California Essential Drug List

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The Essential Drug List (formulary) includes a list of drugs covered by Health Net. The drug list is updated at least monthly and is subject to change. All previous versions are no longer in effect. You can view the most current drug list by going to our website at www.healthnet.com. Refer to Evidence of Coverage or Certificate of Insurance for specific cost share information.

For California Individual & Family Plans: Drug Lists Select Health Net Large Group – Formulary (pdf).

For Small Business Group: Drug Lists Select Health Net Small Business Group – Formulary (pdf).

NOTE: To search the drug list online, open the (pdf) document. Hold down the “Control” (Ctrl) and “F” keys. When the search box appears, type the name of your drug and press the “Enter” key. If you have questions or need more information call us toll free.

California Individual & Family Plans (off-Exchange) If you have questions about your pharmacy coverage call Customer Service at 1-800-839-2172

California Individual & Family Plans (on-Exchange) If you have questions about your pharmacy coverage call Customer Service at 1-888-926-4988

Hours of Operation 8:00am – 7:00pm Monday through Friday 8:00am – 5:00pm Saturday

Small Business Group If you have questions about your pharmacy coverage call Customer Service at 1-800-361-3366

Hours of Operation 8:00am – 6:00pm Monday through Friday

Updated January 1, 2021

Health Net of California, Inc. and Health Net Life Insurance Company are subsidiaries of Health Net, LLC and Centene Corporation. Health Net is a registered service mark of Health Net, LLC.

. Table of Contents

What If I Have Questions Regarding My Pharmacy Benefit? ...... ii What is the Drug List? ...... ii How do I find a drug on the Drug List? ...... ii How are the drugs listed in the categorical list? ...... ii How much will I pay for my drugs? ...... iii Tier description table Are there any limits on my drug coverage? ...... iv Abbreviations table How often does the Drug List change? ...... v How can I get prior authorization or an exception to the rules for drug coverage? ... v Are all contraceptives covered? ...... vi What blood glucose supplies covered? ...... vi What drugs are under my medical benefit? ...... vii Can I go to any pharmacy? ...... vii Can I use a mail order pharmacy? ...... vii How can I save money on my prescription drugs? ...... vii Definitions ...... viii Categorical list of prescription drugs ...... 1 Alphabetical index of prescription drugs ...... Index 1

i Welcome to Health Net

What If I Have Questions Regarding My Pharmacy Benefit? If you have questions about your pharmacy coverage contact Customer Service at the phone number listed on your Health Net ID card or on the cover of this book. Customer Service can help you with questions about your prescription drug benefits, including, but not limited to:  information about drugs covered under the medical benefit  the processes for submitting an exception request, requesting prior authorization and step therapy exceptions  actual dollar amounts of cost sharing for drugs including drugs subject to coinsurance

What is the Drug List? The drug list is a complete list of covered drugs used to treat common diseases or health problems. The drug list is selected by a committee of doctors and pharmacists who meet regularly to decide which drugs should be included. The committee reviews new drugs and new information about existing drugs and chooses drugs based on:  Safety  Effectiveness  Side effects  Value (if two drugs are equally effective, the less costly drug will be preferred)

How do I find a drug in the Drug List? You can search for a drug by using the search tool, alphabetical index or by categorical list. There are three ways to find out if your drug is covered.

Search Tool: Open the List of Drugs (PDF). Hold down the “Control” (Ctrl) and “F” keys. When the search box appears, type the name of your drug. Press the “Enter” key.

Alphabetical Index: The index at the end of the PDF lists the names of generic and brand name drugs from A to Z. Once you find a drug name, go to the page number listed to see if the drug is covered.

Categorical list: The drugs are grouped into therapeutic categories. If you know what therapeutic category your drug is in look through the list to find the category. Then look under the category and class for your drug.

If a generic equivalent for a brand name drug is not available in the market or not covered, the generic drug will not be listed separately. The presence of a drug on the drug list does not guarantee that your doctor will prescribe the drug for a particular medical condition.

How are the drugs listed in the categorical list? A drug is listed alphabetically by its brand and generic names in its therapeutic category and class.

ii Example: Drug Requirements/ Drug Name Tier Limits PA MAVYRET (glecaprevir- 3 pibrentasvir) TABS phentermine hcl caps 1 PA

The generic drug name for a brand drug is included after the brand name in parentheses and all bold italicized lowercase letters.

Brand Drug Example: MAVYRET (glecaprevir-pibrentasvir) TABS

If a generic equivalent for a brand name drug is both available and covered, the generic drug will be listed separately from the brand name drug in all bold and italicized lowercase letters.

Generic Drug Example: terbutaline sulfate tabs If a generic drug is marketed under a proprietary, trademark-protected brand name, the brand name will be listed after the generic name in parentheses and regular typeface in all CAPITAL letters.

Generic Drug Marketed Under A Proprietary Brand Name Example: levothyroxine sodium (LEVOXYL) TABS

How much will I pay for my drugs? To see how much you will pay for a drug, check the abbreviations in the Drug Tier column on the formulary.

Drug Class/Plan Benefit Phase Maximum Cost Share Days Supply Oral Cancer Drugs Deductible Met $250 30 Days All other (non-oral Deductible Met $250 30 Days cancer) Drugs Bronze Plan Members Deductible Met $500 30 Days

Below is a description for each tier. Refer to Evidence of Coverage or Certificate of Insurance for specific cost share information.

Tier Description 1 Drugs in this tier include generic drugs and low-cost preferred brand drugs.

2 Drugs in this tier are higher cost generic drugs and preferred brand drugs

Drugs in this tier are non-preferred brand drugs, brand drugs with generic equivalents on a lower tier, or drugs that have a preferred alternative at a lower 3 tier.

iii Tier 4 Drugs include drugs that are made using biotechnology, drugs that must be distributed through a specialty pharmacy, drugs that require special training for self-administration, or drugs that require regular monitoring of care by a 4 pharmacy, and drugs that cost more than six hundred dollars for a one-month supply.

Includes preventive benefit drugs, including contraceptives, covered at no cost to members under the Affordable Care Act. A deductible does not apply. 5

A Brand name is listed for reference only, when a generic equivalent is available. Generic drugs will be used whenever one is available. To get a brand drug that has a generic equivalent available, your doctor must request prior 7 authorization to show medical necessity. If we approve the request, the drug may be covered at a higher copayment. Refer to your plan documents.

Are there any limits on my drug coverage?

Some drugs have limits on coverage. The table below provides a description of abbreviations that may appear in the Limits column on the drug list: Abbreviation Definition Description

AL Age Limit These drugs may require prior authorization if your age does not fall within manufacturer, FDA, or clinical recommendations. AC Anti-cancer These oral cancer drugs are subject to a maximum $250 copayment for a one-month supply, after any deductible has been met, per state law (or $750 maximum for a three-month supply through mail order). LA Limited Access Some drugs may be subject to limited access or restricted access. This means that a drug may only be available at select pharmacies. Limited access may be due to the following reasons:  The FDA or the manufacturer has restricted distribution of a drug to certain facilities, pharmacies or prescribers, or  Certain drugs require special handling, coordination of care, or patient education that cannot be provided at a retail pharmacy. If the drug is approved, we will let you know how to get limited access drugs. PA Prior Authorization This drug requires prior authorization. This means that you or your prescriber must get approval from us before you fill your prescription. If you don’t get approval, we may not cover the drug

iv PV Preventive Drug Preventive Health Drugs are Affordable Care Act (ACA) preventive health drugs, including contraceptive drugs and devices, covered at no charge. Preventive health drugs are determined based on evidence-based recommendations by the United States Preventive Services Task Force.

QL Quantity Limit These drugs have a limit on the amount that will be covered. Your doctor must request approval for a higher quantity of the drug from Health Net. Health Net covers a 12-month supply when dispensed at one time of all self-administered hormonal contraceptives on the Formulary.

RX/OTC Prescription & Certain drugs are available both in a prescription form and in Over-the- an OTC form. Only prescription drugs are covered by your Counter (OTC) plan with the exception of some insulin, insulin supplies and some covered preventive drugs. OTC drugs on the drug list, including OTC preventive drugs and contraceptives, require a prescription to be covered. ST Step Therapy Step therapy is when you are required to use one drug before another, in a stepwise fashion. Unless an exception is made, one or more preferred drugs must be tried first before progressing to a drug that is subject to step therapy.

How often does the Drug List change? The formulary will be updated with changes on a monthly basis. The types of changes may include the following:

 Removal of a drug or dosage form of a drug from the formulary;  Any change in tier placement of a drug that results in an increase in cost sharing;  Adding or changing utilization management procedures applicable to a drug.

If these changes occur, you will be notified at least 60 days in advance of the change, unless the drug is removed for safety reasons.

How can I get prior authorization or an exception to the rules for drug coverage? Requests for prior authorization may be submitted electronically, by phone at 1-800-548-5524, or by fax at 1-800-314-6223. Once your doctor’s request is received, we will notify your doctor of our decision within 72 hours. If Health Net fails to respond to a completed prior authorization or step therapy exception request within 72 hours of receiving a non-urgent request and 24 hours of receiving a request based on exigent circumstances, the request is deemed approved and the health insurer may not deny the request thereafter.

If your doctor believes that waiting 72 hours for a standard decision could seriously harm your health, your doctor can ask for a fast (expedited) decision. This applies only to requests for drugs that you have not already received. We must make expedited decisions within 24 hours after we get your doctor’s supporting statement.

v If we approve your drug’s exception, the approval continues until the end of the plan year. To keep the exception in place for the plan year, you must remain enrolled in our plan, your doctor must continue to prescribe your drug, and your drug must be safe for treating your condition

In some cases, our plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. This is called step therapy. Step therapy is when you are required to use one drug before another, in a stepwise fashion. The required first step drug or preferred drug is a proven, cost-effective medication. Unless an exception is made, one or more preferred drugs must be tried before progressing to a drug that is subject to step therapy. You or your doctor can request an exception if your health may be harmed by waiting. Your doctor must submit a supporting statement to us explaining why you need the drug. You or your doctor may appeal the denial of an exception request. The denial documents provide more information on appeal rights and procedures if there is a medical need to use a second step drug without trying a first step drug, an exception to coverage may be requested by the prescriber. A request for an exception to a step therapy requirement may be submitted in the same manner as a request for prior authorization. The request shall be treated in the same manner, and shall be responded to in the same manner, as a request for prior authorization for prescription drugs. If you have already tried and failed the preferred drug(s), or if you are already taking a drug that is subject to step therapy when you switch to enrolled in a Health Net plan, you will not have to undergo step therapy and the drug will be approved for coverage when medically necessary.

If a drug is not on the drug list, and is not specifically excluded from coverage, your doctor can ask for an exception. To request an exception, your doctor can submit a prior authorization request along with a supporting statement explaining why you need the drug. Requests for prior authorization may be submitted electronically or by telephone or fax. If we approve an exception for a drug that is not on the drug list, the non-preferred brand drug tier (Tier 3) or Tier 4 (Specialty) copayment applies.

Health Net will cover all medically necessary drugs. If Health Net fails to respond to a completed prior authorization or step therapy exception request within 72 hours of receiving a non-urgent request and 24 hours of receiving an expedited request, the request will be approved and Health Net may not deny the request thereafter.

Are all contraceptives covered? Contraceptive benefits include coverage for a variety of U.S. Food and Drug Administration (FDA)- approved prescription contraceptive methods. If your doctor determines that none of the covered methods on the drug list or if a covered therapeutic equivalent of a drug, device, or product is not available, and is medically necessary for you, Health Net will provide coverage. Coverage is subject to limitations and restrictions. Prior authorization or step therapy may be required for some other FDA- approved prescription contraceptive drugs, devices, or products prescribed by your doctor.

What blood glucose supplies covered? Specific brands of blood glucose monitors, blood glucose testing strips, lancets, ketone testing strips, pen delivery systems for injecting insulin and insulin needles and syringes are covered on the drug list. A prescription from your doctor is required to obtain these from a pharmacy. Insulin pumps and all related necessary supplies, podiatric devices to prevent or treat diabetes-related complications and visual aids, excluding eyewear, to assist the visually impaired with proper dosing of insulin are covered under the medical benefit.

What drugs are under my medical benefit? Drugs that are not considered self-injectable and are administered by your doctor will be covered under your medical benefit. If your doctor does not have the drug, your doctor will give you vi instructions on where you can receive the drug. Certain drugs that are self-administered are covered under your pharmacy benefit. Refer to your Evidence of Coverage or Certificate of Insurance for coverage information and exceptions.

Can I go to any pharmacy? Except in emergency and urgent situations, Health Net does not cover drugs dispensed by non-network pharmacies. Health Net contracts with most U.S. chain pharmacies and many independent pharmacies. These pharmacies are called in-network pharmacies. To find an in-network pharmacy near you, visit our website at Find a pharmacy or call us at the telephone number on your Health Net ID card or listed on the front cover of this book.

Some injectable and high cost drugs are considered specialty drugs. These drugs must be filled at an in-network specialty pharmacy. Specialty drugs are noted on the drug list in the Requirements/Limits column with the abbreviation “LA” or a statement indicating the drug must be dispensed from a network specialty pharmacy. After your drug has been approved, we will arrange for the specialty pharmacy to contact you to set up delivery.

Can I use a mail order pharmacy? For certain kinds of prescription drugs, you can use the Health Net contracted Mail Order Pharmacy. Generally, the drugs available through mail order are drugs that you take on a regular basis for a chronic or long-term medical condition. Tier 4 or Specialty drugs are not available through mail order.

To use the mail order pharmacy, your doctor must provide a new prescription that allows up to a 90-day supply of each drug. Mail order forms are available on our website at Forms and Brochures - Pharmacy or you may call us at the telephone number on your Health Net ID card or on the front cover of this book to request a form.

How can I save money on my prescription drugs? You can save time and money with these simple steps:  Ask your doctor about generic drugs that may work for you.  Fill prescriptions at in-network pharmacies.  Be sure your doctor prescribes drugs on the drug list.  Fill your maintenance drugs through our mail order pharmacy program.

Definitions Brand drug: Is a drug that is marketed under a proprietary, trademark-protected name. A brand drug is listed in this formulary in all CAPITAL letters. Coinsurance: Is a percentage of the cost of a covered health care benefit that you pay after you have paid the deductible, if a deductible applies to the health care benefit. Copayment: Is a fixed dollar amount that you pay for a covered health care benefit after you have paid the deductible, if a deductible applies to the health care benefit. Deductible: Is the amount you pay for covered health care benefits that are subject to the deductible before your health insurer begins to pay. If the plan has a deductible, it may have either one deductible or separate deductibles for medical benefits and prescription drug benefits. After you pay your deductible, you usually pay only a copayment or coinsurance for covered health care benefits. The plan pays the rest. vii Drug Tier: Is a group of prescription drugs that correspond to a specified cost sharing tier. The drug tier in which a prescription drug is placed determines your portion of the cost for the drug. Enrollee: Is a person enrolled in a health plan who is entitled to receive services from the plan. All references to enrollees in this formulary template shall also include subscribers as defined in this section below. Exception request: Is a request for coverage of a non-formulary drug. If you, your designee, or your doctor submits a request for coverage of a non-formulary drug, the plan must cover the non-formulary drug when it is medically necessary for you to take the drug. Exigent circumstances: Is when you are suffering from a medical condition that may seriously jeopardize your life, health, or ability to regain maximum function, or when you are undergoing a current course of treatment using a non-formulary drug. Formulary or prescription drug list: Is the list of drugs that is covered by the plan under the prescription drug benefit of the policy. Generic drug: Is a drug that is the same as its brand name drug equivalent in dosage, strength, effect, how it is taken, quality, safety, and intended use. A generic drug is listed in the drug list in bold and italicized lowercase letters. Medically Necessary: Is a health care benefit needed to diagnose, treat, or prevent a medical condition or its symptoms and that meet accepted standards of medicine. Plans usually do not cover health care benefits that are not medically necessary. Non-formulary drug: Is a prescription drug that is not listed on the drug list. Out-of-pocket costs: Are your expenses for health care benefits that aren't reimbursed by the plan. Out- of-pocket costs include deductibles, copayments, and coinsurance for covered health care benefits, plus all costs for health care benefits that are paid by the Member and not covered by the plan. Prescribing provider: This is a health care provider who can write a prescription for a drug to diagnose, treat, or prevent a medical condition. Prescription: Is an oral, written, or electronic order from a prescribing provider authorizing a prescription drug to be provided to a specific individual. Prescription drug: Is a drug that by law requires a prescription. Prior Authorization: Is a decision by the plan that a health care benefit is medically necessary for you. If a prescription drug is subject to prior authorization in the drug list, your doctor must request approval from the plan to cover the drug before you fill your prescription. The plan must grant a prior authorization request when it is medically necessary for you to take the drug. Step therapy: Is a specific sequence in which prescription drugs for a particular medical condition must be tried. If a drug is subject to step therapy in the drug list, you may have to try one or more other drugs before the plan will cover that drug for your medical condition. If your doctor submits a request for an exception to the step therapy requirement, the plan must grant the request when it is medically necessary for you to take the drug. Subscriber: Means the person who is responsible for payment to a plan or whose employment or other status, except for family dependency, is the basis for eligibility for membership in the plan.

viii Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; ST; ADHD/ANTI-NARCOLEPSY/ANTI- methamphetamine hcl 2 OBESITY/ANOREXIANTS - Drugs to Treat tabs ADHD, Sleep and Eating Disorders VYVANSE CAPS 10 MG, QL(1 ea daily) Amphetamines 20 MG, 30 MG, 40 MG, 50 (Dextroamphetamine MG, 60 MG, 70 MG 2 Sulfate) PROCENTRA 1 (lisdexamfetamine SOLN dimesylate) (Dextroamphetamine VYVANSE CHEW 10 MG, Limited to 1 per Sulfate) ZENZEDI TABS 10 1 20 MG, 30 MG, 40 MG, 50 day;QL(1 ea MG, 2.5 MG, 5 MG, 7.5 MG MG, 60 MG 2 daily) amphetamine- QL(2 ea (lisdexamfetamine dextroamphetamine daily,90 day(s) dimesylate) limit) cp24 1.25 mg-1.25 mg- Analeptics 1.25 mg-1.25 mg, 2.5 mg-2.5 mg-2.5 mg-2.5 caffeine citrate soln 1 mg, 3.75 mg-3.75 mg- 1 Anorexiants Non-Amphetamine 3.75 mg-3.75 mg, 5 PA mg-5 mg-5 mg-5 mg, benzphetamine hcl tabs 1 6.25 mg-6.25 mg-6.25 diethylpropion hcl tabs 1 PA mg-6.25 mg, 7.5 mg- 7.5 mg-7.5 mg-7.5 mg diethylpropion hcl tb24 1 PA amphetamine- LOMAIRA TABS PA 3 dextroamphetamine (phentermine hcl) tabs 1.25 mg-1.25 mg- 1.25 mg-1.25 mg, 2.5 phentermine hcl caps 1 PA mg-2.5 mg-2.5 mg-2.5 1 PA mg, 3.125 mg-3.125 phentermine hcl tabs 1 mg-3.125 mg-3.125 PHENTERMINE PA mg, 5 mg-5 mg-5 mg-5 HYDROCHLORIDE CAPS 3 mg, 7.5 mg-7.5 mg-7.5 (phentermine hcl) mg-7.5 mg QSYMIA CP24 PA; QL(1 ea amphetamine- QL(90 ea per (phentermine hcl- 3 daily) dextroamphetamine fill retail) topiramate) tabs 1.875 mg-1.875 1 Anti-Obesity Agents mg-1.875 mg-1.875 CONTRAVE TB12 PA mg, 3.75 mg-3.75 mg- (naltrexone hcl- 3 3.75 mg-3.75 mg bupropion hcl) dextroamphetamine 1 SAXENDA SOPN PA; QL(0.5 ml sulfate cp24 (liraglutide (weight 3 daily) management)) dextroamphetamine 1 sulfate soln XENICAL CAPS (orlistat) 3 PA dextroamphetamine 1 sulfate tabs Attention-Deficit/Hyperactivity Disorder (ADHD)

1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic is Available AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

1 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(2 ea daily) atomoxetine hcl caps methylphenidate hcl 1 10 mg, 18 mg, 25 mg, 1 tabs 10 mg, 5 mg 40 mg QL(3 ea daily) methylphenidate hcl 1 QL(1 ea daily) atomoxetine hcl caps 1 tabs 20 mg 100 mg, 60 mg, 80 mg methylphenidate hcl QL(1 ea QL(4 ea daily) 1 daily,90 day(s) clonidine hcl (adhd) 1 tb24 18 mg, 27 mg, 54 tb12 mg limit) QL(1 ea daily) QL(2 ea guanfacine hcl (adhd) 1 methylphenidate hcl tb24 1 daily,90 day(s) tb24 36 mg limit) Stimulants - Misc. methylphenidate hcl QL(1 ea QL(1 ea 1 daily,90 ea per (Methylphenidate Hcl) 1 daily,90 ea per tbcr 10 mg, 20 mg METADATE ER TBCR fill retail) fill retail) methylphenidate hcl QL(1 ea daily) armodafinil tabs 1 PA; ST tbcr 18 mg, 27 mg, 36 1 DAYTRANA PTCH QL(1 ea daily) mg 3 QL(2 ea daily) (methylphenidate) methylphenidate hcl 1 dexmethylphenidate hcl QL(1 ea daily) tbcr 54 mg ST; QL(1 ea cp24 10 mg, 15 mg, 20 1 modafinil tabs 2 mg, 25 mg, 30 mg, 35 daily) QUILLIVANT XR SRER PA; ST;QL(12 mg, 40 mg, 5 mg 3 (methylphenidate hcl) ml daily) dexmethylphenidate hcl QL(2 ea daily) tabs 10 mg, 2.5 mg, 5 1 AMINOGLYCOSIDES - Drugs to Treat Bacterial mg Infections methylphenidate hcl Aminoglycosides chew 10 mg, 2.5 mg, 5 1 ARIKAYCE SUSP PA mg (amikacin sulfate 4 methylphenidate hcl QL(1 ea daily) liposome) BETHKIS NEBU PA; LA cp24 10 mg, 20 mg, 30 1 7 mg, 40 mg (tobramycin) methylphenidate hcl QL(1 ea neomycin sulfate tabs 1 1 daily,90 ea per cp24 60 mg fill retail) paromomycin sulfate 1 methylphenidate hcl caps PA cpcr 10 mg, 40 mg, 50 1 streptomycin sulfate 4 mg, 60 mg solr QL(2 ea daily) TOBI PODHALER CAPS PA methylphenidate hcl 1 4 cpcr 20 mg, 30 mg (tobramycin) PA; LA methylphenidate hcl tobramycin nebu 300 4 soln 10 mg/5ml, 5 1 mg/4ml mg/5ml PA tobramycin nebu 300 2 mg/5ml

2 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; Must use HUMIRA PSKT 10 PA; ST;LA tobramycin nebu 300 AcariaHealth MG/0.2ML, 20 MG/0.4ML, 2 Specialty Rx at 40 MG/0.8ML 4 mg/5ml 1-844-538- (adalimumab) 4661 Antirheumatic - Enzyme Inhibitors PA tobramycin sulfate soln 4 RINVOQ TB24 PA; ST 4 ANALGESICS - ANTI-INFLAMMATORY - Drugs (upadacitinib) XELJANZ TABS 10 MG PA to Treat Pain, Swelling, Muscle and Joint 4 Conditions (tofacitinib citrate) XELJANZ TABS 5 MG PA; ST;QL(2 Anti-TNF-alpha - Monoclonal Antibodies 4 HUMIRA PEDIATRIC PA (tofacitinib citrate) ea daily) CROHNS DISEASE XELJANZ XR TB24 11 MG PA; ST;QL(1 4 4 STARTER PACK PSKT (tofacitinib citrate) ea daily) (adalimumab) XELJANZ XR TB24 22 MG PA; QL(1 ea 4 HUMIRA PEDIATRIC PA; ST;LA (tofacitinib citrate) daily) CROHNS DISEASE STARTER PACK PSKT 40 4 Antirheumatic Antimetabolites MG/0.8ML (adalimumab) METHOTREXATE TABS HUMIRA PEDIATRIC PA; ST (methotrexate sodium 3 CROHNS DISEASE (antirheumatic)) 4 STARTER PACK PSKT 80 PA; ST; Must MG/0.8ML (adalimumab) OTREXUP SOAJ 10 use PA; ST; MUST MG/0.4ML ( 4 AcariaHealth methotrexate Specialty Rx at HUMIRA PEN PNKT USE ACARIA (antirheumatic)) 4 SPECIALTY 1-844-538- (adalimumab) RX 844-538- 4661;;LA 4661 OTREXUP SOAJ 12.5 PA; ST;LA PA; ST; MUST MG/0.4ML, 15 MG/0.4ML, HUMIRA PEN-CD/UC/HS USE ACARIA 17.5 MG/0.4ML, 20 STARTER PNKT 4 SPECIALTY MG/0.4ML, 22.5 4 (adalimumab) RX 844-538- MG/0.4ML, 25 MG/0.4ML 4661 (methotrexate PA; ST; MUST (antirheumatic)) HUMIRA PEN-PS/UV USE ACARIA RASUVO SOAJ 10 PA; ST; Must STARTER PNKT 4 SPECIALTY MG/0.2ML, 12.5 use (adalimumab) RX 844-538- MG/0.25ML, 15 MG/0.3ML, AcariaHealth 4661 17.5 MG/0.35ML, 22.5 Specialty Rx at PA; ST; Must MG/0.45ML, 25 MG/0.5ML, 4 1-844-538- use 30 MG/0.6ML, 7.5 4661;;LA HUMIRA PEN-PS/UV MG/0.15ML STARTER PNKT 4 AcariaHealth Specialty Rx at (methotrexate (adalimumab) 1-844-538- (antirheumatic)) 4661 RASUVO SOAJ 20 PA; ST;LA HUMIRA PSKT 10 PA; ST MG/0.4ML (methotrexate 4 MG/0.1ML, 20 MG/0.2ML, ) 40 MG/0.4ML 4 (antirheumatic) (adalimumab) Gold Compounds 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic is Available AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

3 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits RIDAURA CAPS QL(2 ea daily) 2 etodolac tb24 400 mg, 1 (auranofin) 500 mg, 600 mg Interleukin-1 Blockers fenoprofen calcium 1 ARCALYST SOLR PA tabs 4 (rilonacept) flurbiprofen tabs 1 Interleukin-6 Receptor Inhibitors PA; ST; MUST ibuprofen tabs 1 ACTEMRA ACTPEN SOAJ USE ACARIA INDOCIN SUPP RE 50 MG 4 SPECIALTY 3 (tocilizumab) RX 844-538- (indomethacin) INDOCIN SUSP OR 25 4661 2 KEVZARA SOSY PA; ST MG/5ML (indomethacin) 4 (sarilumab) indomethacin caps 20 ST; QL(3 ea 1 daily) Nonsteroidal Anti-inflammatory Agents (NSAIDs) mg indomethacin caps 25 (Fenoprofen Calcium) 1 1 PROFENO TABS mg, 50 mg (Ibuprofen) IBU TABS 1 indomethacin cpcr 75 1 mg (Nabumetone) RELAFEN 1 QL(4 ea daily) TABS 500 MG ketoprofen caps 50 mg, 1 75 mg (Nabumetone) RELAFEN 1 QL(3 ea daily) TABS 750 MG ketoprofen cp24 200 1 ST; AL(At least mg celecoxib caps 100 mg, 1 50 mg 60 yrs old) KETOROLAC QL(1 ea daily,5 ST; QL(2 ea TROMETHAMINE SOLN day(s) limit) NA 15.75 MG/SPRAY 3 1 daily); AL(At celecoxib caps 200 mg least 60 yrs (ketorolac old) tromethamine) ST; QL(1 ea ketorolac tromethamine QL(20 ea per 1 fill retail) 1 daily); AL(At tabs or 10 mg celecoxib caps 400 mg least 60 yrs old) meclofenamate sodium 1 caps diclofenac potassium 1 tabs mefenamic acid caps 1 diclofenac sodium tb24 1 meloxicam tabs 15 mg 1 QL(1 ea daily) diclofenac sodium tbec 1 meloxicam tabs 7.5 mg 1 QL(2 ea daily) diclofenac w/ QL(4 ea daily) 1 nabumetone tabs 500 1 misoprostol tbec mg etodolac caps 200 mg, QL(3 ea daily) 1 nabumetone tabs 750 1 300 mg mg etodolac tabs 400 mg, 1 naproxen sodium tabs 1 500 mg 275 mg, 550 mg 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic is Available AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

4 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; Must use naproxen susp 125 1 mg/5ml ENBREL SOLN 25 AcariaHealth 4 Specialty Rx at MG/0.5ML (etanercept) naproxen tabs 250 mg, 1 1-844-538- 375 mg, 500 mg 4661 ENBREL SOLR 25 MG PA; ST;LA oxaprozin tabs 1 4 (etanercept) piroxicam caps 10 mg 1 ENBREL SOSY 25 PA; ST;LA MG/0.5ML, 50 MG/ML 4 QL(1 ea daily) piroxicam caps 20 mg 1 (etanercept) SPRIX SOLN ( QL(1 ea daily,5 ENBREL SURECLICK PA; ST;LA ketorolac 3 4 tromethamine) day(s) limit) SOAJ (etanercept) 1 QL(2 ea daily) ANALGESICS - NonNarcotic - Drugs to Treat sulindac tabs 150 mg Pain, Muscle and Joint Conditions sulindac tabs 200 mg 1 Analgesic Combinations (Acetaminophen- tolmetin sodium caps 1 Salicylamide- 1 Phenyltoloxamine) tolmetin sodium tabs 1 DURAXIN CAPS (Butalbital-Acetaminophen) 1 Phosphodiesterase 4 (PDE4) Inhibitors BUPAP, TENCON TABS OTEZLA TABS PA; ST 4 (Butalbital-Acetaminophen- 1 (apremilast) Caffeine) BAC TABS PA; ST; Must (Butalbital-Acetaminophen- use Caffeine) ESGIC, OTEZLA TBPK 1 4 AcariaHealth PHRENILIN FORTE, (apremilast) Specialty Rx at ZEBUTAL CAPS 1-844-538- 4661;LA butalbital- acetaminophen tabs 1 Pyrimidine Synthesis Inhibitors 300 mg-50 mg, 325 leflunomide tabs 10 mg 1 QL(2 ea daily) mg-50 mg QL(1 ea daily) butalbital- leflunomide tabs 20 mg 1 acetaminophen- 1 Selective Costimulation Modulators caffeine caps ORENCIA CLICKJECT PA butalbital- 4 SOAJ (abatacept) acetaminophen- 1 ORENCIA SOSY PA caffeine tabs 4 (abatacept) butalbital-aspirin- 1 Soluble Tumor Necrosis Factor Receptor Agents caffeine caps ENBREL MINI SOCT PA; ST Salicylates 4 (etanercept)

5 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Aspirin) ADULT ASPIRIN PV (Aspirin) ASPIRIN 81 LOW PV REGIMEN, ASPIR-LOW, DOSE, ASPIRIN ADULT ASPIRIN 81, ASPIRIN LOW STRENGTH, ADULT LOW DOSE, ASPIRIN CHILDRENS, ASPIRIN ADULT LOW ASPIRIN LOW DOSE, STRENGTH, ASPIRIN EC ASPIRIN LOW LOW DOSE, ASPIRIN STRENGTH, BAYER ENTERIC COATED CHEWABLE LOW DOSE, ADULT LOW STRENGTH, CHILDRENS ASPIRIN, ASPIRIN LOW DOSE, CHILDRENS ASPIRIN BAYER ASPIRIN EC LOW LOW STRENGTH, CVS DOSE, BAYER LOW ASPIRIN ADULT LOW DOSE, CVS ASPIRIN DOSE, EQ ASPIRIN LOW ADULT LOW STRENGTH, DOSE, EQ CHILDRENS CVS ASPIRIN EC, CVS ASPIRIN, EQL ASPIRIN ASPIRIN LOW DOSE, CVS LOW DOSE, GNP ADULT ASPIRIN LOW ASPIRIN LOW STRENGTH, EC-81 STRENGTH, ASPIRIN, ECOTRIN LOW GOODSENSE ASPIRIN STRENGTH, EQ ADULT ADULT LOW STRENGTH, 5 ASPIRIN LOW PX ASPIRIN, QC ASPIRIN STRENGTH, EQ ASPIRIN 5 LOW DOSE, QC ADULT LOW DOSE, EQ CHEWABLE ASPIRIN ASPIRIN LOW DOSE, EQL LOW DOSE, QC ASPIRIN LOW DOSE, CHILDRENS ASPIRIN, RA GNP ASPIRIN LOW ASPIRIN ADULT LOW DOSE, GOODSENSE DOSE, RA ASPIRIN ASPIRIN LOW DOSE, H-E- ADULT LOW STRENGTH, B ASPIRIN, HM ASPIRIN RA ASPIRIN CHILDRENS, EC LOW DOSE, KLS RA CHILDRENS ASPIRIN, ASPIRIN LOW DOSE, KP SB CHILDRENS ASPIRIN, ASPIRIN, MINIPRIN LOW SM ASPIRIN ADULT LOW DOSE, QC ASPIRIN LOW STRENGTH, SM ASPIRIN DOSE, RA ASPIRIN EC LOW DOSE, SM ADULT LOW STRENGTH, CHILDRENS ASPIRIN, ST SB ASPIRIN, SB ASPIRIN JOSEPH LOW DOSE ADULT LOW STRENGTH, ASPIRIN, TGT ASPIRIN, SB LOW DOSE ASA EC, TGT CHILDRENS SM ASPIRIN ADULT LOW ASPIRIN CHEW STRENGTH, SM ASPIRIN EC LOW STRENGTH, ST JOSEPH ASPIRIN, TGT ASPIRIN, TGT ASPIRIN LOW DOSE TBEC

6 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Aspirin) ASPIRIN ADULT, PV (Methadone Hcl) BAYER ADVANCED METHADONE HCL ASPIRIN REGULAR INTENSOL, METHADOSE, 1 STRENGTH, BAYER METHADOSE SUGAR- ASPIRIN, CVS ASPIRIN, FREE CONC EQ ASPIRIN, EQL (Methadone Hcl) 1 ASPIRIN, HM ADULT METHADOSE TBSO ASPIRIN, MEDIQUE 5 ASPIRIN, MM ASPIRIN, codeine sulfate tabs 1 NORWICH ASPIRIN, PX CONZIP CP24 ( ASPIRIN, QC ASPIRIN, RA tramadol 7 ASPIRIN, RA PAIN hcl) RELIEF ASPIRIN, SB EMBEDA CPCR 0.8 MG- PA; ST ASPIRIN, SM ASPIRIN, 20 MG (morphine- 3 TGT ASPIRIN TABS naltrexone) (Aspirin) GNP ASPIRIN, PV EMBEDA CPCR 1.2 MG- PA GOODSENSE ASPIRIN, 5 HM ASPIRIN TABS 325 30 MG, 100 MG-4 MG, 2 MG MG-50 MG, 2.4 MG-60 3 MG, 3.2 MG-80 MG (Aspirin) GNP ASPIRIN, PV ( ) PX ENTERIC ASPIRIN, RA 5 morphine-naltrexone ASPIRIN EC TBEC 81 MG fentanyl citrate lpop bu PA; ST (Aspirin) GOODSENSE PV 1200 mcg, 200 mcg, 2 ASPIRIN, HM ASPIRIN 5 400 mcg, 600 mcg, 800 CHEW 81 MG mcg PV PA; ST;QL(4 aspirin chew 81 mg 5 fentanyl citrate lpop bu 2 1600 mcg ea daily) PV aspirin tabs 325 mg 5 fentanyl pt72 100 Limit 15 per mcg/hr, 12 mcg/hr, 25 month;QL(0.5 aspirin tbec 81 mg 5 PV 1 mcg/hr, 50 mcg/hr, 75 ea daily) diflunisal tabs 1 mcg/hr fentanyl pt72 37.5 PA; Limit 15 salsalate tabs 1 1 patches per mcg/hr, 62.5 mcg/hr, month;QL(0.5 ST JOSEPH ADULT PV 87.5 mcg/hr ea daily) ANALGESICLOW DOSE 7 BITE SIZE CHEW hydromorphone hcl liqd 1 (aspirin) 1 mg/ml ST JOSEPH ADULT PV hydromorphone hcl 7 1 CHEW (aspirin) tabs 2 mg, 4 mg, 8 mg ANALGESICS - OPIOID - Drugs to Treat Pain, hydromorphone hcl QL(4 ea daily) Muscle and Joint Conditions tb24 12 mg, 16 mg, 8 1 Opioid Agonists mg QL(2 ea daily) hydromorphone hcl 1 tb24 32 mg KADIAN CP24 200 MG QL(2 ea daily) 3 (morphine sulfate)

7 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LAZANDA SOLN PA OXAYDO TABS 5 MG 3 2 (fentanyl citrate) (oxycodone hcl) PA; ST OXAYDO TABS 7.5 MG QL(4 ea daily) levorphanol tartrate 1 3 tabs (oxycodone hcl) meperidine hcl soln 1 oxycodone hcl caps 5 1 mg meperidine hcl tabs 1 oxycodone hcl conc 1 100 mg/5ml methadone hcl conc 10 1 mg/ml oxycodone hcl soln 5 1 mg/5ml methadone hcl soln 10 1 mg/5ml, 5 mg/5ml oxycodone hcl tabs 10 QL(12 ea daily) mg, 15 mg, 20 mg, 5 1 methadone hcl tabs 10 1 mg, 5 mg mg QL(4 ea daily) oxycodone hcl tabs 30 1 methadone hcl tbso 40 1 mg mg QL(8 ea daily) QL(1 ea daily) oxymorphone hcl tabs 1 morphine sulfate beads 1 cp24 10 mg oxymorphone hcl tabs morphine sulfate cp24 QL(2 ea daily) 1 5 mg or 10 mg, 100 mg, 20 1 mg, 30 mg, 40 mg, 50 oxymorphone hcl tb12 QL(2 ea daily) mg, 60 mg, 80 mg 10 mg, 15 mg, 20 mg, 1 30 mg, 40 mg, 5 mg, morphine sulfate soln 1 or 10 mg/5ml 7.5 mg SUBSYS LIQD 100 MCG PA; QL(4 ea morphine sulfate soln Not available 3 (fentanyl) daily) or 100 mg/5ml, 20 1 through mail order SUBSYS LIQD 1200 MCG, PA mg/5ml, 20 mg/ml 1600 MCG, 200 MCG, 400 morphine sulfate supp MCG, 600 MCG, 800 MCG 3 re 10 mg, 20 mg, 30 1 (fentanyl) mg tramadol hcl cp24 100 morphine sulfate tabs First fill opioids mg, 150 mg, 200 mg, 1 1 limited to 7 300 mg or 15 mg days. tramadol hcl tabs 50 QL(8 ea daily) morphine sulfate tabs 1 1 mg or 30 mg QL(3 ea daily) QL(3 ea daily) tramadol hcl tb24 100 1 morphine sulfate tbcr or mg 100 mg, 15 mg, 200 1 mg, 30 mg, 60 mg tramadol hcl tb24 100 1 NUCYNTA ER TB12 QL(2 ea daily) mg, 200 mg, 300 mg 2 QL(1 ea daily) (tapentadol hcl) tramadol hcl tb24 200 1 NUCYNTA TABS QL(6 ea daily) mg 2 (tapentadol hcl) Opioid Combinations

8 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Butalbital-Aspirin-Caffeine hydrocodone- W/Cod) 1 acetaminophen soln ASCOMP/CODEINE CAPS 108 mg/5ml-2.5 1 (Hydrocodone- QL(240 ea per mg/5ml, 217 mg/10ml-5 Acetaminophen) LORCET, 1 fill retail) LORCET HD, LORCET mg/10ml, 325 mg/15ml- PLUS TABS 7.5 mg/15ml hydrocodone- (Hydrocodone-Ibuprofen) 1 IBUDONE TABS acetaminophen tabs 10 1 (Oxycodone W/ QL(4 ea daily) mg-300 mg, 300 mg-5 Acetaminophen) 1 mg ENDOCET TABS 10 MG- hydrocodone- QL(240 ea per 325 MG, 325 MG-7.5 MG fill retail) acetaminophen tabs 10 1 (Oxycodone W/ mg-325 mg, 325 mg-5 Acetaminophen) 1 ENDOCET TABS 2.5 MG- mg, 325 mg-7.5 mg 325 MG hydrocodone- QL(6 ea daily) (Oxycodone W/ QL(6 ea daily) acetaminophen tabs 1 Acetaminophen) 1 300 mg-7.5 mg ENDOCET TABS 325 MG- 5 MG hydrocodone-ibuprofen Not available 1 through mail acetaminophen w/ tabs 10 mg-200 mg order codeine soln 12 1 hydrocodone-ibuprofen mg/5ml-120 mg/5ml tabs 10 mg-200 mg, 1 acetaminophen w/ 200 mg-5 mg, 200 mg- codeine tabs 15 mg- 1 7.5 mg 300 mg, 30 mg-300 mg LORTAB ELIX acetaminophen w/ QL(6 ea daily) (hydrocodone- 3 codeine tabs 300 mg- 1 acetaminophen) 60 mg NALOCET TABS butalbital- PA (oxycodone w/ 3 acetaminophen- acetaminophen) caffeine w/ codeine 1 oxycodone w/ QL(4 ea daily) caps 30 mg-300 mg-40 acetaminophen tabs 10 1 mg-50 mg mg-325 mg, 325 mg- butalbital- 7.5 mg acetaminophen- oxycodone w/ caffeine w/ codeine 1 acetaminophen tabs 1 caps 30 mg-325 mg-40 2.5 mg-325 mg mg-50 mg oxycodone w/ QL(6 ea daily) butalbital-aspirin- 1 acetaminophen tabs 1 caffeine w/cod caps 325 mg-5 mg QL(4 ea daily) oxycodone-ibuprofen 1 tabs

9 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits OXYCODONE/ACETAMIN pentazocine w/ OPHEN TABS 1 3 naloxone tabs (oxycodone w/ PROBUPHINE IMPLANT PA acetaminophen) KIT IMPL 4 PRIMLEV TABS (buprenorphine hcl) (oxycodone w/ 3 SUBLOCADE SOSY PA; Covered acetaminophen) 4 under the (buprenorphine) PROLATE TABS 10 MG- Medical Benefit 300 MG, 300 MG-5 MG, ANDROGENS-ANABOLIC - Drugs to Regulate 300 MG-7.5 MG 3 Hormones (oxycodone w/ acetaminophen) Anabolic Steroids ANADROL-50 TABS ROXICET SOLN 3 (oxymetholone) (oxycodone w/ 2 QL(2 ea daily) acetaminophen) oxandrolone tabs 10 2 QL(8 ea daily) mg tramadol- 1 acetaminophen tabs oxandrolone tabs 2.5 2 mg Opioid Partial Agonists QL(3 ea daily) Androgens buprenorphine hcl subl 1 2 mg ST; QL(60 ea ANDRODERM PT24 per fill QL(4 ea daily) 3 buprenorphine hcl subl 1 (testosterone) retail,120 ea 8 mg per fill mail) buprenorphine hcl- danazol caps 1 naloxone hcl dihydrate 1 METHITEST TABS subl 0.5 mg-2 mg, 2 2 mg-8 mg (methyltestosterone) BUPRENORPHINE PTWK Limited to 4 methyltestosterone 1 TD 10 MCG/HR, 15 patches per caps MCG/HR, 20 MCG/HR, 5 3 month;QL(4 ea STRIANT MISC QL(2 ea daily) 3 MCG/HR per 28 days (testosterone) retail) (buprenorphine) TESTIM GEL PA; QL(10 gm 7 BUPRENORPHINE PTWK QL(4 ea per 28 (testosterone) daily) TD 10 MCG/HR, 15 days retail) MCG/HR, 20 MCG/HR, 5 3 testosterone gel 1 % 3 PA; QL(10 gm MCG/HR, 7.5 MCG/HR daily) (buprenorphine) testosterone gel 1 %, Limited to 300 gms per Limited to 4 1.62 %, 20.25 mg/1.25gm, 25 1 month;QL(10 buprenorphine ptwk td patches per gm daily) 3 month;QL(4 ea 7.5 mcg/hr mg/2.5gm, 40.5 per 28 days mg/2.5gm, 50 mg/5gm retail) testosterone gel 1 %, QL(10 gm Limit 7.5mls 25 mg/2.5gm, 50 1 daily) butorphanol tartrate 1 per soln month;QL(0.25 mg/5gm ml daily) 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic is Available AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

10 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(4 gm daily) testosterone gel 10 1 ANTHELMINTICS - Drugs to Treat Worm mg/act Infections testosterone gel 25 1.5 GM/50 Anthelmintics 1 ML;QL(10 gm mg/2.5gm daily) albendazole tabs 1 Limit 300gms BENZNIDAZOLE TABS AL(At least 2 testosterone gel 50 1 per 2 yrs old - Up to mg/5gm month;QL(10 (benznidazole) 12 yrs old) gm daily) QL(6 ml daily) ivermectin tabs 1 testosterone soln 30 1 mg/act praziquantel tabs 1 ANORECTAL AND RELATED PRODUCTS - Rectal Drugs to Treat Pain, Swelling and Itching ANTI-INFECTIVE AGENTS - MISC. - Drugs to Treat Bacterial Infections Intrarectal Steroids (Hydrocortisone QL(60 ml daily) Anti-infective Agents - Misc. (Intrarectal)) COLOCORT 1 metronidazole caps 1 ENEM CORTIFOAM FOAM metronidazole tabs 1 (hydrocortisone acetate 2 pentamidine isethionate (intrarectal)) 1 solr hydrocortisone QL(60 ml daily) 1 PRIMSOL SOLN (intrarectal) enem 3 (trimethoprim hcl) UCERIS FOAM RE 2 PA; ST PA; ST MG/ACT (budesonide 3 tinidazole tabs 250 mg 1 (intrarectal)) tinidazole tabs 500 mg 1 ST Rectal Combinations ANALPRAM-HC LOTN trimethoprim tabs 1 (hydrocortisone acetate 3 XIFAXAN TABS 200 MG PA; QL(9 ea 3 w/ pramoxine) (rifaximin) per fill retail) PROCTOFOAM HC FOAM XIFAXAN TABS 550 MG PA; QL(2 ea 3 (hydrocortisone acetate 2 (rifaximin) daily) w/ pramoxine) Anti-infective Misc. - Combinations Rectal Steroids (Methenamine-Hyosc- (Hydrocortisone (Rectal)) Methylene Blue-Benzoic 1 PROCTO-MED HC, 1 Acid-Phenyl Sal) PROCTOSOL HC, HYOPHEN TABS PROCTOZONE-HC CREA (Sulfamethoxazole- hydrocortisone (rectal) 1 Trimethoprim) SULFATRIM 1 crea PEDIATRIC SUSP Vasodilating Agents sulfamethoxazole- 1 RECTIV OINT trimethoprim susp (nitroglycerin (intra- 3 sulfamethoxazole- 1 anal)) trimethoprim tabs 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic is Available AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

11 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Antiprotozoal Agents linezolid susr 100 QL(210 ml per 1 90 days retail) ALINIA SUSR 100 mg/5ml 3 MG/5ML (nitazoxanide) 1 QL(20 ea per linezolid tabs 600 mg 90 days retail) 2 atovaquone susp SIVEXTRO TABS QL(6 ea per 90 2 days retail) nitazoxanide tabs 1 (tedizolid phosphate) Urinary Anti-infectives Carbapenems fosfomycin 1 doripenem solr 4 PA tromethamine pack PA methenamine hippurate 1 ertapenem sodium solr 4 tabs imipenem-cilastatin solr 2 PA methenamine mandelate tabs 0.5 gm, 1 INVANZ SOLR PA 7 1 gm (ertapenem sodium) PA nitrofurantoin 1 meropenem solr 4 macrocrystal caps MERREM SOLR PA 7 nitrofurantoin monohyd 1 (meropenem) macro caps PRIMAXIN IV SOLR PA 7 nitrofurantoin susp 1 (imipenem-cilastatin) Glycopeptides ANTIANGINAL AGENTS - Drugs to Treat Chest Pain FIRVANQ SOLR PA 3 (vancomycin hcl) Antianginals-Other PA ranolazine tb12 1000 vancomycin hcl caps 1 1 125 mg mg 1 QL(4 ea daily) vancomycin hcl caps 1 ranolazine tb12 500 mg 250 mg Nitrates Leprostatics (Nitroglycerin) MINITRAN 1 QL(1 ea daily) dapsone tabs 100 mg 1 QL(4 ea daily) PT24 DILATRATE SR CPCR 3 dapsone tabs 25 mg 1 (isosorbide dinitrate) GONITRO PACK PA Lincosamides 3 (nitroglycerin) clindamycin hcl caps 1 isosorbide dinitrate tabs 1 clindamycin palmitate 1 hydrochloride solr isosorbide dinitrate tbcr 1 Monobactams isosorbide mononitrate 1 CAYSTON SOLR PA tabs 4 (aztreonam lysine) isosorbide mononitrate 1 Oxazolidinones tb24

12 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NITRO-BID OINT 2 alprazolam tbdp 0.25 2 (nitroglycerin) mg, 0.5 mg, 1 mg, 2 mg NITRO-DUR PT24 0.3 QL(1 ea daily) ATIVAN TABS PA 7 MG/HR, 0.8 MG/HR 2 (lorazepam) (nitroglycerin) chlordiazepoxide hcl 1 nitroglycerin pt24 td 0.1 QL(1 ea daily) caps mg/hr, 0.2 mg/hr, 0.4 1 clorazepate 1 mg/hr, 0.6 mg/hr dipotassium tabs nitroglycerin soln tl 0.4 1 mg/spray diazepam conc 5 mg/ml 1 nitroglycerin subl sl 0.3 1 diazepam soln 5 1 mg, 0.4 mg, 0.6 mg mg/5ml ANTIANXIETY AGENTS - Drugs to Treat Anxiety diazepam tabs 10 mg 1 QL(4 ea daily)

Antianxiety Agents - Misc. diazepam tabs 2 mg, 5 1 mg buspirone hcl tabs 1 1 PA lorazepam conc hydroxyzine hcl soln im 4 25 mg/ml, 50 mg/ml lorazepam tabs 1 hydroxyzine hcl syrp or 1 oxazepam caps 10 mg, 10 mg/5ml 1 15 mg hydroxyzine hcl tabs or 1 QL(2 ea daily) 10 mg, 25 mg, 50 mg oxazepam caps 30 mg 1 hydroxyzine pamoate 1 ANTIARRHYTHMICS - Drugs to treat abnormal caps heart rhythms meprobamate tabs 1 Antiarrhythmics Type I-A disopyramide 1 Benzodiazepines phosphate caps (Alprazolam) 1 ALPRAZOLAM XR TB24 NORPACE CR CP12 100 MG (disopyramide 2 (Diazepam) DIAZEPAM 1 INTENSOL CONC phosphate) NORPACE CR CP12 150 (Lorazepam) LORAZEPAM 1 INTENSOL CONC MG (disopyramide 3 ALPRAZOLAM INTENSOL phosphate) 3 CONC (alprazolam) quinidine gluconate tbcr 1 alprazolam tabs 0.25 mg, 0.5 mg, 1 mg, 2 1 quinidine sulfate tabs 1 mg Antiarrhythmics Type I-B alprazolam tb24 0.5 1 mg, 1 mg, 2 mg, 3 mg mexiletine hcl caps 1 Antiarrhythmics Type I-C

13 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits flecainide acetate tabs 1 SPIRIVA RESPIMAT Limit 1 Inhaler AERS 1.25 MCG/ACT per propafenone hcl cp12 (tiotropium bromide 2 month;QL(0.14 225 mg, 325 mg, 425 1 monohydrate) 3 gm daily) mg SPIRIVA RESPIMAT Limit 1 inhaler propafenone hcl tabs QL(6 ea daily) AERS 2.5 MCG/ACT per 1 (tiotropium bromide 2 month;QL(0.14 150 mg gm daily) QL(3 ea daily) monohydrate) propafenone hcl tabs 1 225 mg, 300 mg Leukotriene Modulators QL(1 ea daily) Antiarrhythmics Type III montelukast sodium 1 (Amiodarone Hcl) chew 1 QL(1 ea daily) PACERONE TABS montelukast sodium 1 pack amiodarone hcl tabs 1 QL(1 ea daily) montelukast sodium 1 dofetilide caps 1 tabs MULTAQ TABS zafirlukast tabs 10 mg 1 2 (dronedarone hcl) zafirlukast tabs 20 mg 1 QL(2 ea daily) ANTIASTHMATIC AND BRONCHODILATOR AGENTS - Drugs to Treat Lung Conditions zileuton tb12 1 ST Anti-Inflammatory Agents ZYFLO TABS (zileuton) 3 ST cromolyn sodium nebu 1 CROMOLYN SODIUM Steroid Inhalants NEBU (cromolyn 2 ARNUITY ELLIPTA AEPB QL(1 ea daily) sodium) (fluticasone furoate 2 (inhalation)) Antiasthmatic - Monoclonal Antibodies budesonide (inhalation) QL(8 ml daily) XOLAIR SOSY PA 2 4 susp 0.25 mg/2ml (omalizumab) QL(4 ml daily) budesonide (inhalation) 2 Bronchodilators - Anticholinergics susp 0.5 mg/2ml Limit 2 inhalers ATROVENT HFA AERS budesonide (inhalation) QL(2 ml daily) ( 2 per 1 ipratropium bromide month;QL(0.86 susp 1 mg/2ml ) hfa gm daily) FLOVENT DISKUS AEPB QL(20 ea daily) INCRUSE ELLIPTA AEPB QL(1 ea daily) 100 MCG/BLIST 2 2 (umeclidinium bromide) (fluticasone propionate (inhalation)) ipratropium bromide 1 soln FLOVENT DISKUS AEPB QL(8 ea daily) 250 MCG/BLIST SPIRIVA HANDIHALER QL(1 ea daily) (fluticasone propionate 2 CAPS (tiotropium 2 (inhalation)) bromide monohydrate)

14 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FLOVENT DISKUS AEPB QL(40 ea daily) ALBUTEROL SULFATE 50 MCG/BLIST NEBU IN 0.5 % ( 2 albuterol 2 (fluticasone propionate sulfate) (inhalation)) albuterol sulfate syrp or 1 FLOVENT HFA AERO 110 Limit 2 inhalers 2 mg/5ml MCG/ACT, 220 MCG/ACT per 2 (fluticasone propionate month;QL(0.8 albuterol sulfate tabs or 1 hfa) gm daily) 2 mg, 4 mg QL(2 ea daily) Limit 1 inhaler albuterol sulfate tb12 or 1 FLOVENT HFA AERO 44 4 mg, 8 mg MCG/ACT (fluticasone 2 per month;QL(0.36 ANORO ELLIPTA AEPB QL(2 ea daily) propionate hfa) gm daily) (umeclidinium- 2 Limit 1 inhaler vilanterol) PULMICORT FLEXHALER per month;QL(1 AEPB (budesonide 2 ea per fill ARCAPTA NEOHALER QL(1 ea daily) (inhalation)) retail,3 ea per CAPS (indacaterol 3 fill mail) maleate) QVAR REDIHALER AERB Limit 1 inhaler BREO ELLIPTA AEPB QL(2 ea daily) 40 MCG/ACT per (fluticasone furoate- 2 2 (beclomethasone month;QL(0.36 vilanterol) gm daily) dipropionate hfa) budesonide-formoterol Limit 1 inhaler QVAR REDIHALER AERB Limit 2 Inhalers 1 per fumarate dihydrate month;QL(0.34 80 MCG/ACT per aero (beclomethasone 2 month;QL(0.72 gm daily) dipropionate hfa) gm daily) COMBIVENT RESPIMAT Limit 1 inhaler AERS ( 3 per Sympathomimetics ipratropium- month;QL(0.2 albuterol) (Fluticasone-Salmeterol) 1 QL(2 ea daily) gm daily) WIXELA INHUB AEPB fluticasone-salmeterol QL(2 ea daily) Limit 1 inhaler aepb 100 mcg/dose-50 ADVAIR HFA AERO 2 per mcg/dose, 250 (fluticasone-salmeterol) month;QL(0.4 gm daily) mcg/dose-50 1 mcg/dose, 50 albuterol sulfate aers in QL(0.47 gm 1 daily) mcg/dose-500 108 mcg/act mcg/dose QL(0.72 gm albuterol sulfate aers in 1 daily) ipratropium-albuterol 1 108 mcg/act soln QL(0.57 gm albuterol sulfate aers in 1 108 mcg/act daily) levalbuterol hcl nebu 1 albuterol sulfate nebu levalbuterol tartrate QL(0.6 gm 1 daily) in 0.083 %, 0.5 %, 0.63 1 aero mg/3ml, 1.25 mg/3ml, metaproterenol sulfate 1 2.5 mg/0.5ml tabs

