(Medicare-Medicaid Plan) Formulary for 2020

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CareSource® MyCare Ohio (Medicare-Medicaid Plan) Formulary for 2020

CareSource MyCare Ohio Member Services Department: 1-855-475-3163 (TTY: 1-800-750-0750 or 711) CareSource.com/MyCare

Formulary ID: 00020474 Version#: 18 Updated: 12/2020 H8452_OHMMC-1466 _V.13

CareSource® MyCare Ohio (Medicare-Medicaid Plan) | 2020 List of Covered Drugs (Formulary)

Introduction

This document is called the List of Covered Drugs (also known as the Drug List). It tells you which prescription drugs and over-the-counter drugs are covered by CareSource MyCare Ohio. The Drug List also tells you if there are any special rules or restrictions on any drugs covered by CareSource MyCare Ohio. Key terms and their definitions appear in the last chapter of the Member Handbook.

Table of Contents

A. Disclaimers...... iii

B. Frequently Asked Questions (FAQ) ...... iv

B1. What prescription drugs are on the List of Covered Drugs? (We call the List of Covered Drugs the “Drug List” for short.) ...... iv

B2. Does the Drug List ever change? ...... iv

B3. What happens when there is a change to the Drug List?...... v

B4. Are there any restrictions or limits on drug coverage or any required actions to take to get certain drugs? ...... vi

B5. How will you know if the drug you want has limitations or if there are required actions to take to get the drug? ...... vi

B6. What happens if we change our rules about some drugs (for example, prior authorization (approval), quantity limits, and/or step therapy restrictions)? ...... vii

B7. How can you find a drug on the Drug List? ...... vii

B8. What if the drug you want to take is not on the Drug List? ...... vii

B9. What if you are a new CareSource MyCare Ohio member and can’t find your drug on the Drug List or have a problem getting your drug? ...... vii

B10. Can you ask for an exception to cover your drug? ...... ix

B11. How can you ask for an exception? ...... ix

B12. How long does it take to get an exception? ...... ix

B14. What are OTC drugs? ...... x

B15. What is your copay? ...... x

B16. What are drug tiers? ...... x

C. List of Covered Drugs by Medical Condition ...... xi

D. Index of Covered Drugs...... 207

This is a list of drugs that members can get in CareSource MyCare Ohio.

 CareSource MyCare Ohio is a health plan that contracts with both Medicare and Ohio Medicaid to provide benefits of both programs to enrollees.

 You can always check CareSource MyCare Ohio’s up-to-date List of Covered Drugs online at CareSource.com/MyCare.

 ATTENTION: If you speak Spanish, language assistance services, free of charge, are available to you. Call 1-855-475-3163 (TTY: 711), Monday – Friday, 8 a.m. – 8 p.m. The call is free.

 ATENCIÓN: Si habla espaol, tiene disponible los servicios de asistencia de idioma gratis. Llame al 1-855-475-3163 (TTY: 711), el lunes a viernes, 8 a.m. a 8 p.m. La llamada es gratis.

 You can get this document for free in other formats, such as large print, braille, or audio. Call 1-855-475-3163 (TTY: 711), Monday – Friday, 8 a.m. – 8 p.m. The call is free.

 To request this document in a language other than English or in an alternate format now and in the future, please call Member Services at 1-855-475-3163 (TTY: 1-800-750-0750 or 711), Monday – Friday, 8 a.m. – 8 p.m. The call is free.  If you would like to receive materials in an alternate format, please let our Member Services department know. We have Member handbooks, our annual notice of change, formularies, the summary of benefits, provider/pharmacy directories, and some letters available in Spanish. We can also send these and other materials in different formats upon request. Call our Member Services department for help at 1-855-475-3163 (TTY: 711), Monday – Friday, 8 a.m. – 8 p.m. The call is free.

Find answers here to questions you have about this List of Covered Drugs. You can read all of the FAQ to learn more, or look for a question and answer.

B1. What prescription drugs are on the List of Covered Drugs? (We call the List of Covered Drugs the “Drug List” for short.) The drugs on the List of Covered Drugs that starts on page 2 are the drugs covered by CareSource MyCare Ohio. These drugs are available at pharmacies within our network. A pharmacy is in our network if we have an agreement with them to work with us and provide you services. We refer to these pharmacies as “network pharmacies.”

• CareSource MyCare Ohio will cover all medically necessary drugs on the Drug List if:

o your doctor or other prescriber says you need them to get better or stay healthy, and

o you fill the prescription at a CareSource MyCare Ohio network pharmacy. • CareSource MyCare Ohio may have additional steps to access certain drugs (see question B4 below)

You can also see an up-to-date list of drugs that we cover on our website at CareSource.com/MyCare or call Member Services at 1-855-475-3163 (TTY: 711).

B2. Does the Drug List ever change? Yes. CareSource MyCare Ohio may add or remove drugs on the Drug List during the year.

We may also change our rules about drugs. For example, we could:

• Decide to require or not require prior approval for a drug. (Prior approval is permission from CareSource MyCare Ohio before you can get a drug.)

• Add or change the amount of a drug you can get (called quantity limits).

• Add or change step therapy restrictions on a drug. (Step therapy means you must try one drug before we will cover another drug.)

For more information on these drug rules, see question B4.

If you are taking a drug that was covered at the beginning of the year, we will generally not remove or change coverage of that drug during the rest of the year unless:

• a new, cheaper drug comes on the market that works as well as a drug on the Drug List now, or

• a drug is removed from the market.

Questions B3 and B6 below have more information on what happens when the Drug List changes.

• You can always check CareSource MyCare Ohio’s up to date Drug List online at CareSource.com/MyCare.

• You can also call Member Services to check the current Drug List at 1-855-475-3163 (TTY:711).

B3. What happens when there is a change to the Drug List? Some changes to the Drug List will happen immediately. For example:

• A drug is taken off the market. If the Food and Drug Administration ( FDA) says a drug you are taking is not safe or the drug’s manufacturer takes a drug off the market , we will take it off the Drug List. If you are taking the drug, we will l et you know that. Please contact y our prescribing doctor if you are notified.

We may make other changes that affect the drugs you take. We will tell you in advance about these other changes to the Drug List. These changes might happen if:

• The FDA provides new guidance or there are new clinical guidelines about a drug.

• We add a generic drug that is not new to the market and

o Replace a brand name drug currently on the Drug List or

Change the coverage rules or limits for the brand name drug. o When these changes happen, we will:

• Tell you at least 30 days before we make the change to the Drug List or

• Let you know and give you a 30-day supply of the drug after you ask for a refill.

This will give you time to talk to your doctor or other prescriber. He or she can help you decide:

• If there is a similar drug on the Drug List you can take instead or

• Whether to ask for an exception from these changes. To learn more about exceptions, see question B10.

B4. Are there any restrictions or limits on drug coverage or any required actions to take to get certain drugs?

Yes, some drugs have coverage rules or have limits on the amount you can get. In some cases you or your doctor or other prescriber must do something before you can get the drug. For example:

• Prior approval (or prior authorization): For some drugs, you or your doctor or other prescriber must get approval from CareSource MyCare Ohio before you fill your prescription. CareSource MyCare Ohio may not cover the drug if you do not get approval.

• Quantity limits: Sometimes CareSource MyCare Ohio limits the amount of a drug you can get.

• Step therapy: Sometimes CareSource MyCare Ohio requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor thinks the first drug doesn’t work for you, then we will cover the second.

• Indication-based coverage: If CareSource MyCare Ohio covers a drug only for some medical conditions, we clearly identify it on the Drug List along with the specific medical conditions that are covered.

You can find out if your drug has any additional requirements or limits by looking in the tables on pages 2-206. You can also get more information by visiting our web site at CareSource.com/MyCare. We have posted online documents that explains our prior authorization and step therapy restrictions . You may also ask us to send you a copy.

You can ask for an exception from these limits. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to ask for an exception. Please see question s B10-B12 for more information about exceptions.

B5. How will you know if the drug you want has limitations or if there are

required actions to take to get the drug?

The List of Covered Drugs on page 2 has a column labeled “Necessary actions, restrictions, or limits on use.”

B6. What happens if we change our rules about some drugs (for example, prior authorization (approval) , quantity limits , and/or step therapy restrictions)?

In some cases, we will tell you in advance if we add or change prior approval, quantity limits, and/or step therapy restrictions on a drug. See question B3 for more information about this advance notice and situations where we may not be able to tell you in advance when our rules about drugs on the Drug List change.

B7. How can you find a drug on the Drug List?

There are two ways to find a drug:

• You can search alphabetically (if you know how to spell the drug), or

• You can search by medical condition.

To search alphabetically, go to the Index of Covered Drugs section. You can find it in the Index section at the end of the formulary.

To search by medical condition, find the section labeled “List of drugs by medical condition” on page xi. The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat . For example, if you have a heart condition , you should look in the category , Diuretics – Drugs to Treat H eart Conditions. That is where you will find drugs that treat heart conditions.

B8. What if the drug you want to take is not on the Drug List?

If you don’t see your drug on the Drug List, call Member Services at 1-855-475-3163 and ask about it. If you learn that CareSource MyCare Ohio will not cover the drug, you can do one of these things:

• Ask Member Services for a list of drugs like the one you want to take. Then show the list to your doctor or other prescriber. He or she can prescribe a drug on the

Drug List that is like the one you want to take. Or

• You can ask the health plan to make an exception to cover your drug. Please see questions B10- B12 for more information about exceptions.

B9. What if you are a new CareSource MyCare Ohio member and can’t find your drug on the Drug List or have a problem getting your drug?

