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Individual and Small Group Formulary

Updated August 1, 2020

For the most current list of covered medications or if you have questions, call the Customer Service number on the back of your ID card or visit YourHealthAllliance.org.

On YourHealthAlliance.org, you can also: • Locate a participating retail pharmacy by ZIP code. • Look up possible lower-cost medication alternatives. • Compare medication pricing and options.

Midwest IND & SG Understanding your formulary

What is a formulary? A formulary is a list of prescribed medications chosen About this formulary by your plan for their safety, cost and effectiveness. Where differences exist between Medications are listed by categories or classes and this formulary and your benefit plan are placed into cost levels known as tiers. The formulary documents, the benefit plan documents includes both brand-name and generic prescription rule. This may not be a complete list of medications approved by the U.S. Food and Drug medications, and not all medications Administration (FDA). listed may be covered by your plan. Please look at the benefit plan How do I use my formulary? documents provided by your employer You and your doctor can consult the formulary to or plan sponsor for full details. help you select the most cost-effective prescription medications. This guide tells you if a medication is generic or brand name, and if special rules apply. Bring this list with you when you see your doctor. If you have questions on how your medication is covered, call the Customer Service number on the back of your ID card or visit YourHealthAlliance.org.

What are tiers? Tiers are the different cost levels you pay for a medication. Generally, the higher your medication’s tier, the more you’ll pay out of pocket for it.

When does the formulary change? • Medications may move to a lower tier at any time. • Medications may move to a higher tier when a generic equivalent becomes available. • Medications may move to a higher tier or be excluded from coverage during the year as other formulary alternatives become available. When a medication changes tiers, you may have to pay a different amount for that medication.

Why are some medications excluded from coverage? A medication may be excluded from coverage under your pharmacy benefit when it works the same as or similar to another prescription or over-the-counter (OTC) medication.

What if I don’t agree with a decision about an excluded medication? You (or your authorized representative) and your doctor can ask for a coverage request by calling the Customer Service number on the back of your ID card.

2 Medication tips

What is the difference between brand-name and generic medications? Over-the-counter (OTC) medications Generic medications contain the same active ingredients An OTC medication may be the right (what makes the medication work) as brand-name treatment option for some conditions. medications, but they often cost less. Once the patent for Talk to your doctor about available a brand-name medication ends, the FDA can approve a OTC options. Even though these generic version with the same active ingredients. If you medications may not be covered by choose a brand-name medication after a generic version your pharmacy benefit, they may cost is available, you may pay the brand-name copayment plus less than a prescription medication. the cost difference between the brand-name and generic medication. These medications will have a comment saying “Brand penalty applies” in the notes section.

What if my doctor writes a brand-name prescription? If your doctor gives you a prescription for a brand-name medication, ask if a generic equivalent or lower-cost option is available and could be right for you. Generic medications are usually your lowest-cost option.

3 Reading your formulary

The formulary gives you choices so you and your doctor can determine your best course of treatment. In this formulary, brand-name medications are shown in UPPERCASE (for example, CLOBEX) and generic medications in lowercase (for example, clobetasol).

Tier Information Using lower tier or preferred medications can help you pay your lowest out-of-pocket cost. Your plan may have multiple or no tiers. Please note: If you have a high-deductible plan, the tier cost levels will apply once you hit your deductible.

Drug Tier Drug Tier Description Helpful Tips Brands and generics Preventive No out-of-pocket cost. Deductible does not apply used for preventive care

Tier 1 Preferred generics No out-of-pocket cost. Deductible may apply

Tier 2 Non-preferred generics Generally the lowest-cost option

Tier 3 Preferred brands Many brands have lower-cost generic options

Tier 4 Non-preferred brands Many brands have lower-cost generic options

Tier 5 Preferred specialty May be limited to a specialty pharmacy

Tier 6 Non-preferred specialty May be limited to a specialty pharmacy

General Provided and administered in a doctor’s office or Medical benefit Medical (GM) hospital and not covered by the pharmacy benefit

Drug list Information In this drug list, some medications are noted with letters next to them to help you see which ones may have coverage requirements or limits. Your benefit plan determines how these medications may be covered for you.

AL Age Limit – Based on government or manufacturer guidelines, these medications are only covered for certain age groups. PA Prior Authorization – Your doctor is required to provide additional information to determine coverage. PV Preventive – These medications are covered at $0 under preventive benefit. PV* Preventive* – These medications may be covered as preventive care if you meet the guidelines based on your plan. QL Quantity Limit – Medication may be limited to a certain quantity. ST Step Therapy – Trial of lower-cost medication(s) is required before a higher-cost medication can be covered.

4 Table of Contents - Drugs for Pain...... 8 Gastrointestinal Agents - Drugs for Acid Analgesics - Drugs for Pain and Reflux and Ulcer...... 137 Inflammation...... 6 Gastrointestinal Agents - Drugs for Anesthetics...... 16 Bowel, Intestine and Stomach Anti-Addiction / Substance Abuse Conditions Treatment Agents...... 20 ...... 139 Antibacterials...... 21 Genetic or Enzyme Disorder - Drugs for Anticoagulants...... 32 Replacement, Modification, Treatment.. 143 Anticonvulsants - Drugs for ...... 34 Genitourinary Agents - Drugs for Bladder, Antidementia Agents - Drugs for Genital and Kidney Conditions...... 146 Alzheimer's Disease and Dementia...... 39 Genitourinary Agents - Drugs for Prostate Antidepressants...... 40 Conditions...... 148 Antiemetics - Drugs for Nausea and Hormonal Agents - Adrenal...... 149 Vomiting...... 43 Hormonal Agents - Men's Health...... 151 Antifungals...... 44 Hormonal Agents - Osteoporosis...... 152 Antigout Agents...... 48 Hormonal Agents - Pituitary...... 152 Anti-inflammatory Agents...... 48 Hormonal Agents - Prostaglandins...... 156 Antimigraine Agents...... 48 Hormonal Agents - Sex Hormones and Antimyasthenic Agents...... 50 Birth Control...... 156 Antimycobacterials...... 51 Hormonal Agents - Thyroid...... 165 Antineoplastics - Drugs for Cancer...... 51 Immunological Agents - Drugs for Antiparasitics...... 64 Immune System Stimulation or Antiparkinson Agents...... 66 Suppression...... 166 Antiplatelets...... 68 Immunological Agents - Drugs for Antipsychotics - Drugs for Mood Vaccination...... 174 Disorders...... 68 Inflammatory Bowel Disease Agents...... 176 Antivirals...... 71 Metabolic Bone Disease Agents - Drugs Anxiolytics - Drugs for Anxiety...... 76 for Osteoporosis...... 178 Bipolar Agents - Drugs for Mood Metabolic Bone Disease Agents - Other.. 179 Disorders...... 78 Miscellaneous Therapeutic Agents...... 180 Blood Products / Modifiers / Volume Ophthalmic Agents - Drugs for Eye Expanders - Drugs for Bleeding Allergy, Infection and Inflammation...... 193 Disorders 78 Ophthalmic Agents - Drugs for Glaucoma Cardiovascular Agents - Drugs for Heart ...... 196 and Circulation Conditions...... 84 Ophthalmic Agents - Drugs for Central Nervous System Agents - Drugs Miscellaneous Eye Conditions...... 198 for Attention Deficit Disorder...... 100 Otic Agents - Drugs for Ear Conditions... 202 Central Nervous System Agents - Drugs Respiratory Tract / Pulmonary Agents - for Multiple Sclerosis...... 102 Drugs for Allergies, Cough, Cold...... 202 Central Nervous System Agents - Respiratory Tract / Pulmonary Agents - Miscellaneous...... 104 Drugs for Asthma and Other Lung Dental and Oral Agents - Drugs for Mouth Conditions...... 205 and Throat Conditions...... 105 Respiratory Tract / Pulmonary Agents - Dermatological Agents - Drugs for Skin Drugs for Cystic Fibrosis...... 209 Conditions...... 107 Respiratory Tract / Pulmonary Agents - Diabetes - Antidiabetic Agents...... 115 Drugs for Pulmonary Hypertension...... 210 Diabetes - Glucose Monitoring...... 119 Skeletal Muscle Relaxants - Drugs for Diabetes - Glycemic Agents...... 119 Muscle Pain and Spasm...... 211 Diabetes - Insulins...... 119 Sleep Disorder Agents...... 212 Electrolytes / Minerals / Metals / Vitamins123 Index of Drugs...... 214

5 Drug Drug Drug Name Notes Drug Name Notes Tier Tier Analgesics - Drugs for CELEBREX ORAL Brand Pain and Inflammation CAPSULE 100 MG, 200 4 penalty MG, 400 MG, 50 MG applies ACTIVE- 4 EXTERNAL CREAM 5 % oral capsule adult regimen oral 100 mg, 200 mg, 400 2 tablet delayed release 81 PV mg, 50 mg mg Brand ANJESO DAYPRO ORAL TABLET 4 penalty INTRAVENOUS GM 600 MG applies INJECTABLE 30 MG/ML ARTHROTEC ORAL EPOLAMINE Brand 4 ST TABLET DELAYED TRANSDERMAL PATCH 4 penalty 1.3 % RELEASE 50-0.2 MG, applies 75-0.2 MG diclofenac potassium oral 2 aspirin adult low strength tablet 50 mg oral tablet delayed PV diclofenac sodium er oral release 81 mg tablet extended release 2 24 hour 100 mg aspirin childrens oral PV tablet chewable 81 mg diclofenac sodium oral aspirin ec low dose oral tablet delayed release 25 2 tablet delayed release 81 PV mg mg diclofenac sodium oral aspirin ec low strength tablet delayed release 50 1 oral tablet delayed PV mg, 75 mg release 81 mg diclofenac sodium 2 transdermal gel 1 % aspirin ec oral tablet PV delayed release 81 mg diclofenac-misoprostol oral tablet delayed aspirin low dose oral PV 2 tablet chewable 81 mg release 50-0.2 mg, 75- 0.2 mg aspirin low dose oral tablet delayed release 81 PV DICLOSTREAM mg EXTERNAL THERAPY 4 PACK 1.5-10 % aspirin oral tablet PV delayed release 81 mg oral tablet 500 2 mg BAYER ASPIRIN EC DIMENTHO EXTERNAL LOW DOSE ORAL PV TABLET DELAYED THERAPY PACK 1.5 & 4 RELEASE 81 MG 10 % CALDOLOR EC-NAPROSYN ORAL Brand INTRAVENOUS GM TABLET DELAYED 4 penalty SOLUTION 800 MG/8ML RELEASE 375 MG applies

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 6 Drug Drug Drug Name Notes Drug Name Notes Tier Tier ec- oral tablet oral 2 delayed release 375 mg, 2 suspension 100 mg/5ml 500 mg ibuprofen oral tablet 400 2 ENOVARX-IBUPROFEN mg, 600 mg, 800 mg EXTERNAL CREAM 10 4 INDOCIN ORAL % SUSPENSION 25 4 EQUAPAX/IBUPROFEN/ MG/5ML MINREX ORAL INDOCIN RECTAL 4 3 THERAPY PACK 800 SUPPOSITORY 50 MG MG indomethacin er oral er oral tablet capsule extended 2 extended release 24 hour 2 release 75 mg 400 mg, 500 mg, 600 mg indomethacin oral 2 etodolac oral capsule 2 capsule 25 mg, 50 mg 200 mg, 300 mg indomethacin sodium etodolac oral tablet 400 2 intravenous solution GM mg, 500 mg reconstituted 1 mg FBL KIT EXTERNAL 4 ketoprofen er oral CREAM 15-4-5 % capsule extended 2 FELDENE ORAL Brand release 24 hour 200 mg CAPSULE 10 MG, 20 4 penalty ketoprofen oral capsule 2 MG applies 25 mg, 50 mg, 75 mg fenoprofen calcium oral 2 tromethamine capsule 200 mg, 400 mg injection solution 15 2 fenoprofen calcium oral 2 mg/ml tablet 600 mg ketorolac tromethamine 2 fenortho oral capsule 200 2 intramuscular solution 60 mg mg/2ml FLECTOR QL (20 EA TRANSDERMAL PATCH 4 ST ketorolac tromethamine 2 per 30 1.3 % oral tablet 10 mg days) oral tablet ketorolac tromethamine 2 100 mg, 50 mg solution 30 mg/ml 2 goodsense aspirin low injection 30 mg/ml dose oral tablet delayed PV KETOROLAC release 81 mg TROMETHAMINE 4 SOLUTION 30 MG/ML ibu oral tablet 400 mg, 2 600 mg, 800 mg INJECTION 30 MG/ML ibuprofen lysine KETOROLAC-BUPIV- intravenous solution 10 GM INJECTION GM mg/ml SOLUTION PREFILLED SYRINGE 60-150-60 MG/50ML Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 7 Drug Drug Drug Name Notes Drug Name Notes Tier Tier KETOROLAC-ROPIV- naproxen oral 2 KETAMINE INJECTION suspension 125 mg/5ml SOLUTION PREFILLED GM naproxen oral tablet 250 2 SYRINGE 15-100-30 mg, 375 mg, 500 mg MG/50ML naproxen sodium er oral LIDOPROFEN tablet extended release 2 4 EXTERNAL CREAM 5-5- 24 hour 375 mg, 500 mg 2 % naproxen sodium oral 2 Brand tablet 275 mg, 550 mg LODINE ORAL TABLET 4 penalty 400 MG applies NEOPROFEN INTRAVENOUS GM meclofenamate sodium SOLUTION 10 MG/ML oral capsule 100 mg, 50 2 oxaprozin oral tablet 600 mg 2 mg oral 2 capsule 250 mg piroxicam oral capsule 10 2 mg, 20 mg meloxicam oral tablet 15 1 mg, 7.5 mg qc aspirin low dose oral tablet delayed release 81 PV Brand mg MOBIC ORAL TABLET 4 penalty salsalate oral tablet 500 15 MG, 7.5 MG applies 2 mg, 750 mg nabumetone oral tablet 2 500 mg, 750 mg ST JOSEPH LOW DOSE ORAL TABLET PV Brand DELAYED RELEASE 81 NALFON ORAL 4 penalty MG CAPSULE 400 MG applies sulindac oral tablet 150 2 Brand mg, 200 mg NALFON ORAL TABLET 4 penalty 600 MG applies tolmetin sodium oral 2 capsule 400 mg NAPRELAN ORAL Brand TABLET EXTENDED tolmetin sodium oral 4 penalty 2 RELEASE 24 HOUR 375 tablet 600 mg applies MG, 500 MG VOLTAREN Brand NAPRELAN ORAL TRANSDERMAL GEL 1 4 penalty % applies TABLET EXTENDED 4 RELEASE 24 HOUR 750 VOPAC KT EXTERNAL 4 MG CREAM 5-5-2 % NAPROSYN ORAL Brand Analgesics - Drugs for SUSPENSION 125 4 penalty Pain MG/5ML applies 7T GUMMY ES ORAL naproxen dr oral tablet TABLET CHEWABLE 4 delayed release 375 mg, 2 500 MG 500 mg

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 8 Drug Drug Drug Name Notes Drug Name Notes Tier Tier acetaminophen- hcl 2 #2 oral tablet 300-15 mg injection solution 0.3 GM mg/ml acetaminophen-codeine 2 #3 oral tablet 300-30 mg buprenorphine transdermal patch weekly acetaminophen-codeine 2 #4 oral tablet 300-60 mg 10 mcg/hr, 15 mcg/hr, 20 2 mcg/hr, 5 mcg/hr, 7.5 acetaminophen-codeine mcg/hr oral solution 120-12 2 mg/5ml butalbital-acetaminophen capsule 50-300 mg oral 2 acetaminophen-codeine 50-300 mg oral tablet 300-15 mg, 2 300-30 mg, 300-60 mg BUTALBITAL- ACETAMINOPHEN 2 ACTIQ BUCCAL CAPSULE 50-300 MG LOZENGE ON A PA; Brand ORAL 50-300 MG HANDLE 1200 MCG, 4 penalty 1600 MCG, 200 MCG, butalbital-acetaminophen applies 2 400 MCG, 600 MCG, 800 oral tablet 50-300 mg, MCG 50-325 mg hcl intravenous butalbital-apap-caff-cod solution 1000 mcg/2ml, GM oral capsule 50-300-40- 2 2500 mcg/5ml 30 mg, 50-325-40-30 mg apap-caff- butalbital-apap-caffeine oral capsule 320.5-30-16 2 oral capsule 50-300-40 2 mg mg, 50-325-40 mg ARYMO ER ORAL butalbital-apap-caffeine 2 TABLET EXTENDED oral tablet 50-325-40 mg RELEASE ABUSE- 4 PA butalbital-asa-caff- DETERRENT 15 MG, 30 codeine oral capsule 50- 2 MG, 60 MG 325-40-30 mg ascomp-codeine oral butalbital-aspirin-caffeine capsule 50-325-40-30 2 oral capsule 50-325-40 2 mg mg

BELBUCA BUCCAL butalbital-aspirin-caffeine 2 FILM 150 MCG, 300 QL (60 EA oral tablet 50-325-40 mg MCG, 450 MCG, 600 4 per 30 tartrate MCG, 75 MCG, 750 days) injection solution 1 GM MCG, 900 MCG mg/ml, 2 mg/ml Brand butorphanol tartrate 2 BUPAP ORAL TABLET 4 penalty nasal solution 10 mg/ml 50-300 MG applies BUPRENEX INJECTION GM SOLUTION 0.3 MG/ML

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 9 Drug Drug Drug Name Notes Drug Name Notes Tier Tier BUTRANS DURAGESIC-25 PA; Brand 4 penalty TRANSDERMAL PATCH Brand TRANSDERMAL PATCH applies WEEKLY 10 MCG/HR, 4 penalty 72 HOUR 25 MCG/HR 15 MCG/HR, 20 applies DURAGESIC-50 PA; Brand MCG/HR, 5 MCG/HR, TRANSDERMAL PATCH 4 penalty 7.5 MCG/HR 72 HOUR 50 MCG/HR applies -aspirin- DURAGESIC-75 PA; Brand codeine oral tablet 200- 2 TRANSDERMAL PATCH 4 penalty 325-16 mg 72 HOUR 75 MCG/HR applies clonidine hcl (analgesia) Specialty duramorph injection 6 epidural solution 100 Medical solution 0.5 mg/ml, 1 GM mcg/ml, 500 mcg/ml mg/ml codeine sulfate oral duraxin oral capsule 300- 2 tablet 15 mg, 30 mg, 60 2 200-20 mg mg EMBEDA ORAL DEMEROL INJECTION CAPSULE EXTENDED SOLUTION 100 RELEASE 100-4 MG, 20- 4 PA MG/2ML, 100 MG/ML, 25 GM 0.8 MG, 30-1.2 MG, 50-2 MG/ML, 50 MG/ML, 75 MG, 60-2.4 MG, 80-3.2 MG/ML MG DILAUDID INJECTION endocet oral tablet 10- SOLUTION 1 MG/ML, 2 GM 325 mg, 2.5-325 mg, 5- 2 MG/ML 325 mg, 7.5-325 mg Brand Brand DILAUDID ORAL LIQUID 4 penalty ESGIC ORAL CAPSULE 4 penalty 1 MG/ML applies 50-325-40 MG applies DILAUDID ORAL Brand Brand TABLET 2 MG, 4 MG, 8 4 penalty ESGIC ORAL TABLET 4 penalty MG applies 50-325-40 MG applies Brand citrate (pf) DOLOPHINE ORAL 4 penalty injection solution 100 TABLET 10 MG, 5 MG applies mcg/2ml, 1000 GM DSUVIA SUBLINGUAL mcg/20ml, 250 mcg/5ml, TABLET SUBLINGUAL 4 2500 mcg/50ml, 500 30 MCG mcg/10ml Specialty DURACLON EPIDURAL 6 fentanyl citrate (pf) SOLUTION 100 MCG/ML Medical injection solution GM DURAGESIC-100 PA; Brand cartridge 100 mcg/2ml TRANSDERMAL PATCH 4 penalty fentanyl citrate buccal 72 HOUR 100 MCG/HR applies lozenge on a handle DURAGESIC-12 PA; Brand 1200 mcg, 1600 mcg, 2 PA TRANSDERMAL PATCH 4 penalty 200 mcg, 400 mcg, 600 72 HOUR 12 MCG/HR applies mcg, 800 mcg

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 10 Drug Drug Drug Name Notes Drug Name Notes Tier Tier FENTANYL CITRATE FENTANYL- BUCCAL TABLET 100 BUPIVACAINE-NACL MCG, 200 MCG, 400 4 PA EPIDURAL SOLUTION MCG, 600 MCG, 800 0.2-0.1-0.9 MG/100ML- MCG %, 0.2-0.125-0.9 GM FENTANYL CITRATE MG/100ML-%, 0.5- INJECTION SOLUTION GM 0.0625-0.9 MG/250ML- 1500 MCG/30ML %, 0.5-0.1-0.9 MG/250ML-%, 0.5-0.125- FENTANYL CITRATE 0.9 MG/250ML-% INTRAVENOUS GM SOLUTION 5000 FENTANYL- MCG/100ML BUPIVACAINE-NACL INJECTION SOLUTION GM FENTANYL CITRATE 2-0.125-0.9 MCG/ML-%- INTRAVENOUS % SOLUTION PREFILLED SYRINGE 1500 GM FENTORA BUCCAL TABLET 100 MCG, 200 MCG/30ML, 250 4 PA MCG/5ML, 2750 MCG, 400 MCG, 600 MCG/55ML MCG, 800 MCG FENTANYL CITRATE- FIORICET ORAL Brand NACL INTRAVENOUS CAPSULE 50-300-40 4 penalty SOLUTION 1-0.9 MG applies MG/100ML-%, 1.25-0.9 GM FIORICET/CODEINE Brand MG/250ML-%, 2-0.9 ORAL CAPSULE 50- 4 penalty MG/100ML-%, 2.5-0.9 300-40-30 MG applies MG/250ML-% FIORINAL ORAL Brand FENTANYL CITRATE- CAPSULE 50-325-40 4 penalty NACL INTRAVENOUS MG applies SOLUTION PREFILLED FIORINAL/CODEINE #3 Brand SYRINGE 10-0.9 GM ORAL CAPSULE 50- 4 penalty MCG/2ML-%, 5-0.9 325-40-30 MG applies MCG/ML-%, 550-0.9 MCG/55ML-% bitartrate er oral capsule er 12 hour FENTANYL CIT- abuse-deterrent 10 mg, 2 PA ROPIVACAINE-NACL GM 15 mg, 20 mg, 30 mg, 40 EPIDURAL SOLUTION mg, 50 mg 0.3-0.2-0.9 MG/150ML-% hydrocodone- fentanyl transdermal acetaminophen oral patch 72 hour 100 solution 10-325 mg/15ml, 2 mcg/hr, 12 mcg/hr, 25 2 PA 2.5-108 mg/5ml, 5-217 mcg/hr, 37.5 mcg/hr, 50 mg/10ml, 7.5-325 mcg/hr, 62.5 mcg/hr, 75 mg/15ml mcg/hr, 87.5 mcg/hr

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 11 Drug Drug Drug Name Notes Drug Name Notes Tier Tier hydrocodone- acetaminophen oral HCL-NACL tablet 10-300 mg, 10-325 2 INTRAVENOUS mg, 5-300 mg, 5-325 mg, SOLUTION PREFILLED 7.5-300 mg, 7.5-325 mg SYRINGE 0.2-0.9 MG/0.2ML-%, 0.5-0.9 hydrocodone-ibuprofen GM oral tablet 10-200 mg, 5- 2 MG/0.5ML-%, 1-0.9 200 mg, 7.5-200 mg MG/5ML-%, 1-0.9 MG/ML-%, 2-0.9 MG/ML- hydromorphone hcl er %, 50-0.9 MG/50ML-%, oral tablet er 24 hour 2 PA 55-0.9 MG/55ML-%, 6- abuse-deterrent 12 mg, 0.9 MG/30ML-% 16 mg, 32 mg, 8 mg HYSINGLA ER ORAL hydromorphone hcl TABLET ER 24 HOUR injection solution 2 GM ABUSE-DETERRENT 4 PA mg/ml, 4 mg/ml 100 MG, 120 MG, 20 MG, 30 MG, 40 MG, 60 hydromorphone hcl oral 2 liquid 1 mg/ml MG, 80 MG hydromorphone hcl oral INFUMORPH 200 2 tablet 2 mg, 4 mg, 8 mg INJECTION SOLUTION GM hydromorphone hcl pf 200 MG/20ML (10 injection solution 1 MG/ML) mg/ml, 10 mg/ml, 2 GM INFUMORPH 500 INJECTION SOLUTION mg/ml, 4 mg/ml, 50 GM mg/5ml, 500 mg/50ml 500 MG/20ML (25 MG/ML) hydromorphone hcl rectal 2 suppository 3 mg KADIAN ORAL CAPSULE EXTENDED HYDROMORPHONE PA; Brand HCL SOLUTION 1 RELEASE 24 HOUR 10 GM 4 penalty MG/ML INJECTION 1 MG, 100 MG, 20 MG, 30 applies MG/ML MG, 40 MG, 50 MG, 60 MG, 80 MG hydromorphone hcl solution 1 mg/ml injection GM KADIAN ORAL CAPSULE EXTENDED 1 mg/ml 4 PA RELEASE 24 HOUR 200 HYDROMORPHONE MG HCL-NACL INJECTION GM SOLUTION 20-0.9 LAZANDA NASAL MG/100ML-% SOLUTION 100 MCG/ACT, 300 4 PA HYDROMORPHONE MCG/ACT, 400 HCL-NACL MCG/ACT INTRAVENOUS GM SOLUTION 20-0.9 tartrate oral 2 MG/100ML-%, 30-0.9 tablet 2 mg, 3 mg lorcet hd oral tablet 10- MG/30ML-% 2 325 mg Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 12 Drug Drug Drug Name Notes Drug Name Notes Tier Tier lorcet oral tablet 5-325 mitigo injection solution 2 mg 200 mg/20ml (10 mg/ml), GM 500 mg/20ml (25 mg/ml) LORTAB ORAL ELIXIR 4 10-300 MG/15ML sulfate MEDI-DERM-RX (concentrate) oral 2 EXTERNAL CREAM 4 solution 100 mg/5ml, 20 0.035-5-20 % mg/ml MEDROX-RX morphine sulfate (pf) EXTERNAL OINTMENT 4 injection solution 0.5 0.05-7-20 % mg/ml, 1 mg/ml, 10 GM mg/ml, 2 mg/ml, 4 mg/ml, meperidine hcl injection 5 mg/ml, 8 mg/ml solution 100 mg/ml, 25 GM mg/ml, 50 mg/ml morphine sulfate (pf) intravenous solution 10 GM meperidine hcl oral 2 mg/ml, 2 mg/ml, 4 mg/ml, solution 50 mg/5ml 8 mg/ml meperidine hcl oral tablet 2 morphine sulfate er 100 mg, 50 mg beads oral capsule extended release 24 hour 2 PA hcl injection GM solution 10 mg/ml 120 mg, 30 mg, 45 mg, methadone hcl intensol 60 mg, 75 mg, 90 mg oral concentrate 10 2 morphine sulfate er oral mg/ml capsule extended methadone hcl oral release 24 hour 10 mg, 2 2 PA concentrate 10 mg/ml 100 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg, 80 methadone hcl oral mg solution 10 mg/5ml, 5 2 mg/5ml morphine sulfate er oral tablet extended release 2 PA methadone hcl oral tablet 2 100 mg, 15 mg, 200 mg, 10 mg, 5 mg 30 mg, 60 mg methadone hcl oral tablet 2 MORPHINE SULFATE soluble 40 mg INJECTION SOLUTION GM METHADOSE ORAL Brand 1 MG/ML CONCENTRATE 10 4 penalty morphine sulfate injection MG/ML applies solution 2 mg/ml, 4 GM methadose oral tablet mg/ml 2 soluble 40 mg morphine sulfate intramuscular device 10 GM METHADOSE SUGAR- Brand mg/0.7ml FREE ORAL 4 penalty CONCENTRATE 10 applies MORPHINE SULFATE MG/ML INTRAVENOUS GM SOLUTION 0.5 MG/ML

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 13 Drug Drug Drug Name Notes Drug Name Notes Tier Tier morphine sulfate oral NORCO ORAL TABLET Brand solution 10 mg/5ml, 20 2 10-325 MG, 5-325 MG, 4 penalty mg/5ml 7.5-325 MG applies morphine sulfate oral 2 NUCYNTA ER ORAL tablet 15 mg, 30 mg TABLET EXTENDED morphine sulfate rectal RELEASE 12 HOUR 100 4 PA suppository 10 mg, 20 2 MG, 150 MG, 200 MG, mg, 30 mg, 5 mg 250 MG, 50 MG MORPHINE SULFATE NUCYNTA ORAL SOLUTION 1 MG/ML TABLET 100 MG, 50 4 ST GM INTRAVENOUS 1 MG, 75 MG MG/ML OXAYDO ORAL TABLET morphine sulfate solution ABUSE-DETERRENT 5 4 PA 1 mg/ml intravenous 1 GM MG, 7.5 MG mg/ml HCL ER MORPHINE SULFATE- ORAL TABLET ER 12 HOUR ABUSE- NACL INJECTION 4 PA SOLUTION PREFILLED GM DETERRENT 10 MG, 15 SYRINGE 5-0.9 MG, 20 MG, 30 MG, 40 MG/5ML-% MG, 60 MG, 80 MG oxycodone hcl oral MORPHINE SULFATE- 2 NACL INTRAVENOUS capsule 5 mg GM SOLUTION 100-0.9 oxycodone hcl oral 2 MG/100ML-%, 500-0.9 concentrate 100 mg/5ml MG/100ML-% oxycodone hcl oral 2 MORPHINE SULFATE- solution 5 mg/5ml NACL INTRAVENOUS oxycodone hcl oral tablet SOLUTION PREFILLED 10 mg, 15 mg, 20 mg, 30 2 SYRINGE 150-0.9 mg, 5 mg MG/30ML-%, 2-0.9 GM MG/ML-%, 30-0.9 oxycodone- MG/30ML-%, 4-0.9 acetaminophen oral MG/ML-%, 55-0.9 tablet 10-325 mg, 2.5- 2 MG/55ML-% 300 mg, 2.5-325 mg, 5- 325 mg, 7.5-325 mg MS CONTIN ORAL TABLET EXTENDED PA; Brand oxycodone-aspirin oral 2 RELEASE 100 MG, 15 4 penalty tablet 4.8355-325 mg MG, 200 MG, 30 MG, 60 applies OXYCONTIN ORAL MG TABLET ER 12 HOUR ABUSE-DETERRENT 10 hcl injection 4 PA solution 10 mg/ml, 20 GM MG, 15 MG, 20 MG, 30 mg/ml MG, 40 MG, 60 MG, 80 MG NALOCET ORAL 4 TABLET 2.5-300 MG

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 14 Drug Drug Drug Name Notes Drug Name Notes Tier Tier hcl er oral tencon oral tablet 50-325 2 tablet extended release mg 12 hour 10 mg, 15 mg, 2 PA hcl er (biphasic) 20 mg, 30 mg, 40 mg, 5 oral tablet extended 2 ST mg, 7.5 mg release 24 hour 100 mg, oxymorphone hcl oral 2 200 mg, 300 mg tablet 10 mg, 5 mg tramadol hcl er oral tablet -naloxone hcl extended release 24 hour 2 ST 2 oral tablet 50-0.5 mg 100 mg, 200 mg, 300 mg PERCOCET ORAL tramadol hcl oral tablet Brand 2 TABLET 10-325 MG, 2.5- 100 mg, 50 mg 4 penalty 325 MG, 5-325 MG, 7.5- tramadol-acetaminophen applies 2 325 MG oral tablet 37.5-325 mg PRIALT INTRATHECAL TREZIX ORAL Brand SOLUTION 100 CAPSULE 320.5-30-16 4 penalty MCG/ML, 500 GM MG applies MCG/20ML, 500 MCG/5ML ULTIVA INTRAVENOUS SOLUTION GM PRIMLEV ORAL RECONSTITUTED 1 TABLET 10-300 MG, 5- 4 MG, 2 MG, 5 MG 300 MG, 7.5-300 MG Brand PROBUPHINE IMPLANT ULTRACET ORAL 4 penalty KIT SUBCUTANEOUS 3 TABLET 37.5-325 MG applies IMPLANT 74.2 MG Brand PROLATE ORAL ULTRAM ORAL TABLET 4 penalty TABLET 10-300 MG, 5- 4 50 MG applies 300 MG, 7.5-300 MG VANATOL LQ ORAL hcl SOLUTION 50-325-40 4 intravenous solution GM MG/15ML reconstituted 1 mg, 2 mg, 5 mg VANATOL S ORAL SOLUTION 50-325-40 4 ROXICODONE ORAL Brand MG/15ML TABLET 15 MG, 30 MG, 4 penalty 5 MG applies VTOL LQ ORAL SOLUTION 50-325-40 4 SUBSYS SUBLINGUAL MG/15ML LIQUID 100 MCG, 1200 XTAMPZA ER ORAL (600 X 2) MCG, 1600 4 PA (800 X 2) MCG, 200 CAPSULE ER 12 HOUR MCG, 400 MCG, 600 ABUSE-DETERRENT 4 PA MCG, 800 MCG 13.5 MG, 18 MG, 27 MG, 36 MG, 9 MG sufentanil citrate ZEBUTAL ORAL Brand intravenous solution 100 GM mcg/2ml, 250 mcg/5ml, CAPSULE 50-325-40 4 penalty 50 mcg/ml MG applies Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 15 Drug Drug Drug Name Notes Drug Name Notes Tier Tier ZOHYDRO ER ORAL bupivacaine in dextrose CAPSULE ER 12 HOUR PA; Brand intrathecal solution 0.75- GM ABUSE-DETERRENT 10 4 penalty 8.25 % MG, 15 MG, 20 MG, 30 applies bupivacaine spinal MG, 40 MG, 50 MG intrathecal solution 0.75- GM Anesthetics 8.25 % 1ST MEDX-PATCH/ bupivacaine-epinephrine LIDOCAINE EXTERNAL 4 (pf) injection solution GM PATCH 4-0.0375-5-20 % 0.25% -1:200000, 0.5% - 7T LIDO EXTERNAL 1:200000 4 GEL 2 % bupivacaine-epinephrine AGONEAZE EXTERNAL injection solution 0.25% - 4 GM KIT 2.5-2.5 % 1:200000, 0.5% - 1:200000 ANODYNE LPT EXTERNAL KIT 2.5-2.5 4 CARBOCAINE % INJECTION SOLUTION GM 1 %, 2 % ARTICADENT DENTAL INJECTION SOLUTION CARBOCAINE GM PRESERVATIVE-FREE CARTRIDGE 4 %- GM 1:100000, 4 %-1:200000 INJECTION SOLUTION 1 %, 1.5 %, 2 % bupivacaine fisiopharma injection solution 2.5 GM CETACAINE EXTERNAL GM mg/ml, 5 mg/ml AEROSOL 2-2-14 % bupivacaine hcl (pf) chloroprocaine hcl (pf) injection solution 0.25 %, GM injection solution 2 %, 3 GM 0.5 %, 0.75 % % bupivacaine hcl injection CITANEST FORTE GM DENTAL INJECTION solution 0.25 %, 0.5 % GM SOLUTION 4% - BUPIVACAINE HCL 1:200000 INJECTION SOLUTION GM 312.5 MG/10ML CITANEST PLAIN DENTAL INJECTION GM BUPIVACAINE HCL SOLUTION 4 % INJECTION SOLUTION PREFILLED SYRINGE CLOROTEKAL 0.125 % (50 ML), 125 GM INTRATHECAL GM MG/4ML, 250 MG/8ML, SOLUTION 50 MG/5ML 312.5 MG/10ML, 625 COCAINE HCL NASAL GM MG/20ML SOLUTION 40 MG/ML BUPIVACAINE HCL- c-topical external solution 2 NACL EPIDURAL GM 4 % SOLUTION PREFILLED SYRINGE 0.25-0.9 %

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 16 Drug Drug Drug Name Notes Drug Name Notes Tier Tier DERMACINRX lidocaine hcl external 2 EMPRICAINE 4 cream 3 % EXTERNAL KIT 2.5-2.5 lidocaine hcl external 2 % lotion 3 % DERMACINRX lidocaine hcl external 2 PRIZOPAK EXTERNAL 4 solution 4 % KIT 2.5-2.5 % lidocaine hcl injection ethyl chloride external GM 2 solution 0.5 % aerosol LIDOCAINE HCL EXPAREL INJECTION INJECTION SOLUTION GM GM SUSPENSION 1.3 % PREFILLED SYRINGE FLEXIN EXTERNAL 10 MG/ML 4 PATCH 0.0375-5 % LIDOCAINE HCL 4 glydo external prefilled 2 INTRADERMAL JET- syringe 2 % INJECTOR 0.5 MG

GOPRELTO NASAL GM LIDOCAINE HCL SOLUTION 40 MG/ML SOLUTION 1 % GM LETS KIT 4 INJECTION 1 % lidocaine hcl solution 1 % LEVATIO EXTERNAL 4 GM PATCH 0.03-5 % injection 1 % LIDO BDK EXTERNAL LIDOCAINE HCL 4 KIT 2.5-2.5 % SOLUTION 2 % GM INJECTION 2 % QL (50 GM lidocaine hcl solution 2 % lidocaine external 2 per 30 GM ointment 5 % days) injection 2 % lidocaine hcl lidocaine external patch 5 2 % urethral/mucosal external 2 gel 2 % lidocaine hcl (cardiac) lidocaine hcl intravenous solution GM prefilled syringe 100 urethral/mucosal external 2 mg/5ml, 50 mg/5ml prefilled syringe 2 % lidocaine hcl (cardiac) pf lidocaine in d5w intravenous solution 100 GM intravenous solution 4-5 GM mg/5ml mg/ml-%, 8-5 mg/ml-% lidocaine hcl (cardiac) pf LIDOCAINE IN intravenous solution DEXTROSE SOLUTION GM GM prefilled syringe 100 5-7.5 % mg/5ml, 50 mg/5ml lidocaine-epinephrine lidocaine hcl (pf) injection injection solution 0.5 %- solution 0.5 %, 1 %, 1.5 GM 1:200000, 1 %-1:100000, GM %, 2 %, 4 % 1.5 %-1:200000, 2 %- 1:100000, 2 %-1:200000, 2 %-1:50000 Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 17 Drug Drug Drug Name Notes Drug Name Notes Tier Tier lidocaine-prilocaine MARCAINE/EPINEPHRI 2 external cream 2.5-2.5 % NE INJECTION SOLUTION 0.25% - GM lidocaine-prilocaine 2 external kit 2.5-2.5 % 1:200000, 0.5% - 1:200000 LIDOCAINE- MARCAINE/EPINEPHRI TETRACAINE 4 EXTERNAL CREAM 7-7 NE PF INJECTION % SOLUTION 0.25% - GM 1:200000, 0.5% - Brand 1:200000 LIDODERM EXTERNAL 4 penalty PATCH 5 % applies MEDI-DERM/L-RX EXTERNAL CREAM 2- 4 LIDO-EPINEPHRINE- 0.035-5-20 % TETRACAINE GM EXTERNAL SOLUTION MEDI-PATCH RX 4-0.05-0.5 % EXTERNAL PATCH 0.5- 4 0.035-5-20 % lidopin external cream 3 2 % NAROPIN INJECTION SOLUTION 10 MG/ML, 2 GM LIDOPRIL EXTERNAL 4 MG/ML, 5 MG/ML, 7.5 KIT 2.5-2.5 % MG/ML LIDOPRIL XR NESACAINE INJECTION GM EXTERNAL KIT 2.5-2.5 4 SOLUTION 1 %, 2 % % NESACAINE-MPF LIDO-PRILO CAINE INJECTION SOLUTION GM PACK EXTERNAL KIT 4 2 %, 3 % 2.5-2.5 % NUMBRINO NASAL GM LIDO-SORB EXTERNAL 4 SOLUTION 40 MG/ML LOTION 3 % NUVAKAAN EXTERNAL 4 LIVIXIL PAK EXTERNAL 4 KIT 2.5-2.5 % KIT 2.5-2.5 % ORABLOC INJECTION MARCAINE INJECTION SOLUTION CARTRIDGE GM SOLUTION 0.25 %, 0.5 GM 4 %-1:100000, 4 %- %, 0.75 % 1:200000 MARCAINE PAINGO KFT PRESERVATIVE FREE GM EXTERNAL KIT 2.5-2.5- GM INJECTION SOLUTION 10-30 % 0.25 %, 0.5 % PLIAGLIS EXTERNAL 4 MARCAINE SPINAL CREAM 7-7 % INTRATHECAL GM polocaine injection SOLUTION 0.75-8.25 % GM solution 1 %, 2 % polocaine-mpf injection GM solution 1 %, 1.5 %, 2 %

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 18 Drug Drug Drug Name Notes Drug Name Notes Tier Tier QL (50 GM ROPIVACAINE HCL premium lidocaine 2 per 30 SOLUTION 2 MG/ML GM external ointment 5 % days) INJECTION 2 MG/ML

PRILOLID EXTERNAL 4 ropivacaine hcl solution 2 GM KIT 2.5-2.5 % mg/ml injection 2 mg/ml

PRILOVIX EXTERNAL 4 ROPIVACAINE HCL- KIT 2.5-2.5 % NACL INJECTION GM PRILOVIX LITE SOLUTION 0.2-0.9 % EXTERNAL KIT 2.5-2.5 4 ROPIV-CLONIDINE- % KETOROLAC PRILOVIX LITE PLUS SOLUTION PREFILLED GM EXTERNAL KIT 2.5-2.5 4 SYRINGE 123-0.04-15 % MG/50ML PRILOVIX PLUS sensorcaine injection GM EXTERNAL KIT 2.5-2.5 4 solution 0.25 %, 0.5 % % sensorcaine/epinephrine injection solution 0.25% - prilovix ultralite external 2 GM kit 2.5-2.5 % 1:200000, 0.5% - 1:200000 prilovix ultralite plus 2 external kit 2.5-2.5 % sensorcaine-mpf injection solution 0.25 %, 0.5 %, GM RECK SOLUTION 0.75 % PREFILLED SYRINGE GM 123-0.25-0.04- 15 sensorcaine- MG/50ML mpf/epinephrine injection solution 0.25% - GM RELADOR PAK 1:200000, 0.5% - EXTERNAL KIT 2.5-2.5 4 1:200000 % SENSORCAINE- RELADOR PAK PLUS MPF/EPINEPHRINE GM EXTERNAL KIT 2.5-2.5 4 INJECTION SOLUTION % 0.75-1:200000 % RENOVO EXTERNAL SYNERA EXTERNAL 4 GM PATCH 0.0375-5 % PATCH 70-70 MG ropivacaine hcl injection SYNVEXIA TC solution 10 mg/ml, 5 GM EXTERNAL CREAM 4-1 4 mg/ml, 7.5 mg/ml % ROPIVACAINE HCL VEXATROL EXTERNAL 4 INJECTION SOLUTION GM KIT 2.5-2.5 % 33.4 MG/ML xylocaine dental injection ROPIVACAINE HCL solution 2 %-1:100000, 2 GM INJECTION SOLUTION GM %-1:50000 PREFILLED SYRINGE 0.2 %, 0.5 %

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 19 Drug Drug Drug Name Notes Drug Name Notes Tier Tier XYLOCAINE INJECTION buprenorphine hcl- GM SOLUTION 0.5 %, 1 %, 2 naloxone hcl sublingual 1 % tablet sublingual 2-0.5 XYLOCAINE/EPINEPHR mg, 8-2 mg INE INJECTION bupropion hcl er GM SOLUTION 0.5 %- (smoking det) oral tablet PV 1:200000, 1 %-1:100000, extended release 12 hour 2 %-1:100000 150 mg XYLOCAINE-MPF CHANTIX CONTINUING INJECTION SOLUTION GM MONTH PAK ORAL PV 0.5 %, 1 %, 1.5 %, 2 % TABLET 1 MG

XYLOCAINE- CHANTIX ORAL PV MPF/EPINEPHRINE TABLET 0.5 MG, 1 MG INJECTION SOLUTION GM CHANTIX STARTING 1 %-1:200000, 1.5 %- MONTH PAK ORAL PV 1:200000, 2 %-1:200000 TABLET 0.5 MG X 11 & ZERUVIA EXTERNAL 1 MG X 42 4 PATCH 4-1 % disulfiram oral tablet 250 1 ZINGO INTRADERMAL mg, 500 mg 4 JET-INJECTOR 0.5 MG goodsense nicotine ZIONODIL 100 mouth/throat gum 2 mg, PV 4 EXTERNAL LOTION 3 % 4 mg QL (224 ZIONODIL EXTERNAL 4 LOTION 3 % LUCEMYRA ORAL 3 EA per 14 Anti-Addiction / TABLET 0.18 MG days) Substance Abuse naloxone hcl injection Treatment Agents solution 0.4 mg/ml, 4 1 acamprosate calcium mg/10ml oral tablet delayed 1 naloxone hcl injection release 333 mg solution cartridge 0.4 1 ANTABUSE ORAL Brand mg/ml TABLET 250 MG, 500 3 penalty naloxone hcl injection MG applies solution prefilled syringe 1 BUNAVAIL BUCCAL 2 mg/2ml FILM 2.1-0.3 MG, 4.2-0.7 3 naltrexone hcl oral tablet 1 MG, 6.3-1 MG 50 mg buprenorphine hcl NALTREXONE sublingual tablet 1 SUBCUTANEOUS 3 sublingual 2 mg, 8 mg IMPLANT 200-6.5 MG buprenorphine hcl- NARCAN NASAL 3 naloxone hcl sublingual 1 LIQUID 4 MG/0.1ML film 12-3 mg, 2-0.5 mg, 4-1 mg, 8-2 mg

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 20 Drug Drug Drug Name Notes Drug Name Notes Tier Tier NICORETTE Antibacterials MOUTH/THROAT GUM PV AEMCOLO ORAL QL (12 EA 2 MG TABLET DELAYED 4 per 30 nicotine polacrilex RELEASE 194 MG days) mouth/throat gum 2 mg, PV ALTABAX EXTERNAL 4 ST 4 mg OINTMENT 1 % nicotine polacrilex amikacin sulfate injection mouth/throat lozenge 2 PV solution 1 gm/4ml, 500 2 mg, 4 mg mg/2ml nicotine step 1 amoxicillin oral capsule 2 transdermal patch 24 PV 250 mg, 500 mg hour 21 mg/24hr amoxicillin oral nicotine step 2 suspension reconstituted 1 transdermal patch 24 PV 125 mg/5ml, 200 mg/5ml, hour 14 mg/24hr 250 mg/5ml, 400 mg/5ml nicotine step 3 amoxicillin oral tablet 500 2 transdermal patch 24 PV mg hour 7 mg/24hr amoxicillin oral tablet 875 1 NICOTROL mg INHALATION INHALER PV 10 MG amoxicillin oral tablet chewable 125 mg, 250 2 NICOTROL NS NASAL PV mg SOLUTION 10 MG/ML amoxicillin-potassium SUBLOCADE clavulanate er oral tablet 2 SUBCUTANEOUS extended release 12 hour SOLUTION PREFILLED 3 1000-62.5 mg SYRINGE 100 MG/0.5ML, 300 amoxicillin-potassium MG/1.5ML clavulanate oral suspension reconstituted 2 SUBOXONE 200-28.5 mg/5ml, 250- SUBLINGUAL FILM 12-3 3 62.5 mg/5ml, 400-57 MG, 2-0.5 MG, 4-1 MG, mg/5ml, 600-42.9 mg/5ml 8-2 MG amoxicillin-potassium VIVITROL clavulanate oral tablet 2 INTRAMUSCULAR 250-125 mg, 500-125 SUSPENSION 3 mg, 875-125 mg RECONSTITUTED 380 MG amoxicillin-potassium clavulanate oral tablet 2 ZUBSOLV SUBLINGUAL chewable 200-28.5 mg, TABLET SUBLINGUAL 400-57 mg 0.7-0.18 MG, 1.4-0.36 3 ampicillin oral capsule MG, 11.4-2.9 MG, 2.9- 1 0.71 MG, 5.7-1.4 MG, 500 mg 8.6-2.1 MG Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 21 Drug Drug Drug Name Notes Drug Name Notes Tier Tier ampicillin sodium AZACTAM INJECTION injection solution SOLUTION GM reconstituted 1 gm, 125 GM RECONSTITUTED 1 mg, 2 gm, 250 mg, 500 GM, 2 GM mg azithromycin intravenous ampicillin sodium solution reconstituted GM intravenous solution 500 mg GM reconstituted 1 gm, 10 azithromycin oral packet 2 gm, 2 gm 1 gm ampicillin-sulbactam azithromycin oral sodium injection solution GM suspension reconstituted 2 reconstituted 1.5 (1-0.5) 100 mg/5ml, 200 mg/5ml gm, 3 (2-1) gm azithromycin oral tablet 2 ampicillin-sulbactam 250 mg, 500 mg, 600 mg sodium intravenous GM solution reconstituted 15 aztreonam injection (10-5) gm solution reconstituted 1 GM gm, 2 gm ARIKAYCE INHALATION SUSPENSION 590 6 PA baciim intramuscular MG/8.4ML solution reconstituted GM 50000 unit AUGMENTIN ES-600 Brand ORAL SUSPENSION bacitracin intramuscular 4 penalty solution reconstituted GM RECONSTITUTED 600- applies 42.9 MG/5ML 50000 unit AUGMENTIN ORAL Brand BACTRIM DS ORAL 4 penalty SUSPENSION 4 RECONSTITUTED 125- TABLET 800-160 MG applies 31.25 MG/5ML Brand AUGMENTIN ORAL BACTRIM ORAL 4 penalty Brand SUSPENSION TABLET 400-80 MG applies 4 penalty RECONSTITUTED 250- applies BAXDELA 62.5 MG/5ML INTRAVENOUS Specialty SOLUTION 5 Brand Medical AUGMENTIN ORAL 4 penalty RECONSTITUTED 300 TABLET 500-125 MG applies MG BAXDELA ORAL avidoxy oral tablet 100 2 5 mg TABLET 450 MG AVYCAZ benzalkonium chloride 2 INTRAVENOUS external solution , 50 % SOLUTION GM BICILLIN C-R 900/300 RECONSTITUTED 2.5 INTRAMUSCULAR GM (2-0.5) GM SUSPENSION 900000- 300000 UNIT/2ML

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 22 Drug Drug Drug Name Notes Drug Name Notes Tier Tier BICILLIN C-R cefazolin sodium GM INTRAMUSCULAR GM intravenous solution SUSPENSION 1200000 reconstituted 1 gm UNIT/2ML cefazolin sodium- BICILLIN L-A dextrose intravenous GM INTRAMUSCULAR solution 1-4 gm/50ml-%, SUSPENSION 1200000 2-4 gm/100ml-% GM UNIT/2ML, 2400000 cefazolin sodium- UNIT/4ML, 600000 dextrose intravenous UNIT/ML solution reconstituted 1-4 GM cefaclor er oral tablet gm-%(50ml), 2-3 gm- extended release 12 hour 2 %(50ml) 500 mg cefdinir oral capsule 300 2 cefaclor oral capsule 250 2 mg mg, 500 mg cefdinir oral suspension cefaclor oral suspension reconstituted 125 2 reconstituted 125 mg/5ml, 250 mg/5ml 2 mg/5ml, 250 mg/5ml, 375 cefditoren pivoxil oral 2 mg/5ml tablet 200 mg, 400 mg cefadroxil oral capsule 2 cefepime hcl injection 500 mg solution reconstituted 1 GM cefadroxil oral gm, 2 gm suspension reconstituted 2 cefepime hcl intravenous 250 mg/5ml, 500 mg/5ml solution 1 gm/50ml, 2 GM cefadroxil oral tablet 1 2 gm/100ml gm cefepime-dextrose CEFAZOLIN IN SODIUM intravenous solution CHLORIDE reconstituted 1-5 gm- GM INTRAVENOUS %(50ml), 2-5 gm- GM SOLUTION 2-0.9 %(50ml) GM/100ML-%, 3-0.9 cefixime oral capsule 400 2 GM/100ML-% mg cefazolin sodium cefixime oral suspension injection solution reconstituted 100 2 reconstituted 1 gm, 10 GM mg/5ml, 200 mg/5ml gm, 100 gm, 300 gm, 500 mg CEFOTAN INJECTION SOLUTION GM CEFAZOLIN SODIUM RECONSTITUTED 1 INTRAVENOUS GM, 2 GM SOLUTION PREFILLED GM SYRINGE 1 GM/10ML, 2 cefotaxime sodium injection solution GM/20ML GM reconstituted 1 gm, 2 gm, 500 mg

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 23 Drug Drug Drug Name Notes Drug Name Notes Tier Tier cefotetan disodium ceftriaxone sodium injection solution GM injection solution reconstituted 1 gm, 2 gm reconstituted 1 gm, 100 GM cefotetan disodium- gm, 2 gm, 250 mg, 500 dextrose intravenous mg solution reconstituted 1- GM ceftriaxone sodium 3.58 gm-%(50ml), 2-2.08 intravenous solution GM gm-%(50ml) reconstituted 1 gm, 10 cefoxitin sodium injection gm, 2 gm solution reconstituted 10 GM ceftriaxone sodium- gm dextrose intravenous cefoxitin sodium solution reconstituted 1- GM intravenous solution GM 3.74 gm-%(50ml), 2-2.22 reconstituted 1 gm, 2 gm gm-%(50ml) CEFOXITIN SODIUM- cefuroxime axetil oral 2 DEXTROSE tablet 250 mg, 500 mg INTRAVENOUS cefuroxime sodium SOLUTION GM injection solution GM RECONSTITUTED 1-4 reconstituted 7.5 gm, 750 GM-%(50ML), 2-2.2 GM- mg %(50ML) cefuroxime sodium cefpodoxime proxetil oral intravenous solution GM suspension reconstituted 2 reconstituted 1.5 gm 100 mg/5ml, 50 mg/5ml CENTANY AT 3 cefpodoxime proxetil oral 2 EXTERNAL KIT 2 % tablet 100 mg, 200 mg cephalexin oral capsule 1 cefprozil oral suspension 250 mg, 500 mg reconstituted 125 2 cephalexin oral capsule 2 mg/5ml, 250 mg/5ml 750 mg cefprozil oral tablet 250 2 cephalexin oral mg, 500 mg suspension reconstituted 2 ceftazidime and dextrose 125 mg/5ml, 250 mg/5ml intravenous solution cephalexin oral tablet 2 reconstituted 1-5 gm- GM 250 mg, 500 mg %(50ml), 2-5 gm- %(50ml) chloramphenicol sod succinate intravenous GM ceftazidime injection solution reconstituted 1 GM solution reconstituted 1 gm gm, 2 gm, 6 gm CIPRO ORAL ceftriaxone sodium in SUSPENSION dextrose intravenous GM RECONSTITUTED 250 3 solution 20 mg/ml, 40 MG/5ML (5%), 500 mg/ml MG/5ML (10%)

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 24 Drug Drug Drug Name Notes Drug Name Notes Tier Tier Brand clindamycin palmitate hcl CIPRO ORAL TABLET 4 penalty oral solution 2 250 MG, 500 MG applies reconstituted 75 mg/5ml ciprofloxacin hcl oral 2 clindamycin phosphate in tablet 100 mg, 750 mg d5w intravenous solution GM 300 mg/50ml, 600 ciprofloxacin hcl oral 1 tablet 250 mg, 500 mg mg/50ml, 900 mg/50ml ciprofloxacin in d5w clindamycin phosphate intravenous solution 200 GM injection solution 300 mg/100ml, 400 mg/200ml mg/2ml, 600 mg/4ml, 9 GM gm/60ml, 900 mg/6ml, clarithromycin er oral 9000 mg/60ml tablet extended release 2 24 hour 500 mg clindamycin phosphate 2 vaginal cream 2 % clarithromycin oral suspension reconstituted 2 CLINDESSE VAGINAL 4 125 mg/5ml, 250 mg/5ml CREAM 2 % clarithromycin oral tablet colistimethate sodium 2 GM 250 mg, 500 mg (cba) injection solution reconstituted 150 mg CLEOCIN ORAL Brand CAPSULE 150 MG, 300 4 penalty COLY-MYCIN M INJECTION SOLUTION MG applies GM RECONSTITUTED 150 Brand MG CLEOCIN ORAL 3 penalty CAPSULE 75 MG applies CUBICIN INTRAVENOUS CLEOCIN ORAL Brand SOLUTION GM SOLUTION 4 penalty RECONSTITUTED 500 RECONSTITUTED 75 applies MG MG/5ML CUBICIN RF CLEOCIN PHOSPHATE INTRAVENOUS INJECTION SOLUTION SOLUTION GM 300 MG/2ML, 600 GM RECONSTITUTED 500 MG/4ML, 9 GM/60ML, MG 900 MG/6ML DALVANCE Brand INTRAVENOUS Specialty CLEOCIN VAGINAL 4 penalty 6 SOLUTION Medical CREAM 2 % applies RECONSTITUTED 500 MG CLEOCIN VAGINAL 3 SUPPOSITORY 100 MG daptomycin intravenous clindamycin hcl oral solution reconstituted GM capsule 150 mg, 300 mg, 2 350 mg, 500 mg 75 mg demeclocycline hcl oral 2 tablet 150 mg, 300 mg

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 25 Drug Drug Drug Name Notes Drug Name Notes Tier Tier dicloxacillin sodium oral ERY-TAB ORAL 2 Brand capsule 250 mg, 500 mg TABLET DELAYED 4 penalty RELEASE 250 MG, 333 DIFICID ORAL TABLET 4 ST applies 200 MG MG, 500 MG doxy 100 intravenous ERYTHROCIN solution reconstituted GM LACTOBIONATE INTRAVENOUS 100 mg GM SOLUTION doxycycline hyclate RECONSTITUTED 500 intravenous solution GM MG reconstituted 100 mg ERYTHROCIN doxycycline hyclate oral 2 STEARATE ORAL 4 capsule 100 mg, 50 mg TABLET 250 MG doxycycline hyclate oral 2 erythromycin base oral tablet 100 mg, 20 mg capsule delayed release 2 doxycycline hyclate oral particles 250 mg tablet delayed release 2 erythromycin base oral 2 100 mg, 150 mg, 75 mg tablet 250 mg, 500 mg doxycycline monohydrate erythromycin base oral oral capsule 100 mg, 150 2 tablet delayed release 2 mg, 50 mg, 75 mg 250 mg, 333 mg, 500 mg doxycycline monohydrate erythromycin oral suspension 2 ethylsuccinate oral 2 reconstituted 25 mg/5ml suspension reconstituted doxycycline monohydrate 200 mg/5ml, 400 mg/5ml oral tablet 100 mg, 150 2 erythromycin mg, 50 mg, 75 mg ethylsuccinate oral tablet 2 400 mg E.E.S. 400 ORAL 4 TABLET 400 MG erythromycin oral tablet delayed release 250 mg, 2 E.E.S. GRANULES Brand 333 mg, 500 mg ORAL SUSPENSION 3 penalty RECONSTITUTED 200 applies FETROJA MG/5ML Specialty INTRAVENOUS 6 ertapenem sodium SOLUTION Medical injection solution 2 RECONSTITUTED 1 GM reconstituted 1 gm FIRVANQ ORAL SOLUTION ERYPED 200 ORAL Brand 4 RECONSTITUTED 25 SUSPENSION 3 penalty MG/ML, 50 MG/ML RECONSTITUTED 200 applies MG/5ML Brand FLAGYL ORAL 4 penalty ERYPED 400 ORAL Brand SUSPENSION CAPSULE 375 MG applies 3 penalty RECONSTITUTED 400 applies MG/5ML Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 26 Drug Drug Drug Name Notes Drug Name Notes Tier Tier Brand LINCOCIN INJECTION GM FLAGYL ORAL TABLET 4 penalty SOLUTION 300 MG/ML 250 MG, 500 MG applies lincomycin hcl injection GM gentamicin in saline solution 300 mg/ml intravenous solution 0.8- linezolid in sodium 0.9 mg/ml-%, 1-0.9 Specialty GM chloride intravenous 5 mg/ml-%, 1.2-0.9 mg/ml- solution 600-0.9 Medical %, 1.6-0.9 mg/ml-%, 2- mg/300ml-% 0.9 mg/ml-% linezolid intravenous Specialty gentamicin sulfate 5 2 solution 600 mg/300ml Medical external cream 0.1 % QL (900 gentamicin sulfate 2 linezolid oral suspension 5 ML per 30 external ointment 0.1 % reconstituted 100 mg/5ml days) gentamicin sulfate QL (60 EA injection solution 10 GM linezolid oral tablet 600 5 per 30 mg/ml, 40 mg/ml mg days) Brand Brand 4 penalty HIPREX ORAL TABLET MACROBID ORAL 4 penalty 1 GM applies CAPSULE 100 MG applies hydrogen peroxide 2 MACRODANTIN ORAL Brand solution 30 % CAPSULE 100 MG, 50 4 penalty imipenem-cilastatin MG applies intravenous solution GM Brand reconstituted 250 mg, MACRODANTIN ORAL 3 penalty 500 mg CAPSULE 25 MG applies INVANZ INJECTION Brand mafenide acetate 2 SOLUTION 4 penalty external packet 5 % RECONSTITUTED 1 GM applies meropenem intravenous iodine tincture external 2 solution reconstituted 1 GM tincture 2 % gm, 500 mg KEFLEX ORAL Brand MEROPENEM-SODIUM CAPSULE 250 MG, 500 4 penalty CHLORIDE MG, 750 MG applies INTRAVENOUS GM levofloxacin in d5w SOLUTION intravenous solution 250 GM RECONSTITUTED 1 mg/50ml, 500 mg/100ml, GM/50ML, 500 MG/50ML 750 mg/150ml MERREM levofloxacin intravenous GM INTRAVENOUS solution 25 mg/ml SOLUTION GM levofloxacin oral solution RECONSTITUTED 1 2 25 mg/ml GM, 500 MG levofloxacin oral tablet methenamine hippurate 2 2 250 mg, 500 mg, 750 mg oral tablet 1 gm Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 27 Drug Drug Drug Name Notes Drug Name Notes Tier Tier methenamine mandelate NAFCILLIN SODIUM IN 2 oral tablet 0.5 gm, 1 gm DEXTROSE metronidazole in nacl INTRAVENOUS GM intravenous solution 5- SOLUTION 1 GM/50ML, 0.79 mg/ml-%, 500-0.74 GM 2 GM/100ML mg/100ml-%, 500-0.79 nafcillin sodium injection mg/100ml-% solution reconstituted 1 GM metronidazole oral gm, 2 gm 2 capsule 375 mg nafcillin sodium metronidazole oral tablet intravenous solution 2 GM 250 mg, 500 mg reconstituted 1 gm, 10 gm, 2 gm metronidazole vaginal gel 2 0.75 % neomycin sulfate oral 2 tablet 500 mg MINOCIN INTRAVENOUS neomycin-polymyxin b gu SOLUTION GM irrigation solution 40- 2 RECONSTITUTED 100 200000 MG nitrofurantoin minocycline hcl oral macrocrystal oral capsule 2 capsule 100 mg, 50 mg, 2 100 mg, 25 mg, 50 mg 75 mg nitrofurantoin minocycline hcl oral monohydrate 2 tablet 100 mg, 50 mg, 75 2 macrocrystals oral mg capsule 100 mg nitrofurantoin oral mondoxyne nl oral 2 2 capsule 100 mg, 75 mg suspension 25 mg/5ml NUTRIDOX ORAL KIT MONUROL ORAL 4 4 PACKET 3 GM 75 MG morgidox oral capsule NUZYRA 2 INTRAVENOUS 100 mg Specialty SOLUTION 6 Medical moxifloxacin hcl in nacl RECONSTITUTED 100 intravenous solution 400 GM MG mg/250ml QL (30 EA MOXIFLOXACIN HCL NUZYRA ORAL TABLET 6 per 14 INTRAVENOUS GM 150 MG days) SOLUTION 400 MG/250ML ofloxacin oral tablet 300 2 mg, 400 mg moxifloxacin hcl oral 2 tablet 400 mg ORBACTIV INTRAVENOUS Specialty mupirocin external SOLUTION 5 2 Medical ointment 2 % RECONSTITUTED 400 MG

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 28 Drug Drug Drug Name Notes Drug Name Notes Tier Tier OXACILLIN SODIUM IN piperacillin sod- DEXTROSE tazobactam so INTRAVENOUS GM intravenous solution SOLUTION 1 GM/50ML, reconstituted 13.5 (12- GM 2 GM/50ML 1.5) gm, 2.25 (2-0.25) oxacillin sodium injection gm, 3.375 (3-0.375) gm, solution reconstituted 1 GM 4.5 (4-0.5) gm, 40.5 (36- gm, 2 gm 4.5) gm oxacillin sodium polymyxin b sulfate intravenous solution GM injection solution GM reconstituted 10 gm reconstituted 500000 unit PRIMAXIN IV paromomycin sulfate oral 2 capsule 250 mg INTRAVENOUS SOLUTION GM PENICILLIN G POT IN RECONSTITUTED 500- DEXTROSE 500 MG INTRAVENOUS PRIMSOL ORAL SOLUTION 20000 GM 4 UNIT/ML, 40000 SOLUTION 50 MG/5ML UNIT/ML, 60000 RECARBRIO UNIT/ML INTRAVENOUS Specialty 6 penicillin g potassium SOLUTION Medical RECONSTITUTED 1.25 injection solution GM reconstituted 20000000 GM unit, 5000000 unit Brand penicillin g procaine SILVADENE EXTERNAL 4 penalty applies intramuscular suspension GM CREAM 1 % 600000 unit/ml silver nitrate external penicillin g sodium solution 0.5 %, 10 %, 25 2 injection solution %, 50 % GM reconstituted 5000000 silver sulfadiazine 2 unit external cream 1 % penicillin v potassium SIVEXTRO oral solution 2 INTRAVENOUS Specialty 6 reconstituted 125 SOLUTION Medical mg/5ml, 250 mg/5ml RECONSTITUTED 200 penicillin v potassium MG oral tablet 250 mg, 500 1 QL (6 EA mg SIVEXTRO ORAL 6 per 30 PFIZERPEN INJECTION TABLET 200 MG days) SOLUTION SOLOSEC ORAL 4 RECONSTITUTED GM PACKET 2 GM 20000000 UNIT, ssd external cream 1 % 2 5000000 UNIT

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 29 Drug Drug Drug Name Notes Drug Name Notes Tier Tier streptomycin sulfate tazicef injection solution intramuscular solution GM reconstituted 1 gm, 2 gm, GM reconstituted 1 gm 6 gm sulfadiazine oral tablet 2 TAZICEF 500 mg INTRAVENOUS GM sulfamethoxazole- SOLUTION 1 GM/50ML trimethoprim intravenous GM tazicef intravenous solution 400-80 mg/5ml solution reconstituted 1 GM sulfamethoxazole- gm, 2 gm trimethoprim oral TEFLARO 2 suspension 200-40 INTRAVENOUS mg/5ml SOLUTION GM sulfamethoxazole- RECONSTITUTED 400 trimethoprim oral tablet 1 MG, 600 MG 400-80 mg, 800-160 mg tetracycline hcl oral 2 SULFAMYLON capsule 250 mg, 500 mg EXTERNAL CREAM 85 4 tigecycline intravenous MG/GM solution reconstituted 50 GM SULFAMYLON Brand mg EXTERNAL PACKET 5 4 penalty tinidazole oral tablet 250 2 % applies mg, 500 mg sulfatrim pediatric oral tobramycin sulfate 2 suspension 200-40 injection solution 1.2 GM mg/5ml gm/30ml, 10 mg/ml, 2 Brand gm/50ml, 80 mg/2ml SUPRAX ORAL 4 penalty tobramycin sulfate CAPSULE 400 MG applies injection solution GM reconstituted 1.2 gm SUPRAX ORAL Brand SUSPENSION trimethoprim oral tablet 4 penalty 2 RECONSTITUTED 100 100 mg applies MG/5ML, 200 MG/5ML TYGACIL SUPRAX ORAL INTRAVENOUS GM SUSPENSION 4 SOLUTION RECONSTITUTED 500 RECONSTITUTED 50 MG/5ML MG SUPRAX ORAL TABLET UNASYN INJECTION 4 CHEWABLE 100 MG, SOLUTION GM 200 MG RECONSTITUTED 1.5 SYNERCID (1-0.5) GM, 3 (2-1) GM INTRAVENOUS SOLUTION GM RECONSTITUTED 150- 350 MG

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 30 Drug Drug Drug Name Notes Drug Name Notes Tier Tier UNASYN vancomycin hcl in nacl INTRAVENOUS solution 750-0.9 GM SOLUTION GM mg/150ml-% intravenous RECONSTITUTED 15 750-0.9 mg/150ml-% (10-5) GM VANCOMYCIN HCL VABOMERE INTRAVENOUS INTRAVENOUS SOLUTION 1000 SOLUTION GM MG/10ML, 1250 RECONSTITUTED 2 (1- MG/12.5ML, 1500 GM 1) GM MG/15ML, 1750 Brand MG/17.5ML, 2000 VANCOCIN HCL ORAL 4 penalty MG/20ML, 750 CAPSULE 125 MG applies MG/7.5ML Brand vancomycin hcl VANCOCIN ORAL 4 penalty intravenous solution CAPSULE 250 MG applies 1000 mg/200ml, 1500 GM mg/300ml, 2000 VANCOMYCIN HCL IN mg/400ml, 500 mg/100ml DEXTROSE INTRAVENOUS vancomycin hcl GM SOLUTION 1.25-5 intravenous solution GM/250ML-%, 1.5-5 reconstituted 1 gm, 1.25 GM GM/250ML-% gm, 1.5 gm, 10 gm, 5 gm, 500 mg, 750 mg vancomycin hcl in dextrose intravenous vancomycin hcl oral 2 solution 1-5 gm/200ml-%, GM capsule 125 mg, 250 mg 500-5 mg/100ml-%, 750- vancomycin hcl oral 5 mg/150ml-% solution reconstituted 2 vancomycin hcl in nacl 250 mg/5ml intravenous solution 1- vandazole vaginal gel GM 2 0.9 gm/200ml-%, 500-0.9 0.75 % mg/100ml-% VIBATIV INTRAVENOUS VANCOMYCIN HCL IN SOLUTION GM NACL INTRAVENOUS RECONSTITUTED 750 SOLUTION 1-0.9 MG GM/250ML-%, 1.25-0.9 GM Brand GM/250ML-%, 1.5-0.9 VIBRAMYCIN ORAL 4 penalty GM/250ML-%, 1.75-0.9 CAPSULE 100 MG applies GM/250ML-%, 2-0.9 VIBRAMYCIN ORAL GM/500ML-% Brand SUSPENSION 4 penalty VANCOMYCIN HCL IN RECONSTITUTED 25 applies NACL SOLUTION 750- MG/5ML 0.9 MG/150ML-% GM INTRAVENOUS 750-0.9 VIBRAMYCIN ORAL 3 MG/150ML-% SYRUP 50 MG/5ML

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 31 Drug Drug Drug Name Notes Drug Name Notes Tier Tier XENLETA ZOSYN INTRAVENOUS Specialty INTRAVENOUS 6 SOLUTION 2-0.25 SOLUTION 150 Medical GM/50ML, 3-0.375 GM MG/15ML GM/50ML, 4-0.5 GM/100ML XENLETA ORAL 6 TABLET 600 MG ZYVOX INTRAVENOUS SOLUTION 200 Specialty XEPI EXTERNAL 4 ST 5 CREAM 1 % MG/100ML, 600 Medical MG/300ML XERAVA INTRAVENOUS ZYVOX ORAL Specialty QL (900 SOLUTION 5 SUSPENSION Medical 5 ML per 30 RECONSTITUTED 50 RECONSTITUTED 100 days) MG MG/5ML QL (60 EA XIFAXAN ORAL TABLET 5 PA 200 MG, 550 MG ZYVOX ORAL TABLET 5 per 30 600 MG days) ZEMDRI INTRAVENOUS Specialty 6 Anticoagulants SOLUTION 500 Medical MG/10ML ACD FORMULA A IN 4 ZERBAXA VITRO SOLUTION 0.73- INTRAVENOUS 2.45-2.2 GM/100ML SOLUTION GM ACD-A NOCLOT-50 IN RECONSTITUTED 1.5 VITRO SOLUTION 0.73- 4 (1-0.5) GM 2.45-2.2 GM/100ML ZITHROMAX ACTIVASE INTRAVENOUS INTRAVENOUS SOLUTION GM SOLUTION GM RECONSTITUTED 500 RECONSTITUTED 100 MG MG, 50 MG ZITHROMAX ORAL ANGIOMAX 4 PACKET 1 GM INTRAVENOUS GM ZITHROMAX ORAL SOLUTION Brand SUSPENSION RECONSTITUTED 250 4 penalty MG RECONSTITUTED 100 applies MG/5ML, 200 MG/5ML anticoagulant cit dext 2 ZITHROMAX ORAL Brand soln a in vitro solution TABLET 250 MG, 500 4 penalty 0.8-2.45-2.2 gm/100ml MG applies anticoagulant sodium Brand citrate in vitro solution 4 2 ZITHROMAX TRI-PAK 4 penalty gm/100ml ORAL TABLET 500 MG applies argatroban in sodium chloride intravenous Brand GM ZITHROMAX Z-PAK 4 penalty solution 50-0.9 mg/50ml- ORAL TABLET 250 MG applies %

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 32 Drug Drug Drug Name Notes Drug Name Notes Tier Tier argatroban intravenous fondaparinux sodium GM solution 250 mg/2.5ml, subcutaneous solution 10 2 50 mg/50ml mg/0.8ml, 2.5 mg/0.5ml, ARIXTRA 5 mg/0.4ml, 7.5 mg/0.6ml SUBCUTANEOUS Brand FRAGMIN SOLUTION 10 4 penalty SUBCUTANEOUS MG/0.8ML, 2.5 SOLUTION 10000 applies MG/0.5ML, 5 MG/0.4ML, UNIT/ML, 12500 7.5 MG/0.6ML UNIT/0.5ML, 15000 BEVYXXA ORAL QL (30 EA UNIT/0.6ML, 18000 3 CAPSULE 40 MG, 80 4 per 30 UNT/0.72ML, 2500 MG days) UNIT/0.2ML, 5000 UNIT/0.2ML, 7500 bivalirudin UNIT/0.3ML, 95000 trifluoroacetate GM UNIT/3.8ML intravenous solution reconstituted 250 mg heparin (porcine) in nacl intravenous solution BIVALIRUDIN-SODIUM 1000-0.9 ut/500ml-%, 2 CHLORIDE 12500-0.45 ut/250ml-%, INTRAVENOUS Specialty 6 2000-0.9 unit/l-%, 25000- SOLUTION 250-0.9 Medical 0.45 ut/250ml-% MG/50ML-%, 500-0.9 MG/100ML-% HEPARIN (PORCINE) IN NACL INTRAVENOUS CATHFLO ACTIVASE SOLUTION 2500-0.9 INJECTION SOLUTION GM UT/500ML-%, 500-0.9 GM RECONSTITUTED 2 MG UT/500ML-%, 5000-0.9 DEFITELIO UNIT/L-%, 5000-0.9 INTRAVENOUS UT/500ML-% GM SOLUTION 200 heparin (porcine) in nacl MG/2.5ML intravenous solution GM ELIQUIS DVT/PE 25000-0.45 ut/500ml-% STARTER PACK ORAL 3 HEPARIN (PORCINE) IN TABLET 5 MG NACL INTRAVENOUS 4 SOLUTION 30000-0.9 ELIQUIS ORAL TABLET 3 2.5 MG, 5 MG UNIT/L-% enoxaparin sodium heparin sod (porcine) in injection solution 300 2 d5w intravenous solution mg/3ml 100 unit/ml, 25000-5 2 enoxaparin sodium ut/500ml-%, 40-5 unit/ml- subcutaneous solution % 100 mg/ml, 120 heparin sodium (porcine) mg/0.8ml, 150 mg/ml, 30 2 injection solution 1000 mg/0.3ml, 40 mg/0.4ml, unit/ml, 10000 unit/ml, 2 60 mg/0.6ml, 80 20000 unit/ml, 5000 mg/0.8ml unit/ml

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 33 Drug Drug Drug Name Notes Drug Name Notes Tier Tier heparin sodium (porcine) THROMBATE III injection solution prefilled GM INTRAVENOUS syringe 5000 unit/0.5ml SOLUTION GM PA heparin sodium (porcine) RECONSTITUTED 1000 pf injection solution 5000 2 UNIT, 500 UNIT unit/0.5ml TNKASE GM heparin sodium (porcine) INTRAVENOUS KIT 50 pf injection solution 5000 GM MG unit/ml TRICITRASOL IN VITRO 4 jantoven oral tablet 1 mg, CONCENTRATE 46.7 % 10 mg, 2 mg, 2.5 mg, 3 warfarin sodium oral 1 mg, 4 mg, 5 mg, 6 mg, tablet 1 mg, 10 mg, 2 mg, 1 7.5 mg 2.5 mg, 3 mg, 4 mg, 5 Brand mg, 6 mg, 7.5 mg LOVENOX INJECTION 3 penalty XARELTO ORAL SOLUTION 300 MG/3ML applies TABLET 10 MG, 15 MG, 3 LOVENOX 2.5 MG, 20 MG SUBCUTANEOUS XARELTO STARTER SOLUTION 100 MG/ML, Brand PACK ORAL TABLET 3 120 MG/0.8ML, 150 4 penalty THERAPY PACK 15 & MG/ML, 30 MG/0.3ML, applies 20 MG 40 MG/0.4ML, 60 Anticonvulsants - MG/0.6ML, 80 MG/0.8ML Drugs for Seizures PRADAXA ORAL APTIOM ORAL TABLET CAPSULE 110 MG, 150 3 200 MG, 400 MG, 600 4 ST MG, 75 MG MG, 800 MG SAVAYSA ORAL BANZEL ORAL TABLET 15 MG, 30 MG, 4 ST SUSPENSION 40 4 60 MG MG/ML SODIUM CITRATE IN BANZEL ORAL TABLET VITRO SOLUTION 4 GM 200 MG, 400 MG PREFILLED SYRINGE 4 % BRIVIACT INTRAVENOUS GM ST SODIUM CITRATE SOLUTION 50 MG/5ML LOCK FLUSH INTRAVENOUS GM BRIVIACT ORAL 4 ST SOLUTION PREFILLED SOLUTION 10 MG/ML SYRINGE 120 MG/3ML BRIVIACT ORAL SODIUM CITRATE- TABLET 10 MG, 100 4 ST GENTAMICIN SULF MG, 25 MG, 50 MG, 75 INTRAVENOUS GM MG SOLUTION 4-320 %- MCG/ML

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 34 Drug Drug Drug Name Notes Drug Name Notes Tier Tier carbamazepine er oral DIACOMIT ORAL 4 capsule extended 2 PACKET 250 MG, 500 release 12 hour 100 mg, MG 200 mg, 300 mg DIASTAT ACUDIAL carbamazepine er oral RECTAL GEL 10 MG, 20 4 tablet extended release 2 MG 12 hour 100 mg, 200 mg, DIASTAT PEDIATRIC 4 400 mg RECTAL GEL 2.5 MG carbamazepine oral rectal gel 10 2 2 suspension 100 mg/5ml mg, 2.5 mg, 20 mg carbamazepine oral 2 DILANTIN INFATABS tablet 200 mg ORAL TABLET 4 carbamazepine oral 2 CHEWABLE 50 MG tablet chewable 100 mg DILANTIN ORAL CARBATROL ORAL CAPSULE 100 MG, 30 4 CAPSULE EXTENDED 4 MG RELEASE 12 HOUR 100 DILANTIN ORAL MG, 200 MG, 300 MG SUSPENSION 125 4 CELONTIN ORAL MG/5ML 4 CAPSULE 300 MG divalproex sodium er oral CEREBYX INJECTION tablet extended release 2 SOLUTION 100 MG 24 hour 250 mg, 500 mg GM PE/2ML, 500 MG divalproex sodium oral PE/10ML capsule delayed release 2 clobazam oral 2 sprinkle 125 mg suspension 2.5 mg/ml divalproex sodium oral 2 clobazam oral tablet 10 2 tablet delayed release mg, 20 mg 125 mg, 250 mg, 500 mg

DEPAKOTE ER ORAL EPIDIOLEX ORAL 6 PA TABLET EXTENDED SOLUTION 100 MG/ML 4 RELEASE 24 HOUR 250 epitol oral tablet 200 mg 2 MG, 500 MG ethosuximide oral 2 DEPAKOTE ORAL capsule 250 mg TABLET DELAYED 4 ethosuximide oral RELEASE 125 MG, 250 2 MG, 500 MG solution 250 mg/5ml DEPAKOTE SPRINKLES felbamate oral 2 suspension 600 mg/5ml ORAL CAPSULE 4 DELAYED RELEASE felbamate oral tablet 400 2 SPRINKLE 125 MG mg, 600 mg DIACOMIT ORAL FELBATOL ORAL CAPSULE 250 MG, 500 4 SUSPENSION 600 3 MG MG/5ML

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 35 Drug Drug Drug Name Notes Drug Name Notes Tier Tier FELBATOL ORAL LAMICTAL ORAL TABLET 400 MG, 600 3 TABLET 100 MG, 150 4 MG MG, 200 MG, 25 MG fosphenytoin sodium LAMICTAL ORAL injection solution 100 mg GM TABLET CHEWABLE 25 4 pe/2ml, 500 mg pe/10ml MG, 5 MG FYCOMPA ORAL LAMICTAL STARTER SUSPENSION 0.5 4 ORAL KIT 35 X 25 MG, MG/ML 42 X 25 MG & 7 X 100 4 FYCOMPA ORAL MG, 84 X 25 MG & TABLET 10 MG, 12 MG, 14X100 MG 4 2 MG, 4 MG, 6 MG, 8 LAMICTAL XR ORAL MG KIT 21 X 25 MG & 7 X 50 4 MG, 25 & 50 & 100 MG, oral capsule 2 100 mg, 300 mg, 400 mg 50 & 100 & 200 MG LAMICTAL XR ORAL gabapentin oral solution 2 250 mg/5ml, 300 mg/6ml TABLET EXTENDED RELEASE 24 HOUR 100 4 gabapentin oral tablet 2 MG, 200 MG, 25 MG, 600 mg, 800 mg 250 MG, 300 MG, 50 MG GABITRIL ORAL lamotrigine er oral tablet TABLET 12 MG, 16 MG, 4 extended release 24 hour 2 2 MG, 4 MG 100 mg, 200 mg, 25 mg, KEPPRA 250 mg, 300 mg, 50 mg INTRAVENOUS GM lamotrigine oral tablet 1 SOLUTION 500 MG/5ML 100 mg, 150 mg, 200 mg KEPPRA ORAL 4 lamotrigine oral tablet 25 2 SOLUTION 100 MG/ML mg KEPPRA ORAL TABLET lamotrigine oral tablet 2 1000 MG, 250 MG, 500 4 chewable 25 mg, 5 mg MG, 750 MG lamotrigine oral tablet KEPPRA XR ORAL dispersible 100 mg, 200 2 TABLET EXTENDED 4 mg, 25 mg, 50 mg RELEASE 24 HOUR 500 MG, 750 MG lamotrigine starter kit- 2 blue oral kit 35 x 25 mg LAMICTAL ODT ORAL KIT 21 X 25 MG & 7 X 50 lamotrigine starter kit- MG, 25 & 50 & 100 MG, 4 green oral kit 84 x 25 mg 2 42 X 50 MG & 14X100 & 14x100 mg MG lamotrigine starter kit- LAMICTAL ODT ORAL orange oral kit 42 x 25 2 TABLET DISPERSIBLE mg & 7 x 100 mg 4 100 MG, 200 MG, 25 MG, 50 MG