15 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limit 2 inhalers ELIQUIS STARTER PACK PROAIR RESPICLICK 2 3 per TBPK (apixaban) AEPB (albuterol sulfate) month;QL(0.07 ELIQUIS TABS 2.5 MG QL(2 ea daily) ea daily) 2 (apixaban) SEREVENT DISKUS QL(2 ea daily) ELIQUIS TABS 5 MG AEPB (salmeterol 2 2 xinafoate) (apixaban) STIOLTO RESPIMAT QL(0.14 gm XARELTO STARTER PACK TBPK 2 AERS ( daily) tiotropium 2 (rivaroxaban) bromide-olodaterol hcl) XARELTO TABS 10 MG, Limit 1 inhaler 15 MG, 2.5 MG 2 STRIVERDI RESPIMAT per 2 (rivaroxaban) AERS (olodaterol hcl) month;QL(0.14 XARELTO TABS 20 MG QL(1 ea daily) gm daily) 2 (rivaroxaban) terbutaline sulfate tabs 1 Heparins And Heparinoid-Like Agents TRELEGY ELLIPTA AEPB QL(2 ea daily) ARIXTRA SOLN 10 PA 100 MCG/INH-25 MG/0.8ML, 5 MG/0.4ML, MCG/INH-62.5 MCG/INH 2 7.5 MG/0.6ML 7 (fluticasone- (fondaparinux sodium) umeclidinium-vilanterol) ARIXTRA SOLN 2.5 PA; QL(4 ml Xanthines MG/0.5ML (fondaparinux 7 per 90 days ELIXOPHYLLIN ELIX retail,4 ml per 3 sodium) (theophylline) 90 days mail) THEO-24 CP24 enoxaparin sodium PA; QL(0.1 ml 2 2 daily) (theophylline) soln ij 300 mg/3ml enoxaparin sodium QL(4 ml per 7 theophylline soln 80 1 mg/15ml soln sc 100 mg/ml, 120 days retail) QL(2 ea daily) mg/0.8ml, 150 mg/ml, 2 theophylline tb12 300 1 mg 30 mg/0.3ml, 40 mg/0.4ml, 60 mg/0.6ml, QL(1 ea daily) theophylline tb12 450 1 80 mg/0.8ml mg fondaparinux sodium PA QL(1 ea daily) theophylline tb24 400 1 soln 10 mg/0.8ml, 5 4 mg, 600 mg mg/0.4ml, 7.5 mg/0.6ml ANTICOAGULANTS - Blood Thinners PA; QL(4 ml fondaparinux sodium 4 per 90 days Coumarin Anticoagulants soln 2.5 mg/0.5ml retail,4 ml per 90 days mail) (Warfarin Sodium) 1 JANTOVEN TABS warfarin sodium tabs 1 Direct Factor Xa Inhibitors BEVYXXA CAPS QL(42 ea per 3 (betrixaban maleate) 42 days retail) 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic is Available AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

16 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FRAGMIN SOLN 10000 PA (Lamotrigine) SUBVENITE ST UNIT/ML, 12500 STARTER KIT/BLUE, UNIT/0.5ML, 15000 SUBVENITE STARTER 1 UNIT/0.6ML, 18000 KIT/GREEN, SUBVENITE UNT/0.72ML, 5000 4 STARTER KIT/ORANGE UNIT/0.2ML, 7500 KIT UNIT/0.3ML, 95000 (Lamotrigine) SUBVENITE 1 UNIT/3.8ML (dalteparin TABS sodium) (Levetiracetam) QL(3 ea daily) FRAGMIN SOLN 2500 ROWEEPRA TABS 1000 1 UNIT/0.2ML (dalteparin 4 MG sodium) (Levetiracetam) QL(6 ea daily) PA ROWEEPRA TABS 500 1 heparin sodium 4 MG, 750 MG (porcine) soln (Levetiracetam) 1 QL(4 ea daily) ANTICONVULSANTS - Drugs to Treat Seizures ROWEEPRA XR TB24 APTIOM TABS PA; QL(2 ea AMPA Glutamate Receptor Antagonists (eslicarbazepine 3 daily) FYCOMPA SUSP 3 acetate) (perampanel) BANZEL SUSP 40 MG/ML FYCOMPA TABS 7 3 (rufinamide) (perampanel) BANZEL TABS 200 MG 3 Anticonvulsants - Benzodiazepines (rufinamide) BANZEL TABS 400 MG QL(8 ea daily) clobazam susp 2.5 1 3 mg/ml (rufinamide) QL(1 ea daily) clobazam tabs 10 mg 1 carbamazepine chew 1 100 mg clobazam tabs 20 mg 1 QL(2 ea daily) carbamazepine cp12 100 mg, 200 mg, 300 1 clonazepam tabs 1 mg clonazepam tbdp 1 carbamazepine susp 1 100 mg/5ml QL(0.14 ea diazepam 1 daily) carbamazepine tabs 1 (anticonvulsant) gel 200 mg NAYZILAM SOLN PA; QL(10 ea carbamazepine tb12 (midazolam 4 per 30 days 1 (anticonvulsant)) retail) 100 mg QL(8 ea daily) carbamazepine tb12 1 Anticonvulsants - Misc. 200 mg (Carbamazepine) EPITOL 1 QL(4 ea daily) TABS carbamazepine tb12 1 400 mg CARBATROL CP12 7 (carbamazepine)

17 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DIACOMIT CAPS 250 MG PA; QL(12 ea LAMICTAL XR TB24 250 PA 4 7 (stiripentol) daily) MG (lamotrigine) DIACOMIT CAPS 500 MG PA; QL(6 ea LAMICTAL XR TB24 300 QL(2 ea daily) 4 7 (stiripentol) daily) MG (lamotrigine) DIACOMIT PACK 250 MG PA; QL(12 ea 4 lamotrigine chew 25 1 (stiripentol) daily) mg, 5 mg DIACOMIT PACK 500 MG PA; QL(6 ea 4 lamotrigine kit 1 PA; ST (stiripentol) daily) EPIDIOLEX SOLN PA; ST ST 4 lamotrigine kit 25 mg 1 (cannabidiol) lamotrigine tabs 100 FINTEPLA SOLN PA mg, 150 mg, 200 mg, 1 (fenfluramine hcl 4 25 mg (anticonvulsant)) lamotrigine tb24 100 PA; QL(1 ea gabapentin caps 1 mg, 200 mg, 25 mg, 50 1 daily) mg gabapentin soln 1 PA lamotrigine tb24 250 1 gabapentin tabs 1 mg KEPPRA SOLN 100 lamotrigine tb24 300 QL(2 ea daily) 7 1 MG/ML (levetiracetam) mg KEPPRA TABS 1000 MG QL(3 ea daily) lamotrigine tbdp 100 PA 7 (levetiracetam) mg, 200 mg, 25 mg, 50 1 KEPPRA TABS 250 MG, QL(6 ea daily) mg 500 MG, 750 MG 7 levetiracetam soln 100 1 (levetiracetam) mg/ml, 500 mg/5ml KEPPRA XR TB24 QL(4 ea daily) QL(3 ea daily) 7 levetiracetam tabs 1 (levetiracetam) 1000 mg LAMICTAL CHEWABLE QL(6 ea daily) levetiracetam tabs 250 1 DISPERSIBLE CHEW 7 mg, 500 mg, 750 mg (lamotrigine) levetiracetam tb24 500 QL(4 ea daily) LAMICTAL ODT KIT PA; ST 1 3 mg, 750 mg (lamotrigine) LYRICA CAPS 100 MG, PA; ST;QL(3 LAMICTAL ODT TBDP 100 PA 150 MG, 200 MG, 25 MG, ea daily) MG, 200 MG, 25 MG, 50 7 50 MG, 75 MG 7 MG (lamotrigine) (pregabalin) LAMICTAL TABS LYRICA CAPS 225 MG, PA; ST;QL(2 7 7 (lamotrigine) 300 MG (pregabalin) ea daily) LAMICTAL XR KIT PA; ST LYRICA SOLN 20 MG/ML PA 3 7 (lamotrigine) (pregabalin) LAMICTAL XR TB24 100 PA; QL(1 ea MYSOLINE TABS MG, 200 MG, 25 MG, 50 7 daily) 7 (primidone) MG (lamotrigine)

18 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NEURONTIN CAPS TOPAMAX SPRINKLE 7 7 (gabapentin) CPSP (topiramate) NEURONTIN SOLN TOPAMAX TABS 100 MG QL(4 ea daily) 7 7 (gabapentin) (topiramate) NEURONTIN TABS TOPAMAX TABS 200 MG QL(2 ea daily) 7 7 (gabapentin) (topiramate) QL(40 ml daily) TOPAMAX TABS 25 MG oxcarbazepine susp 1 7 300 mg/5ml, 60 mg/ml (topiramate) TOPAMAX TABS 50 MG QL(8 ea daily) oxcarbazepine tabs 1 7 150 mg (topiramate) QL(8 ea daily) topiramate cpsp 15 mg, oxcarbazepine tabs 1 1 300 mg 25 mg QL(4 ea daily) topiramate cs24 100 PA; ST;QL(1 oxcarbazepine tabs 1 1 600 mg mg, 150 mg, 200 mg ea daily) PA; ST;QL(2 OXTELLAR XR TB24 150 ST topiramate cs24 25 mg, 1 MG, 300 MG 3 50 mg ea daily) (oxcarbazepine) topiramate tabs 100 mg 1 QL(4 ea daily) OXTELLAR XR TB24 600 ST; QL(4 ea 3 MG (oxcarbazepine) daily) topiramate tabs 200 mg 1 QL(2 ea daily) pregabalin caps 100 PA; ST;QL(3 mg, 150 mg, 200 mg, 1 ea daily) topiramate tabs 25 mg 1 25 mg, 50 mg, 75 mg topiramate tabs 50 mg 1 QL(8 ea daily) PA; ST;QL(2 pregabalin caps 225 1 mg, 300 mg ea daily) TRILEPTAL SUSP 300 QL(40 ml daily) MG/5ML 7 PA pregabalin soln 20 1 (oxcarbazepine) mg/ml TRILEPTAL TABS 150 MG 7 primidone tabs 1 (oxcarbazepine) TRILEPTAL TABS 300 MG QL(8 ea daily) QUDEXY XR CS24 100 PA; ST;QL(1 7 MG, 150 MG, 200 MG 7 ea daily) (oxcarbazepine) (topiramate) TRILEPTAL TABS 600 MG QL(4 ea daily) 7 QUDEXY XR CS24 25 MG, PA; ST;QL(2 (oxcarbazepine) 7 50 MG (topiramate) ea daily) TROKENDI XR CP24 100 PA 3 MG, 50 MG (topiramate) rufinamide susp 1 TROKENDI XR CP24 200 PA; QL(2 ea TEGRETOL SUSP 3 daily) 7 MG (topiramate) (carbamazepine) TROKENDI XR CP24 25 PA; ST TEGRETOL TABS 3 7 MG (topiramate) (carbamazepine) VIMPAT SOLN 10 MG/ML QL(40 ml daily) TEGRETOL-XR TB12 100 2 7 (lacosamide) MG (carbamazepine)

19 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VIMPAT TABS 100 MG, DILANTIN INFATABS 7 150 MG, 200 MG, 50 MG 2 CHEW (phenytoin) (lacosamide) DILANTIN-125 SUSP ZONEGRAN CAPS 100 QL(6 ea daily) 7 7 (phenytoin) MG (zonisamide) PEGANONE TABS ZONEGRAN CAPS 25 MG 3 7 (ethotoin) (zonisamide) phenytoin chew 1 QL(6 ea daily) zonisamide caps 100 1 mg phenytoin sodium 1 extended caps zonisamide caps 25 1 mg, 50 mg phenytoin susp 1 Carbamates Succinimides felbamate susp 1 CELONTIN CAPS 3 (methsuximide) felbamate tabs 1 ethosuximide caps 1 FELBATOL SUSP 600 7 MG/5ML (felbamate) ethosuximide soln 1 GABA Modulators ZARONTIN CAPS 7 (Vigabatrin) VIGADRONE 4 QL(6 ea daily) (ethosuximide) PACK ZARONTIN SOLN GABITRIL TABS 7 7 (ethosuximide) (tiagabine hcl) SABRIL PACK QL(6 ea daily) Valproic Acid 7 DEPAKENE CAPS 250 MG (vigabatrin) 7 (valproic acid) SABRIL TABS 7 DEPAKOTE ER TB24 (vigabatrin) 7 (divalproex sodium) tiagabine hcl tabs 1 DEPAKOTE SPRINKLES CSDR (divalproex 7 vigabatrin pack 4 QL(6 ea daily) sodium) DEPAKOTE TBEC vigabatrin tabs 4 7 (divalproex sodium) Hydantoins divalproex sodium csdr 1 (Phenytoin) PHENYTOIN 1 INFATABS CHEW divalproex sodium tb24 1 DILANTIN CAPS 100 MG (phenytoin sodium 7 divalproex sodium tbec 1 extended) DILANTIN CAPS 30 MG valproate sodium soln 1 (phenytoin sodium 3 extended) valproic acid caps or 1

20 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ANTIDEPRESSANTS - Drugs to Treat escitalopram oxalate 1 Depression soln 5 mg/5ml QL(1 ea daily) Alpha-2 Receptor Antagonists (Tetracyclics) escitalopram oxalate 1 tabs 10 mg, 20 mg mirtazapine tabs 1 QL(2 ea daily) escitalopram oxalate 1 mirtazapine tbdp 1 tabs 5 mg fluoxetine hcl caps 10 Antidepressants - Misc. 1 mg, 20 mg bupropion hcl tabs 100 1 QL(1 ea daily) mg, 75 mg fluoxetine hcl caps 40 1 mg bupropion hcl tb12 100 1 mg, 150 mg, 200 mg fluoxetine hcl cpdr 90 1 mg bupropion hcl tb24 150 QL(1 ea daily) 1 QL(15 ml daily) mg, 300 mg fluoxetine hcl soln 20 1 mg/5ml ST; QL(1 ea bupropion hcl tb24 450 1 mg daily) fluoxetine hcl tabs 10 1 mg FORFIVO XL TB24 ST; QL(1 ea 7 QL(1 ea daily) (bupropion hcl) daily) fluoxetine hcl tabs 20 1 mg, 60 mg maprotiline hcl tabs 1 QL(3 ea daily) fluvoxamine maleate 2 Monoamine Oxidase Inhibitors (MAOIs) cp24 100 mg EMSAM PT24 QL(1 ea daily) fluvoxamine maleate 3 2 (selegiline) cp24 150 mg MARPLAN TABS QL(3 ea daily) 3 fluvoxamine maleate 1 (isocarboxazid) tabs 100 mg phenelzine sulfate tabs 1 fluvoxamine maleate 1 tabs 25 mg, 50 mg tranylcypromine sulfate 2 tabs paroxetine hcl tabs 1 N-Methyl-D-aspartic acid (NMDA) Receptor paroxetine hcl tb24 1 SPRAVATO 56MG DOSE PA; Refill 82% 4 PAXIL SUSP 10 MG/5ML SOPK (esketamine hcl) 3 (paroxetine hcl) SPRAVATO 84MG DOSE PA; Refill 82% 4 SOPK (esketamine hcl) sertraline hcl conc 20 1 mg/ml Selective Serotonin Reuptake Inhibitors (SSRIs) QL(2 ea daily) sertraline hcl tabs 100 1 citalopram QL(20 ml daily) mg, 25 mg, 50 mg hydrobromide soln 10 1 mg/5ml Serotonin Modulators citalopram QL(1 ea daily) nefazodone hcl tabs 1 hydrobromide tabs 10 1 mg, 20 mg, 40 mg trazodone hcl tabs 1

21 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TRINTELLIX TABS ST; QL(1 ea 3 doxepin hcl conc 1 (vortioxetine hbr) daily) VIIBRYD STARTER PACK PA imipramine hcl tabs 10 3 1 KIT (vilazodone hcl) mg, 25 mg VIIBRYD TABS 10 MG, 40 ST imipramine hcl tabs 50 QL(4 ea daily) 3 1 MG (vilazodone hcl) mg VIIBRYD TABS 20 MG ST; QL(2 ea imipramine pamoate 3 1 (vilazodone hcl) daily) caps Serotonin-Norepinephrine Reuptake Inhibitors nortriptyline hcl caps 1 QL(1 ea daily) desvenlafaxine 1 succinate tb24 nortriptyline hcl soln 1 QL(2 ea daily) duloxetine hcl cpep 20 1 protriptyline hcl tabs 1 mg, 30 mg, 60 mg FETZIMA CP24 120 MG, ST; QL(1 ea trimipramine maleate 1 40 MG, 80 MG 3 daily) caps (levomilnacipran hcl) ANTIDIABETICS - Drugs to Regulate Blood FETZIMA CP24 20 MG ST; QL(2 ea Sugar 3 (levomilnacipran hcl) daily) Alpha-Glucosidase Inhibitors FETZIMA TITRATION ST acarbose tabs or 100 1 PACK C4PK 3 mg, 25 mg, 50 mg (levomilnacipran hcl) venlafaxine hcl cp24 QL(2 ea daily) miglitol tabs 1 150 mg, 37.5 mg, 75 1 Antidiabetic - Amylin Analogs mg SYMLINPEN 120 SOPN PA 2 venlafaxine hcl tabs (pramlintide acetate) 100 mg, 25 mg, 37.5 1 SYMLINPEN 60 SOPN PA 2 mg, 50 mg, 75 mg (pramlintide acetate) QL(1 ea daily) venlafaxine hcl tb24 Antidiabetic Combinations 150 mg, 37.5 mg, 75 1 mg ACTOPLUS MET XR TB24 (pioglitazone hcl- 3 venlafaxine hcl tb24 1 metformin hcl) 225 mg glipizide-metformin hcl 1 Tricyclic Agents tabs amitriptyline hcl tabs 1 glyburide-metformin 1 tabs amoxapine tabs 1 GLYXAMBI TABS (empagliflozin- 2 clomipramine hcl caps 2 linagliptin) desipramine hcl tabs 1 JANUMET TABS 1000 MG-50 MG (sitagliptin- 2 doxepin hcl caps 1 metformin hcl)

22 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits JANUMET TABS 50 MG- QL(2 ea daily) Only Covered 500 MG (sitagliptin- 2 Ca On/Off metformin hcl) Individual Exchange JANUMET XR TB24 100 QL(1 ea daily) metformin hcl tabs 5 Plans Covered MG-1000 MG (sitagliptin- 2 1000 mg, 500 mg, 850 at PV Tier- metformin hcl) mg Student Plans JANUMET XR TB24 1000 QL(2 ea daily) and all others MG-50 MG, 50 MG-500 at Tier 1 for MG (sitagliptin- 2 generic;PV metformin hcl) metformin hcl tb24 500 1 mg, 750 mg pioglitazone hcl- 1 glimepiride tabs METFORMIN HYDROCHLORIDE SOLN 1 pioglitazone hcl- 1 (metformin hcl) metformin hcl tabs Diabetic Other repaglinide-metformin 1 BAQSIMI ONE PACK PA; QL(2 ea hcl tabs 4 per 30 days SYNJARDY TABS POWD (glucagon) retail) (empagliflozin- 2 BAQSIMI TWO PACK PA; QL(2 ea metformin hcl) 4 per 30 days POWD (glucagon) SYNJARDY XR TB24 retail) (empagliflozin- 2 diazoxide susp 1 metformin hcl) GLUCAGEN HYPOKIT PA XIGDUO XR TB24 10 MG- QL(1 ea daily) 1000 MG, 10 MG-500 MG SOLR (glucagon hcl 4 (dapagliflozin- 2 (rdna)) metformin hcl) GLUCAGON QL(1 ea per fill EMERGENCY KIT KIT 2 retail,2 ea per XIGDUO XR TB24 1000 QL(2 ea daily) 30 days retail) MG-2.5 MG, 1000 MG-5 (glucagon (rdna)) MG, 5 MG-500 MG 2 GVOKE PFS SOSY PA; QL(0..4 ml 4 per 30 days (dapagliflozin- (glucagon) metformin hcl) retail) Biguanides Dipeptidyl Peptidase-4 (DPP-4) Inhibitors Only Covered JANUVIA TABS 100 MG, QL(1 ea daily) Ca On/Off 50 MG (sitagliptin 2 Individual phosphate) Exchange JANUVIA TABS 25 MG GLUCOPHAGE TABS 2 7 Plans Covered (sitagliptin phosphate) (metformin hcl) at PV Tier- Student Plans Incretin Mimetic Agents (GLP-1 Receptor and all others PA; Not at Tier 1 for OZEMPIC SOPN 2 available generic;PV (semaglutide) through Mail Order metformin hcl soln 500 1 mg/5ml

23 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; Not HUMALOG MIX 75/25 Limit 45mls per TANZEUM PEN 4 available KWIKPEN SUPN (insulin month;QL(1.5 (albiglutide) through mail lispro protamine & 2 ml daily) order lispro) PA; Not TRULICITY SOPN available HUMALOG MIX 75/25 Limit 40mls per 2 month;QL(1.34 (dulaglutide) through mail SUSP (insulin lispro 2 order protamine & lispro) ml daily) PA; Not HUMALOG SOCT (insulin Limit 45mls per VICTOZA SOPN available 2 month;QL(1.5 2 lispro) (liraglutide) through mail ml daily) order HUMALOG SOLN (insulin Limit 45mls per Insulin Sensitizing Agents 2 month;QL(1.5 lispro) ml daily) AVANDIA TABS 2 (rosiglitazone maleate) HUMULIN 70/30 KWIKPEN QL(1.5 ml SUPN (insulin nph daily) 2 pioglitazone hcl tabs 15 1 isophane & reg mg (human)) QL(1 ea daily) pioglitazone hcl tabs 30 1 HUMULIN 70/30 SUSP Limit 40mls per mg, 45 mg (insulin nph isophane & 2 month;QL(1.34 Insulin reg (human)) ml daily) AFREZZA POWD ( QL(6 ea daily) HUMULIN N KWIKPEN Limit 45mls per insulin 3 regular (human)) SUPN (insulin nph 2 month;QL(1.5 ml daily) AFREZZA POWD ( (human) (isophane)) insulin 3 regular (human)) HUMULIN N SUSP Limit 45mls per 2 month;QL(1.5 AFREZZA POWD 12 UNIT, QL(3 ea daily) (insulin nph (human) (isophane)) ml daily) 4 UNIT, 8 UNIT (insulin 3 regular (human)) HUMULIN R SOLN Limit 40mls per (insulin regular 2 month;QL(1.34 HUMALOG JUNIOR Limit 45mls per (human)) ml daily) KWIKPEN SOPN (insulin 2 month;QL(1.5 lispro) ml daily) HUMULIN R SOLN Limit 45mls per (insulin regular 2 month;QL(1.5 HUMALOG KWIKPEN Limit 45mls per (human)) ml daily) SOPN 100 UNIT/ML 2 month;QL(1.5 (insulin lispro) ml daily) HUMULIN R U-500 QL(1.34 ml daily) HUMALOG KWIKPEN Limit 24mls per (CONCENTRATED) 2 SOPN 200 UNIT/ML month;QL(0.8 SOLN (insulin regular 2 (human)) (insulin lispro) ml daily) HUMULIN R U-500 Limit 40mls per HUMALOG MIX 50/50 Limit 45mls per month;QL(1.34 month;QL(1.5 KWIKPEN SOPN (insulin 2 KWIKPEN SUPN (insulin regular (human)) ml daily) lispro protamine & 2 ml daily) INSULIN LISPRO Limit 45mls per lispro) PROTAMINE/INSULIN month;QL(1.5 HUMALOG MIX 50/50 Limit 45mls per LISPRO KWIKPEN SUPN 2 ml daily) SUSP (insulin lispro 2 month;QL(1.5 (insulin lispro protamine protamine & lispro) ml daily) & lispro)

24 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LANTUS SOLN (insulin Limit 45mls per chlorpropamide tabs 1 2 month;QL(1.5 glargine) ml daily) glimepiride tabs 1 LANTUS SOLOSTAR Limit 45mls per 2 month;QL(1.5 glipizide tabs 1 SOPN (insulin glargine) ml daily) Limit 45mls per glipizide tb24 1 LEVEMIR FLEXTOUCH 2 month;QL(1.5 SOPN (insulin detemir) ml daily,135 ml glyburide micronized 1 per fill mail) tabs Limit 45mls per glyburide tabs 1.25 mg, LEVEMIR SOLN ( 1 insulin 2 month;QL(1.5 2.5 mg, 5 mg detemir) ml daily,135 ml per fill mail) tolbutamide tabs 1 Limit 2 pens TOUJEO MAX SOLOSTAR ANTIDIARRHEAL/PROBIOTIC AGENTS - Drugs 2 per SOPN (insulin glargine) month;QL(0.2 to Treat Diarrhea ml daily) Antidiarrheal - Chloride Channel Antagonists Limit 3 pens MYTESI TBEC PA; QL(2 ea TOUJEO SOLOSTAR 3 2 per (crofelemer) daily) SOPN (insulin glargine) month;QL(0.15 ml daily) Antiperistaltic Agents TRESIBA FLEXTOUCH Limit 45mls per (Loperamide Hcl) ANTI- RX/OTC SOPN 100 UNIT/ML 2 month;QL(1.5 DIARRHEAL, CVS ANTI- (insulin degludec) ml daily) DIARRHEAL, EQ ANTI- DIARRHEAL, GNP ANTI- Limited to 27 TRESIBA FLEXTOUCH DIARRHEAL, HM ANTI- mls /month DIARRHEAL, HM 1 SOPN 200 UNIT/ML 2 without prior LOPERAMIDE HCL, QC (insulin degludec) authorization;Q ANTI-DIARRHEAL, RA L(0.9 ml daily) ANTI-DIARRHEAL, SM TRESIBA SOLN ( insulin 2 ANTI-DIARRHEAL, TGT degludec) LOPERAMIDE HCL CAPS Meglitinide Analogues diphenoxylate w/ 1 atropine liqd nateglinide tabs 1 diphenoxylate w/ 1 repaglinide tabs 1 atropine tabs RX/OTC Sodium-Glucose Co-Transporter 2 (SGLT2) loperamide hcl caps 1 FARXIGA TABS QL(1 ea daily) opium tincture tinc 2 QL(2.4 ml (dapagliflozin 2 daily) propanediol) paregoric tinc 1 JARDIANCE TABS QL(1 ea daily) 2 (empagliflozin) ANTIDOTES AND SPECIFIC ANTAGONISTS Sulfonylureas Antidotes - Chelating Agents (Glipizide) GLIPIZIDE XL 1 TB24

25 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CHEMET CAPS NARCAN LIQD QL(4 ea per 30 3 2 (succimer) (naloxone hcl) days retail) PA; Must use ANTIEMETICS - Drugs to Treat Nausea and deferasirox pack 180 AcariaHealth Vomiting 4 Specialty Rx at mg, 360 mg, 90 mg 1-844-538- 5-HT3 Receptor Antagonists 4661 ;LA PA; ST; Limit 2 ANZEMET TABS deferasirox tabs 180 PA 3 per 4 (dolasetron mesylate) month;QL(0.07 mg, 360 mg, 90 mg ea daily) PA deferasirox tbso 125 4 PA; ST; Limit 2 mg, 250 mg, 500 mg granisetron hcl tabs 1 tablets per PA day;QL(2 ea deferiprone tabs 4 daily) EXJADE TBSO PA ondansetron hcl soln 4 Limit 50mls per 7 1 month;QL(1.67 (deferasirox) mg/5ml FERRIPROX SOLN 100 PA ml daily) 4 MG/ML (deferiprone) ondansetron hcl tabs 4 Limit 20 per 1 month;QL(0.67 FERRIPROX TABS 500 PA mg, 8 mg 7 ea daily) MG (deferiprone) Limit 20 per PA; Must use ondansetron tbdp 1 month;QL(0.67 JADENU SPRINKLE PACK AcariaHealth ea daily) 7 Specialty Rx at (deferasirox) PA; ST; Limit 1 1-844-538- SANCUSO PTCH 3 patch per 4661 ;LA (granisetron) month;QL(0.04 JADENU TABS PA 7 ea daily) (deferasirox) ZUPLENZ FILM Limit 20 per Antidotes and Specific Antagonists 3 month;QL(0.67 (ondansetron) ea daily) ANDEXXA SOLR PA (coagulation factor xa Antiemetics - Anticholinergic 4 recomb inact-zhzo scopolamine pt72 1 (andexanet alfa)) VISTOGARD PACK trimethobenzamide hcl 1 (uridine triacetate 4 caps (emergency treatment)) Antiemetics - Miscellaneous Opioid Antagonists AKYNZEO CAPS QL(2 ea per 28 ( days retail) EVZIO SOAJ (naloxone PA netupitant- 3 4 ) hcl) palonosetron QL(4 ea daily) PA doxylamine-pyridoxine 1 naloxone hcl soaj 2 4 mg/0.4ml tbec PA dronabinol caps 10 mg, 2 naloxone hcl sosy 2 1 mg/2ml 5 mg 2 PA; ST naltrexone hcl tabs 1 dronabinol caps 2.5 mg

26 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SYNDROS SOLN PA 4 fluconazole tabs 1 (dronabinol) PA; ST Substance P/Neurokinin 1 (NK1) Receptor itraconazole caps 100 1 mg Limit 3 per PA aprepitant caps 1 month;QL(0.1 itraconazole soln 10 1 ea daily) mg/ml aprepitant caps 125 Limit 1 per 1 1 year;QL(0.04 ketoconazole tabs mg, 80 mg ea daily) NOXAFIL SUSP 40 MG/ML 3 Limit 2 per (posaconazole) aprepitant caps 40 mg 1 month;QL(0.07 ea daily) posaconazole tbec 1 EMEND SUSR 125 QL(1 ea per 30 TOLSURA CAPS PA 3 4 MG/5ML (aprepitant) days retail) (itraconazole) VARUBI TBPK QL(4 ea per fill 3 voriconazole susr 40 1 (rolapitant hcl) retail) mg/ml QL(2 ea daily) ANTIFUNGALS - Drugs to Treat Fungal Infections voriconazole tabs 200 1 mg, 50 mg Antifungals ANTIHISTAMINES - Drugs to Treat Allergies (Nystatin) BIO-STATIN 1 POWD Antihistamines - Alkylamines BIO-STATIN CAPS 1000000 UNIT, 500000 (Dexchlorpheniramine 1 3 Maleate) RYCLORA SOLN UNIT (nystatin) dexchlorpheniramine 1 flucytosine caps 1 maleate soln Antihistamines - Ethanolamines griseofulvin microsize 1 susp carbinoxamine maleate 1 soln 4 mg/5ml griseofulvin microsize 1 tabs carbinoxamine maleate 1 tabs 4 mg griseofulvin 1 ultramicrosize tabs CARBINOXAMINE MALEATE TABS 6 MG 1 nystatin tabs (carbinoxamine 3 QL(1 ea maleate) terbinafine hcl tabs 1 daily,90 ea per clemastine fumarate 365 days retail) 1 tabs Imidazole-Related Antifungals PA diphenhydramine hcl 4 CRESEMBA CAPS Not available soln (isavuconazonium 3 through mail RYVENT TABS sulfate) order (carbinoxamine 3 fluconazole susr 1 maleate) Antihistamines - Non-Sedating

27 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Levocetirizine QL(1 ea daily); QL(3 ea daily) promethazine hcl tabs 1 Dihydrochloride) ALLERGY 1 RX/OTC or 50 mg RELIEF 24HR, CVS ALLERGY RELIEF TABS Antihistamines - Piperidines PA; ST;QL(1 desloratadine tabs 5 1 cyproheptadine hcl syrp 1 mg ea daily) PA; ST cyproheptadine hcl tabs 1 desloratadine tbdp 2.5 1 mg ANTIHYPERLIPIDEMICS - Drugs to Treat High PA Cholesterol desloratadine tbdp 5 1 mg Antihyperlipidemics - Combinations levocetirizine PA; RX/OTC QL(1 ea daily) ezetimibe-simvastatin 1 dihydrochloride soln 1 tabs 2.5 mg/5ml Antihyperlipidemics - Misc. QL(1 ea daily); levocetirizine PA dihydrochloride tabs 5 1 RX/OTC icosapent ethyl caps 1 mg QL(4 ea daily) omega-3-acid ethyl 1 Antihistamines - Phenothiazines esters caps (Promethazine Hcl) VASCEPA CAPS 0.5 GM PA; ST 2 3 PHENADOZ SUPP (icosapent ethyl) (Promethazine Hcl) VASCEPA CAPS 1 GM PA 3 PROMETHEGAN SUPP 2 (icosapent ethyl) 12.5 MG, 25 MG (Promethazine Hcl) QL(3 ea daily) Bile Acid Sequestrants PROMETHEGAN SUPP 50 2 (Cholestyramine Light) 1 MG PREVALITE PACK PHENERGAN SOLN PA (Cholestyramine Light) 7 1 (promethazine hcl) PREVALITE POWD PA cholestyramine light promethazine hcl soln ij 4 1 25 mg/ml, 50 mg/ml pack cholestyramine light promethazine hcl soln 1 1 or 6.25 mg/5ml powd cholestyramine pack or promethazine hcl supp 2 1 re 12.5 mg, 25 mg 4 gm QL(3 ea daily) cholestyramine powd or promethazine hcl supp 2 1 re 50 mg 4 gm/dose colesevelam hcl pack QL(1 ea daily) promethazine hcl syrp 1 1 or 6.25 mg/5ml 3.75 gm colesevelam hcl tabs QL(7 ea daily) promethazine hcl tabs 1 1 or 12.5 mg 625 mg QL(6 ea daily) 1 promethazine hcl tabs 1 colestipol hcl gran 5 gm or 25 mg colestipol hcl pack 5 2 gm 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic is Available AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

28 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits colestipol hcl tabs 1 gm 1 fluvastatin sodium caps 1 QL(1 ea daily) Fibric Acid Derivatives fluvastatin sodium tb24 1 QL(1 ea daily) ANTARA CAPS 3 LIVALO TABS ST; QL(1 ea (fenofibrate micronized) 3 (pitavastatin calcium) daily) QL(1 ea daily) choline fenofibrate cpdr 1 $0 copay for 135 mg 1 Generic only, lovastatin tabs age 40 to choline fenofibrate cpdr 1 45 mg 75;PV fenofibrate caps 150 $0 copay for 1 Generic only, mg, 50 mg pravastatin sodium tabs 1 age 40 to QL(1 ea daily) 75;QL(1 ea fenofibrate micronized 1 caps 130 mg, 200 mg daily); PV QL(1 ea daily) fenofibrate micronized rosuvastatin calcium 1 caps 134 mg, 43 mg, 1 tabs 67 mg simvastatin tabs 10 mg, QL(1 ea daily) QL(1 ea daily) 20 mg, 40 mg, 5 mg, 80 1 fenofibrate tabs 145 1 mg, 160 mg mg FENOFIBRATE TABS 160 QL(1 ea daily) Intestinal Cholesterol Absorption Inhibitors 2 MG (fenofibrate) ezetimibe tabs 1 fenofibrate tabs 48 mg 1 Microsomal Triglyceride Transfer Protein (MTP) fenofibrate tabs 54 mg 1 QL(2 ea daily) JUXTAPID CAPS 10 MG, PA 20 MG, 30 MG, 40 MG, 60 FENOFIBRIC ACID TABS 4 2 MG (lomitapide 105 MG (fenofibric acid) mesylate) fenofibric acid tabs 105 JUXTAPID CAPS 5 MG PA; ST 1 4 mg, 35 mg (lomitapide mesylate) FIBRICOR TABS 105 MG, 2 Nicotinic Acid Derivatives 35 MG (fenofibric acid) (Niacin FIBRICOR TABS 105 MG, 7 (Antihyperlipidemic)) 1 35 MG (fenofibric acid) NIACOR TABS gemfibrozil tabs 1 niacin (antihyperlipidemic) LIPOFEN CAPS 1 7 tbcr 1000 mg, 500 mg, (fenofibrate) 750 mg TRIGLIDE TABS QL(1 ea daily) 2 (fenofibrate) Proprotein Convertase Subtilisin/Kexin Type 9 PRALUENT SOAJ PA 4 HMG CoA Reductase Inhibitors (alirocumab) QL(1 ea daily) atorvastatin calcium 1 REPATHA PUSHTRONEX PA; ST tabs SYSTEM SOCT 4 (evolocumab)

29 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits REPATHA SOSY PA; ST EDARBI TABS 80 MG QL(1 ea daily) 4 3 (evolocumab) (azilsartan medoxomil) REPATHA SURECLICK PA; ST 4 irbesartan tabs 1 SOAJ (evolocumab) ANTIHYPERTENSIVES - Drugs to Treat High losartan potassium tabs Blood Pressure or 100 mg, 25 mg, 50 1 mg ACE Inhibitors olmesartan medoxomil 1 benazepril hcl tabs 1 tabs 20 mg, 5 mg QL(1 ea daily) captopril tabs 1 olmesartan medoxomil 1 tabs 40 mg enalapril maleate tabs 1 QL(2 ea daily) telmisartan tabs 20 mg, 1 40 mg fosinopril sodium tabs 1 telmisartan tabs 80 mg 1 QL(1 ea daily) lisinopril tabs 10 mg, 2.5 mg, 20 mg, 30 mg, 1 valsartan tabs 160 mg 1 QL(2 ea daily) 5 mg valsartan tabs 320 mg, 1 lisinopril tabs 40 mg 1 QL(2 ea daily) 40 mg, 80 mg moexipril hcl tabs 1 Antiadrenergic Antihypertensives clonidine hcl tabs 1 perindopril erbumine 1 tabs doxazosin mesylate 1 QBRELIS SOLN QL(5 ml daily) tabs 3 (lisinopril) guanfacine hcl tabs 1 quinapril hcl tabs 1 methyldopa tabs 1 ramipril caps 1 QL(2 ea daily) prazosin hcl caps 1 trandolapril tabs 1 terazosin hcl caps 1 1 Agents for Pheochromocytoma mg, 2 mg, 5 mg QL(2 ea daily) metyrosine caps 1 terazosin hcl caps 10 1 mg Not available phenoxybenzamine hcl 1 Antihypertensive Combinations caps through mail amlodipine besylate- Angiotensin II Receptor Antagonists benazepril hcl caps 10 1 ST candesartan cilexetil 1 mg-2.5 mg tabs 16 mg, 4 mg, 8 mg amlodipine besylate- QL(1 ea daily) ST; QL(1 ea candesartan cilexetil 1 benazepril hcl caps 10 tabs 32 mg daily) mg-20 mg, 10 mg-40 1 EDARBI TABS 40 MG mg, 10 mg-5 mg, 20 3 (azilsartan medoxomil) mg-5 mg, 40 mg-5 mg

30 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits amlodipine besylate- QL(1 ea daily) lisinopril & QL(2 ea daily) valsartan tabs 10 mg- 1 hydrochlorothiazide 1 160 mg tabs 20 mg-25 mg amlodipine besylate- losartan potassium & 1 valsartan tabs 10 mg- 1 hydrochlorothiazide 320 mg, 160 mg-5 mg, tabs 320 mg-5 mg methyldopa & amlodipine-valsartan- hydrochlorothiazide 1 hydrochlorothiazide 1 tabs tabs metoprolol & 1 atenolol & 1 hydrochlorothiazide chlorthalidone tabs tabs benazepril & olmesartan medoxomil- ST 1 hydrochlorothiazide amlodipine- 1 tabs hydrochlorothiazide bisoprolol & tabs hydrochlorothiazide 1 olmesartan medoxomil- tabs hydrochlorothiazide 1 candesartan cilexetil- tabs 12.5 mg-20 mg hydrochlorothiazide 1 olmesartan medoxomil- QL(1 ea daily) tabs hydrochlorothiazide 1 captopril & tabs 12.5 mg-40 mg, 25 hydrochlorothiazide 1 mg-40 mg tabs propranolol & EDARBYCLOR TABS QL(1 ea daily) hydrochlorothiazide 1 (azilsartan medoxomil- 3 tabs chlorthalidone) quinapril- enalapril maleate & hydrochlorothiazide 1 hydrochlorothiazide 1 tabs 10 mg-12.5 mg, tabs 12.5 mg-20 mg fosinopril sodium & quinapril- QL(1 ea daily) hydrochlorothiazide 1 hydrochlorothiazide 1 tabs tabs 20 mg-25 mg irbesartan- TEKTURNA HCT TABS ST hydrochlorothiazide 1 (aliskiren- 3 tabs hydrochlorothiazide) lisinopril & telmisartan-amlodipine 1 tabs hydrochlorothiazide 1 tabs 10 mg-12.5 mg, telmisartan- 12.5 mg-20 mg hydrochlorothiazide 1 tabs

31 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits trandolapril-verapamil 1 primaquine phosphate 1 hcl tbcr tabs valsartan- pyrimethamine tabs 1 PA hydrochlorothiazide PA; QL(2 ea tabs 12.5 mg-160 mg, 1 quinine sulfate caps 1 12.5 mg-320 mg, 12.5 daily) mg-80 mg, 25 mg-320 ANTIMYASTHENIC/CHOLINERGIC AGENTS mg Antimyasthenic/Cholinergic Agents valsartan- QL(1 ea daily) FIRDAPSE TABS PA; ST hydrochlorothiazide 1 (amifampridine 4 tabs 160 mg-25 mg phosphate) Antihypertensives - Misc. GUANIDINE HCL TABS VECAMYL TABS 2 3 (guanidine hcl) (mecamylamine hcl) MESTINON SOLN 60 PA Selective Aldosterone Receptor Antagonists MG/5ML (pyridostigmine 7 bromide) eplerenone tabs 1 PA pyridostigmine bromide 4 Vasodilators soln 60 mg/5ml hydralazine hcl tabs 1 pyridostigmine bromide 1 tabs 60 mg minoxidil tabs 1 pyridostigmine bromide 1 ANTIMALARIALS - Drugs to Treat Malaria tbcr 180 mg (Parasitic Infections) RUZURGI TABS PA; QL(10 ea 4 daily) Antimalarial Combinations (amifampridine) ANTIMYCOBACTERIAL AGENTS - Drugs to atovaquone-proguanil 1 hcl tabs Treat Tuberculosis (Bacterial Infections) COARTEM TABS Limit 24 doses Anti TB Combinations per RIFAMATE CAPS (artemether- 2 2 month;QL(0.8 (isoniazid & rifampin) lumefantrine) ea daily) RIFATER TABS Antimalarials (isoniazid-rifampin w/ 3 ) chloroquine phosphate 1 pyrazinamide tabs Antimycobacterial Agents hydroxychloroquine 1 sulfate tabs cycloserine caps 1 KRINTAFEL TABS QL(2 ea per 30 2 ethambutol hcl tabs 1 (tafenoquine succinate) days retail) QL(6 ea per fill isoniazid syrp 1 mefloquine hcl tabs 1 retail,6 ea per fill mail) isoniazid tabs 1

32 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PASER PACK PA; LA 3 methotrexate sodium (aminosalicylic acid) soln ij 1 gm/40ml, 250 4 PRIFTIN TABS mg/10ml, 50 mg/2ml 3 (rifapentine) PA methotrexate sodium 4 pyrazinamide tabs 1 soln ij 25 mg/ml PA; LA methotrexate sodium 4 rifabutin caps 1 solr ij 1 gm AC rifampin caps 1 methotrexate sodium 1 tabs or 2.5 mg TRECATOR TABS ONUREG TABS PA; AC 2 4 (ethionamide) (azacitidine) ANTINEOPLASTICS AND ADJUNCTIVE PURIXAN SUSP AL(Up to 13 yrs 3 THERAPIES - Drugs to Treat Cancer (mercaptopurine) old ); AC Alkylating Agents TABLOID TABS AC 2 ALKERAN SOLR IV 50 MG PA; LA (thioguanine) 7 (melphalan hcl) TREXALL TABS AC 3 busulfan soln 4 PA (methotrexate sodium) XATMEP SOLN PA; AC BUSULFEX SOLN PA 4 7 (methotrexate) (busulfan) Antineoplastic - BCL-2 Inhibitors cyclophosphamide AC 1 VENCLEXTA STARTING PA; AC caps PACK TBPK 4 GLEOSTINE CAPS AC 2 (venetoclax) (lomustine) VENCLEXTA TABS 10 MG PA; QL(2 ea LEUKERAN TABS AC 4 2 (venetoclax) daily); AC (chlorambucil) VENCLEXTA TABS 100 PA; QL(4 ea 4 melphalan hcl solr 4 PA; LA MG (venetoclax) daily); AC VENCLEXTA TABS 50 MG PA; AC AC 4 melphalan tabs 1 (venetoclax) MYLERAN TABS AC 2 Antineoplastic - Hedgehog Pathway Inhibitors (busulfan) DAURISMO TABS PA; AC 4 temozolomide caps 1 AC (glasdegib maleate) PA; Must use Antimetabolites ERIVEDGE CAPS AcariaHealth AC 4 Specialty Rx at capecitabine tabs 1 (vismodegib) 1-844-538- fludarabine phosphate PA 4661;LA; AC 4 ODOMZO CAPS PA; Refill solr 4 (sonidegib phosphate) 82%;AC mercaptopurine tabs 1 AC Antineoplastic - Hormonal and Related Agents

33 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; Must use toremifene citrate tabs 1 AC abiraterone acetate AcariaHealth 4 Specialty Rx at PA; New tabs 1-844-538- commercial 4661;LA; AC XTANDI CAPS 4 members to be (enzalutamide) referred to 5 QL(1 ea daily); anastrozole tabs or PV; AC AcariaHealth;A QL(1 ea daily); C bicalutamide tabs 1 YONSA TABS PA; AC AC 4 ELIGARD KIT ( PA (abiraterone acetate) leuprolide 3 acetate (3 month)) PA; Must use AcariaHealth ELIGARD KIT ( PA ZYTIGA TABS leuprolide 3 7 Specialty Rx at acetate (4 month)) (abiraterone acetate) 1-844-538- ELIGARD KIT ( PA 4661;LA; AC leuprolide 3 acetate (6 month)) Antineoplastic - Immunomodulators ELIGARD KIT ( PA PA; Must use leuprolide 3 acetate) POMALYST CAPS Exactus 4 Specialty Rx 1- EMCYT CAPS AC (pomalidomide) 866-458- (estramustine 2 9246;LA; AC phosphate sodium) Antineoplastic - XPO1 Inhibitors ERLEADA TABS PA; AC 4 XPOVIO 100 MG ONCE PA (apalutamide) WEEKLY TBPK 4 exemestane tabs 5 PV; AC (selinexor) XPOVIO 60 MG ONCE PA AC flutamide caps 1 WEEKLY TBPK 4 AC (selinexor) letrozole tabs 1 XPOVIO 80 MG ONCE PA WEEKLY TBPK 4 1 PA leuprolide acetate kit (selinexor) LYSODREN TABS AC 2 XPOVIO 80 MG TWICE PA (mitotane) WEEKLY TBPK 4 (selinexor) megestrol acetate susp 1 AC Antineoplastic Antibiotics megestrol acetate tabs 1 AC mitoxantrone hcl conc 2 PA AC nilutamide tabs 1 Antineoplastic Combinations NUBEQA TABS PA INQOVI TABS PA 4 (darolutamide) (decitabine- 4 SOLTAMOX SOLN PV; AC cedazuridine) 5 (tamoxifen citrate) KISQALI FEMARA 200 PA; AC DOSE TBPK (ribociclib 4 tamoxifen citrate tabs 5 PV; AC succinate-letrozole)

34 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits KISQALI FEMARA 400 PA; AC CABOMETYX TABS PA; AC 4 DOSE TBPK (ribociclib 4 (cabozantinib s-malate) succinate-letrozole) CALQUENCE CAPS PA; AC 4 KISQALI FEMARA 600 PA; AC (acalabrutinib) DOSE TBPK (ribociclib 4 CAPRELSA TABS PA; AC 4 succinate-letrozole) (vandetanib) LONSURF TABS PA; AC COMETRIQ KIT PA; AC 4 4 (trifluridine-tipiracil) (cabozantinib s-malate) COPIKTRA CAPS PA; AC Antineoplastic Enzyme Inhibitors 4 PA; Must use (duvelisib) AcariaHealth COTELLIC TABS PA; AC AFINITOR DISPERZ TBSO 4 4 Specialty Rx at (cobimetinib fumarate) (everolimus) 1-844-538- 4661;LA; AC PA; Must use erlotinib hcl tabs 100 AcariaHealth PA; Must use 4 Specialty Rx at AFINITOR TABS 10 MG AcariaHealth mg, 150 mg, 25 mg 1-844-538- 4 Specialty Rx at 4661;LA; AC (everolimus) 1-844-538- 4661;LA; AC PA; Must use AcariaHealth PA; Must use everolimus tabs 4 Specialty Rx at AFINITOR TABS 2.5 MG, 5 AcariaHealth 1-844-538- 7 Specialty Rx at 4661;LA; AC MG, 7.5 MG (everolimus) 1-844-538- 4661;LA; AC PA; Must use FARYDAK CAPS Caremark SP ALECENSA CAPS PA; AC 4 4 (panobinostat lactate) pharmacy;LA; (alectinib hcl) AC ALUNBRIG TABS PA; AC PA; Must use 4 GILOTRIF TABS ( (brigatinib) afatinib 4 Accredo SP ALUNBRIG TBPK PA; AC dimaleate) pharmacy;LA; 4 AC (brigatinib) PA; Must use AYVAKIT TABS PA; QL(1 ea IBRANCE CAPS 100 MG, 4 125 MG, 75 MG 4 AcariaHlth Sp (avapritinib) daily); SP; AC Rx 1-844-538- BALVERSA TABS PA; AC (palbociclib) 4661;LA; AC 4 (erdafitinib) IBRANCE TABS 100 MG, PA; AC PA; Must use 125 MG, 75 MG 4 BOSULIF TABS 100 MG, AcariaHealth (palbociclib) 4 Specialty Rx at ICLUSIG TABS 15 MG, 45 PA; AC 500 MG (bosutinib) 4 1-844-538- MG (ponatinib hcl) 4661;LA; AC IDHIFA TABS PA; AC BOSULIF TABS 400 MG PA; AC 4 4 (enasidenib mesylate) (bosutinib) PA; AC BRAFTOVI CAPS PA; AC imatinib mesylate tabs 1 4 (encorafenib) IMBRUVICA CAPS 140 PA; AC BRUKINSA CAPS PA; AC 4 4 MG, 70 MG (ibrutinib) (zanubrutinib) 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic is Available AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

35 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits IMBRUVICA TABS 140 PA; QL(1 ea LYNPARZA TABS PA; Refer to MG, 280 MG, 420 MG, 560 daily); AC 4 Accredo SP 4 (olaparib) MG (ibrutinib) Rx;AC PA; Must use MEKINIST TABS PA; AC AcariaHealth (trametinib dimethyl 4 INLYTA TABS (axitinib) 4 Specialty Rx at sulfoxide) 1-844-538- MEKTOVI TABS PA; AC 4661;LA; AC 4 (binimetinib) INREBIC CAPS PA; AC 4 NERLYNX TABS PA; AC (fedratinib hcl) 4 (neratinib maleate) AC IRESSA TABS (gefitinib) 4 NEXAVAR TABS PA; LA; AC 4 PA (sorafenib tosylate) ISTODAX (OVERFILL) 4 SOLR (romidepsin) PA; Limited to NINLARO CAPS JAKAFI TABS (ruxolitinib PA; AC 4 3 capsules per 4 (ixazomib citrate) month;;QL(0.1 phosphate) ea daily); AC KISQALI TBPK (ribociclib PA; AC PEMAZYRE TABS PA; QL(1 ea 4 4 succinate) (pemigatinib) daily); AC PA; AC PIQRAY 200MG DAILY PA; AC lapatinib ditosylate tabs 4 4 DOSE TBPK (alpelisib) LENVIMA 10 MG DAILY PA; AC PIQRAY 250MG DAILY PA; AC DOSE CPPK (lenvatinib 4 4 DOSE TBPK (alpelisib) mesylate) PIQRAY 300MG DAILY PA; AC LENVIMA 14 MG DAILY PA; AC 4 DOSE TBPK (alpelisib) DOSE CPPK (lenvatinib 4 QINLOCK TABS PA; AC mesylate) 4 (ripretinib) LENVIMA 18 MG DAILY PA; AC RETEVMO CAPS PA; AC DOSE CPPK (lenvatinib 4 4 mesylate) (selpercatinib) ROMIDEPSIN SOLR PA LENVIMA 20 MG DAILY PA; AC 4 DOSE CPPK (lenvatinib 4 (romidepsin) ROZLYTREK CAPS PA; AC mesylate) 4 LENVIMA 24 MG DAILY PA; AC (entrectinib) RUBRACA TABS PA; AC DOSE CPPK (lenvatinib 4 4 mesylate) (rucaparib camsylate) RYDAPT CAPS PA; AC LENVIMA 8 MG DAILY PA; AC 4 DOSE CPPK (lenvatinib 4 (midostaurin) mesylate) PA; Must use SPRYCEL TABS 100 MG, LORBRENA TABS 100 MG PA; AC AcariaHealth 4 140 MG, 80 MG 4 Specialty Rx at (lorlatinib) (dasatinib) 1-844-538- LORBRENA TABS 25 MG PA; AC=Anti- 4661;LA; AC 4 (lorlatinib) Cancer ;AC SPRYCEL TABS 20 MG, PA; AC 4 50 MG, 70 MG (dasatinib)

36 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; Must use VERZENIO TABS PA; AC 4 STIVARGA TABS AcariaHealth (abemaciclib) 4 Specialty Rx at ( ) VITRAKVI CAPS 100 MG PA; AC regorafenib 1-844-538- 4 4661;LA; AC (larotrectinib sulfate) VITRAKVI CAPS 25 MG PA; AC=Anti- PA; Must use 4 (larotrectinib sulfate) Cancer ;AC SUTENT CAPS (sunitinib AcariaHealth 4 Specialty Rx at malate) VITRAKVI SOLN 20 PA; AC=Anti- 1-844-538- MG/ML (larotrectinib 4 Cancer ;AC 4661;LA; AC sulfate) TABRECTA TABS PA; AC 4 VIZIMPRO TABS PA; AC ( ) 4 capmatinib hcl (dacomitinib) PA; Must use VOTRIENT TABS PA; AC TAFINLAR CAPS AcariaHealth 4 4 Specialty Rx at (pazopanib hcl) (dabrafenib mesylate) 1-844-538- PA; Must use 4661;LA; AC XALKORI CAPS AcariaHealth TAGRISSO TABS PA; AC 4 Specialty Rx at 4 (crizotinib) (osimertinib mesylate) 1-844-538- 4661;LA; AC TALZENNA CAPS PA; AC 4 XOSPATA TABS PA; AC ( ) 4 talazoparib tosylate (gilteritinib fumarate) PA; Must use ZEJULA CAPS (niraparib PA; AC TASIGNA CAPS 150 MG, AcariaHealth 4 4 Specialty Rx at tosylate) 200 MG (nilotinib hcl) 1-844-538- ZELBORAF TABS PA; AC 4 4661;LA; AC (vemurafenib) TASIGNA CAPS 50 MG PA; AC ZOLINZA CAPS PA; AC 4 4 (nilotinib hcl) (vorinostat) TAZVERIK TABS PA; AC ZYDELIG TABS PA; AC 4 3 (tazemetostat hbr) (idelalisib) 4 PA ZYKADIA CAPS AC temsirolimus soln 4 (ceritinib) TIBSOVO TABS PA; AC 4 ZYKADIA TABS AC (ivosidenib) 4 (ceritinib) TORISEL SOLN PA 7 (temsirolimus) Antineoplastics Misc. TUKYSA TABS PA; AC ACTIMMUNE SOLN PA; LA 4 4 (tucatinib) (interferon gamma-1b) TURALIO CAPS PA; AC ALFERON N SOLN PA; LA 4 4 (pexidartinib hcl) (interferon alfa-n3) TYKERB TABS ( PA; AC 4 PA; AC lapatinib 7 bexarotene caps ) ditosylate AC VELCADE SOLR PA hydroxyurea caps or 1 4 (bortezomib) INTRON A SOLN PA; LA 4 (interferon alfa-2b)

