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2021 Formulary List of covered prescription

This list applies to all Individual HMO products and the following Small Group HMO products: Sharp Platinum 90 Performance HMO, Sharp Platinum 90 Performance HMO AI-AN, Sharp Platinum 90 Premier HMO, Sharp Platinum 90 Premier HMO AI-AN, Sharp Gold 80 Performance HMO, Sharp Gold 80 Performance HMO AI-AN, Sharp Gold 80 Premier HMO, Sharp Gold 80 Premier HMO AI-AN, Sharp 70 Performance HMO, Sharp Silver 70 Performance HMO AI-AN, Sharp Silver 70 Premier HMO, Sharp Silver 70 Premier HMO AI-AN, Sharp Silver 73 Performance HMO, Sharp Silver 73 Premier HMO, Sharp Silver 87 Performance HMO, Sharp Silver 87 Premier HMO, Sharp Silver 94 Performance HMO, Sharp Silver 94 Premier HMO, Sharp Bronze 60 Performance HMO, Sharp Bronze 60 Performance HMO AI-AN, Sharp Bronze 60 Premier HDHP HMO, Sharp Bronze 60 Premier HDHP HMO AI-AN, Sharp Minimum Coverage Performance HMO, Sharp $0 Cost Share Performance HMO AI-AN, Sharp $0 Cost Share Premier HMO AI-AN, Sharp Silver 70 Off Exchange Performance HMO, Sharp Silver 70 Off Exchange Premier HMO, Sharp Performance Platinum 90 HMO 0/15 + Child Dental, Sharp Premier Platinum 90 HMO 0/20 + Child Dental, Sharp Performance Gold 80 HMO 350 /25 + Child Dental, Sharp Premier Gold 80 HMO 250/35 + Child Dental, Sharp Performance Silver 70 HMO 2250/50 + Child Dental, Sharp Premier Silver 70 HMO 2250/55 + Child Dental, Sharp Premier Silver 70 HDHP HMO 2500/20% + Child Dental, Sharp Performance Bronze 60 HMO 6300/65 + Child Dental, Sharp Premier Bronze 60 HDHP HMO 7000/0 + Child Dental, Sharp Performance Platinum 90 HMO 0/15 + Child Dental (INF), Sharp Premier Platinum 90 HMO 0/20 + Child Dental (INF), Sharp Performance Gold 80 HMO 350/25 + Child Dental (INF), Sharp Premier Gold 80 HMO 250/35 + Child Dental (INF), Sharp Performance Silver 70 HMO 2250/50 + Child Dental (INF), Sharp Premier Silver 70 HMO 2250/55 + Child Dental (INF), Sharp Premier Silver 70 HDHP HMO 2500/20% + Child Dental (INF), Sharp Performance Bronze 60 HMO 6300/65 + Child Dental (INF), Sharp Premier Bronze 60 HDHP HMO 7000/0 + Child Dental (INF), Sharp Performance Gold 80 HMO 350/25 + Child Dental, Sharp Premier Silver 70 HDHP 2500/20% + Child Dental, Sharp Platinum 90 HMO 0/15/10% + Child Dental (Pr/V/C), Sharp Platinum 90 HMO 0/20/250 + Child Dental (Pe/V/C), Sharp Gold 80 HMO 350/25/20% + Child Dental (Pr/V/C), Sharp Gold 80 HMO 250/35/600 + Child Dental (Pe/V/C), Sharp Silver 70 HMO 2250/50/30% + Child Dental (Pr/V/C- 30%), Sharp Silver 70 HMO 2250/55/30% + Child Dental (Pe/V/C-300), Sharp Silver 70 HDHP HMO 2500/20%/20% + Child Dental (Pe/V/C), Sharp Bronze 60 HMO 6300/65/40% + Child Dental (Pr/V/C), Sharp Bronze 60 HDHP HMO 7000/0/0 + Child Dental (Pe/V/C)

List of covered prescription drugs for Individual, family & employer-sponsored coverage through Covered and Individual and family coverage directly from Sharp Health Plan

An electronic version of this List is available on the Sharp Health Plan website, by visiting sharphealthplan.com/search-drug-list

You can find specific cost sharing information in your plan’s coverage documents by logging in to your Sharp Connect account on our website by visiting sharphealthplan.com/login

This document is subject to change and all previous versions are no longer in effect. Last updated 10/01/21.

Table of Contents Introduction i - xiii Definitions i How often does the Formulary change? iii Will I be notified of a Formulary change? iii How do I locate a Prescription Drug on the Formulary? iv How do I know if the drug listed on the Formulary is a Brand or ? iv What is a Drug Tier? iv Are There Any Coverage Requirements or Limits? v What is Prior Authorization? vi What is PA**? vi What is Quantity Limit? vi What is Step Therapy? vi What is MO? vii What is a Specialty Drug? vii What is an Oral Anti- Drug? vii What if a Drug is Not Listed on the Formulary? What is a Formulary Exception? vii Where Can I Fill My Prescription Drug? vii What is Therapeutic Interchange? vii What is Generic Substitution? viii

Sharp Health Plan 4 Tier Formulary October 2021

You Have the Right to Appeal viii Questions? viii Exclusions and Limitations to the Outpatient prescription Drug Benefit viii Nondiscrimination Notice xi Language Assistance Services xii

List of Prescription Drugs 1-102

Index 103-141

Step Therapy Criteria 142-145

Sharp Health Plan 4 Tier Formulary October 2021

Introduction October 2021

This document contains a list of the federal and Drug Administration (FDA) approved drugs covered for Sharp Health Plan Members under the pharmacy outpatient prescription drug benefit, and is also known as the Formulary. The outpatient prescription drug benefit covers outpatient drugs provided to Members through a network retail, specialty or mail order pharmacy. Drugs covered under the pharmacy benefit are generally oral or topical , unless otherwise listed on the Formulary. The presence of a drug on the Formulary does not guarantee that it will be prescribed by your Prescribing Provider for a particular medical condition. Refer to the end of this Introduction for information about drug benefit exclusions for the outpatient prescription drug benefit.

If you have questions regarding your outpatient prescription drug benefit, please call our Customer Service department at 1-855-298-4252.

A Medical Benefit drug is a drug that is physician administered or is self-injectable. Medical Benefit drugs are covered under the Medical Benefit. Refer to the “WHAT ARE YOUR COVERED BENEFITS?” section of the Member Handbook for specific information about the Cost Shares, exclusions and limitations for these drugs covered under your Medical Benefit:

1. Medically Necessary formulas and special food products prescribed by a Plan Physician to treat phenylketonuria (PKU), provided that these formulas and special exceed the cost of a normal diet.

2. Medically Necessary injectable and non-injectable drugs and supplies that are administered in a physician’s office or self-injectable drugs.

3. FDA-approved medications used to induce spontaneous and non-spontaneous that may only be dispensed by, or under direct supervision of, a physician.

4. Immunization or immunological agents, including, but not limited to: biological sera, , or other blood products administered on an outpatient basis, sera and testing materials.

5. Equipment and supplies for the management and treatment of , including pumps and all related necessary supplies, blood monitors, testing strips, lancets and lancet puncture devices. (Insulin, and insulin syringes are covered under the outpatient prescription drug benefit.)

6. Items that are approved by the FDA as a medical device. Please refer to the Member Handbook under Disposable Medical Supplies, Durable Medical Equipment, and Family Planning for information about medical devices covered by Sharp Health Plan.

DEFINITIONS

Defined terms are capitalized throughout this Formulary and have the meaning set forth below throughout this Formulary and in the Glossary section of your Member Handbook.

“Appeal” is a written or oral request, by or on behalf of a Member, to re-evaluate a specific determination made by Sharp Health Plan or any of its delegated entities (e.g., Plan Providers).

“Brand-Name Drug” is a drug that is marketed under a proprietary, trademark protected name. The Brand Name Drug shall be listed in all CAPITAL letters.

“Coinsurance” is a percentage of the cost of a Covered Benefit (for example, 20%) that an Enrollee pays after the Enrollee has paid the Deductible, if a Deductible applies to the Covered Benefit, such as the prescription drug benefit.

“Copayment” is a fixed dollar amount (for example, $20) that an Enrollee pays for a Covered Benefit after the Enrollee has paid the Deductible, if a Deductible applies to the Covered Benefit, such as the prescription drug benefit.

Sharp Health Plan 4 Tier Formulary October 2021

i

“Deductible” is the amount an Enrollee pays for certain Covered Benefits before Sharp Health Plan begins payment for all or part of the cost of the Covered Benefit under the terms of the policy.

“Drug Tier” is a group of Prescription Drugs that corresponds to a specified cost sharing tier in Sharp Health Plan’s Prescription Drug coverage. The tier in which a Prescription Drug is placed determines the Enrollee's portion of the cost for the drug.

“Enrollee” is a person enrolled in Sharp Health Plan who is entitled to receive services from the Plan. All references to Enrollees in this Formulary template shall also include Subscribers as defined in this section below. An Enrollee is also referred to as a Member.

“Exception Request” is a request for coverage of a Prescription Drug. If an Enrollee, his or her designee, or prescribing health care provider submits an Exception Request for coverage of a Prescription Drug, Sharp Health Plan must cover the Prescription Drug when the drug is determined to be Medically Necessary to treat the Enrollee's condition. Drugs and supplies that fall within one of the outpatient prescription drug benefit exclusions described in the Member Handbook are not eligible for an Exception Request.

“Exigent Circumstances” are when an Enrollee is suffering from a health condition that may seriously jeopardize the Enrollee's life, health, or ability to regain maximum function, or when an Enrollee is undergoing a current course of treatment using a Nonformulary Drug.

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

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

“Grievance” is a written or oral expression of dissatisfaction regarding Sharp Health Plan, a provider and/or a pharmacy, including quality of care concerns.

“Nonformulary Drug” is a Prescription Drug that is not listed on Sharp Health Plan’s Formulary.

“Out-of-Pocket Cost” are Copayments, Coinsurance, and the applicable Deductible, plus all costs for health care services that are not covered by Sharp Health Plan.

“Prescribing Provider” is a health care provider authorized to write a Prescription to treat a medical condition for a Sharp Health Plan Enrollee.

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

“Prescription Drug” is a drug that is prescribed by the Enrollee's Prescribing Provider and requires a Prescription under applicable law.

“Prior Authorization” is Sharp Health Plan’s requirement that the Enrollee or the Enrollee's Prescribing Provider obtain the Sharp Health Plan’s Authorization for a Prescription Drug before Sharp Health Plan will cover the drug. Sharp Health Plan shall grant a Prior Authorization when it is Medically Necessary for the Enrollee to obtain the drug.

“Step Therapy” is a process specifying the sequence in which different Prescription Drugs for a given medical condition and medically appropriate for a particular patient are prescribed. Sharp Health Plan may require the Enrollee to try one or

Sharp Health Plan 4 Tier Formulary October 2021

ii more drugs to treat the Enrollee's medical condition before Sharp Health Plan will cover a particular drug for the condition pursuant to a Step Therapy request. If the Enrollee's Prescribing Provider submits a request for Step Therapy exception, Sharp Health Plan shall make exceptions to Step Therapy when the criteria is met.

“Subscriber” means the person who is responsible for payment to Sharp Health Plan or whose employment or other status, except for family dependency, is the basis for eligibility for membership in the plan.

How often does the Formulary change?

The Sharp Health Plan Formulary is developed to identify safe and effective drugs for Members while maintaining affordable benefits. The Formulary and Drug Coverage Requirements and Limits are updated regularly by the Pharmacy and Therapeutics (P&T) Committee, which meets quarterly. The Formulary and the Drug Coverage Requirements and Limits are subject to change monthly as new clinical information and new drugs become available. The P&T Committee members are clinical pharmacists and actively practicing physicians of various medical specialties. The P&T Committee frequently consults with other medical experts for input to the Committee.

The P&T Committee evaluates clinical effectiveness, safety and overall value through:

• Medical and scientific publications

• Relevant utilization experience

• Physician recommendations

Will I be notified of a Formulary change?

Sharp Health Plan will provide sixty (60) days written notice of a Formulary change to negatively affected Members. The notice will include the date the Member will be impacted by the change. Some examples of Formulary changes that will result in a notice to the member include, but are not limited to:

• A drug or dosage form is moved to a higher Drug Tier that results in an increase in cost sharing

• A drug or dosage form is removed from the Formulary

• Drug Coverage Requirements or Limits for a drug are added or changed

Changes to the Formulary that may occur without prior written notice to the Member include:

• A drug is removed from the Formulary because it is removed from the market by either the drug manufacturer or the FDA

• A drug is added to the Formulary

• A drug is moved to a lower Drug Tier

• A Drug Coverage Requirement or Limit is removed from a drug

• A generic drug is drug is added to the Formulary and the Brand Name drug is moved to a higher Drug Tier or removed from the Formulary

The drug formulary can be accessed by current and prospective Members. To view the most current Formulary, please visit sharphealthplan.com/search-drug-list. How do I locate a Prescription Drug on the Formulary?

Covered Prescription Drugs are listed alphabetically by Generic name and Brand-Name in the alphabetical Index.

Within the Formulary, drugs are listed alphabetically under the column titled “Prescription Drug Name” by its Brand or

Sharp Health Plan 4 Tier Formulary October 2021

iii Generic name under the therapeutic category and class to which it belongs. If a generic for a Brand Name Drug is not available or is not covered, the Generic Drug name will not be listed separately by its generic name.

You can find a Prescription Drug on the formulary by looking for its Generic or Brand-Name alphabetically in the Index, or by looking for it in the Formulary, where it is listed alphabetically under the therapeutic category and class to which it belongs. Sharp Health Plan uses the Medispan classification system for therapeutic category and class. Medi- Span® maintains the Master Drug Data of drug information for professionals in the health . The Master Drug Data Base provides pricing and descriptive drug information on name brand, generic, prescription and OTC medications, and herbal products and is updated daily.

How do I know if the drug listed on the Formulary is a Brand or Generic Drug?

Brand-Name Drugs are listed in all CAPITALS followed by the generic name in parentheses in (lowercase bold italics).

If a Generic equivalent for a Brand-Name Drug is available and is covered, and both the Brand-Name Drug and the Generic equivalents are covered, the Generic Drug will be listed separately from the Brand-Name Drug in all lowercase bold italics. When a Generic Drug is marketed under a Brand-Name, the Brand-Name will be listed in all capital letters after the Generic name in parentheses with the first letter of each word capitalized.

Here is how this is listed on the Formulary:

Drug Type Listing on the Formulary

Brand-Name Drug and Generic-Name FIBRICOR TAB 35MG (fenofibric )

Generic-Name that is covered on the Formulary fenofibric acid tab 35mg Generic Drug marketed with a Brand-Name ( Hcl Tab 100mg) PACERONE

Some drugs are commercially available as both a Brand-Name and a Generic-Name. Contracted pharmacies are required to dispense the Generic version of the drug, unless Prior Authorization for the Brand-Name Drug is obtained from Sharp Health Plan.

The Brand-Name listed in this document is for reference only and is not an indication that the Brand-Name Drug is covered by Sharp Health Plan, unless Sharp Health Plan has Authorized the Brand-Name Drug due to medical necessity or specifically noted.

What is a Drug Tier?

Each covered drug is assigned to a Drug Tier. The Drug Tier is a group of drugs that indicates what your Copayment or Coinsurance is for each drug. A Deductible may also apply. For information about your Copayments, Coinsurance and/or Deductible, please consult your benefits information available online by visiting sharphealthplan.com/login and log in to your SharpConnect account. When you create a SharpConnect account, you can easily access your benefit information online 24 hours a day, 7 days a week.

A preferred drug is a drug that the Pharmacy and Therapeutics Committee has determined provides greater value than its alternatives when considering clinical effectiveness, safety and overall value.

The Drug Tier is marked throughout this document by one of the following symbols:

Symbol Drug Tier Description

Sharp Health Plan 4 Tier Formulary October 2021

iv 1 Tier 1 Most Generic drugs and low-cost preferred Brand-Name drugs.

2 Tier 2 Non-preferred Generic drugs, preferred Brand-Name drugs, and any other drugs recommended by the Pharmacy and Therapeutics Committee based on safety, , and cost.

3 Tier 3 Non-preferred Brand-Name drugs or drugs that are recommended by the Pharmacy and Therapeutics Committee based on drug safety, efficacy, and cost, or that generally have a preferred and often less costly therapeutic alternative at a lower tier. 4 Tier 4 Drugs that are biologics, drugs that the Food and Drug Administration (FDA) or drug manufacturer requires to be distributed through a specialty pharmacy, drugs that require the enrollee to have special training or clinical monitoring for self- administration, or drugs that cost the health plan (net of rebates) more than six hundred dollars ($600) for a one-month (30-day) supply.

PV PV Select drugs covered with no Copayment, including certain generic and over-the- counter contraceptives for women.

MB MB Drugs covered under the Medical Benefit. Please refer to your Medical Benefit coverage information.

Are There Any Coverage Requirements or Limits?

Some covered Generic and Brand-Name Drugs have coverage requirements or limits on coverage. Symbols are used to identify drugs with a Coverage Requirement or Limit. The following symbols are used in this Formulary:

Symbol Meaning Description PA Prior Authorization Requires Prior Authorization by Sharp Health Plan based on specific clinical criteria. See “What is Prior Authorization?” below for additional information.

PA** Prior Authorization if Requires Prior Authorization by Sharp Health Plan based on specific clinical Step Therapy is not met criteria, if Step Therapy criteria has not been met.

QL Quantity Limit Coverage is limited to a specific quantity per Prescription and/or time period. Prior Authorization is required for other quantities.

ST Step Therapy Coverage depends on previous use of another drug. Prior Authorization may be required. See “What Is Step Therapy?” below for additional information.

MO Mail Order A maintenance drug that is available for up to a 90-day supply and is eligible to be filled through mail order.

SP Specialty A specialty drug that must be filled by a pharmacy in the Sharp Health Plan Specialty Pharmacy network and is limited to a 30-day supply per fill.

OAC Oral Anti-Cancer An orally administered anticancer . Notwithstanding any Deductible, the total amount of Copayments and Coinsurance does not exceed two hundred fifty dollars ($250) for an individual Prescription of up to a 30-day supply.

Sharp Health Plan 4 Tier Formulary October 2021

v What is Prior Authorization?

Drugs with a PA symbol in the Coverage Requirements and Limits column of the Formulary are subject to Prior Authorization. Your Prescribing Provider must request Prior Authorization, or approval for coverage, from Sharp Health Plan by calling our Customer Service department, submitting a fax request, or submitting an electronic Prior Authorization Form. Once all the needed supporting information has been received, the Prior Authorization request will be either approved or denied based on our clinical policies within 72 hours for non-urgent requests, or within 24 hours in urgent or Exigent Circumstances. Exigent Circumstances exist when a Member is suffering from a health condition that may seriously jeopardize the Member’s life, health, or ability to regain maximum function or when an enrollee is undergoing a current course of treatment using a Nonformulary Drug. Sharp Health Plan will provide coverage for the Prescription, including refills, for the duration of the Prescription for non-urgent requests, and for the duration of the exigency for requests based on Exigent Circumstances. If Sharp Health Plan fails to respond to a completed Prior Authorization request within 72 hours of receiving a non-urgent request and 24 hours of receiving a request based on Exigent Circumstances, the request is deemed granted.

If Sharp Health Plan denies a request for Prior Authorization, the Member, an Authorized Representative, or the Prescribing Provider can file an Appeal or Grievance. Information about this process is described in the section of the Formulary called, “You Have the Right to Appeal.”

If Sharp Health Plan approved a Prior Authorization request for your medication and medical condition, Sharp Health Plan will not discontinue or limit coverage if your Prescribing Provider continues to prescribe it for the same medical condition, provided the drug is appropriately prescribed and is safe and effective for treating your medical condition.

What is PA**?

Drugs with a PA** symbol in the Coverage Requirements and Limits column of the Formulary are subject to Prior Authorization based on specific clinical criteria, if Step Therapy has not been met. There may be a situation when it is Medically Necessary for you to receive certain drugs without first trying the alternative drug. In these instances, your doctor may request a Prior Authorization by following the Prior Authorization process described above.

What is Quantity Limit?

Drugs with a QL symbol in the Coverage Requirements and Limits column of the Formulary are subject to Quantity Limits. Quantity Limits exist when drugs are limited to a determined number of doses based on criteria, including, but not limited to, safety, potential overdose hazard, abuse potential, or approximation of usual doses per month, not to exceed the FDA maximum approved dose. A Member’s Prescribing Provider may submit a request for a quantity of medication that exceeds the Quantity Limit by following the Prior Authorization request procedure stated above. Medical Necessity for the quantity requested must be provided. Once all the needed supporting information has been received, the Prior Authorization request will be either approved or denied within 72 hours for non-urgent requests, or within 24 hours in urgent or Exigent Circumstances.

What is Step Therapy?

Drugs with a ST symbol in the Coverage Requirements and Limits column of the Formulary are subject to Step Therapy. The Step Therapy program encourages safe and cost-effective medication use. Under this program, a “step” approach is required to receive coverage for certain drugs. This means that to receive coverage, you may need to first try a proven, cost-effective drug. Remember, treatment decisions are always between you and your doctor. There may be a situation when it is Medically Necessary for you to receive certain drugs without first trying the alternative drug. In these instances, your doctor may request a Step Therapy Exception Request by following the Prior Authorization as described above. If Sharp Health Plan fails to respond to a completed Step Therapy request within 72 hours of receiving a non- urgent request and 24 hours of receiving a request based on Exigent Circumstances, the request is deemed granted.

If you have moved from another insurance plan to Sharp Health Plan and are taking a medication that your previous insurer covered, Sharp Health Plan will not require you to follow Step Therapy in order to obtain the medication. Your

Sharp Health Plan 4 Tier Formulary October 2021

vi doctor may need to submit a request to Sharp Health Plan in order to provide you with this continuity of coverage.

What Is MO?

Drugs with a MO symbol in the Coverage Requirements and Limits column of the Formulary are classified as Maintenance Drugs and can be filled for a 90-day supply at a retail location or at Mail Order.

What is a Specialty Drug?

Drugs with a SP symbol in the Coverage Requirements and Limits column of the Formulary are Specialty drugs. A Specialty drug is a drug that the FDA or the manufacturer states must be distributed through a Specialty pharmacy, drugs that require the Member to have special training or clinical monitoring for self-administration, or drugs that the Pharmacy and Therapeutics Committee determines to be a Specialty medication.

What is an Oral Anti-Cancer Drug?

Drugs with an OAC symbol in the Coverage Requirements and Limits column of the Formulary are Oral Anti-Cancer drugs. Notwithstanding any Deductible, the total amount of Copayments and Coinsurance for these drugs does not exceed two hundred fifty dollars ($250) for an individual Prescription of up to a 30-day supply.

What if a Drug Is Not Listed on the Formulary? What is a Formulary Exception?

Drugs that are not listed on the Formulary are Nonformulary Drugs and are not covered. There may be times when it is Medically Necessary for you to receive a Nonformulary Drug. In these instances, your Prescribing Provider may request a Formulary Exception, by following the Prior Authorization Request process described above. Once all the needed supporting information has been received, the Exception Request will be either approved or denied based on medical necessity within 72 hours for non-urgent requests, or within 24 hours in urgent or Exigent Circumstances. If Sharp Health Plan denies an Exception Request, the Member, an Authorized Representative, or the Provider can file an Appeal with Sharp Health Plan. Nonformulary Brand-Name Drugs approved for coverage will be subject to the Tier 3 Cost Share. Nonformulary Generic Drugs approved for coverage will be subject to the Tier 1 Cost Share. When approved, Sharp Health Plan shall provide coverage of the Nonformulary non-urgent request for the duration of the Prescription, including refills. Sharp Health Plan shall provide coverage, including refills, pursuant to a request based on Exigent Circumstances for the duration of the exigency. Nonformulary Drugs that are approved for coverage and meet the Tier 4 description will be subject to the Tier 4 Cost Share.

Where Can I Fill My Prescription Drug?

To find a pharmacy in our network, use our Pharmacy Locator tool. First, register for an account at www.caremark.com. The Pharmacy Locator tool is available after you log into your account and will allow you to search for a pharmacy that meets your needs. For example, you can search for a pharmacy close to your home, one that is open 24 hours a day, or one that offers drive-thru service.

Specialty drugs can be filled at CVS Specialty Pharmacy and will be mailed to you. Visit www.CVSspecialty.com to enroll. You can also take your Specialty drug prescription to a CVS retail pharmacy. Your Prescription will be sent to CVS Specialty Pharmacy to be filled. You may return to your local CVS pharmacy to pick up your Prescription.

Mail order medications can be filled at CVS/caremark. You can enroll with CVS/caremark by visiting info.caremark.com/mailservice.

What is Therapeutic Interchange?

Sharp Health Plan employs therapeutic interchange as part of its prescription drug benefit. Therapeutic interchange is

Sharp Health Plan 4 Tier Formulary October 2021

vii the practice of replacing (with the Prescribing Provider's approval) a Prescription Drug originally prescribed for a patient with a Prescription Drug that is its therapeutic equivalent. Using therapeutic interchange may offer advantages, such as value through improved convenience, affordability, improved outcomes or fewer . Two or more drugs are considered therapeutically equivalent if they can be expected to produce similar levels of clinical effectiveness and sound medical outcomes in patients. If, during the Prior Authorization process, the requested medication has a preferred therapeutic equivalent on the Sharp Health Plan Formulary, a request to consider the preferred drug(s) may be conveyed to the Prescribing Provider. The Prescribing Provider may choose to use therapeutic interchange and select a pharmaceutical that does not require Prior Authorization or Step Therapy.

What is Generic Substitution?

The FDA applies rigorous standards for identity, strength, quality, purity and before approving a Generic Drug. Generics are required to have the same active ingredient, strength, dosage form, and as their brand-name equivalents. When a Generic Drug is available, the pharmacy is required to switch a Brand-Name Drug to the generic equivalent, unless Sharp Health Plan has authorized the Brand-Name Drug due to medical necessity. If the brand-name drug is Medically Necessary and Prior Authorization is obtained from Sharp Health Plan, you must pay the Cost Share for the corresponding tier.

You Have the Right to Appeal

If you do not agree with a coverage decision, you, your Authorized Representative or your doctor may request an Appeal. You must submit your request within 180 days from the postmark date of the denial notice.

Appeals Due to Denial of Coverage for a Nonformulary Drug

If an exception request for coverage of a Nonformulary drug is denied, you, your Authorized Representative or your doctor may request an external Exception Request review. Sharp Health Plan will ensure that a decision is made within 72 hours in routine circumstances or 24 hours in urgent circumstances.

All Other Appeals

If a decision is made to delay, deny or modify coverage of a Formulary Drug, you, your Authorized Representative or your doctor may request an Appeal. A decision will be made within 30 days in routine circumstances or 72 hours in urgent circumstances.

For all types of Appeals, the circumstance may be considered urgent if the routine decision-making process might seriously jeopardize your life or health, or when you are experiencing severe pain.

Please refer to your Member Handbook for more information on the Appeal process.

Questions

If you have any questions, please contact Customer Care by calling 1-855-298-4252. If you or somebody who you are helping have questions about Sharp Health Plan, you have the right to obtain assistance and information in your language without any cost to you.

Exclusions and Limitations to the Outpatient Prescription Drug Benefit

The services and supplies listed below are exclusions and limitations to your Outpatient Prescription Drug Benefits and are not covered by Sharp Health Plan:

1. Drugs dispensed by a person or entity other than a Plan Pharmacy, except as Medically Necessary for treatment of an Emergency Medical Condition or urgent care condition.

Sharp Health Plan 4 Tier Formulary October 2021

viii 2. Drugs prescribed by non-Plan Providers and not authorized by Sharp Health Plan, except when coverage is otherwise required for treatment of an Emergency Medical Condition. 3. Over-the-counter medications or supplies, even if written on Prescription, except as specifically identified as covered in this Formulary. This exclusion does not apply to over-the-counter products that Sharp Health Plan must cover as a “preventive care” benefit under federal law with a Prescription or if the prescription legend drug is Medically Necessary due to a documented failure or intolerance to the over-the-counter equivalent or therapeutically comparable drug. 4. Drugs dispensed in institutional packaging (such as unit dose) and drugs that are repackaged. 5. Drugs that are packaged with over-the-counter medications or other non-prescription items/supplies. 6. (other than pediatric or prenatal vitamins listed in this Formulary). 7. Drugs and supplies prescribed solely for the treatment of , , athletic performance, cosmetic purposes, anti-aging for cosmetic purposes, and mental performance. (Drugs for mental performance are not excluded from coverage when they are used to treat diagnosed mental illness or medical conditions affecting memory, including, but not limited to, treatment of the conditions or symptoms of or Alzheimer’s disease.) 8. Herbal, nutritional and dietary supplements. 9. Drugs prescribed solely for the purpose of shortening the duration of the . 10. Drugs prescribed by a dentist or when prescribed for a dental treatment. 11. Drugs and supplies prescribed in connection with a service or supply that is not a Covered Benefit, unless required to treat a complication that arises as a result of the service or supply. 12. Travel and/or required work-related immunizations. 13. drugs are excluded, unless added by the employer as a supplemental benefit. 14. Drugs obtained outside of the , unless they are furnished in connection with Urgent Care Services or Emergency Services. 15. Drugs that are prescribed solely for the purposes of losing weight, except when Medically Necessary for the treatment of morbid . Members must be enrolled in a Sharp Health Plan-approved comprehensive program prior to or concurrent with receiving the weight loss drug. 16. Off-label use of FDA-approved Prescription Drugs, unless the drug is recognized for treatment of such indication in one of the standard reference compendia (the United States Pharmacopoeia Drug Information, the American Medical Association Drug Evaluations, or the American Hospital Formulary Service Drug Information) or the safety and effectiveness of use for this indication has been adequately demonstrated by at least two studies published in a nationally recognized, major peer-reviewed journal. 17. Replacement of lost, stolen, or destroyed medications. 18. Compounded medications, unless determined to be Medically Necessary and Prior Authorization is obtained. 19. Brand-Name Drugs when a generic equivalent is available. Some drugs are commercially available as both a brand-name version and a generic version. It is the policy of Sharp Health Plan that when a Generic Drug is available, Sharp Health Plan does not cover the corresponding Brand-Name Drug. If a generic version of a drug is available, the brand-name version will require Prior Authorization. Sharp Health Plan requires the dispensing pharmacy to dispense the Generic Drug, unless Prior Authorization for the Brand-Name Drug is obtained. 20. Any Prescription Drug for which there is an over-the-counter product that has the identical active ingredient and dosage as the Prescription Drug.

The exclusions listed above do not apply to: 1. Coverage of an entire class of Prescription Drugs when one drug within that class becomes available over- the-counter.

2. Drugs listed in this Formulary.

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ix 3. Over-the-counter products that are specifically covered and listed as a preventive care benefit under California State or federal law. Covered preventive drugs include FDA-approved cessation drugs and FDA-approved contraceptive drugs. Preventive drugs are provided at $0 Cost Sharing subject to certain exceptions. For more information regarding coverage of certain over-the-counter drugs as preventive drugs, please see your Formulary and your Member Handbook under Family Planning and Preventive Care Services.

Sharp Health Plan 4 Tier Formulary October 2021

x Nondiscrimination Notice

Sharp Health Plan complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, ancestry, religion, sex, marital status, gender, gender identity, sexual orientation, age or disability. Sharp Health Plan does not exclude people or treat them differently because of race, color, national origin, ancestry, religion, sex, marital status, gender, gender identity, sexual orientation, age or disability.

Sharp Health Plan:

• Provides free aids and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters o Information in other formats (such as large print, audio, accessible electronic formats or other formats) free of charge

• Provides free language services to people whose primary language is not English, such as: o Qualified interpreters o Information written in other languages

If you need these services, contact Customer Care at 1-800-359-2002.

If you believe that Sharp Health Plan has failed to provide these services or discriminated in another way on the basis of race, color, national origin, ancestry, religion, sex, marital status, gender, gender identity, sexual orientation, age or disability, you can file a grievance with our Civil Rights Coordinator at: • Address: Sharp Health Plan Appeal/Grievance Department, 8520 Tech Way, Suite 200, San Diego, CA 92123-1450 • Telephone: 1-800-359-2002 (TTY 711) • Fax: 1-619-740-8572

You can file a grievance in person or by mail or fax, or you can also complete the online Grievance / Appeal form on the plan’s website sharphealthplan.com. Please call our Customer Care team at 1-800-359-2002 if you need help filing a grievance. You can also file a discrimination complaint if there is a concern of discrimination based on race, color, national origin, age, disability or sex with the U.S. Department of Health and Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at 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, DC 20201, 1-800-368-1019, 1-800-537-7697 (TDD).

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

The California Department of Managed Health Care is responsible for regulating health care service plans. If your grievance has not been satisfactorily resolved by Sharp Health Plan or your grievance has remained unresolved for more than 30 days, you may call toll-free the Department of Managed Health Care for assistance: • 1-888-466-2219 Voice • 1-877-688-9891 TDD The Department of Managed Health Care’s website has complaint forms and instructions online: www.dmhc.ca.gov. IMPORTANT: Can you read this letter? If not, we can have somebody help you read it. You may also be able to get this letter written in your language. For free help, please call Sharp Health Plan right away at 1-858-499-8300 or 1-800-359-2002.

IMPORTANTE: ¿Puede leer esta carta? Si no le es posible, podemos ofrecerle ayuda para que alguien se la lea. Además, usted también puede obtener esta carta en su idioma. Para ayuda gratuita, por favor llame a Sharp Health Plan inmediatamente al 1-858-499-8300 o 1-800-359- 2002.

Sharp Health Plan 4 Tier Formulary October 2021

xi Language Assistance Services English ATTENTION: If you do not speak English, language assistance services, free of charge, are available to you. Call 1-800-359-2002 (TTY:711).

Español (Spanish) ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-359-2002 (TTY:711).

繁體中文 (Chinese) 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 1-800-359-2002 (TTY:711)。

Tiếng Việt (Vietnamese) CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-800-359-2002 (TTY:711).

Tagalog (Tagalog – Filipino): PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-800-359-2002 (TTY:711).

한국어 (Korean): 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-800-359-2002 (TTY:711) 번으로 전화해 주십시오.

Հայերեն (Armenian): ՈՒՇԱԴՐՈՒԹՅՈՒՆ՝ Եթե խոսում եք հայերեն, ապա ձեզ անվճար կարող են տրամադրվել լեզվական աջակցության ծառայություններ: Զանգահարեք 1-800-359-2002 (TTY (հեռատիպ)՝ 711).

فارسی (Farsi): توجه :اگر به زبان فارسی گفتگو می کنید، تسهیالت زبانی بصورت رایگان برای شما تماس بگیرید (TTY:711) 2002-359-800-1 با. باشد می فراهم.

Русский (Russian): ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-800-359-2002 (телетайп: 711).

日本語 (Japanese): 注意事項:日本語を話される場合、無料の言語支援をご利用いただけます。1-800-359-2002 (TTY:711) まで、お電話にてご連絡く ださい。

ةيبرعال :(Arabic) ملحوظة :إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغویة تتوافر لك بالمجان. تصل برقم 2002-359-800-1 (رقم هاتف الصم والبكم: 711).

ਪੰਜਾਬੀ (Punjabi): ਚ ਸਹਾਇਤਾ ਸੇ ਾ ਤੁਹਾਡੇ ਲਈ ਮੁਫਤ ਉਪਲਬਿ ਹੈ। 1-800-359-2002 (TTY/TDD: 711) ‘ਤੇ ਕਾਲ ਕਰੋ।ﹱ ਧਿਆਨ ਧਿਓ: ਜੇ ਤੁਸੀ Ȃ ਪੰਜਾਬੀ ਬੋਲਿੇ ਹੋ, ਤਾȂ ਭਾਸ਼ਾ ਧ

ខ្មែរ (Mon Khmer, Cambodian): ប្រយ័㿒ន៖ បរើសិនᾶ诒នកនិ架យ 徶羶ខ្មែរ, បស玶ជំនួយខ្ននក徶羶 បោយមិនគិ㿒⏒ន ួល គឺ讶ច掶នសំ殶រ់រំបរ ើ诒នក។ ចូរ ទូរស័寒ទ 1-800-359-2002(TTY:711)។

Hmoob (Hmong): LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau 1-800-359-2002 (TTY:711).

:(दी (Hindiﴂ ह उपलब्ध ℂ। 1-800-359-2002 (TTY:711) पर कॉल ﴂदी बोलते ℂ तो आपके दलए मुफ्त मᴂ भाषा स ायता सेवाएﴂ ध्यान दᴂ : यदद आप द करᴂ।कॉल करᴂ।

ภาษาไทย (Thai): เรียน: ถา้ คณพดภาษาไทยคณสามารถใชบ้ รกิ ารชว่ ยเหลอื ทางภาษาไดฟ้ ร ี โทร 1-800-359-2002 (TTY:711).

Sharp Health Plan 4 Tier Formulary October 2021

xii

Table of Contents - DRUGS TO TREAT PAIN AND INFLAMMATION ...... 2 - DRUGS FOR NUMBING ...... 11 ANTI-INFECTIVES - DRUGS TO TREAT ...... 11 - DRUGS TO TREAT ...... 22 ANTIMYASTHENIC/ AGENTS ...... 22 ANTINEOPLASTIC AGENTS - DRUGS TO TREAT CANCER ...... 22 ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES ...... 30 CARDIOVASCULAR - DRUGS TO TREAT AND CIRCULATION CONDITIONS ...... 30 CENTRAL - DRUGS TO TREAT NERVOUS SYSTEM DISORDERS ...... 42 ENDOCRINE AND METABOLIC - DRUGS TO TREAT DIABETES AND REGULATE ...... 56 ENDOCRINE AND METABOLIC AGENTS - MISC...... 71 FLUOROQUINOLONES - DRUGS TO TREAT INFECTIONS ...... 71 GASTROINTESTINAL - DRUGS TO TREAT AND INTESTINAL DISORDERS ...... 72 GENITOURINARY - DRUGS TO TREAT GENITAL AND URINARY TRACT CONDITIONS ...... 77 HEMATOLOGIC - DRUGS TO TREAT BLOOD DISORDERS ...... 78 HEMATOPOIETIC AGENTS ...... 80 IMMUNOLOGIC AGENTS - DRUGS TO TREAT DISORDERS OF THE ...... 80 MEDICAL DEVICES ...... 86 NUTRITIONAL/SUPPLEMENTS - VITAMINS AND SUPPLEMENTS ...... 86 OPHTHALMIC - DRUGS TO TREAT EYE CONDITIONS ...... 89 RESPIRATORY - DRUGS TO TREAT BREATHING DISORDERS ...... 92 TOPICAL - DRUGS TO TREAT EAR AND CONDITIONS ...... 97 Index ...... 103

1

Sharp CA 4T eff 10/01/2021 PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS ANALGESICS - DRUGS TO TREAT PAIN AND INFLAMMATION COX-2 INHIBITORS caps 50mg, 100mg, 200mg 1 MO - DRUGS TO TREAT GOUT tabs 100mg, 300mg 1 MO tabs .6mg 1 colchicine w/ tab 0.5-500 1 MO mg febuxostat tabs 40mg, 80mg 1 ST, MO; PA** probenecid tabs 500mg 1 MO NON- ANALGESICS (-Acetaminophen Tab 50-325 1 QL (48 tabs / 25 days) mg) TENCON butalbital-acetaminophen- cap 1 QL (48 caps / 25 days) 50-300-40 mg butalbital-acetaminophen-caffeine cap 1 QL (48 caps / 25 days) 50-325-40 mg butalbital-acetaminophen-caffeine tab 1 QL (48 tabs / 25 days) 50-325-40 mg butalbital--caffeine cap 50-325- 1 QL (48 caps / 25 days) 40 mg NSAIDS - DRUGS TO TREAT PAIN AND INFLAMMATION tabs 50mg 1 MO diclofenac tb24 100mg; tbec 1 MO 25mg, 50mg, 75mg caps 200mg, 300mg; tabs 1 MO 400mg, 500mg; tb24 400mg, 500mg, 600mg tabs 600mg 3 MO tabs 50mg, 100mg 1 MO susp 100mg/5ml 1 ibuprofen tabs 400mg, 600mg, 800mg 1 MO caps 50mg, 75mg 1 MO tromethamine soln MB 15mg/ml, 30mg/ml ketorolac tromethamine tabs 10mg 1 QL (20 tabs / 25 days) meclofenamate sodium caps 50mg, 1 MO 100mg caps 250mg 1 MO tabs 7.5mg, 15mg 1 MO tabs 500mg, 750mg 1 MO tabs 250mg, 375mg, 500mg 1 MO

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 2 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS tabs 600mg 1 MO caps 10mg, 20mg 1 MO tabs 150mg, 200mg 1 MO sodium caps 400mg; tabs 1 MO 600mg NSAIDS, COMBINATIONS diclofenac w/ tab delayed 1 MO release 50-0.2 mg diclofenac w/ misoprostol tab delayed 1 MO release 75-0.2 mg OPIOID /ANTAGONIST hcl- hcl sl film 1 QL (3 units / day) 2-0.5 mg (base equiv) buprenorphine hcl-naloxone hcl sl film 1 QL (3 units / day) 4-1 mg (base equiv) buprenorphine hcl-naloxone hcl sl film 1 QL (3 units / day) 8-2 mg (base equiv) buprenorphine hcl-naloxone hcl sl film 1 QL (2 units / day) 12-3 mg (base equiv) buprenorphine hcl-naloxone hcl sl tab 1 QL (3 tabs / day) 2-0.5 mg (base equiv) buprenorphine hcl-naloxone hcl sl tab 1 QL (3 tabs / day) 8-2 mg (base equiv) ZUBSOLV SUB 0.7-0.18 (buprenorphine 2 QL (3 units / day) hcl-naloxone hcl dihydrate) ZUBSOLV SUB 1.4-0.36 (buprenorphine 2 QL (3 units / day) hcl-naloxone hcl dihydrate) ZUBSOLV SUB 2.9-0.71 (buprenorphine 2 QL (3 units / day) hcl-naloxone hcl dihydrate) ZUBSOLV SUB 5.7-1.4 (buprenorphine 2 QL (3 units / day) hcl-naloxone hcl dihydrate) ZUBSOLV SUB 8.6-2.1 (buprenorphine 2 QL (2 units / day) hcl-naloxone hcl dihydrate) ZUBSOLV SUB 11.4-2.9 (buprenorphine 2 QL (1 unit / day) hcl-naloxone hcl dihydrate) OPIOID ANALGESICS - DRUGS TO TREAT PAIN acetaminophen w/ soln 120- 1 ST, QL (2700 ml / 25 12 mg/5ml days); Subject to initial 7-day limit, PA**; subject to initial 3-day limit under age 19; not available under age 12

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 3 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS acetaminophen w/ codeine tab 300-15 1 ST, QL (400 tabs / 25 mg days); Subject to initial 7-day limit, PA**; subject to initial 3-day limit under age 19; not available under age 12 acetaminophen w/ codeine tab 300-30 1 ST, QL (360 tabs / 25 mg days); Subject to initial 7-day limit, PA**; subject to initial 3-day limit under age 19; not available under age 12 acetaminophen w/ codeine tab 300-60 1 ST, QL (180 tabs / 25 mg days); Subject to initial 7-day limit, PA**; subject to initial 3-day limit under age 19; not available under age 12 butalbital-acetaminophen-caff w/ cod 1 QL (48 caps / 25 days) cap 50-300-40-30 mg soln 1mg/ml, MB 2mg/ml butorphanol tartrate soln 10mg/ml 1 QL (2 bottles / 25 days) codeine sulfate tabs 30mg 1 ST, QL (42 tabs / 25 days); Subject to initial 7-day limit, PA**; subject to initial 3-day limit under age 19; not available under age 12 codeine sulfate tabs 60mg 3 ST, QL (42 tabs / 25 days); Subject to initial 7-day limit pt72 12mcg/hr, 25mcg/hr 1 ST, QL (10 patches / 25 days) fentanyl pt72 50mcg/hr, 75mcg/hr, 1 ST, PA; High Strength 100mcg/hr Requires PA fentanyl citrate lpop 200mcg, 1 PA, QL (120 lozenges / 400mcg, 600mcg, 800mcg, 1200mcg, 25 days) 1600mcg -acetaminophen soln 7.5- 1 ST, QL (2700 ml / 25 325 mg/15ml days); Subject to initial 7-day limit; if age 19 or younger, subject to initial 3-day limit

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 4 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS hydrocodone-acetaminophen tab 5- 1 ST, QL (240 tabs / 25 325 mg days); Subject to initial 7-day limit; if age 19 or younger, subject to initial 3-day limit hydrocodone-acetaminophen tab 7.5- 1 ST, QL (180 tabs / 25 325 mg days); Subject to initial 7-day limit; if age 19 or younger, subject to initial 3-day limit hydrocodone-acetaminophen tab 10- 1 ST, QL (180 tabs / 25 325 mg days); Subject to initial 7-day limit; if age 19 or younger, subject to initial 3-day limit hydrocodone-ibuprofen tab 10-200 mg 1 ST, QL (50 tabs / 25 days); Subject to initial 7-day limit, PA**; if age 19 or younger, subject to initial 3-day limit hcl soln 2mg/ml MB hydromorphone hcl tabs 2mg 1 ST, QL (180 tabs / 25 days); Subject to initial 7-day limit; if age 19 or younger, subject to initial 3-day limit hydromorphone hcl tabs 4mg 1 ST, QL (150 tabs / 25 days); Subject to initial 7-day limit; if age 19 or younger, subject to initial 3-day limit hydromorphone hcl tabs 8mg 1 ST, QL (60 tabs / 25 days); Subject to initial 7-day limit; if age 19 or younger, subject to initial 3-day limit hydromorphone hcl tb24 8mg, 12mg, 1 ST, QL (30 tabs / 25 16mg days) hydromorphone hcl tb24 32mg 1 ST, PA; High Strength Requires PA; if age 19 or younger, subject to initial 3-day limit hcl conc 10mg/ml 1 QL (30 ml / 25 days); (indicated for opioid )

