhaled ASMANEX TWISTHALER 220 MCG #60 MOMETASONE FUROATE 0.04 Analgesics, Salicylates ASPIRIN 300 MG SUPPOSITORY ASPIRIN 6 Analgesics, Salicylates ASPIRIN 325 MG TAB/CAP ASPIRIN 12 Analgesics, Salicylates ASPIRIN 600 MG SUPPOSITORY ASPIRIN 6 Analgesics, Salicylates ASPIRIN 81 MG TAB/CAP ASPIRIN 12 Blood Glucose Test Strips ASSURE 4 BLOOD GLUCOSE TEST STRIPS BLOOD GLUCOSE TEST STRIPS 3.34 Intranasal Rhinitis Agents ASTELIN 0.1% NASAL SPRAY AZELASTINE 1.2 Intranasal Rhinitis Agents ASTEPRO 0.1% NASAL SPRAY AZELASTINE 1.2 Intranasal Rhinitis Agents ASTEPRO 0.15% NASAL SPRAY AZELASTINE 1.2 Angiotensin Modulators ATACAND 16 MG TABLET CANDESARTAN 2 Angiotensin Modulators ATACAND 32 MG TABLET CANDESARTAN 1 Angiotensin Modulators ATACAND 4 MG TABLET CANDESARTAN 2 Angiotensin Modulators ATACAND 8 MG TABLET CANDESARTAN 2 Angiotensin Modulators ATACAND HCT 16/12.5 MG TAB CANDESARTAN/HCTZ 2 Angiotensin Modulators ATACAND HCT 32/12.5 MG TAB CANDESARTAN/HCTZ 1 Angiotensin Modulators ATACAND HCT 32/25 MG TAB CANDESARTAN/HCTZ 1 Bone Density Regulators ATELVIA 35 MG DR TABLET RISEDRONATE 0.15 Bone Density Regulators ATELVIA 35 MG DR TABLET RISEDRONATE 0.14 Anxiolytics ATIVAN 0.5 MG TABLET LORAZEPAM 6 Anxiolytics ATIVAN 1 MG TABLET LORAZEPAM 6 Anxiolytics ATIVAN 2 MG TABLET LORAZEPAM 3 HIV/AIDS Antiretrovirals ATRIPLA 600 MG/200 MG/300 MG TABLET EFAVIRENZ/EMTRICITABINE/TENOFOVIR DF 1 Intranasal Rhinitis Agents ATROVENT 0.03% NASAL SPRAY IPRATROPIUM 1.05 Intranasal Rhinitis Agents ATROVENT 0.06% NASAL SPRAY IPRATROPIUM 1.5 COPD Agents ATROVENT HFA INHALER IPRATROPIUM 0.86 Multiple Sclerosis Agents AUBAGIO 14 MG TABLET TERIFLUNOMIDE 1 Multiple Sclerosis Agents AUBAGIO 7 MG TABLET TERIFLUNOMIDE 1 Phosphate Binders AURYXIA 210 MG TABLET FERRIC CITRATE 12 VMAT2 Inhibitors AUSTEDO 12 MG TABLET DEUTETRABENAZINE 4 VMAT2 Inhibitors AUSTEDO 6 MG TABLET DEUTETRABENAZINE 2 VMAT2 Inhibitors AUSTEDO 9 MG TABLET DEUTETRABENAZINE 4 Diabetic Supplies, Miscellaneous AUTOLET IMPRESS LANCING DEVICE BLOOD GLUCOSE LANCING DEVICE 1 Angiotensin Modulators AVALIDE 150-12.5 MG TABLET IRBESARTAN/HCTZ 2 Angiotensin Modulators AVALIDE 300-12.5 MG TABLET IRBESARTAN/HCTZ 1 Hypoglycemics, TZDs AVANDIA 2 MG TABLET ROSIGLITAZONE 2 Effective 01/04/21 Alphabetical by Brand Name (when applicable)

Hypoglycemics, TZDs AVANDIA 4 MG TABLET ROSIGLITAZONE 2 Hypoglycemics, TZDs AVANDIA 8 MG TABLET ROSIGLITAZONE 1 Angiotensin Modulators AVAPRO 150 MG TABLET IRBESARTAN 1 Angiotensin Modulators AVAPRO 300 MG TABLET IRBESARTAN 1 Angiotensin Modulators AVAPRO 75 MG TABLET IRBESARTAN 1 Oncology, Other AVASTIN 100 MG/4 ML VIAL BEVACIZUMAB 6.5 Oncology, Other AVASTIN 400 MG/16 ML VIAL BEVACIZUMAB 6.5 Androgenic Agents AVEED 750 MG/3 ML VIAL TESTOSTERONE UNDECANOATE 0.11 Analgesics, Opioid Long-Acting AVINZA 120 MG CAPSULE MORPHINE SULFATE ER 1 Analgesics, Opioid Long-Acting AVINZA 30 MG CAPSULE MORPHINE SULFATE ER 1 Analgesics, Opioid Long-Acting AVINZA 45 MG CAPSULE MORPHINE SULFATE ER 1 Analgesics, Opioid Long-Acting AVINZA 60 MG CAPSULE MORPHINE SULFATE ER 1 Analgesics, Opioid Long-Acting AVINZA 75 MG CAPSULE MORPHINE SULFATE ER 1 Analgesics, Opioid Long-Acting AVINZA 90 MG CAPSULE MORPHINE SULFATE ER 1 BPH Treatments AVODART 0.5 MG SOFTGEL DUTASTERIDE 1 Multiple Sclerosis Agents AVONEX ADMIN PACK 30 MCG VIAL INTERFERON BETA-1A 0.15 Multiple Sclerosis Agents AVONEX PEN 30 MCG/0.5 ML AUTOINJECTOR KIT INTERFERON BETA-1A 0.04 Multiple Sclerosis Agents AVONEX PREFILLED SYRINGE 30 MCG KIT INTERFERON BETA-1A 0.04 Migraine Acute Treatment Agents AXERT 12.5 MG TABLET ALMOTRIPTAN 0.3 Migraine Acute Treatment Agents AXERT 6.25 MG TABLET ALMOTRIPTAN 0.3 Androgenic Agents AXIRON 30 MG/ACTUATION SOLUTION TESTOSTERONE 6 Progestational Agents AYGESTIN 5 MG TABLET NORETHINDRONE ACETATE 3 Oncology Agents, Oral AYVAKIT 100 MG TABLET AVAPRITINIB 1 Oncology Agents, Oral AYVAKIT 200 MG TABLET AVAPRITINIB 1 Oncology Agents, Oral AYVAKIT 300 MG TABLET AVAPRITINIB 1 Antibiotics, Injectable AZACTAM 1 GM INJECTION VIAL AZTREONAM 3 Antibiotics, Injectable AZACTAM 2 GM INJECTION VIAL AZTREONAM 4 Antiparkinson's Agents AZILECT 0.5 MG TABLET RASAGILINE 1 Antiparkinson's Agents AZILECT 1 MG TABLET RASAGILINE 1 Angiotensin Modulator Combinations AZOR 10/20 MG TABLET AMLODIPINE/OLMESARTAN 1 Angiotensin Modulator Combinations AZOR 10/40 MG TABLET AMLODIPINE/OLMESARTAN 1 Angiotensin Modulator Combinations AZOR 5/20 MG TABLET AMLODIPINE/OLMESARTAN 1 Angiotensin Modulator Combinations AZOR 5/40 MG TABLET AMLODIPINE/OLMESARTAN 1 Ulcerative Colitis Agents AZULFIDINE 500 MG TABLET SULFASALAZINE 12 Ulcerative Colitis Agents AZULFIDINE EN-TAB 500 MG TABLET SULFASALAZINE 12 Multiple Sclerosis Agents BAFIERTAM DR 95 MG CAPSULE MONOMETHYL FUMARATE 4 Oncology Agents, Oral BALVERSA 3 MG TABLET ERDAFITINIB 3 Oncology Agents, Oral BALVERSA 4 MG TABLET ERDAFITINIB 2 Oncology Agents, Oral BALVERSA 5 MG TABLET ERDAFITINIB 1 Anticonvulsants BANZEL 200 MG TABLET RUFINAMIDE 4 Anticonvulsants BANZEL 40 MG/ML SUSPENSION RUFINAMIDE 80 Effective 01/04/21 Alphabetical by Brand Name (when applicable)

Anticonvulsants BANZEL 400 MG TABLET RUFINAMIDE 8 Hepatitis B Agents BARACLUDE 0.05 MG/ML SOLUTION ENTECAVIR 20 Hepatitis B Agents BARACLUDE 0.5 MG TABLET ENTECAVIR 1 Hepatitis B Agents BARACLUDE 1 MG TABLET ENTECAVIR 1 Analgesics, Salicylates BC ARTHRITIS POWDER PACKET 1000 MG/65 MG ASPIRIN/CAFFEINE 4 Vaccines BCG VACCINE (TICE STRAIN) VIAL BCG VACCINE 1 Blood Glucose Test Strips BD BLOOD GLUCOSE TEST STRIPS BLOOD GLUCOSE TEST STRIPS 3.34 Intranasal Rhinitis Agents BECONASE AQ 0.042% NASAL SPRAY BECLOMETHASONE 1.12 Analgesics, Opioid Long-Acting BELBUCA 150 MCG FILM BUPRENORPHINE 2 Analgesics, Opioid Long-Acting BELBUCA 300 MCG FILM BUPRENORPHINE 2 Analgesics, Opioid Long-Acting BELBUCA 450 MCG FILM BUPRENORPHINE 2 Analgesics, Opioid Long-Acting BELBUCA 600 MCG FILM BUPRENORPHINE 2 Analgesics, Opioid Long-Acting BELBUCA 75 MCG FILM BUPRENORPHINE 2 Analgesics, Opioid Long-Acting BELBUCA 750 MCG FILM BUPRENORPHINE 2 Analgesics, Opioid Long-Acting BELBUCA 900 MCG FILM BUPRENORPHINE 2 Sedative Hypnotics BELSOMRA 10 MG TABLET SUVOREXANT 1 Sedative Hypnotics BELSOMRA 15 MG TABLET SUVOREXANT 1 Sedative Hypnotics BELSOMRA 20 MG TABLET SUVOREXANT 1 Sedative Hypnotics BELSOMRA 5 MG TABLET SUVOREXANT 1 Angiotensin Modulators BENICAR 20 MG TABLET OLMESARTAN 1 Angiotensin Modulators BENICAR 40 MG TABLET OLMESARTAN 1 Angiotensin Modulators BENICAR 5 MG TABLET OLMESARTAN 1 Angiotensin Modulators BENICAR HCT 20-12.5 MG TAB OLMESARTN/HYDROCHLOROTHIAZIDE 1 Angiotensin Modulators BENICAR HCT 40-12.5 MG TABLET OLMESARTN/HYDROCHLOROTHIAZIDE 1 Angiotensin Modulators BENICAR HCT 40-25 MG TABLET OLMESARTN/HYDROCHLOROTHIAZIDE 1 Macular Degeneration Agents BEOVU 6 MG/0.05 ML VIAL BROLUCIZUMAB-DBLL 0.01 Multiple Sclerosis Agents BETASERON 0.3 MG KIT INTERFERON BETA-1B 0.5 Antibiotics, Inhaled BETHKIS 300 MG/4 ML INHALATION SOLUTION VIAL FORMOTEROLTOBRAMYCIN FUMARATE 8 COPD Agents BEVESPI AEROSPHERE DIHYDRATE/GLYCOPYRROLATE 0.36 Vaccines BEXSERO VACCINE SYRINGE MENINGOCOCCAL B VACCINE 4-COMP 0.5 Antibiotics, Injectable BICILLIN L-A 1,200,000 UNITS/2 ML PENICILLIN G BENZATHINE 0.07 Antibiotics, Injectable BICILLIN L-A 2,400,000 UNITS/4 ML PENICILLIN G BENZATHINE 0.59 Antibiotics, Injectable BICILLIN L-A 600,000 UNITS/ML PENICILLIN G BENZATHINE 0.08 Estrogens BIJUVA 1 MG-100 MG CAPSULE BICTEGRAVIR/EMTRICITABINE/TENOFOVIRESTRADIOL/PROGESTERONE 1 HIV/AIDS Antiretrovirals BIKTARVY 50-200-25 MG TABLET ALAFENAMIDE 1 Bone Density Regulators BINOSTO 70 MG EFFERVESCENT TABLET ALENDRONATE 0.15 Bone Density Regulators BONIVA 150 MG TABLET IBANDRONATE 0.04 Bone Density Regulators BONIVA 3 MG/3 ML SYRINGE IBANDRONATE 0.04 Antiemetics/Antivertigo Agents BONJESTA ER 20-20 MG TABLET DOXYLAMINE AND PYRIDOXINE EXTENDED-RELEASE 2 Vaccines BOOSTRIX TDAP VACCINE SYRINGE DIPHTHERIA, PERTUSSIS (ACELL), TETANTUS VACCINE 0.5 Vaccines BOOSTRIX TDAP VACCINE VIAL DIPHTHERIA, PERTUSSIS (ACELL), TETANTUS VACCINE 0.5 Effective 01/04/21 Alphabetical by Brand Name (when applicable)

Oncology Agents, Oral BOSULIF 100 MG TABLET BOSUTINIB 3 Oncology Agents, Oral BOSULIF 400 MG TABLET BOSUTINIB 1 Oncology Agents, Oral BOSULIF 500 MG TABLET BOSUTINIB 1 Botulinum Toxins BOTOX 100 UNITS INJECTION VIAL ONABOTULINUMTOXIN A 0.1 Botulinum Toxins BOTOX 200 UNITS INJECTION VIAL ONABOTULINUMTOXIN A 0.07 Oncology Agents, Oral BRAFTOVI 50 MG CAPSULE ENCORAFENIB 4 Oncology Agents, Oral BRAFTOVI 75 MG CAPSULE ENCORAFENIB 6 Blood Glucose Meters BREEZE 2 BLOOD GLUCOSE METER BLOOD GLUCOSE METER See footnote2 Blood Glucose Test Strips BREEZE 2 BLOOD GLUCOSE TEST STRIPS BLOOD GLUCOSE TEST STRIPS 3.34 Glucocorticoids, Inhaled BREO ELLIPTA 100 MCG/25 MCG FLUTICASONE/VILANTEROL 2 Glucocorticoids, Inhaled BREO ELLIPTA 200 MCG/25 MCG FLUTICASONE/VILANTEROL 2 COPD Agents BREZTRI AEROSPHERE INHALER BUDESONIDE/GLYCOPYRROLATE/FORMOTEROL 0.36 Platelet Aggregation Inhibitors BRILINTA 60 MG TABLET TICAGRELOR 2 Platelet Aggregation Inhibitors BRILINTA 90 MG TABLET TICAGRELOR 2 Antidepressants, SSRIs BRISDELLE 7.5 MG CAPSULE PAROXETINE MESYLATE 1 Anticonvulsants BRIVIACT 10 MG TABLET BRIVARACETAM 4 Anticonvulsants BRIVIACT 10 MG/ML ORAL SOLUTION BRIVARACETAM 20 Anticonvulsants BRIVIACT 100 MG TABLET BRIVARACETAM 2 Anticonvulsants BRIVIACT 25 MG TABLET BRIVARACETAM 4 Anticonvulsants BRIVIACT 50 MG TABLET BRIVARACETAM 4 Anticonvulsants BRIVIACT 50 MG/5 ML VIAL BRIVARACETAM 20 Anticonvulsants BRIVIACT 75 MG TABLET BRIVARACETAM 2 Bronchodilators, Beta Agonist BROVANA 15 MCG/2 ML SOLUTION ARFORMOTEROL 4 Oncology Agents, Oral BRUKINSA 80 MG CAPSULE ZANUBRUTINIB 4 Opioid Dependence Treatments BUNAVAIL 2.1/0.3 MG BUCCAL FILM BUPRENORPHINE/NALOXONE 2 Opioid Dependence Treatments BUNAVAIL 4.2/0.7 MG BUCCAL FILM BUPRENORPHINE/NALOXONE 2 Opioid Dependence Treatments BUNAVAIL 6.3/1 MG BUCCAL FILM BUPRENORPHINE/NALOXONE 2 Analgesics, Non-Opioid Barbiturate Combos BUPAP 50 MG/300 MG TABLET BUTALBITAL/ACETAMINOPHEN 0.6 Analgesics, Non-Opioid Barbiturate Combos BUTALBITAL-ACETAMINOPHEN 50-300 CAPSULE BUTALBITAL/ACETAMINOPHEN 0.6 Sedative Hypnotics BUTISOL SODIUM 30 MG TABLET BUTABARBITAL SODIUM 3.5 Analgesics, Opioid Long-Acting BUTRANS 10 MCG/HR TRANSDERMAL SYSTEM BUPRENORPHINE TRANSDERMAL 0.15 Analgesics, Opioid Long-Acting BUTRANS 15 MCG/HR TRANSDERMAL SYSTEM BUPRENORPHINE TRANSDERMAL 0.15 Analgesics, Opioid Long-Acting BUTRANS 20 MCG/HR TRANSDERMAL SYSTEM BUPRENORPHINE TRANSDERMAL 0.15 Analgesics, Opioid Long-Acting BUTRANS 5 MCG/HR TRANSDERMAL SYSTEM BUPRENORPHINE TRANSDERMAL 0.15 Analgesics, Opioid Long-Acting BUTRANS 7.5 MCG/HR TRANSDERMAL SYSTEM BUPRENORPHINE TRANSDERMAL 0.15 Hypoglycemics, Incretin Mimetics/Enhancers BYDUREON 2 MG PEN INJECT EXENATIDE EXTENDED-RELEASE 0.15 Hypoglycemics, Incretin Mimetics/Enhancers BYDUREON 2 MG VIAL EXENATIDE MICROSPHERES 0.15 Hypoglycemics, Incretin Mimetics/Enhancers BYDUREON BCISE 2MG AUTOINJECT EXENATIDE EXTENDED-RELEASE 0.13 Hypoglycemics, Incretin Mimetics/Enhancers BYETTA 10 MCG/DOSE PREFILLED PEN EXENATIDE 0.08 Hypoglycemics, Incretin Mimetics/Enhancers BYETTA 5 MCG/DOSE PREFILLED PEN EXENATIDE 0.04 Beta-Blockers BYSTOLIC 10 MG TABLET NEBIVOLOL 1.5 Effective 01/04/21 Alphabetical by Brand Name (when applicable)

Beta-Blockers BYSTOLIC 2.5 MG TABLET NEBIVOLOL 1 Beta-Blockers BYSTOLIC 20 MG TABLET NEBIVOLOL 2 Beta-Blockers BYSTOLIC 5 MG TABLET NEBIVOLOL 1.5 Oncology Agents, Oral CABOMETYX 20 MG TABLET CABOZANTINIB 1 Oncology Agents, Oral CABOMETYX 40 MG TABLET CABOZANTINIB 1 Oncology Agents, Oral CABOMETYX 60 MG TABLET CABOZANTINIB 1 Lipotropics, Statins CADUET 10 MG/10 MG TABLET AMLODIPINE/ATORVASTATIN 1 Lipotropics, Statins CADUET 10 MG/20 MG TABLET AMLODIPINE/ATORVASTATIN 1 Lipotropics, Statins CADUET 10 MG/40 MG TABLET AMLODIPINE/ATORVASTATIN 1 Lipotropics, Statins CADUET 10 MG/80 MG TABLET AMLODIPINE/ATORVASTATIN 1 Lipotropics, Statins CADUET 5 MG/10 MG TABLET AMLODIPINE/ATORVASTATIN 1 Lipotropics, Statins CADUET 5 MG/20 MG TABLET AMLODIPINE/ATORVASTATIN 1 Lipotropics, Statins CADUET 5 MG/40 MG TABLET AMLODIPINE/ATORVASTATIN 1 Lipotropics, Statins CADUET 5 MG/80 MG TABLET AMLODIPINE/ATORVASTATIN 1 Calcium Channel Blockers CALAN SR 120 MG CAPLET SA VERAPAMIL 2 Calcium Channel Blockers CALAN SR 180 MG CAPLET SA VERAPAMIL 2 Calcium Channel Blockers CALAN SR 240 MG CAPLET SA VERAPAMIL 2 Oncology Agents, Oral CALQUENCE 100 MG CAPSULE ACALABRUTINIB 2 NSAIDs CAMBIA 50 MG POWDER PACKET DICLOFENAC POTASSIUM POWDER 0.3 Ulcerative Colitis Agents CANASA 1000 MG SUPPOSITORY MESALAMINE 1 Antifungals, Injectable CANCIDAS IV 50 MG VIAL CASPOFUNGIN 1 Antifungals, Injectable CANCIDAS IV 70 MG VIAL CASPOFUNGIN 1 Analgesics, Non-Opioid Barbiturate Combos CAPACET 50 MG/325 MG/40 MG CAPSULE BUTALBITAL/ACETAMINOPHEN/CAFFEINE 0.6 Opioid Antitussive CAPCOF LIQUID CHLORPHENIRAMINE/PE/CODEINE 60 Analgesics, Opioid Short-Acting CAPITAL WITH CODEINE 120 MG-12 MG/5 ML SUSPENSION ACETAMINOPHEN/CODEINE 90 Antipsychotics CAPLYTA 42 MG CAPSULE LUMATEPERONE TOSYLATE 1 Angiotensin Modulators CAPOTEN 100 MG TABLET CAPTOPRIL 3 Angiotensin Modulators CAPOTEN 12.5 MG TABLET CAPTOPRIL 3 Angiotensin Modulators CAPOTEN 25 MG TABLET CAPTOPRIL 3 Angiotensin Modulators CAPOTEN 50 MG TABLET CAPTOPRIL 3 Angiotensin Modulators CAPOZIDE 25 MG/15 MG TABLET CAPTOPRIL/HYDROCHLOROTHIAZIDE 2 Angiotensin Modulators CAPOZIDE 25 MG/25 MG TABLET CAPTOPRIL/HYDROCHLOROTHIAZIDE 2 Angiotensin Modulators CAPOZIDE 50 MG/15 MG TABLET CAPTOPRIL/HYDROCHLOROTHIAZIDE 2 Angiotensin Modulators CAPOZIDE 50 MG/25 MG TABLET CAPTOPRIL/HYDROCHLOROTHIAZIDE 2 Oncology Agents, Oral CAPRELSA 100 MG TABLET VANDETANIB 2 Oncology Agents, Oral CAPRELSA 300 MG TABLET VANDETANIB 1 Anticonvulsants CARBATROL ER 100 MG CAPSULE CARBAMAZEPINE ER 6 Anticonvulsants CARBATROL ER 200 MG CAPSULE CARBAMAZEPINE ER 8 Anticonvulsants CARBATROL ER 300 MG CAPSULE CARBAMAZEPINE ER 5 Calcium Channel Blockers CARDENE 20 MG CAPSULE NICARDIPINE 6 Calcium Channel Blockers CARDENE 30 MG CAPSULE NICARDIPINE 3 Effective 01/04/21 Alphabetical by Brand Name (when applicable)

Calcium Channel Blockers CARDIZEM 120 MG TABLET DILTIAZEM 3 Calcium Channel Blockers CARDIZEM 30 MG TABLET DILTIAZEM 4 Calcium Channel Blockers CARDIZEM 60 MG TABLET DILTIAZEM 4 Calcium Channel Blockers CARDIZEM 90 MG TABLET DILTIAZEM 4 Calcium Channel Blockers CARDIZEM CD 120 MG CAPSULE DILTIAZEM 1 Calcium Channel Blockers CARDIZEM CD 180 MG CAPSULE DILTIAZEM 2 Calcium Channel Blockers CARDIZEM CD 240 MG CAPSULE DILTIAZEM 2 Calcium Channel Blockers CARDIZEM CD 300 MG CAPSULE DILTIAZEM 1 Calcium Channel Blockers CARDIZEM CD 360 MG CAPSULE DILTIAZEM 1 Calcium Channel Blockers CARDIZEM LA 120 MG TABLET DILTIAZEM 1 Calcium Channel Blockers CARDIZEM LA 180 MG TABLET DILTIAZEM 1 Calcium Channel Blockers CARDIZEM LA 240 MG TABLET DILTIAZEM 2 Calcium Channel Blockers CARDIZEM LA 300 MG TABLET DILTIAZEM 1 Calcium Channel Blockers CARDIZEM LA 360 MG TABLET DILTIAZEM 1 Calcium Channel Blockers CARDIZEM LA 420 MG TABLET DILTIAZEM 1 BPH Treatments CARDURA 1 MG TABLET DOXAZOSIN 1 BPH Treatments CARDURA 2 MG TABLET DOXAZOSIN 1 BPH Treatments CARDURA 4 MG TABLET DOXAZOSIN 1 BPH Treatments CARDURA 8 MG TABLET DOXAZOSIN 2 BPH Treatments CARDURA XL 4 MG TABLET DOXAZOSIN 1 BPH Treatments CARDURA XL 8 MG TABLET DOXAZOSIN 1 Calcium Channel Blockers CARTIA XT 120 MG CAPSULE SA DILTIAZEM 1 Calcium Channel Blockers CARTIA XT 180 MG CAPSULE SA DILTIAZEM 2 Calcium Channel Blockers CARTIA XT 240 MG CAPSULE SA DILTIAZEM 2 Calcium Channel Blockers CARTIA XT 300 MG CAPSULE SA DILTIAZEM 1 NSAIDs CATAFLAM 50 MG TABLET DICLOFENAC POTASSIUM 4 Antihypertensive, Sympatholytics CATAPRES-TTS 1 PATCH CLONIDINE 0.14 Antihypertensive, Sympatholytics CATAPRES-TTS 2 PATCH CLONIDINE 0.14 Antihypertensive, Sympatholytics CATAPRES-TTS 3 PATCH CLONIDINE 0.14 Antibiotics, Inhaled CAYSTON 75 MG/ML INHALATION SOLUTION VIAL AZTREONAM LYSINE 3 NSAIDs CELEBREX 100 MG CAPSULE CELECOXIB 2 NSAIDs CELEBREX 200 MG CAPSULE CELECOXIB 2 NSAIDs CELEBREX 400 MG CAPSULE CELECOXIB 1 NSAIDs CELEBREX 50 MG CAPSULE CELECOXIB 2 Antidepressants, SSRIs CELEXA 10 MG TABLET CITALOPRAM 1.5 Antidepressants, SSRIs CELEXA 10 MG/5 ML SOLUTION CITALOPRAM 20 Antidepressants, SSRIs CELEXA 20 MG TABLET CITALOPRAM 1.5 Antidepressants, SSRIs CELEXA 40 MG TABLET CITALOPRAM 1 Anticonvulsants CELONTIN 300 MG CAPSULE METHOSUXIMIDE 4 Opthalmics, Immunomodulators CEQUA 0.09% SOLUTION CYCLOSPORINE 2 Enzyme Replacements, Gaucher Disease CERDELGA 84 MG CAPSULE ELIGLUSTAT 2 Effective 01/04/21 Alphabetical by Brand Name (when applicable)

Vaccines CERVARIX VACCINE SYRINGE HUMAN PAPILLOMAVIRUS VACCINE 0.5 Antiemetics/Antivertigo Agents CESAMET 1 MG CAPSULE NABILONE 6 Smoking Cessation CHANTIX 0.5 MG TABLET VARENICLINE 2 Smoking Cessation CHANTIX 1 MG CONTINUING MONTH PAK VARENICLINE 2 Smoking Cessation CHANTIX 1 MG TABLET VARENICLINE 2 Bile Salts CHENODAL 250 MG TABLET CHENODIOL 6 Opioid Antitussive CHERATUSSIN AC SYRUP CODEINE PHOSPHATE/GUAIFENESIN 60 Antihistamines, Minimally Sedating CHILD LORATADINE 10 MG/10 ML SOLUTION LORATADINE 10 Hypoglycemics, Sulfonylureas CHLORPROPAMIDE 100 MG TABLET CHLORPROPAMIDE 3 Hypoglycemics, Sulfonylureas CHLORPROPAMIDE 250 MG TABLET CHLORPROPAMIDE 2 Analgesics, Salicylates CHOLINE/MAG TRISAL 1000 MG TABLET CHOLINE/MAGNESIUM TRISALICYLATE 4 Analgesics, Salicylates CHOLINE/MAG TRISAL 500 MG TABLET CHOLINE/MAGNESIUM TRISALICYLATE 6 Analgesics, Salicylates CHOLINE/MAG TRISAL 500 MG/5 ML LIQUID CHOLINE/MAGNESIUM TRISALICYLATE 45 Analgesics, Salicylates CHOLINE/MAG TRISAL 750 MG TABLET CHOLINE/MAGNESIUM TRISALICYLATE 6 BPH Treatments CIALIS 10 MG TABLET TADALAFIL 1 BPH Treatments CIALIS 2.5 MG TABLET TADALAFIL 1 BPH Treatments CIALIS 20 MG TABLET TADALAFIL 1 BPH Treatments CIALIS 5 MG TABLET TADALAFIL 1 HIV/AIDS Antiretrovirals CIMDUO 300-300 MG TABLET LAMIVUDINE AND TENOFOVIR DF 1 Cytokine & CAM Antagonists CIMZIA 200 MG VIAL KIT CERTOLIZUMAB PEGOL 0.11 Cytokine & CAM Antagonists CIMZIA 200 MG/ML STARTER KIT CERTOLIZUMAB PEGOL 0.11 Cytokine & CAM Antagonists CIMZIA 200 MG/ML SYRINGE KIT CERTOLIZUMAB PEGOL 0.11 Hereditary Angioedema Treatments CINRYZE 500 UNIT VIAL C1 ESTERASE INHIBITOR 0.67 Antiemetics/Antivertigo Agents CINVANTI 130 MG/18 ML VIAL APREPITANT 1.29 Antihistamines, Minimally Sedating CLARINEX - D 12 HOUR TABLET PSEUDOEPHEDRINE/DESLORATADINE 2 Antihistamines, Minimally Sedating CLARINEX - D 24 HOUR TABLET PSEUDOEPHEDRINE/DESLORATADINE 1 Antihistamines, Minimally Sedating CLARINEX 0.5 MG/ML SYRUP DESLORATADINE 10 Antihistamines, Minimally Sedating CLARINEX 2.5 MG REDITABS DESLORATADINE 1 Antihistamines, Minimally Sedating CLARINEX 5 MG REDITABS DESLORATADINE 1 Antihistamines, Minimally Sedating CLARINEX 5 MG TABLET DESLORATADINE 1 Antihistamines, Minimally Sedating CLARITIN 10 MG REDITABS LORATADINE 1 Antihistamines, Minimally Sedating CLARITIN 10 MG TABLETS LORATADINE 1 Antihistamines, Minimally Sedating CLARITIN 5 MG/5 ML SYRUP LORATADINE 10 Antihistamines, Minimally Sedating CLARITIN CHEWABLE 5 MG TABLET LORATADINE 2 Antihistamines, Minimally Sedating CLARITIN-D 12 HOUR TAB SA PSEUDOEPHEDRINE/LORATADINE 2 Antihistamines, Minimally Sedating CLARITIN-D 24 HOUR TAB ER PSEUDOEPHEDRINE/LORATADINE 1 Blood Glucose Meters CLEVER CHEK BLOOD GLUCOSE METER BLOOD GLUCOSE METER See footnote2 Blood Glucose Test Strips CLEVER CHOICE BLOOD GLUCOSE TEST STRIPS BLOOD GLUCOSE TEST STRIPS 3.34 Blood Glucose Test Strips CLEVER CHOICE VOICE BLOOD GLUCOSE TEST STRIPS BLOOD GLUCOSE TEST STRIPS 3.34 Estrogens CLIMARA 0.025 MG/DAY PATCH ESTRADIOL 0.15 Estrogens CLIMARA 0.0375 MG/DAY PATCH ESTRADIOL 0.15 Effective 01/04/21 Alphabetical by Brand Name (when applicable)

Estrogens CLIMARA 0.05 MG/DAY PATCH ESTRADIOL 0.15 Estrogens CLIMARA 0.06 MG/DAY PATCH ESTRADIOL 0.15 Estrogens CLIMARA 0.075 MG/DAY PATCH ESTRADIOL 0.15 Estrogens CLIMARA 0.1 MG/DAY PATCH ESTRADIOL 0.15 Estrogens CLIMARA PRO PATCH ESTRADIOL/LEVONORGESTREL 0.15 NSAIDs CLINORIL 150 MG TABLET SULINDAC 2 NSAIDs CLINORIL 200 MG TABLET SULINDAC 2 Antipsychotics, Atypical CLOZARIL 100 MG TABLET CLOZAPINE 9 Antipsychotics, Atypical CLOZARIL 200 MG TABLET CLOZAPINE 4 Antipsychotics, Atypical CLOZARIL 25 MG TABLET CLOZAPINE 3 Antipsychotics, Atypical CLOZARIL 50 MG TABLET CLOZAPINE 3 Analgesics, Opioid Short-Acting CODEINE SULFATE 15 MG TABLET CODEINE 6 Analgesics, Opioid Short-Acting CODEINE SULFATE 30 MG TABLET CODEINE 6 Analgesics, Opioid Short-Acting CODEINE SULFATE 60 MG TABLET CODEINE 5 Opioid Antitussive CODEINE-GUAIFEN 10-100 MG/5 ML SOLUTION CODEINE PHOSPHATE/GUAIFENESIN 60 Antiparkinson's Agents COGENTIN 0.5 MG TABLET BENZTROPINE 2 Antiparkinson's Agents COGENTIN 1 MG TABLET BENZTROPINE 4 Antiparkinson's Agents COGENTIN 2 MG TABLET BENZTROPINE 3 Ulcerative Colitis Agents COLAZAL 750 MG CAPSULE BALSALAZIDE 9 Antihyperuricemics COLCRYS 0.6 MG TABLET COLCHICINE 3 Lipotropics, Other COLESTID 1 GRAM TABLET COLESTIPOL 16 Estrogens COMBIPATCH 0.05-0.14 MG PATCH ESTRADIOL/NORETHINDRONE ACETATE 0.29 Estrogens COMBIPATCH 0.05-0.25 MG PATCH ESTRADIOL/NORETHINDRONE ACETATE 0.29 COPD Agents COMBIVENT RESPIMAT INHALATION SPRAY IPRATROPIUM/ALBUTEROL 0.27 HIV/AIDS Antiretrovirals COMBIVIR 50 MG/300 MG TABLET LAMIVUDINE/ZIDOVUDINE 2 Analgesics, Opioid Short-Acting COMBUNOX 5 MG/400 MG TABLET OXYCODONE/IBUPROFEN 4 Oncology Agents, Oral COMETRIQ 100 MG DAILY DOSE PACK CABOZANTINIB 2 Oncology Agents, Oral COMETRIQ 140 MG DAILY DOSE PACK CABOZANTINIB 4 Oncology Agents, Oral COMETRIQ 60 MG DAILY DOSE PACK CABOZANTINIB 3 Smoking Cessation COMMIT 2 MG LOZENGE NICOTINE POLACRILEX 20 Smoking Cessation COMMIT 4 MG LOZENGE NICOTINE POLACRILEX 20 HIV/AIDS Antiretrovirals COMPLERA 200 MG/25 MG/300 MG TABLET EMTRICITABINE/RILPIVIRINE/TENOFOVIR DF 1 Antiparkinson's Agents COMTAN 200 MG ENTACAPONE 8 Stimulants & Related Agents CONCERTA 18 MG TABLET METHYLPHENIDATE 1 Stimulants & Related Agents CONCERTA 27 MG TABLET METHYLPHENIDATE 1 Stimulants & Related Agents CONCERTA 36 MG TABLET METHYLPHENIDATE 2 Stimulants & Related Agents CONCERTA 54 MG TABLET METHYLPHENIDATE 1 Blood Glucose Meters CONTOUR BLOOD GLUCOSE METER BLOOD GLUCOSE METER See footnote2 Blood Glucose Test Strips CONTOUR BLOOD GLUCOSE TEST STRIPS BLOOD GLUCOSE TEST STRIPS 3.34 Blood Glucose Meters CONTOUR LINK BLOOD GLUCOSE METER BLOOD GLUCOSE METER See footnote2 Blood Glucose Test Strips CONTOUR NEXT BLOOD GLUCOSE TEST STRIPS BLOOD GLUCOSE TEST STRIPS 3.34 Effective 01/04/21 Alphabetical by Brand Name (when applicable)

Blood Glucose Meters CONTOUR NEXT EZ BLOOD GLUCOSE METER BLOOD GLUCOSE METER See footnote2 Blood Glucose Meters CONTOUR NEXT LINK BLOOD GLUCOSE METER BLOOD GLUCOSE METER See footnote2 Blood Glucose Meters CONTOUR PLUS BLOOD GLUCOSE METER BLOOD GLUCOSE METER See footnote2 Blood Glucose Test Strips CONTOUR PLUS BLOOD GLUCOSE TEST STRIPS BLOOD GLUCOSE TEST STRIPS 3.34 Blood Glucose Meters CONTOUR USB BLOOD GLUCOSE METER BLOOD GLUCOSE METER See footnote2 Analgesics, Opioid Short-Acting CONZIP 100 MG CAPSULE TRAMADOL 1 Analgesics, Opioid Short-Acting CONZIP 200 MG CAPSULE TRAMADOL 1 Analgesics, Opioid Short-Acting CONZIP 300 MG CAPSULE TRAMADOL 1 Multiple Sclerosis Agents COPAXONE 20 MG/ML SYRINGE GLATIRAMER ACETATE 1 Multiple Sclerosis Agents COPAXONE 40 MG/ML SYRINGE GLATIRAMER ACETATE 0.43 Beta-Blockers COREG 12.5 MG TABLET CARVEDILOL 2 Beta-Blockers COREG 25 MG TABLET CARVEDILOL 4 Beta-Blockers COREG 3.125 MG TABLET CARVEDILOL 2 Beta-Blockers COREG 6.25 MG TABLET CARVEDILOL 2 Beta-Blockers COREG CR 10 MG CAPSULE CARVEDILOL 1 Beta-Blockers COREG CR 20 MG CAPSULE CARVEDILOL 1 Beta-Blockers COREG CR 40 MG CAPSULE CARVEDILOL 1 Beta-Blockers COREG CR 80 MG CAPSULE CARVEDILOL 1 Cardiovascular Agents CORLANOR 5 MG TABLETS IVABRADINE 2 Cardiovascular Agents CORLANOR 5 MG/5 ML ORAL SOLUTION IVABRADINE 20 Cardiovascular Agents CORLANOR 7.5 MG TABLETS IVABRADINE 2 Cytokine & CAM Antagonists COSENTYX 300 MG DOSE 2 PENS SECUKINUMAB 0.29 Cytokine & CAM Antagonists COSENTYX 300 MG DOSE 2 SYRINGES SECUKINUMAB 0.29 Oncology Agents, Oral COTELLIC 20 MG TABLET COBIMETINIB FUMARATE 3 Stimulants & Related Agents COTEMPLA XR-ODT 17.3 MG TABLET METHYLPHENIDATE 2 Stimulants & Related Agents COTEMPLA XR-ODT 25.9 MG TABLET METHYLPHENIDATE 2 Stimulants & Related Agents COTEMPLA XR-ODT 8.6 MG TABLET METHYLPHENIDATE 1 Calcium Channel Blockers COVERA-HS 180 MG TABLET SA VERAPAMIL 2 Calcium Channel Blockers COVERA-HS 240 MG TABLET SA VERAPAMIL 2 Angiotensin Modulators COZAAR 100 MG TABLET LOSARTAN 1 Angiotensin Modulators COZAAR 25 MG TABLET LOSARTAN 2 Angiotensin Modulators COZAAR 50 MG TABLET LOSARTAN 2 Antifungals, Oral CRESEMBA 186 MG CAPSULE ISAVUCONAZONIUM SULFATE 3.15 Lipotropics, Statins CRESTOR 10 MG TABLET ROSUVASTATIN 1.5 Lipotropics, Statins CRESTOR 20 MG TABLET ROSUVASTATIN 1.5 Lipotropics, Statins CRESTOR 40 MG TABLET ROSUVASTATIN 1 Lipotropics, Statins CRESTOR 5 MG TABLET ROSUVASTATIN 1.5 Insect Repellent for Skin Application CUTTER BACKWOODS DRY INSECT REPELLENT 25% AERO. DIETHYLTOLUAMIDE 31 Insect Repellent for Skin Application CUTTER BACKWOODS INSECT REPELLENT 25% AEROSOL DIETHYLTOLUAMIDE 31 Insect Repellent for Skin Application CUTTER BACKWOODS INSECT REPELLENT 25% AEROSOL DIETHYLTOLUAMIDE 31 Insect Repellent for Skin Application CUTTER BACKWOODS INSECT REPELLENT 25% PUMP DIETHYLTOLUAMIDE 30 Effective 01/04/21 Alphabetical by Brand Name (when applicable)