We can help. We may cover a temporary 30-day supply of your drug during the first 90 days you are a member of CareSource MyCare Ohio. This will give you time to talk to your doctor or other

If your prescription is written for fewer days, we will allow multiple refills to provide up to a maximum of 30 days of medication.

We will cover a 30-day supply of your drug if:

• you are taking a drug that is not on our Drug List, or

• health plan rules do not let you get the amount ordered by your prescriber, or

• the drug requires prior approval by CareSource MyCare Ohio, or

• you are taking a drug that is part of a step therapy restriction.

If you are in a nursing home or other long-term care facility and need a drug that is not on the Drug List or if you cannot easily get the drug you need, we can help. If you have been in the plan for more than 90 days, live in a long-term care facility, and need a supply right away:

• We will cover one 31-day supply of the drug you need (unless you have a prescription for fewer days), whether or not you are a new CareSource MyCare Ohio member.

• This is in addition to the temporary supply during the first 90 days you are a member of CareSource MyCare Ohio.

Below is the CareSource MyCare Ohio Transition Policy for current enrollees with level of care changes:

Level of Care Changes

• In addition to circumstances impacting new enrollees who may enroll in CareSource MyCare Ohio with a medication list that contains non-formulary Part D drugs, other circumstances exist in which unplanned transitions for current members could arise and in which prescribed drug regimens may not be on the CareSource MyCare Ohio formulary.

• These circumstances usually involve level of care changes in which a beneficiary is changing from one treatment setting to another.

o Beneficiaries who enter Long Term Care (LTC) facilities with a discharge list of medications from the hospital formulary with very short term planning into account (often under 8 hours);

o Beneficiaries who are admitted to or discharged from a hospital to a home;

o Beneficiaries who give up hospice status to revert to standard Medicare Part A and B benefits;

o Beneficiaries who end a Long Term Care (LTC) facility stay and return to the community; and

o Beneficiaries who are discharged from psychiatric hospitals with drug regimens that are highly individualized.

• For non-Long Term Care (LTC) residents, the pharmacy must call the Pharmacy Benefit Manager (PBM) Pharmacy Help Desk in order to obtain an override to submit a Level of Care transition fill request.

o For Long Term Care (LTC) residents, a submission clarification code is submitted by the pharmacy to allow transition fills and to override Refill Too Soon rejects for new patient admissions.

• When an enrollee is admitted to or discharged from a Long Term Care (LTC) facility, the Pharmacy Benefit Manager (PBM), on behalf of CareSource MyCare Ohio, allows the enrollee to access a refill upon admission or discharge.

B10. Can you ask for an exception to cover your drug? Yes. You can ask CareSource MyCare Ohio to make an exception to cover a drug that is not on the Drug List.

You can also ask us to change the rules on your drug.

• For example, CareSource MyCare Ohio may limit the amount of a drug we will cover. If your drug has a limit, you can ask us to change the limit and cover more.

• Other examples: You can ask us to drop step therapy restrictions or prior approval requirements.

B11. How can you ask for an exception? To ask for an exception, call Member Services. A Member Services representative will work with you and your provider to help you ask for an exception. You can also read Chapter 9, of the Member Handbook to learn more about exceptions.

B12. How long does it take to get an exception? First, we must get a statement from your prescriber supporting your request for an exception. After we get the statement, we will give you a decision on your exception request within 72 hours. If you have questions, please call CareSource MyCare Ohio at 1-855-475-3163 (TTY: 711), ? Monday – Friday, 8 a.m. – 8 p.m. If you need to speak to your care manager, please call 1-866- 206-7861, 24 hours a day, 7 days a week. These calls are free. For more information, visit CareSource.com/MyCare. ix If you or your prescriber think your health may be harmed if you have to wait 72 hours for a decision, you can ask for an expedited exception. This is a faster decision. If your prescriber supports your request, we will give you a decision within 24 hours of getting your prescriber’s supporting statement.

B13. What are generic drugs? Generic drugs are made up of the same active ingredients as brand name drugs. They usually cost less than the brand name drug and usually don’t have well-known names. Generic drugs are approved by the Food and Drug Administration (FDA).

CareSource MyCare Ohio covers both brand name drugs and generic drugs.

B14. What are OTC drugs? OTC stands for “over-the-counter”. CareSource MyCare Ohio covers some OTC drugs when they are written as prescriptions by your provider.

You can read the CareSource MyCare Ohio Drug List to see what OTC drugs are covered.

B15. What is your copay? As a CareSource MyCare Ohio member, you have no copays for prescription and OTC drugs as long as you follow CareSource MyCare Ohio’s rules.

B16. What are drug tiers? Tiers are groups of drugs on our Drug List.

• Tier 1 drugs are generic drugs.

• Tier 2 drugs are brand name drugs.

• Tier 3 Drugs are Medicaid covered drugs.

There are no copays for any of the tiers.

The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat. For example, if you have a heart condition, you should look in the category, Diuretics – Drugs to Treat Heart Conditions. That is where you will find drugs that treat heart conditions.

The following list of covered drugs gives you information about the drugs covered by CareSource MyCare Ohio. If you have trouble finding your drug in the list, turn to the Index of Covered Drugs that begins on page 207. The index alphabetically lists all drugs covered by CareSource MyCare Ohio.

The first column of the chart lists the name of the drug. Brand name drugs are capitalized (e.g., COUMADIN), and generic drugs are listed in lower-case italics (e.g., warfarin sodium).

The information in the necessary actions, restrictions, or limits on use column tells you if CareSource MyCare Ohio has any rules for covering your drug.

Note: The asterisk * next to a drug means the drug is not a “Part D drug.” The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage).

• In addition, if you are getting Extra Help to pay for your prescriptions, you will not get any Extra Help to pay for these drugs. For more information on Extra Help, please see the call-out box below.

Extra Help is a Medicare program that helps people with limited incomes and resources reduce Medicare Part D prescription drug costs, such as premiums, deductibles, and copays.

Extra Help is also called the “Low-Income Subsidy,” or “LIS.”

• These drugs also have different rules for appeals. An appeal is a formal way of asking us to review a coverage decision and to change it if you think we made a mistake. For example, we might decide that a drug that you want is not covered or is no longer covered by Medicare or Medicaid.

• If you or your doctor disagrees with our decision, you can appeal. To ask for instructions on how to appeal, call Member Services at 1-855-475-3163 (TTY: 711). You can also read the Chapter 9 of the Member Handbook to learn how to appeal a decision.

List of Abbreviations

ADD: Non-Part D drugs or OTC items that are covered by Medicaid only

B/D PA: This prescription drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination.

LA: Limited Availability. This prescription may be available only at certain pharmacies. For more information, please call Customer Service.

MO: Mail-Order Drug. This prescription drug is available through our mail-order service, as well as through our retail network pharmacies. Consider using mail order for your long-term (maintenance) medications (such as high blood pressure medications). Retail network pharmacies may be more appropriate for short-term prescriptions (such as antibiotics).

PA: Prior Authorization. The Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescriptions. If you don’t get approval, we may not cover the drug.

QL: Quantity Limit. For certain drugs, the Plan limits the amount of the drug that we will cover.

ST: Step Therapy. In some cases, the Plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B.

* Certain medications called specialty medications are limited to no more than a 30 day supply per fill.

If you have questions, please call CareSource MyCare Ohio at 1-855-475-3163 (TTY: 711), ? Monday – Friday, 8 a.m. – 8 p.m. If you need to speak to your care manager, please call 1-866- 206-7861, 24 hours a day, 7 days a week. These calls are free. For more information, visit CareSource.com/MyCare. 1 Name of Drug What the Necessary Name of Drug What the Necessary Drug Actions, Drug Actions, Will Restrictions, Will Restrictions, Cost You or Limit On Cost You or Limit On (Tier Use (Tier Use Level) Level) ANTI - INFECTIVES NOXAFIL ORAL 2 MO ANTIFUNGAL AGENTS nystatin oral 1 MO suspension ABELCET 2 B/D PA; MO nystatin oral tablet 1 MO AMBISOME 2 B/D PA; MO posaconazole oral 1 MO amphotericin b 1 B/D PA; MO tablet,delayed caspofungin 1 B/D PA release (dr/ec) clotrimazole mucous 1 MO terbinafine hcl oral 1 MO membrane voriconazole 1 PA; MO CRESEMBA 2 PA intravenous INTRAVENOUS voriconazole oral 1 MO CRESEMBA ORAL 2 MO ANTIVIRALS fluconazole 1 MO abacavir 1 MO fluconazole in nacl 1 PA; MO abacavir-lamivudine 1 MO (iso-osm) intravenous abacavir- 1 MO piggyback 200 lamivudine- mg/100 ml zidovudine fluconazole in nacl 1 PA acyclovir oral 1 MO (iso-osm) capsule intravenous acyclovir oral 1 MO piggyback 400 suspension 200 mg/5 mg/200 ml ml flucytosine 1 MO acyclovir oral tablet 1 MO griseofulvin 1 MO acyclovir sodium 1 B/D PA; MO microsize intravenous solution griseofulvin 1 MO adefovir 1 MO ultramicrosize amantadine hcl 1 MO itraconazole 1 MO APTIVUS 2 MO ketoconazole oral 1 MO APTIVUS (WITH 2 micafungin 1 VITAMIN E) MYCAMINE 2 MO atazanavir 1 MO If you have questions, please call CareSource MyCare Ohio at 1-855-475-3163 (TTY: 711), Monday - Friday, 8 a.m. - 8 p.m. If you need to speak to your care manager, please call 1-866-206-7861, 24 hours a day, 7 days a week. These calls are free. For more information, visit CareSource.com/MyCare. 2 Name of Drug What the Necessary Name of Drug What the Necessary Drug Actions, Drug Actions, Will Restrictions, Will Restrictions, Cost You or Limit On Cost You or Limit On (Tier Use (Tier Use Level) Level) ATRIPLA 2 MO EPCLUSA ORAL 2 PA; MO; QL TABLET 400-100 (28 per 28 BARACLUDE 2 MO MG days) ORAL SOLUTION EPIVIR HBV 2 MO BIKTARVY 2 MO ORAL SOLUTION cidofovir 1 B/D PA; MO EVOTAZ 2 MO CIMDUO 2 MO famciclovir 1 MO COMPLERA 2 MO fosamprenavir 1 MO CRIXIVAN ORAL 2 MO FUZEON 2 MO CAPSULE 200 MG, SUBCUTANEOUS 400 MG RECON SOLN DELSTRIGO 2 MO ganciclovir sodium 1 B/D PA; MO DESCOVY 2 MO GENVOYA 2 MO didanosine oral 1 MO HARVONI ORAL 2 PA; MO; QL capsule,delayed PELLETS IN (28 per 28 release(dr/ec) 250 PACKET 33.75-150 days) mg, 400 mg MG DOVATO 2 MO HARVONI ORAL 2 PA; MO; QL EDURANT 2 MO PELLETS IN (56 per 28 efavirenz 1 MO PACKET 45-200 days) MG efavirenz- 1 MO emtricitabin-tenofov HARVONI ORAL 2 PA; MO; QL TABLET 45-200 (56 per 28 efavirenz-lamivu- 1 MO MG days) tenofov disop HARVONI ORAL 2 PA; MO; QL emtricitabine 1 MO TABLET 90-400 (28 per 28 emtricitabine- 1 MO MG days) tenofovir (tdf) INTELENCE 2 MO EMTRIVA 2 MO INVIRASE ORAL 2 MO entecavir 1 MO TABLET EPCLUSA ORAL 2 PA; MO; QL ISENTRESS 2 MO TABLET 200-50 (56 per 28 ISENTRESS HD 2 MO MG days) JULUCA 2 MO

