Contra Costa Health Plan (CCHP) MEDI-CAL & COMMERCIAL HMO Formulary

Last updated: August 1, 2021 Note: The CCHP formulary is subject to change, and all previous versions are no longer in effect. o To access the electronic version of the CCHP formulary on the health plan’s website, please go to the following web address: https://cchealth.org/healthplan/pdf/pdl.pdf o To access the CCHP interactive formulary search tool, please go to the following web address: https://formularynavigator.com/Search.a spx?siteID=MMRREQ3QBC o To access plan-specific coverage information including cost sharing information, member handbook, and other important materials such as your Evidence of Coverage (EOC) documents, please go to the following web address: https://cchealth.org/healthplan/member-publications.php Table of Contents:

Informational Section (ENGLISH) i-xi Sección Informativa (ESPAÑOL) a-m Antihistamine Drugs - Drugs For Allergy 1 Anti-Infective Agents - Drugs For Infections 4 Antineoplastic Agents - Drugs For Cancer 15 Antitoxins,Immune Glob,Toxoids,Vaccines - Drugs For The Immune System 19 Autonomic Drugs - Drugs For The Nervous System 22 Blood Formation, Coagulation, Thrombosis - Drugs For The Blood 28 Cardiovascular Drugs - Drugs For The Heart 31 Central Nervous System Agents - Drugs For The Nervous System 49 Contraceptives (E.G. Foams, Devices) - Drugs For Women 65 Devices - Medical Supplies And Durable Medical Equipment 67 Diagnostic Agents 68 Electrolytic, Caloric, And Water Balance 68 Enzymes 73 Eye, Ear, Nose And Throat (Eent) Preps 73 Gastrointestinal Drugs 78 Gastrointestinal Drugs - Drugs For The Stomach 79 Gold Compounds 83 Heavy Metal Antagonists - Drugs To Reduce Iron 83 Hormones And Synthetic Substitutes - Hormones 84 Local Anesthetics (Parenteral) - Drugs For Numbing 95 Miscellaneous Therapeutic Agents 95 Oxytocics - Drugs For Women 100 Pharmaceutical Aids 101 Respiratory Tract Agents - Drugs For The Lungs 101 Skin And Mucous Membrane Agents - Drugs For The Skin 109 Smooth Muscle Relaxants - Drugs To Relax Muscles 119 Vitamins 120 Index of Prescription Drugs 125 Frequently Asked Questions

What is the CCHP formulary? The CCHP formulary (also known as the CCHP preferred drug list, or PDL) includes drugs used to treat common diseases or health problems. This formulary applies only to outpatient drugs and self-administered drugs – it does not apply to medications used in the inpatient setting or in medical offices.

The formulary is a continually reviewed and revised list of preferred medications based on safety, efficacy, and cost-effectiveness. It is updated on a monthly basis and is effective the first of every month. Updates are based on input from a team of doctors and pharmacists that meet regularly to decide which drugs should be included. These updates may include, but are not limited to the following: (i) removal or addition of drugs and/or dosage forms. (ii) changes in tier placement of a drug (iii) changes to utilization management restrictions (such as quantity limits, step therapy, etc.). Updated documents are available online at: https://www.cchealth.org.

How do I use the CCHP formulary? The list of formulary drugs begins on Page 1. To locate a drug on the formulary, simply look for the name of the drug in the index at the end of this booklet - the index lists all of the drugs on the formulary, including brand name and generic name. Once you have located the name of the drug in the index, you will see the page number where you can find more information about your drug listed next to it.

Instead of using the index, the formulary can also be searched by using ctrl+F to find a specific medication by brand name, generic name, or therapeutic class.

A mobile-enabled version of the CCHP formulary is also available using the ePocrates application. After you have downloaded the application to your mobile device, simply choose the “Contra Costa Health Plan Medi-Cal” formulary to display the formulary status of drugs within the application. If you have any questions about the installation or use of the Epocrates application, please contact Epocrates Customer Support at (800)230-2150 or [email protected].

The presence of a prescription drug on the CCHP formulary does not guarantee that a member will be prescribed that medication by his or her prescribing provider for a particular medical condition. The absence of a drug on the CCHP means that the drug

i is not on the formulary, and will require prior authorization to be covered (specific information about the CCHP prior authorization process is located below in the section titled “What if the drug that I need isn’t listed on the CCHP formulary?”)

How are drugs listed on the formulary?

Drugs are listed alphabetically by brand and generic name within the therapeutic category and class to which they belong. Brand name drugs will appear in all CAPITAL letters, with the generic name listed in parentheses after the brand name in all bold and italicized lowercase letters. If a generic drug is available, it will be listed separately from the brand name drug, and will always be listed in bold and italicized lowercase letters. If a generic equivalent of a brand name drug is not available, then the generic drug will not be listed separately from the brand name drug. In situations where an FDA approved generic equivalent is available, brand names are listed for reference purposes only, and do not denote coverage for the brand, unless specifically noted.

An example listing from the CCHP formulary is below:

What if the drug that I need isn’t listed on the CCHP formulary? If your drug isn’t listed on the CCHP formulary you can ask your doctor if there is a different drug on the formulary that will work the same way. If your doctor decides that you need a drug that is not on the formulary, they can ask CCHP to make an exception through the prior authorization process. All prior authorization requests will be evaluated by a health plan clinician (pharmacist or medical doctor) based upon CCHP prior authorization criteria that is approved by the CCHP Pharmacy and Therapeutics (P&T) committee. In instances where specific criteria do not exist, FDA indications, peer reviewed literature, other plan criteria, national treatment guidelines (such as IDSA, NCCN, AACE, etc.), and other medical compendia will be used for evaluation. Exceptions can be made for a variety of different reasons:

 Your doctor can ask CCHP to cover a drug that is listed on the formulary as requiring a prior authorization (PA): these drugs require approval prior to being dispensed at a network pharmacy. Each request will be reviewed by a health plan clinician, and if the request does not meet the guidelines established by the plan it will not be approved, and alternative therapy may be recommended. ii  Your doctor can ask CCHP to cover a drug that isn’t listed on the formulary: any drug not found on this list is considered non-formulary. Coverage for non-formulary agents may be requested by the prescriber. Each request will be reviewed by a health plan clinician, and approval will be given if a documented medical need exists and if there isn’t an alternate agent on the formulary.  Your doctor can ask CCHP to make an exception to limits on a drug. For example, if a drug has a limit of 1 tablet per day, your doctor can ask us to cover more. If quantities exceeding the limit are necessary, an exception to coverage may be requested by the prescriber. Each request will be reviewed by a health plan clinician, and approval will be given if a documented medical need exists without compromising safety.  Your doctor can ask CCHP to make an exception to Step Therapy (ST) requirements: these drugs require one or more first step drugs to be tried before progressing to the second step drug (for example, if Drug A and Drug B both treat your health condition, CCHP may not cover Drug B unless you try Drug A first). 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. Each request will be reviewed by a health plan clinician, and approval will be given if a documented medical need exists. 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 CCHP, you will not have to try the preferred drugs again. Your doctor can simply request an approval through the plan for continuation of therapy.

To start the CCHP prior authorization process or to ask for an exception, your doctor must fax a prior authorization request to CCHP at 1-866-428-7369 for urgent requests, or 1-866-205-8014 for standard requests. Your doctor may also be able to submit the request electronically to CCHP using the electronic medical record. If the request is approved, you will be able to get your medication filled at a pharmacy that works with CCHP. If we deny the request we will send you and your doctor a letter and will tell you how to file an appeal or a grievance. An “appeal” is when you want a decision to be reviewed again by the health plan (usually with additional information), and a “grievance” is a complaint or concern regarding the health plan.

CCHP will make a decision to deny or approve all prior authorization and exception requests within 24 hours of receiving the request. If CCHP fails to respond to a prior authorization or step therapy request within 72 hours of receiving a non-urgent request or 24 hours of receiving a request based on exigent circumstances, the request shall be deemed approved.

CCHP will provide coverage pursuant to a non-urgent request for the duration of the prescription, including refills. CCHP will provide coverage, including refills, pursuant to a request based on exigent circumstances for the duration of the exigency.

iii If you would like to download the CCHP prior authorization form, it is available at: https://cchealth.org/healthplan/pdf/performrx_medication_prior_auth_form.pdf

What if I need my medication urgently – do pharmacies have the ability to fill emergency supplies of medication?

Yes. To ensure that CCHP members have access to a sufficient supply of medications in emergency situations, CCHP has established an Emergency Supply Policy that allows pharmacists to use their clinical judgement to override claims that deny at the point of sale. When a pharmacist determines that a medication is medically necessary, they may enter an authorization code that allows them to fill a 5-day emergency supply of medication for any CCHP member. CCHP promotes the use of the Emergency Supply Policy through point-of-sale messaging. Instead of using the 5-day Emergency Supply Policy, pharmacies may also choose to call the PerformRx provider call center at 877-234-4269 – representatives are available 24 hours per day, 365 days per year. Staff at the call center have the ability to override prescriptions based on guidance provided by CCHP. What if I’m a new CCHP member?

If you are a new CCHP member you may be taking drugs that are not on our formulary, or you may be taking drugs that are on our formulary but have limits. If possible, you should talk to your doctor to see if you can change to a preferred drug on the CCHP formulary. If you cannot switch to a preferred drug, then your doctor will need to ask CCHP for an exception to cover a drug you have been taking (known as continuation of therapy). See the section above titled “What if the drug that I need isn’t listed on the CCHP formulary?” for more information.

Does CCHP cover generic and brand name medications?

CCHP covers brand and generic drugs, but when a generic drug is available CCHP requires that it be used. All drugs that become available generically are subject to review by the CCHP Pharmacy & Therapeutics committee.

A prescriber may request a brand name product in lieu of an approved generic if the prescriber determines that there is a documented medical need for the brand equivalent. This type of request for coverage may be made through the CCHP prior authorization process described above in the section titled “What if the drug that I need isn’t listed on the CCHP formulary.”

Are there drugs that are excluded from coverage? The CCHP Medi-Cal formulary is very similar to the California Medi-Cal List of Contract Drugs. The following types of drugs are generally not a covered benefit for Medi-Cal members (please note that this list is subject to change):

iv  Erectile or sexual dysfunction drugs  Drugs used for cosmetic reasons or hair growth  Drugs that are considered experimental, or that are being used in an experimental manner  Drugs used to treat infertility  Drugs specifically listed as “not covered” on the formulary  Foreign drugs or drugs not approved by the United States Food & Drug Administration (FDA) If CCHP’s coverage is amended to exclude a drug that we have been covering and providing to you under your current coverage, we will continue to provide the drug if a plan physician continues to prescribe the drug for the same condition and for a use approved by the Food and Drug Administration.

Some drugs are carved-out by the Department of Health Care Services. This means that these drugs are covered by the Medi-Cal Fee-for-Service program for Medi-Cal members, not by CCHP. The following types of drugs are carved-out:  Antipsychotic medications  HIV/AIDS medications  Select alcohol, heroin detoxification, and dependency treatment drugs  Select drugs to treat hemophilia

Can I go to any pharmacy for my medication? No, members must use a pharmacy that is in the CCHP network. To find a network pharmacy, visit the CCHP website or call the health plan directly to have one of our member services or pharmacy staff help you locate a pharmacy near you (see section below titled “How do I find a pharmacy?”).

How do I find a pharmacy? To find a pharmacy near you, visit the CCHP website at https://cchealth.org/healthplan/. Once you have navigated to the CCHP website, follow the directions below:

(1) Scroll down and click on the “Search Doctors/Clinics/Pharmacies in My Area” button (2) Click on the red “Begin Your Search Here” button (a new window will pop up) (3) Click on the “Facility” tab, and choose “Pharmacy” as the facility type (4) Choose how you want to search (by zip code, distance, etc.) (5) Click “Find a Facility” - results will immediately show up (as a map and a list)

Be sure to show your CCHP Member ID card when you fill your prescriptions at the pharmacy.

Note: some medications are subject to limited distribution by the U.S. Food and Drug Administration. These types of drugs are called “specialty medications” because they require special handling, provider coordination, or special education that may not be v provided at your local pharmacy. CCHP has a contract with Walgreens to provide these types of medications. If you have specific questions about these types of drugs please contact the CCHP pharmacy unit directly.

What drugs are covered by CCHP?

You can get the following drugs and other items when they are prescribed by your doctor and are medically necessary:

 Prescription drugs listed on the CCHP formulary  Non-prescription drugs or over-the-counter drugs (such as cough/cold syrups, cough drops or aspirin) listed on the CCHP formulary  Formulary diabetic supplies: insulin, insulin syringes, glucose test strips, lancets and lancet puncture devices, pen delivery systems, and blood glucose monitors  FDA-approved birth control and contraceptives listed on the CCHP formulary  Emergency contraception  Epi-Pens, peak flow meters and spacers

Are intravenous (IV) and injectable drugs covered by CCHP?

Yes, the CCHP formulary lists certain injectable products that are covered as a pharmacy benefit. CCHP also covers most other intravenous medications through the medical benefit. Medications that are generally covered through the medical benefit are those that are given in a doctor’s office, clinic, or hospital setting. Requests for coverage of a medication through the medical benefit should be directed to the CCHP Utilization Management Department by downloading the medical referral form at https://cchealth.org/healthplan/providers/ and faxing to (925) 313-6058 for routine requests or (925) 313-6458 for urgent requests.

Coverage of intravenous and injectable drugs through the pharmacy benefit are outlined below:

 Simple intravenous solutions: simple intravenous solutions are typically used for hydration therapy. Included are commercially available (non-compounded) solutions such as Normal Saline, Dextrose (up to 10% in Water) and Lactated Ringer’s Solution; commercially prepared solutions of potassium chloride in such solutions are also included in this definition. Simple intravenous solutions should be billed using the product’s National Drug Code (NDC) number.  Parenteral nutrition solutions (TPN or hyperalimentation): restricted to dispensing within 10 days following inpatient discharge from an acute care hospital, when (IV) therapy with the same product was started before discharge. There is a maximum of 10 days supply per dispensing within this 10-day period. (Parenteral nutrition solutions are intravenously or intra-arterially administered nutritional products that typically are suspensions or solutions of amino acids or protein, dextrose, lipids, electrolytes, vitamin &/or mineral supplements and trace elements.) Adjuncts to

vi parenteral nutrition are other drugs which are physically mixed into a parenteral nutrition solution at any time prior to administration. Bill for these products as part of the parenteral nutrition billing. Note: Non-compounded products must be billed using the product’s NDC number. Compounded solutions must be billed as a compound claim.  Separately administered intravenous lipids: restricted to dispensing within 10 days following inpatient discharge from an acute care hospital, when (IV) therapy with the same product was started before discharge. There is a maximum of 10 days supply per dispensing within this10-day period. Intravenous lipid solutions or suspensions that are administered separately from parenteral nutrition solutions (that is, are not physically mixed into the parenteral nutrition solution container) should be billed using the product’s NDC number.  Intravenous solutions of unlisted antibiotics: restricted to dispensing within 10 days following inpatient discharge from an acute care hospital, when IV therapy with the same antibiotic was started before discharge. There is a maximum of 10 days supply per dispensing within the 10-day period. Note: Non-compounded products must be billed using the product’s NDC number. Compounded solutions must be billed as a compound claim.  Intravenous solutions of other unlisted drugs: restricted to dispensing within 10 days following inpatient discharge from an acute care hospital, when IV therapy with the same drug was started before discharge. There is a maximum of 10 days supply per dispensing within the10-day period. Note: Non-compounded products must be billed using the product’s NDC number. Compounded solutions must be billed as a compound claim.

How Much I Will Pay for My Drugs? For all CCHP Medi-Cal members, you do not have to pay for covered services; medications are available with no copay. CCHP commercial members (plans such as commercial plan A, plan B, IHSS, etc.) may have small copays for their medications. Please see your plan materials to determine if you have a copay.

Can providers make suggestions to CCHP to improve the formulary? Absolutely. The formulary is a tool to promote cost-effective prescription drug use. CCHP has made every attempt to create a document that meets all therapeutic needs, however the art of medicine makes this a formidable task. CCHP welcomes the participation of physicians, pharmacists, and ancillary medical providers in this dynamic process. Physicians and pharmacists are highly encouraged to direct any suggestions or comments to CCHP via e-mail at: [email protected].

What if I need more information?

vii For more information about your pharmacy benefits, please review your Evidence of Coverage documents or call CCHP directly to discuss. CCHP member services department and pharmacy department staff are available to answer questions Monday through Friday from 8:00am to 5:00pm Pacific Time at the phone numbers listed below: CCHP Member Services Department: (877) 661-6230 x2 CCHP Pharmacy Department: (877) 661-6230 x3

viii Definitions & Abbreviations:

There are a number of terms that are used in this document that Contra Costa Health Plan wants to make sure that you understand. Below are some definitions and abbreviations:

“Brand name drug” is a drug that is marketed under a proprietary, trademark protected name. The brand name drug is listed in all CAPITAL letters.

“Coinsurance” is a percentage of the cost of a covered health care benefit that an enrollee pays after the enrollee has paid the deductible, if a deductible applies to the health care benefit, such as the prescription drug benefit.

“Copayment” is a fixed dollar amount that an enrollee pays for a covered health care benefit after the enrollee has paid the deductible, if a deductible applies to the health care benefit, such as the prescription drug benefit.

“Deductible” is the amount an enrollee pays for covered health care benefits before the enrollee's health plan begins payment for all or part of the cost of the health care benefit under the terms of the policy.

“Drug Tier” is a group of prescription drugs that corresponds to a specified cost sharing tier in the health plan's prescription drug coverage. The tier in which a prescription drug is placed determines the enrollee's 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 prescription drug. If an enrollee, his or her designee, or prescribing healthcare provider submits an exception request for coverage of a prescription drug, the health plan must cover the prescription drug when the drug is determined to be medically necessary to treat the enrollee's condition.

“Exigent circumstances” are when an enrollee is suffering from a health condition that may seriously jeopardize the enrollee's life, health, or ability to regain maximum function, or when an enrollee is undergoing a current course of treatment using a non- formulary drug.

“Formulary” is the complete list of drugs preferred for use and eligible for coverage under a health plan product, and includes all drugs covered under the outpatient prescription drug benefit of the health plan product. Formulary is also known as a prescription drug list,

ix “Generic drug” is the same drug as its brand name equivalent in dosage, safety, strength, how it is taken, quality, performance, and intended use. A generic drug is listed in bold and italicized lowercase letters.

“Nonformulary drug” is a prescription drug that is not listed on the health plan's formulary.

“Out-of-pocket cost” are copayments, coinsurance, and the applicable deductible, plus all costs for health care services that are not covered by the health plan.

“Prescribing provider” is a health care provider authorized to write a prescription to treat a medical condition for a health plan enrollee.

“Prescription” is an oral, written, or electronic order by a prescribing provider for a specific enrollee that contains the name of the prescription drug, the quantity of the prescribed drug, the date of issue, the name and contact information of the prescribing provider, the signature of the prescribing provider if the prescription is in writing, and if requested by the enrollee, the medical condition or purpose for which the drug is being prescribed.

“Prescription drug” is a drug that is prescribed by the enrollee's prescribing provider and requires a prescription under applicable law.

“Prior Authorization” is a health plan's requirement that the enrollee or the enrollee's prescribing provider obtain the health plan's authorization for a prescription drug before the health plan will cover the drug. The health plan shall grant a prior authorization when it is medically necessary for the enrollee to obtain the drug.

“Step therapy” is a process specifying the sequence in which different prescription drugs for a given medical condition and medically appropriate for a particular patient are prescribed. The health plan may require the enrollee to try one or more drugs to treat the enrollee's medical condition before the health plan will cover a particular drug for the condition pursuant to a step therapy request. If the enrollee's prescribing provider submits a request for step therapy exception, the health plans shall make exceptions to step therapy when the criteria is met.

“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.

x Additional abbreviations and terms used on the CCHP formulary document are explained below: Abbreviation Term What it means AL Age Limit Some drugs are only covered for certain ages. NF Non-Formulary These drugs are not covered on the Drug List. If your doctor feels you need a drug that is not covered, he or she can ask us to make an exception. PA Prior Authorization Your doctor must ask for approval from CCHP before some drugs will be covered. QL Quantity Limit Some drugs are only covered for a certain amount. SCO State Carve-Out These drugs are carved out by the Department of Health Care Services. This means these drugs are covered by the Medi-Cal Fee-for- Service program and must be billed to the State by the pharmacy. ST Step Therapy In some cases, you must first try certain drugs before CalViva Health covers another drug for your medical condition.

For example, if Drug A and Drug B both treat your health condition, CCHP may not cover Drug B unless you try Drug A first.

The CCHP formulary uses a 3 tier structure – the tiers are explained below: Abbreviation Term What it means T1 Tier 1 Tier 1 medications are preferred on the CCHP formulary and are available without restriction or prior authorization. T2 Tier 2 Tier 2 medications are preferred on the CCHP formulary and are available without prior authorization, BUT may have certain restrictions such as quantity limits, step therapy, etc. (the specific restrictions are listed on the CCHP formulary). T3 Tier 3 Tier 3 medications are non-preferred. These medications require prior authorization.

xi Plan de Salud de Contra Costa CCHP) ORGANIZACIÓN DE ADMINISTRACIÓN DE SALUD (HMO) COMERCIAL Y DE MEDI-CAL Formulario

Última actualización: 1 de agosto de 2021 Not a: El formulario del CCHP está sujeto a cambios, y todas las versiones anteriores ya no están vigentes. o Para acceder a la versión electrónica del formulario del CCHP en el sitio web del plan de salud, visite la siguiente dirección web: https://cchealth.org/healthplan/pdf/pdl.pdf o Para acceder a la herramienta de búsqueda del formulario interactivo del CCHP, visite la siguiente dirección web: https://formularynavigator.com/Search.aspx?siteID=MMRREQ3QBC o Para acceder a la información de cobertura específica del plan que incluye información de costos compartidos, manual para miembros y otros materiales importantes como los documentos de su Evidencia de cobertura (EOC), visite la siguiente dirección web: https://cchealth.org/healthplan/member-publications.php Preguntas frecuentes

¿Qué es el formulario del CCHP? El formulario del CCHP (también conocido como la lista de medicamentos preferidos del CCHP, o PDL) incluye medicamentos utilizados para tratar enfermedades o problemas de salud comunes. Este formulario aplica solo a los medicamentos para pacientes en consulta externa y medicamentos autoadministrados, no aplica a medicamentos utilizados en el entorno de pacientes internados o en consultorios médicos.

El formulario es una lista de medicamentos preferidos examinada y revisada continuamente en función de la seguridad, eficacia y rentabilidad. Se actualiza mensualmente y es efectiva el primer día de cada mes. Las actualizaciones se basan en comentarios de un grupo de médicos y farmacéuticos que se reúnen regularmente para decidir qué medicamentos deben incluirse. Estas actualizaciones pueden incluir, entre otros, lo siguiente: (i) eliminación o adición de medicamentos o formas farmacéuticas, (ii) cambios en la colocación de nivel de un medicamento, (iii) cambios en las restricciones de administración de utilización (como límites de cantidad, tratamiento escalonado, etc.). Los documentos actualizados están disponibles en línea en: https://www.cchealth.org.

¿Cómo uso el formulario del CCHP? La lista de medicamentos de formulario comienza en la Página 1. Para ubicar un medicamento en el formulario, simplemente busque el nombre del medicamento en el índice al final de este folleto. El índice enumera todos los medicamentos en el formulario, incluidos los medicamentos de marca y los medicamentos genéricos. Una vez que haya ubicado el nombre del medicamento en el índice, verá el número de página en donde puede encontrar más información sobre el medicamento indicado junto a este.

En lugar de usar el índice, también se puede buscar en el formulario usando ctrl+F para encontrar un medicamento específico por marca, nombre genérico o clase terapéutica.

Una versión para teléfonos celulares del formulario del CCHP también está disponible usando la aplicación ePocrates. Después de que haya descargado la aplicación a su dispositivo móvil, simplemente elija el formulario “Plan de Salud de Contra Costa Medi- Cal” para mostrar el estado de formulario de los medicamentos en la aplicación. Si tiene alguna pregunta sobre la instalación o uso de la aplicación Epocrates, comuníquese con atención al cliente de Epocrates al (800)230-2150 o [email protected].

a La presencia de un medicamento que requiere receta en el formulario del CCHP no garantiza que el proveedor que emite recetas le recete a un miembro ese medicamento para una afección médica particular.

Si un medicamento no está en el formulario del CCHP, requerirá una autorización previa para que esté cubierto (la información específica sobre el proceso de autorización previa del CCHP se encuentra a continuación en la sección titulada “¿Qué sucede si el medicamento que necesito no está en el formulario del CCHP?”)

¿Cómo se indican los medicamentos en el formulario?

Los medicamentos están indicados alfabéticamente por marca y nombre genérico en la categoría terapéutica y clase a la que pertenecen. Los medicamentos de marca aparecerán en MAYÚSCULAS, con el nombre genérico indicado en paréntesis después de la marca todo escrito en letra minúscula negrita y cursiva. Si el medicamento genérico está disponible, se indicará de forma separada del medicamento de marca y siempre se indicará en letra minúscula negrita y cursiva. Si un genérico equivalente de un medicamento de marca no está disponible, el medicamento genérico no estará indicado de forma separada del medicamento de marca. En situaciones en las que un equivalente genérico aprobado por la Administración de Alimentos y Medicamentos (Food & Drug Administration, FDA) está disponible, las marcas se indican con fines de referencia únicamente, y no denotan cobertura para la marca, a menos que se indique específicamente.

Una lista de ejemplo del formulario del CCHP se encuentra a continuación:

¿Qué sucede si el medicamento que necesito no está indicado en el formulario del CCHP? Si su medicamento no figura en el formulario del CCHP, puede preguntarle a su médico si hay un medicamento diferente en el formulario que funcione de la misma manera. Si su médico decide que necesita un medicamento que no está en el formulario, puede pedirle al CCHP que haga una excepción a través del proceso de autorización previa. Todas las solicitudes de autorización previa serán evaluadas por un médico del plan de salud (farmacéutico o médico) según los criterios de autorización previa del CCHP

b aprobados por el comité de Farmacia y Terapéutica (P&T) del CCHP. En los casos en que no existan criterios específicos, se utilizarán para la evaluación indicaciones de la FDA, literatura revisada por pares, otros criterios del plan, pautas nacionales de tratamiento (como IDSA, NCCN, AACE, etc.) y otros compendios médicos. Se pueden hacer excepciones por una variedad de motivos diferentes:

 Su médico puede pedirle al CCHP que cubra un medicamento que figura en el formulario que requiere una autorización previa (PA): estos medicamentos requieren aprobación antes de ser despachados en una farmacia de la red. Cada solicitud será revisada por un médico del plan de salud, y si la solicitud no cumple con las pautas establecidas por el plan, no será aprobada, y se puede recomendar una terapia alternativa.  Su médico puede pedirle al CCHP que cubra un medicamento que no figura en el formulario: cualquier medicamento que no se encuentre en esta lista se considera no incluido en el formulario. La persona que emite la receta puede solicitar cobertura para agentes que no figuran en el formulario. Cada solicitud será revisada por un médico del plan de salud y se aprobará si existe una necesidad médica documentada y si no hay un agente alternativo en el formulario.  Su médico puede pedirle al CCHP que haga una excepción a los límites de un medicamento. Por ejemplo, si un medicamento tiene un límite de 1 tableta por día, su médico puede pedirnos que cubramos más. Si se necesitan cantidades que exceden el límite, la persona que emite la receta puede solicitar una excepción a la cobertura. Cada solicitud será revisada por un médico del plan de salud y se aprobará si existe una necesidad médica documentada sin comprometer la seguridad.  Su médico puede pedirle al CCHP que haga una excepción a los requisitos de tratamiento escalonado (ST): estos medicamentos requieren que se prueben uno o más medicamentos de primer paso antes de pasar al medicamento de segundo paso (por ejemplo, si el medicamento A y el medicamento B tratan su afección de salud, el CCHP puede no cubrir el medicamento B a menos que primero pruebe el medicamento A). Si existe una necesidad médica de usar un medicamento de segundo paso sin probar un medicamento de primer paso, la persona que emite la receta puede solicitar una excepción a la cobertura. Cada solicitud será revisada por un médico del plan de salud y se aprobará si existe una necesidad médica documentada. Si ya probó el medicamento preferido y este falló, o si ya está tomando un medicamento sujeto a tratamiento escalonado cuando se cambia al CCHP, no tendrá que probar los medicamentos preferidos nuevamente. Su médico simplemente puede solicitar una aprobación a través del plan para la continuación del tratamiento.

Para comenzar el proceso de autorización previa del CCHP o para solicitar una excepción, su médico debe enviar por fax una solicitud de autorización previa al CCHP al 1-866-428-7369 para solicitudes urgentes, o 1-866-205-8014 para solicitudes

c estándar. Su médico también puede enviar la solicitud electrónicamente al CCHP utilizando la historia clínica electrónica. Si se aprueba la solicitud, podrá surtir su medicamento en una farmacia que trabaje con el CCHP. Si denegamos la solicitud, le enviaremos una carta a usted y a su médico y le diremos cómo presentar una apelación o una queja formal. Una "apelación" es cuando desea que el plan de salud revise nuevamente una decisión (generalmente con información adicional), y una "queja formal" es una queja o inquietud relacionada con el plan de salud.

El CCHP tomará la decisión de denegar o aprobar todas las solicitudes de autorización previa y de excepción dentro de las 24 horas posteriores a la recepción de la solicitud. Si el CCHP no responde a una autorización previa o solicitud de tratamiento escalonado dentro de las 72 horas de haber recibido una solicitud no urgente o 24 horas después de recibir una solicitud basada en circunstancias exigentes, la solicitud se considerará aprobada.

El CCHP proporcionará cobertura de conformidad con una solicitud no urgente por la duración de la receta, incluidos los resurtidos. El CCHP proporcionará cobertura, incluidos los resurtidos, de conformidad con una solicitud basada en circunstancias exigentes por la duración de la exigencia.

Si desea descargar el formulario de autorización previa del CCHP, está disponible en: https://cchealth.org/healthplan/pdf/performrx_medication_prior_auth_form.pdf

¿Qué sucede si necesito mi medicamento con urgencia? ¿Las farmacias tienen la capacidad de surtir suministros de medicamentos de emergencia?

Sí. Para garantizar que los miembros del CCHP tengan acceso a un suministro suficiente de medicamentos en situaciones de emergencia, el CCHP ha establecido una Política de suministros de emergencia que permite a los farmacéuticos utilizar su criterio clínico para anular los reclamos que rechazan en el punto de venta. Cuando un farmacéutico determina que un medicamento es médicamente necesario, puede ingresar un código de autorización que le permita surtir un suministro de medicamentos de emergencia para 5 días para cualquier miembro del CCHP. El CCHP promueve el uso de la Política de suministros de emergencia a través de mensajes en el punto de venta. En lugar de utilizar la Política de suministros de emergencia para 5 días, las farmacias también pueden optar por llamar al centro de llamadas del proveedor de PerformRx al 877-234-4269; los representantes están disponibles las 24 horas del día, los 365 días del año. El personal del centro de llamadas tiene la capacidad de anular las recetas en función de la orientación proporcionada por el CCHP. ¿Qué sucede si soy un miembro nuevo del CCHP?

d Si es un miembro nuevo del CCHP, puede estar tomando medicamentos que no están en nuestro formulario, o puede estar tomando medicamentos que están en nuestro formulario, pero que tienen límites. Si es posible, debe hablar con su médico para ver si puede cambiar a un medicamento preferido en el formulario del CCHP. Si no puede cambiarse a un medicamento preferido, entonces su médico deberá solicitarle al CCHP una excepción para cubrir un medicamento que ha estado tomando (conocido como continuación del tratamiento). Consulte la sección anterior titulada "¿Qué sucede si el medicamento que necesito no figura en el formulario del CCHP?" para obtener más información.

¿El CCHP cubre medicamentos genéricos y de marca?

El CCHP cubre medicamentos de marca y genéricos, pero cuando hay un medicamento genérico disponible, el CCHP requiere que se use. Todos los medicamentos que están disponibles genéricamente están sujetos a revisión por parte del comité de Farmacia y Terapéutica del CCHP.

Una persona que emite una receta puede solicitar un producto de marca en lugar de un genérico aprobado si determina que existe una necesidad médica documentada del equivalente de marca. Este tipo de solicitud de cobertura se puede realizar a través del proceso de autorización previa del CCHP descrito anteriormente en la sección titulada "¿Qué sucede si el medicamento que necesito no está indicado en el formulario del CCHP?"

¿Hay medicamentos que están excluidos de la cobertura? El formulario de Medi-Cal del CCHP es muy similar a la Lista de Medicamentos con Contrato de Medi-Cal de California. Los siguientes tipos de medicamentos generalmente no son un beneficio cubierto para los miembros de Medi-Cal (tenga en cuenta que esta lista está sujeta a cambios):  Medicamentos para la disfunción eréctil o sexual  Medicamentos utilizados por razones estéticas o crecimiento del cabello  Medicamentos que se consideran experimentales, o que se usan de manera experimental  Medicamentos utilizados para tratar la infertilidad  Medicamentos específicamente enumerados como "no cubiertos" en el formulario  Medicamentos extranjeros o medicamentos no aprobados por la Administración de Alimentos y Medicamentos de los Estados Unidos (FDA) Si se modifica la cobertura del CCHP para excluir un medicamento que hemos estado cubriendo y proporcionándole bajo su cobertura actual, continuaremos proporcionándole el medicamento si un médico del plan continúa recetándolo para la misma afección y para un uso aprobado por la Administración de Alimentos y Medicamentos.

Algunos medicamentos están excluidos por el Departamento de Servicios de Atención Médica. Esto significa que estos medicamentos están cubiertos por el programa de

e pago por servicio de Medi-Cal para miembros de Medi-Cal, no por el CCHP. Los siguientes tipos de medicamentos están excluidos:  Medicamentos antipsicóticos  Medicamentos para el VIH/sida  Medicamentos exclusivos para el tratamiento de desintoxicación y dependencia del alcohol y heroína  Medicamentos exclusivos para tratar la hemofilia

¿Puedo ir a cualquier farmacia por mi medicamento? No, los miembros deben usar una farmacia que esté en la red del CCHP. Para encontrar una farmacia de la red, visite el sitio web del CCHP o llame al plan de salud directamente para que uno de los miembros del personal de servicios para miembros o de farmacia le ayuden a ubicar una farmacia cercana (consulte la sección a continuación titulada “¿Cómo encuentro una farmacia?”).

¿Cómo encuentro una farmacia? Para encontrar una farmacia cercana, visite el sitio web del CCHP en https://cchealth.org/healthplan/. Una vez que haya navegado al sitio web del CCHP, siga las instrucciones a continuación:

(1) Desplácese hacia abajo y haga clic en el botón "Buscar médicos/clínicas/farmacias en mi área" (Search Doctors/Clinics/Pharmacies in My Area) (2) Haga clic en el botón rojo "Comenzar aquí" (Begin Your Search Here) (se abrirá una nueva ventana) (3) Haga clic en la pestaña "Instalaciones" (Facility) y elija "Farmacia" (Pharmacy) como tipo de instalación (4) Elija cómo desea buscar (por código postal, distancia, etc.) (5) Haga clic en "Buscar una instalación" (Find a Facility): los resultados aparecerán inmediatamente (como un mapa y una lista)

Asegúrese de mostrar su tarjeta de identificación de miembro del CCHP cuando surta sus recetas en la farmacia.

Nota: algunos medicamentos están sujetos a una distribución limitada por parte de la Administración de Alimentos y Medicamentos de EE. UU. Estos tipos de medicamentos se denominan "medicamentos de especialidad" porque requieren un manejo especial, coordinación de proveedores o instrucciones especiales que es posible que su farmacia local no le proporcione. El CCHP tiene un contrato con Walgreens para proporcionar este tipo de medicamentos. Si tiene preguntas específicas sobre este tipo de medicamentos, comuníquese directamente con la unidad de farmacia del CCHP.

¿Qué medicamentos están cubiertos por el CCHP?

f Usted puede obtener los siguientes medicamentos y otros artículos cuando los haya recetado su médico y sean médicamente necesarios:

 Medicamentos recetados que figuran en el formulario del CCHP  Medicamentos sin receta o medicamentos de venta libre (como jarabes para la tos/resfrío, pastillas para la tos o aspirina) mencionados en el formulario del CCHP  Suministros para diabéticos del formulario: insulina, jeringas de insulina, tiras reactivas de glucosa, lancetas y dispositivos de punción de lancetas, sistemas de administración de plumas y monitores de glucosa en sangre  Anticonceptivos aprobados por la FDA que figuran en el formulario del CCHP  Anticoncepción de emergencia  Epipens, medidores de flujo máximo y espaciadores

¿Los medicamentos intravenosos (IV) e inyectables están cubiertos por el CCHP?

Sí, el formulario del CCHP enumera ciertos productos inyectables que están cubiertos como un beneficio de farmacia. El CCHP también cubre la mayoría de los demás medicamentos intravenosos a través del beneficio médico. Los medicamentos que generalmente están cubiertos a través del beneficio médico son aquellos que se administran en el consultorio de un médico, clínica u hospital. Las solicitudes de cobertura de un medicamento a través del beneficio médico deben dirigirse al Departamento de Administración de Utilización del CCHP descargando el formulario de referencia médica en https://cchealth.org/healthplan/providers/ y enviando un fax al (925) 313-6058 para solicitudes de rutina o (925) 313-6458 para solicitudes urgentes.

La cobertura de medicamentos intravenosos e inyectables a través del beneficio de farmacia se detalla a continuación:

 Soluciones intravenosas simples: las soluciones intravenosas simples normalmente se usan para la terapia de hidratación. Se incluyen soluciones comercialmente disponibles (no compuestas) como solución salina normal, dextrosa (hasta 10% en agua) y solución de ringer lactato; las soluciones de cloruro de potasio preparadas comercialmente en tales soluciones también se incluyen en esta definición. Las soluciones intravenosas simples se deben facturar utilizando el número del Código Nacional de Medicamentos (National Drug Code, NDC) del producto.  Soluciones de nutrición parenteral (TPN o hiperalimentación): restringidas para dispensar dentro de los 10 días posteriores al alta hospitalaria de un hospital de cuidados agudos, cuando se inició la terapia (IV) con el mismo producto antes del alta. Hay un suministro máximo para 10 días por dispensación dentro de este período de 10 días. (Las soluciones de nutrición parenteral son productos nutricionales administrados por vía intravenosa o intraarterial que suelen ser suspensiones o soluciones de aminoácidos o proteínas, dextrosa, lípidos, electrolitos, suplementos vitamínicos y/o minerales y oligoelementos). Los complementos a la nutrición parenteral son otros medicamentos que se mezclan físicamente con una solución de nutrición parenteral en cualquier momento antes de

g la administración. Facture estos productos como parte de la facturación de nutrición parenteral. Nota: Los productos no compuestos deben facturarse utilizando el número NDC del producto. Las soluciones compuestas deben facturarse como un reclamo compuesto.  Lípidos intravenosos administrados por separado: restringidos para ser dispensados dentro de los 10 días posteriores al alta hospitalaria de un hospital de cuidados agudos, cuando la terapia (IV) con el mismo producto se haya iniciado antes del alta. Hay un suministro máximo para 10 días por dispensación dentro de este período de 10 días. Las soluciones o suspensiones de lípidos intravenosos que se administran por separado de las soluciones de nutrición parenteral (es decir, no se mezclan físicamente en el recipiente de la solución de nutrición parenteral) deben facturarse utilizando el número NDC del producto.  Soluciones intravenosas de antibióticos no incluidos en la lista: restringidas para ser dispensadas dentro de los 10 días posteriores al alta hospitalaria de un hospital de cuidados agudos, cuando la terapia IV con el mismo antibiótico se haya iniciado antes del alta. Hay un suministro máximo para 10 días por dispensación dentro del período de 10 días. Nota: Los productos no compuestos deben facturarse utilizando el número NDC del producto. Las soluciones compuestas deben facturarse como un reclamo compuesto.  Soluciones intravenosas de otros medicamentos no indicados en la lista: restringidas para ser dispensadas dentro de los 10 días posteriores al alta hospitalaria de un hospital de cuidados agudos, cuando la terapia IV con el mismo medicamento se haya iniciado antes del alta. Hay un suministro máximo para 10 días por dispensación dentro del período de 10 días. Nota: Los productos no compuestos deben facturarse utilizando el número NDC del producto. Las soluciones compuestas deben facturarse como un reclamo compuesto.

¿Cuánto pagaré por mis medicamentos? Los miembros de Medi-Cal del CCHP no tienen que pagar los servicios cubiertos; los medicamentos están disponibles sin copago. Los miembros comerciales del CCHP (con planes como el plan comercial A, el plan B, IHSS, etc.) pueden tener que pagar pequeños copagos por sus medicamentos. Consulte los materiales de su plan para determinar si tiene un copago.