Insect Repellent for Skin Application CUTTER LEMON EUCALYPTUS INSECT REPELLENT PUMP OIL OF LEMON EUCALYPTUS 30 Insect Repellent for Skin Application CUTTER SKINSATIONS INSECT REPELLENT1 7% PUMP DIETHYLTOLUAMIDE 30 Insect Repellent NOT for Skin Application CVS LICE BEDDING SPRAY PERMETHRIN 0.5% 29 Insect Repellent for Skin Application CVS TOTAL HOME INSECT 30% SPRAY DIETHYLTOLUAMIDE 30 Antidepressants, Other CYMBALTA 20 MG CAPSULE DULOXETINE 4 Antidepressants, Other CYMBALTA 30 MG CAPSULE DULOXETINE 2 Antidepressants, Other CYMBALTA 60 MG CAPSULE DULOXETINE 2 Thyroid Hormones CYTOMEL 25 MCG TABLET LIOTHYRONINE 1 Thyroid Hormones CYTOMEL 5 MCG TABLET LIOTHYRONINE 4 Thyroid Hormones CYTOMEL 50 MCG TABLET LIOTHYRONINE 2 Hepatitis C Agents DAKLINZA 30 MG TABLET DACLATASVIR 1 COPD Agents DALIRESP 250 MCG TABLET ROFLUMILAST 1 COPD Agents DALIRESP 500 MCG TABLET ROFLUMILAST 1 Sedative Hypnotics DALMANE 15 MG CAPSULE FLURAZEPAM 1 Sedative Hypnotics DALMANE 30 MG CAPSULE FLURAZEPAM 1 Skeletal Muscle Relaxants DANTRIUM 100 MG CAPSULE DANTROLENE 4 Skeletal Muscle Relaxants DANTRIUM 25 MG CAPSULE DANTROLENE 4 Skeletal Muscle Relaxants DANTRIUM 50 MG CAPSULE DANTROLENE 4 Antimalarials DARAPRIM 25 MG TABLET PYRIMETHAMINE 3 Oncology Agents, Oral DAURISMO 100 MG TABLET GLASDEGIB 1 Oncology Agents, Oral DAURISMO 25 MG TABLET GLASDEGIB 2 NSAIDs DAYPRO 600 MG TABLET OXAPROZIN 3 Stimulants & Related Agents DAYTRANA TRANSDERMAL 10 MG PATCH METHYLPHENIDATE 1 Stimulants & Related Agents DAYTRANA TRANSDERMAL 15 MG PATCH METHYLPHENIDATE 1 Stimulants & Related Agents DAYTRANA TRANSDERMAL 20 MG PATCH METHYLPHENIDATE 2 Stimulants & Related Agents DAYTRANA TRANSDERMAL 30 MG PATCH METHYLPHENIDATE 2 Sedative Hypnotics DAYVIGO 10 MG TABLET LEMBOREXANT 1 Sedative Hypnotics DAYVIGO 5 MG TABLET LEMBOREXANT 1 Antidiuretic Hormones DDAVP 0.01% NASAL SPRAY PUMP DESMOPRESSIN ACETATE SOLUTION 0.4 Antidiuretic Hormones DDAVP 0.01% NASAL SPRAY PUMP (NON-REFRIGERATED) DESMOPRESSIN ACETATE SOLUTION 0.4 Androgenic Agents DELATESTRYL 200 MG/ML VIAL TESTOSTERONE ENANTHATE 0.15 HIV/AIDS Antiretrovirals DELSTRIGO 100-300-300 MG TABLET DORAVIRINE/LAMIVUDINE/TENOFOVIR DF 1 Ulcerative Colitis Agents DELZICOL 400 MG DR CAPSULE MESALAMINE 6 Analgesics, Opioid Short-Acting DEMEROL 100 MG TABLET MEPERIDINE 5 Analgesics, Opioid Short-Acting DEMEROL 50 MG TABLET MEPERIDINE 10 Analgesics, Opioid Short-Acting DEMEROL 50 MG/5 ML SOLUTION MEPERIDINE 50 Antihypertensives, Miscellaneous DEMSER 250 MG CAPSULE METYROSINE 16 Antivirals, Herpes DENAVIR 1% CREAM PENCICLOVIR 1.25 Contraceptives, Other DEPO-PROVERA 150 MG/ML VIAL/SYRINGE MEDROXYPROGESTERONE ACETATE 0.01 Progestational Agents DEPO-PROVERA 400 MG/ML VIAL/SYRINGE (2.5 ML) MEDROXYPROGESTERONE ACETATE 0.36 Contraceptives, Other DEPO-SUBQ PROVERA 104 SYRINGE MEDROXYPROGESTERONE ACETATE 0.01 Effective 01/04/21 Alphabetical by Brand Name (when applicable)

Androgenic Agents DEPO-TESTOSTERONE 100 MG/ML VIAL TESTOSTERONE CYPIONATE 0.29 Androgenic Agents DEPO-TESTOSTERONE 200 MG/ML VIAL TESTOSTERONE CYPIONATE 0.15 Anesthetics, Topical DERMACINRX ZRM PAK KIT LIDOCAINE/DIMETHICONE 1 HIV/AIDS Antiretrovirals DESCOVY 200/25 MG TABLET EMTRICITABINE/TENOFOVIR ALAFENAMIDE 1 Stimulants & Related Agents DESOXYN 5 MG TABLET METHAMPHETAMINE 5 Antidepressants, Other DESVENLAFAXINE ER 100 MG TABLET DESVENLAFAXINE 1 Antidepressants, Other DESVENLAFAXINE ER 50 MG TABLET DESVENLAFAXINE 1 Antidepressants, Other DESVENLAFAXINE FUMARATE ER 100 MG TABLET DESVENLAFAXINE FUMARATE 1 Antidepressants, Other DESVENLAFAXINE FUMARATE ER 50 MG TABLET DESVENLAFAXINE FUMARATE 1 Bladder Relaxant Preparations DETROL 1 MG TABLET TOLTERODINE 2 Bladder Relaxant Preparations DETROL 2 MG TABLET TOLTERODINE 2 Bladder Relaxant Preparations DETROL LA 2 MG CAPSULE TOLTERODINE 1 Bladder Relaxant Preparations DETROL LA 4 MG CAPSULE TOLTERODINE 1 Continuous Glucose Monitoring Transmitter DEXCOM G5 TRANSMITTER KIT BLOOD GLUCOSE TRANSMITTER 0.02 Continuous Glucose Monitoring Sensor DEXCOM G5-G4 SENSOR KIT BLOOD GLUCOSE SENSOR 0.15 Continuous Glucose Monitoring Receiver DEXCOM G6 RECEIVER BLOOD GLUCOSE METER, CONTINUOUS See footnote2 Continuous Glucose Monitoring Sensor DEXCOM G6 SENSOR BLOOD GLUCOSE SENSOR 0.15 Continuous Glucose Monitoring Transmitter DEXCOM G6 TRANSMITTER BLOOD GLUCOSE TRANSMITTER 0.02 Continuous Glucose Monitoring Receiver DEXCOM RECEIVER KIT BLOOD GLUCOSE METER, CONTINUOUS See footnote2 Stimulants & Related Agents DEXEDRINE SPANSULE 10 MG DEXTROAMPHETAMINE SR 4 Stimulants & Related Agents DEXEDRINE SPANSULE 15 MG DEXTROAMPHETAMINE SR 4 Stimulants & Related Agents DEXEDRINE SPANSULE 5 MG DEXTROAMPHETAMINE SR 2 Proton Pump Inhibitors DEXILANT DR 30 MG CAPSULE DEXLANSOPRAZOLE 1 Proton Pump Inhibitors DEXILANT DR 60 MG CAPSULE DEXLANSOPRAZOLE 1 Stimulants & Related Agents DEXTROSTAT 10 MG TABLET DEXTROAMPHETAMINE 6 Stimulants & Related Agents DEXTROSTAT 5 MG TABLET DEXTROAMPHETAMINE 6 Hypoglycemics, Sulfonylureas DIABETA 1.25 MG TABLET GLYBURIDE 2 Hypoglycemics, Sulfonylureas DIABETA 2.5 MG TABLET GLYBURIDE 2 Hypoglycemics, Sulfonylureas DIABETA 5 MG TABLET GLYBURIDE 4 Anxiolytics DIAZEPAM 5 MG/5ML SOLN DIAZEPAM 40 Anxiolytics DIAZEPAM INTENSOL 5 MG/ML CONCENTRATE DIAZEPAM 8 Antiemetics/Antivertigo Agents DICLEGIS DR 10 MG/10 MG TABLET DOXYLAMINE/PYRIDOXINE 4 Antibiotics, GI and Related Agents DIFICID 200 MG TABLET FIDAXOMICIN 2 Antifungals, Oral DIFLUCAN 10 MG/ML SUSPENSION FLUCONAZOLE 10 Antifungals, Oral DIFLUCAN 100 MG TABLET FLUCONAZOLE 2 Antifungals, Oral DIFLUCAN 150 MG TABLET FLUCONAZOLE 1 Antifungals, Oral DIFLUCAN 200 MG TABLET FLUCONAZOLE 2 Antifungals, Oral DIFLUCAN 40 MG/ML SUSPENSION FLUCONAZOLE 10 Antifungals, Oral DIFLUCAN 50 MG TABLET FLUCONAZOLE 2 Analgesics, Salicylates DIFLUNISAL 500 MG TABLET DIFLUNISAL 3 Calcium Channel Blockers DILACOR XR 120 MG CAPSULE SA DILTIAZEM 1 Effective 01/04/21 Alphabetical by Brand Name (when applicable)

Calcium Channel Blockers DILACOR XR 180 MG CAPSULE SA DILTIAZEM 1 Calcium Channel Blockers DILACOR XR 240 MG CAPSULE SA DILTIAZEM 2 Anticonvulsants DILANTIN 100 MG CAPSULE PHENYTOIN 6 Anticonvulsants DILANTIN 125 MG/5 ML (100 MG/4 ML) LIQUID PHENYTOIN 24 Anticonvulsants DILANTIN 30 MG CAPSULE PHENYTOIN 6 Anticonvulsants DILANTIN 50 MG CHEWABLE INFATAB PHENYTOIN 6 Analgesics, Opioid Short-Acting DILAUDID 1 MG/ML LIQUID HYDROMORPHONE 80 Analgesics, Opioid Short-Acting DILAUDID 2 MG TABLET HYDROMORPHONE 6 Analgesics, Opioid Short-Acting DILAUDID 3 MG SUPPOSITORY HYDROMORPHONE 4 Analgesics, Opioid Short-Acting DILAUDID 4 MG TABLET HYDROMORPHONE 4 Analgesics, Opioid Short-Acting DILAUDID 8 MG TABLET HYDROMORPHONE 4 Calcium Channel Blockers DILT-CD 120 MG CAPSULE DILTIAZEM 1 Calcium Channel Blockers DILT-CD 180 MG CAPSULE DILTIAZEM 1 Calcium Channel Blockers DILT-CD 240 MG CAPSULE DILTIAZEM 2 Calcium Channel Blockers DILT-CD ER 300 MG CAPSULE DILTIAZEM 1 Calcium Channel Blockers DILTIA XT 120 MG CAPSULE SA DILTIAZEM 1 Calcium Channel Blockers DILTIA XT 180 MG CAPSULE SA DILTIAZEM 1 Calcium Channel Blockers DILTIA XT 240 MG CAPSULE SA DILTIAZEM 2 Calcium Channel Blockers DILTIAZEM ER 60 MG CAPSULE DILTIAZEM 2 Calcium Channel Blockers DILTIAZEM ER 90 MG CAPSULE DILTIAZEM 2 Calcium Channel Blockers DILT-XR 120 MG CAP SA DILTIAZEM 1 Calcium Channel Blockers DILT-XR 180 MG CAP SA DILTIAZEM 1 Calcium Channel Blockers DILT-XR 240 MG CAP SA DILTIAZEM 2 Angiotensin Modulators DIOVAN 160 MG TABLET VALSARTAN 2 Angiotensin Modulators DIOVAN 320 MG TABLET VALSARTAN 1 Angiotensin Modulators DIOVAN 40 MG TABLET VALSARTAN 2 Angiotensin Modulators DIOVAN 80 MG TABLET VALSARTAN 2 Angiotensin Modulators DIOVAN HCT 160/12.5 MG TAB VALSARTAN/HCTZ 1 Angiotensin Modulators DIOVAN HCT 160/25 MG TABLET VALSARTAN/HCTZ 1 Angiotensin Modulators DIOVAN HCT 320/12.5 MG TABLET VALSARTAN/HCTZ 1 Angiotensin Modulators DIOVAN HCT 320/25 MG TABLET VALSARTAN/HCTZ 1 Angiotensin Modulators DIOVAN HCT 80/12.5 MG TABLET VALSARTAN/HCTZ 1 Ulcerative Colitis Agents DIPENTUM 250 MG CAPSULE OLSALAZINE 4 Bladder Relaxant Preparations DITROPAN 5 MG TABLET OXYBUTYNIN 4 Bladder Relaxant Preparations DITROPAN 5 MG/5 ML SYRUP OXYBUTYNIN 20 Bladder Relaxant Preparations DITROPAN XL 10 MG TABLET OXYBUTYNIN 2 Bladder Relaxant Preparations DITROPAN XL 15 MG TABLET OXYBUTYNIN 2 Bladder Relaxant Preparations DITROPAN XL 5 MG TABLET OXYBUTYNIN 1 Estrogens DIVIGEL 0.25 MG GEL PACKET ESTRADIOL 1 Estrogens DIVIGEL 0.5 MG GEL PACKET ESTRADIOL 1 Estrogens DIVIGEL 0.75 MG GEL PACKET ESTRADIOL 1 Effective 01/04/21 Alphabetical by Brand Name (when applicable)

Estrogens DIVIGEL 1 MG GEL PACKET ESTRADIOL 1 Analgesics, Opioid Long-Acting DOLOPHINE 10 MG TABLET METHADONE 2 Analgesics, Opioid Long-Acting DOLOPHINE 5 MG TABLET METHADONE 2 Thrombopoietics DOPTELET 20 MG TABLET AVATROMBOPAG 3 Tetracyclines DORYX DR 100 MG TABLET DOXYCYCLINE HYCLATE 1 Tetracyclines DORYX DR 150 MG TABLET DOXYCYCLINE HYCLATE 1 Tetracyclines DORYX DR 200 MG TABLET DOXYCYCLINE HYCLATE 1 Tetracyclines DORYX DR 50 MG TABLET DOXYCYCLINE HYCLATE 1 Tetracyclines DORYX DR 75 MG TABLET DOXYCYCLINE HYCLATE 1 Tetracyclines DORYX MPC DR 120 mg tablet DOXYCYCLINE HYCLATE DELAYED-RELEASE 2 HIV/AIDS Agents DOVATO 50-300 MG TABLET DOLUTEGRAVIR/LAMIVUDINE 1 Neuropathic Pain Agents DRIZALMA SPRINKLE DR 20 MG CAPSULE DULOXETINE DR 2 Neuropathic Pain Agents DRIZALMA SPRINKLE DR 30 MG CAPSULE DULOXETINE DR 2 Neuropathic Pain Agents DRIZALMA SPRINKLE DR 40 MG CAPSULE DULOXETINE DR 1 Neuropathic Pain Agents DRIZALMA SPRINKLE DR 60 MG CAPSULE DULOXETINE DR 1 COPD Agents DUAKLIR PRESSAIR 400-12 MCG INH ACLIDINIUM BROMIDE/FORMOTEROL FUMARATE 0.04 Estrogens DUAVEE 0.45-20 MG TABLET CONJUGATED ESTROGENS/BAZEDOXIFENE 1 Hypoglycemics, TZDs DUETACT 30/2 MG TABLET PIOGLITAZONE/ GLIMEPIRIDE 1 Hypoglycemics, TZDs DUETACT 30/4 MG TABLET PIOGLITAZONE/ GLIMEPIRIDE 1 NSAIDs DUEXIS 800 MG/26.6 MG TABLET IBUPROFEN/FAMOTIDINE 3 Glucocorticoids, Inhaled DULERA 100 MCG-5 MCG INHALER MOMETASONE/FORMOTEROL 0.44 Glucocorticoids, Inhaled DULERA 200 MCG-5 MCG INHALER MOMETASONE/FORMOTEROL 0.44 Glucocorticoids, Inhaled DULERA 50 MCG-5 MCG INHALER MOMETASONE/FORMOTEROL 0.44 COPD Agents DUONEB 0.5 MG-3 MG/3 ML INHALATION SOLUTION IPRATROPIUM/ALBUTEROL 18 Immunomodulators, Atopic Dermatitis DUPIXENT 200 MG/1.14 ML SYRINGE DUPILUMAB 0.17 Immunomodulators, Atopic Dermatitis DUPIXENT 300 MG/2 ML SYRINGE DUPILUMAB 0.29 Analgesics, Opioid Long-Acting DURAGESIC 100 MCG/HR PATCH FENTANYL TRANSDERMAL 0.34 Analgesics, Opioid Long-Acting DURAGESIC 12 MCG/HR PATCH FENTANYL TRANSDERMAL 0.34 Analgesics, Opioid Long-Acting DURAGESIC 25 MCG/HR PATCH FENTANYL TRANSDERMAL 0.34 Analgesics, Opioid Long-Acting DURAGESIC 50 MCG/HR PATCH FENTANYL TRANSDERMAL 0.34 Analgesics, Opioid Long-Acting DURAGESIC 75 MCG/HR PATCH FENTANYL TRANSDERMAL 0.34 Intra-Articular Hyaluronates DUROLANE 60 MG/3 ML SYRINGE HYALURONATE SODIUM 0.2 Stimulants & Related Agents DYANAVEL XR 2.5 MG/ML SUSPENSION DEXTROAMPHETAMINE/AMPHETAMINE 8 Intranasal Rhinitis Agents DYMISTA NASAL SPRAY AZELASTINE/FLUTICASONE 0.77 Calcium Channel Blockers DYNACIRC 2.5 MG CAPSULE ISRADIPINE 2 Calcium Channel Blockers DYNACIRC 5 MG CAPSULE ISRADIPINE 2 Calcium Channel Blockers DYNACIRC CR 10 MG TABLET SA ISRADIPINE 2 Calcium Channel Blockers DYNACIRC CR 5 MG TABLET SA ISRADIPINE 1 Botulinum Toxins DYSPORT 300 UNIT INJECTION VIAL ABOBOTULINUMTOXIN A 0.04 Botulinum Toxins DYSPORT 500 UNIT INJECTION VIAL ABOBOTULINUMTOXIN A 0.04 Blood Glucose Test Strips EASYGLUCO BLOOD GLUCOSE TEST STRIPS BLOOD GLUCOSE TEST STRIPS 3.34 Effective 01/04/21 Alphabetical by Brand Name (when applicable)

NSAIDs EC-NAPROSYN 375 MG TABLET NAPROXEN 3 NSAIDs EC-NAPROSYN 500 MG TABLET NAPROXEN 3 Angiotensin Modulators EDARBI 40 MG TABLET AZILSARTAN 1 Angiotensin Modulators EDARBI 80 MG TABLET AZILSARTAN 1 Angiotensin Modulators EDARBYCLOR 40 MG/12.5 MG TABLET AZILSARTAN/CHLORTHALIDONE 1 Angiotensin Modulators EDARBYCLOR 40 MG/25 MG TABLET AZILSARTAN/CHLORTHALIDONE 1 Sedative Hypnotics EDLUAR 10 MG SL TABLET ZOLPIDEM 1-See footnote3 Sedative Hypnotics EDLUAR 5 MG SL TABLET ZOLPIDEM 1 HIV/AIDS Antiretrovirals EDURANT 25 MG TABLET RILPIVIRINE 1 Antidepressants, Other EFFEXOR 100 MG TABLET VENLAFAXINE 3 Antidepressants, Other EFFEXOR 25 MG TABLET VENLAFAXINE 3 Antidepressants, Other EFFEXOR 37.5 MG TABLET VENLAFAXINE 3 Antidepressants, Other EFFEXOR 50 MG TABLET VENLAFAXINE 3 Antidepressants, Other EFFEXOR 75 MG TABLET VENLAFAXINE 3 Antidepressants, Other EFFEXOR XR 150 MG CAPSULE SA VENLAFAXINE 2 Antidepressants, Other EFFEXOR XR 37.5 MG CAPSULE SA VENLAFAXINE 1 Antidepressants, Other EFFEXOR XR 75 MG CAPSULE SA VENLAFAXINE 3 Platelet Aggregation Inhibitors EFFIENT 10 MG TABLET PRASUGREL 1 Platelet Aggregation Inhibitors EFFIENT 5 MG TABLET PRASUGREL 1 Antiparkinson's Agents ELDEPRYL 5 MG CAPSULE/TABLET SELEGILINE 2 Pituitary Suppressive Agents, LHRH ELIGARD 22.5 MG SYRINGE KIT (3-MONTH) LEUPROLIDE ACETATE 0.2 Pituitary Suppressive Agents, LHRH ELIGARD 30 MG SYRINGE KIT (4-MONTH) LEUPROLIDE ACETATE 0.01 Pituitary Suppressive Agents, LHRH ELIGARD 45 MG SYRINGE KIT (6-MONTH) LEUPROLIDE ACETATE 0.01 Pituitary Suppressive Agents, LHRH ELIGARD 7.5 MG SYRINGE KIT (1-MONTH) LEUPROLIDE ACETATE 0.4 Phosphate Binders ELIPHOS 667 MG TABLET CALCIUM ACETATE 12 Anticoagulants, Oral ELIQUIS 2.5 MG TABLET APIXABAN 2 Anticoagulants, Oral ELIQUIS 5 MG STARTER PACK APIXABAN 2.47 Anticoagulants, Oral ELIQUIS 5 MG TABLET APIXABAN 4 Analgesics, Urinary ELMIRON 100 MG CAPSULE PENTOSAN POLYSULFATE SODIUM 3 Blood Glucose Meters EMBRACE BLOOD GLUCOSE METER BLOOD GLUCOSE METER See footnote2 Blood Glucose Test Strips EMBRACE BLOOD GLUCOSE TEST STRIPS BLOOD GLUCOSE TEST STRIPS 3.34 Antiemetics/Antivertigo Agents EMEND 115 MG INJECTION VIAL FOSAPREPITANT 0.08 Antiemetics/Antivertigo Agents EMEND 125 MG CAPSULE APREPITANT 0.34 Antiemetics/Antivertigo Agents EMEND 125 MG POWDER PACKET APREPITANT 1 Antiemetics/Antivertigo Agents EMEND 150 MG INJECTION VIAL FOSAPREPITANT 0.08 Antiemetics/Antivertigo Agents EMEND 40 MG CAPSULE APREPITANT 1 Antiemetics/Antivertigo Agents EMEND 80 MG CAPSULE APREPITANT 1 Antiemetics/Antivertigo Agents EMEND BIFOLD PACK APREPITANT 1 Antiemetics/Antivertigo Agents EMEND TRIFOLD PACK APREPITANT 1 Glucocorticoids, Oral EMFLAZA 18 MG TABLET DEFLAZACORT 1 Glucocorticoids, Oral EMFLAZA 22.75 MG/ML ORAL SUSPENSION DEFLAZACORT 1.86 Effective 01/04/21 Alphabetical by Brand Name (when applicable)

Glucocorticoids, Oral EMFLAZA 30 MG TABLET DEFLAZACORT 1 Glucocorticoids, Oral EMFLAZA 36 MG TABLET DEFLAZACORT 1 Glucocorticoids, Oral EMFLAZA 6 MG TABLET DEFLAZACORT 2 Migraine Prevention Agents EMGALITY 120 MG/ML PEN GALCANEZUMAB-GNLM 0.08 Migraine Prevention Agents EMGALITY 120 MG/ML SYRINGE GALCANEZUMAB-GNLM 0.08 Migraine Prevention Agents EMGALITY 300 MG (100 MG X 3 SYRINGES) GALCANEZUMAB-GNLM 0.1 Antidepressants, Other EMSAM 12 MG/24 HR TRANSDERMAL PATCH SELEGILINE 1 Antidepressants, Other EMSAM 6 MG/24 HR TRANSDERMAL PATCH SELEGILINE 1 Antidepressants, Other EMSAM 9 MG/24 HR TRANSDERMAL PATCH SELEGILINE 1 HIV/AIDS Antiretrovirals EMTRIVA 10 MG/ML ORAL SOLUTION EMTRICITABINE 24 HIV/AIDS Antiretrovirals EMTRIVA 200 MG CAPSULE EMTRICITABINE 1 Antiparasitics EMVERM 100 MG CHEWABLE TABLET MEBENDAZOLE 2 Bladder Relaxant Preparations ENABLEX 15 MG ER TABLET DARIFENACIN 1 Bladder Relaxant Preparations ENABLEX 7.5 MG ER TABLET DARIFENACIN 1 Cytokine & CAM Antagonists ENBREL 25 MG VIAL KIT ETANERCEPT 0.29 Cytokine & CAM Antagonists ENBREL 25 MG/0.5 ML SYRINGE ETANERCEPT 0.15 Cytokine & CAM Antagonists ENBREL 25 MG/0.5 ML VIAL ETANERCEPT 0.15 Cytokine & CAM Antagonists ENBREL 50 MG/ML MINI CARTRIDGE ETANERCEPT 0.29 Cytokine & CAM Antagonists ENBREL 50 MG/ML SURECLICK SYRINGE ETANERCEPT 0.29 Cytokine & CAM Antagonists ENBREL 50 MG/ML SYRINGE ETANERCEPT 0.29 Sickle Cell Anemia Agents ENDARI 5 GRAM POWDER PACKET L-GLUTAMINE 6 Analgesics, Opioid Short-Acting ENDOCET 10-325 MG TABLET OXYCODONE/ACETAMINOPHEN 4 Analgesics, Opioid Short-Acting ENDOCET 5-325 MG TABLET OXYCODONE/ACETAMINOPHEN 6 Analgesics, Opioid Short-Acting ENDOCET 7.5-325 MG TABLET OXYCODONE/ACETAMINOPHEN 4 Analgesics, Opioid Short-Acting ENDODAN 4.83-325 MG TABLET OXYCODONE/ASPIRIN 6 Vaccines ENGERIX-B 10 MCG/0.5 ML PEDIATRIC SYRINGE HEPATITIS B VIRUS VACCINE 0.5 Vaccines ENGERIX-B 10 MCG/0.5 ML PEDIATRIC VIAL HEPATITIS B VIRUS VACCINE 0.5 Vaccines ENGERIX-B 20 MCG/ML SYRINGE HEPATITIS B VIRUS VACCINE 1 Vaccines ENGERIX-B 20 MCG/ML VIAL HEPATITIS B VIRUS VACCINE 1 Glucocorticoids, Oral ENTOCORT EC 3 MG CAPSULE BUDESONIDE 3 Angiotensin Modulators ENTRESTO 24 MG/26 MG TABLET SACUBITRIL/VALSARTAN 6 Angiotensin Modulators ENTRESTO 49 MG/51 MG TABLET SACUBITRIL/VALSARTAN 2 Angiotensin Modulators ENTRESTO 97 MG/103 MG TABLET SACUBITRIL/VALSARTAN 2 Cytokine & CAM Antagonists ENTYVIO 300 MG/20 ML VIAL VEDOLIZUMAB 0.08 Hepatitis C Agents EPCLUSA 400 MG/100 MG TABLET SOFOSBUVIR/VELPATASVIR 1 Anticonvulsants EPITOL 200 MG TABLET CARBAMAZEPINE 8 HIV/AIDS Antiretrovirals EPIVIR 10 MG/ML ORAL SOLUTION LAMIVUDINE 30 HIV/AIDS Antiretrovirals EPIVIR 150 MG TABLET LAMIVUDINE 2 HIV/AIDS Antiretrovirals EPIVIR 300 MG TABLET LAMIVUDINE 1 Hepatitis B Agents EPIVIR HBV 100 MG TABLET LAMIVUDINE 1 Hepatitis B Agents EPIVIR HBV 25 MG/5 ML SOLUTION LAMIVUDINE 20 Effective 01/04/21 Alphabetical by Brand Name (when applicable)

HIV/AIDS Antiretrovirals EPZICOM 600 MG/300 MG TABLET ABACAVIR/LAMIVUDINE 1 Anticonvulsants EQUETRO 100 MG CAPSULE CARBAMAZEPINE ER 6 Anticonvulsants EQUETRO 200 MG CAPSULE CARBAMAZEPINE ER 8 Anticonvulsants EQUETRO 300 MG CAPSULE CARBAMAZEPINE ER 5 Migraine Acute Treatment Agents ERGOMAR 2 MG TABLET SL ERGOTAMINE TARTRATE 0.72 Oncology Agents, Oral ERIVEDGE 150 MG CAPSULE VISMODEGIB 1 Oncology Agents, Oral ERLEADA 60 MG TABLET APALUTAMIDE 4 Idiopathic Pulmonary Fibrosis Agents ESBRIET 267 MG CAPSULE PERFENIDONE 6.9 Idiopathic Pulmonary Fibrosis Agents ESBRIET 267 MG TABLET PERFENIDONE 6.9 Idiopathic Pulmonary Fibrosis Agents ESBRIET 801 MG TABLET PERFENIDONE 3 Antidepressants, SSRIs ESCITALOPRAM OXALATE 10 MG/10 ML ESCITALOPRAM OXALATE 20 Analgesics, Non-Opioid Barbiturate Combos ESGIC 50 MG/325 MG/40 MG CAPSULE BUTALBITAL/ACETAMINOPHEN/CAFFEINE 0.6 Analgesics, Non-Opioid Barbiturate Combos ESGIC 50 MG/325 MG/40 MG TABLET BUTALBITAL/ACETAMINOPHEN/CAFFEINE 0.6 Proton Pump Inhibitors ESOMEPRAZOLE STRONTIUM 49.3 MG DR CAPSULE ESOMEPRAZOLE STRONTIUM 1 Intra-Articular Hyaluronates EUFLEXXA 20 MG/2 ML SYRINGE HYALURONIC ACID 0.58 Oncology Agents, Oral EULIXIN 125 MG CAPSULE FLUTAMIDE 6 Stimulants & Related Agents EVEKEO 10 MG TABLET AMPHETAMINE SULFATE 6 Stimulants & Related Agents EVEKEO 5 MG TABLET AMPHETAMINE SULFATE 2 Bone Density Regulators EVENITY 210 MG DOSE - 2 SYRINGES ROMOSOZUMAB-AQQG 0.09 Bone Density Regulators EVISTA 60 MG TABLET RALOXIFENE 1 HIV/AIDS Antiretrovirals EVOTAZ 300 MG/150 MG TABLET ATAZANAVIR/COBICISTAT 1 Analgesics, Opioid Long-Acting EXALGO 12 MG ER TABLET HYDROMORPHONE ER 1 Analgesics, Opioid Long-Acting EXALGO 16 MG ER TABLET HYDROMORPHONE ER 1 Analgesics, Opioid Long-Acting EXALGO 32 MG ER TABLET HYDROMORPHONE ER 1 Analgesics, Opioid Long-Acting EXALGO 8 MG ER TABLET HYDROMORPHONE ER 1 Analgesics, Salicylates EXCEDRIN EXTRA STRENGTH 250 MG/250 MG/65 MG ASPIRIN/ACETAMINOPHEN/CAFFEINE 13 Analgesics, Non-Salicylates EXCEDRIN TENSION HEADACHE 500 MG/65 MG ACETAMINOPHEN/CAFFEINE 6 Alzheimer's Agents EXELON 1.5 MG CAPSULE RIVASTIGMINE 2 Alzheimer's Agents EXELON 13.3 MG/24 HR PATCH RIVASTIGMINE 1 Alzheimer's Agents EXELON 2 MG/ML ORAL SOLUTION RIVASTIGMINE 6 Alzheimer's Agents EXELON 3 MG CAPSULE RIVASTIGMINE 2 Alzheimer's Agents EXELON 4.5 MG CAPSULE RIVASTIGMINE 2 Alzheimer's Agents EXELON 4.6 MG/24 HR PATCH RIVASTIGMINE 1 Alzheimer's Agents EXELON 6 MG CAPSULE RIVASTIGMINE 2 Alzheimer's Agents EXELON 9.5 MG/24 HR PATCH RIVASTIGMINE 1 Angiotensin Modulator Combinations EXFORGE 10/160 MG TABLET AMLODIPINE/VALSARTAN 1 Angiotensin Modulator Combinations EXFORGE 10/320 MG TABLET AMLODIPINE/VALSARTAN 1 Angiotensin Modulator Combinations EXFORGE 5/160 MG TABLET AMLODIPINE/VALSARTAN 1 Angiotensin Modulator Combinations EXFORGE 5/320 MG TABLET AMLODIPINE/VALSARTAN 1 Angiotensin Modulator Combinations EXFORGE HCT 10/160/12.5 MG TABLET AMLODIPINE/VALSARTAN/HCTZ 1 Angiotensin Modulator Combinations EXFORGE HCT 10/320/25 MG TABLET AMLODIPINE/VALSARTAN/HCTZ 1 Effective 01/04/21 Alphabetical by Brand Name (when applicable)

Angiotensin Modulator Combinations EXFORGE HCT 5/160/12.5 MG TABLET AMLODIPINE/VALSARTAN/HCTZ 1 Angiotensin Modulator Combinations EXFORGE HCT 5/160/25 MG TABLET AMLODIPINE/VALSARTAN/HCTZ 1 Angiotensin Modulator Combinations EXFORGE HCT10/160/25 MG TABLET AMLODIPINE/VALSARTAN/HCTZ 1 Macular Degeneration Agents EYLEA 2 MG/0.05 INTRAVITREAL INJECTION VIAL AFLIBERCEPT 0.01 Blood Glucose Test Strips EZ SMART BLOOD GLUCOSE TEST STRIPS BLOOD GLUCOSE TEST STRIPS 3.34 Lipotropics, Statins EZALLOR SPRINKLE 10 MG CAPSULE ROSUVASTATIN 1 Lipotropics, Statins EZALLOR SPRINKLE 20 MG CAPSULE ROSUVASTATIN 1 Lipotropics, Statins EZALLOR SPRINKLE 40 MG CAPSULE ROSUVASTATIN 1 Lipotropics, Statins EZALLOR SPRINKLE 5 MG CAPSULE ROSUVASTATIN 1 Antivirals, Herpes FAMVIR 125 MG TABLET FAMCICLOVIR 6 Antivirals, Herpes FAMVIR 250 MG TABLET FAMCICLOVIR 6 Antivirals, Herpes FAMVIR 500 MG TABLET FAMCICLOVIR 4 Antipsychotics, Atypical FANAPT 1 MG TABLET ILOPERIDONE 2 Antipsychotics, Atypical FANAPT 10 MG TABLET ILOPERIDONE 2 Antipsychotics, Atypical FANAPT 12 MG TABLET ILOPERIDONE 2 Antipsychotics, Atypical FANAPT 2 MG TABLET ILOPERIDONE 2 Antipsychotics, Atypical FANAPT 4 MG TABLET ILOPERIDONE 2 Antipsychotics, Atypical FANAPT 6 MG TABLET ILOPERIDONE 2 Antipsychotics, Atypical FANAPT 8 MG TABLET ILOPERIDONE 2 Antipsychotics, Atypical FANAPT TITRATION PACK ILOPERIDONE 2 Oncology Agents, Breast Cancer FARESTON 60 MG TABLET TOREMIFENE 1 Hypoglycemics, SGLT2 Inhibitors FARXIGA 10 MG TABLET DAPAGLIFLOZIN 1 Hypoglycemics, SGLT2 Inhibitors FARXIGA 5 MG TABLET DAPAGLIFLOZIN 1 Oncology Agents, Oral FARYDAK 10 MG CAPSULE PANOBINOSTAT 0.43 Oncology Agents, Oral FARYDAK 15 MG CAPSULE PANOBINOSTAT 0.43 Oncology Agents, Oral FARYDAK 20 MG CAPSULE PANOBINOSTAT 0.43 MABs - Anti-IL, Anti-IgE FASENRA 30 MG/ML SYRINGE BENRALIZUMAB 0.04 Antipsychotics, Atypical FAZACLO 100 MG ODT CLOZAPINE 9 Antipsychotics, Atypical FAZACLO 12.5 MG ODT CLOZAPINE 2 Antipsychotics, Atypical FAZACLO 150 MG ODT CLOZAPINE 6 Antipsychotics, Atypical FAZACLO 200 MG ODT CLOZAPINE 4 Antipsychotics, Atypical FAZACLO 25 MG ODT CLOZAPINE 3 NSAIDs FELDENE 10 MG CAPSULE PIROXICAM 1 NSAIDs FELDENE 20 MG CAPSULE PIROXICAM 1 Oncology Agents, Breast Cancer FEMARA 2.5 MG TABLET LETROZOLE 1 Estrogens FEMHRT 0.5 MG-2.5 MCG TABLET NORETHINDRONE ACET/ETHINYL ESTRADIOL 1 Lipotropics, Other FENOGLIDE 120 MG TABLET FENOFIBRATE 1 Lipotropics, Other FENOGLIDE 40 MG TABLET FENOFIBRATE 2 Pituitary Suppressive Agents, LHRH FENSOLVI 45 MG SYRINGE KIT LEUPROLIDE ACETATE 0.01 Analgesics, Opioid Long-Acting FENTANYL 37.5 MCG/HR PATCH FENTANYL TRANSDERMAL 0.34 Analgesics, Opioid Long-Acting FENTANYL 62.5 MCG/HR PATCH FENTANYL TRANSDERMAL 0.34 Effective 01/04/21 Alphabetical by Brand Name (when applicable)

Analgesics, Opioid Long-Acting FENTANYL 87.5 MCG/HR PATCH FENTANYL TRANSDERMAL 0.34 Analgesics, Opioid Short-Acting FENTORA 100 MCG BUCCAL TABLET FENTANYL CITRATE BUCCAL 4 Analgesics, Opioid Short-Acting FENTORA 200 MCG BUCCAL TABLET FENTANYL CITRATE BUCCAL 4 Analgesics, Opioid Short-Acting FENTORA 300 MCG BUCCAL TABLET FENTANYL CITRATE BUCCAL 4 Analgesics, Opioid Short-Acting FENTORA 400 MCG BUCCAL TABLET FENTANYL CITRATE BUCCAL 4 Analgesics, Opioid Short-Acting FENTORA 600 MCG BUCCAL TABLET FENTANYL CITRATE BUCCAL 4 Analgesics, Opioid Short-Acting FENTORA 800 MCG BUCCAL TABLET FENTANYL CITRATE BUCCAL 4 Iron, Parenteral FERAHEME 510 MG/17 ML VIAL FERUMOXYTOL 17 Antidepressants, Other FETZIMA ER 120 MG CAPSULE LEVOMILNACIPRIN 1 Antidepressants, Other FETZIMA ER 20 MG CAPSULE LEVOMILNACIPRIN 1 Antidepressants, Other FETZIMA ER 40 MG CAPSULE LEVOMILNACIPRIN 1 Antidepressants, Other FETZIMA ER 80 MG CAPSULE LEVOMILNACIPRIN 1 Skeletal Muscle Relaxants FEXMID 7.5 MG TABLET CYCLOBENZAPRINE 3 Lipotropics, Other FIBRICOR 105 MG TABLET FENOFIBRIC ACID 1 Lipotropics, Other FIBRICOR 35 MG TABLET FENOFIBRIC ACID 2 Anticonvulsants FINTEPLA 2.2 MG/ML SOLUTION FENFLURAMINE 11.82 Analgesics, Non-Opioid Barbiturate Combos FIORICET 50 MG/300 MG/40 MG CAPSULE BUTALBITAL/ACETAMINOPHEN/CAFFEINE 0.6 Analgesics, Non-Opioid Barbiturate Combos FIORICET 50 MG/325 MG/40 MG TABLET BUTALBITAL/ACETAMINOPHEN/CAFFEINE 0.6 Analgesics, Opioid Short-Acting FIORICET W/ CODEINE 50MG/300 MG/40MG/30MG CAPSULE BUTALBITAL/ACETAMINOPHEN/CAFFEINE/CODEINE 0.6 Analgesics, Opioid Short-Acting FIORICET W/ CODEINE 50MG/325 MG/40MG/30MG CAPSULE BUTALBITAL/ACETAMINOPHEN/CAFFEINE/CODEINE 0.6 Analgesics, Non-Opioid Barbiturate Combos FIORINAL 50 MG/325 MG/40 MG CAPSULE BUTALBITAL/ASA/CAFFEINE 0.6 Analgesics, Opioid Short-Acting FIORINAL W/ CODEINE 50 MG/325 MG/40 MG/30 MG CAPSULE BUTALBITAL/ASA/CAFFEINE/CODEINE 0.6 Hereditary Angioedema Treatments FIRAZYR 30 MG/3 ML SYRINGE ICATIBANT ACETATE 9 NSAIDs FLECTOR 180 MG PATCH DICLOFENAC EPOLAMINE TRANSDERMAL 2 Skeletal Muscle Relaxants FLEXERIL 10 MG TABLET CYCLOBENZAPRINE 3 Skeletal Muscle Relaxants FLEXERIL 5 MG TABLET CYCLOBENZAPRINE 3 BPH Treatments FLOMAX 0.4 MG CAPSULE TAMSULOSIN 2 Intranasal Rhinitis Agents FLONASE ALLERGY RELIEF OTC NASAL SPRAY FLUTICASONE 0.66 Intranasal Rhinitis Agents FLONASE NASAL SPRAY (RX) FLUTICASONE 0.54 Intranasal Rhinitis Agents FLONASE SENSIMIST 27.5 MCG SPRAY FLUTICASONE FUROATE 0.66 Glucocorticoids, Inhaled FLOVENT 100 MCG DISKUS #28 FLUTICASONE 2 Glucocorticoids, Inhaled FLOVENT 100 MCG DISKUS #60 FLUTICASONE 2 Glucocorticoids, Inhaled FLOVENT 250 MCG DISKUS #28 FLUTICASONE 8 Glucocorticoids, Inhaled FLOVENT 250 MCG DISKUS #60 FLUTICASONE 8 Glucocorticoids, Inhaled FLOVENT 50 MCG DISKUS #60 FLUTICASONE 2 Glucocorticoids, Inhaled FLOVENT HFA 110 MCG INHALER FLUTICASONE 0.4 Glucocorticoids, Inhaled FLOVENT HFA 220 MCG INHALER FLUTICASONE 0.8 Glucocorticoids, Inhaled FLOVENT HFA 44 MCG INHALER FLUTICASONE 0.36 Opioid Antitussive FLOWTUSS 2.5-200 MG/5 ML SOLUTION GUAIFENESIN/HYDROCODONE 60 Vaccines FLU VACCINE INTRADERMAL SYRINGE INFLUENZA VIRUS VACCINE 0.1 Vaccines FLU VACCINE PEDIATRIC SYRINGE INFLUENZA VIRUS VACCINE 0.25 Effective 01/04/21 Alphabetical by Brand Name (when applicable)