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 5 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS (Methadone Hcl Conc 10mg/ml) 1 ST, QL (60 mL / 25 METHADONE HYDROCHLORIDE I days); (generic of Methadone Intensol, indicated for pain) methadone hcl soln 5mg/5ml 1 ST, QL (450 ml / 25 days) methadone hcl soln 10mg/5ml 1 ST, QL (300 mL / 25 days) methadone hcl tabs 5mg 1 ST, QL (90 tabs / 25 days) methadone hcl tabs 10mg 1 ST, QL (60 tabs / 25 days) methadone hcl tbso 40mg 1 QL (9 tabs / 25 days) (Methadone Hcl Tbso 40mg) METHADOSE 1 QL (9 tabs / 25 days) sulfate cp24 10mg, 20mg, 1 ST, QL (60 caps / 25 30mg days) morphine sulfate cp24 50mg, 60mg, 1 ST, QL (30 caps / 25 80mg days) morphine sulfate cp24 100mg; tbcr 1 ST, PA; High Strength 60mg, 100mg, 200mg Requires PA morphine sulfate soln 4mg/ml, MB 10mg/ml morphine sulfate soln 10mg/5ml 1 ST, QL (900 ml / 25 days); Subject to initial 7-day limit; if age 19 or younger, subject to initial 3-day limit morphine sulfate soln 20mg/5ml 1 ST, QL (675 mL / 25 days); Subject to initial 7-day limit; if age 19 or younger, subject to initial 3-day limit morphine sulfate soln 100mg/5ml 1 ST, QL (135 mL / 25 days); Subject to initial 7-day limit; if age 19 or younger, subject to initial 3-day limit morphine sulfate supp 5mg, 10mg 1 ST, QL (180 / 25 days); Subject to initial 7-day limit; if age 19 or younger, subject to initial 3-day limit

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 6 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS morphine sulfate supp 20mg 1 ST, QL (120 supp / 25 days); Subject to initial 7-day limit; if age 19 or younger, subject to initial 3-day limit morphine sulfate supp 30mg 1 ST, QL (90 supp / 25 days); Subject to initial 7-day limit; if age 19 or younger, subject to initial 3-day limit morphine sulfate tabs 15mg 1 ST, QL (180 tabs / 25 days); Subject to initial 7-day limit; if age 19 or younger, subject to initial 3-day limit morphine sulfate tabs 30mg 1 ST, QL (90 tabs / 25 days); Subject to initial 7-day limit; if age 19 or younger, subject to initial 3-day limit morphine sulfate tbcr 15mg, 30mg 1 ST, QL (90 tabs / 25 days) morphine sulfate beads cp24 30mg, 1 ST, QL (30 caps / 25 45mg, 60mg, 75mg, 90mg days) morphine sulfate beads cp24 120mg 1 ST, PA; High Strength Requires PA hcl soln 10mg/ml, MB 20mg/ml NUCYNTA TABS 50mg ( hcl) 2 ST, QL (120 tabs / 25 days); Subject to initial 7-day limit; if age 19 or younger, subject to initial 3-day limit NUCYNTA TABS 75mg (tapentadol hcl) 2 ST, QL (90 tabs / 25 days); Subject to initial 7-day limit; if age 19 or younger, subject to initial 3-day limit NUCYNTA TABS 100mg (tapentadol hcl) 2 ST, QL (60 tabs / 25 days); Subject to initial 7-day limit; if age 19 or younger, subject to initial 3-day limit NUCYNTA ER TB12 50mg, 100mg 3 ST, QL (60 tabs / 25 (tapentadol hcl) days)

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 7 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS NUCYNTA ER TB12 150mg, 200mg, 3 ST, PA; High Strength 250mg (tapentadol hcl) Requires PA hcl caps 5mg 1 ST, QL (180 caps / 25 days); Subject to initial 7-day limit; if age 19 or younger, subject to initial 3-day limit oxycodone hcl conc 100mg/5ml 1 ST, QL (90 mL / 25 days); Subject to initial 7-day limit; if age 19 or younger, subject to initial 3-day limit oxycodone hcl soln 5mg/5ml 1 ST, QL (900 ml / 25 days); Subject to initial 7-day limit; if age 19 or younger, subject to initial 3-day limit oxycodone hcl t12a 10mg, 15mg, 1 ST, QL (60 tabs / 25 20mg, 30mg days) oxycodone hcl t12a 40mg, 60mg, 1 ST, PA; High Strength 80mg Requires PA oxycodone hcl tabs 5mg, 10mg 1 ST, QL (180 tabs / 25 days); Subject to initial 7-day limit; if age 19 or younger, subject to initial 3-day limit oxycodone hcl tabs 15mg 1 ST, QL (120 tabs / 25 days); Subject to initial 7-day limit; if age 19 or younger, subject to initial 3-day limit oxycodone hcl tabs 20mg 1 ST, QL (90 tabs / 25 days); Subject to initial 7-day limit; if age 19 or younger, subject to initial 3-day limit oxycodone hcl tabs 30mg 1 ST, QL (60 tabs / 25 days); Subject to initial 7-day limit; if age 19 or younger, subject to initial 3-day limit

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 8 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS oxycodone w/ acetaminophen tab 2.5- 1 ST, QL (360 tabs / 25 325 mg days); Subject to initial 7-day limit, PA**; if age 19 or younger, subject to initial 3-day limit (Oxycodone W/ Acetaminophen Tab 2.5- 1 ST, QL (360 tabs / 25 325 mg) ENDOCET days); Subject to initial 7-day limit, PA**; if age 19 or younger, subject to initial 3-day limit oxycodone w/ acetaminophen tab 5- 1 ST, QL (360 tabs / 25 325 mg days); Subject to initial 7-day limit, PA**; if age 19 or younger, subject to initial 3-day limit (Oxycodone W/ Acetaminophen Tab 5-325 1 ST, QL (360 tabs / 25 mg) ENDOCET days); Subject to initial 7-day limit, PA**; if age 19 or younger, subject to initial 3-day limit oxycodone w/ acetaminophen tab 7.5- 1 ST, QL (240 tabs / 25 325 mg days); Subject to initial 7-day limit, PA**; if age 19 or younger, subject to initial 3-day limit (Oxycodone W/ Acetaminophen Tab 7.5- 1 ST, QL (240 tabs / 25 325 mg) ENDOCET days); Subject to initial 7-day limit, PA**; if age 19 or younger, subject to initial 3-day limit oxycodone w/ acetaminophen tab 10- 1 ST, QL (180 tabs / 25 325 mg days); Subject to initial 7-day limit, PA**; if age 19 or younger, subject to initial 3-day limit (Oxycodone W/ Acetaminophen Tab 10- 1 ST, QL (180 tabs / 25 325 mg) ENDOCET days); Subject to initial 7-day limit, PA**; if age 19 or younger, subject to initial 3-day limit oxycodone-aspirin tab 4.8355-325 mg 1 ST, QL (360 tabs / 25 days); Subject to initial 7-day limit

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 9 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS oxycodone-ibuprofen tab 5-400 mg 1 ST, QL (28 tabs / 25 days); Subject to initial 7-day limit hcl tabs 5mg 1 ST, QL (180 tabs / 25 days); Subject to initial 7-day limit; if age 19 or younger, subject to initial 3-day limit oxymorphone hcl tabs 10mg 1 ST, QL (90 tabs / 25 days); Subject to initial 7-day limit; if age 19 or younger, subject to initial 3-day limit oxymorphone hcl tb12 5mg, 7.5mg, 1 ST, QL (60 tabs / 25 10mg, 15mg days) oxymorphone hcl tb12 20mg, 30mg, 1 ST, PA; High Strength 40mg Requires PA hcl tabs 50mg 1 ST, QL (180 tabs / 25 days); Subject to initial 7-day limit; subject to initial 3-day limit under age 19; not available under age 12 tramadol hcl tb24 100mg 1 ST, QL (30 tabs / 25 days) tramadol hcl tb24 200mg, 300mg 1 ST, PA; High Strength Requires PA tramadol-acetaminophen tab 37.5-325 1 ST, QL (40 tabs / 25 mg days); Subject to initial 7-day limit, PA**; subject to initial 3-day limit under age 19; not available under age 12 XTAMPZA ER C12A 9mg, 13.5mg, 18mg, 2 ST, QL (60 caps / 25 27mg (oxycodone) days) XTAMPZA ER C12A 36mg (oxycodone) 2 ST, PA; High Strength Requires Prior Auth OPIOID PARTIAL BELBUCA FILM 75mcg, 150mcg, 300mcg, 2 ST, QL (60 films / 25 450mcg (buprenorphine hcl) days) BELBUCA FILM 600mcg, 750mcg, 900mcg 2 ST, PA; High Strength (buprenorphine hcl) Requires Prior Auth buprenorphine ptwk 5mcg/hr, 1 ST, QL (4 patches / 25 7.5mcg/hr, 10mcg/hr days)

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 10 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS buprenorphine ptwk 15mcg/hr, 1 ST, PA; High Strength 20mcg/hr Requires Prior Auth buprenorphine hcl soln .3mg/ml MB buprenorphine hcl subl 2mg, 8mg 1 QL (90 tabs / 25 days); Must obtain approval after the first 30 day supply SUBLOCADE SOSY 100mg/0.5ml, MB 300mg/1.5ml (buprenorphine) SALICYLATES (Aspirin Chew 81mg) GOODSENSE PV QL (100 tabs / 30 days); ASPIRIN $0 copay for members age 50-59 or age 12-59 years at risk for preeclampsia, otherwise not covered (Aspirin Tbec 81mg) ASPIRIN ENTERIC PV QL (100 tabs / 30 days); COATED AD $0 copay for members age 50-59 or age 12-59 years at risk for preeclampsia, otherwise not covered tabs 500mg 1 MO ANESTHETICS - DRUGS FOR NUMBING LOCAL ANESTHETICS hcl (local anesth.) soln .5%, MB 1%, 2% ANTI-INFECTIVES - DRUGS TO TREAT INFECTIONS ANTI-BACTERIALS - MISCELLANEOUS sulfate soln 1gm/4ml, MB 500mg/2ml tromethamine pack 3gm 1 sulfate soln 40mg/ml MB sulfate tabs 500mg 1 sulfate caps 250mg 1 TABS 500mg 3 tabs 250mg, 500mg 1 nebu 300mg/4ml 4 SP, PA, QL (224 mL / 28 days), MO tobramycin nebu 300mg/5ml 4 SP, PA, QL (280 mL / 28 days), MO tobramycin sulfate soln 40mg/ml, MB 80mg/2ml; solr 1.2gm

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 11 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS ANTI-INFECTIVES - MISCELLANEOUS ALINIA SUSR 100mg/5ml () 3 QL (540mL / 25 days) susp 750mg/5ml 1 solr 1gm, 2gm MB CAYSTON SOLR 75mg (aztreonam 4 SP, PA, QL (84 vials / 28 ) days) hcl caps 75mg, 150mg, 1 300mg clindamycin palmitate hydrochloride 1 solr 75mg/5ml clindamycin soln MB 9gm/60ml, 300mg/2ml, 600mg/4ml, 9000mg/60ml tabs 25mg, 100mg 1 MO EMVERM CHEW 100mg () 3 QL (12 tabs / 365 days) sodium solr 1gm MB tabs 3mg 1 soln 600mg/300ml MB linezolid susr 100mg/5ml; tabs 1 600mg linezolid in iv soln 600 MB mg/300ml-0.9% solr 1gm, 500mg MB methenamine hippurate tabs 1gm 1 caps 375mg; tabs 1 250mg, 500mg metronidazole in nacl 0.79% iv soln MB 500 mg/100ml nitazoxanide tabs 500mg 1 QL (20 tabs / 25 days) nitrofurantoin susp 25mg/5ml 1 PA; High Risk Medications require PA for members age 70 and older nitrofurantoin macrocrystal caps 1 PA; High Risk 25mg, 50mg, 100mg Medications require PA for members age 70 and older nitrofurantoin monohyd macro caps 1 PA; High Risk 100mg Medications require PA for members age 70 and older isethionate solr 300mg 1 pentamidine isethionate solr 300mg MB b sulfate solr 500000unit MB

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 12 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS tabs 600mg 1 QL (24 tabs / 365 days) PRIMSOL SOLN 50mg/5ml ( 2 hcl) tabs 25mg 3 PA sulfamethoxazole-trimethoprim susp 1 200-40 mg/5ml sulfamethoxazole-trimethoprim tab 1 400-80 mg sulfamethoxazole-trimethoprim tab 1 800-160 mg trimethoprim tabs 100mg 1 hcl caps 125mg, 250mg 1 QL (80 caps / 10 days) vancomycin hcl solr 1gm, 5gm, 10gm, MB 500mg, 750mg XIFAXAN TABS 200mg () 2 QL (9 tabs / 25 days) XIFAXAN TABS 550mg (rifaximin) 2 PA, MO - DRUGS TO TREAT FUNGAL INFECTIONS solr 50mg MB BIO- CAPS 500000unit, 2 1000000unit () CRESEMBA CAPS 186mg 3 ( sulfate) susr 10mg/ml, 40mg/ml; 1 tabs 50mg, 100mg, 150mg, 200mg microsize susp 1 125mg/5ml; tabs 500mg griseofulvin ultramicrosize tabs 1 125mg, 250mg caps 100mg; soln 1 PA 10mg/ml NOXAFIL SUSP 40mg/ml () 2 PA, MO nystatin tabs 500000unit 1 (*nystatin Oral Powder*) BIO-STATIN 1 posaconazole tbec 100mg 3 PA, MO hcl tabs 250mg 1 susr 40mg/ml; tabs 2 PA 50mg, 200mg ANTIMALARIALS - DRUGS TO TREAT atovaquone- hcl tab 62.5-25 1 mg atovaquone-proguanil hcl tab 250-100 1 mg phosphate tabs 250mg, 1 MO 500mg

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 13 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS COARTEM TAB 20-120MG (- 3 ) hcl tabs 250mg 1 MO phosphate tabs 26.3mg 1 sulfate caps 324mg 1 ANTIRETROVIRAL AGENTS - DRUGS TO SUPPRESS HIV/AIDS sulfate soln 20mg/ml 1 SP, QL (900 mL / 30 days), MO abacavir sulfate tabs 300mg 1 SP, QL (60 tabs / 30 days), MO APTIVUS CAPS 250mg () 2 SP, QL (120 caps / 30 days), MO APTIVUS SOLN 100mg/ml (tipranavir) 2 SP, QL (285 mL / 28 days), MO sulfate caps 150mg, 1 SP, QL (30 caps / 30 300mg days), MO atazanavir sulfate caps 200mg 1 SP, QL (60 caps / 30 days), MO CRIXIVAN CAPS 200mg ( 2 SP, QL (450 caps / 30 sulfate) days), MO CRIXIVAN CAPS 400mg (indinavir 2 SP, QL (180 caps / 30 sulfate) days), MO cpdr 200mg, 250mg, 1 SP, QL (30 caps / 30 400mg days), MO EDURANT TABS 25mg ( hcl) 2 SP, QL (60 tabs / 30 days), MO caps 50mg, 200mg 1 SP, QL (90 caps / 30 days), MO efavirenz tabs 600mg 1 SP, QL (30 tabs / 30 days), MO caps 200mg 1 SP, QL (30 caps / 30 days), MO EMTRIVA SOLN 10mg/ml (emtricitabine) 2 SP, QL (680 ml / 28 days), MO tabs 100mg 1 SP, QL (120 tabs / 30 days), MO etravirine tabs 200mg 1 SP, QL (60 tabs / 30 days), MO calcium tabs 700mg 1 SP, QL (120 tabs / 30 days), MO FUZEON SOLR 90mg () MB MO INTELENCE TABS 25mg, 100mg 2 SP, QL (120 tabs / 30 (etravirine) days), MO

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 14 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS INTELENCE TABS 200mg (etravirine) 2 SP, QL (60 tabs / 30 days), MO INVIRASE TABS 500mg ( 2 SP, QL (120 tabs / 30 mesylate) days), MO ISENTRESS CHEW 25mg, 100mg 2 SP, QL (180 tabs / 30 ( potassium) days), MO ISENTRESS PACK 100mg (raltegravir 2 SP, QL (60 packets / 30 potassium) days), MO ISENTRESS TABS 400mg (raltegravir 2 SP, QL (120 tabs / 30 potassium) days), MO ISENTRESS HD TABS 600mg (raltegravir 2 SP, QL (60 tabs / 30 potassium) days), MO soln 10mg/ml 1 SP, QL (900 ml / 30 days), MO lamivudine tabs 150mg 1 SP, QL (60 tabs / 30 days), MO lamivudine tabs 300mg 1 SP, QL (30 tabs / 30 days), MO LEXIVA SUSP 50mg/ml (fosamprenavir 2 SP, QL (1575 mL / 28 calcium) days), MO susp 50mg/5ml 1 SP, QL (1200 mL / 30 days), MO nevirapine tabs 200mg 1 SP, QL (60 tabs / 30 days), MO nevirapine tb24 100mg 1 SP, QL (90 tabs / 30 days), MO nevirapine tb24 400mg 1 SP, QL (30 tabs / 30 days), MO NORVIR PACK 100mg () 2 SP, QL (360 packets / 30 days), MO NORVIR SOLN 80mg/ml (ritonavir) 2 SP, QL (480 mL / 30 days), MO PREZISTA SUSP 100mg/ml ( 2 SP, QL (400 ml / 30 ethanolate) days), MO PREZISTA TABS 75mg (darunavir 2 SP, QL (300 tabs / 30 ethanolate) days), MO PREZISTA TABS 150mg (darunavir 2 SP, QL (180 tabs / 30 ethanolate) days), MO PREZISTA TABS 600mg (darunavir 2 SP, QL (60 tabs / 30 ethanolate) days), MO PREZISTA TABS 800mg (darunavir 2 SP, QL (30 tabs / 30 ethanolate) days), MO RETROVIR IV INFUSION SOLN 10mg/ml MB ()

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 15 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS REYATAZ PACK 50mg (atazanavir 2 SP, QL (180 packets / sulfate) 30 days), MO ritonavir tabs 100mg 1 SP, QL (360 tabs / 30 days), MO SELZENTRY SOLN 20mg/ml () 2 SP, QL (1840 mL / 30 days), MO SELZENTRY TABS 25mg (maraviroc) 2 SP, QL (240 tabs / 30 days), MO SELZENTRY TABS 75mg, 150mg 2 SP, QL (60 tabs / 30 (maraviroc) days), MO SELZENTRY TABS 300mg (maraviroc) 2 SP, QL (120 tabs / 30 days), MO caps 15mg, 20mg, 30mg, 1 SP, QL (60 caps / 30 40mg days), MO fumarate tabs 1 SP, QL (30 tabs / 30 300mg days), MO TIVICAY TABS 10mg ( 2 SP, QL (240 tabs / 30 sodium) days), MO TIVICAY TABS 25mg, 50mg 2 SP, QL (60 tabs / 30 (dolutegravir sodium) days), MO TIVICAY PD TBSO 5mg (dolutegravir 2 SP, QL (360 tabs / 30 sodium) days), MO TROGARZO SOLN 200mg/1.33ml MB MO (-uiyk) TYBOST TABS 150mg () 2 SP, QL (30 tabs / 30 days), MO VIDEX EC CPDR 125mg (didanosine) 2 SP, QL (30 caps / 30 days), MO VIDEX PEDIATRIC SOLR 2gm 2 SP, QL (1200 ml / 30 (didanosine) days), MO VIRACEPT TABS 250mg ( 2 SP, QL (300 tabs / 30 mesylate) days), MO VIRACEPT TABS 625mg (nelfinavir 2 SP, QL (120 tabs / 30 mesylate) days), MO VIREAD POWD 40mg/gm (tenofovir 2 SP, QL (240 gm / 30 disoproxil fumarate) days), MO VIREAD TABS 150mg, 200mg, 250mg 2 SP, QL (30 tabs / 30 (tenofovir disoproxil fumarate) days), MO zidovudine caps 100mg 1 SP, QL (180 caps / 30 days), MO zidovudine syrp 50mg/5ml 1 SP, QL (1800 ml / 30 days), MO zidovudine tabs 300mg 1 SP, QL (60 tabs / 30 days), MO

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 16 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS ANTIRETROVIRAL COMBINATION AGENTS - DRUGS TO SUPPRESS HIV/AIDS INFECTION abacavir sulfate-lamivudine tab 600- 1 SP, QL (30 tabs / 30 300 mg days), MO abacavir sulfate-lamivudine- 1 SP, QL (60 tabs / 30 zidovudine tab 300-150-300 mg days), MO BIKTARVY TAB (- 2 SP, QL (30 tabs / 30 emtricitabine- days), MO fumarate) CIMDUO TAB 300-300 (lamivudine- 2 SP, QL (30 tabs / 30 tenofovir disoproxil fumarate) days), MO DESCOVY TAB 200/25MG (emtricitabine- 2 SP, QL (30 tabs / 30 tenofovir alafenamide fumarate) days), MO; $0 Copay for PrEP DOVATO TAB 50-300MG (dolutegravir 2 SP, QL (30 tabs / 30 sodium-lamivudine) days), MO efavirenz-emtricitabine-tenofovir df 1 SP, QL (30 tabs / 30 tab 600-200-300 mg days), MO efavirenz-lamivudine-tenofovir df tab 1 SP, QL (30 tabs / 30 400-300-300 mg days), MO efavirenz-lamivudine-tenofovir df tab 1 SP, QL (30 tabs / 30 600-300-300 mg days), MO emtricitabine-tenofovir disoproxil 1 SP, QL (30 tabs / 30 fumarate tab 100-150 mg days), MO emtricitabine-tenofovir disoproxil 1 SP, QL (30 tabs / 30 fumarate tab 133-200 mg days), MO emtricitabine-tenofovir disoproxil 1 SP, QL (30 tabs / 30 fumarate tab 167-250 mg days), MO emtricitabine-tenofovir disoproxil 1 SP, QL (30 tabs / 30 fumarate tab 200-300 mg days), MO; $0 Copay for PrEP EVOTAZ TAB 300-150 (atazanavir 2 SP, QL (30 tabs / 30 sulfate-cobicistat) days), MO GENVOYA TAB (-cobicistat- 2 SP, QL (30 tabs / 30 emtricitabine-tenofovir alafenamide) days), MO KALETRA TAB 100-25MG (- 2 SP, QL (240 tabs / 30 ritonavir) days), MO KALETRA TAB 200-50MG (lopinavir- 2 SP, QL (120 tabs / 30 ritonavir) days), MO lamivudine-zidovudine tab 150-300 1 SP, QL (60 tabs / 30 mg days), MO lopinavir-ritonavir soln 400-100 1 SP, QL (390 mL / 30 mg/5ml (80-20 mg/ml) days), MO

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 17 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS lopinavir-ritonavir tab 100-25 mg 1 SP, QL (240 tabs / 30 days), MO lopinavir-ritonavir tab 200-50 mg 1 SP, QL (120 tabs / 30 days), MO ODEFSEY TAB (emtricitabine-rilpivirine- 2 SP, QL (30 tabs / 30 tenofovir alafenamide fumarate) days), MO PREZCOBIX TAB 800-150 (darunavir- 2 SP, QL (30 tabs / 30 cobicistat) days), MO TEMIXYS TAB 300-300 (lamivudine- 2 SP, QL (30 tabs / 30 tenofovir disoproxil fumarate) days), MO TRIUMEQ TAB (abacavir-dolutegravir- 2 SP, QL (30 tabs / 30 lamivudine) days), MO ANTITUBERCULAR AGENTS - DRUGS TO TREAT caps 250mg 1 ethambutol hcl tabs 100mg, 400mg 1 soln 100mg/ml MB isoniazid syrp 50mg/5ml; tabs 1 MO 100mg, 300mg PASER PACK 4gm (aminosalicylic acid) 3 PRIFTIN TABS 150mg (rifapentine) 2 pyrazinamide tabs 500mg 1 caps 150mg 1 RIFAMATE CAP (isoniazid & rifampin) 2 rifampin caps 150mg, 300mg 1 rifampin solr 600mg MB RIFATER TAB (isoniazid-rifampin w/ 2 pyrazinamide) SIRTURO TABS 20mg, 100mg 4 PA ( fumarate) TRECATOR TABS 250mg (ethionamide) 2 ANTIVIRALS - DRUGS TO TREAT VIRAL INFECTIONS acyclovir caps 200mg; susp 1 200mg/5ml; tabs 400mg, 800mg adefovir dipivoxil tabs 10mg 4 SP, MO BARACLUDE SOLN .05mg/ml (entecavir) 3 SP, MO soln 75mg/ml MB entecavir tabs .5mg, 1mg 4 SP, MO EPIVIR HBV SOLN 5mg/ml (lamivudine 2 SP, MO (hbv)) famciclovir tabs 125mg, 250mg, 1 500mg lamivudine (hbv) tabs 100mg 1 SP, MO oseltamivir phosphate caps 30mg 1 QL (40 caps / 90 days)

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 18 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS oseltamivir phosphate caps 45mg, 1 QL (20 caps / 90 days) 75mg oseltamivir phosphate susr 6mg/ml 1 QL (360 mL / 90 days) RELENZA DISKHALER AEPB 5mg/blister 2 QL (2 inhalers / 90 () days) ribavirin solr 6gm MB hydrochloride tabs 1 100mg valacyclovir hcl tabs 500mg, 1000mg 1 valganciclovir hcl solr 50mg/ml 4 PA, QL (1000 mL / 30 days), MO valganciclovir hcl tabs 450mg 4 PA, QL (120 tabs / 30 days), MO - DRUGS TO TREAT INFECTIONS caps 250mg, 500mg; susr 1 125mg/5ml, 250mg/5ml, 375mg/5ml caps 500mg; susr 1 250mg/5ml, 500mg/5ml; tabs 1gm sodium solr 1gm MB caps 300mg; susr 1 125mg/5ml, 250mg/5ml pivoxil tabs 200mg, 400mg 1 hcl solr 1gm, 2gm MB caps 400mg; susr 1 100mg/5ml, 200mg/5ml proxetil susr 50mg/5ml, 1 100mg/5ml; tabs 100mg, 200mg susr 125mg/5ml, 1 250mg/5ml; tabs 250mg, 500mg ( Solr 1gm) TAZICEF MB ceftazidime solr 2gm MB sodium solr 1gm, 2gm, MB 10gm, 250mg, 500mg axetil tabs 250mg, 500mg 1 cephalexin caps 250mg, 500mg, 1 750mg; susr 125mg/5ml, 250mg/5ml; tabs 250mg, 500mg SUPRAX CHEW 100mg, 200mg; SUSR 2 500mg/5ml (cefixime) / - DRUGS TO TREAT INFECTIONS pack 1gm; susr 1 100mg/5ml, 200mg/5ml; tabs 250mg, 500mg, 600mg

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 19 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS susr 125mg/5ml, 1 250mg/5ml; tabs 250mg, 500mg; tb24 500mg DIFICID SUSR 40mg/ml; TABS 200mg 2 PA (fidaxomicin) base cpep 250mg; tabs 1 250mg, 500mg (Erythromycin Base Tbec 250mg, 333mg, 1 500mg) ERY-TAB erythromycin ethylsuccinate susr 1 200mg/5ml, 400mg/5ml; tabs 400mg (Erythromycin Stearate Tabs 250mg) 1 ERYTHROCIN STEARATE FLUOROQUINOLONES - DRUGS TO TREAT INFECTIONS CIPRO SUSR 500mg/5ml () 3 ciprofloxacin hcl tabs 100mg, 250mg, 1 500mg, 750mg soln 25mg/ml MB levofloxacin soln 25mg/ml; tabs 1 250mg, 500mg, 750mg moxifloxacin hcl tabs 400mg 1 tabs 300mg, 400mg 1 C EPCLUSA TAB 200-50MG (- 4 SP, PA, QL (28 tabs / 28 velpatasvir) days) EPCLUSA TAB 400-100 (sofosbuvir- 4 SP, PA, QL (28 tabs / 28 velpatasvir) days) HARVONI PAK (ledipasvir-sofosbuvir) 4 SP, PA, QL (28 pellets / 28 days) HARVONI PAK 45-200MG (ledipasvir- 4 SP, PA, QL (28 pellets / sofosbuvir) 28 days) HARVONI TAB 45-200MG (ledipasvir- 4 SP, PA, QL (28 tabs / 28 sofosbuvir) days) HARVONI TAB 90-400MG (ledipasvir- 4 SP, PA, QL (28 tabs / 28 sofosbuvir) days) PEGASYS SOLN 180mcg/0.5ml, MB 180mcg/ml (peginterferon alfa-2a) ribavirin (hepatitis c) caps 200mg; 1 SP, PA tabs 200mg SOVALDI PACK 150mg, 200mg 4 SP, ST, PA, QL (28 (sofosbuvir) pellets / 28 days) SOVALDI TABS 200mg, 400mg 4 SP, ST, PA, QL (28 tabs (sofosbuvir) / 28 days)

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 20 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS VOSEVI TAB (sofosbuvir-velpatasvir- 4 SP, PA, QL (28 tabs / 28 voxilaprevir) days) - DRUGS TO TREAT INFECTIONS caps 250mg, 500mg; chew 1 125mg, 250mg; susr 125mg/5ml, 200mg/5ml, 250mg/5ml, 400mg/5ml; tabs 500mg, 875mg amoxicillin & k clavulanate chew tab 1 200-28.5 mg amoxicillin & k clavulanate chew tab 1 400-57 mg amoxicillin & k clavulanate for susp 1 200-28.5 mg/5ml amoxicillin & k clavulanate for susp 1 250-62.5 mg/5ml amoxicillin & k clavulanate for susp 1 400-57 mg/5ml amoxicillin & k clavulanate for susp 1 600-42.9 mg/5ml amoxicillin & k clavulanate tab 250- 1 125 mg amoxicillin & k clavulanate tab 500- 1 125 mg amoxicillin & k clavulanate tab 875- 1 125 mg amoxicillin & k clavulanate tab er 12hr 1 1000-62.5 mg caps 500mg 1 ampicillin sodium solr 1gm, 2gm MB sodium caps 250mg, 1 500mg ( G Potassium Solr 20mu) MB PFIZERPEN penicillin g potassium solr MB 5000000unit, 20000000unit penicillin g sodium solr 5000000unit MB penicillin v potassium solr 1 125mg/5ml, 250mg/5ml; tabs 250mg, 500mg sod- na for inj MB 3.375 gm (3-0.375 gm) piperacillin sod-tazobactam sod for inj MB 2.25 gm (2-0.25 gm)

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 21 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS piperacillin sod-tazobactam sod for inj MB 40.5 gm (36-4.5 gm) - DRUGS TO TREAT INFECTIONS hcl tabs 150mg, 1 300mg (monohydrate) caps 1 50mg, 100mg; susr 25mg/5ml; tabs 50mg, 75mg, 150mg (Doxycycline (Monohydrate) Tabs 100mg) 1 AVIDOXY doxycycline hyclate caps 50mg, 1 100mg; tabs 100mg; tbec 75mg, 150mg (Doxycycline Hyclate Caps 100mg) 1 MORGIDOX 1X100MG doxycycline hyclate solr 100mg MB (Doxycycline Hyclate Solr 100mg) DOXY MB 100 hcl caps 50mg, 75mg, 1 100mg; tabs 50mg, 75mg, 100mg hcl caps 250mg, 500mg 1 VIBRAMYCIN SYRP 50mg/5ml 3 (doxycycline calcium) ANTICONVULSANTS - DRUGS TO TREAT SEIZURES ANTICONVULSANTS - MISC. BRIVIACT SOLN 10mg/ml; TABS 10mg, 3 MO 25mg, 50mg, 75mg, 100mg () ANTIMYASTHENIC/CHOLINERGIC AGENTS ANTIMYASTHENIC/CHOLINERGIC AGENTS methylsulfate soln MB 10mg/10ml ANTINEOPLASTIC AGENTS - DRUGS TO TREAT CANCER ALKYLATING AGENTS soln 6mg/ml MB solr 100mg MB caps 25mg, 50mg 1 OAC cyclophosphamide solr 1gm, 2gm, MB 500mg solr 100mg, 200mg MB EMCYT CAPS 140mg ( 4 OAC phosphate sodium)

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 22 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS GLEOSTINE CAPS 10mg, 40mg, 100mg 4 OAC () GLIADEL WAF 7.7MG (carmustine in MB polifeprosan) soln 1gm/20ml, MB 3gm/60ml; solr 1gm LEUKERAN TABS 2mg () 2 OAC tabs 2mg 1 OAC melphalan hcl solr 50mg MB TEMODAR SOLR 100mg () MB temozolomide caps 5mg, 20mg, 4 SP, PA; OAC 100mg, 140mg, 180mg, 250mg hcl soln 20mg/4ml MB hcl soln 2mg/ml MB (Doxorubicin Hcl Solr 10mg, 50mg) MB ADRIAMYCIN doxorubicin hcl liposomal inj 2mg/ml MB hcl soln 50mg/25ml, MB 200mg/100ml hcl soln 5mg/5ml, MB 10mg/10ml, 20mg/20ml sulfate solr 15unit, 30unit MB mitomycin solr 5mg, 20mg, 40mg MB ALIMTA SOLR 100mg, 500mg MB ( disodium) susr 100mg MB tabs 150mg 4 SP, PA, QL (120 tabs / 30 days); OAC capecitabine tabs 500mg 4 SP, PA, QL (300 tabs / 30 days); OAC soln 10mg/10ml MB soln 1mg/ml MB soln 20mg/ml, 100mg/ml MB solr 50mg MB solr .5gm MB phosphate soln MB 50mg/2ml; solr 50mg soln 1gm/20ml, MB 2.5gm/50ml, 5gm/100ml, 500mg/10ml

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 23 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS hcl soln 1gm/26.3ml, MB 2gm/52.6ml, 200mg/5.26ml; solr 1gm, 2gm, 200mg tabs 50mg 1 OAC sodium soln 1gm/40ml, MB 50mg/2ml, 250mg/10ml; solr 1gm NIPENT SOLR 10mg () MB TABLOID TABS 40mg (thioguanine) 2 OAC ANTIMITOTIC, TAXOIDS ABRAXANE INJ 100MG ( MB -bound particles) conc 20mg/ml, 80mg/4ml, MB 160mg/8ml; soln 20mg/2ml, 80mg/8ml, 160mg/16ml paclitaxel conc 30mg/5ml, MB 100mg/16.7ml, 150mg/25ml, 300mg/50ml ANTIMITOTIC, VINCA sulfate soln 1mg/ml MB sulfate soln 1mg/ml MB tartrate soln 10mg/ml, MB 50mg/5ml BIOLOGIC RESPONSE MODIFIERS ERBITUX SOLN 100mg/50ml, MB 200mg/100ml () ERIVEDGE CAPS 150mg () 4 SP, PA, QL (30 caps / 30 days); OAC FARYDAK CAPS 10mg, 15mg, 20mg 4 SP, PA, QL (6 caps / 21 ( lactate) days); OAC GAZYVA SOLN 1000mg/40ml MB () IBRANCE CAPS 75mg, 100mg, 125mg 4 SP, PA, QL (21 caps / 28 () days); OAC IBRANCE TABS 75mg, 100mg, 125mg 4 SP, PA, QL (21 tabs / 28 (palbociclib) days); OAC KADCYLA SOLR 100mg, 160mg (ado- MB emtansine) KEYTRUDA SOLN 100mg/4ml MB () KISQALI TBPK 200mg ( 4 SP, PA, QL (21 tabs / 28 succinate) days); 200 mg dose; OAC

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 24 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS KISQALI TBPK 200mg (ribociclib 4 SP, PA, QL (42 tabs / 28 succinate) days); 400 mg dose; OAC KISQALI TBPK 200mg (ribociclib 4 SP, PA, QL (63 tabs / 28 succinate) days); 600 mg dose; OAC LYNPARZA TABS 100mg, 150mg 4 SP, PA, QL (120 tabs / () 30 days); OAC RYDAPT CAPS 25mg () 4 SP, PA, QL (224 caps / 28 days); OAC ZEJULA CAPS 100mg ( 4 PA, QL (90 caps / 30 tosylate) days); OAC ZOLINZA CAPS 100mg () 4 SP, PA, QL (120 caps / 30 days); OAC HORMONAL ANTINEOPLASTIC AGENTS abiraterone tabs 250mg 4 SP, PA, QL (120 tabs / 30 days); OAC tabs 500mg 4 SP, PA, QL (60 tabs / 30 days); OAC tabs 1mg 1 MO; OAC; $0 copay ages 35 and older for the primary prevention of cancer tabs 50mg 1 OAC DEPO-PROVERA SUSP 400mg/ml MB ( acetate (antineoplastic)) ELIGARD KIT 7.5mg (leuprolide MB acetate) ELIGARD KIT 22.5mg (leuprolide MB acetate (3 month)) ELIGARD KIT 30mg (leuprolide acetate MB (4 month)) ELIGARD KIT 45mg (leuprolide acetate MB (6 month)) ERLEADA TABS 60mg () 4 SP, PA, QL (120 tabs / 30 days); OAC tabs 25mg 1 MO; OAC; $0 copay ages 35 and older for the primary prevention of caps 125mg 1 OAC soln 250mg/5ml MB tabs 2.5mg 1 MO; OAC

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 25 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS leuprolide acetate 1mg/0.2ml MB LUPRON DEPOT-PED (1-MONTH KIT MB 7.5mg, 11.25mg, 15mg (leuprolide acetate (cpp)) LUPRON DEPOT-PED (3-MONTH KIT MB 11.25mg, 30mg (leuprolide acetate (cpp) (3 month)) LYSODREN TABS 500mg () 2 OAC acetate susp 40mg/ml; 1 OAC tabs 20mg, 40mg () susp 1 MO; OAC 625mg/5ml tabs 150mg 1 OAC NUBEQA TABS 300mg () 4 SP, PA, QL (120 tabs / 30 days); OAC citrate tabs 10mg, 20mg 1 MO; OAC; $0 copay ages 35 and older for the primary prevention of breast cancer citrate tabs 60mg 1 MO; OAC XTANDI CAPS 40mg () 4 SP, PA, QL (120 caps / 30 days); OAC XTANDI TABS 40mg (enzalutamide) 4 SP, PA, QL (120 tabs / 30 days); OAC XTANDI TABS 80mg (enzalutamide) 4 SP, PA, QL (60 tabs / 30 days); OAC YONSA TABS 125mg (abiraterone 4 SP, PA, QL (120 tabs / acetate) 30 days); OAC KINASE INHIBITORS AFINITOR TABS 10mg () 4 SP, PA, QL (30 tabs / 30 days); OAC AFINITOR DISPERZ TBSO 2mg, 5mg 4 SP, PA, QL (60 tabs / 30 (everolimus) days); OAC AFINITOR DISPERZ TBSO 3mg 4 SP, PA, QL (90 tabs / 30 (everolimus) days); OAC ALECENSA CAPS 150mg ( hcl) 4 SP, PA, QL (240 caps / 30 days); OAC BOSULIF TABS 100mg () 4 SP, PA, QL (90 tabs / 30 days); OAC BOSULIF TABS 400mg, 500mg 4 SP, PA, QL (30 tabs / 30 (bosutinib) days); OAC CABOMETYX TABS 20mg, 40mg, 60mg 4 SP, PA, QL (30 tabs / 30 ( s-malate) days); OAC

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 26 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS CALQUENCE CAPS 100mg 4 PA, QL (60 caps / 30 () days); OAC CAPRELSA TABS 100mg () 4 PA, QL (60 tabs / 30 days); OAC CAPRELSA TABS 300mg (vandetanib) 4 PA, QL (30 tabs / 30 days); OAC COMETRIQ KIT 20mg (cabozantinib s- 4 SP, PA, QL (1 kit / 28 malate) days); OAC COMETRIQ KIT 100MG (cabozantinib s- 4 SP, PA, QL (1 kit / 28 malate) days); OAC COMETRIQ KIT 140MG (cabozantinib s- 4 SP, PA, QL (1 kit / 28 malate) days); OAC hcl tabs 25mg 4 SP, PA, QL (60 tabs / 30 days); OAC erlotinib hcl tabs 100mg, 150mg 4 SP, PA, QL (30 tabs / 30 days); OAC everolimus tabs 2.5mg, 5mg, 7.5mg 4 SP, PA, QL (30 tabs / 30 days); OAC ICLUSIG TABS 10mg, 15mg, 30mg, 45mg 4 PA, QL (30 tabs / 30 ( hcl) days); OAC IDHIFA TABS 50mg, 100mg ( 4 SP, PA, QL (30 tabs / 30 mesylate) days); OAC mesylate tabs 100mg 4 SP, PA, QL (90 tabs / 30 days); OAC imatinib mesylate tabs 400mg 4 SP, PA, QL (60 tabs / 30 days); OAC IMBRUVICA CAPS 70mg () 4 PA, QL (30 caps / 30 days); OAC IMBRUVICA CAPS 140mg (ibrutinib) 4 PA, QL (90 caps / 30 days); OAC IMBRUVICA TABS 140mg, 280mg, 420mg, 4 PA, QL (30 tabs / 30 560mg (ibrutinib) days); OAC INLYTA TABS 1mg () 4 SP, PA, QL (240 tabs / 30 days); OAC INLYTA TABS 5mg (axitinib) 4 SP, PA, QL (120 tabs / 30 days); OAC JAKAFI TABS 5mg, 10mg, 15mg, 20mg, 4 SP, PA, QL (60 tabs / 30 25mg ( phosphate) days); OAC ditosylate tabs 250mg 4 SP, PA, QL (180 tabs / 30 days); OAC LENVIMA 4 MG DAILY DOSE CPPK 4mg 4 SP, PA, QL (30 caps / 30 ( mesylate) days); OAC LENVIMA 8 MG DAILY DOSE CPPK 4mg 4 SP, PA, QL (60 caps / 30 (lenvatinib mesylate) days); OAC

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 27 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS LENVIMA 10 MG DAILY DOSE CPPK 10mg 4 SP, PA, QL (30 caps / 30 (lenvatinib mesylate) days); OAC LENVIMA 12MG DAILY DOSE CPPK 4mg 4 SP, PA, QL (90 caps / 30 (lenvatinib mesylate) days); OAC LENVIMA 20 MG DAILY DOSE CPPK 10mg 4 SP, PA, QL (60 caps / 30 (lenvatinib mesylate) days); OAC LENVIMA CAP 14 MG (lenvatinib 4 SP, PA, QL (60 caps / 30 mesylate) days); OAC LENVIMA CAP 18 MG (lenvatinib 4 SP, PA, QL (90 caps / 30 mesylate) days); OAC LENVIMA CAP 24 MG (lenvatinib 4 SP, PA, QL (90 caps / 30 mesylate) days); OAC LORBRENA TABS 25mg () 4 SP, PA, QL (90 tabs / 30 days); OAC LORBRENA TABS 100mg (lorlatinib) 4 SP, PA, QL (30 tabs / 30 days); OAC MEKINIST TABS 2mg ( 4 SP, PA, QL (30 tabs / 30 dimethyl ) days); OAC MEKINIST TABS .5mg (trametinib 4 SP, PA, QL (90 tabs / 30 ) days); OAC NEXAVAR TABS 200mg ( 4 SP, PA, QL (120 tabs / tosylate) 30 days); OAC SPRYCEL TABS 20mg () 4 SP, PA, QL (90 tabs / 30 days); OAC SPRYCEL TABS 50mg, 70mg, 80mg, 4 SP, PA, QL (30 tabs / 30 100mg, 140mg (dasatinib) days); OAC STIVARGA TABS 40mg () 4 SP, PA, QL (84 tabs / 28 days); OAC SUTENT CAPS 12.5mg, 25mg, 37.5mg, 4 SP, PA, QL (30 caps / 30 50mg ( malate) days); OAC TAFINLAR CAPS 50mg, 75mg 4 SP, PA, QL (120 caps / ( mesylate) 30 days); OAC TUKYSA TABS 50mg, 150mg () 4 PA, QL (120 tabs / 30 days); OAC VITRAKVI CAPS 25mg ( 4 SP, PA, QL (180 caps / sulfate) 30 days); OAC VITRAKVI CAPS 100mg (larotrectinib 4 SP, PA, QL (60 caps / 30 sulfate) days); OAC VITRAKVI SOLN 20mg/ml (larotrectinib 4 SP, PA, QL (300 mL / 30 sulfate) days); OAC VOTRIENT TABS 200mg ( hcl) 4 SP, PA, QL (120 tabs / 30 days); OAC XALKORI CAPS 200mg, 250mg 4 SP, PA, QL (120 caps / () 30 days); OAC

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 28 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS ZELBORAF TABS 240mg () 4 SP, PA, QL (240 tabs / 30 days); OAC ZYDELIG TABS 100mg, 150mg 4 SP, PA, QL (60 tabs / 30 () days); OAC ZYKADIA TABS 150mg () 4 SP, PA, QL (90 tabs / 30 days); OAC MISCELLANEOUS trioxide soln 10mg/10ml, MB 12mg/6ml caps 75mg 4 SP, PA; OAC DROXIA CAPS 200mg, 300mg, 400mg 2 MO; OAC (hydroxyurea (sickle )) hydroxyurea caps 500mg 1 OAC MATULANE CAPS 50mg ( 2 OAC hcl) hcl conc 2mg/ml MB ODOMZO CAPS 200mg ( 4 SP, PA, QL (30 caps / 30 phosphate) days); OAC ONCASPAR SOLN 750unit/ml MB () PHOTOFRIN SOLR 75mg (porfimer MB sodium) QUADRAMET SOLN 1850mbq/ml MB (samarium sm 153 lexidronam) TICE BCG SUSR 50mg (bcg live MB intravesical) () caps 10mg 1 OAC VISTOGARD PACK 10gm (uridine 4 QL (20 packets / 5 triacetate (emergency treatment)) days); OAC PLATINUM-BASED AGENTS soln 50mg/5ml, MB 150mg/15ml, 450mg/45ml, 600mg/60ml (Carboplatin Soln 1000mg/100ml) MB PARAPLATIN soln 50mg/50ml, MB 100mg/100ml, 200mg/200ml soln 50mg/10ml, MB 100mg/20ml; solr 50mg, 100mg PROTECTIVE AGENTS dexrazoxane hcl solr 250mg, 500mg MB leucovorin calcium solr 50mg, 100mg, MB 200mg, 350mg, 500mg