If you have questions, please call CareSource MyCare Ohio at 1-855-475-3163 (TTY: 711), Monday - Friday, 8 a.m. - 8 p.m. If you need to speak to your care manager, please call 1-866-206-7861, 24 hours a day, 7 days a week. These calls are free. For more information, visit CareSource.com/MyCare. 11 Name of Drug What the Necessary Name of Drug What the Necessary Drug Actions, Drug Actions, Will Restrictions, Will Restrictions, Cost You or Limit On Cost You or Limit On (Tier Use (Tier Use Level) Level) nitrofurantoin 1 MO VISTOGARD 2 PA; MO monohyd/m-cryst XGEVA 2 B/D PA; MO trimethoprim 1 MO ANTINEOPLASTIC / ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS IMMUNOSUPPRESSANT abiraterone 1 PA; MO; QL DRUGS (120 per 30 days) ADJUNCTIVE AGENTS ABRAXANE 2 B/D PA; MO dexrazoxane hcl 1 B/D PA intravenous recon ADCETRIS 2 B/D PA; MO soln 250 mg adriamycin 1 B/D PA; MO dexrazoxane hcl 1 B/D PA; MO intravenous recon intravenous recon soln 10 mg soln 500 mg adriamycin 1 B/D PA ELITEK 2 MO intravenous solution KEPIVANCE 2 MO adrucil intravenous 1 B/D PA solution 2.5 gram/50 KHAPZORY 2 B/D PA ml leucovorin calcium 1 B/D PA; MO AFINITOR 2 PA; MO; QL injection recon soln (30 per 30 100 mg, 200 mg, 350 days) mg, 50 mg AFINITOR 2 PA; MO leucovorin calcium 1 B/D PA DISPERZ injection recon soln 500 mg ALECENSA 2 PA; MO; QL (240 per 30 leucovorin calcium 1 MO days) oral ALIMTA 2 B/D PA; MO levoleucovorin 1 B/D PA calcium intravenous ALIQOPA 2 B/D PA; MO; recon soln 50 mg LA levoleucovorin 1 B/D PA ALUNBRIG ORAL 2 PA; MO; QL calcium intravenous TABLET 180 MG, (30 per 30 solution 90 MG days) mesna 1 B/D PA; MO MESNEX ORAL 2 MO If you have questions, please call CareSource MyCare Ohio at 1-855-475-3163 (TTY: 711), Monday - Friday, 8 a.m. - 8 p.m. If you need to speak to your care manager, please call 1-866-206-7861, 24 hours a day, 7 days a week. These calls are free. For more information, visit CareSource.com/MyCare. 12 Name of Drug What the Necessary Name of Drug What the Necessary Drug Actions, Drug Actions, Will Restrictions, Will Restrictions, Cost You or Limit On Cost You or Limit On (Tier Use (Tier Use Level) Level) ALUNBRIG ORAL 2 PA; MO; QL BLENREP 2 PA; MO TABLET 30 MG (60 per 30 bleomycin 1 B/D PA; MO days) BLINCYTO 2 B/D PA; MO ALUNBRIG ORAL 2 PA; MO; QL INTRAVENOUS TABLETS,DOSE (30 per 30 KIT PACK days) BORTEZOMIB 2 B/D PA; MO anastrozole 1 MO BOSULIF ORAL 2 PA; MO; QL ARRANON 2 B/D PA TABLET 100 MG (90 per 30 ARSENIC 2 B/D PA days) TRIOXIDE BOSULIF ORAL 2 PA; MO; QL INTRAVENOUS TABLET 400 MG, (30 per 30 SOLUTION 1 500 MG days) MG/ML BRAFTOVI ORAL 2 PA; MO; LA; arsenic trioxide 1 B/D PA; MO CAPSULE 50 MG QL (120 per intravenous solution 30 days) 2 mg/ml BRAFTOVI ORAL 2 PA; MO; LA; ARZERRA 2 B/D PA; MO CAPSULE 75 MG QL (180 per AVASTIN 2 B/D PA; MO 30 days) AYVAKIT 2 PA; MO; LA BRUKINSA 2 PA; MO; LA azacitidine 1 B/D PA; MO busulfan 1 B/D PA azathioprine 1 B/D PA; MO BYNFEZIA 2 MO azathioprine sodium 1 B/D PA CABOMETYX 2 PA; MO; LA BALVERSA 2 PA; MO; LA CALQUENCE 2 PA; MO; LA; QL (60 per 30 BAVENCIO 2 B/D PA; MO; days) LA CAPRELSA ORAL 2 PA; LA; QL BELEODAQ 2 B/D PA; MO TABLET 100 MG (60 per 30 BENDEKA 2 B/D PA; MO days) BESPONSA 2 B/D PA; MO; CAPRELSA ORAL 2 PA; LA; QL LA TABLET 300 MG (30 per 30 bexarotene 1 PA; MO days) bicalutamide 1 MO carboplatin 1 B/D PA; MO intravenous solution BICNU 2 B/D PA; MO If you have questions, please call CareSource MyCare Ohio at 1-855-475-3163 (TTY: 711), Monday - Friday, 8 a.m. - 8 p.m. If you need to speak to your care manager, please call 1-866-206-7861, 24 hours a day, 7 days a week. These calls are free. For more information, visit CareSource.com/MyCare. 13 Name of Drug What the Necessary Name of Drug What the Necessary Drug Actions, Drug Actions, Will Restrictions, Will Restrictions, Cost You or Limit On Cost You or Limit On (Tier Use (Tier Use Level) Level) carmustine 1 B/D PA; MO cytarabine (pf) 1 B/D PA injection solution 20 cisplatin intravenous 1 B/D PA; MO mg/ml solution dacarbazine 1 B/D PA; MO cladribine 1 B/D PA; MO dactinomycin 1 B/D PA clofarabine 1 B/D PA DARZALEX 2 B/D PA; MO; COMETRIQ 2 PA; MO LA COPIKTRA 2 PA; MO; LA; daunorubicin 1 B/D PA QL (60 per 30 intravenous solution days) DAURISMO ORAL 2 PA; MO; QL COSMEGEN 2 B/D PA; MO TABLET 100 MG (30 per 30 COTELLIC 2 PA; MO; LA; days) QL (63 per 28 DAURISMO ORAL 2 PA; MO; QL days) TABLET 25 MG (60 per 30 cyclophosphamide 1 B/D PA; MO days) intravenous recon decitabine 1 B/D PA; MO soln docetaxel 1 B/D PA cyclophosphamide 1 B/D PA; MO intravenous solution oral capsule 160 mg/16 ml (10 cyclosporine 1 B/D PA mg/ml), 20 mg/2 ml intravenous (10 mg/ml) cyclosporine 1 B/D PA; MO docetaxel 1 B/D PA; MO modified intravenous solution cyclosporine oral 1 B/D PA; MO 160 mg/8 ml (20 capsule mg/ml), 20 mg/ml (1 ml), 80 mg/4 ml (20 CYRAMZA 2 B/D PA; MO mg/ml), 80 mg/8 ml cytarabine 1 B/D PA; MO (10 mg/ml) cytarabine (pf) 1 B/D PA; MO doxorubicin 1 B/D PA; MO injection solution intravenous recon 100 mg/5 ml (20 soln 50 mg mg/ml), 2 gram/20 doxorubicin 1 B/D PA; MO ml (100 mg/ml) intravenous solution doxorubicin, peg- 1 B/D PA; MO liposomal If you have questions, please call CareSource MyCare Ohio at 1-855-475-3163 (TTY: 711), Monday - Friday, 8 a.m. - 8 p.m. If you need to speak to your care manager, please call 1-866-206-7861, 24 hours a day, 7 days a week. These calls are free. For more information, visit CareSource.com/MyCare. 14 Name of Drug What the Necessary Name of Drug What the Necessary Drug Actions, Drug Actions, Will Restrictions, Will Restrictions, Cost You or Limit On Cost You or Limit On (Tier Use (Tier Use Level) Level) DROXIA 2 MO FIRMAGON KIT W 2 B/D PA; MO DILUENT ELZONRIS 2 PA; MO; LA SYRINGE EMCYT 2 MO floxuridine 1 B/D PA EMPLICITI 2 B/D PA; MO fludarabine 1 B/D PA; MO ENVARSUS XR 2 B/D PA; MO intravenous recon epirubicin 1 B/D PA; MO soln intravenous solution fludarabine 1 B/D PA ERBITUX 2 B/D PA; MO intravenous solution ERIVEDGE 2 PA; MO; QL fluorouracil 1 B/D PA; MO (30 per 30 intravenous days) flutamide 1 MO ERLEADA 2 PA; MO FOLOTYN 2 B/D PA; MO erlotinib oral tablet 1 PA; MO; QL fulvestrant 1 B/D PA; MO 100 mg, 150 mg (30 per 30 GAVRETO 2 PA; MO; LA days) GAZYVA 2 B/D PA; MO erlotinib oral tablet 1 PA; MO; QL 25 mg (60 per 30 gemcitabine 1 B/D PA; MO days) intravenous recon soln 1 gram, 200 mg ERWINAZE 2 B/D PA; MO gemcitabine 1 B/D PA ETOPOPHOS 2 B/D PA; MO intravenous recon etoposide 1 B/D PA; MO soln 2 gram intravenous gemcitabine 1 B/D PA; MO everolimus 1 PA; MO; QL intravenous solution (antineoplastic) (30 per 30 1 gram/26.3 ml (38 days) mg/ml), 200 mg/5.26 everolimus 1 B/D PA; MO ml (38 mg/ml) (immunosuppressive GEMCITABINE 2 B/D PA ) INTRAVENOUS exemestane 1 MO SOLUTION 100 MG/ML FARYDAK 2 PA; MO; QL (6 per 21 days) FASLODEX 2 B/D PA; MO