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 36 Drug Drug Drug Name Notes Drug Name Notes Tier Tier levetiracetam er oral OXTELLAR XR ORAL 2 tablet extended release TABLET EXTENDED 4 24 hour 500 mg, 750 mg RELEASE 24 HOUR 150 levetiracetam in nacl MG, 300 MG, 600 MG intravenous solution GM PEGANONE ORAL 4 1000 mg/100ml, 1500 TABLET 250 MG mg/100ml, 500 mg/100ml sodium levetiracetam injection solution 50 GM intravenous solution 500 GM mg/ml mg/5ml oral elixir 2 levetiracetam oral 20 mg/5ml 2 solution 100 mg/ml phenobarbital oral 2 levetiracetam oral tablet solution 20 mg/5ml 1000 mg, 250 mg, 500 2 phenobarbital oral tablet mg, 750 mg 100 mg, 15 mg, 16.2 mg, 2 MYSOLINE ORAL 3 30 mg, 32.4 mg, 60 mg, TABLET 250 MG 64.8 mg, 97.2 mg

MYSOLINE ORAL 4 phenobarbital sodium TABLET 50 MG injection solution 130 GM NAYZILAM NASAL mg/ml, 65 mg/ml 4 SOLUTION 5 MG/0.1ML PHENYTEK ORAL NEMBUTAL INJECTION CAPSULE 200 MG, 300 4 GM SOLUTION 50 MG/ML MG NEURONTIN ORAL phenytoin infatabs oral 2 CAPSULE 100 MG, 300 4 tablet chewable 50 mg MG, 400 MG phenytoin oral 2 suspension 125 mg/5ml NEURONTIN ORAL 4 SOLUTION 250 MG/5ML phenytoin oral tablet 2 NEURONTIN ORAL chewable 50 mg TABLET 600 MG, 800 4 phenytoin sodium MG extended oral capsule 2 ONFI ORAL 100 mg, 200 mg, 300 mg SUSPENSION 2.5 4 phenytoin sodium MG/ML injection solution 50 GM ONFI ORAL TABLET 10 mg/ml 4 MG, 20 MG primidone oral tablet 250 2 mg, 50 mg oxcarbazepine oral 2 suspension 300 mg/5ml QUDEXY XR ORAL CAPSULE ER 24 HOUR oxcarbazepine oral tablet 2 150 mg, 300 mg, 600 mg SPRINKLE 100 MG, 150 4 PA MG, 200 MG, 25 MG, 50 MG

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 37 Drug Drug Drug Name Notes Drug Name Notes Tier Tier roweepra oral tablet 1000 TOPAMAX ORAL 2 mg, 500 mg, 750 mg TABLET 100 MG, 200 4 roweepra xr oral tablet MG, 25 MG, 50 MG extended release 24 hour 2 TOPAMAX SPRINKLE 500 mg, 750 mg ORAL CAPSULE 4 SPRINKLE 15 MG, 25 SABRIL ORAL PACKET 6 PA 500 MG MG SABRIL ORAL TABLET topiramate er oral 6 PA capsule er 24 hour 500 MG 2 PA sprinkle 100 mg, 150 mg, SPRITAM ORAL 200 mg, 25 mg, 50 mg TABLET DISINTEGRATING 4 ST topiramate oral capsule 2 SOLUBLE 1000 MG, 250 sprinkle 15 mg, 25 mg MG, 500 MG, 750 MG topiramate oral tablet 100 mg, 200 mg, 25 mg, 50 2 subvenite oral tablet 100 1 mg, 150 mg, 200 mg mg subvenite oral tablet 25 TRILEPTAL ORAL 2 4 mg SUSPENSION 300 MG/5ML subvenite starter kit-blue 2 oral kit 35 x 25 mg TRILEPTAL ORAL TABLET 150 MG, 300 4 subvenite starter kit- MG, 600 MG green oral kit 84 x 25 mg 2 & 14x100 mg TROKENDI XR ORAL CAPSULE EXTENDED subvenite starter kit- RELEASE 24 HOUR 100 4 PA orange oral kit 42 x 25 2 MG, 200 MG, 25 MG, 50 mg & 7 x 100 mg MG SYMPAZAN ORAL FILM 4 valproate sodium 10 MG, 20 MG, 5 MG intravenous solution 100 GM TEGRETOL ORAL mg/ml, 500 mg/5ml SUSPENSION 100 4 valproic acid oral capsule 2 MG/5ML 250 mg TEGRETOL ORAL 4 valproic acid oral solution 2 TABLET 200 MG 250 mg/5ml TEGRETOL-XR ORAL VALTOCO 10 MG DOSE TABLET EXTENDED 4 NASAL LIQUID 10 4 RELEASE 12 HOUR 100 MG/0.1ML MG, 200 MG, 400 MG VALTOCO 15 MG DOSE tiagabine hcl oral tablet NASAL LIQUID 4 12 mg, 16 mg, 2 mg, 4 2 THERAPY PACK 7.5 mg MG/0.1ML

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 38 Drug Drug Drug Name Notes Drug Name Notes Tier Tier VALTOCO 20 MG DOSE hcl oral tablet 2 NASAL LIQUID 4 dispersible 10 mg, 5 mg THERAPY PACK 10 EXELON MG/0.1ML TRANSDERMAL PATCH Brand VALTOCO 5 MG DOSE 24 HOUR 13.3 3 penalty NASAL LIQUID 5 4 MG/24HR, 4.6 applies MG/0.1ML MG/24HR, 9.5 MG/24HR vigabatrin oral packet galantamine 5 PA 500 mg hydrobromide er oral vigabatrin oral tablet 500 capsule extended 2 5 PA mg release 24 hour 16 mg, 24 mg, 8 mg vigadrone oral packet 5 PA 500 mg galantamine hydrobromide oral 2 VIMPAT INTRAVENOUS solution 4 mg/ml SOLUTION 200 GM MG/20ML galantamine hydrobromide oral tablet 2 VIMPAT ORAL 4 12 mg, 4 mg, 8 mg SOLUTION 10 MG/ML memantine hcl er oral VIMPAT ORAL TABLET capsule extended 2 100 MG, 150 MG, 200 4 release 24 hour 14 mg, MG, 50 MG 21 mg, 28 mg, 7 mg ZARONTIN ORAL 4 memantine hcl oral CAPSULE 250 MG solution 10 mg/5ml, 2 2 ZARONTIN ORAL mg/ml 4 SOLUTION 250 MG/5ML memantine hcl oral tablet ZONEGRAN ORAL 10 mg, 28 x 5 mg & 21 x 2 CAPSULE 100 MG, 25 4 10 mg, 5 mg MG Brand NAMENDA ORAL 4 penalty zonisamide oral capsule 2 100 mg, 25 mg, 50 mg TABLET 10 MG, 5 MG applies Antidementia Agents - NAMENDA TITRATION Brand Drugs for Alzheimer's PAK ORAL TABLET 28 4 penalty Disease and Dementia X 5 MG & 21 X 10 MG applies Brand NAMENDA XR ORAL ARICEPT ORAL 4 penalty CAPSULE EXTENDED Brand TABLET 10 MG, 5 MG applies RELEASE 24 HOUR 14 4 penalty Brand MG, 21 MG, 28 MG, 7 applies ARICEPT ORAL 3 penalty MG TABLET 23 MG applies NAMENDA XR TITRATION PACK ORAL donepezil hcl oral tablet 2 10 mg, 23 mg, 5 mg CAPSULE EXTENDED 4 RELEASE 24 HOUR 7 & 14 & 21 Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 39 Drug Drug Drug Name Notes Drug Name Notes Tier Tier NAMZARIC ORAL bupropion hcl er (xl) oral 2 CAPSULE ER 24 HOUR 4 tablet extended release THERAPY PACK 7 & 14 24 hour 150 mg, 300 mg & 21 &28 -10 MG bupropion hcl oral tablet 2 NAMZARIC ORAL 100 mg, 75 mg CAPSULE EXTENDED Brand 4 RELEASE 24 HOUR 14- CELEXA ORAL TABLET 4 penalty 10 MG, 21-10 MG, 28-10 10 MG, 20 MG, 40 MG applies MG, 7-10 MG chlordiazepoxide- RAZADYNE ER ORAL Brand oral tablet 2 CAPSULE EXTENDED 4 penalty 10-25 mg, 5-12.5 mg RELEASE 24 HOUR 16 applies citalopram hydrobromide MG, 24 MG, 8 MG 2 oral solution 10 mg/5ml Brand RAZADYNE ORAL 4 penalty citalopram hydrobromide TABLET 4 MG applies oral tablet 10 mg, 20 mg, 1 40 mg rivastigmine tartrate oral capsule 1.5 mg, 3 mg, 2 clomipramine hcl oral 4.5 mg, 6 mg capsule 25 mg, 50 mg, 2 75 mg rivastigmine transdermal CYMBALTA ORAL patch 24 hour 13.3 Brand 2 CAPSULE DELAYED mg/24hr, 4.6 mg/24hr, 4 penalty RELEASE PARTICLES 9.5 mg/24hr applies 20 MG, 30 MG, 60 MG Antidepressants desipramine hcl oral amitriptyline hcl oral tablet 10 mg, 100 mg, 2 tablet 10 mg, 100 mg, 2 150 mg, 25 mg, 50 mg, 150 mg, 25 mg, 50 mg, 75 mg 75 mg DESVENLAFAXINE ER amoxapine oral tablet ORAL TABLET 2 100 mg, 150 mg, 25 mg, EXTENDED RELEASE 4 PA 50 mg 24 HOUR 100 MG, 50 ANAFRANIL ORAL Brand MG 4 penalty CAPSULE 25 MG, 50 desvenlafaxine succinate MG, 75 MG applies er oral tablet extended 2 PA APLENZIN ORAL ST; QL (30 release 24 hour 100 mg, TABLET EXTENDED 4 EA per 30 25 mg, 50 mg RELEASE 24 HOUR 174 days) hcl oral capsule MG, 348 MG, 522 MG 10 mg, 100 mg, 150 mg, 2 bupropion hcl er (sr) oral 25 mg, 50 mg, 75 mg tablet extended release doxepin hcl oral 2 2 12 hour 100 mg, 150 mg, concentrate 10 mg/ml 200 mg

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 40 Drug Drug Drug Name Notes Drug Name Notes Tier Tier duloxetine hcl oral imipramine hcl oral tablet 2 capsule delayed release 2 10 mg, 25 mg, 50 mg particles 20 mg, 30 mg, imipramine pamoate oral 60 mg capsule 100 mg, 125 mg, 2 EFFEXOR XR ORAL Brand 150 mg, 75 mg CAPSULE EXTENDED 4 penalty LEXAPRO ORAL Brand RELEASE 24 HOUR 150 applies TABLET 10 MG, 20 MG, 4 penalty MG, 37.5 MG, 75 MG 5 MG applies EMSAM maprotiline hcl oral tablet TRANSDERMAL PATCH 2 3 25 mg, 50 mg, 75 mg 24 HOUR 12 MG/24HR, MARPLAN ORAL 6 MG/24HR, 9 MG/24HR 4 TABLET 10 MG escitalopram oxalate oral 2 solution 5 mg/5ml oral tablet 15 mg, 30 mg, 45 mg, 7.5 2 escitalopram oxalate oral mg tablet 10 mg, 20 mg, 5 2 mg mirtazapine oral tablet dispersible 15 mg, 30 2 FETZIMA ORAL mg, 45 mg CAPSULE EXTENDED RELEASE 24 HOUR 120 4 PA Brand MG, 20 MG, 40 MG, 80 NARDIL ORAL TABLET 4 penalty MG 15 MG applies FETZIMA TITRATION nefazodone hcl oral tablet 100 mg, 150 mg, 2 ORAL CAPSULE ER 24 4 HOUR THERAPY PACK 200 mg, 250 mg, 50 mg 20 & 40 MG Brand fluoxetine hcl oral NORPRAMIN ORAL 4 penalty capsule 10 mg, 20 mg, 1 TABLET 10 MG, 25 MG applies 40 mg nortriptyline hcl oral fluoxetine hcl oral capsule 10 mg, 25 mg, 2 capsule delayed release 2 50 mg, 75 mg 90 mg nortriptyline hcl oral 2 solution 10 mg/5ml fluoxetine hcl oral 2 solution 20 mg/5ml olanzapine-fluoxetine hcl oral capsule 12-25 mg, fluoxetine hcl oral tablet 2 2 PA 10 mg, 20 mg 12-50 mg, 3-25 mg, 6-25 mg, 6-50 mg fluvoxamine maleate er PAMELOR ORAL Brand oral capsule extended 2 release 24 hour 100 mg, CAPSULE 10 MG, 25 4 penalty 150 mg MG, 50 MG, 75 MG applies fluvoxamine maleate oral Brand tablet 100 mg, 25 mg, 50 2 PARNATE ORAL 4 penalty mg TABLET 10 MG applies

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 41 Drug Drug Drug Name Notes Drug Name Notes Tier Tier paroxetine hcl er oral sertraline hcl oral tablet 1 tablet extended release 2 100 mg, 25 mg, 50 mg 24 hour 12.5 mg, 25 mg, SPRAVATO (56 MG 37.5 mg PA; DOSE) NASAL 6 Specialty paroxetine hcl oral tablet SOLUTION THERAPY Medical 10 mg, 20 mg, 30 mg, 40 2 PACK 28 MG/DEVICE mg SPRAVATO (84 MG PA; PAXIL CR ORAL DOSE) NASAL 6 Specialty TABLET EXTENDED Brand SOLUTION THERAPY Medical RELEASE 24 HOUR 4 penalty PACK 28 MG/DEVICE 12.5 MG, 25 MG, 37.5 applies SYMBYAX ORAL MG PA; Brand CAPSULE 12-50 MG, 3- 4 penalty PAXIL ORAL 25 MG, 6-25 MG, 6-50 applies SUSPENSION 10 3 MG MG/5ML tranylcypromine sulfate 2 PAXIL ORAL TABLET 10 Brand oral tablet 10 mg 4 penalty MG, 20 MG, 30 MG, 40 hcl oral tablet MG applies 100 mg, 150 mg, 300 2 perphenazine- mg, 50 mg amitriptyline oral tablet 2- 2 maleate oral 10 mg, 2-25 mg, 4-10 capsule 100 mg, 25 mg, 2 mg, 4-25 mg, 4-50 mg 50 mg phenelzine sulfate oral 2 TRINTELLIX ORAL tablet 15 mg TABLET 10 MG, 20 MG, 4 PA PRISTIQ ORAL TABLET PA; Brand 5 MG EXTENDED RELEASE 4 penalty venlafaxine hcl er oral 24 HOUR 100 MG, 25 applies capsule extended 2 MG, 50 MG release 24 hour 150 mg, protriptyline hcl oral 37.5 mg, 75 mg 2 tablet 10 mg, 5 mg venlafaxine hcl oral tablet PROZAC ORAL Brand 100 mg, 25 mg, 37.5 mg, 2 CAPSULE 10 MG, 20 4 penalty 50 mg, 75 mg MG, 40 MG applies VIIBRYD ORAL TABLET 4 PA Brand 10 MG, 20 MG, 40 MG REMERON ORAL 4 penalty VIIBRYD STARTER TABLET 15 MG, 30 MG applies PACK ORAL KIT 10 & 20 4 PA REMERON SOLTAB Brand MG ORAL TABLET 4 penalty WELLBUTRIN SR ORAL DISPERSIBLE 15 MG, Brand applies TABLET EXTENDED 4 penalty 30 MG, 45 MG RELEASE 12 HOUR 100 applies sertraline hcl oral MG, 150 MG, 200 MG 2 concentrate 20 mg/ml

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 42 Drug Drug Drug Name Notes Drug Name Notes Tier Tier WELLBUTRIN XL ORAL dronabinol oral capsule Brand 2 TABLET EXTENDED 4 penalty 10 mg, 2.5 mg, 5 mg RELEASE 24 HOUR 150 applies droperidol injection GM MG, 300 MG solution 2.5 mg/ml ZOLOFT ORAL Brand EMEND INTRAVENOUS CONCENTRATE 20 4 penalty SOLUTION applies GM PA MG/ML RECONSTITUTED 150 Brand MG ZOLOFT ORAL TABLET 4 penalty Brand 100 MG, 25 MG, 50 MG applies penalty Antiemetics - Drugs for EMEND ORAL 4 applies; QL Nausea and Vomiting CAPSULE 40 MG, 80 (6 EA per AKYNZEO MG 30 days) INTRAVENOUS GM EMEND ORAL QL (6 EA SOLUTION 235-0.25 SUSPENSION 3 per 30 MG/20ML RECONSTITUTED 125 days) AKYNZEO MG INTRAVENOUS Brand SOLUTION GM penalty RECONSTITUTED 235- EMEND TRI-PACK 4 applies; QL 0.25 MG ORAL CAPSULE 80 & (6 EA per QL (3 EA 125 MG 30 days) AKYNZEO ORAL 4 per 21 fosaprepitant CAPSULE 300-0.5 MG days) dimeglumine intravenous GM PA ALOXI INTRAVENOUS solution reconstituted SOLUTION 0.25 GM 150 mg MG/5ML granisetron hcl ANZEMET ORAL intravenous solution 1 GM 3 TABLET 100 MG, 50 MG mg/ml, 4 mg/4ml granisetron hcl oral tablet aprepitant oral capsule QL (6 EA 2 125 mg, 40 mg, 80 & 125 2 per 30 1 mg mg, 80 mg days) MARINOL ORAL Brand BONJESTA ORAL CAPSULE 10 MG, 2.5 4 penalty TABLET EXTENDED 4 MG, 5 MG applies RELEASE 20-20 MG meclizine hcl oral tablet 2 12.5 mg, 25 mg CINVANTI QL (6 ML INTRAVENOUS GM per 30 metoclopramide hcl GM EMULSION 130 days) injection solution 5 mg/ml MG/18ML metoclopramide hcl oral compro rectal 2 2 solution 10 mg/10ml, 5 suppository 25 mg mg/5ml injection metoclopramide hcl oral GM 2 solution 50 mg/ml tablet 10 mg, 5 mg

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 43 Drug Drug Drug Name Notes Drug Name Notes Tier Tier metoclopramide hcl oral SYNDROS ORAL 4 tablet dispersible 10 mg, 2 SOLUTION 5 MG/ML 5 mg TIGAN ondansetron hcl injection INTRAMUSCULAR GM solution 4 mg/2ml, 40 GM SOLUTION 100 MG/ML mg/20ml Brand 4 penalty ondansetron hcl oral 2 TIGAN ORAL CAPSULE solution 4 mg/5ml 300 MG applies ondansetron hcl oral TRANSDERM SCOP 2 Brand tablet 24 mg, 4 mg, 8 mg (1.5 MG) 4 penalty TRANSDERMAL PATCH ondansetron odt oral applies tablet dispersible 4 mg, 8 2 72 HOUR 1 MG/3DAYS mg TRANSDERM-SCOP Brand palonosetron hcl (1.5 MG) 4 penalty intravenous solution 0.25 GM TRANSDERMAL PATCH applies mg/2ml, 0.25 mg/5ml 72 HOUR 1 MG/3DAYS palonosetron hcl trimethobenzamide hcl 2 oral capsule 300 mg intravenous solution GM prefilled syringe 0.25 VARUBI (180 MG DOSE) QL (2 EA mg/5ml ORAL TABLET 4 per 30 perphenazine oral tablet THERAPY PACK 2 X 90 2 days) 16 mg, 2 mg, 4 mg, 8 mg MG prochlorperazine Brand ZOFRAN ORAL TABLET 4 penalty edisylate injection GM solution 10 mg/2ml, 50 4 MG, 8 MG applies mg/10ml ZUPLENZ ORAL FILM 4 4 MG, 8 MG prochlorperazine maleate 2 oral tablet 10 mg, 5 mg Antifungals ABELCET prochlorperazine rectal 2 suppository 25 mg INTRAVENOUS GM Brand SUSPENSION 5 MG/ML REGLAN ORAL TABLET 4 penalty AMBISOME 10 MG, 5 MG applies INTRAVENOUS GM SANCUSO QL (1 EA SUSPENSION TRANSDERMAL PATCH 3 per 30 RECONSTITUTED 50 3.1 MG/24HR days) MG scopolamine transdermal amphotericin b GM patch 72 hour 1 2 intravenous solution mg/3days reconstituted 50 mg Brand SUSTOL ANCOBON ORAL QL (2 ML 4 penalty SUBCUTANEOUS CAPSULE 250 MG, 500 6 per 30 applies PREFILLED SYRINGE MG days) 10 MG/0.4ML Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 44 Drug Drug Drug Name Notes Drug Name Notes Tier Tier BIO-STATIN ORAL CRESEMBA CAPSULE 1000000 4 INTRAVENOUS PA; UNIT, 500000 UNIT SOLUTION 6 Specialty bio-statin oral powder 2 RECONSTITUTED 372 Medical MG CANCIDAS INTRAVENOUS CRESEMBA ORAL 6 PA SOLUTION GM CAPSULE 186 MG RECONSTITUTED 50 DIFLUCAN ORAL Brand MG, 70 MG SUSPENSION 4 penalty RECONSTITUTED 10 caspofungin acetate applies intravenous solution MG/ML, 40 MG/ML GM reconstituted 50 mg, 70 DIFLUCAN ORAL Brand mg TABLET 100 MG, 150 4 penalty QL (13.2 MG, 200 MG, 50 MG applies 2 ML per 30 ciclodan external solution econazole nitrate 2 8 % days) external cream 1 % ciclopirox external gel 2 ERAXIS INTRAVENOUS 0.77 % SOLUTION GM ciclopirox external RECONSTITUTED 100 2 shampoo 1 % MG, 50 MG ERTACZO EXTERNAL QL (13.2 4 ST ciclopirox external 2 ML per 30 CREAM 2 % days) solution 8 % EXELDERM EXTERNAL 4 ST CREAM 1 % ciclopirox olamine 2 external cream 0.77 % EXELDERM EXTERNAL 4 ST ciclopirox olamine SOLUTION 1 % 2 external suspension 0.77 EXODERM EXTERNAL 4 % LOTION 25-1 % Brand clotrimazole external 2 cream 1 % EXTINA EXTERNAL 4 penalty clotrimazole external FOAM 2 % applies 2 solution 1 % fluconazole in sodium clotrimazole mouth/throat chloride intravenous 2 lozenge 10 mg solution 200-0.9 GM mg/100ml-%, 400-0.9 clotrimazole mouth/throat 2 mg/200ml-% troche 10 mg fluconazole oral clotrimazole- suspension reconstituted 2 betamethasone external 2 10 mg/ml, 40 mg/ml cream 1-0.05 % fluconazole oral tablet clotrimazole- 100 mg, 150 mg, 200 2 betamethasone external 2 mg, 50 mg lotion 1-0.05 %

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 45 Drug Drug Drug Name Notes Drug Name Notes Tier Tier flucytosine oral capsule LULICONAZOLE 2 4 ST 250 mg, 500 mg EXTERNAL CREAM 1 %

FUNGIMEZ EXTERNAL 4 LUZU EXTERNAL 4 ST SOLUTION CREAM 1 % griseofulvin microsize MENTAX EXTERNAL 4 ST oral suspension 125 2 CREAM 1 % mg/5ml micafungin sodium griseofulvin microsize intravenous solution 2 GM oral tablet 500 mg reconstituted 100 mg, 50 griseofulvin mg ultramicrosize oral tablet 2 miconazole 3 vaginal 2 125 mg, 250 mg suppository 200 mg GYNAZOLE-1 VAGINAL MICONAZOLE-ZINC 4 CREAM 2 % OXIDE-PETROLAT 4 EXTERNAL OINTMENT itraconazole oral capsule 2 100 mg 0.25-15-81.35 % MYCAMINE itraconazole oral solution 2 10 mg/ml INTRAVENOUS SOLUTION GM JUBLIA EXTERNAL 4 PA RECONSTITUTED 100 SOLUTION 10 % MG, 50 MG KERYDIN EXTERNAL naftifine hcl external 4 PA 2 ST SOLUTION 5 % cream 1 %, 2 % ketoconazole external 2 naftifine hcl external gel 1 2 ST cream 2 % % ketoconazole external 2 ST; Brand foam 2 % NAFTIN EXTERNAL 4 penalty CREAM 2 % applies ketoconazole external 2 shampoo 2 % ST; Brand NAFTIN EXTERNAL 4 penalty ketoconazole oral tablet 2 200 mg GEL 1 % applies NAFTIN EXTERNAL ketodan external foam 2 2 4 ST % GEL 2 % Brand NOXAFIL 4 penalty Specialty LOPROX EXTERNAL INTRAVENOUS 6 CREAM 0.77 % applies SOLUTION 300 Medical Brand MG/16.7ML LOPROX EXTERNAL 4 penalty NOXAFIL ORAL SHAMPOO 1 % applies SUSPENSION 40 6 Brand MG/ML LOPROX EXTERNAL 4 penalty NOXAFIL ORAL TABLET SUSPENSION 0.77 % applies DELAYED RELEASE 6 100 MG Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 46 Drug Drug Drug Name Notes Drug Name Notes Tier Tier nystatin external cream SULCONAZOLE 2 100000 unit/gm NITRATE EXTERNAL 4 ST CREAM 1 % nystatin external 2 ointment 100000 unit/gm SULCONAZOLE NITRATE EXTERNAL 4 ST nystatin external powder 2 100000 unit/gm SOLUTION 1 % nystatin mouth/throat terbinafine hcl oral tablet 2 suspension 100000 2 250 mg unit/ml terconazole vaginal 2 nystatin oral tablet cream 0.4 %, 0.8 % 2 500000 unit terconazole vaginal 2 nystatin-triamcinolone suppository 80 mg external cream 100000- 2 VFEND IV 0.1 unit/gm-% INTRAVENOUS Specialty 5 nystatin-triamcinolone SOLUTION Medical external ointment 2 RECONSTITUTED 200 100000-0.1 unit/gm-% MG nystop external powder VFEND ORAL 2 SUSPENSION 100000 unit/gm 6 RECONSTITUTED 40 ORAVIG BUCCAL 4 MG/ML TABLET 50 MG VFEND ORAL TABLET oxiconazole nitrate 6 2 ST 200 MG, 50 MG external cream 1 % voriconazole intravenous Specialty ST; Brand 5 solution reconstituted Medical OXISTAT EXTERNAL 4 penalty 200 mg CREAM 1 % applies voriconazole oral OXISTAT EXTERNAL 4 ST suspension reconstituted 5 LOTION 1 % 40 mg/ml posaconazole oral tablet voriconazole oral tablet 6 5 delayed release 100 mg 200 mg, 50 mg RECURA EXTERNAL 4 VUSION EXTERNAL CREAM OINTMENT 0.25-15- 4 Brand 81.35 % SPORANOX ORAL 4 penalty XOLEGEL COREPAK 4 CAPSULE 100 MG applies EXTERNAL KIT 2 & 1 % Brand XOLEGEL DUO/HEAD & SPORANOX ORAL 4 penalty SHOULDERS 4 SOLUTION 10 MG/ML applies EXTERNAL KIT 2 & 1 % SPORANOX PULSEPAK Brand XOLEGEL DUO/XOLEX 4 ORAL CAPSULE 100 4 penalty EXTERNAL KIT 2 & 1 % MG applies

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 47 Drug Drug Drug Name Notes Drug Name Notes Tier Tier XOLEGEL EXTERNAL Anti-inflammatory 4 GEL 2 % Agents EMFLAZA ORAL ZOLPAK EXTERNAL KIT 4 1 % SUSPENSION 22.75 6 PA Antigout Agents MG/ML EMFLAZA ORAL allopurinol oral tablet 100 1 mg, 300 mg TABLET 18 MG, 30 MG, 6 PA 36 MG, 6 MG allopurinol sodium Antimigraine Agents intravenous solution GM reconstituted 500 mg AIMOVIG PA; QL (1 ALOPRIM SUBCUTANEOUS 4 ML per 28 INTRAVENOUS SOLUTION AUTO- days) SOLUTION GM INJECTOR 140 MG/ML, RECONSTITUTED 500 70 MG/ML MG AJOVY PA; QL COLCHICINE ORAL SUBCUTANEOUS 3 4 (1.5 ML per CAPSULE 0.6 MG SOLUTION AUTO- INJECTOR 225 28 days) colchicine tablet 0.6 mg 2 MG/1.5ML oral 0.6 mg AJOVY COLCHICINE TABLET 3 SUBCUTANEOUS PA; QL 0.6 MG ORAL 0.6 MG SOLUTION PREFILLED 4 (1.5 ML per colchicine-probenecid SYRINGE 225 28 days) 2 oral tablet 0.5-500 mg MG/1.5ML COLCRYS ORAL QL (9 EA 3 TABLET 0.6 MG almotriptan malate oral 2 per 30 tablet 12.5 mg, 6.25 mg days) febuxostat oral tablet 40 2 mg, 80 mg Brand penalty GLOPERBA ORAL 4 4 applies; QL SOLUTION 0.6 MG/5ML AMERGE ORAL (9 EA per KRYSTEXXA PA; TABLET 1 MG, 2.5 MG 30 days) INTRAVENOUS 6 Specialty Brand SOLUTION 8 MG/ML Medical CAFERGOT ORAL 4 penalty MITIGARE ORAL 3 TABLET 1-100 MG applies CAPSULE 0.6 MG CAMBIA ORAL PACKET probenecid oral tablet 4 2 50 MG 500 mg D.H.E. 45 INJECTION GM Brand SOLUTION 1 MG/ML ULORIC ORAL TABLET 4 penalty 40 MG, 80 MG applies dihydroergotamine mesylate injection GM ZYLOPRIM ORAL Brand solution 1 mg/ml TABLET 100 MG, 300 4 penalty MG applies Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 48 Drug Drug Drug Name Notes Drug Name Notes Tier Tier dihydroergotamine PA; QL (8 IMITREX STATDOSE Brand 2 ML per 30 mesylate nasal solution 4 REFILL penalty days) mg/ml SUBCUTANEOUS 4 applies; QL QL (9 EA SOLUTION CARTRIDGE (2 ML per eletriptan hydrobromide 2 per 30 4 MG/0.5ML, 6 30 days) oral tablet 20 mg, 40 mg days) MG/0.5ML IMITREX STATDOSE EMGALITY (300 MG Brand SYSTEM DOSE) PA; QL (3 penalty SUBCUTANEOUS SUBCUTANEOUS 4 ML per 28 4 applies; QL SOLUTION PREFILLED days) SOLUTION AUTO- (2 ML per SYRINGE 100 MG/ML INJECTOR 4 MG/0.5ML, 30 days) 6 MG/0.5ML EMGALITY PA; QL (2 SUBCUTANEOUS Brand 4 ML per 28 penalty SOLUTION AUTO- days) INJECTOR 120 MG/ML IMITREX 4 applies; QL SUBCUTANEOUS (2 ML per EMGALITY PA; QL (2 SOLUTION 6 MG/0.5ML 30 days) SUBCUTANEOUS 4 ML per 28 SOLUTION PREFILLED Brand days) SYRINGE 120 MG/ML penalty 4 applies; QL ERGOMAR MAXALT ORAL TABLET (12 EA per SUBLINGUAL TABLET 4 10 MG 30 days) SUBLINGUAL 2 MG Brand ergotamine-caffeine oral 2 penalty tablet 1-100 mg MAXALT-MLT ORAL 4 applies; QL Brand TABLET DISPERSIBLE (12 EA per penalty 10 MG 30 days) 4 applies; QL MIGERGOT RECTAL FROVA ORAL TABLET (9 EA per SUPPOSITORY 2-100 4 2.5 MG 30 days) MG QL (9 EA PA; Brand frovatriptan succinate 2 per 30 penalty oral tablet 2.5 mg days) 4 applies; QL Brand MIGRANAL NASAL (8 ML per penalty SOLUTION 4 MG/ML 30 days) IMITREX NASAL 3 applies; QL QL (9 EA SOLUTION 20 MG/ACT, (6 EA per naratriptan hcl oral tablet 2 per 30 5 MG/ACT 30 days) 1 mg, 2.5 mg days) Brand Brand penalty penalty 4 applies; QL 4 applies; QL IMITREX ORAL TABLET (9 EA per RELPAX ORAL TABLET (9 EA per 100 MG, 25 MG, 50 MG 30 days) 20 MG, 40 MG 30 days)

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 49 Drug Drug Drug Name Notes Drug Name Notes Tier Tier QL (12 EA Brand rizatriptan benzoate oral 2 per 30 penalty tablet 10 mg, 5 mg days) 4 applies; QL rizatriptan benzoate oral QL (12 EA ZOMIG ORAL TABLET (9 EA per tablet dispersible 10 mg, 2 per 30 2.5 MG, 5 MG 30 days) 5 mg days) Brand penalty sumatriptan nasal QL (6 EA solution 20 mg/act, 5 2 per 30 ZOMIG ZMT ORAL 4 applies; QL mg/act days) TABLET DISPERSIBLE (9 EA per 2.5 MG, 5 MG 30 days) sumatriptan succinate QL (9 EA Antimyasthenic Agents oral tablet 100 mg, 25 2 per 30 mg, 50 mg days) BLOXIVERZ INTRAVENOUS sumatriptan succinate QL (2 ML GM refill subcutaneous SOLUTION 10 2 per 30 MG/10ML, 5 MG/10ML solution cartridge 4 days) mg/0.5ml, 6 mg/0.5ml GUANIDINE HCL ORAL 4 sumatriptan succinate QL (2 ML TABLET 125 MG subcutaneous solution 6 2 per 30 Brand mg/0.5ml days) MESTINON ORAL 3 penalty applies sumatriptan succinate SOLUTION 60 MG/5ML QL (2 ML subcutaneous solution Brand 2 per 30 MESTINON ORAL 4 penalty auto-injector 4 mg/0.5ml, days) 6 mg/0.5ml TABLET 60 MG applies MESTINON ORAL Brand sumatriptan succinate QL (2 ML TABLET EXTENDED 3 penalty subcutaneous solution 2 per 30 RELEASE 180 MG applies prefilled syringe 6 days) mg/0.5ml neostigmine PA; methylsulfate intravenous GM VYEPTI INTRAVENOUS 6 Specialty solution 10 mg/10ml, 5 SOLUTION 100 MG/ML Medical mg/10ml QL (9 EA NEOSTIGMINE zolmitriptan oral tablet 2 per 30 METHYLSULFATE 2.5 mg, 5 mg days) INTRAVENOUS GM QL (9 EA SOLUTION 3 MG/3ML, 5 zolmitriptan oral tablet 2 per 30 MG/5ML dispersible 2.5 mg, 5 mg days) NEOSTIGMINE ZOMIG NASAL QL (6 EA METHYLSULFATE INTRAVENOUS SOLUTION 2.5 MG, 5 4 per 30 GM MG days) SOLUTION PREFILLED SYRINGE 3 MG/3ML, 4 MG/4ML bromide er oral tablet extended 2 release 180 mg Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 50 Drug Drug Drug Name Notes Drug Name Notes Tier Tier pyridostigmine bromide RIFADIN 2 oral solution 60 mg/5ml INTRAVENOUS SOLUTION GM pyridostigmine bromide 2 oral tablet 30 mg, 60 mg RECONSTITUTED 600 MG REGONOL INTRAVENOUS GM RIFADIN ORAL Brand 4 penalty SOLUTION 10 MG/2ML CAPSULE 150 MG, 300 MG applies Antimycobacterials rifampin intravenous CAPASTAT SULFATE solution reconstituted GM GM INJECTION SOLUTION 600 mg RECONSTITUTED 1 GM rifampin oral capsule 150 cycloserine oral capsule 2 2 mg, 300 mg 250 mg SIRTURO ORAL 6 PA dapsone oral tablet 100 2 TABLET 100 MG, 20 MG mg, 25 mg TRECATOR ORAL 4 ethambutol hcl oral tablet 2 TABLET 250 MG 100 mg, 400 mg Antineoplastics - Drugs isoniazid injection GM for Cancer solution 100 mg/ml abiraterone acetate oral 5 PA isoniazid oral syrup 50 2 tablet 250 mg mg/5ml ABRAXANE isoniazid oral tablet 100 2 INTRAVENOUS PA; mg, 300 mg SUSPENSION 6 Specialty Brand RECONSTITUTED 100 Medical MYAMBUTOL ORAL 4 penalty MG TABLET 400 MG applies ADCETRIS Brand INTRAVENOUS PA; MYCOBUTIN ORAL 3 penalty SOLUTION 6 Specialty CAPSULE 150 MG applies RECONSTITUTED 50 Medical MG PASER ORAL PACKET 4 adriamycin intravenous 4 GM GM PA PA; QL (30 solution 2 mg/ml PRETOMANID ORAL 4 EA per 30 adriamycin intravenous TABLET 200 MG days) solution reconstituted 10 GM PA PRIFTIN ORAL TABLET mg, 50 mg 4 150 MG AFINITOR DISPERZ pyrazinamide oral tablet ORAL TABLET 2 6 PA 500 mg SOLUBLE 2 MG, 3 MG, 5 MG rifabutin oral capsule 150 2 mg AFINITOR ORAL TABLET 10 MG, 2.5 MG, 6 PA 5 MG, 7.5 MG

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 51 Drug Drug Drug Name Notes Drug Name Notes Tier Tier ALECENSA ORAL ASPARLAS 6 PA PA; CAPSULE 150 MG INTRAVENOUS 6 Specialty ALIMTA INTRAVENOUS SOLUTION 3750 Medical PA; UNIT/5ML SOLUTION 6 Specialty RECONSTITUTED 100 Medical AVASTIN PA; MG, 500 MG INTRAVENOUS 6 Specialty SOLUTION 100 ALIQOPA Medical INTRAVENOUS PA; MG/4ML, 400 MG/16ML SOLUTION 6 Specialty AYVAKIT ORAL TABLET RECONSTITUTED 60 Medical 100 MG, 200 MG, 300 6 PA MG MG ALKERAN azacitidine injection PA; INTRAVENOUS PA; suspension reconstituted 6 Specialty SOLUTION 6 Specialty 100 mg Medical RECONSTITUTED 50 Medical AZEDRA DOSIMETRIC MG INTRAVENOUS GM PA; Brand SOLUTION 15 MCI/ML ALKERAN ORAL 3 penalty AZEDRA TABLET 2 MG applies THERAPEUTIC GM ALUNBRIG ORAL INTRAVENOUS TABLET 180 MG, 30 6 PA SOLUTION 15 MCI/ML MG, 90 MG BALVERSA ORAL ALUNBRIG ORAL TABLET 3 MG, 4 MG, 5 6 PA TABLET THERAPY 6 PA MG PACK 90 & 180 MG BAVENCIO anastrozole oral tablet 1 2 INTRAVENOUS GM mg SOLUTION 200 Brand MG/10ML ARIMIDEX ORAL 4 penalty BELEODAQ TABLET 1 MG applies INTRAVENOUS PA; Brand SOLUTION 6 Specialty AROMASIN ORAL 4 penalty RECONSTITUTED 500 Medical TABLET 25 MG applies MG ARRANON PA; BELRAPZO PA; INTRAVENOUS 6 Specialty INTRAVENOUS 6 Specialty SOLUTION 5 MG/ML Medical SOLUTION 100 MG/4ML Medical arsenic trioxide PA; BENDAMUSTINE HCL PA; 6 Specialty intravenous solution 10 6 Specialty INTRAVENOUS mg/10ml Medical SOLUTION 100 MG/4ML Medical ARZERRA BENDEKA PA; PA; INTRAVENOUS INTRAVENOUS 6 Specialty 6 Specialty CONCENTRATE 100 SOLUTION 100 MG/4ML Medical Medical MG/5ML, 1000 MG/50ML

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 52 Drug Drug Drug Name Notes Drug Name Notes Tier Tier BESPONSA CALQUENCE ORAL 6 PA INTRAVENOUS PA; CAPSULE 100 MG SOLUTION 6 Specialty CAMPATH PA; RECONSTITUTED 0.9 Medical INTRAVENOUS 6 Specialty MG SOLUTION 30 MG/ML Medical bexarotene oral capsule 6 PA CAMPTOSAR 75 mg INTRAVENOUS bicalutamide oral tablet SOLUTION 100 GM PA 2 50 mg MG/5ML, 300 MG/15ML, BICNU INTRAVENOUS 40 MG/2ML PA; SOLUTION capecitabine oral tablet 6 Specialty 4 PA RECONSTITUTED 100 Medical 150 mg, 500 mg MG CAPRELSA ORAL 6 PA bleomycin sulfate PA; TABLET 100 MG, 300 injection solution 6 Specialty MG reconstituted 15 unit, 30 Medical carboplatin intravenous unit solution 150 mg/15ml, GM PA BLINCYTO 450 mg/45ml, 50 mg/5ml, INTRAVENOUS PA; 600 mg/60ml SOLUTION 6 Specialty carmustine intravenous PA; RECONSTITUTED 35 Medical solution reconstituted 6 Specialty MCG 100 mg Medical BORTEZOMIB Brand INTRAVENOUS PA; CASODEX ORAL 4 penalty SOLUTION 6 Specialty TABLET 50 MG applies RECONSTITUTED 3.5 Medical MG cisplatin intravenous solution 100 mg/100ml, GM PA BOSULIF ORAL TABLET PA; QL (30 200 mg/200ml, 50 100 MG, 400 MG, 500 6 EA per 30 mg/50ml MG days) PA; BRAFTOVI ORAL 6 PA cladribine intravenous 6 Specialty CAPSULE 75 MG solution 10 mg/10ml Medical BRUKINSA ORAL 6 PA PA; CAPSULE 80 MG clofarabine intravenous 6 Specialty PA; solution 1 mg/ml Medical busulfan intravenous 6 Specialty CLOLAR PA; solution 6 mg/ml Medical INTRAVENOUS 6 Specialty BUSULFEX PA; SOLUTION 1 MG/ML Medical INTRAVENOUS 6 Specialty COMETRIQ (100 MG SOLUTION 6 MG/ML Medical DAILY DOSE) ORAL KIT 6 PA CABOMETYX ORAL 1 X 80 & 1 X 20 MG TABLET 20 MG, 40 MG, 6 PA 60 MG

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 53 Drug Drug Drug Name Notes Drug Name Notes Tier Tier COMETRIQ (140 MG DARZALEX FASPRO 6 PA DAILY DOSE) ORAL KIT SUBCUTANEOUS 6 PA 1 X 80 & 3 X 20 MG SOLUTION 1800-30000 COMETRIQ (60 MG MG-UT/15ML 6 PA DAILY DOSE) ORAL KIT DARZALEX PA; 20 MG INTRAVENOUS 6 Specialty SOLUTION 100 COPIKTRA ORAL Medical CAPSULE 15 MG, 25 6 PA MG/5ML, 400 MG/20ML MG daunorubicin hcl COSMEGEN intravenous solution 20 GM PA INTRAVENOUS PA; mg/4ml, 50 mg/10ml 6 Specialty SOLUTION DAURISMO ORAL 6 PA RECONSTITUTED 0.5 Medical TABLET 100 MG, 25 MG MG decitabine intravenous PA; 6 Specialty COTELLIC ORAL 6 PA solution reconstituted 50 TABLET 20 MG mg Medical cyclophosphamide PA; dexrazoxane hcl injection solution intravenous solution 6 Specialty GM reconstituted 1 gm, 2 gm, reconstituted 250 mg, Medical 500 mg 500 mg cyclophosphamide oral docetaxel intravenous 2 PA PA; capsule 25 mg, 50 mg concentrate 160 mg/8ml, 6 Specialty CYRAMZA 20 mg/ml, 200 mg/10ml, Medical PA; 80 mg/4ml INTRAVENOUS 6 Specialty PA; SOLUTION 100 Medical docetaxel intravenous MG/10ML, 500 MG/50ML solution 160 mg/16ml, 20 6 Specialty cytarabine (pf) injection PA; mg/2ml, 80 mg/8ml Medical solution 100 mg/ml, 20 6 Specialty PA; mg/ml Medical DOXIL INTRAVENOUS 6 Specialty PA; INJECTABLE 2 MG/ML Medical cytarabine injection 6 Specialty doxorubicin hcl solution 20 mg/ml Medical intravenous solution 2 GM PA dacarbazine intravenous PA; mg/ml solution reconstituted 6 Specialty doxorubicin hcl liposomal PA; 100 mg, 200 mg Medical intravenous injectable 2 6 Specialty DACOGEN mg/ml Medical INTRAVENOUS PA; DROXIA ORAL SOLUTION 6 Specialty CAPSULE 200 MG, 300 4 RECONSTITUTED 50 Medical MG, 400 MG MG ELITEK INTRAVENOUS dactinomycin intravenous PA; SOLUTION Specialty 6 solution reconstituted 0.5 6 Specialty RECONSTITUTED 1.5 Medical mg Medical MG, 7.5 MG

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 54 Drug Drug Drug Name Notes Drug Name Notes Tier Tier ELLENCE etoposide intravenous PA; GM PA INTRAVENOUS 6 Specialty solution 1 gm/50ml, 100 SOLUTION 200 Medical mg/5ml, 500 mg/25ml MG/100ML, 50 MG/25ML etoposide oral capsule 2 PA ELZONRIS PA; 50 mg INTRAVENOUS 6 Specialty everolimus oral tablet 2.5 SOLUTION 1000 6 PA Medical mg, 5 mg, 7.5 mg MCG/ML EVOMELA EMCYT ORAL 3 PA INTRAVENOUS CAPSULE 140 MG SOLUTION GM EMPLICITI RECONSTITUTED 50 INTRAVENOUS PA; MG SOLUTION 6 Specialty exemestane oral tablet 2 RECONSTITUTED 300 Medical 25 mg MG, 400 MG PA; Brand ENHERTU FARESTON ORAL 3 penalty PA; INTRAVENOUS TABLET 60 MG applies SOLUTION 6 Specialty RECONSTITUTED 100 Medical FARYDAK ORAL MG CAPSULE 10 MG, 20 6 PA MG epirubicin hcl intravenous PA; solution 200 mg/100ml, 6 Specialty FASLODEX PA; 50 mg/25ml Medical INTRAMUSCULAR 6 Specialty SOLUTION 250 MG/5ML Medical ERBITUX INTRAVENOUS PA; Brand SOLUTION 100 6 Specialty FEMARA ORAL TABLET 4 penalty MG/50ML, 200 Medical 2.5 MG applies MG/100ML floxuridine injection PA; ERIVEDGE ORAL solution reconstituted 0.5 6 Specialty 6 PA CAPSULE 150 MG gm Medical ERLEADA ORAL fludarabine phosphate PA; 6 PA TABLET 60 MG intravenous solution 50 6 Specialty mg/2ml Medical erlotinib hcl oral tablet 5 PA 100 mg, 150 mg, 25 mg fludarabine phosphate PA; intravenous solution 6 Specialty ERWINAZE INJECTION PA; reconstituted 50 mg Medical SOLUTION 6 Specialty fluorouracil intravenous RECONSTITUTED Medical 10000 UNIT solution 1 gm/20ml, 2.5 GM PA gm/50ml, 5 gm/100ml, ETOPOPHOS 500 mg/10ml INTRAVENOUS PA; flutamide oral capsule SOLUTION 6 Specialty 2 PA RECONSTITUTED 100 Medical 125 mg MG

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 55 Drug Drug Drug Name Notes Drug Name Notes Tier Tier FOLOTYN HERCEPTIN HYLECTA PA; INTRAVENOUS 6 Specialty SUBCUTANEOUS 6 PA SOLUTION 20 MG/ML, Medical SOLUTION 600-10000 40 MG/2ML MG-UNT/5ML PA; HERCEPTIN fulvestrant intramuscular 6 Specialty INTRAVENOUS PA; solution 250 mg/5ml Medical SOLUTION 6 Specialty GAZYVA RECONSTITUTED 150 Medical PA; INTRAVENOUS MG 6 Specialty SOLUTION 1000 HERZUMA Medical MG/40ML INTRAVENOUS PA; gemcitabine hcl SOLUTION 5 Specialty RECONSTITUTED 150 Medical intravenous solution 1 GM gm/10ml, 1.5 gm/15ml, 2 MG, 420 MG gm/20ml, 200 mg/2ml HYCAMTIN INTRAVENOUS gemcitabine hcl GM PA intravenous solution 1 SOLUTION GM PA gm/26.3ml, 2 gm/52.6ml, RECONSTITUTED 4 MG 200 mg/5.26ml HYCAMTIN ORAL gemcitabine hcl CAPSULE 0.25 MG, 1 4 PA intravenous solution MG GM PA reconstituted 1 gm, 2 gm, Brand 200 mg HYDREA ORAL 4 penalty GILOTRIF ORAL CAPSULE 500 MG applies 6 PA TABLET 20 MG, 30 MG, hydroxyurea oral capsule 2 40 MG 500 mg PA; QL (90 IBRANCE ORAL GLEEVEC ORAL 6 EA per 30 CAPSULE 100 MG, 125 6 PA TABLET 100 MG days) MG, 75 MG PA; QL (30 IBRANCE ORAL GLEEVEC ORAL 6 EA per 30 TABLET 100 MG, 125 6 PA TABLET 400 MG days) MG, 75 MG GLEOSTINE ORAL PA; QL (30 CAPSULE 10 MG, 100 6 PA ICLUSIG ORAL TABLET 6 EA per 30 MG, 40 MG 15 MG, 45 MG days) GLIADEL WAFER IDAMYCIN PFS IMPLANT WAFER 7.7 GM INTRAVENOUS PA; MG SOLUTION 10 6 Specialty HALAVEN PA; MG/10ML, 20 MG/20ML, Medical INTRAVENOUS 6 Specialty 5 MG/5ML SOLUTION 1 MG/2ML Medical idarubicin hcl intravenous PA; solution 10 mg/10ml, 20 6 Specialty mg/20ml, 5 mg/5ml Medical

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 56 Drug Drug Drug Name Notes Drug Name Notes Tier Tier IDHIFA ORAL TABLET INREBIC ORAL 6 PA 6 PA 100 MG, 50 MG CAPSULE 100 MG

IFEX INTRAVENOUS PA; IRESSA ORAL TABLET 6 PA SOLUTION 6 Specialty 250 MG RECONSTITUTED 1 Medical irinotecan hcl intravenous GM, 3 GM solution 100 mg/5ml, 300 GM PA ifosfamide intravenous PA; mg/15ml, 40 mg/2ml, 500 solution 1 gm/20ml, 3 6 Specialty mg/25ml gm/60ml Medical ISTODAX (OVERFILL) ifosfamide intravenous PA; INTRAVENOUS PA; solution reconstituted 1 6 Specialty SOLUTION 6 Specialty gm, 3 gm Medical RECONSTITUTED 10 Medical PA; QL (90 MG imatinib mesylate oral 5 EA per 30 IXEMPRA KIT tablet 100 mg days) INTRAVENOUS PA; PA; QL (30 SOLUTION 6 Specialty Medical imatinib mesylate oral 5 EA per 30 RECONSTITUTED 15 tablet 400 mg days) MG, 45 MG IMBRUVICA ORAL JAKAFI ORAL TABLET CAPSULE 140 MG, 70 6 PA 10 MG, 15 MG, 20 MG, 6 PA MG 25 MG, 5 MG IMBRUVICA ORAL JELMYTO SOLUTION PA; TABLET 140 MG, 280 6 PA RECONSTITUTED 40 6 Specialty MG, 420 MG, 560 MG MG Medical IMLYGIC JEVTANA PA; INTRALESIONAL PA; INTRAVENOUS 6 Specialty SUSPENSION 1000000 6 Specialty SOLUTION 60 Medical UNIT/ML, 100000000 Medical MG/1.5ML UNIT/ML KADCYLA INFUGEM INTRAVENOUS PA; INTRAVENOUS SOLUTION 6 Specialty SOLUTION 1200-0.9 RECONSTITUTED 100 Medical MG/120ML-%, 1300-0.9 MG, 160 MG MG/130ML-%, 1400-0.9 KANJINTI MG/140ML-%, 1500-0.9 PA; INTRAVENOUS PA; MG/150ML-%, 1600-0.9 6 Specialty SOLUTION 5 Specialty MG/160ML-%, 1700-0.9 Medical RECONSTITUTED 150 Medical MG/170ML-%, 1800-0.9 MG, 420 MG MG/180ML-%, 1900-0.9 KEYTRUDA PA; MG/190ML-%, 2000-0.9 INTRAVENOUS 6 Specialty MG/200ML-%, 2200-0.9 SOLUTION 100 MG/4ML Medical MG/220ML-%

INLYTA ORAL TABLET 6 PA 1 MG, 5 MG

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 57 Drug Drug Drug Name Notes Drug Name Notes Tier Tier KHAPZORY LENVIMA (20 MG DAILY PA; INTRAVENOUS DOSE) ORAL CAPSULE 6 PA SOLUTION 6 Specialty THERAPY PACK 2 X 10 RECONSTITUTED 175 Medical MG MG, 300 MG LENVIMA (24 MG DAILY KISQALI (200 MG DOSE) ORAL CAPSULE 6 PA DOSE) ORAL TABLET THERAPY PACK 2 X 10 6 PA THERAPY PACK 200 MG & 4 MG MG LENVIMA (4 MG DAILY KISQALI (400 MG DOSE) ORAL CAPSULE 6 PA DOSE) ORAL TABLET 6 PA THERAPY PACK 4 MG THERAPY PACK 200 LENVIMA (8 MG DAILY MG DOSE) ORAL CAPSULE 6 PA KISQALI (600 MG THERAPY PACK 2 X 4 DOSE) ORAL TABLET 6 PA MG THERAPY PACK 200 letrozole oral tablet 2.5 2 MG mg KOSELUGO ORAL leucovorin calcium CAPSULE 10 MG, 25 6 PA injection solution 100 GM PA MG mg/10ml, 500 mg/50ml KYPROLIS leucovorin calcium INTRAVENOUS PA; injection solution SOLUTION 6 Specialty reconstituted 100 mg, GM PA RECONSTITUTED 10 Medical 200 mg, 350 mg, 50 mg, MG, 30 MG, 60 MG 500 mg LARTRUVO PA; leucovorin calcium oral INTRAVENOUS 6 Specialty tablet 10 mg, 15 mg, 25 2 SOLUTION 190 Medical mg, 5 mg MG/19ML, 500 MG/50ML LEUKERAN ORAL 3 PA LENVIMA (10 MG DAILY TABLET 2 MG DOSE) ORAL CAPSULE 6 PA THERAPY PACK 10 MG levoleucovorin calcium PA; intravenous solution 6 Specialty LENVIMA (12 MG DAILY reconstituted 50 mg Medical DOSE) ORAL CAPSULE 6 PA THERAPY PACK 3 X 4 levoleucovorin calcium pf PA; MG intravenous solution 175 6 Specialty mg/17.5ml, 250 mg/25ml Medical LENVIMA (14 MG DAILY DOSE) ORAL CAPSULE LIBTAYO PA; 6 PA THERAPY PACK 10 & 4 INTRAVENOUS 6 Specialty MG SOLUTION 350 MG/7ML Medical LENVIMA (18 MG DAILY LONSURF ORAL TABLET 15-6.14 MG, 20- 6 PA DOSE) ORAL CAPSULE 6 PA THERAPY PACK 10 MG 8.19 MG & 2 X 4 MG

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 58 Drug Drug Drug Name Notes Drug Name Notes Tier Tier LORBRENA ORAL mitoxantrone hcl 6 PA Specialty TABLET 100 MG, 25 MG intravenous concentrate 6 LUMOXITI 20 mg/10ml, 25 Medical PA; mg/12.5ml, 30 mg/15ml INTRAVENOUS 6 Specialty SOLUTION Medical mutamycin intravenous RECONSTITUTED 1 MG solution reconstituted 20 GM PA LYNPARZA ORAL mg, 40 mg, 5 mg TABLET 100 MG, 150 6 PA MVASI INTRAVENOUS PA; MG SOLUTION 100 5 Specialty LYSODREN ORAL MG/4ML, 400 MG/16ML Medical 3 PA TABLET 500 MG MYLERAN ORAL 3 MARQIBO TABLET 2 MG PA; INTRAVENOUS 6 Specialty MYLOTARG PA; SUSPENSION 5 Medical INTRAVENOUS MG/31ML SOLUTION 6 Specialty RECONSTITUTED 4.5 Medical MATULANE ORAL 6 PA CAPSULE 50 MG MG NAVELBINE MEKINIST ORAL PA; 6 PA INTRAVENOUS TABLET 0.5 MG, 2 MG 6 Specialty SOLUTION 10 MG/ML, MEKTOVI ORAL Medical 6 PA 50 MG/5ML TABLET 15 MG NERLYNX ORAL 6 PA melphalan hcl PA; TABLET 40 MG intravenous solution 6 Specialty reconstituted 50 mg Medical NEXAVAR ORAL 6 PA TABLET 200 MG melphalan oral tablet 2 2 PA mg Brand NILANDRON ORAL 3 penalty mercaptopurine oral 2 TABLET 150 MG applies tablet 50 mg nilutamide oral tablet 150 Specialty 2 mesna intravenous 6 mg solution 100 mg/ml Medical NINLARO ORAL MESNEX Specialty CAPSULE 2.3 MG, 3 6 PA INTRAVENOUS 6 Medical MG, 4 MG SOLUTION 100 MG/ML NIPENT INTRAVENOUS MESNEX ORAL TABLET PA; 3 SOLUTION 400 MG 6 Specialty RECONSTITUTED 10 Medical mitomycin intravenous MG solution reconstituted 20 GM PA NUBEQA ORAL TABLET 6 PA mg, 40 mg, 5 mg 300 MG MITOMYCIN ODOMZO ORAL 6 PA INTRAVESICAL GM CAPSULE 200 MG SOLUTION PREFILLED SYRINGE 20 MG/40ML

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 59 Drug Drug Drug Name Notes Drug Name Notes Tier Tier OGIVRI INTRAVENOUS PEMAZYRE ORAL PA; 6 PA SOLUTION 5 Specialty TABLET 13.5 MG, 4.5 RECONSTITUTED 150 Medical MG, 9 MG MG, 420 MG PERJETA PA; PA; INTRAVENOUS 6 Specialty 6 Specialty ONCASPAR INJECTION SOLUTION 420 Medical SOLUTION 750 UNIT/ML Medical MG/14ML ONIVYDE PHESGO PA; INTRAVENOUS SUBCUTANEOUS PA; 6 Specialty INJECTABLE 43 SOLUTION 60-60-2000 6 Specialty Medical MG/10ML MG-MG-U/ML, 80-40- Medical ONTRUZANT 2000 MG-MG-U/ML INTRAVENOUS PA; PHOTOFRIN SOLUTION 5 Specialty INTRAVENOUS PA; RECONSTITUTED 150 Medical SOLUTION 6 Specialty MG, 420 MG RECONSTITUTED 75 Medical OPDIVO MG INTRAVENOUS PA; PIQRAY (200 MG DAILY SOLUTION 100 6 Specialty DOSE) ORAL TABLET 6 PA MG/10ML, 240 Medical THERAPY PACK 200 MG/24ML, 40 MG/4ML MG oxaliplatin intravenous PIQRAY (250 MG DAILY GM PA solution 100 mg/20ml, 50 DOSE) ORAL TABLET 6 PA mg/10ml THERAPY PACK 200 & oxaliplatin intravenous 50 MG solution reconstituted GM PA PIQRAY (300 MG DAILY 100 mg, 50 mg DOSE) ORAL TABLET 6 PA paclitaxel PACK 2 X PA; concentrate 100 150 MG 6 Specialty mg/16.7ml, 150 mg/25ml, POLIVY INTRAVENOUS Medical PA; 30 mg/5ml, 300 mg/50ml SOLUTION 6 Specialty PADCEV RECONSTITUTED 140 Medical INTRAVENOUS PA; MG SOLUTION 6 Specialty POMALYST ORAL RECONSTITUTED 20 Medical CAPSULE 1 MG, 2 MG, 6 PA MG, 30 MG 3 MG, 4 MG PANRETIN EXTERNAL PORTRAZZA 4 PA; GEL 0.1 % INTRAVENOUS 6 Specialty SOLUTION 800 paraplatin intravenous Medical solution 150 mg/15ml, MG/50ML GM PA 450 mg/45ml, 50 mg/5ml, POTELIGEO PA; 600 mg/60ml INTRAVENOUS 6 Specialty SOLUTION 20 MG/5ML Medical

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 60 Drug Drug Drug Name Notes Drug Name Notes Tier Tier PROLEUKIN RYDAPT ORAL 6 PA INTRAVENOUS PA; CAPSULE 25 MG SOLUTION 6 Specialty SARCLISA PA; RECONSTITUTED Medical INTRAVENOUS 22000000 UNIT 6 Specialty SOLUTION 100 Medical PURIXAN ORAL MG/5ML, 500 MG/25ML 4 SUSPENSION 2000 SPRYCEL ORAL MG/100ML TABLET 100 MG, 140 6 PA QINLOCK ORAL MG, 20 MG, 50 MG, 70 6 PA TABLET 50 MG MG, 80 MG QUADRAMET STIVARGA ORAL 6 PA Specialty INTRAVENOUS 6 TABLET 40 MG SOLUTION 1850 Medical STRONTIUM MBQ/ML CHLORIDE SR-89 GM RETEVMO ORAL INTRAVENOUS CAPSULE 40 MG, 80 6 PA SOLUTION 1 MCI/ML MG SUTENT ORAL REVLIMID ORAL CAPSULE 12.5 MG, 25 6 PA CAPSULE 10 MG, 15 MG, 37.5 MG, 50 MG 6 PA MG, 2.5 MG, 20 MG, 25 SYLVANT MG, 5 MG INTRAVENOUS PA; RITUXAN HYCELA SOLUTION 6 Specialty SUBCUTANEOUS PA; RECONSTITUTED 100 Medical SOLUTION 1400-23400 6 Specialty MG, 400 MG MG -UT/11.7ML, 1600- Medical SYNRIBO 26800 MG -UT/13.4ML SUBCUTANEOUS 6 PA RITUXAN PA; SOLUTION INTRAVENOUS RECONSTITUTED 3.5 6 Specialty SOLUTION 100 MG Medical MG/10ML, 500 MG/50ML TABLOID ORAL TABLET 3 ROMIDEPSIN 40 MG PA; INTRAVENOUS 6 Specialty TABRECTA ORAL SOLUTION 27.5 Medical TABLET 150 MG, 200 6 PA MG/5.5ML MG ROZLYTREK ORAL TAFINLAR ORAL CAPSULE 100 MG, 200 6 PA CAPSULE 50 MG, 75 6 PA MG MG RUBRACA ORAL TAGRISSO ORAL 6 PA TABLET 200 MG, 250 6 PA TABLET 40 MG, 80 MG MG, 300 MG TALZENNA ORAL RUXIENCE PA; CAPSULE 0.25 MG, 1 6 PA INTRAVENOUS 5 Specialty MG SOLUTION 100 Medical MG/10ML, 500 MG/50ML Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 61 Drug Drug Drug Name Notes Drug Name Notes Tier Tier tamoxifen citrate oral THALOMID ORAL PV tablet 10 mg, 20 mg CAPSULE 100 MG, 150 6 PA TARCEVA ORAL MG, 200 MG, 50 MG TABLET 100 MG, 150 6 PA thiotepa injection solution PA; MG, 25 MG reconstituted 100 mg, 15 6 Specialty mg Medical TARGRETIN EXTERNAL 6 PA GEL 1 % TIBSOVO ORAL 6 PA TARGRETIN ORAL TABLET 250 MG 6 PA CAPSULE 75 MG toposar intravenous TASIGNA ORAL PA; QL (30 solution 1 gm/50ml, 100 GM PA CAPSULE 150 MG, 200 5 EA per 30 mg/5ml, 500 mg/25ml MG, 50 MG days) topotecan hcl TAXOTERE intravenous solution 4 GM PA PA; mg/4ml INTRAVENOUS 6 Specialty CONCENTRATE 80 Medical topotecan hcl MG/4ML intravenous solution GM PA reconstituted 4 mg TAZVERIK ORAL 6 PA TABLET 200 MG toremifene citrate oral 2 PA tablet 60 mg TECENTRIQ PA; INTRAVENOUS TOTECT 6 Specialty SOLUTION 1200 INTRAVENOUS Medical MG/20ML, 840 MG/14ML SOLUTION GM TEMODAR RECONSTITUTED 500 INTRAVENOUS PA; MG SOLUTION 6 Specialty TRAZIMERA RECONSTITUTED 100 Medical INTRAVENOUS PA; MG SOLUTION 5 Specialty Medical TEMODAR ORAL RECONSTITUTED 420 CAPSULE 100 MG, 140 MG 6 PA MG, 180 MG, 20 MG, TREANDA 250 MG, 5 MG INTRAVENOUS PA; temozolomide oral SOLUTION 6 Specialty capsule 100 mg, 140 mg, RECONSTITUTED 100 Medical 5 PA 180 mg, 20 mg, 250 mg, MG, 25 MG 5 mg tretinoin oral capsule 10 2 PA PA; mg teniposide intravenous 6 Specialty TRODELVY solution 10 mg/ml Medical INTRAVENOUS PA; SOLUTION 6 Specialty TEPADINA INJECTION PA; SOLUTION RECONSTITUTED 180 Medical 6 Specialty RECONSTITUTED 100 MG Medical MG, 15 MG

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 62 Drug Drug Drug Name Notes Drug Name Notes Tier Tier TRUXIMA VIDAZA INJECTION PA; PA; INTRAVENOUS 6 Specialty SUSPENSION 6 Specialty SOLUTION 100 Medical RECONSTITUTED 100 Medical MG/10ML, 500 MG/50ML MG PA; TUKYSA ORAL TABLET 6 PA vinblastine sulfate 150 MG, 50 MG intravenous solution 1 6 Specialty mg/ml Medical TURALIO ORAL 6 PA CAPSULE 200 MG vincristine sulfate TYKERB ORAL TABLET intravenous solution 1 GM PA 6 PA 250 MG mg/ml UNITUXIN vinorelbine tartrate PA; PA; INTRAVENOUS intravenous solution 10 6 Specialty 6 Specialty mg/ml, 50 mg/5ml Medical SOLUTION 17.5 Medical MG/5ML VITRAKVI ORAL CAPSULE 100 MG, 25 6 PA VALCHLOR EXTERNAL 6 PA GEL 0.016 % MG PA; VITRAKVI ORAL 6 PA valrubicin intravesical 6 Specialty SOLUTION 20 MG/ML solution 40 mg/ml Medical VIZIMPRO ORAL VALSTAR PA; TABLET 15 MG, 30 MG, 6 PA INTRAVESICAL 6 Specialty 45 MG SOLUTION 40 MG/ML Medical VORAXAZE VECTIBIX INTRAVENOUS PA; INTRAVENOUS SOLUTION GM 6 Specialty RECONSTITUTED 1000 SOLUTION 100 Medical MG/5ML, 400 MG/20ML UNIT VELCADE INJECTION VOTRIENT ORAL 6 PA PA; TABLET 200 MG SOLUTION 6 Specialty RECONSTITUTED 3.5 VYXEOS Medical MG INTRAVENOUS PA; VENCLEXTA ORAL SUSPENSION 6 Specialty TABLET 10 MG, 100 6 PA RECONSTITUTED 44- Medical MG, 50 MG 100 MG VENCLEXTA STARTING XALKORI ORAL CAPSULE 200 MG, 250 6 PA PACK ORAL TABLET 6 PA THERAPY PACK 10 & MG 50 & 100 MG XELODA ORAL TABLET 6 PA VERZENIO ORAL 150 MG, 500 MG TABLET 100 MG, 150 6 PA XOFIGO PA; MG, 200 MG, 50 MG INTRAVENOUS 6 Specialty SOLUTION 30 MCCI/ML Medical XOSPATA ORAL 6 PA TABLET 40 MG

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 63 Drug Drug Drug Name Notes Drug Name Notes Tier Tier XPOVIO (100 MG ONCE ZALTRAP PA; WEEKLY) ORAL 6 PA INTRAVENOUS 6 Specialty TABLET THERAPY SOLUTION 100 Medical PACK 20 MG MG/4ML, 200 MG/8ML

XPOVIO (40 MG ONCE ZANOSAR PA; WEEKLY) ORAL 6 PA INTRAVENOUS 6 Specialty TABLET THERAPY SOLUTION Medical PACK 20 MG RECONSTITUTED 1 GM XPOVIO (40 MG TWICE ZEJULA ORAL 6 PA WEEKLY) ORAL CAPSULE 100 MG 6 PA TABLET THERAPY ZELBORAF ORAL 6 PA PACK 20 MG TABLET 240 MG XPOVIO (60 MG ONCE ZEPZELCA PA; WEEKLY) ORAL 6 PA INTRAVENOUS TABLET THERAPY 6 Specialty SOLUTION Medical PACK 20 MG RECONSTITUTED 4 MG XPOVIO (60 MG TWICE ZEVALIN Y-90 Specialty WEEKLY) ORAL INTRAVENOUS KIT 3.2 6 6 PA Medical TABLET THERAPY MG/2ML PACK 20 MG ZIRABEV PA; XPOVIO (80 MG ONCE INTRAVENOUS WEEKLY) ORAL 5 Specialty 6 PA SOLUTION 100 Medical TABLET THERAPY MG/4ML, 400 MG/16ML PACK 20 MG ZOLINZA ORAL 6 PA XPOVIO (80 MG TWICE CAPSULE 100 MG WEEKLY) ORAL 6 PA TABLET THERAPY ZYDELIG ORAL TABLET 6 PA PACK 20 MG 100 MG, 150 MG XTANDI ORAL ZYKADIA ORAL TABLET 6 PA 6 PA CAPSULE 40 MG 150 MG ZYTIGA ORAL TABLET YERVOY 6 PA PA; 250 MG, 500 MG INTRAVENOUS 6 Specialty Antiparasitics SOLUTION 200 Medical MG/40ML, 50 MG/10ML albendazole oral tablet 2 YESCARTA PA; 200 mg INTRAVENOUS 6 Specialty Brand SUSPENSION Medical ALBENZA ORAL 4 penalty YONDELIS TABLET 200 MG applies PA; INTRAVENOUS 6 Specialty ALINIA ORAL SOLUTION Medical SUSPENSION 4 RECONSTITUTED 1 MG RECONSTITUTED 100 MG/5ML YONSA ORAL TABLET 6 PA 125 MG

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 64 Drug Drug Drug Name Notes Drug Name Notes Tier Tier ALINIA ORAL TABLET MALARONE ORAL Brand 4 500 MG TABLET 250-100 MG, 4 penalty 62.5-25 MG applies ARAKODA ORAL 3 TABLET 100 MG malathion external lotion 2 0.5 % atovaquone oral 2 suspension 750 mg/5ml mefloquine hcl oral tablet 2 atovaquone-proguanil hcl 250 mg oral tablet 250-100 mg, 2 MEPRON ORAL Brand 62.5-25 mg SUSPENSION 750 3 penalty BENZNIDAZOLE ORAL MG/5ML applies TABLET 100 MG, 12.5 4 Brand MG NATROBA EXTERNAL 4 penalty Brand SUSPENSION 0.9 % applies BILTRICIDE ORAL 4 penalty NEBUPENT TABLET 600 MG applies INHALATION Brand chloroquine phosphate SOLUTION 4 penalty oral tablet 250 mg, 500 2 RECONSTITUTED 300 applies mg MG Brand COARTEM ORAL 3 TABLET 20-120 MG OVIDE EXTERNAL 4 penalty LOTION 0.5 % applies crotan external lotion 10 2 PA % PENTAM INJECTION SOLUTION DARAPRIM ORAL GM 6 RECONSTITUTED 300 TABLET 25 MG MG Brand pentamidine isethionate ELIMITE EXTERNAL 4 penalty inhalation solution 2 CREAM 5 % applies reconstituted 300 mg EMVERM ORAL pentamidine isethionate TABLET CHEWABLE 4 injection solution GM 100 MG reconstituted 300 mg hydroxychloroquine permethrin external 2 2 sulfate oral tablet 200 mg cream 5 % IMPAVIDO ORAL 4 Brand CAPSULE 50 MG PLAQUENIL ORAL 4 penalty ivermectin oral tablet 3 TABLET 200 MG applies 2 mg praziquantel oral tablet 2 QL (2 EA 600 mg KRINTAFEL ORAL 3 per 30 primaquine phosphate 2 TABLET 150 MG days) oral tablet 26.3 mg lindane external pyrimethamine oral tablet 2 6 shampoo 1 % 25 mg

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 65 Drug Drug Drug Name Notes Drug Name Notes Tier Tier PYRIMETHAMINE- bromocriptine mesylate 2 LEUCOVORIN ORAL oral tablet 2.5 mg CAPSULE 12.5-2.5 MG, 4 carbidopa oral tablet 25 2 25-10 MG, 25-5 MG, 50- mg 10 MG, 50-20 MG, 50-25 MG, 75-25 MG carbidopa-levodopa er oral tablet extended Brand 2 release 25-100 mg, 50- QUALAQUIN ORAL 4 penalty 200 mg CAPSULE 324 MG applies carbidopa-levodopa oral sulfate oral 2 tablet 10-100 mg, 25-100 2 capsule 324 mg mg, 25-250 mg SKLICE EXTERNAL 4 carbidopa-levodopa oral LOTION 0.5 % tablet dispersible 10-100 2 spinosad external 2 mg, 25-100 mg, 25-250 suspension 0.9 % mg Brand carbidopa-levodopa- STROMECTOL ORAL 4 penalty entacapone oral tablet TABLET 3 MG applies 12.5-50-200 mg, 18.75- sulfurated lime external 75-200 mg, 25-100-200 2 2 solution mg, 31.25-125-200 mg, 37.5-150-200 mg, 50- Antiparkinson Agents 200-200 mg amantadine hcl oral 2 COGENTIN INJECTION GM capsule 100 mg SOLUTION 1 MG/ML amantadine hcl oral 2 Brand syrup 50 mg/5ml COMTAN ORAL 4 penalty applies amantadine hcl oral 2 TABLET 200 MG tablet 100 mg entacapone oral tablet 2 APOKYN 200 mg SUBCUTANEOUS INBRIJA INHALATION 6 PA 6 PA SOLUTION CARTRIDGE CAPSULE 42 MG 30 MG/3ML KYNMOBI SUBLINGUAL Brand FILM 10 MG, 15 MG, 20 6 PA 4 penalty AZILECT ORAL TABLET MG, 25 MG, 30 MG 0.5 MG, 1 MG applies Brand benztropine mesylate GM LODOSYN ORAL 4 penalty injection solution 1 mg/ml TABLET 25 MG applies benztropine mesylate MIRAPEX ER ORAL oral tablet 0.5 mg, 1 mg, 1 TABLET EXTENDED Brand 2 mg RELEASE 24 HOUR 4 penalty bromocriptine mesylate 0.375 MG, 0.75 MG, 1.5 2 applies oral capsule 5 mg MG, 2.25 MG, 3 MG, 3.75 MG, 4.5 MG

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 66 Drug Drug Drug Name Notes Drug Name Notes Tier Tier MIRAPEX ORAL Brand RYTARY ORAL TABLET 0.125 MG, 0.5 4 penalty CAPSULE EXTENDED MG, 0.75 MG, 1 MG applies RELEASE 23.75-95 MG, 4 NEUPRO 36.25-145 MG, 48.75- TRANSDERMAL PATCH 195 MG, 61.25-245 MG 24 HOUR 1 MG/24HR, 2 4 selegiline hcl oral 2 MG/24HR, 3 MG/24HR, capsule 5 mg 4 MG/24HR, 6 selegiline hcl oral tablet 5 2 MG/24HR, 8 MG/24HR mg NOURIANZ ORAL 6 PA SINEMET ORAL Brand TABLET 20 MG, 40 MG TABLET 10-100 MG, 25- 4 penalty Brand 100 MG, 25-250 MG applies PARLODEL ORAL 4 penalty Brand CAPSULE 5 MG applies STALEVO 100 ORAL 4 penalty Brand TABLET 25-100-200 MG applies PARLODEL ORAL 4 penalty STALEVO 125 ORAL Brand applies TABLET 2.5 MG TABLET 31.25-125-200 4 penalty pramipexole MG applies dihydrochloride er oral STALEVO 150 ORAL Brand tablet extended release 2 TABLET 37.5-150-200 4 penalty 24 hour 0.375 mg, 0.75 MG applies mg, 1.5 mg, 2.25 mg, 3 mg, 3.75 mg, 4.5 mg Brand STALEVO 200 ORAL 4 penalty pramipexole TABLET 50-200-200 MG applies dihydrochloride oral tablet 0.125 mg, 0.25 mg, 2 Brand 0.5 mg, 0.75 mg, 1 mg, STALEVO 50 ORAL 4 penalty 1.5 mg TABLET 12.5-50-200 MG applies rasagiline mesylate oral STALEVO 75 ORAL Brand 2 tablet 0.5 mg, 1 mg TABLET 18.75-75-200 4 penalty MG applies REQUIP XL ORAL Brand TABLET EXTENDED Brand 4 penalty TASMAR ORAL TABLET 4 penalty RELEASE 24 HOUR 12 applies MG, 6 MG 100 MG applies ropinirole hcl er oral tolcapone oral tablet 100 2 mg tablet extended release 2 24 hour 12 mg, 2 mg, 4 trihexyphenidyl hcl oral 2 mg, 6 mg, 8 mg solution 0.4 mg/ml ropinirole hcl oral tablet trihexyphenidyl hcl oral 2 0.25 mg, 0.5 mg, 1 mg, 2 2 tablet 2 mg, 5 mg mg, 3 mg, 4 mg, 5 mg XADAGO ORAL TABLET 4 100 MG, 50 MG

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 67 Drug Drug Drug Name Notes Drug Name Notes Tier Tier ZELAPAR ORAL INTEGRILIN TABLET DISPERSIBLE 4 INTRAVENOUS 1.25 MG SOLUTION 20 GM Antiplatelets MG/10ML, 200 MG/100ML, 75 AGGRASTAT MG/100ML INTRAVENOUS GM CONCENTRATE 3.75 KENGREAL MG/15ML INTRAVENOUS SOLUTION GM AGGRASTAT RECONSTITUTED 50 INTRAVENOUS MG SOLUTION 12.5-0.9 GM MG/250ML-%, 5-0.9 Brand MG/100ML-% PLAVIX ORAL TABLET 4 penalty 75 MG applies AGGRENOX ORAL Brand CAPSULE EXTENDED prasugrel hcl oral tablet 2 4 penalty 10 mg, 5 mg RELEASE 12 HOUR 25- applies 200 MG ZONTIVITY ORAL 4 aspirin-dipyridamole er TABLET 2.08 MG oral capsule extended Antipsychotics - Drugs 2 release 12 hour 25-200 for Mood Disorders mg ABILIFY MAINTENA BRILINTA ORAL 3 INTRAMUSCULAR 5 TABLET 60 MG, 90 MG PREFILLED SYRINGE 300 MG, 400 MG CABLIVI INJECTION KIT 6 PA 11 MG ABILIFY MAINTENA INTRAMUSCULAR cilostazol oral tablet 100 2 mg, 50 mg SUSPENSION 5 RECONSTITUTED ER clopidogrel bisulfate oral 2 300 MG, 400 MG tablet 300 mg Brand clopidogrel bisulfate oral 1 penalty tablet 75 mg ABILIFY ORAL TABLET 4 applies; QL dipyridamole oral tablet 10 MG, 15 MG, 2 MG, 20 (30 EA per 2 25 mg, 50 mg, 75 mg MG, 30 MG, 5 MG 30 days) Brand ADASUVE INHALATION 4 penalty EFFIENT ORAL TABLET AEROSOL POWDER GM 10 MG, 5 MG applies BREATH ACTIVATED 10 eptifibatide intravenous MG GM aripiprazole oral solution solution 20 mg/10ml, 200 2 mg/100ml, 75 mg/100ml 1 mg/ml aripiprazole oral tablet 10 QL (30 EA mg, 15 mg, 2 mg, 20 mg, 2 per 30 30 mg, 5 mg days)

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 68 Drug Drug Drug Name Notes Drug Name Notes Tier Tier QL (30 EA fluphenazine hcl oral 2 aripiprazole oral tablet 2 per 30 concentrate 5 mg/ml dispersible 10 mg, 15 mg days) fluphenazine hcl oral 2 ARISTADA INITIO elixir 2.5 mg/5ml INTRAMUSCULAR 5 fluphenazine hcl oral PREFILLED SYRINGE tablet 1 mg, 10 mg, 2.5 2 675 MG/2.4ML mg, 5 mg ARISTADA GEODON INTRAMUSCULAR INTRAMUSCULAR PREFILLED SYRINGE SOLUTION GM 1064 MG/3.9ML, 441 5 RECONSTITUTED 20 MG/1.6ML, 662 MG MG/2.4ML, 882 MG/3.2ML GEODON ORAL Brand CAPSULE 20 MG, 40 4 penalty CAPLYTA ORAL 4 PA MG, 60 MG, 80 MG applies CAPSULE 42 MG HALDOL DECANOATE chlorpromazine hcl INTRAMUSCULAR GM injection solution 25 GM SOLUTION 100 MG/ML, mg/ml, 50 mg/2ml 50 MG/ML chlorpromazine hcl oral HALDOL INJECTION GM tablet 10 mg, 100 mg, 2 SOLUTION 5 MG/ML 200 mg, 25 mg, 50 mg haloperidol decanoate clozapine oral tablet 100 intramuscular solution GM mg, 200 mg, 25 mg, 50 2 100 mg/ml, 50 mg/ml mg haloperidol lactate GM clozapine oral tablet injection solution 5 mg/ml dispersible 100 mg, 12.5 2 mg, 150 mg, 200 mg, 25 haloperidol lactate oral 2 mg concentrate 2 mg/ml CLOZARIL ORAL Brand haloperidol oral tablet 0.5 1 TABLET 100 MG, 200 4 penalty mg, 1 mg, 2 mg, 5 mg MG, 25 MG, 50 MG applies haloperidol oral tablet 10 2 FANAPT ORAL TABLET mg, 20 mg 1 MG, 10 MG, 12 MG, 2 4 PA Brand MG, 4 MG, 6 MG, 8 MG INVEGA ORAL TABLET penalty FANAPT TITRATION EXTENDED RELEASE 4 applies; QL PACK ORAL TABLET 1 4 PA 24 HOUR 1.5 MG, 3 MG, (30 EA per & 2 & 4 & 6 MG 6 MG, 9 MG 30 days) fluphenazine decanoate injection solution 25 GM mg/ml fluphenazine hcl injection GM solution 2.5 mg/ml