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 29 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS leucovorin calcium tabs 5mg, 10mg, 1 OAC 15mg, 25mg soln 100mg/ml MB MESNEX TABS 400mg (mesna) 4 OAC INHIBITORS caps 50mg 1 OAC (Etoposide Soln 1gm/50ml, 100mg/5ml, MB 500mg/25ml) TOPOSAR etoposide soln 100mg/5ml MB hcl soln 40mg/2ml, MB 100mg/5ml, 300mg/15ml, 500mg/25ml SOLN 10mg/ml MB hcl solr 4mg MB ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES ANTINEOPLASTIC, BCL-2 INHIBITORS VENCLEXTA TABS 10mg, 50mg 4 PA, QL (120 / 30 days); () OAC VENCLEXTA TABS 100mg (venetoclax) 4 PA, QL (180 / 30 days); OAC VENCLEXTA TAB START PK (venetoclax) 4 PA, QL (1 pack / 28 days); OAC CARDIOVASCULAR - DRUGS TO TREAT HEART AND CIRCULATION CONDITIONS ACE INHIBITOR COMBINATIONS - DRUGS TO TREAT HIGH besylate- hcl cap 1 MO 2.5-10 mg amlodipine besylate-benazepril hcl cap 1 MO 5-10 mg amlodipine besylate-benazepril hcl cap 1 MO 5-20 mg amlodipine besylate-benazepril hcl cap 1 MO 5-40 mg amlodipine besylate-benazepril hcl cap 1 MO 10-20 mg amlodipine besylate-benazepril hcl cap 1 MO 10-40 mg benazepril & tab 1 MO 5-6.25 mg benazepril & hydrochlorothiazide tab 1 MO 10-12.5 mg

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 30 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS benazepril & hydrochlorothiazide tab 1 MO 20-12.5 mg benazepril & hydrochlorothiazide tab 1 MO 20-25 mg & hydrochlorothiazide tab 1 MO 25-15 mg captopril & hydrochlorothiazide tab 1 MO 25-25 mg captopril & hydrochlorothiazide tab 1 MO 50-15 mg captopril & hydrochlorothiazide tab 1 MO 50-25 mg maleate & 1 MO hydrochlorothiazide tab 5-12.5 mg enalapril maleate & 1 MO hydrochlorothiazide tab 10-25 mg sodium & 1 MO hydrochlorothiazide tab 10-12.5 mg fosinopril sodium & 1 MO hydrochlorothiazide tab 20-12.5 mg & hydrochlorothiazide tab 1 MO 10-12.5 mg lisinopril & hydrochlorothiazide tab 1 MO 20-12.5 mg lisinopril & hydrochlorothiazide tab 1 MO 20-25 mg -hydrochlorothiazide tab 10- 1 MO 12.5 mg quinapril-hydrochlorothiazide tab 20- 1 MO 12.5 mg quinapril-hydrochlorothiazide tab 20- 1 MO 25 mg - hcl tab er 1- 1 MO 240 mg trandolapril-verapamil hcl tab er 2- 1 MO 180 mg trandolapril-verapamil hcl tab er 2- 1 MO 240 mg trandolapril-verapamil hcl tab er 4- 1 MO 240 mg ACE INHIBITORS - DRUGS TO TREAT HIGH BLOOD PRESSURE benazepril hcl tabs 5mg, 10mg, 20mg, 1 MO 40mg

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 31 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS captopril tabs 12.5mg, 25mg, 50mg, 1 MO 100mg enalapril maleate tabs 2.5mg, 5mg, 1 MO 10mg, 20mg fosinopril sodium tabs 10mg, 20mg, 1 MO 40mg lisinopril tabs 2.5mg, 5mg, 10mg, 1 MO 20mg, 30mg, 40mg hcl tabs 7.5mg, 15mg 1 MO erbumine tabs 2mg, 4mg, 1 MO 8mg quinapril hcl tabs 5mg, 10mg, 20mg, 1 MO 40mg caps 1.25mg, 2.5mg, 5mg, 1 MO 10mg trandolapril tabs 1mg, 2mg, 4mg 1 MO ANTAGONISTS - DRUGS TO TREAT HIGH BLOOD PRESSURE tabs 25mg, 50mg 1 MO ALPHA BLOCKERS - DRUGS TO TREAT HIGH BLOOD PRESSURE mesylate tabs 1mg, 2mg, 1 MO 4mg, 8mg hcl caps 1mg, 2mg, 5mg 1 MO hcl caps 1mg, 2mg, 5mg, 1 MO 10mg II COMBINATIONS - DRUGS TO TREAT HIGH BLOOD PRESSURE amlodipine besylate- 1 MO medoxomil tab 5-20 mg amlodipine besylate-olmesartan 1 MO medoxomil tab 5-40 mg amlodipine besylate-olmesartan 1 MO medoxomil tab 10-20 mg amlodipine besylate-olmesartan 1 MO medoxomil tab 10-40 mg amlodipine besylate- tab 5- 1 MO 160 mg amlodipine besylate-valsartan tab 5- 1 MO 320 mg amlodipine besylate-valsartan tab 10- 1 MO 160 mg amlodipine besylate-valsartan tab 10- 1 MO 320 mg

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 32 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS amlodipine-valsartan- 1 MO hydrochlorothiazide tab 5-160-12.5 mg amlodipine-valsartan- 1 MO hydrochlorothiazide tab 5-160-25 mg amlodipine-valsartan- 1 MO hydrochlorothiazide tab 10-160-12.5 mg amlodipine-valsartan- 1 MO hydrochlorothiazide tab 10-160-25 mg amlodipine-valsartan- 1 MO hydrochlorothiazide tab 10-320-25 mg cilexetil- 1 MO hydrochlorothiazide tab 16-12.5 mg candesartan cilexetil- 1 MO hydrochlorothiazide tab 32-12.5 mg candesartan cilexetil- 1 MO hydrochlorothiazide tab 32-25 mg -hydrochlorothiazide tab 1 MO 150-12.5 mg irbesartan-hydrochlorothiazide tab 1 MO 300-12.5 mg potassium & 1 MO hydrochlorothiazide tab 50-12.5 mg losartan potassium & 1 MO hydrochlorothiazide tab 100-12.5 mg losartan potassium & 1 MO hydrochlorothiazide tab 100-25 mg olmesartan medoxomil- 1 MO hydrochlorothiazide tab 20-12.5 mg olmesartan medoxomil- 1 MO hydrochlorothiazide tab 40-12.5 mg olmesartan medoxomil- 1 MO hydrochlorothiazide tab 40-25 mg olmesartan-amlodipine- 1 MO hydrochlorothiazide tab 20-5-12.5 mg olmesartan-amlodipine- 1 MO hydrochlorothiazide tab 40-5-12.5 mg olmesartan-amlodipine- 1 MO hydrochlorothiazide tab 40-5-25 mg olmesartan-amlodipine- 1 MO hydrochlorothiazide tab 40-10-12.5 mg olmesartan-amlodipine- 1 MO hydrochlorothiazide tab 40-10-25 mg

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 33 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS -amlodipine tab 40-5 mg 1 MO telmisartan-amlodipine tab 40-10 mg 1 MO telmisartan-amlodipine tab 80-5 mg 1 MO telmisartan-amlodipine tab 80-10 mg 1 MO telmisartan-hydrochlorothiazide tab 1 MO 40-12.5 mg telmisartan-hydrochlorothiazide tab 1 MO 80-12.5 mg telmisartan-hydrochlorothiazide tab 1 MO 80-25 mg valsartan-hydrochlorothiazide tab 80- 1 MO 12.5 mg valsartan-hydrochlorothiazide tab 1 MO 160-12.5 mg valsartan-hydrochlorothiazide tab 1 MO 160-25 mg valsartan-hydrochlorothiazide tab 1 MO 320-12.5 mg valsartan-hydrochlorothiazide tab 1 MO 320-25 mg ANGIOTENSIN II RECEPTOR ANTAGONISTS - DRUGS TO TREAT HIGH BLOOD PRESSURE candesartan cilexetil tabs 4mg, 8mg, 1 MO 16mg, 32mg mesylate tabs 600mg 1 MO irbesartan tabs 75mg, 150mg, 300mg 1 MO losartan potassium tabs 25mg, 50mg, 1 MO 100mg olmesartan medoxomil tabs 5mg, 1 MO 20mg, 40mg telmisartan tabs 20mg, 40mg, 80mg 1 MO valsartan tabs 40mg, 80mg, 160mg, 1 MO 320mg ANTIARRHYTHMICS - DRUGS TO CONTROL HEART RHYTHM (Amiodarone Hcl Tabs 100mg, 200mg) 1 MO PACERONE amiodarone hcl tabs 200mg, 400mg 1 MO phosphate caps 100mg, 1 MO 150mg caps 125mcg, 250mcg, 1 SP, PA, MO 500mcg acetate tabs 50mg, 100mg, 1 MO 150mg

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 34 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS lidocaine hcl (cardiac) sosy MB 50mg/5ml, 100mg/5ml hcl caps 150mg, 200mg, 1 MO 250mg MULTAQ TABS 400mg ( 3 PA, MO hcl) NORPACE CR CP12 100mg, 150mg 2 MO (disopyramide phosphate) hcl soln 100mg/ml MB hcl cp12 225mg, 325mg, 1 MO 425mg; tabs 150mg, 225mg, 300mg hcl tabs 80mg, 120mg, 160mg, 1 MO 240mg (Sotalol Hcl Tabs 80mg, 120mg, 160mg, 1 MO 240mg) SORINE sotalol hcl (afib/afl) tabs 80mg, 1 MO 120mg, 160mg ANTILIPEMICS, ACID RESINS cholestyramine pack 4gm; powd 1 MO 4gm/dose cholestyramine pack 4gm; powd 1 MO 4gm/dose (Cholestyramine Light Powd 4gm/dose) 1 MO PREVALITE hcl gran 5gm; pack 5gm; 1 MO tabs 1gm ANTILIPEMICS, ABSORPTION INHIBITOR tabs 10mg 1 MO ANTILIPEMICS, cpdr 45mg, 135mg 1 MO fenofibrate caps 150mg; tabs 48mg, 1 MO 54mg, 145mg, 160mg fenofibrate micronized caps 43mg, 1 MO 67mg, 134mg, 200mg tabs 600mg 1 MO ANTILIPEMICS, HMG-COA REDUCTASE INHIBITORS/COMBINATIONS ezetimibe- tab 10-10 mg 1 MO ezetimibe-simvastatin tab 10-20 mg 1 MO ezetimibe-simvastatin tab 10-40 mg 1 MO ezetimibe-simvastatin tab 10-80 mg 1 MO

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 35 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS - DRUGS TO TREAT HIGH CHOLESTEROL calcium tabs 10mg, 1 MO; $0 copay for 20mg members age 40 through 75 atorvastatin calcium tabs 40mg, 1 MO 80mg sodium caps 20mg, 40mg; 1 MO; $0 copay for tb24 80mg members age 40 through 75 tabs 10mg, 20mg, 40mg 1 MO; $0 copay for members age 40 through 75 sodium tabs 10mg, 20mg, 1 MO; $0 copay for 40mg, 80mg members age 40 through 75 calcium tabs 5mg, 10mg 1 MO; $0 copay for members age 40 through 75 rosuvastatin calcium tabs 20mg, 1 MO 40mg simvastatin tabs 5mg, 10mg, 20mg, 1 MO; $0 copay for 40mg members age 40 through 75 simvastatin tabs 80mg 1 ST, MO; PA** ANTILIPEMICS, MISCELLANEOUS - DRUGS TO TREAT HIGH CHOLESTEROL (antihyperlipidemic) tbcr 1 MO 500mg, 750mg, 1000mg ANTILIPEMICS, OMEGA-3 FATTY omega-3-acid ethyl cap 1 gm 1 MO VASCEPA CAPS .5gm, 1gm (icosapent 2 MO ethyl) ANTILIPEMICS, PCSK9 INHIBITORS PRALUENT SOAJ 75mg/ml, 150mg/ml MB MO () BETA-BLOCKER/ COMBINATIONS - DRUGS TO TREAT HIGH BLOOD PRESSURE AND HEART CONDITIONS & chlorthalidone tab 50-25 1 MO mg atenolol & chlorthalidone tab 100-25 1 MO mg

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 36 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS & hydrochlorothiazide tab 1 MO 2.5-6.25 mg bisoprolol & hydrochlorothiazide tab 1 MO 5-6.25 mg bisoprolol & hydrochlorothiazide tab 1 MO 10-6.25 mg & hydrochlorothiazide tab 1 MO 50-25 mg metoprolol & hydrochlorothiazide tab 1 MO 100-25 mg metoprolol & hydrochlorothiazide tab 1 MO 100-50 mg & hydrochlorothiazide tab 1 MO 40-25 mg propranolol & hydrochlorothiazide tab 1 MO 80-25 mg BETA-BLOCKERS - DRUGS TO TREAT HIGH BLOOD PRESSURE AND HEART CONDITIONS hcl caps 200mg, 400mg 1 MO atenolol tabs 25mg, 50mg, 100mg 1 MO hcl tabs 10mg, 20mg 1 MO bisoprolol fumarate tabs 5mg, 10mg 1 MO BYSTOLIC TABS 2.5mg, 5mg, 10mg, 3 MO 20mg ( hcl) tabs 3.125mg, 6.25mg, 1 MO 12.5mg, 25mg carvedilol phosphate cp24 10mg, 1 MO 20mg, 40mg, 80mg hcl tabs 100mg, 200mg, 1 MO 300mg metoprolol succinate tb24 25mg, 1 MO 50mg, 100mg, 200mg metoprolol tartrate tabs 25mg, 50mg, 1 MO 100mg tabs 20mg, 40mg, 80mg 1 MO tabs 5mg, 10mg 1 MO propranolol hcl cp24 60mg, 80mg, 1 MO 120mg, 160mg; soln 20mg/5ml, 40mg/5ml; tabs 10mg, 20mg, 40mg, 60mg, 80mg maleate tabs 5mg, 10mg, 1 MO 20mg

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 37 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS BLOCKER/ANTILIPEMIC COMBINATIONS amlodipine besylate-atorvastatin 1 MO calcium tab 2.5-10 mg amlodipine besylate-atorvastatin 1 MO calcium tab 2.5-20 mg amlodipine besylate-atorvastatin 1 MO calcium tab 2.5-40 mg amlodipine besylate-atorvastatin 1 MO calcium tab 5-10 mg amlodipine besylate-atorvastatin 1 MO calcium tab 5-20 mg amlodipine besylate-atorvastatin 1 MO calcium tab 5-40 mg amlodipine besylate-atorvastatin 1 MO calcium tab 5-80 mg amlodipine besylate-atorvastatin 1 MO calcium tab 10-10 mg amlodipine besylate-atorvastatin 1 MO calcium tab 10-20 mg amlodipine besylate-atorvastatin 1 MO calcium tab 10-40 mg amlodipine besylate-atorvastatin 1 MO calcium tab 10-80 mg CALCIUM CHANNEL BLOCKERS - DRUGS TO TREAT HIGH BLOOD PRESSURE AND HEART CONDITIONS amlodipine besylate tabs 2.5mg, 5mg, 1 MO 10mg CARDIZEM LA TB24 120mg ( 3 MO hcl coated beads) diltiazem hcl cp12 60mg, 90mg, 1 MO 120mg; tabs 30mg, 60mg, 90mg, 120mg (Diltiazem Hcl Cp24 120mg, 180mg, 1 MO 240mg) DILT-XR diltiazem hcl soln 25mg/5ml, MB 125mg/25ml (Diltiazem Hcl Coated Beads Cp24 120mg, 1 MO 180mg, 240mg, 300mg) CARTIA XT diltiazem hcl coated beads cp24 1 MO 120mg, 180mg, 240mg, 300mg, 360mg (Diltiazem Hcl Coated Beads Tb24 180mg, 1 MO 240mg, 300mg, 360mg, 420mg) MATZIM LA

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 38 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS (Diltiazem Hcl Extended Release Beads 1 MO Cp24 120mg, 180mg, 240mg, 300mg, 360mg) TAZTIA XT diltiazem hcl extended release beads 1 MO cp24 120mg, 180mg, 240mg, 300mg, 360mg, 420mg tb24 2.5mg, 5mg, 10mg 1 MO caps 2.5mg, 5mg 1 MO hcl caps 20mg, 30mg 1 MO tb24 30mg, 60mg, 90mg 1 MO caps 30mg 1 tb24 8.5mg, 17mg, 20mg, 1 MO 25.5mg, 30mg, 34mg, 40mg verapamil hcl cp24 100mg, 120mg, 1 MO 180mg, 200mg, 240mg, 300mg, 360mg; tabs 40mg, 80mg, 120mg; tbcr 120mg, 180mg, 240mg GLYCOSIDES - DRUGS TO TREAT HEART CONDITIONS soln .05mg/ml; tabs 125mcg, 1 MO 250mcg (Digoxin Tabs 125mcg, 250mcg) DIGOX 1 MO LANOXIN TABS 62.5mcg (digoxin) 2 MO DIRECT INHIBITORS/COMBINATIONS - DRUGS TO TREAT HEART CONDITIONS fumarate tabs 150mg, 1 MO 300mg - DRUGS TO TREAT HEART CONDITIONS cp12 500mg; tabs 1 MO 125mg, 250mg ALDACTAZIDE TAB 50/50 2 MO ( & hydrochlorothiazide) & hydrochlorothiazide tab 5- 1 MO 50 mg amiloride hcl tabs 5mg 1 MO tabs .5mg, 1mg, 2mg 1 MO tabs 250mg, 500mg 1 MO chlorthalidone tabs 25mg, 50mg 1 MO DIURIL SUSP 250mg/5ml 3 MO (chlorothiazide) ethacrynic acid tabs 25mg 3 MO soln 8mg/ml, 10mg/ml; 1 MO tabs 20mg, 40mg, 80mg

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 39 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS furosemide soln 10mg/ml MB hydrochlorothiazide caps 12.5mg; 1 MO tabs 12.5mg, 25mg, 50mg tabs 1.25mg, 2.5mg 1 MO tabs 25mg, 50mg 1 MO tabs 2.5mg, 5mg, 10mg 1 MO spironolactone tabs 25mg, 50mg, 1 MO 100mg spironolactone & hydrochlorothiazide 1 MO tab 25-25 mg torsemide tabs 5mg, 10mg, 20mg, 1 MO 100mg caps 50mg, 100mg 1 MO triamterene & hydrochlorothiazide cap 1 MO 37.5-25 mg triamterene & hydrochlorothiazide tab 1 MO 37.5-25 mg triamterene & hydrochlorothiazide tab 1 MO 75-50 mg MISCELLANEOUS ptwk .1mg/24hr, 1 MO .2mg/24hr, .3mg/24hr clonidine hcl tabs .1mg, .2mg, .3mg 1 MO ENTRESTO TAB 24-26MG (- 2 MO valsartan) ENTRESTO TAB 49-51MG (sacubitril- 2 MO valsartan) ENTRESTO TAB 97-103MG (sacubitril- 2 MO valsartan) hcl tabs 1mg, 2mg 1 MO hydralazine hcl tabs 10mg, 25mg, 1 MO 50mg, 100mg tabs 250mg, 500mg 1 MO hcl tabs 2.5mg, 5mg, 10mg 1 tabs 2.5mg, 10mg 1 MO hcl caps 10mg 4 PA, QL (360 caps / 25 days) tb12 500mg, 1000mg 1 ST, MO; PA** - DRUGS TO TREAT HEART CONDITIONS DILATRATE SR CPCR 40mg (isosorbide 3 MO dinitrate) tabs 5mg, 10mg, 1 MO 20mg, 30mg

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 40 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS tabs 10mg, 1 MO 20mg; tb24 30mg, 60mg, 120mg NITRO-BID OINT 2% () 3 MO NITRO-DUR PT24 .3mg/hr, .8mg/hr 2 MO (nitroglycerin) (Nitroglycerin Pt24 .1mg/hr, .2mg/hr, 1 MO .4mg/hr, .6mg/hr) MINITRAN nitroglycerin pt24 .1mg/hr, .2mg/hr, 1 MO .4mg/hr, .6mg/hr; soln .4mg/spray; subl .3mg, .4mg, .6mg PULMONARY ARTERIAL - DRUGS TO TREAT ADEMPAS TABS .5mg, 1mg, 1.5mg, 2mg, 4 SP, PA, QL (90 tabs / 30 2.5mg () days), MO tabs 5mg, 10mg 4 SP, PA, QL (30 tabs / 30 days), MO tabs 62.5mg, 125mg 4 SP, PA, QL (60 tabs / 30 days), MO OPSUMIT TABS 10mg () 4 SP, PA, QL (30 tabs / 30 days), MO ORENITRAM TBCR .125mg, .25mg, 1mg, 4 SP, PA, MO 2.5mg, 5mg (treprostinil diolamine) REMODULIN SOLN 20mg/20ml, MB 50mg/20ml, 100mg/20ml, 200mg/20ml (treprostinil) citrate (pulmonary MB hypertension) soln 10mg/12.5ml sildenafil citrate (pulmonary 4 SP, PA, QL (90 tabs / 30 hypertension) tabs 20mg days), MO (pulmonary hypertension) 4 SP, PA, QL (60 tabs / 30 tabs 20mg days), MO TRACLEER TBSO 32mg (bosentan) 4 SP, PA, QL (112 tabs / 28 days), MO TYVASO STARTER SOLN .6mg/ml 4 SP, PA, QL (28 ampules (treprostinil) / 28 days), MO UPTRAVI TABS 200mcg (selexipag) 4 SP, PA, QL (140 tabs / 28 days), MO UPTRAVI TABS 400mcg, 600mcg, 4 SP, PA, QL (60 tabs / 30 800mcg, 1000mcg, 1200mcg, 1400mcg, days), MO 1600mcg (selexipag) UPTRAVI TAB 200/800 (selexipag) 4 SP, PA, QL (1 pack / 28 days) VENTAVIS SOLN 10mcg/ml, 20mcg/ml 4 SP, PA, QL (270 (iloprost) ampules / 30 days), MO

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 41 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS - DRUGS TO TREAT NERVOUS SYSTEM DISORDERS ANTIANXIETY - DRUGS TO TREAT tabs .25mg, .5mg, 1mg, 1 QL (150 tabs / 25 days) 2mg; tbdp .25mg, .5mg, 1mg, 2mg ALPRAZOLAM INTENSOL CONC 1mg/ml 2 QL (300 mL / 25 days) (alprazolam) conc 2mg/ml 1 QL (150 mL / 25 days) lorazepam tabs .5mg, 1mg, 2mg 1 QL (150 tabs / 25 days) tabs 200mg, 400mg 1 caps 10mg, 15mg, 30mg 1 QL (120 caps / 25 days) ANTICONVULSANTS - DRUGS TO TREAT SEIZURES APTIOM TABS 200mg, 400mg, 600mg, 3 PA, MO 800mg () chew 100mg; cp12 1 MO 100mg, 200mg, 300mg; susp 100mg/5ml; tabs 200mg; tb12 100mg, 200mg, 400mg (Carbamazepine Tabs 200mg) EPITOL 1 MO CELONTIN CAPS 300mg (methsuximide) 3 MO susp 2.5mg/ml; tabs 10mg, 1 PA, MO 20mg tabs .5mg, 1mg, 2mg 1 dipotassium tabs 3.75mg, 1 QL (180 tabs / 25 days) 7.5mg, 15mg ( Conc 5mg/ml) DIAZEPAM 1 QL (240 mL / 25 days) INTENSOL diazepam soln 5mg/5ml 1 QL (1200 mL / 25 days) diazepam soln 5mg/ml MB diazepam tabs 2mg, 5mg, 10mg 1 QL (120 tabs / 25 days) DILANTIN CAPS 30mg ( 3 MO sodium extended) divalproex sodium csdr 125mg; tb24 1 MO 250mg, 500mg; tbec 125mg, 250mg, 500mg caps 250mg; soln 1 MO 250mg/5ml susp 600mg/5ml; tabs 1 MO 400mg, 600mg sodium soln MB 100mgpe/2ml, 500mgpe/10ml

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 42 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS FYCOMPA SUSP .5mg/ml; TABS 2mg, 2 MO 4mg, 6mg, 8mg, 10mg, 12mg () caps 100mg, 300mg, 1 MO 400mg; soln 250mg/5ml; tabs 600mg, 800mg chew 5mg, 25mg; tabs 1 MO 25mg, 100mg, 150mg, 200mg; tb24 25mg, 50mg, 100mg, 200mg, 250mg, 300mg; tbdp 25mg, 50mg, 100mg, 200mg lamotrigine kit 25mg 1 lamotrigine tab 25 mg (42) & 100 mg 1 (7) starter kit lamotrigine tab 84 x 25 mg & 14 x 100 1 mg starter kit soln 100mg/ml; tabs 1 MO 250mg, 500mg, 750mg, 1000mg; tb24 500mg, 750mg levetiracetam soln 500mg/5ml MB levetiracetam in sodium chloride iv MB soln 500 mg/100ml levetiracetam in sodium chloride iv MB soln 1000 mg/100ml levetiracetam in sodium chloride iv MB soln 1500 mg/100ml susp 60mg/ml; tabs 1 MO 150mg, 300mg, 600mg PEGANONE TABS 250mg () 3 MO elix 20mg/5ml; tabs 1 MO 15mg, 16.2mg, 30mg, 32.4mg, 60mg, 64.8mg, 97.2mg, 100mg phenytoin chew 50mg; susp 1 MO 125mg/5ml phenytoin sodium soln 50mg/ml MB phenytoin sodium extended caps 1 MO 100mg, 200mg, 300mg caps 25mg, 50mg, 75mg, 1 ST, MO; PA** 100mg, 150mg, 200mg, 225mg, 300mg; soln 20mg/ml tabs 50mg, 250mg 1 MO hcl tabs 2mg, 4mg, 12mg, 1 MO 16mg cpsp 15mg, 25mg; tabs 1 MO 25mg, 50mg, 100mg, 200mg

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 43 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS sodium soln 100mg/ml MB valproate sodium soln 250mg/5ml 1 MO valproic acid caps 250mg 1 MO pack 500mg 4 SP, PA, QL (180 packets / 30 days), MO vigabatrin tabs 500mg 4 SP, PA, QL (180 tabs / 30 days), MO VIMPAT SOLN 10mg/ml; TABS 50mg, 3 MO 100mg, 150mg, 200mg () VIMPAT SOLN 200mg/20ml (lacosamide) MB caps 25mg, 50mg, 100mg 1 MO ANTIDEMENTIA - DRUGS TO TREAT DEMENTIA AND MEMORY LOSS hydrochloride tabs 5mg, 1 MO 10mg, 23mg; tbdp 5mg, 10mg mesylates tabs 1mg 1 MO hydrobromide cp24 8mg, 1 MO 16mg, 24mg; soln 4mg/ml; tabs 4mg, 8mg, 12mg hcl cp24 7mg, 14mg, 1 PA, MO; PA applies for 21mg, 28mg; soln 2mg/ml; tabs 5mg, members less than 30 10mg years of age memantine hcl tab 28 x 5 mg & 21 x 1 PA; PA applies for 10 mg titration pack members less than 30 years of age NAMENDA XR CAP TITRATIO (memantine 2 PA; PA applies for hcl) members less than 30 years of age pt24 4.6mg/24hr, 1 PA, MO 9.5mg/24hr, 13.3mg/24hr rivastigmine tartrate caps 1.5mg, 1 PA, MO 3mg, 4.5mg, 6mg - DRUGS TO TREAT hcl tabs 10mg 1 QL (150 tabs / 25 days), MO; QL applies to members age 65 and older amitriptyline hcl tabs 25mg 1 QL (60 tabs / 25 days), MO; QL applies to members age 65 and older amitriptyline hcl tabs 50mg 1 QL (30 tabs / 25 days), MO; QL applies to members age 65 and older

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 44 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS amitriptyline hcl tabs 75mg, 100mg, 1 PA, MO; High strength 150mg requires PA for members age 70 and older tabs 25mg, 50mg, 100mg 1 QL (90 tabs / 25 days), MO; QL applies to members age 65 and older amoxapine tabs 150mg 1 QL (60 tabs / 25 days), MO; QL applies to members age 65 and older hcl tabs 75mg, 100mg; 1 MO tb12 100mg, 150mg, 200mg; tb24 150mg, 300mg hydrobromide soln 1 MO 10mg/5ml; tabs 10mg, 20mg, 40mg hcl tabs 10mg, 25mg, 1 QL (90 tabs / 25 days), 50mg MO; QL applies to members age 65 and older desipramine hcl tabs 75mg 1 QL (60 tabs / 25 days), MO; QL applies to members age 65 and older desipramine hcl tabs 100mg, 150mg 1 QL (30 tabs / 25 days), MO; QL applies to members age 65 and older succinate tb24 25mg, 1 ST, QL (30 tabs / 25 50mg, 100mg days), MO; (generic of Pristiq) PA** hcl caps 10mg, 25mg, 50mg 1 QL (90 caps / 25 days), MO; QL applies to members age 65 and older doxepin hcl caps 75mg 1 QL (60 caps / 25 days), MO; QL applies to members age 65 and older doxepin hcl caps 100mg, 150mg 1 QL (30 caps / 25 days), MO; QL applies to members age 65 and older

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 45 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS doxepin hcl conc 10mg/ml 1 QL (450 mL / 25 days), MO; QL applies to members age 65 and older hcl cpep 20mg, 30mg, 1 MO 60mg EMSAM PT24 6mg/24hr, 9mg/24hr, 3 PA, MO 12mg/24hr () oxalate soln 5mg/5ml; 1 MO tabs 5mg, 10mg, 20mg FETZIMA CP24 20mg, 40mg, 80mg, 3 ST, QL (30 caps / 25 120mg ( hcl) days), MO; PA** FETZIMA CAP TITRATIO (levomilnacipran 3 ST, QL (30 caps / 25 hcl) days); PA** hcl caps 10mg, 20mg, 1 MO 40mg; cpdr 90mg; soln 20mg/5ml fluoxetine hcl tabs 10mg, 20mg 1 MO; (generic Sarafem not covered) hcl tabs 10mg, 25mg 1 QL (120 tabs / 25 days), MO; QL applies to members age 65 and older imipramine hcl tabs 50mg 1 QL (60 tabs / 25 days), MO; QL applies to members age 65 and older imipramine pamoate caps 75mg, 1 QL (30 caps / 25 days), 100mg MO; QL applies to members age 65 and older imipramine pamoate caps 125mg, 1 PA, MO; High strength 150mg requires PA for members age 70 and older hcl tabs 25mg, 50mg, 1 MO 75mg MARPLAN TABS 10mg () 3 MO tabs 7.5mg, 15mg, 30mg, 1 MO 45mg; tbdp 15mg, 30mg, 45mg hcl tabs 50mg, 100mg, 1 MO 150mg, 200mg, 250mg hcl caps 10mg 1 QL (150 caps / 25 days), MO; QL applies to members age 65 and older

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 46 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS nortriptyline hcl caps 25mg 1 QL (60 caps / 25 days), MO; QL applies to members age 65 and older nortriptyline hcl caps 50mg 1 QL (30 caps / 25 days), MO; QL applies to members age 65 and older nortriptyline hcl caps 75mg 1 PA, MO; High strength requires PA for members age 65 and older nortriptyline hcl soln 10mg/5ml 1 QL (750 mL / 25 days), MO; QL applies to members age 65 and older hcl tabs 10mg, 20mg, 1 MO 30mg, 40mg; tb24 12.5mg, 25mg, 37.5mg sulfate tabs 15mg 1 MO hcl tabs 5mg 1 QL (90 tabs / 25 days), MO; QL applies to members age 65 and older protriptyline hcl tabs 10mg 1 QL (60 tabs / 25 days), MO; QL applies to members age 65 and older hcl conc 20mg/ml; tabs 1 MO 25mg, 50mg, 100mg sulfate tabs 10mg 1 MO hcl tabs 50mg, 100mg, 1 MO 150mg, 300mg maleate caps 25mg, 1 QL (60 caps / 25 days), 50mg MO; QL applies to members age 65 and older trimipramine maleate caps 100mg 1 QL (30 caps / 25 days), MO; QL applies to members age 65 and older hcl cp24 37.5mg, 75mg, 1 MO 150mg; tabs 25mg, 37.5mg, 50mg, 75mg, 100mg; tb24 37.5mg, 75mg, 150mg

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 47 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS VIIBRYD TABS 10mg, 20mg, 40mg 3 ST, MO; PA** ( hcl) VIIBRYD KIT STARTER (vilazodone hcl) 3 ST; PA** ANTIPARKINSONIAN AGENTS - DRUGS TO TREAT PARKINSONS DISEASE hcl caps 100mg; syrp 1 MO 50mg/5ml; tabs 100mg APOKYN SOCT 30mg/3ml ( MB hydrochloride) benztropine mesylate soln 1mg/ml MB benztropine mesylate tabs .5mg, 1mg, 1 MO 2mg mesylate caps 5mg; 1 MO tabs 2.5mg carbidopa tabs 25mg 1 MO carbidopa & levodopa orally 1 MO disintegrating tab 10-100 mg carbidopa & levodopa orally 1 MO disintegrating tab 25-100 mg carbidopa & levodopa orally 1 MO disintegrating tab 25-250 mg carbidopa & levodopa tab 10-100 mg 1 MO carbidopa & levodopa tab 25-100 mg 1 MO carbidopa & levodopa tab 25-250 mg 1 MO carbidopa & levodopa tab er 25-100 1 MO mg carbidopa & levodopa tab er 50-200 1 MO mg carbidopa-levodopa-entacapone tabs 1 MO 12.5-50-200 mg carbidopa-levodopa-entacapone tabs 1 MO 18.75-75-200 mg carbidopa-levodopa-entacapone tabs 1 MO 25-100-200 mg carbidopa-levodopa-entacapone tabs 1 MO 31.25-125-200 mg carbidopa-levodopa-entacapone tabs 1 MO 37.5-150-200 mg carbidopa-levodopa-entacapone tabs 1 MO 50-200-200 mg entacapone tabs 200mg 1 MO NEUPRO PT24 1mg/24hr, 2mg/24hr, 2 MO 3mg/24hr, 4mg/24hr, 6mg/24hr, 8mg/24hr ()

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 48 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS dihydrochloride tabs 1 MO .125mg, .25mg, .5mg, .75mg, 1mg, 1.5mg; tb24 .375mg, .75mg, 1.5mg, 2.25mg, 3mg, 3.75mg, 4.5mg mesylate tabs .5mg, 1mg 1 MO hydrochloride tabs .25mg, 1 MO .5mg, 1mg, 2mg, 3mg, 4mg, 5mg selegiline hcl caps 5mg; tabs 5mg 1 MO tolcapone tabs 100mg 1 MO hcl soln .4mg/ml; 1 MO tabs 2mg, 5mg - DRUGS TO TREAT PSYCHOSES soln 1mg/ml; tabs 2mg, 1 MO 5mg, 10mg, 15mg, 20mg, 30mg; tbdp 10mg, 15mg ARISTADA PRSY 441mg/1.6ml, MB MO 662mg/2.4ml, 882mg/3.2ml, 1064mg/3.9ml () ARISTADA INITIO PRSY 675mg/2.4ml MB (aripiprazole lauroxil) maleate subl 2.5mg, 5mg, 1 MO 10mg hcl soln 25mg/ml, MB 50mg/2ml chlorpromazine hcl tabs 10mg, 25mg, 1 MO 50mg, 100mg, 200mg tabs 25mg, 50mg, 100mg, 1 200mg; tbdp 12.5mg, 25mg, 100mg, 150mg, 200mg decanoate soln MB 25mg/ml fluphenazine hcl conc 5mg/ml; elix 1 MO 2.5mg/5ml; tabs 1mg, 2.5mg, 5mg, 10mg fluphenazine hcl soln 2.5mg/ml MB tabs .5mg, 1mg, 2mg, 1 MO 5mg, 10mg, 20mg soln 50mg/ml, MB 100mg/ml haloperidol lactate conc 2mg/ml 1 MO haloperidol lactate soln 5mg/ml MB LATUDA TABS 20mg, 40mg, 60mg, 80mg, 2 ST, MO; PA** 120mg ( hcl)

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 49 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS succinate caps 5mg, 10mg, 1 MO 25mg, 50mg solr 10mg MB olanzapine tabs 2.5mg, 5mg, 7.5mg, 1 MO 10mg, 15mg, 20mg; tbdp 5mg, 10mg, 15mg, 20mg tb24 1.5mg, 3mg, 6mg, 1 MO 9mg tabs 2mg, 4mg, 8mg, 1 MO 16mg fumarate tabs 25mg, 1 MO 50mg, 100mg, 200mg, 300mg, 400mg; tb24 50mg, 150mg, 200mg, 300mg, 400mg REXULTI TABS .25mg, .5mg, 1mg, 2mg, 3 ST, MO; PA** 3mg, 4mg () soln 1mg/ml; tabs .25mg, 1 MO .5mg, 1mg, 2mg, 3mg, 4mg; tbdp .25mg, .5mg, 1mg, 2mg, 3mg, 4mg hcl tabs 10mg, 25mg, 1 MO 50mg, 100mg thiothixene caps 1mg, 2mg, 5mg, 1 MO 10mg hcl tabs 1mg, 2mg, 1 MO 5mg, 10mg hcl caps 20mg, 40mg, 1 MO 60mg, 80mg ATTENTION DEFICIT HYPERACTIVITY DISORDER - DRUGS TO TREAT ADHD - cap 1 QL (90 caps / 25 days), er 24hr 5 mg MO amphetamine-dextroamphetamine cap 1 QL (90 caps / 25 days), er 24hr 10 mg MO amphetamine-dextroamphetamine cap 1 QL (30 caps / 25 days), er 24hr 15 mg MO amphetamine-dextroamphetamine cap 1 QL (30 caps / 25 days), er 24hr 20 mg MO amphetamine-dextroamphetamine cap 1 QL (30 caps / 25 days), er 24hr 25 mg MO amphetamine-dextroamphetamine cap 1 QL (30 caps / 25 days), er 24hr 30 mg MO amphetamine-dextroamphetamine tab 1 QL (90 tabs / 25 days), 5 mg MO

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 50 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS amphetamine-dextroamphetamine tab 1 QL (90 tabs / 25 days), 7.5 mg MO amphetamine-dextroamphetamine tab 1 QL (90 tabs / 25 days), 10 mg MO amphetamine-dextroamphetamine tab 1 QL (90 tabs / 25 days), 12.5 mg MO amphetamine-dextroamphetamine tab 1 QL (60 tabs / 25 days), 15 mg MO amphetamine-dextroamphetamine tab 1 QL (60 tabs / 25 days), 20 mg MO amphetamine-dextroamphetamine tab 1 QL (30 tabs / 25 days), 30 mg MO hcl caps 10mg, 18mg, 1 MO 25mg, 40mg, 60mg, 80mg, 100mg hcl cp24 5mg, 1 PA, QL (60 caps / 25 10mg, 15mg, 20mg days), MO dexmethylphenidate hcl cp24 25mg, 1 PA, QL (30 caps / 25 30mg, 35mg, 40mg days), MO dexmethylphenidate hcl tabs 2.5mg, 1 PA, QL (120 tabs / 25 5mg days), MO dexmethylphenidate hcl tabs 10mg 1 PA, QL (60 tabs / 25 days), MO dextroamphetamine sulfate cp24 1 QL (120 caps / 25 5mg, 10mg days), MO dextroamphetamine sulfate cp24 1 QL (60 caps / 25 days), 15mg MO dextroamphetamine sulfate soln 1 QL (1,200 mL / 25 5mg/5ml days), MO (Dextroamphetamine Sulfate Tabs 2.5mg, 1 QL (120 tabs / 25 days), 7.5mg) ZENZEDI MO dextroamphetamine sulfate tabs 5mg, 1 QL (120 tabs / 25 days), 10mg MO (Dextroamphetamine Sulfate Tabs 15mg, 1 QL (60 tabs / 25 days), 20mg) ZENZEDI MO (Dextroamphetamine Sulfate Tabs 30mg) 1 QL (30 tabs / 25 days), ZENZEDI MO guanfacine hcl (adhd) tb24 1mg, 1 MO 2mg, 3mg, 4mg hcl tabs 5mg 1 QL (150 tabs / 25 days), MO hcl chew 2.5mg, 1 PA, QL (180 chew tabs / 5mg, 10mg 25 days), MO methylphenidate hcl cp24 20mg, 1 PA, QL (60 caps / 25 30mg; cpcr 10mg, 20mg, 30mg days), MO

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 51 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS methylphenidate hcl cp24 40mg, 1 PA, QL (30 caps / 25 60mg; cpcr 40mg, 50mg, 60mg days), MO methylphenidate hcl soln 5mg/5ml 1 PA, QL (1800 mL / 25 days), MO methylphenidate hcl soln 10mg/5ml 1 PA, QL (900 mL / 25 days), MO methylphenidate hcl tabs 5mg, 10mg 1 PA, QL (180 tabs / 25 days), MO methylphenidate hcl tabs 20mg; tbcr 1 PA, QL (90 tabs / 25 10mg, 20mg days), MO methylphenidate hcl tbcr 18mg, 1 QL (60 tabs / 25 days), 27mg, 36mg MO methylphenidate hcl tbcr 54mg 1 QL (30 tabs / 25 days), MO VYVANSE CAPS 10mg, 20mg, 30mg 2 QL (60 caps / 25 days), (lisdexamfetamine dimesylate) MO VYVANSE CAPS 40mg, 50mg, 60mg, 2 QL (30 caps / 25 days), 70mg (lisdexamfetamine dimesylate) MO VYVANSE CHEW 10mg, 20mg, 30mg 2 QL (60 tabs / 25 days), (lisdexamfetamine dimesylate) MO VYVANSE CHEW 40mg, 50mg, 60mg 2 QL (30 tabs / 25 days), (lisdexamfetamine dimesylate) MO - DRUGS TO TREAT BELSOMRA TABS 5mg, 10mg, 15mg, 2 ST; PA** 20mg () tabs 1mg, 2mg, 3mg 1 QL (15 tabs / 25 days) HETLIOZ CAPS 20mg () 4 PA, QL (30 caps / 30 days), MO tabs 8mg 1 QL (15 tabs / 25 days) caps 7.5mg, 15mg, 1 QL (15 caps / 25 days) 22.5mg, 30mg caps 5mg, 10mg 1 QL (15 caps / 25 days) tartrate tabs 5mg, 10mg; 1 QL (15 tabs / 25 days) tbcr 6.25mg, 12.5mg - DRUGS TO TREAT SEVERE AIMOVIG SOAJ 70mg/ml, 140mg/ml MB MO (-aooe) AJOVY SOAJ 225mg/1.5ml; SOSY MB MO 225mg/1.5ml (-vfrm) malate tabs 6.25mg, 1 QL (12 tabs / 25 days) 12.5mg mesylate soln MB 1mg/ml

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 52 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS hydrobromide tabs 20mg, 1 QL (12 tabs / 25 days) 40mg EMGALITY SOAJ 120mg/ml; SOSY MB MO 100mg/ml, 120mg/ml (- gnlm) w/ caffeine tab 1-100 mg 3 succinate tabs 2.5mg 1 QL (18 tabs / 25 days) hcl tabs 1mg, 2.5mg 1 QL (12 tabs / 25 days) benzoate tabs 5mg, 10mg; 1 QL (18 tabs / 25 days) tbdp 5mg, 10mg soln 5mg/act 1 QL (24 sprays / 25 days) sumatriptan soln 20mg/act 1 QL (12 sprays / 25 days) sumatriptan succinate soaj 1 QL (18 syringes / 25 4mg/0.5ml; soct 4mg/0.5ml days) sumatriptan succinate soaj 1 QL (12 units / 25 days) 6mg/0.5ml; soct 6mg/0.5ml; sosy 6mg/0.5ml sumatriptan succinate soln 1 QL (12 vials / 25 days) 6mg/0.5ml sumatriptan succinate tabs 25mg, 1 QL (12 tabs / 25 days) 50mg, 100mg soln 2.5mg, 5mg 1 QL (12 sprays / 25 days) zolmitriptan tabs 2.5mg, 5mg; tbdp 1 QL (12 tabs / 25 days) 2.5mg, 5mg MISCELLANEOUS hcl tabs 5mg, 7.5mg, 1 10mg, 15mg, 30mg hcl caps 25mg, 50mg 1 QL (150 caps / 25 days), MO; QL applies to members age 65 and older clomipramine hcl caps 75mg 1 QL (90 caps / 25 days), MO; QL applies to members age 65 and older EVRYSDI SOLR .75mg/ml (risdiplam) 4 PA, QL (2 bottles / 24 days), MO maleate cp24 100mg, 1 MO 150mg; tabs 25mg, 50mg, 100mg HCL TABS 125mg 3 SOLN 8meq/5ml 3 MO

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 53 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS caps 150mg, 1 MO 300mg, 600mg; tabs 300mg; tbcr 300mg, 450mg NUEDEXTA CAP 20-10MG 2 PA, MO ( hbr- sulfate) tabs 1mg, 2mg 1 MO soln 1 60mg/5ml; tabs 60mg; tbcr 180mg tabs 50mg 1 MO tetrabenazine tabs 12.5mg 4 SP, PA, QL (120 tabs / 30 days), MO tetrabenazine tabs 25mg 4 SP, PA, QL (60 tabs / 30 days), MO AGENTS - DRUGS TO TREAT MULTIPLE SCLEROSIS AUBAGIO TABS 7mg, 14mg 4 SP, PA, QL (30 tabs / 30 () days), MO AVONEX PSKT 30mcg/0.5ml ( MB MO beta-1a) AVONEX PEN AJKT 30mcg/0.5ml MB MO (interferon beta-1a) BETASERON KIT .3mg (interferon beta- MB MO 1b) COPAXONE SOSY 20mg/ml, 40mg/ml MB MO (glatiramer acetate) dalfampridine tb12 10mg 4 SP, PA, QL (60 tabs / 30 days), MO cpdr 120mg 4 SP, PA, QL (14 caps / 28 days), MO dimethyl fumarate cpdr 240mg 4 SP, PA, QL (60 caps / 30 days), MO dimethyl fumarate dr starter 4 SP, PA, QL (1 kit / 30 pack 120 mg & 240 mg days) GILENYA CAPS .5mg ( hcl) 4 SP, PA, QL (30 caps / 30 days), MO (Glatiramer Acetate Sosy 20mg/ml) MB MO GLATOPA glatiramer acetate sosy 40mg/ml MB MO PLEGRIDY SOPN 125mcg/0.5ml; SOSY MB MO 125mcg/0.5ml (peginterferon beta-1a) PLEGRIDY INJ STARTER (peginterferon MB beta-1a)