¿Los proveedores pueden hacer sugerencias al CCHP para mejorar el formulario? Por supuesto que sí. El formulario es una herramienta para promover el uso rentable de medicamentos recetados. El CCHP ha hecho todo lo posible para crear un documento que satisfaga todas las necesidades terapéuticas; sin embargo, el arte de la medicina hace que esta sea una tarea formidable. El CCHP agradece la participación de médicos, farmacéuticos y proveedores de servicios médicos auxiliares en este proceso dinámico. Se alienta a los médicos y farmacéuticos a dirigir

h cualquier sugerencia o comentario al CCHP por correo electrónico a: [email protected].

¿Qué puedo hacer si necesito más información? Para obtener más información sobre sus beneficios de farmacia, revise los documentos de su Evidencia de cobertura o llame al CCHP directamente para hablar sobre ellos. El departamento de servicios para miembros del CCHP y el personal del departamento de farmacia están disponibles para responder preguntas de lunes a viernes de 8 a.m. a 5 p.m., hora del Pacífico, en los números de teléfono que se detallan a continuación: Departamento de Servicios a Miembros del CCHP: (877) 661-6230 x2 Departamento de Farmacia del CCHP: (877) 661-6230 x3

i Definiciones y abreviaturas:

En este documento, se usan varios términos que el Plan de Salud Contra Costa quiere asegurarse de que usted entienda. A continuación se presentan algunas definiciones y abreviaturas:

“Medicamento de marca” es un medicamento que se comercializa bajo un nombre patentado y protegido por marca registrada. El medicamento de marca aparece en todas las letras en MAYÚSCULAS.

“Coseguro” es un porcentaje del costo de un beneficio de atención médica cubierto que un afiliado paga después de que haya pagado el deducible, si se aplica un deducible al beneficio de atención médica, como el beneficio de medicamentos recetados.

“Copago” es un monto fijo en dólares que un afiliado paga por un beneficio de atención médica cubierto después de que haya pagado el deducible, si se aplica un deducible al beneficio de atención médica, como el beneficio de medicamentos recetados.

“Deducible” es el monto que un afiliado paga por los beneficios de atención médica cubiertos antes de que el plan de salud del afiliado comience a pagar la totalidad o parte del costo del beneficio de atención médica según los términos de la póliza.

“Nivel de medicamento” es un grupo de medicamentos recetados que corresponde a un nivel de costo compartido especificado en la cobertura de medicamentos recetados del plan de salud. El nivel en el que se coloca un medicamento recetado determina la parte del costo del medicamento para el afiliado.

“Afiliado” es una persona inscrita en un plan de salud que tiene derecho a recibir servicios del plan. Todas las referencias a los afiliados en esta plantilla del formulario también incluirán suscriptores como se define en esta sección a continuación.

“Solicitud de excepción” es una solicitud de cobertura de un medicamento recetado. Si un afiliado, su persona designada o el proveedor de atención médica que emite la receta presenta una solicitud de excepción para la cobertura de un medicamento recetado, el plan de salud debe cubrir el medicamento recetado cuando se determina que el medicamento es médicamente necesario para tratar la afección del afiliado.

“Circunstancias exigentes” se producen cuando un afiliado sufre una afección de salud que puede poner en grave peligro la vida, la salud o la capacidad del afiliado de recuperar su función máxima, o cuando un afiliado se somete a un tratamiento actual con un medicamento que no figura en el formulario.

j “Formulario” es la lista completa de medicamentos preferidos para su uso y elegibles para la cobertura de un producto del plan de salud, e incluye todos los medicamentos cubiertos bajo el beneficio de medicamentos recetados para pacientes ambulatorios del producto del plan de salud. El formulario también se conoce como una lista de medicamentos recetados,

“Medicamento genérico” es el mismo medicamento que su equivalente de marca en dosis, seguridad, concentración, cómo se toma, calidad, rendimiento y uso previsto. Un medicamento genérico aparece en letra minúscula negrita y cursiva.

“Medicamento que no figura en el formulario” es un medicamento recetado que no figura en el formulario del plan de salud.

“Costo de bolsillo” son copagos, coseguros y el deducible aplicable, más todos los costos por servicios de atención médica que no están cubiertos por el plan de salud.

“Proveedor que emite la receta” es un proveedor de atención médica autorizado para emitir una receta médica para tratar una afección médica de un afiliado al plan de salud.

“Receta” es una orden oral, escrita o electrónica de un proveedor que emite recetas para un afiliado específico que contiene el nombre del medicamento recetado, la cantidad del medicamento recetado, la fecha de emisión, el nombre y la información de contacto del proveedor que receta, la firma del proveedor que emite recetas si la receta es por escrito, y si la persona inscrita lo solicita, la afección médica o el propósito para el cual se receta el medicamento.

“Medicamento recetado” es un medicamento recetado por el proveedor del afiliado que emite recetas y requiere una receta en virtud de la ley aplicable.

“Autorización previa” es un requisito del plan de salud de que el afiliado o el proveedor del afiliado que emite recetas obtenga la autorización del plan de salud para un medicamento recetado antes de que el plan de salud cubra el medicamento. El plan de salud otorgará una autorización previa cuando sea médicamente necesario que el afiliado obtenga el medicamento.

“Tratamiento escalonado” es un proceso que especifica la secuencia en la que se recetan diferentes medicamentos recetados para una afección médica determinada y médicamente apropiados para un paciente en particular. El plan de salud puede requerir que el afiliado pruebe uno o más medicamentos para tratar la afección médica del afiliado antes de que el plan de salud cubra un medicamento en particular para la afección de conformidad con una solicitud de tratamiento escalonado. Si el proveedor que emite recetas al afiliado presenta una solicitud de excepción de tratamiento

k escalonado, los planes de salud harán excepciones al tratamiento escalonado cuando se cumplan los criterios.

“Suscriptor” es la persona responsable del pago de un plan o cuyo empleo u otra circunstancia, excepto la dependencia familiar, es la base para la elegibilidad para la membresía en el plan.

A continuación se explican abreviaturas y términos adicionales utilizados en el documento del formulario del CCHP: Abreviatura Término Qué significa AL Límite de edad Algunos medicamentos solo están cubiertos para ciertas edades. NF No figura en el Estos medicamentos no están cubiertos en la formulario Lista de medicamentos. Si su médico considera que necesita un medicamento que no está cubierto, puede solicitarnos que hagamos una excepción. PA Autorización previa Su médico debe solicitar la aprobación del CCHP antes de que se cubran algunos medicamentos. QL Límite de cantidad Algunos medicamentos solo están cubiertos para ciertas cantidades. SCO Exclusión estatal Estos medicamentos están excluidos por el Departamento de Servicios de Atención Médica. Esto significa que estos medicamentos están cubiertos por el programa de tarifa por servicio de Medi-Cal y deben ser facturados al estado por la farmacia. ST Tratamiento En algunos casos, primero debe probar ciertos escalonado medicamentos antes de que CalViva Health cubra otro medicamento para su afección médica.

Por ejemplo, si el Medicamento A y el Medicamento B tratan su afección de salud, es posible que el CCHP no cubra el Medicamento B a menos que pruebe el Medicamento A primero.

El formulario del CCHP utiliza una estructura de 3 niveles; los niveles se explican a continuación: Abreviatura Término Qué significa

l T1 Nivel 1 Los medicamentos de nivel 1 se prefieren en el formulario del CCHP y están disponibles sin restricción o autorización previa. T2 Nivel 2 Los medicamentos de nivel 2 se prefieren en el formulario del CCHP y están disponibles sin autorización previa, PERO pueden tener ciertas restricciones, como límites de cantidad, tratamiento escalonado, etc. (las restricciones específicas se enumeran en el formulario del CCHP). T3 Nivel 3 Los medicamentos de nivel 3 no son preferidos. Estos medicamentos requieren autorización previa.

m 397 CCHP 08/01/2021 Contra Costa Health Plan Formulary Informational Section ...... 2 Antihistamine Drugs - Drugs For Allergy ...... 1 Anti-Infective Agents - Drugs For Infections ...... 4 Antineoplastic Agents - Drugs For Cancer ...... 17 Antitoxins,Immune Glob,Toxoids,Vaccines - Drugs For The Immune System ...... 22 Autonomic Drugs - Drugs For The Nervous System ...... 25 Blood Formation, Coagulation, Thrombosis - Drugs For The Blood ...... 32 Cardiovascular Drugs - Drugs For The Heart ...... 37 Central Nervous System Agents - Drugs For The Nervous System ...... 58 Devices - Medical Supplies And Durable Medical Equipment ...... 78 Diagnostic Agents ...... 81 Electrolytic, Caloric, And Water Balance ...... 81 Enzymes ...... 87 Eye, Ear, Nose And Throat (Eent) Preps...... 87 Gastrointestinal Drugs ...... 93 Gastrointestinal Drugs - Drugs For The Stomach ...... 94 Gold Compounds ...... 99 Heavy Metal Antagonists - Drugs To Reduce Iron ...... 99 Hormones And Synthetic Substitutes - Hormones ...... 99 Local Anesthetics (Parenteral) - Drugs For Numbing ...... 114 Miscellaneous Therapeutic Agents ...... 114 Nonhormonal Contraceptives - Drugs For Women ...... 121 Oxytocics - Drugs For Women ...... 122 Pharmaceutical Aids ...... 122 Respiratory Tract Agents - Drugs For The Lungs ...... 123 Skin And Mucous Membrane Agents - Drugs For The Skin ...... 133 Smooth Muscle Relaxants - Drugs To Relax Muscles ...... 146 Vitamins ...... 147

TOC-1 Informational Section

2 CURRENT AS OF 08/01/2021

Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits Antihistamine Drugs - Drugs For Allergy Ethanolamine Derivatives - Drugs For Allergy CHILDREN'S ALLERGY (DIPHENHYD) ORAL T2 TABLET,CHEWABLE (diphenhydramine HCl) clemastine oral tablet 2.68 mg T1 dimenhydrinate injection solution T3 PA diphenhydramine HCl injection solution 50 mg/mL T2 QL (1 EA per 30 days) diphenhydramine HCl injection syringe T2 QL (1 EA per 30 days) diphenhydramine HCl oral capsule T2 diphenhydramine HCl oral elixir T2 diphenhydramine HCl oral liquid T2 diphenhydramine HCl oral tablet 25 mg T2 SLEEP AID (DIPHENHYDRAMINE) ORAL CAPSULE 50 T2 MG (diphenhydramine HCl) SLEEP AID (DIPHENHYDRAMINE) ORAL TABLET T2 (diphenhydramine HCl) WAL-SOM (DOXYLAMINE) (doxylamine succinate) T2 First Gen. Antihist. Derivatives, Misc. - Drugs For Allergy cyproheptadine T1 First Generation Antihistamines - Drugs For Allergy carbinoxamine maleate oral tablet 4 mg T1 CHILDREN'S ALLERGY (DIPHENHYD) ORAL T2 TABLET,CHEWABLE (diphenhydramine HCl) chlorpheniramine maleate oral tablet T2 chlorpheniramine maleate oral tablet extended release T2 PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

1 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits clemastine oral tablet 2.68 mg T1 cyproheptadine T1 dimenhydrinate injection solution T3 PA diphenhydramine HCl injection solution 50 mg/mL T2 QL (1 EA per 30 days) diphenhydramine HCl injection syringe T2 QL (1 EA per 30 days) diphenhydramine HCl oral capsule T2 diphenhydramine HCl oral elixir T2 diphenhydramine HCl oral liquid T2 diphenhydramine HCl oral tablet 25 mg T2 SLEEP AID (DIPHENHYDRAMINE) ORAL CAPSULE 50 T2 MG (diphenhydramine HCl) SLEEP AID (DIPHENHYDRAMINE) ORAL TABLET T2 (diphenhydramine HCl) WAL-SOM (DOXYLAMINE) (doxylamine succinate) T2 Phenothiazine Derivatives - Drugs For Allergy promethazine HCl (Phenadoz Rectal Suppository 25 Mg) T1 promethazine injection solution 25 mg/mL T2 QL (1 EA per 30 days) promethazine injection solution 50 mg/mL T1 promethazine oral T1 promethazine rectal suppository 12.5 mg, 50 mg T1 phenylephrine HCl/promethazine HCl (Promethazine Vc) T1 QL (240 ML per 30 days); AL promethazine-phenyleph-codeine T2 (Min 18 Years) Piperazine Derivatives - Drugs For Allergy hydroxyzine HCl intramuscular T2 QL (1 EA per 30 days) hydroxyzine HCl oral solution 10 mg/5 mL T1 hydroxyzine HCl oral tablet T1 PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

2 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits hydroxyzine pamoate T1 meclizine oral tablet 12.5 mg T2 meclizine oral tablet 25 mg T1 meclizine oral tablet,chewable T2 Propylamine Derivatives - Drugs For Allergy chlorpheniramine maleate oral tablet T2 chlorpheniramine maleate oral tablet extended release T2 chlorpheniramine-phenyleph-DM T3 PA ED A-HIST DM ORAL LIQUID (chlorpheniramine T2 maleate/phenylephrine HCl/dextromethorphan) LOHIST - D (chlorpheniramine T1 maleate/pseudoephedrine HCl) PEDIATRIC COUGH AND COLD ORAL LIQUID 1-15-5 MG/5 ML (chlorpheniramine T2 maleate/pseudoephedrine/dextromethorphan) RESCON-DM (chlorpheniramine T2 maleate/pseudoephedrine/dextromethorphan) SCOT-TUSSIN DM (chlorpheniramine T2 maleate/dextromethorphan HBr) Second Generation Antihistamines - Drugs For Allergy ALAVERT (loratadine) T2 ALAVERT D-12 ALLERGY-SINUS T2 (loratadine/pseudoephedrine sulfate) cetirizine oral solution 1 mg/mL T2 cetirizine oral tablet T2 cetirizine oral tablet,chewable T2 cetirizine-pseudoephedrine T2 CHILDREN'S ALLERGY RELIEF(FEX) (fexofenadine HCl) T2 ST PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

3 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits fexofenadine oral tablet 180 mg, 60 mg T2 ST fexofenadine-pseudoephedrine T2 ST levocetirizine oral tablet T2 loratadine oral solution T2 loratadine oral tablet T2 LORATADINE-D ORAL TABLET EXTENDED RELEASE 24 T2 HR (loratadine/pseudoephedrine sulfate) WAL-FEX D 24 HOUR (fexofenadine T2 ST HCl/pseudoephedrine HCl) Anti-Infective Agents - Drugs For Infections 1St Generation Cephalosporin Antibiotics - Antibiotics cephalexin oral capsule 250 mg, 500 mg T1 cephalexin oral capsule 750 mg T3 PA cephalexin oral suspension for reconstitution T1 cephalexin oral tablet T3 PA 2Nd Generation Cephalosporin Antibiotics - Antibiotics cefaclor oral capsule T1 cefaclor oral suspension for reconstitution 125 mg/5 T1 mL, 250 mg/5 mL, 375 mg/5 mL cefaclor oral tablet extended release 12 hr T3 PA cefuroxime axetil oral suspension for reconstitution 125 T1 mg/5 mL cefuroxime axetil oral tablet T1 3Rd Generation Cephalosporin Antibiotics - Antibiotics cefdinir oral capsule T2 QL (20 QY per 10 DYs) cefdinir oral suspension for reconstitution 125 mg/5 mL T2 QL (200 QY per 10 DYs) cefdinir oral suspension for reconstitution 250 mg/5 mL T2 QL (100 QY per 10 DYs) PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

4 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits cefixime oral suspension for reconstitution 100 mg/5 T2 PA; ST mL cefpodoxime oral suspension for reconstitution T2 QL (2 Fills per 180 DYs) cefpodoxime oral tablet T2 QL (4 EA per 1 DY) SUPRAX ORAL CAPSULE (cefixime) T2 QL (1 Tablet per 30 days) SUPRAX ORAL SUSPENSION FOR RECONSTITUTION T2 PA 200 MG/5 ML (cefixime) Adamantane Antivirals - Drugs For Viral Infections amantadine HCl T2 SCO Allylamine Antifungals - Drugs For Fungus terbinafine HCl oral T1 Amebicides - Drugs For The Mouth And Throat metronidazole oral T1 Aminoglycoside Antibiotics - Antibiotics gentamicin injection solution 20 mg/2 mL T2 QL (1 EA per 30 days) neomycin T1 streptomycin T2 QL (1 EA per 30 days) tobramycin sulfate injection solution 10 mg/mL T2 QL (1 EA per 30 days) Aminopenicillin Antibiotics - Antibiotics amoxicillin oral capsule T1 amoxicillin oral suspension for reconstitution T1 amoxicillin oral tablet T1 amoxicillin oral tablet,chewable 125 mg, 250 mg T1 amoxicillin-pot clavulanate oral suspension for T1 reconstitution 200-28.5 mg/5 mL

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

5 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits amoxicillin-pot clavulanate oral suspension for T2 QL (14 QY per 1 Fill) reconstitution 250-62.5 mg/5 mL amoxicillin-pot clavulanate oral suspension for T2 QL (14 DS per 1 Fill) reconstitution 400-57 mg/5 mL amoxicillin-pot clavulanate oral tablet T2 QL (14 DS per 1 Fill) amoxicillin-pot clavulanate oral tablet extended release T2 QL (14 QY per 1 Fill) 12 hr amoxicillin-pot clavulanate oral tablet,chewable T2 QL (14 DS per 1 Fill) ampicillin oral capsule T1 AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTION 125-31.25 MG/5 ML T2 QL (14 DS per 1 Fill) (amoxicillin/potassium clavulanate) Anthelmintics - Drugs For Parasites EMVERM (mebendazole) T2 QL (6 EA per 3 days) ivermectin oral T2 QL (30 EA per 365 days) REESE'S PINWORM MEDICINE (pyrantel pamoate) T2 Antifungals, Miscellaneous - Drugs For Fungus griseofulvin microsize T1 griseofulvin ultramicrosize T1 SSKI (potassium iodide) T1 Antimalarials - Drugs For The Mouth And Throat atovaquone-proguanil oral tablet 250-100 mg T2 QL (180 EA per 365 days) atovaquone-proguanil oral tablet 62.5-25 mg T2 QL (540 EA per 365 days) chloroquine phosphate T1 DARAPRIM (pyrimethamine) T1 hydroxychloroquine T1 mefloquine T1

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

6 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits primaquine T1 quinidine gluconate oral T1 quinidine sulfate oral tablet T1 quinine sulfate T3 PA Antimycobacterials, Miscellaneous - Antibiotics dapsone oral T1 Antiprotozoals, Miscellaneous - Drugs For The Mouth And Throat atovaquone T3 PA dapsone oral T1 metronidazole oral T1 PENTAM (pentamidine isethionate) T2 QL (1 EA per 30 days) Antituberculosis Agents - Antibiotics CAPASTAT (capreomycin sulfate) T3 PA ciprofloxacin T1 ciprofloxacin HCl oral T1 clarithromycin oral suspension for reconstitution T3 PA clarithromycin oral tablet T1 clarithromycin oral tablet extended release 24 hr T3 PA ethambutol T1 isoniazid T1 levofloxacin oral solution T3 PA levofloxacin oral tablet T2 QL (30 QY per 30 DYs) moxifloxacin oral T2 QL (21 QY per 21 DYs) pyrazinamide T1 rifabutin T1 rifampin T1 PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

7 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits streptomycin T2 QL (1 EA per 30 days) TRECATOR (ethionamide) T1 Antivirals, Miscellaneous - Drugs For Viral Infections foscarnet T2 QL (0.5 ML per 30 days) Azole Antifungals - Drugs For Fungus fluconazole oral suspension for reconstitution T1 fluconazole oral tablet 100 mg, 150 mg, 200 mg T1 itraconazole oral capsule T3 PA SPORANOX ORAL SOLUTION (itraconazole) T3 PA Erythromycin Antibiotics - Antibiotics erythromycin ethylsuccinate (E.E.S. 400 Oral Tablet) T1 erythromycin stearate (Erythrocin (As Stearate) Oral T1 Tablet 250 Mg) erythromycin ethylsuccinate oral suspension for T1 reconstitution 400 mg/5 mL erythromycin ethylsuccinate oral tablet T1 erythromycin oral T1 Glycopeptide Antibiotics - Antibiotics FIRVANQ ORAL RECON SOLN 25 MG/ML (vancomycin T1 HCl) vancomycin intravenous recon soln 1,000 mg, 10 gram, T1 500 mg vancomycin intravenous recon soln 5 gram T1 vancomycin oral capsule T1 vancomycin oral recon soln T1 Hcv Polymerase Inhibitor Antivirals - Drugs For Viral Infections

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

8 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits sofosbuvir-velpatasvir T3 PA VOSEVI (sofosbuvir/velpatasvir/voxilaprevir) T3 PA Hcv Protease Inhibitor Antivirals - Drugs For Viral Infections MAVYRET (glecaprevir/pibrentasvir) T2 PA ZEPATIER (elbasvir/grazoprevir) T3 PA Hcv Replication Complex Inhibitors - Drugs For Viral Infections MAVYRET (glecaprevir/pibrentasvir) T2 PA sofosbuvir-velpatasvir T3 PA VOSEVI (sofosbuvir/velpatasvir/voxilaprevir) T3 PA ZEPATIER (elbasvir/grazoprevir) T3 PA Hiv Entry And Fusion Inhibitors - Drugs For Viral Infections FUZEON SUBCUTANEOUS RECON SOLN (enfuvirtide) T2 SCO RUKOBIA (fostemsavir tromethamine) T3 PA SELZENTRY ORAL TABLET 150 MG, 300 MG (maraviroc) T2 PA; SCO TROGARZO (ibalizumab-uiyk) T2 SCO Hiv Integrase Inhibitor Antiretrovirals - Drugs For Viral Infections BIKTARVY (bictegravir sodium/emtricitabine/tenofovir T2 SCO alafenamide fumar) CABENUVA (cabotegravir/rilpivirine) T2 SCO DOVATO (dolutegravir sodium/lamivudine) T2 SCO GENVOYA (elvitegravir/cobicistat/emtricitabine/tenofovir T2 SCO alafenamide) ISENTRESS HD (raltegravir potassium) T2 SCO ISENTRESS ORAL TABLET (raltegravir potassium) T2 SCO ISENTRESS ORAL TABLET,CHEWABLE (raltegravir T2 SCO potassium) PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

9 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits JULUCA (dolutegravir sodium/rilpivirine HCl) T2 SCO STRIBILD (elvitegravir/cobicistat/emtricitabine/tenofovir T2 SCO disoproxil) TIVICAY (dolutegravir sodium) T2 SCO TIVICAY PD (dolutegravir sodium) T2 TRIUMEQ (abacavir sulfate/dolutegravir T2 SCO sodium/lamivudine) Hiv Nonnucleoside Rev.Transcrip. Inhib. - Drugs For Viral Infections COMPLERA (emtricitabine/rilpivirine HCl/tenofovir T2 SCO disoproxil fumarate) DELSTRIGO (doravirine/lamivudine/tenofovir disoproxil T2 SCO fumarate) EDURANT (rilpivirine HCl) T2 SCO efavirenz-emtricitabin-tenofov T2 SCO efavirenz-lamivu-tenofov disop T2 SCO etravirine T2 SCO INTELENCE ORAL TABLET 25 MG (etravirine) T2 SCO JULUCA (dolutegravir sodium/rilpivirine HCl) T2 SCO nevirapine T2 SCO ODEFSEY (emtricitabine/rilpivirine HCl/tenofovir T2 SCO alafenamide fumarate) PIFELTRO (doravirine) T2 SCO SUSTIVA (efavirenz) T2 SCO Hiv Nucleoside, Nucleotide Rt Inhibitors - Drugs For Viral Infections abacavir oral tablet T2 SCO abacavir-lamivudine T2 SCO abacavir-lamivudine-zidovudine T2 SCO

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

10 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits BIKTARVY (bictegravir sodium/emtricitabine/tenofovir T2 SCO alafenamide fumar) CIMDUO (lamivudine/tenofovir disoproxil fumarate) T2 SCO COMPLERA (emtricitabine/rilpivirine HCl/tenofovir T2 SCO disoproxil fumarate) DELSTRIGO (doravirine/lamivudine/tenofovir disoproxil T2 SCO fumarate) DESCOVY (emtricitabine/tenofovir alafenamide T2 SCO fumarate) didanosine oral capsule,delayed release(DR/EC) 250 T1 mg, 400 mg DOVATO (dolutegravir sodium/lamivudine) T2 SCO efavirenz-emtricitabin-tenofov T2 SCO efavirenz-lamivu-tenofov disop T2 SCO emtricitabine T2 SCO emtricitabine-tenofovir (TDF) T2 SCO EMTRIVA ORAL SOLUTION (emtricitabine) T2 SCO EPIVIR HBV ORAL SOLUTION (lamivudine) T3 PA; SCO GENVOYA (elvitegravir/cobicistat/emtricitabine/tenofovir T2 SCO alafenamide) lamivudine oral solution T2 SCO lamivudine oral tablet 100 mg T2 PA; SCO lamivudine oral tablet 150 mg, 300 mg T2 SCO lamivudine-zidovudine T2 SCO ODEFSEY (emtricitabine/rilpivirine HCl/tenofovir T2 SCO alafenamide fumarate) stavudine oral capsule T2 SCO

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

11 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits STRIBILD (elvitegravir/cobicistat/emtricitabine/tenofovir T2 SCO disoproxil) SYMTUZA (darunavir T2 SCO eth/cobicistat/emtricitabine/tenofovir alafenamide) TRIUMEQ (abacavir sulfate/dolutegravir T2 SCO sodium/lamivudine) TRUVADA ORAL TABLET 100-150 MG, 133-200 MG, 167- T2 250 MG (emtricitabine/tenofovir disoproxil fumarate) VIREAD (tenofovir disoproxil fumarate) T2 SCO ZIAGEN ORAL SOLUTION (abacavir sulfate) T2 SCO zidovudine oral capsule T1 zidovudine oral tablet T1 Hiv Protease Inhibitor Antiretrovirals - Drugs For Viral Infections APTIVUS (tipranavir) T2 SCO atazanavir oral capsule 150 mg, 300 mg T2 SCO atazanavir oral capsule 200 mg T2 EVOTAZ (atazanavir sulfate/cobicistat) T2 SCO fosamprenavir T2 SCO INVIRASE ORAL TABLET (saquinavir mesylate) T2 SCO LEXIVA ORAL SUSPENSION (fosamprenavir calcium) T2 SCO lopinavir-ritonavir T2 SCO NORVIR ORAL CAPSULE (ritonavir) T2 SCO NORVIR ORAL POWDER IN PACKET (ritonavir) T2 SCO NORVIR ORAL SOLUTION (ritonavir) T2 SCO PREZISTA ORAL SUSPENSION (darunavir ethanolate) T2 SCO PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 T2 SCO MG (darunavir ethanolate)

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

12 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits REYATAZ ORAL POWDER IN PACKET (atazanavir T2 SCO sulfate) ritonavir T2 SCO SYMTUZA (darunavir T2 SCO eth/cobicistat/emtricitabine/tenofovir alafenamide) VIRACEPT ORAL TABLET (nelfinavir mesylate) T2 SCO Interferon Antivirals - Drugs For Viral Infections INTRON A INJECTION RECON SOLN (interferon alfa- T2 PA 2b,recomb.) INTRON A INJECTION SOLUTION 10 MILLION UNIT/ML T3 PA (interferon alfa-2b,recomb.) INTRON A INJECTION SOLUTION 6 MILLION UNIT/ML T2 QL (0.5 ML per 30 days) (interferon alfa-2b,recomb.) PEGASYS SUBCUTANEOUS SOLUTION (peginterferon T2 QL (0.5 ML per 30 days) alfa-2a) Lincomycin Antibiotics - Antibiotics clindamycin HCl T1 clindamycin palmitate HCl (Clindamycin Pediatric) T1 AL (Max 12 Years) clindamycin phosphate injection T3 PA Macrolide Antibiotics - Antibiotics erythromycin ethylsuccinate (E.E.S. 400 Oral Tablet) T1 erythromycin stearate (Erythrocin (As Stearate) Oral T1 Tablet 250 Mg) erythromycin ethylsuccinate oral suspension for T1 reconstitution 400 mg/5 mL erythromycin ethylsuccinate oral tablet T1 erythromycin oral T1 Natural Penicillin Antibiotics - Antibiotics PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

13 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits BICILLIN C-R INTRAMUSCULAR SYRINGE 1,200,000 UNIT/ 2 ML(900K/300K) (penicillin G T2 QL (1 EA per 30 days) benzathine/penicillin G procaine) BICILLIN L-A INTRAMUSCULAR SYRINGE 600,000 T2 QL (1 EA per 30 days) UNIT/ML (penicillin G benzathine) penicillin G potassium T2 QL (1 EA per 30 days) penicillin G sodium T2 QL (1 EA per 30 days) penicillin V potassium T1 Neuraminidase Inhibitor Antivirals - Drugs For Viral Infections oseltamivir oral capsule T2 QL (10 EA per 180 days) oseltamivir oral suspension for reconstitution T2 QL (120 ML per 180 days) Nucleoside And Nucleotide Antivirals - Drugs For Viral Infections acyclovir oral capsule T1 acyclovir oral suspension 200 mg/5 mL T1 acyclovir oral tablet T1 adefovir T3 PA BARACLUDE ORAL SOLUTION (entecavir) T3 PA cidofovir T2 QL (0.5 ML per 30 days) entecavir oral tablet 0.5 mg T3 PA; QL (90 EA per 90 days) entecavir oral tablet 1 mg T3 PA; QL (30 EA per 30 days) ganciclovir sodium intravenous recon soln T2 QL (1 EA per 30 days) ribavirin oral capsule T1 ribavirin oral tablet 200 mg T1 SYMTUZA (darunavir T2 SCO eth/cobicistat/emtricitabine/tenofovir alafenamide) valacyclovir T1 valganciclovir oral tablet T3 PA PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

14 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits VEMLIDY (tenofovir alafenamide) T3 PA; SCO Other Macrolide Antibiotics - Antibiotics azithromycin oral packet T1 azithromycin oral suspension for reconstitution 100 T2 QL (30 EA per 90 DYs) mg/5 mL azithromycin oral suspension for reconstitution 200 T2 QL (60 EA per 90 DYs) mg/5 mL azithromycin oral tablet 250 mg T2 QL (12 EA per 90 DYs) azithromycin oral tablet 500 mg T2 QL (6 EA per 90 DYs) azithromycin oral tablet 600 mg T1 clarithromycin oral suspension for reconstitution T3 PA clarithromycin oral tablet T1 clarithromycin oral tablet extended release 24 hr T3 PA Oxazolidinone Antibiotics - Antibiotics linezolid oral tablet T3 PA ZYVOX ORAL SUSPENSION FOR RECONSTITUTION T3 PA (linezolid) Penicillinase-Resistant Penicillins - Antibiotics dicloxacillin T1 Polyene Antifungals - Drugs For Fungus amphotericin B T2 QL (1 EA per 30 days) nystatin oral suspension T1 nystatin oral tablet T1 Polymyxin Antibiotics - Antibiotics colistin (colistimethate Na) T3 PA polymyxin B sulfate T1

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

15 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits Quinolone Antibiotics - Antibiotics ciprofloxacin T1 ciprofloxacin HCl oral T1 levofloxacin oral solution T3 PA levofloxacin oral tablet T2 QL (30 QY per 30 DYs) moxifloxacin oral T2 QL (21 QY per 21 DYs) ofloxacin oral tablet 300 mg, 400 mg T3 PA Rifamycin Antibiotics - Antibiotics rifabutin T1 rifampin T1 XIFAXAN (rifaximin) T3 PA Sulfonamide Antibiotics (Systemic) - Antibiotics sulfadiazine T1 sulfamethoxazole-trimethoprim T1 sulfasalazine T1 SULFATRIM (sulfamethoxazole/trimethoprim) T1 Tetracycline Antibiotics - Antibiotics demeclocycline T3 PA doxycycline hyclate (Doxy-100) T3 PA doxycycline hyclate oral capsule T1 doxycycline hyclate oral tablet 100 mg T1 doxycycline monohydrate oral capsule 100 mg, 50 mg T1 doxycycline monohydrate oral tablet 100 mg, 50 mg T1 minocycline oral capsule 100 mg, 50 mg T2 QL (60 QY per 30 DYs) QL (60 QY per 30 DYs); AL minocycline oral capsule 75 mg T2 (Max 30 Years) PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

16 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits minocycline oral tablet T3 PA; AL (Max 30 Years) tetracycline T1 VIBRAMYCIN ORAL SYRUP (doxycycline calcium) T3 PA Urinary Anti-Infectives - Drugs For The Urinary System methenamine hippurate T1 methenamine mandelate T1 MONUROL (fosfomycin tromethamine) T1 nitrofurantoin T1 nitrofurantoin macrocrystal T1 nitrofurantoin monohyd/m-cryst T1 PRIMSOL (trimethoprim) T1 trimethoprim T1 URETRON D-S ORAL TABLET 81.6-10.8-40.8 MG (methenamine/methylene blue/sod T1 phos/p.salicylate/hyoscyamine) Antineoplastic Agents - Drugs For Cancer Antineoplastic Agents - Drugs For Cancer ALIMTA INTRAVENOUS RECON SOLN 500 MG T2 QL (1 EA per 30 days) (pemetrexed disodium) ALKERAN (melphalan) T3 PA anastrozole T1 ARRANON (nelarabine) T2 QL (0.5 ML per 30 days) ARZERRA INTRAVENOUS SOLUTION 100 MG/5 ML T2 QL (0.5 ML per 30 days) (ofatumumab) AVASTIN (bevacizumab) T2 QL (0.5 ML per 30 days) BAVENCIO (avelumab) T2 QL (0.5 ML per 30 days) BENDEKA (bendamustine HCl) T2 QL (0.5 ML per 30 days) PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

17 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits bicalutamide T1 BICNU (carmustine) T2 QL (1 EA per 30 days) bleomycin injection recon soln 15 unit T2 QL (1 EA per 30 days) capecitabine T3 PA carboplatin intravenous recon soln T2 QL (1 EA per 30 DYs) cisplatin intravenous solution T2 QL (1 EA per 30 days) cladribine T2 QL (0.5 ML per 30 days) cyclophosphamide intravenous recon soln T2 QL (1 EA per 30 days) CYRAMZA (ramucirumab) T2 QL (0.5 ML per 30 days) cytarabine (PF) injection solution 20 mg/mL T2 QL (0.5 ML per 30 days) dacarbazine T2 QL (1 EA per 30 days) DARZALEX (daratumumab) T2 QL (0.5 ML per 30 days) daunorubicin intravenous solution T2 QL (0.5 ML per 30 days) decitabine T2 QL (1 EA per 30 days) docetaxel intravenous solution 20 mg/mL (1 mL) T2 QL (0.5 ML per 30 days) doxorubicin intravenous recon soln T2 QL (1 EA per 30 days) doxorubicin intravenous solution 2 mg/mL T2 QL (1 EA per 30 days) DROXIA (hydroxyurea) T1 EMCYT (estramustine phosphate sodium) T1 EMPLICITI INTRAVENOUS RECON SOLN 300 MG T2 QL (1 EA per 30 days) (elotuzumab) epirubicin intravenous solution 200 mg/100 mL T2 QL (0.5 ML per 30 days) ERBITUX INTRAVENOUS SOLUTION 100 MG/50 ML T2 QL (0.5 ML per 30 days) (cetuximab) erlotinib oral tablet 100 mg, 150 mg T3 PA erlotinib oral tablet 25 mg T3 ETOPOPHOS (etoposide phosphate) T2 QL (1 EA per 30 days) PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

18 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits etoposide T1 exemestane T1 FARESTON (toremifene citrate) T1 FASLODEX (fulvestrant) T2 QL (0.5 ML per 30 days) FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS T2 QL (1 EA per 30 days) RECON SOLN 80 MG (degarelix acetate) floxuridine T2 QL (1 EA per 30 days) fludarabine intravenous recon soln T2 QL (1 EA per 30 days) FLUOROPLEX (fluorouracil) T1 fluorouracil intravenous solution 500 mg/10 mL T2 QL (0.5 ML per 30 days) fluorouracil topical cream 5 % T1 fluorouracil topical solution T1 flutamide T1 GAZYVA (obinutuzumab) T2 QL (0.5 ML per 30 days) gemcitabine intravenous recon soln 200 mg T2 QL (1 EA per 30 days) GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG T1 (lomustine) HALAVEN (eribulin mesylate) T2 QL (0.5 ML per 30 days) hydroxyurea T1 ifosfamide intravenous recon soln 3 gram T2 QL (1 EA per 30 days) imatinib T3 PA IMFINZI (durvalumab) T2 QL (0.5 ML per 30 days) INTRON A INJECTION RECON SOLN (interferon alfa- T2 PA 2b,recomb.) INTRON A INJECTION SOLUTION 10 MILLION UNIT/ML T3 PA (interferon alfa-2b,recomb.)