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 69 Drug Drug Drug Name Notes Drug Name Notes Tier Tier INVEGA SUSTENNA PERSERIS INTRAMUSCULAR SUBCUTANEOUS 5 SUSPENSION PREFILLED SYRINGE PREFILLED SYRINGE 5 120 MG, 90 MG 117 MG/0.75ML, 156 pimozide oral tablet 1 2 MG/ML, 234 MG/1.5ML, mg, 2 mg 39 MG/0.25ML, 78 MG/0.5ML quetiapine fumarate er oral tablet extended QL (30 EA INVEGA TRINZA release 24 hour 150 mg, 2 per 30 INTRAMUSCULAR 200 mg, 300 mg, 400 days) SUSPENSION mg, 50 mg PREFILLED SYRINGE 5 273 MG/0.875ML, 410 quetiapine fumarate oral MG/1.315ML, 546 tablet 100 mg, 200 mg, 2 MG/1.75ML, 819 25 mg, 300 mg, 400 mg, MG/2.625ML 50 mg LATUDA ORAL TABLET REXULTI ORAL TABLET 120 MG, 20 MG, 40 MG, 4 PA 0.25 MG, 0.5 MG, 1 MG, 4 PA 60 MG, 80 MG 2 MG, 3 MG, 4 MG loxapine succinate oral RISPERDAL CONSTA capsule 10 mg, 25 mg, 5 2 INTRAMUSCULAR SUSPENSION mg, 50 mg 5 RECONSTITUTED ER molindone hcl oral tablet 2 12.5 MG, 25 MG, 37.5 10 mg, 25 mg, 5 mg MG, 50 MG NUPLAZID ORAL 4 PA Brand CAPSULE 34 MG RISPERDAL ORAL 4 penalty NUPLAZID ORAL SOLUTION 1 MG/ML applies 4 PA TABLET 10 MG RISPERDAL ORAL Brand olanzapine intramuscular TABLET 0.5 MG, 1 MG, 4 penalty solution reconstituted 10 GM 2 MG, 3 MG, 4 MG applies mg risperidone oral solution 2 olanzapine oral tablet 10 1 mg/ml mg, 15 mg, 2.5 mg, 20 2 risperidone oral tablet mg, 5 mg, 7.5 mg 0.25 mg, 0.5 mg, 1 mg, 2 1 olanzapine oral tablet mg, 3 mg, 4 mg dispersible 10 mg, 15 2 risperidone oral tablet mg, 20 mg, 5 mg dispersible 0.25 mg, 0.5 2 paliperidone er oral tablet mg, 1 mg, 2 mg, 3 mg, 4 QL (30 EA extended release 24 hour mg 2 per 30 1.5 mg, 3 mg, 6 mg, 9 days) SAPHRIS SUBLINGUAL mg TABLET SUBLINGUAL 4 PA 10 MG, 2.5 MG, 5 MG

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 70 Drug Drug Drug Name Notes Drug Name Notes Tier Tier SECUADO ZYPREXA ORAL Brand TRANSDERMAL PATCH TABLET 10 MG, 15 MG, 4 penalty 4 PA 24 HOUR 3.8 MG/24HR, 2.5 MG, 20 MG, 5 MG, applies 5.7 MG/24HR, 7.6 7.5 MG MG/24HR ZYPREXA RELPREVV SEROQUEL ORAL Brand INTRAMUSCULAR TABLET 100 MG, 200 SUSPENSION 5 4 penalty MG, 25 MG, 300 MG, RECONSTITUTED 210 applies 400 MG, 50 MG MG, 300 MG, 405 MG SEROQUEL XR ORAL Brand ZYPREXA ZYDIS ORAL Brand penalty TABLET EXTENDED TABLET DISPERSIBLE 4 penalty 4 applies; QL RELEASE 24 HOUR 150 10 MG, 15 MG, 20 MG, 5 applies MG, 200 MG, 300 MG, (30 EA per MG 400 MG, 50 MG 30 days) Antivirals thioridazine hcl oral tablet abacavir sulfate oral 2 10 mg, 100 mg, 25 mg, 2 solution 20 mg/ml 50 mg abacavir sulfate oral thiothixene oral capsule 1 2 2 tablet 300 mg mg, 10 mg, 2 mg, 5 mg abacavir sulfate- trifluoperazine hcl oral lamivudine oral tablet 2 tablet 1 mg, 10 mg, 2 mg, 2 600-300 mg 5 mg abacavir-lamivudine- VERSACLOZ ORAL zidovudine oral tablet 2 SUSPENSION 50 4 300-150-300 mg MG/ML acyclovir external cream 2 VRAYLAR ORAL 5 % CAPSULE 1.5 MG, 3 4 PA QL (15 GM MG, 4.5 MG, 6 MG acyclovir external 2 per 30 VRAYLAR ORAL ointment 5 % days) CAPSULE THERAPY 4 PA acyclovir oral capsule PACK 1.5 & 3 MG 2 200 mg ziprasidone hcl oral acyclovir oral suspension capsule 20 mg, 40 mg, 2 2 60 mg, 80 mg 200 mg/5ml acyclovir oral tablet 400 ziprasidone mesylate 2 intramuscular solution GM mg, 800 mg reconstituted 20 mg acyclovir sodium GM ZYPREXA intravenous solution 50 INTRAMUSCULAR mg/ml GM SOLUTION adefovir dipivoxil oral 2 PA RECONSTITUTED 10 tablet 10 mg MG APTIVUS ORAL 3 CAPSULE 250 MG

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 71 Drug Drug Drug Name Notes Drug Name Notes Tier Tier APTIVUS ORAL DOVATO ORAL TABLET 3 6 SOLUTION 100 MG/ML 50-300 MG atazanavir sulfate oral EDURANT ORAL 4 capsule 150 mg, 200 mg, 2 TABLET 25 MG 300 mg efavirenz oral capsule 2 ATRIPLA ORAL TABLET 6 200 mg, 50 mg 600-200-300 MG efavirenz oral tablet 600 2 BARACLUDE ORAL mg 4 PA SOLUTION 0.05 MG/ML EMTRIVA ORAL 3 PA; Brand CAPSULE 200 MG BARACLUDE ORAL 4 penalty EMTRIVA ORAL 3 TABLET 0.5 MG, 1 MG applies SOLUTION 10 MG/ML BIKTARVY ORAL entecavir oral tablet 0.5 6 2 PA TABLET 50-200-25 MG mg, 1 mg cidofovir intravenous GM EPCLUSA ORAL 5 PA solution 75 mg/ml TABLET 400-100 MG CIMDUO ORAL TABLET 6 EPIVIR HBV ORAL 4 300-300 MG SOLUTION 5 MG/ML Brand Brand COMBIVIR ORAL 4 penalty EPIVIR HBV ORAL 4 penalty TABLET 150-300 MG applies TABLET 100 MG applies COMPLERA ORAL 6 Brand TABLET 200-25-300 MG EPIVIR ORAL 4 penalty CRIXIVAN ORAL SOLUTION 10 MG/ML applies CAPSULE 200 MG, 400 3 Brand MG EPIVIR ORAL TABLET 4 penalty CYTOVENE 150 MG, 300 MG applies INTRAVENOUS Brand SOLUTION GM EPZICOM ORAL 4 penalty RECONSTITUTED 500 TABLET 600-300 MG applies MG EVOTAZ ORAL TABLET 6 DELSTRIGO ORAL 300-150 MG TABLET 100-300-300 6 famciclovir oral tablet 125 MG 2 mg, 250 mg, 500 mg DENAVIR EXTERNAL 4 ST fosamprenavir calcium CREAM 1 % 2 oral tablet 700 mg DESCOVY ORAL 6 PV* TABLET 200-25 MG FOSCAVIR INTRAVENOUS GM didanosine oral capsule SOLUTION 6000 delayed release 200 mg, 2 MG/250ML 250 mg, 400 mg

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 72 Drug Drug Drug Name Notes Drug Name Notes Tier Tier FUZEON ISENTRESS HD ORAL 3 SUBCUTANEOUS TABLET 600 MG SOLUTION 6 ISENTRESS ORAL 3 RECONSTITUTED 90 PACKET 100 MG MG ISENTRESS ORAL 3 GANCICLOVIR TABLET 400 MG INTRAVENOUS GM SOLUTION 500 ISENTRESS ORAL MG/250ML TABLET CHEWABLE 3 100 MG, 25 MG ganciclovir sodium JULUCA ORAL TABLET intravenous solution 500 GM 6 mg/10ml 50-25 MG ganciclovir sodium KALETRA ORAL Brand intravenous solution GM SOLUTION 400-100 3 penalty reconstituted 500 mg MG/5ML applies GENVOYA ORAL KALETRA ORAL TABLET 150-150-200-10 6 TABLET 100-25 MG, 3 MG 200-50 MG HARVONI ORAL lamivudine oral solution 2 PACKET 33.75-150 MG, 5 PA 10 mg/ml 45-200 MG lamivudine oral tablet 2 HARVONI ORAL 100 mg, 150 mg, 300 mg TABLET 45-200 MG, 90- 5 PA lamivudine-zidovudine 2 400 MG oral tablet 150-300 mg PA; Brand LEDIPASVIR- HEPSERA ORAL 4 penalty SOFOSBUVIR ORAL 5 PA TABLET 10 MG applies TABLET 90-400 MG INTELENCE ORAL LEXIVA ORAL TABLET 100 MG, 200 4 SUSPENSION 50 4 MG, 25 MG MG/ML INTRON A INJECTION Brand PA; SOLUTION 10000000 4 penalty 6 Specialty LEXIVA ORAL TABLET applies UNIT/ML, 6000000 Medical 700 MG UNIT/ML lopinavir-ritonavir oral 2 INTRON A INJECTION solution 400-100 mg/5ml SOLUTION MAVYRET ORAL PA; 5 PA RECONSTITUTED 6 Specialty TABLET 100-40 MG 10000000 UNIT, Medical 18000000 UNIT, nevirapine er oral tablet 50000000 UNIT extended release 24 hour 2 100 mg, 400 mg INVIRASE ORAL 3 TABLET 500 MG nevirapine oral 2 suspension 50 mg/5ml

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 73 Drug Drug Drug Name Notes Drug Name Notes Tier Tier nevirapine oral tablet 200 PREZISTA ORAL 2 mg SUSPENSION 100 4 MG/ML NORVIR ORAL PACKET 4 100 MG PREZISTA ORAL TABLET 150 MG, 600 4 NORVIR ORAL 3 SOLUTION 80 MG/ML MG, 75 MG, 800 MG Brand RAPIVAB INTRAVENOUS NORVIR ORAL TABLET 3 penalty GM 100 MG applies SOLUTION 200 MG/20ML ODEFSEY ORAL 6 TABLET 200-25-25 MG RELENZA DISKHALER INHALATION AEROSOL QL (20 EA QL (20 EA POWDER BREATH 4 per 180 oseltamivir phosphate 2 per 180 ACTIVATED 5 days) oral capsule 30 mg days) MG/BLISTER oseltamivir phosphate QL (10 EA RETROVIR oral capsule 45 mg, 75 2 per 180 INTRAVENOUS GM mg days) SOLUTION 10 MG/ML oseltamivir phosphate QL (120 Brand oral suspension 2 ML per 180 RETROVIR ORAL 4 penalty reconstituted 6 mg/ml days) CAPSULE 100 MG applies PEGASYS PROCLICK Brand SUBCUTANEOUS 6 PA RETROVIR ORAL 4 penalty SOLUTION 180 SYRUP 50 MG/5ML applies MCG/0.5ML REYATAZ ORAL Brand PEGASYS CAPSULE 150 MG, 200 3 penalty SUBCUTANEOUS MG, 300 MG applies SOLUTION 180 6 PA REYATAZ ORAL MCG/0.5ML, 180 4 MCG/ML PACKET 50 MG PEGINTRON ribavirin inhalation PA; SUBCUTANEOUS KIT 5 PA solution reconstituted 6 6 Specialty 50 MCG/0.5ML gm Medical PIFELTRO ORAL ribavirin oral capsule 200 4 5 TABLET 100 MG mg PREVYMIS ribavirin oral tablet 200 5 PA; mg INTRAVENOUS 6 Specialty SOLUTION 240 Medical rimantadine hcl oral 2 MG/12ML, 480 MG/24ML tablet 100 mg

PREVYMIS ORAL ritonavir oral tablet 100 2 TABLET 240 MG, 480 6 PA mg MG PREZCOBIX ORAL 6 TABLET 800-150 MG Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 74 Drug Drug Drug Name Notes Drug Name Notes Tier Tier RUKOBIA ORAL Brand penalty TABLET EXTENDED 4 RELEASE 12 HOUR 600 TAMIFLU ORAL 4 applies; QL MG CAPSULE 45 MG, 75 (10 EA per MG 180 days) SELZENTRY ORAL 4 SOLUTION 20 MG/ML Brand penalty SELZENTRY ORAL TAMIFLU ORAL applies; QL TABLET 150 MG, 25 4 4 MG, 300 MG, 75 MG SUSPENSION (120 ML RECONSTITUTED 6 per 180 SOFOSBUVIR- MG/ML days) VELPATASVIR ORAL 5 PA TABLET 400-100 MG TEMIXYS ORAL 6 TABLET 300-300 MG SOVALDI ORAL PACKET 150 MG, 200 6 PA tenofovir disoproxil MG fumarate oral tablet 300 2 mg SOVALDI ORAL TIVICAY ORAL TABLET TABLET 200 MG, 400 6 PA 6 MG 10 MG, 25 MG, 50 MG stavudine oral capsule 15 TIVICAY PD ORAL mg, 20 mg, 30 mg, 40 2 TABLET SOLUBLE 5 6 mg MG STRIBILD ORAL TRIUMEQ ORAL 6 TABLET 150-150-200- 6 TABLET 600-50-300 MG 300 MG Brand SUSTIVA ORAL Brand TRIZIVIR ORAL TABLET 4 penalty CAPSULE 200 MG, 50 3 penalty 300-150-300 MG applies MG applies TROGARZO INTRAVENOUS Specialty Brand 6 SUSTIVA ORAL TABLET 3 penalty SOLUTION 200 Medical 600 MG applies MG/1.33ML SYMFI LO ORAL TRUVADA ORAL TABLET 100-150 MG, TABLET 400-300-300 6 6 PV* MG 133-200 MG, 167-250 MG, 200-300 MG SYMFI ORAL TABLET 6 600-300-300 MG TYBOST ORAL TABLET 4 ST 150 MG SYMTUZA ORAL TABLET 800-150-200-10 6 valacyclovir hcl oral 2 MG tablet 1 gm, 500 mg Brand VALCYTE ORAL SOLUTION penalty 6 4 applies; QL RECONSTITUTED 50 TAMIFLU ORAL (20 EA per MG/ML CAPSULE 30 MG 180 days)

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 75 Drug Drug Drug Name Notes Drug Name Notes Tier Tier VALCYTE ORAL XOFLUZA (40 MG 6 QL (2 EA TABLET 450 MG DOSE) ORAL TABLET 4 per 180 valganciclovir hcl oral THERAPY PACK 2 X 20 days) solution reconstituted 50 5 MG mg/ml XOFLUZA (80 MG QL (2 EA valganciclovir hcl oral DOSE) ORAL TABLET 4 per 180 5 THERAPY PACK 2 X 40 tablet 450 mg days) MG Brand ZEPATIER ORAL VALTREX ORAL 4 penalty 6 PA TABLET 1 GM, 500 MG applies TABLET 50-100 MG VEMLIDY ORAL Brand 5 PA TABLET 25 MG ZIAGEN ORAL 4 penalty SOLUTION 20 MG/ML applies VIEKIRA PAK ORAL TABLET THERAPY 6 PA Brand PACK 12.5-75-50 ZIAGEN ORAL TABLET 4 penalty 300 MG applies VIRACEPT ORAL TABLET 250 MG, 625 4 zidovudine oral capsule 2 MG 100 mg zidovudine oral syrup 50 VIRAMUNE ORAL Brand 2 SUSPENSION 50 4 penalty mg/5ml MG/5ML applies zidovudine oral tablet 2 Brand 300 mg VIRAMUNE ORAL 4 penalty Brand TABLET 200 MG applies ZOVIRAX EXTERNAL 3 penalty CREAM 5 % applies VIRAMUNE XR ORAL Brand Brand TABLET EXTENDED 4 penalty penalty RELEASE 24 HOUR 400 applies MG 3 applies; QL (15 GM per VIRAZOLE INHALATION PA; ZOVIRAX EXTERNAL SOLUTION 6 Specialty OINTMENT 5 % 30 days) RECONSTITUTED 6 GM Medical ZOVIRAX ORAL Brand VIREAD ORAL SUSPENSION 200 4 penalty 3 POWDER 40 MG/GM MG/5ML applies Anxiolytics - Drugs for VIREAD ORAL TABLET Anxiety 150 MG, 200 MG, 250 3 MG alprazolam er oral tablet Brand extended release 24 hour 2 VIREAD ORAL TABLET 3 penalty 0.5 mg, 1 mg, 2 mg, 3 300 MG applies mg alprazolam intensol oral VOSEVI ORAL TABLET 6 PA 2 400-100-100 MG concentrate 1 mg/ml

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 76 Drug Drug Drug Name Notes Drug Name Notes Tier Tier alprazolam oral tablet DIAZEPAM SOLUTION 5 0.25 mg, 0.5 mg, 1 mg, 2 2 MG/ML INJECTION 5 GM mg MG/ML alprazolam oral tablet Brand dispersible 0.25 mg, 0.5 2 ST DORAL ORAL TABLET 4 penalty mg, 1 mg, 2 mg 15 MG applies alprazolam xr oral tablet oral tablet 1 2 extended release 24 hour mg, 2 mg 2 0.5 mg, 1 mg, 2 mg, 3 Brand mg HALCION ORAL 4 penalty ATIVAN INJECTION TABLET 0.25 MG applies SOLUTION 2 MG/ML, 4 GM hcl MG/ML intramuscular solution 25 GM Brand mg/ml, 50 mg/ml ATIVAN ORAL TABLET 4 penalty hydroxyzine hcl oral 2 0.5 MG, 1 MG, 2 MG applies syrup 10 mg/5ml buspirone hcl oral tablet 1 hydroxyzine hcl oral 10 mg, 15 mg, 5 mg tablet 10 mg, 25 mg, 50 2 buspirone hcl oral tablet mg 2 30 mg, 7.5 mg hydroxyzine pamoate chlordiazepoxide hcl oral oral capsule 100 mg, 25 2 capsule 10 mg, 25 mg, 5 2 mg, 50 mg mg KLONOPIN ORAL 4 oral tablet 2 TABLET 0.5 MG, 1 MG, 0.5 mg, 1 mg, 2 mg 2 MG clonazepam oral tablet injection GM dispersible 0.125 mg, 2 solution 2 mg/ml, 4 0.25 mg, 0.5 mg, 1 mg, 2 mg/ml mg lorazepam intensol oral 2 clorazepate dipotassium concentrate 2 mg/ml oral tablet 15 mg, 3.75 2 lorazepam oral 2 mg, 7.5 mg concentrate 2 mg/ml diazepam intensol oral lorazepam oral tablet 0.5 2 2 concentrate 5 mg/ml mg, 1 mg, 2 mg diazepam oral oral tablet 2 2 concentrate 5 mg/ml 200 mg, 400 mg diazepam oral solution 5 2 hcl (pf) mg/5ml injection solution 10 GM diazepam oral tablet 10 2 mg/2ml, 2 mg/2ml, 5 mg, 2 mg, 5 mg mg/5ml, 5 mg/ml diazepam solution 5 GM mg/ml injection 5 mg/ml

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 77 Drug Drug Drug Name Notes Drug Name Notes Tier Tier midazolam hcl injection XANAX ORAL TABLET Brand solution 10 mg/10ml, 10 0.25 MG, 0.5 MG, 1 MG, 4 penalty mg/2ml, 2 mg/2ml, 25 GM 2 MG applies mg/5ml, 5 mg/5ml, 5 XANAX XR ORAL mg/ml, 50 mg/10ml Brand TABLET EXTENDED 4 penalty MIDAZOLAM HCL RELEASE 24 HOUR 0.5 applies INTRAVENOUS MG, 1 MG, 2 MG, 3 MG GM SOLUTION 150 Bipolar Agents - Drugs MG/30ML for Mood Disorders MIDAZOLAM HCL- EQUETRO ORAL SODIUM CHLORIDE CAPSULE EXTENDED 4 INTRAVENOUS RELEASE 12 HOUR 100 SOLUTION 100-0.8 GM MG, 200 MG, 300 MG MG/100ML-%, 50-0.8 MG/50ML-%, 50-0.9 lithium carbonate er oral 2 MG/50ML-% tablet extended release 300 mg, 450 mg MIDAZOLAM HCL- SODIUM CHLORIDE lithium carbonate oral 1 INTRAVENOUS capsule 150 mg, 300 mg, 600 mg SOLUTION PREFILLED GM lithium carbonate oral SYRINGE 2-0.9 2 MG/2ML-%, 5-0.9 tablet 300 mg MG/5ML-%, 55-0.9 lithium oral solution 8 2 MG/55ML-% meq/5ml MIDAZOLAM-SODIUM LITHOBID ORAL CHLORIDE TABLET EXTENDED 4 INTRAVENOUS GM RELEASE 300 MG SOLUTION 50-0.9 Blood Products / MG/50ML-% Modifiers / Volume oxazepam oral capsule 2 Expanders - Drugs for 10 mg, 15 mg, 30 mg Bleeding Disorders oral tablet 15 2 ADVATE mg INTRAVENOUS Brand SOLUTION 4 penalty Specialty TRANXENE-T ORAL RECONSTITUTED 1000 6 TABLET 7.5 MG applies UNIT, 1500 UNIT, 2000 Medical oral tablet UNIT, 250 UNIT, 3000 2 0.125 mg, 0.25 mg UNIT, 4000 UNIT, 500 UNIT Brand VALIUM ORAL TABLET 4 penalty 10 MG, 2 MG, 5 MG applies VISTARIL ORAL Brand CAPSULE 25 MG, 50 4 penalty MG applies

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 78 Drug Drug Drug Name Notes Drug Name Notes Tier Tier ADYNOVATE Brand INTRAVENOUS AMICAR ORAL TABLET 4 penalty applies SOLUTION Specialty 1000 MG, 500 MG 6 RECONSTITUTED 1000 Medical aminocaproic acid UNIT, 1500 UNIT, 2000 intravenous solution 250 GM UNIT, 250 UNIT, 500 mg/ml UNIT, 750 UNIT aminocaproic acid oral 2 ADYNOVATE solution 0.25 gm/ml INTRAVENOUS PA; aminocaproic acid oral SOLUTION 6 Specialty 2 RECONSTITUTED 3000 Medical tablet 1000 mg, 500 mg UNIT anagrelide hcl oral 2 AFSTYLA capsule 0.5 mg, 1 mg INTRAVENOUS KIT ARANESP (ALBUMIN Specialty 1000 UNIT, 1500 UNIT, 6 FREE) INJECTION 2000 UNIT, 250 UNIT, Medical SOLUTION 100 2500 UNIT, 3000 UNIT, MCG/ML, 200 MCG/ML, 6 500 UNIT 25 MCG/ML, 300 Brand MCG/ML, 40 MCG/ML, AGRYLIN ORAL 4 penalty 60 MCG/ML CAPSULE 0.5 MG applies ARANESP (ALBUMIN ALPHANATE/VWF FREE) INJECTION COMPLEX/HUMAN SOLUTION PREFILLED INTRAVENOUS SYRINGE 10 SOLUTION Specialty MCG/0.4ML, 100 6 RECONSTITUTED 1000 Medical MCG/0.5ML, 150 6 UNIT, 1500 UNIT, 2000 MCG/0.3ML, 200 UNIT, 250 UNIT, 500 MCG/0.4ML, 25 UNIT MCG/0.42ML, 300 MCG/0.6ML, 40 ALPHANINE SD MCG/0.4ML, 500 INTRAVENOUS MCG/ML, 60 MCG/0.3ML Specialty SOLUTION 6 RECONSTITUTED 1000 Medical BENEFIX UNIT, 1500 UNIT, 500 INTRAVENOUS KIT Specialty 6 UNIT 1000 UNIT, 2000 UNIT, Medical 250 UNIT, 3000 UNIT, ALPROLIX 500 UNIT INTRAVENOUS CEPROTIN SOLUTION Specialty 6 INTRAVENOUS RECONSTITUTED 1000 Medical UNIT, 2000 UNIT, 250 SOLUTION GM UNIT, 3000 UNIT, 4000 RECONSTITUTED 1000 UNIT, 500 UNIT UNIT, 500 UNIT Brand AMICAR ORAL 4 penalty SOLUTION 0.25 GM/ML applies

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 79 Drug Drug Drug Name Notes Drug Name Notes Tier Tier COAGADEX FULPHILA INTRAVENOUS Specialty SUBCUTANEOUS 5 6 SOLUTION Medical SOLUTION PREFILLED RECONSTITUTED 250 SYRINGE 6 MG/0.6ML UNIT, 500 UNIT GRANIX CORIFACT Specialty SUBCUTANEOUS INTRAVENOUS KIT 6 SOLUTION 300 5 Medical 1000-1600 UNIT MCG/ML, 480 CYKLOKAPRON MCG/1.6ML INTRAVENOUS GRANIX GM SOLUTION 1000 SUBCUTANEOUS MG/10ML SOLUTION PREFILLED 5 SYRINGE 300 DOPTELET ORAL 6 PA TABLET 20 MG MCG/0.5ML, 480 MCG/0.8ML ELOCTATE INTRAVENOUS HEMLIBRA SOLUTION SUBCUTANEOUS RECONSTITUTED 1000 SOLUTION 105 GM Specialty UNIT, 1500 UNIT, 2000 6 MG/0.7ML, 150 MG/ML, Medical UNIT, 250 UNIT, 3000 30 MG/ML, 60 MG/0.4ML UNIT, 4000 UNIT, 500 HEMOFIL M UNIT, 5000 UNIT, 6000 INTRAVENOUS Specialty UNIT, 750 UNIT SOLUTION 6 EPOGEN INJECTION RECONSTITUTED 1000 Medical SOLUTION 10000 UNIT, 1700 UNIT, 250 UNIT/ML, 2000 UNIT/ML, 6 UNIT, 500 UNIT 20000 UNIT/ML, 3000 HESPAN UNIT/ML, 4000 UNIT/ML INTRAVENOUS GM ESPEROCT SOLUTION 6-0.9 % INTRAVENOUS hetastarch-nacl GM SOLUTION Specialty intravenous solution 6- 6 RECONSTITUTED 1000 Medical 0.9 % UNIT, 1500 UNIT, 2000 HEXTEND UNIT, 3000 UNIT, 500 INTRAVENOUS GM UNIT SOLUTION 6 % FEIBA INTRAVENOUS HUMATE-P SOLUTION Specialty INTRAVENOUS RECONSTITUTED 1000 6 SOLUTION Specialty Medical 6 UNIT, 2500 UNIT, 500 RECONSTITUTED 1000- Medical UNIT 2400 UNIT, 250-600 FIBRYGA UNIT, 500-1200 UNIT INTRAVENOUS GM SOLUTION RECONSTITUTED

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 80 Drug Drug Drug Name Notes Drug Name Notes Tier Tier IDELVION LEUKINE INJECTION Specialty INTRAVENOUS SOLUTION 6 Medical SOLUTION Specialty RECONSTITUTED 250 6 RECONSTITUTED 1000 Medical MCG UNIT, 2000 UNIT, 250 LMD IN D5W UNIT, 3500 UNIT, 500 INTRAVENOUS GM UNIT SOLUTION 10-5 % IXINITY INTRAVENOUS LMD IN NACL SOLUTION INTRAVENOUS GM Specialty RECONSTITUTED 1000 6 SOLUTION 10-0.9 % UNIT, 1500 UNIT, 2000 Medical UNIT, 250 UNIT, 3000 Brand UNIT, 500 UNIT LYSTEDA ORAL 3 penalty TABLET 650 MG applies JIVI INTRAVENOUS MIRCERA INJECTION SOLUTION Specialty RECONSTITUTED 1000 6 SOLUTION PREFILLED Medical UNIT, 2000 UNIT, 3000 SYRINGE 100 UNIT, 500 UNIT MCG/0.3ML, 150 MCG/0.3ML, 200 4 KCENTRA MCG/0.3ML, 30 INTRAVENOUS KIT GM MCG/0.3ML, 50 1000 UNIT, 500 UNIT MCG/0.3ML, 75 KOATE INTRAVENOUS MCG/0.3ML SOLUTION Specialty MONONINE RECONSTITUTED 1000 6 Medical INTRAVENOUS Specialty UNIT, 250 UNIT, 500 6 SOLUTION Medical UNIT RECONSTITUTED 1000 KOATE-DVI UNIT INTRAVENOUS MONSELS FERRIC SOLUTION Specialty 6 SUBSULFATE 4 RECONSTITUTED 1000 Medical EXTERNAL SOLUTION UNIT, 250 UNIT, 500 UNIT MOZOBIL PA; SUBCUTANEOUS KOGENATE FS 6 Specialty SOLUTION 24 Medical INTRAVENOUS KIT Specialty MG/1.2ML 1000 UNIT, 2000 UNIT, 6 Medical 250 UNIT, 3000 UNIT, MULPLETA ORAL 6 PA 500 UNIT TABLET 3 MG KOVALTRY NEULASTA ONPRO SUBCUTANEOUS INTRAVENOUS 6 PREFILLED SYRINGE SOLUTION Specialty 6 KIT 6 MG/0.6ML RECONSTITUTED 1000 Medical UNIT, 2000 UNIT, 250 NEULASTA UNIT, 3000 UNIT, 500 SUBCUTANEOUS 6 UNIT SOLUTION PREFILLED SYRINGE 6 MG/0.6ML

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 81 Drug Drug Drug Name Notes Drug Name Notes Tier Tier NEUPOGEN INJECTION NUWIQ INTRAVENOUS SOLUTION 300 6 SOLUTION MCG/ML, 480 RECONSTITUTED 1000 Specialty 6 MCG/1.6ML UNIT, 2000 UNIT, 250 Medical NEUPOGEN INJECTION UNIT, 2500 UNIT, 3000 SOLUTION PREFILLED UNIT, 4000 UNIT, 500 SYRINGE 300 6 UNIT MCG/0.5ML, 480 OBIZUR INTRAVENOUS MCG/0.8ML SOLUTION Specialty 6 NIVESTYM INJECTION RECONSTITUTED 500 Medical UNIT SOLUTION 300 5 MCG/ML, 480 PANHEMATIN MCG/1.6ML INTRAVENOUS NIVESTYM INJECTION SOLUTION GM SOLUTION PREFILLED RECONSTITUTED 350 SYRINGE 300 5 MG MCG/0.5ML, 480 PROCRIT INJECTION MCG/0.8ML SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, NOVOEIGHT 6 INTRAVENOUS 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML, SOLUTION Specialty 6 40000 UNIT/ML RECONSTITUTED 1000 Medical UNIT, 1500 UNIT, 2000 PROFILNINE UNIT, 250 UNIT, 3000 INTRAVENOUS UNIT, 500 UNIT SOLUTION Specialty 6 NOVOSEVEN RT RECONSTITUTED 1000 Medical INTRAVENOUS UNIT, 1500 UNIT, 500 Specialty SOLUTION 6 UNIT Medical RECONSTITUTED 1 PROFILNINE SD MG, 2 MG, 5 MG, 8 MG INTRAVENOUS Specialty 6 NPLATE SOLUTION Medical SUBCUTANEOUS RECONSTITUTED 1000 PA; UNIT, 1500 UNIT SOLUTION 6 Specialty RECONSTITUTED 125 Medical PROMACTA ORAL 6 PA MCG, 250 MCG, 500 PACKET 25 MG MCG PROMACTA ORAL NUWIQ INTRAVENOUS TABLET 12.5 MG, 25 6 PA KIT 1000 UNIT, 2000 MG, 50 MG, 75 MG Specialty 6 UNIT, 250 UNIT, 2500 Medical protamine sulfate UNIT, 3000 UNIT, 4000 intravenous solution 10 GM UNIT, 500 UNIT mg/ml

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 82 Drug Drug Drug Name Notes Drug Name Notes Tier Tier REBINYN SOLIRIS PA; INTRAVENOUS INTRAVENOUS 6 Specialty SOLUTION GM SOLUTION 300 Medical RECONSTITUTED 1000 MG/30ML UNIT, 2000 UNIT, 500 TAVALISSE ORAL UNIT TABLET 100 MG, 150 6 PA REBLOZYL MG SUBCUTANEOUS PA; THROMBIN-JMI SOLUTION 6 Specialty EPISTAXIS EXTERNAL 4 RECONSTITUTED 25 Medical KIT 5000 UNIT MG, 75 MG THROMBIN-JMI RECOMBINATE EXTERNAL KIT 20000 4 INTRAVENOUS UNIT, 5000 UNIT SOLUTION Specialty THROMBIN-JMI RECONSTITUTED 1241- 6 1800 UNIT, 1801-2400 Medical EXTERNAL SOLUTION 4 UNIT, 220-400 UNIT, RECONSTITUTED 401-800 UNIT, 801-1240 20000 UNIT, 5000 UNIT UNIT THROMBOGEN RECOTHROM EXTERNAL KIT 10000 4 UNIT EXTERNAL SOLUTION 4 RECONSTITUTED THROMBOGEN 20000 UNIT, 5000 UNIT EXTERNAL SOLUTION 4 RECOTHROM SPRAY RECONSTITUTED 1000 KIT EXTERNAL UNIT, 10000 UNIT SOLUTION 4 tranexamic acid RECONSTITUTED intravenous solution GM 20000 UNIT 1000 mg/10ml RETACRIT INJECTION tranexamic acid oral 2 SOLUTION 10000 tablet 650 mg UNIT/ML, 2000 UNIT/ML, 5 TRANEXAMIC ACID- 3000 UNIT/ML, 4000 NACL INTRAVENOUS GM UNIT/ML, 40000 SOLUTION 1000-0.7 UNIT/ML MG/100ML-% RIASTAP TRETTEN INTRAVENOUS GM INTRAVENOUS Specialty SOLUTION 6 SOLUTION Medical RECONSTITUTED RECONSTITUTED 2000- RIXUBIS 3125 UNIT INTRAVENOUS UDENYCA SOLUTION Specialty SUBCUTANEOUS 6 5 RECONSTITUTED 1000 Medical SOLUTION PREFILLED UNIT, 2000 UNIT, 250 SYRINGE 6 MG/0.6ML UNIT, 3000 UNIT, 500 UNIT

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 83 Drug Drug Drug Name Notes Drug Name Notes Tier Tier ULTOMIRIS ADENOCARD PA; GM INTRAVENOUS 6 Specialty INTRAVENOUS SOLUTION 300 Medical SOLUTION 6 MG/2ML MG/30ML adenosine intravenous VONVENDI solution 12 mg/4ml, 6 GM INTRAVENOUS Specialty mg/2ml SOLUTION 6 Medical AKOVAZ RECONSTITUTED 1300 INTRAVENOUS GM UNIT, 650 UNIT SOLUTION 50 MG/ML WILATE INTRAVENOUS Specialty Brand 6 KIT 1000-1000 UNIT, Medical ALDACTAZIDE ORAL 4 penalty 500-500 UNIT TABLET 25-25 MG applies XYNTHA ALDACTAZIDE ORAL Specialty 3 INTRAVENOUS KIT 6 TABLET 50-50 MG 1000 UNIT, 2000 UNIT, Medical 250 UNIT, 500 UNIT ALDACTONE ORAL Brand TABLET 100 MG, 25 4 penalty XYNTHA SOLOFUSE MG, 50 MG applies INTRAVENOUS KIT Specialty 1000 UNIT, 2000 UNIT, 6 aliskiren fumarate oral Medical 2 250 UNIT, 3000 UNIT, tablet 150 mg, 300 mg 500 UNIT alprostadil injection GM ZARXIO INJECTION solution 500 mcg/ml SOLUTION PREFILLED ALTACE ORAL Brand SYRINGE 300 5 CAPSULE 1.25 MG, 10 4 penalty MCG/0.5ML, 480 MG, 2.5 MG, 5 MG applies MCG/0.8ML ALTOPREV ORAL ZIEXTENZO TABLET EXTENDED 4 PA SUBCUTANEOUS 5 RELEASE 24 HOUR 20 SOLUTION PREFILLED MG, 40 MG, 60 MG SYRINGE 6 MG/0.6ML amiloride hcl oral tablet 5 2 Cardiovascular Agents mg - Drugs for Heart and amiloride- Circulation Conditions hydrochlorothiazide oral 2 ACCUPRIL ORAL Brand tablet 5-50 mg 4 penalty TABLET 10 MG, 20 MG, amiodarone hcl 40 MG, 5 MG applies intravenous solution 150 GM ACCURETIC ORAL Brand mg/3ml, 450 mg/9ml, 900 TABLET 10-12.5 MG, 20- 4 penalty mg/18ml applies 12.5 MG, 20-25 MG amiodarone hcl oral acebutolol hcl oral 2 2 tablet 100 mg, 200 mg, capsule 200 mg, 400 mg 400 mg acetazolamide sodium amlodipine besylate oral injection solution GM tablet 10 mg, 2.5 mg, 5 1 reconstituted 500 mg mg Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 84 Drug Drug Drug Name Notes Drug Name Notes Tier Tier amlodipine besylate- atorvastatin calcium oral 2 benazepril hcl oral tablet 40 mg, 80 mg capsule 10-20 mg, 10-40 2 AVALIDE ORAL TABLET Brand mg, 2.5-10 mg, 5-10 mg, 150-12.5 MG, 300-12.5 4 penalty 5-20 mg, 5-40 mg MG applies amlodipine besylate- Brand valsartan oral tablet 10- 2 AVAPRO ORAL TABLET 4 penalty 160 mg, 10-320 mg, 5- 150 MG, 300 MG, 75 MG applies 160 mg, 5-320 mg AZOR ORAL TABLET Brand amlodipine-atorvastatin 10-20 MG, 10-40 MG, 5- 3 penalty oral tablet 10-10 mg, 10- 20 MG, 5-40 MG applies 20 mg, 10-40 mg, 10-80 mg, 2.5-10 mg, 2.5-20 2 benazepril hcl oral tablet mg, 2.5-40 mg, 5-10 mg, 10 mg, 20 mg, 40 mg, 5 1 5-20 mg, 5-40 mg, 5-80 mg mg benazepril- amlodipine-olmesartan hydrochlorothiazide oral oral tablet 10-20 mg, 10- 2 tablet 10-12.5 mg, 20- 2 40 mg, 5-20 mg, 5-40 mg 12.5 mg, 20-25 mg, 5- 6.25 mg amlodipine-valsartan- hctz oral tablet 10-160- BENICAR HCT ORAL Brand 12.5 mg, 10-160-25 mg, 2 TABLET 20-12.5 MG, 40- 3 penalty 10-320-25 mg, 5-160- 12.5 MG, 40-25 MG applies 12.5 mg, 5-160-25 mg BENICAR ORAL Brand ANTARA ORAL TABLET 20 MG, 40 MG, 3 penalty CAPSULE 30 MG, 90 4 5 MG applies MG BETAPACE AF ORAL Brand ASCLERA TABLET 120 MG, 160 4 penalty INTRAVENOUS GM MG, 80 MG applies SOLUTION 0.5 %, 1 % BETAPACE ORAL Brand ATACAND HCT ORAL Brand TABLET 120 MG, 160 4 penalty TABLET 16-12.5 MG, 32- 4 penalty MG, 80 MG applies 12.5 MG, 32-25 MG applies betaxolol hcl oral tablet 2 ATACAND ORAL Brand 10 mg, 20 mg TABLET 16 MG, 32 MG, 4 penalty BIDIL ORAL TABLET 20- 4 4 MG, 8 MG applies 37.5 MG atenolol oral tablet 100 2 BIORPHEN mg, 25 mg, 50 mg INTRAVENOUS GM atenolol-chlorthalidone SOLUTION 0.5 MG/5ML oral tablet 100-25 mg, 2 bisoprolol fumarate oral 2 50-25 mg tablet 10 mg, 5 mg atorvastatin calcium oral 2 PV* tablet 10 mg, 20 mg

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 85 Drug Drug Drug Name Notes Drug Name Notes Tier Tier bisoprolol- candesartan cilexetil-hctz 2 hydrochlorothiazide oral 1 oral tablet 16-12.5 mg, tablet 10-6.25 mg, 2.5- 32-12.5 mg, 32-25 mg 6.25 mg, 5-6.25 mg captopril oral tablet 100 BREVIBLOC IN NACL mg, 12.5 mg, 25 mg, 50 2 INTRAVENOUS mg GM SOLUTION 2000 captopril- MG/100ML, 2500 hydrochlorothiazide oral 2 MG/250ML tablet 25-15 mg, 25-25 BREVIBLOC mg, 50-15 mg, 50-25 mg INTRAVENOUS GM CARDENE IV SOLUTION 100 INTRAVENOUS MG/10ML SOLUTION 20-0.86 GM BREVIBLOC PREMIXED MG/200ML-%, 20-4.8 DS INTRAVENOUS GM MG/200ML-%, 40-0.83 SOLUTION 2000 MG/200ML-% MG/100ML CARDIZEM CD ORAL BREVIBLOC PREMIXED CAPSULE EXTENDED Brand INTRAVENOUS RELEASE 24 HOUR 120 4 penalty GM SOLUTION 2500 MG, 180 MG, 240 MG, applies MG/250ML 300 MG bumetanide injection GM CARDIZEM CD ORAL Brand solution 0.25 mg/ml CAPSULE EXTENDED 3 penalty RELEASE 24 HOUR 360 bumetanide oral tablet 2 applies 0.5 mg, 1 mg, 2 mg MG Brand CARDIZEM LA ORAL TABLET EXTENDED BUMEX ORAL TABLET 4 penalty 4 0.5 MG, 1 MG, 2 MG applies RELEASE 24 HOUR 120 MG BYSTOLIC ORAL TABLET 10 MG, 2.5 MG, 3 CARDIZEM LA ORAL 20 MG, 5 MG TABLET EXTENDED Brand RELEASE 24 HOUR 180 4 penalty CADUET ORAL TABLET MG, 240 MG, 300 MG, applies 10-10 MG, 10-20 MG, Brand 360 MG, 420 MG 10-40 MG, 10-80 MG, 5- 4 penalty 10 MG, 5-20 MG, 5-40 applies CARDIZEM ORAL Brand 4 penalty MG, 5-80 MG TABLET 120 MG, 30 MG, 60 MG applies CALAN SR ORAL Brand TABLET EXTENDED CARDURA ORAL Brand 4 penalty RELEASE 120 MG, 180 TABLET 1 MG, 2 MG, 4 4 penalty applies MG, 240 MG MG, 8 MG applies candesartan cilexetil oral cartia xt oral capsule tablet 16 mg, 32 mg, 4 2 extended release 24 hour 2 mg, 8 mg 120 mg, 180 mg, 240 mg, 300 mg

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 86 Drug Drug Drug Name Notes Drug Name Notes Tier Tier carvedilol oral tablet 12.5 clonidine transdermal 1 mg, 25 mg, 3.125 mg, patch weekly 0.1 2 6.25 mg mg/24hr, 0.2 mg/24hr, carvedilol phosphate er 0.3 mg/24hr oral capsule extended 2 colesevelam hcl oral 2 release 24 hour 10 mg, packet 3.75 gm 20 mg, 40 mg, 80 mg colesevelam hcl oral 2 CATAPRES ORAL Brand tablet 625 mg TABLET 0.1 MG, 0.2 4 penalty Brand MG, 0.3 MG applies COLESTID FLAVORED 4 penalty CATAPRES-TTS-1 Brand ORAL GRANULES 5 GM applies TRANSDERMAL PATCH 4 penalty Brand WEEKLY 0.1 MG/24HR applies COLESTID FLAVORED 4 penalty CATAPRES-TTS-2 Brand ORAL PACKET 5 GM applies TRANSDERMAL PATCH 4 penalty Brand WEEKLY 0.2 MG/24HR applies COLESTID ORAL 4 penalty CATAPRES-TTS-3 Brand GRANULES 5 GM applies TRANSDERMAL PATCH 4 penalty Brand WEEKLY 0.3 MG/24HR applies COLESTID ORAL 4 penalty chlorothiazide oral tablet PACKET 5 GM applies 2 250 mg, 500 mg Brand chlorothiazide sodium COLESTID ORAL 4 penalty intravenous solution GM TABLET 1 GM applies reconstituted 500 mg colestipol hcl oral 2 chlorthalidone oral tablet 2 granules 5 gm 25 mg, 50 mg colestipol hcl oral packet 2 cholestyramine light oral 2 5 gm packet 4 gm colestipol hcl oral tablet 1 2 cholestyramine light oral 2 gm powder 4 gm/dose COREG CR ORAL cholestyramine oral CAPSULE EXTENDED Brand 2 packet 4 gm RELEASE 24 HOUR 10 4 penalty cholestyramine oral MG, 20 MG, 40 MG, 80 applies 2 powder 4 gm/dose MG CLEVIPREX COREG ORAL TABLET Brand 12.5 MG, 25 MG, 3.125 4 penalty INTRAVENOUS GM EMULSION 25 MG, 6.25 MG applies MG/50ML, 50 MG/100ML CORGARD ORAL Brand clonidine hcl oral tablet TABLET 20 MG, 40 MG, 4 penalty 2 applies 0.1 mg, 0.2 mg, 0.3 mg 80 MG CORLANOR ORAL 4 PA SOLUTION 5 MG/5ML

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 87 Drug Drug Drug Name Notes Drug Name Notes Tier Tier CORLANOR ORAL diltiazem hcl er coated 4 PA TABLET 5 MG, 7.5 MG beads oral capsule CORLOPAM extended release 24 hour 2 120 mg, 180 mg, 240 INTRAVENOUS GM SOLUTION 10 MG/ML, mg, 300 mg, 360 mg 20 MG/2ML diltiazem hcl er coated CORVERT beads oral tablet INTRAVENOUS GM extended release 24 hour 2 SOLUTION 1 MG/10ML 180 mg, 240 mg, 300 mg, 360 mg, 420 mg Brand COZAAR ORAL TABLET 4 penalty diltiazem hcl er oral 100 MG, 25 MG, 50 MG applies capsule extended 2 release 12 hour 120 mg, CRESTOR ORAL Brand 60 mg, 90 mg TABLET 10 MG, 20 MG, 4 penalty 40 MG, 5 MG applies diltiazem hcl intravenous solution 125 mg/25ml, 25 GM DEMSER ORAL 4 mg/5ml, 50 mg/10ml CAPSULE 250 MG diltiazem hcl intravenous PA; Brand solution reconstituted GM penalty 100 mg 4 applies; QL DIBENZYLINE ORAL (14 EA per diltiazem hcl oral tablet CAPSULE 10 MG 30 days) 120 mg, 30 mg, 60 mg, 2 90 mg digitek oral tablet 125 2 mcg, 250 mcg DILTIAZEM HCL- SODIUM CHLORIDE digox oral tablet 125 2 INTRAVENOUS GM mcg, 250 mcg SOLUTION 125-0.7 MG/125ML-%, 125-0.9 digoxin injection solution GM 0.25 mg/ml MG/125ML-% dilt-xr oral capsule digoxin oral solution 0.05 2 mg/ml extended release 24 hour 2 digoxin oral tablet 125 120 mg, 180 mg, 240 mg 2 mcg, 250 mcg DIOVAN HCT ORAL Brand DILATRATE-SR ORAL TABLET 160-12.5 MG, 4 penalty CAPSULE EXTENDED 3 160-25 MG, 320-12.5 applies RELEASE 40 MG MG, 320-25 MG, 80-12.5 MG diltiazem hcl er beads Brand oral capsule extended DIOVAN ORAL TABLET 4 penalty release 24 hour 120 mg, 2 160 MG, 320 MG, 40 applies 180 mg, 240 mg, 300 MG, 80 MG mg, 360 mg, 420 mg disopyramide phosphate oral capsule 100 mg, 150 2 mg

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 88 Drug Drug Drug Name Notes Drug Name Notes Tier Tier DIURIL ORAL EMERPHED SUSPENSION 250 4 INTRAVENOUS GM MG/5ML SOLUTION 5 MG/ML dobutamine hcl enalapril maleate oral intravenous solution 250 GM tablet 10 mg, 2.5 mg, 20 2 mg/20ml mg, 5 mg dobutamine in d5w enalaprilat intravenous GM intravenous solution 1-5 injectable 1.25 mg/ml GM mg/ml-%, 2 mg/ml, 4-5 enalapril- mg/ml-% hydrochlorothiazide oral 2 dofetilide oral capsule tablet 10-25 mg, 5-12.5 125 mcg, 250 mcg, 500 2 mg mcg ENTRESTO ORAL dopamine hcl TABLET 24-26 MG, 49- 4 intravenous solution 40 GM 51 MG, 97-103 MG mg/ml EPANED ORAL 4 dopamine in d5w SOLUTION 1 MG/ML intravenous solution 0.8- GM EPHEDRINE SULFATE 5 mg/ml-%, 1.6-5 mg/ml- (PRESSORS) %, 3.2-5 mg/ml-% INJECTION SOLUTION GM doxazosin mesylate oral PREFILLED SYRINGE tablet 1 mg, 2 mg, 4 mg, 2 25 MG/5ML, 50 MG/5ML 8 mg ephedrine sulfate DUTOPROL ORAL injection solution 50 GM TABLET EXTENDED mg/ml RELEASE 24 HOUR 4 ephedrine sulfate 100-12.5 MG, 25-12.5 intravenous solution 50 GM MG, 50-12.5 MG mg/ml Brand EPHEDRINE SULFATE DYAZIDE ORAL 4 penalty INTRAVENOUS GM CAPSULE 37.5-25 MG applies SOLUTION PREFILLED DYRENIUM ORAL Brand SYRINGE 25 MG/5ML CAPSULE 100 MG, 50 4 penalty EPINEPHRINE HCL- MG applies DEXTROSE GM EDARBI ORAL TABLET 4 ST INTRAVENOUS 40 MG, 80 MG SOLUTION 4-5 EDARBYCLOR ORAL MG/250ML-% TABLET 40-12.5 MG, 40- 4 ST EPINEPHRINE HCL- 25 MG NACL INTRAVENOUS GM Brand SOLUTION 8-0.9 EDECRIN ORAL 4 penalty MG/250ML-% TABLET 25 MG applies epinephrine pf injection GM solution 1 mg/ml

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 89 Drug Drug Drug Name Notes Drug Name Notes Tier Tier epinephrine solution EXFORGE HCT ORAL Brand prefilled syringe 1 GM TABLET 10-160-12.5 mg/10ml injection 1 MG, 10-160-25 MG, 10- 4 penalty mg/10ml 320-25 MG, 5-160-12.5 applies EPINEPHRINE MG, 5-160-25 MG SOLUTION PREFILLED GM EXFORGE ORAL Brand SYRINGE 1 MG/10ML TABLET 10-160 MG, 10- 4 penalty INJECTION 1 MG/10ML 320 MG, 5-160 MG, 5- applies EPINEPHRINE- 320 MG DEXTROSE EZALLOR SPRINKLE GM INTRAVENOUS ORAL CAPSULE 4 PA SOLUTION 2-5 SPRINKLE 10 MG, 20 MG/250ML-% MG, 40 MG, 5 MG

EPINEPHRINE-NACL ezetimibe oral tablet 10 2 INTRAVENOUS GM mg SOLUTION 2-0.9 ezetimibe-simvastatin MG/250ML-% oral tablet 10-10 mg, 10- 2 EPINEPHRINE-NACL 20 mg, 10-40 mg, 10-80 INTRAVENOUS mg SOLUTION PREFILLED GM felodipine er oral tablet SYRINGE 1-0.9 extended release 24 hour 2 MG/10ML-% 10 mg, 2.5 mg, 5 mg eplerenone oral tablet 25 2 fenofibrate micronized mg, 50 mg oral capsule 130 mg, 134 2 EQUAPAX/ATORVASTA mg, 200 mg, 43 mg, 67 TIN/COQ10 ORAL 4 mg THERAPY PACK 20 & fenofibrate oral capsule 100 MG 134 mg, 150 mg, 200 2 esmolol hcl intravenous mg, 50 mg, 67 mg GM solution 100 mg/10ml fenofibrate oral tablet 145 ESMOLOL HCL mg, 160 mg, 48 mg, 54 2 INTRAVENOUS mg SOLUTION 2000 GM fenofibric acid oral MG/100ML, 2500 capsule delayed release 2 MG/250ML 135 mg, 45 mg esmolol hcl-sodium fenofibric acid oral tablet chloride intravenous 2 GM 105 mg solution 2000 mg/100ml, 2500 mg/250ml FIBRICOR ORAL 4 TABLET 105 MG, 35 MG ethacrynate sodium intravenous solution GM flecainide acetate oral reconstituted 50 mg tablet 100 mg, 150 mg, 2 50 mg ethacrynic acid oral tablet 2 25 mg Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 90 Drug Drug Drug Name Notes Drug Name Notes Tier Tier fluvastatin sodium er oral indapamide oral tablet 2 tablet extended release 2 PA 1.25 mg, 2.5 mg 24 hour 80 mg INDERAL LA ORAL Brand fluvastatin sodium oral 2 CAPSULE EXTENDED capsule 20 mg, 40 mg RELEASE 24 HOUR 120 4 penalty fosinopril sodium oral MG, 160 MG, 60 MG, 80 applies tablet 10 mg, 20 mg, 40 2 MG mg INDERAL XL ORAL CAPSULE EXTENDED fosinopril sodium-hctz 4 oral tablet 10-12.5 mg, 2 RELEASE 24 HOUR 120 20-12.5 mg MG, 80 MG FUROSEMIDE IN INNOPRAN XL ORAL SODIUM CHLORIDE CAPSULE EXTENDED 4 INTRAVENOUS GM RELEASE 24 HOUR 120 SOLUTION 100-0.9 MG, 80 MG MG/100ML-% Brand INSPRA ORAL TABLET 4 penalty furosemide injection GM solution 10 mg/ml 25 MG, 50 MG applies furosemide oral solution irbesartan oral tablet 150 2 2 10 mg/ml, 8 mg/ml mg, 300 mg, 75 mg furosemide oral tablet 20 irbesartan- 1 mg, 40 mg, 80 mg hydrochlorothiazide oral 2 tablet 150-12.5 mg, 300- gemfibrozil oral tablet 2 12.5 mg 600 mg isoproterenol hcl injection GM guanfacine hcl oral tablet 1 solution 0.2 mg/ml 1 mg, 2 mg Brand hydralazine hcl injection GM ISORDIL TITRADOSE 3 penalty solution 20 mg/ml ORAL TABLET 40 MG applies hydralazine hcl oral tablet Brand 10 mg, 100 mg, 25 mg, 2 ISORDIL TITRADOSE 4 penalty 50 mg ORAL TABLET 5 MG applies hydrochlorothiazide oral 1 isosorbide dinitrate oral capsule 12.5 mg tablet 10 mg, 20 mg, 30 2 hydrochlorothiazide oral mg, 40 mg, 5 mg tablet 12.5 mg, 25 mg, 50 1 isosorbide mononitrate er mg oral tablet extended 2 HYZAAR ORAL TABLET Brand release 24 hour 120 mg, 100-12.5 MG, 100-25 4 penalty 30 mg, 60 mg MG, 50-12.5 MG applies isosorbide mononitrate 2 ibutilide fumarate oral tablet 10 mg, 20 mg intravenous solution 1 GM isradipine oral capsule 2 mg/10ml 2.5 mg, 5 mg

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 91 Drug Drug Drug Name Notes Drug Name Notes Tier Tier ISUPREL INJECTION lisinopril oral tablet 10 GM SOLUTION 0.2 MG/ML mg, 2.5 mg, 20 mg, 30 1 JUXTAPID ORAL mg, 40 mg, 5 mg CAPSULE 10 MG, 20 6 PA lisinopril- MG, 30 MG, 40 MG, 5 hydrochlorothiazide oral 1 MG, 60 MG tablet 10-12.5 mg, 20- LABETALOL HCL 12.5 mg, 20-25 mg INTRAVENOUS LIVALO ORAL TABLET GM 4 PA SOLUTION PREFILLED 1 MG, 2 MG, 4 MG SYRINGE 20 MG/4ML Brand labetalol hcl oral tablet LOPID ORAL TABLET 4 penalty 2 100 mg, 200 mg, 300 mg 600 MG applies labetalol hcl solution 5 LOPRESSOR HCT Brand mg/ml intravenous 5 GM ORAL TABLET 50-25 4 penalty mg/ml MG applies LABETALOL HCL Brand 4 penalty SOLUTION 5 MG/ML GM LOPRESSOR ORAL INTRAVENOUS 5 TABLET 100 MG, 50 MG applies MG/ML losartan potassium oral LANOXIN INJECTION tablet 100 mg, 25 mg, 50 1 GM SOLUTION 0.25 MG/ML mg LANOXIN ORAL losartan potassium-hctz TABLET 125 MCG, 250 4 oral tablet 100-12.5 mg, 1 MCG, 62.5 MCG 100-25 mg, 50-12.5 mg LANOXIN PEDIATRIC LOTENSIN HCT ORAL Brand INJECTION SOLUTION GM TABLET 10-12.5 MG, 20- 4 penalty 0.1 MG/ML 12.5 MG, 20-25 MG applies Brand LOTENSIN ORAL Brand LASIX ORAL TABLET 20 4 penalty TABLET 10 MG, 20 MG, 4 penalty MG, 40 MG, 80 MG applies 40 MG applies LESCOL XL ORAL LOTREL ORAL PA; Brand Brand TABLET EXTENDED CAPSULE 10-20 MG, 4 penalty 4 penalty RELEASE 24 HOUR 80 10-40 MG, 5-10 MG, 5- applies applies MG 20 MG

LEVOPHED lovastatin oral tablet 10 2 PV* INTRAVENOUS GM mg, 20 mg, 40 mg SOLUTION 1 MG/ML PA; Brand LIPITOR ORAL TABLET Brand LOVAZA ORAL 4 penalty 10 MG, 20 MG, 40 MG, 4 penalty CAPSULE 1 GM applies 80 MG applies mannitol intravenous GM LIPOFEN ORAL solution 20 %, 25 % CAPSULE 150 MG, 50 4 MG

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 92 Drug Drug Drug Name Notes Drug Name Notes Tier Tier matzim la oral tablet midodrine hcl oral tablet 2 extended release 24 hour 2 10 mg, 2.5 mg, 5 mg 180 mg, 240 mg, 300 milrinone lactate in mg, 360 mg, 420 mg dextrose intravenous GM Brand solution 20-5 mg/100ml- MAXZIDE ORAL 4 penalty %, 40-5 mg/200ml-% applies TABLET 75-50 MG milrinone lactate Brand intravenous solution 10 GM MAXZIDE-25 ORAL 4 penalty mg/10ml, 20 mg/20ml, 50 TABLET 37.5-25 MG applies mg/50ml methyldopa oral tablet MINIPRESS ORAL Brand 2 250 mg, 500 mg CAPSULE 1 MG, 2 MG, 4 penalty methyldopa- 5 MG applies hydrochlorothiazide oral 2 minitran transdermal tablet 250-15 mg, 250-25 patch 24 hour 0.1 mg/hr, 2 mg 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr metolazone oral tablet 10 2 mg, 2.5 mg, 5 mg minoxidil oral tablet 10 2 metoprolol succinate er mg, 2.5 mg oral tablet extended moexipril hcl oral tablet 2 2 release 24 hour 100 mg, 15 mg, 7.5 mg 200 mg, 25 mg, 50 mg MULTAQ ORAL TABLET 3 metoprolol tartrate 400 MG intravenous solution 5 GM nadolol oral tablet 20 mg, 2 mg/5ml 40 mg, 80 mg metoprolol tartrate oral NEXLETOL ORAL 4 PA tablet 100 mg, 25 mg, 50 1 TABLET 180 MG mg NEXLIZET ORAL metoprolol tartrate oral 4 PA 2 TABLET 180-10 MG tablet 37.5 mg, 75 mg NEXTERONE metoprolol- INTRAVENOUS hydrochlorothiazide oral 2 SOLUTION 150-4.21 GM tablet 100-25 mg, 100-50 MG/100ML-%, 360-4.14 mg, 50-25 mg MG/200ML-% hcl oral niacin capsule 150 mg, 200 mg, 2 (antihyperlipidemic) oral 2 250 mg tablet 500 mg MICARDIS HCT ORAL Brand niacin er TABLET 40-12.5 MG, 80- 4 penalty (antihyperlipidemic) oral 12.5 MG, 80-25 MG applies tablet extended release 2 MICARDIS ORAL Brand 1000 mg, 500 mg, 750 TABLET 20 MG, 40 MG, 4 penalty mg 80 MG applies niacor oral tablet 500 mg 2 Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 93 Drug Drug Drug Name Notes Drug Name Notes Tier Tier NIASPAN ORAL NITRO-DUR Brand TABLET EXTENDED 4 penalty TRANSDERMAL PATCH 3 RELEASE 1000 MG, 500 applies 24 HOUR 0.3 MG/HR, MG, 750 MG 0.8 MG/HR NICARDIPINE HCL IN nitroglycerin in d5w NACL INTRAVENOUS intravenous solution 100- SOLUTION 20-0.9 GM 5 mcg/ml-%, 200-5 GM MG/200ML-%, 40-0.9 mcg/ml-%, 400-5 MG/200ML-% mcg/ml-% nicardipine hcl nitroglycerin intravenous GM intravenous solution 2.5 GM solution 5 mg/ml mg/ml nitroglycerin sublingual 2 nicardipine hcl oral 2 tablet sublingual 0.3 mg, capsule 20 mg, 30 mg 0.4 mg, 0.6 mg nifedipine er oral tablet nitroglycerin transdermal 2 extended release 24 hour patch 24 hour 0.1 mg/hr, 2 30 mg, 60 mg, 90 mg 0.2 mg/hr, 0.4 mg/hr, 0.6 nifedipine er osmotic mg/hr release oral tablet nitroglycerin translingual 2 2 extended release 24 hour solution 0.4 mg/spray 30 mg, 60 mg, 90 mg NITROLINGUAL Brand nifedipine oral capsule 10 2 TRANSLINGUAL 4 penalty mg, 20 mg SOLUTION 0.4 applies MG/SPRAY nimodipine oral capsule 2 30 mg NITROMIST NIPRIDE RTU TRANSLINGUAL 3 INTRAVENOUS AEROSOL SOLUTION SOLUTION 20-0.9 GM 400 MCG/SPRAY MG/100ML-%, 50-0.9 NITROPRESS MG/100ML-% INTRAVENOUS GM nisoldipine er oral tablet SOLUTION 25 MG/ML extended release 24 hour nitroprusside sodium 17 mg, 20 mg, 25.5 mg, 2 intravenous solution 25 GM 30 mg, 34 mg, 40 mg, mg/ml 8.5 mg NITROSTAT Brand NITRO-BID SUBLINGUAL TABLET 3 penalty 3 TRANSDERMAL SUBLINGUAL 0.3 MG, applies OINTMENT 2 % 0.4 MG, 0.6 MG NITRO-DUR nitro-time oral capsule TRANSDERMAL PATCH Brand extended release 6.5 mg, 2 24 HOUR 0.1 MG/HR, 3 penalty 9 mg 0.2 MG/HR, 0.4 MG/HR, applies 0.6 MG/HR

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 94 Drug Drug Drug Name Notes Drug Name Notes Tier Tier norepinephrine bitartrate osmitrol intravenous GM intravenous solution 1 GM solution 15 %, 20 % mg/ml PACERONE ORAL Brand NOREPINEPHRINE- TABLET 100 MG, 400 4 penalty DEXTROSE MG applies INTRAVENOUS GM pacerone oral tablet 200 2 SOLUTION 8-5 mg MG/500ML-% pentoxifylline er oral NOREPINEPHRINE- tablet extended release 2 SODIUM CHLORIDE 400 mg INTRAVENOUS GM perindopril erbumine oral SOLUTION 16-0.9 2 MG/250ML-% tablet 2 mg, 4 mg, 8 mg NORPACE CR ORAL PA; QL (14 phenoxybenzamine hcl 2 EA per 30 CAPSULE EXTENDED 3 RELEASE 12 HOUR 100 oral capsule 10 mg days) MG, 150 MG phentolamine mesylate NORPACE ORAL Brand injection solution GM CAPSULE 100 MG, 150 4 penalty reconstituted 5 mg MG applies PHENYLEPHRINE HCL NORTHERA ORAL (PRESSORS) INTRAVENOUS CAPSULE 100 MG, 200 6 PA GM MG, 300 MG SOLUTION PREFILLED SYRINGE 0.5 MG/5ML, NORVASC ORAL Brand 1 MG/10ML TABLET 10 MG, 2.5 MG, 4 penalty 5 MG applies phenylephrine hcl intravenous solution 10 GM olmesartan medoxomil mg/ml oral tablet 20 mg, 40 mg, 2 5 mg PHENYLEPHRINE HCL INTRAVENOUS olmesartan medoxomil- SOLUTION PREFILLED hctz oral tablet 20-12.5 GM 2 SYRINGE 0.4 MG/10ML, mg, 40-12.5 mg, 40-25 0.8 MG/10ML, 1 mg MG/10ML olmesartan-amlodipine- PHENYLEPHRINE HCL- hctz oral tablet 20-5-12.5 NACL INTRAVENOUS mg, 40-10-12.5 mg, 40- 2 SOLUTION 10-0.9 10-25 mg, 40-5-12.5 mg, MG/250ML-%, 20-0.9 GM 40-5-25 mg MG/250ML-%, 40-0.9 omega-3-acid ethyl MG/250ML-%, 50-0.9 2 PA esters oral capsule 1 gm MG/250ML-%, 80-0.9 OSMITROL MG/250ML-% INTRAVENOUS GM SOLUTION 10 %

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 95 Drug Drug Drug Name Notes Drug Name Notes Tier Tier PHENYLEPHRINE HCL- propafenone hcl er oral NACL INTRAVENOUS capsule extended 2 SOLUTION PREFILLED GM release 12 hour 225 mg, SYRINGE 0.5-0.9 325 mg, 425 mg MG/5ML-% propafenone hcl oral 2 pindolol oral tablet 10 2 tablet 150 mg, 225 mg, mg, 5 mg 300 mg POLIDOCANOL propranolol hcl er oral INTRAVENOUS GM capsule extended 2 SOLUTION 5 % release 24 hour 120 mg, PRALUENT 160 mg, 60 mg, 80 mg SUBCUTANEOUS propranolol hcl SOLUTION AUTO- 4 PA intravenous solution 1 GM INJECTOR 150 MG/ML, mg/ml 75 MG/ML propranolol hcl oral Brand solution 20 mg/5ml, 40 2 PRAVACHOL ORAL 4 penalty mg/5ml TABLET 20 MG, 40 MG applies propranolol hcl oral tablet pravastatin sodium oral 10 mg, 20 mg, 40 mg, 60 2 tablet 10 mg, 20 mg, 40 2 PV* mg, 80 mg mg, 80 mg propranolol-hctz oral 2 prazosin hcl oral capsule 2 tablet 40-25 mg, 80-25 1 mg, 2 mg, 5 mg mg PRESTALIA ORAL PROSTIN VR TABLET 14-10 MG, 3.5- 4 INJECTION SOLUTION GM 2.5 MG, 7-5 MG 500 MCG/ML prevalite oral packet 4 2 QBRELIS ORAL 4 gm SOLUTION 1 MG/ML prevalite oral powder 4 QUESTRAN LIGHT Brand 2 gm/dose ORAL POWDER 4 4 penalty Brand GM/DOSE applies PRINIVIL ORAL TABLET 4 penalty Brand 10 MG, 20 MG applies QUESTRAN ORAL 4 penalty procainamide hcl PACKET 4 GM applies injection solution 100 GM Brand mg/ml, 500 mg/ml QUESTRAN ORAL 4 penalty Brand POWDER 4 GM/DOSE applies PROCARDIA ORAL 4 penalty quinapril hcl oral tablet CAPSULE 10 MG applies 10 mg, 20 mg, 40 mg, 5 2 PROCARDIA XL ORAL mg Brand TABLET EXTENDED 4 penalty RELEASE 24 HOUR 30 applies MG, 60 MG, 90 MG

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 96 Drug Drug Drug Name Notes Drug Name Notes Tier Tier quinapril- simvastatin oral tablet 5 1 hydrochlorothiazide oral 2 mg, 80 mg tablet 10-12.5 mg, 20- SODIUM DIURIL 12.5 mg, 20-25 mg INTRAVENOUS quinidine gluconate er SOLUTION GM oral tablet extended 2 RECONSTITUTED 500 release 324 mg MG quinidine sulfate oral SODIUM EDECRIN 2 tablet 200 mg, 300 mg INTRAVENOUS ramipril oral capsule 1.25 SOLUTION GM 2 mg, 10 mg, 2.5 mg, 5 mg RECONSTITUTED 50 MG RANEXA ORAL TABLET Brand EXTENDED RELEASE sodium tetradecyl sulfate GM 4 penalty intravenous solution 3 % 12 HOUR 1000 MG, 500 applies MG sorine oral tablet 120 mg, 2 ranolazine er oral tablet 160 mg, 240 mg, 80 mg 2 extended release 12 hour sotalol hcl (af) oral tablet 2 1000 mg, 500 mg 120 mg, 160 mg, 80 mg RECTIV RECTAL SOTALOL HCL 4 OINTMENT 0.4 % INTRAVENOUS GM REPATHA SOLUTION 150 PUSHTRONEX SYSTEM MG/10ML SUBCUTANEOUS 4 PA sotalol hcl oral tablet 120 SOLUTION CARTRIDGE mg, 160 mg, 240 mg, 80 2 420 MG/3.5ML mg REPATHA SOTRADECOL GM SUBCUTANEOUS 4 PA INTRAVENOUS SOLUTION PREFILLED SOLUTION 1 %, 3 % SYRINGE 140 MG/ML SOTYLIZE ORAL 4 REPATHA SURECLICK SOLUTION 5 MG/ML SUBCUTANEOUS spironolactone oral tablet 4 PA 2 SOLUTION AUTO- 100 mg, 25 mg, 50 mg INJECTOR 140 MG/ML spironolactone-hctz oral 2 rosuvastatin calcium oral tablet 25-25 mg tablet 10 mg, 20 mg, 40 2 mg, 5 mg SULAR ORAL TABLET Brand EXTENDED RELEASE RYTHMOL SR ORAL 4 penalty Brand 24 HOUR 17 MG, 34 applies CAPSULE EXTENDED 4 penalty MG, 8.5 MG RELEASE 12 HOUR 225 applies MG, 325 MG, 425 MG TARKA ORAL TABLET Brand EXTENDED RELEASE 4 penalty simvastatin oral tablet 10 2-180 MG, 2-240 MG, 4- 1 PV* applies mg, 20 mg, 40 mg 240 MG

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 97 Drug Drug Drug Name Notes Drug Name Notes Tier Tier taztia xt oral capsule timolol maleate oral 2 extended release 24 hour 2 tablet 10 mg, 20 mg, 5 120 mg, 180 mg, 240 mg mg, 300 mg, 360 mg TOPROL XL ORAL TEKTURNA HCT ORAL TABLET EXTENDED Brand 4 penalty TABLET 150-12.5 MG, 3 RELEASE 24 HOUR 100 150-25 MG, 300-12.5 MG, 200 MG, 25 MG, 50 applies MG, 300-25 MG MG TEKTURNA ORAL Brand torsemide oral tablet 10 TABLET 150 MG, 300 3 penalty mg, 100 mg, 20 mg, 5 2 MG applies mg telmisartan oral tablet 20 2 trandolapril oral tablet 1 2 mg, 40 mg, 80 mg mg, 2 mg, 4 mg telmisartan-amlodipine trandolapril-verapamil hcl 2 oral tablet 40-10 mg, 40- er oral tablet extended 2 5 mg, 80-10 mg, 80-5 mg release 1-240 mg, 2-180 telmisartan-hctz oral mg, 2-240 mg, 4-240 mg tablet 40-12.5 mg, 80- 2 triamterene oral capsule 2 12.5 mg, 80-25 mg 100 mg, 50 mg Brand triamterene-hctz oral 2 TENORETIC 100 ORAL 4 penalty capsule 37.5-25 mg TABLET 100-25 MG applies triamterene-hctz oral Brand tablet 37.5-25 mg, 75-50 2 TENORETIC 50 ORAL 4 penalty mg TABLET 50-25 MG applies TRIBENZOR ORAL TENORMIN ORAL Brand TABLET 20-5-12.5 MG, Brand TABLET 100 MG, 25 4 penalty 40-10-12.5 MG, 40-10-25 3 penalty MG, 50 MG applies MG, 40-5-12.5 MG, 40-5- applies tiadylt er oral capsule 25 MG extended release 24 hour Brand 120 mg, 180 mg, 240 2 TRICOR ORAL TABLET 4 penalty mg, 300 mg, 360 mg, 145 MG, 48 MG applies 420 mg TRIGLIDE ORAL 4 TIAZAC ORAL TABLET 160 MG CAPSULE EXTENDED Brand TRILIPIX ORAL Brand RELEASE 24 HOUR 120 4 penalty CAPSULE DELAYED MG, 180 MG, 240 MG, 4 penalty applies RELEASE 135 MG, 45 applies 300 MG, 360 MG, 420 MG MG TWYNSTA ORAL Brand TIKOSYN ORAL Brand TABLET 40-10 MG, 40-5 4 penalty CAPSULE 125 MCG, 4 penalty MG, 80-10 MG, 80-5 MG applies 250 MCG, 500 MCG applies

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 98 Drug Drug Drug Name Notes Drug Name Notes Tier Tier valsartan oral tablet 160 VERELAN PM ORAL Brand 2 mg, 320 mg, 40 mg, 80 CAPSULE EXTENDED 4 penalty mg RELEASE 24 HOUR 100 applies valsartan- MG, 200 MG, 300 MG hydrochlorothiazide oral VYNDAMAX ORAL 6 PA tablet 160-12.5 mg, 160- 2 CAPSULE 61 MG 25 mg, 320-12.5 mg, VYNDAQEL ORAL 6 PA 320-25 mg, 80-12.5 mg CAPSULE 20 MG VARITHENA VYTORIN ORAL Brand INTRAVENOUS FOAM GM TABLET 10-10 MG, 10- 4 penalty 180 MG/18ML 20 MG, 10-40 MG, 10-80 applies VASCEPA ORAL 4 PA MG CAPSULE 0.5 GM, 1 GM Brand Brand WELCHOL ORAL 4 penalty VASERETIC ORAL 4 penalty PACKET 3.75 GM applies TABLET 10-25 MG applies Brand VASOTEC ORAL Brand WELCHOL ORAL 4 penalty TABLET 10 MG, 2.5 MG, 4 penalty TABLET 625 MG applies 20 MG, 5 MG applies ZESTORETIC ORAL Brand VAZCULEP TABLET 10-12.5 MG, 20- 4 penalty INTRAVENOUS GM 12.5 MG, 20-25 MG applies SOLUTION 10 MG/ML ZESTRIL ORAL TABLET Brand 4 penalty VECAMYL ORAL 4 10 MG, 2.5 MG, 20 MG, TABLET 2.5 MG 30 MG, 40 MG, 5 MG applies verapamil hcl er oral Brand capsule extended ZETIA ORAL TABLET 10 4 penalty applies release 24 hour 100 mg, 2 MG 120 mg, 180 mg, 200 ZIAC ORAL TABLET 10- Brand mg, 240 mg, 300 mg, 6.25 MG, 2.5-6.25 MG, 4 penalty 360 mg 5-6.25 MG applies verapamil hcl er oral ZOCOR ORAL TABLET Brand tablet extended release 2 10 MG, 20 MG, 40 MG, 4 penalty 120 mg, 180 mg, 240 mg 80 MG applies verapamil hcl intravenous GM ZYPITAMAG ORAL solution 2.5 mg/ml TABLET 1 MG, 2 MG, 4 4 PA verapamil hcl oral tablet 2 MG 120 mg, 40 mg, 80 mg VERELAN ORAL CAPSULE EXTENDED Brand RELEASE 24 HOUR 120 4 penalty MG, 180 MG, 240 MG, applies 360 MG

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 99 Drug Drug Drug Name Notes Drug Name Notes Tier Tier Central Nervous atomoxetine hcl oral QL (30 EA System Agents - Drugs capsule 100 mg, 40 mg, 2 per 30 for Attention Deficit 60 mg, 80 mg days) Disorder clonidine hcl er oral tablet Brand extended release 12 hour 2 ADDERALL ORAL penalty 0.1 mg TABLET 10 MG, 12.5 4 applies; QL Brand (90 EA per MG, 15 MG, 20 MG, 30 CONCERTA ORAL penalty 30 days) MG, 5 MG, 7.5 MG TABLET EXTENDED 4 applies; QL Brand RELEASE 18 MG, 27 (30 EA per ADDERALL XR ORAL penalty MG, 54 MG 30 days) CAPSULE EXTENDED 4 applies; QL Brand RELEASE 24 HOUR 10 (30 EA per penalty 30 days) MG, 15 MG, 5 MG CONCERTA ORAL 4 applies; QL Brand TABLET EXTENDED (60 EA per ADDERALL XR ORAL penalty RELEASE 36 MG 30 days) 4 applies; QL CAPSULE EXTENDED DAYTRANA (60 EA per RELEASE 24 HOUR 20 TRANSDERMAL PATCH QL (30 EA 30 days) MG, 25 MG, 30 MG 10 MG/9HR, 15 4 per 30 amphetamine- MG/9HR, 20 MG/9HR, days) dextroamphetamine er QL (30 EA 30 MG/9HR oral capsule extended 2 per 30 Brand days) release 24 hour 10 mg, DESOXYN ORAL 4 penalty 15 mg, 5 mg TABLET 5 MG applies amphetamine- Brand dextroamphetamine er QL (60 EA penalty 2 per 30 oral capsule extended DEXEDRINE ORAL applies; QL days) 4 release 24 hour 20 mg, CAPSULE EXTENDED (150 EA 25 mg, 30 mg RELEASE 24 HOUR 10 per 30 amphetamine- MG, 15 MG, 5 MG days) QL (90 EA dextroamphetamine oral dexmethylphenidate hcl 2 per 30 tablet 10 mg, 12.5 mg, 15 er oral capsule extended QL (30 EA days) mg, 20 mg, 30 mg, 5 mg, release 24 hour 10 mg, 2 per 30 7.5 mg 15 mg, 20 mg, 25 mg, 30 days) APTENSIO XR ORAL mg, 35 mg, 40 mg, 5 mg CAPSULE EXTENDED dexmethylphenidate hcl QL (90 EA RELEASE 24 HOUR 10 4 oral tablet 10 mg, 2.5 mg, 2 per 30 MG, 15 MG, 20 MG, 30 5 mg days) MG, 40 MG, 50 MG, 60 dextroamphetamine MG QL (150 sulfate er oral capsule QL (60 EA 2 EA per 30 atomoxetine hcl oral extended release 24 hour 2 per 30 days) capsule 10 mg, 18 mg, 10 mg, 15 mg, 5 mg 25 mg days)

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 100 Drug Drug Drug Name Notes Drug Name Notes Tier Tier dextroamphetamine methylphenidate hcl er sulfate oral solution 5 2 (cd) oral capsule QL (30 EA mg/5ml extended release 10 mg, 2 per 30 dextroamphetamine QL (180 20 mg, 30 mg, 40 mg, 50 days) sulfate oral tablet 10 mg, 2 EA per 30 mg, 60 mg 5 mg days) methylphenidate hcl er PA; AL (la) oral capsule QL (30 EA DYANAVEL XR ORAL (Min 6 extended release 24 hour 2 per 30 SUSPENSION 4 Years and 10 mg, 20 mg, 30 mg, 40 days) EXTENDED RELEASE Max 12 mg, 60 mg 2.5 MG/ML Years) METHYLPHENIDATE Brand HCL ER (XR) ORAL penalty CAPSULE EXTENDED FOCALIN ORAL 4 applies; QL RELEASE 24 HOUR 10 4 TABLET 10 MG, 2.5 MG, (90 EA per MG, 15 MG, 20 MG, 30 5 MG 30 days) MG, 40 MG, 50 MG, 60 MG FOCALIN XR ORAL Brand CAPSULE EXTENDED methylphenidate hcl er penalty RELEASE 24 HOUR 10 oral tablet extended 2 4 applies; QL MG, 15 MG, 20 MG, 25 release 10 mg (30 EA per MG, 30 MG, 35 MG, 40 30 days) methylphenidate hcl er QL (30 EA MG, 5 MG oral tablet extended 2 per 30 guanfacine hcl er oral release 18 mg, 27 mg, 54 days) mg tablet extended release 2 24 hour 1 mg, 2 mg, 3 methylphenidate hcl er QL (90 EA mg, 4 mg oral tablet extended 2 per 30 INTUNIV ORAL TABLET release 20 mg days) Brand EXTENDED RELEASE methylphenidate hcl er 4 penalty 24 HOUR 1 MG, 2 MG, 3 oral tablet extended applies 2 MG, 4 MG release 24 hour 18 mg, KAPVAY ORAL TABLET Brand 27 mg, 36 mg, 54 mg EXTENDED RELEASE 4 penalty methylphenidate hcl er QL (60 EA 12 HOUR 0.1 MG applies oral tablet extended 2 per 30 QL (90 EA release 36 mg days) 2 per 30 metadate er oral tablet methylphenidate hcl er QL (1 EA extended release 20 mg days) oral tablet extended 1 per 1 day) methamphetamine hcl release 72 mg 2 oral tablet 5 mg methylphenidate hcl oral QL (900 Brand solution 10 mg/5ml, 5 2 ML per 30 penalty mg/5ml days) applies; QL QL (180 4 METHYLIN ORAL (900 ML methylphenidate hcl oral 2 EA per 30 SOLUTION 10 MG/5ML, per 30 tablet 10 mg days) 5 MG/5ML days)

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 101 Drug Drug Drug Name Notes Drug Name Notes Tier Tier methylphenidate hcl oral Brand 2 tablet 20 mg penalty QL (90 EA 4 applies; QL methylphenidate hcl oral 2 per 30 RITALIN ORAL TABLET (90 EA per tablet 5 mg days) 5 MG 30 days) methylphenidate hcl oral Brand 2 penalty tablet chewable 10 mg STRATTERA ORAL 4 applies; QL methylphenidate hcl oral QL (90 EA CAPSULE 10 MG, 18 (60 EA per tablet chewable 2.5 mg, 2 per 30 MG, 25 MG 30 days) 5 mg days) Brand Brand penalty PROCENTRA ORAL 4 penalty STRATTERA ORAL 4 applies; QL SOLUTION 5 MG/5ML applies CAPSULE 100 MG, 40 (30 EA per PA; AL MG, 60 MG, 80 MG 30 days) QUILLICHEW ER ORAL (Min 6 VYVANSE ORAL QL (30 EA TABLET CHEWABLE 4 Years and CAPSULE 10 MG, 20 4 per 30 EXTENDED RELEASE Max 12 MG, 30 MG, 40 MG, 50 days) 20 MG, 30 MG, 40 MG Years) MG, 60 MG, 70 MG PA; QL PA; QL (30 (180 ML EA per 30 per 30 days); AL days); AL 4 VYVANSE ORAL 4 (Min 6 QUILLIVANT XR ORAL (Min 6 TABLET CHEWABLE 10 Years and SUSPENSION Years and MG, 20 MG, 30 MG, 40 Max 12 RECONSTITUTED ER Max 12 MG, 50 MG, 60 MG Years) 25 MG/5ML Years) Brand QL (1 EA relexxii oral tablet 1 penalty extended release 72 mg per 1 day) 4 applies; QL RITALIN LA ORAL Brand ZENZEDI ORAL TABLET (2 EA per 1 CAPSULE EXTENDED penalty 10 MG, 5 MG day) RELEASE 24 HOUR 10 4 applies; QL ZENZEDI ORAL TABLET QL (60 EA MG, 20 MG, 30 MG, 40 (30 EA per 15 MG, 2.5 MG, 20 MG, 4 per 30 MG 30 days) 30 MG, 7.5 MG days) Brand Central Nervous penalty System Agents - Drugs applies; QL 4 for Multiple Sclerosis (180 EA AUBAGIO ORAL RITALIN ORAL TABLET per 30 5 10 MG days) TABLET 14 MG, 7 MG Brand AVONEX PEN RITALIN ORAL TABLET 4 penalty INTRAMUSCULAR 5 20 MG applies AUTO-INJECTOR KIT 30 MCG/0.5ML