If you have questions, please call CareSource MyCare Ohio at 1-855-475-3163 (TTY: 711), Monday - Friday, 8 a.m. - 8 p.m. If you need to speak to your care manager, please call 1-866-206-7861, 24 hours a day, 7 days a week. These calls are free. For more information, visit CareSource.com/MyCare. 49 Name of Drug What the Necessary Name of Drug What the Necessary Drug Actions, Drug Actions, Will Restrictions, Will Restrictions, Cost You or Limit On Cost You or Limit On (Tier Use (Tier Use Level) Level) heparin (porcine) in 1 MO HEPARIN, 2 5 % dex intravenous PORCINE (PF) parenteral solution INJECTION 25,000 unit/250 SYRINGE 5,000 ml(100 unit/ml), UNIT/ML 25,000 unit/500 ml HEPARIN, 2 (50 unit/ml) PORCINE (PF) heparin (porcine) in 1 SUBCUTANEOUS nacl (pf) jantoven 1 MO heparin (porcine) 1 MO mephyton 3 MO; ADD injection cartridge MULPLETA 2 PA; MO heparin (porcine) 1 MO injection solution NPLATE 2 MO heparin (porcine) 1 MO pentoxifylline 1 MO injection syringe PHYTONADIONE 3 ADD 5,000 unit/ml (VITAMIN K1) HEPARIN(PORCIN 2 INJECTION E) IN 0.45% NACL SOLUTION INTRAVENOUS phytonadione 3 MO; ADD PARENTERAL (vitamin k1) SOLUTION 12,500 injection syringe UNIT/250 ML phytonadione 3 MO; ADD heparin(porcine) in 1 MO (vitamin k1) oral 0.45% nacl tablet 100 mcg intravenous parenteral solution PHYTONADIONE 3 MO; ADD 25,000 unit/250 ml, (VITAMIN K1) 25,000 unit/500 ml ORAL TABLET 5 MG heparin, porcine (pf) 1 MO injection solution phytonadione 3 ADD (vitamin k1) heparin, porcine (pf) 1 MO sublingual injection syringe 5,000 unit/0.5 ml PRADAXA 2 MO prasugrel 1 MO PROMACTA 2 PA; MO; LA protamine 1 If you have questions, please call CareSource MyCare Ohio at 1-855-475-3163 (TTY: 711), Monday - Friday, 8 a.m. - 8 p.m. If you need to speak to your care manager, please call 1-866-206-7861, 24 hours a day, 7 days a week. These calls are free. For more information, visit CareSource.com/MyCare. 50 Name of Drug What the Necessary Name of Drug What the Necessary Drug Actions, Drug Actions, Will Restrictions, Will Restrictions, Cost You or Limit On Cost You or Limit On (Tier Use (Tier Use Level) Level) VITAMIN K 3 MO; ADD ezetimibe 1 MO vitamin k-1 3 ADD ezetimibe- 1 MO; QL (30 simvastatin per 30 days) VITAMIN K1 3 MO; ADD INJECTION fenofibrate 1 MO micronized warfarin 1 MO fenofibrate 1 MO XARELTO 2 MO nanocrystallized XARELTO DVT-PE 2 MO oral tablet 145 mg, TREAT 30D 48 mg START fenofibrate oral 1 MO ZONTIVITY 2 MO tablet LIPID/CHOLESTEROL LOWERING fenofibric acid 1 MO AGENTS fenofibric acid 1 MO amlodipine- 1 MO; QL (30 (choline) atorvastatin per 30 days) FISH OIL 3 ADD atorvastatin 1 MO; QL (30 CONCENTRATE per 30 days) fluvastatin oral 1 MO; QL (30 cholestyramine (with 1 MO capsule 20 mg per 30 days) sugar) fluvastatin oral 1 MO; QL (60 cholestyramine light 1 MO capsule 40 mg per 30 days) colesevelam 1 MO fluvastatin oral 1 MO; QL (30 tablet extended per 30 days) colestipol 1 MO release 24 hr ENDUR-ACIN 3 MO; ADD gemfibrozil 1 MO ORAL TABLET EXTENDED JUXTAPID ORAL 2 PA; MO; LA RELEASE 250 MG CAPSULE 10 MG, 20 MG, 30 MG, 5 ENDUR-ACIN 3 ADD MG ORAL TABLET EXTENDED LIVALO 2 MO; QL (30 RELEASE 500 MG, per 30 days) 750 MG lovastatin oral tablet 1 MO; QL (30 endur-amide 3 ADD 10 mg per 30 days) endur-thine 3 ADD lovastatin oral tablet 1 MO; QL (60 20 mg, 40 mg per 30 days) If you have questions, please call CareSource MyCare Ohio at 1-855-475-3163 (TTY: 711), Monday - Friday, 8 a.m. - 8 p.m. If you need to speak to your care manager, please call 1-866-206-7861, 24 hours a day, 7 days a week. These calls are free. For more information, visit CareSource.com/MyCare. 51 Name of Drug What the Necessary Name of Drug What the Necessary Drug Actions, Drug Actions, Will Restrictions, Will Restrictions, Cost You or Limit On Cost You or Limit On (Tier Use (Tier Use Level) Level) MAXEPA 3 ADD niacinamide (bulk) 3 ADD crystals NEXLETOL 2 PA; MO NIACINAMIDE 3 MO; ADD NEXLIZET 2 PA; MO ORAL TABLET niacin (bulk) 3 ADD 500 MG niacin (inositol 3 ADD niacinamide oral 3 ADD niacinate) oral tablet extended capsule 455 mg release niacin (500 mg) nicotinic acid 3 ADD NIACIN 3 MO; ADD OMEGA-3 FATTY 3 MO; ADD (INOSITOL ACIDS ORAL NIACINATE) CAPSULE ORAL CAPSULE 500 MG PRALUENT PEN 2 PA; MO; QL (2 per 28 days) niacin (inositol 3 ADD niacinate) oral tablet pravastatin 1 MO; QL (30 per 30 days) NIACIN 3 ADD (NIACINAMIDE) prevalite 1 MO NIACIN ORAL 3 MO; ADD REPATHA 2 PA; MO; QL CAPSULE, (3 per 28 days) EXTENDED REPATHA 2 PA; MO; QL RELEASE 250 MG, PUSHTRONEX (3.5 per 28 500 MG days) NIACIN ORAL 3 MO; ADD REPATHA 2 PA; MO; QL TABLET SURECLICK (3 per 28 days) niacin oral tablet 3 MO; ADD rosuvastatin 1 MO; QL (30 extended release per 30 days) 1,000 mg simvastatin oral 1 MO; QL (30 niacin oral tablet 1 MO tablet per 30 days) extended release 24 hr slo-niacin oral tablet 3 MO; ADD extended release 250 NIACIN ORAL 3 MO; ADD mg, 750 mg TABLET EXTENDED RELEASE 250 MG, 500 MG, 750 MG If you have questions, please call CareSource MyCare Ohio at 1-855-475-3163 (TTY: 711), Monday - Friday, 8 a.m. - 8 p.m. If you need to speak to your care manager, please call 1-866-206-7861, 24 hours a day, 7 days a week. These calls are free. For more information, visit CareSource.com/MyCare. 52 Name of Drug What the Necessary Name of Drug What the Necessary Drug Actions, Drug Actions, Will Restrictions, Will Restrictions, Cost You or Limit On Cost You or Limit On (Tier Use (Tier Use Level) Level) SLO-NIACIN 3 MO; ADD dobutamine 1 B/D PA ORAL TABLET intravenous solution EXTENDED 250 mg/20 ml (12.5 RELEASE 500 MG mg/ml) SUPER OMEGA-3 3 ADD dopamine in 5 % 1 B/D PA ORAL CAPSULE dextrose intravenous 1,000 MG solution 200 mg/250 ml (800 mcg/ml), super twin epa-dha 3 ADD 400 mg/250 ml VASCEPA 2 MO (1,600 mcg/ml), 400 MISCELLANEOUS mg/500 ml (800 mcg/ml), 800 CARDIOVASCULAR AGENTS mg/500 ml (1,600 cardioplegic soln 1 mcg/ml) CORLANOR ORAL 2 PA dopamine in 5 % 1 B/D PA; MO SOLUTION dextrose intravenous solution 800 mg/250 CORLANOR ORAL 2 PA; MO ml (3,200 mcg/ml) TABLET dopamine 1 B/D PA digitek 1 MO intravenous solution digox 1 MO 200 mg/5 ml (40 digoxin oral solution 1 MO mg/ml) 50 mcg/ml (0.05 dopamine 1 B/D PA; MO mg/ml) intravenous solution digoxin oral tablet 1 MO 400 mg/10 ml (40 mg/ml) dobutamine in d5w 1 B/D PA; MO intravenous ENTRESTO 2 MO; QL (60 parenteral solution per 30 days) 1,000 mg/250 ml LANOXIN ORAL 2 MO (4,000 mcg/ml), 250 TABLET 62.5 MCG mg/250 ml (1 mg/ml) (0.0625 MG) dobutamine in d5w 1 B/D PA milrinone 1 B/D PA; MO intravenous milrinone in 5 % 1 B/D PA; MO parenteral solution dextrose 500 mg/250 ml (2,000 mcg/ml) norepinephrine 1 bitartrate

