Supplemental Preferred Drug List (PDL)

Pennsylvania – UnitedHealthcare Community Plan

Effective Date: 1/1/2021

© 2021 United HealthCare Services, Inc. All Rights Reserved.

UnitedHealthcare Community Plan complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, creed, religious affiliation, ancestry, sex gender, gender identity or expression, or sexual orientation.

UnitedHealthcare Community Plan does not exclude people or treat them differently because of race, color, national origin, age, disability, creed, religious affiliation, ancestry, sex gender, gender identity or expression, or sexual orientation.

UnitedHealthcare Community Plan provides free aids and services to people with disabilities to communicate effectively with us, such as: • Qualified sign language interpreters • Written information in other formats (large print, audio, accessible electronic formats, other formats)

UnitedHealthcare Community Plan provides free language services to people whose primary language is not English, such as: • Qualified interpreters • Information written in other languages

If you need these services, contact UnitedHealthcare Community Plan at 1-800-414-9025, TTY/PA RELAY 711.

If you believe that UnitedHealthcare Community Plan has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, creed, religious affiliation, ancestry, sex gender, gender identity or expression, or sexual orientation, you can file a complaint with: UnitedHealthcare Community Plan The Bureau of Equal Opportunity P.O. Box 30608 Room 223, Health and Welfare Building Salt Lake City, UT 84131-0364 P.O. Box 2675 Harrisburg, PA 17105-2675 Phone: 717-787-1127, TTY/PA Relay 711 Fax: 717-772-4366, or Email: [email protected]

You can file a complaint in person or by mail, fax, or email. If you need help filing a complaint, UnitedHealthcare Community Plan and the Bureau of Equal Opportunity are available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 1-800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

CSPA15MC4049801_001 UnitedHealthcare Community Plan cumple con las leyes federales de derechos civiles aplicables y no discrimina por raza, color, nacionalidad, edad, discapacidad, creencias, afiliación religiosa, ascendencia, sexo, identificación de sexo, expresión sexual u orientación sexual.

UnitedHealthcare Community Plan no excluye a las personas ni las trata de manera diferente debido a su raza, color, nacionalidad, edad, discapacidad, creencias, afiliación religiosa, ascendencia, sexo, identificación de sexo, expresión sexual u orientación sexual.

UnitedHealthcare Community Plan proporciona ayuda y servicios gratuitos a personas con discapacidades para que puedan comunicarse con nosotros de manera efectiva, por ejemplo: • Intérpretes de lenguaje de señas calificados • Información escrita en otros formatos (letra grande, audio, formatos electrónicos accesibles y demás formatos)

UnitedHealthcare Community Plan ofrece servicios de idioma gratuitos a las personas cuyo idioma principal no es el inglés, por ejemplo: • Intérpretes calificados • Información escrita en otros idiomas

Si necesita estos servicios, comuníquese con UnitedHealthcare Community Plan al 1-800-414-9025, TTY/PA RELAY 711.

Si considera que UnitedHealthcare Community Plan no ha proporcionado estos servicios o ha discriminado de otro modo en función de la raza, el color, la nacionalidad, la edad, la discapacidad, las creencias, la afiliación religiosa, la ascendencia, el sexo, la identificación de sexo, la expresión sexual o la orientación sexual, puede presentar una queja con: UnitedHealthcare Community Plan The Bureau of Equal Opportunity P.O. Box 30608 Room 223, Health and Welfare Building Salt Lake City, UT 84131-0364 P.O. Box 2675 Harrisburg, PA 17105-2675 Teléfono: 717-787-1127, TTY/PA Relay 711 Fax: 717-772-4366, o Correo electrónico: [email protected] Usted puede presentar una queja en persona o por correo, fax o por correo electrónico. Si necesita ayuda para presentar una queja, UnitedHealthcare Community Plan y la Oficina de Igualdad de Oportunidades están disponibles para brindarle asistencia.

También puede presentar un reclamo de derechos civiles ante la Oficina de Derechos Civiles del Departamento de Salud y Servicios Humanos de los EE. UU. por vía electrónica a través del Portal de Quejas de la Oficina de Derechos Civiles disponible en https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, o por correo postal o teléfono al: U.S. Department of Health and Human Services 200 Independence Avenue SW Room 509F, HHH Building Washington, DC 20201 1-800-368-1019, 1-800-537-7697 (TDD) Los formularios de reclamos están disponibles en http://www.hhs.gov/ocr/office/file/index.html. ATTENTION: IfIf you speakdo not English,speak English, language language assistance assistance services, freeservices, of charge, free of are charge, available are toavailable you. Call: to you.1-800-414-9025, TTY/PACall: 1-800-414-9025, RELAY: 711. TTY/PA RELAY: 711. ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-414-9025, TTY/PA RELAY: 711. ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните по телефону 1-800-414-9025, TTY/PA RELAY: 711. 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-800-414-9025, TTY/PA RELAY: 711。 CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-800-414-9025, TTY/PA RELAY: 711. ملحوظة: إذا كنت تتحدث اللغة العربية، فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم 1-800-414-9025، .TTY/PA RELAY: 711

ध्봾न दिनुहोस:् तप봾셍ᴂले नेप봾ली बोलनुहुन㔛 भने तप봾셍ᴂको ननम्त भ봾ष봾 सह봾्त봾 सेव봾ह셂 ननःशुलक 셂पम봾 उपलब㔧 㔛 । फोन गनुꅁहोस ्1-800-414-9025, TTY/PA RELAY: 711 । 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-800-414-9025, TTY/PA RELAY: 711 번으로 전화해 주십시오.

សូមាប់讶រម䮘ណ៍ ៖ បបសិនបបើអ䮓កនិ架យ徶羶ខ្䮘រ បស玶ជំនួយខ្䮓ក徶羶ឥតគិតថ្濃 គឺ讶ច掶នសប掶ប់បំបរើជូនអ䮓ក ។ ចូរទូរស័ព䮑បៅបេ្ 1-800-414-9025, TTY/PA RELAY: 711។ ATTENTION : Si vous parlez français, des services d’aide linguistique vous sont proposés gratuitement. Appelez le 1-800-414-9025, TTY/PA RELAY: 711.

သတိျပဳရန္ - အကယ္၍ သင္သည္ ျမန္မာစကား ေျပာပါက၊ ဘာသာစကား အကူအညီ၊ အခမဲ့၊ သင့္အတြက္ စီစဥ္ေဆာင္ရြက္ေပးပါမည္။ ဖုန္းနံပါတ္ 1-800-414-9025, TTY/PA RELAY: 711 သုိ႔ ေခၚဆိုပါ။ ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-800-414-9025, TTY/PA RELAY: 711. ATENÇÃO: se fala português, encontram-se disponíveis serviços linguísticos gratuitos. Ligue para 1-800-414-9025, TTY/PA RELAY: 711.

ল嗍ষ্য ক쇁ন: আপনন যনি বাংলায় কথা বললন, তাহলল আপনার জনষ্য নবনা খরলে ভাষা সহায়তা পনরলষবা উপলব্ধ আলে। 1-800-414-9025, TTY/PA RELAY: 711 নম্বলর ফ�ান ক쇁ন। KUJDES: Nëse flisni shqip, për ju ka në dispozicion shërbime falas të ndihmës gjuhësore. Telefononi në 1-800-414-9025, TTY/PA RELAY: 711.

સચના:ૂ જો તમે ગજરાતીુ બોલતા હો, તો નન:શલ㚕ુ ભાષા સહાયતા સેવાઓ તમારા માટે ઉપલબ㚧 છે. 㚕ૉલ 㚕રો 1-800-414-9025, TTY/PA RELAY: 711.

CSPA15MC3971164_000 Table of Contents Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint Conditions ...... 3 Anesthetics - Drugs for Numbing ...... 7 Anti-Addiction/Substance Abuse Treatment Agents - Drugs for Overdose or Deterrence ...... 7 Antibacterials ...... 7 Antibacterials - Drugs to Treat Bacterial Infections ...... 7 Antimyasthenic Agents - Drugs to Treat Myasthenia Gravis ...... 8 Antimycobacterials - Drugs to Treat Infections ...... 8 Antineoplastics - Drugs to Treat Cancer...... 8 Antiparasitics - Drugs to Treat Parasitic Infections ...... 10 Antivirals - Drugs to Treat Viral Infections ...... 10 Bipolar Agents - Drugs to Treat Mood Disorders ...... 10 Blood Glucose Regulators - Drugs to Regulate Blood Sugar ...... 10 Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood Disorders ...... 11 Cardiovascular Agents - Drugs to Treat Heart and Circulation Conditions ...... 11 Central Nervous System Agents - Drugs to Treat Nerve Conditions ...... 13 Dental and Oral Agents - Drugs to Treat Mouth and Throat Conditions ...... 13 Dermatological Agents - Drugs to Treat Skin Conditions ...... 13 Electrolytes/Minerals/Metals/Vitamins ...... 16 Gastrointestinal Agents - Drugs to Treat Bowel, Intestine and Stomach Conditions ...... 26 Genetic or Enzyme Disorder: Replacement, Modifiers, Treatment ...... 38 Genitourinary Agents - Drugs to Treat Bladder, Genital and Kidney Conditions ...... 38 Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Drugs to Regulate Hormones 39 Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins) - Drugs to Regulate Hormones ...... 39 Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) - Drugs to Regulate Hormones ...... 40 Hormonal Agents, Suppressant (Adrenal) - Drugs to Regulate Hormones...... 40 Hormonal Agents, Suppressant (Pituitary) - Drugs to Regulate Hormones ...... 40 Hormonal Agents, Suppressant (Thyroid) - Drugs to Suppress Thyroid Hormones ...... 41 Immunological Agents - Drugs that Stimulate or Suppress the Immune System ...... 41 Inflammatory Bowel Disease Agents - Drugs to Treat Inflammatory Bowel Disease ...... 42 Metabolic Bone Disease Agents - Drugs to Treat Bone Conditions ...... 42 Miscellaneous Therapeutic Agents ...... 43 Ophthalmic Agents - Drugs to Treat Eye Conditions ...... 45 Otic Agents - Drugs to Treat Ear Conditions ...... 48 Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold and Lung Conditions ...... 49 1 Sleep Disorder Agents - Drugs for Sedation and Sleep ...... 59 Therapeutic Nutrients/Minerals/Electrolytes - Drugs to Treat Vitamin, Mineral and Body Fluid Deficiencies...... 59

2 Drug Name Reference Brand-Generic Requirements & Limits Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint Conditions Analgesics - Miscellaneous Analgesics 8 hour arthritis pain reliever Tylenol 8 Hour Generic QL 8 hour arthritis relief Tylenol 8 Hour Generic QL 8 hour pain reliever Tylenol 8 Hour Generic QL 8 hr arthritis pain relief Tylenol 8 Hour Generic QL 8hr arthritis pain relief Tylenol 8 Hour Generic QL 8hr muscle aches & pain Tylenol 8 Hour Generic QL acetaminophen 8 hour Tylenol 8 Hour Generic QL acetaminophen childrens Generic QL acetaminophen er Tylenol 8 Hour Generic QL acetaminophen ex st oral liquid 500 Mapap Acetaminophen Generic QL mg/15ml Extra Str acetaminophen ex st oral tablet 500 mg Medi-Tabs Extra Strength Generic QL acetaminophen extra strength Medi-Tabs Extra Strength Generic QL acetaminophen infants Panadol Childrens Generic QL Mapap Acetaminophen acetaminophen oral liquid 500 mg/15ml Generic QL Extra Str acetaminophen oral solution 160 mg/5ml, Generic QL 325 mg/10.15ml, 650 mg/20.3ml acetaminophen oral suspension 160 Panadol Childrens Generic QL mg/5ml, 650 mg/20.3ml acetaminophen oral tablet 325 mg Pharbetol Generic QL acetaminophen oral tablet 500 mg Medi-Tabs Extra Strength Generic QL acetaminophen oral tablet chewable 160 Mapap Childrens Generic QL mg acetaminophen rectal suppository 120 mg FeverAll Childrens Generic QL acetaminophen rectal suppository 650 mg FeverAll Adults Generic QL added strength headache relief Excedrin Extra Strength Generic QL aminofen Pharbetol Generic QL apra Medi-Tabs Childrens Generic QL arthritis pain oral tablet extended release Tylenol 8 Hour Generic QL 650 mg arthritis pain relief oral tablet extended Tylenol 8 Hour Generic QL release 650 mg arthritis pain reliever oral Tylenol 8 Hour Generic QL

AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication 3 Drug Name Reference Brand-Generic Requirements & Limits aurophen childrens Panadol Childrens Generic QL betatemp childrens Panadol Childrens Generic QL CASTIVA WARMING Brand childrens acetaminophen oral suspension Panadol Childrens Generic QL 160 mg/5ml childrens apap Childrens Medi-Tabs Generic QL childrens medi-tabs Childrens Medi-Tabs Generic QL childrens non-aspirin Childrens Medi-Tabs Generic QL childrens silapap Little Remedies for Fever Generic QL childrens tactinal Childrens Medi-Tabs Generic QL childs non-aspirin Childrens Medi-Tabs Generic QL ed-apap Little Remedies for Fever Generic QL EXCEDRIN EXTRA STRENGTH Brand QL EXCEDRIN MIGRAINE Brand QL fever reducer childrens FeverAll Childrens Generic QL fever reducing childrens FeverAll Childrens Generic QL feverall adults FeverAll Adults Generic QL feverall childrens FeverAll Childrens Generic QL FEVERALL INFANTS Brand QL feverall junior strength Generic QL headache formula Excedrin Extra Strength Generic QL headache relief Excedrin Extra Strength Generic QL headache relief extra str Excedrin Extra Strength Generic QL headrin ex strength pain rel Excedrin Extra Strength Generic QL infants pain & fever Panadol Childrens Generic QL infants pain relief drops Panadol Childrens Generic QL infants pain relief oral suspension 80 Generic QL mg/0.8ml infants pain/fever Panadol Childrens Generic QL liquid acetaminophen Little Remedies for Fever Generic QL liquid pain relief Little Remedies for Fever Generic QL Mapap Acetaminophen mapap acetaminophen extra str Generic Extra Str mapap arthritis pain Tylenol 8 Hour Generic QL mapap childrens Mapap Childrens Generic QL mapap oral capsule Generic QL medi-tabs extra strength Medi-Tabs Extra Strength Generic QL

AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication 4 Drug Name Reference Brand-Generic Requirements & Limits migraine formula Excedrin Extra Strength Generic QL migraine relief Excedrin Extra Strength Generic QL mm arthritis pain Tylenol 8 Hour Generic QL m-pap Little Remedies for Fever Generic QL non-aspirin Pharbetol Generic QL non-aspirin childrens Panadol Childrens Generic QL non-aspirin extra strength Medi-Tabs Extra Strength Generic QL non-aspirin jr strength Mapap Childrens Generic QL non-aspirin pain relief Pharbetol Generic QL non-aspirin pain reliever oral tablet 325 Pharbetol Generic QL mg pain & fever child Panadol Childrens Generic QL pain & fever childrens Panadol Childrens Generic QL pain & fever infants Panadol Childrens Generic QL pain relief childrens Panadol Childrens Generic QL pain relief extra st Medi-Tabs Extra Strength Generic QL pain relief extra strength oral capsule 500 Generic QL mg pain relief extra strength oral liquid 500 Mapap Acetaminophen Generic mg/15ml Extra Str pain relief extra strength oral tablet 500 Medi-Tabs Extra Strength Generic QL mg Mapap Acetaminophen pain relief oral liquid 500 mg/15ml Generic Extra Str pain relief oral tablet 325 mg Pharbetol Generic QL pain relief oral tablet 500 mg Medi-Tabs Extra Strength Generic QL pain relief oral tablet extended release Tylenol 8 Hour Generic QL 650 mg pain relief regular st Pharbetol Generic QL pain relief regular strength Pharbetol Generic QL pain reliever extra strength Excedrin Extra Strength Generic QL pain reliever oral tablet Pharbetol Generic QL pain reliever plus Excedrin Extra Strength Generic QL pain-off Excedrin Extra Strength Generic QL PANADOL CHILDRENS Brand QL PANADOL EXTRA STRENGTH Brand QL PANADOL INFANTS Brand QL pharbetol extra strength Medi-Tabs Extra Strength Generic QL

AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication 5 Drug Name Reference Brand-Generic Requirements & Limits pharbetol oral tablet 325 mg Pharbetol Generic QL tactinal Pharbetol Generic QL tactinal extra strength Medi-Tabs Extra Strength Generic QL TYLENOL 8 HOUR Brand QL TYLENOL 8 HOUR ARTHRITIS PAIN Brand QL TYLENOL CHILDRENS CHEWABLES Brand QL TYLENOL CHILDRENS ORAL Brand QL SUSPENSION TYLENOL EXTRA STRENGTH Brand QL TYLENOL INFANTS Brand QL TYLENOL INFANTS PAIN+FEVER Brand QL TYLENOL ORAL TABLET Brand QL Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs adult aspirin ec low strength oral tablet Miniprin Low Dose Generic QL delayed release 81 mg adult aspirin low strength St Joseph Low Dose Generic QL adult aspirin regimen Miniprin Low Dose Generic QL aspirin 81 oral tablet delayed release Miniprin Low Dose Generic QL aspirin adult Bayer Aspirin Generic QL aspirin adult low dose St Joseph Low Dose Generic QL aspirin adult low st St Joseph Low Dose Generic QL aspirin adult low strength Miniprin Low Dose Generic QL aspirin childrens St Joseph Low Dose Generic QL aspirin ec EcPirin Generic QL aspirin ec low dose Miniprin Low Dose Generic QL aspirin ec low strength Miniprin Low Dose Generic QL aspirin low dose Miniprin Low Dose Generic QL aspirin low strength St Joseph Low Dose Generic QL aspirin oral St Joseph Low Dose Generic QL aspirin rectal Generic QL aspirtab EcPirin Generic QL Bayer Advanced Aspirin aspirtab maximum strength Generic QL Ex St BAYER ASPIRIN Brand QL BAYER ASPIRIN EC LOW DOSE Brand QL

AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication 6 Drug Name Reference Brand-Generic Requirements & Limits childrens aspirin St Joseph Low Dose Generic QL childrens aspirin low strength St Joseph Low Dose Generic QL ECOTRIN MAXIMUM STRENGTH Brand QL ecpirin EcPirin Generic QL miniprin low dose Miniprin Low Dose Generic QL salsalate oral Generic QL ST JOSEPH LOW DOSE Brand QL Anesthetics - Drugs for Numbing Local Anesthetics lidocaine hcl mouth/throat Generic Anti-Addiction/Substance Abuse Treatment Agents - Drugs for Overdose or Deterrence Alcohol Deterrents/Anti-craving - Antidotes/Deterrents/Protectants acamprosate calcium Generic disulfiram oral tablet 250 mg Generic disulfiram oral tablet 500 mg Generic Antibacterials Antibacterials, Other methenamine hippurate Hiprex Generic QL nitrofurantoin macrocrystal oral Macrodantin Generic QL nitrofurantoin monohydrate macrocrystals Macrobid Generic QL Antibacterials - Drugs to Treat Bacterial Infections Antibacterials, Other - Antibiotics aplicare povidone-iodine external solution Aplicare Povidone-Iodine Generic BETADINE EXTERNAL SOLUTION 10 % Brand clindamycin hcl oral capsule 150 mg, 300 Cleocin Generic mg clindamycin palmitate hcl Cleocin Generic linezolid oral suspension reconstituted Zyvox Generic PA linezolid oral tablet Zyvox Generic PA metronidazole external Rosadan Generic povidone-iodine external solution Aplicare Povidone-Iodine Generic pvp prep Aplicare Povidone-Iodine Generic

AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication 7 Drug Name Reference Brand-Generic Requirements & Limits rosadan external cream Rosadan Generic rosadan external gel Rosadan Generic SCRUB CARE POVIDONE-IODINE Brand trimethoprim oral Generic Sulfonamides - Antibiotics silver sulfadiazine external SSD Generic ssd SSD Generic sulfamethoxazole-trimethoprim oral Bactrim Generic sulfatrim pediatric Sulfatrim Pediatric Generic Antimyasthenic Agents - Drugs to Treat Myasthenia Gravis Parasympathomimetics - Myasthenia Gravis Drugs pyridostigmine bromide er Mestinon Generic pyridostigmine bromide oral solution Mestinon Generic pyridostigmine bromide oral tablet 60 mg Mestinon Generic Antimycobacterials - Drugs to Treat Infections Antimycobacterials, Other - Miscellaneous Anti-Infectives dapsone oral Generic rifabutin Mycobutin Generic Antituberculars - Tuberculosis Drugs cycloserine oral Generic ethambutol hcl oral tablet 100 mg Generic ethambutol hcl oral tablet 400 mg Myambutol Generic isoniazid oral Generic PASER Brand PRIFTIN Brand pyrazinamide oral Generic rifampin oral Generic SIRTURO Brand QL TRECATOR Brand Antineoplastics - Drugs to Treat Cancer

AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication 8 Drug Name Reference Brand-Generic Requirements & Limits Alkylating Agents - Chemotherapy Agents cyclophosphamide oral Generic GLEOSTINE Brand LEUKERAN Brand MATULANE Brand SP melphalan Alkeran Generic MYLERAN Brand Antiandrogens - Hormone Suppressants flutamide Generic QL Antiestrogens/Modifiers - Chemotherapy Agents EMCYT Brand Antimetabolites - Chemotherapy Agents mercaptopurine oral Generic TABLOID Brand SP Antineoplastics, Other - Chemotherapy Agents leucovorin calcium oral tablet 10 mg Generic leucovorin calcium oral tablet 15 mg, 25 Generic mg, 5 mg Enzyme Inhibitors - Chemotherapy Agents etoposide oral Generic HYCAMTIN ORAL Brand PA; SP Molecular Target Inhibitors - Chemotherapy Agents FARYDAK ORAL CAPSULE 15 MG Brand PA; SP; QL Retinoids - Chemotherapy Agents bexarotene Targretin Generic PA; SP PANRETIN Brand PA TARGRETIN EXTERNAL Brand PA; SP tretinoin oral Generic SP Treatment Adjuncts - Supportive Chemotherapy Drugs

AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication 9 Drug Name Reference Brand-Generic Requirements & Limits MESNEX ORAL Brand SP Antiparasitics - Drugs to Treat Parasitic Infections Anthelmintics - Worm Infection Drugs albendazole oral Albenza Generic PA; QL ivermectin oral Stromectol Generic praziquantel oral Biltricide Generic DX2RX Antiprotozoals - Protozoal Infection Drugs ALINIA ORAL TABLET Brand PA atovaquone oral Mepron Generic PA; QL BENZNIDAZOLE Brand PA IMPAVIDO Brand QL pentamidine isethionate inhalation Nebupent Generic pyrimethamine oral Daraprim Generic PA; SP; QL Antivirals - Drugs to Treat Viral Infections Anti-hepatitis C (HCV) Agents, Other - Hepatitis C Drugs INTRON A Brand PA; SP Antiherpetic Agents - Herpes Drugs trifluridine Generic Bipolar Agents - Drugs to Treat Mood Disorders Mood Stabilizers - Mood Disorder Drugs lithium Generic lithium carbonate er Lithobid Generic lithium carbonate oral Generic Blood Glucose Regulators - Drugs to Regulate Blood Sugar Glycemic Agents - Diabetic Drugs Dex4 Quick Dissolve glucose oral tablet chewable 4 gm Generic Glucose Dex4 Quick Dissolve soft glucose Generic Glucose

AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication 10 Drug Name Reference Brand-Generic Requirements & Limits Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood Disorders Anticoagulants - Blood Thinners heparin sodium (porcine) Generic heparin sodium (porcine) pf Generic Blood Formation Modifiers - Blood Formation Drugs anagrelide hcl Agrylin Generic MOZOBIL Brand PA; SP; QL Hemostasis Agents - Drugs to Stop Bleeding aminocaproic acid oral Amicar Generic tranexamic acid oral Lysteda Generic PA; QL Platelet Modifying Agents - Platelet Modifying Drugs CABLIVI Brand PA; SP cilostazol Generic QL Cardiovascular Agents - Drugs to Treat Heart and Circulation Conditions Alpha-adrenergic Agonists - Blood Pressure Drugs midodrine hcl Generic Antiarrhythmics - Heart Regulation Drugs amiodarone hcl oral tablet 200 mg, 400 Pacerone Generic mg disopyramide phosphate Norpace Generic dofetilide Tikosyn Generic QL flecainide acetate Generic mexiletine hcl oral Generic NORPACE CR Brand pacerone oral tablet 200 mg Pacerone Generic propafenone hcl Generic quinidine gluconate er Generic quinidine sulfate Generic

AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication 11 Drug Name Reference Brand-Generic Requirements & Limits Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs amiloride-hydrochlorothiazide Generic digitek Digitek Generic digox Digitek Generic digoxin oral Digitek Generic pentoxifylline er Generic spironolactone-hctz Aldactazide Generic triamterene-hctz Maxzide-25 Generic VYNDAMAX Brand PA; SP; QL VYNDAQEL Brand PA; SP; QL Diuretics, Carbonic Anhydrase Inhibitors - Cardiac Drugs methazolamide oral Generic Diuretics, Loop - Cardiac Drugs bumetanide oral Bumex Generic furosemide oral solution 10 mg/ml Generic furosemide oral tablet Lasix Generic torsemide Generic Diuretics, Potassium-sparing - Cardiac Drugs amiloride hcl oral Generic spironolactone oral Aldactone Generic Diuretics, Thiazide - Cardiac Drugs chlorthalidone Generic DIURIL Brand hydrochlorothiazide oral Generic indapamide Generic metolazone Generic Vasodilators, Direct-acting Arterial - Chest Pain Drugs hydralazine hcl oral Generic minoxidil oral Generic Vasodilators, Direct-acting Arterial/Venous - Chest Pain Drugs RECTIV Brand DX2RX; QL

AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication 12 Drug Name Reference Brand-Generic Requirements & Limits Central Nervous System Agents - Drugs to Treat Nerve Conditions Central Nervous System, Other - Miscellaneous Central Nervous System Drugs caffeine citrate oral Generic QL; AL NUEDEXTA Brand DX2RX; QL riluzole Rilutek Generic QL Dental and Oral Agents - Drugs to Treat Mouth and Throat Conditions cavarest Cavarest Generic chlorhexidine gluconate mouth/throat Paroex Generic denta 5000 plus Denta 5000 Plus Generic dentagel Cavarest Generic easygel Generic fluoridex daily renewal Generic oralone Oralone Generic paroex Paroex Generic periogard Paroex Generic pilocarpine hcl oral Salagen Generic PREVIDENT 5000 DRY MOUTH Brand PREVIDENT 5000 PLUS Brand PREVIDENT DENTAL Brand sf Cavarest Generic sf 5000 plus Denta 5000 Plus Generic sodium fluoride 5000 plus Denta 5000 Plus Generic sodium fluoride 5000 ppm dental cream Denta 5000 Plus Generic sodium fluoride dental cream Denta 5000 Plus Generic sodium fluoride dental gel Cavarest Generic triamcinolone acetonide mouth/throat Oralone Generic Dermatological Agents - Drugs to Treat Skin Conditions acne Clearskin Generic acne control cleanser Clearskin Generic acne treatment external cream 10 % Clearskin Generic

AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication 13 Drug Name Reference Brand-Generic Requirements & Limits Neutrogena Oil-Free adv acne spot treatment Generic Acne Wash Clean & Clear Acne advanced acne spot treat Generic Scrub advanced healing DermaPhor Generic alum sulfate-ca acetate Domeboro Generic amcinonide external ointment Generic ammonium lactate external AL12 Generic AQUAPHILIC Brand AQUAPHOR Brand astringent solution Domeboro Generic azelaic acid external Finacea Generic beauty 360 pure glycerin Generic betasept surgical scrub Betasept Surgical Scrub Generic boro-packs Domeboro Generic BOUDREAUXS BABY BUTT SMOOTH Brand boudreauxs butt paste external ointment Boudreauxs Butt Paste Generic 40 % bp wash external liquid 2.5 % PanOxyl Generic calamine external lotion Generic cerovel Cerovel Generic chlorhexidine gluconate external liquid 4 Betasept Surgical Scrub Generic % clearskin Clearskin Generic corn & callus remover Compound W Generic Neutrogena Oil-Free daily acne wash Generic Acne Wash dermaphor DermaPhor Generic diaper rash creamy Dr Smiths Diaper Generic diaper rash external ointment Boudreauxs Butt Paste Generic DR SMITHS DIAPER Brand duofilm Duofilm Generic flanders buttocks DermaPhor Generic fluorouracil external cream 5 % Efudex Generic fluorouracil external solution Generic glycerin external Generic

AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication 14 Drug Name Reference Brand-Generic Requirements & Limits glycerin external liquid 99.5 % Generic gormel Generic gormel 10 Nutraplus Generic HIBICLENS Brand hydrolatum DermaPhor Generic hydrophor DermaPhor Generic LAC-HYDRIN FIVE Brand lactic acid external Generic LANAPHILIC Brand Clean & Clear Acne medicated spot Generic Scrub NEUTROGENA OIL-FREE ACNE WASH Brand NUTRAPLUS EXTERNAL CREAM Brand nutraplus lotion 10 % external Nutraplus Generic NUTRAPLUS LOTION 10 % EXTERNAL Brand OINTMENT BASE Brand OVACE PLUS EXTERNAL CREAM Brand PANOXYL Brand podofilox external Generic REGRANEX Brand DX2RX SANTYL Brand scalp relief Psoriasin Generic selenium sulfide external lotion Generic Aveeno Baby Bath soothing bath treatment Generic Treatment sulfacetamide sodium-sulfur external Generic lotion 10-5 % sulfacetamide sodium-sulfur external Generic suspension 10-5 % urea 20 intensive hydrating Generic urea external lotion Cerovel Generic urea-c40 Cerovel Generic ureacin-10 Nutraplus Generic ureacin-20 Generic VANICREAM EXTERNAL OINTMENT Brand wart remover external liquid 17 % Compound W Generic

AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication 15 Drug Name Reference Brand-Generic Requirements & Limits wart remover maximum strength external Compound W Generic liquid zaclir cleansing Generic zinc oxide external ointment 40 % Boudreauxs Butt Paste Generic Electrolytes/Minerals/Metals/Vitami ns Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs Advanced cal mag zinc +d3 Generic Calcium/D/Magnesium calcitrate oral tablet 950 mg Generic calcium 1200 Generic calcium 500/d RA Hi Cal Generic calcium 600 Generic calcium 600/d Generic calcium 600+d oral tablet 600-200 mg-unit Generic calcium 600+d oral tablet 600-400 mg-unit Generic calcium carb-cholecalciferol oral tablet Generic calcium carbonate oral tablet 600 mg Generic calcium carbonate oral tablet chewable Generic 1250 (500 ca) mg calcium carbonate-vitamin d oral tablet RA Hi Cal Generic 500-200 mg-unit calcium carbonate-vitamin d oral tablet Generic 600-200 mg-unit calcium carbonate-vitamin d oral tablet Generic 600-400 mg-unit calcium carbonate-vitamin d3 Generic calcium citrate + d oral tablet 315-250 mg- Calcitrate Generic unit calcium citrate + d3 maximum Calcitrate Generic calcium citrate + oral tablet 315-200 mg- Generic unit calcium citrate +d3 Calcitrate Generic calcium citrate+d maximum Calcitrate Generic calcium citrate+d3 Calcitrate Generic

AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication 16 Drug Name Reference Brand-Generic Requirements & Limits Advanced calcium citrate+d3 w/magne Generic Calcium/D/Magnesium calcium citrate-vitamin d oral tablet 315- Generic 200 mg-unit calcium high potency Generic calcium high potency/vitamin d Generic calcium oral tablet 600 mg Generic calcium oyster shell oral tablet 1250 (500 Generic ca) mg calcium plus 600 +d Generic calcium plus vitamin d oral tablet Oysco 500+D Generic calcium/vitamin d/minerals Generic calcium-magnesium-zinc oral tablet 333- Generic 133-5 mg, 333.33-133.33-5 mg calcium-vitamin d oral tablet 600-200 mg- Generic unit, 600-400 mg-unit calcium-vitamin d3 oral tablet 600-400 Generic mg-unit CARBAGLU Brand PA; SP cytra-2 Generic effer-k oral tablet effervescent 25 meq Generic electrolyte solution Oralyte Freezer Pops Generic ENFAMIL ENFALYTE Brand ezfe 200 Generic fa-8 oral tablet FA-8 Generic ferretts Generic ferrous gluconate oral tablet 324 (37.5 fe) Generic mg fluoritab Generic FLURA-DROPS Brand folic acid oral tablet 1 mg Generic folic acid oral tablet 400 mcg Generic folic acid oral tablet 800 mcg FA-8 Generic klor-con Klor-Con Generic klor-con 10 Klor-Con 10 Generic klor-con m10 Klor-Con M10 Generic klor-con m20 Klor-Con M20 Generic

AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication 17 Drug Name Reference Brand-Generic Requirements & Limits klor-con sprinkle oral capsule extended Klor-Con Sprinkle Generic release 10 meq klor-con/ef Generic kp calcium 600+d oral tablet 600-400 mg- Generic unit kp calcium citrate+d Calcitrate Generic kp calcium-magnesium-zinc Generic kp ferrous gluconate Generic kp folic acid oral tablet 1 mg Generic kp folic acid oral tablet 800 mcg FA-8 Generic K-PHOS Brand K-PHOS-NEUTRAL Brand k-prime Generic magnesium oral tablet 500 mg Generic magnesium oxide oral tablet 400 (241.3 MAGnesium-Oxide Generic mg) mg magnesium oxide oral tablet 500 mg Generic magnesium-oxide MAGnesium-Oxide Generic nafrinse NaFrinse Generic nafrinse drops NaFrinse Drops Generic oralyte freezer pops Oralyte Freezer Pops Generic oscal 500/200 d-3 RA Hi Cal Generic OS-CAL CALCIUM + D3 Brand oysco 500+d oral tablet Oysco 500+D Generic oyster calcium + d Generic oyster shell calcium RA Hi-Cal Generic oyster shell calcium 500 + d Generic oyster shell calcium plus d oral tablet 500- Oysco 500+D Generic 200 mg-unit oyster shell calcium/d oral tablet 250-125 Generic mg-unit oyster shell calcium/d oral tablet 250-250 Generic mg-unit, 500-400 mg-unit oyster shell calcium/d oral tablet 500-200 RA Hi Cal Generic mg-unit oyster shell calcium/vitamin d oral tablet Oysco 500+D Generic oyster shell/vitamin d Generic

AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication 18 Drug Name Reference Brand-Generic Requirements & Limits pa calcium/vitamin d Generic pa oyster shell calcium RA Hi Cal Generic ped electrolyte freeze pop Oralyte Freezer Pops Generic ped electrolyte freezer pops Oralyte Freezer Pops Generic PEDIALYTE FREEZER POPS Brand PEDIALYTE ORAL SOLUTION Brand PEDIALYTE SINGLES Brand pediatric electrolyte oral solution Oralyte Freezer Pops Generic phospha 250 neutral Phospha 250 Neutral Generic phosphorous Phospha 250 Neutral Generic phospho-trin 250 neutral Phospha 250 Neutral Generic potassium chloride crys er Klor-Con M10 Generic potassium chloride er oral capsule Klor-Con Sprinkle Generic extended release 10 meq potassium chloride er oral tablet extended Klor-Con 10 Generic release potassium chloride oral Klor-Con Generic potassium citrate er oral tablet extended Urocit-K 10 Generic release 10 meq (1080 mg) potassium citrate er oral tablet extended Urocit-K 15 Generic release 15 meq (1620 mg) potassium citrate er oral tablet extended Urocit-K 5 Generic release 5 meq (540 mg) PREVIDENT MOUTH/THROAT Brand rehydralyte Oralyte Freezer Pops Generic sod citrate-citric acid Generic sodium fluoride oral solution Generic sodium fluoride oral tablet 1.1 (0.5 f) mg Generic sodium fluoride oral tablet chewable Generic virt-phos 250 neutral Phospha 250 Neutral Generic zinc chelated oral tablet 50 mg IS-ZC 50 Generic AL zinc oral tablet 50 mg IS-ZC 50 Generic AL Electrolyte/Mineral/Metal Modifiers CHEMET Brand kionex Kionex Generic sodium polystyrene sulfonate oral Kionex Generic suspension

AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication 19 Drug Name Reference Brand-Generic Requirements & Limits sodium polystyrene sulfonate rectal Generic sps Kionex Generic Vitamins a-25 Generic AL adc/f (0.5mg/ml) Generic AL alph-e Ester-E Generic AL alph-e-mixed oral capsule 400 unit Ester-E Generic AL animal shapes Animal Shapes Generic AL animal shapes plus extra c Dino-Life w/Extra C Generic AL Land Before Time animal shapes plus iron Generic AL Multivitamin animal shapes/iron Cerovite Jr Generic AL AQUADEKS Brand AL aqueous vitamin d BProtected Pedia D-Vite Generic AL ascorbic acid oral tablet 500 mg PureWay-C Generic AL asco-tabs-1000 Generic AL ATABEX OB Brand GE; AL b complex oral capsule Generic AL b complex vitamins Generic AL b-1 Generic AL b6 Generic AL BACMIN Brand AL biocel Lysiplex Plus Generic AL b-plex plus Lysiplex Plus Generic AL bprotected pedia d-vite BProtected Pedia D-Vite Generic AL BProtected Pedia Poly- bprotected pedia poly-vite Generic AL Vite bprotected pedia poly-vite/fe Generic AL bprotected vitamin c BProtected Vitamin C Generic AL c 250 oral tablet Generic AL c 500/rose hips PureWay-C Generic AL c-1000/rose hips Generic AL calcidol Calcidol Generic AL calciferol Calcidol Generic AL CENTRUM FLAVOR BURST KIDS Brand AL CENTRUM KIDS Brand AL

AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication 20 Drug Name Reference Brand-Generic Requirements & Limits cerovite jr Cerovite Jr Generic AL chewable c with rose hips Sunkist Vitamin C Generic AL chewable childrens vitamin Cerovite Jr Generic AL chew-c Sunkist Vitamin C Generic AL Land Before Time child chewable vitamins/iron Generic AL Multivitamin childrens animal shapes Cerovite Jr Generic AL childrens chewable vitamins Animal Shapes Generic AL childrens chewables/ex c Dino-Life w/Extra C Generic AL Land Before Time childrens chewables/iron Generic AL Multivitamin Centrum Flavor Burst childrens complete Generic AL Kids Land Before Time childrens vitamins/iron Generic AL Multivitamin classic prenatal Generic AL cyanocobalamin injection solution 1000 Generic AL mcg/ml d 1000 oral tablet Vitamin D-1000 Max St Generic AL d 10000 Decara Generic AL d 400 oral tablet Generic AL d 400 oral tablet chewable Healthy Kids Vitamin D3 Generic AL Radiance Platinum d 5000 oral tablet Generic AL Vitamin D3 d3 high potency oral capsule 25 mcg Pronutrients Vitamin D3 Generic AL (1000 ut) d3 oral capsule 10 mcg (400 unit), 50 mcg Generic AL (2000 ut) d3 oral capsule 125 mcg (5000 ut) Dialyvite Vitamin D 5000 Generic AL d3 oral capsule 25 mcg (1000 ut) Pronutrients Vitamin D3 Generic AL d3 super strength Generic AL d-3-5 Dialyvite Vitamin D 5000 Generic AL d3-50 D3-50 Generic AL One-A-Day Womens daily prenatal Generic GE; AL Prenatal daily vitamin formula+iron Generic AL decara oral capsule 1.25 mg (50000 ut) D3-50 Generic AL decara oral capsule 250 mcg (10000 ut) Decara Generic AL

AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication 21 Drug Name Reference Brand-Generic Requirements & Limits DECARA ORAL CAPSULE 625 MCG Brand AL (25000 UT) DIALYVITE 800 ORAL TABLET Brand AL DIALYVITE VITAMIN D 5000 Brand AL dino-life Animal Shapes Generic AL dino-life w/extra c Dino-Life w/Extra C Generic AL D-VI-SOL Brand AL d-vite pediatric BProtected Pedia D-Vite Generic AL e-400-clear Ester-E Generic AL e-400-mixed Ester-E Generic AL ENFAMIL EXPECTA Brand GE; AL ergocalciferol oral Drisdol Generic AL fruity c Generic AL full spectrum b/vitamin c Dialyvite 800 Generic AL Centrum Flavor Burst gummy dinos Generic AL Kids Centrum Flavor Burst gummy multivitamin kids Generic AL Kids HYLAZINC Brand AL little ones childrens Animal Shapes Generic AL lysiplex plus oral tablet Lysiplex Plus Generic AL multiple vitamins/iron Generic AL Land Before Time multiple vitamins-iron oral tablet chewable Generic AL Multivitamin multi-vit/iron/fluoride Generic AL multi-vitamin/fluoride Floriva Plus Generic AL multivitamin/fluoride oral solution Floriva Plus Generic AL multivitamin/fluoride oral tablet chewable Quflora Pediatric Generic AL 0.25 mg, 0.5 mg, 1 mg multi-vitamin/fluoride/iron Generic AL multi-vitamin/iron Generic AL multivitamins/fluoride Quflora Pediatric Generic AL mynephrocaps Mynephron Generic AL mynephron Mynephron Generic AL NASCOBAL Brand AL NEONATAL VITAMIN Brand GE; AL NEOVITE Brand AL

AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication 22 Drug Name Reference Brand-Generic Requirements & Limits nephro vitamins Dialyvite 800 Generic AL NEPHRO-VITE Brand AL NEURO-K-250 T.D. Brand AL neuro-k-250 vitamin b6 Generic AL neuro-k-50 Generic AL neuro-k-500 Generic AL NICADAN Brand AL NICAZEL Brand AL NICAZEL FORTE Brand AL novamv pediatric multi-vitamin Generic AL NUTRICAP Brand AL nutrifac zx Lysiplex Plus Generic AL once daily/iron Generic AL one daily plus iron Generic AL ONE VITE WOMENS Brand GE; AL one-daily multi-vitamin/iron Generic AL one-daily/iron Generic AL pa vitamin d-3 gummy Healthy Kids Vitamin D3 Generic AL pa vitamin d-3 oral capsule 125 mcg Dialyvite Vitamin D 5000 Generic AL (5000 ut) pa vitamin d-3 oral capsule 50 mcg (2000 Generic AL ut) pa vitamin d-3 oral tablet Vitamin D-1000 Max St Generic AL pa vitamin e Ester-E Generic AL pediavit Generic AL phytonadione oral Mephyton Generic AL BProtected Pedia Poly- poly-vite pediatric Generic AL Vite prenatal low iron NeoNatal Vitamin Generic GE; AL prenatal multi+dha Generic GE; AL prenatal oral tablet 27-0.8 mg NeoNatal Vitamin Generic GE; AL prenatal oral tablet 28-0.8 mg Generic GE; AL prenatal vitamins Generic GE; AL prenatal/iron Generic GE; AL PRENATAL-U Brand GE; AL PRENATVITE RX Brand GE; AL

AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication 23 Drug Name Reference Brand-Generic Requirements & Limits pronutrients vitamin d3 Pronutrients Vitamin D3 Generic AL pyridoxine hcl oral Generic AL QUFLORA PEDIATRIC ORAL Brand AL SOLUTION 0.5 MG/ML QUFLORA PEDIATRIC ORAL TABLET Brand AL CHEWABLE Radiance Platinum radiance platinum vitamin d3 Generic AL Vitamin D3 renal Mynephron Generic AL RENAL MULTIVITAMIN FORMULA Brand AL renal-vite Dialyvite 800 Generic AL rena-vite Dialyvite 800 Generic AL REQ 49+ Brand AL RIGHT STEP PRENATAL Brand GE; AL SIDEROL Brand AL stress formula/iron Generic AL STROVITE FORTE ORAL TABLET Brand PA; AL STROVITE ONE Brand PA; AL support Alive Multi-Vitamin Generic AL tab-a-vite/iron Generic AL thiamine hcl oral Generic AL thiamine mononitrate oral Generic AL triphrocaps Mynephron Generic AL tri-vite pediatric BProtected Pedia Tri-Vite Generic AL tri-vite/fluoride Generic AL vinate ii Generic GE; AL virt-caps Mynephron Generic AL vita s forte Lysiplex Plus Generic AL vitacel Lysiplex Plus Generic AL Centrum Flavor Burst vitachew multiple vitamin Generic AL Kids VITAMAX Brand AL vitamin a oral capsule 2400 mcg (8000 Generic AL ut), 3 mg (10000 ut) vitamin b1 Generic AL vitamin b-1 Generic AL

AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication 24 Drug Name Reference Brand-Generic Requirements & Limits vitamin b-12 er oral tablet extended Generic AL release 1000 mcg vitamin b12 oral tablet extended release Generic AL vitamin b-12 tr Generic AL vitamin b-6 Generic AL vitamin b-6 er Generic AL vitamin c cr Endur-C Generic AL vitamin c er oral tablet extended release Generic AL 1500 mg vitamin c oral liquid 500 mg/5ml BProtected Vitamin C Generic AL vitamin c oral tablet 1000 mg, 250 mg Generic AL vitamin c oral tablet 500 mg PureWay-C Generic AL vitamin c oral tablet chewable 100 mg, Generic AL 250 mg vitamin c oral tablet chewable 500 mg Sunkist Vitamin C Generic AL vitamin c w/rose hips oral tablet 500 mg PureWay-C Generic AL vitamin c/rose hips tr Endur-C Generic AL vitamin c-rose hips oral tablet PureWay-C Generic AL vitamin d (cholecalciferol) oral tablet Generic AL vitamin d (ergocalciferol) oral capsule Drisdol Generic AL 1.25 mg (50000 ut) vitamin d oral capsule 400 unit Generic AL vitamin d oral liquid 10 mcg/ml BProtected Pedia D-Vite Generic AL vitamin d oral tablet 25 mcg (1000 ut) Vitamin D-1000 Max St Generic AL vitamin d oral tablet 50 mcg (2000 ut) Thera-D 2000 Generic AL vitamin d3 oral capsule 1.25 mg (50000 D3-50 Generic AL ut) vitamin d3 oral capsule 125 mcg (5000 ut) Dialyvite Vitamin D 5000 Generic AL vitamin d3 oral capsule 25 mcg (1000 ut) Pronutrients Vitamin D3 Generic AL vitamin d3 oral capsule 250 mcg (10000 Decara Generic AL ut) vitamin d3 oral capsule 50 mcg (2000 ut) Generic AL vitamin d3 oral liquid 10 mcg/ml BProtected Pedia D-Vite Generic AL vitamin d3 oral tablet 10 mcg (400 unit) Generic AL Radiance Platinum vitamin d3 oral tablet 125 mcg (5000 ut) Generic AL Vitamin D3 vitamin d3 oral tablet 25 mcg (1000 ut) Vitamin D-1000 Max St Generic AL vitamin d3 oral tablet 50 mcg (2000 ut) Thera-D 2000 Generic AL

AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication 25 Drug Name Reference Brand-Generic Requirements & Limits vitamin d3 oral tablet chewable 10 mcg Healthy Kids Vitamin D3 Generic AL (400 unit) vitamin d3 super strength oral tablet Thera-D 2000 Generic AL vitamin d-400 Generic AL vitamin e oral capsule 400 unit Ester-E Generic AL vitamins acd-fluoride Generic AL VITAROCA PLUS Brand AL VITREXYL Brand PA; AL VITREXYL + IRON Brand PA; AL weekly-d D3-50 Generic AL WEST-VITE W/FOLIC ACID Brand AL womens prenatal+dha Generic GE; AL Centrum Flavor Burst zoo friends Generic AL Kids Centrum Flavor Burst zoo friends complete Generic AL Kids Centrum Flavor Burst zoo friends gummies Generic AL Kids zoo friends plus extra c Dino-Life w/Extra C Generic AL Land Before Time zoo friends plus iron Generic AL Multivitamin Centrum Flavor Burst zoochews gummies Generic AL Kids Gastrointestinal Agents - Drugs to Treat Bowel, Intestine and Stomach Conditions Antispasmodics, Gastrointestinal - Stomach and Intestine Drugs dicyclomine hcl oral capsule Generic dicyclomine hcl oral solution Generic dicyclomine hcl oral tablet Generic glycopyrrolate oral tablet 1 mg, 2 mg Generic propantheline bromide oral Generic Gastrointestinal Agents, Other - Miscellaneous Gastrointestinal Drugs abatinex Abatinex Generic acid gone Acid Gone Generic

AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication 26 Drug Name Reference Brand-Generic Requirements & Limits acidophilus lactobacillus oral Abatinex Generic acidophilus oral capsule Abatinex Generic acidophilus probiotic Floranex Generic acidophilus probiotic oral capsule 10 mg Abatinex Generic acidophilus/l-sporogenes Floranex Generic Digestive Adv Lactose adult 50+ probiotic Generic Defense Digestive Adv Lactose adult probiotic Generic Defense Almacone Double almacone double strength Generic Strength alum & mag hydroxide-simeth Mi-Acid Generic alumina-magnesia-simethicone Mi-Acid Generic antacid & anti-gas oral suspension 200- Mi-Acid Generic 200-20 mg/5ml antacid & anti-gas oral suspension 400- Almacone Double Generic 400-40 mg/5ml Strength Almacone Double antacid advanced Generic Strength antacid anti-gas Mi-Acid Generic Almacone Double antacid anti-gas max strength Generic Strength antacid anti-gas reg strength Mi-Acid Generic antacid calcium Cal-Gest Antacid Generic CVS Chewy Not Chalky antacid calcium extra strength Generic Flavor antacid calcium rich Cal-Gest Antacid Generic CVS Chewy Not Chalky antacid extra Generic Flavor Almacone Double antacid extra strength oral suspension Generic Strength antacid extra strength oral tablet Acid Gone Generic chewable 160-105 mg antacid extra strength oral tablet CVS Chewy Not Chalky Generic chewable 750 mg Flavor antacid fast relief Mi-Acid Generic antacid i Mi-Acid Generic Almacone Double antacid iii Generic Strength

AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication 27 Drug Name Reference Brand-Generic Requirements & Limits CVS Chewy Not Chalky antacid kids Generic Flavor antacid liquid Mi-Acid Generic antacid m Mi-Acid Generic antacid maximum Tums Ultra 1000 Generic Almacone Double antacid maximum strength Generic Strength antacid maximum strength oral tablet Tums Ultra 1000 Generic chewable 1000 mg antacid oral suspension Mi-Acid Generic antacid oral tablet chewable 1000 mg Tums Ultra 1000 Generic antacid oral tablet chewable 500 mg Cal-Gest Antacid Generic CVS Chewy Not Chalky antacid oral tablet chewable 750 mg Generic Flavor Almacone Double antacid plus antigas Generic Strength antacid plus anti-gas fast act Mi-Acid Generic Almacone Double antacid plus anti-gas relief Generic Strength antacid regular strength oral suspension Mi-Acid Generic antacid regular strength oral tablet Cal-Gest Antacid Generic chewable antacid supreme Generic antacid ultra strength oral tablet chewable Tums Ultra 1000 Generic 1000 mg Almacone Double antacid/anti-gas Generic Strength Almacone Double antacid/simethicone ds Generic Strength Imodium Multi-Symptom anti-diarr/ant-gas Generic Relief anti-diarrheal oral liquid 1 mg/5ml Generic anti-diarrheal oral suspension 262 Soothe Generic mg/15ml anti-diarrheal oral tablet 2 mg Imodium A-D Generic anti-gas Gas-X Ultra Strength Generic biotinex Abatinex Generic Soothe Maximum bismatrol maximum strength Generic Strength

AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication 28 Drug Name Reference Brand-Generic Requirements & Limits bismatrol oral suspension Soothe Generic bismatrol oral tablet chewable Soothe Generic bismuth Soothe Generic bismuth subsalicylate oral suspension Soothe Generic bismuth subsalicylate oral tablet chewable Soothe Generic calcium antacid Cal-Gest Antacid Generic CVS Chewy Not Chalky calcium antacid extra strength Generic Flavor calcium antacid ultra max st Tums Ultra 1000 Generic calcium antacid ultra strength Tums Ultra 1000 Generic calcium carbonate antacid oral Generic suspension calcium carbonate antacid oral tablet Generic calcium carbonate antacid oral tablet Cal-Gest Antacid Generic chewable calcium carbonate oral tablet chewable Cal-Gest Antacid Generic 500 mg cal-gest antacid Cal-Gest Antacid Generic CVS Chewy Not Chalky chewy not chalky flavor Generic Flavor childrens soothe Childrens Soothe Generic comfort gel Mi-Acid Generic comfort gel antacid anti-gas oral Almacone Double Generic suspension 400-400-40 mg/5ml Strength diamode Imodium A-D Generic diarrhea Soothe Generic DIGESTIVE ADV LACTOSE DEFENSE Brand Digestive Adv Lactose digestive probiotic oral capsule Generic Defense digestive probiotic oral capsule 250 mg Florastor Generic diotame instydose Soothe Generic diphenoxylate-atropine Generic Almacone Double fast acting antacid/anti-gas Generic Strength FLORA VANCE Brand floranex oral tablet Floranex Generic foaming antacid Acid Gone Generic

AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication 29 Drug Name Reference Brand-Generic Requirements & Limits freeze dried acidophilus Abatinex Generic gas relief drops infants Little Tummys Gas Relief Generic gas relief extra strength Gas-X Extra Strength Generic gas relief infants Little Tummys Gas Relief Generic gas relief max st Gas-X Extra Strength Generic gas relief oral capsule 125 mg Gas-X Extra Strength Generic gas relief oral capsule 180 mg Gas-X Ultra Strength Generic gas relief oral suspension Little Tummys Gas Relief Generic gas relief oral tablet chewable Generic gas relief ultra strength Gas-X Ultra Strength Generic GAS-X EXTRA STRENGTH ORAL Brand CAPSULE GAS-X EXTRA STRENGTH ORAL Brand TABLET CHEWABLE GAS-X ULTRA STRENGTH Brand GATTEX Brand PA; SP gavis-care Acid Gone Generic GAVISCON EXTRA RELIEF FORMULA Brand GAVISCON EXTRA STRENGTH Brand GAVISCON ORAL SUSPENSION Brand GELUSIL Brand geri-lanta Mi-Acid Generic geri-lanta supreme Generic geri-mox Mi-Acid Generic geri-pectate Soothe Generic heartburn antacid ex st Acid Gone Generic Gaviscon Extra Relief heartburn relief ex st Generic Formula heartburn relief oral tablet chewable 160- Acid Gone Generic 105 mg Digestive Adv Lactose high potency probiotic Generic Defense IMODIUM A-D ORAL TABLET Brand IMODIUM MULTI-SYMPTOM RELIEF Brand infant gas relief Little Tummys Gas Relief Generic infants gas relief Little Tummys Gas Relief Generic

AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication 30 Drug Name Reference Brand-Generic Requirements & Limits infants simethicone Little Tummys Gas Relief Generic intestinex Abatinex Generic k-pec Soothe Generic lactobacillus oral tablet Floranex Generic LACTOJEN Brand lacto-key-100 Abatinex Generic lacto-key-600 Abatinex Generic Digestive Adv Lactose lacto-pectin Generic Defense little tummys gas relief Little Tummys Gas Relief Generic long lasting antacid Cal-Gest Antacid Generic loperamide hcl oral capsule Imodium A-D Generic QL loperamide hcl oral tablet Imodium A-D Generic MAALOX Brand MAALOX CHILDRENS Brand MAALOX MAX ORAL SUSPENSION Brand MAALOX MULTI SYMPTOM MAX ST Brand mag-al plus Mi-Acid Generic Almacone Double mag-al plus xs Generic Strength magnesium oxide oral tablet 400 mg Generic magnesium oxide oral tablet 420 mg Maox Generic AL MAOX Brand AL medi-bismuth Soothe Generic Digestive Adv Lactose mega probiotic Generic Defense Almacone Double meijer antacid Generic Strength meijer anti-diarrheal Imodium A-D Generic mi-acid Mi-Acid Generic mi-acid gas relief Generic Almacone Double mi-acid maximum strength Generic Strength milantex Mi-Acid Generic Almacone Double milantex extra strength Generic Strength

AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication 31 Drug Name Reference Brand-Generic Requirements & Limits Almacone Double mintox maximum strength Generic Strength mintox plus Generic Digestive Adv Lactose mood support probiotic Generic Defense MYTESI Brand DX2RX; QL peptic relief Soothe Generic PEPTO-BISMOL ORAL SUSPENSION Brand 524 MG/30ML PHAZYME Brand PHAZYME ULTRA STRENGTH Brand Soothe Maximum pink bismuth maximum strength Generic Strength pink bismuth oral suspension 262 Soothe Generic mg/15ml pink bismuth oral tablet 262 mg Soothe Generic pink bismuth oral tablet chewable 262 mg Soothe Generic Digestive Adv Lactose pro-biotic blend Generic Defense Digestive Adv Lactose probiotic maximum strength Generic Defense Digestive Adv Lactose probiotic oral capsule Generic Defense probiotic oral capsule 250 mg Florastor Generic Digestive Adv Lactose probiotic pearls ex st Generic Defense RESTORA Brand RESTORA RX Brand RISAQUAD Brand RISAQUAD-2 Brand saccharomyces boulardii Florastor Generic Digestive Adv Lactose senior probiotic Generic Defense simeped Little Tummys Gas Relief Generic simethicone oral Gas-X Extra Strength Generic CVS Chewy Not Chalky smooth antacid extra st Generic Flavor sodium bicarbonate oral tablet Generic

AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication 32 Drug Name Reference Brand-Generic Requirements & Limits Soothe Maximum soothe maximum strength Generic Strength soothe oral suspension Soothe Generic soothe oral tablet Soothe Generic soothe oral tablet chewable Soothe Generic Soothe Maximum stomach relief extra strength Generic Strength Soothe Maximum stomach relief max st Generic Strength stomach relief oral suspension 1050 Soothe Maximum Generic mg/30ml, 525 mg/15ml Strength stomach relief oral suspension 262 Soothe Generic mg/15ml, 525 mg/30ml, 527 mg/30ml stomach relief oral tablet 262 mg Soothe Generic stomach relief oral tablet chewable 262 Soothe Generic mg Soothe Maximum stomach relief plus Generic Strength Soothe Maximum stomach relief ultra Generic Strength TUMS Brand TUMS CHEWY BITES Brand TUMS E-X 750 Brand TUMS EXTRA STRENGTH 750 Brand TUMS LASTING EFFECTS Brand TUMS SMOOTHIES Brand TUMS ULTRA 1000 Brand VISBIOME HIGH POTENCY ORAL Brand CAPSULE ZELAC Brand Laxatives - Drugs to treat Constipation bisacodyl ec GNP Bisa-Lax Generic bisacodyl laxative The Magic Bullet Generic bisacodyl rectal The Magic Bullet Generic bisa-lax GNP Bisa-Lax Generic calcium polycarbophil FiberCon Generic citrate of magnesia Citroma Generic

AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication 33 Drug Name Reference Brand-Generic Requirements & Limits citroma Citroma Generic CITRUCEL Brand c-lax laxative GNP Bisa-Lax Generic clearlax oral powder 17 gm/scoop ClearLax Generic COLACE Brand constulose Generic correct GNP Bisa-Lax Generic daily fiber Medi-Mucil Generic diocto Generic docu Generic docusate calcium Surfak Generic docusate mini DocuSol Mini Generic docusate sodium oral capsule Docusil Generic docusate sodium oral liquid 50 mg/5ml Generic docusate sodium oral syrup Generic docusate sodium-casanthranol oral Generic capsule 100-30 mg docusil Docusil Generic DOCUSOL MINI Brand docuzen Senexon-S Generic dok oral capsule Docusil Generic dss Docusil Generic ducodyl GNP Bisa-Lax Generic easy-lax plus Senexon-S Generic enema Pure & Gentle Enema Generic enema disposable Pure & Gentle Enema Generic enema mineral oil Fleet Oil Generic enema ready-to-use Pure & Gentle Enema Generic ENEMEEZ MINI Brand enulose Generic EVAC Brand EX-LAX ULTRA Brand fiber laxative FiberCon Generic fiber oral powder Wal-Mucil Generic fiber oral tablet FiberCon Generic

AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication 34 Drug Name Reference Brand-Generic Requirements & Limits fiber therapy Citrucel Generic fiber-caps FiberCon Generic FIBERCON Brand fiber-lax FiberCon Generic FLEET BISACODYL Brand FLEET ENEMA Brand FLEET OIL Brand FLEET PEDIATRIC Brand gavilax oral powder ClearLax Generic gavilyte-c Generic GaviLyte-N with Flavor gavilyte-n with flavor pack Generic Pack generlac Generic gentle laxative GNP Bisa-Lax Generic gentle laxative womens GNP Bisa-Lax Generic gentlelax ClearLax Generic geri-kot Senno Generic geri-mucil Generic glycerin (adult) rectal suppository 2 gm Generic glycerin (infant) Generic glycerin (infants & children) rectal Pedia-Lax Generic suppository 1 gm glycerin (pediatric) rectal suppository 1 Pedia-Lax Generic gm glycerin adult rectal suppository 2 gm Generic glycerin child Generic glycerin childrens Pedia-Lax Generic glycolax ClearLax Generic kao-tin oral capsule 240 mg Surfak Generic KONSYL DAILY FIBER ORAL POWDER Brand 100 % konsyl daily fiber oral powder 28.3 % Wal-Mucil Generic ks stool softener Docusil Generic lactulose encephalopathy Generic lactulose oral solution Generic laxa basic Docusil Generic

AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication 35 Drug Name Reference Brand-Generic Requirements & Limits laxacin Senexon-S Generic laxative GNP Bisa-Lax Generic laxative max str Generic laxative pills Generic laxative regular strength Senna Smooth Generic magnesium citrate oral solution Citroma Generic medi-mucil Medi-Mucil Generic medi-natural Senno Generic milk of magnesia Phillips Milk of Magnesia Generic mineral oil enema Fleet Oil Generic mineral oil heavy oral Generic mineral oil oral Generic MIRALAX ORAL POWDER Brand mm stool softener laxative Docusil Generic natural daily fiber Wal-Mucil Generic natural fiber laxative oral powder 28.3 % Wal-Mucil Generic natural fiber laxative oral powder 30.9 % Generic natural fiber laxative oral powder 58.6 % Wal-Mucil Generic natural fiber oral capsule 0.52 gm Medi-Mucil Generic natural fiber oral powder 28.3 % Wal-Mucil Generic natural fiber oral powder 48.57 %, 58.6 % Wal-Mucil Generic natural fiber supplement oral powder Wal-Mucil Generic natural senna laxative Senno Generic natural vegetable fiber Wal-Mucil Generic PEDIA-LAX ORAL LIQUID Brand PEDIA-LAX RECTAL SUPPOSITORY 1 Brand GM peg 3350 oral powder ClearLax Generic GaviLyte-N with Flavor peg 3350-kcl-na bicarb-nacl Generic Pack PERDIEM OVERNIGHT RELIEF Brand PHILLIPS MILK OF MAGNESIA ORAL Brand SUSPENSION 400 MG/5ML polyethylene glycol 3350 oral powder ClearLax Generic polyethylene glycol 3350-grx oral powder ClearLax Generic psyldex Generic

AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication 36 Drug Name Reference Brand-Generic Requirements & Limits pure & gentle enema Pure & Gentle Enema Generic purelax oral powder ClearLax Generic sb docusate sodium/senna Senexon-S Generic senexon-s Senexon-S Generic senna lax Senno Generic senna laxative Senno Generic senna oral liquid Generic senna oral syrup Generic senna oral tablet Senno Generic senna plus oral tablet Senexon-S Generic senna s Senexon-S Generic senna smooth Senna Smooth Generic senna-docusate sodium Senexon-S Generic senna-lax Senno Generic senna-plus Senexon-S Generic senna-s Senexon-S Generic senna-tabs Senno Generic senna-time Senno Generic senna-time s Senexon-S Generic sennazon Generic senno Senno Generic sennosides-docusate sodium Senexon-S Generic SENOKOT Brand SENOKOT S Brand silace oral liquid Generic silace oral syrup Generic smooth lax oral powder ClearLax Generic soluble fiber therapy Generic sorbitol oral Generic stimulant laxative Senexon-S Generic stool softener laxative oral capsule Docusil Generic stool softener laxative oral tablet Senexon-S Generic stool softener oral capsule 100 mg Docusil Generic stool softener oral capsule 240 mg Surfak Generic

AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication 37 Drug Name Reference Brand-Generic Requirements & Limits stool softener oral capsule 250 mg Generic stool softener oral capsule 50 mg Colace Clear Generic stool softener oral liquid 50 mg/5ml Generic stool softener oral syrup 60 mg/15ml Generic stool softener plus laxative Senexon-S Generic stool softener/laxative Senexon-S Generic the magic bullet The Magic Bullet Generic GaviLyte-N with Flavor trilyte Generic Pack vegetable lax+stool softener Senexon-S Generic veracolate GNP Bisa-Lax Generic womans laxative GNP Bisa-Lax Generic womens gentle laxative GNP Bisa-Lax Generic womens laxative GNP Bisa-Lax Generic Protectants - Ulcer and Stomach Acid Drugs CARAFATE ORAL SUSPENSION Brand misoprostol oral Cytotec Generic sucralfate oral tablet Carafate Generic Genetic or Enzyme Disorder: Replacement, Modifiers, Treatment CYSTAGON Brand SP NITYR Brand DX2RX; SP sapropterin dihydrochloride Kuvan Generic DX2RX; SP STRENSIQ Brand PA; SP TEGSEDI Brand PA; SP Genitourinary Agents - Drugs to Treat Bladder, Genital and Kidney Conditions Genitourinary Agents, Other - Miscellaneous Bladder, Genital, and Kidney Conditions Drugs azo tabs Phenazo Generic bethanechol chloride oral Generic ELMIRON Brand DX2RX; QL penicillamine oral tablet Depen Titratabs Generic DX2RX; SP

AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication 38 Drug Name Reference Brand-Generic Requirements & Limits phenazo oral tablet 200 mg Phenazo Generic phenazo oral tablet 95 mg Phenazo Generic phenazopyridine hcl oral tablet 100 mg Pyridium Generic phenazopyridine hcl oral tablet 200 mg Phenazo Generic PYRIDIUM Brand SHUR-SEAL CONTRACEPTIVE Brand urinary pain relief oral tablet 95 mg Phenazo Generic VCF VAGINAL CONTRACEPTIVE Brand VAGINAL FOAM Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Drugs to Regulate Hormones Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Hormone Replacement/Modifying Drugs chorionic gonadotropin intramuscular Novarel Generic DX2RX DDAVP RHINAL TUBE Brand desmopressin ace spray refrig Generic QL desmopressin acetate oral DDAVP Generic desmopressin acetate spray DDAVP Generic QL INCRELEX Brand PA; SP NOCDURNA Brand PA; QL NORDITROPIN FLEXPRO Brand PA; SP novarel intramuscular solution Novarel Generic DX2RX reconstituted 10000 unit NOVAREL INTRAMUSCULAR SOLUTION RECONSTITUTED 5000 Brand DX2RX UNIT OMNITROPE SUBCUTANEOUS Brand PA; SP SOLUTION CARTRIDGE OVIDREL Brand DX2RX pregnyl Novarel Generic DX2RX Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins) - Drugs to Regulate Hormones

AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication 39 Drug Name Reference Brand-Generic Requirements & Limits Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins) - Hormone Replacement/Modifying Drugs KORLYM Brand PA; SP; QL Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) - Drugs to Regulate Hormones Androgens - Hormone Replacement/Modifying Drugs danazol oral Generic Progestins - Hormone Replacement/Modifying Drugs aftera Aftera Generic econtra ez Aftera Generic econtra one-step Aftera Generic levonorgestrel Aftera Generic megestrol acetate oral suspension 40 Generic mg/ml megestrol acetate oral tablet Generic my choice Aftera Generic my way Aftera Generic new day Aftera Generic opcicon one-step Aftera Generic option 2 Aftera Generic PLAN B ONE-STEP Brand react Aftera Generic take action Aftera Generic Hormonal Agents, Suppressant (Adrenal) - Drugs to Regulate Hormones Hormonal Agents, Suppressant (Adrenal) - Hormone Suppressants LYSODREN Brand Hormonal Agents, Suppressant (Pituitary) - Drugs to Regulate Hormones

AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication 40 Drug Name Reference Brand-Generic Requirements & Limits Hormonal Agents, Suppressant (Pituitary) - Hormone Suppressants cabergoline Generic QL EGRIFTA SV Brand DX2RX; SP octreotide acetate SandoSTATIN Generic SP SIGNIFOR Brand PA; SP; QL SOMAVERT Brand PA; SP; QL Hormonal Agents, Suppressant (Thyroid) - Drugs to Suppress Thyroid Hormones Antithyroid Agents - Thyroid Suppressing Drugs methimazole oral Tapazole Generic propylthiouracil oral Generic Immunological Agents - Drugs that Stimulate or Suppress the Immune System Immunomodulators - Immune System Drugs ACTIMMUNE Brand PA; SP leflunomide oral Arava Generic RIDAURA Brand SYNAGIS Brand PA; SP Vaccines ADACEL Brand QL AFLURIA QUADRIVALENT Brand QL BEXSERO Brand QL BOOSTRIX Brand QL DAPTACEL Brand QL DIPHTHERIA-TETANUS TOXOIDS DT Brand QL ENGERIX-B Brand QL FLUAD Brand QL FLUAD QUADRIVALENT Brand QL FLUARIX QUADRIVALENT Brand QL FLUCELVAX QUADRIVALENT Brand QL FLULAVAL QUADRIVALENT Brand QL

AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication 41 Drug Name Reference Brand-Generic Requirements & Limits FLUMIST QUADRIVALENT Brand QL FLUZONE QUADRIVALENT Brand QL GARDASIL 9 Brand QL HAVRIX Brand QL HEPLISAV-B Brand QL HYPERTET S/D Brand QL INFANRIX Brand QL MENACTRA Brand QL MENQUADFI Brand QL MENVEO Brand QL M-M-R II Brand QL PNEUMOVAX 23 Brand QL PREVNAR 13 Brand QL RECOMBIVAX HB Brand QL SHINGRIX Brand QL; AL TDVAX Brand QL TENIVAC Brand QL TETANUS-DIPHTHERIA TOXOIDS TD Brand QL TRUMENBA Brand QL TWINRIX Brand QL VAQTA Brand QL VARIVAX Brand QL Inflammatory Bowel Disease Agents - Drugs to Treat Inflammatory Bowel Disease Glucocorticoids - Drugs to Treat Inflammation hydrocortisone (perianal) Procto-Pak Generic hydrocortisone rectal Cortenema Generic procto-med hc Procto-Med HC Generic procto-pak Procto-Pak Generic proctozone-hc Procto-Med HC Generic Metabolic Bone Disease Agents - Drugs to Treat Bone Conditions Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs

AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication 42 Drug Name Reference Brand-Generic Requirements & Limits cinacalcet hcl Sensipar Generic PA; QL Miscellaneous Therapeutic Agents ACCU-CHEK AVIVA IN VITRO Brand ACCU-CHEK COMPACT PLUS Brand CONTROL ACCU-CHEK GUIDE CONTROL Brand ACCU-CHEK SMARTVIEW CONTROL Brand ACCUTREND GLUCOSE CONTROL Brand AIRZONE PEAK FLOW METER Brand ALCOHOL PREP PADS PAD Brand ALCOHOL PREP PADS PAD 70 % Brand ASSESS FULL RANGE PEAK METER Brand ASSESS LOW RANGE PEAK METER Brand BD AUTOSHIELD DUO PEN NEEDLES Brand BD ULTRA-FINE INSULIN SYRINGES Brand BD ULTRA-FINE PEN NEEDLES Brand BREATHE EASE HUMIDIFIER Brand CARETOUCH CONTROL SOL LEVEL 2 Brand CAYA Brand CHEMSTRIP 10 MD Brand CHEMSTRIP 10/SG Brand CHEMSTRIP 2 GP Brand CHEMSTRIP 5 OB Brand CHEMSTRIP 7 Brand CHEMSTRIP 9 Brand CHEMSTRIP K Brand CHEMSTRIP UGK Brand CONDOMS Brand COOL MIST HUMIDIFER Brand EASIVENT Brand EASIVENT MASK LARGE Brand EASIVENT MASK MEDIUM Brand EASIVENT MASK SMALL Brand EASYMAX 15 LEVEL 2 CONTROL Brand EASYMAX 15 LEVEL 2-3 CONTROL Brand

AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication 43 Drug Name Reference Brand-Generic Requirements & Limits EASYMAX CONTROL NORMAL/HIGH Brand GLUCOSE CONTROL SOLUTION IN Brand VITRO SOLUTION INSPIREASE Brand INSPIREASE RESERVOIR BAGS Brand KETO-DIASTIX Brand KETONE CARE Brand KETONE TEST Brand KETOSTIX Brand LANCETS Brand MASK VORTEX Brand MEDISENSE GLUCOSE KETONE Brand CONTR MEDISENSE HI/MID/LOW CONTROL Brand MEDISENSE HIGH/LOW CONTROL Brand MEDISENSE MID CONTROL Brand methergine Methergine Generic methylergonovine maleate oral Methergine Generic MINI WRIGHT PEAK FLOW METER Brand NEODOT THERMOMETER Brand NEUTEK 2TEK CONTROL Brand OMNIFLEX DIAPHRAGM Brand ONETOUCH ULTRA CONTROL Brand ONETOUCH VERIO IN VITRO Brand SOLUTION OPTICHAMBER ADVANTAGE-LG MASK Brand OPTICHAMBER ADVANTAGE-MED Brand MASK OPTICHAMBER ADVANTAGE-SM MASK Brand OPTICHAMBER FACE MASK-LARGE Brand OPTICHAMBER FACE MASK-MEDIUM Brand OPTICHAMBER FACE MASK-SMALL Brand OPTIHALER DEVICE Brand PRECISION GLUCOSE CONTROL Brand PRECISION GLUCOSE CONTROL Brand SOLN

AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication 44 Drug Name Reference Brand-Generic Requirements & Limits PRECISION GLUCOSE KETONE Brand CONTR PRECISION GLUCOSE/KETONE Brand CONTR PREMIUM CONDOMS LUBRICATED Brand QUINTET CONTROL HIGH/NORMAL Brand RELION KETONE Brand SOLARTEK GLUCOSE CONTROL Brand SSKI Brand SUPREME II HIGH/LOW CONTROL Brand TRUECONTROL GLUCOSE CONT LEV Brand 0 TRUECONTROL GLUCOSE CONT LEV Brand 1 VAPORIZER WARM STEAM Brand VISTOGARD Brand VORTEX HOLDING CHAMBER/MASK Brand VORTEX VALVED HOLDING CHAMBER Brand WIDE-SEAL DIAPHRAGM 60 Brand WIDE-SEAL DIAPHRAGM 65 Brand WIDE-SEAL DIAPHRAGM 70 Brand WIDE-SEAL DIAPHRAGM 75 Brand WIDE-SEAL DIAPHRAGM 80 Brand WIDE-SEAL DIAPHRAGM 85 Brand WIDE-SEAL DIAPHRAGM 90 Brand WIDE-SEAL DIAPHRAGM 95 Brand Ophthalmic Agents - Drugs to Treat Eye Conditions Ophthalmic Agents, Other - Miscellaneous Eye Drugs altachlore ophthalmic ointment Altachlore Generic altachlore ophthalmic solution Altachlore Generic altafrin Altafrin Generic altalube Altalube Generic artificial tears ophthalmic solution 1.4 % Generic astringent eye drops Visine-AC Generic

AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication 45 Drug Name Reference Brand-Generic Requirements & Limits atropine sulfate ophthalmic ointment Generic atropine sulfate ophthalmic solution 1 % Isopto Atropine Generic biolle tears Biolle Tears Generic bion tears pf Bion Tears PF Generic cyclopentolate hcl ophthalmic solution 1 Cyclogyl Generic % CYSTARAN Brand DX2RX; SP dry-eye relief nighttime Altalube Generic eye drops advanced relief Visine Advanced Relief Generic eye drops allergy relief Visine-AC Generic eye drops ar Visine-AC Generic eye drops long lasting Systane Generic eye drops ophthalmic solution 0.05-0.1-1- Visine Advanced Relief Generic 1 % eye drops ophthalmic solution 0.4-0.3 % Systane Generic eye drops ophthalmic solution 0.5 % Ultra Fresh Generic eye lubricant Altalube Generic for sty relief Altalube Generic GENTEAL SEVERE Brand GENTEAL TEARS Brand GENTEAL TEARS MODERATE PF Brand GENTEAL TEARS NIGHT-TIME Brand GENTEAL TEARS PF Brand HYPOTEARS Brand ISOPTO ATROPINE Brand lubricant drops fast act Systane Generic lubricant drops long last Systane Generic lubricant drops ophthalmic gel 0.25-0.3 % Generic lubricant drops ophthalmic solution Systane Complete Generic lubricant eye drops (pf) ophthalmic Systane Hydration PF Generic solution 0.4-0.3 % lubricant eye drops (pf) ophthalmic Biolle Tears Generic solution 0.5 % lubricant eye drops ophthalmic solution Systane Generic 0.4-0.3 % lubricant eye drops ophthalmic solution Ultra Fresh Generic 0.5 %

AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication 46 Drug Name Reference Brand-Generic Requirements & Limits lubricant eye drops ophthalmic solution Systane Complete Generic 0.6 % lubricant eye drops pf Biolle Tears Generic lubricant eye nighttime Altalube Generic lubricant eye pm Altalube Generic lubricant pm Altalube Generic lubricating eye drop Biolle Tears Generic lubricating eye drops ophthalmic solution Systane Generic 0.4-0.3 % lubricating eye/overnight Altalube Generic lubricating plus eye drops Biolle Tears Generic lubrifresh p.m. Altalube Generic MURO 128 OPHTHALMIC OINTMENT Brand MURO 128 OPHTHALMIC SOLUTION 5 Brand % natural tears pf Bion Tears PF Generic nighttime dry-eye relief Altalube Generic phenylephrine hcl ophthalmic Altafrin Generic polyvinyl alcohol ophthalmic Generic puralube Altalube Generic pure & gentle lubricant Generic REFRESH LACRI-LUBE Brand REFRESH P.M. Brand REFRESH PLUS Brand REFRESH TEARS Brand relief eye drops Visine-AC Generic sodium chloride (hypertonic) ophthalmic Altachlore Generic ointment sodium chloride (hypertonic) ophthalmic Altachlore Generic solution sodium chloride ophthalmic ointment 5 % Altachlore Generic sodium chloride ophthalmic solution 5 % Altachlore Generic SYSTANE Brand SYSTANE COMPLETE Brand SYSTANE CONTACTS Brand SYSTANE HYDRATION PF Brand

AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication 47 Drug Name Reference Brand-Generic Requirements & Limits SYSTANE NIGHTTIME Brand SYSTANE OVERNIGHT THERAPY Brand SYSTANE PRESERVATIVE FREE Brand SYSTANE ULTRA Brand SYSTANE ULTRA PF Brand tears again Altalube Generic TEARS AGAIN ADVANCED EYELID Brand OPHTHALMIC tears pure GenTeal Tears Generic ultra fresh Ultra Fresh Generic ultra fresh pm Altalube Generic ultra lubricant drop Systane Generic ultra lubricating eye drops Systane Generic VISINE ADVANCED RELIEF Brand Ophthalmic Anti-allergy Agents - Allergy, Infection and Inflammation Drugs CLEAR EYES REDNESS RELIEF Brand eye drops ophthalmic solution 0.05 % Visine Red Eye Comfort Generic VASOCLEAR-A Brand Ophthalmic Antiglaucoma Agents - Glaucoma Drugs acetazolamide er Generic acetazolamide oral Generic BETIMOL Brand Otic Agents - Drugs to Treat Ear Conditions Otic Agents - Drugs for the Ear acetic acid otic Generic Clearcanal Earwax auraphene-b Generic Softener Clearcanal Earwax clearcanal earwax softener Generic Softener Clearcanal Earwax ear drops Generic Softener Clearcanal Earwax ear drops earwax aid Generic Softener

AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication 48 Drug Name Reference Brand-Generic Requirements & Limits Clearcanal Earwax ear systems Generic Softener Clearcanal Earwax ear wax kit Generic Softener Clearcanal Earwax ear wax removal Generic Softener Clearcanal Earwax ear wax removal drops Generic Softener Clearcanal Earwax ear wax removal kit Generic Softener Clearcanal Earwax ear wax removal system Generic Softener Clearcanal Earwax earwax removal Generic Softener Clearcanal Earwax earwax removal drops Generic Softener Clearcanal Earwax earwax removal kit Generic Softener hydrocortisone-acetic acid Acetasol HC Generic Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold and Lung Conditions Antihistamines - Allergy Drugs allergy oral tablet extended release Chlor-Trimeton Allergy Generic allergy relief oral tablet extended release Chlor-Trimeton Allergy Generic 12 mg chlorpheniramine maleate er Chlor-Trimeton Allergy Generic CHLOR-TRIMETON ALLERGY Brand CHLOR-TRIMETON ORAL SYRUP Brand ed chlorped jr Chlor-Trimeton Generic Antihistamines - Drugs to Treat Allergies aler-dryl Generic aller-chlor Wal-finate Generic allergy antihistamine Naramin Generic allergy childrens oral liquid Naramin Generic allergy oral capsule Banophen Generic allergy oral tablet Wal-finate Generic allergy relief adult Naramin Generic

AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication 49 Drug Name Reference Brand-Generic Requirements & Limits allergy relief childrens oral liquid 12.5 Naramin Generic mg/5ml allergy relief oral capsule 25 mg Banophen Generic allergy relief oral liquid 25 mg/10ml Naramin Generic allergy relief oral tablet 25 mg Banophen Generic allergy relief oral tablet 4 mg Wal-finate Generic Benadryl Allergy allergy relief oral tablet chewable 12.5 mg Generic Childrens allergy-time Wal-finate Generic anti-hist allergy Banophen Generic aurodryl allergy childrens Naramin Generic banophen oral capsule 25 mg Banophen Generic banophen oral tablet Banophen Generic BENADRYL ALLERGY CHILDRENS Brand ORAL LIQUID BENADRYL ALLERGY CHILDRENS Brand ORAL TABLET CHEWABLE BENADRYL ALLERGY ORAL TABLET Brand childrens allergy Naramin Generic chlorpheniramine maleate oral Wal-finate Generic CHLOR-TRIMETON ORAL TABLET Brand clemastine fumarate oral tablet 2.68 mg Generic complete allergy medicine oral capsule Banophen Generic complete allergy relief Banophen Generic cyproheptadine hcl oral Generic Dayhist Allergy 12 Hour dayhist allergy 12 hour relief Generic Relief diphen Generic DI-PHEN Brand diphenhist Banophen Generic diphenhydramine hcl oral capsule Banophen Generic diphenhydramine hcl oral elixir Generic diphenhydramine hcl oral liquid 12.5 Naramin Generic mg/5ml diphenhydramine hcl oral tablet Banophen Generic dye-free allergy relief Naramin Generic geri-dryl Banophen Generic

AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication 50 Drug Name Reference Brand-Generic Requirements & Limits m-dryl Naramin Generic medi-phedryl Banophen Generic naramin Naramin Generic ormir Unisom Sleepgels Generic pharbechlor Wal-finate Generic pharbedryl Banophen Generic siladryl allergy Naramin Generic sleep aid nighttime oral capsule 50 mg Unisom Sleepgels Generic sleep aid oral capsule 50 mg Unisom Sleepgels Generic sleep-aid nighttime oral capsule 50 mg Unisom Sleepgels Generic sleep-aid oral capsule Unisom Sleepgels Generic total allergy Banophen Generic total allergy medicine Naramin Generic Cystic Fibrosis Agents - Drugs to treat Cystic Fibrosis KALYDECO Brand PA; SP; QL ORKAMBI Brand PA; SP; QL SYMDEKO ORAL TABLET THERAPY Brand PA; SP; QL PACK 100-150 & 150 MG SYMDEKO ORAL TABLET THERAPY Brand SP; QL PACK 50-75 & 75 MG TRIKAFTA Brand PA; SP; QL Mast Cell Stabilizers - Drugs for the Lungs cromolyn sodium inhalation Generic Phosphodiesterase Inhibitors, Airways Disease - Drugs for the Lungs ELIXOPHYLLIN Brand THEO-24 Brand theophylline Generic theophylline er Generic Respiratory Tract Agents, Other - Asthma/Lung Drugs 12 hour decongestant Wal-phed 12 Hour Generic 12 hour nasal decongestant Wal-phed 12 Hour Generic

AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication 51 Drug Name Reference Brand-Generic Requirements & Limits Mucinex Sinus-Max Clear 12 hour nasal relief spray Generic & Cool Mucinex Sinus-Max Clear 12 hour nasal spray Generic & Cool 4-WAY FAST ACTING Brand 4-WAY MENTHOL Brand acetylcysteine inhalation solution 10 % Generic acetylcysteine inhalation solution 20 % Generic ADVIL COLD/SINUS Brand AL AFRIN NODRIP ORIGINAL Brand AFRIN SALINE NASAL MIST Brand AFRIN SINUS Brand altamist spray Nasal Moist Generic altarussin Diabetic Tussin EX Generic AL Wal-Tussin Cough/Chest altarussin dm Generic AL DM altarussin-pe Generic AL Mucinex Sinus-Max Clear anefrin spray Generic & Cool aprodine Generic AL AYR Brand AYR NASAL MIST ALLERGY/SINUS Brand AYR SALINE NASAL DROPS Brand BABY AYR SALINE Brand benzonatate oral capsule 100 mg Tessalon Perles Generic AL benzonatate oral capsule 200 mg Generic AL bidex Bidex Generic bromfed dm Bromfed DM Generic AL Delsym Cgh/Chest Cong chest congest/cough child Generic DM Child Wal-Tussin Cough/Chest chest congestion relief dm Generic AL DM chest congestion relief oral syrup Diabetic Tussin EX Generic AL chest congestion relief oral tablet Bidex Generic childrens cold & allergy Dimetapp Cold/Allergy Generic AL Delsym Cgh/Chest Cong childrens cough Generic DM Child

AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication 52 Drug Name Reference Brand-Generic Requirements & Limits Delsym Cgh/Chest Cong childrens mucus relief cough Generic DM Child cold & allergy Dimetapp Cold/Allergy Generic AL cold & cough childrens oral liquid 2.5-1-5 Dimaphen DM Generic AL mg/5ml Cold/Cough cold & sinus relief Wal-Profen Cold & Sinus Generic AL cold/allergy childrens Dimetapp Cold/Allergy Generic AL Dimaphen DM cold/cough childrens Generic AL Cold/Cough cold/cough dm childrens oral elixir 2.5-1-5 Generic AL mg/5ml CORICIDIN HBP COUGH/COLD Brand AL Delsym Cgh/Chest Cong cough & chest congestion Generic DM Child Coricidin HBP cough & cold Generic AL Cough/Cold Coricidin HBP cough & cold hbp Generic AL Cough/Cold cough dm Delsym Generic AL cough dm childrens Delsym Generic AL cough dm er Delsym Generic AL Wal-Tussin Cough/Chest cough/chest congestion dm Generic AL DM Delsym Cgh/Chest Cong cough/chest dm childrens oral liquid Generic DM Child decongestant 12hour max st Wal-phed 12 Hour Generic deep sea nasal spray Nasal Moist Generic DELSYM Brand AL Delsym Cgh/Chest Cong delsym cgh/chest cong dm child Generic DM Child DELSYM COUGH CHILDRENS Brand AL desgen dm oral liquid Desgen DM Generic AL dextromethorphan polistirex er Delsym Generic AL Wal-Tussin Cough/Chest dextromethorphan-guaifenesin oral syrup Generic AL DM diabetic tussin ex Diabetic Tussin EX Generic AL diabetic tussin max st Diabetic Tussin Max St Generic AL Dimaphen DM dimaphen dm cold/cough Generic AL Cold/Cough

AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication 53 Drug Name Reference Brand-Generic Requirements & Limits DIMETAPP COLD RELIEF CHILDRENS Brand AL DIMETAPP COLD/ALLERGY Brand AL DIMETAPP DM COLD/COUGH Brand AL DIMETAPP LONG ACT COUGH/COLD Brand AL Delsym Cgh/Chest Cong dm maximum adult Generic DM Child DRISTAN SPRAY Brand ED A-HIST ORAL LIQUID Brand AL ed bron gp Generic AL Dimaphen DM endacof-dm Generic AL Cold/Cough ephrine nose drops Wal-Four Generic fenesin ir Bidex Generic g tussin ac Generic AL; QL genaphed SudoGest Generic Wal-Tussin Cough/Chest geri-tussin dm Generic AL DM geri-tussin oral syrup Diabetic Tussin EX Generic AL guaiatussin ac Generic AL; QL Wal-Tussin Cough/Chest guaicon dms Generic AL DM guaifenesin ac Generic AL; QL guaifenesin dac Generic AL; QL guaifenesin er oral tablet extended EQ Mucus ER Generic AL release 12 hour 1200 mg guaifenesin oral tablet 400 mg Bidex Generic guaifenesin-codeine Generic AL; QL Wal-Tussin Cough/Chest guaifenesin-dm oral syrup Generic AL DM hydrocodone-homatropine Hycodan Generic QL; AL hydromet Hycodan Generic QL; AL HYPERSAL INHALATION Brand NEBULIZATION SOLUTION 7 % ibuprofen cold & sinus Wal-Profen Cold & Sinus Generic AL kp pseudoephedrine hcl oral tablet 30 mg SudoGest Generic liquibid Bidex Generic Mucinex Sinus-Max Clear long acting nasal spray Generic & Cool

AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication 54 Drug Name Reference Brand-Generic Requirements & Limits Mucinex Sinus-Max Clear long lasting nasal spray Generic & Cool maxi-tuss ac Generic AL; QL maxi-tuss gmx Diabetic Tussin Max St Generic AL maxi-tuss pe max Generic AL m-clear wc Generic AL Wal-Tussin Cough/Chest medi-tussin dm Generic AL DM MUCINEX CHILDRENS FREEFROM Brand ORAL LIQUID 5-100 MG/5ML MUCINEX CHILDRENS STUFFY NOSE Brand Delsym Cgh/Chest Cong mucinex cough childrens Generic DM Child MUCINEX D Brand AL MUCINEX D MAX STRENGTH Brand AL MUCINEX DM Brand AL Delsym Cgh/Chest Cong mucinex fast-max dm max Generic DM Child MUCINEX MAXIMUM STRENGTH Brand AL Mucinex Sinus-Max Clear mucinex sinus-max clear & cool Generic & Cool Mucinex Sinus-Max Clear mucinex sinus-max sinus/allrgy Generic & Cool mucosa Bidex Generic Delsym Cgh/Chest Cong mucus & cough relief childrens Generic DM Child mucus d Mucinex D Generic AL mucus d extended release Mucinex D Generic AL mucus d max st er Mucinex D Max Strength Generic AL mucus dm Mucinex DM Generic AL mucus er oral tablet extended release 12 EQ Mucus ER Generic AL hour 1200 mg mucus extended release oral tablet EQ Mucus ER Generic AL extended release 12 hour 1200 mg Delsym Cgh/Chest Cong mucus relief cough child Generic DM Child Delsym Cgh/Chest Cong mucus relief cough childrens Generic DM Child mucus relief d oral tablet extended Mucinex D Generic AL release 12 hour

AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication 55 Drug Name Reference Brand-Generic Requirements & Limits Delsym Cgh/Chest Cong mucus relief dm max oral liquid Generic DM Child Delsym Cgh/Chest Cong mucus relief dm oral liquid Generic DM Child mucus relief dm oral tablet extended Mucinex DM Generic AL release 12 hour 30-600 mg mucus relief er oral tablet extended EQ Mucus ER Generic AL release 12 hour 1200 mg mucus relief max st EQ Mucus ER Generic AL mucus relief oral tablet Bidex Generic mucus-d Mucinex D Generic AL mucus-dm Mucinex DM Generic AL mucus-er max EQ Mucus ER Generic AL mucus-er oral tablet extended release 12 EQ Mucus ER Generic AL hour 1200 mg nasal decongestant 12hr Wal-phed 12 Hour Generic nasal decongestant max st SudoGest Generic nasal decongestant oral tablet 30 mg SudoGest Generic nasal decongestant pe Sudogest PE Generic nasal decongestant pe max st Sudogest PE Generic Mucinex Sinus-Max Clear nasal decongestant spray Generic & Cool nasal four Wal-Four Generic Mucinex Sinus-Max Clear nasal mist nasal solution Generic & Cool nasal moist nasal solution Nasal Moist Generic nasal moisturizing Nasal Moist Generic nasal moisturizing spray Nasal Moist Generic Mucinex Sinus-Max Clear nasal relief Generic & Cool Mucinex Sinus-Max Clear nasal spray Generic & Cool Mucinex Sinus-Max Clear nasal spray 12 hour Generic & Cool Mucinex Sinus-Max Clear nasal spray anti-drip Generic & Cool Mucinex Sinus-Max Clear nasal spray extra moist Generic & Cool

AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication 56 Drug Name Reference Brand-Generic Requirements & Limits Mucinex Sinus-Max Clear nasal spray extra moisturizing Generic & Cool nasal spray fast acting Wal-Four Generic Mucinex Sinus-Max Clear nasal spray no drip Generic & Cool Mucinex Sinus-Max Clear nasal spray sinus Generic & Cool NEO-SYNEPHRINE COLD/ALLRG MILD Brand NEO-SYNEPHRINE COLD/ALLRGY EXT Brand NEO-SYNEPHRINE COLD/ALLRGY REG Brand Mucinex Sinus-Max Clear no drip nasal spray Generic & Cool nohist-lq Ed A-Hist Generic AL non-pseudo sinus decongestant Sudogest PE Generic nose drops Wal-Four Generic nose drops extra strength Wal-Four Generic OCEAN FOR KIDS Brand OCEAN NASAL SPRAY Brand pharbinex Bidex Generic phenylephrine hcl oral Sudogest PE Generic promethazine-codeine Generic QL; AL promethazine-dm Generic AL promethazine-phenylephrine Generic AL pseudoephedrine hcl 12 hr Wal-phed 12 Hour Generic pseudoephedrine hcl er Wal-phed 12 Hour Generic pseudoephedrine hcl oral tablet 30 mg SudoGest Generic pseudoephedrine-bromphen-dm Bromfed DM Generic AL pseudoephedrine-guaifenesin er Mucinex D Generic AL PULMOZYME Brand DX2RX; SP; QL Delsym Cgh/Chest Cong recofen d Generic DM Child refenesen 400 Bidex Generic robafen cf multi-symptom cold Desgen DM Generic AL ROBITUSSIN 12 HOUR COUGH Brand AL ROBITUSSIN 12 HOUR COUGH CHILD Brand AL ROBITUSSIN CHILD COUGH/COLD LA Brand AL robitussin childrens cough la Generic AL

AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication 57 Drug Name Reference Brand-Generic Requirements & Limits ROBITUSSIN COUGH+CHEST CONG Brand DM ORAL LIQUID 20-400 MG/20ML ROBITUSSIN NIGHTTIME COUGH Brand AL ROBITUSSIN PEAK COLD MULTI-SYM Brand AL Dimaphen DM rynex dm Generic AL Cold/Cough rynex pe Dimetapp Cold/Allergy Generic AL rynex pse Generic AL saline mist spray Nasal Moist Generic saline nasal spray Nasal Moist Generic sb cough control dm max Diabetic Tussin Max St Generic AL sb mucus relief Bidex Generic siltussin sa Diabetic Tussin EX Generic AL Wal-Tussin Cough/Chest siltussin-dm alcohol free Generic AL DM sinus 12 hour Wal-phed 12 Hour Generic sinus congestion max strength SudoGest Generic Mucinex Sinus-Max Clear sinus nasal spray Generic & Cool sinus pe decongestant Sudogest PE Generic sinus relief extra strength Wal-Four Generic sodium chloride inhalation nebulization Generic solution 0.9 %, 10 %, 3 % sodium chloride inhalation nebulization HyperSal Generic solution 7 % SUDAFED Brand SUDAFED CHILDRENS Brand SUDAFED CONGESTION Brand SUDAFED PE CONGESTION ORAL Brand TABLET 10 MG SUDAFED PE SINUS CONGESTION Brand SUDAFED SINUS CONGESTION Brand SUDAFED SINUS CONGESTION 12HR Brand sudogest 12 hour Wal-phed 12 Hour Generic sudogest maximum strength SudoGest Generic sudogest oral tablet 30 mg SudoGest Generic sudogest pe Sudogest PE Generic

AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication 58 Drug Name Reference Brand-Generic Requirements & Limits suphedrin Sudafed Childrens Generic tab tussin Bidex Generic tussin cf Desgen DM Generic AL tussin cf cough & cold Desgen DM Generic AL tussin cf multi-symptom cold Desgen DM Generic AL tussin cough long acting Wal-Tussin Cough Generic AL tussin cough oral syrup Wal-Tussin Cough Generic AL tussin dm cough + chest oral liquid 10- Diabetic Tussin Max St Generic AL 200 mg/5ml tussin dm max adult oral liquid 10-200 Diabetic Tussin Max St Generic AL mg/5ml tussin dm max adult oral liquid 5-100 Delsym Cgh/Chest Cong Generic mg/5ml DM Child tussin dm max oral liquid 10-200 mg/5ml Diabetic Tussin Max St Generic AL Delsym Cgh/Chest Cong tussin dm max oral liquid 20-400 mg/20ml Generic DM Child Delsym Cgh/Chest Cong tussin dm max st Generic DM Child Wal-Tussin Cough/Chest tussin dm oral syrup 100-10 mg/5ml Generic AL DM tussin maximum strength Wal-Tussin Cough Generic AL tussin mucus+chest congestion oral syrup Diabetic Tussin EX Generic AL tussin multi-symptom cold cf Desgen DM Generic AL virtussin a/c Generic QL; AL virtussin ac w/alc Generic QL; AL virtussin dac Generic QL; AL xpect Bidex Generic Sleep Disorder Agents - Drugs for Sedation and Sleep Sleep Disorders, Other - Drugs for Sleeping NYTOL MAXIMUM STRENGTH Brand tetra-formula nighttime sleep Nytol Maximum Strength Generic Therapeutic Nutrients/Minerals/Electrolytes - Drugs to Treat Vitamin, Mineral and Body Fluid Deficiencies

AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication 59 Drug Name Reference Brand-Generic Requirements & Limits Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs PRENATAL GUMMY ORAL TABLET Brand GE; AL CHEWABLE 0.4-25 MG

AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication 60