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 102 Drug Drug Drug Name Notes Drug Name Notes Tier Tier AVONEX PREFILLED MAVENCLAD (7 TABS) 6 PA INTRAMUSCULAR 5 ORAL TABLET PREFILLED SYRINGE THERAPY PACK 10 MG KIT 30 MCG/0.5ML MAVENCLAD (8 TABS) AVONEX VIAL ORAL TABLET 6 PA INTRAMUSCULAR KIT 5 THERAPY PACK 10 MG INTRAMUSCULAR KIT MAVENCLAD (9 TABS) 30 MCG ORAL TABLET 6 PA BETASERON THERAPY PACK 10 MG SUBCUTANEOUS KIT 5 MAYZENT ORAL 6 0.3 MG TABLET 0.25 MG, 2 MG dalfampridine er oral MAYZENT STARTER tablet extended release 6 PA PACK ORAL TABLET 6 12 hour 10 mg THERAPY PACK 0.25 EXTAVIA MG SUBCUTANEOUS KIT 6 OCREVUS 0.3 MG PA; INTRAVENOUS 6 Specialty GILENYA ORAL SOLUTION 300 Medical CAPSULE 0.25 MG, 0.5 6 MG/10ML MG PLEGRIDY STARTER glatiramer acetate PACK SUBCUTANEOUS 5 subcutaneous solution 5 SOLUTION PEN- prefilled syringe 20 INJECTOR 63 & 94 mg/ml, 40 mg/ml MCG/0.5ML glatopa subcutaneous PLEGRIDY solution prefilled syringe 5 SUBCUTANEOUS 20 mg/ml, 40 mg/ml SOLUTION PEN- 5 LEMTRADA INJECTOR 125 PA; INTRAVENOUS MCG/0.5ML 6 Specialty SOLUTION 12 REBIF REBIDOSE Medical MG/1.2ML SUBCUTANEOUS MAVENCLAD (10 TABS) SOLUTION AUTO- 5 ORAL TABLET 6 PA INJECTOR 22 THERAPY PACK 10 MG MCG/0.5ML, 44 MCG/0.5ML MAVENCLAD (4 TABS) ORAL TABLET 6 PA REBIF REBIDOSE THERAPY PACK 10 MG TITRATION PACK SUBCUTANEOUS 5 MAVENCLAD (5 TABS) SOLUTION AUTO- ORAL TABLET 6 PA INJECTOR 6X8.8 & THERAPY PACK 10 MG 6X22 MCG MAVENCLAD (6 TABS) ORAL TABLET 6 PA THERAPY PACK 10 MG

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 103 Drug Drug Drug Name Notes Drug Name Notes Tier Tier REBIF Central Nervous SUBCUTANEOUS System Agents - Miscellaneous SOLUTION PREFILLED 5 SYRINGE 22 ANECTINE INJECTION GM MCG/0.5ML, 44 SOLUTION 20 MG/ML MCG/0.5ML atracurium besylate REBIF TITRATION intravenous solution 100 GM PACK SUBCUTANEOUS mg/10ml, 50 mg/5ml SOLUTION PREFILLED 5 SYRINGE 6X8.8 & 6X22 AUSTEDO ORAL 6 PA MCG TABLET 12 MG, 6 MG, 9 MG TECFIDERA ORAL 120 5 CAFCIT INTRAVENOUS & 240 MG GM SOLUTION 60 MG/3ML TECFIDERA ORAL CAPSULE DELAYED caffeine citrate 5 GM RELEASE 120 MG, 240 intravenous solution 60 MG mg/3ml TYSABRI caffeine citrate oral PA; 2 INTRAVENOUS solution 20 mg/ml, 60 6 Specialty CONCENTRATE 300 mg/3ml Medical MG/15ML cisatracurium besylate GM VUMERITY (STARTER) (pf) intravenous solution 10 mg/5ml, 200 mg/20ml ORAL CAPSULE 6 PA DELAYED RELEASE cisatracurium besylate 231 MG intravenous solution 20 GM VUMERITY ORAL mg/10ml CAPSULE DELAYED 6 PA DOPRAM RELEASE 231 MG INTRAVENOUS GM ZEPOSIA 7-DAY SOLUTION 20 MG/ML STARTER PACK ORAL GRALISE ORAL CAPSULE THERAPY 6 PA TABLET 300 MG, 600 4 ST PACK 4 X 0.23MG & 3 X MG 0.46MG GRALISE STARTER 4 ST ORAL 300 & 600 MG ZEPOSIA ORAL 6 PA CAPSULE 0.92 MG HORIZANT ORAL ZEPOSIA STARTER KIT TABLET EXTENDED 4 ST ORAL CAPSULE RELEASE 300 MG, 600 THERAPY PACK 6 PA MG 0.23MG & 0.46MG & INGREZZA ORAL 0.92MG CAPSULE 40 MG, 80 6 PA MG INGREZZA ORAL CAPSULE THERAPY 6 PA PACK 40 & 80 MG Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 104 Drug Drug Drug Name Notes Drug Name Notes Tier Tier LYRICA CR ORAL ROCURONIUM TABLET EXTENDED 4 BROMIDE RELEASE 24 HOUR 165 INTRAVENOUS GM MG, 330 MG, 82.5 MG SOLUTION PREFILLED LYRICA ORAL SYRINGE 100 CAPSULE 100 MG, 150 MG/10ML, 75 MG/7.5ML MG, 200 MG, 225 MG, 4 SAVELLA ORAL 25 MG, 300 MG, 50 MG, TABLET 100 MG, 12.5 4 PA 75 MG MG, 25 MG, 50 MG LYRICA ORAL SAVELLA TITRATION 4 SOLUTION 20 MG/ML PACK ORAL 12.5 & 25 & 4 PA NIMBEX INTRAVENOUS 50 MG SOLUTION 10 MG/5ML, GM succinylcholine chloride 20 MG/10ML, 200 injection solution 20 GM MG/20ML mg/ml ONPATTRO PA; SUCCINYLCHOLINE INTRAVENOUS 6 Specialty CHLORIDE INJECTION SOLUTION 10 MG/5ML Medical SOLUTION PREFILLED GM SYRINGE 100 MG/5ML, intravenous solution 1 GM 140 MG/7ML, 200 mg/ml MG/10ML oral capsule TEGSEDI SUBCUTANEOUS 100 mg, 150 mg, 200 2 mg, 225 mg, 25 mg, 300 SOLUTION PREFILLED 6 PA mg, 50 mg, 75 mg SYRINGE 284 MG/1.5ML pregabalin oral solution 2 tetrabenazine oral tablet 20 mg/ml 5 PA 12.5 mg, 25 mg QUELICIN INJECTION GM SOLUTION 20 MG/ML TIGLUTIK ORAL SUSPENSION 50 6 RADICAVA PA; MG/10ML INTRAVENOUS 6 Specialty SOLUTION 30 Medical MG/100ML intravenous solution GM reconstituted 10 mg, 20 RILUTEK ORAL TABLET 6 mg 50 MG XENAZINE ORAL riluzole oral tablet 50 mg 6 TABLET 12.5 MG, 25 6 PA MG intravenous solution 100 GM Dental and Oral Agents mg/10ml, 50 mg/5ml - Drugs for Mouth and Throat Conditions ARESTIN DENTAL 1 MG GM

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 105 Drug Drug Drug Name Notes Drug Name Notes Tier Tier BOCASAL MI PASTE DENTAL 4 MOUTH/THROAT 4 PASTE PACKET MI PASTE PLUS 4 cavarest dental gel 1.1 % 2 DENTAL PASTE cevimeline hcl oral 2 MUCOSITISRX capsule 30 mg MOUTH/THROAT 4 chlorhexidine gluconate PACKET mouth/throat solution 2 NAFRINSE DAILY 0.12 % ACIDULATED clinpro 5000 dental paste MOUTH/THROAT 2 4 1.1 % SOLUTION RECONSTITUTED 1 DEBACTEROL MG/5ML MOUTH/THROAT 4 SOLUTION 30-50 % NAFRINSE DAILY/NEUTRAL denta 5000 plus dental 2 MOUTH/THROAT 4 cream 1.1 % SOLUTION dentagel dental gel 1.1 % 2 RECONSTITUTED 0.05 easygel dental gel 0.4 % 2 % Brand NAFRINSE WEEKLY MOUTH/THROAT EVOXAC ORAL 4 penalty 4 CAPSULE 30 MG applies SOLUTION RECONSTITUTED 0.2 % FIRST-MOUTHWASH BLM MOUTH/THROAT 4 neutral sodium fluoride 2 SUSPENSION mouth/throat solution 0.2 % fluoridex daily renewal mouth/throat concentrate 2 NEUTRASAL 4 0.63 % MOUTH/THROAT PACKET fluoridex dental paste 1.1 2 % NUMOISYN MOUTH/THROAT 4 fluoridex enhanced LOZENGE whitening dental paste 2 1.1 % oralone mouth/throat 2 paste 0.1 % fluoridex sensitivity relief 2 dental paste 1.1-5 % paroex mouth/throat 2 solution 0.12 % KEPIVANCE Brand INTRAVENOUS PA; PERIDEX 4 penalty SOLUTION 6 Specialty MOUTH/THROAT applies RECONSTITUTED 6.25 Medical SOLUTION 0.12 % periogard mouth/throat MG 2 solution 0.12 % lidocaine viscous hcl 2 pilocarpine hcl oral tablet mouth/throat solution 2 % 2 5 mg, 7.5 mg

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 106 Drug Drug Drug Name Notes Drug Name Notes Tier Tier PREVIDENT 5000 sodium fluoride dental 2 BOOSTER PLUS 4 cream 1.1 % DENTAL PASTE 1.1 % sodium fluoride dental 2 PREVIDENT 5000 DRY gel 1.1 % MOUTH DENTAL GEL 4 TOPEX TOPICAL 1.1 % ANESTHETIC 4 PREVIDENT 5000 MOUTH/THROAT ENAMEL PROTECT 4 AEROSOL 20 % DENTAL PASTE 1.1-5 % triamcinolone acetonide 2 PREVIDENT 5000 mouth/throat paste 0.1 % ORTHO DEFENSE 4 XEROSTOMIA RELIEF DENTAL PASTE 1.1 % SPRAY 4 PREVIDENT 5000 PLUS 4 MOUTH/THROAT DENTAL CREAM 1.1 % SOLUTION PREVIDENT 5000 Dermatological Agents SENSITIVE DENTAL 4 - Drugs for Skin PASTE 1.1-5 % Conditions ABSORICA LD ORAL PREVIDENT DENTAL 4 GEL 1.1 % CAPSULE 16 MG, 24 4 PA prevident mouth/throat MG, 32 MG, 8 MG 2 solution 0.2 % ABSORICA ORAL REMESENSE DENTAL 3 CAPSULE 10 MG, 20 4 4 PA % MG, 25 MG, 30 MG, 35 MG, 40 MG Brand SALAGEN ORAL 4 penalty acitretin oral capsule 10 2 TABLET 5 MG, 7.5 MG applies mg, 17.5 mg, 25 mg Brand SALIVAMAX 4 penalty MOUTH/THROAT 4 ACZONE EXTERNAL applies PACKET GEL 5 % adapalene external sf 5000 plus dental 2 2 cream 1.1 % cream 0.1 % adapalene external gel sf dental gel 1.1 % 2 2 0.1 %, 0.3 % sodium fluoride 5000 2 ala-cort external cream 1 plus dental cream 1.1 % 2 %, 2.5 % sodium fluoride 5000 2 ppm dental cream 1.1 % alclometasone dipropionate external 2 sodium fluoride 5000 2 cream 0.05 % ppm dental paste 1.1 % alclometasone sodium fluoride 5000 dipropionate external 2 sensitive dental paste 2 ointment 0.05 % 1.1-5 %

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 107 Drug Drug Drug Name Notes Drug Name Notes Tier Tier PREP PADS beser external lotion 0.05 4 2 EXTERNAL 70 % % amcinonide external 2 betamethasone cream 0.1 % dipropionate aug external 2 cream 0.05 % amcinonide external 2 lotion 0.1 % betamethasone dipropionate aug external 2 amcinonide external 2 ointment 0.1 % gel 0.05 % ammonium lactate betamethasone 2 external cream 12 % dipropionate aug external 2 lotion 0.05 % ammonium lactate 2 external lotion 12 % betamethasone dipropionate aug external 2 amnesteem oral capsule QL (2 EA 2 ointment 0.05 % 10 mg, 20 mg, 40 mg per 1 day) betamethasone ANACAINE EXTERNAL 4 dipropionate external 2 OINTMENT 10 % cream 0.05 % AQUACEL AG BURN 4 betamethasone EXTERNAL PAD 4"X5" dipropionate external 2 lotion 0.05 % arzol silver nit applicators 2 external 75-25 % betamethasone ATRAPRO DERMAL dipropionate external 2 SPRAY EXTERNAL 4 ointment 0.05 % LIQUID betamethasone valerate 2 avar cleanser external external cream 0.1 % 2 emulsion 10-5 % betamethasone valerate 2 avita external cream external lotion 0.1 % 2 0.025 % betamethasone valerate 2 external ointment 0.1 % avita external gel 0.025 2 % bp 10-1 external 2 emulsion 10-1 % azelaic acid external gel 2 PA 15 % BP CLEANSING WASH EXTERNAL EMULSION 4 AZELEX EXTERNAL 4 PA CREAM 20 % 10-4 % BPCO EXTERNAL balsam peru-castor oil 2 4 external ointment OINTMENT BENSAL HP EXTERNAL calcipotriene external 4 2 OINTMENT 3-6 % cream 0.005 % benzoin compound calcipotriene external 2 2 external tincture ointment 0.005 % 2 benzoin external tincture calcipotriene external 2 solution 0.005 %

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 108 Drug Drug Drug Name Notes Drug Name Notes Tier Tier calcipotriene-betameth clobetasol propionate 2 diprop external ointment 2 ST external lotion 0.05 % 0.005-0.064 % clobetasol propionate 2 calcitriol external 2 ST external ointment 0.05 % ointment 3 mcg/gm clobetasol propionate 2 cem-urea external 2 external shampoo 0.05 % solution 45 % clobetasol propionate 2 cerovel external lotion 40 external solution 0.05 % 2 % clocortolone pivalate 2 claravis oral capsule 10 external cream 0.1 % QL (2 EA mg, 20 mg, 30 mg, 40 2 clodan external shampoo per 1 day) 2 mg 0.05 % clindacin etz external 2 Brand swab 1 % CLODERM EXTERNAL 4 penalty applies clindacin-p external swab 2 CREAM 0.1 % 1 % coal tar external solution 2 clindamycin phosphate 2 20 % external foam 1 % CONDYLOX EXTERNAL 3 clindamycin phosphate 2 GEL 0.5 % external gel 1 % CORDRAN EXTERNAL 4 clindamycin phosphate CREAM 0.025 % 2 external lotion 1 % Brand clindamycin phosphate CORDRAN EXTERNAL 4 penalty 2 external solution 1 % CREAM 0.05 % applies clindamycin phosphate Brand 2 external swab 1 % CORDRAN EXTERNAL 4 penalty clobetasol prop emollient LOTION 0.05 % applies 2 base external cream 0.05 CORDRAN EXTERNAL 4 % TAPE 4 MCG/SQCM clobetasol propionate e 2 CORTISPORIN external cream 0.05 % EXTERNAL CREAM 3.5- 4 clobetasol propionate 10000-0.5 emulsion external foam 2 CORTISPORIN 0.05 % EXTERNAL OINTMENT 4 clobetasol propionate 1 % 2 external cream 0.05 % dapsone external gel 5 % 2 clobetasol propionate DERMULCERA 2 4 external foam 0.05 % EXTERNAL OINTMENT clobetasol propionate 2 desonide external cream 2 external gel 0.05 % 0.05 %

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 109 Drug Drug Drug Name Notes Drug Name Notes Tier Tier desonide external gel erythromycin external gel 2 2 0.05 % 2 % desonide external lotion 2 erythromycin external 2 0.05 % solution 2 % desonide external 2 EUCRISA EXTERNAL 4 PA ointment 0.05 % OINTMENT 2 % desoximetasone external 2 FINACEA EXTERNAL 4 PA cream 0.05 %, 0.25 % FOAM 15 % desoximetasone external PA; Brand 2 gel 0.05 % FINACEA EXTERNAL 4 penalty desoximetasone external GEL 15 % applies 2 liquid 0.25 % fluocinolone acetonide 2 desoximetasone external body external oil 0.01 % 2 ointment 0.05 %, 0.25 % fluocinolone acetonide external cream 0.01 %, 2 diclofenac sodium 2 transdermal gel 3 % 0.025 % fluocinolone acetonide diflorasone diacetate 2 external cream 0.05 % external ointment 0.025 2 % diflorasone diacetate 2 fluocinolone acetonide external ointment 0.05 % 2 external solution 0.01 % doxepin hcl external 2 fluocinolone acetonide cream 5 % 2 scalp external oil 0.01 % DRITHO-CREME HP 3 EXTERNAL CREAM 1 % fluocinonide emulsified base external cream 0.05 2 DRYSOL EXTERNAL 3 % SOLUTION 20 % fluocinonide external 2 DUPIXENT cream 0.05 % SUBCUTANEOUS 5 PA SOLUTION PEN- fluocinonide external gel 2 INJECTOR 300 MG/2ML 0.05 % DUPIXENT fluocinonide external 2 SUBCUTANEOUS ointment 0.05 % SOLUTION PREFILLED fluocinonide external 5 PA 2 SYRINGE 200 solution 0.05 % MG/1.14ML, 300 fluorouracil external 2 MG/2ML cream 5 % Brand fluorouracil external 2 ELIDEL EXTERNAL 4 penalty solution 2 %, 5 % CREAM 1 % applies flurandrenolide external 2 EPIFOAM EXTERNAL 4 cream 0.05 % FOAM 1-1 % ery external pad 2 % 2 Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 110 Drug Drug Drug Name Notes Drug Name Notes Tier Tier flurandrenolide external hydrocortisone external 2 2 lotion 0.05 % cream 1 %, 2.5 % flurandrenolide external 2 hydrocortisone external 2 ointment 0.05 % lotion 2.5 % fluticasone propionate 2 hydrocortisone external 2 external cream 0.05 % ointment 1 %, 2.5 % fluticasone propionate 2 hydrocortisone valerate 2 external lotion 0.05 % external cream 0.2 % fluticasone propionate hydrocortisone valerate 2 external ointment 0.005 2 external ointment 0.2 % % imiquimod external 2 glycolic acid solution 70 cream 5 % 2 % isotretinoin oral capsule QL (2 EA 2 GORDOFILM 10 mg, 20 mg, 30 mg, 40 per 1 day) EXTERNAL SOLUTION 4 mg 16.7-16.7 % KERALYT EXTERNAL 4 grafco silver nit applicator 2 GEL 6 % external 75-25 % KERALYT SCALP 4 halcinonide external 2 EXTERNAL KIT 6 % cream 0.1 % KERAMATRIX halobetasol propionate REPLICINE 5CMX5CM 4 2 external cream 0.05 % EXTERNAL SHEET halobetasol propionate lactic acid e external 2 external ointment 0.05 % cream 10-3500 %- 2 Brand unt/30gm 4 penalty HALOG EXTERNAL lactic acid external lotion 2 CREAM 0.1 % applies 10 %

HALOG EXTERNAL 4 LATRIX XM EXTERNAL 4 OINTMENT 0.1 % EMULSION 45 % hydrocortisone butyr lipo LEVULAN KERASTICK base external cream 0.1 2 EXTERNAL SOLUTION GM % RECONSTITUTED 20 % hydrocortisone butyrate LOYON EXTERNAL 2 4 external cream 0.1 % SOLUTION hydrocortisone butyrate methoxsalen rapid oral 2 2 external lotion 0.1 % capsule 10 mg hydrocortisone butyrate methyl salicylate external 2 2 external ointment 0.1 % liquid hydrocortisone butyrate 2 metronidazole external 2 external solution 0.1 % cream 0.75 %

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 111 Drug Drug Drug Name Notes Drug Name Notes Tier Tier metronidazole external PICATO EXTERNAL 2 4 PA gel 0.75 %, 1 % GEL 0.015 %, 0.05 % metronidazole external 2 pimecrolimus external 2 lotion 0.75 % cream 1 %

MICROCYN EXTERNAL 4 podocon external 2 LIQUID 0.023 % solution 25 %

MIRVASO EXTERNAL 4 PA podofilox external 2 GEL 0.33 % solution 0.5 % mometasone furoate pramox external gel 1 % 2 2 external cream 0.1 % PRE & POST SX mometasone furoate POUCH EXTERNAL 2 4 external ointment 0.1 % THERAPY PACK 4 & 2 & mometasone furoate 5 % 2 external solution 0.1 % prednicarbate external 2 cream 0.1 % myorisan oral capsule 10 QL (2 EA 2 mg, 20 mg, 30 mg, 40 per 1 day) prednicarbate external 2 mg ointment 0.1 % NEO-SYNALAR Brand EXTERNAL CREAM 0.5- 4 PRUDOXIN EXTERNAL 4 penalty 0.025 % CREAM 5 % applies nolix external cream 0.05 PSORCON EXTERNAL 2 4 % CREAM 0.05 % nolix external lotion 0.05 PURAPLY EXTERNAL 2 GM % SHEET 6X9CM NUVAIL EXTERNAL PYROGALLIC ACID 4 SOLUTION EXTERNAL OINTMENT 4 OVACE PLUS 25-2 % 4 EXTERNAL CREAM 10 QBREXZA EXTERNAL 4 PA % PAD 2.4 % Specialty OVACE PLUS QUTENZA (2 PATCH) 6 EXTERNAL SHAMPOO 4 EXTERNAL KIT 8 % Medical 10 % Specialty QUTENZA EXTERNAL 6 OVACE PLUS WASH KIT 8 % Medical EXTERNAL LIQUID 10 4 REGRANEX EXTERNAL 4 PA % GEL 0.01 % OVACE WASH RESORCINOL-SULFUR EXTERNAL LIQUID 10 4 EXTERNAL LOTION 2-5 4 % % Brand Brand OXSORALEN ULTRA 3 penalty RETIN-A MICRO 4 penalty ORAL CAPSULE 10 MG applies EXTERNAL GEL 0.1 % applies

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 112 Drug Drug Drug Name Notes Drug Name Notes Tier Tier Brand SALVAX EXTERNAL 4 RETIN-A MICRO PUMP 4 penalty FOAM 6 % EXTERNAL GEL 0.1 % applies SANTYL EXTERNAL 6 RHOFADE EXTERNAL 4 PA OINTMENT 250 CREAM 1 % UNIT/GM rosadan external cream 2 SCALACORT DK 0.75 % EXTERNAL KIT 2 & 2-2 4 rosadan external gel 0.75 % 2 % SCENESSE PA; SALEX EXTERNAL KIT SUBCUTANEOUS 6 Specialty 6 % (CREAM), 6 % 4 IMPLANT 16 MG Medical (LOTION) selenium sulfide external 2 SALEX EXTERNAL lotion 2.5 % 4 SHAMPOO 6 % selenium sulfide external 2 shampoo 2.25 %, 2.3 % external 2 cream 6 % SELRX EXTERNAL 4 SHAMPOO 2.3 % salicylic acid external 2 foam 6 % sodium sulfacetamide 2 external shampoo 10 % salicylic acid external gel 2 6 % sodium sulfacetamide salicylic acid external wash liquid 10 % external 2 2 liquid 27.5 % 10 % salicylic acid external SODIUM 2 SULFACETAMIDE lotion 6 % 4 WASH LIQUID 10 % salicylic acid external 2 EXTERNAL 10 % shampoo 6 % SOOLANTRA 4 PA salicylic acid external 2 EXTERNAL CREAM 1 % solution 26 % SORIATANE ORAL Brand salicylic acid wart CAPSULE 10 MG, 25 3 penalty remover external liquid 2 MG applies 27.5 % sss 10-5 external cream 2 salicylic acid-cleanser 10-5 % external kit 6 % (cream), 2 6 % (lotion) sulfacetamide sodium (acne) external lotion 10 2 salimez external cream 6 2 % % sulfacetamide sodium 2 SALIMEZ FORTE external liquid 10 % EXTERNAL CREAM 10 4 % sulfacetamide sodium- sulfur external cream 10- 2 SALVAX DUO PLUS 2 %, 10-5 % EXTERNAL KIT 6 & 35 4 % Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 113 Drug Drug Drug Name Notes Drug Name Notes Tier Tier sulfacetamide sodium- tretinoin microsphere sulfur external emulsion 2 pump external gel 0.04 2 10-5 % %, 0.1 % sulfacetamide sodium- triamcinolone acetonide sulfur external lotion 10-5 2 external aerosol solution 2 %, 9.8-4.8 % 0.147 mg/gm sulfacetamide sodium- triamcinolone acetonide sulfur external pad 10-4 2 external cream 0.025 %, 2 % 0.1 %, 0.5 % sulfacetamide sodium- triamcinolone acetonide sulfur external external lotion 0.025 %, 2 2 suspension 10-5 %, 8-4 0.1 % % triamcinolone acetonide sulfacetamide-sulfur in external ointment 0.025 2 urea external emulsion 2 %, 0.05 %, 0.1 %, 0.5 % 10-5 % trianex external ointment 2 sulfacleanse 8/4 external 2 0.05 % suspension 8-4 % TRI-CHLOR EXTERNAL 4 sulfamez wash external LIQUID 80 % 2 emulsion 10-1 % triderm external cream 2 tacrolimus external 0.1 %, 0.5 % 2 ointment 0.03 %, 0.1 % turpentine external spirit 2 tazarotene external urea external cream 39 2 PA 2 cream 0.1 % %, 40 %, 41 %, 45 % TAZORAC EXTERNAL 4 PA urea external lotion 40 % 2 CREAM 0.05 % urea external suspension 2 PA; Brand 40 % TAZORAC EXTERNAL 4 penalty CREAM 0.1 % applies urea hydrating external 2 foam 35 % TAZORAC EXTERNAL 4 PA GEL 0.05 %, 0.1 % urea nail external gel 45 2 % THERAHONEY 4 EXTERNAL SHEET urea-c40 external lotion 2 40 % tovet external foam 0.05 2 uredeb external cream % 2 39 % tretinoin external cream 2 uremez-40 external 0.025 %, 0.05 %, 0.1 % 2 cream 40 % tretinoin external gel 0.01 2 %, 0.025 % ST; Brand VECTICAL EXTERNAL 4 penalty tretinoin microsphere OINTMENT 3 MCG/GM applies external gel 0.04 %, 0.1 2 %

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 114 Drug Drug Drug Name Notes Drug Name Notes Tier Tier VENELEX EXTERNAL Brand 4 OINTMENT ZONALON EXTERNAL 4 penalty CREAM 5 % applies VEREGEN EXTERNAL 4 OINTMENT 15 % Diabetes - Antidiabetic Agents VIRASAL EXTERNAL 4 LIQUID 27.5 % acarbose oral tablet 100 2 mg, 25 mg, 50 mg XERAC AC EXTERNAL 4 SOLUTION 6.25 % ACTOPLUS MET ORAL Brand 4 penalty XEROFORM OIL TABLET 15-500 MG, 15- applies EMULSION 2"X2" 4 850 MG EXTERNAL PAD Brand 4 penalty XEROFORM OIL ACTOS ORAL TABLET applies EMULSION GAUZE 4 15 MG, 30 MG, 45 MG EXTERNAL PAD ADLYXIN STARTER XEROFORM OIL PACK SUBCUTANEOUS 4 PA EMULSION STRIP 4 PEN-INJECTOR KIT 10 EXTERNAL & 20 MCG/0.2ML ADLYXIN XEROFORM OIL ROLL 4 4"X9' EXTERNAL 3 % SUBCUTANEOUS SOLUTION PEN- 4 PA XEROFORM PETROLAT INJECTOR 20 GAUZE 1"X8" 4 MCG/0.2ML EXTERNAL ALOGLIPTIN PA; QL (30 XEROFORM PETROLAT BENZOATE ORAL GAUZE 5"X9" 4 4 EA per 30 TABLET 12.5 MG, 25 days) EXTERNAL MG, 6.25 MG XEROFORM PETROLAT ALOGLIPTIN- PA; QL (60 PATCH 2"X2" 4 METFORMIN HCL ORAL 4 EA per 30 EXTERNAL PAD TABLET 12.5-1000 MG, days) XEROFORM PETROLAT 12.5-500 MG PATCH 4"X4" 4 ALOGLIPTIN- EXTERNAL PAD PIOGLITAZONE ORAL PA; QL (30 XEROFORM TABLET 12.5-15 MG, 4 EA per 30 4 PETROLATUM ROLL 12.5-30 MG, 12.5-45 days) 4"X9' EXTERNAL MG, 25-15 MG, 25-30 xurea external cream 39 MG, 25-45 MG 2 % Brand AMARYL ORAL TABLET 4 penalty zenatane oral capsule 10 QL (2 EA 2 1 MG, 2 MG, 4 MG applies mg, 20 mg, 30 mg, 40 per 1 day) AVANDIA ORAL mg 4 ST TABLET 2 MG, 4 MG ZITHRANOL EXTERNAL 4 SHAMPOO 1 %

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 115 Drug Drug Drug Name Notes Drug Name Notes Tier Tier BYDUREON BCISE glipizide-metformin hcl AUTOINJECTOR PA; QL oral tablet 2.5-250 mg, 2 SUBCUTANEOUS 3 (3.4 ML per 2.5-500 mg, 5-500 mg AUTO-INJECTOR 2 28 days) Brand MG/0.85ML GLUCOTROL ORAL 4 penalty BYDUREON PA; QL (4 TABLET 10 MG, 5 MG applies SUBCUTANEOUS PEN- 3 EA per 28 GLUCOTROL XL ORAL Brand INJECTOR 2 MG days) TABLET EXTENDED 4 penalty BYDUREON RELEASE 24 HOUR 10 applies SUBCUTANEOUS PA; QL (4 MG, 2.5 MG, 5 MG SUSPENSION 3 EA per 28 glyburide micronized oral 2 RECONSTITUTED ER 2 days) tablet 1.5 mg, 3 mg, 6 mg MG glyburide oral tablet 1.25 2 BYETTA 10 MCG PEN mg, 2.5 mg, 5 mg SUBCUTANEOUS PA; QL SOLUTION PEN- 3 (2.4 ML per glyburide-metformin oral INJECTOR 10 30 days) tablet 1.25-250 mg, 2.5- 2 MCG/0.04ML 500 mg, 5-500 mg BYETTA 5 MCG PEN GLYNASE ORAL Brand SUBCUTANEOUS PA; QL TABLET 1.5 MG, 3 MG, 4 penalty SOLUTION PEN- 3 (1.2 ML per 6 MG applies INJECTOR 5 30 days) Brand MCG/0.02ML GLYSET ORAL TABLET 4 penalty 100 MG, 25 MG, 50 MG applies CYCLOSET ORAL 4 TABLET 0.8 MG GLYXAMBI ORAL PA; QL (30 DUETACT ORAL Brand TABLET 10-5 MG, 25-5 4 EA per 30 TABLET 30-2 MG, 30-4 3 penalty MG days) MG applies INVOKAMET ORAL ST; QL (60 PA; QL (30 TABLET 150-1000 MG, 3 EA per 30 150-500 MG, 50-1000 FARXIGA ORAL 4 EA per 30 days) TABLET 10 MG, 5 MG days) MG, 50-500 MG glimepiride oral tablet 1 INVOKAMET XR ORAL 1 TABLET EXTENDED mg, 2 mg, 4 mg ST; QL (60 RELEASE 24 HOUR glipizide er oral tablet 3 EA per 30 150-1000 MG, 150-500 days) extended release 24 hour 2 MG, 50-1000 MG, 50- 10 mg, 2.5 mg, 5 mg 500 MG glipizide oral tablet 10 1 INVOKANA ORAL ST; QL (30 mg, 5 mg TABLET 100 MG, 300 3 EA per 30 glipizide xl oral tablet MG days) extended release 24 hour 2 JANUMET ORAL ST; QL (60 10 mg, 2.5 mg, 5 mg TABLET 50-1000 MG, 3 EA per 30 50-500 MG days)

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 116 Drug Drug Drug Name Notes Drug Name Notes Tier Tier JANUMET XR ORAL metformin hcl oral tablet TABLET EXTENDED ST; QL (30 1000 mg, 500 mg, 850 1 RELEASE 24 HOUR 3 EA per 30 mg 100-1000 MG, 50-500 days) miglitol oral tablet 100 2 MG mg, 25 mg, 50 mg JANUMET XR ORAL ST; QL (60 nateglinide oral tablet TABLET EXTENDED 2 3 EA per 30 120 mg, 60 mg RELEASE 24 HOUR 50- days) 1000 MG NESINA ORAL TABLET PA; QL (30 12.5 MG, 25 MG, 6.25 4 EA per 30 ST; QL (30 MG days) JANUVIA ORAL TABLET 3 EA per 30 100 MG, 25 MG, 50 MG days) PA; QL (30 ONGLYZA ORAL 4 EA per 30 ST; QL (30 TABLET 2.5 MG, 5 MG days) JARDIANCE ORAL 3 EA per 30 TABLET 10 MG, 25 MG days) OSENI ORAL TABLET 12.5-15 MG, 12.5-30 PA; QL (30 JENTADUETO ORAL ST; QL (60 MG, 12.5-45 MG, 25-15 4 EA per 30 3 EA per 30 TABLET 2.5-1000 MG, MG, 25-30 MG, 25-45 days) 2.5-500 MG, 2.5-850 MG days) MG JENTADUETO XR ORAL OZEMPIC ST; QL (60 PA; QL TABLET EXTENDED SUBCUTANEOUS 3 EA per 30 3 (1.5 ML per RELEASE 24 HOUR 2.5- SOLUTION PEN- days) 28 days) 1000 MG INJECTOR 2 MG/1.5ML JENTADUETO XR ORAL ST; QL (30 OZEMPIC PA; QL (3 TABLET EXTENDED 3 EA per 30 SUBCUTANEOUS RELEASE 24 HOUR 5- 3 ML per 28 days) SOLUTION PEN- days) 1000 MG INJECTOR 2 MG/1.5ML KAZANO ORAL TABLET PA; QL (60 pioglitazone hcl oral 12.5-1000 MG, 12.5-500 4 EA per 30 tablet 15 mg, 30 mg, 45 2 MG days) mg KOMBIGLYZE XR ORAL PA; QL (60 pioglitazone hcl- TABLET EXTENDED 4 EA per 30 glimepiride oral tablet 30- 2 RELEASE 24 HOUR 2.5- days) 2 mg, 30-4 mg 1000 MG pioglitazone hcl- KOMBIGLYZE XR ORAL PA; QL (30 metformin hcl oral tablet 2 TABLET EXTENDED 4 EA per 30 15-500 mg, 15-850 mg RELEASE 24 HOUR 5- days) 1000 MG, 5-500 MG PRECOSE ORAL Brand TABLET 100 MG, 25 4 penalty metformin hcl er oral MG, 50 MG applies tablet extended release 1 24 hour 500 mg, 750 mg PA; QL (30 QTERN ORAL TABLET 4 EA per 30 metformin hcl oral 2 10-5 MG days) solution 500 mg/5ml

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 117 Drug Drug Drug Name Notes Drug Name Notes Tier Tier PA; QL (1 SYNJARDY XR ORAL QTERN ORAL TABLET 4 EA per 1 TABLET EXTENDED ST; QL (60 5-5 MG day) RELEASE 24 HOUR 10- 3 EA per 30 1000 MG, 12.5-1000 MG, days) repaglinide oral tablet 0.5 2 mg, 1 mg, 2 mg 25-1000 MG, 5-1000 MG Brand tolbutamide oral tablet 2 RIOMET ORAL 4 penalty 500 mg SOLUTION 500 MG/5ML applies ST; QL (30 RYBELSUS ORAL PA; QL (30 TRADJENTA ORAL 3 EA per 30 TABLET 14 MG, 3 MG, 7 3 EA per 30 TABLET 5 MG days) MG days) TRIJARDY XR ORAL SEGLUROMET ORAL TABLET EXTENDED PA; QL (30 PA; QL (60 TABLET 2.5-1000 MG, RELEASE 24 HOUR 10- 4 EA per 30 4 EA per 30 5-1000 MG, 25-5-1000 days) 2.5-500 MG, 7.5-1000 days) MG, 7.5-500 MG MG SOLIQUA TRIJARDY XR ORAL PA; QL (60 SUBCUTANEOUS PA; QL (18 TABLET EXTENDED SOLUTION PEN- 4 ML per 30 RELEASE 24 HOUR 4 EA per 30 INJECTOR 100-33 UNT- days) 12.5-2.5-1000 MG, 5-2.5- days) MCG/ML 1000 MG Brand TRULICITY STARLIX ORAL TABLET 4 penalty SUBCUTANEOUS PA; QL (4 120 MG, 60 MG applies SOLUTION PEN- 3 ML per 28 INJECTOR 0.75 days) PA; QL (30 MG/0.5ML, 1.5 STEGLATRO ORAL 4 EA per 30 MG/0.5ML TABLET 15 MG, 5 MG days) VICTOZA SOLUTION STEGLUJAN ORAL PA; QL (30 PEN-INJECTOR 18 PA; QL (6 TABLET 15-100 MG, 5- 4 EA per 30 MG/3ML 3 ML per 30 100 MG days) SUBCUTANEOUS 18 days) SYMLINPEN 120 MG/3ML SUBCUTANEOUS VICTOZA SOLUTION SOLUTION PEN- 4 ST PEN-INJECTOR 18 PA; QL (9 INJECTOR 2700 MG/3ML 3 ML per 30 MCG/2.7ML SUBCUTANEOUS 18 days) SYMLINPEN 60 MG/3ML SUBCUTANEOUS XIGDUO XR ORAL SOLUTION PEN- 4 ST TABLET EXTENDED PA; QL (30 INJECTOR 1500 RELEASE 24 HOUR 10- 4 EA per 30 MCG/1.5ML 1000 MG, 10-500 MG, 5- days) SYNJARDY ORAL 500 MG ST; QL (60 TABLET 12.5-1000 MG, 3 EA per 30 12.5-500 MG, 5-1000 days) MG, 5-500 MG

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 118 Drug Drug Drug Name Notes Drug Name Notes Tier Tier XIGDUO XR ORAL Diabetes - Glycemic Agents TABLET EXTENDED 4 PA RELEASE 24 HOUR 2.5- BAQSIMI ONE PACK 1000 MG NASAL POWDER 3 4 MG/DOSE XIGDUO XR ORAL PA; QL (60 TABLET EXTENDED 4 EA per 30 BAQSIMI TWO PACK RELEASE 24 HOUR 5- days) NASAL POWDER 3 4 1000 MG MG/DOSE XULTOPHY diazoxide oral 2 SUBCUTANEOUS PA; QL (15 suspension 50 mg/ml SOLUTION PEN- 4 ML per 30 INJECTOR 100-3.6 days) GLUCAGEN HYPOKIT 3 UNIT-MG/ML INJECTION SOLUTION RECONSTITUTED 1 MG Diabetes - Glucose Monitoring GLUCAGON EMERGENCY KIT 3 QL (150 INJECTION KIT 1 MG FREESTYLE INSULINX 3 EA per 30 TEST IN VITRO STRIP days) GLUCAGON EMERGENCY KIT QL (150 INJECTION SOLUTION GM FREESTYLE LITE TEST 3 EA per 30 RECONSTITUTED 1 IN VITRO STRIP days) MG/ML FREESTYLE QL (150 GVOKE PFS PRECISION NEO TEST 3 EA per 30 SUBCUTANEOUS IN VITRO STRIP days) SOLUTION PREFILLED 4 QL (150 SYRINGE 0.5 FREESTYLE TEST IN 3 EA per 30 MG/0.1ML, 1 MG/0.2ML VITRO STRIP days) PROGLYCEM ORAL Brand QL (150 SUSPENSION 50 4 penalty PRECISION PCX PLUS 3 EA per 30 MG/ML applies TEST IN VITRO STRIP days) Diabetes - Insulins QL (150 ADMELOG SOLOSTAR ST; QL (60 PRECISION QID TEST 3 EA per 30 SUBCUTANEOUS IN VITRO STRIP days) 4 ML per 30 SOLUTION PEN- days) QL (150 INJECTOR 100 UNIT/ML PRECISION SOF-TACT 3 EA per 30 ADMELOG ST; QL (60 TEST IN VITRO STRIP days) SUBCUTANEOUS 4 ML per 30 PRECISION XTRA QL (150 SOLUTION 100 UNIT/ML days) BLOOD GLUCOSE IN 3 EA per 30 AFREZZA INHALATION QL (60 EA VITRO STRIP days) POWDER 12 UNIT, 4 & 4 per 30 8 & 12 UNIT, 8 UNIT, 90 PRECISION XTRA days) KETONE IN VITRO 3 X 4 UNIT & 90X8 UNIT STRIP

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 119 Drug Drug Drug Name Notes Drug Name Notes Tier Tier QL (180 FIASP PENFILL ST; QL (60 4 EA per 30 AFREZZA INHALATION SUBCUTANEOUS 4 ML per 30 days) POWDER 4 UNIT SOLUTION CARTRIDGE days) AFREZZA INHALATION 100 UNIT/ML POWDER 90 X 8 UNIT & 4 FIASP ST; QL (60 90X12 UNIT SUBCUTANEOUS 4 ML per 30 SOLUTION 100 UNIT/ML days) APIDRA SOLOSTAR QL (60 ML SUBCUTANEOUS HUMALOG KWIKPEN 4 per 30 SOLUTION PEN- SUBCUTANEOUS QL (60 ML days) INJECTOR 100 UNIT/ML SOLUTION PEN- 3 per 30 APIDRA VIAL QL (60 ML INJECTOR 100 days) INJECTION SOLUTION 4 per 30 UNIT/ML, 200 UNIT/ML 100 UNIT/ML days) HUMALOG MIX 50/50 BD AUTOSHIELD DUO KWIKPEN QL (60 ML PEN NEEDLES 30G X 5 3 SUBCUTANEOUS 3 per 30 SUSPENSION PEN- MM days) INJECTOR (50-50) 100 BD ULTRA-FINE UNIT/ML INSULIN SYRINGES HUMALOG MIX 50/50 27G X 1/2" 1 ML, 29G X QL (60 ML VIAL SUBCUTANEOUS 1/2" 0.3 ML, 29G X 1/2" 3 per 30 0.5 ML, 29G X 1/2" 1 ML, SUSPENSION (50-50) days) 30G X 1/2" 0.3 ML, 30G 100 UNIT/ML X 1/2" 0.5 ML, 30G X 3 HUMALOG MIX 75/25 1/2" 1 ML, 31G X 15/64" KWIKPEN QL (60 ML 0.3 ML, 31G X 15/64" 0.5 SUBCUTANEOUS 3 per 30 ML, 31G X 15/64" 1 ML, SUSPENSION PEN- days) 31G X 5/16" 0.3 ML, 31G INJECTOR (75-25) 100 X 5/16" 0.5 ML, 31G X UNIT/ML 5/16" 1 ML, 31G X 6MM HUMALOG MIX 75/25 0.5 ML QL (60 ML VIAL SUBCUTANEOUS 3 per 30 BD ULTRA-FINE PEN SUSPENSION (75-25) days) NEEDLES 29G X 100 UNIT/ML 12.7MM , 31G X 5 MM , 3 HUMALOG U-100 31G X 8 MM , 32G X 4 JUNIOR KWIKPEN QL (60 ML MM , 32G X 6 MM SUBCUTANEOUS 3 per 30 BD VEO INSULIN SYR SOLUTION PEN- days) U/F 1/2UNIT 31G X 3 INJECTOR 100 UNIT/ML 15/64" 0.3 ML HUMALOG VIAL QL (60 ML DROPLET MICRON 34G SUBCUTANEOUS 3 per 30 3 X 3.5 MM SOLUTION 100 UNIT/ML days)

FIASP FLEXTOUCH ST; QL (60 HUMALOG VIAL QL (60 ML SUBCUTANEOUS 4 ML per 30 SUBCUTANEOUS 3 per 30 SOLUTION PEN- days) SOLUTION CARTRIDGE days) INJECTOR 100 UNIT/ML 100 UNIT/ML

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 120 Drug Drug Drug Name Notes Drug Name Notes Tier Tier HUMULIN 70/30 INSULIN ASPART ST; QL (60 KWIKPEN QL (60 ML PENFILL 4 ML per 30 SUBCUTANEOUS 3 per 30 SUBCUTANEOUS days) SUSPENSION PEN- days) SOLUTION CARTRIDGE INJECTOR (70-30) 100 100 UNIT/ML UNIT/ML INSULIN ASPART PROT HUMULIN 70/30 VIAL & ASPART ST; QL (60 QL (60 ML SUBCUTANEOUS SUBCUTANEOUS 4 ML per 30 3 per 30 SUSPENSION (70-30) SUSPENSION (70-30) days) days) 100 UNIT/ML 100 UNIT/ML ST; QL (60 HUMULIN N KWIKPEN QL (60 ML INSULIN ASPART 4 ML per 30 SUBCUTANEOUS 3 per 30 SUBCUTANEOUS days) SUSPENSION PEN- days) SOLUTION 100 UNIT/ML INJECTOR 100 UNIT/ML INSULIN PEN NEEDLES HUMULIN N VIAL QL (60 ML 29G X 12.7MM , 29G X SUBCUTANEOUS 12MM , 29G X 5MM , 3 per 30 SUSPENSION 100 29G X 8MM , 30G X 5 days) UNIT/ML MM , 30G X 8 MM , 31G HUMULIN R U-500 X 5 MM , 31G X 6 MM , 3 KWIKPEN QL (60 ML 31G X 8 MM , 32G X 4 SUBCUTANEOUS 3 per 30 MM , 32G X 5 MM , 32G SOLUTION PEN- days) X 6 MM , 32G X 8 MM , INJECTOR 500 UNIT/ML 33G X 4 MM , 33G X 5 MM , 33G X 6 MM HUMULIN R U-500 VIAL QL (60 ML SUBCUTANEOUS 3 per 30 INSULIN SYRINGES SOLUTION 500 UNIT/ML days) 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML, 29G 0.3 ML, HUMULIN R VIAL QL (60 ML 29G X 1/2" 0.3 ML, 29G INJECTION SOLUTION 3 per 30 X 1/2" 0.5 ML, 29G X 100 UNIT/ML days) 1/2" 1 ML, 30G X 1/2" 0.3 INSULIN ASP PROT & ML, 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 30G X ASP FLEXPEN ST; QL (60 5/16" 0.3 ML, 30G X SUBCUTANEOUS 4 ML per 30 3 5/16" 0.5 ML, 30G X SUSPENSION PEN- days) INJECTOR (70-30) 100 5/16" 1 ML, 31G X 15/64" UNIT/ML 0.3 ML, 31G X 15/64" 0.5 INSULIN ASPART ML, 31G X 15/64" 1 ML, FLEXPEN ST; QL (60 31G X 5/16" 0.3 ML, 31G SUBCUTANEOUS 4 ML per 30 X 5/16" 0.5 ML, 31G X SOLUTION PEN- days) 5/16" 1 ML, 32G X 5/16" INJECTOR 100 UNIT/ML 0.5 ML, 32G X 5/16" 1 ML LANTUS SOLOSTAR QL (60 ML SUBCUTANEOUS 3 per 30 SOLUTION PEN- days) INJECTOR 100 UNIT/ML Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 121 Drug Drug Drug Name Notes Drug Name Notes Tier Tier LANTUS U-100 VIAL QL (60 ML NOVOLIN 70/30 VIAL ST; QL (60 3 per 30 SUBCUTANEOUS SUBCUTANEOUS 4 ML per 30 days) SOLUTION 100 UNIT/ML SUSPENSION (70-30) days) LEVEMIR U-100 100 UNIT/ML QL (60 ML FLEXTOUCH NOVOLIN N RELION ST; QL (60 3 per 30 SUBCUTANEOUS SUBCUTANEOUS 4 ML per 30 SOLUTION PEN- days) SUSPENSION 100 days) INJECTOR 100 UNIT/ML UNIT/ML LEVEMIR U-100 VIAL QL (60 ML NOVOLIN N VIAL ST; QL (60 SUBCUTANEOUS 3 per 30 SUBCUTANEOUS 4 ML per 30 days) SOLUTION 100 UNIT/ML SUSPENSION 100 days) MAXICOMFORT SYR UNIT/ML 27G X 1/2" 27G X 1/2" 3 NOVOLIN R RELION ST; QL (60 0.5 ML, 27G X 1/2" 1 ML INJECTION SOLUTION 4 ML per 30 MYXREDLIN 100 UNIT/ML days) ST; QL (60 INTRAVENOUS GM NOVOLIN R VIAL SOLUTION 100-0.9 INJECTION SOLUTION 4 ML per 30 UT/100ML-% 100 UNIT/ML days) NOVOFINE NOVOLOG FLEXPEN ST; QL (60 AUTOCOVER PEN 3 SUBCUTANEOUS 4 ML per 30 NEEDLE 30G X 8 MM SOLUTION PEN- days) INJECTOR 100 UNIT/ML NOVOFINE PEN 3 NEEDLE 32G X 6 MM NOVOLOG MIX 70/30 FLEXPEN NOVOFINE PLUS PEN 3 ST; QL (60 NEEDLE 32G X 4 MM SUBCUTANEOUS 4 ML per 30 SUSPENSION PEN- days) NOVOLIN 70/30 INJECTOR (70-30) 100 FLEXPEN RELION ST; QL (60 UNIT/ML SUBCUTANEOUS 4 ML per 30 NOVOLOG MIX 70/30 SUSPENSION PEN- ST; QL (60 days) VIAL SUBCUTANEOUS INJECTOR (70-30) 100 4 ML per 30 UNIT/ML SUSPENSION (70-30) days) 100 UNIT/ML NOVOLIN 70/30 NOVOLOG PENFILL FLEXPEN ST; QL (60 ST; QL (60 SUBCUTANEOUS SUBCUTANEOUS 4 ML per 30 4 ML per 30 SOLUTION CARTRIDGE SUSPENSION PEN- days) days) INJECTOR (70-30) 100 100 UNIT/ML UNIT/ML NOVOLOG U-100 VIAL ST; QL (60 NOVOLIN 70/30 RELION SUBCUTANEOUS 4 ML per 30 ST; QL (60 SUBCUTANEOUS SOLUTION 100 UNIT/ML days) 4 ML per 30 SUSPENSION (70-30) NOVOTWIST PEN days) 3 100 UNIT/ML NEEDLE 32G X 5 MM

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 122 Drug Drug Drug Name Notes Drug Name Notes Tier Tier TOUJEO MAX ANIMI-3/VITAMIN D 4 SOLOSTAR QL (60 ML ORAL CAPSULE 1 MG SUBCUTANEOUS 3 per 30 AQUASOL A SOLUTION PEN- days) INTRAMUSCULAR GM INJECTOR 300 UNIT/ML SOLUTION 15 MG/ML TOUJEO SOLOSTAR QL (60 ML ARGININE HCL SUBCUTANEOUS 3 per 30 INJECTION SOLUTION GM SOLUTION PEN- days) 6 GM/30ML INJECTOR 300 UNIT/ML argyle sterile saline 2 TRESIBA FLEXTOUCH irrigation solution 0.9 % SUBCUTANEOUS QL (60 ML argyle sterile water SOLUTION PEN- 3 per 30 2 INJECTOR 100 days) irrigation solution UNIT/ML, 200 UNIT/ML ASCOR INTRAVENOUS TRESIBA QL (60 ML SOLUTION 25000 GM SUBCUTANEOUS 3 per 30 MG/50ML SOLUTION 100 UNIT/ML days) ASCORBIC ACID Electrolytes / Minerals / INTRAVENOUS GM Metals / Vitamins SOLUTION 15000 MG/30ML ABANEU-SL SUBLINGUAL TABLET ATABEX OB ORAL 4 4 SUBLINGUAL 600-600 TABLET 29-1 MG MCG b-6 folic acid oral capsule 2 8.333-100-1 mg ACTIVE FE ORAL 4 TABLET 75-1.25 MG BACMIN ORAL TABLET 4 2 ACTIVITE ORAL 4 biocel oral tablet TABLET 1 MG bp vit 3 oral capsule 1 2 adc/f (0.5mg/ml) oral 2 mg solution 0.5 mg/ml b-plex oral tablet 2 ADRENAL C FORMULA 4 b-plex plus oral tablet 2 ORAL TABLET CALCIFOL ORAL aminoamrms oral 4 2 WAFER 1342-1.6 MG capsule CALCIUM CHLORIDE aminoreliefrms oral 2 SOLUTION 10 % GM capsule INTRAVENOUS 10 % AMINOSYN II calcium chloride solution GM GM INTRAVENOUS 10 % intravenous 10 % SOLUTION 10 %, 15 % CALCIUM GLUCONATE- AMINOSYN-PF NACL INTRAVENOUS GM INTRAVENOUS SOLUTION 1-0.675 GM SOLUTION 10 %, 7 % GM/50ML-%, 2-0.675 ANIMI-3 ORAL 4 GM/100ML-% CAPSULE 1 MG Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 123 Drug Drug Drug Name Notes Drug Name Notes Tier Tier CALCIUM-FOLIC ACID CARNITOR PLUS D ORAL WAFER 4 INTRAVENOUS GM 1342-1 MG SOLUTION 200 MG/ML Brand CARBAGLU ORAL 6 PA TABLET 200 MG CARNITOR ORAL 4 penalty CARDIOPLEGIA DEL SOLUTION 1 GM/10ML applies NIDO FORMULA GM Brand PERFUSION SOLUTION CARNITOR ORAL 4 penalty CARDIOPLEGIA IND TABLET 330 MG applies PLASMA HIGH K GM Brand PERFUSION SOLUTION CARNITOR SF ORAL 4 penalty CARDIOPLEGIA IND SOLUTION 1 GM/10ML applies GM PLASMA-TROMET CENTRATEX ORAL 4 PERFUSION SOLUTION CAPSULE 106-1 MG

CARDIOPLEGIA CHEMET ORAL 4 INDUCTION HIGH K GM CAPSULE 100 MG PERFUSION SOLUTION chromagen oral capsule 2 CARDIOPLEGIA chromic chloride INDUCTION LOW DEX GM intravenous solution 40 GM PERFUSION SOLUTION mcg/10ml CARDIOPLEGIA CITRANATAL ESSENCE INDUCTION NON-ENR GM ORAL THERAPY PACK 4 PERFUSION SOLUTION 35-1 & 300 MG CARDIOPLEGIA MAIN CITRANATAL MEDLEY LOW DEXTROSE GM ORAL CAPSULE 27-1- 4 PERFUSION SOLUTION 200 MG CARDIOPLEGIA MAIN CLINIMIX E/DEXTROSE LOW TROMETHA GM (2.75/5) INTRAVENOUS GM PERFUSION SOLUTION SOLUTION 2.75 % CARDIOPLEGIA MAIN CLINIMIX E/DEXTROSE PLASMA-TROME GM (4.25/10) GM PERFUSION SOLUTION INTRAVENOUS CARDIOPLEGIA SOLUTION 4.25 % MAINTENANCE GM CLINIMIX E/DEXTROSE PERFUSION SOLUTION (4.25/5) INTRAVENOUS GM CARDIOPLEGIA SOLUTION 4.25 % REPERFUSATE 4:1 GM CLINIMIX E/DEXTROSE PERFUSION SOLUTION (5/15) INTRAVENOUS GM CARDIOPLEGIC GM SOLUTION 5 % SOLUTION PERFUSION CLINIMIX E/DEXTROSE cardioplegic solution (5/20) INTRAVENOUS GM GM perfusion SOLUTION 5 %

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 124 Drug Drug Drug Name Notes Drug Name Notes Tier Tier CLINIMIX/DEXTROSE DAVITE ORAL TABLET 4 (4.25/10) GM 1 MG INTRAVENOUS DECARA ORAL SOLUTION 4.25 % CAPSULE 1.25 MG 2 CLINIMIX/DEXTROSE (50000 UT) (4.25/5) INTRAVENOUS GM deferasirox oral tablet 5 PA SOLUTION 4.25 % 180 mg, 360 mg, 90 mg CLINIMIX/DEXTROSE deferasirox oral tablet (5/15) INTRAVENOUS GM soluble 125 mg, 250 mg, 5 PA SOLUTION 5 % 500 mg CLINIMIX/DEXTROSE DELFLEX-LC/1.5% (5/20) INTRAVENOUS GM DEXTROSE 4 SOLUTION 5 % INTRAPERITONEAL CLINISOL SF SOLUTION 344 MOSM/L INTRAVENOUS GM DELFLEX-LC/2.5% SOLUTION 15 % DEXTROSE 4 CLINOLIPID INTRAPERITONEAL INTRAVENOUS GM SOLUTION 394 MOSM/L EMULSION 20 % DELFLEX-LC/4.25% clovique oral capsule 250 DEXTROSE 6 PA 4 mg INTRAPERITONEAL cod oil oral oil 2 SOLUTION 483 MOSM/L corvita 150 oral tablet delflex-sm/1.5% dextrose 2 150-1.25 mg intraperitoneal solution 2 347 mosm/l corvita oral tablet 1.25 2 mg delflex-sm/2.5% dextrose intraperitoneal solution 2 CORVITE 150 ORAL 4 398 mosm/l TABLET , 150-1.25 MG dexifol oral tablet 5 mg 2 CORVITE FE ORAL 4 TABLET DEXTROSE 5%/ELECTROLYTE #48 GM CUPRIC CHLORIDE INTRAVENOUS INTRAVENOUS GM SOLUTION SOLUTION 0.4 MG/ML dextrose in lactated curity sterile saline 2 ringers intravenous GM irrigation solution 0.9 % solution 5 % cyanocobalamin injection 2 dextrose intravenous solution 1000 mcg/ml solution 10 %, 20 %, 30 GM CYANOCOBALAMIN %, 40 %, 5 %, 70 % INJECTION SOLUTION GM DEXTROSE SOLUTION 2000 MCG/ML 250 MG/ML GM INTRAVENOUS 250 cytra k crystals oral 2 packet 3300-1002 mg MG/ML

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 125 Drug Drug Drug Name Notes Drug Name Notes Tier Tier dextrose solution 250 DIANEAL PD-2/2.5% GM mg/ml intravenous 250 DEXTROSE 4 mg/ml INTRAPERITONEAL DEXTROSE SOLUTION SOLUTION 396 MOSM/L 50 % INTRAVENOUS 50 GM DIANEAL PD-2/4.25% % DEXTROSE 4 INTRAPERITONEAL dextrose solution 50 % GM intravenous 50 % SOLUTION 485 MOSM/L dextrose-nacl DILUENT FOR LEFAMULIN intravenous solution 10- GM 0.2 %, 10-0.45 %, 2.5- INTRAVENOUS GM 0.45 %, 5-0.2 %, 5-0.3 SOLUTION 0.9 % %, 5-0.33 %, 5-0.45 %, DRISDOL ORAL Brand 5-0.9 % CAPSULE 1.25 MG 4 penalty dextrose-sodium chloride (50000 UT) applies intravenous solution 5- GM EFFER-K ORAL TABLET 0.225 %, 5-0.3 %, 5-0.45 EFFERVESCENT 10 4 %, 5-0.9 % MEQ, 20 MEQ DIALYVITE 3000 ORAL effer-k oral tablet 4 2 TABLET 3 MG effervescent 25 meq DIALYVITE 5000 ORAL ELITE-OB ORAL 4 4 TABLET 5 MG TABLET 50-1.25 MG dialyvite oral tablet 2 ELLIOTTS B INTRATHECAL GM DIALYVITE SUPREME D 4 ORAL TABLET 3 MG SOLUTION ENBRACE HR ORAL DIALYVITE/ZINC ORAL 4 4 TABLET CAPSULE DIANEAL LOW ergocalciferol oral capsule 1.25 mg (50000 2 CALCIUM/1.5% DEX 4 INTRAPERITONEAL ut) SOLUTION 344 MOSM/L EXJADE ORAL TABLET DIANEAL LOW SOLUBLE 125 MG, 250 6 PA CALCIUM/2.5% DEX MG, 500 MG 4 INTRAPERITONEAL EXTRANEAL SOLUTION 395 MOSM/L INTRAPERITONEAL 4 DIANEAL LOW SOLUTION 7.5 % CALCIUM/4.25% DEX 4 fabb oral tablet 2.2-25-1 2 INTRAPERITONEAL mg SOLUTION 483 MOSM/L fa-vitamin b-6-vitamin b- DIANEAL PD-2/1.5% 12 oral tablet 2.2-25-0.5 2 DEXTROSE mg 4 INTRAPERITONEAL SOLUTION 346 MOSM/L

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 126 Drug Drug Drug Name Notes Drug Name Notes Tier Tier FERAHEME folbee plus oral tablet 2 INTRAVENOUS GM FOLGARD OS ORAL 4 SOLUTION 510 TABLET 500-1.1 MG MG/17ML FOLGARD RX ORAL 4 FERIVAFA ORAL 4 TABLET 2.2-25-1 MG CAPSULE 110-1 MG folic acid injection GM ferocon oral capsule 2 solution 5 mg/ml ferotrinsic oral capsule 2 folic acid oral tablet 1 mg 2 FERRALET 90 ORAL 4 folic acid oral tablet 400 PV TABLET 90-1 MG mcg, 800 mcg FERRAPLUS 90 ORAL FOLIVANE-F ORAL 4 4 TABLET 90-1 MG CAPSULE 125-1 MG FERRIPROX ORAL FOLIVANE-PLUS ORAL 6 PA 4 SOLUTION 100 MG/ML CAPSULE FERRIPROX ORAL folplex 2.2 oral tablet 2.2- 2 TABLET 1000 MG, 500 6 PA 25-0.5 mg MG FOLTRATE ORAL 4 FERRIPROX TWICE-A- TABLET 500-1 MCG-MG DAY ORAL TABLET 4 1000 MG foltrin oral capsule 2 FERRLECIT FORTAVIT ORAL 4 INTRAVENOUS GM CAPSULE SOLUTION 12.5 MG/ML FREAMINE HBC FERRO-PLEX INTRAVENOUS GM HEMATINIC ORAL 4 SOLUTION 6.9 % TABLET 115-1 MG FREAMINE III INTRAVENOUS GM FERROTRIN ORAL 4 CAPSULE SOLUTION 10 % FUSION PLUS ORAL FLORIVA PLUS ORAL 4 4 SOLUTION 0.25 MG/ML CAPSULE FLUORABON ORAL GALZIN ORAL SOLUTION 0.55 (0.25 F) 4 CAPSULE 25 MG, 50 3 MG/0.6ML MG fluoritab oral solution GENICIN VITA-S ORAL PV 4 0.275 (0.125 f) mg/drop TABLET 1 MG fluoritab oral tablet GLUTATHIONE INJECTION SOLUTION GM chewable 0.55 (0.25 f) PV mg, 1.1 (0.5 f) mg, 2.2 (1 200 MG/ML, 6 GM/30ML f) mg GLUTATHIONE FLURA-DROPS ORAL INTRAVENOUS GM SOLUTION 0.55 (0.25 F) 4 SOLUTION 6 GM/30ML MG/DROP

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 127 Drug Drug Drug Name Notes Drug Name Notes Tier Tier GLYCINE INJECTION INFUVITE PEDIATRIC GM SOLUTION 50 MG/ML INTRAVENOUS GM SOLUTION gnp folic acid oral tablet PV 400 mcg INJECTAFER INTRAVENOUS hematinic/folic acid oral 2 GM tablet 324-1 mg SOLUTION 750 MG/15ML HEMATOGEN FA ORAL INTEGRA F ORAL CAPSULE 200-250-0.01- 4 4 1 MG CAPSULE 125-1 MG INTEGRA PLUS ORAL hematogen forte oral 4 capsule 460-60-0.01-1 2 CAPSULE mg intralipid intravenous GM hematogen oral capsule 2 emulsion 20 % INTRALIPID HEMATRON-AF ORAL 4 TABLET 150-1 MG INTRAVENOUS GM EMULSION 30 % HEMOCYTE PLUS ORAL CAPSULE 106-1 4 iodine strong oral 2 MG solution 5 % IONOSOL-MB IN D5W hemocyte-f oral tablet 2 324-1 mg INTRAVENOUS GM SOLUTION HEPATAMINE INTRAVENOUS GM IROSPAN 24/6 ORAL 4 SOLUTION 8 % IS 24/6 ORAL 4 hydroxocobalamin ISOLYTE-P IN D5W acetate intramuscular GM INTRAVENOUS GM solution 1000 mcg/ml SOLUTION

HYLAVITE ORAL 4 ISOLYTE-S TABLET INTRAVENOUS GM HYPERLYTE-CR SOLUTION INTRAVENOUS GM ISOLYTE-S PH 7.4 CONCENTRATE INTRAVENOUS GM ICAR-C PLUS ORAL SOLUTION TABLET 100-250-0.025- 4 JADENU ORAL TABLET 6 PA 1 MG 180 MG, 360 MG, 90 MG iferex 150 forte oral JADENU SPRINKLE capsule 150-25-1 mg- 2 ORAL PACKET 180 MG, 6 PA mcg-mg 360 MG, 90 MG

INFUVITE ADULT JYNARQUE ORAL 6 PA INTRAVENOUS GM TABLET 15 MG, 30 MG INJECTABLE

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 128 Drug Drug Drug Name Notes Drug Name Notes Tier Tier JYNARQUE ORAL klor-con sprinkle oral TABLET THERAPY capsule extended 2 PACK 15 MG, 30 & 15 6 PA release 10 meq, 8 meq MG, 45 & 15 MG, 60 & klor-con/ef oral tablet 2 30 MG, 90 & 30 MG effervescent 25 meq KABIVEN K-PHOS NO 2 ORAL INTRAVENOUS 4 GM TABLET 305-700 MG EMULSION 3.3-9.8-3.9- K-PHOS ORAL TABLET 0.7 % 4 500 MG kcl in dextrose-nacl intravenous solution K-PHOS-NEUTRAL 0.15-5-0.45 %, 10-5-0.45 ORAL TABLET 155-852- 4 meq/l-%-%, 20-5-0.2 130 MG meq/l-%-%, 20-5-0.225 k-prime oral tablet 2 meq/l-%-%, 20-5-0.45 GM effervescent 25 meq meq/l-%-%, 20-5-0.9 K-TAB ORAL TABLET Brand meq/l-%-%, 30-5-0.45 EXTENDED RELEASE meq/l-%-%, 40-5-0.45 4 penalty 10 MEQ, 20 MEQ, 8 applies meq/l-%-%, 40-5-0.9 MEQ meq/l-%-% k-tan plus oral capsule 2 kcl-lactated ringers-d5w 162-115.2-1 mg intravenous solution 20 GM lactated ringers meq/l GM intravenous solution KCL-LIDOCAINE-NACL INTRAVENOUS lactated ringers irrigation GM 2 SOLUTION 10-10 MEQ- solution MG /100ML LEVOCARNITINE kionex oral suspension INJECTION SOLUTION GM 2 15 gm/60ml 500 MG/ML levocarnitine oral solution klor-con 10 oral tablet 2 2 extended release 10 meq 1 gm/10ml levocarnitine oral tablet klor-con m10 oral tablet 2 2 extended release 10 meq 330 mg levocarnitine sf oral KLOR-CON M15 ORAL 2 TABLET EXTENDED 4 solution 1 gm/10ml RELEASE 15 MEQ LIPO INTRAMUSCULAR klor-con m20 oral tablet SOLUTION 50-50-25 GM 2 extended release 20 meq MG/ML klor-con oral packet 20 LIPO-C 2 meq INTRAMUSCULAR GM SOLUTION klor-con oral tablet 2 extended release 8 meq LIQUIVIDA HYDRATION INTRAVENOUS KIT 0.9 GM %

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 129 Drug Drug Drug Name Notes Drug Name Notes Tier Tier LORID ORAL TABLET 1 MANGANESE 4 MG CHLORIDE GM ludent oral tablet INTRAVENOUS SOLUTION 0.1 MG/ML chewable 0.55 (0.25 f) PV mg, 1.1 (0.5 f) mg, 2.2 (1 Brand f) mg MEPHYTON ORAL 4 penalty applies LYSINE HCL TABLET 5 MG INJECTION SOLUTION GM METHYLCOBALAMIN 100 MG/ML INJECTION SOLUTION GM lysiplex plus oral tablet 2 150 MG/30ML, 30 MG/30ML, 300 MG/30ML M.V.I. ADULT INTRAVENOUS GM METHYLCOBALAMIN INJECTABLE INJECTION SOLUTION GM RECONSTITUTED M.V.I. PEDIATRIC 10000 MCG, 50000 MCG INTRAVENOUS GM SOLUTION MIC-L-CARNITINE GM RECONSTITUTED INJECTION SOLUTION 25-50-50-50 MG/ML MAGNEBIND 400 ORAL 4 TABLET 400-200-1 MG MICROPLEGIA MSA- MSG PERFUSION GM magnesium sulfate in SOLUTION d5w intravenous solution GM 1-5 gm/100ml-% Brand MIFEPREX ORAL 4 penalty magnesium sulfate 2 TABLET 200 MG applies injection solution 50 % mifepristone oral tablet 2 MAGNESIUM SULFATE 200 mg INTRAVENOUS QL (1 EA SOLUTION 1000 M-NATAL PLUS ORAL 4 per 1 day) MG/1.6ML, 2000 GM TABLET 27-1 MG MG/3.2ML, 3000 monoject flush syringe MG/4.8ML, 4000 intravenous solution 0.9 2 MG/6.4ML % magnesium sulfate monoject sodium chloride intravenous solution 2 flush intravenous solution 2 gm/50ml, 20 gm/500ml, 4 GM 0.9 % gm/100ml, 4 gm/50ml, 40 MULTIGEN FOLIC gm/1000ml ORAL TABLET 70-150- 4 MAGNESIUM SULFATE- 2-1 MG NACL INTRAVENOUS GM MULTIGEN ORAL 4 SOLUTION 2-0.9 TABLET 70 MG GM/50ML-% MULTIGEN PLUS ORAL 4 TABLET 50-101-1 MG MULTIPRO ORAL 4 CAPSULE Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 130 Drug Drug Drug Name Notes Drug Name Notes Tier Tier multi-vit/iron/fluoride oral NEONATAL PLUS ORAL QL (1 EA 2 4 solution 0.25-10 mg/ml TABLET 27-1 MG per 1 day) multivitamin/fluoride oral NEOVITE ORAL 4 solution 0.25 mg/ml, 0.5 2 TABLET mg/ml NEPHPLEX RX ORAL 4 multi-vitamin/fluoride oral TABLET solution 0.25 mg/ml, 0.5 2 NEPHRAMINE mg/ml INTRAVENOUS GM multivitamin/fluoride oral SOLUTION 5.4 % tablet chewable 0.25 mg, 2 NEPHRON FA ORAL 4 1 mg TABLET multivitamin/fluoride/iron nephronex oral tablet 2 oral solution 0.25-10 2 NEPHRO-VITE RX mg/ml 4 ORAL TABLET 1 MG multi-vitamin/fluoride/iron oral solution 0.25-10 2 NESTABS ORAL 4 mg/ml TABLET 32-1 MG NEURIN-SL mvc-fluoride oral tablet 2 chewable 0.25 mg, 1 mg SUBLINGUAL TABLET 4 SUBLINGUAL 600-600 myferon 150 forte oral MCG capsule 150-25-1 mg- 2 NICADAN ORAL mcg-mg 4 TABLET mynephrocaps oral 2 NICAZEL FORTE ORAL capsule 1 mg 4 TABLET mynephron oral capsule 2 1 mg NICAZEL ORAL TABLET 4 na ferric gluc cplx in NICOMIDE ORAL sucrose intravenous GM TABLET 750-27-2-0.5 4 solution 12.5 mg/ml MG NIFEREX ORAL n-acetyl-l-cysteine oral 2 4 capsule 600 mg TABLET nafrinse drops oral normal saline flush solution 0.275 (0.125 f) PV intravenous solution 0.9 2 mg/drop % nafrinse oral tablet NORMOSOL-M IN D5W PV chewable 2.2 (1 f) mg INTRAVENOUS GM SOLUTION NASCOBAL NASAL SOLUTION 500 3 NORMOSOL-R IN D5W MCG/0.1ML INTRAVENOUS GM SOLUTION QL (1 EA NEONATAL COMPLETE 4 ORAL TABLET 27-1 MG per 1 day) NORMOSOL-R INTRAVENOUS GM SOLUTION Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 131 Drug Drug Drug Name Notes Drug Name Notes Tier Tier NORMOSOL-R PH 7.4 phytonadione oral tablet 2 INTRAVENOUS GM 5 mg SOLUTION PLASMA-LYTE 148 NUFERA ORAL TABLET 4 INTRAVENOUS GM SOLUTION NUTRICAP ORAL 4 TABLET PLASMA-LYTE A nutrifac zx oral tablet 2 INTRAVENOUS GM SOLUTION nutrilipid intravenous GM PLEGISOL PERFUSION emulsion 20 % GM SOLUTION NUTRIVIT ORAL LIQUID 4 PLENAMINE OMEGAVEN PA; INTRAVENOUS GM INTRAVENOUS 6 Specialty SOLUTION 15 % EMULSION 10 Medical GM/100ML, 5 GM/50ML pnv prenatal plus multivit+dha oral 27-1 & 2 ONE VITE WOMENS QL (1 EA 312 mg 4 PLUS ORAL TABLET per 1 day) 27-1 MG poly-iron 150 forte oral capsule 150-25-1 mg- 2 ONEVITE ORAL 4 mcg-mg TABLET 1 MG polysaccharide iron forte ORACIT ORAL oral capsule 150-25-1 2 SOLUTION 490-640 3 mg-mcg-mg MG/5ML POLY-VI-FLOR FS PERIKABIVEN ORAL STRIP 0.25 MG, 4 INTRAVENOUS GM 0.5 MG, 1 MG EMULSION 2.4-6.8-3.5- 0.5 % POLY-VI-FLOR ORAL SUSPENSION 0.25 4 phospha 250 neutral oral 2 MG/ML tablet 155-852-130 mg POLY-VI-FLOR ORAL phosphorous oral tablet 2 TABLET CHEWABLE 4 155-852-130 mg 0.25 MG, 0.5 MG, 1 MG phospho-trin 250 neutral POLY-VI-FLOR/IRON oral tablet 155-852-130 2 ORAL SUSPENSION 4 mg 0.25-7 MG/ML PHYSIOLYTE 4 POLY-VI-FLOR/IRON IRRIGATION SOLUTION ORAL TABLET 4 PHYSIOSOL CHEWABLE 0.5-10 MG IRRIGATION 4 pot bicarb-pot chloride IRRIGATION SOLUTION oral tablet effervescent 2 phytonadione injection 25 meq solution 1 mg/0.5ml, 10 GM potassium acetate mg/ml intravenous solution 2 GM meq/ml Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 132 Drug Drug Drug Name Notes Drug Name Notes Tier Tier potassium bicarbonate PREMASOL oral tablet effervescent 2 INTRAVENOUS GM 25 meq SOLUTION 10 % potassium chloride crys PREMESISRX ORAL 4 er oral tablet extended 2 TABLET 1 MG release 10 meq, 20 meq PRENAISSANCE ORAL potassium chloride er CAPSULE 29-1.25-325 4 oral capsule extended 2 MG release 10 meq, 8 meq PRENATA ORAL potassium chloride er TABLET CHEWABLE 4 oral tablet extended 29-1 MG 2 release 10 meq, 20 meq, prenatal oral tablet 27-1 QL (1 EA 2 8 meq mg per 1 day) potassium chloride in prenatal plus iron oral 2 dextrose intravenous GM tablet 29-1 mg solution 20-5 meq/l-% PRENATE DHA ORAL potassium chloride in CAPSULE 18-0.6-0.4- 4 nacl intravenous solution GM 300 MG 20-0.45 meq/l-%, 20-0.9 meq/l-%, 40-0.9 meq/l-% PRENATE ELITE ORAL 4 TABLET 20-0.6-0.4 MG potassium chloride intravenous solution 10 PRENATE ENHANCE ORAL CAPSULE 28-0.6- 4 meq/100ml, 10 GM meq/50ml, 2 meq/ml, 20 0.4-400 MG meq/100ml, 20 PRENATE ESSENTIAL meq/50ml, 40 meq/100ml ORAL CAPSULE 18-0.6- 4 0.4-300 MG potassium chloride oral 2 packet 20 meq PRENATE MINI ORAL potassium chloride oral CAPSULE 18-0.6-0.4- 4 solution 20 meq/15ml 350 MG 2 (10%), 40 meq/15ml PRENATE ORAL (20%) TABLET CHEWABLE 4 potassium citrate er oral 0.6-0.4 MG tablet extended release PRENATE PIXIE ORAL 10 meq (1080 mg), 15 2 CAPSULE 10-0.6-0.4- 4 meq (1620 mg), 5 meq 200 MG (540 mg) PRENATE RESTORE potassium citrate-citric ORAL CAPSULE 27-0.6- 4 acid oral solution 1100- 2 0.4-400 MG 334 mg/5ml PRENATVITE potassium COMPLETE ORAL 4 phosphates(71 meq k) GM TABLET 1 MG intravenous solution 45 mmole/15ml Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 133 Drug Drug Drug Name Notes Drug Name Notes Tier Tier PRENATVITE PLUS pyridoxine hcl solution 4 ORAL TABLET 1 MG 100 mg/ml injection 100 GM mg/ml PRENATVITE RX ORAL 4 TABLET 0.8 MG QUFLORA PEDIATRIC PRISMASOL B22GK 4/0 ORAL SOLUTION 0.25 4 INTRAVENOUS GM MG/ML, 0.5 MG/ML SOLUTION 22-4 MEQ/L QUFLORA PEDIATRIC ORAL TABLET PRISMASOL BGK 0/2.5 4 INTRAVENOUS CHEWABLE 0.25 MG, 1 GM SOLUTION 32-2.5 MG MEQ/L RELNATE DHA ORAL 4 PRISMASOL BGK 2/0 CAPSULE 28-1-200 MG INTRAVENOUS GM renal oral capsule 1 mg 2 SOLUTION 32-2 MEQ/L RENATABS ORAL 4 PRISMASOL BGK 2/3.5 TABLET 1 MG INTRAVENOUS GM RENATABS WITH IRON 4 SOLUTION 32-2-3.5 ORAL 1 & 100 MG MEQ/L REQ 49+ ORAL TABLET 4 PRISMASOL BGK 4/2.5 INTRAVENOUS ringers intravenous GM GM SOLUTION 32-4-2.5 solution MEQ/L ringers irrigation irrigation 2 PRISMASOL BK 0/0/1.2 solution INTRAVENOUS saline bacteriostatic GM GM SOLUTION 32-1.2 injection solution 0.9 % MEQ/L saline flush intravenous 2 PROCALAMINE solution 0.9 % GM INTRAVENOUS saline flush zr SOLUTION 3 % intravenous solution 0.9 2 PROSOL % GM INTRAVENOUS SALINE-PHENOL SOLUTION 20 % INJECTION SOLUTION GM purevit dualfe plus oral 2 0.4-0.9 % capsule 162-115.2-1 mg SAMSCA ORAL TABLET 6 PA PYRIDOXAL-5 15 MG, 30 MG PHOSPHATE GM SELECT-OB ORAL INJECTION SOLUTION TABLET CHEWABLE 4 100 MG/ML 29-1 MG PYRIDOXINE HCL SELENIOUS ACID GM SOLUTION 100 MG/ML INTRAVENOUS GM INJECTION 100 MG/ML SOLUTION 60 MCG/ML

se-tan plus oral capsule 2 162-115.2-1 mg Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 134 Drug Drug Drug Name Notes Drug Name Notes Tier Tier SIDEROL ORAL sodium fluoride oral 4 TABLET tablet chewable 0.55 PV SMOFLIPID (0.25 f) mg, 1.1 (0.5 f) INTRAVENOUS GM mg, 2.2 (1 f) mg EMULSION 20 % sodium polystyrene 2 sulfonate oral powder sod citrate-citric acid oral 2 solution 500-334 mg/5ml sodium polystyrene sodium acetate sulfonate oral suspension 2 intravenous solution 2 GM 15 gm/60ml meq/ml sodium polystyrene sulfonate rectal SODIUM 2 BICARBONATE suspension 30 GM SOLUTION 8.4 % gm/120ml, 50 gm/200ml INTRAVENOUS 8.4 % sps oral suspension 15 2 sodium bicarbonate gm/60ml GM solution 8.4 % sterile water for irrigation 2 intravenous 8.4 % irrigation solution

SODIUM STROVITE FORTE 4 BICARBONATE- ORAL SYRUP DEXTROSE STROVITE FORTE GM 4 INTRAVENOUS ORAL TABLET SOLUTION 150-5 STROVITE ONE ORAL MEQ/L-% 4 TABLET sodium chloride (pf) GM SUPERVITE ORAL injection solution 0.9 % 4 LIQUID sodium chloride bacteriostatic injection GM SUPPORT ORAL 4 solution 0.9 % LIQUID sodium chloride flush SUPPORT-500 ORAL 4 intravenous solution 0.9 2 CAPSULE % swabflush saline flush sodium chloride injection intravenous solution 0.9 2 GM solution 2.5 meq/ml % SYNAGEX ORAL sodium chloride 4 intravenous solution 0.45 GM CAPSULE 1.25 MG %, 0.9 %, 3 %, 5 % SYNATEK ORAL 4 CAPSULE 1.25 MG sodium chloride irrigation 2 solution 0.9 % SYPRINE ORAL 6 PA CAPSULE 250 MG sodium fluoride oral PV solution 1.1 (0.5 f) mg/ml TALIVA ORAL 4 sodium fluoride oral CAPSULE 1 MG tablet 1.1 (0.5 f) mg, 2.2 PV TARON FORTE ORAL 4 (1 f) mg CAPSULE Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 135 Drug Drug Drug Name Notes Drug Name Notes Tier Tier taron-crystals oral packet TRONVITE ORAL 2 4 3300-1002 mg TABLET 1 MG

TAURINE INJECTION GM TROPHAMINE SOLUTION 50 MG/ML INTRAVENOUS GM SOLUTION 10 % thiamine hcl injection GM solution 100 mg/ml tryptophan oral capsule 2 tis-u-sol irrigation solution 2 500 mg UDAMIN SP ORAL tl-hem 150 oral tablet 2 4 150-1 mg TABLET 1 MG tolvaptan oral tablet 30 ULTRABAG/DIANEAL 6 PA PD-2/1.5% DEX mg 4 INTRAPERITONEAL tpn electrolytes GM SOLUTION 346 MOSM/L intravenous concentrate ULTRABAG/DIANEAL TRAVASOL PD-2/2.5% DEX 4 INTRAVENOUS GM INTRAPERITONEAL SOLUTION 10 % SOLUTION 396 MOSM/L TRICARE PRENATAL ULTRABAG/DIANEAL DHA ONE ORAL 4 PD-2/4.25%DEX 4 CAPSULE 27-1-500 MG INTRAPERITONEAL SOLUTION 485 MOSM/L tricitrates oral solution 2 550-500-334 mg/5ml ULTRABAG/DIANEAL/1. 2 tricon oral capsule 5% DEXTROSE 4 trientine hcl oral capsule INTRAPERITONEAL 6 PA 250 mg SOLUTION 344 MOSM/L trigels-f forte oral capsule ULTRABAG/DIANEAL/2. 2 460-60-0.01-1 mg 5% DEXTROSE 4 INTRAPERITONEAL trinate oral tablet 2 SOLUTION 395 MOSM/L triphrocaps oral capsule 2 ULTRABAG/DIANEAL/4. 1 mg 25% DEX 4 TRI-VI-FLOR ORAL INTRAPERITONEAL SUSPENSION 0.25 4 SOLUTION 483 MOSM/L MG/ML, 0.5 MG/ML UROCIT-K 10 ORAL Brand TRI-VI-FLORO ORAL TABLET EXTENDED 3 penalty 4 SUSPENSION 0.25 RELEASE 10 MEQ applies MG/ML, 0.5 MG/ML (1080 MG) tri-vitamin/fluoride oral UROCIT-K 15 ORAL Brand 2 TABLET EXTENDED solution 0.25 mg/ml, 0.5 3 penalty RELEASE 15 MEQ mg/ml applies tri-vite/fluoride oral (1620 MG) solution 0.25 mg/ml, 0.5 2 mg/ml