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

19 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits INTRON A INJECTION SOLUTION 6 MILLION UNIT/ML T2 QL (0.5 ML per 30 days) (interferon alfa-2b,recomb.) irinotecan intravenous solution 100 mg/5 mL T2 QL (0.5 ML per 30 days) IXEMPRA INTRAVENOUS RECON SOLN 15 MG T2 QL (1 EA per 30 days) (ixabepilone) JEVTANA (cabazitaxel) T2 QL (0.5 ML per 30 days) KEYTRUDA INTRAVENOUS SOLUTION T2 QL (0.5 ML per 30 days) (pembrolizumab) letrozole T1 LEUKERAN (chlorambucil) T3 PA LUPRON DEPOT (3 MONTH) (leuprolide acetate) T3 PA LUPRON DEPOT (4 MONTH) (leuprolide acetate) T3 PA LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 T3 PA MG (leuprolide acetate) LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 7.5 T2 QL (1 EA per 30 days) MG (leuprolide acetate) LUPRON DEPOT-PED (leuprolide acetate) T3 PA LYSODREN (mitotane) T1 MATULANE (procarbazine HCl) T3 PA megestrol oral suspension 400 mg/10 mL (40 mg/mL) T1 megestrol oral tablet T1 mercaptopurine T1 methotrexate sodium T1 methotrexate sodium (PF) T1 mitomycin intravenous T2 QL (1 EA per 30 DYs) mitoxantrone T2 QL (0.5 ML per 30 days) MYLERAN (busulfan) T3 PA

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

20 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits NEXAVAR (sorafenib tosylate) T3 PA nilutamide T1 NIPENT (pentostatin) T2 QL (1 EA per 30 days) ONCASPAR (pegaspargase) T2 QL (0.5 ML per 30 days) OPDIVO INTRAVENOUS SOLUTION 40 MG/4 ML T2 QL (0.5 ML per 30 days) (nivolumab) oxaliplatin intravenous solution 50 mg/10 mL (5 mg/mL) T2 QL (0.5 ML per 30 days) paclitaxel T2 QL (0.5 ML per 30 days) PERJETA (pertuzumab) T2 QL (0.5 ML per 30 days) PHOTOFRIN (porfimer sodium) T2 QL (1 EA per 30 days) PORTRAZZA (necitumumab) T2 QL (0.5 ML per 30 days) PROLEUKIN (aldesleukin) T2 QL (1 EA per 30 days) REVLIMID ORAL CAPSULE 10 MG, 15 MG, 25 MG, 5 MG T3 PA (lenalidomide) RITUXAN (rituximab) T2 QL (0.5 ML per 30 days) SPRYCEL ORAL TABLET 100 MG, 20 MG, 50 MG, 70 MG T3 PA (dasatinib) SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 50 MG T3 PA (sunitinib malate) SYNRIBO (omacetaxine mepesuccinate) T2 QL (1 EA per 30 days) TABLOID (thioguanine) T1 tamoxifen T1 TASIGNA ORAL CAPSULE 200 MG (nilotinib HCl) T3 PA TECENTRIQ INTRAVENOUS SOLUTION 1,200 MG/20 ML T2 QL (0.5 ML per 30 days) (60 MG/ML) (atezolizumab) TEMODAR INTRAVENOUS (temozolomide) T2 QL (1 EA per 30 days) temozolomide T3 PA

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

21 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits teniposide T2 QL (0.5 ML per 30 days) thiotepa injection recon soln 15 mg T2 QL (1 EA per 30 days) topotecan intravenous solution 4 mg/4 mL (1 mg/mL) T2 QL (0.5 ML per 30 days) TORISEL (temsirolimus) T2 QL (0.5 ML per 30 days) TRELSTAR INTRAMUSCULAR SUSPENSION FOR T2 QL (1 EA per 30 days) RECONSTITUTION 11.25 MG (triptorelin pamoate) TYKERB (lapatinib ditosylate) T3 PA VECTIBIX INTRAVENOUS SOLUTION 100 MG/5 ML (20 T2 QL (0.5 ML per 30 days) MG/ML) (panitumumab) VELCADE (bortezomib) T2 QL (1 EA per 30 days) vinblastine intravenous solution T2 QL (1 EA per 30 days) vincristine intravenous solution 1 mg/mL T2 QL (1 EA per 30 days) vinorelbine intravenous solution 50 mg/5 mL T2 QL (0.5 ML per 30 days) YERVOY INTRAVENOUS SOLUTION 50 MG/10 ML (5 T2 QL (0.5 ML per 30 days) MG/ML) (ipilimumab) YONDELIS (trabectedin) T2 QL (1 EA per 30 days) ZALTRAP INTRAVENOUS SOLUTION 100 MG/4 ML (25 T2 QL (0.5 ML per 30 days) MG/ML) (ziv-aflibercept) ZANOSAR (streptozocin) T2 QL (1 EA per 30 days) ZOLINZA (vorinostat) T3 PA Antitoxins,Immune Glob,Toxoids,Vaccines - Drugs For The Immune System Antitoxins And Immune Globulins - Organ Transplant RHOGAM ULTRA-FILTERED PLUS (Rho(D) immune T2 globulin) Toxoids - Vaccines ADACEL(TDAP ADOLESN/ADULT)(PF) QL (0.5 ML per 1 Fill); AL T2 (diphtheria,pertussis(acellular),tetanus vaccine/PF) (Min 19 Years)

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

22 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits BOOSTRIX TDAP QL (0.5 ML per 1 Fill); AL T2 (diphtheria,pertussis(acellular),tetanus vaccine) (Min 19 Years) TENIVAC (PF) (tetanus and diphtheria toxoids, QL (0.5 ML per 1 Fill); AL T2 adsorbed, adult/PF) (Min 19 Years) Vaccines - Vaccines ACTHIB (PF) (Haemophilus b conjugate vaccine(tetanus QL (0.5 ml per 1 Fill); AL T2 toxoid conjugate)/PF) (Min 19 Years) BEXSERO (meningococcal group B vaccine, 4- QL (0.5 ML per 1 Fill); AL T2 component) (Min 19 Years) ENGERIX-B (PF) (hepatitis B virus vaccine QL (1 ML per 1 Fill); AL (Min T2 recombinant/PF) 19 Years) QL (0.5 ML per 1 Fill); AL GARDASIL 9 (PF) (human papillomavirus vaccine, 9- T2 (Min 19 Years and Max 45 valent/PF) Years) HAVRIX (PF) INTRAMUSCULAR SUSPENSION 1,440 QL (1 ML per 1 Fill); AL (Min T2 ELISA UNIT/ML (hepatitis A virus vaccine/PF) 19 Years) HAVRIX (PF) INTRAMUSCULAR SYRINGE (hepatitis A QL (1 ML per 1 Fill); AL (Min T2 virus vaccine/PF) 19 Years) HEPLISAV-B (PF) INTRAMUSCULAR SYRINGE (hepatitis QL (0.5 ML per 1 Fill); AL T2 B vaccine recombinant/vaccine adjuvant CpG 1018/PF) (Min 19 Years) HIBERIX (PF) (Haemophilus b conjugate QL (0.5 ml per 1 Fill); AL T2 vaccine(tetanus toxoid conjugate)/PF) (Min 19 Years) IMOVAX RABIES VACCINE (PF) (rabies vaccine, human QL (1 ml per 1 Fill); AL (Min T2 diploid cell/PF) 19 Years) IXIARO (PF) (Japanese encephalitis vaccine/PF) T3 PA MENACTRA (PF) INTRAMUSCULAR SOLUTION QL (0.5 ML per 1 Fill); AL (meningococcalvaccine A,C,Y,W-135,diphtheria toxoid T2 (Min 19 Years) conj/PF) MENQUADFI (PF) (meningococcal vaccine A,C,Y and W- QL (0.5 ML per 1 Fill); AL T2 135,conj tetanus toxoid/PF) (Min 19 Years) PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

23 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits MENVEO A-C-Y-W-135-DIP (PF) (meningococcalvaccine QL (0.5 EA per 1 Fill); AL T2 A,C,Y,W-135,diphtheria toxoid conj/PF) (Min 19 Years) M-M-R II (PF) (measles, mumps, and rubella vaccine QL (0.5 ml per 1 Fill); AL T2 live/PF) (Min 19 Years) PENTACEL ACTHIB COMPONENT (PF) (Haemophilus B QL (0.5 ml per 1 Fill); AL T2 polysacc conj-tetanus tox,component 2 of 2/PF) (Min 19 Years) PNEUMOVAX-23 (pneumococcal 23-valent QL (0.5 ML per 1 Fill); AL T2 polysaccharide vaccine) (Min 19 Years) PREVNAR 13 (PF) (pneumococcal 13-valent conjugate QL (0.5 ML per 1 Fill); AL T2 vaccine (Diphtheria crm)/PF) (Min 19 Years) RABAVERT (PF) (rabies vaccine, purified chicken QL (1 ml per 1 Fill); AL (Min T2 embryo cell (PCEC)/PF) 19 Years) RECOMBIVAX HB (PF) (hepatitis B virus vaccine QL (1 ML per 1 Fill); AL (Min T2 recombinant/PF) 19 Years) SHINGRIX (PF) (varicella-zoster virus glycoprotein T2 AL (Min 50 Years) E,rec/AS01B adjuvant/PF) TRUMENBA (Neisseria meningitidis group B, lipidated QL (0.5 ML per 1 Fill); AL T2 fHBP recombinant) (Min 19 Years) TWINRIX (PF) INTRAMUSCULAR SYRINGE (hepatitis A QL (1 ML per 1 Fill); AL (Min T2 virus and hepatitis B virus vaccine/PF) 19 Years) TYPHIM VI (typhoid vaccine VI capsular QL (1 ML per 365 days); AL T2 polysaccharide) (Min 18 Years) QL (0.5 ML per 1 Fill); AL VAQTA (PF) (hepatitis A virus vaccine/PF) T2 (Min 19 Years) QL (1 EA per 1 Fill); AL (Min VARIVAX (PF) (varicella virus vaccine live/PF) T2 19 Years) YF-VAX (PF) (yellow fever vaccine live/PF) T3 PA QL (1 Fill per 1 Lifetime); AL ZOSTAVAX (PF) (zoster vaccine live/PF) T2 (Min 60 Years)

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

24 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits Autonomic Drugs - Drugs For The Nervous System Alpha- And Beta-Adrenergic Agonists - Drugs For Heart And Lungs ALAVERT D-12 ALLERGY-SINUS T2 (loratadine/pseudoephedrine sulfate) bupivacaine-epinephrine T3 PA bupivacaine-epinephrine (PF) injection solution 0.5 %- T3 PA 1:200,000 cetirizine-pseudoephedrine T2 CHILDREN'S SILFEDRINE (pseudoephedrine HCl) T2 ephedrine sulfate injection solution T3 PA epinephrine injection auto-injector 0.15 mg/0.3 mL T2 QL (4 EA per 180 days) epinephrine injection auto-injector 0.3 mg/0.3 mL T2 QL (4 EA per 6 monthss) epinephrine injection solution T2 QL (1 EA per 30 days) epinephrine injection syringe 0.1 mg/mL T2 QL (1 EA per 30 days) fexofenadine-pseudoephedrine T2 ST LEVOPHED (BITARTRATE) (norepinephrine bitartrate) T3 PA lidocaine-epinephrine injection solution 0.5 %-1:200,000 T3 PA lidocaine-epinephrine injection solution 1 %-1:100,000, T1 2 %-1:100,000 LOHIST - D (chlorpheniramine T1 maleate/pseudoephedrine HCl) LORATADINE-D ORAL TABLET EXTENDED RELEASE 24 T2 HR (loratadine/pseudoephedrine sulfate) MUCUS D ORAL TABLET EXTENDED RELEASE 12 HR T2 60-600 MG (guaifenesin/pseudoephedrine HCl) MUCUS RELIEF D (PSEUDOEPHED) ORAL TABLET EXTENDED RELEASE 12 HR 120-1,200 MG T2 (guaifenesin/pseudoephedrine HCl) PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

25 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits PEDIA RELIEF INFANT NASAL (pseudoephedrine HCl) T2 PEDIATRIC COUGH AND COLD ORAL LIQUID 1-15-5 MG/5 ML (chlorpheniramine T2 maleate/pseudoephedrine/dextromethorphan) pseudoephedrine HCl oral tablet T2 RESCON-DM (chlorpheniramine T2 maleate/pseudoephedrine/dextromethorphan) SUDOGEST 12-HOUR (pseudoephedrine HCl) T2 SYMJEPI (epinephrine) T2 QL (4 EA per 180 days) TUSNEL NEW FORMULA ORAL TABLET (guaifenesin/dextromethorphan HBr/pseudoephedrine T3 PA HCl) WAL-FEX D 24 HOUR (fexofenadine T2 ST HCl/pseudoephedrine HCl) XYLOCAINE-MPF/EPINEPHRINE (lidocaine T1 HCl/epinephrine/PF) Alpha-Adrenergic Agonists - Drugs For Heart And Lungs chlorpheniramine-phenyleph-DM T3 PA clonidine T1 clonidine HCl oral tablet T1 ED A-HIST DM ORAL LIQUID (chlorpheniramine T2 maleate/phenylephrine HCl/dextromethorphan) methyldopa T1 methyldopa-hydrochlorothiazide oral tablet 250-15 mg T1 methyldopa-hydrochlorothiazide oral tablet 250-25 mg T3 PA methyldopate T1 phenylephrine HCl injection T2 QL (1 EA per 30 days) phenylephrine HCl/promethazine HCl (Promethazine Vc) T1

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

26 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits QL (240 ML per 30 days); AL promethazine-phenyleph-codeine T2 (Min 18 Years) ROBAFEN CF (PHENYLEPHRINE) T2 (guaifenesin/dextromethorphan HBr/phenylephrine) Antimuscarinics/Antispasmodics - Drugs For Parkinson ANORO ELLIPTA (umeclidinium bromide/vilanterol T1 trifenatate) atropine injection solution T1 atropine injection syringe 0.05 mg/mL, 0.1 mg/mL T1 ATROVENT HFA (ipratropium bromide) T1 BENTYL INTRAMUSCULAR (dicyclomine HCl) T1 BREZTRI AEROSPHERE T3 PA (budesonide/glycopyrrolate/formoterol fumarate) chlordiazepoxide-clidinium T1 COMBIVENT RESPIMAT (ipratropium bromide/albuterol T1 sulfate) dicyclomine intramuscular T3 PA dicyclomine oral capsule T1 dicyclomine oral solution T3 PA dicyclomine oral tablet T1 diphenoxylate-atropine T1 glycopyrrolate injection T2 QL (0.5 ML per 30 days) glycopyrrolate oral tablet 1 mg, 2 mg T1 hydrocodone-homatropine oral syrup 5-1.5 mg/5 mL T2 AL (Min 18 Years) hyoscyamine sulfate oral T1 hyoscyamine sulfate sublingual T1 INCRUSE ELLIPTA (umeclidinium bromide) T2 QL (30 EA per 30 DYs)

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

27 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits ipratropium bromide inhalation T1 ipratropium-albuterol T1 phenobarb-hyoscy-atropine-scop oral elixir 16.2-0.1037 T1 -0.0194 mg/5 mL phenobarb-hyoscy-atropine-scop oral tablet T1 SPIRIVA RESPIMAT (tiotropium bromide) T2 QL (4 GM per 30 days) SPIRIVA WITH HANDIHALER (tiotropium bromide) T1 STIOLTO RESPIMAT (tiotropium bromide/olodaterol T1 HCl) TRELEGY ELLIPTA INHALATION BLISTER WITH DEVICE 100-62.5-25 MCG (fluticasone furoate/umeclidinium T3 PA bromide/vilanterol trifenat) Antiparkinsonian Agents - Drugs For Parkinson benztropine oral T2 SCO trihexyphenidyl oral tablet T2 SCO Autonomic Drugs, Miscellaneous - Drugs For The Nervous System CHANTIX (varenicline tartrate) T2 QL (180 DS per 365 days) CHANTIX CONTINUING MONTH BOX (varenicline T2 QL (180 DS per 365 days) tartrate) CHANTIX STARTING MONTH BOX (varenicline tartrate) T2 QL (180 DS per 365 days) nicotine (polacrilex) buccal gum T2 QL (340 QY per 30 DYs) nicotine (polacrilex) buccal lozenge T2 QL (324 QY per 30 DYs) nicotine transdermal patch 24 hour 14 mg/24 hr, 21 T2 QL (28 EA per 28 days) mg/24 hr, 7 mg/24 hr NICOTROL (nicotine) T3 PA NICOTROL NS (nicotine) T3 PA Centrally Acting Skeletal Muscle Relaxnt - Drugs For Relaxing Muscles

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

28 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits chlorzoxazone oral tablet 500 mg T1 cyclobenzaprine oral tablet 10 mg, 5 mg T1 methocarbamol T1 tizanidine oral tablet 2 mg T2 QL (540 QY per 30 DYs) tizanidine oral tablet 4 mg T2 QL (270 QY per 30 DYs) Direct-Acting Skeletal Muscle Relaxants - Drugs For Relaxing Muscles dantrolene oral T1 Gaba-Derivative Skeletal Muscle Relaxant - Drugs For Relaxing Muscles baclofen oral tablet 10 mg, 20 mg T1 baclofen oral tablet 5 mg T2 QL (90 EA per 30 days) Non-Sel. Beta-Adrenergic Blocking Agents - Drugs For The Heart carvedilol T1 labetalol intravenous solution T1 labetalol oral T1 nadolol T1 pindolol T3 PA propranolol intravenous T2 QL (0.5 ML per 30 days) propranolol oral T1 propranolol-hydrochlorothiazid T1 sotalol HCl (Sotalol Af) T1 sotalol oral T1 timolol maleate oral T3 PA Non-Sel.Alpha-1-Adrenergic Blocking Agts - Drugs For The Heart doxazosin T1 prazosin T1 terazosin T1 PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

29 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits Non-Sel.Alpha-Adrenergic Blocking Agents - Drugs For The Heart ergoloid T3 ergotamine-caffeine T1 MIGERGOT (ergotamine tartrate/caffeine) T1 phenoxybenzamine T3 PA Parasympathomimetic (Cholinergic Agents) - Drugs For Bladder Incontinence ARICEPT ORAL TABLET 23 MG (donepezil HCl) T3 PA bethanechol chloride oral tablet 10 mg, 25 mg, 5 mg T1 bethanechol chloride oral tablet 50 mg T3 PA cevimeline T1 donepezil oral tablet 10 mg, 5 mg T1 donepezil oral tablet,disintegrating T1 MESTINON ORAL SYRUP (pyridostigmine bromide) T1 MESTINON TIMESPAN (pyridostigmine bromide) T1 pilocarpine HCl oral tablet 5 mg T1 pyridostigmine bromide oral tablet 60 mg T1 REGONOL (pyridostigmine bromide) T2 QL (1 EA per 30 days) rivastigmine transdermal patch 24 hour 4.6 mg/24 hour, T3 PA 9.5 mg/24 hour Selective Alpha-1-Adrenergic Block.Agent - Drugs For The Heart alfuzosin T1 carvedilol T1 labetalol intravenous solution T1 labetalol oral T1 tamsulosin T1 Selective Beta-1-Adrenergic Agonists - Drugs For Heart And Lungs PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

30 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits dopamine in 5 % dextrose intravenous solution 800 T3 PA mg/250 mL (3,200 mcg/mL) dopamine intravenous solution 800 mg/5 mL (160 T3 PA mg/mL) Selective Beta-2-Adrenergic Agonists - Drugs For Heart And Lungs ADVAIR HFA (fluticasone propionate/salmeterol T1 xinafoate) albuterol sulfate inhalation HFA aerosol inhaler T2 QL (2 QY per 30 days) albuterol sulfate inhalation solution for nebulization 2.5 T1 mg /3 mL (0.083 %), 5 mg/mL albuterol sulfate oral T1 ANORO ELLIPTA (umeclidinium bromide/vilanterol T1 trifenatate) BREO ELLIPTA (fluticasone furoate/vilanterol T3 PA trifenatate) BREZTRI AEROSPHERE T3 PA (budesonide/glycopyrrolate/formoterol fumarate) budesonide-formoterol T2 QL (10.2 GM per 30 days) COMBIVENT RESPIMAT (ipratropium bromide/albuterol T1 sulfate) DULERA (mometasone furoate/formoterol fumarate) T1 fluticasone propion-salmeterol inhalation blister with T1 device ipratropium-albuterol T1 levalbuterol HCl T3 PA levalbuterol tartrate T3 PA metaproterenol oral syrup T1 SEREVENT DISKUS (salmeterol xinafoate) T1

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

31 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits STIOLTO RESPIMAT (tiotropium bromide/olodaterol T1 HCl) terbutaline oral T1 TRELEGY ELLIPTA INHALATION BLISTER WITH DEVICE 100-62.5-25 MCG (fluticasone furoate/umeclidinium T3 PA bromide/vilanterol trifenat) fluticasone propionate/salmeterol xinafoate (Wixela T1 Inhub) Selective Beta-Adrenergic Blocking Agent - Drugs For The Heart acebutolol T1 atenolol T1 atenolol-chlorthalidone T1 bisoprolol fumarate T1 bisoprolol-hydrochlorothiazide T1 esmolol intravenous solution T3 PA metoprolol succinate T1 metoprolol tartrate intravenous solution T2 QL (1 EA per 30 DYs) metoprolol tartrate oral tablet 100 mg, 50 mg T1 metoprolol tartrate oral tablet 25 mg T1 Skeletal Muscle Relaxants, Miscellaneous - Drugs For Relaxing Muscles orphenadrine citrate injection T2 QL (1 EA per 30 days) Blood Formation, Coagulation, Thrombosis - Drugs For The Blood Coumarin Derivatives - Drugs To Prevent Blood Clots warfarin sodium (Jantoven) T1 warfarin T1 Direct Factor Xa Inhibitors - Drugs To Prevent Blood Clots

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

32 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits ELIQUIS (apixaban) T2 QL (60 EA per 30 days) ELIQUIS DVT-PE TREAT 30D START (apixaban) T2 QL (74 EA per 30 days) XARELTO DVT-PE TREAT 30D START (rivaroxaban) T2 QL (51 EA per 30 days) XARELTO ORAL TABLET 10 MG, 20 MG (rivaroxaban) T2 QL (30 EA per 30 days) XARELTO ORAL TABLET 15 MG (rivaroxaban) T2 QL (42 EA per 21 days) XARELTO ORAL TABLET 2.5 MG (rivaroxaban) T2 QL (60 EA per 30 days) Hematopoietic Agents - Drugs For Anemia EPOGEN INJECTION SOLUTION 10,000 UNIT/ML, 2,000 T3 PA UNIT/ML, 4,000 UNIT/ML (epoetin alfa) FULPHILA (pegfilgrastim-jmdb) T3 PA GRANIX SUBCUTANEOUS SYRINGE (tbo-filgrastim) T3 PA NIVESTYM SUBCUTANEOUS (filgrastim-aafi) T3 PA RETACRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 T3 PA UNIT/ML, 40,000 UNIT/ML (epoetin alfa-epbx) UDENYCA (pegfilgrastim-cbqv) T3 PA Hemorrheologic Agents - Drugs For Blood Flow pentoxifylline T1 Hemostatics - Drugs To Prevent Bleeding AMICAR ORAL TABLET (aminocaproic acid) T3 PA aminocaproic acid intravenous T2 QL (1 EA per 30 days) aminocaproic acid oral solution T3 PA desmopressin injection T3 PA desmopressin nasal spray,non-aerosol T3 PA desmopressin oral T2 AL (Min 6 Years) tranexamic acid oral T3 PA

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

33 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits Heparins - Drugs To Prevent Blood Clots enoxaparin subcutaneous solution T3 PA enoxaparin subcutaneous syringe 100 mg/mL, 150 T2 QL (40 ML per 180 days) mg/mL enoxaparin subcutaneous syringe 120 mg/0.8 mL, 80 T2 QL (32 ML per 180 days) mg/0.8 mL enoxaparin subcutaneous syringe 30 mg/0.3 mL T2 QL (12 ML per 180 days) enoxaparin subcutaneous syringe 40 mg/0.4 mL T2 QL (16 ML per 180 days) enoxaparin subcutaneous syringe 60 mg/0.6 mL T2 QL (24 ML per 180 days) heparin (porcine) injection solution T2 QL (1 EA per 30 days) heparin (porcine) injection syringe 5,000 unit/mL T2 QL (1 EA per 30 days) heparin flush(porcine)-0.9NaCl T2 QL (1 EA per 30 days) heparin lock flush (porcine) intravenous solution 100 T2 QL (1 EA per 30 days) unit/mL HEPARIN LOCK FLUSH INTRAVENOUS SOLUTION T2 QL (1 EA per 30 days) (heparin sodium,porcine) heparin, porcine (PF) injection syringe 5,000 unit/0.5 mL T2 QL (1 EA per 30 days) Iron Preparations - Vitamins And Minerals FEOSOL ORAL TABLET 45 MG (iron,carbonyl) T2 ferrous gluconate oral tablet 324 mg (37.5 mg iron), 324 T2 mg (38 mg iron) ferrous sulfate oral drops T2 ferrous sulfate oral elixir T1 ferrous sulfate oral tablet 325 mg (65 mg iron) T2 ferrous sulfate oral tablet,delayed release (DR/EC) 325 T1 mg (65 mg iron) FOLITAB (ferrous sulfate/ascorbic acid/folic acid) T1

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

34 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits GERITOL TONIC WITH FERREX 18 (thiamine/riboflavin/niacin/pant T1 acid/B6/iron/methion/choline) HEMOCYTE-F (ferrous fumarate/folic acid) T1 INFED (iron dextran complex) T2 QL (1 EA per 30 DYs) KOSHER PRENATAL PLUS IRON (prenatal vitamins T3 PA no.108/iron,carbonyl/folic acid) OB COMPLETE PETITE (prenatal no56/iron T3 PA carbonyl,asparto glycinate/folic acid/dha) polysaccharide iron complex T1 PRENATAL + DHA ORAL COMBO PACK 28 MG IRON-800 MCG-200 MG (prenatal vit with calcium 95/ferrous T2 QL (1 EA per 1 day) fumarate/folic acid/dha) PRENATAL PLUS (CALCIUM CARB) (prenatal vits with AL (Min 13 Years and Max T2 calcium no.72/ferrous fumarate/folic acid) 45 Years) PRENATE DHA (FERR ASP GLYCIN) (prenatal vitamins T3 PA no.78/iron asparto glycin/folate no.1/dha) PRENATE ENHANCE (prenatal vitamins no.68/iron T3 PA fumarate/folate no.6/dha) PRENATE MINI (FERR ASP GLYCIN) (prenatal vits T3 PA no.87/iron carb-asp.glycinate/folate no.1/dha) PRENATE PIXIE (prenatal vitamins no.85/iron asparto T3 PA glycin/folate no.1/dha) PRIMACARE (prenatal vits no.118/iron asparto T3 PA glycinate/folate no.6/dha) SELECT-OB + DHA (prenatal vitamins no.33/iron T3 PA polysach complex/folic acid/dha) VITAMED MD ONE RX (prenatal vits no.25/ferrous T3 PA fumarate/folate comb. no.6/dha)

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

35 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits Platelet-Aggregation Inhibitors - Drugs To Prevent Blood Clots aspirin oral tablet T2 aspirin oral tablet,chewable T2 aspirin oral tablet,delayed release (DR/EC) 325 mg, 500 T2 mg, 650 mg, 81 mg aspirin rectal T2 aspirin-dipyridamole T1 BAYER ADVANCED 500 MG TABLET T1 BAYER ADVANCED ORAL TABLET 500 MG (aspirin) T1 BRILINTA ORAL TABLET 60 MG (ticagrelor) T3 PA BRILINTA ORAL TABLET 90 MG (ticagrelor) T2 QL (60 EA per 30 days) butalbital-aspirin-caffeine oral capsule T1 cilostazol T1 clopidogrel oral tablet 300 mg T2 QL (2 EA per 30 days) clopidogrel oral tablet 75 mg T1 dipyridamole oral T1 prasugrel T2 QL (30 EA per 30 days) Platelet-Reducing Agents - Drugs To Prevent Blood Clots anagrelide oral capsule 0.5 mg T1 Thrombolytic Agents - Drugs To Prevent Blood Clots aspirin oral tablet T2 aspirin oral tablet,chewable T2 aspirin oral tablet,delayed release (DR/EC) 325 mg, 500 T2 mg, 650 mg, 81 mg aspirin rectal T2 butalbital-aspirin-caffeine oral capsule T1

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

36 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits Cardiovascular Drugs - Drugs For The Heart Alpha-Adrenergic Blocking Agents - Drugs For High Blood Pressure carvedilol T1 doxazosin T1 labetalol intravenous solution T1 labetalol oral T1 prazosin T1 terazosin T1 Alpha-Adrenergic Blocking Agt.(Hypoten) - Drugs For High Blood Pressure & Angina doxazosin T1 labetalol intravenous solution T1 labetalol oral T1 prazosin T1 terazosin T1 Angiotensin Ii Receptor Antagon.(Hypotn) - Drugs For High Blood Pressure & Angina irbesartan T1 irbesartan-hydrochlorothiazide T1 losartan T1 losartan-hydrochlorothiazide T1 MICARDIS (telmisartan) T3 PA MICARDIS HCT (telmisartan/hydrochlorothiazide) T3 PA olmesartan T1 olmesartan-hydrochlorothiazide T1 telmisartan T1 PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

37 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits valsartan T1 valsartan-hydrochlorothiazide T1 Angiotensin Ii Receptor Antagonists - Drugs For The Heart ENTRESTO (sacubitril/valsartan) T2 QL (60 EA per 30 days) irbesartan T1 irbesartan-hydrochlorothiazide T1 losartan T1 losartan-hydrochlorothiazide T1 MICARDIS (telmisartan) T3 PA MICARDIS HCT (telmisartan/hydrochlorothiazide) T3 PA olmesartan T1 olmesartan-hydrochlorothiazide T1 telmisartan T1 valsartan T1 valsartan-hydrochlorothiazide T1 Angiotensin-Convert.Enzyme Inhib(Hypotn) - Drugs For High Blood Pressure & Angina amlodipine-benazepril oral capsule 10-20 mg, 10-40 mg, T1 5-10 mg, 5-20 mg, 5-40 mg benazepril T1 benazepril-hydrochlorothiazide oral tablet 10-12.5 mg, T1 20-12.5 mg, 5-6.25 mg captopril T1 captopril-hydrochlorothiazide T2 PA enalapril maleate T1 enalapril-hydrochlorothiazide oral tablet 10-25 mg T1

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

38 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits fosinopril T1 lisinopril T1 lisinopril-hydrochlorothiazide T1 quinapril T1 quinapril-hydrochlorothiazide T1 ramipril T1 trandolapril T1 Angiotensin-Converting Enzyme Inhibitors - Drugs For The Heart amlodipine-benazepril oral capsule 10-20 mg, 10-40 mg, T1 5-10 mg, 5-20 mg, 5-40 mg benazepril T1 benazepril-hydrochlorothiazide oral tablet 10-12.5 mg, T1 20-12.5 mg, 5-6.25 mg captopril T1 captopril-hydrochlorothiazide T2 PA enalapril maleate T1 enalapril-hydrochlorothiazide oral tablet 10-25 mg T1 fosinopril T1 lisinopril T1 lisinopril-hydrochlorothiazide T1 quinapril T1 quinapril-hydrochlorothiazide T1 ramipril T1 trandolapril T1 Antiarrhythmics, Miscellaneous - Drugs For Angina digoxin (Digox) T1

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

39 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits digoxin injection solution T1 digoxin injection syringe T2 QL (1 EA per 30 days) digoxin oral solution 50 mcg/mL (0.05 mg/mL) T1 digoxin oral tablet T1 LANOXIN PEDIATRIC (digoxin) T1 Antilipemic Agents, Miscellaneous - Drugs For Cholesterol omega-3 acid ethyl esters (Lovaza) T2 ST NEXLETOL (bempedoic acid) T3 PA NEXLIZET (bempedoic acid/ezetimibe) T3 PA niacin oral capsule, extended release 125 mg, 250 mg, T2 500 mg niacin oral tablet T2 niacin oral tablet extended release T2 niacin oral tablet extended release 24 hr T3 PA omega 3-dha-epa-fish oil oral capsule 300-1,000 mg T1 omega 3-dha-epa-fish oil oral capsule,delayed T1 release(DR/EC) 300 mg (120 mg- 180mg)-1,000 mg omega 3-dha-epa-fish oil oral capsule,delayed T1 release(DR/EC) 300-1,000 mg omega-3 fatty acids oral capsule T1 omega-3 fatty acids-fish oil oral capsule 300-1,000 mg T1 Beta-Adrenergic Blocking Agents - Drugs For Abnormal Heart Rhythms acebutolol T1 atenolol T1 atenolol-chlorthalidone T1 bisoprolol fumarate T1 bisoprolol-hydrochlorothiazide T1 PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

40 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits carvedilol T1 esmolol intravenous solution T3 PA labetalol intravenous solution T1 labetalol oral T1 LEVATOL (penbutolol sulfate) T3 PA metoprolol succinate T1 metoprolol tartrate intravenous solution T2 QL (1 EA per 30 DYs) metoprolol tartrate oral tablet 100 mg, 50 mg T1 metoprolol tartrate oral tablet 25 mg T1 nadolol T1 pindolol T3 PA propranolol intravenous T2 QL (0.5 ML per 30 days) propranolol oral T1 propranolol-hydrochlorothiazid T1 sotalol HCl (Sotalol Af) T1 sotalol oral T1 timolol maleate oral T3 PA Beta-Adrenergic Blocking Agt.(Hypoten) - Drugs For High Blood Pressure & Angina acebutolol T1 atenolol T1 atenolol-chlorthalidone T1 bisoprolol fumarate T1 bisoprolol-hydrochlorothiazide T1 esmolol intravenous solution T3 PA labetalol intravenous solution T1

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

41 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits labetalol oral T1 metoprolol succinate T1 metoprolol tartrate intravenous solution T2 QL (1 EA per 30 DYs) metoprolol tartrate oral tablet 100 mg, 50 mg T1 metoprolol tartrate oral tablet 25 mg T1 nadolol T1 pindolol T3 PA propranolol intravenous T2 QL (0.5 ML per 30 days) propranolol oral T1 propranolol-hydrochlorothiazid T1 sotalol HCl (Sotalol Af) T1 sotalol oral T1 timolol maleate oral T3 PA Bile Acid Sequestrants - Drugs For Cholesterol cholestyramine (with sugar) T1 cholestyramine/aspartame (Cholestyramine Light Oral T1 Powder In Packet) colestipol T1 cholestyramine/aspartame (Prevalite) T1 Calcium-Channel Block.Agt,Misc(Hypoten) - Drugs For High Blood Pressure & Angina CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 T3 PA HR 120 MG (diltiazem HCl) diltiazem HCl (Cartia Xt) T1 diltiazem HCl oral capsule,ext.rel 24h degradable T1 diltiazem HCl oral capsule,extended release 12 hr T2 ST

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

42 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits diltiazem HCl oral capsule,extended release 24 hr T1 diltiazem HCl oral capsule,extended release 24hr 120 T1 mg, 180 mg, 240 mg, 300 mg diltiazem HCl oral capsule,extended release 24hr 360 T3 PA mg diltiazem HCl oral tablet T1 diltiazem HCl oral tablet extended release 24 hr T3 PA DILT-XR (diltiazem HCl) T1 diltiazem HCl (Matzim La) T3 PA diltiazem HCl (Taztia Xt Oral Capsule,Extended Release T1 24 Hr 120 Mg, 180 Mg, 240 Mg, 360 Mg) diltiazem HCl (Taztia Xt Oral Capsule,Extended Release T2 PA 24 Hr 300 Mg) verapamil intravenous T1 verapamil oral capsule,ext rel. pellets 24 hr 120 mg, 180 T1 mg, 240 mg verapamil oral capsule,ext rel. pellets 24 hr 360 mg T3 PA verapamil oral tablet T1 verapamil oral tablet extended release T1 Calcium-Channel Blocking Agents - Drugs For High Blood Pressure & Angina amlodipine T1 amlodipine-atorvastatin oral tablet 10-10 mg, 10-20 mg, T3 PA 10-40 mg, 10-80 mg, 5-10 mg, 5-20 mg, 5-40 mg, 5-80 mg amlodipine-benazepril oral capsule 10-20 mg, 10-40 mg, T1 5-10 mg, 5-20 mg, 5-40 mg CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 T3 PA HR 120 MG (diltiazem HCl) diltiazem HCl (Cartia Xt) T1

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

43 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits diltiazem HCl oral capsule,ext.rel 24h degradable T1 diltiazem HCl oral capsule,extended release 12 hr T2 ST diltiazem HCl oral capsule,extended release 24 hr T1 diltiazem HCl oral capsule,extended release 24hr 120 T1 mg, 180 mg, 240 mg, 300 mg diltiazem HCl oral capsule,extended release 24hr 360 T3 PA mg diltiazem HCl oral tablet T1 diltiazem HCl oral tablet extended release 24 hr T3 PA DILT-XR (diltiazem HCl) T1 felodipine T1 isradipine T2 ST diltiazem HCl (Matzim La) T3 PA nicardipine oral T3 PA nifedipine oral capsule T3 PA nifedipine oral tablet extended release T1 nifedipine oral tablet extended release 24hr T1 nimodipine T3 PA diltiazem HCl (Taztia Xt Oral Capsule,Extended Release T1 24 Hr 120 Mg, 180 Mg, 240 Mg, 360 Mg) diltiazem HCl (Taztia Xt Oral Capsule,Extended Release T2 PA 24 Hr 300 Mg) verapamil intravenous T1 verapamil oral capsule,ext rel. pellets 24 hr 120 mg, 180 T1 mg, 240 mg verapamil oral capsule,ext rel. pellets 24 hr 360 mg T3 PA verapamil oral tablet T1

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

44 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits verapamil oral tablet extended release T1 Calcium-Channel Blocking Agents(Hypoten) - Drugs For High Blood Pressure & Angina CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 T3 PA HR 120 MG (diltiazem HCl) diltiazem HCl (Cartia Xt) T1 diltiazem HCl oral capsule,ext.rel 24h degradable T1 diltiazem HCl oral capsule,extended release 12 hr T2 ST diltiazem HCl oral capsule,extended release 24 hr T1 diltiazem HCl oral capsule,extended release 24hr 120 T1 mg, 180 mg, 240 mg, 300 mg diltiazem HCl oral capsule,extended release 24hr 360 T3 PA mg diltiazem HCl oral tablet T1 diltiazem HCl oral tablet extended release 24 hr T3 PA DILT-XR (diltiazem HCl) T1 diltiazem HCl (Matzim La) T3 PA diltiazem HCl (Taztia Xt Oral Capsule,Extended Release T1 24 Hr 120 Mg, 180 Mg, 240 Mg, 360 Mg) diltiazem HCl (Taztia Xt Oral Capsule,Extended Release T2 PA 24 Hr 300 Mg) verapamil intravenous T1 verapamil oral capsule,ext rel. pellets 24 hr 120 mg, 180 T1 mg, 240 mg verapamil oral capsule,ext rel. pellets 24 hr 360 mg T3 PA verapamil oral tablet T1 verapamil oral tablet extended release T1

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

45 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits Calcium-Channel Blocking Agents, Misc. - Drugs For High Blood Pressure & Angina CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 T3 PA HR 120 MG (diltiazem HCl) diltiazem HCl (Cartia Xt) T1 diltiazem HCl oral capsule,ext.rel 24h degradable T1 diltiazem HCl oral capsule,extended release 12 hr T2 ST diltiazem HCl oral capsule,extended release 24 hr T1 diltiazem HCl oral capsule,extended release 24hr 120 T1 mg, 180 mg, 240 mg, 300 mg diltiazem HCl oral capsule,extended release 24hr 360 T3 PA mg diltiazem HCl oral tablet T1 diltiazem HCl oral tablet extended release 24 hr T3 PA DILT-XR (diltiazem HCl) T1 diltiazem HCl (Matzim La) T3 PA diltiazem HCl (Taztia Xt Oral Capsule,Extended Release T1 24 Hr 120 Mg, 180 Mg, 240 Mg, 360 Mg) diltiazem HCl (Taztia Xt Oral Capsule,Extended Release T2 PA 24 Hr 300 Mg) verapamil intravenous T1 verapamil oral capsule,ext rel. pellets 24 hr 120 mg, 180 T1 mg, 240 mg verapamil oral capsule,ext rel. pellets 24 hr 360 mg T3 PA verapamil oral tablet T1 verapamil oral tablet extended release T1 Carbonic Anhydrase Inhibitors(Hypoten) - Drugs For High Blood Pressure & Angina PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

46 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits acetazolamide T1 Cardiotonic Agents - Drugs For Angina digoxin (Digox) T1 digoxin injection solution T1 digoxin injection syringe T2 QL (1 EA per 30 days) digoxin oral solution 50 mcg/mL (0.05 mg/mL) T1 digoxin oral tablet T1 dopamine in 5 % dextrose intravenous solution 800 T3 PA mg/250 mL (3,200 mcg/mL) dopamine intravenous solution 800 mg/5 mL (160 T3 PA mg/mL) LANOXIN PEDIATRIC (digoxin) T1 Central Alpha-Agonists - Drugs For High Blood Pressure & Angina clonidine T1 clonidine HCl oral tablet T1 guanfacine T1 methyldopa T1 methyldopa-hydrochlorothiazide oral tablet 250-15 mg T1 methyldopa-hydrochlorothiazide oral tablet 250-25 mg T3 PA methyldopate T1 Cholesterol Absorption Inhibitors - Drugs For Cholesterol ezetimibe T2 ST NEXLIZET (bempedoic acid/ezetimibe) T3 PA Class Ia Antiarrhythmics - Drugs For Angina disopyramide phosphate oral capsule T1 NORPACE CR (disopyramide phosphate) T1

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

47 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits procainamide injection solution 100 mg/mL T2 QL (0.5 ML per 30 days) procainamide injection solution 500 mg/mL T1 quinidine gluconate oral T1 quinidine sulfate oral tablet T1 Class Ib Antiarrhythmics - Drugs For Angina DILANTIN (phenytoin sodium extended) T1 mexiletine T1 phenytoin oral suspension 125 mg/5 mL T1 phenytoin oral tablet,chewable T1 phenytoin sodium T1 phenytoin sodium extended T1 Class Ic Antiarrhythmics - Drugs For Angina flecainide T1 propafenone T1 Class Ii Antiarrhythmics - Drugs For Angina acebutolol T1 atenolol T1 atenolol-chlorthalidone T1 bisoprolol fumarate T1 bisoprolol-hydrochlorothiazide T1 carvedilol T1 esmolol intravenous solution T3 PA labetalol intravenous solution T1 labetalol oral T1 metoprolol succinate T1 metoprolol tartrate intravenous solution T2 QL (1 EA per 30 DYs) PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

48 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits metoprolol tartrate oral tablet 100 mg, 50 mg T1 metoprolol tartrate oral tablet 25 mg T1 nadolol T1 pindolol T3 PA propranolol intravenous T2 QL (0.5 ML per 30 days) propranolol oral T1 propranolol-hydrochlorothiazid T1 sotalol HCl (Sotalol Af) T1 sotalol oral T1 timolol maleate oral T3 PA Class Iii Antiarrhythmics - Drugs For Angina amiodarone oral T1 dofetilide oral capsule 250 mcg, 500 mcg T1 MULTAQ (dronedarone HCl) T3 PA sotalol HCl (Sotalol Af) T1 sotalol oral T1 TIKOSYN ORAL CAPSULE 125 MCG (dofetilide) T1 Class Iv Antiarrhythmics - Drugs For Angina CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 T3 PA HR 120 MG (diltiazem HCl) diltiazem HCl (Cartia Xt) T1 diltiazem HCl oral capsule,ext.rel 24h degradable T1 diltiazem HCl oral capsule,extended release 12 hr T2 ST diltiazem HCl oral capsule,extended release 24 hr T1 diltiazem HCl oral capsule,extended release 24hr 120 T1 mg, 180 mg, 240 mg, 300 mg