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 54 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS PLEGRIDY PEN INJ STARTER MB (peginterferon beta-1a) REBIF SOSY 22mcg/0.5ml, 44mcg/0.5ml MB MO (interferon beta-1a) REBIF REBIDO INJ TITRATN (interferon MB MO beta-1a) REBIF REBIDOSE SOAJ 22mcg/0.5ml, MB MO 44mcg/0.5ml (interferon beta-1a) REBIF TITRTN INJ PACK (interferon beta- MB MO 1a) TYSABRI CONC 300mg/15ml MB () MUSCULOSKELETAL THERAPY AGENTS - DRUGS TO TREAT MUSCLE SPASMS tabs 5mg, 10mg, 20mg 1 tabs 350mg 1 PA tabs 500mg 1 PA; High Risk Medications require PA for members age 70 and older hcl tabs 5mg, 10mg 1 PA; High Risk Medications require PA for members age 70 and older sodium caps 25mg, 50mg, 1 100mg tabs 800mg 1 PA; High Risk Medications require PA for members age 70 and older tabs 500mg, 750mg 1 PA; High Risk Medications require PA for members age 70 and older citrate soln 30mg/ml MB orphenadrine citrate tb12 100mg 1 PA; High Risk Medications require PA for members age 70 and older hcl tabs 2mg, 4mg 1 NARCOLEPSY/CATAPLEXY - DRUGS FOR DISORDERS tabs 50mg 1 PA, QL (60 tabs / 25 days), MO

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 55 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS armodafinil tabs 150mg, 200mg, 1 PA, QL (30 tabs / 25 250mg days), MO tabs 100mg, 200mg 1 PA, QL (60 tabs / 25 days), MO PSYCHOTHERAPEUTIC-MISC acamprosate calcium tbec 333mg 1 PA, MO bupropion hcl (smoking deterrent) PV $0 limited to 2 tb12 150mg treatment cycles/year CHANTIX TABS .5mg, 1mg ( PV $0 limited to 2 tartrate) treatment cycles/year CHANTIX CONTINUING MONTH TABS 1mg PV $0 limited to 2 (varenicline tartrate) treatment cycles/year CHANTIX PAK 0.5& 1MG (varenicline PV $0 limited to 2 tartrate) treatment cycles/year tabs 250mg, 500mg 1 MO naloxone hcl soct .4mg/ml; soln MB .4mg/ml, 4mg/10ml; sosy 2mg/2ml hcl tabs 50mg 1 Must obtain approval after the first 30 day supply NARCAN LIQD 4mg/0.1ml (naloxone hcl) 2 ( Pt24 7mg/24hr) NICOTINE STEP PV $0 limited to 2 3 treatment cycles/year nicotine pt24 7mg/24hr, 14mg/24hr, PV $0 limited to 2 21mg/24hr treatment cycles/year (Nicotine Pt24 7mg/24hr, 14mg/24hr, PV $0 limited to 2 21mg/24hr) SM NICOTINE treatment cycles/year S nicotine polacrilex gum 2mg, 4mg; PV $0 limited to 2 lozg 2mg treatment cycles/year (Nicotine Polacrilex Gum 4mg; Lozg 4mg) PV $0 limited to 2 GOODSENSE NICOTINE POLACR treatment cycles/year NICOTROL INHALER INHA 10mg PV QL (max 168 days / (nicotine) year); $0 limited to 2 treatment cycles/year NICOTROL NS SOLN 10mg/ml (nicotine) PV QL (max 168 days / year); $0 limited to 2 treatment cycles/year VIVITROL SUSR 380mg (naltrexone) MB ENDOCRINE AND METABOLIC - DRUGS TO TREAT DIABETES AND REGULATE HORMONES - DRUGS TO REGULATE MALE HORMONES INTRAROSA INST 6.5mg ( 3 MO vaginal)

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 56 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS caps 10mg 1 PA, MO 10mg/act, 1 PA, MO 25mg/2.5gm soln MB MO 100mg/ml, 200mg/ml soln MB MO 200mg/ml ANTIDIABETICS, ALPHA-GLUCOSIDASE INHIBITORS acarbose tabs 25mg, 50mg, 100mg 1 MO tabs 25mg, 50mg, 100mg 1 MO ANTIDIABETICS, ANALOGS SYMLINPEN 60 SOPN 1500mcg/1.5ml 3 ST, MO; PA** ( acetate) SYMLINPEN 120 SOPN 2700mcg/2.7ml 3 ST, MO; PA** (pramlintide acetate) ANTIDIABETICS, hcl tabs 500mg, 850mg, 1 MO 1000mg; tb24 500mg, 750mg ANTIDIABETICS, BIGUANIDE/ COMBINATIONS -metformin hcl tab 2.5-250 1 MO mg glipizide-metformin hcl tab 2.5-500 1 MO mg glipizide-metformin hcl tab 5-500 mg 1 MO ANTIDIABETICS, DIPEPTIDYL PEPTIDASE-4 INHIBITORS alogliptin benzoate tabs 6.25mg, 1 ST, MO; PA** 12.5mg, 25mg JANUVIA TABS 25mg, 50mg, 100mg 2 ST, MO; PA** ( phosphate) ANTIDIABETICS, RECEPTOR AGONISTS CYCLOSET TABS .8mg (bromocriptine 3 MO mesylate (diabetes)) ANTIDIABETICS, DPP-4 INHIBITOR COMBINATIONS alogliptin-metformin hcl tab 12.5-500 1 ST, MO; PA** mg alogliptin-metformin hcl tab 12.5-1000 1 ST, MO; PA** mg JANUMET TAB 50-500MG (sitagliptin- 2 ST, MO; PA** metformin hcl) JANUMET TAB 50-1000 (sitagliptin- 2 ST, MO; PA** metformin hcl) JANUMET XR TAB 50-500MG (sitagliptin- 2 ST, MO; PA** metformin hcl)

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 57 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS JANUMET XR TAB 50-1000 (sitagliptin- 2 ST, MO; PA** metformin hcl) JANUMET XR TAB 100-1000 (sitagliptin- 2 ST, MO; PA** metformin hcl) JENTADUETO TAB XR (linagliptin- 3 ST, MO; PA** metformin hcl) ANTIDIABETICS, INCRETIN MIMETIC AGENTS OZEMPIC SOPN 2mg/1.5ml, 4mg/3ml 2 ST, MO; PA** () TRULICITY SOPN .75mg/0.5ml, 2 ST, MO; PA** 1.5mg/0.5ml, 3mg/0.5ml, 4.5mg/0.5ml () VICTOZA SOPN 18mg/3ml () 2 ST, MO; PA** ANTIDIABETICS, INCRETIN MIMETIC COMBINATION AGENTS SOLIQUA INJ 100/33 (- 2 MO; PA** ) XULTOPHY INJ 100/3.6 (insulin 2 MO; PA** degludec-liraglutide) ANTIDIABETICS, INSULIN BASAGLAR KWIKPEN SOPN 100unit/ml 2 MO (insulin glargine) FIASP FLEX INJ TOUCH ( 2 MO (with niacinamide)) FIASP INJ 100/ML (insulin aspart (with 2 MO niacinamide)) FIASP PENFIL INJ U-100 (insulin aspart 2 MO (with niacinamide)) HUMULIN INJ 70/30 (insulin nph 3 MO isophane & reg (human)) HUMULIN INJ 70/30KWP (insulin nph 3 MO isophane & reg (human)) HUMULIN N SUSP 100unit/ml (insulin 3 MO nph (human) (isophane)) HUMULIN N KWIKPEN SUPN 100unit/ml 3 MO (insulin nph (human) (isophane)) HUMULIN R SOLN 100unit/ml (insulin 3 MO regular (human)) HUMULIN R U-500 (CONCENTR SOLN 2 MO 500unit/ml (insulin regular (human)) HUMULIN R U-500 KWIKPEN SOPN 2 MO 500unit/ml (insulin regular (human)) LEVEMIR SOLN 100unit/ml (insulin 2 MO detemir)

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 58 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS LEVEMIR FLEXTOUCH SOPN 100unit/ml 2 MO () NOVOLIN INJ 70/30 (insulin nph 2 MO; RELION not covered isophane & reg (human)) NOVOLIN INJ 70/30 FP (insulin nph 2 MO; RELION not covered isophane & reg (human)) NOVOLIN N SUSP 100unit/ml (insulin 2 MO; RELION not covered nph (human) (isophane)) NOVOLIN N FLEXPEN SUPN 100unit/ml 2 MO; RELION not covered (insulin nph (human) (isophane)) NOVOLIN R SOLN 100unit/ml (insulin 2 MO; RELION not covered regular (human)) NOVOLIN R FLEXPEN SOPN 100unit/ml 2 MO; RELION not covered (insulin regular (human)) NOVOLOG SOLN 100unit/ml (insulin 2 MO; RELION not covered aspart) NOVOLOG FLEXPEN SOPN 100unit/ml 2 MO; RELION not covered (insulin aspart) NOVOLOG MIX INJ 70/30 (insulin aspart 2 MO; RELION not covered & aspart (human)) NOVOLOG MIX INJ FLEXPEN (insulin 2 MO; RELION not covered aspart protamine & aspart (human)) NOVOLOG PENFILL SOCT 100unit/ml 2 MO; RELION not covered (insulin aspart) TRESIBA SOLN 100unit/ml (insulin 2 MO degludec) TRESIBA FLEXTOUCH SOPN 100unit/ml, 2 MO 200unit/ml () ANTIDIABETICS, INSULIN SENSITIZER hcl tabs 15mg, 30mg, 1 MO 45mg ANTIDIABETICS, INSULIN SENSITIZER/BIGUANIDE COMBINATION pioglitazone hcl-metformin hcl tab 15- 1 MO 500 mg pioglitazone hcl-metformin hcl tab 15- 1 MO 850 mg ANTIDIABETICS, INSULIN SENSITIZER/SULFONYLUREA COMBINATION pioglitazone hcl- tab 30-2 1 MO mg pioglitazone hcl-glimepiride tab 30-4 1 MO mg ANTIDIABETICS, MEGLITINIDE tabs 60mg, 120mg 1 MO

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 59 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS tabs .5mg, 1mg, 2mg 1 MO ANTIDIABETICS, SODIUM-GLUC CO-TRANSPOR2 INHIB (SGLT2) COMBO SYNJARDY TAB (empagliflozin- 2 ST, MO; PA** metformin hcl) SYNJARDY TAB 5-500MG (empagliflozin- 2 ST, MO; PA** metformin hcl) SYNJARDY TAB 5-1000MG 2 ST, MO; PA** (empagliflozin-metformin hcl) SYNJARDY TAB 12.5-500 (empagliflozin- 2 ST, MO; PA** metformin hcl) SYNJARDY XR TAB (empagliflozin- 2 ST, MO; PA** metformin hcl) SYNJARDY XR TAB 5-1000MG 2 ST, MO; PA** (empagliflozin-metformin hcl) SYNJARDY XR TAB 10-1000 2 ST, MO; PA** (empagliflozin-metformin hcl) SYNJARDY XR TAB 25-1000 2 ST, MO; PA** (empagliflozin-metformin hcl) XIGDUO XR TAB 2.5-1000 (dapagliflozin- 2 ST, MO; PA** metformin hcl) XIGDUO XR TAB 5-500MG (dapagliflozin- 2 ST, MO; PA** metformin hcl) XIGDUO XR TAB 5-1000MG 2 ST, MO; PA** (dapagliflozin-metformin hcl) XIGDUO XR TAB 10-500MG 2 ST, MO; PA** (dapagliflozin-metformin hcl) XIGDUO XR TAB 10-1000 (dapagliflozin- 2 ST, MO; PA** metformin hcl) ANTIDIABETICS, SODIUM-GLUC CO-TRANSPOR2 INHIB (SGLT2)/DPP-4 INHIBITOR COMBINATIONS GLYXAMBI TAB 10-5 MG (empagliflozin- 2 ST, MO; PA** linagliptin) GLYXAMBI TAB 25-5 MG (empagliflozin- 2 ST, MO; PA** linagliptin) ANTIDIABETICS, SODIUM-GLUCOSE COTRANSPORTER2(SGLT2) INHIB FARXIGA TABS 5mg, 10mg 2 ST, MO; PA** (dapagliflozin propanediol) JARDIANCE TABS 10mg, 25mg 2 ST, MO; PA** (empagliflozin) ANTIDIABETICS, SULFONYLUREA glimepiride tabs 1mg, 2mg, 4mg 1 MO

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 60 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS glipizide tabs 5mg, 10mg; tb24 1 MO 2.5mg, 5mg, 10mg - DRUGS TO TREAT LOSS alendronate sodium soln 70mg/75ml; 1 MO tabs 5mg, 10mg, 35mg, 70mg FOSAMAX + D TAB 70-2800 (alendronate 3 ST, MO; PA** sodium-) FOSAMAX + D TAB 70-5600 (alendronate 3 ST, MO; PA** sodium-cholecalciferol) ibandronate sodium soln 3mg/3ml MB ibandronate sodium tabs 150mg 1 MO pamidronate disodium soln MB 30mg/10ml risedronate sodium tabs 5mg, 35mg, 1 MO 150mg; tbec 35mg risedronate sodium tabs 30mg 1 zoledronic acid conc 4mg/5ml; soln MB 5mg/100ml CALCIUM RECEPTOR AGONISTS cinacalcet hcl tabs 30mg, 60mg 4 SP, PA, QL (60 tabs / 30 days), MO cinacalcet hcl tabs 90mg 4 SP, PA, QL (120 tabs / 30 days), MO CHELATING AGENTS CHEMET CAPS 100mg (succimer) 3 deferiprone tabs 500mg 4 SP, PA, MO FERRIPROX SOLN 100mg/ml; TABS 4 PA, MO 1000mg (deferiprone) FERRIPROX TWICE-A-DAY TABS 1000mg 4 PA, MO (deferiprone) tabs 250mg 1 SP, PA (Sodium Polystyrene Sulfonate Susp 1 15gm/60ml) SPS sodium polystyrene sulfonate susp 1 15gm/60ml, 30gm/120ml CONTRACEPTIVES - DRUGS FOR ANNOVERA MIS ( acetate- PV QL (1 / 300 days), MO ethinyl ) BALCOLTRA TAB 0.1-20 (- PV MO ethinyl estradiol-ferrous bisglycinate) DEPO-SUBQ PROVERA 104 SUSY MB 104mg/0.65ml (medroxyprogesterone acetate (contraceptive))

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 61 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS (Desogest-Eth Estrad & Eth Estrad Tab PV MO 0.15-0.02/0.01 mg(21/5)) AZURETTE (Desogest-Eth Estrad & Eth Estrad Tab PV MO 0.15-0.02/0.01 mg(21/5)) KARIVA (Desogest-Eth Estrad & Eth Estrad Tab PV MO 0.15-0.02/0.01 mg(21/5)) VIORELE (Desogest-Ethin Est Tab 0.1-0.025/0.125- PV MO 0.025/0.15-0.025mg-Mg) CAZIANT (Desogest-Ethin Est Tab 0.1-0.025/0.125- PV MO 0.025/0.15-0.025mg-Mg) VELIVET ( & Ethinyl Estradiol Tab 0.15 PV MO mg-30 mcg) APRI (Desogestrel & Ethinyl Estradiol Tab 0.15 PV MO mg-30 mcg) EMOQUETTE (Desogestrel & Ethinyl Estradiol Tab 0.15 PV MO mg-30 mcg) ENSKYCE (Desogestrel & Ethinyl Estradiol Tab 0.15 PV MO mg-30 mcg) RECLIPSEN -ethinyl estrad- PV MO levomefolate tab 3-0.02-0.451 mg drospirenone-ethinyl estrad- PV MO levomefolate tab 3-0.03-0.451 mg (Drospirenone-Ethinyl Estradiol Tab 3-0.02 PV MO mg) GIANVI (Drospirenone-Ethinyl Estradiol Tab 3-0.02 PV MO mg) LORYNA (Drospirenone-Ethinyl Estradiol Tab 3-0.02 PV MO mg) NIKKI drospirenone-ethinyl estradiol tab 3- PV MO 0.03 mg (Drospirenone-Ethinyl Estradiol Tab 3-0.03 PV MO mg) OCELLA (Drospirenone-Ethinyl Estradiol Tab 3-0.03 PV MO mg) SYEDA (Drospirenone-Ethinyl Estradiol Tab 3-0.03 PV MO mg) ZARAH ELLA TABS 30mg () PV (Ethynodiol Diacetate & Ethinyl Estradiol PV MO Tab 1 mg-35 mcg) KELNOR 1/35 (Ethynodiol Diacetate & Ethinyl Estradiol PV MO Tab 1 mg-35 mcg) ZOVIA 1/35E ethynodiol diacetate & ethinyl PV MO estradiol tab 1 mg-50 mcg -ethinyl estradiol va ring PV QL (13 / 300 days), MO 0.120-0.015 mg/24hr

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 62 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS KYLEENA IUD 19.5mg (levonorgestrel MB (iud)) (Levonor-Eth Est Tab 0.15- PV MO 0.02/0.025/0.03 mg ð Est 0.01 mg) FAYOSIM (Levonor-Eth Est Tab 0.15- PV MO 0.02/0.025/0.03 mg ð Est 0.01 mg) RIVELSA levonorg-eth est tab 0.1-0.02mg(84) PV MO & eth est tab 0.01mg(7) (Levonorg-Eth Est Tab 0.15-0.03mg(84) & PV MO Eth Est Tab 0.01mg(7)) AMETHIA (Levonorg-Eth Est Tab 0.15-0.03mg(84) & PV MO Eth Est Tab 0.01mg(7)) ASHLYNA levonorgestrel & ethinyl estradiol (91- PV MO day) tab 0.15-0.03 mg (Levonorgestrel & Ethinyl Estradiol (91- PV MO Day) Tab 0.15-0.03 mg) INTROVALE (Levonorgestrel & Ethinyl Estradiol (91- PV MO Day) Tab 0.15-0.03 mg) JOLESSA (Levonorgestrel & Ethinyl Estradiol Tab 0.1 PV MO mg-20 mcg) AVIANE (Levonorgestrel & Ethinyl Estradiol Tab 0.1 PV MO mg-20 mcg) DELYLA (Levonorgestrel & Ethinyl Estradiol Tab 0.1 PV MO mg-20 mcg) FALMINA (Levonorgestrel & Ethinyl Estradiol Tab 0.1 PV MO mg-20 mcg) LESSINA (Levonorgestrel & Ethinyl Estradiol Tab 0.1 PV MO mg-20 mcg) LUTERA (Levonorgestrel & Ethinyl Estradiol Tab 0.1 PV MO mg-20 mcg) ORSYTHIA (Levonorgestrel & Ethinyl Estradiol Tab 0.1 PV MO mg-20 mcg) SRONYX levonorgestrel & ethinyl estradiol tab PV MO 0.15 mg-30 mcg (Levonorgestrel & Ethinyl Estradiol Tab PV MO 0.15 mg-30 mcg) ALTAVERA (Levonorgestrel & Ethinyl Estradiol Tab PV MO 0.15 mg-30 mcg) CHATEAL (Levonorgestrel & Ethinyl Estradiol Tab PV MO 0.15 mg-30 mcg) KURVELO (Levonorgestrel & Ethinyl Estradiol Tab PV MO 0.15 mg-30 mcg) LEVORA 0.15/30-28

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 63 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS (Levonorgestrel & Ethinyl Estradiol Tab PV MO 0.15 mg-30 mcg) MARLISSA (Levonorgestrel & Ethinyl Estradiol Tab PV MO 0.15 mg-30 mcg) PORTIA-28 (Levonorgestrel (Emergency Oc) Tabs PV 1.5mg) TAKE ACTION (Levonorgestrel-Eth Estra Tab 0.05- PV MO 30/0.075-40/0.125-30mg-Mcg) ENPRESSE-28 (Levonorgestrel-Eth Estra Tab 0.05- PV MO 30/0.075-40/0.125-30mg-Mcg) LEVONEST (Levonorgestrel-Eth Estra Tab 0.05- PV MO 30/0.075-40/0.125-30mg-Mcg) TRIVORA- 28 (Levonorgestrel-Ethinyl Estradiol PV MO (Continuous) Tab 90-20 mcg) AMETHYST LILETTA IUD 19.5mcg/day MB (levonorgestrel (iud)) LO LOESTRIN TAB 1-10-10 PV MO (norethindrone acetate-ethinyl estradiol-fe fum (biphasic)) medroxyprogesterone acetate MB (contraceptive) susp 150mg/ml; susy 150mg/ml MIRENA IUD 20mcg/24hr MB (levonorgestrel (iud)) NATAZIA TAB (- PV MO ) NEXPLANON IMPL 68mg (etonogestrel) MB NEXTSTELLIS TAB 3-14.2MG PV MO (drospirenone-) (-Ethinyl Estradiol Td Ptwk PV MO 150-35 mcg/24hr) XULANE (Norethindrone & Ethinyl Estradiol Tab 0.4 PV MO mg-35 mcg) VYFEMLA (Norethindrone & Ethinyl Estradiol Tab 0.5 PV MO mg-35 mcg) NECON 0.5/35-28 (Norethindrone & Ethinyl Estradiol Tab 0.5 PV MO mg-35 mcg) NORTREL 0.5/35 (28) (Norethindrone & Ethinyl Estradiol Tab 0.5 PV MO mg-35 mcg) WERA (Norethindrone & Ethinyl Estradiol Tab 1 PV MO mg-35 mcg) ALYACEN 1/35 (Norethindrone & Ethinyl Estradiol Tab 1 PV MO mg-35 mcg) CYCLAFEM 1/35

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 64 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS (Norethindrone & Ethinyl Estradiol Tab 1 PV MO mg-35 mcg) DASETTA 1/35 (Norethindrone & Ethinyl Estradiol Tab 1 PV MO mg-35 mcg) NORTREL 1/35 (Norethindrone & Ethinyl Estradiol Tab 1 PV MO mg-35 mcg) PIRMELLA 1/35 norethindrone & ethinyl estradiol-fe PV MO chew tab 0.4 mg-35 mcg norethindrone & ethinyl estradiol-fe PV MO chew tab 0.8 mg-25 mcg norethindrone (contraceptive) tabs PV MO .35mg (Norethindrone (Contraceptive) Tabs PV MO .35mg) CAMILA (Norethindrone (Contraceptive) Tabs PV MO .35mg) ERRIN (Norethindrone (Contraceptive) Tabs PV MO .35mg) HEATHER (Norethindrone (Contraceptive) Tabs PV MO .35mg) NORA-BE (Norethindrone Ac-Ethinyl Estrad-Fe Tab 1- PV MO 20/1-30/1-35 mg-Mcg) TILIA FE norethindrone ace & ethinyl estradiol PV MO tab 1 mg-20 mcg (Norethindrone Ace & Ethinyl Estradiol Tab PV MO 1 mg-20 mcg) JUNEL 1/20 (Norethindrone Ace & Ethinyl Estradiol Tab PV MO 1.5 mg-30 mcg) JUNEL 1.5/30 (Norethindrone Ace & Ethinyl Estradiol Tab PV MO 1.5 mg-30 mcg) LARIN 1.5/30 (Norethindrone Ace & Ethinyl Estradiol Tab PV MO 1.5 mg-30 mcg) MICROGESTIN 1.5/30 (Norethindrone Ace & Ethinyl Estradiol-Fe PV MO Tab 1 mg-20 mcg) JUNEL FE 1/20 (Norethindrone Ace & Ethinyl Estradiol-Fe PV MO Tab 1.5 mg-30 mcg) JUNEL FE 1.5/30 (Norethindrone Ace-Eth Estradiol-Fe Chew PV MO Tab 1 mg-20 mcg (24)) MIBELAS 24 FE norethindrone ace-ethinyl estradiol-fe PV MO cap 1 mg-20 mcg (24) (Norethindrone Ace-Ethinyl Estradiol-Fe PV MO Cap 1 mg-20 mcg (24)) GEMMILY (Norethindrone Ace-Ethinyl Estradiol-Fe PV MO Tab 1 mg-20 mcg (24)) JUNEL FE 24

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 65 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS (Norethindrone-Eth Estradiol Tab 0.5- PV MO 35/0.75-35/1-35 mg-Mcg) ALYACEN 7/7/7 (Norethindrone-Eth Estradiol Tab 0.5- PV MO 35/0.75-35/1-35 mg-Mcg) CYCLAFEM 7/7/7 (Norethindrone-Eth Estradiol Tab 0.5- PV MO 35/0.75-35/1-35 mg-Mcg) DASETTA 7/7/7 (Norethindrone-Eth Estradiol Tab 0.5- PV MO 35/0.75-35/1-35 mg-Mcg) NORTREL 7/7/7 (Norethindrone-Eth Estradiol Tab 0.5- PV MO 35/0.75-35/1-35 mg-Mcg) PIRMELLA 7/7/7 (Norethindrone-Eth Estradiol Tab 0.5-35/1- PV MO 35/0.5-35 mg-Mcg) ARANELLE (Norethindrone-Eth Estradiol Tab 0.5-35/1- PV MO 35/0.5-35 mg-Mcg) LEENA & ethinyl estradiol tab PV MO 0.25 mg-35 mcg (Norgestimate & Ethinyl Estradiol Tab 0.25 PV MO mg-35 mcg) MONO-LINYAH (Norgestimate & Ethinyl Estradiol Tab 0.25 PV MO mg-35 mcg) PREVIFEM (Norgestimate & Ethinyl Estradiol Tab 0.25 PV MO mg-35 mcg) SPRINTEC 28 norgestimate-eth estrad tab 0.18- PV MO 25/0.215-25/0.25-25 mg-mcg norgestimate-eth estrad tab 0.18- PV MO 35/0.215-35/0.25-35 mg-mcg (Norgestimate-Eth Estrad Tab 0.18- PV MO 35/0.215-35/0.25-35 mg-Mcg) TRI-LINYAH (Norgestimate-Eth Estrad Tab 0.18- PV MO 35/0.215-35/0.25-35 mg-Mcg) TRI- SPRINTEC ( & Ethinyl Estradiol Tab 0.3 mg- PV MO 30 mcg) CRYSELLE-28 (Norgestrel & Ethinyl Estradiol Tab 0.3 mg- PV MO 30 mcg) ELINEST (Norgestrel & Ethinyl Estradiol Tab 0.3 mg- PV MO 30 mcg) LOW-OGESTREL (Norgestrel & Ethinyl Estradiol Tab 0.5 mg- PV MO 50 mcg) OGESTREL PARAGARD IUD T380A ( (iud)) MB SKYLA IUD 13.5mg (levonorgestrel MB (iud)) SLYND TABS 4mg (drospirenone) PV MO

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 66 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS TWIRLA DIS 120-30 (levonorgestrel- PV MO ethinyl estradiol) TYBLUME CHW 0.1-0.02 (levonorgestrel PV MO & eth estradiol) ENDOMETRIOSIS caps 50mg, 100mg, 200mg 1 ORILISSA TABS 150mg, 200mg ( 2 sodium) SYNAREL SOLN 2mg/ml ( 4 PA acetate) REPLACEMENTS - DRUGS TO TREAT ENZYME DEFICIENCIES CARBAGLU TABS 200mg (carglumic 4 PA, MO acid) CERDELGA CAPS 84mg ( 4 SP, PA, QL (60 caps / 30 tartrate) days), MO CYSTADANE POW (betaine) 4 PA, MO CYSTAGON CAPS 50mg, 150mg 4 SP, PA, MO ( bitartrate) caps 2mg, 5mg, 10mg 4 SP, PA, MO ORFADIN CAPS 20mg; SUSP 4mg/ml 4 PA, MO (nitisinone) sapropterin dihydrochloride pack 4 SP, PA, MO 100mg, 500mg; tabs 100mg powd 4 SP, PA, QL (600g / 30 3gm/tsp days), MO sodium phenylbutyrate tabs 500mg 4 SP, PA, QL (1200 tabs / 30 days), MO - DRUGS TO REGULATE FEMALE HORMONES CLIMARA PRO DIS WEEKLY (estradiol- 2 MO levonorgestrel) DEPO-ESTRADIOL 5mg/ml (estradiol MB cypionate) DIVIGEL GEL .25mg/0.25gm, 3 PA, MO; High Risk .5mg/0.5gm, .75mg/0.75gm, 1mg/gm, Medications require PA 1.25mg/1.25gm (estradiol) for members age 70 and older DUAVEE TAB 0.45-20 (conjugated 2 MO estrogens-) ELESTRIN GEL .06% (estradiol) 3 PA, MO; High Risk Medications require PA for members age 70 and older

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 67 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS estradiol pttw .025mg/24hr, 1 PA, MO; High Risk .037mg/24hr, .05mg/24hr, Medications require PA .075mg/24hr, .1mg/24hr; ptwk for members age 70 and .025mg/24hr, .05mg/24hr, older .06mg/24hr, .075mg/24hr, .1mg/24hr, 37.5mcg/24hr; tabs .5mg, 1mg, 2mg estradiol & norethindrone acetate tab 1 MO 0.5-0.1 mg estradiol & norethindrone acetate tab 1 MO 1-0.5 mg (Estradiol & Norethindrone Acetate Tab 1- 1 MO 0.5 mg) MIMVEY estradiol vaginal crea .1mg/gm 1 MO (Estradiol Vaginal Tabs 10mcg) YUVAFEM 1 MO estradiol valerate oil 20mg/ml, MB 40mg/ml ESTROGEL GEL .06% (estradiol) 3 PA, MO; High Risk Medications require PA for members age 70 and older EVAMIST SOLN 1.53mg/spray (estradiol) 3 PA, MO; High Risk Medications require PA for members age 70 and older MENEST TABS .3mg, .625mg, 1.25mg 3 PA, MO; High Risk () Medications require PA for members age 70 and older norethindrone acetate-ethinyl 1 MO estradiol tab 0.5 mg-2.5 mcg (Norethindrone Acetate-Ethinyl Estradiol 1 MO Tab 1 mg-5 mcg) JINTELI PREMARIN CREA .625mg/gm (estrogens, 3 MO conjugated vaginal) PREMARIN TABS .3mg, .45mg, .625mg, 3 PA, MO; High Risk .9mg, 1.25mg (estrogens, conjugated) Medications require PA for members age 70 and older - DRUGS TO TREAT INFLAMMATORY RESPONSE acetate tabs 25mg 1 DEPO-MEDROL SUSP 20mg/ml MB ( acetate)

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 68 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS elix .5mg/5ml; soln 1 .5mg/5ml; tabs .5mg, .75mg, 1mg, 1.5mg, 2mg, 4mg, 6mg DEXAMETHASONE INTENSOL CONC 2 1mg/ml (dexamethasone) dexamethasone sodium phosphate MB soln 4mg/ml, 10mg/ml, 20mg/5ml, 100mg/10ml, 120mg/30ml acetate tabs .1mg 1 MO tabs 5mg, 10mg, 1 20mg MEDROL TABS 2mg 2 (methylprednisolone) methylprednisolone tabs 4mg, 8mg, 1 16mg, 32mg; tbpk 4mg methylprednisolone acetate susp MB 40mg/ml, 80mg/ml methylprednisolone sod succ solr MB 125mg, 1000mg soln 15mg/5ml 1 prednisolone sodium phosphate soln 1 5mg/5ml, 10mg/5ml, 15mg/5ml, 20mg/5ml, 25mg/5ml; tbdp 10mg, 15mg, 30mg soln 5mg/5ml; tabs 1mg, 1 2.5mg, 5mg, 10mg, 20mg, 50mg; tbpk 5mg, 10mg PREDNISONE INTENSOL CONC 5mg/ml 2 (prednisone) SOLU-CORTEF SOLR 100mg, 250mg, MB 500mg, 1000mg (hydrocortisone sod succinate) SOLU-MEDROL SOLR 2gm MB (methylprednisolone sod succ) GLUCOSE ELEVATING AGENTS - DRUGS TO TREAT LOW BLOOD glucagon (rdna) kit 1mg 1 HUMAN GROWTH HORMONES - DRUGS TO REGULATE PITUITARY HORMONES HUMATROPE SOLR 6mg, 12mg, 24mg MB MO (somatropin) HUMATROPE COMBO PACK SOLR 5mg MB MO (somatropin)

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 69 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS MISCELLANEOUS tabs .5mg 1 (salmon) soln 200unit/act 1 MO INCRELEX SOLN 40mg/4ml MB MO () acetate soln 50mcg/ml, MB MO 100mcg/ml, 200mcg/ml, 500mcg/ml, 1000mcg/ml OSPHENA TABS 60mg () 2 MO PROLIA SOSY 60mg/ml (denosumab) MB hcl tabs 60mg 1 MO; $0 copay ages 35 and older for the primary prevention of breast cancer SIGNIFOR SOLN .3mg/ml, .6mg/ml, MB MO .9mg/ml (pasireotide diaspartate) SOMATULINE DEPOT SOLN 60mg/0.2ml, MB 90mg/0.3ml, 120mg/0.5ml (lanreotide acetate) SOMAVERT SOLR 10mg, 15mg, 20mg, MB MO 25mg, 30mg (pegvisomant) tabs 15mg, 30mg 4 SP, PA TYMLOS SOPN 3120mcg/1.56ml MB MO () PHOSPHATE BINDER AGENTS - DRUGS TO REGULATE CALCIUM AND PHOSPHORUS LEVELS calcium acetate (phosphate binder) 1 MO caps 667mg; tabs 667mg FOSRENOL PACK 750mg, 1000mg 3 MO ( carbonate) PHOSLYRA SOLN 667mg/5ml (calcium 2 MO acetate (phosphate binder)) sevelamer carbonate pack .8gm, 1 MO 2.4gm; tabs 800mg VELPHORO CHEW 500mg (sucroferric 3 MO oxyhydroxide) PROGESTINS - DRUGS TO REGULATE FEMALE HORMONES CRINONE GEL 4% ( 2 (vaginal)) CRINONE GEL 8% (progesterone 2 PA (vaginal)) LUPANETA KIT 3.75-5 (leuprolide MB acetate & norethindrone acetate)

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 70 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS LUPANETA KIT 11.25-5 (leuprolide MB acetate & norethindrone acetate) medroxyprogesterone acetate tabs 1 MO 2.5mg, 5mg, 10mg norethindrone acetate tabs 5mg 1 MO progesterone caps 100mg, 200mg 1 MO THYROID AGENTS - DRUGS TO REGULATE THYROID LEVELS ( Sodium Tabs 25mcg, 1 MO 50mcg, 75mcg, 88mcg, 100mcg, 112mcg, 125mcg, 137mcg, 150mcg, 175mcg, 200mcg) LEVOXYL levothyroxine sodium tabs 25mcg, 1 MO 50mcg, 75mcg, 88mcg, 100mcg, 112mcg, 125mcg, 137mcg, 150mcg, 175mcg, 200mcg, 300mcg (Levothyroxine Sodium Tabs 25mcg, 1 MO 50mcg, 75mcg, 88mcg, 100mcg, 112mcg, 125mcg, 200mcg, 300mcg) UNITHROID liothyronine sodium tabs 5mcg, 1 MO 25mcg, 50mcg methimazole tabs 5mg, 10mg 1 MO propylthiouracil tabs 50mg 1 MO SYNTHROID TABS 25mcg, 50mcg, 75mcg, 2 MO 88mcg, 100mcg, 112mcg, 125mcg, 137mcg, 150mcg, 175mcg, 200mcg, 300mcg (levothyroxine sodium) VASOPRESSINS - DRUGS TO REGULATE PITUITARY HORMONES desmopressin acetate soln 4mcg/ml MB desmopressin acetate tabs .1mg, 1 MO .2mg desmopressin acetate spray soln 1 MO .01% desmopressin acetate spray 1 MO refrigerated soln .01% ENDOCRINE AND METABOLIC AGENTS - MISC. METABOLIC MODIFIERS MYALEPT SOLR 11.3mg () MB MO FLUOROQUINOLONES - DRUGS TO TREAT INFECTIONS FLUOROQUINOLONES - DRUGS TO TREAT INFECTIONS BAXDELA TABS 450mg (delafloxacin 3 )

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 71 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS GASTROINTESTINAL - DRUGS TO TREAT STOMACH AND INTESTINAL DISORDERS - DRUGS TO TREAT COPD sulfate sosy .25mg/5ml, MB 1mg/10ml CUVPOSA SOLN 1mg/5ml 2 MO (glycopyrrolate) dicyclomine hcl caps 10mg; soln 1 10mg/5ml; tabs 20mg dicyclomine hcl soln 10mg/ml MB glycopyrrolate soln 1mg/5ml, MB 4mg/20ml glycopyrrolate tabs 1mg, 2mg 1 ( Sulfate Subl .125mg) 1 MO SYMAX-SL (Hyoscyamine Sulfate Subl .125mg; Tabs 1 MO .125mg) OSCIMIN hyoscyamine sulfate subl .125mg; 1 MO tabs .125mg; tbdp .125mg (Hyoscyamine Sulfate Tbdp .125mg) ED- 1 MO SPAZ (Hyoscyamine Sulfate Tbdp .125mg) 1 MO NULEV methscopolamine bromide tabs 1 PA; High Risk 2.5mg, 5mg Medications require PA for members age 70 and older - DRUGS FOR AND AKYNZEO CAP 300-0.5 (- 3 QL (2 caps / 21 days) ) caps 40mg 1 QL (3 caps / 180 days) aprepitant caps 80mg 1 QL (4 caps / 21 days) aprepitant caps 125mg 1 QL (2 caps / 21 days) aprepitant capsule therapy pack 80 & 1 QL (2 packs / 21 days) 125 mg caps 2.5mg, 5mg, 10mg 1 QL (60 caps / 25 days) hcl soln 1mg/ml MB granisetron hcl tabs 1mg 1 QL (12 tabs / 21 days) hcl tabs 12.5mg, 25mg 1 hcl soln 5mg/ml MB metoclopramide hcl soln 10mg/10ml; 1 tabs 5mg, 10mg; tbdp 5mg tbdp 4mg, 8mg 1 QL (18 tabs / 21 days)

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 72 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS ondansetron hcl soln 4mg/2ml, MB 40mg/20ml ondansetron hcl soln 4mg/5ml 1 QL (200 mL / 21 days) ondansetron hcl tabs 4mg, 8mg 1 QL (18 tabs / 21 days) ondansetron hcl tabs 24mg 1 QL (2 tabs / 21 days) supp 25mg 1 (Prochlorperazine Supp 25mg) COMPRO 1 prochlorperazine maleate tabs 5mg, 1 MO 10mg hcl soln 25mg/ml, MB 50mg/ml promethazine hcl supp 12.5mg, 25mg 1 (Promethazine Hcl Supp 12.5mg, 25mg, 1 50mg) PROMETHEGAN promethazine hcl syrp 6.25mg/5ml; 1 PA; High Risk tabs 12.5mg, 25mg, 50mg Medications require PA for members age 70 and older SANCUSO PTCH 3.1mg/24hr 2 QL (2 patches / 21 (granisetron) days) pt72 1mg/3days 1 hcl caps 300mg 1 VARUBI TBPK 90mg ( hcl) 2 H2-RECEPTOR ANTAGONISTS - DRUGS FOR ULCERS AND STOMACH ACID tabs 200mg 1 cimetidine tabs 300mg, 400mg, 1 MO 800mg cimetidine hcl soln 300mg/5ml 1 MO soln 20mg/2ml MB famotidine susr 40mg/5ml; tabs 1 MO 20mg, 40mg famotidine in nacl 0.9% iv soln 20 MB mg/50ml caps 150mg, 300mg; soln 1 MO 15mg/ml hcl soln 50mg/2ml MB INFLAMMATORY BOWEL DISEASE balsalazide disodium caps 750mg 1 cpep 3mg 1 DIPENTUM CAPS 250mg (olsalazine 3 PA, MO sodium)

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 73 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS hydrocortisone (intrarectal) enem 1 100mg/60ml mesalamine cp24 .375gm; cpdr 1 MO 400mg; tbec 1.2gm mesalamine enem 4gm; supp 1 1000mg; tbec 800mg sulfasalazine tabs 500mg; tbec 1 MO 500mg WITH LINZESS CAPS 72mcg, 145mcg, 290mcg 2 MO () caps 8mcg, 24mcg 1 MO IRRITABLE BOWEL SYNDROME WITH hcl tabs .5mg, 1mg 1 PA, MO ( Tab & Peg 3350-Kcl-Sod Bicarb- PV $0 copay for members Nacl For Soln Kit) GAVILYTE-H age 50 through 74, otherwise not covered CLENPIQ SOL (- PV $0 copay for members oxide-anhydrous citric age 50 through 74, acid) otherwise not covered GOLYTELY SOL (peg 3350-kcl-sod 2 bicarb-sod chloride-sod sulfate) soln 10gm/15ml 1 MO (Lactulose () Soln 1 MO 10gm/15ml) ENULOSE (Lactulose (Encephalopathy) Soln 1 MO 10gm/15ml) GENERLAC OSMOPREP TAB 1.5GM (sodium 3 phosphate monobasic-sodium phosphate dibasic) peg 3350-kcl-na bicarb-nacl-na sulfate 1 for soln 236 gm (Peg 3350-Kcl-Na Bicarb-Nacl-Na Sulfate 1 For Soln 236 gm) GAVILYTE-G (Peg 3350-Kcl-Na Bicarb-Nacl-Na Sulfate 1 For Soln 240 gm) GAVILYTE-C peg 3350-kcl-nacl-na sulfate-na PV $0 copay for members ascorbate-c for soln 100 gm age 50 through 74; Tier 1 for all others peg 3350-kcl-sod bicarb-nacl for soln 1 420 gm (Peg 3350-Kcl-Sod Bicarb-Nacl For Soln 1 420 gm) GAVILYTE-N/ PACK

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 74 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS PLENVU SOL (peg 3350-kcl-nacl-na PV $0 copay for members sulfate-na ascorbate-ascorbic acid) age 50 through 74, otherwise not covered PREPOPIK PAK (sodium picosulfate- PV $0 copay for members -anhydrous citric age 50 through 74, acid) otherwise not covered SUPREP BOWEL SOL PREP KIT (sodium PV $0 copay for members sulfate-potassium sulfate-magnesium age 50 through 74; Tier sulfate) 2 for all others SUTAB TAB (-magnesium PV $0 copay for members sulfate-potassium chloride) age 50 through 74, otherwise not covered MISCELLANEOUS cromolyn sodium () conc 1 MO 100mg/5ml w/ atropine liq 2.5- 1 0.025 mg/5ml diphenoxylate w/ atropine tab 2.5- 1 0.025 mg hcl caps 2mg 1 misoprostol tabs 100mcg, 200mcg 1 MO MOTOFEN TAB 1-0.025 ( w/ 3 atropine) MOVANTIK TABS 12.5mg, 25mg 2 ( oxalate) SUCRAID SOLN 8500unit/ml 3 PA, QL (354 mL / 25 () days), MO tabs 1gm 1 MO ursodiol caps 300mg; tabs 250mg, 1 MO 500mg PANCREATIC CREON CAP 3000UNIT (pancrelipase 2 PA, MO (-protease-)) CREON CAP 6000UNIT (pancrelipase 2 PA, MO (lipase-protease-amylase)) CREON CAP 12000UNT (pancrelipase 2 PA, MO (lipase-protease-amylase)) CREON CAP 24000UNT (pancrelipase 2 PA, MO (lipase-protease-amylase)) CREON CAP 36000UNT (pancrelipase 2 PA, MO (lipase-protease-amylase)) VIOKACE TAB 10440 (pancrelipase 2 PA, MO (lipase-protease-amylase))

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 75 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS VIOKACE TAB 20880 (pancrelipase 2 PA, MO (lipase-protease-amylase)) ZENPEP CAP 3000UNIT (pancrelipase 2 PA, MO (lipase-protease-amylase)) ZENPEP CAP 5000UNIT (pancrelipase 2 PA, MO (lipase-protease-amylase)) ZENPEP CAP 10000UNT (pancrelipase 2 PA, MO (lipase-protease-amylase)) ZENPEP CAP 15000UNT (pancrelipase 2 PA, MO (lipase-protease-amylase)) ZENPEP CAP 20000UNT (pancrelipase 2 PA, MO (lipase-protease-amylase)) ZENPEP CAP 25000 (pancrelipase 2 PA, MO (lipase-protease-amylase)) ZENPEP CAP 40000 (pancrelipase 2 PA, MO (lipase-protease-amylase)) PUMP INHIBITORS - DRUGS FOR ULCERS AND STOMACH ACID DEXILANT CPDR 30mg, 60mg 3 ST, QL (90 caps / 365 () days), MO; PA** magnesium cpdr 20mg, 1 QL (90 caps / 365 40mg days), MO esomeprazole magnesium pack 10mg 1 QL (90 packets / 365 days), MO; Covered for age less than 1 year only cpdr 15mg, 30mg 1 QL (90 caps / 365 days), MO NEXIUM PACK 2.5mg, 5mg 3 QL (90 packets / 365 (esomeprazole magnesium) days), MO; Covered for age less than 1 year only cpdr 10mg, 20mg, 40mg 1 QL (90 caps / 365 days), MO sodium tbec 20mg, 1 QL (90 tabs / 365 days), 40mg MO sodium tbec 20mg 1 QL (90 tabs / 365 days), MO RECTAL, (Hydrocortisone (Rectal) Crea 1%) 1 PROCTO-PAK hydrocortisone (rectal) crea 2.5% 1 (Hydrocortisone (Rectal) Crea 2.5%) 1 PROCTOZONE-HC