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 136 Drug Drug Drug Name Notes Drug Name Notes Tier Tier UROCIT-K 5 ORAL vitamins acd-fluoride oral Brand 2 TABLET EXTENDED 3 penalty solution 0.25 mg/ml RELEASE 5 MEQ (540 applies VITAROCA PLUS ORAL 4 MG) TABLET urosex oral tablet 2 VITA-RX DIABETIC v-c forte oral capsule 2 VITAMIN ORAL 4 VELTASSA ORAL CAPSULE PACKET 16.8 GM, 25.2 4 PA VITASURE ORAL 4 GM, 8.4 GM TABLET 1 MG VENOFER VITATHELY WITH QL (1 EA INTRAVENOUS GM GINGER ORAL TABLET 4 per 1 day) SOLUTION 20 MG/ML 27-1 MG vic-forte oral capsule 2 vp-pnv-dha oral capsule 2 28-1-215.8 mg virt-caps oral capsule 1 2 mg vp-vite rx oral tablet 1 mg 2

VIRT-FEFA PLUS ORAL 4 water for irrigation, sterile 2 CAPSULE irrigation solution virt-gard oral tablet 2.2- 2 weekly-d oral capsule 2 25-1 mg 1.25 mg (50000 ut) 2 virt-phos 250 neutral oral 2 wheat germ oil oral oil tablet 155-852-130 mg XVITE ORAL TABLET 1 4 visiv intravenous solution MG GM 5 % ZINC CHLORIDE vita s forte oral tablet 2 INTRAVENOUS GM vitacel oral tablet 2 SOLUTION 1 MG/ML VITAFOL ORAL TABLET 4 ZINC SULFATE INTRAVENOUS GM VITAFOL-OB+DHA 4 SOLUTION 3 MG/ML ORAL 65-1 & 250 MG Gastrointestinal Agents VITAL-D RX ORAL 4 - Drugs for Acid Reflux TABLET 1 MG and Ulcer VITAMAX PEDIATRIC 4 ACIPHEX ORAL Brand ORAL SOLUTION TABLET DELAYED 4 penalty RELEASE 20 MG applies VITAMEZ ORAL 4 CAPSULE 1 MG ACIPHEX SPRINKLE vitamin d (ergocalciferol) ORAL CAPSULE 4 oral capsule 1.25 mg 2 SPRINKLE 10 MG, 5 MG (50000 ut) CARAFATE ORAL Brand vitamin k1 injection SUSPENSION 1 3 penalty solution 1 mg/0.5ml, 10 GM GM/10ML applies mg/ml vita-min oral capsule 2 Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 137 Drug Drug Drug Name Notes Drug Name Notes Tier Tier Brand NEXIUM 24HR ORAL QL (120 CARAFATE ORAL 4 penalty CAPSULE DELAYED 2 EA per 30 TABLET 1 GM applies RELEASE 20 MG days) QL (120 cimetidine hcl oral 2 NEXIUM 24HR ORAL solution 300 mg/5ml TABLET DELAYED 2 EA per 30 cimetidine oral tablet 200 RELEASE 20 MG days) mg, 300 mg, 400 mg, 2 NEXIUM I.V. 800 mg INTRAVENOUS CYTOTEC ORAL Brand SOLUTION GM TABLET 100 MCG, 200 4 penalty RECONSTITUTED 40 MCG applies MG DEXILANT ORAL nizatidine oral capsule 2 150 mg, 300 mg CAPSULE DELAYED 4 PA RELEASE 30 MG, 60 nizatidine oral solution 15 2 MG mg/ml esomeprazole sodium omeprazole oral capsule intravenous solution GM delayed release 10 mg, 2 reconstituted 40 mg 20 mg, 40 mg famotidine intravenous OMEPRAZOLE+SYRSP solution 20 mg/2ml, 200 GM END SF ALKA ORAL 2 mg/20ml, 40 mg/4ml SUSPENSION 2 MG/ML famotidine oral pantoprazole sodium suspension reconstituted 2 intravenous solution GM 40 mg/5ml reconstituted 40 mg famotidine oral tablet 20 2 pantoprazole sodium oral mg, 40 mg tablet delayed release 20 2 famotidine premixed mg, 40 mg intravenous solution 20- GM Brand 0.9 mg/50ml-% PEPCID ORAL TABLET 4 penalty FIRST-LANSOPRAZOLE 20 MG, 40 MG applies ORAL SUSPENSION 3 4 PREVACID ORAL Brand MG/ML CAPSULE DELAYED 4 penalty FIRST-OMEPRAZOLE RELEASE 15 MG, 30 applies ORAL SUSPENSION 2 2 MG MG/ML PREVACID SOLUTAB lansoprazole oral capsule ORAL TABLET Brand delayed release 15 mg, 2 DELAYED RELEASE 4 penalty 30 mg DISPERSIBLE 15 MG, applies 30 MG lansoprazole oral tablet PRILOSEC ORAL delayed release 2 4 dispersible 15 mg, 30 mg PACKET 10 MG, 2.5 MG misoprostol oral tablet 2 100 mcg, 200 mcg Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 138 Drug Drug Drug Name Notes Drug Name Notes Tier Tier PROTONIX belladonna - INTRAVENOUS opium rectal suppository 2 SOLUTION GM 16.2-30 mg, 16.2-60 mg RECONSTITUTED 40 BENTYL MG INTRAMUSCULAR GM PROTONIX ORAL 4 SOLUTION 10 MG/ML PACKET 40 MG CHENODAL ORAL 6 PROTONIX ORAL TABLET 250 MG Brand TABLET DELAYED 4 penalty chlordiazepoxide- RELEASE 20 MG, 40 applies clidinium oral capsule 5- 2 MG 2.5 mg RABEPRAZOLE PV*; QL (1 SODIUM ORAL 4 GM per CAPSULE SPRINKLE 10 365 days); MG 2 AL (Min 50 rabeprazole sodium oral Years and tablet delayed release 20 2 clearlax oral powder 17 Max 75 mg gm/scoop Years) sucralfate oral CLENPIQ ORAL 2 suspension 1 gm/10ml SOLUTION 10-3.5-12 4 sucralfate oral tablet 1 MG-GM -GM/160ML 2 gm constulose oral solution 2 Gastrointestinal Agents 10 gm/15ml - Drugs for Bowel, cromolyn sodium oral 2 Intestine and Stomach concentrate 100 mg/5ml Conditions CUVPOSA ORAL 4 Brand SOLUTION 1 MG/5ML 4 penalty ACTIGALL ORAL dicyclomine hcl applies CAPSULE 300 MG intramuscular solution 10 GM alosetron hcl oral tablet 2 mg/ml 0.5 mg, 1 mg dicyclomine hcl oral 1 AMITIZA ORAL QL (60 EA capsule 10 mg 3 per 30 CAPSULE 24 MCG, 8 dicyclomine hcl oral days) 2 MCG solution 10 mg/5ml amoxicill-clarithro- 2 dicyclomine hcl oral 1 lansopraz oral tablet 20 mg ANASPAZ ORAL diphenoxylate-atropine 4 TABLET DISPERSIBLE oral liquid 2.5-0.025 2 0.125 MG mg/5ml ATROPINE SULFATE diphenoxylate-atropine INTRAVENOUS 2 GM oral tablet 2.5-0.025 mg SOLUTION PREFILLED SYRINGE 1.2 MG/3ML

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 139 Drug Drug Drug Name Notes Drug Name Notes Tier Tier ed-spaz oral tablet PV*; QL (1 2 dispersible 0.125 mg GM per 365 days); ENTEREG ORAL 4 CAPSULE 12 MG 2 AL (Min 50 Years and enulose oral solution 10 2 glycolax oral powder 17 Max 75 gm/15ml gm/scoop Years) GASTROCROM ORAL Brand glycopyrrolate injection CONCENTRATE 100 4 penalty solution 0.2 mg/ml, 0.4 GM MG/5ML applies mg/2ml, 1 mg/5ml, 4 GATTEX mg/20ml SUBCUTANEOUS KIT 5 6 PA GLYCOPYRROLATE MG INJECTION SOLUTION GM PV*; QL (1 PREFILLED SYRINGE GM per 0.6 MG/3ML, 1 MG/5ML 365 days); glycopyrrolate oral tablet 2 2 AL (Min 50 1 mg, 2 mg Years and gavilax oral powder 17 Max 75 glycopyrrolate pf injection gm/scoop Years) solution prefilled syringe GM 0.2 mg/ml, 0.4 mg/2ml PV*; QL (1 ML per 365 GLYRX-PF INJECTION days); AL SOLUTION 0.2 MG/ML, GM 2 (Min 50 0.4 MG/2ML Years and QL (1 EA gavilyte-c oral solution Max 75 per 365 reconstituted 240 gm Years) days); AL PV*; QL (1 GOLYTELY ORAL 4 (Min 50 ML per 365 SOLUTION Years and days); AL RECONSTITUTED 227.1 Max 75 2 (Min 50 GM Years) Years and Brand gavilyte-g oral solution Max 75 penalty reconstituted 236 gm Years) applies; QL (1 ML per gavilyte-h oral kit 5-210 2 mg-gm 4 365 days); GOLYTELY ORAL AL (Min 50 PV*; QL (1 SOLUTION Years and ML per 365 RECONSTITUTED 236 Max 75 days); AL GM Years) 2 (Min 50 gavilyte-n with flavor Years and pack oral solution Max 75 reconstituted 420 gm Years) generlac oral solution 10 2 gm/15ml

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 140 Drug Drug Drug Name Notes Drug Name Notes Tier Tier PV*; QL (1 LEVSIN ORAL TABLET 4 EA per 365 0.125 MG days); AL LEVSIN/SL 2 (Min 50 SUBLINGUAL TABLET 4 Years and SUBLINGUAL 0.125 MG healthylax oral packet 17 Max 75 gm Years) Brand LIBRAX ORAL 4 penalty HELIDAC THERAPY 4 CAPSULE 5-2.5 MG applies ORAL LINZESS ORAL QL (30 EA hyoscyamine sulfate er CAPSULE 145 MCG, 3 per 30 oral tablet extended 2 290 MCG, 72 MCG days) release 12 hour 0.375 mg Brand LOMOTIL ORAL 4 penalty hyoscyamine sulfate oral 2 TABLET 2.5-0.025 MG applies elixir 0.125 mg/5ml loperamide hcl oral 2 hyoscyamine sulfate oral 2 capsule 2 mg solution 0.125 mg/ml Brand hyoscyamine sulfate oral 2 LOTRONEX ORAL 4 penalty tablet 0.125 mg TABLET 0.5 MG, 1 MG applies hyoscyamine sulfate oral methscopolamine tablet dispersible 0.125 2 bromide oral tablet 2.5 2 mg mg, 5 mg hyoscyamine sulfate sl mineral oil heavy oral oil 2 sublingual tablet 2 sublingual 0.125 mg QL (30 EA MOTEGRITY ORAL 4 per 30 hyoscyamine sulfate TABLET 1 MG, 2 MG days) sublingual tablet 2 sublingual 0.125 mg MOTOFEN ORAL 4 TABLET 1-0.025 MG KRISTALOSE ORAL 4 PACKET 10 GM, 20 GM MOVANTIK ORAL QL (30 EA TABLET 12.5 MG, 25 4 per 30 LACTOJEN ORAL 4 MG days) CAPSULE MOVIPREP ORAL lactulose encephalopathy SOLUTION 2 4 oral solution 10 gm/15ml RECONSTITUTED 100 lactulose oral packet 10 2 GM gm MYTESI ORAL TABLET 4 PA lactulose oral solution 10 2 DELAYED RELEASE gm/15ml, 20 gm/30ml 125 MG

LEVBID ORAL TABLET nulev oral tablet 2 EXTENDED RELEASE 4 dispersible 0.125 mg 12 HOUR 0.375 MG

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 141 Drug Drug Drug Name Notes Drug Name Notes Tier Tier Brand peg-prep oral kit 5-210 2 penalty mg-gm applies; QL phenobarbital-belladonna 2 (1 ML per alk oral elixir 16.2 mg/5ml NULYTELY WITH 4 365 days); FLAVOR PACKS ORAL AL (Min 50 PV*; QL (1 SOLUTION Years and EA per 365 RECONSTITUTED 420 Max 75 days); AL GM Years) 2 (Min 50 Years and OMECLAMOX-PAK 4 3350 Max 75 ORAL 500-500-20 MG oral packet 17 gm Years) opium oral tincture 10 2 PREPOPIK ORAL mg/ml (1%) PACKET 10-3.5-12 MG- 4 oscimin oral tablet 0.125 2 GM-GM mg propantheline bromide 2 oscimin sr oral tablet oral tablet 15 mg 2 extended release 12 hour PYLERA ORAL 0.375 mg CAPSULE 140-125-125 4 oscimin sublingual tablet MG 2 sublingual 0.125 mg RELISTOR ORAL 3 PA OSMOPREP ORAL TABLET 150 MG 4 TABLET 1.102-0.398 GM RELISTOR PV*; QL (1 SUBCUTANEOUS 3 PA EA per 365 SOLUTION 12 days); AL MG/0.6ML, 8 MG/0.4ML 2 (Min 50 SEROSTIM Years and SUBCUTANEOUS peg 3350 oral packet 17 Max 75 SOLUTION 6 PA gm Years) RECONSTITUTED 4 PV*; QL (1 MG, 5 MG, 6 MG ML per 365 sodium bicarbonate oral 2 days); AL powder 2 (Min 50 peg 3350-kcl-na bicarb- Years and SUPREP BOWEL PREP nacl oral solution Max 75 KIT ORAL SOLUTION 4 reconstituted 420 gm Years) 17.5-3.13-1.6 GM/177ML PV*; QL (1 SYMAX DUOTAB ORAL ML per 365 TABLET EXTENDED 4 days); AL RELEASE 0.375 MG 2 (Min 50 symax-sr oral tablet peg-3350/electrolytes Years and extended release 12 hour 2 oral solution Max 75 0.375 mg reconstituted 236 gm Years)

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 142 Drug Drug Drug Name Notes Drug Name Notes Tier Tier QL (30 EA PA; SYMPROIC ORAL 4 per 30 BRINEURA KIT 2 X 150 6 Specialty TABLET 0.2 MG days) MG/5ML Medical PV*; QL (1 Brand ML per 365 BUPHENYL ORAL 4 penalty days); AL POWDER 3 GM/TSP applies 2 (Min 50 Brand Years and BUPHENYL ORAL 4 penalty trilyte oral solution Max 75 TABLET 500 MG applies reconstituted 420 gm Years) CERDELGA ORAL 6 PA QL (30 EA CAPSULE 84 MG TRULANCE ORAL 4 per 30 TABLET 3 MG days) CEREZYME INTRAVENOUS PA; Brand SOLUTION 6 Specialty URSO 250 ORAL 4 penalty RECONSTITUTED 400 Medical applies TABLET 250 MG UNIT Brand CHOLBAM ORAL URSO FORTE ORAL 4 penalty CAPSULE 250 MG, 50 6 PA TABLET 500 MG applies MG ursodiol oral capsule 300 2 CREON ORAL mg CAPSULE DELAYED ursodiol oral tablet 250 2 RELEASE PARTICLES mg, 500 mg 12000 UNIT, 24000- 3 76000 UNIT, 3000-9500 VIBERZI ORAL TABLET 5 PA 100 MG, 75 MG UNIT, 36000 UNIT, 6000 UNIT XERMELO ORAL 6 PA CRYSVITA TABLET 250 MG PA; SUBCUTANEOUS 6 Specialty ZORBTIVE SOLUTION 10 MG/ML, Medical SUBCUTANEOUS 20 MG/ML, 30 MG/ML SOLUTION 6 PA CYSTADANE ORAL RECONSTITUTED 8.8 4 MG POWDER Genetic or Enzyme CYSTAGON ORAL Disorder - Drugs for CAPSULE 150 MG, 50 4 Replacement, MG Modification, Treatment ELAPRASE PA; ALDURAZYME PA; INTRAVENOUS 6 Specialty INTRAVENOUS 6 Specialty SOLUTION 6 MG/3ML Medical SOLUTION 2.9 MG/5ML Medical ELELYSO AMMONUL INTRAVENOUS PA; INTRAVENOUS GM SOLUTION 6 Specialty SOLUTION 10-10 % RECONSTITUTED 200 Medical UNIT

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 143 Drug Drug Drug Name Notes Drug Name Notes Tier Tier ENZADYNE ORAL ORFADIN ORAL 4 6 PA CAPSULE SUSPENSION 4 MG/ML FABRAZYME PALYNZIQ INTRAVENOUS PA; SUBCUTANEOUS 6 Specialty SOLUTION SOLUTION PREFILLED 6 PA RECONSTITUTED 35 Medical SYRINGE 10 MG/0.5ML, MG, 5 MG 2.5 MG/0.5ML, 20 GALAFOLD ORAL MG/ML 6 PA CAPSULE 123 MG PANCREAZE ORAL KANUMA PA; CAPSULE DELAYED INTRAVENOUS 6 Specialty RELEASE PARTICLES 4 SOLUTION 20 MG/10ML Medical 10500 UNIT, 16800 UNIT, 21000 UNIT, 2600 KUVAN ORAL PACKET 6 UNIT, 4200 UNIT 100 MG, 500 MG PERTZYE ORAL KUVAN ORAL TABLET 6 PA CAPSULE DELAYED SOLUBLE 100 MG RELEASE PARTICLES 4 LUMIZYME 16000 UNIT, 24000- INTRAVENOUS PA; 86250 UNIT, 4000 UNIT, SOLUTION 6 Specialty 8000 UNIT RECONSTITUTED 50 Medical RAVICTI ORAL LIQUID 6 PA MG 1.1 GM/ML MEPSEVII PA; REVCOVI PA; INTRAVENOUS 6 Specialty INTRAMUSCULAR SOLUTION 10 MG/5ML Medical 6 Specialty SOLUTION 2.4 Medical MG/1.5ML miglustat oral capsule 6 PA 100 mg sod benz-sod phenylacet MYALEPT intravenous solution 10- GM SUBCUTANEOUS 10 % SOLUTION 6 PA sodium phenylbutyrate 2 RECONSTITUTED 11.3 oral powder 3 gm/tsp MG sodium phenylbutyrate 2 NAGLAZYME PA; oral tablet 500 mg INTRAVENOUS 6 Specialty SOLUTION 1 MG/ML Medical STRENSIQ SUBCUTANEOUS nitisinone oral capsule 10 PA; 6 PA SOLUTION 18 6 Specialty mg, 2 mg, 5 mg MG/0.45ML, 28 Medical MG/0.7ML, 40 MG/ML, NITYR ORAL TABLET 6 PA 10 MG, 2 MG, 5 MG 80 MG/0.8ML SUCRAID ORAL OCALIVA ORAL 6 PA TABLET 10 MG, 5 MG SOLUTION 8500 6 PA ORFADIN ORAL UNIT/ML CAPSULE 10 MG, 2 MG, 6 PA 20 MG, 5 MG Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 144 Drug Drug Drug Name Notes Drug Name Notes Tier Tier PA; ZOLGENSMA 13.1-13.5 PA; VIMIZIM INTRAVENOUS 6 Specialty KG INTRAVENOUS KIT 6 Specialty SOLUTION 5 MG/5ML Medical 9X8.3 ML Medical VIOKACE ORAL ZOLGENSMA 2.6-3.0 PA; TABLET 10440 UNIT, 4 KG INTRAVENOUS KIT 6 Specialty 20880 UNIT 2X8.3 ML Medical PA; VPRIV INTRAVENOUS PA; ZOLGENSMA 3.1-3.5 SOLUTION KG INTRAVENOUS KIT 6 Specialty 6 Specialty RECONSTITUTED 400 2X5.5ML & 1X8.3ML Medical Medical UNIT ZOLGENSMA 3.6-4.0 PA; XURIDEN ORAL KG INTRAVENOUS KIT 6 Specialty 6 PA PACKET 2 GM 1X5.5ML & 2X8.3ML Medical PA; ZAVESCA ORAL 6 PA ZOLGENSMA 4.1-4.5 CAPSULE 100 MG KG INTRAVENOUS KIT 6 Specialty ZENPEP ORAL 3X8.3 ML Medical CAPSULE DELAYED ZOLGENSMA 4.6-5.0 PA; RELEASE PARTICLES KG INTRAVENOUS KIT 6 Specialty 10000-32000 UNIT, 2X5.5ML & 2X8.3ML Medical 15000-47000 UNIT, 3 ZOLGENSMA 5.1-5.5 PA; 20000-63000 UNIT, KG INTRAVENOUS KIT 6 Specialty 25000-79000 UNIT, 1X5.5ML & 3X8.3ML Medical 3000-14000 UNIT, 40000-126000 UNIT, ZOLGENSMA 5.6-6.0 PA; 5000-24000 UNIT KG INTRAVENOUS KIT 6 Specialty 4X8.3 ML Medical ZOLGENSMA 10.1-10.5 PA; KG INTRAVENOUS KIT 6 Specialty ZOLGENSMA 6.1-6.5 PA; 7X8.3 ML Medical KG INTRAVENOUS KIT 6 Specialty 2X5.5ML & 3X8.3ML Medical ZOLGENSMA 10.6-11.0 PA; KG INTRAVENOUS KIT 6 Specialty ZOLGENSMA 6.6-7.0 PA; 2X5.5ML & 6X8.3ML Medical KG INTRAVENOUS KIT 6 Specialty 1X5.5ML & 4X8.3ML Medical ZOLGENSMA 11.1-11.5 PA; KG INTRAVENOUS KIT 6 Specialty ZOLGENSMA 7.1-7.5 PA; 1X5.5ML & 7X8.3ML Medical KG INTRAVENOUS KIT 6 Specialty 5X8.3 ML Medical ZOLGENSMA 11.6-12.0 PA; KG INTRAVENOUS KIT 6 Specialty ZOLGENSMA 7.6-8.0 PA; 8X8.3 ML Medical KG INTRAVENOUS KIT 6 Specialty 2X5.5ML & 4X8.3ML Medical ZOLGENSMA 12.1-12.5 PA; KG INTRAVENOUS KIT 6 Specialty ZOLGENSMA 8.1-8.5 PA; 2X5.5ML & 7X8.3ML Medical KG INTRAVENOUS KIT 6 Specialty 1X5.5ML & 5X8.3ML Medical ZOLGENSMA 12.6-13.0 PA; KG INTRAVENOUS KIT 6 Specialty ZOLGENSMA 8.6-9.0 PA; 1X5.5ML & 8X8.3ML Medical KG INTRAVENOUS KIT 6 Specialty 6X8.3 ML Medical

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 145 Drug Drug Drug Name Notes Drug Name Notes Tier Tier ZOLGENSMA 9.1-9.5 PA; PA; Brand KG INTRAVENOUS KIT 6 Specialty penalty 2X5.5ML & 5X8.3ML Medical applies; QL ZOLGENSMA 9.6-10.0 PA; 4 (30 EA per KG INTRAVENOUS KIT 6 Specialty 30 days); AL (Min 18 1X5.5ML & 6X8.3ML Medical CIALIS ORAL TABLET 2.5 MG, 5 MG Years) Genitourinary Agents - Drugs for Bladder, darifenacin hydrobromide er oral tablet extended Genital and Kidney 2 Conditions release 24 hour 15 mg, 7.5 mg acetic acid irrigation 2 solution 0.25 % DEPEN TITRATABS 5 ORAL TABLET 250 MG aminoacetic acid 2 irrigation solution 1.5 % DETROL LA ORAL Brand CAPSULE EXTENDED 4 penalty AURYXIA ORAL RELEASE 24 HOUR 2 4 applies TABLET 1 GM 210 MG, 4 MG MG(FE) Brand bethanechol chloride oral DETROL ORAL TABLET 4 penalty 2 tablet 10 mg, 25 mg, 5 1 MG, 2 MG applies mg, 50 mg DITROPAN XL ORAL BI-MIX Brand TABLET EXTENDED 4 penalty INTRACAVERNOSAL RELEASE 24 HOUR 10 GM applies SOLUTION MG, 5 MG RECONSTITUTED 150-5 MG ELMIRON ORAL 4 CAPSULE 100 MG calcium acetate (phos binder) oral capsule 667 2 ENABLEX ORAL Brand TABLET EXTENDED mg 4 penalty RELEASE 24 HOUR 7.5 applies calcium acetate (phos MG binder) oral tablet 667 2 flavoxate hcl oral tablet mg 2 100 mg calcium acetate oral 2 tablet 667 mg FOSRENOL ORAL Brand TABLET CHEWABLE CERVIDIL VAGINAL 4 penalty 4 1000 MG, 500 MG, 750 applies INSERT 10 MG MG PA; Brand GELNIQUE penalty TRANSDERMAL GEL 10 4 applies; QL % 4 (4 EA per glycine irrigation solution 30 days); 2 CIALIS ORAL TABLET AL (Min 18 1.5 % 10 MG, 20 MG Years) glycine urologic irrigation 2 solution 1.5 %

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 146 Drug Drug Drug Name Notes Drug Name Notes Tier Tier hyophen oral tablet 81.6 PYRIDIUM ORAL 2 mg TABLET 100 MG, 200 4 MG INTRAROSA VAGINAL 4 INSERT 6.5 MG QUAD-MIX lanthanum carbonate oral INTRACAVERNOSAL tablet chewable 1000 2 SOLUTION GM mg, 500 mg, 750 mg RECONSTITUTED 150- 10-0.1-1 MG LITHOSTAT ORAL 4 RENACIDIN TABLET 250 MG 4 IRRIGATION SOLUTION me/naphos/mb/hyo1 oral 2 tablet 81.6 mg Brand RENAGEL ORAL 4 penalty MYRBETRIQ ORAL TABLET 800 MG applies TABLET EXTENDED 3 RELEASE 24 HOUR 25 RENVELA ORAL Brand MG, 50 MG PACKET 0.8 GM, 2.4 4 penalty GM applies oxybutynin chloride er oral tablet extended Brand 2 4 penalty release 24 hour 10 mg, RENVELA ORAL 15 mg, 5 mg TABLET 800 MG applies oxybutynin chloride oral RIMSO-50 2 syrup 5 mg/5ml INTRAVESICAL GM SOLUTION 50 % oxybutynin chloride oral 2 tablet 5 mg sevelamer carbonate oral 2 packet 0.8 gm, 2.4 gm penicillamine oral tablet 5 250 mg sevelamer carbonate oral 2 tablet 800 mg phenazo oral tablet 200 2 mg sevelamer hcl oral tablet 2 400 mg, 800 mg phenazopyridine hcl oral 2 tablet 100 mg, 200 mg sildenafil citrate oral PA; QL (4 tablet 100 mg, 25 mg, 50 2 EA per 30 PHENYLEPHRINE HCL mg days) INTRACAVERNOSAL GM solifenacin succinate oral SOLUTION 2 MG/2ML 2 tablet 10 mg, 5 mg PHOSLYRA ORAL 4 SOLUTION 667 MG/5ML SUPER BI-MIX INTRACAVERNOSAL phosphasal oral tablet 2 SOLUTION GM 81.6 mg RECONSTITUTED 150- PREPIDIL VAGINAL 10 MG 4 GEL 0.5 MG/3GM SUPER QUAD-MIX INTRACAVERNOSAL PROSTIN E2 VAGINAL 4 SUPPOSITORY 20 MG SOLUTION GM RECONSTITUTED 150- 20-0.2-2 MG

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 147 Drug Drug Drug Name Notes Drug Name Notes Tier Tier SUPER TRI-MIX UROGESIC-BLUE ORAL 4 INTRACAVERNOSAL TABLET 81.6 MG SOLUTION GM uro-mp oral capsule 118 2 RECONSTITUTED 150- mg 10-100 MG-MG-MCG URYL ORAL TABLET 4 PA; QL (4 81.6 MG EA per 30 2 days); AL ustell oral capsule 120 2 tadalafil oral tablet 10 (Min 18 mg mg, 20 mg Years) uticap oral capsule 120 2 PA; QL (30 mg EA per 30 utira-c oral tablet 81.6 mg 2 2 days); AL utrona-c oral tablet 81.6 (Min 18 2 tadalafil oral tablet 2.5 mg mg, 5 mg Years) VELPHORO ORAL THIOLA EC ORAL TABLET CHEWABLE 6 TABLET DELAYED 4 PA 500 MG RELEASE 100 MG, 300 MG Brand VESICARE ORAL 3 penalty THIOLA ORAL TABLET 4 PA TABLET 10 MG, 5 MG applies 100 MG PA; Brand tolterodine tartrate er oral penalty capsule extended 2 4 applies; QL release 24 hour 2 mg, 4 VIAGRA ORAL TABLET (4 EA per mg 100 MG, 25 MG, 50 MG 30 days) tolterodine tartrate oral vilamit mb oral capsule 2 2 tablet 1 mg, 2 mg 118 mg TOVIAZ ORAL TABLET VILEVEV MB ORAL 4 4 EXTENDED RELEASE TABLET 81 MG 24 HOUR 4 MG, 8 MG Genitourinary Agents - trospium chloride er oral Drugs for Prostate capsule extended 2 Conditions release 24 hour 60 mg alfuzosin hcl er oral tablet trospium chloride oral 2 extended release 24 hour 2 tablet 20 mg 10 mg uretron d/s oral tablet 2 Brand AVODART ORAL 4 penalty uribel oral capsule 118 2 mg CAPSULE 0.5 MG applies URIMAR-T ORAL CARDURA XL ORAL 4 TABLET 120 MG TABLET EXTENDED 3 urin ds oral tablet 2 RELEASE 24 HOUR 4 MG, 8 MG URO-458 ORAL TABLET 4 81 MG Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 148 Drug Drug Drug Name Notes Drug Name Notes Tier Tier dutasteride oral capsule betamethasone sod phos 2 0.5 mg & acet suspension 6 (3- GM dutasteride-tamsulosin 3) mg/ml injection 6 (3-3) hcl oral capsule 0.5-0.4 2 mg/ml mg BETAMETHASONE SODIUM PHOSPHATE finasteride oral tablet 5 2 GM mg INJECTION SOLUTION 12 MG/2ML, 6 MG/ML Brand FLOMAX ORAL 4 penalty CELESTONE SOLUSPAN INJECTION CAPSULE 0.4 MG applies GM SUSPENSION 6 (3-3) Brand MG/ML JALYN ORAL CAPSULE 4 penalty 0.5-0.4 MG applies Brand CORTEF ORAL TABLET 4 penalty Brand 10 MG, 20 MG, 5 MG applies PROSCAR ORAL 4 penalty TABLET 5 MG applies cortisone acetate oral 2 tablet 25 mg Brand RAPAFLO ORAL 4 penalty DECADRON ORAL CAPSULE 4 MG, 8 MG applies TABLET 0.5 MG, 0.75 4 MG, 4 MG, 6 MG silodosin oral capsule 4 2 mg, 8 mg DEPO-MEDROL INJECTION tamsulosin hcl oral 2 SUSPENSION 20 GM capsule 0.4 mg MG/ML, 40 MG/ML, 80 terazosin hcl oral capsule MG/ML 1 1 mg, 10 mg, 2 mg, 5 mg dexamethasone intensol 2 oral concentrate 1 mg/ml UROXATRAL ORAL Brand TABLET EXTENDED dexamethasone oral 4 penalty 2 RELEASE 24 HOUR 10 applies elixir 0.5 mg/5ml MG dexamethasone oral Hormonal Agents - 2 solution 0.5 mg/5ml Adrenal dexamethasone oral BETAMETHASONE tablet 0.5 mg, 0.75 mg, 1 COMBO INJECTION 1 GM mg, 1.5 mg, 2 mg, 4 mg, SUSPENSION 6 (3-3) 6 mg MG/ML dexamethasone oral BETAMETHASONE tablet therapy pack 1.5 2 SOD PHOS & ACET mg (21), 1.5 mg (35), 1.5 GM SUSPENSION 6 (3-3) mg (51) MG/ML INJECTION 6 (3- 3) MG/ML

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 149 Drug Drug Drug Name Notes Drug Name Notes Tier Tier DEXAMETHASONE Brand SOD PHOS-BUPIV MEDROL ORAL TABLET 4 penalty INJECTION SOLUTION GM THERAPY PACK 4 MG applies PREFILLED SYRINGE METHYLPREDNISOLON 0.01-0.375 % E ACETATE INJECTION GM dexamethasone sod SUSPENSION 50 phosphate pf injection GM MG/ML solution 10 mg/ml METHYLPREDNISOLON dexamethasone sod E ACETATE phosphate pf injection SUSPENSION 40 GM GM solution prefilled syringe MG/ML INJECTION 40 10 mg/ml MG/ML dexamethasone sodium methylprednisolone phosphate injection acetate suspension 40 GM solution 10 mg/ml, 100 GM mg/ml injection 40 mg/ml mg/10ml, 120 mg/30ml, METHYLPREDNISOLON 20 mg/5ml, 4 mg/ml E ACETATE DEXONTO 0.4% SUSPENSION 80 GM IONTOPHORESIS GM MG/ML INJECTION 80 SOLUTION 20 MG/5ML MG/ML fludrocortisone acetate methylprednisolone 2 oral tablet 0.1 mg acetate suspension 80 GM HIDEX 6-DAY ORAL mg/ml injection 80 mg/ml TABLET THERAPY 4 methylprednisolone oral PACK 1.5 MG (21) tablet 16 mg, 32 mg, 4 2 mg, 8 mg hydrocortisone oral tablet 2 10 mg, 20 mg, 5 mg methylprednisolone oral 2 KENALOG INJECTION tablet therapy pack 4 mg SUSPENSION 10 GM methylprednisolone MG/ML, 40 MG/ML sodium succ injection KENALOG-80 solution reconstituted GM INJECTION 1000 mg, 125 mg, 40 GM SUSPENSION 80 mg, 500 mg MG/ML METHYLPREDNISOLON LIDOCIDEX I E-BUPIVACAINE INJECTION SOLUTION GM INJECTION GM 5-10 MG/1.5ML SUSPENSION 40-5 MG/ML, 80-5 MG/ML MEDROL ORAL TABLET Brand 16 MG, 32 MG, 4 MG, 8 3 penalty MILLIPRED DP 12-DAY ORAL TABLET MG applies 4 THERAPY PACK 5 MG MEDROL ORAL TABLET 3 (48) 2 MG MILLIPRED ORAL 3 TABLET 5 MG Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 150 Drug Drug Drug Name Notes Drug Name Notes Tier Tier ORAPRED ODT ORAL Brand triamcinolone acetonide TABLET DISPERSIBLE 4 penalty suspension 40 mg/ml GM 10 MG, 15 MG, 30 MG applies injection 40 mg/ml PEDIAPRED ORAL Brand TRIAMCINOLONE SOLUTION 6.7 (5 BASE) 4 penalty ACETONIDE MG/5ML applies SUSPENSION 40 GM MG/ML INJECTION 40 prednisolone oral 2 solution 15 mg/5ml MG/ML prednisolone sodium TRIAMCINOLONE- phosphate oral solution BUPIVACAINE 10 mg/5ml, 15 mg/5ml, 2 INJECTION GM 20 mg/5ml, 25 mg/5ml, SUSPENSION 40-5 6.7 (5 base) mg/5ml MG/ML prednisolone sodium ZILRETTA INTRA- phosphate oral tablet ARTICULAR 2 GM dispersible 10 mg, 15 SUSPENSION mg, 30 mg RECONSTITUTED ER 32 MG prednisone intensol oral 2 Hormonal Agents - concentrate 5 mg/ml Men's Health prednisone oral solution 2 ANADROL-50 ORAL 5 mg/5ml 4 TABLET 50 MG prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 1 ANDRODERM mg, 5 mg, 50 mg TRANSDERMAL PATCH 4 PA 24 HOUR 2 MG/24HR, 4 prednisone oral tablet MG/24HR therapy pack 10 mg (21), 2 PA; Brand 10 mg (48), 5 mg (21), 5 ANDROGEL PUMP 3 penalty mg (48) TRANSDERMAL GEL 20.25 MG/ACT (1.62%) applies SOLU-CORTEF INJECTION SOLUTION ANDROGEL RECONSTITUTED 100 GM TRANSDERMAL GEL PA; Brand MG, 1000 MG, 250 MG, 20.25 MG/1.25GM 3 penalty 500 MG (1.62%), 25 MG/2.5GM (1%), 40.5 MG/2.5GM applies SOLU-MEDROL (1.62%), 50 MG/5GM INJECTION SOLUTION (1%) RECONSTITUTED 1000 GM danazol oral capsule 100 MG, 125 MG, 2 GM, 40 2 MG, 500 MG mg, 200 mg, 50 mg DEPO-TESTOSTERONE TAPERDEX 6-DAY Brand ORAL TABLET INTRAMUSCULAR 4 4 penalty THERAPY PACK 1.5 SOLUTION 100 MG/ML, applies MG, 1.5 MG (21) 200 MG/ML

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 151 Drug Drug Drug Name Notes Drug Name Notes Tier Tier FORTESTA PA; Brand VOGELXO PA; Brand TRANSDERMAL GEL 10 4 penalty TRANSDERMAL GEL 50 4 penalty MG/ACT (2%) applies MG/5GM (1%) applies JATENZO ORAL Hormonal Agents - CAPSULE 158 MG, 198 4 PA Osteoporosis MG, 237 MG Brand EVISTA ORAL TABLET 4 penalty METHITEST ORAL 4 TABLET 10 MG 60 MG applies methyltestosterone oral OSPHENA ORAL 2 4 capsule 10 mg TABLET 60 MG oxandrolone oral tablet raloxifene hcl oral tablet 2 PV 10 mg, 2.5 mg 60 mg TESTIM PA; Brand Hormonal Agents - TRANSDERMAL GEL 50 4 penalty Pituitary MG/5GM (1%) applies ACTHAR INJECTION 6 PA TESTONE CIK GEL 80 UNIT/ML INTRAMUSCULAR KIT 4 BYNFEZIA PEN 200 MG/ML SUBCUTANEOUS SOLUTION PEN- 6 PA TESTOPEL IMPLANT GM PA PELLET 75 MG INJECTOR 2500 TESTOSTERONE MCG/ML (2.8 ML) 4 cabergoline oral tablet CYPIONATE INJECTION 2 SOLUTION 200 MG/ML 0.5 mg testosterone cypionate carboprost tromethamine intramuscular solution 2 intramuscular solution GM 100 mg/ml, 200 mg/ml 250 mcg/ml testosterone enanthate CETROTIDE intramuscular solution 2 SUBCUTANEOUS KIT 6 PA 200 mg/ml 0.25 MG testosterone transdermal chorionic gonadotropin gel 1.62 %, 10 mg/act intramuscular solution 6 PA (2%), 12.5 mg/act (1%), reconstituted 10000 unit 20.25 mg/1.25gm clomiphene citrate oral 2 PA (1.62%), 20.25 mg/act 2 PA tablet 50 mg (1.62%), 25 mg/2.5gm DDAVP INJECTION (1%), 40.5 mg/2.5gm GM (1.62%), 50 mg/5gm SOLUTION 4 MCG/ML (1%) Brand 4 penalty testosterone transdermal DDAVP NASAL 2 PA applies solution 30 mg/act SOLUTION 0.01 % Brand VOGELXO PUMP PA; Brand 4 penalty TRANSDERMAL GEL 4 penalty DDAVP ORAL TABLET applies 12.5 MG/ACT (1%) applies 0.1 MG, 0.2 MG

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 152 Drug Drug Drug Name Notes Drug Name Notes Tier Tier DDAVP RHINAL TUBE ganirelix acetate 4 NASAL SOLUTION 0.01 subcutaneous solution 6 PA % prefilled syringe 250 desmopressin ace spray mcg/0.5ml refrig nasal solution 0.01 2 GENOTROPIN % MINIQUICK desmopressin acetate SUBCUTANEOUS injection solution 4 GM SOLUTION mcg/ml RECONSTITUTED 0.2 6 PA MG, 0.4 MG, 0.6 MG, 0.8 desmopressin acetate 2 MG, 1 MG, 1.2 MG, 1.4 oral tablet 0.1 mg, 0.2 mg MG, 1.6 MG, 1.8 MG, 2 desmopressin acetate MG spray nasal solution 0.01 2 GENOTROPIN % SUBCUTANEOUS EGRIFTA SV SOLUTION 6 PA RECONSTITUTED 12 SUBCUTANEOUS 6 PA SOLUTION MG, 5 MG RECONSTITUTED 2 MG GONAL-F INJECTION ELIGARD SOLUTION PA; 6 PA SUBCUTANEOUS KIT RECONSTITUTED 1050 6 Specialty 22.5 MG, 30 MG, 45 MG, UNIT, 450 UNIT Medical 7.5 MG GONAL-F RFF FENSOLVI PA; REDIJECT SUBCUTANEOUS KIT 6 Specialty SUBCUTANEOUS 45 MG Medical SOLUTION 300 6 PA FIRMAGON (240 MG UNIT/0.5ML, 450 UNT/0.75ML, 900 DOSE) PA; SUBCUTANEOUS UNIT/1.5ML 6 Specialty SOLUTION GONAL-F RFF Medical RECONSTITUTED 120 SUBCUTANEOUS MG/VIAL SOLUTION 6 PA FIRMAGON RECONSTITUTED 75 SUBCUTANEOUS PA; UNIT SOLUTION 6 Specialty HEMABATE RECONSTITUTED 80 Medical INTRAMUSCULAR GM MG SOLUTION 250 MCG/ML FOLLISTIM AQ HUMATROPE SUBCUTANEOUS INJECTION SOLUTION 6 PA SOLUTION 300 RECONSTITUTED 12 5 PA UNT/0.36ML, 600 MG, 24 MG, 5 MG, 6 MG UNT/0.72ML, 900 INCRELEX UNT/1.08ML SUBCUTANEOUS 6 PA SOLUTION 40 MG/4ML

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 153 Drug Drug Drug Name Notes Drug Name Notes Tier Tier ISTURISA ORAL MENOPUR TABLET 1 MG, 10 MG, 5 6 PA SUBCUTANEOUS MG SOLUTION 6 PA RECONSTITUTED 75 leuprolide acetate 6 PA injection kit 1 mg/0.2ml UNIT LEUPROLIDE MYCAPSSA ORAL 4 ACETATE- CAPSULE DELAYED BUPIVACAINE GM RELEASE 20 MG INTRAMUSCULAR NORDITROPIN SOLUTION 25-5 MG/ML FLEXPRO LUPANETA PACK SUBCUTANEOUS PA; COMBINATION KIT SOLUTION 10 6 PA 6 Specialty MG/1.5ML, 15 11.25 & 5 MG, 3.75 & 5 Medical MG MG/1.5ML, 30 MG/3ML, 5 MG/1.5ML LUPRON DEPOT (1- PA; novarel intramuscular MONTH) 6 Specialty INTRAMUSCULAR KIT solution reconstituted 6 PA Medical 3.75 MG, 7.5 MG 10000 unit LUPRON DEPOT (3- NOVAREL PA; MONTH) INTRAMUSCULAR 6 Specialty INTRAMUSCULAR KIT SOLUTION 6 PA Medical 11.25 MG, 22.5 MG RECONSTITUTED 5000 UNIT LUPRON DEPOT (4- NUTROPIN AQ NUSPIN MONTH) PA; INTRAMUSCULAR KIT 10 SUBCUTANEOUS 6 PA 6 Specialty SOLUTION 10 MG/2ML 30MG Medical INTRAMUSCULAR KIT NUTROPIN AQ NUSPIN 30 MG 20 SUBCUTANEOUS 6 PA LUPRON DEPOT (6- SOLUTION 20 MG/2ML MONTH) NUTROPIN AQ NUSPIN PA; 6 PA INTRAMUSCULAR KIT 6 Specialty 5 SUBCUTANEOUS 45MG Medical SOLUTION 5 MG/2ML INTRAMUSCULAR KIT octreotide acetate 45 MG solution 100 mcg/ml 6 PA LUPRON DEPOT-PED injection 100 mcg/ml PA; (1-MONTH) octreotide acetate INTRAMUSCULAR KIT 6 Specialty solution 100 mcg/ml 5 PA 11.25 MG, 15 MG, 7.5 Medical injection 100 mcg/ml MG octreotide acetate LUPRON DEPOT-PED solution 1000 mcg/ml 6 PA (3-MONTH) PA; injection 1000 mcg/ml INTRAMUSCULAR KIT 6 Specialty 11.25 MG (PED), 30 MG Medical octreotide acetate (PED) solution 1000 mcg/ml 5 PA injection 1000 mcg/ml Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 154 Drug Drug Drug Name Notes Drug Name Notes Tier Tier octreotide acetate OXYTOCIN-SODIUM solution 200 mcg/ml 6 PA CHLORIDE injection 200 mcg/ml INTRAVENOUS GM octreotide acetate SOLUTION 15-0.9 solution 200 mcg/ml 5 PA UT/250ML-%, 30-0.9 injection 200 mcg/ml UT/500ML-% PITOCIN INJECTION octreotide acetate GM solution 50 mcg/ml 6 PA SOLUTION 10 UNIT/ML injection 50 mcg/ml pregnyl intramuscular octreotide acetate solution reconstituted 6 PA solution 50 mcg/ml 5 PA 10000 unit injection 50 mcg/ml SAIZEN INJECTION octreotide acetate SOLUTION 6 PA solution 500 mcg/ml 6 PA RECONSTITUTED 5 injection 500 mcg/ml MG, 8.8 MG octreotide acetate SAIZENPREP INJECTION SOLUTION solution 500 mcg/ml 5 PA 6 PA injection 500 mcg/ml RECONSTITUTED 8.8 MG OMNITROPE SUBCUTANEOUS SANDOSTATIN 5 PA INJECTION SOLUTION SOLUTION 10 6 PA MG/1.5ML, 5 MG/1.5ML 100 MCG/ML, 50 MCG/ML, 500 MCG/ML OMNITROPE SUBCUTANEOUS SANDOSTATIN LAR PA; SOLUTION 5 PA DEPOT 6 Specialty RECONSTITUTED 5.8 INTRAMUSCULAR KIT Medical MG 10 MG, 20 MG, 30 MG ORILISSA ORAL SIGNIFOR LAR TABLET 150 MG, 200 4 PA INTRAMUSCULAR PA; MG SUSPENSION 6 Specialty RECONSTITUTED ER Medical OVIDREL 10 MG, 30 MG SUBCUTANEOUS 6 PA INJECTABLE 250 SIGNIFOR MCG/0.5ML SUBCUTANEOUS 6 PA SOLUTION 0.3 MG/ML, oxytocin injection solution GM 0.6 MG/ML, 0.9 MG/ML 10 unit/ml SOMATULINE DEPOT OXYTOCIN-LACTATED SUBCUTANEOUS PA; RINGERS GM SOLUTION 120 6 Specialty INTRAVENOUS MG/0.5ML, 60 Medical SOLUTION 20 UNIT/L MG/0.2ML, 90 MG/0.3ML

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 155 Drug Drug Drug Name Notes Drug Name Notes Tier Tier SOMAVERT Hormonal Agents - SUBCUTANEOUS Prostaglandins SOLUTION 6 PA KORLYM ORAL TABLET 6 PA RECONSTITUTED 10 300 MG MG, 15 MG, 20 MG, 25 Hormonal Agents - Sex MG, 30 MG Hormones and Birth STIMATE NASAL 3 Control SOLUTION 1.5 MG/ML Brand SUPPRELIN LA PA; ACTIVELLA ORAL 4 penalty SUBCUTANEOUS KIT 6 Specialty TABLET 1-0.5 MG applies 50 MG Medical afirmelle oral tablet 0.1- PV SYNAREL NASAL 3 20 mg-mcg SOLUTION 2 MG/ML ALORA TRANSDERMAL TEPEZZA PATCH TWICE WEEKLY INTRAVENOUS PA; 0.025 MG/24HR, 0.05 4 SOLUTION 6 Specialty MG/24HR, 0.075 RECONSTITUTED 500 Medical MG/24HR, 0.1 MG/24HR MG altavera oral tablet 0.15- PV TRELSTAR MIXJECT 30 mg-mcg INTRAMUSCULAR PA; alyacen 1/35 oral tablet SUSPENSION 6 Specialty PV RECONSTITUTED 11.25 Medical 1-35 mg-mcg alyacen 7/7/7 oral tablet MG, 22.5 MG, 3.75 MG PV TRIPTODUR 0.5/0.75/1-35 mg-mcg PA; amabelz oral tablet 0.5- INTRAMUSCULAR 2 SUSPENSION 6 Specialty 0.1 mg, 1-0.5 mg RECONSTITUTED ER Medical amethia lo oral tablet 0.1- PV 22.5 MG 0.02 & 0.01 mg VANTAS PA; amethia oral tablet 0.15- PV SUBCUTANEOUS KIT 6 Specialty 0.03 &0.01 mg 50 MG Medical amethyst oral tablet 90- PV VAPRISOL 20 mcg INTRAVENOUS GM SOLUTION 20-5 ANGELIQ ORAL 4 MG/100ML-% TABLET 0.25-0.5 MG, 0.5-1 MG VASOSTRICT INTRAVENOUS GM ANNOVERA VAGINAL 4 SOLUTION 20 UNIT/ML RING 0.013-0.15 MG/24HR ZOLADEX PA; SUBCUTANEOUS apri oral tablet 0.15-30 PV 6 Specialty mg-mcg IMPLANT 10.8 MG, 3.6 Medical MG aranelle oral tablet PV 0.5/1/0.5-35 mg-mcg

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 156 Drug Drug Drug Name Notes Drug Name Notes Tier Tier ashlyna oral tablet 0.15- briellyn oral tablet 0.4-35 PV PV 0.03 &0.01 mg mg-mcg aubra eq oral tablet 0.1- PV camila oral tablet 0.35 PV 20 mg-mcg mg aubra oral tablet 0.1-20 PV camrese lo oral tablet PV mg-mcg 0.1-0.02 & 0.01 mg aurovela 1.5/30 oral PV camrese oral tablet 0.15- PV tablet 1.5-30 mg-mcg 0.03 &0.01 mg aurovela 1/20 oral tablet caziant oral tablet PV PV 1-20 mg-mcg 0.1/0.125/0.15 -0.025 mg aurovela 24 fe oral tablet charlotte 24 fe oral tablet PV 1-20 mg-mcg(24) chewable 1-20 mg- PV aurovela fe 1.5/30 oral mcg(24) PV tablet 1.5-30 mg-mcg chateal eq oral tablet PV 0.15-30 mg-mcg aurovela fe 1/20 oral PV tablet 1-20 mg-mcg chateal oral tablet 0.15- PV 30 mg-mcg aviane oral tablet 0.1-20 PV mg-mcg CLIMARA PRO Brand TRANSDERMAL PATCH 4 AYGESTIN ORAL 4 penalty WEEKLY 0.045-0.015 TABLET 5 MG applies MG/DAY ayuna oral tablet 0.15-30 CLIMARA PV mg-mcg TRANSDERMAL PATCH WEEKLY 0.025 azurette oral tablet 0.15- Brand PV MG/24HR, 0.0375 0.02/0.01 mg (21/5) 4 penalty MG/24HR, 0.05 applies BALCOLTRA ORAL MG/24HR, 0.06 TABLET 0.1-20 MG- 4 MG/24HR, 0.075 MCG(21) MG/24HR, 0.1 MG/24HR COMBIPATCH balziva oral tablet 0.4-35 PV mg-mcg TRANSDERMAL PATCH TWICE WEEKLY 0.05- 4 bekyree oral tablet 0.15- PV 0.02/0.01 mg (21/5) 0.14 MG/DAY, 0.05-0.25 MG/DAY Brand BEYAZ ORAL TABLET 4 penalty covaryx hs oral tablet 2 3-0.02-0.451 MG applies 0.625-1.25 mg blisovi 24 fe oral tablet 1- covaryx oral tablet 1.25- PV 2 20 mg-mcg(24) 2.5 mg blisovi fe 1.5/30 oral CRINONE VAGINAL PV 4 tablet 1.5-30 mg-mcg GEL 4 %, 8 % cryselle-28 oral tablet blisovi fe 1/20 oral tablet PV PV 1-20 mg-mcg 0.3-30 mg-mcg

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 157 Drug Drug Drug Name Notes Drug Name Notes Tier Tier cyclafem 1/35 oral tablet DEPO-SUBQ PROVERA PV 1-35 mg-mcg 104 SUBCUTANEOUS SUSPENSION 4 cyclafem 7/7/7 oral tablet PV 0.5/0.75/1-35 mg-mcg PREFILLED SYRINGE 104 MG/0.65ML cyred eq oral tablet 0.15- PV 30 mg-mcg desogestrel-ethinyl estradiol oral tablet 0.15- PV cyred oral tablet 0.15-30 PV 0.02/0.01 mg (21/5), mg-mcg 0.15-30 mg-mcg dasetta 1/35 oral tablet 1- PV DIVIGEL 35 mg-mcg TRANSDERMAL GEL dasetta 7/7/7 oral tablet 0.25 MG/0.25GM, 0.5 PV 4 0.5/0.75/1-35 mg-mcg MG/0.5GM, 0.75 daysee oral tablet 0.15- MG/0.75GM, 1 MG/GM, PV 0.03 &0.01 mg 1.25 MG/1.25GM dotti transdermal patch deblitane oral tablet 0.35 PV mg twice weekly 0.025 mg/24hr, 0.0375 2 DELESTROGEN mg/24hr, 0.05 mg/24hr, INTRAMUSCULAR OIL 4 0.075 mg/24hr, 0.1 10 MG/ML mg/24hr DELESTROGEN Brand drospiren-eth estrad- INTRAMUSCULAR OIL 4 penalty levomefol oral tablet 3- PV 20 MG/ML, 40 MG/ML applies 0.02-0.451 mg, 3-0.03- delyla oral tablet 0.1-20 0.451 mg PV mg-mcg drospirenone-ethinyl DEPO-ESTRADIOL estradiol oral tablet 3- PV INTRAMUSCULAR OIL 5 GM 0.02 mg, 3-0.03 mg MG/ML DUAVEE ORAL TABLET 4 0.45-20 MG DEPO-PROVERA Brand INTRAMUSCULAR 4 penalty EC-RX SUSPENSION 150 applies PROGESTERONE 4 MG/ML TRANSDERMAL DEPO-PROVERA CREAM 10 % INTRAMUSCULAR GM eemt hs oral tablet 0.625- 2 SUSPENSION 400 1.25 mg MG/ML eemt oral tablet 1.25-2.5 2 DEPO-PROVERA mg INTRAMUSCULAR Brand SUSPENSION 4 penalty ELESTRIN TRANSDERMAL GEL PREFILLED SYRINGE applies 4 150 MG/ML 0.52 MG/0.87 GM (0.06%)

elinest oral tablet 0.3-30 PV mg-mcg Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 158 Drug Drug Drug Name Notes Drug Name Notes Tier Tier ELLA ORAL TABLET 30 estradiol vaginal cream PV 2 MG 0.1 mg/gm eluryng vaginal ring 0.12- PV estradiol vaginal tablet 10 2 0.015 mg/24hr mcg emoquette oral tablet PV estradiol valerate 0.15-30 mg-mcg intramuscular oil 20 2 mg/ml, 40 mg/ml ENDOMETRIN VAGINAL 3 INSERT 100 MG estradiol-norethindrone enpresse-28 oral tablet acet oral tablet 0.5-0.1 2 PV 50-30/75-40/ 125-30 mcg mg, 1-0.5 mg enskyce oral tablet 0.15- ESTRING VAGINAL PV 3 30 mg-mcg RING 2 MG errin oral tablet 0.35 mg PV ESTROGEL TRANSDERMAL GEL est estrogens-methyltest 4 2 0.75 MG/1.25 GM ds oral tablet 1.25-2.5 mg (0.06%) est estrogens-methyltest ESTROSTEP FE ORAL Brand hs oral tablet 0.625-1.25 2 TABLET 1-20/1-30/1-35 4 penalty mg MG-MCG applies est estrogens-methyltest 2 ethynodiol diac-eth oral tablet 1.25-2.5 mg estradiol oral tablet 1-35 PV mg-mcg, 1-50 mg-mcg estarylla oral tablet 0.25- PV 35 mg-mcg etonogestrel-ethinyl ESTRACE ORAL Brand estradiol vaginal ring PV TABLET 0.5 MG, 1 MG, 4 penalty 0.12-0.015 mg/24hr 2 MG applies EVAMIST Brand TRANSDERMAL 4 ESTRACE VAGINAL 3 penalty SOLUTION 1.53 CREAM 0.1 MG/GM applies MG/SPRAY FALESSA ORAL KIT 20- estradiol oral tablet 0.5 1 4 mg, 1 mg, 2 mg 1-0.1 MCG-MG falmina oral tablet 0.1-20 estradiol transdermal PV patch twice weekly 0.025 mg-mcg mg/24hr, 0.0375 fayosim oral tablet 42-21- 2 PV mg/24hr, 0.05 mg/24hr, 21-7 days 0.075 mg/24hr, 0.1 mg/24hr FEMHRT LOW DOSE Brand ORAL TABLET 0.5-2.5 3 penalty estradiol transdermal MG-MCG applies patch weekly 0.025 FEMRING VAGINAL mg/24hr, 0.0375 2 mg/24hr, 0.05 mg/24hr, RING 0.05 MG/24HR, 4 0.06 mg/24hr, 0.075 0.1 MG/24HR mg/24hr, 0.1 mg/24hr

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 159 Drug Drug Drug Name Notes Drug Name Notes Tier Tier femynor oral tablet 0.25- jinteli oral tablet 1-5 mg- PV 2 35 mg-mcg mcg

FIRST- jolessa oral tablet 0.15- PV PROGESTERONE VGS 0.03 mg VAGINAL 4 juleber oral tablet 0.15-30 PV SUPPOSITORY 100 MG, mg-mcg 200 MG junel 1.5/30 oral tablet fyavolv oral tablet 0.5-2.5 PV 2 1.5-30 mg-mcg mg-mcg, 1-5 mg-mcg junel 1/20 oral tablet 1-20 PV GENERESS FE ORAL Brand mg-mcg TABLET CHEWABLE 4 penalty junel fe 1.5/30 oral tablet 0.8-25 MG-MCG applies PV 1.5-30 mg-mcg gianvi oral tablet 3-0.02 PV junel fe 1/20 oral tablet 1- mg PV 20 mg-mcg hailey 1.5/30 oral tablet PV 1.5-30 mg-mcg junel fe 24 oral tablet 1- PV 20 mg-mcg(24) hailey 24 fe oral tablet 1- PV 20 mg-mcg(24) kaitlib fe oral tablet PV chewable 0.8-25 mg-mcg hailey fe 1.5/30 oral PV tablet 1.5-30 mg-mcg kalliga oral tablet 0.15-30 PV mg-mcg hailey fe 1/20 oral tablet PV 1-20 mg-mcg kariva oral tablet 0.15- PV 0.02/0.01 mg (21/5) heather oral tablet 0.35 PV kelnor 1/35 oral tablet 1- mg PV 35 mg-mcg hydroxyprogesterone PA; kelnor 1/50 oral tablet 1- caproate intramuscular 6 Specialty PV oil 250 mg/ml Medical 50 mg-mcg kurvelo oral tablet 0.15- hydroxyprogesterone PV caproate intramuscular 5 PA 30 mg-mcg solution 1.25 gm/5ml KYLEENA INTRAUTERINE incassia oral tablet 0.35 PV GM PV mg INTRAUTERINE DEVICE 19.5 MG introvale oral tablet 0.15- PV 0.03 mg larin 1.5/30 oral tablet PV 1.5-30 mg-mcg isibloom oral tablet 0.15- PV larin 1/20 oral tablet 1-20 30 mg-mcg PV mg-mcg jaimiess oral tablet 0.15- PV larin 24 fe oral tablet 1-20 0.03 &0.01 mg PV mg-mcg(24) jasmiel oral tablet 3-0.02 PV larin fe 1.5/30 oral tablet mg PV 1.5-30 mg-mcg jencycla oral tablet 0.35 PV mg Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 160 Drug Drug Drug Name Notes Drug Name Notes Tier Tier larin fe 1/20 oral tablet 1- LOESTRIN 1.5/30 (21) Brand PV 20 mg-mcg ORAL TABLET 1.5-30 4 penalty MG-MCG applies larissia oral tablet 0.1-20 PV mg-mcg LOESTRIN 1/20 (21) Brand ORAL TABLET 1-20 MG- 4 penalty layolis fe oral tablet PV chewable 0.8-25 mg-mcg MCG applies LOESTRIN FE 1.5/30 Brand leena oral tablet PV 0.5/1/0.5-35 mg-mcg ORAL TABLET 1.5-30 4 penalty MG-MCG applies lessina oral tablet 0.1-20 PV mg-mcg LOESTRIN FE 1/20 Brand ORAL TABLET 1-20 MG- 4 penalty levonest oral tablet 50- PV MCG applies 30/75-40/ 125-30 mcg lojaimiess oral tablet 0.1- PV levonorgest-eth est & eth 0.02 & 0.01 mg est oral tablet 42-21-21-7 PV days lopreeza oral tablet 1-0.5 2 mg levonorgest-eth estrad 91-day oral tablet 0.1- loryna oral tablet 3-0.02 PV 0.02 & 0.01 mg, 0.15- PV mg 0.03 &0.01 mg, 0.15-0.03 LOSEASONIQUE ORAL Brand mg TABLET 0.1-0.02 & 0.01 4 penalty levonorgestrel oral tablet MG applies PV 1.5 mg low-ogestrel oral tablet PV levonorgestrel-ethinyl 0.3-30 mg-mcg estrad oral tablet 0.1-20 lo-zumandimine oral PV PV mg-mcg, 0.15-30 mg- tablet 3-0.02 mg mcg, 90-20 mcg lutera oral tablet 0.1-20 PV levonorg-eth estrad mg-mcg triphasic oral tablet 50- PV lyza oral tablet 0.35 mg PV 30/75-40/ 125-30 mcg MAKENA PA; levora 0.15/30 (28) oral PV INTRAMUSCULAR OIL 6 Specialty tablet 0.15-30 mg-mcg 250 MG/ML Medical LILETTA (52 MG) MAKENA INTRAUTERINE GM PV SUBCUTANEOUS INTRAUTERINE SOLUTION AUTO- 6 PA DEVICE 19.5 MCG/DAY INJECTOR 275 lillow oral tablet 0.15-30 PV MG/1.1ML mg-mcg marlissa oral tablet 0.15- PV LO LOESTRIN FE ORAL 30 mg-mcg TABLET 1 MG-10 MCG / 4 medroxyprogesterone 10 MCG acetate intramuscular PV suspension 150 mg/ml

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 161 Drug Drug Drug Name Notes Drug Name Notes Tier Tier medroxyprogesterone MINIVELLE acetate intramuscular PV TRANSDERMAL PATCH suspension prefilled TWICE WEEKLY 0.025 syringe 150 mg/ml MG/24HR, 0.0375 3 medroxyprogesterone MG/24HR, 0.05 acetate oral tablet 10 mg, 1 MG/24HR, 0.075 2.5 mg, 5 mg MG/24HR, 0.1 MG/24HR megestrol acetate oral MIRCETTE ORAL Brand suspension 40 mg/ml, TABLET 0.15-0.02/0.01 4 penalty 2 400 mg/10ml, 625 MG (21/5) applies mg/5ml MIRENA (52 MG) INTRAUTERINE megestrol acetate oral 2 GM PV tablet 20 mg, 40 mg INTRAUTERINE DEVICE 20 MCG/24HR melodetta 24 fe oral tablet chewable 1-20 mg- PV mono-linyah oral tablet PV mcg(24) 0.25-35 mg-mcg NATAZIA ORAL TABLET MENEST ORAL TABLET PV 0.3 MG, 0.625 MG, 1.25 3 3/2-2/2-3/1 MG MG necon 0.5/35 (28) oral PV MENOSTAR tablet 0.5-35 mg-mcg TRANSDERMAL PATCH 3 NEXPLANON WEEKLY 14 MCG/24HR SUBCUTANEOUS GM PV mibelas 24 fe oral tablet IMPLANT 68 MG PV chewable 1-20 mg- nikki oral tablet 3-0.02 PV mcg(24) mg microgestin 1.5/30 oral PV nora-be oral tablet 0.35 PV tablet 1.5-30 mg-mcg mg microgestin 1/20 oral PV norethin ace-eth estrad- tablet 1-20 mg-mcg fe oral tablet 1-20 mg- PV microgestin fe 1.5/30 oral mcg, 1.5-30 mg-mcg PV tablet 1.5-30 mg-mcg norethin ace-eth estrad- microgestin fe 1/20 oral fe oral tablet chewable 1- PV PV tablet 1-20 mg-mcg 20 mg-mcg(24) mili oral tablet 0.25-35 norethindrone acetate PV 2 mg-mcg oral tablet 5 mg norethindrone acet- mimvey oral tablet 1-0.5 2 mg ethinyl est oral tablet 1- PV 20 mg-mcg, 1.5-30 mg- MINASTRIN 24 FE Brand mcg ORAL TABLET 4 penalty norethindrone oral tablet CHEWABLE 1-20 MG- applies PV MCG(24) 0.35 mg

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 162 Drug Drug Drug Name Notes Drug Name Notes Tier Tier norethindrone-eth PARAGARD estradiol oral tablet 0.5- 2 INTRAUTERINE 2.5 mg-mcg, 1-5 mg-mcg COPPER GM PV norethin-eth estradiol-fe INTRAUTERINE INTRAUTERINE oral tablet chewable 0.4- PV 35 mg-mcg, 0.8-25 mg- DEVICE mcg philith oral tablet 0.4-35 PV norgestimate-eth mg-mcg estradiol oral tablet 0.25- PV pimtrea oral tablet 0.15- PV 35 mg-mcg 0.02/0.01 mg (21/5) norgestimate-ethinyl pirmella 1/35 oral tablet PV estradiol triphasic oral 1-35 mg-mcg tablet 0.18/0.215/0.25 PV pirmella 7/7/7 oral tablet PV mg-25 mcg, 0.5/0.75/1-35 mg-mcg 0.18/0.215/0.25 mg-35 mcg PLAN B ONE-STEP PV ORAL TABLET 1.5 MG norlyda oral tablet 0.35 PV mg portia-28 oral tablet 0.15- PV 30 mg-mcg norlyroc oral tablet 0.35 PV mg PREFEST ORAL TABLET 1/1-0.09 MG 4 nortrel 0.5/35 (28) oral PV (15/15) tablet 0.5-35 mg-mcg PREMARIN INJECTION nortrel 1/35 (21) oral SOLUTION PV GM tablet 1-35 mg-mcg RECONSTITUTED 25 nortrel 1/35 (28) oral PV MG tablet 1-35 mg-mcg PREMARIN ORAL nortrel 7/7/7 oral tablet PV TABLET 0.3 MG, 0.45 4 0.5/0.75/1-35 mg-mcg MG, 0.625 MG, 0.9 MG, NUVARING VAGINAL Brand 1.25 MG RING 0.12-0.015 4 penalty PREMARIN VAGINAL 4 MG/24HR applies CREAM 0.625 MG/GM ocella oral tablet 3-0.03 PREMPHASE ORAL PV 4 mg TABLET 0.625-5 MG orsythia oral tablet 0.1-20 PREMPRO ORAL PV mg-mcg TABLET 0.3-1.5 MG, 4 Brand 0.45-1.5 MG, 0.625-2.5 ORTHO MICRONOR 4 penalty MG, 0.625-5 MG applies ORAL TABLET 0.35 MG preventeza oral tablet 1.5 PV mg

previfem oral tablet 0.25- PV 35 mg-mcg

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 163 Drug Drug Drug Name Notes Drug Name Notes Tier Tier progesterone sronyx oral tablet 0.1-20 PV intramuscular oil 50 2 mg-mcg mg/ml syeda oral tablet 3-0.03 PV progesterone micronized mg oral capsule 100 mg, 200 2 tarina 24 fe oral tablet 1- PV mg 20 mg-mcg(24) progesterone micronized 2 tarina fe 1/20 eq oral PV transdermal cream 10 % tablet 1-20 mg-mcg PROMETRIUM ORAL Brand tarina fe 1/20 oral tablet PV CAPSULE 100 MG, 200 4 penalty 1-20 mg-mcg MG applies TAYTULLA ORAL PROVERA ORAL Brand CAPSULE 1-20 MG- 4 TABLET 10 MG, 2.5 MG, 4 penalty MCG(24) 5 MG applies tilia fe oral tablet 1-20/1- PV QUARTETTE ORAL Brand 30/1-35 mg-mcg TABLET 42-21-21-7 4 penalty DAYS applies tri femynor oral tablet 0.18/0.215/0.25 mg-35 PV reclipsen oral tablet 0.15- PV mcg 30 mg-mcg tri-estarylla oral tablet rivelsa oral tablet 42-21- PV 0.18/0.215/0.25 mg-35 PV 21-7 days mcg SAFYRAL ORAL Brand tri-legest fe oral tablet 1- PV TABLET 3-0.03-0.451 4 penalty 20/1-30/1-35 mg-mcg MG applies tri-linyah oral tablet SEASONIQUE ORAL Brand 0.18/0.215/0.25 mg-35 PV TABLET 0.15-0.03 &0.01 4 penalty mcg MG applies tri-lo-estarylla oral tablet setlakin oral tablet 0.15- PV 0.18/0.215/0.25 mg-25 PV 0.03 mg mcg sharobel oral tablet 0.35 PV tri-lo-marzia oral tablet mg 0.18/0.215/0.25 mg-25 PV simliya oral tablet 0.15- mcg PV 0.02/0.01 mg (21/5) tri-lo-mili oral tablet simpesse oral tablet 0.18/0.215/0.25 mg-25 PV PV 0.15-0.03 &0.01 mg mcg SKYLA INTRAUTERINE tri-lo-sprintec oral tablet INTRAUTERINE GM PV 0.18/0.215/0.25 mg-25 PV DEVICE 13.5 MG mcg

SLYND ORAL TABLET 4 PV tri-mili oral tablet MG 0.18/0.215/0.25 mg-35 PV mcg sprintec 28 oral tablet PV 0.25-35 mg-mcg

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 164 Drug Drug Drug Name Notes Drug Name Notes Tier Tier tri-previfem oral tablet vylibra oral tablet 0.25-35 PV 0.18/0.215/0.25 mg-35 PV mg-mcg mcg wera oral tablet 0.5-35 PV tri-sprintec oral tablet mg-mcg 0.18/0.215/0.25 mg-35 PV wymzya fe oral tablet PV mcg chewable 0.4-35 mg-mcg trivora (28) oral tablet 50- PV xulane transdermal patch PV 30/75-40/ 125-30 mcg weekly 150-35 mcg/24hr tri-vylibra lo oral tablet Brand 0.18/0.215/0.25 mg-25 PV YASMIN 28 ORAL 4 penalty mcg TABLET 3-0.03 MG applies tri-vylibra oral tablet Brand 0.18/0.215/0.25 mg-35 PV YAZ ORAL TABLET 3- 4 penalty mcg 0.02 MG applies tulana oral tablet 0.35 mg PV yuvafem vaginal tablet 10 2 TWIRLA mcg TRANSDERMAL PATCH 4 zarah oral tablet 3-0.03 PV WEEKLY 120-30 mg MCG/24HR zovia 1/35e (28) oral tydemy oral tablet 3-0.03- PV PV tablet 1-35 mg-mcg 0.451 mg zumandimine oral tablet PV Brand 3-0.03 mg VAGIFEM VAGINAL 4 penalty Hormonal Agents - TABLET 10 MCG applies Thyroid velivet oral tablet PV 0.1/0.125/0.15 -0.025 mg ARMOUR THYROID ORAL TABLET 120 MG, vienva oral tablet 0.1-20 PV 15 MG, 180 MG, 240 3 mg-mcg MG, 30 MG, 300 MG, 60 MG, 90 MG viorele oral tablet 0.15- PV 0.02/0.01 mg (21/5) CYTOMEL ORAL Brand VIVELLE-DOT TABLET 25 MCG, 5 4 penalty TRANSDERMAL PATCH MCG, 50 MCG applies TWICE WEEKLY 0.025 Brand euthyrox oral tablet 100 MG/24HR, 0.0375 4 penalty mcg, 112 mcg, 125 mcg, MG/24HR, 0.05 applies 137 mcg, 150 mcg, 175 2 MG/24HR, 0.075 mcg, 200 mcg, 25 mcg, MG/24HR, 0.1 MG/24HR 50 mcg, 75 mcg, 88 mcg volnea oral tablet 0.15- PV levo-t oral tablet 100 0.02/0.01 mg (21/5) mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 vyfemla oral tablet 0.4-35 PV 2 mg-mcg mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 165 Drug Drug Drug Name Notes Drug Name Notes Tier Tier levothyroxine sodium SYNTHROID ORAL intravenous solution 100 GM TABLET 100 MCG, 112 mcg/5ml, 200 mcg/5ml, MCG, 125 MCG, 137 500 mcg/5ml MCG, 150 MCG, 175 3 levothyroxine sodium MCG, 200 MCG, 25 MCG, 300 MCG, 50 intravenous solution GM reconstituted 100 mcg, MCG, 75 MCG, 88 MCG 200 mcg, 500 mcg Brand levothyroxine sodium oral TAPAZOLE ORAL 4 penalty tablet 100 mcg, 112 mcg, TABLET 10 MG, 5 MG applies 125 mcg, 137 mcg, 150 2 TIROSINT ORAL mcg, 175 mcg, 200 mcg, CAPSULE 100 MCG, 25 mcg, 300 mcg, 50 112 MCG, 125 MCG, 13 4 mcg, 75 mcg, 88 mcg MCG, 137 MCG, 150 levoxyl oral tablet 100 MCG, 25 MCG, 50 MCG, mcg, 112 mcg, 125 mcg, 75 MCG, 88 MCG 137 mcg, 150 mcg, 175 2 TRIOSTAT mcg, 200 mcg, 25 mcg, INTRAVENOUS GM 50 mcg, 75 mcg, 88 mcg SOLUTION 10 MCG/ML liothyronine sodium unithroid oral tablet 100 intravenous solution 10 GM mcg, 112 mcg, 125 mcg, mcg/ml 137 mcg, 150 mcg, 175 2 liothyronine sodium oral mcg, 200 mcg, 25 mcg, tablet 25 mcg, 5 mcg, 50 2 300 mcg, 50 mcg, 75 mcg mcg, 88 mcg methimazole oral tablet WESTHROID ORAL 2 TABLET 130 MG, 195 10 mg, 5 mg 4 MG, 32.5 MG, 65 MG, NATURE-THROID ORAL 97.5 MG TABLET 113.75 MG, 130 MG, 146.25 MG, 16.25 WP THYROID ORAL MG, 162.5 MG, 195 MG, 4 TABLET 113.75 MG, 130 260 MG, 32.5 MG, 325 MG, 16.25 MG, 32.5 MG, 4 MG, 48.75 MG, 65 MG, 48.75 MG, 65 MG, 81.25 81.25 MG, 97.5 MG MG, 97.5 MG Immunological Agents - np thyroid oral tablet 120 Drugs for Immune mg, 15 mg, 30 mg, 60 2 System Stimulation or mg, 90 mg Suppression propylthiouracil oral 2 tablet 50 mg ACTEMRA ACTPEN SUBCUTANEOUS SOLUTION AUTO- 6 PA INJECTOR 162 MG/0.9ML

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 166 Drug Drug Drug Name Notes Drug Name Notes Tier Tier ACTEMRA azathioprine sodium INTRAVENOUS PA; injection solution GM SOLUTION 200 6 Specialty reconstituted 100 mg MG/10ML, 400 Medical BENLYSTA MG/20ML, 80 MG/4ML INTRAVENOUS PA; ACTEMRA SOLUTION 6 Specialty SUBCUTANEOUS RECONSTITUTED 120 Medical SOLUTION PREFILLED 6 PA MG, 400 MG SYRINGE 162 BENLYSTA MG/0.9ML SUBCUTANEOUS 6 PA ACTIMMUNE SOLUTION AUTO- SUBCUTANEOUS 6 PA INJECTOR 200 MG/ML SOLUTION 2000000 BENLYSTA UNIT/0.5ML SUBCUTANEOUS 6 PA ALFERON N INJECTION PA; SOLUTION PREFILLED SOLUTION 5000000 6 Specialty SYRINGE 200 MG/ML UNIT/ML Medical BERINERT PA; Brand INTRAVENOUS KIT 500 6 Specialty ARAVA ORAL TABLET 4 penalty UNIT Medical 10 MG, 20 MG applies BIVIGAM PA; ARCALYST INTRAVENOUS 6 Specialty SUBCUTANEOUS SOLUTION 5 GM/50ML Medical SOLUTION 6 PA CARIMUNE NF RECONSTITUTED 220 INTRAVENOUS PA; MG SOLUTION 6 Specialty ASCENIV PA; RECONSTITUTED 12 Medical INTRAVENOUS 6 Specialty GM, 6 GM SOLUTION 5 GM/50ML Medical CELLCEPT ASTAGRAF XL ORAL INTRAVENOUS CAPSULE EXTENDED INTRAVENOUS 4 GM RELEASE 24 HOUR 0.5 SOLUTION MG, 1 MG, 5 MG RECONSTITUTED 500 PA; MG 6 Specialty ATGAM INTRAVENOUS CELLCEPT ORAL 4 INJECTABLE 50 MG/ML Medical CAPSULE 250 MG AVSOLA CELLCEPT ORAL INTRAVENOUS PA; SUSPENSION 4 SOLUTION 6 Specialty RECONSTITUTED 200 RECONSTITUTED 100 Medical MG/ML MG CELLCEPT ORAL 4 AZASAN ORAL TABLET 4 TABLET 500 MG 100 MG, 75 MG CIMZIA PREFILLED KIT 5 PA azathioprine oral tablet 2 SUBCUTANEOUS KIT 2 50 mg X 200 MG/ML Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 167 Drug Drug Drug Name Notes Drug Name Notes Tier Tier CIMZIA STARTER KIT cyclosporine modified SUBCUTANEOUS KIT 6 5 PA oral capsule 100 mg, 25 2 X 200 MG/ML mg, 50 mg PA; CIMZIA cyclosporine modified 2 SUBCUTANEOUS KIT 2 5 Specialty oral solution 100 mg/ml X 200 MG Medical cyclosporine oral capsule 2 CINRYZE 100 mg, 25 mg INTRAVENOUS PA; CYTOGAM Specialty SOLUTION 6 Specialty INTRAVENOUS 6 Medical RECONSTITUTED 500 Medical INJECTABLE 50 MG/ML UNIT ENBREL MINI COSENTYX (300 MG SUBCUTANEOUS 6 PA DOSE) SOLUTION CARTRIDGE SUBCUTANEOUS 6 PA 50 MG/ML SOLUTION PREFILLED SYRINGE 150 MG/ML ENBREL SUBCUTANEOUS COSENTYX 150 MG/ML SOLUTION PREFILLED 6 PA SUBCUTANEOUS 6 PA SYRINGE 25 MG/0.5ML, SOLUTION PREFILLED 50 MG/ML SYRINGE 150 MG/ML ENBREL COSENTYX SUBCUTANEOUS SENSOREADY (300 SOLUTION 6 PA MG) SUBCUTANEOUS 6 PA RECONSTITUTED 25 SOLUTION AUTO- MG INJECTOR 150 MG/ML ENBREL SURECLICK COSENTYX SUBCUTANEOUS 6 PA SENSOREADY PEN SOLUTION AUTO- SUBCUTANEOUS 6 PA INJECTOR 50 MG/ML SOLUTION AUTO- INJECTOR 150 MG/ML ENTYVIO INTRAVENOUS PA; CUTAQUIG SOLUTION 6 Specialty SUBCUTANEOUS RECONSTITUTED 300 Medical SOLUTION 1 GM/6ML, 6 PA MG 1.65 GM/10ML, 2 GM/12ML, 3.3 GM/20ML, ENVARSUS XR ORAL 4 GM/24ML, 8 GM/48ML TABLET EXTENDED 4 RELEASE 24 HOUR CUVITRU 0.75 MG, 1 MG, 4 MG SUBCUTANEOUS SOLUTION 1 GM/5ML, everolimus oral tablet 6 PA 10 GM/50ML, 2 0.25 mg, 0.5 mg, 0.75 6 GM/10ML, 4 GM/20ML, 8 mg GM/40ML FIRAZYR PA; QL (18 SUBCUTANEOUS 6 ML per 30 cyclosporine intravenous GM solution 50 mg/ml SOLUTION 30 MG/3ML days)

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 168 Drug Drug Drug Name Notes Drug Name Notes Tier Tier FLEBOGAMMA DIF GAMMAPLEX INTRAVENOUS INTRAVENOUS SOLUTION 0.5 SOLUTION 10 PA; GM/10ML, 10 PA; GM/100ML, 10 6 Specialty GM/100ML, 10 6 Specialty GM/200ML, 20 Medical GM/200ML, 2.5 GM/200ML, 20 Medical GM/50ML, 20 GM/400ML, 5 GM/200ML, 20 GM/100ML, 5 GM/50ML GM/400ML, 5 GAMUNEX-C GM/100ML, 5 GM/50ML INJECTION SOLUTION GAMASTAN PA; 1 GM/10ML, 10 PA; INTRAMUSCULAR 6 Specialty GM/100ML, 2.5 6 Specialty INJECTABLE Medical GM/25ML, 20 Medical GAMASTAN S/D PA; GM/200ML, 40 INTRAMUSCULAR 6 Specialty GM/400ML, 5 GM/50ML INJECTABLE Medical gengraf oral capsule 100 2 GAMIFANT mg, 25 mg PA; INTRAVENOUS gengraf oral solution 100 6 Specialty 2 SOLUTION 10 MG/2ML, mg/ml Medical 50 MG/10ML HAEGARDA GAMMAGARD SUBCUTANEOUS INJECTION SOLUTION SOLUTION 6 PA 1 GM/10ML, 10 PA; RECONSTITUTED 2000 GM/100ML, 2.5 6 Specialty UNIT, 3000 UNIT GM/25ML, 20 Medical HEPAGAM B GM GM/200ML, 30 INJECTION SOLUTION GM/300ML, 5 GM/50ML HIZENTRA GAMMAGARD S/D SUBCUTANEOUS LESS IGA PA; SOLUTION 1 GM/5ML, 6 PA INTRAVENOUS 6 Specialty 10 GM/50ML, 2 SOLUTION Medical GM/10ML, 4 GM/20ML RECONSTITUTED 10 GM, 5 GM HIZENTRA SUBCUTANEOUS GAMMAKED SOLUTION PREFILLED 6 PA PA; INJECTION SOLUTION SYRINGE 1 GM/5ML, 2 1 GM/10ML, 10 6 Specialty GM/10ML, 4 GM/20ML GM/100ML, 20 Medical GM/200ML, 5 GM/50ML HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE 5 PA KIT 80 MG/0.8ML, 80 MG/0.8ML & 40MG/0.4ML