37 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits INTRON A SOLR PA; LA HYCAMTIN SOLR IV 4 MG PA; LA 4 7 (interferon alfa-2b) (topotecan hcl) MATULANE CAPS PA; AC PA; LA 4 topotecan hcl solr 4 (procarbazine hcl) SYLATRON KIT PA; Must use ANTIPARKINSON AND RELATED THERAPY AGENTS - Drugs to Treat Parkinson's Disease (peginterferon alfa-2b 4 AcariaHlth Sp Rx 1-844-538- Antiparkinson Adjunctive Therapy (antineoplastic)) 4661 TARGRETIN CAPS OR 75 PA; AC carbidopa tabs 2 7 MG ( ) bexarotene Antiparkinson Anticholinergics tretinoin AC PA 2 benztropine mesylate 4 (chemotherapy) caps soln ij 1 mg/ml Chemotherapy Rescue/Antidote Agents benztropine mesylate ETHYOL SOLR PA 7 tabs or 0.5 mg, 1 mg, 2 1 (amifostine crystalline) mg leucovorin calcium solr PA COGENTIN SOLN PA 7 ij 100 mg, 200 mg, 350 4 (benztropine mesylate) mg, 50 mg trihexyphenidyl hcl soln 1 leucovorin calcium tabs AC or 10 mg, 15 mg, 25 1 trihexyphenidyl hcl tabs 1 mg, 5 mg Antiparkinson COMT Inhibitors MESNEX TABS (mesna) 3 AC entacapone tabs 1 Mitotic Inhibitors (Etoposide) TOPOSAR PA tolcapone tabs 1 SOLN 1 GM/50ML, 500 2 MG/25ML Antiparkinson Dopaminergics (Etoposide) TOPOSAR 2 PA; AC amantadine hcl caps 1 SOLN 100 MG/5ML ETOPOPHOS SOLR PA amantadine hcl syrp 1 3 (etoposide phosphate) 1 AC amantadine hcl tabs etoposide caps or 50 1 mg bromocriptine mesylate 1 PA caps etoposide soln iv 1 2 gm/50ml, 500 mg/25ml bromocriptine mesylate 1 PA; AC tabs etoposide soln iv 100 2 mg/5ml carbidopa-levodopa Topoisomerase I Inhibitors tabs 10 mg-100 mg, 1 HYCAMTIN CAPS OR 0.25 PA; AC 100 mg-25 mg, 25 mg- MG, 1 MG (topotecan 4 250 mg QL(8 ea daily) hcl) carbidopa-levodopa 1 tbcr 100 mg-25 mg

38 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits carbidopa-levodopa 1 ropinirole hydrochloride tbcr 200 mg-50 mg tabs 0.25 mg, 0.5 mg, 1 1 carbidopa-levodopa mg, 2 mg, 3 mg, 4 mg, 5 mg tbdp 10 mg-100 mg, 1 QL(2 ea daily) 100 mg-25 mg, 25 mg- ropinirole hydrochloride 2 250 mg tb24 12 mg carbidopa-levodopa- ropinirole hydrochloride 2 entacapone tabs 100 tb24 2 mg, 4 mg, 6 mg mg-200 mg-25 mg, ropinirole hydrochloride 1 12.5 mg-200 mg-50 1 tb24 8 mg mg, 150 mg-200 mg- RYTARY CPCR 145 MG- PA; QL(10 ea 37.5 mg, 18.75 mg-200 36.25 MG, 195 MG-48.75 daily) mg-75 mg, 200 mg-200 MG, 245 MG-61.25 MG 3 mg-50 mg (carbidopa-levodopa) carbidopa-levodopa- RYTARY CPCR 23.75 MG- PA; ST;QL(10 entacapone tabs 12.5 95 MG (carbidopa- 3 ea daily) levodopa) mg-200 mg-50 mg, 125 2 mg-200 mg-31.25 mg, Antiparkinson Monoamine Oxidase Inhibitors 18.75 mg-200 mg-75 rasagiline mesylate 1 mg tabs NEUPRO PT24 3 QL(2 ea daily) (rotigotine) selegiline hcl caps 1 pramipexole selegiline hcl tabs 1 QL(2 ea daily) dihydrochloride tabs 1 XADAGO TABS PA 0.125 mg, 0.25 mg, 0.5 3 mg, 0.75 mg (safinamide mesylate) ZELAPAR TBDP pramipexole QL(4 ea daily) 3 dihydrochloride tabs 1 1 (selegiline hcl) mg ANTIPSYCHOTICS/ANTIMANIC AGENTS - pramipexole QL(3 ea daily) Drugs to Treat Mood Disorders dihydrochloride tabs 1 Antimanic Agents 1.5 mg lithium carbonate caps 1 pramipexole 150 mg, 600 mg dihydrochloride tb24 QL(6 ea daily) 2 lithium carbonate caps 1 0.375 mg, 0.75 mg, 1.5 300 mg mg, 2.25 mg, 4.5 mg lithium carbonate tabs 1 pramipexole QL(1 ea daily) 300 mg dihydrochloride tb24 3 2 lithium carbonate tbcr 1 mg 300 mg, 450 mg pramipexole dihydrochloride tb24 1 LITHIUM SOLN (lithium) 3 3.75 mg

39 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LITHOBID TBCR ( lithium 7 risperidone tbdp 0.25 carbonate) mg, 0.5 mg, 1 mg, 2 1 Antipsychotics - Misc. mg, 3 mg, 4 mg EQUETRO CP12 Butyrophenones (carbamazepine 3 haloperidol lactate conc 1 (antipsychotic)) LATUDA TABS haloperidol tabs 1 3 (lurasidone hcl) Dibenzapines NUPLAZID CAPS 34 MG PA; QL(1 ea 4 (pimavanserin tartrate) daily) asenapine maleate 1 NUPLAZID TABS 10 MG PA; QL(1 ea subl 4 (pimavanserin tartrate) daily) clozapine tabs 100 mg, 1 NUPLAZID TABS 17 MG PA 200 mg, 25 mg, 50 mg 4 (pimavanserin tartrate) clozapine tbdp 12.5 1 VRAYLAR CAPS QL(1 ea daily) mg, 150 mg, 200 mg 4 ( ) FAZACLO TBDP 150 MG, cariprazine hcl 7 VRAYLAR CPPK QL(1 ea daily) 200 MG (clozapine) 4 (cariprazine hcl) loxapine succinate 1 caps ziprasidone hcl caps 20 1 mg, 40 mg olanzapine tabs 10 mg, 1 QL(2 ea daily) 2.5 mg, 5 mg, 7.5 mg ziprasidone hcl caps 60 1 mg, 80 mg QL(1 ea daily) olanzapine tabs 15 mg, 1 Benzisoxazoles 20 mg (Risperidone) olanzapine tbdp 10 mg, 2 RISPERIDONE M-TAB 1 15 mg, 20 mg, 5 mg TBDP quetiapine fumarate FANAPT TABS QL(2 ea daily) 4 tabs 100 mg, 25 mg, 50 1 (iloperidone) mg FANAPT TITRATION QL(4 ea daily) quetiapine fumarate 1 PACK TABS 4 tabs 200 mg (iloperidone) QL(2 ea daily) quetiapine fumarate 1 paliperidone tb24 1 tabs 300 mg, 400 mg PERSERIS PRSY PA PA 4 quetiapine fumarate (risperidone) tb24 150 mg, 200 mg, 1 300 mg, 400 mg risperidone soln 1 1 mg/ml PA; ST quetiapine fumarate 1 risperidone tabs 0.25 tb24 50 mg mg, 0.5 mg, 1 mg, 2 1 SAPHRIS SUBL 5 MG 3 mg, 4 mg (asenapine maleate) QL(2 ea daily) SECUADO PT24 QL(1 ea daily) risperidone tabs 3 mg 1 3 (asenapine)

40 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VERSACLOZ SUSP QL(18 ml daily) 3 Thioxanthenes (clozapine) thiothixene caps 1 Dihydroindolones molindone hcl tabs 1 ANTISEPTICS & DISINFECTANTS Phenothiazines Antiseptics & Disinfectants (Prochlorperazine) 1 QL(2 ea daily) formaldehyde soln 1 COMPRO SUPP ANTIVIRALS - Drugs to Treat Viral Infections chlorpromazine hcl 2 tabs Antiretrovirals fluphenazine hcl conc 5 1 mg/ml abacavir sulfate soln 1 fluphenazine hcl elix 1 abacavir sulfate tabs 1 2.5 mg/5ml abacavir sulfate- 1 fluphenazine hcl tabs 1 lamivudine tabs mg, 10 mg, 2.5 mg, 5 1 mg abacavir sulfate- lamivudine-zidovudine 1 perphenazine tabs 1 tabs APTIVUS CAPS prochlorperazine 1 2 maleate tabs (tipranavir) APTIVUS SOLN 1 QL(2 ea daily) 2 prochlorperazine supp (tipranavir) thioridazine hcl tabs 10 1 atazanavir sulfate caps 1 mg, 100 mg, 25 mg QL(4 ea daily) BIKTARVY TABS thioridazine hcl tabs 50 1 mg (bictegravir- emtricitabine-tenofovir 2 trifluoperazine hcl tabs 1 alafenamide fumarate) Quinolinone Derivatives CIMDUO TABS (lamivudine-tenofovir 2 aripiprazole soln 1 1 disoproxil fumarate) mg/ml COMPLERA TABS aripiprazole tabs 10 1 (emtricitabine- mg, 2 mg, 30 mg, 5 mg rilpivirine-tenofovir 2 aripiprazole tabs 15 mg 1 QL(2 ea daily) disoproxil fumarate) CRIXIVAN CAPS QL(1 ea daily) 2 aripiprazole tabs 20 mg 1 (indinavir sulfate) aripiprazole tbdp 10 PA DELSTRIGO TABS 1 (doravirine-lamivudine- mg, 15 mg 2 REXULTI TABS tenofovir disoproxil 3 (brexpiprazole) fumarate)

41 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DESCOVY TABS INVIRASE TABS 2 (emtricitabine-tenofovir 2 (saquinavir mesylate) alafenamide fumarate) ISENTRESS CHEW 2 didanosine cpdr 1 (raltegravir potassium) ISENTRESS HD TABS 2 DOVATO TABS (raltegravir potassium) (dolutegravir sodium- 2 ISENTRESS PACK lamivudine) 2 (raltegravir potassium) EDURANT TABS 2 ISENTRESS TABS (rilpivirine hcl) 2 (raltegravir potassium) efavirenz caps 1 JULUCA TABS (dolutegravir sodium- 2 efavirenz tabs 1 rilpivirine hcl) efavirenz-emtricitabine- QL(1 ea daily) KALETRA TABS 100 MG- tenofovir disoproxil 1 25 MG, 200 MG-50 MG 2 fumarate tabs (lopinavir-ritonavir) efavirenz-lamivudine- lamivudine soln 1 tenofovir disoproxil 1 fumarate tabs lamivudine tabs 1 emtricitabine caps 1 lamivudine-zidovudine 1 tabs PV emtricitabine-tenofovir LEXIVA SUSP 50 MG/ML 1 disoproxil fumarate (fosamprenavir 2 tabs calcium) EMTRIVA SOLN 10 2 MG/ML (emtricitabine) lopinavir-ritonavir soln 1 EVOTAZ TABS nevirapine susp 1 (atazanavir sulfate- 2 cobicistat) nevirapine tabs 1 fosamprenavir calcium 1 tabs nevirapine tb24 1 FUZEON SOLR PA; ST;LA NORVIR PACK 100 MG 4 2 (enfuvirtide) (ritonavir) GENVOYA TABS NORVIR SOLN 80 MG/ML (elvitegravir-cobicistat- 2 2 (ritonavir) emtricitabine-tenofovir PIFELTRO TABS 2 alafenamide) (doravirine) INTELENCE TABS PREZCOBIX TABS QL(1 ea daily) 2 2 (etravirine) (darunavir-cobicistat) INVIRASE CAPS 2 PREZISTA SUSP 100 (saquinavir mesylate) MG/ML (darunavir 3 ethanolate)

42 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PREZISTA TABS 150 MG, VIDEXPEDIATRIC SOLR 2 600 MG, 75 MG, 800 MG 2 (didanosine) (darunavir ethanolate) VIRACEPT TABS RESCRIPTOR TABS 2 2 (nelfinavir mesylate) (delavirdine mesylate) VIREAD POWD 40 MG/GM REYATAZ PACK 50 MG 2 (tenofovir disoproxil 2 (atazanavir sulfate) fumarate) ritonavir tabs 1 VIREAD TABS 150 MG, 200 MG, 250 MG SELZENTRY SOLN 2 2 (tenofovir disoproxil (maraviroc) fumarate) SELZENTRY TABS 2 1 (maraviroc) zidovudine caps stavudine caps 1 zidovudine syrp 1 STRIBILD TABS zidovudine tabs 1 (elvitegravir-cobicistat- emtricitabine-tenofovir 2 CMV Agents df) cidofovir soln 4 PA SYMTUZA TABS QL(1 ea daily) (darunavir-cobicistat- Limit 630mls 2 valganciclovir hcl solr 1 per emtricitabine-tenofovir 50 mg/ml month;QL(21 alafenamide) ml daily) TEMIXYS TABS valganciclovir hcl tabs 1 (lamivudine-tenofovir 2 450 mg disoproxil fumarate) Hepatitis Agents tenofovir disoproxil 1 (Ribavirin (Hepatitis C)) PA fumarate tabs RIBASPHERE CAPS 200 1 TIVICAY TABS MG 2 (dolutegravir sodium) adefovir dipivoxil tabs 2 TRIUMEQ TABS BARACLUDE SOLN 0.05 (abacavir-dolutegravir- 2 4 lamivudine) MG/ML (entecavir) TRUVADA TABS 100 MG- entecavir tabs 2 150 MG, 133 MG-200 MG, 167 MG-250 MG 2 EPCLUSA TABS 100 MG- PA (emtricitabine-tenofovir 400 MG (sofosbuvir- 3 disoproxil fumarate) velpatasvir) TYBOST TABS EPIVIR HBV SOLN 5 2 (cobicistat) MG/ML (lamivudine 3 VIDEX EC CPDR 125 MG (hbv)) 2 (didanosine) lamivudine (hbv) tabs 1

43 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; MUST Influenza Agents MAVYRET TABS USE ACARIA QL(10 ea per ( 4 SPECIALTY glecaprevir- fill retail,10 ea pibrentasvir) RX 844-538- oseltamivir phosphate 1 4661 per fill mail); caps or 30 mg, 45 mg AL(At least 1 PEGASYS PROCLICK PA yrs old) SOLN (peginterferon 3 oseltamivir phosphate 1 alfa-2a) caps or 75 mg PEGASYS SOLN PA 3 QL(75 ml (peginterferon alfa-2a) oseltamivir phosphate 1 daily,5 day(s) PEGINTRON KIT PA limit); AL(At 3 susr or 6 mg/ml (peginterferon alfa-2b) least 1 yrs old) PA RELENZA DISKHALER ribavirin (hepatitis c) 1 3 caps AEPB (zanamivir) SOFOSBUVIR/VELPATAS PA rimantadine 1 VIR TABS (sofosbuvir- 3 hydrochloride tabs velpatasvir) Respiratory Syncytial Virus (RSV) Agents PA; Must use ribavirin solr 1 SOVALDI TABS 400 MG AcariaHealth 4 Specialty Rx at (sofosbuvir) BETA BLOCKERS - Drugs to Treat High Blood 1-844-538- Pressure 4661;LA VEMLIDY TABS ST Alpha-Beta Blockers (tenofovir alafenamide 4 carvedilol phosphate 1 fumarate) cp24 PA; Must use VOSEVI TABS carvedilol tabs 12.5 mg, 1 ( 3 AcariaHlth Sp 25 mg, 6.25 mg sofosbuvir-velpatasvir- Rx 1-844-538- ) QL(2 ea daily) voxilaprevir 4661 carvedilol tabs 3.125 1 mg Herpes Agents labetalol hcl tabs 1 acyclovir caps 200 mg 1 Beta Blockers Cardio-Selective acyclovir susp 200 1 mg/5ml acebutolol hcl caps or 1 200 mg, 400 mg acyclovir tabs 400 mg 1 atenolol tabs or 100 1 acyclovir tabs 800 mg 1 QL(5 ea daily) mg, 25 mg, 50 mg betaxolol hcl tabs 1 famciclovir tabs or 125 1 mg, 250 mg, 500 mg QL(1 ea daily) bisoprolol fumarate 1 QL(4 ea daily) tabs valacyclovir hcl tabs 1 1 gm, 1000 mg BYSTOLIC TABS 2 QL(8 ea daily) (nebivolol hcl) valacyclovir hcl tabs 1 500 mg

44 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Diltiazem Hcl Coated metoprolol succinate 1 1 tb24 Beads) MATZIM LA TB24 metoprolol tartrate tabs (Diltiazem Hcl Extended Release Beads) TAZTIA 1 or 100 mg, 25 mg, 37.5 1 XT, TIADYLT ER CP24 mg, 50 mg, 75 mg (Diltiazem Hcl) DILT-XR 1 Beta Blockers Non-Selective CP24 (Sotalol Hcl) SORINE QL(1 ea daily) 1 amlodipine besylate 1 TABS tabs 10 mg, 5 mg INDERAL XL CP24 QL(2 ea daily) amlodipine besylate 1 (propranolol hcl tabs 2.5 mg sustained-release 3 CARDIZEM LA TB24 120 beads) MG (diltiazem hcl 2 INNOPRAN XL CP24 coated beads) (propranolol hcl sustained-release 3 diltiazem hcl coated QL(1 ea daily) beads cp24 120 mg, beads) 1 180 mg, 240 mg, 300 nadolol tabs 1 mg, 360 mg diltiazem hcl coated pindolol tabs 1 1 beads tb24 360 mg propranolol hcl cp24 or diltiazem hcl cp12 120 1 120 mg, 160 mg, 60 1 mg, 60 mg, 90 mg mg, 80 mg diltiazem hcl cp24 120 1 propranolol hcl soln or 1 mg, 180 mg, 240 mg 20 mg/5ml, 40 mg/5ml diltiazem hcl extended 1 propranolol hcl tabs or release beads cp24 10 mg, 20 mg, 40 mg, 1 diltiazem hcl tabs 120 60 mg, 80 mg mg, 30 mg, 60 mg, 90 1 sotalol hcl (afib/afl) tabs 1 mg QL(1 ea daily) sotalol hcl tabs 1 felodipine tb24 10 mg 1 SOTYLIZE SOLN ( felodipine tb24 2.5 mg, sotalol 3 1 hcl) 5 mg QL(6 ea daily) isradipine caps 1 timolol maleate tabs or 1 10 mg 1 QL(2 ea daily) nicardipine hcl caps timolol maleate tabs or 1 20 mg, 5 mg nifedipine caps 10 mg, 1 CALCIUM CHANNEL BLOCKERS - Drugs to 20 mg Treat High Blood Pressure nifedipine tb24 30 mg, 1 Calcium Channel Blockers 60 mg nifedipine tb24 30 mg, QL(1 ea daily) (Diltiazem Hcl Coated 1 QL(1 ea daily) 1 Beads) CARTIA XT CP24 60 mg, 90 mg 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic is Available AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

45 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits nimodipine caps 1 amlodipine besylate- PA atorvastatin calcium nisoldipine tb24 1 tabs 10 mg-10 mg, 10 mg-2.5 mg, 10 mg-5 NYMALIZE SOLN 30 1 MG/10ML, 60 MG/20ML 3 mg, 2.5 mg-20 mg, 2.5 (nimodipine) mg-40 mg, 20 mg-5 mg, 40 mg-5 mg, 5 mg- verapamil hcl cp24 100 80 mg mg, 120 mg, 200 mg, 1 240 mg, 300 mg amlodipine besylate- atorvastatin calcium verapamil hcl cp24 180 QL(2 ea daily) 1 tabs 10 mg-20 mg, 10 1 mg mg-40 mg, 10 mg-80 QL(1 ea daily) verapamil hcl cp24 360 1 mg mg BIDIL TABS (isosorbide verapamil hcl tabs 120 1 dinitrate-hydralazine 3 mg, 40 mg, 80 mg hcl) verapamil hcl tbcr 120 1 ENTRESTO TABS 103 PA mg MG-97 MG, 49 MG-51 MG 3 QL(2 ea daily) (sacubitril-valsartan) verapamil hcl tbcr 180 1 mg, 240 mg ENTRESTO TABS 24 MG- PA; QL(2 ea VERELAN CP24 360 MG QL(1 ea daily) 26 MG (sacubitril- 3 daily) 7 (verapamil hcl) valsartan) VERELAN PM CP24 Impotence Agents 7 (verapamil hcl) 1 PA; QL(0.27 ea sildenafil citrate tabs daily) CARDIOTONICS - Drugs to Treat Heart Failure and Abnormal Heart Rhythm Limit 8 per month - Not Cardiac Glycosides available vardenafil hcl tbdp 10 through (Digoxin) DIGITEK, DIGOX 1 1 TABS mg Mail;QL(0.27 ea daily); AL(At digoxin soln 0.05 mg/ml 1 least 21 yrs old) digoxin tabs 0.125 mg, 1 125 mcg, 250 mcg Peripheral Vasodilators LANOXIN TABS 125 MCG, 7 isoxsuprine hcl tabs 1 250 MCG (digoxin) LANOXIN TABS 62.5 MCG Prostaglandin Vasodilators 3 ORENITRAM TBCR PA (digoxin) 4 (treprostinil diolamine) CARDIOVASCULAR AGENTS - MISC. - Drugs to TYVASO REFILL SOLN PA Treat Heart and Circulation Conditions 4 (treprostinil) Cardiovascular Agents Misc. - Combinations TYVASO SOLN PA 4 (treprostinil)

46 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TYVASO STARTER SOLN PA PA; New 4 (treprostinil) (Tadalafil (Pulmonary commercial VENTAVIS SOLN PA Hypertension)) ALYQ 4 members to be 4 TABS referred to (iloprost) AcariaHealth;Q Pulmonary Hypertension - Endothelin Receptor L(2 ea daily) PA; Must use PA; New commercial ambrisentan tabs 10 AcariaHealth ADCIRCA TABS (tadalafil 4 Specialty Rx at (pulmonary 7 members to be mg 1-844-538- referred to 4661 - ST hypertension)) AcariaHealth;Q PA; Must use L(2 ea daily) AcariaHealth REVATIO SUSR 10 PA Specialty Rx at MG/ML (sildenafil citrate ambrisentan tabs 5 mg 4 7 1-844-538- (pulmonary 4661 - ST for 5 hypertension)) mg PA PA; ST; MUST sildenafil citrate USE ACARIA (pulmonary 4 bosentan tabs 125 mg 4 SPECIALTY hypertension) susr 10 RX 844-538- mg/ml 4661 sildenafil citrate PA; QL(3 ea PA; ST; Must daily) (pulmonary 1 use hypertension) tabs 20 4 AcariaHealth bosentan tabs 62.5 mg Specialty Rx at mg 1-844-538- PA; New 4661 commercial PA; Must use tadalafil (pulmonary 4 members to be hypertension) tabs referred to LETAIRIS TABS 10 MG AcariaHealth 7 Specialty Rx at AcariaHealth;Q (ambrisentan) 1-844-538- L(2 ea daily) 4661 - ST Pulmonary Hypertension - Prostacyclin Receptor PA; Must use UPTRAVI TABS 1000 PA AcariaHealth MCG, 1200 MCG, 1400 LETAIRIS TABS 5 MG 7 Specialty Rx at MCG, 1600 MCG, 400 4 (ambrisentan) 1-844-538- MCG, 600 MCG, 800 MCG 4661 - ST for 5 (selexipag) mg UPTRAVI TABS 200 MCG PA; ST OPSUMIT TABS PA; ST 4 4 (selexipag) (macitentan) UPTRAVI TBPK PA; ST TRACLEER TBSO 32 MG PA; ST 4 4 (selexipag) (bosentan) Pulmonary Hypertension - Sol Guanylate Cyclase Pulmonary Hypertension - Phosphodiesterase ADEMPAS TABS 0.5 MG PA; ST 4 (riociguat)

47 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ADEMPAS TABS 1 MG, PA PA cefoxitin sodium solr iv 4 1.5 MG, 2 MG, 2.5 MG 4 1 gm, 2 gm (riociguat) CEFOXITIN SODIUM PA Sinus Node Inhibitors SOLR IV 1 GM-4 %, 2 GM- 4 CORLANOR SOLN 5 ST; QL(15 ml 2.2 % (cefoxitin sodium 3 MG/5ML (ivabradine hcl) daily) and dextrose) CORLANOR TABS 5 MG, ST; QL(2 ea 3 cefprozil susr 1 7.5 MG (ivabradine hcl) daily) Transthyretin Stabilizers cefprozil tabs 1 VYNDAMAX CAPS PA; QL(1 ea 4 cefuroxime axetil tabs 1 (tafamidis) daily) VYNDAQEL CAPS PA; QL(4 ea Cephalosporins - 3rd Generation (tafamidis meglumine 4 daily) cefdinir caps 1 (cardiac)) CEPHALOSPORINS - Drugs to Treat Bacterial cefdinir susr 1 Infections cefditoren pivoxil tabs 1 Cephalosporins - 1st Generation cefadroxil caps 1 cefixime caps 1 cefadroxil susr 1 cefixime susr 1 cefpodoxime proxetil 1 cefadroxil tabs 1 susr PA cefazolin sodium solr 4 cefpodoxime proxetil 1 tabs cephalexin caps 1 SUPRAX CHEW 100 MG, 3 200 MG (cefixime) cephalexin susr 1 SUPRAX SUSR 500 3 cephalexin tabs 1 MG/5ML (cefixime) Cephalosporins - 2nd Generation CHEMICALS cefaclor caps 1 Bulk Chemicals - P's PROGESTERONE CEFACLOR ER TB12 3 CONCENTRATE CREA 3 (cefaclor monohydrate) (progesterone (bulk)) cefaclor susr 1 CONTRACEPTIVES - Drugs to Prevent CEFOTAN SOLR PA Pregnancy 7 (cefotetan disodium) Combination Contraceptives - Oral cefotetan disodium solr 4 PA PA cefoxitin sodium solr ij 4 10 gm

48 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Desogestrel & Ethinyl PV (Levonorgestrel-Ethinyl PV Estradiol) APRI, CYRED, Estradiol (91-Day)) CYRED EQ, AMETHIA, AMETHIA LO, EMOQUETTE, ENSKYCE, 5 ASHLYNA, CAMRESE, ISIBLOOM, JULEBER, CAMRESE LO, DAYSEE, KALLIGA, RECLIPSEN FAYOSIM, ICLEVIA, 5 TABS INTROVALE, JAIMIESS, (Desogestrel-Ethinyl PV JOLESSA, LOJAIMIESS, Estradiol (Biphasic)) QUASENSE, RIVELSA, SETLAKIN, SIMPESSE AZURETTE, BEKYREE, 5 KARIVA, PIMTREA, TABS SIMLIYA, VIORELE, (Levonorgestrel-Ethinyl PV VOLNEA TABS Estradiol (Continuous)) 5 (Desogestrel-Ethinyl PV AMETHYST TABS Estradiol (Triphasic)) 5 (Norethin Acet & Estrad- PV CAZIANT, VELIVET TABS Fe) AUROVELA 24 FE, (Drospirenone-Ethinyl PV AUROVELA FE 1.5/30, Estradiol) GIANVI, AUROVELA FE 1/20, JASMIEL, LO- BLISOVI 24 FE, BLISOVI ZUMANDIMINE, LORYNA, 5 FE 1.5/30, BLISOVI FE NIKKI, OCELLA, SYEDA, 1/20, HAILEY 24 FE, ZARAH, ZUMANDIMINE HAILEY FE 1.5/30, HAILEY TABS FE 1/20, JUNEL FE 1.5/30, JUNEL FE 1/20, JUNEL FE 5 (Drospirenone-Ethinyl PV 24, LARIN 24 FE, LARIN Estradiol-Levomefolate 5 FE 1.5/30, LARIN FE 1/20, Calcium) TYDEMY TABS LOESTRIN FE 1.5/30, (Ethynodiol Diacet & Eth PV LOESTRIN FE 1/20, Estrad) KELNOR 1/35, 5 MICROGESTIN 24 FE, KELNOR 1/50, ZOVIA MICROGESTIN FE 1.5/30, 1/35, ZOVIA 1/35E TABS MICROGESTIN FE 1/20, (Levonorgestrel & Eth PV TARINA 24 FE, TARINA Estradiol) AFIRMELLE, FE 1/20, TARINA FE 1/20 ALTAVERA, AUBRA, EQ TABS AUBRA EQ, AVIANE, (Norethin Acet & Estrad- PV AYUNA, CHATEAL, Fe) CHARLOTTE 24 FE, 5 CHATEAL EQ, DELYLA, MELODETTA 24 FE, FALMINA, KURVELO, 5 MIBELAS 24 FE CHEW LARISSIA, LESSINA, (Norethin Acet & Estrad- 5 PV LEVORA 0.15/30-28, Fe) GEMMILY CAPS LILLOW, LUTERA, MARLISSA, ORSYTHIA, (Norethindrone & Eth PV PORTIA-28, SRONYX, Estradiol) ALYACEN 1/35, TYBLUME, VIENVA TABS BALZIVA, BRIELLYN, CYCLAFEM 1/35, (Levonorgestrel-Eth PV DASETTA 1/35, NECON 5 Estradiol (Triphasic)) 0.5/35-28, NORTREL ENPRESSE-28, 5 0.5/35 (28), NORTREL LEVONEST, MYZILRA, 1/35, PHILITH, PIRMELLA TRIVORA-28 TABS 1/35, VYFEMLA, WERA TABS

49 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Norethindrone & Ethinyl PV BALCOLTRA TABS QL(1 ea daily); Estradiol-Fe) KAITLIB FE, 5 (levonorgestrel-ethinyl PV LAYOLIS FE, WYMZYA FE estradiol-ferrous 5 CHEW bisglycinate) (Norethindrone Acet & Eth PV Estra) AUROVELA 1.5/30, BEYAZ TABS PV (drospirenone-ethinyl AUROVELA 1/20, HAILEY 7 1.5/30, JUNEL 1.5/30, estradiol-levomefolate JUNEL 1/20, LARIN 1.5/30, 5 calcium) LARIN 1/20, LOESTRIN desogestrel & ethinyl PV 1.5/30-21, LOESTRIN 5 1/20-21, MICROGESTIN estradiol tabs 1.5/30, MICROGESTIN PV desogestrel-ethinyl 5 1/20 TABS estradiol (biphasic) tabs (Norethindrone Acetate- PV drospirenone-ethinyl PV Ethinyl Estradiol-Fe) TILIA 5 5 FE, TRI-LEGEST FE TABS estradiol tabs (Norethindrone-Eth PV drospirenone-ethinyl PV Estradiol (Triphasic)) estradiol-levomefolate 5 ALYACEN 7/7/7, calcium tabs ARANELLE, CYCLAFEM 5 ESTROSTEP FE TABS PV 7/7/7, DASETTA 7/7/7, LEENA, NORTREL 7/7/7, (norethindrone acetate- 7 PIRMELLA 7/7/7 TABS ethinyl estradiol-fe) PV (Norgestimate-Ethinyl PV ethynodiol diacet & eth 5 Estradiol (Triphasic)) TRI estrad tabs FEMYNOR, TRI- GENERESS FE CHEW PV ESTARYLLA, TRI-LINYAH, (norethindrone & 7 TRI-LO-ESTARYLLA, TRI- 5 LO-MARZIA, TRI-LO-MILI, ethinyl estradiol-fe) TRI-LO-SPRINTEC, TRI- PV levonorgestrel & eth 5 MILI, TRI-PREVIFEM, TRI- estradiol tabs SPRINTEC, TRI-VYLIBRA, TRI-VYLIBRA LO TABS levonorgestrel-eth PV 5 (Norgestimate-Ethinyl PV estradiol (triphasic) Estradiol) ESTARYLLA, tabs FEMYNOR, MILI, MONO- PV levonorgestrel-ethinyl 5 LINYAH, MONONESSA, 5 estradiol (91-day) tabs NYMYO, PREVIFEM, SPRINTEC 28, VYLIBRA levonorgestrel-ethinyl PV TABS estradiol (continuous) 5 (Norgestrel & Ethinyl PV tabs Estradiol) CRYSELLE-28, LO LOESTRIN FE TABS PV ELINEST, LOW- 5 (norethindrone acetate- OGESTREL, OGESTREL ethinyl estradiol-fe fum 5 TABS (biphasic)) LOSEASONIQUE TABS PV (levonorgestrel-ethinyl 7 estradiol (91-day)) 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic is Available AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

50 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MINASTRIN 24 FE CHEW PV ORTHO-NOVUM 7/7/7 PV (norethin acet & estrad- 5 TABS (norethindrone- 7 fe) eth estradiol (triphasic)) MINASTRIN 24 FE CHEW PV QUARTETTE TABS PV (norethin acet & estrad- 7 (levonorgestrel-ethinyl 7 fe) estradiol (91-day)) MIRCETTE TABS PV SAFYRAL TABS PV (desogestrel-ethinyl 7 (drospirenone-ethinyl 7 estradiol (biphasic)) estradiol-levomefolate NATAZIA TABS PV calcium) (estradiol valerate- 5 SEASONIQUE TABS PV dienogest) (levonorgestrel-ethinyl 7 PV estradiol (91-day)) norethin acet & estrad- 5 fe caps TAYTULLA CAPS PV PV (norethin acet & estrad- 7 norethin acet & estrad- 5 fe chew fe) PV TRI-NORINYL 28 TABS PV norethin acet & estrad- 5 fe tabs (norethindrone-eth 7 estradiol (triphasic)) norethindrone & ethinyl PV 5 YASMIN 28 TABS PV estradiol-fe chew (drospirenone-ethinyl 7 PV norethindrone acet & 5 estradiol) eth estra tabs YAZ TABS PV norgestimate-ethinyl PV (drospirenone-ethinyl 7 estradiol (triphasic) 5 estradiol) tabs Combination Contraceptives - Transdermal norgestimate-ethinyl PV 5 (Norelgestromin-Ethinyl 5 PV estradiol tabs Estradiol) XULANE PTWK ORTHO TRI-CYCLEN LO PV TWIRLA PTWK QL(3 ea per 28 TABS (norgestimate- days retail); PV 7 (levonorgestrel-ethinyl 5 ethinyl estradiol estradiol) (triphasic)) Combination Contraceptives - Vaginal ORTHO TRI-CYCLEN PV (Etonogestrel-Ethinyl PV TABS (norgestimate- 5 7 Estradiol) ELURYNG RING ethinyl estradiol ANNOVERA RING QL(1 ea daily); (triphasic)) (segesterone acetate- 5 PV ORTHO-CYCLEN TABS PV ethinyl estradiol) (norgestimate-ethinyl 7 PV etonogestrel-ethinyl 5 estradiol) estradiol ring ORTHO-NOVUM 1/35 PV NUVARING RING PV TABS (norethindrone & 7 (etonogestrel-ethinyl 7 eth estradiol) estradiol)

51 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Emergency Contraceptives budesonide cpep 3 mg 2 QL(3 ea daily) (Levonorgestrel PV (Emergency Oc)) AFTERA, budesonide tb24 9 mg 1 PA ECONTRA EZ, ECONTRA ONE-STEP, MY CHOICE, cortisone acetate tabs 2 MY WAY, NEW DAY, 5 OPCICON ONE-STEP, dexamethasone elix 0.5 1 OPTION 2, PREVENTEZA, mg/5ml REACT, TAKE ACTION DEXAMETHASONE TABS INTENSOL CONC 2 ELLA TABS ( PV ulipristal 5 (dexamethasone) acetate) dexamethasone soln PV 1 levonorgestrel 5 0.5 mg/5ml (emergency oc) tabs dexamethasone tabs PLAN B ONE-STEP TABS PV 0.5 mg, 0.75 mg, 1 mg, 1 (levonorgestrel 7 1.5 mg, 2 mg, 4 mg, 6 (emergency oc)) mg Progestin Contraceptives - Oral dexamethasone tbpk 1 (Norethindrone PV 1.5 mg (Contraceptive)) CAMILA, DEBLITANE, ERRIN, hydrocortisone tabs 1 HEATHER, INCASSIA, MEDROL TABS 2 MG JENCYCLA, JOLIVETTE, 5 2 LYZA, NORA-BE, (methylprednisolone) NORLYDA, NORLYROC, methylprednisolone 1 SHAROBEL, TULANA tabs TABS methylprednisolone PV 1 norethindrone 5 tbpk (contraceptive) tabs MILLIPRED DP TBPK 3 ORTHO MICRONOR PV (prednisolone) TABS ( 7 norethindrone MILLIPRED TABS 5 MG (contraceptive)) 2 (prednisolone) SLYND TABS QL(1 ea daily); 5 prednisolone sodium (drospirenone) PV phosphate soln or 10 CORTICOSTEROIDS - Steroid Hormone Drugs to mg/5ml, 15 mg/5ml, 20 1 Treat Systemic Swelling Conditions mg/5ml, 25 mg/5ml, 5 Glucocorticosteroids mg/5ml (Dexamethasone) 1 prednisolone sodium DECADRON ELIX phosphate tbdp or 10 1 (Dexamethasone) 1 mg, 15 mg, 30 mg DECADRON TABS (Dexamethasone) prednisolone soln 1 DEXPAK 13 DAY, 1 PREDNISONE INTENSOL TAPERDEX 12-DAY TBPK 2 CONC (prednisone)

52 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits prednisone soln 1 CARBAPHEN 12 LIQD (phenylephrine- 3 prednisone tabs 1 chlorpheniramine- carbetapentane) prednisone tbpk 1 CARBAPHEN 12 PED SUSP ( Mineralocorticoids phenylephrine- chlorpheniramine- 3 fludrocortisone acetate 1 carbetapentane) tabs CODITUSSIN AC LIQD 3 COUGH/COLD/ALLERGY - Drugs to Treat (guaifenesin-codeine) Cough, Cold and Allergy Symptoms DOCTOR MANZANILLA Antitussives PE SYRUP ANTIHISTAMINE/DECON (Hydrocodone W/ 3 Homatropine) HYCODAN, 1 GESTANT LIQD HYDROMET SYRP (triprolidine- phenylephrine) benzonatate caps 100 1 mg, 150 mg, 200 mg DOMETUSS-DMX LIQD (phenylephrine w/ dm- 3 hydrocodone w/ 1 homatropine syrp gg) hydrocodone w/ EXACTUSS TR TABS RX/OTC 1 (phenylephrine w/ dm- 3 homatropine tabs gg) Cough/Cold/Allergy Combinations EXAPHEX TR TABS RX/OTC (Guaifenesin-Codeine) (phenylephrine- 3 CHERATUSSIN AC, 1 guaifenesin) GUAIATUSSIN AC, GUAIFENESIN AC SYRP GILPHEX TR TABS RX/OTC (Guaifenesin-Codeine) G (phenylephrine- 3 guaifenesin) TUSSIN AC, MAXI-TUSS 1 AC, ROBAFEN AC, GILTUSS COUGH & COLD RX/OTC VIRTUSSIN A/C SOLN TABS (phenylephrine w/ 3 (Guaifenesin-Codeine) 1 dm-gg) VIRTUSSIN AC/ALC LIQD GILTUSS SINUS & RX/OTC (Phenylephrine W/ Dm-Gg) RX/OTC CONGESTION TABS BIOGTUSS, GILTUSS 1 (phenylephrine- 3 PEDIATRIC LIQD guaifenesin) (Pseudoephed-Bromphen- 1 Dm) BROMFED DM SYRP GILTUSS TR TABS RX/OTC (phenylephrine w/ dm- 3 (Pseudoephedrine W/ gg) Codeine-Gg) 1 GUAIFENESIN DAC, guaifenesin-codeine 1 VIRTUSSIN DAC SOLN soln ACTIDOM DMX LIQD HYDROCODONE (phenylephrine w/ dm- 3 BITARTRATE/GUAIFENES gg) IN SOLN (hydrocodone- 3 guaifenesin) 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic is Available AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

53 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits hydrocodone polistirex- (Sodium Chloride chlorpheniramine 1 (Inhalant)) NEBUSAL 1 polistirex suer NEBU 3 % NEOTUSS PLUS LIQD (Sodium Chloride (Inhalant)) PULMOSAL 1 (phenylephrine- 3 NEBU chlorphen-dm) HYPERSAL NEBU 3.5 % PRO-RED AC SYRP (sodium chloride 3 (phenylephrine- 3 (inhalant)) dexchlorpheniramine- NEBUSAL NEBU 6 % codeine) (sodium chloride 3 QL(30 ml daily) promethazine & 1 (inhalant)) phenylephrine syrp sodium chloride QL(30 ml daily) 1 promethazine 1 (inhalant) nebu w/codeine soln Mucolytics QL(30 ml daily) promethazine 1 w/codeine syrp acetylcysteine soln 1 promethazine-dm soln 1 QL(30 ml daily) DERMATOLOGICALS - Drugs to Treat Skin Conditions QL(30 ml daily) promethazine-dm syrp 1 Acne Products promethazine- (Clindamycin Phosphate phenylephrine-codeine 1 (Topical)) CLINDACIN ETZ 1 PLEDGETS, CLINDACIN-P syrp SWAB pseudoephed- 1 (Clindamycin Phosphate- bromphen-dm syrp Benzoyl Peroxide 1 (Refrigerate)) NEUAC GEL pseudoephed-cpm w/ 1 hydrocod soln (Erythromycin (Acne Aid)) 1 ERY PADS TUSNEL TABS (pseudoephedrine w/ 3 (Isotretinoin) QL(4 ea daily) AMNESTEEM, CLARAVIS, 1 dm-gg) MYORISAN, ZENATANE TUSSICAPS CP12 CAPS 10 MG (hydrocodone (Isotretinoin) QL(5 ea daily) 3 polistirex- AMNESTEEM, CLARAVIS, 1 chlorpheniramine MYORISAN, ZENATANE polistirex) CAPS 20 MG TUSSLIN LIQD RX/OTC (Isotretinoin) QL(5 ea AMNESTEEM, CLARAVIS, 1 daily,150 (phenylephrine w/ dm- 3 MYORISAN, ZENATANE day(s) limit) gg) CAPS 20 MG TUSSLIN PEDIATRIC RX/OTC (Isotretinoin) QL(2 ea daily) LIQD (phenylephrine w/ 3 AMNESTEEM, CLARAVIS, 1 dm-gg) MYORISAN, ZENATANE CAPS 40 MG Misc. Respiratory Inhalants

54 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Isotretinoin) QL(2 ea clindamycin phosphate 1 AMNESTEEM, CLARAVIS, 1 daily,150 (topical) lotn MYORISAN, ZENATANE day(s) limit) CAPS 40 MG clindamycin phosphate 1 (Isotretinoin) CLARAVIS, (topical) soln MYORISAN, ZENATANE 1 clindamycin phosphate 1 CAPS 30 MG (topical) swab (Isotretinoin) CLARAVIS, QL(2 ea daily) clindamycin phosphate- MYORISAN, ZENATANE 1 1 CAPS 30 MG benzoyl peroxide (refrigerate) gel (Sulfacetamide Sodium W/ Sulfur) BP 10-1, 1 clindamycin phosphate- SULFAMEZ WASH EMUL benzoyl peroxide gel 1 1 %-5 % (Sulfacetamide Sodium W/ 1 Sulfur) SSS 10-5 FOAM clindamycin phosphate- 1 (Sulfacetamide Sodium- tretinoin gel Sulfur In Urea Vehicle) BP 1 PA; ST CLEANSING WASH EMUL dapsone (topical) gel 5 1 % (Tretinoin) AVITA CREA 1 DIFFERIN LOTN 0.1 % 3 (Tretinoin) AVITA GEL 1 (adapalene) erythromycin (acne aid) 1 Limit 45gms gel adapalene crea 0.1 % 1 per month;QL(1.5 erythromycin (acne aid) 1 gm daily) pads Limit 45gms erythromycin (acne aid) 1 per soln adapalene gel 0.1 % 1 month;QL(1.5 gm daily); Limit 50gms FABIOR FOAM RX/OTC 3 per (tazarotene (acne)) month;QL(1.67 QL(45 gm per gm daily) adapalene gel 0.3 % 1 fill retail,135 gm per fill mail) isotretinoin caps 10 mg 1 QL(4 ea daily) adapalene lotn 0.1 % 1 isotretinoin caps 20 mg 1 QL(5 ea daily) adapalene-benzoyl 1 peroxide gel isotretinoin caps 30 mg 1 AZELEX CREA ( QL(2 ea daily) azelaic 3 isotretinoin caps 40 mg 1 acid (acne)) RIAX FOAM ( QL(2 gm daily) benzoyl 3 benzoyl peroxide- 1 erythromycin gel peroxide) clindamycin phosphate 1 (topical) foam clindamycin phosphate 1 (topical) gel

55 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SODIUM (Diclofenac Sodium QL(5 ml daily) SULFACETAMIDE/SULFU (Topical)) KLOFENSAID II 1 R CLEANSER IN UREA SOLN 3 EMUL (sulfacetamide QL(2 ea daily) diclofenac epolamine 1 sodium-sulfur in urea ptch vehicle) RX/OTC diclofenac sodium 1 sulfacetamide sodium 1 (topical) gel 1 % (acne) lotn QL(5 ml daily) diclofenac sodium 1 sulfacetamide sodium (topical) soln 1.5 % w/ sulfur crea 4.8 %-9.8 1 FLECTOR PTCH QL(2 ea daily) 7 % (diclofenac epolamine) sulfacetamide sodium PENNSAID SOLN PA; QL(4 gm w/ sulfur liqd 4.8 %-9.8 2 (diclofenac sodium 3 daily) % (topical)) QL(1 gm daily) sulfacetamide sodium 1 Antibiotics - Topical w/ sulfur lotn 10 %-5 % ALTABAX OINT 3 sulfacetamide sodium PA (retapamulin) w/ sulfur lotn 4.8 %-9.8 1 CENTANY OINT 2 % (mupirocin) tretinoin crea 1 CORTISPORIN CREA (neomycin-polymyxin- 3 tretinoin gel 1 hc) Limit 45gms CORTISPORIN OINT ( 3 tretinoin microsphere 1 per bacitracin-polymyxin- gel 0.04 % month;QL(1.7 neomycin hc) gm daily) gentamicin sulfate QL(1.67 gm 1 tretinoin microsphere 1 (topical) crea gel 0.1 % daily) gentamicin sulfate 1 VELTIN GEL (topical) oint (clindamycin 3 phosphate-tretinoin) mupirocin oint 1 Agents for External Genital and Perianal Warts Antifungals - Topical VEREGEN OINT QL(30 gm per 3 (Iodoquinol-Hydrocortisone (sinecatechins) fill retail) In Aloe Vehicle) 1 IODOQUIMEZ-HC CREA Anti-inflammatory Agents - Topical (Diclofenac Sodium RX/OTC (Ketoconazole (Topical)) 2 (Topical)) ARTHRITIS KETODAN FOAM PAIN RELIEVER, GNP (Nystatin (Topical)) ARTHRITIS PAIN, 1 NYAMYC, NYSTOP 1 GOODSENSE ARTHRITIS POWD PAIN, QC DICLOFENAC 1 SODIIUM GEL ciclopirox gel ex 0.77 %

56 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ciclopirox olamine crea 1 nystatin-triamcinolone 1 crea ciclopirox olamine susp 1 nystatin-triamcinolone 1 oint ciclopirox sham ex 1 % 1 oxiconazole nitrate crea 1 ciclopirox soln ex 8 % 1 OXISTAT LOTN 3 clotrimazole w/ Limit 1 tube per (oxiconazole nitrate) 1 month;QL(1.5 betamethasone crea gm daily) sulconazole nitrate crea 1 clotrimazole w/ QL(2 ml daily) 1 sulconazole nitrate soln 1 betamethasone lotn econazole nitrate crea 1 Antineoplastic or Premalignant Lesion Agents - CARAC CREA QL(1 gm daily) 7 ERTACZO CREA PA; QL(1 gm (fluorouracil (topical)) 4 daily) (sertaconazole nitrate) diclofenac sodium PA EXELDERM CREA 2 7 (actinic keratoses) gel (sulconazole nitrate) FLUOROPLEX CREA EXELDERM SOLN 2 2 (fluorouracil (topical)) (sulconazole nitrate) QL(1 gm daily) fluorouracil (topical) 1 EXODERM LOTN crea 0.5 % (sodium thiosulfate- 3 salicylic acid) fluorouracil (topical) 1 crea 5 % iodoquinol- hydrocortisone in aloe 1 fluorouracil (topical) 1 vehicle crea soln 2 %, 5 % QL(2 gm daily) PANRETIN GEL PA ketoconazole (topical) 1 3 crea (alitretinoin) PICATO GEL (ingenol ketoconazole (topical) 2 3 foam mebutate) TARGRETIN GEL EX 1 % PA ketoconazole (topical) 4 1 (bexarotene (topical)) sham VALCHLOR GEL PA; ST naftifine hcl crea 1 (mechlorethamine hcl 4 (topical)) naftifine hcl gel 1 Antipruritics - Topical NAFTIN GEL 2 % QL(3 gm daily) 3 doxepin hcl 1 (naftifine hcl) (antipruritic) crea nystatin (topical) crea 1 Antipsoriatics 1 (Calcipotriene) 1 QL(5 gm daily) nystatin (topical) oint CALCITRENE OINT nystatin (topical) powd 1 acitretin caps 10 mg 2 QL(1 ea daily)

57 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TAZORAC GEL 0.05 %, acitretin caps 17.5 mg 2 2 0.1 % (tazarotene) acitretin caps 25 mg 2 QL(2 ea daily) PA; Must use TREMFYA SOPN AcariaHealth calcipotriene crea 2 QL(5 gm daily) 4 Specialty Rx at (guselkumab) 1-844-538- calcipotriene foam 1 PA 4661;LA PA; Must use CALCIPOTRIENE FOAM PA 3 TREMFYA SOSY AcariaHealth (calcipotriene) 4 Specialty Rx at (guselkumab) 1 QL(5 gm daily) 1-844-538- calcipotriene oint 4661;LA calcipotriene soln 1 Antiseborrheic Products Limit 100gms (Sulfacetamide Sodium) SODIUM 1 per 1 calcitriol (topical) oint month;QL(3.4 SULFACETAMIDE WASH gm daily) LIQD 10 % COSENTYX PA; ST;LA selenium sulfide lotn 1 SENSOREADY PEN SOAJ 4 2.5 % (secukinumab) SODIUM COSENTYX SOSY PA; ST;LA SULFACETAMIDE WASH 4 LIQD 0.5 %-10 % (secukinumab) 3 (sulfacetamide sodium ILUMYA SOSY PA; ST 4 in bakuchiol vehicle) (tildrakizumab-asmn) sulfacetamide sodium methoxsalen rapid 1 1 liqd caps SKYRIZI PSKT PA sulfacetamide sodium 1 4 sham (risankizumab-rzaa) SORILUX FOAM PA Antivirals - Topical 3 (calcipotriene) acyclovir topical oint 1 QL(1 gm daily) PA; Must use Burn Products STELARA SOLN SC 45 AcariaHealth 4 Specialty Rx at MG/0.5ML ( ) (Silver Sulfadiazine) SSD 1 ustekinumab 1-844-538- CREA 4661;LA 1 PA; Must use mafenide acetate pack STELARA SOSY SC 90 AcariaHealth 4 Specialty Rx at silver sulfadiazine crea 1 MG/ML (ustekinumab) 1-844-538- SULFAMYLON CREA 85 4661;LA MG/GM (mafenide 3 tazarotene crea 1 acetate) TAZORAC CREA 0.05 % Corticosteroids - Topical 2 (tazarotene)

58 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Clobetasol Propionate betamethasone Emollient Base) dipropionate (topical) 1 CLOBETASOL lotn PROPIONATE E, 1 CLOBETASOL betamethasone PROPIONATE dipropionate (topical) 1 EMOLLIENT CREA oint (Clobetasol Propionate 1 betamethasone Emulsion) TOVET FOAM dipropionate 1 (Clobetasol Propionate) 1 augmented crea CLODAN SHAM betamethasone (Diflorasone Diacetate) 1 PSORCON CREA dipropionate 1 augmented gel (Flurandrenolide) NOLIX 1 CREA betamethasone 1 (Fluticasone Propionate) 1 dipropionate BESER LOTN augmented lotn (Hydrocortisone (Topical)) 1 betamethasone ALA-CORT CREA dipropionate 1 (Triamcinolone Acetonide 1 augmented oint (Topical)) TRIDERM CREA ALA SCALP LOTN betamethasone 1 (hydrocortisone 3 valerate crea (topical)) betamethasone 1 ALA-SCALP LOTN valerate foam (hydrocortisone 3 betamethasone 1 (topical)) valerate lotn betamethasone alclometasone 1 1 dipropionate crea valerate oint calcipotriene- ST alclometasone 1 dipropionate oint betamethasone 2 dipropionate oint amcinonide crea 1 calcipotriene- ST; QL(2 gm amcinonide lotn 1 betamethasone 1 daily) dipropionate susp AMCINONIDE OINT 3 CAPEX SHAM (amcinonide) 2 (fluocinolone acetonide) APEXICON E CREA (diflorasone diacetate 2 clobetasol propionate 1 emollient base) crea betamethasone clobetasol propionate 1 dipropionate (topical) 1 emollient base crea crea clobetasol propionate 1 emulsion foam

59 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits clobetasol propionate 1 desoximetasone gel 1 foam 0.05 % ST clobetasol propionate 1 desoximetasone liqd 1 gel 0.25 % clobetasol propionate 1 desoximetasone oint 1 liqd 0.05 %, 0.25 % clobetasol propionate 1 diflorasone diacetate 1 lotn crea clobetasol propionate 1 diflorasone diacetate 1 oint oint EPIFOAM FOAM clobetasol propionate 1 3 sham (pramoxine-hc) fluocinolone acetonide clobetasol propionate 1 1 soln crea fluocinolone acetonide clocortolone pivalate 1 1 crea oil CLODERM CREA fluocinolone acetonide 3 1 (clocortolone pivalate) oint CLODERM CREA 7 fluocinolone acetonide 1 (clocortolone pivalate) soln CLODERM PUMP CREA 3 fluocinonide crea 1 (clocortolone pivalate) CORDRAN TAPE 4 fluocinonide emulsified 1 MCG/SQCM 3 base crea (flurandrenolide) fluocinonide gel 1 CORTANE-B LOTN (hydrocortisone- fluocinonide oint 1 pramoxine- 3 chloroxylenol) fluocinonide soln 1 desonide crea 1 flurandrenolide crea 1 1 desonide gel fluticasone propionate 1 crea desonide lotn 1 fluticasone propionate 1 desonide oint 1 lotn fluticasone propionate 1 DESOXIMETASONE oint CREA 0.05 % 2 (desoximetasone) halobetasol propionate 1 crea desoximetasone crea 1 0.05 %, 0.25 % halobetasol propionate 1 oint

60 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits hydrocortisone (topical) 1 triamcinolone acetonide crea (topical) aers 0.147 1 mg/gm hydrocortisone (topical) 1 lotn triamcinolone acetonide (topical) crea 0.025 %, 1 hydrocortisone (topical) 1 oint 0.1 %, 0.5 % triamcinolone acetonide hydrocortisone butyrate 1 crea (topical) lotn 0.025 %, 1 hydrocortisone butyrate 0.1 % hydrophilic lipo base 1 triamcinolone acetonide crea (topical) oint 0.025 %, 1 0.1 %, 0.5 % hydrocortisone butyrate 1 oint Eczema Agents DUPIXENT SOPN 300 PA hydrocortisone butyrate 1 4 soln MG/2ML (dupilumab) DUPIXENT SOSY 200 PA hydrocortisone valerate 1 4 crea MG/1.14ML (dupilumab) hydrocortisone valerate PA; Must use 1 DUPIXENT SOSY 300 AcariaHealth oint 4 Specialty Rx at MG/2ML (dupilumab) 1-844-538- mometasone furoate 1 crea 4661;;LA Emollient/Keratolytic Agents mometasone furoate 1 oint (Urea In Lactic Acid Vehicle) UREA 1 mometasone furoate 1 HYDRATING FOAM soln (Urea) CEROVEL, UREA- 1 NUCORT LOTN C40 LOTN (hydrocortisone acetate 3 GORDONS UREA OINT 3 (topical)) (urea) PRAMOSONE E CREA (pramoxine-hc 3 urea lotn 1 emollient base) urea susp 1 PRAMOSONE LOTN 3 (pramoxine-hc) Emollients PRAMOSONE OINT (Lactic Acid (Ammonium RX/OTC 3 (pramoxine-hc) Lactate)) GERI- 1 HYDROLAC 12 CREA prednicarbate crea 1 hyaluronate sodium 1 (emollient) gel prednicarbate oint 1 HYLINATE LOTN TEXACORT SOLN (hyaluronate sodium 3 (hydrocortisone 3 (emollient)) (topical)) 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic is Available AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