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 76 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS GENITOURINARY - DRUGS TO TREAT GENITAL AND URINARY TRACT CONDITIONS BENIGN PROSTATIC HYPERPLASIA - DRUGS TO TREAT ENLARGED hcl tb24 10mg 1 MO CARDURA XL TB24 4mg, 8mg (doxazosin 3 ST, MO; PA** mesylate (bph)) caps .5mg 1 MO dutasteride- hcl cap 0.5-0.4 1 MO mg tabs 5mg 1 MO caps 4mg, 8mg 1 MO tadalafil tabs 2.5mg, 5mg 1 PA, QL (30 tabs / 25 days), MO tamsulosin hcl caps .4mg 1 MO CONTRACEPTIVES - DRUGS FOR BIRTH CONTROL ENCARE SUPP 100mg (nonoxynol-9) PV OPTIONS GYNOL II VAGINAL GEL 3% PV (nonoxynol-9) SHUR-SEAL GEL 2% (nonoxynol-9) PV TODAY SPONGE MISC 1000mg PV (nonoxynol-9) VCF VAGINAL CONTRACEPTIVE FILM 28%; PV FOAM 12.5%; GEL 4% (nonoxynol-9) MISCELLANEOUS chloride tabs 5mg, 10mg, 1 25mg, 50mg ELMIRON CAPS 100mg (pentosan 3 polysulfate sodium) hcl tabs 100mg 1 MO potassium citrate (alkalinizer) tbcr 1 15meq, 540mg, 1080mg URINARY - DRUGS TO TREAT URINARY INCONTINENCE hydrobromide tb24 1 MO 7.5mg, 15mg chloride syrp 5mg/5ml; 1 MO tabs 5mg; tb24 5mg, 10mg, 15mg succinate tabs 5mg, 10mg 1 MO tartrate cp24 2mg, 4mg; 1 MO tabs 1mg, 2mg TOVIAZ TB24 4mg, 8mg ( 2 MO fumarate)

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 77 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS cp24 60mg; tabs 1 MO 20mg VAGINAL ANTI-INFECTIVES CLEOCIN SUPP 100mg (clindamycin 2 phosphate vaginal) clindamycin phosphate vaginal crea 1 2% GYNAZOLE-1 CREA 2% ( 3 (one dose)) metronidazole vaginal gel .75% 1 (Metronidazole Vaginal Gel .75%) 1 VANDAZOLE ( Nitrate Vaginal Supp 200mg) 1 MICONAZOLE 3 vaginal crea .4%, .8%; 1 supp 80mg HEMATOLOGIC - DRUGS TO TREAT BLOOD DISORDERS - BLOOD THINNERS ELIQUIS TABS 2.5mg, 5mg (apixaban) 2 MO ELIQUIS STARTER PACK TBPK 5mg 2 (apixaban) enoxaparin sodium soln 30mg/0.3ml, MB 40mg/0.4ml, 60mg/0.6ml, 80mg/0.8ml, 100mg/ml, 120mg/0.8ml, 150mg/ml, 300mg/3ml sodium soln MB 2.5mg/0.5ml, 5mg/0.4ml, 7.5mg/0.6ml, 10mg/0.8ml FRAGMIN SOLN 2500unit/0.2ml, MB 5000unit/0.2ml, 7500unit/0.3ml, 10000unit/ml, 12500unit/0.5ml, 15000unit/0.6ml, 18000unt/0.72ml, 95000unit/3.8ml (dalteparin sodium) sodium (porcine) soln MB 1000unit/ml, 5000unit/0.5ml, 5000unit/ml, 10000unit/ml, 20000unit/ml PRADAXA CAPS 75mg, 110mg, 150mg 3 MO (dabigatran etexilate mesylate) sodium tabs 1mg, 2mg, 1 MO 2.5mg, 3mg, 4mg, 5mg, 6mg, 7.5mg, 10mg

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 78 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS (Warfarin Sodium Tabs 1mg, 2mg, 2.5mg, 1 MO 3mg, 4mg, 5mg, 6mg, 7.5mg, 10mg) JANTOVEN XARELTO TABS 2.5mg, 10mg, 15mg, 2 MO 20mg (rivaroxaban) XARELTO STAR TAB 15/20MG 2 (rivaroxaban) HEMATOPOIETIC GROWTH FACTORS ARANESP ALBUMIN FREE SOLN 25mcg/ml, MB 40mcg/ml, 60mcg/ml, 100mcg/ml, 200mcg/ml, 300mcg/ml; SOSY 10mcg/0.4ml, 25mcg/0.42ml, 40mcg/0.4ml, 60mcg/0.3ml, 100mcg/0.5ml, 150mcg/0.3ml, 200mcg/0.4ml, 300mcg/0.6ml, 500mcg/ml (darbepoetin alfa) MIRCERA SOSY 30mcg/0.3ml, MB 50mcg/0.3ml, 75mcg/0.3ml, 100mcg/0.3ml, 150mcg/0.3ml, 200mcg/0.3ml (methoxy -epoetin beta) NEULASTA SOSY 6mg/0.6ml MB () NEULASTA ONPRO KIT PSKT 6mg/0.6ml MB (pegfilgrastim) NIVESTYM SOLN 300mcg/ml, MB 480mcg/1.6ml; SOSY 300mcg/0.5ml, 480mcg/0.8ml (-aafi) PROMACTA TABS 12.5mg, 25mg 4 SP, PA, QL (30 tabs / 30 ( olamine) days), MO PROMACTA TABS 50mg, 75mg 4 SP, PA, QL (60 tabs / 30 (eltrombopag olamine) days), MO RETACRIT SOLN 2000unit/ml, MB 3000unit/ml, 4000unit/ml, 10000unit/ml, 20000unit/ml, 40000unit/ml (epoetin alfa-epbx) UDENYCA SOSY 6mg/0.6ml MB (pegfilgrastim-cbqv) MISCELLANEOUS hcl caps .5mg, 1mg 1 MO tabs 50mg, 100mg 1 MO HEMLIBRA SOLN 30mg/ml, 60mg/0.4ml, MB MO 105mg/0.7ml, 150mg/ml (emicizumab- kxwh)

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 79 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS acetate soln 30mg/3ml MB tbcr 400mg 1 MO tranexamic acid soln 1000mg/10ml MB tranexamic acid tabs 650mg 1 AGGREGATION INHIBITORS aspirin- cap er 12hr 25- 1 MO 200 mg BRILINTA TABS 60mg, 90mg () 2 MO bisulfate tabs 75mg 1 MO clopidogrel bisulfate tabs 300mg 1 dipyridamole tabs 25mg, 50mg, 75mg 1 PA, MO; High Risk Medications require PA for members age 70 and older prasugrel hcl tabs 5mg, 10mg 1 MO ZONTIVITY TABS 2.08mg (vorapaxar 2 MO sulfate) HEMATOPOIETIC AGENTS FOLIC ACID/ folic acid tabs 1mg 1 MO IMMUNOLOGIC AGENTS - DRUGS TO TREAT DISORDERS OF THE IMMUNE SYSTEM BIOLOGIC DISEASE-MODIFYING AGENTS ACTEMRA SOLN 80mg/4ml, 200mg/10ml, MB 400mg/20ml () ACTEMRA SOSY 162mg/0.9ml MB MO (tocilizumab) ENBREL SOLN 25mg/0.5ml; SOLR 25mg; MB MO SOSY 25mg/0.5ml, 50mg/ml () ENBREL MINI SOCT 50mg/ml MB MO (etanercept) ENBREL SURECLICK SOAJ 50mg/ml MB MO (etanercept) HUMIRA PSKT 10mg/0.1ml, 10mg/0.2ml, MB MO 20mg/0.2ml, 20mg/0.4ml, 40mg/0.4ml, 40mg/0.8ml () HUMIRA PEDIA INJ CROHNS MB MO (adalimumab) HUMIRA PEDIATRIC CROHNS D PSKT MB MO 80mg/0.8ml (adalimumab) HUMIRA PEN PNKT 40mg/0.4ml MB MO (adalimumab)

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 80 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS HUMIRA PEN KIT PS/UV (adalimumab) MB MO HUMIRA PEN-CD/UC/HS START PNKT MB MO 40mg/0.8ml, 80mg/0.8ml (adalimumab) HUMIRA PEN-PS/UV STARTER PNKT MB MO 40mg/0.8ml (adalimumab) KEVZARA SOAJ 150mg/1.14ml, MB MO 200mg/1.14ml; SOSY 150mg/1.14ml, 200mg/1.14ml (sarilumab) RINVOQ TB24 15mg () 4 SP, PA, QL (30 tabs / 30 days), MO; Preferred agent for SIMPONI SOAJ 50mg/0.5ml, 100mg/ml; MB MO SOSY 50mg/0.5ml, 100mg/ml () SIMPONI ARIA SOLN 50mg/4ml MB MO (golimumab) SKYRIZI PSKT 75mg/0.83ml; SOSY MB MO 150mg/ml (risankizumab-rzaa) SKYRIZI PEN SOAJ 150mg/ml MB MO (risankizumab-rzaa) STELARA SOSY 45mg/0.5ml, 90mg/ml MB MO () TALTZ SOAJ 80mg/ml; SOSY 80mg/ml MB MO (ixekizumab) TREMFYA SOPN 100mg/ml; SOSY MB MO 100mg/ml (guselkumab) XELJANZ SOLN 1mg/ml ( 4 SP, PA, QL (240 mL / 24 citrate) days), MO XELJANZ TABS 5mg (tofacitinib citrate) 4 SP, PA, QL (60 tabs / 30 days), MO; Preferred agent for Rheumatoid Arthritis XELJANZ TABS 10mg (tofacitinib 4 SP, PA, QL (60 tabs / 30 citrate) days), MO; Preferred agent for Ulcerative XELJANZ XR TB24 11mg (tofacitinib 4 SP, PA, QL (30 tabs / 30 citrate) days), MO; Preferred agent for Rheumatoid Arthritis XELJANZ XR TB24 22mg (tofacitinib 4 SP, PA, QL (30 tabs / 30 citrate) days), MO; Preferred agent for

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 81 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS) - DRUGS TO TREAT RHEUMATOID ARTHRITIS sulfate tabs 1 MO 200mg tabs 10mg, 20mg 1 MO methotrexate sodium tabs 2.5mg 1 OAC OTEZLA TABS 30mg () 4 SP, PA, QL (60 tabs / 30 days), MO; Preferred agent for and Psoriatic Arthritis OTEZLA TAB 10/20/30 (apremilast) 4 SP, PA, QL (55 tabs / 28 days); Preferred agent for Psoriasis and Psoriatic Arthritis IMMUNOGLOBULIN HYQVIA INJ 2.5-200 (immune globulin MB (human)- (human recombinant)) HYQVIA INJ 5-400 (immune globulin MB (human)-hyaluronidase (human recombinant)) HYQVIA INJ 10-800 (immune globulin MB (human)-hyaluronidase (human recombinant)) HYQVIA INJ 20-1600 (immune globulin MB (human)-hyaluronidase (human recombinant)) HYQVIA INJ 30-2400 (immune globulin MB (human)-hyaluronidase (human recombinant)) IMMUNOMODULATORS ACTIMMUNE SOLN 2000000unit/0.5ml MB MO (-1b) ARCALYST SOLR 220mg () MB MO INTRON A SOLN 10mu/ml, MB MO 6000000unit/ml; SOLR 10mu, 18mu, 50mu (interferon alfa-2b) POMALYST CAPS 1mg, 2mg, 3mg, 4mg 4 SP, PA, QL (21 caps / 28 () days); OAC REVLIMID CAPS 2.5mg, 5mg, 10mg, 4 SP, PA, QL (28 caps / 28 15mg () days); OAC REVLIMID CAPS 20mg, 25mg 4 SP, PA, QL (21 caps / 28 (lenalidomide) days); OAC

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 82 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS THALOMID CAPS 50mg, 100mg 4 SP, PA, QL (28 caps / 28 () days), MO; OAC THALOMID CAPS 150mg, 200mg 4 SP, PA, QL (56 caps / 28 (thalidomide) days), MO; OAC IMMUNOSUPPRESSANTS AZASAN TABS 75mg, 100mg 3 MO () azathioprine tabs 50mg 1 MO cyclosporine caps 25mg, 100mg 1 SP, MO cyclosporine soln 50mg/ml MB cyclosporine modified (for 1 SP, MO microemulsion) caps 25mg, 50mg, 100mg; soln 100mg/ml (Cyclosporine Modified (For Microemulsion) 1 SP, MO Caps 25mg, 100mg; Soln 100mg/ml) GENGRAF everolimus (immunosuppressant) 1 SP, MO tabs .25mg, .5mg, .75mg mycophenolate mofetil caps 250mg; 1 SP, MO susr 200mg/ml; tabs 500mg mycophenolate mofetil hcl solr 500mg MB mycophenolate sodium tbec 180mg, 1 SP, MO 360mg PROGRAF SOLN 5mg/ml () MB SANDIMMUNE SOLN 100mg/ml 3 SP, MO (cyclosporine) soln 1mg/ml; tabs .5mg, 1 SP, MO 1mg, 2mg tacrolimus caps .5mg, 1mg, 5mg 1 SP, MO ZORTRESS TABS 1mg (everolimus 2 SP, MO (immunosuppressant)) ACTHIB INJ (haemophilus b polysac MB conj vac) ADACEL INJ ( toxoid-- MB acellular pertussis adsorb (tdap)) AFLURIA QUAD INJ 2020-21 ( MB split quadrivalent) BEXSERO INJ (meningococcal vac group MB b (recombant omv adjuvanted)) BOOSTRIX INJ (tetanus toxoid- MB diphtheria-acellular pertussis adsorb (tdap))

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 83 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS DAPTACEL INJ (diphtheria, acellular MB pertussis & tetanus toxoids) DIP/TET PED INJ 25-5LFU MB ENGERIX-B INJ 10mcg/0.5ml, 20mcg/ml; MB SUSP 10mcg/0.5ml, 20mcg/ml (hepatitis b vaccine (recomb)) FLUAD INJ 2020-21 (influenza virus MB vaccine types a & b surface antigen adjuvant) FLUAD QUADRIVALENT INFLUE PRSY .5ml MB (influenza virus vacc types a & b surf antigen adjuvant quad) FLUARIX QUAD INJ 2020-21 (influenza MB virus vaccine split quadrivalent) FLUBLOK QUAD INJ 2020-21 (influenza MB virus vac recomb hemagglutinin (ha) quadrivalent) FLUCLVX QUAD INJ 2020-21 (influenza MB virus vaccine -cultured subunit quadrivalent) FLULAVAL QUA INJ 2020-21 (influenza MB virus vaccine split quadrivalent) FLUMIST QUAD SUS 2020-21 (influenza MB virus vaccine live quadrivalent) FLUZONE HD INJ PF 20-21 (influenza MB virus vac split high-dose quad free) FLUZONE QUAD INJ 2020-21 (influenza MB virus vaccine split quadrivalent) GARDASIL 9 INJ (human papillomavirus MB (hpv) 9-valent recombinant vaccine) HAVRIX SUSP 720elu/0.5ml, 1440elu/ml MB ( vaccine) HEPLISAV-B SOSY 20mcg/0.5ml MB (hepatitis b vaccine recombinant adjuvanted) HIBERIX SOLR 10mcg (haemophilus b MB polysac conj vac) INFANRIX INJ (diphtheria, acellular MB pertussis & tetanus toxoids) IPOL INJ INACTIVE (poliovirus vaccine, MB ipv) KINRIX INJ (diph-tetanus tox ad-acell MB pertussis & polio virus, ipv vac)

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 84 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS M-M-R II INJ (measles, mumps & MB rubella virus vaccines) MENACTRA INJ (meningococcal MB (a,c,y&w-135) conjugate vaccine) MENVEO INJ (meningococcal (a,c,y&w- MB 135) oligosaccharide conjugate vac) PEDIARIX INJ 0.5ML (diph-tetanus tox- MB acell pert-hepatitis b recomb-polio ipv vac) PEDVAX HIB SUSP 7.5mcg/0.5ml MB (haemophilus b polysac conj vac) PENTACEL INJ (diph-ac pert-tet tox ad- MB polio ipv-haemophil b poly vac) PNEUMOVAX 23/1 DOSE INJ 25mcg/0.5ml MB (pneumococcal vac polyvalent) PREVNAR 13 INJ (pneumococcal 13- MB valent conjugate vaccine) PROQUAD INJ (measles-mumps- MB rubella-varicella virus vaccines) RECOMBIVAX HB SUSP 5mcg/0.5ml, MB 10mcg/ml, 40mcg/ml (hepatitis b vaccine (recomb)) ROTARIX SUS ( vaccine, live PV $0 copay for members oral) age 18 and younger, otherwise not covered ROTATEQ SOL (rotavirus vaccine, live PV $0 copay for members oral pentavalent) age 18 and younger, otherwise not covered SHINGRIX SUSR 50mcg/0.5ml (zoster MB vaccine recombinant adjuvanted) TDVAX INJ 2-2 LF (tetanus-diphtheria MB toxoids (td)) TENIVAC INJ 5-2LF (tetanus-diphtheria MB toxoids (td)) TRUMENBA INJ (meningococcal group b MB vaccine (recombinant)) TWINRIX INJ (hepatitis a (inactivated)- MB hepatitis b (recombinant) vaccines) VAQTA SUSP 25unit/0.5ml, 50unit/ml MB (hepatitis a vaccine) VARIVAX INJ 1350pfu/0.5ml (varicella MB virus vaccine live) VAXELIS INJ (diph-tet tox-acell pert ad- MB polio ipv-hib-hepatitis b recomb)

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 85 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS ZOSTAVAX SUSR 19400unt/0.65ml MB ( live) MEDICAL DEVICES CONTRACEPTIVES - DRUGS FOR BIRTH CONTROL FC2 FEMALE MIS ( - PV female) FEMCAP MIS 22MM (cervical caps) MB FEMCAP MIS 26MM (cervical caps) MB FEMCAP MIS 30MM (cervical caps) MB DIABETIC SUPPLIES CAREFINE MIS 32GX6MM (insulin pen 2 needle) INSULIN PEN NEEDLES/SYRINGES 2 (insulin syringe/needle u-100) NOVOFINE PEN NEEDLES (insulin pen 2 needle) MISCELLANEOUS ADULT RESPIRATORY MASK 2 (spacer/aerosol-holding chambers) ADULT RESPIRATORY MASK 2 (spacer/aerosol-holding chambers) HUMATROPEN MIS FOR 6MG (injection MB device) HUMATROPEN MIS FOR 12MG (injection MB device) HUMATROPEN MIS FOR 24MG (injection MB device) PEDIATRIC RESPIRATORY MASK 2 (spacer/aerosol-holding chamber supplies - masks) PEDIATRIC RESPIRATORY MASK 2 (spacer/aerosol-holding chamber supplies - masks) NUTRITIONAL/SUPPLEMENTS - VITAMINS AND SUPPLEMENTS FLUORABON SOLN .55mg/0.6ml (sodium PV MO; $0 applies for ages fluoride) 5 and under, otherwise not covered soln 2gm/50ml, MB 50% magnesium sulfate in dextrose 5% iv MB soln 1 gm/100ml

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 86 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS (Potassium Bicarbonate Tbef 25meq) 1 MO EFFER-K potassium chloride cpcr 8meq, 1 MO 10meq; soln 10%, 20%; tbcr 8meq, 10meq, 20meq (Potassium Chloride Tbcr 8meq) KLOR- 1 MO CON 8 (Potassium Chloride Tbcr 10meq) KLOR- 1 MO CON 10 potassium chloride microencapsulated 1 MO crystals er tbcr 10meq, 20meq (Potassium Chloride Microencapsulated 1 MO Crystals Er Tbcr 15meq) KLOR-CON M15 (Potassium Chloride Microencapsulated 1 MO Crystals Er Tbcr 20meq) KLOR-CON M20 sodium chloride soln 2.5meq/ml MB (Sodium Chloride Flush Soln .9%) MB MONOJECT SODIUM CHLORIDE ( Chew 1mg) FLUORITAB 1 MO (Sodium Fluoride Chew 1mg) LUDENT 1 MO sodium fluoride chew 1mg; tabs 1mg 1 MO (Sodium Fluoride Chew 2.2mg) NAFRINSE 1 MO (Sodium Fluoride Chew .25mg, .5mg) PV MO; $0 applies for ages LUDENT 5 and under, otherwise not covered sodium fluoride chew .25mg, .5mg; PV MO; $0 applies for ages soln .5mg/ml; tabs .5mg 5 and under, otherwise not covered (Sodium Fluoride Chew .25mg, .5mg; Soln PV MO; $0 applies for ages .125mg/drop) FLUORITAB 5 and under, otherwise not covered (Sodium Fluoride Soln .25mg/drop) PV MO; $0 applies for ages FLURA-DROPS 5 and under, otherwise not covered (Sodium Fluoride Soln .125mg/drop) PV MO; $0 applies for ages NAFRINSE DROPS 5 and under, otherwise not covered IV REPLACEMENT potassium chloride soln 2meq/ml MB sodium chloride soln .45%, .9%, 3%, MB 5% VITAMINS calcitriol caps .25mcg, .5mcg; soln 1 MO 1mcg/ml

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 87 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS CITRANATAL CAP HARMONY (prenatal 2 w/o vit a w/ fe fumarate-fe carbonyl- dss-fa-dha) CITRANATAL CAP MEDLEY (prenatal w/o 2 vit a w/ fe fumarate-fe carbonyl-fa- dha) CITRANATAL MIS (prenatal w/o vit a w/ 2 fe carbonyl-fe gluconate-dss-fa-dha) CITRANATAL MIS 90 DHA (prenatal w/o 2 vit a w/ fe carbonyl-fe gluconate-dss- fa-dha) CITRANATAL MIS B-CALM (prenatal w/o 2 vit a w/ fe carbonyl-fe gluconate-fa & vit b6) CITRANATAL PAK ASSURE (prenatal w/o 2 vit a w/ fe carbonyl-fe gluconate-dss- fa-dha) CITRANATAL PAK DHA (prenatal w/o vit 2 a w/ fe carbonyl-fe gluconate-dss-fa- dha) CITRANATAL TAB BLOOM (prenatal vit 2 w/ -fe carbonyl-fe gluconate- folic acid) CITRANATAL TAB RX (prenatal without 2 vit a w/ fe carbonyl-fe gluc-docusate- fa) cyanocobalamin soln 1000mcg/ml MB doxercalciferol caps .5mcg, 1mcg, 1 MO 2.5mcg ergocalciferol caps 50000unit 1 MO folic acid caps 800mcg PV QL (100 caps / 30 days), MO; $0 copay for ages 55 and under, otherwise not covered folic acid tabs 1mg 1 MO folic acid tabs 400mcg PV QL (100 tabs / 30 days); $0 copay for ages 55 and under, otherwise not covered folic acid tabs 800mcg PV QL (100 tabs / 30 days), MO; $0 copay for ages 55 and under, otherwise not covered caps 1mcg, 2mcg, 4mcg 1 MO phytonadione tabs 5mg 1

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 88 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS (*prenatal Vit W/ Carbonyl-Fa Tab 29- 1 1 mg***) PRENATABS RX (*prenatal Vit W/ Iron Carbonyl-Fa Tab 50- 1 1.25 mg***) ELITE-OB OPHTHALMIC - DRUGS TO TREAT EYE CONDITIONS ANTI-INFECTIVE/ANTI-INFLAMMATORY - DRUGS TO TREAT INFECTIONS AND INFLAMMATION -polymyxin-neomycin-hc 1 ophth oint 1% BLEPHAMIDE OIN S.O.P. ( 2 sod-prednisolone) BLEPHAMIDE SUS OP (sulfacetamide 2 sod-prednisolone) neomycin-polymyxin-dexamethasone 1 ophth oint 0.1% neomycin-polymyxin-dexamethasone 1 ophth susp 0.1% neomycin-polymyxin-hc ophth susp 1 sulfacetamide sodium-prednisolone 1 ophth soln 10-0.23(0.25)% TOBRADEX OIN 0.3-0.1% (tobramycin- 2 dexamethasone) TOBRADEX ST SUS 0.3-0.05 2 (tobramycin-dexamethasone) tobramycin-dexamethasone ophth 1 susp 0.3-0.1% ANTI-INFECTIVES - DRUGS TO TREAT INFECTIONS AZASITE SOLN 1% (azithromycin 2 (ophth)) bacitracin (ophthalmic) oint 1 500unit/gm bacitracin- ophth oint 1 (Bacitracin-Polymyxin B Ophth Oint) 1 POLYCIN BESIVANCE SUSP .6% (besifloxacin hcl) 3 ciprofloxacin hcl (ophth) soln .3% 1 erythromycin (ophth) oint 5mg/gm 1 gatifloxacin (ophth) soln .5% 1 (Gentamicin Sulfate (Ophth) Oint .3%) 1 GENTAK gentamicin sulfate (ophth) soln .3% 1 levofloxacin (ophth) soln .5% 1 moxifloxacin hcl (ophth) soln .5% 1

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 89 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS NATACYN SUSP 5% () 2 neomycin-polymy-gramicid op sol 1 1.75-10000-0.025mg-unt-mg/ml ofloxacin (ophth) soln .3% 1 polymyxin b-trimethoprim ophth soln 1 10000 unit/ml-0.1% sulfacetamide sodium (ophth) oint 1 10%; soln 10% tobramycin (ophth) soln .3% 1 trifluridine soln 1% 1 ZIRGAN GEL .15% (ganciclovir 3 ophthalmic) ANTI-INFLAMMATORIES - DRUGS TO TREAT INFLAMMATION ACUVAIL SOLN .45% (ketorolac 2 tromethamine (ophth)) sodium (ophth) soln .09% 1 dexamethasone sodium phosphate 1 (ophth) soln .1% diclofenac sodium (ophth) soln .1% 1 DUREZOL EMUL .05% () 2 flurbiprofen sodium soln .03% 1 FML OINT .1% ( 2 (ophth)) FML FORTE SUSP .25% 2 (fluorometholone (ophth)) ILEVRO SUSP .3% (nepafenac) 2 ketorolac tromethamine (ophth) soln 1 .4%, .5% etabonate susp .5% 1 MAXIDEX SUSP .1% (dexamethasone 2 (ophth)) NEVANAC SUSP .1% (nepafenac) 2 PRED MILD SUSP .12% (prednisolone 2 acetate (ophth)) (ophth) susp 1 1% PREDNISOLONE SODIUM PHOSP SOLN 1% 2 ANTIALLERGICS - DRUGS TO TREAT ALOCRIL SOLN 2% ( sodium 3 (ophth)) ALOMIDE SOLN .1% ( 3 tromethamine) hcl (ophth) soln .05% 1

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 90 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS besilate soln 1.5% 1 BEPREVE SOLN 1.5% (bepotastine 3 besilate) cromolyn sodium (ophth) soln 4% 1 hcl (ophth) soln .05% 1 LASTACAFT SOLN .25% () 2 hcl soln .1%, .2% 1 PAZEO SOLN .7% (olopatadine hcl) 2 ANTIGLAUCOMA - DRUGS TO TREAT ALPHAGAN P SOLN .1% ( 3 MO tartrate) hcl soln .5% 1 betaxolol hcl (ophth) soln .5% 1 MO BETIMOL SOLN .25%, .5% (timolol) 3 MO BETOPTIC-S SUSP .25% (betaxolol hcl 2 MO (ophth)) brimonidine tartrate soln .15%, .2% 1 MO susp 1% 1 MO hcl (ophth) soln 1% 1 MO COMBIGAN SOL 0.2/0.5% (brimonidine 2 MO tartrate-timolol maleate) hcl soln 2% 1 MO dorzolamide hcl-timolol maleate ophth 1 MO soln 22.3-6.8 mg/ml IOPIDINE SOLN 1% (apraclonidine hcl) 3 soln .005% 1 MO hcl soln .5% 1 MO LUMIGAN SOLN .01% () 2 ST, MO; PA** PHOSPHOLINE IODIDE SOLR .125% 3 MO ( iodide) hcl soln 1% 1 MO SIMBRINZA SUS 1-0.2% (brinzolamide- 2 MO brimonidine tartrate) timolol maleate (ophth) solg .25%, 1 MO .5%; soln .25%, .5% soln .004% 1 MO ZIOPTAN SOLN .015mg/ml () 3 ST, MO; PA** MISCELLANEOUS atropine sulfate soln 1% 3 MO CYSTARAN SOLN .44% (cysteamine hcl) 4 PA, QL (4 bottles / 28 days), MO LACRISERT INST 5mg (artificial tear 3 insert)

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 91 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS hcl (mydriatic) soln 1 2.5%, 10% RESTASIS EMUL .05% (cyclosporine 2 MO (ophth)) soln .5%, 1% 1 MO RESPIRATORY - DRUGS TO TREAT BREATHING DISORDERS TREATMENT AGENTS epinephrine (anaphylaxis) soaj 1 QL (4 auto-injectors / 25 .15mg/0.3ml, .3mg/0.3ml days) epinephrine (anaphylaxis) soaj 1 QL (4 auto-injectors / 25 .15mg/0.15ml days); (generic of Adrenaclick) EPIPEN 2-PAK SOAJ .3mg/0.3ml 2 QL (4 auto-injectors / 25 (epinephrine (anaphylaxis)) days) EPIPEN-JR 2-PAK SOAJ .15mg/0.3ml 2 QL (4 auto-injectors / 25 (epinephrine (anaphylaxis)) days) /BETA AGONIST COMBINATIONS - DRUGS TO TREAT COPD ANORO ELLIPT AER 62.5-25 2 QL (1 package / 25 (umeclidinium-) days), MO BEVESPI AER 9-4.8MCG (glycopyrrolate- 2 QL (1 package / 25 fumarate) days), MO ipratropium-albuterol nebu soln 0.5- 1 QL (6 boxes / 25 days), 2.5(3) mg/3ml MO TRELEGY AER ELLIPTA (- 2 QL (1 package / 25 umeclidinium-vilanterol) days), MO ANTICHOLINERGICS - DRUGS TO TREAT COPD INCRUSE ELLIPTA AEPB 62.5mcg/inh 2 QL (1 package / 25 () days), MO soln .02% 1 QL (5 boxes / 25 days), MO ipratropium bromide (nasal) soln 1 MO .03%, .06% SPIRIVA HANDIHALER CAPS 18mcg 2 QL (1 package / 25 ( monohydrate) days), MO SPIRIVA RESPIMAT AERS 1.25mcg/act, 2 QL (1 package / 25 2.5mcg/act (tiotropium bromide days), MO monohydrate) COMBINATIONS azelastine hcl-fluticasone prop nasal 1 QL (1 package / 25 spray 137-50 mcg/act days) - DRUGS TO TREAT ALLERGIES azelastine hcl soln .1%, .15% 1 QL (2 bottles / 25 days)

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 92 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS tannate chew 12mg 1 maleate soln 1 4mg/5ml; tabs 4mg fumarate tabs 2.68mg 1 PA; High Risk Medications require PA for members age 70 and older hcl syrp 2mg/5ml; 1 tabs 4mg tabs 5mg; tbdp 2.5mg, 1 5mg hcl soln 50mg/ml MB hcl soln 25mg/ml, MB 50mg/ml hydroxyzine hcl syrp 10mg/5ml; tabs 1 PA; High Risk 10mg, 25mg, 50mg Medications require PA for members age 70 and older hydroxyzine pamoate caps 25mg, 1 PA; High Risk 50mg, 100mg Medications require PA for members age 70 and older dihydrochloride soln 1 2.5mg/5ml; tabs 5mg olopatadine hcl (nasal) soln .6% 1 QL (1 container / 25 days) BETA AGONISTS - DRUGS TO TREAT AND COPD albuterol sulfate aers 108mcg/act 1 QL (2 inhalers / 25 days), MO albuterol sulfate nebu .5% 1 QL (60 mL / 25 days), MO albuterol sulfate nebu .083%, 1 QL (5 boxes / 25 days), .63mg/3ml, 1.25mg/3ml MO albuterol sulfate syrp 2mg/5ml; tabs 1 MO 2mg, 4mg; tb12 4mg, 8mg formoterol fumarate nebu 20mcg/2ml 1 QL (60 vials / 25 days), MO levalbuterol hcl nebu 1.25mg/0.5ml 1 QL (45 mL / 25 days), MO levalbuterol hcl nebu .31mg/3ml, 1 QL (300 mL / 25 days), .63mg/3ml, 1.25mg/3ml MO levalbuterol tartrate aero 45mcg/act 1 QL (2 inhalers / 25 days), MO

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 93 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS metaproterenol sulfate syrp 1 MO 10mg/5ml PERFOROMIST NEBU 20mcg/2ml 2 QL (60 vials / 25 days), (formoterol fumarate) MO STRIVERDI RESPIMAT AERS 2.5mcg/act 2 QL (1 package / 25 ( hcl) days), MO sulfate tabs 2.5mg, 5mg 1 MO BIOLOGIC RESPONSE MODIFIERS NUCALA SOAJ 100mg/ml; SOLR 100mg; MB MO SOSY 100mg/ml () XOLAIR SOLR 150mg; SOSY 75mg/0.5ml, MB 150mg/ml () COLD/ caps 100mg, 200mg 1 (-Codeine Soln 100-10 1 mg/5ml) GUAIFENESIN AC hydrocodone w/ syrup 5- 1 1.5 mg/5ml (Hydrocodone W/ Homatropine Syrup 5- 1 1.5 mg/5ml) HYDROMET hydrocodone w/ homatropine tab 5- 1 1.5 mg promethazine & phenylephrine syrup 1 6.25-5 mg/5ml promethazine w/ codeine syrup 6.25- 1 10 mg/5ml promethazine-dm syrup 6.25-15 1 mg/5ml promethazine-phenylephrine-codeine 1 syrup 6.25-5-10 mg/5ml pseudoephed-bromphen-dm syrup 30- 1 2-10 mg/5ml TUZISTRA XR SUS (codeine polistirex- 3 chlorpheniramine polistirex) MODIFIERS tb12 600mg 2 MO ANTAGONISTS - DRUGS TO TREAT ASTHMA AND ALLERGIES sodium chew 4mg, 5mg; 1 MO pack 4mg; tabs 10mg tabs 10mg, 20mg 1 MO

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 94 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS STABILIZERS - DRUGS TO TREAT ALLERGIES cromolyn sodium nebu 20mg/2ml 1 QL (2 boxes / 25 days), MO MISCELLANEOUS soln 10%, 20% 1 DALIRESP TABS 250mcg, 500mcg 3 PA, MO () ESBRIET CAPS 267mg () 4 SP, PA, QL (270 caps / 30 days), MO ESBRIET TABS 267mg (pirfenidone) 4 SP, PA, QL (270 tabs / 30 days), MO ESBRIET TABS 801mg (pirfenidone) 4 SP, PA, QL (90 tabs / 30 days), MO KALYDECO PACK 25mg, 50mg, 75mg 4 PA, QL (56 packets / 28 () days), MO KALYDECO TABS 150mg (ivacaftor) 4 PA, QL (56 tabs / 28 days), MO; carton consists of 56 tablets KALYDECO TABS 150mg (ivacaftor) 4 PA, QL (60 tabs / 30 days), MO; packet consists of 60 tablets ORKAMBI GRA 100-125 (lumacaftor- 4 PA, QL (56 packets / 28 ivacaftor) days), MO ORKAMBI GRA 150-188 (lumacaftor- 4 PA, QL (56 packets / 28 ivacaftor) days), MO ORKAMBI TAB 100-125 (lumacaftor- 4 PA, QL (112 tabs / 28 ivacaftor) days), MO ORKAMBI TAB 200-125 (lumacaftor- 4 PA, QL (112 tabs / 28 ivacaftor) days), MO PROLASTIN-C SOLN 1000mg/20ml; SOLR MB 1000mg (alpha1-proteinase inhibitor (human)) sodium chloride (inhalant) nebu .9%, 1 3%, 7%, 10% SYMDEKO TAB 50-75MG (tezacaftor- 4 PA, QL (56 tabs / 28 ivacaftor) days), MO SYMDEKO TAB 100-150 (tezacaftor- 4 PA, QL (56 tabs / 28 ivacaftor) days), MO TRIKAFTA TAB (elexacaftor-tezacaftor- 4 PA, QL (84 tabs / 28 ivacaftor) days), MO NASAL - DRUGS TO TREAT ALLERGIES (nasal) soln .025% 1 QL (3 containers / 25 days)

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 95 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS (nasal) susp 1 QL (1 container / 25 50mcg/act days) OMNARIS SUSP 50mcg/act ( 3 ST, QL (1 package / 25 (nasal)) days); PA** INHALANTS - DRUGS TO TREAT ASTHMA ARNUITY ELLIPTA AEPB 50mcg/act, 2 QL (1 package / 25 100mcg/act, 200mcg/act (fluticasone days), MO furoate ()) budesonide (inhalation) susp 1 QL (1 box / 25 days), 1mg/2ml MO budesonide (inhalation) susp 1 QL (2 boxes / 25 days), .5mg/2ml MO budesonide (inhalation) susp 1 QL (3 boxes / 25 days), .25mg/2ml MO QVAR REDIHALER AERB 40mcg/act, 2 QL (2 packages / 25 80mcg/act (beclomethasone days), MO dipropionate hfa) STEROID/BETA-AGONIST COMBINATIONS - DRUGS TO TREAT ASTHMA AND COPD ADVAIR DISKU AER 100/50 (fluticasone- 1 QL (1 package / 25 ) days), MO ADVAIR DISKU AER 250/50 (fluticasone- 1 QL (1 package / 25 salmeterol) days), MO ADVAIR DISKU AER 500/50 (fluticasone- 1 QL (1 package / 25 salmeterol) days), MO ADVAIR HFA AER 45/21 (fluticasone- 2 QL (1 package / 25 salmeterol) days), MO ADVAIR HFA AER 115/21 (fluticasone- 2 QL (1 package / 25 salmeterol) days), MO ADVAIR HFA AER 230/21 (fluticasone- 2 QL (1 package / 25 salmeterol) days), MO BREO ELLIPTA INH 100-25 (fluticasone 2 QL (1 package / 25 furoate-vilanterol) days), MO BREO ELLIPTA INH 200-25 (fluticasone 2 QL (1 package / 25 furoate-vilanterol) days), MO SYMBICORT AER 80-4.5 (budesonide- 2 QL (1 package / 25 formoterol fumarate dihydrate) days), MO SYMBICORT AER 160-4.5 (budesonide- 2 QL (1 package / 25 formoterol fumarate dihydrate) days), MO - DRUGS TO TREAT COPD soln 25mg/ml MB ELIXOPHYLLIN ELIX 80mg/15ml 3 MO ()

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 96 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS theophylline soln 80mg/15ml; tb12 1 MO 300mg, 450mg; tb24 400mg, 600mg TOPICAL - DRUGS TO TREAT EAR AND SKIN CONDITIONS , crea .1%; gel .1%, .3% 1 PA; PA applies for members age 35 and older adapalene- gel 0.1- 1 2.5% BENZIQ GEL 5.25% (benzoyl peroxide) 2 BENZIQ LS GEL 2.75% (benzoyl 2 peroxide) (Benzoyl Peroxide Liqd 2.5%) BP WASH 1 (Benzoyl Peroxide Liqd 5.25%) BENZIQ 1 WASH benzoyl peroxide-erythromycin gel 5- 1 3% clindamycin phosph-benzoyl peroxide 1 (refrig) gel 1.2 (1)-5% clindamycin phosphate (topical) foam 1 1%; swab 1% clindamycin phosphate (topical) gel 1 QL (75g / 25 days) 1% clindamycin phosphate (topical) lotn 1 QL (60mL / 25 days) 1%; soln 1% clindamycin phosphate-benzoyl 1 peroxide gel 1-5% clindamycin phosphate-benzoyl 1 peroxide gel 1.2-2.5% EPIDUO FORTE GEL 0.3-2.5% 3 (adapalene-benzoyl peroxide) erythromycin (acne aid) gel 2% 1 QL (60g / 25 days) (Erythromycin (Acne Aid) Pads 2%) ERY 1 erythromycin (acne aid) soln 2% 1 QL (60mL / 25 days) caps 10mg, 20mg, 30mg, 1 PA 40mg sulfacetamide sodium (acne) lotn 1 10% tretinoin crea .025%, .05%, .1%; gel 1 PA; PA applies for .01%, .025%, .05% members age 35 and older (Tretinoin Crea .025%; Gel .025%) AVITA 1 PA; PA applies for members age 35 and older

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 97 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS tretinoin microsphere gel .04%, .1% 1 PA; PA applies for members age 35 and older DERMATOLOGY, fluorouracil (topical) crea 5%; soln 1 2%, 5% crea 5% 1 PICATO GEL .015%, .05% (ingenol 3 mebutate) DERMATOLOGY, ANTIBIOTICS gentamicin sulfate (topical) crea .1%; 1 oint .1% oint 2% 1 QL (30g / 25 days) crea 1% 1 (Silver Sulfadiazine Crea 1%) SSD 1 SULFAMYLON CREA 85mg/gm ( 3 acetate) DERMATOLOGY, ANTIFUNGALS gel .77% 1 QL (120g / 25 days) ciclopirox sham 1% 1 QL (120mL / 25 days) ciclopirox soln 8% 1 ciclopirox olamine crea .77% 1 QL (120g / 25 days) ciclopirox olamine susp .77% 1 QL (120mL / 25 days) (topical) crea 1% 1 QL (120g / 25 days) clotrimazole (topical) soln 1% 1 QL (120mL / 25 days) clotrimazole w/ 1 QL (60g / 25 days) 1-0.05% clotrimazole w/ betamethasone 1 QL (60mL / 25 days) 1-0.05% nitrate crea 1% 1 QL (60g / 25 days) ERTACZO CREA 2% ( 3 QL (60g / 25 days) nitrate) JUBLIA SOLN 10% () 3 PA, QL (4mL / 21 days) (topical) crea 2% 1 QL (120g / 25 days) MENTAX CREA 1% ( hcl) 3 QL (60g / 25 days) hcl crea 1%, 2% 1 QL (60g / 25 days) nystatin (topical) crea 1 QL (120g / 25 days) 100000unit/gm; oint 100000unit/gm; powd 100000unit/gm (Nystatin (Topical) Powd 100000unit/gm) 1 QL (120g / 25 days) NYAMYC (Nystatin (Topical) Powd 100000unit/gm) 1 QL (120g / 25 days) NYSTOP

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 98 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS nystatin- cream 100000- 1 QL (60g / 25 days) 0.1 unit/gm-% nystatin-triamcinolone oint 100000- 1 QL (60g / 25 days) 0.1 unit/gm-% nitrate crea 1% 1 QL (60g / 25 days) nitrate crea 1% 1 QL (60g / 25 days) sulconazole nitrate soln 1% 1 QL (60mL / 25 days) DERMATOLOGY, doxepin hcl (antipruritic) crea 5% 3 ST, QL (45 grams / 25 days); PA** DERMATOLOGY, ANTIPSORIATICS caps 10mg, 17.5mg, 25mg 1 calcipotriene soln .005% 1 calcitriol (topical) oint 3mcg/gm 3 COSENTYX SOSY 75mg/0.5ml, 150mg/ml MB MO () COSENTYX SENSOREADY PEN SOAJ MB MO 150mg/ml (secukinumab) methoxsalen rapid caps 10mg 1 crea .1% 1 PA TAZORAC CREA .05%; GEL .05%, .1% 2 PA (tazarotene) DERMATOLOGY, ANTISEBORRHEICS ketoconazole (topical) sham 2% 1 lotn 2.5% 1 DERMATOLOGY, CORTICOSTEROIDS dipropionate crea 1 QL (120g / 25 days) .05%; oint .05% crea .1% 1 QL (120g / 25 days) amcinonide lotn .1% 1 QL (120mL / 25 days) AMCINONIDE OINT .1% 2 QL (120g / 25 days) betamethasone dipropionate (topical) 1 QL (120g / 25 days) crea .05%; oint .05% betamethasone dipropionate (topical) 1 QL (120mL / 25 days) lotn .05% betamethasone dipropionate 1 QL (120g / 25 days) augmented crea .05%; gel .05%; oint .05% betamethasone dipropionate 1 QL (120mL / 25 days) augmented lotn .05% crea .1%; 1 QL (120g / 25 days) foam .12%; oint .1% betamethasone valerate lotn .1% 1 QL (120mL / 25 days)

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 99 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS calcipotriene-betamethasone 2 dipropionate oint 0.005-0.064% propionate crea .05%; 1 QL (120g / 25 days) foam .05%; gel .05%; oint .05% liqd .05%; lotn 1 QL (120mL / 25 days) .05%; sham .05%; soln .05% pivalate crea .1% 3 QL (120g / 25 days) crea .05%; oint .05% 1 QL (120g / 25 days) desonide lotn .05% 1 QL (120mL / 25 days) crea .05%, .25%; gel 1 QL (120g / 25 days) .05%; oint .25% diacetate crea .05%; oint 3 QL (120g / 25 days) .05% acetonide crea .01%, 1 QL (120g / 25 days) .025%; oint .025% oil .01%; soln 1 QL (120mL / 25 days) .01% crea .05%; gel .05%; 1 QL (120g / 25 days) oint .05% fluocinonide soln .05% 1 QL (120mL / 25 days) fluticasone propionate crea .05%; 1 QL (120g / 25 days) oint .005% fluticasone propionate lotn .05% 1 QL (120mL / 25 days) halobetasol propionate crea .05%; 1 QL (120g / 25 days) oint .05% (Hydrocortisone (Topical) Crea 1%) ALA- 1 QL (120g / 25 days) CORT hydrocortisone (topical) crea 1%, 1 QL (120g / 25 days) 2.5%; oint 2.5% hydrocortisone (topical) lotn 2.5% 1 QL (120mL / 25 days) crea .1%; 1 QL (120g / 25 days) oint .1% hydrocortisone butyrate soln .1% 1 QL (120mL / 25 days) crea .2%; 1 QL (120g / 25 days) oint .2% furoate crea .1%; oint 1 QL (120g / 25 days) .1% mometasone furoate soln .1% 1 QL (120mL / 25 days) crea .1%; oint .1% 1 QL (120g / 25 days) ( (Topical) Crea 1 QL (120g / 25 days) .1%) TRIDERM triamcinolone acetonide (topical) crea 1 QL (120g / 25 days) .025%, .1%, .5%; oint .025%, .1%, .5%

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 100 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS triamcinolone acetonide (topical) lotn 1 QL (120mL / 25 days) .025%, .1% DERMATOLOGY, LOCAL ANESTHETICS lidocaine oint 5% 1 QL (50gm / 25 days) lidocaine ptch 5% 1 PA, QL (90 patches / 25 days) lidocaine hcl gel 2% 1 QL (60mL / 25 days) lidocaine hcl prsy 2% MB lidocaine hcl soln 4% 1 QL (50mL / 25 days) lidocaine- cream 2.5-2.5% 1 QL (30gm / 25 days) DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE CONDYLOX GEL .5% (podofilox) 3 DENAVIR CREA 1% () 3 diclofenac sodium (topical) gel 1% 1 QL (300g / 25 days) EUCRISA OINT 2% () 2 ST, QL (60 grams / 25 days); PA** lotn 10% 1 lactic acid (ammonium lactate) crea 1 12%; lotn 12% podofilox soln .5% 1 RECTIV OINT .4% (nitroglycerin (intra- 3 anal)) tacrolimus (topical) oint .03%, .1% 1 TARGRETIN GEL 1% (bexarotene 4 SP, PA (topical)) DERMATOLOGY, gel 15% 1 FINACEA FOAM 15% (azelaic acid) 2 (Metronidazole (Topical) Crea .75%) 1 ROSADAN metronidazole (topical) crea .75%; 1 gel .75%, 1%; lotn .75% MIRVASO GEL .33% (brimonidine 3 PA tartrate (topical)) DERMATOLOGY, SCABICIDES AND PEDICULIDES ( Lotn 10%) CROTAN 1 EURAX CREA 10% (crotamiton) 3 ivermectin (pediculicide) lotn .5% 1 ST; PA** sham 1% 1 lotn .5% 1 crea 5% 1 susp .9% 1