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

49 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits diltiazem HCl oral capsule,extended release 24hr 360 T3 PA mg diltiazem HCl oral tablet T1 diltiazem HCl oral tablet extended release 24 hr T3 PA DILT-XR (diltiazem HCl) T1 diltiazem HCl (Matzim La) T3 PA verapamil intravenous T1 verapamil oral capsule,ext rel. pellets 24 hr 120 mg, 180 T1 mg, 240 mg verapamil oral capsule,ext rel. pellets 24 hr 360 mg T3 PA verapamil oral tablet T1 verapamil oral tablet extended release T1 Dihydropyridines - Drugs For High Blood Pressure & Angina amlodipine T1 amlodipine-atorvastatin oral tablet 10-10 mg, 10-20 mg, T3 PA 10-40 mg, 10-80 mg, 5-10 mg, 5-20 mg, 5-40 mg, 5-80 mg amlodipine-benazepril oral capsule 10-20 mg, 10-40 mg, T1 5-10 mg, 5-20 mg, 5-40 mg felodipine T1 isradipine T2 ST nicardipine oral T3 PA nifedipine oral capsule T3 PA nifedipine oral tablet extended release T1 nifedipine oral tablet extended release 24hr T1 nimodipine T3 PA Dihydropyridines (Antihypertensive) - Drugs For High Blood Pressure & Angina amlodipine T1 PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

50 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits amlodipine-atorvastatin oral tablet 10-10 mg, 10-20 mg, T3 PA 10-40 mg, 10-80 mg, 5-10 mg, 5-20 mg, 5-40 mg, 5-80 mg amlodipine-benazepril oral capsule 10-20 mg, 10-40 mg, T1 5-10 mg, 5-20 mg, 5-40 mg felodipine T1 isradipine T2 ST nicardipine oral T3 PA nifedipine oral capsule T3 PA nifedipine oral tablet extended release T1 nifedipine oral tablet extended release 24hr T1 nimodipine T3 PA Direct Vasodilators - Drugs For High Blood Pressure & Angina hydralazine T1 minoxidil oral T1 Diuretics, Miscellaneous (Hypotensive) - Drugs For High Blood Pressure & Angina theophylline in dextrose 5 % intravenous parenteral T2 QL (1 EA per 30 days) solution 200 mg/100 mL theophylline oral elixir T1 theophylline oral tablet extended release 12 hr 300 mg, T1 450 mg theophylline oral tablet extended release 24 hr T1 Fibric Acid Derivatives - Drugs For Cholesterol fenofibrate micronized oral capsule 134 mg T1 fenofibrate micronized oral capsule 200 mg, 67 mg T2 ST fenofibrate nanocrystallized oral tablet 145 mg, 48 mg T1 fenofibrate oral tablet 160 mg, 54 mg T1 PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

51 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits gemfibrozil T1 Hmg-Coa Reductase Inhibitors - Drugs For Cholesterol amlodipine-atorvastatin oral tablet 10-10 mg, 10-20 mg, T3 PA 10-40 mg, 10-80 mg, 5-10 mg, 5-20 mg, 5-40 mg, 5-80 mg atorvastatin T1 fluvastatin oral capsule T3 PA fluvastatin oral tablet extended release 24 hr T2 PA lovastatin T1 pravastatin T2 QL (30 EA per 30 days) rosuvastatin T2 QL (30 EA per 30 days) simvastatin oral tablet T1 Hypotensive Agents, Miscellaneous - Drugs For High Blood Pressure & Angina acebutolol T1 amlodipine T1 amlodipine-benazepril oral capsule 10-20 mg, 10-40 mg, T1 5-10 mg, 5-20 mg, 5-40 mg carvedilol T1 doxazosin T1 felodipine T1 isradipine T2 ST nicardipine oral T3 PA nifedipine oral capsule T3 PA nifedipine oral tablet extended release T1 nifedipine oral tablet extended release 24hr T1 nimodipine T3 PA phenoxybenzamine T3 PA

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

52 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits pindolol T3 PA propranolol intravenous T2 QL (0.5 ML per 30 days) propranolol oral T1 sotalol HCl (Sotalol Af) T1 sotalol oral T1 terazosin T1 timolol maleate oral T3 PA Loop Diuretics (Hypotensive Agents) - Drugs For High Blood Pressure & Angina bumetanide T1 EDECRIN (ethacrynic acid) T1 ethacrynate sodium T1 furosemide injection T2 QL (1 EA per 30 days) furosemide oral solution 10 mg/mL T2 QL (1 EA per 30 days) furosemide oral solution 40 mg/5 mL (8 mg/mL) T1 furosemide oral tablet T1 torsemide oral T1 Mineralocorticoid (Aldosterone) Antagnts - Drugs For The Heart ALDACTAZIDE ORAL TABLET 50-50 MG T3 PA (spironolactone/hydrochlorothiazide) spironolactone T1 spironolacton-hydrochlorothiaz T1 Mineralocorticoid(Aldoster.)Antag(Hypot) - Drugs For High Blood Pressure & Angina ALDACTAZIDE ORAL TABLET 50-50 MG T3 PA (spironolactone/hydrochlorothiazide) spironolactone T1

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

53 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits spironolacton-hydrochlorothiaz T1 Nitrates And Nitrites - Drugs For The Heart DILATRATE-SR (isosorbide dinitrate) T1 isosorbide dinitrate oral T1 isosorbide mononitrate T1 nitroglycerin (Nitro-Bid) T1 nitroglycerin oral T1 nitroglycerin sublingual T1 nitroglycerin transdermal patch 24 hour T1 Osmotic Diuretics (Hypotensive Agents) - Drugs For High Blood Pressure & Angina mannitol 10 % T2 QL (1 EA per 30 days) mannitol 20 % T2 QL (1 EA per 30 days) mannitol 25 % intravenous solution T2 QL (1 EA per 30 days) mannitol 5 % T2 QL (1 EA per 30 days) Pcsk9 Inhibitors - Drugs For Cholesterol REPATHA PUSHTRONEX (evolocumab) T3 PA REPATHA SURECLICK (evolocumab) T3 PA REPATHA SYRINGE (evolocumab) T3 PA Phosphodiesterase Type 5 Inhibitors - Drugs For The Heart CIALIS (tadalafil) T3 PA; QL (3 QY per 30 DYs) cilostazol T1 LEVITRA ORAL TABLET 10 MG (vardenafil HCl) T3 PA; QL (3 QY per 30 DYs) sildenafil (pulm.hypertension) oral tablet T3 PA tadalafil (pulm. hypertension) T3 PA VIAGRA (sildenafil citrate) T3 PA; QL (3 QY per 30 DYs) PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

54 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits Potassium-Sparing Diuretics (Hypoten) - Drugs For High Blood Pressure & Angina ALDACTAZIDE ORAL TABLET 50-50 MG T3 PA (spironolactone/hydrochlorothiazide) amiloride T1 amiloride-hydrochlorothiazide T1 DYRENIUM (triamterene) T3 PA spironolactone T1 spironolacton-hydrochlorothiaz T1 triamterene-hydrochlorothiazid oral capsule 37.5-25 mg T1 triamterene-hydrochlorothiazid oral tablet T1 Renin-Angioten.-Aldost. Sys. Inhib, Misc - Drugs For The Heart ENTRESTO (sacubitril/valsartan) T2 QL (60 EA per 30 days) Thiazide Diuretics(Hypotensive Agents) - Drugs For High Blood Pressure & Angina ALDACTAZIDE ORAL TABLET 50-50 MG T3 PA (spironolactone/hydrochlorothiazide) amiloride-hydrochlorothiazide T1 benazepril-hydrochlorothiazide oral tablet 10-12.5 mg, T1 20-12.5 mg, 5-6.25 mg bisoprolol-hydrochlorothiazide T1 captopril-hydrochlorothiazide T2 PA chlorothiazide oral tablet 500 mg T1 DIURIL (chlorothiazide) T1 enalapril-hydrochlorothiazide oral tablet 10-25 mg T1 hydrochlorothiazide oral capsule T1 hydrochlorothiazide oral tablet 25 mg, 50 mg T1 PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

55 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits irbesartan-hydrochlorothiazide T1 lisinopril-hydrochlorothiazide T1 losartan-hydrochlorothiazide T1 methyldopa-hydrochlorothiazide oral tablet 250-15 mg T1 methyldopa-hydrochlorothiazide oral tablet 250-25 mg T3 PA MICARDIS HCT (telmisartan/hydrochlorothiazide) T3 PA olmesartan-hydrochlorothiazide T1 propranolol-hydrochlorothiazid T1 quinapril-hydrochlorothiazide T1 spironolacton-hydrochlorothiaz T1 triamterene-hydrochlorothiazid oral capsule 37.5-25 mg T1 triamterene-hydrochlorothiazid oral tablet T1 valsartan-hydrochlorothiazide T1 Thiazide-Like Diuretics(Hypotensive Agt) - Drugs For High Blood Pressure & Angina atenolol-chlorthalidone T1 chlorthalidone oral tablet 25 mg, 50 mg T1 indapamide T1 metolazone T1 Vasodilating Agents, Miscellaneous - Drugs For The Heart amlodipine T1 amlodipine-atorvastatin oral tablet 10-10 mg, 10-20 mg, T3 PA 10-40 mg, 10-80 mg, 5-10 mg, 5-20 mg, 5-40 mg, 5-80 mg amlodipine-benazepril oral capsule 10-20 mg, 10-40 mg, T1 5-10 mg, 5-20 mg, 5-40 mg aspirin-dipyridamole T1

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

56 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 T3 PA HR 120 MG (diltiazem HCl) diltiazem HCl (Cartia Xt) T1 CAVERJECT IMPULSE (alprostadil) T3 PA CAVERJECT INTRACAVERNOSAL RECON SOLN T3 PA (alprostadil) diltiazem HCl oral capsule,ext.rel 24h degradable T1 diltiazem HCl oral capsule,extended release 12 hr T2 ST diltiazem HCl oral capsule,extended release 24 hr T1 diltiazem HCl oral capsule,extended release 24hr 120 T1 mg, 180 mg, 240 mg, 300 mg diltiazem HCl oral capsule,extended release 24hr 360 T3 PA mg diltiazem HCl oral tablet T1 diltiazem HCl oral tablet extended release 24 hr T3 PA DILT-XR (diltiazem HCl) T1 dipyridamole oral T1 felodipine T1 isradipine T2 ST diltiazem HCl (Matzim La) T3 PA MUSE INTRA-URETHRAL SUPPOSITORY 1,000 MCG, T3 PA 250 MCG (alprostadil) nicardipine oral T3 PA nifedipine oral capsule T3 PA nifedipine oral tablet extended release T1 nifedipine oral tablet extended release 24hr T1 nimodipine T3 PA

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

57 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits diltiazem HCl (Taztia Xt Oral Capsule,Extended Release T1 24 Hr 120 Mg, 180 Mg, 240 Mg, 360 Mg) diltiazem HCl (Taztia Xt Oral Capsule,Extended Release T2 PA 24 Hr 300 Mg) VENTAVIS INHALATION SOLUTION FOR NEBULIZATION T3 PA 20 MCG/ML (iloprost tromethamine) verapamil intravenous T1 verapamil oral capsule,ext rel. pellets 24 hr 120 mg, 180 T1 mg, 240 mg verapamil oral capsule,ext rel. pellets 24 hr 360 mg T3 PA verapamil oral tablet T1 verapamil oral tablet extended release T1 VERQUVO (vericiguat) T3 PA Central Nervous System Agents - Drugs For The Nervous System Adamantanes (Cns) - Drugs For Parkinson amantadine HCl T2 SCO Amphetamine Derivatives - Drugs For The Nervous System QSYMIA (phentermine HCl/topiramate) T3 PA Amphetamines - Drugs For The Nervous System QL (30 EA per 30 days); AL dextroamphetamine oral capsule, extended release T2 (Max 18 Years) QL (60 EA per 30 days); AL dextroamphetamine oral tablet T2 (Max 18 Years) dextroamphetamine-amphetamine oral QL (30 QY per 30 DYs); AL T2 capsule,extended release 24hr (Max 18 Years) dextroamphetamine-amphetamine oral tablet 10 mg, QL (60 EA per 30 days); AL T2 12.5 mg, 15 mg, 20 mg, 5 mg, 7.5 mg (Max 18 Years)

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

58 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits QL (30 EA per 30 days); AL dextroamphetamine-amphetamine oral tablet 30 mg T2 (Max 18 Years) methamphetamine T3 PA VYVANSE ORAL CAPSULE (lisdexamfetamine T3 PA dimesylate) Analgesics And Antipyretics, Misc. - Drugs For Pain acetaminophen oral elixir T2 acetaminophen oral liquid 500 mg/5 mL T2 acetaminophen rectal T2 acetaminophen-codeine oral solution 120-12 mg/5 mL T1 acetaminophen-codeine oral solution 240 mg-24 mg /10 T1 mL (10 mL) acetaminophen-codeine oral tablet T1 butalbital-acetaminop-caf-cod oral capsule 50-325-40-30 T3 PA mg butalbital-acetaminophen-caff oral capsule 50-325-40 T1 mg butalbital-acetaminophen-caff oral tablet 50-325-40 mg T1 oxycodone HCl/acetaminophen (Endocet Oral Tablet 5- T1 325 Mg) FEVERALL RECTAL SUPPOSITORY 325 MG, 80 MG T2 (acetaminophen) gabapentin oral capsule T1 gabapentin oral solution 250 mg/5 mL T1 gabapentin oral tablet 600 mg, 800 mg T1 hydrocodone-acetaminophen oral solution 7.5-325 T1 mg/15 mL

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

59 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits hydrocodone-acetaminophen oral tablet 10-325 mg, 5- T1 325 mg, 7.5-325 mg INFANT'S NON-ASPIRIN ORAL DROPS (acetaminophen) T2 isometh-dichloral-acetaminophn T3 PA MAPAP (ACETAMINOPHEN) ORAL CAPSULE T2 (acetaminophen) MAPAP (ACETAMINOPHEN) ORAL LIQUID 500 MG/15 T2 ML (acetaminophen) MAPAP ARTHRITIS PAIN (acetaminophen) T2 oxycodone-acetaminophen oral tablet 10-325 mg T2 QL (30 tablets per 1 fill) oxycodone-acetaminophen oral tablet 5-325 mg T1 pregabalin oral capsule T1 pregabalin oral solution T2 ST tramadol-acetaminophen T1 Anorexigenic Agents, Miscellaneous - Drugs For The Nervous System CONTRAVE (naltrexone HCl/bupropion HCl) T3 PA QSYMIA (phentermine HCl/topiramate) T3 PA Anticholinergic Agents (Cns) - Drugs For Parkinson benztropine oral T2 SCO trihexyphenidyl oral tablet T2 SCO Anticonvulsants, Miscellaneous - Drugs For Seizures carbamazepine oral capsule, ER multiphase 12 hr T1 carbamazepine oral suspension 100 mg/5 mL T1 carbamazepine oral tablet T1 carbamazepine oral tablet extended release 12 hr T1 carbamazepine oral tablet,chewable T1

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

60 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits divalproex T1 EPIDIOLEX (cannabidiol (CBD)) T3 PA felbamate T3 PA gabapentin oral capsule T1 gabapentin oral solution 250 mg/5 mL T1 gabapentin oral tablet 600 mg, 800 mg T1 GABITRIL ORAL TABLET 12 MG, 16 MG (tiagabine HCl) T1 lamotrigine oral tablet T1 lamotrigine oral tablet, chewable dispersible T1 levetiracetam oral solution T1 levetiracetam oral tablet T1 oxcarbazepine T1 pregabalin oral capsule T1 pregabalin oral solution T2 ST QSYMIA (phentermine HCl/topiramate) T3 PA rufinamide oral tablet T3 PA tiagabine oral tablet 2 mg, 4 mg T1 topiramate oral capsule, sprinkle T1 topiramate oral tablet T1 valproic acid T1 valproic acid (as sodium salt) oral solution T1 VIMPAT ORAL SOLUTION (lacosamide) T3 PA VIMPAT ORAL TABLET (lacosamide) T3 PA zonisamide T1 Antidepressants, Miscellaneous - Drugs For Depression & Psychosis bupropion HCl (smoking deter) T2 QL (60 EA per 30 days)

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

61 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits bupropion HCl oral tablet T1 bupropion HCl oral tablet extended release 24 hr 150 T1 mg, 300 mg bupropion HCl oral tablet sustained-release 12 hr 100 T1 mg, 200 mg bupropion HCl oral tablet sustained-release 12 hr 150 T2 QL (60 QY per 30 DYs) mg mirtazapine oral tablet T1 mirtazapine oral tablet,disintegrating 15 mg, 30 mg T1 mirtazapine oral tablet,disintegrating 45 mg T3 PA Antimanic Agents - Drugs For Personality Disorder aripiprazole oral tablet T2 SCO carbamazepine oral capsule, ER multiphase 12 hr T1 carbamazepine oral suspension 100 mg/5 mL T1 carbamazepine oral tablet T1 carbamazepine oral tablet extended release 12 hr T1 carbamazepine oral tablet,chewable T1 divalproex T1 lamotrigine oral tablet T1 lamotrigine oral tablet, chewable dispersible T1 lithium carbonate T2 SCO lithium citrate oral solution 8 mEq/5 mL T2 SCO olanzapine oral tablet T2 SCO olanzapine oral tablet,disintegrating T3 PA; SCO quetiapine T2 SCO risperidone oral solution T2 SCO risperidone oral tablet T2 SCO PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

62 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits risperidone oral tablet,disintegrating T2 SCO valproic acid T1 valproic acid (as sodium salt) oral solution T1 ziprasidone HCl T2 SCO ZYPREXA ZYDIS (olanzapine) T3 PA; SCO Antimigraine Agents, Miscellaneous - Migraine Treatment AIMOVIG AUTOINJECTOR SUBCUTANEOUS AUTO- T3 PA INJECTOR 70 MG/ML (erenumab-aooe) AJOVY SYRINGE (fremanezumab-vfrm) T3 PA aspirin oral tablet T2 aspirin oral tablet,chewable T2 aspirin oral tablet,delayed release (DR/EC) 325 mg, 500 T2 mg, 650 mg, 81 mg aspirin rectal T2 codeine phosphate/butalbital/aspirin/caffeine (Butalbital T3 PA Compound W/Codeine) butalbital-acetaminop-caf-cod oral capsule 50-325-40-30 T3 PA mg butalbital-acetaminophen-caff oral capsule 50-325-40 T1 mg butalbital-acetaminophen-caff oral tablet 50-325-40 mg T1 butalbital-aspirin-caffeine oral capsule T1 divalproex T1 EMGALITY PEN (galcanezumab-gnlm) T3 PA EMGALITY SYRINGE SUBCUTANEOUS SYRINGE 120 T3 PA MG/ML (galcanezumab-gnlm) ergotamine-caffeine T1

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

63 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits MIGERGOT (ergotamine tartrate/caffeine) T1 propranolol intravenous T2 QL (0.5 ML per 30 days) propranolol oral T1 timolol maleate oral T3 PA tramadol-acetaminophen T1 valproic acid T1 valproic acid (as sodium salt) oral solution T1 Antipsychotics, Miscellaneous - Drugs For Depression & Psychosis loxapine succinate T2 SCO pimozide T2 SCO Anxiolytics,Sedatives,And Hypnotics,Misc - Drugs For Anxiety & Sleep Disorder AMBIEN CR (zolpidem tartrate) T3 PA BELSOMRA (suvorexant) T3 PA buspirone oral tablet 30 mg, 5 mg, 7.5 mg T1 droperidol injection solution T1 eszopiclone T1 hydroxyzine HCl intramuscular T2 QL (1 EA per 30 days) hydroxyzine HCl oral solution 10 mg/5 mL T1 hydroxyzine HCl oral tablet T1 hydroxyzine pamoate T1 promethazine HCl (Phenadoz Rectal Suppository 25 Mg) T1 promethazine injection solution 25 mg/mL T2 QL (1 EA per 30 days) promethazine injection solution 50 mg/mL T1 promethazine oral T1 promethazine rectal suppository 12.5 mg, 50 mg T1 ROZEREM (ramelteon) T3 PA PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

64 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits SLEEP AID (DIPHENHYDRAMINE) ORAL CAPSULE 50 T2 MG (diphenhydramine HCl) SLEEP AID (DIPHENHYDRAMINE) ORAL TABLET T2 (diphenhydramine HCl) WAL-SOM (DOXYLAMINE) (doxylamine succinate) T2 zaleplon T1 zolpidem oral tablet T2 QL (30 QY per 30 DYs) zolpidem oral tablet,ext release multiphase T3 PA Atypical Antipsychotics - Drugs For Depression & Psychosis aripiprazole oral tablet T2 SCO clozapine oral tablet T2 SCO olanzapine oral tablet T2 SCO olanzapine oral tablet,disintegrating T3 PA; SCO quetiapine T2 SCO REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG, 3 T3 PA; SCO MG (brexpiprazole) risperidone oral solution T2 SCO risperidone oral tablet T2 SCO risperidone oral tablet,disintegrating T2 SCO ziprasidone HCl T2 SCO ZYPREXA ZYDIS (olanzapine) T3 PA; SCO Barbiturates (Anticonvulsants) - Drugs For Seizures phenobarb-hyoscy-atropine-scop oral elixir 16.2-0.1037 T1 -0.0194 mg/5 mL phenobarb-hyoscy-atropine-scop oral tablet T1 phenobarbital T1 primidone T1 PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

65 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits Barbiturates (Anxiolytic, Sedative/Hyp) - Drugs For Anxiety & Sleep Disorder codeine phosphate/butalbital/aspirin/caffeine (Butalbital T3 PA Compound W/Codeine) butalbital-acetaminop-caf-cod oral capsule 50-325-40-30 T3 PA mg butalbital-acetaminophen-caff oral capsule 50-325-40 T1 mg butalbital-acetaminophen-caff oral tablet 50-325-40 mg T1 butalbital-aspirin-caffeine oral capsule T1 phenobarb-hyoscy-atropine-scop oral elixir 16.2-0.1037 T1 -0.0194 mg/5 mL phenobarb-hyoscy-atropine-scop oral tablet T1 phenobarbital oral elixir T1 phenobarbital oral tablet 100 mg, 16.2 mg, 32.4 mg, 64.8 T1 mg, 97.2 mg phenobarbital oral tablet 15 mg, 60 mg T1 Benzodiazepines (Anticonvulsants) - Drugs For Seizures clobazam oral tablet T2 QL (60 EA per 30 DYs) clonazepam T1 clorazepate dipotassium T1 diazepam (Diazepam Intensol) T1 diazepam oral solution T1 diazepam oral tablet T1 lorazepam oral concentrate T1 lorazepam oral tablet T1 Benzodiazepines (Anxiolytic,Sedativ/Hyp) - Drugs For Anxiety & Sleep Disorder ALPRAZOLAM INTENSOL (alprazolam) T1

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

66 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits alprazolam oral tablet T1 alprazolam oral tablet,disintegrating T3 PA chlordiazepoxide HCl T1 chlordiazepoxide-clidinium T1 clobazam oral tablet T2 QL (60 EA per 30 DYs) clonazepam T1 clorazepate dipotassium T1 diazepam (Diazepam Intensol) T1 diazepam oral solution T1 diazepam oral tablet T1 flurazepam T1 lorazepam oral concentrate T1 lorazepam oral tablet T1 oxazepam T3 PA temazepam oral capsule 15 mg, 30 mg T1 temazepam oral capsule 22.5 mg, 7.5 mg T3 PA triazolam T1 Butyrophenones - Drugs For Depression & Psychosis haloperidol T2 SCO haloperidol decanoate T2 SCO haloperidol lactate injection T2 SCO haloperidol lactate oral T2 SCO Calcitonin Gene-Related Peptide Antag. - Migraine Treatment AIMOVIG AUTOINJECTOR SUBCUTANEOUS AUTO- T3 PA INJECTOR 70 MG/ML (erenumab-aooe) AJOVY SYRINGE (fremanezumab-vfrm) T3 PA

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

67 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits EMGALITY PEN (galcanezumab-gnlm) T3 PA EMGALITY SYRINGE (galcanezumab-gnlm) T3 PA NURTEC ODT (rimegepant sulfate) T3 PA UBRELVY (ubrogepant) T3 PA Catechol-O-Methyltransferase(Comt)Inhib. - Drugs For Parkinson entacapone T2 QL (120 EA per 30 days) Central Nervous System Agents, Misc. - Drugs For Attention Deficit Disorder acamprosate T2 SCO atomoxetine T3 PA AUSTEDO (deutetrabenazine) T3 PA guanfacine T1 INGREZZA ORAL CAPSULE 40 MG, 80 MG (valbenazine T3 PA tosylate) memantine oral tablet T1 memantine oral tablets,dose pack T1 QELBREE (viloxazine HCl) T3 PA riluzole T1 Cyclooxygenase-2 (Cox-2) Inhibitors - Drugs For Pain celecoxib oral capsule 100 mg, 200 mg T1 celecoxib oral capsule 400 mg, 50 mg T3 PA Dopamine Precursors - Drugs For Parkinson carbidopa-levodopa oral tablet T1 carbidopa-levodopa oral tablet extended release T1 Ergot-Deriv. Dopamine Receptor Agonists - Drugs For Parkinson bromocriptine T1 cabergoline T1 PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

68 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits Fibromyalgia Agents - Drugs For Nerve Pain duloxetine oral capsule,delayed release(DR/EC) 20 mg, T2 QL (60 EA per 30 days) 30 mg, 60 mg duloxetine oral capsule,delayed release(DR/EC) 40 mg T3 PA pregabalin oral capsule T1 pregabalin oral solution T2 ST SAVELLA ORAL TABLET (milnacipran HCl) T3 PA Hydantoins - Drugs For Seizures DILANTIN (phenytoin sodium extended) T1 phenytoin oral suspension 125 mg/5 mL T1 phenytoin oral tablet,chewable T1 phenytoin sodium T1 phenytoin sodium extended T1 Monoamine Oxidase B Inhibitors - Drugs For Parkinson selegiline HCl T1 Monoamine Oxidase Inhibitors - Drugs For Depression & Psychosis selegiline HCl T1 Nonergot-Deriv.Dopamine Receptor Agonist - Drugs For Parkinson pramipexole oral tablet 0.125 mg, 0.25 mg, 0.5 mg, 1 mg T1 ropinirole oral tablet T1 Opiate Agonists - Drugs For Pain acetaminophen-codeine oral solution 120-12 mg/5 mL T1 acetaminophen-codeine oral solution 240 mg-24 mg /10 T1 mL (10 mL) acetaminophen-codeine oral tablet T1

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

69 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits codeine phosphate/butalbital/aspirin/caffeine (Butalbital T3 PA Compound W/Codeine) butalbital-acetaminop-caf-cod oral capsule 50-325-40-30 T3 PA mg codeine sulfate oral tablet T1 DEMEROL INJECTION SOLUTION 50 MG/ML T2 PA (meperidine HCl) oxycodone HCl/acetaminophen (Endocet Oral Tablet 5- T1 325 Mg) fentanyl transdermal patch 72 hour 100 mcg/hr, 12 T3 PA; QL (10 QY per 30 DYs) mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr hydrocodone-acetaminophen oral solution 7.5-325 T1 mg/15 mL hydrocodone-acetaminophen oral tablet 10-325 mg, 5- T1 325 mg, 7.5-325 mg hydrocodone-homatropine oral syrup 5-1.5 mg/5 mL T2 AL (Min 18 Years) hydromorphone injection solution 2 mg/mL T1 hydromorphone injection syringe 1 mg/mL, 2 mg/mL, 4 T1 mg/mL hydromorphone oral liquid T1 hydromorphone oral tablet T1 hydromorphone rectal T1 levorphanol tartrate oral tablet 2 mg T3 PA meperidine injection cartridge T1 meperidine oral solution T3 PA meperidine oral tablet 50 mg T3 PA methadone injection solution T1 methadone oral concentrate T1

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

70 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits methadone oral solution T1 methadone oral tablet T1 morphine concentrate oral solution T1 morphine injection solution 8 mg/mL T2 QL (1 EA per 30 days) morphine injection syringe 10 mg/mL, 2 mg/mL, 4 T2 QL (1 EA per 30 days) mg/mL, 8 mg/mL morphine oral solution T1 morphine oral tablet T1 morphine oral tablet extended release T1 morphine rectal T1 oxycodone oral concentrate T3 PA oxycodone oral solution T3 PA oxycodone oral tablet 15 mg, 30 mg T3 PA oxycodone oral tablet 5 mg T2 QL (10 EA per 5 days) oxycodone oral tablet,oral only,ext.rel.12 hr 10 mg, 15 T3 PA mg, 20 mg, 40 mg, 60 mg, 80 mg oxycodone oral tablet,oral only,ext.rel.12 hr 30 mg T2 PA oxycodone-acetaminophen oral tablet 10-325 mg T2 QL (30 tablets per 1 fill) oxycodone-acetaminophen oral tablet 5-325 mg T1 oxycodone-aspirin T3 PA QL (240 ML per 30 days); AL promethazine-codeine T2 (Min 18 Years) QL (240 ML per 30 days); AL promethazine-phenyleph-codeine T2 (Min 18 Years) ROXICODONE ORAL TABLET 15 MG, 30 MG (oxycodone T3 PA HCl) tramadol oral tablet 50 mg T1

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

71 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits tramadol-acetaminophen T1 Opiate Antagonists - Drugs For Overdose Or Poisoning SCO; QL (2 QY per 180 naloxone injection syringe 1 mg/mL T2 DYs) naltrexone T2 SCO NARCAN NASAL SPRAY,NON-AEROSOL 4 SCO; QL (2 EA per 180 T2 MG/ACTUATION (naloxone HCl) days) Opiate Partial Agonists - Drugs For Pain buprenorphine T3 PA; SCO buprenorphine HCl sublingual T2 SCO buprenorphine-naloxone sublingual film 2-0.5 mg, 8-2 T2 SCO mg buprenorphine-naloxone sublingual tablet T2 SCO nalbuphine T1 pentazocine-naloxone T3 PA SUBOXONE SUBLINGUAL FILM 12-3 MG, 4-1 MG T3 PA; SCO (buprenorphine HCl/naloxone HCl) Other Nonsteroidal Anti-Inflam. Agents - Drugs For Pain CHILDREN'S IBUPROFEN (ibuprofen) T2 diclofenac potassium T1 diclofenac sodium oral T1 diclofenac sodium topical gel 1 % T2 QL (200 GM per 30 days) diclofenac-misoprostol T3 PA diflunisal T1 etodolac T1 fenoprofen oral capsule 200 mg T3 PA fenoprofen oral tablet T3 PA PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

72 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits flurbiprofen oral tablet 100 mg T3 PA ibuprofen oral tablet 400 mg, 600 mg, 800 mg T1 INDOCIN ORAL (indomethacin) T1 indomethacin oral T1 ketoprofen oral capsule 50 mg, 75 mg T3 PA ketorolac oral T3 PA meclofenamate T3 PA meloxicam T1 nabumetone T1 naproxen oral suspension T1 naproxen oral tablet T1 naproxen sodium oral tablet 275 mg, 550 mg T1 oxaprozin T2 QL (270 EA per 90 days) piroxicam T1 sulindac T1 tolmetin T3 PA TREXIMET ORAL TABLET 85-500 MG (sumatriptan T3 PA succinate/naproxen sodium) Phenothiazines - Drugs For Depression & Psychosis chlorpromazine oral T2 SCO fluphenazine decanoate T2 SCO fluphenazine HCl injection T2 SCO fluphenazine HCl oral tablet T2 SCO perphenazine T2 SCO prochlorperazine T1 prochlorperazine Edisylate injection solution 5 mg/mL T2 QL (1 EA per 30 days)

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

73 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits prochlorperazine maleate T1 thioridazine T2 SCO trifluoperazine T2 SCO Respiratory And Cns Stimulants - Drugs For The Nervous System codeine phosphate/butalbital/aspirin/caffeine (Butalbital T3 PA Compound W/Codeine) butalbital-acetaminop-caf-cod oral capsule 50-325-40-30 T3 PA mg butalbital-acetaminophen-caff oral capsule 50-325-40 T1 mg butalbital-acetaminophen-caff oral tablet 50-325-40 mg T1 butalbital-aspirin-caffeine oral capsule T1 dexmethylphenidate oral capsule,ER biphasic 50-50 10 QL (60 EA per 30 days); AL T2 mg, 5 mg (Max 18 Years) dexmethylphenidate oral capsule,ER biphasic 50-50 15 QL (30 EA per 30 days); AL T2 mg, 20 mg (Max 18 Years) QL (60 EA per 30 days); AL dexmethylphenidate oral tablet T2 (Max 18 Years) doxapram T3 PA QL (30 EA per 30 days); AL methylphenidate HCl oral capsule, ER biphasic 30-70 T2 (Max 18 Years) methylphenidate HCl oral capsule,ER biphasic 50-50 10 QL (30 EA per 30 DYs); AL T2 mg (Max 18 Years) methylphenidate HCl oral capsule,ER biphasic 50-50 20 QL (30 QY per 30 DYs); AL T2 mg, 40 mg (Max 18 Years) methylphenidate HCl oral capsule,ER biphasic 50-50 30 QL (60 EA per 30 days); AL T2 mg (Max 18 Years) methylphenidate HCl oral capsule,ER biphasic 50-50 60 QL (30 EA per 30 days); AL T2 mg (Max 18 Years) PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

74 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits QL (30 ML per 30 days); AL methylphenidate HCl oral solution T2 (Max 18 Years) QL (90 EA per 30 days); AL methylphenidate HCl oral tablet 10 mg, 5 mg T2 (Max 18 Years) QL (60 EA per 30 days); AL methylphenidate HCl oral tablet 20 mg T2 (Max 18 Years) QL (90 EA per 30 days); AL methylphenidate HCl oral tablet extended release T2 (Max 18 Years) methylphenidate HCl oral tablet extended release 24hr QL (30 QY per 30 DYs); AL T2 18 mg, 27 mg, 54 mg (Max 18 Years) methylphenidate HCl oral tablet extended release 24hr QL (60 QY per 30 DYs); AL T2 36 mg (Max 18 Years) methylphenidate HCl oral tablet extended release 24hr QL (30 EA per 30 days); AL T2 72 mg (Max 18 Years) QL (30 EA per 30 days); AL methylphenidate HCl oral tablet,chewable T2 (Max 18 Years) Salicylates - Drugs For Pain aspirin oral tablet T2 aspirin oral tablet,chewable T2 aspirin oral tablet,delayed release (DR/EC) 325 mg, 500 T2 mg, 650 mg, 81 mg aspirin rectal T2 aspirin-dipyridamole T1 codeine phosphate/butalbital/aspirin/caffeine (Butalbital T3 PA Compound W/Codeine) butalbital-aspirin-caffeine oral capsule T1 choline,magnesium salicylate T3 oxycodone-aspirin T3 PA

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

75 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits salsalate T1 Sel.Serotonin,Norepi Reuptake Inhibitor - Drugs For Depression & Psychosis duloxetine oral capsule,delayed release(DR/EC) 20 mg, T2 QL (60 EA per 30 days) 30 mg, 60 mg duloxetine oral capsule,delayed release(DR/EC) 40 mg T3 PA SAVELLA ORAL TABLET (milnacipran HCl) T3 PA venlafaxine oral capsule,extended release 24hr T1 venlafaxine oral tablet T1 Selective Serotonin Agonists - Migraine Treatment almotriptan malate T3 PA; QL (12 QY per 30 days) ALSUMA (sumatriptan succinate) T3 PA FROVA (frovatriptan succinate) T3 PA; QL (12 QY per 30 DYs) frovatriptan T3 PA; QL (12 QY per 30 days) IMITREX NASAL (sumatriptan) T3 PA IMITREX STATDOSE PEN (sumatriptan succinate) T3 PA IMITREX STATDOSE REFILL (sumatriptan succinate) T3 PA IMITREX SUBCUTANEOUS (sumatriptan succinate) T3 PA naratriptan T2 ST; QL (12 QY per 30 days) RELPAX (eletriptan hydrobromide) T3 PA; QL (12 QY per 30 DYs) rizatriptan oral tablet T2 QL (12 QY per 30 days) rizatriptan oral tablet,disintegrating T2 QL (12 EA per 30 days) sumatriptan T3 PA sumatriptan succinate oral tablet 100 mg, 50 mg T2 QL (18 QY per 30 DYs) sumatriptan succinate oral tablet 25 mg T2 QL (12 QY per 30 DYs) sumatriptan succinate subcutaneous cartridge T3 PA sumatriptan succinate subcutaneous pen injector T3 PA

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

76 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits sumatriptan succinate subcutaneous solution T3 PA TREXIMET ORAL TABLET 85-500 MG (sumatriptan T3 PA succinate/naproxen sodium) zolmitriptan oral tablet 2.5 mg T3 PA; QL (12 QY per 30 days) zolmitriptan oral tablet 5 mg T3 PA; QL (12 QY per 30 DYs) zolmitriptan oral tablet,disintegrating T3 PA; QL (12 QY per 30 DYs) ZOMIG NASAL SPRAY,NON-AEROSOL 5 MG T3 PA (zolmitriptan) ZOMIG ORAL (zolmitriptan) T3 PA; QL (12 QY per 30 DYs) ZOMIG ZMT (zolmitriptan) T3 PA; QL (12 QY per 30 DYs) Selective-Serotonin Reuptake Inhibitors - Drugs For Depression & Psychosis citalopram oral solution T2 QL (900 ML per 30 days) citalopram oral tablet T1 escitalopram oxalate T1 fluoxetine oral capsule T1 fluoxetine oral capsule,delayed release(DR/EC) T3 PA fluoxetine oral solution T1 fluvoxamine oral tablet T1 paroxetine HCl oral tablet T1 paroxetine HCl oral tablet extended release 24 hr T3 PA PEXEVA (paroxetine mesylate) T3 PA sertraline T1 Serotonin Modulators - Drugs For Depression & Psychosis nefazodone T1 trazodone T1 TRINTELLIX (vortioxetine hydrobromide) T3 PA

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

77 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits VIIBRYD ORAL TABLET (vilazodone HCl) T3 PA VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 20 MG T3 PA (23) (vilazodone HCl) Succinimides - Drugs For Seizures ethosuximide T1 Thioxanthenes - Drugs For Depression & Psychosis thiothixene oral capsule 1 mg, 10 mg, 2 mg T2 SCO Tricyclics, Other Norepi-Ru Inhibitors - Drugs For Depression & Psychosis amitriptyline T1 clomipramine T1 desipramine T1 doxepin oral capsule 10 mg, 100 mg, 25 mg, 50 mg, 75 T1 mg doxepin oral concentrate T1 imipramine HCl T1 imipramine pamoate T3 PA nortriptyline oral capsule T1 protriptyline T3 PA Vesicular Monoamine Transport2 Inhibitor - Drugs For The Nervous System AUSTEDO (deutetrabenazine) T3 PA INGREZZA ORAL CAPSULE 40 MG, 80 MG (valbenazine T3 PA tosylate) Wakefulness-Promoting Agents - Drugs For The Nervous System modafinil T3 PA Devices - Medical Supplies And Durable Medical Equipment Devices - Medical Supplies And Durable Medical Equipment

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

78 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits ADVOCATE BLOOD PRESSURE MONITR (blood T1 pressure test kit-large) BD ULTRA-FINE NANO PEN NEEDLE (pen needle, T2 diabetic) blood pressure kit-extra large kit T3 BLOOD PRESSURE MONITOR KIT ACCUFIT XL,UA-789 T3 PA blood pressure test kit-large T1 blood pressure test kit-medium T2 QL (1 EA per 5 yearss) CARETOUCH BP MONITOR (blood pressure test kit- T1 large) CLEVER CHOICE BP MONITOR (blood pressure test kit- T1 large) DUROLANE (hyaluronate sodium, stabilized) T2 FEMCAP (cervical cap) T1 FORA TEST N'GO BP SYSTEM (blood pressure test kit- T1 large) FREESTYLE LIBRE 14 DAY READER (flash glucose T3 PA scanning reader) FREESTYLE LIBRE 14 DAY SENSOR (flash glucose T3 PA sensor) FREESTYLE LIBRE 2 SENSOR (flash glucose sensor) T3 PA heparin flush(porcine)-0.9NaCl T2 QL (1 EA per 30 days) heparin lock flush (porcine) intravenous solution 100 T2 QL (1 EA per 30 days) unit/mL HEPARIN LOCK FLUSH INTRAVENOUS SOLUTION T2 QL (1 EA per 30 days) (heparin sodium,porcine) HYALGAN INTRA-ARTICULAR SYRINGE (hyaluronate T2 sodium)