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 169 Drug Drug Drug Name Notes Drug Name Notes Tier Tier HUMIRA PEN HYQVIA SUBCUTANEOUS PEN- 5 PA SUBCUTANEOUS KIT INJECTOR KIT 40 10 GM/100ML, 2.5 6 PA MG/0.4ML, 40 MG/0.8ML GM/25ML, 20 HUMIRA PEN- GM/200ML, 30 CD/UC/HS STARTER GM/300ML, 5 GM/50ML SUBCUTANEOUS PEN- 5 PA icatibant acetate PA; QL (18 INJECTOR KIT 40 subcutaneous solution 30 6 ML per 30 MG/0.8ML, 80 MG/0.8ML mg/3ml days) HUMIRA PEN- ILARIS PS/UV/ADOL HS START SUBCUTANEOUS 6 PA SUBCUTANEOUS PEN- 5 PA SOLUTION 150 MG/ML INJECTOR KIT 40 ILUMYA MG/0.8ML, 80 MG/0.8ML SUBCUTANEOUS 6 PA & 40MG/0.4ML SOLUTION PREFILLED HUMIRA SYRINGE 100 MG/ML SUBCUTANEOUS IMOGAM RABIES-HT PREFILLED SYRINGE INJECTION SOLUTION KIT 10 MG/0.1ML, 10 GM 5 PA 1500 UNIT/10ML, 300 MG/0.2ML, 20 UNIT/2ML MG/0.2ML, 20 MG/0.4ML, 40 Brand MG/0.4ML, 40 MG/0.8ML IMURAN ORAL TABLET 4 penalty 50 MG applies HYPERHEP B S/D INTRAMUSCULAR GM INFLECTRA SOLUTION INTRAVENOUS PA; SOLUTION 5 Specialty HYPERRAB INJECTION RECONSTITUTED 100 Medical SOLUTION 1500 GM MG UNIT/5ML, 300 UNIT/ML, 900 UNIT/3ML KALBITOR PA; SUBCUTANEOUS 6 Specialty HYPERRAB S/D SOLUTION 10 MG/ML Medical INJECTION SOLUTION GM 1500 UNIT/10ML, 300 KEDRAB INJECTION UNIT/2ML SOLUTION 1500 GM UNIT/10ML, 300 HYPERRHO S/D UNIT/2ML INTRAMUSCULAR Specialty SOLUTION PREFILLED 6 KEVZARA Medical SYRINGE 1500 UNIT, SUBCUTANEOUS SOLUTION AUTO- 250 UNIT 6 PA INJECTOR 150 HYPERTET S/D MG/1.14ML, 200 INTRAMUSCULAR GM MG/1.14ML INJECTABLE 250 UNIT/ML

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 170 Drug Drug Drug Name Notes Drug Name Notes Tier Tier KEVZARA mycophenolate mofetil 2 SUBCUTANEOUS oral tablet 500 mg SOLUTION PREFILLED 6 PA mycophenolate sodium SYRINGE 150 oral tablet delayed 2 MG/1.14ML, 200 release 180 mg, 360 mg MG/1.14ML MYFORTIC ORAL KINERET Brand TABLET DELAYED 4 penalty SUBCUTANEOUS RELEASE 180 MG, 360 applies SOLUTION PREFILLED 6 PA MG SYRINGE 100 MG/0.67ML NABI-HB INTRAMUSCULAR GM KYMRIAH PA; SOLUTION INTRAVENOUS 6 Specialty SUSPENSION Medical NEORAL ORAL CAPSULE 100 MG, 25 3 leflunomide oral tablet 10 2 MG mg, 20 mg NEORAL ORAL methotrexate oral tablet 3 2 SOLUTION 100 MG/ML 2.5 mg NULOJIX methotrexate sodium (pf) INTRAVENOUS injection solution 1 2 SOLUTION GM gm/40ml, 250 mg/10ml, RECONSTITUTED 250 50 mg/2ml MG methotrexate sodium OCTAGAM injection solution 250 2 INTRAVENOUS mg/10ml, 50 mg/2ml SOLUTION 1 GM/20ML, PA; methotrexate sodium Specialty 10 GM/100ML, 10 6 GM/200ML, 2 GM/20ML, 6 Specialty injection solution Medical reconstituted 1 gm 2.5 GM/50ML, 20 Medical methotrexate sodium oral GM/200ML, 25 2 tablet 2.5 mg GM/500ML, 5 GM/100ML, 5 GM/50ML MICRHOGAM ULTRA- FILTERED PLUS OLUMIANT ORAL Specialty 6 PA 6 TABLET 1 MG, 2 MG INTRAMUSCULAR Medical SOLUTION PREFILLED ORENCIA CLICKJECT SYRINGE 250 UNIT SUBCUTANEOUS 6 PA mycophenolate mofetil SOLUTION AUTO- hcl intravenous solution GM INJECTOR 125 MG/ML reconstituted 500 mg ORENCIA mycophenolate mofetil INTRAVENOUS PA; 2 oral capsule 250 mg SOLUTION 6 Specialty RECONSTITUTED 250 Medical mycophenolate mofetil MG oral suspension 2 reconstituted 200 mg/ml

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 171 Drug Drug Drug Name Notes Drug Name Notes Tier Tier ORENCIA RENFLEXIS SUBCUTANEOUS INTRAVENOUS PA; 5 Specialty SOLUTION PREFILLED 6 PA SOLUTION SYRINGE 125 MG/ML, RECONSTITUTED 100 Medical 50 MG/0.4ML, 87.5 MG MG/0.7ML RHOGAM ULTRA- OTEZLA ORAL TABLET FILTERED PLUS 5 PA Specialty 30 MG INTRAMUSCULAR 6 Medical OTEZLA ORAL TABLET SOLUTION PREFILLED THERAPY PACK 10 & 5 PA SYRINGE 1500 UNIT 20 & 30 MG RHOPHYLAC Specialty PANZYGA INJECTION SOLUTION 6 INTRAVENOUS PREFILLED SYRINGE Medical SOLUTION 1 GM/10ML, PA; 1500 UNIT/2ML 6 Specialty 10 GM/100ML, 2.5 RIDAURA ORAL 3 GM/25ML, 20 Medical CAPSULE 3 MG GM/200ML, 30 RINVOQ ORAL TABLET GM/300ML, 5 GM/50ML EXTENDED RELEASE 5 PA PRIVIGEN 24 HOUR 15 MG INTRAVENOUS PA; RUCONEST SOLUTION 10 6 Specialty INTRAVENOUS PA; GM/100ML, 20 Medical SOLUTION 6 Specialty GM/200ML, 40 RECONSTITUTED 2100 Medical GM/400ML, 5 GM/50ML UNIT PROGRAF SANDIMMUNE GM INTRAVENOUS INTRAVENOUS GM SOLUTION 5 MG/ML SOLUTION 50 MG/ML PROGRAF ORAL SANDIMMUNE ORAL CAPSULE 0.5 MG, 1 3 CAPSULE 100 MG, 25 3 MG, 5 MG MG PROVENGE PA; SANDIMMUNE ORAL 3 INTRAVENOUS 6 Specialty SOLUTION 100 MG/ML SUSPENSION Medical SILIQ SUBCUTANEOUS RAPAMUNE ORAL 3 SOLUTION PREFILLED 6 PA SOLUTION 1 MG/ML SYRINGE 210 RAPAMUNE ORAL MG/1.5ML 3 TABLET 0.5 MG, 1 MG, SIMPONI ARIA PA; 2 MG INTRAVENOUS 5 Specialty REMICADE SOLUTION 50 MG/4ML Medical INTRAVENOUS PA; SIMPONI SOLUTION 6 Specialty SUBCUTANEOUS RECONSTITUTED 100 Medical SOLUTION AUTO- 5 PA MG INJECTOR 100 MG/ML, 50 MG/0.5ML Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 172 Drug Drug Drug Name Notes Drug Name Notes Tier Tier SIMPONI TALTZ SUBCUTANEOUS SUBCUTANEOUS 6 PA SOLUTION PREFILLED 5 PA SOLUTION AUTO- SYRINGE 100 MG/ML, INJECTOR 80 MG/ML 50 MG/0.5ML TALTZ SIMULECT SUBCUTANEOUS 6 PA INTRAVENOUS SOLUTION PREFILLED SOLUTION GM SYRINGE 80 MG/ML RECONSTITUTED 10 PA; MG, 20 MG temsirolimus intravenous 6 Specialty Medical sirolimus oral solution 1 2 solution 25 mg/ml mg/ml THYMOGLOBULIN sirolimus oral tablet 0.5 2 INTRAVENOUS mg, 1 mg, 2 mg SOLUTION GM SKYRIZI (150 MG RECONSTITUTED 25 DOSE) MG SUBCUTANEOUS 5 PA TICE BCG PREFILLED SYRINGE INTRAVESICAL KIT 75 MG/0.83ML SUSPENSION GM PA STELARA RECONSTITUTED 50 PA; INTRAVENOUS MG 5 Specialty PA; SOLUTION 130 Medical TORISEL MG/26ML INTRAVENOUS 6 Specialty STELARA SOLUTION 25 MG/ML Medical SUBCUTANEOUS 5 PA TREMFYA SOLUTION 45 SUBCUTANEOUS 5 PA MG/0.5ML SOLUTION PEN- STELARA INJECTOR 100 MG/ML SUBCUTANEOUS TREMFYA SOLUTION PREFILLED 5 PA SUBCUTANEOUS 5 PA SYRINGE 45 MG/0.5ML, SOLUTION PREFILLED 90 MG/ML SYRINGE 100 MG/ML

SYNAGIS PA; TREXALL ORAL 3 INTRAMUSCULAR 6 Specialty TABLET 10 MG, 15 MG, SOLUTION 100 MG/ML, Medical 5 MG, 7.5 MG 50 MG/0.5ML UPLIZNA PA; tacrolimus oral capsule INTRAVENOUS 2 6 Specialty 0.5 mg, 1 mg, 5 mg SOLUTION 100 Medical TAKHZYRO PA; QL (4 MG/10ML SUBCUTANEOUS 6 ML per 28 SOLUTION 300 MG/2ML days)

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 173 Drug Drug Drug Name Notes Drug Name Notes Tier Tier WINRHO SDF BCG VACCINE INJECTION SOLUTION INJECTION GM Specialty 1500 UNIT/1.3ML, 15000 6 INJECTABLE UNIT/13ML, 2500 Medical BEXSERO UNIT/2.2ML, 5000 INTRAMUSCULAR PV UNIT/4.4ML SUSPENSION XELJANZ ORAL PREFILLED SYRINGE 5 PA TABLET 10 MG, 5 MG BIOTHRAX XELJANZ XR ORAL INTRAMUSCULAR GM TABLET EXTENDED SUSPENSION 5 PA RELEASE 24 HOUR 11 BOOSTRIX MG, 22 MG INTRAMUSCULAR PV XEMBIFY SUSPENSION 5-2.5- SUBCUTANEOUS 18.5 LF-MCG/0.5 SOLUTION 1 GM/5ML, 6 PA DAPTACEL 10 GM/50ML, 2 INTRAMUSCULAR PV GM/10ML, 4 GM/20ML SUSPENSION 23-15-5 ZINPLAVA DIPHTHERIA- INTRAVENOUS GM TOXOIDS DT SOLUTION 1000 INTRAMUSCULAR PV MG/40ML SUSPENSION 25-5 ZORTRESS ORAL LFU/0.5ML TABLET 0.25 MG, 0.5 6 ENGERIX-B INJECTION MG, 0.75 MG, 1 MG SUSPENSION 10 PV Immunological Agents - MCG/0.5ML, 20 MCG/ML Drugs for Vaccination ENGERIX-B ACTHIB INTRAMUSCULAR PV INTRAMUSCULAR AL (Max 6 PV INJECTABLE 10 SOLUTION Years) MCG/0.5ML, 20 MCG/ML RECONSTITUTED FLUAD ADACEL INTRAMUSCULAR AL (Min 65 INTRAMUSCULAR PV PV SUSPENSION Years) SUSPENSION 5-2-15.5 PREFILLED SYRINGE LF-MCG/0.5 0.5 ML AFLURIA FLUAD QUADRIVALENT QUADRIVALENT AL (Min 65 PV INTRAMUSCULAR PV INTRAMUSCULAR PREFILLED SYRINGE Years) SUSPENSION 0.5 ML AFLURIA FLUARIX QUADRIVALENT QUADRIVALENT INTRAMUSCULAR PV INTRAMUSCULAR PV SUSPENSION SUSPENSION PREFILLED SYRINGE PREFILLED SYRINGE 0.25 ML, 0.5 ML 0.5 ML

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 174 Drug Drug Drug Name Notes Drug Name Notes Tier Tier FLUBLOK HAVRIX QUADRIVALENT INTRAMUSCULAR PV INTRAMUSCULAR PV SUSPENSION 1440 EL SOLUTION PREFILLED U/ML, 720 EL U/0.5ML SYRINGE 0.5 ML HEPLISAV-B FLUCELVAX INTRAMUSCULAR AL (Min 18 QUADRIVALENT SOLUTION PREFILLED PV PV Years) INTRAMUSCULAR SYRINGE 20 SUSPENSION MCG/0.5ML FLUCELVAX HIBERIX INJECTION AL (Max 6 QUADRIVALENT SOLUTION PV Years) INTRAMUSCULAR PV RECONSTITUTED 10 SUSPENSION MCG PREFILLED SYRINGE IMOVAX RABIES 0.5 ML INTRAMUSCULAR GM FLULAVAL INJECTABLE 2.5 QUADRIVALENT UNIT/ML INTRAMUSCULAR PV INFANRIX SUSPENSION INTRAMUSCULAR PV PREFILLED SYRINGE SUSPENSION 25-58-10 0.5 ML IPOL INJECTION AL (Max 17 PV FLUZONE HIGH-DOSE INJECTABLE Years) QUADRIVALENT AL (Min 65 IXIARO INTRAMUSCULAR PV SUSPENSION Years) INTRAMUSCULAR GM PREFILLED SYRINGE SUSPENSION 0.7 ML KINRIX FLUZONE INTRAMUSCULAR PV QUADRIVALENT SUSPENSION PV INTRAMUSCULAR MENACTRA SUSPENSION , 0.5 ML INTRAMUSCULAR PV FLUZONE INJECTABLE QUADRIVALENT MENVEO INTRAMUSCULAR PV INTRAMUSCULAR PV SUSPENSION SOLUTION PREFILLED SYRINGE RECONSTITUTED 0.5 ML M-M-R II INJECTION AL (Min 9 SOLUTION PV Years and GARDASIL 9 PV RECONSTITUTED Max 27 INTRAMUSCULAR PEDIARIX Years) SUSPENSION INTRAMUSCULAR PV GARDASIL 9 AL (Min 9 SUSPENSION Years and INTRAMUSCULAR PV SUSPENSION Max 27 PREFILLED SYRINGE Years) Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 175 Drug Drug Drug Name Notes Drug Name Notes Tier Tier PEDVAX HIB TDVAX AL (Max 6 INTRAMUSCULAR PV INTRAMUSCULAR PV SUSPENSION 7.5 Years) SUSPENSION 2-2 MCG/0.5ML LF/0.5ML PENTACEL TENIVAC PV INTRAMUSCULAR PV INTRAMUSCULAR SUSPENSION INJECTABLE 5-2 LFU RECONSTITUTED TRUMENBA PNEUMOVAX 23 INTRAMUSCULAR PV INJECTION SUSPENSION PV INJECTABLE 25 PREFILLED SYRINGE MCG/0.5ML TWINRIX PREVNAR 13 INTRAMUSCULAR INTRAMUSCULAR PV SUSPENSION PV SUSPENSION PREFILLED SYRINGE PROQUAD 720-20 ELU-MCG/ML SUBCUTANEOUS TYPHIM VI PV SUSPENSION INTRAMUSCULAR GM RECONSTITUTED SOLUTION 25 QUADRACEL MCG/0.5ML INTRAMUSCULAR PV VAQTA SUSPENSION INTRAMUSCULAR PV RABAVERT SUSPENSION 25 UNIT/0.5ML, 50 UNIT/ML INTRAMUSCULAR GM SUSPENSION VARIVAX RECONSTITUTED SUBCUTANEOUS PV RECOMBIVAX HB INJECTABLE 1350 INJECTION PFU/0.5ML SUSPENSION 10 PV VIVOTIF ORAL QL (4 EA MCG/ML, 40 MCG/ML, 5 CAPSULE DELAYED 4 per 365 MCG/0.5ML RELEASE days)

ROTARIX ORAL AL (Max 8 YF-VAX PV GM SUSPENSION Months) SUBCUTANEOUS RECONSTITUTED INJECTABLE AL (Max 8 Inflammatory Bowel ROTATEQ ORAL PV SOLUTION Months) Disease Agents SHINGRIX QL (2 EA ana-lex rectal kit 2-2 % 2 INTRAMUSCULAR per 1 ANUSOL-HC Brand SUSPENSION PV lifetime); EXTERNAL CREAM 2.5 4 penalty RECONSTITUTED 50 AL (Min 50 % applies MCG/0.5ML Years) STAMARIL INJECTION SUSPENSION GM RECONSTITUTED Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 176 Drug Drug Drug Name Notes Drug Name Notes Tier Tier APRISO ORAL ENTOCORT EC ORAL Brand CAPSULE EXTENDED 3 penalty CAPSULE DELAYED 6 RELEASE 24 HOUR applies RELEASE PARTICLES 3 0.375 GM MG ASACOL HD ORAL Brand hydrocortisone (perianal) TABLET DELAYED 4 penalty external cream 1 %, 2.5 2 RELEASE 800 MG applies % AZULFIDINE EN-TABS hydrocortisone ace- Brand ORAL TABLET pramoxine external 2 4 penalty DELAYED RELEASE cream 1-1 % applies 500 MG hydrocortisone rectal 2 Brand enema 100 mg/60ml AZULFIDINE ORAL 4 penalty LIALDA ORAL TABLET Brand TABLET 500 MG applies DELAYED RELEASE 1.2 4 penalty applies balsalazide disodium oral 2 GM capsule 750 mg lidocaine-hydrocort budesonide er oral tablet (perianal) external cream 2 extended release 24 hour 5 PA 3-0.5 % 9 mg lidocaine-hydrocortisone 2 budesonide oral capsule ace rectal cream 3-0.5 % delayed release particles 5 LIDOCAINE- 3 mg HYDROCORTISONE 4 CANASA RECTAL Brand ACE RECTAL GEL 2.8- SUPPOSITORY 1000 3 penalty 0.55 % MG applies lidocaine-hydrocortisone Brand ace rectal kit 2-2 %, 3-0.5 2 COLAZAL ORAL 4 penalty %, 3-1 %, 3-2.5 % applies CAPSULE 750 MG mesalamine er oral colocort rectal enema capsule extended 2 2 100 mg/60ml release 24 hour 0.375 Brand gm CORTENEMA RECTAL 4 penalty mesalamine oral capsule 2 ENEMA 100 MG/60ML applies delayed release 400 mg

CORTIFOAM 3 mesalamine oral tablet EXTERNAL FOAM 10 % delayed release 1.2 gm, 2 DELZICOL ORAL Brand 800 mg 3 penalty CAPSULE DELAYED mesalamine rectal 2 RELEASE 400 MG applies enema 4 gm

DIPENTUM ORAL 3 mesalamine rectal 2 CAPSULE 250 MG suppository 1000 mg mesalamine-cleanser 2 rectal kit 4 gm

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 177 Drug Drug Drug Name Notes Drug Name Notes Tier Tier ORTIKOS ORAL alendronate sodium oral 2 CAPSULE EXTENDED 6 solution 70 mg/75ml RELEASE 24 HOUR 6 alendronate sodium oral 1 MG tablet 10 mg PENTASA ORAL QL (4 EA CAPSULE EXTENDED 4 alendronate sodium oral 1 per 28 RELEASE 250 MG, 500 tablet 35 mg, 70 mg days) MG alendronate sodium oral 2 Brand tablet 5 mg PROCTOCORT 4 penalty EXTERNAL CREAM 1 % applies ATELVIA ORAL TABLET ST; Brand DELAYED RELEASE 35 4 penalty PROCTOFOAM HC 4 MG applies EXTERNAL FOAM 1-1 % BINOSTO ORAL procto-med hc external 2 TABLET 4 ST cream 2.5 % EFFERVESCENT 70 MG procto-pak external 2 BONIVA INTRAVENOUS GM cream 1 % SOLUTION 3 MG/3ML proctosol hc external 2 Brand cream 2.5 % BONIVA ORAL TABLET 4 penalty proctozone-hc external 150 MG applies 2 cream 2.5 % calcitonin (salmon) nasal 2 Brand solution 200 unit/act ROWASA RECTAL KIT 4 4 penalty EVENITY GM applies SUBCUTANEOUS PA; 6 Specialty SFROWASA RECTAL 4 SOLUTION PREFILLED ENEMA 4 GM/60ML SYRINGE 105 Medical MG/1.17ML sulfasalazine oral tablet 2 500 mg FORTEO sulfasalazine oral tablet SUBCUTANEOUS 2 6 PA delayed release 500 mg SOLUTION PEN- INJECTOR 600 UCERIS ORAL TABLET MCG/2.4ML EXTENDED RELEASE 6 PA 24 HOUR 9 MG Brand penalty UCERIS RECTAL FOAM 4 4 applies; QL 2 MG/ACT FOSAMAX ORAL (4 EA per Metabolic Bone TABLET 70 MG 28 days) Disease Agents - Drugs FOSAMAX PLUS D for Osteoporosis ORAL TABLET 70-2800 4 ACTONEL ORAL ST; Brand MG-UNIT, 70-5600 MG- TABLET 150 MG, 30 4 penalty UNIT MG, 35 MG, 5 MG applies

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 178 Drug Drug Drug Name Notes Drug Name Notes Tier Tier ibandronate sodium XGEVA GM Specialty intravenous solution 3 SUBCUTANEOUS 6 mg/3ml SOLUTION 120 Medical MG/1.7ML ibandronate sodium oral 2 tablet 150 mg zoledronic acid Specialty intravenous concentrate 5 MIACALCIN INJECTION 3 Medical SOLUTION 200 UNIT/ML 4 mg/5ml zoledronic acid pamidronate disodium Specialty intravenous solution 30 Specialty intravenous solution 4 5 5 Medical mg/10ml, 6 mg/ml, 90 Medical mg/100ml, 5 mg/100ml mg/10ml Metabolic Bone Disease Agents - Other pamidronate disodium Specialty calcitriol intravenous intravenous solution 5 GM reconstituted 30 mg, 90 Medical solution 1 mcg/ml mg calcitriol oral capsule 2 PROLIA 0.25 mcg, 0.5 mcg SUBCUTANEOUS Specialty 6 calcitriol oral solution 1 2 SOLUTION PREFILLED Medical mcg/ml SYRINGE 60 MG/ML cinacalcet hcl oral tablet 5 PA RAYALDEE ORAL 30 mg, 60 mg, 90 mg CAPSULE EXTENDED 6 PA RELEASE 30 MCG doxercalciferol intravenous solution 4 GM RECLAST Specialty mcg/2ml 6 INTRAVENOUS Medical SOLUTION 5 MG/100ML doxercalciferol oral capsule 0.5 mcg, 1 mcg, 2 PA risedronate sodium oral 2.5 mcg tablet 150 mg, 30 mg, 35 2 ST mg, 5 mg HECTOROL INTRAVENOUS GM risedronate sodium oral SOLUTION 2 MCG/ML, 4 tablet delayed release 35 2 ST MCG/2ML mg NATPARA TERIPARATIDE SUBCUTANEOUS PA; (RECOMBINANT) CARTRIDGE 100 MCG, 6 Specialty SUBCUTANEOUS 6 PA 25 MCG, 50 MCG, 75 Medical SOLUTION PEN- MCG INJECTOR 620 MCG/2.48ML paricalcitol intravenous solution 2 mcg/ml, 5 GM TYMLOS mcg/ml SUBCUTANEOUS SOLUTION PEN- 6 PA paricalcitol oral capsule 1 2 ST INJECTOR 3120 mcg, 2 mcg, 4 mcg MCG/1.56ML

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 179 Drug Drug Drug Name Notes Drug Name Notes Tier Tier PARSABIV ADAKVEO PA; Specialty INTRAVENOUS 6 INTRAVENOUS 6 Specialty Medical SOLUTION 10 MG/2ML, SOLUTION 100 Medical 2.5 MG/0.5ML, 5 MG/ML MG/10ML ROCALTROL ORAL Brand adenosine (diagnostic) CAPSULE 0.25 MCG, 4 penalty intravenous solution 3 GM 0.5 MCG applies mg/ml Brand adenosine intravenous GM ROCALTROL ORAL 4 penalty solution 3 mg/ml SOLUTION 1 MCG/ML applies ALBUKED 25 SENSIPAR ORAL INTRAVENOUS GM TABLET 30 MG, 60 MG, 6 PA SOLUTION 25 % 90 MG ALBUKED 5 ZEMPLAR INTRAVENOUS GM INTRAVENOUS GM SOLUTION 5 % SOLUTION 2 MCG/ML, 5 albumin human MCG/ML intravenous solution 25 GM ZEMPLAR ORAL ST; Brand %, 5 % CAPSULE 1 MCG, 2 4 penalty ALBUMINEX MCG applies INTRAVENOUS GM Miscellaneous SOLUTION 25 %, 5 % Therapeutic Agents albumin-zlb intravenous GM ACACIA solution 25 %, 5 % SUBCUTANEOUS GM alburx intravenous GM SOLUTION 1:20 solution 5 % ACETADOTE ALBUTEIN GM INTRAVENOUS INTRAVENOUS GM SOLUTION 200 MG/ML SOLUTION 25 %, 5 % acetylcysteine ALDER GM intravenous solution 200 SUBCUTANEOUS GM mg/ml SOLUTION 1:20 ACREMONIUM ALPHA-LIPOIC ACID SUBCUTANEOUS GM INJECTION SOLUTION GM SOLUTION 20000 25 MG/ML PNU/ML ALTERNARIA ACTHREL SUBCUTANEOUS GM INTRAVENOUS SOLUTION 20000 GM SOLUTION PNU/ML RECONSTITUTED 100 MCG AMD FOAM DRESSING PAD 3-1/2"X3" , 4"X4" , 4 6"X6" AMD FOAM DRESSING 4 TOPSHEET PAD 4"X4" Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 180 Drug Drug Drug Name Notes Drug Name Notes Tier Tier AMERICAN BEECH ANESTHESIA S/I-60 SUBCUTANEOUS GM INTRAVENOUS KIT 200 GM SOLUTION 1:20 MG/20ML AMERICAN ANTIVENIN MICRURUS COCKROACH GM FULVIUS SUBCUTANEOUS INTRAVENOUS GM SOLUTION 1:20 SOLUTION AMERICAN ELM RECONSTITUTED SUBCUTANEOUS GM APP SLIM RMS ORAL 4 SOLUTION 1:20 CAPSULE AMERICAN SYCAMORE ARIZONA CYPRESS SUBCUTANEOUS GM SUBCUTANEOUS GM SOLUTION 1:20 SOLUTION 1:20 AMIDATE arnica flower tincture 2 INTRAVENOUS GM ARTISS EXTERNAL 4 SOLUTION 2 MG/ML SOLUTION AMPHADASE ASPERGILLUS INJECTION SOLUTION GM FUMIGATUS GM 150 UNIT/ML INJECTION SOLUTION ANASCORP 1:10 , 1:20 INTRAVENOUS GM AUREOBASIDIUM SOLUTION PULLULANS GM RECONSTITUTED INJECTION SOLUTION ANAVIP INTRAVENOUS Specialty 1:20 6 SOLUTION Medical AUREOBASIDIUM RECONSTITUTED SUBCUTANEOUS GM ANDEXXA SOLUTION 10000 INTRAVENOUS PNU/ML, 20000 PNU/ML Specialty SOLUTION 6 Medical AUSTRALIAN PINE RECONSTITUTED 100 SUBCUTANEOUS GM MG, 200 MG SOLUTION 1:20 ANESTHESIA S/I-40 BACTERIOSTATIC INTRAVENOUS KIT 200 GM WATER(BENZ ALC) GM MG/20ML INJECTION SOLUTION ANESTHESIA S/I-40A BAHIA INTRAVENOUS KIT 200 GM SUBCUTANEOUS GM MG/20ML SOLUTION 1:20 ANESTHESIA S/I-40H bal in oil intramuscular GM INTRAVENOUS KIT 200 GM solution 100 mg/ml MG/20ML BALD CYPRESS ANESTHESIA S/I-40S SUBCUTANEOUS GM INTRAVENOUS KIT 200 GM SOLUTION 1:20 MG/20ML

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 181 Drug Drug Drug Name Notes Drug Name Notes Tier Tier BAYBERRY (WAX BRIDION MYRTLE) GM INTRAVENOUS GM SUBCUTANEOUS SOLUTION 200 SOLUTION 1:20 MG/2ML, 500 MG/5ML BERMUDA GRASS BROME GM SUBCUTANEOUS GM SUBCUTANEOUS SOLUTION 10000 SOLUTION 1:20 BAU/ML CALCIUM DISODIUM BIOFREQUENCY VERSENATE 4 GM INSOLES INJECTION SOLUTION BIOGUARD GAUZE 1 GM/5ML 4 SPONGES PAD 4"X4" CALIFORNIA PEPPER BIOGUARD ISLAND TREE SUBCUTANEOUS GM DRESSINGS PAD 4 SOLUTION 1:20 4"X10" , 4"X14" , 4"X5" CANDIDA ALBICANS BIOGUARD NON- EXTRACT INJECTION GM ADHERENT DRESSING 4 SOLUTION 100 MG/ML PAD 3"X4" , 3"X8" CANDIDA ALBICANS BLACK WALNUT EXTRACT POLLEN SUBCUTANEOUS GM GM SUBCUTANEOUS SOLUTION 10000 SOLUTION 1:20 PNU/ML, 20000 PNU/ML BLACK WILLOW CARDIOVID PLUS 4 SUBCUTANEOUS GM ORAL CAPSULE SOLUTION 1:20 CAT HAIR EXTRACT BOTOX INJECTION SUBCUTANEOUS GM SOLUTION 10000 SOLUTION GM PA RECONSTITUTED 100 BAU/ML UNIT, 200 UNIT CATTLE EPITHELIUM BOTRYTIS INJECTION SUBCUTANEOUS GM SOLUTION 1:20 , 43000 GM SOLUTION 1:20 PNU/ML CAYA VAGINAL PV BOTRYTIS DIAPHRAGM SUBCUTANEOUS GM CEDAR ELM SOLUTION 20000 SUBCUTANEOUS GM PNU/ML SOLUTION 1:20 BOX ELDER CHIRHOSTIM SUBCUTANEOUS GM INTRAVENOUS SOLUTION 1:20 SOLUTION GM BREVITAL SODIUM RECONSTITUTED 16 INJECTION SOLUTION MCG GM RECONSTITUTED 2.5 GM, 500 MG

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 182 Drug Drug Drug Name Notes Drug Name Notes Tier Tier CHLORHEXIDINE CURITY IODOFORM 4 GLUCONATE 4 PACKING STRIP SOLUTION 20 % CURVULARIA CLADOSPORIUM SUBCUTANEOUS GM CLADOSPORIOIDES GM SOLUTION 20000 INJECTION SOLUTION PNU/ML 1:20 , 64000 PNU/ML CYANOKIT CLADOSPORIUM INTRAVENOUS GM CLADOSPORIOIDES SOLUTION GM INTRADERMAL RECONSTITUTED 5 GM SOLUTION 1:20 CYSVIEW CLADOSPORIUM INTRAVESICAL CLADOSPORIOIDES SOLUTION GM SUBCUTANEOUS GM RECONSTITUTED 100 SOLUTION 10000 MG PNU/ML, 20000 PNU/ML DANDELION CLADOSPORIUM SUBCUTANEOUS GM SPHAEROSPERMUM SOLUTION 1:20 SUBCUTANEOUS GM deferoxamine mesylate SOLUTION 20000 injection solution GM PNU/ML reconstituted 2 gm, 500 COCKLEBUR mg SUBCUTANEOUS GM DEFLUX INJECTION SOLUTION 1:20 PREFILLED SYRINGE GM CORN POLLEN 50-15 MG/ML SUBCUTANEOUS GM DESFERAL INJECTION SOLUTION 1:20 SOLUTION GM CORTROSYN RECONSTITUTED 500 INJECTION SOLUTION MG GM RECONSTITUTED 0.25 hcl in MG nacl intravenous solution GM cosyntropin injection 200 mcg/50ml, 400 solution reconstituted GM mcg/100ml, 80 mcg/20ml 0.25 mg DEXMEDETOMIDINE CROFAB HCL INTRAVENOUS GM INTRAVENOUS GM SOLUTION 1000 SOLUTION MCG/10ML, 400 RECONSTITUTED MCG/4ML CURITY AMD dexmedetomidine hcl ANTIMICROBIAL 4 intravenous solution 200 GM SPNGE PAD 4"X4" mcg/2ml

CURITY AMD 4 ANTIMICROBIAL STRIP

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 183 Drug Drug Drug Name Notes Drug Name Notes Tier Tier DEXMEDETOMIDINE DUROLANE INTRA- HCL-DEXTROSE ARTICULAR GM INTRAVENOUS GM PREFILLED SYRINGE SOLUTION 60 MG/3ML 200MCG/50ML -5%, DUST MITE MIXED 400MCG/100ML -5% ALLERGEN EXT DIGIFAB SUBCUTANEOUS GM INTRAVENOUS SOLUTION 10000 SOLUTION GM AU/ML RECONSTITUTED 40 DYSPORT MG INTRAMUSCULAR GM PA diluent for treprostinil GM SOLUTION intravenous solution RECONSTITUTED 300 DIMERCAPTOPROPAN UNIT, 500 UNIT E-SULFONATE GM EASTERN INJECTION SOLUTION COTTONWOOD GM 250 MG/5ML SUBCUTANEOUS DIPRIVAN SOLUTION 1:20 INTRAVENOUS ENCARE VAGINAL PV EMULSION 100 SUPPOSITORY 100 MG GM MG/10ML, 1000 ENDARI ORAL PACKET 6 MG/100ML, 200 5 GM MG/20ML, 500 MG/50ML ENGLISH PLANTAIN dipyridamole intravenous GM SUBCUTANEOUS GM solution 5 mg/ml SOLUTION 1:20 DOG EPITHELIUM EPICOCCUM NIGRUM GM SUBCUTANEOUS INJECTION SOLUTION GM SOLUTION 1:10 , 1:20 1:10 DOG FENNEL EPICOCCUM SUBCUTANEOUS GM SUBCUTANEOUS GM SOLUTION 1:20 SOLUTION 10000 DOJOLVI ORAL LIQUID 4 PNU/ML, 20000 PNU/ML 100 % ergoloid mesylates oral 2 DRECHSLERA tablet 1 mg SUBCUTANEOUS GM etomidate intravenous GM SOLUTION 10000 solution 2 mg/ml PNU/ML, 20000 PNU/ML EUFLEXXA INTRA- DUODOTE ARTICULAR SOLUTION INTRAMUSCULAR GM GM PREFILLED SYRINGE SOLUTION AUTO- 20 MG/2ML INJECTOR 2.1-600 MG EXCILON AMD DRAIN 4 SPONGES PAD 4"X4"

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 184 Drug Drug Drug Name Notes Drug Name Notes Tier Tier QL (36 EA GELSYN-3 INTRA- PV per 365 ARTICULAR SOLUTION GM FC FEMALE CONDOM days) PREFILLED SYRINGE QL (36 EA 16.8 MG/2ML PV per 365 GENVISC 850 INTRA- days) FC2 FEMALE CONDOM ARTICULAR SOLUTION GM FEMCAP VAGINAL PREFILLED SYRINGE DEVICE 22 MM, 26 MM, PV 25 MG/2.5ML 30 MM GERMAN COCKROACH FIRE ANT SUBCUTANEOUS GM SUBCUTANEOUS GM SOLUTION 1:20 SOLUTION 1:10 , 1:20 GIVLAARI FLEXBUMIN SUBCUTANEOUS 6 PA INTRAVENOUS GM SOLUTION 189 MG/ML SOLUTION 25 %, 5 % GLEOLAN ORAL flumazenil intravenous SOLUTION GM solution 0.5 mg/5ml, 1 GM RECONSTITUTED 1.5 mg/10ml GM fomepizole intravenous GLUCAGEN GM DIAGNOSTIC solution 1.5 gm/1.5ml GM INJECTION SOLUTION formaldehyde external 2 RECONSTITUTED 1 MG solution 10 %, 37 % GLUCAGON HCL fresenius propoven (DIAGNOSTIC) GM intravenous emulsion GM INJECTION SOLUTION 1000 mg/100ml, 200 RECONSTITUTED 1 MG mg/20ml, 500 mg/50ml glutaraldehyde external 2 FRESENIUS solution 25 % PROPOVEN INTRAVENOUS GM GOLDENROD EMULSION 2000 SUBCUTANEOUS GM MG/100ML SOLUTION 1:20 FUSARIUM GRASTEK SUBLINGUAL TABLET 3 SUBCUTANEOUS GM SOLUTION 10000 SUBLINGUAL 2800 BAU PNU/ML, 20000 PNU/ML HACKBERRY GELFOAM-JMI SUBCUTANEOUS GM SPONGE EXTERNAL 4 SOLUTION 1:20 KIT heparin lock flush GEL-ONE INTRA- intravenous solution 1 2 ARTICULAR unit/ml, 10 unit/ml GM PREFILLED SYRINGE heparin sodium lock flush 30 MG/3ML intravenous solution 100 2 unit/ml

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 185 Drug Drug Drug Name Notes Drug Name Notes Tier Tier HEPMED INFED INJECTION GM COMBINATION KIT 4 SOLUTION 50 MG/ML 100&0.9&2.5-2.5 UT/ML isosulfan blue GM HISTATROL INJECTION GM subcutaneous solution 1 SOLUTION 2.75 MG/ML % HONEY BEE VENOM IV STABILIZER FOR PROTEIN INJECTION LUMOXITI SOLUTION GM INTRAVENOUS GM RECONSTITUTED 550 SOLUTION 0.7-6.5-6.4 MCG MG/ML HONEY BEE VENOM JOHNSON GRASS SUBCUTANEOUS SUBCUTANEOUS GM SOLUTION GM SOLUTION 1:20 RECONSTITUTED 1100 JUNE GRASS POLLEN MCG, 120 MCG STANDARDIZED HORSE EPITHELIUM SUBCUTANEOUS GM SUBCUTANEOUS GM SOLUTION 100000 SOLUTION 1:10 , 1:20 BAU/ML HUMAN ALBUMIN KAPOK GRIFOLS SUBCUTANEOUS GM GM INTRAVENOUS SOLUTION 1:20 SOLUTION 25 % kedbumin intravenous GM HYALGAN INTRA- solution 25 % ARTICULAR SOLUTION GM KERLIX AMD 4 20 MG/2ML ANTIMICROBIAL HYALGAN INTRA- KERLIX AMD SUPER ARTICULAR SOLUTION GM SPONGES PAD 6"X6- 4 PREFILLED SYRINGE 3/4" 20 MG/2ML KETALAR INJECTION HYLENEX INJECTION GM SOLUTION 10 MG/ML, GM SOLUTION 150 UNIT/ML 100 MG/ML, 50 MG/ML HYMOVIS INTRA- KETAMINE HCL ARTICULAR SOLUTION GM INJECTION SOLUTION GM PREFILLED SYRINGE 0.6 MG/ML, 1 MG/ML 24 MG/3ML ketamine hcl injection IC GREEN solution 10 mg/ml, 100 GM INTRAVENOUS mg/ml, 50 mg/ml SOLUTION GM RECONSTITUTED 25 KETAMINE HCL MG INJECTION SOLUTION PREFILLED SYRINGE GM indocyanine green 30 MG/3ML, 50 MG/5ML, intravenous solution GM 50 MG/ML reconstituted 25 mg

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 186 Drug Drug Drug Name Notes Drug Name Notes Tier Tier KETAMINE HCL- methylergonovine SODIUM CHLORIDE maleate oral tablet 0.2 2 INTRAVENOUS GM mg SOLUTION PREFILLED MITE (D. FARINAE) SYRINGE 10-0.9 SUBCUTANEOUS GM MG/ML-% SOLUTION 10000 KINEVAC INJECTION AU/ML SOLUTION GM MITE (D. RECONSTITUTED 5 PTERONYSSINUS) MCG SUBCUTANEOUS GM KOCHIA SOLUTION 10000 SUBCUTANEOUS GM AU/ML SOLUTION 1:20 MIXED ASPERGILLUS LAMBS QUARTERS SUBCUTANEOUS GM SUBCUTANEOUS GM SOLUTION 20000 SOLUTION 1:20 PNU/ML LENSCALE MIXED FEATHERS SUBCUTANEOUS GM SUBCUTANEOUS GM SOLUTION 1:20 SOLUTION 1:20 LEXISCAN MIXED RAGWEED INTRAVENOUS GM SUBCUTANEOUS GM SOLUTION 0.4 MG/5ML SOLUTION 1:20

MACI INTRA- GM MIXED VESPID VENOM ARTICULAR SHEET PROTEIN INJECTION SOLUTION GM MACRILEN ORAL 6 PACKET 60 MG RECONSTITUTED 550- 550-550 MCG MEADOW FESCUE GRASS POLLEN mixed vespid venom protein subcutaneous SUBCUTANEOUS GM GM SOLUTION 100000 solution reconstituted BAU/ML 1100-1100-1100 mcg MELALEUCA MIXED VESPID VENOM SUBCUTANEOUS GM PROTEIN SOLUTION 1:20 SUBCUTANEOUS GM SOLUTION MESQUITE RECONSTITUTED 120- SUBCUTANEOUS GM 120-120 MCG SOLUTION 1:20 MONOVISC INTRA- methergine oral tablet 0.2 ARTICULAR SOLUTION 2 GM mg PREFILLED SYRINGE methylergonovine 88 MG/4ML maleate injection solution GM MOUNTAIN CEDAR 0.2 mg/ml SUBCUTANEOUS GM SOLUTION 1:20

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 187 Drug Drug Drug Name Notes Drug Name Notes Tier Tier MOUSE EPITHELIUM OLIVE TREE SUBCUTANEOUS GM SUBCUTANEOUS GM SOLUTION 1:20 SOLUTION 1:20

MUCOR INJECTION GM OPTIONS SOLUTION 1:20 CONCEPTROL PV VAGINAL GEL 4 % MUCOR INTRADERMAL GM SOLUTION 1:20 ORAFATE MUCOR MOUTH/THROAT 4 SUBCUTANEOUS PASTE 10 % GM SOLUTION 10000 ORALAIR ADULT PNU/ML, 20000 PNU/ML SAMPLE KIT 4 MUGWORT SUBLINGUAL TABLET SUBCUTANEOUS GM SUBLINGUAL 300 IR SOLUTION 1:20 ORALAIR ADULT MYOBLOC STARTER PACK 4 INTRAMUSCULAR SUBLINGUAL TABLET SUBLINGUAL 300 IR SOLUTION 10000 GM PA UNIT/2ML, 2500 ORALAIR CHILDRENS UNIT/0.5ML, 5000 SAMPLE KIT UNIT/ML SUBLINGUAL THERAPY 4 NITHIODOTE PACK 3 X 100 IR & 6 X 300 IR INTRAVENOUS KIT GM 300MG/10ML&12.5 ORALAIR CHILDRENS GM/50ML STARTER PACK 4 OCTAPLAS BLOOD SUBLINGUAL TABLET SUBLINGUAL 100 IR GROUP A GM INTRAVENOUS ORALAIR SUBLINGUAL SOLUTION TABLET SUBLINGUAL 4 OCTAPLAS BLOOD 300 IR GROUP AB ORCHARD GRASS GM INTRAVENOUS POLLEN SOLUTION SUBCUTANEOUS GM OCTAPLAS BLOOD SOLUTION 100000 BAU/ML GROUP B GM INTRAVENOUS ORTHOVISC INTRA- SOLUTION ARTICULAR SOLUTION GM OCTAPLAS BLOOD PREFILLED SYRINGE GROUP O 30 MG/2ML GM INTRAVENOUS OXBRYTA ORAL 6 PA SOLUTION TABLET 500 MG ODACTRA PECAN POLLEN GM SUBLINGUAL TABLET 4 SUBCUTANEOUS SUBLINGUAL 12 SQ- SOLUTION 1:20 HDM Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 188 Drug Drug Drug Name Notes Drug Name Notes Tier Tier PENICILLIUM PRECEDEX NOTATUM INJECTION GM INTRAVENOUS SOLUTION 1:10 , 1:20 SOLUTION 200 PENICILLIUM MCG/2ML, 200 GM NOTATUM MCG/50ML, 400 SUBCUTANEOUS GM MCG/100ML, 80 SOLUTION 10000 MCG/20ML PNU/ML, 20000 PNU/ML PRIVET PERENNIAL RYE SUBCUTANEOUS GM GRASS POLLEN SOLUTION 1:20 SUBCUTANEOUS GM intravenous SOLUTION 100000 emulsion 1000 GM BAU/ML mg/100ml, 200 mg/20ml, 500 mg/50ml PHENOL INJECTION GM SOLUTION 6 % PROTHELIAL 4 PHOMA EXIGUA MOUTH/THROAT SUBCUTANEOUS PASTE 10 % GM SOLUTION 20000 PROTOPAM CHLORIDE PNU/ML INTRAVENOUS GM PHOTREXA VISCOUS SOLUTION OPHTHALMIC RECONSTITUTED 1 GM 6 PA SOLUTION PREFILLED PROVAYBLUE SYRINGE 0.146-20 % INTRAVENOUS GM PLASBUMIN-25 SOLUTION 50 MG/10ML INTRAVENOUS GM QUEEN PALM SOLUTION 25 % SUBCUTANEOUS GM PLASBUMIN-5 SOLUTION 1:20 INTRAVENOUS GM RABBIT EPITHELIUM SOLUTION 5 % SUBCUTANEOUS GM PLASMANATE SOLUTION 1:10 , 1:20 INTRAVENOUS GM RADIOGARDASE ORAL 6 SOLUTION 5 % CAPSULE 0.5 GM pralidoxime chloride RAGWITEK GM intramuscular solution SUBLINGUAL TABLET 3 auto-injector 600 mg/2ml SUBLINGUAL 12 AMB A PRAXBIND 1-U INTRAVENOUS GM RED BIRCH SOLUTION 2.5 SUBCUTANEOUS GM GM/50ML SOLUTION 1:20 RED CEDAR SUBCUTANEOUS GM SOLUTION 1:20

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 189 Drug Drug Drug Name Notes Drug Name Notes Tier Tier RED MAPLE SHAGBARK HICKORY SUBCUTANEOUS GM SUBCUTANEOUS GM SOLUTION 1:20 SOLUTION 1:20 RED MULBERRY SHEEP SORREL SUBCUTANEOUS GM SUBCUTANEOUS GM SOLUTION 1:20 SOLUTION 1:20 RED TOP GRASS SHORT RAGWEED POLLEN POLLEN EXT GM SUBCUTANEOUS GM SUBCUTANEOUS SOLUTION 100000 SOLUTION 1:20 BAU/ML SODIUM R-GENE 10 HYALURONATE INTRA- INTRAVENOUS GM ARTICULAR SOLUTION GM SOLUTION 10 % PREFILLED SYRINGE RHIZOPUS 20 MG/2ML SUBCUTANEOUS GM sodium nitrite SOLUTION 20000 intravenous solution 30 GM PNU/ML mg/ml ROUGH MARSH ELDER sodium saccharin powder 2 SUBCUTANEOUS GM sodium thiosulfate SOLUTION 1:20 intravenous solution 25 GM ROUGH PIGWEED % SUBCUTANEOUS GM SOLESTA INJECTION GM SOLUTION 1:20 GEL 50-15 MG/ML RUSSIAN THISTLE SORBITOL IRRIGATION 4 SUBCUTANEOUS GM SOLUTION 3 % SOLUTION 1:20 sorbitol irrigation solution RUZURGI ORAL 2 6 PA 3.3 % TABLET 10 MG sorbitol-mannitol SACCHAROMYCES irrigation solution 2.7- 2 CEREVISIAE GM 0.54 gm/100ml INJECTION SOLUTION 1:20 SORREL/DOCK MIX SUBCUTANEOUS GM SACCHAROMYCES SOLUTION 1:20 CEREVISIAE SUBCUTANEOUS GM SPINRAZA PA; SOLUTION 20000 INTRATHECAL 6 Specialty PNU/ML SOLUTION 12 MG/5ML Medical SAGEBRUSH SPINY PIGWEED SUBCUTANEOUS GM SUBCUTANEOUS GM SOLUTION 1:20 SOLUTION 1:20

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 190 Drug Drug Drug Name Notes Drug Name Notes Tier Tier STEMPHYLIUM TELFA AMD ISLAND 4 SUBCUTANEOUS GM DRESSING PAD 4"X5" , SOLUTION 20000 4"X8" PNU/ML TELFA AMD NON- 4 STERILE DILUENT ADHERENT PAD 3"X8" FLOLAN PH 12 GM THYROGEN INTRAVENOUS INTRAMUSCULAR SOLUTION SOLUTION GM sterile RECONSTITUTED 1.1 diluent/epoprostenol GM MG intravenous solution TIMOTHY GRASS sterile water for injection GM POLLEN ALLERGEN injection solution SUBCUTANEOUS GM SOLUTION 10000 sterile water for injection GM intravenous solution BAU/ML, 100000 BAU/ML SUPARTZ FX INTRA- TISSEEL EXTERNAL ARTICULAR SOLUTION GM 4 PREFILLED SYRINGE KIT 10 ML, 2 ML, 4 ML 25 MG/2.5ML TISSEEL EXTERNAL 4 SWEET GUM SOLUTION SUBCUTANEOUS GM TODAY SPONGE PV SOLUTION 1:20 VAGINAL 1000 MG SWEET VERNAL TRICHOPHYTON GRASS POLLEN SUBCUTANEOUS GM SUBCUTANEOUS GM SOLUTION 20000 SOLUTION 100000 PNU/ML BAU/ML TRILURON INTRA- SYNVISC INTRA- ARTICULAR SOLUTION GM ARTICULAR SOLUTION PREFILLED SYRINGE GM PREFILLED SYRINGE 20 MG/2ML 16 MG/2ML TRIVISC INTRA- SYNVISC ONE INTRA- ARTICULAR SOLUTION GM ARTICULAR SOLUTION GM PREFILLED SYRINGE PREFILLED SYRINGE 25 MG/2.5ML 48 MG/6ML VCF VAGINAL TACHOSIL EXTERNAL CONTRACEPTIVE PV PATCH 4.8 X 4.8 CM, 4 VAGINAL FILM 28 % 9.5 X 4.8 CM vcf vaginal contraceptive PV TALL RAGWEED vaginal gel 4 % SUBCUTANEOUS GM SOLUTION 1:20

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 191 Drug Drug Drug Name Notes Drug Name Notes Tier Tier VENOMIL MIXED WHITE MULBERRY VESPID VENOM SUBCUTANEOUS GM INJECTION SOLUTION GM SOLUTION 1:20 RECONSTITUTED 550- WHITE OAK 550-550 MCG SUBCUTANEOUS GM VIRGINIA LIVE OAK SOLUTION 1:20 GM SUBCUTANEOUS WHITE PINE SOLUTION 1:20 SUBCUTANEOUS GM VISCO-3 INTRA- SOLUTION 1:20 ARTICULAR SOLUTION GM WHITE-FACED PREFILLED SYRINGE HORNET VENOM 25 MG/2.5ML INJECTION SOLUTION GM VISTOGARD ORAL 6 RECONSTITUTED 550 PACKET 10 GM MCG

VITRASE INJECTION GM WIDE-SEAL SOLUTION 200 UNIT/ML DIAPHRAGM 60 PV WASP VENOM VAGINAL DIAPHRAGM PROTEIN INJECTION 2 % SOLUTION GM WIDE-SEAL RECONSTITUTED 550 DIAPHRAGM 65 PV MCG VAGINAL DIAPHRAGM WASP VENOM 2 % PROTEIN WIDE-SEAL SUBCUTANEOUS GM DIAPHRAGM 70 PV SOLUTION VAGINAL DIAPHRAGM RECONSTITUTED 1100 2 % MCG, 120 MCG WIDE-SEAL WESTERN JUNIPER DIAPHRAGM 75 PV SUBCUTANEOUS GM VAGINAL DIAPHRAGM SOLUTION 1:20 2 % WHITE ASH WIDE-SEAL GM SUBCUTANEOUS DIAPHRAGM 80 PV SOLUTION 1:20 VAGINAL DIAPHRAGM WHITE BIRCH 2 % SUBCUTANEOUS GM WIDE-SEAL SOLUTION 1:20 DIAPHRAGM 85 PV WHITE FACED VAGINAL DIAPHRAGM HORNET VENOM 2 % SUBCUTANEOUS WIDE-SEAL GM SOLUTION DIAPHRAGM 90 PV RECONSTITUTED 1100 VAGINAL DIAPHRAGM MCG, 120 MCG 2 %

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 192 Drug Drug Drug Name Notes Drug Name Notes Tier Tier WIDE-SEAL Ophthalmic Agents - Drugs for Eye Allergy, DIAPHRAGM 95 PV VAGINAL DIAPHRAGM Infection and 2 % Inflammation XEOMIN ACULAR LS Brand INTRAMUSCULAR OPHTHALMIC 4 penalty SOLUTION SOLUTION 0.4 % applies GM PA RECONSTITUTED 100 Brand UNIT, 200 UNIT, 50 ACULAR OPHTHALMIC 4 penalty UNIT SOLUTION 0.5 % applies XIAFLEX INJECTION ACUVAIL OPHTHALMIC PA; 4 SOLUTION 6 Specialty SOLUTION 0.45 % RECONSTITUTED 0.9 Medical MG ALOCRIL OPHTHALMIC 4 SOLUTION 2 % YELLOW DOCK SUBCUTANEOUS GM ALOMIDE OPHTHALMIC 3 SOLUTION 1:20 SOLUTION 0.1 % YELLOW HORNET ALREX OPHTHALMIC 4 VENOM PROTEIN SUSPENSION 0.2 % GM INJECTION SOLUTION AZASITE OPHTHALMIC 4 RECONSTITUTED 550 SOLUTION 1 % MCG azelastine hcl ophthalmic 2 YELLOW HORNET solution 0.05 % VENOM PROTEIN bacitracin ophthalmic 2 SUBCUTANEOUS GM ointment 500 unit/gm SOLUTION RECONSTITUTED 1100 BEPREVE 4 MCG, 120 MCG OPHTHALMIC SOLUTION 1.5 % YELLOW JACKET VENOM PROTEIN BESIVANCE 4 INJECTION SOLUTION GM OPHTHALMIC RECONSTITUTED 550 SUSPENSION 0.6 % MCG BETADINE OPHTHALMIC PREP YELLOW JACKET 4 VENOM PROTEIN OPHTHALMIC SUBCUTANEOUS SOLUTION 5 % GM SOLUTION BLEPH-10 Brand RECONSTITUTED 120 OPHTHALMIC 4 penalty MCG SOLUTION 10 % applies bromfenac sodium (once- daily) ophthalmic solution 2 0.09 %

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 193 Drug Drug Drug Name Notes Drug Name Notes Tier Tier BROMSITE FML LIQUIFILM Brand OPHTHALMIC 4 OPHTHALMIC 4 penalty SOLUTION 0.075 % SUSPENSION 0.1 % applies

CILOXAN OPHTHALMIC 4 FML OPHTHALMIC 3 OINTMENT 0.3 % OINTMENT 0.1 % Brand gatifloxacin ophthalmic 2 CILOXAN OPHTHALMIC 4 penalty solution 0.5 % SOLUTION 0.3 % applies gentak ophthalmic 2 ciprofloxacin hcl ointment 0.3 % ophthalmic solution 0.3 2 gentamicin sulfate % ophthalmic solution 0.3 2 cromolyn sodium % 1 ophthalmic solution 4 % ILEVRO OPHTHALMIC 4 dexamethasone sodium SUSPENSION 0.3 % phosphate ophthalmic 2 ILUVIEN INTRAVITREAL 4 solution 0.1 % IMPLANT 0.19 MG DEXYCU INVELTYS INTRAOCULAR 5 OPHTHALMIC 4 SUSPENSION 9 % SUSPENSION 1 % diclofenac sodium ketorolac tromethamine ophthalmic solution 0.1 2 ophthalmic solution 0.4 2 % %, 0.5 % DUREZOL KLARITY-A OPHTHALMIC 4 OPHTHALMIC 4 EMULSION 0.05 % SOLUTION 1 % epinastine hcl ophthalmic 2 levofloxacin ophthalmic 2 solution 0.05 % solution 0.5 % erythromycin ophthalmic 2 LOTEMAX ointment 5 mg/gm OPHTHALMIC GEL 0.5 4 FLAREX OPHTHALMIC 3 % SUSPENSION 0.1 % LOTEMAX fluorometholone OPHTHALMIC 4 ophthalmic suspension 2 OINTMENT 0.5 % 0.1 % LOTEMAX Brand flurbiprofen sodium OPHTHALMIC 4 penalty ophthalmic solution 0.03 2 SUSPENSION 0.5 % applies % LOTEMAX SM FML FORTE OPHTHALMIC GEL 0.38 4 OPHTHALMIC 3 % SUSPENSION 0.25 % loteprednol etabonate ophthalmic suspension 2 0.5 %

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 194 Drug Drug Drug Name Notes Drug Name Notes Tier Tier MAXIDEX OPHTHALMIC PRED FORTE Brand 4 SUSPENSION 0.1 % OPHTHALMIC 4 penalty SUSPENSION 1 % applies MITOSOL OPHTHALMIC GM KIT 0.2 MG PRED MILD Brand OPHTHALMIC 3 MOXEZA OPHTHALMIC 4 penalty SUSPENSION 0.12 % SOLUTION 0.5 % applies PREDNISOL ACE- moxifloxacin hcl (2x day) MOXIFLOX-BROMFEN ophthalmic solution 0.5 2 OPHTHALMIC 4 % SUSPENSION 1-0.5- 0.075 % MOXIFLOXACIN HCL INTRAOCULAR prednisolone acetate GM SOLUTION 1 MG/ML, 5 ophthalmic suspension 1 2 MG/ML % MOXIFLOXACIN HCL prednisolone acetate p-f ophthalmic suspension 1 2 INTRAOCULAR GM SOLUTION PREFILLED % SYRINGE 0.3 MG/0.3ML prednisolone sodium moxifloxacin hcl phosphate ophthalmic 2 ophthalmic solution 0.5 2 solution 1 % % PROLENSA NATACYN OPHTHALMIC 4 OPHTHALMIC 4 SOLUTION 0.07 % SUSPENSION 5 % sulfacetamide sodium NEVANAC ophthalmic ointment 10 2 OPHTHALMIC 4 % SUSPENSION 0.1 % sulfacetamide sodium 2 OCUFLOX Brand ophthalmic solution 10 % OPHTHALMIC 4 penalty tobramycin ophthalmic 1 SOLUTION 0.3 % applies solution 0.3 % ofloxacin ophthalmic TOBREX OPHTHALMIC 2 3 solution 0.3 % OINTMENT 0.3 % olopatadine hcl Brand ophthalmic solution 0.1 2 TOBREX OPHTHALMIC 4 penalty %, 0.2 % SOLUTION 0.3 % applies

OZURDEX Specialty TRIESENCE 6 INTRAVITREAL Medical INTRAOCULAR 4 IMPLANT 0.7 MG SUSPENSION 40 MG/ML PAZEO OPHTHALMIC 4 SOLUTION 0.7 % trifluridine ophthalmic 2 POVIDONE-IODINE solution 1 % OPHTHALMIC 4 SOLUTION 5 % Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 195 Drug Drug Drug Name Notes Drug Name Notes Tier Tier TRIPLE PMB BETIMOL OPHTHALMIC OPHTHALMIC SOLUTION 0.25 %, 0.5 4 SOLUTION 4 % RECONSTITUTED 1- BETOPTIC-S 0.5-0.09 % OPHTHALMIC 3 TRIPLE PMK SUSPENSION 0.25 % OPHTHALMIC bimatoprost ophthalmic 2 SOLUTION 4 solution 0.03 % RECONSTITUTED 1- 0.5-0.5 % brimonidine tartrate ophthalmic solution 0.15 2 VIGAMOX Brand % OPHTHALMIC 4 penalty SOLUTION 0.5 % applies brimonidine tartrate ophthalmic solution 0.2 1 ZERVIATE % OPHTHALMIC 4 SOLUTION 0.24 % BRIMONIDINE- DORZOLAMIDE ZIRGAN OPHTHALMIC 4 4 OPHTHALMIC GEL 0.15 % SOLUTION 0.15-2 % Brand carteolol hcl ophthalmic 2 ZYMAXID OPHTHALMIC 4 penalty solution 1 % SOLUTION 0.5 % applies COMBIGAN Ophthalmic Agents - OPHTHALMIC 4 Drugs for Glaucoma SOLUTION 0.2-0.5 % acetazolamide er oral COSOPT OPHTHALMIC Brand 2 capsule extended SOLUTION 22.3-6.8 4 penalty release 12 hour 500 mg MG/ML applies acetazolamide oral tablet 2 COSOPT PF Brand 125 mg, 250 mg OPHTHALMIC 4 penalty ALPHAGAN P SOLUTION 2-0.5 % applies 3 OPHTHALMIC DORZOLAMIDE HCL SOLUTION 0.1 % SOLUTION 2 % 4 ALPHAGAN P Brand OPHTHALMIC 2 % 3 penalty OPHTHALMIC dorzolamide hcl solution applies 2 SOLUTION 0.15 % 2 % ophthalmic 2 % apraclonidine hcl dorzolamide hcl-timolol 2 ophthalmic solution 0.5 mal ophthalmic solution 2 % 22.3-6.8 mg/ml AZOPT OPHTHALMIC 4 dorzolamide hcl-timolol SUSPENSION 1 % mal pf ophthalmic 2 betaxolol hcl ophthalmic 2 solution 2-0.5 % solution 0.5 % DURYSTA PA; INTRAOCULAR 6 Specialty IMPLANT 10 MCG Medical Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 196 Drug Drug Drug Name Notes Drug Name Notes Tier Tier IOPIDINE OPHTHALMIC timolol maleate 4 SOLUTION 1 % ophthalmic gel forming 2 solution 0.25 %, 0.5 % ISOPTO CARPINE Brand OPHTHALMIC 4 penalty timolol maleate 1 SOLUTION 1 %, 2 %, 4 applies ophthalmic solution 0.25 % %, 0.5 % Brand timolol maleate ISTALOL OPHTHALMIC 4 penalty ophthalmic solution 0.5 2 SOLUTION 0.5 % applies % (daily) KEVEYIS ORAL TABLET TIMOLOL-BRIMON- 6 PA 50 MG DORZOL-LATANOPR latanoprost ophthalmic OPHTHALMIC 4 2 solution 0.005 % SOLUTION 0.5-0.15-2 - 0.005% LATANOPROST- TIMOLOL- TIMOLOL MALEATE 4 OPHTHALMIC BRIMONIDINE- 4 SOLUTION 0.005-0.5 % DORZOLAMID OPHTHALMIC levobunolol hcl SOLUTION 0.5-0.15-2 % ophthalmic solution 0.5 2 % TIMOLOL- DORZOLAMID- LUMIGAN LATANOPROST 4 OPHTHALMIC 3 OPHTHALMIC SOLUTION 0.01 % SOLUTION 0.5-0.15- 0.005 % methazolamide oral 2 tablet 25 mg, 50 mg TIMOPTIC OCUDOSE OPHTHALMIC PHOSPHOLINE IODIDE 4 OPHTHALMIC SOLUTION 0.25 %, 0.5 SOLUTION 3 % RECONSTITUTED 0.125 TIMOPTIC % Brand OPHTHALMIC 3 penalty pilocarpine hcl SOLUTION 0.25 %, 0.5 applies ophthalmic solution 1 %, 2 % 2 %, 4 % TIMOPTIC-XE Brand RHOPRESSA OPHTHALMIC GEL 4 penalty 4 FORMING SOLUTION OPHTHALMIC applies SOLUTION 0.02 % 0.25 %, 0.5 % ROCKLATAN TRAVATAN Z Brand OPHTHALMIC 4 OPHTHALMIC 3 penalty SOLUTION 0.02-0.005 % SOLUTION 0.004 % applies SIMBRINZA travoprost (bak free) OPHTHALMIC 4 ophthalmic solution 0.004 2 SUSPENSION 1-0.2 % %

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 197 Drug Drug Drug Name Notes Drug Name Notes Tier Tier TRUSOPT Brand bacitracin-polymyxin b OPHTHALMIC 4 penalty ophthalmic ointment 500- 2 SOLUTION 2 % applies 10000 unit/gm

VYZULTA OPHTHALMIC 4 bacitra-neomycin- SOLUTION 0.024 % polymyxin-hc ophthalmic 2 XALATAN Brand ointment 1 % 4 penalty OPHTHALMIC balanced salt intraocular 2 SOLUTION 0.005 % applies solution ZIOPTAN OPHTHALMIC BEOVU INTRAVITREAL 4 Specialty SOLUTION 0.0015 % SOLUTION 6 6 Medical Ophthalmic Agents - MG/0.05ML Drugs for BEVACIZUMAB Miscellaneous Eye INTRAOCULAR PA; Conditions SOLUTION PREFILLED 6 Specialty SYRINGE 2.75 ak-fluor intravenous GM Medical solution 10 %, 25 % MG/0.11ML, 3.75 MG/0.15ML ak-poly-bac ophthalmic ointment 500-10000 2 BEVACIZUMAB unit/gm INTRAVITREAL SOLUTION PREFILLED PA; AKTEN OPHTHALMIC 4 SYRINGE 2.5 6 Specialty GEL 3.5 % MG/0.1ML, 3.25 Medical Brand MG/0.13ML, 3.75 ALCAINE OPHTHALMIC 4 penalty MG/0.15ML SOLUTION 0.5 % applies BIOLON INTRAOCULAR 4 altacaine ophthalmic 2 SOLUTION 10 MG/ML solution 0.5 % BLEPHAMIDE 3 altafrin ophthalmic 2 OPHTHALMIC solution 10 %, 2.5 % SUSPENSION 10-0.2 %

AMVISC INTRAOCULAR 4 BLEPHAMIDE S.O.P. SOLUTION 12 MG/ML OPHTHALMIC 3 AMVISC PLUS OINTMENT 10-0.2 % INTRAOCULAR 4 bss intraocular solution 2 SOLUTION 16 MG/ML CYCLOGYL Brand atropine sulfate 2 OPHTHALMIC 3 penalty ophthalmic ointment 1 % SOLUTION 0.5 %, 1 %, 2 applies ATROPINE SULFATE % OPHTHALMIC 4 CYCLOMYDRIL SOLUTION 0.01 % OPHTHALMIC 3 SOLUTION 0.2-1 % atropine sulfate 2 ophthalmic solution 1 % cyclopentolate hcl ophthalmic solution 0.5 2 %

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 198 Drug Drug Drug Name Notes Drug Name Notes Tier Tier cyclopentolate hcl HEALON5 PRO ophthalmic solution 1 %, 1 INTRAOCULAR 4 2 % SOLUTION 23 MG/ML

CYCLOSPORINE IN homatropaire ophthalmic 2 KLARITY OPHTHALMIC 4 solution 5 % EMULSION 0.1 % HYALURONIDASE DEXAMETHASONE- (INTRAOCULAR) GM MOXIFLOXACIN INTRAOCULAR GM INTRAOCULAR SOLUTION 175 UNIT/ML SOLUTION 1-5 MG/ML ISOPTO ATROPINE DEXAMETH- OPHTHALMIC 4 MOXIFLOX- SOLUTION 1 % KETOROLAC GM LACRISERT INTRAOCULAR OPHTHALMIC INSERT 5 4 SOLUTION 1-0.5-0.4 MG MG/ML LASTACAFT EYLEA INTRAVITREAL Specialty OPHTHALMIC 4 SOLUTION 2 6 Medical SOLUTION 0.25 % MG/0.05ML LIDOCAINE- EYLEA INTRAVITREAL Specialty EPINEPHRINE SOLUTION PREFILLED 6 Medical INTRAOCULAR GM SYRINGE 2 MG/0.05ML SOLUTION 7.5-0.25 FLUORESCITE MG/ML INTRAVENOUS GM LIDOCAINE- SOLUTION 10 % PHENYLEPHRINE GM GELFILM OPHTHALMIC 4 INTRAOCULAR FILM SOLUTION 1-1.5 % GLOSTRIPS LIDOCAINE- OPHTHALMIC STRIP GM PHENYLEPHRINE-BSS 1.3 MG INTRAOCULAR GM HEALON GV SOLUTION PREFILLED INTRAOCULAR 4 SYRINGE 1-1.5 % (1ML) SOLUTION 14 MG/ML LUCENTIS HEALON INTRAVITREAL Specialty 6 INTRAOCULAR 4 SOLUTION 0.3 Medical SOLUTION 10 MG/ML MG/0.05ML, 0.5 MG/0.05ML HEALON PRO INTRAOCULAR 4 LUCENTIS SOLUTION 10 MG/ML INTRAVITREAL SOLUTION PREFILLED 4 HEALON5 SYRINGE 0.3 INTRAOCULAR 4 MG/0.05ML SOLUTION 23 MG/ML

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 199 Drug Drug Drug Name Notes Drug Name Notes Tier Tier LUCENTIS neomycin-polymyxin- INTRAVITREAL Specialty dexameth ophthalmic 2 6 SOLUTION PREFILLED Medical suspension 3.5-10000- SYRINGE 0.5 0.1 MG/0.05ML neomycin-polymyxin- 2 LUXTURNA PA; gramicidin ophthalmic INTRAOCULAR solution 1.75-10000-.025 6 Specialty SUSPENSION Medical neomycin-polymyxin-hc 5000000000000 VG/ML ophthalmic suspension 2 MACUGEN 3.5-10000-1 Specialty INTRAOCULAR 6 neo-polycin hc Medical 2 SOLUTION 0.3 MG ophthalmic ointment 1 % MAXITROL Brand neo-polycin ophthalmic 2 OPHTHALMIC 4 penalty ointment 3.5-400-10000 OINTMENT 3.5-10000- applies 0.1 OMIDRIA INTRAOCULAR GM MAXITROL Brand SOLUTION 1-0.3 % OPHTHALMIC 4 penalty SUSPENSION 3.5- OXERVATE applies 10000-0.1 OPHTHALMIC 6 PA SOLUTION 0.002 % MEMBRANEBLUE OPHTHALMIC GM phenylephrine hcl SOLUTION 0.15 % ophthalmic solution 10 2 %, 2.5 % MIOCHOL-E INTRAOCULAR polycin ophthalmic SOLUTION 4 ointment 500-10000 2 RECONSTITUTED 20 unit/gm MG polymyxin b-trimethoprim MIOSTAT ophthalmic solution 2 INTRAOCULAR 4 10000-0.1 unit/ml-% SOLUTION 0.01 % POLYTRIM Brand OPHTHALMIC MOXIFLOXACIN HCL- 4 penalty SOLUTION 10000-0.1 BSS INTRAVITREAL GM applies SOLUTION 1 MG/ML UNIT/ML-% neomycin-bacitracin zn- PRED-G OPHTHALMIC 3 SUSPENSION 0.3-1 % polymyx ophthalmic 2 ointment 3.5-400-10000 , PRED-G S.O.P. 5-400-10000 OPHTHALMIC 3 neomycin-polymyxin- OINTMENT 0.3-0.6 % dexameth ophthalmic 2 PREDNISOLONE- ointment 3.5-10000-0.1 BROMFENAC 4 OPHTHALMIC SOLUTION 1-0.075 %

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 200 Drug Drug Drug Name Notes Drug Name Notes Tier Tier PREDNISOLONE- TISSUEBLUE BROMFENAC INTRAOCULAR GM OPHTHALMIC GM SOLUTION PREFILLED SUSPENSION 1-0.075 SYRINGE 0.025 % % TOBRADEX PREDNISOLONE- OPHTHALMIC 3 GATIFLOXACIN OINTMENT 0.3-0.1 % 4 OPHTHALMIC TOBRADEX Brand SUSPENSION 1-0.5 % OPHTHALMIC 3 penalty PREDNISOLON- SUSPENSION 0.3-0.1 % applies GATIFLOX- TOBRADEX ST BROMFENAC 4 OPHTHALMIC 3 OPHTHALMIC SUSPENSION 0.3-0.05 SOLUTION 1-0.5-0.075 % % tobramycin- PREDNISOLON- dexamethasone 2 GATIFLOX- ophthalmic suspension BROMFENAC 4 0.3-0.1 % OPHTHALMIC SUSPENSION 1-0.5- TRIAMCINOLONE- 0.075 % MOXIFLOXACIN INTRAOCULAR GM PREDNISOLON- SUSPENSION 15-1 MOXIFLOX- MG/ML BROMFENAC 4 OPHTHALMIC TROPICAMIDE- SOLUTION 1-0.5-0.075 CYCLOPENTOLATE-PE 4 % OPHTHALMIC SOLUTION 1-1-2.5 % proparacaine hcl ophthalmic solution 0.5 2 TROPICAMIDE- PHENYLEPHRINE % 4 OPHTHALMIC PROVISC SOLUTION 1-2.5 % INTRAOCULAR 4 SOLUTION 10 MG/ML TROPIC-PROPARACA- PE-KETOROLAC RESTASIS MULTIDOSE OPHTHALMIC 4 OPHTHALMIC 3 SOLUTION 1-0.5-2.5-0.5 EMULSION 0.05 % % RESTASIS VISIONBLUE OPHTHALMIC 3 OPHTHALMIC GM EMULSION 0.05 % SOLUTION 0.06 % sulfacetamide- VISUDYNE prednisolone ophthalmic 2 INTRAVENOUS Specialty solution 10-0.23 % 6 SOLUTION Medical tetracaine hcl ophthalmic 2 RECONSTITUTED 15 solution 0.5 % MG

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 201 Drug Drug Drug Name Notes Drug Name Notes Tier Tier XIIDRA OPHTHALMIC PRAMOTIC OTIC 4 4 SOLUTION 5 % LIQUID 1-0.1 % Respiratory Tract / ZYLET OPHTHALMIC 4 SUSPENSION 0.5-0.3 % Pulmonary Agents - Otic Agents - Drugs for Drugs for Allergies, Ear Conditions Cough, Cold ADRENALIN NASAL acetic acid otic solution 2 2 4 % SOLUTION 0.1 % Brand azelastine hcl nasal CETRAXAL OTIC 4 penalty solution 0.1 %, 0.15 %, 2 SOLUTION 0.2 % applies 137 mcg/spray CIPRO HC OTIC BECONASE AQ NASAL 4 SUSPENSION 0.2-1 % SUSPENSION 42 4 MCG/SPRAY CIPRODEX OTIC 4 SUSPENSION 0.3-0.1 % benzonatate oral capsule 2 100 mg, 150 mg, 200 mg ciprofloxacin hcl otic 2 solution 0.2 % bromfed dm oral syrup 2 30-2-10 mg/5ml CIPROFLOXACIN- brompheniramine FLUOCINOLONE PF 4 OTIC SOLUTION 0.3- tannate oral tablet 2 0.025 % chewable 12 mg budesonide nasal Brand 2 DERMOTIC OTIC OIL 4 penalty suspension 32 mcg/act 0.01 % applies carbinoxamine maleate 2 flac otic oil 0.01 % 2 oral solution 4 mg/5ml carbinoxamine maleate fluocinolone acetonide 2 2 otic oil 0.01 % oral tablet 4 mg CINQAIR hydrocortisone-acetic 2 PA; acid otic solution 1-2 % INTRAVENOUS 6 Specialty SOLUTION 100 Medical neomycin-polymyxin-hc MG/10ML otic solution 1 %, 3.5- 2 clemastine fumarate oral 10000-1 2 tablet 2.68 mg neomycin-polymyxin-hc otic suspension 3.5- 2 CUROSURF INTRATRACHEAL 10000-1 4 SUSPENSION 120 ofloxacin otic solution 0.3 2 MG/1.5ML, 240 MG/3ML % hcl oral 2 OTIPRIO syrup 2 mg/5ml INTRATYMPANIC 4 SUSPENSION 6 % cyproheptadine hcl oral 2 tablet 4 mg OTOVEL OTIC 4 SOLUTION 0.3-0.025 % Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 202 Drug Drug Drug Name Notes Drug Name Notes Tier Tier desloratadine oral tablet hydromet oral syrup 5- 2 2 5 mg 1.5 mg/5ml desloratadine oral tablet 2 HYPERSAL dispersible 2.5 mg, 5 mg INHALATION 4 dexchlorpheniramine NEBULIZATION maleate oral solution 2 2 SOLUTION 3.5 %, 7 % mg/5ml INFASURF diphen oral elixir 12.5 INTRATRACHEAL 2 4 mg/5ml SUSPENSION 35-0.9 MG/ML-% hcl injection solution 50 2 ipratropium bromide mg/ml nasal solution 0.03 %, 2 0.06 % diphenhydramine hcl oral 2 elixir 12.5 mg/5ml KARBINAL ER ORAL SUSPENSION 4 FASENRA PEN EXTENDED RELEASE 4 SUBCUTANEOUS 6 PA MG/5ML SOLUTION AUTO- INJECTOR 30 MG/ML levocetirizine dihydrochloride oral 2 FASENRA PA; solution 2.5 mg/5ml SUBCUTANEOUS 6 Specialty SOLUTION PREFILLED levocetirizine Medical SYRINGE 30 MG/ML dihydrochloride oral 2 tablet 5 mg flunisolide nasal solution 2 25 mcg/act (0.025%) mometasone furoate nasal suspension 50 2 fluticasone propionate mcg/act nasal suspension 50 2 mcg/act NASONEX NASAL Brand SUSPENSION 50 4 penalty GILPHEX TR ORAL 4 MCG/ACT applies TABLET 10-388 MG nebusal inhalation 2 GILTUSS TR ORAL 4 nebulization solution 3 % TABLET 10-28-388 MG NEBUSAL INHALATION hydrocodone polst-cpm NEBULIZATION 4 polst er oral suspension 2 SOLUTION 6 % extended release 10-8 mg/5ml NEOTUSS PLUS ORAL LIQUID 7.5-4-30 4 hydrocodone- MG/5ML homatropine oral syrup 2 5-1.5 mg/5ml NUCALA SUBCUTANEOUS 6 PA hydrocodone- SOLUTION AUTO- homatropine oral tablet 2 INJECTOR 100 MG/ML 5-1.5 mg

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 203 Drug Drug Drug Name Notes Drug Name Notes Tier Tier NUCALA -phenyleph- 2 SUBCUTANEOUS 6 PA codeine oral syrup 6.25- SOLUTION PREFILLED 5-10 mg/5ml SYRINGE 100 MG/ML promethazine- NUCALA phenylephrine oral syrup 2 SUBCUTANEOUS PA; 6.25-5 mg/5ml 6 Specialty SOLUTION promethegan rectal RECONSTITUTED 100 Medical suppository 12.5 mg, 25 2 MG mg, 50 mg olopatadine hcl nasal 2 pseudoephedrine- solution 0.6 % bromphen-dm oral liquid 2 OMNARIS NASAL 30-2-10 mg/5ml SUSPENSION 50 4 pseudoephedrine- MCG/ACT bromphen-dm oral syrup 2 Brand 30-2-10 mg/5ml PATANASE NASAL 4 penalty pulmosal inhalation applies 2 SOLUTION 0.6 % nebulization solution 7 % Brand PHENERGAN QNASL CHILDRENS INJECTION SOLUTION 4 penalty NASAL AEROSOL 4 25 MG/ML, 50 MG/ML applies SOLUTION 40 promethazine hcl MCG/ACT injection solution 25 2 QNASL NASAL mg/ml, 50 mg/ml AEROSOL SOLUTION 4 promethazine hcl oral 2 80 MCG/ACT solution 6.25 mg/5ml QUZYTTIR GM promethazine hcl oral 2 INTRAVENOUS syrup 6.25 mg/5ml SOLUTION 10 MG/ML promethazine hcl oral Brand tablet 12.5 mg, 25 mg, 50 2 RYCLORA ORAL 4 penalty mg SOLUTION 2 MG/5ML applies promethazine hcl rectal SINUVA NASAL Specialty 5 suppository 12.5 mg, 25 2 IMPLANT 1350 MCG Medical mg sodium chloride promethazine-codeine inhalation nebulization 2 oral solution 6.25-10 2 solution 0.9 %, 10 %, 3 mg/5ml %, 7 % promethazine-codeine SSKI ORAL SOLUTION 4 oral syrup 6.25-10 2 1 GM/ML mg/5ml SURVANTA promethazine-dm oral INTRATRACHEAL 2 4 syrup 6.25-15 mg/5ml SUSPENSION 25-0.9 MG/ML-%

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 204 Drug Drug Drug Name Notes Drug Name Notes Tier Tier TESSALON PERLES Brand ADVAIR DISKUS ORAL CAPSULE 100 4 penalty INHALATION AEROSOL MG applies POWDER BREATH PA; Brand TUSSICAPS ORAL ACTIVATED 100-50 4 penalty MCG/DOSE, 250-50 applies CAPSULE EXTENDED 4 RELEASE 12 HOUR 10- MCG/DOSE, 500-50 8 MG MCG/DOSE TUXARIN ER ORAL ADVAIR HFA TABLET EXTENDED INHALATION AEROSOL 4 RELEASE 12 HOUR 115-21 MCG/ACT, 230- 4 PA 54.3-8 MG 21 MCG/ACT, 45-21 MCG/ACT TUZISTRA XR ORAL albuterol sulfate er oral SUSPENSION 4 EXTENDED RELEASE tablet extended release 2 14.7-2.8 MG/5ML 12 hour 4 mg, 8 mg albuterol sulfate hfa XHANCE NASAL QL (3 GM inhalation aerosol EXHALER 2 per 30 4 solution 108 (90 base) SUSPENSION 93 days) MCG/ACT mcg/act XOLAIR albuterol sulfate SUBCUTANEOUS PA; inhalation nebulization SOLUTION PREFILLED 6 Specialty solution (2.5 mg/3ml) 2 SYRINGE 150 MG/ML, Medical 0.083%, 0.63 mg/3ml, 75 MG/0.5ML 1.25 mg/3ml, 2.5 mg/0.5ml XOLAIR SUBCUTANEOUS PA; ALBUTEROL SULFATE SOLUTION 6 Specialty NEBULIZATION RECONSTITUTED 150 Medical SOLUTION (5 MG/ML) 4 MG 0.5% INHALATION (5 MG/ML) 0.5% ZETONNA NASAL AEROSOL SOLUTION 4 albuterol sulfate 37 MCG/ACT nebulization solution (5 2 mg/ml) 0.5% inhalation (5 Respiratory Tract / mg/ml) 0.5% Pulmonary Agents - Drugs for Asthma and albuterol sulfate oral 2 Other Lung Conditions syrup 2 mg/5ml albuterol sulfate oral Brand 2 ACCOLATE ORAL 4 penalty tablet 2 mg TABLET 10 MG, 20 MG applies albuterol sulfate oral 1 acetylcysteine inhalation tablet 4 mg 2 solution 10 %, 20 % ALVESCO INHALATION ADRENALIN INJECTION QL (4 ML AEROSOL SOLUTION 4 SOLUTION 1 MG/ML, 30 GM per 30 160 MCG/ACT, 80 MG/30ML days) MCG/ACT Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 205 Drug Drug Drug Name Notes Drug Name Notes Tier Tier aminophylline ASMANEX (60 2 intravenous solution 25 METERED DOSES) QL (1 EA mg/ml INHALATION AEROSOL 3 per 30 ANORO ELLIPTA POWDER BREATH days) INHALATION AEROSOL ACTIVATED 220 POWDER BREATH 3 MCG/INH ACTIVATED 62.5-25 ASMANEX (7 METERED MCG/INH DOSES) INHALATION QL (1 EA ARALAST NP AEROSOL POWDER 3 per 30 INTRAVENOUS PA; BREATH ACTIVATED days) SOLUTION 6 Specialty 110 MCG/INH RECONSTITUTED 1000 Medical ASMANEX HFA MG, 500 MG INHALATION AEROSOL 3 ARCAPTA NEOHALER QL (30 EA 100 MCG/ACT, 200 INHALATION CAPSULE 4 per 30 MCG/ACT, 50 MCG/ACT 75 MCG days) ATROVENT HFA INHALATION AEROSOL ARNUITY ELLIPTA 3 INHALATION AEROSOL SOLUTION 17 POWDER BREATH MCG/ACT 4 PA ACTIVATED 100 BEVESPI MCG/ACT, 200 AEROSPHERE 4 MCG/ACT, 50 MCG/ACT INHALATION AEROSOL ASMANEX (120 9-4.8 MCG/ACT METERED DOSES) QL (1 EA BREO ELLIPTA INHALATION AEROSOL 3 per 30 INHALATION AEROSOL POWDER BREATH POWDER BREATH days) 4 PA ACTIVATED 220 ACTIVATED 100-25 MCG/INH MCG/INH, 200-25 ASMANEX (14 MCG/INH METERED DOSES) QL (1 EA BROVANA INHALATION 4 INHALATION AEROSOL 3 per 30 NEBULIZATION POWDER BREATH days) SOLUTION 15 MCG/2ML ACTIVATED 220 budesonide inhalation MCG/INH suspension 0.25 mg/2ml, 2 ASMANEX (30 0.5 mg/2ml, 1 mg/2ml METERED DOSES) QL (1 EA COMBIVENT RESPIMAT INHALATION AEROSOL 3 per 30 INHALATION AEROSOL POWDER BREATH 3 days) SOLUTION 20-100 ACTIVATED 110 MCG/ACT MCG/INH, 220 MCG/INH cromolyn sodium inhalation nebulization 2 solution 20 mg/2ml