Vaccines FLU VACCINE SYRINGE INFLUENZA VIRUS VACCINE 0.5 Vaccines FLU VACCINE VIAL INFLUENZA VIRUS VACCINE 0.5 Vaccines FLUMIST NASAL SPRAY INFLUENZA VIRUS VACCINE 1 Antidepressants, SSRIs FLUOXETINE 60 MG TABLET FLUOXETINE 60 MG TABLET 1 NSAIDs FLURBIPROFEN 100 MG TABLET FLURBIPROFEN 3 NSAIDs FLURBIPROFEN 50 MG TABLET FLURBIPROFEN 4 Stimulants & Related Agents FOCALIN 10 MG TABLET DEXMETHYLPHENIDATE 2 Stimulants & Related Agents FOCALIN 2.5 MG TABLET DEXMETHYLPHENIDATE 2 Stimulants & Related Agents FOCALIN 5 MG TABLET DEXMETHYLPHENIDATE 2 Stimulants & Related Agents FOCALIN XR 10 MG CAPSULE DEXMETHYLPHENIDATE 1 Stimulants & Related Agents FOCALIN XR 15 MG CAPSULE DEXMETHYLPHENIDATE 1 Stimulants & Related Agents FOCALIN XR 20 MG CAPSULE DEXMETHYLPHENIDATE 1 Stimulants & Related Agents FOCALIN XR 25 MG CAPSULE DEXMETHYLPHENIDATE 1 Stimulants & Related Agents FOCALIN XR 30 MG CAPSULE DEXMETHYLPHENIDATE 1 Stimulants & Related Agents FOCALIN XR 35 MG CAPSULE DEXMETHYLPHENIDATE 1 Stimulants & Related Agents FOCALIN XR 40 MG CAPSULE DEXMETHYLPHENIDATE 1 Stimulants & Related Agents FOCALIN XR 5 MG CAPSULE DEXMETHYLPHENIDATE 1 Antidepressants, Other FORFIVO XL 450 MG TABLET BUPROPION 1 Hypoglycemics, Metformins FORTAMET ER 1,000 MG TABLET METFORMIN ER 2 Hypoglycemics, Metformins FORTAMET ER 500 MG TABLET METFORMIN ER 3 Antibiotics, Injectable FORTAZ 1 GM TWISTVIAL CEFTAZIDIME 3 Antibiotics, Injectable FORTAZ 1 GM VIAL CEFTAZIDIME 3 Antibiotics, Injectable FORTAZ 2 GM TWISTVIAL CEFTAZIDIME 3 Antibiotics, Injectable FORTAZ 2 GM VIAL CEFTAZIDIME 3 Antibiotics, Injectable FORTAZ 500 MG VIAL CEFTAZIDIME 3 Antibiotics, Injectable FORTAZ 6 GM VIAL CEFTAZIDIME 1 Antibiotics, Injectable FORTAZ-ISO-OSMOT 1 GM/50 ML CEFTAZIDIME 150 Antibiotics, Injectable FORTAZ-ISO-OSMOT 2 GM/50 ML CEFTAZIDIME 150 Bone Density Regulators FORTEO 600 MCG/2.4 ML PEN INJ TERIPARATIDE 0.09 Androgenic Agents FORTESTA 10 MG GEL PUMP TESTOSTERONE 3.51 Bone Density Regulators FORTICAL 200 UNITS NASAL SPRAY CALCITONIN-SALMON 0.13 Bone Density Regulators FOSAMAX 10 MG TABLET ALENDRONATE 1 Bone Density Regulators FOSAMAX 35 MG TABLET ALENDRONATE 0.15 Bone Density Regulators FOSAMAX 40 MG TABLET ALENDRONATE 1 Bone Density Regulators FOSAMAX 5 MG TABLET ALENDRONATE 1 Bone Density Regulators FOSAMAX 70 MG TABLET ALENDRONATE 0.15 Bone Density Regulators FOSAMAX 70 MG/75 ML ORAL SOLUTION ALENDRONATE 10.71 Bone Density Regulators FOSAMAX PLUS D 70 MG-2800 IU TABLET ALENDRONATE/CHOLECALCIFEROL 0.14 Bone Density Regulators FOSAMAX PLUS D 70 MG-5600 IU TABLET ALENDRONATE/CHOLECALCIFEROL 0.14 Phosphate Binders FOSRENOL 1000 MG CHEWABLE TABLET LANTHANUM CARBONATE 3 Phosphate Binders FOSRENOL 1000 MG POWDER PACKET LANTHANUM CARBONATE 3 Effective 01/04/21 Alphabetical by Brand Name (when applicable)

Phosphate Binders FOSRENOL 500 MG CHEWABLE TABLET LANTHANUM CARBONATE 3 Phosphate Binders FOSRENOL 750 MG CHEWABLE TABLET LANTHANUM CARBONATE 3 Phosphate Binders FOSRENOL 750 MG POWDER PACKET LANTHANUM CARBONATE 3 Anticoagulants, Injectable FRAGMIN 10,000 UNITS/ML INJECTION SYRINGE DALTEPARIN See footnote1 Anticoagulants, Injectable FRAGMIN 12,500 UNITS/0.5 ML INJECTION SYRINGE DALTEPARIN See footnote1 Anticoagulants, Injectable FRAGMIN 15,000 UNITS/0.6 ML INJECTION SYRINGE DALTEPARIN See footnote1 Anticoagulants, Injectable FRAGMIN 18,000 UNITS/0.72 ML INJECTION SYRINGE DALTEPARIN See footnote1 Anticoagulants, Injectable FRAGMIN 25,000 UNITS/ML INJECTION VIAL DALTEPARIN See footnote1 Anticoagulants, Injectable FRAGMIN 2500 UNITS/0.2 ML INJECTION SYRINGE DALTEPARIN See footnote1 Anticoagulants, Injectable FRAGMIN 5000 UNITS/0.2 ML INJECTION SYRINGE DALTEPARIN See footnote1 Anticoagulants, Injectable FRAGMIN 7500 UNITS/0.3 ML INJECTION SYRINGE DALTEPARIN See footnote1 Blood Glucose Meters FREESTYLE BLOOD GLUCOSE METER BLOOD GLUCOSE METER See footnote2 Blood Glucose Test Strips FREESTYLE BLOOD GLUCOSE TEST STRIPS BLOOD GLUCOSE TEST STRIPS 3.34 Blood Glucose Meters FREESTYLE FLASH BLOOD GLUCOSE METER BLOOD GLUCOSE METER See footnote2 Blood Glucose Meters FREESTYLE FREEDOM LITE BLOOD GLUCOSE METER BLOOD GLUCOSE METER See footnote2 Blood Glucose Meters FREESTYLE INSULINX BLOOD GLUCOSE METER BLOOD GLUCOSE METER See footnote2 Blood Glucose Test Strips FREESTYLE INSULINX BLOOD GLUCOSE TEST STRIPS BLOOD GLUCOSE TEST STRIPS 3.34 Diabetic Supplies, Miscellaneous FREESTYLE LANCING DEVICE BLOOD GLUCOSE LANCING DEVICE 1 Blood Glucose Meters FREESTYLE LITE BLOOD GLUCOSE METER BLOOD GLUCOSE METER See footnote2 Blood Glucose Test Strips FREESTYLE LITE BLOOD GLUCOSE TEST STRIPS BLOOD GLUCOSE TEST STRIPS 3.34 Blood Glucose Meters FREESTYLE PRECISION NEO BLOOD GLUCOSE METER BLOOD GLUCOSE METER See footnote2 Blood Glucose Test Strips FREESTYLE PRECISION NEO BLOOD GLUCOSE TEST STRIPS BLOOD GLUCOSE TEST STRIPS 3.34 Migraine Acute Treatment Agents FROVA 2.5 MG TABLET FROVATRIPTAN 0.4 Colony Stimulating Factors FULPHILA 6 MG/0.6ML SYRINGE PEGFILGRASTIM-JMDB 0.05 Urinary Anti-infectives FURADANTIN 25 MG/5 ML SUSPENSION NITROFURANTOIN 80 HIV/AIDS Antiretrovirals FUZEON INJECTION 90 MG CONVENIENCE KIT ENFUVIRTIDE 0.04 HIV/AIDS Antiretrovirals FUZEON INJECTION 90 MG VIAL ENFUVIRTIDE 2 Anticonvulsants FYCOMPA 0.5 MG/ML SUSPENSION PERAMPANEL 24 Anticonvulsants FYCOMPA 10 MG TABLET PERAMPANEL 1 Anticonvulsants FYCOMPA 12 MG TABLET PERAMPANEL 1 Anticonvulsants FYCOMPA 2 MG TABLET PERAMPANEL 2 Anticonvulsants FYCOMPA 4 MG TABLET PERAMPANEL 1 Anticonvulsants FYCOMPA 6 MG TABLET PERAMPANEL 1 Anticonvulsants FYCOMPA 8 MG TABLET PERAMPANEL 1 Alpha-Gal A Pharmacological Chaperone GALAFOLD 123 MG CAPSULE MIGALASTAT 0.5 Vaccines GARDASIL 9 VACCINE SYRINGE HUMAN PAPILLOMAVIRUS VACCINE 9-VALENT 0.5 Vaccines GARDASIL 9 VACCINE VIAL HUMAN PAPILLOMAVIRUS VACCINE 9-VALENT 0.5 Vaccines GARDASIL VACCINE PREFILLED SYR HPV RECOMBINANT VACCINE 0.5 Vaccines GARDASIL VACCINE SINGLE DOSE VIAL HPV RECOMBINANT VACCINE 0.5 Vaccines GARDASIL VACCINE SYRINGE HUMAN PAPILLOMAVIRUS VACCINE QUADVALENT 0.5 Vaccines GARDASIL VACCINE VIAL HUMAN PAPILLOMAVIRUS VACCINE QUADVALENT 0.5 Effective 01/04/21 Alphabetical by Brand Name (when applicable)

Oncology Agents, Oral GAVRETO 100 MG CAPSULE PRALSETINIB 4 Bladder Relaxant Preparations GELNIQUE 10% GEL PUMP OXYBUTYNIN 1 Bladder Relaxant Preparations GELNIQUE 10% GEL SACHET OXYBUTYNIN 1 Bladder Relaxant Preparations GELNIQUE 3% TOPICAL GEL PUMP OXYBUTYNIN 3.1 Intra-Articular Hyaluronates GEL-ONE 30 MG/3 ML SYRINGE HYALURONATE SODIUM, CROSS-LINKED 0.2 Intra-Articular Hyaluronates GELSYN-3 16.8 MG/2 ML SYRINGE HYALURONATE SODIUM 0.58 Intra-Articular Hyaluronates GENVISC 850 25 MG/2.5 ML SYRINGE HYALURONATE SODIUM 0.72 HIV/AIDS Antiretrovirals GENVOYA TABLET ELVITEGRAVIR/COBI/EMTRICITABINE/TENOFOVIR AF 1 Antipsychotics, Atypical GEODON 20 MG CAPSULE ZIPRASIDONE 2 Antipsychotics, Atypical GEODON 20 MG INJECTION VIAL ZIPRASIDONE 2 Antipsychotics, Atypical GEODON 40 MG CAPSULE ZIPRASIDONE 2 Antipsychotics, Atypical GEODON 60 MG CAPSULE ZIPRASIDONE 2 Antipsychotics, Atypical GEODON 80 MG CAPSULE ZIPRASIDONE 2 Ulcerative Colitis Agents GIAZO 1.1 GRAM TABLET BALSALAZIDE 6 Multiple Sclerosis Agents GILENYA 0.5 MG CAPSULE FINGOLIMOD 1 Oncology Agents, Oral GILOTRIF 20 MG TABLET AFATINIB DIMALEATE 1 Oncology Agents, Oral GILOTRIF 30 MG TABLET AFATINIB DIMALEATE 1 Oncology Agents, Oral GILOTRIF 40 MG TABET AFATINIB DIMALEATE 1 Oncology Agents, Oral GLEEVEC 100 MG TABLET IMATINIB MESYLATE 6 Oncology Agents, Oral GLEEVEC 400 MG TABLET IMATINIB MESYLATE 2 Antihyperuricemics GLOPERBA 0.6 MG/5 ML SOLUTION COLCHICINE 10 Hypoglycemics, Metformins GLUCOPHAGE 1,000 MG TABLET METFORMIN HCL 1,000 MG TABLET 2.5 Hypoglycemics, Metformins GLUCOPHAGE 500 MG TABLET METFORMIN HCL 500 MG TABLET 5 Hypoglycemics, Metformins GLUCOPHAGE 850 MG TABLET METFORMIN HCL 850 MG TABLET 3 Hypoglycemics, Metformins GLUCOPHAGE XR 500 MG TABLET METFORMIN HCL ER 500 MG TABLET 5 Hypoglycemics, Metformins GLUCOPHAGE XR 750 MG TABLET METFORMIN HCL ER 750 MG TABLET 3 Hypoglycemics, Sulfonylureas GLUCOTROL 10 MG TABLET GLIPIZIDE 4 Hypoglycemics, Sulfonylureas GLUCOTROL 5 MG TABLET GLIPIZIDE 4 Hypoglycemics, Sulfonylureas GLUCOTROL XL 10 MG TABLET GLIPIZIDE ER 2 Hypoglycemics, Sulfonylureas GLUCOTROL XL 2.5 MG TABLET GLIPIZIDE ER 1 Hypoglycemics, Sulfonylureas GLUCOTROL XL 5 MG TABLET GLIPIZIDE ER 1 Hypoglycemics, Metformins GLUCOVANCE 1.25 MG/250 MG TABLET GLYBURIDE/METFORMIN 4 Hypoglycemics, Metformins GLUCOVANCE 2.5 MG/500 MG TABLET GLYBURIDE/METFORMIN 4 Hypoglycemics, Metformins GLUCOVANCE 5 MG/500 MG TABLET GLYBURIDE/METFORMIN 4 Hypoglycemics, Metformins GLUMETZA ER 1000 MG TABLET METFORMIN ER 2 Hypoglycemics, Metformins GLUMETZA ER 500 MG TABLET METFORMIN ER 3 Hypoglycemics, Sulfonylureas GLYNASE 1.5 MG TABLET GLYBURIDE MICRONIZED 4 Hypoglycemics, Sulfonylureas GLYNASE 3 MG TABLET GLYBURIDE MICRONIZED 4 Hypoglycemics, Sulfonylureas GLYNASE 6 MG TABLET GLYBURIDE MICRONIZED 2 Hypoglycemics, Alpha-Glucosidase Inhibitors GLYSET 100 MG TABLET MIGLITOL 3 Hypoglycemics, Alpha-Glucosidase Inhibitors GLYSET 25 MG TABLET MIGLITOL 3 Effective 01/04/21 Alphabetical by Brand Name (when applicable)

Hypoglycemics, Alpha-Glucosidase Inhibitors GLYSET 50 MG TABLET MIGLITOL 3 Hypoglycemics, Incretin Mimetics/Enhancers GLYXAMBI 10 MG/5 MG TABLET EMPAGLIFLOZIN/LINAGLIPTIN 1 Hypoglycemics, Incretin Mimetics/Enhancers GLYXAMBI 25 MG/5 MG TABLET EMPAGLIFLOZIN/LINAGLIPTIN 1 Antiparkinson's Agents GOCOVRI ER 137 MG CAPSULE AMANTADINE ER 2 Antiparkinson's Agents GOCOVRI ER 68.5 MG CAPSULE AMANTADINE ER 1 Insect Repellent NOT for Skin Application GOOD NEIGHBOR LICE BEDDING SPRAY PERMETHRIN 0.5% 29 Analgesics, Salicylates GOODY'S EX-STR POWDER PACKET 500 MG/325 MG/CAFFEINE 65 MG ASPIRIN/ACETAMINOPHEN/CAFFEINE 8 Neuropathic Pain Agents GRALISE 300 MG TABLETS GABAPENTIN 1 Neuropathic Pain Agents GRALISE 600 MG TABLETS GABAPENTIN 3 Opioid Antitussive GUAIFEN-CODEINE 100-10 MG/5 ML SOLUTION CODEINE PHOSPHATE/GUAIFENESIN 60 Opioid Antitussive GUAIFEN-CODEINE 200-20 MG/10 ML SOLUTION CODEINE PHOSPHATE/GUAIFENESIN 60 Opioid Antitussive GUAIFENESIN AC COUGH SYRUP CODEINE PHOSPHATE/GUAIFENESIN 60 Opioid Antitussive GUAIFENESIN DAC ORAL SOLUTION PSEUDOEPHED/CODEINE/GUAIFENESIN 40 Hereditary Angioedema Treatments HAEGARDA 2000 UNIT VIAL C1 ESTERASE INHIBITOR 0.58 Hereditary Angioedema Treatments HAEGARDA 3000 UNIT VIAL C1 ESTERASE INHIBITOR 1.15 Sedative Hypnotics HALCION 0.125 MG TABLET TRIAZOLAM 1 Sedative Hypnotics HALCION 0.25 MG TABLET TRIAZOLAM 2 Hepatitis C Agents HARVONI 33.75-150 MG PELLET PACKET LEDIPASVIR/SOFOSBUVIR 1 Hepatitis C Agents HARVONI 45-200 MG PELLET PACKET LEDIPASVIR/SOFOSBUVIR 2 Hepatitis C Agents HARVONI 45-200 MG TABLET LEDIPASVIR/SOFOSBUVIR 2 Hepatitis C Agents HARVONI 90 MG/400 MG TABLET LEDIPASVIR/SOFOSBUVIR 1 Vaccines HAVRIX 1440 UNITS/ML SYRINGE HEPATITIS A VIRUS VACCINE 1 Vaccines HAVRIX 1440 UNITS/ML VIAL HEPATITIS A VIRUS VACCINE 1 Vaccines HAVRIX 720 UNITS/0.5 ML SYRINGE HEPATITIS A VIRUS VACCINE 0.5 Vaccines HAVRIX 720 UNITS/0.5 ML VIAL HEPATITIS A VIRUS VACCINE 0.5 Hepatitis B Agents HEPSERA 10 MG TABLET ADEFOVIR DIPIVOXIL 1 Sedative Hypnotics HETLIOZ 20 MG CAPSULE TASIMELTEON 1 Urinary Anti-infectives HIPREX 1 GM TABLET METHENAMINE HIPPURATE 2 Neuropathic Pain Agents HORIZANT ER 300 MG TABLET GABAPENTIN ENACARBIL 2 Neuropathic Pain Agents HORIZANT ER 600 MG TABLET GABAPENTIN ENACARBIL 2 Cytokine & CAM Antagonists HUMIRA (CF) 10 MG/0.1 ML SYRINGE ADALIMUMAB 0.08 Cytokine & CAM Antagonists HUMIRA (CF) 20 MG/0.2 ML SYRINGE ADALIMUMAB 0.08 Cytokine & CAM Antagonists HUMIRA (CF) 40 MG/0.4 ML PEN ADALIMUMAB 0.22 Cytokine & CAM Antagonists HUMIRA (CF) 40 MG/0.4 ML SYRINGE ADALIMUMAB 0.22 Cytokine & CAM Antagonists HUMIRA (CF) PEDIATRIC CROHN'S 80 MG/0.8 ML STARTER PACK ADALIMUMAB 0.11 Cytokine & CAM Antagonists HUMIRA (CF) PEDIATRIC CROHN'S 80-40 MG STARTER PACK ADALIMUMAB 0.08 Cytokine & CAM Antagonists HUMIRA (CF) PEN CROHN'S-UC-HS 80 MG STARTER PACK ADALIMUMAB 0.11 Cytokine & CAM Antagonists HUMIRA (CF) PEN PSORIASIS-UVEITIS-AHS 80-40 MG STARTER PACK ADALIMUMAB 0.09 Cytokine & CAM Antagonists HUMIRA 10 MG/0.2 ML SYRINGE KIT ADALIMUMAB 0.08 Cytokine & CAM Antagonists HUMIRA 20 MG/0.4 ML SYRINGE KIT ADALIMUMAB 0.08 Cytokine & CAM Antagonists HUMIRA 40 MG/0.8 ML PEN KIT ADALIMUMAB 0.22 Effective 01/04/21 Alphabetical by Brand Name (when applicable)

Cytokine & CAM Antagonists HUMIRA 40 MG/0.8 ML SYRINGE KIT ADALIMUMAB 0.22 Cytokine & CAM Antagonists HUMIRA PEDIATRIC CROHN'S 3-SYRINGE STARTER KIT ADALIMUMAB (< 88 LBS) 0.22 Cytokine & CAM Antagonists HUMIRA PEDIATRIC CROHN'S 6-SYRINGE STARTER KIT ADALIMUMAB (≥ 88 LBS) 0.22 Cytokine & CAM Antagonists HUMIRA PEN CROHN'S-US-HS STARTER KIT ADALIMUMAB 0.22 Cytokine & CAM Antagonists HUMIRA PEN PSORIASIS-UVEITIS-AHS 40 MG STARTER PACK ADALIMUMAB 0.22 Intra-Articular Hyaluronates HYALGAN 10 MG/ML SYRINGE HYALURONATE SODIUM 0.72 Intra-Articular Hyaluronates HYALGAN 20 MG/2 ML SYRINGE HYALURONATE SODIUM 0.72 Intra-Articular Hyaluronates HYALGAN 20 MG/2 ML VIAL HYALURONATE SODIUM 0.72 Analgesics, Opioid Short-Acting HYCET SOLUTION 7.5 MG-325 MG/15 ML HYDROCODONE/ACETAMINOPHEN 100 Opioid Antitussive HYCOFENIX 2.5-30-200 MG/5 ML SOLUTION HYDROCODONE/PSEUDOEPHED/GUAIFENESIN 40 Ergotamine Derivatives HYDERGINE 1 MG TABLET ERGOLOID MESYLATES 3 Analgesics, Opioid Short-Acting HYDROCODONE/APAP 2.5-167 MG/5 ML ORAL SOLUTION HYDROCODONE/ACETAMINOPHEN 60 Analgesics, Opioid Short-Acting HYDROCODONE/APAP 2.5-325 MG TABLET HYDROCODONE/ACETAMINOPHEN 8 Analgesics, Opioid Short-Acting HYDROCODONE/APAP 5-217 MG/10 ML ORAL SOLUTION HYDROCODONE/ACETAMINOPHEN 100 Opioid Antitussive HYDROCODONE-HOMATROPINE 5-1.5 MG TABLET HYDROCODONE BIT/HOMATROPINE 6 Opioid Antitussive HYDROMET SYRUP HYDROCODONE BIT/HOMATROPINE 30 Progestational Agents HYDROXYPROGESTERONE CAPROATE 1.25 GM/5 ML MDV HYDROXYPROGESTERONE CAPROATE 0.15 Intra-Articular Hyaluronates HYMOVIS 24 MG/3 ML SYRINGE HYALURONATE, NON-CROSSLINKED 0.86 Analgesics, Opioid Long-Acting HYSINGLA ER 100 MG TABLET HYDROCODONE ER 1 Analgesics, Opioid Long-Acting HYSINGLA ER 120 MG TABLET HYDROCODONE ER 1 Analgesics, Opioid Long-Acting HYSINGLA ER 20 MG TABLET HYDROCODONE ER 1 Analgesics, Opioid Long-Acting HYSINGLA ER 30 MG TABLET HYDROCODONE ER 1 Analgesics, Opioid Long-Acting HYSINGLA ER 40 MG TABLET HYDROCODONE ER 1 Analgesics, Opioid Long-Acting HYSINGLA ER 60 MG TABLET HYDROCODONE ER 1 Analgesics, Opioid Long-Acting HYSINGLA ER 80 MG TABLET HYDROCODONE ER 1 BPH Treatments HYTRIN 1 MG CAPSULE TERAZOSIN 1 BPH Treatments HYTRIN 10 MG CAPSULE TERAZOSIN 2 BPH Treatments HYTRIN 2 MG CAPSULE TERAZOSIN 1 BPH Treatments HYTRIN 5 MG CAPSULE TERAZOSIN 1 Angiotensin Modulators HYZAAR 100-12.5 TABLET LOSARTAN/HCTZ 1 Angiotensin Modulators HYZAAR 100-25 TABLET LOSARTAN/HCTZ 1 Angiotensin Modulators HYZAAR 50-12.5 TABLET LOSARTAN/HCTZ 2 Oncology Agents, Oral IBRANCE 100 MG CAPSULE PALBOCICLIB 0.75 Oncology Agents, Oral IBRANCE 100 MG TABLET PALBOCICLIB 0.75 Oncology Agents, Oral IBRANCE 125 MG CAPSULE PALBOCICLIB 0.75 Oncology Agents, Oral IBRANCE 125 MG TABLET PALBOCICLIB 0.75 Oncology Agents, Oral IBRANCE 75 MG CAPSULE PALBOCICLIB 0.75 Oncology Agents, Oral IBRANCE 75 MG TABLET PALBOCICLIB 0.75 Analgesics, Opioid Short-Acting IBUDONE 10-200 MG TABLET HYDROCODONE/IBUPROFEN 5 Analgesics, Opioid Short-Acting IBUDONE 5-200 MG TABLET HYDROCODONE/IBUPROFEN 5 NSAIDs IBUPROFEN 100 MG TABLET/CAPLET IBUPROFEN 4 Effective 01/04/21 Alphabetical by Brand Name (when applicable)

NSAIDs IBUPROFEN 100 MG/5 ML LIQUID IBUPROFEN 60 NSAIDs IBUPROFEN 200 MG TABLET/CAPLET IBUPROFEN 4 NSAIDs IBUPROFEN 400 MG TABLET/CAPLET IBUPROFEN 4 NSAIDs IBUPROFEN 50 MG/1.25 ML LIQUID IBUPROFEN 8 NSAIDs IBUPROFEN 600 MG TABLET/CAPLET IBUPROFEN 4 NSAIDs IBUPROFEN 800 MG TABLET/CAPLET IBUPROFEN 4 Oncology Agents, Oral ICLUSIG 15 MG TABLET PONATINIB 2 Oncology Agents, Oral ICLUSIG 45 MG TABLET PONATINIB 1 Oncology Agents, Oral IDHIFA 1000 MG TABLET ENASIDENIB 1 Oncology Agents, Oral IDHIFA 50 MG TABLET ENASIDENIB 1 Cytokine & CAM Antagonists ILARIS 150 MG/ML VIAL CANAKINUMAB 0.08 Cytokine & CAM Antagonists ILUMYA 100 MG/ML SYRINGE TILDRAKIZUMAB-ASMN 0.04 Ophthalmics, Anti-Inflammatories ILUVIEN 0.19 MG INTRAOCULAR IMPLANT FLUOCINOLONE INTRAOCULAR 0.04 Oncology Agents, Oral IMBRUVICA 140 MG CAPSULE IBRUTINIB 1 Oncology Agents, Oral IMBRUVICA 140 MG TABLET IBRUTINIB 1 Oncology Agents, Oral IMBRUVICA 280 MG TABLET IBRUTINIB 1 Oncology Agents, Oral IMBRUVICA 420 MG TABLET IBRUTINIB 1 Oncology Agents, Oral IMBRUVICA 560 MG TABLET IBRUTINIB 1 Oncology Agents, Oral IMBRUVICA 70 MG CAPSULE IBRUTINIB 1 Migraine Acute Treatment Agents IMITREX 100 MG TABLET SUMATRIPTAN 0.3 Migraine Acute Treatment Agents IMITREX 20 MG NASAL SPRAY SUMATRIPTAN 0.3 Migraine Acute Treatment Agents IMITREX 25 MG TABLET SUMATRIPTAN 0.3 Migraine Acute Treatment Agents IMITREX 4 MG/0.5 ML KIT REFILL SUMATRIPTAN 0.14 Migraine Acute Treatment Agents IMITREX 4 MG/0.5 ML SYRNG KIT SUMATRIPTAN 0.14 Migraine Acute Treatment Agents IMITREX 5 MG NASAL SPRAY SUMATRIPTAN 1 Migraine Acute Treatment Agents IMITREX 50 MG TABLET SUMATRIPTAN 0.3 Migraine Acute Treatment Agents IMITREX 6 MG/0.5 ML KIT REFLL SUMATRIPTAN 0.14 Migraine Acute Treatment Agents IMITREX 6 MG/0.5 ML SYRNG KIT SUMATRIPTAN 0.14 Migraine Acute Treatment Agents IMITREX 6 MG/0.5 ML VIAL SUMATRIPTAN 0.14 Antidiarrheals IMODIUM 2 MG CAPSULE LOPERAMIDE 8 Antidiarrheals IMODIUM A-D 1 MG/5 ML SOLUTION LOPERAMIDE 80 Antidiarrheals IMODIUM A-D 1 MG/7.5 ML (2 MG/15 ML) SUSPENSION LOPERAMIDE 120 Antiprotozoals IMPAVIDO 50 MG CAPSULE MILTEFOSINE 3 Antiparkinson's Agents INBRIJA 42 MG INHALATION CAP LEVODOPA 10 COPD Agents INCRUSE ELLIPTA UMECLIDINIUM 1 Beta-Blockers INDERAL XL 120 MG CAPSULE PROPRANOLOL 1 Beta-Blockers INDERAL XL 80 MG CAPSULE PROPRANOLOL 1 NSAIDs INDOCIN 25 MG CAPSULE INDOMETHACIN 4 NSAIDs INDOCIN 25 MG/5 ML LIQUID INDOMETHACIN 40 NSAIDs INDOCIN 50 MG CAPSULE INDOMETHACIN 4 NSAIDs INDOCIN 50 MG SUPPOSITORY INDOMETHACIN 4 Effective 01/04/21 Alphabetical by Brand Name (when applicable)

NSAIDs INDOCIN ER 75 MG CAPSULE INDOMETHACIN 2 VMAT2 Inhibitors INGREZZA 40 MG CAPSULE VALBENAZINE TOSYLATE 1 VMAT2 Inhibitors INGREZZA 80 MG CAPSULE VALBENAZINE TOSYLATE 1 VMAT2 Inhibitors INGREZZA INITIATION PACK VALBENAZINE TOSYLATE 1 Oncology Agents, Oral INLYTA 1 MG TABLET AXITINIB 6 Oncology Agents, Oral INLYTA 5 MG TABLET AXITINIB 4 Beta-Blockers INNOPRAN XL 120 MG CAPSULE PROPRANOLOL 1 Beta-Blockers INNOPRAN XL 80 MG CAPSULE PROPRANOLOL 1 Oncology Agents, Oral INREBIC 100 MG CAPSULE FEDRATINIB 4 Diuretics INSPRA 25 MG TABLET EPLERENONE 4 Diuretics INSPRA 50 MG TABLET EPLERENONE 2 HIV/AIDS Antiretrovirals INTELENCE 100 MG TABLET ETRAVIRINE 4 HIV/AIDS Antiretrovirals INTELENCE 200 MG TABLET ETRAVIRINE 2 HIV/AIDS Antiretrovirals INTELENCE 25 MG TABLET ETRAVIRINE 4 Sedative Hypnotics INTERMEZZO SL TABLET 1.75 MG ZOLPIDEM 1 Sedative Hypnotics INTERMEZZO SL TABLET 3.5 MG ZOLPIDEM 1 Stimulants & Related Agents INTUNIV ER 1 MG TABLET GUANFACINE ER 1 Stimulants & Related Agents INTUNIV ER 2 MG TABLET GUANFACINE ER 1 Stimulants & Related Agents INTUNIV ER 3 MG TABLET GUANFACINE ER 1 Stimulants & Related Agents INTUNIV ER 4 MG TABLET GUANFACINE ER 1 Antibiotics, Injectable INVANZ 1 GM ADD-VANTAGE VIAL ERTAPENEM 1 Antibiotics, Injectable INVANZ 1 GM VIAL ERTAPENEM 1 Antipsychotics, Atypical INVEGA ER 1.5 MG TABLET PALIPERIDONE ER 1 Antipsychotics, Atypical INVEGA ER 3 MG TABLET PALIPERIDONE ER 1 Antipsychotics, Atypical INVEGA ER 6 MG TABLET PALIPERIDONE ER 2 Antipsychotics, Atypical INVEGA ER 9 MG TABLET PALIPERIDONE ER 1 Antipsychotics, Atypical INVEGA SUSTENNA 117 MG/0.75 ML SYRINGE PALIPERIDONE ER 0.03 Antipsychotics, Atypical INVEGA SUSTENNA 156 MG/ML SYRINGE PALIPERIDONE ER 0.05 Antipsychotics, Atypical INVEGA SUSTENNA 234 MG/1.5 ML SYRINGE PALIPERIDONE ER 0.08 Antipsychotics, Atypical INVEGA SUSTENNA 39 MG/0.25 ML SYRINGE PALIPERIDONE ER 0.01 Antipsychotics, Atypical INVEGA SUSTENNA 78 MG/0.5 ML SYRINGE PALIPERIDONE ER 0.02 Antipsychotics, Atypical INVEGA TRINZA 273 MG/0.875 ML PALIPERIDONE ER 0.02 Antipsychotics, Atypical INVEGA TRINZA 410 MG/1.315 ML PALIPERIDONE ER 0.02 Antipsychotics, Atypical INVEGA TRINZA 546 MG/1.75 ML PALIPERIDONE ER 0.03 Antipsychotics, Atypical INVEGA TRINZA 819 MG/2.625 ML PALIPERIDONE ER 0.04 HIV/AIDS Antiretrovirals INVIRASE 500 MG TABLET SAQUINAVIR 4 Hypoglycemics, SGLT2 Inhibitors INVOKAMET 150/1000 MG TABLET CANAGLIFLOZIN/METFORMIN 2 Hypoglycemics, SGLT2 Inhibitors INVOKAMET 150/500 MG TABLET CANAGLIFLOZIN/METFORMIN 2 Hypoglycemics, SGLT2 Inhibitors INVOKAMET 50/1000 MG TABLET CANAGLIFLOZIN/METFORMIN 2 Hypoglycemics, SGLT2 Inhibitors INVOKAMET 50/500 MG TABLET CANAGLIFLOZIN/METFORMIN 3 Hypoglycemics, SGLT2 Inhibitors INVOKAMET XR 150/1000 MG TABLET CANAGLIFLOZIN/METFORMIN 2 Effective 01/04/21 Alphabetical by Brand Name (when applicable)

Hypoglycemics, SGLT2 Inhibitors INVOKAMET XR 150/500 MG TABLET CANAGLIFLOZIN/METFORMIN 2 Hypoglycemics, SGLT2 Inhibitors INVOKAMET XR 50/1000 MG TABLET CANAGLIFLOZIN/METFORMIN 2 Hypoglycemics, SGLT2 Inhibitors INVOKAMET XR 50/500 MG TABLET CANAGLIFLOZIN/METFORMIN 2 Hypoglycemics, SGLT2 Inhibitors INVOKANA 100 MG TABLET CANAGLIFLOZIN 2 Hypoglycemics, SGLT2 Inhibitors INVOKANA 300 MG TABLET CANAGLIFLOZIN 1 Neuropathic Pain Agents IRENKA DR 40 MG CAPSULE DULOXETINE 3 Oncology Agents, Oral IRESSA 250 MG TABLET GEFITINIB 2 HIV/AIDS Antiretrovirals ISENTRESS 100 MG CHEWABLE TABLET RALTEGRAVIR 6 HIV/AIDS Antiretrovirals ISENTRESS 100 MG POWDER PACKETS RALTEGRAVIR POWDER 2 HIV/AIDS Antiretrovirals ISENTRESS 25 MG CHEWABLE TABLET RALTEGRAVIR 6 HIV/AIDS Antiretrovirals ISENTRESS 400 MG TABLET RALTEGRAVIR 2 HIV/AIDS Antiretrovirals ISENTRESS HD 600 MG TABLET RALTEGRAVIR 2 Calcium Channel Blockers ISOPTIN S.R. 120 MG TAB SA VERAPAMIL 2 Calcium Channel Blockers ISOPTIN S.R. 180 MG TAB SA VERAPAMIL 2 Calcium Channel Blockers ISOPTIN S.R. 240 MG TAB SA VERAPAMIL 2 Oncology Agents, Oral JAKAFI 10 MG TABLET RUXOLITINIB 2 Oncology Agents, Oral JAKAFI 15 MG TABLET RUXOLITINIB 2 Oncology Agents, Oral JAKAFI 20 MG TABLET RUXOLITINIB 2 Oncology Agents, Oral JAKAFI 25 MG TABLET RUXOLITINIB 2 Oncology Agents, Oral JAKAFI 5 MG TABLET RUXOLITINIB 2 BPH Treatments JALYN 0.5 MG/0.4 MG CAPSULE DUTASTERIDE/TAMSULOSIN 1 Hypoglycemics, Incretin Mimetics/Enhancers JANUMET 50 MG/1000 MG TABLET SITAGLIPTIN/METFORMIN 2 Hypoglycemics, Incretin Mimetics/Enhancers JANUMET 50 MG/500 MG TABLET SITAGLIPTIN/ METFORMIN 2 Hypoglycemics, Incretin Mimetics/Enhancers JANUMET XR 100 MG/1000 MG TABLET SITAGLIPTIN/METFORMIN 1 Hypoglycemics, Incretin Mimetics/Enhancers JANUMET XR 50 MG/1000 MG TABLET SITAGLIPTIN/METFORMIN 2 Hypoglycemics, Incretin Mimetics/Enhancers JANUMET XR 50 MG/500 MG TABLET SITAGLIPTIN/METFORMIN 1 Hypoglycemics, Incretin Mimetics/Enhancers JANUVIA 100 MG TABLET SITAGLIPTIN 1 Hypoglycemics, Incretin Mimetics/Enhancers JANUVIA 25 MG TABLET SITAGLIPTIN 1 Hypoglycemics, Incretin Mimetics/Enhancers JANUVIA 50 MG TABLET SITAGLIPTIN 1 Hypoglycemics, SGLT2 Inhibitors JARDIANCE 10 MG TABLET EMPAGLIFLOZIN 1 Hypoglycemics, SGLT2 Inhibitors JARDIANCE 25 MG TABLET EMPAGLIFLOZIN 1 Androgenic Agents JATENZO 158 MG CAPSULE TESTOSTERONE UNDECANOATE 4 Androgenic Agents JATENZO 198 MG CAPSULE TESTOSTERONE UNDECANOATE 4 Androgenic Agents JATENZO 237 MG CAPSULE TESTOSTERONE UNDECANOATE 2 Hypoglycemics, Incretin Mimetics/Enhancers JENTADUETO 2.5 MG/1000 MG TABLET LINAGLIPTIN/METFORMIN 2 Hypoglycemics, Incretin Mimetics/Enhancers JENTADUETO 2.5 MG/500 MG TABLET LINAGLIPTIN/METFORMIN 2 Hypoglycemics, Incretin Mimetics/Enhancers JENTADUETO 2.5 MG/850 MG TABLET LINAGLIPTIN/METFORMIN 2 Hypoglycemics, Incretin Mimetics/Enhancers JENTADUETO XR 2.5 MG/1000 MG TABLET LINAGLIPTIN/METFORMIN ER 2 Hypoglycemics, Incretin Mimetics/Enhancers JENTADUETO XR 5 MG/1000 MG TABLET LINAGLIPTIN/METFORMIN ER 1 Ophthalmic Proteolytic Enzyme JETREA 0.5 MG/0.2 ML INTRAOCULAR SOLUTION OCRIPLASMIN 0.06 Ophthalmic Proteolytic Enzyme JETREA 1.25 MG/ML VIAL OCRIPLASMIN 0.08 Effective 01/04/21 Alphabetical by Brand Name (when applicable)

Estrogens JINTELI 1 MG-5 MCG TABLET NORETHINDRONE ACET/ETHINYL ESTRADIOL 1 Stimulants & Related Agents JORNAY PM 100 MG CAPSULE METHYLPHENIDATE ER 1 Stimulants & Related Agents JORNAY PM 20 MG CAPSULE METHYLPHENIDATE ER 1 Stimulants & Related Agents JORNAY PM 40 MG CAPSULE METHYLPHENIDATE ER 1 Stimulants & Related Agents JORNAY PM 60 MG CAPSULE METHYLPHENIDATE ER 1 Stimulants & Related Agents JORNAY PM 80 MG CAPSULE METHYLPHENIDATE ER 1 HIV/AIDS Antiretrovirals JULUCA 50-25 MG TABLET DOLUTEGRAVIR AND RILPIVIRINE 1 Lipotropics, Other JUXTAPID 10 MG CAPSULE LOMITAPIDE 1 Lipotropics, Other JUXTAPID 20 MG CAPSULE LOMITAPIDE 1 Lipotropics, Other JUXTAPID 30 MG CAPSULE LOMITAPIDE 1 Lipotropics, Other JUXTAPID 40 MG CAPSULE LOMITAPIDE 1 Lipotropics, Other JUXTAPID 5 MG CAPSULE LOMITAPIDE 1 Lipotropics, Other JUXTAPID 60 MG CAPSULE LOMITAPIDE 1 Analgesics, Opioid Long-Acting KADIAN ER 10 MG CAPSULE MORPHINE SULFATE ER 2 Analgesics, Opioid Long-Acting KADIAN ER 100 MG CAPSULE MORPHINE SULFATE ER 1 Analgesics, Opioid Long-Acting KADIAN ER 20 MG CAPSULE MORPHINE SULFATE ER 2 Analgesics, Opioid Long-Acting KADIAN ER 200 MG CAPSULE MORPHINE SULFATE ER 1 Analgesics, Opioid Long-Acting KADIAN ER 30 MG CAPSULE MORPHINE SULFATE ER 1 Analgesics, Opioid Long-Acting KADIAN ER 40 MG CAPSULE MORPHINE SULFATE ER 1 Analgesics, Opioid Long-Acting KADIAN ER 50 MG CAPSULE MORPHINE SULFATE ER 1 Analgesics, Opioid Long-Acting KADIAN ER 60 MG CAPSULE MORPHINE SULFATE ER 1 Analgesics, Opioid Long-Acting KADIAN ER 70 MG CAPSULE MORPHINE SULFATE ER 1 Analgesics, Opioid Long-Acting KADIAN ER 80 MG CAPSULE MORPHINE SULFATE ER 1 Hereditary Angioedema Treatments KALBITOR 10 MG/ML VIAL ECALLANTIDE 6 HIV/AIDS Antiretrovirals KALETRA 100 MG/25 MG TABLET LOPINAVIR/RITONAVIR 10 HIV/AIDS Antiretrovirals KALETRA 200 MG/50 MG TABLET LOPINAVIR/RITONAVIR 4 HIV/AIDS Antiretrovirals KALETRA 80 MG/20 MG PER ML ORAL SOLUTION LOPINAVIR/RITONAVIR 13 CFTR Modulators KALYDECO 150 MG TABLET IVACAFTOR 2 CFTR Modulators KALYDECO 25 MG GRANULES PACKET IVACAFTOR 2 CFTR Modulators KALYDECO 50 MG GRANULES PACKET IVACAFTOR 2 CFTR Modulators KALYDECO 75 MG GRANULES PACKET IVACAFTOR 2 Beta-Blockers KAPSPARGO SPRINKLE 100 MG CAPSULE METOPROLOL SUCCINATE ER 1 Beta-Blockers KAPSPARGO SPRINKLE 200 MG CAPSULE METOPROLOL SUCCINATE ER 2 Beta-Blockers KAPSPARGO SPRINKLE 25 MG CAPSULE METOPROLOL SUCCINATE ER 1 Beta-Blockers KAPSPARGO SPRINKLE 50 MG CAPSULE METOPROLOL SUCCINATE ER 1 Stimulants & Related Agents KAPVAY 0.1 MG ER TABLET CLONIDINE ER 4 Calcium Channel Blockers KATERZIA 1 MG/ML SUSPENSION AMLODIPINE BENZOATE 10 Hypoglycemics, Incretin Mimetics/Enhancers KAZANO 12.5 MG/1000 MG TABLET ALOGLIPTIN/METFORMIN 2 Hypoglycemics, Incretin Mimetics/Enhancers KAZANO 12.5 MG/500 MG TABLET ALOGLIPTIN/METFORMIN 2 Steroids, Topical KENALOG IN ORABASE DENTAL PASTE TRIAMCINOLONE 0.72 Anticonvulsants KEPPRA 100 MG/ML ORAL SOLN LEVETIRACETAM 40 Effective 01/04/21 Alphabetical by Brand Name (when applicable)