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

79 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits HYPER-SAL INHALATION SOLUTION FOR T1 NEBULIZATION 3.5 % (sodium chloride for inhalation) lancets T1 OPTICHAMBER ADULT MASK-LARGE (inhaler, assist T1 devices, accessories) OPTICHAMBER DIAMOND LG MASK (inhaler,assist T2 QL (2 QY per 365 DYs) device with large mask) OPTICHAMBER DIAMOND VHC (inhaler, assist devices) T2 QL (2 QY per 365 DYs) OPTICHAMBER DIAMOND-MED MSK (inhaler,assist T2 QL (2 QY per 365 DYs) device with medium mask) OPTICHAMBER DIAMOND-SML MASK (inhaler,assist T2 QL (2 QY per 365 DYs) device with small mask) PROCARE BLOOD PRESSURE MONITOR (blood T1 pressure test kit-large) PROCHAMBER (inhaler, assist devices) T1 SELF-TAKING BLOOD PRESSURE (blood pressure test T1 kit-large) sodium chloride inhalation solution for nebulization 0.9 T2 % sodium chloride inhalation solution for nebulization 3 % T1 SURELIFE ARM BP MONITOR (blood pressure test kit- T1 large) SURELIFE TALKING ARM BP MONITR (blood pressure T1 test kit-large) TRUE METRIX AIR GLUCOSE METER (blood-glucose T2 QL (1 EA per 365 days) meter) TRUE METRIX GLUCOSE METER (blood-glucose meter) T2 QL (1 EA per 365 days) TRUETRACK SMART SYSTEM KIT (blood-glucose T2 meter)

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

80 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits Diagnostic Agents Diabetes Mellitus TRUE METRIX GLUCOSE TEST STRIP (blood sugar T2 diagnostic) TRUETRACK TEST (blood sugar diagnostic) T2 Kidney Function mannitol 10 % T2 QL (1 EA per 30 days) mannitol 20 % T2 QL (1 EA per 30 days) mannitol 25 % intravenous solution T2 QL (1 EA per 30 days) mannitol 5 % T2 QL (1 EA per 30 days) Electrolytic, Caloric, And Water Balance Acidifying Agents K-PHOS NO 2 (sodium phosphate,monobasic/potassium T1 phosphate,monobasic) K-PHOS ORIGINAL (potassium phosphate,monobasic) T1 PHOSPHA 250 NEUTRAL (sodium phosphate,dibasic/pot phos,monob/sod phosphate T1 mono) Alkalinizing Agents ORACIT (citric acid/sodium citrate) T1 potassium citrate oral tablet extended release 5 mEq T1 (540 mg) sodium bicarbonate intravenous syringe 4.2 % (0.5 T2 QL (1 EA per 30 days) mEq/mL), 7.5 % (0.9 mEq/mL), 8.4 % (1 mEq/mL) THAM (tromethamine) T2 QL (1 EA per 30 days) Ammonia Detoxicants

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

81 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits lactulose (Constulose) T1 lactulose (Generlac) T1 lactulose (Kristalose) T1 lactulose oral solution T1 Carbonic Anhydrase Inhibitors - Drugs For Water Balance acetazolamide T1 Diuretics, Miscellaneous - Drugs For Water Balance theophylline anhydrous (Elixophyllin Oral Elixir 80 Mg/15 T1 Ml) theophylline in dextrose 5 % intravenous parenteral T2 QL (1 EA per 30 days) solution 200 mg/100 mL theophylline oral elixir T1 theophylline oral tablet extended release 12 hr 300 mg, T1 450 mg theophylline oral tablet extended release 24 hr 600 mg T1 Irrigating Solutions acetic acid irrigation T1 glycine urologic solution T3 PA Ringer's irrigation T2 QL (1 EA per 30 days) sodium chloride irrigation T1 sorbitol-mannitol T2 QL (1 EA per 30 days) water for irrigation, sterile T1 Loop Diuretics - Drugs For Water Balance bumetanide T1 EDECRIN (ethacrynic acid) T1 ethacrynate sodium T1

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

82 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits furosemide injection T2 QL (1 EA per 30 days) furosemide oral solution 10 mg/mL T2 QL (1 EA per 30 days) furosemide oral solution 40 mg/5 mL (8 mg/mL) T1 furosemide oral tablet T1 torsemide oral T1 Osmotic Diuretics - Drugs For Water Balance mannitol 10 % T2 QL (1 EA per 30 days) mannitol 20 % T2 QL (1 EA per 30 days) mannitol 25 % intravenous solution T2 QL (1 EA per 30 days) mannitol 5 % T2 QL (1 EA per 30 days) sorbitol-mannitol T2 QL (1 EA per 30 days) Phosphate-Removing Agents calcium acetate(phosphat bind) T1 lanthanum T3 PA RENAGEL ORAL TABLET 800 MG (sevelamer HCl) T3 PA sevelamer carbonate oral powder in packet T3 PA sevelamer carbonate oral tablet T2 ST Potassium-Removing Agents LOKELMA (sodium zirconium cyclosilicate) T2 QL (34 EA per 30 days) sodium polystyrene sulfonate oral powder T1 VELTASSA (patiromer calcium sorbitex) T2 ST; QL (30 EA per 30 days) Potassium-Sparing Diuretics - Drugs For Water Balance ALDACTAZIDE ORAL TABLET 50-50 MG T3 PA (spironolactone/hydrochlorothiazide) amiloride T1 amiloride-hydrochlorothiazide T1 PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

83 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits DYRENIUM (triamterene) T3 PA spironolactone T1 spironolacton-hydrochlorothiaz T1 triamterene-hydrochlorothiazid oral capsule 37.5-25 mg T1 triamterene-hydrochlorothiazid oral tablet T1 Replacement Preparations ANTACID EXTRA-STRENGTH ORAL TABLET,CHEWABLE 168 MG CALCIUM (420 MG) T2 (calcium carbonate) CALCIUM 500 ORAL TABLET,CHEWABLE (calcium T1 carbonate) CALCIUM ANTACID ORAL TABLET,CHEWABLE 300 MG T2 (750 MG) (calcium carbonate) CALCIUM ANTACID ULTRA MAX ST (calcium carbonate) T2 calcium carbonate oral suspension T1 calcium carbonate oral tablet 260 mg calcium (648 mg) T2 calcium carbonate oral tablet 600 mg calcium (1,500 T1 mg), 650 mg calcium (1,625 mg) calcium carbonate oral tablet,chewable 200 mg calcium T2 (500 mg) calcium carbonate-vitamin D3 oral tablet 1,000 mg(2,500 T1 mg)-800 unit calcium carbonate-vitamin D3 oral tablet 250-125 mg- unit, 600 mg(1,500mg) -200 unit, 600 mg(1,500mg) -400 T1 unit, 600 mg(1,500mg) -800 unit calcium lactate oral tablet 650 mg T2 dextrose 5 %-lactated ringers T1

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

84 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits FLINTSTONES PLUS CALCIUM (calcium T1 carbonate/multivitamin) HYPER-SAL INHALATION SOLUTION FOR T1 NEBULIZATION 3.5 % (sodium chloride for inhalation) ORALYTE (electrolytes/dextrose) T2 OYSTER SHELL CALCIUM 500 (calcium carbonate) T2 OYSTER SHELL CALCIUM-VIT D2 ORAL TABLET 250 (625)-125 MG-UNIT (calcium carbonate/ergocalciferol T1 (vitamin D2)) potassium acetate intravenous solution 2 mEq/mL T2 QL (1 EA per 30 days) potassium chloride oral capsule, extended release 8 T1 mEq potassium chloride oral liquid T1 potassium chloride oral packet T3 PA potassium chloride oral tablet extended release T1 potassium chloride oral tablet,ER particles/crystals T1 potassium chloride-D5-0.2%NaCl intravenous T2 QL (1 EA per 30 days) parenteral solution 30 mEq/L potassium chloride-D5-0.9%NaCl intravenous T2 QL (1 EA per 30 days) parenteral solution 40 mEq/L potassium phosphate m-/d-basic intravenous solution 3 T2 QL (1 EA per 30 days) mmol/mL PRENATAL PLUS (CALCIUM CARB) (prenatal vits with AL (Min 13 Years and Max T2 calcium no.72/ferrous fumarate/folic acid) 45 Years) sodium acetate T2 QL (1 EA per 30 days) sodium chloride 5 % T2 QL (1 EA per 30 days) sodium chloride inhalation solution for nebulization 0.9 T2 %

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

85 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits sodium chloride inhalation solution for nebulization 10 T1 %, 3 % sodium chloride intravenous parenteral solution 4 T1 mEq/mL zinc chloride T1 zinc sulfate intravenous solution 1 mg/mL, 5 mg/mL T1 Thiazide Diuretics - Drugs For Water Balance ALDACTAZIDE ORAL TABLET 50-50 MG T3 PA (spironolactone/hydrochlorothiazide) amiloride-hydrochlorothiazide T1 benazepril-hydrochlorothiazide oral tablet 10-12.5 mg, T1 20-12.5 mg, 5-6.25 mg bisoprolol-hydrochlorothiazide T1 captopril-hydrochlorothiazide T2 PA enalapril-hydrochlorothiazide oral tablet 10-25 mg T1 hydrochlorothiazide oral capsule T1 hydrochlorothiazide oral tablet 25 mg, 50 mg T1 irbesartan-hydrochlorothiazide T1 lisinopril-hydrochlorothiazide T1 losartan-hydrochlorothiazide T1 methyldopa-hydrochlorothiazide oral tablet 250-15 mg T1 methyldopa-hydrochlorothiazide oral tablet 250-25 mg T3 PA MICARDIS HCT (telmisartan/hydrochlorothiazide) T3 PA olmesartan-hydrochlorothiazide T1 propranolol-hydrochlorothiazid T1 quinapril-hydrochlorothiazide T1 spironolacton-hydrochlorothiaz T1

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

86 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits triamterene-hydrochlorothiazid oral capsule 37.5-25 mg T1 triamterene-hydrochlorothiazid oral tablet T1 valsartan-hydrochlorothiazide T1 Thiazide-Like Diuretics - Drugs For Water Balance atenolol-chlorthalidone T1 chlorthalidone oral tablet 25 mg, 50 mg T1 indapamide T1 metolazone T1 Uricosuric Agents probenecid T1 probenecid-colchicine T1 Enzymes Enzymes AMPHADASE (hyaluronidase) T3 PA PULMOZYME (dornase alfa) T3 PA Eye, Ear, Nose And Throat (Eent) Preps. Alpha-Adrenergic Agonists (Eent) - Drugs For The Eye ALPHAGAN P OPHTHALMIC (EYE) DROPS 0.1 % T3 PA (brimonidine tartrate) brimonidine ophthalmic (eye) drops 0.15 % T3 PA brimonidine ophthalmic (eye) drops 0.2 % T1 Antiallergic Agents - Drugs For Allergy ALLERGY EYE (KETOTIFEN) (ketotifen fumarate) T2 QL (10 ML per 30 DYs) ALOCRIL (nedocromil sodium) T3 PA; QL (1 QY per 30 DYs) ALOMIDE (lodoxamide tromethamine) T3 PA; QL (1 QY per 30 DYs)

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

87 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits azelastine nasal T1 azelastine ophthalmic (eye) T2 QL (1 QY per 30 DYs) cromolyn ophthalmic (eye) T2 QL (1 QY per 30 DYs) epinastine T3 PA; QL (1 QY per 30 DYs) ketotifen fumarate T2 QL (10 ML per 30 days) olopatadine ophthalmic (eye) drops 0.1 % T2 QL (5 ML per 25 days) olopatadine ophthalmic (eye) drops 0.2 % T3 PA; QL (2.5 ML per 25 days) Antibacterials (Eent) - Drugs For Infections bacitracin ophthalmic (eye) T1 bacitracin-polymyxin B ophthalmic (eye) T1 BLEPHAMIDE (sulfacetamide sodium/prednisolone T1 acetate) sulfacetamide sodium/prednisolone acetate T1 (Blephamide S.O.P.) CIPRO HC (ciprofloxacin HCl/hydrocortisone) T1 CIPRODEX (ciprofloxacin HCl/dexamethasone) T1 ciprofloxacin HCl ophthalmic (eye) T1 erythromycin ophthalmic (eye) T1 gentamicin sulfate (Gentak Ophthalmic (Eye) Ointment) T1 gentamicin ophthalmic (eye) drops T1 moxifloxacin ophthalmic (eye) drops T1 neomycin-bacitracin-poly-HC T1 neomycin-bacitracin-polymyxin T1 neomycin-polymyxin B-dexameth T1 neomycin-polymyxin-gramicidin T1 neomycin-polymyxin-HC T1

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

88 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits ofloxacin ophthalmic (eye) T1 ofloxacin otic (ear) T1 polymyxin B sulf-trimethoprim T1 PRED-G (gentamicin sulfate/prednisolone acetate) T1 PRED-G S.O.P. (gentamicin sulfate/prednisolone T1 acetate) sulfacetamide sodium ophthalmic (eye) T1 sulfacetamide-prednisolone T1 TOBRADEX OPHTHALMIC (EYE) OINTMENT T1 (tobramycin/dexamethasone) tobramycin ophthalmic (eye) T1 tobramycin-dexamethasone T1 TOBREX OPHTHALMIC (EYE) OINTMENT (tobramycin) T1 Antifungals (Eent) - Drugs For Infections NATACYN (natamycin) T1 Antiglaucoma Agents, Miscellaneous - Drugs For The Eye RHOPRESSA (netarsudil mesylate) T3 PA Antivirals (Eent) - Drugs For Infections trifluridine T1 Beta-Adrenergic Blocking Agents (Eent) - Drugs For The Eye betaxolol ophthalmic (eye) T3 PA BETIMOL (timolol) T1 BETOPTIC S (betaxolol HCl) T3 PA dorzolamide-timolol T1 levobunolol ophthalmic (eye) drops 0.5 % T1 metipranolol T1

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

89 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits timolol maleate ophthalmic (eye) drops T1 timolol maleate ophthalmic (eye) gel forming solution T1 Carbonic Anhydrase Inhibitors (Eent) - Drugs For The Eye acetazolamide T1 AZOPT (brinzolamide) T3 PA dorzolamide T1 dorzolamide-timolol T1 methazolamide T3 PA Corticosteroids (Eent) - Drugs For Inflammation ALLERGY RELIEF (FLUTICASONE) (fluticasone T2 QL (1 QY per 30 days) propionate) BECONASE AQ (beclomethasone dipropionate) T3 PA budesonide nasal T2 QL (8.43 ML per 30 days) CIPRO HC (ciprofloxacin HCl/hydrocortisone) T1 CIPRODEX (ciprofloxacin HCl/dexamethasone) T1 dexamethasone sodium phosphate ophthalmic (eye) T1 DUREZOL (difluprednate) T2 ST; QL (5 ML per 30 days) FLAREX (fluorometholone acetate) T1 FLONASE SENSIMIST (fluticasone furoate) T2 QL (9.1 ML per 30 days) flunisolide nasal spray,non-aerosol 25 mcg (0.025 %) T3 PA; QL (1 QY per 30 DYs) fluorometholone T1 fluticasone propionate nasal T2 QL (1 QY per 30 DYs) FML FORTE (fluorometholone) T1 FML S.O.P. (fluorometholone) T1 hydrocortisone-acetic acid T1

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

90 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits loteprednol etabonate ophthalmic (eye) T1 drops,suspension MAXIDEX (dexamethasone) T1 mometasone nasal T3 PA NASAL ALLERGY (triamcinolone acetonide) T2 QL (1 qy per 30 days) NASONEX (mometasone furoate) T3 PA neomycin-bacitracin-poly-HC T1 neomycin-polymyxin B-dexameth T1 neomycin-polymyxin-HC ophthalmic (eye) T1 OMNARIS (ciclesonide) T3 PA PRED MILD (prednisolone acetate) T1 PRED-G (gentamicin sulfate/prednisolone acetate) T1 PRED-G S.O.P. (gentamicin sulfate/prednisolone T1 acetate) prednisolone acetate T1 prednisolone sodium phosphate ophthalmic (eye) T1 QNASL (beclomethasone dipropionate) T3 PA RHINOCORT ALLERGY (budesonide) T2 QL (8.43 ML per 30 days) TOBRADEX OPHTHALMIC (EYE) OINTMENT T1 (tobramycin/dexamethasone) tobramycin-dexamethasone T1 triamcinolone acetonide nasal T2 QL (1 QY per 30 days) ZETONNA (ciclesonide) T3 PA Eent Anti-Infectives, Miscellaneous - Drugs For Infections acetic acid otic (ear) T1 chlorhexidine gluconate mucous membrane T1 hydrocortisone-acetic acid T1 PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

91 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits Eent Drugs, Miscellaneous ARTIFICIAL TEARS (POLYVIN ALC) (polyvinyl alcohol) T2 QL (30 ML per 30 days) ENUCLENE (tyloxapol) T2 GONIOVISC (hypromellose) T1 IOPIDINE OPHTHALMIC (EYE) DROPPERETTE T1 (apraclonidine HCl) ipratropium bromide nasal T1 LUBRICANT EYE (PG-PEG 400) (propylene T2 QL (30 ML per 30 days) glycol/polyethylene glycol 400) LUBRICANT EYE DROPS OPHTHALMIC (EYE) DROPS T2 QL (30 ML per 30 days) 0.5 % (carboxymethylcellulose sodium) LUBRICANT EYE OPHTHALMIC (EYE) OINTMENT 57.3- T2 QL (7 GM per 30 days) 42.5 % (mineral oil/petrolatum,white) MURO 128 OPHTHALMIC (EYE) DROPS 2 % (sodium T2 chloride) polyvinyl alcohol T2 QL (30 ML per 30 days) REFRESH LIQUIGEL (carboxymethylcellulose sodium) T2 QL (30 ML per 30 days) REFRESH P.M. (mineral oil/petrolatum,white) T2 QL (7 GM per 30 days) REFRESH TEARS (carboxymethylcellulose sodium) T2 QL (30 ML per 30 days) RESTORE TEARS (carboxymethylcellulose sodium) T2 QL (30 ML per 30 days) sodium chloride ophthalmic (eye) T2 SYSTANE NIGHTTIME (mineral oil/petrolatum,white) T2 QL (7 GM per 30 days) ULTRA FRESH (carboxymethylcellulose sodium) T2 QL (30 ML per 30 days) Eent Nonsteroidal Anti-Inflam. Agents - Drugs For Inflammation diclofenac sodium ophthalmic (eye) T1 flurbiprofen sodium T3 PA ketorolac ophthalmic (eye) T1

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

92 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits Local Anesthetics (Eent) - Drugs For Numbing lidocaine HCl mucous membrane jelly T1 lidocaine HCl mucous membrane solution 4 % (40 T3 PA mg/mL) lidocaine HCl (Lidocaine Viscous) T1 proparacaine T1 tetracaine HCl T1 Miotics - Drugs For The Eye pilocarpine HCl ophthalmic (eye) drops 1 %, 2 %, 4 % T1 Mydriatics - Drugs For The Eye atropine ophthalmic (eye) drops T1 atropine ophthalmic (eye) ointment T1 cyclopentolate T1 HOMATROPAIRE (homatropine Hbr) T1 tropicamide T1 Prostaglandin Analogs - Drugs For The Eye bimatoprost ophthalmic (eye) T3 PA latanoprost T1 LUMIGAN OPHTHALMIC (EYE) DROPS 0.01 % T3 PA (bimatoprost) travoprost T3 PA Rho Kinase Inhibitors - Drugs For The Eye RHOPRESSA (netarsudil mesylate) T3 PA Vasoconstrictors phenylephrine HCl ophthalmic (eye) drops 2.5 % T1 Gastrointestinal Drugs PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

93 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits Antacids And Adsorbents ACID GONE ANTACID E.STRENGTH (magnesium T2 carbonate/aluminum hydroxide) ADVANCED ANTACID-ANTIGAS ORAL SUSPENSION 200-200-20 MG/5 ML (magnesium hydroxide/aluminum T2 hydroxide/simethicone) aluminum hydroxide gel oral suspension 320 mg/5 mL T2 ANTACID SUPREME (calcium carbonate/magnesium T1 hydroxide) ANTACID-SIMETHICONE (magnesium T2 hydroxide/aluminum hydroxide/simethicone) CALCIUM ANTACID ORAL TABLET,CHEWABLE 300 MG T2 (750 MG) (calcium carbonate) CALCIUM ANTACID ULTRA MAX ST (calcium carbonate) T2 calcium carbonate oral tablet 260 mg calcium (648 mg) T2 calcium carbonate oral tablet,chewable 200 mg calcium T2 (500 mg) GAVISCON ORAL TABLET,CHEWABLE (magnesium T2 trisilicate/aluminum hydrox/sod bicarb/alginic ac) MAALOX MAXIMUM STRENGTH (magnesium T2 hydroxide/aluminum hydroxide/simethicone) magnesium oxide oral tablet 400 mg (241.3 mg T2 magnesium) MINTOX PLUS (magnesium hydroxide/aluminum T2 hydroxide/simethicone) PINK BISMUTH ORAL TABLET,CHEWABLE (bismuth T2 subsalicylate) Gastrointestinal Drugs - Drugs For The Stomach 5-Ht3 Receptor Antagonists - Drugs For Vomiting And Nausea PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

94 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits ALOXI (palonosetron HCl) T2 QL (0.5 ML per 30 days) granisetron HCl oral T2 ST; QL (12 QY per 30 DYs) ondansetron T1 ondansetron HCl oral solution T1 ondansetron HCl oral tablet 4 mg, 8 mg T1 Antidiarrhea Agents - Drugs For Diarrhea diphenoxylate-atropine T1 loperamide oral capsule T1 loperamide oral tablet T1 PINK BISMUTH ORAL TABLET,CHEWABLE (bismuth T2 subsalicylate) Antiemetics, Miscellaneous - Drugs For Vomiting And Nausea dronabinol T3 PA Antiflatulents - Drugs For Gas ADVANCED ANTACID-ANTIGAS ORAL SUSPENSION 200-200-20 MG/5 ML (magnesium hydroxide/aluminum T2 hydroxide/simethicone) ANTACID-SIMETHICONE (magnesium T2 hydroxide/aluminum hydroxide/simethicone) MAALOX MAXIMUM STRENGTH (magnesium T2 hydroxide/aluminum hydroxide/simethicone) MINTOX PLUS (magnesium hydroxide/aluminum T2 hydroxide/simethicone) simethicone oral capsule 125 mg T1 simethicone oral tablet,chewable T1 Antihistamines (Gi Drugs) - Drugs For Vomiting And Nausea dimenhydrinate injection solution T3 PA

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

95 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits meclizine oral tablet 12.5 mg T2 meclizine oral tablet 25 mg T1 meclizine oral tablet,chewable T2 prochlorperazine T1 prochlorperazine Edisylate injection solution 5 mg/mL T2 QL (1 EA per 30 days) prochlorperazine maleate T1 trimethobenzamide oral T1 Anti-Inflammatory Agents (Gi Drugs) - Drugs For Inflammation alosetron T1 balsalazide T1 mesalamine oral capsule (with del rel tablets) T1 mesalamine oral tablet,delayed release (DR/EC) T1 mesalamine rectal T1 PENTASA (mesalamine) T1 sulfasalazine T1 Cathartics And Laxatives - Drugs For Constipation bisacodyl T2 DIOCTO ORAL SYRUP (docusate sodium) T2 docusate sodium oral capsule T2 docusate sodium oral liquid T2 docusate sodium oral tablet T1 DOCUSOL (docusate sodium) T2 magnesium citrate oral solution T2 PEDIA-LAX STOOL SOFTENER (docusate sodium) T1 peg 3350-electrolytes oral recon soln 236-22.74-6.74 - T1 5.86 gram

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

96 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits PEG-3350 WITH FLAVOR PACKS (sodium T1 chloride/sodium bicarbonate/potassium chloride/peg) polyethylene glycol 3350 oral powder T2 SENNA ORAL TABLET (sennosides) T1 SENNA-S (sennosides/docusate sodium) T2 sorbitol solution 70 % T1 STOOL SOFTENER ORAL CAPSULE 50 MG (docusate T1 sodium) SUPREP BOWEL PREP KIT (sodium sulfate/potassium T1 sulfate/magnesium sulfate) Cholelitholytic Agents - Drugs For The Stomach ursodiol oral capsule T1 Digestants - Drugs For The Stomach CREON (lipase/protease/amylase) T1 ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10,000-32,000 -42,000 UNIT, 15,000-47,000 -63,000 UNIT, 20,000-63,000- 84,000 UNIT, 25,000-79,000- 105,000 T1 UNIT, 3,000-10,000 -14,000-UNIT, 40,000-126,000- 168,000 UNIT, 5,000-17,000- 24,000 UNIT (lipase/protease/amylase) Gi Drugs, Miscellaneous - Drugs For The Stomach ENTYVIO (vedolizumab) T3 PA HUMIRA PEN (adalimumab) T3 PA HUMIRA PEN CROHNS-UC-HS START (adalimumab) T3 PA HUMIRA PEN PSOR-UVEITS-ADOL HS (adalimumab) T3 PA HUMIRA SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML T3 PA (adalimumab) INFLECTRA (infliximab-dyyb) T3 PA

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

97 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits REMICADE (infliximab) T3 PA RENFLEXIS (infliximab-abda) T3 PA Histamine H2-Antagonists - Drugs For Ulcers And Stomach Acid ACID REDUCER (FAMOTIDINE) ORAL TABLET 10 MG T2 (famotidine) cimetidine HCl oral T1 cimetidine oral tablet 300 mg, 400 mg, 800 mg T1 famotidine intravenous solution T3 PA famotidine oral suspension T1 famotidine oral tablet 20 mg, 40 mg T1 Neurokinin-1 Receptor Antagonists - Drugs For Vomiting And Nausea aprepitant T1 Prokinetic Agents - Drugs For The Stomach metoclopramide HCl injection solution T1 metoclopramide HCl oral solution T1 metoclopramide HCl oral tablet T1 Prostaglandins - Drugs For Ulcers And Stomach Acid diclofenac-misoprostol T3 PA misoprostol T1 Protectants - Drugs For Ulcers And Stomach Acid sucralfate T1 Proton-Pump Inhibitors - Drugs For Ulcers And Stomach Acid DEXILANT (dexlansoprazole) T3 PA esomeprazole magnesium oral capsule,delayed T3 PA release(DR/EC) lansoprazole oral capsule,delayed release(DR/EC) T1 PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

98 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits lansoprazole oral tablet,disintegrat, delay rel 15 mg T3 PA; AL (Max 9 Years) NEXIUM (esomeprazole magnesium) T3 PA NEXIUM PACKET ORAL GRANULES DR FOR SUSP IN PACKET 10 MG, 20 MG, 40 MG (esomeprazole T3 PA magnesium) omeprazole oral capsule,delayed release(DR/EC) 10 mg, T1 20 mg omeprazole-sodium bicarbonate oral capsule T3 PA pantoprazole oral tablet,delayed release (DR/EC) T1 PREVACID 24HR (lansoprazole) T1 PRILOSEC ORAL SUSP,DELAYED RELEASE FOR T3 PA RECON (omeprazole magnesium) rabeprazole oral tablet,delayed release (DR/EC) T1 ZEGERID ORAL CAPSULE (omeprazole/sodium T3 PA bicarbonate) ZEGERID ORAL PACKET 40-1,680 MG T3 PA (omeprazole/sodium bicarbonate) ZEGERID OTC (omeprazole/sodium bicarbonate) T3 PA Gold Compounds Gold Compounds RIDAURA (auranofin) T1 Heavy Metal Antagonists - Drugs To Reduce Iron Heavy Metal Antagonists - Drugs To Reduce Iron CHEMET (succimer) T1 Hormones And Synthetic Substitutes - Hormones Adrenals - Hormones

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

99 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits ADVAIR HFA (fluticasone propionate/salmeterol T1 xinafoate) ARISTOSPAN INTRA-ARTICULAR (triamcinolone T3 PA hexacetonide) ARISTOSPAN INTRALESIONAL (triamcinolone T3 PA hexacetonide) ARNUITY ELLIPTA (fluticasone furoate) T1 ASMANEX HFA (mometasone furoate) T1 ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG/ ACTUATION (30), 220 MCG/ ACTUATION (120), 220 MCG/ T2 QL (1 EA per 30 days) ACTUATION (14), 220 MCG/ ACTUATION (30), 220 MCG/ ACTUATION (60) (mometasone furoate) BREO ELLIPTA (fluticasone furoate/vilanterol T3 PA trifenatate) BREZTRI AEROSPHERE T3 PA (budesonide/glycopyrrolate/formoterol fumarate) budesonide inhalation suspension for nebulization 0.25 T2 QL (120 ML per 30 days) mg/2 mL budesonide inhalation suspension for nebulization 0.5 T2 QL (120 ML per 30 DYs) mg/2 mL budesonide inhalation suspension for nebulization 1 T2 QL (60 ML per 30 days) mg/2 mL budesonide oral capsule,delayed,extend.release T2 QL (90 EA per 30 days) budesonide-formoterol T2 QL (10.2 GM per 30 days) DEPO-MEDROL INJECTION SUSPENSION 20 MG/ML T2 QL (1 EA per 30 days) (methylprednisolone acetate) DEXAMETHASONE INTENSOL (dexamethasone) T1 dexamethasone oral elixir T1

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

100 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits dexamethasone oral solution T1 dexamethasone oral tablet T1 dexamethasone sodium phosphate injection solution T1 DULERA (mometasone furoate/formoterol fumarate) T1 FLOVENT DISKUS (fluticasone propionate) T1 FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION, 220 MCG/ACTUATION T2 QL (12 GM per 30 days) (fluticasone propionate) FLOVENT HFA INHALATION HFA AEROSOL INHALER 44 T2 QL (10.6 GM per 30 days) MCG/ACTUATION (fluticasone propionate) fludrocortisone T1 fluticasone propion-salmeterol inhalation blister with T1 device hydrocortisone oral T1 MEDROL ORAL TABLET 2 MG (methylprednisolone) T1 methylprednisolone acetate T1 methylprednisolone oral tablet 16 mg, 32 mg, 8 mg T1 methylprednisolone oral tablets,dose pack T1 methylprednisolone sodium succ injection recon soln T2 QL (1 EA per 30 days) 125 mg methylprednisolone sodium succ intravenous recon T2 QL (1 EA per 30 days) soln 1,000 mg MILLIPRED ORAL TABLET (prednisolone) T1 prednisolone oral solution 15 mg/5 mL T1 prednisolone sodium phosphate oral solution 15 mg/5 T1 mL (3 mg/mL) PREDNISONE INTENSOL (prednisone) T1 prednisone oral solution T1 PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

101 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits prednisone oral tablet T1 PULMICORT FLEXHALER (budesonide) T3 PA QVAR REDIHALER (beclomethasone dipropionate) T1 SOLU-CORTEF (hydrocortisone sod succinate) T2 QL (1 EA per 30 days) SOLU-MEDROL INTRAVENOUS RECON SOLN 2 GRAM, T2 QL (1 EA per 30 days) 500 MG (methylprednisolone sodium succinate) TRELEGY ELLIPTA INHALATION BLISTER WITH DEVICE 100-62.5-25 MCG (fluticasone furoate/umeclidinium T3 PA bromide/vilanterol trifenat) triamcinolone acetonide injection T2 QL (1 EA per 30 days) UCERIS (budesonide) T3 PA fluticasone propionate/salmeterol xinafoate (Wixela T1 Inhub) Alpha-Glucosidase Inhibitors - Drugs For Diabetes acarbose T1 miglitol T2 ST Amylinomimetics - Drugs For Diabetes SYMLINPEN 120 (pramlintide acetate) T3 PA SYMLINPEN 60 (pramlintide acetate) T3 PA Androgens - Hormones ANDRODERM (testosterone) T3 PA ANDROGEL TRANSDERMAL GEL IN PACKET 1 % (25 T3 PA MG/2.5GRAM), 1 % (50 MG/5 GRAM) (testosterone) estrogens-methyltestosterone T1 METHITEST (methyltestosterone) T3 PA oxandrolone oral tablet 2.5 mg T3 PA testosterone cypionate intramuscular oil 200 mg/mL T2 QL (4 ML per 28 days)

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

102 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits testosterone enanthate T1 testosterone transdermal gel in packet 1 % (25 T3 PA mg/2.5gram), 1 % (50 mg/5 gram) Antiestrogens - Drugs For Women anastrozole T1 exemestane T1 letrozole T1 Antigonadtropins - Hormones FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS T2 QL (1 EA per 30 days) RECON SOLN 80 MG (degarelix acetate) ORILISSA (elagolix sodium) T3 PA Antihypoglycemic Agents, Miscellaneous - Hormones PROGLYCEM (diazoxide) T3 PA Antiparathyroid Agents - Drugs For Bones calcitonin (salmon) injection T2 QL (0.5 ML per 30 days) calcitonin (salmon) nasal T1 Antithyroid Agents - Drugs For The Thyroid methimazole oral tablet 10 mg, 5 mg T1 propylthiouracil T1 SSKI (potassium iodide) T1 Biguanides - Drugs For Diabetes alogliptin-metformin T2 ST; QL (60 EA per 30 days) glipizide-metformin T1 glyburide-metformin oral tablet 2.5-500 mg, 5-500 mg T1 INVOKAMET (canagliflozin/metformin HCl) T2 ST JANUMET (sitagliptin phosphate/metformin HCl) T2 ST PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

103 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits metformin oral tablet T1 metformin oral tablet extended release 24 hr T1 SYNJARDY (empagliflozin/metformin HCl) T2 ST Contraceptives - Drugs For Women desogestrel-ethinyl estradiol (Apri) T1 norethindrone-ethinyl estradiol (Aranelle (28)) T1 levonorgestrel/ethinyl estradiol (Aviane) T1 norethindrone-ethinyl estradiol (Balziva (28)) T1 norethindrone (Camila) T1 norgestrel-ethinyl estradiol (Cryselle (28)) T1 drospirenone-e.estradiol-lm.FA oral tablet 3-0.02-0.451 T1 mg (24) (4) drospirenone-ethinyl estradiol oral tablet 3-0.02 mg T1 ELLA (ulipristal acetate) T1 levonorgestrel/ethinyl estradiol (Enpresse) T1 norethindrone (Errin) T1 ESTROSTEP FE-28 (norethindrone acetate-ethinyl T1 estradiol/ferrous fumarate) etonogestrel-ethinyl estradiol T1 norethindrone acetate-ethinyl estradiol (Junel 1.5/30 T1 (21)) norethindrone acetate-ethinyl estradiol (Junel 1/20 (21)) T1 norethindrone acetate-ethinyl estradiol/ferrous T1 fumarate (Junel Fe 1.5/30 (28)) norethindrone acetate-ethinyl estradiol/ferrous T1 fumarate (Junel Fe 1/20 (28))

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

104 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits desogestrel-ethinyl estradiol/ethinyl estradiol (Kariva T1 (28)) ethynodiol diacetate-ethinyl estradiol (Kelnor 1/35 (28)) T1 L norgest/e.estradiol-e.estrad T1 LEENA 28 (norethindrone-ethinyl estradiol) T1 levonorgestrel/ethinyl estradiol (Lessina) T1 levonorgestrel-ethinyl estrad oral tablet 90-20 mcg (28) T1 levonorgestrel-ethinyl estrad oral tablets,dose pack,3 T1 month levonorgestrel/ethinyl estradiol (Levora-28) T1 LO LOESTRIN FE (norethindrone acetate-ethinyl T1 estradiol/ferrous fumarate) norgestrel-ethinyl estradiol (Low-Ogestrel (28)) T1 levonorgestrel/ethinyl estradiol (Lutera (28)) T1 norethindrone acetate-ethinyl estradiol (Microgestin T1 1.5/30 (21)) norethindrone acetate-ethinyl estradiol (Microgestin 1/20 T1 (21)) norethindrone acetate-ethinyl estradiol/ferrous T1 fumarate (Microgestin Fe 1.5/30 (28)) norethindrone acetate-ethinyl estradiol/ferrous T1 fumarate (Microgestin Fe 1/20 (28)) MY WAY (levonorgestrel) T1 NATAZIA (estradiol valerate/dienogest) T1 norethindrone-ethinyl estradiol (Necon 0.5/35 (28)) T1 NORA-BE (norethindrone) T1 noreth-ethinyl estradiol-iron T1 norethindrone-e.estradiol-iron oral tablet,chewable T1 PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

105 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits norgestimate-ethinyl estradiol oral tablet 0.18/0.215/0.25 T1 mg-35 mcg (28) norethindrone-ethinyl estradiol (Nortrel 0.5/35 (28)) T1 NORTREL 1/35 (21) (norethindrone-ethinyl estradiol) T1 norethindrone-ethinyl estradiol (Nortrel 1/35 (28)) T1 norethindrone-ethinyl estradiol (Nortrel 7/7/7 (28)) T1 OCELLA (ethinyl estradiol/drospirenone) T1 PLAN B ONE-STEP (levonorgestrel) T1 levonorgestrel/ethinyl estradiol (Portia 28) T1 desogestrel-ethinyl estradiol (Reclipsen (28)) T1 SAFYRAL (drospirenone/ethinyl estradiol/levomefolate T1 calcium) norgestimate-ethinyl estradiol (Sprintec (28)) T1 levonorgestrel/ethinyl estradiol (Sronyx) T1 levonorgestrel/ethinyl estradiol (Trivora (28)) T1 desogestrel-ethinyl estradiol (Velivet Triphasic Regimen T1 (28)) XULANE (norelgestromin/ethinyl estradiol) T1 ethynodiol diacetate-ethinyl estradiol (Zovia 1/35E (28)) T1 Dipeptidyl Peptidase-4(Dpp-4) Inhibitors - Drugs For Diabetes alogliptin T2 ST; QL (30 EA per 30 days) alogliptin-metformin T2 ST; QL (60 EA per 30 days) JANUMET (sitagliptin phosphate/metformin HCl) T2 ST JANUVIA (sitagliptin phosphate) T2 ST Estrogen Agonist-Antagonists - Drugs For Women FARESTON (toremifene citrate) T1 raloxifene T1 PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

106 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits tamoxifen T1 Estrogens - Drugs For Women CLIMARA PRO (estradiol/levonorgestrel) T3 PA COMBIPATCH (estradiol/norethindrone acetate) T2 ST estradiol oral T1 estradiol transdermal patch semiweekly T2 QL (8 EA per 28 days) estradiol transdermal patch weekly T1 estradiol vaginal cream T1 estradiol valerate intramuscular oil 20 mg/mL, 40 T3 PA mg/mL ESTRING (estradiol) T3 PA ESTROGEL (estradiol) T1 estrogens-methyltestosterone T1 FEMRING (estradiol acetate) T3 PA MENEST (estrogens,esterified) T1 MENOSTAR (estradiol) T3 PA PREMARIN (estrogens, conjugated) T1 PREMPHASE (estrogens, T1 conjugated/medroxyprogesterone acetate) PREMPRO (estrogens, T1 conjugated/medroxyprogesterone acetate) estradiol (Yuvafem) T1 Glycogenolytic Agents - Hormones BAQSIMI (glucagon) T1 glucagon (Glucagon Emergency Kit (Human)) T1 Gonadotropins - Hormones

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

107 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits LUPRON DEPOT (3 MONTH) (leuprolide acetate) T3 PA LUPRON DEPOT (4 MONTH) (leuprolide acetate) T3 PA LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 T3 PA MG (leuprolide acetate) LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 7.5 T2 QL (1 EA per 30 days) MG (leuprolide acetate) LUPRON DEPOT-PED (leuprolide acetate) T3 PA NOVAREL (chorionic gonadotropin, human) T3 PA TRELSTAR INTRAMUSCULAR SUSPENSION FOR T2 QL (1 EA per 30 days) RECONSTITUTION 11.25 MG (triptorelin pamoate) Gonadotropins And Antigonadotropins - Hormones LUPRON DEPOT (3 MONTH) (leuprolide acetate) T3 PA LUPRON DEPOT (4 MONTH) (leuprolide acetate) T3 PA LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 T3 PA MG (leuprolide acetate) LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 7.5 T2 QL (1 EA per 30 days) MG (leuprolide acetate) LUPRON DEPOT-PED (leuprolide acetate) T3 PA NOVAREL (chorionic gonadotropin, human) T3 PA Incretin Mimetics - Drugs For Diabetes BYETTA (exenatide) T3 PA OZEMPIC SUBCUTANEOUS PEN INJECTOR 0.25 MG T2 ST; QL (1.5 ML per 28 days) OR 0.5 MG(2 MG/1.5 ML) (semaglutide) OZEMPIC SUBCUTANEOUS PEN INJECTOR 1 MG/DOSE T2 ST; QL (3 ML per 28 days) (2 MG/1.5 ML), 1 MG/DOSE (4 MG/3 ML) (semaglutide) RYBELSUS (semaglutide) T2 ST; QL (30 EA per 30 days) TRULICITY (dulaglutide) T2 ST VICTOZA 2-PAK (liraglutide) T2 ST; QL (9 ML per 30 days) PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