If you have questions, please call CareSource MyCare Ohio at 1-855-475-3163 (TTY: 711), Monday - Friday, 8 a.m. - 8 p.m. If you need to speak to your care manager, please call 1-866-206-7861, 24 hours a day, 7 days a week. These calls are free. For more information, visit CareSource.com/MyCare. 76 Name of Drug What the Necessary Name of Drug What the Necessary Drug Actions, Drug Actions, Will Restrictions, Will Restrictions, Cost You or Limit On Cost You or Limit On (Tier Use (Tier Use Level) Level) corn starch (bulk) 3 MO; ADD DEX4 GLUCOSE 3 ADD QUICK DISSOLVE cottonseed oil (bulk) 3 MO; ADD dextrose 10 % and 1 creatine 3 ADD 0.2 % nacl monohydrate (bulk) dextrose 10 % in 1 MO croton oil (bulk) 3 ADD water (d10w) d10 %-0.45 % 1 dextrose 25 % in 1 sodium chloride water (d25w) d2.5 %-0.45 % 1 dextrose 30 % in 1 sodium chloride water (d30w) d5 % and 0.9 % 1 MO dextrose 40 % in 1 sodium chloride water (d40w) d5 %-0.45 % sodium 1 MO dextrose 5 % in 1 MO chloride water (d5w) DAKIN'S 3 MO; ADD dextrose 5 %- 1 MO SOLUTION lactated ringers SOLUTION 0.5 % dextrose 5%-0.2 % 1 deferasirox 1 PA; MO sod chloride deferiprone 1 PA; MO dextrose 5%-0.3 % 1 deferoxamine 1 B/D PA; MO sod.chloride DEX4 GLUCOSE 3 ADD dextrose 50 % in 1 MO BITS water (d50w) DEX4 GLUCOSE 3 MO; ADD dextrose 70 % in 1 MO ORAL GEL water (d70w) dex4 glucose oral 3 MO; ADD DEXTROSE ORAL 3 ADD gel in packet GEL dex4 glucose oral 3 MO; ADD dextrose oral liquid 3 ADD liquid diethylene glycol 3 ADD DEX4 GLUCOSE 3 MO; ADD monoethyl et ORAL disulfiram 1 MO TABLET,CHEWAB LE dry mouth mucous 3 ADD membrane DEX4 GLUCOSE 3 ADD mouthwash POUCH PACK If you have questions, please call CareSource MyCare Ohio at 1-855-475-3163 (TTY: 711), Monday - Friday, 8 a.m. - 8 p.m. If you need to speak to your care manager, please call 1-866-206-7861, 24 hours a day, 7 days a week. These calls are free. For more information, visit CareSource.com/MyCare. 77 Name of Drug What the Necessary Name of Drug What the Necessary Drug Actions, Drug Actions, Will Restrictions, Will Restrictions, Cost You or Limit On Cost You or Limit On (Tier Use (Tier Use Level) Level) durex avanti bare 3 MO; ADD GLUCO BURST 3 ADD real feel gluco shot 3 ADD d-xylose (bulk) 3 ADD glucosamine (bulk) 3 MO; ADD easivent mask large 3 ADD GLUCOSAMINE- 3 MO; ADD easivent mask 3 MO; ADD CHONDROITIN medium ORAL TABLET 500-400 MG easivent mask small 3 MO; ADD GLUCOSE BITS 3 ADD ethoxy ethoxy 3 MO; ADD ethanol reagent GLUCOSE GEL 3 ADD ethyl alcohol (bulk) 3 MO; ADD GLUCOSE ORAL 3 MO; ADD TABLET,CHEWAB ethyl oleate (bulk) 3 MO; ADD LE 4 GRAM fantasy condom 3 ADD glutamine (bulk) 3 ADD fc2 female condom 3 MO; ADD glutathione (bulk) 3 MO; ADD fd and c blue no.1 3 ADD GLUTOSE-5 3 ADD (bulk) grape seed oil (bulk) 3 ADD FERRIPROX 2 PA; MO HYDROGEN 3 MO; ADD FERRIPROX (2 2 PA PEROXIDE TIMES A DAY) HYSEPT 3 ADD ferrlecit 3 MO; ADD SOLUTION 0.5 % flavor sweet 3 MO; ADD in-check nasal with 3 ADD flavor sweet-sf 3 MO; ADD mask flexichamber-lg 3 ADD in-check oral flow 3 ADD child mask meter flexichamber-sm 3 ADD INCRELEX 2 MO; LA adult mask indole-3-carbinol 3 ADD flexichamber-sm 3 ADD (bulk) child mask iodine (bulk) crystals 3 MO; ADD formaldehyde (bulk) 3 ADD ISOPROPYL 3 ADD solution 37 % ALCOHOL fructose (bulk) 3 ADD SOLUTION 91 % fuller's earth (bulk) 3 ADD If you have questions, please call CareSource MyCare Ohio at 1-855-475-3163 (TTY: 711), Monday - Friday, 8 a.m. - 8 p.m. If you need to speak to your care manager, please call 1-866-206-7861, 24 hours a day, 7 days a week. These calls are free. For more information, visit CareSource.com/MyCare. 78 Name of Drug What the Necessary Name of Drug What the Necessary Drug Actions, Drug Actions, Will Restrictions, Will Restrictions, Cost You or Limit On Cost You or Limit On (Tier Use (Tier Use Level) Level) ISOPROPYL 3 MO; ADD lipmax 3 MO; ADD ALCOHOL lipoic acid 3 ADD SOLUTION 99 % lipoil 3 MO; ADD ISOPROPYL 3 MO; ADD PALMITATE lite touch-medium 3 MO; ADD (BULK) mask kaolin (bulk) 3 ADD litetouch-large mask 3 ADD kimono 3 ADD litetouch-small mask 3 ADD condoms(non- LOKELMA 2 MO lubricated) lollibase 3 ADD kimono maxx 3 ADD condoms lozibase 3 ADD kimono microthin 3 ADD malic acid (bulk) 3 ADD aqua lube con medibase c 3 ADD kimono microthin 3 ADD MELATIN 3 ADD condoms melatonin oral drops 3 MO; ADD kimono microthin 3 ADD large condoms melatonin oral liquid 3 MO; ADD 1 mg/ml kimono textured 3 ADD condoms melatonin oral liquid 3 ADD 2.5 mg/10 ml kionex (with 1 MO sorbitol) MELATONIN 3 MO; ADD ORAL TABLET 1 kojic acid (bulk) 3 MO; ADD MG, 3 MG, 5 MG lactose (bulk) 3 MO; ADD melatonin oral tablet 3 MO; ADD lanthanum 1 MO 300 mcg lecithin organogel 3 ADD melatonin oral 3 ADD tablet,chewable 2.5 levocarnitine (with 1 MO mg sugar) melatonin oral 3 MO; ADD levocarnitine oral 1 MO tablet,disintegrating solution 100 mg/ml 5 mg levocarnitine oral 1 MO methylcellulose 3 ADD tablet (bulk) gel 2 %, 3 % l-glutamine 3 ADD If you have questions, please call CareSource MyCare Ohio at 1-855-475-3163 (TTY: 711), Monday - Friday, 8 a.m. - 8 p.m. If you need to speak to your care manager, please call 1-866-206-7861, 24 hours a day, 7 days a week. These calls are free. For more information, visit CareSource.com/MyCare. 79 Name of Drug What the Necessary Name of Drug What the Necessary Drug Actions, Drug Actions, Will Restrictions, Will Restrictions, Cost You or Limit On Cost You or Limit On (Tier Use (Tier Use Level) Level) METHYLCELLUL 3 ADD optichamber adult 3 MO; ADD OSE 1500CPS mask-large (BULK) ora-blend sf 3 MO; ADD methylcellulose 3 MO; ADD oral mix 3 ADD 4000cps (bulk) oral relief dry mouth 3 ADD methylparaben 3 MO; ADD (bulk) oral suspend 3 ADD methylsulfonylmetha 3 ADD oral syrup 3 ADD ne (bulk) crystals oral syrup sf 3 ADD microlife peak flow 3 MO; ADD ORA-SWEET 3 MO; ADD meter ora-sweet sf 3 MO; ADD midodrine 1 MO ORFADIN 2 PA; MO; LA MINERAL OIL 3 ADD panda mask 3 ADD MINERAL OIL 3 ADD HEAVY peak air peak flow 3 MO; ADD meter MINERAL OIL 3 MO; ADD LIGHT pediatric medium 3 ADD mask mini wright peak 3 ADD flow meter pediatric panda 3 ADD mask MONOJECT 0.9% 3 ADD SODIUM pediatric small mask 3 ADD CHLORIDE pegblend 3 ADD MONOJECT 3 MO; ADD personal best full 3 MO; ADD PREFILL range ADVANCED NS personal best low 3 MO; ADD mouthpiece 3 ADD range mx-sol 3 ADD phenol (bulk) liquid 3 MO; ADD nitisinone 1 PA; MO phosphatidyl serine 3 ADD NORMAL SALINE 3 MO; ADD (bulk) powder 20 % FLUSH piko 1 3 ADD NORTHERA 2 PA; MO pilocarpine hcl oral 1 MO one way valved 3 ADD plo20 flowable 3 MO; ADD mouthpiece If you have questions, please call CareSource MyCare Ohio at 1-855-475-3163 (TTY: 711), Monday - Friday, 8 a.m. - 8 p.m. If you need to speak to your care manager, please call 1-866-206-7861, 24 hours a day, 7 days a week. These calls are free. For more information, visit CareSource.com/MyCare. 80 Name of Drug What the Necessary Name of Drug What the Necessary Drug Actions, Drug Actions, Will Restrictions, Will Restrictions, Cost You or Limit On Cost You or Limit On (Tier Use (Tier Use Level) Level) pocket peak flow 3 ADD RAVICTI 2 PA; MO meter REVCOVI 2 PA; MO; LA POLYETHYLENE 3 MO; ADD riluzole 1 MO GLYCOL 1000(BULK) risedronate oral 1 MO; QL (30 tablet 30 mg per 30 days) polyethylene glycol 3 ADD 300 (bulk) safflower oil (bulk) 3 ADD polyethylene glycol 3 ADD sevelamer carbonate 1 MO 3350(bulk) powder sevelamer hcl 1 MO polyethylene glycol 3 ADD shea butter (bulk) 3 ADD 400 (bulk) sidestream pediatric 3 ADD polyethylene glycol 3 ADD face mask 8000(bulk) powder silicone mask - 3 ADD polyoxyl 40 stearate 3 ADD infant (bulk) wax silicone mask - 3 ADD polysorbate 20 3 ADD pediatric (bulk) SIMPLE SYRUP 3 MO; ADD potassium citrate m- 3 ADD hyd(bulk) granules sodium benzoate-sod 1 phenylacet potassium sorbate 3 ADD (bulk) crystals sodium borate (bulk) 3 MO; ADD PROLASTIN-C 2 LA sodium bromide 3 ADD INTRAVENOUS (bulk) RECON SOLN SODIUM 3 MO; ADD PROLASTIN-C 2 MO; LA CHLORIDE 0.9 % INTRAVENOUS (FLUSH) SOLUTION INJECTION SYRINGE propylparaben 3 MO; ADD (bulk) crystals sodium chloride 0.9 1 MO % intravenous pyruvic acid (bulk) 3 ADD sodium chloride 1 MO raspberry 3 MO; ADD irrigation raspberry flavor 3 MO; ADD (bulk) liquid