Anticonvulsants KEPPRA 1000 MG TABLET LEVETIRACETAM 3 Anticonvulsants KEPPRA 250 MG TABLET LEVETIRACETAM 6 Anticonvulsants KEPPRA 500 MG TABLET LEVETIRACETAM 6 Anticonvulsants KEPPRA 500 MG/5 ML INJECTION VIAL LEVETIRACETAM 30 Anticonvulsants KEPPRA 750 MG TABLET LEVETIRACETAM 4 Anticonvulsants KEPPRA XR 500 MG TABLET LEVETIRACETAM 6 Anticonvulsants KEPPRA XR 750 MG TABLET LEVETIRACETAM 4 Multiple Sclerosis Agents KESIMPTA 20 MG/0.4 ML PEN OFATUMUMAB 0.06 NSAIDs KETOPROFEN 50 MG CAPSULE KETOPROFEN 6 NSAIDs KETOPROFEN 75 MG CAPSULE KETOPROFEN 4 NSAIDs KETOPROFEN ER 200 MG CAPSULE KETOPROFEN 1 Cytokine & CAM Antagonists KEVZARA 150 MG/1.14 ML SYRINGE SARILUMAB 0.09 Cytokine & CAM Antagonists KEVZARA 200 MG/1.14 ML SYRINGE SARILUMAB 0.09 Antidepressants, Other KHEDEZLA ER 100 MG TABLET DESVENLAFAXINE 1 Antidepressants, Other KHEDEZLA ER 50 MG TABLET DESVENLAFAXINE 1 Blood Glucose Test Strips KINRAY BLOOD GLUCOSE TEST STRIPS BLOOD GLUCOSE TEST STRIPS 3.34 Oncology Agents, Oral KISQALI 200 MG DAILY DOSE (21 X 200 MG TABLETS) RIBOCICLIB SUCCINATE 0.75 Oncology Agents, Oral KISQALI 400 MG DAILY DOSE (42 X 200 MG TABLETS) RIBOCICLIB SUCCINATE 1.5 Oncology Agents, Oral KISQALI 600 MG DAILY DOSE (63 X 200 MG TABLETS) RIBOCICLIB SUCCINATE 2.25 Oncology Agents, Oral KISQALI FEMARA 200 MG CO-PACK RIBOCICLIB SUCCINATE/LETROZOLE 1.75 Oncology Agents, Oral KISQALI FEMARA 400 MG CO-PACK RIBOCICLIB SUCCINATE/LETROZOLE 2.5 Oncology Agents, Oral KISQALI FEMARA 600 MG CO-PACK RIBOCICLIB SUCCINATE/LETROZOLE 3.25 Antibiotics, Inhaled KITABIS PAK 300 MG/5 ML NEBULIZER KIT TOBRAMYCIN 10 Anticonvulsants KLONOPIN 0.5 MG TABLET CLONAZEPAM 6 Anticonvulsants KLONOPIN 1 MG TABLET CLONAZEPAM 4 Anticonvulsants KLONOPIN 2 MG TABLET CLONAZEPAM 3 Anticonvulsants KLONOPIN WAFERS 0.125 MG ODT CLONAZEPAM ODT 6 Anticonvulsants KLONOPIN WAFERS 0.25 MG ODT CLONAZEPAM ODT 6 Anticonvulsants KLONOPIN WAFERS 0.5 MG ODT CLONAZEPAM ODT 6 Anticonvulsants KLONOPIN WAFERS 1 MG ODT CLONAZEPAM ODT 4 Anticonvulsants KLONOPIN WAFERS 2 MG ODT CLONAZEPAM ODT 3 Hypoglycemics, Incretin Mimetics/Enhancers KOMBIGLYZE XR 2.5 MG/1000 MG TABLET SAXAGLIPTIN/METFORMIN ER 2 Hypoglycemics, Incretin Mimetics/Enhancers KOMBIGLYZE XR 5 MG/1000 MG TABLET SAXAGLIPTIN/METFORMIN ER 1 Hypoglycemics, Incretin Mimetics/Enhancers KOMBIGLYZE XR 5 MG/500 MG TABLET SAXAGLIPTIN/METFORMIN ER 1 Antihyperglycemics, Miscellaneous KORLYM 300 MG TABLET MIFEPRISTONE 4 Oncology Agents, Oral KOSELUGO 10 MG CAPSULE SELUMETINIB 8 Oncology Agents, Oral KOSELUGO 25 MG CAPSULE SELUMETINIB 4 Antihyperuricemics KRYSTEXXA 8 MG/ML VIAL PEGLOTICASE 0.08 Contraceptives, Other KYLEENA 19.5 MG INTRAUTERINE SYSTEM LEVONORGESTREL INTRAUTERINE see footnote4 Antiemetics/Antivertigo Agents KYTRIL 1 MG GRANISETRON 2 Antifungals, Oral LAMISIL 125 MG GRANULES PACKET TERBINAFINE 2 Effective 01/04/21 Alphabetical by Brand Name (when applicable)

Antifungals, Oral LAMISIL 187.5 MG GRANULES PACKET TERBINAFINE 1 Antifungals, Oral LAMISIL 250 MG TABLET TERBINAFINE 1 Antipsychotics, Atypical LATUDA 120 MG TABLET LURASIDONE 1 Antipsychotics, Atypical LATUDA 20 MG TABLET LURASIDONE 1 Antipsychotics, Atypical LATUDA 40 MG TABLET LURASIDONE 1 Antipsychotics, Atypical LATUDA 60 MG TABLET LURASIDONE 1 Antipsychotics, Atypical LATUDA 80 MG TABLET LURASIDONE 2 Analgesics, Opioid Short-Acting LAZANDA 100 MCG NASAL SPRAY FENTANYL CITRATE NASAL 0.5 Analgesics, Opioid Short-Acting LAZANDA 300 MCG NASAL SPRAY FENTANYL CITRATE 0.5 Analgesics, Opioid Short-Acting LAZANDA 400 MCG NASAL SPRAY FENTANYL CITRATE NASAL 0.5 Insect Repellent NOT for Skin Application LEADER BEDDING 0.5% SPRAY PERMETHRIN 0.5% 29 Multiple Sclerosis Agents LEMTRADA 12 MG/1.2 ML VIAL ALEMTUZUMAB 0.02 Oncology Agents, Oral LENVIMA 10 MG DAILY DOSE LENVATINIB MESYLATE 1 Oncology Agents, Oral LENVIMA 12 MG DAILY DOSE LENVATINIB MESYLATE 3 Oncology Agents, Oral LENVIMA 14 MG DAILY DOSE LENVATINIB MESYLATE 2 Oncology Agents, Oral LENVIMA 18 MG DAILY DOSE LENVATINIB MESYLATE 3 Oncology Agents, Oral LENVIMA 20 MG DAILY DOSE LENVATINIB MESYLATE 2 Oncology Agents, Oral LENVIMA 24 MG DAILY DOSE LENVATINIB MESYLATE 3 Oncology Agents, Oral LENVIMA 4 MG CAPSULE LENVATINIB MESYLATE 1 Oncology Agents, Oral LENVIMA 8 MG DAILY DOSE LENVATINIB MESYLATE 2 Lipotropics, Statins LESCOL 20 MG CAPSULE FLUVASTATIN 2 Lipotropics, Statins LESCOL 40 MG CAPSULE FLUVASTATIN 2 Lipotropics, Statins LESCOL XL 80 MG TABLET SA FLUVASTATIN 1 PAH Agents, Oral & Inhaled LETAIRIS 10 MG TABLET AMBRISENTAN 1 PAH Agents, Oral & Inhaled LETAIRIS 5 MG TABLET AMBRISENTAN 1 Analgesics, Opioid Short-Acting LEVO-DROMORAN 2 MG TABLET LEVORPHANOL 4 Analgesics, Opioid Short-Acting LEVORPHANOL 3 MG TABLET LEVORPHANOL 3 Antidepressants, SSRIs LEXAPRO 10 MG TABLET ESCITALOPRAM 1.5 Antidepressants, SSRIs LEXAPRO 20 MG TABLET ESCITALOPRAM 1 Antidepressants, SSRIs LEXAPRO 5 MG TABLET ESCITALOPRAM 1 Antidepressants, SSRIs LEXAPRO 5 MG/5 ML SOLUTION ESCITALOPRAM 20 HIV/AIDS Antiretrovirals LEXIVA 50 MG/ML ORAL SUSPENSION FOSAMPRENAVIR 56 HIV/AIDS Antiretrovirals LEXIVA 700 MG TABLET FOSAMPRENAVIR 4 Ulcerative Colitis Agents LIALDA DR 1.2 GRAM TABLET MESALAMINE 4 Blood Glucose Meters LIBERTY BLOOD GLUCOSE METER BLOOD GLUCOSE METER See footnote2 Blood Glucose Test Strips LIBERTY BLOOD GLUCOSE TEST STRIPS BLOOD GLUCOSE TEST STRIPS 3.34 Benzodiazepines LIBRAX 2.5 MG/5 MG CAPSULE CLIDINIUM/CHLORDIAZEPOXIDE 8 Anxiolytics LIBRIUM 10 MG CAPSULE CHLORDIAZEPOXIDE 8 Anxiolytics LIBRIUM 25 MG CAPSULE CHLORDIAZEPOXIDE 4 Anxiolytics LIBRIUM 5 MG CAPSULE CHLORDIAZEPOXIDE 4 NSAIDs LICART 1.3% PATCH DICLOFENAC EPOLAMINE 1 Effective 01/04/21 Alphabetical by Brand Name (when applicable)

Neuropathic Pain Agents LIDODERM 5% PATCH LIDOCAINE 3 Contraceptives, Other LILETTA 52 MG SYSTEM (IUD) LEVONORGESTREL INTRAUTERINE see footnote4 Benzodiazepines LIMBITROL 12.5/5 MG TABLET AMITRIPTYLINE/CHLORDIAZEPOXIDE 6 Benzodiazepines LIMBITROL DS 25/10 MG TABLET AMITRIPTYLINE/CHLORDIAZEPOXIDE 6 GI Motility, Chronic LINZESS 145 MCG CAPSULE LINACLOTIDE 1 GI Motility, Chronic LINZESS 290 MCG CAPSULE LINACLOTIDE 1 GI Motility, Chronic LINZESS 72 MCG CAPSULE LINACLOTIDE 1 Skeletal Muscle Relaxants LIORESAL 10 MG TABLET BACLOFEN 6 Skeletal Muscle Relaxants LIORESAL 20 MG TABLET BACLOFEN 4 Lipotropics, Statins LIPITOR 10 MG TABLET ATORVASTATIN 1 Lipotropics, Statins LIPITOR 20 MG TABLET ATORVASTATIN 1 Lipotropics, Statins LIPITOR 40 MG TABLET ATORVASTATIN 1 Lipotropics, Statins LIPITOR 80 MG TABLET ATORVASTATIN 1 Lipotropics, Other LIPOFEN 150 MG CAPSULE FENOFIBRATE 1 Lipotropics, Other LIPOFEN 50 MG CAPSULE FENOFIBRATE 2 Lipotropics, Statins LIVALO 1 MG TABLET PITAVASTATIN 1 Lipotropics, Statins LIVALO 2 MG TABLET PITAVASTATIN 1 Lipotropics, Statins LIVALO 4 MG TABLET PITAVASTATIN 1 NSAIDs LODINE 200 MG CAPSULE ETODOLAC 4 NSAIDs LODINE 300 MG CAPSULE ETODOLAC 3 NSAIDs LODINE 400 MG TABLET ETODOLAC 2 NSAIDs LODINE 500 MG TABLET ETODOLAC 2 NSAIDs LODINE XL 400 MG TABLET ETODOLAC ER 2 NSAIDs LODINE XL 500 MG TABLET ETODOLAC ER 2 NSAIDs LODINE XL 600 MG TABLET ETODOLAC ER 1 Antiparkinson's Agents LODOSYN 25 MG TABLET CARBIDOPA 8 Lipotropics, Other LOFIBRA 134 MG CAPSULE FENOFIBRATE MICRONIZED 1 Lipotropics, Other LOFIBRA 160 MG TABLET FENOFIBRATE MICRONIZED 1 Lipotropics, Other LOFIBRA 200 MG CAPSULE FENOFIBRATE MICRONIZED 1 Lipotropics, Other LOFIBRA 54 MG TABLET FENOFIBRATE MICRONIZED 1 Lipotropics, Other LOFIBRA 67 MG CAPSULE FENOFIBRATE MICRONIZED 1 Potassium Removing Agents LOKELMA 10 GRAM POWDER PACKET SODIUM ZIRCONIUM CYCLOSILICATE 1.16 Potassium Removing Agents LOKELMA 5 GRAM POWDER PACKET SODIUM ZIRCONIUM CYCLOSILICATE 1 COPD Agents LONHALA MAGNAIR 25 MCG REFILL GLYCOPYRROLATE 2 COPD Agents LONHALA MAGNAIR 25 MCG STARTER GLYCOPYRROLATE 2 Oncology Agents, Oral LONSURF 15 MG/6.14 MG TABLET TRIFLURIDINE/TIPIRACIL 2.15 Oncology Agents, Oral LONSURF 20 MG/8.19 MG TABLET TRIFLURIDINE/TIPIRACIL 2.86 Lipotropics, Other LOPID 600 MG TABLET GEMFIBROZIL 2 Anxiolytics LORAZEPAM INTENSOL 2 MG/ML CONCENTRATE LORAZEPAM 5 Oncology Agents, Oral LORBRENA 100 MG TABLET LORLATINIB 1 Oncology Agents, Oral LORBRENA 25 MG TABLET LORLATINIB 3 Effective 01/04/21 Alphabetical by Brand Name (when applicable)

Analgesics, Opioid Short-Acting LORTAB 10 MG/325 MG TABLET HYDROCODONE/ACETAMINOPHEN 5 Analgesics, Opioid Short-Acting LORTAB 5 MG/325 MG TABLET HYDROCODONE/ACETAMINOPHEN 10 Analgesics, Opioid Short-Acting LORTAB 7.5 MG/325 MG TABLET HYDROCODONE/ACETAMINOPHEN 6 Analgesics, Opioid Short-Acting LORTAB ELIXIR 10 MG-300 MG/15 ML HYDROCODONE/ACETAMINOPHEN 75 Opioid Antitussive LORTUSS EX LIQUID PSEUDOEPHED/CODEINE/GUAIFENESIN 40 Skeletal Muscle Relaxants LORZONE 375 MG TABLET CHLORZOXAZONE 4 Skeletal Muscle Relaxants LORZONE 750 MG TABLET CHLORZOXAZONE 4 Angiotensin Modulators LOTENSIN 10 MG TABLET BENAZEPRIL 2 Angiotensin Modulators LOTENSIN 20 MG TABLET BENAZEPRIL 2 Angiotensin Modulators LOTENSIN 40 MG TABLET BENAZEPRIL 2 Angiotensin Modulators LOTENSIN HCT 10 MG/12.5 MG TABLET BENAZEPRIL/HYDROCHLOROTHIAZIDE 1 Angiotensin Modulators LOTENSIN HCT 20 MG/12.5 MG TABLET BENAZEPRIL/HYDROCHLOROTHIAZIDE 1 Angiotensin Modulators LOTENSIN HCT 20 MG/25 MG TABLET BENAZEPRIL/HYDROCHLOROTHIAZIDE 1 Angiotensin Modulator Combinations LOTREL 10/20 MG CAPSULE AMLODIPINE/BENAZEPRIL 1 Angiotensin Modulator Combinations LOTREL 10/40 MG CAPSULE AMLODIPINE/BENAZEPRIL 1 Angiotensin Modulator Combinations LOTREL 2.5/10 MG CAPSULE AMLODIPINE/BENAZEPRIL 1 Angiotensin Modulator Combinations LOTREL 5/10 MG CAPSULE AMLODIPINE/BENAZEPRIL 1 Angiotensin Modulator Combinations LOTREL 5/20 MG CAPSULE AMLODIPINE/BENAZEPRIL 1 Angiotensin Modulator Combinations LOTREL 5/40 MG CAPSULE AMLODIPINE/BENAZEPRIL 1 GI Motility, Chronic LOTRONEX 0.5 MG TABLET ALOSETRON 2 GI Motility, Chronic LOTRONEX 1 MG TABLET ALOSETRON 2 Lipotropics, Other LOVAZA 1 GRAM CAPSULE OMEGA-3-ACID ETHYL ESTERS 4 Anticoagulants, Injectable LOVENOX 100 MG/ML INJECTION SYRINGE ENOXAPARIN See footnote1 Anticoagulants, Injectable LOVENOX 100 MG/ML INJECTION VIAL ENOXAPARIN See footnote1 Anticoagulants, Injectable LOVENOX 120 MG/0.8 ML INJECTION SYRINGE ENOXAPARIN See footnote1 Anticoagulants, Injectable LOVENOX 150 MG/ML INJECTION SYRINGE ENOXAPARIN See footnote1 Anticoagulants, Injectable LOVENOX 30 MG/0.3 ML INJECTION SYRINGE ENOXAPARIN See footnote1 Anticoagulants, Injectable LOVENOX 40 MG/0.4 ML INJECTION SYRINGE ENOXAPARIN See footnote1 Anticoagulants, Injectable LOVENOX 60 MG/0.6 ML INJECTION SYRINGE ENOXAPARIN See footnote1 Anticoagulants, Injectable LOVENOX 80 MG/0.8 ML INJECTION SYRINGE ENOXAPARIN See footnote1 Opioid Dependence Treatments LUCEMYRA 0.18 MG TABLET LOFEXIDINE 16 Macular Degeneration Agents LUCENTIS 0.3 MG/0.05 ML INTRAVITREAL INJECTION SYRINGE RANIBIZUMAB 0.01 Macular Degeneration Agents LUCENTIS 0.3 MG/0.05 ML INTRAVITREAL INJECTION VIAL RANIBIZUMAB 0.01 Macular Degeneration Agents LUCENTIS 0.5 MG/0.05 ML INTRAVITREAL INJECTION SYRINGE RANIBIZUMAB 0.01 Macular Degeneration Agents LUCENTIS 0.5 MG/0.05 ML INTRAVITREAL INJECTION VIAL RANIBIZUMAB 0.01 Sedative Hypnotics LUNESTA 1 MG TABLET ESZOPICLONE 1 Sedative Hypnotics LUNESTA 2 MG TABLET ESZOPICLONE 1 Sedative Hypnotics LUNESTA 3 MG TABLET ESZOPICLONE 1 Pituitary Suppressive Agents, LHRH LUPANETA PACK 11.25/5 MG 3-MONTH KIT LEUPROLIDE ACETATE/NORETHINDRONE ACETATE 0.2 Pituitary Suppressive Agents, LHRH LUPANETA PACK 3.75/5 MG 1-MONTH KIT LEUPROLIDE ACETATE/NORETHINDRONE ACETATE 0.4 Pituitary Suppressive Agents, LHRH LUPRON DEPOT 11.25 MG 3-MONTH KIT LEUPROLIDE ACETATE 0.2 Effective 01/04/21 Alphabetical by Brand Name (when applicable)

Pituitary Suppressive Agents, LHRH LUPRON DEPOT 22.5 MG 3-MONTH KIT LEUPROLIDE ACETATE 0.2 Pituitary Suppressive Agents, LHRH LUPRON DEPOT 3.75 MG KIT LEUPROLIDE ACETATE 0.4 Pituitary Suppressive Agents, LHRH LUPRON DEPOT 30 MG 4-MONTH KIT LEUPROLIDE ACETATE 0.01 Pituitary Suppressive Agents, LHRH LUPRON DEPOT 45 MG 6-MONTH KIT LEUPROLIDE ACETATE 0.01 Pituitary Suppressive Agents, LHRH LUPRON DEPOT 7.5 MG KIT LEUPROLIDE ACETATE 0.4 Pituitary Suppressive Agents, LHRH LUPRON DEPOT-PED 11.25 MG 3-MONTH KIT LEUPROLIDE ACETATE 0.2 Pituitary Suppressive Agents, LHRH LUPRON DEPOT-PED 11.25 MG KIT LEUPROLIDE ACETATE 0.4 Pituitary Suppressive Agents, LHRH LUPRON DEPOT-PED 30 MG 3-MONTH KIT LEUPROLIDE ACETATE 0.2 Pituitary Suppressive Agents, LHRH LUPRON DEPOT-PED 7.5 MG KIT LEUPROLIDE ACETATE 0.4 Antidepressants, SSRIs LUVOX 100 MG TABLET FLUVOXAMINE MALEATE 3 Antidepressants, SSRIs LUVOX 25 MG TABLET FLUVOXAMINE MALEATE 1 Antidepressants, SSRIs LUVOX 50 MG TABLET FLUVOXAMINE MALEATE 1.5 Antidepressants, SSRIs LUVOX CR 100 MG CAPSULE FLUVOXAMINE MALEATE 2 Antidepressants, SSRIs LUVOX CR 150 MG CAPSULE FLUVOXAMINE MALEATE 2 Oncology Agents, Oral LYNPARZA 100 MG TABLET OLAPARIB 4 Oncology Agents, Oral LYNPARZA 150 MG TABLET OLAPARIB 4 Oncology Agents, Oral LYNPARZA 50 MG CAPSULE OLAPARIB 16 Neuropathic Pain Agents LYRICA 100 MG CAPSULE PREGABALIN 3 Neuropathic Pain Agents LYRICA 150 MG CAPSULE PREGABALIN 3 Neuropathic Pain Agents LYRICA 20 MG/ML SOLUTION PREGABALIN 30 Neuropathic Pain Agents LYRICA 200 MG CAPSULE PREGABALIN 3 Neuropathic Pain Agents LYRICA 225 MG CAPSULE PREGABALIN 2 Neuropathic Pain Agents LYRICA 25 MG CAPSULE PREGABALIN 3 Neuropathic Pain Agents LYRICA 300 MG CAPSULE PREGABALIN 2 Neuropathic Pain Agents LYRICA 50 MG CAPSULE PREGABALIN 3 Neuropathic Pain Agents LYRICA 75 MG CAPSULE PREGABALIN 3 Neuropathic Pain Agents LYRICA CR 165 MG TABLET PREGABALIN EXTENDED-RELEASE 3 Neuropathic Pain Agents LYRICA CR 330 MG TABLET PREGABALIN EXTENDED-RELEASE 2 Neuropathic Pain Agents LYRICA CR 82.5 MG TABLET PREGABALIN EXTENDED-RELEASE 3 Antifibrinolytics LYSTEDA 650 MG TABLET TRANEXAMIC ACID 6 Urinary Anti-infectives MACROBID 100 MG CAPSULE NITROFURANTOIN MONOHYD-MACRO 2 Urinary Anti-infectives MACRODANTIN 100 MG CAPSULE NITROFURANTOIN MACROCRYSTAL 4 Urinary Anti-infectives MACRODANTIN 25 MG CAPSULE NITROFURANTOIN MACROCRYSTAL 1 Urinary Anti-infectives MACRODANTIN 50 MG CAPSULE NITROFURANTOIN MACROCRYSTAL 4 Macular Degeneration Agents MACUGEN 0.3 MG/0.09 ML INTRAVITREAL INJ. SYRINGE PEGAPTANIB SODIUM 0.01 Progestational Agents MAKENA 1250 MG/5 ML MULTI-DOSE VIAL HYDROXYPROGESTERONE CAPROATE 0.15 Progestational Agents MAKENA 250 MG/ML SINGLE-DOSE VIAL HYDROXYPROGESTERONE CAPROATE 0.15 Progestational Agents MAKENA 275 MG/1.1 ML AUTOINJECTOR HYDROXYPROGESTERONE CAPROATE 0.16 Antimalarials MALARONE 250 MG/100 MG TABLET ATOVAQUONE/PROGUANIL 4 Antimalarials MALARONE 62.5 MG/25 MG PEDIATRIC TABLET ATOVAQUONE/PROGUANIL 3 Opioid Antitussive MAR-COF CG LIQUID CODEINE PHOSPHATE/GUAIFENESIN 45 Effective 01/04/21 Alphabetical by Brand Name (when applicable)

Analgesics, Non-Opioid Barbiturate Combos MARGESIC 50 MG/325 MG/40 MG CAPSULE BUTALBITAL/ACETAMINOPHEN/CAFFEINE 0.6 Antiemetics/Antivertigo Agents MARINOL 10 MG CAPSULE DRONABINOL 3 Antiemetics/Antivertigo Agents MARINOL 2.5 MG CAPSULE DRONABINOL 6 Antiemetics/Antivertigo Agents MARINOL 5 MG CAPSULE DRONABINOL 6 Multiple Sclerosis Agents MAVENCLAD 10 MG TABLET CLADRIBINE 2 Angiotensin Modulators MAVIK 1 MG TABLET TRANDOLAPRIL 1 Angiotensin Modulators MAVIK 2 MG TABLET TRANDOLAPRIL 1 Angiotensin Modulators MAVIK 4 MG TABLET TRANDOLAPRIL 2 Hepatitis C Agents MAVYRET 100-40 MG TABLET GLECAPREVIR/PIBRENTASVIR 3 Migraine Acute Treatment Agents MAXALT 10 MG TABLET/MLT RIZATRIPTAN 0.4 Migraine Acute Treatment Agents MAXALT 5 MG TABLET/MLT RIZATRIPTAN 0.4 Multiple Sclerosis Agents MAYZENT 0.25 MG STARTER PACK SIPONIMOD 2.4 Multiple Sclerosis Agents MAYZENT 0.25 MG TABLET SIPONIMOD 4 Multiple Sclerosis Agents MAYZENT 2 MG TABLET SIPONIMOD 1 NSAIDs MECLOFENAMATE 100 MG CAPSULE MECLOFENAMATE 4 NSAIDs MECLOFENAMATE 50 MG CAPSULE MECLOFENAMATE 6 Oncology Agents, Oral MEKINIST 0.5 MG TABLET TRAMETINIB 3 Oncology Agents, Oral MEKINIST 2 MG TABLET TRAMETINIB 1 Oncology Agents, Oral MEKTOVI 15 MG TABLET BINIMETINIB 6 Vaccines MENACTRA VACCINE VIAL MENINGOCOCCAL A, C, Y, W-135 VACCINE 0.5 Opioid Antitussive M-END PE LIQUID BROMPHENIRAMINE/P-EPH/CODEINE 90 Vaccines MENOMUNE-A/C/Y/W-135 VIAL VACCINE WITH DILUENT MENINGOCOCCAL A, C, Y, W-135 VACCINE 1 Estrogens MENOSTAR 14 MCG/DAY PATCH ESTRADIOL 0.15 Vaccines MENVEO A/C/Y/W-135 DIP VACCINE VIAL KIT MENINGOCOCCAL A, C, Y, W-135 VACCINE 1 Antiprotozoals MEPRON 750 MG/5 ML SUSPENSION ATOVAQUONE 20 Stimulants & Related Agents METADATE CD 10 MG CAPSULE METHYLPHENIDATE 1 Stimulants & Related Agents METADATE CD 20 MG CAPSULE METHYLPHENIDATE 1 Stimulants & Related Agents METADATE CD 30 MG CAPSULE METHYLPHENIDATE 1 Stimulants & Related Agents METADATE CD 40 MG CAPSULE METHYLPHENIDATE 1 Stimulants & Related Agents METADATE CD 50 MG CAPSULE METHYLPHENIDATE 1 Stimulants & Related Agents METADATE CD 60 MG CAPSULE METHYLPHENIDATE 1 Stimulants & Related Agents METADATE ER 10 MG TABLET METHYLPHENIDATE 3 Stimulants & Related Agents METADATE ER 20 MG TABLET METHYLPHENIDATE 3 Hypoglycemics, Metformins METAGLIP 2.5 MG/250 MG TABLET GLIPIZIDE/METFORMIN 4 Hypoglycemics, Metformins METAGLIP 2.5 MG/500 MG TABLET GLIPIZIDE/METFORMIN 4 Hypoglycemics, Metformins METAGLIP 5 MG/500 MG TABLET GLIPIZIDE/METFORMIN 4 Analgesics, Opioid Long-Acting METHADONE 10MG/5ML SOLN METHADONE 10 Analgesics, Opioid Long-Acting METHADONE 5MG/5ML SOLN METHADONE 10 Analgesics, Opioid Long-Acting METHADOSE 10MG/ML ORAL CONCENTRATE METHADONE 2 Androgenic Agents METHITEST 10 MG TABLET METHYLTESTOSTERONE 5 Stimulants & Related Agents METHYLIN 10 MG TABLET METHYLPHENIDATE 3 Effective 01/04/21 Alphabetical by Brand Name (when applicable)

Stimulants & Related Agents METHYLIN 20 MG TABLET METHYLPHENIDATE 3 Stimulants & Related Agents METHYLIN 5 MG TABLET METHYLPHENIDATE 3 Stimulants & Related Agents METHYLIN CHEWABLE 10 MG METHYLPHENIDATE 6 Stimulants & Related Agents METHYLIN CHEWABLE 2.5 MG METHYLPHENIDATE 3 Stimulants & Related Agents METHYLIN CHEWABLE 5 MG METHYLPHENIDATE 3 Stimulants & Related Agents METHYLIN ER 10 MG TABLET METHYLPHENIDATE 3 Stimulants & Related Agents METHYLIN ER 20 MG TABLET METHYLPHENIDATE 3 Stimulants & Related Agents METHYLIN ORAL SOLUTION 10 MG/ 5 ML METHYLPHENIDATE 30 Stimulants & Related Agents METHYLIN ORAL SOLUTION 5 MG/5 ML METHYLPHENIDATE 15 Stimulants & Related Agents METHYLPHENIDATE ER 72 MG TABLET METHYLPHENIDATE ER 1 Lipotropics, Statins MEVACOR 10 MG TABLET LOVASTATIN 1.5 Lipotropics, Statins MEVACOR 20 MG TABLET LOVASTATIN 1.5 Lipotropics, Statins MEVACOR 40 MG TABLET LOVASTATIN 2 Bone Density Regulators MIACALCIN 200 UNIT NASAL SPRAY CALCITONIN-SALMON 0.13 Bone Density Regulators MIACALCIN 200 UNIT/ML VIAL CALCITONIN-SALMON 0.5 Angiotensin Modulators MICARDIS 20 MG TABLET TELMISARTAN 1 Angiotensin Modulators MICARDIS 40 MG TABLET TELMISARTAN 1 Angiotensin Modulators MICARDIS 80 MG TABLET TELMISARTAN 1 Angiotensin Modulators MICARDIS HCT 40/12.5 MG TAB TELMISARTAN/HCTZ 1 Angiotensin Modulators MICARDIS HCT 80/12.5 MG TAB TELMISARTAN/HCTZ 2 Angiotensin Modulators MICARDIS HCT 80/25 MG TABLET TELMISARTAN/HCTZ 1 Diabetic Supplies, Miscellaneous MICROLET 2 LANCING DEVICE BLOOD GLUCOSE LANCING DEVICE 1 Sedative Hypnotics MIDAZOLAM 2 MG/ML SYRUP MIDAZOLAM 10 Migraine Acute Treatment Agents MIGERGOT SUPPOSITORY ERGOTAMINE TARTRATE/CAFFEINE 0.72 Migraine Acute Treatment Agents MIGRANAL 4 MG/ML NASAL SPRAY DIHYDROERGOTAMINE 0.3 Anxiolytics MILTOWN 200 MG TABLET MEPROBAMATE 4 Anxiolytics MILTOWN 400 MG TABLET MEPROBAMATE 4 Antiparkinson's Agents MIRAPEX 0.125 MG TABLET PRAMIPEXOLE 3 Antiparkinson's Agents MIRAPEX 0.25 MG TABLET PRAMIPEXOLE 3 Antiparkinson's Agents MIRAPEX 0.5 MG TABLET PRAMIPEXOLE 3 Antiparkinson's Agents MIRAPEX 0.75 MG TABLET PRAMIPEXOLE 3 Antiparkinson's Agents MIRAPEX 1 MG TABLET PRAMIPEXOLE 3 Antiparkinson's Agents MIRAPEX 1.5 MG TABLET PRAMIPEXOLE 3 Antiparkinson's Agents MIRAPEX ER 0.375 MG TABLET PRAMIPEXOLE ER 1 Antiparkinson's Agents MIRAPEX ER 0.75 MG TABLET PRAMIPEXOLE ER 1 Antiparkinson's Agents MIRAPEX ER 1.5 MG TABLET PRAMIPEXOLE ER 1 Antiparkinson's Agents MIRAPEX ER 3 MG TABLET PRAMIPEXOLE ER 1 Antiparkinson's Agents MIRAPEX ER 4.5 MG TABLET PRAMIPEXOLE ER 1 Contraceptives, Other MIRENA INTRAUTERINE SYSTEM LEVONORGESTREL see footnote4 Antihyperuricemics MITIGARE 0.6 MG CAPSULE COLCHICINE 3 Vaccines M-M-R II VACCINE VIAL WITH DILUENT MEASLES, MUMPS, RUBELLA VACCINE 1 Effective 01/04/21 Alphabetical by Brand Name (when applicable)

Antipsychotics MOBAN 10 MG TABLET MOLINDONE 4 Antipsychotics MOBAN 25 MG TABLET MOLINDONE 9 Antipsychotics MOBAN 5 MG TABLET MOLINDONE 4 NSAIDs MOBIC 15 MG TABLET MELOXICAM 1 NSAIDs MOBIC 7.5 MG TABLET MELOXICAM 2 NSAIDs MOBIC 7.5 MG/5 ML LIQUID MELOXICAM 10 Angiotensin Modulators MONOPRIL 10 MG TABLET FOSINOPRIL 2 Angiotensin Modulators MONOPRIL 20 MG TABLET FOSINOPRIL 2 Angiotensin Modulators MONOPRIL 40 MG TABLET FOSINOPRIL 1 Angiotensin Modulators MONOPRIL-HCT 10 MG/12.5 MG TABLET FOSINOPRIL/HYDROCHLOROTHIAZIDE 2 Angiotensin Modulators MONOPRIL-HCT 20 MG/12.5 MG TABLET FOSINOPRIL/HYDROCHLOROTHIAZIDE 2 Intra-Articular Hyaluronates MONOVISC 88 MG/4 ML SYRINGE HYALURONATE SODIUM, STABILIZED 0.27 Urinary Anti-infectives MONUROL 3 GM SACHET FOSFOMYCIN TROMETHAMINE 1 Tetracyclines MORGIDOX 1 X 50 MG KIT DOXYCYCLINE/SKIN CLEANSER 0.04 Tetracyclines MORGIDOX 1X100 MG KIT DOXYCYCLINE/SKIN CLEANSER 0.04 Tetracyclines MORGIDOX 2X100 MG KIT DOXYCYCLINE/SKIN CLEANSER 0.04 Analgesics, Opioid Long-Acting MORPHABOND ER 100 MG TABLET MORPHINE SULFATE 2 Analgesics, Opioid Long-Acting MORPHABOND ER 15 MG TABLET MORPHINE SULFATE 2 Analgesics, Opioid Long-Acting MORPHABOND ER 30 MG TABLET MORPHINE SULFATE 2 Analgesics, Opioid Long-Acting MORPHABOND ER 60 MG TABLET MORPHINE SULFATE 2 Analgesics, Opioid Short-Acting MORPHINE 100 MG/5 ML CONCENTRATE (INTENSOL) MORPHINE SULFATE 9 Analgesics, Opioid Short-Acting MORPHINE 20 MG/ML CONCENTRATE (INTENSOL) MORPHINE SULFATE 9 GI Motility, Chronic MOTEGRITY 1 MG TABLET PRUCALOPRIDE 1 GI Motility, Chronic MOTEGRITY 2 MG TABLET PRUCALOPRIDE 1 GI Motility, Chronic MOVANTIK 12.5 MG TABLET NALOXEGOL 1 GI Motility, Chronic MOVANTIK 25 MG TABLET NALOXEGOL 1 Hemantics & Blood Cell Stimulators MOZOBIL 24 MG/1.2 ML VIAL PLERIXAFOR 2.4 Analgesics, Opioid Long-Acting MS CONTIN 100 MG TABLET MORPHINE SULFATE ER 2 Analgesics, Opioid Long-Acting MS CONTIN 15 MG TABLET MORPHINE SULFATE ER 3 Analgesics, Opioid Long-Acting MS CONTIN 200 MG TABLET MORPHINE SULFATE ER 2 Analgesics, Opioid Long-Acting MS CONTIN 30 MG TABLET MORPHINE SULFATE ER 2 Analgesics, Opioid Long-Acting MS CONTIN 60 MG TABLET MORPHINE SULFATE ER 2 Analgesics, Opioid Short-Acting MSIR 10 MG/5 ML SOLN MORPHINE SULFATE IR 30 Analgesics, Opioid Short-Acting MSIR 15 MG TABLET MORPHINE SULFATE IR 6 Analgesics, Opioid Short-Acting MSIR 20 MG/5 ML SOLN MORPHINE SULFATE IR 15 Analgesics, Opioid Short-Acting MSIR 30 MG TABLET MORPHINE SULFATE IR 6 Thrombopoietics MULPLETA 3 MG TABLET LUSUTROMBOPAG 1 Antiarrhythmics MULTAQ 400 MG TABLET DRONEDARONE 2 Leptin Hormone Analogs MYALEPT 11.3 MG (5 MG/ML) VIAL METRELEPTIN 1 Antifungals, Injectable MYCAMINE 100 MG VIAL MICAFUNGIN 1 Antifungals, Injectable MYCAMINE 50 MG VIAL MICAFUNGIN 3 Effective 01/04/21 Alphabetical by Brand Name (when applicable)

Antifungals, Oral MYCELEX 10 MG TROCHE CLOTRIMAZOLE 5 Stimulants & Related Agents MYDAYIS ER 12.5 MG AMPHETAMINE MIXED SALTS 1 Stimulants & Related Agents MYDAYIS ER 25 MG AMPHETAMINE MIXED SALTS 1 Stimulants & Related Agents MYDAYIS ER 37.5 MG AMPHETAMINE MIXED SALTS 1 Stimulants & Related Agents MYDAYIS ER 50 MG AMPHETAMINE MIXED SALTS 1 Botulinum Toxins MYOBLOC 10000 UNITS INJECTION VIAL RIMABOTULINUMTOXIN B 0.07 Botulinum Toxins MYOBLOC 2500 UNITS INJECTION VIAL RIMABOTULINUMTOXIN B 0.02 Botulinum Toxins MYOBLOC 5000 UNITS INJECTION VIAL RIMABOTULINUMTOXIN B 0.04 Bladder Relaxant Preparations MYRBETRIQ ER 25 MG TABLET MIRABEGRON 1 Bladder Relaxant Preparations MYRBETRIQ ER 50 MG TABLET MIRABEGRON 1 Anticonvulsants MYSOLINE 250 MG TABLET PRIMIDONE 8 Anticonvulsants MYSOLINE 50 MG TABLET PRIMIDONE 8 Antidiarrheals MYTESI DR 125 MG TABLET CROFELEMER 2 NSAIDs NALFON 200 MG PULVULE FENOPROFEN 12 NSAIDs NALFON 400 MG CAPSULE FENOPROFEN 4 Alzheimer's Agents NAMENDA 10 MG TABLET MEMANTINE 2 Alzheimer's Agents NAMENDA 10 MG/5 ML ORAL SOLUTION MEMANTINE 10 Alzheimer's Agents NAMENDA 5 MG TABLET MEMANTINE 2 Alzheimer's Agents NAMENDA XR 14 MG CAPSULE MEMANTINE HCL EXTENDED-RELEASE 1 Alzheimer's Agents NAMENDA XR 21 MG CAPSULE MEMANTINE HCL EXTENDED-RELEASE 1 Alzheimer's Agents NAMENDA XR 28 MG CAPSULE MEMANTINE HCL EXTENDED-RELEASE 1 Alzheimer's Agents NAMENDA XR 7 MG CAPSULE MEMANTINE HCL EXTENDED-RELEASE 1 Alzheimer's Agents NAMENDA XR TITRATION PACK MEMANTINE HCL EXTENDED-RELEASE 1 Alzheimer's Agents NAMZARIC 10 MG/14 MG ER CAPSULE MEMANTINE/DONEPEZIL 1 Alzheimer's Agents NAMZARIC 10 MG/28 MG ER CAPSULES MEMANTINE/DONEPEZIL 1 Alzheimer's Agents NAMZARIC 21/10 MG CAPSULE MEMANTINE/DONEPEZIL 1 Alzheimer's Agents NAMZARIC 7/10 MG CAPSULE MEMANTINE/DONEPEZIL 1 Alzheimer's Agents NAMZARIC TITRATION PACK MEMANTINE/DONEPEZIL 1 NSAIDs NAPRELAN CR 375 MG TABLET NAPROXEN 3 NSAIDs NAPRELAN CR 500 MG TABLET NAPROXEN 3 NSAIDs NAPRELAN CR 750 MG TABLET NAPROXEN 2 NSAIDs NAPRELAN CR DOSECARD 500 MG/750 MG NAPROXEN 2 NSAIDs NAPROSYN 250 MG TABLET/CAPLET NAPROXEN 4 NSAIDs NAPROSYN 375 MG TABLET/CAPLET NAPROXEN 3 NSAIDs NAPROSYN 500 MG TABLET/CAPLET NAPROXEN 3 NSAIDs NAPROXEN 125 MG/5 ML LIQUID NAPROXEN 60 NSAIDs NAPROXEN 220 MG TABLET/CAPLET NAPROXEN 4 NSAIDs NAPROXEN SODIUM 220 MG CAPSULE NAPROXEN 4 Intranasal Rhinitis Agents NASAL ALLERGY 24HR SPRAY TRIAMCINOLONE ACETONIDE 0.57 Intranasal Rhinitis Agents NASALIDE 0.025% NASAL SPRAY FLUNISOLIDE 1.51 Intranasal Rhinitis Agents NASAREL 0.025% NASAL SPRAY FLUNISOLIDE 1.51 Effective 01/04/21 Alphabetical by Brand Name (when applicable)