108 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits VICTOZA 3-PAK (liraglutide) T2 ST; QL (9 ML per 30 days) Insulins - Drugs For Diabetes APIDRA SOLOSTAR U-100 INSULIN (insulin glulisine) T2 QL (30 QY per 30 DYs) APIDRA U-100 INSULIN (insulin glulisine) T2 QL (30 ML per 30 DYs) HUMALOG MIX 50-50 INSULN U-100 (insulin lispro T2 QL (30 ML per 30 DYs) protamine and insulin lispro) HUMALOG MIX 50-50 KWIKPEN (insulin lispro T2 QL (30 ML per 30 DYs) protamine and insulin lispro) HUMALOG MIX 75-25(U-100)INSULN (insulin lispro T2 QL (30 ML per 30 DYs) protamine and insulin lispro) HUMALOG U-100 INSULIN SUBCUTANEOUS T2 QL (30 ML per 30 DYs) CARTRIDGE (insulin lispro) HUMULIN 70/30 U-100 INSULIN (insulin NPH human T2 QL (6 QY per 30 DYs) isophane/insulin regular, human) HUMULIN N NPH U-100 INSULIN (insulin NPH human T2 QL (6 QY per 30 DYs) isophane) HUMULIN R REGULAR U-100 INSULN (insulin regular, T2 QL (6 QY per 30 DYs) human) insulin asp prt-insulin aspart T2 QL (30 ML per 30 DYs) PA; ST; QL (30 ML per 30 insulin aspart U-100 subcutaneous cartridge T3 DYs) insulin aspart U-100 subcutaneous insulin pen T2 QL (30 ML per 30 days) insulin aspart U-100 subcutaneous solution T2 QL (30 ML per 30 days) insulin lispro protamin-lispro T2 QL (30 ML per 30 days) insulin lispro subcutaneous insulin pen T2 QL (30 ML per 30 days) insulin lispro subcutaneous solution T2 QL (30 ML per 30 days) LANTUS SOLOSTAR U-100 INSULIN (insulin T2 QL (2 QY per 30 DYs) glargine,human recombinant analog)

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

109 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits LANTUS U-100 INSULIN (insulin glargine,human T2 QL (3 QY per 30 DYs) recombinant analog) LEVEMIR FLEXTOUCH U-100 INSULN (insulin detemir) T2 QL (2 QY per 30 days) LEVEMIR U-100 INSULIN (insulin detemir) T2 QL (3 QY per 30 DYs) NOVOLIN 70/30 U-100 INSULIN (insulin NPH human T2 QL (6 QY per 30 DYs) isophane/insulin regular, human) NOVOLIN N NPH U-100 INSULIN (insulin NPH human T2 QL (6 QY per 30 DYs) isophane) NOVOLIN R REGULAR U-100 INSULN (insulin regular, T2 QL (6 QY per 30 DYs) human) Intermediate-Acting Insulins - Drugs For Diabetes HUMALOG MIX 50-50 INSULN U-100 (insulin lispro T2 QL (30 ML per 30 DYs) protamine and insulin lispro) HUMALOG MIX 50-50 KWIKPEN (insulin lispro T2 QL (30 ML per 30 DYs) protamine and insulin lispro) HUMALOG MIX 75-25 KWIKPEN (insulin lispro T2 QL (30 ML per 30 DYs) protamine and insulin lispro) HUMALOG MIX 75-25(U-100)INSULN (insulin lispro T2 QL (30 ML per 30 DYs) protamine and insulin lispro) HUMULIN 70/30 U-100 INSULIN (insulin NPH human T2 QL (6 QY per 30 DYs) isophane/insulin regular, human) HUMULIN N NPH U-100 INSULIN (insulin NPH human T2 QL (6 QY per 30 DYs) isophane) insulin asp prt-insulin aspart T2 QL (30 ML per 30 DYs) insulin lispro protamin-lispro T2 QL (30 ML per 30 days) NOVOLIN 70/30 U-100 INSULIN (insulin NPH human T2 QL (6 QY per 30 DYs) isophane/insulin regular, human) NOVOLIN N NPH U-100 INSULIN (insulin NPH human T2 QL (6 QY per 30 DYs) isophane)

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

110 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits Long-Acting Insulins - Drugs For Diabetes LANTUS SOLOSTAR U-100 INSULIN (insulin T2 QL (2 QY per 30 DYs) glargine,human recombinant analog) LANTUS U-100 INSULIN (insulin glargine,human T2 QL (3 QY per 30 DYs) recombinant analog) LEVEMIR FLEXTOUCH U-100 INSULN (insulin detemir) T2 QL (2 QY per 30 days) LEVEMIR U-100 INSULIN (insulin detemir) T2 QL (3 QY per 30 DYs) Meglitinides - Drugs For Diabetes nateglinide T2 ST repaglinide T2 ST Parathyroid And Antiparathyroid Agents - Drugs For Bones calcitonin (salmon) injection T2 QL (0.5 ML per 30 days) calcitonin (salmon) nasal T1 Pituitary - Hormones desmopressin injection T3 PA desmopressin nasal spray,non-aerosol T3 PA desmopressin oral T2 AL (Min 6 Years) HUMATROPE INJECTION RECON SOLN (somatropin) T2 QL (1 EA per 30 days) vasopressin T2 QL (1 EA per 30 days) Progestins - Drugs For Women COMBIPATCH (estradiol/norethindrone acetate) T2 ST DEPO-SUBQ PROVERA 104 (medroxyprogesterone T1 acetate) medroxyprogesterone T1 megestrol oral suspension 400 mg/10 mL (40 mg/mL) T1 megestrol oral tablet T1

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

111 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits norethindrone acetate T1 progesterone micronized T2 QL (30 EA per 30 days) Rapid-Acting Insulins - Drugs For Diabetes APIDRA SOLOSTAR U-100 INSULIN (insulin glulisine) T2 QL (30 QY per 30 DYs) APIDRA U-100 INSULIN (insulin glulisine) T2 QL (30 ML per 30 DYs) HUMALOG MIX 50-50 INSULN U-100 (insulin lispro T2 QL (30 ML per 30 DYs) protamine and insulin lispro) HUMALOG MIX 50-50 KWIKPEN (insulin lispro T2 QL (30 ML per 30 DYs) protamine and insulin lispro) HUMALOG MIX 75-25(U-100)INSULN (insulin lispro T2 QL (30 ML per 30 DYs) protamine and insulin lispro) HUMALOG U-100 INSULIN SUBCUTANEOUS T2 QL (30 ML per 30 DYs) CARTRIDGE (insulin lispro) insulin asp prt-insulin aspart T2 QL (30 ML per 30 DYs) PA; ST; QL (30 ML per 30 insulin aspart U-100 subcutaneous cartridge T3 DYs) insulin aspart U-100 subcutaneous insulin pen T2 QL (30 ML per 30 days) insulin aspart U-100 subcutaneous solution T2 QL (30 ML per 30 days) insulin lispro protamin-lispro T2 QL (30 ML per 30 days) insulin lispro subcutaneous insulin pen T2 QL (30 ML per 30 days) insulin lispro subcutaneous solution T2 QL (30 ML per 30 days) Short-Acting Insulins - Drugs For Diabetes HUMULIN 70/30 U-100 INSULIN (insulin NPH human T2 QL (6 QY per 30 DYs) isophane/insulin regular, human) HUMULIN R REGULAR U-100 INSULN (insulin regular, T2 QL (6 QY per 30 DYs) human) NOVOLIN 70/30 U-100 INSULIN (insulin NPH human T2 QL (6 QY per 30 DYs) isophane/insulin regular, human) PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

112 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits NOVOLIN R REGULAR U-100 INSULN (insulin regular, T2 QL (6 QY per 30 DYs) human) Sodium-Gluc Cotransport 2 (Sglt2) Inhib - Drugs For Diabetes FARXIGA (dapagliflozin propanediol) T2 QL (30 EA per 30 days) INVOKAMET (canagliflozin/metformin HCl) T2 ST INVOKANA (canagliflozin) T2 ST JARDIANCE (empagliflozin) T2 ST SYNJARDY (empagliflozin/metformin HCl) T2 ST Sulfonylureas - Drugs For Diabetes glimepiride T1 glipizide T1 glipizide-metformin T1 glyburide micronized T1 glyburide oral tablet 1.25 mg, 2.5 mg T1 glyburide-metformin oral tablet 2.5-500 mg, 5-500 mg T1 Thiazolidinediones - Drugs For Diabetes pioglitazone T1 Thyroid Agents - Drugs For The Thyroid ARMOUR THYROID ORAL TABLET 120 MG, 240 MG, 300 T1 MG (thyroid,pork) levothyroxine intravenous recon soln 200 mcg, 500 mcg T3 PA levothyroxine oral tablet T1 liothyronine oral T1 NP THYROID ORAL TABLET 15 MG, 30 MG, 60 MG, 90 T1 MG (thyroid,pork) UNITHROID ORAL TABLET 100 MCG, 112 MCG T3 PA (levothyroxine sodium) PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

113 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits UNITHROID ORAL TABLET 125 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 T1 MCG (levothyroxine sodium) Local Anesthetics (Parenteral) - Drugs For Numbing Local Anesthetics (Parenteral) - Drugs For Numbing bupivacaine HCl T1 bupivacaine-epinephrine T3 PA bupivacaine-epinephrine (PF) injection solution 0.5 %- T3 PA 1:200,000 lidocaine HCl injection solution 10 mg/mL (1 %) T3 PA lidocaine HCl injection solution 20 mg/mL (2 %), 5 T1 mg/mL (0.5 %) lidocaine-epinephrine injection solution 0.5 %-1:200,000 T3 PA lidocaine-epinephrine injection solution 1 %-1:100,000, T1 2 %-1:100,000 mepivacaine HCl (Polocaine Injection Solution) T3 PA XYLOCAINE-MPF/EPINEPHRINE (lidocaine T1 HCl/epinephrine/PF) Miscellaneous Therapeutic Agents 5-Alpha-Reductase Inhibitors finasteride oral tablet 5 mg T1 Alcohol Deterrents - Drugs For Alcohol Dependence disulfiram T2 SCO naltrexone T2 SCO Antidotes - Drugs For Overdose Or Poisoning BAQSIMI (glucagon) T1 CHEMET (succimer) T1 PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

114 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits GLUCAGEN HYPOKIT (glucagon) T1 glucagon (Glucagon Emergency Kit (Human)) T1 lanthanum T3 PA leucovorin calcium injection recon soln 50 mg T2 QL (1 EA per 30 days) leucovorin calcium oral tablet 5 mg T1 MEPHYTON (phytonadione (vit K1)) T1 SCO; QL (2 QY per 180 naloxone injection syringe 1 mg/mL T2 DYs) NARCAN NASAL SPRAY,NON-AEROSOL 4 SCO; QL (2 EA per 180 T2 MG/ACTUATION (naloxone HCl) days) phytonadione (vitamin K1) injection syringe T2 QL (1 EA per 30 days) RENAGEL ORAL TABLET 800 MG (sevelamer HCl) T3 PA sevelamer carbonate oral powder in packet T3 PA sevelamer carbonate oral tablet T2 ST SSKI (potassium iodide) T1 phytonadione (vit K1) (Vitamin K) T1 phytonadione (vit K1) (Vitamin K1 Injection) T1 Antigout Agents - Drugs For Gout allopurinol T1 colchicine oral capsule T2 QL (15 EA per 30 DYs) colchicine oral tablet T2 QL (15 EA per 30 days) INDOCIN ORAL (indomethacin) T1 indomethacin oral T1 naproxen oral suspension T1 naproxen oral tablet T1 naproxen sodium oral tablet 275 mg, 550 mg T1

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

115 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits probenecid T1 probenecid-colchicine T1 Bone Resorption Inhibitors - Drugs For Bone Loss alendronate oral tablet 10 mg, 35 mg, 5 mg, 70 mg T1 calcitonin (salmon) injection T2 QL (0.5 ML per 30 days) calcitonin (salmon) nasal T1 etidronate disodium oral tablet 200 mg T3 PA ibandronate oral T2 QL (1 EA per 30 days) PROLIA (denosumab) T3 PA raloxifene T1 XGEVA (denosumab) T3 PA zoledronic acid intravenous solution T2 QL (0.5 ML per 30 days) Cariostatic Agents - Vitamins And Fluoride fluoride (sodium) dental solution T1 fluoride (sodium) oral drops T1 fluoride (sodium) oral tablet,chewable T1 PREVIDENT 5000 DRY MOUTH (fluoride (sodium)) T1 PREVIDENT DENTAL GEL (fluoride (sodium)) T1 SF (fluoride (sodium)) T1 TRI-VITAMIN WITH FLUORIDE (pediatric multivit with T1 A,C,D3 no.21/sodium fluoride) Disease-Modifying Antirheumatic Agents - Drugs For Arthritis azathioprine T1 cyclosporine modified T1 cyclosporine oral capsule T1 ENBREL MINI (etanercept) T3 PA

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

116 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits ENBREL SUBCUTANEOUS SOLUTION (etanercept) T3 PA ENBREL SUBCUTANEOUS SYRINGE 50 MG/ML (1 ML) T3 PA (etanercept) ENBREL SURECLICK (etanercept) T3 PA cyclosporine, modified (Gengraf Oral Capsule 100 Mg, 25 T1 Mg) cyclosporine, modified (Gengraf Oral Solution) T1 HUMIRA PEN (adalimumab) T3 PA HUMIRA PEN CROHNS-UC-HS START (adalimumab) T3 PA HUMIRA PEN PSOR-UVEITS-ADOL HS (adalimumab) T3 PA HUMIRA SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML T3 PA (adalimumab) hydroxychloroquine T1 INFLECTRA (infliximab-dyyb) T3 PA leflunomide T1 methotrexate sodium T1 methotrexate sodium (PF) T1 OTEZLA (apremilast) T3 PA OTEZLA STARTER (apremilast) T3 PA REMICADE (infliximab) T3 PA RENFLEXIS (infliximab-abda) T3 PA RIDAURA (auranofin) T1 SANDIMMUNE ORAL SOLUTION (cyclosporine) T1 sulfasalazine T1 Gonadotropin-Releasing Hormone Antagnts - Hormones FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS T2 QL (1 EA per 30 days) RECON SOLN 80 MG (degarelix acetate)

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

117 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits Immunomodulatory Agents - Drugs For The Immune System AVONEX INTRAMUSCULAR PEN INJECTOR KIT T1 (interferon beta-1a) AVONEX INTRAMUSCULAR SYRINGE KIT (interferon T1 beta-1a) azathioprine T1 BETASERON SUBCUTANEOUS KIT (interferon beta-1b) T1 cyclosporine modified T1 cyclosporine oral capsule T1 dimethyl fumarate T3 PA ENBREL MINI (etanercept) T3 PA ENBREL SUBCUTANEOUS SOLUTION (etanercept) T3 PA ENBREL SUBCUTANEOUS SYRINGE 50 MG/ML (1 ML) T3 PA (etanercept) ENBREL SURECLICK (etanercept) T3 PA ENTYVIO (vedolizumab) T3 PA EXTAVIA (interferon beta-1b) T1 cyclosporine, modified (Gengraf Oral Capsule 100 Mg, 25 T1 Mg) cyclosporine, modified (Gengraf Oral Solution) T1 GILENYA ORAL CAPSULE 0.5 MG (fingolimod HCl) T3 PA glatiramer T1 glatiramer acetate (Glatopa) T1 HUMIRA PEN (adalimumab) T3 PA HUMIRA PEN CROHNS-UC-HS START (adalimumab) T3 PA HUMIRA PEN PSOR-UVEITS-ADOL HS (adalimumab) T3 PA

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

118 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits HUMIRA SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML T3 PA (adalimumab) hydroxychloroquine T1 INFLECTRA (infliximab-dyyb) T3 PA INTRON A INJECTION RECON SOLN (interferon alfa- T2 PA 2b,recomb.) INTRON A INJECTION SOLUTION 10 MILLION UNIT/ML T3 PA (interferon alfa-2b,recomb.) INTRON A INJECTION SOLUTION 6 MILLION UNIT/ML T2 QL (0.5 ML per 30 days) (interferon alfa-2b,recomb.) leflunomide T1 methotrexate sodium T1 methotrexate sodium (PF) T1 OTEZLA (apremilast) T3 PA OTEZLA STARTER (apremilast) T3 PA PROLEUKIN (aldesleukin) T2 QL (1 EA per 30 days) REBIF (WITH ALBUMIN) (interferon beta-1a/albumin T1 human) REBIF TITRATION PACK (interferon beta-1a/albumin T1 human) REMICADE (infliximab) T3 PA RENFLEXIS (infliximab-abda) T3 PA REVLIMID ORAL CAPSULE 10 MG, 15 MG, 25 MG, 5 MG T3 PA (lenalidomide) RIDAURA (auranofin) T1 SANDIMMUNE ORAL SOLUTION (cyclosporine) T1 sulfasalazine T1 THALOMID (thalidomide) T3 PA PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

119 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits Immunosuppressive Agents - Drugs For Transplant azathioprine T1 cyclophosphamide intravenous recon soln T2 QL (1 EA per 30 days) cyclosporine modified T1 cyclosporine oral capsule T1 cyclosporine, modified (Gengraf Oral Capsule 100 Mg, 25 T1 Mg) cyclosporine, modified (Gengraf Oral Solution) T1 mercaptopurine T1 methotrexate sodium T1 methotrexate sodium (PF) T1 mycophenolate mofetil T1 mycophenolate sodium T1 pimecrolimus T3 PA RAPAMUNE ORAL SOLUTION (sirolimus) T1 RAPAMUNE ORAL TABLET 2 MG (sirolimus) T1 SANDIMMUNE ORAL SOLUTION (cyclosporine) T1 sirolimus oral tablet 0.5 mg, 1 mg T1 tacrolimus oral T1 Other Miscellaneous Therapeutic Agents acetylcysteine T1 DEMSER (metyrosine) T1 EVOTAZ (atazanavir sulfate/cobicistat) T2 SCO levocarnitine oral tablet T1 REMICADE (infliximab) T3 PA

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

120 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits SYMTUZA (darunavir T2 SCO eth/cobicistat/emtricitabine/tenofovir alafenamide) Protective Agents ELMIRON (pentosan polysulfate sodium) T1 MESNEX ORAL (mesna) T1 Nonhormonal Contraceptives - Drugs For Women Nonhormonal Contraceptives - Drugs For Women CAYA CONTOURED (diaphragms, contoured) T1 DUREX AVANTI BARE REAL FEEL (condoms, non-latex, T2 lubricated) FANTASY CONDOM (condoms, latex, lubricated) T2 FC2 FEMALE CONDOM (condoms, female) T2 FEMCAP (cervical cap) T1 GYNOL II (nonoxynol 9) T2 KIMONO CONDOMS(NON-LUBRICATED) (condoms, T2 latex, non-lubricated) KIMONO MAXX CONDOMS (condoms, latex, non- T2 lubricated) KIMONO MICROTHIN AQUA LUBE CON (condoms, T2 latex, lubricated) KIMONO MICROTHIN CONDOMS (condoms, latex, non- T2 lubricated) KIMONO MICROTHIN LARGE CONDOMS (condoms, T2 latex, lubricated) KIMONO TEXTURED CONDOMS (condoms, latex, T2 lubricated) TODAY CONTRACEPTIVE SPONGE (nonoxynol 9) T2 TRUSTEX LATEX CONDOM (condoms, latex, lubricated) T2 PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

121 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits TRUSTEX LUBRICATED CONDOMS (condoms, latex, T2 lubricated) TRUSTEX NON-LUB CONDOMS (condoms, latex, non- T2 lubricated) TRUSTEX-RIA LUB/SPERMICIDE (condoms, latex, T2 lubricated) TRUSTEX-RIA LUBRICATED CONDOMS (condoms, T2 latex, lubricated) TRUSTEX-RIA NON-LUB CONDOMS (condoms, latex, T2 non-lubricated) VAGINAL CONTRACEPTIVE FOAM (nonoxynol 9) T2 VCF CONTRACEPTIVE FILM (nonoxynol 9) T2 VCF CONTRACEPTIVE GEL (nonoxynol 9) T2 WIDE-SEAL DIAPHRAGM 60 (diaphragms, wide seal) T1 WIDE-SEAL DIAPHRAGM 65 (diaphragms, wide seal) T1 WIDE-SEAL DIAPHRAGM 70 (diaphragms, wide seal) T1 WIDE-SEAL DIAPHRAGM 75 (diaphragms, wide seal) T1 WIDE-SEAL DIAPHRAGM 80 (diaphragms, wide seal) T1 WIDE-SEAL DIAPHRAGM 85 (diaphragms, wide seal) T1 WIDE-SEAL DIAPHRAGM 90 (diaphragms, wide seal) T1 WIDE-SEAL DIAPHRAGM 95 (diaphragms, wide seal) T1 Oxytocics - Drugs For Women Oxytocics - Drugs For Women methylergonovine maleate (Methergine) T2 QL (4 EA per 1 day) methylergonovine injection T1 oxytocin injection solution T2 QL (1 EA per 30 days) Pharmaceutical Aids

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

122 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits Pharmaceutical Aids water for injection,sterile (Sterile Water For Injection) T1 water for inject, bacteriostat T1 water for injection, sterile injection solution T1 water for injection, sterile intravenous T1 Respiratory Tract Agents - Drugs For The Lungs Alpha And Beta Adrenergic Agonist(Respr) - Drugs For Asthma/Copd ALAVERT D-12 ALLERGY-SINUS T2 (loratadine/pseudoephedrine sulfate) cetirizine-pseudoephedrine T2 CHILDREN'S SILFEDRINE (pseudoephedrine HCl) T2 ephedrine sulfate injection solution T3 PA epinephrine injection auto-injector 0.15 mg/0.3 mL T2 QL (4 EA per 180 days) epinephrine injection auto-injector 0.3 mg/0.3 mL T2 QL (4 EA per 6 monthss) epinephrine injection solution T2 QL (1 EA per 30 days) epinephrine injection syringe 0.1 mg/mL T2 QL (1 EA per 30 days) fexofenadine-pseudoephedrine T2 ST LOHIST - D (chlorpheniramine T1 maleate/pseudoephedrine HCl) LORATADINE-D ORAL TABLET EXTENDED RELEASE 24 T2 HR (loratadine/pseudoephedrine sulfate) MUCUS D ORAL TABLET EXTENDED RELEASE 12 HR T2 60-600 MG (guaifenesin/pseudoephedrine HCl) MUCUS RELIEF D (PSEUDOEPHED) ORAL TABLET EXTENDED RELEASE 12 HR 120-1,200 MG T2 (guaifenesin/pseudoephedrine HCl) PEDIA RELIEF INFANT NASAL (pseudoephedrine HCl) T2

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

123 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits PEDIATRIC COUGH AND COLD ORAL LIQUID 1-15-5 MG/5 ML (chlorpheniramine T2 maleate/pseudoephedrine/dextromethorphan) pseudoephedrine HCl oral tablet T2 RESCON-DM (chlorpheniramine T2 maleate/pseudoephedrine/dextromethorphan) SUDOGEST 12-HOUR (pseudoephedrine HCl) T2 SYMJEPI (epinephrine) T2 QL (4 EA per 180 days) TUSNEL NEW FORMULA ORAL TABLET (guaifenesin/dextromethorphan HBr/pseudoephedrine T3 PA HCl) WAL-FEX D 24 HOUR (fexofenadine T2 ST HCl/pseudoephedrine HCl) Anticholinergic Agents (Respir.Tract) - Drugs For Asthma/Copd ANORO ELLIPTA (umeclidinium bromide/vilanterol T1 trifenatate) atropine injection solution T1 atropine injection syringe 0.05 mg/mL, 0.1 mg/mL T1 ATROVENT HFA (ipratropium bromide) T1 BREZTRI AEROSPHERE T3 PA (budesonide/glycopyrrolate/formoterol fumarate) COMBIVENT RESPIMAT (ipratropium bromide/albuterol T1 sulfate) diphenoxylate-atropine T1 INCRUSE ELLIPTA (umeclidinium bromide) T2 QL (30 EA per 30 DYs) ipratropium bromide inhalation T1 ipratropium-albuterol T1 SPIRIVA RESPIMAT (tiotropium bromide) T2 QL (4 GM per 30 days)

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

124 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits SPIRIVA WITH HANDIHALER (tiotropium bromide) T1 STIOLTO RESPIMAT (tiotropium bromide/olodaterol T1 HCl) TRELEGY ELLIPTA INHALATION BLISTER WITH DEVICE 100-62.5-25 MCG (fluticasone furoate/umeclidinium T3 PA bromide/vilanterol trifenat) Anti-Inflammatory Agents (Respiratory) - Drugs For Inflammation NUCALA SUBCUTANEOUS RECON SOLN T3 PA (mepolizumab) Antitussives - Drugs For Cough And Cold benzonatate oral capsule 100 mg T1 chlorpheniramine-phenyleph-DM T3 PA codeine sulfate oral tablet 30 mg, 60 mg T1 ED A-HIST DM ORAL LIQUID (chlorpheniramine T2 maleate/phenylephrine HCl/dextromethorphan) hydrocodone-homatropine oral syrup 5-1.5 mg/5 mL T2 AL (Min 18 Years) MUCUS DM (guaifenesin/dextromethorphan HBr) T2 NEO-TUSS (guaifenesin/dextromethorphan HBr) T2 PEDIATRIC COUGH AND COLD ORAL LIQUID 1-15-5 MG/5 ML (chlorpheniramine T2 maleate/pseudoephedrine/dextromethorphan) QL (240 ML per 30 days); AL promethazine-codeine T2 (Min 18 Years) promethazine-DM T1 QL (240 ML per 30 days); AL promethazine-phenyleph-codeine T2 (Min 18 Years) RESCON-DM (chlorpheniramine T2 maleate/pseudoephedrine/dextromethorphan)

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

125 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits ROBAFEN CF (PHENYLEPHRINE) T2 (guaifenesin/dextromethorphan HBr/phenylephrine) SCOT-TUSSIN DM (chlorpheniramine T2 maleate/dextromethorphan HBr) TUSNEL NEW FORMULA ORAL TABLET (guaifenesin/dextromethorphan HBr/pseudoephedrine T3 PA HCl) WAL-TUSSIN MAX STRENGTH COUGH T2 (dextromethorphan HBr) Expectorants - Drugs For The Lungs guaifenesin oral liquid T2 guaifenesin oral tablet 200 mg T1 MUCUS D ORAL TABLET EXTENDED RELEASE 12 HR T2 60-600 MG (guaifenesin/pseudoephedrine HCl) MUCUS DM (guaifenesin/dextromethorphan HBr) T2 MUCUS RELIEF D (PSEUDOEPHED) ORAL TABLET EXTENDED RELEASE 12 HR 120-1,200 MG T2 (guaifenesin/pseudoephedrine HCl) MUCUS RELIEF ORAL TABLET 400 MG (guaifenesin) T2 NEO-TUSS (guaifenesin/dextromethorphan HBr) T2 ROBAFEN CF (PHENYLEPHRINE) T2 (guaifenesin/dextromethorphan HBr/phenylephrine) SSKI (potassium iodide) T1 TUSNEL NEW FORMULA ORAL TABLET (guaifenesin/dextromethorphan HBr/pseudoephedrine T3 PA HCl) First Generation Antihist.(Respir Tract) - Drugs For Allergy CHILDREN'S ALLERGY (DIPHENHYD) ORAL T2 TABLET,CHEWABLE (diphenhydramine HCl) PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

126 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits chlorpheniramine maleate oral tablet T2 chlorpheniramine maleate oral tablet extended release T2 chlorpheniramine-phenyleph-DM T3 PA clemastine oral tablet 2.68 mg T1 cyproheptadine T1 dimenhydrinate injection solution T3 PA diphenhydramine HCl injection solution 50 mg/mL T2 QL (1 EA per 30 days) diphenhydramine HCl injection syringe T2 QL (1 EA per 30 days) diphenhydramine HCl oral capsule T2 diphenhydramine HCl oral elixir T2 diphenhydramine HCl oral liquid T2 diphenhydramine HCl oral tablet 25 mg T2 ED A-HIST DM ORAL LIQUID (chlorpheniramine T2 maleate/phenylephrine HCl/dextromethorphan) LOHIST - D (chlorpheniramine T1 maleate/pseudoephedrine HCl) PEDIATRIC COUGH AND COLD ORAL LIQUID 1-15-5 MG/5 ML (chlorpheniramine T2 maleate/pseudoephedrine/dextromethorphan) promethazine injection solution 25 mg/mL T2 QL (1 EA per 30 days) promethazine injection solution 50 mg/mL T1 promethazine oral T1 phenylephrine HCl/promethazine HCl (Promethazine Vc) T1 QL (240 ML per 30 days); AL promethazine-codeine T2 (Min 18 Years) promethazine-DM T1 QL (240 ML per 30 days); AL promethazine-phenyleph-codeine T2 (Min 18 Years) PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

127 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits RESCON-DM (chlorpheniramine T2 maleate/pseudoephedrine/dextromethorphan) SCOT-TUSSIN DM (chlorpheniramine T2 maleate/dextromethorphan HBr) SLEEP AID (DIPHENHYDRAMINE) ORAL CAPSULE 50 T2 MG (diphenhydramine HCl) SLEEP AID (DIPHENHYDRAMINE) ORAL TABLET T2 (diphenhydramine HCl) WAL-SOM (DOXYLAMINE) (doxylamine succinate) T2 Interleukin Antagonists - Drugs For Inflammation DUPIXENT PEN SUBCUTANEOUS PEN INJECTOR 300 T3 PA MG/2 ML (dupilumab) DUPIXENT SYRINGE (dupilumab) T3 PA FASENRA (benralizumab) T3 PA FASENRA PEN (benralizumab) T3 PA NUCALA (mepolizumab) T3 PA Leukotriene Modifiers - Drugs For Inflammation montelukast oral granules in packet T3 PA montelukast oral tablet T1 montelukast oral tablet,chewable T1 SINGULAIR ORAL GRANULES IN PACKET (montelukast T3 PA sodium) zafirlukast T3 PA zileuton T3 PA ZYFLO (zileuton) T3 PA Mast-Cell Stabilizers - Drugs For Inflammation ALOCRIL (nedocromil sodium) T3 PA; QL (1 QY per 30 DYs)

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

128 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits cromolyn inhalation T1 cromolyn ophthalmic (eye) T2 QL (1 QY per 30 DYs) Mucolytic Agents - Drugs For The Lungs acetylcysteine T1 PULMOZYME (dornase alfa) T3 PA Nasal Preparations (Steroids) - Drugs For Inflammation ALLERGY RELIEF (FLUTICASONE) (fluticasone T2 QL (1 QY per 30 days) propionate) BECONASE AQ (beclomethasone dipropionate) T3 PA budesonide nasal T2 QL (8.43 ML per 30 days) FLONASE SENSIMIST (fluticasone furoate) T2 QL (9.1 ML per 30 days) flunisolide nasal spray,non-aerosol 25 mcg (0.025 %) T3 PA; QL (1 QY per 30 DYs) fluticasone propionate nasal T2 QL (1 QY per 30 DYs) mometasone nasal T3 PA NASAL ALLERGY (triamcinolone acetonide) T2 QL (1 qy per 30 days) NASONEX (mometasone furoate) T3 PA OMNARIS (ciclesonide) T3 PA QNASL (beclomethasone dipropionate) T3 PA RHINOCORT ALLERGY (budesonide) T2 QL (8.43 ML per 30 days) triamcinolone acetonide nasal T2 QL (1 QY per 30 days) ZETONNA (ciclesonide) T3 PA Orally Inhaled Preparations (Steroids) - Drugs For Inflammation ADVAIR HFA (fluticasone propionate/salmeterol T1 xinafoate) ARNUITY ELLIPTA (fluticasone furoate) T1 ASMANEX HFA (mometasone furoate) T1

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

129 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG/ ACTUATION (30), 220 MCG/ ACTUATION (120), 220 MCG/ T2 QL (1 EA per 30 days) ACTUATION (14), 220 MCG/ ACTUATION (30), 220 MCG/ ACTUATION (60) (mometasone furoate) BREO ELLIPTA (fluticasone furoate/vilanterol T3 PA trifenatate) BREZTRI AEROSPHERE T3 PA (budesonide/glycopyrrolate/formoterol fumarate) budesonide inhalation suspension for nebulization 0.25 T2 QL (120 ML per 30 days) mg/2 mL budesonide inhalation suspension for nebulization 0.5 T2 QL (120 ML per 30 DYs) mg/2 mL budesonide inhalation suspension for nebulization 1 T2 QL (60 ML per 30 days) mg/2 mL budesonide-formoterol T2 QL (10.2 GM per 30 days) DULERA (mometasone furoate/formoterol fumarate) T1 FLOVENT DISKUS (fluticasone propionate) T1 FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION, 220 MCG/ACTUATION T2 QL (12 GM per 30 days) (fluticasone propionate) FLOVENT HFA INHALATION HFA AEROSOL INHALER 44 T2 QL (10.6 GM per 30 days) MCG/ACTUATION (fluticasone propionate) fluticasone propion-salmeterol inhalation blister with T1 device PULMICORT FLEXHALER (budesonide) T3 PA QVAR REDIHALER (beclomethasone dipropionate) T1 TRELEGY ELLIPTA INHALATION BLISTER WITH DEVICE 100-62.5-25 MCG (fluticasone furoate/umeclidinium T3 PA bromide/vilanterol trifenat) PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

130 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits fluticasone propionate/salmeterol xinafoate (Wixela T1 Inhub) Phosphodiesterase Type 4 Inhibitors - Drugs For The Lungs DALIRESP (roflumilast) T3 PA Respiratory Tract Agents, Miscellaneous - Drugs For The Lungs XOLAIR (omalizumab) T3 PA Second Generation Antihist(Respir Tract) - Drugs For Allergy ALAVERT (loratadine) T2 ALAVERT D-12 ALLERGY-SINUS T2 (loratadine/pseudoephedrine sulfate) cetirizine oral solution 1 mg/mL T2 cetirizine oral tablet T2 cetirizine oral tablet,chewable T2 cetirizine-pseudoephedrine T2 CHILDREN'S ALLERGY RELIEF(FEX) (fexofenadine HCl) T2 ST fexofenadine oral tablet 180 mg, 60 mg T2 ST fexofenadine-pseudoephedrine T2 ST levocetirizine oral tablet T2 loratadine oral solution T2 loratadine oral tablet T2 LORATADINE-D ORAL TABLET EXTENDED RELEASE 24 T2 HR (loratadine/pseudoephedrine sulfate) WAL-FEX D 24 HOUR (fexofenadine T2 ST HCl/pseudoephedrine HCl) Select.Beta-2-Adrenergic Agonist(Respir) - Drugs For Asthma/Copd ADVAIR HFA (fluticasone propionate/salmeterol T1 xinafoate) PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

131 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits albuterol sulfate inhalation HFA aerosol inhaler T2 QL (2 QY per 30 days) albuterol sulfate inhalation solution for nebulization 2.5 T1 mg /3 mL (0.083 %), 5 mg/mL albuterol sulfate oral T1 ANORO ELLIPTA (umeclidinium bromide/vilanterol T1 trifenatate) BREO ELLIPTA (fluticasone furoate/vilanterol T3 PA trifenatate) BREZTRI AEROSPHERE T3 PA (budesonide/glycopyrrolate/formoterol fumarate) budesonide-formoterol T2 QL (10.2 GM per 30 days) COMBIVENT RESPIMAT (ipratropium bromide/albuterol T1 sulfate) DULERA (mometasone furoate/formoterol fumarate) T1 fluticasone propion-salmeterol inhalation blister with T1 device ipratropium-albuterol T1 levalbuterol HCl T3 PA levalbuterol tartrate T3 PA metaproterenol oral syrup T1 SEREVENT DISKUS (salmeterol xinafoate) T1 STIOLTO RESPIMAT (tiotropium bromide/olodaterol T1 HCl) terbutaline oral T1 TRELEGY ELLIPTA INHALATION BLISTER WITH DEVICE 100-62.5-25 MCG (fluticasone furoate/umeclidinium T3 PA bromide/vilanterol trifenat) fluticasone propionate/salmeterol xinafoate (Wixela T1 Inhub) PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

132 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits Vasodilating Agents (Respiratory Tract) - Drugs For The Lungs sildenafil (pulm.hypertension) oral tablet T3 PA tadalafil (pulm. hypertension) T3 PA VENTAVIS INHALATION SOLUTION FOR NEBULIZATION T3 PA 20 MCG/ML (iloprost tromethamine) Xanthine Derivatives - Drugs For Asthma/Copd theophylline anhydrous (Elixophyllin Oral Elixir 80 Mg/15 T1 Ml) theophylline in dextrose 5 % intravenous parenteral T2 QL (1 EA per 30 days) solution 200 mg/100 mL theophylline oral elixir T1 theophylline oral tablet extended release 12 hr 300 mg, T1 450 mg theophylline oral tablet extended release 24 hr 600 mg T1 Skin And Mucous Membrane Agents - Drugs For The Skin Allylamines (Skin And Mucous Membrane) - Drugs For The Skin naftifine topical cream 1 % T1 terbinafine HCl topical T1 Antibacterials (Skin, Mucous Membrane) - Drugs For The Skin bacitracin topical ointment T2 bacitracin zinc T2 BENZAMYCIN (erythromycin base/benzoyl peroxide) T3 PA CLEOCIN VAGINAL SUPPOSITORY (clindamycin T3 PA phosphate) clindamycin phosphate topical gel T1 clindamycin phosphate topical gel, once daily T1 clindamycin phosphate topical lotion T1 PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

133 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits clindamycin phosphate topical solution T1 clindamycin phosphate topical swab T1 clindamycin phosphate vaginal T1 clindamycin-benzoyl peroxide topical gel 1-5 % T3 PA ERY PADS (erythromycin base in ethanol) T3 PA erythromycin with ethanol topical gel T1 erythromycin with ethanol topical solution T1 erythromycin-benzoyl peroxide T3 PA gentamicin topical T1 metronidazole topical cream T2 QL (45 GM per 30 days) metronidazole topical gel T2 QL (45 GM per 30 days) metronidazole topical gel with pump T3 PA metronidazole vaginal T1 mupirocin T1 neomycin-polymyxin B GU T1 NORITATE (metronidazole) T3 PA Antifulgals (Skin, Mucous Membrane),Misc - Drugs For The Skin EXODERM (sodium thiosulfate/salicylic acid) T1 gentian violet T2 Anti-Inflammatory Agents (Skin, Mucous) - Drugs For The Skin alclometasone T3 PA amcinonide topical cream T3 PA amcinonide topical lotion T3 PA APEXICON E (diflorasone diacetate/emollient base) T3 PA betamethasone dipropionate T1 betamethasone valerate topical cream T1 PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

134 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits betamethasone valerate topical lotion T1 betamethasone valerate topical ointment T1 betamethasone, augmented topical cream T1 betamethasone, augmented topical gel T1 betamethasone, augmented topical lotion T3 PA betamethasone, augmented topical ointment T3 PA clobetasol scalp T1 clobetasol topical cream T1 clobetasol topical foam T1 clobetasol topical gel T1 clobetasol topical lotion T1 clobetasol topical ointment T1 clobetasol-emollient topical cream T1 clotrimazole-betamethasone T1 CORDRAN TAPE LARGE ROLL (flurandrenolide) T3 PA CORDRAN TOPICAL CREAM 0.05 % (flurandrenolide) T3 PA CORDRAN TOPICAL LOTION (flurandrenolide) T3 PA CORDRAN TOPICAL OINTMENT (flurandrenolide) T3 PA CORTIFOAM (hydrocortisone acetate) T1 CORTISONE COOLING (hydrocortisone) T1 desonide topical cream T1 desonide topical lotion T3 PA desonide topical ointment T1 desoximetasone topical cream T3 PA desoximetasone topical gel T3 PA desoximetasone topical ointment 0.25 % T3 PA

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

135 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits diflorasone topical ointment T3 PA fluocinolone T1 fluocinolone and shower cap T1 fluocinonide T1 fluocinonide/emollient base (Fluocinonide-E) T1 fluticasone propionate topical cream T1 fluticasone propionate topical lotion T3 PA fluticasone propionate topical ointment T1 halobetasol propionate topical cream T1 halobetasol propionate topical ointment T1 HALOG TOPICAL CREAM (halcinonide) T3 PA HALOG TOPICAL OINTMENT (halcinonide) T3 PA hydrocortisone acetate rectal suppository 30 mg T1 hydrocortisone acetate topical cream T2 hydrocortisone butyrate topical cream T3 PA hydrocortisone butyrate topical ointment T3 PA hydrocortisone butyrate topical solution T3 PA hydrocortisone rectal T1 hydrocortisone topical cream T2 hydrocortisone topical cream with perineal applicator 1 T1 % hydrocortisone topical lotion 1 % T2 hydrocortisone topical lotion 2.5 % T1 hydrocortisone topical ointment 0.5 %, 1 % T2 hydrocortisone topical ointment 2.5 % T1 hydrocortisone valerate T3 PA