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 206 Drug Drug Drug Name Notes Drug Name Notes Tier Tier DALIRESP ORAL fluticasone-salmeterol TABLET 250 MCG, 500 4 PA inhalation aerosol MCG powder breath activated 2 100-50 mcg/dose, 250- difil-g forte oral liquid 2 100-100 mg/5ml 50 mcg/dose, 500-50 mcg/dose DULERA INHALATION AEROSOL 100-5 FLUTICASONE- MCG/ACT, 200-5 3 SALMETEROL MCG/ACT, 50-5 INHALATION AEROSOL POWDER BREATH MCG/ACT 2 ACTIVATED 113-14 ELIXOPHYLLIN ORAL 4 MCG/ACT, 232-14 ELIXIR 80 MG/15ML MCG/ACT, 55-14 QL (4 ML MCG/ACT epinephrine injection GM per 30 GLASSIA PA; solution 30 mg/30ml days) INTRAVENOUS 6 Specialty SOLUTION 1000 epinephrine injection QL (4 EA Medical MG/50ML solution auto-injector 2 per 30 0.15 mg/0.15ml, 0.15 days) INCRUSE ELLIPTA mg/0.3ml, 0.3 mg/0.3ml INHALATION AEROSOL Brand POWDER BREATH 3 EPIPEN 2-PAK penalty ACTIVATED 62.5 INJECTION SOLUTION 4 applies; QL MCG/INH AUTO-INJECTOR 0.3 (4 EA per ipratropium bromide MG/0.3ML 30 days) inhalation solution 0.02 2 Brand % EPIPEN JR 2-PAK penalty ipratropium-albuterol INJECTION SOLUTION 4 applies; QL inhalation solution 0.5- 2 AUTO-INJECTOR 0.15 (4 EA per 2.5 (3) mg/3ml MG/0.3ML 30 days) levalbuterol hcl inhalation ESBRIET ORAL 6 PA nebulization solution 0.31 CAPSULE 267 MG mg/3ml, 0.63 mg/3ml, 2 ESBRIET ORAL TABLET 1.25 mg/0.5ml, 1.25 6 PA 267 MG, 801 MG mg/3ml

FLOVENT DISKUS metaproterenol sulfate 2 INHALATION AEROSOL oral syrup 10 mg/5ml POWDER BREATH montelukast sodium oral 2 ACTIVATED 100 4 packet 4 mg MCG/BLIST, 250 montelukast sodium oral MCG/BLIST, 50 2 MCG/BLIST tablet 10 mg FLOVENT HFA montelukast sodium oral QL (24 GM INHALATION AEROSOL tablet chewable 4 mg, 5 2 4 per 30 mg 110 MCG/ACT, 220 days) MCG/ACT, 44 MCG/ACT Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 207 Drug Drug Drug Name Notes Drug Name Notes Tier Tier OFEV ORAL CAPSULE SCLEROSOL 6 PA 100 MG, 150 MG INTRAPLEURAL PERFOROMIST INTRAPLEURAL 4 AEROSOL POWDER 4 INHALATION 4 NEBULIZATION GM SOLUTION 20 MCG/2ML SEREVENT DISKUS INHALATION AEROSOL PROAIR HFA QL (3 GM INHALATION AEROSOL POWDER BREATH 3 2 per 30 SOLUTION 108 (90 ACTIVATED 50 days) BASE) MCG/ACT MCG/DOSE PROAIR RESPICLICK Brand INHALATION AEROSOL QL (3 EA SINGULAIR ORAL 4 penalty POWDER BREATH 2 per 30 PACKET 4 MG applies ACTIVATED 108 (90 days) Brand BASE) MCG/ACT SINGULAIR ORAL 4 penalty TABLET 10 MG applies PROLASTIN-C PA; INTRAVENOUS SINGULAIR ORAL Brand 6 Specialty SOLUTION 1000 TABLET CHEWABLE 4 4 penalty Medical MG/20ML MG, 5 MG applies PROLASTIN-C SPIRIVA HANDIHALER INTRAVENOUS PA; INHALATION CAPSULE 3 SOLUTION 6 Specialty 18 MCG RECONSTITUTED 1000 Medical SPIRIVA RESPIMAT MG INHALATION AEROSOL PULMICORT SOLUTION 1.25 3 FLEXHALER MCG/ACT, 2.5 INHALATION AEROSOL MCG/ACT 3 POWDER BREATH STERILE TALC ACTIVATED 180 POWDER MCG/ACT, 90 MCG/ACT INTRAPLEURAL 4 PULMICORT SUSPENSION SUSPENSION Brand RECONSTITUTED 5 GM INHALATION 4 penalty STIOLTO RESPIMAT SUSPENSION 0.25 applies INHALATION AEROSOL 3 MG/2ML, 0.5 MG/2ML, 1 SOLUTION 2.5-2.5 MG/2ML MCG/ACT QVAR REDIHALER STRIVERDI RESPIMAT INHALATION AEROSOL INHALATION AEROSOL 3 3 BREATH ACTIVATED 40 SOLUTION 2.5 MCG/ACT, 80 MCG/ACT MCG/ACT SYMBICORT INHALATION AEROSOL 3 160-4.5 MCG/ACT, 80- 4.5 MCG/ACT

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 208 Drug Drug Drug Name Notes Drug Name Notes Tier Tier terbutaline sulfate XOPENEX GM injection solution 1 mg/ml CONCENTRATE Brand INHALATION terbutaline sulfate oral 2 4 penalty tablet 2.5 mg, 5 mg NEBULIZATION applies SOLUTION 1.25 THEO-24 ORAL MG/0.5ML CAPSULE EXTENDED RELEASE 24 HOUR 100 4 XOPENEX INHALATION MG, 200 MG, 300 MG, NEBULIZATION Brand 400 MG SOLUTION 0.31 4 penalty MG/3ML, 0.63 MG/3ML, applies theophylline er oral tablet 1.25 MG/3ML extended release 12 hour 2 300 mg, 450 mg YUPELRI INHALATION SOLUTION 175 6 PA theophylline er oral tablet MCG/3ML extended release 24 hour 2 400 mg, 600 mg zafirlukast oral tablet 10 2 mg, 20 mg theophylline in d5w intravenous solution 0.8- GM ZEMAIRA 5 mg/ml-% INTRAVENOUS PA; SOLUTION 6 Specialty theophylline oral solution 2 RECONSTITUTED 1000 Medical 80 mg/15ml MG TRELEGY ELLIPTA zileuton er oral tablet INHALATION AEROSOL extended release 12 hour 5 POWDER BREATH 3 600 mg ACTIVATED 100-62.5-25 MCG/INH ZYFLO ORAL TABLET 5 600 MG TUDORZA PRESSAIR Respiratory Tract / INHALATION AEROSOL Pulmonary Agents - POWDER BREATH 3 Drugs for Cystic ACTIVATED 400 Fibrosis MCG/ACT UTIBRON NEOHALER BETHKIS INHALATION 6 PA INHALATION CAPSULE 4 NEBULIZATION 27.5-15.6 MCG SOLUTION 300 MG/4ML CAYSTON INHALATION VENTOLIN HFA QL (3 GM INHALATION AEROSOL SOLUTION 6 PA 2 per 30 RECONSTITUTED 75 SOLUTION 108 (90 days) BASE) MCG/ACT MG wixela inhub inhalation KALYDECO ORAL 6 PA aerosol powder breath PACKET 25 MG, 50 MG, activated 100-50 75 MG 2 KALYDECO ORAL mcg/dose, 250-50 6 PA mcg/dose, 500-50 TABLET 150 MG mcg/dose

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 209 Drug Drug Drug Name Notes Drug Name Notes Tier Tier KITABIS PAK ADEMPAS ORAL 6 PA INHALATION 6 PA TABLET 0.5 MG, 1 MG, NEBULIZATION 1.5 MG, 2 MG, 2.5 MG SOLUTION 300 MG/5ML alyq oral tablet 20 mg 5 PA ORKAMBI ORAL ambrisentan oral tablet 5 PA PACKET 100-125 MG, 6 PA 10 mg, 5 mg 150-188 MG bosentan oral tablet 125 5 PA ORKAMBI ORAL mg, 62.5 mg TABLET 100-125 MG, 6 PA epoprostenol sodium 200-125 MG PA; intravenous solution 5 Specialty PULMOZYME reconstituted 0.5 mg, 1.5 Medical INHALATION 6 PA mg SOLUTION 1 MG/ML FLOLAN SYMDEKO ORAL INTRAVENOUS PA; TABLET THERAPY 6 PA SOLUTION 6 Specialty PACK 100-150 & 150 RECONSTITUTED 0.5 Medical MG, 50-75 & 75 MG MG, 1.5 MG TOBI NEBULIZER LETAIRIS ORAL INHALATION 6 PA 6 PA TABLET 10 MG, 5 MG NEBULIZATION OPSUMIT ORAL SOLUTION 300 MG/5ML 6 PA TABLET 10 MG TOBI PODHALER INHALATION CAPSULE 6 PA ORENITRAM ORAL 28 MG TABLET EXTENDED RELEASE 0.125 MG, 6 PA tobramycin nebulization 0.25 MG, 1 MG, 2.5 MG, solution 300 mg/5ml 5 PA 5 MG inhalation 300 mg/5ml REMODULIN TOBRAMYCIN INJECTION SOLUTION PA; NEBULIZATION 100 MG/20ML, 20 6 Specialty SOLUTION 300 MG/5ML 6 PA MG/20ML, 200 Medical INHALATION 300 MG/20ML, 50 MG/20ML MG/5ML REVATIO PA; TRIKAFTA ORAL INTRAVENOUS TABLET THERAPY 6 Specialty 6 PA SOLUTION 10 Medical PACK 100-50-75 & 150 MG/12.5ML MG REVATIO ORAL Respiratory Tract / SUSPENSION Pulmonary Agents - 6 PA RECONSTITUTED 10 Drugs for Pulmonary MG/ML Hypertension REVATIO ORAL ADCIRCA ORAL 6 PA 6 PA TABLET 20 MG TABLET 20 MG

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 210 Drug Drug Drug Name Notes Drug Name Notes Tier Tier sildenafil citrate PA; VENTAVIS INHALATION intravenous solution 10 5 Specialty SOLUTION 10 MCG/ML, 6 PA mg/12.5ml Medical 20 MCG/ML sildenafil citrate oral Skeletal Muscle suspension reconstituted 6 PA Relaxants - Drugs for 10 mg/ml Muscle Pain and Spasm sildenafil citrate oral 5 PA tablet 20 mg intrathecal GM tadalafil (pah) oral tablet solution 10 mg/20ml, 40 5 PA 20 mg mg/20ml baclofen oral tablet 10 TRACLEER ORAL 2 TABLET 125 MG, 62.5 6 PA mg, 20 mg, 5 mg MG carisoprodol oral tablet 2 TRACLEER ORAL 250 mg, 350 mg 6 PA TABLET SOLUBLE 32 carisoprodol-aspirin oral 2 MG tablet 200-325 mg oral tablet treprostinil injection PA; 250 mg, 375 mg, 500 2 solution 100 mg/20ml, 20 6 Specialty mg/20ml, 200 mg/20ml, mg, 750 mg Medical 50 mg/20ml hcl oral TYVASO INHALATION tablet 10 mg, 5 mg, 7.5 2 6 PA SOLUTION 0.6 MG/ML mg TYVASO REFILL DANTRIUM INHALATION 6 PA INTRAVENOUS SOLUTION 0.6 MG/ML SOLUTION GM TYVASO STARTER RECONSTITUTED 20 INHALATION 6 PA MG SOLUTION 0.6 MG/ML DANTRIUM ORAL Brand 4 penalty UPTRAVI ORAL CAPSULE 25 MG, 50 applies TABLET 1000 MCG, MG 1200 MCG, 1400 MCG, sodium 6 PA 1600 MCG, 200 MCG, intravenous solution GM 400 MCG, 600 MCG, 800 reconstituted 20 mg MCG dantrolene sodium oral UPTRAVI ORAL capsule 100 mg, 25 mg, 2 TABLET THERAPY 4 50 mg PACK 200 & 800 MCG Brand VELETRI FEXMID ORAL TABLET 4 penalty INTRAVENOUS PA; 7.5 MG applies SOLUTION 6 Specialty RECONSTITUTED 0.5 Medical MG, 1.5 MG

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 211 Drug Drug Drug Name Notes Drug Name Notes Tier Tier GABLOFEN RYANODEX INTRATHECAL INTRAVENOUS SOLUTION 10000 GM SUSPENSION GM MCG/20ML, 40000 RECONSTITUTED 250 MCG/20ML MG LIORESAL Brand INTRATHECAL SKELAXIN ORAL 4 penalty SOLUTION 0.05 MG/ML, GM TABLET 800 MG applies 10 MG/20ML, 10 Brand MG/5ML, 40 MG/20ML SOMA ORAL TABLET 4 penalty LORZONE ORAL Brand 250 MG, 350 MG applies TABLET 375 MG, 750 4 penalty hcl oral MG applies capsule 2 mg, 4 mg, 6 2 oral tablet 2 mg 400 mg, 800 mg tizanidine hcl oral tablet 2 2 methocarbamol injection GM mg, 4 mg solution 1000 mg/10ml Brand methocarbamol oral VANADOM ORAL 4 penalty 2 tablet 500 mg, 750 mg TABLET 350 MG applies NORGESIC FORTE ZANAFLEX ORAL Brand ORAL TABLET 50-770- 4 CAPSULE 2 MG, 4 MG, 4 penalty 60 MG 6 MG applies citrate er Brand oral tablet extended 2 ZANAFLEX ORAL 4 penalty release 12 hour 100 mg TABLET 4 MG applies orphenadrine citrate Sleep Disorder Agents injection solution 30 GM AMBIEN CR ORAL mg/ml Brand TABLET EXTENDED 4 penalty RELEASE 12.5 MG, 6.25 orphenadrine-asa- applies caffeine oral tablet 50- 2 MG 770-60 mg Brand ORPHENGESIC FORTE AMBIEN ORAL TABLET 4 penalty ORAL TABLET 770-60- 4 10 MG, 5 MG applies 50 MG armodafinil oral tablet revonto intravenous 150 mg, 200 mg, 250 2 solution reconstituted 20 GM mg, 50 mg mg BELSOMRA ORAL ROBAXIN INJECTION TABLET 10 MG, 15 MG, 4 SOLUTION 1000 GM 20 MG, 5 MG MG/10ML doxepin hcl oral tablet 3 2 Brand mg, 6 mg ROBAXIN-750 ORAL 4 penalty oral tablet 1 2 TABLET 750 MG applies mg, 2 mg, 3 mg Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 212 Drug Drug Drug Name Notes Drug Name Notes Tier Tier hcl oral tartrate er oral 2 capsule 15 mg, 30 mg tablet extended release 2 12.5 mg, 6.25 mg HETLIOZ ORAL 6 PA CAPSULE 20 MG zolpidem tartrate oral 2 LUNESTA ORAL Brand tablet 10 mg, 5 mg TABLET 1 MG, 2 MG, 3 4 penalty MG applies modafinil oral tablet 100 2 mg, 200 mg NUVIGIL ORAL TABLET Brand 150 MG, 200 MG, 250 4 penalty MG, 50 MG applies PROVIGIL ORAL Brand TABLET 100 MG, 200 4 penalty MG applies oral tablet 8 2 mg RESTORIL ORAL Brand CAPSULE 15 MG, 22.5 4 penalty MG, 30 MG, 7.5 MG applies Brand ROZEREM ORAL 4 penalty TABLET 8 MG applies SECONAL ORAL 4 CAPSULE 100 MG Brand SILENOR ORAL 4 penalty TABLET 3 MG, 6 MG applies PA; QL (30 SUNOSI ORAL TABLET 4 EA per 30 150 MG, 75 MG days) oral capsule 15 mg, 22.5 mg, 30 mg, 2 7.5 mg WAKIX ORAL TABLET 6 PA 17.8 MG, 4.45 MG

XYREM ORAL 6 PA SOLUTION 500 MG/ML oral capsule 10 2 mg, 5 mg

Updated August 1, 2020 PA=Prior Auth Required; ST=Step Therapy; QL=Quantity Limits; AL=Age Limit; PV=Preventive; PV*=Preventive if member meets criteria 213 Index of Drugs 1ST MEDX-PATCH/ ACTOPLUS MET...... 115 AKYNZEO...... 43 LIDOCAINE...... 16 ACTOS...... 115 ala-cort...... 107 7T GUMMY ES...... 8 ACULAR...... 193 albendazole...... 64 7T LIDO...... 16 ACULAR LS...... 193 ALBENZA...... 64 abacavir sulfate...... 71 ACUVAIL...... 193 ALBUKED 25...... 180 abacavir sulfate-lamivudine 71 acyclovir...... 71 ALBUKED 5...... 180 abacavir-lamivudine- acyclovir sodium...... 71 albumin human...... 180 zidovudine...... 71 ACZONE...... 107 ALBUMINEX...... 180 ABANEU-SL...... 123 ADACEL...... 174 albumin-zlb...... 180 ABELCET...... 44 ADAKVEO...... 180 alburx...... 180 ABILIFY...... 68 adapalene...... 107 ALBUTEIN...... 180 ABILIFY MAINTENA...... 68 ADASUVE...... 68 albuterol sulfate...... 205 abiraterone acetate...... 51 adc/f (0.5mg/ml)...... 123 ALBUTEROL SULFATE... 205 ABRAXANE...... 51 ADCETRIS...... 51 albuterol sulfate er...... 205 ABSORICA...... 107 ADCIRCA...... 210 albuterol sulfate hfa...... 205 ABSORICA LD...... 107 ADDERALL...... 100 ALCAINE...... 198 ACACIA...... 180 ADDERALL XR...... 100 alclometasone acamprosate calcium...... 20 adefovir dipivoxil...... 71 dipropionate...... 107 acarbose...... 115 ADEMPAS...... 210 ALCOHOL PREP PADS... 108 ACCOLATE...... 205 ADENOCARD...... 84 ALDACTAZIDE...... 84 ACCUPRIL...... 84 adenosine...... 84, 180 ALDACTONE...... 84 ACCURETIC...... 84 adenosine (diagnostic)...... 180 ALDER...... 180 ACD FORMULA A...... 32 ADLYXIN...... 115 ALDURAZYME...... 143 ACD-A NOCLOT-50...... 32 ADLYXIN STARTER ALECENSA...... 52 acebutolol hcl...... 84 PACK...... 115 alendronate sodium...... 178 ACETADOTE...... 180 ADMELOG...... 119 alfentanil hcl...... 9 acetaminophen-codeine...... 9 ADMELOG SOLOSTAR... 119 ALFERON N...... 167 acetaminophen-codeine #2.. 9 ADRENAL C FORMULA...123 alfuzosin hcl er...... 148 acetaminophen-codeine #3.. 9 ADRENALIN...... 202, 205 ALIMTA...... 52 acetaminophen-codeine #4.. 9 adriamycin...... 51 ALINIA...... 64, 65 acetazolamide...... 196 adult aspirin regimen...... 6 ALIQOPA...... 52 acetazolamide er...... 196 ADVAIR DISKUS...... 205 aliskiren fumarate...... 84 acetazolamide sodium...... 84 ADVAIR HFA...... 205 ALKERAN...... 52 acetic acid...... 146, 202 ADVATE...... 78 allopurinol...... 48 acetylcysteine...... 180, 205 ADYNOVATE...... 79 allopurinol sodium...... 48 ACIPHEX...... 137 AEMCOLO...... 21 almotriptan malate...... 48 ACIPHEX SPRINKLE...... 137 AFINITOR...... 51 ALOCRIL...... 193 acitretin...... 107 AFINITOR DISPERZ...... 51 ALOGLIPTIN BENZOATE 115 ACREMONIUM...... 180 afirmelle...... 156 ALOGLIPTIN- ACTEMRA...... 167 AFLURIA METFORMIN HCL...... 115 ACTEMRA ACTPEN...... 166 QUADRIVALENT...... 174 ALOGLIPTIN- ACTHAR...... 152 AFREZZA...... 119, 120 PIOGLITAZONE...... 115 ACTHIB...... 174 AFSTYLA...... 79 ALOMIDE...... 193 ACTHREL...... 180 AGGRASTAT...... 68 ALOPRIM...... 48 ACTIGALL...... 139 AGGRENOX...... 68 ALORA...... 156 ACTIMMUNE...... 167 AGONEAZE...... 16 alosetron hcl...... 139 ACTIQ...... 9 AGRYLIN...... 79 ALOXI...... 43 ACTIVASE...... 32 AIMOVIG...... 48 ALPHAGAN P...... 196 ACTIVE FE...... 123 AJOVY...... 48 ALPHA-LIPOIC ACID...... 180 ACTIVE-KETOPROFEN...... 6 ak-fluor...... 198 ALPHANATE/VWF ACTIVELLA...... 156 AKOVAZ...... 84 COMPLEX/HUMAN...... 79 ACTIVITE...... 123 ak-poly-bac...... 198 ALPHANINE SD...... 79 ACTONEL...... 178 AKTEN...... 198 alprazolam...... 77 214 alprazolam er...... 76 amitriptyline hcl...... 40 ANGIOMAX...... 32 alprazolam intensol...... 76 amlodipine besylate...... 84 ANIMI-3...... 123 alprazolam xr...... 77 amlodipine besylate- ANIMI-3/VITAMIN D...... 123 ALPROLIX...... 79 benazepril hcl...... 85 ANJESO...... 6 alprostadil...... 84 amlodipine besylate- ANNOVERA...... 156 ALREX...... 193 valsartan...... 85 ANODYNE LPT...... 16 ALTABAX...... 21 amlodipine-atorvastatin...... 85 ANORO ELLIPTA...... 206 altacaine...... 198 amlodipine-olmesartan...... 85 ANTABUSE...... 20 ALTACE...... 84 amlodipine-valsartan-hctz...85 ANTARA...... 85 altafrin...... 198 ammonium lactate...... 108 anticoagulant cit dext soln altavera...... 156 AMMONUL...... 143 a...... 32 ALTERNARIA...... 180 amnesteem...... 108 anticoagulant sodium ALTOPREV...... 84 amoxapine...... 40 citrate...... 32 ALUNBRIG...... 52 amoxicill-clarithro- ANTIVENIN MICRURUS ALVESCO...... 205 lansopraz...... 139 FULVIUS...... 181 alyacen 1/35...... 156 amoxicillin...... 21 ANUSOL-HC...... 176 alyacen 7/7/7...... 156 amoxicillin-potassium ANZEMET...... 43 alyq...... 210 clavulanate...... 21 apap-caff-dihydrocodeine..... 9 amabelz...... 156 amoxicillin-potassium APIDRA SOLOSTAR...... 120 amantadine hcl...... 66 clavulanate er...... 21 APIDRA VIAL...... 120 AMARYL...... 115 AMPHADASE...... 181 APLENZIN...... 40 AMBIEN...... 212 amphetamine- APOKYN...... 66 AMBIEN CR...... 212 dextroamphetamine...... 100 APP SLIM RMS...... 181 AMBISOME...... 44 amphetamine- apraclonidine hcl...... 196 ambrisentan...... 210 dextroamphetamine er...... 100 aprepitant...... 43 amcinonide...... 108 amphotericin b...... 44 apri...... 156 AMD FOAM DRESSING...180 ampicillin...... 21 APRISO...... 177 AMD FOAM DRESSING ampicillin sodium...... 22 APTENSIO XR...... 100 TOPSHEET...... 180 ampicillin-sulbactam APTIOM...... 34 AMERGE...... 48 sodium...... 22 APTIVUS...... 71, 72 AMERICAN BEECH...... 181 AMVISC...... 198 AQUACEL AG BURN...... 108 AMERICAN COCKROACH AMVISC PLUS...... 198 AQUASOL A...... 123 ...... 181 ANACAINE...... 108 ARAKODA...... 65 AMERICAN ELM...... 181 ANADROL-50...... 151 ARALAST NP...... 206 AMERICAN SYCAMORE. 181 ANAFRANIL...... 40 aranelle...... 156 amethia...... 156 anagrelide hcl...... 79 ARANESP (ALBUMIN amethia lo...... 156 ana-lex...... 176 FREE)...... 79 amethyst...... 156 ANASCORP...... 181 ARAVA...... 167 AMICAR...... 79 ANASPAZ...... 139 ARCALYST...... 167 AMIDATE...... 181 anastrozole...... 52 ARCAPTA NEOHALER.... 206 amikacin sulfate...... 21 ANAVIP...... 181 ARESTIN...... 105 amiloride hcl...... 84 ANCOBON...... 44 argatroban...... 33 amiloride- ANDEXXA...... 181 argatroban in sodium hydrochlorothiazide...... 84 ANDRODERM...... 151 chloride...... 32 aminoacetic acid...... 146 ANDROGEL...... 151 ARGININE HCL...... 123 aminoamrms...... 123 ANDROGEL PUMP...... 151 argyle sterile saline...... 123 aminocaproic acid...... 79 ANECTINE...... 104 argyle sterile water...... 123 aminophylline...... 206 ANESTHESIA S/I-40...... 181 ARICEPT...... 39 aminoreliefrms...... 123 ANESTHESIA S/I-40A...... 181 ARIKAYCE...... 22 AMINOSYN II...... 123 ANESTHESIA S/I-40H...... 181 ARIMIDEX...... 52 AMINOSYN-PF...... 123 ANESTHESIA S/I-40S...... 181 aripiprazole...... 68, 69 amiodarone hcl...... 84 ANESTHESIA S/I-60...... 181 ARISTADA...... 69 AMITIZA...... 139 ANGELIQ...... 156 ARISTADA INITIO...... 69

215 ARIXTRA...... 33 ATIVAN...... 77 AZEDRA DOSIMETRIC...... 52 ARIZONA CYPRESS...... 181 atomoxetine hcl...... 100 AZEDRA THERAPEUTIC...52 armodafinil...... 212 atorvastatin calcium...... 85 azelaic acid...... 108 ARMOUR THYROID...... 165 atovaquone...... 65 azelastine hcl...... 193, 202 arnica flower...... 181 atovaquone-proguanil hcl... 65 AZELEX...... 108 ARNUITY ELLIPTA...... 206 atracurium besylate...... 104 AZILECT...... 66 AROMASIN...... 52 ATRAPRO DERMAL azithromycin...... 22 ARRANON...... 52 SPRAY...... 108 AZOPT...... 196 arsenic trioxide...... 52 ATRIPLA...... 72 AZOR...... 85 ARTHROTEC...... 6 ATROPINE SULFATE aztreonam...... 22 ARTICADENT DENTAL...... 16 ...... 139, 198 AZULFIDINE...... 177 ARTISS...... 181 atropine sulfate...... 198 AZULFIDINE EN-TABS.... 177 ARYMO ER...... 9 ATROVENT HFA...... 206 azurette...... 157 ARZERRA...... 52 AUBAGIO...... 102 b-6 folic acid...... 123 arzol silver nit applicators. 108 aubra...... 157 baciim...... 22 ASACOL HD...... 177 aubra eq...... 157 bacitracin...... 22, 193 ASCENIV...... 167 AUGMENTIN...... 22 bacitracin-polymyxin b...... 198 ASCLERA...... 85 AUGMENTIN ES-600...... 22 bacitra-neomycin- ascomp-codeine...... 9 AUREOBASIDIUM...... 181 polymyxin-hc...... 198 ASCOR...... 123 AUREOBASIDIUM baclofen...... 211 ASCORBIC ACID...... 123 PULLULANS...... 181 BACMIN...... 123 ashlyna...... 157 aurovela 1.5/30...... 157 BACTERIOSTATIC ASMANEX (120 aurovela 1/20...... 157 WATER(BENZ ALC)...... 181 METERED DOSES)...... 206 aurovela 24 fe...... 157 BACTRIM...... 22 ASMANEX (14 METERED aurovela fe 1.5/30...... 157 BACTRIM DS...... 22 DOSES)...... 206 aurovela fe 1/20...... 157 BAHIA...... 181 ASMANEX (30 METERED AURYXIA...... 146 bal in oil...... 181 DOSES)...... 206 AUSTEDO...... 104 balanced salt...... 198 ASMANEX (60 METERED AUSTRALIAN PINE...... 181 BALCOLTRA...... 157 DOSES)...... 206 AVALIDE...... 85 BALD CYPRESS...... 181 ASMANEX (7 METERED AVANDIA...... 115 balsalazide disodium...... 177 DOSES)...... 206 AVAPRO...... 85 balsam peru-castor oil...... 108 ASMANEX HFA...... 206 avar cleanser...... 108 BALVERSA...... 52 ASPARLAS...... 52 AVASTIN...... 52 balziva...... 157 ASPERGILLUS aviane...... 157 BANZEL...... 34 FUMIGATUS...... 181 avidoxy...... 22 BAQSIMI ONE PACK...... 119 aspirin...... 6 avita...... 108 BAQSIMI TWO PACK...... 119 aspirin adult low strength...... 6 AVODART...... 148 BARACLUDE...... 72 aspirin childrens...... 6 AVONEX PEN...... 102 BAVENCIO...... 52 aspirin ec...... 6 AVONEX PREFILLED...... 103 BAXDELA...... 22 aspirin ec low dose...... 6 AVONEX VIAL BAYBERRY (WAX aspirin ec low strength...... 6 INTRAMUSCULAR KIT... 103 MYRTLE)...... 182 aspirin low dose...... 6 AVSOLA...... 167 BAYER ASPIRIN EC LOW aspirin-dipyridamole er...... 68 AVYCAZ...... 22 DOSE...... 6 ASTAGRAF XL...... 167 AYGESTIN...... 157 BCG VACCINE...... 174 ATABEX OB...... 123 ayuna...... 157 BD AUTOSHIELD DUO ATACAND...... 85 AYVAKIT...... 52 PEN NEEDLES...... 120 ATACAND HCT...... 85 azacitidine...... 52 BD ULTRA-FINE INSULIN atazanavir sulfate...... 72 AZACTAM...... 22 SYRINGES...... 120 ATELVIA...... 178 AZASAN...... 167 BD ULTRA-FINE PEN atenolol...... 85 AZASITE...... 193 NEEDLES...... 120 atenolol-chlorthalidone...... 85 azathioprine...... 167 BD VEO INSULIN SYR ATGAM...... 167 azathioprine sodium...... 167 U/F 1/2UNIT...... 120

216 BECONASE AQ...... 202 BETIMOL...... 196 BONIVA...... 178 bekyree...... 157 BETOPTIC-S...... 196 BONJESTA...... 43 BELBUCA...... 9 BEVACIZUMAB...... 198 BOOSTRIX...... 174 BELEODAQ...... 52 BEVESPI AEROSPHERE 206 BORTEZOMIB...... 53 belladonna alkaloids-opium BEVYXXA...... 33 bosentan...... 210 ...... 139 bexarotene...... 53 BOSULIF...... 53 BELRAPZO...... 52 BEXSERO...... 174 BOTOX...... 182 BELSOMRA...... 212 BEYAZ...... 157 BOTRYTIS...... 182 benazepril hcl...... 85 bicalutamide...... 53 BOX ELDER...... 182 benazepril- BICILLIN C-R...... 23 bp 10-1...... 108 hydrochlorothiazide...... 85 BICILLIN C-R 900/300...... 22 BP CLEANSING WASH... 108 BENDAMUSTINE HCL...... 52 BICILLIN L-A...... 23 bp vit 3...... 123 BENDEKA...... 52 BICNU...... 53 BPCO...... 108 BENEFIX...... 79 BIDIL...... 85 b-plex...... 123 BENICAR...... 85 BIKTARVY...... 72 b-plex plus...... 123 BENICAR HCT...... 85 BILTRICIDE...... 65 BRAFTOVI...... 53 BENLYSTA...... 167 bimatoprost...... 196 BREO ELLIPTA...... 206 BENSAL HP...... 108 BI-MIX...... 146 BREVIBLOC...... 86 BENTYL...... 139 BINOSTO...... 178 BREVIBLOC IN NACL...... 86 benzalkonium chloride...... 22 biocel...... 123 BREVIBLOC PREMIXED... 86 BENZNIDAZOLE...... 65 BIOFREQUENCY BREVIBLOC PREMIXED benzoin...... 108 INSOLES...... 182 DS...... 86 benzoin compound...... 108 BIOGUARD GAUZE BREVITAL SODIUM...... 182 benzonatate...... 202 SPONGES...... 182 BRIDION...... 182 benztropine mesylate...... 66 BIOGUARD ISLAND briellyn...... 157 BEOVU...... 198 DRESSINGS...... 182 BRILINTA...... 68 BEPREVE...... 193 BIOGUARD NON- brimonidine tartrate...... 196 BERINERT...... 167 ADHERENT DRESSING.. 182 BRIMONIDINE- BERMUDA GRASS...... 182 BIOLON...... 198 DORZOLAMIDE...... 196 beser...... 108 BIORPHEN...... 85 BRINEURA...... 143 BESIVANCE...... 193 BIO-STATIN...... 45 BRIVIACT...... 34 BESPONSA...... 53 bio-statin...... 45 BROME...... 182 BETADINE OPHTHALMIC BIOTHRAX...... 174 bromfed dm...... 202 PREP...... 193 bisoprolol fumarate...... 85 bromfenac sodium (once- BETAMETHASONE bisoprolol- daily)...... 193 COMBO...... 149 hydrochlorothiazide...... 86 bromocriptine mesylate...... 66 betamethasone bivalirudin trifluoroacetate...33 brompheniramine tannate.202 dipropionate...... 108 BIVALIRUDIN-SODIUM BROMSITE...... 194 betamethasone CHLORIDE...... 33 BROVANA...... 206 dipropionate aug...... 108 BIVIGAM...... 167 BRUKINSA...... 53 BETAMETHASONE SOD BLACK WALNUT POLLEN bss...... 198 PHOS & ACET...... 149 ...... 182 budesonide...... 177, 202, 206 betamethasone sod phos BLACK WILLOW...... 182 budesonide er...... 177 & acet...... 149 bleomycin sulfate...... 53 bumetanide...... 86 BETAMETHASONE BLEPH-10...... 193 BUMEX...... 86 SODIUM PHOSPHATE.... 149 BLEPHAMIDE...... 198 BUNAVAIL...... 20 betamethasone valerate... 108 BLEPHAMIDE S.O.P...... 198 BUPAP...... 9 BETAPACE...... 85 BLINCYTO...... 53 BUPHENYL...... 143 BETAPACE AF...... 85 blisovi 24 fe...... 157 bupivacaine fisiopharma..... 16 BETASERON...... 103 blisovi fe 1.5/30...... 157 bupivacaine hcl...... 16 betaxolol hcl...... 85, 196 blisovi fe 1/20...... 157 BUPIVACAINE HCL...... 16 bethanechol chloride...... 146 BLOXIVERZ...... 50 bupivacaine hcl (pf)...... 16 BETHKIS...... 209 BOCASAL...... 106 BUPIVACAINE HCL-NACL.16

217 bupivacaine in dextrose...... 16 CALCIUM DISODIUM CARDIOPLEGIA bupivacaine spinal...... 16 VERSENATE...... 182 INDUCTION HIGH K...... 124 bupivacaine-epinephrine.....16 CALCIUM GLUCONATE- CARDIOPLEGIA bupivacaine-epinephrine NACL...... 123 INDUCTION LOW DEX.... 124 (pf)...... 16 CALCIUM-FOLIC ACID CARDIOPLEGIA BUPRENEX...... 9 PLUS D...... 124 INDUCTION NON-ENR.... 124 buprenorphine...... 9 CALDOLOR...... 6 CARDIOPLEGIA MAIN buprenorphine hcl...... 9, 20 CALIFORNIA PEPPER LOW DEXTROSE...... 124 buprenorphine hcl- TREE...... 182 CARDIOPLEGIA MAIN naloxone hcl...... 20 CALQUENCE...... 53 LOW TROMETHA...... 124 bupropion hcl...... 40 CAMBIA...... 48 CARDIOPLEGIA MAIN bupropion hcl er (smoking camila...... 157 PLASMA-TROME...... 124 det)...... 20 CAMPATH...... 53 CARDIOPLEGIA bupropion hcl er (sr)...... 40 CAMPTOSAR...... 53 MAINTENANCE...... 124 bupropion hcl er (xl)...... 40 camrese...... 157 CARDIOPLEGIA buspirone hcl...... 77 camrese lo...... 157 REPERFUSATE 4:1...... 124 busulfan...... 53 CANASA...... 177 CARDIOPLEGIC...... 124 BUSULFEX...... 53 CANCIDAS...... 45 cardioplegic...... 124 butalbital-acetaminophen...... 9 candesartan cilexetil...... 86 CARDIOVID PLUS...... 182 BUTALBITAL- candesartan cilexetil-hctz... 86 CARDIZEM...... 86 ACETAMINOPHEN...... 9 CANDIDA ALBICANS CARDIZEM CD...... 86 butalbital-apap-caff-cod...... 9 EXTRACT...... 182 CARDIZEM LA...... 86 butalbital-apap-caffeine...... 9 CAPASTAT SULFATE...... 51 CARDURA...... 86 butalbital-asa-caff-codeine....9 capecitabine...... 53 CARDURA XL...... 148 butalbital-aspirin-caffeine...... 9 CAPLYTA...... 69 CARIMUNE NF...... 167 butorphanol tartrate...... 9 CAPRELSA...... 53 carisoprodol...... 211 BUTRANS...... 10 captopril...... 86 carisoprodol-aspirin...... 211 BYDUREON...... 116 captopril- carisoprodol-aspirin- BYDUREON BCISE hydrochlorothiazide...... 86 codeine...... 10 AUTOINJECTOR...... 116 CARAFATE...... 137, 138 carmustine...... 53 BYETTA 10 MCG PEN..... 116 CARBAGLU...... 124 CARNITOR...... 124 BYETTA 5 MCG PEN...... 116 carbamazepine...... 35 CARNITOR SF...... 124 BYNFEZIA PEN...... 152 carbamazepine er...... 35 carteolol hcl...... 196 BYSTOLIC...... 86 CARBATROL...... 35 cartia xt...... 86 cabergoline...... 152 carbidopa...... 66 carvedilol...... 87 CABLIVI...... 68 carbidopa-levodopa...... 66 carvedilol phosphate er...... 87 CABOMETYX...... 53 carbidopa-levodopa er...... 66 CASODEX...... 53 CADUET...... 86 carbidopa-levodopa- caspofungin acetate...... 45 CAFCIT...... 104 entacapone...... 66 CAT HAIR EXTRACT...... 182 CAFERGOT...... 48 carbinoxamine maleate.....202 CATAPRES...... 87 caffeine citrate...... 104 CARBOCAINE...... 16 CATAPRES-TTS-1...... 87 CALAN SR...... 86 CARBOCAINE CATAPRES-TTS-2...... 87 CALCIFOL...... 123 PRESERVATIVE-FREE..... 16 CATAPRES-TTS-3...... 87 calcipotriene...... 108 carboplatin...... 53 CATHFLO ACTIVASE...... 33 calcipotriene-betameth carboprost tromethamine..152 CATTLE EPITHELIUM..... 182 diprop...... 109 CARDENE IV...... 86 cavarest...... 106 calcitonin (salmon)...... 178 CARDIOPLEGIA DEL CAYA...... 182 calcitriol...... 109, 179 NIDO FORMULA...... 124 CAYSTON...... 209 calcium acetate...... 146 CARDIOPLEGIA IND caziant...... 157 calcium acetate (phos PLASMA HIGH K...... 124 CEDAR ELM...... 182 binder)...... 146 CARDIOPLEGIA IND cefaclor...... 23 CALCIUM CHLORIDE...... 123 PLASMA-TROMET...... 124 cefaclor er...... 23 calcium chloride...... 123 cefadroxil...... 23

218 CEFAZOLIN IN SODIUM CHANTIX CONTINUING ciprofloxacin in d5w...... 25 CHLORIDE...... 23 MONTH PAK...... 20 CIPROFLOXACIN- cefazolin sodium...... 23 CHANTIX STARTING FLUOCINOLONE PF...... 202 CEFAZOLIN SODIUM...... 23 MONTH PAK...... 20 cisatracurium besylate...... 104 cefazolin sodium-dextrose.. 23 charlotte 24 fe...... 157 cisatracurium besylate (pf)104 cefdinir...... 23 chateal...... 157 cisplatin...... 53 cefditoren pivoxil...... 23 chateal eq...... 157 citalopram hydrobromide.... 40 cefepime hcl...... 23 CHEMET...... 124 CITANEST FORTE cefepime-dextrose...... 23 CHENODAL...... 139 DENTAL...... 16 cefixime...... 23 CHIRHOSTIM...... 182 CITANEST PLAIN CEFOTAN...... 23 chloramphenicol sod DENTAL...... 16 cefotaxime sodium...... 23 succinate...... 24 CITRANATAL ESSENCE. 124 cefotetan disodium...... 24 chlordiazepoxide hcl...... 77 CITRANATAL MEDLEY....124 cefotetan disodium- chlordiazepoxide- CLADOSPORIUM dextrose...... 24 amitriptyline...... 40 CLADOSPORIOIDES...... 183 cefoxitin sodium...... 24 chlordiazepoxide-clidinium139 CLADOSPORIUM CEFOXITIN SODIUM- chlorhexidine gluconate.... 106 SPHAEROSPERMUM...... 183 DEXTROSE...... 24 CHLORHEXIDINE cladribine...... 53 cefpodoxime proxetil...... 24 GLUCONATE...... 183 claravis...... 109 cefprozil...... 24 chloroprocaine hcl (pf)...... 16 clarithromycin...... 25 ceftazidime...... 24 chloroquine phosphate...... 65 clarithromycin er...... 25 ceftazidime and dextrose....24 chlorothiazide...... 87 clearlax...... 139 ceftriaxone sodium...... 24 chlorothiazide sodium...... 87 clemastine fumarate...... 202 ceftriaxone sodium in chlorpromazine hcl...... 69 CLENPIQ...... 139 dextrose...... 24 chlorthalidone...... 87 CLEOCIN...... 25 ceftriaxone sodium- chlorzoxazone...... 211 CLEOCIN PHOSPHATE.....25 dextrose...... 24 CHOLBAM...... 143 CLEVIPREX...... 87 cefuroxime axetil...... 24 cholestyramine...... 87 CLIMARA...... 157 cefuroxime sodium...... 24 cholestyramine light...... 87 CLIMARA PRO...... 157 CELEBREX...... 6 chorionic gonadotropin..... 152 clindacin etz...... 109 celecoxib...... 6 chromagen...... 124 clindacin-p...... 109 CELESTONE SOLUSPAN149 chromic chloride...... 124 clindamycin hcl...... 25 CELEXA...... 40 CIALIS...... 146 clindamycin palmitate hcl....25 CELLCEPT...... 167 ciclodan...... 45 clindamycin phosphate25, 109 CELLCEPT ciclopirox...... 45 clindamycin phosphate in INTRAVENOUS...... 167 ciclopirox olamine...... 45 d5w...... 25 CELONTIN...... 35 cidofovir...... 72 CLINDESSE...... 25 cem-urea...... 109 cilostazol...... 68 CLINIMIX E/DEXTROSE CENTANY AT...... 24 CILOXAN...... 194 (2.75/5)...... 124 CENTRATEX...... 124 CIMDUO...... 72 CLINIMIX E/DEXTROSE cephalexin...... 24 cimetidine...... 138 (4.25/10)...... 124 CEPROTIN...... 79 cimetidine hcl...... 138 CLINIMIX E/DEXTROSE CERDELGA...... 143 CIMZIA...... 168 (4.25/5)...... 124 CEREBYX...... 35 CIMZIA PREFILLED KIT.. 167 CLINIMIX E/DEXTROSE CEREZYME...... 143 CIMZIA STARTER KIT..... 168 (5/15)...... 124 cerovel...... 109 cinacalcet hcl...... 179 CLINIMIX E/DEXTROSE CERVIDIL...... 146 CINQAIR...... 202 (5/20)...... 124 CETACAINE...... 16 CINRYZE...... 168 CLINIMIX/DEXTROSE CETRAXAL...... 202 CINVANTI...... 43 (4.25/10)...... 125 CETROTIDE...... 152 CIPRO...... 24, 25 CLINIMIX/DEXTROSE cevimeline hcl...... 106 CIPRO HC...... 202 (4.25/5)...... 125 CHANTIX...... 20 CIPRODEX...... 202 CLINIMIX/DEXTROSE ciprofloxacin hcl.. 25, 194, 202 (5/15)...... 125

219 CLINIMIX/DEXTROSE COLY-MYCIN M...... 25 CRESEMBA...... 45 (5/20)...... 125 COMBIGAN...... 196 CRESTOR...... 88 CLINISOL SF...... 125 COMBIPATCH...... 157 CRINONE...... 157 CLINOLIPID...... 125 COMBIVENT RESPIMAT. 206 CRIXIVAN...... 72 clinpro 5000...... 106 COMBIVIR...... 72 CROFAB...... 183 clobazam...... 35 COMETRIQ (100 MG cromolyn sodium clobetasol prop emollient DAILY DOSE)...... 53 ...... 139, 194, 206 base...... 109 COMETRIQ (140 MG crotan...... 65 clobetasol propionate...... 109 DAILY DOSE)...... 54 cryselle-28...... 157 clobetasol propionate e.....109 COMETRIQ (60 MG CRYSVITA...... 143 clobetasol propionate DAILY DOSE)...... 54 c-topical...... 16 emulsion...... 109 COMPLERA...... 72 CUBICIN...... 25 clocortolone pivalate...... 109 compro...... 43 CUBICIN RF...... 25 clodan...... 109 COMTAN...... 66 CUPRIC CHLORIDE...... 125 CLODERM...... 109 CONCERTA...... 100 CURITY AMD clofarabine...... 53 CONDYLOX...... 109 ANTIMICROBIAL SPNGE 183 CLOLAR...... 53 constulose...... 139 CURITY AMD clomiphene citrate...... 152 COPIKTRA...... 54 ANTIMICROBIAL STRIP.. 183 clomipramine hcl...... 40 CORDRAN...... 109 CURITY IODOFORM clonazepam...... 77 COREG...... 87 PACKING STRIP...... 183 clonidine...... 87 COREG CR...... 87 curity sterile saline...... 125 clonidine hcl...... 87 CORGARD...... 87 CUROSURF...... 202 clonidine hcl (analgesia)..... 10 CORIFACT...... 80 CURVULARIA...... 183 clonidine hcl er...... 100 CORLANOR...... 87, 88 CUTAQUIG...... 168 clopidogrel bisulfate...... 68 CORLOPAM...... 88 CUVITRU...... 168 clorazepate dipotassium..... 77 CORN POLLEN...... 183 CUVPOSA...... 139 CLOROTEKAL...... 16 CORTEF...... 149 cyanocobalamin...... 125 clotrimazole...... 45 CORTENEMA...... 177 CYANOCOBALAMIN...... 125 clotrimazole- CORTIFOAM...... 177 CYANOKIT...... 183 betamethasone...... 45 cortisone acetate...... 149 cyclafem 1/35...... 158 clovique...... 125 CORTISPORIN...... 109 cyclafem 7/7/7...... 158 clozapine...... 69 CORTROSYN...... 183 cyclobenzaprine hcl...... 211 CLOZARIL...... 69 CORVERT...... 88 CYCLOGYL...... 198 COAGADEX...... 80 corvita...... 125 CYCLOMYDRIL...... 198 coal tar...... 109 corvita 150...... 125 cyclopentolate hcl..... 198, 199 COARTEM...... 65 CORVITE 150...... 125 cyclophosphamide...... 54 COCAINE HCL...... 16 CORVITE FE...... 125 cycloserine...... 51 COCKLEBUR...... 183 COSENTYX (300 MG CYCLOSET...... 116 cod liver oil...... 125 DOSE)...... 168 cyclosporine...... 168 codeine sulfate...... 10 COSENTYX 150 MG/ML.. 168 CYCLOSPORINE IN COGENTIN...... 66 COSENTYX KLARITY...... 199 COLAZAL...... 177 SENSOREADY (300 MG).168 cyclosporine modified...... 168 COLCHICINE...... 48 COSENTYX CYKLOKAPRON...... 80 colchicine...... 48 SENSOREADY PEN...... 168 CYMBALTA...... 40 colchicine-probenecid...... 48 COSMEGEN...... 54 cyproheptadine hcl...... 202 COLCRYS...... 48 COSOPT...... 196 CYRAMZA...... 54 colesevelam hcl...... 87 COSOPT PF...... 196 cyred...... 158 COLESTID...... 87 cosyntropin...... 183 cyred eq...... 158 COLESTID FLAVORED..... 87 COTELLIC...... 54 CYSTADANE...... 143 colestipol hcl...... 87 covaryx...... 157 CYSTAGON...... 143 colistimethate sodium covaryx hs...... 157 CYSVIEW...... 183 (cba)...... 25 COZAAR...... 88 cytarabine...... 54 colocort...... 177 CREON...... 143 cytarabine (pf)...... 54

220 CYTOGAM...... 168 delyla...... 158 DEXAMETH-MOXIFLOX- CYTOMEL...... 165 DELZICOL...... 177 KETOROLAC...... 199 CYTOTEC...... 138 demeclocycline hcl...... 25 dexchlorpheniramine CYTOVENE...... 72 DEMEROL...... 10 maleate...... 203 cytra k crystals...... 125 DEMSER...... 88 DEXEDRINE...... 100 D.H.E. 45...... 48 DENAVIR...... 72 dexifol...... 125 dacarbazine...... 54 denta 5000 plus...... 106 DEXILANT...... 138 DACOGEN...... 54 dentagel...... 106 DEXMEDETOMIDINE HCL dactinomycin...... 54 DEPAKOTE...... 35 ...... 183 dalfampridine er...... 103 DEPAKOTE ER...... 35 dexmedetomidine hcl...... 183 DALIRESP...... 207 DEPAKOTE SPRINKLES... 35 dexmedetomidine hcl in DALVANCE...... 25 DEPEN TITRATABS...... 146 nacl...... 183 danazol...... 151 DEPO-ESTRADIOL...... 158 DEXMEDETOMIDINE DANDELION...... 183 DEPO-MEDROL...... 149 HCL-DEXTROSE...... 184 DANTRIUM...... 211 DEPO-PROVERA...... 158 dexmethylphenidate hcl.... 100 dantrolene sodium...... 211 DEPO-SUBQ PROVERA dexmethylphenidate hcl er 100 dapsone...... 51, 109 104...... 158 DEXONTO 0.4%...... 150 DAPTACEL...... 174 DEPO-TESTOSTERONE. 151 dexrazoxane hcl...... 54 daptomycin...... 25 DERMACINRX dextroamphetamine sulfate DARAPRIM...... 65 EMPRICAINE...... 17 ...... 101 darifenacin hydrobromide DERMACINRX PRIZOPAK 17 dextroamphetamine sulfate er...... 146 DERMOTIC...... 202 er...... 100 DARZALEX...... 54 DERMULCERA...... 109 dextrose...... 125, 126 DARZALEX FASPRO...... 54 DESCOVY...... 72 DEXTROSE...... 125, 126 dasetta 1/35...... 158 DESFERAL...... 183 DEXTROSE dasetta 7/7/7...... 158 desipramine hcl...... 40 5%/ELECTROLYTE #48...125 daunorubicin hcl...... 54 desloratadine...... 203 dextrose in lactated ringers DAURISMO...... 54 desmopressin ace spray ...... 125 DAVITE...... 125 refrig...... 153 dextrose-nacl...... 126 DAYPRO...... 6 desmopressin acetate...... 153 dextrose-sodium chloride..126 daysee...... 158 desmopressin acetate DEXYCU...... 194 DAYTRANA...... 100 spray...... 153 DIACOMIT...... 35 DDAVP...... 152 desogestrel-ethinyl dialyvite...... 126 DDAVP RHINAL TUBE.....153 estradiol...... 158 DIALYVITE 3000...... 126 DEBACTEROL...... 106 desonide...... 109, 110 DIALYVITE 5000...... 126 deblitane...... 158 desoximetasone...... 110 DIALYVITE SUPREME D. 126 DECADRON...... 149 DESOXYN...... 100 DIALYVITE/ZINC...... 126 DECARA...... 125 DESVENLAFAXINE ER...... 40 DIANEAL LOW decitabine...... 54 desvenlafaxine succinate CALCIUM/1.5% DEX...... 126 deferasirox...... 125 er...... 40 DIANEAL LOW deferoxamine mesylate.....183 DETROL...... 146 CALCIUM/2.5% DEX...... 126 DEFITELIO...... 33 DETROL LA...... 146 DIANEAL LOW DEFLUX...... 183 dexamethasone...... 149 CALCIUM/4.25% DEX...... 126 DELESTROGEN...... 158 dexamethasone intensol...149 DIANEAL PD-2/1.5% DELFLEX-LC/1.5% DEXAMETHASONE SOD DEXTROSE...... 126 DEXTROSE...... 125 PHOS-BUPIV...... 150 DIANEAL PD-2/2.5% DELFLEX-LC/2.5% dexamethasone sod DEXTROSE...... 126 DEXTROSE...... 125 phosphate pf...... 150 DIANEAL PD-2/4.25% DELFLEX-LC/4.25% dexamethasone sodium DEXTROSE...... 126 DEXTROSE...... 125 phosphate...... 150, 194 DIASTAT ACUDIAL...... 35 delflex-sm/1.5% dextrose. 125 DEXAMETHASONE- DIASTAT PEDIATRIC...... 35 delflex-sm/2.5% dextrose. 125 MOXIFLOXACIN...... 199 diazepam...... 35, 77 DELSTRIGO...... 72 DIAZEPAM...... 77

221 diazepam intensol...... 77 disopyramide phosphate.....88 DULERA...... 207 diazoxide...... 119 disulfiram...... 20 duloxetine hcl...... 41 DIBENZYLINE...... 88 DITROPAN XL...... 146 DUODOTE...... 184 DICLOFENAC DIURIL...... 89 DUPIXENT...... 110 EPOLAMINE...... 6 divalproex sodium...... 35 DURACLON...... 10 diclofenac potassium...... 6 divalproex sodium er...... 35 DURAGESIC-100...... 10 diclofenac sodium. 6, 110, 194 DIVIGEL...... 158 DURAGESIC-12...... 10 diclofenac sodium er...... 6 dobutamine hcl...... 89 DURAGESIC-25...... 10 diclofenac-misoprostol...... 6 dobutamine in d5w...... 89 DURAGESIC-50...... 10 DICLOSTREAM...... 6 docetaxel...... 54 DURAGESIC-75...... 10 dicloxacillin sodium...... 26 dofetilide...... 89 duramorph...... 10 dicyclomine hcl...... 139 DOG EPITHELIUM...... 184 duraxin...... 10 didanosine...... 72 DOG FENNEL...... 184 DUREZOL...... 194 DIFICID...... 26 DOJOLVI...... 184 DUROLANE...... 184 difil-g forte...... 207 DOLOPHINE...... 10 DURYSTA...... 196 diflorasone diacetate...... 110 donepezil hcl...... 39 DUST MITE MIXED DIFLUCAN...... 45 dopamine hcl...... 89 ALLERGEN EXT...... 184 diflunisal...... 6 dopamine in d5w...... 89 dutasteride...... 149 DIGIFAB...... 184 DOPRAM...... 104 dutasteride-tamsulosin hcl 149 digitek...... 88 DOPTELET...... 80 DUTOPROL...... 89 digox...... 88 DORAL...... 77 DYANAVEL XR...... 101 digoxin...... 88 DORZOLAMIDE HCL...... 196 DYAZIDE...... 89 dihydroergotamine dorzolamide hcl...... 196 DYRENIUM...... 89 mesylate...... 48, 49 dorzolamide hcl-timolol mal DYSPORT...... 184 DILANTIN...... 35 ...... 196 E.E.S. 400...... 26 DILANTIN INFATABS...... 35 dorzolamide hcl-timolol mal E.E.S. GRANULES...... 26 DILATRATE-SR...... 88 pf...... 196 EASTERN DILAUDID...... 10 dotti...... 158 COTTONWOOD...... 184 diltiazem hcl...... 88 DOVATO...... 72 easygel...... 106 diltiazem hcl er...... 88 doxazosin mesylate...... 89 EC-NAPROSYN...... 6 diltiazem hcl er beads...... 88 doxepin hcl...... 40, 110, 212 ec-naproxen...... 7 diltiazem hcl er coated doxercalciferol...... 179 econazole nitrate...... 45 beads...... 88 DOXIL...... 54 EC-RX PROGESTERONE158 DILTIAZEM HCL-SODIUM doxorubicin hcl...... 54 EDARBI...... 89 CHLORIDE...... 88 doxorubicin hcl liposomal....54 EDARBYCLOR...... 89 dilt-xr...... 88 doxy 100...... 26 EDECRIN...... 89 DILUENT FOR doxycycline hyclate...... 26 ed-spaz...... 140 LEFAMULIN...... 126 doxycycline monohydrate... 26 EDURANT...... 72 diluent for treprostinil...... 184 DRECHSLERA...... 184 eemt...... 158 dimenhydrinate...... 43 DRISDOL...... 126 eemt hs...... 158 DIMENTHO...... 6 DRITHO-CREME HP...... 110 efavirenz...... 72 DIMERCAPTOPROPANE- dronabinol...... 43 EFFER-K...... 126 SULFONATE...... 184 droperidol...... 43 effer-k...... 126 DIOVAN...... 88 DROPLET MICRON...... 120 EFFEXOR XR...... 41 DIOVAN HCT...... 88 drospiren-eth estrad- EFFIENT...... 68 DIPENTUM...... 177 levomefol...... 158 EGRIFTA SV...... 153 diphen...... 203 drospirenone-ethinyl ELAPRASE...... 143 diphenhydramine hcl...... 203 estradiol...... 158 ELELYSO...... 143 diphenoxylate-atropine..... 139 DROXIA...... 54 ELESTRIN...... 158 DIPHTHERIA-TETANUS DRYSOL...... 110 eletriptan hydrobromide...... 49 TOXOIDS DT...... 174 DSUVIA...... 10 ELIDEL...... 110 DIPRIVAN...... 184 DUAVEE...... 158 ELIGARD...... 153 dipyridamole...... 68, 184 DUETACT...... 116 ELIMITE...... 65

222 elinest...... 158 ENTYVIO...... 168 ery...... 110 ELIQUIS...... 33 enulose...... 140 ERYPED 200...... 26 ELIQUIS DVT/PE ENVARSUS XR...... 168 ERYPED 400...... 26 STARTER PACK...... 33 ENZADYNE...... 144 ERY-TAB...... 26 ELITEK...... 54 EPANED...... 89 ERYTHROCIN ELITE-OB...... 126 EPCLUSA...... 72 LACTOBIONATE...... 26 ELIXOPHYLLIN...... 207 ephedrine sulfate...... 89 ERYTHROCIN ELLA...... 159 EPHEDRINE SULFATE...... 89 STEARATE...... 26 ELLENCE...... 55 EPHEDRINE SULFATE erythromycin...... 26, 110, 194 ELLIOTTS B...... 126 (PRESSORS)...... 89 erythromycin base...... 26 ELMIRON...... 146 EPICOCCUM...... 184 erythromycin ELOCTATE...... 80 EPICOCCUM NIGRUM.... 184 ethylsuccinate...... 26 eluryng...... 159 EPIDIOLEX...... 35 ESBRIET...... 207 ELZONRIS...... 55 EPIFOAM...... 110 escitalopram oxalate...... 41 EMBEDA...... 10 epinastine hcl...... 194 ESGIC...... 10 EMCYT...... 55 epinephrine...... 90, 207 esmolol hcl...... 90 EMEND...... 43 EPINEPHRINE...... 90 ESMOLOL HCL...... 90 EMEND TRI-PACK...... 43 EPINEPHRINE HCL- esmolol hcl-sodium EMERPHED...... 89 DEXTROSE...... 89 chloride...... 90 EMFLAZA...... 48 EPINEPHRINE HCL-NACL 89 esomeprazole sodium...... 138 EMGALITY...... 49 epinephrine pf...... 89 ESPEROCT...... 80 EMGALITY (300 MG EPINEPHRINE- est estrogens-methyltest...159 DOSE)...... 49 DEXTROSE...... 90 est estrogens-methyltest emoquette...... 159 EPINEPHRINE-NACL...... 90 ds...... 159 EMPLICITI...... 55 EPIPEN 2-PAK...... 207 est estrogens-methyltest EMSAM...... 41 EPIPEN JR 2-PAK...... 207 hs...... 159 EMTRIVA...... 72 epirubicin hcl...... 55 estarylla...... 159 EMVERM...... 65 epitol...... 35 estazolam...... 77 ENABLEX...... 146 EPIVIR...... 72 ESTRACE...... 159 enalapril maleate...... 89 EPIVIR HBV...... 72 estradiol...... 159 enalaprilat...... 89 eplerenone...... 90 estradiol valerate...... 159 enalapril- EPOGEN...... 80 estradiol-norethindrone hydrochlorothiazide...... 89 epoprostenol sodium...... 210 acet...... 159 ENBRACE HR...... 126 eptifibatide...... 68 ESTRING...... 159 ENBREL...... 168 EPZICOM...... 72 ESTROGEL...... 159 ENBREL MINI...... 168 EQUAPAX/ATORVASTATI ESTROSTEP FE...... 159 ENBREL SURECLICK...... 168 N/COQ10...... 90 eszopiclone...... 212 ENCARE...... 184 EQUAPAX/IBUPROFEN/M ethacrynate sodium...... 90 ENDARI...... 184 INREX...... 7 ethacrynic acid...... 90 endocet...... 10 EQUETRO...... 78 ethambutol hcl...... 51 ENDOMETRIN...... 159 ERAXIS...... 45 ethosuximide...... 35 ENGERIX-B...... 174 ERBITUX...... 55 ethyl chloride...... 17 ENGLISH PLANTAIN...... 184 ergocalciferol...... 126 ethynodiol diac-eth ENHERTU...... 55 ergoloid mesylates...... 184 estradiol...... 159 ENOVARX-IBUPROFEN...... 7 ERGOMAR...... 49 etodolac...... 7 enoxaparin sodium...... 33 ergotamine-caffeine...... 49 etodolac er...... 7 enpresse-28...... 159 ERIVEDGE...... 55 etomidate...... 184 enskyce...... 159 ERLEADA...... 55 etonogestrel-ethinyl entacapone...... 66 erlotinib hcl...... 55 estradiol...... 159 entecavir...... 72 errin...... 159 ETOPOPHOS...... 55 ENTEREG...... 140 ERTACZO...... 45 etoposide...... 55 ENTOCORT EC...... 177 ertapenem sodium...... 26 EUCRISA...... 110 ENTRESTO...... 89 ERWINAZE...... 55 EUFLEXXA...... 184

223 euthyrox...... 165 FEMCAP...... 185 FIRMAGON (240 MG EVAMIST...... 159 FEMHRT LOW DOSE...... 159 DOSE)...... 153 EVENITY...... 178 FEMRING...... 159 FIRST-LANSOPRAZOLE. 138 everolimus...... 55, 168 femynor...... 160 FIRST-MOUTHWASH EVISTA...... 152 fenofibrate...... 90 BLM...... 106 EVOMELA...... 55 fenofibrate micronized...... 90 FIRST-OMEPRAZOLE..... 138 EVOTAZ...... 72 fenofibric acid...... 90 FIRST-PROGESTERONE EVOXAC...... 106 fenoprofen calcium...... 7 VGS...... 160 EXCILON AMD DRAIN fenortho...... 7 FIRVANQ...... 26 SPONGES...... 184 FENSOLVI...... 153 flac...... 202 EXELDERM...... 45 fentanyl...... 11 FLAGYL...... 26, 27 EXELON...... 39 fentanyl citrate...... 10 FLAREX...... 194 exemestane...... 55 FENTANYL CITRATE...... 11 flavoxate hcl...... 146 EXFORGE...... 90 fentanyl citrate (pf)...... 10 FLEBOGAMMA DIF...... 169 EXFORGE HCT...... 90 FENTANYL CITRATE- flecainide acetate...... 90 EXJADE...... 126 NACL...... 11 FLECTOR...... 7 EXODERM...... 45 FENTANYL CIT- FLEXBUMIN...... 185 EXPAREL...... 17 ROPIVACAINE-NACL...... 11 FLEXIN...... 17 EXTAVIA...... 103 FENTANYL- FLOLAN...... 210 EXTINA...... 45 BUPIVACAINE-NACL...... 11 FLOMAX...... 149 EXTRANEAL...... 126 FENTORA...... 11 FLORIVA PLUS...... 127 EYLEA...... 199 FERAHEME...... 127 FLOVENT DISKUS...... 207 EZALLOR SPRINKLE...... 90 FERIVAFA...... 127 FLOVENT HFA...... 207 ezetimibe...... 90 ferocon...... 127 floxuridine...... 55 ezetimibe-simvastatin...... 90 ferotrinsic...... 127 FLUAD...... 174 fabb...... 126 FERRALET 90...... 127 FLUAD QUADRIVALENT. 174 FABRAZYME...... 144 FERRAPLUS 90...... 127 FLUARIX FALESSA...... 159 FERRIPROX...... 127 QUADRIVALENT...... 174 falmina...... 159 FERRIPROX TWICE-A- FLUBLOK famciclovir...... 72 DAY...... 127 QUADRIVALENT...... 175 famotidine...... 138 FERRLECIT...... 127 FLUCELVAX famotidine premixed...... 138 FERRO-PLEX QUADRIVALENT...... 175 FANAPT...... 69 HEMATINIC...... 127 fluconazole...... 45 FANAPT TITRATION FERROTRIN...... 127 fluconazole in sodium PACK...... 69 FETROJA...... 26 chloride...... 45 FARESTON...... 55 FETZIMA...... 41 flucytosine...... 46 FARXIGA...... 116 FETZIMA TITRATION...... 41 fludarabine phosphate...... 55 FARYDAK...... 55 FEXMID...... 211 fludrocortisone acetate..... 150 FASENRA...... 203 FIASP...... 120 FLULAVAL FASENRA PEN...... 203 FIASP FLEXTOUCH...... 120 QUADRIVALENT...... 175 FASLODEX...... 55 FIASP PENFILL...... 120 flumazenil...... 185 fa-vitamin b-6-vitamin b-12126 FIBRICOR...... 90 flunisolide...... 203 fayosim...... 159 FIBRYGA...... 80 fluocinolone acetonide FBL KIT...... 7 FINACEA...... 110 ...... 110, 202 FC FEMALE CONDOM.... 185 finasteride...... 149 fluocinolone acetonide FC2 FEMALE CONDOM.. 185 FIORICET...... 11 body...... 110 febuxostat...... 48 FIORICET/CODEINE...... 11 fluocinolone acetonide FEIBA...... 80 FIORINAL...... 11 scalp...... 110 felbamate...... 35 FIORINAL/CODEINE #3.....11 fluocinonide...... 110 FELBATOL...... 35, 36 FIRAZYR...... 168 fluocinonide emulsified FELDENE...... 7 FIRE ANT...... 185 base...... 110 felodipine er...... 90 FIRMAGON...... 153 FLUORABON...... 127 FEMARA...... 55 FLUORESCITE...... 199

224 fluoridex...... 106 FOSAMAX PLUS D...... 178 GASTROCROM...... 140 fluoridex daily renewal...... 106 fosamprenavir calcium...... 72 gatifloxacin...... 194 fluoridex enhanced fosaprepitant dimeglumine..43 GATTEX...... 140 whitening...... 106 FOSCAVIR...... 72 gavilax...... 140 fluoridex sensitivity relief...106 fosinopril sodium...... 91 gavilyte-c...... 140 fluoritab...... 127 fosinopril sodium-hctz...... 91 gavilyte-g...... 140 fluorometholone...... 194 fosphenytoin sodium...... 36 gavilyte-h...... 140 fluorouracil...... 55, 110 FOSRENOL...... 146 gavilyte-n with flavor pack.140 fluoxetine hcl...... 41 FRAGMIN...... 33 GAZYVA...... 56 fluphenazine decanoate...... 69 FREAMINE HBC...... 127 GELFILM...... 199 fluphenazine hcl...... 69 FREAMINE III...... 127 GELFOAM-JMI SPONGE.185 FLURA-DROPS...... 127 FREESTYLE INSULINX GELNIQUE...... 146 flurandrenolide...... 110, 111 TEST...... 119 GEL-ONE...... 185 flurazepam hcl...... 213 FREESTYLE LITE TEST.. 119 GELSYN-3...... 185 flurbiprofen...... 7 FREESTYLE PRECISION gemcitabine hcl...... 56 flurbiprofen sodium...... 194 NEO TEST...... 119 gemfibrozil...... 91 flutamide...... 55 FREESTYLE TEST...... 119 GENERESS FE...... 160 fluticasone propionate fresenius propoven...... 185 generlac...... 140 ...... 111, 203 FRESENIUS PROPOVEN 185 gengraf...... 169 fluticasone-salmeterol...... 207 FROVA...... 49 GENICIN VITA-S...... 127 FLUTICASONE- frovatriptan succinate...... 49 GENOTROPIN...... 153 SALMETEROL...... 207 FULPHILA...... 80 GENOTROPIN fluvastatin sodium...... 91 fulvestrant...... 56 MINIQUICK...... 153 fluvastatin sodium er...... 91 FUNGIMEZ...... 46 gentak...... 194 fluvoxamine maleate...... 41 furosemide...... 91 gentamicin in saline...... 27 fluvoxamine maleate er...... 41 FUROSEMIDE IN gentamicin sulfate...... 27, 194 FLUZONE HIGH-DOSE SODIUM CHLORIDE...... 91 GENVISC 850...... 185 QUADRIVALENT...... 175 FUSARIUM...... 185 GENVOYA...... 73 FLUZONE FUSION PLUS...... 127 GEODON...... 69 QUADRIVALENT...... 175 FUZEON...... 73 GERMAN COCKROACH..185 FML...... 194 fyavolv...... 160 gianvi...... 160 FML FORTE...... 194 FYCOMPA...... 36 GILENYA...... 103 FML LIQUIFILM...... 194 gabapentin...... 36 GILOTRIF...... 56 FOCALIN...... 101 GABITRIL...... 36 GILPHEX TR...... 203 FOCALIN XR...... 101 GABLOFEN...... 212 GILTUSS TR...... 203 folbee plus...... 127 GALAFOLD...... 144 GIVLAARI...... 185 FOLGARD OS...... 127 galantamine hydrobromide. 39 GLASSIA...... 207 FOLGARD RX...... 127 galantamine hydrobromide glatiramer acetate...... 103 folic acid...... 127 er...... 39 glatopa...... 103 FOLIVANE-F...... 127 GALZIN...... 127 GLEEVEC...... 56 FOLIVANE-PLUS...... 127 GAMASTAN...... 169 GLEOLAN...... 185 FOLLISTIM AQ...... 153 GAMASTAN S/D...... 169 GLEOSTINE...... 56 FOLOTYN...... 56 GAMIFANT...... 169 GLIADEL WAFER...... 56 folplex 2.2...... 127 GAMMAGARD...... 169 glimepiride...... 116 FOLTRATE...... 127 GAMMAGARD S/D LESS glipizide...... 116 foltrin...... 127 IGA...... 169 glipizide er...... 116 fomepizole...... 185 GAMMAKED...... 169 glipizide xl...... 116 fondaparinux sodium...... 33 GAMMAPLEX...... 169 glipizide-metformin hcl...... 116 formaldehyde...... 185 GAMUNEX-C...... 169 GLOPERBA...... 48 FORTAVIT...... 127 GANCICLOVIR...... 73 GLOSTRIPS...... 199 FORTEO...... 178 ganciclovir sodium...... 73 GLUCAGEN DIAGNOSTIC FORTESTA...... 152 ganirelix acetate...... 153 ...... 185 FOSAMAX...... 178 GARDASIL 9...... 175 GLUCAGEN HYPOKIT.....119

225 GLUCAGON hailey fe 1/20...... 160 HETLIOZ...... 213 EMERGENCY KIT...... 119 HALAVEN...... 56 HEXTEND...... 80 GLUCAGON HCL halcinonide...... 111 HIBERIX...... 175 (DIAGNOSTIC)...... 185 HALCION...... 77 HIDEX 6-DAY...... 150 GLUCOTROL...... 116 HALDOL...... 69 HIPREX...... 27 GLUCOTROL XL...... 116 HALDOL DECANOATE...... 69 HISTATROL...... 186 glutaraldehyde...... 185 halobetasol propionate..... 111 HIZENTRA...... 169 GLUTATHIONE...... 127 HALOG...... 111 homatropaire...... 199 glyburide...... 116 haloperidol...... 69 HONEY BEE VENOM...... 186 glyburide micronized...... 116 haloperidol decanoate...... 69 HONEY BEE VENOM glyburide-metformin...... 116 haloperidol lactate...... 69 PROTEIN...... 186 GLYCINE...... 128 HARVONI...... 73 HORIZANT...... 104 glycine...... 146 HAVRIX...... 175 HORSE EPITHELIUM...... 186 glycine urologic...... 146 HEALON...... 199 HUMALOG KWIKPEN...... 120 glycolax...... 140 HEALON GV...... 199 HUMALOG MIX 50/50 glycolic acid...... 111 HEALON PRO...... 199 KWIKPEN...... 120 glycopyrrolate...... 140 HEALON5...... 199 HUMALOG MIX 50/50 GLYCOPYRROLATE...... 140 HEALON5 PRO...... 199 VIAL...... 120 glycopyrrolate pf...... 140 healthylax...... 141 HUMALOG MIX 75/25 glydo...... 17 heather...... 160 KWIKPEN...... 120 GLYNASE...... 116 HECTOROL...... 179 HUMALOG MIX 75/25 GLYRX-PF...... 140 HELIDAC THERAPY...... 141 VIAL...... 120 GLYSET...... 116 HEMABATE...... 153 HUMALOG U-100 JUNIOR GLYXAMBI...... 116 hematinic/folic acid...... 128 KWIKPEN...... 120 gnp folic acid...... 128 hematogen...... 128 HUMALOG VIAL...... 120 GOLDENROD...... 185 HEMATOGEN FA...... 128 HUMAN ALBUMIN GOLYTELY...... 140 hematogen forte...... 128 GRIFOLS...... 186 GONAL-F...... 153 HEMATRON-AF...... 128 HUMATE-P...... 80 GONAL-F RFF...... 153 HEMLIBRA...... 80 HUMATROPE...... 153 GONAL-F RFF REDIJECT153 HEMOCYTE PLUS...... 128 HUMIRA...... 170 goodsense aspirin low hemocyte-f...... 128 HUMIRA PEDIATRIC dose...... 7 HEMOFIL M...... 80 CROHNS START...... 169 goodsense nicotine...... 20 HEPAGAM B...... 169 HUMIRA PEN...... 170 GOPRELTO...... 17 heparin (porcine) in nacl..... 33 HUMIRA PEN-CD/UC/HS GORDOFILM...... 111 HEPARIN (PORCINE) IN STARTER...... 170 grafco silver nit applicator. 111 NACL...... 33 HUMIRA PEN- GRALISE...... 104 heparin lock flush...... 185 PS/UV/ADOL HS START. 170 GRALISE STARTER...... 104 heparin sod (porcine) in HUMULIN 70/30 granisetron hcl...... 43 d5w...... 33 KWIKPEN...... 121 GRANIX...... 80 heparin sodium (porcine) HUMULIN 70/30 VIAL...... 121 GRASTEK...... 185 ...... 33, 34 HUMULIN N KWIKPEN.... 121 griseofulvin microsize...... 46 heparin sodium (porcine) HUMULIN N VIAL...... 121 griseofulvin ultramicrosize.. 46 pf...... 34 HUMULIN R U-500 guanfacine hcl...... 91 heparin sodium lock flush. 185 KWIKPEN...... 121 guanfacine hcl er...... 101 HEPATAMINE...... 128 HUMULIN R U-500 VIAL.. 121 GUANIDINE HCL...... 50 HEPLISAV-B...... 175 HUMULIN R VIAL...... 121 GVOKE PFS...... 119 HEPMED...... 186 HYALGAN...... 186 GYNAZOLE-1...... 46 HEPSERA...... 73 HYALURONIDASE HACKBERRY...... 185 HERCEPTIN...... 56 (INTRAOCULAR)...... 199 HAEGARDA...... 169 HERCEPTIN HYLECTA..... 56 HYCAMTIN...... 56 hailey 1.5/30...... 160 HERZUMA...... 56 hydralazine hcl...... 91 hailey 24 fe...... 160 HESPAN...... 80 HYDREA...... 56 hailey fe 1.5/30...... 160 hetastarch-nacl...... 80 hydrochlorothiazide...... 91

226 hydrocodone bitartrate er....11 ibutilide fumarate...... 91 INGREZZA...... 104 hydrocodone polst-cpm IC GREEN...... 186 INJECTAFER...... 128 polst er...... 203 ICAR-C PLUS...... 128 INLYTA...... 57 hydrocodone- icatibant acetate...... 170 INNOPRAN XL...... 91 acetaminophen...... 11, 12 ICLUSIG...... 56 INREBIC...... 57 hydrocodone-homatropine 203 IDAMYCIN PFS...... 56 INSPRA...... 91 hydrocodone-ibuprofen...... 12 idarubicin hcl...... 56 INSULIN ASP PROT & hydrocortisone.. 111, 150, 177 IDELVION...... 81 ASP FLEXPEN...... 121 hydrocortisone (perianal).. 177 IDHIFA...... 57 INSULIN ASPART...... 121 hydrocortisone ace- iferex 150 forte...... 128 INSULIN ASPART pramoxine...... 177 IFEX...... 57 FLEXPEN...... 121 hydrocortisone butyr lipo ifosfamide...... 57 INSULIN ASPART base...... 111 ILARIS...... 170 PENFILL...... 121 hydrocortisone butyrate.... 111 ILEVRO...... 194 INSULIN ASPART PROT hydrocortisone valerate.... 111 ILUMYA...... 170 & ASPART...... 121 hydrocortisone-acetic acid 202 ILUVIEN...... 194 INSULIN PEN NEEDLES. 121 hydrogen peroxide...... 27 imatinib mesylate...... 57 INSULIN SYRINGES...... 121 hydromet...... 203 IMBRUVICA...... 57 INTEGRA F...... 128 hydromorphone hcl...... 12 imipenem-cilastatin...... 27 INTEGRA PLUS...... 128 HYDROMORPHONE HCL. 12 imipramine hcl...... 41 INTEGRILIN...... 68 hydromorphone hcl er...... 12 imipramine pamoate...... 41 INTELENCE...... 73 hydromorphone hcl pf...... 12 imiquimod...... 111 intralipid...... 128 HYDROMORPHONE HCL- IMITREX...... 49 INTRALIPID...... 128 NACL...... 12 IMITREX STATDOSE INTRAROSA...... 147 hydroxocobalamin acetate 128 REFILL...... 49 INTRON A...... 73 hydroxychloroquine sulfate. 65 IMITREX STATDOSE introvale...... 160 hydroxyprogesterone SYSTEM...... 49 INTUNIV...... 101 caproate...... 160 IMLYGIC...... 57 INVANZ...... 27 hydroxyurea...... 56 IMOGAM RABIES-HT...... 170 INVEGA...... 69 hydroxyzine hcl...... 77 IMOVAX RABIES...... 175 INVEGA SUSTENNA...... 70 hydroxyzine pamoate...... 77 IMPAVIDO...... 65 INVEGA TRINZA...... 70 HYLAVITE...... 128 IMURAN...... 170 INVELTYS...... 194 HYLENEX...... 186 INBRIJA...... 66 INVIRASE...... 73 HYMOVIS...... 186 incassia...... 160 INVOKAMET...... 116 hyophen...... 147 INCRELEX...... 153 INVOKAMET XR...... 116 hyoscyamine sulfate...... 141 INCRUSE ELLIPTA...... 207 INVOKANA...... 116 hyoscyamine sulfate er..... 141 indapamide...... 91 iodine strong...... 128 hyoscyamine sulfate sl...... 141 INDERAL LA...... 91 iodine tincture...... 27 HYPERHEP B S/D...... 170 INDERAL XL...... 91 IONOSOL-MB IN D5W..... 128 HYPERLYTE-CR...... 128 INDOCIN...... 7 IOPIDINE...... 197 HYPERRAB...... 170 indocyanine green...... 186 IPOL...... 175 HYPERRAB S/D...... 170 indomethacin...... 7 ipratropium bromide..203, 207 HYPERRHO S/D...... 170 indomethacin er...... 7 ipratropium-albuterol...... 207 HYPERSAL...... 203 indomethacin sodium...... 7 irbesartan...... 91 HYPERTET S/D...... 170 INFANRIX...... 175 irbesartan- HYQVIA...... 170 INFASURF...... 203 hydrochlorothiazide...... 91 HYSINGLA ER...... 12 INFED...... 186 IRESSA...... 57 HYZAAR...... 91 INFLECTRA...... 170 irinotecan hcl...... 57 ibandronate sodium...... 179 INFUGEM...... 57 IROSPAN 24/6...... 128 IBRANCE...... 56 INFUMORPH 200...... 12 IS 24/6...... 128 ibu...... 7 INFUMORPH 500...... 12 ISENTRESS...... 73 ibuprofen...... 7 INFUVITE ADULT...... 128 ISENTRESS HD...... 73 ibuprofen lysine...... 7 INFUVITE PEDIATRIC..... 128 isibloom...... 160