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 101 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

PRESCRIPTION DRUG NAME DRUG COVERAGE TIER REQUIREMENTS AND LIMITS DERMATOLOGY, WOUND CARE AGENTS REGRANEX GEL .01% () 3 PA, QL (30g / 25 days) MOUTH/THROAT/DENTAL AGENTS hcl caps 30mg 1 MO clotrimazole troc 10mg 1 lidocaine hcl (mouth-throat) soln 2% 1 nystatin (mouth-throat) susp 1 100000unit/ml ORAVIG TABS 50mg (miconazole 3 QL (14 tabs / 25 days) (mouth-throat)) pilocarpine hcl (oral) tabs 5mg, 1 MO 7.5mg triamcinolone acetonide (mouth) pste 1 .1% (Triamcinolone Acetonide (Mouth) Pste 1 .1%) ORALONE DENTAL PASTE OTIC - DRUGS TO TREAT CONDITIONS OF THE EAR (otic) soln 2% 1 ciprofloxacin hcl (otic) soln .2% 1 ciprofloxacin-dexamethasone otic 1 susp 0.3-0.1% CORTISPORIN SUS -TC OTIC (neomycin- 3 -hc-thonzonium) fluocinolone acetonide (otic) oil .01% 1 hydrocortisone w/ acetic acid otic soln 1 1-2% neomycin-polymyxin-hc otic soln 1% 1 neomycin-polymyxin-hc otic susp 3.5 1 mg/ml-10000 unit/ml-1% ofloxacin (otic) soln .3% 1

MB - Medical Benefit MO - Available at mail-order PA - Prior Authorization PA** - PA 102 Applies if Step is Not Met QL - Quantity Limits SP - Specialty ST - Step Therapy

Index * see HUMIRA PEDIATRIC CROHNS D *nystatin Oral Powder* ...... 13 ...... 80 *prenatal Vit W/ Iron Carbonyl-Fa Tab see HUMIRA PEN ...... 80 29-1 mg*** ...... 89 see HUMIRA PEN KIT PS/UV ...... 81 *prenatal Vit W/ Iron Carbonyl-Fa Tab see HUMIRA PEN-CD/UC/HS START 50-1.25 mg*** ...... 89 ...... 81 A see HUMIRA PEN-PS/UV STARTER . 81 abacavir sulfate ...... 14 adapalene ...... 97 abacavir sulfate-lamivudine tab adapalene-benzoyl peroxide 600-300 mg ...... 17 see EPIDUO FORTE GEL 0.3-2.5% . 97 abacavir sulfate-lamivudine- adapalene-benzoyl peroxide gel zidovudine tab 300-150-300 mg 0.1-2.5% ...... 97 ...... 17 adefovir dipivoxil ...... 18 abacavir-dolutegravir-lamivudine ADEMPAS ...... 41 see TRIUMEQ TAB ...... 18 ado- abaloparatide see KADCYLA ...... 24 see TYMLOS ...... 70 ADRIAMYCIN abiraterone acetate ...... 25 see Doxorubicin Hcl ...... 23 see YONSA ...... 26 ADULT RESPIRATORY MASK ...... 86 ABRAXANE INJ 100MG ...... 24 ADVAIR DISKU AER 100/50 ...... 96 acalabrutinib ADVAIR DISKU AER 250/50 ...... 96 see CALQUENCE ...... 27 ADVAIR DISKU AER 500/50 ...... 96 acamprosate calcium ...... 56 ADVAIR HFA AER 115/21 ...... 96 acarbose ...... 57 ADVAIR HFA AER 230/21 ...... 96 acebutolol hcl ...... 37 ADVAIR HFA AER 45/21 ...... 96 acetaminophen w/ codeine soln AFINITOR ...... 26 120-12 mg/5ml ...... 3 AFINITOR DISPERZ ...... 26 acetaminophen w/ codeine tab AFLURIA QUAD INJ 2020-21 ...... 83 300-15 mg ...... 4 AIMOVIG ...... 52 acetaminophen w/ codeine tab AJOVY ...... 52 300-30 mg ...... 4 AKYNZEO CAP 300-0.5 ...... 72 acetaminophen w/ codeine tab ALA-CORT 300-60 mg ...... 4 see Hydrocortisone (Topical) ...... 100 acetazolamide ...... 39 albuterol sulfate ...... 93 acetic acid (otic) ...... 102 alcaftadine acetylcysteine ...... 95 see LASTACAFT ...... 91 acitretin...... 99 alclometasone dipropionate ...... 99 ACTEMRA ...... 80 ALDACTAZIDE TAB 50/50 ...... 39 ACTHIB INJ ...... 83 ALECENSA ...... 26 ACTIMMUNE ...... 82 alectinib hcl ACUVAIL ...... 90 see ALECENSA ...... 26 acyclovir ...... 18 alendronate sodium ...... 61 ADACEL INJ ...... 83 alendronate sodium-cholecalciferol adalimumab see FOSAMAX + D TAB 70-2800 .... 61 see HUMIRA ...... 80 see FOSAMAX + D TAB 70-5600 .... 61 see HUMIRA PEDIA INJ CROHNS ... 80 alfuzosin hcl ...... 77 103

ALIMTA ...... 23 aminosalicylic acid ALINIA ...... 12 see PASER ...... 18 alirocumab amiodarone hcl ...... 34 see PRALUENT ...... 36 Amiodarone Hcl...... 34 aliskiren fumarate ...... 39 amitriptyline hcl ...... 44, 45 allopurinol ...... 2 amlodipine besylate ...... 38 almotriptan malate ...... 52 amlodipine besylate-atorvastatin ALOCRIL ...... 90 calcium tab 10-10 mg ...... 38 alogliptin benzoate ...... 57 amlodipine besylate-atorvastatin alogliptin-metformin hcl tab 12.5- calcium tab 10-20 mg ...... 38 1000 mg ...... 57 amlodipine besylate-atorvastatin alogliptin-metformin hcl tab 12.5- calcium tab 10-40 mg ...... 38 500 mg ...... 57 amlodipine besylate-atorvastatin ALOMIDE ...... 90 calcium tab 10-80 mg ...... 38 alosetron hcl ...... 74 amlodipine besylate-atorvastatin alpha1-proteinase inhibitor calcium tab 2.5-10 mg ...... 38 (human) amlodipine besylate-atorvastatin see PROLASTIN-C ...... 95 calcium tab 2.5-20 mg ...... 38 ALPHAGAN P ...... 91 amlodipine besylate-atorvastatin alprazolam ...... 42 calcium tab 2.5-40 mg ...... 38 see ALPRAZOLAM INTENSOL ...... 42 amlodipine besylate-atorvastatin ALPRAZOLAM INTENSOL ...... 42 calcium tab 5-10 mg ...... 38 ALTAVERA amlodipine besylate-atorvastatin see Levonorgestrel & Ethinyl Estradiol calcium tab 5-20 mg ...... 38 Tab 0.15 mg-30 mcg ...... 63 amlodipine besylate-atorvastatin ALYACEN 1/35 calcium tab 5-40 mg ...... 38 see Norethindrone & Ethinyl Estradiol amlodipine besylate-atorvastatin Tab 1 mg-35 mcg ...... 64 calcium tab 5-80 mg ...... 38 ALYACEN 7/7/7 amlodipine besylate-benazepril hcl see Norethindrone-Eth Estradiol Tab cap 10-20 mg ...... 30 0.5-35/0.75-35/1-35 mg-Mcg .... 66 amlodipine besylate-benazepril hcl amantadine hcl ...... 48 cap 10-40 mg ...... 30 ambrisentan ...... 41 amlodipine besylate-benazepril hcl amcinonide ...... 99 cap 2.5-10 mg ...... 30 AMCINONIDE ...... 99 amlodipine besylate-benazepril hcl AMETHIA cap 5-10 mg ...... 30 see Levonorg-Eth Est Tab 0.15- amlodipine besylate-benazepril hcl 0.03mg(84) & Eth Est Tab cap 5-20 mg ...... 30 0.01mg(7) ...... 63 amlodipine besylate-benazepril hcl AMETHYST cap 5-40 mg ...... 30 see Levonorgestrel-Ethinyl Estradiol amlodipine besylate-olmesartan (Continuous) Tab 90-20 mcg ...... 64 medoxomil tab 10-20 mg ...... 32 amikacin sulfate ...... 11 amlodipine besylate-olmesartan amiloride & hydrochlorothiazide medoxomil tab 10-40 mg ...... 32 tab 5-50 mg ...... 39 amlodipine besylate-olmesartan amiloride hcl ...... 39 medoxomil tab 5-20 mg ...... 32 aminophylline ...... 96 104 amlodipine besylate-olmesartan amphetamine-dextroamphetamine medoxomil tab 5-40 mg ...... 32 cap er 24hr 10 mg ...... 50 amlodipine besylate-valsartan tab amphetamine-dextroamphetamine 10-160 mg ...... 32 cap er 24hr 15 mg ...... 50 amlodipine besylate-valsartan tab amphetamine-dextroamphetamine 10-320 mg ...... 32 cap er 24hr 20 mg ...... 50 amlodipine besylate-valsartan tab amphetamine-dextroamphetamine 5-160 mg ...... 32 cap er 24hr 25 mg ...... 50 amlodipine besylate-valsartan tab amphetamine-dextroamphetamine 5-320 mg ...... 32 cap er 24hr 30 mg ...... 50 amlodipine-valsartan- amphetamine-dextroamphetamine hydrochlorothiazide tab 10-160- cap er 24hr 5 mg ...... 50 12.5 mg ...... 33 amphetamine-dextroamphetamine amlodipine-valsartan- tab 10 mg ...... 51 hydrochlorothiazide tab 10-160- amphetamine-dextroamphetamine 25 mg ...... 33 tab 12.5 mg ...... 51 amlodipine-valsartan- amphetamine-dextroamphetamine hydrochlorothiazide tab 10-320- tab 15 mg ...... 51 25 mg ...... 33 amphetamine-dextroamphetamine amlodipine-valsartan- tab 20 mg ...... 51 hydrochlorothiazide tab 5-160- amphetamine-dextroamphetamine 12.5 mg ...... 33 tab 30 mg ...... 51 amlodipine-valsartan- amphetamine-dextroamphetamine hydrochlorothiazide tab 5-160-25 tab 5 mg ...... 50 mg ...... 33 amphetamine-dextroamphetamine amoxapine ...... 45 tab 7.5 mg ...... 51 amoxicillin ...... 21 amphotericin b ...... 13 amoxicillin & k clavulanate chew ampicillin ...... 21 tab 200-28.5 mg ...... 21 ampicillin sodium ...... 21 amoxicillin & k clavulanate chew anagrelide hcl ...... 79 tab 400-57 mg ...... 21 anastrozole ...... 25 amoxicillin & k clavulanate for susp ANNOVERA MIS ...... 61 200-28.5 mg/5ml ...... 21 ANORO ELLIPT AER 62.5-25 ...... 92 amoxicillin & k clavulanate for susp apalutamide 250-62.5 mg/5ml ...... 21 see ERLEADA ...... 25 amoxicillin & k clavulanate for susp apixaban 400-57 mg/5ml ...... 21 see ELIQUIS ...... 78 amoxicillin & k clavulanate for susp see ELIQUIS STARTER PACK ...... 78 600-42.9 mg/5ml ...... 21 APOKYN ...... 48 amoxicillin & k clavulanate tab apomorphine hydrochloride 250-125 mg ...... 21 see APOKYN ...... 48 amoxicillin & k clavulanate tab apraclonidine hcl ...... 91 500-125 mg ...... 21 see IOPIDINE ...... 91 amoxicillin & k clavulanate tab apremilast 875-125 mg ...... 21 see OTEZLA ...... 82 amoxicillin & k clavulanate tab er see OTEZLA TAB 10/20/30 ...... 82 12hr 1000-62.5 mg ...... 21 aprepitant ...... 72 105 aprepitant capsule therapy pack 80 atovaquone-proguanil hcl tab 250- & 125 mg ...... 72 100 mg ...... 13 APRI atovaquone-proguanil hcl tab 62.5- see Desogestrel & Ethinyl Estradiol 25 mg ...... 13 Tab 0.15 mg-30 mcg ...... 62 atropine sulfate ...... 72, 91 APTIOM ...... 42 AUBAGIO ...... 54 APTIVUS ...... 14 AVIANE ARANELLE see Levonorgestrel & Ethinyl Estradiol see Norethindrone-Eth Estradiol Tab Tab 0.1 mg-20 mcg ...... 63 0.5-35/1-35/0.5-35 mg-Mcg ...... 66 AVIDOXY ARANESP ALBUMIN FREE ...... 79 see Doxycycline (Monohydrate) ..... 22 ARCALYST ...... 82 AVITA aripiprazole ...... 49 see Tretinoin ...... 97 aripiprazole lauroxil AVONEX ...... 54 see ARISTADA ...... 49 AVONEX PEN ...... 54 see ARISTADA INITIO ...... 49 axitinib ARISTADA ...... 49 see INLYTA ...... 27 ARISTADA INITIO ...... 49 azacitidine ...... 23 armodafinil ...... 55, 56 AZASAN ...... 83 ARNUITY ELLIPTA ...... 96 AZASITE ...... 89 ...... 29 azathioprine ...... 83 artemether-lumefantrine see AZASAN ...... 83 see COARTEM TAB 20-120MG ...... 14 azelaic acid ...... 101 artificial tear insert see FINACEA ...... 101 see LACRISERT ...... 91 azelastine hcl ...... 92 asenapine maleate ...... 49 azelastine hcl (ophth) ...... 90 ASHLYNA azelastine hcl-fluticasone prop see Levonorg-Eth Est Tab 0.15- 137-50 mcg/act ..... 92 0.03mg(84) & Eth Est Tab azithromycin ...... 19 0.01mg(7) ...... 63 azithromycin (ophth) Aspirin ...... 11 see AZASITE ...... 89 ASPIRIN ENTERIC COATED AD aztreonam ...... 12 see Aspirin ...... 11 aztreonam lysine aspirin-dipyridamole cap er 12hr see CAYSTON ...... 12 25-200 mg ...... 80 AZURETTE atazanavir sulfate...... 14 see Desogest-Eth Estrad & Eth Estrad see REYATAZ ...... 16 Tab 0.15-0.02/0.01 mg(21/5) .... 62 atazanavir sulfate-cobicistat B see EVOTAZ TAB 300-150 ...... 17 bacitracin (ophthalmic) ...... 89 atenolol ...... 37 bacitracin-polymyxin b ophth oint atenolol & chlorthalidone tab 100- ...... 89 25 mg ...... 36 Bacitracin-Polymyxin B Ophth Oint ... 89 atenolol & chlorthalidone tab 50-25 bacitracin-polymyxin-neomycin-hc mg ...... 36 ophth oint 1% ...... 89 atomoxetine hcl...... 51 baclofen ...... 55 atorvastatin calcium ...... 36 BALCOLTRA TAB 0.1-20 ...... 61 atovaquone ...... 12 balsalazide disodium ...... 73 106

BARACLUDE ...... 18 BETASERON ...... 54 BASAGLAR KWIKPEN ...... 58 betaxolol hcl...... 37 BAXDELA ...... 71 betaxolol hcl (ophth) ...... 91 bcg live intravesical see BETOPTIC-S ...... 91 see TICE BCG ...... 29 bethanechol chloride ...... 77 becaplermin BETIMOL ...... 91 see REGRANEX ...... 102 BETOPTIC-S ...... 91 beclomethasone dipropionate hfa BEVESPI AER 9-4.8MCG ...... 92 see QVAR REDIHALER ...... 96 bexarotene ...... 29 bedaquiline fumarate bexarotene (topical) see SIRTURO ...... 18 see TARGRETIN ...... 101 BELBUCA ...... 10 BEXSERO INJ ...... 83 BELSOMRA ...... 52 bicalutamide ...... 25 benazepril & hydrochlorothiazide bictegravir-emtricitabine-tenofovir tab 10-12.5 mg ...... 30 alafenamide fumarate benazepril & hydrochlorothiazide see BIKTARVY TAB ...... 17 tab 20-12.5 mg ...... 31 BIKTARVY TAB ...... 17 benazepril & hydrochlorothiazide bimatoprost tab 20-25 mg ...... 31 see LUMIGAN ...... 91 benazepril & hydrochlorothiazide BIO-STATIN...... 13 tab 5-6.25 mg ...... 30 see *nystatin Oral Powder* ...... 13 benazepril hcl ...... 31 Bisacodyl Tab & Peg 3350-Kcl-Sod BENZIQ ...... 97 Bicarb-Nacl For Soln Kit...... 74 BENZIQ LS ...... 97 bisoprolol & hydrochlorothiazide BENZIQ WASH tab 10-6.25 mg ...... 37 see Benzoyl Peroxide ...... 97 bisoprolol & hydrochlorothiazide benzonatate ...... 94 tab 2.5-6.25 mg ...... 37 benzoyl peroxide bisoprolol & hydrochlorothiazide see BENZIQ ...... 97 tab 5-6.25 mg ...... 37 see BENZIQ LS ...... 97 bisoprolol fumarate ...... 37 Benzoyl Peroxide ...... 97 bleomycin sulfate ...... 23 benzoyl peroxide-erythromycin gel BLEPHAMIDE OIN S.O.P...... 89 5-3% ...... 97 BLEPHAMIDE SUS OP ...... 89 benztropine mesylate ...... 48 BOOSTRIX INJ ...... 83 bepotastine besilate ...... 91 bosentan ...... 41 see BEPREVE ...... 91 see TRACLEER ...... 41 BEPREVE ...... 91 BOSULIF ...... 26 besifloxacin hcl bosutinib see BESIVANCE ...... 89 see BOSULIF ...... 26 BESIVANCE ...... 89 BP WASH betaine see Benzoyl Peroxide ...... 97 see CYSTADANE POW ...... 67 BREO ELLIPTA INH 100-25 ...... 96 betamethasone dipropionate BREO ELLIPTA INH 200-25 ...... 96 (topical) ...... 99 brexpiprazole betamethasone dipropionate see REXULTI ...... 50 augmented ...... 99 BRILINTA ...... 80 betamethasone valerate ...... 99 brimonidine tartrate ...... 91 107

see ALPHAGAN P ...... 91 buprenorphine hcl-naloxone hcl sl brimonidine tartrate (topical) tab 8-2 mg (base equiv) ...... 3 see MIRVASO ...... 101 bupropion hcl ...... 45 brimonidine tartrate-timolol bupropion hcl (smoking deterrent) maleate ...... 56 see COMBIGAN SOL 0.2/0.5%...... 91 buspirone hcl ...... 53 brinzolamide ...... 91 busulfan ...... 22 brinzolamide-brimonidine tartrate Butalbital-Acetaminophen Tab 50-325 see SIMBRINZA SUS 1-0.2% ...... 91 mg ...... 2 brivaracetam butalbital-acetaminophen-caff w/ see BRIVIACT ...... 22 cod cap 50-300-40-30 mg ...... 4 BRIVIACT ...... 22 butalbital-acetaminophen-caffeine bromfenac sodium (ophth) ...... 90 cap 50-300-40 mg ...... 2 bromocriptine mesylate...... 48 butalbital-acetaminophen-caffeine bromocriptine mesylate (diabetes) cap 50-325-40 mg ...... 2 see CYCLOSET ...... 57 butalbital-acetaminophen-caffeine brompheniramine tannate ...... 93 tab 50-325-40 mg ...... 2 budesonide ...... 73 butalbital-aspirin-caffeine cap 50- budesonide (inhalation) ...... 96 325-40 mg ...... 2 budesonide-formoterol fumarate butenafine hcl dihydrate see MENTAX ...... 98 see SYMBICORT AER 160-4.5 ...... 96 butoconazole nitrate (one dose) see SYMBICORT AER 80-4.5 ...... 96 see GYNAZOLE-1 ...... 78 bumetanide ...... 39 butorphanol tartrate ...... 4 buprenorphine ...... 10, 11 BYSTOLIC ...... 37 see SUBLOCADE ...... 11 C buprenorphine hcl ...... 11 cabergoline ...... 70 see BELBUCA ...... 10 CABOMETYX ...... 26 buprenorphine hcl-naloxone hcl cabozantinib s-malate dihydrate see CABOMETYX ...... 26 see ZUBSOLV SUB 0.7-0.18 ...... 3 see COMETRIQ ...... 27 see ZUBSOLV SUB 1.4-0.36 ...... 3 see COMETRIQ KIT 100MG ...... 27 see ZUBSOLV SUB 11.4-2.9 ...... 3 see COMETRIQ KIT 140MG ...... 27 see ZUBSOLV SUB 2.9-0.71 ...... 3 calcipotriene ...... 99 see ZUBSOLV SUB 5.7-1.4 ...... 3 calcipotriene-betamethasone see ZUBSOLV SUB 8.6-2.1 ...... 3 dipropionate oint 0.005-0.064% buprenorphine hcl-naloxone hcl sl ...... 100 film 12-3 mg (base equiv) ...... 3 calcitonin (salmon) ...... 70 buprenorphine hcl-naloxone hcl sl calcitriol ...... 87 film 2-0.5 mg (base equiv) ...... 3 calcitriol (topical) ...... 99 buprenorphine hcl-naloxone hcl sl calcium acetate (phosphate binder) film 4-1 mg (base equiv) ...... 3 ...... 70 buprenorphine hcl-naloxone hcl sl see PHOSLYRA ...... 70 film 8-2 mg (base equiv) ...... 3 CALQUENCE ...... 27 buprenorphine hcl-naloxone hcl sl CAMILA tab 2-0.5 mg (base equiv) ...... 3 see Norethindrone (Contraceptive) 65 candesartan cilexetil ...... 34 108 candesartan cilexetil- carbidopa-levodopa-entacapone hydrochlorothiazide tab 16-12.5 tabs 31.25-125-200 mg ...... 48 mg ...... 33 carbidopa-levodopa-entacapone candesartan cilexetil- tabs 37.5-150-200 mg ...... 48 hydrochlorothiazide tab 32-12.5 carbidopa-levodopa-entacapone mg ...... 33 tabs 50-200-200 mg ...... 48 candesartan cilexetil- carbinoxamine maleate ...... 93 hydrochlorothiazide tab 32-25 carboplatin ...... 29 mg ...... 33 Carboplatin...... 29 capecitabine ...... 23 CARDIZEM LA ...... 38 CAPRELSA ...... 27 CARDURA XL ...... 77 captopril ...... 32 CAREFINE MIS 32GX6MM ...... 86 captopril & hydrochlorothiazide tab 25-15 mg ...... 31 see CARBAGLU ...... 67 captopril & hydrochlorothiazide tab carisoprodol ...... 55 25-25 mg ...... 31 carmustine ...... 22 captopril & hydrochlorothiazide tab carmustine in polifeprosan 50-15 mg ...... 31 see GLIADEL WAF 7.7MG ...... 23 captopril & hydrochlorothiazide tab carteolol hcl (ophth) ...... 91 50-25 mg ...... 31 CARTIA XT CARBAGLU ...... 67 see Diltiazem Hcl Coated Beads ..... 38 carbamazepine ...... 42 carvedilol ...... 37 Carbamazepine ...... 42 carvedilol phosphate ...... 37 carbidopa ...... 48 CAYSTON ...... 12 carbidopa & levodopa orally CAZIANT disintegrating tab 10-100 mg ... 48 see Desogest-Ethin Est Tab 0.1- carbidopa & levodopa orally 0.025/0.125-0.025/0.15-0.025mg- disintegrating tab 25-100 mg ... 48 Mg ...... 62 carbidopa & levodopa orally cefaclor ...... 19 disintegrating tab 25-250 mg ... 48 cefadroxil ...... 19 carbidopa & levodopa tab 10-100 cefazolin sodium ...... 19 mg ...... 48 cefdinir ...... 19 carbidopa & levodopa tab 25-100 cefditoren pivoxil ...... 19 mg ...... 48 cefepime hcl ...... 19 carbidopa & levodopa tab 25-250 cefixime ...... 19 mg ...... 48 see SUPRAX ...... 19 carbidopa & levodopa tab er 25- cefpodoxime proxetil ...... 19 100 mg ...... 48 cefprozil ...... 19 carbidopa & levodopa tab er 50- ceftazidime ...... 19 200 mg ...... 48 Ceftazidime ...... 19 carbidopa-levodopa-entacapone ceftriaxone sodium...... 19 tabs 12.5-50-200 mg ...... 48 ...... 19 carbidopa-levodopa-entacapone celecoxib ...... 2 tabs 18.75-75-200 mg ...... 48 CELONTIN ...... 42 carbidopa-levodopa-entacapone cephalexin ...... 19 tabs 25-100-200 mg ...... 48 CERDELGA ...... 67 ceritinib 109

see ZYKADIA ...... 29 CITRANATAL CAP HARMONY ...... 88 cervical caps CITRANATAL CAP MEDLEY ...... 88 see FEMCAP MIS 22MM ...... 86 CITRANATAL MIS ...... 88 see FEMCAP MIS 26MM ...... 86 CITRANATAL MIS 90 DHA ...... 88 see FEMCAP MIS 30MM ...... 86 CITRANATAL MIS B-CALM ...... 88 cetuximab CITRANATAL PAK ASSURE ...... 88 see ERBITUX ...... 24 CITRANATAL PAK DHA ...... 88 cevimeline hcl ...... 102 CITRANATAL TAB BLOOM ...... 88 CHANTIX ...... 56 CITRANATAL TAB RX ...... 88 CHANTIX CONTINUING MONTH ...... 56 cladribine ...... 23 CHANTIX PAK 0.5& 1MG ...... 56 clarithromycin ...... 20 CHATEAL clemastine fumarate ...... 93 see Levonorgestrel & Ethinyl Estradiol CLENPIQ SOL ...... 74 Tab 0.15 mg-30 mcg ...... 63 CLEOCIN ...... 78 CHEMET ...... 61 CLIMARA PRO DIS WEEKLY ...... 67 chlorambucil clindamycin hcl ...... 12 see LEUKERAN ...... 23 clindamycin palmitate chloroquine phosphate ...... 13 hydrochloride ...... 12 chlorothiazide ...... 39 clindamycin phosphate ...... 12 see DIURIL ...... 39 clindamycin phosphate (topical) . 97 chlorpromazine hcl ...... 49 clindamycin phosphate vaginal ... 78 chlorthalidone ...... 39 see CLEOCIN ...... 78 chlorzoxazone ...... 55 clindamycin phosphate-benzoyl cholestyramine ...... 35 peroxide gel 1.2-2.5% ...... 97 cholestyramine light ...... 35 clindamycin phosphate-benzoyl Cholestyramine Light ...... 35 peroxide gel 1-5% ...... 97 choline fenofibrate ...... 35 clindamycin phosph-benzoyl ciclesonide (nasal) peroxide (refrig) gel 1.2 (1)-5% see OMNARIS ...... 96 ...... 97 ciclopirox...... 98 clobazam ...... 42 ciclopirox olamine ...... 98 clobetasol propionate ...... 100 cidofovir ...... 18 ...... 100 cilostazol ...... 79 clofarabine ...... 23 CIMDUO TAB 300-300 ...... 17 clomipramine hcl ...... 53 cimetidine ...... 73 clonazepam ...... 42 cimetidine hcl ...... 73 clonidine ...... 40 cinacalcet hcl...... 61 clonidine hcl ...... 40 CIPRO ...... 20 clopidogrel bisulfate ...... 80 ciprofloxacin clorazepate dipotassium ...... 42 see CIPRO ...... 20 clotrimazole ...... 102 ciprofloxacin hcl ...... 20 clotrimazole (topical) ...... 98 ciprofloxacin hcl (ophth) ...... 89 clotrimazole w/ betamethasone ciprofloxacin hcl (otic) ...... 102 cream 1-0.05% ...... 98 ciprofloxacin-dexamethasone otic clotrimazole w/ betamethasone susp 0.3-0.1% ...... 102 lotion 1-0.05% ...... 98 cisplatin ...... 29 clozapine ...... 49 citalopram hydrobromide ...... 45 COARTEM TAB 20-120MG ...... 14 110 cobicistat CROTAN see TYBOST ...... 16 see Crotamiton ...... 101 codeine polistirex- CRYSELLE-28 chlorpheniramine polistirex see Norgestrel & Ethinyl Estradiol Tab see TUZISTRA XR SUS ...... 94 0.3 mg-30 mcg ...... 66 codeine sulfate ...... 4 CUVPOSA ...... 72 colchicine ...... 2 cyanocobalamin ...... 88 colchicine w/ probenecid tab 0.5- CYCLAFEM 1/35 500 mg ...... 2 see Norethindrone & Ethinyl Estradiol colestipol hcl ...... 35 Tab 1 mg-35 mcg ...... 64 COMBIGAN SOL 0.2/0.5% ...... 91 CYCLAFEM 7/7/7 COMETRIQ ...... 27 see Norethindrone-Eth Estradiol Tab COMETRIQ KIT 100MG ...... 27 0.5-35/0.75-35/1-35 mg-Mcg .... 66 COMETRIQ KIT 140MG ...... 27 cyclobenzaprine hcl ...... 55 COMPRO cyclophosphamide ...... 22 see Prochlorperazine ...... 73 cycloserine ...... 18 condoms - female CYCLOSET ...... 57 see FC2 FEMALE MIS CONDOM ...... 86 cyclosporine ...... 83 CONDYLOX ...... 101 see SANDIMMUNE ...... 83 - cyclosporine (ophth) bazedoxifene see RESTASIS ...... 92 see DUAVEE TAB 0.45-20 ...... 67 cyclosporine modified (for COPAXONE ...... 54 microemulsion) ...... 83 copper (iud) Cyclosporine Modified (For see PARAGARD IUD T380A ...... 66 Microemulsion)...... 83 ...... 68 cyproheptadine hcl ...... 93 CORTISPORIN SUS -TC OTIC ...... 102 CYSTADANE POW ...... 67 COSENTYX ...... 99 CYSTAGON ...... 67 COSENTYX SENSOREADY PEN ...... 99 CYSTARAN ...... 91 CREON CAP 12000UNT ...... 75 cysteamine bitartrate CREON CAP 24000UNT ...... 75 see CYSTAGON ...... 67 CREON CAP 3000UNIT ...... 75 cysteamine hcl CREON CAP 36000UNT ...... 75 see CYSTARAN ...... 91 CREON CAP 6000UNIT ...... 75 cytarabine ...... 23 CRESEMBA ...... 13 D CRINONE ...... 70 dabigatran etexilate mesylate crisaborole see PRADAXA ...... 78 see EUCRISA ...... 101 dabrafenib mesylate CRIXIVAN ...... 14 see TAFINLAR ...... 28 crizotinib dacarbazine ...... 22 see XALKORI ...... 28 dalfampridine ...... 54 cromolyn sodium ...... 95 DALIRESP ...... 95 cromolyn sodium (mastocytosis) 75 dalteparin sodium cromolyn sodium (ophth) ...... 91 see FRAGMIN ...... 78 crotamiton danazol ...... 67 see EURAX ...... 101 dantrolene sodium ...... 55 Crotamiton ...... 101 dapagliflozin propanediol 111

see FARXIGA ...... 60 desmopressin acetate ...... 71 dapagliflozin-metformin hcl desmopressin acetate spray ...... 71 see XIGDUO XR TAB 10-1000 ...... 60 desmopressin acetate spray see XIGDUO XR TAB 10-500MG ..... 60 refrigerated ...... 71 see XIGDUO XR TAB 2.5-1000 ...... 60 Desogest-Eth Estrad & Eth Estrad Tab see XIGDUO XR TAB 5-1000MG ..... 60 0.15-0.02/0.01 mg(21/5) ...... 62 see XIGDUO XR TAB 5-500MG ...... 60 Desogest-Ethin Est Tab 0.1- dapsone...... 12 0.025/0.125-0.025/0.15-0.025mg- DAPTACEL INJ ...... 84 Mg ...... 62 darbepoetin alfa Desogestrel & Ethinyl Estradiol Tab see ARANESP ALBUMIN FREE ...... 79 0.15 mg-30 mcg ...... 62 darifenacin hydrobromide ...... 77 desonide ...... 100 darolutamide desoximetasone ...... 100 see NUBEQA ...... 26 desvenlafaxine succinate ...... 45 darunavir ethanolate dexamethasone ...... 69 see PREZISTA ...... 15 see DEXAMETHASONE INTENSOL .. 69 darunavir-cobicistat dexamethasone (ophth) see PREZCOBIX TAB 800-150 ...... 18 see MAXIDEX ...... 90 dasatinib DEXAMETHASONE INTENSOL ...... 69 see SPRYCEL ...... 28 dexamethasone sodium phosphate DASETTA 1/35 ...... 69 see Norethindrone & Ethinyl Estradiol dexamethasone sodium phosphate Tab 1 mg-35 mcg ...... 65 (ophth) ...... 90 DASETTA 7/7/7 DEXILANT ...... 76 see Norethindrone-Eth Estradiol Tab dexlansoprazole 0.5-35/0.75-35/1-35 mg-Mcg .... 66 see DEXILANT ...... 76 daunorubicin hcl ...... 23 dexmethylphenidate hcl ...... 51 decitabine ...... 23 dexrazoxane hcl ...... 29 deferiprone ...... 61 dextroamphetamine sulfate ...... 51 see FERRIPROX ...... 61 Dextroamphetamine Sulfate ...... 51 see FERRIPROX TWICE-A-DAY ...... 61 dextromethorphan hbr-quinidine delafloxacin meglumine sulfate see BAXDELA ...... 71 see NUEDEXTA CAP 20-10MG ...... 54 DELYLA diazepam...... 42 see Levonorgestrel & Ethinyl Estradiol Diazepam ...... 42 Tab 0.1 mg-20 mcg ...... 63 DIAZEPAM INTENSOL demeclocycline hcl ...... 22 see Diazepam ...... 42 DENAVIR ...... 101 diclofenac potassium ...... 2 denosumab diclofenac sodium ...... 2 see PROLIA ...... 70 diclofenac sodium (ophth) ...... 90 DEPO-ESTRADIOL ...... 67 diclofenac sodium (topical) ...... 101 DEPO-MEDROL ...... 68 diclofenac w/ misoprostol tab DEPO-PROVERA ...... 25 delayed release 50-0.2 mg ...... 3 DEPO-SUBQ PROVERA 104 ...... 61 diclofenac w/ misoprostol tab DESCOVY TAB 200/25MG ...... 17 delayed release 75-0.2 mg ...... 3 desipramine hcl ...... 45 dicloxacillin sodium ...... 21 desloratadine ...... 93 dicyclomine hcl ...... 72 112 didanosine ...... 14 see KINRIX INJ ...... 84 see VIDEX EC ...... 16 diph-tetanus tox-acell pert- see VIDEX PEDIATRIC ...... 16 hepatitis b recomb-polio ipv vac difenoxin w/ atropine see PEDIARIX INJ 0.5ML ...... 85 see MOTOFEN TAB 1-0.025 ...... 75 diphtheria, acellular pertussis & DIFICID ...... 20 tetanus toxoids ...... 100 see DAPTACEL INJ ...... 84 diflunisal ...... 11 see INFANRIX INJ ...... 84 difluprednate dipyridamole ...... 80 see DUREZOL ...... 90 disopyramide phosphate ...... 34 DIGOX see NORPACE CR ...... 35 see Digoxin ...... 39 disulfiram ...... 56 digoxin ...... 39 DIURIL...... 39 see LANOXIN ...... 39 divalproex sodium ...... 42 Digoxin ...... 39 DIVIGEL ...... 67 dihydroergotamine mesylate ...... 52 docetaxel ...... 24 DILANTIN ...... 42 dofetilide ...... 34 DILATRATE SR ...... 40 dolutegravir sodium diltiazem hcl ...... 38 see TIVICAY...... 16 Diltiazem Hcl ...... 38 see TIVICAY PD ...... 16 diltiazem hcl coated beads ...... 38 dolutegravir sodium-lamivudine see CARDIZEM LA ...... 38 see DOVATO TAB 50-300MG ...... 17 Diltiazem Hcl Coated Beads ...... 38 donepezil hydrochloride ...... 44 diltiazem hcl extended release dorzolamide hcl ...... 91 beads ...... 39 dorzolamide hcl-timolol maleate Diltiazem Hcl Extended Release Beads ophth soln 22.3-6.8 mg/ml ...... 91 ...... 39 DOVATO TAB 50-300MG ...... 17 DILT-XR doxazosin mesylate ...... 32 see Diltiazem Hcl ...... 38 doxazosin mesylate (bph) dimethyl fumarate ...... 54 see CARDURA XL ...... 77 dimethyl fumarate capsule dr doxepin hcl ...... 45, 46 starter pack 120 mg & 240 mg . 54 doxepin hcl (antipruritic) ...... 99 DIP/TET PED INJ 25-5LFU ...... 84 doxercalciferol ...... 88 DIPENTUM ...... 73 doxorubicin hcl ...... 23 diph-ac pert-tet tox ad-polio ipv- Doxorubicin Hcl ...... 23 haemophil b poly vac doxorubicin hcl liposomal ...... 23 see PENTACEL INJ ...... 85 DOXY 100 diphenhydramine hcl ...... 93 see Doxycycline Hyclate ...... 22 diphenoxylate w/ atropine liq 2.5- doxycycline (monohydrate) ...... 22 0.025 mg/5ml ...... 75 Doxycycline (Monohydrate) ...... 22 diphenoxylate w/ atropine tab 2.5- doxycycline calcium 0.025 mg ...... 75 see VIBRAMYCIN ...... 22 diph-tet tox-acell pert ad-polio ipv- doxycycline hyclate ...... 22 hib-hepatitis b recomb Doxycycline Hyclate ...... 22 see VAXELIS INJ ...... 85 dronabinol ...... 72 diph-tetanus tox ad-acell pertussis dronedarone hcl & polio virus, ipv vac see MULTAQ ...... 35 113 drospirenone elexacaftor-tezacaftor-ivacaftor see SLYND ...... 66 see TRIKAFTA TAB ...... 95 drospirenone-estetrol ELIGARD ...... 25 see NEXTSTELLIS TAB 3-14.2MG ... 64 eliglustat tartrate Drospirenone-Ethinyl Estradiol Tab 3- see CERDELGA ...... 67 0.02 mg ...... 62 ELINEST drospirenone-ethinyl estradiol tab see Norgestrel & Ethinyl Estradiol Tab 3-0.03 mg ...... 62 0.3 mg-30 mcg ...... 66 Drospirenone-Ethinyl Estradiol Tab 3- ELIQUIS ...... 78 0.03 mg ...... 62 ELIQUIS STARTER PACK ...... 78 drospirenone-ethinyl estrad- ELITE-OB levomefolate tab 3-0.02-0.451 see *prenatal Vit W/ Iron Carbonyl- mg ...... 62 Fa Tab 50-1.25 mg*** ...... 89 drospirenone-ethinyl estrad- ELIXOPHYLLIN ...... 96 levomefolate tab 3-0.03-0.451 ELLA ...... 62 mg ...... 62 ELMIRON...... 77 DROXIA ...... 29 eltrombopag olamine DUAVEE TAB 0.45-20 ...... 67 see PROMACTA ...... 79 dulaglutide elvitegravir-cobicistat- see TRULICITY ...... 58 emtricitabine-tenofovir duloxetine hcl ...... 46 alafenamide DUREZOL ...... 90 see GENVOYA TAB ...... 17 dutasteride ...... 77 EMCYT ...... 22 dutasteride-tamsulosin hcl cap 0.5- EMGALITY ...... 53 0.4 mg ...... 77 emicizumab-kxwh E see HEMLIBRA ...... 79 echothiophate iodide EMOQUETTE see PHOSPHOLINE IODIDE ...... 91 see Desogestrel & Ethinyl Estradiol econazole nitrate ...... 98 Tab 0.15 mg-30 mcg...... 62 ED-SPAZ empagliflozin see Hyoscyamine Sulfate ...... 72 see JARDIANCE ...... 60 EDURANT ...... 14 empagliflozin-linagliptin efavirenz ...... 14 see GLYXAMBI TAB 10-5 MG ...... 60 efavirenz-emtricitabine-tenofovir see GLYXAMBI TAB 25-5 MG ...... 60 df tab 600-200-300 mg ...... 17 empagliflozin-metformin hcl efavirenz-lamivudine-tenofovir df see SYNJARDY TAB ...... 60 tab 400-300-300 mg ...... 17 see SYNJARDY TAB 12.5-500 ...... 60 efavirenz-lamivudine-tenofovir df see SYNJARDY TAB 5-1000MG ...... 60 tab 600-300-300 mg ...... 17 see SYNJARDY TAB 5-500MG ...... 60 EFFER-K see SYNJARDY XR TAB ...... 60 see Potassium Bicarbonate ...... 87 see SYNJARDY XR TAB 10-1000 .... 60 efinaconazole see SYNJARDY XR TAB 25-1000 .... 60 see JUBLIA ...... 98 see SYNJARDY XR TAB 5-1000MG.. 60 elagolix sodium EMSAM ...... 46 see ORILISSA ...... 67 emtricitabine ...... 14 ELESTRIN ...... 67 see EMTRIVA ...... 14 eletriptan hydrobromide ...... 53 114 emtricitabine-rilpivirine-tenofovir see Desogestrel & Ethinyl Estradiol alafenamide fumarate Tab 0.15 mg-30 mcg...... 62 see ODEFSEY TAB ...... 18 entacapone ...... 48 emtricitabine-tenofovir entecavir ...... 18 alafenamide fumarate see BARACLUDE ...... 18 see DESCOVY TAB 200/25MG ...... 17 ENTRESTO TAB 24-26MG ...... 40 emtricitabine-tenofovir disoproxil ENTRESTO TAB 49-51MG ...... 40 fumarate tab 100-150 mg ...... 17 ENTRESTO TAB 97-103MG ...... 40 emtricitabine-tenofovir disoproxil ENULOSE fumarate tab 133-200 mg ...... 17 see Lactulose (Encephalopathy) .... 74 emtricitabine-tenofovir disoproxil enzalutamide fumarate tab 167-250 mg ...... 17 see XTANDI ...... 26 emtricitabine-tenofovir disoproxil EPCLUSA TAB 200-50MG ...... 20 fumarate tab 200-300 mg ...... 17 EPCLUSA TAB 400-100 ...... 20 EMTRIVA ...... 14 EPIDUO FORTE GEL 0.3-2.5% ...... 97 EMVERM ...... 12 epinastine hcl (ophth) ...... 91 enalapril maleate ...... 32 epinephrine (anaphylaxis) ...... 92 enalapril maleate & see EPIPEN 2-PAK ...... 92 hydrochlorothiazide tab 10-25 see EPIPEN-JR 2-PAK ...... 92 mg ...... 31 EPIPEN 2-PAK ...... 92 enalapril maleate & EPIPEN-JR 2-PAK ...... 92 hydrochlorothiazide tab 5-12.5 epirubicin hcl ...... 23 mg ...... 31 EPITOL enasidenib mesylate see Carbamazepine ...... 42 see IDHIFA ...... 27 EPIVIR HBV ...... 18 ENBREL ...... 80 eplerenone ...... 32 ENBREL MINI ...... 80 epoetin alfa-epbx ENBREL SURECLICK ...... 80 see RETACRIT ...... 79 ENCARE ...... 77 eprosartan mesylate ...... 34 ENDOCET ERBITUX ...... 24 see Oxycodone W/ Acetaminophen erenumab-aooe Tab 10-325 mg ...... 9 see AIMOVIG ...... 52 see Oxycodone W/ Acetaminophen ergocalciferol ...... 88 Tab 2.5-325 mg ...... 9 ergoloid mesylates ...... 44 see Oxycodone W/ Acetaminophen ergotamine w/ caffeine tab 1-100 Tab 5-325 mg ...... 9 mg ...... 53 see Oxycodone W/ Acetaminophen ERIVEDGE ...... 24 Tab 7.5-325 mg ...... 9 ERLEADA ...... 25 enfuvirtide erlotinib hcl ...... 27 see FUZEON ...... 14 ERRIN ENGERIX-B ...... 84 see Norethindrone (Contraceptive) 65 enoxaparin sodium ...... 78 ERTACZO ...... 98 ENPRESSE-28 ertapenem sodium ...... 12 see Levonorgestrel-Eth Estra Tab ERY 0.05-30/0.075-40/0.125-30mg- see Erythromycin (Acne Aid) ...... 97 Mcg ...... 64 ERY-TAB ENSKYCE see Erythromycin Base ...... 20 115