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

136 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits hydrocortisone-aloe vera topical cream 0.5 % T1 hydrocortisone-aloe vera topical cream 1 % T2 hydrocortisone-pramoxine rectal cream 1-1 %, 2.5-1 % T1 hydrocortisone-pramoxine topical T1 lidocaine HCl-hydrocortison ac topical T2 mometasone topical T1 PANDEL (hydrocortisone probutate) T3 PA PRAMOSONE TOPICAL CREAM 1-1 % (hydrocortisone T1 acetate/pramoxine HCl) PRAMOSONE TOPICAL OINTMENT (hydrocortisone T1 acetate/pramoxine HCl) prednicarbate T3 PA hydrocortisone (Proctozone-Hc) T1 SCALACORT (hydrocortisone) T3 SCALP RELIEF TOPICAL SOLUTION (hydrocortisone) T1 SCALPICIN ANTI-ITCH (hydrocortisone) T1 triamcinolone acetonide dental T1 triamcinolone acetonide topical aerosol T3 PA triamcinolone acetonide topical cream T1 triamcinolone acetonide topical lotion T1 triamcinolone acetonide topical ointment 0.025 %, 0.1 T1 %, 0.5 % triamcinolone acetonide (Trianex) T3 PA Antipruritics And Local Anesthetics - Drugs For The Skin CALACLEAR (pramoxine HCl/camphor/zinc acetate) T2 CALAGESIC (pramoxine HCl/calamine) T2 hydrocortisone-pramoxine rectal cream 1-1 %, 2.5-1 % T1 PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

137 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits hydrocortisone-pramoxine topical T1 lidocaine HCl topical cream 3 % T2 QL (85 GM per 30 days) lidocaine HCl-hydrocortison ac topical T2 LIDOCAINE PLUS (lidocaine HCl) T2 QL (60 GM per 30 days) lidocaine topical adhesive patch,medicated 5 % T3 PA lidocaine topical cream 4 % T2 QL (60 GM per 30 days) lidocaine topical ointment T2 QL (60 GM per 30 days) lidocaine-prilocaine topical cream T2 QL (60 GM per 30 days) phenazopyridine oral tablet 100 mg, 200 mg T1 PRAMOSONE TOPICAL CREAM 1-1 % (hydrocortisone T1 acetate/pramoxine HCl) PRAMOSONE TOPICAL OINTMENT (hydrocortisone T1 acetate/pramoxine HCl) Antivirals (Skin And Mucous Membrane) - Drugs For The Skin ABREVA (docosanol) T2 acyclovir topical T3 PA Astringents - Drugs For The Skin DRYSOL (aluminum chloride) T1 XERAC AC (aluminum chloride) T1 Azoles (Skin And Mucous Membrane) - Drugs For The Skin ANTIFUNGAL CREAM (MICONAZOLE) (miconazole T2 nitrate) clotrimazole mucous membrane T1 clotrimazole topical T1 clotrimazole vaginal cream T2 clotrimazole-betamethasone T1

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

138 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits econazole T1 FUNGI CURE (clotrimazole) T2 JUBLIA (efinaconazole) T3 PA ketoconazole topical cream T1 ketoconazole topical shampoo T1 LOTRIMIN AF (miconazole nitrate) T2 LOTRIMIN AF POWDER (miconazole nitrate) T2 miconazole nitrate vaginal cream T2 miconazole nitrate vaginal suppository T2 MICONAZOLE-3 VAGINAL KIT (miconazole nitrate) T2 MICONAZOLE-3 VAGINAL SUPPOSITORY (miconazole T1 nitrate) NIZORAL A-D (ketoconazole) T1 terconazole vaginal cream T2 terconazole vaginal suppository T3 PA tioconazole T1 Basic Lotions And Liniments - Drugs For The Skin calamine T2 calamine-zinc oxide T2 Cell Stimulants And Proliferants - Drugs For The Skin REGRANEX (becaplermin) T3 PA tretinoin microspheres topical gel T2 AL (Max 30 Years) tretinoin microspheres topical gel with pump 0.04 % T2 AL (Max 30 Years) tretinoin microspheres topical gel with pump 0.1 % T2 tretinoin topical cream T2 AL (Max 30 Years) tretinoin topical gel 0.01 %, 0.025 % T2 AL (Max 30 Years)

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

139 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits Corticosteroids (Skin, Mucous Membrane) - Drugs For The Skin alclometasone T3 PA amcinonide topical cream T3 PA amcinonide topical lotion T3 PA APEXICON E (diflorasone diacetate/emollient base) T3 PA betamethasone dipropionate T1 betamethasone valerate topical cream T1 betamethasone valerate topical lotion T1 betamethasone valerate topical ointment T1 betamethasone, augmented topical cream T1 betamethasone, augmented topical gel T1 betamethasone, augmented topical lotion T3 PA betamethasone, augmented topical ointment T3 PA clobetasol scalp T1 clobetasol topical cream T1 clobetasol topical foam T1 clobetasol topical gel T1 clobetasol topical lotion T1 clobetasol topical ointment T1 clobetasol-emollient topical cream T1 clotrimazole-betamethasone T1 CORDRAN TAPE LARGE ROLL (flurandrenolide) T3 PA CORDRAN TOPICAL CREAM 0.05 % (flurandrenolide) T3 PA CORDRAN TOPICAL LOTION (flurandrenolide) T3 PA CORDRAN TOPICAL OINTMENT (flurandrenolide) T3 PA CORTIFOAM (hydrocortisone acetate) T1

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

140 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits CORTISONE COOLING (hydrocortisone) T1 desonide topical cream T1 desonide topical lotion T3 PA desonide topical ointment T1 desoximetasone topical cream T3 PA desoximetasone topical gel T3 PA desoximetasone topical ointment 0.25 % T3 PA diflorasone topical ointment T3 PA fluocinolone T1 fluocinolone and shower cap T1 fluocinonide T1 fluocinonide/emollient base (Fluocinonide-E) T1 fluticasone propionate topical cream T1 fluticasone propionate topical lotion T3 PA fluticasone propionate topical ointment T1 halobetasol propionate topical cream T1 halobetasol propionate topical ointment T1 HALOG TOPICAL CREAM (halcinonide) T3 PA HALOG TOPICAL OINTMENT (halcinonide) T3 PA hydrocortisone acetate rectal suppository 30 mg T1 hydrocortisone acetate topical cream T2 hydrocortisone butyrate topical cream T3 PA hydrocortisone butyrate topical ointment T3 PA hydrocortisone butyrate topical solution T3 PA hydrocortisone rectal T1 hydrocortisone topical cream T2

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

141 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits hydrocortisone topical cream with perineal applicator 1 T1 % hydrocortisone topical lotion 1 % T2 hydrocortisone topical lotion 2.5 % T1 hydrocortisone topical ointment 0.5 %, 1 % T2 hydrocortisone topical ointment 2.5 % T1 hydrocortisone valerate T3 PA hydrocortisone-aloe vera topical cream 0.5 % T1 hydrocortisone-aloe vera topical cream 1 % T2 hydrocortisone-iodoquinol T1 hydrocortisone-pramoxine rectal cream 1-1 %, 2.5-1 % T1 hydrocortisone-pramoxine topical T1 lidocaine HCl-hydrocortison ac topical T2 mometasone topical T1 PANDEL (hydrocortisone probutate) T3 PA PRAMOSONE TOPICAL CREAM 1-1 % (hydrocortisone T1 acetate/pramoxine HCl) PRAMOSONE TOPICAL OINTMENT (hydrocortisone T1 acetate/pramoxine HCl) prednicarbate T3 PA hydrocortisone (Proctozone-Hc) T1 SCALACORT (hydrocortisone) T3 SCALP RELIEF TOPICAL SOLUTION (hydrocortisone) T1 SCALPICIN ANTI-ITCH (hydrocortisone) T1 triamcinolone acetonide dental T1 triamcinolone acetonide topical aerosol T3 PA triamcinolone acetonide topical cream T1 PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

142 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits triamcinolone acetonide topical lotion T1 triamcinolone acetonide topical ointment 0.025 %, 0.1 T1 %, 0.5 % triamcinolone acetonide (Trianex) T3 PA Hydroxypyridones (Skin, Mucous Membrane) - Drugs For The Skin ciclopirox T1 Keratolytic Agents - Drugs For The Skin ACNE CLEANSING BAR (benzoyl peroxide) T2 ACNE MEDICATION TOPICAL LOTION 5 % (benzoyl T1 peroxide) benzoyl peroxide topical cleanser 10 %, 5 % T1 benzoyl peroxide topical gel 10 %, 2.5 %, 5 % T1 clindamycin-benzoyl peroxide topical gel 1-5 % T3 PA salicylic acid topical cream T1 salicylic acid topical lotion T1 salicylic acid topical shampoo T1 silver nitrate topical solution 10 % T3 PA sodium hydroxide (bulk) solution 10 % T2 QL (1 EA per 30 days) sulfacetamide sodium-sulfur topical cream 10-5 % (w/w) T1 sulfacetamide sodium-sulfur topical lotion 10-5 % (w/v), T1 10-5 % (w/w) sulfacetamide sod-sulfur-urea topical cleanser T1 TARGETED ACNE SPOT TREATMENT (benzoyl T1 peroxide) urea topical cream 20 % T1 urea topical cream 40 % T3 PA Keratoplastic Agents - Drugs For The Skin PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

143 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits IONIL T (coal tar) T2 X-SEB T PLUS (coal tar) T2 Local Anti-Infectives, Miscellaneous - Drugs For The Skin hydrocortisone-iodoquinol T1 selenium sulfide topical lotion T1 selenium sulfide topical shampoo 2.25 % T1 silver sulfadiazine T1 SSD (silver sulfadiazine) T1 sulfacetamide sodium-sulfur topical cream 10-5 % (w/w) T1 sulfacetamide sodium-sulfur topical lotion 10-5 % (w/v) T1 sulfacetamide sod-sulfur-urea topical cleanser T1 Nonsteroidal Anti-Inflammat.Agents(Skin) - Drugs For The Skin diclofenac sodium topical gel 1 % T2 QL (200 GM per 30 days) Polyenes (Skin And Mucous Membrane) - Drugs For The Skin nystatin topical T1 nystatin-triamcinolone T1 Scabicides And Pediculicides - Drugs For The Skin EURAX TOPICAL CREAM (crotamiton) T2 ivermectin topical lotion T3 PA lindane topical shampoo T3 PA malathion T3 PA permethrin topical cream T1 Skin And Mucous Membrane Agents, Misc. - Drugs For The Skin acitretin oral capsule 10 mg, 25 mg T1 QL (15 GM per 30 days); AL adapalene topical gel 0.1 % T2 (Max 40 Years) PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

144 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits azelaic acid T3 PA calcipotriene scalp T3 PA calcipotriene topical cream T3 PA calcipotriene topical ointment T3 PA capsaicin topical cream 0.025 %, 0.1 % T1 isotretinoin (Claravis) T3 PA CONDYLOX TOPICAL GEL (podofilox) T2 QL (2 QY per 28 DYs) COSENTYX (2 SYRINGES) (secukinumab) T3 PA COSENTYX PEN (secukinumab) T3 PA COSENTYX PEN (2 PENS) (secukinumab) T3 PA COSENTYX SUBCUTANEOUS SYRINGE 150 MG/ML T3 PA (secukinumab) diclofenac sodium topical gel 1 % T2 QL (200 GM per 30 days) DUPIXENT PEN SUBCUTANEOUS PEN INJECTOR 300 T3 PA MG/2 ML (dupilumab) DUPIXENT SYRINGE (dupilumab) T3 PA ENBREL MINI (etanercept) T3 PA ENBREL SUBCUTANEOUS SOLUTION (etanercept) T3 PA ENBREL SUBCUTANEOUS SYRINGE 50 MG/ML (1 ML) T3 PA (etanercept) ENBREL SURECLICK (etanercept) T3 PA FINACEA TOPICAL FOAM (azelaic acid) T3 PA FLUOROPLEX (fluorouracil) T1 fluorouracil topical cream 5 % T1 fluorouracil topical solution T1 HUMIRA PEN (adalimumab) T3 PA HUMIRA PEN CROHNS-UC-HS START (adalimumab) T3 PA PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

145 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits HUMIRA PEN PSOR-UVEITS-ADOL HS (adalimumab) T3 PA HUMIRA SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML T3 PA (adalimumab) imiquimod topical cream in packet 5 % T1 INFLECTRA (infliximab-dyyb) T3 PA OTEZLA (apremilast) T3 PA OTEZLA STARTER (apremilast) T3 PA pimecrolimus T3 PA podofilox T2 QL (2 QY per 28 DYs) REGRANEX (becaplermin) T3 PA REMICADE (infliximab) T3 PA RENFLEXIS (infliximab-abda) T3 PA SANTYL (collagenase Clostridium histolyticum) T1 tacrolimus topical T2 QL (30 GM per 30 days) tazarotene topical cream T1 TAZORAC TOPICAL CREAM 0.05 % (tazarotene) T1 TAZORAC TOPICAL GEL (tazarotene) T1 Thiocarbamates(Skin And Mucous Membrane) - Drugs For The Skin ANTIFUNGAL (TOLNAFTATE) TOPICAL POWDER T2 (tolnaftate) LAMISIL AF TOPICAL POWDER (tolnaftate) T2 tolnaftate topical aerosol powder T2 tolnaftate topical cream T2 Smooth Muscle Relaxants - Drugs To Relax Muscles Antimuscarinics - Drugs For The Urinary System darifenacin oral tablet extended release 24 hr 7.5 mg T3 PA

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

146 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits flavoxate T3 PA oxybutynin chloride T1 tolterodine T2 ST trospium oral tablet T3 PA Respiratory Smooth Muscle Relaxants - Drugs For Lungs theophylline anhydrous (Elixophyllin Oral Elixir 80 Mg/15 T1 Ml) theophylline in dextrose 5 % intravenous parenteral T2 QL (1 EA per 30 days) solution 200 mg/100 mL theophylline oral elixir T1 theophylline oral tablet extended release 12 hr 300 mg, T1 450 mg theophylline oral tablet extended release 24 hr 600 mg T1 Selective Beta-3-Adrenergic Agonists - Drugs For The Urinary System MYRBETRIQ (mirabegron) T3 PA Vitamins Multivitamin Preparations CENTRAVITES (folic acid/multivit,calcium,iron,other T2 mins/lycopene/lutein) COMPLETE SENIOR ORAL TABLET (multivitamin with T1 iron and other minerals) KOSHER PRENATAL PLUS IRON (prenatal vitamins T3 PA no.108/iron,carbonyl/folic acid) multivitamin oral tablet T2 MULTI-VITAMINS WITH IRON (multivitamin with iron and T1 other minerals) OB COMPLETE PETITE (prenatal no56/iron T3 PA carbonyl,asparto glycinate/folic acid/dha) PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

147 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits PEDIA TRI-VITE (vitamin A palmitate/ascorbic T1 acid/cholecalciferol (vit D3)) PRENATAL + DHA ORAL COMBO PACK 28 MG IRON-800 MCG-200 MG (prenatal vit with calcium 95/ferrous T2 QL (1 EA per 1 day) fumarate/folic acid/dha) PRENATAL PLUS (CALCIUM CARB) (prenatal vits with AL (Min 13 Years and Max T2 calcium no.72/ferrous fumarate/folic acid) 45 Years) PRENATE DHA (FERR ASP GLYCIN) (prenatal vitamins T3 PA no.78/iron asparto glycin/folate no.1/dha) PRENATE ENHANCE (prenatal vitamins no.68/iron T3 PA fumarate/folate no.6/dha) PRENATE MINI (FERR ASP GLYCIN) (prenatal vits T3 PA no.87/iron carb-asp.glycinate/folate no.1/dha) PRENATE PIXIE (prenatal vitamins no.85/iron asparto T3 PA glycin/folate no.1/dha) PRIMACARE (prenatal vits no.118/iron asparto T3 PA glycinate/folate no.6/dha) SELECT-OB + DHA (prenatal vitamins no.33/iron T3 PA polysach complex/folic acid/dha) STRESS FORMULA (multivitamin,stress formula) T1 TRI-VI-SOL (vitamin A palmitate/ascorbic T1 acid/cholecalciferol (vit D3)) TRI-VITAMIN WITH FLUORIDE (pediatric multivit with T1 A,C,D3 no.21/sodium fluoride) VITAMED MD ONE RX (prenatal vits no.25/ferrous T3 PA fumarate/folate comb. no.6/dha) Vitamin A PEDIA TRI-VITE (vitamin A palmitate/ascorbic T1 acid/cholecalciferol (vit D3))

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

148 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits TRI-VI-SOL (vitamin A palmitate/ascorbic T1 acid/cholecalciferol (vit D3)) TRI-VITAMIN WITH FLUORIDE (pediatric multivit with T1 A,C,D3 no.21/sodium fluoride) Vitamin B Complex B-complex with vitamin C oral tablet T1 cyanocobalamin (vitamin B-12) injection T2 QL (4 ML per 28 days) cyanocobalamin (vitamin B-12) oral tablet 1,000 mcg T2 DIALYVITE 800 ORAL TABLET (folic acid/vitamin B T1 complex and vitamin C) folic acid injection T3 PA folic acid oral tablet 1 mg T1 GERITOL TONIC WITH FERREX 18 (thiamine/riboflavin/niacin/pant T1 acid/B6/iron/methion/choline) hydroxocobalamin T3 PA KOSHER PRENATAL PLUS IRON (prenatal vitamins T3 PA no.108/iron,carbonyl/folic acid) niacinamide oral tablet 500 mg T3 PA OB COMPLETE PETITE (prenatal no56/iron T3 PA carbonyl,asparto glycinate/folic acid/dha) PRENATAL + DHA ORAL COMBO PACK 28 MG IRON-800 MCG-200 MG (prenatal vit with calcium 95/ferrous T2 QL (1 EA per 1 day) fumarate/folic acid/dha) PRENATAL PLUS (CALCIUM CARB) (prenatal vits with AL (Min 13 Years and Max T2 calcium no.72/ferrous fumarate/folic acid) 45 Years) PRENATE DHA (FERR ASP GLYCIN) (prenatal vitamins T3 PA no.78/iron asparto glycin/folate no.1/dha)

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

149 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits PRENATE ENHANCE (prenatal vitamins no.68/iron T3 PA fumarate/folate no.6/dha) PRENATE MINI (FERR ASP GLYCIN) (prenatal vits T3 PA no.87/iron carb-asp.glycinate/folate no.1/dha) PRENATE PIXIE (prenatal vitamins no.85/iron asparto T3 PA glycin/folate no.1/dha) PRIMACARE (prenatal vits no.118/iron asparto T3 PA glycinate/folate no.6/dha) pyridoxine (vitamin B6) injection T1 pyridoxine (vitamin B6) oral tablet 50 mg, 500 mg T2 RENA-VITE (folic acid/vitamin B complex and vitamin C) T1 riboflavin (vitamin B2) oral tablet 100 mg T1 riboflavin (vitamin B2) oral tablet 400 mg T1 SELECT-OB + DHA (prenatal vitamins no.33/iron T3 PA polysach complex/folic acid/dha) thiamine HCl (vitamin B1) injection T2 QL (1 EA per 30 days) thiamine mononitrate (vit B1) T2 VITAMED MD ONE RX (prenatal vits no.25/ferrous T3 PA fumarate/folate comb. no.6/dha) VITAMIN B COMPLEX WITH C (B-complex with vitamin T1 C) VITAMIN B-12 ORAL TABLET 1,000 MCG, 100 MCG, 250 T2 MCG, 500 MCG (cyanocobalamin (vitamin B-12)) VITAMIN B-12 ORAL TABLET 50 MCG (cyanocobalamin T1 (vitamin B-12)) VITAMIN B-12 ORAL TABLET EXTENDED RELEASE T1 1,000 MCG (cyanocobalamin (vitamin B-12)) VITAMIN B-12 ORAL TABLET EXTENDED RELEASE T2 2,000 MCG (cyanocobalamin (vitamin B-12)) PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

150 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits VITAMIN B-6 ORAL TABLET 100 MG, 25 MG, 250 MG T2 (pyridoxine HCl (vitamin B6)) Vitamin C DIALYVITE 800 ORAL TABLET (folic acid/vitamin B T1 complex and vitamin C) PEDIA TRI-VITE (vitamin A palmitate/ascorbic T1 acid/cholecalciferol (vit D3)) RENA-VITE (folic acid/vitamin B complex and vitamin C) T1 TRI-VI-SOL (vitamin A palmitate/ascorbic T1 acid/cholecalciferol (vit D3)) TRI-VITAMIN WITH FLUORIDE (pediatric multivit with T1 A,C,D3 no.21/sodium fluoride) Vitamin D CALCIDOL (ergocalciferol (vitamin D2)) T2 calcitriol oral T1 calcium carbonate-vitamin D3 oral tablet 1,000 mg(2,500 T1 mg)-800 unit calcium carbonate-vitamin D3 oral tablet 250-125 mg- unit, 600 mg(1,500mg) -200 unit, 600 mg(1,500mg) -400 T1 unit, 600 mg(1,500mg) -800 unit cholecalciferol (vitamin D3) oral capsule 1,250 mcg T2 (50,000 unit) cholecalciferol (vitamin D3) oral drops 10 mcg/mL (400 T2 QL (100 ML per 30 days) unit/mL) cholecalciferol (vitamin D3) oral drops 125 mcg/mL T2 (5,000 unit/mL) cholecalciferol (vitamin D3) oral tablet 50 mcg (2,000 T2 unit)

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

151 Drug Tier Coverage Requirements and SCO = State Carve Out Limits T1 = Preferred Medication AL = Age Limit T2 = Preferred Medication with PA = Prior Authorization bold italics = Generic drugs Restriction QL = Quantity Limit UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out drugs Prior Authorization is Required ST = Step Therapy Coverage Prescription Drug Name Drug Tier Requirements and Limits ergocalciferol (vitamin D2) oral capsule 1,250 mcg T1 (50,000 unit) KIDS VITAMIN D3 (cholecalciferol (vitamin D3)) T2 PEDIA TRI-VITE (vitamin A palmitate/ascorbic T1 acid/cholecalciferol (vit D3)) TRI-VI-SOL (vitamin A palmitate/ascorbic T1 acid/cholecalciferol (vit D3)) TRI-VITAMIN WITH FLUORIDE (pediatric multivit with T1 A,C,D3 no.21/sodium fluoride) VITAMIN D3 ORAL CAPSULE 10 MCG (400 UNIT), 25 MCG (1,000 UNIT), 50 MCG (2,000 UNIT) (cholecalciferol T2 (vitamin D3)) VITAMIN D3 ORAL TABLET 10 MCG (400 UNIT), 25 MCG T2 (1,000 UNIT) (cholecalciferol (vitamin D3)) VITAMIN D3 ORAL TABLET,CHEWABLE 25 MCG (1,000 T2 UNIT) (cholecalciferol (vitamin D3)) Vitamin K Activity MEPHYTON (phytonadione (vit K1)) T1 phytonadione (vitamin K1) injection syringe T2 QL (1 EA per 30 days) phytonadione (vit K1) (Vitamin K) T1 phytonadione (vit K1) (Vitamin K1 Injection) T1

PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each; GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum

152 Contra Costa Health Plan Formulary

A ALLERGY EYE ANTACID-SIMETHICONE 94, abacavir ...... 10 (KETOTIFEN) ...... 87 95 abacavir-lamivudine ...... 10 ALLERGY RELIEF ANTIFUNGAL abacavir-lamivudine- (FLUTICASONE) .... 90, 129 (TOLNAFTATE) ...... 146 zidovudine ...... 10 allopurinol ...... 115 ANTIFUNGAL CREAM ABREVA ...... 138 almotriptan malate ...... 76 (MICONAZOLE) ...... 138 acamprosate ...... 68 ALOCRIL ...... 87, 128 APEXICON E ...... 134, 140 acarbose ...... 102 alogliptin ...... 106 APIDRA SOLOSTAR U-100 acebutolol .. 32, 40, 41, 48, 52 alogliptin-metformin .. 103, 106 INSULIN ...... 109, 112 acetaminophen ...... 59 ALOMIDE ...... 87 APIDRA U-100 INSULIN 109, acetaminophen-codeine ... 59, alosetron ...... 96 112 69 ALOXI ...... 95 aprepitant ...... 98 acetazolamide ...... 47, 82, 90 ALPHAGAN P ...... 87 Apri ...... 104 acetic acid ...... 82, 91 alprazolam ...... 67 APTIVUS ...... 12 acetylcysteine ...... 120, 129 ALPRAZOLAM INTENSOL 66 Aranelle (28) ...... 104 ACID GONE ANTACID ALSUMA ...... 76 ARICEPT ...... 30 E.STRENGTH ...... 94 aluminum hydroxide gel ..... 94 aripiprazole ...... 62, 65 ACID REDUCER amantadine HCl ...... 5, 58 ARISTOSPAN INTRA- (FAMOTIDINE) ...... 98 AMBIEN CR ...... 64 ARTICULAR ...... 100 acitretin ...... 144 amcinonide ...... 134, 140 ARISTOSPAN ACNE CLEANSING BAR 143 AMICAR ...... 33 INTRALESIONAL ...... 100 ACNE MEDICATION ...... 143 amiloride ...... 55, 83 ARMOUR THYROID ...... 113 ACTHIB (PF) ...... 23 amiloride-hydrochlorothiazide ARNUITY ELLIPTA . 100, 129 acyclovir ...... 14, 138 ...... 55, 83, 86 ARRANON ...... 17 ADACEL(TDAP aminocaproic acid ...... 33 ARTIFICIAL TEARS ADOLESN/ADULT)(PF) . 22 amiodarone ...... 49 (POLYVIN ALC) ...... 92 adapalene ...... 144 amitriptyline ...... 78 ARZERRA ...... 17 adefovir ...... 14 amlodipine ...... 43, 50, 52, 56 ASMANEX HFA ...... 100, 129 ADVAIR HFA .... 31, 100, 129, amlodipine-atorvastatin ..... 43, ASMANEX TWISTHALER 131 50, 51, 52, 56 ...... 100, 130 ADVANCED ANTACID- amlodipine-benazepril . 38, 39, aspirin ...... 36, 63, 75 ANTIGAS ...... 94, 95 43, 50, 51, 52, 56 aspirin-dipyridamole ... 36, 56, ADVOCATE BLOOD amoxicillin ...... 5 75 PRESSURE MONITR .... 79 amoxicillin-pot clavulanate .. 5, atazanavir ...... 12 AIMOVIG AUTOINJECTOR 6 atenolol ...... 32, 40, 41, 48 ...... 63, 67 AMPHADASE ...... 87 atenolol-chlorthalidone 32, 40, AJOVY SYRINGE ...... 63, 67 amphotericin B ...... 15 41, 48, 56, 87 ALAVERT ...... 3, 131 ampicillin ...... 6 atomoxetine ...... 68 ALAVERT D-12 ALLERGY- anagrelide ...... 36 atorvastatin ...... 52 SINUS ...... 3, 25, 123, 131 anastrozole ...... 17, 103 atovaquone ...... 7 albuterol sulfate ...... 31, 132 ANDRODERM ...... 102 atovaquone-proguanil ...... 6 alclometasone ...... 134, 140 ANDROGEL ...... 102 atropine ...... 27, 93, 124 ALDACTAZIDE 53, 55, 83, 86 ANORO ELLIPTA ...... 27, 31, ATROVENT HFA ...... 27, 124 alendronate ...... 116 124, 132 AUGMENTIN ...... 6 alfuzosin ...... 30 ANTACID EXTRA- AUSTEDO ...... 68, 78 ALIMTA ...... 17 STRENGTH ...... 84 AVASTIN ...... 17 ALKERAN ...... 17 ANTACID SUPREME ...... 94 Aviane ...... 104 AVONEX ...... 118

153 azathioprine ..... 116, 118, 120 bisacodyl ...... 96 C azelaic acid ...... 145 bisoprolol fumarate ..... 32, 40, CABENUVA ...... 9 azelastine ...... 88 41, 48 cabergoline ...... 68 azithromycin ...... 15 bisoprolol- CALACLEAR ...... 137 AZOPT ...... 90 hydrochlorothiazide . 32, 40, CALAGESIC ...... 137 B 41, 48, 55, 86 calamine ...... 139 bacitracin ...... 88, 133 bleomycin ...... 18 calamine-zinc oxide ...... 139 bacitracin zinc ...... 133 BLEPHAMIDE ...... 88 CALCIDOL ...... 151 bacitracin-polymyxin B ...... 88 Blephamide S.O.P...... 88 calcipotriene ...... 145 baclofen ...... 29 blood pressure kit-extra large calcitonin (salmon) .. 103, 111, balsalazide ...... 96 ...... 79 116 Balziva (28) ...... 104 blood pressure test kit-large calcitriol ...... 151 BAQSIMI ...... 107, 114 ...... 79 CALCIUM 500 ...... 84 BARACLUDE ...... 14 blood pressure test kit- calcium acetate(phosphat BAVENCIO ...... 17 medium ...... 79 bind) ...... 83 Bayer Advanced ...... 36 BOOSTRIX TDAP ...... 23 CALCIUM ANTACID .... 84, 94 BAYER ADVANCED ...... 36 BREO ELLIPTA 31, 100, 130, CALCIUM ANTACID ULTRA B-complex with vitamin C 149 132 MAX ST ...... 84, 94 BD ULTRA-FINE NANO PEN BREZTRI AEROSPHERE . 27, calcium carbonate ...... 84, 94 NEEDLE ...... 79 31, 100, 124, 130, 132 calcium carbonate-vitamin D3 BECONASE AQ ...... 90, 129 BRILINTA ...... 36 ...... 84, 151 BELSOMRA ...... 64 brimonidine ...... 87 calcium lactate ...... 84 benazepril ...... 38, 39 bromocriptine ...... 68 Camila ...... 104 benazepril- budesonide 90, 100, 129, 130 CAPASTAT ...... 7 hydrochlorothiazide 38, 39, budesonide-formoterol ...... 31, capecitabine ...... 18 55, 86 100, 130, 132 capsaicin ...... 145 BENDEKA ...... 17 bumetanide ...... 53, 82 captopril ...... 38, 39 BENTYL ...... 27 bupivacaine HCl ...... 114 captopril-hydrochlorothiazide BENZAMYCIN ...... 133 bupivacaine-epinephrine ... 25, ...... 38, 39, 55, 86 benzonatate ...... 125 114 carbamazepine ...... 60, 62 benzoyl peroxide ...... 143 bupivacaine-epinephrine (PF) carbidopa-levodopa ...... 68 benztropine ...... 28, 60 ...... 25, 114 carbinoxamine maleate ...... 1 betamethasone dipropionate buprenorphine ...... 72 carboplatin ...... 18 ...... 134, 140 buprenorphine HCl ...... 72 CARDIZEM LA 42, 43, 45, 46, betamethasone valerate . 134, buprenorphine-naloxone .... 72 49, 57 135, 140 bupropion HCl ...... 62 CARETOUCH BP MONITOR betamethasone, augmented bupropion HCl (smoking ...... 79 ...... 135, 140 deter) ...... 61 Cartia Xt .... 42, 43, 45, 46, 49, BETASERON ...... 118 buspirone ...... 64 57 betaxolol ...... 89 Butalbital Compound carvedilol .. 29, 30, 37, 41, 48, bethanechol chloride ...... 30 W/Codeine ... 63, 66, 70, 74, 52 BETIMOL ...... 89 75 CAVERJECT ...... 57 BETOPTIC S ...... 89 butalbital-acetaminop-caf-cod CAVERJECT IMPULSE .... 57 BEXSERO ...... 23 ...... 59, 63, 66, 70, 74 CAYA CONTOURED ...... 121 bicalutamide ...... 18 butalbital-acetaminophen-caff cefaclor ...... 4 BICILLIN C-R ...... 14 ...... 59, 63, 66, 74 cefdinir ...... 4 BICILLIN L-A ...... 14 butalbital-aspirin-caffeine .. 36, cefixime ...... 5 BICNU ...... 18 63, 66, 74, 75 cefpodoxime ...... 5 BIKTARVY...... 9, 11 BYETTA ...... 108 cefuroxime axetil ...... 4 bimatoprost ...... 93 celecoxib ...... 68

154 CENTRAVITES ...... 147 cisplatin ...... 18 COSENTYX (2 SYRINGES) cephalexin ...... 4 citalopram ...... 77 ...... 145 cetirizine ...... 3, 131 cladribine ...... 18 COSENTYX PEN ...... 145 cetirizine-pseudoephedrine 3, Claravis ...... 145 COSENTYX PEN (2 PENS) 25, 123, 131 clarithromycin ...... 7, 15 ...... 145 cevimeline ...... 30 clemastine ...... 1, 2, 127 CREON ...... 97 CHANTIX ...... 28 CLEOCIN ...... 133 cromolyn ...... 88, 129 CHANTIX CONTINUING CLEVER CHOICE BP Cryselle (28) ...... 104 MONTH BOX ...... 28 MONITOR ...... 79 cyanocobalamin (vitamin B- CHANTIX STARTING CLIMARA PRO ...... 107 12) ...... 149 MONTH BOX ...... 28 clindamycin HCl ...... 13 cyclobenzaprine ...... 29 CHEMET ...... 99, 114 Clindamycin Pediatric ...... 13 cyclopentolate ...... 93 CHILDREN'S ALLERGY clindamycin phosphate ..... 13, cyclophosphamide ..... 18, 120 (DIPHENHYD) ...... 1, 126 133, 134 cyclosporine ..... 116, 118, 120 CHILDREN'S ALLERGY clindamycin-benzoyl peroxide cyclosporine modified ..... 116, RELIEF(FEX) ...... 3, 131 ...... 134, 143 118, 120 CHILDREN'S IBUPROFEN72 clobazam ...... 66, 67 cyproheptadine ...... 1, 2, 127 CHILDREN'S SILFEDRINE clobetasol ...... 135, 140 CYRAMZA ...... 18 ...... 25, 123 clobetasol-emollient . 135, 140 cytarabine (PF) ...... 18 chlordiazepoxide HCl ...... 67 clomipramine ...... 78 D chlordiazepoxide-clidinium 27, clonazepam ...... 66, 67 dacarbazine ...... 18 67 clonidine ...... 26, 47 DALIRESP ...... 131 chlorhexidine gluconate .... 91 clonidine HCl ...... 26, 47 dantrolene ...... 29 chloroquine phosphate ...... 6 clopidogrel ...... 36 dapsone ...... 7 chlorothiazide ...... 55 clorazepate dipotassium ... 66, DARAPRIM ...... 6 chlorpheniramine maleate .. 1, 67 darifenacin ...... 146 3, 127 clotrimazole ...... 138 DARZALEX ...... 18 chlorpheniramine-phenyleph- clotrimazole-betamethasone daunorubicin ...... 18 DM ...... 3, 26, 125, 127 ...... 135, 138, 140 decitabine ...... 18 chlorpromazine ...... 73 clozapine ...... 65 DELSTRIGO ...... 10, 11 chlorthalidone ...... 56, 87 codeine sulfate ...... 70, 125 demeclocycline ...... 16 chlorzoxazone ...... 29 colchicine ...... 115 DEMEROL ...... 70 cholecalciferol (vitamin D3) colestipol ...... 42 DEMSER ...... 120 ...... 151 colistin (colistimethate Na) . 15 DEPO-MEDROL ...... 100 cholestyramine (with sugar) COMBIPATCH ...... 107, 111 DEPO-SUBQ PROVERA 104 ...... 42 COMBIVENT RESPIMAT . 27, ...... 111 Cholestyramine Light ...... 42 31, 124, 132 DESCOVY ...... 11 choline,magnesium salicylate COMPLERA ...... 10, 11 desipramine ...... 78 ...... 75 COMPLETE SENIOR ...... 147 desmopressin ...... 33, 111 CIALIS ...... 54 CONDYLOX ...... 145 desonide ...... 135, 141 ciclopirox ...... 143 Constulose ...... 82 desoximetasone ...... 135, 141 cidofovir ...... 14 CONTRAVE ...... 60 dexamethasone ...... 100, 101 cilostazol ...... 36, 54 CORDRAN ...... 135, 140 DEXAMETHASONE CIMDUO ...... 11 CORDRAN TAPE LARGE INTENSOL ...... 100 cimetidine ...... 98 ROLL ...... 135, 140 dexamethasone sodium cimetidine HCl ...... 98 CORTIFOAM ...... 135, 140 phosphate ...... 90, 101 CIPRO HC ...... 88, 90 CORTISONE COOLING . 135, DEXILANT ...... 98 CIPRODEX ...... 88, 90 141 dexmethylphenidate ...... 74 ciprofloxacin ...... 7, 16 COSENTYX ...... 145 dextroamphetamine ...... 58 ciprofloxacin HCl ..... 7, 16, 88

155 dextroamphetamine- doxorubicin ...... 18 enalapril-hydrochlorothiazide amphetamine ...... 58, 59 Doxy-100 ...... 16 ...... 38, 39, 55, 86 dextrose 5 %-lactated ringers doxycycline hyclate ...... 16 ENBREL ...... 117, 118, 145 ...... 84 doxycycline monohydrate .. 16 ENBREL MINI .. 116, 118, 145 DIALYVITE 800 ...... 149, 151 dronabinol ...... 95 ENBREL SURECLICK .... 117, diazepam ...... 66, 67 droperidol ...... 64 118, 145 Diazepam Intensol ...... 66, 67 drospirenone-e.estradiol- Endocet ...... 59, 70 diclofenac potassium ...... 72 lm.FA ...... 104 ENGERIX-B (PF) ...... 23 diclofenac sodium ...... 72, 92, drospirenone-ethinyl estradiol enoxaparin ...... 34 144, 145 ...... 104 Enpresse ...... 104 diclofenac-misoprostol 72, 98 DROXIA ...... 18 entacapone ...... 68 dicloxacillin ...... 15 DRYSOL ...... 138 entecavir ...... 14 dicyclomine ...... 27 DULERA ... 31, 101, 130, 132 ENTRESTO ...... 38, 55 didanosine ...... 11 duloxetine ...... 69, 76 ENTYVIO ...... 97, 118 diflorasone ...... 136, 141 DUPIXENT PEN ...... 128, 145 ENUCLENE ...... 92 diflunisal ...... 72 DUPIXENT SYRINGE ..... 128, ephedrine sulfate ...... 25, 123 Digox ...... 39, 47 145 EPIDIOLEX ...... 61 digoxin ...... 40, 47 DUREX AVANTI BARE epinastine ...... 88 DILANTIN ...... 48, 69 REAL FEEL ...... 121 epinephrine ...... 25, 123 DILATRATE-SR ...... 54 DUREZOL ...... 90 epirubicin ...... 18 diltiazem HCl .. 42, 43, 44, 45, DUROLANE ...... 79 EPIVIR HBV ...... 11 46, 49, 50, 57 DYRENIUM ...... 55, 84 EPOGEN ...... 33 DILT-XR ... 43, 44, 45, 46, 50, E ERBITUX ...... 18 57 E.E.S. 400 ...... 8, 13 ergocalciferol (vitamin D2) dimenhydrinate .. 1, 2, 95, 127 econazole ...... 139 ...... 152 dimethyl fumarate ...... 118 ED A-HIST DM ...... 3, 26, 125, ergoloid ...... 30 DIOCTO ...... 96 127 ergotamine-caffeine ..... 30, 63 diphenhydramine HCl ..... 1, 2, EDECRIN ...... 53, 82 erlotinib ...... 18 127 EDURANT ...... 10 Errin ...... 104 diphenoxylate-atropine 27, 95, efavirenz-emtricitabin-tenofov ERY PADS ...... 134 124 ...... 10, 11 Erythrocin (As Stearate) 8, 13 dipyridamole ...... 36, 57 efavirenz-lamivu-tenofov erythromycin ...... 8, 13, 88 disopyramide phosphate ... 47 disop ...... 10, 11 erythromycin ethylsuccinate 8, disulfiram ...... 114 ELIQUIS ...... 33 13 DIURIL ...... 55 ELIQUIS DVT-PE TREAT erythromycin with ethanol 134 divalproex ...... 61, 62, 63 30D START ...... 33 erythromycin-benzoyl docetaxel ...... 18 Elixophyllin ...... 82, 133, 147 peroxide ...... 134 docusate sodium ...... 96 ELLA ...... 104 escitalopram oxalate ...... 77 DOCUSOL ...... 96 ELMIRON ...... 121 esmolol ...... 32, 41, 48 dofetilide ...... 49 EMCYT ...... 18 esomeprazole magnesium 98 donepezil ...... 30 EMGALITY PEN ...... 63, 68 estradiol ...... 107 dopamine ...... 31, 47 EMGALITY SYRINGE .. 63, 68 estradiol valerate ...... 107 dopamine in 5 % dextrose 31, EMPLICITI ...... 18 ESTRING ...... 107 47 emtricitabine ...... 11 ESTROGEL ...... 107 dorzolamide ...... 90 emtricitabine-tenofovir (TDF) estrogens-methyltestosterone dorzolamide-timolol ..... 89, 90 ...... 11 ...... 102, 107 DOVATO ...... 9, 11 EMTRIVA ...... 11 ESTROSTEP FE-28 ...... 104 doxapram ...... 74 EMVERM ...... 6 eszopiclone ...... 64 doxazosin ...... 29, 37, 52 enalapril maleate ...... 38, 39 ethacrynate sodium ..... 53, 82 doxepin ...... 78 ethambutol ...... 7