61 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits RX/OTC MEDROX-RX OINT PA lactic acid (ammonium 1 lactate) crea (capsaicin-menthol- 3 ) Enzymes - Topical methyl salicylate SANTYL OINT Local Anesthetics - Topical 3 (collagenase) (Cocaine Hcl) C-TOPICAL 1 SOLN Immunomodulating Agents - Topical ANASTIA LOTN 2 imiquimod crea 5 % 1 (lidocaine hcl) CETACAINE AERO Immunosuppressive Agents - Topical (butamben-tetracaine- 3 QL(2 gm daily) pimecrolimus crea 1 benzocaine) tacrolimus (topical) oint QL(2 gm daily); lidocaine hcl soln 1 1 AL(At least 2 0.03 % yrs old) Limited to 3 patches per tacrolimus (topical) oint QL(2 gm daily); lidocaine ptch 1 1 AL(At least 15 day;QL(3 ea 0.1 % yrs old) daily) Keratolytic/Antimitotic Agents lidocaine-prilocaine 1 crea (Salicylic Acid) SALIMEZ 1 NUMBONEX LOTN CREA 2 (lidocaine hcl) (Salicylic Acid) SALITECH 1 FORTE LOTN PREMIUM SCAR PATCH BENSAL HP OINT PTCH (allantoin- 3 (salicylic acid & benzoic 3 lidocaine-petrolatum) acid) Misc. Topical CONDYLOX GEL DRYSOL SOLN 2 2 (podofilox) (aluminum chloride) PODOCON 25 IN XERAC AC SOLN BENZOIN TINCTURE 3 (aluminum chloride in 3 SOLN (podophyllum alcohol) resin) Phosphodiesterase 4 (PDE4) Inhibitors - Topical podofilox soln 1 PA; ST; Limited EUCRISA OINT 3 to 60 gm per salicylic acid crea 6 % 1 (crisaborole) month;QL(2 gm daily) salicylic acid in ammonium lactate 1 Rosacea Agents vehicle foam (Metronidazole (Topical)) 1 ROSADAN CREA salicylic acid lotn 6 % 1 Limit 45gms (Metronidazole (Topical)) 1 per salicylic acid sham 6 % 1 ROSADAN GEL month;QL(1.5 gm daily) Liniments azelaic acid gel 1

62 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits doxycycline (rosacea) PA; ST;QL(1 Diagnostic Drugs 1 ea daily) cpdr GLUCAGEN DIAGNOSTIC PA FINACEA FOAM ( SOLR (glucagon hcl 4 azelaic 3 acid) rdna (diagnostic)) PA; ST;QL(1.5 METOPIRONE CAPS ivermectin (rosacea) 1 3 crea gm daily) (metyrapone) Diagnostic Tests metronidazole (topical) 1 crea 0.75 % FREESTYLE INSULINX Limit 200 per Limit 45gms BLOODGLUCOSE TEST month without metronidazole (topical) per STRIPS STRP ( 2 authorization;Q 1 glucose L(6.7 ea daily); gel 0.75 % month;QL(1.5 blood) gm daily) RX/OTC metronidazole (topical) Limit 200 per 1 FREESTYLE INSULINX month without gel 1 % BLOODGLUCOSE TEST 2 authorization;Q QL(2 ml daily) L(6.7 ea daily); metronidazole (topical) 1 STRP (glucose blood) lotn 0.75 % RX/OTC MIRVASO GEL PA; ST Limit 200 per FREESTYLE LITE TEST (brimonidine tartrate 3 month without STRIPS STRP (glucose 2 authorization;Q (topical)) blood) L(6.7 ea daily); NORITATE CREA PA RX/OTC (metronidazole 4 Limit 200 per (topical)) FREESTYLE TEST month without ORACEA CPDR PA; ST;QL(1 STRIPS STRP (glucose 2 authorization;Q 7 (doxycycline (rosacea)) ea daily) blood) L(6.7 ea daily); RX/OTC RHOFADE CREA PA; ST Limit 200 per (oxymetazoline hcl 3 ONETOUCH ULTRA STRP month without (topical)) 2 authorization;Q SOOLANTRA CREA PA; ST;QL(1.5 (glucose blood) L(6.7 ea daily); 7 (ivermectin (rosacea)) gm daily) RX/OTC Scabicides & Pediculicides Limit 200 per ONETOUCH VERIO TEST month without ivermectin 1 STRIPS STRP (glucose 2 authorization;Q (pediculicide) lotn blood) L(6.7 ea daily); RX/OTC 1 malathion lotn Limit 200 per QL(2 gm daily) PRECISION XTRA BLOOD month without permethrin crea 1 GLUCOSE TEST STRIPS 2 authorization;Q Wound Care Products STRP (glucose blood) L(6.7 ea daily); RX/OTC Limit 15gms REGRANEX GEL DIGESTIVE AIDS - Drugs to Treat Low Digestive 3 per (becaplermin) month;QL(0.5 Enzymes gm daily) Digestive Enzymes DIAGNOSTIC PRODUCTS

63 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CREON CPEP triamterene & (pancrelipase (lipase- 2 hydrochlorothiazide 1 protease-amylase)) caps 25 mg-37.5 mg PANCREAZE CPEP triamterene & QL(2 ea daily) (pancrelipase (lipase- 3 hydrochlorothiazide 1 protease-amylase)) tabs 25 mg-37.5 mg PERTZYE CPEP triamterene & QL(1 ea daily) (pancrelipase (lipase- 3 hydrochlorothiazide 1 protease-amylase)) tabs 50 mg-75 mg SUCRAID SOLN PA; AC 4 Loop Diuretics (sacrosidase) VIOKACE TABS bumetanide tabs 0.5 1 (pancrelipase (lipase- 3 mg, 1 mg protease-amylase)) bumetanide tabs 2 mg 1 QL(5 ea daily) ZENPEP CPEP ST (pancrelipase (lipase- 2 ethacrynic acid tabs 1 protease-amylase)) furosemide soln 1 DIURETICS - Drugs to Treat Heart, Circulation Conditions and Blood Pressure furosemide tabs 1 Carbonic Anhydrase Inhibitors torsemide tabs 10 mg, QL(2 ea daily) 1 acetazolamide cp12 1 20 mg, 5 mg 500 mg torsemide tabs 100 mg 1 QL(2 ea daily) acetazolamide tabs 1 125 mg Potassium Sparing Diuretics QL(4 ea daily) acetazolamide tabs 1 amiloride hcl tabs 1 250 mg KEVEYIS TABS PA spironolactone tabs 1 4 (dichlorphenamide) triamterene caps 1 methazolamide tabs 1 Thiazides and Thiazide-Like Diuretics Diuretic Combinations 1 ALDACTAZIDE TABS 50 chlorothiazide tabs MG-50 MG 2 chlorthalidone tabs 1 (spironolactone & ) DIURIL SUSP hydrochlorothiazide 3 amiloride & (chlorothiazide) 1 hydrochlorothiazide hydrochlorothiazide 1 tabs caps spironolactone & hydrochlorothiazide 1 hydrochlorothiazide 1 tabs tabs indapamide tabs 1

64 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits methyclothiazide tabs 1 ST; Limited to 1 risedronate sodium 1 per 1 tabs 150 mg month;QL(0.04 metolazone tabs ea daily) ENDOCRINE AND METABOLIC AGENTS - risedronate sodium ST MISC. - Drugs to Treat Bone Disease and tabs 30 mg, 35 mg, 5 1 Regulate Hormones mg Bone Density Regulators TYMLOS SOPN PA; LA 4 (abaloparatide) alendronate sodium 1 soln 70 mg/75ml Fertility Regulators QL(1 ea daily) alendronate sodium 1 Check plan tabs 10 mg, 5 mg documents for coverage;QL(1 alendronate sodium Limit 1 tab per 1 week;QL(0.144 clomiphene citrate tabs 1 5 ea per fill tabs 35 mg ea daily) retail,00 ea per fill mail,15 ea alendronate sodium 1 per 30 days tabs 40 mg retail) alendronate sodium Limit 1 tab per Growth Hormone Receptor Antagonists 1 week;QL(0.15 SOMAVERT SOLR PA; LA tabs 70 mg ea daily) 4 (pegvisomant) PA; Limit 4 BINOSTO TBEF Growth Hormones 3 packets per (alendronate sodium) month;QL(0.15 PA; Must use ea daily) HUMATROPE COMBO PACK SOLR 4 AcariaHlth Sp 1 Rx 1-844-538- calcitonin (salmon) soln (somatropin) 4661;LA etidronate disodium HUMATROPE SOLR PA; LA 1 4 tabs (somatropin) FORTEO SOPN PA; LA NORDITROPIN FLEXPRO PA; LA (teriparatide 4 SOPN 10 MG/1.5ML, 5 4 (recombinant)) MG/1.5ML (somatropin) FOSAMAX PLUS D TABS PA; Limit 4 per NORDITROPIN FLEXPRO PA; Refill (alendronate sodium- 3 month;QL(0.15 SOPN 15 MG/1.5ML, 30 4 82%;LA cholecalciferol) ea daily) MG/3ML (somatropin) SEROSTIM SOLR PA; LA ibandronate sodium Limit 1 per 1 month;QL(0.04 (somatropin (non- 4 tabs ea daily) refrigerated)) MIACALCIN SOLN PA; LA ZORBTIVE SOLR PA; LA 4 (calcitonin (salmon)) (somatropin (non- 4 NATPARA CART PA; LA refrigerated)) (parathyroid hormone 4 Hormone Receptor Modulators (recombinant)) EVISTA TABS (raloxifene PV PROLIA SOSY PA; LA 7 4 hcl) (denosumab)

65 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits OSPHENA TABS 3 levocarnitine (metabolic 1 (ospemifene) modifiers) soln PV raloxifene hcl tabs 5 levocarnitine (metabolic 1 modifiers) tabs Insulin-Like Growth Factors (Somatomedins) MYALEPT SOLR PA; LA INCRELEX SOLN PA; LA 4 4 (metreleptin) (mecasermin) nitisinone caps 10 mg 4 PA LHRH/GnRH Agonist Analog Pituitary PA FENSOLVI KIT PA nitisinone caps 2 mg, 5 1 (leuprolide acetate 3 mg (cpp) (6 month)) NITYR TABS (nitisinone) 4 PA SYNAREL SOLN 2 ORFADIN CAPS 10 MG PA (nafarelin acetate) 7 (nitisinone) Metabolic Modifiers ORFADIN CAPS 20 MG PA 3 BUPHENYL POWD PA (nitisinone) (sodium 7 ORFADIN SUSP 4 MG/ML PA phenylbutyrate) 4 (nitisinone) BUPHENYL TABS PA PALYNZIQ SOSY PA (sodium 7 4 (pegvaliase-pqpz) phenylbutyrate) paricalcitol caps 1 calcitriol caps 0.25 mcg 1 RAVICTI LIQD ( QL(4 ea daily) glycerol 4 calcitriol caps 0.5 mcg 1 phenylbutyrate) calcitriol soln 1 mcg/ml 1 Specialty Drug sapropterin 4 refer to CARBAGLU TABS PA dihydrochloride pack Caremark SP 4 (carglumic acid) RX Specialty Drug cinacalcet hcl tabs 1 PA sapropterin 4 refer to CYSTADANE POWD PA dihydrochloride tbso Caremark SP 4 RX (betaine) PA sodium phenylbutyrate 4 doxercalciferol caps 2 powd GALAFOLD CAPS PA; QL(0.5 ea sodium phenylbutyrate PA 4 4 (migalastat hcl) daily) tabs Specialty Drug STRENSIQ SOLN PA KUVAN PACK 4 ( 7 refer to (asfotase alfa) sapropterin Caremark SP XURIDEN PACK ( dihydrochloride) RX uridine 4 triacetate) KUVAN TBSO Specialty Drug ( 7 refer to Posterior Pituitary Hormones sapropterin Caremark SP dihydrochloride) RX

66 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DDAVP SOLN NA 0.01 % (Norethindrone Acetate- (desmopressin acetate 2 Ethinyl Estradiol) 1 refrigerated) FYAVOLV, JINTELI TABS ANGELIQ TABS desmopressin acetate 1 3 spray refrigerated soln (drospirenone-estradiol) desmopressin acetate CLIMARA PRO PTWK 1 (estradiol- 2 spray soln levonorgestrel) desmopressin acetate 1 COMBIPATCH PTTW tabs 0.1 mg (estradiol & 3 QL(6 ea daily) desmopressin acetate 1 norethindrone acetate) tabs 0.2 mg DUAVEE TABS NOCTIVA EMUL PA 3 (conjugated estrogens- 3 (desmopressin acetate) bazedoxifene) STIMATE SOLN 3 estradiol & (desmopressin acetate) norethindrone acetate 1 Prolactin Inhibitors tabs cabergoline tabs 1 norethindrone acetate- 1 ethinyl estradiol tabs Somatostatic Agents ORIAHNN CPPK PA octreotide acetate soln PA (elagolix sodium- 4 100 mcg/ml, 200 4 estradiol-norethindrone mcg/ml, 50 mcg/ml acetate) PA; LA PREFEST TABS octreotide acetate soln 3 1000 mcg/ml, 500 4 (estradiol-norgestimate) mcg/ml PREMPHASE TABS (conjugated estrogens- SANDOSTATIN SOLN 500 PA; LA 2 MCG/ML (octreotide 7 medroxyprogesterone acetate) acetate) SIGNIFOR SOLN PA; LA PREMPRO TABS (conjugated estrogens- (pasireotide 4 2 diaspartate) medroxyprogesterone ) Vasopressin Receptor Antagonists acetate JYNARQUE TBPK 15 MG PA Estrogens 4 (tolvaptan) Limit 8 patches (Estradiol) DOTTI, 1 per ESTROGENS - Hormone Replacement/Modifying LYLLANA PTTW month;QL(0.29 Drugs ea daily) Estrogen Combinations Limit 8 patches (Estradiol & Norethindrone 2 per ALORA PTTW (estradiol) month;QL(0.29 Acetate) AMABELZ, 1 LOPREEZA, MIMVEY, ea daily) MIMVEY LO TABS

67 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DIVIGEL GEL 0.25 ciprofloxacin hcl tabs 1 MG/0.25GM, 0.5 3 MG/0.5GM, 1 MG/GM ciprofloxacin susr 1 (estradiol) ELESTRIN GEL ciprofloxacin- QL(14 ea per 3 ( ) ciprofloxacin hcl tb24 1 fill retail,14 ea estradiol per fill mail) estradiol pttw td 0.025 Limit 8 patches 1000 mg mg/24hr, 0.0375 per ciprofloxacin- QL(3 ea per fill 1 month;QL(0.29 ciprofloxacin hcl tb24 1 retail,3 ea per mg/24hr, 0.05 mg/24hr, fill mail) 0.075 mg/24hr, 0.1 ea daily) 500 mg mg/24hr levofloxacin soln 25 1 estradiol ptwk td 0.025 Limit 4 patches mg/ml mg/24hr, 0.05 mg/24hr, per QL(14 ea per levofloxacin tabs 250 1 0.06 mg/24hr, 0.075 1 month;QL(0.14 mg, 500 mg, 750 mg fill retail) mg/24hr, 0.1 mg/24hr, 3 ea daily) 37.5 mcg/24hr moxifloxacin hcl tabs 1 estradiol tabs or 0.5 1 ofloxacin tabs 300 mg 1 mg, 1 mg, 2 mg QL(28 ea per Limit 50gms 90 days ESTROGEL GEL ofloxacin tabs 400 mg 1 3 per retail,28 ea per (estradiol) month;QL(1.67 90 days mail) gm daily) EVAMIST SOLN GASTROINTESTINAL AGENTS - MISC. - 3 Miscellaneous Gastrointestinal Drugs (estradiol) MENEST TABS Farnesoid X Receptor (FXR) Agonists 2 OCALIVA TABS 10 MG PA (esterified estrogens) 4 Limit 4 patches (obeticholic acid) MENOSTAR PTWK OCALIVA TABS 5 MG PA; ST 3 per 4 (estradiol) month;QL(0.14 (obeticholic acid) 3 ea daily) Gallstone Solubilizing Agents PREMARIN TABS OR 0.3 QL(1 ea daily) CHENODAL TABS PA MG, 0.45 MG, 0.625 MG, 4 1.25 MG (estrogens, 2 (chenodiol) conjugated) ursodiol caps 300 mg 2 PREMARIN TABS OR 0.9 ursodiol tabs 250 mg, MG (estrogens, 2 1 500 mg conjugated) Gastrointestinal Chloride Channel Activators FLUOROQUINOLONES - Drugs to Treat Bacterial AMITIZA CAPS Infections 2 (lubiprostone) Fluoroquinolones CIPRO SUSR 5 Gastrointestinal Stimulants GM/100ML, 500 MG/5ML 2 metoclopramide hcl 1 (ciprofloxacin) soln

68 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SFROWASA ENEM metoclopramide hcl 1 2 tabs (mesalamine) STELARA SOLN IV 130 PA; LA metoclopramide hcl 1 tbdp MG/26ML (ustekinumab 4 METOCLOPRAMIDE ODT (iv)) TBDP (metoclopramide 3 sulfasalazine tabs 1 QL(8 ea daily) hcl) QL(8 ea daily) Inflammatory Bowel Agents sulfasalazine tbec 1 balsalazide disodium Limit 280 caps Intestinal Acidifiers 1 per month;QL(9 caps (Lactulose ea daily) (Encephalopathy)) CIMZIA KIT PA; LA 1 4 ENULOSE, GENERLAC (certolizumab pegol) SOLN CIMZIA STARTER KIT KIT PA; LA 4 lactulose 1 (certolizumab pegol) (encephalopathy) soln DIPENTUM CAPS 3 Irritable Bowel Syndrome (IBS) Agents (olsalazine sodium) PA; Must use alosetron hcl tabs 2 AcariaHealth LINZESS CAPS INFLECTRA SOLR 2 4 Specialty Rx at (linaclotide) (infliximab-dyyb) 1-844-538- VIBERZI TABS 100 MG PA 4661 3 mesalamine cp24 or QL(4 ea daily) (eluxadoline) 1 VIBERZI TABS 75 MG PA; ST 0.375 gm 3 (eluxadoline) QL(6 ea daily) mesalamine cpdr or 1 400 mg Peripheral Opioid Receptor Antagonists QL(60 ml daily) alvimopan caps 1 mesalamine enem re 4 1 gm MOVANTIK TABS 12.5 MG QL(1 ea daily) 3 mesalamine supp re 1 (naloxegol oxalate) 1000 mg MOVANTIK TABS 25 MG QL(1 ea daily) QL(4 ea daily) 3 mesalamine tbec or 1.2 1 (naloxegol oxalate) gm RELISTOR SOLN SC 12 PA; LA MG/0.6ML, 8 MG/0.4ML mesalamine tbec or 1 4 800 mg (methylnaltrexone PENTASA CPCR 250 MG PA bromide) 3 (mesalamine) RELISTOR TABS OR 150 PA; ST PENTASA CPCR 500 MG PA; QL(8 ea MG (methylnaltrexone 4 3 (mesalamine) daily) bromide) PA; Must use Phosphate Binder Agents REMICADE SOLR AcariaHealth (Calcium Acetate RX/OTC 4 Specialty Rx at (infliximab) (Phosphate Binder)) 1 1-844-538- CALPHRON TABS 4661;;LA

69 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AURYXIA TABS ( PA; ST ferric 3 GENITOURINARY AGENTS - MISCELLANEOUS citrate) - Miscellaneous Drugs to Treat Reproductive calcium acetate Organs and Urinary System (phosphate binder) 1 Acidifiers caps K-PHOS NO 2 TABS calcium acetate RX/OTC (potassium & sodium 2 (phosphate binder) 1 acid phosphates) tabs Alkalinizers FOSRENOL PACK 1000 (Pot & Sod Citrates MG, 750 MG (lanthanum 3 W/Citric Ac) CYTRA-3 1 carbonate) SYRP QL(3 ea daily) (Potassium Citrate-Citric lanthanum carbonate 1 Acid) CYTRA K 1 chew 1000 mg CRYSTALS, TARON- CRYSTALS PACK lanthanum carbonate 1 chew 500 mg (Potassium Citrate-Citric 1 RX/OTC QL(4 ea daily) Acid) CYTRA-K SOLN lanthanum carbonate 1 chew 750 mg (Sodium Citrate & Citric 1 RX/OTC Acid) CYTRA-2 SOLN PHOSLYRA SOLN ORACIT SOLN ( (calcium acetate 3 sodium 3 (phosphate binder)) citrate & citric acid) pot & sod citrates sevelamer carbonate 1 1 pack 0.8 gm w/citric ac soln QL(5 ea daily) potassium citrate sevelamer carbonate 1 pack 2.4 gm (alkalinizer) tbcr 15 1 meq, 540 mg sevelamer carbonate 1 RX/OTC tabs 800 mg potassium citrate-citric 1 acid soln sevelamer hcl tabs 400 PA; ST 1 RX/OTC mg sodium citrate & citric 1 PA; ST;QL(16 acid soln sevelamer hcl tabs 800 1 mg ea daily) Cystinosis Agents CYSTAGON CAPS PA Short Bowel Syndrome (SBS) Agents 4 (cysteamine bitartrate) PA; ST; PROCYSBI CPDR 25 MG, GATTEX KIT Specialty Drug 4 refer to 75 MG (cysteamine 4 (teduglutide (rdna)) Caremark SP bitartrate) RX;LA PROCYSBI PACK 300 MG, PA Tryptophan Hydroxylase Inhibitors 75 MG (cysteamine 4 ) XERMELO TABS PA; ST; Not bitartrate 4 available Interstitial Cystitis Agents (telotristat etiprate) through mail

70 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ELMIRON CAPS QL(3 ea daily) febuxostat tabs 80 mg 1 QL(1 ea daily) (pentosan polysulfate 3 MITIGARE CAPS sodium) 7 (colchicine) Prostatic Hypertrophy Agents Uricosurics alfuzosin hcl tb24 1 QL(1 ea daily) probenecid tabs 1 CARDURA XL TB24 (doxazosin mesylate 3 HEMATOLOGICAL AGENTS - MISC. - Drugs to (bph)) Treat Blood Disorders dutasteride caps 1 AL(At least 40 Antihemophilic Products yrs old) ADVATE SOLR PA; LA dutasteride-tamsulosin 1 (antihemophilic factor 4 hcl caps (rcmb) plasma/albumin QL(1 ea daily); free (rahf-pfm)) finasteride tabs 1 AL(At least 40 PA; Must use yrs old) ADYNOVATE SOLR AcariaHealth (antihemophilic factor 4 Specialty Rx at 1 silodosin caps 4 mg (recombinant) pegylated) 1-844-538- 4661;LA silodosin caps 8 mg 1 QL(1 ea daily) AFSTYLA KIT PA; Must use QL(2 ea daily) AcariaHealth tamsulosin hcl caps 1 (antihemophilic factor 4 Specialty Rx at (recombinant) single Urinary Stone Agents 1-844-538- chain) 4661;LA LITHOSTAT TABS 3 ALPHANATE/VON PA; Must use (acetohydroxamic acid) WILLEBRANDFACTOR AcariaHealth THIOLA EC TBEC COMPLEX/HUMAN SOLR Specialty Rx at 3 (tiopronin) (antihemophilic 4 1-844-538- 4661;LA THIOLA TABS (tiopronin) 3 factor/von willebrand factor complex GOUT AGENTS - Drugs to Treat Gout (human)) PA; Must use Gout Agent Combinations ALPHANINE SD SOLR AcariaHealth 4 Specialty Rx at colchicine w/ 1 (coagulation factor ix) probenecid tabs 1-844-538- 4661;LA Gout Agents ALPROLIX SOLR PA; Must use allopurinol tabs 100 mg 1 QL(3 ea daily) AcariaHealth (coagulation factor ix 4 Specialty Rx at (recomb) fc fusion protein allopurinol tabs 300 mg 1 QL(2 ea daily) 1-844-538- (rfixfc)) 4661;LA colchicine caps 1 PA; Must use BENEFIX KIT AcariaHealth colchicine tabs 1 (coagulation factor ix 4 Specialty Rx at (recombinant)) 1-844-538- febuxostat tabs 40 mg 1 QL(2 ea daily) 4661;LA

71 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; Must use PA; Must use COAGADEX SOLR AcariaHealth JIVI SOLR (antihemophil AcariaHealth (coagulation factor x 4 Specialty Rx at fact(rcmb) pegylated-aucl 4 Specialty Rx at (human)) 1-844-538- (bdd-rfviii peg-aucl)) 1-844-538- 4661;;LA 4661;LA PA; MUST PA; Must use CORIFACT KIT (factor USE ACARIA KCENTRA KIT AcariaHealth xiii concentrate 4 SPECIALTY (prothrombin complex 4 Specialty Rx at (human)) RX 844-538- concentrate human) 1-844-538- 4661;LA 4661;LA ELOCTATE SOLR PA; Must use PA; MUST AcariaHealth KOATE SOLR USE ACARIA ( antihemophilic factor 4 Specialty Rx at (antihemophilic factor 3 SPECIALTY (rcmb) fc fusion 1-844-538- (human)) RX 844-538- protein(bdd-rfviiifc)) 4661;LA 4661;LA PA; MUST PA; MUST FEIBA SOLR USE ACARIA KOATE-DVI SOLR USE ACARIA (antiinhibitor coagulant 4 SPECIALTY (antihemophilic factor 3 SPECIALTY complex) RX 844-538- (human)) RX 844-538- 4661;LA 4661;LA PA; MUST KOVALTRY SOLR PA; LA HEMOFIL M SOLR USE ACARIA (antihemophilic factor 4 (antihemophilic factor 3 SPECIALTY (rcmb) plasma/albumin (human)) RX 844-538- free (rahf-pfm)) 4661;LA PA; Must use HUMATE-P SOLR PA; Must use MONOCLATE-P KIT AcariaHealth (antihemophilic AcariaHealth (antihemophilic factor 4 Specialty Rx at factor/von willebrand 4 Specialty Rx at (human)) 1-844-538- 1-844-538- 4661 ;LA factor complex 4661;LA (human)) PA; Must use IDELVION SOLR 1000 PA; Must use MONONINE SOLR AcariaHealth 4 Specialty Rx at UNIT, 2000 UNIT, 250 AcariaHealth (coagulation factor ix) UNIT, 500 UNIT Specialty Rx at 1-844-538- 4661;LA (coagulation factor ix 4 1-844-538- recomb albumin fusion 4661;LA NOVOEIGHT SOLR PA; Must use AcariaHealth protein (rix-fp)) (antihemophilic factor 4 Specialty Rx at IDELVION SOLR 3500 PA; MUST (rcmb) bd truncated (bd 1-844-538- trunc-rfviii)) UNIT (coagulation factor USE ACARIA 4661;LA 4 SPECIALTY PA; Must use ix recomb albumin RX 844-538- NOVOSEVEN RT SOLR fusion protein (rix-fp)) ( 4 AcariaHlth Sp 4661;LA coagulation factor viia Rx 1-844-538- PA; Must use (recombinant)) 4661;LA IXINITY SOLR AcariaHealth NUWIQ KIT PA; MUST (coagulation factor ix 4 Specialty Rx at USE ACARIA ( (recombinant)) 1-844-538- antihemophilic factor 4 SPECIALTY 4661;LA (rcmb) simoctocog RX 844-538- alfa(bdd-rfviii,sim)) 4661;LA

72 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits OBIZUR SOLR PA; Must use XYNTHA SOLOFUSE KIT PA; Must use AcariaHealth AcariaHealth (antihemophilic factor 4 Specialty Rx at (antihemophilic factor 4 Specialty Rx at (recombinant porcine) 1-844-538- (rcmb) moroctocog 1-844-538- (rpfviii)) 4661;LA alfa(bdd-rfviii,mor)) 4661;LA PA; Must use Bradykinin B2 Receptor Antagonists PROFILNINE SD SOLR AcariaHealth PA; Must use 4 Specialty Rx at (factor ix complex) AcariaHealth 1-844-538- icatibant acetate soln 4 Specialty Rx at 4661;LA 1-844-538- PA; Must use 4661;;LA PROFILNINE SOLR AcariaHealth 4 Specialty Rx at Hemataologic - Tyrosine Kinase Inhibitors (factor ix complex) 1-844-538- TAVALISSE TABS 100 MG PA; ST 4 4661;LA (fostamatinib disodium) PA; Must use TAVALISSE TABS 150 MG PA RECOMBINATE SOLR 4 AcariaHealth (fostamatinib disodium) (antihemophilic factor 4 Specialty Rx at (recombinant)) 1-844-538- Hematorheologic Agents 4661;LA pentoxifylline tbcr 1 QL(3 ea daily) PA; Must use RIXUBIS SOLR AcariaHealth Human Protein C ( coagulation factor ix 4 Specialty Rx at CEPROTIN SOLR PA; LA (recombinant)) 1-844-538- 4661;LA (protein c concentrate 4 (human)) TRETTEN SOLR PA; Must use (coagulation factor xiii AcariaHealth Platelet Aggregation Inhibitors 4 Specialty Rx at a-subunit 1-844-538- anagrelide hcl caps 1 (recombinant)) 4661;LA aspirin-dipyridamole 1 PA; Must use cp12 VONVENDI SOLR (von AcariaHealth BRILINTA TABS 60 MG QL(2 ea daily) willebrand factor 4 Specialty Rx at 2 (recombinant)) 1-844-538- (ticagrelor) 4661;LA BRILINTA TABS 90 MG 2 WILATE KIT PA; Must use (ticagrelor) (antihemophilic AcariaHealth 1 QL(2 ea daily) factor/von willebrand 4 Specialty Rx at cilostazol tabs 1-844-538- factor complex QL(2 ea daily) 4661;LA clopidogrel bisulfate 1 (human)) tabs XYNTHA KIT PA; Must use AcariaHealth dipyridamole tabs 1 (antihemophilic factor 4 Specialty Rx at (rcmb) moroctocog 1-844-538- prasugrel hcl tabs 1 alfa(bdd-rfviii,mor)) 4661;LA HEMATOPOIETIC AGENTS - Drugs to Treat Blood Disorders Agents for Gaucher Disease

73 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CERDELGA CAPS PA PA; Must use 4 (eliglustat tartrate) GRANIX SOSY (tbo- AcariaHealth CEREZYME SOLR PA; LA 4 Specialty Rx at 4 filgrastim) 1-844-538- (imiglucerase) 4661 4 PA; ST LEUKINE SOLR PA; LA miglustat caps 4 (sargramostim) ZAVESCA CAPS PA; ST 7 MULPLETA TABS PA (miglustat) 4 (lusutrombopag) Agents for Sickle Cell Disease NIVESTYM SOLN 300 PA; ST 4 DROXIA CAPS MCG/ML (filgrastim-aafi) ( 2 hydroxyurea (sickle NIVESTYM SOLN 480 PA cell anemia)) MCG/1.6ML (filgrastim- 4 SIKLOS TABS 100 MG PA; ST;AC aafi) ( 4 hydroxyurea (sickle NIVESTYM SOSY 300 PA cell anemia)) MCG/0.5ML, 480 SIKLOS TABS 1000 MG PA; AC MCG/0.8ML (filgrastim- 4 (hydroxyurea (sickle 4 aafi) cell anemia)) PROMACTA PACK 12.5 PA; QL(1 ea Folic Acid/Folates MG (eltrombopag 4 daily) (Folic Acid) CVS FOLIC PV olamine) ACID, FA-8, FOLATE, GNP PROMACTA PACK 25 MG PA 4 FOLIC ACID, HM FOLIC (eltrombopag olamine) ACID, PX FOLIC ACID, QC 5 FOLIC ACID, RA FOLIC PROMACTA TABS 12.5 PA; QL(1 ea ACID, SM FOLIC ACID, YL MG, 25 MG, 50 MG, 75 MG 4 daily) FOLIC ACID TABS (eltrombopag olamine) RETACRIT SOLN 10000 PA (Folic Acid) KP FOLIC 1 RX/OTC ACID TABS 1 MG UNIT/ML, 2000 UNIT/ML, 20000 UNIT/2ML, 3000 (Folic Acid) KP FOLIC 5 PV 4 ACID TABS 800 MCG UNIT/ML, 4000 UNIT/ML, 40000 UNIT/ML ( RX/OTC epoetin folic acid tabs 1 mg 1 alfa-epbx) folic acid tabs 400 mcg, PV PA; ST; Must 5 use 800 mcg UDENYCA SOSY 4 AcariaHealth Hematopoietic Growth Factors (pegfilgrastim-cbqv) Specialty Rx at FULPHILA SOSY PA 1-844-538- 4 (pegfilgrastim-jmdb) 4661 PA; Must use PA; Must use AcariaHealth ZARXIO SOSY AcariaHealth GRANIX SOLN (tbo- 4 Specialty Rx at 4 Specialty Rx at (filgrastim-sndz) filgrastim) 1-844-538- 1-844-538- 4661 4661;;LA ZIEXTENZO SOSY PA; ST 4 (pegfilgrastim-bmez)

74 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(1 ea daily) Hematopoietic Mixtures flurazepam hcl caps 30 1 FOLIVANE-F CAPS mg (ferrous fumarate-iron midazolam hcl syrp 1 polysaccharide 2 QL(2 ea daily) complex-folic acid-c-b3) temazepam caps 15 1 INTEGRA F CAPS mg QL(1 ea daily) (ferrous fumarate-iron temazepam caps 22.5 1 polysaccharide 2 mg, 30 mg complex-folic acid-c-b3) temazepam caps 7.5 1 HEMOSTATICS - Drugs to Stop Bleeding/Treat mg Blood Disorders triazolam tabs 0.125 1 Hemostatics - Systemic mg aminocaproic acid soln 1 triazolam tabs 0.25 mg 1 QL(1 ea daily) aminocaproic acid tabs 1 zaleplon caps 1 QL(1 ea daily) CYKLOKAPRON SOLN PA zolpidem tartrate tabs QL(1 ea daily) 7 1 (tranexamic acid) or 10 mg, 5 mg tranexamic acid soln iv PA QL(1 ea daily) 4 zolpidem tartrate tbcr or 1 1000 mg/10ml 12.5 mg, 6.25 mg tranexamic acid tabs or QL(6 ea daily,5 Orexin Receptor Antagonists 1 day(s) limit) 650 mg BELSOMRA TABS ST; QL(1 ea 2 HYPNOTICS/SEDATIVES/SLEEP DISORDER (suvorexant) daily) AGENTS Selective Melatonin Receptor Agonists Barbiturate Hypnotics HETLIOZ CAPS PA; ST 4 BUTISOL SODIUM TABS ( ) 3 tasimelteon (butabarbital sodium) ramelteon tabs 1 ST; QL(1 ea phenobarbital elix 1 daily) LAXATIVES - Bowel Treatment Drugs phenobarbital soln 1 Laxative Combinations phenobarbital tabs 1 (Bisacodyl-Peg 3350-Pot QL(1 ea per fill Chloride-Sod Bicarb-Sod 5 retail); PV Non-Barbiturate Hypnotics Chloride) GAVILYTE-H, DORAL TABS PEG-PREP KIT 7 (quazepam) (Peg 3350-Kcl-Nacl-Na PA; PV Sulfate-Na Ascorbate- estazolam tabs 1 Ascorbic Acid) PEG- 5 QL(1 ea daily) 3350/ELECTROLYTES/AS eszopiclone tabs 1 CORBATE SOLR QL(2 ea daily) (Peg 3350-Kcl-Sod Bicarb- QL(4000 ml per flurazepam hcl caps 15 1 mg Sod Chloride-Sod Sulfate) 5 fill retail); PV GAVILYTE-C, GAVILYTE- G SOLR

75 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Peg 3350-Potassium PV peg 3350-kcl-sod QL(4000 ml per Chloride-Sod Bicarbonate- bicarb-sod chloride-sod 5 fill retail); PV Sod Chloride) GAVILYTE- 5 sulfate solr N/FLAVOR PACK, TRILYTE SOLR peg 3350-potassium PV CLENPIQ SOLN (sodium PV chloride-sod 5 bicarbonate-sod picosulfate-magnesium 5 oxide-anhydrous citric chloride solr acid) PLENVU SOLR (peg PA; PV COLYTE-FLAVOR PACKS QL(4000 ml per 3350-kcl-nacl-na 5 SOLR (peg 3350-kcl- fill retail); PV sulfate-na ascorbate- sod bicarb-sod 7 ascorbic acid) chloride-sod sulfate) SUPREP BOWEL PREP PV GOLYTELY SOLR 2.82 PA; QL(4000 KIT SOLN (sodium GM-21.5 GM-227.1 GM- ea per fill sulfate-potassium 5 5.53 GM-6.36 GM (peg retail); PV sulfate-magnesium 3350-kcl-sod bicarb- 5 sulfate) sod chloride-sod Laxatives - Miscellaneous sulfate) (Lactulose) CONSTULOSE 1 GOLYTELY SOLR 2.97 QL(4000 ml per SOLN GM-22.74 GM-236 GM- fill retail); PV (Polyethylene Glycol 3350) Limit 528gms 5.86 GM-6.74 GM (peg 7 CLEARLAX, CVS per 3350-kcl-sod bicarb- PURELAX, EQ month;QL(17.6 sod chloride-sod CLEARLAX, EQL gm daily) sulfate) CLEARLAX, GAVILAX, GENTLELAX, GLYCOLAX, MOVIPREP SOLR (peg PA; PV GNP CLEARLAX, 3350-kcl-nacl-na 7 GOODSENSE CLEARLAX, 1 sulfate-na ascorbate- HM CLEARLAX, KLS ascorbic acid) LAXACLEAR, QC NATURA-LAX, SB NULYTELY SOLR (peg PV POLYETHYLENE GLYCOL 3350-potassium 3350, SM CLEARLAX, chloride-sod 7 SMOOTH LAX, TGT bicarbonate-sod POWDERLAX POWD chloride) Limit 528gms (Polyethylene Glycol 3350) per NULYTELY/FLAVOR PV RA LAXATIVE POWD 17 1 GM/SCOOP month;QL(17.6 PACKS SOLR (peg 3350- gm daily) potassium chloride-sod 7 bicarbonate-sod lactulose soln 1 chloride) Limit 528gms PA; PV peg 3350-kcl-nacl-na polyethylene glycol 1 per sulfate-na ascorbate- 5 3350 powd month;QL(17.6 ascorbic acid solr gm daily) Saline Laxatives

76 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits OSMOPREP TABS PA; PV (Bisacodyl) BISACODYL Available for (sodium phosphate LAXATIVE, BISCOLAX, members in monobasic-sodium 5 CVS BISACODYL, CVS non- ) GENTLE LAXATIVE, grandfathered phosphate dibasic GENTLE LAXATIVE, GNP plans ages 50- Stimulant Laxatives GENTLE LAXATIVE, GNP 74;AL(At least (Bisacodyl) ALOPHEN, Available for LAXATIVE, HM LAXATIVE, 1 50 yrs old - Up BISACODYL EC, members in LAXATIVE, QC GENTLE to 74 yrs old); CORRECT, CORRECTOL, non- LAXATIVE, RA FAST PV CVS BISACODYL, CVS C- grandfathered RELIEF LAXATIVE, RA LAX LAXATIVE, CVS plans ages 50- STIMULANT LAXATIVE, GENTLE LAXATIVE, CVS 74;AL(At least SB LAXATIVE, SM GENTLE LAXATIVE 50 yrs old - Up LAXATIVE, THE MAGIC WOMENS, DUCODYL, EQ to 74 yrs old); BULLET SUPP GENTLE LAXATIVE, EQ PV Available for WOMENS LAXATIVE, EQL members in GENTLE LAXATIVE, EQL non- LAXATIVE, EQL WOMANS grandfathered (Bisacodyl) RA LAXATIVE 1 plans ages 50- LAXATIVE, EX-LAX TBEC 5 MG ULTRA, FEENAMINT, 74;AL(At least GENTLE LAXATIVE, GNP 50 yrs old - Up BISA-LAX, GNP GENTLE to 74 yrs old); LAXATIVE, GNP PV LAXATIVE, GNP Available for WOMENS GENTLE members in LAXATIVE, GNP 1 non- WOMENS LAXATIVE, grandfathered GOODSENSE bisacodyl supp 1 plans ages 50- BISACODYL EC, 74;AL(At least GOODSENSE WOMENS 50 yrs old - Up LAXATIVE, HM LAXATIVE, to 74 yrs old); KP BISACODYL, PV LAXATIVE, PX LAXATIVE, QC GENTLE LAXATIVE, MACROLIDES - Drugs to Treat Bacterial RA WOMENS LAXATIVE, Infections SB BISACODYL Azithromycin LAXATIVE EC, SB GENTLE LAX-WOMEN, azithromycin pack 1 gm 1 SM GENTLE LAXATIVE, SM WOMANS LAXATIVE, azithromycin susr 100 1 STIMULANT LAXATIVE, mg/5ml, 200 mg/5ml TGT GENTLE LAXATIVE, azithromycin tabs 250 QL(6 ea per fill TGT WOMENS LAXATIVE, 1 retail) VERACOLATE, WOMANS mg QL(3 ea daily) LAXATIVE, WOMENS azithromycin tabs 500 1 LAXATIVE TBEC mg QL(10 ea per azithromycin tabs 600 1 mg fill retail) Clarithromycin

77 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FEMCAP DEVI ( PV clarithromycin susr 125 1 cervical 5 mg/5ml, 250 mg/5ml caps) OMNIFLEX DIAPHRAGM PV clarithromycin tabs 250 1 5 mg, 500 mg DPRH (diaphragms) QL(14 ea per WIDE-SEAL SILICONE PV clarithromycin tb24 500 1 mg fill retail) DIAPHRAGM KIT 60 DPRH (diaphragm wide 5 Erythromycins seal) (Erythromycin Base) ERY- 1 WIDE-SEAL SILICONE PV TAB TBEC DIAPHRAGM KIT 65 (Erythromycin DPRH (diaphragm wide 5 Ethylsuccinate) E.E.S. 400 1 ) TABS seal (Erythromycin Stearate) WIDE-SEAL SILICONE PV DIAPHRAGM KIT 70 ERYTHROCIN STEARATE 1 5 TABS DPRH (diaphragm wide seal) erythromycin base 1 cpep 250 mg WIDE-SEAL SILICONE PV DIAPHRAGM KIT 75 5 erythromycin base tabs 1 DPRH (diaphragm wide 250 mg, 500 mg seal) erythromycin base tbec WIDE-SEAL SILICONE PV 250 mg, 333 mg, 500 1 DIAPHRAGM KIT 80 mg DPRH (diaphragm wide 5 seal) erythromycin 1 ethylsuccinate susr WIDE-SEAL SILICONE PV DIAPHRAGM KIT 85 erythromycin 1 5 ethylsuccinate tabs DPRH (diaphragm wide seal) Fidaxomicin WIDE-SEAL SILICONE PV DIFICID TABS 200 MG 3 DIAPHRAGM KIT 90 (fidaxomicin) DPRH (diaphragm wide 5 ) MEDICAL DEVICES AND SUPPLIES seal WIDE-SEAL SILICONE PV Contraceptives DIAPHRAGM KIT 95 DPRH (diaphragm wide 5 CAYA DPRH (diaphragm QL(1 ea per 5 365 days seal) arc-spring) retail); PV Diabetic Supplies FC FEMALE CONDOM PV 1ST TIER UNILET QL(6.67 ea MISC (condoms - 5 daily,200 ea female) COMFORTOUCH LANCETS 28G MISC 2 per fill FC2 FEMALE CONDOM PV retail,600 ea (lancets) MISC (condoms - 5 per fill mail) female)

78 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 1ST TIER UNILET QL(6.67 ea QL(6.67 ea COMFORTOUCH daily,200 ea ACTI-LANCE SPECIAL daily,200 ea SAFETYLANCETS 17G LANCETS 30G MISC 2 per fill 2 per fill retail,600 ea MISC (lancets) retail,600 ea (lancets) per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea ACCU-CHEK FASTCLIX daily,200 ea ACTI-LANCE UNIVERSAL daily,200 ea LANCETS MISC 2 per fill SAFETY LANCETS 23G 2 per fill (lancets) retail,600 ea MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea ACCU-CHEK MULTICLIX daily,200 ea ADVANCED MOBILE daily,200 ea LANCETS MISC 2 per fill LANCET 30G MISC 2 per fill (lancets) retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea ACCU-CHEK SAFE-T-PRO daily,200 ea ADVOCATE LANCETS daily,200 ea LANCETS MISC 2 per fill 2 per fill ) (lancets) retail,600 ea 30G MISC (lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea ACCU-CHEK SAFE-T-PRO daily,200 ea ADVOCATE LANCETS daily,200 ea PLUSLANCETS MISC 2 per fill 2 per fill ) (lancets) retail,600 ea MISC (lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea ACCU-CHEK SOFTCLIX daily,200 ea ADVOCATE SAFETY daily,200 ea LANCETS MISC 2 per fill LANCETS 26G MISC 2 per fill (lancets) retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea ACTI-LANCE LANCETS daily,200 ea ADVOCATE SAFETY daily,200 ea 2 per fill 2 per fill 28G MISC (lancets) retail,600 ea LANCETS MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea ACTI-LANCE LITE daily,200 ea AGAMATRIX ULTRA-THIN daily,200 ea SAFETY LANCETS 28G 2 per fill LANCETS 33G MISC 2 per fill MISC (lancets) retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea ACTI-LANCE SPECIAL daily,200 ea AIMSCO TWIST LANCETS daily,200 ea SAFETY LANCETS 17G 2 per fill 2 per fill ) MISC (lancets) retail,600 ea 32G MISC (lancets retail,600 ea per fill mail) per fill mail)

79 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(6.67 ea QL(6.67 ea AIMSCO TWIST LANCETS daily,200 ea ASSURE LANCE daily,200 ea 2 per fill 2 per fill 33G MISC (lancets) retail,600 ea LANCETS MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea AQUALANCE LANCETS daily,200 ea ASSURE LANCE PLUS daily,200 ea ULTRA THIN 30G MISC 2 per fill SAFETYLANCETS 25G 2 per fill (lancets) retail,600 ea MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea ASSURE COMFORT daily,200 ea ASSURE LANCE PLUS daily,200 ea LANCETS ULTRA THIN 2 per fill SAFETYLANCETS 30G 2 per fill 28G MISC (lancets) retail,600 ea MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea ASSURE HAEMOLANCE daily,200 ea ASSURE LANCE SAFETY daily,200 ea PLUS HIGH FLOW 18G 2 per fill LANCET 28G MISC 2 per fill MISC (lancets) retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea ASSURE HAEMOLANCE daily,200 ea ASSURE LANCETS MISC daily,200 ea PLUS LOW FLOW 25G 2 per fill 2 per fill ) MISC (lancets) retail,600 ea (lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea ASSURE HAEMOLANCE daily,200 ea AURORA LANCET SUPER daily,200 ea PLUS MICRO FLOW 28G 2 per fill 2 per fill ) MISC (lancets) retail,600 ea THIN30G MISC (lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea ASSURE HAEMOLANCE daily,200 ea AURORA LANCET THIN daily,200 ea PLUS NORMAL FLOW 2 per fill 2 per fill ) 21G MISC (lancets) retail,600 ea 23G MISC (lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea ASSURE HAEMOLANCE daily,200 ea BD LANCET ULTRAFINE daily,200 ea PLUS PEDIATRIC BLADE 2 per fill 2 per fill ) MISC (lancets) retail,600 ea 30G MISC (lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea ASSURE LANCE daily,200 ea BD LANCET ULTRAFINE daily,200 ea LANCETS 21G MISC 2 per fill 2 per fill ) (lancets) retail,600 ea 33G MISC (lancets retail,600 ea per fill mail) per fill mail)

80 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(6.67 ea QL(6.67 ea BD MICROTAINER daily,200 ea CARETOUCH TWIST daily,200 ea LANCETS MISC 2 per fill LANCETS 28G MISC 2 per fill (lancets) retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea BULLSEYE MINI SAFETY daily,200 ea CARETOUCH TWIST daily,200 ea LANCETS MISC 2 per fill LANCETS 30G MISC 2 per fill (lancets) retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea BULLSEYE SAFETY daily,200 ea CARETOUCH TWIST daily,200 ea LANCETS MISC 2 per fill LANCETS 33G MISC 2 per fill (lancets) retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea CAREONE LANCET daily,200 ea CLEANLET LANCETS 28G daily,200 ea SUPER THIN/30G MISC 2 per fill 2 per fill ) (lancets) retail,600 ea MISC (lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea CLEVER CHEK LANCETS CAREONE LANCET THIN daily,200 ea daily,200 ea 2 per fill ULTRATHIN 30G MISC 2 per fill ) MISC (lancets retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea CLEVER CHEK LANCETS CARESENS LANCETS daily,200 ea daily,200 ea 2 per fill ULTRATHIN MISC 2 per fill ) MISC (lancets retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea CARETOUCH SAFETY daily,200 ea CLEVER CHOICE daily,200 ea LANCETS/26G MISC 2 per fill COMFORT EZLANCETS 2 per fill (lancets) retail,600 ea 21G MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea CARETOUCH SAFETY daily,200 ea CLEVER CHOICE daily,200 ea LANCETS/28G MISC 2 per fill COMFORT EZLANCETS 2 per fill (lancets) retail,600 ea 23G MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea CARETOUCH SAFETY daily,200 ea CLEVER CHOICE daily,200 ea LANCETS/30G MISC 2 per fill COMFORT EZLANCETS 2 per fill (lancets) retail,600 ea 28G MISC (lancets) retail,600 ea per fill mail) per fill mail)

81 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(6.67 ea QL(6.67 ea COAGUCHEK LANCETS daily,200 ea CVS LANCETS ULTRA daily,200 ea 2 per fill 2 per fill MISC (lancets) retail,600 ea THIN 30G MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea COMFORT ASSURED daily,200 ea CVS LANCETS ULTRA- daily,200 ea LANCETS MICRO THIN 2 per fill 2 per fill ) 33G MISC (lancets) retail,600 ea THIN 30G MISC (lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea COMFORT ASSURED daily,200 ea CVS ULTRA THIN daily,200 ea LANCETS SUPER THIN 2 per fill 2 per fill ) 28G MISC (lancets) retail,600 ea LANCETS MISC (lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea COMFORT LANCETS daily,200 ea DIATHRIVE LANCETS daily,200 ea 2 per fill 2 per fill MISC (lancets) retail,600 ea MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea DIATHRIVE LANCETS CVS LANCETS 21G MISC daily,200 ea daily,200 ea 2 per fill ULTRA THIN 30G MISC 2 per fill ) (lancets retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea DROPLET LANCETS CVS LANCETS MICRO daily,200 ea daily,200 ea 2 per fill ULTRA THIN 30G MISC 2 per fill ) THIN 33G MISC (lancets retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea CVS LANCETS MICRO- daily,200 ea DROPLET PERSONAL daily,200 ea 2 per fill LANCETS30G MISC 2 per fill ) THIN 33G MISC (lancets retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea CVS LANCETS ORIGINAL daily,200 ea DRUG MART LANCETS daily,200 ea 2 per fill 2 per fill MISC (lancets) retail,600 ea THIN MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea DRUG MART ON-THE-GO CVS LANCETS THIN 26G daily,200 ea daily,200 ea 2 per fill LANCETS GENTLE 30G 2 per fill ) MISC (lancets retail,600 ea MISC (lancets) retail,600 ea per fill mail) per fill mail)

82 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(6.67 ea QL(6.67 ea DRUG MART UNILET daily,200 ea EASY COMFORT daily,200 ea LANCETSSUPER THIN 2 per fill LANCETS 30G/PULL TOP 2 per fill 30G MISC (lancets) retail,600 ea MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea DRUG MART UNILET daily,200 ea EASY COMFORT daily,200 ea LANCETSULTRA THIN 2 per fill LANCETS 30G/THIN TOP 2 per fill 28G MISC (lancets) retail,600 ea MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea DRUG MART UNILET daily,200 ea EASY COMFORT daily,200 ea MICRO THIN LANCETS 2 per fill 2 per fill ) 33G MISC (lancets) retail,600 ea LANCETS MISC (lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea EASY COMFORT E-Z JECT LANCETS 21G daily,200 ea daily,200 ea 2 per fill LANCETS TWIST TOP 2 per fill ) MISC (lancets retail,600 ea MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea EASY TOUCH LANCETS QL(6.67 ea E-Z JECT LANCETS daily,200 ea 21G/PRESSURE daily,200 ea 2 per fill ACTIVATED MISC 2 per fill COLOR MISC (lancets) retail,600 ea retail,600 ea per fill mail) (lancets) per fill mail) QL(6.67 ea EASY TOUCH LANCETS QL(6.67 ea E-Z JECT LANCETS MISC daily,200 ea 23G/PRESSURE daily,200 ea 2 per fill ACTIVATED MISC 2 per fill (lancets) retail,600 ea retail,600 ea per fill mail) (lancets) per fill mail) QL(6.67 ea EASY TOUCH LANCETS QL(6.67 ea E-Z JECT LANCETS daily,200 ea daily,200 ea SUPER THIN 30G MISC 26G/PRESSURE 2 per fill ACTIVATED MISC 2 per fill (lancets) retail,600 ea retail,600 ea per fill mail) (lancets) per fill mail) QL(6.67 ea QL(6.67 ea EASY TOUCH LANCETS E-Z JECT LANCETS THIN daily,200 ea daily,200 ea 2 per fill 26G/PULL-TOP MISC 2 per fill ) 26G MISC (lancets retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea EASY TOUCH LANCETS QL(6.67 ea E-ZJECT LANCETS daily,200 ea daily,200 ea MICRO-THIN 33G MISC 28G/PRESSURE 2 per fill ACTIVATED MISC 2 per fill (lancets) retail,600 ea retail,600 ea per fill mail) (lancets) per fill mail)

83 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(6.67 ea QL(6.67 ea EASY TOUCH LANCETS daily,200 ea EASY TOUCH LANCETS daily,200 ea 28G/PULL-TOP MISC 2 per fill 33G/TWIST MISC 2 per fill (lancets) retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea EASY TOUCH SAFETY QL(6.67 ea EASY TOUCH LANCETS daily,200 ea daily,200 ea 28G/TWIST MISC LANCETS21G/PRESSURE 2 per fill ACTIVATED MISC 2 per fill (lancets) retail,600 ea retail,600 ea per fill mail) (lancets) per fill mail) QL(6.67 ea EASY TOUCH SAFETY QL(6.67 ea EASY TOUCH LANCETS daily,200 ea daily,200 ea 30G/BUTTON-ACTIVATED LANCETS23G/PRESSURE 2 per fill ACTIVATED MISC 2 per fill MISC (lancets) retail,600 ea retail,600 ea per fill mail) (lancets) per fill mail) EASY TOUCH LANCETS QL(6.67 ea EASY TOUCH SAFETY QL(6.67 ea 30G/PRESSURE daily,200 ea LANCETS26G/BUTTON daily,200 ea ACTIVATED MISC 2 per fill ACTIVATED MISC 2 per fill retail,600 ea retail,600 ea (lancets) per fill mail) (lancets) per fill mail) QL(6.67 ea EASY TOUCH SAFETY QL(6.67 ea EASY TOUCH LANCETS daily,200 ea daily,200 ea 30G/PULL-TOP MISC LANCETS26G/PRESSURE 2 per fill ACTIVATED MISC 2 per fill (lancets) retail,600 ea retail,600 ea per fill mail) (lancets) per fill mail) QL(6.67 ea EASY TOUCH SAFETY QL(6.67 ea EASY TOUCH LANCETS daily,200 ea daily,200 ea 30G/TWIST MISC LANCETS28G/BUTTON 2 per fill ACTIVATED MISC 2 per fill (lancets) retail,600 ea retail,600 ea per fill mail) (lancets) per fill mail) EASY TOUCH LANCETS QL(6.67 ea EASY TOUCH SAFETY QL(6.67 ea 32G/PRESSURE daily,200 ea LANCETS28G/PRESSURE daily,200 ea ACTIVATED MISC 2 per fill ACTIVATED MISC 2 per fill retail,600 ea retail,600 ea (lancets) per fill mail) (lancets) per fill mail) QL(6.67 ea QL(6.67 ea EASY TOUCH LANCETS daily,200 ea EASY TWIST & CAP daily,200 ea 32G/PULL-TOP MISC 2 per fill 2 per fill ) (lancets) retail,600 ea LANCETS MISC (lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea EASY TOUCH LANCETS daily,200 ea EMBRACE LANCETS daily,200 ea 32G/TWIST MISC 2 per fill ULTRA THIN 30G MISC 2 per fill (lancets) retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail)