If you have questions, please call CareSource MyCare Ohio at 1-855-475-3163 (TTY: 711), Monday - Friday, 8 a.m. - 8 p.m. If you need to speak to your care manager, please call 1-866-206-7861, 24 hours a day, 7 days a week. These calls are free. For more information, visit CareSource.com/MyCare. 175 Name of Drug What the Necessary Name of Drug What the Necessary Drug Actions, Drug Actions, Will Restrictions, Will Restrictions, Cost You or Limit On Cost You or Limit On (Tier Use (Tier Use Level) Level) a thru z select oral 3 ADD alive women's 3 ADD tablet 300-600-300 energy mcg ANIMAL CHEWS 3 ADD A THRU Z SELECT 3 ADD ANIMAL SHAPES 3 ADD WOMEN'S ANIMAL SHAPES 3 ADD abaneu-sl 3 ADD COMPLETE ORAL abatron 3 ADD TABLET,CHEWAB LE ABC PLUS 3 MO; ADD animal shapes 3 ADD ACEROLA C-500 3 ADD complete oral ACTICAL 3 MO; ADD tablet,chewable 18 adult multivitamin 3 MO; ADD mg iron gummies ANTIOXIDANT 3 ADD adult one daily 3 ADD A/C/E/SELENIUM gummies antioxidant formula 3 MO; ADD ADULT ONE 3 ADD (selenium) DAILY ANTIOXIDANT 3 ADD MULTIVITAMIN VITAMINS ORAL ADULTS 50 PLUS 3 ADD TABLET 1,000 UNIT-200 MG-60 adults' daily formula 3 ADD UNIT-2 MG adults multivitamin 3 ADD apatate 3 MO; ADD advanced calcium 3 ADD APATATE FORTE 3 ADD advanced multi ea 3 ADD apetex 3 ADD airborne (ascorbate 3 ADD apetigen 3 ADD sodium) oral tablet,chewable 333- APETIGEN PLUS 3 ADD 1.7 mg ORAL LIQUID airborne (with lysine 3 ADD apetigen plus oral 3 MO; ADD acetate) tablet alba-lybe 3 ADD aquadeks oral 3 MO; ADD tablet,chewable alive once daily 3 ADD women 50 plus aquadeks pediatric 3 MO; ADD alive prenatal 3 MO; ADD aqua-e concentrate 3 ADD If you have questions, please call CareSource MyCare Ohio at 1-855-475-3163 (TTY: 711), Monday - Friday, 8 a.m. - 8 p.m. If you need to speak to your care manager, please call 1-866-206-7861, 24 hours a day, 7 days a week. These calls are free. For more information, visit CareSource.com/MyCare. 176 Name of Drug What the Necessary Name of Drug What the Necessary Drug Actions, Drug Actions, Will Restrictions, Will Restrictions, Cost You or Limit On Cost You or Limit On (Tier Use (Tier Use Level) Level) aquasol a 3 MO; ADD ASCORBIC ACID 3 ADD (VITAMIN C) ASCORBATE 3 ADD ORAL CALCIUM TABLET,CHEWAB (VITAMIN C) LE 500 MG ASCORBIC ACID 3 MO; ADD ascorbic 3 ADD (VITAMIN C) acid(vitamin c)(bulk) ORAL CAPSULE, granules EXTENDED RELEASE ascorbic 3 MO; ADD acid(vitamin c)(bulk) ascorbic acid 3 ADD powder (vitamin c) oral granules B COMPLEX 1 3 MO; ADD (WITH FOLIC ascorbic acid 3 ADD ACID) (vitamin c) oral powder in packet B COMPLEX 100 3 ADD ORAL ASCORBIC ACID 3 ADD (VITAMIN C) b complex plus 3 MO; ADD ORAL SYRUP vitamin c ASCORBIC ACID 3 MO; ADD b complex 3 ADD (VITAMIN C) sublingual ORAL TABLET b complex w-vit c 3 ADD ASCORBIC ACID 3 MO; ADD B COMPLEX- 3 MO; ADD (VITAMIN C) VITAMIN B12 ORAL TABLET EXTENDED B COMPLEX- 3 MO; ADD RELEASE 1,500 VITAMIN C-FOLIC MG ACID ORAL TABLET ASCORBIC ACID 3 ADD (VITAMIN C) b complex-vitamin c- 3 MO; ADD ORAL TABLET folic acid oral tablet EXTENDED extended release RELEASE 500 MG B-100 COMPLEX 3 ADD ORAL TABLET EXTENDED RELEASE B-12 DOTS 3 MO; ADD If you have questions, please call CareSource MyCare Ohio at 1-855-475-3163 (TTY: 711), Monday - Friday, 8 a.m. - 8 p.m. If you need to speak to your care manager, please call 1-866-206-7861, 24 hours a day, 7 days a week. These calls are free. For more information, visit CareSource.com/MyCare. 177 Name of Drug What the Necessary Name of Drug What the Necessary Drug Actions, Drug Actions, Will Restrictions, Will Restrictions, Cost You or Limit On Cost You or Limit On (Tier Use (Tier Use Level) Level) b-12 plus 3 MO; ADD B-COMPLEX 3 ADD WITH VITAMIN C baby ddrops 3 ADD ORAL TABLET baby vitamin d3 3 ADD 400-500 MCG-MG baby's super daily 3 ADD B-COMPLEX 3 ADD d3 WITH VITAMIN C BALANCE B-100 3 ADD ORAL TABLET (FOLIC ACID) EXTENDED RELEASE BALANCE B-50 3 MO; ADD (WITH FOLIC berocca (fa- 3 ADD ACID) guarana-caff) BALANCED B-100 3 MO; ADD BETA CAROTENE 3 MO; ADD COMPLEX ORAL ORAL CAPSULE TABLET 25,000 UNIT EXTENDED bio-35, gluten free 3 ADD RELEASE 100 MG biocal 3 ADD BALANCED B-100 3 ADD bio-d-mulsion 3 ADD ORAL TABLET 0.4 MG bio-d-mulsion forte 3 ADD balanced b-100 oral 3 ADD biotin (bulk) 3 MO; ADD tablet extended biotin oral capsule 1 3 ADD release mg BALANCED B-50 3 ADD biotin oral capsule 3 MO; ADD ORAL TABLET 10,000 mcg B-COMPLEX 3 ADD BIOTIN ORAL 3 MO; ADD b-complex plus vit c 3 ADD CAPSULE 2,500 (calcium) MCG, 5 MG b-complex with b-12 3 ADD BIOTIN ORAL 3 MO; ADD TABLET 1 MG B-COMPLEX 3 MO; ADD WITH VITAMIN C biotin oral tablet 5 3 ADD ORAL CAPSULE mg B-COMPLEX 3 MO; ADD biotin plus-calcium 3 ADD WITH VITAMIN C and vit d3 ORAL TABLET body, hair, skin and 3 ADD nails If you have questions, please call CareSource MyCare Ohio at 1-855-475-3163 (TTY: 711), Monday - Friday, 8 a.m. - 8 p.m. If you need to speak to your care manager, please call 1-866-206-7861, 24 hours a day, 7 days a week. These calls are free. For more information, visit CareSource.com/MyCare. 