156 ethosuximide ...... 78 FLINTSTONES PLUS frovatriptan ...... 76 etidronate disodium ...... 116 CALCIUM ...... 85 FULPHILA ...... 33 etodolac ...... 72 FLONASE SENSIMIST ..... 90, FUNGI CURE ...... 139 etonogestrel-ethinyl estradiol 129 furosemide ...... 53, 83 ...... 104 FLOVENT DISKUS .. 101, 130 FUZEON ...... 9 ETOPOPHOS ...... 18 FLOVENT HFA ...... 101, 130 G etoposide ...... 19 floxuridine ...... 19 gabapentin ...... 59, 61 etravirine ...... 10 fluconazole ...... 8 GABITRIL ...... 61 EURAX ...... 144 fludarabine ...... 19 ganciclovir sodium ...... 14 EVOTAZ ...... 12, 120 fludrocortisone ...... 101 GARDASIL 9 (PF) ...... 23 exemestane ...... 19, 103 flunisolide ...... 90, 129 GAVISCON ...... 94 EXODERM ...... 134 fluocinolone ...... 136, 141 GAZYVA ...... 19 EXTAVIA ...... 118 fluocinolone and shower cap gemcitabine ...... 19 ezetimibe ...... 47 ...... 136, 141 gemfibrozil ...... 52 F fluocinonide ...... 136, 141 Generlac ...... 82 famotidine ...... 98 Fluocinonide-E ...... 136, 141 Gengraf ...... 117, 118, 120 FANTASY CONDOM ...... 121 fluoride (sodium) ...... 116 Gentak ...... 88 FARESTON ...... 19, 106 fluorometholone ...... 90 gentamicin ...... 5, 88, 134 FARXIGA ...... 113 FLUOROPLEX ...... 19, 145 gentian violet ...... 134 FASENRA ...... 128 fluorouracil ...... 19, 145 GENVOYA ...... 9, 11 FASENRA PEN ...... 128 fluoxetine ...... 77 GERITOL TONIC WITH FASLODEX ...... 19 fluphenazine decanoate ..... 73 FERREX 18 ...... 35, 149 FC2 FEMALE CONDOM . 121 fluphenazine HCl ...... 73 GILENYA ...... 118 felbamate ...... 61 flurazepam ...... 67 glatiramer ...... 118 felodipine ... 44, 50, 51, 52, 57 flurbiprofen ...... 73 Glatopa ...... 118 FEMCAP ...... 79, 121 flurbiprofen sodium ...... 92 GLEOSTINE ...... 19 FEMRING ...... 107 flutamide ...... 19 glimepiride ...... 113 fenofibrate ...... 51 fluticasone propionate ...... 90, glipizide ...... 113 fenofibrate micronized ...... 51 129, 136, 141 glipizide-metformin .. 103, 113 fenofibrate nanocrystallized fluticasone propion- GLUCAGEN HYPOKIT .... 115 ...... 51 salmeterol ...... 31, 101, 130, Glucagon Emergency Kit fenoprofen ...... 72 132 (Human) ...... 107, 115 fentanyl ...... 70 fluvastatin ...... 52 glyburide ...... 113 FEOSOL ...... 34 fluvoxamine ...... 77 glyburide micronized ...... 113 ferrous gluconate ...... 34 FML FORTE ...... 90 glyburide-metformin . 103, 113 ferrous sulfate ...... 34 FML S.O.P...... 90 glycine urologic solution .... 82 FEVERALL ...... 59 folic acid ...... 149 glycopyrrolate ...... 27 fexofenadine ...... 4, 131 FOLITAB ...... 34 GONIOVISC ...... 92 fexofenadine- FORA TEST N'GO BP granisetron HCl ...... 95 pseudoephedrine ...... 4, 25, SYSTEM ...... 79 GRANIX ...... 33 123, 131 fosamprenavir ...... 12 griseofulvin microsize ...... 6 FINACEA ...... 145 foscarnet ...... 8 griseofulvin ultramicrosize ... 6 finasteride ...... 114 fosinopril ...... 39 guaifenesin ...... 126 FIRMAGON KIT W DILUENT FREESTYLE LIBRE 14 DAY guanfacine ...... 47, 68 SYRINGE ...... 19, 103, 117 READER ...... 79 GYNOL II ...... 121 FIRVANQ ...... 8 FREESTYLE LIBRE 14 DAY H FLAREX ...... 90 SENSOR ...... 79 HALAVEN ...... 19 flavoxate ...... 147 FREESTYLE LIBRE 2 halobetasol propionate ... 136, flecainide ...... 48 SENSOR ...... 79 141 FROVA ...... 76 HALOG ...... 136, 141

157 haloperidol ...... 67 hydrocortisone 101, 136, 141, insulin asp prt-insulin aspart haloperidol decanoate ...... 67 142 ...... 109, 110, 112 haloperidol lactate ...... 67 hydrocortisone acetate .... 136, insulin aspart U-100 . 109, 112 HAVRIX (PF) ...... 23 141 insulin lispro ...... 109, 112 HEMOCYTE-F ...... 35 hydrocortisone butyrate .. 136, insulin lispro protamin-lispro heparin (porcine) ...... 34 141 ...... 109, 110, 112 heparin flush(porcine)- hydrocortisone valerate ... 136, INTELENCE ...... 10 0.9NaCl ...... 34, 79 142 INTRON A ..... 13, 19, 20, 119 HEPARIN LOCK FLUSH .. 34, hydrocortisone-acetic acid 90, INVIRASE ...... 12 79 91 INVOKAMET ...... 103, 113 heparin lock flush (porcine) hydrocortisone-aloe vera 137, INVOKANA ...... 113 ...... 34, 79 142 IONIL T ...... 144 heparin, porcine (PF) ...... 34 hydrocortisone-iodoquinol IOPIDINE ...... 92 HEPLISAV-B (PF) ...... 23 ...... 142, 144 ipratropium bromide .... 28, 92, HIBERIX (PF) ...... 23 hydrocortisone-pramoxine 124 HOMATROPAIRE ...... 93 ...... 137, 138, 142 ipratropium-albuterol ... 28, 31, HUMALOG MIX 50-50 hydromorphone ...... 70 124, 132 INSULN U-100 .... 109, 110, hydroxocobalamin ...... 149 irbesartan ...... 37, 38 112 hydroxychloroquine ..... 6, 117, irbesartan- HUMALOG MIX 50-50 119 hydrochlorothiazide . 37, 38, KWIKPEN .... 109, 110, 112 hydroxyurea ...... 19 56, 86 HUMALOG MIX 75-25 hydroxyzine HCl ...... 2, 64 irinotecan ...... 20 KWIKPEN ...... 110 hydroxyzine pamoate ..... 3, 64 ISENTRESS ...... 9 HUMALOG MIX 75-25(U- hyoscyamine sulfate ...... 27 ISENTRESS HD ...... 9 100)INSULN 109, 110, 112 HYPER-SAL ...... 80, 85 isometh-dichloral- HUMALOG U-100 INSULIN I acetaminophn ...... 60 ...... 109, 112 ibandronate ...... 116 isoniazid ...... 7 HUMATROPE ...... 111 ibuprofen ...... 73 isosorbide dinitrate ...... 54 HUMIRA .... 97, 117, 119, 146 ifosfamide ...... 19 isosorbide mononitrate ...... 54 HUMIRA PEN ... 97, 117, 118, imatinib ...... 19 isradipine ... 44, 50, 51, 52, 57 145 IMFINZI ...... 19 itraconazole ...... 8 HUMIRA PEN CROHNS-UC- imipramine HCl ...... 78 ivermectin ...... 6, 144 HS START .... 97, 117, 118, imipramine pamoate ...... 78 IXEMPRA ...... 20 145 imiquimod ...... 146 IXIARO (PF) ...... 23 HUMIRA PEN PSOR- IMITREX ...... 76 J UVEITS-ADOL HS 97, 117, IMITREX STATDOSE PEN 76 Jantoven ...... 32 118, 146 IMITREX STATDOSE JANUMET ...... 103, 106 HUMULIN 70/30 U-100 REFILL ...... 76 JANUVIA ...... 106 INSULIN ...... 109, 110, 112 IMOVAX RABIES VACCINE JARDIANCE ...... 113 HUMULIN N NPH U-100 (PF) ...... 23 JEVTANA ...... 20 INSULIN ...... 109, 110 INCRUSE ELLIPTA ... 27, 124 JUBLIA ...... 139 HUMULIN R REGULAR U- indapamide ...... 56, 87 JULUCA ...... 10 100 INSULN ...... 109, 112 INDOCIN ...... 73, 115 Junel 1.5/30 (21) ...... 104 HYALGAN ...... 79 indomethacin ...... 73, 115 Junel 1/20 (21) ...... 104 hydralazine ...... 51 INFANT'S NON-ASPIRIN .. 60 Junel Fe 1.5/30 (28) ...... 104 hydrochlorothiazide ..... 55, 86 INFED ...... 35 Junel Fe 1/20 (28) ...... 104 hydrocodone-acetaminophen INFLECTRA ...... 97, 117, 119, K ...... 59, 60, 70 146 Kariva (28) ...... 105 hydrocodone-homatropine 27, INGREZZA ...... 68, 78 Kelnor 1/35 (28) ...... 105 70, 125 ketoconazole ...... 139

158 ketoprofen ...... 73 LEVEMIR FLEXTOUCH U- Lovaza ...... 40 ketorolac ...... 73, 92 100 INSULN ...... 110, 111 Low-Ogestrel (28) ...... 105 ketotifen fumarate ...... 88 LEVEMIR U-100 INSULIN loxapine succinate ...... 64 KEYTRUDA ...... 20 ...... 110, 111 LUBRICANT EYE ...... 92 KIDS VITAMIN D3 ...... 152 levetiracetam ...... 61 LUBRICANT EYE (PG-PEG KIMONO CONDOMS(NON- LEVITRA ...... 54 400) ...... 92 LUBRICATED) ...... 121 levobunolol ...... 89 LUBRICANT EYE DROPS 92 KIMONO MAXX CONDOMS levocarnitine ...... 120 LUMIGAN ...... 93 ...... 121 levocetirizine ...... 4, 131 LUPRON DEPOT ...... 20, 108 KIMONO MICROTHIN AQUA levofloxacin ...... 7, 16 LUPRON DEPOT (3 LUBE CON ...... 121 levonorgestrel-ethinyl estrad MONTH) ...... 20, 108 KIMONO MICROTHIN ...... 105 LUPRON DEPOT (4 CONDOMS ...... 121 LEVOPHED (BITARTRATE) MONTH) ...... 20, 108 KIMONO MICROTHIN ...... 25 LUPRON DEPOT-PED ..... 20, LARGE CONDOMS ..... 121 Levora-28 ...... 105 108 KIMONO TEXTURED levorphanol tartrate ...... 70 Lutera (28) ...... 105 CONDOMS ...... 121 levothyroxine ...... 113 LYSODREN ...... 20 KOSHER PRENATAL PLUS LEXIVA ...... 12 M IRON ...... 35, 147, 149 lidocaine ...... 138 MAALOX MAXIMUM K-PHOS NO 2 ...... 81 lidocaine HCl ...... 93, 114, 138 STRENGTH ...... 94, 95 K-PHOS ORIGINAL ...... 81 lidocaine HCl-hydrocortison magnesium citrate ...... 96 Kristalose ...... 82 ac ...... 137, 138, 142 magnesium oxide ...... 94 L LIDOCAINE PLUS ...... 138 malathion ...... 144 L norgest/e.estradiol-e.estrad Lidocaine Viscous ...... 93 mannitol 10 % ...... 54, 81, 83 ...... 105 lidocaine-epinephrine . 25, 114 mannitol 20 % ...... 54, 81, 83 labetalol 29, 30, 37, 41, 42, 48 lidocaine-prilocaine ...... 138 mannitol 25 % ...... 54, 81, 83 lactulose ...... 82 lindane ...... 144 mannitol 5 % ...... 54, 81, 83 LAMISIL AF ...... 146 linezolid ...... 15 MAPAP (ACETAMINOPHEN) lamivudine ...... 11 liothyronine ...... 113 ...... 60 lamivudine-zidovudine ...... 11 lisinopril ...... 39 MAPAP ARTHRITIS PAIN . 60 lamotrigine ...... 61, 62 lisinopril-hydrochlorothiazide MATULANE ...... 20 lancets ...... 80 ...... 39, 56, 86 Matzim La . 43, 44, 45, 46, 50, LANOXIN PEDIATRIC 40, 47 lithium carbonate ...... 62 57 lansoprazole ...... 98, 99 lithium citrate ...... 62 MAVYRET ...... 9 lanthanum ...... 83, 115 LO LOESTRIN FE ...... 105 MAXIDEX ...... 91 LANTUS SOLOSTAR U-100 LOHIST - D ... 3, 25, 123, 127 meclizine ...... 3, 96 INSULIN ...... 109, 111 LOKELMA ...... 83 meclofenamate ...... 73 LANTUS U-100 INSULIN 110, loperamide ...... 95 MEDROL ...... 101 111 lopinavir-ritonavir ...... 12 medroxyprogesterone ...... 111 latanoprost ...... 93 loratadine ...... 4, 131 mefloquine ...... 6 LEENA 28 ...... 105 LORATADINE-D ... 4, 25, 123, megestrol ...... 20, 111 leflunomide ...... 117, 119 131 meloxicam ...... 73 Lessina ...... 105 lorazepam ...... 66, 67 memantine ...... 68 letrozole ...... 20, 103 losartan ...... 37, 38 MENACTRA (PF) ...... 23 leucovorin calcium ...... 115 losartan-hydrochlorothiazide MENEST ...... 107 LEUKERAN ...... 20 ...... 37, 38, 56, 86 MENOSTAR ...... 107 levalbuterol HCl ...... 31, 132 loteprednol etabonate ...... 91 MENQUADFI (PF) ...... 23 levalbuterol tartrate ... 31, 132 LOTRIMIN AF ...... 139 MENVEO A-C-Y-W-135-DIP LEVATOL ...... 41 LOTRIMIN AF POWDER . 139 (PF) ...... 24 lovastatin ...... 52 meperidine ...... 70

159 MEPHYTON ...... 115, 152 Microgestin Fe 1.5/30 (28) NARCAN ...... 72, 115 mercaptopurine ...... 20, 120 ...... 105 NASAL ALLERGY ..... 91, 129 mesalamine ...... 96 Microgestin Fe 1/20 (28) .. 105 NASONEX ...... 91, 129 MESNEX ...... 121 MIGERGOT ...... 30, 64 NATACYN ...... 89 MESTINON ...... 30 miglitol ...... 102 NATAZIA ...... 105 MESTINON TIMESPAN .... 30 MILLIPRED ...... 101 nateglinide ...... 111 metaproterenol ...... 31, 132 minocycline ...... 16, 17 Necon 0.5/35 (28) ...... 105 metformin ...... 104 minoxidil ...... 51 nefazodone ...... 77 methadone ...... 70, 71 MINTOX PLUS ...... 94, 95 neomycin ...... 5 methamphetamine ...... 59 mirtazapine ...... 62 neomycin-bacitracin-poly-HC methazolamide ...... 90 misoprostol ...... 98 ...... 88, 91 methenamine hippurate .... 17 mitomycin ...... 20 neomycin-bacitracin- methenamine mandelate ... 17 mitoxantrone ...... 20 polymyxin ...... 88 Methergine ...... 122 M-M-R II (PF) ...... 24 neomycin-polymyxin B GU methimazole ...... 103 modafinil ...... 78 ...... 134 METHITEST ...... 102 mometasone ..... 91, 129, 137, neomycin-polymyxin B- methocarbamol ...... 29 142 dexameth ...... 88, 91 methotrexate sodium 20, 117, montelukast ...... 128 neomycin-polymyxin- 119, 120 MONUROL ...... 17 gramicidin ...... 88 methotrexate sodium (PF) 20, morphine ...... 71 neomycin-polymyxin-HC ... 88, 117, 119, 120 morphine concentrate ...... 71 91 methyldopa ...... 26, 47 moxifloxacin ...... 7, 16, 88 NEO-TUSS ...... 125, 126 methyldopa- MUCUS D ...... 25, 123, 126 nevirapine ...... 10 hydrochlorothiazide 26, 47, MUCUS DM ...... 125, 126 NEXAVAR ...... 21 56, 86 MUCUS RELIEF ...... 126 NEXIUM ...... 99 methyldopate ...... 26, 47 MUCUS RELIEF D NEXIUM PACKET ...... 99 methylergonovine ...... 122 (PSEUDOEPHED) 25, 123, NEXLETOL ...... 40 methylphenidate HCl ... 74, 75 126 NEXLIZET ...... 40, 47 methylprednisolone ...... 101 MULTAQ ...... 49 niacin ...... 40 methylprednisolone acetate multivitamin ...... 147 niacinamide ...... 149 ...... 101 MULTI-VITAMINS WITH nicardipine . 44, 50, 51, 52, 57 methylprednisolone sodium IRON ...... 147 nicotine ...... 28 succ ...... 101 mupirocin ...... 134 nicotine (polacrilex) ...... 28 metipranolol ...... 89 MURO 128 ...... 92 NICOTROL ...... 28 metoclopramide HCl ...... 98 MUSE ...... 57 NICOTROL NS ...... 28 metolazone ...... 56, 87 MY WAY ...... 105 nifedipine ... 44, 50, 51, 52, 57 metoprolol succinate .. 32, 41, mycophenolate mofetil ..... 120 nilutamide ...... 21 42, 48 mycophenolate sodium .... 120 nimodipine . 44, 50, 51, 52, 57 metoprolol tartrate 32, 41, 42, MYLERAN ...... 20 NIPENT ...... 21 48, 49 MYRBETRIQ ...... 147 Nitro-Bid ...... 54 metronidazole ...... 5, 7, 134 N nitrofurantoin ...... 17 mexiletine ...... 48 nabumetone ...... 73 nitrofurantoin macrocrystal 17 MICARDIS ...... 37, 38 nadolol ...... 29, 41, 42, 49 nitrofurantoin monohyd/m- MICARDIS HCT ... 37, 38, 56, naftifine ...... 133 cryst ...... 17 86 nalbuphine ...... 72 nitroglycerin ...... 54 miconazole nitrate ...... 139 naloxone ...... 72, 115 NIVESTYM ...... 33 MICONAZOLE-3 ...... 139 naltrexone ...... 72, 114 NIZORAL A-D ...... 139 Microgestin 1.5/30 (21) ... 105 naproxen ...... 73, 115 NORA-BE ...... 105 Microgestin 1/20 (21) ...... 105 naproxen sodium ...... 73, 115 noreth-ethinyl estradiol-iron naratriptan ...... 76 ...... 105

160 norethindrone acetate ..... 112 OPTICHAMBER DIAMOND penicillin G sodium ...... 14 norethindrone-e.estradiol-iron LG MASK ...... 80 penicillin V potassium ...... 14 ...... 105 OPTICHAMBER DIAMOND PENTACEL ACTHIB norgestimate-ethinyl estradiol VHC ...... 80 COMPONENT (PF) ...... 24 ...... 106 OPTICHAMBER DIAMOND- PENTAM ...... 7 NORITATE ...... 134 MED MSK ...... 80 PENTASA ...... 96 NORPACE CR ...... 47 OPTICHAMBER DIAMOND- pentazocine-naloxone ...... 72 Nortrel 0.5/35 (28) ...... 106 SML MASK ...... 80 pentoxifylline ...... 33 NORTREL 1/35 (21) ...... 106 ORACIT ...... 81 PERJETA ...... 21 Nortrel 1/35 (28) ...... 106 ORALYTE ...... 85 permethrin ...... 144 Nortrel 7/7/7 (28) ...... 106 ORILISSA ...... 103 perphenazine ...... 73 nortriptyline ...... 78 orphenadrine citrate ...... 32 PEXEVA ...... 77 NORVIR ...... 12 oseltamivir ...... 14 Phenadoz ...... 2, 64 NOVAREL ...... 108 OTEZLA ...... 117, 119, 146 phenazopyridine ...... 138 NOVOLIN 70/30 U-100 OTEZLA STARTER 117, 119, phenobarb-hyoscy-atropine- INSULIN ...... 110, 112 146 scop ...... 28, 65, 66 NOVOLIN N NPH U-100 oxaliplatin ...... 21 phenobarbital ...... 65, 66 INSULIN ...... 110 oxandrolone ...... 102 phenoxybenzamine ..... 30, 52 NOVOLIN R REGULAR U- oxaprozin ...... 73 phenylephrine HCl ...... 26, 93 100 INSULN ...... 110, 113 oxazepam ...... 67 phenytoin ...... 48, 69 NP THYROID ...... 113 oxcarbazepine ...... 61 phenytoin sodium ...... 48, 69 NUCALA ...... 125, 128 oxybutynin chloride ...... 147 phenytoin sodium extended NURTEC ODT ...... 68 oxycodone ...... 71 ...... 48, 69 nystatin ...... 15, 144 oxycodone-acetaminophen PHOSPHA 250 NEUTRAL 81 nystatin-triamcinolone ..... 144 ...... 60, 71 PHOTOFRIN ...... 21 O oxycodone-aspirin ...... 71, 75 phytonadione (vitamin K1) OB COMPLETE PETITE .. 35, oxytocin ...... 122 ...... 115, 152 147, 149 OYSTER SHELL CALCIUM PIFELTRO ...... 10 OCELLA ...... 106 500 ...... 85 pilocarpine HCl ...... 30, 93 ODEFSEY ...... 10, 11 OYSTER SHELL CALCIUM- pimecrolimus ...... 120, 146 ofloxacin ...... 16, 89 VIT D2 ...... 85 pimozide ...... 64 olanzapine ...... 62, 65 OZEMPIC ...... 108 pindolol ...... 29, 41, 42, 49, 53 olmesartan ...... 37, 38 P PINK BISMUTH ...... 94, 95 olmesartan- paclitaxel ...... 21 pioglitazone ...... 113 hydrochlorothiazide 37, 38, PANDEL ...... 137, 142 piroxicam ...... 73 56, 86 pantoprazole ...... 99 PLAN B ONE-STEP ...... 106 olopatadine ...... 88 paroxetine HCl ...... 77 PNEUMOVAX-23 ...... 24 omega 3-dha-epa-fish oil .. 40 PEDIA RELIEF INFANT podofilox ...... 146 omega-3 fatty acids ...... 40 NASAL ...... 26, 123 Polocaine ...... 114 omega-3 fatty acids-fish oil 40 PEDIA TRI-VITE ..... 148, 151, polyethylene glycol 3350 ... 97 omeprazole ...... 99 152 polymyxin B sulfate ...... 15 omeprazole-sodium PEDIA-LAX STOOL polymyxin B sulf-trimethoprim bicarbonate ...... 99 SOFTENER ...... 96 ...... 89 OMNARIS ...... 91, 129 PEDIATRIC COUGH AND polysaccharide iron complex ONCASPAR ...... 21 COLD 3, 26, 124, 125, 127 ...... 35 ondansetron ...... 95 peg 3350-electrolytes ...... 96 polyvinyl alcohol ...... 92 ondansetron HCl ...... 95 PEG-3350 WITH FLAVOR Portia 28 ...... 106 OPDIVO ...... 21 PACKS ...... 97 PORTRAZZA ...... 21 OPTICHAMBER ADULT PEGASYS ...... 13 potassium acetate ...... 85 MASK-LARGE ...... 80 penicillin G potassium ...... 14 potassium chloride ...... 85

161 potassium chloride-D5- PRIMSOL ...... 17 quinine sulfate ...... 7 0.2%NaCl ...... 85 probenecid ...... 87, 116 QVAR REDIHALER . 102, 130 potassium chloride-D5- probenecid-colchicine 87, 116 R 0.9%NaCl ...... 85 procainamide ...... 48 RABAVERT (PF) ...... 24 potassium citrate ...... 81 PROCARE BLOOD rabeprazole ...... 99 potassium phosphate m-/d- PRESSURE MONITOR .. 80 raloxifene ...... 106, 116 basic ...... 85 PROCHAMBER ...... 80 ramipril ...... 39 pramipexole ...... 69 prochlorperazine ...... 73, 96 RAPAMUNE ...... 120 PRAMOSONE . 137, 138, 142 prochlorperazine Edisylate 73, REBIF (WITH ALBUMIN) 119 prasugrel ...... 36 96 REBIF TITRATION PACK 119 pravastatin ...... 52 prochlorperazine maleate . 74, Reclipsen (28) ...... 106 prazosin ...... 29, 37 96 RECOMBIVAX HB (PF) ..... 24 PRED MILD ...... 91 Proctozone-Hc ...... 137, 142 REESE'S PINWORM PRED-G ...... 89, 91 progesterone micronized . 112 MEDICINE ...... 6 PRED-G S.O.P...... 89, 91 PROGLYCEM ...... 103 REFRESH LIQUIGEL ...... 92 prednicarbate ...... 137, 142 PROLEUKIN ...... 21, 119 REFRESH P.M...... 92 prednisolone ...... 101 PROLIA ...... 116 REFRESH TEARS ...... 92 prednisolone acetate ...... 91 promethazine ...... 2, 64, 127 REGONOL ...... 30 prednisolone sodium Promethazine Vc .... 2, 26, 127 REGRANEX ...... 139, 146 phosphate ...... 91, 101 promethazine-codeine ...... 71, RELPAX ...... 76 prednisone ...... 101, 102 125, 127 REMICADE ...... 98, 117, 119, PREDNISONE INTENSOL promethazine-DM .... 125, 127 120, 146 ...... 101 promethazine-phenyleph- RENAGEL ...... 83, 115 pregabalin ...... 60, 61, 69 codeine 2, 27, 71, 125, 127 RENA-VITE ...... 150, 151 PREMARIN ...... 107 propafenone ...... 48 RENFLEXIS ...... 98, 117, 119, PREMPHASE ...... 107 proparacaine ...... 93 146 PREMPRO ...... 107 propranolol 29, 41, 42, 49, 53, repaglinide ...... 111 PRENATAL + DHA ... 35, 148, 64 REPATHA PUSHTRONEX 54 149 propranolol- REPATHA SURECLICK .... 54 PRENATAL PLUS hydrochlorothiazid ... 29, 41, REPATHA SYRINGE ...... 54 (CALCIUM CARB) .. 35, 85, 42, 49, 56, 86 RESCON-DM 3, 26, 124, 125, 148, 149 propylthiouracil ...... 103 128 PRENATE DHA (FERR ASP protriptyline ...... 78 RESTORE TEARS ...... 92 GLYCIN) ...... 35, 148, 149 pseudoephedrine HCl 26, 124 RETACRIT ...... 33 PRENATE ENHANCE ...... 35, PULMICORT FLEXHALER REVLIMID ...... 21, 119 148, 150 ...... 102, 130 REXULTI ...... 65 PRENATE MINI (FERR ASP PULMOZYME ...... 87, 129 REYATAZ ...... 13 GLYCIN) ...... 35, 148, 150 pyrazinamide ...... 7 RHINOCORT ALLERGY .. 91, PRENATE PIXIE 35, 148, 150 pyridostigmine bromide ...... 30 129 PREVACID 24HR ...... 99 pyridoxine (vitamin B6) .... 150 RHOGAM ULTRA- Prevalite ...... 42 Q FILTERED PLUS ...... 22 PREVIDENT ...... 116 QELBREE ...... 68 RHOPRESSA ...... 89, 93 PREVIDENT 5000 DRY QNASL ...... 91, 129 ribavirin ...... 14 MOUTH ...... 116 QSYMIA ...... 58, 60, 61 riboflavin (vitamin B2) ...... 150 PREVNAR 13 (PF) ...... 24 quetiapine ...... 62, 65 RIDAURA ...... 99, 117, 119 PREZISTA ...... 12 quinapril ...... 39 rifabutin ...... 7, 16 PRILOSEC ...... 99 quinapril-hydrochlorothiazide rifampin ...... 7, 16 PRIMACARE ..... 35, 148, 150 ...... 39, 56, 86 riluzole ...... 68 primaquine ...... 7 quinidine gluconate ...... 7, 48 Ringer's ...... 82 primidone ...... 65 quinidine sulfate ...... 7, 48 risperidone ...... 62, 63, 65

162 ritonavir...... 13 SLEEP AID sulfacetamide-prednisolone RITUXAN ...... 21 (DIPHENHYDRAMINE) ... 1, ...... 89 rivastigmine ...... 30 2, 65, 128 sulfadiazine ...... 16 rizatriptan ...... 76 sodium acetate ...... 85 sulfamethoxazole- ROBAFEN CF sodium bicarbonate ...... 81 trimethoprim ...... 16 (PHENYLEPHRINE) ..... 27, sodium chloride ..... 80, 82, 85, sulfasalazine 16, 96, 117, 119 126 86, 92 SULFATRIM ...... 16 ropinirole ...... 69 sodium chloride 5 % ...... 85 sulindac ...... 73 rosuvastatin ...... 52 sodium hydroxide (bulk) ... 143 sumatriptan ...... 76 ROXICODONE ...... 71 sodium polystyrene sulfonate sumatriptan succinate .. 76, 77 ROZEREM ...... 64 ...... 83 SUPRAX ...... 5 rufinamide ...... 61 sofosbuvir-velpatasvir ...... 9 SUPREP BOWEL PREP KIT RUKOBIA ...... 9 SOLU-CORTEF ...... 102 ...... 97 RYBELSUS ...... 108 SOLU-MEDROL ...... 102 SURELIFE ARM BP S sorbitol ...... 97 MONITOR ...... 80 SAFYRAL ...... 106 sorbitol-mannitol ...... 82, 83 SURELIFE TALKING ARM salicylic acid ...... 143 sotalol ...... 29, 41, 42, 49, 53 BP MONITR ...... 80 salsalate ...... 76 Sotalol Af ... 29, 41, 42, 49, 53 SUSTIVA ...... 10 SANDIMMUNE 117, 119, 120 SPIRIVA RESPIMAT . 28, 124 SUTENT ...... 21 SANTYL ...... 146 SPIRIVA WITH SYMJEPI ...... 26, 124 SAVELLA ...... 69, 76 HANDIHALER ...... 28, 125 SYMLINPEN 120 ...... 102 SCALACORT ...... 137, 142 spironolactone ...... 53, 55, 84 SYMLINPEN 60 ...... 102 SCALP RELIEF ...... 137, 142 spironolacton- SYMTUZA ..... 12, 13, 14, 121 SCALPICIN ANTI-ITCH .. 137, hydrochlorothiaz 53, 54, 55, SYNJARDY ...... 104, 113 142 56, 84, 86 SYNRIBO ...... 21 SCOT-TUSSIN DM .... 3, 126, SPORANOX ...... 8 SYSTANE NIGHTTIME ..... 92 128 Sprintec (28) ...... 106 T SELECT-OB + DHA . 35, 148, SPRYCEL ...... 21 TABLOID ...... 21 150 Sronyx ...... 106 tacrolimus ...... 120, 146 selegiline HCl ...... 69 SSD ...... 144 tadalafil (pulm. hypertension) selenium sulfide ...... 144 SSKI ...... 6, 103, 115, 126 ...... 54, 133 SELF-TAKING BLOOD stavudine ...... 11 tamoxifen ...... 21, 107 PRESSURE ...... 80 Sterile Water For Injection tamsulosin ...... 30 SELZENTRY ...... 9 ...... 123 TARGETED ACNE SPOT SENNA ...... 97 STIOLTO RESPIMAT . 28, 32, TREATMENT ...... 143 SENNA-S ...... 97 125, 132 TASIGNA ...... 21 SEREVENT DISKUS. 31, 132 STOOL SOFTENER ...... 97 tazarotene ...... 146 sertraline ...... 77 streptomycin ...... 5, 8 TAZORAC ...... 146 sevelamer carbonate . 83, 115 STRESS FORMULA ...... 148 Taztia Xt .... 43, 44, 45, 46, 58 SF ...... 116 STRIBILD ...... 10, 12 TECENTRIQ ...... 21 SHINGRIX (PF) ...... 24 SUBOXONE ...... 72 telmisartan ...... 37, 38 sildenafil (pulm.hypertension) sucralfate ...... 98 temazepam ...... 67 ...... 54, 133 SUDOGEST 12-HOUR ..... 26, TEMODAR ...... 21 silver nitrate ...... 143 124 temozolomide ...... 21 silver sulfadiazine ...... 144 sulfacetamide sodium ...... 89 teniposide ...... 22 simethicone ...... 95 sulfacetamide sodium-sulfur TENIVAC (PF) ...... 23 simvastatin ...... 52 ...... 143, 144 terazosin ...... 29, 37, 53 SINGULAIR ...... 128 sulfacetamide sod-sulfur-urea terbinafine HCl ...... 5, 133 sirolimus ...... 120 ...... 143, 144 terbutaline ...... 32, 132 terconazole ...... 139

163 testosterone ...... 103 tretinoin ...... 139 TRUVADA ...... 12 testosterone cypionate .... 102 tretinoin microspheres ...... 139 TUSNEL NEW FORMULA 26, testosterone enanthate ... 103 TREXIMET ...... 73, 77 124, 126 tetracaine HCl ...... 93 triamcinolone acetonide .... 91, TWINRIX (PF) ...... 24 tetracycline ...... 17 102, 129, 137, 142, 143 TYKERB ...... 22 THALOMID ...... 119 triamterene- TYPHIM VI ...... 24 THAM ...... 81 hydrochlorothiazid ... 55, 56, U theophylline . 51, 82, 133, 147 84, 87 UBRELVY ...... 68 theophylline in dextrose 5 % Trianex ...... 137, 143 UCERIS ...... 102 ...... 51, 82, 133, 147 triazolam ...... 67 UDENYCA ...... 33 thiamine HCl (vitamin B1) 150 trifluoperazine ...... 74 ULTRA FRESH ...... 92 thiamine mononitrate (vit B1) trifluridine ...... 89 UNITHROID ...... 113, 114 ...... 150 trihexyphenidyl ...... 28, 60 urea ...... 143 thioridazine ...... 74 trimethobenzamide ...... 96 URETRON D-S ...... 17 thiotepa ...... 22 trimethoprim ...... 17 ursodiol ...... 97 thiothixene ...... 78 TRINTELLIX ...... 77 V tiagabine ...... 61 TRIUMEQ ...... 10, 12 VAGINAL CONTRACEPTIVE TIKOSYN ...... 49 TRI-VI-SOL .... 148, 149, 151, FOAM ...... 122 timolol maleate 29, 41, 42, 49, 152 valacyclovir ...... 14 53, 64, 90 TRI-VITAMIN WITH valganciclovir ...... 14 tioconazole ...... 139 FLUORIDE . 116, 148, 149, valproic acid ...... 61, 63, 64 TIVICAY ...... 10 151, 152 valproic acid (as sodium salt) TIVICAY PD ...... 10 Trivora (28) ...... 106 ...... 61, 63, 64 tizanidine ...... 29 TROGARZO ...... 9 valsartan ...... 38 TOBRADEX ...... 89, 91 tropicamide ...... 93 valsartan-hydrochlorothiazide tobramycin ...... 89 trospium ...... 147 ...... 38, 56, 87 tobramycin sulfate ...... 5 TRUE METRIX AIR vancomycin ...... 8 tobramycin-dexamethasone GLUCOSE METER ...... 80 VAQTA (PF) ...... 24 ...... 89, 91 TRUE METRIX GLUCOSE VARIVAX (PF) ...... 24 TOBREX ...... 89 METER ...... 80 vasopressin ...... 111 TODAY CONTRACEPTIVE TRUE METRIX GLUCOSE VCF CONTRACEPTIVE SPONGE ...... 121 TEST STRIP ...... 81 FILM ...... 122 tolmetin ...... 73 TRUETRACK SMART VCF CONTRACEPTIVE GEL tolnaftate ...... 146 SYSTEM ...... 80 ...... 122 tolterodine ...... 147 TRUETRACK TEST ...... 81 VECTIBIX ...... 22 topiramate ...... 61 TRULICITY ...... 108 VELCADE ...... 22 topotecan ...... 22 TRUMENBA ...... 24 Velivet Triphasic Regimen TORISEL ...... 22 TRUSTEX LATEX CONDOM (28) ...... 106 torsemide ...... 53, 83 ...... 121 VELTASSA ...... 83 tramadol ...... 71 TRUSTEX LUBRICATED VEMLIDY ...... 15 tramadol-acetaminophen . 60, CONDOMS ...... 122 venlafaxine ...... 76 64, 72 TRUSTEX NON-LUB VENTAVIS ...... 58, 133 trandolapril ...... 39 CONDOMS ...... 122 verapamil .. 43, 44, 45, 46, 50, tranexamic acid ...... 33 TRUSTEX-RIA 58 travoprost ...... 93 LUB/SPERMICIDE ...... 122 VERQUVO ...... 58 trazodone ...... 77 TRUSTEX-RIA VIAGRA ...... 54 TRECATOR ...... 8 LUBRICATED CONDOMS VIBRAMYCIN ...... 17 TRELEGY ELLIPTA ... 28, 32, ...... 122 VICTOZA 2-PAK ...... 108 102, 125, 130, 132 TRUSTEX-RIA NON-LUB VICTOZA 3-PAK ...... 109 TRELSTAR ...... 22, 108 CONDOMS ...... 122 VIIBRYD ...... 78

164 VIMPAT ...... 61 WIDE-SEAL DIAPHRAGM YF-VAX (PF) ...... 24 vinblastine ...... 22 65 ...... 122 YONDELIS ...... 22 vincristine ...... 22 WIDE-SEAL DIAPHRAGM Yuvafem ...... 107 vinorelbine ...... 22 70 ...... 122 Z VIRACEPT ...... 13 WIDE-SEAL DIAPHRAGM zafirlukast ...... 128 VIREAD ...... 12 75 ...... 122 zaleplon ...... 65 VITAMED MD ONE RX .... 35, WIDE-SEAL DIAPHRAGM ZALTRAP ...... 22 148, 150 80 ...... 122 ZANOSAR ...... 22 VITAMIN B COMPLEX WITH WIDE-SEAL DIAPHRAGM ZEGERID ...... 99 C ...... 150 85 ...... 122 ZEGERID OTC ...... 99 VITAMIN B-12 ...... 150 WIDE-SEAL DIAPHRAGM ZENPEP ...... 97 VITAMIN B-6 ...... 151 90 ...... 122 ZEPATIER ...... 9 VITAMIN D3 ...... 152 WIDE-SEAL DIAPHRAGM ZETONNA ...... 91, 129 Vitamin K ...... 115, 152 95 ...... 122 ZIAGEN ...... 12 Vitamin K1 ...... 115, 152 Wixela Inhub .....32, 102, 131, zidovudine ...... 12 VOSEVI ...... 9 132 zileuton ...... 128 VYVANSE ...... 59 X zinc chloride ...... 86 W XARELTO ...... 33 zinc sulfate ...... 86 WAL-FEX D 24 HOUR . 4, 26, XARELTO DVT-PE TREAT ziprasidone HCl ...... 63, 65 124, 131 30D START ...... 33 zoledronic acid ...... 116 WAL-SOM (DOXYLAMINE) 1, XERAC AC ...... 138 ZOLINZA ...... 22 2, 65, 128 XGEVA ...... 116 zolmitriptan ...... 77 WAL-TUSSIN MAX XIFAXAN ...... 16 zolpidem ...... 65 STRENGTH COUGH ... 126 XOLAIR ...... 131 ZOMIG ...... 77 warfarin...... 32 X-SEB T PLUS ...... 144 ZOMIG ZMT ...... 77 water for inject, bacteriostat XULANE ...... 106 zonisamide ...... 61 ...... 123 XYLOCAINE- ZOSTAVAX (PF) ...... 24 water for injection, sterile 123 MPF/EPINEPHRINE ..... 26, Zovia 1/35E (28) ...... 106 water for irrigation, sterile .. 82 114 ZYFLO ...... 128 WIDE-SEAL DIAPHRAGM Y ZYPREXA ZYDIS ...... 63, 65 60 ...... 122 YERVOY ...... 22 ZYVOX ...... 15

165