84 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(6.67 ea QL(6.67 ea FIFTY50 SAFETY SEAL EQL COLOR LANCETS daily,200 ea daily,200 ea 2 per fill LANCETS 30G MISC 2 per fill 21G MISC ( ) lancets retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea EQL COLOR LANCETS daily,200 ea FIFTY50 SAFETY SEAL daily,200 ea MICRO THIN 33G MISC 2 per fill LANCETS 32G MISC 2 per fill (lancets) retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea EQL SUPER THIN daily,200 ea FIFTY50 UNILET daily,200 ea LANCETS 30G MISC 2 per fill LANCETS 33G MISC 2 per fill (lancets) retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea EQL THIN LANCETS 26G daily,200 ea daily,200 ea 2 per fill FINE 30 MISC (lancets) 2 per fill MISC (lancets) retail,600 ea retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea EZ SMART BLOOD daily,200 ea FINGERSTIX LANCETS daily,200 ea GLUCOSE LANCETS 2 per fill 2 per fill MISC ( ) MISC (lancets) retail,600 ea lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea EZ-LETS LANCETS 21G daily,200 ea FORA LANCETS MISC daily,200 ea 2 per fill 2 per fill MISC (lancets) retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea EZ-LETS LANCETS 26G daily,200 ea FREDS PHARMACY daily,200 ea SUPER-SOFT MISC 2 per fill UNILET LANCETS SUPER 2 per fill (lancets) retail,600 ea THIN 30G MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea EZ-LETS LANCETS 28G daily,200 ea FREDS PHARMACY daily,200 ea ULTRA-SOFT MISC 2 per fill UNILET LANCETS ULTRA 2 per fill (lancets) retail,600 ea THIN 28G MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea EZ-LETS LANCETS 30G daily,200 ea FREESTYLE LANCETS daily,200 ea 2 per fill 2 per fill MISC (lancets) retail,600 ea MISC (lancets) retail,600 ea per fill mail) per fill mail)

85 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(6.67 ea QL(6.67 ea FREESTYLE UNISTICK II daily,200 ea GLUCOCOM LANCETS daily,200 ea LANCETS MISC 2 per fill 2 per fill ) (lancets) retail,600 ea 28G MISC (lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea GENTEEL BUTTERFLY daily,200 ea GLUCOCOM LANCETS daily,200 ea TOUCH LANCETS MISC 2 per fill 2 per fill ) (lancets) retail,600 ea 30G MISC (lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea GENTLE-LET GP daily,200 ea GLUCOCOM LANCETS daily,200 ea LANCETS MISC 2 per fill 2 per fill ) (lancets) retail,600 ea 33G MISC (lancets retail,600 ea per fill mail) per fill mail) GENTLE-LET LANCETS QL(6.67 ea QL(6.67 ea GENERAL PURPOSE daily,200 ea GNP LANCETS 21G MISC daily,200 ea STYLE/FINE POINT MISC 2 per fill 2 per fill retail,600 ea (lancets) retail,600 ea (lancets) per fill mail) per fill mail) GENTLE-LET LANCETS QL(6.67 ea QL(6.67 ea GENERAL PURPOSE daily,200 ea GNP LANCETS MICRO daily,200 ea STYLE/MEDIUM POINT 2 per fill 2 per fill retail,600 ea THIN 33G MISC (lancets) retail,600 ea MISC (lancets) per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea GENTLE-LET LANCETS daily,200 ea GNP LANCETS MISC daily,200 ea SAFETY STYLE/FINE 2 per fill 2 per fill ) POINT MISC (lancets) retail,600 ea (lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea GENTLE-LET LANCETS daily,200 ea GNP LANCETS SUPER daily,200 ea SAFETY STYLE/MEDIUM 2 per fill 2 per fill ) POINT MISC (lancets) retail,600 ea THIN 30G MISC (lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea GLOBAL INJECT EASE daily,200 ea GNP LANCETS THIN 26G daily,200 ea LANCETS 28G MISC 2 per fill 2 per fill ) (lancets) retail,600 ea MISC (lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea GLOBAL INJECT EASE daily,200 ea GNP LANCETS THIN daily,200 ea LANCETS 30G MISC 2 per fill 2 per fill ) (lancets) retail,600 ea MISC (lancets retail,600 ea per fill mail) per fill mail)

86 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(6.67 ea QL(6.67 ea GNP MICRO THIN daily,200 ea H-E-B INCONTROL daily,200 ea LANCETS 33G MISC 2 per fill LANCETS MICRO THIN 2 per fill (lancets) retail,600 ea 33G MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea GNP SUPER THIN daily,200 ea H-E-B INCONTROL daily,200 ea LANCETS/30G MISC 2 per fill LANCETS SUPER THIN 2 per fill (lancets) retail,600 ea 30G MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea H-E-B INCONTROL GOJJI STERILE LANCETS daily,200 ea daily,200 ea 2 per fill LANCETS ULTRA THIN 2 per fill ) 30G MISC (lancets retail,600 ea 28G MISC (lancets) retail,600 ea per fill mail) per fill mail) GOODSENSE COLOR QL(6.67 ea QL(6.67 ea daily,200 ea HAEMOLANCE LOW daily,200 ea LANCETS MICRO-THIN FLOW LANCETS MISC 33G UNIVERSAL MISC 2 per fill 2 per fill retail,600 ea (lancets) retail,600 ea (lancets) per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea GOODSENSE LANCETS daily,200 ea HAEMOLANCE MISC daily,200 ea MICRO-THIN 33G MISC 2 per fill 2 per fill ) (lancets) retail,600 ea (lancets retail,600 ea per fill mail) per fill mail) GOODSENSE LANCETS QL(6.67 ea QL(6.67 ea daily,200 ea HAEMOLANCE PLUS daily,200 ea MICRO-THIN 33G HIGH FLOW MISC UNIVERSAL MISC 2 per fill 2 per fill retail,600 ea (lancets) retail,600 ea (lancets) per fill mail) per fill mail) GOODSENSE LANCETS QL(6.67 ea QL(6.67 ea daily,200 ea HAEMOLANCE PLUS daily,200 ea ULTRA-THIN 26G LOW FLOW MISC UNIVERSAL MISC 2 per fill 2 per fill retail,600 ea (lancets) retail,600 ea (lancets) per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea GOODSENSE LANCETS daily,200 ea HAEMOLANCE PLUS daily,200 ea ULTRA-THIN 30G MISC 2 per fill MAX FLOW MISC 2 per fill (lancets) retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) GOODSENSE LANCETS QL(6.67 ea QL(6.67 ea ULTRA-THIN 30G daily,200 ea HAEMOLANCE PLUS daily,200 ea UNIVERSAL MISC 2 per fill 2 per fill retail,600 ea MISC (lancets) retail,600 ea (lancets) per fill mail) per fill mail)

87 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(6.67 ea QL(6.67 ea HAEMOLANCE PLUS daily,200 ea KROGER LANCETS daily,200 ea PEDIATRIC FLOW MISC 2 per fill MICRO THIN33G MISC 2 per fill (lancets) retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea HEALTHY ACCENTS daily,200 ea KROGER LANCETS MISC daily,200 ea UNILET LANCETS SUPER 2 per fill 2 per fill ) THIN 30G MISC (lancets) retail,600 ea (lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea KROGER LANCETS HY-VEE LANCETS MISC daily,200 ea daily,200 ea 2 per fill SUPER THIN MISC 2 per fill ) (lancets retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea HY-VEE THIN LANCETS daily,200 ea KROGER LANCETS THIN daily,200 ea 2 per fill 2 per fill MISC (lancets) retail,600 ea 26G MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea IN TOUCH STERILE daily,200 ea KROGER LANCETS THIN daily,200 ea LANCETS30G MISC 2 per fill 2 per fill ) (lancets) retail,600 ea MISC (lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea KROGER LANCETS KINNEY LANCETS MISC daily,200 ea daily,200 ea 2 per fill ULTRATHIN30G MISC 2 per fill ) (lancets retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea KINNEY THIN LANCETS daily,200 ea LANCETS 26G TWIST daily,200 ea 2 per fill 2 per fill MISC (lancets) retail,600 ea TOP MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea KROGER HEALTHPRO daily,200 ea LANCETS 28G MISC daily,200 ea TWIST LANCETS/26G 2 per fill 2 per fill ) MISC (lancets) retail,600 ea (lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea KROGER LANCETS 21G daily,200 ea LANCETS 30G MISC daily,200 ea 2 per fill 2 per fill MISC (lancets) retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail)

88 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(6.67 ea QL(6.67 ea LANCETS 30G TWIST daily,200 ea LANCETS SAFETY SEAL daily,200 ea 2 per fill 2 per fill TOP MISC (lancets) retail,600 ea 30G MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea LANCETS 30G/TWIST daily,200 ea LANCETS SUPER THIN daily,200 ea 2 per fill 2 per fill TOP MISC (lancets) retail,600 ea 28G MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea LANCETS 31G TWIST daily,200 ea LANCETS THIN MISC daily,200 ea 2 per fill 2 per fill TOP MISC (lancets) retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea LANCETS 33G daily,200 ea LANCETS TWIST TOP daily,200 ea UNIVERSAL DESIGN 2 per fill 2 per fill ) MISC (lancets) retail,600 ea MISC (lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea LANCETS MICRO THIN daily,200 ea LANCETS ULTRA FINE daily,200 ea 2 per fill 2 per fill 33G MISC (lancets) retail,600 ea MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea LANCETS MISC daily,200 ea LANCETS ULTRA THIN daily,200 ea 2 per fill 2 per fill (lancets) retail,600 ea 30G MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea LANCETS SAFETY SEAL daily,200 ea LANCETS ULTRA THIN daily,200 ea 2 per fill 2 per fill 21G MISC (lancets) retail,600 ea MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea LANCETS SAFETY SEAL daily,200 ea LANCETSBULLSEYE daily,200 ea 2 per fill 2 per fill 26G MISC (lancets) retail,600 ea SAFETY MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea LIBERTY MEDICAL LANCETS SAFETY SEAL daily,200 ea daily,200 ea 2 per fill LANCETS 30G MISC 2 per fill ) 28G MISC (lancets retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail)

89 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(6.67 ea QL(6.67 ea LIFESCAN UNISTIK 2 daily,200 ea MEDICHOICE PRE-SET daily,200 ea DEEP PENETRATION 2 per fill SAFETY LANCET DUAL 2 per fill MISC (lancets) retail,600 ea USE MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea LIFESCAN UNISTIK II daily,200 ea MEDICHOICE PRE-SET daily,200 ea LANCETS MISC 2 per fill SAFETY LANCET LOW 2 per fill (lancets) retail,600 ea FLOW MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea MEDICHOICE PRE-SET QL(6.67 ea LITE TOUCH LANCETS daily,200 ea SAFETY LANCET daily,200 ea 2 per fill MEDIUM FLOW MISC 2 per fill MISC (lancets) retail,600 ea retail,600 ea per fill mail) (lancets) per fill mail) QL(6.67 ea MEDICHOICE PRE-SET QL(6.67 ea LITETOUCH LANCETS daily,200 ea daily,200 ea MICRO THIN 33G MISC SAFETY LANCET 2 per fill MODERATE FLOW MISC 2 per fill (lancets) retail,600 ea retail,600 ea per fill mail) (lancets) per fill mail) QL(6.67 ea QL(6.67 ea LIVE BETTER LANCET daily,200 ea MEDICHOICE SAFETY daily,200 ea SUPERTHIN 30G MISC 2 per fill LANCETEXTRA MISC 2 per fill (lancets) retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea LIVE BETTER LANCET daily,200 ea MEDICHOICE SAFETY daily,200 ea ULTRATHIN 28G MISC 2 per fill LANCETNORMAL MISC 2 per fill (lancets) retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea LONGS LANCETS daily,200 ea MEDISENSE THIN daily,200 ea STANDARD MISC 2 per fill 2 per fill ) (lancets) retail,600 ea LANCETS MISC (lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea MEDLANCE PLUS EXTRA LONGS LANCETS THIN daily,200 ea daily,200 ea 2 per fill LANCETS 21G MISC 2 per fill ) MISC (lancets retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea MEDLANCE PLUS LONGS LANCETS ULTRA daily,200 ea daily,200 ea 2 per fill LANCETS LITE 25G MISC 2 per fill ) THIN MISC (lancets retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail)

90 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(6.67 ea QL(6.67 ea MEDLANCE PLUS daily,200 ea MEDLANCE/UNIVERSAL daily,200 ea LANCETS MISC 2 per fill 2 per fill ) (lancets) retail,600 ea MISC (lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea MEDLANCE PLUS LITE daily,200 ea MEIJER COLOR daily,200 ea LANCETS 25G MISC 2 per fill LANCETS UNIVERSAL 2 per fill (lancets) retail,600 ea 33G MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea MEDLANCE PLUS daily,200 ea MEIJER LANCETS MISC daily,200 ea SPECIAL LANCETS 2 per fill 2 per fill ) 0.8MM MISC (lancets) retail,600 ea (lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea MEDLANCE PLUS daily,200 ea MEIJER LANCETS THIN daily,200 ea SUPERLITE 30G MISC 2 per fill 2 per fill ) (lancets) retail,600 ea MISC (lancets retail,600 ea per fill mail) per fill mail) MEDLANCE PLUS QL(6.67 ea QL(6.67 ea daily,200 ea MEIJER LANCETS daily,200 ea SUPERLITE UNIVERSAL21G MISC 30G/COMFORT MAX 2 per fill 2 per fill retail,600 ea (lancets) retail,600 ea MISC (lancets) per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea MEDLANCE PLUS daily,200 ea MEIJER LANCETS daily,200 ea UNIVERSAL LANCETS 2 per fill UNIVERSAL30G MISC 2 per fill 21G MISC (lancets) retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea MEIJER LANCETS MEDLANCE PLUS/LITE daily,200 ea daily,200 ea 2 per fill UNIVERSAL33G MISC 2 per fill ) 25G MISC (lancets retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea MEDLANCE/EXTRA MISC daily,200 ea MEIJER SUPER THIN daily,200 ea 2 per fill 2 per fill (lancets) retail,600 ea LANCETS MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea MEDLANCE/LITE MISC daily,200 ea MICROLET LANCETS daily,200 ea 2 per fill 2 per fill (lancets) retail,600 ea MISC (lancets) retail,600 ea per fill mail) per fill mail)

91 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MICROTAINER SAFETY QL(6.67 ea QL(6.67 ea FLOW daily,200 ea MYGLUCOHEALTH MGH daily,200 ea SOFTLANCE LANCETS LANCET/STERILE/SINGL 2 per fill 2 per fill retail,600 ea 30G MISC (lancets) retail,600 ea E-USE MISC (lancets) per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea MM TWIST LANCETS daily,200 ea NOVA SAFETY LANCETS daily,200 ea 2 per fill 2 per fill MISC (lancets) retail,600 ea 23G MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea MONOLET LANCETS daily,200 ea NOVA SAFETY LANCETS daily,200 ea 2 per fill 2 per fill MISC (lancets) retail,600 ea 28G MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea MONOLET OPD LANCETS daily,200 ea NOVA SUREFLEX daily,200 ea 2 per fill 2 per fill MISC (lancets) retail,600 ea LANCETS MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea MONOLETTOR SAFETY daily,200 ea ON CALL LANCETS MISC daily,200 ea LANCETS MISC 2 per fill 2 per fill ) (lancets) retail,600 ea (lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea MPD SAFETY LANCET daily,200 ea ON CALL PLUS LANCETS daily,200 ea 21G/1.8MM MISC 2 per fill 2 per fill ) (lancets) retail,600 ea MISC (lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea MPD SAFETY LANCET daily,200 ea ONETOUCH CLUB daily,200 ea 28G/1.8MM MISC 2 per fill LANCETS FINE POINT 2 per fill (lancets) retail,600 ea MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea MPD SAFETY LANCET daily,200 ea ONETOUCH DELICA daily,200 ea 30G/1.8MM MISC 2 per fill LANCETS EXTRA FINE 2 per fill (lancets) retail,600 ea 33G MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea MPD SAFETY LANCETS daily,200 ea ONETOUCH DELICA daily,200 ea 23G/1.8MM MISC 2 per fill LANCETS FINE 30G MISC 2 per fill (lancets) retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail)

92 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(6.67 ea QL(6.67 ea ONETOUCH DELICA daily,200 ea PHARMACIST CHOICE daily,200 ea PLUS LANCETS EXTRA 2 per fill ULTRA THIN LANCETS 2 per fill FINE 33G MISC (lancets) retail,600 ea 30G MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea ONETOUCH DELICA daily,200 ea PHARMACIST CHOICE daily,200 ea PLUS LANCETS FINE 30G 2 per fill ULTRA THIN LANCETS 2 per fill MISC (lancets) retail,600 ea 31G MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea ONETOUCH FINEPOINT daily,200 ea PHARMACIST CHOICE daily,200 ea LANCETS MISC 2 per fill ULTRA THIN LANCETS 2 per fill (lancets) retail,600 ea 33G MISC (lancets) retail,600 ea per fill mail) per fill mail) ONETOUCH ULTRA 2 KIT QL(1 ea per QL(6.67 ea (blood glucose 2 365 days PHARMACIST CHOICE daily,200 ea monitoring supplies) retail); RX/OTC ULTRA THIN LANCETS 2 per fill MISC (lancets) retail,600 ea QL(6.67 ea per fill mail) ONETOUCH ULTRASOFT daily,200 ea LANCETS MISC 2 per fill QL(6.67 ea (lancets) retail,600 ea PHARMACY COUNTER daily,200 ea per fill mail) 2 per fill LANCETS MISC (lancets) retail,600 ea ONETOUCH VERIO FLEX QL(1 ea per per fill mail) BLOOD GLUCOSE 365 days QL(6.67 ea MONITORING SYSTEM 2 retail); RX/OTC PIP LANCETS/28G MISC daily,200 ea KIT (blood glucose 2 per fill monitoring supplies) (lancets) retail,600 ea QL(6.67 ea per fill mail) PC LANCETS SUPER daily,200 ea QL(6.67 ea 2 per fill THIN 30G MISC (lancets) PIP LANCETS/30G MISC daily,200 ea retail,600 ea 2 per fill per fill mail) (lancets) retail,600 ea QL(6.67 ea per fill mail) PERFECT LANCETS 30G daily,200 ea QL(6.67 ea 2 per fill MISC (lancets) PRECISION THINS GP daily,200 ea retail,600 ea 2 per fill per fill mail) LANCET MISC (lancets) retail,600 ea PERFECT PRESSURE QL(6.67 ea per fill mail) ACTIVATED SAFETY daily,200 ea QL(6.67 ea LANCETS 28G MISC 2 per fill PREFERRED PLUS daily,200 ea retail,600 ea (lancets) LANCETS COLORED 21G 2 per fill per fill mail) MISC (lancets) retail,600 ea QL(6.67 ea per fill mail) PHARMACIST CHOICE daily,200 ea ULTRA THIN LANCETS 2 per fill 28G MISC (lancets) retail,600 ea per fill mail)

93 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(6.67 ea QL(6.67 ea PREFERRED PLUS daily,200 ea PSS SELECT SAFETY daily,200 ea LANCETS SUPER THIN 2 per fill 2 per fill ) 30G MISC (lancets) retail,600 ea LANCETS MISC (lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea PREFERRED PLUS daily,200 ea PUSH BUTTON SAFETY daily,200 ea LANCETS THIN 26G MISC 2 per fill LANCETS 21G MISC 2 per fill (lancets) retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea PRESSURE ACTIVATED daily,200 ea PUSH BUTTON SAFETY daily,200 ea SAFETYLANCET 21G 2 per fill LANCETS 28G MISC 2 per fill MISC (lancets) retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea PRO COMFORT daily,200 ea PX LANCETS ULTRA daily,200 ea LANCETS 30G MISC 2 per fill 2 per fill ) (lancets) retail,600 ea THIN 28G MISC (lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea PRO COMFORT daily,200 ea PX LANCETS ULTRA daily,200 ea LANCETS 31G MISC 2 per fill 2 per fill ) (lancets) retail,600 ea THIN MISC (lancets retail,600 ea per fill mail) per fill mail) PRODIGY PRESSURE QL(6.67 ea QL(6.67 ea ACTIVATED SAFETY daily,200 ea QC LANCETS SUPER daily,200 ea LANCETS MISC 2 per fill 2 per fill retail,600 ea THIN MISC (lancets) retail,600 ea (lancets) per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea PRODIGY SAFETY daily,200 ea QC LANCETS ULTRA daily,200 ea LANCETS MISC 2 per fill 2 per fill ) (lancets) retail,600 ea THIN MISC (lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea PRODIGY TWIST TOP daily,200 ea QC UNILET LANCETS daily,200 ea LANCETS MISC 2 per fill 28G/ULTRA THIN MISC 2 per fill (lancets) retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea PSS SELECT GP daily,200 ea QC UNILET LANCETS daily,200 ea LANCETS MISC 2 per fill 33G/MICRO THIN MISC 2 per fill (lancets) retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail)

94 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(6.67 ea QL(6.67 ea RA E-ZJECT COLOR daily,200 ea READYLANCE SAFETY daily,200 ea LANCETSMICRO-THIN 2 per fill LANCETS/30G/1.6MM 2 per fill 33G MISC (lancets) retail,600 ea MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea RA E-ZJECT LANCETS daily,200 ea REALITY LANCETS MISC daily,200 ea 2 per fill 2 per fill 28G MISC (lancets) retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea RA E-ZJECT LANCETS daily,200 ea REALITY TRIGGER daily,200 ea 2 per fill 2 per fill THIN 26G MISC (lancets) retail,600 ea LANCETS MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea RELION LANCETS RA E-ZJECT LANCETS daily,200 ea daily,200 ea 2 per fill MICRO-THIN33G MISC 2 per fill ) THIN 28G MISC (lancets retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea RA E-ZJECT LANCETS daily,200 ea RELION LANCETS daily,200 ea ULTRATHIN 30G MISC 2 per fill STANDARD 21G MISC 2 per fill (lancets) retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea READYLANCE SAFETY daily,200 ea RELION LANCETS THIN daily,200 ea LANCETS/21G/2.2MM 2 per fill 2 per fill ) MISC (lancets) retail,600 ea 26G MISC (lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea READYLANCE SAFETY daily,200 ea RELION LANCETS daily,200 ea LANCETS/23G/1.8MM 2 per fill ULTRA-THIN30G MISC 2 per fill MISC (lancets) retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea READYLANCE SAFETY daily,200 ea RELION ULTRA THIN daily,200 ea LANCETS/26G/1.8MM 2 per fill LANCETS/30G MISC 2 per fill MISC (lancets) retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea READYLANCE SAFETY daily,200 ea RELION ULTRA THIN daily,200 ea LANCETS/28G/1.8MM 2 per fill LANCETS30G MISC 2 per fill MISC (lancets) retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail)

95 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(6.67 ea QL(6.67 ea RELION ULTRA THIN SAFETY LANCET daily,200 ea 21G/PRESSURE daily,200 ea PLUS LANCETS 32G 2 per fill ACTIVATED MISC 2 per fill MISC (lancets) retail,600 ea retail,600 ea per fill mail) (lancets) per fill mail) QL(6.67 ea SAFETY LANCET QL(6.67 ea RELION ULTRA THIN daily,200 ea daily,200 ea PLUS LANCETS 33G 23G/PRESSURE 2 per fill ACTIVATED MISC 2 per fill MISC (lancets) retail,600 ea retail,600 ea per fill mail) (lancets) per fill mail) QL(6.67 ea SAFETY LANCET QL(6.67 ea REXALL LANCETS ULTRA daily,200 ea 28G/PRESSURE daily,200 ea 2 per fill ACTIVATED MISC 2 per fill THIN MISC (lancets) retail,600 ea retail,600 ea per fill mail) (lancets) per fill mail) QL(6.67 ea SAFETY LANCET QL(6.67 ea RIGHTEST GL300 daily,200 ea daily,200 ea LANCETS MISC 30G/PRESSURE 2 per fill ACTIVATED MISC 2 per fill (lancets) retail,600 ea retail,600 ea per fill mail) (lancets) per fill mail) QL(6.67 ea QL(6.67 ea SAFE-T-LANCE LOW daily,200 ea SAFETY LANCETS 21G daily,200 ea FLOW 25G MISC 2 per fill 2 per fill ) (lancets) retail,600 ea MISC (lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea SAFE-T-LANCE NORMAL daily,200 ea SAFETY LANCETS 28G daily,200 ea FLOW21G MISC 2 per fill 2 per fill ) (lancets) retail,600 ea MISC (lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea SAFE-T-LANCE PLUS daily,200 ea SAFETY LANCETS MISC daily,200 ea SAFETYLANCET HIGH 2 per fill 2 per fill ) FLOW MISC (lancets) retail,600 ea (lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea SAFE-T-LANCE PLUS daily,200 ea SAFETY LET LANCETS daily,200 ea SAFETYLANCET LOW 2 per fill 2 per fill ) FLOW MISC (lancets) retail,600 ea MISC (lancets retail,600 ea per fill mail) per fill mail) SAFE-T-LANCE PLUS QL(6.67 ea QL(6.67 ea SAFETYLANCET daily,200 ea SAFETY SEAL LANCETS daily,200 ea NORMAL FLOW MISC 2 per fill 2 per fill retail,600 ea 28G MISC (lancets) retail,600 ea (lancets) per fill mail) per fill mail)

96 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(6.67 ea QL(6.67 ea SIDE BUTTON SAFETY SAFETY SEAL LANCETS daily,200 ea daily,200 ea 2 per fill LANCET21G MISC 2 per fill 30G MISC ( ) lancets retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea SAPS HEALTH CARE daily,200 ea SINGLE-LET MISC daily,200 ea TWIST TOP LANCETS 2 per fill 2 per fill ) MISC (lancets) retail,600 ea (lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea SAPS HEALTH TWIST daily,200 ea SM MICRO THIN daily,200 ea TOP LANCETS 30G MISC 2 per fill LANCETS 33G MISC 2 per fill (lancets) retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea SAPSCARE TWIST TOP daily,200 ea SMART SENSE COLOR daily,200 ea LANCETS 30G MISC 2 per fill LANCETS UNIVERSAL 2 per fill (lancets) retail,600 ea 33G MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea SMART SENSE QL(6.67 ea SB LANCETS THIN MISC daily,200 ea STANDARD LANCETS daily,200 ea 2 per fill UNIVERSAL 21G MISC 2 per fill (lancets) retail,600 ea retail,600 ea per fill mail) (lancets) per fill mail) QL(6.67 ea SMART SENSE SUPER QL(6.67 ea SB LANCETS ULTRA daily,200 ea THIN LANCETS daily,200 ea 2 per fill UNIVERSAL 30G MISC 2 per fill THIN MISC (lancets) retail,600 ea retail,600 ea per fill mail) (lancets) per fill mail) QL(6.67 ea QL(6.67 ea SHOPKO ON-THE-GO daily,200 ea SMART SENSE THIN daily,200 ea COMFORTLANCETS 30G 2 per fill LANCETSUNIVERSAL 2 per fill MISC (lancets) retail,600 ea 26G MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea SHOPKO UNILET daily,200 ea SMARTEST LANCETS daily,200 ea LANCETS SUPER THIN 2 per fill 2 per fill ) 30G MISC (lancets) retail,600 ea 28G MISC (lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea SOLUS V2 PRESSURE QL(6.67 ea SHOPKO UNILET daily,200 ea daily,200 ea LANCETS ULTRA THIN ACTIVATED SAFETY 2 per fill LANCETS 28G MISC 2 per fill 28G MISC (lancets) retail,600 ea retail,600 ea per fill mail) (lancets) per fill mail)

97 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(6.67 ea QL(6.67 ea SOLUS V2 TWIST daily,200 ea SURE-LANCE LANCETS daily,200 ea LANCETS 30G MISC 2 per fill 2 per fill ) (lancets) retail,600 ea 26G MISC (lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea SURE-LANCE THIN STERILANCE TL MISC daily,200 ea daily,200 ea 2 per fill LANCETS 28G MISC 2 per fill ) (lancets retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea SURE-LANCE ULTRA SUPER THIN LANCETS daily,200 ea daily,200 ea 2 per fill THIN LANCETS MISC 2 per fill ) MISC (lancets retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea SURE COMFORT daily,200 ea SURE-TOUCH LANCETS daily,200 ea LANCETS 18G MISC 2 per fill UNIVERSAL MISC 2 per fill (lancets) retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea SURE COMFORT daily,200 ea SURELITE LANCETS daily,200 ea LANCETS 21G MISC 2 per fill 2 per fill ) (lancets) retail,600 ea MISC (lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea SURE COMFORT daily,200 ea TECHLITE AST LANCETS daily,200 ea LANCETS 23G MISC 2 per fill 2 per fill ) (lancets) retail,600 ea MISC (lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea SURE COMFORT daily,200 ea TECHLITE LANCETS 30G daily,200 ea LANCETS 28G MISC 2 per fill 2 per fill ) (lancets) retail,600 ea MISC (lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea SURE COMFORT daily,200 ea TECHLITE LANCETS daily,200 ea LANCETS 30G MISC 2 per fill 2 per fill ) (lancets) retail,600 ea MISC (lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea SURE-LANCE FLAT daily,200 ea TGT LANCET MICRO daily,200 ea LANCETS MISC 2 per fill 2 per fill ) (lancets) retail,600 ea THIN 33G MISC (lancets retail,600 ea per fill mail) per fill mail)

98 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(6.67 ea QL(6.67 ea TGT LANCET THIN 26G daily,200 ea TRUEPLUS LANCETS daily,200 ea 2 per fill 2 per fill MISC (lancets) retail,600 ea 26G MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea TGT LANCET ULTRA daily,200 ea TRUEPLUS LANCETS daily,200 ea 2 per fill 2 per fill THIN 30G MISC (lancets) retail,600 ea 28G MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea TRUEPLUS LANCETS THINLETS GP LANCETS daily,200 ea daily,200 ea 2 per fill 28G SUPER THIN MISC 2 per fill ) MISC (lancets retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea TODAYS HEALTH SUPER daily,200 ea TRUEPLUS LANCETS daily,200 ea THINLANCETS 30G MISC 2 per fill 2 per fill ) (lancets) retail,600 ea 30G MISC (lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea TODAYS HEALTH ULTRA daily,200 ea TRUEPLUS LANCETS daily,200 ea THINLANCETS 28G MISC 2 per fill 30G ULTRA THIN MISC 2 per fill (lancets) retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea TOPCARE LANCETS daily,200 ea TRUEPLUS LANCETS daily,200 ea MICRO-THIN 33G MISC 2 per fill 33G MICRO THIN MISC 2 per fill (lancets) retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea TRAVEL LANCETS 30G daily,200 ea TRUEPLUS LANCETS daily,200 ea 2 per fill 2 per fill MISC (lancets) retail,600 ea 33G MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea TRAVEL LANCETS daily,200 ea TRUEPLUS SAFETY daily,200 ea ADVANCED 28G MISC 2 per fill LANCETS 28G MISC 2 per fill (lancets) retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea TRUE COMFORT TWIST daily,200 ea ULTILET CLASSIC daily,200 ea TOP LANCETS 30G MISC 2 per fill 2 per fill ) (lancets) retail,600 ea LANCETS MISC (lancets retail,600 ea per fill mail) per fill mail)

99 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(6.67 ea QL(6.67 ea ULTILET LANCETS 33G daily,200 ea UNILET COMFORTOUCH daily,200 ea 2 per fill 2 per fill MISC (lancets) retail,600 ea LANCET MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea ULTILET LANCETS MISC daily,200 ea UNILET EXCELITE II MISC daily,200 ea 2 per fill 2 per fill (lancets) retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea ULTILET SAFETY daily,200 ea UNILET EXCELITE MISC daily,200 ea LANCETS 21G X 2.2MM 2 per fill 2 per fill ) MISC (lancets) retail,600 ea (lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea ULTILET SAFETY daily,200 ea UNILET G.P. LANCET daily,200 ea LANCETS 23G MISC 2 per fill 2 per fill ) (lancets) retail,600 ea MISC (lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea ULTRA THIN LANCETS daily,200 ea UNILET G.P. SUPERLITE daily,200 ea 2 per fill 2 per fill 31G MISC (lancets) retail,600 ea LANCET MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea ULTRA-CARE LANCETS daily,200 ea UNILET GP 28 ULTRA daily,200 ea 2 per fill 2 per fill 30G MISC (lancets) retail,600 ea THIN MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea ULTRA-THIN II AUTO daily,200 ea UNILET LANCET MISC daily,200 ea 2 per fill 2 per fill LANCET MISC (lancets) retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea UNILET LANCETS ULTRA-THIN II LANCETS daily,200 ea daily,200 ea 2 per fill MICRO-THIN33G MISC 2 per fill ) 28G MISC (lancets retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea UNILET LANCETS ULTRA-THIN II LANCETS daily,200 ea daily,200 ea 2 per fill SUPER-THIN30G MISC 2 per fill ) 30G MISC (lancets retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail)

100 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(6.67 ea QL(6.67 ea UNILET LANCETS daily,200 ea UNISTIK TOUCH SAFETY daily,200 ea ULTRA-THIN 28G MISC 2 per fill LANCETS 23G MISC 2 per fill (lancets) retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea UNISTIK TOUCH SAFETY UNILET SUPERLITE daily,200 ea daily,200 ea 2 per fill LANCETS 28G MISC 2 per fill ) LANCET MISC (lancets retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea UNISTIK TOUCH SAFETY UNISTIK 3 GENTLE MISC daily,200 ea daily,200 ea 2 per fill LANCETS 30G MISC 2 per fill ) (lancets retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea UNISTIK PRO SAFETY daily,200 ea UNIVERSAL 1 LANCETS daily,200 ea LANCET 21G MISC 2 per fill 2 per fill ) (lancets) retail,600 ea THIN26G MISC (lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea UNISTIK PRO SAFETY daily,200 ea UNIVERSAL 1 LANCETS daily,200 ea LANCET 25G MISC 2 per fill ULTRA THIN 30G MISC 2 per fill (lancets) retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea UNISTIK PRO SAFETY daily,200 ea UNIVERSAL 1 daily,200 ea LANCET 28G MISC 2 per fill LANCETS/33G/MICRO- 2 per fill (lancets) retail,600 ea THIN MISC (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea UNISTIK SAFETY daily,200 ea VALUE PLUS LANCETS daily,200 ea LANCETS 28G MISC 2 per fill STANDARD 21G MISC 2 per fill (lancets) retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea UNISTIK SAFETY daily,200 ea VALUE PLUS LANCETS daily,200 ea LANCETS 30G MISC 2 per fill SUPERTHIN 30G MISC 2 per fill (lancets) retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea UNISTIK TOUCH SAFETY daily,200 ea VALUE PLUS LANCETS daily,200 ea LANCETS 21G MISC 2 per fill 2 per fill ) (lancets) retail,600 ea THIN 26G MISC (lancets retail,600 ea per fill mail) per fill mail)

101 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(6.67 ea QL(6.67 ea VALUMARK LANCET WALGREENS COMFORT daily,200 ea ASSUREDLANCETS daily,200 ea SUPER THIN 30G MISC 2 per fill SUPER THIN/28G MISC 2 per fill (lancets) retail,600 ea retail,600 ea per fill mail) (lancets) per fill mail) QL(6.67 ea QL(6.67 ea VALUMARK LANCET daily,200 ea WALGREENS LANCETS daily,200 ea ULTRA THIN 28G MISC 2 per fill 2 per fill ) (lancets) retail,600 ea MISC (lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea VIDA MIA UNILET daily,200 ea WALGREENS THIN daily,200 ea LANCETS SUPER THIN 2 per fill 2 per fill ) 30G MISC (lancets) retail,600 ea LANCETS MISC (lancets retail,600 ea per fill mail) per fill mail) QL(6.67 ea QL(6.67 ea VIDA MIA UNILET daily,200 ea WALGREENS ULTRA daily,200 ea LANCETS ULTRA THIN 2 per fill THIN LANCETS MISC 2 per fill 28G MISC (lancets) retail,600 ea (lancets) retail,600 ea per fill mail) per fill mail) QL(6.67 ea Parenteral Therapy Supplies VITALET PRO LANCETS daily,200 ea Limit 200 per 2 per fill 1ST TIER UNIFINE month without MISC (lancets) retail,600 ea PENTIPS/MINI/31GX5MM MISC ( 2 authorization;Q per fill mail) insulin pen L(6.67 ea QL(6.67 ea needle) daily); RX/OTC VITALET PRO PLUS daily,200 ea Limit 200 per LANCETS MISC 2 per fill 1ST TIER UNIFINE month without (lancets) retail,600 ea PENTIPSPLUS/MINI/31GX 5MM MISC ( 2 authorization;Q per fill mail) insulin pen L(6.67 ea QL(6.67 ea needle) daily); RX/OTC VIVAGUARD LANCETS daily,200 ea Limit 200 per 2 per fill ABOUTTIME PEN month without MISC (lancets) retail,600 ea NEEDLES 31G X 3/16" MISC ( 2 authorization;Q per fill mail) insulin pen L(6.67 ea QL(6.67 ea needle) daily); RX/OTC WALGREENS ADVANCED daily,200 ea Limit 200 per TRAVELLANCETS 28G 2 per fill ADVOCATE INSULIN PEN month without MISC (lancets) retail,600 ea NEEDLES 31GX5MM MISC ( 2 authorization;Q per fill mail) insulin pen L(6.67 ea ) WALGREENS COMFORT QL(6.67 ea needle daily); RX/OTC ASSUREDLANCETS daily,200 ea Limit 200 per 2 per fill ASSURE ID SAFETY PEN MICRO THIN/33G MISC month without retail,600 ea NEEDLES 31G X 3/16" (lancets) MISC ( 2 authorization;Q per fill mail) insulin pen L(6.67 ea needle) daily); RX/OTC

102 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AURORA UNIFINE Limit 200 per BD VEO INSULIN QL(6.67 ea PENTIPS/MINI/31GX3/16" month without SYRINGE ULTRA- daily) MISC ( 2 authorization;Q FINE/0.5ML/31G X 6MM 2 insulin pen L(6.67 ea needle) MISC (insulin daily); RX/OTC syringe/needle u-100) BD ECLIPSE NEEDLE BD VEO INSULIN Limit 200 per 30G X1/2" MISC (needle 2 SYRINGE ULTRA- month;QL(6.67 (disp) 30 g) FINE/1ML/31G X 6MM 2 ea daily) BD NEEDLE/30G X 1/2" MISC (insulin MISC (needle (disp) 30 2 syringe/needle u-100) g) BD VEO INSULIN Limit 200 per Limited to 1 SYRINGE ULTRA-FINE/U- month;QL(6.67 device per 100/1ML/31G X 15/64" 2 ea daily) BD PEN MINI MISC year;QL(1 ea MISC (insulin (injection device for 3 per fill retail,1 syringe/needle u-100) ea per 365 insulin) Limit 200 per days retail); CAREONE UNIFINE RX/OTC month without PENTIPS 31GX5MM MISC 2 authorization;Q Limited to 1 (insulin pen needle) L(6.67 ea device per daily); RX/OTC BD PEN MISC (injection year;QL(1 ea 3 per fill retail,1 CAREONE UNIFINE Limit 200 per device for insulin) ea per 365 PENTIPS PLUS PEN month without days retail); NEEDLES 31GX5MM 2 authorization;Q RX/OTC MISC (insulin pen L(6.67 ea needle) daily); RX/OTC BD PEN Limit 200 per NEEDLE/MINI/ULTRA- month without CARETOUCH PEN Limit 200 per FINE/31G X 5MM MISC 2 authorization;Q NEEDLES 31GX 5MM month without L(6.67 ea MISC (insulin pen 2 authorization;Q (insulin pen needle) daily); RX/OTC L(6.67 ea needle) BD SAFETYGLIDE QL(6.67 ea daily); RX/OTC INSULIN daily) CLEVER CHOICE Limit 200 per SYRINGE/0.5ML/31G X 2 COMFORT EZPEN month without 15/64" MISC (insulin NEEDLES 31GX5MM 2 authorization;Q syringe/needle u-100) MISC (insulin pen L(6.67 ea daily); RX/OTC BD SAFETYGLIDE Limit 200 per needle) INSULIN month;QL(6.67 CLICKFINE PEN Limit 200 per SYRINGE/1ML/31G X 2 ea daily) NEEDLES 31G X 3/16" month without 15/64" MISC (insulin MISC (insulin pen 2 authorization;Q syringe/needle u-100) L(6.67 ea needle) daily); RX/OTC BD VEO INSULIN QL(6.67 ea Limit 200 per SYRINGE ULTR-FINE/U- daily) COMFORT EZ/31G X 5MM 100/0.5ML/31G X 15/64" month without 2 MISC (insulin pen 2 authorization;Q MISC (insulin needle) L(6.67 ea syringe/needle u-100) daily); RX/OTC

103 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limit 200 per Limit 200 per DIATHRIVE PEN month without FIFTY50 PEN NEEDLES month without NEEDLE/31GX 5MM MISC 2 authorization;Q 31G X3/16" (5MM) MISC 2 authorization;Q (insulin pen needle) L(6.67 ea (insulin pen needle) L(6.67 ea daily); RX/OTC daily); RX/OTC DROPLET INSULIN Limit 200 per Limit 200 per SYRINGE U-100/1ML/31G month;QL(6.67 FIFTY50 PEN NEEDLES month without X 15/64" MISC (insulin 2 ea daily) 31GX5MM MISC (insulin 2 authorization;Q syringe/needle u-100) pen needle) L(6.67 ea daily); RX/OTC DROPLET INSULIN QL(6.67 ea SYRINGE/U- daily) FREDS PHARMACY Limit 200 per month without 100/0.5ML/31G X 15/64" 2 UNIFINE PENTIPS PLUS 31GX5MM MISC ( 2 authorization;Q MISC (insulin insulin L(6.67 ea syringe/needle u-100) pen needle) daily); RX/OTC DROPLET INSULIN Limit 200 per Limit 200 per SYRINGE/U-100/1ML/31G month;QL(6.67 GLOBAL EASE INJECT PEN NEEEDLES month without X 15/64" MISC (insulin 2 ea daily) 31GX5MM MISC (insulin 2 authorization;Q syringe/needle u-100) L(6.67 ea pen needle) Limit 200 per daily); RX/OTC DROPLET PEN NEEDLES month without GLOBAL EASY GLIDE QL(6.67 ea 31GX5MM MISC (insulin 2 authorization;Q INSULIN daily) pen needle) L(6.67 ea SYRINGE/0.5ML/31G X 2 daily); RX/OTC 15/64" MISC (insulin Limit 200 per syringe/needle u-100) DRUG MART UNIFINE month without GLOBAL EASY GLIDE Limit 200 per PENTIPS 31GX5MM MISC 2 authorization;Q INSULIN month;QL(6.67 (insulin pen needle) L(6.67 ea SYRINGE/1ML/31G X 2 ea daily) daily); RX/OTC 15/64" MISC (insulin EASY COMFORT PEN Limit 200 per syringe/needle u-100) month without NEEDLES31GX3/16" GOODSENSE CLICKFINE Limit 200 per MISC ( 2 authorization;Q insulin pen L(6.67 ea SAFETY PEN month without needle) daily); RX/OTC NEEDLE/31G X 3/16" 2 authorization;Q MISC (insulin pen L(6.67 ea EASY TOUCH FLIPLOCK daily); RX/OTC NEEDLES 30GX1/2" MISC 2 needle) (needle (disp) 30 g) GOODSENSE PEN Limit 200 per EASY TOUCH NEEDLE/PENFINE month without HYPODERMIC NEEDLES CLASSIC/31G X 3/16" 2 authorization;Q 2 MISC (insulin pen L(6.67 ea 30GX1/2" MISC (needle daily); RX/OTC (disp) 30 g) needle) Limit 200 per H-E-B IN CONTROL PEN Limit 200 per EASY TOUCH PEN month without NEEDLES/31G X 3/16" month without NEEDLES 31GX5MM 2 authorization;Q MISC ( 2 authorization;Q MISC (insulin pen insulin pen L(6.67 ea L(6.67 ea needle) needle) daily); RX/OTC daily); RX/OTC

104 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits H-E-B IN CONTROL Limit 200 per LITETOUCH PEN Limit 200 per UNIFINEPENTIPS PLUS month without NEEDLES/31G X month without 31GX5MM MISC ( 2 authorization;Q 5MM/MINI MISC ( 2 authorization;Q insulin L(6.67 ea insulin L(6.67 ea pen needle) daily); RX/OTC pen needle) daily); RX/OTC HEALTHWISE SHORT Limit 200 per Limit 200 per PEN NEEDLES/31G X month without MARATHON MEDICAL month without PENTIPS31GX5MM MISC 3/16" MISC (insulin pen 2 authorization;Q 2 authorization;Q L(6.67 ea (insulin pen needle) L(6.67 ea needle) daily); RX/OTC daily); RX/OTC HEALTHY ACCENTS Limit 200 per Limit 200 per UNIFINE PENTIPS PEN month without MM PEN NEEDLES 31G X month without NEEDLES 31GX5MM 2 authorization;Q 3/16" MISC (insulin pen 2 authorization;Q MISC (insulin pen L(6.67 ea needle) L(6.67 ea needle) daily); RX/OTC daily); RX/OTC HYPODERMIC NEEDLE Limited to 1 device per 30GX1/2" MISC (needle 2 NOVOPEN ECHO DEVI year;QL(1 ea (disp) 30 g) (injection device for 3 per fill retail,1 ea per 365 INSULIN SYRINGES AND 2 MO insulin) PEN NEEDLES days retail); Limit 200 per RX/OTC INSUPEN 31G X 5MM month without Limit 200 per MISC (insulin pen 2 authorization;Q PC UNIFINE PENTIPS month without needle) L(6.67 ea 31G X5MM MINI MISC 2 authorization;Q daily); RX/OTC (insulin pen needle) L(6.67 ea daily); RX/OTC KROGER PEN Limit 200 per month without Limit 200 per NEEDLES/31G X3/16" PEN NEEDLES 31G X MISC ( 2 authorization;Q month without insulin pen L(6.67 ea 3/16" MISC (insulin pen 2 authorization;Q needle) daily); RX/OTC needle) L(6.67 ea LEADER UNIFINE Limit 200 per daily); RX/OTC PENTIPS month without Limit 200 per PLUS/MINI/31GX3/16" 2 authorization;Q PEN NEEDLES 31G X month without MISC (insulin pen L(6.67 ea 5MM MISC (insulin pen 2 authorization;Q needle) daily); RX/OTC needle) L(6.67 ea daily); RX/OTC LEADER UNIFINE Limit 200 per month without Limit 200 per PENTIPS/MINI/31GX3/16" PEN NEEDLES/31G X month without MISC ( 2 authorization;Q insulin pen L(6.67 ea 3/16" MISC (insulin pen 2 authorization;Q needle) daily); RX/OTC needle) L(6.67 ea daily); RX/OTC LITETOUCH PEN Limit 200 per month without Limit 200 per NEEDLES/31G X 3/16" PENTIPS 31G X 5MM month without MISC ( 2 authorization;Q insulin pen L(6.67 ea MISC (insulin pen 2 authorization;Q needle) daily); RX/OTC needle) L(6.67 ea daily); RX/OTC

105 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limit 200 per SURE COMFORT PEN Limit 200 per PENTIPS 31GX5MM MISC month without NEEDLES31GX3/16" month without 2 authorization;Q 2 authorization;Q (insulin pen needle) L(6.67 ea (5MM) MISC (insulin pen L(6.67 ea daily); RX/OTC needle) daily); RX/OTC POLY HUB NEEDLE/30G SURE-FINE PEN Limit 200 per X 1/2" MISC (needle 2 NEEDLES 31GX3/16" 5MM month without (disp) 30 g) MISC ( 2 authorization;Q insulin pen L(6.67 ea PREFERRED PLUS Limit 200 per needle) daily); RX/OTC UNIFINE month without PENTIPS/MINI/31GX5MM authorization;Q TECHLITE INSULIN QL(6.67 ea 2 SYRINGEU- daily) MISC (insulin pen L(6.67 ea daily); RX/OTC 100/0.5ML/31G X 15/64" 2 needle) MISC (insulin Limit 200 per syringe/needle u-100) PX MINI PEN NEEDLES month without 31GX5MM MISC (insulin 2 authorization;Q TECHLITE INSULIN Limit 200 per SYRINGEU-100/1ML/31G month;QL(6.67 pen needle) L(6.67 ea 2 daily); RX/OTC X 15/64" MISC (insulin ea daily) Limit 200 per syringe/needle u-100) RA PEN NEEDLES 31G X month without Limit 200 per 5MM3/16" MISC (insulin 2 authorization;Q TECHLITE PEN NEEDLES month without pen needle) L(6.67 ea 31GX 5MM MISC (insulin 2 authorization;Q daily); RX/OTC pen needle) L(6.67 ea RELION INSULIN QL(6.67 ea daily); RX/OTC SYRINGE 0.5ML/31G X daily) Limit 200 per 2 TECHLITE PEN 15/64" MISC (insulin NEEDLES/31GX 5MM month without syringe/needle u-100) MISC ( 2 authorization;Q insulin pen L(6.67 ea RELION INSULIN Limit 200 per needle) daily); RX/OTC SYRINGE month;QL(6.67 1ML/31GX15/64" MISC ea daily) TRUE COMFORT PEN Limit 200 per 2 month without (insulin syringe/needle NEEDLES31G X 5MM MISC ( 2 authorization;Q u-100) insulin pen L(6.67 ea RELION INSULIN Limit 200 per needle) daily); RX/OTC SYRINGE/U-100/1ML/31G month;QL(6.67 Limit 200 per 2 ea daily) TRUEPLUS 5-BEVEL PEN X 15/64" MISC (insulin NEEDLES 31GX5MM month without syringe/needle u-100) MISC ( 2 authorization;Q insulin pen L(6.67 ea SHOPKO UNIFINE Limit 200 per needle) PENTIPS PEN month without daily); RX/OTC NEEDLES/MINI/31GX5MM 2 authorization;Q TRUEPLUS PEN Limit 200 per MISC (insulin pen L(6.67 ea NEEDLES 31GX5MM month without needle) daily); RX/OTC MISC ( 2 authorization;Q insulin pen L(6.67 ea SHOPKO UNIFINE Limit 200 per needle) daily); RX/OTC PENTIPS PLUS PEN month without Limit 200 per NEEDLES/MINI/REMOVE 2 authorization;Q ULTICARE PEN NEEDLES R/31GX5MM MISC L(6.67 ea month without 31GX 5MM MISC (insulin 2 authorization;Q ( ) daily); RX/OTC insulin pen needle pen needle) L(6.67 ea daily); RX/OTC 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic is Available AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

106 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limit 200 per Limit 200 per ULTICARE PEN NEEDLES month without UNIFINE PENTIPS PLUS month without 31GX 5MM/MINI MISC 2 authorization;Q 31GX5MM MISC (insulin 2 authorization;Q (insulin pen needle) L(6.67 ea pen needle) L(6.67 ea daily); RX/OTC daily); RX/OTC ULTIGUARD Limit 200 per WEGMANS UNIFINE Limit 200 per SAFEPACK/MINI PEN month without PENTIPS month without NEEDLE/31G X authorization;Q PLUS/MINI/31GX5MM 2 authorization;Q 3/16"/SHARPS CONTAI 2 L(6.67 ea MISC (insulin pen L(6.67 ea MISC (insulin pen daily); RX/OTC needle) daily); RX/OTC needle) MIGRAINE PRODUCTS - Drugs to Treat Migraine ULTILET INSULIN QL(6.67 ea Headaches SYRINGE/U- daily) 100/0.5ML/31GX6MM 2 Calcitonin Gene-Related Peptide (CGRP) AIMOVIG SOAJ PA; ST MISC (insulin 2 syringe/needle u-100) (erenumab-aooe) EMGALITY SOAJ PA Limit 200 per 2 ULTILET PEN NEEDLE month without (galcanezumab-gnlm) 31GX5MM MISC (insulin 2 authorization;Q EMGALITY SOSY PA 2 pen needle) L(6.67 ea ( ) daily); RX/OTC galcanezumab-gnlm Migraine Combinations ULTILET SHORT PEN Limit 200 per month without NEEDLES31GX3/16" (Ergotamine W/ Caffeine) 1 MISC ( 2 authorization;Q MIGERGOT SUPP insulin pen L(6.67 ea needle) ergotamine w/ caffeine 1 daily); RX/OTC tabs ULTRA-THIN II MINI PEN Limit 200 per NEEEDLES/31GX3/16" month without Migraine Products MISC ( 2 authorization;Q D.H.E. 45 SOLN PA insulin pen L(6.67 ea needle) (dihydroergotamine 7 daily); RX/OTC mesylate) Limit 200 per ULTRACARE PEN PA month without dihydroergotamine NEEDLES/31G X 3/16" mesylate soln ij 1 2 MISC ( 2 authorization;Q insulin pen L(6.67 ea mg/ml needle) daily); RX/OTC dihydroergotamine PA; QL(0.27 ml Limit 200 per mesylate soln na 4 1 daily) UNIFINE PENTIPS 31G X month without mg/ml 3/16" MISC (insulin pen 2 authorization;Q ERGOMAR SUBL needle) L(6.67 ea 2 daily); RX/OTC (ergotamine tartrate) Limit 200 per Serotonin Agonists UNIFINE PENTIPS month without Limit 6 per 31GX5MM MISC (insulin 2 authorization;Q almotriptan malate tabs 1 month;QL(0.2 pen needle) L(6.67 ea ea daily) daily); RX/OTC eletriptan hydrobromide Limit 6 tabs per 1 month;QL(0.2 tabs ea daily)

107 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limit 9 per PA frovatriptan succinate sumatriptan succinate 4 1 month;QL(0.3 sosy sc 6 mg/0.5ml tabs ea daily) sumatriptan succinate Limit 9 per PA; ST; Limit IMITREX SOLN SC 6 tabs or 100 mg, 25 mg, 1 month;QL(2 ea MG/0.5ML ( 7 2mls per daily) sumatriptan month;QL(0.07 50 mg succinate) ml daily) zolmitriptan tabs 2.5 Limit 6 per 1 month;QL(0.2 IMITREX STATDOSE PA; ST mg, 5 mg REFILL SOCT 4 MG/0.5ML 7 ea daily) (sumatriptan succinate) zolmitriptan tbdp 2.5 Limit 6 tabs per 1 month;QL(0.2 IMITREX STATDOSE PA mg, 5 mg REFILL SOCT 6 MG/0.5ML 7 ea daily) (sumatriptan succinate) QL(6 ea per 30 ZOMIG SOLN NA 2.5 MG, 3 days retail,18 IMITREX STATDOSE PA 5 MG (zolmitriptan) ea per 90 days SYSTEM SOAJ 7 mail) (sumatriptan succinate) Limit 9 per MINERALS & ELECTROLYTES naratriptan hcl tabs 1 month;QL(0.3 ea daily) Calcium Limit 18 tabs CALCIFOL WAFR (calcium carbonate-folic rizatriptan benzoate 1 per 3 tabs month;QL(0.6 acid-vit d-b6-b12- ea daily) boron-magnesium) Limit 18 tabs CALCIUM-FOLIC ACID rizatriptan benzoate 1 per PLUS D WAFR (calcium tbdp month;QL(0.6 carbonate-folic acid-vit 3 ea daily) d-b6-b12-boron- Limit 6 magnesium) sumatriptan soln 20 1 sprayers per mg/act month;QL(2 ea Electrolyte Mixtures daily) potassium chloride in PA sumatriptan soln 5 Limit 6 per dextrose & sodium 4 1 month;QL(0.2 chloride soln mg/act ea daily) sumatriptan succinate PA Fluoride soaj sc 4 mg/0.5ml, 6 4 (Sodium Fluoride) AL(Up to 6 yrs FLUORITAB, FLURA- 1 old ); PV mg/0.5ml DROPS, NAFRINSE PA; ST sumatriptan succinate 4 DROPS SOLN soct sc 4 mg/0.5ml (Sodium Fluoride) AL(Up to 6 yrs PA FLUORITAB, NAFRINSE 1 old ); PV sumatriptan succinate 4 soct sc 6 mg/0.5ml CHEW FLORIVA LIQD ( PA; ST; Limit sodium 3 fluoride-vitamin d) sumatriptan succinate 4 2mls per soln sc 6 mg/0.5ml month;QL(0.07 FLUORABON SOLN AL(Up to 6 yrs 2 ml daily) (sodium fluoride) old ); PV