178 Name of Drug What the Necessary Name of Drug What the Necessary Drug Actions, Drug Actions, Will Restrictions, Will Restrictions, Cost You or Limit On Cost You or Limit On (Tier Use (Tier Use Level) Level) bone essentials 3 ADD CALCIUM 600 + 3 ADD MINERALS brainstrong prenatal 3 ADD CALCIUM 600-D3 3 ADD b-stress 3 ADD PLUS (MAG-ZINC) c 1000- 3 ADD calcium adult 3 ADD bioflavonoids-rose (calcium phos) hips calcium carb-d3- 3 ADD C COMPLEX 3 ADD mag cmb11-zinc ORAL TABLET EXTENDED calcium carb-mag 3 ADD RELEASE 1,000 oxide-zinc ox MG calcium carb-mag 3 ADD C COMPLEX 3 MO; ADD ox-zinc gluc ORAL TABLET CALCIUM 3 ADD EXTENDED CARBONATE-VIT RELEASE 500 MG D3-MIN ORAL C-1000 ORAL 3 ADD TABLET TABLET CALCIUM FOR 3 ADD C-1000 ORAL 3 MO; ADD WOMEN TABLET calcium magnesium 3 ADD EXTENDED + d oral tablet 400- RELEASE 167-133 mg-mg-unit C-1000 WITH 3 MO; ADD calcium phosphate- 3 ADD ROSE HIPS vitamin d3 C-500 3 ADD CALCIUM SOFT 3 ADD CA-D3-MAG OX- 3 ADD CHEW ORAL ZINC-COP-MANG- TABLET,CHEWAB BOR LE 500-100-40 MG- UNIT-MCG, 500- CA-D3-MAG- 3 ADD 200-40 MG-UNIT- ZINC-COP-MANG- MCG BOR CALCIUM- 3 ADD cal mag zinc plus d3 3 ADD MAGNESIUM- calcet petites 3 MO; ADD COPPER-ZINC CALCIDOL 3 MO; ADD calci-max 3 ADD If you have questions, please call CareSource MyCare Ohio at 1-855-475-3163 (TTY: 711), Monday - Friday, 8 a.m. - 8 p.m. If you need to speak to your care manager, please call 1-866-206-7861, 24 hours a day, 7 days a week. These calls are free. For more information, visit CareSource.com/MyCare. 179 Name of Drug What the Necessary Name of Drug What the Necessary Drug Actions, Drug Actions, Will Restrictions, Will Restrictions, Cost You or Limit On Cost You or Limit On (Tier Use (Tier Use Level) Level) CALCIUM- 3 ADD centrum chewables 3 MO; ADD VITAMIN D3- centrum complete 3 MO; ADD VITAMIN K ORAL TABLET,CHEWAB centrum men 3 MO; ADD LE 500-200-40 MG- centrum oral liquid 3 MO; ADD UNIT-MCG 9 mg iron/15 ml calcium-vitamin d3- 3 ADD centrum silver 3 MO; ADD vitamin k oral tablet,chewable 650 centrum silver men 3 ADD mg-12.5 mcg-40 mcg centrum silver ultra 3 MO; ADD cal-mag 3 ADD men's cal-mag complex 3 ADD centrum silver 3 MO; ADD women caltrate + d3 plus 3 MO; ADD minerals centrum specialist 3 MO; ADD heart caltrate 600-d plus 3 MO; ADD minerals centrum ultra men's 3 MO; ADD caltrate gummy bites 3 MO; ADD CENTRUM 3 MO; ADD WOMEN CENTAMIN 3 ADD CENTURY 3 ADD central-vite oral 3 ADD ADULTS 50 PLUS tablet 18 mg iron- 400 mcg-25 mcg CENTURY 3 ADD CARDIO central-vite women's 3 ADD mature CENTURY 3 ADD MATURE ORAL centram-care 3 ADD TABLET 0.4-300- CENTRAVITES 3 ADD 250 MG-MCG- MCG, 400-30 MCG CENTRAVITES 50 3 MO; ADD PLUS ORAL century men's 3 ADD TABLET CENTURY ORAL 3 ADD CENTRAVITES 50 3 ADD TABLET 18-400 PLUS ORAL MG-MCG TABLET 0.4-300- century ultimate 3 ADD 250 MG-MCG- men's MCG centravites adults 3 ADD If you have questions, please call CareSource MyCare Ohio at 1-855-475-3163 (TTY: 711), Monday - Friday, 8 a.m. - 8 p.m. If you need to speak to your care manager, please call 1-866-206-7861, 24 hours a day, 7 days a week. These calls are free. For more information, visit CareSource.com/MyCare. 180 Name of Drug What the Necessary Name of Drug What the Necessary Drug Actions, Drug Actions, Will Restrictions, Will Restrictions, Cost You or Limit On Cost You or Limit On (Tier Use (Tier Use Level) Level) CENTURY 3 ADD children's chewable 3 ADD ULTIMATE complete oral WOMEN'S tablet,chewable 9- 200 mg iron-mcg CEROVITE 3 MO; ADD ADVANCED CHILDREN'S 3 ADD FORMULA CHEWABLE MULTIVITMN CEROVITE JR 3 MO; ADD ORAL CHILDREN'S 3 ADD TABLET,CHEWAB CHEWABLE LE 18 MG IRON- VITAMIN 10 MCG CHILDREN'S 3 ADD CEROVITE 3 MO; ADD CHEWABLES SENIOR CHILDREN'S 3 ADD CERTA PLUS 3 ADD CHEWABLES EXTRA C CERTAVITE 3 MO; ADD SENIOR- CHILDREN'S IRON 3 ADD ANTIOXIDANT children's multi-vit 3 ADD CERTAVITE- 3 MO; ADD gummies ANTIOXIDANT children's 3 ADD child chewable 3 ADD multivitamin vitamn complete CHILD'S 3 ADD child complete 3 ADD CHEWABLE multivitamin VITAMINS/IRON ORAL child multivitamin 3 ADD TABLET,CHEWAB plus iron LE child multivitamins 3 ADD child's chewable 3 ADD children 3 ADD vitamins/iron oral multivitamin tablet,chewable 15 CHILDREN'S 3 ADD mg CHEW child's omega-3 dha 3 ADD MULTIVITAMIN multivitam CHILDS/IRON 3 MO; ADD