Intranasal Rhinitis Agents NASONEX NASAL SPRAY MOMETASONE 0.57 Parathyroid Hormones NATPARA 100 MCG DOSE CARTRIDGE PARATHYROID HORMONE 0.08 Parathyroid Hormones NATPARA 25 MCG DOSE CARTRIDGE PARATHYROID HORMONE 0.08 Parathyroid Hormones NATPARA 50 MCG DOSE CARTRIDGE PARATHYROID HORMONE 0.08 Parathyroid Hormones NATPARA 75 MCG DOSE CARTRIDGE PARATHYROID HORMONE 0.08 Insect Repellent for Skin Application NATRAPEL 20% CONTINUOUS SPRAY PICARIDIN 30 Irrigants NEOSPORIN GU IRRIGATION 40 MG/ML AMP NEOMYCIN/POLYMIXIN B IRRIG. 2 Irrigants NEOSPORIN GU IRRIGATION 40 MG/ML VIAL NEOMYCIN/POLYMIXIN B IRRIG. 2 Oncology Agents, Oral NERLYNX 40 MG TABLET NERATINIB 6 Hypoglycemics, Incretin Mimetics/Enhancers NESINA 12.5 MG TABLET ALOGLIPTIN 1 Hypoglycemics, Incretin Mimetics/Enhancers NESINA 25 MG TABLET ALOGLIPTIN 1 Hypoglycemics, Incretin Mimetics/Enhancers NESINA 6.25 MG TABLET ALOGLIPTIN 1 Colony Stimulating Factors NEULASTA 6 MG/0.6 ML ONPRO DELIVERY KIT PEGFILGRASTIM 0.05 Colony Stimulating Factors NEULASTA 6 MG/0.6 ML SYRINGE PEGFILGRASTIM 0.15 Antiparkinson's Agents NEUPRO 1 MG/24 HR PATCH ROTIGOTINE 1 Antiparkinson's Agents NEUPRO 2 MG/24 HR PATCH ROTIGOTINE 1 Antiparkinson's Agents NEUPRO 3 MG/24 HR PATCH ROTIGOTINE 1 Antiparkinson's Agents NEUPRO 4 MG/24 HR PATCH ROTIGOTINE 1 Antiparkinson's Agents NEUPRO 6 MG/24 HR PATCH ROTIGOTINE 1 Antiparkinson's Agents NEUPRO 8 MG/24 HR PATCH ROTIGOTINE 1 Neuropathic Pain Agents NEURONTIN 100 MG CAPSULE GABAPENTIN 6 Neuropathic Pain Agents NEURONTIN 250 MG/5 ML SOLN GABAPENTIN 72 Neuropathic Pain Agents NEURONTIN 300 MG CAPSULE GABAPENTIN 12 Neuropathic Pain Agents NEURONTIN 400 MG CAPSULE GABAPENTIN 9 Neuropathic Pain Agents NEURONTIN 600 MG TABLET GABAPENTIN 6 Neuropathic Pain Agents NEURONTIN 800 MG TABLET GABAPENTIN 4 Oncology Agents, Oral NEXAVAR 200 MG TABLET SORAFENIB 4 Proton Pump Inhibitors NEXIUM 20 MG CAPSULE ESOMEPRAZOLE 1 Proton Pump Inhibitors NEXIUM 40 MG CAPSULE ESOMEPRAZOLE 1 Proton Pump Inhibitors NEXIUM ORAL SUSPENSION 10 MG PACKET ESOMEPRAZOLE 1 Proton Pump Inhibitors NEXIUM ORAL SUSPENSION 2.5 MG PACKET ESOMEPRAZOLE 1 Proton Pump Inhibitors NEXIUM ORAL SUSPENSION 20 MG PACKET ESOMEPRAZOLE 1 Proton Pump Inhibitors NEXIUM ORAL SUSPENSION 40 MG PACKET ESOMEPRAZOLE 1 Proton Pump Inhibitors NEXIUM ORAL SUSPENSION 5 MG PACKET ESOMEPRAZOLE 1 Lipotropics, Other NEXLETOL 180 MG TABLET BEMPEDOIC ACID 1 Lipotropics, Other NEXLIZET 180-10 MG TABLET BEMPEDOIC ACID/EZETIMIBE 1 Contraceptives, Other NEXPLANON 68 MG IMPLANT ETONOGESTREL IMPLANT see footnote4 Smoking Cessation NICODERM CQ 14 MG/24 HOURS TRANSDERMAL PATCH NICOTINE 1 Smoking Cessation NICODERM CQ 21 MG/24 HOURS TRANSDERMAL PATCH NICOTINE 1 Smoking Cessation NICODERM CQ 7 MG/24 HOURS TRANSDERMAL PATCH NICOTINE 1 Smoking Cessation NICORETTE 2 MG GUM NICOTINE POLACRILEX 24 Effective 01/04/21 Alphabetical by Brand Name (when applicable)

Smoking Cessation NICORETTE 2 MG LOZENGE NICOTINE POLACRILEX 20 Smoking Cessation NICORETTE 4 MG GUM NICOTINE POLACRILEX 24 Smoking Cessation NICORETTE 4 MG LOZENGE NICOTINE POLACRILEX 20 Smoking Cessation NICOTROL NS 10 MG/ML NASAL SPRAY NICOTINE 4 Smoking Cessation NICOTROL ORAL INHALATION CARTRIDGE NICOTINE 16 Calcium Channel Blockers NIFEDIAC CC 30 MG TABLET NIFEDIPINE 1 Calcium Channel Blockers NIFEDIAC CC 60 MG TABLET NIFEDIPINE 2 Calcium Channel Blockers NIFEDIAC CC 90 MG TABLET NIFEDIPINE 1 Calcium Channel Blockers NIFEDICAL XL 30 MG TABLET NIFEDIPINE 1 Calcium Channel Blockers NIFEDICAL XL 60 MG TABLET NIFEDIPINE 2 Oncology Agents, Oral NILANDRON 150 MG TABLET NILUTAMIDE 2 Opioid Antitussive NINJACOF-XG LIQUID CODEINE PHOSPHATE/GUAIFENESIN 60 Oncology Agents, Oral NINLARO 2.3 MG CAPSULE IXAZOMIB 0.15 Oncology Agents, Oral NINLARO 3 MG CAPSULE IXAZOMIB 0.15 Oncology Agents, Oral NINLARO 4 MG CAPSULE IXAZOMIB 0.15 Anxiolytics NIRAVAM 0.25 MG TABLET ALPRAZOLAM ODT 6 Anxiolytics NIRAVAM 0.5 MG TABLET ALPRAZOLAM ODT 6 Anxiolytics NIRAVAM 1 MG TABLET ALPRAZOLAM ODT 4 Anxiolytics NIRAVAM 2 MG TABLET ALPRAZOLAM ODT 2 Calcium Channel Blockers NISOLDIPINE ER 20 MG TABLET NISOLDIPINE 1 Calcium Channel Blockers NISOLDIPINE ER 30 MG TABLET NISOLDIPINE 2 Calcium Channel Blockers NISOLDIPINE ER 40 MG TABLET NISOLDIPINE 1 Antifungals, Oral NIZORAL 200 MG TABLET KETOCONAZOLE 1 Antidiuretic and Vasopressor Hormones NOCDURNA 27.7 MCG TABLET SL DESMOPRESSIN ACETATE SL 1 Antidiuretic and Vasopressor Hormones NOCDURNA 55.3 MCG TABLET SL DESMOPRESSIN ACETATE SL 1 Oncology Agents, Breast Cancer NOLVADEX 10 MG TABLET TAMOXIFEN 2 Oncology Agents, Breast Cancer NOLVADEX 20 MG TABLET TAMOXIFEN 2 Analgesics, Opioid Short-Acting NORCO 10 MG/325 MG TABLET HYDROCODONE/ACETAMINOPHEN 5 Analgesics, Opioid Short-Acting NORCO 5 MG/325 MG TABLET HYDROCODONE/ACETAMINOPHEN 10 Analgesics, Opioid Short-Acting NORCO 7.5 MG/325 MG TABLET HYDROCODONE/ACETAMINOPHEN 6 Skeletal Muscle Relaxants NORFLEX ER 100 MG SR TABLET ORPHENADRINE SR 2 Skeletal Muscle Relaxants NORGESIC FORTE 50-770-60 MG TABLET ORPHENADRINE CITRATE/ASPIRIN/CAFFEINE 4 Vasopressors NORTHERA 100 MG CAPSULE DROXIDOPA 3 Vasopressors NORTHERA 200 MG CAPSULE DROXIDOPA 3 Vasopressors NORTHERA 300 MG CAPSULE DROXIDOPA 6 Calcium Channel Blockers NORVASC 10 MG TABLET AMLODIPINE 1 Calcium Channel Blockers NORVASC 2.5 MG TABLET AMLODIPINE 4 Calcium Channel Blockers NORVASC 5 MG TABLET AMLODIPINE 2 HIV/AIDS Antiretrovirals NORVIR 100 MG CAPSULE/TABLET RITONAVIR 12 HIV/AIDS Antiretrovirals NORVIR 100 MG POWDER PACKET RITONAVIR 12 HIV/AIDS Antiretrovirals NORVIR 80 MG/ML ORAL SOLUTION RITONAVIR 16 Effective 01/04/21 Alphabetical by Brand Name (when applicable)

Antiparkinson's Agents NOURIANZ 20 MG TABLET ISTRADEFYLLINE 1 Antiparkinson's Agents NOURIANZ 40 MG TABLET ISTRADEFYLLINE 1 Blood Glucose Test Strips NOVA MAX BLOOD GLUCOSE TEST STRIPS BLOOD GLUCOSE TEST STRIPS 3.34 Antifungals, Injectable NOXAFIL 300 MG/16.7 ML VIAL POSACONAZOLE 25.1 Antifungals, Oral NOXAFIL 40 MG/ML SUSPENSION POSACONAZOLE 20 Antifungals, Oral NOXAFIL DR 100 MG TABLET POSACONAZOLE 3.22 Oncology Agents, Oral NUBEQA 300 MG TABLET DAROLUTAMIDE 4 MABs - Anti-IL, Anti-IgE NUCALA 100 MG VIAL MEPOLIZUMAB 0.11 Analgesics, Opioid Short-Acting NUCYNTA 100 MG TABLET TAPENTADOL 4 Analgesics, Opioid Short-Acting NUCYNTA 50 MG TABLET TAPENTADOL 4 Analgesics, Opioid Short-Acting NUCYNTA 75 MG TABLET TAPENTADOL 4 Analgesics, Opioid Long-Acting NUCYNTA ER 100 MG TABLET TAPENTADOL HCL ER 2 Analgesics, Opioid Long-Acting NUCYNTA ER 150 MG TABLET TAPENTADOL HCL ER 2 Analgesics, Opioid Long-Acting NUCYNTA ER 200 MG TABLET TAPENTADOL HCL ER 2 Analgesics, Opioid Long-Acting NUCYNTA ER 250 MG TABLET TAPENTADOL HCL ER 2 Analgesics, Opioid Long-Acting NUCYNTA ER 50 MG TABLET TAPENTADOL HCL ER 2 NMDA Antagonists NUEDEXTA 20-10 MG CAPSULE DEXTROMETHORPHAN/QUINIDINE 2 Antipsychotics NUPLAZID 10 MG TABLET PIMAVANSERIN 1 Antipsychotics NUPLAZID 17 MG TABLET PIMAVANSERIN 2 Antipsychotics NUPLAZID 34 MG CAPSULE PIMAVANSERIN 1 Migraine Acute Treatment Agents NURTEC ODT 75 MG TABLET RIMEGEPANT 0.27 Contraceptives, Other NUVARING VAGINAL RING ETONOGESTREL/ETHINYL ESTRADIOL 0.05 Stimulants & Related Agents NUVIGIL 150 MG TABLET ARMODAFINIL 1 Stimulants & Related Agents NUVIGIL 200MG TABLET ARMODAFINIL 1 Stimulants & Related Agents NUVIGIL 250 MG TABLET ARMODAFINIL 1 Stimulants & Related Agents NUVIGIL 50 MG TABLET ARMODAFINIL 2 Tetracyclines NUZYRA 150 MG TABLET OMADACYCLINE 3 Bile Salts OCALIVA 10 MG TABLET OBETICHOLIC ACID 1 Bile Salts OCALIVA 5 MG TABLET OBETICHOLIC ACID 1 Multiple Sclerosis Agents OCREVUS 300 MG/10 MLVIAL EMTRICITABINE/RILPIVIRINE/TENOFOVIROCRELIZUMAB 0.72 HIV/AIDS Antiretrovirals ODEFSEY 200 MG/25 MG/25 MG TABLET ALAFENAMIDE 1 Oncology Agents, Oral ODOMZO 200 MG CAPSULE SONIDEGIB 1 Idiopathic Pulmonary Fibrosis Agents OFEV 100 MG CAPSULE NINTEDANIB ESYLATE 2 Idiopathic Pulmonary Fibrosis Agents OFEV 150 MG CAPSULE NINTEDANIB ESYLATE 2 Insect Repellent for Skin Application OFF! ACTIVE INSECT REPELLENT I 15% AEROSOL DIETHYLTOLUAMIDE 30 Insect Repellent for Skin Application OFF! DEEP WOODS INSECT REPELLENT V 25% AEROSOL DIETHYLTOLUAMIDE 31 Insect Repellent for Skin Application OFF! DEEP WOODS INSECT REPELLENT VII PUMP DIETHYLTOLUAMIDE 30 Insect Repellent for Skin Application OFF! DEEP WOODS INSECT REPELLENT VIII DRY 25% AERO. DIETHYLTOLUAMIDE 30 Insect Repellent for Skin Application OFF! FAMILYCARE INSECT REPELLENT I SMOOTH & DRY 15% DIETHYLTOLUAMIDE 36 Cytokine & CAM Antagonists OLUMIANT 1 MG TABLET BARICITINIB 1 Cytokine & CAM Antagonists OLUMIANT 2 MG TABLET BARICITINIB 1 Effective 01/04/21 Alphabetical by Brand Name (when applicable)

Intranasal Rhinitis Agents OMNARIS NASAL SPRAY CICLESONIDE AQUEOUS 0.42 Diabetic Supplies, Miscellaneous ONE TOUCH DELICA LANCING DEVICE BLOOD GLUCOSE LANCING DEVICE 1 Diabetic Supplies, Miscellaneous ONE TOUCH PENLET PLUS BLOOD GLUCOSE LANCING DEVICE 1 Blood Glucose Meters ONE TOUCH ULTRA 2 BLOOD GLUCOSE METER BLOOD GLUCOSE METER See footnote2 Blood Glucose Test Strips ONE TOUCH ULTRA BLOOD GLUCOSE TEST STRIPS BLOOD GLUCOSE TEST STRIPS 3.34 Blood Glucose Meters ONE TOUCH ULTRA LINK BLOOD GLUCOSE METER BLOOD GLUCOSE METER See footnote2 Blood Glucose Meters ONE TOUCH ULTRA MINI BLOOD GLUCOSE METER BLOOD GLUCOSE METER See footnote2 Blood Glucose Meters ONE TOUCH ULTRA SMART BLOOD GLUCOSE METER BLOOD GLUCOSE METER See footnote2 Blood Glucose Meters ONE TOUCH ULTRA SYSTEM BLOOD GLUCOSE METER BLOOD GLUCOSE METER See footnote2 Blood Glucose Test Strips ONE TOUCH VERIO BLOOD GLUCOSE TEST STRIPS BLOOD GLUCOSE TEST STRIPS 3.34 Blood Glucose Meters ONE TOUCH VERIO FLEX METER BLOOD GLUCOSE METER See footnote2 Blood Glucose Meters ONE TOUCH VERIO IQ BLOOD GLUCOSE METER BLOOD GLUCOSE METER See footnote2 Blood Glucose Meters ONE TOUCH VERIO METER BLOOD GLUCOSE METER See footnote2 Blood Glucose Meters ONE TOUCH VERIO REFLECT METER BLOOD GLUCOSE METER See footnote2 Anticonvulsants ONFI 10 MG TABLET CLOBAZAM 2 Anticonvulsants ONFI 2.5 MG/ML SUSPENSION CLOBAZAM 16 Anticonvulsants ONFI 20 MG TABLET CLOBAZAM 2 Anticonvulsants ONFI 5 MG TABLET CLOBAZAM 2 Antiparkinson's Agents ONGENTYS 50 MG CAPSULE OPICAPONE 1 Hypoglycemics, Incretin Mimetics/Enhancers ONGLYZA 2.5 MG TABLET SAXAGLIPTIN 1 Hypoglycemics, Incretin Mimetics/Enhancers ONGLYZA 5 MG TABLET SAXAGLIPTIN 1 Antifungals, Oral ONMEL 200 MG TABLET ITRACONAZOLE 1 Migraine Acute Treatment Agents ONZETRA XSAIL 11 MG NASAL SUMATRIPTAN 0.54 Analgesics, Opioid Long-Acting OPANA ER 10 MG TABLET OXYMORPHONE HCL ER 2 Analgesics, Opioid Long-Acting OPANA ER 15 MG TABLET OXYMORPHONE HCL ER 2 Analgesics, Opioid Long-Acting OPANA ER 20 MG TABLET OXYMORPHONE HCL ER 2 Analgesics, Opioid Long-Acting OPANA ER 30 MG TABLET OXYMORPHONE HCL ER 2 Analgesics, Opioid Long-Acting OPANA ER 40 MG TABLET OXYMORPHONE HCL ER 2 Analgesics, Opioid Long-Acting OPANA ER 5 MG TABLET OXYMORPHONE HCL ER 2 Analgesics, Opioid Long-Acting OPANA ER 7.5 MG TABLET OXYMORPHONE HCL ER 2 Analgesics, Opioid Short-Acting OPANA IR 10 MG TABLET OXYMORPHONE HCL 4 Analgesics, Opioid Short-Acting OPANA IR 5 MG TABLET OXYMORPHONE HCL 4 Analgesics, Opioids OPIUM TINCTURE 10 MG/ML OPIUM 5 PAH Agents, Oral & Inhaled OPSUMIT 10 MG TABLET MACITENTAN 1 Blood Glucose Test Strips OPTIUM BLOOD GLUCOSE TEST STRIPS BLOOD GLUCOSE TEST STRIPS 3.34 Tetracyclines ORACEA 40 MG CAPSULE DOXYCYCLINE MONOHYDRATE 1 Analgesics, Opioid Long-Acting ORAMORPH SR 100 MG TABLET MORPHINE SULFATE SR 2 Analgesics, Opioid Long-Acting ORAMORPH SR 15 MG TABLET MORPHINE SULFATE SR 3 Analgesics, Opioid Long-Acting ORAMORPH SR 30 MG TABLET MORPHINE SULFATE SR 2 Analgesics, Opioid Long-Acting ORAMORPH SR 60 MG TABLET MORPHINE SULFATE SR 2 Antifungals, Oral ORAVIG 50 MG BUCCAL TABLET MICONAZOLE 1 Effective 01/04/21 Alphabetical by Brand Name (when applicable)

Cytokine & CAM Antagonists ORENCIA 125 MG INJECTION SYRINGE ABATACEPT 0.15 Cytokine & CAM Antagonists ORENCIA 125 MG/ML CLICKJET ABATACEPT 0.15 Cytokine & CAM Antagonists ORENCIA 250 MG INJECTION VIAL ABATACEPT 0.29 Cytokine & CAM Antagonists ORENCIA 50 MG/0.4ML SYRINGE ABATACEPT 0.06 Cytokine & CAM Antagonists ORENCIA 87.5 MG/0.7 ML SYRINGE ABATACEPT 0.1 Pituitary Suppressive Agents, LHRH ORIAHNN 300-1-0.5 MG/300 MG CAPS ELAGOLIX, ESTRADIOL, NORETHINDRONE ACETATE 2 Pituitary Suppressive Agents, LHRH ORILISSA 150 MG TABLET ELAGOLIX 1 Pituitary Suppressive Agents, LHRH ORILISSA 200 MG TABLET ELAGOLIX 2 CFTR Modulators ORKAMBI 100 MG/125 MG TABLET LUMACAFTOR/IVACAFTOR 4 CFTR Modulators ORKAMBI 100-125 MG GRANULE PACKET LUMACAFTOR/IVACAFTOR 2 CFTR Modulators ORKAMBI 150-188 MG GRANULE PACKET LUMACAFTOR/IVACAFTOR 2 CFTR Modulators ORKAMBI 200 MG/125 MG TABLET LUMACAFTOR/IVACAFTOR 4 Intra-Articular Hyaluronates ORTHOVISC 15 MG/ML SYRINGE HYALURONATE SODIUM 0.58 Glucocorticoids, Oral ORTIKOS ER 6 MG CAPSULE BUDESONIDE 1 Glucocorticoids, Oral ORTIKOS ER 9 MG CAPSULE BUDESONIDE 1 Hypoglycemics, Incretin Mimetics/Enhancers OSENI 12.5 MG/15 MG TABLET ALOGLIPTIN/PIOGLITAZONE 1 Hypoglycemics, Incretin Mimetics/Enhancers OSENI 12.5 MG/30 MG TABLET ALOGLIPTIN/PIOGLITAZONE 1 Hypoglycemics, Incretin Mimetics/Enhancers OSENI 12.5 MG/45 MG TABLET ALOGLIPTIN/PIOGLITAZONE 1 Hypoglycemics, Incretin Mimetics/Enhancers OSENI 25 MG/15 MG TABLET ALOGLIPTIN/PIOGLITAZONE 1 Hypoglycemics, Incretin Mimetics/Enhancers OSENI 25 MG/30 MG TABLET ALOGLIPTIN/PIOGLITAZONE 1 Hypoglycemics, Incretin Mimetics/Enhancers OSENI 25 MG/45 MG TABLET ALOGLIPTIN/PIOGLITAZONE 1 Antiparkinson's Agents OSMOLEX ER 129 MG TABLET AMANTADINE ER 1 Antiparkinson's Agents OSMOLEX ER 193 MG TABLET AMANTADINE ER 1 Antiparkinson's Agents OSMOLEX ER 258 MG TABLET AMANTADINE ER 1 Cytokine & CAM Antagonists OTEZLA 30 MG TABLET APREMILAST 2 Cytokine & CAM Antagonists OTEZLA STARTER PACK (28 DAY, 55 TABLETS) APREMILAST 1.97 Methotrexates OTREXUP 10 MG/0.4 ML AUTO-INJECTOR METHOTREXATE 0.06 Methotrexates OTREXUP 15 MG/0.4 ML AUTO-INJECTOR METHOTREXATE 0.06 Methotrexates OTREXUP 20 MG/0.4 ML AUTO-INJECTOR METHOTREXATE 0.06 Methotrexates OTREXUP 25 MG/0.4 ML AUTO-INJECTOR METHOTREXATE 0.06 Androgenic Agents OXANDRIN 10 MG TABLET OXANDROLONE 2 Androgenic Agents OXANDRIN 2.5 MG TABLET OXANDROLONE 8 Analgesics, Opioid Short-Acting OXAYDO 5 MG TABLET OXYCODONE HCL 6 Analgesics, Opioid Short-Acting OXAYDO 7.5 MG TABLET OXYCODONE HCL 4 Sickle Cell Anemia Agents OXBRYTA 500 MG TABLET VOXELOTOR 3 Anticonvulsants OXTELLAR XR 150 MG TABLET OXCARBAZEPINE 3 Anticonvulsants OXTELLAR XR 300 MG TABLET OXCARBAZEPINE 3 Anticonvulsants OXTELLAR XR 600 MG TABLET OXCARBAZEPINE 4 Analgesics, Opioid Short-Acting OXY IR 5MG CAPSULE OXYCODONE 6 Analgesics, Opioid Short-Acting OXYCODONE 10 MG/0.5 ML ORAL SYRINGE OXYCODONE HCL 9 Analgesics, Opioid Short-Acting OXYCODONE 20 MG/ML SOLN OXYCODONE 9 Effective 01/04/21 Alphabetical by Brand Name (when applicable)

Analgesics, Opioid Short-Acting OXYCODONE 5 MG/5 ML SOLN OXYCODONE 30 Analgesics, Opioid Long-Acting OXYCONTIN 10 MG CR TABLET OXYCODONE CR 2 Analgesics, Opioid Long-Acting OXYCONTIN 15 MG CR TABLET OXYCODONE CR 2 Analgesics, Opioid Long-Acting OXYCONTIN 20 MG CR TABLET OXYCODONE CR 2 Analgesics, Opioid Long-Acting OXYCONTIN 30 MG CR TABLET OXYCODONE CR 2 Analgesics, Opioid Long-Acting OXYCONTIN 40 MG CR TABLET OXYCODONE CR 2 Analgesics, Opioid Long-Acting OXYCONTIN 60 MG CR TABLET OXYCODONE CR 2 Analgesics, Opioid Long-Acting OXYCONTIN 80 MG CR TABLET OXYCODONE CR 2 Bladder Relaxant Preparations OXYTROL 3.9 MG/DAY TD PATCH OXYBUTYNIN 0.29 Bladder Relaxant Preparations OXYTROL FOR WOMEN 3.9 MG/DAY TD PATCH OXYBUTYNIN 0.29 Hypoglycemics, Incretin Mimetics/Enhancers OZEMPIC 0.25-0.5 MG DOSE PEN SEMAGLUTIDE 0.06 Hypoglycemics, Incretin Mimetics/Enhancers OZEMPIC 1 MG DOSE PEN SEMAGLUTIDE 0.11 PKU Treatment Agents PALYNZIQ 10 MG/0.5 ML SYRINGE PEGVALIASE 0.5 PKU Treatment Agents PALYNZIQ 2.5 MG/0.5 ML SYRINGE PEGVALIASE 0.15 PKU Treatment Agents PALYNZIQ 20 MG/ML SYRINGE PEGVALIASE 3 Analgesics, Opioid Short-Acting PANLOR 325-30-16 MG TABLET ACETAMINOPHEN/CAFFEINE/DIHYDROCODEINE 10 Skeletal Muscle Relaxants PARAFON FORTE DSC 500 MG TABLET CHLORZOXAZONE 6 Contraceptives, Other PARAGARD T 380-A IUD COPPER INTRAUTERINE DEVICE see footnote4 Antiparkinson's Agents PARCOPA 10/100 MG ODT CARBIDOPA/LEVODOPA 8 Antiparkinson's Agents PARCOPA 25/100 MG ODT CARBIDOPA/LEVODOPA 8 Antiparkinson's Agents PARCOPA 25/250 MG ODT CARBIDOPA/LEVODOPA 8 Antiparkinson's Agents PARLODEL 2.5 MG TABLET BROMOCRIPTINE 20 Antiparkinson's Agents PARLODEL 5 MG CAPSULE BROMOCRIPTINE 10 Intranasal Rhinitis Agents PATANASE 0.6% NASAL SPRAY OLOPATADINE 1.02 Antidepressants, SSRIs PAXIL 10 MG TABLET PAROXETINE 3 Antidepressants, SSRIs PAXIL 10 MG/5 ML SUSPENSION PAROXETINE 30 Antidepressants, SSRIs PAXIL 20 MG TABLET PAROXETINE 3 Antidepressants, SSRIs PAXIL 30 MG TABLET PAROXETINE 2 Antidepressants, SSRIs PAXIL 40 MG TABLET PAROXETINE 1.5 Antidepressants, SSRIs PAXIL CR 12.5 MG TABLET PAROXETINE 1 Antidepressants, SSRIs PAXIL CR 25 MG TABLET PAROXETINE 2 Antidepressants, SSRIs PAXIL CR 37.5 MG TABLET PAROXETINE 2 Anticonvulsants PEGANONE 250 MG TABLET ETHOTOIN 12 Hepatitis C Agents PEGASYS 180 MCG/0.5 ML MONTHLY CONVENIENCE PAK PEGINTERFERON ALFA-2A 0.04 Hepatitis C Agents PEGASYS 180 MCG/ML SINGE USE VIAL PEGINTERFERON ALFA-2A 0.14 Oncology Agents, Oral PEMAZYRE 13.5 MG TABLET PEMIGATINIB 0.67 Oncology Agents, Oral PEMAZYRE 4.5 MG TABLET PEMIGATINIB 0.67 Oncology Agents, Oral PEMAZYRE 9 MG TABLET PEMIGATINIB 0.67 NSAIDs PENNSAID 1.5% SOLUTION DICLOFENAC SODIUM 10 NSAIDs PENNSAID 2% PUMP DICLOFENAC SODIUM 8 Ulcerative Colitis Agents PENTASA 250 MG ER CAPSULE MESALAMINE 16 Effective 01/04/21 Alphabetical by Brand Name (when applicable)

Ulcerative Colitis Agents PENTASA 500 MG ER CAPSULE MESALAMINE 8 Histamine 2 Receptor Blockers PEPCID 10 MG TABLET FAMOTIDINE 2 Histamine 2 Receptor Blockers PEPCID 20 MG TABLET FAMOTIDINE 4 Histamine 2 Receptor Blockers PEPCID 40 MG TABLET FAMOTIDINE 2 Analgesics, Opioid Short-Acting PERCOCET 10 MG/325 MG TABLET OXYCODONE/APAP 4 Analgesics, Opioid Short-Acting PERCOCET 2.5 MG/325 MG TABLET OXYCODONE/APAP 10 Analgesics, Opioid Short-Acting PERCOCET 5 MG/325 MG TABLET OXYCODONE/APAP 6 Analgesics, Opioid Short-Acting PERCOCET 7.5 MG/325 MG TABLET OXYCODONE/APAP 4 Analgesics, Opioid Short-Acting PERCODAN TABLET OXYCODONE/ASA 6 Bronchodilators, Beta Agonist PERFOROMIST 20 MCG/2 ML SOLN FORMOTEROL 4 Oncology, Other PERJETA 420 MG/14 ML VIAL PERTUZUMAB 1.34 Insect Repellent NOT for Skin Application PERRIGO LICE BEDDING SPRAY PERMETHRIN 0.5% 29 Platelet Aggregation Inhibitors PERSANTINE 25 MG TABLET DIPYRIDAMOLE 4 Platelet Aggregation Inhibitors PERSANTINE 50 MG TABLET DIPYRIDAMOLE 8 Platelet Aggregation Inhibitors PERSANTINE 75 MG TABLET DIPYRIDAMOLE 4 Antipsychotics, Atypical PERSERIS ER 120 MG SYRINGE KIT RISPERIDONE ER 0.04 Antipsychotics, Atypical PERSERIS ER 90 MG SYRINGE KIT RISPERIDONE ER 0.04 Antidepressants, SSRIs PEXEVA 10 MG TABLET PAROXETINE MESYLATE 1 Antidepressants, SSRIs PEXEVA 20 MG TABLET PAROXETINE MESYLATE 1 Antidepressants, SSRIs PEXEVA 30 MG TABLET PAROXETINE MESYLATE 2 Antidepressants, SSRIs PEXEVA 40 MG TABLET PAROXETINE MESYLATE 1 Antiemetics/Antivertigo Agents PHENERGAN 12.5 MG SUPPOSITORY PROMETHAZINE 6 Antiemetics/Antivertigo Agents PHENERGAN 12.5 MG TABLET PROMETHAZINE 6 Antiemetics/Antivertigo Agents PHENERGAN 25 MG SUPPOSITORY PROMETHAZINE 6 Antiemetics/Antivertigo Agents PHENERGAN 25 MG TABLET PROMETHAZINE 6 Antiemetics/Antivertigo Agents PHENERGAN 50 MG SUPPOSITORY PROMETHAZINE 3 Antiemetics/Antivertigo Agents PHENERGAN 50 MG TABLET PROMETHAZINE 3 Anticonvulsants PHENYTEK 200 MG CAPSULE PHENYTOIN 3 Anticonvulsants PHENYTEK 300 MG CAPSULE PHENYTOIN 2 Phosphate Binders PHOSLO 667 MG CAPSULE/TABLET CALCIUM ACETATE 12 Phosphate Binders PHOSLYRA 667 MG/5 ML ORAL SOLUTION CALCIUM ACETATE 60 Analgesics, Non-Opioid Barbiturate Combos PHRENILIN 50 MG/325 MG TABLET BUTALBITAL/ACETAMINOPHEN 0.6 HIV/AIDS Antiretrovirals PIFELTRO 100 MG TABLET DORAVIRINE 1 Oncology Agents, Oral PIQRAY 200 MG DAILY DOSE ALPELISIB 1 Oncology Agents, Oral PIQRAY 250 MG DAILY DOSE ALPELISIB 2 Oncology Agents, Oral PIQRAY 300 MG DAILY DOSE ALPELISIB 2 Platelet Aggregation Inhibitors PLAVIX 300 MG TABLET CLOPIDOGREL 1 Platelet Aggregation Inhibitors PLAVIX 75 MG TABLET CLOPIDOGREL 1 Multiple Sclerosis Agents PLEGRIDY 125 MCG/0.5 ML PEN PEGINTERFERON BETA-1A 0.04 Multiple Sclerosis Agents PLEGRIDY 125 MCG/0.5 ML SYRINGE PEGINTERFERON BETA-1A 0.04 Multiple Sclerosis Agents PLEGRIDY PEN INJECTION STARTER PACK PEGINTERFERON BETA-1A 0.04 Effective 01/04/21 Alphabetical by Brand Name (when applicable)

Multiple Sclerosis Agents PLEGRIDY SYRINGE STARTER PACK PEGINTERFERON BETA-1A 0.04 Calcium Channel Blockers PLENDIL 10 MG TABLET SA FELODIPINE 1 Calcium Channel Blockers PLENDIL 2.5 MG TABLET SA FELODIPINE 1 Calcium Channel Blockers PLENDIL 5 MG TABLET SA FELODIPINE 1 Platelet Aggregation Inhibitors PLETAL 100 MG TABLET CILOSTAZOL 2 Platelet Aggregation Inhibitors PLETAL 50 MG TABLET CILOSTAZOL 2 Vaccines PNEUMOVAX 23 SYRINGE/VIAL PNEUMOCOCCAL VACCINE 0.5 Thalidomides & Derivatives POMALYST 1 MG CAPSULE POMALIDOMIDE 1 Thalidomides & Derivatives POMALYST 2 MG CAPSULE POMALIDOMIDE 1 Thalidomides & Derivatives POMALYST 3 MG CAPSULE POMALIDOMIDE 1 Thalidomides & Derivatives POMALYST 4 MG CAPSULE POMALIDOMIDE 1 NSAIDs PONSTEL 250 MG CAPSULE MEFENAMIC ACID 5 Anticoagulants, Oral PRADAXA 110 MG CAPSULE DABIGATRAN 2 Anticoagulants, Oral PRADAXA 150 MG CAPSULE DABIGATRAN 2 Anticoagulants, Oral PRADAXA 75 MG CAPSULE DABIGATRAN 2 Lipotropics, Other PRALUENT 150 MG/ML INJECTION PEN ALIROCUMAB 0.08 Lipotropics, Other PRALUENT 150 MG/ML INJECTION SYRINGE ALIROCUMAB 0.08 Lipotropics, Other PRALUENT 75 MG/ML INJECTION PEN ALIROCUMAB 0.08 Lipotropics, Other PRALUENT 75 MG/ML INJECTION SYRINGE ALIROCUMAB 0.08 Hypoglycemics, Meglitinides PRANDIMET 1 MG/500 MG TABLET REPAGLINIDE/METFORMIN 5 Hypoglycemics, Meglitinides PRANDIMET 2 MG/500 MG TABLET REPAGLINIDE/METFORMIN 5 Hypoglycemics, Meglitinides PRANDIN 0.5 MG TABLET REPAGLINIDE 4 Hypoglycemics, Meglitinides PRANDIN 1 MG TABLET REPAGLINIDE 4 Hypoglycemics, Meglitinides PRANDIN 2 MG TABLET REPAGLINIDE 8 Lipotropics, Statins PRAVACHOL 10 MG TABLET PRAVASTATIN 1.5 Lipotropics, Statins PRAVACHOL 20 MG TABLET PRAVASTATIN 1.5 Lipotropics, Statins PRAVACHOL 40 MG TABLET PRAVASTATIN 1.5 Lipotropics, Statins PRAVACHOL 80 MG TABLET PRAVASTATIN 1 Blood Glucose Test Strips PRECISION PCX BLOOD GLUCOSE TEST STRIPS BLOOD GLUCOSE TEST STRIPS 3.34 Blood Glucose Test Strips PRECISION Q-I-D BLOOD GLUCOSE TEST STRIPS BLOOD GLUCOSE TEST STRIPS 3.34 Blood Glucose Meters PRECISION XTRA BLOOD GLUCOSE METER BLOOD GLUCOSE METER See footnote2 Blood Glucose Test Strips PRECISION XTRA BLOOD GLUCOSE TEST STRIPS BLOOD GLUCOSE TEST STRIPS 3.34 Hypoglycemics, Alpha-Glucosidase Inhibitors PRECOSE 100 MG TABLET ACARBOSE 3 Hypoglycemics, Alpha-Glucosidase Inhibitors PRECOSE 25 MG TABLET ACARBOSE 3 Hypoglycemics, Alpha-Glucosidase Inhibitors PRECOSE 50 MG TABLET ACARBOSE 3 Estrogens PREFEST TABLET ESTRADIOL/NORGESTIMATE 1 Estrogens PREMARIN 25 MG VIAL CONJUGATED ESTROGENS 2 Estrogens PREMPHASE 0.625-5 MG TABLET CONJUGATED ESTROGENS/M-PROGEST ACET 1 Estrogens PREMPRO 0.3 MG-1.5 MG TABLET CONJUGATED ESTROGENS/M-PROGEST ACET 1 Estrogens PREMPRO 0.45-1.5 MG TABLET CONJUGATED ESTROGENS/M-PROGEST ACET 1 Estrogens PREMPRO 0.625-2.5 MG TABLET CONJUGATED ESTROGENS/M-PROGEST ACET 1 Effective 01/04/21 Alphabetical by Brand Name (when applicable)

Estrogens PREMPRO 0.625-5 MG TABLET CONJUGATED ESTROGENS/M-PROGEST ACET 1 Blood Glucose Meters PRESTIGE BLOOD GLUCOSE METER BLOOD GLUCOSE METER See footnote2 Blood Glucose Test Strips PRESTIGE BLOOD GLUCOSE TEST STRIPS BLOOD GLUCOSE TEST STRIPS 3.34 Blood Glucose Test Strips PRESTIGE SMART BLOOD GLUCOSE TEST STRIPS BLOOD GLUCOSE TEST STRIPS 3.34 Proton Pump Inhibitors PREVACID 15 MG CAPSULE/SOLUTAB LANSOPRAZOLE 1 Proton Pump Inhibitors PREVACID 24 HR (OTC) 15 MG CAPSULE LANSOPRAZOLE 1 Proton Pump Inhibitors PREVACID 30 MG CAPSULE/SOLUTAB LANSOPRAZOLE 1 Vaccines PREVNAR 13 VACCINE SYRINGE PNEUMOCOCCAL 13-VALENT CONJUGATED VACCINE 0.5 H. Pylori Treatments PREVPAC PATIENT PACK LANSOPRAZOLE/AMOXICILLIN/CLARITHR 8 Antivirals, CMV PREVYMIS 240 MG TABLET LETERMOVIR 1 Antivirals, CMV PREVYMIS 240 MG/ 12 ML VIAL LETERMOVIR 12 Antivirals, CMV PREVYMIS 480 MG TABLET LETERMOVIR 1 Antivirals, CMV PREVYMIS 480 MG/ 24 ML VIAL LETERMOVIR 24 HIV/AIDS Antiretrovirals PREZCOBIX 800 MG/150 MG TABLET DARUNAVIR/COBICISTAT 1 HIV/AIDS Antiretrovirals PREZISTA 100 MG/ML SUSPENSION DARUNAVIR 8 HIV/AIDS Antiretrovirals PREZISTA 150 MG TABLET DARUNAVIR 6 HIV/AIDS Antiretrovirals PREZISTA 400 MG TABLET DARUNAVIR 2 HIV/AIDS Antiretrovirals PREZISTA 600 MG TABLET DARUNAVIR 2 HIV/AIDS Antiretrovirals PREZISTA 75 MG TABLET DARUNAVIR 2 HIV/AIDS Antiretrovirals PREZISTA 800 MG TABLET DARUNAVIR 1 Proton Pump Inhibitors PRILOSEC 10 MG CAPSULE DR OMEPRAZOLE 2 Proton Pump Inhibitors PRILOSEC 10 MG SUSPENSION PACKET OMEPRAZOLE 2 Proton Pump Inhibitors PRILOSEC 2.5 MG SUSPENSION PACKET OMEPRAZOLE 2 Proton Pump Inhibitors PRILOSEC 20 MG CAPSULE DR OMEPRAZOLE 2 Proton Pump Inhibitors PRILOSEC 40 MG CAPSULE DR OMEPRAZOLE 2 Proton Pump Inhibitors PRILOSEC OTC 20 MG TABLET OMEPRAZOLE 2 Antibiotics, Injectable PRIMAXIN 250 MG VIAL IMIPENEM/CILASTATIN 8 Antibiotics, Injectable PRIMAXIN 500 MG VIAL IMIPENEM/CILASTATIN 8 Angiotensin Modulators PRINIVIL 10 MG TABLET LISINOPRIL 2 Angiotensin Modulators PRINIVIL 2.5 MG TABLET LISINOPRIL 2 Angiotensin Modulators PRINIVIL 20 MG TABLET LISINOPRIL 2 Angiotensin Modulators PRINIVIL 30 MG TABLET LISINOPRIL 2 Angiotensin Modulators PRINIVIL 40 MG TABLET LISINOPRIL 2 Angiotensin Modulators PRINIVIL 5 MG TABLET LISINOPRIL 2 Antidepressants, Other PRISTIQ 100 MG TABLET DESVENLAFAXINE SUCCINATE MONOHYDRATE 1 Antidepressants, Other PRISTIQ 50 MG TABLET DESVENLAFAXINE SUCCINATE MONOHYDRATE 1 Bronchodilators, Beta Agonist PROAIR DIGIHALER 90 MCG INHALER ALBUTEROL SULFATE 0.07 Bronchodilators, Beta Agonist PROAIR HFA 90 MCG INHALER ALBUTEROL 1.2 Bronchodilators, Beta Agonist PROAIR RESPICLICK INHALATION POWDER ALBUTEROL 0.07 Opioid Dependence Treatments PROBUPHINE 74.2 MG IMPLANT BUPRENORPHINE HCL 0.03 Calcium Channel Blockers PROCARDIA XL 30 MG TABLET NIFEDIPINE 1 Effective 01/04/21 Alphabetical by Brand Name (when applicable)