108 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits 1 AL(Up to 6 yrs (Potassium Chloride) K- 1 sodium fluoride chew old ); PV SOL SOLN 1 AL(Up to 6 yrs (Potassium Chloride) sodium fluoride soln old ); PV KLOR-CON 10, KLOR- 1 CON 8 TBCR sodium fluoride tabs 1 AL(Up to 6 yrs old ); PV (Potassium Chloride) 1 KLOR-CON PACK Magnesium MAGNEBIND 400 TABS (Potassium Chloride) KLOR-CON SPRINKLE 1 (magnesium-calcium- 3 CPCR folic acid) EFFER-K TBEF 0.84 GM-1 PA GM, 1.68 GM-2 GM magnesium sulfate soln 4 ij 50 % (potassium 3 Phosphate bicarbonate-citric acid) K-TAB TBCR 8 MEQ (Pot Phosphate Monobasic 7 W/ Sod Phosphate Dibasic (potassium chloride) & Monobasic) AV-PHOS potassium chloride cpcr 1 250 NEUTRAL, PHOSPHA 1 or 10 meq, 8 meq 250 NEUTRAL, PHOSPHO-TRIN 250 potassium chloride NEUTRAL, VIRT-PHOS microencapsulated 1 250 NEUTRAL TABS crystals er tbcr K-PHOS TABS potassium chloride 1 (potassium phosphate 2 pack or 20 meq ) monobasic POTASSIUM CHLORIDE PA pot phosphate SOLN IV 20 MEQ/100ML 4 monobasic w/ sod 1 (potassium chloride) phosphate dibasic & potassium chloride soln 1 monobasic tabs or 10 %, 20 % Potassium potassium chloride tbcr (Potassium Bicarb & or 10 meq, 20 meq, 8 1 Chloride) 1 meq EFFERVESCENT POT CHLORIDE TBEF Sodium QL(500 ml (Potassium Bicarbonate) 1 sodium chloride soln 3 EFFER-K TBEF 25 MEQ daily) (Potassium Bicarbonate) K- Zinc EFFERVESCENT, K- 1 GALZIN CAPS (zinc PRIME, K-VESCENT, 3 KLOR-CON/EF TBEF acetate (oral)) (Potassium Chloride MISCELLANEOUS THERAPEUTIC CLASSES Microencapsulated Crystals Er) KLOR-CON 1 Chelating Agents M10, KLOR-CON M15, (Trientine Hcl) CLOVIQUE 4 PA KLOR-CON M20 TBCR CAPS

109 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits D-PENAMINE TABS 2 everolimus (penicillamine) (immunosuppressant) 1 penicillamine caps 1 PA tabs mycophenolate mofetil 1 penicillamine tabs 1 caps SYPRINE CAPS ( PA mycophenolate mofetil trientine 7 1 hcl) susr PA mycophenolate mofetil 1 trientine hcl caps 4 tabs Immunomodulators mycophenolate sodium 1 PA; Must use tbec REVLIMID CAPS Exactus PROGRAF PACK 0.2 MG, PA 4 4 Specialty Rx 1- 1 MG ( ) (lenalidomide) 866-458- tacrolimus SANDIMMUNE SOLN 100 9246;LA; AC 3 Must use MG/ML (cyclosporine) THALOMID CAPS Exactus sirolimus soln 1 3 Specialty Rx 1- (thalidomide) 866-458- 1 9246;AC sirolimus tabs Immunosuppressive Agents tacrolimus caps 1 (Cyclosporine Modified THYMOGLOBULIN SOLR PA (For Microemulsion)) 1 GENGRAF CAPS (anti-thymocyte globulin 3 (Cyclosporine Modified (rabbit), lymphocyte (For Microemulsion)) 1 immune globulin) GENGRAF SOLN ZORTRESS TABS 1 MG ASTAGRAF XL CP24 ST (everolimus 2 3 (tacrolimus) (immunosuppressant)) AZASAN TABS Potassium Removing Agents 3 (azathioprine) (Sodium Polystyrene Sulfonate) KIONEX, SPS 1 azathioprine tabs 1 SUSP cyclosporine caps 1 LOKELMA PACK ST (sodium zirconium 3 cyclosporine modified cyclosilicate) (for microemulsion) 1 sodium polystyrene 1 caps 100 mg, 25 mg, sulfonate powd 50 mg sodium polystyrene 1 cyclosporine modified sulfonate susp (for microemulsion) 1 soln 100 mg/ml Systemic Lupus Erythematosus Agents

110 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; MUST MUCOTROL WAFR ( oral 3 BENLYSTA SOAJ USE ACARIA wound care products) 4 SPECIALTY (belimumab) QL(6 ea daily) RX 844-538- pilocarpine hcl (oral) 1 4661;LA tabs 5 mg PA; MUST QL(4 ea daily) pilocarpine hcl (oral) 1 BENLYSTA SOSY USE ACARIA tabs 7.5 mg 4 SPECIALTY (belimumab) RX 844-538- MULTIVITAMINS 4661;LA Multiple Vitamins & Fluoride-Folic Acid MOUTH/THROAT/DENTAL AGENTS MULTIVITAMIN WITH FLUORIDE CHEW 0.25 Anesthetics Topical Oral MG-0.3 MG-1.05 MG-1.05 FIRST-MOUTHWASH BLM MG-1.2 MG-13.5 MG-15 SUSP UNIT-2500 UNIT-4.5 MCG- (diphenhydramine- 400 UNIT-60 MG, 0.3 MG- lidocaine-alum 3 0.5 MG-1.05 MG-1.05 MG- 1.2 MG-13.5 MG-15 UNIT- hydroxide-mg 3 hydroxide-simeth) 2500 UNIT-4.5 MCG-400 UNIT-60 MG, 0.3 MG-1 lidocaine hcl (mouth- 1 MG-1.05 MG-1.05 MG-1.2 throat) soln MG-13.5 MG-15 UNIT- 2500 UNIT-4.5 MCG-400 Anti-infectives - Throat UNIT-60 MG (multiple clotrimazole troc 1 vitamins & fluoride-folic acid) nystatin (mouth-throat) 1 susp Multiple Vitamins w/ Minerals ORAVIG TABS THRIVITE 19 TABS (miconazole (mouth- 3 (multiple vitamins w/ 3 throat)) minerals & folic acid) Antiseptics - Mouth/Throat Ped MV w/ Fluoride (Chlorhexidine Gluconate (Pediatric Multivitamins AL(Up to 6 yrs (Mouth-Throat)) PAROEX, 1 W/Fl) MULTI- 1 old ) PERIOGARD SOLN VITAMIN/FLUORIDE chlorhexidine gluconate DROPS SOLN 1 (Pediatric Multivitamins AL(Up to 6 yrs (mouth-throat) soln W/Fl) MULTIVITAMIN old ) Steroids - Mouth/Throat/Dental WITH FLUORIDE SOLN (Triamcinolone Acetonide 0.25 MG/ML-0.4 MG/ML- (Mouth)) ORALONE 1 0.5 MG/ML-0.6 MG/ML- DENTAL PASTE PSTE 1500 UNIT/ML-2 MCG/ML- 35 MG/ML-400 UNIT/ML-5 1 triamcinolone 1 UNIT/ML-8 MG/ML, 0.4 acetonide (mouth) pste MG/ML-0.5 MG/ML-0.5 Throat Products - Misc. MG/ML-0.6 MG/ML-1500 UNIT/ML-2 MCG/ML-35 cevimeline hcl caps 1 QL(3 ea daily) MG/ML-400 UNIT/ML-5 UNIT/ML-8 MG/ML 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic is Available AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

111 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Pediatric Multivitamins AL(Up to 6 yrs (Ped Multivitamins W/Fl & AL(Up to 6 yrs W/Fl) old ) Iron) MULTI- old ) MULTIVITAMIN/FLUORID 1 VIT/IRON/FLUORIDE, 1 E, MULTI- MULTIVITAMINS/FLUORI VITAMIN/FLUORIDE/IRON DE CHEW SOLN (Pediatric Multivitamins AL(Up to 6 yrs POLY-VI-FLOR/IRON AL(Up to 6 yrs W/Fl) POLY-VI-FLOR old ) CHEW 0.5 MG-10 MG-15 old ) CHEW 0.25 MG-15 UNIT- UNIT-200 MCG-400 UNIT 3 200 MCG-400 UNIT, 0.5 1 (ped multivitamins w/fl MG-15 UNIT-200 MCG- & iron) 400 UNIT, 1 MG-15 UNIT- 200 MCG-400 UNIT POLY-VI-FLOR/IRON SUSP 0.25 MG/ML-200 (Pediatric Vitamins Acd W/ AL(Up to 6 yrs Fluoride) TRI- old ) MCG/ML-7 MG/ML (ped 3 VITE/FLUORIDE, 1 multivitamins w/fl & VITAMINS iron) A/C/D/FLUORIDE SOLN QUFLORA FE PEDIATRIC AL(Up to 6 yrs FLORIVA PLUS SOLN AL(Up to 6 yrs LIQD (ped multivitamins 2 old ) (pediatric multivitamins 2 old ) w/fl & iron) w/fl) Pediatric Multiple Vitamins & Minerals w/ Fluoride pediatric vitamins acd AL(Up to 6 yrs FLORIVA CHEW 1 old ) w/ fluoride soln (pediatric multiple POLY-VI-FLOR SUSP 0.25 vitamins & minerals w/ 3 MG/ML-200 MCG/ML fluoride) (pediatric multivitamins 3 w/fl) Prenatal Vitamins (Prenatal Vit W/ Docusate- RX/OTC QUFLORA GUMMIES AL(Up to 6 yrs Fe Fumarate-Folic Acid) CHEW (pediatric 2 old ) PRENATAL 19 TABS 1 multivitamins w/fl) MG-100 MG-1000 UNIT-12 1 QUFLORA PEDIATRIC AL(Up to 6 yrs MCG-15 MG-20 MG-20 CHEW (pediatric 2 old ) MG-200 MG-25 MG-29 ) MG-3 MG-3 MG-30 UNIT- multivitamins w/fl 400 UNIT-7 MG QUFLORA PEDIATRIC AL(Up to 6 yrs (Prenatal Vit W/ Docusate- SOLN (pediatric 2 old ) Iron Carbonyl-Folic Acid) 1 multivitamins w/fl) INATAL GT TABS TRI-VI-FLOR SUSP (Prenatal Vit W/ Ferrous (pediatric vitamins acd Fumarate-Folic Acid) & l-methylfolate w/ 3 PRENATAL 19 CHEW 1 fluoride) MG-100 MG-1000 UNIT-12 1 MCG-20 MG-20 MG-200 TRI-VI-FLORO SUSP MG-25 MG-29 MG-3 MG-3 (pediatric vitamins acd 3 MG-30 UNIT-400 UNIT-6 & l-methylfolate w/ MG-7 MG fluoride) Ped Multi Vitamins w/Fl & FE

112 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Prenatal Vit W/ Ferrous CITRANATAL DHA MISC Fumarate-L Methylfolate- 1 (prenatal w/o vit a w/ fe Folic Acid) PNV-SELECT carbonyl-fe gluconate- 2 TABS dss-fa-dha) (Prenatal Vit W/ Iron Carbonyl-Folic Acid) 1 CITRANATAL ESSENCE THPK (prenatal w/o vit PRENATABS RX TABS 2 (Prenatal Without A W/ Fe a w/ fe carbonyl-fe Fumarate-L Methylfolate- 1 gluconate-fa-dha) Fa-Dha) PNV-DHA CAPS CITRANATAL HARMONY ATABEX EC TBEC CAPS (prenatal w/o vit 3 (prenatal vit w/ a w/ fe fumarate-fe 2 docusate-iron carbonyl- carbonyl-dss-fa-dha) folic acid) CITRANATAL MEDLEY BAL-CARE DHA MISC CAPS (prenatal w/o vit 3 (prenatal w/fe a w/ fe fumarate-fe 2 polysacch cmplx-sod carbonyl-fa-dha) feredetate-fa-omega 3) CITRANATAL RX TABS C-NATE DHA CAPS (prenatal without vit a 3 (prenatal vit w/ ferrous w/ fe carbonyl-fe gluc- 3 fumarate-fa-omega 3 docusate-fa) fatty acids) COMPLETENATE CHEW CITRANATAL 90 DHA (prenatal vit w/ ferrous 2 MISC (prenatal w/o vit a fumarate-folic acid) 2 w/ fe carbonyl-fe CONCEPT DHA CAPS gluconate-dss-fa-dha) (prenatal vit w/ fe fum- 2 CITRANATAL ASSURE iron polysacch complex MISC (prenatal w/o vit a -fa-omega 3) 3 w/ fe carbonyl-fe CONCEPT OB CAPS gluconate-dss-fa-dha) (prenatal without a vit 2 CITRANATAL B-CALM w/ fe fum-iron MISC (prenatal w/o vit a polysacch complex -fa) 3 w/ fe carbonyl-fe DOTHELLE DHA CAPS gluconate-fa & vit b6) (prenatal vit w/ fe fum- 2 CITRANATAL BLOOM iron polysacch complex DHA MISC (prenatal w/o -fa-omega 3) 2 vit a w/ fe carbonyl-fe DUET DHA 400 MISC gluconate-dss-fa-dha) (prenatal w/fe 3 CITRANATAL BLOOM polysacch cmplx-sod TABS (prenatal vit w/ feredetate-fa-omega 3) 3 docusate-fe carbonyl-fe DUET DHA BALANCED gluconate-folic acid) MISC (prenatal w/fe polysacch cmplx-sod 3 feredetate-fa-omega 3)

113 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FOLET DHA THPK NEEVO DHA CAPS (prenatal vit w/fe (prenatal without vit a carbonyl-fe bisglyc- 3 w/ fe fumarate-l 3 methylfol-dss & dha) methylfolate-omegas) FOLET ONE CAPS NEONATAL COMPLETE RX/OTC (prenatal w/o a w/fe TABS (prenatal vit w/ carbonyl-fe bisglyc-l 3 ferrous fumarate-folic 2 methylfol-dss-dha) acid) FOLIVANE-OB CAPS NEONATAL PLUS TABS RX/OTC (prenatal without a vit (prenatal vit w/ ferrous 2 2 w/ fe fum-iron fumarate-folic acid) polysacch complex -fa) NESTABS ABC MISC HEMENATAL OB + DHA (prenatal mv & min w/o 3 MISC (prenatal vit w/ fe vit a w/fe polysac 2 poly cmplx-fe heme cmplx-fa-ca-omega 3) polypept-fa & omega 3) NESTABS DHA MISC HEMENATAL OB TABS (prenatal vit without vit 2 (prenatal vit w/ fe a w/ fe bisglycinate-fa- 3 polysacch complex-fe omeg 3) heme polypeptide-fa) NESTABS ONE CAPS M-NATAL PLUS TABS RX/OTC (prenatal w/o a w/fe 3 (prenatal vit w/ ferrous 2 carbonyl-fe bisglyc-l fumarate-folic acid) methylfol-dha) MARNATAL-F CAPS NESTABS TABS (prenatal without vit a (prenatal vit without vit w/ iron polysaccharide 2 a w/ fe bisglycinate-folic 3 complex-fa) acid) MYNATAL ADVANCE NEXA PLUS CAPS TABS (prenatal vit w/ (prenatal w/o vit a w/fe docusate-iron carbonyl- 2 fumarate-docusate ca- 3 folic acid) folic acid-dha) MYNATAL ULTRACAPLET NIVA-PLUS TABS RX/OTC TABS (prenatal vit w/ (prenatal vit w/ ferrous 2 2 docusate-iron carbonyl- fumarate-folic acid) folic acid) O-CAL FA TABS RX/OTC NATACHEW CHEW (prenatal vit w/ ferrous 2 (prenatal vit w/ fe fum- fumarate-folic acid) 3 fe bisglycinate chelate- OB COMPLETE ONE folic acid) CAPS (prenatal w/o vit 3 NATELLE ONE CAPS a w/ fe carbonyl-fe (prenatal without vit a aspart glyc-fa-fish oil) w/ fe fum-fa-omega 3 fatty acids)

114 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits OB COMPLETE PETITE PR NATAL 430 EC MISC CAPS (prenatal w/o vit (prenatal mv & min w/fe a w/ fe carbonyl-fe 3 bisglyc-fe prot succ-fa- 3 aspart glyc-fa-omega 3) ca-omega 3) OB COMPLETE PREMIER PR NATAL 430 MISC TABS (prenatal vit w/ (prenatal mv & min w/fe iron carbonyl-fe aspart 3 bisglyc-fe prot succ-fa- 3 glycinate-fa) ca-omega 3) OB COMPLETE/DHA PRENA 1 TRUE MISC CAPS (prenat vit w/ iron (prenatal without a w/ carbonyl-fe asp glyc-fa- 3 fe amino acid chelate- 2 omega fatty acid) fa-dha) OBSTETRIX ONE CAPS PRENA1 CHEW CHEW (prenatal w/o a w/fe (prenatal w/ vit b2-b6- carbonyl-fe bisglyc-l 3 b12-cholecalciferol-folic 3 methylfol-dss-dha) acid) ONE VITE WOMENS RX/OTC PRENA1 PEARL CPCR PRENATALVITAMIN PLUS (prenatal without a w/ TABS (prenatal vit w/ 2 fe fumarate-sod 3 ferrous fumarate-folic feredetate-fa-dha) acid) PRENAISSANCE CAPS PNV OB+DHA MISC (prenatal w/o vit a w/ fe 3 (prenatal w/o vit a w/ fe 2 fumarate-dss-fa-dha) carbonyl-fe gluconate- PRENAISSANCE PLUS dss-fa-dha) CAPS (prenatal w/o vit PNV TABS 29-1 TABS a w/ fe carbonyl-dss-fa- 3 (prenatal vit w/ iron 2 dha) carbonyl-folic acid) PRENATAL + DHA THPK PNV-DHA+DOCUSATE (prenatal w/o vit a w/ CAPS (prenatal w/o vit 3 3 ferrous fumarate-folic a w/ fe fumarate-dss- acid-dha) fa-dha) PRENATAL 19 CHEW 1 PNV-OMEGA CAPS MG-100 MG-1000 UNIT-12 (prenatal without a w/ MCG-15 MG-20 MG-20 MG-200 MG-29 MG-3 MG- fe fumarate-l 3 2 methylfolate-fa-omega 3 MG-30 UNIT-400 UNIT-7 3) MG (prenatal vit w/ ferrous fumarate-folic PR NATAL 400 EC MISC acid) (prenatal mv & min w/fe bisglyc-fe prot succ-fa- 3 ca-omega 3)

115 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PRENATAL 19 TABS 1 RX/OTC PRENATE ESSENTIAL MG-100 MG-1000 UNIT-12 CAPS (prenatal w/o a MCG-15 MG-20 MG-20 w/ fe asparto glyc-l 3 MG-200 MG-25 MG-29 ) MG-3 MG-3 MG-30 UNIT- 3 methylfolate-fa-dha 400 UNIT-7 MG (prenatal PRENATE MINI CAPS (prenatal w/o vit a w/ fe vit w/ docusate-fe 3 fumarate-folic acid) carbonyl-fe asp glyc- ) PRENATAL PLUS IRON methfol-fa-dha TABS (prenatal vit w/ 2 PRENATE PIXIE CAPS (prenatal w/o a w/ fe iron carbonyl-folic acid) 3 PRENATAL PLUS TABS RX/OTC asparto glyc-l ) (prenatal vit w/ ferrous 2 methylfolate-fa-dha fumarate-folic acid) PRENATE RESTORE CAPS (prenatal without PRENATAL TABS RX/OTC 3 (prenatal vit w/ ferrous 2 a w/ fe fumarate-l fumarate-folic acid) methylfolate-fa-dha) PRENATRIX TABS RX/OTC PRENATAL VITAMINS RX/OTC PLUS LOW IRON TABS (prenatal vit w/ ferrous 2 (prenatal vit w/ ferrous 2 fumarate-folic acid) fumarate-folic acid) PRENATRYL TABS RX/OTC PRENATAL-U CAPS (prenatal vit w/ ferrous 2 (prenatal without a vit fumarate-folic acid) w/ fe fumarate-folic 2 PREPLUS TABS RX/OTC acid) (prenatal vit w/ ferrous 2 PRENATE CHEW fumarate-folic acid) (prenatal multivitamins PROVIDA DHA CAPS 3 (prenatal without a w/fe & minerals w/ l- 2 methylfolate-fa) fum-fe polysacch PRENATE DHA CAPS complex-fa-dha) (prenatal w/o a w/ fe R-NATAL OB CAPS asparto glyc-l 3 (prenatal w/o vit a w/ fe 2 methylfolate-fa-dha) carbonyl-folic acid-dha) PRENATE ELITE TABS RELNATE DHA CAPS (prenatal vit w/ ferrous (prenatal w/ fe asparto 3 glycinate-l methylfolate- 3 fumarate-fa-omega 3 folic acid) fatty acids) PRENATE ENHANCE SE-NATAL 19 CHEW CAPS (prenatal without (prenatal vit w/ ferrous 2 a w/ fe fumarate-l 3 fumarate-folic acid) methylfolate-fa-dha) SE-NATAL 19 TABS RX/OTC (prenatal vit w/ docusate-fe fumarate- 3 folic acid)

116 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SELECT-OB CHEW 0.4 TRI-TABS DHA MISC MG-0.6 MG-1.6 MG-1.8 (prenatal vit without vit MG-15 MG-15 MG-1700 a w/ fe bisglycinate-fa- 2 UNIT-2.5 MG-25 MG-29 ) MG-30 UNIT-400 UNIT-5 2 omeg 3 MCG-60 MG (prenatal vit TRICARE PRENATAL w/ iron polysaccharide DHA ONE CAPS (prenatal w/fe 3 cmplx-l methylfolate-fa) fumarate-fa-dss-fish oil) SELECT-OB CHEW 1 MG- 1.6 MG-1.8 MG-15 MG-15 TRICARE PRENATAL DHA ONE/FOLATE CAPS MG-1700 UNIT-2.5 MG-25 2 MG-29 MG-30 UNIT-400 (prenatal multivit-min UNIT-5 MCG-60 MG 3 w/fe-fa) (prenatal vit w/ iron TRICARE TABS RX/OTC polysaccharide (prenatal vit w/ ferrous 2 complex-folic acid) fumarate-folic acid) SELECT-OB+DHA MISC TRINATAL RX 1 TABS (prenatal mv & min w/fe 3 (prenatal vit w/ ferrous 2 polysaccharide fumarate-folic acid) complex-fa-dha) TRISTART DHA CAPS TARON-BC MISC (prenatal without a w/ (prenatal without vit a 3 3 fe carbonyl-l w/ iron carbonyl-folic methylfolate-fa-dha) acid & vit b6) TRISTART ONE CAPS TARON-C DHA CAPS (prenatal without a w/ (prenatal vit w/ fe fum- 3 2 fe carbonyl-l iron polysacch complex methylfolate-fa-dha) -fa-omega 3) ULTIMATECARE ONE TARON-PREX CAPS CAPS (prenatal vit w/ (prenatal w/o vit a w/ fe 3 iron carbonyl-fe aspart 3 fumarate-dss-fa-dha) glyc-fa-omega 3) THERANATAL CORE RX/OTC VENA-BAL DHA MISC NUTRITION TABS 2 (prenatal w/fe (prenatal vit w/ ferrous polysacch cmplx-sod 2 fumarate-folic acid) feredetate-fa-omega 3) THRIVITE RX TABS VIL-RX TABS (prenatal (prenatal vit w/ iron 2 vit w/ iron carbonyl-folic 2 carbonyl-folic acid) acid) TL-CARE DHA CAPS VINATE DHA RF CAPS (prenatal w/fe 3 (prenatal without vit a fumarate-fa-dss-fish oil) w/ fe fumarate-l 3 TL-SELECT CAPS methylfolate-omegas) (prenatal w/o vit a w/ fe 3 fumarate-dss-fa-dha)

117 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VINATE ONE TABS VITAFOL-ONE CAPS (prenatal vit w/ ferrous 2 (prenatal mv & min w/fe 3 fumarate-folic acid) polysaccharide VIRT-C DHA CAPS complex-fa-dha) (prenatal vit w/ fe fum- VITAMEDMD ONE iron polysacch complex 2 RX/QUATREFOLIC CAPS -fa-omega 3) (prenatal without a w/ 3 VIRT-NATE DHA CAPS fe fumarate-l (prenatal vit w/ ferrous methylfolate-fa-dha) fumarate-fa-omega 3 3 VITAMEDMD REDICHEW fatty acids) RX CHEW (prenatal w/ VIRT-PN DHA CAPS vit b2-b6-b12- 3 (prenatal without a w/ cholecalciferol-folic fe fumarate-l 3 acid) methylfolate-fa-dha) VITAPEARL CPCR (prenatal without a w/ VIRT-PN PLUS CAPS 3 (prenatal without a w/ fe fumarate-sod fe fumarate-l 3 feredetate-fa-dha) methylfolate-fa-omega VITATHELY/GINGER RX/OTC TABS (prenatal vit w/ 3) 2 VIRT-PN TABS (prenatal ferrous fumarate-folic vit w/ ferrous fumarate-l 3 acid) methylfolate-folic acid) VITATRUE MISC (prenatal without a w/ VITAFOL FE+ CPPK 0.4 2 MG-0.6 MG-1.6 MG-1.8 fe amino acid chelate- MG-1000 UNIT-1100 fa-dha) UNIT-15 MG-150 MCG-2 VIVA DHA CAPS MG-2.5 MG-20 MG-20 (prenatal vit w/ ferrous UNIT-200 MG-25 MCG-25 3 3 MG-415 MG-50 MG-60 fumarate-fa-omega 3 MG-90 MG (prenatal vit fatty acids) w/ fe polysacch VOL-PLUS TABS RX/OTC complex-l methylfol-fa- (prenatal vit w/ ferrous 2 dha-dss) fumarate-folic acid) VITAFOL GUMMIES VOL-TAB RX TABS CHEW (prenatal vit w/ (prenatal vit w/ iron 2 ferric phosphate-fa- 3 carbonyl-folic acid) omega 3 fatty acids) VP-HEME OB + DHA MISC (prenatal vit w/ fe poly VITAFOL-NANO TABS 2 (prenatal w/o a vit w/ fe cmplx-fe heme fumarate-l methylfolate- 3 polypept-fa & omega 3) folic acid)

118 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VP-PNV-DHA CAPS cyclobenzaprine hcl (prenatal vit w/ ferrous 1 3 tabs 10 mg, 5 mg, 7.5 fumarate-fa-omega 3 mg fatty acids) GABLOFEN SOLN PA; Must use WESTAB PLUS TABS RX/OTC 4 Accredo SP (baclofen) (prenatal vit w/ ferrous 2 pharmacy;LA fumarate-folic acid) LIORESAL INTRATHECAL PA; Must use WESTGEL DHA CAPS SOLN 0.05 MG/ML, 10 4 Accredo SP pharmacy;LA (prenatal without a w/ MG/5ML (baclofen) fe carbonyl-l 3 LIORESAL INTRATHECAL PA; Must use methylfolate-fa-dha) SOLN 10 MG/20ML, 40 7 Accredo SP MG/20ML (baclofen) pharmacy;LA ZATEAN-PN DHA CAPS (prenatal without a w/ metaxalone tabs 400 1 fe fumarate-l 3 mg QL(4 ea daily) methylfolate-fa-dha) metaxalone tabs 800 1 ZATEAN-PN PLUS CAPS mg (prenatal without a w/ methocarbamol tabs 1 fe fumarate-l 3 methylfolate-fa-omega orphenadrine citrate 1 3) tb12 MUSCULOSKELETAL THERAPY AGENTS - tizanidine hcl caps 2 1 Drugs to Treat Spasms mg, 4 mg, 6 mg Central Muscle Relaxants tizanidine hcl tabs 2 mg 1 (Carisoprodol) VANADOM 1 QL(9 ea daily) TABS tizanidine hcl tabs 4 mg 1 (Chlorzoxazone) 1 LORZONE TABS Direct Muscle Relaxants dantrolene sodium (Cyclobenzaprine Hcl) 1 1 FEXMID TABS caps (Metaxalone) METAXALL 1 QL(4 ea daily) Muscle Relaxant Combinations TABS carisoprodol w/ aspirin 1 baclofen soln it 40 PA; Must use & codeine tabs 4 Accredo SP mg/20ml, 500 mcg/ml pharmacy;LA carisoprodol w/ aspirin 1 tabs baclofen tabs or 10 mg 1 QL(6 ea daily) orphenadrine w/ aspirin baclofen tabs or 20 mg 1 QL(4 ea daily) & caff tabs 25 mg-30 1 mg-385 mg baclofen tabs or 5 mg 1 NASAL AGENTS - SYSTEMIC AND TOPICAL - Drugs to treat the Nose or Sinus carisoprodol tabs 1 Nasal Agent Combinations chlorzoxazone tabs 1

119 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits azelastine hcl- Limit 1 inhaler (Fluticasone Propionate Limit 2 inhalers 1 per (Nasal)) ALLERGY per fluticasone propionate month;QL(0.77 RELIEF, CLARISPRAY, month;QL(1.2 susp gm daily) CVS FLUTICASONE ml daily); PROPRIONATE NASAL RX/OTC Nasal Anti-infectives SPRAY, EQ ALLERGY BACTROBAN NASAL RELIEF, EQL OINT (mupirocin 2 FLUTICASONE calcium) PROPIONATE, EQL FLUTICASONE Nasal Antiallergy PROPIONATE Limit 1 sprayer CHILDRENS, GNP azelastine hcl soln 0.1 1 per FLUTICASONE %, 137 mcg/spray month;QL(1.2 PROPIONATE, GNP 1 ml daily) FLUTICASONE QL(1 ml daily) PROPIONATE azelastine hcl soln 0.15 1 % CHILDRENS, HM ALLERGY RELIEF NASAL olopatadine hcl (nasal) 1 SPRAY 24HR, KLS soln ALLER-FLO, KP FLUTICASONE Nasal Anticholinergics PROPIONATE, QC ALLERGY RELIEF, QC ipratropium bromide 1 (nasal) soln FLUTICASONE PROPIONATE, SM Nasal Steroids ALLERGY RELIEF NASAL (Fluticasone Propionate Limit 2 inhalers SPRAY SUSP (Nasal)) ALLERGY NASAL per (Triamcinolone Acetonide QL(1.2 ml 1 month;QL(1.2 (Nasal)) ALLERGY NASAL daily) SPRAY 24 HOUR SUSP ml daily); 1 50 MCG/ACT SPRAY 24 HOUR AERO RX/OTC 55 MCG/ACT (Triamcinolone Acetonide QL(1.2 ml (Nasal)) CVS NASAL daily) ALLERGY SPRAY, EQ NASAL ALLERGY SPRAY, GNP 24 HOUR NASAL ALLERGY SPRAY, GOODSENSE NASAL 1 ALLERGY SPRAY, NASAL ALLERGY 24 HOUR, NASAL ALLERGY 24 HOUR MULTI-SYMPTOM, RA NASAL ALLERGY SPRAY AERO Limit 2 inhalers fluticasone propionate per 1 month;QL(1.2 (nasal) susp ml daily); RX/OTC

120 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limit 2 inhalers timolol maleate (ophth) 1 mometasone furoate 1 per soln 0.25 %, 0.5 % (nasal) susp month;QL(1.22 gm daily) TIMOPTIC OCUDOSE SOLN 0.25 % (timolol 3 triamcinolone QL(1.2 ml 1 maleate (ophth)) acetonide (nasal) aero daily) TIMOPTIC-XE SOLG NEUROMUSCULAR AGENTS - Drugs to (timolol maleate 7 Relax/Paralyze Muscles (ophth)) ALS Agents Cycloplegic Mydriatics 1 riluzole tabs (Homatropine Hbr) 1 HOMATROPAIRE SOLN Spinal Muscular Atrophy Agents (SMA) (Phenylephrine Hcl EVRYSDI SOLR PA 4 (Mydriatic)) ALTAFRIN 1 (risdiplam) SOLN ATROPINE SULFATE NUTRIENTS OINT OP 1 % (atropine 3 Lipids sulfate (ophthalmic)) DOJOLVI LIQD PA ATROPINE SULFATE 4 (triheptanoin) SOLN OP 1 % (atropine 2 sulfate (ophthalmic)) OPHTHALMIC AGENTS - Drugs to Treat the Eye CYCLOMYDRIL SOLN Artificial Tears and Lubricants (cyclopentolate w/ 3 LACRISERT INST phenylephrine) 3 (artificial tear insert) cyclopentolate hcl soln 1 Beta-blockers - Ophthalmic homatropine hbr soln 1 betaxolol hcl (ophth) 1 soln ISOPTO ATROPINE SOLN BETIMOL SOLN (timolol) 2 (atropine sulfate 2 (ophthalmic)) BETOPTIC-S SUSP 2 phenylephrine hcl 1 (betaxolol hcl (ophth)) (mydriatic) soln carteolol hcl (ophth) 1 soln tropicamide soln 1 COMBIGAN SOLN Miotics (brimonidine tartrate- 3 PHOSPHOLINE IODIDE timolol maleate) SOLR (echothiophate 2 dorzolamide hcl-timolol 1 iodide) maleate soln pilocarpine hcl soln 1 QL(0.5 ml levobunolol hcl soln 1 daily) Ophthalmic Adrenergic Agents timolol maleate (ophth) 1 ALPHAGAN P SOLN 0.1 % 2 solg 0.25 %, 0.5 % (brimonidine tartrate)

121 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits apraclonidine hcl soln 1 KLARITY-A SOLN Limit 5mls per 3 month;QL(0.17 (azithromycin (ophth)) ml daily) brimonidine tartrate 1 soln levofloxacin (ophth) 1 IOPIDINE SOLN 1 % soln 3 (apraclonidine hcl) moxifloxacin hcl (ophth) 1 SIMBRINZA SUSP soln (brinzolamide- 3 NATACYN SUSP 2 brimonidine tartrate) (natamycin) Ophthalmic Anti-infectives neomycin-bacitracin zn- 1 (Bacitracin-Polymyxin B polymyxin oint (Ophth)) AK-POLY-BAC, 1 neomycin-polymyxin- 1 POLYCIN OINT gramicidin soln (Erythromycin (Ophth)) 1 ILOTYCIN OINT QL(5 ml per fill ofloxacin (ophth) soln 1 retail,5 ml per (Gentamicin Sulfate 1 fill mail) (Ophth)) GENTAK OINT polymyxin b- (Neomycin-Bacitracin Zn- 1 Polymyxin) NEO-POLYCIN 1 trimethoprim soln OINT POVIDONE IODINE SOLN (povidone-iodine 3 AZASITE SOLN Limit 5mls per 3 month;QL(0.17 (ophth)) (azithromycin (ophth)) ml daily) sulfacetamide sodium 1 bacitracin (ophthalmic) 2 (ophth) oint oint sulfacetamide sodium 1 bacitracin-polymyxin b 1 (ophth) soln (ophth) oint tobramycin (ophth) soln 1 BESIVANCE SUSP 3 TOBREX OINT (besifloxacin hcl) 2 BETADINE OPHTHALMIC (tobramycin (ophth)) PREP SOLN (povidone- 3 trifluridine soln 1 iodine (ophth)) ZIRGAN GEL CILOXAN OINT 3 ( ) (ciprofloxacin hcl 2 ganciclovir ophthalmic (ophth)) Ophthalmic Immunomodulators QL(2 ml ciprofloxacin hcl 1 RESTASIS EMUL (ophth) soln 2 daily,64 ml per (cyclosporine (ophth)) fill retail) erythromycin (ophth) 1 RESTASIS MULTIDOSE QL(2 ml oint EMUL (cyclosporine 2 daily,64 ml per fill retail) gatifloxacin (ophth) 1 (ophth)) soln Ophthalmic Local Anesthetics gentamicin sulfate 1 (ophth) soln

122 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Tetracaine Hcl (Ophth)) FML FORTE SUSP ALTACAINE, TETCAINE, 1 (fluorometholone 2 TETRAVISC, TETRAVISC (ophth)) FORTE SOLN FML OINT AKTEN GEL ( lidocaine 3 (fluorometholone 2 hcl (ophth)) (ophth)) proparacaine hcl soln 1 LOTEMAX GEL 3 (loteprednol etabonate) tetracaine hcl (ophth) 1 LOTEMAX OINT soln 3 (loteprednol etabonate) Ophthalmic Nerve Growth Factors loteprednol etabonate OXERVATE SOLN PA 1 4 susp (cenegermin-bkbj) MAXIDEX SUSP Ophthalmic Steroids (dexamethasone 2 (Bacitracin-Poly-Neomycin- QL(4 gm per fill (ophth)) Hc) NEO-POLYCIN HC 1 retail,4 gm per OINT fill mail) neomycin-polymy- 1 dexameth oint (Prednisolone Acetate (Ophth)) PREDNISOLONE 1 neomycin-polymy- 1 ACETATE P-F SUSP dexameth susp ALREX SUSP 3 neomycin-polymyxin-hc 1 (loteprednol etabonate) (ophth) susp bacitracin-poly- QL(4 gm per fill PRED-G S.O.P. OINT 1 retail,4 gm per (gentamicin- 3 neomycin-hc oint fill mail) prednisolone acetate) BLEPHAMIDE S.O.P. PRED-G SUSP OINT (sulfacetamide 2 (gentamicin- 3 sod-prednisolone) prednisolone acetate) BLEPHAMIDE SUSP (sulfacetamide sod- 2 prednisolone acetate 1 prednisolone) (ophth) susp PREDNISOLONE SODIUM dexamethasone PHOSPHATE SOLN OP 1 sodium phosphate 1 % (prednisolone sodium 3 (ophth) soln phosphate (ophth)) DUREZOL EMUL 3 PREDNISOLONE SODIUM (difluprednate) PHOSPHATE/MOXIFLOXA FLAREX SUSP CIN SOLN 3 (fluorometholone 2 (prednisolone- acetate) moxifloxacin) sulfacetamide sod- fluorometholone 1 1 (ophth) susp prednisolone soln

123 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TOBRADEX OINT diclofenac sodium 1 (tobramycin- 3 (ophth) soln dexamethasone) Limit 10mls per TOBRADEX ST SUSP dorzolamide hcl soln 1 month;QL(0.34 (tobramycin- 3 ml daily) dexamethasone) DORZOLAMIDE HCL Limit 10mls per 2 month;QL(0.34 QL(5 ml per fill SOLN ( ) tobramycin- 1 dorzolamide hcl ml daily) dexamethasone susp retail) EMADINE SOLN ZYLET SUSP QL(5 ml per fill (emedastine 3 retail) (loteprednol etabonate- 3 difumarate) tobramycin) epinastine hcl (ophth) 1 Ophthalmic Surgical Aids soln GELFILM OP FILM flurbiprofen sodium 1 (gelatin adsorbable 3 soln (ophth)) ILEVRO SUSP 3 Ophthalmics - Misc. (nepafenac) ACUVAIL SOLN ketorolac tromethamine 1 (ketorolac 3 (ophth) soln tromethamine (ophth)) LASTACAFT SOLN ST 3 ALOCRIL SOLN (alcaftadine) (nedocromil sodium 3 NEVANAC SUSP (ophth)) 3 (nepafenac) ALOMIDE SOLN Limit 10mls per (lodoxamide 2 olopatadine hcl soln 0.1 1 month;QL(0.34 tromethamine) % ml daily); RX/OTC azelastine hcl (ophth) 1 soln olopatadine hcl soln 0.2 QL(0.09 ml 1 daily); RX/OTC AZOPT SUSP Limit 10mls per % 2 month;QL(0.4 (brinzolamide) PAREMYD SOLN ml daily) (hydroxyamphetamine- 3 BEPREVE SOLN ST; QL(0.34 ml tropicamide) 3 daily) (bepotastine besilate) PROLENSA SOLN bromfenac sodium 1 (bromfenac sodium 3 (ophth) soln (ophth)) BROMSITE SOLN Prostaglandins - Ophthalmic (bromfenac sodium 3 Limit 2.5mls (ophth)) 1 per bimatoprost soln month;QL(0.09 cromolyn sodium 1 (ophth) soln ml daily) CYSTARAN SOLN Limit 2.5mls 4 1 per (cysteamine hcl) latanoprost soln op month;QL(0.09 ml daily) 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic is Available AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

124 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limit 2.5mls neomycin-polymyxin-hc LUMIGAN SOLN 1 2 per (otic) susp (bimatoprost) month;QL(0.09 ml daily) OTOVEL SOLN Limit 15mls per ( 7 month;QL(0.5 Limit 2.5mls ciprofloxacin- fluocinolone acetonide) ea daily) 1 per travoprost soln month;QL(0.09 PRAMOTIC LIQD ml daily) (pramoxine- 3 ZIOPTAN SOLN chloroxylenol) 3 (tafluprost) Otic Steroids OTIC AGENTS - Drugs to Treat the Ear (Fluocinolone Acetonide 1 (Otic)) FLAC OIL Otic Agents - Miscellaneous fluocinolone acetonide 1 acetic acid (otic) soln 1 (otic) oil QL(10 ml per hydrocortisone w/acetic 2 Otic Anti-infectives acid soln fill retail) CETRAXAL SOLN QL(14 ea per 7 (ciprofloxacin hcl (otic)) fill retail) OXYTOCICS - Drugs to Prevent/Control Uterine Bleeding QL(14 ea per ciprofloxacin hcl (otic) 1 soln fill retail) Abortifacients/Agents for Cervical Ripening CERVIDIL INST 3 ofloxacin (otic) soln 1 (dinoprostone) PREPIDIL GEL Otic Combinations 3 (Pramoxine-Hc- (dinoprostone) Chloroxylenol) CORTIC- 1 PROSTIN E2 SUPP 3 ND, EXOTIC-HC SOLN (dinoprostone) CIPRO HC SUSP Oxytocics ( ciprofloxacin- 3 (Methylergonovine hydrocortisone) Maleate) METHERGINE 1 TABS ciprofloxacin- 1 dexamethasone susp methylergonovine 1 ciprofloxacin- Limit 15mls per maleate tabs fluocinolone acetonide 1 month;QL(0.5 ea daily) PASSIVE IMMUNIZING AND TREATMENT soln AGENTS - Antibody Drugs to Treat Low Immune COLY-MYCIN S SUSP System (neomycin-colistin-hc- 3 Immune Serums thonzonium) CARIMUNE PA; LA CORTISPORIN-TC SUSP NANOFILTERED SOLR 6 4 (neomycin-colistin-hc- 3 GM (immune globulin thonzonium) (human) iv) neomycin-polymyxin-hc 1 (otic) soln

125 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FLEBOGAMMA DIF SOLN PA; LA HYQVIA KIT 1600 PA; Some 10 GM/100ML, 10 UNIT/10ML-20 GM/200ML, members may GM/200ML, 2.5 GM/50ML, 2.5 GM/25ML-200 obtain their 20 GM/200ML, 5 4 UNT/1.25ML, 2400 medications UNIT/15ML-30 GM/300ML, through their GM/100ML (immune 4 globulin (human) iv) 400 UNIT/2.5ML-5 Medical Group;LA GAMMAGARD LIQUID PA; Covered GM/50ML (immune SOLN 1 GM/10ML under Medical globulin (human)- ( 4 Benefit;LA hyaluronidase (human immune globulin recombinant)) (human) iv or subcutaneous) PENICILLINS - Drugs to Treat Bacterial Infections GAMMAGARD LIQUID PA; Must use SOLN 2.5 GM/25ML AcariaHlth Sp Aminopenicillins (immune globulin 4 Rx 1-844-538- amoxicillin caps 1 (human) iv or 4661;LA subcutaneous) amoxicillin chew 1 GAMMAKED SOLN PA; Covered under Medical amoxicillin susr 1 (immune globulin 4 (human) iv or Benefit;LA subcutaneous) amoxicillin tabs 1 GAMMAPLEX SOLN 10 PA; LA 1 GM/100ML, 10 GM/200ML, ampicillin caps 20 GM/200ML, 5 4 ampicillin sodium solr 4 PA GM/100ML (immune globulin (human) iv) Natural Penicillins GAMUNEX-C SOLN 1 PA; Covered (Penicillin G Potassium) 4 PA under Medical PFIZERPEN SOLR GM/10ML (immune 4 globulin (human) iv or Benefit;LA BICILLIN L-A SUSP PA 4 subcutaneous) (penicillin g benzathine) GAMUNEX-C SOLN 2.5 PA; Must use PENICILLIN G PA AcariaHlth Sp GM/25ML (immune 4 POTASSIUM IN ISO- globulin (human) iv or Rx 1-844-538- OSMOTIC DEXTROSE 4 subcutaneous) 4661;LA SOLN (penicillin g pot in OCTAGAM SOLN 1 PA; LA dextrose) GM/20ML, 10 GM/100ML, penicillin g potassium PA 10 GM/200ML, 2 4 GM/20ML, 2.5 GM/50ML, solr 20 GM/200ML, 25 4 PENICILLIN G PROCAINE PA GM/500ML, 5 GM/100ML SUSP (penicillin g 4 (immune globulin procaine) (human) iv) penicillin g sodium solr 4 PA PRIVIGEN SOLN 10 PA; LA GM/100ML, 20 GM/200ML, penicillin v potassium 1 40 GM/400ML (immune 4 solr globulin (human) iv) penicillin v potassium 1 Passive Immunizing Agents - Combinations tabs

126 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Penicillin Combinations NAFCILLIN SOLN PA (nafcillin sodium in 4 amoxicillin & pot 1 clavulanate chew dextrose) oxacillin sodium solr 4 PA amoxicillin & pot 1 clavulanate susr PROGESTINS - Hormone Replacement/Modifying amoxicillin & pot 1 Drugs clavulanate tabs Progestins amoxicillin & pot QL(1 ea daily) 1 medroxyprogesterone 1 clavulanate tb12 acetate tabs 10 mg PA ampicillin & sulbactam 4 medroxyprogesterone sodium solr acetate tabs 2.5 mg, 5 1 AUGMENTIN SUSR 125 mg MG/5ML-31.25 MG/5ML 2 AC (amoxicillin & pot megestrol acetate 1 clavulanate) (appetite) susp BICILLIN C-R SUSP PA norethindrone acetate 1 (penicillin g benzathine 4 tabs ) QL(1 ea daily) & procaine progesterone 1 piperacillin sodium- PA micronized caps tazobactam sodium 4 progesterone oil 1 PA solr UNASYN BULK PACK PA PSYCHOTHERAPEUTIC AND NEUROLOGICAL SOLR (ampicillin & 7 AGENTS - MISC. - Drugs to Treat Mental and Emotional Conditions sulbactam sodium) UNASYN SOLR PA Agents for Chemical Dependency (ampicillin & sulbactam 7 acamprosate calcium 1 sodium) tbec ZOSYN SOLR PA disulfiram tabs 1 (piperacillin sodium- 7 tazobactam sodium) LUCEMYRA TABS PA; ST;QL(224 4 ea per 14 days Penicillinase-Resistant Penicillins (lofexidine hcl) retail) dicloxacillin sodium 1 Anti-Cataplectic Agents caps XYREM SOLN (sodium PA; ST PA 4 nafcillin sodium solr ij 1 4 oxybate) gm Antidementia Agents NAFCILLIN SODIUM PA QL(1 ea daily) donepezil 1 SOLR IJ 10 GM (nafcillin 4 hydrochloride tabs sodium) donepezil QL(1 ea daily) nafcillin sodium solr iv PA 1 4 hydrochloride tbdp 2 gm

127 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(1 ea daily) galantamine perphenazine- 1 hydrobromide cp24 16 1 amitriptyline tabs mg, 24 mg, 8 mg Fibromyalgia Agents galantamine SAVELLA TABS 100 MG, PA; QL(2 ea hydrobromide soln 4 1 25 MG, 50 MG 3 daily) mg/ml (milnacipran hcl) SAVELLA TABS 12.5 MG PA; ST;QL(2 galantamine 3 hydrobromide tabs 12 1 (milnacipran hcl) ea daily) mg, 4 mg, 8 mg SAVELLA TITRATION PA; QL(2 ea PA PACK MISC 3 daily) memantine hcl cp24 14 1 mg, 21 mg, 28 mg (milnacipran hcl) memantine hcl cp24 7 PA; ST Movement Disorder Drug Therapy 1 AUSTEDO TABS 12 MG, 9 PA mg 4 memantine hcl soln 10 MG (deutetrabenazine) 1 AUSTEDO TABS 6 MG PA; ST mg/5ml, 2 mg/ml 4 (deutetrabenazine) 1 memantine hcl tabs INGREZZA CAPS PA 4 QL(2 ea daily) (valbenazine tosylate) memantine hcl tabs 10 1 mg INGREZZA CPPK PA 4 QL(4 ea daily) (valbenazine tosylate) memantine hcl tabs 5 1 mg PA; Specialty NAMENDA XR TITRATION PA; ST 4 drug-Health tetrabenazine tabs Net will refer to PACK CP24 (memantine 3 SP Pharmacy ) hcl PA; Specialty NAMZARIC C4PK 10 MG PA XENAZINE TABS 7 drug-Health (memantine hcl- 3 (tetrabenazine) Net will refer to donepezil hcl) SP Pharmacy rivastigmine pt24 1 Multiple Sclerosis Agents (Glatiramer Acetate) 1 PA rivastigmine tartrate 1 GLATOPA SOSY caps AUBAGIO TABS PA 2 Combination Psychotherapeutics (teriflunomide) AVONEX PEN AJKT PA; LA chlordiazepoxide- 1 4 amitriptyline tabs (interferon beta-1a) AVONEX PSKT PA; LA olanzapine-fluoxetine 4 hcl caps 12 mg-25 mg, (interferon beta-1a) 1 BETASERON KIT PA 12 mg-50 mg, 25 mg-6 4 mg (interferon beta-1b) olanzapine-fluoxetine dalfampridine tb12 1 PA hcl caps 25 mg-3 mg, 2 50 mg-6 mg dimethyl fumarate cpdr 2 PA; LA

128 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits dimethyl fumarate misc 2 PA; LA GRALISE TABS 300 MG PA; ST (gabapentin (once- 3 EXTAVIA KIT ( PA; LA interferon 2 daily)) beta-1b) GRALISE TABS 600 MG PA; ST;QL(3 GILENYA CAPS PA ea daily) 3 (gabapentin (once- 3 (fingolimod hcl) daily)) glatiramer acetate sosy 1 PA Premenstrual Dysphoric Disorder (PMDD) Agents MAVENCLAD TBPK PA; ST;;Refill fluoxetine hcl (pmdd) 1 (cladribine (multiple 4 82% caps 10 mg QL(1 ea daily) sclerosis)) fluoxetine hcl (pmdd) 1 MAYZENT STARTER PA caps 20 mg PACK TBPK (siponimod 3 fluoxetine hcl (pmdd) 1 fumarate) tabs 10 mg, 20 mg MAYZENT TABS PA 3 Pseudobulbar Affect (PBA) Agents (siponimod fumarate) NUEDEXTA CAPS PA PLEGRIDY SOPN PA; LA 4 (dextromethorphan hbr- 4 (peginterferon beta-1a) quinidine sulfate) PLEGRIDY SOSY PA; LA 4 Psychotherapeutic and Neurological Agents - (peginterferon beta-1a) PLEGRIDY STARTER PA; LA ergoloid mesylates tabs 1 PACK SOPN 4 (peginterferon beta-1a) pimozide tabs 1 PLEGRIDY STARTER PA; LA Restless Leg Syndrome (RLS) Agents PACK SOSY 4 Limited to 1 (peginterferon beta-1a) HORIZANT TBCR 300 MG 3 tablet REBIF REBIDOSE SOAJ PA; LA (gabapentin enacarbil) daily;QL(1 ea 4 (interferon beta-1a) daily) HORIZANT TBCR 600 MG QL(2 ea daily) REBIF REBIDOSE PA; LA 3 TITRATIONPACK SOAJ 4 (gabapentin enacarbil) (interferon beta-1a) Smoking Deterrents REBIF SOSY ( PA; LA interferon 4 beta-1a) REBIF TITRATION PACK PA; LA SOSY (interferon beta- 4 1a) PA; Must use TYSABRI CONC AcariaHealth 4 Specialty Rx at (natalizumab) 1-844-538- 4661;;LA Postherpetic Neuralgia (PHN)/Neuropathic Pain

129 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Nicotine Polacrilex) CVS PV (Nicotine Polacrilex) CVS PV NICOTINE LOZENGE, NICOTINE, CVS CVS NICOTINE NICOTINE POLACRILEX, POLACRILEX, EQ CVS NICOTINE NICOTINE, EQ NICOTINE POLACRILEX STARTER, LOZENGES, EQ EQ NICOTINE GUM NICOTINE POLACRILEX, REFILL, EQ NICOTINE EQL NICOTINE GUM STARTER, EQ POLACRILEX, GNP NICOTINE POLACRILEX, NICOTINE MINI EQL NICOTINE LOZENGE, GNP POLACRILEX, EQL NICOTINE POLACRILEX, NICOTINE POLACRILEX GNP NICOTINE REFILL, EQL NICOTINE POLACRILEX MINI, 5 POLACRILEX STARTER, GOODSENSE NICOTINE, GNP NICOTINE GUM, GOODSENSE NICOTINE GNP NICOTINE POLACRILEX, HM POLACRILEX, 5 NICOTINE POLACRILEX, GOODSENSE NICOTINE KLS QUIT2, KLS QUIT4, GUM, GOODSENSE NICOTINE MINI NICOTINE POLACRILEX LOZENGE, PX STOP GUM, HM NICOTINE SMOKING AID, RA MINI POLACRILEX, KLS QUIT2, NICOTINE, RA NICOTINE KLS QUIT4, NICORELIEF, POLACRILEX, SM PX STOP SMOKING AID, NICOTINE, SM NICOTINE RA NICOTINE, RA POLACRILEX, TGT NICOTINE GUM, RA NICOTINE POLACRILEX NICOTINE POLACRILEX, LOZG SM NICOTINE, SM NICOTINE POLACRILEX, SR NICOTINE GUM, TGT NICOTINE GUM, TGT NICOTINE POLACRILEX, THRIVE GUM