ERYTHROCIN STEARATE see ENBREL MINI ...... 80 see Erythromycin Stearate ...... 20 see ENBREL SURECLICK ...... 80 erythromycin (acne aid) ...... 97 ethacrynic acid ...... 39 Erythromycin (Acne Aid) ...... 97 ethambutol hcl ...... 18 erythromycin (ophth) ...... 89 ethionamide erythromycin base...... 20 see TRECATOR ...... 18 Erythromycin Base ...... 20 ethosuximide ...... 42 erythromycin ethylsuccinate ...... 20 ethotoin Erythromycin Stearate ...... 20 see PEGANONE ...... 43 ESBRIET ...... 95 Ethynodiol Diacetate & Ethinyl Estradiol escitalopram oxalate ...... 46 Tab 1 mg-35 mcg ...... 62 eslicarbazepine acetate ethynodiol diacetate & ethinyl see APTIOM ...... 42 estradiol tab 1 mg-50 mcg ...... 62 esomeprazole magnesium ...... 76 etodolac ...... 2 see NEXIUM ...... 76 etonogestrel esterified estrogens see NEXPLANON ...... 64 see MENEST ...... 68 etonogestrel-ethinyl estradiol va estradiol ...... 68 ring 0.120-0.015 mg/24hr ...... 62 see DIVIGEL ...... 67 etoposide ...... 30 see ELESTRIN ...... 67 Etoposide ...... 30 see ESTROGEL ...... 68 etravirine ...... 14 see EVAMIST ...... 68 see INTELENCE ...... 14, 15 estradiol & norethindrone acetate EUCRISA ...... 101 tab 0.5-0.1 mg ...... 68 EURAX ...... 101 estradiol & norethindrone acetate EVAMIST ...... 68 tab 1-0.5 mg ...... 68 everolimus ...... 27 Estradiol & Norethindrone Acetate Tab see AFINITOR ...... 26 1-0.5 mg ...... 68 see AFINITOR DISPERZ ...... 26 everolimus (immunosuppressant) see DEPO-ESTRADIOL ...... 67 ...... 83 estradiol vaginal ...... 68 see ZORTRESS ...... 83 Estradiol Vaginal ...... 68 EVOTAZ TAB 300-150 ...... 17 estradiol valerate ...... 68 EVRYSDI ...... 53 estradiol valerate-dienogest exemestane ...... 25 see NATAZIA TAB ...... 64 ezetimibe ...... 35 estradiol-levonorgestrel ezetimibe-simvastatin tab 10-10 see CLIMARA PRO DIS WEEKLY ..... 67 mg ...... 35 sodium ezetimibe-simvastatin tab 10-20 see EMCYT ...... 22 mg ...... 35 ESTROGEL ...... 68 ezetimibe-simvastatin tab 10-40 estrogens, conjugated mg ...... 35 see PREMARIN ...... 68 ezetimibe-simvastatin tab 10-80 estrogens, conjugated vaginal mg ...... 35 see PREMARIN ...... 68 F eszopiclone ...... 52 FALMINA etanercept see Levonorgestrel & Ethinyl Estradiol see ENBREL ...... 80 Tab 0.1 mg-20 mcg ...... 63 116 famciclovir ...... 18 fluconazole ...... 13 famotidine ...... 73 fludarabine phosphate ...... 23 famotidine in nacl 0.9% iv soln 20 fludrocortisone acetate ...... 69 mg/50ml ...... 73 FLULAVAL QUA INJ 2020-21 ...... 84 FARXIGA ...... 60 FLUMIST QUAD SUS 2020-21 ...... 84 FARYDAK...... 24 flunisolide (nasal) ...... 95 FAYOSIM fluocinolone acetonide ...... 100 see Levonor-Eth Est Tab 0.15- fluocinolone acetonide (otic) .... 102 0.02/0.025/0.03 mg ð Est 0.01 fluocinonide ...... 100 mg ...... 63 FLUORABON ...... 86 FC2 FEMALE MIS CONDOM ...... 86 FLUORITAB febuxostat ...... 2 see Sodium Fluoride ...... 87 felbamate ...... 42 fluorometholone (ophth) felodipine ...... 39 see FML...... 90 FEMCAP MIS 22MM ...... 86 see FML FORTE ...... 90 FEMCAP MIS 26MM ...... 86 fluorouracil ...... 23 FEMCAP MIS 30MM ...... 86 fluorouracil (topical) ...... 98 fenofibrate ...... 35 fluoxetine hcl ...... 46 fenofibrate micronized ...... 35 fluphenazine decanoate ...... 49 fenoprofen calcium ...... 2 fluphenazine hcl ...... 49 fentanyl ...... 4 FLURA-DROPS fentanyl citrate ...... 4 see Sodium Fluoride ...... 87 FERRIPROX ...... 61 flurbiprofen ...... 2 FERRIPROX TWICE-A-DAY ...... 61 flurbiprofen sodium ...... 90 fesoterodine fumarate flutamide ...... 25 see TOVIAZ ...... 77 (inhalation) FETZIMA ...... 46 see ARNUITY ELLIPTA ...... 96 FETZIMA CAP TITRATIO ...... 46 fluticasone furoate-vilanterol FIASP FLEX INJ TOUCH ...... 58 see BREO ELLIPTA INH 100-25 ...... 96 FIASP INJ 100/ML ...... 58 see BREO ELLIPTA INH 200-25 ...... 96 FIASP PENFIL INJ U-100 ...... 58 fluticasone propionate ...... 100 fidaxomicin fluticasone propionate (nasal) .... 96 see DIFICID ...... 20 fluticasone-salmeterol filgrastim-aafi see ADVAIR DISKU AER 100/50 .... 96 see NIVESTYM ...... 79 see ADVAIR DISKU AER 250/50 .... 96 FINACEA ...... 101 see ADVAIR DISKU AER 500/50 .... 96 finasteride ...... 77 see ADVAIR HFA AER 115/21 ...... 96 fingolimod hcl see ADVAIR HFA AER 230/21 ...... 96 see GILENYA ...... 54 see ADVAIR HFA AER 45/21 ...... 96 flavoxate hcl ...... 77 fluticasone-umeclidinium-vilanterol flecainide acetate ...... 34 see TRELEGY AER ELLIPTA ...... 92 floxuridine ...... 23 fluvastatin sodium ...... 36 FLUAD INJ 2020-21 ...... 84 fluvoxamine maleate ...... 53 FLUAD QUADRIVALENT INFLUE ...... 84 FLUZONE HD INJ PF 20-21 ...... 84 FLUARIX QUAD INJ 2020-21 ...... 84 FLUZONE QUAD INJ 2020-21 ...... 84 FLUBLOK QUAD INJ 2020-21 ...... 84 FML ...... 90 FLUCLVX QUAD INJ 2020-21 ...... 84 FML FORTE ...... 90 117 folic acid ...... 80, 88 GAZYVA ...... 24 fondaparinux sodium...... 78 gemcitabine hcl ...... 24 formoterol fumarate ...... 93 gemfibrozil ...... 35 see PERFOROMIST ...... 94 GEMMILY FOSAMAX + D TAB 70-2800 ...... 61 see Norethindrone Ace-Ethinyl FOSAMAX + D TAB 70-5600 ...... 61 Estradiol-Fe Cap 1 mg-20 mcg (24) fosamprenavir calcium ...... 14 ...... 65 see LEXIVA ...... 15 GENERLAC fosfomycin tromethamine ...... 11 see Lactulose (Encephalopathy) .... 74 fosinopril sodium ...... 32 GENGRAF fosinopril sodium & see Cyclosporine Modified (For hydrochlorothiazide tab 10-12.5 Microemulsion) ...... 83 mg ...... 31 GENTAK fosinopril sodium & see Gentamicin Sulfate (Ophth) .... 89 hydrochlorothiazide tab 20-12.5 gentamicin sulfate...... 11 mg ...... 31 gentamicin sulfate (ophth) ...... 89 fosphenytoin sodium ...... 42 Gentamicin Sulfate (Ophth) ...... 89 FOSRENOL ...... 70 gentamicin sulfate (topical) ...... 98 FRAGMIN ...... 78 GENVOYA TAB ...... 17 fremanezumab-vfrm GIANVI see AJOVY ...... 52 see Drospirenone-Ethinyl Estradiol frovatriptan succinate ...... 53 Tab 3-0.02 mg ...... 62 fulvestrant ...... 25 GILENYA ...... 54 furosemide ...... 39, 40 glatiramer acetate ...... 54 FUZEON ...... 14 see COPAXONE ...... 54 FYCOMPA ...... 43 Glatiramer Acetate ...... 54 G GLATOPA gabapentin ...... 43 see Glatiramer Acetate ...... 54 galantamine hydrobromide ...... 44 GLEOSTINE ...... 23 galcanezumab-gnlm GLIADEL WAF 7.7MG ...... 23 see EMGALITY ...... 53 glimepiride ...... 60 ganciclovir ophthalmic glipizide ...... 61 see ZIRGAN ...... 90 glipizide-metformin hcl tab 2.5-250 GARDASIL 9 INJ ...... 84 mg ...... 57 gatifloxacin (ophth) ...... 89 glipizide-metformin hcl tab 2.5-500 GAVILYTE-C mg ...... 57 see Peg 3350-Kcl-Na Bicarb-Nacl-Na glipizide-metformin hcl tab 5-500 Sulfate For Soln 240 gm ...... 74 mg ...... 57 GAVILYTE-G glucagon (rdna) ...... 69 see Peg 3350-Kcl-Na Bicarb-Nacl-Na glycopyrrolate ...... 72 Sulfate For Soln 236 gm ...... 74 see CUVPOSA ...... 72 GAVILYTE-H glycopyrrolate-formoterol fumarate see Bisacodyl Tab & Peg 3350-Kcl- see BEVESPI AER 9-4.8MCG ...... 92 Sod Bicarb-Nacl For Soln Kit ...... 74 GLYXAMBI TAB 10-5 MG ...... 60 GAVILYTE-N/FLAVOR PACK GLYXAMBI TAB 25-5 MG ...... 60 see Peg 3350-Kcl-Sod Bicarb-Nacl golimumab For Soln 420 gm ...... 74 see SIMPONI ...... 81 118

see SIMPONI ARIA ...... 81 see ENGERIX-B ...... 84 GOLYTELY SOL ...... 74 see RECOMBIVAX HB ...... 85 GOODSENSE ASPIRIN hepatitis b vaccine recombinant see Aspirin ...... 11 adjuvanted GOODSENSE NICOTINE POLACR see HEPLISAV-B ...... 84 see Nicotine Polacrilex ...... 56 HEPLISAV-B ...... 84 granisetron HETLIOZ ...... 52 see SANCUSO ...... 73 HIBERIX ...... 84 granisetron hcl ...... 72 human papillomavirus (hpv) 9- griseofulvin microsize ...... 13 valent recombinant vaccine griseofulvin ultramicrosize ...... 13 see GARDASIL 9 INJ ...... 84 GUAIFENESIN AC HUMATROPE ...... 69 see Guaifenesin-Codeine Soln 100-10 HUMATROPE COMBO PACK ...... 69 mg/5ml ...... 94 HUMATROPEN MIS FOR 12MG ...... 86 Guaifenesin-Codeine Soln 100-10 HUMATROPEN MIS FOR 24MG ...... 86 mg/5ml ...... 94 HUMATROPEN MIS FOR 6MG...... 86 guanfacine hcl ...... 40 HUMIRA ...... 80 guanfacine hcl (adhd) ...... 51 HUMIRA PEDIA INJ CROHNS ...... 80 GUANIDINE HCL ...... 53 HUMIRA PEDIATRIC CROHNS D ...... 80 guselkumab HUMIRA PEN ...... 80 see TREMFYA ...... 81 HUMIRA PEN KIT PS/UV ...... 81 GYNAZOLE-1 ...... 78 HUMIRA PEN-CD/UC/HS START ...... 81 H HUMIRA PEN-PS/UV STARTER ...... 81 haemophilus b polysac conj vac HUMULIN INJ 70/30 ...... 58 see ACTHIB INJ ...... 83 HUMULIN INJ 70/30KWP ...... 58 see HIBERIX ...... 84 HUMULIN N ...... 58 see PEDVAX HIB ...... 85 HUMULIN N KWIKPEN ...... 58 halobetasol propionate ...... 100 HUMULIN R ...... 58 haloperidol ...... 49 HUMULIN R U-500 (CONCENTR ...... 58 haloperidol decanoate ...... 49 HUMULIN R U-500 KWIKPEN ...... 58 haloperidol lactate ...... 49 hydralazine hcl ...... 40 HARVONI PAK ...... 20 hydrochlorothiazide ...... 40 HARVONI PAK 45-200MG ...... 20 hydrocodone w/ homatropine HARVONI TAB 45-200MG ...... 20 syrup 5-1.5 mg/5ml ...... 94 HARVONI TAB 90-400MG ...... 20 Hydrocodone W/ Homatropine Syrup 5- HAVRIX ...... 84 1.5 mg/5ml ...... 94 HEATHER hydrocodone w/ homatropine tab see Norethindrone (Contraceptive) 65 5-1.5 mg ...... 94 HEMLIBRA ...... 79 hydrocodone-acetaminophen soln heparin sodium (porcine) ...... 78 7.5-325 mg/15ml ...... 4 hepatitis a (inactivated)-hepatitis b hydrocodone-acetaminophen tab (recombinant) vaccines 10-325 mg ...... 5 see TWINRIX INJ ...... 85 hydrocodone-acetaminophen tab 5- hepatitis a vaccine 325 mg ...... 5 see HAVRIX ...... 84 hydrocodone-acetaminophen tab see VAQTA...... 85 7.5-325 mg ...... 5 hepatitis b vaccine (recomb) 119 hydrocodone-ibuprofen tab 10-200 ifosfamide ...... 23 mg ...... 5 ILEVRO ...... 90 hydrocortisone ...... 69 iloprost hydrocortisone (intrarectal) ...... 74 see VENTAVIS ...... 41 hydrocortisone (rectal) ...... 76 imatinib mesylate ...... 27 Hydrocortisone (Rectal)...... 76 IMBRUVICA ...... 27 hydrocortisone (topical) ...... 100 imipramine hcl ...... 46 Hydrocortisone (Topical) ...... 100 imipramine pamoate ...... 46 hydrocortisone butyrate ...... 100 imiquimod ...... 98 hydrocortisone sod succinate immune globulin (human)- see SOLU-CORTEF ...... 69 hyaluronidase (human hydrocortisone valerate ...... 100 recombinant) hydrocortisone w/ acetic acid otic see HYQVIA INJ 10-800 ...... 82 soln 1-2% ...... 102 see HYQVIA INJ 2.5-200 ...... 82 HYDROMET see HYQVIA INJ 20-1600 ...... 82 see Hydrocodone W/ Homatropine see HYQVIA INJ 30-2400 ...... 82 Syrup 5-1.5 mg/5ml ...... 94 see HYQVIA INJ 5-400 ...... 82 hydromorphone hcl ...... 5 INCRELEX ...... 70 hydroxychloroquine sulfate ...... 82 INCRUSE ELLIPTA ...... 92 hydroxyurea ...... 29 indapamide ...... 40 hydroxyurea (sickle cell anemia) indinavir sulfate see DROXIA ...... 29 see CRIXIVAN ...... 14 hydroxyzine hcl ...... 93 INFANRIX INJ ...... 84 hydroxyzine pamoate ...... 93 influenza virus vac recomb hyoscyamine sulfate ...... 72 hemagglutinin (ha) quadrivalent Hyoscyamine Sulfate ...... 72 see FLUBLOK QUAD INJ 2020-21 ... 84 HYQVIA INJ 10-800 ...... 82 influenza virus vac split high-dose HYQVIA INJ 2.5-200 ...... 82 quad preservative free HYQVIA INJ 20-1600 ...... 82 see FLUZONE HD INJ PF 20-21 ...... 84 HYQVIA INJ 30-2400 ...... 82 influenza virus vacc types a & b HYQVIA INJ 5-400 ...... 82 surf antigen adjuvant quad I see FLUAD QUADRIVALENT INFLUE 84 ibalizumab-uiyk influenza virus vaccine live see TROGARZO ...... 16 quadrivalent ibandronate sodium ...... 61 see FLUMIST QUAD SUS 2020-21 .. 84 IBRANCE ...... 24 influenza virus vaccine split ibrutinib quadrivalent see IMBRUVICA ...... 27 see AFLURIA QUAD INJ 2020-21 ... 83 ibuprofen ...... 2 see FLUARIX QUAD INJ 2020-21 ... 84 icatibant acetate ...... 80 see FLULAVAL QUA INJ 2020-21 .... 84 ICLUSIG ...... 27 see FLUZONE QUAD INJ 2020-21 .. 84 icosapent ethyl influenza virus vaccine tissue- see VASCEPA ...... 36 cultured subunit quadrivalent idarubicin hcl ...... 23 see FLUCLVX QUAD INJ 2020-21 ... 84 idelalisib influenza virus vaccine types a & b see ZYDELIG ...... 29 surface antigen adjuvant IDHIFA ...... 27 see FLUAD INJ 2020-21 ...... 84 120 see HUMULIN R ...... 58 see PICATO ...... 98 see HUMULIN R U-500 (CONCENTR 58 injection device see HUMULIN R U-500 KWIKPEN ... 58 see HUMATROPEN MIS FOR 12MG . 86 see NOVOLIN R ...... 59 see HUMATROPEN MIS FOR 24MG . 86 see NOVOLIN R FLEXPEN ...... 59 see HUMATROPEN MIS FOR 6MG ... 86 insulin syringe/needle u-100 INLYTA...... 27 see INSULIN PEN insulin aspart NEEDLES/SYRINGES ...... 86 see NOVOLOG ...... 59 INTELENCE ...... 14, 15 see NOVOLOG FLEXPEN ...... 59 interferon alfa-2b see NOVOLOG PENFILL ...... 59 see INTRON A ...... 82 insulin aspart (with niacinamide) interferon beta-1a see FIASP FLEX INJ TOUCH ...... 58 see AVONEX ...... 54 see FIASP INJ 100/ML ...... 58 see AVONEX PEN ...... 54 see FIASP PENFIL INJ U-100 ...... 58 see REBIF ...... 55 insulin aspart protamine & aspart see REBIF REBIDO INJ TITRATN .... 55 (human) see REBIF REBIDOSE ...... 55 see NOVOLOG MIX INJ 70/30 ...... 59 see REBIF TITRTN INJ PACK ...... 55 see NOVOLOG MIX INJ FLEXPEN .... 59 interferon beta-1b insulin degludec see BETASERON ...... 54 see TRESIBA ...... 59 interferon gamma-1b see TRESIBA FLEXTOUCH ...... 59 see ACTIMMUNE ...... 82 insulin degludec-liraglutide INTRAROSA ...... 56 see XULTOPHY INJ 100/3.6 ...... 58 INTRON A ...... 82 insulin detemir INTROVALE see LEVEMIR ...... 58 see Levonorgestrel & Ethinyl Estradiol see LEVEMIR FLEXTOUCH ...... 59 (91-Day) Tab 0.15-0.03 mg ...... 63 insulin glargine INVIRASE ...... 15 see BASAGLAR KWIKPEN ...... 58 IOPIDINE ...... 91 insulin glargine-lixisenatide IPOL INJ INACTIVE ...... 84 see SOLIQUA INJ 100/33 ...... 58 ipratropium bromide ...... 92 insulin nph (human) (isophane) ipratropium bromide (nasal) ...... 92 see HUMULIN N ...... 58 ipratropium-albuterol nebu soln see HUMULIN N KWIKPEN...... 58 0.5-2.5(3) mg/3ml ...... 92 see NOVOLIN N ...... 59 irbesartan ...... 34 see NOVOLIN N FLEXPEN ...... 59 irbesartan-hydrochlorothiazide tab insulin nph isophane & reg 150-12.5 mg ...... 33 (human) irbesartan-hydrochlorothiazide tab see HUMULIN INJ 70/30 ...... 58 300-12.5 mg ...... 33 see HUMULIN INJ 70/30KWP ...... 58 irinotecan hcl ...... 30 see NOVOLIN INJ 70/30 ...... 59 isavuconazonium sulfate see NOVOLIN INJ 70/30 FP ...... 59 see CRESEMBA ...... 13 insulin pen needle ISENTRESS ...... 15 see CAREFINE MIS 32GX6MM ...... 86 ISENTRESS HD ...... 15 see NOVOFINE PEN NEEDLES ...... 86 isocarboxazid INSULIN PEN NEEDLES/SYRINGES ... 86 see MARPLAN ...... 46 insulin regular (human) isoniazid ...... 18 121 isoniazid & rifampin see Norethindrone Ace & Ethinyl see RIFAMATE CAP ...... 18 Estradiol-Fe Tab 1 mg-20 mcg ... 65 isoniazid-rifampin w/ JUNEL FE 24 pyrazinamide see Norethindrone Ace-Ethinyl see RIFATER TAB ...... 18 Estradiol-Fe Tab 1 mg-20 mcg (24) isosorbide dinitrate ...... 40 ...... 65 see DILATRATE SR ...... 40 K isosorbide mononitrate ...... 41 KADCYLA ...... 24 isotretinoin ...... 97 KALETRA TAB 100-25MG ...... 17 isradipine ...... 39 KALETRA TAB 200-50MG ...... 17 itraconazole ...... 13 KALYDECO ...... 95 ivacaftor KARIVA see KALYDECO ...... 95 see Desogest-Eth Estrad & Eth Estrad ivermectin ...... 12 Tab 0.15-0.02/0.01 mg(21/5) .... 62 ivermectin (pediculicide)...... 101 KELNOR 1/35 ixekizumab see Ethynodiol Diacetate & Ethinyl see TALTZ ...... 81 Estradiol Tab 1 mg-35 mcg ...... 62 J ketoconazole (topical) ...... 98, 99 JAKAFI ...... 27 ketoprofen ...... 2 JANTOVEN ketorolac tromethamine ...... 2 see Warfarin Sodium ...... 79 ketorolac tromethamine (ophth) . 90 JANUMET TAB 50-1000 ...... 57 see ACUVAIL ...... 90 JANUMET TAB 50-500MG ...... 57 KEVZARA ...... 81 JANUMET XR TAB 100-1000 ...... 58 KEYTRUDA ...... 24 JANUMET XR TAB 50-1000 ...... 58 KINRIX INJ ...... 84 JANUMET XR TAB 50-500MG ...... 57 KISQALI ...... 24, 25 JANUVIA ...... 57 KLOR-CON 10 JARDIANCE ...... 60 see Potassium Chloride ...... 87 JENTADUETO TAB XR ...... 58 KLOR-CON 8 JINTELI see Potassium Chloride ...... 87 see Norethindrone Acetate-Ethinyl KLOR-CON M15 Estradiol Tab 1 mg-5 mcg ...... 68 see Potassium Chloride JOLESSA Microencapsulated Crystals Er .... 87 see Levonorgestrel & Ethinyl Estradiol KLOR-CON M20 (91-Day) Tab 0.15-0.03 mg ...... 63 see Potassium Chloride JUBLIA ...... 98 Microencapsulated Crystals Er .... 87 JUNEL 1.5/30 KURVELO see Norethindrone Ace & Ethinyl see Levonorgestrel & Ethinyl Estradiol Estradiol Tab 1.5 mg-30 mcg ..... 65 Tab 0.15 mg-30 mcg...... 63 JUNEL 1/20 KYLEENA ...... 63 see Norethindrone Ace & Ethinyl L Estradiol Tab 1 mg-20 mcg ...... 65 labetalol hcl ...... 37 JUNEL FE 1.5/30 lacosamide see Norethindrone Ace & Ethinyl see VIMPAT ...... 44 Estradiol-Fe Tab 1.5 mg-30 mcg . 65 LACRISERT ...... 91 JUNEL FE 1/20 lactic acid ...... 101 lactic acid (ammonium lactate) . 101 122 lactulose ...... 74 see LENVIMA 8 MG DAILY DOSE .... 27 Lactulose (Encephalopathy) ...... 74 see LENVIMA CAP 14 MG ...... 28 lamivudine ...... 15 see LENVIMA CAP 18 MG ...... 28 lamivudine (hbv) ...... 18 see LENVIMA CAP 24 MG ...... 28 see EPIVIR HBV ...... 18 LENVIMA 10 MG DAILY DOSE ...... 28 lamivudine-tenofovir disoproxil LENVIMA 12MG DAILY DOSE ...... 28 fumarate LENVIMA 20 MG DAILY DOSE ...... 28 see CIMDUO TAB 300-300 ...... 17 LENVIMA 4 MG DAILY DOSE ...... 27 see TEMIXYS TAB 300-300 ...... 18 LENVIMA 8 MG DAILY DOSE ...... 27 lamivudine-zidovudine tab 150-300 LENVIMA CAP 14 MG ...... 28 mg ...... 17 LENVIMA CAP 18 MG ...... 28 lamotrigine ...... 43 LENVIMA CAP 24 MG ...... 28 lamotrigine tab 25 mg (42) & 100 LESSINA mg (7) starter kit ...... 43 see Levonorgestrel & Ethinyl Estradiol lamotrigine tab 84 x 25 mg & 14 x Tab 0.1 mg-20 mcg ...... 63 100 mg starter kit ...... 43 letrozole ...... 25 LANOXIN ...... 39 leucovorin calcium ...... 29, 30 lanreotide acetate LEUKERAN ...... 23 see SOMATULINE DEPOT ...... 70 leuprolide acetate ...... 26 lansoprazole ...... 76 see ELIGARD ...... 25 lanthanum carbonate leuprolide acetate & norethindrone see FOSRENOL ...... 70 acetate lapatinib ditosylate ...... 27 see LUPANETA KIT 11.25-5 ...... 71 LARIN 1.5/30 see LUPANETA KIT 3.75-5 ...... 70 see Norethindrone Ace & Ethinyl leuprolide acetate (3 month) Estradiol Tab 1.5 mg-30 mcg ..... 65 see ELIGARD ...... 25 larotrectinib sulfate leuprolide acetate (4 month) see VITRAKVI...... 28 see ELIGARD ...... 25 LASTACAFT...... 91 leuprolide acetate (6 month) latanoprost ...... 91 see ELIGARD ...... 25 LATUDA ...... 49 leuprolide acetate (cpp) ledipasvir-sofosbuvir see LUPRON DEPOT-PED (1-MONTH see HARVONI PAK ...... 20 ...... 26 see HARVONI PAK 45-200MG ...... 20 leuprolide acetate (cpp) (3 month) see HARVONI TAB 45-200MG ...... 20 see LUPRON DEPOT-PED (3-MONTH see HARVONI TAB 90-400MG ...... 20 ...... 26 LEENA levalbuterol hcl ...... 93 see Norethindrone-Eth Estradiol Tab levalbuterol tartrate ...... 93 0.5-35/1-35/0.5-35 mg-Mcg ...... 66 LEVEMIR ...... 58 leflunomide ...... 82 LEVEMIR FLEXTOUCH ...... 59 lenalidomide levetiracetam ...... 43 see REVLIMID ...... 82 levetiracetam in sodium chloride iv lenvatinib mesylate soln 1000 mg/100ml ...... 43 see LENVIMA 10 MG DAILY DOSE .. 28 levetiracetam in sodium chloride iv see LENVIMA 12MG DAILY DOSE ... 28 soln 1500 mg/100ml ...... 43 see LENVIMA 20 MG DAILY DOSE .. 28 levetiracetam in sodium chloride iv see LENVIMA 4 MG DAILY DOSE .... 27 soln 500 mg/100ml ...... 43 123 levobunolol hcl ...... 91 see Levonorgestrel & Ethinyl Estradiol levocetirizine dihydrochloride ..... 93 Tab 0.15 mg-30 mcg...... 63 levofloxacin ...... 20 levothyroxine sodium ...... 71 levofloxacin (ophth) ...... 89 see SYNTHROID ...... 71 levomilnacipran hcl Levothyroxine Sodium ...... 71 see FETZIMA ...... 46 LEVOXYL see FETZIMA CAP TITRATIO ...... 46 see Levothyroxine Sodium ...... 71 LEVONEST LEXIVA ...... 15 see Levonorgestrel-Eth Estra Tab lidocaine...... 101 0.05-30/0.075-40/0.125-30mg- lidocaine hcl ...... 101 Mcg ...... 64 lidocaine hcl (cardiac) ...... 35 Levonor-Eth Est Tab 0.15- lidocaine hcl (local anesth.) ...... 11 0.02/0.025/0.03 mg ð Est 0.01 lidocaine hcl (mouth-throat) ..... 102 mg ...... 63 lidocaine-prilocaine cream 2.5- levonorgestrel & eth estradiol 2.5% ...... 101 see TYBLUME CHW 0.1-0.02 ...... 67 LILETTA ...... 64 levonorgestrel & ethinyl estradiol linaclotide (91-day) tab 0.15-0.03 mg ...... 63 see LINZESS ...... 74 Levonorgestrel & Ethinyl Estradiol (91- linagliptin-metformin hcl Day) Tab 0.15-0.03 mg ...... 63 see JENTADUETO TAB XR ...... 58 Levonorgestrel & Ethinyl Estradiol Tab lindane ...... 101 0.1 mg-20 mcg ...... 63 linezolid ...... 12 levonorgestrel & ethinyl estradiol linezolid in sodium chloride iv soln tab 0.15 mg-30 mcg ...... 63 600 mg/300ml-0.9% ...... 12 Levonorgestrel & Ethinyl Estradiol Tab LINZESS ...... 74 0.15 mg-30 mcg ...... 63, 64 liothyronine sodium ...... 71 Levonorgestrel (Emergency Oc) ...... 64 liraglutide levonorgestrel (iud) see VICTOZA ...... 58 see KYLEENA ...... 63 lisdexamfetamine dimesylate see LILETTA ...... 64 see VYVANSE ...... 52 see MIRENA ...... 64 lisinopril ...... 32 see SKYLA ...... 66 lisinopril & hydrochlorothiazide tab Levonorgestrel-Eth Estra Tab 0.05- 10-12.5 mg ...... 31 30/0.075-40/0.125-30mg-Mcg ...... 64 lisinopril & hydrochlorothiazide tab levonorgestrel-ethinyl estradiol 20-12.5 mg ...... 31 see TWIRLA DIS 120-30 ...... 67 lisinopril & hydrochlorothiazide tab Levonorgestrel-Ethinyl Estradiol 20-25 mg ...... 31 (Continuous) Tab 90-20 mcg ...... 64 LITHIUM ...... 53 levonorgestrel-ethinyl estradiol- lithium carbonate ...... 54 ferrous bisglycinate LO LOESTRIN TAB 1-10-10 ...... 64 see BALCOLTRA TAB 0.1-20 ...... 61 lodoxamide tromethamine levonorg-eth est tab 0.1- see ALOMIDE ...... 90 0.02mg(84) & eth est tab lomustine 0.01mg(7) ...... 63 see GLEOSTINE ...... 23 Levonorg-Eth Est Tab 0.15-0.03mg(84) loperamide hcl ...... 75 & Eth Est Tab 0.01mg(7) ...... 63 lopinavir-ritonavir LEVORA 0.15/30-28 see KALETRA TAB 100-25MG ...... 17 124

see KALETRA TAB 200-50MG ...... 17 see Levonorgestrel & Ethinyl Estradiol lopinavir-ritonavir soln 400-100 Tab 0.1 mg-20 mcg ...... 63 mg/5ml (80-20 mg/ml) ...... 17 LYNPARZA ...... 25 lopinavir-ritonavir tab 100-25 mg LYSODREN ...... 26 ...... 18 M lopinavir-ritonavir tab 200-50 mg macitentan ...... 18 see OPSUMIT ...... 41 lorazepam ...... 42 mafenide acetate LORBRENA ...... 28 see SULFAMYLON ...... 98 lorlatinib magnesium sulfate ...... 86 see LORBRENA ...... 28 magnesium sulfate in dextrose 5% LORYNA iv soln 1 gm/100ml ...... 86 see Drospirenone-Ethinyl Estradiol malathion ...... 101 Tab 3-0.02 mg ...... 62 maprotiline hcl ...... 46 losartan potassium ...... 34 maraviroc losartan potassium & see SELZENTRY ...... 16 hydrochlorothiazide tab 100-12.5 MARLISSA mg ...... 33 see Levonorgestrel & Ethinyl Estradiol losartan potassium & Tab 0.15 mg-30 mcg...... 64 hydrochlorothiazide tab 100-25 MARPLAN ...... 46 mg ...... 33 MATULANE ...... 29 losartan potassium & MATZIM LA hydrochlorothiazide tab 50-12.5 see Diltiazem Hcl Coated Beads ..... 38 mg ...... 33 MAXIDEX ...... 90 loteprednol etabonate ...... 90 measles, mumps & rubella virus lovastatin ...... 36 vaccines LOW-OGESTREL see M-M-R II INJ ...... 85 see Norgestrel & Ethinyl Estradiol Tab measles-mumps-rubella-varicella 0.3 mg-30 mcg ...... 66 virus vaccines loxapine succinate ...... 50 see PROQUAD INJ ...... 85 lubiprostone ...... 74 mebendazole LUDENT see EMVERM ...... 12 see Sodium Fluoride ...... 87 mecasermin lumacaftor-ivacaftor see INCRELEX ...... 70 see ORKAMBI GRA 100-125 ...... 95 meclizine hcl ...... 72 see ORKAMBI GRA 150-188 ...... 95 meclofenamate sodium ...... 2 see ORKAMBI TAB 100-125 ...... 95 MEDROL ...... 69 see ORKAMBI TAB 200-125 ...... 95 medroxyprogesterone acetate .... 71 LUMIGAN ...... 91 medroxyprogesterone acetate LUPANETA KIT 11.25-5 ...... 71 (antineoplastic) LUPANETA KIT 3.75-5 ...... 70 see DEPO-PROVERA ...... 25 LUPRON DEPOT-PED (1-MONTH ...... 26 medroxyprogesterone acetate LUPRON DEPOT-PED (3-MONTH ...... 26 (contraceptive) ...... 64 lurasidone hcl see DEPO-SUBQ PROVERA 104 ..... 61 see LATUDA ...... 49 mefenamic acid ...... 2 LUTERA mefloquine hcl ...... 14 megestrol acetate ...... 26 125 megestrol acetate (appetite)...... 26 methocarbamol ...... 55 MEKINIST ...... 28 methotrexate sodium ...... 24, 82 meloxicam ...... 2 methoxsalen rapid ...... 99 melphalan ...... 23 methoxy polyethylene glycol- melphalan hcl ...... 23 epoetin beta memantine hcl...... 44 see MIRCERA ...... 79 see NAMENDA XR CAP TITRATIO ... 44 methscopolamine bromide ...... 72 memantine hcl tab 28 x 5 mg & 21 methsuximide x 10 mg titration pack ...... 44 see CELONTIN ...... 42 MENACTRA INJ ...... 85 methyldopa ...... 40 MENEST ...... 68 methylphenidate hcl ...... 51, 52 meningococcal (a,c,y&w-135) methylprednisolone ...... 69 oligosaccharide conjugate vac see MEDROL ...... 69 see MENVEO INJ ...... 85 methylprednisolone acetate ...... 69 meningococcal (a,c,y&w-135) see DEPO-MEDROL ...... 68 polysaccharide conjugate vaccine methylprednisolone sod succ ...... 69 see MENACTRA INJ ...... 85 see SOLU-MEDROL ...... 69 meningococcal group b vaccine methyltestosterone ...... 57 (recombinant) metoclopramide hcl ...... 72 see TRUMENBA INJ ...... 85 metolazone ...... 40 meningococcal vac group b metoprolol & hydrochlorothiazide (recombant omv adjuvanted) tab 100-25 mg ...... 37 see BEXSERO INJ ...... 83 metoprolol & hydrochlorothiazide MENTAX ...... 98 tab 100-50 mg ...... 37 MENVEO INJ ...... 85 metoprolol & hydrochlorothiazide mepolizumab tab 50-25 mg ...... 37 see NUCALA ...... 94 metoprolol succinate ...... 37 meprobamate ...... 42 metoprolol tartrate ...... 37 mercaptopurine ...... 24 metreleptin meropenem ...... 12 see MYALEPT ...... 71 mesalamine ...... 74 metronidazole ...... 12 mesna ...... 30 metronidazole (topical) ...... 101 see MESNEX ...... 30 Metronidazole (Topical) ...... 101 MESNEX ...... 30 metronidazole in nacl 0.79% iv metaproterenol sulfate ...... 94 soln 500 mg/100ml ...... 12 metaxalone ...... 55 metronidazole vaginal ...... 78 metformin hcl ...... 57 Metronidazole Vaginal ...... 78 methadone hcl ...... 5, 6 mexiletine hcl ...... 35 Methadone Hcl ...... 6 MIBELAS 24 FE METHADONE HYDROCHLORIDE I see Norethindrone Ace-Eth Estradiol- see Methadone Hcl ...... 6 Fe Chew Tab 1 mg-20 mcg (24) . 65 METHADOSE miconazole (mouth-throat) see Methadone Hcl ...... 6 see ORAVIG ...... 102 methamphetamine hcl ...... 51 MICONAZOLE 3 methazolamide ...... 40 see Miconazole Nitrate Vaginal ...... 78 methenamine hippurate ...... 12 Miconazole Nitrate Vaginal ...... 78 methimazole ...... 71 MICROGESTIN 1.5/30 126

see Norethindrone Ace & Ethinyl N Estradiol Tab 1.5 mg-30 mcg ..... 65 nabumetone ...... 2 midodrine hcl ...... 40 nadolol ...... 37 midostaurin nafarelin acetate see RYDAPT ...... 25 see SYNAREL ...... 67 miglitol ...... 57 NAFRINSE MIMVEY see Sodium Fluoride ...... 87 see Estradiol & Norethindrone NAFRINSE DROPS Acetate Tab 1-0.5 mg ...... 68 see Sodium Fluoride ...... 87 MINITRAN naftifine hcl ...... 98 see Nitroglycerin ...... 41 nalbuphine hcl ...... 7 minocycline hcl ...... 22 naloxegol oxalate minoxidil ...... 40 see MOVANTIK ...... 75 MIRCERA ...... 79 naloxone hcl ...... 56 MIRENA ...... 64 see NARCAN ...... 56 mirtazapine ...... 46 naltrexone MIRVASO ...... 101 see VIVITROL ...... 56 misoprostol ...... 75 naltrexone hcl ...... 56 mitomycin ...... 23 NAMENDA XR CAP TITRATIO ...... 44 mitotane naproxen ...... 2 see LYSODREN ...... 26 naratriptan hcl ...... 53 mitoxantrone hcl ...... 29 NARCAN ...... 56 M-M-R II INJ ...... 85 NATACYN ...... 90 modafinil ...... 56 natalizumab moexipril hcl ...... 32 see TYSABRI ...... 55 mometasone furoate ...... 100 natamycin MONOJECT SODIUM CHLORIDE see NATACYN ...... 90 see Sodium Chloride Flush ...... 87 NATAZIA TAB ...... 64 MONO-LINYAH nateglinide ...... 59 see Norgestimate & Ethinyl Estradiol nebivolol hcl Tab 0.25 mg-35 mcg ...... 66 see BYSTOLIC ...... 37 montelukast sodium ...... 94 NECON 0.5/35-28 MORGIDOX 1X100MG see Norethindrone & Ethinyl Estradiol see Doxycycline Hyclate ...... 22 Tab 0.5 mg-35 mcg ...... 64 morphine sulfate ...... 6, 7 nedocromil sodium (ophth) morphine sulfate beads ...... 7 see ALOCRIL ...... 90 MOTOFEN TAB 1-0.025 ...... 75 nefazodone hcl ...... 46 MOVANTIK ...... 75 nelfinavir mesylate moxifloxacin hcl ...... 20 see VIRACEPT ...... 16 moxifloxacin hcl (ophth) ...... 89 neomycin sulfate ...... 11 MULTAQ ...... 35 neomycin-colistin-hc-thonzonium mupirocin ...... 98 see CORTISPORIN SUS -TC OTIC 102 MYALEPT ...... 71 neomycin-polymy-gramicid op sol mycophenolate mofetil ...... 83 1.75-10000-0.025mg-unt-mg/ml mycophenolate mofetil hcl ...... 83 ...... 90 mycophenolate sodium ...... 83

127 neomycin-polymyxin- see ZEJULA ...... 25 dexamethasone ophth oint 0.1% nisoldipine ...... 39 ...... 89 nitazoxanide ...... 12 neomycin-polymyxin- see ALINIA ...... 12 dexamethasone ophth susp 0.1% nitisinone ...... 67 ...... 89 see ORFADIN ...... 67 neomycin-polymyxin-hc ophth susp NITRO-BID ...... 41 ...... 89 NITRO-DUR ...... 41 neomycin-polymyxin-hc otic soln nitrofurantoin ...... 12 1% ...... 102 nitrofurantoin macrocrystal ...... 12 neomycin-polymyxin-hc otic susp nitrofurantoin monohyd macro ... 12 3.5 mg/ml-10000 unit/ml-1% 102 nitroglycerin ...... 41 neostigmine methylsulfate ...... 22 see NITRO-BID ...... 41 nepafenac see NITRO-DUR ...... 41 see ILEVRO ...... 90 Nitroglycerin ...... 41 see NEVANAC ...... 90 nitroglycerin (intra-anal) netupitant-palonosetron see RECTIV ...... 101 see AKYNZEO CAP 300-0.5 ...... 72 NIVESTYM ...... 79 NEULASTA ...... 79 nizatidine ...... 73 NEULASTA ONPRO KIT ...... 79 nonoxynol-9 NEUPRO ...... 48 see ENCARE ...... 77 NEVANAC ...... 90 see OPTIONS GYNOL II VAGINAL... 77 nevirapine ...... 15 see SHUR-SEAL ...... 77 NEXAVAR ...... 28 see TODAY SPONGE ...... 77 NEXIUM ...... 76 see VCF VAGINAL CONTRACEPTIVE77 NEXPLANON ...... 64 NORA-BE NEXTSTELLIS TAB 3-14.2MG ...... 64 see Norethindrone (Contraceptive) 65 niacin (antihyperlipidemic) ...... 36 Norelgestromin-Ethinyl Estradiol Td nicardipine hcl ...... 39 Ptwk 150-35 mcg/24hr ...... 64 nicotine ...... 56 Norethindrone & Ethinyl Estradiol Tab see NICOTROL INHALER ...... 56 0.4 mg-35 mcg ...... 64 see NICOTROL NS ...... 56 Norethindrone & Ethinyl Estradiol Tab Nicotine ...... 56 0.5 mg-35 mcg ...... 64 nicotine polacrilex ...... 56 Norethindrone & Ethinyl Estradiol Tab 1 Nicotine Polacrilex ...... 56 mg-35 mcg ...... 64, 65 NICOTINE STEP 3 norethindrone & ethinyl estradiol- see Nicotine ...... 56 fe chew tab 0.4 mg-35 mcg ...... 65 NICOTROL INHALER ...... 56 norethindrone & ethinyl estradiol- NICOTROL NS ...... 56 fe chew tab 0.8 mg-25 mcg ...... 65 nifedipine ...... 39 norethindrone (contraceptive) .... 65 NIKKI Norethindrone (Contraceptive) ...... 65 see Drospirenone-Ethinyl Estradiol norethindrone ace & ethinyl Tab 3-0.02 mg ...... 62 estradiol tab 1 mg-20 mcg ...... 65 nilutamide ...... 26 Norethindrone Ace & Ethinyl Estradiol nimodipine ...... 39 Tab 1 mg-20 mcg ...... 65 NIPENT ...... 24 Norethindrone Ace & Ethinyl Estradiol niraparib tosylate Tab 1.5 mg-30 mcg ...... 65 128

Norethindrone Ace & Ethinyl Estradiol- see Norethindrone & Ethinyl Estradiol Fe Tab 1 mg-20 mcg ...... 65 Tab 1 mg-35 mcg ...... 65 Norethindrone Ace & Ethinyl Estradiol- NORTREL 7/7/7 Fe Tab 1.5 mg-30 mcg ...... 65 see Norethindrone-Eth Estradiol Tab Norethindrone Ace-Eth Estradiol-Fe 0.5-35/0.75-35/1-35 mg-Mcg .... 66 Chew Tab 1 mg-20 mcg (24) ...... 65 nortriptyline hcl ...... 46, 47 norethindrone ace-ethinyl NORVIR ...... 15 estradiol-fe cap 1 mg-20 mcg NOVOFINE PEN NEEDLES ...... 86 (24) ...... 65 NOVOLIN INJ 70/30 ...... 59 Norethindrone Ace-Ethinyl Estradiol-Fe NOVOLIN INJ 70/30 FP ...... 59 Cap 1 mg-20 mcg (24) ...... 65 NOVOLIN N ...... 59 Norethindrone Ace-Ethinyl Estradiol-Fe NOVOLIN N FLEXPEN ...... 59 Tab 1 mg-20 mcg (24) ...... 65 NOVOLIN R ...... 59 norethindrone acetate ...... 71 NOVOLIN R FLEXPEN ...... 59 norethindrone acetate-ethinyl NOVOLOG ...... 59 estradiol tab 0.5 mg-2.5 mcg .... 68 NOVOLOG FLEXPEN ...... 59 Norethindrone Acetate-Ethinyl Estradiol NOVOLOG MIX INJ 70/30 ...... 59 Tab 1 mg-5 mcg ...... 68 NOVOLOG MIX INJ FLEXPEN ...... 59 norethindrone acetate-ethinyl NOVOLOG PENFILL ...... 59 estradiol-fe fum (biphasic) NOXAFIL ...... 13 see LO LOESTRIN TAB 1-10-10 ..... 64 NUBEQA ...... 26 Norethindrone Ac-Ethinyl Estrad-Fe Tab NUCALA ...... 94 1-20/1-30/1-35 mg-Mcg ...... 65 NUCYNTA ...... 7 Norethindrone-Eth Estradiol Tab 0.5- NUCYNTA ER ...... 7, 8 35/0.75-35/1-35 mg-Mcg ...... 66 NUEDEXTA CAP 20-10MG ...... 54 Norethindrone-Eth Estradiol Tab 0.5- NULEV 35/1-35/0.5-35 mg-Mcg ...... 66 see Hyoscyamine Sulfate ...... 72 norgestimate & ethinyl estradiol NYAMYC tab 0.25 mg-35 mcg ...... 66 see Nystatin (Topical) ...... 98 Norgestimate & Ethinyl Estradiol Tab nystatin ...... 13 0.25 mg-35 mcg ...... 66 see BIO-STATIN ...... 13 norgestimate-eth estrad tab 0.18- nystatin (mouth-throat) ...... 102 25/0.215-25/0.25-25 mg-mcg . 66 nystatin (topical) ...... 98 norgestimate-eth estrad tab 0.18- Nystatin (Topical) ...... 98 35/0.215-35/0.25-35 mg-mcg . 66 nystatin-triamcinolone cream Norgestimate-Eth Estrad Tab 0.18- 100000-0.1 unit/gm-% ...... 99 35/0.215-35/0.25-35 mg-Mcg ...... 66 nystatin-triamcinolone oint Norgestrel & Ethinyl Estradiol Tab 0.3 100000-0.1 unit/gm-% ...... 99 mg-30 mcg ...... 66 NYSTOP Norgestrel & Ethinyl Estradiol Tab 0.5 see Nystatin (Topical) ...... 98 mg-50 mcg ...... 66 O NORPACE CR ...... 35 obinutuzumab NORTREL 0.5/35 (28) see GAZYVA ...... 24 see Norethindrone & Ethinyl Estradiol OCELLA Tab 0.5 mg-35 mcg ...... 64 see Drospirenone-Ethinyl Estradiol NORTREL 1/35 Tab 3-0.03 mg ...... 62 octreotide acetate ...... 70 129