Calcium Channel Blockers PROCARDIA XL 60 MG TABLET NIFEDIPINE 2 Calcium Channel Blockers PROCARDIA XL 90 MG TABLET NIFEDIPINE 1 Stimulants & Related Agents PROCENTRA 5 MG/5 ML ORAL SOLUTION DEXTROAMPHETAMINE 60 Blood Glucose Meters PRODIGY AUTOCODE BLOOD GLUCOSE METER BLOOD GLUCOSE METER See footnote2 Blood Glucose Test Strips PRODIGY NO CODING BLOOD GLUCOSE TEST STRIPS BLOOD GLUCOSE TEST STRIPS 3.34 Blood Glucose Meters PRODIGY VOICE BLOOD GLUCOSE METER BLOOD GLUCOSE METER See footnote2 Bone Density Regulators PROLIA 60 MG/ML INJECTION SYRINGE DENOSUMAB 0.04 Thrombopoietics PROMACTA 12.5 MG SUSP. PACKET ELTROMBOPAG 6 Thrombopoietics PROMACTA 12.5 MG TABLET ELTROMBOPAG 4 Thrombopoietics PROMACTA 25 MG TABLET ELTROMBOPAG 3 Thrombopoietics PROMACTA 50 MG TABLET ELTROMBOPAG 2 Thrombopoietics PROMACTA 75 MG TABLET ELTROMBOPAG 2 Opioid Antitussive PROMETHAZINE VC-CODEINE SYRUP PROMETHAZINE/PHENYLEPH/CODEINE 30 Opioid Antitussive PROMETHAZINE-CODEINE SYRUP PROMETHAZINE HCL/CODEINE 30 Opioid Antitussive PROMETHAZINE-PE-CODEINE SYRUP PROMETHAZINE/PHENYLEPH/CODEINE 30 Progestational Agents PROMETRIUM 100 MG CAPSULE PROGESTERONE 1 Progestational Agents PROMETRIUM 200 MG CAPSULE PROGESTERONE 2 BPH Treatments PROSCAR 5 MG TABLET FINASTERIDE 1 Sedative Hypnotics PROSOM 1 MG TABLET ESTAZOLAM 1 Sedative Hypnotics PROSOM 2 MG TABLET ESTAZOLAM 1 Proton Pump Inhibitors PROTONIX 20 MG TABLET EC PANTOPRAZOLE 2 Proton Pump Inhibitors PROTONIX 40 MG SUSPENSION PACKET PANTOPRAZOLE 2 Proton Pump Inhibitors PROTONIX 40 MG TABLET EC PANTOPRAZOLE 2 Oncology, Other PROVENGE INFUSION BAG SIPULEUCEL-T 27 Bronchodilators, Beta Agonist PROVENTIL HFA 90 MCG INHALER ALBUTEROL 1.2 Progestational Agents PROVERA 10 MG TABLET MEDROXYPROGESTERONE ACETATE 1 Progestational Agents PROVERA 2.5 MG TABLET MEDROXYPROGESTERONE ACETATE 1 Progestational Agents PROVERA 5 MG TABLET MEDROXYPROGESTERONE ACETATE 1 Stimulants & Related Agents PROVIGIL 100 MG TABLET MODAFINIL 1 Stimulants & Related Agents PROVIGIL 200 MG TABLET MODAFINIL 2 Antidepressants, SSRIs PROZAC 10 MG PULVULE/CAPSULE/TABLET FLUOXETINE 6 Antidepressants, SSRIs PROZAC 20 MG PULVULE/CAPSULE/TABLET FLUOXETINE 4 Antidepressants, SSRIs PROZAC 20 MG/5 ML SOLUTION FLUOXETINE 20 Antidepressants, SSRIs PROZAC 40 MG PULVULE/CAPSULE FLUOXETINE 2 Antidepressants, SSRIs PROZAC WEEKLY 90 MG CAPSULE FLUOXETINE 0.14 Blood Glucose Test Strips PSS BLOOD GLUCOSE TEST STRIPS BLOOD GLUCOSE TEST STRIPS 3.34 Glucocorticoids, Inhaled PULMICORT 0.25 MG/2 ML RESPULE BUDESONIDE 4 Glucocorticoids, Inhaled PULMICORT 0.5 MG/2 ML RESPULE BUDESONIDE 4 Glucocorticoids, Inhaled PULMICORT 1 MG/2 ML RESPULE BUDESONIDE 2 Glucocorticoids, Inhaled PULMICORT 180 MCG FLEXHALER BUDESONIDE 0.07 Glucocorticoids, Inhaled PULMICORT 90 MCG FLEXHALER BUDESONIDE 0.04 Effective 01/04/21 Alphabetical by Brand Name (when applicable)

Mucolytics PULMOZYME 1 MG/ML AMPULE (2.5 ML/AMPULE) DORNASE ALFA 5 Angiotensin Modulators QBRELIS 1 MG/ML SOLUTION LISINOPRIL 40 Oncology Agents, Oral QINLOCK 50 MG TABLET RIPRETINIB 3 NSAIDs QMIIZ ODT 15 MG TABLET MELOXICAM 1 NSAIDs QMIIZ ODT 7.5 MG TABLET MELOXICAM 1 Intranasal Rhinitis Agents QNASL 80 MCG NASAL SPRAY BECLOMETHASONE 0.36 Intranasal Rhinitis Agents QNASL CHILDREN'S 40 MCG NASAL SPRAY BECLOMETHASONE 0.23 Hypoglycemics, Incretin Mimetics/Enhancers QTERN 10 MG-5 MG TABLET DAPAGLIFLOZIN AND SAXAGLIPTIN 1 Anticonvulsants QUDEXY XR 100 MG SPRINKLE CAPSULE TOPIRAMATE ER 2 Anticonvulsants QUDEXY XR 150 MG SPRINKLE CAPSULE TOPIRAMATE ER 2 Anticonvulsants QUDEXY XR 200 MG SPRINKLE CAPSULE TOPIRAMATE ER 2 Anticonvulsants QUDEXY XR 25 MG SPRINKLE CAPSULE TOPIRAMATE ER 4 Anticonvulsants QUDEXY XR 50 MG SPRINKLE CAPSULE TOPIRAMATE ER 4 Stimulants & Related Agents QUILLICHEW ER 20 MG TABLET METHYLPHENIDATE 1.5 Stimulants & Related Agents QUILLICHEW ER 30 MG TABLET METHYLPHENIDATE 2 Stimulants & Related Agents QUILLICHEW ER 40 MG TABLET METHYLPHENIDATE 1.5 Stimulants & Related Agents QUILLIVANT XR 25 MG/5 ML SUSPENSION METHYLPHENIDATE 12 Neuropathic Pain Agents QUTENZA 8% KIT CAPSAICIN 0.05 Glucocorticoids, Inhaled QVAR REDIHALER 40 MCG BECLOMETHASONE 0.36 Glucocorticoids, Inhaled QVAR REDIHALER 80 MCG BECLOMETHASONE 0.71 ALS Agents RADICAVA 30 MG/100 ML BAG EDARAVONE 100 Antianginal Agents RANEXA 1000 MG TABLET RANOLAZINE 2 Antianginal Agents RANEXA 500 MG TABLET RANOLAZINE 2 BPH Treatments RAPAFLO 4 MG CAPSULE SILODOSIN 1 BPH Treatments RAPAFLO 8 MG CAPSULE SILODOSIN 1 Methotrexates RASUVO 10 MG/0.2 ML AUTOINJECTOR METHOTREXATE 0.03 Methotrexates RASUVO 12.5 MG/0.25 ML AUTOINJECTOR METHOTREXATE 0.04 Methotrexates RASUVO 15 MG/0.3 ML AUTOINJECTOR METHOTREXATE 0.05 Methotrexates RASUVO 17.5 MG/0.35 ML AUTOINJECTOR METHOTREXATE 0.05 Methotrexates RASUVO 20 MG/0.4 ML AUTOINJECTOR METHOTREXATE 0.06 Methotrexates RASUVO 22.5 MG/0.45 ML AUTOINJECTOR METHOTREXATE 0.07 Methotrexates RASUVO 25 MG/0.5 ML AUTOINJECTOR METHOTREXATE 0.08 Methotrexates RASUVO 27.5 MG/0.55 ML AUTOINJECTOR METHOTREXATE 0.08 Methotrexates RASUVO 30 MG/0.6 ML AUTOINJECTOR METHOTREXATE 0.09 Methotrexates RASUVO 7.5 MG/0.15 ML AUTOINJECTOR METHOTREXATE 0.03 Urea Cycle Disorder Agents RAVICTI 1.1 GRAM/ML LIQUID GLYCEROL PHENYLBUTYRATE 18 Vitamin D Analogs RAYALDEE ER 30 MCG CAPSULE CALCIFEDIOL 2 Alzheimer's Agents RAZADYNE 12 MG TABLET GALANTAMINE 2 Alzheimer's Agents RAZADYNE 4 MG TABLET GALANTAMINE 2 Alzheimer's Agents RAZADYNE 4 MG/ML ORAL SOLUTION GALANTAMINE 6 Alzheimer's Agents RAZADYNE 8 MG TABLET GALANTAMINE 2 Effective 01/04/21 Alphabetical by Brand Name (when applicable)

Alzheimer's Agents RAZADYNE ER 16 MG CAPSULE GALANTAMINE ER 1 Alzheimer's Agents RAZADYNE ER 24 MG CAPSULE GALANTAMINE ER 1 Alzheimer's Agents RAZADYNE ER 8 MG CAPSULE GALANTAMINE ER 1 Multiple Sclerosis Agents REBIF 22 MCG/0.5 ML SYRINGE INTERFERON BETA-1A 0.22 Multiple Sclerosis Agents REBIF 44 MCG/0.5 ML SYRINGE INTERFERON BETA-1A 0.22 Multiple Sclerosis Agents REBIF REBIDOSE 22 MCG/0.5ML INTERFERON BETA-1A 0.22 Multiple Sclerosis Agents REBIF REBIDOSE 44 MCG/0.5ML INTERFERON BETA-1A 0.22 Bone Density Regulators RECLAST 5 ML/100 ML IV INJECTION ZOLEDRONIC ACID 3.4 Vaccines RECOMBIVAX HB 10 MCG/ML SYRINGE HEPATITIS B VIRUS VACCINE 1 Vaccines RECOMBIVAX HB 10 MCG/ML VIAL HEPATITIS B VIRUS VACCINE 1 Vaccines RECOMBIVAX HB 40 MCG/ML VIAL HEPATITIS B VIRUS VACCINE 1 Vaccines RECOMBIVAX HB 5 MCG/0.5 ML SYRINGE HEPATITIS B VIRUS VACCINE 0.5 Vaccines RECOMBIVAX HB 5 MCG/0.5 ML VIAL HEPATITIS B VIRUS VACCINE 0.5 Anorectal Nitrate Preparations RECTIV 0.4% OINTMENT NITROGLYCERIN RECTAL 1.2 NSAIDs RELAFEN 500 MG TABLET NABUMETONE 4 NSAIDs RELAFEN 750 MG TABLET NABUMETONE 2 Antivirals, Influenza RELENZA 5 MG DISKHALER ZANAMAVIR 4 Diabetic Supplies, Miscellaneous RELION LANCING DEVICE BLOOD GLUCOSE LANCING DEVICE 1 Blood Glucose Test Strips RELION ULTIMA BLOOD GLUCOSE TEST STRIPS BLOOD GLUCOSE TEST STRIPS 3.34 GI Motility, Chronic RELISTOR 12 MG/0.6 ML SYRINGE METHYLNALTREXONE BROMIDE 0.6 GI Motility, Chronic RELISTOR 150 MG TABLET METHYLNALTREXONE BROMIDE 3 GI Motility, Chronic RELISTOR 8 MG/0.4 ML SYRINGE METHYLNALTREXONE BROMIDE 0.4 Migraine Acute Treatment Agents RELPAX 20 MG TABLET ELETRIPTAN 0.3 Migraine Acute Treatment Agents RELPAX 40 MG TABLET ELETRIPTAN 0.3 Antidepressants, Other REMERON 15 MG SOLTAB MIRTAZAPINE 1 Antidepressants, Other REMERON 15 MG TABLET MIRTAZAPINE 1 Antidepressants, Other REMERON 30 MG SOLTAB MIRTAZAPINE 1 Antidepressants, Other REMERON 30 MG TABLET MIRTAZAPINE 1 Antidepressants, Other REMERON 45 MG SOLTAB MIRTAZAPINE 1 Antidepressants, Other REMERON 45 MG TABLET MIRTAZAPINE 1 Antidepressants, Other REMERON 7.5 MG TABLET MIRTAZAPINE 1 Phosphate Binders RENAGEL 400 MG TABLET SEVELAMER HCL 33 Phosphate Binders RENAGEL 800 MG TABLET SEVELAMER HCL 17 Phosphate Binders RENVELA 0.8 GM POWDER PACKET SEVELAMER CARBONATE 6 Phosphate Binders RENVELA 2.4 GM POWDER PACKET SEVELAMER CARBONATE 6 Phosphate Binders RENVELA 800 MG TABLET SEVELAMER CARBONATE 18 Lipotropics, Other REPATHA 140 MG/ML INJECTION SURECLICK AUTOINJECTOR EVOLOCUMAB 0.1 Lipotropics, Other REPATHA 140 MG/ML INJECTION SYRINGE EVOLOCUMAB 0.1 Lipotropics, Other REPATHA 420 MG/3.5 ML PUSHTRONEX SYSTEM EVOLOCUMAB 0.12 Insect Repellent for Skin Application REPEL FAMILY 10% INSECT REPELLENT DRY AEROSOL DIETHYLTOLUAMIDE 30 Insect Repellent for Skin Application REPEL FAMILY 15% INSECT REPELLENT SPRAY DIETHYLTOLUAMIDE 36 Effective 01/04/21 Alphabetical by Brand Name (when applicable)

Insect Repellent for Skin Application REPEL SPORTSMEN 25% SPRAY DIETHYLTOLUAMIDE 31 Insect Repellent for Skin Application REPEL SPORTSMEN MAX 40% LOTION DIETHYLTOLUAMIDE 30 Insect Repellent for Skin Application REPEL SPORTSMEN MAX 40% PEN-SIZE PUMP SPRAY DIETHYLTOLUAMIDE 30 Insect Repellent for Skin Application REPEL SPORTSMEN MAX 40% PUMP SPRAY DIETHYLTOLUAMIDE 31 Insect Repellent for Skin Application REPEL SPORTSMEN MAX 40% PUMP SPRAY DIETHYLTOLUAMIDE 30 Insect Repellent for Skin Application REPEL TICK DEFENSE 15% AEROSOL PICARIDIN 31 Analgesics, Opioid Short-Acting REPREXAIN 10-200 MG TABLET HYDROCODONE/IBUPROFEN 5 Analgesics, Opioid Short-Acting REPREXAIN 2.5-200 MG TABLET HYDROCODONE/IBUPROFEN 5 Analgesics, Opioid Short-Acting REPREXAIN 5-200 MG TABLET HYDROCODONE/IBUPROFEN 5 Analgesics, Opioid Short-Acting REPREXAIN 7.5-200 MG TABLET HYDROCODONE/IBUPROFEN 5 Antiparkinson's Agents REQUIP 0.25 MG TABLET ROPINIROLE 4 Antiparkinson's Agents REQUIP 0.5 MG TABLET ROPINIROLE 4 Antiparkinson's Agents REQUIP 1 MG TABLET ROPINIROLE 3 Antiparkinson's Agents REQUIP 2 MG TBALET ROPINIROLE 3 Antiparkinson's Agents REQUIP 3 MG TABLET ROPINIROLE 6 Antiparkinson's Agents REQUIP 4 MG TABLET ROPINIROLE 6 Antiparkinson's Agents REQUIP 5 MG TABLET ROPINIROLE 4 Antiparkinson's Agents REQUIP XL 12 MG TABLET ROPINIROLE 2 Antiparkinson's Agents REQUIP XL 2 MG TABLET ROPINIROLE 1 Antiparkinson's Agents REQUIP XL 4 MG TABLET ROPINIROLE 1 Antiparkinson's Agents REQUIP XL 6 MG TABLET ROPINIROLE 1 Antiparkinson's Agents REQUIP XL 8 MG TABLET ROPINIROLE 2 Ophthalmics, Immunomodulators RESTASIS 0.05% EYE DROPS CYCLOSPORINE 2 Ophthalmics, Immunomodulators RESTASIS MULTIDOSE 0.05% EYE DROP CYCLOSPORINE 0.19 Sedative Hypnotics RESTORIL 15 MG CAPSULE TEMAZEPAM 1 Sedative Hypnotics RESTORIL 22.5 MG CAPSULE TEMAZEPAM 1 Sedative Hypnotics RESTORIL 30 MG CAPSULE TEMAZEPAM 1 Sedative Hypnotics RESTORIL 7.5 MG CAPSULE TEMAZEPAM 1 Oncology Agents, Oral RETEVMO 40 MG CAPSULE SELPERCATINIB 2 Oncology Agents, Oral RETEVMO 80 MG CAPSULE SELPERCATINIB 4 Ophthalmics, Anti-Inflammatories RETISERT 0.59 MG INTRAOCULAR IMPLANT FLUOCINOLONE INTRAOCULAR 0.04 HIV/AIDS Antiretrovirals RETROVIR 10 MG/ML ORAL SOLUTION ZIDOVUDINE 60 HIV/AIDS Antiretrovirals RETROVIR 100 MG CAPSULE ZIDOVUDINE 6 HIV/AIDS Antiretrovirals RETROVIR 300 MG TABLET ZIDOVUDINE 2 PAH Agents, Oral & Inhaled REVATIO 10 MG/ML SUSPENSION SILDENAFIL 6 PAH Agents, Oral & Inhaled REVATIO 20 MG SILDENAFIL 3 Thalidomides & Derivatives REVLIMID 10 MG TABLET LENALIDOMIDE 1 Thalidomides & Derivatives REVLIMID 15 MG TABLET LENALIDOMIDE 1 Thalidomides & Derivatives REVLIMID 2.5 MG TABLET LENALIDOMIDE 1 Thalidomides & Derivatives REVLIMID 20 MG TABLET LENALIDOMIDE 1 Thalidomides & Derivatives REVLIMID 25 MG TABLET LENALIDOMIDE 1 Effective 01/04/21 Alphabetical by Brand Name (when applicable)

Thalidomides & Derivatives REVLIMID 5 MG TABLET LENALIDOMIDE 1 Antipsychotics, Atypical REXULTI 0.25 MG TABLET BREXPIPRAZOLE 2 Antipsychotics, Atypical REXULTI 0.5 MG TABLET BREXPIPRAZOLE 2 Antipsychotics, Atypical REXULTI 1 MG TABLET BREXPIPRAZOLE 2 Antipsychotics, Atypical REXULTI 2 MG TABLET BREXPIPRAZOLE 1 Antipsychotics, Atypical REXULTI 3 MG TABLET BREXPIPRAZOLE 1 Antipsychotics, Atypical REXULTI 4 MG TABLET BREXPIPRAZOLE 1 HIV/AIDS Antiretrovirals REYATAZ 100 MG CAPSULE ATAZANAVIR 1 HIV/AIDS Antiretrovirals REYATAZ 150 MG CAPSULE ATAZANAVIR 1 HIV/AIDS Antiretrovirals REYATAZ 200 MG CAPSULE ATAZANAVIR 2 HIV/AIDS Antiretrovirals REYATAZ 300 MG CAPSULE ATAZANAVIR 1 HIV/AIDS Antiretrovirals REYATAZ 50 MG POWDER PACKET ATAZANAVIR 6 Migraine Acute Treatment Agents REYVOW 100 MG TABLET LASMIDITAN 0.27 Migraine Acute Treatment Agents REYVOW 50 MG TABLET LASMIDITAN 0.14 Intranasal Rhinitis Agents RHINOCORT AQUA 32 MCG NASAL SPRAY (RX) BUDESONIDE 0.58 Insect Repellent NOT for Skin Application RID HOME LICE CONTROL SPRAY PERMETHRIN 0.5% 29 ALS Agents RILUTEK 50 MG TABLET RILUZOLE 2 Interstitial Cystitis Agents RIMSO-50 SOLUTION DIMETHYL SULFOXIDE 7.15 Cytokine & CAM Antagonists RINVOQ ER 15 MG TABLET UPADACITINIB 1 Hypoglycemics, Metformins RIOMET 500 MG/5 ML SOLUTION METFORMIN 25 Hypoglycemics, Metformins RIOMET ER 500 MG/5 ML SUSPENSION METFORMIN ER 20 Antipsychotics, Atypical RISPERDAL 0.25 MG TABLET RISPERIDONE 2 Antipsychotics, Atypical RISPERDAL 0.5 MG TABLET RISPERIDONE 2 Antipsychotics, Atypical RISPERDAL 1 MG TABLET RISPERIDONE 2 Antipsychotics, Atypical RISPERDAL 1 MG/ML SOLUTION RISPERIDONE 8 Antipsychotics, Atypical RISPERDAL 2 MG TABLET RISPERIDONE 2 Antipsychotics, Atypical RISPERDAL 3 MG TABLET RISPERIDONE 2 Antipsychotics, Atypical RISPERDAL 4 MG TABLET RISPERIDONE 2 Antipsychotics, Atypical RISPERDAL CONSTA 12.5 MG SYRINGE RISPERIDONE 0.07 Antipsychotics, Atypical RISPERDAL CONSTA 25 MG SYRINGE RISPERIDONE 0.07 Antipsychotics, Atypical RISPERDAL CONSTA 37.5 MG SYRINGE RISPERIDONE 0.07 Antipsychotics, Atypical RISPERDAL CONSTA 50 MG SYRINGE RISPERIDONE 0.07 Antipsychotics, Atypical RISPERDAL M-TAB 0.5 MG ODT RISPERIDONE 2 Antipsychotics, Atypical RISPERDAL M-TAB 1 MG ODT RISPERIDONE 2 Antipsychotics, Atypical RISPERDAL M-TAB 2 MG ODT RISPERIDONE 2 Antipsychotics, Atypical RISPERDAL M-TAB 3 MG ODT RISPERIDONE 2 Antipsychotics, Atypical RISPERDAL M-TAB 4 MG ODT RISPERIDONE 2 Stimulants & Related Agents RITALIN 10 MG TABLET METHYLPHENIDATE 3 Stimulants & Related Agents RITALIN 20 MG TABLET METHYLPHENIDATE 3 Stimulants & Related Agents RITALIN 5 MG TABLET METHYLPHENIDATE 3 Stimulants & Related Agents RITALIN LA 10 MG CAPSULE METHYLPHENIDATE 1 Effective 01/04/21 Alphabetical by Brand Name (when applicable)

Stimulants & Related Agents RITALIN LA 20 MG CAPSULE METHYLPHENIDATE 1 Stimulants & Related Agents RITALIN LA 30 MG CAPSULE METHYLPHENIDATE 1 Stimulants & Related Agents RITALIN LA 40 MG CAPSULE METHYLPHENIDATE 1 Stimulants & Related Agents RITALIN LA 60 MG CAPSULE METHYLPHENIDATE 1 Stimulants & Related Agents RITALIN SR 20 MG TABLET METHYLPHENIDATE 3 Insect Repellent NOT for Skin Application RITE AID LICE BEDDING SPRAY PERMETHRIN 0.5% 29 Analgesics, Opioid Short-Acting RMS 10 MG SUPPOSITORY MORPHINE SULFATE 6 Analgesics, Opioid Short-Acting RMS 20 MG SUPPOSITORY MORPHINE SULFATE 6 Analgesics, Opioid Short-Acting RMS 30 MG SUPPOSITORY MORPHINE SULFATE 4 Analgesics, Opioid Short-Acting RMS 5 MG SUPPOSITORY MORPHINE SULFATE 10 Opioid Antitussive ROBAFEN AC ORAL SOLUTION CODEINE PHOSPHATE/GUAIFENESIN 60 Skeletal Muscle Relaxants ROBAXIN 500 MG TABLET METHOCARBAMOL 16 Skeletal Muscle Relaxants ROBAXIN-750 TABLET METHOCARBAMOL 10 Antibiotics, Injectable ROCEPHIN 1 GM PIGGYBACK CEFTRIAXONE 200 Antibiotics, Injectable ROCEPHIN 1 GM VIAL CEFTRIAXONE 2 Antibiotics, Injectable ROCEPHIN 10 GM VIAL CEFTRIAXONE 0.4 Antibiotics, Injectable ROCEPHIN 2 GM PIGGYBACK CEFTRIAXONE 100 Antibiotics, Injectable ROCEPHIN 2 GM VIAL CEFTRIAXONE 2 Antibiotics, Injectable ROCEPHIN 250 MG VIAL CEFTRIAXONE 1 Antibiotics, Injectable ROCEPHIN 500 MG VIAL CEFTRIAXONE 2 Analgesics, Opioid Short-Acting ROXICET 5 MG/325 MG TABLET OXYCODONE/ACETAMINOPHEN 6 Analgesics, Opioid Short-Acting ROXICET 5 MG-325 MG/5 ML ORAL SOLUTION OXYCODONE/ACETAMINOPHEN 30 Analgesics, Opioid Short-Acting ROXICODONE 10 MG TABLET OXYCODONE 4 Analgesics, Opioid Short-Acting ROXICODONE 15 MG TABLET OXYCODONE 4 Analgesics, Opioid Short-Acting ROXICODONE 20 MG TABLET OXYCODONE 4 Analgesics, Opioid Short-Acting ROXICODONE 30 MG TABLET OXYCODONE 4 Analgesics, Opioid Short-Acting ROXICODONE 5 MG TABLET OXYCODONE 6 Analgesics, Opioid Short-Acting ROXYBOND 15 MG TABLET OXYCODONE HYDROCHLORIDE 4 Analgesics, Opioid Short-Acting ROXYBOND 30 MG TABLET OXYCODONE HYDROCHLORIDE 4 Analgesics, Opioid Short-Acting ROXYBOND 5 MG TABLET OXYCODONE HYDROCHLORIDE 6 Sedative Hypnotics ROZEREM 8 MG TABLET RAMELTEON 1 Oncology Agents, Oral ROZLYTREK 100 MG CAPSULE ENTRECTINIB 1 Oncology Agents, Oral ROZLYTREK 200 MG CAPSULE ENTRECTINIB 3 Oncology Agents, Oral RUBRACA 200 MG TABLET RUCAPARIB CAMSYLATE 4 Oncology Agents, Oral RUBRACA 250 MG TABLET RUCAPARIB 4 Oncology Agents, Oral RUBRACA 300 MG TABLET RUCAPARIB CAMSYLATE 4 Hereditary Angioedema Treatments RUCONEST 2100 UNIT VIAL C1 ESTERASE INHIBITOR 4 HIV/AIDS Antiretrovirals RUKOBIA ER 600 MG TABLET FOSTEMSAVIR 2 Potassium Channel Blocker RUZURGI 10 MG TABLET AMIFAMPRIDINE 10 Hypoglycemics, Incretin Mimetics/Enhancers RYBELSUS 14 MG TABLET SEMAGLUTIDE 1 Hypoglycemics, Incretin Mimetics/Enhancers RYBELSUS 3 MG TABLET SEMAGLUTIDE 1 Effective 01/04/21 Alphabetical by Brand Name (when applicable)

Hypoglycemics, Incretin Mimetics/Enhancers RYBELSUS 7 MG TABLET SEMAGLUTIDE 1 Analgesics, Opioid Short-Acting RYBIX 50 MG ODT TRAMADOL 8 Oncology Agents, Oral RYDAPT 25 MG CAPSULE MIDOSTAURIN 8 Opioid Antitussive RYDEX LIQUID BROMPHENIRA/PSEUDOEPHED/CODEINE 90 Antiparkinson's Agents RYTARY 23.75/95 MG ER CAPSULE CARBIDOPA/LEVODOPA 12 Antiparkinson's Agents RYTARY 36.25/145 MG ER CAPSULE CARBIDOPA/LEVODOPA 9 Antiparkinson's Agents RYTARY 48.75/195 MG ER CAPSULE CARBIDOPA/LEVODOPA 12 Antiparkinson's Agents RYTARY 61.25/245 MG ER CAPSULE CARBIDOPA/LEVODOPA 10 Analgesics, Opioid Long-Acting RYZOLT ER 100 MG TABLET TRAMADOL ER 1 Analgesics, Opioid Long-Acting RYZOLT ER 200 MG TABLET TRAMADOL ER 1 Analgesics, Opioid Long-Acting RYZOLT ER 300 MG TABLET TRAMADOL ER 1 Anticonvulsants SABRIL 500 MG POWDER PACKET VIGABATRIN 6 Anticonvulsants SABRIL 500 MG TABLET VIGABATRIN 6 Analgesics, Salicylates SALSALATE 500 MG TABLET SALSALATE 4 Analgesics, Salicylates SALSALATE 750 MG TABLET SALSALATE 4 Diuretics, Vasopressin Receptor Antagonists SAMSCA 15 MG TABLET TOLVAPTAN 1 Diuretics, Vasopressin Receptor Antagonists SAMSCA 30 MG TABLET TOLVAPTAN 2 Bladder Relaxant Preparations SANCTURA 20 MG TABLET TROSPIUM 2 Bladder Relaxant Preparations SANCTURA XR 60MG CAPSULE TROSPIUM 1 Antiemetics/Antivertigo Agents SANCUSO 3.1 MG/24 HR PATCH GRANISETRON 0.15 Somatostatic Agents SANDOSTATIN LAR 10 MG KIT OCTREOTIDE INTRAMUSCULAR 0.04 Somatostatic Agents SANDOSTATIN LAR 10MG DEPOT KIT OCTREOTIDE ACETATE 0.04 Somatostatic Agents SANDOSTATIN LAR 20MG DEPOT KIT OCTREOTIDE ACETATE 0.08 Somatostatic Agents SANDOSTATIN LAR 30MG DEPOT KIT OCTREOTIDE ACETATE 0.04 Antipsychotics, Atypical SAPHRIS 10 MG SUBLINGUAL TABLET ASENAPINE 2 Antipsychotics, Atypical SAPHRIS 5 MG SUBLINGUAL TABLET ASENAPINE 2 Antidepressants, SSRIs SARAFEM 10 MG PULVULE FLUOXETINE 3 Antidepressants, SSRIs SARAFEM 20 MG PULVULE FLUOXETINE 4 Anticoagulants, Oral SAVAYSA 15 MG TABLET EDOXABAN 1 Anticoagulants, Oral SAVAYSA 30 MG TABLET EDOXABAN 1 Anticoagulants, Oral SAVAYSA 60 MG TABLET EDOXABAN 1 Neuropathic Pain Agents SAVELLA 100 MG TABLET MILNACIPRAN 2 Neuropathic Pain Agents SAVELLA 12.5 MG TABLET MILNACIPRAN 2 Neuropathic Pain Agents SAVELLA 25 MG TABLET MILNACIPRAN 2 Neuropathic Pain Agents SAVELLA 50 MG TABLET MILNACIPRAN 2 Insect Repellent for Skin Application SAWYER PREMIUM INSECT REPELLENT 20% PUMP SPRAY PICARIDIN 30 Sedative Hypnotics SECONAL SODIUM 100 MG CAPSULE SECOBARBITAL SODIUM 1 Antipsychotics SECUADO 3.8 MG/24 HR PATCH ASENAPINE 1 Antipsychotics SECUADO 5.7 MG/24 HR PATCH ASENAPINE 1 Antipsychotics SECUADO 7.6 MG/24 HR PATCH ASENAPINE 1 Hypoglycemics, SGLT2 Inhibitors SEGLUROMET 2.5-1000 MG TABLET ERTUGLIFLOZIN AND METFORMIN 2 Effective 01/04/21 Alphabetical by Brand Name (when applicable)

Hypoglycemics, SGLT2 Inhibitors SEGLUROMET 2.5-500 MG TABLET ERTUGLIFLOZIN AND METFORMIN 2 Hypoglycemics, SGLT2 Inhibitors SEGLUROMET 7.5-1000 MG TABLET ERTUGLIFLOZIN AND METFORMIN 2 Hypoglycemics, SGLT2 Inhibitors SEGLUROMET 7.5-500 MG TABLET ERTUGLIFLOZIN AND METFORMIN 2 HIV/AIDS Antiretrovirals SELZENTRY 150 MG TABLET MARAVIROC 2 HIV/AIDS Antiretrovirals SELZENTRY 20 MG/ML SOLUTION MARAVIROC 60 HIV/AIDS Antiretrovirals SELZENTRY 25 MG TABLET MARAVIROC 4 HIV/AIDS Antiretrovirals SELZENTRY 300 MG TABLET MARAVIROC 4 HIV/AIDS Antiretrovirals SELZENTRY 75 MG TABLET MARAVIROC 2 Antihistamines, Minimally Sedating SEMPREX-D CAPSULE ACRIVASTINE/PSEUDOEPHEDRINE 4 Calcimimetics SENSIPAR 30 MG TABLET CINACALCET 4 Calcimimetics SENSIPAR 60 MG TABLET CINACALCET 4 Calcimimetics SENSIPAR 90 MG TABLET CINACALCET 4 Anxiolytics SERAX 10 MG CAPSULE OXAZEPAM 8 Anxiolytics SERAX 15 MG CAPSULE OXAZEPAM 4 Anxiolytics SERAX 30 MG CAPSULE OXAZEPAM 4 Bronchodilators, Beta Agonist SEREVENT DISKUS 50 MCG SALMETEROL 2 Antipsychotics, Atypical SEROQUEL 100 MG TABLET QUETIAPINE 3 Antipsychotics, Atypical SEROQUEL 200 MG TABLET QUETIAPINE 4 Antipsychotics, Atypical SEROQUEL 25 MG TABLET QUETIAPINE 6 Antipsychotics, Atypical SEROQUEL 300 MG TABLET QUETIAPINE 2 Antipsychotics, Atypical SEROQUEL 400 MG TABLET QUETIAPINE 2 Antipsychotics, Atypical SEROQUEL 50 MG TABLET QUETIAPINE 3 Antipsychotics, Atypical SEROQUEL XR 150 MG TABLET QUETIAPINE 1 Antipsychotics, Atypical SEROQUEL XR 200 MG TABLET QUETIAPINE 1 Antipsychotics, Atypical SEROQUEL XR 300 MG TABLET QUETIAPINE 2 Antipsychotics, Atypical SEROQUEL XR 400 MG TABLET QUETIAPINE 2 Antipsychotics, Atypical SEROQUEL XR 50 MG TABLET QUETIAPINE 2 Growth Hormones SEROSTIM 6 MG VIAL SOMATROPIN 2 Ulcerative Colitis Agents SF ROWASA 4 GRAM/60 ML ENEMA MESALAMINE 60 Vaccines SHINGRIX VIAL KIT ZOSTER VACCINE RECOMBINANT, ADJUVANTED 1 Somatostatic Agents SIGNIFOR 0.3 MG/ML AMPULE PASIREOTIDE DIASPARTATE 2 Somatostatic Agents SIGNIFOR 0.6 MG/ML AMPULE PASIREOTIDE DIASPARTATE 2 Somatostatic Agents SIGNIFOR 0.9 MG/ML AMPULE PASIREOTIDE DIASPARTATE 2 Somatostatic Agents SIGNIFOR LAR 20 MG KIT PASIREOTIDE PAMOATE 0.04 Somatostatic Agents SIGNIFOR LAR 20 MG VIAL PASIREOTIDE PAMOATE 0.04 Somatostatic Agents SIGNIFOR LAR 40 MG KIT PASIREOTIDE PAMOATE 0.04 Somatostatic Agents SIGNIFOR LAR 40 MG VIAL PASIREOTIDE PAMOATE 0.04 Somatostatic Agents SIGNIFOR LAR 60 MG KIT PASIREOTIDE PAMOATE 0.04 Somatostatic Agents SIGNIFOR LAR 60 MG VIAL PASIREOTIDE PAMOATE 0.04 Sedative Hypnotics SILENOR 3 MG TABLET DOXEPIN 1 Sedative Hypnotics SILENOR 6 MG TABLET DOXEPIN 1 Effective 01/04/21 Alphabetical by Brand Name (when applicable)

Cytokine & CAM Antagonists SILIQ 210 MG/1.5 ML SYRINGE BRODALUMAB 0.15 Cytokine & CAM Antagonists SIMPONI 100 MG/ML PEN INJECTOR GOLIMUMAB 0.15 Cytokine & CAM Antagonists SIMPONI 100 MG/ML SYRINGE GOLIMUMAB 0.15 Cytokine & CAM Antagonists SIMPONI 50 MG/0.5 ML PEN INJECTOR GOLIMUMAB 0.02 Cytokine & CAM Antagonists SIMPONI 50 MG/0.5 ML SYRINGE GOLIMUMAB 0.02 Immunosuppresives SIMULECT 10 MG VIAL BASILIXIMAB 1 Immunosuppresives SIMULECT 20 MG VIAL BASILIXIMAB 1 Antiparkinson's Agents SINEMET 10/100 MG TABLET CARBIDOPA/LEVODOPA 8 Antiparkinson's Agents SINEMET 25/100 MG TABLET CARBIDOPA/LEVODOPA 8 Antiparkinson's Agents SINEMET 25/250 MG TABLET CARBIDOPA/LEVODOPA 8 Antiparkinson's Agents SINEMET CR 25/100 MG TABLET CARBIDOPA/LEVODOPA 8 Antiparkinson's Agents SINEMET CR 50/200 MG TABLET CARBIDOPA/LEVODOPA 8 Leukotriene Modifiers SINGULAIR 10 MG TABLET MONTELUKAST 1 Leukotriene Modifiers SINGULAIR 4 MG GRANULES MONTELUKAST 1 Leukotriene Modifiers SINGULAIR 4 MG TABLET CHEW MONTELUKAST 1 Leukotriene Modifiers SINGULAIR 5 MG TABLET CHEW MONTELUKAST 1 Antibiotics, Other SIRTURO 100 MG TABLET BEDAQUILINE 4 Antivirals, Herpes SITAVIG 50 MG BUCCAL TABLET ACYCLOVIR DR 1 Antibiotics, Other SIVEXTRO 200 MG TABLET TEDIZOLID PHOSPHATE 1 Antibiotics, Injectable SIVEXTRO 200 MG VIAL TEDIZOLID PHOSPHATE 1 Skeletal Muscle Relaxants SKELAXIN 400 MG TABLET METAXOLONE 8 Skeletal Muscle Relaxants SKELAXIN 800 MG TABLET METAXALONE 4 Contraceptives, Other SKYLA INTRAUTERINE SYSTEM LEVONORGESTREL INTRAUTERINE see footnote4 Cytokine & CAM Antagonists SKYRIZI 150 MG DOSE KIT-2 SYRINGE RISANKIZUMAB-RZAA 0.04 Intra-Articular Hyaluronates SODIUM HYALURONATE 1% SYRINGE HYALURONATE SODIUM 0.72 Hypoglycemics, Insulin and Related Agents SOLIQUA 100 UNIT-33 MCG/ML PEN INSULIN GLARGINE/LIXISENATIDE 0.6 Complement Inhibitors SOLIRIS 300 MG/30 ML VIAL ECULIZUMAB 12.86 Tetracyclines SOLODYN ER 105 MG TABLET MINOCYCLINE HYDROCHLORIDE 1 Tetracyclines SOLODYN ER 115 MG TABLET MINOCYCLINE HYDROCHLORIDE 1 Tetracyclines SOLODYN ER 135 MG TABLET MINOCYCLINE HYDROCHLORIDE 1 Tetracyclines SOLODYN ER 45 MG TABLET MINOCYCLINE HYDROCHLORIDE 1 Tetracyclines SOLODYN ER 55 MG TABLET MINOCYCLINE HYDROCHLORIDE 1 Tetracyclines SOLODYN ER 65 MG TABLET MINOCYCLINE HYDROCHLORIDE 1 Tetracyclines SOLODYN ER 80 MG TABLET MINOCYCLINE HYDROCHLORIDE 1 Tetracyclines SOLODYN ER 90 MG TABLET MINOCYCLINE HYDROCHLORIDE 1 Oncology Agents, Breast Cancer SOLTAMOX 10 MG/5 ML SOLUTION TAMOXIFEN 20 Skeletal Muscle Relaxants SOMA 250 MG TABLET CARISOPRODOL 4 Skeletal Muscle Relaxants SOMA 350 MG TABLET CARISOPRODOL 4 Skeletal Muscle Relaxants SOMA COMPOUND CARISOPRODOL/ASPIRIN 4 Analgesics, Opioids SOMA COMPOUND WITH CODEINE CARISOPRODOL/ASPIRIN/CODEINE 4 Somatostatic Agents SOMATULINE DEPOT 120 MG/0.5 ML LANREOTIDE 0.02 Effective 01/04/21 Alphabetical by Brand Name (when applicable)