130 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Nicotine) CVS NICOTINE PV TRANSDERMAL TRANSDERMALSYSTEM, SYSTEM/STEP 2/CLEAR, CVS NICOTINE SM NICOTINE TRANSDERMALSYSTEM TRANSDERMAL STEP 1, CVS NICOTINE SYSTEM/STEP 3/CLEAR, TRANSDERMALSYSTEM TGT NICOTINE STEP STEP 2, CVS NICOTINE ONE, TGT NICOTINE TRANSDERMALSYSTEM/ STEP THREE, TGT STEP 3, EQ NICOTINE, NICOTINE STEP TWO EQ NICOTINE STEP 3, PT24 GNP NICOTINE PV bupropion hcl (smoking 5 TRANSDERMALSYSTEM, deterrent) tb12 GNP NICOTINE TRANSDERMALSYSTEM CHANTIX CONTINUING QL(2 ea daily); STEP 2, HM NICOTINE MONTHPAK TABS 5 PV TRANSDERMAL SYSTEM, (varenicline tartrate) HM NICOTINE CHANTIX STARTING PV TRANSDERMAL SYSTEM MONTH PAK TABS 5 STEP 1, HM NICOTINE (varenicline tartrate) TRANSDERMAL SYSTEM CHANTIX TABS 0.5 MG PV STEP 2, HM NICOTINE 5 TRANSDERMAL SYSTEM (varenicline tartrate) STEP 3, HM NICOTINE CHANTIX TABS 1 MG QL(2 ea daily); 5 TRANSDERMALSYSTEM, (varenicline tartrate) PV NICOTINE STEP 1, NICODERM CQ PT24 PV NICOTINE STEP 3, 5 7 NICOTINE (nicotine) TRANSDERMAL SYSTEM NICORETTE GUM PV 7 STEP 1, NICOTINE (nicotine polacrilex) TRANSDERMAL SYSTEM NICORETTE LOZG PV STEP 1/CLEAR, 7 NICOTINE (nicotine polacrilex) TRANSDERMAL SYSTEM NICORETTE MINI LOZG PV 7 STEP 2, NICOTINE (nicotine polacrilex) TRANSDERMAL SYSTEM STEP 2/CLEAR, NICORETTE STARTER PV NICOTINE KIT GUM (nicotine 7 TRANSDERMAL SYSTEM polacrilex) STEP 3, NICOTINE PV TRANSDERMAL nicotine polacrilex gum 5 SYSTSTEM STEP PV 3/CLEAR, RA NICOTINE, nicotine polacrilex lozg 5 RA NICOTINE PV TRANSDERMAL SYSTEM, nicotine pt24 5 RA NICOTINE NICOTINE PV TRANSDERMAL SYSTEM TRANSDERMAL SYSTEM STEP 3, SM NICOTINE 5 TRANSDERMAL SYSTEM, KIT (nicotine) SM NICOTINE NICOTROL INHALER PV 5 TRANSDERMAL INHA (nicotine) SYSTEM/STEP 1/CLEAR, SM NICOTINE 1=Preferred Generics 2=Preferred Brands/High Cost Generics 3=Non-Preferred Brands 4=High Cost Drugs 5=Preventive Drugs 7=Brand Reference Only, Generic is Available AL=Age Limit AC=Anti-cancer LA=Limited Access QL=Quantity Limit ST=Step Therapy PA=Prior Authorization PV=Preventive Drugs RX/OTC=Prescription & Over-the-Counter

131 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NICOTROL NS SOLN PV PA; Must use 5 (nicotine) ESBRIET TABS Exactus 4 Specialty Rx 1- ZYBAN TB12 ( PV (pirfenidone) bupropion 7 866-458- hcl (smoking deterrent)) 9246;LA Transthyretin Amyloidosis Agents OFEV CAPS ( PA; QL(1 ea nintedanib 4 TEGSEDI SOSY PA esylate) daily) 4 (inotersen sodium) SULFONAMIDES - Drugs to Treat Bacterial RESPIRATORY AGENTS - MISC. - Drugs to Infections Treat Lung Conditions Sulfonamides Cystic Fibrosis Agents SULFADIAZINE TABS 3 PA; Must use (sulfadiazine) KALYDECO PACK 25 MG AcariaHlth Sp 4 TETRACYCLINES - Drugs to Treat Bacterial (ivacaftor) Rx 1-844-538- 4662;LA Infections Tetracyclines KALYDECO PACK 50 MG, PA; Must use 4 Accredo SP (Doxycycline 75 MG (ivacaftor) pharmacy;LA (Monohydrate)) AVIDOXY 1 TABS KALYDECO TABS 150 MG PA; Must use 4 Accredo SP (Doxycycline (ivacaftor) pharmacy;LA (Monohydrate)) 2 PA; MUST MONDOXYNE NL, OKEBO ORKAMBI PACK 100 MG- USE ACARIA CAPS 125 MG, 150 MG-188 MG 4 SPECIALTY (Doxycycline Hyclate) (lumacaftor-ivacaftor) RX 844-538- MORGIDOX 1X100MG, 4661;LA MORGIDOX 1X50MG, 1 PA; Must use MORGIDOX 2X100MG ORKAMBI TABS 100 MG- AcariaHealth CAPS 125 MG, 125 MG-200 MG 4 Specialty Rx at demeclocycline hcl tabs 1 (lumacaftor-ivacaftor) 1-844-538- 4661;LA doxycycline PULMOZYME SOLN PA; QL(5 ml 2 (monohydrate) caps 2 (dornase alfa) daily) 100 mg, 50 mg, 75 mg SYMDEKO TBPK PA; LA 4 doxycycline ST (tezacaftor-ivacaftor) (monohydrate) caps 2 PA; Must use 150 mg TRIKAFTA TBPK AcariaHlth Sp (elexacaftor-tezacaftor- 4 Rx 1-844-538- doxycycline ivacaftor) 4662;QL(3 ea (monohydrate) susr 25 1 daily); LA mg/5ml Pulmonary Fibrosis Agents doxycycline PA; Must use (monohydrate) tabs 1 ESBRIET CAPS Exactus 100 mg, 50 mg 4 Specialty Rx 1- (pirfenidone) doxycycline ST 866-458- 2 9246;LA (monohydrate) tabs 150 mg

132 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits doxycycline ST (Levothyroxine Sodium) (monohydrate) tabs 75 1 LEVO-T, UNITHROID mg TABS 100 MCG, 137 MCG, 1 150 MCG, 25 MCG, 300 doxycycline hyclate 1 MCG, 50 MCG, 75 MCG, caps 100 mg, 50 mg 88 MCG (Thyroid) NP THYROID 30, doxycycline hyclate 1 tabs 100 mg, 20 mg NP THYROID 60, NP 1 THYROID 90 TABS MINOCIN CAPS PA 7 ARMOUR THYROID TABS ( ) minocycline hcl 120 MG, 15 MG, 30 MG, 2 minocycline hcl caps 1 60 MG, 90 MG (thyroid) 100 mg, 50 mg, 75 mg ARMOUR THYROID TABS ST 180 MG, 240 MG, 300 MG 3 minocycline hcl cp24 3 135 mg, 45 mg, 90 mg (thyroid) CYTOMEL TABS 5 MCG minocycline hcl tabs 1 7 100 mg, 50 mg (liothyronine sodium) PA levothyroxine sodium minocycline hcl tabs 75 1 mg tabs or 100 mcg, 137 mcg, 150 mcg, 25 mcg, 1 tetracycline hcl caps 1 500 mg 300 mcg, 50 mcg, 75 mcg, 88 mcg VIBRAMYCIN SYRP 50 QL(1 ea daily) MG/5ML (doxycycline 2 levothyroxine sodium calcium) tabs or 112 mcg, 125 1 XIMINO CP24 135 MG, 45 ST mcg, 175 mcg, 200 mcg MG, 90 MG (minocycline 3 QL(2 ea daily) hcl) liothyronine sodium 1 tabs 25 mcg, 50 mcg THYROID AGENTS - Drugs to Regulate Thyroid Hormones liothyronine sodium 1 tabs 5 mcg Antithyroid Agents NATURE-THROID NT-2.5 3 methimazole tabs 1 TABS (thyroid) QL(3 ea daily) NATURE-THROID TABS propylthiouracil tabs 1 113.75 MG, 146.25 MG, Thyroid Hormones 16.25 MG, 260 MG, 325 2 MG, 48.75 MG, 81.25 MG, (Levothyroxine Sodium) QL(1 ea daily) 97.5 MG (thyroid) EUTHYROX, LEVO-T, LEVOXYL, UNITHROID 1 NATURE-THROID TABS TABS 112 MCG, 125 MCG, 130 MG, 195 MG, 32.5 3 175 MCG, 200 MCG MG, 65 MG (thyroid) (Levothyroxine Sodium) SYNTHROID TABS 100 EUTHYROX, LEVOXYL MCG, 137 MCG, 150 MCG, TABS 100 MCG, 137 MCG, 1 25 MCG, 300 MCG, 50 7 150 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG MCG, 75 MCG, 88 MCG (levothyroxine sodium)

133 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SYNTHROID TABS 112 QL(1 ea daily) GLYCATE TABS MCG, 125 MCG, 175 3 7 (glycopyrrolate) MCG, 200 MCG glycopyrrolate tabs or 1 (levothyroxine sodium) 1 mg, 2 mg thyroid tabs 1 GLYCOPYRROLATE WESTHROID TABS 130 TABS OR 1.5 MG 3 MG, 195 MG, 32.5 MG, 65 3 (glycopyrrolate) MG (thyroid) hyoscyamine sulfate 1 WESTHROID TABS 97.5 subl 2 MG (thyroid) hyoscyamine sulfate 1 WP THYROID TABS tabs 113.75 MG, 16.25 MG, 2 hyoscyamine sulfate 1 48.75 MG, 81.25 MG, 97.5 tb12 MG (thyroid) hyoscyamine sulfate WP THYROID TABS 130 1 MG, 32.5 MG, 65 MG 3 tbdp (thyroid) methscopolamine 1 ULCER DRUGS - Drugs to Treat Bowel, Intestine bromide tabs and Stomach Conditions propantheline bromide 1 Antispasmodics tabs (Hyoscyamine Sulfate) ED- H-2 Antagonists SPAZ, NULEV, OSCIMIN 1 (Famotidine) ACID RX/OTC TBDP CONTROL MAXIMUM (Hyoscyamine Sulfate) STRENGTH, ACID OSCIMIN SR, SYMAX-SR 1 REDUCER MAXIMUM TB12 STRENGTH, PX ACID REDUCER MAXIMUM 1 (Hyoscyamine Sulfate) 1 OSCIMIN TABS STRENGTH, RA ACID REDUCER MAXIMUM (Hyoscyamine Sulfate) STRENGTH, SM ACID OSCIMIN, SYMAX-SL 1 REDUCER MAXIMUM SUBL STRENGTH TABS 20 MG BELLADONNA/OPIUM SUPP (belladonna 3 alkaloids & opium) chlordiazepoxide hcl- 1 clidinium bromide caps CUVPOSA SOLN 2 (glycopyrrolate) dicyclomine hcl caps 1 dicyclomine hcl soln 1 dicyclomine hcl tabs 1

134 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Famotidine) ACID RX/OTC (Lansoprazole) CVS QL(2 ea daily); CONTROLLER MAXIMUM 1 AL(Up to 12 yrs LANSOPRAZOLE TBDD STRENGTH, CVS ACID old ); RX/OTC CONTROLLER MAXIMUM ACIPHEX SPRINKLE PA STRENGTH, EQ ACID CPSP 10 MG 3 REDUCER MAXIMUM (rabeprazole sodium) STRENGTH, EQ FAMOTIDINE MAXIMUM ACIPHEX SPRINKLE PA; ST STRENGTH, EQL CPSP 5 MG (rabeprazole 3 HEARTBURN sodium) PREVENTION/MAXIMUM PA STRENGTH, FAMOTIDINE esomeprazole magnesium pack 10 1 MAXIMUM STRENGTH, 1 GNP ACID REDUCER mg, 20 mg, 40 mg MAXIMUMSTRENGTH, FIRST-OMEPRAZOLE 3 HEARTBURN RELIEF SUSP (omeprazole) MAXIMUMSTRENGTH, QL(1 ea daily) HM FAMOTIDINE, KLS lansoprazole cpdr 30 1 ACID CONTROLLER mg MAXIMUM STRENGTH, lansoprazole tbdd 15 QL(2 ea daily); MM FAMOTIDINE, QC 1 AL(Up to 12 yrs ACID CONTROLLER mg old ); RX/OTC MAXIMUM STRENGTH, lansoprazole tbdd 30 QL(1 ea daily); SB ACID CONTROLLER 1 AL(Up to 12 yrs MAXIMUM STRENGTH mg old ) TABS NEXIUM PACK 2.5 MG, 5 PA cimetidine hcl soln 1 MG (esomeprazole 3 magnesium) cimetidine tabs 300 1 mg, 800 mg OMEPRAZOLE + SYRSPEND SFALKA QL(4 ea daily) 3 cimetidine tabs 400 mg 1 SUSP (omeprazole) famotidine susr 40 1 omeprazole cpdr 10 mg 1 mg/5ml omeprazole cpdr 20 mg 1 QL(1 ea daily); famotidine tabs 20 mg 1 RX/OTC RX/OTC QL(1 ea daily) famotidine tabs 40 mg 1 QL(2 ea daily) omeprazole cpdr 40 mg 1 QL(1 ea daily) pantoprazole sodium 1 nizatidine caps 1 pack QL(1 ea daily) nizatidine soln 1 pantoprazole sodium 1 tbec Misc. Anti-Ulcer PRILOSEC PACK PA sucralfate susp 1 1 (omeprazole 3 gm/10ml magnesium) sucralfate tabs 1 gm 1 QL(4 ea daily) RABEPRAZOLE SODIUM PA DR SPRINKLE CPSP 3 Proton Pump Inhibitors (rabeprazole sodium)

135 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; ST;QL(1 rabeprazole sodium 2 solifenacin succinate 1 tbec ea daily) tabs 5 mg QL(1 ea daily) Ulcer Drugs - Prostaglandins tolterodine tartrate cp24 1 2 mg, 4 mg misoprostol tabs 1 QL(2 ea daily) tolterodine tartrate tabs 1 Ulcer Therapy Combinations 1 mg, 2 mg amoxicillin- TOVIAZ TB24 QL(1 ea daily) 2 clarithromycin w/ 2 (fesoterodine fumarate) lansoprazole misc trospium chloride cp24 1 HELIDAC THERAPY MISC 60 mg (metronidazole- QL(2 ea daily) 3 trospium chloride tabs 1 tetracycline w/ bismuth 20 mg subsalicylate) Urinary Antispasmodics - Beta-3 Adrenergic OMECLAMOX-PAK MISC MYRBETRIQ TB24 QL(1 ea daily) (amoxicillin- 3 clarithromycin w/ 3 (mirabegron) omeprazole) Urinary Antispasmodics - Cholinergic Agonists PYLERA CAPS (bismuth bethanechol chloride 1 tabs subcitrate potassium- 3 metronidazole- Urinary Antispasmodics - Direct Muscle Relaxants tetracycline) flavoxate hcl tabs 1 URINARY ANTI-INFECTIVES - Drugs to Treat Bladder/Kidney Infections VACCINES Urinary Anti-infectives Viral Vaccines nitrofurantoin monohyd 1 FLUMIST PV macro caps QUADRIVALENT SUSP URINARY ANTISPASMODICS - Drugs to Treat (influenza virus vaccine 5 Miscellaneous Bladder Spasms live quadrivalent) Urinary Antispasmodic - Antimuscarinics VAGINAL AND RELATED PRODUCTS darifenacin 1 hydrobromide tb24 Miscellaneous Vaginal Products QL(15 ml daily) (Acetic Acid-Oxyquinoline oxybutynin chloride 1 1 syrp 5 mg/5ml Vaginal) RELAGARD GEL oxybutynin chloride QL(4 ea daily) Spermicides 1 ENCARE SUPP PV tabs 5 mg 5 (nonoxynol-9) oxybutynin chloride 1 OPTIONS CONCEPTROL PV tb24 10 mg, 15 mg, 5 VAGINAL mg CONTRACEPTIVE GEL 7 QL(1 ea daily) ( ) solifenacin succinate 1 nonoxynol-9 tabs 10 mg

136 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits OPTIONS GYNOL II PV PHEXXI GEL (lactic PA VAGINALCONTRACEPTIV 5 acid-citric acid- 3 E GEL (nonoxynol-9) potassium bitartrate) SHUR-SEAL GEL PV 5 Vaginal Estrogens (nonoxynol-9) (Estradiol Vaginal) TODAY SPONGE MISC PV 1 5 YUVAFEM TABS (nonoxynol-9) VCF VAGINAL PV estradiol vaginal crea 1 CONTRACEPTIVE FILM 5 estradiol vaginal tabs 1 FILM (nonoxynol-9) ESTRING RING QL(1 ea per fill VCF VAGINAL PV 3 CONTRACEPTIVE FOAM 5 (estradiol vaginal) mail) FOAM (nonoxynol-9) FEMRING RING QL(1 ea per 90 VCF VAGINAL PV ( 3 days retail,1 ea estradiol acetate per 90 days CONTRACEPTIVEGEL 5 vaginal) GEL (nonoxynol-9) mail) PREMARIN CREA VA QL(2 gm daily) Vaginal Anti-infectives 0.625 MG/GM 2 (Metronidazole Vaginal) 1 (estrogens, conjugated VANDAZOLE GEL vaginal) (Miconazole Nitrate Vaginal) MICONAZOLE 3 1 Vaginal Progestins SUPP CRINONE GEL PA AVC CREA (progesterone 3 3 (sulfanilamide vaginal) (vaginal)) CLEOCIN SUPP VA 100 ENDOMETRIN INST PA; ST MG (clindamycin 3 (progesterone 3 phosphate vaginal) (vaginal)) VASOPRESSORS - Drugs to Treat Heart and clindamycin phosphate 1 vaginal crea Circulation Conditions CLINDESSE CREA Anaphylaxis Therapy Agents (clindamycin phosphate 3 Limited to 2 (one dose)) epinephrine auto-injectors GYNAZOLE-1 CREA (anaphylaxis) soaj 0.15 3 per fill;QL(2 ea per fill retail,4 (butoconazole nitrate 3 mg/0.15ml, 0.3 mg/0.3ml ea per 30 days (one dose)) retail) metronidazole vaginal 1 epinephrine QL(2 ea per fill gel (anaphylaxis) soaj 0.15 3 retail,4 ea per 30 days retail) terconazole vaginal 1 mg/0.3ml, 0.3 mg/0.3ml crea terconazole vaginal 1 supp Vaginal Contraceptive - pH Modulators

137 Drug Requirements/ Drug Name Tier Limits Limited to 2 pens per fill; 4 EPINEPHRINE SOAJ 0.3 pens per MG/0.3ML (epinephrine 3 month;QL(2 ea (anaphylaxis)) per fill retail,4 ea per 30 days retail) SYMJEPI SOSY 0.15 QL(2 ea per fill MG/0.3ML (epinephrine 3 retail) (anaphylaxis)) SYMJEPI SOSY 0.3 QL(2 ea per fill MG/0.3ML (epinephrine 3 retail,4 ea per (anaphylaxis)) 30 days retail) Neurogenic Orthostatic Hypotension (NOH) - NORTHERA CAPS PA 4 (droxidopa) Vasopressors midodrine hcl tabs 1

VITAMINS Oil Soluble Vitamins ergocalciferol caps 1 phytonadione tabs 1 Water Soluble Vitamins POTABA CAPS (potassium 3 aminobenzoate) potassium 1 aminobenzoate pack

138 Index 1ST TIER UNIFINE ACUVAIL 124 alendronate sodium 65 PENTIPS/MINI/31GX5MM 102 acyclovir 44 ALFERON N 37 1ST TIER UNIFINE PENTIPSPLUS/MINI/31GX5MM acyclovir topical 58 alfuzosin hcl 71 102 adapalene 55 ALINIA 12 1ST TIER UNILET adapalene-benzoyl ALKERAN 33 COMFORTOUCH LANCETS peroxide 55 allergy nasal spray 24 hour 120 28G 78 ADCIRCA 47 1ST TIER UNILET allergy relief 120 adefovir dipivoxil 43 COMFORTOUCH LANCETS allergy relief 24hr 28 ADEMPAS 47,48 30G 79 allopurinol 71 abacavir sulfate 41 adult aspirin regimen 6 almotriptan malate 107 abacavir sulfate-lamivudine 41 ADVAIR HFA 15 ALOCRIL 124 abacavir sulfate-lamivudine- ADVANCED MOBILE LANCET zidovudine 41 30G 79 ALOMIDE 124 abiraterone acetate 34 ADVATE 71 alophen 77 ABOUTTIME PEN NEEDLES ADVOCATE INSULIN PEN ALORA 67 31G X 3/16" 102 NEEDLES 31GX5MM 102 alosetron hcl 69 acamprosate calcium 127 ADVOCATE LANCETS 79 ALPHAGAN P 121 acarbose 22 ADVOCATE LANCETS ALPHANATE/VON ACCU-CHEK FASTCLIX 30G 79 WILLEBRANDFACTOR ADVOCATE SAFETY LANCETS 79 COMPLEX/HUMAN 71 LANCETS 79 ACCU-CHEK MULTICLIX ALPHANINE SD 71 LANCETS 79 ADVOCATE SAFETY ACCU-CHEK SAFE-T-PRO LANCETS 26G 79 alprazolam 13 LANCETS 79 ADYNOVATE 71 ALPRAZOLAM INTENSOL 13 ACCU-CHEK SAFE-T-PRO AFINITOR 35 alprazolam xr 13 PLUSLANCETS 79 AFINITOR DISPERZ 35 ALPROLIX 71 ACCU-CHEK SOFTCLIX LANCETS 79 AFREZZA 24 ALREX 123 acebutolol hcl 44 AFSTYLA 71 ALTABAX 56 acetaminophen w/ codeine 9 aftera 52 altacaine 123 acetazolamide 64 AGAMATRIX ULTRA-THIN altafrin 121 LANCETS 33G 79 acetic acid (otic) 125 ALUNBRIG 35 AIMOVIG 107 acetylcysteine 54 AIMSCO TWIST LANCETS alvimopan 69 acid controller maximum 32G 79 alyacen 1/35 49 strength 135 AIMSCO TWIST LANCETS alyacen 7/7/7 50 acid reducer maximum 33G 80 alyq 47 strength 134 ak-poly-bac 122 ACIPHEX SPRINKLE 135 amabelz 67 AKTEN 123 acitretin 57,58 amantadine hcl 38 AKYNZEO 26 ACTEMRA ACTPEN 4 ambrisentan 47 ALA SCALP 59 ACTI-LANCE LANCETS amcinonide 59 59 28G 79 ala-cort AMCINONIDE 59 59 ACTI-LANCE LITE SAFETY ALA-SCALP amethia 49 LANCETS 28G 79 albendazole 11 ACTI-LANCE SPECIAL SAFETY amethyst 49 LANCETS 17G 79 albuterol sulfate 15 amiloride & ACTI-LANCE SPECIAL ALBUTEROL SULFATE 15 hydrochlorothiazide 64 SAFETYLANCETS 17G 79 albuterol sulfate 15 amiloride hcl 64 ACTI-LANCE UNIVERSAL alclometasone aminocaproic acid 75 SAFETY LANCETS 23G 79 dipropionate 59 amiodarone hcl 14 ACTIDOM DMX 53 64 ALDACTAZIDE AMITIZA 68 ACTIMMUNE 37 35 ALECENSA amitriptyline hcl 22 ACTOPLUS MET XR 22

Index 1 amlodipine besylate 45 ARNUITY ELLIPTA 14 AURORA UNIFINE amlodipine besylate-atorvastatin arthritis pain reliever 56 PENTIPS/MINI/31GX3/16" 103 aurovela 1.5/30 50 calcium 46 ascomp/codeine 9 amlodipine besylate-benazepril aurovela 24 fe 49 asenapine maleate 40 hcl 30 AURYXIA 70 amlodipine besylate- aspirin 7 AUSTEDO 128 valsartan 31 aspirin 81 low dose 6 amlodipine-valsartan- av-phos 250 neutral 109 aspirin adult 7 hydrochlorothiazide 31 AVANDIA 24 aspirin-dipyridamole 73 amnesteem 54 AVC 137 amoxapine 22 ASSURE COMFORT LANCETS ULTRA THIN avidoxy 132 amoxicillin 126 28G 80 avita 55 amoxicillin & pot ASSURE HAEMOLANCE AVONEX 128 clavulanate 127 PLUS HIGH FLOW 18G 80 amoxicillin-clarithromycin w/ ASSURE HAEMOLANCE AVONEX PEN 128 lansoprazole 136 PLUS LOW FLOW 25G 80 AYVAKIT 35 amphetamine- ASSURE HAEMOLANCE AZASAN 110 dextroamphetamine 1 PLUS MICRO FLOW 28G 80 ampicillin 126 ASSURE HAEMOLANCE AZASITE 122 ampicillin & sulbactam PLUS NORMAL FLOW azathioprine 110 sodium 127 21G 80 azelaic acid 62 ampicillin sodium 126 ASSURE HAEMOLANCE azelastine hcl 120 PLUS PEDIATRIC BLADE 80 ANADROL-50 10 ASSURE ID SAFETY PEN azelastine hcl (ophth) 124 anagrelide hcl 73 NEEDLES 31G X 3/16" 102 azelastine hcl-fluticasone ANALPRAM-HC 11 ASSURE LANCE propionate 120 ANASTIA 62 LANCETS 80 AZELEX 55 ASSURE LANCE LANCETS azithromycin 77 anastrozole 34 21G 80 ANDEXXA 26 ASSURE LANCE PLUS AZOPT 124 ANDRODERM 10 SAFETYLANCETS 25G 80 azurette 49 ASSURE LANCE PLUS ANGELIQ 67 bac 5 SAFETYLANCETS 30G 80 bacitracin (ophthalmic) 122 ANNOVERA 51 ASSURE LANCE SAFETY LANCET 28G 80 bacitracin-poly-neomycin-hc ANORO ELLIPTA 15 123 ANTARA 29 ASSURE LANCETS 80 bacitracin-polymyxin b anti-diarrheal 25 ASTAGRAF XL 110 (ophth) 122 ANZEMET 26 ATABEX EC 113 baclofen 119 APEXICON E 59 atazanavir sulfate 41 BACTROBAN NASAL 120 apraclonidine hcl 122 atenolol 44 BAL-CARE DHA 113 aprepitant 27 atenolol & chlorthalidone 31 BALCOLTRA 50 apri 49 ATIVAN 13 balsalazide disodium 69 APTIOM 17 atomoxetine hcl 2 BALVERSA 35 APTIVUS 41 atorvastatin calcium 29 BANZEL 17 AQUALANCE LANCETS ULTRA atovaquone 12 BAQSIMI ONE PACK 23 THIN 30G 80 atovaquone-proguanil hcl 32 BAQSIMI TWO PACK 23 ARCALYST 4 ATROPINE SULFATE 121 BARACLUDE 43 ARCAPTA NEOHALER 15 ATROVENT HFA 14 BD ECLIPSE NEEDLE 30G ARIKAYCE 2 AUBAGIO 128 X1/2" 103 aripiprazole 41 BD LANCET ULTRAFINE AUGMENTIN 127 30G 80 ARIXTRA 16 AURORA LANCET SUPER BD LANCET ULTRAFINE armodafinil 2 THIN30G 80 33G 80 ARMOUR THYROID 133 AURORA LANCET THIN BD MICROTAINER 23G 80 LANCETS 81

Index 2 BD NEEDLE/30G X 1/2" 103 BETOPTIC-S 121 buprenorphine hcl 10 BD PEN 103 BEVYXXA 16 buprenorphine hcl-naloxone hcl BD PEN MINI 103 bexarotene 37 dihydrate 10 bupropion hcl 21 BD PEN NEEDLE/MINI/ULTRA- BEYAZ 50 bupropion hcl (smoking FINE/31G X 5MM 103 bicalutamide 34 BD SAFETYGLIDE INSULIN deterrent) 131 SYRINGE/0.5ML/31G X BICILLIN C-R 127 buspirone hcl 13 15/64" 103 BICILLIN L-A 126 busulfan 33 BD SAFETYGLIDE INSULIN BIDIL 46 BUSULFEX 33 SYRINGE/1ML/31G X 15/64" 103 BIKTARVY 41 butalbital-acetaminophen 5 BD VEO INSULIN SYRINGE bimatoprost 124 butalbital-acetaminophen- ULTR-FINE/U-100/0.5ML/31G X BINOSTO 65 caffeine 5 butalbital-acetaminophen- 15/64" 103 bio-statin 27 BD VEO INSULIN SYRINGE caffeine w/ codeine 9 ULTRA-FINE/0.5ML/31G X BIO-STATIN 27 butalbital-aspirin-caffeine 5 6MM 103 biogtuss 53 butalbital-aspirin-caffeine BD VEO INSULIN SYRINGE bisacodyl 77 w/cod 9 ULTRA-FINE/1ML/31G X bisacodyl laxative 77 BUTISOL SODIUM 75 6MM 103 butorphanol tartrate 10 BD VEO INSULIN SYRINGE bisoprolol & ULTRA-FINE/U-100/1ML/31G X hydrochlorothiazide 31 BYSTOLIC 44 15/64" 103 bisoprolol fumarate 44 C-NATE DHA 113 BELLADONNA/OPIUM 134 BLEPHAMIDE 123 c-topical 62 BELSOMRA 75 BLEPHAMIDE S.O.P. 123 cabergoline 67 benazepril & bosentan 47 CABOMETYX 35 hydrochlorothiazide 31 BOSULIF 35 caffeine citrate 1 benazepril hcl 30 bp 10-1 55 CALCIFOL 108 BENEFIX 71 bp cleansing wash 55 calcipotriene 58 BENLYSTA 111 BRAFTOVI 35 CALCIPOTRIENE 58 BENSAL HP 62 BREO ELLIPTA 15 calcipotriene-betamethasone BENZNIDAZOLE 11 BRILINTA 73 dipropionate 59 benzonatate 53 brimonidine tartrate 122 calcitonin (salmon) 65 benzoyl peroxide- calcitrene 57 erythromycin 55 bromfed dm 53 calcitriol 66 benzphetamine hcl 1 bromfenac sodium (ophth) 124 calcitriol (topical) 58 benztropine mesylate 38 bromocriptine mesylate 38 calcium acetate (phosphate BEPREVE 124 BROMSITE 124 binder) 70 beser 59 BRUKINSA 35 CALCIUM-FOLIC ACID PLUS D 108 BESIVANCE 122 budesonide 52 BETADINE OPHTHALMIC calphron 69 PREP 122 budesonide (inhalation) 14 CALQUENCE 35 budesonide-formoterol betamethasone dipropionate camila 52 (topical) 59 fumarate dihydrate 15 betamethasone dipropionate BULLSEYE MINI SAFETY candesartan cilexetil 30 augmented 59 LANCETS 81 candesartan cilexetil- betamethasone valerate 59 BULLSEYE SAFETY hydrochlorothiazide 31 LANCETS 81 capecitabine 33 BETASERON 128 bumetanide 64 CAPEX 59 betaxolol hcl 44 bupap 5 CAPRELSA 35 betaxolol hcl (ophth) 121 BUPHENYL 66 captopril 30 bethanechol chloride 136 BUPRENORPHINE 10 captopril & BETHKIS 2 buprenorphine 10 hydrochlorothiazide 31 BETIMOL 121

Index 3 CARAC 57 CEFACLOR ER 48 cholestyramine light 28 CARBAGLU 66 cefadroxil 48 choline fenofibrate 29 carbamazepine 17 cefazolin sodium 48 ciclopirox 56,57 CARBAPHEN 12 53 cefdinir 48 ciclopirox olamine 57 CARBAPHEN 12 PED 53 cefditoren pivoxil 48 cidofovir 43 CARBATROL 17 cefixime 48 cilostazol 73 carbidopa 38 CEFOTAN 48 CILOXAN 122 carbidopa-levodopa 38,39 cefotetan disodium 48 CIMDUO 41 carbidopa-levodopa-entacapone cefoxitin sodium 48 cimetidine 135 39 CEFOXITIN SODIUM 48 cimetidine hcl 135 carbinoxamine maleate 27 cefpodoxime proxetil 48 CIMZIA 69 CARBINOXAMINE MALEATE 27 cefprozil 48 CIMZIA STARTER KIT 69 CARDIZEM LA 45 cefuroxime axetil 48 cinacalcet hcl 66 CARDURA XL 71 celecoxib 4 CIPRO 68 CAREONE LANCET SUPER CELONTIN 20 CIPRO HC 125 THIN/30G 81 CENTANY 56 ciprofloxacin 68 CAREONE LANCET THIN 81 cephalexin 48 ciprofloxacin hcl 68 CAREONE UNIFINE PENTIPS 31GX5MM 103 CEPROTIN 73 ciprofloxacin hcl (ophth) 122 CAREONE UNIFINE PENTIPS CERDELGA 74 ciprofloxacin hcl (otic) 125 PLUS PEN NEEDLES CEREZYME 74 ciprofloxacin-ciprofloxacin 31GX5MM 103 cerovel 61 hcl 68 CARESENS LANCETS 81 ciprofloxacin-dexamethasone CERVIDIL 125 CARETOUCH PEN NEEDLES 125 31GX 5MM 103 CETACAINE 62 ciprofloxacin-fluocinolone CARETOUCH SAFETY CETRAXAL 125 acetonide 125 LANCETS/26G 81 cevimeline hcl 111 citalopram hydrobromide 21 CARETOUCH SAFETY CHANTIX 131 CITRANATAL 90 DHA 113 LANCETS/28G 81 CITRANATAL ASSURE 113 CARETOUCH SAFETY CHANTIX CONTINUING LANCETS/30G 81 MONTHPAK 131 CITRANATAL B-CALM 113 CARETOUCH TWIST LANCETS CHANTIX STARTING MONTH CITRANATAL BLOOM 113 28G 81 PAK 131 CITRANATAL BLOOM CARETOUCH TWIST LANCETS charlotte 24 fe 49 DHA 113 30G 81 CHEMET 26 CITRANATAL DHA 113 CARETOUCH TWIST LANCETS CHENODAL 68 33G 81 CITRANATAL ESSENCE 113 CARIMUNE cheratussin ac 53 CITRANATAL HARMONY 113 NANOFILTERED 125 chlordiazepoxide hcl 13 CITRANATAL MEDLEY 113 carisoprodol 119 chlordiazepoxide hcl-clidinium CITRANATAL RX 113 carisoprodol w/ aspirin 119 bromide 134 chlordiazepoxide-amitriptyline claravis 55 carisoprodol w/ aspirin & clarithromycin 78 codeine 119 128 chlorhexidine gluconate carteolol hcl (ophth) 121 CLEANLET LANCETS 28G 81 (mouth-throat) 111 clearlax 76 cartia xt 45 chloroquine phosphate 32 clemastine fumarate 27 carvedilol 44 chlorothiazide 64 CLENPIQ 76 carvedilol phosphate 44 chlorpromazine hcl 41 CAYA 78 CLEOCIN 137 chlorpropamide 25 CLEVER CHEK LANCETS CAYSTON 12 chlorthalidone 64 ULTRATHIN 81 caziant 49 chlorzoxazone 119 CLEVER CHEK LANCETS cefaclor 48 cholestyramine 28 ULTRATHIN 30G 81

Index 4 CLEVER CHOICE COMFORT COARTEM 32 CRESEMBA 27 EZLANCETS 21G 81 codeine sulfate 7 CRINONE 137 CLEVER CHOICE COMFORT EZLANCETS 23G 81 CODITUSSIN AC 53 CRIXIVAN 41 CLEVER CHOICE COMFORT COGENTIN 38 cromolyn sodium 14 EZLANCETS 28G 81 colchicine 71 CROMOLYN SODIUM 14 CLEVER CHOICE COMFORT EZPEN NEEDLES colchicine w/ probenecid 71 cromolyn sodium (ophth) 124 31GX5MM 103 colesevelam hcl 28 cryselle-28 50 CLICKFINE PEN NEEDLES 31G colestipol hcl 28,29 CUVPOSA 134 X 3/16" 103 colocort 11 cvs folic acid 74 CLIMARA PRO 67 COLY-MYCIN S 125 CVS LANCETS 21G 82 clindacin etz pledgets 54 COLYTE-FLAVOR PACKS76 CVS LANCETS MICRO THIN clindamycin hcl 12 COMBIGAN 121 33G 82 clindamycin palmitate CVS LANCETS MICRO-THIN hydrochloride 12 COMBIPATCH 67 33G 82 clindamycin phosphate COMBIVENT RESPIMAT 15 CVS LANCETS ORIGINAL 82 (topical) 55 COMETRIQ 35 CVS LANCETS THIN 26G 82 clindamycin phosphate COMFORT ASSURED vaginal 137 CVS LANCETS ULTRA THIN LANCETS MICRO THIN 30G 82 clindamycin phosphate-benzoyl 33G 82 peroxide 55 CVS LANCETS ULTRA-THIN COMFORT ASSURED 30G 82 clindamycin phosphate-benzoyl LANCETS SUPER THIN 55 cvs lansoprazole 135 peroxide (refrigerate) 28G 82 clindamycin phosphate- COMFORT EZ/31G X cvs nasal allergy spray 120 55 tretinoin 5MM 103 cvs nicotine 130 137 CLINDESSE COMFORT LANCETS 82 cvs nicotine lozenge 130 17 clobazam COMPLERA 41 cvs nicotine 59 clobetasol propionate COMPLETENATE 113 transdermalsystem 131 59 CVS ULTRA THIN clobetasol propionate e compro 41 clobetasol propionate emollient LANCETS 82 base 59 CONCEPT DHA 113 cyclobenzaprine hcl 119 clobetasol propionate CONCEPT OB 113 CYCLOMYDRIL 121 emulsion 59 CONDYLOX 62 cyclopentolate hcl 121 clocortolone pivalate 60 constulose 76 cyclophosphamide 33 clodan 59 CONTRAVE 1 cycloserine 32 CLODERM 60 CONZIP 7 cyclosporine 110 CLODERM PUMP 60 COPIKTRA 35 cyclosporine modified (for clomiphene citrate 65 CORDRAN 60 microemulsion) 110 CYKLOKAPRON 75 clomipramine hcl 22 CORIFACT 72 cyproheptadine hcl 28 clonazepam 17 CORLANOR 48 CYSTADANE 66 clonidine hcl 30 CORTANE-B 60 CYSTAGON 70 clonidine hcl (adhd) 2 cortic-nd 125 CYSTARAN 124 clopidogrel bisulfate 73 CORTIFOAM 11 CYTOMEL 133 clorazepate dipotassium 13 cortisone acetate 52 cytra k crystals 70 clotrimazole 111 CORTISPORIN 56 clotrimazole w/ cytra-2 70 CORTISPORIN-TC 125 betamethasone 57 cytra-3 70 COSENTYX 58 clovique 109 cytra-k 70 clozapine 40 COSENTYX SENSOREADY PEN 58 D-PENAMINE 110 COAGADEX 72 COTELLIC 35 D.H.E. 45 107 COAGUCHEK LANCETS 82 CREON 64 dalfampridine 128

Index 5 danazol 10 diazepam (anticonvulsant) 17 DOMETUSS-DMX 53 dantrolene sodium 119 diazepam intensol 13 donepezil hydrochloride 127 dapsone 12 diazoxide 23 DORAL 75 dapsone (topical) 55 diclofenac epolamine 56 doripenem 12 darifenacin hydrobromide 136 diclofenac potassium 4 dorzolamide hcl 124 DAURISMO 33 diclofenac sodium 4 DORZOLAMIDE HCL 124 DAYTRANA 2 diclofenac sodium (actinic dorzolamide hcl-timolol DDAVP 67 keratoses) 57 maleate 121 diclofenac sodium (ophth)124 DOTHELLE DHA 113 decadron 52 diclofenac sodium (topical) 56 dotti 67 deferasirox 26 diclofenac w/ misoprostol 4 DOVATO 42 deferiprone 26 dicloxacillin sodium 127 doxazosin mesylate 30 DELSTRIGO 41 dicyclomine hcl 134 doxepin hcl 22 delyla 49 didanosine 42 doxepin hcl (antipruritic) 57 demeclocycline hcl 132 diethylpropion hcl 1 doxercalciferol 66 DEPAKENE 20 DIFFERIN 55 doxycycline DEPAKOTE 20 DIFICID 78 (monohydrate) 132,133 DEPAKOTE ER 20 doxycycline (rosacea) 63 diflorasone diacetate 60 DEPAKOTE SPRINKLES 20 doxycycline hyclate 133 diflunisal 7 DESCOVY 42 doxylamine-pyridoxine 26 digitek 46 desipramine hcl 22 dronabinol 26 digoxin 46 desloratadine 28 DROPLET INSULIN SYRINGE dihydroergotamine desmopressin acetate 67 U-100/1ML/31G X 15/64" 104 mesylate 107 DROPLET INSULIN desmopressin acetate spray 67 DILANTIN 20 SYRINGE/U-100/0.5ML/31G X desmopressin acetate spray DILANTIN INFATABS 20 15/64" 104 refrigerated 67 DILANTIN-125 20 DROPLET INSULIN desogestrel & ethinyl SYRINGE/U-100/1ML/31G X estradiol 50 DILATRATE SR 12 15/64" 104 desogestrel-ethinyl estradiol dilt-xr 45 DROPLET LANCETS ULTRA (biphasic) 50 diltiazem hcl 45 THIN 30G 82 desonide 60 diltiazem hcl coated beads 45 DROPLET PEN NEEDLES 31GX5MM 104 DESOXIMETASONE 60 diltiazem hcl extended release desoximetasone 60 DROPLET PERSONAL beads 45 LANCETS30G 82 desvenlafaxine succinate 22 dimethyl fumarate 128 drospirenone-ethinyl dexamethasone 52 DIPENTUM 69 estradiol 50 DEXAMETHASONE diphenhydramine hcl 27 drospirenone-ethinyl estradiol- levomefolate calcium 50 INTENSOL 52 diphenoxylate w/ atropine 25 dexamethasone sodium DROXIA 74 phosphate (ophth) 123 dipyridamole 73 DRUG MART LANCETS dexchlorpheniramine disopyramide phosphate 13 THIN 82 maleate 27 disulfiram 127 DRUG MART ON-THE-GO dexmethylphenidate hcl 2 DIURIL 64 LANCETS GENTLE 30G 82 dexpak 13 day 52 DRUG MART UNIFINE PENTIPS divalproex sodium 20 31GX5MM 104 dextroamphetamine sulfate 1 DIVIGEL 68 DRUG MART UNILET DIACOMIT 18 DOCTOR MANZANILLA PE LANCETSSUPER THIN 30G83 DIATHRIVE LANCETS 82 SYRUP DRUG MART UNILET DIATHRIVE LANCETS ULTRA ANTIHISTAMINE/DECONGES LANCETSULTRA THIN 28G 83 THIN 30G 82 TANT 53 DRUG MART UNILET MICRO DIATHRIVE PEN NEEDLE/31GX dofetilide 14 THIN LANCETS 33G 83 DRYSOL 62 5MM 104 DOJOLVI 121 diazepam 13 DUAVEE 67

Index 6 DUET DHA 400 113 EASY TOUCH LANCETS ELLA 52 DUET DHA BALANCED 113 30G/PULL-TOP 84 ELMIRON 71 EASY TOUCH LANCETS duloxetine hcl 22 30G/TWIST 84 ELOCTATE 72 DUPIXENT 61 EASY TOUCH LANCETS eluryng 51 duraxin 5 32G/PRESSURE EMADINE 124 ACTIVATED 84 DUREZOL 123 EASY TOUCH LANCETS EMBEDA 7 dutasteride 71 32G/PULL-TOP 84 EMBRACE LANCETS ULTRA dutasteride-tamsulosin hcl 71 EASY TOUCH LANCETS THIN 30G 84 EMCYT 34 E-Z JECT LANCETS 83 32G/TWIST 84 EASY TOUCH LANCETS EMEND 27 E-Z JECT LANCETS 21G 83 33G/TWIST 84 EMGALITY 107 E-Z JECT LANCETS EASY TOUCH PEN COLOR 83 NEEDLES/31G X 3/16" 104 EMSAM 21 E-Z JECT LANCETS SUPER EASY TOUCH SAFETY emtricitabine 42 THIN 30G 83 LANCETS21G/PRESSURE emtricitabine-tenofovir disoproxil E-Z JECT LANCETS THIN ACTIVATED 84 fumarate 42 26G 83 EASY TOUCH SAFETY EMTRIVA 42 E-ZJECT LANCETS MICRO- LANCETS23G/PRESSURE THIN 33G 83 ACTIVATED 84 enalapril maleate 30 e.e.s. 400 78 EASY TOUCH SAFETY enalapril maleate & hydrochlorothiazide 31 EASY COMFORT LANCETS83 LANCETS26G/BUTTON ENBREL 5 EASY COMFORT LANCETS ACTIVATED 84 30G/PULL TOP 83 EASY TOUCH SAFETY ENBREL MINI 5 EASY COMFORT LANCETS LANCETS26G/PRESSURE ENBREL SURECLICK 5 ACTIVATED 84 30G/THIN TOP 83 ENCARE 136 EASY COMFORT LANCETS EASY TOUCH SAFETY TWIST TOP 83 LANCETS28G/BUTTON endocet 9 EASY COMFORT PEN ACTIVATED 84 ENDOMETRIN 137 NEEDLES31GX3/16" 104 EASY TOUCH SAFETY enoxaparin sodium 16 LANCETS28G/PRESSURE EASY TOUCH FLIPLOCK enpresse-28 49 NEEDLES 30GX1/2" 104 ACTIVATED 84 EASY TOUCH HYPODERMIC EASY TWIST & CAP entacapone 38 NEEDLES 30GX1/2" 104 LANCETS 84 entecavir 43 EASY TOUCH LANCETS econazole nitrate 57 ENTRESTO 46 21G/PRESSURE ed-spaz 134 enulose 69 ACTIVATED 83 EDARBI 30 EASY TOUCH LANCETS EPCLUSA 43 23G/PRESSURE EDARBYCLOR 31 EPIDIOLEX 18 ACTIVATED 83 EDURANT 42 EPIFOAM 60 EASY TOUCH LANCETS efavirenz 42 epinastine hcl (ophth) 124 26G/PRESSURE efavirenz-emtricitabine- ACTIVATED 83 tenofovir disoproxil EPINEPHRINE 138 EASY TOUCH LANCETS fumarate 42 epinephrine (anaphylaxis) 137 26G/PULL-TOP 83 efavirenz-lamivudine-tenofovir epitol 17 EASY TOUCH LANCETS disoproxil fumarate 42 28G/PRESSURE EPIVIR HBV 43 effer-k 109 ACTIVATED 83 eplerenone 32 EFFER-K 109 EASY TOUCH LANCETS EQL COLOR LANCETS 21G85 28G/PULL-TOP 84 effervescent pot chloride 109 EQL COLOR LANCETS MICRO EASY TOUCH LANCETS ELESTRIN 68 28G/TWIST 84 THIN 33G 85 EASY TOUCH LANCETS eletriptan hydrobromide 107 EQL SUPER THIN LANCETS 30G/BUTTON-ACTIVATED 84 ELIGARD 34 30G 85 EQL THIN LANCETS 26G 85 EASY TOUCH LANCETS ELIQUIS 16 30G/PRESSURE EQUETRO 40 ELIQUIS STARTER PACK 16 ACTIVATED 84 ergocalciferol 138 ELIXOPHYLLIN 16

Index 7 ergoloid mesylates 129 EVOTAZ 42 FERRIPROX 26 ERGOMAR 107 EVRYSDI 121 FETZIMA 22 ergotamine w/ caffeine 107 EVZIO 26 FETZIMA TITRATION PACK22 ERIVEDGE 33 EXACTUSS TR 53 fexmid 119 ERLEADA 34 EXAPHEX TR 53 FIBRICOR 29 erlotinib hcl 35 EXELDERM 57 FIFTY50 PEN NEEDLES 31G ERTACZO 57 exemestane 34 X3/16" (5MM) 104 FIFTY50 PEN NEEDLES ertapenem sodium 12 EXJADE 26 31GX5MM 104 ery 54 EXODERM 57 FIFTY50 SAFETY SEAL ery-tab 78 EXTAVIA 129 LANCETS 30G 85 FIFTY50 SAFETY SEAL erythrocin stearate 78 EZ SMART BLOOD GLUCOSE LANCETS 85 LANCETS 32G 85 erythromycin (acne aid) 55 FIFTY50 UNILET LANCETS EZ-LETS LANCETS 21G 85 erythromycin (ophth) 122 33G 85 EZ-LETS LANCETS 26G FINACEA 63 erythromycin base 78 SUPER-SOFT 85 erythromycin ethylsuccinate 78 EZ-LETS LANCETS 28G finasteride 71 ESBRIET 132 ULTRA-SOFT 85 FINE 30 85 escitalopram oxalate 21 EZ-LETS LANCETS 30G 85 FINGERSTIX LANCETS 85 esgic 5 ezetimibe 29 FINTEPLA 18 esomeprazole magnesium 135 ezetimibe-simvastatin 28 FIRDAPSE 32 estarylla 50 FABIOR 55 FIRST-MOUTHWASH BLM 111 estazolam 75 famciclovir 44 FIRST-OMEPRAZOLE 135 estradiol 68 famotidine 135 FIRVANQ 12 estradiol & norethindrone FANAPT 40 flac 125 acetate 67 FANAPT TITRATION FLAREX 123 PACK 40 estradiol vaginal 137 flavoxate hcl 136 FARXIGA 25 ESTRING 137 FLEBOGAMMA DIF 126 FARYDAK 35 ESTROGEL 68 flecainide acetate 14 FAZACLO 40 ESTROSTEP FE 50 FLECTOR 56 FC FEMALE CONDOM 78 eszopiclone 75 FLORIVA 108 FC2 FEMALE CONDOM 78 ethacrynic acid 64 FLORIVA PLUS 112 febuxostat 71 ethambutol hcl 32 FLOVENT DISKUS 14,15 FEIBA 72 ethosuximide 20 FLOVENT HFA 15 felbamate 20 ethynodiol diacet & eth fluconazole 27 estrad 50 FELBATOL 20 flucytosine 27 ETHYOL 38 felodipine 45 fludarabine phosphate 33 etidronate disodium 65 FEMCAP 78 fludrocortisone acetate 53 etodolac 4 FEMRING 137 FLUMIST QUADRIVALENT136 etonogestrel-ethinyl estradiol51 fenofibrate 29 fluocinolone acetonide 60 ETOPOPHOS 38 FENOFIBRATE 29 fluocinolone acetonide etoposide 38 fenofibrate 29 (otic) 125 EUCRISA 62 fenofibrate micronized 29 fluocinonide 60 euthyrox 133 FENOFIBRIC ACID 29 fluocinonide emulsified base 60 EVAMIST 68 fenofibric acid 29 FLUORABON 108 everolimus 35 fenoprofen calcium 4 fluoritab 108 everolimus FENSOLVI 66 fluorometholone (ophth) 123 (immunosuppressant) 110 fentanyl 7 EVISTA 65 FLUOROPLEX 57 fentanyl citrate 7 fluorouracil (topical) 57

Index 8 fluoxetine hcl 21 FREESTYLE TEST GENTLE-LET LANCETS fluoxetine hcl (pmdd) 129 STRIPS 63 SAFETY STYLE/MEDIUM FREESTYLE UNISTICK II POINT 86 fluphenazine hcl 41 LANCETS 86 GENVOYA 42 flurandrenolide 60 frovatriptan succinate 108 geri-hydrolac 12 61 flurazepam hcl 75 FULPHILA 74 gianvi 49 flurbiprofen 4 furosemide 64 GILENYA 129 flurbiprofen sodium 124 FUZEON 42 GILOTRIF 35 flutamide 34 fyavolv 67 GILPHEX TR 53 fluticasone propionate 60 FYCOMPA 17 GILTUSS COUGH & COLD 53 fluticasone propionate g tussin ac 53 GILTUSS SINUS & (nasal) 120 gabapentin 18 CONGESTION 53 fluticasone-salmeterol 15 GABITRIL 20 GILTUSS TR 53 fluvastatin sodium 29 GABLOFEN 119 glatiramer acetate 129 fluvoxamine maleate 21 GALAFOLD 66 glatopa 128 FML 123 galantamine GLEOSTINE 33 FML FORTE 123 hydrobromide 128 glimepiride 25 FOLET DHA 114 GALZIN 109 glipizide 25 FOLET ONE 114 GAMMAGARD LIQUID 126 glipizide xl 25 folic acid 74 GAMMAKED 126 glipizide-metformin hcl 22 FOLIVANE-F 75 GAMMAPLEX 126 GLOBAL EASE INJECT PEN FOLIVANE-OB 114 GAMUNEX-C 126 NEEEDLES 31GX5MM 104 fondaparinux sodium 16 gatifloxacin (ophth) 122 GLOBAL EASY GLIDE INSULIN SYRINGE/0.5ML/31G X FORA LANCETS 85 GATTEX 70 15/64" 104 FORFIVO XL 21 gavilyte-c 75 GLOBAL EASY GLIDE INSULIN formaldehyde 41 gavilyte-h 75 SYRINGE/1ML/31G X FORTEO 65 15/64" 104 gavilyte-n/flavor pack 76 GLOBAL INJECT EASE FOSAMAX PLUS D 65 GELFILM OP 124 LANCETS 28G 86 fosamprenavir calcium 42 gemfibrozil 29 GLOBAL INJECT EASE fosfomycin tromethamine 12 gemmily 49 LANCETS 30G 86 GLUCAGEN DIAGNOSTIC 63 fosinopril sodium 30 GENERESS FE 50 GLUCAGEN HYPOKIT 23 fosinopril sodium & gengraf 110 hydrochlorothiazide 31 GLUCAGON EMERGENCY gentak 122 FOSRENOL 70 KIT 23 gentamicin sulfate GLUCOCOM LANCETS FRAGMIN 17 (ophth) 122 28G 86 FREDS PHARMACY UNIFINE gentamicin sulfate (topical) 56 GLUCOCOM LANCETS PENTIPS PLUS 31GX5MM 104 GENTEEL BUTTERFLY 30G 86 FREDS PHARMACY UNILET TOUCH LANCETS 86 GLUCOCOM LANCETS LANCETS SUPER THIN GENTLE-LET GP 33G 86 30G 85 LANCETS 86 GLUCOPHAGE 23 FREDS PHARMACY UNILET GENTLE-LET LANCETS glyburide 25 LANCETS ULTRA THIN GENERAL PURPOSE 28G 85 STYLE/FINE POINT 86 glyburide micronized 25 FREESTYLE INSULINX GENTLE-LET LANCETS glyburide-metformin 22 BLOODGLUCOSE TEST 63 GENERAL PURPOSE FREESTYLE INSULINX GLYCATE 134 STYLE/MEDIUM POINT 86 glycopyrrolate 134 BLOODGLUCOSE TEST GENTLE-LET LANCETS STRIPS 63 SAFETY STYLE/FINE GLYCOPYRROLATE 134 FREESTYLE LANCETS 85 POINT 86 GLYXAMBI 22 FREESTYLE LITE TEST gnp aspirin 7 STRIPS 63 GNP LANCETS 86