227 ISOLYTE-P IN D5W...... 128 junel fe 1.5/30...... 160 ketorolac tromethamine 7, 194 ISOLYTE-S...... 128 junel fe 1/20...... 160 KETOROLAC ISOLYTE-S PH 7.4...... 128 junel fe 24...... 160 TROMETHAMINE...... 7 isoniazid...... 51 JUXTAPID...... 92 KETOROLAC-BUPIV- isoproterenol hcl...... 91 JYNARQUE...... 128, 129 KETAMINE...... 7 ISOPTO ATROPINE...... 199 KABIVEN...... 129 KETOROLAC-ROPIV- ISOPTO CARPINE...... 197 KADCYLA...... 57 KETAMINE...... 8 ISORDIL TITRADOSE...... 91 KADIAN...... 12 KEVEYIS...... 197 isosorbide dinitrate...... 91 kaitlib fe...... 160 KEVZARA...... 170, 171 isosorbide mononitrate...... 91 KALBITOR...... 170 KEYTRUDA...... 57 isosorbide mononitrate er... 91 KALETRA...... 73 KHAPZORY...... 58 isosulfan blue...... 186 kalliga...... 160 KINERET...... 171 isotretinoin...... 111 KALYDECO...... 209 KINEVAC...... 187 isradipine...... 91 KANJINTI...... 57 KINRIX...... 175 ISTALOL...... 197 KANUMA...... 144 kionex...... 129 ISTODAX (OVERFILL)...... 57 KAPOK...... 186 KISQALI (200 MG DOSE).. 58 ISTURISA...... 154 KAPVAY...... 101 KISQALI (400 MG DOSE).. 58 ISUPREL...... 92 KARBINAL ER...... 203 KISQALI (600 MG DOSE).. 58 itraconazole...... 46 kariva...... 160 KITABIS PAK...... 210 IV STABILIZER FOR KAZANO...... 117 KLARITY-A...... 194 LUMOXITI...... 186 KCENTRA...... 81 KLONOPIN...... 77 ivermectin...... 65 kcl in dextrose-nacl...... 129 klor-con...... 129 IXEMPRA KIT...... 57 kcl-lactated ringers-d5w....129 klor-con 10...... 129 IXIARO...... 175 KCL-LIDOCAINE-NACL... 129 klor-con m10...... 129 IXINITY...... 81 kedbumin...... 186 KLOR-CON M15...... 129 JADENU...... 128 KEDRAB...... 170 klor-con m20...... 129 JADENU SPRINKLE...... 128 KEFLEX...... 27 klor-con sprinkle...... 129 jaimiess...... 160 kelnor 1/35...... 160 klor-con/ef...... 129 JAKAFI...... 57 kelnor 1/50...... 160 KOATE...... 81 JALYN...... 149 KENALOG...... 150 KOATE-DVI...... 81 jantoven...... 34 KENALOG-80...... 150 KOCHIA...... 187 JANUMET...... 116 KENGREAL...... 68 KOGENATE FS...... 81 JANUMET XR...... 117 KEPIVANCE...... 106 KOMBIGLYZE XR...... 117 JANUVIA...... 117 KEPPRA...... 36 KORLYM...... 156 JARDIANCE...... 117 KEPPRA XR...... 36 KOSELUGO...... 58 jasmiel...... 160 KERALYT...... 111 KOVALTRY...... 81 JATENZO...... 152 KERALYT SCALP...... 111 K-PHOS...... 129 JELMYTO...... 57 KERAMATRIX REPLICINE K-PHOS NO 2...... 129 jencycla...... 160 5CMX5CM...... 111 K-PHOS-NEUTRAL...... 129 JENTADUETO...... 117 KERLIX AMD k-prime...... 129 JENTADUETO XR...... 117 ANTIMICROBIAL...... 186 KRINTAFEL...... 65 JEVTANA...... 57 KERLIX AMD SUPER KRISTALOSE...... 141 jinteli...... 160 SPONGES...... 186 KRYSTEXXA...... 48 JIVI...... 81 KERYDIN...... 46 K-TAB...... 129 JOHNSON GRASS...... 186 KETALAR...... 186 k-tan plus...... 129 jolessa...... 160 KETAMINE HCL...... 186 kurvelo...... 160 JUBLIA...... 46 ketamine hcl...... 186 KUVAN...... 144 juleber...... 160 KETAMINE HCL-SODIUM KYLEENA...... 160 JULUCA...... 73 CHLORIDE...... 187 KYMRIAH...... 171 JUNE GRASS POLLEN ketoconazole...... 46 KYNMOBI...... 66 STANDARDIZED...... 186 ketodan...... 46 KYPROLIS...... 58 junel 1.5/30...... 160 ketoprofen...... 7 LABETALOL HCL...... 92 junel 1/20...... 160 ketoprofen er...... 7 labetalol hcl...... 92

228 LACRISERT...... 199 LENVIMA (14 MG DAILY levora 0.15/30 (28)...... 161 lactated ringers...... 129 DOSE)...... 58 levorphanol tartrate...... 12 lactic acid...... 111 LENVIMA (18 MG DAILY levo-t...... 165 lactic acid e...... 111 DOSE)...... 58 levothyroxine sodium...... 166 LACTOJEN...... 141 LENVIMA (20 MG DAILY levoxyl...... 166 lactulose...... 141 DOSE)...... 58 LEVSIN...... 141 lactulose encephalopathy. 141 LENVIMA (24 MG DAILY LEVSIN/SL...... 141 LAMBS QUARTERS...... 187 DOSE)...... 58 LEVULAN KERASTICK.... 111 LAMICTAL...... 36 LENVIMA (4 MG DAILY LEXAPRO...... 41 LAMICTAL ODT...... 36 DOSE)...... 58 LEXISCAN...... 187 LAMICTAL STARTER...... 36 LENVIMA (8 MG DAILY LEXIVA...... 73 LAMICTAL XR...... 36 DOSE)...... 58 LIALDA...... 177 lamivudine...... 73 LESCOL XL...... 92 LIBRAX...... 141 lamivudine-zidovudine...... 73 lessina...... 161 LIBTAYO...... 58 lamotrigine...... 36 LETAIRIS...... 210 LIDO BDK...... 17 lamotrigine er...... 36 letrozole...... 58 lidocaine...... 17 lamotrigine starter kit-blue.. 36 LETS...... 17 lidocaine hcl...... 17 lamotrigine starter kit- leucovorin calcium...... 58 LIDOCAINE HCL...... 17 green...... 36 LEUKERAN...... 58 lidocaine hcl (cardiac)...... 17 lamotrigine starter kit- LEUKINE...... 81 lidocaine hcl (cardiac) pf..... 17 orange...... 36 leuprolide acetate...... 154 lidocaine hcl (pf)...... 17 LANOXIN...... 92 LEUPROLIDE ACETATE- lidocaine hcl LANOXIN PEDIATRIC...... 92 BUPIVACAINE...... 154 urethral/mucosal...... 17 lansoprazole...... 138 levalbuterol hcl...... 207 lidocaine in d5w...... 17 lanthanum carbonate...... 147 LEVATIO...... 17 LIDOCAINE IN LANTUS SOLOSTAR...... 121 LEVBID...... 141 DEXTROSE...... 17 LANTUS U-100 VIAL...... 122 LEVEMIR U-100 lidocaine viscous hcl...... 106 larin 1.5/30...... 160 FLEXTOUCH...... 122 lidocaine-epinephrine...... 17 larin 1/20...... 160 LEVEMIR U-100 VIAL...... 122 LIDOCAINE- larin 24 fe...... 160 levetiracetam...... 37 EPINEPHRINE...... 199 larin fe 1.5/30...... 160 levetiracetam er...... 37 lidocaine-hydrocort larin fe 1/20...... 161 levetiracetam in nacl...... 37 (perianal)...... 177 larissia...... 161 levobunolol hcl...... 197 lidocaine-hydrocortisone LARTRUVO...... 58 LEVOCARNITINE...... 129 ace...... 177 LASIX...... 92 levocarnitine...... 129 LIDOCAINE- LASTACAFT...... 199 levocarnitine sf...... 129 HYDROCORTISONE ACE latanoprost...... 197 levocetirizine ...... 177 LATANOPROST- dihydrochloride...... 203 LIDOCAINE- TIMOLOL MALEATE...... 197 levofloxacin...... 27, 194 PHENYLEPHRINE...... 199 LATRIX XM...... 111 levofloxacin in d5w...... 27 LIDOCAINE- LATUDA...... 70 levoleucovorin calcium...... 58 PHENYLEPHRINE-BSS... 199 layolis fe...... 161 levoleucovorin calcium pf....58 lidocaine-prilocaine...... 18 LAZANDA...... 12 levonest...... 161 LIDOCAINE-TETRACAINE 18 LEDIPASVIR- levonorgest-eth est & eth LIDOCIDEX I...... 150 SOFOSBUVIR...... 73 est...... 161 LIDODERM...... 18 leena...... 161 levonorgest-eth estrad 91- LIDO-EPINEPHRINE- leflunomide...... 171 day...... 161 TETRACAINE...... 18 LEMTRADA...... 103 levonorgestrel...... 161 lidopin...... 18 LENSCALE...... 187 levonorgestrel-ethinyl LIDOPRIL...... 18 LENVIMA (10 MG DAILY estrad...... 161 LIDOPRIL XR...... 18 DOSE)...... 58 levonorg-eth estrad LIDO-PRILO CAINE PACK.18 LENVIMA (12 MG DAILY triphasic...... 161 LIDOPROFEN...... 8 DOSE)...... 58 LEVOPHED...... 92 LIDO-SORB...... 18

229 LILETTA (52 MG)...... 161 losartan potassium...... 92 M.V.I. ADULT...... 130 lillow...... 161 losartan potassium-hctz...... 92 M.V.I. PEDIATRIC...... 130 LINCOCIN...... 27 LOSEASONIQUE...... 161 MACI...... 187 lincomycin hcl...... 27 LOTEMAX...... 194 MACRILEN...... 187 lindane...... 65 LOTEMAX SM...... 194 MACROBID...... 27 linezolid...... 27 LOTENSIN...... 92 MACRODANTIN...... 27 linezolid in sodium chloride.27 LOTENSIN HCT...... 92 MACUGEN...... 200 LINZESS...... 141 loteprednol etabonate...... 194 mafenide acetate...... 27 LIORESAL...... 212 LOTREL...... 92 MAGNEBIND 400...... 130 liothyronine sodium...... 166 LOTRONEX...... 141 magnesium sulfate...... 130 LIPITOR...... 92 lovastatin...... 92 MAGNESIUM SULFATE.. 130 LIPO...... 129 LOVAZA...... 92 magnesium sulfate in d5w 130 LIPO-C...... 129 LOVENOX...... 34 MAGNESIUM SULFATE- LIPOFEN...... 92 low-ogestrel...... 161 NACL...... 130 LIQUIVIDA HYDRATION..129 loxapine succinate...... 70 MAKENA...... 161 lisinopril...... 92 LOYON...... 111 MALARONE...... 65 lisinopril- lo-zumandimine...... 161 malathion...... 65 hydrochlorothiazide...... 92 LUCEMYRA...... 20 MANGANESE CHLORIDE130 lithium...... 78 LUCENTIS...... 199, 200 mannitol...... 92 lithium carbonate...... 78 ludent...... 130 maprotiline hcl...... 41 lithium carbonate er...... 78 LULICONAZOLE...... 46 MARCAINE...... 18 LITHOBID...... 78 LUMIGAN...... 197 MARCAINE LITHOSTAT...... 147 LUMIZYME...... 144 PRESERVATIVE FREE...... 18 LIVALO...... 92 LUMOXITI...... 59 MARCAINE SPINAL...... 18 LIVIXIL PAK...... 18 LUNESTA...... 213 MARCAINE/EPINEPHRIN LMD IN D5W...... 81 LUPANETA PACK...... 154 E...... 18 LMD IN NACL...... 81 LUPRON DEPOT (1- MARCAINE/EPINEPHRIN LO LOESTRIN FE...... 161 MONTH)...... 154 E PF...... 18 LODINE...... 8 LUPRON DEPOT (3- MARINOL...... 43 LODOSYN...... 66 MONTH)...... 154 marlissa...... 161 LOESTRIN 1.5/30 (21)..... 161 LUPRON DEPOT (4- MARPLAN...... 41 LOESTRIN 1/20 (21)...... 161 MONTH) MARQIBO...... 59 LOESTRIN FE 1.5/30...... 161 INTRAMUSCULAR KIT MATULANE...... 59 LOESTRIN FE 1/20...... 161 30MG...... 154 matzim la...... 93 lojaimiess...... 161 LUPRON DEPOT (6- MAVENCLAD (10 TABS)..103 LOMOTIL...... 141 MONTH) MAVENCLAD (4 TABS)....103 LONSURF...... 58 INTRAMUSCULAR KIT MAVENCLAD (5 TABS)....103 loperamide hcl...... 141 45MG...... 154 MAVENCLAD (6 TABS)....103 LOPID...... 92 LUPRON DEPOT-PED (1- MAVENCLAD (7 TABS)....103 lopinavir-ritonavir...... 73 MONTH)...... 154 MAVENCLAD (8 TABS)....103 lopreeza...... 161 LUPRON DEPOT-PED (3- MAVENCLAD (9 TABS)....103 LOPRESSOR...... 92 MONTH)...... 154 MAVYRET...... 73 LOPRESSOR HCT...... 92 lutera...... 161 MAXALT...... 49 LOPROX...... 46 LUXTURNA...... 200 MAXALT-MLT...... 49 lorazepam...... 77 LUZU...... 46 MAXICOMFORT SYR 27G lorazepam intensol...... 77 LYNPARZA...... 59 X 1/2"...... 122 LORBRENA...... 59 LYRICA...... 105 MAXIDEX...... 195 lorcet...... 13 LYRICA CR...... 105 MAXITROL...... 200 lorcet hd...... 12 LYSINE HCL...... 130 MAXZIDE...... 93 LORID...... 130 lysiplex plus...... 130 MAXZIDE-25...... 93 LORTAB...... 13 LYSODREN...... 59 MAYZENT...... 103 loryna...... 161 LYSTEDA...... 81 MAYZENT STARTER LORZONE...... 212 lyza...... 161 PACK...... 103

230 me/naphos/mb/hyo1...... 147 methadone hcl...... 13 MI PASTE PLUS...... 106 MEADOW FESCUE methadone hcl intensol...... 13 MIACALCIN...... 179 GRASS POLLEN...... 187 METHADOSE...... 13 mibelas 24 fe...... 162 meclizine hcl...... 43 methadose...... 13 micafungin sodium...... 46 meclofenamate sodium...... 8 METHADOSE SUGAR- MICARDIS...... 93 MEDI-DERM/L-RX...... 18 FREE...... 13 MICARDIS HCT...... 93 MEDI-DERM-RX...... 13 methamphetamine hcl...... 101 MIC-L-CARNITINE...... 130 MEDI-PATCH RX...... 18 methazolamide...... 197 miconazole 3...... 46 MEDROL...... 150 methenamine hippurate...... 27 MICONAZOLE-ZINC MEDROX-RX...... 13 methenamine mandelate.... 28 OXIDE-PETROLAT...... 46 medroxyprogesterone methergine...... 187 MICRHOGAM ULTRA- acetate...... 161, 162 methimazole...... 166 FILTERED PLUS...... 171 mefenamic acid...... 8 METHITEST...... 152 MICROCYN...... 112 mefloquine hcl...... 65 methocarbamol...... 212 microgestin 1.5/30...... 162 megestrol acetate...... 162 methotrexate...... 171 microgestin 1/20...... 162 MEKINIST...... 59 methotrexate sodium...... 171 microgestin fe 1.5/30...... 162 MEKTOVI...... 59 methotrexate sodium (pf)..171 microgestin fe 1/20...... 162 MELALEUCA...... 187 methoxsalen rapid...... 111 MICROPLEGIA MSA-MSG melodetta 24 fe...... 162 methscopolamine bromide141 ...... 130 meloxicam...... 8 methyl salicylate...... 111 midazolam hcl...... 78 melphalan...... 59 METHYLCOBALAMIN...... 130 MIDAZOLAM HCL...... 78 melphalan hcl...... 59 methyldopa...... 93 midazolam hcl (pf)...... 77 memantine hcl...... 39 methyldopa- MIDAZOLAM HCL- memantine hcl er...... 39 hydrochlorothiazide...... 93 SODIUM CHLORIDE...... 78 MEMBRANEBLUE...... 200 methylergonovine maleate187 MIDAZOLAM-SODIUM MENACTRA...... 175 METHYLIN...... 101 CHLORIDE...... 78 MENEST...... 162 methylphenidate hcl..101, 102 midodrine hcl...... 93 MENOPUR...... 154 methylphenidate hcl er...... 101 MIFEPREX...... 130 MENOSTAR...... 162 methylphenidate hcl er (cd) mifepristone...... 130 MENTAX...... 46 ...... 101 MIGERGOT...... 49 MENVEO...... 175 methylphenidate hcl er (la)101 miglitol...... 117 meperidine hcl...... 13 METHYLPHENIDATE HCL miglustat...... 144 MEPHYTON...... 130 ER (XR)...... 101 MIGRANAL...... 49 meprobamate...... 77 methylprednisolone...... 150 mili...... 162 MEPRON...... 65 METHYLPREDNISOLONE MILLIPRED...... 150 MEPSEVII...... 144 ACETATE...... 150 MILLIPRED DP 12-DAY... 150 mercaptopurine...... 59 methylprednisolone milrinone lactate...... 93 meropenem...... 27 acetate...... 150 milrinone lactate in MEROPENEM-SODIUM methylprednisolone dextrose...... 93 CHLORIDE...... 27 sodium succ...... 150 mimvey...... 162 MERREM...... 27 METHYLPREDNISOLONE MINASTRIN 24 FE...... 162 mesalamine...... 177 -BUPIVACAINE...... 150 mineral oil heavy...... 141 mesalamine er...... 177 methyltestosterone...... 152 MINIPRESS...... 93 mesalamine-cleanser...... 177 metoclopramide hcl...... 43, 44 minitran...... 93 mesna...... 59 metolazone...... 93 MINIVELLE...... 162 MESNEX...... 59 metoprolol succinate er...... 93 MINOCIN...... 28 MESQUITE...... 187 metoprolol tartrate...... 93 minocycline hcl...... 28 MESTINON...... 50 metoprolol- minoxidil...... 93 metadate er...... 101 hydrochlorothiazide...... 93 MIOCHOL-E...... 200 metaproterenol sulfate...... 207 metronidazole..... 28, 111, 112 MIOSTAT...... 200 metaxalone...... 212 metronidazole in nacl...... 28 MIRAPEX...... 67 metformin hcl...... 117 mexiletine hcl...... 93 MIRAPEX ER...... 66 metformin hcl er...... 117 MI PASTE...... 106 MIRCERA...... 81

231 MIRCETTE...... 162 MOVANTIK...... 141 n-acetyl-l-cysteine...... 131 MIRENA (52 MG)...... 162 MOVIPREP...... 141 nadolol...... 93 mirtazapine...... 41 MOXEZA...... 195 nafcillin sodium...... 28 MIRVASO...... 112 MOXIFLOXACIN HCL 28, 195 NAFCILLIN SODIUM IN misoprostol...... 138 moxifloxacin hcl...... 28, 195 DEXTROSE...... 28 MITE (D. FARINAE)...... 187 moxifloxacin hcl (2x day).. 195 nafrinse...... 131 MITE (D. moxifloxacin hcl in nacl...... 28 NAFRINSE DAILY PTERONYSSINUS)...... 187 MOXIFLOXACIN HCL- ACIDULATED...... 106 MITIGARE...... 48 BSS...... 200 NAFRINSE mitigo...... 13 MOZOBIL...... 81 DAILY/NEUTRAL...... 106 mitomycin...... 59 MS CONTIN...... 14 nafrinse drops...... 131 MITOMYCIN...... 59 MUCOR...... 188 NAFRINSE WEEKLY...... 106 MITOSOL...... 195 MUCOSITISRX...... 106 naftifine hcl...... 46 mitoxantrone hcl...... 59 MUGWORT...... 188 NAFTIN...... 46 MIXED ASPERGILLUS.... 187 MULPLETA...... 81 NAGLAZYME...... 144 MIXED FEATHERS...... 187 MULTAQ...... 93 nalbuphine hcl...... 14 MIXED RAGWEED...... 187 MULTIGEN...... 130 NALFON...... 8 MIXED VESPID VENOM MULTIGEN FOLIC...... 130 NALOCET...... 14 PROTEIN...... 187 MULTIGEN PLUS...... 130 naloxone hcl...... 20 mixed vespid venom MULTIPRO...... 130 NALTREXONE...... 20 protein...... 187 multi-vit/iron/fluoride...... 131 naltrexone hcl...... 20 M-M-R II...... 175 multivitamin/fluoride...... 131 NAMENDA...... 39 M-NATAL PLUS...... 130 multi-vitamin/fluoride...... 131 NAMENDA TITRATION MOBIC...... 8 multivitamin/fluoride/iron... 131 PAK...... 39 modafinil...... 213 multi-vitamin/fluoride/iron..131 NAMENDA XR...... 39 moexipril hcl...... 93 mupirocin...... 28 NAMENDA XR molindone hcl...... 70 mutamycin...... 59 TITRATION PACK...... 39 mometasone furoate.112, 203 MVASI...... 59 NAMZARIC...... 40 mondoxyne nl...... 28 mvc-fluoride...... 131 NAPRELAN...... 8 monoject flush syringe...... 130 MYALEPT...... 144 NAPROSYN...... 8 monoject sodium chloride MYAMBUTOL...... 51 naproxen...... 8 flush...... 130 MYCAMINE...... 46 naproxen dr...... 8 mono-linyah...... 162 MYCAPSSA...... 154 naproxen sodium...... 8 MONONINE...... 81 MYCOBUTIN...... 51 naproxen sodium er...... 8 MONOVISC...... 187 mycophenolate mofetil...... 171 naratriptan hcl...... 49 MONSELS FERRIC mycophenolate mofetil hcl 171 NARCAN...... 20 SUBSULFATE...... 81 mycophenolate sodium.....171 NARDIL...... 41 montelukast sodium...... 207 myferon 150 forte...... 131 NAROPIN...... 18 MONUROL...... 28 MYFORTIC...... 171 NASCOBAL...... 131 morgidox...... 28 MYLERAN...... 59 NASONEX...... 203 MORPHINE SULFATE. 13, 14 MYLOTARG...... 59 NATACYN...... 195 morphine sulfate...... 13, 14 mynephrocaps...... 131 NATAZIA...... 162 morphine sulfate mynephron...... 131 nateglinide...... 117 (concentrate)...... 13 MYOBLOC...... 188 NATPARA...... 179 morphine sulfate (pf)...... 13 myorisan...... 112 NATROBA...... 65 morphine sulfate er...... 13 MYRBETRIQ...... 147 NATURE-THROID...... 166 morphine sulfate er beads.. 13 MYSOLINE...... 37 NAVELBINE...... 59 MORPHINE SULFATE- MYTESI...... 141 NAYZILAM...... 37 NACL...... 14 MYXREDLIN...... 122 NEBUPENT...... 65 MOTEGRITY...... 141 na ferric gluc cplx in nebusal...... 203 MOTOFEN...... 141 sucrose...... 131 NEBUSAL...... 203 MOUNTAIN CEDAR...... 187 NABI-HB...... 171 necon 0.5/35 (28)...... 162 MOUSE EPITHELIUM...... 188 nabumetone...... 8 nefazodone hcl...... 41

232 NEMBUTAL...... 37 niacin er NORCO...... 14 neomycin sulfate...... 28 (antihyperlipidemic)...... 93 NORDITROPIN FLEXPRO neomycin-bacitracin zn- niacor...... 93 ...... 154 polymyx...... 200 NIASPAN...... 94 norepinephrine bitartrate.....95 neomycin-polymyxin b gu... 28 NICADAN...... 131 NOREPINEPHRINE- neomycin-polymyxin- nicardipine hcl...... 94 DEXTROSE...... 95 dexameth...... 200 NICARDIPINE HCL IN NOREPINEPHRINE- neomycin-polymyxin- NACL...... 94 SODIUM CHLORIDE...... 95 gramicidin...... 200 NICAZEL...... 131 norethin ace-eth estrad-fe.162 neomycin-polymyxin-hc NICAZEL FORTE...... 131 norethindrone...... 162 ...... 200, 202 NICOMIDE...... 131 norethindrone acetate...... 162 NEONATAL COMPLETE..131 NICORETTE...... 21 norethindrone acet-ethinyl NEONATAL PLUS...... 131 nicotine polacrilex...... 21 est...... 162 neo-polycin...... 200 nicotine step 1...... 21 norethindrone-eth estradiol neo-polycin hc...... 200 nicotine step 2...... 21 ...... 163 NEOPROFEN...... 8 nicotine step 3...... 21 norethin-eth estradiol-fe....163 NEORAL...... 171 NICOTROL...... 21 NORGESIC FORTE...... 212 neostigmine methylsulfate.. 50 NICOTROL NS...... 21 norgestimate-eth estradiol 163 NEOSTIGMINE nifedipine...... 94 norgestimate-ethinyl METHYLSULFATE...... 50 nifedipine er...... 94 estradiol triphasic...... 163 NEO-SYNALAR...... 112 nifedipine er osmotic norlyda...... 163 NEOTUSS PLUS...... 203 release...... 94 norlyroc...... 163 NEOVITE...... 131 NIFEREX...... 131 normal saline flush...... 131 NEPHPLEX RX...... 131 nikki...... 162 NORMOSOL-M IN D5W... 131 NEPHRAMINE...... 131 NILANDRON...... 59 NORMOSOL-R...... 131 NEPHRON FA...... 131 nilutamide...... 59 NORMOSOL-R IN D5W... 131 nephronex...... 131 NIMBEX...... 105 NORMOSOL-R PH 7.4..... 132 NEPHRO-VITE RX...... 131 nimodipine...... 94 NORPACE...... 95 NERLYNX...... 59 NINLARO...... 59 NORPACE CR...... 95 NESACAINE...... 18 NIPENT...... 59 NORPRAMIN...... 41 NESACAINE-MPF...... 18 NIPRIDE RTU...... 94 NORTHERA...... 95 NESINA...... 117 nisoldipine er...... 94 nortrel 0.5/35 (28)...... 163 NESTABS...... 131 NITHIODOTE...... 188 nortrel 1/35 (21)...... 163 NEULASTA...... 81 nitisinone...... 144 nortrel 1/35 (28)...... 163 NEULASTA ONPRO...... 81 NITRO-BID...... 94 nortrel 7/7/7...... 163 NEUPOGEN...... 82 NITRO-DUR...... 94 nortriptyline hcl...... 41 NEUPRO...... 67 nitrofurantoin...... 28 NORVASC...... 95 NEURIN-SL...... 131 nitrofurantoin macrocrystal. 28 NORVIR...... 74 NEURONTIN...... 37 nitrofurantoin monohydrate NOURIANZ...... 67 neutral sodium fluoride..... 106 macrocrystals...... 28 novarel...... 154 NEUTRASAL...... 106 nitroglycerin...... 94 NOVAREL...... 154 NEVANAC...... 195 nitroglycerin in d5w...... 94 NOVOEIGHT...... 82 nevirapine...... 73, 74 NITROLINGUAL...... 94 NOVOFINE AUTOCOVER nevirapine er...... 73 NITROMIST...... 94 PEN NEEDLE...... 122 NEXAVAR...... 59 NITROPRESS...... 94 NOVOFINE PEN NEEDLE122 NEXIUM 24HR...... 138 nitroprusside sodium...... 94 NOVOFINE PLUS PEN NEXIUM I.V...... 138 NITROSTAT...... 94 NEEDLE...... 122 NEXLETOL...... 93 nitro-time...... 94 NOVOLIN 70/30 FLEXPEN NEXLIZET...... 93 NITYR...... 144 ...... 122 NEXPLANON...... 162 NIVESTYM...... 82 NOVOLIN 70/30 FLEXPEN NEXTERONE...... 93 nizatidine...... 138 RELION...... 122 niacin (antihyperlipidemic).. 93 nolix...... 112 NOVOLIN 70/30 RELION. 122 nora-be...... 162 NOVOLIN 70/30 VIAL...... 122

233 NOVOLIN N RELION...... 122 OCTAPLAS BLOOD ORALAIR...... 188 NOVOLIN N VIAL...... 122 GROUP A...... 188 ORALAIR ADULT NOVOLIN R RELION...... 122 OCTAPLAS BLOOD SAMPLE KIT...... 188 NOVOLIN R VIAL...... 122 GROUP AB...... 188 ORALAIR ADULT NOVOLOG FLEXPEN...... 122 OCTAPLAS BLOOD STARTER PACK...... 188 NOVOLOG MIX 70/30 GROUP B...... 188 ORALAIR CHILDRENS FLEXPEN...... 122 OCTAPLAS BLOOD SAMPLE KIT...... 188 NOVOLOG MIX 70/30 GROUP O...... 188 ORALAIR CHILDRENS VIAL...... 122 octreotide acetate..... 154, 155 STARTER PACK...... 188 NOVOLOG PENFILL...... 122 OCUFLOX...... 195 oralone...... 106 NOVOLOG U-100 VIAL.... 122 ODACTRA...... 188 ORAPRED ODT...... 151 NOVOSEVEN RT...... 82 ODEFSEY...... 74 ORAVIG...... 47 NOVOTWIST PEN ODOMZO...... 59 ORBACTIV...... 28 NEEDLE...... 122 OFEV...... 208 ORCHARD GRASS NOXAFIL...... 46 ofloxacin...... 28, 195, 202 POLLEN...... 188 np thyroid...... 166 OGIVRI...... 60 ORENCIA...... 171, 172 NPLATE...... 82 olanzapine...... 70 ORENCIA CLICKJECT.....171 NUBEQA...... 59 olanzapine-fluoxetine hcl.... 41 ORENITRAM...... 210 NUCALA...... 203, 204 OLIVE TREE...... 188 ORFADIN...... 144 NUCYNTA...... 14 olmesartan medoxomil...... 95 ORILISSA...... 155 NUCYNTA ER...... 14 olmesartan medoxomil- ORKAMBI...... 210 NUFERA...... 132 hctz...... 95 orphenadrine citrate...... 212 nulev...... 141 olmesartan-amlodipine- orphenadrine citrate er...... 212 NULOJIX...... 171 hctz...... 95 orphenadrine-asa-caffeine 212 NULYTELY WITH olopatadine hcl...... 195, 204 ORPHENGESIC FORTE.. 212 FLAVOR PACKS...... 142 OLUMIANT...... 171 orsythia...... 163 NUMBRINO...... 18 OMECLAMOX-PAK...... 142 ORTHO MICRONOR...... 163 NUMOISYN...... 106 omega-3-acid ethyl esters.. 95 ORTHOVISC...... 188 NUPLAZID...... 70 OMEGAVEN...... 132 ORTIKOS...... 178 NUTRICAP...... 132 omeprazole...... 138 oscimin...... 142 NUTRIDOX...... 28 OMEPRAZOLE+SYRSPE oscimin sr...... 142 nutrifac zx...... 132 ND SF ALKA...... 138 oseltamivir phosphate...... 74 nutrilipid...... 132 OMIDRIA...... 200 OSENI...... 117 NUTRIVIT...... 132 OMNARIS...... 204 OSMITROL...... 95 NUTROPIN AQ NUSPIN OMNITROPE...... 155 osmitrol...... 95 10...... 154 ONCASPAR...... 60 OSMOPREP...... 142 NUTROPIN AQ NUSPIN ondansetron hcl...... 44 OSPHENA...... 152 20...... 154 ondansetron odt...... 44 OTEZLA...... 172 NUTROPIN AQ NUSPIN 5154 ONE VITE WOMENS OTIPRIO...... 202 NUVAIL...... 112 PLUS...... 132 OTOVEL...... 202 NUVAKAAN...... 18 ONEVITE...... 132 OVACE PLUS...... 112 NUVARING...... 163 ONFI...... 37 OVACE PLUS WASH...... 112 NUVIGIL...... 213 ONGLYZA...... 117 OVACE WASH...... 112 NUWIQ...... 82 ONIVYDE...... 60 OVIDE...... 65 NUZYRA...... 28 ONPATTRO...... 105 OVIDREL...... 155 nystatin...... 47 ONTRUZANT...... 60 oxacillin sodium...... 29 nystatin-triamcinolone...... 47 OPDIVO...... 60 OXACILLIN SODIUM IN nystop...... 47 opium...... 142 DEXTROSE...... 29 OBIZUR...... 82 OPSUMIT...... 210 oxaliplatin...... 60 OCALIVA...... 144 OPTIONS CONCEPTROL188 oxandrolone...... 152 ocella...... 163 ORABLOC...... 18 oxaprozin...... 8 OCREVUS...... 103 ORACIT...... 132 OXAYDO...... 14 OCTAGAM...... 171 ORAFATE...... 188 oxazepam...... 78

234 OXBRYTA...... 188 PAXIL...... 42 phenobarbital sodium...... 37 oxcarbazepine...... 37 PAXIL CR...... 42 phenobarbital-belladonna OXERVATE...... 200 PAZEO...... 195 alk...... 142 oxiconazole nitrate...... 47 PECAN POLLEN...... 188 PHENOL...... 189 OXISTAT...... 47 PEDIAPRED...... 151 phenoxybenzamine hcl...... 95 OXSORALEN ULTRA...... 112 PEDIARIX...... 175 phentolamine mesylate...... 95 OXTELLAR XR...... 37 PEDVAX HIB...... 176 phenylephrine hcl...... 95, 200 oxybutynin chloride...... 147 peg 3350...... 142 PHENYLEPHRINE HCL oxybutynin chloride er...... 147 peg 3350-kcl-na bicarb- ...... 95, 147 oxycodone hcl...... 14 nacl...... 142 PHENYLEPHRINE HCL OXYCODONE HCL ER...... 14 peg-3350/electrolytes...... 142 (PRESSORS)...... 95 oxycodone-acetaminophen.14 PEGANONE...... 37 PHENYLEPHRINE HCL- oxycodone-aspirin...... 14 PEGASYS...... 74 NACL...... 95, 96 OXYCONTIN...... 14 PEGASYS PROCLICK...... 74 PHENYTEK...... 37 oxymorphone hcl...... 15 PEGINTRON...... 74 phenytoin...... 37 oxymorphone hcl er...... 15 peg-prep...... 142 phenytoin infatabs...... 37 oxytocin...... 155 PEMAZYRE...... 60 phenytoin sodium...... 37 OXYTOCIN-LACTATED penicillamine...... 147 phenytoin sodium RINGERS...... 155 PENICILLIN G POT IN extended...... 37 OXYTOCIN-SODIUM DEXTROSE...... 29 PHESGO...... 60 CHLORIDE...... 155 penicillin g potassium...... 29 philith...... 163 OZEMPIC...... 117 penicillin g procaine...... 29 PHOMA EXIGUA...... 189 OZURDEX...... 195 penicillin g sodium...... 29 PHOSLYRA...... 147 PACERONE...... 95 penicillin v potassium...... 29 phospha 250 neutral...... 132 pacerone...... 95 PENICILLIUM NOTATUM 189 phosphasal...... 147 paclitaxel...... 60 PENTACEL...... 176 PHOSPHOLINE IODIDE.. 197 PADCEV...... 60 PENTAM...... 65 phosphorous...... 132 PAINGO KFT...... 18 pentamidine isethionate...... 65 phospho-trin 250 neutral...132 paliperidone er...... 70 PENTASA...... 178 PHOTOFRIN...... 60 palonosetron hcl...... 44 pentazocine-naloxone hcl... 15 PHOTREXA VISCOUS.....189 PALYNZIQ...... 144 pentobarbital sodium...... 37 PHYSIOLYTE...... 132 PAMELOR...... 41 pentoxifylline er...... 95 PHYSIOSOL IRRIGATION pamidronate disodium...... 179 PEPCID...... 138 ...... 132 PANCREAZE...... 144 PERCOCET...... 15 phytonadione...... 132 pancuronium bromide...... 105 PERENNIAL RYE GRASS PICATO...... 112 PANHEMATIN...... 82 POLLEN...... 189 PIFELTRO...... 74 PANRETIN...... 60 PERFOROMIST...... 208 pilocarpine hcl...... 106, 197 pantoprazole sodium...... 138 PERIDEX...... 106 pimecrolimus...... 112 PANZYGA...... 172 PERIKABIVEN...... 132 pimozide...... 70 PARAGARD perindopril erbumine...... 95 pimtrea...... 163 INTRAUTERINE COPPER periogard...... 106 pindolol...... 96 ...... 163 PERJETA...... 60 pioglitazone hcl...... 117 paraplatin...... 60 permethrin...... 65 pioglitazone hcl-glimepiride paricalcitol...... 179 perphenazine...... 44 ...... 117 PARLODEL...... 67 perphenazine-amitriptyline..42 pioglitazone hcl-metformin PARNATE...... 41 PERSERIS...... 70 hcl...... 117 paroex...... 106 PERTZYE...... 144 piperacillin sod-tazobactam paromomycin sulfate...... 29 PFIZERPEN...... 29 so...... 29 paroxetine hcl...... 42 phenazo...... 147 PIQRAY (200 MG DAILY paroxetine hcl er...... 42 phenazopyridine hcl...... 147 DOSE)...... 60 PARSABIV...... 180 phenelzine sulfate...... 42 PIQRAY (250 MG DAILY PASER...... 51 PHENERGAN...... 204 DOSE)...... 60 PATANASE...... 204 phenobarbital...... 37

235 PIQRAY (300 MG DAILY potassium citrate-citric acid PREDNISOLON- DOSE)...... 60 ...... 133 MOXIFLOX-BROMFENAC pirmella 1/35...... 163 potassium phosphates(71 ...... 201 pirmella 7/7/7...... 163 meq k)...... 133 prednisone...... 151 piroxicam...... 8 POTELIGEO...... 60 prednisone intensol...... 151 PITOCIN...... 155 POVIDONE-IODINE...... 195 PREFEST...... 163 PLAN B ONE-STEP...... 163 PRADAXA...... 34 pregabalin...... 105 PLAQUENIL...... 65 pralidoxime chloride...... 189 pregnyl...... 155 PLASBUMIN-25...... 189 PRALUENT...... 96 PREMARIN...... 163 PLASBUMIN-5...... 189 pramipexole PREMASOL...... 133 PLASMA-LYTE 148...... 132 dihydrochloride...... 67 PREMESISRX...... 133 PLASMA-LYTE A...... 132 pramipexole premium lidocaine...... 19 PLASMANATE...... 189 dihydrochloride er...... 67 PREMPHASE...... 163 PLAVIX...... 68 PRAMOTIC...... 202 PREMPRO...... 163 PLEGISOL...... 132 pramox...... 112 PRENAISSANCE...... 133 PLEGRIDY...... 103 prasugrel hcl...... 68 PRENATA...... 133 PLEGRIDY STARTER PRAVACHOL...... 96 prenatal...... 133 PACK...... 103 pravastatin sodium...... 96 prenatal plus iron...... 133 PLENAMINE...... 132 PRAXBIND...... 189 PRENATE...... 133 PLIAGLIS...... 18 praziquantel...... 65 PRENATE DHA...... 133 PNEUMOVAX 23...... 176 prazosin hcl...... 96 PRENATE ELITE...... 133 pnv prenatal plus PRE & POST SX POUCH 112 PRENATE ENHANCE...... 133 multivit+dha...... 132 PRECEDEX...... 189 PRENATE ESSENTIAL.... 133 podocon...... 112 PRECISION PCX PLUS PRENATE MINI...... 133 podofilox...... 112 TEST...... 119 PRENATE PIXIE...... 133 POLIDOCANOL...... 96 PRECISION QID TEST.... 119 PRENATE RESTORE...... 133 POLIVY...... 60 PRECISION SOF-TACT PRENATVITE COMPLETE polocaine...... 18 TEST...... 119 ...... 133 polocaine-mpf...... 18 PRECISION XTRA PRENATVITE PLUS...... 134 polycin...... 200 BLOOD GLUCOSE...... 119 PRENATVITE RX...... 134 polyethylene glycol 3350.. 142 PRECISION XTRA PREPIDIL...... 147 poly-iron 150 forte...... 132 KETONE...... 119 PREPOPIK...... 142 polymyxin b sulfate...... 29 PRECOSE...... 117 PRESTALIA...... 96 polymyxin b-trimethoprim..200 PRED FORTE...... 195 PRETOMANID...... 51 polysaccharide iron forte...132 PRED MILD...... 195 PREVACID...... 138 POLYTRIM...... 200 PRED-G...... 200 PREVACID SOLUTAB...... 138 POLY-VI-FLOR...... 132 PRED-G S.O.P...... 200 prevalite...... 96 POLY-VI-FLOR FS...... 132 prednicarbate...... 112 preventeza...... 163 POLY-VI-FLOR/IRON...... 132 PREDNISOL ACE- PREVIDENT...... 107 POMALYST...... 60 MOXIFLOX-BROMFEN.... 195 prevident...... 107 portia-28...... 163 prednisolone...... 151 PREVIDENT 5000 PORTRAZZA...... 60 prednisolone acetate...... 195 BOOSTER PLUS...... 107 posaconazole...... 47 prednisolone acetate p-f... 195 PREVIDENT 5000 DRY pot bicarb-pot chloride...... 132 prednisolone sodium MOUTH...... 107 potassium acetate...... 132 phosphate...... 151, 195 PREVIDENT 5000 potassium bicarbonate...... 133 PREDNISOLONE- ENAMEL PROTECT...... 107 potassium chloride...... 133 BROMFENAC...... 200, 201 PREVIDENT 5000 ORTHO potassium chloride crys er 133 PREDNISOLONE- DEFENSE...... 107 potassium chloride er...... 133 GATIFLOXACIN...... 201 PREVIDENT 5000 PLUS..107 potassium chloride in PREDNISOLON- PREVIDENT 5000 dextrose...... 133 GATIFLOX-BROMFENAC 201 SENSITIVE...... 107 potassium chloride in nacl 133 previfem...... 163 potassium citrate er...... 133 PREVNAR 13...... 176

236 PREVYMIS...... 74 PROGRAF...... 172 PURIXAN...... 61 PREZCOBIX...... 74 PROLASTIN-C...... 208 PYLERA...... 142 PREZISTA...... 74 PROLATE...... 15 pyrazinamide...... 51 PRIALT...... 15 PROLENSA...... 195 PYRIDIUM...... 147 PRIFTIN...... 51 PROLEUKIN...... 61 pyridostigmine bromide...... 51 PRILOLID...... 19 PROLIA...... 179 pyridostigmine bromide er.. 50 PRILOSEC...... 138 PROMACTA...... 82 PYRIDOXAL-5 PRILOVIX...... 19 promethazine hcl...... 204 PHOSPHATE...... 134 PRILOVIX LITE...... 19 promethazine-codeine...... 204 PYRIDOXINE HCL...... 134 PRILOVIX LITE PLUS...... 19 promethazine-dm...... 204 pyridoxine hcl...... 134 PRILOVIX PLUS...... 19 promethazine-phenyleph- pyrimethamine...... 65 prilovix ultralite...... 19 codeine...... 204 PYRIMETHAMINE- prilovix ultralite plus...... 19 promethazine- LEUCOVORIN...... 66 primaquine phosphate...... 65 phenylephrine...... 204 PYROGALLIC ACID...... 112 PRIMAXIN IV...... 29 promethegan...... 204 QBRELIS...... 96 primidone...... 37 PROMETRIUM...... 164 QBREXZA...... 112 PRIMLEV...... 15 propafenone hcl...... 96 qc aspirin low dose...... 8 PRIMSOL...... 29 propafenone hcl er...... 96 QINLOCK...... 61 PRINIVIL...... 96 propantheline bromide...... 142 QNASL...... 204 PRISMASOL B22GK 4/0.. 134 proparacaine hcl...... 201 QNASL CHILDRENS...... 204 PRISMASOL BGK 0/2.5... 134 propofol...... 189 QTERN...... 117, 118 PRISMASOL BGK 2/0...... 134 propranolol hcl...... 96 QUAD-MIX...... 147 PRISMASOL BGK 2/3.5... 134 propranolol hcl er...... 96 QUADRACEL...... 176 PRISMASOL BGK 4/2.5... 134 propranolol-hctz...... 96 QUADRAMET...... 61 PRISMASOL BK 0/0/1.2... 134 propylthiouracil...... 166 QUALAQUIN...... 66 PRISTIQ...... 42 PROQUAD...... 176 QUARTETTE...... 164 PRIVET...... 189 PROSCAR...... 149 quazepam...... 78 PRIVIGEN...... 172 PROSOL...... 134 QUDEXY XR...... 37 PROAIR HFA...... 208 PROSTIN E2...... 147 QUEEN PALM...... 189 PROAIR RESPICLICK...... 208 PROSTIN VR...... 96 QUELICIN...... 105 probenecid...... 48 protamine sulfate...... 82 QUESTRAN...... 96 PROBUPHINE IMPLANT PROTHELIAL...... 189 QUESTRAN LIGHT...... 96 KIT...... 15 PROTONIX...... 139 quetiapine fumarate...... 70 procainamide hcl...... 96 PROTOPAM CHLORIDE..189 quetiapine fumarate er...... 70 PROCALAMINE...... 134 protriptyline hcl...... 42 QUFLORA PEDIATRIC.... 134 PROCARDIA...... 96 PROVAYBLUE...... 189 QUILLICHEW ER...... 102 PROCARDIA XL...... 96 PROVENGE...... 172 QUILLIVANT XR...... 102 PROCENTRA...... 102 PROVERA...... 164 quinapril hcl...... 96 prochlorperazine...... 44 PROVIGIL...... 213 quinapril- prochlorperazine edisylate..44 PROVISC...... 201 hydrochlorothiazide...... 97 prochlorperazine maleate... 44 PROZAC...... 42 quinidine gluconate er...... 97 PROCRIT...... 82 PRUDOXIN...... 112 quinidine sulfate...... 97 PROCTOCORT...... 178 pseudoephedrine- quinine sulfate...... 66 PROCTOFOAM HC...... 178 bromphen-dm...... 204 QUTENZA...... 112 procto-med hc...... 178 PSORCON...... 112 QUTENZA (2 PATCH)...... 112 procto-pak...... 178 PULMICORT FLEXHALER QUZYTTIR...... 204 proctosol hc...... 178 ...... 208 QVAR REDIHALER...... 208 proctozone-hc...... 178 PULMICORT RABAVERT...... 176 PROFILNINE...... 82 SUSPENSION...... 208 RABBIT EPITHELIUM...... 189 PROFILNINE SD...... 82 pulmosal...... 204 RABEPRAZOLE SODIUM 139 progesterone...... 164 PULMOZYME...... 210 rabeprazole sodium...... 139 progesterone micronized.. 164 PURAPLY...... 112 RADICAVA...... 105 PROGLYCEM...... 119 purevit dualfe plus...... 134 RADIOGARDASE...... 189

237 RAGWITEK...... 189 RENACIDIN...... 147 RISPERDAL CONSTA...... 70 raloxifene hcl...... 152 RENAGEL...... 147 risperidone...... 70 ramelteon...... 213 renal...... 134 RITALIN...... 102 ramipril...... 97 RENATABS...... 134 RITALIN LA...... 102 RANEXA...... 97 RENATABS WITH IRON.. 134 ritonavir...... 74 ranolazine er...... 97 RENFLEXIS...... 172 RITUXAN...... 61 RAPAFLO...... 149 RENOVO...... 19 RITUXAN HYCELA...... 61 RAPAMUNE...... 172 RENVELA...... 147 rivastigmine...... 40 RAPIVAB...... 74 repaglinide...... 118 rivastigmine tartrate...... 40 rasagiline mesylate...... 67 REPATHA...... 97 rivelsa...... 164 RAVICTI...... 144 REPATHA PUSHTRONEX RIXUBIS...... 83 RAYALDEE...... 179 SYSTEM...... 97 rizatriptan benzoate...... 50 RAZADYNE...... 40 REPATHA SURECLICK..... 97 ROBAXIN...... 212 RAZADYNE ER...... 40 REQ 49+...... 134 ROBAXIN-750...... 212 REBIF...... 104 REQUIP XL...... 67 ROCALTROL...... 180 REBIF REBIDOSE...... 103 RESORCINOL-SULFUR.. 112 ROCKLATAN...... 197 REBIF REBIDOSE RESTASIS...... 201 rocuronium bromide...... 105 TITRATION PACK...... 103 RESTASIS MULTIDOSE.. 201 ROCURONIUM BROMIDE REBIF TITRATION PACK 104 RESTORIL...... 213 ...... 105 REBINYN...... 83 RETACRIT...... 83 ROMIDEPSIN...... 61 REBLOZYL...... 83 RETEVMO...... 61 ropinirole hcl...... 67 RECARBRIO...... 29 RETIN-A MICRO...... 112 ropinirole hcl er...... 67 RECK...... 19 RETIN-A MICRO PUMP... 113 ropivacaine hcl...... 19 RECLAST...... 179 RETROVIR...... 74 ROPIVACAINE HCL...... 19 reclipsen...... 164 REVATIO...... 210 ROPIVACAINE HCL-NACL 19 RECOMBINATE...... 83 REVCOVI...... 144 ROPIV-CLONIDINE- RECOMBIVAX HB...... 176 REVLIMID...... 61 KETOROLAC...... 19 RECOTHROM...... 83 revonto...... 212 rosadan...... 113 RECOTHROM SPRAY KIT 83 REXULTI...... 70 rosuvastatin calcium...... 97 RECTIV...... 97 REYATAZ...... 74 ROTARIX...... 176 RECURA...... 47 R-GENE 10...... 190 ROTATEQ...... 176 RED BIRCH...... 189 RHIZOPUS...... 190 ROUGH MARSH ELDER. 190 RED CEDAR...... 189 RHOFADE...... 113 ROUGH PIGWEED...... 190 RED MAPLE...... 190 RHOGAM ULTRA- ROWASA...... 178 RED MULBERRY...... 190 FILTERED PLUS...... 172 roweepra...... 38 RED TOP GRASS RHOPHYLAC...... 172 roweepra xr...... 38 POLLEN...... 190 RHOPRESSA...... 197 ROXICODONE...... 15 REGLAN...... 44 RIASTAP...... 83 ROZEREM...... 213 REGONOL...... 51 ribavirin...... 74 ROZLYTREK...... 61 REGRANEX...... 112 RIDAURA...... 172 RUBRACA...... 61 RELADOR PAK...... 19 rifabutin...... 51 RUCONEST...... 172 RELADOR PAK PLUS...... 19 RIFADIN...... 51 RUKOBIA...... 75 RELENZA DISKHALER...... 74 rifampin...... 51 RUSSIAN THISTLE...... 190 relexxii...... 102 RILUTEK...... 105 RUXIENCE...... 61 RELISTOR...... 142 riluzole...... 105 RUZURGI...... 190 RELNATE DHA...... 134 rimantadine hcl...... 74 RYANODEX...... 212 RELPAX...... 49 RIMSO-50...... 147 RYBELSUS...... 118 REMERON...... 42 ringers...... 134 RYCLORA...... 204 REMERON SOLTAB...... 42 ringers irrigation...... 134 RYDAPT...... 61 REMESENSE...... 107 RINVOQ...... 172 RYTARY...... 67 REMICADE...... 172 RIOMET...... 118 RYTHMOL SR...... 97 remifentanil hcl...... 15 risedronate sodium...... 179 SABRIL...... 38 REMODULIN...... 210 RISPERDAL...... 70

238 SACCHAROMYCES sensorcaine- sodium acetate...... 135 CEREVISIAE...... 190 mpf/epinephrine...... 19 SODIUM BICARBONATE.135 SAFYRAL...... 164 SENSORCAINE- sodium bicarbonate.. 135, 142 SAGEBRUSH...... 190 MPF/EPINEPHRINE...... 19 SODIUM BICARBONATE- SAIZEN...... 155 SEREVENT DISKUS...... 208 DEXTROSE...... 135 SAIZENPREP...... 155 SEROQUEL...... 71 sodium chloride...... 135, 204 SALAGEN...... 107 SEROQUEL XR...... 71 sodium chloride (pf)...... 135 SALEX...... 113 SEROSTIM...... 142 sodium chloride salicylic acid...... 113 sertraline hcl...... 42 bacteriostatic...... 135 salicylic acid wart remover 113 se-tan plus...... 134 sodium chloride flush...... 135 salicylic acid-cleanser...... 113 setlakin...... 164 SODIUM CITRATE...... 34 salimez...... 113 sevelamer carbonate...... 147 SODIUM CITRATE LOCK SALIMEZ FORTE...... 113 sevelamer hcl...... 147 FLUSH...... 34 saline bacteriostatic...... 134 sf...... 107 SODIUM CITRATE- saline flush...... 134 sf 5000 plus...... 107 GENTAMICIN SULF...... 34 saline flush zr...... 134 SFROWASA...... 178 SODIUM DIURIL...... 97 SALINE-PHENOL...... 134 SHAGBARK HICKORY.... 190 SODIUM EDECRIN...... 97 SALIVAMAX...... 107 sharobel...... 164 sodium fluoride...... 107, 135 salsalate...... 8 SHEEP SORREL...... 190 sodium fluoride 5000 plus.107 SALVAX...... 113 SHINGRIX...... 176 sodium fluoride 5000 ppm 107 SALVAX DUO PLUS...... 113 SHORT RAGWEED sodium fluoride 5000 SAMSCA...... 134 POLLEN EXT...... 190 sensitive...... 107 SANCUSO...... 44 SIDEROL...... 135 SODIUM HYALURONATE190 SANDIMMUNE...... 172 SIGNIFOR...... 155 sodium nitrite...... 190 SANDOSTATIN...... 155 SIGNIFOR LAR...... 155 sodium phenylbutyrate...... 144 SANDOSTATIN LAR sildenafil citrate...... 147, 211 sodium polystyrene DEPOT...... 155 SILENOR...... 213 sulfonate...... 135 SANTYL...... 113 SILIQ...... 172 sodium saccharin...... 190 SAPHRIS...... 70 silodosin...... 149 sodium sulfacetamide...... 113 SARCLISA...... 61 SILVADENE...... 29 sodium sulfacetamide SAVAYSA...... 34 silver nitrate...... 29 wash...... 113 SAVELLA...... 105 silver sulfadiazine...... 29 SODIUM SAVELLA TITRATION SIMBRINZA...... 197 SULFACETAMIDE WASH 113 PACK...... 105 simliya...... 164 sodium tetradecyl sulfate.... 97 SCALACORT DK...... 113 simpesse...... 164 sodium thiosulfate...... 190 SCENESSE...... 113 SIMPONI...... 172, 173 SOFOSBUVIR- SCLEROSOL SIMPONI ARIA...... 172 VELPATASVIR...... 75 INTRAPLEURAL...... 208 SIMULECT...... 173 SOLESTA...... 190 scopolamine...... 44 simvastatin...... 97 solifenacin succinate...... 147 SEASONIQUE...... 164 SINEMET...... 67 SOLIQUA...... 118 SECONAL...... 213 SINGULAIR...... 208 SOLIRIS...... 83 SECUADO...... 71 SINUVA...... 204 SOLOSEC...... 29 SEGLUROMET...... 118 sirolimus...... 173 SOLU-CORTEF...... 151 SELECT-OB...... 134 SIRTURO...... 51 SOLU-MEDROL...... 151 selegiline hcl...... 67 SIVEXTRO...... 29 SOMA...... 212 SELENIOUS ACID...... 134 SKELAXIN...... 212 SOMATULINE DEPOT..... 155 selenium sulfide...... 113 SKLICE...... 66 SOMAVERT...... 156 SELRX...... 113 SKYLA...... 164 SOOLANTRA...... 113 SELZENTRY...... 75 SKYRIZI (150 MG DOSE) 173 SORBITOL...... 190 SENSIPAR...... 180 SLYND...... 164 sorbitol...... 190 sensorcaine...... 19 SMOFLIPID...... 135 sorbitol-mannitol...... 190 sensorcaine/epinephrine.....19 sod benz-sod phenylacet..144 SORIATANE...... 113 sensorcaine-mpf...... 19 sod citrate-citric acid...... 135 sorine...... 97

239 SORREL/DOCK MIX...... 190 STRENSIQ...... 144 SUPPORT...... 135 SOTALOL HCL...... 97 streptomycin sulfate...... 30 SUPPORT-500...... 135 sotalol hcl...... 97 STRIBILD...... 75 SUPPRELIN LA...... 156 sotalol hcl (af)...... 97 STRIVERDI RESPIMAT... 208 SUPRAX...... 30 SOTRADECOL...... 97 STROMECTOL...... 66 SUPREP BOWEL PREP SOTYLIZE...... 97 STRONTIUM CHLORIDE KIT...... 142 SOVALDI...... 75 SR-89...... 61 SURVANTA...... 204 spinosad...... 66 STROVITE FORTE...... 135 SUSTIVA...... 75 SPINRAZA...... 190 STROVITE ONE...... 135 SUSTOL...... 44 SPINY PIGWEED...... 190 SUBLOCADE...... 21 SUTENT...... 61 SPIRIVA HANDIHALER... 208 SUBOXONE...... 21 swabflush saline flush...... 135 SPIRIVA RESPIMAT...... 208 SUBSYS...... 15 SWEET GUM...... 191 spironolactone...... 97 subvenite...... 38 SWEET VERNAL GRASS spironolactone-hctz...... 97 subvenite starter kit-blue.....38 POLLEN...... 191 SPORANOX...... 47 subvenite starter kit-green.. 38 syeda...... 164 SPORANOX PULSEPAK... 47 subvenite starter kit-orange 38 SYLVANT...... 61 SPRAVATO (56 MG succinylcholine chloride.... 105 SYMAX DUOTAB...... 142 DOSE)...... 42 SUCCINYLCHOLINE symax-sr...... 142 SPRAVATO (84 MG CHLORIDE...... 105 SYMBICORT...... 208 DOSE)...... 42 SUCRAID...... 144 SYMBYAX...... 42 sprintec 28...... 164 sucralfate...... 139 SYMDEKO...... 210 SPRITAM...... 38 sufentanil citrate...... 15 SYMFI...... 75 SPRYCEL...... 61 SULAR...... 97 SYMFI LO...... 75 sps...... 135 SULCONAZOLE NITRATE.47 SYMLINPEN 120...... 118 sronyx...... 164 sulfacetamide sodium SYMLINPEN 60...... 118 ssd...... 29 ...... 113, 195 SYMPAZAN...... 38 SSKI...... 204 sulfacetamide sodium SYMPROIC...... 143 sss 10-5...... 113 (acne)...... 113 SYMTUZA...... 75 ST JOSEPH LOW DOSE..... 8 sulfacetamide sodium- SYNAGEX...... 135 STALEVO 100...... 67 sulfur...... 113, 114 SYNAGIS...... 173 STALEVO 125...... 67 sulfacetamide- SYNAREL...... 156 STALEVO 150...... 67 prednisolone...... 201 SYNATEK...... 135 STALEVO 200...... 67 sulfacetamide-sulfur in SYNDROS...... 44 STALEVO 50...... 67 urea...... 114 SYNERA...... 19 STALEVO 75...... 67 sulfacleanse 8/4...... 114 SYNERCID...... 30 STAMARIL...... 176 sulfadiazine...... 30 SYNJARDY...... 118 STARLIX...... 118 sulfamethoxazole- SYNJARDY XR...... 118 stavudine...... 75 trimethoprim...... 30 SYNRIBO...... 61 STEGLATRO...... 118 sulfamez wash...... 114 SYNTHROID...... 166 STEGLUJAN...... 118 SULFAMYLON...... 30 SYNVEXIA TC...... 19 STELARA...... 173 sulfasalazine...... 178 SYNVISC...... 191 STEMPHYLIUM...... 191 sulfatrim pediatric...... 30 SYNVISC ONE...... 191 STERILE DILUENT sulfurated lime...... 66 SYPRINE...... 135 FLOLAN PH 12...... 191 sulindac...... 8 TABLOID...... 61 sterile diluent/epoprostenol sumatriptan...... 50 TABRECTA...... 61 ...... 191 sumatriptan succinate...... 50 TACHOSIL...... 191 STERILE TALC POWDER208 sumatriptan succinate refill. 50 tacrolimus...... 114, 173 sterile water for injection... 191 SUNOSI...... 213 tadalafil...... 148 sterile water for irrigation.. 135 SUPARTZ FX...... 191 tadalafil (pah)...... 211 STIMATE...... 156 SUPER BI-MIX...... 147 TAFINLAR...... 61 STIOLTO RESPIMAT...... 208 SUPER QUAD-MIX...... 147 TAGRISSO...... 61 STIVARGA...... 61 SUPER TRI-MIX...... 148 TAKHZYRO...... 173 STRATTERA...... 102 SUPERVITE...... 135 TALIVA...... 135

240 TALL RAGWEED...... 191 tenofovir disoproxil tilia fe...... 164 TALTZ...... 173 fumarate...... 75 timolol maleate...... 98, 197 TALZENNA...... 61 TENORETIC 100...... 98 TIMOLOL-BRIMON- TAMIFLU...... 75 TENORETIC 50...... 98 DORZOL-LATANOPR...... 197 tamoxifen citrate...... 62 TENORMIN...... 98 TIMOLOL-BRIMONIDINE- tamsulosin hcl...... 149 TEPADINA...... 62 DORZOLAMID...... 197 TAPAZOLE...... 166 TEPEZZA...... 156 TIMOLOL-DORZOLAMID- TAPERDEX 6-DAY...... 151 terazosin hcl...... 149 LATANOPROST...... 197 TARCEVA...... 62 terbinafine hcl...... 47 TIMOPTIC...... 197 TARGRETIN...... 62 terbutaline sulfate...... 209 TIMOPTIC OCUDOSE..... 197 tarina 24 fe...... 164 terconazole...... 47 TIMOPTIC-XE...... 197 tarina fe 1/20...... 164 TERIPARATIDE TIMOTHY GRASS tarina fe 1/20 eq...... 164 (RECOMBINANT)...... 179 POLLEN ALLERGEN...... 191 TARKA...... 97 TESSALON PERLES...... 205 tinidazole...... 30 TARON FORTE...... 135 TESTIM...... 152 TIROSINT...... 166 taron-crystals...... 136 TESTONE CIK...... 152 TISSEEL...... 191 TASIGNA...... 62 TESTOPEL...... 152 TISSUEBLUE...... 201 TASMAR...... 67 testosterone...... 152 tis-u-sol...... 136 TAURINE...... 136 TESTOSTERONE TIVICAY...... 75 TAVALISSE...... 83 CYPIONATE...... 152 TIVICAY PD...... 75 TAXOTERE...... 62 testosterone cypionate...... 152 tizanidine hcl...... 212 TAYTULLA...... 164 testosterone enanthate..... 152 tl-hem 150...... 136 tazarotene...... 114 tetrabenazine...... 105 TNKASE...... 34 tazicef...... 30 tetracaine hcl...... 201 TOBI NEBULIZER...... 210 TAZICEF...... 30 tetracycline hcl...... 30 TOBI PODHALER...... 210 TAZORAC...... 114 THALOMID...... 62 TOBRADEX...... 201 taztia xt...... 98 THEO-24...... 209 TOBRADEX ST...... 201 TAZVERIK...... 62 theophylline...... 209 tobramycin...... 195, 210 TDVAX...... 176 theophylline er...... 209 TOBRAMYCIN...... 210 TECENTRIQ...... 62 theophylline in d5w...... 209 tobramycin sulfate...... 30 TECFIDERA...... 104 THERAHONEY...... 114 tobramycin- TEFLARO...... 30 thiamine hcl...... 136 dexamethasone...... 201 TEGRETOL...... 38 THIOLA...... 148 TOBREX...... 195 TEGRETOL-XR...... 38 THIOLA EC...... 148 TODAY SPONGE...... 191 TEGSEDI...... 105 thioridazine hcl...... 71 tolbutamide...... 118 TEKTURNA...... 98 thiotepa...... 62 tolcapone...... 67 TEKTURNA HCT...... 98 thiothixene...... 71 tolmetin sodium...... 8 TELFA AMD ISLAND THROMBATE III...... 34 tolterodine tartrate...... 148 DRESSING...... 191 THROMBIN-JMI...... 83 tolterodine tartrate er...... 148 TELFA AMD NON- THROMBIN-JMI tolvaptan...... 136 ADHERENT...... 191 EPISTAXIS...... 83 TOPAMAX...... 38 telmisartan...... 98 THROMBOGEN...... 83 TOPAMAX SPRINKLE...... 38 telmisartan-amlodipine...... 98 THYMOGLOBULIN...... 173 TOPEX TOPICAL telmisartan-hctz...... 98 THYROGEN...... 191 ANESTHETIC...... 107 temazepam...... 213 tiadylt er...... 98 topiramate...... 38 TEMIXYS...... 75 tiagabine hcl...... 38 topiramate er...... 38 TEMODAR...... 62 TIAZAC...... 98 toposar...... 62 temozolomide...... 62 TIBSOVO...... 62 topotecan hcl...... 62 temsirolimus...... 173 TICE BCG...... 173 TOPROL XL...... 98 tencon...... 15 TIGAN...... 44 toremifene citrate...... 62 teniposide...... 62 tigecycline...... 30 TORISEL...... 173 TENIVAC...... 176 TIGLUTIK...... 105 torsemide...... 98 TIKOSYN...... 98 TOTECT...... 62

241 TOUJEO MAX triamterene...... 98 trivora (28)...... 165 SOLOSTAR...... 123 triamterene-hctz...... 98 tri-vylibra...... 165 TOUJEO SOLOSTAR...... 123 trianex...... 114 tri-vylibra lo...... 165 tovet...... 114 triazolam...... 78 TRIZIVIR...... 75 TOVIAZ...... 148 TRIBENZOR...... 98 TRODELVY...... 62 tpn electrolytes...... 136 TRICARE PRENATAL TROGARZO...... 75 TRACLEER...... 211 DHA ONE...... 136 TROKENDI XR...... 38 TRADJENTA...... 118 TRI-CHLOR...... 114 TRONVITE...... 136 tramadol hcl...... 15 TRICHOPHYTON...... 191 TROPHAMINE...... 136 tramadol hcl er...... 15 TRICITRASOL...... 34 TROPICAMIDE- tramadol hcl er (biphasic)... 15 tricitrates...... 136 CYCLOPENTOLATE-PE.. 201 tramadol-acetaminophen.... 15 tricon...... 136 TROPICAMIDE- trandolapril...... 98 TRICOR...... 98 PHENYLEPHRINE...... 201 trandolapril-verapamil hcl triderm...... 114 TROPIC-PROPARACA- er...... 98 trientine hcl...... 136 PE-KETOROLAC...... 201 tranexamic acid...... 83 TRIESENCE...... 195 trospium chloride...... 148 TRANEXAMIC ACID- tri-estarylla...... 164 trospium chloride er...... 148 NACL...... 83 trifluoperazine hcl...... 71 TRULANCE...... 143 TRANSDERM SCOP (1.5 trifluridine...... 195 TRULICITY...... 118 MG)...... 44 trigels-f forte...... 136 TRUMENBA...... 176 TRANSDERM-SCOP (1.5 TRIGLIDE...... 98 TRUSOPT...... 198 MG)...... 44 trihexyphenidyl hcl...... 67 TRUVADA...... 75 TRANXENE-T...... 78 TRIJARDY XR...... 118 TRUXIMA...... 63 tranylcypromine sulfate...... 42 TRIKAFTA...... 210 tryptophan...... 136 TRAVASOL...... 136 tri-legest fe...... 164 TUDORZA PRESSAIR..... 209 TRAVATAN Z...... 197 TRILEPTAL...... 38 TUKYSA...... 63 travoprost (bak free)...... 197 tri-linyah...... 164 tulana...... 165 TRAZIMERA...... 62 TRILIPIX...... 98 TURALIO...... 63 trazodone hcl...... 42 tri-lo-estarylla...... 164 turpentine...... 114 TREANDA...... 62 tri-lo-marzia...... 164 TUSSICAPS...... 205 TRECATOR...... 51 tri-lo-mili...... 164 TUXARIN ER...... 205 TRELEGY ELLIPTA...... 209 tri-lo-sprintec...... 164 TUZISTRA XR...... 205 TRELSTAR MIXJECT...... 156 TRILURON...... 191 TWINRIX...... 176 TREMFYA...... 173 trilyte...... 143 TWIRLA...... 165 treprostinil...... 211 trimethobenzamide hcl...... 44 TWYNSTA...... 98 TRESIBA...... 123 trimethoprim...... 30 TYBOST...... 75 TRESIBA FLEXTOUCH....123 tri-mili...... 164 tydemy...... 165 tretinoin...... 62, 114 trimipramine maleate...... 42 TYGACIL...... 30 tretinoin microsphere...... 114 trinate...... 136 TYKERB...... 63 tretinoin microsphere pump TRINTELLIX...... 42 TYMLOS...... 179 ...... 114 TRIOSTAT...... 166 TYPHIM VI...... 176 TRETTEN...... 83 triphrocaps...... 136 TYSABRI...... 104 TREXALL...... 173 TRIPLE PMB...... 196 TYVASO...... 211 TREZIX...... 15 TRIPLE PMK...... 196 TYVASO REFILL...... 211 tri femynor...... 164 tri-previfem...... 165 TYVASO STARTER...... 211 triamcinolone acetonide TRIPTODUR...... 156 UCERIS...... 178 ...... 107, 114, 151 tri-sprintec...... 165 UDAMIN SP...... 136 TRIAMCINOLONE TRIUMEQ...... 75 UDENYCA...... 83 ACETONIDE...... 151 TRI-VI-FLOR...... 136 ULORIC...... 48 TRIAMCINOLONE- TRI-VI-FLORO...... 136 ULTIVA...... 15 BUPIVACAINE...... 151 TRIVISC...... 191 ULTOMIRIS...... 84 TRIAMCINOLONE- tri-vitamin/fluoride...... 136 ULTRABAG/DIANEAL PD- MOXIFLOXACIN...... 201 tri-vite/fluoride...... 136 2/1.5% DEX...... 136

242 ULTRABAG/DIANEAL PD- valrubicin...... 63 venlafaxine hcl...... 42 2/2.5% DEX...... 136 valsartan...... 99 venlafaxine hcl er...... 42 ULTRABAG/DIANEAL PD- valsartan- VENOFER...... 137 2/4.25%DEX...... 136 hydrochlorothiazide...... 99 VENOMIL MIXED VESPID ULTRABAG/DIANEAL/1.5 VALSTAR...... 63 VENOM...... 192 % DEXTROSE...... 136 VALTOCO 10 MG DOSE....38 VENTAVIS...... 211 ULTRABAG/DIANEAL/2.5 VALTOCO 15 MG DOSE....38 VENTOLIN HFA...... 209 % DEXTROSE...... 136 VALTOCO 20 MG DOSE....39 verapamil hcl...... 99 ULTRABAG/DIANEAL/4.2 VALTOCO 5 MG DOSE...... 39 verapamil hcl er...... 99 5% DEX...... 136 VALTREX...... 76 VEREGEN...... 115 ULTRACET...... 15 VANADOM...... 212 VERELAN...... 99 ULTRAM...... 15 VANATOL LQ...... 15 VERELAN PM...... 99 UNASYN...... 30, 31 VANATOL S...... 15 VERSACLOZ...... 71 unithroid...... 166 VANCOCIN...... 31 VERZENIO...... 63 UNITUXIN...... 63 VANCOCIN HCL...... 31 VESICARE...... 148 UPLIZNA...... 173 VANCOMYCIN HCL...... 31 VEXATROL...... 19 UPTRAVI...... 211 vancomycin hcl...... 31 VFEND...... 47 urea...... 114 VANCOMYCIN HCL IN VFEND IV...... 47 urea hydrating...... 114 DEXTROSE...... 31 VIAGRA...... 148 urea nail...... 114 vancomycin hcl in dextrose.31 VIBATIV...... 31 urea-c40...... 114 vancomycin hcl in nacl...... 31 VIBERZI...... 143 uredeb...... 114 VANCOMYCIN HCL IN VIBRAMYCIN...... 31 uremez-40...... 114 NACL...... 31 vic-forte...... 137 uretron d/s...... 148 vandazole...... 31 VICTOZA...... 118 uribel...... 148 VANTAS...... 156 VIDAZA...... 63 URIMAR-T...... 148 VAPRISOL...... 156 VIEKIRA PAK...... 76 urin ds...... 148 VAQTA...... 176 vienva...... 165 URO-458...... 148 VARITHENA...... 99 vigabatrin...... 39 UROCIT-K 10...... 136 VARIVAX...... 176 vigadrone...... 39 UROCIT-K 15...... 136 VARUBI (180 MG DOSE)... 44 VIGAMOX...... 196 UROCIT-K 5...... 137 VASCEPA...... 99 VIIBRYD...... 42 UROGESIC-BLUE...... 148 VASERETIC...... 99 VIIBRYD STARTER PACK.42 uro-mp...... 148 VASOSTRICT...... 156 vilamit mb...... 148 urosex...... 137 VASOTEC...... 99 VILEVEV MB...... 148 UROXATRAL...... 149 VAZCULEP...... 99 VIMIZIM...... 145 URSO 250...... 143 v-c forte...... 137 VIMPAT...... 39 URSO FORTE...... 143 VCF VAGINAL vinblastine sulfate...... 63 ursodiol...... 143 CONTRACEPTIVE...... 191 vincristine sulfate...... 63 URYL...... 148 vcf vaginal contraceptive.. 191 vinorelbine tartrate...... 63 ustell...... 148 VECAMYL...... 99 VIOKACE...... 145 UTIBRON NEOHALER.....209 VECTIBIX...... 63 viorele...... 165 uticap...... 148 VECTICAL...... 114 VIRACEPT...... 76 utira-c...... 148 vecuronium bromide...... 105 VIRAMUNE...... 76 utrona-c...... 148 VELCADE...... 63 VIRAMUNE XR...... 76 VABOMERE...... 31 VELETRI...... 211 VIRASAL...... 115 VAGIFEM...... 165 velivet...... 165 VIRAZOLE...... 76 valacyclovir hcl...... 75 VELPHORO...... 148 VIREAD...... 76 VALCHLOR...... 63 VELTASSA...... 137 VIRGINIA LIVE OAK...... 192 VALCYTE...... 75, 76 VEMLIDY...... 76 virt-caps...... 137 valganciclovir hcl...... 76 VENCLEXTA...... 63 VIRT-FEFA PLUS...... 137 VALIUM...... 78 VENCLEXTA STARTING virt-gard...... 137 valproate sodium...... 38 PACK...... 63 virt-phos 250 neutral...... 137 valproic acid...... 38 VENELEX...... 115 VISCO-3...... 192

243 VISIONBLUE...... 201 VYXEOS...... 63 XELJANZ XR...... 174 visiv...... 137 VYZULTA...... 198 XELODA...... 63 VISTARIL...... 78 WAKIX...... 213 XEMBIFY...... 174 VISTOGARD...... 192 warfarin sodium...... 34 XENAZINE...... 105 VISUDYNE...... 201 WASP VENOM PROTEIN 192 XENLETA...... 32 vita s forte...... 137 water for irrigation, sterile. 137 XEOMIN...... 193 vitacel...... 137 weekly-d...... 137 XEPI...... 32 VITAFOL...... 137 WELCHOL...... 99 XERAC AC...... 115 VITAFOL-OB+DHA...... 137 WELLBUTRIN SR...... 42 XERAVA...... 32 VITAL-D RX...... 137 WELLBUTRIN XL...... 43 XERMELO...... 143 VITAMAX PEDIATRIC...... 137 wera...... 165 XEROFORM OIL VITAMEZ...... 137 WESTERN JUNIPER...... 192 EMULSION 2"X2"...... 115 vita-min...... 137 WESTHROID...... 166 XEROFORM OIL vitamin d (ergocalciferol)...137 wheat germ oil...... 137 EMULSION GAUZE...... 115 vitamin k1...... 137 WHITE ASH...... 192 XEROFORM OIL vitamins acd-fluoride...... 137 WHITE BIRCH...... 192 EMULSION STRIP...... 115 VITAROCA PLUS...... 137 WHITE FACED HORNET XEROFORM OIL ROLL VITA-RX DIABETIC VENOM...... 192 4"X9'...... 115 VITAMIN...... 137 WHITE MULBERRY...... 192 XEROFORM PETROLAT VITASURE...... 137 WHITE OAK...... 192 GAUZE 1"X8"...... 115 VITATHELY WITH WHITE PINE...... 192 XEROFORM PETROLAT GINGER...... 137 WHITE-FACED HORNET GAUZE 5"X9"...... 115 VITRAKVI...... 63 VENOM...... 192 XEROFORM PETROLAT VITRASE...... 192 WIDE-SEAL DIAPHRAGM PATCH 2"X2"...... 115 VIVELLE-DOT...... 165 60...... 192 XEROFORM PETROLAT VIVITROL...... 21 WIDE-SEAL DIAPHRAGM PATCH 4"X4"...... 115 VIVOTIF...... 176 65...... 192 XEROFORM VIZIMPRO...... 63 WIDE-SEAL DIAPHRAGM PETROLATUM ROLL VOGELXO...... 152 70...... 192 4"X9'...... 115 VOGELXO PUMP...... 152 WIDE-SEAL DIAPHRAGM XEROSTOMIA RELIEF volnea...... 165 75...... 192 SPRAY...... 107 VOLTAREN...... 8 WIDE-SEAL DIAPHRAGM XGEVA...... 179 VONVENDI...... 84 80...... 192 XHANCE...... 205 VOPAC KT...... 8 WIDE-SEAL DIAPHRAGM XIAFLEX...... 193 VORAXAZE...... 63 85...... 192 XIFAXAN...... 32 voriconazole...... 47 WIDE-SEAL DIAPHRAGM XIGDUO XR...... 118, 119 VOSEVI...... 76 90...... 192 XIIDRA...... 202 VOTRIENT...... 63 WIDE-SEAL DIAPHRAGM XOFIGO...... 63 vp-pnv-dha...... 137 95...... 193 XOFLUZA (40 MG DOSE)..76 VPRIV...... 145 WILATE...... 84 XOFLUZA (80 MG DOSE)..76 vp-vite rx...... 137 WINRHO SDF...... 174 XOLAIR...... 205 VRAYLAR...... 71 wixela inhub...... 209 XOLEGEL...... 48 VTOL LQ...... 15 WP THYROID...... 166 XOLEGEL COREPAK...... 47 VUMERITY...... 104 wymzya fe...... 165 XOLEGEL DUO/HEAD & VUMERITY (STARTER)... 104 XADAGO...... 67 SHOULDERS...... 47 VUSION...... 47 XALATAN...... 198 XOLEGEL DUO/XOLEX..... 47 VYEPTI...... 50 XALKORI...... 63 XOPENEX...... 209 vyfemla...... 165 XANAX...... 78 XOPENEX vylibra...... 165 XANAX XR...... 78 CONCENTRATE...... 209 VYNDAMAX...... 99 XARELTO...... 34 XOSPATA...... 63 VYNDAQEL...... 99 XARELTO STARTER XPOVIO (100 MG ONCE VYTORIN...... 99 PACK...... 34 WEEKLY)...... 64 VYVANSE...... 102 XELJANZ...... 174

244 XPOVIO (40 MG ONCE ZEJULA...... 64 ZOLGENSMA 11.1-11.5 WEEKLY)...... 64 ZELAPAR...... 68 KG...... 145 XPOVIO (40 MG TWICE ZELBORAF...... 64 ZOLGENSMA 11.6-12.0 WEEKLY)...... 64 ZEMAIRA...... 209 KG...... 145 XPOVIO (60 MG ONCE ZEMDRI...... 32 ZOLGENSMA 12.1-12.5 WEEKLY)...... 64 ZEMPLAR...... 180 KG...... 145 XPOVIO (60 MG TWICE zenatane...... 115 ZOLGENSMA 12.6-13.0 WEEKLY)...... 64 ZENPEP...... 145 KG...... 145 XPOVIO (80 MG ONCE ZENZEDI...... 102 ZOLGENSMA 13.1-13.5 WEEKLY)...... 64 ZEPATIER...... 76 KG...... 145 XPOVIO (80 MG TWICE ZEPOSIA...... 104 ZOLGENSMA 2.6-3.0 KG.145 WEEKLY)...... 64 ZEPOSIA 7-DAY ZOLGENSMA 3.1-3.5 KG.145 XTAMPZA ER...... 15 STARTER PACK...... 104 ZOLGENSMA 3.6-4.0 KG.145 XTANDI...... 64 ZEPOSIA STARTER KIT..104 ZOLGENSMA 4.1-4.5 KG.145 xulane...... 165 ZEPZELCA...... 64 ZOLGENSMA 4.6-5.0 KG.145 XULTOPHY...... 119 ZERBAXA...... 32 ZOLGENSMA 5.1-5.5 KG.145 xurea...... 115 ZERUVIA...... 20 ZOLGENSMA 5.6-6.0 KG.145 XURIDEN...... 145 ZERVIATE...... 196 ZOLGENSMA 6.1-6.5 KG.145 XVITE...... 137 ZESTORETIC...... 99 ZOLGENSMA 6.6-7.0 KG.145 XYLOCAINE...... 20 ZESTRIL...... 99 ZOLGENSMA 7.1-7.5 KG.145 xylocaine dental...... 19 ZETIA...... 99 ZOLGENSMA 7.6-8.0 KG.145 XYLOCAINE/EPINEPHRIN ZETONNA...... 205 ZOLGENSMA 8.1-8.5 KG.145 E...... 20 ZEVALIN Y-90...... 64 ZOLGENSMA 8.6-9.0 KG.145 XYLOCAINE-MPF...... 20 ZIAC...... 99 ZOLGENSMA 9.1-9.5 KG.146 XYLOCAINE- ZIAGEN...... 76 ZOLGENSMA 9.6-10.0 KG MPF/EPINEPHRINE...... 20 zidovudine...... 76 ...... 146 XYNTHA...... 84 ZIEXTENZO...... 84 ZOLINZA...... 64 XYNTHA SOLOFUSE...... 84 zileuton er...... 209 zolmitriptan...... 50 XYREM...... 213 ZILRETTA...... 151 ZOLOFT...... 43 YASMIN 28...... 165 ZINC CHLORIDE...... 137 ZOLPAK...... 48 YAZ...... 165 ZINC SULFATE...... 137 zolpidem tartrate...... 213 YELLOW DOCK...... 193 ZINGO...... 20 zolpidem tartrate er...... 213 YELLOW HORNET ZINPLAVA...... 174 ZOMIG...... 50 VENOM PROTEIN...... 193 ZIONODIL...... 20 ZOMIG ZMT...... 50 YELLOW JACKET ZIONODIL 100...... 20 ZONALON...... 115 VENOM PROTEIN...... 193 ZIOPTAN...... 198 ZONEGRAN...... 39 YERVOY...... 64 ziprasidone hcl...... 71 zonisamide...... 39 YESCARTA...... 64 ziprasidone mesylate...... 71 ZONTIVITY...... 68 YF-VAX...... 176 ZIRABEV...... 64 ZORBTIVE...... 143 YONDELIS...... 64 ZIRGAN...... 196 ZORTRESS...... 174 YONSA...... 64 ZITHRANOL...... 115 ZOSYN...... 32 YUPELRI...... 209 ZITHROMAX...... 32 zovia 1/35e (28)...... 165 yuvafem...... 165 ZITHROMAX TRI-PAK...... 32 ZOVIRAX...... 76 zafirlukast...... 209 ZITHROMAX Z-PAK...... 32 ZUBSOLV...... 21 zaleplon...... 213 ZOCOR...... 99 zumandimine...... 165 ZALTRAP...... 64 ZOFRAN...... 44 ZUPLENZ...... 44 ZANAFLEX...... 212 ZOHYDRO ER...... 16 ZYDELIG...... 64 ZANOSAR...... 64 ZOLADEX...... 156 ZYFLO...... 209 zarah...... 165 zoledronic acid...... 179 ZYKADIA...... 64 ZARONTIN...... 39 ZOLGENSMA 10.1-10.5 ZYLET...... 202 ZARXIO...... 84 KG...... 145 ZYLOPRIM...... 48 ZAVESCA...... 145 ZOLGENSMA 10.6-11.0 ZYMAXID...... 196 ZEBUTAL...... 15 KG...... 145 ZYPITAMAG...... 99

245 ZYPREXA...... 71 ZYPREXA RELPREVV...... 71 ZYPREXA ZYDIS...... 71 ZYTIGA...... 64 ZYVOX...... 32

246 DISCRIMINATION IS AGAINST THE LAW

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