Somatostatic Agents SOMATULINE DEPOT 60 MG/0.2 ML INJECTION LANREOTIDE 0.01 Somatostatic Agents SOMATULINE DEPOT 90 MG/0.3 ML INJECTION LANREOTIDE 0.02 Growth Hormone Receptor Antagonists SOMAVERT 10 MG VIAL PEGVISOMANT 1 Growth Hormone Receptor Antagonists SOMAVERT 15 MG VIAL PEGVISOMANT 1 Growth Hormone Receptor Antagonists SOMAVERT 20 MG VIAL PEGVISOMANT 2 Growth Hormone Receptor Antagonists SOMAVERT 25 MG VIAL PEGVISOMANT 1 Growth Hormone Receptor Antagonists SOMAVERT 30 MG VIAL PEGVISOMANT 1 Sedative Hypnotics SONATA 10 MG CAPSULE ZALEPLON 2 Sedative Hypnotics SONATA 5 MG CAPSULE ZALEPLON 1 Antipsoriatics, Oral SORIATANE 10 MG CAPSULE ACITRETIN 4 Antipsoriatics, Oral SORIATANE 17.5 MG CAPSULE ACITRETIN 2 Antipsoriatics, Oral SORIATANE 25 MG CAPSULE ACITRETIN 2 Hepatitis C Agents SOVALDI 150 MG PELLET PACKET SOFOSBUVIR 1 Hepatitis C Agents SOVALDI 200 MG PELLET PACKET SOFOSBUVIR 2 Hepatitis C Agents SOVALDI 200 MG TABLET SOFOSBUVIR 2 Hepatitis C Agents SOVALDI 400 MG TABLET SOFOSBUVIR 1 COPD Agents SPIRIVA 1.25 MCG RESPIMAT #60 TIOTROPIUM 0.14 COPD Agents SPIRIVA 18 MCG HANDIHALER #30 TIOTROPIUM 1 COPD Agents SPIRIVA 18 MCG HANDIHALER #5 TIOTROPIUM 1 COPD Agents SPIRIVA 18 MCG HANDIHALER #90 TIOTROPIUM 1 COPD Agents SPIRIVA 2.5 MCG RESPIMAT #60 TIOTROPIUM 0.14 Antifungals, Oral SPORANOX 10 MG/ML SOLUTION ITRACONAZOLE 20 Antifungals, Oral SPORANOX 100 MG CAPSULE ITRACONAZOLE 4 Antidepressants, Other SPRAVATO 56 MG DOSE PACK ESKETAMINE 0.58 Antidepressants, Other SPRAVATO 84 MG DOSE PACK ESKETAMINE 0.86 Anticonvulsants SPRITAM 1000 MG TABLET LEVETIRACETAM FOR SUSPENSION 2 Anticonvulsants SPRITAM 250 MG TABLET LEVETIRACETAM FOR SUSPENSION 6 Anticonvulsants SPRITAM 500 MG TABLET LEVETIRACETAM FOR SUSPENSION 6 Anticonvulsants SPRITAM 750 MG TABLET LEVETIRACETAM FOR SUSPENSION 4 NSAIDs SPRIX 15.75 MG NASAL SPRAY KETOROLAC TROMETHAMINE 1 Oncology Agents, Oral SPRYCEL 100 MG TABLET DASATINIB 1 Oncology Agents, Oral SPRYCEL 140 MG TABLET DASATINIB 1 Oncology Agents, Oral SPRYCEL 20 MG TABLET DASATINIB 1 Oncology Agents, Oral SPRYCEL 50 MG TABLET DASATINIB 1 Oncology Agents, Oral SPRYCEL 70 MG TABLET DASATINIB 1 Oncology Agents, Oral SPRYCEL 80 MG TABLET DASATINIB 1 Analgesics, Opioid Short-Acting STADOL NS 10 MG/ML SPRAY BUTORPHANOL TARTRATE 0.17 Antiparkinson's Agents STALEVO 100 MG TABLET CARBIDOPA/LEVODOPA/ENTACAPONE 8 Antiparkinson's Agents STALEVO 125 MG TABLET CARBIDOPA/LEVODOPA/ENTACAPONE 8 Antiparkinson's Agents STALEVO 150 MG TABLET CARBIDOPA/LEVODOPA/ENTACAPONE 8 Antiparkinson's Agents STALEVO 200 MG TABLET CARBIDOPA/LEVODOPA/ENTACAPONE 6 Effective 01/04/21 Alphabetical by Brand Name (when applicable)

Antiparkinson's Agents STALEVO 50 MG TABLET CARBIDOPA/LEVODOPA/ENTACAPONE 8 Antiparkinson's Agents STALEVO 75 MG TABLET CARBIDOPA/LEVODOPA/ENTACAPONE 8 Vaccines STAMARIL VIAL YELLOW FEVER VACCINE 1 Hypoglycemics, Meglitinides STARLIX 120 MG TABLET NATEGLINIDE 3 Hypoglycemics, Meglitinides STARLIX 60 MG TABLET NATEGLINIDE 3 Hypoglycemics, SGLT2 Inhibitors STEGLATRO 15 MG TABLET ERTUGLIFLOZIN 1 Hypoglycemics, SGLT2 Inhibitors STEGLATRO 5 MG TABLET ERTUGLIFLOZIN 1 Hypoglycemics, Incretin Mimetics/Enhancers STEGLUJAN 15-100 MG TABLET ERTUGLIFLOZIN AND SITAGLIPTIN 1 Hypoglycemics, Incretin Mimetics/Enhancers STEGLUJAN 5-100 MG TABLET ERTUGLIFLOZIN AND SITAGLIPTIN 1 Cytokine & CAM Antagonists STELARA 130 MG/26 ML VIAL USTEKINUMAB 1.86 Cytokine & CAM Antagonists STELARA 45 MG/0.5 ML SYRINGE USTEKINUMAB 0.02 Cytokine & CAM Antagonists STELARA 45 MG/0.5 ML VIAL USTEKINUMAB 0.02 Cytokine & CAM Antagonists STELARA 90 MG/ML SYRINGE USTEKINUMAB 0.04 COPD Agents STIOLTO RESPIMAT TIOTROPIUM/OLODATEROL 0.14 Oncology Agents, Oral STIVARGA 40 MG TABLET REGORAFENIB 4 Stimulants & Related Agents STRATTERA 10 MG CAPSULE ATOMOXETINE 2 Stimulants & Related Agents STRATTERA 100 MG CAPSULE ATOMOXETINE 1 Stimulants & Related Agents STRATTERA 18 MG CAPSULE ATOMOXETINE 4 Stimulants & Related Agents STRATTERA 25 MG CAPSULE ATOMOXETINE 2 Stimulants & Related Agents STRATTERA 40 MG CAPSULE ATOMOXETINE 2 Stimulants & Related Agents STRATTERA 60 MG CAPSULE ATOMOXETINE 1 Stimulants & Related Agents STRATTERA 80 MG CAPSULE ATOMOXETINE 1 Androgenic Agents STRIANT 30 MG MUCOADHESIVE TESTOSTERONE 2 HIV/AIDS Antiretrovirals STRIBILD TABLET ELVITEGRAVIR/COBI/EMTRICITAPINE/TENOFOVIR DF 1 Bronchodilators, Beta Agonist STRIVERDI RESPIMAT #60 OLODATEROL 0.14 Opioid Dependence Treatments SUBLOCADE 100 MG/0.5 ML BUPRENORPHINE EXTENDED-RELEASE 0.02 Opioid Dependence Treatments SUBLOCADE 300 MG/1.5 ML BUPRENORPHINE EXTENDED-RELEASE 0.06 Opioid Dependence Treatments SUBOXONE 12 MG/3 MG SL FILM BUPRENORPHINE/NALOXONE 2 Opioid Dependence Treatments SUBOXONE 2 MG/0.5 MG SL FILM BUPRENORPHINE/NALOXONE 3 Opioid Dependence Treatments SUBOXONE 2 MG/0.5 MG SL TABLET BUPRENORPHINE/NALOXONE 3 Opioid Dependence Treatments SUBOXONE 4 MG/1 MG SL FILM BUPRENORPHINE/NALOXONE 2 Opioid Dependence Treatments SUBOXONE 8 MG/2 MG SL FILM BUPRENORPHINE/NALOXONE 3 Opioid Dependence Treatments SUBOXONE 8 MG/2 MG SL TABLET BUPRENORPHINE/NALOXONE 3 Analgesics, Opioid Short-Acting SUBSYS 100 MCG SUBLINGUAL SPRAY FENTANYL SUBLINQUAL 4 Analgesics, Opioid Short-Acting SUBSYS 1200 MCG SUBLINGUAL SPRAY FENTANYL SUBLINQUAL 4 Analgesics, Opioid Short-Acting SUBSYS 1600 MCG SUBLINGUAL SPRAY FENTANYL SUBLINQUAL 4 Analgesics, Opioid Short-Acting SUBSYS 200 MCG SUBLINGUAL SPRAY FENTANYL SUBLINQUAL 4 Analgesics, Opioid Short-Acting SUBSYS 400 MCG SUBLINGUAL SPRAY FENTANYL SUBLINQUAL 4 Analgesics, Opioid Short-Acting SUBSYS 600 MCG SUBLINGUAL SPRAY FENTANYL SUBLINQUAL 4 Analgesics, Opioid Short-Acting SUBSYS 800 MCG SUBLINGUAL SPRAY FENTANYL SUBLINQUAL 4 Opioid Dependence Treatments SUBUTEX 2 MG SL TABLET BUPRENORPHINE 3 Effective 01/04/21 Alphabetical by Brand Name (when applicable)

Opioid Dependence Treatments SUBUTEX 8 MG SL TABLET BUPRENORPHINE 3 Calcium Channel Blockers SULAR 17 MG TABLET NISOLDIPINE 1 Calcium Channel Blockers SULAR 25.5 MG TABLET NISOLDIPINE 1 Calcium Channel Blockers SULAR 34 MG TABLET NISOLDIPINE 1 Calcium Channel Blockers SULAR 8.5 MG TABLET NISOLDIPINE 1 Ulcerative Colitis Agents SULFAZINE 500 MG TABLET SULFASALAZINE 12 Ulcerative Colitis Agents SULFAZINE EC 500 MG TABLET SULFASALAZINE 12 Acne Agents, Topical SUMADAN KIT SULFACETAMIDE/SULFUR/CLEANSER COMBO 1 Migraine Acute Treatment Agents SUMATRIPTAN 6 MG/0.5 ML SYRINGE (GSN 33592) SUMATRIPTAN 0.14 Acne Agents, Topical SUMAXIN CP KIT SULFACETAMIDE/SULFUR/CLEANSER COMBO 1 Insect Repellent NOT for Skin Application SUNMARK LICE BEDDING SPRAY PERMETHRIN 0.5% 29 Stimulants & Related Agents SUNOSI 150 MG TABLET SOLRIAMFETOL 1 Stimulants & Related Agents SUNOSI 75 MG TABLET SOLRIAMFETOL 1 Intra-Articular Hyaluronates SUPARTZ FX 25 MG/2.5 ML SYRINGE HYALURONATE SODIUM 0.72 Pituitary Suppressive Agents, LHRH SUPPRELIN LA 50 MG IMPLANT KIT HISTRELIN AC IMPLANT 0.04 Blood Glucose Test Strips SURESTEP PRO BLOOD GLUCOSE TEST STRIPS BLOOD GLUCOSE TEST STRIPS 3.34 HIV/AIDS Antiretrovirals SUSTIVA 200 MG CAPSULE EFAVIRENZ 2 HIV/AIDS Antiretrovirals SUSTIVA 50 MG CAPSULE EFAVIRENZ 3 HIV/AIDS Antiretrovirals SUSTIVA 600 MG TABLET EFAVIRENZ 1 Antiemetics/Antivertigo Agents SUSTOL 10 MG/0.4 ML SYRINGE GRANISETRON 0.06 Oncology Agents, Oral SUTENT 12.5 MG CAPSULE SUNITINIB 1 Oncology Agents, Oral SUTENT 25 MG CAPSULE SUNITINIB 1 Oncology Agents, Oral SUTENT 37.5 MG CAPSULE SUNITINIB 1 Oncology Agents, Oral SUTENT 50 MG CAPSULE SUNITINIB 1 Glucocorticoids, Inhaled SYMBICORT INHALER 160/4.5 MCG BUDESONIDE/FORMOTEROL 0.34 Glucocorticoids, Inhaled SYMBICORT INHALER 80/4.5 MCG BUDESONIDE/FORMOTEROL 0.34 Antipsychotics, Atypical SYMBYAX 12-25 MG CAPSULE OLANZAPINE/FLUOXETINE 1 Antipsychotics, Atypical SYMBYAX 12-50 MG CAPSULE OLANZAPINE/FLUOXETINE 1 Antipsychotics, Atypical SYMBYAX 3-25 MG CAPSULE OLANZAPINE/FLUOXETINE 1 Antipsychotics, Atypical SYMBYAX 6-25 MG CAPSULE OLANZAPINE/FLUOXETINE 1 Antipsychotics, Atypical SYMBYAX 6-50 MG CAPSULE OLANZAPINE/FLUOXETINE 1 CFTR Modulators SYMDEKO 100/150 MG-150 MG TABLET TEZACAFTOR/IVACAFTOR 2 CFTR Modulators SYMDEKO 50/75 MG-75 MG TABLET TEZACAFTOR/IVACAFTOR 2 HIV/AIDS Antiretrovirals SYMFI 600-300-300 MG TABLET EFAVIRENZ/LAMIVUDINE/TENOFOVIR DF 1 HIV/AIDS Antiretrovirals SYMFI LO 400-300-300 MG TABLET EFAVIRENZ/LAMIVUDINE/TENOFOVIR DF 1 Hypoglycemics, Incretin Mimetics/Enhancers SYMLIN 0.6 MG/ML VIAL PRAMLINTIDE 0.6 Hypoglycemics, Incretin Mimetics/Enhancers SYMLINPEN 120 PEN INJECTOR PRAMLINTIDE 0.36 Hypoglycemics, Incretin Mimetics/Enhancers SYMLINPEN 60 PEN INJECTOR PRAMLINTIDE 0.18 Anticonvulsants SYMPAZAN 10 MG FILM CLOBAZAM 2 Anticonvulsants SYMPAZAN 20 MG FILM CLOBAZAM 2 Anticonvulsants SYMPAZAN 5 MG FILM CLOBAZAM 2 Effective 01/04/21 Alphabetical by Brand Name (when applicable)

GI Motility, Chronic SYMPROIC 0.2 MG TABLET DARUNAVIR/COBICISTAT/EMTRICITABINE/TENOFOVIRNALDEMEDINE 1 HIV/AIDS Antiretrovirals SYMTUZA 800-150-200-10 MG TABLET AF 1 Analgesics, Opioid Short-Acting SYNALGOS-DC CAPSULE DIHYDROCODEINE/ASPIRIN/CAFFEINE 10 Pituitary Suppressive Agents, LHRH SYNAREL 2 MG/ML NASAL SPRAY NAFARELIN ACETATE 1.1 Hypoglycemics, SGLT2 Inhibitors SYNJARDY 12.5 MG/1000 MG TABLET EMPAGLIFLOZIN/METFORMIN 2 Hypoglycemics, SGLT2 Inhibitors SYNJARDY 12.5 MG/500 MG TABLET EMPAGLIFLOZIN/METFORMIN 2 Hypoglycemics, SGLT2 Inhibitors SYNJARDY 5 MG/1000 MG TABLET EMPAGLIFLOZIN/METFORMIN 2 Hypoglycemics, SGLT2 Inhibitors SYNJARDY 5 MG/500 MG TABLET EMPAGLIFLOZIN/METFORMIN 4 Hypoglycemics, SGLT2 Inhibitors SYNJARDY XR 10 MG/1000 MG TABLET EMPAGLIFLOZIN/METFORMIN 2 Hypoglycemics, SGLT2 Inhibitors SYNJARDY XR 12.5 MG/1000 MG TABLET EMPAGLIFLOZIN/METFORMIN 2 Hypoglycemics, SGLT2 Inhibitors SYNJARDY XR 25 MG/1000 MG TABLET EMPAGLIFLOZIN/METFORMIN 1 Hypoglycemics, SGLT2 Inhibitors SYNJARDY XR 5 MG/1000 MG TABLET EMPAGLIFLOZIN/METFORMIN 2 Intra-Articular Hyaluronates SYNVISC SYRINGE HYLAN G-F POLYMERS 0.58 Intra-Articular Hyaluronates SYNVISC-ONE SYRINGE HYLAN G-F POLYMERS 0.4 Oncology Agents, Oral TABRECTA 150 MG TABLET CAPMATINIB 4 Oncology Agents, Oral TABRECTA 200 MG TABLET CAPMATINIB 4 Oncology Agents, Oral TAFINLAR 50 MG CAPSULE DABRAFENIB 4 Oncology Agents, Oral TAFINLAR 75 MG CAPSULE DABRAFENIB 4 Oncology Agents, Oral TAGRISSO 40 MG TABLET OSIMERTINIB 1 Oncology Agents, Oral TAGRISSO 80 MG TABLET OSIMERTINIB 1 Hereditary Angioedema Treatments TAKHZYRO 300 MG/2 ML VIAL LANADELUMAB-FLYO 0.15 Hereditary Angioedema Treatments TAKHZYRO 300 MG/2 ML VIAL LANADELUMAB-FLYO 0.15 Cytokine & CAM Antagonists TALTZ 80 MG/ML AUTOINJECTOR IXEKIZUMAB 0.15 Cytokine & CAM Antagonists TALTZ 80 MG/ML SYRINGE IXEKIZUMAB 0.15 Analgesics, Opioid Short-Acting TALWIN NX 50MG/0.5MG TABLET PENTAZOCINE/NALOXONE 3 Oncology Agents, Oral TALZENNA 0.25 MG CAPSULE TALAZOPARIB 3 Oncology Agents, Oral TALZENNA 1 MG CAPSULE TALAZOPARIB 1 Antivirals, Influenza TAMIFLU 30 MG CAPSULE OSELTAMIVIR PHOSPHATE 45 Antivirals, Influenza TAMIFLU 45 MG CAPSULE OSELTAMIVIR PHOSPHATE 25 Antivirals, Influenza TAMIFLU 6 MG/ML SUSPENSION OSELTAMIVIR PHOSPHATE 365 Antivirals, Influenza TAMIFLU 75 MG CAPSULE OSELTAMIVIR PHOSPHATE 25 Oncology Agents, Oral TARCEVA 100 MG TABLET ERLOTINIB HYDROCHLORIDE 1 Oncology Agents, Oral TARCEVA 150 MG TABLET ERLOTINIB HYDROCHLORIDE 2 Oncology Agents, Oral TARCEVA 25 MG TABLET ERLOTINIB HYDROCHLORIDE 2 Angiotensin Modulator Combinations TARKA 1/240 MG TABLET SA TRANDOLAPRIL/VERAPAMIL 1 Angiotensin Modulator Combinations TARKA 2/180 MG TABLET SA TRANDOLAPRIL/VERAPAMIL 1 Angiotensin Modulator Combinations TARKA 2/240 MG TABLET SA TRANDOLAPRIL/VERAPAMIL 1 Angiotensin Modulator Combinations TARKA 4/240 MG TABLET SA TRANDOLAPRIL/VERAPAMIL 1 Oncology Agents, Oral TASIGNA 150 MG CAPSULE NILOTINIB 4 Oncology Agents, Oral TASIGNA 200 MG CAPSULE NILOTINIB 4 Oncology Agents, Oral TASIGNA 50 MG CAPSULE NILOTINIB 4 Effective 01/04/21 Alphabetical by Brand Name (when applicable)

Antiparkinson's Agents TASMAR 100 MG TABLET TOLCAPONE 6 Thrombopoietics TAVALISSE 100 MG TABLET FOSTAMATINIB DISODIUM HEXAHYDRATE 2 Thrombopoietics TAVALISSE 150 MG TABLET FOSTAMATINIB DISODIUM HEXAHYDRATE 2 Calcium Channel Blockers TAZTIA XT 120 MG CAPSULE DILTIAZEM 1 Calcium Channel Blockers TAZTIA XT 180 MG CAPSULE DILTIAZEM 1 Calcium Channel Blockers TAZTIA XT 240 MG CAPSULE DILTIAZEM 2 Calcium Channel Blockers TAZTIA XT 300 MG CAPSULE DILTIAZEM 1 Calcium Channel Blockers TAZTIA XT 360 MG CAPSULE DILTIAZEM 1 Oncology Agents, Oral TAZVERIK 200 MG TABLET TAZEMETOSTAT 8 Multiple Sclerosis Agents TECFIDERA 120 MG DR CAPSULE DIMETHYL FUMARATE 2 Multiple Sclerosis Agents TECFIDERA 240 MG DR CAPSULE DIMETHYL FUMARATE 2 Multiple Sclerosis Agents TECFIDERA 30-DAY STARTER PACK DIMETHYL FUMARATE 2 Anticonvulsants TEGRETOL 100 MG CHEWABLE TABLET CARBAMAZEPINE 6 Anticonvulsants TEGRETOL 100 MG/5 ML SUSPENSION CARBAMAZEPINE 80 Anticonvulsants TEGRETOL 200 MG TABLET CARBAMAZEPINE 8 Anticonvulsants TEGRETOL XR 100 MG TABLET CARBAMAZEPINE ER 6 Anticonvulsants TEGRETOL XR 200 MG TABLET CARBAMAZEPINE ER 8 Anticonvulsants TEGRETOL XR 400 MG TABLET CARBAMAZEPINE ER 4 Angiotensin Modulators TEKTURNA 150 MG TABLET ALISKIREN 1 Angiotensin Modulators TEKTURNA 300 MG TABLET ALISKIREN 1 Angiotensin Modulators TEKTURNA HCT 150-12.5 MG TAB ALISKIREN/HCTZ 1 Angiotensin Modulators TEKTURNA HCT 150-25 MG TABLET ALISKIREN/HCTZ 1 Angiotensin Modulators TEKTURNA HCT 300-12.5 MG TAB ALISKIREN/HCTZ 1 Angiotensin Modulators TEKTURNA HCT 300-25 MG TABLET ALISKIREN/HCTZ 1 HIV/AIDS Antiretrovirals TEMIXYS 300-300 MG TABLET LAMIVUDINE/TENOFOVIR DF 1 Antihypertensive, Sympatholytics TENEX 1 MG TABLET GUANFACINE IMMEDIATE-RELEASE 3 Antihypertensive, Sympatholytics TENEX 2 MG TABLET GUANFACINE IMMEDIATE-RELEASE 2 Vaccines TENIVAC VACCINE SYRINGE TETANUS & DIPHTHERIA VACCINE 0.5 Vaccines TENIVAC VACCINE VIAL TETANUS & DIPHTHERIA VACCINE 0.5 Bone Density Regulators TERIPARATIDE 620 MCG/2.48 ML TERIPARATIDE 0.09 Androgenic Agents TESTIM 1% (50 MG) GEL TUBES TESTOSTERONE 10 Androgenic Agents TESTOPEL 75 MG PELLETS TESTOSTERONE IMPLANT 0.2 Androgenic Agents TESTRED 10 MG CAPSULE METHYLTESTOSTERONE 5 Angiotensin Modulators TEVETEN 400 MG TABLET EPROSARTAN 2 Angiotensin Modulators TEVETEN 600 MG TABLET EPROSARTAN 1 Angiotensin Modulators TEVETEN HCT 600-12.5 MG TAB EPROSARTAN/HCTZ 1 Angiotensin Modulators TEVETEN HCT 600-25 MG TAB EPROSARTAN/HCTZ 1 Thalidomides & Derivatives THALOMID 100 MG CAPSULE THALIDOMIDE 1 Thalidomides & Derivatives THALOMID 150 MG CAPSULE THALIDOMIDE 2 Thalidomides & Derivatives THALOMID 200 MG CAPSULE THALIDOMIDE 2 Thalidomides & Derivatives THALOMID 50 MG CAPSULE THALIDOMIDE 1 Effective 01/04/21 Alphabetical by Brand Name (when applicable)

Calcium Channel Blockers TIAZAC 120 MG CAPSULE SA DILTIAZEM 1 Calcium Channel Blockers TIAZAC 180 MG CAPSULE SA DILTIAZEM 1 Calcium Channel Blockers TIAZAC 240 MG CAPSULE SA DILTIAZEM 2 Calcium Channel Blockers TIAZAC 300 MG CAPSULE SA DILTIAZEM 1 Calcium Channel Blockers TIAZAC 360 MG CAPSULE SA DILTIAZEM 1 Calcium Channel Blockers TIAZAC 420 MG CAPSULE SA DILTIAZEM 1 Oncology Agents, Oral TIBSOVO 250 MG TABLET IVOSIDENIB 2 Antiemetics/Antivertigo Agents TIGAN 100 MG/ML MULTI-DOSE 20 ML VIAL TRIMETHOBENZAMIDE 8 Antiemetics/Antivertigo Agents TIGAN 100 MG/ML SINGLE-DOSE 2 ML VIAL TRIMETHOBENZAMIDE 8 Antiemetics/Antivertigo Agents TIGAN 300 MG CAPSULE TRIMETHOBENZAMIDE 4 Antiarrhythmics TIKOSYN 125 MCG CAPSULE DOFETILIDE 2 Antiarrhythmics TIKOSYN 250 MCG CAPSULE DOFETILIDE 2 Antiarrhythmics TIKOSYN 500 MCG CAPSULE DOFETILIDE 2 Antibiotics, GI and Related Agents TINDAMAX 250 MG TABLET TINIDAZOLE 8 Antibiotics, GI and Related Agents TINDAMAX 500 MG TABLET TINIDAZOLE 4 HIV/AIDS Antiretrovirals TIVICAY 10 MG TABLET DOLUTEGRAVIR 4 HIV/AIDS Antiretrovirals TIVICAY 25 MG TABLET DOLUTEGRAVIR 1 HIV/AIDS Antiretrovirals TIVICAY 50 MG TABLET DOLUTEGRAVIR 2 HIV/AIDS Antiretrovirals TIVICAY PD 5 MG TABLET FOR SUSPENSION DOLUTEGRAVIR 6 NSAIDs TIVORBEX 20 MG CAPSULE INDOMETHACIN SUBMICRONIZED 3 NSAIDs TIVORBEX 40 MG CAPSULE INDOMETHACIN SUBMICRONIZED 3 Antibiotics, Inhaled TOBI 300 MG/5 ML INHALATION SOLUTION VIAL TOBRAMYCIN 10 Antibiotics, Inhaled TOBI PODHALER 28 MG CAPSULES TOBRAMYCIN 8 Hypoglycemics, Sulfonylureas TOLBUTAMIDE 500 MG TABLET TOLBUTAMIDE 6 NSAIDs TOLECTIN 200 MG TABLET TOLMETIN 3 NSAIDs TOLECTIN 400 MG CAPSULE TOLMETIN 3 NSAIDs TOLECTIN 600 MG TABLET TOLMETIN 3 Antifungals, Oral TOLSURA 65 MG CAPSULE ITRACONAZOLE 4.58 Anticonvulsants TOPAMAX 100 MG TABLET TOPIRAMATE 3 Anticonvulsants TOPAMAX 15 MG SPRINKLE CAPSULE TOPIRAMATE 6 Anticonvulsants TOPAMAX 200 MG TABLET TOPIRAMATE 2 Anticonvulsants TOPAMAX 25 MG SPRINKLE CAPSULE TOPIRAMATE 6 Anticonvulsants TOPAMAX 25 MG TABLET TOPIRAMATE 6 Anticonvulsants TOPAMAX 50 MG TABLET TOPIRAMATE 6 NSAIDs TORADOL 10 MG TABLET KETOROLAC 4 Bladder Relaxant Preparations TOVIAZ 4 MG ER TABLET FESOTERODINE 1 Bladder Relaxant Preparations TOVIAZ 8 MG ER TABLET FESOTERODINE 1 PAH Agents, Oral & Inhaled TRACLEER 125 MG TABLET BOSENTAN 2 PAH Agents, Oral & Inhaled TRACLEER 32 MG TABLET FOR SUSP BOSENTAN 4 PAH Agents, Oral & Inhaled TRACLEER 62.5 MG TABLET BOSENTAN 2 Hypoglycemics, Incretin Mimetics/Enhancers TRADJENTA 5 MG TABLET LINAGLIPTIN 1 Effective 01/04/21 Alphabetical by Brand Name (when applicable)

Analgesics, Opioid Short-Acting TRAMADOL HCL 100 MG TABLET TRAMADOL 4 Antiemetics/Antivertigo Agents TRANSDERM-SCOP PATCH SCOPOLAMINE 0.4 Anxiolytics TRANXENE T-TAB 15 MG CLORAZEPATE 4 Anxiolytics TRANXENE T-TAB 3.75 MG CLORAZEPATE 4 Anxiolytics TRANXENE T-TAB 7.5 MG CLORAZEPATE 4 COPD Agents TRELEGY ELLIPTA 100-62.5-25 FLUTICASONE/UMECLIDINIUM/VILANTEROL 2 Pituitary Suppressive Agents, LHRH TRELSTAR 11.25 MG SYRINGE TRIPTORELIN PAMOATE 0.02 Pituitary Suppressive Agents, LHRH TRELSTAR 22.5 MG SYRINGE TRIPTORELIN PAMOATE 0.01 Pituitary Suppressive Agents, LHRH TRELSTAR 3.75 MG SYRINGE TRIPTORELIN PAMOATE 0.04 Cytokine & CAM Antagonists TREMFYA 100 MG/ML INJECTOR GUSELKUMAB 0.04 Cytokine & CAM Antagonists TREMFYA 100 MG/ML SYRINGE GUSELKUMAB 0.04 Migraine Acute Treatment Agents TREXIMET 10 MG/60 MG TABLET SUMATRIPTAN/NAPROXEN SODIUM 0.3 Migraine Acute Treatment Agents TREXIMET 85 MG/500 MG TABLET SUMATRIPTAN/NAPROXEN 0.3 Intranasal Rhinitis Agents TRIAMCINOLONE 55 MCG NASAL SPRAY TRIAMCINOLONE ACETONIDE 0.57 Angiotensin Modulator Combinations TRIBENZOR 20 MG/5 MG/12.5 MG TABLET AMLODIPINE/OLMESARTAN/HCTZ 1 Angiotensin Modulator Combinations TRIBENZOR 40 MG/10 MG/12.5 MG TABLET AMLODIPINE/OLMESARTAN/HCTZ 1 Angiotensin Modulator Combinations TRIBENZOR 40 MG/10 MG/25 MG TABLET AMLODIPINE/OLMESARTAN/HCTZ 1 Angiotensin Modulator Combinations TRIBENZOR 40 MG/5 MG/12.5 MG TABLET AMLODIPINE/OLMESARTAN/HCTZ 1 Angiotensin Modulator Combinations TRIBENZOR 40 MG/5 MG/25 MG TABLET AMLODIPINE/OLMESARTAN/HCTZ 1 Lipotropics, Other TRICOR 145 MG TABLET FENOFIBRATE NANOCRYSTALLIZED 1 Lipotropics, Other TRICOR 48 MG TABLET FENOFIBRATE NANOCRYSTALLIZED 2 Ophthalmics, Anti-Inflammatories TRIESENCE 40 MG/ML INTRAOCULAR INJ VIAL TRIAMCINOLONE INTRAOCULAR 0.07 Lipotropics, Other TRIGLIDE 160 MG TABLET FENOFIBRATE NANOCRYSTALLIZED 1 Lipotropics, Other TRIGLIDE 50 MG TABLET FENOFIBRATE NANOCRYSTALLIZED 3 Hypoglycemics, Incretin Mimetics/Enhancers TRIJARDY XR 10-5-1000 MG TABLET EMPAGLIFLOZIN/LINAGLIPTIN/METFORMIN 1 Hypoglycemics, Incretin Mimetics/Enhancers TRIJARDY XR 12.5-2.5-1000 MG TABLET EMPAGLIFLOZIN/LINAGLIPTIN/METFORMIN 2 Hypoglycemics, Incretin Mimetics/Enhancers TRIJARDY XR 25-5-1000 MG TABLET EMPAGLIFLOZIN/LINAGLIPTIN/METFORMIN 1 Hypoglycemics, Incretin Mimetics/Enhancers TRIJARDY XR 5-2.5-1000 MG TABLET EMPAGLIFLOZIN/LINAGLIPTIN/METFORMIN 2 CFTR Modulators TRIKAFTA 100/50/75 MG-150 MG ELEXACAFTOR/TEZACAFTOR/IVACAFTOR 3 Anticonvulsants TRILEPTAL 150 MG TABLET OXCARBAZEPINE 6 Anticonvulsants TRILEPTAL 300 MG TABLET OXCARBAZEPINE 7 Anticonvulsants TRILEPTAL 300 MG/5 ML LIQUID OXCARBAZEPINE 40 Anticonvulsants TRILEPTAL 600 MG TABLET OXCARBAZEPINE 4 Lipotropics, Other TRILIPIX 135 MG DR CAPSULE FENOFIBRIC ACID (CHOLINE) 1 Lipotropics, Other TRILIPIX 45 MG DR CAPSULE FENOFIBRIC ACID (CHOLINE) 2 Intra-Articular Hyaluronates TRILURON 20 MG/2ML HYALURONATE SODIUM 0.72 Antidepressants, Other TRINTELLIX 10 MG TABLET VORTIOXETINE 2 Antidepressants, Other TRINTELLIX 20 MG TABLET VORTIOXETINE 1 Antidepressants, Other TRINTELLIX 5 MG TABLET VORTIOXETINE 2 Pituitary Suppressive Agents, LHRH TRIPTODUR 22.5 MG KIT TRIPTORELIN 0.01 HIV/AIDS Antiretrovirals TRIUMEQ 600/50/300 MG TABLET ABACAVIR/DOLUTEGRAVIR/LAMIVUDINE 1 Effective 01/04/21 Alphabetical by Brand Name (when applicable)

Intra-Articular Hyaluronates TRIVISC 25 MG/2.5 ML SYRINGE HYALURONATE SODIUM 0.72 HIV/AIDS Antiretrovirals TRIZIVIR 300 MG/150 MG/300 MG TABLET ABACAVIR/LAMIVUDINE/ZIDOVUDINE 2 HIV/AIDS Antiretrovirals TROGARZO 200 MG/1.33 ML VIAL IBALIZUMAB-UIYK 0.95 Anticonvulsants TROKENDI XR 100 MG CAPSULE TOPIRAMATE ER 3 Anticonvulsants TROKENDI XR 200 MG CAPSULE TOPIRAMATE ER 2 Anticonvulsants TROKENDI XR 25 MG CAPSULE TOPIRAMATE ER 4 Anticonvulsants TROKENDI XR 50 MG CAPSULE TOPIRAMATE ER 4 Blood Glucose Meters TRUE2GO BLOOD GLUCOSE METER BLOOD GLUCOSE METER See footnote2 Blood Glucose Meters TRUERESULT BLOOD GLUCOSE METER BLOOD GLUCOSE METER See footnote2 Blood Glucose Test Strips TRUETEST BLOOD GLUCOSE TEST STRIPS BLOOD GLUCOSE TEST STRIPS 3.34 Blood Glucose Test Strips TRUETRACK BLOOD GLUCOSE TEST STRIPS BLOOD GLUCOSE TEST STRIPS 3.34 Blood Glucose Meters TRUETRACK SMART BLOOD GLUCOSE METER BLOOD GLUCOSE METER See footnote2 GI Motility, Chronic TRULANCE 3 MG TABLET PLECANATIDE 1 Hypoglycemics, Incretin Mimetics/Enhancers TRULICITY 0.75 MG/0.5 ML PEN DULAGLUTIDE 0.08 Hypoglycemics, Incretin Mimetics/Enhancers TRULICITY 1.5 MG/0.5 ML PEN DULAGLUTIDE 0.08 Hypoglycemics, Incretin Mimetics/Enhancers TRULICITY 3 MG/0.5 ML PEN DULAGLUTIDE 0.08 Hypoglycemics, Incretin Mimetics/Enhancers TRULICITY 4.5 MG/0.5 ML PEN DULAGLUTIDE 0.08 Vaccines TRUMENBA 120 MCG/0.5 ML VACCINE VIAL MENINGOCOCCAL B VACCINE LIP FHBP 0.5 HIV/AIDS Antiretrovirals TRUVADA 100 MG/150 MG TABLET EMTRICITABINE/TENOFOVIR DF 1 HIV/AIDS Antiretrovirals TRUVADA 133 MG/200 MG TABLET EMTRICITABINE/TENOFOVIR DF 1 HIV/AIDS Antiretrovirals TRUVADA 167 MG/250 MG TABLET EMTRICITABINE/TENOFOVIR DF 1 HIV/AIDS Antiretrovirals TRUVADA 200 MG/300 MG TABLET EMTRICITABINE/TENOFOVIR DF 1 COPD Agents TUDORZA 400 MCG PRESSAIR INHALER ACLIDINIUM 0.04 Oncology Agents, Oral TUKYSA 150 MG TABLET TUCATINIB 4 Oncology Agents, Oral TUKYSA 50 MG TABLET TUCATINIB 4 Oncology Agents, Oral TURALIO 200 MG CAPSULE PEXIDARTINIB 4 Opioid Antitussive TUSSICAPS 10 MG-8 MG CAPSULE HYDROCODONE/CHLORPHEN 2 Opioid Antitussive TUSSICAPS 5 MG-4 MG CAPSULE HYDROCODONE/CHLORPHEN 2 Opioid Antitussive TUSSIGON 5-1.5 MG TABLET HYDROCODONE BIT/HOMATROPINE 6 Opioid Antitussive TUSSIONEX PENNKINETIC SUSPENSION HYDROCODONE/CHLORPHEN 10 Vaccines TWINRIX VACCINE SYRINGE HEPATITIS A & B VACCINE 1 Vaccines TWINRIX VACCINE VIAL HEPATITIS A & B VACCINE 1 Angiotensin Modulator Combinations TWYNSTA 40/10 MG TABLET AMLODIPINE/TELMISARTAN 1 Angiotensin Modulator Combinations TWYNSTA 40/5 MG TABLET AMLODIPINE/TELMISARTAN 1 Angiotensin Modulator Combinations TWYNSTA 80/10 MG TABLET AMLODIPINE/TELMISARTAN 1 Angiotensin Modulator Combinations TWYNSTA 80/5 MG TABLET AMLODIPINE/TELMISARTAN 1 HIV/AIDS Antiretrovirals TYBOST 150 MG TABLET COBICISTAT 1 Oncology Agents, Oral TYKERB 250 MG TABLET LAPATINIB 6 Analgesics, Non-Salicylates TYLENOL 100 MG/ML LIQUID (INFANTS SILAPAP) ACETAMINOPHEN 8 Analgesics, Non-Salicylates TYLENOL 120 MG TAB/CAP/SUPPOSITORY ACETAMINOPHEN 20 Analgesics, Non-Salicylates TYLENOL 160 MG TAB/CAP/SUPPOSITORY ACETAMINOPHEN 20 Effective 01/04/21 Alphabetical by Brand Name (when applicable)

Analgesics, Non-Salicylates TYLENOL 160 MG/5 ML LIQUID ACETAMINOPHEN 75 Analgesics, Non-Salicylates TYLENOL 320 MG/10 ML LIQUID ACETAMINOPHEN 100 Analgesics, Non-Salicylates TYLENOL 325 MG TAB/CAP/SUPPOSITORY ACETAMINOPHEN 10 Analgesics, Non-Salicylates TYLENOL 325 MG/10.15 ML LIQUID ACETAMINOPHEN 100 Analgesics, Non-Salicylates TYLENOL 500 MG CAP/TAB/SUPPOSITORY ACETAMINOPHEN 6 Analgesics, Non-Salicylates TYLENOL 500 MG/15 ML LIQUID ACETAMINOPHEN 90 Analgesics, Non-Salicylates TYLENOL 500 MG/5 ML LIQUID ACETAMINOPHEN 30 Analgesics, Non-Salicylates TYLENOL 640 MG/20 ML LIQUID ACETAMINOPHEN 125 Analgesics, Non-Salicylates TYLENOL 650 MG TAB/CAP/SUPPOSITORY ACETAMINOPHEN 6 Analgesics, Non-Salicylates TYLENOL 650 MG/20.3 ML ACETAMINOPHEN 100 Analgesics, Non-Salicylates TYLENOL 80 MG TAB/CAP/SUPPOSITORY ACETAMINOPHEN 30 Analgesics, Non-Salicylates TYLENOL 80 MG/0.8 ML LIQUID ACETAMINOPHEN 8 Analgesics, Non-Salicylates TYLENOL 80 MG/2.5 ML LIQUID ACETAMINOPHEN 75 Analgesics, Opioid Short-Acting TYLENOL WITH CODEINE #2 ACETAMINOPHEN/CODEINE 10 Analgesics, Opioid Short-Acting TYLENOL WITH CODEINE #3 ACETAMINOPHEN/CODEINE 10 Analgesics, Opioid Short-Acting TYLENOL WITH CODEINE #4 ACETAMINOPHEN/CODEINE 5 Analgesics, Opioid Short-Acting TYLENOL WITH CODEINE 120 MG-12 MG/5 ML ELIXIR ACETAMINOPHEN/CODEINE 90 Bone Density Regulators TYMLOS 80 MCG DOSE PEN INJECTOR ABALOPARATIDE 0.06 Vaccines TYPHIM VI 25 MCG/0.5 ML SYRINGE TYPHOID VACCINE 0.5 Vaccines TYPHIM VI 25 MCG/0.5 ML VIAL TYPHOID VACCINE 0.5 Multiple Sclerosis Agents TYSABRI 300 MG/15 ML INJECTION VIAL NATALIZUMAB 0.54 PAH Agents, Oral & Inhaled TYVASO 4-PACK CARTON TREPROSTINIL 2.9 PAH Agents, Oral & Inhaled TYVASO INHALATION SYSTEM REFILL KIT TREPROSTINIL 2.9 PAH Agents, Oral & Inhaled TYVASO INHALATION SYSTEM STARTER KIT TREPROSTINIL 2.9 Migraine Acute Treatment Agents UBRELVY 100 MG TABLET UBROGEPANT 0.54 Migraine Acute Treatment Agents UBRELVY 50 MG TABLET UBROGEPANT 0.54 Glucocorticoids, Oral UCERIS 9 MG ER TABLET BUDESONIDE 1 Ulcerative Colitis Agents UCERIS RECTAL FOAM BUDESONIDE 4.78 Colony Stimulating Factors UDENYCA 6 MG/0.6ML SYRINGE PEGFILGRASTIM-CBQV 0.05 Antihyperuricemics ULORIC 40 MG TABLET FEBUXOSTAT 1 Antihyperuricemics ULORIC 80 MG TABLET FEBUXOSTAT 1.5 Complement Inhibitors ULTOMIRIS 300 MG/30 ML VIAL RAVULIZUMAB-CWVZ 21.43 Analgesics, Opioid Short-Acting ULTRACET 37.5 MG/325 MG TABLET TRAMADOL/ACETAMINOPHEN 8 Analgesics, Opioid Short-Acting ULTRAM 50 MG TABLET TRAMADOL 8 Analgesics, Opioid Long-Acting ULTRAM ER 100 MG TABLET TRAMADOL ER 1 Analgesics, Opioid Long-Acting ULTRAM ER 200 MG TABLET TRAMADOL ER 1 Analgesics, Opioid Long-Acting ULTRAM ER 300 MG TABLET TRAMADOL ER 1 Angiotensin Modulators UNIRETIC 15 MG/12.5 MG TABLET MOEXIPRIL/HYDROCHLOROTHIAZIDE 2 Angiotensin Modulators UNIRETIC 15 MG/25 MG TABLET MOEXIPRIL/HYDROCHLOROTHIAZIDE 2 Angiotensin Modulators UNIRETIC 7.5 MG/12.5 MG TABLET MOEXIPRIL/HYDROCHLOROTHIAZIDE 2 Angiotensin Modulators UNIVASC 15 MG TABLET MOEXIPRIL 2 Effective 01/04/21 Alphabetical by Brand Name (when applicable)