Index 9 GNP LANCETS 21G 86 H-E-B IN CONTROL HUMATROPE COMBO GNP LANCETS MICRO THIN UNIFINEPENTIPS PLUS PACK 65 33G 86 31GX5MM 105 HUMIRA 3 GNP LANCETS SUPER THIN H-E-B INCONTROL LANCETS HUMIRA PEDIATRIC CROHNS 30G 86 MICRO THIN 33G 87 DISEASE STARTER PACK 3 GNP LANCETS THIN 86 H-E-B INCONTROL LANCETS HUMIRA PEN 3 SUPER THIN 30G 87 GNP LANCETS THIN 26G 86 H-E-B INCONTROL LANCETS HUMIRA PEN-CD/UC/HS GNP MICRO THIN LANCETS 87 STARTER 3 ULTRA THIN 28G HUMIRA PEN-PS/UV 33G 87 HAEMOLANCE 87 GNP SUPER THIN STARTER 3 HAEMOLANCE LOW FLOW HUMULIN 70/30 24 LANCETS/30G 87 LANCETS 87 GOJJI STERILE LANCETS HAEMOLANCE PLUS 87 HUMULIN 70/30 KWIKPEN 24 30G 87 HUMULIN N 24 GOLYTELY 76 HAEMOLANCE PLUS HIGH FLOW 87 HUMULIN N KWIKPEN 24 GONITRO 12 HAEMOLANCE PLUS LOW HUMULIN R 24 goodsense aspirin 7 FLOW 87 HUMULIN R U-500 GOODSENSE CLICKFINE HAEMOLANCE PLUS MAX (CONCENTRATED) 24 SAFETY PEN NEEDLE/31G X FLOW 87 HUMULIN R U-500 3/16" 104 HAEMOLANCE PLUS KWIKPEN 24 PEDIATRIC FLOW 88 GOODSENSE COLOR HY-VEE LANCETS 88 LANCETS MICRO-THIN 33G halobetasol propionate 60 HY-VEE THIN LANCETS 88 UNIVERSAL 87 haloperidol 40 GOODSENSE LANCETS hyaluronate sodium MICRO-THIN 33G 87 haloperidol lactate 40 (emollient) 61 GOODSENSE LANCETS HEALTHWISE SHORT PEN HYCAMTIN 38 NEEDLES/31G X 3/16" 105 MICRO-THIN 33G hycodan 53 UNIVERSAL 87 HEALTHY ACCENTS UNIFINE GOODSENSE LANCETS PENTIPS PEN NEEDLES hydralazine hcl 32 ULTRA-THIN 26G 31GX5MM 105 hydrochlorothiazide 64 UNIVERSAL 87 HEALTHY ACCENTS UNILET HYDROCODONE GOODSENSE LANCETS LANCETS SUPER THIN BITARTRATE/GUAIFENESIN ULTRA-THIN 30G 87 30G 88 53 GOODSENSE LANCETS HELIDAC THERAPY 136 hydrocodone polistirex- ULTRA-THIN 30G HEMENATAL OB 114 chlorpheniramine polistirex 54 UNIVERSAL 87 HEMENATAL OB + DHA 114 hydrocodone w/ GOODSENSE PEN homatropine 53 NEEDLE/PENFINE HEMOFIL M 72 hydrocodone-acetaminophen 9 CLASSIC/31G X 3/16" 104 heparin sodium (porcine) 17 hydrocodone-ibuprofen 9 GORDONS UREA 61 HETLIOZ 75 hydrocortisone 52 GRALISE 129 homatropaire 121 hydrocortisone (intrarectal) 11 granisetron hcl 26 homatropine hbr 121 hydrocortisone (rectal) 11 GRANIX 74 HORIZANT 129 hydrocortisone (topical) 61 griseofulvin microsize 27 HUMALOG 24 hydrocortisone butyrate 61 griseofulvin ultramicrosize 27 HUMALOG JUNIOR hydrocortisone butyrate guaifenesin dac 53 KWIKPEN 24 hydrophilic lipo base 61 HUMALOG KWIKPEN 24 guaifenesin-codeine 53 hydrocortisone valerate 61 HUMALOG MIX 50/50 24 guanfacine hcl 30 hydrocortisone w/acetic HUMALOG MIX 50/50 acid 125 guanfacine hcl (adhd) 2 KWIKPEN 24 hydromorphone hcl 7 GUANIDINE HCL 32 HUMALOG MIX 75/25 24 hydroxychloroquine sulfate 32 GVOKE PFS 23 HUMALOG MIX 75/25 hydroxyurea 37 GYNAZOLE-1 137 KWIKPEN 24 hydroxyzine hcl 13 H-E-B IN CONTROL PEN HUMATE-P 72 NEEDLES 31GX5MM 104 HUMATROPE 65 hydroxyzine pamoate 13 HYLINATE 61

Index 10 hyophen 11 INSULIN SYRINGES AND PEN K-PHOS 109 hyoscyamine sulfate 134 NEEDLES 105 K-PHOS NO 2 70 INSUPEN 31G X 5MM 105 HYPERSAL 54 k-sol 109 INTEGRA F 75 HYPODERMIC NEEDLE K-TAB 109 INTELENCE 42 30GX1/2" 105 KADIAN 7 HYQVIA 126 INTRON A 37 kaitlib fe 50 ibandronate sodium 65 INVANZ 12 KALETRA 42 IBRANCE 35 INVIRASE 42 KALYDECO 132 ibu 4 iodoquimez-hc 56 KCENTRA 72 ibudone 9 iodoquinol-hydrocortisone in kelnor 1/35 49 ibuprofen 4 aloe vehicle 57 IOPIDINE 122 KEPPRA 18 icatibant acetate 73 ipratropium bromide 14 KEPPRA XR 18 ICLUSIG 35 ipratropium bromide ketoconazole 27 icosapent ethyl 28 (nasal) 120 ketoconazole (topical) 57 IDELVION 72 ipratropium-albuterol 15 ketodan 56 IDHIFA 35 irbesartan 30 ketoprofen 4 ILEVRO 124 irbesartan-hydrochlorothiazide KETOROLAC ilotycin 122 31 TROMETHAMINE 4 ILUMYA 58 IRESSA 36 ketorolac tromethamine 4 imatinib mesylate 35 ISENTRESS 42 ketorolac tromethamine IMBRUVICA 35,36 ISENTRESS HD 42 (ophth) 124 KEVEYIS 64 imipenem-cilastatin 12 isoniazid 32 KEVZARA 4 imipramine hcl 22 ISOPTO ATROPINE 121 KINNEY LANCETS 88 imipramine pamoate 22 isosorbide dinitrate 12 KINNEY THIN LANCETS 88 imiquimod 62 isosorbide mononitrate 12 kionex 110 IMITREX 108 isotretinoin 55 IMITREX STATDOSE isoxsuprine hcl 46 KISQALI 36 REFILL 108 isradipine 45 KISQALI FEMARA 200 DOSE 34 IMITREX STATDOSE ISTODAX (OVERFILL) 36 SYSTEM 108 KISQALI FEMARA 400 IN TOUCH STERILE itraconazole 27 DOSE 35 LANCETS30G 88 ivermectin 11 KISQALI FEMARA 600 inatal gt 112 ivermectin (pediculicide) 63 DOSE 35 KLARITY-A 122 INCRELEX 66 ivermectin (rosacea) 63 klofensaid ii 56 INCRUSE ELLIPTA 14 IXINITY 72 klor-con 109 indapamide 64 JADENU 26 klor-con 10 109 INDERAL XL 45 JADENU SPRINKLE 26 klor-con m10 109 INDOCIN 4 JAKAFI 36 klor-con sprinkle 109 indomethacin 4 jantoven 16 KOATE 72 INFLECTRA 69 JANUMET 22,23 KOATE-DVI 72 INGREZZA 128 JANUMET XR 23 KOVALTRY 72 INLYTA 36 JANUVIA 23 kp folic acid 74 INNOPRAN XL 45 JARDIANCE 25 KRINTAFEL 32 INQOVI 34 JIVI 72 KROGER HEALTHPRO TWIST INREBIC 36 JULUCA 42 LANCETS/26G 88 INSULIN LISPRO JUXTAPID 29 KROGER LANCETS 88 PROTAMINE/INSULIN LISPRO JYNARQUE 67 KWIKPEN 24 KROGER LANCETS 21G 88 k-effervescent 109

Index 11 KROGER LANCETS MICRO LANCETS ULTRA THIN levonorgestrel & eth THIN33G 88 30G 89 estradiol 50 KROGER LANCETS SUPER LANCETSBULLSEYE levonorgestrel (emergency THIN 88 SAFETY 89 oc) 52 KROGER LANCETS THIN 88 LANOXIN 46 levonorgestrel-eth estradiol KROGER LANCETS THIN lansoprazole 135 (triphasic) 50 levonorgestrel-ethinyl estradiol 26G 88 lanthanum carbonate 70 KROGER LANCETS (91-day) 50 ULTRATHIN30G 88 LANTUS 25 levonorgestrel-ethinyl estradiol KROGER PEN NEEDLES/31G LANTUS SOLOSTAR 25 (continuous) 50 X3/16" 105 lapatinib ditosylate 36 levorphanol tartrate 8 KUVAN 66 LASTACAFT 124 levothyroxine sodium 133 labetalol hcl 44 latanoprost 124 LEXIVA 42 LIBERTY MEDICAL LANCETS LACRISERT 121 LATUDA 40 lactic acid (ammonium 30G 89 lactate) 62 LAZANDA 8 lidocaine 62 lactulose 76 LEADER UNIFINE PENTIPS lidocaine hcl 62 PLUS/MINI/31GX3/16" 105 lactulose (encephalopathy) 69 LEADER UNIFINE lidocaine hcl (mouth-throat) 111 LAMICTAL 18 PENTIPS/MINI/31GX3/16" lidocaine-prilocaine 62 LAMICTAL CHEWABLE 105 LIFESCAN UNISTIK 2 DEEP DISPERSIBLE 18 leflunomide 5 PENETRATION 90 LAMICTAL ODT 18 LENVIMA 10 MG DAILY LIFESCAN UNISTIK II LAMICTAL XR 18 DOSE 36 LANCETS 90 LENVIMA 14 MG DAILY linezolid 12 lamivudine 42 DOSE 36 LINZESS 69 lamivudine (hbv) 43 LENVIMA 18 MG DAILY LIORESAL INTRATHECAL 119 lamivudine-zidovudine 42 DOSE 36 liothyronine sodium 133 lamotrigine 18 LENVIMA 20 MG DAILY DOSE 36 LIPOFEN 29 LANCETS 89 LENVIMA 24 MG DAILY lisinopril 30 LANCETS 26G TWIST TOP 88 36 DOSE lisinopril & LANCETS 28G 88 LENVIMA 8 MG DAILY DOSE 36 hydrochlorothiazide 31 LANCETS 30G 88 LETAIRIS 47 LITE TOUCH LANCETS 90 LANCETS 30G TWIST TOP 89 LITETOUCH LANCETS MICRO letrozole 34 LANCETS 30G/TWIST TOP 89 THIN 33G 90 leucovorin calcium 38 LITETOUCH PEN LANCETS 31G TWIST TOP 89 LEUKERAN 33 NEEDLES/31G X 3/16" 105 LANCETS 33G UNIVERSAL LEUKINE 74 LITETOUCH PEN DESIGN 89 NEEDLES/31G X LANCETS MICRO THIN leuprolide acetate 34 5MM/MINI 105 33G 89 levalbuterol hcl 15 LITHIUM 39 LANCETS SAFETY SEAL 21G 89 levalbuterol tartrate 15 lithium carbonate 39 LANCETS SAFETY SEAL LEVEMIR 25 LITHOBID 40 26G 89 LEVEMIR FLEXTOUCH 25 LITHOSTAT 71 LANCETS SAFETY SEAL levetiracetam 18 28G 89 LIVALO 29 LANCETS SAFETY SEAL levo-t 133 LIVE BETTER LANCET 30G 89 levobunolol hcl 121 SUPERTHIN 30G 90 LANCETS SUPER THIN levocarnitine (metabolic LIVE BETTER LANCET 28G 89 modifiers) 66 ULTRATHIN 28G 90 LANCETS THIN 89 levocetirizine LO LOESTRIN FE 50 LANCETS TWIST TOP 89 dihydrochloride 28 LOKELMA 110 LANCETS ULTRA FINE 89 levofloxacin 68 LOMAIRA 1 LANCETS ULTRA THIN 89 levofloxacin (ophth) 122 LONGS LANCETS STANDARD 90

Index 12 LONGS LANCETS THIN 90 MEDICHOICE PRE-SET MEIJER LANCETS LONGS LANCETS ULTRA SAFETY LANCET LOW UNIVERSAL33G 91 THIN 90 FLOW 90 MEIJER SUPER THIN LONSURF 35 MEDICHOICE PRE-SET LANCETS 91 SAFETY LANCET MEDIUM MEKINIST 36 loperamide hcl 25 FLOW 90 MEKTOVI 36 lopinavir-ritonavir 42 MEDICHOICE PRE-SET meloxicam 4 lorazepam 13 SAFETY LANCET MODERATE melphalan 33 lorazepam intensol 13 FLOW 90 MEDICHOICE SAFETY melphalan hcl 33 LORBRENA 36 LANCETEXTRA 90 memantine hcl 128 lorcet 9 MEDICHOICE SAFETY MENEST 68 LORTAB 9 LANCETNORMAL 90 MEDISENSE THIN MENOSTAR 68 lorzone 119 LANCETS 90 meperidine hcl 8 losartan potassium 30 MEDLANCE PLUS EXTRA losartan potassium & LANCETS 21G 90 meprobamate 13 hydrochlorothiazide 31 MEDLANCE PLUS mercaptopurine 33 LOSEASONIQUE 50 LANCETS 91 meropenem 12 MEDLANCE PLUS LANCETS LOTEMAX 123 LITE 25G 90 MERREM 12 loteprednol etabonate 123 MEDLANCE PLUS LITE mesalamine 69 lovastatin 29 LANCETS 25G 91 MESNEX 38 loxapine succinate 40 MEDLANCE PLUS SPECIAL MESTINON 32 LANCETS 0.8MM 91 LUCEMYRA 127 MEDLANCE PLUS metadate er 2 LUMIGAN 125 SUPERLITE 30G 91 metaproterenol sulfate 15 LYNPARZA 36 MEDLANCE PLUS metaxall 119 SUPERLITE 30G/COMFORT LYRICA 18 MAX 91 metaxalone 119 LYSODREN 34 MEDLANCE PLUS metformin hcl 23 M-NATAL PLUS 114 UNIVERSAL LANCETS METFORMIN mafenide acetate 58 21G 91 HYDROCHLORIDE 23 MEDLANCE PLUS/LITE methadone hcl 8 MAGNEBIND 400 109 25G 91 methadone hcl intensol 7 magnesium sulfate 109 MEDLANCE/EXTRA 91 methadose 7 malathion 63 MEDLANCE/LITE 91 methamphetamine hcl 1 maprotiline hcl 21 MEDLANCE/UNIVERSAL 91 methazolamide 64 MARATHON MEDICAL MEDROL 52 PENTIPS31GX5MM 105 methenamine hippurate 12 MARNATAL-F 114 MEDROX-RX 62 methenamine mandelate 12 medroxyprogesterone MARPLAN 21 acetate 127 methergine 125 MATULANE 38 mefenamic acid 4 methimazole 133 matzim la 45 mefloquine hcl 32 METHITEST 10 MAVENCLAD 129 megestrol acetate 34 methocarbamol 119 MAVYRET 44 megestrol acetate METHOTREXATE 3 MAXIDEX 123 (appetite) 127 methotrexate sodium 33 MEIJER COLOR LANCETS MAYZENT 129 UNIVERSAL 33G 91 methoxsalen rapid 58 MAYZENT STARTER MEIJER LANCETS 91 methscopolamine bromide 134 PACK 129 methyclothiazide 65 meclofenamate sodium 4 MEIJER LANCETS THIN 91 methyldopa 30 MEDICHOICE PRE-SET MEIJER LANCETS SAFETY LANCET DUAL UNIVERSAL21G 91 methyldopa & USE 90 MEIJER LANCETS hydrochlorothiazide 31 UNIVERSAL30G 91 methylergonovine maleate 125 methylphenidate hcl 2

Index 13 methylprednisolone 52 mondoxyne nl 132 nafcillin sodium 127 methyltestosterone 10 MONOCLATE-P 72 NAFCILLIN SODIUM 127 metoclopramide hcl 68 MONOLET LANCETS 92 nafcillin sodium 127 METOCLOPRAMIDE ODT 69 MONOLET OPD naftifine hcl 57 metolazone 65 LANCETS 92 NAFTIN 57 MONOLETTOR SAFETY METOPIRONE 63 LANCETS 92 NALOCET 9 metoprolol & MONONINE 72 naloxone hcl 26 hydrochlorothiazide 31 montelukast sodium 14 naltrexone hcl 26 metoprolol succinate 45 morgidox 1x100mg 132 NAMENDA XR TITRATION metoprolol tartrate 45 PACK 128 morphine sulfate 8 metronidazole 11 NAMZARIC 128 morphine sulfate beads 8 metronidazole (topical) 63 naproxen 5 MOVANTIK 69 metronidazole vaginal 137 naproxen sodium 4 MOVIPREP 76 metyrosine 30 naratriptan hcl 108 moxifloxacin hcl 68 mexiletine hcl 13 NARCAN 26 moxifloxacin hcl (ophth) 122 MIACALCIN 65 NATACHEW 114 MPD SAFETY LANCET miconazole 3 137 21G/1.8MM 92 NATACYN 122 MICROLET LANCETS 91 MPD SAFETY LANCET NATAZIA 51 MICROTAINER SAFETY FLOW 28G/1.8MM 92 nateglinide 25 MPD SAFETY LANCET LANCET/STERILE/SINGLE-USE NATELLE ONE 114 92 30G/1.8MM 92 midazolam hcl 75 MPD SAFETY LANCETS NATPARA 65 23G/1.8MM 92 midodrine hcl 138 NATURE-THROID 133 MUCOTROL 111 migergot 107 NATURE-THROID NT-2.5 133 MULPLETA 74 miglitol 22 NAYZILAM 17 MULTAQ 14 miglustat 74 nebusal 54 multi-vit/iron/fluoride 112 MILLIPRED 52 NEBUSAL 54 multi-vitamin/fluoride NEEVO DHA 114 MILLIPRED DP 52 drops 111 MINASTRIN 24 FE 51 MULTIVITAMIN WITH nefazodone hcl 21 minitran 12 FLUORIDE 111 neo-polycin 122 multivitamin with fluoride 111 MINOCIN 133 neo-polycin hc 123 multivitamin/fluoride 112 minocycline hcl 133 neomycin sulfate 2 mupirocin 56 neomycin-bacitracin zn- minoxidil 32 MYALEPT 66 polymyxin 122 MIRCETTE 51 neomycin-polymy- mycophenolate mofetil 110 mirtazapine 21 dexameth 123 mycophenolate sodium 110 MIRVASO 63 neomycin-polymyxin-gramicidin MYGLUCOHEALTH MGH 122 misoprostol 136 SOFTLANCE LANCETS neomycin-polymyxin-hc MITIGARE 71 30G 92 (ophth) 123 mitoxantrone hcl 34 MYLERAN 33 neomycin-polymyxin-hc MM PEN NEEDLES 31G X MYNATAL ADVANCE 114 (otic) 125 3/16" 105 MYNATAL NEONATAL COMPLETE 114 MM TWIST LANCETS 92 ULTRACAPLET 114 NEONATAL PLUS 114 modafinil 2 MYRBETRIQ 136 NEOTUSS PLUS 54 moexipril hcl 30 MYSOLINE 18 NERLYNX 36 molindone hcl 41 MYTESI 25 NESTABS 114 mometasone furoate 61 nabumetone 4 NESTABS ABC 114 mometasone furoate nadolol 45 NESTABS DHA 114 (nasal) 121 NAFCILLIN 127 NESTABS ONE 114

Index 14 neuac 54 norethindrone acet & eth OBSTETRIX ONE 115 NEUPRO 39 estra 51 OCALIVA 68 norethindrone acetate 127 NEURONTIN 19 OCTAGAM 126 norethindrone acetate-ethinyl NEVANAC 124 estradiol 67 octreotide acetate 67 nevirapine 42 norgestimate-ethinyl ODOMZO 33 NEXA PLUS 114 estradiol 51 OFEV 132 norgestimate-ethinyl estradiol NEXAVAR 36 (triphasic) 51 ofloxacin 68 NEXIUM 135 NORITATE 63 ofloxacin (ophth) 122 niacin (antihyperlipidemic) 29 NORPACE CR 13 ofloxacin (otic) 125 niacor 29 NORTHERA 138 olanzapine 40 nicardipine hcl 45 nortriptyline hcl 22 olanzapine-fluoxetine hcl 128 NICODERM CQ 131 NORVIR 42 olmesartan medoxomil 30 NICORETTE 131 NOVA SAFETY LANCETS olmesartan medoxomil- NICORETTE MINI 131 23G 92 amlodipine-hydrochlorothiazide 31 NICORETTE STARTER NOVA SAFETY LANCETS 28G 92 olmesartan medoxomil- KIT 131 hydrochlorothiazide 31 nicotine 131 NOVA SUREFLEX LANCETS 92 olopatadine hcl 124 nicotine polacrilex 131 NOVOEIGHT 72 olopatadine hcl (nasal) 120 NICOTINE TRANSDERMAL SYSTEM 131 NOVOPEN ECHO 105 OMECLAMOX-PAK 136 NICOTROL INHALER 131 NOVOSEVEN RT 72 omega-3-acid ethyl esters 28 NICOTROL NS 132 NOXAFIL 27 omeprazole 135 nifedipine 45 np thyroid 30 133 OMEPRAZOLE + SYRSPEND NUBEQA 34 SFALKA 135 nilutamide 34 OMNIFLEX DIAPHRAGM 78 NUCORT 61 nimodipine 46 ON CALL LANCETS 92 NUCYNTA 8 NINLARO 36 ON CALL PLUS LANCETS 92 NUCYNTA ER 8 nisoldipine 46 ondansetron 26 NUEDEXTA 129 nitazoxanide 12 ondansetron hcl 26 NULYTELY 76 nitisinone 66 ONE VITE WOMENS NULYTELY/FLAVOR NITRO-BID 13 PRENATALVITAMIN PLUS 115 PACKS 76 NITRO-DUR 13 ONETOUCH CLUB LANCETS NUMBONEX 62 FINE POINT 92 nitrofurantoin 12 NUPLAZID 40 ONETOUCH DELICA LANCETS nitrofurantoin macrocrystal 12 NUVARING 51 EXTRA FINE 33G 92 nitrofurantoin monohyd ONETOUCH DELICA LANCETS macro 12 NUWIQ 72 FINE 30G 92 nitroglycerin 13 nyamyc 56 ONETOUCH DELICA PLUS NITYR 66 NYMALIZE 46 LANCETS EXTRA FINE nystatin 27 33G 93 NIVA-PLUS 114 ONETOUCH DELICA PLUS NIVESTYM 74 nystatin (mouth-throat) 111 LANCETS FINE 30G 93 nizatidine 135 nystatin (topical) 57 ONETOUCH FINEPOINT LANCETS 93 NOCTIVA 67 nystatin-triamcinolone 57 ONETOUCH ULTRA 63 nolix 59 O-CAL FA 114 OB COMPLETE ONE 114 ONETOUCH ULTRA 2 93 NORDITROPIN FLEXPRO 65 ONETOUCH ULTRASOFT norethin acet & estrad-fe 51 OB COMPLETE PETITE 115 LANCETS 93 norethindrone & ethinyl estradiol- OB COMPLETE ONETOUCH VERIO FLEX fe 51 PREMIER 115 BLOOD GLUCOSE norethindrone OB COMPLETE/DHA 115 MONITORING SYSTEM 93 (contraceptive) 52 OBIZUR 73

Index 15 ONETOUCH VERIO TEST oxybutynin chloride 136 PENICILLIN G POTASSIUM IN STRIPS 63 oxycodone hcl 8 ISO-OSMOTIC 126 ONUREG 33 oxycodone w/ DEXTROSE opium tincture 25 acetaminophen 9 PENICILLIN G PROCAINE 126 OPSUMIT 47 oxycodone-ibuprofen 9 penicillin g sodium 126 OPTIONS CONCEPTROL OXYCODONE/ACETAMINOPH penicillin v potassium 126 VAGINAL EN 10 PENNSAID 56 CONTRACEPTIVE 136 oxymorphone hcl 8 pentamidine isethionate 11 OPTIONS GYNOL II OZEMPIC 23 VAGINALCONTRACEPTIVE PENTASA 69 137 pacerone 14 pentazocine w/ naloxone 10 ORACEA 63 paliperidone 40 PENTIPS 31G X 5MM 105 ORACIT 70 PALYNZIQ 66 PENTIPS 31GX5MM 106 oralone dental paste 111 PANCREAZE 64 pentoxifylline 73 ORAVIG 111 PANRETIN 57 PERFECT LANCETS 30G 93 ORENCIA 5 pantoprazole sodium 135 PERFECT PRESSURE ORENCIA CLICKJECT 5 paregoric 25 ACTIVATED SAFETY LANCETS 28G 93 ORENITRAM 46 PAREMYD 124 perindopril erbumine 30 ORFADIN 66 paricalcitol 66 permethrin 63 ORIAHNN 67 paroex 111 perphenazine 41 ORKAMBI 132 paromomycin sulfate 2 perphenazine-amitriptyline 128 orphenadrine citrate 119 paroxetine hcl 21 PERSERIS 40 orphenadrine w/ aspirin & PASER 33 PERTZYE 64 caff 119 PAXIL 21 ORTHO MICRONOR 52 PC LANCETS SUPER THIN pfizerpen 126 ORTHO TRI-CYCLEN 51 30G 93 PHARMACIST CHOICE ULTRA THIN LANCETS 93 ORTHO TRI-CYCLEN LO 51 PC UNIFINE PENTIPS 31G X5MM MINI 105 PHARMACIST CHOICE ULTRA ORTHO-CYCLEN 51 pediatric vitamins acd w/ THIN LANCETS 28G 93 ORTHO-NOVUM 1/35 51 fluoride 112 PHARMACIST CHOICE ULTRA ORTHO-NOVUM 7/7/7 51 peg 3350-kcl-nacl-na sulfate-na THIN LANCETS 30G 93 ascorbate-ascorbic acid 76 PHARMACIST CHOICE ULTRA oscimin 134 peg 3350-kcl-sod bicarb-sod THIN LANCETS 31G 93 oscimin sr 134 chloride-sod sulfate 76 PHARMACIST CHOICE ULTRA oseltamivir phosphate 44 peg 3350-potassium chloride- THIN LANCETS 33G 93 PHARMACY COUNTER OSMOPREP 77 sod bicarbonate-sod chloride 76 LANCETS 93 OSPHENA 66 peg- phenadoz 28 OTEZLA 5 3350/electrolytes/ascorbate phenelzine sulfate 21 OTOVEL 125 75 PHENERGAN 28 PEGANONE 20 OTREXUP 3 phenobarbital 75 PEGASYS 44 oxacillin sodium 127 phenoxybenzamine hcl 30 PEGASYS PROCLICK 44 oxandrolone 10 phentermine hcl 1 oxaprozin 5 PEGINTRON 44 PHENTERMINE OXAYDO 8 PEMAZYRE 36 HYDROCHLORIDE 1 oxazepam 13 PEN NEEDLES 31G X phenylephrine hcl 3/16" 105 (mydriatic) 121 oxcarbazepine 19 PEN NEEDLES 31G X phenytoin 20 OXERVATE 123 5MM 105 phenytoin infatabs 20 oxiconazole nitrate 57 PEN NEEDLES/31G X 3/16" 105 phenytoin sodium extended 20 OXISTAT 57 penicillamine 110 PHEXXI 137 OXTELLAR XR 19 penicillin g potassium 126 PHOSLYRA 70

Index 16 PHOSPHOLINE IODIDE 121 pot phosphate monobasic w/ PREFERRED PLUS LANCETS phytonadione 138 sod phosphate dibasic & COLORED 21G 93 monobasic 109 PREFERRED PLUS LANCETS PICATO 57 POTABA 138 SUPER THIN 30G 94 PIFELTRO 42 potassium PREFERRED PLUS LANCETS pilocarpine hcl 121 aminobenzoate 138 THIN 26G 94 potassium chloride 109 PREFERRED PLUS UNIFINE pilocarpine hcl (oral) 111 PENTIPS/MINI/31GX5MM 106 pimecrolimus 62 POTASSIUM CHLORIDE 109 PREFEST 67 pimozide 129 potassium chloride 109 pregabalin 19 pindolol 45 potassium chloride in dextrose & sodium chloride 108 PREMARIN 68,137 pioglitazone hcl 24 potassium chloride PREMIUM SCAR PATCH 62 pioglitazone hcl-glimepiride 23 microencapsulated crystals PREMPHASE 67 pioglitazone hcl-metformin er 109 PREMPRO 67 hcl 23 potassium citrate PIP LANCETS/28G 93 (alkalinizer) 70 PRENA 1 TRUE 115 PIP LANCETS/30G 93 potassium citrate-citric acid70 PRENA1 CHEW 115 piperacillin sodium-tazobactam POVIDONE IODINE 122 PRENA1 PEARL 115 sodium 127 PR NATAL 400 EC 115 PRENAISSANCE 115 PIQRAY 200MG DAILY PR NATAL 430 115 PRENAISSANCE PLUS 115 DOSE 36 PIQRAY 250MG DAILY PR NATAL 430 EC 115 prenatabs rx 113 DOSE 36 PRALUENT 29 PRENATAL 116 PIQRAY 300MG DAILY pramipexole PRENATAL + DHA 115 DOSE 36 dihydrochloride 39 prenatal 19 112 piroxicam 5 PRAMOSONE 61 PRENATAL 19 115,116 PLAN B ONE-STEP 52 PRAMOSONE E 61 PRENATAL PLUS 116 PLEGRIDY 129 PRAMOTIC 125 PRENATAL PLUS IRON 116 PLEGRIDY STARTER prasugrel hcl 73 PACK 129 PRENATAL VITAMINS PLUS pravastatin sodium 29 LOW IRON 116 PLENVU 76 praziquantel 11 PRENATAL-U 116 PNV OB+DHA 115 prazosin hcl 30 PRENATE 116 PNV TABS 29-1 115 PRECISION THINS GP PRENATE DHA 116 pnv-dha 113 LANCET 93 PRENATE ELITE 116 PNV-DHA+DOCUSATE 115 PRECISION XTRA BLOOD PRENATE ENHANCE 116 PNV-OMEGA 115 GLUCOSE TEST STRIPS 63 PRENATE ESSENTIAL 116 pnv-select 113 PRED-G 123 PRENATE MINI 116 PODOCON 25 IN BENZOIN PRED-G S.O.P. 123 TINCTURE 62 prednicarbate 61 PRENATE PIXIE 116 podofilox 62 prednisolone 52 PRENATE RESTORE 116 POLY HUB NEEDLE/30G X prednisolone acetate PRENATRIX 116 1/2" 106 (ophth) 123 PRENATRYL 116 poly-vi-flor 112 prednisolone acetate p-f 123 PREPIDIL 125 POLY-VI-FLOR 112 prednisolone sodium PREPLUS 116 POLY-VI-FLOR/IRON 112 phosphate 52 PREDNISOLONE SODIUM PRESSURE ACTIVATED polyethylene glycol 3350 76 PHOSPHATE 123 SAFETYLANCET 21G 94 polymyxin b-trimethoprim 122 PREDNISOLONE SODIUM prevalite 28 POMALYST 34 PHOSPHATE/MOXIFLOXACIN PREZCOBIX 42 posaconazole 27 123 PREZISTA 42,43 prednisone 53 pot & sod citrates w/citric ac 70 PRIFTIN 33 PREDNISONE INTENSOL 52 PRILOSEC 135 primaquine phosphate 32

Index 17 PRIMAXIN IV 12 propranolol & quinapril hcl 30 primidone 19 hydrochlorothiazide 31 quinapril-hydrochlorothiazide propranolol hcl 45 PRIMLEV 10 31 propylthiouracil 133 quinidine gluconate 13 PRIMSOL 11 PROSTIN E2 125 quinidine sulfate 13 PRIVIGEN 126 PRO COMFORT LANCETS protriptyline hcl 22 quinine sulfate 32 30G 94 PROVIDA DHA 116 QVAR REDIHALER 15 PRO COMFORT LANCETS pseudoephed-bromphen- R-NATAL OB 116 31G 94 dm 54 RA E-ZJECT COLOR PRO-RED AC 54 pseudoephed-cpm w/ LANCETSMICRO-THIN 33G 95 PROAIR RESPICLICK 16 hydrocod 54 RA E-ZJECT LANCETS 28G95 psorcon 59 probenecid 71 RA E-ZJECT LANCETS THIN PSS SELECT GP PROBUPHINE IMPLANT 26G 95 LANCETS 94 RA E-ZJECT LANCETS THIN KIT 10 PSS SELECT SAFETY procentra 1 28G 95 LANCETS 94 RA E-ZJECT LANCETS prochlorperazine 41 PULMICORT FLEXHALER15 ULTRATHIN 30G 95 prochlorperazine maleate 41 pulmosal 54 ra laxative 76,77 procto-med hc 11 PULMOZYME 132 RA PEN NEEDLES 31G X PROCTOFOAM HC 11 PURIXAN 33 5MM3/16" 106 PROCYSBI 70 PUSH BUTTON SAFETY rabeprazole sodium 136 PRODIGY PRESSURE LANCETS 21G 94 RABEPRAZOLE SODIUM DR ACTIVATED SAFETY PUSH BUTTON SAFETY SPRINKLE 135 LANCETS 94 LANCETS 28G 94 raloxifene hcl 66 PRODIGY SAFETY PX LANCETS ULTRA ramelteon 75 LANCETS 94 THIN 94 ramipril 30 PRODIGY TWIST TOP PX LANCETS ULTRA THIN LANCETS 94 28G 94 ranolazine 12 profeno 4 PX MINI PEN NEEDLES rasagiline mesylate 39 31GX5MM 106 PROFILNINE 73 RASUVO 3 PYLERA 136 PROFILNINE SD 73 RAVICTI 66 pyrazinamide 33 progesterone 127 READYLANCE SAFETY pyridostigmine bromide 32 LANCETS/21G/2.2MM 95 PROGESTERONE pyrimethamine 32 READYLANCE SAFETY CONCENTRATE 48 LANCETS/23G/1.8MM 95 progesterone micronized 127 QBRELIS 30 READYLANCE SAFETY PROGRAF 110 QC LANCETS SUPER LANCETS/26G/1.8MM 95 THIN 94 PROLATE 10 READYLANCE SAFETY QC LANCETS ULTRA LANCETS/28G/1.8MM 95 PROLENSA 124 THIN 94 READYLANCE SAFETY PROLIA 65 QC UNILET LANCETS LANCETS/30G/1.6MM 95 28G/ULTRA THIN 94 REALITY LANCETS 95 PROMACTA 74 QC UNILET LANCETS promethazine & 33G/MICRO THIN 94 REALITY TRIGGER LANCETS 95 phenylephrine 54 QINLOCK 36 promethazine hcl 28 REBIF 129 QSYMIA 1 promethazine w/codeine 54 REBIF REBIDOSE 129 QUARTETTE 51 promethazine-dm 54 REBIF REBIDOSE promethazine-phenylephrine- QUDEXY XR 19 TITRATIONPACK 129 codeine 54 quetiapine fumarate 40 REBIF TITRATION PACK 129 promethegan 28 QUFLORA FE RECOMBINATE 73 propafenone hcl 14 PEDIATRIC 112 RECTIV 11 QUFLORA GUMMIES 112 propantheline bromide 134 REGRANEX 63 QUFLORA PEDIATRIC 112 proparacaine hcl 123 relafen 4 QUILLIVANT XR 2

Index 18 relagard 136 rifampin 33 SAFETY LANCET RELENZA DISKHALER 44 RIFATER 32 28G/PRESSURE ACTIVATED 96 RELION INSULIN SYRINGE RIGHTEST GL300 SAFETY LANCET 0.5ML/31G X 15/64" 106 LANCETS 96 30G/PRESSURE RELION INSULIN SYRINGE riluzole 121 ACTIVATED 96 1ML/31GX15/64" 106 rimantadine hydrochloride 44 RELION INSULIN SYRINGE/U- SAFETY LANCETS 96 100/1ML/31G X 15/64" 106 RINVOQ 3 SAFETY LANCETS 21G 96 RELION LANCETS MICRO- risedronate sodium 65 SAFETY LANCETS 28G 96 THIN33G 95 risperidone 40 RELION LANCETS STANDARD SAFETY LET LANCETS 96 21G 95 risperidone m-tab 40 SAFETY SEAL LANCETS RELION LANCETS THIN ritonavir 43 28G 96 26G 95 SAFETY SEAL LANCETS rivastigmine 128 30G 97 RELION LANCETS ULTRA- rivastigmine tartrate 128 THIN30G 95 SAFYRAL 51 RELION ULTRA THIN RIXUBIS 73 salicylic acid 62 LANCETS/30G 95 rizatriptan benzoate 108 salicylic acid in ammonium RELION ULTRA THIN ROMIDEPSIN 36 lactate vehicle 62 LANCETS30G 95 salimez 62 RELION ULTRA THIN PLUS ropinirole hydrochloride 39 LANCETS 32G 96 rosadan 62 salitech forte 62 RELION ULTRA THIN PLUS rosuvastatin calcium 29 salsalate 7 LANCETS 33G 96 roweepra 17 SANCUSO 26 RELISTOR 69 roweepra xr 17 SANDIMMUNE 110 RELNATE DHA 116 ROXICET 10 SANDOSTATIN 67 REMICADE 69 ROZLYTREK 36 SANTYL 62 repaglinide 25 RUBRACA 36 SAPHRIS 40 repaglinide-metformin hcl 23 rufinamide 19 sapropterin dihydrochloride 66 REPATHA 30 RUZURGI 32 SAPS HEALTH CARE TWIST REPATHA PUSHTRONEX TOP LANCETS 97 SYSTEM 29 ryclora 27 SAPS HEALTH TWIST TOP REPATHA SURECLICK 30 RYDAPT 36 LANCETS 30G 97 RESCRIPTOR 43 RYTARY 39 SAPSCARE TWIST TOP LANCETS 30G 97 RESTASIS 122 RYVENT 27 SAVELLA 128 RESTASIS MULTIDOSE 122 SABRIL 20 SAVELLA TITRATION RETACRIT 74 SAFE-T-LANCE LOW FLOW PACK 128 25G 96 SAXENDA 1 RETEVMO 36 SAFE-T-LANCE NORMAL REVATIO 47 FLOW21G 96 SB LANCETS THIN 97 REVLIMID 110 SAFE-T-LANCE PLUS SB LANCETS ULTRA THIN 97 REXALL LANCETS ULTRA SAFETYLANCET HIGH scopolamine 26 FLOW 96 THIN 96 SE-NATAL 19 116 REXULTI 41 SAFE-T-LANCE PLUS SAFETYLANCET LOW SEASONIQUE 51 REYATAZ 43 FLOW 96 SECUADO 40 RHOFADE 63 SAFE-T-LANCE PLUS SELECT-OB 117 RIAX 55 SAFETYLANCET NORMAL SELECT-OB+DHA 117 ribasphere 43 FLOW 96 SAFETY LANCET selegiline hcl 39 ribavirin 44 21G/PRESSURE selenium sulfide 58 ribavirin (hepatitis c) 44 ACTIVATED 96 SELZENTRY 43 RIDAURA 4 SAFETY LANCET 23G/PRESSURE SEREVENT DISKUS 16 rifabutin 33 ACTIVATED 96 SEROSTIM 65 RIFAMATE 32

Index 19 sertraline hcl 21 sodium sulfacetamide SUBLOCADE 10 sevelamer carbonate 70 wash 58 SUBSYS 8 SODIUM SULFACETAMIDE sevelamer hcl 70 WASH 58 subvenite 17 SFROWASA 69 SODIUM subvenite starter kit/blue 17 SHOPKO ON-THE-GO SULFACETAMIDE/SULFUR SUCRAID 64 CLEANSER IN UREA 56 COMFORTLANCETS 30G 97 sucralfate 135 SHOPKO UNIFINE PENTIPS SOFOSBUVIR/VELPATASVIR PEN NEEDLES/MINI/31GX5MM 44 sulconazole nitrate 57 106 solifenacin succinate 136 sulfacetamide sod- SHOPKO UNIFINE PENTIPS SOLTAMOX 34 prednisolone 123 PLUS PEN SOLUS V2 PRESSURE sulfacetamide sodium 58 NEEDLES/MINI/REMOVER/31G ACTIVATED SAFETY sulfacetamide sodium (acne)56 X5MM 106 LANCETS 28G 97 sulfacetamide sodium SHOPKO UNILET LANCETS SOLUS V2 TWIST LANCETS (ophth) 122 SUPER THIN 30G 97 30G 98 sulfacetamide sodium w/ SHOPKO UNILET LANCETS SOMAVERT 65 sulfur 56 ULTRA THIN 28G 97 SULFADIAZINE 132 SHUR-SEAL 137 SOOLANTRA 63 SORILUX 58 sulfamethoxazole-trimethoprim SIDE BUTTON SAFETY 11 LANCET21G 97 sorine 45 SULFAMYLON 58 SIGNIFOR 67 sotalol hcl 45 sulfasalazine 69 SIKLOS 74 sotalol hcl (afib/afl) 45 sulfatrim pediatric 11 sildenafil citrate 46 SOTYLIZE 45 sulindac 5 sildenafil citrate (pulmonary SOVALDI 44 hypertension) 47 sumatriptan 108 silodosin 71 SPIRIVA HANDIHALER 14 sumatriptan succinate 108 silver sulfadiazine 58 SPIRIVA RESPIMAT 14 SUPER THIN LANCETS 98 SIMBRINZA 122 spironolactone 64 SUPRAX 48 spironolactone & simvastatin 29 hydrochlorothiazide 64 SUPREP BOWEL PREP KIT76 SINGLE-LET 97 SPRAVATO 56MG DOSE 21 SURE COMFORT LANCETS 18G 98 sirolimus 110 SPRAVATO 84MG DOSE 21 SURE COMFORT LANCETS SIVEXTRO 12 SPRIX 5 21G 98 SKYRIZI 58 SPRYCEL 36 SURE COMFORT LANCETS SLYND 52 23G 98 ssd 58 SURE COMFORT LANCETS SM MICRO THIN LANCETS sss 10-5 55 28G 98 33G 97 SURE COMFORT LANCETS SMART SENSE COLOR ST JOSEPH ADULT 7 30G 98 LANCETS UNIVERSAL 33G 97 ST JOSEPH ADULT ANALGESICLOW DOSE BITE SURE COMFORT PEN SMART SENSE STANDARD NEEDLES31GX3/16" LANCETS UNIVERSAL 21G 97 SIZE 7 SMART SENSE SUPER THIN (5MM) 106 stavudine 43 SURE-FINE PEN NEEDLES LANCETS UNIVERSAL 30G 97 STELARA 58,69 SMART SENSE THIN 31GX3/16" 5MM 106 SURE-LANCE FLAT LANCETSUNIVERSAL 26G 97 STERILANCE TL 98 STIMATE 67 LANCETS 98 SMARTEST LANCETS 28G 97 SURE-LANCE LANCETS sodium chloride 109 STIOLTO RESPIMAT 16 26G 98 sodium chloride (inhalant) 54 STIVARGA 37 SURE-LANCE THIN LANCETS STRENSIQ 66 28G 98 sodium citrate & citric acid 70 SURE-LANCE ULTRA THIN sodium fluoride 109 streptomycin sulfate 2 LANCETS 98 sodium phenylbutyrate 66 STRIANT 10 SURE-TOUCH LANCETS sodium polystyrene STRIBILD 43 UNIVERSAL 98 sulfonate 110 STRIVERDI RESPIMAT 16 SURELITE LANCETS 98

Index 20 SUTENT 37 TEGRETOL-XR 19 TIMOPTIC-XE 121 SYLATRON 38 TEGSEDI 132 tinidazole 11 SYMDEKO 132 TEKTURNA HCT 31 TIVICAY 43 SYMJEPI 138 telmisartan 30 tizanidine hcl 119 SYMLINPEN 120 22 telmisartan-amlodipine 31 TL-CARE DHA 117 SYMLINPEN 60 22 telmisartan-hydrochlorothiazide TL-SELECT 117 SYMTUZA 43 31 TOBI PODHALER 2 temazepam 75 SYNAREL 66 TOBRADEX 124 TEMIXYS 43 SYNDROS 27 TOBRADEX ST 124 temozolomide 33 SYNJARDY 23 tobramycin 2 temsirolimus 37 SYNJARDY XR 23 tobramycin (ophth) 122 tenofovir disoproxil SYNTHROID 133,134 fumarate 43 tobramycin sulfate 3 SYPRINE 110 terazosin hcl 30 tobramycin- dexamethasone 124 TABLOID 33 terbinafine hcl 27 TOBREX 122 TABRECTA 37 terbutaline sulfate 16 TODAY SPONGE 137 tacrolimus 110 terconazole vaginal 137 TODAYS HEALTH SUPER tacrolimus (topical) 62 TESTIM 10 THINLANCETS 30G 99 tadalafil (pulmonary testosterone 10,11 TODAYS HEALTH ULTRA hypertension) 47 tetrabenazine 128 THINLANCETS 28G 99 TAFINLAR 37 tolbutamide 25 tetracaine hcl (ophth) 123 TAGRISSO 37 tolcapone 38 tetracycline hcl 133 TALZENNA 37 tolmetin sodium 5 TEXACORT 61 tamoxifen citrate 34 TGT LANCET MICRO THIN TOLSURA 27 tamsulosin hcl 71 33G 98 tolterodine tartrate 136 TANZEUM 24 TGT LANCET THIN 26G 99 TOPAMAX 19 TARGRETIN 38,57 TGT LANCET ULTRA THIN TOPAMAX SPRINKLE 19 TARON-BC 117 30G 99 TOPCARE LANCETS MICRO- TARON-C DHA 117 THALOMID 110 THIN 33G 99 TARON-PREX 117 THEO-24 16 topiramate 19 TASIGNA 37 theophylline 16 toposar 38 THERANATAL CORE TAVALISSE 73 topotecan hcl 38 NUTRITION 117 toremifene citrate 34 TAYTULLA 51 THINLETS GP LANCETS 99 TORISEL 37 tazarotene 58 THIOLA 71 torsemide 64 TAZORAC 58 THIOLA EC 71 TOUJEO MAX SOLOSTAR 25 taztia xt 45 thioridazine hcl 41 TOUJEO SOLOSTAR 25 TAZVERIK 37 thiothixene 41 tovet 59 TECHLITE AST LANCETS 98 THRIVITE 19 111 TOVIAZ 136 TECHLITE INSULIN SYRINGEU- THRIVITE RX 117 100/0.5ML/31G X 15/64" 106 TRACLEER 47 THYMOGLOBULIN 110 TECHLITE INSULIN SYRINGEU- tramadol hcl 8 100/1ML/31G X 15/64" 106 thyroid 134 tramadol-acetaminophen 10 TECHLITE LANCETS 98 tiagabine hcl 20 trandolapril 30 TECHLITE LANCETS 30G 98 TIBSOVO 37 trandolapril-verapamil hcl 32 TECHLITE PEN NEEDLES 31GX tilia fe 50 5MM 106 tranexamic acid 75 timolol maleate 45 TECHLITE PEN NEEDLES/31GX tranylcypromine sulfate 21 timolol maleate (ophth) 121 5MM 106 TRAVEL LANCETS 30G 99 TEGRETOL 19 TIMOPTIC OCUDOSE 121

Index 21 TRAVEL LANCETS ADVANCED TRISTART ONE 117 ULTIGUARD SAFEPACK/MINI 28G 99 TRIUMEQ 43 PEN NEEDLE/31G X travoprost 125 3/16"/SHARPS CONTAI 107 TROKENDI XR 19 trazodone hcl 21 ULTILET CLASSIC tropicamide 121 LANCETS 99 TRECATOR 33 trospium chloride 136 ULTILET INSULIN SYRINGE/U- TRELEGY ELLIPTA 16 TRUE COMFORT PEN 100/0.5ML/31GX6MM 107 TREMFYA 58 NEEDLES31G X 5MM 106 ULTILET LANCETS 100 TRESIBA 25 TRUE COMFORT TWIST TOP ULTILET LANCETS 33G 100 TRESIBA FLEXTOUCH 25 LANCETS 30G 99 ULTILET PEN NEEDLE TRUEPLUS 5-BEVEL PEN 31GX5MM 107 tretinoin 56 NEEDLES 31GX5MM 106 ULTILET SAFETY LANCETS tretinoin (chemotherapy) 38 TRUEPLUS LANCETS 21G X 2.2MM 100 tretinoin microsphere 56 26G 99 ULTILET SAFETY LANCETS TRUEPLUS LANCETS TRETTEN 73 23G 100 28G 99 ULTILET SHORT PEN TREXALL 33 TRUEPLUS LANCETS 28G NEEDLES31GX3/16" 107 tri femynor 50 SUPER THIN 99 ULTIMATECARE ONE 117 TRI-NORINYL 28 51 TRUEPLUS LANCETS ULTRA THIN LANCETS 30G 99 TRI-TABS DHA 117 31G 100 TRUEPLUS LANCETS 30G ULTRA-CARE LANCETS TRI-VI-FLOR 112 ULTRA THIN 99 30G 100 TRI-VI-FLORO 112 TRUEPLUS LANCETS ULTRA-THIN II AUTO 33G 99 LANCET 100 tri-vite/fluoride 112 TRUEPLUS LANCETS 33G triamcinolone acetonide ULTRA-THIN II LANCETS MICRO THIN 99 28G 100 (mouth) 111 TRUEPLUS PEN NEEDLES triamcinolone acetonide ULTRA-THIN II LANCETS 31GX5MM 106 30G 100 (nasal) 121 TRUEPLUS SAFETY triamcinolone acetonide ULTRA-THIN II MINI PEN LANCETS 28G 99 NEEEDLES/31GX3/16" 107 (topical) 61 TRULICITY 24 triamterene 64 ULTRACARE PEN TRUVADA 43 NEEDLES/31G X 3/16" 107 triamterene & hydrochlorothiazide 64 TUKYSA 37 UNASYN 127 triazolam 75 TURALIO 37 UNASYN BULK PACK 127 TRICARE 117 TUSNEL 54 UNIFINE PENTIPS 31G X 3/16" 107 TRICARE PRENATAL DHA TUSSICAPS 54 UNIFINE PENTIPS ONE 117 TUSSLIN 54 31GX5MM 107 TRICARE PRENATAL DHA UNIFINE PENTIPS PLUS ONE/FOLATE 117 TUSSLIN PEDIATRIC 54 TWIRLA 51 31GX5MM 107 triderm 59 UNILET COMFORTOUCH trientine hcl 110 TYBOST 43 LANCET 100 trifluoperazine hcl 41 tydemy 49 UNILET EXCELITE 100 trifluridine 122 TYKERB 37 UNILET EXCELITE II 100 TRIGLIDE 29 TYMLOS 65 UNILET G.P. LANCET 100 trihexyphenidyl hcl 38 TYSABRI 129 UNILET G.P. SUPERLITE TYVASO 46 LANCET 100 TRIKAFTA 132 UNILET GP 28 ULTRA TRILEPTAL 19 TYVASO REFILL 46 THIN 100 trimethobenzamide hcl 26 TYVASO STARTER 47 UNILET LANCET 100 trimethoprim 11 UCERIS 11 UNILET LANCETS MICRO- UDENYCA 74 THIN33G 100 trimipramine maleate 22 UNILET LANCETS SUPER- TRINATAL RX 1 117 ULTICARE PEN NEEDLES 31GX 5MM 106 THIN30G 100 TRINTELLIX 22 ULTICARE PEN NEEDLES UNILET LANCETS ULTRA-THIN TRISTART DHA 117 31GX 5MM/MINI 107 28G 101

Index 22 UNILET SUPERLITE VASCEPA 28 virtussin ac/alc 53 LANCET 101 VCF VAGINAL VISTOGARD 26 UNISTIK 3 GENTLE 101 CONTRACEPTIVE FILM 137 VITAFOL FE+ 118 UNISTIK PRO SAFETY LANCET VCF VAGINAL 21G 101 CONTRACEPTIVE VITAFOL GUMMIES 118 UNISTIK PRO SAFETY LANCET FOAM 137 VITAFOL-NANO 118 25G 101 VCF VAGINAL VITAFOL-ONE 118 UNISTIK PRO SAFETY LANCET CONTRACEPTIVEGEL 137 VITALET PRO LANCETS 102 28G 101 VECAMYL 32 VITALET PRO PLUS UNISTIK SAFETY LANCETS VELCADE 37 28G 101 LANCETS 102 UNISTIK SAFETY LANCETS VELTIN 56 VITAMEDMD ONE 30G 101 VEMLIDY 44 RX/QUATREFOLIC 118 VITAMEDMD REDICHEW UNISTIK TOUCH SAFETY VENA-BAL DHA 117 LANCETS 21G 101 RX 118 UNISTIK TOUCH SAFETY VENCLEXTA 33 VITAPEARL 118 LANCETS 23G 101 VENCLEXTA STARTING VITATHELY/GINGER 118 PACK 33 UNISTIK TOUCH SAFETY VITATRUE 118 LANCETS 28G 101 venlafaxine hcl 22 UNISTIK TOUCH SAFETY VENTAVIS 47 VITRAKVI 37 LANCETS 30G 101 verapamil hcl 46 VIVA DHA 118 UNIVERSAL 1 LANCETS VIVAGUARD LANCETS 102 THIN26G 101 VEREGEN 56 UNIVERSAL 1 LANCETS ULTRA VERELAN 46 VIZIMPRO 37 THIN 30G 101 VERELAN PM 46 VOL-PLUS 118 UNIVERSAL 1 VERSACLOZ 41 VOL-TAB RX 118 LANCETS/33G/MICRO-THIN VONVENDI 73 101 VERZENIO 37 UPTRAVI 47 VIBERZI 69 voriconazole 27 urea 61 VIBRAMYCIN 133 VOSEVI 44 urea hydrating 61 VICTOZA 24 VOTRIENT 37 ursodiol 68 VIDA MIA UNILET LANCETS VP-HEME OB + DHA 118 valacyclovir hcl 44 SUPER THIN 30G 102 VP-PNV-DHA 119 VIDA MIA UNILET LANCETS VRAYLAR 40 VALCHLOR 57 ULTRA THIN 28G 102 VYNDAMAX 48 valganciclovir hcl 43 VIDEX EC 43 VYNDAQEL 48 valproate sodium 20 VIDEXPEDIATRIC 43 VYVANSE 1 valproic acid 20 vigabatrin 20 WALGREENS ADVANCED valsartan 30 vigadrone 20 TRAVELLANCETS 28G 102 valsartan-hydrochlorothiazide VIIBRYD 22 WALGREENS COMFORT 32 VIIBRYD STARTER PACK 22 ASSUREDLANCETS MICRO VALUE PLUS LANCETS THIN/33G 102 STANDARD 21G 101 VIL-RX 117 WALGREENS COMFORT VALUE PLUS LANCETS VIMPAT 19,20 ASSUREDLANCETS SUPER SUPERTHIN 30G 101 THIN/28G 102 VALUE PLUS LANCETS THIN VINATE DHA RF 117 26G 101 VINATE ONE 118 WALGREENS LANCETS 102 VALUMARK LANCET SUPER VIOKACE 64 WALGREENS THIN LANCETS 102 THIN 30G 102 VIRACEPT 43 VALUMARK LANCET ULTRA WALGREENS ULTRA THIN THIN 28G 102 VIREAD 43 LANCETS 102 vanadom 119 VIRT-C DHA 118 warfarin sodium 16 vancomycin hcl 12 VIRT-NATE DHA 118 WEGMANS UNIFINE PENTIPS PLUS/MINI/31GX5MM 107 VIRT-PN 118 vandazole 137 WESTAB PLUS 119 VIRT-PN DHA 118 vardenafil hcl 46 WESTGEL DHA 119 VARUBI 27 VIRT-PN PLUS 118

Index 23 WESTHROID 134 YAZ 51 WIDE-SEAL SILICONE YONSA 34 DIAPHRAGM KIT 60 78 yuvafem 137 WIDE-SEAL SILICONE DIAPHRAGM KIT 65 78 zafirlukast 14 WIDE-SEAL SILICONE zaleplon 75 DIAPHRAGM KIT 70 78 ZARONTIN 20 WIDE-SEAL SILICONE DIAPHRAGM KIT 75 78 ZARXIO 74 WIDE-SEAL SILICONE ZATEAN-PN DHA 119 DIAPHRAGM KIT 80 78 ZATEAN-PN PLUS 119 WIDE-SEAL SILICONE ZAVESCA 74 DIAPHRAGM KIT 85 78 WIDE-SEAL SILICONE ZEJULA 37 DIAPHRAGM KIT 90 78 ZELAPAR 39 WIDE-SEAL SILICONE ZELBORAF 37 DIAPHRAGM KIT 95 78 zenatane 54,55 WILATE 73 ZENPEP 64 wixela inhub 15 zenzedi 1 WP THYROID 134 zidovudine 43 XADAGO 39 ZIEXTENZO 74 XALKORI 37 zileuton 14 XARELTO 16 ZIOPTAN 125 XARELTO STARTER PACK 16 ziprasidone hcl 40 XATMEP 33 ZIRGAN 122 XELJANZ 3 ZOLINZA 37 XELJANZ XR 3 zolmitriptan 108 XENAZINE 128 zolpidem tartrate 75 XENICAL 1 ZOMIG 108 XERAC AC 62 ZONEGRAN 20 XERMELO 70 zonisamide 20 XIFAXAN 11 ZORBTIVE 65 XIGDUO XR 23 ZORTRESS 110 XIMINO 133 ZOSYN 127 XOLAIR 14 ZUPLENZ 26 XOSPATA 37 XPOVIO 100 MG ONCE ZYBAN 132 WEEKLY 34 ZYDELIG 37 XPOVIO 60 MG ONCE ZYFLO 14 WEEKLY 34 XPOVIO 80 MG ONCE ZYKADIA 37 WEEKLY 34 ZYLET 124 XPOVIO 80 MG TWICE ZYTIGA 34 WEEKLY 34 XTANDI 34 xulane 51 XURIDEN 66 XYNTHA 73 XYNTHA SOLOFUSE 73 XYREM 127 YASMIN 28 51

Index 24