ODEFSEY TAB ...... 18 omeprazole ...... 76 ODOMZO ...... 29 OMNARIS ...... 96 ofloxacin ...... 20 ONCASPAR ...... 29 ofloxacin (ophth) ...... 90 ondansetron ...... 72 ofloxacin (otic) ...... 102 ondansetron hcl ...... 73 OGESTREL OPSUMIT ...... 41 see Norgestrel & Ethinyl Estradiol Tab OPTIONS GYNOL II VAGINAL ...... 77 0.5 mg-50 mcg ...... 66 ORALONE DENTAL PASTE olanzapine ...... 50 see Triamcinolone Acetonide (Mouth) olaparib ...... 102 see LYNPARZA ...... 25 ORAVIG ...... 102 olmesartan medoxomil ...... 34 ORENITRAM...... 41 olmesartan medoxomil- ORFADIN...... 67 hydrochlorothiazide tab 20-12.5 ORILISSA ...... 67 mg ...... 33 ORKAMBI GRA 100-125 ...... 95 olmesartan medoxomil- ORKAMBI GRA 150-188 ...... 95 hydrochlorothiazide tab 40-12.5 ORKAMBI TAB 100-125 ...... 95 mg ...... 33 ORKAMBI TAB 200-125 ...... 95 olmesartan medoxomil- orphenadrine citrate ...... 55 hydrochlorothiazide tab 40-25 ORSYTHIA mg ...... 33 see Levonorgestrel & Ethinyl Estradiol olmesartan-amlodipine- Tab 0.1 mg-20 mcg ...... 63 hydrochlorothiazide tab 20-5- OSCIMIN 12.5 mg ...... 33 see Hyoscyamine Sulfate ...... 72 olmesartan-amlodipine- oseltamivir phosphate ...... 18, 19 hydrochlorothiazide tab 40-10- OSMOPREP TAB 1.5GM ...... 74 12.5 mg ...... 33 ospemifene olmesartan-amlodipine- see OSPHENA ...... 70 hydrochlorothiazide tab 40-10-25 OSPHENA ...... 70 mg ...... 33 OTEZLA...... 82 olmesartan-amlodipine- OTEZLA TAB 10/20/30 ...... 82 hydrochlorothiazide tab 40-5- oxaliplatin ...... 29 12.5 mg ...... 33 oxaprozin ...... 3 olmesartan-amlodipine- oxazepam ...... 42 hydrochlorothiazide tab 40-5-25 oxcarbazepine ...... 43 mg ...... 33 oxiconazole nitrate ...... 99 olodaterol hcl oxybutynin chloride...... 77 see STRIVERDI RESPIMAT ...... 94 oxycodone olopatadine hcl ...... 91 see XTAMPZA ER ...... 10 see PAZEO ...... 91 oxycodone hcl ...... 8 olopatadine hcl (nasal) ...... 93 oxycodone w/ acetaminophen tab olsalazine sodium 10-325 mg ...... 9 see DIPENTUM ...... 73 Oxycodone W/ Acetaminophen Tab 10- omalizumab 325 mg ...... 9 see XOLAIR ...... 94 oxycodone w/ acetaminophen tab omega-3-acid ethyl esters cap 1 2.5-325 mg ...... 9 gm ...... 36 130

Oxycodone W/ Acetaminophen Tab see Carboplatin ...... 29 2.5-325 mg ...... 9 paricalcitol ...... 88 oxycodone w/ acetaminophen tab paromomycin sulfate ...... 11 5-325 mg ...... 9 paroxetine hcl ...... 47 Oxycodone W/ Acetaminophen Tab 5- PASER ...... 18 325 mg ...... 9 pasireotide diaspartate oxycodone w/ acetaminophen tab see SIGNIFOR ...... 70 7.5-325 mg ...... 9 PAZEO ...... 91 Oxycodone W/ Acetaminophen Tab pazopanib hcl 7.5-325 mg ...... 9 see VOTRIENT ...... 28 oxycodone-aspirin tab 4.8355-325 PEDIARIX INJ 0.5ML ...... 85 mg ...... 9 PEDIATRIC RESPIRATORY MASK ...... 86 oxycodone-ibuprofen tab 5-400 mg PEDVAX HIB ...... 85 ...... 10 peg 3350-kcl-na bicarb-nacl-na oxymorphone hcl ...... 10 sulfate for soln 236 gm ...... 74 OZEMPIC ...... 58 Peg 3350-Kcl-Na Bicarb-Nacl-Na P Sulfate For Soln 236 gm ...... 74 PACERONE Peg 3350-Kcl-Na Bicarb-Nacl-Na see Amiodarone Hcl ...... 34 Sulfate For Soln 240 gm ...... 74 paclitaxel...... 24 peg 3350-kcl-nacl-na sulfate-na paclitaxel protein-bound particles ascorbate-ascorbic acid see ABRAXANE INJ 100MG ...... 24 see PLENVU SOL ...... 75 palbociclib peg 3350-kcl-nacl-na sulfate-na see IBRANCE ...... 24 ascorbate-c for soln 100 gm ..... 74 paliperidone ...... 50 peg 3350-kcl-sod bicarb-nacl for pamidronate disodium ...... 61 soln 420 gm ...... 74 pancrelipase (lipase-protease- Peg 3350-Kcl-Sod Bicarb-Nacl For Soln amylase) 420 gm ...... 74 see CREON CAP 12000UNT ...... 75 peg 3350-kcl-sod bicarb-sod see CREON CAP 24000UNT ...... 75 chloride-sod sulfate see CREON CAP 3000UNIT ...... 75 see GOLYTELY SOL ...... 74 see CREON CAP 36000UNT ...... 75 PEGANONE ...... 43 see CREON CAP 6000UNIT ...... 75 pegaspargase see VIOKACE TAB 10440 ...... 75 see ONCASPAR ...... 29 see VIOKACE TAB 20880 ...... 76 PEGASYS...... 20 see ZENPEP CAP 10000UNT ...... 76 pegfilgrastim see ZENPEP CAP 15000UNT ...... 76 see NEULASTA ...... 79 see ZENPEP CAP 20000UNT ...... 76 see NEULASTA ONPRO KIT ...... 79 see ZENPEP CAP 25000 ...... 76 pegfilgrastim-cbqv see ZENPEP CAP 3000UNIT ...... 76 see UDENYCA ...... 79 see ZENPEP CAP 40000 ...... 76 peginterferon alfa-2a see ZENPEP CAP 5000UNIT ...... 76 see PEGASYS ...... 20 panobinostat lactate peginterferon beta-1a see FARYDAK ...... 24 see PLEGRIDY ...... 54 pantoprazole sodium ...... 76 see PLEGRIDY INJ STARTER ...... 54 PARAGARD IUD T380A ...... 66 see PLEGRIDY PEN INJ STARTER ... 55 PARAPLATIN pegvisomant 131

see SOMAVERT ...... 70 pioglitazone hcl-glimepiride tab pembrolizumab 30-4 mg ...... 59 see KEYTRUDA ...... 24 pioglitazone hcl-metformin hcl tab pemetrexed disodium 15-500 mg ...... 59 see ALIMTA ...... 23 pioglitazone hcl-metformin hcl tab penciclovir 15-850 mg ...... 59 see DENAVIR ...... 101 piperacillin sod-tazobactam na for penicillamine ...... 61 inj 3.375 gm (3-0.375 gm) ...... 21 penicillin g potassium ...... 21 piperacillin sod-tazobactam sod for Penicillin G Potassium ...... 21 inj 2.25 gm (2-0.25 gm) ...... 21 penicillin g sodium ...... 21 piperacillin sod-tazobactam sod for penicillin v potassium ...... 21 inj 40.5 gm (36-4.5 gm) ...... 22 PENTACEL INJ ...... 85 pirfenidone pentamidine isethionate ...... 12 see ESBRIET ...... 95 pentosan polysulfate sodium PIRMELLA 1/35 see ELMIRON ...... 77 see Norethindrone & Ethinyl Estradiol pentostatin Tab 1 mg-35 mcg ...... 65 see NIPENT ...... 24 PIRMELLA 7/7/7 pentoxifylline ...... 80 see Norethindrone-Eth Estradiol Tab perampanel 0.5-35/0.75-35/1-35 mg-Mcg .... 66 see FYCOMPA ...... 43 piroxicam ...... 3 PERFOROMIST ...... 94 PLEGRIDY ...... 54 perindopril erbumine ...... 32 PLEGRIDY INJ STARTER ...... 54 permethrin ...... 101 PLEGRIDY PEN INJ STARTER ...... 55 perphenazine ...... 50 PLENVU SOL ...... 75 PFIZERPEN pneumococcal 13-valent conjugate see Penicillin G Potassium ...... 21 vaccine phenelzine sulfate ...... 47 see PREVNAR 13 INJ ...... 85 phenobarbital ...... 43 pneumococcal vac polyvalent phenoxybenzamine hcl ...... 40 see PNEUMOVAX 23/1 DOSE ...... 85 phenylephrine hcl (mydriatic) ..... 92 PNEUMOVAX 23/1 DOSE ...... 85 phenytoin ...... 43 podofilox ...... 101 phenytoin sodium ...... 43 see CONDYLOX ...... 101 phenytoin sodium extended ...... 43 poliovirus vaccine, ipv see DILANTIN ...... 42 see IPOL INJ INACTIVE ...... 84 PHOSLYRA ...... 70 POLYCIN PHOSPHOLINE IODIDE ...... 91 see Bacitracin-Polymyxin B Ophth PHOTOFRIN ...... 29 Oint ...... 89 phytonadione ...... 88 polymyxin b sulfate ...... 12 PICATO ...... 98 polymyxin b-trimethoprim ophth pilocarpine hcl ...... 91 soln 10000 unit/ml-0.1% ...... 90 pilocarpine hcl (oral) ...... 102 pomalidomide pimozide ...... 54 see POMALYST ...... 82 pindolol ...... 37 POMALYST ...... 82 pioglitazone hcl ...... 59 ponatinib hcl pioglitazone hcl-glimepiride tab see ICLUSIG ...... 27 30-2 mg ...... 59 132

see PHOTOFRIN ...... 29 see CITRANATAL MIS 90 DHA ...... 88 PORTIA-28 see CITRANATAL PAK ASSURE ...... 88 see Levonorgestrel & Ethinyl Estradiol see CITRANATAL PAK DHA ...... 88 Tab 0.15 mg-30 mcg ...... 64 prenatal w/o vit a w/ fe carbonyl- posaconazole ...... 13 fe gluconate-fa & vit b6 see NOXAFIL ...... 13 see CITRANATAL MIS B-CALM ...... 88 Potassium Bicarbonate ...... 87 prenatal w/o vit a w/ fe fumarate- potassium chloride ...... 87 fe carbonyl-dss-fa-dha Potassium Chloride ...... 87 see CITRANATAL CAP HARMONY.... 88 potassium chloride prenatal w/o vit a w/ fe fumarate- microencapsulated crystals er .. 87 fe carbonyl-fa-dha Potassium Chloride Microencapsulated see CITRANATAL CAP MEDLEY...... 88 Crystals Er ...... 87 prenatal without vit a w/ fe potassium citrate (alkalinizer) .... 77 carbonyl-fe gluc-docusate-fa PRADAXA ...... 78 see CITRANATAL TAB RX ...... 88 PRALUENT ...... 36 PREPOPIK PAK ...... 75 pramipexole dihydrochloride ...... 49 PREVALITE pramlintide acetate see Cholestyramine Light ...... 35 see SYMLINPEN 120 ...... 57 PREVIFEM see SYMLINPEN 60 ...... 57 see Norgestimate & Ethinyl Estradiol prasterone vaginal Tab 0.25 mg-35 mcg...... 66 see INTRAROSA ...... 56 PREVNAR 13 INJ ...... 85 prasugrel hcl ...... 80 PREZCOBIX TAB 800-150 ...... 18 pravastatin sodium...... 36 PREZISTA ...... 15 praziquantel ...... 13 PRIFTIN ...... 18 prazosin hcl ...... 32 primaquine phosphate ...... 14 PRED MILD ...... 90 primidone ...... 43 prednicarbate ...... 100 PRIMSOL ...... 13 prednisolone ...... 69 probenecid ...... 2 prednisolone acetate (ophth) ...... 90 procainamide hcl ...... 35 see PRED MILD ...... 90 procarbazine hcl PREDNISOLONE SODIUM PHOSP ...... 90 see MATULANE ...... 29 prednisolone sodium phosphate .. 69 prochlorperazine ...... 73 prednisone ...... 69 Prochlorperazine ...... 73 see PREDNISONE INTENSOL ...... 69 prochlorperazine maleate ...... 73 PREDNISONE INTENSOL ...... 69 PROCTO-PAK pregabalin ...... 43 see Hydrocortisone (Rectal) ...... 76 PREMARIN ...... 68 PROCTOZONE-HC PRENATABS RX see Hydrocortisone (Rectal) ...... 76 see *prenatal Vit W/ Iron Carbonyl- progesterone ...... 71 Fa Tab 29-1 mg*** ...... 89 progesterone (vaginal) prenatal vit w/ docusate-fe see CRINONE ...... 70 carbonyl-fe gluconate-folic acid PROGRAF ...... 83 see CITRANATAL TAB BLOOM ...... 88 PROLASTIN-C ...... 95 prenatal w/o vit a w/ fe carbonyl- PROLIA ...... 70 fe gluconate-dss-fa-dha PROMACTA ...... 79 see CITRANATAL MIS ...... 88 133 promethazine & phenylephrine ranitidine hcl ...... 73 syrup 6.25-5 mg/5ml ...... 94 ranolazine ...... 40 promethazine hcl ...... 73 rasagiline mesylate ...... 49 Promethazine Hcl ...... 73 REBIF ...... 55 promethazine w/ codeine syrup REBIF REBIDO INJ TITRATN ...... 55 6.25-10 mg/5ml ...... 94 REBIF REBIDOSE ...... 55 promethazine-dm syrup 6.25-15 REBIF TITRTN INJ PACK ...... 55 mg/5ml ...... 94 RECLIPSEN promethazine-phenylephrine- see Desogestrel & Ethinyl Estradiol codeine syrup 6.25-5-10 mg/5ml Tab 0.15 mg-30 mcg...... 62 ...... 94 RECOMBIVAX HB ...... 85 PROMETHEGAN RECTIV ...... 101 see Promethazine Hcl ...... 73 regorafenib propafenone hcl ...... 35 see STIVARGA ...... 28 propranolol & hydrochlorothiazide REGRANEX ...... 102 tab 40-25 mg ...... 37 RELENZA DISKHALER ...... 19 propranolol & hydrochlorothiazide REMODULIN ...... 41 tab 80-25 mg ...... 37 repaglinide ...... 60 propranolol hcl ...... 37 RESTASIS ...... 92 propylthiouracil ...... 71 RETACRIT ...... 79 PROQUAD INJ ...... 85 RETROVIR IV INFUSION ...... 15 protriptyline hcl ...... 47 REVLIMID ...... 82 pseudoephed-bromphen-dm syrup REXULTI ...... 50 30-2-10 mg/5ml ...... 94 REYATAZ ...... 16 pyrazinamide...... 18 ribavirin ...... 19 pyridostigmine bromide ...... 54 ribavirin (hepatitis c) ...... 20 pyrimethamine ...... 13 ribociclib succinate Q see KISQALI ...... 24, 25 QUADRAMET ...... 29 rifabutin ...... 18 quetiapine fumarate ...... 50 RIFAMATE CAP ...... 18 quinapril hcl ...... 32 rifampin ...... 18 quinapril-hydrochlorothiazide tab rifapentine 10-12.5 mg ...... 31 see PRIFTIN ...... 18 quinapril-hydrochlorothiazide tab RIFATER TAB ...... 18 20-12.5 mg ...... 31 rifaximin quinapril-hydrochlorothiazide tab see XIFAXAN ...... 13 20-25 mg ...... 31 rilonacept quinine sulfate ...... 14 see ARCALYST ...... 82 QVAR REDIHALER...... 96 rilpivirine hcl R see EDURANT ...... 14 rabeprazole sodium ...... 76 riluzole ...... 54 raloxifene hcl ...... 70 rimantadine hydrochloride ...... 19 raltegravir potassium RINVOQ ...... 81 see ISENTRESS ...... 15 riociguat see ISENTRESS HD ...... 15 see ADEMPAS ...... 41 ramelteon ...... 52 risankizumab-rzaa ramipril ...... 32 see SKYRIZI ...... 81 134

see SKYRIZI PEN ...... 81 SANDIMMUNE ...... 83 risdiplam sapropterin dihydrochloride ...... 67 see EVRYSDI ...... 53 saquinavir mesylate risedronate sodium ...... 61 see INVIRASE ...... 15 risperidone ...... 50 sarilumab ritonavir ...... 16 see KEVZARA ...... 81 see NORVIR ...... 15 scopolamine ...... 73 rivaroxaban secukinumab see XARELTO ...... 79 see COSENTYX ...... 99 see XARELTO STAR TAB 15/20MG . 79 see COSENTYX SENSOREADY PEN . 99 rivastigmine ...... 44 -ethinyl rivastigmine tartrate ...... 44 estradiol RIVELSA see ANNOVERA MIS ...... 61 see Levonor-Eth Est Tab 0.15- selegiline 0.02/0.025/0.03 mg ð Est 0.01 see EMSAM ...... 46 mg ...... 63 selegiline hcl ...... 49 rizatriptan benzoate ...... 53 selenium sulfide ...... 99 roflumilast selexipag see DALIRESP ...... 95 see UPTRAVI ...... 41 rolapitant hcl see UPTRAVI TAB 200/800 ...... 41 see VARUBI ...... 73 SELZENTRY ...... 16 ropinirole hydrochloride ...... 49 semaglutide ROSADAN see OZEMPIC ...... 58 see Metronidazole (Topical) ...... 101 sertaconazole nitrate rosuvastatin calcium ...... 36 see ERTACZO ...... 98 ROTARIX SUS ...... 85 sertraline hcl ...... 47 ROTATEQ SOL ...... 85 sevelamer carbonate ...... 70 rotavirus vaccine, live oral SHINGRIX ...... 85 see ROTARIX SUS ...... 85 SHUR-SEAL ...... 77 rotavirus vaccine, live oral SIGNIFOR ...... 70 pentavalent sildenafil citrate (pulmonary see ROTATEQ SOL ...... 85 hypertension) ...... 41 rotigotine silodosin ...... 77 see NEUPRO ...... 48 silver sulfadiazine ...... 98 ruxolitinib phosphate Silver Sulfadiazine ...... 98 see JAKAFI ...... 27 SIMBRINZA SUS 1-0.2% ...... 91 RYDAPT ...... 25 SIMPONI ...... 81 S SIMPONI ARIA ...... 81 sacrosidase simvastatin ...... 36 see SUCRAID ...... 75 sirolimus ...... 83 sacubitril-valsartan SIRTURO ...... 18 see ENTRESTO TAB 24-26MG ...... 40 sitagliptin phosphate see ENTRESTO TAB 49-51MG ...... 40 see JANUVIA ...... 57 see ENTRESTO TAB 97-103MG ...... 40 sitagliptin-metformin hcl samarium sm 153 lexidronam see JANUMET TAB 50-1000 ...... 57 see QUADRAMET ...... 29 see JANUMET TAB 50-500MG ...... 57 SANCUSO ...... 73 see JANUMET XR TAB 100-1000 .... 58 135

see JANUMET XR TAB 50-1000 ...... 58 see ODOMZO ...... 29 see JANUMET XR TAB 50-500MG ... 57 sorafenib tosylate SKYLA ...... 66 see NEXAVAR ...... 28 SKYRIZI ...... 81 SORINE SKYRIZI PEN ...... 81 see Sotalol Hcl ...... 35 SLYND ...... 66 sotalol hcl...... 35 SM NICOTINE TRANSDERMAL S Sotalol Hcl ...... 35 see Nicotine ...... 56 sotalol hcl (afib/afl) ...... 35 sodium chloride ...... 87 SOVALDI ...... 20 sodium chloride (inhalant) ...... 95 spacer/aerosol-holding chamber Sodium Chloride Flush ...... 87 supplies - masks sodium fluoride ...... 87 see PEDIATRIC RESPIRATORY MASK see FLUORABON ...... 86 ...... 86 Sodium Fluoride ...... 87 spacer/aerosol-holding chambers sodium phenylbutyrate ...... 67 see ADULT RESPIRATORY MASK .... 86 sodium phosphate monobasic- spinosad ...... 101 sodium phosphate dibasic SPIRIVA HANDIHALER ...... 92 see OSMOPREP TAB 1.5GM ...... 74 SPIRIVA RESPIMAT...... 92 sodium picosulfate-magnesium spironolactone ...... 40 oxide-anhydrous citric acid spironolactone & see CLENPIQ SOL ...... 74 hydrochlorothiazide see PREPOPIK PAK ...... 75 see ALDACTAZIDE TAB 50/50 ...... 39 sodium polystyrene sulfonate ..... 61 spironolactone & Sodium Polystyrene Sulfonate ...... 61 hydrochlorothiazide tab 25-25 sodium sulfate-magnesium sulfate- mg ...... 40 potassium chloride SPRINTEC 28 see SUTAB TAB ...... 75 see Norgestimate & Ethinyl Estradiol sodium sulfate-potassium sulfate- Tab 0.25 mg-35 mcg...... 66 magnesium sulfate SPRYCEL ...... 28 see SUPREP BOWEL SOL PREP KIT . 75 SPS sofosbuvir see Sodium Polystyrene Sulfonate . 61 see SOVALDI ...... 20 SRONYX sofosbuvir-velpatasvir see Levonorgestrel & Ethinyl Estradiol see EPCLUSA TAB 200-50MG ...... 20 Tab 0.1 mg-20 mcg ...... 63 see EPCLUSA TAB 400-100 ...... 20 SSD sofosbuvir-velpatasvir-voxilaprevir see Silver Sulfadiazine ...... 98 see VOSEVI TAB ...... 21 stavudine ...... 16 solifenacin succinate ...... 77 STELARA ...... 81 SOLIQUA INJ 100/33 ...... 58 STIVARGA ...... 28 SOLU-CORTEF ...... 69 STRIVERDI RESPIMAT ...... 94 SOLU-MEDROL ...... 69 SUBLOCADE ...... 11 somatropin succimer see HUMATROPE ...... 69 see CHEMET ...... 61 see HUMATROPE COMBO PACK ...... 69 SUCRAID...... 75 SOMATULINE DEPOT ...... 70 sucralfate ...... 75 SOMAVERT ...... 70 sonidegib phosphate see VELPHORO ...... 70 136 sulconazole nitrate ...... 99 SYNJARDY XR TAB 5-1000MG ...... 60 sulfacetamide sodium (acne) ...... 97 SYNTHROID ...... 71 sulfacetamide sodium (ophth) .... 90 T sulfacetamide sodium-prednisolone TABLOID ...... 24 ophth soln 10-0.23(0.25)% ...... 89 tacrolimus ...... 83 sulfacetamide sod-prednisolone see PROGRAF ...... 83 see BLEPHAMIDE OIN S.O.P...... 89 tacrolimus (topical) ...... 101 see BLEPHAMIDE SUS OP ...... 89 tadalafil ...... 77 SULFADIAZINE ...... 11 tadalafil (pulmonary hypertension) sulfamethoxazole-trimethoprim ...... 41 susp 200-40 mg/5ml ...... 13 TAFINLAR ...... 28 sulfamethoxazole-trimethoprim tab tafluprost 400-80 mg ...... 13 see ZIOPTAN ...... 91 sulfamethoxazole-trimethoprim tab TAKE ACTION 800-160 mg ...... 13 see Levonorgestrel (Emergency Oc) SULFAMYLON ...... 98 ...... 64 sulfasalazine ...... 74 TALTZ ...... 81 sulindac ...... 3 tamoxifen citrate ...... 26 sumatriptan ...... 53 tamsulosin hcl ...... 77 sumatriptan succinate ...... 53 tapentadol hcl sunitinib malate see NUCYNTA ...... 7 see SUTENT ...... 28 see NUCYNTA ER ...... 7, 8 SUPRAX ...... 19 TARGRETIN ...... 101 SUPREP BOWEL SOL PREP KIT ...... 75 tasimelteon SUTAB TAB ...... 75 see HETLIOZ ...... 52 SUTENT ...... 28 tazarotene ...... 99 suvorexant see TAZORAC ...... 99 see BELSOMRA ...... 52 TAZICEF SYEDA see Ceftazidime ...... 19 see Drospirenone-Ethinyl Estradiol TAZORAC ...... 99 Tab 3-0.03 mg ...... 62 TAZTIA XT SYMAX-SL see Diltiazem Hcl Extended Release see Hyoscyamine Sulfate ...... 72 Beads ...... 39 SYMBICORT AER 160-4.5 ...... 96 TDVAX INJ 2-2 LF ...... 85 SYMBICORT AER 80-4.5 ...... 96 telmisartan ...... 34 SYMDEKO TAB 100-150 ...... 95 telmisartan-amlodipine tab 40-10 SYMDEKO TAB 50-75MG ...... 95 mg ...... 34 SYMLINPEN 120 ...... 57 telmisartan-amlodipine tab 40-5 SYMLINPEN 60 ...... 57 mg ...... 34 SYNAREL ...... 67 telmisartan-amlodipine tab 80-10 SYNJARDY TAB...... 60 mg ...... 34 SYNJARDY TAB 12.5-500 ...... 60 telmisartan-amlodipine tab 80-5 SYNJARDY TAB 5-1000MG ...... 60 mg ...... 34 SYNJARDY TAB 5-500MG ...... 60 telmisartan-hydrochlorothiazide SYNJARDY XR TAB ...... 60 tab 40-12.5 mg ...... 34 SYNJARDY XR TAB 10-1000 ...... 60 telmisartan-hydrochlorothiazide SYNJARDY XR TAB 25-1000 ...... 60 tab 80-12.5 mg ...... 34 137 telmisartan-hydrochlorothiazide TICE BCG ...... 29 tab 80-25 mg ...... 34 TILIA FE temazepam ...... 52 see Norethindrone Ac-Ethinyl Estrad- TEMIXYS TAB 300-300 ...... 18 Fe Tab 1-20/1-30/1-35 mg-Mcg . 65 TEMODAR ...... 23 timolol temozolomide ...... 23 see BETIMOL ...... 91 see TEMODAR ...... 23 timolol maleate ...... 37 TENCON timolol maleate (ophth) ...... 91 see Butalbital-Acetaminophen Tab tinidazole ...... 11 50-325 mg ...... 2 tiotropium bromide monohydrate TENIPOSIDE ...... 30 see SPIRIVA HANDIHALER ...... 92 TENIVAC INJ 5-2LF ...... 85 see SPIRIVA RESPIMAT ...... 92 tenofovir disoproxil fumarate ...... 16 tipranavir see VIREAD ...... 16 see APTIVUS ...... 14 terazosin hcl ...... 32 TIVICAY ...... 16 terbinafine hcl ...... 13 TIVICAY PD ...... 16 terbutaline sulfate ...... 94 tizanidine hcl ...... 55 terconazole vaginal ...... 78 TOBRADEX OIN 0.3-0.1% ...... 89 teriflunomide TOBRADEX ST SUS 0.3-0.05 ...... 89 see AUBAGIO ...... 54 tobramycin ...... 11 testosterone ...... 57 tobramycin (ophth) ...... 90 testosterone cypionate ...... 57 tobramycin sulfate ...... 11 testosterone enanthate ...... 57 tobramycin-dexamethasone tetanus toxoid-diphtheria-acellular see TOBRADEX OIN 0.3-0.1% ...... 89 pertussis adsorb (tdap) see TOBRADEX ST SUS 0.3-0.05 ... 89 see ADACEL INJ ...... 83 tobramycin-dexamethasone ophth see BOOSTRIX INJ ...... 83 susp 0.3-0.1% ...... 89 tetanus-diphtheria toxoids (td) tocilizumab see TDVAX INJ 2-2 LF ...... 85 see ACTEMRA...... 80 see TENIVAC INJ 5-2LF ...... 85 TODAY SPONGE ...... 77 tetrabenazine ...... 54 tofacitinib citrate tetracycline hcl ...... 22 see XELJANZ ...... 81 tezacaftor-ivacaftor see XELJANZ XR ...... 81 see SYMDEKO TAB 100-150 ...... 95 tolcapone ...... 49 see SYMDEKO TAB 50-75MG ...... 95 tolmetin sodium ...... 3 thalidomide tolterodine tartrate ...... 77 see THALOMID ...... 83 tolvaptan ...... 70 THALOMID ...... 83 topiramate ...... 43 theophylline ...... 97 TOPOSAR see ELIXOPHYLLIN ...... 96 see Etoposide ...... 30 thioguanine topotecan hcl ...... 30 see TABLOID ...... 24 toremifene citrate ...... 26 thioridazine hcl ...... 50 torsemide ...... 40 thiothixene ...... 50 TOVIAZ ...... 77 tiagabine hcl ...... 43 TRACLEER ...... 41 ticagrelor tramadol hcl ...... 10 see BRILINTA ...... 80 138 tramadol-acetaminophen tab 37.5- trifluoperazine hcl ...... 50 325 mg ...... 10 trifluridine ...... 90 trametinib dimethyl sulfoxide trihexyphenidyl hcl...... 49 see MEKINIST ...... 28 TRIKAFTA TAB ...... 95 trandolapril ...... 32 TRI-LINYAH trandolapril-verapamil hcl tab er 1- see Norgestimate-Eth Estrad Tab 240 mg ...... 31 0.18-35/0.215-35/0.25-35 mg-Mcg trandolapril-verapamil hcl tab er 2- ...... 66 180 mg ...... 31 trimethobenzamide hcl...... 73 trandolapril-verapamil hcl tab er 2- trimethoprim ...... 13 240 mg ...... 31 trimethoprim hcl trandolapril-verapamil hcl tab er 4- see PRIMSOL ...... 13 240 mg ...... 31 trimipramine maleate ...... 47 tranexamic acid ...... 80 TRI-SPRINTEC tranylcypromine sulfate ...... 47 see Norgestimate-Eth Estrad Tab travoprost ...... 91 0.18-35/0.215-35/0.25-35 mg-Mcg trazodone hcl ...... 47 ...... 66 TRECATOR ...... 18 TRIUMEQ TAB ...... 18 TRELEGY AER ELLIPTA ...... 92 TRIVORA-28 TREMFYA ...... 81 see Levonorgestrel-Eth Estra Tab treprostinil 0.05-30/0.075-40/0.125-30mg- see REMODULIN ...... 41 Mcg ...... 64 see TYVASO STARTER ...... 41 TROGARZO ...... 16 treprostinil diolamine tropicamide ...... 92 see ORENITRAM ...... 41 trospium chloride ...... 78 TRESIBA ...... 59 TRULICITY ...... 58 TRESIBA FLEXTOUCH ...... 59 TRUMENBA INJ ...... 85 tretinoin ...... 97 tucatinib Tretinoin ...... 97 see TUKYSA ...... 28 tretinoin (chemotherapy) ...... 29 TUKYSA ...... 28 tretinoin microsphere ...... 98 TUZISTRA XR SUS ...... 94 triamcinolone acetonide (mouth) TWINRIX INJ ...... 85 ...... 102 TWIRLA DIS 120-30 ...... 67 Triamcinolone Acetonide (Mouth) ... 102 TYBLUME CHW 0.1-0.02 ...... 67 triamcinolone acetonide (topical) TYBOST ...... 16 ...... 100, 101 TYMLOS ...... 70 Triamcinolone Acetonide (Topical) .. 100 TYSABRI ...... 55 triamterene ...... 40 TYVASO STARTER ...... 41 triamterene & hydrochlorothiazide U cap 37.5-25 mg ...... 40 UDENYCA ...... 79 triamterene & hydrochlorothiazide ulipristal acetate tab 37.5-25 mg ...... 40 see ELLA ...... 62 triamterene & hydrochlorothiazide umeclidinium bromide tab 75-50 mg ...... 40 see INCRUSE ELLIPTA ...... 92 TRIDERM umeclidinium-vilanterol see Triamcinolone Acetonide see ANORO ELLIPT AER 62.5-25 .... 92 (Topical) ...... 100 UNITHROID 139

see Levothyroxine Sodium ...... 71 see Desogest-Ethin Est Tab 0.1- upadacitinib 0.025/0.125-0.025/0.15-0.025mg- see RINVOQ ...... 81 Mg ...... 62 UPTRAVI ...... 41 VELPHORO ...... 70 UPTRAVI TAB 200/800 ...... 41 vemurafenib (emergency see ZELBORAF ...... 29 treatment) VENCLEXTA ...... 30 see VISTOGARD ...... 29 VENCLEXTA TAB START PK ...... 30 ursodiol ...... 75 venetoclax ustekinumab see VENCLEXTA...... 30 see STELARA ...... 81 see VENCLEXTA TAB START PK ..... 30 V venlafaxine hcl ...... 47 valacyclovir hcl ...... 19 VENTAVIS ...... 41 valganciclovir hcl...... 19 verapamil hcl ...... 39 valproate sodium...... 44 VIBRAMYCIN ...... 22 valproic acid ...... 44 VICTOZA ...... 58 valsartan ...... 34 VIDEX EC ...... 16 valsartan-hydrochlorothiazide tab VIDEX PEDIATRIC ...... 16 160-12.5 mg ...... 34 vigabatrin ...... 44 valsartan-hydrochlorothiazide tab VIIBRYD ...... 48 160-25 mg ...... 34 VIIBRYD KIT STARTER ...... 48 valsartan-hydrochlorothiazide tab vilazodone hcl 320-12.5 mg ...... 34 see VIIBRYD ...... 48 valsartan-hydrochlorothiazide tab see VIIBRYD KIT STARTER ...... 48 320-25 mg ...... 34 VIMPAT ...... 44 valsartan-hydrochlorothiazide tab vinblastine sulfate ...... 24 80-12.5 mg ...... 34 vincristine sulfate ...... 24 vancomycin hcl ...... 13 vinorelbine tartrate ...... 24 VANDAZOLE VIOKACE TAB 10440 ...... 75 see Metronidazole Vaginal ...... 78 VIOKACE TAB 20880 ...... 76 vandetanib VIORELE see CAPRELSA ...... 27 see Desogest-Eth Estrad & Eth Estrad VAQTA ...... 85 Tab 0.15-0.02/0.01 mg(21/5) .... 62 varenicline tartrate VIRACEPT ...... 16 see CHANTIX ...... 56 VIREAD ...... 16 see CHANTIX CONTINUING MONTH56 vismodegib see CHANTIX PAK 0.5& 1MG ...... 56 see ERIVEDGE ...... 24 varicella virus vaccine live VISTOGARD...... 29 see VARIVAX...... 85 VITRAKVI ...... 28 VARIVAX ...... 85 VIVITROL ...... 56 VARUBI ...... 73 vorapaxar sulfate VASCEPA ...... 36 see ZONTIVITY ...... 80 VAXELIS INJ ...... 85 voriconazole ...... 13 VCF VAGINAL CONTRACEPTIVE ...... 77 vorinostat VELIVET see ZOLINZA ...... 25 VOSEVI TAB ...... 21 VOTRIENT ...... 28 140

VYFEMLA ZEJULA ...... 25 see Norethindrone & Ethinyl Estradiol ZELBORAF ...... 29 Tab 0.4 mg-35 mcg ...... 64 ZENPEP CAP 10000UNT ...... 76 VYVANSE ...... 52 ZENPEP CAP 15000UNT ...... 76 W ZENPEP CAP 20000UNT ...... 76 warfarin sodium ...... 78 ZENPEP CAP 25000 ...... 76 Warfarin Sodium ...... 79 ZENPEP CAP 3000UNIT ...... 76 WERA ZENPEP CAP 40000 ...... 76 see Norethindrone & Ethinyl Estradiol ZENPEP CAP 5000UNIT ...... 76 Tab 0.5 mg-35 mcg ...... 64 ZENZEDI X see Dextroamphetamine Sulfate .... 51 XALKORI ...... 28 zidovudine ...... 16 XARELTO ...... 79 see RETROVIR IV INFUSION ...... 15 XARELTO STAR TAB 15/20MG ...... 79 zileuton ...... 94 XELJANZ ...... 81 ZIOPTAN ...... 91 XELJANZ XR ...... 81 ziprasidone hcl ...... 50 XIFAXAN ...... 13 ZIRGAN ...... 90 XIGDUO XR TAB 10-1000 ...... 60 zoledronic acid ...... 61 XIGDUO XR TAB 10-500MG ...... 60 ZOLINZA ...... 25 XIGDUO XR TAB 2.5-1000 ...... 60 zolmitriptan ...... 53 XIGDUO XR TAB 5-1000MG ...... 60 zolpidem tartrate ...... 52 XIGDUO XR TAB 5-500MG ...... 60 zonisamide ...... 44 XOLAIR ...... 94 ZONTIVITY ...... 80 XTAMPZA ER ...... 10 ZORTRESS ...... 83 XTANDI ...... 26 ZOSTAVAX ...... 86 XULANE zoster vaccine live see Norelgestromin-Ethinyl Estradiol see ZOSTAVAX ...... 86 Td Ptwk 150-35 mcg/24hr ...... 64 zoster vaccine recombinant XULTOPHY INJ 100/3.6 ...... 58 adjuvanted Y see SHINGRIX ...... 85 YONSA ...... 26 ZOVIA 1/35E YUVAFEM see Ethynodiol Diacetate & Ethinyl see Estradiol Vaginal ...... 68 Estradiol Tab 1 mg-35 mcg ...... 62 Z ZUBSOLV SUB 0.7-0.18 ...... 3 zafirlukast ...... 94 ZUBSOLV SUB 1.4-0.36 ...... 3 zaleplon ...... 52 ZUBSOLV SUB 11.4-2.9 ...... 3 zanamivir ZUBSOLV SUB 2.9-0.71 ...... 3 see RELENZA DISKHALER ...... 19 ZUBSOLV SUB 5.7-1.4 ...... 3 ZARAH ZUBSOLV SUB 8.6-2.1 ...... 3 see Drospirenone-Ethinyl Estradiol ZYDELIG ...... 29 Tab 3-0.03 mg ...... 62 ZYKADIA ...... 29

141 Step Therapy Criteria Step Therapy Group AMYLIN ANALOG 676-D Drug Names SYMLINPEN 120, SYMLINPEN 60 Step Therapy Criteria Coverage will be provided if the member has filled a prescription for a 30 day supply of rapid-acting insulin or short-acting insulin, or pre-mixed insulin within the past 120 days

Step Therapy Group ANTIPSYCHOTICS 657-D Drug Names LATUDA, REXULTI Step Therapy Criteria Coverage will be provided if the member has filled a prescription for a 30 day supply of generic aripiprazole, asenapine, olanzapine, paliperidone, quetiapine (regular or extended release), risperidone, or ziprasidone within the past 180 days

Step Therapy Group DESVENLAFAXINE/FETZIMA 1888-E Drug Names DESVENLAFAXINE ER, FETZIMA, FETZIMA TITRATION PACK Step Therapy Criteria Coverage will be provided if the patient has filled a prescription for a 30 day supply of a generic - inhibitor (SNRI) OR generic mirtazapine, generic bupropion, or a generic selective serotonin (SSRI) within the past 120 days.

Step Therapy Group DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS 1009-D Drug Names ALOGLIPTIN, ALOGLIPTIN/METFORMIN HCL, JANUMET, JANUMET XR, JANUVIA, JENTADUETO XR Step Therapy Criteria Coverage will be provided if the member has filled a prescription for a 30 day supply of metformin within the past 180 days

Step Therapy Group DOXEPIN 1496-E Drug Names DOXEPIN HYDROCHLORIDE Step Therapy Criteria Coverage will be provided if the member has filled a prescription for at least a 7 day supply of a generic topical AND at least a 7 day supply of topical tacrolimus (Protopic) within the past 120 days.

Step Therapy Group EUCRISA 3199-E Drug Names EUCRISA Step Therapy Criteria Coverage will be provided if the member has filled a prescription for at least a one day supply of a medium or higher potency topical corticosteroid within the past 180 days.

Step Therapy Group GLP- 1 AGONIST 676-D Drug Names OZEMPIC, TRULICITY, VICTOZA Step Therapy Criteria Coverage will be provided if the member has filled a prescription for a 30 day supply of metformin within the past 180 days

Updated 10/01/2021 142 Step Therapy Group GLP-1 AGONIST/LONG ACTING INSULIN COMBO 676-D Drug Names SOLIQUA 100/33, XULTOPHY 100/3.6 Step Therapy Criteria Coverage will be provided if the member has filled a prescription for a 30 day supply of metformin within the past 180 days

Step Therapy Group LYRICA 656-D Drug Names PREGABALIN Step Therapy Criteria Coverage will be provided if the member has filled a prescription for regular release generic gabapentin (at least a 30 day supply within the past 120 days)

Step Therapy Group OPIOID ER 2219-M Drug Names BELBUCA, BUPRENORPHINE, FENTANYL, HYDROMORPHONE HCL ER, HYDROMORPHONE HYDROCHLORI, METHADONE HCL, METHADONE HYDROCHLORIDE I, MORPHINE SULFATE ER, NUCYNTA ER, OXYCODONE HCL ER, OXYMORPHONE HYDROCHLORIDE, TRAMADOL HCL ER, XTAMPZA ER Step Therapy Criteria Coverage will be provided if the member has filled a cumulative 7-day or greater supply of an immediate-release opioid agent within the past 90 days OR has been receiving an extended-release opioid agent for a cumulative 30 days or greater within the past 90 days.

Step Therapy Group OPIOID IR 2221-M Drug Names CODEINE SULFATE, HYDROMORPHONE HCL, MORPHINE SULFATE, NUCYNTA, OXYCODONE HCL, OXYCODONE HYDROCHLORIDE, OXYMORPHONE HYDROCHLORIDE, TRAMADOL HCL Step Therapy Criteria Coverage will be provided to the member for up to a 7-day supply of immediate-release if the member does not have at least a cumulative 7-day supply of an opioid agent (immediate- or extended-release) within the past 90 days.

Step Therapy Group OPIOID IR COMBO PRODUCTS 1358-E Drug Names ACETAMINOPHEN/CODEINE, ENDOCET, HYDROCODONE BITARTRATE/AC, HYDROCODONE/ACETAMINOPHEN, HYDROCODONE/IBUPROFEN, OXYCODONE/ACETAMINOPHEN, OXYCODONE/ASPIRIN, OXYCODONE/IBUPROFEN, TRAMADOL HYDROCHLORIDE/AC Step Therapy Criteria Coverage will be provided to the member for up to a 7-day supply of immediate-release opioids if the member does not have at least a cumulative 7-day supply of an opioid agent (immediate- or extended-release) within the past 90 days.

Step Therapy Group PDPD HEP C Drug Names SOVALDI Step Therapy Criteria Must try Epclusa or Harvoni

Updated 10/01/2021 143 Step Therapy Group RANEXA 658-D Drug Names RANOLAZINE ER Step Therapy Criteria Coverage will be provided if the member has filled a prescription for a in combination with either a calcium or long-acting nitrate (at least a 30 day supply within the past 365 days)

Step Therapy Group SIMVA 80MG 981-D Drug Names SIMVASTATIN Step Therapy Criteria Coverage will be provided if the member has filled a prescription for 80mg strength of simvastatin (Zocor) or 10-80mg strength of ezetimibe-simvastatin (Vytorin) (at least a 290 day supply within the past 365 days)

Step Therapy Group SKLICE 3744-D Drug Names IVERMECTIN Step Therapy Criteria Coverage will be provided if the member has filled a prescription for at least a 14 day supply of permethrin 1% within the past 60 days

Step Therapy Group SODIUM-GLUCOSE CO-TRANSPORTER 2 INHIBITOR (SGLT2) AND SGLT2 COMBINATIONS 676-D Drug Names FARXIGA, GLYXAMBI, JARDIANCE, SYNJARDY, SYNJARDY XR, XIGDUO XR Step Therapy Criteria Coverage will be provided if the member has filled a prescription for a 30 day supply of metformin within the past 180 days

Step Therapy Group TGST BISPHOSPHONATES 377-D Drug Names FOSAMAX PLUS D Step Therapy Criteria Coverage will be provided if the member has filled a prescription for a generic product (at least a 28 day supply within the past 365 days)

Step Therapy Group TGST BPH-ALPHA1 BLCK 606-D Drug Names CARDURA XL Step Therapy Criteria Coverage will be provided if the member has filled a prescription for a generic Benign Prostatic Hyperplasia (BPH) agent (e.g., alfuzosin ext-rel, doxazosin, silodosin, tamsulosin, terazosin) (at least a 30 day supply within the past 365 days)

Step Therapy Group TGST NASAL STEROIDS 4591-D Drug Names OMNARIS Step Therapy Criteria Coverage will be provided if the member has filled a prescription for at least a 30 day supply of at least one brand or generic over-the-counter (OTC) nasal steroid or at least one generic prescription nasal steroid within the past 180 days.

Step Therapy Group TGST PPI 383-D Drug Names DEXILANT Step Therapy Criteria Coverage will be provided if the member has filled a prescription for a generic proton pump inhibitor (at least a 30 day supply within the past 180 days)

Updated 10/01/2021 144 Step Therapy Group TGST PROSTAGL ANALOG 613-D Drug Names LUMIGAN, ZIOPTAN Step Therapy Criteria Coverage will be provided if the member has filled a prescription for a generic analogue (other than bimatoprost) (at least a 30 day supply within the past 365 days)

Step Therapy Group TGST SLEEP AGENTS 382-D Drug Names BELSOMRA Step Therapy Criteria Coverage will be provided if the member has filled a prescription for a generic (at least a 30 day supply within the past 180 days)

Step Therapy Group TGST SSRI 384-D Drug Names VIIBRYD, VIIBRYD STARTER PACK Step Therapy Criteria Coverage will be provided if the member has filled a prescription for a generic SSRI product (at least a 30 day supply within the past 365 days)

Step Therapy Group ULORIC 540-D Drug Names FEBUXOSTAT Step Therapy Criteria Coverage will be provided if the member has filled a prescription for allopurinol (at least a 30 day supply within the past 180 days)

Updated 10/01/2021 145

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