If you have questions, please call CareSource MyCare Ohio at 1-855-475-3163 (TTY: 711), Monday - Friday, 8 a.m. - 8 p.m. If you need to speak to your care manager, please call 1-866-206-7861, 24 hours a day, 7 days a week. These calls are free. For more information, visit CareSource.com/MyCare. 195 Name of Drug What the Necessary Name of Drug What the Necessary Drug Actions, Drug Actions, Will Restrictions, Will Restrictions, Cost You or Limit On Cost You or Limit On (Tier Use (Tier Use Level) Level) one-a-day proactive 3 ADD one-a-day women's 3 ADD 65 plus prenatal 1 ONE-A-DAY TEEN 3 ADD optimal d3 3 ADD ADVANTAGE optimal d3 m 3 ADD one-a-day teen her 3 ADD optisource 3 MO; ADD vitacraves OPTI-VITAMINS 3 ADD one-a-day teen him 3 ADD vitacraves opurity multivitamin 3 ADD one-a-day vitacraves 3 ADD ortho-tabs 3 MO; ADD one-a-day vitacraves 3 ADD OYSTER SHELL 3 ADD immunity CALCIUM-VIT D2 ORAL TABLET one-a-day vitacraves 3 ADD 250 (625)-125 MG- omega-3 UNIT one-a-day 3 ADD pan-c 500 3 ADD weightsmart parva-cal 250 3 ADD one-a-day women 3 ADD vitacraves parva-cal 500 3 ADD one-a-day women's 3 MO; ADD parvlex 3 ADD 50 plus oral tablet pedia d-vite oral 3 ADD 400-20 mcg drops one-a-day women's 3 ADD PEDIA IRON 3 ADD active pedia poly-vite 3 ADD one-a-day womens 3 ADD formula oral tablet pedia poly-vite with 3 ADD 18 mg iron-400 mcg- iron oral drops 500 mg pedia tri-vite 3 ADD one-a-day womens 3 MO; ADD perfect iron 3 ADD formula oral tablet 18 mg iron-400 mcg- peridin-c 3 MO; ADD 500 mg ca phytomulti 3 ADD one-a-day women's 3 ADD PNV CMB#95- 3 ADD healthy skin FERROUS one-a-day women's 3 MO; ADD FUMARATE-FA petites POLY-IRON 3 MO; ADD If you have questions, please call CareSource MyCare Ohio at 1-855-475-3163 (TTY: 711), Monday - Friday, 8 a.m. - 8 p.m. If you need to speak to your care manager, please call 1-866-206-7861, 24 hours a day, 7 days a week. These calls are free. For more information, visit CareSource.com/MyCare. 196 Name of Drug What the Necessary Name of Drug What the Necessary Drug Actions, Drug Actions, Will Restrictions, Will Restrictions, Cost You or Limit On Cost You or Limit On (Tier Use (Tier Use Level) Level) POLY-IRON 150 3 MO; ADD prenatal oral tablet 3 ADD FORTE 28-800 mg-mcg POLYSACCHARID 3 ADD PRENATAL 3 ADD E IRON COMPLEX TABLET poly-vi-sol oral 3 MO; ADD prenatal vitamin 1 MO drops oral tablet poly-vi-sol with iron 3 MO; ADD PRENATAL 3 MO; ADD VITAMIN ORAL posture-d (with 3 MO; ADD TABLET 27 MG magnesium) IRON- 0.8 MG prenatal + dha oral 3 MO; ADD prenatal vitamin 3 ADD combo pack 28 mg oral tablet 27 mg iron-800 mcg-200 iron- 800 mcg mg PRENATAL 3 ADD PRENATAL 3 MO; ADD VITAMIN WITH FORMULA ORAL MINERALS TABLET 28 MG IRON- 800 MCG PRENATAL VIT- 3 ADD IRON FUM-FOLIC prenatal formula 3 ADD AC oral tablet 9 mg iron- 267 mcg PRENATAL 3 ADD VITS96-IRON prenatal formula- 3 ADD FUM-FOLIC dha prenatal with dha- 3 ADD prenatal multi 3 ADD folic acid PRENATAL 3 ADD preservision areds 3 MO; ADD MULTI-DHA (ALGAL OIL) preservision areds-2 3 MO; ADD PRENATAL 3 ADD preservision lutein 3 MO; ADD MULTIVITAMINS prevent 3 ADD PRENATAL ONE 3 MO; ADD pro fe 3 MO; ADD DAILY pro-cal oral tablet 3 ADD PRENATAL ORAL 3 MO; ADD TABLET 28 MG procerv hp 3 ADD IRON- 800 MCG proferrin es 3 MO; ADD proferrin-forte 3 MO; ADD If you have questions, please call CareSource MyCare Ohio at 1-855-475-3163 (TTY: 711), Monday - Friday, 8 a.m. - 8 p.m. If you need to speak to your care manager, please call 1-866-206-7861, 24 hours a day, 7 days a week. These calls are free. For more information, visit CareSource.com/MyCare. 197 Name of Drug What the Necessary Name of Drug What the Necessary Drug Actions, Drug Actions, Will Restrictions, Will Restrictions, Cost You or Limit On Cost You or Limit On (Tier Use (Tier Use Level) Level) prorenal 3 MO; ADD RENA-VITE RX 3 MO; ADD prorenal qd 3 MO; ADD RENO CAPS 3 MO; ADD PROSIGHT 3 MO; ADD REPLESTA 3 MO; ADD protect cardio af 3 MO; ADD replesta nx 3 MO; ADD protect iron 3 MO; ADD RIBOFLAVIN 3 ADD (VITAMIN B2) protect plus so 3 ADD ORAL TABLET PYRIDOXINE 3 MO; ADD 100 MG, 50 MG (VITAMIN B6) riboflavin (vitamin 3 MO; ADD INJECTION b2) oral tablet 400 PYRIDOXINE 3 MO; ADD mg (VITAMIN B6) RISACAL-D 3 MO; ADD ORAL TABLET 100 MG, 250 MG, savision 3 ADD 50 MG scooby-doo one a 3 ADD PYRIDOXINE 3 ADD day (VITAMIN B6) scooby-doo one a 3 ADD ORAL TABLET 25 day kids MG SENIOR TABS 3 MO; ADD pyridoxine (vitamin 3 ADD b6) oral tablet 500 SENTRY 3 ADD mg SENTRY SENIOR 3 ADD quin b strong 3 ADD ORAL TABLET 0.4-300-250 MG- quintabs 3 ADD MCG-MCG quintabs-m 3 ADD SENTRY SENIOR 3 MO; ADD QUINTABS-M 3 ADD ORAL TABLET IRON FREE 500-300-250 MCG RENAL CAPS 3 MO; ADD slow fe 3 MO; ADD renal vitamin 3 MO; ADD renal-vite 3 ADD renaplex 3 ADD renaplex-d 3 MO; ADD RENA-VITE 3 MO; ADD If you have questions, please call CareSource MyCare Ohio at 1-855-475-3163 (TTY: 711), Monday - Friday, 8 a.m. - 8 p.m. If you need to speak to your care manager, please call 1-866-206-7861, 24 hours a day, 7 days a week. These calls are free. For more information, visit CareSource.com/MyCare. 198 Name of Drug What the Necessary Name of Drug What the Necessary Drug Actions, Drug Actions, Will Restrictions, Will Restrictions, Cost You or Limit On Cost You or Limit On (Tier Use (Tier Use Level) Level) SLOW RELEASE 3 ADD SPECTRAVITE 3 ADD IRON ORAL ADVANCED TABLET FORMULA ORAL EXTENDED TABLET 18-400 RELEASE 142 MG MG-MCG (45 MG IRON), 143 SPECTRAVITE 3 ADD MG (45 MG IRON), MEN'S 160 MG (50 MG IRON), 250 MG (50 SPECTRAVITE 3 ADD MG IRON) SENIOR ORAL TABLET 500-300- slow release iron 3 ADD 250 MCG oral tablet extended release 144 mg (45 spectravite ultra men 3 ADD mg iron) 50+ SLOW RELEASE 3 MO; ADD spectravite ultra 3 ADD IRON ORAL men's sr TABLET SPECTRAVITE 3 ADD EXTENDED ULTRA WOMEN RELEASE 159 MG (45 MG IRON) SPECTRAVITE 3 ADD ULTRA WOMEN'S slow release iron 3 MO; ADD SR oral tablet extended release 168 mg (50 STRAWBERRY C 3 ADD mg iron) STRESS B PLUS 3 ADD sodium fluoride 3 MO; ADD ZINC (bulk) STRESS B WITH 3 ADD solo 3 ADD ZINC SOOTHING 3 ADD stress b-complex 3 ADD PUREWAY-C oral tablet 500 mg- 400 mcg- 24 mg-3 span c 3 ADD mg SPECTRAVITE 3 ADD stress b-complex 3 MO; ADD ADULT 50 PLUS oral tablet 500-400- spectravite adult 50 3 ADD 23.9-3 mg-mcg-mg- plus(lut) mg STRESS 3 MO; ADD FORMULA If you have questions, please call CareSource MyCare Ohio at 1-855-475-3163 (TTY: 711), Monday - Friday, 8 a.m. - 8 p.m. If you need to speak to your care manager, please call 1-866-206-7861, 24 hours a day, 7 days a week. These calls are free. For more information, visit CareSource.com/MyCare. 199 Name of Drug What the Necessary Name of Drug What the Necessary Drug Actions, Drug Actions, Will Restrictions, Will Restrictions, Cost You or Limit On Cost You or Limit On (Tier Use (Tier Use Level) Level) STRESS 3 ADD SUPER MULTIPLE 3 ADD FORMULA 600 C ORAL TABLET STRESS 3 MO; ADD SUPER 3 ADD FORMULA WITH MULTIVITAMIN IRON SUPER QUINTS 3 ADD STRESS 3 MO; ADD SUPER QUINTS B- 3 ADD FORMULA WITH 50 IRON(SULF) SUPER THERA 3 MO; ADD STRESS 3 MO; ADD VITE M FORMULA WITH ZINC SUPPORT 3 MO; ADD stuart one 3 ADD TAB-A-VITE 3 MO; ADD SUNVITE 3 ADD TAB-A-VITE/IRON 3 MO; ADD SUPER 3 ADD TARON FORTE 3 MO; ADD ANTIOXIDANT THERA M PLUS 3 MO; ADD SUPER B 3 ADD (FERROUS COMPLEX- FUMARAT) VITAMIN C THERA ORAL 3 MO; ADD SUPER B MAXI 3 ADD TABLET 400 MCG COMPLEX THERA-D 3 ADD SUPER B/C 3 ADD thera-d 4000 3 ADD SUPER B-50 3 ADD theragran-m premier 3 ADD COMPLEX 50 plus super daily d3 oral 3 MO; ADD THERALOGIX 3 ADD drops 25 mcg/drop ( COMPANION 1000 unit/drop) THERA-M ORAL 3 ADD super daily d3 oral 3 ADD TABLET 27-0.4 drops 50 mcg/drop MG (2, 000 unit/drop) THERA-M ORAL 3 MO; ADD super multiple - low 3 ADD TABLET 9 MG iron IRON-400 MCG super multiple oral 3 ADD theranatal one 3 ADD capsule

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CareSource Attn: Civil Rights Coordinator P.O. Box 1947, Dayton, Ohio 45401 1-844-539-1732, TTY: 711 Fax: 1-844-417-6254

[email protected]

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You may also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office of Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD)

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