Angiotensin Modulators UNIVASC 7.5 MG TABLET MOEXIPRIL 2 PAH Agents, Oral & Inhaled UPTRAVI 1000 MCG TABLET SELEXIPAG 2 PAH Agents, Oral & Inhaled UPTRAVI 1200 MCG TABLET SELEXIPAG 2 PAH Agents, Oral & Inhaled UPTRAVI 1400 MCG TABLET SELEXIPAG 2 PAH Agents, Oral & Inhaled UPTRAVI 1600 MCG TABLET SELEXIPAG 2 PAH Agents, Oral & Inhaled UPTRAVI 200 MCG TABLET SELEXIPAG 2 PAH Agents, Oral & Inhaled UPTRAVI 200 MCG-800 MCG TITRATION PACK SELEXIPAG 4.55 PAH Agents, Oral & Inhaled UPTRAVI 400 MCG TABLET SELEXIPAG 2 PAH Agents, Oral & Inhaled UPTRAVI 600 MCG TABLET SELEXIPAG 2 PAH Agents, Oral & Inhaled UPTRAVI 800 MCG TABLET SELEXIPAG 2 Urinary Anti-infectives URELLE TABLET METH/MEBLUE/SOD PHOS/PSAL/HYOS 4 Urinary Anti-infectives URIMAR-T TABLET METHEN/MBLUE/SAL/SOD PHOS/HYOS 4 Urinary Anti-infectives URIN D.S. METH/MEBLUE/SOD PHOS/PSAL/HYOS 4 Urinary Anti-infectives UROGESIC-BLUE TABLET METHENAM/SOD PHOS/MBLUE/HYOSCY 4 BPH Treatments UROXATRAL 10 MG TABLET ALFUZOSIN 1 Bile Salts URSO 250 MG TABLET URSODIOL 3 Bile Salts URSO FORTE 500 MG TABLET URSODIOL 3 Anxiolytics VALIUM 10 MG TABLET DIAZEPAM 4 Anxiolytics VALIUM 2 MG TABLET DIAZEPAM 8 Anxiolytics VALIUM 5 MG TABLET DIAZEPAM 6 Antivirals, Herpes VALTREX 1000 MG TABLET VALACYCLOVIR 4 Antivirals, Herpes VALTREX 500 MG TABLET VALACYCLOVIR 2 Analgesics, Non-Opioid Barbiturate Combos VANATOL LQ 50 MG-325 MG-40 MG/15 ML ORAL SOLUTION BUTALBITAL/ACETAMINOPHEN/CAFFEINE 9 Pituitary Suppressive Agents, LHRH VANTAS 50 MG KIT HISTRELIN IMPLANT 0.04 Vaccines VAQTA 25 UNITS/0.5 ML VIAL HEPATITIS A VIRUS VACCINE 0.5 Vaccines VAQTA 50 UNITS/ML VIAL HEPATITIS A VIRUS VACCINE 1 Vaccines VARIVAX VACCINE VIAL VARICELLA VACCINE 1 Antiemetics/Antivertigo Agents VARUBI 90 MG TABLET ROLAPITANT 2 Lipotropics, Other VASCEPA 0.5 GM CAPSULE ICOSAPENT ETHYL 8 Lipotropics, Other VASCEPA 1 GM CAPSULE ICOSAPENT ETHYL 4 Lipotropics, Other VASCEPA 1 GRAM CAPSULE ICOSAPENT ETHYL 4 Angiotensin Modulators VASERETIC 10 MG/25 MG TABLET ENALAPRIL/HYDROCHLOROTHIAZIDE 2 Angiotensin Modulators VASERETIC 5 MG/12.5 MG TABLET ENALAPRIL/HYDROCHLOROTHIAZIDE 2 Angiotensin Modulators VASOTEC 10 MG TABLET ENALAPRIL 2 Angiotensin Modulators VASOTEC 2.5 MG TABLET ENALAPRIL 2 Angiotensin Modulators VASOTEC 20 MG TABLET ENALAPRIL 2 Angiotensin Modulators VASOTEC 5 MG TABLET ENALAPRIL 2 Antihypertensives, Miscellaneous VECAMYL 2.5 MG TABLET MECAMYLAMINE 10 Phosphate Binders VELPHORO 500 MG CHEWABLE TABLET SUCROFERRIC OXYHYDROXIDE 6 Potassium Removing Agents VELTASSA 16.8 GM POWDER PACKET PATIROMER SORBITEX CALCIUM 1 Potassium Removing Agents VELTASSA 25.2 GM POWDER PACKET PATIROMER SORBITEX CALCIUM 1 Effective 01/04/21 Alphabetical by Brand Name (when applicable)

Potassium Removing Agents VELTASSA 8.4 GM POWDER PACKET PATIROMER SORBITEX CALCIUM 1 Hepatitis B Agents VEMLIDY 25 MG TABLET TENOFOVIR ALAFENAMIDE FUMARATE 1 Oncology Agents, Oral VENCLEXTA 10 MG TABLET VENETOCLAX 2 Oncology Agents, Oral VENCLEXTA 100 MG TABLET VENETOCLAX 6 Oncology Agents, Oral VENCLEXTA 50 MG TABLET VENETOCLAX 1 Antidepressants, Other VENLAFAXINE ER 150 MG TABLET VENLAFAXINE 1 Antidepressants, Other VENLAFAXINE ER 225 MG TABLET VENLAFAXINE 1 Antidepressants, Other VENLAFAXINE ER 37.5 MG TABLET VENLAFAXINE 1 Antidepressants, Other VENLAFAXINE ER 75 MG TABLET VENLAFAXINE 1 Iron, Parenteral VENOFER 100 MG/5 ML VIAL IRON SUCROSE COMPLEX 20 Iron, Parenteral VENOFER 200 MG/10 ML VIAL IRON SUCROSE COMPLEX 20 Iron, Parenteral VENOFER 50 MG/2.5 ML VIAL IRON SUCROSE COMPLEX 5 Bronchodilators, Beta Agonist VENTOLIN HFA 90 MCG INHALER (18 GRAMS) ALBUTEROL 1.2 Bronchodilators, Beta Agonist VENTOLIN HFA 90 MCG INHALER (8 GRAMS) ALBUTEROL 1.2 Calcium Channel Blockers VERELAN 120 MG CAPSULE PELLET VERAPAMIL 1 Calcium Channel Blockers VERELAN 180 MG CAPSULE PELLET VERAPAMIL 1 Calcium Channel Blockers VERELAN 240 MG CAPSULE PELLET VERAPAMIL 2 Calcium Channel Blockers VERELAN 360 MG CAPSULE PELLET VERAPAMIL 1 Calcium Channel Blockers VERELAN PM 100 MG CAP VERAPAMIL 1 Calcium Channel Blockers VERELAN PM 200 MG CAP VERAPAMIL 2 Calcium Channel Blockers VERELAN PM 300 MG CAP VERAPAMIL 1 Oncology Agents, Oral VERZENIO 100 MG TABLET ABEMACICLIB 2 Oncology Agents, Oral VERZENIO 150 MG TABLET ABEMACICLIB 2 Oncology Agents, Oral VERZENIO 200 MG TABLET ABEMACICLIB 2 Oncology Agents, Oral VERZENIO 50 MG TABLET ABEMACICLIB 2 Bladder Relaxant Preparations VESICARE 10 MG TABLET SOLIFENACIN 1 Bladder Relaxant Preparations VESICARE 5 MG TABLET SOLIFENACIN 1 GI Motility, Chronic VIBERZI 100 MG TABLET ELUXADOLINE 2 GI Motility, Chronic VIBERZI 75 MG TABLET ELUXADOLINE 2 Analgesics, Opioid Short-Acting VICODIN 5 MG/300 MG TABLET HYDROCODONE/ACETAMINOPHEN 10 Analgesics, Opioid Short-Acting VICODIN ES 7.5 MG/300 MG TABLET HYDROCODONE/ACETAMINOPHEN 6 Analgesics, Opioid Short-Acting VICODIN HP 10 MG/300 MG TABLET HYDROCODONE/ACETAMINOPHEN 5 Analgesics, Opioid Short-Acting VICOPROFEN 7.5 MG/200 MG HYDROCODONE/IBUPROFEN 5 Hypoglycemics, Incretin Mimetics/Enhancers VICTOZA 2-PAK 18 MG/3 ML PEN LIRAGLUTIDE 0.3 Hypoglycemics, Incretin Mimetics/Enhancers VICTOZA 3-PAK 18 MG/3 ML PEN LIRAGLUTIDE 0.3 HIV/AIDS Antiretrovirals VIDEX 10 MG/ML POWDER FOR ORAL SOLUTION DIDANOSINE 40 HIV/AIDS Antiretrovirals VIDEX EC 125 MG CAPSULE DIDANOSINE 2 HIV/AIDS Antiretrovirals VIDEX EC 200 MG CAPSULE DIDANOSINE 2 HIV/AIDS Antiretrovirals VIDEX EC 250 MG CAPSULE DIDANOSINE 1 HIV/AIDS Antiretrovirals VIDEX EC 400 MG CAPSULE DIDANOSINE 1 Hepatitis C Agents VIEKIRA PAK OMBITASVIR/PARITAPREVIR/RITONAVIR/DASABUVIR 4 Effective 01/04/21 Alphabetical by Brand Name (when applicable)

Antidepressants, Other VIIBRYD 10 MG TABLET VILAZODONE 1 Antidepressants, Other VIIBRYD 20 MG TABLET VILAZODONE 1 Antidepressants, Other VIIBRYD 40 MG TABLET VILAZODONE 1 NSAIDs VIMOVO 375 MG/20 MG TABLET NAPROXEN/ESOMEPRAZOLE 2 NSAIDs VIMOVO 500 MG/20 MG TABLET NAPROXEN/ESOMEPRAZOLE 2 Anticonvulsants VIMPAT 10 MG/ML SOLUTION LACOSAMIDE 40 Anticonvulsants VIMPAT 100 MG TABLET LACOSAMIDE 2 Anticonvulsants VIMPAT 150 MG TABLET LACOSAMIDE 2 Anticonvulsants VIMPAT 200 MG TABLET LACOSAMIDE 2 Anticonvulsants VIMPAT 50 MG TABLET LACOSAMIDE 4 HIV/AIDS Antiretrovirals VIRACEPT 250 MG TABLET NELFINAVIR 9 HIV/AIDS Antiretrovirals VIRACEPT 625 MG TABLET NELFINAVIR 4 HIV/AIDS Antiretrovirals VIRAMUNE 200 MG TABLET NEVIRAPINE 2 HIV/AIDS Antiretrovirals VIRAMUNE 50 MG/5 ML ORAL SUSPENSION NEVIRAPINE 40 HIV/AIDS Antiretrovirals VIRAMUNE XR 100 MG TABLET NEVIRAPINE 3 HIV/AIDS Antiretrovirals VIRAMUNE XR 400 MG TABLET NEVIRAPINE 1 HIV/AIDS Antiretrovirals VIREAD 150 MG TABLET TENOFOVIR DISOPROXIL FUMARATE (TDF) 2 HIV/AIDS Antiretrovirals VIREAD 200 MG TABLET TENOFOVIR DISOPROXIL FUMARATE (TDF) 1.5 HIV/AIDS Antiretrovirals VIREAD 250 MG TABLET TENOFOVIR DISOPROXIL FUMARATE (TDF) 1 HIV/AIDS Antiretrovirals VIREAD 300 MG TABLET TENOFOVIR DISOPROXIL FUMARATE (TDF) 1 HIV/AIDS Antiretrovirals VIREAD 40 MG/SCOOP POWDER TENOFOVIR DISOPROXIL FUMARATE (TDF) 7.5 Opioid Antitussive VIRTUSSIN AC LIQUID CODEINE PHOSPHATE/GUAIFENESIN 60 Opioid Antitussive VIRTUSSIN DAC LIQUID PSEUDOEPHED/CODEINE/GUAIFENESIN 40 Intra-Articular Hyaluronates VISCO-3 25 MG/2.5 ML SYRINGE HYALURONATE SODIUM 0.72 Estrogens VIVELLE-DOT 0.0375 MG PATCH ESTRADIOL 0.29 Opioid Dependence Treatments VIVITROL INJECTABLE SUSPENSION KIT NALTREXONE 1 NSAIDs VIVLODEX 10 MG CAPSULE MELOXICAM 1 NSAIDs VIVLODEX 5 MG CAPSULE MELOXICAM 1 Vaccines VIVOTIF BERNA EC CAPSULE TYPHOID VACCINE 0.58 Oncology Agents, Oral VIZIMPRO 15 MG TABLET DACOMITINIB 1 Oncology Agents, Oral VIZIMPRO 30 MG TABLET DACOMITINIB 1 Oncology Agents, Oral VIZIMPRO 45 MG TABLET DACOMITINIB 1 NSAIDs VOLTAREN 1% GEL DICLOFENAC SODIUM 32 NSAIDs VOLTAREN EC 50 MG TABLET DICLOFENAC SODIUM DR 4 NSAIDs VOLTAREN EC 75 MG TABLET DICLOFENAC SODIUM DR 3 NSAIDs VOLTAREN XR 100 MG TABLET DICLOFENAC SODIUM ER 2 Hepatitis C Agents VOSEVI 400-100-100 MG TABLET SOFOSBUVIR/VELPATAS/VOXILAPREV 1 Oncology Agents, Oral VOTRIENT 200 MG TABLET PAZOPANIB HYDROCHLORIDE 4 Blood Glucose Test Strips V-R BLOOD GLUCOSE TEST STRIPS BLOOD GLUCOSE TEST STRIPS 3.34 Antipsychotics, Atypical VRAYLAR 1.5 MG CAPSULE CARIPRAZINE 1 Antipsychotics, Atypical VRAYLAR 1.5 MG/3 MG PACK CARIPRAZINE 1 Effective 01/04/21 Alphabetical by Brand Name (when applicable)

Antipsychotics, Atypical VRAYLAR 3 MG CAPSULE CARIPRAZINE 1 Antipsychotics, Atypical VRAYLAR 4.5 MG CAPSULE CARIPRAZINE 1 Antipsychotics, Atypical VRAYLAR 6 MG CAPSULE CARIPRAZINE 1 Multiple Sclerosis Agents VUMERITY DR 231 MG CAPSULE DIROXIMEL FUMARATE 4 Migraine Prevention Agents VYEPTI 100 MG/ML VIAL EPTINEZUMAB-JJMR 0.04 Migraine Prevention Agents VYEPTI 100 MG/ML VIAL EPTINEZUMAB-JJMR 0.04 Transthyretin Stabilizer VYNDAMAX 61 MG CAPSULE TAFAMIDIS 1 Transthyretin Stabilizer VYNDAQEL 20 MG CAPSULE TAFAMIDIS MEGLUMINE 4 Lipotropics, Statins VYTORIN 10/10 TABLET EZETIMIBE/SIMVASTATIN 1 Lipotropics, Statins VYTORIN 10/20 TABLET EZETIMIBE/SIMVASTATIN 1 Lipotropics, Statins VYTORIN 10/40 TABLET EZETIMIBE/SIMVASTATIN 1 Lipotropics, Statins VYTORIN 10/80 TABLET EZETIMIBE/SIMVASTATIN 1 Stimulants & Related Agents VYVANSE 10 MG CAPSULE LISDEXAMFETAMINE 1 Stimulants & Related Agents VYVANSE 10 MG CHEWABLE TABLET LISDEXAMFETAMINE 1 Stimulants & Related Agents VYVANSE 20 MG CAPSULE LISDEXAMFETAMINE 1 Stimulants & Related Agents VYVANSE 20 MG CHEWABLE TABLET LISDEXAMFETAMINE 1 Stimulants & Related Agents VYVANSE 30 MG CAPSULE LISDEXAMFETAMINE 1 Stimulants & Related Agents VYVANSE 30 MG CHEWABLE TABLET LISDEXAMFETAMINE 1 Stimulants & Related Agents VYVANSE 40 MG CAPSULE LISDEXAMFETAMINE 1 Stimulants & Related Agents VYVANSE 40 MG CHEWABLE TABLET LISDEXAMFETAMINE 1 Stimulants & Related Agents VYVANSE 50 MG CAPSULE LISDEXAMFETAMINE 1 Stimulants & Related Agents VYVANSE 50 MG CHEWABLE TABLET LISDEXAMFETAMINE 1 Stimulants & Related Agents VYVANSE 60 MG CAPSULE LISDEXAMFETAMINE 1 Stimulants & Related Agents VYVANSE 60 MG CHEWABLE TABLET LISDEXAMFETAMINE 1 Stimulants & Related Agents VYVANSE 70 MG CAPSULE LISDEXAMFETAMINE 1 Stimulants & Related Agents WAKIX 17.8 MG TABLET PITOLISANT 2 Stimulants & Related Agents WAKIX 4.45 MG TABLET PITOLISANT 2 Insect Repellent NOT for Skin Application WALGREENS STOP LICE IN-HOME SPRAY PERMETHRIN 0.5% 29 Blood Glucose Test Strips WAVESENSE PRESTO BLOOD GLUCOSE TEST STRIPS BLOOD GLUCOSE TEST STRIPS 3.34 Lipotropics, Other WELCHOL 3.75 GRAM POWDER PACKET COLESEVELAM 1 Lipotropics, Other WELCHOL 625 MG TABLET COLESEVELAM 6 Antidepressants, Other WELLBUTRIN SR 100 MG TABLET BUPROPION 2 Antidepressants, Other WELLBUTRIN SR 150 MG TABLET BUPROPION 2 Antidepressants, Other WELLBUTRIN SR 200 MG TABLET BUPROPION 2 Antidepressants, Other WELLBUTRIN XL 150 MG TABLET BUPROPION 1 Antidepressants, Other WELLBUTRIN XL 300 MG TABLET BUPROPION 1 Antiparkinson's Agents XADAGO 100 MG TABLET SAFINAMIDE MESYLATE 1 Antiparkinson's Agents XADAGO 50 MG TABLET SAFINAMIDE MESYLATE 1 Oncology Agents, Oral XALKORI 200 MG CAPSULE CRIZOTINIB 2 Oncology Agents, Oral XALKORI 250 MG CAPSULE CRIZOTINIB 2 Anxiolytics XANAX 0.25 MG TABLET ALPRAZOLAM 6 Effective 01/04/21 Alphabetical by Brand Name (when applicable)

Anxiolytics XANAX 0.5 MG TABLET ALPRAZOLAM 6 Anxiolytics XANAX 1 MG TABLET ALPRAZOLAM 4 Anxiolytics XANAX 2 MG TABLET ALPRAZOLAM 3 Anxiolytics XANAX XR 0.5 MG TABLET ALPRAZOLAM ER 2 Anxiolytics XANAX XR 1 MG TABLET ALPRAZOLAM ER 2 Anxiolytics XANAX XR 2 MG TABLET ALPRAZOLAM ER 2 Anxiolytics XANAX XR 3 MG TABLET ALPRAZOLAM ER 2 Anticoagulants, Oral XARELTO 10 MG TABLET RIVAROXOBAN 1 Anticoagulants, Oral XARELTO 15 MG TABLET RIVAROXOBAN 2 Anticoagulants, Oral XARELTO 2.5 MG TABLET RIVAROXOBAN 2 Anticoagulants, Oral XARELTO 20 MG TABLET RIVAROXOBAN 1 Anticoagulants, Oral XARELTO STARTER PACK RIVAROXOBAN 1.7 Anticonvulsants XCOPRI 100 MG TABLET CENOBAMATE 1 Anticonvulsants XCOPRI 12.5-25 MG TITRATION PK CENOBAMATE 1 Anticonvulsants XCOPRI 150 MG TABLET CENOBAMATE 2 Anticonvulsants XCOPRI 150-200 MG TITRATION PK CENOBAMATE 1 Anticonvulsants XCOPRI 200 MG TABLET CENOBAMATE 2 Anticonvulsants XCOPRI 250 MG DAILY DOSE PACK CENOBAMATE 2 Anticonvulsants XCOPRI 350 MG DAILY DOSE PACK CENOBAMATE 2 Anticonvulsants XCOPRI 50 MG TABLET CENOBAMATE 1 Anticonvulsants XCOPRI 50-100 MG TITRATION PAK CENOBAMATE 1 Cytokine & CAM Antagonists XELJANZ 10 MG TABLET TOFACITINIB 2 Cytokine & CAM Antagonists XELJANZ 5 MG TABLET TOFACITINIB 2 Cytokine & CAM Antagonists XELJANZ XR 11 MG TABLET TOFACITINIB 1 Cytokine & CAM Antagonists XELJANZ XR 22 MG TABLET TOFACITINIB 1 VMAT2 Inhibitors XENAZINE 12.5 MG TABLET TETRABENAZINE 4 VMAT2 Inhibitors XENAZINE 25 MG TABLET TETRABENAZINE 4 Botulinum Toxins XEOMIN 100 UNIT INJECTION VIAL INCOBOTULINUMTOXIN A 0.14 Botulinum Toxins XEOMIN 200 UNIT INJECTION VIAL INCOBOTULINUMTOXIN A 0.07 Botulinum Toxins XEOMIN 50 UNIT INJECTION VIAL INCOBOTULINUMTOXIN A 0.14 Antivirals, Herpes XERESE 5%/1% CREAM ACYCLOVIR/HYDROCORTISONE 1 Antidiarrheals XERMELO 250 MG TABLET TELOTRISTAT ETHYL 3 Bone Density Regulators XGEVA 120 MG/1.7 ML VIAL DENOSUMAB 0.19 Intranasal Rhinitis Agents XHANCE 93 MCG NASAL SPRAY FLUTICASONE PROPIONATE 1.07 Enzymes XIAFLEX 0.9 MG VIAL COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 0.15 Antibiotics, GI and Related Agents XIFAXAN 200 MG TABLET RIVAMIXIN 2 Antibiotics, GI and Related Agents XIFAXAN 550 MG TABLET RIFAXIMIN 3 Hypoglycemics, SGLT2 Inhibitors XIGDUO XR 10/1000 MG TABLET DAPAGLIFLOZIN/METFORMIN 1 Hypoglycemics, SGLT2 Inhibitors XIGDUO XR 10/500 MG TABLET DAPAGLIFLOZIN/METFORMIN 1 Hypoglycemics, SGLT2 Inhibitors XIGDUO XR 2.5-1000 MG TABLET DAPAGLIFLOZIN AND METFORMIN ER 2 Hypoglycemics, SGLT2 Inhibitors XIGDUO XR 5/1000 MG TABLET DAPAGLIFLOZIN/METFORMIN 2 Effective 01/04/21 Alphabetical by Brand Name (when applicable)

Hypoglycemics, SGLT2 Inhibitors XIGDUO XR 5/500 MG TABLET DAPAGLIFLOZIN/METFORMIN 1 Ophthalmics, Immunomodulators XIIDRA 5% EYE DROPS LEFITEGRAST 2 Tetracyclines XIMINO ER 135 MG CAPSULE MINOCYCLINE HYDROCHLORIDE 1 Tetracyclines XIMINO ER 45 MG CAPSULE MINOCYCLINE HYDROCHLORIDE 1 Tetracyclines XIMINO ER 90 MG CAPSULE MINOCYCLINE HYDROCHLORIDE 1 Analgesics, Opioid Short-Acting XODOL 10 MG/300 MG TABLET HYDROCODONE/ACETAMINOPHEN 5 Analgesics, Opioid Short-Acting XODOL 5 MG/300 MG TABLET HYDROCODONE/ACETAMINOPHEN 10 Analgesics, Opioid Short-Acting XODOL 7.5 MG/300 MG TABLET HYDROCODONE/ACETAMINOPHEN 6 Antivirals, Influenza XOFLUZA 20 MG TABLET (40 MG DOSE) BALOXAVIR MARBOXIL 2 Antivirals, Influenza XOFLUZA 40 MG TABLET (80 MG DOSE) BALOXAVIR MARBOXIL 2 MABs - Anti-IL, Anti-IgE XOLAIR 150 MG/5 ML INJECTION VIAL OMALIZUMAB 0.22 MABs - Anti-IL, Anti-IgE XOLAIR 150 MG/ML SYRINGE OMALIZUMAB 0.15 MABs - Anti-IL, Anti-IgE XOLAIR 75 MG/0.5 ML SYRINGE OMALIZUMAB 0.04 Bronchodilators, Beta Agonist XOPENEX 0.31 MG/3 ML SOLUTION LEVALBUTEROL NEBULIZER VIAL 9 Bronchodilators, Beta Agonist XOPENEX 0.63 MG/3 ML SOLUTION LEVALBUTEROL NEBULIZER VIAL 9 Bronchodilators, Beta Agonist XOPENEX 1.25 MG/3 ML SOLUTION LEVALBUTEROL NEBULIZER VIAL 9 Bronchodilators, Beta Agonist XOPENEX CONCENTRATE 1.25 MG/0.5 ML SOLUTION LEVALBUTEROL CONCENTRATE SOLUTION 3 Bronchodilators, Beta Agonist XOPENEX HFA 45 MCG INHALER LEVALBUTEROL 1 Oncology Agents, Oral XOSPATA 40 MG TABLET GILTERITINIB 3 Oncology Agents, Oral XPOVIO 100 MG ONCE WEEKLY DOSE SILENEXOR 0.72 Oncology Agents, Oral XPOVIO 60 MG ONCE WEEKLY DOSE SILENEXOR 0.43 Oncology Agents, Oral XPOVIO 80 MG ONCE WEEKLY DOSE SILENEXOR 0.58 Oncology Agents, Oral XPOVIO 80 MG TWICE WEEKLY DOSE SILENEXOR 1.15 Analgesics, Opioid Long-Acting XTAMPZA 36 MG CAPSULE OXYCODONE MYRISTATE 2 Analgesics, Opioid Long-Acting XTAMPZA 9 MG CAPSULE OXYCODONE MYRISTATE 2 Analgesics, Opioid Long-Acting XTAMPZA ER 13.5 MG CAPSULE OXYCODONE MYRISTATE 2 Analgesics, Opioid Long-Acting XTAMPZA ER 18 MG CAPSULE OXYCODONE MYRISTATE 2 Analgesics, Opioid Long-Acting XTAMPZA ER 27 MG CAPSULE OXYCODONE MYRISTATE 2 Oncology Agents, Oral XTANDI 40 MG CAPSULE ENZALUTAMIDE 4 Contraceptives, Other XULANE PATCH NORELGESTROMIN/ETHINYL ESTRADIOL 0.15 Hypoglycemics, Insulin and Related Agents XULTOPHY 100 UNIT-3.6 MG/ML PEN INSULIN DEGLUDEC/LIRAGLUTIDE 0.5 Analgesics, Opioid Short-Acting XYLON 10/200 MG TABLET HYDROCODONE/IBUPROFEN 5 Androgenic Agents XYOSTED 100 MG/0.5 ML AUTO-INJ TESTOSTERONE ENANTHATE 0.08 Androgenic Agents XYOSTED 50 MG/0.5 ML AUTO-INJ TESTOSTERONE ENANTHATE 0.08 Androgenic Agents XYOSTED 75 MG/0.5 ML AUTO-INJ TESTOSTERONE ENANTHATE 0.08 Sedative, Non-Barbiturate XYREM 500 MG/ML ORAL SOLUTION SODIUM OXYBATE 18 Antihistamines, Minimally Sedating XYZAL 0.5 MG/ML SOLUTION LEVOCETIRIZINE 10 Antihistamines, Minimally Sedating XYZAL 5 MG TABLET LEVOCETIRIZINE 1 Oncology Agents, Oral YONSA 125 MG TABLET ABIRATERONE ACETATE 4 Platelet Aggregation Inhibitors YOSPRALA DR 325 MG/40 MG TABLET ASPIRIN/OMEPRAZOLE 1 Platelet Aggregation Inhibitors YOSPRALA DR 81 MG/40 MG TABLET ASPIRIN/OMEPRAZOLE 1 Effective 01/04/21 Alphabetical by Brand Name (when applicable)

COPD Agents YUPELRI 175 MCG/3 ML SOLUTION REVEFENACIN 3 Analgesics, Opioid Short-Acting ZAMICET 10 MG-325 MG/15 ML SOLUTION HYDROCODONE/ACETAMINOPHEN 75 Skeletal Muscle Relaxants ZANAFLEX 2 MG CAPSULE TIZANIDINE 3 Skeletal Muscle Relaxants ZANAFLEX 2 MG TABLET TIZANIDINE 3 Skeletal Muscle Relaxants ZANAFLEX 4 MG CAPSULE TIZANIDINE 8 Skeletal Muscle Relaxants ZANAFLEX 4 MG TABLET TIZANIDINE 9 Skeletal Muscle Relaxants ZANAFLEX 6 MG CAPSULE TIZANIDINE 6 Anticonvulsants ZARONTIN 250 MG CAPSULE ETHOSUXIMIDE 6 Anticonvulsants ZARONTIN 250 MG/5 ML SOLUTION ETHOSUXIMIDE 30 Enzyme Replacements, Gaucher Disease ZAVESCA 100 MG CAPSULE MIGLUSTAT 3 Analgesics, Non-Opioid Barbiturate Combos ZEBUTAL 50 MG/325 MG/40 MG CAPSULE BUTALBITAL/ACETAMINOPHEN/CAFFEINE 0.6 Proton Pump Inhibitors ZEGERID 40/1100 MG CAPSULE OMEPRAZOLE/SODIUM BICARBONATE 1 Proton Pump Inhibitors ZEGERID OTC 20/1100 MG CAPSULE OMEPRAZOLE/SODIUM BICARBONATE 1 Oncology Agents, Oral ZEJULA 100 MG CAPSULE NIRAPARIB TOSYLATE 3 Antiparkinson's Agents ZELAPAR 1.25 MG ODT SELEGILINE 2 Oncology Agents, Oral ZELBORAF 240 MG TABLET VEMURAFENIB 8 GI Motility, Chronic ZELNORM 6 MG TABLET TEGASEROD 2 Migraine Acute Treatment Agents ZEMBRACE SYMTOUCH 3 MG/0.5 ML PEN SUMATRIPTAN 0.27 Stimulants & Related Agents ZENZEDI 10 MG TABLET DEXTROAMPHETAMINE 3 Stimulants & Related Agents ZENZEDI 15 MG TABLET DEXTROAMPHETAMINE 3 Stimulants & Related Agents ZENZEDI 2.5 MG TABLET DEXTROAMPHETAMINE 3 Stimulants & Related Agents ZENZEDI 20 MG TABLET DEXTROAMPHETAMINE 3 Stimulants & Related Agents ZENZEDI 30 MG TABLET DEXTROAMPHETAMINE 2 Stimulants & Related Agents ZENZEDI 5 MG TABLET DEXTROAMPHETAMINE 3 Stimulants & Related Agents ZENZEDI 7.5 MG TABLET DEXTROAMPHETAMINE 3 Hepatitis C Agents ZEPATIER 50 MG/100 MG TABLET ELBASVIR/GRAZOPREVIR 1 Multiple Sclerosis Agents ZEPOSIA 0.23-0.46 MG START PACK OZANIMOD 1 Multiple Sclerosis Agents ZEPOSIA 0.23-0.46-0.92 MG KIT OZANIMOD 1 Multiple Sclerosis Agents ZEPOSIA 0.92 MG CAPSULE OZANIMOD 1 HIV/AIDS Antiretrovirals ZERIT 1 MG/ML POWDER FOR ORAL SOLUTION STAVUDINE 80 HIV/AIDS Antiretrovirals ZERIT 15 MG CAPSULE STAVUDINE 2 HIV/AIDS Antiretrovirals ZERIT 20 MG CAPSULE STAVUDINE 2 HIV/AIDS Antiretrovirals ZERIT 30 MG CAPSULE STAVUDINE 2 HIV/AIDS Antiretrovirals ZERIT 40 MG CAPSULE STAVUDINE 2 Angiotensin Modulators ZESTORETIC 10 MG/12.5 MG TABLET LISINOPRIL/HYDROCHLOROTHIAZIDE 2 Angiotensin Modulators ZESTORETIC 20 MG/12.5 MG TABLET LISINOPRIL/HYDROCHLOROTHIAZIDE 2 Angiotensin Modulators ZESTORETIC 20 MG/25 MG TABLET LISINOPRIL/HYDROCHLOROTHIAZIDE 2 Angiotensin Modulators ZESTRIL 10 MG TABLET LISINOPRIL 2 Angiotensin Modulators ZESTRIL 2.5 MG TABLET LISINOPRIL 2 Angiotensin Modulators ZESTRIL 20 MG TABLET LISINOPRIL 2 Angiotensin Modulators ZESTRIL 30 MG TABLET LISINOPRIL 2 Effective 01/04/21 Alphabetical by Brand Name (when applicable)

Angiotensin Modulators ZESTRIL 40 MG TABLET LISINOPRIL 2 Angiotensin Modulators ZESTRIL 5 MG TABLET LISINOPRIL 2 Lipotropics, Other ZETIA 10 MG TABLET EZETIMIBE 1 Intranasal Rhinitis Agents ZETONNA NASAL SPRAY CICLESONIDE 0.21 HIV/AIDS Antiretrovirals ZIAGEN 20 MG/ML ORAL SOLUTION ABACAVIR 30 HIV/AIDS Antiretrovirals ZIAGEN 300 MG TABLET ABACAVIR 2 Colony Stimulating Factors ZIEXTENZO 6 MG/0.6 ML SYRINGE PEGFILGRASTIM-BMEZ 0.05 Antibiotics, GI and Related Agents ZINPLAVA 1,000 MG/40 ML VIAL BEZLOTOXUMAB 80 NSAIDs ZIPSOR 25 MG CAPSULE DICLOFENAC POTASSIUM 4 Antibiotics, Injectable ZITHROMAX I.V. 500 MG VIAL AZITHROMYCIN 1 Lipotropics, Statins ZOCOR 10 MG TABLET SIMVASTATIN 1.5 Lipotropics, Statins ZOCOR 20 MG TABLET SIMVASTATIN 1.5 Lipotropics, Statins ZOCOR 40 MG TABLET SIMVASTATIN 1 Lipotropics, Statins ZOCOR 5 MG TABLET SIMVASTATIN 1.5 Lipotropics, Statins ZOCOR 80 MG TABLET SIMVASTATIN 1 Antiemetics/Antivertigo Agents ZOFRAN 2 MG/ML VIAL ONDANSETRON 24 Antiemetics/Antivertigo Agents ZOFRAN 4 MG TABLET ONDANSETRON 4 Antiemetics/Antivertigo Agents ZOFRAN 4 MG/5 ML ORAL SOLUTION ONDANSETRON 30 Antiemetics/Antivertigo Agents ZOFRAN 8 MG TABLET ONDANSETRON 3 Antiemetics/Antivertigo Agents ZOFRAN ODT 4 MG TABLET ONDANSETRON 3 Antiemetics/Antivertigo Agents ZOFRAN ODT 8 MG TABLET ONDANSETRON 3 Analgesics, Opioid Long-Acting ZOHYDRO ER 10 MG CAPSULE HYDROCODONE ER 2 Analgesics, Opioid Long-Acting ZOHYDRO ER 15 MG CAPSULE HYDROCODONE ER 2 Analgesics, Opioid Long-Acting ZOHYDRO ER 20 MG CAPSULE HYDROCODONE ER 2 Analgesics, Opioid Long-Acting ZOHYDRO ER 30 MG CAPSULE HYDROCODONE ER 2 Analgesics, Opioid Long-Acting ZOHYDRO ER 40 MG CAPSULE HYDROCODONE ER 2 Analgesics, Opioid Long-Acting ZOHYDRO ER 50 MG CAPSULE HYDROCODONE ER 2 Pituitary Suppressive Agents, LHRH ZOLADEX 10.8 MG IMPLANT SYRINGE GOSERELIN 0.02 Pituitary Suppressive Agents, LHRH ZOLADEX 3.6 MG IMPLANT SYRINGE GOSERELIN 0.15 Oncology Agents, Oral ZOLINZA 100 MG TABLET VORINOSTAT 4 Antidepressants, SSRIs ZOLOFT 100 MG TABLET SERTRALINE 2 Antidepressants, SSRIs ZOLOFT 20 MG/ML ORAL CONCENTRATE SERTRALINE 10 Antidepressants, SSRIs ZOLOFT 25 MG TABLET SERTRALINE 3 Antidepressants, SSRIs ZOLOFT 50 MG TABLET SERTRALINE 3 Sedative Hypnotics ZOLPIMIST 5 MG ORAL SPRAY ZOLPIDEM 0.26-See footnote3 Bone Density Regulators ZOMETA 4 MG/100 ML INJECTION VIAL ZOLEDRONIC ACID 14.29 Bone Density Regulators ZOMETA 4 MG/5 ML VIAL ZOLEDRONIC ACID 0.72 Migraine Acute Treatment Agents ZOMIG 2.5 MG TABLET ZOLMITRIPTAN 0.3 Migraine Acute Treatment Agents ZOMIG 5 MG NASAL SPRAY ZOLMITRIPTAN 0.2 Migraine Acute Treatment Agents ZOMIG 5 MG TABLET ZOLMITRIPTAN 0.3 Migraine Acute Treatment Agents ZOMIG-ZMT 2.5 MG ODT ZOLMITRIPTAN 0.3 Effective 01/04/21 Alphabetical by Brand Name (when applicable)

Migraine Acute Treatment Agents ZOMIG-ZMT 5 MG ODT ZOLMITRIPTAN 0.3 Anticonvulsants ZONEGRAN 100 MG CAPSULE ZONISAMIDE 6 Anticonvulsants ZONEGRAN 25 MG CAPSULE ZONISAMIDE 6 Anticonvulsants ZONEGRAN 50 MG CAPSULE ZONISAMIDE 6 Platelet Aggregation Inhibitors ZONTIVITY 2.08 MG TABLET VORAPAXAR 1 NSAIDs ZORVOLEX 18 MG CAPSULE DICLOFENAC 3 NSAIDs ZORVOLEX 35 MG CAPSULE DICLOFENAC 3 Vaccines ZOSTAVAX VACCINE VIAL ZOSTER VACCINE 1 Antivirals, Herpes ZOVIRAX 5% CREAM ACYCLOVIR 1.25 Antivirals, Herpes ZOVIRAX 5% OINTMENT ACYCLOVIR 4.29 Opioid Dependence Treatments ZUBSOLV 0.7 MG/0.18 MG SL TABLET BUPRENORPHINE/NALOXONE 3 Opioid Dependence Treatments ZUBSOLV 1.4 MG/0.36 MG SL TABLET BUPRENORPHINE/NALOXONE 3 Opioid Dependence Treatments ZUBSOLV 11.4 MG/2.9 MG SL TABLET BUPRENORPHINE/NALOXONE 1 Opioid Dependence Treatments ZUBSOLV 2.9 MG/0.71 MG SL TABLET BUPRENORPHINE/NALOXONE 1 Opioid Dependence Treatments ZUBSOLV 5.7 MG/1.4 MG SL TABLET BUPRENORPHINE/NALOXONE 1 Opioid Dependence Treatments ZUBSOLV 8.6 MG/2.1 MG SL TABLET BUPRENORPHINE/NALOXONE 2 Antiemetics/Antivertigo Agents ZUPLENZ 4 MG SOLUBLE FILM ONDANSETRON 3 Antiemetics/Antivertigo Agents ZUPLENZ 8 MG SOLUBLE FILM ONDANSETRON 3 Opioid Antitussive ZUTRIPRO SOLUTION HYDROCODONE/CPM/PSEUDOEPHED 20 Smoking Cessation ZYBAN SR 150 MG TABLET BUPROPION 2 Oncology Agents, Oral ZYDELIG 100 MG TABLET IDELALISIB 2 Oncology Agents, Oral ZYDELIG 150 MG TABLET IDELALISIB 2 Leukotriene Modifiers ZYFLO CR 600 MG TABLET ZILEUTON 4 Oncology Agents, Oral ZYKADIA 150 MG CAPSULE CERITINIB 3 Lipotropics, Statins ZYPITAMAG 1 MG TABLET PITAVASTATIN 1 Lipotropics, Statins ZYPITAMAG 2 MG TABLET PITAVASTATIN 1 Lipotropics, Statins ZYPITAMAG 4 MG TABLET PITAVASTATIN 1 Antipsychotics, Atypical ZYPREXA 10 MG INJECTION VIAL OLANZAPINE 3 Antipsychotics, Atypical ZYPREXA 10 MG TABLET OLANZAPINE 1 Antipsychotics, Atypical ZYPREXA 15 MG TABLET OLANZAPINE 1 Antipsychotics, Atypical ZYPREXA 2.5 MG TABLET OLANZAPINE 1 Antipsychotics, Atypical ZYPREXA 20 MG TABLET OLANZAPINE 1 Antipsychotics, Atypical ZYPREXA 5 MG TABLET OLANZAPINE 1 Antipsychotics, Atypical ZYPREXA 7.5 MG TABLET OLANZAPINE 1 Antipsychotics, Atypical ZYPREXA RELPREVV 210 MG INJECTION VIAL OLANZAPINE 0.07 Antipsychotics, Atypical ZYPREXA RELPREVV 300 MG INJECTION VIAL OLANZAPINE 0.07 Antipsychotics, Atypical ZYPREXA RELPREVV 405 MG INJECTION VIAL OLANZAPINE 0.04 Antipsychotics, Atypical ZYPREXA ZYDIS 10 MG TABLET OLANZAPINE 1 Antipsychotics, Atypical ZYPREXA ZYDIS 15 MG TAB OLANZAPINE 1 Antipsychotics, Atypical ZYPREXA ZYDIS 20 MG TABLET OLANZAPINE 1 Antipsychotics, Atypical ZYPREXA ZYDIS 5 MG TABLET OLANZAPINE 1 Effective 01/04/21 Alphabetical by Brand Name (when applicable)

Antihistamines, Minimally Sedating ZYRTEC 10 MG LIQUID GELS CETIRIZINE 1 Antihistamines, Minimally Sedating ZYRTEC 10 MG TABLET/CHEW TAB CETIRIZINE 1 Antihistamines, Minimally Sedating ZYRTEC 5 MG TABLET/CHEW TAB CETIRIZINE 1 Antihistamines, Minimally Sedating ZYRTEC-D TABLET PSEUDOEPHEDRINE/CETIRIZINE 2 Oncology Agents, Oral ZYTIGA 250 MG TABLET ABIRATERONE 4 Oncology Agents, Oral ZYTIGA 500 MG TABLET ABIRATERONE 2